challenges for collective health in caring for socially vulnerable individuals, families, and communities amidst the pandemic editorial challenges for collective health in caring for socially vulnerable individuals, families, and communities amidst the pandemic desafíos para la salud colectiva en el cuidado con personas, familias y comunidades vulnerables socialmente frente a la pandemia desafios para a saúde coletiva no cuidado de pessoas, famílias e comunidades vulneráveis socialmente durante a pandemia dora lucia gaviria-noreña1 1 0000-0002-1779-7402. facultad de enfermería, universidad de antioquia, colombia. dora.gaviria@udea.edu.co 10.5294/aqui.2020.20.4.1 to reference this editorial / para citar este editorial / para citar este editorial: gaviria-noreña dl. challenges for collective health in caring for socially vulnerable individuals, families, and communities amidst the pandemic. aquichan. 2020;20(4): e2041. doi: 10.5294/aqui.2020.20.4.1 keywords (source: decs): social vulnerability; nursing care; nursing ethics; public policy; health equity. palabras clave (fuente: decs): vulnerabilidad social; atención de enfermería; ética en enfermería; política pública; equidad en salud. palavras-chave (fonte: decs): vulnerabilidade social; cuidados de enfermagem; ética em enfermagem; política pública; equidade em saúde. covid-19 pandemic is one of the most devastating events humanity has experienced globally, nationally, and locally. on the one hand, it has revealed the fragility of life and human suffering and, on the other, uncertainty and paradoxes. for health care, the collapse of services, the precarious conditions of workers, and the reproduction of social inequities and inequalities have exacerbated issues such as poverty, hunger, domestic violence, mental health problems, complications due to chronic diseases, and disability, adversely affecting socially vulnerable people, families, and communities. at present, care is on the political, social, and economic agenda. it has moved from individuality and invisibility to collective so­lidarity and public practices that must be maintained over time to achieve essential healthy processes for human life and survival in diverse, complex, and uncertain sociocultural contexts. in attempting to raise awareness of care, this reflection aims to outline the challenges for nursing in collective health based on the legacy of care in a pandemic, care as a creative and transformative action, and the advocacy of law for essential health care. historical challenge of nursing care to alleviate human suffering as a knowledge and practice domain, collective health conceives the health-disease process—determined by historical, social, and cultural processes—as opposed to the primacy of individual biology and the fragmentation of the human being subordinated to the clinic and pathology of organs and systems, depending on the medical model (1). nursing as a discipline has developed its practice close to individuals, families, and communities, and its work is invaluable in relieving suffering, preventing complications, and reducing mortality. accordingly, the who (2) has reiterated the importance of nursing staff in the health care system. from 38 experiences, it has stressed best practices in primary care (3, 4) and health education, leadership in policy formulation, and the development of social and community empowerment in vulnerable populations. considering the pandemic, this input to achieving universal health coverage and equitable access inspires us to replicate and implement care strategies for covid-19 mitigation and the post-pandemic world, reappraising community nursing work and not only the clinical and biomedical perspectives. political challenge: care as a creative and transformative action in one of the most important political events in nursing in recent years, the who designated 2020 (5) as the international year of the nurse and the midwife for their contribution to the population's health. however, with the covid-19, nursing initiatives in the public and political sphere have not aroused interest. the focus has been on the epidemiological and institutional public health views, leaving aside collective health proposals and ongoing nursing work in territories with social and community participation. this concealment exposes the paradox of nurses' value and work, a lack of staff to meet the urgent demands for care, and the burden of both professional and informal care. the political challenge is to vindicate and recognize care as a creative and transformative action taken in territories for health promotion, disease prevention, and care. it includes not only the pandemic but also daily health actions and efforts made for the survival of individuals, families, and communities within a proper pedagogy for life care. ethical challenge: advocacy of the right to essential health care given the covid-19, the society's ethical project is the lifeline to reach universal consensus for justice and equity, respect for the other, and the defense of their dignity. the advocacy of the right to health requires knowledge that transcends and contributes to solving critical problems through research, information, and innovation. this advocacy will promote the transformation of realities and help us dodge a bullet (6), as expressed by callista roy, in overcoming the theory-practice dichotomy, detours, and dead ends that we face as a planet. the ethical challenge is to achieve continuous care as a guarantee to clearly understand safe, supportive, and sustainable actions that mitigate social inequalities and strengthen equity and ethos of caring as a project oriented towards welfare, compassion, and the defense of the right to health. references 1. gaviria ndl. un debate producto de la experiencia y la construcción académica en antioquia. in morales mc, editor. salud colectiva y salud pública: ¿se está hablando de lo mismo?; universidad nacional de colombia; 2017. available from: http://www.doctoradosaludp.unal.edu.co/?p=414 2. world health organization. a compendium of primary care case studies [internet]; 2009. available from: https://drive.google.com/file/d/0bzdvluwbe2u4ufd3c01nz2jbbwm/view 3. olaya-cuadros bl, gaviria-noreña dl. cuidado de la salud de la familia. rev. cienc. cuidad. 2017;14(1):79-94. doi: 10.22463/17949831.808 4. gobernación de antioquia dirección seccional de salud y protección social de antioquia. lineamientos para la promoción de la salud con-sentido humano en el departamento de antioquia. medellín: universidad antioquia; 2010. available from: https://www.dssa.gov.co/index.php/descargas/733-libro-lineamientos-promocion-salud/file 5. world health organization. 2020: international year of the nurse and the midwife report by the director-genera. geneve: world health organization; 2019. available from: http://apps.who.int/gb/ebwha/pdf_files/wha72/a72_54rev1-en.pdf 6. roy c. key issues in nursing theory. developments, challenges, and future directions. nurs res. 2018;67(2):81-92. doi: 10.1097/nnr.0000000000000266 home covid-19, teaching, and service: the challenge of nursing training practices editorial covid-19, teaching, and service: the challenge of nursing training practices covid-19, docencia y servicio: el reto de las prácticas formativas en enfermería covid-19, ensino e serviço: o desafio das práticas pedagógicas em enfermagem 10.5294/aqui.2021.21.2.1 sonia patricia carreño-moreno1 1 0000-0002-4386-6053. associate professor, nursing school, universidad nacional de colombia. cuidado de enfermería al paciente crónico research group. colombia. spcarrenom@unal.edu.co keywords (source decs): education; nursing; practical nursing; nursing schools; nursing students; coronavirus infections. palabras clave (fuente decs): educación en enfermería; enfermería práctica; facultades de enfermería; estudiantes de enfermería; infecciones por coronavirus. palavras-chave (fonte decs): educação em enfermagem; enfermagem prática; escolas de enfermagem; estudantes de enfermagem; infecções por coronavirus. the covid-19 pandemic has jeopardized not only global health, the economy, and politics but also education (1). mainly, health sciences programs have suspended on-site practical experiences in hospital and community settings (2). the fear of possible contagion, the uncertainty about how the training processes could take place in risky environments, and the regulations that some countries such as colombia issued restricting the training of health workers prevented nursing students from having on-site practice for almost a year. this paper aims to discuss the situation of nursing students regarding their return to nursing training practices in the context of the covid-19 pandemic, the challenges, and potential strategies for such practices amidst the teaching-service relationship. the pandemic has had a significant impact on the academic nursing community. a study conducted in colombia in which i participated (in press activities), with more than 1,600 nursing students and recent graduates involved, revealed that, although the participants had adequate knowledge, attitudes, and practices regarding covid-19, the prevalence of stress and fear was high. these findings concur with those in mexico in a sample of 912 students (3); it was observed that stress and fear are correlated, and both increase with limited knowledge. both studies noted a significantly higher prevalence of fear and stress due to covid-19 than reported in other research conducted in the philippines, bangladesh, new zealand, and turkey (4). these results point to the first challenge: returning on-site training practices under vulnerable mental health conditions for students. with the antecedent of affected mental health for students and, of course, professors, we faced the return to on-site training practices and all kinds of additional challenges presented. issues such as the type and quantity of personal protection equipment and the responsibility for its provision and distribution; the concentration of students per patient or per available area in square meters; the internal epidemiological surveillance system; the procedure in case of contact with or occurrence of suspected cases; the type and material of the uniforms to be worn on the street and at practice sites; the type of adequate contact among students and between them and the professor, health team, and patients; the management of students with comorbidities; collective mental haze, among others, are some examples of everyday problems during the return to nursing training practices. however, despite the challenges, the continuous review of research results, short-term planning and assessment, adherence to contagion prevention protocols, and flexibility have allowed rising to them gradually but firmly. all this resulted from collaborative work between academia and care, which have joined efforts to guarantee not only service to the population but also the training of competent nurses for current demands. after three months of my first training experience in a pandemic, i reaffirm that it is time to take advantage of the crisis to rethink nursing training. at a time that calls for flexibility, remote teaching supported by virtual and augmented reality, and simulated practice (5), i would add the need to maintain on-site practice under the premises of flexibility, autonomy, and innovation. the opening, adaptation, and adjustment of the curricula and the teaching-service relationship are imperative. let us not lose sight of the obligation we have, as academia, to train competent professionals to cater to the needs of our population. at present, we have a unique opportunity to train a nursing force that, in the future, will be sensitive to actual problems. therefore, we need to combine various practice alternatives that ensure clinical judgment and technical, critical thinking, and problem-solving skills. it is essential to open up to the possibility of on-site and remote simulated practice, practice in telehealth programs, and, of course, strengthening on-site practice. the alternatives mentioned are not the only ones, but they are a good starting point. in the united kingdom (1), for instance, given the limitation of on-site practice settings, nursing students, at their discretion, have had the chance to do their training practices in the health services available for the pandemic. this initiative enabled students to add their training activities to the system’s efforts to contain the pandemic and continue comprehensive care for the entire population. clearly, the initiative entails risks and challenges but is an alternative that has responded to the contingency of training future professionals and the deficit of nurses in these times. rather than replicating this proposed practice, the invitation is to consider each of our contexts and devise flexible strategies that guarantee students’ skills. of the british proposal, i highlight the deference granted to the student’s autonomy to opt for this practice model, so i urge academia to promote practical exercises that strengthen such autonomy. in conclusion, today, when most of the world has prevailed over the third wave of infections, with limited on-site practice environments and a new lockdown, i emphasize the pressing need to stop and review the traditional forms of practice in our profession, consider the opportunities that the conjunction has given us, and reinvent nursing skills training. nursing professors are called to take these actions in our role as agents for change in times of crisis (6). references 1. haslam mb. what might covid-19 have taught us about the delivery of nurse education, in a post-covid-19 world? nurse educ today. 2021; 97:104707. doi: https://doi.org/10.1016/j.nedt.2020.104707 2. yancey nr. disrupting rhythms: nurse education and a pandemic. nurs sci q. 2020; 33(4):299-302. doi: https://doi.org/10.1177/0894318420946493 3. medina fernández ia, carreño moreno s, chaparro díaz l, gallegos-torres rm., medina fernández ja, hernández martínez ek. fear, stress, and knowledge regarding covid-19 in nursing students and recent graduates in mexico. investigación y educación en enfermería, 2021; 39(1):1-12. doi: https://doi.org/10.17533/udea.iee.v39n1e05 4. gohel kh, patel pb, shah pm, patel jr, pandit n, raut a. knowledge and perceptions about covid-19 among the medical and allied health science students in india: an online cross-sectional survey. clin epidemiol glob heal. 2020; 9(1):104-109. doi: https://doi.org/10.1016/j.cegh.2020.07.008 5. agu cf, stewart j, mcfarlane-stewart n, rae t. covid-19 pandemic effects on nursing education: looking through the lens of a developing country. int nurs rev. 2021; 68(2):153-158. doi: https://doi.org/10.1111/inr.12663 6. klar rt. nurse educators as agents of change in the sars-cov-2 pandemic. nurs womens health. 2020; 24(4):253-5. doi: https://doi.org/10.1016/j.nwh.2020.05.010 home 207 211 primeras paginas.indd 210 aquichan issn 1657-5997 editorial en octubre de 2009 tuve la oportunidad de participar en el segundo seminario internacional de enfermería, organizado por la universidad autónoma de tamaulipas, en nuevo laredo, méxico. el tema central del evento fue la globalización y el desarrollo del conocimiento en enfermería. un tema trascendental, si se tiene en cuenta que cuando se habla del mismo muchos piensan exclusivamente en política neoliberal y en la expansión de los mercados y de las empresas, minimizando las repercusiones sociales, culturales y de desarrollo del conocimiento que la globalización ha traído en los últimos treinta años gracias a los avances en las tecnologías de la información y la comunicación (tic) (1). las tic eliminaron las fronteras y permitieron la comunicación en tiempo real con personas en cualquier lugar del mundo, el acceso a fuentes de información actualizada, y se convirtieron en un recurso invaluable a la hora de crear redes académicas y fortalecer la investigación y el desarrollo del conocimiento. los avances en este sentido han sido disímiles. en el caso particular de enfermería, aunque el conocimiento teórico ha traspasado las fronteras, éste aún no se refleja en la práctica, de manera que en nuestro caso, la globalización no ha sido relevante (2). el asunto no es solamente de conocimiento al alcance de todos, sino de la forma como lo entendemos, lo aplicamos y desarrollamos. con relación al desarrollo del conocimiento, es indiscutible la importancia de la teoría de enfermería para cualificar la práctica, para demostrar nuestra contribución a la salud de la población, para reforzar nuestra identidad como profesionales y alcanzar la autonomía que deseamos. ahora bien, las inquietudes relacionadas con la aplicación de teoría que se origina en otros países y en ámbitos culturales tan diversos, están bien fundamentadas. si bien el conocimiento es universal, su aplicación requiere análisis y verificación para que sea culturalmente congruente, y esto es indispensable para una disciplina como enfermería, cuyo campo de dominio es el cuidado de las personas como seres holísticos y, por tanto, está determinado por las condiciones particulares de cada individuo y por el contexto social y cultural donde se encuentra. la aplicación del conocimiento exige procesos de traducción rigurosa de la información. pero la “traducción del conocimiento” no se limita al idioma, incluye ajustes que permitan adecuarlo al contexto cultural donde se va a aplicar para no perder su esencia. año 9 vol. 9 nº 3 chía, colombia diciembre 2009 210-211 la globalización y el conocimiento de enfermería 211 editorial también demanda de la investigación colaborativa entre profesionales de enfermería que se encuentran en diferentes regiones de un país o en países que comparten la misma lengua, para validar y fortalecer ese conocimiento. las revistas de enfermería constituyen una ventana global al conocimiento de la disciplina, no solo porque están disponibles en la web y permiten a todos sus lectores la consulta de los artículos en texto completo, sino también por la diversidad de los autores que publican en ellas. desde esta perspectiva, el proceso de globalización se constituye en una oportunidad, en la medida en que contribuye al fortalecimiento de la ciencia de enfermería, a incrementar la evidencia científica para la práctica, y con ello a mejorar la prestación del cuidado en beneficio de la salud de las personas en todo el mundo. maría elisa moreno-fergusson editora mariae.moreno@unisabana.edu.co globalization and nursing know-how globalização e conhecimento em enfermagem referencias 1. riquelme sa, michelle lh. la globalización: historia y actualidad. publicación del componente fortalecimiento de la profesión docente, enseñanza media, ministerio de educación, república de chile; 2003. disponible en http://www.mineduc.cl/biblio/documento/modulo_globalizacion.pdf. [fecha de consulta: 18 de octubre de 2009]. 2. ketefian s, redman r. nursing science in the global community. journal of nursing scholarship 1997; 29 (1): 11-5. 01 07 primeras paginas.indd 6 año 9 vol. 9 nº 1 chía, colombia abril 2009 6-7 correo del lector salud de la mujer imaginar el estilo de vida de las personas como un factor salutogénico (productor de salud) es, desde una perspectiva de cuidados promotores de vida, el principal elemento que configura la posibilidad de empoderamiento de las personas en torno a sus opciones y elecciones. en el estudio publicado en el vol. 8 no. 2 “estilo de vida y salud en la mujer adulta joven”, de pardo-torres y núñez-gómez, se plantea un enfoque integral que supera la “orientación biomédica” y las estrategias preventivistas y terapéuticas. la concepción de la salud de la mujer adulta joven “como un evento complejo” que redimensiona el rol del profesional enfermero como “facilitador y agente de cambio” necesita ser sustentada con evidencia que muestre la pertinencia de trabajar desde la salud, ya que, como expresan los autores de la investigación, la mayoría de los estudios sobre estilos de vida buscan demostrar la conexión de determinados comportamientos con la aparición de enfermedades. así, la evidencia se refiere a la prevención de la enfermedad y no sustenta la promoción de una vida saludable, que supone una actitud proactiva de las personas en su cotidianidad. el artículo muestra las dimensiones de la mujer que han representado cambios a partir de una estrategia de promoción de la salud. la dimensión en que se registra un “cambio alto” es la de “familiares y amigos” cuando existía percepción de apoyo social. se reconoce como interesante este resultado para generar una línea investigativa para desarrollar un modelo de cuidados enfermeros que busquen reforzar las relaciones de la persona con su entorno, facilitando la expresión de sus sentimientos y emociones significativas, tal como lo expresan pardo-torres y núñez-gómez. esta categoría es, tal vez, la menos tenida en cuenta en nuestras propuestas profesionales. los conocimientos generados invitan a revisar las prácticas enfermeras, desde la visión de la simultaneidad y la transformación. además, a partir de los resultados del reporte, se pueden orientar estudios en que el diseño metodológico contemple la inclusión de grupos control y se realicen en otros contextos y escenarios. las estrategias de promoción de salud, desde este estudio, se proponen soportadas por los conocimientos generados a partir de su implementación. refuerzan y valoran el impacto de acciones desde una perspectiva humanista que rescata, en la trayectoria vital de las personas, sus búsquedas hacia el bienestar y la felicidad. ángela n. m. aimar licenciada en enfermería. candidata a doctora en ciencias de la salud. docente licenciatura en enfermería, instituto académico pedagógico de ciencias humanas universidad nacional de villa maría, córdoba, argentina. 7 correo del lector fortalecer la profesión los artículos publicados basándose en investigaciones son productos definidos que ofrecen seguridad en la aplicación del cuidado, además dan a conocer el análisis de los resultados investigados según la metodología seleccionada, propiciando cambios y compromisos en el disciplinar del proceso de enfermería. por otra parte estas publicaciones dan conocer y a resaltar el rol básico o especializado de la enfermera profesional. espero que la presentación y divulgación de los artículos publicados en tan importante revista científica de atención y cuidado de enfermería conduzca a los autores y especialmente a los lectores a la aplicación y superación en la atención y cuidado de la población objetivo, además que se fomente el fortalecimiento de la profesión y el reforzamiento de prácticas en el campo de la salud humana. por su valor, una revista como aquichan contribuye a cumplir el horizonte basado en las evidencias, los marcos conceptuales y teóricos. fortalece y refuerza los estándares de calidad del cuidado del enfermo, asegurando así el cuidado de enfermería humanizado e integral, tal como se requiere en la salud global. esperamos que continúen con el desarrollo de la misión de la facultad de enfermería de la universidad de la sabana, ya que así nos permiten a todos los lectores un espacio para expresarnos como colaboradores externos con publicaciones científicas que evidencian nuestras regiones. elba e de isaza magíster en enfermería decana facultad de enfermería universidad de panamá, panamá. 02. palabras despedida ok. año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 6 queridas compañeras y amigas: solo pretendo, con estas cortas palabras, llegar al corazón de cada una de ustedes, para darles los más sinceros agradecimientos por haberme acompañado tan de cerca, y de manera tan efectiva, en el desarrollo de esta facultad. gracias por su entusiasmo, por su dedicación al trabajo, por su apertura al cambio, por sus aportes y por secundarme en tantas ideas, propuestas y proyectos, que hoy vemos realizados y que serán los pilares sobre los que se siga apoyando el desarrollo futuro de nuestro programa. todos los plazos se vencen, y hoy me llegó el momento de despedirme. no me voy lejos... es verdad, pero sí dejo un grupo de grandes amigas, y eso duele... sin embargo, me voy tranquila y optimista con relación al futuro de la facultad, pues conozco el compromiso y el tesón con que todas trabajan, y porque sé que, al igual que a mí, les preocupa el desarrollo y la estabilidad del programa. no permitan que en épocas difíciles la rutina, el conformismo o el desaliento entren en el diario vivir, sino, muy por el contrario, luchen por mantener el espíritu de innovación y el entusiasmo que las caracteriza y que ha sido el motor del desarrollo alcanzado. es posible que desde mi nuevo cargo siga requiriendo el apoyo de ustedes, y entonces nos encontraremos nuevamente en los grupos de trabajo o en las mesas de reunión, siempre para buscar las soluciones o propuestas más acertadas, en beneficio de la facultad y de la universidad. mil gracias de nuevo por todo el apoyo, pero especialmente por el cariño y la comprensión con que supieron llevar estos nueve años que estuve al frente de la decanatura. pueden estar seguras de que seguiré llevándolas en mi mente y en mi corazón. con mucho cariño, leonor pardo novoa 285 311 ultimas paginas.indd 285 reseña esta publicación es la compilación de 17 artículos científicos y de reflexión que recogen las ponencias centrales y algunos documentos de las distintas mesas de trabajo del primer encuentro de lectura y escritura en la educación superior, realizado en mayo de 2006, por el departamento de lenguaje de la facultad de comunicación social, de la universidad autónoma de occidente de santiago de cali, colombia. la obra está organizada en cuatro capítulos: el primero agrupa artículos de investigación, cuyo objeto de estudio ha sido la evaluación del desempeño o de las concepciones de los estudiantes en relación con sus prácticas de lectura y escritura. el segundo capítulo recoge varios artículos que se ocupan de la sistematización de propuestas pedagógicas y didácticas, que favorecen el desempeño de los estudiantes. el tercero presenta tres artículos sobre la necesidad de la formación de maestros universitarios, atendiendo al lugar que ocupan la escritura y la lectura en la cotidianidad del trabajo académico desarrollado por los estudiantes. en el capítulo de cierre se presentan algunos fundamentos teóricos e investigativos desde el análisis del discurso, como una de las ciencias del lenguaje que puede aportar a la formación de estudiantes universitarios. los escritos vienen del trabajo investigativo de diversos autores de la academia nacional e internacional: universidad nacional del río cuarto y de buenos aires en argentina, universidad del zulia y de los andes en venezuela, universidad pompeu fabra en españa, universidad autónoma de méxico y autónoma de tamaulipas en méxico, y por colombia las universidades de ibagué, del valle, de antioquia, de medellín, tecnológica de pereira, distrital francisco josé de caldas, del norte, escuela nacional del deporte y la autónoma de occidente. los desafíos de la lectura y la escritura en la educación superior: caminos posibles año 8 vol. 8 nº 2 chía, colombia octubre 2008 285-286 compilación y edición: elizabeth narváez cardona y sonia cadena castillo. universidad autónoma de occidente. facultad de comunicación social. departamento de lenguaje. cali. 2008. 286 reseña de acuerdo con estudios llevados a cabo por mabel giammatteo e hilda alabano, de la universidad de buenos aires, los estudiantes que ingresan a la universidad no manejan el vocabulario del discurso académico, lo que les impide comprender textos y desarrollar el pensamiento crítico. esta problemática ha estado presente no solo en las universidades de américa latina, sino también en estados unidos, canadá y europa. diferentes experiencias se han documentado para promover el trabajo de la escritura en clase como lo es “escribir a través del currículum”, experiencia chilena descrita por juana marinkovich y pilar morán, de la universidad católica de valparaíso. en este sentido el libro aporta, como lo expresa su título, “caminos posibles” a los desafíos de la lectura y la escritura en la educación superior, a través de los artículos compilados, marcos teóricos claros, y métodos para desarrollar, desde lo pedagógico, la lectura y la escritura en la educación superior. conceptos como alfabetización académica, síntesis discursiva, análisis discursivo, literacidad crítica se hacen presentes para darle fuerza a la necesidad de desarrollar una comprensión lectora y de escritura como medio para mejorar el pensamiento crítico. los estudiantes aprenden a usar el lenguaje para distintos propósitos, como relatar hechos, ya sean verídicos o ficticios, situados en lugares y tiempos específicos (narrar); presentar por medio del lenguaje, la imagen de objetos, seres vivos u otros aspectos de la realidad (describir); dar a conocer las diferentes facetas o aspectos de un tema (exponer) y formular razones para sustentar un planteamiento u opinión para convencer a otros (argumentar). interactuar de manera oral sobre los textos que se leen y escriben facilitará comprender la esencia de lo que constituye la construcción del conocimiento, estos es, la conversación (la mayoría de veces escrita) entre pares sobre los temas que le atañen al campo de estudio. por consiguiente, una de las funciones de los estudios superiores es posibilitar a sus alumnos el ingreso a esas prácticas y comunidades discursivas; esta concepción de la educación superior desde el aprendizaje y uso de la lectura y la escritura es lo que hace referencia al término alfabetización académica de la profesora paula carlino, expuesto a lo largo del libro. este libro constituye una guía interesante de propuestas de intervención en los procesos de enseñanza-aprendizaje de distintas ciencias y profesiones, a través de las prácticas desarrolladas en lectura y escritura en la educación superior, a partir de las investigaciones expuestas. mónica castilla luna directora de currículo universidad de la sabana chía, colombia año 8 vol. 8 nº 2 chía, colombia octubre 2008 285-289 1 editorial lecciones que deja la pandemia por la covid-19 lessons from the covid-19 pandemic lições que a pandemia da covid-19 deixa olivia sanhueza-alvarado1 1 https://orcid.org/0000-0002-0184-8957. presidenta asociación latinoamericana de escuelas y facultades de enfermería (aladefe), universidad de concepción, chile. osanhue@udec.cl doi: 10.5294/aqui.2020.20.3.1 para citar este editorial / to reference this editorial / para citar este editorial sanhueza-alvarado o. lessons from the covid-19 pandemic. aquichan. 2020;20(3):e2031. doi: https://doi.org/10.5294/aqui.2020.20.3.1 palabras clave (fuente: decs) atención primaria de salud; enfermería de práctica avanzada; sistemas de salud; enfermería; recursos humanos de enfermería. keywords (source: decs) primary health care; advanced practice nursing; health systems; nursing workforce. palavras-chave (fonte: decs) atenção primária à saúde; prática avançada de enfermagem; sistemas de saúde; recursos humanos em enfermagem. año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2031 https://orcid.org/0000-0002-0184-8957 mailto:osanhue@udec.cl https://doi.org/10.5294/aqui.2020.20.3.1 https://orcid.org/0000-0002-0184-8957 https://doi.org/10.5294/aqui.2020.20.3.1 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2031 la estrategia para el acceso universal a la salud y la cobertura universal de salud, legado de la declaración de alma-ata, así como el fortalecimiento del marco de la atención primaria de salud (aps), han dirigido los esfuerzos de los países de la región de las américas para mantener los logros alcanzados en salud y seguir avanzando hacia el derecho al grado máximo de salud con equidad y solidaridad (1). en este contexto regional, la ops/oms ha desarrollado iniciativas para apoyar el fortalecimiento de los sistemas de salud basados en la aps, apoyando oportunidades para dar voz a quienes no han sido escuchados, impulsando la participación social y el trabajo intersectorial, fomentando cambios en la respuesta de los sistemas de salud en la región acompañando a los países en el abordaje de sus retos prioritarios, todo ello con el fin de disminuir las inequidades en salud (1). sin embargo, todo ello no fue suficiente para que los sistemas de salud, con recursos sanitarios limitados en los diversos países de américa latina y el caribe, salvo honrosas excepciones, pudieran enfrentar de manera adecuada la desigual lucha que se sabía sobrevendría en un corto tiempo, con la llegada del coronavirus sars-cov-2. no fue suficiente para los gobiernos saber con antelación lo que habían realizado sus congéneres de europa y asia. sencillamente, lo que propusieron no alcanzó para atender, con equidad, calidad y solidaridad, a la gran cantidad de personas que día a día necesitan una cama de hospital. a tres meses de los primeros contagios confirmados en américa latina, nos enfrentamos con sistemas de salud colapsados y un gran porcentaje de sus camas de cuidados intensivos ocupadas. gobiernos como los de singapur y hong kong respondieron anticipadamente con acciones básicas de salud pública frente a los casos positivos que fueron detectados en los inicios de la pandemia (2). en américa latina, los equipos de salud siguen haciendo su máximo esfuerzo, en una lucha incansable, que día a día también cobra vidas entre ellos. con una escasez insalvable de recursos para la bioseguridad, siendo la insuficiencia de recursos humanos uno de los más graves escollos, para permitir dar abasto a la necesidad de cuidado, y esto se debe expresar claramente, es el bajo número de profesionales de enfermería, tanto en el área de la atención primaria en salud (aps), como en las unidades de atención critica, donde ha sido más aguda esta carencia de enfermeras/os. es doloroso decir que, aunque se adquieran todos los ventiladores del mundo, no se podrán hacer funcionar, si no existen las suficientes profesionales enfermeras/os, en número y con una preparación especializada. las preguntas son concretamente, ¿cómo podemos superar obstáculos tan importantes como son la gobernanza de salud deficiente, la escasez de personal sanitario preparado y el problema del financiamiento en salud para la atención a grupos vulnerables de la población? (3). efectivamente, la atención primaria de salud es uno de los sistemas que puede cambiar sustancialmente las condiciones de salud de las comunidades (3), siendo otro fundamental, el recurso humano de enfermería, ligado a una práctica de trabajo interprofesional. la respuesta ya la conocen quienes trabajan en la atención primaria de salud, área de los sistemas sanitarios que, desafortunadamente no ha logrado estimular cambios en quienes toman las decisiones, desde los niveles estatales a los ministeriales, sobre el paradigma con que piensan y planifican la salud, en donde predomina el modelo curativo. modelo que ha sido normalizado por la mayoría de los países, que, a estas alturas del contexto epidemiológico y demográfico mundial, ha demostrado ser obsoleto y retrogrado. sobre todo, en estos momentos de la pandemia, es válido insistir en que la gobernanza de salud debe mantener políticas eficientes en la primera línea de atención a la población como lo es la aps, que es prioritario inyectar más recursos a este nivel, humanos y en infraestructura, dando prioridad a formar en práctica avanzada en enfermería en aps (4,5). los “centros de atención primaria en todo el mundo han aprendido mucho de otros, pero también de ellos mismos”, dice judit vall (6), quien ha estado monitoreando cómo los sistemas de salud están lidiando con el coronavirus desde la facultad de economía de la universidad de barcelona, “y estarán en una mejor posición para manejar la próxima ola cuando esta llegue”, refiriéndose a que existirá una segunda ola de contagios por coronavirus. también la sinergia entre universidades y el área asistencial es fundamental para mantener actualizados y se desarrollen nuevos programas de formación, siendo las universidades quienes pueden entregar aquellas especialidades que la sociedad y la población necesitan con urgencia, siendo observadores aventajados respecto a cómo dar cuenta de las necesidades que emergen en la población. es urgente concentrar los esfuerzos, en una mirada de futuro de corto plazo, en la atención primaria de salud, la que requiere 3 lecciones que deja la pandemia por la covid-19 l olivia sanhueza-alvarado se la fortalezca, se la innove, se provea de recursos materiales y humanos, en número suficiente y con formación especializada, de forma que los países de la región puedan actuar preventiva y proactivamente, para salvaguardar la salud pública de la población. referencias 1. organización panamericana de la salud. orientación estratégica para enfermería en la región de las américas. washington, d.c.: ops; 2019. 2. legido-quigley helena, asgari nima, teo yik ying, m leung gabriel, oshitani hitoshi, fukuda keiji et al. ¿ are highperforming health systems resilient against the covid-19 epidemic? v. 395 (10227):848-850. 2020. the lancet. doi: https://doi.org/10.1016/s0140-6736(20)30551-1 3. chan, margaret. contribución de la atención primaria de salud a los objetivos de desarrollo del milenio. alocución de apertura ante la conferencia internacional de salud para el desarrollo. buenos aires, argentina, 16 de agosto de 2007. 4. l. san martín-rodríguez. editorial. práctica avanzada en enfermería y nuevos modelos de organización sanitaria. enfermería clínica, v. 26 (3):155-157. 2016. doi: https://doi.org/10.1016/j.enfcli.2016.04.007 5. aguirre-bozafa f. el rol de la enfermería de práctica avanzada en atención primaria en chile. medicina. clin. condes. 29(3):343-6;2018. https://doi.org/10.1016/j.rmclc.2018.03.006 6. foremny, dirk y sorribas-navarro, pilar y vall castelló, judit. living at the peak: health and public finance during the covid-19 pandemic (publicado: 17 de abril de 2020). doi: http://dx.doi.org/10.2139/ssrn.3578483 https://doi.org/10.1016/s0140-6736(20)30551-1 https://doi.org/10.1016/j.enfcli.2016.04.007 https://doi.org/10.1016/j.rmclc.2018.03.006 http://dx.doi.org/10.2139/ssrn.3578483 1 editorial nursing research priorities in light of the sustainable development goals: the 2030 agenda prioridades de investigación de enfermería a la luz de los objetivos de desarrollo sostenible: agenda 2030 prioridades de pesquisa de enfermagem à luz dos objetivos de desenvolvimento sustentável: agenda 2030 maria helena palucci marziale1 1 orcid.org/0000-0003-2790-3333. universidad de são paulo, brasil. marziale@eerp.usp.br doi: 10.5294/aqui.2019.19.2.1 to reference this article / para citar este artículo / para citar este artigo palucci mh. nursing research priorities in light of the sustainable development goals: the 2030 agenda. aquichan; 19(2): e1921. doi: 10.5294/aqui.2019.19.2.1 keywords (source: decs) nursing research; public health; the 2030 agenda for sustainable development; sustainable development goals; health research agenda; health priority agenda; nursing. palabras clave (fuente: decs) investigación en enfermería; salud pública; agenda 2030 para el desarrollo sostenible; objetivos de desarrollo sostenible; agenda de investigación en salud; agenda de prioridades en salud; enfermería. palavras-chave (fonte: decs) pesquisa em enfermagem; saúde pública; agenda 2030 para o desenvolvimento sustentável; objetivos de desenvolvimento sustentável; agenda de pesquisa em saúde; agenda de prioridades em saúde; enfermagem. https://orcid.org/0000-0003-2790-3333 mailto:marziale@eerp.usp.br http://dx.doi.org/10.5294/aqui.2019.19.2.1 https://orcid.org/0000-0003-2790-3333 http://dx.doi.org/10.5294/aqui.2019.19.2.1 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1921 the 2030 agenda, adopted by the united nations (1), is a global guide to action designed to transform the world based on sustainable development. it seeks to satisfy the needs of the current generation, without compromising the possibility that future ones can do the same. this road map strives for the eradication of poverty in all its forms and dimensions by promoting a dignified life for people and by strengthening universal peace. the 2030 agenda is comprised of 17 sustainable development goals (sdgs) and 169 goals to be met by governments, businesses, academia and citizens. these goals combine the economic, social and environmental dimensions of sustainable development. the sustainable health agenda for the americas: 2018-2030 (assa 2030) (2) was created in light of the specific characteristics of the americas and is a call to action to improve health and wellbeing throughout the region. it includes regional public health challenges and has eleven goals; namely, 1) to expand equitable access to comprehensive quality health services that are centered on people, the family and the community, with an emphasis on health promotion and disease prevention; 2) to strengthen the office and governance of the national health authority and to promote social participation; 3) to reinforce the management and development of human resources in health; 4) to obtain adequate and sustainable financing for health, with equity and efficiency, and to advance towards protection against financial risks for all persons and their families; 5) to guarantee access to essential medicines, vaccines and other priority health technologies, according to the available scientific evidence and the national context; 6) to strengthen health information systems in support of the creation of policies and decision-making based on evidence; 7) to develop the capacity to generate, transfer and use evidence and knowledge in health, by promoting research, innovation and the use of technology; 8) to strengthen national and regional capabilities for preparedness, prevention, detection, surveillance and response to outbreaks of diseases and to emergencies and disasters that affect the health of the population; 9) to reduce morbidity, disability and mortality caused by non-transmittable diseases, injuries, violence and mental health disorders; 10) to reduce the burden of transmittable diseases and to eliminate unattended diseases that are ignored; and 11) to reduce inequality in health through cross-sector, multi-sector and regional approaches to the social and environmental determinants of health. the contribution nurses make to compliance with the sdgs (1) and assa 2030 (2) is significant, since they are part of an effective system of health care that is essential to shape the development of the workforce in the field and to rationalize the various demands for health care. therefore, it is necessary to adopt action in interprofessional education and collaborative practice, to assess human resources, and to improve working conditions and local health systems. in other words, this means schools must train nurses who are qualified in advanced nursing practices (3). an extensive study done by the team of the pan american health organization’s regional advisor on nursing and health technicians (4) identifies the region’s priorities in terms of research in nursing for the promotion of universal access to health care and its universal coverage: policies and training for human resources in nursing; the structure, organization and dynamics of health systems and services; science, technology, innovation and information systems in public health; financing for health systems and services; and health policies, governance and social control and social studies in the field of health. paho will launch a document in may 2019 outlining strategic actions for nursing aimed at the americas region. these lines of action are designed to strengthen and consolidate nursing leadership and strategic management in the context of health systems and in policy formulation and monitoring; to address the working conditions and capabilities of nurses to expand universal health-care access and coverage with equity and excellence, and to strengthen the quality of nursing education to respond to the needs of universal access and coverage in terms of health systems and the sdgs (1). there is currently no global agenda for research priorities in nursing. however, the ribeirão preto school of nursing at the university of são paulo (brazil), which is a collaborating center of the pan american health organization (paho) / world health organization (who), has been tasked with helping to implement a regional agenda of priorities in nursing research for latin america and the caribbean. accordingly, it hopes to count on collaboration from the nursing schools and the researchers in graduate programs throughout the countries of the region. the hope is that nurse researchers will be able to help meet the goals in national and international agendas through studies that result in strong scientific evidence. we nurses play a very important role in health care: we make a difference in the lives of people and in services. we should be extremely proud of that and must continue in our quest to conquer ever broader areas. 3 references 1. nações unidas. transformar nuestro mundo: la agenda 2030 para el desarrollo sostenible. seventieth session of the un general assembly, resolution a/res/70/1 [internet]. available from: https://documents-dds-ny.un.org/doc/undoc/gen/n15/291/93/pdf/n1529193.pdf?openelement 2. organización panamericana de la salud. agenda de salud sostenible para las américas 2018-2030: un llamado a la acción para la salud y el bienestar en la región. washington, dc, eua [internet] [cited 2017 sept.]. available from: https://www. paho.org/hq/index.php?option=com_content&view=article&id=13246:health-agenda-americas&itemid=42349&lang=es 3. darzi a, evans t. the global shortage of health workers: an opportunity to transform care. lancet [internet]. 2016 [cited 2019 feb. 10];388(10060): 2576-77. doi:10.1016/s0140-6736(16)32235-8 4. cassiani-silvia hdb, bassalobre-garcia a, reveiz l. acceso universal a la salud y cobertura universal de salud: la identificación de prioridades de investigación en la enfermería en américa latina. rev. latino am. enfermagem [internet]. 2015 dec. [cited 2019 feb.];23(6):1195-1208. doi:10.1590/0104-1169.1075.2667 https://documents-dds-ny.un.org/doc/undoc/gen/n15/291/93/pdf/n1529193.pdf?openelement https://documents-dds-ny.un.org/doc/undoc/gen/n15/291/93/pdf/n1529193.pdf?openelement https://www.paho.org/hq/index.php?option=com_content&view=article&id=13246:health-agenda-americas&itemid=42349&lang=es https://www.paho.org/hq/index.php?option=com_content&view=article&id=13246:health-agenda-americas&itemid=42349&lang=es http://dx.doi.org/10.1016/s0140-6736(16)32235-8 http://dx.doi.org/10.1590/0104-1169.1075.2667 empirical indicators: conceptual and theoretical origins. article empirical indicators: conceptual and theoretical origins indicadores empíricos: orígenes teóricos y conceptuales indicadores empíricos: origens teóricas e conceituais 10.5294/aqui.2021.21.4.4 jacqueline fawcett1 1 0000-0002-1091-8873 department of nursing, university of massachusetts, united states of america. jacqueline.fawcett@umb.edu received: 08/05/2021 sent to peers: 29/09/2021 approved by peers: 21/10/2021 accepted: 21/10/2021 theme: epistemology. contribution to the discipline: this paper advances nursology knowledge by clarifying the meaning and importance of empirical indicators as measures of human beings' health-related experiences. para citar este artículo / to reference this article / para citar este artigo:fawcett j. empirical indicators: conceptual and theoretical origins. aquichan. 2021;21(4):e2144. doi: https://doi.org/10.5294/aqui.2021.21.4.4 abstract this paper discusses the connections between nursing conceptual model concepts, middle-range theory, and situation-specific theory concepts, as well as between the theory concepts and how they are measured, that is, empirical indicators. three types of empirical indicators are described—instruments, assessment tools, and interventions—and an example of each type is given. the paper's central thesis is that a conceptual model concept is —or should be— the starting point for selecting or constructing an empirical indicator. keywords (source mesh): models; theoretical; nursing theories; data collection; surveys and questionnaires. resumen en el presente artículo, se analizan las conexiones entre los conceptos del modelo conceptual, la teoría de rango medio y los conceptos de la teoría de situaciones específicas de enfermería, así como entre los conceptos teóricos y cómo se miden estos, es decir, los indicadores empíricos. se describen tres tipos de indicadores empíricos —instrumentos, herramientas de evaluación e intervenciones— y se da un ejemplo de cada tipo. la tesis central del artículo es que un concepto de modelo conceptual es —o debería ser— el punto de partida para seleccionar o construir un indicador empírico. palabras clave (fuente mesh): modelos; teórico; teorías de enfermería; recopilación de datos; encuestas y cuestionarios. resumo neste artigo, são analisadas as conexões entre os conceitos do modelo conceitual, a teoria de médio alcance e os conceitos da teoria de situações específicas de enfermagem, bem como entre os conceitos teóricos e como estes são medidos, isto é, os indicadores empíricos. são descritos três tipos de indicadores empíricos (instrumentos, ferramentas de avaliação e intervenções) e é dado um exemplo de cada tipo. argumenta-se que um conceito de modelo conceitual é — ou deveria ser — o ponto de partida para selecionar ou construir um indicador empírico. palavras-chave (fonte decs): modelos; teórico; teorias de enfermagem; coleta de dados; pesquisas e questionários. all scholarly work and practice is based on a conceptual-theoretical-empirical (cte) structure. the c component is the abstract and general conceptual model that guides the selection of phenomena for the scholarly work or practice, such as the roy adaptation model (1). the t component is the relatively specific and concrete theory that is the outcome of the scholarly work or the why, when, where, and how of what is done in practice. both conceptual models and theories are made up of concepts, which express ideas about things, and statements, which are definitions of and associations between these concepts. the e component encompasses the design of scholarly work or the practice delivery model; the people who are involved in the scholarly work or practice; how the theoretical concepts are measured, that is, the empirical indicators; the procedures used to administer the empirical indicators; and how the information obtained from the empirical indicators is analyzed (2). the purpose of this paper is to present a discussion of empirical indicators and their connection with the concepts of conceptual models and theories. empirical indicators an empirical indicator is a very concrete and specific real-world proxy for a concept of a middle-range theory or a situation-specific theory (2). the function of empirical indicators is to provide how middle-range theories and situation-specific theories are generated or tested by measuring the theory concepts (3). types of empirical indicators empirical indicators include instruments, assessment tools, and interventions. an instrument, such as an interview guide or a questionnaire, is typically used for scholarly work. an assessment tool is used in practice; the format can be an interview guide, a questionnaire, or a combination of the two. an an intervention is a procedure used to observe or measure a theory concept about what is being done in scholarly work or in practice, such as experimental treatment or a practice protocol. interview guides typically include one or more open-ended items and may include prompts or probes to encourage interviewees to provide additional details about their responses to the open-ended questions. questionnaires include one or more fixed-choice items and various types of rating scales, such as yes/no or a numeric rating scale that usually has descriptors for at least some of the numbers (e.g., 0 = no pain to 10 = worst pain imaginable). rating scales with an even number of rating points are less prone to response set bias than rating scales with an odd number of rating points. response set bias refers to the tendency to select the mid-point or neutral rating point when there is an odd number of rating points. assessment tools can include either or both open-ended items and fixed choice items. the information obtained from empirical indicators is typically called data. data obtained from empirical indicators that are instruments or assessment tools are qualitative words transformed into themes or categories or quantitative numbers transformed into scores. thus, responses to an interview guide made up of open-ended items can be analyzed to yield themes or categories, and responses to questionnaires made up of fixed-choice items can be subjected to mathematical calculations that yield a number or score. examples are given in table 1. table 1. examples of empirical indicators that are instruments or assessment tools types of empirical indicator examples of items and scoring interview guide with open-ended items item: please tell me how you are feeling physically today. scoring: themes or categories are extracted from responses to the item, such as feeling fine, feeling just ok, feeling tired, feeling sick. questionnaire with fixed-choice items item: on a scale of 0 to 10, where 0 means no pain and 10 means worst pain imaginable, how much pain are you feeling right now? scoring. each response is scored as anywhere from 0 to 10. source: own elaboration empirical indicators that are interventions tell the person using them exactly what to do and when, where, and how to implement the intervention. thus, they are protocols or scripts that direct actions in a precise manner. examples are given in table 2. table 2. examples of empirical indicators that are interventions types of empirical indicator examples an experimental treatment a roy adaptation model (1) guided experimental intervention—cognitive stimulation therapy (cst)—was developed by lok and colleagues (4) for people with a medical diagnosis of alzheimer's disease. this empirical indicator was linked to the roy adaptation model concept of cognator coping process. the outcomes of the intervention were linked to the roy adaptation model adaptive modes. lok et al. (4, pp 585-6) explained, "cst consisted of 14 sessions with different themes... the sessions lasted 45 minutes. the introduction, activity, and final sessions lasted 10, 25, and 10 minutes, respectively. the therapy was conducted for 7 weeks (two sessions per week)." the themes for the 14 sessions were physical games, sounds, childhood, food, current affairs faces/scenes, word associations, being creative, categorizing objects, orientation, using money, number games, word games, and team quiz, respectively. lok et al. (4, p585) provided a description of each theme. for example, physical games are described as "the nurse encourages the patients to introduce themselves to the group, mention their favorite team, meal, color, and so forth. supporting the self-perception and playing basketball are also included." a practice protocol seah and tham (5) described a roy adaptation model (1) practice protocol used for care of a young woman (fictional name of julie) with the medical diagnosis of bulimia nervosa. the practice protocol included three parts, each for management of stimuli for a different nursing diagnosis. for example, one part of the practice protocol is the intervention that was management of stimuli for the nursing diagnosis of imbalanced nutrition. the intervention was targeted to restoring a balance of electrolytes and nutrition. seah and tham (5, p139) explained, as julie was placed under the hospital's eating disorder (ed) protocol, the nurse weighed her daily. this ensured that her daily weight was charted for review by the multi-disciplinary team (mdt)... julie had to eat 3 meals daily with 2 snacks that included a protein drink, as a form of nutrition rehabilitation... this was crucial as the main goal was to achieve optimal nutrition and a bmi of at least 18.5 during the course of treatment. she also participated in a lunch group support session, which was facilitated by a nurse who ate with her, while monitoring her eating behavior and duration. this allowed the nurse to note any abnormal eating patterns and feedback to the mdt. when a nurse eats with the client, the client will also learn proper eating habits from the nurse. source: own elaboration practical considerations the length, reading level, and ease of completion should be considered when selecting an empirical indicator. in addition, if the empirical indicator is to be used with people of diverse cultures, translation of the empirical indicator must be considered. length of empirical indicators although no definitive rules are available for the length of empirical indicators, a "rule of thumb" is the shorter, the better, in that fewer items are more likely to be administered or answered by people than more items. noteworthy is that one-item empirical indicators (called single-item indicators) may yield as much information as many-item empirical indicators (6). reading level the reading level of an empirical indicator should be consistent with the literacy level of the people who are administering and responding to the empirical indicator. some methods for determining the reading level of empirical indicators are flesch's (7), fry's (8), and the simple measure of gobbledygook (9). reading level calculators also can be found on the internet; for example, see http://www.readabilityformulas.com/free-readability-formula-tests.php ease of completion an empirical indicator should be easy to complete and analyze the data, which means that the instrument and assessment tool items (open-ended items or fixed-choice items) should be written clearly and concisely, and the response options should be easy to understand. ease of completion can be checked using cognitive interviews prior to administering the instrument or assessment tool to the people who will be asked to respond to it. a cognitive interview is conducted by the person planning to use the empirical indicator with a few (typically 5-10) people who have the same characteristics as the people who will be asked to respond to the empirical indicator. the interviewer may use "probing questions [to] help to identify whether changes in format and presentation might affect the way [people] respond to the [items]" (10, p41). cultural equivalence of empirical indicators fawcett and garity (2) explained that back-translation is a frequently used procedure to translate empirical indicators from one language to another. this procedure involves the translation of the empirical indicator from the language in which it was originally written to another language and then translation from the other language back to the original language. although back-translation may seem to be an adequate method to ensure cultural relevance of an empirical indicator, determining the cultural relevance or equivalence of an empirical indicator requires a great deal of effort to maintain the original meaning of the concept being measured and the words used for each item of the empirical indicator. drawing from flaherty et al. (11), fawcett and garity (2) identified five different types of cross-cultural equivalence for empirical indicators. 1.   content equivalence refers to the relevance of each item to the culture of interest. 2.   semantic equivalence refers to the extent to which the connotative meaning of each item is the same in the original culture and the culture for which the instrument is being translated. 3.   technical equivalence refers to the extent to which the way the data were collected—such as an interview guide or a questionnaire—is similar in each culture. 4.   criterion equivalence refers to the extent to which the interpretation of the data is similar across cultures. 5.   conceptual equivalence refers to the extent to which the same theory concept is measured in each culture. explicit and implicit conceptual-theoretical-empirical connections ideally, each empirical indicator is explicitly connected to a theory concept derived from a conceptual model concept. for example, as shown in figure 1, several inventories of functional status have been designed to measure the theory concept of functional status. the theory concept of functional status, which is defined as the performance of usual and special activities, was directly derived from the roy adaptation model (1, 12) concept of role function adaptive mode, which is defined as the performance of usual and special role activities of living based on the developmental stage of life (1, 12). an example of these inventories is the inventory of functional status after childbirth (13), which measures the functional status of women who have experienced childbirth. figure 1. linkage of an empirical indicator with the theory concept derived from a conceptual model concept however, not all empirical indicators are connected to a theory concept, and not all theory concepts are connected to a conceptual model concept. thus, the user of the empirical indicator must guess what the empirical indicator is measuring, that is, the definition of the theory concept that is supposed to be measured and the connection between the theory concept and a conceptual model concept that initially guided identification of the theory concept. measurement validity the connection of an empirical indicator with a theory concept and the connection of the theory concept with a conceptual model concept are important if measurement validity is to be assured. measurement validity refers to the appropriateness of an empirical indicator as a measure of the theory concept, as that concept is defined (2, 14). the question to be asked is: •     does the empirical indicator measure the theory concept as that concept is defined? fawcett (14) pointed out that a frequently neglected consideration in determining measurement validity is identifying whether the definition of the theory concept measured by the empirical indicator is congruent with the definition of the conceptual model concept that guides the scholarly work or practice. for example, if a theory concept is defined as people's actual performance of role activities, and if the theory concept has been directly derived from a conceptual model concept about the performance of role activities, then an empirical indicator that measures people's ability to perform role activities is not congruent with either the conceptual model concept or the theory concept. various methodological techniques can estimate measurement validity. frequently used methods are content validity and construct validity (2). in the real world of scholarly work and practice, there is a tendency to find an empirical indicator to measure a theory concept of interest and then determine whether the empirical indicator "fits" with a concept of the conceptual model that guides the scholarly work or practice. although creating new empirical indicators is time-con­suming and challenging, measurement validity is more likely to be supported if the starting point is a conceptual model (14). the steps of creating a new empirical indicator rather than searching for an empirical indicator that might be an acceptable fit with the theory concept and the conceptual model concept are listed in table 3. table 3. phases of constructing an empirical indicator phases description phase 1 identify a conceptual model to guide the scholarly work or practice (2, 15) phase 2 derive a theory concept from a concept of that conceptual model (2, 15) phase 3 generate items from the literature that are appropriate measures of the theory concept (15) phase 4 determine measurement validity (13) phase 5 calculate a content validity index based on ratings by a panel of 5 to 10 experts (15) phase 6 conduct cognitive interviews with 5 to 10 people (10, 15) phase 7 administer the empirical indicator to a large number of people (at least 10—30 persons for each item) (2) phase 8 use the data obtained from open-ended interview items to determine estimates of trustworthiness of the empirical indicator, including dependability (e.g., inquiry audit) and credibility (e.g., member checks) (2) use the data obtained from fixed choice questionnaire items to calculate the psychometric properties of the empirical indicator, including internal consistency reliability and construct validity (2) source: own elaboration conclusion in conclusion, a conceptual model concept should be the start of a search for an existing empirical indicator or the development of a new empirical indicator. a theory concept should be directly derived from the conceptual model concept, such that there is a clear and logical connection between the conceptual model and theory concepts. the empirical indicator then should be a precise, logical, and valid measure of the theory concept. conflict of interests: none declared. references 1. roy c. the roy adaptation model. 3rd ed., upper saddle river (nj): pearson; 2009. 2. fawcett j, garity j. evaluating research for evidence-based practice. philadelphia (pa): f. a. davis; 2009. 3. fawcett j, desanto-madeya s. contemporary nursing knowledge. analysis and evaluation of nursing models and theories. 3rd ed. philadelphia (pa): f. a. davis; 2013. 4. lok n, buldukoglu k, barcin e. effects of the cognitive stimulation therapy based on roy's adaptation model on alzheimer's patients' cognitive functions, coping-adaptation skills, and quality of life: a randomized controlled trial. perspect psychiatr care. 2020(3);56:581-592. doi: https://doi.org/10.1111/ppc.12472 5. seah xy, tham xc. management of bulimia nervosa: a case study with the roy adaptation model. nurs sci quart. 2015;28(2):136-141. doi: https://doi.org/10.1177/0894318415571599 6. youngblut j, casper g. single-item indicators in nursing research. res nurs health. 1993;16(6)459-465. doi: https://doi.org/10.1002/nur.4770160610 7. flesch r. a new readability yardstick. j appl psych. 1948;32(3):221-233. doi: https://doi.org/10.1037/h0057532 8. fry eb. a readability formula that saves time. j reading. 1968;11(7):513-516, 578. 9. mclaughlin gh. smog grading-a new readability formula. j reading. 1969;12(8):639-646. available from: https://www.jstor.org/stable/40011226 10. muehlhausen w, byrom b, skerritt b, mccarth, m, mcdowell b, sohn j. standards for instrument migration when implementing paper patient-reported outcome instruments electronically: recommendations from a qualitative synthesis of cognitive interview and usability studies. value health. 2018;21(1):41-48. doi: https://doi.org/10.1016/j .jval .2017.07.002 11. flaherty ja, gaviria fm, pathak d, mitchell t, wintrob r, richman ja, birz s. developing instruments for cross-cultural psychiatric research. j nerv ment dis. 1988;176(5):257-263. doi: https://doi.org/10.1097/00005053-198805000-00001 12. roy c. introduction to nursing: an adaptation model. 2nd ed.. englewood cliffs (nj): prentice-hall; 1984. 13. fawcett j, tulman l, myers st. development of the inventory of functional status after childbirth. j nurse midwifery. 1988;33(6):252-260. doi: https://doi.org/10.1016/0091-2182(88)90080-8 14. fawcett j. thoughts about conceptual models and measurement validity. nurs sci q. 2013;26(2):189-191. doi: https://doi.org/10.1177/0894318413477143 15. waddell a. measuring nurses' health policy participation: wsppir instrument development and psychometric evaluation. j adv nurs. 2021;7700:461-472. doi: https://doi.org/10.1111/jan.14582 home experience of people in mild and moderate stages of alzheimer's disease in spain article experience of people in mild and moderate stages of alzheimer's disease in spain experiencia de personas con alzheimer en fases leves y moderadas en españa a experiência de pessoas com alzheimer na espanha nas fases leve e moderada jorge riquelme-galindo 1 sofía garcía-sanjuán 2 manuel lillo-crespo 3 maria-antonia martorell-poveda 4 1 0000-0002-6010-208x. universidad de alicante, department of nursing, spain. jorge.riquelme@grupohla.com 2 0000-0001-7985-7864. universidad de alicante, department of nursing, spain. sofia.garcia@ua.es 3 0000-0003-2053-2808. universidad de alicante, department of nursing, spain. manuel.lillo@ua.es 4 0000-0002-0309-1812. universidad rovira i virgili, department of nursing, spain. mariaantonia.martorell@urv.cat 10.5294/aqui.2020.20.4.4 received: 05/04/2020 sent to peers: 16/04/2020 approved by peers: 20/08/2020 accepted: 24/08/2020 theme: chronic care contribution to the discipline: despite being aware of their memory loss, people with dementia tend to minimize their memory problems and consider them part of the natural aging process. they choose not to express their feelings to avoid worrying their relatives, who often are their main physical, moral, and emotional support. some of the people with early-stage dementia claim that they have developed strategies to hide their memory loss from close relatives. para citar este artículo / to reference this article / para citar este artigo: riquelme-galindo jr, garcía-sanjuán s, lillo-crespo m, martorell-poveda ma. experience of people in mild and moderate stages of alzheimer's disease in spain. aquichan. 2020;20(4):e2044. doi: https://doi.org/10.5294/aqui.2020.20.4.4 abstract objective: to analyze the meaning of dementia by those affected by it, and to give them a voice. material and methods: descriptive phenomenology through interviews with people of both genders who are over 50 years old and living in tarragona (spain), with a diagnosis of mild or moderate dementia, mainly related to alzheimer's disease. results: three main themes emerged: 1) normalization of memory loss in early stages as part of the natural aging process; 2) self-awareness of progressive memory decline, which is concealed from others, and 3) adaptation processes and strategies to coexist with their condition after diagnosis. conclusions: the most evident features were the lack of specialized infrastructures within the health system in terms of care, prevention programs, and early detection. keywords (source decs): dementia; alzheimer disease; qualitative research; life experience; interviews. resumen objetivo: analizar el significado que adquiere la enfermedad para las personas afectadas por demencia, proporcionándoles voz. material y métodos: aproximación a la fenomenología descriptiva a través de entrevistas a personas de ambos sexos y mayores de 50 años residentes en tarragona (españa) con un diagnóstico de demencia leve o moderada, principalmente enfermedad tipo alzheimer. resultados: surgieron tres grandes temáticas: 1) normalización de la pérdida de memoria en fases incipientes en relación al proceso natural de envejecimiento; 2) autopercepción de que existe un problema de memoria instaurándose que se disimula frente a su entorno y 3) procesos de adaptación y aprendizaje de estrategias para convivir con su condición tras el diagnóstico. conclusiones: la falta de infraestructuras especializadas dentro del sistema sanitario en materia de cuidados, programas de prevención y detección precoz son los aspectos más evidentes remarcados. palabras clave (fuente decs): demencia; enfermedad de alzheimer; investigación cualitativa; acontecimientos que cambian la vida; entrevistas. resumo objetivo: analisar o significado que a doença adquire para as pessoas afetadas pela demência, dando voz a elas. material e métodos: abordagem da fenomenologia descritiva por meio de entrevistas com pessoas residentes em tarragona (espanha) com diagnóstico de demência leve ou moderada, principalmente doença do tipo alzheimer de ambos os sexos e com mais de 50 anos. resultados: surgiram três grandes temas: 1) normalização da perda de memória em fases incipientes relacionadas ao processo natural de envelhecimento; 2) autopercepção de que existe um problema de memória que se esconde do ambiente; 3) processo de adaptação e estratégias de aprendizado para conviver com sua condição após o diagnóstico. conclusões: a falta de infra-estruturas especializadas no sistema de saúde, programas de prevenção e detecção precoce são os aspectos mais evidentes. palavras-chave (fonte decs): demência; doença de alzheimer; pesquisa qualitativa; eventos que mudam a vida; entrevistas. introduction around 50 million people suffer from dementia worldwide, with 10 million new cases diagnosed each year(1). people with alzheimer's disease comprise 2/3 of the total number of people who suffer from some type of dementia(2). this is one of the greatest challenges that our society faces nowadays. in 2020, the estimated worldwide cost of dementia-related health care is over us$ 818 billion, considering the annual increase in the prevalence of people suffering from dementia, which is equivalent to 1.1 % of the domestic product worldwide. this proportion varies between 0.2 % in countries with a medium-low socioeconomic level and 1.4 % in countries with a high socioeconomic level. moreover, it is estimated that by 2030, the cost of health care of people with dementia worldwide will have risen to us$ 2 trillion. this amount could undermine social and economic development globally, and overwhelm health and social care services, specifically, those systems bearing the burden of caring for people in a situation of chronicity(3). this situation will affect spain especially, whose percentage of older population will double by 2050, becoming one of the oldest countries in the world. giving a voice to people who suffer from dementia and changing the approach to their care needs are paramount if we are to improve the quality of care provided and reduce the complications caused by poor management in health services and the global economy(4). awareness campaigns about dementia and the world health organization (who) document on aging and health emphasize the need to empower people with dementia to become active members in their community, instead of more dependent(5). however, the implementation of these campaigns within the reality of each country has been extremely different. in the 1990s, several authors highlighted the relevance of listening to the affected person(6-7) to understand more about the subjective experience of dementia and to develop a holistic approach to person-centered care. although, for some time, it was assumed that collecting information from people with dementia was methodologically difficult and unreliable, due to their cognitive impairment that limited effective reasoning and communication.(8) therefore, studies carried out in that period that focused on how people with dementia felt and coped with their situation adopted an external perspective based on the answers given by caregivers and professionals(9-10). opposite to this perspective, through interviews and data from different sources, other studies offered people with dementia the opportunity to speak about themselves, consequently acknowledging a new perspective and validating the reliability of the subjective responses of people with cognitive impairment, and the significance of the subjective data(11-13). thus, progressively, studies from the perspective of individuals with dementia have been developed, contemplating their individual experience of the disease(14-17). the lack of scientific evidence from biomedical and pharmacological research has also motivated this change of perspective in recent years, focusing on the needs of people with dementia and their experiences. a clear example is an article published in 2018, following the european palliare project,(18) in which seven participating countries, including spain, gave a voice to people with dementia, their relatives, and close professionals. the objective was to determine the conditions in europe and expose the aspects involved in the care of people in an advanced stage of dementia, within the typical context of each nation. this research showed, for the first time in the continent, the experience of care in individuals with dementia through 56 in-depth interviews that assessed six key aspects, namely: 1) dementia/adaptation process; 2) care in dementia; 3) the role of the caregiver; 4) care planning in different stages of dementia; 5) home adaptation for people with dementia; and, 6) essential tools for proper care. despite the differences between nations, there were common needs throughout europe, especially the lack of specific training for professionals and caregivers, as well as the absence of a consensus and a common approach. a european healthcare model based on an individual-centered approach, instead of the traditional biomedical approach, requires a thorough study of the most prevalent diseases and the affected individuals and their environment. this model provides and comprehensive set of data based on evidence and experiences, allowing to develop consensual and holistic strategies and to present them the scientific community(19). as our population grows older, healthcare needs change accordingly, becoming more complex. in europe, relevant data show a slight increase in the age-standardized prevalence of people over 65 with dementia in recent years, around 4.4 %(20). the objective of this article is to analyze what this disease means to the people with mild to moderate stages of dementia, immediately after diagnosis, and to invite them to actively participate in their own care. material and methods we performed this study through a descriptive phenomenology approach(21-22) that reflects the interest on this matter, and captures, describes, and helps understand the investigated subject and their personal experiences regarding their condition (23). the study sample consisted of people of both genders, aged 50 years or more, residents of tarragona (spain), and that had been recently diagnosed (12 months or less) with mild or moderate dementia, mainly alzheimer's disease. the participants have attended alzheimer's family associations and day centers, located in the study area. the first contact was facilitated by professionals (a social worker and nurses) of these institutions. the data was collected through in-depth interviews conducted between march and june 2016. after selecting the participants, a member of the research team called them to explain the characteristics of the study and invited them to participate. an appointment was made with those who agreed to participate. the interviews were conducted either in the participant's home or in the day center, according to their preference. in both locations, researchers created a safe and intimate area for the interviews, which were arranged as per the participant's convenience. interviews lasted between 20 and 50 minutes. a second meeting was held under the same conditions, between 2 to 3 weeks after the first interview. in some cases, a third interview was conducted, also under the same circumstances. the interviews focused on the following areas: routines and activities of daily living, recent changes perceived during those activities, feelings and thoughts regarding the current situation, social life with their partner, family and friends, concerns, and the meaning of the disease. the researchers designed an ad hoc questionnaire to describe the sociodemographic profile of the participants. clinical variables were defined based on the functional status and the activities of daily living using the barthel index and the lawton and brody scale. the spanish version of the quality of life in alzheimer's disease scale was used in the interview with the affected person and their caregiver to understand their quality of life concerning the disease(24-25). finally, six people were recruited, all of them women with a mean age of 74 years. the participants presented indicators of mild to moderate dementia according to the mini-mental state examination (mmse)(26). the global deterioration scale (gds)(27) showed a moderate dependence on activities of daily living and severe dependence on the instrumental activities of daily living. the perception of the quality of life by the participant and their family member was good (see table 1). table 1. participant data interviewee age mmse gds barthel scale lawton and brody scale qol-ad affected person/relative 1 84 23 4 75 3 36/27 2 85 23 4 100 3 29/27 3 88 24 4 80 1 36/35 4 88 24 3 70 1 38/37 5 70 24 3 85 2 32/38 6 60 23 3 65 1 35/27 source: own elaboration qualitative research validity is present both in the systematic process of data gathering and analysis(28). interviews were recorded with an audio device and transcribed verbatim. researchers used the colaizzi method(29) for data analysis, in which units of personal experiences are organized and grouped together, disclosing the phenomenon after several readings and analyzes. the data analysis was carried out at the end of 2019. the interviews were analyzed by the study authors who were in contact by telephone and email. the study authors met on three occasions to discuss and assess the gathered information, thus triangulating the different data. after contrasting the information against the available literature and the conceptual framework, the team refined and agreed on the most relevant data that explain the different themes and subthemes (table 2). we included quotations in the study to illustrate the different themes. table 2. themes and subthemes arising from the interviews themes subthemes 1. normalization of memory loss in early stages related to the natural aging process 1.1 minimizing memory loss 1.2 delay in seeking medical consultation 2. self-awareness of memory decline concealed from their environment 2.1 hiding changes from their environment 2.2 limitations in daily life 2.3 memories from the past 3. adaptation and strategies used to live with their condition after diagnosis 3.1 resignation or adaptation to their current situation 3.2 importance of family support source: own elaboration this study has been approved by the clinical research ethics committee of the hospital universitario sant joan de reus (tarragona, spain). all interested participants and their appointed family member received a written informed consent document describing the characteristics of their participation and the objectives of the study. likewise, they were informed about the confidential nature of the study and their voluntary participation, explaining their right to withdraw from the study at any given time. results theme 1. normalization of memory loss in early stages related to the natural aging process 1.1 minimizing memory loss although the interviewees are aware of their memory loss, they minimize the issue attributing it to the natural aging process. they do not think it is a problem "every year i lose my memory a little, but that is expected at our age" (p01). they also justify for-getfulness as something they have experienced throughout their lives or due to distraction: "sometimes my husband tells me they ran into someone [...] and then explains who that person is and suddenly, i cannot remember, but i always had a hard time remembering people" (p04). "i forget things, but it is because i am not focused, i am not paying attention" (p02). this perception, which is inherent to advanced age, occurs as follows: despite realizing other older persons experience memory loss or forget-fulness, patients consider that their mental health is not affected. "in here, all the older people have some memory loss, but it is normal. i make mistakes sometimes because i am old" (p05). 1.2 delay in seeking medical consultation for our interviewees, it was clear that memory loss was to be expected over time. in fact, they did not consider that "mild forgetfulness" should be communicated to the doctor or even relevant enough to seek medical consultation: "i do go to the doctor, but not because of my brain, which is fine, but because i live alone" (p02), "i did not want to go to the doctor, because i am well; my daughter took me" (p06). they also downplay the issue, stating that they do not have any problem, and accusing others: "i'm great [...] it's the others who say i have a memory problem" (p03). theme 2. self-awareness of memory decline concealed from their environment 2.1 hiding the changes from their environment on some occasions, all the women who participated in the study assured that they were aware of their memory loss, but that they had enough strategies to hide this forgetfulness from their closest relatives: "others don't notice it, but i do" (p02). they fear the possibility of losing their autonomy: "if it takes me a while to get downstairs when they come for me because i forgot to take something, they immediately tell me that i cannot live alone anymore and that i would have to go to a care home" (p04). 2.2 limitations in daily life they are aware that they may have a real problem when they forget important things: "my daughter leaves my clothes ready for me because that way i don't have to worry" (p03), "i don't go shopping anymore, because i would always forget something or couldn't manage money properly. so now, they bring me the groceries" (p02). they also acknowledge that they get disoriented when running errands, but they do not express it explicitly: "they pick me up at home, because i don't like to go by bus" (p06), "i am well here at the center [...] they bring me everything i need, so i can spend more time reading" (p03). 2.3 memories from the past their discourse about their personal and professional life is very clear, however, when it comes to recent events, it is not: ".and i stayed inside the library, which had glass doors and i was always there, reading books [... ] i can't tell you about the news that i read this morning in the newspaper" (p01), "i owned a butcher shop and my aunt would bring us all the clothes [... ] tomorrow, saturday, they will bathe me and then i'll go home... wait, today, tuesday, wednesday ... well, on saturdays." (p04). theme 3. adaptation and strategies used to live with their condition after diagnosis 3.1 resignation and adaptation to their current situation once they become aware of their new reality, they try to adapt and normalize their memory loss to avoid further changes to their life "although it is very variable. i am adapting" (p01). moreover, all the interviewees, to a greater or lesser extent, consciously carry out activities that improve cognitive abilities (reading, studying, discussing current affairs, writing, crocheting, etc.) as part of the adaptation process: " i think reading is key to keeping my head sane" (p01), "and i crochet, even if i don't need it, and then i give them away" (p03). they have also developed routines and strategies: "since i can't remember it, i write down the phone number on the back of the phone and look at it when i need it" (p06), "i always do the same: i get up, go to the bathroom, have breakfast and sit on the sofa to wait for the bell to ring" (p05). 3.2 importance of family support despite trying to prove that they do not have any difficulties, the interviewees emphasize that without family support they would not be autonomous: "my husband takes care of me and my children too; they love me very much" (p04), "my daughter buys my clothes because i can't anymore" (p03), "she [daughter] takes care of the household supplies and i am very happy because there is nobody better than her to take care of me" (p02). also, in all the interviews, they exclaim how lucky they are for their families and that they do not feel alone: "i have lived many years with my husband and with my children and my grandchildren, and always having someone to talk to makes me feel alive" (p01), "my whole family loves me and thinks about me a lot; of course, i have always been there for them" (p06). discussion this study explored the experiences of people suffering from mild to moderate dementia immediately after the diagnosis, which is when it tends to go unnoticed, mainly due to contextual and cultural beliefs, as we have shown. the selected cases were in the range of mild to moderate stages of development. since there is no infrastructure for early detection in the spanish system, many cases are diagnosed during the moderate or intermediate stage of the disease. however, all the participants were taking the first steps, from a chronological point of view, after their diagnosis. the most characteristic and predominant symptom in the different types of dementia is memory loss (30). despite this, our participants attributed their memory loss to the aging process itself. the attribution of symptoms as part of the normal aging process rather than a disease is a coping strategy since normalizing the situation helps to understand and eases suffering(31). furthermore, this social construct is inaccurate, since studies show that there are hardly any memory deficits associated with aging. the degree of impairment is more related to attention and learning disorders rather than with specific alterations(32). also, we need to add that the lack of access and of clinical guidelines in spain causes that many people spend years experiencing a decrease in their cognitive abilities without any type of professional intervention, unlike other european regions such as scotland, where the strategy to approach dementia has been further developed not only at the professional level but also in civil society. failure to recognize memory loss as a symptom of the disease and to normalize the situation result in our interviewees not going to a health center since it is not perceived as a health problem, therefore, delaying the diagnosis(33). these findings coincide with the known framework of other chronic diseases in which people struggle not to lose their health identity. like with any other chronic disease, they assume that dementia threatens their identity, encouraging them to seek balance through coping strategies(34-35). achieving emotional balance and a sense of self is one of the main obstacles they need to endure in the adaptation process of the disease(36). these statements may be intended to assert their well-being and not to seek health care for that deficit. in other similar studies, the interviewed subjects admitted to suffering from memory loss as a symptom of their dementia(37). furthermore, some cases showed that memory loss prevented individuals from remembering their disease during the interview(38). in this study, the authors reflected upon the importance of having watched documentaries and audiovisual resources introducing people with the same diagnosis and how they recognized their memory loss. concerning this, qualitative interviews and participant observation(39), have shown that patients with mild alzheimer's disease deliberately and effectively implement certain strategies to socialize with the environment and to understand the change in their identities and their lives, as a result of the memory decline. according to this author, people with alzheimer are engaged in preserving their personal and social identity, thus explaining their refusal to accept the disease by hiding their memory loss, which coincides with the accounts of our interviewees. people with dementia often speak about past experiences and seem more comfortable holding a conversation about past times instead of recalling more recent events. this process of recalling past personal experiences is called "reminiscence"(40). other authors add that reminiscence is an interaction between the person who remembers the memory and one or more individuals. in parallel, the term "nostalgia" arises, which is described as the longing for things, people, or situations that are not present, or a perceived ideal past(41). throughout our interviews, episodes of reminiscence and nostalgia were frequent, which is characteristic of people with mild dementia. these studies suggest that using reminiscence therapy in patients with dementia helps maintain higher levels of well-being and improves the interaction with healthcare personnel when introducing it as an inclusive, stimulating, and social activity.(42) thus, authors, such as woods, demonstrated in a review carried out in 2005 that reminiscence therapy leads to improvements at the cognitive level, mood, and behavior, as well as a reduction in the burden on the caregiver(43). regarding the signs of memory loss, the interviewees were also aware that they encountered limitations when carrying out activities such as shopping or remembering a scheduled task. recognizing these limitations leads people with mild dementia to feel frustrated because they do not understand what is happening to them. as they do not realize it is a disease, they are unable to determine what cognitive tools are needed to delay the consequences of their dementia(44). another important theme found in the interviews was the relevance of family support during the development of the disease. in spanish culture, family plays a fundamental role in ensuring the well-being of a person suffering from dementia(45). the loss of autonomy to perform basic activities of daily living causes the person to leave their home, sometimes prematurely, due to the risk of injury or inability to satisfy their needs(46). that is why cohesive families with defined roles and with tasks divided between family members ease the caregiver's burden, hence, avoiding overload and exhaustion that negatively impacts the care of the person with alzheimer's(47). these experiences, recounted in the first person, allowed us to understand the crucial aspects when approaching people with some type of dementia from a holistic perspective. similar to the cases in the european palliare study aforementioned, our results suggest that they will only achieve better control over their own lives by increasing the communication channels and allowing them to express themselves whilst they still preserve their communication skills(18). it is of the utmost importance that their demands and wishes are heard while they can still express their rights, such as autonomy and independence, as established by the spanish law. helping them express their own voice in the scientific literature allows this resource to be used as a teaching tool for professional development and for the preparation of guides, protocols, projects, and other scientific articles. conclusion through the analysis of representative cases, this study provides the key to understanding how people with dementia experience alzheimer's disease during mild and moderate stages, immediately after diagnosis, in spain. the step from being unconscious to being aware of the clinical situation and of the social consequences of this disease are highlighted as the most relevant elements. indirectly, the lack of specialized infrastructure within the healthcare system in terms of care, prevention, and early detection programs becomes evident, as well as the insufficient training of professionals and caregivers to deal with an increasing phenomenon. this information can contribute to the design of new resources within the health system directed at the affected individuals, and for developing further awareness about dementia and other neurodegenerative diseases to improve their inclusion in society. limitations although the cases we studied were representative in terms of the period after the diagnosis and the stage of dementia of the participants, we found a limitation of gender and context. however, the outreach of the saturation of data should be noted, considering that there are no substantial differences between the infrastructures available in the different autonomous regions that comprise the spanish health system. therefore, we can extrapolate that the a priori situation should not affect the results obtained in another region of our territory. conflicts of interest: none declared. references 1. organización mundial de 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school of health, university of trás-os-montes e alto douro, portugal. vmcpr@utad.pt doi: 10.5294/aqui.2020.20.1.1 para citar este editorial / to reference this editorial / para citar este editorial rodrigues, vmcp. technology at the service of the elderly. aquichan. 2020;20(1):e2011. doi: https://doi.org/10.5294/aqui.2020.20.1.1 keywords (source: decs) technology; the elderly; delivery of health care; family; robotics. palabras clave (fuente: decs) tecnología; anciano; prestación de atención de salud; familia; robótica. palavras-chave (fonte: decs) tecnologia; idoso; assistência à saúde; família; robótica. año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2011 https://orcid.org/0000-0002-2795-685x mailto:vmcpr@utad.pt https://doi.org/10.5294/aqui.2020.20.1.1 https://orcid.org/0000-0002-2795-685x https://doi.org/10.5294/aqui.2020.20.1.1 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2011 as we all know, aging is a natural process and entails many changes and limitations for people. in this regard, it should be recalled that in 2015 the united nations approved the 2030 agenda for sustainable development whose third objective states that it is necessary to guarantee a healthy life and promote well-being for all at all ages (1). when aging is associated with limitations, they are related to multiple health problems and the consequent search for better healthcare and medical attention by the family/informal caregivers, especially because of care needs and the concern for the elderly’s well-being and quality of life, increases steadily, either if they are at home or in nursing homes. of course, this concerns the elderly, but also their family members (2), and there has been a need for developing new technological systems that enable families and even health professionals to accompany their elderly (3). with this concern, some researchers at university of trás-os-montes e alto douro (portugal) are carrying out two projects in the area of technologies and old people (4), namely, “nie natural interfaces with the elderly” whose main objective is to develop new forms of relationship between the elderly and family/friends in order to reduce loneliness and contribute to a better quality of life, and “ipavpsi impact of a therapeutic plan assistance and surveillance program supported by a sensor network on promoting the health of the dependent elderly at home” whose main objective is to implement several sensors (mobilization, body temperature, humidity, and medication) that help the informal caregiver to fulfill the therapeutic plan. when we mention new forms of relationship, we are talking about telepresence robots that are similar to videoconferencing equipment; however, they have a feature for the user (family/ friends/healthcare professional) to make a call and remotely control the physical displacement of the equipment by taking the robot to where their relative is. at the technical level, the robotic telepresence equipment is usually composed of a screen, a camera, microphones, speakers, and a locomotion system, allowing communication between the two parties. in a pilot study conducted in a nursing home in northern portugal, and with a view to promoting social interaction, decreasing loneliness, and increasing the elderly's quality of life and well-being, calls through the telepresence robot were tested with ten seniors. it was found that the average call duration using the robot was 7.60 minutes, and at the end of the call with the telepresence robot, 70 % of the elderly expressed joy. relatives of these ten seniors who interacted with them through the telepresence robot rated the experience with the robot as “very interesting.” it should also be noted that the workers in this nursing home considered this experience very useful and described it as a “different way of interacting,” “a necessary good,” “a novelty.” they also highlighted the ease with which the “elderly can interact with relatives,” and stated that the elderly would like to continue interacting with their relatives through the robot. regarding the aid and surveillance programs for therapeutic plans supported by a sensor network in promoting the health of the dependent elderly at home, we must be aware that the aging index leads to more chronic diseases and greater dependence by the elderly. many old people have difficulty moving and are often bedridden. immobility produces pathophysiological and musculoskeletal alterations that cause deformities and postural affections, which increases the appearance of pressure injuries (5). if there is no regular care, these changes will affect the quality of life of the elderly, predisposing them to the onset of diseases (6). it should be emphasized that care for the dependent elderly at home is mostly provided by the family and/or informal caregivers. and the caregiver, when assuming the responsibility for this care, faces many difficulties regarding adherence to the therapeutic plans established by the health team (7). at present, we are beginning the informal caregiver's difficulty assessment phase and to test respiration, heart rate, humidity, body temperature, position change, and fall detection sensors with a view to implementing care and surveillance plans of the therapy instituted. at the same time, a web interface will be built where family, informal caregivers, and health professionals can see in real time what is happening to their family member. reflecting on the theme of this article “technology at the service of the elderly,” we note that: i) the ability to communicate by video call and the mobility that is provided by robot control creates a sense of presence on both sides and enhances the well-being of the elderly and family members by cutting the physical distances —normally existing in this context— and fostering social interaction. https://www.linguee.pt/ingles-portugues/traducao/aging+index.html https://www.linguee.pt/ingles-portugues/traducao/aging+index.html 3 technology at the service of the elderly l vitor manuel costa pereira rodrigues these systems help the elderly to overcome the feeling of social isolation and loneliness that affects their physical, mental, and emotional health (3). ii) caring for an elderly person requires that the family/informal caregiver restructure their lives because caregiving also means following the therapeutic plans established by the health team (8). and here, clearly, we can point out the benefits of installing a sensor network, especially because alerts/ alarms can take the form of sounds or written messages for family, informal caregivers, and healthcare professionals, as well as the web interface that allows a real-time 24-hour monitoring of everything that happens to the elderly. iii) telepresence robots, as well as therapeutic plan support and surveillance programs using a sensor network, do not replace or intend to replace the human factor —whether social, family, or health support—, but complement the care for the elderly, which is increasingly relevant to the work that health professionals performs. references 1. united nations. transforming our world: the 2030 agenda for sustainable development, a/res/70/1. united nations; 2015. available from: https://www.un.org/sustainabledevelopment/sustainable-development-goals/ 2. warpenius e, alasaarela e, sorvoja h, kinnunen, m. a mobile user-interface for elderly care from the perspective of relatives. informatics for health and social care. 2015;40(2):113–124. doi: https://doi.org/10.3109/17538157.2013. 879148 3. koceski s, koceska n. evaluation of an assistive telepresence robot for elderly healthcare. journal of medical systems. 2016;40(5):1–7. doi: https://doi.org/10.1007/s10916-016-0481-x 4. school of health and school of science and technology. project saict-pol/24048/2016 “nie natural interfaces with the elderly” and project saict-pol/ 23428/2016 “ipavpsi impact of a therapeutic plan assistance and surveillance program supported by a sensor network. [portugal]: university of trás-os-montes and alto douro; 2018. 5. silva j, santos c, zoche d, argenta c, ascari r. diagnósticos e cuidados de enfermagem para pacientes com risco de lesão por pressão: relato de experiência. brazilian journal of surgery & clinical research. 2017;20(1):98-103. available from: https://www.mastereditora.com.br/periodico/20170905_173650.pdf 6. assis v, vidal a, dias f. avaliação postural e de deformidades em idosos acamados de uma instituição de longa permanência. revista brasileira de ciências do envelhecimento humano. 2015;12(2):123–133. doi: https://doi.org/10.5335/rbceh.v12i2.4926 7. nunes d, brito t, corona l, alexandre t, duarte y. idoso e demanda de cuidador: proposta de classificação da necessidade de cuidado. revista brasileira de enfermagem. 2018;71(suppl2):897–904. doi: http://doi.org/10.1590/00347167-2017-0123 8. monteiro mj, barroso i, rodrigues v, soares s, barroso j, reis a. designing and evaluating technology for the dependent elderly in their homes. in: antona m, stephanidis c, editors. part of the lecture notes in computer science book series (lncs, volume 11573). 2019. pp. 506–510. doi: https://doi.org/10.1007/978-3-030-23563-5_40 https://www.un.org/sustainabledevelopment/sustainable-development-goals/ https://doi.org/10.3109/17538157.2013.879148 https://doi.org/10.3109/17538157.2013.879148 https://doi.org/10.1007/s10916-016-0481-x https://www.mastereditora.com.br/periodico/20170905_173650.pdf https://doi.org/10.5335/rbceh.v12i2.4926 https://doi.org/10.5335/rbceh.v12i2.4926 http://doi.org/10.1590/0034-7167-2017-0123 http://doi.org/10.1590/0034-7167-2017-0123 https://doi.org/10.1007/978-3-030-23563-5_40 reducing work-related stress in nursing personnel: applying an intervention article reducing work-related stress in nursing personnel: applying an intervention* reducción del estrés laboral en profesionales de enfermería: aplicación de una intervención** redução do estresse laboral em profissionais de enfermagem: aplicação de uma intervenção*** 10.5294/aqui.2021.21.3.4 márcia daiane ferreira da silva1 fernando lopes e silva-júnior2 maria lucia do carmo cruz robazzi3 márcia teles de oliveira gouveia4 1 0000-0003-1938-7201. universidade federal do piauí, brasil. marciaferreira@ufpi.edu.br 2 0000-0002-0273-6738. universidade federal do piauí, brasil; universidade federal do delta do parnaíba, brasil. fernando.lopes@ufpi.edu.br 3 0000-0003-2364-5787. escola de enfermagem de ribeirão preto, universidade de são paulo, brasil. avrmlccr@eerp.usp.br 4 0000-0002-2401-4947. universidade federal do piauí, brasil. marciateles@ufpi.edu.br * este artigo se deriva da tese de mestrado intitulada "redução do estresse laboral em profissionais de enfermagem", apresentada ao programa de pós-graduação em enfermagem da faculdade de enfermagem da universidade federal do piauí, brasil. * este artículo se deriva de la tesis de maestría "redução do estresse laboral em profissionais de enfermagem" presentada al programa de posgrados en enfermería de la facultad de enfermería de la universidade federal do piauí, brasil. * este artigo se deriva da tese de mestrado intitulada "redução do estresse laboral em profissionais de enfermagem", apresentada ao programa de pós-graduação em enfermagem da faculdade de enfermagem da universidade federal do piauí, brasil. received: 22/09/2020 submitted to peers: 10/11/2020 accepted by peers: 09/06/2021 approved: 06/08/2021 theme: evidence-based practice. contribution to the subject: educational interventions are key in favoring changes in nurses' stances towards research. therefore, this study proposes a new approach to the management of stress among nursing personnel through a novel, innovative and consistent proposal in the scientific community. para citar este artículo / to reference this article / para citar este artigo: silva mdf, gouveia mto, silva-júnior fl, robazzi mlcc. reducing work-related stress in nursing personnel: applying an intervention. aquichan. 2021;21(3):e2134. do https://doi.org/10.5294/aqui.2021.21.3.4 abstract objective: to compare the levels of ex-post-facto stress between nursing personnel who participated in an educational intervention with nursing personnel on work duties, within the hospital work environment. materials and method: this was an observational and cross-sectional study. the final sample was composed of 30 nursing personnel, with 15 of them composing the group exposed to the intervention and 15 being selected by simple random sampling to compose the unexposed group. the intervention consisted of a program focused on the employees, structured in four sessions, applied in a course format twice a week, and lasted two months. the student's t-test for independent samples and the mann-whitney u-test were used to compare the groups. results: using the mann-whitney u-test, the stress levels could be compared between the groups, and a statistical difference in stress levels was observed between the control group (3.34 ± 0.71 a.u.) and the intervention group (2.52 ± 0.59 a.u.) (p = 0.002; d = 1.26). conclusions: comparing the general stress levels between the groups, it was found that the intervention significantly decreased the stress levels in the participants; it was also possible to identify the mental stressors faced by the participants using the scale of stress in professionals. keywords (source deos/mesh): psychological stress; occupational stress; occupational health; intervention; mediation analysis; nursing. resumen objetivo: comparar los niveles de estrés ex-post-fact entre los profesionales de enfermería en el ambiente del trabajo hospitalario participantes de intervención educativa con profesionales de enfermería en actividades laborales. materiales y método: estudio observacional y transversal. la muestra final se compuso por 30 profesionales de enfermería, de la que 15 profesionales compusieron el grupo expuesto a intervención y 15 se seleccionaron por muestreo aleatorio para componer el grupo no expuesto. la intervención consistió en un programa, con enfoque en el trabajador, estructurado en cuatro sesiones, aplicado en formato de curso, con periodicidad quincenal y duración de dos meses. en la comparación entre los grupos, se utilizaron la prueba t de student para amuestras independientes y la prueba u de mann-whitney. resultados: por medio de la prueba u de mann-whitney, se puede comparar el nivel de estrés entre los grupos, en el que se observó diferencia estadística del nivel de estrés entre el grupo control (3,34 ± 0,71 u.a.) y el grupo intervención (2,52 ± 0,59 u.a.) (p = 0,002; d = 1,26). conclusiones: comparando el nivel de estrés general entre los grupos, se constata que la intervención disminuyó significativamente el nivel de estrés en los profesionales; se logró aun identificar los estresores mentales de los profesionales por medio de la escala de estrés en profesionales. palabra clave (fuente deos/mesh): estrés psicológico; estrés laboral; salud laboral; intervención; análisis de mediación; enfermería. resumo objetivo: comparar os níveis de estresse ex-post-fact entre os profissionais de enfermagem no ambiente do trabalho hospitalar participantes de intervenção educativa com profissionais de enfermagem em atividades laborais. materiais e método: estudo observacional e transversal. a amostra final foi composta por 30 profissionais de enfermagem, da qual 15 profissionais compuseram o grupo exposto à intervenção e 15 foram selecionados por amostragem aleatória simples para compor o grupo não exposto. a intervenção consistiu em um programa, com foco no trabalhador, estruturado em quatro sessões, aplicado em formato de curso, com periodicidade quinzenal e duração de dois meses. na comparação entre os grupos, foram utilizados o teste t de student para amostras independentes e o teste u de mann-whitney. resultados: por meio do teste u de mann-whitney, pode-se comparar o nível de estresse entre os grupos, no qual se observou diferença estatística do nível de estresse entre o grupo controle (3,34 ± 0,71 u.a.) e o grupo intervenção (2,52 ± 0,59 u.a.) (p = 0,002; d = 1,26). conclusões: comparando o nível de estresse geral entre os grupos, constata-se que a intervenção diminuiu significativamente o nível de estresse nos profissionais; foi possível ainda identificar os estressores mentais dos profissionais por meio da escala de estresse em profissionais. palavras-chaves (fonte deos/mesh): estresse psicológico; estresse ocupacional; saúde do trabalhador; intervenção; análise de mediação; enfermagem. introduction the number of studies in the scientific literature regarding the negative impacts of psychosocial factors on the onset of stress in the work environment, health, and well-being of employees is growing (1). in the nursing field, the literature expresses the onset of work-related stress for reasons intrinsic to the physical environment, conflicts with other healthcare providers, overload, and demands stemming from the work environment (2). as common as it may seem, the theme of stress in the workplace and how healthcare providers cope with it, nursing personnel act with little to no awareness of the stress they cope with during their work routine. consequently, a lack of knowledge exists regarding the stress process, which is essential for adequate coping, otherwise, stress may lead employees to physical and emotional exhaustion (3). in this context, the stress in the workplace can be understood as a strain on the human being's dynamic balance generated due to changes occurring in the work environment (4). this instability generated, in turn, can develop a pattern of cognitive, behavioral, or physiological emotional responses, which are toxic and adverse components of the work content, resulting in low performance, low morale, high turnover, absenteeism, and violence in the workplace (5). individual responses on how to cope with stress in the workplace in a healthy way can minimize the negative impacts of working conditions and organization and, consequently, reduce the risk of disease. as a result, interventions for the management of occupational stress that aim to promote healthy coping procedures have been under development (6). currently, researchers have been searching for the development and implementation of interventions to mitigate the pain suffered by nursing personnel (7). for these situations, interventions have been developed with the purpose of reducing symptoms of depression, anxiety, and stress, as well as improving the general well-being, without requiring medical consultation or medication interventions (8). among these interventions, there are programs of prevention and/or reduction of stress and/or burnout management. these programs can be structured with the combination of more than one intervention and with strategies that seek to minimize the effects of stress on the employees' health. these programs are developed through interventions that aim to improve interpersonal relationships in the work environment or organizational interventions, which aim to provide changes in the personal context and, consequently, in the occupational environment (9). the literature points out that interventions with combined approaches that use more than one technique produce better effects on work-related stress and contribute to mentally healthy work environments (10). however, there is no guidance to date as to which interventions provide the best combination and balance; there is only guidance as to which intervention to use for a particular audience, for instance: nonspecific population (universal prevention), high-risk population (selective prevention), or for those presenting emergent symptoms (indicated prevention) (11). in light of the above, the existence of means that enable the prevention and/or reduction of occupational stress is of utmost importance within the work environment, thus influencing the physical and mental well-being of nursing personnel, as well as providing improvements in their performance, motivating the assistance provided by them to patients. the null hypothesis was that the intervention does not decrease stress in the work environment of nursing personnel, and the alternative hypothesis was that the intervention decreases stress levels in the work environment of nursing personnel. finally, the objective of this study was to compare the levels of ex-post-facto stress between nursing personnel who participated in an educational intervention with nursing personnel on work duties, within the hospital work environment. materials and methods this is an observational, cross-sectional, ex-post-facto study. the final convenience sample was composed of 30 nursing personnel working at a university hospital. the participants were informed of the study at their workplace regarding the pre-test application period, which was considered enrollment for the course (intervention), as well as the starting date of the intervention and the post-intervention date; the post-test was applied only to participants who reached at least 75 % of participation in the intervention. between april and may 2019, the pre-test (application of the sociodemographic form, general work stress scale gwss) was carried out; then, the dates for the application of the course, which was held from may to july, were announced. in august, upon verification of the participants, those who had participated in the interventions were recruited to perform the post-test (filling out the gwss again) one month after the last day of the intervention. during the pre-test application, 132 healthcare providers were interested in participating and all of them filled out the sociodemographic form and the gwss. from these providers, 45 attended the course and 15 met the minimum requirement of 75 % participation, which composed the exposed group (eg) to the intervention; for the composition of the non-exposed group (neg), 15 nursing personnel were selected from the use of a simple random sampling technique among the 87 participants who did not participate in the intervention, but who voluntarily took the pre-test and continued with their work activities. only 15 participants were selected to compose the sample so that it would be homogeneous. the intervention proposal was based on the psychoeducational group approach (12) aimed at managing stress stemming from work-related situations and, despite being a well-known approach, no instances of these interventions applied to nursing personnel in their work environments can be found in the literature; therefore, this intervention, set up in a course format in order to increase the participants' interest, is unprecedented within the nursing field. aiming to allow a greater number of healthcare providers to participate in the intervention, we have applied the intervention in the form of a course entitled "prevention and management of stress in nursing personnel"; it was structured in four sessions, it was held every two weeks and lasted for two months. the meetings were held in the institution's auditorium, in order to provide easy access, comfort, and privacy to the participants. the sessions were held in the morning and afternoon shifts, during the workday, with each meeting lasting an hour. the intervention was carried out by the main researcher, and specialized professionals were invited to minister each session; in the first session, the work agreement, self-diagnosis, and coping strategies were addressed, which were carried out by the main researcher; in the second session, which was on compassion fatigue, the invited nurse presented the theme "compassion for patients who are suffering" to open the discussion; in the third session, stress management, and relaxation techniques were presented, as well as the physical activity itself, and there was a practical self-massage class; finally, the last session was carried out by a psychologist who presented the theme "social skills training". the inclusion criteria established were nursing personnel who had been working for more than six months in direct or indirect patient care during the data collection period; the exclusion criteria were nursing personnel who were on leave or vacation during the data collection period. to analyze the level of stress experienced by these healthcare providers, the gwss, which presents psychometric characteristics, was used. the gwss avoids making separate evaluations and considers the individual's perception, which meets the criticism regarding approaches that focus on stressors or reactions in isolation and, therefore, fills some gaps in existing instruments for evaluating occupational stress (13). the gwss consists of 23 items, and for each question, individuals must choose one of the following five options: 1 strongly disagree; 2 disagree; 3 partially agree; 4 agree; 5 strongly agree. the higher the overall average, the higher the level of stress. the instrument is composed of the following dimensions: "autonomy/control", "roles and work environment", "relationship with the boss", "interpersonal relationships" and "growth and appreciation . through the gwss, it is possible to calculate the average for each item on the scale, thus finding an indicator that will vary between 1 and 5. the higher the average, the greater the stress associated with the factor related to the question. a value for the average equal to or higher than 2.5 should already be understood as an indicator of considerable stress. therefore, the average of the responses for each of the questions enables the evaluation of the most prevalent stressors, according to the employees' perception. the dimensions of the gwss were investigated using student's t-test for independent samples to analyze the dimensions named "autonomy/control", "roles and work environment", "relationship with the boss", and "interpersonal relationships". the mann-whitney u-test was used for the "growth and appreciation dimension due to the existence of outliers in the intervention group. the data collected in this study were recorded by a double entry in excel spreadsheets and later processed by the statistical package for the social sciences (spss, version 20.0). in the descriptive analysis, the qualitative variables were distributed in absolute (n) and relative (%) frequency, and the quantitative variables in medians and interquartile ranges. in the inferential analysis, data distribution was verified using the shapiro-wilk test, in which the variables "time of admission and "workload in other institutions of the control and intervention groups did not present normal distribution. for the classification of the occupational stress level of the research group, from the data survey, the providers' perceptions obtained through the gwss were evaluated by the points attributed to calculate the averages defined by paschoal and tamayo (13). when the distribution of these variables was verified, both the overall score and the domains presented normal distribution in the control group (cg) and in the intervention group (ig), except for the domain "professional growth and appreciation , which was not normally distributed in the intervention group. as a result, the overall score, even with normal distribution, presented outliers in the intervention group. in the comparison of stress between the groups, the student's t-test for independent samples was used for the variables "autonomy , "work environment , and "relationship with the boss , and the mann-whitney u-test for the general stress score and "professional growth and appreciation for the non-parametric data, with a significance level of p < 0.05 for two-tailed hypothesis tests. in addition to statistical significance, it was attempted to calculate the effect size using cohen's d. this measure was selected since it is a common measure of effect size for several types of tests or when the samples of the two groups are similar beyond clinical significance (14). calculating effect size, besides the advantage of not depending on sample size, informs the significance of the results and is a common metric for comparing results from different studies (15). this study was approved by the research ethics committee of the universidade federal do piauí, under legal opinion no. 3,169,631. the nursing personnel who met the inclusion criteria were individually invited to participate in the study, upon clarification of its objectives, methods, and purpose. those who agreed to participate signed the free and informed consent form and responded to the other instruments in their own work environment. results regarding participant characterization, the cg was composed of 10 nurses and 5 nursing technicians, 80 % of them were female, adults (34 ± 34-41 years old), and 66.7 % were married. the ig was also composed of 10 nurses and 5 nursing technicians, adults (37 ± 34-40 years old), of which 93.3 % were female; regarding marital status, 60 % were married. regarding the employment profile of these healthcare providers, 67.7 % of the cg employees were employed in other jobs, while 86.7 % of the ig employees were employed in other jobs. among those who were employed in more than one job in the cg, 40 % worked 30 hours a week, and in the ig, 33.3 % worked 30 hours. concerning the length of time of employment in the institution where the study was carried out, a median of five years was obtained in both groups. the following is the comparison of the stress levels of nursing personnel in the cg and ig assessed by the gwss. figure 1. the general mean of stress of the neg and eg assessed by the gwss. brazil, 2019 (n = 30). source: own elaboration. through the mann-whitney u-test, the level of stress between the groups could be compared, and a statistical difference in stress levels was observed (u = 40.500, p = 0.002). based on this result, the intervention reduces stress levels in the work environment, thus the alternative hypothesis is considered. table 1 below presents the mean for each dimension of the gwss between the eg and neg. table 1. comparison between the control and intervention groups concerning the dimensions of the gwss among nursing personnel. brazil, 2019 (n = 30).   eg (n = 15) neg (n = 15) p-value cohen's d m ± sd* m ± sd     autonomy** 3,82 ± 0,50 2,86 ± 0,67 p < 0,001 1,62 roles and work environment** 3,33 ± 0,75 2,44 ± 0,75 p = 0,003 1,18 relationship with the boss** 3,24 ± 1,04 2,45 ± 0,81 p = 0,029 0,84 interpersonal relationships** 2,91 ± 1,01 2,56 ± 0,71 p = 0,274 0,40 growth and appreciation*** 3,07 ± 0,95 2,25 ± 0,78 p = 0,023 0,94 *standard deviation; **student's t-test; *** mann-whitney u-test source: own elaboration. discussion it is noteworthy that this study stems from a master's thesis, in which the null hypothesis was that the intervention program does not reduce the stress levels in the nursing staff's work environment, and the alternative hypothesis was that the intervention program reduces the stress levels in the nursing staff's work environment. it was verified that the level of stress decreased significantly (p = 0.002), rejecting the null hypothesis and confirming that the intervention decreased the stress levels in these nurses' work environments. in the evaluation of the staff members' stress levels, the items composing the gwss are employee-oriented, presenting questions that evaluate the major stressors in the work environment based on the employees' perception, as the following items, for instance: "the lack of communication between me and my coworkers makes me angry"; "i get in a bad mood for having to work many hours in a row ; and the "type of control existing in my job makes me angry . the main stressors that affect nursing personnel, ordered from highest to lowest level of consensus, are work overload, frequent interruptions during the execution of their tasks, the performance of different tasks simultaneously, working during the night shift, and insufficient time to provide emotional support to patients (16). when comparing the gwss scores between the cg and the ig, it was found that the stress levels decreased significantly, which confirms that the intervention decreased the stress levels in these employees' work environments. however, the literature points out that in small samples, the p-value may not be significant, regardless of how large the sample size may be (15); in turn, the large effect size (d= 1.26) demonstrates the significance of this result allowing comparison with other studies. these findings contribute to knowledge regarding combinations in multimodal interventions, as there is no guidance as to which interventions can best be combined and balanced, only those that can be targeted to a nonspecific, high-risk population or to those with emergent symptoms (11). the results, if positive, may highlight its relevance, since no national studies were found that evaluated the combination of mental health and educational interventions, even though these are low in individual and social costs, associated with work-related stress in nursing personnel. in the "autonomy/control dimension of the gwss, lower values of stress levels and large effect size were observed, which are important facts, since autonomy is highly requested by nursing personnel, especially nurses. it is worth noting that the roles of nurses, nursing technicians, and nursing assistants are defined in decree no. 94.406/1987, which regulates law no. 7.498/1986, concerning the professional practice of nursing. the duties of nurses are defined in articles 8 and 9 of this decree, while the duties of nursing technicians are defined in article 10, and those of nursing assistants in article 11 (17). historically, nurses have sought their own identity within the nursing team, in a professional context hardly recognized by society and sometimes marginalized, including by the patients themselves (18). in a study carried out with nursing personnel working at a public general hospital that analyzed the association between occupational stress, quality of life at work, and factors associated with it, it was observed that nurses, nursing technicians, and nursing assistants in active work presented a higher prevalence of dissatisfaction with the quality of life than those in passive work. this demonstrates that even a high level of control, especially of nurses who are granted more autonomy to make decisions regarding their own work, is sometimes not able to suppress the negative aspects provided by high demand, which is characterized mainly by the disproportionality between the number of patients and nursing personnel (2). moreover, it is worth emphasizing the relationship between autonomy and responsibility, since work has been recognized as an important factor of illness, triggering and increasing the incidence of mental disorders (19). therefore, theoretically, the measure of autonomy, pressure, and freedom to use abilities in daily life can represent greater responsibility, which resonates negatively in these staff members' professional lives (20). despite this fact, the stressor included in the scale "i feel irritated with the deficiency in the disclosure of information regarding organizational decisions draws attention since, even with the significant decrease, the stress levels remain high. it is noteworthy that situations in the work environment that demand a greater work effort than a professional's capacity to perform can be perceived as stress triggers since the employee may experience a feeling of incompetence and lack of control over the situation. the existence of poorly defined responsibilities also causes stress, since it makes it impossible for nurses to make decisions (21). it is essential for nursing personnel to be aware of their rights and duties, which are protected by resolutions issued by the federal council of nursing so that they can better understand their responsibilities and try to prevent the onset of stress. in turn, the stressor "i get irritated with discrimination/favoritism in my work environment is still high. similar data was found in another study that used the gwss, the point being that discrimination and favoritism issues are related to the antisocial behavior of people in organizations, with the intention of harming colleagues and the organization itself (22). concurrently, the work performed by nursing personnel is mostly considered rewarding and a source of pleasure and well-being. however, the lack of appreciation can lead them to go through a stressful factor (23). consequently, the work performed by professionals under these circumstances can become mechanical since they are unmotivated, harming both the professionals themselves and patients. moreover, the lack of recognition causes feelings of inferiority, low self-esteem, loss of enthusiasm, and inability to build bonds (24). in a study carried out with a qualitative approach, nursing personnel working at a philanthropic oncology hospital in the north of paraná, brazil, summarized the interpersonal relationships with the "lack of commitment of the workgroup words of the staff members (25). the study that identified the main occupational factors which were the most stressful affecting nursing personnel in the medical units of a general university hospital in murcia demonstrated that the lack of interpersonal relationships was considered one of the most stressful factors (17). a study (26) highlighted that nursing personnel considers their work environment more stressful due to interpersonal relationships among the multi-professional team, communication with patients and family members, administrative management, and human resources. the nursing team is inserted in a professional environment (hospital) as an indispensable component in the provision of care; however, relationship difficulties within the team can hinder the progress of the care process, in addition to rendering the work environment unpleasant. interpersonal relationships in the nursing team may either be a contributing or disturbing factor in the work environment, causing positive or negative consequences for both healthcare providers and patients (27). the relevance of this data is highlighted, since the lack of professional growth perspectives combined with low wages are determining factors for dissatisfaction at work, which can lead to an increase in absenteeism, professional turnover, and physical and emotional wear of that team, directly interfering with the quality of services provided. in this era where knowledge and innovation are valued, human capital is the most valuable asset in organizations. in this sense, attention is drawn to the need for actions to promote well-being and prevent diseases through programs developed by the institutions' occupational health services, aiming to encourage the adoption of healthy behaviors by staff members (19). it is noteworthy that the stressor "the few perspectives of career growth have left me distressed causes high stress levels in the control group participants (m = 4.33); however, the staff members who participated in the intervention presented moderate stress levels (m = 2.80), demonstrating that the approaches applied in the intervention can improve these staff members' perspective on their profession and, possibly, reduce their stress levels. the recognition of staff members starts within the hospital where their activities are performed; when the hospital management encourages them, it demonstrates the importance of their work and promotes an environment that enables the improvement of the work process, allowing the staff to be encouraged to improve their work with each passing day. in turn, the staff members, when well cared for, transfer the appropriate assistance to patients with more enthusiasm (28). valuing nursing personnel implies including them in the definitions regarding the operation of healthcare organizations, decentralizing decisions, and increasing the possibility of control over their own work and its demands, effectively improving working conditions and identifying the elements and factors that interfere in the generation of the employees' health (29). it is worth noting the institution's importance in providing activities implemented by the managers that increase the healthcare team's feelings of appreciation. it is noteworthy that the absence of adequate prevention of occupational diseases leads to profound negative effects, not only for employees and their families but also for society. despite the contributions of this study, limitations are acknowledged, such as the loss of participants, the convenience sampling technique of the cg, and so on. therefore, the generalization of the results to other units may not be possible. the use of a nationally produced data collection instrument limits discussion with the international scientific literature. finally, the cross-sectional design, which allows the analysis of associations between variables, without establishing causality relationships, is yet an­other limitation. however, these conclusions may be the basis for new studies nationally and perhaps internationally. a relevant contribution was the approval of the program's continuity for execution as an extension project in the hospital; thus, it contributes not only to the nursing field but also to other employees working in this hospital. this achievement will enable the improvement of the intervention used, along with the long-term evaluation of the effects of the intervention on the staff members. conclusion it was possible to identify the stressors in nursing personnel working at a university hospital through the use of the gwss. comparing the level of general stress between the cg and the ig, it was found that the intervention significantly decreased the level of stress in these staff members. it is noteworthy that, despite the statistical significance in most dimensions, some stressors still remained at high levels. however, only in the dimension "interpersonal relationships no statistical significance was found, yet, it presented a medium effect size, which, for clinical evidence, becomes relevant. the main stressors identified were deficient training for a professional qualification, deficient disclosure of information concerning organizational decisions, discrimination and favoritism in the work environment, competition in the organizational environment, and limited prospects for career growth. it is known that professionals subjected to low levels of stress work more efficiently; in addition to the better quality of life and the well-being enjoyed by these staff members in more favorable conditions, this also benefits patients through improved quality of care. therefore, it is possible to reflect upon the reasons why nursing personnel experience work-related stress, as well as to alert the institution's management teams. conflict of interest: none 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10.5294/aqui.2021.21.2.4 elizabeth a rosser1 1 0000-0002-2548-4924. bournemouth university, england. erosser@bournemouth.ac.uk recibido: 12/03/2021 enviado a pares: 18/03/2021 aceptado por pares: 06/04/2021 aprobado: 28/04/2021 theme: evidence-based practice contribution  to  the  discipline: it is important to highlight the responsibility that nurses with a ph.d. qualification have to promote innovation in practice and stimulate other professionals to use practice based on scientific evidence, as well as generate contributions to health policies, maintaining critical and creative thinking in the solution of problems. para citar este artículo / to reference this article / para citar este artigo: rosser ea. reflections: the responsibility of doctoral nurses to lead a change in practice. aquichan. 2021;21(2):e2124. doi: https://doi.org/10.5294/aqui.2021.21.2.4 abstract this paper aims to consider the responsibilities of doctoral nurses to lead changes in practice through a very personal reflection of over 52 years in nursing. the reflective learning moves from an early training experience where i learned to ‘do’ to becoming a nursing professor with a doctoral qualification and an ‘evidence-based doer.’ the change witnessed has been considerable. as the highest educated professional, i have learned that doctoral nurses are responsible for leading and directly influencing clinical practice, either as a practitioner, an educator, or a researcher. they are capable of encouraging the development of critical thinking skills and helping practitioners to be curious, take risks with ideas, identify gaps in the evidence base, and be creative in their problem-solving. if the strategic vision for nurses globally is to provide the best quality of patient care, then evidence-based practice is key to leading from the head, hand, and heart. doctoral nurses understand the patient benefits of a high staff-to-patient ratio and having a critical mass of university qualified nurses and must strive to influence policy to this effect. as each country, particularly in latin america, develops a critical mass of doctorally qualified nurses, then they can harness their innovation, create new ways of working, attract them back into practice, and strengthen their political voice to lead strategic change. doctoral nurses must develop their leadership skills and their confidence to lead. they have a responsibility to realise their potential and identify the opportunities to really make a difference. keywords (source decs): leadership; practical nursing; nursing education; graduate education; nursing; nurse practitioners; evidence-based practice. resumen el presente artículo tiene como objetivo considerar las responsabilidades de las enfermeras con doctorado de liderar cambios en la práctica a través de una reflexión muy personal de mis más de 52 años de experiencia en enfermería. el aprendizaje reflexivo transita de una experiencia de formación temprana en la que aprendí a “hacer” a convertirme en una profesora de enfermería con un título de doctorado y en una enfermera que actúa “con base en la evidencia”. el cambio que he observado ha sido enorme. como profesional con el más alto nivel educativo, he aprendido que las enfermeras con doctorado son responsables de liderar e influir directamente en la práctica clínica, ya sea como practicantes, educadoras o investigadoras, pues son capaces de fomentar el desarrollo de habilidades de pensamiento crítico y de ayudar a las practicantes a ser curiosas, a tomar riesgos en las ideas, a identificar lagunas en la evidencia y a ser creativas en la resolución de problemas. si la visión estratégica de las enfermeras a nivel mundial es brindar la mejor calidad de atención al paciente, entonces la práctica basada en la evidencia es clave para liderar desde la cabeza, la mano y el corazón. las enfermeras con doctorado comprenden los beneficios de contar tanto con una alta proporción de personal por paciente como con una masa crítica de enfermeras con título universitario y, por lo tanto, deben esforzarse por influir en las políticas para este fin. a medida que cada país, en particular en américa latina, desarrolla una masa crítica de enfermeras con doctorado, puede aprovechar su innovación, crear nuevas formas de trabajo, atraerlas nuevamente a la práctica y fortalecer su voz política para liderar el cambio estratégico. las enfermeras con doctorado deben desarrollar sus habilidades de liderazgo y su confianza para liderar, puesto que tienen la responsabilidad de desarrollar su potencial e identificar las oportunidades para marcar la diferencia. palabras clave (fuente decs): liderazgo; enfermería práctica; educación en enfermería; educación de postgrado; enfermería; enfermeras practicantes; práctica clínica basada en la evidencia. resumo o objetivo deste artigo é identificar as responsabilidades das enfermeiras com doutorado de liderar mudanças na prática por meio de uma reflexão pessoal com base nos meus 52 anos de experiência em enfermagem. a aprendizagem reflexiva transita de uma experiência de formação precoce na qual aprendi a “fazer”, a me tornar uma professora de enfermagem com título de doutorado e uma enfermeira que atua com base na evidência. a mudança que venho observando é enorme. como profissional com mais alto nível educacional, aprendi que as enfermeiras com doutorado são as responsáveis por liderar e influenciar diretamente a prática clínica, seja como profissionais da saúde, seja como educadoras ou pesquisadoras, pois são capazes de fomentar o desenvolvimento de habilidades de pensamento crítico e de ajudar as profissionais da saúde a serem curiosas, a correr riscos com suas ideias, a identificar lacunas na evidência e a buscar solução de problemas. se a visão estratégica das enfermeiras no âmbito mundial é oferecer melhor qualidade de atenção ao paciente, então a prática baseada na evidência é fundamental para liderar a partir da cabeça, da mão e do coração. as enfermeiras com doutorado compreendem os benefícios de contar tanto com uma alta proporção de pessoal por paciente quanto com um corpus crítico de enfermeiras com título universitário e, portanto, devem se esforçar por influenciar as políticas para esse objetivo. à medida que cada país, em particular na américa latina, desenvolve um corpus crítico de enfermeiras com doutorado, pode aproveitar sua inovação, criar formas de trabalho, atraí-las novamente para a prática e fortalecer sua voz política para liderar a mudança estratégia. as enfermeiras doutoras devem desenvolver suas habilidades de lideranças e sua confiança para liderar, visto que têm a responsabilidade de desenvolver seu potencial e identificar as oportunidades para fazer a diferença. palavras-chave (fonte: decs): liderança; enfermagem prática; educação em enfermagem; educação de pós-graduação; enfermagem; profissionais de enfermagem; prática clínica baseada em evidências. introduction having celebrated 52 years in nursing, i reflect on my nursing career and observe how nursing has come of age. in the space of my lifetime, many countries have moved to becoming a degree qualification as compulsory for professional nursing. additionally, there are many master’s and doctoral qualified nurses across the world with most countries now offering them positions as professors of nursing at the highest academic level of the university, once they have achieved the requirements for such a role. this is indeed progress and unheard of when i commenced my training. nevertheless, many countries still organise their healthcare with few professional nurses supervising a mostly unqualified workforce. therefore, as nursing practice attempts to keep abreast of the scientific and technological changes, education to lead is key to ensure that nursing practice follows the evidence base to avoid a theory-practice gap. through my reflections, this paper will explore the role of the doctoral nurse to lead changes in nursing practice. globally, doctoral education for nurses is relatively new. university undergraduate degrees were introduced in the usa in the 1920s to prepare professionally qualified nurses, and it was many years later before other countries followed. once nurses were prepared with baccalaureate degrees, there was the need to ensure that nurse educators held higher qualifications, and thus master’s and doctoral programmes were developed. anthony et al. (1) identify the first dedicated nursing doctoral programme by columbia university, new york, in 1934, with other universities quickly following suit. the first in the united kingdom (uk) was in 1967, and over several decades, doctoral programmes in nursing developed in australia, brazil, china, japan, jordan, and korea (1). apart from brazil, which introduced its doctoral programme in 1979, most latin american countries began their doctoral programmes in the early 2000s, but most of them remain with only one programme in their portfolio (2). why do we need doctoral nurses? the question must be asked, why do we need nurses to be educated to doctoral level? the quality assurance agency in the uk (3) identified the characteristics of a doctoral qualification. principally, it recognised the professional need to generate a body of knowledge to improve the quality of care. additionally, with many countries requiring professional education in institutes of higher education, universities are interested in developing their research leadership. however, perhaps most importantly, through doctoral education, clinical nurses need to develop their critical thinking skills, identify gaps in the evidence base, take risks with ideas, and be creative and imaginative in their problem-solving. primarily, doctoral education aims to prepare nurse scientists as leaders in nursing practice, education, and research. in my own early years as a nurse, there was very little evidence base for nursing practice, which was mostly based on intuition and tradition. generally, nurses did not research as they did not have the education to do so. nursing was a very practical occupation. only when doctoral preparation became common practice were nurses and importantly others able to take their leadership seriously as they spoke from the same educational level as others across the healthcare professions and within the university system, capable of logical, evidence-based argument and above all, critical thinking. as the uk quality assurance agency (3) acknowledge, doctoral education offers the ability for nurses to lead in a dynamic way. with the unprecedented pace of change in the world and the need for nurses to be responsive to the new workplace environments, which require them to question existing assumptions, doctoral education can provide nurses with the skills to analyse trends and create a vision that sees the bigger picture (3). indeed, as clinical nurse leaders need the vision to transform nursing practice, it is their capacity to translate that vision into a reality that validates their leadership. vision for nursing as i reflect over the past 52 years, the vision for all nurses has always been to strive towards the highest quality of patient care. however, as we travel through this technological age and the world of healthcare changes at a pace, the evidence to support that quality is continually changing. so, if we interpret ‘vision’ to be the ability to imagine the future that at present does not exist, what is it that will help us to translate that vision into reality? having spent six years leading a small community hospital in a remote village in colombia without access to the internet or up-to-date textbooks, i was hungry for knowledge. i felt my leadership lacked the latest evidence on which to base my practice, and i returned to london, england, to take a specialist course with the idea of returning to lead ‘knowledgeably’! however, in london, the nursing theory was beginning to take shape, and the uk had adopted the nursing process, nursing theory, and nursing models mainly from the usa. the concepts were completely new to me, and i was keen to learn more. i soon studied for a master’s in nursing programme, of which one year of the three-year programme was devoted entirely to nursing models, originally developed by the early doctoral nurses in the usa. however, more recently, the models were heavily criticised and since the early 2000s in the uk, they fell out of favour. what they attempted to do was to help us to translate our vision into reality. each model reflected a different way of looking at the patient. rather like a model aeroplane or motorcar, nursing models helped us to explain our nursing reality and, according to burns et al. (4), each nursing model contained the following components to advance nursing knowledge: 1. a set of beliefs and values 2. a statement of the goals and assumptions about nursing so, each model or conceptual framework illustrated that the beliefs and values underpinning the care of diverse patients might be different, leading to a different goal for each patient and so varying the knowledge and skills required. considering the bigger picture, the practice of nursing locally, nationally, and globally differs. it is also culturally dependent, e.g., nursing practice in the heat of the tropical coast of colombia with reduced resources is, in my own experience, different from nursing in the cool mountainous urban regions of bogota and different again between the remote village community where i worked and the private hospital in cartagena where i moved to. therefore, the reality that nursing models are trying to represent will be different in different parts of every country and across different countries, and i am sure, quite different from the 1960s in the usa when the models were developed. from my own experience, different countries are developing their own philosophical (beliefs and values) approaches to guide practice, and these, in turn, will impact the different nursing goals and the subsequent knowledge and skills required of them. as an example, there have been a number of atrocities occurring in the uk national health service which have influenced the development of a country-wide philosophy promoting person-centred care and compassionate care. this occurred as a direct result of one hospital where many patients lost their lives unnecessarily due to their focusing on measurable targets rather than the quality of care (5). it is the doctoral nurses who are developing these philosophies and frameworks both through their research (6) and their teaching. it is the doctoral nurses who are best positioned to think critically and creatively through their research and teaching to guide nursing practice, and they have a responsibility to do so. the importance of evidence-based practice (ebp) once the doctoral nurses have developed their philosophical visions, we need to explore what we mean by the quality of care. as rosser et al. (7) acknowledge, practice based on best evidence offers the best quality care; they indeed noted that nursing’s regulatory body in the uk, the nursing and midwifery council, states in their standards for professional nurse education throughout the uk that all nurses must “safely demonstrate evidence-based practice in all skills and procedures… [and] demonstrate the knowledge, skills, and ability to think critically when applying evidence” (8). additionally, from an education perspective, rosser et al. (7) recognised the universal commitment of nurses to ebp, certainly in the western world, though they acknowledge that the support structures in practice are often lacking. sackett et al. (9), who instigated the ebp movement in medicine in the 1990s, explained ebp as not merely the evidence from research but ensuring that the best quality care embraces a combination of knowledge for the head (technical knowledge based on research evidence), knowledge for the hand (professional and life resources), and knowledge for the heart (first-person accounts of patient experience) (10). otherwise, nursing care will be based on tradition and often on the command of others and be possibly harmful. so, it is important to understand that ebp is based on a combination of all three types of evidence and not merely research. in spite of the widespread acceptance of ebp, there remains much resistance to its continued adoption (7). although it is the responsibility of all nurses to support the implementation of ebp, it is those doctorally educated nurses who are responsible for the leadership. hence the need to recognise the institute of medicine in their report on the future of nursing, as reported by luckett (11) too, which advocates increasing the number of doctoral nurses in the usa and for nurses to practise at their educational level. strategically, it is those doctoral nurses who have the education to develop the evidence base on which to change nursing practice for the better, create nursing philosophy and theory to guide nursing practice, and assist governments at the policy level to improve the health of the population. more importantly, at the clinical practice level, doctoral nurses should be influencing the creation of new roles in practice, contributing to new ways of working in light of best practice recommendations to improve the quality of care, be cost-effective, and be leaders in the practice environment. traditional ways of working fail to attract doctoral nurses at the bedside. so, it is essential that new roles to influence practice are created that advance the role of nurses who understand the patient perspective and assist those in practice to overcome the resistance to change. due to the lack of ability to sustain good senior nurses at the bedside within the uk and elsewhere, the government introduced the role of the nurse consultant, the highest level of clinical nurse in the country. the nurse consultant is positioned at the same level in the hospital hierarchy as the medical consultant and is involved in strategic decision-making at the organisational level. nurse consultants’ time is divided as follows: 50 % of their time in patient contact and the remaining 50 % divided between leadership, service development, education, and research. they are increasingly required to have a doctoral qualification. consequently, doctoral nurses become motivated to remain at the bedside and have a clearly mapped out role in influencing and leading direct care as well as leading nationally at the policy level. they are skilled practitioners yet have a role in clinical research as well as in education. creating autonomous and leadership roles at the bedside assumes that there is a critical mass of professional nurses in clinical practice able to understand the importance of ebp and supervising and leading others in its implementation. however, many countries have very few professional nurses in clinical practice, and practice is supported by an unqualified workforce. aiken et al. found in their study of nursing staff in nine hospitals across europe that each increase of one patient per nurse is associated with a 7 % increase in the likelihood of a surgical patient dying within 30 days of admission, whereas each 10 % increase in the percent of bachelor degree nurses in a hospital is associated with a 7 % decrease in this likelihood. these associations suggest that patients in hospitals in which 60 % of the nurses had bachelor’s degrees and nurses cared for an average of six patients would have almost 30 % lower mortality than patients in hospitals in which only 30 % of the nurses had bachelor’s degrees and nurses cared for an average of eight patients. (12, p1828) although not representative of other contexts, it is strong evidence to suggest that nurses’ educational qualifications and the nurse-to-patient ratio seem to have a direct impact on the outcomes of hospital patients, reinforcing the importance of having a critical mass of professional nurses on duty at the same time and that they have an undergraduate degree qualification. with this evidence, doctoral nurses must influence government policy at a strategic level to ensure an adequate nurse-to-patient ratio for the survival of their patients. çadditional to creating leadership roles in clinical practice, doctoral nurses have a responsibility to support interprofessional working. since 2010, the world health organisation (13) has advocated the importance of interprofessional working, recognising the weight of evidence to support the need for effective interprofessional education, which in turn enables effective collaborative practice, strengthens healthcare systems, and improves health outcome. additionally, interprofessional collaboration helps prevent medication errors, improves the patient experience, and ultimately reduces healthcare costs. as leaders in practice, education and research, doctoral nurses are well placed to take the responsibility to lead the ongoing move to effective interprofessional collaboration (13). finally, unlike the us, student nurses in the uk are supervised and formally assessed as competent by practice assessors. it is the responsibility of the professional nurses to determine a student’s competency to practise and not the educationalist. in this way, doctorally qualified nurses in senior clinical roles can influence professional practice by raising the standards in each clinical area. the importance of self-leadership having identified the importance of doctoral nurses taking responsibility for leading changes in clinical nursing practice, it is worth considering what this means for the individual. reflecting on my own career, after completing my doctoral degree, i cannot say that i felt any more of a leader than before. whilst there are many leadership theories to draw upon, the importance of collaborative leadership is gaining recognition. given the complexity of today’s health and social care, the days of individual ‘superheroes’ have long gone, requiring a much more collaborative model of leadership. nevertheless, i recognised the importance of myself stepping up to face the interprofessional team as an equal partner to contribute meaningfully to the team. i recognised the importance of self-leadership. i had to find that self-leadership in myself while my team looked to me to take the lead in day-to-day decisions and collaborate when appropriate. i recognised the need to think and work differently and work from deep within me. thinking about myself differently, i needed to influence myself to create the direction and motivation to perform and change my behaviour as a result of the way i began to think. i needed to empower myself to lead. i recognised my responsibilities as a doctoral nurse. it is imperative to know your own scope of practice, when to lead and when to follow. i invite you to step up and feel that inner strength to lead. conclusion i have shared my reflections on the importance of doctoral nurses as leaders and the cultural context of their vision. nevertheless, high-quality care is the same vision that nurses have across the globe, and we need to understand better what this means for us, using knowledge from the head, hand, and heart. as a doctoral nurse, you have the knowledge and capability to lead in whatever speciality you care to focus, whether that be education, research, or practice. recognising the patient benefits of a critical mass of professional nurses in practice, the importance of a high staff-to-patient ratio by staff who have a university bachelor’ degree can save lives (12). as each country, particularly in latin america, gains a critical mass of doctoral nurses, then they will become more inventive in their ability to create new ways of working, integrate new technologies clinically, innovate new roles, and ultimately attract doctoral nurses back into practice. through collaboration, doctoral nurses can learn from the international community, and by educating nurses at all levels to find their political voice, they can become visible at their country’s strategic leadership table and ultimately realise radical change. nurses know what they want to achieve and are innovative professionals. through the leadership of doctoral nurses back into practice, now is the time to empower nurses to think differently, to change practice at a strategic level, both at a national and organisational level, but also to lead the quality of care based on evidence. you are nursing’s future; please see the challenges ahead as opportunities to really make a difference. references 1. anthony d, alosaimi d, dyson s, korsah ka, saleh m. development of nurse education in saudi arabia, jordan and ghana: from undergraduate to doctoral programmes. nurse educ pract. 2020;47:102857. doi: https://doi.org/10.1016/j.nepr.2020.102857 2. organización panamericana de la salud y organización mundial de salud. formación doctoral en enfermería en américa latina y el caribe. washington; 2017 [cited 2021 apr 15].  available from: https://iris.paho.org/handle/10665.2/34312 3. the quality assurance agency characteristics statement: doctoral degree, united kingdom; 2020 feb [cited 2021 apr 8]. available from: https://www.qaa.ac.uk/docs/qaa/quality-code/doctoral-degree-characteristics-statement-2020.pdf?sfvrsn=a3c5ca81_14 4. burns m, bally j, burles m, holtslander l, peacock s. influences of the culture of science on nursing knowledge development: using conceptual frameworks as nursing philosophy in critical care nursing. nurs philos. 2020 oct;21(4). doi: https://doi.org/10.1111/nup.12310 5. francis r. report of the mid staffordshire nhs foundation trust, public inquiry; 2013 [cited 2016 apr 24]. available from: http://www.midstaffspublicinquiry.com 6. mccormack b mccance t, editors. person-centred practice in nursing and healthcare: theory and practice. 2nd ed. chichester, uk: wiley blackwell; 2016. 7. rosser e, neal d, reeve j, valentine j, grey r.  evidence-based practice as taught and experienced: education, practice and context. in: lipscomb m, editor. exploring evidence-based practice: debates and challenges in nursing. abingdon, oxfordshire, uk: routledge; 2016. doi: https://doi.org/10.4324/9781315764559-4 8. nursing and midwifery council. standards of proficiency for registered nurses. london: nursing and midwifery council; 2018 [cited 2021 apr 9]. available from:  https://www.nmc.org.uk/globalassets/sitedocuments/standards-of-proficiency/nurses/future-nurse-proficiencies.pdf 9. sackett dl, strauss se, richardson ws, rosenberg wmc, haynes rb. evidence-based medicine: how to practice and teach ebm. london: churchill-livingstone; 2000. 10. wright ta. distinguished scholar invited essay: reflections on the role of character in business education and student leadership development. j leadersh organ stud. 2015;22(3):253–264. doi: https://doi.org/10.1177/1548051815578950 11. luckett ty. a motivational profile of nurses who pursue doctoral education [dissertation]. long beach, mississippi: university of southern mississippi; 2017 [cited 2021 apr 10]. available from: https://aquila.usm.edu/cgi/viewcontent.cgi?article=2347&context=dissertations 12. aiken lh, sloane dm, bruyneel l, van den heede k, griffiths p, busse r, doimidous m, kinnunen j, kózka m, lesaffre e, mchugh md, moreno-casbas mt, rafferty am, schwendimann r, scott pa, tishelman c, van achterberg t, sermeus w. nurse staffing and education and hospital mortality in nine european countries: a retrospective observational study. lancet. 2014 may 24;383(9931):1824-30. doi: https://doi.org/10.1016/s0140-6736(13)62631-8 13. world health organization. framework for action on interprofessional education & collaborative practice. geneva; 2010 [cited 2021 jan 1]. available from: https://apps.who.int/iris/bitstream/handle/10665/70185/who_hrh_hpn_10.3_eng.pdf;jsessionid=ada0ea9576640ca76aa0aa491fc4974b?sequence=1 home 34 aquichan issn 1657-5997 ángela maría henao-castaño1 martha lucía núñez-rodríguez2 josé humberto quimbayo-díaz3 el rol del profesional de la salud como docente universitario 1 especialista en cuidado de enfermería al adulto en estado crítico de salud. docente, universidad del tolima. angiemaria54@yahoo.es 2 especialista en cardiorrespiratorio. docente, universidad del tolima. mnunez@ut.edu.co 3 especialista en salud ocupacional. docente, universidad del tolima. jhquimbayo@hotmail.com recibido: 31 de marzo de 2009 reenviado: 14 de octubre de 2009 aceptado: 10 de marzo de 2010 resumen este artículo hace un análisis del “ser” profesor universitario en los programas del área de la salud. se incluyen tópicos relacionados con el ejercicio de la profesión docente como un arte en el que se comparten aspectos relacionados con el ejercicio de las disciplinas. a partir de estos enunciados se da una mirada relacionando el ejercicio docente y los sentimientos de amor y amistad involucrados en esta actividad, destacando que de ninguna manera se constituyen en un irrespeto por la investidura del docente universitario. para este debe ser una motivación diaria en su ejercicio profesional el análisis y la reflexión permanente acerca de su accionar con el propósito de diseñar e implementar estrategias de enseñanza que generen nuevas actitudes personales, académicas, sociales y ciudadanas en sus estudiantes. palabras clave docente, enfermería, salud, pedagogía, universidad (fuente: decs, bireme). the role of the health professional as a university professor abstract the purpose of this article is to analyze “being” a university professor in programs in the health area. it includes topics related to exercise of the teaching profession as an art in which aspects associated with exercise of the respective disciplines are shared. on that basis, it examines teaching practice and the feelings of affection and friendship involved in that activity, while emphasizing that they do not constitute a lack of respect for the rank and mandate of a university professor. constant analysis and reflection on one’s actions as a teacher should serve as daily motivation in professional practice to design and apply teaching strategies that create new personal, academic, social and civic attitudes among students. key words faculty, nursing, health, teaching, university (source: decs, bireme). año 10 vol. 10 nº 1 chía, colombia abril 2010 l 34-42 35 el rol del profesional de la salud como docente universitario l ángela maría henao-castaño, martha lucía núñez-rodríguez, josé humberto quimbayo-díaz o papel do profissional de saúde o ensino universitário resumo este artigo pretende analisar o “ser” professor universitário nos programas da área da saúde. inclui temas relacionados com o exercício da profissão docente como uma arte em que são compartilhados com aspectos do exercício das disciplinas. a partir desses postulados, se vincula a prática docente e os sentimentos de amor e amizade envolvidos nesta atividade, salientando que este aspecto não constitui um desrespeito para os professores universitários. a análise e a reflexão contínua sobre suas ações devem ser uma motivação constante no seu exercício profissional, a fim de projetar e implementar estratégias de ensino que geram novas atitudes pessoais, acadêmicas, sociais e de cidadania em seus alunos. palavras-chave docente, enfermagem, saúde, pedagogia, universidade. (fonte: decs, bireme). 36 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 este artículo se compone de dos grandes cuerpos de análisis, el primero es una reflexión sobre el quehacer del docente universitario como tal, y el segundo aborda la relación entre el cuerpo disciplinar del área de la salud y el ejercicio docente; esta estructura permite enfocar el tema a través de la disciplina encargada de escudriñar la relación enseñanza-aprendizaje: la pedagogía. a partir de allí se explora el área de la salud con el fin de poner a dialogar estos dos cuerpos y proponer unas características que permitan identificar el rol del docente universitario en el área de salud. pedagogía y profesión docente el ejercicio docente en el área de la salud debe tener respuestas claras al siguiente interrogante: ¿qué es ser un docente universitario? para dar respuesta a esta pregunta, alfredo gorrochotegui aporta este enunciado: es profesar, enseñar, amar […] profesar la profesión de “profesor universitario” es ejercer –con inclinación voluntaria– el arte de enseñar a un grupo de estudiantes (también universitarios), una disciplina en la que nos hemos especializado. pero “profesar” tiene la fuerza de algo que se ejerce porque se tiene dentro: se lleva dentro con cierta pasión y posibilidad de desarrollo y perfeccionamiento (1). estos postulados propuestos para explicar la esencia del docente tienen marcadas correspondencias con las prácticas del cuidado de la salud realizadas por enfermería en particular, en donde estas acciones se entienden como eminentemente humanísticas y cargadas de un alto sentido ético. más adelante, hablando sobre “el amor de amistad y su aplicación en las relaciones universitarias”, gorrochotegui dice: “efectivamente, la amistad es una clase de amor. el ‘amor de amistad’ (1) existe y es conveniente que lo hagamos realidad con nuestros alumnos”. para sustentar sus postulados, gorrochotegui se apoya en palabras de la cuna de la civilización occidental: grecia y roma. amar es, según lo ha dicho aristóteles, citado por gorrochotegui, querer el bien para el otro. y el amor de amistad, decía cicerón, también citado por gorrochotegui, “no es otra cosa que una consonancia absoluta de pareceres sobre las cosas divinas y humanas, unida a benevolencia y amor recíprocos” (1). ¿podemos desarrollar un amor de amistad con nuestros estudiantes? creemos que sí. pensamos que es conveniente y que permitiría rescatar el antiguo y verdadero sentido de la universidad a la cual, en sus primeros momentos, se le reconocía como una corporación en la que se juntaban discípulos y maestros, y en la que ambos desarrollaban fuertes sentimientos de fraternidad, respeto, admiración, reciprocidad, diálogo, aceptación, camaradería, corrección entre unos y otros, e intercambio de pareceres y opiniones. esto no es un sueño. la universidad debe ser una comunidad donde existe la verdadera amistad. y esto no es irrespeto por el docente; evidentemente, éste debe hacerse respetar y reconocer que tiene una investidura, debe poner la distancia que hay que poner, pero con naturalila universidad debe ser una comunidad donde existe la verdadera amistad. y esto no es irrespeto por el docente; evidentemente, éste debe hacerse respetar y reconocer que tiene una investidura, debe poner la distancia que hay que poner, pero con naturalidad, sin caras largas ni falsas actitudes. 37 el rol del profesional de la salud como docente universitario l ángela maría henao-castaño, martha lucía núñez-rodríguez, josé humberto quimbayo-díaz dad, sin caras largas ni falsas actitudes. sonreír cuesta poco y es una gran ganancia (1). estos presupuestos pedagógicos pueden también impregnar la actitud y el desempeño profesional de quienes desde un consultorio atienden niños, adolescentes, adultos, adultos mayores, hombres y mujeres; pero ante todo, seres humanos, personas. en el sentido estricto del ámbito universitario esta afirmación de gorrochotegui sobre lo que significa ser un profesor universitario deja el camino abierto para la construcción de lo que se denomina “una comunidad académica” que fortalezca la docencia, la investigación y la proyección que la universidad debe tener hacia la sociedad. en su artículo: “generalidades de la evaluación”, mario orlando parra pineda afirma que: la universidad es el espacio natural para la construcción social del conocimiento, en donde se indaga, comprende y busca transformar la sociedad. en este contexto, los acelerados cambios sociales, económicos y científicos actuales nos obligan a su transformación, con el fin de garantizar su calidad y pertinencia. para ello se deben priorizar los procesos de evaluación en su interior, como guías efectivas para el cambio (2). parra retoma las palabras del semiólogo italiano umberto eco, quien considera que esta afirmación podría ser considerada como un topoi, un lugar común, un secreto a voces que en el ejercicio de la docencia universitaria ha sido objeto de análisis, reflexiones y propuestas pedagógicas con el propósito de diseñar e implementar estrategias de enseñanza que generen nuevas actitudes personales y académicas en los estudiantes, de modo que logren superar sus deficiencias de aprendizaje. toda la labor docente pareciera estar encaminada a establecer unas pistas seguras a través de las cuales ellos puedan aterrizar el cúmulo de información que navega en sus cerebros, como también aquella que desglosan de los textos de las bibliotecas modernizadas y los textos virtuales que les ofrece el ciberespacio en internet. sin embargo, el dilema sigue latente: ¿cómo asumir esa responsabilidad compartida entre el docente y el estudiante cuando se trata de consolidar un proyecto de vida? ¿cómo compaginar ese proyecto de vida con los procesos de formación profesional y su proyección social efectiva? las posibles respuestas para estos interrogantes, donde se dimensiona el compromiso del alma máter para forjar nuevos ciudadanos y profesionales competentes en las diversas disciplinas y en las áreas específicas del saber —que en este caso particular el artículo aborda una reflexión sobre la formación de profesionales en el área de salud como investigadores de la realidad—, se hallan en la voz autorizada de sócrates y su método mayéutico de preguntar para argumentar con la respuesta y, sobre esa base, contraargumentar con otra pregunta que posibilite la apertura a nuevos saberes bajo la guía del maestro en interacción permanente con sus discípulos (3). en ese orden de ideas, la pedagogía constituye el ejercicio cotidiano de la paideia, que en palabras de los griegos era la permanente construcción del saber en la vida, por la vida y para la vida desde unos principios éticos y filosóficos siempre en búsqueda de la verdad. principios que en cierto modo se encuentran plasmados en todas las teorías de enfermería, y en general de las disciplinas que componen ¿cómo asumir esa responsabilidad compartida entre el docente y el estudiante cuando se trata de consolidar un proyecto de vida? ¿cómo compaginar ese proyecto de vida con los procesos de formación profesional y su proyección social efectiva? 38 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 el área de la salud, pilares del ejercicio de la profesión enfermera y médica así como la asistencia social en salud. de igual manera, tal como lo expresa fawcett (4), las filosofías de enfermería comprenden reclamos ontológicos y epistémicos sobre los fenómenos de interés para la disciplina, y reclamos éticos acerca de las acciones de enfermería, de su práctica y del carácter de los individuos que han elegido practicarla. escobar (5) reflexiona sobre la relación que se establece entre las nociones de salud y enfermedad a partir de dinámicas culturales y sociales, buscando la interdisciplinariedad. tarea del docente universitario corresponde, entonces, al docente universitario en su quehacer pedagógico, como sócrates, “hacer surgir” (3) desde las entrañas de la lógica y desde lo ilógico de la existencia —en ese eterno cuestionamiento sobre el saber aprender, el saber hacer y saber ser— todas las posibilidades que el estudiante de enfermería o de cualquier otra profesión tiene con respecto al desarrollo de sus potencialidades humanas, en un proceso educativo acorde con las necesidades del contexto sociocultural y coherente con el enfoque de su futuro desempeño profesional. el docente universitario deberá tener bien claro que: la educación es un proceso intencional de carácter social, cuyos fines han variado de una época a otra, de una cultura a otra, de una clase social a otra, determinados en gran parte por los sistemas sociales, políticos, económicos, filosóficos, éticos y religiosos que le han dado origen. sin embargo, sus objetivos comunes son: la socialización, la búsqueda de la adaptación social del hombre al grupo, a su cultura y a sus instituciones; y la individualización, la promoción del sujeto para su realización, según sus propias aspiraciones. por tanto, su problemática se sitúa en la búsqueda del equilibrio entre estos dos aspectos complementarios entre sí, más que contradictorios; teniendo en cuenta el carácter individual y social del hombre (1). en consecuencia, el docente universitario —dentro de los parámetros institucionales que establece la institución— habrá de convertirse en un pedagogo que asuma con entereza de espíritu los retos de la docencia, la investigación y la acción social que caracterizan el proceso educativo del nivel superior (6). en la docencia habrá de definir, como ocurre en el diálogo entre alicia y su interlocutor: el gato, en el texto de lewis carroll, alicia en el país de las maravillas (5), hacia dónde se dirige y a dónde quiere llegar con sus estudiantes. antes de avanzar deberá autoevaluarse y saber dónde se encuentra, en términos del constructivismo, su mapa cognitivo; cuál es el estado del arte de sus acciones pedagógicas, cómo están funcionando sus estrategias de enseñanza, o por qué ya no logra que algunos procesos produzcan los resultados pronosticados o cuáles son las variables intervinientes que afectan el ritmo de aprendizaje sostenido que desea de sus estudiantes, y la profundización en los niveles de comprensión lectora y producción de textos orales y escritos; es decir, todo un programa de autoevaluación que aterrice su discurso pedagógico en la realidad de lo que ocurre con él y con sus estudiantes dentro y fuera del aula de clases. desde luego que en esa introspección y retrospección de su oficio pedagógico habrá de tomar atenta nota del pro y contra del modelo pedagógico que ha la pedagogía constituye el ejercicio cotidiano de la paideia, que en palabras de los griegos era la permanente construcción del saber en la vida, por la vida y para la vida desde unos principios éticos y filosóficos siempre en búsqueda de la verdad. 39 el rol del profesional de la salud como docente universitario l ángela maría henao-castaño, martha lucía núñez-rodríguez, josé humberto quimbayo-díaz incorporado: su vigencia, su pertinencia, su flexibilidad, su sentido humanístico, sus fundamentos epistemológicos, su carácter vivencial, experiencial y científico (7). establecer si su modelo pedagógico brinda a los alumnos la posibilidad de aprender comprendiendo las mediaciones y formas sociales que moldean sus propias experiencias no sólo es importante porque les provee una manera crítica de entender el terreno conocido de la vida práctica cotidiana, sino también porque es parte de una estrategia pedagógica que intenta recuperar y poner en juego las experiencias que los alumnos muestran, a fin de comprender cómo se cumplieron y legitimaron dentro de condiciones sociales e históricas específicas (8). en esa fase exploratoria el docente universitario debe ante todo comprender que su responsabilidad es compartida con las directivas y administrativos de la institución educativa, como también con sus colegas, con quienes forma equipos interdisciplinarios o transdisciplinarios de trabajo. personas que por el diseño curricular y el plan de estudios están comprometidas con el desarrollo de la personalidad y la profesionalización de sus estudiantes. el docente universitario no debe cerrarse en su propio universo académico y profesional como un autista dando por hecho que solamente a él corresponde dar la solución a las múltiples situaciones problemáticas que la pedagogía conceptual reconoce y legitima como opciones para aprender. la corresponsabilidad convoca el esfuerzo y trabajo académico de los estudiantes como beneficiarios directos del “derecho constitucional a la educación”, y el cumplimiento sagrado de los deberes que se derivan del disfrute pleno de este derecho fundamental. en palabras de juan miguel campanario l., “aclare dónde quiere ir a parar y ayude a los alumnos a saber dónde están” (9). por otra parte al educador, como sujeto mediador del proceso enseñanzaaprendizaje de sus estudiantes, se le exige indicarles cómo hallar soluciones a los “conflictos” que se derivan del acto educativo y su relación con la vida, con los espacios vitales donde habrá de actuar como profesional de la salud. además, facilitarle al estudiante medios para comprender la ansiedad que provoca el ensayo-error durante la ejecución de procedimientos por primera vez, ya que son sensaciones que se mueven en el plano de lo mental, lo psíquico, lo cognitivo del ser humano para permitir la incorporación del conocimiento a la práctica. siendo el pedagogo un “mediador” entre la realidad, el estudiante y los procesos de abstracción que éste realiza para aprehender, procesar y aplicar la información, su acción se mueve en la esfera de ser, así como lo expresa perea, un “posibilitador para que el alumno mejore sus niveles de competencias” y en este proceso logre: “1) acercar al sujeto a una metodología mediante la cual pueda aprender a aprender, y 2) dirigir su práctica hacia la adquisición de conceptos científicos” (10), los cuales logre aplicar en los contextos pertinentes. el “ojo clínico” del docente el docente universitario avezado sabrá leer e interpretar, desde la semiótica, las evidencias del aprendizaje y del autoaprendizaje. todos los signos vitales de la actividad académica. no se limitará, como analiza torres, al análisis detectivesco de los textos escritos y pruebas objetivas cuando de evaluar se trata durante “las semanas de previas y exámenes finales” (11) el docente universitario debe ante todo comprender que su responsabilidad es compartida con las directivas y administrativos de la institución educativa, como también con sus colegas, con quienes forma equipos interdisciplinarios o transdisciplinarios de trabajo. 40 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 presentados por sus pupilos como si fuera la anamnesis de otro paciente a quien hay que diagnosticarle la fase inicial o terminal de una patología. el docente tampoco puede asumir una actitud resignada con la expresión: “no hay nada que hacer”, tal como lo haría el médico cuando el resucitador manual o “ambu” no funciona en un centro hospitalario mal dotado, o cuando definitivamente hubo un paro cardiorrespiratorio cognitivo en sus estudiantes. por supuesto que no, porque aun en los casos más críticos la ciencia médica está buscando alternativas de solución. de igual manera, el estudiante de enfermería aprenderá del “currículo oculto” de su maestro, de su guía, de su ejemplo, el valor del esfuerzo y la dedicación constantes in situ. a partir de esta reflexión, el docente promoverá entre sus estudiantes un aprendizaje significativo con base en los saberes previos como lo plantea ausubel (12) y, si se lo propone, propiciará los procesos metacognitivos aplicando los presupuestos teóricos vigotskianos y su “zona próxima de desarrollo” (12), en donde vigostski reconoce una distancia entre la solución de problemas en forma independiente y el nivel de desarrollo posible con la dirección o ayuda de alguien más diestro. este presupuesto, incluido en las teorías de vigostski, puede servir de respaldo al uso del aprendizaje basado en problemas para los estudiantes de enfermería utilizando como estrategia el análisis de las situaciones de la disciplina como vehículo para favorecer los aprendizajes. la “negociación de saberes” entre docente, estudiantes y demás actores que participan directa o indirectamente en los procesos de formación académica, mediante el uso de la palabra, surge como el producto de la interacción social, y de participar en largas jornadas de práctica compartiendo experiencias. el estudiante aprenderá a través del uso apropiado del lenguaje en todas sus formas (incluidas las simbólicas y no verbales), que la palabra tiene un poder inconmensurable cuando de pensar in situ, dialogar y actuar se trata; que la palabra con argumentos permite establecer la sociedad de la comunicación (13). en estos procesos de interacción el docente también aprende, y entre estos aprendizajes son destacables la identificación de los códigos lingüísticos propios de los estudiantes así como otros saberes disciplinares que surgen de las búsquedas realizadas por los estudiantes. qué docente universitario necesitan los programas del área de la salud el área de la salud está en las agendas gubernamentales como uno de los ejes de desarrollo de las políticas públicas, y a pesar de los grandes avances científicos y técnicos que se presentan constantemente, los problemas para asegurar la cobertura y la calidad de los sistemas de salud son palpables en los países menos adelantados o de economías en crecimiento. este es un elemento que debe ser tenido en cuenta ya que el docente universitario debe estar al corriente, tanto de los avances científicos como de los documentos que dirigen las políticas públicas en torno al área de la salud. así, el docente universitario debe estar en capacidad de proponer puntos de vista en torno a las discusiones que se están dando la “negociación de saberes” entre docente, estudiantes y demás actores que participan directa o indirectamente en los procesos de formación académica, mediante el uso de la palabra, surge como el producto de la interacción social, y de participar en largas jornadas de práctica compartiendo experiencias. 41 el rol del profesional de la salud como docente universitario l ángela maría henao-castaño, martha lucía núñez-rodríguez, josé humberto quimbayo-díaz en su campo disciplinar. a modo de ejemplo, se puede citar un tema que está en estos momentos alimentando las reflexiones del área de la salud: la concepción de ser humano. diversos autores están orientando sus trabajos sobre esta área (14). en la formación de los profesionales en el área de la salud se requiere un docente que reivindique la enseñanza como una profesión, que además del conocimiento de la materia tenga conocimientos pedagógicos específicos para el nivel en el que se desempeña. sí es indispensable un conocimiento de la materia, pero este por sí solo no genera ideas de cómo presentar un contenido particular a alumnos específicos, por lo que se requiere un conocimiento didáctico del contenido, propio del buen hacer docente. a partir de esta premisa, gudmundsdottir (16) realiza este aporte: “los conocimientos didácticos son la parte más importante del conocimiento base de la enseñanza y permiten distinguir al profesor veterano del novel, y al buen profesor del erudito”. este aporte denota la importancia de la evolución de los saberes didácticos de los profesores en el curso de su práctica docente, poniendo de presente un interrogante que tenemos que hacernos y que para muchos de nosotros tiene una respuesta negativa: ¿para ser docente del programa de enfermería es suficiente la formación disciplinar específica? se ha demostrado que las disciplinas poseen sus propias especificidades y, en consecuencia, reclaman una didáctica específica como lo expresa leinhardt (17), señalando además que el argumento que lo sustenta es que la especificidad (epistemología, lenguaje, tareas, modos de trabajo, etc.) de cada una de las materias transforma y modula los lugares comunes (alumno, profesor, materia) que constituyen la enseñanza. el docente universitario en el área de la salud debe tener una convicción y predisposición al trabajo interdisciplinario (18). pero la apuesta interdisciplinaria va más allá del mero esfuerzo epistemológico, implica que esté conectado con la comunidad de profesionales del campo específico, debe estar en capacidad de liderar proyectos de integración entre los sectores estatales y privados con la universidad, con el fin de que los avances presentados en los primeros repercutan en la segunda, y que las reflexiones e investigaciones de la segunda sean escuchados por los primeros. si bien es cierto que el campo de las ciencias de la salud que ha dominado en este artículo es la enfermería, por la formación de los autores, no se pueden dejar a un lado los aportes que desde otras áreas de la salud se hacen para resolver la pregunta que convoca esta reflexión en torno al rol del docente universitario en esta área específica, es el caso de un nuevo campo que está surgiendo, y es el de la educación médica. este nuevo campo se define a partir de los aportes que se hacen desde la investigación educativa en el campo de la medicina. el docente universitario en el área de la salud debe poseer cualidades en el aspecto ético bien definidas por su campo profesional como tal, más el respeto y la responsabilidad frente al quehacer pedagógico. en un estudio chileno (19) frente a lo que los estudiantes esperan de sus docentes se puede resumir la posición que compartimos de cara a los retos que debemos afrontar los formadores de los profesionales en salud; dice el estudio que: “mejorar la calidad de la formación de los profesionales de la salud, pasa necesariamente por las competencias que posean los docentes en desempeñar su rol. identificarlas, valorarlas y desarrollarlas constituye todo un desafío para enfrentar las nuevas tendencias educacionales que implican un cambio en la conducción de los procesos educativos”. 42 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 referencias bibliográficas 1. gorrochotegui a. ser profesor universitario. reflexiones acerca de la docencia universitaria. conciencia activa 2006; 11: 114-115. 2. parra m o. generalidades de la evaluación. rev med univ nalcol 1999; 47 (4). 3. platón. diálogos. barcelona: aguilar; 1986. 4. fawcett j. estructura del conocimiento contemporaneo en área de la salud. en fawcett j. analisis an evaluation of contemporary nursing knowledge. philadelphia: f.a. davis company; 2000. pp. 26-48. 5. escobar c l. antropología médica: una visión cultural de la salud. revista promoción salud 2006; 8: 46-55. 6. carroll l. alicia en el país de las maravillas. madrid: siruela; 1995. 7. vattimo g. hermenéutica, ciencias humanas y sociedad de la comunicación. revista de occidente 1987; 340: 74-78. 8. giroux h. pedagogía y política de la esperanza. buenos aires: amorrortu editores; 2003. pp. 158-169. 9. campanario j m. ¿qué puede hacer un profesor como tú con una clase tan masificada como ésta? revista docencia universitaria 2002; 3 (1): 27-41. 10. perea c. el concepto de competencia y su aplicación en el campo de la educación. ased col 2000; 44-45. 11. torres g. otra evaluación, otra educación. santa fe de bogotá: editorial pontificia universidad javeriana; 1993. 12. ausubel d j n, hanesian h. psicología educativa. mexico: trillas; 1983. 13. alonso l m, vásquez e. el ser humano como una totalidad. barranquilla: salud uninorte 2003; (17): 3-8. 14. de zubiría j. de la escuela nueva al constructivismo. un análisis crítico. bogotá: editorial magisterio; 2001. 15. gardner h. la educación de las inteligencias en el texto: estructuras de la mente. teoría de las inteligencias múltiples. santafé de bogotá: fondo de cultura económica; 1999. 16. gudmundsdottir s. nancy: pedagogical content knowledge of an expert teacher. annual meeting of the american educational research association. boston;1990. 17. leinhardt g. instructional explanations: a commonplace for teaching and location for contrast. en richarson v. (ed.). handbook of research on teaching. 4 ed. washington, dc: aera; 2001. pp. 333-357. 18. palencia e. reflexión sobre el ejercicio docente de enfermería en nuestros días. invest educ enferm 2006; 2 (24): 130-134. 19. cabalín d, navarro n. conceptualización de los estudiantes sobre el buen profesor universitario en las carreras de la salud de la universidad de la frontera chile. int j morphol 2008; 26 (4): 887-894. 05 formando docentes.indd 64 aquichan issn 1657-5997 ana maría cerezo-bautista.1 julia hernández-álvarez.1 formando docentes, una experiencia desde el constructivismo recibido: 9 de julio de 2007 aceptado: 13 de noviembre de 2007 1 docentes. facultad de enfermería de la benemérita. universidad autónoma de puebla, méxico. acerezob@hotmail.com maestrajulia@ unicup.edu.mx resumen introducción: la universidad, como institución de educación superior, requiere docentes altamente calificados para formar profesionales autónomos, creativos y comprometidos con la humanidad. la enfermería universitaria al servicio de personas, contempla la formación de su planta docente en esquemas teóricos afines, por lo que se realizó un estudio con el objetivo de identificar los resultados en aprovechamiento al aplicar el diseño de aprendizaje constructivista de mayer en un grupo de profesores. metodología: estudio descriptivo y de intervención, aplicando preprueba y posprueba. se diseñaron: un plan de clase, examen diagnóstico, prueba de retención y prueba de transferencia, de acuerdo con los requerimientos del aprendizaje constructivista, por sesión y por cada uno de los siguientes temas: andragogía, elementos teóricos y diseño de estrategias para el aprendizaje grupal. el procedimiento de aplicación fue el mismo en las tres sesiones. resultados: se destaca el incremento en el conocimiento del tema reflejado en la posprueba: tema 1, de 50 a 90 y 91%; tema 2, de 33 a 77 y 95%; tema 3 de 28 a 71,6 y 90%. conclusiones: el diseño educativo para el aprendizaje constructivista de mayer permitió el incremento en los porcentajes de aprovechamiento del grupo de docentes participantes. palabras clave educación superior, docentes, enseñanza, aprendizaje. año 8 vol. 8 nº 1 chía, colombia abril 2008 64-73 65 formando docentes, una experiencia desde el constructivismo educating teachers: an experience based on constructivism abstract introduction: as an institution of higher education, the university needs extremely qualified teachers to educate independent and creative professionals who are committed to others. a university education in nursing dedicated to the service of others requires a teaching staff that is trained in a number of related theoretical concepts. with this in mind, a study was done to identify the results of mayer’s constructivist learning model applied to a group of teachers. methodology: a descriptive intervention study was done, with a pre-test and a post-test. a class plan, a diagnostic examination, a retention test and a transfer test pursuant to the requirements for constructivist learning were designed for each session and for each of the following topics: andragogy, theoretical elements and the design of group learning strategies. results: the post-test reflected increased knowledge of the topics: topic 1: from 50 to 90 91%; topic 2: from 33 to 77 95%; topic 3: from 28 to 71.6 90%. conclusions: education based on mayer’s constructivist learning model enabled the group of participating teachers to raise their improvement rates. key words higher education, teachers, teaching, learning. formar docentes: uma experiência construtivista resumo introdução: a universidade, como instituição de educação superior, necessita docentes muito qualificados para formar profissionais autônomos, criativos e comprometidos com a humanidade. a enfermagem universitária, al serviço de pessoas, fundamenta a formação do seu corpo docente em esquemas teóricos afines. por tanto, foi realizado um estudo em um grupo de professores para identificar os resultados em aproveitamento aplicando o desenho da aprendizagem construtivista de mayer. metodologia: estudo descritivo e de intervenção aplicando pré-prova e post-prova. foram desenhados plano de aula, exame diagnóstico, prova de retenção e de referência, de acordo com as exigências da aprendizagem construtivista por sessão e por cada um dos temas a seguir: andragogia, elementos teóricos e desenho de estratégias para a aprendizagem grupal. foi aplicado o mesmo procedimento durante as três sessões. resultados: se destaca o incremento no conhecimento do tema, refletido na post-prova: tema 1: de 50 a 90 y 91%; tema 2: de 33 a 77 y 95%; tema 3: de 28 a 71,6 y 90%. conclusões: o desenho educativo para a aprendizagem construtivista de mayer permitiu incrementar as percentagens de aproveitamento do grupo de docentes participantes. palavras-chave educação superior, docentes, ensino, aprendizagem. 66 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 introducción la universidad como institución de educación superior, en la que se forman los profesionales del futuro que respondan a las necesidades sociales, requiere docentes capacitados para facilitar el aprendizaje de sus estudiantes. en esta temática, kantún (1) identifica a la universidad como la estructura que además de facilitar el aprendizaje, es un organismo dinámico, formador de profesionales que dispone de una profunda capacidad de reflexión y una significativa capacidad de desarrollo. enfatiza que si queremos formar parte activa de la sociedad, y contribuir en su desarrollo para el futuro, hay que realizar un cambio radical en la enseñanza de enfermería, tema de interés en este trabajo. uno de los cambios es el ejercicio de la autoridad que, de línea vertical, pase a una horizontal en las interacciones sociales profesor-alumno (1), de tal forma que también la formación de los profesores incorpore este cambio en el ejercicio docente en aula. fernández (2) concibe al aula como un espacio diseñado para promover la formación de estudiantes constructores, con capacidad para asumir la responsabilidad de su propio aprendizaje y de evaluar su progreso (2), esta afirmación coincide con la de garcía-barrón (3) al argumentar a favor de que los profesores promuevan estrategias cognitivas en los estudiantes que favorezcan el aprendizaje autónomo y permanente para ser utilizado por los que lo reciben en el contexto escolar, en la vida diaria y en el futuro ejercicio profesional (3). al respecto, la literatura especializada tiene un número importante de teóricos del aprendizaje que han intentado explicar cómo aprende la gente. para este trabajo se ha revisado, entre otras, lo propuesto por ausebel, vigotsky, coll y mayer, en el interés de apoyar la construcción individual y grupal de nuevos conocimientos. ausebel, con la teoría de asimilación del aprendizaje, establece tres tipos de aprendizajes significativos: de vocabulario o representativos, de conceptos, y preposicionales. esta teoría ofrece un marco apropiado para el desarrollo de la labor educativa, así como para el diseño de técnicas coherentes con los principios de aprendizaje educacionales que favorecen que ocurra el aprendizaje. plantea que el aprendizaje del alumno depende de la estructura cognitiva previa que se relaciona con la nueva información. para ausebel, la “estructura cognitiva” es el conjunto de conceptos e ideas que un individuo posee en un determinado campo del conocimiento, así como su organización (4). a partir de estas ideas, la labor educativa ya no se verá como algo que debe desarrollarse en mentes en blanco, o que el aprendizaje de los alumnos inicie de cero, sino más bien reconociendo que los educandos tienen una serie de experiencias y conocimientos que afectan su aprendizaje y pueden ser aprovechadas en su beneficio por tanto, en el proceso educativo es importante considerar lo que el individuo ya sabe, de tal manera que establezca una relación con aquello que debe aprender. así las cosas, el aprendizaje significativo tiene lugar cuando el educando tiene en su estructura cognitiva conceptos, es decir, ideas y proposiciones estables así como claramente definidas, con las cuales la nueva información puede interactuar y que funcionan como un punto de anclaje para el nuevo conocimiento. 67 formando docentes, una experiencia desde el constructivismo para entender desde este enfoque la labor educativa, es necesario considerar tres elementos del proceso educativo: los profesores y su manera de enseñar; la estructura de los conocimientos que conforman el currículo y el modo en que éste se produce y, por último, el entramado social en el que se desarrolla el proceso educativo (5). el modelo de aprendizaje sociocultural de vigotsky plantea que desarrollo y aprendizaje interactúan entre sí considerando el aprendizaje como un factor de desarrollo. es esta estrecha relación entre desarrollo y aprendizaje que vigotsky destaca, lo lleva a formular la teoría de desarrollo próximo (zdp). esto significa, en palabras del autor, “la distancia entre el nivel de desarrollo, determinado por la capacidad para resolver independientemente un problema, y el nivel de desarrollo potencial, determinado a través de la resolución de un problema bajo la guía de un adulto o en colaboración con otro compañero más capaz” (6). la teoría de vigotsky se basa principalmente en el aprendizaje sociocultural de cada individuo y, por tanto, en el medio en que se desarrolla (7). la concepción constructivista, como marco explicativo, es un conjunto articulado de principios, desde donde es posible diagnosticar, establecer juicios y tomar decisiones fundamentadas sobre la enseñanza. aprendemos cuando somos capaces de elaborar una representación personal sobre un objeto de la realidad o contenido que pretendemos aprender. coll (8) sugiere la idea de vigotski de aprendizaje mediatizado por la cultura del grupo social al que pertenece, la cual establece y modela el tipo de aprendizaje específico y las experiencias educativas. por tanto “no es un proceso que conduzca a la acumulación de nuevos conocimientos, sino a la integración, modificación, establecimiento de relaciones y coordinación entre esquemas de conocimientos que ya poseíamos, dotados de una cierta estructura y organización que varía en nudos (nexos) y en relaciones a cada aprendizaje que realizamos” (8). esta forma de pensamiento gira en torno a principios que rigen su desarrollo: a) plantear problemas de emergencia relevantes a los alumnos, b) estructurar el aprendizaje alrededor de conceptos grandes y relevantes, c) buscar y valorar los puntos de vista de los estudiantes, d) adaptar el currículo en función de las suposiciones de los alumnos (ideas, puntos de vista, etc.), e) evaluar el aprendizaje de los alumnos en el contexto de la enseñanza (9). de esta manera, el aprendizaje escolar consiste en “un proceso de construcción de significados y de atribución de sentidos cuya responsabilidad última corresponde al alumno...”, enfatiza que “la función prioritaria de la educación escolar es, o mejor debería ser, la de promover el desarrollo y el crecimiento personal de los alumnos” (10); en este aprendizaje se motiva la creatividad definida por betancourt (2002) como “...el potencial humano integrado por componentes cognoscitivos, afectivos, intelectuales y volitivos, que a través de una atmósfera creativa se pone de manifiesto para generar productos novedosos y de gran valor social, y comunicarlos trascendiendo en determinados momentos el contexto histórico social en el que se vive” (11). entendida así la educación, quien se encuentra con mayor dinamismo en el proceso educativo son los estudiantes; sin embargo, es conveniente señalar que los para entender desde este enfoque la labor educativa, es necesario considerar tres elementos del proceso educativo: los profesores y su manera de enseñar; la estructura de los conocimientos que conforman el currículo y el modo en que éste se produce y, por último, el entramado social en el que se desarrolla el proceso educativo. 68 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 profesores, al estar involucrados en las actividades de ellos, también están promoviendo su propio desarrollo, siempre y cuando el ambiente lo permita. como personas, los docentes interiorizan nuevos conocimientos en relación con los seres humanos (sus alumnos), sus conductas y formas de acceder al conocimiento. también adquieren habilidades intelectuales para manejar situaciones difíciles en el aula y fuera de ella. ante esta situación, la enfermería requiere de docentes altamente calificados para promover el aprendizaje autónomo de sus estudiantes, el mismo que dará origen a egresados comprometidos con su autoeducación, de tal forma que como grupo profesional asuman un papel protagónico en el desarrollo de la humanidad, y aprendan desde el aula a crear y participar en un mundo más humano, equitativo y responsable. en ese contexto, el papel del maestro o facilitador es importante para el diseño de programas y planes de estudio, en la gestión de nuevas formas de aprender, y en la asesoría para que los alumnos desarrollen todo su potencial humano en el trabajo individual y colectivo. a partir de las reflexiones de e. luengo, es importante destacar que la construcción compleja del conocimiento debe integrarse a los modos de conocer de los estudiantes de enfermería y profesionales en ejercicio, pensando que los fenómenos de la vida y la salud son altamente complejos. para este estudio se retoma el diseño educativo para el aprendizaje constructivista de richard e. mayer (12); esta propuesta se centra en la forma en la que los alumnos elaboran el conocimiento dentro de su memoria activa, con información previa y con información nueva. destaca que el aprendizaje se produce cuando los alumnos participan en forma directa en la construcción de la memoria activa de una representación de conocimiento. en esta situación educativa participa de forma importante el alumno que tiene como tarea comprender durante el proceso de aprendizaje. para lograrlo, es necesario prestar atención a la información pertinente, organizar dicha información en imágenes coherentes, e integrar esas imágenes en los conocimientos ya existentes. el modelo de aprendizaje de mayer (12) se compone de selección, organización e integración (soi). en la selección se requiere que el docente haga hincapié en las palabras e imágenes pertinentes, y esto puede ser a través de un resumen o una presentación. en la organización de la información nueva, el estudiante recibe representaciones auditivas o imágenes; las representaciones auditivas se reciben por medio de representaciones verbales coherentes, y las de imágenes por una serie de representaciones gráficas también coherentes. la integración puede ser hecha en el alumno en forma de mapa conceptual o solución de guías de trabajo. de esta forma, el alumno realiza conexiones una por una entre los elementos correspondientes a las representaciones gráficas y verbales creadas mediante los conocimientos previos. un último paso en el proceso de aprendizaje es la codificación mediante la cual las representaciones mentales construidas en la memoria activa se almacenan en forma permanente en la memoria a largo plazo. el aprendizaje escolar consiste en “un proceso de construcción de significados y de atribución de sentidos cuya responsabilidad última corresponde al alumno...”, enfatiza que “la función prioritaria de la educación escolar es, o mejor debería ser, la de promover el desarrollo y el crecimiento personal de los alumnos”. 69 formando docentes, una experiencia desde el constructivismo respecto a la evaluación del aprendizaje, considera la aplicación de dos tipos de pruebas: de retención y de transferencia. las primeras responden a la pregunta ¿cuánto he aprendido? las pruebas de transferencia responden a la pregunta ¿qué he aprendido?, y se refieren a la aplicación de lo aprendido en situaciones nuevas, utilizando la experiencia previa (12). con esta propuesta se elabora una intervención educativa, que para efecto de este trabajo abordó tres temas: tema 1, andragogia; tema 2, aprendizaje grupal, elementos teóricos para la planeación didáctica, y tema 3, diseño de estrategias para el aprendizaje grupal. las estrategias educativas se diseñaron para favorecer el aprendizaje en pequeños grupos (parejas) y la discusión en plenaria; se utilizó también el taller con hojas guía que contenían instrucciones claras respecto al resultado que se requería, y la lluvia de ideas, enfocados a las tareas y los problemas propios de la temática que se iba a tratar. metodología se realizó un estudio descriptivo y de intervención, aplicando preprueba y posprueba por sesión y por tema, con el objetivo de identificar los resultados en aprovechamiento al aplicar el diseño de aprendizaje constructivista de mayer (12) en un grupo de profesores. fueron incluidos docentes que estuvieran participando en el denaep (programa de educación semiescolarizada de enfermería), y que no tuvieran conocimiento de los temas por tratar. se diseñaron: un plan de clase por sesión y por tema cubriendo los requerimientos del aprendizaje constructivista (figura 1); un examen diagnóstico por sesión y por tema; una prueba de retención por tema, que se basó en el logro de los estudiantes respecto al área cognoscitiva del nivel i en la taxonomía de b. bloom, y una prueba de transferencia por tema, que se refiere a la aplicación de lo aprendido para resolver situaciones nuevas, utilizando la experiencia previa así como el nuevo conocimiento, que se basó en el logro de objetivos de aprendizaje de nivel ii y vi de la misma taxonomía. procedimiento: a) se explicó el motivo de su participación y se solicitó al grupo consentimiento para video grabar la situación educativa, así como su presentación en un seminario, b) aplicación de la evaluación diagnóstica, c) encuadre a través de la hoja de plan de clase, d) inicio, desarrollo y culminación de la sesión de acuerdo al plan de clase, y e) evaluación final con pruebas de retención y de transferencia. es importante hacer notar que el material del tema no se dio a conocer a ninguno de los participantes antes de las sesiones. las sesiones 1 y 2 se realizaron el mismo día con un descanso de 30 minutos entre ellas. la sesión 3 se realizó una semana después. cada sesión fue de 3 horas. resultados en las sesiones 1 y 2 el grupo se integró por 12 docentes coordinadores de grupo y 1 docente de asignatura. de ellos el 23% hombres y el resto mujeres. el 69% son menores de 28 años, 46% del total tiene menos de un año de experiencia como profesor de aula. el mismo porcentaje cuenta con formación de licenciado en enfermería, 30,8% tienen una especialidad, y el 23% con maestría. en el diseño constructivista de aprendizaje el papel del educador se reduce al de asesor, guía y cuidadoso diseñador de experiencias de aprendizaje congruentes con el grupo y los contenidos temáticos. 70 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 con respecto al ingreso como docentes a esta institución, el 61% tiene menos de un año. del grupo de los 13, el 38% participan en el programa educativo de técnico en enfermería, 23,1% en la licenciatura, 15,4% en podología, y el 23,4% trabaja en dos programas. tema 1: no se recibieron sugerencias de cambio. el plan de clase se aplicó en tres horas. la permanencia de los participantes fue del 100%. la preprueba aplicada de forma individual muestra un 50% de conocimiento del tema. la posprueba en parejas, en el apartado de retención, tuvo como resultado el 90% de conocimiento del tema, y en la prueba de transferencia como aplicación del conocimiento nuevo a situaciones nuevas bajo criterios específicos de evaluación, y realizada en parejas, muestra que la aplicación del conocimiento fue del 91% de la información que se solicitaba para resolver la guía de trabajo 1 (figura 2). tema 2: no se recibieron sugerencias de cambio, la sesión se realizó en 3 horas y la permanencia fue del 92,3%. los resultados de la preprueba individual muestran que el grupo conocía el 33,3% de la información respecto al tema. en la posprueba aplicada en parejas, los resultados fueron: prueba de retención 77,6% de información, y en la de transferencia con criterios preestablecidos se obtuvo un 95% de aplicación de la información en la solución de la guía 2 (figura 3). tema 3: en esta sesión participaron 9 docentes; un hombre y 8 mujeres. la permanencia fue del 88,8%. el tiempo de trabajo en aula fue de 3 horas, sin cambios en el plan de clase y sin receso. la preprueba individual refleja que el grupo conocía el 28% de la información respecto al tema. la posprueba en esta sesión se aplicó de forma individual y se encontró que la retención de la información fue del 71,6%. respecto a la prueba de transferencia, concertada por pequeños grupos, y presentada en plenaria bajo la coordinación del facilitador, tuvo un aprovechamiento del 90% en la aplicación de la información de acuerdo con la guía 3 (figura 4). discusión los datos encontrados en este estudio, relacionados con el aprovechamiento del grupo al aplicar un diseño con enfoque constructivista, concuerdan con lo expresado por mayer respecto a que la participación activa de los estudiantes propicia el aprendizaje. los resultados muestran un incremento en el porcentaje de información al final de cada sesión. también fueron cuidadosamente seleccionadas las estrategias de aprendizaje para acercar el trabajo en aula a lo propuesto por fernández y garcía-barrón, y diseñar un escenario áulico promotor de estudiantes constructores, capaces de asumir la responsabilidad de su propio aprendizaje y de evaluar su progreso, situación que se reflejó en el trabajo de los participantes en los pequeños grupos, y en su participación activa y comprometida en las sesiones de discusión plenaria. ante las evidencias se concluye que el diseño educativo para un aprendizaje constructivista ofrece la posibilidad de incrementar la información y aplicación del conocimiento de los estudiantes a partir del trabajo en aula. pero requiere de planes de trabajo en aula congruentes con los principios del enfoque constructivista, con mayor inversión de tiempo del facilitador para preparar el plan de clase, así como mantener una comunicación horizontal con los participantes. sin embargo, es necesario puntualizar que los docentes participantes tienen el hábito de la lectura, lo que facilitó la comprensión rápida de los contenidos; así mismo, el que sean colaboradores en un mismo departamento también facilita la posibilidad de discutir la temática, a pesar de no tener conocimiento previo. se recomienda realizar estudios con jóvenes de nivel licenciatura para conocer el nivel de aprovechamiento con esta forma de apoyar el aprendizaje. conclusiones el aprovechamiento en aula se incrementa con un diseño constructivista de aprendizaje. en el diseño constructivista de aprendizaje el papel del educador se reduce al de asesor, guía y cuidadoso diseñador de experiencias de aprendizaje congruentes con el grupo y los contenidos temáticos. la posprueba de retención, como oportunidad de incrementar el conocimiento, aplicada en parejas ofrece más posibilidades de aprendizaje que la que se realiza en forma individual. la posprueba de transferencia con guías muestra un espacio de discusión y de reflexión respecto a los contenidos y su aplicación a situaciones reales. agradecimientos a los docentes del denaep de la facultad de enfermería de la buap, méxico, por su desinteresada participación. 71 formando docentes, una experiencia desde el constructivismo referencias 1 kantún ma. el aprendizaje significativo en la formación del profesional de enfermería. rev des cientif enferm 2005; 13 (10): 314-316. 2 fernández e. valoración del enfoque constructivista de las competencias en enfermería en la universidad europea de madrid. rev. des cientif enferm 2005; 13 (10): 304-313. 3 garcía-barrón a. aprendizaje significativo y rol docente en la enseñanza de enfermería 2005; 14 (10): 424-427. 4 quinn fm hughes s. principles and practice of nurse education. cap. 4 cognitive perspectives on teaching and learning. en: antología educación en enfermería 1; 2006. 5 palomino w, delgado z, valcarcel l. enseñanza termodinámica: un enfoque constructivista. ii encuentro de físicos en la región inka unsaac, perú; 1996. disponible en: monografías.com [fecha de acceso marzo de 2006]. 6 fundación chile. modelo de aprendizaje sociocultural de vigotsky; 2006. disponible en: http:www. educarechile [fecha de acceso mayo de 2006]. 7 lópez mm. definición de teoría del aprendizaje de vigotsky. disponible en www.psicopedagogia.com [fecha de acceso mayo de 2006]. 8 coll c et al. el constructivismo en el aula. 11 ed. españa: graó; 1999. 9 palacios cf. algunos principios rectores del constructivismo. rev. mexicana de pedagogía 1996; vii (31): 12-16. 10 barberá e et al. el constructivismo en la práctica. españa: graó; 2000. 11 betancourt mj. creatividad en la educación: educar para transformar. méxico: centro de estudios e investigaciones de creatividad aplicada; 2002. 12 mayer re. diseño educativo para un aprendizaje constructivista. journal of educational psychology 1993; (6): 153-169. 72 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 73 formando docentes, una experiencia desde el constructivismo 1 valentina andrea garcía-portuguez1 mónica muñoz-serrano2 claudia uribe-torres3 padre comprometido con la crianza temprana desde el primer contacto padre-hijo/a vivido en el nacimiento* 1 https://orcid.org/0000-0002-1594-435x. pontificia universidad católica de chile, escuela de enfermería, chile. vdgarcia@uc.cl 2 https://orcid.org/0000-0001-9104-3687. pontificia universidad católica de chile, escuela de enfermería, chile. mmunozse@uc.cl 3 https://orcid.org/0000-0002-0699-7695. pontificia universidad católica de chile, escuela de enfermería, chile. curibet@uc.cl * artículo derivado de la tesis doctoral “investigación acción: intervención educativa para la promoción del contacto precoz padre-hijo en el contexto del nacimiento”, presentada a la universidade de são paulo en 2017. disponible en: https://doi.org/10.11606/t.7.2017. tde-27102017-095652 recibido: 03/04/2020 enviado a pares: 21/04/2020 aceptado por pares: 26/05/2020 aprobado: 10/06/2020 resumen objetivo: conocer cómo se muestra el fenómeno de la crianza paterna activa a partir de la experiencia de contacto padre-hijo/a, vivida durante el nacimiento. método: análisis de información secundaria de un estudio cualitativo de naturaleza fenomenológica. transcripciones de entrevistas y grupos focales de todos los padres que participaron de un protocolo de contacto padre-hijo/a para una tesis doctoral. resultados: el estudio reveló la estructura global del fenómeno, cuyo eje central corresponde a “padre que transita hacia la conexión integral con su hijo/a y se compromete con la crianza”, y sus tres categorías comprensivas: expectativas de ser padre y actor en la crianza; la vivencia de ser padre en el momento del nacimiento; el día a día de la crianza. conclusión: la preparación antenatal y el contacto piel con piel durante el nacimiento movilizan al padre hacia el compromiso e involucramiento con la crianza de su hijo/a desde el comienzo. palabras clave (fuente: decs) crianza del niño; educación prenatal; relación padre-hijo; investigación cualitativa; nacimiento. año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2037 temática: promoción y prevención. aporte a la disciplina: incorporar a los padres de manera activa mediante la educación prenatal participativa favorece la actitud que tendrán hacia la futura crianza de su hijo/a. cobra relevancia realizar sesiones de preparación prenatal en función de las expectativas planteadas por el padre y por la madre, evitando la estandarización de la educación, ya que cada individuo tiene necesidades de aprendizaje particulares. dicha preparación culmina en un acto de conexión por medio del contacto piel con piel entre el padre y el bebé durante el momento del nacimiento y con el surgimiento de un vínculo único entre ambos, lo cual favorece una paternidad comprometida con la crianza activa del hijo/a. el abordaje desde la disciplina de la enfermería permite convertir un evento obstétrico en el que son protagonistas la madre y el hijo/a en un acto social inclusivo y familiar para la promoción de lazos saludables. doi: 10.5294/aqui.2020.20.3.7 para citar este artículo / to reference this article / para citar este artigo garcía-portuguez va, muñoz-serrano m, uribe-torres c. father committed to early parenting from the first father-child contact experienced at birth. aquichan. 2020;20(3):e2037. doi: https://doi.org/10.5294/aqui.2020.20.3.7 https://orcid.org/0000-0002-1594-435x mailto:vdgarcia@uc.cl https://orcid.org/0000-0001-9104-3687 mailto:mmunozse@uc.cl https://orcid.org/0000-0002-0699-7695 mailto:curibet@uc.cl https://doi.org/10.11606/t.7.2017.tde-27102017-095652 https://doi.org/10.11606/t.7.2017.tde-27102017-095652 https://doi.org/10.5294/aqui.2020.20.3.7 https://orcid.org/0000-0002-1594-435x https://orcid.org/0000-0001-9104-3687 https://orcid.org/0000-0002-0699-7695 https://doi.org/10.5294/aqui.2020.20.3.7 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2037 father committed to early parenting from the first father-child contact experienced at birth* abstract objective: to know how the phenomenon of active paternal upbringing is shown from the father-child contact experience during birth. method: analysis of secondary information from a qualitative study of a phenomenological nature. transcripts of interviews and focus groups of all the fathers who participated in a father-child contact protocol for a doctoral thesis. results: the study revealed the global structure of the phenomenon, whose central axis corresponds to “father who advances towards the integral connection with his child and is committed with parenting”, and its three comprehensive categories: expectations of being a father and actor in parenting; the experience of being a father at birth time; and the everyday of the upbringing. conclusion: prenatal preparation and skin-to-skin contact during birth mobilize the father towards commitment and involvement with the upbringing of his child from the beginning. keywords (source: decs) child rearing; prenatal education; father-child relations; qualitative research; childbirth. * article derived from the doctoral thesis entitled “action research: educational intervention for promoting early father-child contact in the context of birth”, submitted in 2017 to the university of de são paulo. available in: https://doi.org/10.11606/t.7.2017.tde-27102017-095652 https://doi.org/10.11606/t.7.2017.tde-27102017-095652 3 padre comprometido con la crianza temprana desde el primer contacto padre-hijo/a vivido en el nacimiento l valentina andrea garcía-portuguez y otros pai engajado na criação precoce desde o primeiro contato pai-filho(a) vivido no parto* resumo objetivo: conhecer como o fenômeno da educação paterna ativa é demonstrado a partir da experiência de contato pai-filho/a vivida durante o nascimento. método: análise de informações secundárias a partir de um estudo qualitativo de natureza fenomenológica. transcrições de entrevistas e grupos focais de todos os pais que participaram de um protocolo de contato pai-filho para uma tese de doutorado. resultados: o estudo revelou a estrutura global do fenômeno, cujo eixo central corresponde ao “pai que transita em direção à conexão integral com o filho / a e está comprometido em criar”, e suas três categorias abrangentes: expectativas de ser pai e ator na criação; a experiência de ser pai ao nascer; o dia a dia no processo de criação. conclusão: o preparo pré-natal e o contato pele a pele durante o parto mobilizam o pai para o comprometimento e o envolvimento com a criação do filho desde o início. palavras-chave (fonte: decs) educação infantil; educação pré-natal; relações pai-filho; pesquisa qualitativa; parto. año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2037 * artigo derivado da tese de doutorado intitulada “pesquisa-ação: intervenção educativa para a promoção do contato precoce pai-filho no contexto do nascimento”, defendida na universidade de são paulo em 2017. disponível em: https://doi.org/10.11606/t.7.2017.tde-27102017-095652 https://doi.org/10.11606/t.7.2017.tde-27102017-095652 4 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2037 aquichan issn 1657-5997 eissn 2027-5374 introducción está demostrado que el contacto piel con piel entre una madre y su recién nacido/a supone beneficios para ambos, especialmente para el vínculo. en la madre aumenta la efectividad de la lactancia, mientras que en el recién-nacido se estabiliza el sistema cardiorrespiratorio, junto con otros efectos positivos (1). en un estudio chileno, se demostró que el contacto precoz piel con piel presenta una asociación significativa con la disminución de sintomatología depresiva materna, lo que constituye una estrategia importante para mejorar la calidad de vida del binomio (2). no obstante, esta práctica beneficiosa para la madre y su hijo/a también puede serlo para la relación padre-hijo/a. el contacto piel con piel del padre con su hijo/a (en adelante cppph) produciría un aumento de los niveles de oxitocina paterna y una disminución de los niveles de estrés (3), por lo cual es fundamental favorecer esta práctica inclusiva en los nacimientos. pese a que la práctica descrita aún no es culturalmente aceptada, incluso por las propias mujeres (3), en otros estudios se describen diferencias entre los contactos madre-hijo/a y padrehijo/a (4), así como los beneficios para las habilidades parentales a futuro (5) y el fortalecimiento del vínculo padre-hijo/a (6). como se ha visto en algunos estudios, la suposición de que el contacto paterno fortalece el vínculo entre padre e hijo/a (6) cobra relevancia para el ámbito de la enfermería. estudiar en profundidad este fenómeno le permitirá conocer las directrices para dirigir posibles intervenciones futuras en atención primaria o en los partos. asimismo, comprender los beneficios del cppph para las habilidades parentales a futuro (5) le ayudará a incorporar al padre de manera precoz en todo el proceso de embarazo y parto. según una metasíntesis encontrada, el cppph facilita el rol paternal cuando el padre toma conciencia de las necesidades de su recién-nacido, punto a partir del cual marca sus habilidades de crianza (7). en chile, la práctica de cppph no se realiza de manera rutinaria. por lo tanto, el objetivo de este proyecto de investigación es conocer cómo se muestra el fenómeno de la crianza paterna activa a partir de la experiencia de contacto padre-hijo/a, vivida durante el nacimiento, desde la perspectiva de padres varones cuyos hijos/as nacieron en algún establecimiento de la red salud uc-christus. la pregunta que guía este estudio es: ¿cómo viven los padres la experiencia de crianza de su hijo/a a partir del contacto establecido entre ambos al momento del nacimiento? marco teórico filosófico los supuestos planteados para esta investigación son: a) las experiencias de cppph son particulares y múltiples; b) la fenomenología permite develar la experiencia vivida y los significados que los padres varones asignan a esta vivencia; c) la experiencia consciente de la persona es develada mediante el testimonio de quien es portador del fenómeno en estudio. lo anterior propone un enfoque fenomenológico como metodología cualitativa para responder la pregunta planteada. este corresponde a la metodología que se enfoca en la comprensión de la vivencia sobre un fenómeno en particular, que se encuentra oculto a la conciencia. como filosofía, concierne al estudio de las esencias mediante una descripción de la experiencia vivida día a día por la persona. no pretende conocer la etiología de la esencia, sino más bien busca comprenderla para así poder entender lo que esa persona está mostrando al compartir el relato de su vivencia (8). metodología para este estudio, se utilizó un análisis de información secundaria generada a partir de una tesis doctoral llevada a cabo entre 2015 y 2016 (9), que combinó dos metodologías en dos etapas de la vivencia de los padres: investigación-acción, para la preparación antenatal de los padres varones, y abordaje fenomenológico, para comprender la experiencia paterna vivida a partir del nacimiento. el análisis desde la perspectiva fenomenológica se basó en tres conceptos clave: esencia, intuición y reducción fenomenológica. la esencia es la unidad de significado más básica que permite la descripción personal y subjetiva del fenómeno en estudio. la intuición corresponde a la interpretación del fenómeno, a partir de la descripción realizada por el participante-portador. la reducción fenomenológica es un proceso en el cual el investigador debe aislar todos los elementos personales que tengan relación con el fenómeno en estudio y que pudiesen interferir en dicha interpretación y comprensión (8). la selección de los participantes del estudio original correspondió a doce padres y sus parejas gestantes, todos adultos, que cursaban un embarazo fisiológico de tercer trimestre (9). los grupos focales previos al parto y las entrevistas individuales realizadas al mes del parto fueron previamente transcri5 padre comprometido con la crianza temprana desde el primer contacto padre-hijo/a vivido en el nacimiento l valentina andrea garcía-portuguez y otros tas de manera textual; su contenido revelaba información del fenómeno relacionado con la crianza paterna y con el cppph. en los grupos focales, se identificaron expectativas relacionadas con la crianza paterna; en las entrevistas, aquellas unidades de significado que develaron el fenómeno de la crianza en el día a día posterior al nacimiento. el análisis de la información se realizó según lo planteado por streubert (10), que consiste, primero, en la descripción personal sobre el fenómeno de interés y en el registro escrito de los supuestos propios del investigador (bracketing); segundo, en la lectura y la relectura de las trascripciones para la visión general y el detalle del levantamiento de las esencias (unidades de significado); tercero, en la comprensión de la relación entre las unidades de significado y la agrupación, según las concordancias. este proceso completo permite desarrollar y presentar una estructura formal del fenómeno estudiado, junto con la riqueza de una atingente discusión con la literatura relevante y disponible. respecto al rigor metodológico, según lo planteado por guba y lincoln en streubert (10, 11), se identificaron cuatro criterios que sustentan el trabajo realizado: credibilidad, dependencia, confirmabilidad y transferibilidad. la credibilidad y el proceso de member checking fue asegurado en el estudio original, conforme se respetó el principio de coparticipación y validación de los temas emergentes y expectativas surgidas en la investigación-acción. la credibilidad se logra al conectar las esencias surgidas con información disponible en estudios relacionados y la triangulación del análisis entre los investigadores. respecto a la dependencia, hubo una descripción minuciosa de cada paso realizado en la metodología, tanto en el estudio original como en el actual. para la confirmabilidad, se realizó la triangulación del análisis entre el investigador principal, el guía y el revisor. esta se llevó a cabo en sesiones entre el investigador principal y el guía. luego, el investigador principal envió por separado su análisis al investigador guía y al revisor para obtener tres puntos de vista. finalmente, las tres impresiones se recogieron en una sesión de cierre para llegar a un consenso y a una comprensión profunda del fenómeno develado. para la confirmabilidad, fue necesario describir paso a paso cada una de las etapas realizadas, de modo que sea reproducible para otros investigadores. finalmente, para la transferibilidad, se registraron en una tabla (tabla 1) las características de los padres del estudio original, para que futuros investigadores puedan extrapolar los resultados a poblaciones similares. tabla 1. caracterización de los participantes participante edad nacionalidad escolaridad previsión estado civil sistema de salud público institucionalizado dorado 31 chileno técnico profesional fonasa soltero rojo 23 chileno educación media isapre soltero sepia 35 chileno técnico profesional fonasa soltero marrón 39 chileno técnico profesional isapre casado gris 54 chileno educación media fonasa casado calipso 27 chileno educación media fonasa soltero jade 45 chileno técnico profesional fonasa soltero sistema de salud privado messi 30 argentino educación superior isapre casado vidal 34 chileno educación superior isapre casado pinilla 32 chileno educación superior isapre casado medel 35 chileno educación superior isapre casado sánchez 29 chileno postgrado isapre casado fuente: elaboración para la tesis doctoral original, con base en uribe-torres y hoga (9). otro punto importante por destacar es que las consideraciones éticas, tanto del estudio original como del actual, fueron analizadas a la luz de los principios propuestos por emanuel (12). asimismo, este estudio contó con la aprobación del comité ético científico de la facultad de medicina de la pontificia universidad católica de chile (puc). el proyecto de tesis doctoral original contó con la aprobación de la misma entidad chilena y con la del comitê de ética em pesquisa da eeusp, brasil, teniendo en cuenta que los procedimientos de la investigación original fueron desarrollados conforme a la resolución 466/2012, do conselho nacional de saúde-brasil y de la ley 20.120 en chile. 6 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2037 aquichan issn 1657-5997 eissn 2027-5374 resultados categorías comprensivas y fenómeno central las esencias develadas a partir de los relatos transcritos confluyen en tres grandes categorías: las expectativas de ser padre y actor en la crianza , la vivencia del cppph en el nacimiento y el día a día de la crianza paterna. estas permiten dar sustento y comprender el fenómeno del “padre que transita hacia la conexión integral con su hijo/a y se compromete con la crianza”, representado en la figura 1. figura 1. figura descriptiva del fenómeno develado expectativas de ser padre y actor en la crianza las expectativas paternas consideradas en este estudio fueron identificadas desde el contenido de los grupos focales de la fase exploratoria de la preparación antenatal (estudio original). aquellas más relevantes correspondieron a: lograr reconocer a futuro las necesidades de su hijo/a, desarrollar habilidades de crianza, evolucionar cultural y generacionalmente respecto de cómo fueron sus padres con ellos y querer ser parte de la vida de sus hijos/as desde el nacimiento. ser capaz de reconocer las necesidades de mi hijo/a la expectativa de ser un buen padre surge en la medida en que el sujeto se siente capaz y desea aprender a reconocer las necesidades más básicas de sus hijos/as, como el llanto, el descanso y el hambre. “reconocer los tipos de llanto, cuando tiene hambre, cuando tiene sueño […]. saber si tiene hambre o podemos intentar dormirlo…” (p5). desarrollar habilidades de crianza los relatos de los padres, durante la fase exploratoria, muestran la necesidad de aprender habilidades técnicas básicas para la crianza de sus hijos/as, como mudar, tomar, vestir y calmar. “… de cómo tomarlo y con qué fuerza; de cómo cambiarlo, ponerle ropa, sacarle ropa. esas son cosas que nadie a uno le enseña” (p3). “… es muy importante ver el tema de mudar porque yo a mis hijos nunca los mudé; en algunas situaciones por emergencia, pero que a mí me naciera yo ir a mudar al niño” (p4). evolucionar cultural y generacionalmente: desde una crianza paterna pasiva a una activa en sus relatos, algunos padres refieren que las generaciones más antiguas mostraban un involucramiento nulo del padre como figura activa en la crianza. asimismo, destacan que todas las tareas se las llevaba la madre, mientras que al padre le correspondía el rol de proveedor y figura de autoridad. sin embargo, una expectativas de ser padre y actor en la crianza la vivencia de ser padre en el momento del nacimiento día a día: al encuentro con la crianza l reconocer las necesidades del hijo/a l querer aprender habilidades de crianza l evolucionar cultural y generacionalmente l querer ser parte de la vida del hijo/a desde el nacimiento l disfrutando la crianza desde el primer contacto con el recién nacido l comprometiendo la crianza y el cuidado a partir de la conexión padre-hijo/a l reconociendo y atendiendo las necesidades de su hijo/a l infundiendo tranquilidad y calma l consolidando habilidades y destrezas de la crianza l disfrutando de los cuidados básicos de su hijo/a “padre que transita hacia la conexión integral son su hijo/a y se compromete con la crianza” fuente: elaboración propia. 7 padre comprometido con la crianza temprana desde el primer contacto padre-hijo/a vivido en el nacimiento l valentina andrea garcía-portuguez y otros necesidad de cambio se observa en el relato de un padre. ya con hijos mayores, quiere involucrarse desde el inicio, por primera vez, en la crianza del hijo/a que está por nacer y lamenta no haber podido hacerlo con sus otros hijos. es una cuestión de familia también, como todo esto evoluciona. mi abuelo y mi papá eran de una forma, más distanciados de lo que fuimos mi papá y yo. también mi papá y yo fuimos más distanciados de lo que voy a ser yo con mi hija, posiblemente. las mujeres antes eran para tener hijos y para la crianza. el hombre era figura de autoridad para el hijo y con rol de proveedor. (p5) querer ser parte de la vida del hijo/a desde el momento del nacimiento se encontró que los padres buscan ser algo más que un ente que acompaña; buscan formar parte de la vida de sus hijos/as e involucrarse desde el nacimiento; esperan establecer un vínculo que se desarrolle a lo largo de una crianza activa y que se perpetúe en el tiempo y en la vida junto a sus hijos/as. “… pero también significa ser parte del día uno (nacimiento) en la formación de mi hijo, y que él pueda sentirse confiado [de] que tendrá un padre presente y activo en su formación y crecimiento a lo largo de toda su vida” (p1). “no quiero quedarme fuera, sino que ir insertándome ya desde el principio en la vida de ella” (p5). la vivencia de ser padre en el momento del nacimiento la vivencia del nacimiento, ser y sentirse padre, fue recogida de los relatos obtenidos por medio de entrevistas individuales en profundidad, efectuadas al mes de vida del niño/a. los testimonios dan a conocer sensaciones múltiples, algunas relacionadas con el momento mismo, otras que proyectan sentimientos hacia el futuro, como el deseo de criar a partir de un primer contacto. disfrutando la crianza desde el primer contacto con el recién-nacido el fenómeno se muestra como una conexión única entre padre e hijo/a, generada a partir del primer contacto piel con piel establecido entre ambos. el padre disfruta este momento como un actor, no como un espectador. “yo veo que la conexión que tengo con mi hija es exquisita […] en este momento estoy disfrutando a mi hija desde el momento en que nació. en esta situación fui más que un espectador, a mi hija la disfruté de un inicio” (pa). comprometiendo la crianza y el cuidado a partir de la conexión padre-hijo/a algunos padres expresan la vivencia del nacimiento como una “conexión” que los llama al compromiso y a la responsabilidad con su hijo/a, a través de la cual le entregan la seguridad, tranquilidad y protección que necesita. “lo vi y sentí la responsabilidad, sentí que yo soy necesario para él, y él es necesario para mí también. sentí una especie de conexión con él” (pc). yo le conversaba que mientras yo estuviera ahí con ella no le va a faltar nada, no le va a pasar nada, que se sienta protegida conmigo, que me cuente todo. uno sueña mucho, ser el padre ideal, que no tenga ninguna carencia, que confíe, que me diga todo, que estoy disponible para ella cien por ciento, eso trataba de expresárselo (en el nacimiento). (pg) “tiene que ver con una contención que uno le entrega a ella, y que a ella le transmite tranquilidad, no miedo” (pe). la conexión experimentada durante el nacimiento permite al padre proyectarse hacia el futuro de la crianza con un rol especial, querer ver crecer a su hijo/a y sentirse orgulloso de su condición. “ternura, amor, empecé a soñar en seguida; cuando crecía, su primer día de clases, su primer baile, todas las pequeñas cosas que uno no ve cuando te las cuentan, sino que cuando tú las empiezas a vivir es diferente, se siente todo más directo, en primera persona” (pg). “muchas cosas… sentía miedo por lo frágil, alegría de que era mi hija y tenerla por primera vez, orgullo de ser padre, orgullo de que ya haya nacido. sentí ganas de verla crecer” (pb). día a día: al encuentro con la crianza los relatos develan los sentimientos que tienen relación con el día a día, luego del nacimiento, tanto en el vínculo como en la crianza. surgen esencias donde los padres se muestran se8 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2037 aquichan issn 1657-5997 eissn 2027-5374 guros al lograr reconocer y atender las necesidades que tienen sus hijos/as, consolidando habilidades técnicas básicas para el cuidado de ellos. reconociendo y atendiendo las necesidades de su hijo/a al relatar su experiencia vivida en el posparto, los padres logran dar a conocer un tópico relacionado con el saber ser padre, saber reconocer y atender las necesidades de su hijo/a. logran leer sus necesidades, lo cual les deja satisfechos con sus propios logros. mi bebé puede llorar, pero ni siquiera tengo que hacerme de paciencia, ya que para mí es parte del proceso de entender que quiere algo. yo ahora tomo a mi bebé, la trato de entender, creo que ahora tengo una conexión gracias a la cual sé lo que va a pasar después [de] que tome leche, cuándo tiene sueño. todos esos procesos los entiendo, puedo leer lo que está diciendo la bebé. (pa) “ya identifico cuándo es algo que realmente necesita y cuándo no. su manera de llorar es diferente cuando realmente tiene hambre o frío […] el día a día uno va conociéndola más” (pg). infundiendo tranquilidad y calma: beneficio para la relación padre-hijo/a los testimonios dan a conocer que los padres sienten una complicidad con su hijo/a tal que llegan a ser la persona que logra transmitir tranquilidad y calma a su bebé. un padre relata sentir que dicha tranquilidad genera un beneficio mutuo; se produce una “tranquilidad sincrónica” entre ambos. la bebé se dice que tiene más apego hacia mí. cuando estoy con ella no tengo ningún problema, mi hija se porta el “descueve” (muy bien), no molesta en nada, pero mi pareja me dice que cuando yo no estoy, la bebé llora mucho; cuando yo estoy ella no llora, ¿te das cuenta del cambio? (pa) cuando está en la pieza, me he dado cuenta de que lo tranquilizo. ahora, los últimos días, en la noche, lo paseo yo, lo hago dormir un ratito y lo acuesto más cerca mío. mañosea y me acerco, le respiro más cerca y se queda tranquilo, se empieza a quedar dormido, se tranquiliza con uno, eso se sigue manteniendo. (pd) “como es tranquilo, me hace estar tranquilo a mí, yo creo que él siente eso. cuando lo tomo estoy tranquilo” (pc). a partir de la necesidad de tranquilidad por parte del bebé, los padres revelan en sus relatos que han ido desarrollando estrategias para calmar a sus hijos/as, dependiendo de cada necesidad identificada. “en ese momento se puso a llorar, y nadie podía calmarla. la tomé y se quedó tranquila; quería estar de pie también porque si me sentaba se ponía inquieta, entonces me puse de pie, la empecé a mecer y se calmó” (pb). “me gusta tomarla de muchas formas porque encuentro que es mucho más relajante para ella. es increíble: cuando uno la toma, se siente enseguida cuando está incómoda, cuando se siente inquieta o cuando no está bien” (pf). “ahora, yo la tomo, la paseo un poquito, le susurro algo y ella se calma. creo que una parte de ella debe volver a ese momento de calor, de confort y de unión (nacimiento)” (pe). consolidando habilidades y destrezas para la crianza otra de las esencias develadas a partir de los relatos de los padres comprende el logro de competencias, destrezas y habilidades para la crianza de sus hijos/as. en estos se destaca el sentimiento de confianza, no tener miedo. “yo tomo a mi bebé con confianza, tranquilamente, no tengo problema de darle vuelta para allá o para acá, entonces eso para mí creo que fue muy positivo” (pa). “ahora estoy hecho un maestro en cambiar pañales, ya no tengo ningún problema. he estado practicando el cambio de pañal, aprendiendo cosas técnicas […] hasta lo he vestido. al principio se me complicaba más, pero ahora ya encontré la técnica para poder ponerle su ropa, había que agarrar confianza” (pd). “me siento bien confiado; de hecho, creo que lo puedo hacer dormir fácil, o si hay que cambiarle pañales, también lo hago” (pc). atribuyen al logro de estas destrezas el haber tenido el primer contacto piel con piel con sus hijo/as al momento del nacimiento. pese a que para algunos en un comienzo no fue sencillo, sienten que esta instancia les permitió estar preparados para enfrentarse a nuevas situaciones de cuidado de sus hijos/as. 9 padre comprometido con la crianza temprana desde el primer contacto padre-hijo/a vivido en el nacimiento l valentina andrea garcía-portuguez y otros “al hacer apego, uno tiene que enfrentarse con el contacto físico inmediato; entonces, cuando uno tiene que tomarla por segunda vez, ya no está esa barrera de no haberla tomado nunca” (pe). “con la seguridad que me dio esto de poder tomarlo porque nunca había tomado una guagua, y ya con usted me dio un poco más de seguridad, me sentí más capacitado” (pd). disfrutando de los cuidados básicos de su hijo/a en sus relatos, los padres se muestran a gusto, disfrutando, felices de cuidar físicamente de sus hijo/as. no lo ven como una obligación, así que el sentirse motivados les genera satisfacción. “cambiarlo, bañarlo, sacarle los chanchitos, hacerle el bolso para salir. hay que estar ahí participando y haciendo todo lo que se pueda hacer. lo hago con gusto, con mucho gusto” (pd). “sí, aunque esté muerto de sueño, disfruto de vestirla, de bañarla, aunque llore mucho también por eso” (pg). discusión en este estudio, los relatos mostraron que los padres que han recibido preparación antenatal del tipo participativa se muestran involucrados con la crianza de su hijo/a desde el comienzo. manifiestan, espontáneamente, expectativas de ser buenos padres y cuidadores, capaces de reconocer las necesidades de sus hijo/as que están por nacer. según otros autores, gracias a las sesiones de preparación antenatal especial para padres, estos lograrían sentir más confianza a la hora de enfrentarse a sus distintos roles a partir del nacimiento (10). en el estudio original (9, 13), ningún padre refirió sentirse excluido durante la preparación antenatal. esto, debido a que en las sesiones exploratorias y educativas se definieron conjuntamente los temas por desarrollar. sin embargo, en otros estudios, pese a haber recibido preparación antenatal, los padres se sintieron excluidos al participar en unas sesiones orientadas solo a las madres. por lo tanto, plantearon que les hubiese gustado que les enseñaran habilidades básicas para la crianza (14). en los relatos, los padres expresaron que buscaban reconvertir experiencias culturales y generacionales del pasado, pasando de una crianza paterna pasiva a una activa. sostenían que antiguamente el padre era el proveedor, mientras que la madre era la que se encargaba de la crianza. al recibir preparación antenatal, lograron visibilizar esta percepción sobre la crianza, y ahora buscan involucrarse de manera activa en esta y cambiar la historia. otros autores refuerzan esta idea: padres que recibieron preparación antenatal tuvieron la posibilidad de reflexionar sobre la influencia del medio cultural, social e histórico como barrera de la crianza paterna (15). en los relatos de este estudio, los padres refirieron no sentir temor para enfrentarse al primer contacto padre-hijo/a. sin embargo, otros estudios muestran que, al sentir que la crianza siempre ha sido una función materna, los padres temen a la paternidad, sintiéndose excluidos de dicha labor. sponsler et al. señalan que una de las principales estrategias para traspasar esta barrera del miedo es la preparación parental antenatal y el contacto físico durante el nacimiento (16). por su parte, nyqvist et al. exponen que de manera espontánea, sin preparación antenatal parental, es difícil que se establezca cppph, ya que lo atribuyen a privilegios de la madre (17). para los padres de este estudio, la crianza comenzó desde el momento del nacimiento, desde el primer cppph. los relatos muestran el surgimiento del vínculo que los conectó y los comprometió con sus hijos/as; la necesidad de cuidarlos, de verlos crecer y de ser padres; la seguridad y la confianza para criar. se pudieron develar dichas esencias gracias al enfoque fenomenológico utilizado para analizar las entrevistas (8). otros autores reafirman esta idea, con el refuerzo del vínculo, la conexión profunda y la sensación de seguridad y confianza que transmiten para criar (15, 18). posteriormente, en el día a día de la crianza, los padres refirieron en sus relatos que las expectativas antenatales se cumplieron. lograron reconocer y atender las necesidades básicas de sus hijo/as; desarrollaron autoconfianza y habilidades básicas para la crianza, como mudar, pasear, vestir y tomar en brazos a sus recién-nacidos/as. esto, gracias al haberse involucrado desde un primer momento (el nacimiento) en la crianza de sus hijos/ as. este aspecto lo refuerza una metasíntesis cuyo planteamiento es que los padres se sienten más seguros y cercanos a la crianza desde el primer contacto en el nacimiento hasta el primer año de vida, progresivamente. el mudar o bañar les permite sentirse más seguros con el cuidado de sus hijo/as (19). a su vez, otros autores plantean que mientras más temprano se involucre el padre, existirá un mayor compromiso de su parte con la crianza (20). 10 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2037 aquichan issn 1657-5997 eissn 2027-5374 conclusión la preparación antenatal paterna inclusiva resulta en un padre comprometido con la crianza desde antes del nacimiento. con este beneficio, los padres pueden comprender y manifestar sus debilidades y sus fortalezas, y esto permite orientar la intervención con base en esas dificultades. comenzar con el cppph en el nacimiento otorga herramientas técnicas y afectivas que empoderan al padre en este rol. el vínculo temprano padre-hijo/a establecido impacta positivamente en la familia, así como en la relación con la pareja. no obstante, es necesario continuar explorando cómo este tipo de intervención contribuye a establecer relaciones de pareja y familiares saludables, protectoras de la infancia. conflicto de intereses: ninguno declarado. referencias 1. moore e, bergman n, anderson g, medley n. early skin-to-skin contact for mothers and their healthy newborn infants (review). summary of findings for the main comparison. cochrane database syst rev [internet]. 2016;5(11). disponible en: https://www.ncbi.nlm.nih.gov/pubmed/27885658 2. dois ca, lucchini rc, villarroel dl, uribe tc. efecto del contacto piel con piel sobre la presencia de síntomas depresivos postparto en mujeres de bajo riesgo obstétrico. rev chil pediatr [internet]. 2013;84(3):285-92. disponible en: https://scielo.conicyt.cl/pdf/rcp/v84n3/art06.pdf 3. smith er, bergelson i, constantian s, valsangkar b, chan gj. barriers and enablers of health system adoption of kangaroo mother care: a systematic review of caregiver perspectives. bmc pediatr [internet]. 2017;17(1):1-17. doi: http:// doi.org/10.1186/s12887-016-0769-5 4. velandia m, uvnäs-moberg k, nissen e. sex differences in newborn interaction with mother or father during skinto-skin contact after caesarean section. acta paediatr int j paediatr [internet]. 2012;101(4):360-7. doi: https://doi. org/10.1111/j.1651-2227.2011.02523.x 5. blomqvist yt, rubertsson c, kylberg e, jöreskog k, nyqvist kh. kangaroo mother care helps fathers of preterm infants gain confidence in the paternal role. j adv nurs [internet]. 2012;68(9):1988-96. doi: https://doi.org/10.1111/j.13652648.2011.05886.x 6. velandia m, matthisen as, uvnäs-moberg k, nissen e. onset of vocal interaction between parents and newborns in skin-to-skin contact immediately after elective cesarean section. birth [internet]. 2010;37(3):192-201. doi: https://doi. org/10.1111/j.1523-536x.2010.00406.x 7. anderzén-carlsson a, lamy zc, tingvall m, eriksson m. parental experiences of providing skin-to-skin care to their newborn infant. part 2: a qualitative meta-synthesis. int j qual stud health well-being [internet]. 2014;9. doi: https:// doi.org/10.3402/qhw.v9.24907 8. carpenter d. phenomenology as method. in: streubert h, carpenter d, editors. qualitative research in nursing: advancing the humanistic imperative. philadelphia: wolters kluwer health/ lippincott williams & w; 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2003. 13. muñoz-serrano m, uribe-torres c, hoga l. fathers prepared for and committed to their role as companions during the birth process. aquichan [internet]. 2018;18(4):415-25. doi: https://doi.org/10.5294/aqui.2018.18.4.4 14. entsieh aa, hallström ik. first-time parents’ prenatal needs for early parenthood preparation: a systematic review and meta-synthesis of qualitative literature. midwifery [internet]. 2016;39:1-11. doi: http://dx.doi.org/10.1016/j. midw.2016.04.006 15. erlandsson k, häggström-nordin e. prenatal parental education from the perspective of fathers with experience as primary caregiver immediately following birth: a phenomenographic study. j perinat educ [internet]. 2010;19(1):19-28. doi: https://doi.org/10.1624/105812410x481537 16. sponsler w, weatherspoon c, weatherspoon d, campbell d. fear of fatherhood. int j childbirth educ [internet]. 2015;30(1):3337 5p. disponible en: https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=1061&context=sn_pubs 17. nyqvist kh, rosenblad a, volgsten h, funkquist el, mattsson e. early skin-to-skin contact between healthy late preterm infants and their parents: an observational cohort study. s.d. [internet]. 2017;2017(10):1-18. doi: https://doi. org/10.7717/peerj.3949 18. chen em, gau ml, liu cy, lee ty. effects of father-neonate skin-to-skin contact on attachment: a randomized controlled trial. nurs res pract [internet]. 2017;2017:1-8. doi: http://dx.doi.org/10.1155/2017/8612024 19. shorey s, ang l. experiences, needs, and perceptions of paternal involvement during the first year after their infants’ birth: a meta-synthesis. plos one [internet]. 2019;14(1):1-22. doi: http://dx.doi.org/10.1371/journal.pone.0210388 20. castillo-carre a, espinoza-venegas m, luengo-machuca l. compromiso paterno y la relación con sus conductas promotoras de salud. rev salud pública [internet]. 2018;20(5):541-7. doi: https://doi.org/10.15446/rsap.v20n5.72033 https://doi.org/10.5294/aqui.2018.18.4.4 http://dx.doi.org/10.1016/j.midw.2016.04.006 http://dx.doi.org/10.1016/j.midw.2016.04.006 https://doi.org/10.1624/105812410x481537 https://scholarworks.waldenu.edu/cgi/viewcontent.cgi?article=1061&context=sn_pubs https://doi.org/10.7717/peerj.3949 https://doi.org/10.7717/peerj.3949 http://dx.doi.org/10.1155/2017/8612024 http://dx.doi.org/10.1371/journal.pone.0210388 https://doi.org/10.15446/rsap.v20n5.72033 1 michelle ferraz martins jamarim1 camila zucato da silva2 gerusa marcondes pimentel de abreu lima3 cibele leite siqueira4 claudinei josé gomes campos5 comunicação não verbal por meio do toque: significados para fisioterapeutas que atuam em ambiente hospitalar 1 https://orcid.org/0000-0002-7656-3745. universidade estadual de campinas, brasil. m142890@dac.unicamp.br 2 https://orcid.org/0000-0001-6717-0168. universidade estadual de campinas, brasil. 3 https://orcid.org/0000-0001-8690-4948. universidade estadual de campinas, brasil. 4 https://orcid.org/0000-0003-0999-6943. universidade estadual de campinas, brasil. 5 https://orcid.org/0000-0001-9587-6694. universidade estadual de campinas, brasil. recebido: 21/03/2019 submetido: 06/05/2019 aceito por pares: 25/08/2019 aceito: 26/08/2019 doi: 10.5294/aqui.2019.19.4.2 para citar este artigo / para citar este artículo / to reference this article jamarim mfm, silva cz, lima gmpa, siqueira cl, campos cjg. nonverbal communication through touch: meanings for physical therapists working in a hospital environment. aquichan 2019; 19(4): e1942. doi: https://doi.org/10.5294/aqui.2019.19.4.2 resumo objetivos: conhecer os tipos de toque mais utilizados e compreender seus significados para fisioterapeutas que atuam em ambiente hospitalar, na perspectiva de seus sentimentos, atitudes e comportamentos durante a assistência. materiais e métodos: estudo de caso qualitativo realizado com fisioterapeutas que atuam em um hospital do brasil. para a coleta de dados, utilizaram-se como técnicas a observação participante e a entrevista semiestruturada. os dados foram analisados segundo a análise temática de conteúdo proposta por minayo. resultados: participaram do estudo 16 fisioterapeutas e, da análise do material empírico, emergiram quatro categorias teaño 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1942 temática: cuidado crônico. contribuição para a disciplina: uma das contribuições deste estudo se refere à importância de o profissional fisioterapeuta receber capacitação necessária durante sua formação para obter habilidades quanto aos tipos e às formas de se tocar. isso permite entender as reais necessidades do paciente por meio da subjetividade que existe nessa relação, o que poderia proporcionar melhoria na qualidade e na humanização da assistência. dessa forma, sugere-se uma reflexão crítica com relação à grade curricular que compõe a formação do fisioterapeuta, a qual, apesar de conter disciplinas na área do conhecimento humano, não contém conteúdos sobre a importância dos tipos e das formas de se tocar; assim, surgem profissionais que confundem assistencialismo com humanização. embora o estudo tenha sido realizado com fisioterapeutas, o toque é uma forma de comunicação não verbal muito utilizada por outros profissionais da área da saúde, inclusive pela enfermagem, o que possibilita reflexões similares na atuação hospitalar desses profissionais. os achados deste estudo ainda podem estimular a realização de pesquisas com a mesma temática que envolvam profissionais da enfermagem. https://orcid.org/0000-0002-7656-3745 https://orcid.org/0000-0001-6717-0168 https://orcid.org/0000-0001-8690-4948 https://orcid.org/0000-0003-0999-6943 https://orcid.org/0000-0001-9587-6694 https://doi.org/10.5294/aqui.2019.19.4.2 https://orcid.org/0000-0002-7656-3745 https://orcid.org/0000-0001-6717-0168 https://orcid.org/0000-0001-8690-4948 https://orcid.org/0000-0003-0999-6943 https://orcid.org/0000-0001-9587-6694 https://doi.org/10.5294/aqui.2019.19.4.2 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1942 máticas: toque instrumental como recurso fundamental da assistência fisioterapêutica hospitalar; toque expressivo: sua pouca presença não significa ausência de afetividade; sentimentos do fisioterapeuta relacionados ao toque e dificuldade em falar sobre o toque traduz deficiência na formação. conclusões: a subutilização do toque expressivo revelou o desconhecimento e o despreparo na formação do fisioterapeuta que, somados à ausência de autoconhecimento, dificulta a afetividade e a criação de vínculos nas relações. tudo isso justifica os raros estudos sobre o toque afetivo na saúde, o que traduz uma área a ser explorada e a necessidade de sensibilizar os profissionais para influenciar na qualidade e humanização da assistência. palavras-chave (fonte: decs) fisioterapeuta; percepção do tato; comunicação não verbal; linguagem corporal; cinésica; humanização da assistência. comunicación no verbal por medio del toque: significados para los fisioterapeutas que actúan en ambiente hospitalario resumen objetivos: conocer los tipos de toque más utilizados y comprender sus significados para fisioterapeutas que actúan en ambiente hospitalario, en la perspectiva de sus sentimientos, actitudes y comportamientos durante la asistencia. materiales y métodos: estudio de caso cualitativo realizado con fisioterapeutas que trabajan en un hospital en brasil. para la recolección de datos se utilizaron como técnicas la observación participante y las entrevistas semiestructuradas. los datos se analizaron según el análisis de contenido temático propuesto por minayo. resultados: 16 fisioterapeutas participaron en el estudio y, desde el análisis del material empírico, surgieron cuatro categorías temáticas: toque instrumental como recurso fundamental de la asistencia de fisioterapia hospitalaria; toque expresivo: su poca presencia no significa ausencia de afecto; sentimientos del fisioterapeuta relacionados con el toque y dificultad para hablar sobre el toque se traduce en una deficiencia en la formación. conclusiones: la subutilización del tacto expresivo reveló la falta de conocimiento y preparación en la formación del fisioterapeuta, lo que, sumados a la falta de autoconocimiento, dificulta el afecto y la creación de vínculos en las relaciones. lo anterior justifica los escasos estudios sobre el toque afectivo en la salud, que refleja un área por explorar y la necesidad de sensibilizar a los profesionales para que influyan en la calidad y la humanización de la asistencia. palabras clave (fuente: decs) fisioterapeuta; percepción del tacto; comunicación no verbal; lenguaje corporal; cinésica; humanización de la atención. 3 comunicação não verbal por meio do toque: significados para fisioterapeutas que atuam em ambiente hospitalar l michelle ferraz martins jamarim e outros nonverbal communication through touch: meanings for physical therapists working in a hospital environment abstract objectives: to know the most used types of touch and understand their meanings for physical therapists working in a hospital environment, from the perspective of their feelings, attitudes and behaviors during care. materials and methods: qualitative case study conducted by physical therapists working in a hospital in brazil. for data collection, participant observation and semi-structured interviews were used as techniques. data were analyzed according to the thematic content analysis proposed by minayo. results: 16 physical therapists participated in the study and, from the analysis of the empirical material, four thematic categories emerged: instrumental touch as a fundamental resource of hospital physical therapy assistance; expressive touch: its little presence does not mean absence of affection; physical therapist’s feelings related to touch and difficulty talking about touch means that there is a deficiency in training. conclusions: the underuse of expressive touch revealed the lack of knowledge and unpreparedness in the formation of the physical therapist, which, added to the lack of self-knowledge, hinders the affection and the creation of bonds in relationships. all of this justifies the rare studies on affective touch in health, which reflects an area to be explored and the need to sensitize professionals to influence the quality and humanization of care. keywords (source: decs) physical therapists; touch perception; nonverbal communication; kinesics; body language; humanization of assistance. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1942 4 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1942 aquichan issn 1657-5997 eissn 2027-5374 introdução a comunicação é parte indissociável das relações humanas e é por meio dela que transformamos a realidade em que vivemos (1). quando apropriada, favorece a efetividade, a qualidade, a humanização da assistência (1-3), a confiança na relação e o auxílio no tratamento dos pacientes (4). a comunicação se dá de duas formas: a verbal, que ocorre por meio de palavras, mensagens faladas, escritas ou sons, e a não verbal, transmitida em sua maioria de forma inconsciente e demonstrada por meio do toque, do olhar, da linguagem corporal, dos gestos, das expressões faciais, que revelam sentimentos e intenções (5-6). a comunicação não verbal refere-se a toda mensagem enviada não por meio de palavras (7), e suas habilidades correspondem a 60-90 % da comunicação interpessoal, além de aumentar a satisfação dos pacientes e a adesão ao tratamento (8). o toque é parte efetiva e inevitável das práticas da maioria dos profissionais de saúde (9) e pode ser do tipo: instrumental, quando o contato físico só existe durante procedimentos técnicos e para a prestação da assistência; expressivo ou afetivo, que normalmente é espontâneo e aplicado de maneira mais humanizada, não relacionada a uma atividade específica; expressivo instrumental, quando um procedimento técnico é acompanhado do toque afetivo (1). existe ainda o toque terapêutico, considerado uma terapia holística de imposição das mãos, não rotineiramente utilizada pelos profissionais da saúde e que, por esse motivo, não teve enfoque no presente estudo (10). o toque estimula a comunicação, demonstra carinho, aceitação, apoio, segurança, empatia e proximidade em relação ao paciente. nesse contexto da interação humana, o toque expressivo é um estímulo positivo que promove vínculo e confiança (11), facilita as relações de qualidade e pode proporcionar maior proximidade na relação (12) e acarretar bem-estar físico (13). a pouca utilização do toque ou seu uso de forma inadequada pode proporcionar distanciamento entre o paciente e o profissional (14), e pode ser resultado do desconhecimento ou do medo do profissional em ser mal interpretado (15), de problemas de autoconhecimento e equilíbrio interno ou de um ambiente com pouca segurança e apoio para sua realização (16-17). portanto, a utilização do toque exige do profissional conhecimento e habilidades em relação à comunicação não verbal para fazer de seu atendimento um momento focado no aspecto humano (18). tal conhecimento evolui com o treinamento e a experiência (19), devendo também haver competência afetiva (20). de forma inerente à sua atuação, o fisioterapeuta possui uma relação próxima com o corpo do paciente, comunicando-se com ele também por meio do toque (11). apesar dessa proximidade, a fisioterapia tem sua origem vinculada ao modelo cartesiano e biomédico (21) e uma formação tecnicista restrita aos aspectos e recursos físicos, que não considera o ponto de vista humano no entendimento das necessidades emocionais e sociais do indivíduo (22). essa perspectiva se reflete na lacuna de conhecimento identificada na busca de estudos sobre comunicação não verbal, especificamente em relação ao toque, na atuação do fisioterapeuta. nesse sentido, delimitou-se o problema de pesquisa na pouca utilização do toque expressivo, que parece retratar o desconhecimento dos valores agregados a este, e o despreparo na formação desse profissional, oriundo do nosso modelo de saúde. assim, o objetivo do estudo foi conhecer os tipos de toque mais utilizados e compreender os significados do ato de tocar para os profissionais fisioterapeutas que atuam em ambiente hospitalar, na perspectiva de seus sentimentos, atitudes e comportamentos durante a assistência. material e método trata-se de um estudo exploratório, de abordagem qualitativa (23), que utilizou o estudo de caso (24) como estratégia de investigação e a análise de conteúdo de minayo (25) como técnica de análise de dados. o estudo de caso é a estratégia de escolha para investigar um fenômeno contemporâneo em seu contexto de vida real, especialmente quando os limites entre o fenômeno e o contexto não estão claramente definidos (24). é uma investigação naturalística e flexível, que, mediante a utilização de variadas fontes de evidência e informações, objetiva descrever de forma intensiva e profunda um ou mais casos que, na área da saúde, podem ser representados pelo paciente, pelo profissional da saúde, pela díade paciente terapeuta, pelo processo terapêutico, entre outros (26). 5 comunicação não verbal por meio do toque: significados para fisioterapeutas que atuam em ambiente hospitalar l michelle ferraz martins jamarim e outros o estudo foi realizado em um hospital de grande porte no brasil, prestador de serviços de alta complexidade, sendo previamente aprovado pelo comitê de ética em pesquisa, sob o certificado de apresentação para apreciação ética n.o 45938215.6.0000.5404. a participação no estudo era condicionada à assinatura do termo de consentimento livre e esclarecido (tcle), que elucidava aos participantes os objetivos e procedimentos de estudo; garantia o anonimato na exposição dos achados de pesquisa; assegurava que nenhum dano de qualquer origem era previsto diante da participação no estudo e citava, como único benefício previsto, a contribuição com a expansão do conhecimento científico sobre o tema de estudo. a população de estudo constituiu-se de 18 fisioterapeutas que compunham a equipe de fisioterapia de um hospital brasileiro. a amostra de estudo foi composta de modo intencional, determinada pelo seguinte critério de inclusão: ser fisioterapeuta contratado por tempo mínimo de seis meses. definiu-se como critério de exclusão ser pesquisador envolvido no processo de pesquisa. todos os profissionais convidados aceitaram participar do estudo, e a amostra final foi representada por 16 fisioterapeutas, não tendo sido incorporadas à amostra duas profissionais da equipe que também eram autoras deste estudo. o fechamento amostral ocorreu por exaustão, ou seja, a coleta dos dados ocorreu com todos os participantes que faziam parte do universo do pesquisador (27). para a coleta de dados, foi realizada primeiramente a observação de campo, na modalidade participante, na qual o papel do pesquisador na situação investigada pode variar de total participação até um completo distanciamento (28). considerando que a pesquisadora principal também era coordenadora da equipe de fisioterapia da instituição e que sua presença poderia ocasionar intimidação na prática dos profissionais, outra fisioterapeuta da instituição que participava do mesmo grupo de pesquisa realizou as observações. uma vez que o observador deve conhecer os propósitos específicos do estudo para que sua observação permita uma análise mais completa do problema (23), utilizou-se, para a observação de campo, um roteiro para anotações de natureza reflexiva e descritiva baseado no modelo de triviños (28), e um roteiro para a análise do toque nas perspectivas tacêsica e proxêmica, como sugerido por maria júlia paes (1), o que permitiu identificar se o toque realizado era do tipo expressivo ou instrumental. as observações foram realizadas no período de agosto de 2015 a novembro de 2016, de modo aleatório, sem prévio aviso e respeitando o setor de atuação de cada fisioterapeuta. foram realizadas 19 observações, com duração média de cinco horas cada uma, sendo a variação de 4,47 horas. um sujeito requereu três observações e outro duas observações, ambos para a confirmação dos dados, sendo que tal necessidade decorreu da alta demanda do setor, que resultou em atendimentos rápidos. após o término de cada observação, a colaboradora se reunia com a pesquisadora principal para descrever o que percebia durante os atendimentos: como e quando os fisioterapeutas tocavam seus pacientes, a maneira como se comunicavam com eles, a afetividade, suas atitudes e comportamentos, sendo tudo devidamente registrado na área destinada às anotações reflexivas livres do roteiro de observação. as observações participantes foram nomeadas pela letra “o”, seguida do número da observação. as entrevistas semiestruturadas foram realizadas pela autora principal do estudo e coletadas imediatamente após o término das observações de campo, no intuito de evitar influências no comportamento dos participantes durante as observações. para a sua realização, foi elaborado um roteiro de entrevista baseado no modelo proposto por turato (29). as 16 entrevistas foram gravadas em áudio e realizadas no próprio trabalho do participante, em um lugar reservado de acordo com a disponibilidade dele. as entrevistas tiveram duração máxima de 23 minutos e mínima de 16 minutos, com perceptível dificuldade dos participantes em falar sobre o tema. os participantes não tiveram acesso à transcrição das entrevistas para a confirmação dos dados. as entrevistas foram posteriormente transcritas e nomeadas pela letra “e”, seguida do número correspondente à ordem de realização. os dados obtidos das observações participantes e das entrevistas semiestruturadas foram analisados por meio da análise temática de conteúdo de minayo (25), que propõe três etapas: na primeira, denominada “pré-análise”, realiza-se a leitura flutuante, a constituição do corpus, a formulação e reformulação de hipóteses e objetivos; o recorte do texto em unidades de registro, unidades de contexto, os recortes, a forma de categorização, a modalidade de codificação e os conceitos teóricos mais gerais; na segunda etapa, é feita a exploração do material em que o pesquisador, a partir dos dados, propõe inferências, realiza interpretações e busca a formação de categorias teóricas ou empíricas 6 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1942 aquichan issn 1657-5997 eissn 2027-5374 que especificarão os temas; na terceira etapa, a autora sugere o tratamento dos resultados obtidos e sua interpretação (25-30). para embasar o processo de análise e criação de inferências, utilizaram-se como referencial teórico duas obras principais: comunicação tem remédio, de maria júlia paes da silva (1), e tocar: o significado humano da pele, de asley montagu (31). em relação ao rigor metodológico, com o objetivo de garantir a credibilidade do estudo, foram utilizadas diferentes técnicas de coleta de dados (observação e entrevista) com o uso de instrumentos construídos de acordo com a literatura, analisados por pares e testados em uma coleta-piloto de dados. para garantir a confirmabilidade, o material empírico oriundo da coleta de dados foi analisado por pares, incluindo a pesquisadora, o orientador do estudo e o grupo de pesquisa, e com embasamento teórico nos referenciais já citados. o local de estudo, os critérios de inclusão e exclusão de participantes, bem como o processo de coleta e a análise de dados foram detalhados a fim de garantir, por sua vez, a transferibilidade e a confiabilidade do estudo (32). nenhuma devolutiva foi dada aos participantes ao final do estudo. resultados a faixa etária dos fisioterapeutas variou entre 25 e 39 anos, e apenas um participante era do sexo masculino. como proposto por minayo (28-29), a partir da análise dos dados, emergiram quatro categorias temáticas principais descritas a seguir. toque instrumental como recurso fundamental da assistência fisioterapêutica hospitalar a primeira categoria emergente da análise do material revelou que o toque é o instrumento fundamental no trabalho do fisioterapeuta, uma exigência da própria prática e, como consequência, o toque instrumental é predominante durante sua assistência no meio hospitalar. por meio do roteiro de análise tacêsica e proxêmica, constatou-se que o toque era frequente durante a assistência do fisioterapeuta, o que corroborou a estreita proximidade física entre profissional e paciente. apesar dessa proximidade física, o afeto foi raramente evidenciado por meio do toque do tipo expressivo, que é aquele realizado para compreender as subjetividades implícitas na relação. toque expressivo: sua pouca presença não significa ausência de afetividade apesar da rara presença do toque expressivo, foram constatadas manifestações claras de afetividade, com sinais visíveis de seu cuidado por meio da comunicação verbal e não verbal. mesmo durante o toque instrumental, foram observados atitudes e gestos de afeto, vínculo e humanização na maioria dos profissionais. tais ações de cuidado ao tocar foram demonstradas por pedidos de permissão que antecediam o atendimento, preocupação em explicar a técnica, deixar o paciente confortável, além da proximidade e do tom de voz calmo durante a comunicação verbal. assim, o toque demonstrou favorecer a proximidade e as ações de cuidado e afeto desse profissional. nesse contexto, ao tocar o paciente, mesmo que instrumentalmente, o profissional utilizou o olhar, os gestos, as posturas empáticas, as expressões faciais, as quais eram sempre acompanhadas de um sorriso, da atenção e do cuidado com a pressão exercida durante o toque. os fisioterapeutas também se atentaram aos sinais de conforto do paciente mediante o posicionamento realizado, aos sinais de dor manifestados pela resistência ao exercício ou pelo reflexo de retirada dos estímulos dolorosos, pelas expressões de desagrado e, ainda, pelas expressões ante os sinais vitais observados nos monitores ou ante o padrão respiratório, por meio de ventiladores mecânicos. sentimentos do fisioterapeuta relacionados ao toque apesar de o toque expressivo ter sido raro durante as observações, foram relatados sentimentos de afeto, vínculo e troca de energia durante o tocar, contrapondo-se aos comportamentos visualizados. os fisioterapeutas que perceberam o toque como afeto o relacionaram com sensibilidade, sentimento e percepção: “eu muitas vezes toco, assim... com carinho mesmo. passo a mão na cabeça, toco no rosto”. [e6] “[...] porque ele [o paciente] não consegue se expressar, então acho que isso te gera uma... necessidade de um cuidado maior, de uma atenção maior”. [e9] 7 comunicação não verbal por meio do toque: significados para fisioterapeutas que atuam em ambiente hospitalar l michelle ferraz martins jamarim e outros o equilíbrio entre afetos positivos e negativos torna-se um desafio para os profissionais de saúde, pois o ambiente hospitalar faz com que experimentem momentos de cura, esperança, bem-estar e, em contrapartida, há períodos de sofrimento, dor e morte. confirmou-se ocorrer afetividade quando se existe vínculo com o paciente, que pareceu ser mais evidente nos pacientes com dor, idosos, bebês, de longa permanência, que não conseguem se expressar ou quando estão gravemente enfermos: “[...] tem paciente que a gente envolve muito mais, ainda mais se ele tiver grave... aí a gente sempre toca com mais cuidado”. [e7] “[...] porque ele [o paciente] não consegue se expressar, então acho que isso já te gera uma... necessidade de um cuidado maior, de uma atenção maior”. [e9] os fisioterapeutas que percebem o toque como promotor de vínculo também o associam à proximidade, ao contato, à intimidade e à confiança: “então, o toque é uma forma de você se aproximar desse paciente e de pensar no paciente como um ser humano e não só como um paciente que precisa de reabilitação”. [e4] os sujeitos que descreveram o toque como troca de energia relataram que também desejam transmitir aos pacientes sentimentos positivos para auxiliar em sua recuperação. confirmando essa crença, exprimem sentimentos positivos ou negativos após tocar pacientes deprimidos: “eu acho que o toque é uma transmissão de energia. é uma coisa que eu recebo. é uma doação, né?” [e15] dificuldade em falar sobre o toque traduz deficiência na formação a dificuldade em discorrer sobre o toque expressivo foi inferida como uma deficiência na formação do profissional fisioterapeuta. nas falas, percebe-se constrangimento em comentar algo que parecia ser desconhecido, o que pode ser apreendido pelos diversos momentos de silêncio e reflexão sobre o que dizer. alguns relatavam surpresa e vergonha por nunca terem percebido a importância do toque afetivo, e a maioria reconhecia a dificuldade em abordar o tema em função do despreparo desde a formação acadêmica. atribuíam tal dificuldade pelo fato de o foco de aprendizagem principal ser tecnicista. isso pode ser comprovado por meio das diversas falas dos profissionais fisioterapeutas: “[...] acho que devia ter na grade curricular porque faz uma diferença e-nor-me [ênfase na pronúncia]”. [e4] “[...] na graduação [o tema é tratado] muito pouco, a gente não falava muito sobre isso”. [e10] atualmente, a organização curricular é baseada em técnicas, procedimentos, métodos de atendimento e de abordagem clínico terapêutica e muito pouco se ensina sobre práticas humanas, capazes de proporcionar uma aproximação entre a fisioterapia e as necessidades dos pacientes. discussão na saúde, o ato de tocar é um meio de se relacionar e se comunicar, utilizado por diversas profissões para expressar o cuidado (33). na fisioterapia, em especial, o tato fundamenta as ações desse profissional, por permitir aproximar o terapeuta do corpo do paciente de forma profunda e legítima, indo além do simples contato pele a pele, o que diferencia essa profissão (15). o fisioterapeuta permite-se aproximar do corpo do paciente devido ao diálogo que ocorre por meio do toque e do movimento que se torna vital na prática dessa profissão, e, por meio de suas habilidades, explora a capacidade, os limites e as possibilidades do corpo. isso se deve ao fato de o profissional participar diretamente da terapia, que o faz vivenciar experiências, permite coletar dados e compreendê-los em seus significados diversos (15). tendo em vista que o toque instrumental é muito frequente na assistência do fisioterapeuta e que o simples ato de tocar favorece a proximidade física, afetiva e cognitiva com o paciente (11), esse profissional possui uma posição privilegiada para o cuidado humanizado; contudo, necessita conhecimento para desempenhar tais habilidades. dentre os tipos de toque, o toque expressivo destaca-se por facilitar o desenvolvimento das relações de qualidade, sendo empregado nas relações mais próximas para demonstrar apoio e aceitação, o que promove conforto de forma individual (9). para o receptor, o toque do outro pode ser calmante, aliviar a dor e minimizar as emoções negativas (12), de forma que seu uso por 8 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1942 aquichan issn 1657-5997 eissn 2027-5374 profissionais de saúde pode trazer inúmeros benefícios e propiciar melhor relação com o paciente. desse modo, é importante que o fisioterapeuta compreenda os tipos de toque que pode empregar em sua prática e que utilize com maior frequência o toque expressivo, de maneira consciente e intencional, por este estar associado a uma melhor interação e ao envolvimento assistencial, o que favorece o cuidado integral, capaz de se moldar continuamente às necessidades de saúde do paciente. à medida que os profissionais se envolvem com os pacientes, características como afetividade, reciprocidade, confiança, respeito e vínculo se manifestam e se tornam mais evidentes (15). a evidência de afeto pode aparecer nas diversas formas de se comunicar, na proximidade com o outro (proxêmica), no jeito como se fala (paralinguagem) e durante o comportamento do corpo quando nos relacionamos (cinésica) (8). constatou-se que os fisioterapeutas utilizavam a comunicação não verbal para proporcionar maior empatia, vínculo e afetividade durante os atendimentos, mas que o toque expressivo foi subutilizado para esse fim. por outro lado, durante as entrevistas, os profissionais relataram experimentar sentimentos de afeto ao tocar os pacientes, o que indica que o toque está tão próximo do cuidado que os profissionais não percebem que, em suas atitudes automáticas, utilizam vários tipos de toque, pois não há como separar suas técnicas da subjetividade que envolve essa relação. nesse contexto, destaca-se que a comunicação não verbal foi poucas vezes utilizada de forma consciente pelos profissionais, como uma forma de facilitar a comunicação ou demonstrar afetividade da relação com o paciente, o que indica o desconhecimento e o despreparo desses profissionais para esse tipo de comunicação. além de formação profissional, tocar o outro, especialmente quando ele sofre, exige do profissional preparo emocional e autoconhecimento. alguns fisioterapeutas demonstram sensibilidade para interpretar as mensagens dos pacientes, sobretudo quando se trata da comunicação não verbal e de sentimentos (22). no entanto, a aprendizagem da comunicação não verbal é possível e necessária, tendo em vista a sua importância para as interações intersubjetivas, além da promoção da qualidade na atuação assistencial em saúde (34). na saúde, a atenção geralmente se volta para os aspectos cognitivos e racionais, e pouco se enfatiza o afeto nas relações humanas, sociais e ambientais. entender a importância da afetividade nas relações se justifica pela necessidade de contemplar o sujeito em sua integralidade, reconhecer as dimensões psicossociais do profissional que surgem na inter-relação pessoa-ambiente e desvelar o quanto esses afetos implicam o desenvolvimento de sua atuação (35). os afetos apresentados pelos aspectos positivos geram motivação e satisfação nos profissionais (36). e, quando surgidos nas relações e vínculos, contribuem para o fortalecimento do profissional na busca de melhoria do seu trabalho e no compromisso social (37). o conceito de vínculo é polissêmico e apresenta-se articulado aos conceitos de humanização (37). o vínculo promove a possibilidade de o profissional estabelecer planos terapêuticos mais apropriados à realidade dos pacientes, o que pode determinar adesão ao tratamento devido à confiança e à partilha de compromissos (38). assim, tocar significa envolver-se com o outro em uma troca de energia recíproca (36). ao tocar em alguém, não se toca somente o seu corpo, toca-se uma pessoa com toda a memória, o que constitui uma dimensão essencial para o cuidar (39). percebe-se, neste estudo, que a formação acadêmica desses profissionais voltada à atenção social e/ou ao lado ético e humano não incluiu o conhecimento quanto aos tipos e às formas de tocar, o que não alcança totalmente as necessidades do paciente; além disso, esses profissionais devem adequar-se ao modelo de organização e atenção junto à população. uma das possibilidades de alterar esse cenário é inserir, na grade curricular do curso de fisioterapia, ensinamentos sobre temas das ciências humanas, além de reflexões que favoreçam o relacionamento interpessoal do fisioterapeuta com o paciente (22). conclusões o toque está tão inserido no universo das atividades do fisioterapeuta que parece ter se limitado a uma técnica, sendo raramente utilizado como uma ferramenta de afeto e humanização. tal constatação comprova-se pelas entrevistas e pelas atitudes de afeto observadas durante o atendimento, mas que se materia9 comunicação não verbal por meio do toque: significados para fisioterapeutas que atuam em ambiente hospitalar l michelle ferraz martins jamarim e outros lizavam por meio de palavras, gestos, proximidade, olhar e preocupação, mas não por meio do toque expressivo. a subutilização do toque expressivo evidencia o despreparo na formação do fisioterapeuta, caracterizado pelo desconhecimento quanto aos tipos e às formas de se tocar e pela falta de estímulo ao autoconhecimento, requisito primordial ao afeto e à criação de vínculos. é necessária mais literatura acerca do toque humano e afetivo na área da saúde, em contraponto à formação mecanicista ainda predominante, o que traduz uma área a ser explorada e uma das formas de sensibilizar os profissionais da importância e valorização do toque expressivo, o qual proporciona uma assistência individualizada que contempla as reais necessidades do paciente, uma melhor relação e comunicação fisioterapeuta-paciente e uma assistência à saúde mais humanizada. diante dos achados deste estudo, recomenda-se o repensar sobre como o ato de tocar vem sendo ensinado e utilizado pelo fisioterapeuta durante a assistência ao paciente hospitalizado. como limitação do estudo, percebe-se que a amostra estudada foi somente de fisioterapeutas egressos de universidades privadas, o que não permite generalizar os resultados. desse modo, sugerem-se novos estudos em populações egressas de instituições federais e estaduais. nota-se, ainda, que a pouca utilização do toque expressivo foi evidenciada no ambiente hospitalar, visto que este estudo não abrangeu outras esferas de atuação do profissional fisioterapeuta como a atenção primária e secundária, portanto não se podem generalizar os achados. conflito de interesse: nenhum declarado. referências 1. silva mjp. comunicação tem remédio: a comunicação nas relações interpessoais em saúde. são paulo: loyola; 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https://doi.org/10.1590/s0080-62342010000400007 https://doi.org/10.1590/s0080-62342010000400007 https://doi.org/10.5380/ce.v8i1.44969 nursing interventions to promote self-care in a candidate for a bowel elimination ostomy: scoping review article nursing interventions to promote self-care in a candidate for a bowel elimination ostomy: scoping review intervenciones de enfermería para promover el autocuidado en un candidato a ostomía de eliminación intestinal intervenções de enfermagem para promover o autocuidado num candidato à estomia intestinal de eliminação 10.5294/aqui.2022.22.1.2 igor emanuel soares-pinto1 , sílvia maria moreira queirós2 paulo jorge pereira alves3 tânia manuel sousa carvalho4 célia samarina vilaça de brito santos5 maria alice correia de brito6 1 0000-0003-3739-2020 universidade católica portuguesa, portugal. igor.pinto@ulsm.min-saude.pt 2 0000-0002-1884-0134 universidade católica portuguesa, portugal. silvia.queiros@chsj.min-saude.pt 3 0000-0002-6348-3316 universidade católica portuguesa, portugal. pjalves@porto.ucp.pt 4 0000-0003-0915-9950 universidade católica portuguesa, portugal. s-tmscarvalho@ucp.pt 5 0000-0001-9198-2668 escola superior de enfermagem do porto, portugal. celiasantos@esenf.pt 6 0000-0003-4414-4383 escola superior de enfermagem do porto, portugal. alice@esenf.pt received: 07/02/2021 sent to peers: 26/05/2021 approved by peers: 01/10/2021 accepted: 04/10/2021 theme: chronic care, promotion and prevention. contribution to the discipline: self-care competence in a bowel elimination ostomy is a factor commonly associated to facilitating adaptation to life with a stoma, improving quality of life, and reducing stoma and peristomal skin complications. nurses play a central and often exclusive role in promoting self-care in people with an ostomy. several nursing interventions and their direct and indirect outcomes were identified to promote self-care for the bowel elimination ostomy. para citar este artículo / to reference this article / para citar este artigo: soares-pinto ie, queirós s, alves p, carvalho t, santos c, brito ma. nursing interventions to promote self-care in a candidate for a bowel elimination ostomy: scoping review. aquichan. 2022;22(1):e2212. doi: https://doi.org/10.5294/aqui.2022.22.1.2 abstract objectives: to identify nursing interventions, their characteristics, and outcomes for promoting self-care in candidates for a bowel elimination ostomy. materials and methods: a scoping review was carried out based on the joanna briggs institute's recommendations. for this, studies published in portuguese, english, and spanish on the web of science, cinahl, and scopus databases and without a time limit were selected on november 9, 2020. results: of 2248 articles identified, 41 were included in this review. we identified 20 nursing interventions associated with the self-care of patients with an ostomy; most of them have gaps in their content, method, and frequency or dosing. more than 30 indicators were identified to assess the impact of nursing interventions; however, most of them were indirect assessments. conclusion: there is scarce evidence regarding the different aspects that must be involved in nursing interventions for patients with a stoma. moreover, there is no standardization in methods, frequency, or dosing of intervention. it is urgent to define the content, method, and frequency of nursing interventions necessary to promote self-care in patients with a bowel elimination ostomy and to use assessment tools that directly measure stoma self-care competence. keywords (source decs): nursing care; evidence-based practice; self-care; ostomy; patient education as topic. resumen objetivos: identificar las intervenciones de enfermería, sus características y resultados para promover el autocuidado en candidatos a estoma de eliminación intestinal. materiales y métodos: se llevó a cabo una revisión de alcance con base en las recomendaciones del instituto joanna briggs. para este fin, se seleccionaron estudios publicados en portugués, inglés y español en las bases de datos web of science, cinahl y scopus al 9 de noviembre de 2020. resultados: de un total de 2248 artículos identificados, se incluyeron 41 en esta revisión. se identificaron 20 intervenciones de enfermería asociadas al autocuidado de pacientes con ostomía; la mayoría tiene lagunas en su contenido, método y frecuencia o dosis. se identificaron más de treinta indicadores para evaluar el impacto de las intervenciones de enfermería; sin embargo, la mayoría de ellas fueron evaluaciones indirectas. conclusión: es escasa la evidencia sobre los diferentes aspectos que deben considerarse en las intervenciones de enfermería para pacientes con estoma. además, no existe una estandarización en los métodos, la frecuencia o la dosis de intervención. es urgente definir el contenido, el método y la frecuencia de las intervenciones de enfermería necesarias para promover el autocuidado en pacientes con estoma de eliminación intestinal y utilizar herramientas de evaluación que midan directamente ese autocuidado. palabras clave (fuente decs): atención de enfermería; práctica clínica basada en la evidencia; autocuidado; estomía; educación del paciente como asunto. resumo objetivos: identificar as intervenções de enfermagem, suas características e resultados para promover o autocuidado em candidatos à estomia intestinal de eliminação. materiais e métodos: foi realizada uma revisão de escopo com base nas recomendações do instituto joanna briggs. para isso, foram selecionados estudos pu­blicados em português, inglês e espanhol nas bases de dados web of science, cinahl e scopus de 9 de novembro de 2020. resultados: de 2 248 artigos identificados, foram incluídos 41 nesta revisão. foram identificadas 20 intervenções de enfermagem associadas ao autocuidado de pacientes com estomia; a maioria tem lacunas em seu conteúdo, método e frequência ou dose. foram identificados mais de 30 indicadores para avaliar o impacto das intervenções de enfermagem; contudo, a maioria delas foi avaliação indireta. conclusões: é escassa a evidência sobre os diferentes aspectos que devem ser considerados nas intervenções de enfermagem para pacientes com estomia. além disso, não há um padrão nos métodos, na frequência ou na dose de intervenção. é urgente definir o conteúdo, o método e a frequência das intervenções de enfermagem necessárias para promover o autocuidado em pacientes com estomia intestinal de eliminação e utilizar ferramentas de avaliação que meçam diretamente esse autocuidado. palavras-chave (fonte decs): cuidados de enfermagem; prática clínica baseada em evidências; autocuidado; estomia; educação de pacientes como assunto. introduction the word ostomy derives from the greek "stoma" and means "mouth" or opening, being understood as a surgical communication between an internal organ (intestinal or urinary) and the body surface (1). a bowel elimination ostomy is the exteriorization of a part of the intestine through the abdominal wall as an artificial outlet for feces, constructed from the mucous lining of the intestine (2). worldwide, about one million people annually undergo ostomy surgery (3). this number is expected to increase, given that the most likely diagnosis for a bowel elimination ostomy is colorectal cancer (4). currently, colorectal cancer is the third most common type of cancer worldwide, with more than 1.9 million new cases per year (5), whose incidence is predicted to grow by 60 % as of 2040, with more than 3 million new cases per year (6). a stoma construction is a life-changing event. while this surgery can have several positive effects, such as reducing symptoms and improving health, it can also adversely affect the person (7) physically, psychologically, socially, and spiritually. it may represent a potential threat to all aspects of the lives of people who must not only learn how to manage stoma care but also incorporate it in their daily lives (7-10) . how this event is experienced is conditioned by several factors, including stoma care competence (1,3,11). considering the various factors associated with the acceptance process and its impact on quality of life, literature was identified (12-14) sustaining that a systematic and complete care approach by a nurse from the preoperative phase to follow-up after hospital discharge significantly impacts these factors. in addition, the entire perioper-ative approach improves life quality, reduces health costs (7,15), and has a positive effect on the life of the person with an ostomy (13). the nurse must give the right information to the right person at the right time to reduce some concerns expressed by the person/patient submitted to ostomy construction, being responsible for recognizing and responding to the educational needs of each one (16). furthermore, the nurse plays an important supporting role for patients facing changes and their impact. these interventions help the person return to their previous life as soon as possible (7). in an early stage of the educational process, the goal for the person undergoing a stoma surgery is to develop autonomy and selfcare, increasing their quality of life and achieving competence in all aspects of their self-care (17). perioperative education is a key component in approaching a person with a stoma; however, evidence is lacking to support improved outcomes. it is crucial to carry out more in-depth studies using rigorous models to design a viable educational intervention that improves patient care and outcomes (15,18). implementing intervention programs for the person with a bowel elimination ostomy, considering the different moments of nurse intervention, enhances the management of stoma care, emphasizing adaptation, problem-solving, self-efficacy, cognitive reformulation, and goal definition (19). the present review aims to know the nursing interventions promoting stoma self-care and their characteristics for candidates for a bowel elimination ostomy, from the preoperative phase to follow-up after hospital discharge. it also intends to explore the outcomes used to assess the impact of those interventions. materials and methods a scoping review of the scientific literature was carried out following the methodology of joanna briggs institute (20) and the guidelines established by the prisma model (preferred reporting items for systematic reviews and meta-analyses). for the research structuring and execution, a protocol was developed with information regarding the objectives of this review. the topics are the population to be included in the research, the formulation of the research question, the eligibility criteria, the strategy, and databases used to obtain the relevant information, the definition of topics for data extraction, and how the data would be condensed. the definition of the starting question followed the strategic parameters p (population), c (concept), and c (context), with the research being guided by the following questions: •     what are the nursing interventions for promoting stoma self-care, from the perioperative period to follow-up after hospital discharge, for a candidate to a bowel elimination ostomy? •     what are the outcomes used to assess nursing interventions to promote bowel elimination ostomy self-care? firstly, a preliminary search for possible similar studies was carried out in the cinahl database in august 2019. secondly, we conducted another search on the web of science, cinahl complete, and scopus databases on september 4, 2019, using combinations based on mesh, cinahl headings, and natural language, as shown in table 1. given the time elapsed from research completion to the conclusion of article analysis, new research was carried out on november 9, 2020. table 1. bibliographic research strategies web of science cinahl complete scopus (* stom * not tracheostom * not cystostom * not urostom *) and ("model of care" or "care model" or model * or "patient * education" or "centered care" or discharge *) and nurs * (* stom * not tracheostom * not cistostom * not urostom *) and ("model of care" or "care model" or model * or "patient * education" or "centered care" or discharge *) and nurs * (* stom * and not tracheostom * and not cystostom * and not urostom *) and ("model of care" or "care model" or model * or "patient * education" or "centered care" or discharge *) and nurs * source: own elaboration the selection criteria for the articles were: studies that included people referred to or with a bowel elimination ostomy, either permanent or temporary, aged 18 years or older, and with a potential for regaining autonomy; addressed nursing interventions to promote stoma self-care; in in the preoperative, postoperative, or post-hospital contexts; were primary or secondary studies, qualitative or quantitative, published in portuguese, english or spanish, with no time limit. the research carried out in the databases was loaded and grouped in the zotero 5.0.96.3 software (21), and the duplicates were removed. two researchers independently conducted the search in databases and the analysis and selection of the articles. in the case of disagreement on the inclusion of any article, a third researcher was consulted. the title and abstract of the identified studies were evaluated in the first phase based on the pre-established eligibility criteria. posteriorly, all articles included in the first phase were submitted to the analysis process after full reading. figure 1 highlights the process of identifying and selecting the articles included in the review. figure 1. search and study selection process prisma diagram flow source: prisma — flowchart for scoping review (adapted) (22) finally, two independent reviewers extracted data using the data extraction tool developed by the authors for this purpose according to the following aspects: year of publication; country where the research was carried out; objective of the research; type of study; methodological approach; nursing interventions, as well as the content, method, and dosing of interventions. since this review does not collect deeply personal, sensitive, or conidential information from participants and uses documents accessible to the public as evidence, it does not require approval of an ethics committee. results of 2248 articles identified, 41 were included in the scoping review, with publication dates from 2004 to 2020: 24 % (10) in 2020, 19.5 % (8) in 2019, 17 °% (7) in 2012, and 12.2 <% (5) in 2018. regarding the type of study, the majority are experimental (14) and quasi-experimental studies (6), followed by literature reviews without a defined method (10), systematic literature reviews (3), cohort studies (3), economic analysis (1), and mixed and qualitative studies (4). the 41 included studies cover a popualtion spread over 13 countries from five different continents: china (5 °%), thailand (5 °%), taiwan (7 °%), singapore (2 °%), turkey (2 °%), iran (2 °%), brazil (2 °%), united states of america (24 °%), united kingdom (22 °%), norway (2 °%), sweden (2 °%), spain (2 °%), and australia (2 °%). all analyzed articles refer to nursing interventions in promoting self-care in a candidate for or a person with a bowel elimination ostomy. some articles analyze the impact of nursing interventions on different indicators. considering the elements that underlie the design of a nursing intervention (22), and to facilitate the reading and analysis of the references included in this review, table 2 shows the interventions identified, as well as the content, method of administration, and dosing of each intervention, including amount, frequency, and duration. the syntax of interventions was adjusted to the classification of interventions for nursing practice (cipe), version 2019, as it is an international language used to document nursing care. table 2. nursing interventions to promote stoma self-care in a candidate for a bowel elimination ostomy intervention time content method dosing (quantity / frequency /duration) and moment performing the stoma location site (9, 16, 23 28) preoperative justifying and explaining to the user the choice of the stoma site (16, 26) face to face (26, 27) one session (26) on the day of admission to the hospital (23, 28) encouraging the manipulation of ostomy devices (25) preoperative -— -— -— promoting interaction with people with a bowel elimination ostomy (25) preoperative -— -— -— assessing the potential for stoma self-care (29) postoperative -hospitalization assessing the presence of co-morbidities or psychomotor deficits that condition the capacity for self-care (arthritis, paralysis, fatigue, visual problems) (29)     informing about resources (9, 25, 27 34) preoperative information about nurses who follow up from the preoperative period until after hospital discharge (16, 27) information on national associations of people with an ostomy (28) support groups (9) stomatherapist nurse contact (16) face to face (27) two sessions (28) a session on the day of admission (28) ----------- 45 to 60 minutes (28)   postoperative -hospitalization providing support contacts (30, 31, 35) informing about available resources (35): groups of ostomized users (31) smartphone application (31) purchase of devices (25, 29) support to manage problems / complications (25, 29, 34) follow-up after discharge by a stoma nurse (16) face to face (30) at discharge (31)   after hospital discharge informing about available resources (25, 32): support groups (25) programs developed by the industry (25) telephone contact (3234) 24-hour support (34) stomatherapy consultation (32) stoma clinic (32) contact with people with an ostomy(32) association of people with an ostomy (32) mobile applications (33) internet pages (16, 33) tailored clothing companies (16) telephone contact (34) home visits (34) — teaching about bowel elimination ostomy (16, 2328, 30, 31, 36 -41) preoperative teaching about the stoma formation process (10, 23, 25, 28, 30, 31): anatomy stoma physiology teaching about ostomy (16): location of the stoma (25, 26, 36) clinical indications (2325) duration (temporary / definitive condition) (30, 36) type of stoma and its function (10, 23, 25, 26, 30, 3638) type of effluent and frequency of operation (16, 25, 36, 37) production of gases and odor (36) face to face home (23) face to face hospital (23, 30, 31) face to face (25) expository method (31) use of digital media (videos or animated images) (25) imagery (28) use of written material (10, 23, 25, 26, 28, 31, 38) information leaflet (10, 30) use of a model (23, 36) or the candidate to a stoma (36) use of ostomy devices (30) two sessions (23, 28), which can be at home (23) a session on the day of admission to the hospital (23, 28) ---------------- 30 to 90 minutes (23, 26, 28, 36, 38)   postoperative -hospitalization teaching about the stoma formation process (10, 24, 25, 40): anatomy (24, 25, 40) physiology (24, 25, 40) instructions for training (24, 25, 40) teaching about recording the ileostomy outputs and calculating the input and output balance (39) face to face (40) use of written material (3941) information leaflet (10, 40) with illustrated instructions (40) expository and demonstrative method (39) use of material in digital support -2d animations, films, photos (40) additional educational resources written instructions or links to websites (42) one session (27) two sessions (40) ----------------- 30 to 40 minutes (40) teaching bowel elimination ostomy self-care (7,16,23,25,27-29,31 -33, 35,40-51) preoperative showing ostomy devices indicated for the stoma (16, 23, 28) teaching / showing how to put plate and bag, how to change / empty ostomy bag (10, 16, 23, 25, 26, 28, 30, 31, 33, 3638, 41) stoma cleaning (41) impact / adaptation to previous lifestyle (16): possible impact of a stoma on relationships (16, 28) impact on sexuality (16, 28) impact on daily life activities (28) job (16) clothing changes (16) changes in hygiene (26, 28) changes in recreational activities (26) exercise and sports (16) travel (16) diet (16, 51) face to face (24, 41): home (23) hospital (23) use of digital media videos (33, 51) or animated images (25) use of written material (10, 16, 23, 25, 26, 28, 30, 31, 33, 38 ,51) use of a model (23, 36) or of the candidate to a stoma (36) recourse to ostomy devices (26, 28, 30) two sessions (23) one session on the day of hospital admission (23, 28, 52) 24 h before hospital admission (33) 30 to 90 minutes (23, 28, 36, 38)   postoperative -hospitalization defining goals to be achieved with the user (16) selection of the ostomy device (16, 31) organizational advice and strategies to facilitate self-care (29, 30, 35,42) device removal and application procedure (10, 16, 24, 2729, 35, 40­ 42, 4450) useful accessories for stoma self-care (24, 31, 42, 46) possible implications / need for adaptation(24, 25): hygiene (26) / taking a bath (29, 42) clothing (24, 26, 27) daily life activities (24, 27, 29, 31, 33, 42, 45) recreational activities (26, 27, 29, 42) sexuality (24, 27, 29) job (27) travel (27) dietary regime (33, 35, 42, 45, 46) exercise regime (29, 42) medication regime (24, 27, 42) intestinal irrigation procedure (42) monitoring of intestinal elimination (35 ,51) face to face (27, 31, 40, 42, 44, 47) use of written material (10, 16, 37, 3941, 45, 47, 51) information leaflet with illustrated instructions (40) use of digital media (40, 45) 2d animations, movies and photos (40, 49), dvd / video (45, 49) additional educational resources written instructions or links to websites (42) use of an ostomy simulator (50) starting as soon as possible after surgery (23, 37, 42), even on the day of surgery (37) or the first postoperative day (16, 28, 40, 47) at least one (27), two (38, 40), or four sessions (50) daily sessions (16, 28, 51) two days before discharge (41) at discharge (31, 45) 30, 40, 45 or 50 minutes (38, 40, 47, 49) maximum one hour (45)   after hospital discharge addressing device removal and application procedure (32, 33, 46) addressing device selection (32) where to buy devices (16) ostomy accessories (7) possible implications / need for adaptation: sexuality (16, 27) job (16) exercise (16) diet (16) travel (16) clothing (16) impact / adaptation to lifestyle (7) face to face (27, 46) home visits (7, 48) using the mobile app (wechat) (46) use of written material (7, 33) once a month (7, 46) for six months (7) once a week (7, 48) for six months (7) teaching about bowel elimination ostomy complications (7, 25, 29, 31, 32, 35, 41, 42, 45, 46, 51) preoperative teaching about complications: dehydration (25, 51), intestinal occlusion (25), changes in stoma and peristomal skin (25), peristomal hernia (25) recognizing changes that require examination by a health professional (51) face to face (25): face-to-face at home (23) use of digital media videos (25, 51) or animated images (25) use of written material (23, 25, 26, 38, 51) using a model (23, 36) or the candidate for a stoma (36) 30 to 90 minutes (23, 36, 38)   postoperative -hospitalization stoma and skin assessment (10, 42) what to do when complications occur and how to avoid them (42) recognizeing changes that require examination by a health professional (29, 42) skin erythema, mucocutaneous dehiscence, change in stoma color from red to dark brown or black, changes in stoma height such as prolapse or hernia (29, 42), persistent leaks and ulcers (29) in ileostomy, the volume production of more than 1,000 (4 2) or 1, 200 ml (35) in 24 hours is considered high, and less than 500 ml in 24 hours too low (35) dehydration (35) face to face (42) use of digital media dvd / video (45) use of written material leaflet (10) starting as early as possible after surgery(42) more than one session (42) three sessions (45) two days before discharge (41) one hour (45)   after hospital discharge risk of dehydration (25) identifying if the wear time of the device is shorter than expec ted (25) stoma complications (7): signs and symptoms of obstruction (25) change in stoma size (32) stoma bleeding (32) diarrhea (32) constipation (32) peristomal skin complications (25): peristomal hernia (25) dermatitis of peristomal skin (32) prevention of complications (7, 46) face to face (25) home visit (7) use of mobile application (wechat) (46) use of written material (7) once a month for six months after discharge (7)   preoperative demonstration of application, emptying, and how to change the effluent collection device, one or two pieces according to the type of stoma (2326, 28, 36) face to face (2326, 36) face to face at home (23) use of a model (23) recourse to ostomy devices (28) two sessions (28) at home (23) one session on the day of hospital admission (23) --------- 45 to 60 minute sessions (23, 28) instructing on bowel elimination ostomy self-care (2426, 28, 31, 36, 40, 41, 45, 50, 53) postoperative -hospitalization procedure for removal, hygiene, and application of the device (50) goals defined for each postoperative day, centered on the ostomy device exchange procedure: on first day after the op, the user observes the stoma (25) and stoma care (2325, 37 -40) (29) and participates in dumping the bag and cutting out the plate for the following exchange (23, 25, 37, 45). on the 2nd post-op day, the user must autonomously change the ostomy bag (23, 25, 37), remove the device with help, clean stoma and skin, and cut the plate (23, 37) the user's involvement progressively increases until the device is removed, the stoma and skin are cleaned and dried, and a new device is inserted, ending the procedure with cutting the plate for the next exchange (2325, 37) face to face (30, 42) expository and demonstration method (45) use of digital media dvd / video (45) use of an ostomy simulator (50) starting as early as possible after surgery (42), e.g., first postoperative day (30) more than one session (42) or program based on user needs (30) two days before discharge (41) three sessions (45) or four sessions (50) one hour (45)   after hospital discharge   face to face (53) home visits (53) use of smartphone application (31) video call feature (53) the first month after discharge four times a week (31) twice a week until autonomy in self-care (53) assessing stoma self-care competence (7, 25, 27, 33, 44, 46, 51, 5355) preoperative changing the ostomy device (23) use of a model (23) in the second session of two, at home (23) on the day of admission to the hospital (23) 45 minutes to one hour (23)   postoperative -hospitalization eighteen topics considered minimal aspects for discharge, centered on knowledge and performance of stoma self-care, stoma and skin self-surveillance, and resource management (55)   at discharge (55)   after hospital discharge parameters of the self-care agency scale (esca) (44) ability to properly perform stoma self-care (7, 25, 33, 51) how ostomy products/accessories are used (7) to evaluate: peristomal skincare (25) adaptation of lifestyles to the presence of the stoma (25) ability of the user or family caregiver to identify and make decisions regarding possible complications: dehydration, intestinal occlusion, stoma or skin complications, peristomal skin, development of peristomal hernia (25) normal wear time of the effluent collecting device, always ensuring that the user is autonomous in stoma self-care or that the family caregiver can replace it (25) discussion of ostomy device exchange routines (27) nurse observing the patient remove and apply the device (27) skin cleansing ability (25) monitoring of intestinal elimination (51) telephone contact (7, 44, 51, 53, 54, 56, 57) face to face (27, 44, 46) home visits (7, 23, 53, 58) hospital consultation (38, 58) use of mobile application (51) sessions according to the needs of the user or family (25) first contact within seven days of hospital discharge (25, 54, 58), can vary between the first 48h and the first two weeks (25, 27, 38, 54, 58) once a week (7, 44) for six months (7) the 2nd contact must occur between 14 to 20 days (54), the maximum interval being two, four, and six weeks after hospital discharge (25, 27) if the level of autonomy in self-care is low on the 2nd contact, the 3rd contact should be made 23 to 27 days after discharge (54) evaluating twice a week until autonomy in self-care (53) in the first six months at least once a month (58) or with home visits every two weeks (53) or three months, six months, and one year after discharge (27) after six months annual follow-up (58) training bowel elimination ostomy self-care (25, 27, 30, 4143, 45, 47, 59) postoperative -hospitalization removal, hygiene, and cleaning procedure (50) regularly training the cutout and, if possible, using pre-cutout devices (30) practicing emptying the bag and changing the device (42) third post-op day: the patient, with supervision, removes the device, washes and dries the skin and stoma, and puts the new device on (23, 37) fourth post-op day: the patient, without supervision, removes the device, washes, and dries the skin and stoma, and places the new device. nurse validates at the end (23, 37) the plate exchange must be carried out by the patient autonomously on the 3rd or fourth post-op day (25) fifth and subsequent days: training switching devices until autonomy (23, 37) face to face (23) use of an ostomy simulator (50) starting on the 1st postoperative day and scheduling remaining training based on the user's needs (30) all possible opportunities (42) in the 2nd and third training sessions (45) four sessions (50) 40 minutes (47) after hospital discharge focused on problem-solving: peristomal skin problems selection of ostomy devices people with an ostomy who experience problems or difficulties share what actions they took to resolve them focused on demonstrating problem-solving strategies (59) face to face group sessions managed by a nurse (59) five sessions (59) ------- one hour (59) planning follow-up consultation after hospital discharge (7, 23, 27, 31, 34, 41, 43, 44, 46, 52, 58) postoperative – hospitalization + after hospital discharge informing about follow-up contacts: first contact: first seven days after hospital discharge (23, 25, 54, 58), can vary between the first 48h to 72h and the first two weeks (25, 27, 38, 46, 52, 54, 58) second contact must occur between 14 to 20 days (54), the maximum interval, after the first contact being two, four, and six weeks after hospital discharge (25, 27) or the first month after discharge four times (31) or once a week (7,43,44, 46) in the first six months (7) second and third contact between three and six weeks after discharge (23) second and third month after discharge -15 in 15 days (31) one, three (41) and 6 months after discharge (31, 52) home visit ten weeks after surgery (48) home visits once a month for the first six months (7, 31, 58) after six months annual contacts (52, 58) for problem-solving / when requested by the user or health professional (34, 43, 52) informing about the methodology of follow-up contacts: face to face (23, 25, 31) telephone contact (7, 34, 41, 43, 44, 46) home visit (7, 34, 58) use of mobile application (31) wechat (43) face to face (23, 25, 31) telephone contact (7, 34, 41, 43, 44, 46) one hour (41) encouraging community interaction (25, 31, 54, 59) after hospital discharge focused on problem solving: peristomal skin problems selection of ostomy devices people with an ostomy who experience problems or difficulties share what actions they took to resolve them focused on demonstrating problem-solving strategies (59) face to face group sessions managed by a nurse (59) one-hour sessions (59) assessing for signs of stoma and peristomal skin complications (7, 16, 25, 27, 31, 44, 46) postoperative -hospitalization skin evaluation with ostomy skin tool (16) — ------ after hospital discharge hemorrhage, stenosis, allergic dermatitis, edema, and mucocutaneous dehiscence (44) face to face (44) telephone contact (7, 44, 46) use of mobile application (wechat) (46) once a week for four to five months (44, 46) or six months (7) encouraging stoma self-care (23, 25, 31, 32, 37) after hospital discharge persuasion for stoma self-care (32) verbal persuasion dependence on care positive reinforcement (32) confidence building appropriate behavior ------ ------ assessing knowledge of stoma and peristomal skin complications (25, 27) after hospital discharge ------ ------ ------ assessing the diet (46, 56) after hospital discharge ------ telephone contact (46) ------ evaluating intestinal elimination (31, 39, 56) after hospital discharge ------ ------ ------ evaluating the use of health resources (56) after hospital discharge ------ ------ ------ informing about health resources (31) after hospital discharge ------ ------ ------ teaching about self-surveillance (33) after hospital discharge verifying changes and solutions used for troubleshooting (33) face to face (33) ------source: own elaboration we could identify 20 nursing interventions associated with the self-care of the patient with an ostomy. those interventions are described at various times (preand immediate postoperative period, during hospitalization, and even after hospital discharge). we also found adequate interventions only at one point in the hospitaliza-tion period (preand post-hospitalization or discharge) or interventions performed at various times, with the following distribution: four interventions during the preoperative period, five interven­tions during postoperative inpatient, and 16 interventions after hospital discharge. as for the implementation methods used, most contact is face-to-face (77 %), in the hospital (67 %), or at home (33 %). other options are con­tact by telephone (10 °%) or through a smartphone application (13 %%). the used resources in most interventions are in writing, with the most referenced information being in a leaflet format. digital support is also employed, namely videos, photographs, or 2d anima­tions. for teaching, instructing, and training interventions, simulators or models are a common approach. in the analysis of the included articles, we identified indicators to assess the impact of one or more interventions. table 3 shows the outcomes and the method used for their assessment —answering the second research question—, the outcomes of the nursing interventions for the promotion of stoma self-care, and the instruments used to assess these results. table 3.outcomes and methods for assessing the impact of nursing interventions outcomes assessment method length of hospital stay (23, 28, 39)   hospital readmission rates (28, 39, 51) general readmission rate; readmission rate for dehydration (28, 51) or kidney failure (51); readmission rate for complications associated with the ostomy (39); readmission rate up to 30 days after discharge (51) number of consultations / contacts with health professionals (23, 53), including unplanned ones (48)   time of contact with a nurse (7)   use of hospital consumables (7)   estimated direct costs (51) 30 days after surgery (51) incidence of early complications (28)   incidence of complications (7, 31, 33, 43, 44, 46, 54) form to assess ostomy complication (43, 44) or ostomy complication severity index (ocsi) (7) health-related quality of life (28) hrqol generic 15d instrument (28) quality of life (7, 33, 43, 44, 46, 47) sleep quality, activity, mental state, and appetite (43) quality of life questionnaire-core 30 (qlq-c30) (44) 36-item short form quality of life scale (sf-36 qols) (46, 47) stoma quality of life scale (stoma-qol) (7, 33) quality of life associated with adaptation to an ostomy (27) questionnaire to assess physical, psychological, and social adaptation to an ostomy (27) major and minor morbidities (28)   negative psychological emotions (43, 46) self-rating anxiety scale (sas) (43, 46) self-rating depression scale (sds) (43, 46) anxiety (23, 33) state-trait anxiety inventory (stai) (33) depression (23)   knowledge of the disease (46, 47) the self-designed disease knowledge questionnaire (includes complication management, knowledge of drug use, device change) (46) knowledge of the ostomy (43)   knowledge of, attitude, and behavior towards ostomy self-care (40) behavior assessment form (behavior skills) (47) knowledge of and capacity for ostomy self-care (38, 45)   psychological adaptation (31)   adaptation to an ostomy (7, 50, 54) ostomy adjustment scale (54), ostomy adjustment inventory (oai) (7), ostomy adjustment inventory-23 (oai-23) (50) self-efficacy (31, 33, 41, 50, 54) self-efficacy scale (31), stoma self-efficacy scale (33, 50, 54) confidence for self-care (45) visual analog scale (eva) (45) capacity for self-care (44, 46) exercise of self-care agency scale (esca) (44, 46) ostomy self-management (41) questionnaire form for self-management of ostomy (41) number of days / weeks until autonomy in self-care (23, 48, 53)   degree of user satisfaction (23, 33, 44, 46, 49, 51, 53, 54)   satisfaction with nursing care / intervention (38, 43) questionnaire on areas of intervention and level of satisfaction (very satisfied, satisfied, dissatisfied) (43) user perception regarding the usefulness of the nurse's intervention (56)   intervention effectiveness rate (26)   evaluation of the quality of multimedia resources (49)   source: own elaboration we established a relationship between interventions and indicators since this information is not expressed objectively in the literature. in addition, the same indicator can respond to a single or all interventions. discussion this paper is the first literature review to map nursing interventions centered on promoting the self-care of a candidate for or a person with a bowel elimination ostomy. the review showed that research is conducted within the scope of the definition of nursing interventions prescribed to the candidate or person with a bowel elimination ostomy, noting that most are experimental studies. however, those are more directed towards assessing methods for implementing nursing interventions, namely simulators (50), telephone contact (43, 54), mobile apps (31), and multimedia resources (40). methods to improve the educational process of patients through information and communication technologies, such as computer-aided education models, are evolving rapidly, and nurses play a central and privileged role in using these technologies to enhance and optimize their interventions for patients (49). the technology most referred to in the literature is a communication-only mobile phone application. however, technology, especially mobile technology, is being used by community nurses for various purposes, including knowledge sharing, reporting, and caseload planning (60). advances in information technologies, such as smartphones and mobile applications, have created more opportunities for people to have information related to their health status available at any time or place according to their needs and preference. as health professionals with exclusive intervention in promoting stoma self-care, nurses must develop content that integrates into different implementation methods, whether using mobile phone applications, videos, or interactive images. this content is the disciplinary knowledge of nursing. for the challenges faced by health professionals and people with an ostomy regarding reduced hospitalization time and increased complex therapy, whether surgical or pharmacological, it is pertinent to develop instruments that facilitate and enhance the acquisition of stoma self-care competence. the literature maintains that self-care competence positively influences the adaptation process to the stoma (54) and life quality (28, 43), reduces the incidence of stoma and peristomal skin complications (43, 44), and increases self-efficacy (44) and confidence in self-care (45). it is also evident that the most significant difficulties experienced after discharge are related to insufficient knowledge and the capacity for self-care and preand postoperative care (10). the results promote the importance of the nurse's intervention in the three perioperative moments to develop the stoma self-care competence. the designed nursing interventions presume the definition of the content, the method of administering it, and the dosing, which includes the intervention's frequency, duration, and intensity (22, 61). however, no studies addressing these characteristics systematically and completely were identified. from the identified literature, specific interventions are mentioned without any reference to content, method, and dosing, namely "encouraging the manipulation of ostomy devices," "promoting interaction with people with a bowel elimination ostomy," "assessing knowledge of stoma and peristomal skin complications," "assessing the diet," "assessing intestinal elimination," "assessing the use of health resources" and "informing about health resources." the content is the most described component in the remaining interventions and where there is the most significant consensus. meanwhile, the administration method and dosing are referenced but is incomplete in most articles, with the dosing being the component of interventions with major discrepancies and less information available. within each intervention, we identified that they are repeated throughout the different administration moments (preoperative phase, postoperative hospitalization, or after hospital discharge). however, there are differences in the content and dosing of interventions at each moment. in the preoperative period, concerning the method for the different interventions, these can be in person, via telephone, or both, the most common being only one face-to-face session on the eve of the surgery (24, 26, 3639). regardless of the interventions, method, and dosing, it is agreed that when performed preoperatively, they significantly impact the well-being of the person with a stoma, the reduction of complications, and the use of health resources (62, 63). in addition, there seems to be a consensus among all authors on performing stoma site and the positive impact it has (62). in this context, "teaching about intestinal elimination ostomy" and "teaching about bowel elimination ostomy self-care" appear to be the most referenced preoperative interventions in the literature. concerning the interventions implemented in the postoperative period, during hospitalization, we found comparative studies between the use of the face-to-face expository method, face-to-face intervention combined with multimedia resources, or the exclusive use of multimedia methods. the results suggest that the use of multimedia tools can be used to implement the intervention. nevertheless, it is enhanced when combined with the face-to-face intervention by the nurse (40, 45). one aspect to be considered before the execution of any nursing intervention to promote self-care is to ensure that the patient is prepared and available without any discomfort or pain (42). the use of the internet has emerged as an intervention method with excellent cost-effectiveness in the following cases: "teaching about bowel elimination ostomy," and "teaching about bowel elimination ostomy self-care," (31, 64). considering the approach after hospital discharge, the methods of implementing the interventions are telephone or face-to-face contact in the context of a consultation in a hospital or through home visits. telephone contact emerges as an effective strategy in specific interventions such as "assessing stoma self-care competence" and "watching for signs of stoma and peristomal skin complications." these interventions have beneits regarding associated costs and health gains, scope of customer satisfaction, improved adaptation to the stoma, perception of self-efficacy, and reduced incidence of stoma or peristomal skin complications (54, 56). consensus among the authors was identified regarding follow-up by a stoma nurse and early start of follow-up, namely in the first week after hospital discharge, being the non-face-to-face contact via telephone call one of the most mentioned methods (54, 56, 65). the intervention "planning a follow-up appointment after hospital discharge" is the one with more variable dosing options after discharge. however, the first six weeks are defined as the most vulnerable phase and require a closer intervention (25, 27, 44). some studies evaluated the impact that interventions, or a set of them, could have on specific indicators. from the analysis of table 2, not all authors express how they evaluate the indicator in question, which emerges as a limitation to research rigor and replication. in the review context, the indicators most sensitive to nursing interventions are highlighted, which we group into ive categories: safety, economic, psychological well-being, functional status and, symptom experience (22). in the sensitive results to nursing interventions and safety categories, the incidence of stoma and peristomal skin complications was considered, which stands out as the most common in the articles, followed by economic results as length of stay, the rate of hospital readmission, and the number of consultations. for the psychological well-being category, indicators such as anxiety, depression, and negative emotions are used. the functional status category groups indicators such as adaptation and the capacity for self-care and indirect indicators such as user satisfaction. for the symptom experience category, no indicator is shown. considering the direct and autonomous intervention of nurses in promoting stoma self-care, they would be expected to use reliable and rigorous instruments to assess the level of stoma self-care competence (66). however, only three authors use direct indicators to assess the impact of nursing interventions on self-care competence (41, 44, 46), while the remaining indicators evaluate it indirectly. for assessing the impact of interventions, their contents, methods, and dosing on self-care competence, it is imperative to use direct indicators, that is, stoma self-care competence of and the dimensions comprising it (66). regarding the analyzed literature, the interventions and the contents to be included in the different moments of the perioperative period are defined; nevertheless, they are still poorly consolidated. it should be noted that the period after hospital discharge is the one that lacks the most evidence regarding the definition of nursing interventions, contents, and dosing, also emerging as the period of greatest vulnerability for the person with a new ostomy (67). this review highlights evidence that can facilitate the intervention of nurses in providing care to the person proposed for stoma construction or after its construction. the results of this review must be examined in light of several limitations. the broad nature of our boolean research phrase was intended to include the most significant number of studies, but did not cover all the databases and gray literature, certainly excluding some references. conclusion stoma self-care is enhanced by an appropriate nursing intervention from the preoperative moment, to the immediate postoperative period, to adjusted follow-up after hospital discharge. the promotion of self-care is a critical component in the recovery of people with an ostomy, with a significant impact on several indicators sensitive to the intervention of nurses, namely functional status, safety, and psychological and economic impact. the knowledge and use of these indicators are of crucial importance for, on the one hand, highlighting the condition of patients, and on the other hand, demonstrating the relevance of nursing care to the person. while there is available literature that supports the nurse's intervention in elimination ostomy self-care, more research is needed on the definition of content, methods, and dosing of interventions, especially after hospital discharge where a more significant lack of information and vulnerability of the person with a new ostomy are detected. there is no evidence to support the improvement in clinical results, suggesting that further studies should be carried out through rigorous programs to develop a viable educational intervention that improves the care provided to patients. the use of multiple and indirect outcomes in assessing nursing interventions is beneficial to understand their impact on different areas; however, a direct indicator of the objective of the intervention should always be used. thus, when evaluating interventions or intervention programs aimed at promoting stoma self-care, it is crucial to employ tools that directly assess self-care competence. conflicts of interest: none declared. references 1. giordano v, nicolotti m, 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https://doi.org/10.12707/riv15044 home 1 jonay perera gil1 francisco lópez muñoz2 rosa maría candelas ocejo3 rodrigo chacón ferrera4 gloria morizot5 prevalencia y enfoque terapéutico del dolor agudo en urgencias brindado por la enfermería de triaje 1 https://orcid.org/0000-0003-1478-4961. universidad camilo josé cela, españa. jonay.perera-gil@vyv-care-idf.fr 2 https://orcid.org/0000-0002-5188-6038. universidad camilo josé cela, españa. flopez@ucjc.edu 3 https://orcid.org/0000-0001-8594-2862. universidade fernando pessoa, portugal. rcandela@ufp.edu.pt 4 https://orcid.org/0000-0002-7227-5658. universidad de las palmas de gran canaria, españa. rodrigo.chacon@ulpgc.es 5 https://orcid.org/0000-0003-3126-2399. institut pasteur, francia. gloria.morizot@pasteur.fr recibido: 08/04/2019 enviado a pares: 30/04/2019 aceptado por pares: 14/05/2019 aprobado: 11/08/2019 doi: 10.5254/aqui.2019.19.4.4 para citar este artículo / para citar este artigo / to reference this article perera j, lópez f, candelas rm, chacón r, morizot g. prevalence and therapeutic approach of acute pain in emergency provided by triage nursing. aquichan 2019; 19(4): e1944. doi: https://doi.org/10.5254/aqui.2019.19.4.4 resumen objetivo: valorar la efectividad del tratamiento aplicado en pacientes con dolor agudo en el servicio de urgencias por la enfermería de triaje. materiales y métodos: estudio descriptivo observacional, de corte transversal y de abordaje cuantitativo, con medidas de tendencia central en 348 pacientes, realizado en 2016. se utilizó un cuestionario ad hoc, elaborado por el servicio de urgencias, que valora la intensidad del dolor mediante escala numérica y un protocolo de intervención ante el dolor que incluye medidas físicas y farmacológicas. resultados: tras la aplicación del primer tratamiento, el 80,17 % de los pacientes experimentó mejoría; el 7,18 % requirió un segundo tratamiento y, de este, el 87,5 % mejoró y el 12,5 % no sufrió modificaciones. el personal de enfermería trató a los pacientes según el protocolo, con aines y metamizol, mayoritariamente. el resto fue dirigido a valoración médica y otros 40 pacientes rechazaron el tratamiento. conclusiones: existe un alto porcentaje de pacientes que mejoran su percepción del dolor tras el primer tratamiento administrado por el personal de enfermería de triaje. los resultados sugieren revisar y actualizar el protocolo en el primer tratamiento. palabras clave (fuente: decs) triaje; protocolos; enfermería; emergencias; urgencias médicas; dolor agudo. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1944 temática: práctica basada en evidencia. contribución a la disciplina: este estudio se dirige a la solución de problemas surgidos de la práctica clínica, en la que la toma de decisiones está basada en la mejor evidencia existente. permite un mayor control del estado de salud de los pacientes que acuden a urgencias con dolor, al tratar el problema de manera eficaz gracias a un protocolo de valoración del dolor, con varias posibilidades terapéuticas y de responsabilidad enfermera con muy buenos resultados. https://orcid.org/0000-0002-5188-6038 https://orcid.org/0000-0001-8594-2862 https://orcid.org/0000-0002-7227-5658 https://orcid.org/0000-0003-3126-2399 https://doi.org/10.5294/aqui.2019.19.4.4 https://orcid.org/0000-0003-1478-4961 https://orcid.org/0000-0002-5188-6038 https://orcid.org/0000-0001-8594-2862 https://orcid.org/0000-0002-7227-5658 https://orcid.org/0000-0003-3126-2399 https://doi.org/10.5294/aqui.2019.19.4.4 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1944 prevalence and therapeutic approach of acute pain in emergency provided by triage nursing abstract objective: this work sought to assess the effectiveness of the treatment applied in patients with acute pain in the emergency service by triage nursing. materials and methods: cross-sectional, observational descriptive study of quantitative approach, with measures of central tendency in 348 patients, conducted in 2016. an ad hoc questionnaire was used, elaborated by the emergency service, which assesses the intensity of pain through a numerical scale and a pain intervention protocol that includes physical and pharmacological measures. results: after applying the first treatment, 80.17 % of the patients experienced improvement; 7.18 % required a second treatment and, of these, 87.5 % improved and 12.5 % suffered no modifications. the nursing staff treated the patients according to the protocol, with aines and metamizole, primarily. the rest were remitted to medical evaluation and another 40 patients rejected treatment. conclusions: a high percentage of patients exist who improve their perception of pain after the first treatment administered by the triage nursing personnel. the results suggest revising and updating the protocol in the first treatment. keywords (source: decs) triage; protocols; nursing; emergencies; medical emergencies; acute pain. 3 prevalencia y enfoque terapéutico del dolor agudo en urgencias brindado por la enfermería de triaje l jonay perera gil y otros prevalência e abordagem terapêutica da dor aguda em pronto-socorro oferecidas pela enfermagem de triagem resumo objetivo: avaliar a efetividade do tratamento aplicado em pacientes com dor aguda no serviço de pronto-socorro pela enfermagem de triagem. materiais e métodos: estudo descritivo observacional, de corte transversal e de abordagem quantitativa, com medidas de tendência central em 348 pacientes, realizado em 2016. foi utilizado um questionário ad hoc, elaborado pelo serviço de pronto-socorro, que avalia a intensidade da dor mediante escala numérica, e um protocolo de intervenção ante a dor que incluiu medidas físicas e farmacológicas. resultados: após a aplicação do primeiro tratamento, 80,17 % dos pacientes experimentaram melhora; 7,18 % necessitaram segundo tratamento e, destes, 87,5 % melhoraram e 12,5 % não sofreram alterações. a equipe de enfermagem tratou os pacientes segundo o protocolo, com aines e metamizol, predominantemente. os demais foram dirigidos à avaliação médica, e outros 40 pacientes recusaram o tratamento. conclusões: existe alta porcentagem de pacientes que melhoram sua percepção da dor após o primeiro tratamento receitado pela equipe de enfermagem de triagem. os resultados sugerem revisar e atualizar o protocolo no primeiro tratamento. palavras-chave (fonte: decs) triagem; protocolos; enfermagem; emergências; emergências médicas; dor aguda. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1944 4 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1944 aquichan issn 1657-5997 eissn 2027-5374 cuando se gesta un problema como el dolor, si no se toman medidas para aliviarlo, crecerá hasta convertirse en un gran inconveniente para el estado de salud del paciente, no solo desde el plano físico, sino también emocional. según esta investigación, los enfermeros toman decisiones sobre la prestación de cuidados a los pacientes que acuden con dolor a urgencias, teniendo en cuenta sus necesidades individuales y según marca un protocolo estipulado. hay que tener en cuenta que una intervención a tiempo es más efectiva, rápida y económica. este estudio demuestra que una intervención a tiempo mejora la calidad en la atención al paciente que acude a urgencias con dolor. introducción el dolor es una sensación altamente desagradable y muy personal que no puede compartirse con otros; el paciente encuentra dificultades para comunicarlo, y los enfermeros no pueden ni sentir ni ver lo que el paciente experimenta. las diferencias en la percepción del dolor, así como las diferentes causas que lo producen, enfrentan al profesional de enfermería con el objetivo de desarrollar un plan estándar para aliviarlo y proporcionar confort (1-3). la valoración y el tratamiento eficaz del dolor es una parte importante de los cuidados de enfermería y representa un problema de alta prioridad por sí mismo, ya que es uno de los motivos más frecuentes de consulta en los servicios de urgencia. además de suponer un peligro fisiológico y psicológico para la salud y la recuperación, el dolor grave requiere atención y tratamientos inmediatos (4-7). según la organización mundial de la salud (oms) y el observatorio de derechos humanos (human rights watch), el tratamiento contra el dolor es un derecho humano. en el mundo, entre el 25 y el 29 % de la población padece dolor (8), y este es el principal motivo de consulta en los servicios de urgencia (aproximadamente el 78 %, del cual un tercio manifiesta dolor intenso). a pesar de esto, el tratamiento está lejos de ser óptimo; se debe desarrollar un estándar de atención que abarque desde las estrategias no farmacológicas hasta los regímenes terapéuticos protocolizados, con el objetivo de hacer del servicio de urgencias un lugar de manejo integral y humanizado del dolor (9). según la sociedad española del dolor, el dolor es uno de los motivos más frecuentes de consulta en urgencias, sea por su padecimiento exclusivo, sea por las patologías que lo ocasionan. si bien su prevalencia (alrededor del 78 %) es muy alta, numerosos estudios han demostrado que el manejo de este síntoma es inadecuado en muchas ocasiones y que los pacientes pueden recibir tratamiento analgésico subóptimo por pautas inadecuadas, dosis insuficientes o fármacos inapropiados (1, 8). para el tratamiento del dolor, es primordial su detección y evaluación, tanto en el triaje, como durante la estancia en urgencias. uno de cada cinco europeos sufre de dolor, y, de los que lo padecen, cuatro experimentan dolor agudo. solo en los veintiocho países de la unión europea, cien millones de personas viven con él, y la mitad de estas no recibe ningún tratamiento o, incluso, no se le trata con seriedad (10). estos datos demuestran la necesidad de considerar el tratamiento del dolor y el acceso a la atención médica una prioridad de la salud pública (11). actualmente, la ingesta de analgésicos y las técnicas antiálgicas neuromoduladoras son las más utilizadas para mitigar el dolor, mientras que las técnicas invasivas quedan relegadas a un segundo plano. se resalta la importancia del automanejo y autocontrol del paciente, siempre que no se caiga en la autoprescripción indiscriminada. algunas de las técnicas no farmacológicas empleadas en el tratamiento del dolor son la presión/masaje, vibración, calor y frío superficiales, aplicación de criolíquidos como el mentol, la estimulación nerviosa eléctrica transcutánea, y a estas se pueden añadir otras como la distracción y la relajación (12-13). según datos de la sociedad española del dolor y del banco mundial (organismo dependiente de las naciones unidas), existen 182 unidades del dolor (14), lo que para españa representa, con sus 45.840.050 de habitantes a 2018, una unidad especial de tratamiento del dolor por cada 251.868 habitantes (15). en comparación con países vecinos de la unión europea, y como bien lo señala el ministère de la santé et de la protection sociale, en toda la región francesa, incluyendo reunión, martinica, guadalupe, guayana, córcega y mayotte, se dispone de un total de 266 unidades o centros de tratamiento del dolor, es decir, de una unidad por cada 248.898 habitantes (16). cada hospital dispone en españa de su unidad de dolor dependiente del ministerio de sanidad política social e igualdad, según fuentes del ministerio (17). 5 prevalencia y enfoque terapéutico del dolor agudo en urgencias brindado por la enfermería de triaje l jonay perera gil y otros la sociedad española del dolor refiere no tener constancia de ningún protocolo sobre la valoración y el tratamiento del dolor agudo en los servicios de urgencias hospitalarios, y este es el motivo de este estudio. así, el objetivo general fue valorar la aceptación y efectividad en el tratamiento inicial y secundario aplicado en pacientes con dolor agudo en el servicio de urgencias por la enfermería de triaje. los objetivos específicos son 1) valorar la aceptación de los tratamientos iniciales y secundarios del protocolo aplicado y 2) valorar la efectividad de los tratamientos iniciales y secundarios del protocolo aplicado. método estudio descriptivo observacional, de corte transversal y de abordaje cuantitativo, con medidas de tendencia central (media, mediana y moda) (19-20) y un tipo de muestreo no aleatorio por conveniencia o accidental. la muestra está constituida por todos los pacientes que acudieron a urgencias con dolor, independientemente del tipo de patología, y que precisaron un tratamiento contra dicho síntoma en un servicio de urgencias hospitalario durante un periodo de seis meses (julio-diciembre de 2016). incluye un total de 348 personas, teniendo en cuenta los siguientes criterios de exclusión: pacientes sin dolor, menores de 14 años y aquellos que, por deficiencias, no podían contestar el cuestionario. se creó un protocolo ad hoc para el tratamiento de dolor agudo en el servicio de urgencias, realizado por el personal médico y de enfermería, y avalado con el vºbº de la comisión de docencia/ investigación, el servicio de farmacología y el servicio de ética del centro. el cuestionario consta de tres partes, con un total de seis preguntas que varían entre preguntas dicotómicas y cerradas y preguntas de respuestas múltiples y abiertas (anexo i)6. según grinspun (18), para la recogida de datos se recomienda la utilización de un cuestionario previamente aprobado y validado 6 nota del editor: encuentre los anexos de este artículo en el siguiente enlace: https:// aquichan.unisabana.edu.co/index.php/aquichan/rt/suppfiles/10727/0. también puede ponerse en contacto con el autor corresponsal o con la revista. por el centro hospitalario, y además incluir diferentes instrumentos de medida cuantitativa para la evaluación del dolor. en la primera parte, se recogen datos sociodemográficos de la muestra; en la segunda, se evalúa el dolor a la llegada a urgencias; en la tercera, se precisa el primer tratamiento tras la valoración del dolor; y en la cuarta, se estima el dolor tras 45 minutos del inicio del primer tratamiento y se indica un segundo tratamiento, si procede, con posterior reevaluación del mismo. antes de poner en práctica el cuestionario, se realizó un pretest al 10 % de la muestra de 348 pacientes, para valorar la eficacia y fiabilidad del cuestionario. estos 35 cuestionarios, fuera de los 348 totales, no han formado parte del resultado final; tampoco formaron parte de la muestra y sirvieron para adaptar y demostrar la idoneidad del instrumento de recogida de datos. la persona entrevistada respondió el cuestionario, con la intervención de un encuestador (los enfermeros del servicio de urgencias a quienes se formó en el manejo del cuestionario durante un periodo de dos meses, a través de seminarios y entrenamiento) encargado de solicitar al paciente, mediante un consentimiento informado, su participación en el estudio (anexo ii). según el protocolo, el enfermero de triaje entrevista al paciente y evalúa la intensidad del dolor que padece, mediante la escala numérica del dolor (en) (0: no dolor; 1-3: leve; 4-6: moderado; 7-10: intenso). luego, inicia las medidas terapéuticas no farmacológicas (posturales, frío local), si el dolor va de leve a moderado (1-3), o las medidas terapéuticas farmacológicas, si el dolor va de moderado a grave (4-6). cuando existe dolor intenso (7-10), el enfermero dirige el paciente hacia el médico para que este indique otra terapia no incluida en el protocolo, como en el caso de alergia o dolor extremo. tras 45 minutos, se reevalúa al paciente y, en función de la nueva valoración, se sigue el protocolo, variando o repitiendo el tratamiento, si fuera necesario. el estudio ha sido aprobado por el comité de ética, investigación y docencia del hospital universitario de gran canaria doctor negrín, de acuerdo con la legislación vigente, y se lleva a cabo con respecto a los principios enunciados en la declaración del helsinki y a las normas de buena práctica clínica. https://aquichan.unisabana.edu.co/index.php/aquichan/rt/suppfiles/10727/0 https://aquichan.unisabana.edu.co/index.php/aquichan/rt/suppfiles/10727/0 6 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1944 aquichan issn 1657-5997 eissn 2027-5374 la descripción de las características de la muestra se realiza resumiendo las variables nominales con las frecuencias absolutas y relativas de sus categorías, y las de escala con media o mediana y percentiles (p5-p95), una vez comprobada su distribución normal de probabilidades con la exploración de sus histogramas y los resultados de la prueba de kolmogorov-smirnov. todas las pruebas estadísticas empleadas fueron bilaterales en términos de significación p<0,05, y los cálculos correspondientes se ejecutaron con ayuda del paquete de software estadístico para ordenador personal con entorno operativo ibm spss statistics 19 (statistical package for social sciences) para entorno de windows. resultados una vez desglosadas las muestras, se evaluó la información aportada por los cuestionarios. de los 348 participantes, el 58,3 % fueron mujeres, y el 41,7 % fueron hombres. la media de edad fue de 48,14 años, con una desviación típica de 19,58. la escala de valoración en fue utilizada por el 100 % de los enfermeros. los valores arrojados por el índice de dolor, tras la evaluación de los 348 pacientes, se reflejan en la tabla 1. tabla 1. valores del índice de dolor índice de dolor frecuencia hugc dr negrin* (%) 1 0 0 2 0 0 3 5 1,44 4 12 3,45 5 27 7,7 6 35 10,1 7 69 19,9 8 64 18,4 9 45 12,9 10 91 26,14 * hospital universitario de gran canaria doctor negrín. fuente: elaboración propia. tras la aplicación del protocolo con tratamiento inicial, el 80,17 % de los pacientes experimentan mejoría, lo que permite considerar un índice apropiado para la valoración comparativa de las metodologías reductoras del dolor de los pacientes, según se aprecia en la tabla 2. tabla 2. resultados de la valoración del dolor tras el tratamiento inicial valoración del dolor frecuencia porcentaje (%) rechazo 40 11,49 mejoría 279 80,17 ningún cambio 26 7,47 empeora 3 0,87 fuente: elaboración propia. los pacientes que requirieron un segundo tratamiento fueron 24 (7,18 % de la muestra). la valoración del dolor tras el segundo tratamiento se muestra en la tabla 3. tabla 3. resultados de valoración del dolor tras segundo tratamiento valoración del dolor frecuencia porcentaje (%) mejoría 21 87,5 ningún cambio 3 12,5 fuente: elaboración propia. a su llegada a urgencias, y tras la evaluación del dolor, al paciente se le propuso la aplicación de un primer tratamiento farmacológico, según el protocolo (aines o metamizol), o no farmacológico (frío, calor local o cambio postural). algunos pacientes, según los criterios del enfermero de triaje o ante la duda, fueron valorados fuera del protocolo en “evaluación médica” o, simplemente, rechazaron cualquier medida terapéutica contra el dolor. todo ello quedó reflejado en la tabla 4, donde se aprecia que 145 pacientes fueron tratados según el protocolo por el personal de enfermería, con una administración mayoritaria de aines y de metamizol; 13 fueron tratados según las medidas terapéuticas no farmacológicas; 150 fueron dirigidos a valoración médica; y 40 rechazaron el tratamiento. 7 prevalencia y enfoque terapéutico del dolor agudo en urgencias brindado por la enfermería de triaje l jonay perera gil y otros tabla 4. tratamiento utilizado según el protocolo enfermero tratamiento inicial r ec ha zo d el pa ci en te c am bi o po st ur al fr ío lo ca l c al or lo ca l a in es m et am iz ol ev al ua ci ón m éd ic a hugc dr. negrín 40 10 1 2 90 55 150 * hospital universitario de gran canaria doctor negrín. fuente: elaboración propia. el tratamiento utilizado tras la evaluación médica (es decir, los tratamientos prescritos fuera del protocolo enfermero) queda reflejado en la tabla 5. tabla 5. tratamiento inicial utilizado tras evaluación médica en españa tratamiento inicial tras evaluación médica p ar ac et am ol 1 g d ex ke to pr of en o tr am ad ol m or fi na b us ca pi na o tr os h.u.g.c. dr. negrín 27 34 37 3 34 15 * hospital universitario de gran canaria doctor negrín. fuente: elaboración propia. la tabla 6 expone, tras la valoración médica y enfermera inicial, el grado de satisfacción del paciente según el tratamiento aplicado. se observa una mejoría del 3,5 % de los pacientes por el cambio postural; del 0,3 % por el frío local; del 0,7 % por el calor local; del 30,1 % por los aines; del 17,5 % por el metamizol; del 6,8 % por el paracetamol 1g; del 11,46 % por el dexketoprofeno; del 12,18 % por el tramadol; del 1,07 % por la morfina; del 10,75 % por la buscapina; y del 5,37 % por otros tratamientos. discusión el dolor es uno de los principales motivos de consulta en el área de urgencias. en la presentación de un estudio durante la celebración del día mundial del dolor, se mostró que el 43 % de las personas que ingresan en el servicio de urgencias de un hostabla 6. percepción del dolor según el tratamiento utilizado en españa tras el inicial españa fr ec ue nc ia r ec ha zo de l p ac ie nt e m ej or ía n in gú n ca m bi o em pe or a rechazo del paciente 40 40 0 0 0 cambio postural 10 0 10 0 0 frío local 1 0 1 0 0 calor local 2 0 2 0 0 aines 90 0 84 5 1 metamizol 55 0 49 5 1 paracetamol 1g 27 0 19 8 0 dexketoprofeno 34 0 32 2 0 tramadol 37 0 34 3 0 morfina 3 0 3 0 0 buscapina 34 0 30 3 1 otros 15 0 15 0 0 total 348 40 279 26 3 fuente: elaboración propia. pital manifiesta dolor agudo como síntoma principal (21). según abiuso, para los casos de dolor en general, el porcentaje asciende a 78, y un tercio de este manifiesta dolor intenso (9). por su parte, este estudio muestra que el 38,21 % de los pacientes manifiesta dolor intenso, y el 39,08 % dolor muy intenso, cifra que llega al 77,29 % cuando se tienen en cuenta los dos niveles, lo cual coincide con los resultados de abiuso (9). según potter (22), la valoración del dolor consta de dos componentes importantes: una historia del dolor para obtener datos del paciente (inicio, localización, duración, factores agravantes, tratamientos anteriores que fueron eficaces o ineficaces) y la observación directa de las respuestas conductuales y fisiológicas del paciente, con la finalidad de lograr una comprensión objetiva de una experiencia subjetiva. en los pacientes que experimentan dolor agudo, la enfermera se centra en la localización, la calidad, la intensidad y la intervención precoz. en este caso, la valoración del dolor coincide con los datos de abiuso y de potter y se centra en la valoración del dolor agudo, a través de una en, en un servicio de urgencias. 8 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1944 aquichan issn 1657-5997 eissn 2027-5374 según moreno (23), el tratamiento del dolor comprende dos intervenciones básicas de enfermería: farmacológicas y no farmacológicas. las intervenciones farmacológicas protocolizadas y por prescripción médica comprenden el empleo de opiáceos, no opiáceos/aines y fármacos adyuvantes, y las intervenciones cognitivo-conductuales abarcan técnicas de distracción, técnicas de relajación, visualización, biofeedback, tacto terapéutico e hipnosis. en este estudio, se han utilizado los diferentes tratamientos disponibles en el protocolo, tras la valoración enfermera, desde técnicas posturales físicas (de frío o calor, etc.) hasta la administración de los fármacos indicados en el protocolo, según el grado de dolor valorado. se permitieron dos tipos de escalas de valoración del dolor: el algoplus y la en; en todos los casos estudiados por los enfermeros se usó la segunda. la en es equivalente a otras escalas de valoración del dolor y sirve de orientación sobre la eficacia de los tratamientos. para la mayoría de personas, la cifra de 5 o más representa una interferencia significativa en la vida diaria y la necesidad de que se haga algo para contrarrestarla, aunque no diferencia los componentes psicológicos, emocionales y sociales. en el protocolo (anexo iii), la evaluación del tratamiento del dolor del paciente incluye la respuesta de este, las modificaciones del dolor y la percepción del paciente frente a la eficacia del tratamiento. en este estudio, el 14,4 % refiere dolor leve; el 21,26 %, dolor moderado; el 38,21 %, dolor intenso; y el 39,08 %, dolor muy intenso, por lo que es imprescindible implementar este tipo de protocolos con medidas consensuadas y profundizar en ellas, dados los positivos resultados obtenidos. se puede considerar que, en su gran mayoría, los pacientes se encuentran satisfechos con los tratamientos aplicados, sin tener la necesidad de requerir un segundo tratamiento: el 80,17 % refiere mejoría tras el primer tratamiento y el 87,5 %, tras el segundo. estos datos permiten reconsiderar el primer tratamiento y la posterior valoración del dolor en el protocolo utilizado. en cuanto a los tratamientos analgésicos no farmacológicos, se destaca que, descartando a los pacientes que rechazaron cualquier tipo de tratamiento contra el dolor, se utilizó una analgesia no farmacológica (cambio de postura, frío o calor local) en el 4,2 % de los casos, tratamiento cuya efectividad se observó en el 100 % de los casos. hay un porcentaje importante de pacientes que no acepta el tratamiento propuesto para el dolor según el protocolo, y en la bibliografía consultada no se han encontrado datos para comparar esta información. la importancia y la monitorización del tratamiento del dolor en los servicios de urgencias sugiere la necesidad de incluir el dolor como el quinto signo vital, realizando la valoración de enfermería a través de la en, para poder contemplarlo en el plan de atención de enfermería (pae). se trata de cuantificar, comunicar y registrar la intensidad desde el inicio, y de aportar los datos en la anamnesis, examen físico, observación y seguimiento, para ofrecer un tratamiento más racional e individualizado. en 2001, la comisión conjunta para la acreditación de organizaciones del cuidado de la salud (joint commission for the accreditation of health organizations) estableció unas nuevas normas para el manejo del dolor en los pacientes hospitalizados. de ahí en adelante, se conoce el manejo de dolor como el quinto signo vital. aunque el dolor es un síntoma subjetivo, muy difícil de medir con certeza, se pretendía que cada hospital desarrollara políticas y procedimientos adecuados para evaluar el dolor y el uso de analgésicos como tratamiento. a los adultos se les insta a evaluar el dolor inicial, utilizando una escala de 0 a 10, al igual que para evaluar el efecto analgésico del medicamento utilizado (24). en la actualidad, según la sociedad española del dolor, no hay constancia de ningún protocolo sobre la valoración y el tratamiento del dolor agudo en los servicios de urgencias hospitalarios en españa, es decir, en el acceso no programado de los pacientes al hospital; de ahí la validez de este estudio, por ser el primero en el que se establece un protocolo de valoración del dolor en un servicio de urgencias. en relación con la satisfacción de los pacientes tras el tratamiento administrado por el enfermero de triaje, según el protocolo establecido a su llegada a urgencias, podemos decir que dicho tratamiento tiene una buena valoración en cuanto a la percepción del dolor, pues el 89,19 % de los pacientes refieren mejoría. conclusiones las escalas propuestas en los cuestionarios fueron el algoplus y la en, las dos escalas que se adaptan mejor al tipo de pacientes que frecuentan urgencias, pero la en fue la elegida por los enfermeros de triaje en todos los cuestionarios estudiados. 9 prevalencia y enfoque terapéutico del dolor agudo en urgencias brindado por la enfermería de triaje l jonay perera gil y otros existe un alto porcentaje de pacientes que valoran positivamente el primer tratamiento tras el triaje enfermero y la aplicación del protocolo del dolor, lo cual muestra la importancia de tratar el dolor y de mejorar la calidad asistencial y la atención sanitaria prestada al paciente que acude al servicio de urgencias con dolor. durante el segundo tratamiento, tras la valoración médica, el porcentaje de pacientes que lo valora positivamente es mayor, aunque hay un porcentaje importante que no acepta el tratamiento propuesto para el dolor según el protocolo. estos resultados sugieren revisar y actualizar el primer tratamiento y la valoración del dolor en el protocolo aplicado. en el tratamiento inicial, los fármacos más utilizados fueron los aines y el metamizol; tras la valoración médica, fueron el dexketoprofeno, el paracetamol 1g, el tramadol, la buscapina y la morfina. esto demuestra la necesidad de valorar la incorporación del paracetamol y de los opiáceos al protocolo enfermero inicial. asimismo, se debe tener en cuenta que medios físicos como el frío, el calor local o un simple cambio postural han servido para reducir, en un alto porcentaje, el dolor de los pacientes tratados. a partir de los datos analizados, se puede considerar que, en su mayoría, los pacientes se encuentran satisfechos con los tratamientos aplicados en el servicio de urgencias, tras ser evaluados por el enfermero de triaje, y a la espera de ser atendidos por el equipo médico. se destaca la utilización de aines, metamizol, paracetamol 1g, dexketoprofeno, tramadol y buscapina. esto lleva a valorar positivamente la efectividad del tratamiento aplicado en pacientes con dolor agudo en el servicio de urgencias por la enfermería de triaje. recomendaciones para garantizar la fiabilidad de la utilización de los protocolos o recomendaciones de actuación, se deben elaborar programas de formación continuada específicos en el tratamiento del dolor para las enfermeras de triaje, y los facultativos en los servicios de urgencias. asimismo, talleres para desarrollar habilidades de comunicación, autocontrol de las emociones y manejo adecuado de las herramientas disponibles. finalmente, junto a la necesidad de una coordinación interna entre los miembros del equipo, es necesario actualizar periódicamente los protocolos y las recomendaciones, estudiando los indicadores de cumplimiento de los mismos, a través de los programas de gestión de calidad del centro hospitalario. se debe incluir el dolor como quinto signo vital. conflicto de intereses: ninguno declarado. referencias 1. euleche a, sumayaji r, james nr. toma de decisiones en el tratamiento del dolor. segunda edición. madrid: elsevier; 2007. p. 122-220. 2. muñoz jm. manual de dolor agudo postoperatorio. madrid: hardcover; 2010. 3. international association for the study of pain. iasp terminology. [internet]. 2017. [acceso 2019 jul. 15]. disponible en: https://www.iasp-pain.org/terminology?navitemnumber=576 4. benito u. competencias y técnicas de enfermería en los servicios de urgencias. [internet]. alicante: medicina y salud; 2016. [acceso 2019 jul. 15]. disponible en: https://dialnet.unirioja.es/descarga/libro/681451.pdf 5. vassort e, le gall, j. douleur. programme d’amelioration de la qualité. mode d’emploi. parís: elsevier-masso; 2013. 6. rivas-jiménez m. manual de urgencias. tercera edición. madrid: panamericana; 2017. 7. viveiros wl, pinto mf, vancini cr, barbosa mc, novelli g, assayag re. pain in emergency units: correlation with risk classification categories. rev. latino-am. enfermagem. [internet]. 2018, nov. [acceso 2019 jul. 15]; 26(1): 1-8. doi: http://dx.doi.org/10.1590/1518-8345.2415.3070 8. clúster salud la industria de la vida. [internet]. 2017. 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[acceso 2019 jul. 15] disponible en: http://datos.bancomundial.org/ indicador/sp.pop.totl 16. sociedad francesa de estudio y tratamiento del dolor. société française d’étude et de traitement de la douleur. [internet]. francia; 2019. [acceso 2019 jul. 15]. disponible en: http://www.sfetd-douleur.org/clud 17. ministerio de sanidad, política social e igualdad. unidad de tratamiento del dolor. estándares y recomendaciones de calidad y seguridad. estudios, informes e investigación. [internet]. 2011. 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[acceso 2019 jul. 15]. disponible en: https://www.osakidetza.euskadi.eus/contenidos/informacion/seguridad_paciente/eu_def/adjuntos/2_doc_referencia/jci%204a%20edicion%20 estandareshospitales2011.pdf file:///d:/temporales/ https://doi.org/10.1016/j.ejpain.2005.06.009 https://www.boe.es/buscar/doc.php?id=doue-z-2010-70003 https://oncouasd.files.wordpress.com/2015/06/medicina-de-urgencias-y-emergencias.pdf https://oncouasd.files.wordpress.com/2015/06/medicina-de-urgencias-y-emergencias.pdf http://dx.doi.org/10.5935/2595-0118.20190026 http://portal.sedolor.es/pagina/index.php?id=60&title=directorio-u.-del-dolor http://portal.sedolor.es/pagina/index.php?id=60&title=directorio-u.-del-dolor http://datos.bancomundial.org/indicador/sp.pop.totl http://datos.bancomundial.org/indicador/sp.pop.totl http://www.sfetd-douleur.org/clud http://www.mscbs.gob.es/organizacion/sns/plancalidadsns/docs/eerr/unidad_de_tratamiento_del_dolor.pdf http://dx.doi.org/10.4321/s1134-80462014000400004 https://www.osakidetza.euskadi.eus/contenidos/informacion/seguridad_paciente/eu_def/adjuntos/2_doc_referencia/jci 4a edicion estandareshospitales2011.pdf https://www.osakidetza.euskadi.eus/contenidos/informacion/seguridad_paciente/eu_def/adjuntos/2_doc_referencia/jci 4a edicion estandareshospitales2011.pdf https://www.osakidetza.euskadi.eus/contenidos/informacion/seguridad_paciente/eu_def/adjuntos/2_doc_referencia/jci 4a edicion estandareshospitales2011.pdf 207 211 primeras paginas.indd 236 aquichan issn 1657-5997 margarita lazcano-ortiz1 bertha cecilia salazar-gonzález2 adaptación en pacientes con diabetes mellitus tipo 2, según modelo de roy 1 doctora en ciencias de enfermería; profesora investigadora. universidad autónoma del estado de hidalgo. pachuca, hidalgo, méxico. magos1000@hotmail.com 2 ph.d. secretaria de investigación, universidad autónoma de nuevo león. monterrey, méxico. bsalazar@fe.uanl.mx recibido: 19 de enero de 2009 aceptado: 15 de septiembre de 2009 resumen objetivo. determinar la influencia entre estímulos focales y contextuales, y la adaptación fisiológica y psicosocial en personas con diabetes mellitus tipo 2 (dmt2). material y método. el diseño fue descriptivo, transversal, predictivo. el muestreo fue probabilístico, sistemático. la muestra con 200 participantes de ambos géneros de 30 a 65 años, se determinó para un 95% de confianza, con una potencia de prueba de 90%. resultados. los resultados mostraron que el tiempo desde diagnóstico explicó la adaptación fisiológica f (1,198) = 9,18, p = ,003. se observó efecto entre complicaciones y adaptación psicosocial f (4,195) = 4,97, p = ,001, con un coeficiente de determinación del 74%. los estímulos contextuales influyeron en la adaptación fisiológica y psicosocial, f (6,193) = 2,89, p = ,010, y f (6, 193) = 2,41, p = ,029. conclusiones. los resultados de este estudio permiten sugerir relaciones entre las proposiciones teóricas propuestas y derivadas del modelo de adaptación de roy, particularmente entre los estímulos y la adaptación fisiológica y psicosocial en pacientes con diabetes mellitus tipo 2. palabras clave diabetes mellitus tipo 2, hiperlipidemia, adaptación fisiológica, adaptación psicológica, calidad de vida, autoconcepto. (fuente: decs, bireme). adaptation in patients with diabetes mellitus type 2, according to the roy model abstract purpose. to determine the influence between focal and contextual stimuli and the physiological and psychosocial adaptation in people with dmt2. material and method. the design was descriptive, cross, predictive. the sampling was probabilistic, systematic. the sample with 200 participants of both genders from 30 to 65 years, was determined for 95% of confidence, with a test power of 90%. results. the results showed that years of diagnosis explained the physiologic adaptation f (1,198) = 9.18, p = .003. effect was observed between complications and psychosocial adaptation f (4,195) = 4.97, p = .001, with a coefficient of determination of 74%. the contextual stimuli influenced in the physiological and psychosocial adaptation, f (6,193) = 2.89, p = .010, and f (6, 193) = 2.41, p = .029. conclusions. the results of this study allowed testing theoretical propositions derived from the roy adaptation model particularly between stimuli and the physiological and psychosocial adaptation in patients with type 2 diabetes mellitus. key words diabetes mellitus type 2, hyperlipidemia, adaptation physiological, adaptation psychological, quality of life, self concept. (source: decs, bireme). año 9 vol. 9 nº 3 chía, colombia diciembre 2009 236 245 237 adaptación en pacientes con diabetes mellitus tipo 2 según modelo de roy margarita lazcano-ortiz, bertha cecilia salazar-gonzález adaptação em pacientes com diabetes mellitus tipo 2. modelo de roy resumo objetivo. determinar a influência entre os estímulos focal, contextual e fisiológicos, e a adaptação psicossocial de pessoas com diabetes mellitus tipo 2 (dm2). material e métodos. o desenho foi transversal, descritivo, preditivo. a amostra foi probabilística, sistemática. a amostra de 200 participantes de ambos os sexos, 30-65 anos, foi determinada para 95% de confiança, com um poder de teste de 90%. resultados. os resultados mostraram que anos de diagnóstico explicaram a adaptação fisiológica f (1,198) = 9,18, p = .003. foi detectado efeito entre as complicações e o ajuste psicossocial f (4,195) = 4,97, p = .001, com um coeficiente de determinação de 74%. os estímulos contextuais influenciaram na adaptação fisiológica e psicossocial, f (6,193) = 2,89, p =, 010, e f (6, 193) = 2,41, p =, 029. conclusões. os resultados deste estudo sugerem relações entre proposições teóricas e as propostas resultantes do modelo de adaptação de roy, sobretudo entre os estímulos e os ajustes fisiológicos e psicossociais em pacientes com diabetes mellitus tipo 2. palavras-chave diabetes mellitus tipo 2, hiperlipidemia, adaptação fisiológica, ajustamento psicológico, qualidade de vida, auto-conceito. (fonte: decs, bireme). 238 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 introducción la diabetes mellitus tipo 2 (dmt2), enfermedad crónica degenerativa relacionada con factores ambientales entre los que se encuentran estilos de vida de la población, representa un problema de salud pública, dado que ocupa los primeros lugares en la morbilidad y mortalidad general en méxico (1), incluyendo a la ciudad de monterrey, nuevo león. se estima que para el año 2025 cerca de 11,7 millones de mexicanos tendrán diabetes (2). su principal manifestación, la hiperglucemia, lesiona varios órganos y sistemas del organismo (3), especialmente ojos, corazón, riñones y sistema nervioso, con potencial discapacidad causada por una disminución en la funcionalidad física, psicológica y social de la persona, lo que lleva a su desadaptación (4). frecuentemente, la dmt2 cursa con factores de riesgo como la hiperlipidemia caracterizada por elevación de niveles de triglicéridos y colesterol (5) que a su vez desencadenan problemas cardiovasculares como hipertensión, ateroesclerosis, angina coronaria, infarto del miocardio, factores que afectan la adaptación de la persona y su vida productiva. por esta razón, el control glucémico es crítico por parte de la persona que padece dmt2 para reducir el riesgo de las complicaciones a largo plazo. el paciente con dmt2 requiere adaptarse tanto a la evolución de la enfermedad, como a las demandas que ésta le plantea en su vida diaria. esto incluye dieta, ejercicio, medicamentos orales o aplicación de insulina, vigilancia regular de la glucosa capilar, y revisión periódica por el equipo de salud (6). diversos estudios muestran que la observancia del tratamiento disminuye la probabilidad de complicaciones (7). sin embargo, algunos autores (8) han concluido que las dificultades principales en las recomendaciones del tratamiento de la diabetes están relacionadas con la dieta y el ejercicio. esto consiste en una prescripción individualizada para lograr el control glucémico mediante la reducción de hidratos de carbono y la ingesta calórica, y el aumento de la actividad. en méxico, un estudio reportó que el 58% de las mujeres y el 53% de los hombres con tratamiento presentaron cifras de glucemia mayor de 200 mg/dl (9). pollock (10) señala que la adaptación a las enfermedades crónicas es un proceso complejo que implica un balance entre las demandas de la situación y la habilidad del individuo para responder a dichas demandas, dado que el tratamiento y control de la dmt2 tiene un efecto sobre la adaptación del paciente en términos de bienestar social y psicológico (11). de acuerdo con shesla et ál. (12) los factores psicosociales (frustración, ansiedad, satisfacción e impacto de la diabetes en el ambiente laboral, en la relación marital, en el ambiente social y familiar) juegan un rol muy importante en el control glucémico, y sugieren considerarlos para mejorar el manejo clínico de los pacientes. otro estudio señala que la satisfacción marital fue predictiva de control glucémico (p <0,05) (13). la diabetes mellitus tipo 2 (dmt2), enfermedad crónica degenerativa relacionada con factores ambientales entre los que se encuentran estilos de vida de la población, representa un problema de salud pública, dado que ocupa los primeros lugares en la morbilidad y mortalidad general en méxico. 239 adaptación en pacientes con diabetes mellitus tipo 2 según modelo de roy margarita lazcano-ortiz, bertha cecilia salazar-gonzález los objetivos de investigación son: determinar si los estímulos focales (tiempo de diagnóstico y complicaciones) influyen en la adaptación fisiológica (hb1c, colesterol y triglicéridos) y psicosocial (autoconcepto, función del rol e interdependencia) en pacientes con dmt2. determinar si los estímulos contextuales (género, ocupación, estado marital, ejercicio y tratamiento) influyen en la adaptación fisiológica y psicosocial en pacientes con dmt2. marco teórico el modelo de adaptación de roy (14) describe a los individuos como sistemas adaptativos holísticos, que reciben estímulos del medioambiente, los cuales procesan por mecanismos de afrontamiento y dan como resultado respuestas fisiológicas y psicosociales adaptativas o ineficaces. el ambiente, para roy, son todas las condiciones que rodean y afectan la conducta de la persona, que categoriza como estímulos focales, contextuales y residuales. los focales son los estímulos internos o externos que enfrenta la persona de manera inmediata y que le demandan toda su atención o energía. los contextuales son todos los otros estímulos presentes en una situación dada que pueden contribuir al efecto del estímulo focal. las respuestas del sistema adaptativo son llamadas conductas, y pueden ser observadas a través de cuatro modos adaptativos: fisiológico, autoconcepto, función del rol e interdependencia. en el modo fisiológico las conductas están asociadas con los procesos físicos y químicos que involucran la función del organismo. en el modo de autoconcepto las conductas se enfocan sobre aspectos psicológicos, espirituales, de sentimientos y creencias que una persona tiene acerca de sí misma en un tiempo determinado. el modo de función de rol incluye la posición, el desempeño y el dominio del rol que la persona ocupa en la sociedad. el modo de interdependencia se enfoca en las interacciones cercanas de las personas con el propósito de satisfacer las necesidades de afecto, amor, respeto, desarrollo, para lograr la integridad en las relaciones (14). metodología el diseño de la investigación fue descriptivo, transversal, predictivo (15). la población la conformaron 600 personas adultas con diagnóstico de dmt2 con tratamiento ambulatorio, registradas en el programa de control de un hospital de tercer nivel de atención de la ciudad de monterrey. se usó un muestreo de tipo probabilístico, sistemático, de 1 en 3 con inicio aleatorio. la muestra la constituyeron 200 participantes, para un 95% de confianza y ,05 de nivel de significancia, con una potencia de prueba de 90% para un coeficiente de determinación de ,10. los criterios de inclusión fueron personas con diabetes tipo 2 de ambos sexos, de 30 a 65 años, que tuvieran al menos un año de diagnóstico con dmt2 verificado en el expediente clínico. los criterios de exclusión fueron mujeres embarazadas con diabetes mellitus tipo 2. la recolección de datos se llevó a cabo de octubre a marzo de 2006. los estímulos focales estuvieron representados por el tiempo de diagnóstico y las complicaciones de la dmt2; los estímulos contextuales fueron representados por: género, ocupación, estado marital, escolariel modelo de adaptación de roy describe a los individuos como sistemas adaptativos holísticos, que reciben estímulos del medioambiente, los cuales procesan por mecanismos de afrontamiento y dan como resultado respuestas fisiológicas y psicosociales adaptativas o ineficaces. 240 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 dad, ejercicio y tratamiento; la adaptación fisiológica estuvo determinada por la medición de índice de masa corporal (imc), los niveles de hemoglobina glicosilada (hba1c), el colesterol y los triglicéridos; la adaptación psicosocial por autoconcepto, función del rol e interdependencia. mediciones las mediciones fueron antropométricas, bioquímicas y por instrumentos —reporte de ejercicio, registro de tratamiento y escala de adaptación psicosocial—. para valorar las variables demográficas se utilizó una cédula de datos demográficos y clínicos, donde se incluyó información sobre: edad, género, estado marital, ocupación, años de escolaridad, años de diagnóstico con dmt2, peso, talla, imc, circunferencia de cintura y cadera. los estímulos focales se representaron por el número de complicaciones de diabetes reportada por el médico y el tiempo de diagnóstico. los estímulos contextuales se midieron a través de un reporte de ejercicio y registro de tratamiento elaborado por margarita lazcano y bertha cecilia salazar. para medir la adaptación fisiológica se integraron tres marcadores bioquímicos (hba1c, colesterol total, triglicéridos), peso y talla, de los cuales se obtuvo una sola cifra. los resultados de cada marcador se categorizaron de acuerdo con la norma oficial mexicana (3) de la siguiente forma: valor bueno = 1, valor regular = 2 y valor malo = 3 (tabla 1). la muestra la constituyeron 200 participantes, para un 95% de confianza y ,05 de nivel de significancia, con una potencia de prueba de 90% para un coeficiente de determinación de ,10. tabla 1. marcadores bioquímicos mediciones nivel valor hba1c bueno <6,5 mg/dl regular 6,5 a 8 mg/dl malo >8 mg/dl triglicéridos bueno <150 mg/dl regular 150-200 mg/dl malo >200 mg/dl colesterol total bueno <200 mg/dl regular 200239 mg/dl malo ≥240 mg/dl para medir la adaptación psicosocial se utilizó la escala de adaptación psicosocial a enfermedades crónicas (pais, por sus siglas en inglés) (16), que mide siete dimensiones independientes: orientación al cuidado de la salud, ambiente laboral, ambiente familiar, relación sexual, experiencia familiar, ambiente social y pena psicológica. la escala consta de 46 reactivos, con un patrón de respuesta que va de 0 a 3 puntos. el puntaje crudo oscila entre 0 y 138; a mayor puntaje mejor adaptación psicosocial. el coeficiente de confiabilidad alfa de cronbach de este estudio fue de ,92. para medir la actividad física se aplicó el reporte de ejercicio. se categorizó el tiempo de cada sesión de ejercicio repor241 adaptación en pacientes con diabetes mellitus tipo 2 según modelo de roy margarita lazcano-ortiz, bertha cecilia salazar-gonzález tado y la frecuencia por semana en términos de aceptable y no aceptable, considerando como mínimo 90 minutos por semana (8). con respecto al tratamiento se aplicó el registro de medicamentos para obtener información correspondiente a dosis y frecuencia de hipoglucemiantes orales e insulina. procedimiento para la realización del estudio se contó con la aprobación del comité de investigación y ética de la facultad de enfermería y de la institución correspondiente. los participantes fueron reclutados de aquellos que acudían a control de diabetes mellitus tipo 2 en la consulta externa de un hospital público de monterrey, nuevo león. la selección de los participantes fue sistemática de 1 en 3. el primer sujeto se obtuvo al azar mediante números aleatorios. una vez comprobado que cubrían los criterios de inclusión, se les invitó a participar explicando el propósito del estudio, y se les pidió su autorización en forma verbal y escrita aplicando el consentimiento informado (17). la información y toma de muestras de sangre fueron recogidas por el investigador, y fueron procesadas en el laboratorio químico clínico de la facultad de enfermería de la universidad autónoma de nuevo león. análisis de resultados el procesamiento de datos estadísticos se realizó electrónicamente en el paquete estadístico spss versión 13. se utilizó estadística descriptiva a través de las medidas de tendencia central, el coeficiente de confiabilidad del instrumento (alfa de cronbach), y prueba de kolmogorov-smirnov para determinar la normalidad de las variables. a fin de responder a los objetivos se realizó regresión lineal simple y múltiple. los datos descriptivos de las variables demográficas del estudio fueron los siguientes: el promedio de edad fue de 52,2 años (de = 7,5), de los cuales el 72% fueron del sexo femenino; el 52% de los participantes dijeron dedicarse al hogar, y el 77% vivir con su pareja; la escolaridad promedio correspondió a 6,19 años (de = 4,05). el promedio de tiempo de padecer la enfermedad fue de 8,43 años (de = 6,98), con un mínimo de 1 y un máximo de 30 años. el tipo de ejercicio reportado con mayor frecuencia (61%) fue la caminata. el 40% manifestó practicarlo diariamente. el tratamiento reportado para el control de la enfermedad fue hipoglucemiantes orales con 70%. las complicaciones relacionadas con la enfermedad fueron neuropatías con 57,5% y cardiovasculares con 59%. la mayoría de los participantes fueron mujeres, y el nivel de escolaridad que cursaron fue muy limitado dado que no concluyeron estudios de enseñanza media. tabla 2. datos descriptivos variables x de valor valor mínimo máximo edad 52,26 7,57 32,00 65,00 escolaridad 6,19 4,05 0 20 tiempo/diagnóstico 008,43 006,98 001,00 030,00 peso 72,77 12,77 46,00 137,00 talla 01,56 00,09 01,35 001,83 imc 29,85 04,60 20,20 044,61 hba1c 006,790 01,05 04,80 010,40 colesterol 195,280 42,38 79,00 434,00 triglicéridos 195,160 150,680 45,00 1490,000 fuente: cédula de datos demográficos, resultados bioquímicos n = 200 242 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 para dar respuesta al objetivo uno —determinar si los estímulos focales (tiempo de diagnóstico y complicaciones) influyen en la adaptación fisiológica y psicosocial de los pacientes con dmt2—, se ajustaron dos modelos de regresión lineal. se introdujeron como variables independientes tiempo de diagnóstico y complicaciones (neuropatía, cardiovascular, nefropatía y retinopatía), y como variables dependientes adaptación fisiológica (modelo 1), psicosocial (modelo 2). los resultados mostraron que años de diagnóstico explicaron la adaptación fisiológica f (1,198) = 9,18, p = ,003, con un coeficiente de determinación del 44%. por cada año que se incrementa el tiempo de diagnóstico la adaptación fisiológica disminuye ,087. sin embargo, los años de diagnóstico no influyeron en la adaptación psicosocial. en el primer modelo mostró significancia entre complicaciones y adaptación fisiológica f (4,195) = 4,21, p = ,003, con un coeficiente de determinación del 61%. en el procedimiento de eliminación de variables hacia atrás (backward) se observa que contribuyeron al modelo las complicaciones cardiovasculares y la retinopatía f (2,197) = 7,80, p = ,001, y el coeficiente de determinación se incrementó a 64%. en el segundo modelo se observa un efecto entre complicaciones y adaptación complicaciones f % neuropatía 115 57,5 cardiovascular 118 59,0 nefropatía 010 05,0 retinopatía 019 09,5 tabla 3. complicaciones de la dm tipo 2 presentadas por los pacientes fuente: hoja de complicaciones n = 200 psicosocial f (4,195) = 4,97, p = ,001, con un coeficiente de determinación del 74%. al analizar la contribución de las variables se observa que solamente neuropatía contribuye al modelo global f (1,198) = 16,83, p = < ,001. los modelos de regresión lineal simple empleados para responder al objetivo dos que señala determinar la influencia de estímulos contextuales (género, ocupación, estado marital, escolaridad, ejercicio y tratamiento) en la adaptación fisiológica y psicosocial en pacientes con dmt2, resultaron significativos f (6,193) = 2,89, p = ,010, con r2 ajustada = ,054 y f (6,193) = 2,41, p = ,029, con r2 ajustada = ,041 respectivamente. se realizó el proceso de eliminación de variables en cada modelo global. al analizar la contribución de las variables contextuales con adaptación fisiológica se observó que solamente el estado marital y la ocupación contribuyeron al modelo f (2,197) = 6,38, p = ,002, la explicación fue r2 = ,051. con respecto a la adaptación psicosocial, los estímulos contextuales que contribuyeron al modelo fueron estado marital, ocupación y escolaridad, con explicación de f (3,196) = 4,71, p = ,003 con r2 ajustada = ,053. discusión este estudio permitió conocer las relaciones derivadas del modelo de adapeste estudio permitió conocer las relaciones derivadas del modelo de adaptación de roy, particularmente entre los estímulos (focales y contextuales), y la adaptación (fisiológica y psicosocial) en pacientes con dmt2. 243 adaptación en pacientes con diabetes mellitus tipo 2 según modelo de roy margarita lazcano-ortiz, bertha cecilia salazar-gonzález tación de roy, particularmente entre los estímulos (focales y contextuales), y la adaptación (fisiológica y psicosocial) en pacientes con dmt2. la adaptación psicosocial representa los modos de autoconcepto, función del rol e interdependencia que, junto con la adaptación fisiológica, para roy (14) son fundamentales para que en los individuos se facilite su integralidad. los resultados encontrados mostraron que el tiempo transcurrido desde el diagnóstico de la enfermedad hasta el tiempo en que se le entrevistó afectó negativamente la adaptación fisiológica pero no la adaptación psicosocial. por cada año de diagnóstico de dmt2 la adaptación fisiológica disminuye, observada a través de los indicadores de imc, hba1c, colesterol y triglicéridos. lo anterior sugiere que conforme transcurre el tiempo, los efectos de una alimentación inadecuada, y tal vez falta de ejercicio, se van agravando. el resultado anterior, aunado al alto porcentaje de participantes con complicaciones neuropáticas y cardiovasculares, sugieren una respuesta orgánica indicativa de un control metabólico deficiente, que en última instancia refleja cierto nivel de desadaptación al estado de cronicidad que sufren los pacientes con dmt2. zafra et ál. (18) y mundet et ál. (19) muestran, al igual que en este estudio, que las complicaciones predominantes en pacientes con dmt2 son enfermedades vasculares, retinopatía y enfermedades del corazón. hart et ál. (20) reportaron que la ocupación se asoció con un alto nivel de hba1c. en contraparte, el tiempo de padecer dmt2 no impactó el nivel de adaptación psicosocial pudiendo indicar que hay independencia de estas variables. según los participantes la dmt2 no interfiere en la realización de sus actividades cotidianas, en el trabajo y las tareas en el hogar; sin embargo, algunos manifestaron que les ha limitado cumplir adecuadamente con sus responsabilidades pues se sienten cansados, pero tratan de cumplirlas aunque las realicen poco a poco. la falta de relación coincide con lo reportado por pollock (21) y shuler (22) acerca de que el tiempo de padecer una enfermedad crónica no influyó en la adaptación psicosocial. en este estudio las medias de adaptación psicosocial reflejan adaptación, resultado contrario a west y mcdowell (23) que reportaron que las personas con cinco años de haber sido diagnosticadas con diabetes tuvieron significativamente menor impacto sobre la pena emocional (dimensión de adaptación psicosocial) comparadas con las diagnosticadas con periodos más largos de tiempo. sin embargo, la ocupación y el estado marital influyeron de manera negativa en la adaptación psicosocial. esto sugiere que las personas con dmt2, a pesar de que la mayoría viven con pareja, no perciben el apoyo necesario. aunque no se exploró el apoyo por parte de la familia, el hecho de tener pareja no ayuda en la adaptación psicosocial, tal vez por no saber cómo interactuar con un familiar con problema crónico, lo que hace que lo señalen o lo traten diferente. trief et ál. (13) reportaron que una pobre relación marital se asocia con mala adaptación psicosocial y, por ende, con mala calidad de vida. conclusiones los resultados de este estudio permitieron probar las siguientes proposiciones teóricas del modelo de roy: a) el tiempo influye en la adaptación fisiológica con un coeficiente de determinación de 44%, las complicaciones (cardiovasculares y retilos resultados encontrados mostraron que el tiempo transcurrido desde el diagnóstico de la enfermedad hasta el tiempo en que se le entrevistó afectó negativamente la adaptación fisiológica pero no la adaptación psicosocial. 244 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 nopatía) con 65%; b) las complicaciones influyen en la adaptación psicosocial con 74% de la variación explicada; c) los estímulos (ocupación y estado marital) influyen en la adaptación fisiológica con 51%, y ocupación, estado marital y escolaridad influyen en la adaptación psicosocial con 53%. el tiempo de padecer la enfermedad no influyó en la adaptación psicosocial. referencias bibliográficas 1. instituto nacional de estadística, geografía e informática. dirección de estadísticas demográficas y sociales. cuaderno 19. méxico: inegi; 2001. 2. instituto nacional de estadística geografía e informática. dirección de estadísticas demográficas y sociales. cuaderno 19. méxico: inegi; 2002. 3. secretaría de salud. norma oficial mexicana para la prevención, tratamiento y control de la diabetes (nom-015-ssa2). méxico: diario oficial de la federación; 1994. 4. american diabetes association. standards of medical care in diabetes. diabetes care 2004; 27 (1): 15-35. 5. islas a, lifshitz g. diabetes mellitus. 2 ed. méxico: mc graw hill interamericana; 1999. 6. whittemore r, chase s, mandle c, roy c. lifestyle change in type 2 diabetes. a process model. nursing research 2002; 51 (1): 18-24. 7. diabetes control and complications trial research group. the diabetes control and complications trial implications for policy and practice. the new england journal of medicine 1993; 329: 1035-1036. 8. villa c, frati m, ponce m, hernández s, becerra p. acerca de la prescripción de ejercicio en el paciente diabético. gaceta médica de méxico 2000; 6 (136): 629-637. 9. olais g, rojas r, barquera s, shamah t, aguilar c, cravioto p et ál. encuesta nacional de salud 2000. la salud de los adultos; tomo 2. méxico: instituto nacional de salud pública; 2003. 10. pollock s, chistian b, sands d. responses to chonic illness: analysis of psychological and physiological adaptation. nursing research 1990; 39 (5): 300-304. 11. garrat a, schmidt l, fitzpatrik r. patient-assesses health outcome measures for diabetes: a structures review. diabetic medicine 2002; 19: 1-11. 12. shesla c, fisher l, skaff m, mullan j, gilliss c, kanter r. family predictors of disease management over one year in latino and european american patients with type 2 diabetes. family process 2003; 42 (3): 375-390. 13. trief p, himes c, orendorff r, weinstock r. the marital relationship and psychosocial adaptation and glycemic control of individuals with diabetes. diabetes care 2001; 24 (8): 1384-1389. 14. roy c, andrews h. the roy adaptation model. 2 ed. stanford: apleton & lange;1999. 15. burns n, grove s. the practice of nursing research: conduct, critique, and utilization. 5 ed. philadelphia: saunders; 2005. 16. derogatis l. the psychosocial adjustment to illness scale. journal of psychosomatic research 1985; 1 (30): 77-91. 17. ley general de salud. reglamento de la ley general de salud en materia de investigación para la salud. 2 ed. méxico: porrúa; 1987. 18. zafra m, méndez s, novalbos r, costa a, failde m. chronic complications in patients with type 2 diabetes mellitus cared for at a health center. atención primaria 2000; 25 (8): 29-35. 19. mundet t, carmona j, gussinyer c, alcalde t, garcía v, farrus p, romea l. chronic complications of type 2 diabetes mellitus. clinical course alter 5 years of follow-up. atención primaria 2000; 25 (6): 405-411. 20. hart h, bilo h, redekop w, stolk r, assink j, meyboom j. quality of life of patients with type 1 diabetes mellitus. quality of life research 2003; 12: 1089-1097. 21. pollock s. human responses to chronic illness: physiologic and psychosocial adaptation. nursing research 1986; 35 (2): 90-95. 22. shuler p. physical and psychosocial adaptation, social isolation, loneliness, and self-concept of individuals with cancer. dissertation abstracts international 1990; (51): 2289. 23. west c, mcdowell j. the distress experienced by people with type 2 diabetes. british journal of community nursing 2002; 7 (12): 606-613. 245 adaptación en pacientes con diabetes mellitus tipo 2 según modelo de roy margarita lazcano-ortiz, bertha cecilia salazar-gonzález figura 1. modelo de adaptación de roy con diabetes mellitus tipo 2 146 158 dolor.indd 146 aquichan issn 1657-5997 diana marcela achury-saldaña1 dolor: la verdadera realidad 1 magíster en enfermería con énfasis en el cuidado de la salud cardiovascular. profesora asistente pontificia universidad javeriana. facultad de enfermería. carrera 7 nº 40-62. hospital universitario de san ignacio. p. 7. bogotá d.c. colombia. dachury@javeriana.edu.co recibido: 19 de noviembre de 2007 aceptado: 26 de agosto de 2008 año 8 vol. 8 nº 2 chía, colombia octubre 2008 146-158 resumen el dolor es un síntoma frecuente, manifestado por los pacientes en diferentes situaciones, entre las cuales se encuentra la persona hospitalizada en la unidad de cuidado intensivo (uci). en estas áreas, en ocasiones, el dolor es subvalorado y, por tanto, apenas tratado. las respuestas psicológicas, hemodinámicas, metabólicas y neuroendocrinas provocadas por un control inadecuado del dolor pueden producir mayor morbilidad e incluso mortalidad. es por esto que la evaluación del dolor se ha convertido en un reto para los profesionales de la salud, en especial para los enfermeros y las enfermeras ya que son quienes proporcionan cuidado directo y permanente; además, poseen la capacidad de detectar y controlar el dolor y el sufrimiento de los pacientes, como un principio fundamental para su valoración. con frecuencia se pasa por alto la importancia de un conocimiento integral que permita comprender no solo los cambios fisiológicos sino la influencia del dolor en la vida del paciente y su entorno. este artículo tiene como objetivo analizar la necesidad de aplicar en la práctica diaria la teoría de los síntomas desagradables, como una herramienta para evaluar el dolor y entender el significado integral de éste, conocer las características que son propias de cada individuo al igual que sus factores fisiológicos, psicológicos y ambientales. para este fin se revisarán conceptos generales sobre dolor, teorías de mediano rango, y la aplicación de la teoría de síntomas desagradables que permite evaluar de una forma adecuada y oportuna el dolor en los pacientes en situación crítica. palabras clave dolor, nocicepción, terminaciones nerviosas, sufrimiento, síntoma, angustia. (fuente: decs) pain: a genuine reality abstract pain is a frequent symptom manifest by patients in different situations, including those who are hospitalized in intensive care units (icu). in such units, pain is occasionally underestimated and, therefore, hardly treated. the psychological, hemodynamic, metabolic and neuroendocrine reactions provoked by inadequate pain control can produce increased illness and even death. this is why pain assessment has become a challenge to health professionals, especially nurses, as it is they who provide direct and permanent care. nurses also have the ability to detect and control a patient’s pain and suffering, as a fundamental principle in their assessment. the importance of a thorough grasp of the situation, specifically one that allows for an understanding of physiological changes, as well as the impact of pain on the patient’s life and his/her environment, is often overlooked. the purpose of this article is to analyze the necessity and significance of applying the theory of unpleasant symptoms in everyday practice, as a way to assess pain, to understand its integral meaning, and to know the characteristics particular to each person, as well as their physiological, psychological and environmental factors. to this end, general concepts of pain, medium range theories and application of the theory of unpleasant symptoms are reviewed for an adequate and well-timed assessment of pain in critically ill patients. key words pain, nociception, nerve endings, suffering, symptom, anxiety. 147 dolor: la verdadera realidad diana marcela achury-saldaña a dor: a verdadeira realidadde resumo a dor é um sintoma freqüente que os pacientes manifestam nas diversas situações; por exemplo, pessoas hospitalizadas em uma unidade de cuidado intensivo (uci). nestes sítios, a dor é subestimado e, portanto, é tratado superficialmente. as respostas psicológicas, hemodinâmicas, metabólicas e neuroendócrinas, resultado do controle inapropriado da dor, podem causar maior morbilidade e até mortalidade. em conseqüência, a avaliação da dor constitui um desafio para os profissionais da saúde, sobretudo enfermeiros e enfermeiras, que dão cuidado direto e permanente. além disso, têm a capacidade para detectar e controlar a dor e o sofrimento dos pacientes, princípio fundamental para valorá-lo. amiúde, é ignorada a importância de um conhecimento integral que possibilite compreender não somente as mudanças fisiológicas do paciente, senão também a influência da dor na sua vida. o objetivo deste artigo é analisar a necessidade de aplicar na prática cotidiana a teoria dos sintomas desagradáveis como ferramenta para avaliar a dor e compreender o significado íntegro deste e conhecer as características próprias de cada indivíduo, assim como seus fatores psicológicos, fisiológicos e ambientais. portanto, são revisados conceitos gerais relacionados com a dor, teorias de classe mediana e a aplicação da teoria dos sintomas desagradáveis, que possibilite avaliar oportuna e adequadamente a dor nos pacientes em situação crítica. palavras-chave dor, terminais nerviosos, sofrimento, síntoma, nocicepção, angústia. 148 año 8 vol. 8 nº 2 chía, colombia octubre 2008 146-158 aquichan issn 1657-5997 el dolor es el síntoma cardinal experimentado por el paciente en las unidades de cuidado intensivo –los pacientes recuerdan haber tenido dolor durante su permanencia–. múltiples factores pueden influir en la percepción del dolor, entre los cuales se encuentran la expectativa del mismo (percepción), experiencias dolorosas anteriores, estado emocional y procesos cognitivos; lo anterior hace que el dolor se considere como un problema multidimensional. por el contrario, en el día a día de la práctica clínica el abordaje del dolor por parte de los profesionales se ha reducido al control fisiológico y farmacológico, dejando atrás el componente social, emocional y suss repercusiones. muchas veces el abordaje del dolor se ve limitado porque los profesionales de la salud, en especial los enfermeros, desconocen la existencia y utilidad de herramientas propias de la disciplina que permiten una valoración integral y que proporcionan elementos para direccionar el manejo multidimensional e integral del dolor; es por esto que las teorías de rango medio, en especial la teoría de síntomas desagradables, permiten delimitar el campo de la práctica profesional, la acción o intervención de la enfermera y el resultado propuesto. el dolor es el síntoma más frecuente en el manejo clínico o quirúrgico de las enfermedades que afectan al ser humano. la asociación internacional para el estudio del dolor (iasp) lo define como “una experiencia emocional y sensorial desagradable asociada con daño tisular potencial o real” (1, 2, 3). desde el punto de vista asistencial está definido como “cualquier molestia corporal que indique el enfermo y que existe siempre que él lo señale” (2). la existencia de muchos tipos de dolor se puede comprender a través del conocimiento de cuatro conceptos generales: 1) la nocicepción, que determina la detección del daño tisular a través de aferentes primarios: terminaciones nerviosas libres. 2) la percepción del dolor, frecuentemente desencadenada por un estímulo nocivo tal como lesión o enfermedad. también puede ser generada por lesiones en el sistema nervioso central o periférico, como se ve en pacientes con neuropatía diabética, lesiones medulares, etc. 3) el sufrimiento, considerado como una respuesta negativa inducida por el dolor, y también por miedo, ansiedad, temor y otros estados psicológicos. 4) la conducta dolorosa, resultado del dolor y del sufrimiento, que se acompaña de expresiones y acciones que la persona manifiesta, atribuibles algunas a la presencia de lesión tisular. ejemplos de ellas son: quejas, muecas, recostarse, ir al médico, negarse a trabajar, etc. estas conductas son percibidas por otras personas y pueden ser cuantificadas. todos estos comportamientos son reales y probablemente sean influenciados por la continua exposición al dolor no tratado correctamente. podemos considerar tres componentes esenciales que intervienen en la percepción dolorosa y se convierten en elementos necesarios al valorar y manejar el dolor: el sensorial, que se relaciona con la transmisión del impulso desencadenado, informando su intensidad, localización y cualidad. el motivacional-afectivo, que hace referencia a las emociones manifestadas frente a un impulso doloroso y la manera como éstas pueden influir en la interpretación del mismo, caracterizando el dolor como desagradable, genemúltiples factores pueden influir en la percepción del dolor, entre los cuales se encuentran la expectativa del mismo (percepción), experiencias dolorosas anteriores, estado emocional y procesos cognitivos. 149 dolor: la verdadera realidad diana marcela achury-saldaña rando ansiedad y depresión. finalmente, el componente evaluador, que determina la influencia del dolor en la vida diaria y cotidiana del paciente (2, 3). el dolor en los pacientes críticos puede desencadenarse por múltiples causas tales como: la propia enfermedad, los procedimientos invasivos que se realizan para su tratamiento (quirúrgicos, colocación de drenajes, etc.), los procedimientos y las técnicas necesarias para el manejo de los pacientes (presencia del tubo orotraqueal, máscaras de ventilación mecánica no invasiva, colocación y presencia de sondas y catéteres, etc.), cuidados directos (aspiración endotraqueal, movilizaciones, curaciones, fisioterapia, etc.), y la propia inmovilidad del paciente. este dolor genera consecuencias en el paciente que pueden ser de origen hemodinámico, metabólico y psicológico. con frecuencia las respuestas de tipo fisiológico se manejan en las unidades de cuidado intensivo pero se olvidan las consecuencias de tipo emocional que puede provocar el dolor, tales como ansiedad, insomnio, desorientación, agitación y delirio (4, 5). como profesionales de la salud desempeñamos un papel muy importante en el manejo del dolor, pues no basta administrar analgésicos ignorando la verdadera experiencia de dolorosa. es necesario mirar más allá y profundizar sobre el verdadero significado de este síntoma, no solo desde el punto de vista teórico sino práctico-vivencial de las personas que lo padecen. partiendo de la importancia en el manejo del dolor, es fundamental analizarlo a la luz de la teoría de los síntomas desagradables, puesto que esta teoría de mediano rango se convierte en una herramienta en la práctica claramente aplicable y, por consiguiente, permite definir los síntomas como indicadores percibidos del cambio en el funcionamiento normal, como lo experimenta el paciente y, a la vez, nos brinda información acerca del dolor destacando unas características propias, conociendo los factores que afectan el síntoma, las consecuencias y la resolución del dolor (6, 7). las teorías de rango medio se derivan de trabajos de otras disciplinas relacionadas con la enfermería, proponen resultados menos abstractos y más específicos en la práctica que las grandes teorías, delimitan el campo de la práctica profesional, la acción o intervención de la enfermera, y el resultado propuesto. durante los años ochenta, afaf meleis propuso e hizo claridad acerca de la necesidad que tenía la enfermería de desarrollar teorías sustantivas que generaran fundamentos específicos para la práctica, de ahí la importancia de aplicar teorías de mediano rango para diseñar parámetros generales de la práctica (8, 9, 10, 11). en este grupo de teorías se encuentra la de síntomas desagradables, que consta de tres componentes y cuatro dimensiones (12, 13, 14, 15). los componentes son: 1. los síntomas experimentados por el individuo, definidos como los indicadores del cambio, percibidos en el funcionamiento normal como lo experimentan los pacientes. en ocasiones un síntoma puede considerarse una experiencia multidimensional, es decir, tiene una cierta intensidad, una coordinación (duración y frecuencia), y un nivel percibido de angustia y de calidad. con frecuencia las respuestas de tipo fisiológico se manejan en las unidades de cuidado intensivo pero se olvidan las consecuencias de tipo emocional que puede provocar el dolor, tales como ansiedad, insomnio, desorientación, agitación y delirio. 150 año 8 vol. 8 nº 2 chía, colombia octubre 2008 146-158 aquichan issn 1657-5997 2. los factores influyentes son tres: los fisiológicos, los psicológicos y los situacionales, los cuales interactúan entre sí e intervienen en las dimensiones de los síntomas. los fisiológicos están relacionados con los sistemas orgánicos normales, las patologías y los niveles de nutrición, entre otros. los psicológicos se asocian con el estado anímico, la personalidad y el grado de ansiedad. los situacionales se relacionan con las experiencias personales, el estilo de vida y el apoyo social. 3. la realización de la experiencia del síntoma es el componente final de la teoría, es el resultado o efecto de la experiencia del síntoma, e incluye actividades funcionales y cognitivas. la realización funcional se conceptualiza ampliamente porque incluye actividades de la vida diaria, físicas, sociales y laborales. la realización cognitiva incluye la concentración, el pensamiento y la resolución del problema. una vez analizados los componentes anteriores de la teoría, es necesario conocer las dimensiones que son atributos, antecedentes, similitudes o analogías, relaciones y consecuencias para lograr un mejor entendimiento de la experiencia de los síntomas desagradables, donde el sustrato principal es el mismo paciente y su cuidador más cercano, éstas son: la angustia es un atributo que se refiere al grado en el cual la persona es molestada por la experiencia del síntoma; dada su severidad un síntoma puede ser incapacitante para algunos individuos y menos molesto para otros. la calidad es la coordinación existente entre la aparición de un síntoma y una actividad específica. la duración incluye la frecuencia con la que un síntoma ocurre. la intensidad hace referencia a la severidad, fuerza o cantidad del síntoma que se experimenta. en seguida analizaremos esta teoría en la valoración del dolor en el paciente crítico. al ser el dolor un fenómeno multidimensional, requiere una valoración completa que permita obtener datos objetivos y subjetivos sobre las respuestas fisiológicas, cognitivas y emocionales al mismo. con frecuencia, en las unidades la valoración del dolor es unidimensional, ya que se valora basándose en respuestas fisiológicas, olvidando que el dolor, como toda experiencia emocional, es subjetivo; solo el paciente conoce el dolor y cuánto le duele, por eso su valoración debe atenerse necesariamente al informe del paciente cuando este puede verbalizarlo, pero cuando el paciente se encuentra en la unidad de cuidado intensivo y se le dificulta verbalizar el grado de dolor, se hace imperioso el análisis del mismo por medio de los referentes de la teoría de síntomas desagradables, y utilizando escalas visuales o conductuales que permitan valorarlo (16). a continuación se muestra el análisis del dolor por medio de los referentes (síntomas, factores influyentes, realización) de la teoría de síntomas desagradables. síntomas la intensidad, duración, frecuencia y calidad del dolor es un parámetro que ha despertado gran interés en la investigación reciente. los diferentes estudios han demostrado que el empleo sistemático de una herramienta visual ayuda al paciente y al profesional a identificar con mayor precisión la intensidad del dolor. en el paciente crítico la valoración requiere que los profesionales utilicen herramientas que permitan determinar dicha intensidad en los diferentes casos (conscientes-intubados), de ahí la necesidad de conocer las escalas ideales en ellos (17, 18, 19, 20). la angustia es un atributo que se refiere al grado en el cual la persona es molestada por la experiencia del síntoma; dada su severidad un síntoma puede ser incapacitante para algunos individuos y menos molesto para otros. 151 dolor: la verdadera realidad diana marcela achury-saldaña evaluación del dolor en el paciente consciente y comunicativo se debe preguntar acerca de las características del dolor (localización, irradiación, tipo de dolor, factores precipitantes o de alivio), la intensidad, el mecanismo generador, el tipo de dolor, y la respuesta al tratamiento instaurado. para la correcta interpretación de las escalas hay que tener en cuenta no sólo el valor inicial que refiere el paciente, sino los cambios que se producen al instaurar el tratamiento. existen algunas escalas que permiten la valoración del dolor, como la escala visual análoga, la escala verbal numérica, y la escala verbal descriptiva. la escala visual análoga (eva) es una escala unidimensional que valora la intensidad del dolor, representada en una línea de 0 a 10 cm. en el extremo que corresponde al 0 está la frase de “no dolor” y en el extremo opuesto, que corresponde a 10, “el peor dolor imaginable”. la distancia en centímetros desde el punto de “no dolor”, a la marcada por el paciente, representa la intensidad del dolor. cada centímetro puede disponer o no de marcas, aunque para algunos autores la presencia de estas marcas disminuye su precisión. la forma en la que se presenta al paciente, ya sea horizontal o vertical, no afecta el resultado. es la escala más usada, incluso en los pacientes críticos. para algunos autores tiene ventajas con respecto a otras. se necesita que el paciente tenga buena coordinación motora y visual, por lo que tiene limitaciones en el paciente anciano y en el sedado. un valor inferior a 4 en la eva significa dolor leve o leve-moderado, un valor entre 4 y 6 implica la presencia de dolor moderado-grave, y un valor superior a 6 implica la presencia de un dolor muy intenso. la eva se ha convertido en una escala fiable y válida para numerosas poblaciones de pacientes (21, 22, 23). la escala verbal numérica (evn) es también una escala unidimensional, permite que el paciente exprese su percepción del dolor desde el 0 (“no dolor”) al 10 (el “peor dolor imaginable”). puede ser por tanto hablada o escrita y, por consiguiente, más útil en pacientes críticos o geriátricos (24). la escala verbal descriptiva (evd) es similar a la anterior, salvo que el paciente califica su percepción de acuerdo con 6 grados: no dolor, dolor leve, moderado, intenso, muy intenso e insoportable (25). existen otras escalas más sofisticadas que son habitualmente empleadas en la valoración del dolor. entre éstas se destacan escalas multidimensionales como el mcgill pain questionnaire (mpq), que miden la intensidad del dolor y sus componentes sensitivos, afectivos, evaluativos y conductuales; se basa en el lenguaje, por tanto, depende del grado de aptitud verbal del paciente, es frecuentemente utilizada en los pacientes con dolor crónico y demanda más tiempo debido a su complejidad, no supone ninguna ventaja ni en los pacientes críticos ni durante el posoperatorio inmediato (26). evaluación del dolor en el paciente intubado al valorar el dolor en el paciente crítico intubado existe un concepto errado, pues se cree que en éstos no se puede valorar la intensidad, duración y frecuencia del al valorar el dolor en el paciente crítico intubado existe un concepto errado, pues se cree que en éstos no se puede valorar la intensidad, duración y frecuencia del dolor, y se olvida el abordaje de este signo tan importante. 152 año 8 vol. 8 nº 2 chía, colombia octubre 2008 146-158 aquichan issn 1657-5997 dolor, y se olvida el abordaje de este signo tan importante; es por esto que se hace necesario considerar que el paciente intubado ha perdido su comunicación verbal pero nunca su capacidad de comunicarse ya que pueden hacerlo con movimientos y usando escalas como la eva. muchas veces en las unidades se encuentran pacientes intubados con sedación profunda donde es muy difícil que puedan comunicarse, a diferencia de los pacientes que no están con grados de sedación profunda. al valorar la intensidad del dolor es necesario utilizar herramientas indirectas que permitan cuantificarlo, algunas de estas herramientas son: a) indicadores fisiológicos, el dolor va asociado a manifestaciones previas como taquicardia, hipertensión arterial, diaforesis; b) indicadores conductuales, como la expresión facial, presencia de movimientos, posturas, tono; c) aplicación de escalas que permiten cuantificar el dolor evaluando aspectos objetivos y subjetivos, algunas de estas escalas son la de bps y campbell (27), que evalúan las conductas relacionadas con el dolor (movimiento, expresión facial y postura) e indicadores fisiológicos; d) información de los familiares: en ocasiones la información recogida de los familiares directos, que conocen la expresión del paciente, puede orientar hacia la presencia de dolor; su capacidad para observar la presencia e intensidad de éste ha sido evaluada en diferentes estudios. pueden estimar la ausencia o presencia de dolor en un 73% de los pacientes, aunque son menos fiables para detectar el grado de dolor (53%) (28). en resumen, la valoración del dolor como síntoma está sujeta a factores subjetivos comprendidos por la percepción del medio social y cultural que rodea al paciente, indicadores conductuales, ideas, sentimientos y los factores objetivos entre los que se encuentran los parámetros hemodinámicos; sin embargo, es necesario que el profesional de enfermería posea la habilidad para poder combinar en su labor estos dos elementos (subjetivos y objetivos), y logre realizar una adecuada valoración. es por esto que la selección del instrumento más apropiada para evaluar el dolor depende del paciente, de su capacidad para comunicarse, y de la habilidad del profesional para interpretar conductas o indicadores fisiológicos. factores que influyen en la valoración del dolor existen una serie de factores físicos, emocionales y sociales que pueden modular la vivencia o la intensidad dolorosa. los aspectos físicos propios del paciente crítico que generan dolor son desencadenados por factores evidentes, como enfermedades preexistentes, procedimientos invasivos, dispositivos utilizados para la monitorización y el tratamiento, inmovilización permanente y actividades de rutina, generando en el paciente incomodidad e insomnio. la incomodidad y el insomnio contribuyen al agotamiento, la agitación y la desorientación de los pacientes (29). por otro lado, las limitaciones que tiene el paciente crítico en la comunicación se convierten en un elemento emocional y situacional que influye en la experiencia del dolor porque un paciente incapaz de verbalizar su dolor genera estados de ansiedad, agitación, depresión, tristeza y temor. en los momentos iniciales de padecimiento del dolor las reacciones de ansiedad e ira suelen ser frecuentes, sin embargo, cuando el problema se vuelve crónico, la conducta emocional que más la selección del instrumento más apropiada para evaluar el dolor depende del paciente, de su capacidad para comunicarse, y de la habilidad del profesional para interpretar conductas o indicadores fisiológicos. 153 dolor: la verdadera realidad diana marcela achury-saldaña se presenta es la depresión. no obstante, dadas las complejas y variadas relaciones entre estado emocional y dolor, se recomienda su valoración tanto en la evaluación inicial como al final del tratamiento, con el objeto de estimar la eficacia de la intervención sobre el estado emocional alterado (30, 31). con lo anterior se hace necesario que los profesionales de enfermería busquen alternativas de comunicación y observen con atención los signos no verbales para valorar la presencia o intensidad del dolor. dado que los enfermeros no pueden basarse en conductas previsibles ante el dolor, deben recurrir a otras fuentes de evaluación. la familia del paciente se convierte en un factor social de valiosa importancia en la identificación y el manejo del dolor, ya que puede contribuir de un modo significativo a su valoración conductual por medio del reconocimiento de respuestas normales del paciente reflejadas en la expresión, el comportamiento, los ruidos y los movimientos. las influencias culturales son otro factor de importancia en la valoración del dolor, que se pueden convertir en un obstáculo; la primera consideración es conocer el grupo cultural al que pertenece el paciente para comprender las manifestaciones verbales y no verbales del dolor. los pacientes son individuos únicos en su respuesta al dolor, y el profesional de enfermería no debe esperar o asignar de forma injusta una conducta que el paciente no tiene por qué presentar. una segunda consideración que se suele olvidar es la influencia del dolor en la vida del paciente, la enfermera o el enfermero debe comunicarse con él y su familia para discernir sobre este aspecto. en algunas culturas se cree que el dolor se debe a una prueba o un castigo de dios, y los pertenecientes a ellas piensan a veces que debe ser eliminado. otras culturas perciben el dolor como asociado a un desequilibrio vital, por ejemplo el calor o el frío, y los que pertenecen a ellas creen que deben manipular su entorno para restablecer el equilibrio que permita controlar el dolor. las complejidades y peculiaridades de las creencias culturales requieren un análisis más profundo. en algunas unidades de cuidado intensivo se han establecido recursos para afrontar la diversidad cultural de los pacientes en situación crítica (32, 33). finalmente, todos estos factores influyentes nos permiten conocer la realidad del dolor, no es suficiente su conocimiento fisiológico y científico, es necesario conocer y explorar las sensaciones de cada individuo y trabajar en modificar esos factores con el fin de mejorar la experiencia de este síntoma, a la vez es importante que el profesional de enfermería apoye, siempre que sea posible, las creencias y necesidades especiales de cada paciente y su familia para crear el ambiente terapéutico más adecuado que permita la pronta recuperación y el manejo oportuno del dolor. la realización del síntoma este último componente de la teoría de síntomas desagradables nos permite desarrollar una serie de estrategias dirigidas al manejo de ese dolor que se ha evaluado con los elementos anteriores de la teoría a fin de asegurar el confort del paciente durante su estadía en uci, disminuir la morbi-mortalidad, prevenir la aparición de dolor crónico por un manejo inadecuado del dolor originalmente agudo, y evitar las secuelas psicológicas por mal manejo de este síntoma. estos propósitos –que se convierten en la realización real del sínen algunas unidades de cuidado intensivo se han establecido recursos para afrontar la diversidad cultural de los pacientes en situación crítica. 154 año 8 vol. 8 nº 2 chía, colombia octubre 2008 146-158 aquichan issn 1657-5997 toma– se logran con estrategias dirigidas a la prevención, el manejo farmacológico y no farmacológico, y el conocimiento de las herramientas de valoración del dolor por parte de los profesionales. lo ideal es eliminar el dolor por medio de la prevención, la cual en las unidades de cuidado intensivo está destinada a evitar el dolor que se sabe va a ser producido por la realización de procedimientos invasivos, crear un ambiente físico más apropiado disminuyendo los estímulos sonoros, facilitar el ritmo de sueño fisiológico, permitir en lo posible la presencia de la familia, propiciar el contacto físico agradable –como las caricias–, evitar las inmovilizaciones traumáticas y propiciar en su lugar posiciones anatómicas favorables y cómodas. las medidas no farmacológicas se refieren a las intervenciones ambientales y conductuales, las cuales pueden reducir de manera indirecta el dolor al disminuir la cantidad total de estímulos nocivos, reduciendo el temor, la ansiedad o el efecto negativo. los métodos más usados son la explicación oportuna de los procedimientos que generan dolor, la distracción, la sugestión, las técnicas de respiración, la imaginación guiada, posiciones adecuadas, y eliminación de estímulos físicos; el propósito de estos métodos es incrementar la comodidad y estabilidad del paciente, reducir el estrés y las consecuencias indeseables relacionadas con los procedimientos ambientales y terapéuticos; por último, la comunicación con el paciente es una medida no farmacológica que permite integrar la palabra y distintas formas de lenguaje no verbal: la mirada, el silencio, el acompañamiento, la escritura, las señas y la gesticulación, pero quizás el sentido del tacto y la presión son los principales puentes de comunicación y manejo del dolor (34). por otro lado se encuentran las medidas farmacológicas en el manejo del dolor, consistes en la administración de opiodes, antiinflamatorios no esteroides (aines), y coadyuvantes (anticonvulsivantes, antidepresivos, anestésicos locales). aunque el objetivo de este artículo no es la realización de una revisión farmacológica completa de cada uno de ellos, se formulan algunas pautas básicas para su uso. la selección de un medicamento depende de su farmacología (farmacodinamia y farmacocinética) y los efectos adversos. los medicamentos más utilizados en el paciente crítico son los opiodes; los atributos deseables de un opiode son: su acción central, el comienzo rápido del efecto, la facilidad para graduar la dosis, la ausencia de acumulación de metabolitos y el bajo costo. el fentanilo tiene el comienzo de acción más rápido y la duración más breve, pero la dosificación repetida puede causar acumulación y efectos prolongados, es muy eficaz pero es un fuerte depresor respiratorio. la acción de la morfina es más prolongada, de manera que se pueden administrar dosis intermitentes, sin embargo, la vasodilatación como efecto secundario puede provocar hipotensión, y su metabolito activo puede causar sedación prolongada en caso de insuficiencia renal. la meperidina tiene un metabolito activo que causa neuroexcitación (aprensión, temblor, delirio, desorientacion y convulsiones), y puede interactuar con antidepresivos, de manera que no se recomienda para administración repetitiva. los efectos adversos de los analgésicos opioides son comunes y afectan a menudo a los pacientes críticos. los efectos respiratorios, hemodinámicos, neurológicos y gastrointestinales son los que más preocupan, de ahí el temor y las limitaciones que existen al administrar un opioide para manejo del la comunicación con el paciente es una medida no farmacológica que permite integrar la palabra y distintas formas de lenguaje no verbal: la mirada, el silencio, el acompañamiento, la escritura, las señas y la gesticulación. 155 dolor: la verdadera realidad diana marcela achury-saldaña dolor. los aines pueden causar efectos adversos significativos, como hemorragia gastrointestinal; los pacientes con hipovolemia o hipoperfusión, los ancianos y aquellos con disfunción renal pueden ser más susceptibles a lesiones renales inducidas por aines. el acetaminofén es un analgésico que se indica para tratar el dolor leve a moderado. en combinación con un opioide ejerce mayor efecto analgésico (35). prevenir el dolor es más efectivo que tratar uno ya establecido cuando se adopta el criterio según necesidad para administrar los medicamentos, los pacientes pueden recibir dosis menores que la prescripta y el tratamiento se puede demorar significativamente; los analgésicos se deben administrar de manera continua o intermitente programada, con dosis en bolo suplementarias según necesidad, utilizando dosis de rescate si la intensidad del dolor persiste, y previa valoración del estado hemodinámico del paciente. múltiples estudios señalan que más de un 50% de los pacientes tienen un control insuficiente de su dolor durante su estancia en uci (36, 20, 37). son muchas las causas que conducen a un tratamiento inadecuado del mismo. entre otras se destacan tres principalmente: la primera causa es la medicación insuficiente, a menudo los pacientes reciben una dosis de analgesia inferior a la necesaria; la creencia de que el paciente inconsciente o sedado no puede manifestar dolor se debe fundamentalmente a una infravaloración del síntoma, a la ausencia de una correcta valoración de éste, y al miedo a los opiáceos; la formación inadecuada de los profesionales de la salud acerca del dolor, el desconocimiento de su fisiopatología, y de la farmacocinética y farmacodinamia de los analgésicos son en muchos casos la causa de un mal tratamiento, así como la opinión que tienen muchos profesionales de la salud de que el dolor debe soportarse lo máximo posible; la tercera causa es la comunicación inadecuada entre los profesionales de la salud y los pacientes debido a distintas circunstancias como puede ser la tecnología que rodea a la uci, la incapacidad de comunicarse por la condición crítica de los pacientes, los sistemas de monitoria, la atención de enfermería de rutina (aspiración de secreciones, movilización del paciente); éstos se convierten en factores influyentes para que los profesionales no establezcan una comunicación adecuada con el paciente, generando un manejo inapropiado del dolor. con lo anterior se hace necesario el manejo del dolor no solo utilizando un tratamiento farmacológico por medio del establecimiento de un plan terapéutico y un objetivo de analgesia para cada paciente, sino también el uso del tratamiento no farmacológico que permita un control óptimo del dolor y evite las causas de la analgesia inadecuada. para terminar, la última estrategia que permite la realización del dolor es el conocimiento de herramientas de valoración por parte de los profesionales de enfermería; existen algunos estudios que muestran que el déficit de conocimientos, creencias y actitudes de los profesionales en relación con el dolor, su valoración y manejo son un obstáculo habitual en la evaluación precisa y adecuada del síntoma (38, 14, 15). algunos de los conceptos erróneos en la valoración y el manejo del dolor están relacionados con: “todo paciente que se encuentre en uci está sedado y no tiene dolor”, “en los pacientes que están intubados no es posible valorar el dolor”, “todo paciente con dolor debe tener una respuesta fisiológica, y muy pocas emolos efectos respiratorios, hemodinámicos, neurológicos y gastrointestinales son los que más preocupan, de ahí el temor y las limitaciones que existen al administrar un opioide para manejo del dolor. 156 año 8 vol. 8 nº 2 chía, colombia octubre 2008 146-158 aquichan issn 1657-5997 cionales o sociales”, “temor a que el tratamiento intensivo del dolor con opiáceos provoque depresión respiratoria y tolerancia”, y con el desconocimiento del verdadero significado del dolor y las diferentes herramientas con que cuenta el personal de enfermería para su valoración, como la aplicación en la práctica diaria de la teoría de síntomas desagradables y las diferentes escalas en la valoración del dolor; estas herramientas ofrecen un análisis de una situación real de un paciente con dolor, demostrando que la teoría, la investigación y la práctica no están desligadas entre sí y que, por el contrario, nuestro quehacer diario se encuentra más respaldado por la investigación y, por tanto, cuenta con un amplio y razonable sustento científico, además de una propiedad unida e inherente a nuestra disciplina. conclusiones 1. el dolor es un fenómeno multidimensional que requiere una valoración y evaluación completa que permita obtener datos objetivos y subjetivos sobre la respuesta fisiológica, cognitiva y emocional al mismo. con frecuencia en las unidades de cuidado intensivo la valoración del dolor se realiza unidimensionalmente puesto que se valora el dolor fundamentados en respuestas fisiológicas olvidando que este síntoma, como toda experiencia emocional, es subjetivo; solo el paciente conoce el dolor y cuánto le duele, por eso su valoración debe atenerse necesariamente al informe del paciente cuando éste puede verbalizarlo, pero cuando el paciente se encuentra en la unidad de cuidado intensivo y se le dificulta verbalizar el grado del dolor se hace imperioso su análisis por medio de los referentes de la teoría de síntomas desagradables, y utilizando escalas visuales, descriptivas y conductuales que permitan valorarlo. 2. la valoración del dolor como síntoma está sujeta a factores subjetivos comprendidos por la percepción del medio social y cultural que rodea al paciente, indicadores conductuales, ideas y sentimientos, y factores objetivos entre los que se encuentran los parámetros hemodinámicos; sin embargo, es necesario que el profesional de enfermería posea la habilidad para poder combinar en su labor estos dos elementos (subjetivos y objetivos) en la realización de una adecuada valoración. es por esto que la selección apropiada del instrumento para evaluar el dolor depende del paciente, de su capacidad para comunicarse y de la habilidad del profesional para interpretar conductas o indicadores fisiológicos. 3. existen una serie de factores físicos, emocionales y sociales que pueden modular la vivencia o la intensidad dolorosa. los factores físicos propios del paciente crítico que generan dolor, tales como incomodidad e insomnio, son desencadenados por factores evidentes, como enfermedades preexistentes, procedimientos invasivos, dispositivos utilizados para la monitorización y el tratamiento, inmovilización permanente y actividades de rutina. la incomodidad y el insomnio contribuyen al agotamiento, la agitación y la desorientación de los pacientes. por otro lado, las limitaciones que tiene el paciente crítico en la comunicación se convierten en un elemento emocional y situacional que influye el dolor es un fenómeno multidimensional que requiere una valoración y evaluación completa que permita obtener datos objetivos y subjetivos sobre la respuesta fisiológica, cognitiva y emocional al mismo. 157 dolor: la verdadera realidad diana marcela achury-saldaña en la experiencia del dolor porque un paciente que es incapaz de verbalizar su dolor o de hacerse comprender genera estados de ansiedad, agitación, depresión, tristeza y temor; la familia se convierte en un factor social de valiosa importancia en la identificación y el manejo del dolor ya que puede contribuir de un modo significativo a su valoración conductual, por medio del reconocimiento de respuestas normales del paciente reflejadas en la expresión, la conducta, los ruidos y los movimientos. las influencias culturales son otro factor que influye en la valoración del dolor y se pueden convertir en un obstáculo, la primera consideración es conocer el grupo cultural al que pertenece el paciente para comprender las manifestaciones verbales y no verbales del dolor. 4. la realización del dolor es el último componente de la teoría de síntomas desagradables, este componente permite desarrollar una serie de estrategias dirigidas al manejo del dolor, estas estrategias están dirigidas a la prevención del dolor; la utilización de medidas no farmacológicas fundamentadas en intervenciones ambientales, conductuales y comunicativas; medidas farmacológicas, y el conocimiento de herramientas en la valoración del dolor por parte de los profesionales de enfermería como lo es la aplicación en la práctica diaria de la teoría de síntomas desagradables y las diferentes escalas en la valoración del dolor; estas herramientas ofrecen un análisis de una situación real de un paciente con dolor, demostrando que la teoría, la investigación y la práctica no están desligadas entre sí, y que, por el contrario, nuestro quehacer diario se encuentra más respaldado por la investigación y por tanto cuenta con un amplio y razonable sustento científico, además de una propiedad unida e inherente a nuestra disciplina. referencias 1. gutiérrez g. breve reseña histórica sobre el dolor. bogotá: med unab; 2001. 2. álvarez t. teorías sobre el dolor. proceso de enfermería en las personas con 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data analysis was performed in microsoft excel 2016 and spss, version 22.0. parametric (student’s t-test for paired samples) and non-parametric (wilcoxon) statistical tests were also used, considering p-values < 0.05 as statistically significant. results: the initial self-care agency capacity was 61.48 (low) and the final was 80.43 (fair); therapeutic adherence compliance in the initial assessment was occasionally shown (2.82) and frequently shown at the end (4.38), with both variables showing a statistically significant difference with p-values < 0.05. conclusions: it was determined that the intervention performed had a positive effect on therapeutic adherence and the self-care agency capacity of the diabetic patients subjected to the intervention. keywords (source decs): self-care; adherence; diabetes mellitus; discharge planning; education in health. resumen objetivo: evaluar el efecto del plan de preparación para el alta hospitalaria en la capacidad de agencia de autocuidado y la adherencia al tratamiento en los pacientes con diabetes mellitus del hospital universitario erasmo meoz (huem) en el año 2019. materiales y métodos: estudio cuasiexperimental, con medición pretest-postest en grupo de estudio, orientado bajo la teoría de dorothea orem, muestreo no probabilístico a conveniencia de 88 personas. se realizó implementando los siguientes instrumentos: conducta terapéutica, enfermedad o lesión y escala para evaluar la capacidad de agencia de autocuidado (asa), análisis de datos en microsoft excel 2016 y  spss versión 22,0. se usaron además pruebas estadísticas paramétricas (t de student para muestras pareadas) y no paramétricas (wilcoxon), considerando estadísticamente significativos los valores de p <0,05. resultados: la capacidad de agencia de autocuidado inicial fue de 61,48 (baja) y la final de 80,43 (regular); el cumplimiento de la adherencia terapéutica en la medición inicial fue en ocasiones demostrado (2,82) y al final frecuentemente demostrado (4,38), las dos variables mostraron diferencia estadísticamente significativa con valores de p < 0,05. conclusiones: se determinó que la intervención realizada tuvo un efecto positivo sobre la adherencia terapéutica y la capacidad de agencia de autocuidado de los pacientes diabéticos intervenidos. palabras clave (fuente decs):  autocuidado; cumplimiento; diabetes mellitus; planificación del alta; educación en salud. resumo objetivo: avaliar o efeito do plano de preparação para a alta hospitalar na capacidade da agência de autocuidado e na adesão ao tratamento em pacientes com diabetes mellitus do hospital universitário erasmo meoz (huem) em 2019. materiais e métodos: estudo quase-experimental, com medição pré-pós-teste em grupo de estudo, orientado sob a teoria de dorothea orem, amostragem não probabilística por conveniência de 88 pessoas. foi realizada por meio da aplicação dos seguintes instrumentos: comportamento terapêutico, doença ou lesão e escala para avaliação da capacidade de agência de autocuidado (asa), análise dos dados em microsoft excel 2016 e spss versão 22.0. também foram utilizados testes estatísticos paramétricos (teste t de student para amostras pareadas) e não paramétricos (wilcoxon), considerando valores de p <0,05 estatisticamente significantes. resultados: a capacidade inicial de agência de autocuidado foi de 61,48 (baixa) e a final foi de 80,43 (regular); a adesão à adesão terapêutica na medida inicial foi demonstrada ocasionalmente (2,82) e freqüentemente demonstrada ao final (4,38), as duas variáveis ​​apresentaram diferença estatisticamente significativa com valores de p <0,05. conclusões: determinou-se que a intervenção realizada teve um efeito positivo na adesão terapêutica e na capacidade de agência de autocuidado dos pacientes diabéticos interveio. palavras-chave (fonte decs): autocuidado; adesão; diabetes mellitus; planejamento de alta; educação em saúde. introduction according to the who (1), diabetes mellitus is a chronic disease that develops when the pancreas does not produce sufficient insulin or when the organism is not able to use it effectively; according to world statistics, by 2017, 425 million people presented this pathology and there were four million deaths, being the fourth cause of death in latin america (2). according to the colombian health situational analysis corresponding to the same year, diabetes mellitus was the sixth cause of death with a mortality rate of 34.18 per 100,000 inhabitants and with 1,099,417 people affected by the disease, the rate being higher in women (58.9 %). the cases reported by the northern santander department were 29,516 with a prevalence of 2.1%, ranking 12th at the national level (3); in the erasmo meoz university hospital, 1,018 diabetic patients were recorded who were seen in the internal medicine service and its specialties. hospital readmissions represent a problem of major relevance for the health services worldwide; in catalonia, the mean of readmissions due to diabetes mellitus complications in 2016 was 4.6% (4). a study conducted in colombia revealed that 1 out of 10 patients are readmitted within 30 days, generating a longer stay in comparison with their first admission (5). diabetes mellitus is a pathology in which outpatient treatment is easily interrupted by the patients, making them susceptible to presenting complications such as retinopathy, nephropathy, neuropathy, and cardiovascular diseases that need hospitalization and alter the biopsychosocial sphere; this implies a major challenge since diagnosis represents important changes in lifestyle since, without adequate educational support, the outcomes can be anxiety, depression, and deterioration in the quality of life, which is translated into decreased self-care (6). the aforementioned can be avoided with timely support in disease management, this being one of the nursing staff’s competencies, thus managing that the patients understand their disease and adhere to the treatment to prevent possible readmissions. to reduce the number of complications, the pan american health organization (paho) (7) launched an action plan for the prevention and control of non-communicable diseases in the american continent (2013-2019), thus urging to introduce mechanisms that improved care quality, follow-up, and assessment with interventions targeted at the control of non-communicable diseases. according to dorothea orem’s theory, one of the desired objectives is to enhance the self-care activities in the patient using the supporting educational system, whose purpose is to offer guidance on the actions that must be performed in case of deviations from health, this being the approach for implementing the preparation plan for hospital discharge. internationally, in spain, mexico and ecuador, studies have been conducted in which it is shown that health education at discharge and phone follow-up manages to reduce the number of complaints and hospital readmissions, thus increasing therapeutic adherence and self-care; it is considered that this process must be led by the nursing staff, not only providing the patients with recommendations for the subsequent medical controls but also explaining the disease process and how they must adjust the changes to their lifestyle (8-11). in colombia, several projects have been developed centered on assessing self-care capacity and therapeutic adherence in patients with chronic diseases after the development of educational sessions, and studies have also been documented proposing the structure of a preparation plan for hospital discharge with the fundamental participation of the nursing professional (12-14). in northern santander, no experiences of developments of this type of plan have yet been documented; the erasmo meoz university hospital, a reference institution for the region, lacks a care plan for after hospital discharge targeted at diabetic patients to provide the information that the patient and primary caregiver need to prevent readmissions due to the disease complications. because of the above, gaps are evidenced concerning the implementation of preparation plans for hospital discharge at the local level, the reason why the following research question was set forth: does the application of the preparation plan for hospital discharge generate any effect on adherence to treatment and the self-care agency capacity in patients with diabetes mellitus? materials y methods this paper is a longitudinal and quasi-experimental study guided by dorothea orem’s theory on the development of a preparation plan for hospital discharge in patients with diabetes mellitus. patients who met the following criteria were included: • individuals come of age (18 years old or over). • having been admitted to the health institution in the period from june to september 2019. • having been treated in the internal medicine, specialty surgery, or urgency services of the erasmo meoz university hospital. intentional or convenience sampling was employed as the recruitment phase was developed, which lasted 10 weeks. the sample size was calculated having as a reference the health institution’s databases with the admissions due to diabetes mellitus in the months before the study, estimating a total population of 120 individuals. a 95 % confidence level was proposed for the z parameter, which adopts a value of 1.96; therefore, it was possible to handle a 5 % error margin, considering a 50 % success probability, and the result obtained was a sample of 90 individuals. subsequently, during the follow-up phase, which lasted two months for each patient, two of them died during the process, continuing and ending the study with a sample of 88 patients; also, the study included the participation of 36 caregivers. the execution was conducted in the following phases: • first phase: design of the abc (adherence to treatment, providing knowledge, and self-care capacity; from spanish: “adherencia al tratamiento, brindar conocimientos and capacidad de autocuidado”) of the preparation for hospital discharge in people with diabetes; recruitment, initial appraisal and assessment of the self-care agency capacity and of adherence to treatment in each of the services offered by the institution. the “therapeutic conduct: disease or lesion” instruments (12) were used, with high reproducibility (0.98) and questions grouped in eleven indicators with likert-type scale results, namely: 1 never, 2 rarely, 3 occasionally, 4 frequently, and 5 constantly shown; in addition, the “scale to assess the self-care agency capacity (asa)” elaborated by isemberg and evers was implemented with a cronbach’s alpha of 0.74; this scale was adapted and modified for colombia in 2004 by edilma de reales (15) and comprises five categories: very low self-care agency: 24-43, low self-care agency: 44-62, fair self-care agency: 63-81, and good self-care agency: 82-96. • second phase: the preparation plan for hospital discharge was developed with education for self-care of the 88 patients and 36 caregivers who were present, and was conducted in the hospitalization services. • third phase: follow-up was performed and an individual record was managed in microsoft excel for two months through phone calls every week; also, counseling was provided to the patients or, in case this was not possible, to the family member who answered the call, and home visits were conducted when the patients expressed doubts regarding their treatment, how to handle the glucose meter or the healings. • fourth phase: home visits were conducted to perform the final assessment of the self-care agency capacity and therapeutic adherence, by applying the instruments used in the initial assessment with comparison purposes. the abc of the preparation for hospital discharge in people with diabetes was structured as follows: comprehensive assessment of the patients and the caregivers; patient assessment according to the health domains that fit their condition, by applying the following instruments or scales: folstein’s mini-mental state examination (mmse) (16), with eleven items that assess the cognitive function; competence for care (cuidar) (17) with 20 items that include six dimensions with stratification in high, medium and low ranges; the lawton and brody scale for the instrumental activities of daily living (iadls) (17) with a classification of 0-1: total dependence, 2-3: severe dependence, 4-5: moderate dependence, 6-7: slight dependence; and 8: independence, and with a reproducibility index of 0.94. diabetic foot screening (18) was also performed, classified as risk 0: without loss of protective sensation, without peripheral disease and deformities; risk 1: loss of protective sensitivity plus deformity; risk 2: loss of protective sensitivity plus peripheral disease; and risk 3: ulcer or amputation history. similarly, wagner’s scale (19) was used for the classification of the existing ulcers on the diabetic patients’ feet. for the frequency of phone follow-up, the risk classification at discharge (14) was used, which assessed the complexity of the care associated with the treatment with four items (number of medications > 5, parenteral administration route, control medication, and invasive devices); low risk was determined if these parameters were negative with medium or high competence for home care, and high risk was indicated if the patients presented at least one of these conditions and low or medium competence for home care. education to patients or caregivers was based on the application of the abc (treatment adherence, providing knowledge, and self-care capacity) educational methodology contained in the booklet-type support material that was developed by the researchers, which was socialized with the patients and the caregivers at the first meeting during 30 minutes, and later at the follow-up in another session of the same duration to reinforce knowledge and clarify doubts. referral to the support groups is only performed when criteria such as deterioration of the nutritional status, complications resulting from the disease, and changes in mental state are identified; it is worth noting that none of these cases was recorded in the study; therefore, no need for referrals arose. the frequency of the follow-up to be performed was determined according to the instrument for risk classification at discharge: if it was classified as low, follow-up was performed every 15 days and, if high, every week. data analysis was performed in microsoft excel 2016 and the statistical package for the social sciences (spss) software, version 22.0. with the presentation in tables and graphs, parametric (student’s t for paired samples) and non-parametric (wilcoxon) tests were used, considering p-values < 0.05 as statistically significant according to normality distribution in which the shapiro-wilk and kolmogorov-smirnov tests were applied, with a 95 % confidence level and a 5 % error margin. the following was set forth as an alternative hypothesis: the implementation of a preparation plan for hospital discharge manages to exert a positive effect on the self-care agency capacity and adherence to treatment in diabetic patients; in opposition, the null hypothesis was also proposed: the implementation of a preparation plan for hospital discharge has a null effect on the self-care capacity and adherence to treatment in diabetic patients. considering the ethical aspects, the research was classified in the category of research without risk; informed consent was applied, in which all aspects regarding the study were explained, both verbally and in written form. likewise, the authors’ approval was obtained to use the instruments employed, as well as acceptance from the ethics committee of the health institution, always acting under the principles of autonomy, beneficence, and non-maleficence. results a total of 88 individuals participated in the study; their sociodemographic characteristics are shown in table 1: 53 % were women and the predominant age group was from 61 to 70 years old, with 34 %; the participants are married or in a consensual union, with 35 % each marital status; 33 % has complete elementary school, and 69 % is unemployed. of the health characteristics shown in table 2, it was found that 32 % have a diagnosis time of between 6 and 10 years and that 73 % present some comorbidity, with arterial hypertension (aht) being the most frequent (50 %). table 1. sociodemographic characterization variable n % gender male 41 47 % female 47 53 % age 20-30 years old 1 1 % 31-40 years old 2 2 % 41-50 years old 8 9 % 51-60 years old 23 26 % 61-70 years old 30 34 % 71+ years old 24 28 % marital status single 15 17 % married 31 35 % consensual union 31 35 % widowed 7 8 % separated 4 5 % schooling level university 1 1 % technical 1 1 % complete high school 9 10 % incomplete high school 14 16 % complete elementary school 29 33 % incomplete elementary school 25 29 % none 9 10 % occupation none 61 69 % autonomous worker 16 18 % employee 10 12 % pensioner 1 1 % source: the authors. table 2. health characteristics variable n % diagnosis time     0-5 years 22 26 % 6-10 years 28 32 % 11-15 years 18 20 % 16-20 years 12 13 % 21-25 years 6 7 % 26 years or more 2 2 % comorbidity     yes 64 73 % no 24 27 % pathologies     47 50 % circulatory diseases (chf, heart failure, embolism, venous thrombosis, peripheral vascular disease, stroke) 15 16 % renal diseases (ckd, utis, prostatic hyperplasia) 10 11 % metabolic diseases (hypothyroidism, obesity) 6 7 % musculoskeletal diseases (osteoarthrosis, arthritis) 4 4 % pulmonary diseases (pneumonia, copd, asthma, pleural stroke) 4 4 % liver diseases (cirrhosis, hepatitis) 3 3 % hematologic diseases (idiopathic thrombocytopenic purpura, anemia) 2 2 % cancer (colon, leukemia) 2 2 % diseases of the nervous system (parkinson) 1 1 % bmi (body mass index)     underweight 6 7 % normal 36 41 % overweight 28 32 % obesity 18 20 % insulin dependence     yes 40 45 % no 48 55 % source: the authors. within the appraisal scales employed, 86 % of the participants were identified as with normal mental performance, with medium competence for self-care (63 %), followed by a low level of competence (34 %); of the 36 participating caregivers, 72 % presented medium competence. regarding the dependence level, it was evidenced that 36 % presented slight dependence, followed by moderate level (26 %); the screening for the classification of the risk for diabetic foot revealed that 63 % were at risk 0 (no changes) and, for wagner’s scale, 94 % of the participants did not present lesions. follow-up was performed once a week via phone calls during the two months proposed, with a total of 685 calls; six home visits were conducted at the patients’ request to clarify doubts regarding adequate administration of medications, healings, and use of the glucose meter. at the end of the follow-up period, the assessments were conducted, through 86 home visits and two phone assessments, as the patients were not in the metropolitan area of cúcuta. regarding the therapeutic adherence shown by the patients, significant differences were found in all the indicators when comparing the initial assessment and the final one after the application of the preparation plan for hospital discharge employing wilcoxon’s non-parametric test, in which a positive effect was accepted if p < 0.05. the indicators that presented the greatest positive effect were indicator 7 (monitors the changes in the disease status), indicator 8 (monitors the treatment’s secondary effects), and indicator 9 (recognizes the disease complications), with an adherence degree scale ranging from “never shown” to “frequently shown” (figure 1). figure 1. comparison of therapeutic adherence by initial and final indicators source: the authors. concerning the global score obtained in the initial and final assessments, a significant difference was obtained in the parametric student’s t-test (0.000029) (table 3), accepting the alternative hypothesis which set forth that the implementation of the preparation plan for hospital discharge would manage to exert a positive effect on adherence to treatment in diabetic patients. table 3. statistical analysis of the general score of therapeutic adherence variables n mean sd median normality as per shapiro-wilk significance as per student’s t-test for paired samples p<0.05 ia 88 2.82 1.19 3 p>0.05 0.000029 fa 88 4.38 0.6 4 p>0.05 sd: standard deviation; ia: initial assessment; fa: final assessment. source: the authors. by analyzing the effect generated by the preparation plan for hospital discharge on adherence to treatment according to gender, it was found that both men and women were categorized as with an adherence level of “frequently shown”, with scores of 4.44 ± 0.26 and 4.30 ± 0.26, respectively; as was the case in the “presence of comorbidity” and “insulin dependence” variables, in which the scores fell into the “frequently shown” scale, with their affirmative and negative answers being similar, thus determining that the presence or absence of comorbidity and insulin dependence do not exert any influence on the patients’ level of therapeutic adherence. the diagnosis time ranges fell into “frequently shown” therapeutic adherence, headed by the group of people with 16 to 20 years of diagnosis time, with 4.45 ± 0.26 points. with the dependence level, the independent participants presented “frequently shown” adherence, followed by those with total dependence, also in the same scale. a statistically significant change validated by the parametric and non-parametric tests was found according to data distribution, except on the “high competence for self-care” variable, in which no significant change was recorded (table 4). table 4. distribution of therapeutic adherence by variables   variables n mean sd median normality significance gender women ia 7 2.91 0.46 2.82 sw p<0.05 wilcoxon p<0.05 fa 4.30 0.26 4.27 sw p>0.05 men ia 41 2.71 0.60 2.82 sw p>0.05 paired t p<0.05 fa 4.44 0.26 4.45 sw p>0.05 comorbidity yes ia 64 2.83 0.50 2.82 ks p>0.05 wilcoxon p<0.05 fa 4.34 0.27 4.36 ks p<0.05 no ia 24 2.77 0.63 2.82 sw p>0.05 paired t p<0.05 fa 4.42 0.27 4.45 sw p>0.05 insulin dependence yes ia 40 2.72 0.48 2.82 sw p>0.05 paired t p<0.05 fa 4.36 0.30 436 sw p>0.05 no ia 48 2.90 0.57 2.86 sw p>0.05 paired t p<0.05 fa 4.37 0.24 4.36 sw p>0.05 years of diagnosis 0-5 ia 22 2.85 0.54 2.68 sw p>0.05 paired t p<0.05 fa 4.38 0.26 4.31 sw p>0.05 6-10 ia 28 2.83 0.56 2.86 sw p>0.05 paired t p<0.05 fa 4.33 0.31 4.36 sw p>0.05 11-15 ia 18 2.78 0.53 2.73 sw p>0.05 paired t p<0.05 fa 4.32 0.25 4.31 sw p>0.05 16-20 ia 12 2.72 0.53 2.82 sw p>0.05 paired t p<0.05 fa 4.45 0.26 4.45 sw p>0.05 21-25 ia 6 2.81 0.64 2.91 sw p>0.05 paired t p<0.05 fa 4.37 0.24 4.36 sw p>0.05 dependence level total ia 9 3.24 0.45 3.09 sw p>0.05 paired t p<0.05 fa 4.41 0.30 4.36 sw p>0.05 severe ia 3 2.77 0.44 2.64 sw p>0.05 paired t p<0.05 fa 4.31 0.18 4.27 sw p>0.05 moderate ia 23 2.67 0.54 2.73 sw p>0.05 paired t p<0.05 fa 4.33 0.25 4.36 sw p>0.05 slight ia 32 2.74 0.55 2.73 sw p>0.05 paired t p<0.05 fa 4.38 0.31 4.45 sw p>0.05 independence ia 11 3.04 0.51 3.18 sw p>0.05 paired t p<0.05 fa 4.43 0.29 4.55 sw p>0.05 competence for care low ia 28 2.70 0.55 2.64 sw p>0.05 paired t p<0.05 fa 4.34 0.23 4.36 sw p>0.05 medium ia 57 2.84 0.52 2.82 ks p>0.05 wilcoxon p<0.05 fa 4.37 0.28 4.36 ks p<0.05 high ia 3 3.48 0.28 3.55 sw p>0.05 paired t p>0.05 fa 4.51 0.41 4.55 sw p>0.05 sd: standard deviation; ia: initial assessment; fa: final assessment; sw: shapiro-wilk; ks: kolmogorov-smirnov. source: the authors. in the initial assessment of the self-care agency capacity, a mean of 61.48 points was found, falling into the “low self-care agency capacity” scale; whereas in the final assessment, a mean of 80.43 points was observed, which reflects a fair self-care agency capacity; significance was verified by means of the wilcoxon’s test, with p < 0.05 (table 5) and accepting the alternative hypothesis in which it is stated that the effect of the plan is positive. table 5. statistical analysis, self-care agency capacity variables n mean sd median normality kolmogorov-smirnov significance wilcoxon’s test p<0.05 initial asa 88 61.48 8.22 61 p>0.05 0.00 final asa 88 80.43 6.04 81 p<0.05   asa: appraisal of self-care agency; sd: standard deviation. source: the authors. regarding gender, it was found that both men and women were categorized as with fair self-care agency capacity in the range of its average scores; as was the case in the “insulin dependence” variable, in which the scores are similar both in the group that self-administers insulin and in the group that only takes oral medications. the patients who do not have any other disease showed greater self-care agency capacity with an approximate average value of 82 points (good), in opposition to those who do have some other disease, with 80 points (fair). the diagnosis time ranges fell into fair self-care agency capacity, except in the patients with recent diagnoses. regarding the dependence level, at the end of the study, the participants who were classified as with total and severe dependence showed good self-care agency with an approximate average value of 82 points, differently from the other categories, which fell into the fair scale (see table 6). table 6. distribution of the self-care agency capacity according to the variables variables n mean sd median normality significance gender women ia 47 61.34 8.67 60 sw p>0.05 paired t p<0.05 fa 80.30 6.20 81 sw p>0.05 men ia 41 61.76 7.84 62 sw p>0.05 paired t p<0.05 fa 80.95 5.94 82 sw p>0.05 comorbidity yes ia 64 61.17 7.44 61 ks p>0.05 paired t p<0.05     fa   80.08 5.66 80.5 ks p>0.05     no ia 24 62.5 10.22 61 sw p>0.05 paired t p<0.05     fa   82 6.79 82.5 sw p>0.05   insulin dependence yes ia 40 61.38 9.91 61 sw p>0.05 paired t p<0.05     fa   80.38 6.44 80 sw p>0.05     no ia 48 61.67 6.67 61.5 sw p>0.05 paired t p<0.05     fa   80.58 5.66 82 sw p>0.05   years of diagnosis 0-5 ia 22 62.64 6.60 66 sw p<0.05 wilcoxon p<0.05     fa   82.36 4.67 83 sw p>0.05     6-10 ia 28 61.79 10.9 62 sw p>0.05 paired t p<0.05     fa   79.61 6.13 80 sw p>0.05     11-15 ia 18 59.06 7.78 59 sw p>0.05 paired t p<0.05     fa   80.61 5.91 82.5 sw p>0.05     16-20 ia 12 60.58 7.48 60.5 sw p>0.05 paired t p<0.05     fa   79.5 7 79.5 sw p>0.05     21-25 ia 6 64.67 8.66 64 sw p>0.05 paired t p<0.05     fa   78.33 8.43 76.5 sw p>0.05   dependence level total ia 9 63.89 7.18 66 sw p<0.05 paired t p<0.05     fa   81.56 4.97 79 sw p<0.05     severe ia 3 59 7.55 59 sw p>0.05 paired t p<0.05     fa   82.15 5.97 84 sw p>0.05     moderate ia 23 59.74 7.60 61 sw p>0.05 paired t p<0.05     fa   78.26 5.21 78 sw p>0.05     slight ia 32 61.81 7.97 60.5 sw p>0.05 paired t p<0.05     fa   81.06 6.43 82 sw p>0.05     independence ia 11 65.55 10.98 68 sw p>0.05 paired t p<0.05     fa   80.64 6.68 83 sw p>0.05   competence for care low ia 28 58.89 7.15 58 sw p>0.05 paired t p<0.05   fa   80.75 6.54 82 sw p>0.05     medium ia 57 62 7.94 63 ks p>0.05 paired t p<0.05   fa   80.28 5.81 80 ks p>0.05     high ia 3 77.33 5.13 76 sw p>0.05 paired t p>0.05   fa   82 5.56 83 sw p>0.05   sd: standard deviation; ia: initial assessment; fa: final assessment; sw: shapiro-wilk; ks: kolmogorov-smirnov. source: the authors. discussion in this study, what was stated in the situational health analysis of colombia for 2017 (3) is reasserted, since there was a 53 % predominance of the female gender with the disease, which coincides with previous studies (12-13, 20-21). regarding age, the relevant group was that from 61 to 70 years old, similar to another study in which the most frequent age group was from 66 to 69 years old (13). taking as a reference dorothea orem’s theory about self-care, it can be asserted that age is a conditioning factor that exerts a negative influence on people since the greatest incidence of the disease was recorded in the oldest participants; this leads us to think that the cause of this affectation is that, in older adults, self-care actions are influenced by the aging process that entails deviations from health (22). regarding therapeutic adherence, it becomes relevant to contrast the indicators that obtained greater effects due to the intervention performed: monitors the changes in the disease status, monitors the treatment’s secondary effects, and recognizes the disease complications. two of the studies found in the bibliographic review were also compared, in which the same instrument was implemented (12-13). for the “monitors the changes in the disease status” indicator, the initial assessment obtained a mean of 1.85 points (rarely shown) and, in the final assessment, the mean was 4.31 points (frequently shown), only the initial assessment in which the individuals rarely recorded their changes being similar; likewise, the “monitors the treatment’s secondary effects” indicator obtained a mean of 1.03 points in the initial assessment (never shown), equaling one of the antecedents (12). in its turn, the “recognizes the disease complications” indicator obtained an initial average of 1.34 points (never shown), a similar value to that obtained in one of the studies conducted by universidad industrial de santander in which the patients did not recognize the possible disease complications; the opposite was observed for the final assessment, which obtained a mean of 3.91 points (frequently shown), differently from other studies in which the individuals did not present any increase in the ability to recognize the complications (12-13). finally, when assessing the general score for therapeutic adherence in the assessments of this research, the initial one revealed a mean of 2.82 points, being similar to what was obtained in the study of therapeutic adherence of patients with arterial hypertension and type 2 diabetes mellitus where the mean also fell into the “occasionally shown” scale (12); besides, a median of 4 was obtained in the final assessment, being similar to the research on self-efficacy and therapeutic adherence in people with type 2 diabetes mellitus where the median was 3.7 points (13); therefore, it can be noticed that there was a significant change in the general scores, thus confirming that the preparation plan for hospital discharge implemented in diabetic patients exerted a positive effect on their therapeutic adherence. on the other hand, the initial self-care agency capacity for this study presented a mean of 61.48 points, falling into the low agency scale and bearing some resemblance with a study conducted in the same health institution, which showed low self-care agency capacity in hypertensive patients (23); in opposition, the study resulting from an educational intervention for the self-care of hospitalized patients with type 2 diabetes mellitus (2016-2017) revealed an initial mean of 43.79 points, this value representing very low self-care agency capacity (11, 21). according to the results obtained in the final assessment, the average score was 80.43, which falls into the fair self-care agency scale. this value bears some resemblance with the study conducted in myocardial revascularization patients in which an average of 77.07 points was obtained; it is to be emphasized that no patient fell into the very low self-care agency capacity scale, which is following this study (24); also, a pilot study in patients undergoing peritoneal dialysis obtained a mean of 66.4 points, falling into the same scale, which demonstrates that the educational interventions on the patients do exert an effect on the improvement in their self-care agency capacity (25). in opposition to both assessments of this research, the study on self-care agency in patients with type 2 diabetes mellitus differs from the average results, since more than 90 % of its population presented good self-care agency (20). according to the above, if the significance level between the study assessments is considered to assess the effect on the self-care agency capacity, a statistically significant difference was determined (p<0.05) employing wilcoxon’s test, rejecting the null hypothesis and accepting the alternative one, which is under one of the studies in which this same comparison was made by applying the same non-parametric test, and a difference was found between the preand post-test assessments (21). likewise, it is to be mentioned that, in the nursing educational intervention study on the self-care capacities of people with type 2 diabetes mellitus by tenosique and tabasco, it was determined that there is indeed a positive effect on the patients after an educational intervention (9) which is included within the components of the abc for the preparation of hospital discharge in people with diabetes. in the final score obtained about self-care agency capacity, an improvement was evidenced in the universal self-care requirements embedded in the instrument, which establishes that continuous stimulation of diabetic patients is necessary to attain an improvement in the self-care agency capacity, as set forth by orem in one of her main assumptions, taking into account the concept of help methods of such theory (26). among the implications inherent to the nursing staff there must be a greater appropriation of dorothea orem’s theory of self-care deficit, which sets forth that the role of the professional is to encourage the patients to take the lead in their self-care, leveraging their role as educators to bridge possible knowledge gaps related to the pathology and the management of their health. likewise, health institutions can contribute to this initiative, by adopting plans to empower users in self-care after their hospitalizations. conclusions in the beginning, the participants presented “occasionally shown” therapeutic adherence, with 2.82 points; and the most relevant aspect was their lack of knowledge about their disease, as well as low self-care agency capacity: 61.48 points. after the implementation of the preparation plan for hospital discharge, “frequently shown” therapeutic adherence was obtained, with 4.38 points and with significance according to the student’s t-test (0.000029), p<0.05, and fair self-care agency capacity (80.43 points), with p-value < 0.05 significance according to wilcoxon’s test, thus showing a favorable variation jointly between the measures before and after implementing the plan, both for therapeutic adherence in each of its indicators and for self-care agency capacity. when comparing therapeutic adherence and self-care agency capacity with the gender, presence of comorbidity, insulin dependence, dependence level, diagnosis time, and competence for self-care variables, a statistically significant change was found in all, in which a p-value<0.05 is observed between the initial and final measurements. finally, through the statistical analysis performed, the implementation of the preparation plan for hospital discharge in people with diabetes mellitus had a positive effect, since the statistical p-values were < 0.05 in both variables assessed; in other words, the educational intervention was effective on therapeutic adherence and self-care agency capacity, thus reasserting the alternative hypothesis, which allows reflecting on the importance of exercising the guidance, education and patient follow-up role during their hospitalization and after discharge, being determinant in the process of adaptation to the disease, enhancing self-care and therapeutic adherence for the maintenance of health, as set forth by orem in her theory, which reflects the evident need to conduct activities aimed at the development of these roles by the nursing professional. study limitations • the sample size of the different services, for having been selected by estimating a population with this chronic disease condition possibly treated during a period in the institution. • not implementing a control group when working with an estimated population possibly treated with this health condition. • deterioration/complication in the patients’ health status, or even their death. • lack of participants’ cooperation when not informing their new street address or phone number during the follow-up process. • lack of previous studies on the research theme or of projects aimed at the preparation for hospital discharge. • the project does not include verifying if the health institutions implemented the educational products and materials generated. acknowledgments: we thank the people who accepted to be part of this experience; 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[citado 2019 feb. 8]. disponible en: https://repository.javeriana.edu.co/bitstream/handle/10554/20441/leonrodrigueznatalyandrea2016.pdf?sequence=1&isallowed=y 25. carrillo algarra a, díaz f. capacidad de autocuidado de los pacientes en diálisis peritoneal: un estudio piloto en bogotá. enfermería global. 2013; 12(2): 54-64. disponible en: http://scielo.isciii.es/pdf/eg/v12n30/clinica4.pdf 26. raile alligood m. marriner tomey a. modelos y teorías de enfermería. 7ma ed. barcelona: elsevier españa; 2011. home 1 potiguara de oliveira paz1 natália silva pires2 leticia becker vieira3 regina rigatto witt4 vulnerability of women in situation of violence in specialized service 1 orcid.org/0000-0003-2944-7001. school of nursing, universidade federal do rio grande do sul, brasil. 2 orcid.org/0000-0002-6582-6511. school of nursing, universidade federal do rio grande do sul, brasil. 3 orcid.org/0000-0001-5850-7814. school of nursing, universidade federal do rio grande do sul, brasil. 4 orcid.org/0000-0002-3893-2829. school of nursing, universidade federal do rio grande do sul, brasil. regina.witt@ufrgs.br received: 13/01/2019 sent to peer reviewers: 01/03/2019 accepted by peers: 12/04/2019 approved submission: 12/04/2019 doi: 10.5294/aqui.2019.19.2.2 para citar este artigo / para citar este artículo / to cite this article paz pdo, silva n, becker l, rigatto r. vulnerability of women in situation of violence in specialized service. aquichan 2019; 19(2): e1922. doi: 10.5294/aqui.2019.19.2.2 abstract objective: to analyze the vulnerabilities of women cared for in a reference center to women in situation of violence. method: qualitative study, from semi-structured interviews with 15 women, in 2017 and 2018. data analysis occurred through thematic content analysis. results: the category “vulnerability of women in situation of violence” covered social isolation, fear, or shame in denouncing, financial dependence, loss of freedom, fragile self-esteem, lack of formal support, decision to denounce and seeking help, interpersonal bond, protective measure, and difficulty of access to information. conclusions: vulnerability was apprehended in its individual and programmatic dimensions, inter-related with the social dimension. these vulnerabilities must be considered in the formulation of policies for care of women in situation of violence, given that it is the first step for gender equality and eliminate violence against women. keywords (source: decs): gender-based violence; violence against women; domestic violence; gender and health; health vulnerability; women’s health. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1922 theme: promotion and prevention. contribution to the discipline: the study presents the vulnerabilities of women in situation of violence. the results stimulate reflection on the manifestation of violence and reveal a social nature of a complex problem that affects the health of women. besides, the study reinforces the need to consolidate progress in public policies for gender equality, eliminating all forms of violence and enhancing the empowerment of women. https://orcid.org/0000-0003-2944-7001 https://orcid.org/0000-0002-6582-6511 https://orcid.org/0000-0001-5850-7814 https://orcid.org/0000-0002-3893-2829 mailto:regina.witt@ufrgs.br http://dx.doi.org/10.5294/aqui.2019.19.2.2 http://dx.doi.org/10.5294/aqui.2019.19.2.2 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1922 vulnerabilidad de mujeres en situación de violencia atendidas en servicio especializado resumen objetivo: analizar la vulnerabilidad de mujeres atendidas en un centro de referencia de atención a la mujer en situación de violencia. método: estudio cualitativo, a partir de entrevistas semiestructuradas con 15 mujeres en 2017 y 2018. el estudio de los informes se realizó por análisis de contenido temático. resultados: la categoría “vulnerabilidad de mujeres en situación de violencia” abarcó: aislamiento social, miedo o vergüenza por denunciar, dependencia financiera, pérdida de libertad, baja autoestima, ausencia de respaldo formal, decisión en denunciar y buscar ayuda, vínculo interpersonal, medida protección y dificultad en acceder a información pertinente. conclusiones: la vulnerabilidad se aprehendió en la dimensión individual y programática y se interrelacionaron con la dimensión social. estas vulnerabilidades deben considerarse en la formulación de políticas de atención a mujeres en situación de violencia, pues el primer paso para la igualdad de género es eliminar la violencia en contra de las mujeres. palabras clave (fuente: decs) violencia de género; violencia en contra de la mujer; violencia doméstica; género y salud; vulnerabilidad en salud; salud de la mujer. 3 vulnerability of women in situation of violence in specialized service l potiguara de oliveira paz and others vulnerabilidade de mulheres em situação de violência atendidas em serviço especializado resumo objetivo: analisar as vulnerabilidades de mulheres atendidas em um centro de referência de atendimento à mulher em situação de violência. método: estudo qualitativo, a partir de entrevistas semiestruturadas com 15 mulheres, em 2017 e 2018. a análise das informações ocorreu por análise de conteúdo temática. resultados: a categoria “vulnerabilidade das mulheres em situação de violência” abrangeu isolamento social, medo ou vergonha em denunciar, dependência financeira, perda da liberdade, autoestima fragilizada, ausência de apoio formal, decisão de denunciar e buscar ajuda, vínculo interpessoal, medida protetiva e dificuldade de acesso à informação. considerações finais: a vulnerabilidade foi apreendida nas suas dimensões individual e programática, inter-relacionadas com a dimensão social. essas vulnerabilidades devem ser consideradas na formulação de políticas de atenção a mulheres em situação de violência, pois o primeiro passo para a igualdade de gênero é eliminar a violência contra as mulheres. palavras-chave (fonte: decs) violência de gênero; violência contra a mulher; violência doméstica; gênero e saúde; vulnerabilidade em saúde; saúde da mulher. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1922 4 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1922 aquichan issn 1657-5997 eissn 2027-5374 introduction all forms of violence against women and girls represent a violation of human rights, and must be eliminated according to areas of action of the sustainable development objectives for 2030, which require drastic advances in statistics, financing, and policies of gender equality (1). violence against women and girls is a global problem: one in every three women experiences physical or sexual violence throughout her life (1). from latin america and the caribbean, in 2017, brazil had the highest absolute number of feminicide or femicide of women and girls over 15 years of age (1 133 for every 100 000 women), followed by mexico (760), el salvador (345), and argentina (251) (2). the fifth among the 17 sustainable development objectives for 2030, “achieve gender equality and empower all women and girls”, proposes guaranteeing the end of discrimination based on gender inequality through the search for equal rights and access to information, goods and services, and to the job market. it aims at the empowerment of women, through wage equality, as well as public policies that guarantee gender equality, avoid setbacks to women’s rights, and promote the elimination of violence (3). the potential for advancement towards substantive equality is greater when the claims of women and groups organized based on gender equity find receptivity in the diverse instances of power. feminism that seeks equal rights (4), equality of opportunity between the sexes in the family and in society, is based on strengthening the autonomy of women. a society without gender inequalities is a reality one wishes to achieve (5). the greater the disregard for human rights, the grater the possibility of a population to become ill (6). violence compromises the physical, mental, and reproductive health of women, and can result in unwanted pregnancy, unsafe abortions, sexually transmitted diseases, and children with low birth weight. hence, women in situation of violence use health services more frequently (7, 8). researching violence against women, under the focus of the concept of “health vulnerability”, becomes relevant, because the context of a grievance and its interventions admit different evaluations. these depend on the theoretical and ethical-political perspective of whom describes them, as well as on the knowledge and technological resources available or which are planned to become accessible (9). thus, violence against women must be considered in relation to the susceptibility to this grievance and to lower availability of resources for their protection, in an individual, social, and programmatic mediation of the social policies (6). within the context of violence, the motivation strategies for coping are important to establish positive behaviors in the lives of women (10). in this sense, the reference centers are introduced as specialized services that promote the rescue of self-esteem to stimulate awareness, and reaching financial autonomy. besides, it enables alternatives of encouragement to overcome violence and stimulate the creation of support links (11). in brazil, the reference centers were implemented by the secretary of policies for women, as essential structures of the program for the prevention and coping with violence against women. from the technical standard of 2006, it aims to promote the rupture of the situation of violence and the construction of women’s citizenship through interdisciplinary care and inter-sectorial articulation of services that integrate their network of care (12). in this context, the aim of this article is to analyze the vulnerabilities of women cared for in a reference center to women in situation of violence. method descriptive and exploratory study, of qualitative approach, based on the thematic content analysis technique by minayo, was developed (13). qualitative studies are based on the quest to understand in depth values, practices, logics of action, habits, beliefs, attitudes of groups with the degree of reality that cannot be quantified, which corresponds to the most profound space of relationships and phenomena that cannot be reduced to the operability of variables (13). the analysis is based on the interpretation of the research process, which seeks to comprehend in depth the vulnerability of women in situation of violence who decided to seek help. the study had the participation of 15 women in a reference center of care to women in situation of violence (cram, for the term in portuguese), of the municipality of porto alegre, rio grande do sul, brazil. the cram is the service of reference for the psychological and social care of these women. the sample was defined through data saturation (14). the women interviewed 5 vulnerability of women in situation of violence in specialized service l potiguara de oliveira paz and others were indicated by the psychologists in the cram, with the concern of being in the monitoring phase, which represents the most advanced stage of follow up, when the women have better conditions of verbalizing about the violence, because, in the initial follow-up, the post-traumatic stress is quite present and it is perceived that talking about the experience of violence would not do the women well. the inclusion criterion was being women over 18 years of age and being cared in the cram; the exclusion criterion was being in the initial stage of care in the cram. information was collected during the second semester of 2017 and on the first of 2018, through semistructured interview. the interviews were conducted in the cram, in a room reserved to provide privacy to the participants; these lasted an average of 60 minutes and were recorded with the approval of the participants and completely transcribed. the data obtained from the interviews were treated according to the technique of thematic content analysis, composed by the phases: a) pre-analysis, b) exploration of the material, and c) treatment of the results obtained (13). in the pre-analysis phase, an overview reading was conducted of the interviews to have better contact with the contents. in the sequence, we proceeded to capture the sense nuclei, grouping by affinity of common ideas, and elaborated a cutoff of the answers regarding the central research question with the aid of the nvivo software version 11; then, the general concepts that guided the analysis were categorized. through exhaustive reading, theoretical questions were raised in order to have a better identification of the relevance of the content. during the exploration of the material, the common ideas reflected in these cuts were identified. each interview was read and re-read fully to confirm if these ideas were expressed along the lines of the subjects. by reading the interviews, it was sought to identify the relationship of the categories among each other, thus, arriving at common and inter-related aspects. the classification stage permitted constructing the empirical category responsible for specifying the themes and theoretical concepts that guided the discovery and construction of the sense nuclei, which provide a basis for this analysis. the final analysis consisted of the treatment of the results obtained and their interpretation, trying to articulate the structured material of the interviews with specialized literature, seeking to identify the underlying content of what was manifested. the referential of vulnerability in health was adopted as an analytical category (9), upon substantiating and validating the knowledge of the object studied. in relation to the ethical aspects, this study fulfilled the requirements for research with humans, recommended by the national health council, in accordance with resolution 466/2012 (15), and was approved by the research ethics committee at universidade federal do rio grande do sul, under notion 2.546.536, certificate of presentation for ethical appreciation 68940717.3.0000.5347. all participants signed the informed consent form, in duplicate, in two tracks, with one remaining with each participant. to preserve anonymity, participant identification was coded by the letters int (interlocutor), followed by the number of the order of the interviews. after transcription, a second individual meeting was held with each participant to read and validate the transcripts. this allowed the participants to change their narration in the transcription and favored the reliability of the data. results vulnerability of women in situation of violence analysis of the information evidenced the vulnerabilities of the women in the individual and programmatic dimensions; having the social dimension of vulnerability manifested in the inequality of gender relations. the maintenance of violence by an intimate partner relies on dynamics that presuppose social isolation and fear or shame in denouncing, as well as a restricted network of people who do not threaten the power of the perpetrator. this network is often characterized as fragile in the view of women and does not have the resources to offer support or openness to dialogue in case of need. “i will be very sincere, i believed that violence was something very distant and that it happened in socially vulnerable places, i never thought it could happen to me in a relationship, but we do not choose, it just happens. and, when i found myself in a situation of violence, i could not believe what was happening, i felt very ashamed to talk about it with my family and friends.” (int 10) fear and financial dependence on the partner are the main reasons for not placing a complaint, given that the manifestation of fear seems to turn women into permanent hostages of violence and generates the submission to a cycle of violence sustained by economic insecurity. 6 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1922 aquichan issn 1657-5997 eissn 2027-5374 “i was afraid of getting separated and starving and not having enough money to support my daughter.” (int 12) in addition to the restriction of ties, the strategy of male domination also occurs from the prohibition of the possibility of working, studying, choosing a religious orientation, even imposing distancing from family members, characterized as the loss of freedom. “he controlled my schedules, the days of services, with whom i was talking, if i was on the phone he wanted to know and i had to put it on speaker, he wanted to hear what i was talking about. i never asked him to put his phone calls on speakerphone. i did not touch his phone, but he always touched mine.” (int 14) “i think i need to have a strong inner strength to get out of this cycle and break the relationship, i still have not separated and this is damaging my health. i cannot sleep right, i cannot enjoy sex because i do not feel like it; i do it so he won’t say i have a lover. now, during the interview, he called me twice. i felt my mobile phone vibrate, but i am not going to answer.” (int 8) violence materializes domination in women’s lives, its practice establishes physical and/or psychological control of their bodies and in how they think and act. moreover, it reflects negatively and leads to sadness and indignation amid a set of feelings involved in a relationship in which they have fragile self-esteem about their identity and autonomy. “i was very emotionally unbalanced, very exhausted and i got very fat. i felt like the ugliest woman in the world, my personal image was destroyed, i would lie down and did not want to leave the house. my mother encouraged me to get dressed, take care of my hair. i went to a beauty salon and the hairdresser destroyed my hair, i got really bad. i felt the way he said: stupid, incompetent, and fat.” (int 12) in another approach, interpersonal bonding as protection for women represents the possibility of having someone to talk to about violence, having support to denounce, to listen to advice and visualize the possibility of confrontation. “he attacked me inside my mother’s house and my brother and my eldest son defended me. he pushed me and threatened to punch me in the face, my brother and son noticed and did not let him, they talked to me and encouraged me to place a complaint.” (int 14) “i have difficulty talking about what i went through. i felt sorry for not having someone to help me. i felt i did not want to involve my family in the violence that i was suffering. now i can understand that if they had known what i was going through, they could have helped me. i told my father about the violence, but my father is very chauvinist and told me not to split up, not to give up the marriage, he said that i had to take care of my husband. i believed in my father and that’s why the years went by and i delayed in denouncing.” (int 11) with the guide of a social support network that promotes shelter and protection, the decision to complain and seek help becomes more accessible. “i received a booklet on violence, so i recognized myself in that booklet and realized that i suffered psychological violence. the greatest act of courage i ever had in my life was to denounce and decide to seek help.” (int 6) in the analysis of the testimonies, isolation, fear and shame appear as important barriers in the search for help. another aspect related to the individual vulnerability is the difficulty of access to information, which keeps women from being able to visualize ways of coping. support and access to information are fundamental to manage to seek help. with the support of a network of services and legislation providing support to women in situation of violence, it is possible to establish the confrontation. “i got separated in 2007, the maria penal law came into force in 2006. at that time, this law was not so publicized and i did not have so much information, it could have more disclosure maybe even be shown on television. i believed that the law was for very serious cases of physical aggression or death threats and did not know how it worked to achieve a protective measure. i did not know that i could denounce the psychological aggression i suffered, if i had known, i would have denounced a long time ago.” (int 6) for women in situation of violence, the protective measure, supervised by the public security service, is an assurance that guarantees to distance the perpetrator and punishes with imprisonment not obeying the judicial mandate. many times, for fear of being arrested, the aggressor ends up moving away from home. in this perspective, the protective measure is an effective strategy for coping with and preventing re-victimization. 7 vulnerability of women in situation of violence in specialized service l potiguara de oliveira paz and others “he started to shake the light pole in front of my house, i was worried about a short circuit and called the police. he kept waiting for the police and said ‘you can call, because it won’t work, i won’t be arrested’. the police arrived and talked to him, said that he could be arrested if he did not leave, but he paid no attention. the policeman asked me if i wanted him arrested because of the protective measure, i said, ‘yes, you can arrest him’, because i got tired and there is the law, he’s threatening me and my family. we went to the police station to file the complaint and then he was taken to jail. he stayed in jail for 15 days. we had to build a wall in my house so he did not have more access, with the wall we have more protection.” (int 15) lack of informal support hinders women from seeking help, but the lack of formal support weakens the confrontation of violence. when looking for services, many women still experience situations based on a reproduction of the relational patterns derived from gender inequalities, which disqualify them and make them feel inferior. “i went to the police station near my house to report it, but the police officer did not believe me and treated me very badly, he said that i would end up going back to my ex-husband. he embarrassed me when he said this because he spoke loudly in front of other people at the police station. he said: ‘look, now she comes to report, but at night she goes to sleep with him again’. i answered: ‘are you kidding me, do you think my life is worthless? i would not come here and say that i was threatened with death if it were not true and yet you believe i’m joking?’ and he responded: ‘maybe, but there are many women who come here to complain and the next day they are back with the aggressor’. he filled out the occurrence bulletin, but did not advise me that i should seek a protective measure in the justice forum.” (int 15) likewise, it is important to consolidate a space for women’s services in an integrated manner, avoiding their spending time in traveling in search of help. “there was a day that my son asked me what was missing so i could get separated and i said i needed time, because to solve this i would have to go to many places and i would have to walk a lot, probably i would lose a whole day to solve, walking from one place to another. the police station and the forum are distant places and there isn’t a single service for me to report the violence, to get a protective measure and start the separation process. in addition, i needed psychological help and i searched for the cram. going to all these places, i would lose a lot of time with displacement” (int 3). discussion individual and programmatic vulnerability characteristics articulate and constitute social vulnerability based on gender inequality. this is reinforced by male domination in which men feel ownership of women and impose control over their behavior, dress, with whom they relate, and about their money. individual vulnerability is constituted as women losing their freedom, their autonomy to come and go, to decide the best for themselves (16). in addition, by establishing distance from close individuals, women become isolated and, if there is a situation of violence, it is more difficult to establish coping means. the isolation of women happens often through fear of frequent threats and aggressions, and the shame that keeps them from talking about the violence suffered, influencing their decision to denounce. contacts, friendships, and close bonds are avoided when considered unwanted by the husband due to the fear of originating possible aggression, which causes in women the attitude to seek refuge in silence and isolation (17). fear of reporting becomes a barrier to overcoming violence, regardless of social status and emotional fragility, which is characterized as an individual vulnerability (18). financial dependence, lack of family support, and social isolation also limit the autonomy of women because, without support, they cannot visualize strategies of coping and protection due to the psychological dependence (19). with this, it is considered that the physical and psychological recovery of women is only possible when they can break away from the violent relationship (20). thus, the dimension of individual vulnerability involves the social vulnerability, structured in gender inequality in which women have no financial independence and social support. additionally, the programmatic dimension of vulnerability should be considered in the search for help. the lack of a specialized network in caring for women can influence negatively on the decision to seek help, as well as lead women to suffering, either through insecurity in exposing their lives to others or through the endless paths that run through the trajectory of seeking solutions to the situation of violence (21). lack of preparation of professionals and services due to the naturalization/invisibility of violence generates discrimination in which professionals put the blame on women for the situation in 8 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1922 aquichan issn 1657-5997 eissn 2027-5374 which they live and underestimate their suffering (22). in these circumstances, women no longer believe in such services because they suffer from secondary victimization (also called institutional violence), which is carried out by public agents and creates gaps in the network of legal and social assistance, public safety or health services, which should provide formal care and support (23). in this context, it is important to ensure policies and laws that rigorously punish acts of violence and ensure adequate intervention and care services (24). absence of professional qualification compromises service. it is not only a matter of mastering administrative procedures or care techniques, but to know the specificities of violence based on gender. the lack of professional specialization is an obstacle to women’s access (25), a programmatic vulnerability that may occur at different times in the search for help. addressing programmatic vulnerability, therefore, requires drastic progress in gender equality policies. thus, government must be responsible for regulating public policy of social equity and empowering women whose concern is to combat violence and provide intervention tools (26). violence needs to be an object in the formulation of policies that cover the operationalization of actions in health and strengthen good practices for the care and training of professionals (27). caring for women in situation of violence requires the integration of multi-professional work (28), which needs dialogue and planning between services and care professionals, permeating communication to avoid the fragmentation of care. this occurs when the professional meets only its demand, with difficulty in evaluating each case in extended manner and perceiving the real needs of women (29). in order to place the complaint, it is important that a network of care be provided to ensure follow-up and support for women to promote prevention and coping with violence. in addition to being assisted by the judicial system, in many cases, they need access to the health system, given that many seek care in these services before they arrive at a police station to complain (26). the absence of specialized services constitutes programmatic vulnerability that prejudices women in seeking help. as a way to meet the needs of women, since 2013, in some brazilian capitals, the brazilian women’s house was created, linked to the program women: living without violence. these services contribute to facilitating assistance, by promoting the integration of women’s services, and focus on integral care (30), consolidating different options in a single space, which allows women not to waste time traveling in search of help. the program remains in effect, but in many capitals it has not been implemented and there is still no integrated physical space for service, which turns the situation into a programmatic vulnerability. in brazil, progress to combat violence against women are the maria da penha law and the feminicide law. the development of legislation that punishes violence and protects women is essential in addressing programmatic vulnerability. in addition, the importance of the protective measure as a right of women who denounce violence to ensure the legal support of protection and distancing of the perpetrator is emphasized (31). this distancing is fundamental and guaranteed by the protective measure, because to continue living in the same place with the perpetrator makes women susceptible to future repetition of violence (20). another important action in this context was the creation, in 2003, of a secretary of policies for women, later linked to the ministry of human rights, whose focus is to coordinate management of public policies to ensure that governmental spheres assume the responsibility for the reduction of violence and strengthen gender equality (32). thus, it is possible to establish the programmatic confrontation of violence based on current legislation and a specialized services network that ensures the refuge and protection of women. within the scope of collective health, it is necessary to consolidate the promotion of health through the mobilization of various government agencies against violence, in an intersectoral context of social visibility. this would strengthen the construction of care networks and mobilize civil society in participatory instances, in order to promote debates of the social problem in the search of solutions to confront violence against women (33, 34). in addition, it is imperative to ensure the support and security of women and their children by investing in training programs in different sectors of society, especially in the judicial, for the correct application of protection laws and to strengthen care systems that involve taking action in care, within the health system, to reinforce the detection of violence in primary care. at the same time, it is necessary to develop government awareness campaigns in partnership with feminist organizations with a focus on gender equality (34). 9 vulnerability of women in situation of violence in specialized service l potiguara de oliveira paz and others these results evidence actions that, according to the united nations, in the 2030 agenda, are urgent to confront violence against women and achieve gender equality. for this, four actions are configured in the public spheres: implementation and enforcement of comprehensive laws and policies; universal attention to intersectoral and quality services in support of women; social awareness and prevention measures to combat underlying factors and root causes of violence; and compilation of databases on violence (1), consolidating epidemiological surveillance by structuring and strengthening observatories of violence. concern to develop such actions demonstrates the government’s initiative to eliminate violence against women. conclusions analysis of women’s vulnerabilities when cared for in a reference center to women in situation of violence evidenced elements of their individual dimension, such as: social isolation, fear, shame of denouncing, financial dependence, loss of freedom, fragile self-esteem, lack of support, and difficulty of access to information. confronting these difficulties revealed actions related to the programmatic dimension, because when deciding to denounce and seek help, having an interpersonal bond as social support, women obtained protection through a legal measure. in addition, women need financial independence, to regain their self-esteem and their physical and mental health, making it necessary to (re)organize their lives in the initiative of empowering themselves to cope and overcome violence. within the context studied, vulnerability revealed subjective aspects of the women, as well as programmatic and social components, with emphasis on the connections among individuals, in their community relations, in the socio-cultural and economic context. the mismatch among the actions undertaken to meet the demands of the women was evidenced, which reinforces the importance of integrating the services network to address gender violence. in the governmental setting, it becomes essential to create legislation that protects women from violence, which goes beyond punitive actions. it is essential to develop projects to promote gender equality and the articulation of different sectors of society to debate about violence, which would generate visibility to this serious social problem. by mobilizing society, it is possible to strengthen the network of services, in inter-sectorial manner, from the perspective of integral care of women in situation of violence. in this sense, the recognition of vulnerabilities should be considered in the formulation of policies for care, to support the fifth objective of sustainable development, since the first step for gender equality is the elimination of violence against women. the limitation of the study is related to the context of the source of the information: women attending a reference center. for future studies, it is important to investigate attendance to other services of the network and to approach the dialogue among the professionals from the inter-sectorial perspective of the service. the vulnerabilities of women in situation of violence, apprehended in their individual and programmatic dimensions, are interrelated with the social dimension. the importance of confronting violence, both in its macrosocial dimension, as part of a transformation structure, and in its microsocial dimension, based on behaviors whose senses are socially and culturally constructed, is reaffirmed. in the formulation of public policies, these cannot be confined to merely confronting violence, but to ensuring gender equality and avoiding setbacks as a result of such discrimination. conflict of interest: none declared. 10 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1922 aquichan issn 1657-5997 eissn 2027-5374 references 1. onu mujeres. hacer las promesas realidad: la igualdad de género en la agenda 2030 para el desarrollo sostenible. nova york: nações unidas; 2018. available from: http://www.unwomen.org/-/media/headquarters/attachments/sections/ library/publications/2018/sdg-report-gender-equality-in-the-2030-agenda-for-sustainable-development-2018-es. pdf?la=en&vs=834 2. observatorio de igualdad de género de américa latina y el caribe. feminicidio. naciones unidas; 2017. available from: https://oig.cepal.org/es/indicadores/feminicidio 3. united nations. transforming our world: the 2030 agenda for sustainable development. nova york: the general assembly. 2015. available from: https://sustainabledevelopment.un.org/post2015/transformingourworld 4. 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https://doi.org/10.1177/0886260518779065 https://doi.org/10.1177/0886260518779065 1 carolina marques de almeida1 camila fernandes pollo2 silmara meneguin3 intervenções de enfermagem para pacientes com hipertensão intracraniana: revisão integrativa da literatura 1 https://orcid.org/0000-0002-7872-8558. unidade de terapia intensiva, universidade estadual paulista, brasil. 2 https://orcid.org/0000-0003-0264-5841. departamento de enfermagem, universidade estadual paulista, brasil. 3 https://orcid.org/0000-0003-3853-5134. departamento de enfermagem, universidade estadual paulista, brasil. s.meneguin@unesp.br recebido: 07/05/2019 submetido: 09/06/2019 aceito por pares: 15/08/2019 aceito: 09/09/2019 doi: 10.5294/aqui.2019.19.4.9 para citar este artigo / para citar este artículo / to reference this article de almeida cm, pollo cf, meneguin s. nursing interventions for patients with intracranial hypertension: integrative literature review. aquichan 2019; 19(4): e1949. doi: https://doi.org/10.5294/aqui.2019.19.4.9 resumo objetivo: este estudo objetiva identificar, nas publicações nacionais e internacionais, as principais intervenções de enfermagem direcionadas a pacientes com hipertensão intracraniana. materiais e método: revisão integrativa da literatura com busca nas bases de dados lilacs, pubmed, scopus, web of science, cinahal e google acadêmico, de 2013 a 2018. resultados: a amostra foi constituída por sete artigos que atenderam aos critérios de inclusão. elencaram-se duas categorias temáticas para as intervenções de enfermagem direcionadas ao paciente com hipertensão intracraniana: habilidades cognitivas e raciocínio clínico, necessárias para o controle de parâmetros neurofisiológicos e para a prevenção de hipertensão intracraniana, e práticas baseadas em evidências para a melhoria da assistência ao paciente neurocrítico. conclusões: a hipertensão intracraniana é um evento de grande repercussão clínica, cujas complicações podem ser minimizadas e controladas mediante intervenções de enfermagem específicas que abrangem controles de parâmetros neurofisiológicos, hemodinâmicos, bem como prevenção de aumento da pressão intracraniana atrelado à realização de procedimentos pela equipe de enfermagem. palavras-chave (fonte: decs) monitorização hemodinâmica; pressão intracraniana; cuidados de enfermagem; assistência de enfermagem; enfermagem. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1949 tema: prática baseada em evidência. contribuição para a disciplina: este estudo oferece subsídios para uma prática de enfermagem segura, pautada em evidências científicas, que pode subsidiar a implantação de modelos de intervenção mais propositivas para enfermeiros que atuam em unidades de terapia intensiva. ademais, os achados deste estudo poderiam ser utilizados por esses profissionais para a reflexão sobre a prática profissional, o que contribuiria para a oferta de cuidados condizentes com as necessidades de cada paciente. também estimula a realização de futuras pesquisas nessa temática, com novos enfoques para a qualificação da assistência ao paciente crítico. https://orcid.org/0000-0002-7872-8558 https://orcid.org/0000-0003-0264-5841 https://orcid.org/0000-0003-3853-5134 mailto:s.meneguin@unesp.br https://doi.org/10.5294/aqui.2019.19.4.9 https://orcid.org/0000-0002-7872-8558 https://orcid.org/0000-0003-0264-5841 https://orcid.org/0000-0003-3853-5134 https://doi.org/10.5294/aqui.2019.19.4.9 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1949 intervenciones de enfermería para pacientes con hipertensión intracraneal: revisión integradora de la literatura resumen objetivo: el estudio tiene como objetivo identificar, en publicaciones nacionales e internacionales, las principales intervenciones de enfermería dirigidas a pacientes con hipertensión intracraneal. materiales y método: revisión integradora de la literatura con búsqueda en las bases de datos lilacs, pubmed, scopus, web of science, cinahal y google académico, del 2013 al 2018. resultados: la muestra se conformó de siete artículos que cumplieron con los criterios de inclusión. se establecieron dos categorías temáticas para las intervenciones de enfermería dirigidas a pacientes con hipertensión intracraneal: habilidades cognitivas y razonamiento clínico, necesarias para el control de parámetros neurofisiológicos y la prevención de hipertensión intracraneal, y prácticas basadas en evidencias para la mejora de la asistencia al paciente neurocrítico. conclusiones: la hipertensión intracraneal es un evento de gran repercusión clínica, cuyas complicaciones se pueden minimizar y controlar mediante intervenciones de enfermería específicas que abarcan controles de parámetros neurofisiológicos, hemodinámicos y prevención de aumento de la presión intracraneal relacionado a la realización de procedimientos por el equipo de enfermería. palabras clave (fuente: decs) monitorización hemodinámica; presión intracraneal; cuidados de enfermería; atención de enfermería; enfermería. 3 intervenções de enfermagem para pacientes com hipertensão intracraniana: revisão integrativa da literatura l carolina marques de almeida e outros nursing interventions for patients with intracranial hypertension: integrative literature review abstract objective: the study sought to identify, in national and international publications, the principal nursing interventions aimed at patients with intracranial hypertension. materials and method: integrative literature review with search in lilacs, pubmed, scopus, web of science, cinahal, and google scholar databases, from 2013 to 2018. results: the sample was comprised of seven articles fulfilling the inclusion criteria. two thematic categories were established for the nursing interventions aimed at patients with intracranial hypertension: cognitive skills and clinical reasoning, necessary to control neuro-physiological parameters and prevent intracranial hypertension, and evidence-based practices to improve care for neuro-critical patients. conclusions: intracranial hypertension is an event of great clinical impact, whose complications can be minimized and control through specific nursing interventions that encompass control of neuro-physiological and hemodynamic parameters and prevention of increased intracranial pressure related with the performance of procedures by the nursing staff. keywords (source: decs) hemodynamic monitoring; intracranial pressure; nursing care management; nursing care; nursing. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1949 4 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1949 aquichan issn 1657-5997 eissn 2027-5374 introdução a pressão intracraniana (pic) é um evento de grande repercussão clínica que acomete pacientes vítimas de tumores cerebrais, traumatismo crânioencefálico grave, acidente vascular cerebral isquêmico extenso e hemorrágico. o aumento da pic é uma causa importante de lesão cerebral secundária e está frequentemente associado à pior evolução neurológica (1-3). conceituada como a pressão do líquido cefalorraquidiano (lcr), advinda da pressão do sangue e do tecido cerebral, os valores normais oscilam entre 5 e 15 mmhg (4). no paciente crítico, a pic pode variar em função de alterações pressóricas, ventilatórias, posicionamento do paciente, bem como pelas mudanças das pressões de dióxido de carbono e oxigênio (5). o aumento da pic, acima de 20 mmhg, tem como importante repercussão fisiológica a redução da pressão de perfusão cerebral e do fluxo sanguíneo cerebral, além de comprimir as estruturas cerebrais e contribuir para hidrocefalia, além de causar herniação cerebral (6-9). a monitorização da pic, realizada por meio da implantação de um cateter de polietileno na cavidade ventricular conectado a um transdutor de pressão, é fundamental para a prevenção de danos cerebrais secundários que contribuem para o aumento da morbimortalidade (10-13). a despeito de ser um procedimento invasivo e que envolve riscos à saúde e à segurança daqueles que o utilizam, é o único método aceito para o diagnóstico seguro do aumento da pic, bem como para o seu tratamento em algumas situações clínicas (14-16). acrescida do controle de parâmetros clínicos, hemodinâmicos, respiratórios e metabólicos, a monitorização da pic ajuda e orienta a terapêutica dos pacientes neurológicos, uma vez que permite o rápido reconhecimento desta e permite avaliar a eficácia terapêutica, bem como a injúria cerebral (17-18). embora a passagem do cateter seja um procedimento inerente à equipe de neurocirurgia, o seu cuidado e a monitorização da pic competem à equipe de enfermagem da unidade de terapia intensiva (uti) (19). além disso, há que se considerar que o enfermeiro é o profissional que está na beira do leito dando significado aos parâmetros de monitorização da pic, por meio do conhecimento teórico, do raciocínio lógico e da experiência adquirida na prática (20). cuidado esse que coaduna com saberes e práticas aliados a ações educativas e assistenciais no exercício da prática profissional, para garantir qualidade no atendimento prestado ao paciente neurocrítico (21). nas utis, os profissionais de enfermagem devem ter a premissa de evitar danos desnecessários durante a atenção prestada nos serviços de saúde, a fim de melhorar a assistência prestada e prevenir iatrogenias (22-23). os eventos iatrogênicos, nesse contexto, podem colocar o paciente em risco de vida e trazer complicações que podem comprometer sua evolução clínica e sua segurança (24). cumpre destacar que o aumento da pic ocorre, muitas vezes, em decorrência de procedimentos de enfermagem de rotina, como banho no leito, posicionamento do paciente e higiene oral e brônquica, dentre outros (25-26). nessa direção, a equipe de enfermagem deve estar atenta aos sinais e aos sintomas de piora de hipertensão intracraniana, que dependem da localização da injúria cerebral. no entanto, o sintoma mais comum é a piora do estado mental (27-29). nesse sentido, a sistematização da assistência de enfermagem (sae) é uma ferramenta importante, pois permite que a equipe de enfermagem organize e direcione suas atuações às necessidades específicas de cada paciente e previna agravos desnecessários (30). considerando que a qualidade da assistência em saúde está atrelada à incorporação de boas práticas de enfermagem, buscou-se, neste estudo, conhecer as intervenções direcionadas ao paciente com monitorização da pic com o propósito de contribuir para uma assistência pautada em princípios científicos e nas melhores evidências. o objetivo deste estudo foi identificar, nas publicações nacionais e internacionais, as principais intervenções de enfermagem direcionadas a pacientes com hipertensão intracraniana. materiais e métodos revisão integrativa da literatura, realizada em cinco etapas: identificação do problema, busca na literatura, avaliação dos dados, análise dos dados e apresentação da revisão integrativa ou síntese do conhecimento (31-32). para conduzir este estudo, uti5 intervenções de enfermagem para pacientes com hipertensão intracraniana: revisão integrativa da literatura l carolina marques de almeida e outros figura 1. processo de seleção dos artigos na revisão integrativa (botucatu, brasil, 2019) fonte: elaboração própria. estudos identificados nas bases de dados lilacs (n = 235), pubmed (n = 227), scopus (n = 4), web of science (n = 0), cinahal (n = 0), google acadêmico (n = 164) excluídos • estudos repetidos (n = 200) •estudos em duplicidade (n = 180) excluídos artigos baseados nos critérios de exclusão (n = 200) excluídos não respondem à questão orientadora (n = 43) estudos analisados pelos títulos e pelo resumo (n = 250) estudos lidos na íntegra para a avaliação de critérios de elegibilidade (n = 50) estudos incluídos (n = 7) id en ti fi ca çã o se le çã o el eg ib il id ad e in cl u sã o lizou-se a seguinte questão: “quais intervenções de enfermagem são descritas na literatura científica para pacientes com hipertensão intracraniana?” para a busca dos artigos, foi utilizado o acesso on-line às seguintes bases de dados: literatura latino-americana e do caribe em ciências da saúde (lilacs), pubmed, scopus, web of science, cinahl e google acadêmico. os descritores selecionados na lista de descritores das ciências da saúde (decs) foram: “monitorização hemodinâmica”, “pressão intracraniana”, “cuidados de enfermagem” e “assistência de enfermagem”, “intervenções de enfermagem”, “cuidados neurointensivos”, com os operadores booleanos or e and. a busca foi realizada em dezembro de 2018. para a inclusão dos artigos, foram considerados os seguintes critérios: artigos originais que atendessem à questão orientadora, publicados entre 2013 e 2018, nos idiomas português, inglês e espanhol. foram excluídos artigos não disponíveis na íntegra, relatos de experiência, revisões da literatura, teses e dissertações. na intenção de obter maior precisão nos resultados, a busca foi auxiliada por dois pesquisadores envolvidos no estudo. para a coleta de dados dos estudos, foi elaborado um instrumento que englobava as seguintes informações: ano de publicação, autores, objetivo, país em que foi realizado o estudo, base de dados, delineamento da pesquisa, detalhamento amostral, intervenção, resultados e recomendação/conclusões. essas informações contribuíram para a análise e a síntese das informações obtidas na busca. resultados identificaram-se, inicialmente, 630 artigos; destes, 380 foram excluídos por estarem duplicados nas bases de dados. assim, foram selecionados 250 artigos para a leitura do título e do resumo, o que resultou numa amostra de 50 artigos para a leitura do texto completo. destes, 43 foram excluídos por não responderem à questão orientadora, o que levou ao total de sete artigos (figura 1). quatro estudos foram desenvolvidos nos estados unidos, dois na europa e um no brasil. o quadro 1 apresenta as características dos artigos selecionados para esta revisão, segundo autor, ano de publicação, base de dados, delineamento da pesquisa e resultados associados às intervenções de enfermagem. na figura 2, encontra-se descrita a síntese estrutural das intervenções de enfermagem identificadas na literatura (botucatu, brasil, 2019). a leitura e a análise dos artigos permitiram observar que as intervenções de enfermagem estão atreladas às habilidades cognitivas e ao raciocínio clínico, mas que também devem ser respaldadas em práticas baseadas nas melhores evidências científicas. as habilidades cognitivas e o raciocínio clínico do enfermeiro são fundamentais para: interpretar os parâmetros neurofisiológicos e hemodinâmicos, prevenir o aumento da pic durante a realização de procedimentos de enfermagem e a administração da terapia farmacológica prescrita. contudo, é na prática baseada em evidências (pbe) que o cuidado tem respaldo científico necessário para a melhoria da prática assistencial. discussão cuidar de pacientes com alterações neurológicas é um grande desafio para toda a equipe de enfermagem. o paciente com pic requer cuidados específicos e contínuos na uti e exige a máxima atenção da equipe de saúde e a mínima manipulação, com o intuito de evitar possíveis lesões deletérias ou o agravamento das existentes (20, 39-41). 6 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1949 aquichan issn 1657-5997 eissn 2027-5374 autor/ano/local da pesquisa/ base de dados título do artigo delineamento resultados associados às intervenções de enfermagem artigo 1 rosa nm, lima jf, inoue kc, 2013 (33), brasil, lilacs conhecimento da equipe de enfermagem sobre neurointensivismo e a influência da educação continuada estudo descritivo, exploratório e quantitativo que teve como objetivo caracterizar o conhecimento da equipe de enfermagem sobre neuroitensivismo. • parâmetros de normalidade de ppc, pam, pvc, svjo2, etco2, pic. • parâmetros que devem ser anotados para a avaliação do doente. • cuidados de enfermagem após a manipulação do paciente. • aspiração do tubo endotraqueal. • representação matemática de parâmetros para o cálculo de ppc. • fatores e/ou procedimentos que contribuem para a elevação da pic. artigo 2 uğraş ga, yüksel s, temiz z et al., 2018 (34), estados unidos da américa, pubmed effects of different headof-bed elevations and body positions on intracranial pressure and cerebral perfusion pressure in neurosurgical patients estudo quase experimental. o estudo mostrou que diferentes posições dos pacientes e da cabeceira da cama levaram a alterações insignificantes na pic e na ppc. artigo 3 sacco tl, delibert, sa, 2018 (35), estados unidos da américa, pubmed management of intracranial pressure: part i estudo descritivo. o cuidado de enfermagem desses pacientes inclui a colaboração com uma equipe interprofissional e é direcionado ao conforto do paciente e da família. a utilização de uma diretriz baseada em evidências para o manejo da pic é fortemente encorajada para melhorar os resultados dos pacientes. artigo 4 nyholm l, steffansson e, frojd c et al., 2014 (36), suécia, pubmed secondary insults related to nursing interventions in neurointensive care: a descriptive pilot study estudo prospectivo, observacional que teve como objetivo investigar os eventos secundários à higiene oral, à mobilização no leito, à aspiração endotraqueal, a medidas de higiene e a intervenções simultâneas de cuidados neurointensivos. o tipo mais comum de evento após cuidados de enfermagem foi o aumento da pic, seguido de baixa pressão de perfusão cerebral e pressão arterial média. artigo 5 robinson jd, 2015 (37), estados unidos da américa, pubmed management of refractory intracranial pressure artigo descritivo que aborda as condutas para o tratamento da injúria cerebral e enfatiza o papel da enfermagem no controle da pic. • via aérea segura. • manter eucapnia. • evitar hipotensão. • pam > 90mmhg. • manter níveis de glicemia entre 80 e 180 mg/dl. • manter temperatura em 37 °c. • adequada sedação. • manutenção da cabeceira da cama em 30 graus. • manter cabeça neutra (alinhada com o corpo). • na utilização de colar cervical, dois dedos devem encaixar dentro do colar. • medicações utilizadas para controle de pic: manitol 20 % e solução salina hipertônica. • para a diminuição de metabolismo cerebral, barbitúricos ou hipotermia. os autores ressaltam o papel da enfermagem no controle de hipotensão após bolus de pentobarbital. hipotermia (32 c a 34° c) reduz a pic por 24 a 72 horas. • reconhecimento dos sinais de herniação cerebral: pupilas assimétricas, não reagentes, postura de decorticação ou descerebração, hipertensão com bradicardia e parada respiratória. artigo 6 szabo cm, grap, mj, starkweather a et al., 2014 (38), estados unidos da américa, pubmed the effect of oral care on intracranial pressure in critically ill adults estudo observacional, não experimental, que teve como objetivo investigar os efeitos dos cuidados de higiene oral na pic. o modelo de análise de variância de medidas repetidas de efeito misto indicou que houve um aumento estatisticamente significativo na pic em resposta à higiene bucal (p = 0,0031). não houve, no entanto, efeito clinicamente significativo na pic. esse estudo fornece evidências de que a higiene bucal é segura para o desempenho de pacientes na ausência de pic elevada preexistente. artigo 7 nyholm l, howells t, enblad p, 2017 (25), suécia, pubmed predictive factors that may contribute to secondary insults with nursing interventions in adults with traumatic brain injury estudo prospectivo, quantitativo, que teve como objetivo investigar o risco de induzir alta pressão intracraniana relacionada a intervenções de enfermagem. aumento de pic secundário relacionado às intervenções de enfermagem ocorreu em 6 pacientes (21 %) e 8 ocasiões (12 %). pacientes com pic basal de 15 mmhg ou mais apresentaram risco 4,7 vezes maior de desenvolver um insulto. a pic inicial de 15 mm hg ou mais foi o fator mais importante para determinar o risco de insulto secundário à pic. quadro 1. artigos incluídos no estudo segundo título, autores, local, ano de publicação, bases de dados e países de origem, delineamento da pesquisa e principais resultados e intervenções (botucatu, brasil, 2019) ppc — pressão de perfusão cerebral; pam — pressão arterial média; pvc — pressão venosa central; svjo2 — oximetria do bulbo jugular; etco2 — co2 ao final da expiração. fonte: elaboração própria. 7 intervenções de enfermagem para pacientes com hipertensão intracraniana: revisão integrativa da literatura l carolina marques de almeida e outros figura 2. síntese estrutural das intervenções de enfermagem (botucatu, brasil 2019) fonte: elaboração própria. como pré-requisito para a monitorização da pic, o enfermeiro necessita ter conhecimento sobre os princípios da monitorização, da neuroanatomia e da neurofisiologia, bem como da fisiopatologia da hipertensão intracraniana (hic) (42). sabe-se que o aumento da pic pode estar associado à condição clínica do paciente ou ocorrer em resposta aos cuidados de enfermagem de rotina. para tanto, o foco das intervenções médicas e de enfermagem deve ser a prevenção ou a minimização da injúria cerebral secundária (37, 43-44). estudo realizado com 18 pacientes com diagnósticos neurocirúrgicos mostrou que os tipos mais comuns de eventos secundários após os cuidados de enfermagem foram o aumento da pressão intracraniana, seguido da queda da pressão de perfusão cerebral e da pressão arterial média. os autores concluíram que pacientes com risco aumentado de eventos secundários devem ser reconhecidos, e seu cuidado e tratamento rigorosamente planejados (36). nesse sentido, a literatura enfatiza a importância do empoderamento da enfermagem na equipe multiprofissional e a utilização de protocolos assistenciais que incluam intervenções para o controle e o gerenciamento da pic, a fim de intervir de forma breve e eficaz nos tratamentos que visam atenuar esse evento, assim como adequar os procedimentos de enfermagem que, por associação, possam aumentar a hipertensão intracraniana e diminuir a pressão de perfusão cerebral (25-27). no levantamento realizado nesta pesquisa, identificou-se que as intervenções de enfermagem estão atreladas às habilidades cognitivas e ao raciocínio clínico, imprescindíveis para interpretar os parâmetros de monitorização e implementar cuidados para o controle da pic. as intervenções descritas na literatura encontradas no período de busca são neurofisiológicas e abarcam a monitorização de parâmetros hemodinâmicos como saturação de oxigênio, pressão arterial média, temperatura, pic e pressão de perfusão cerebral. nessa busca, foram identificados dois trabalhos que descrevem procedimentos que, indiretamente, podem contribuir para o aumento da pic e cujas evidências científicas respaldam o melhor cuidado. um dos procedimentos é a elevação da cabeceira da cama e a posição corporal. embora o único estudo que abordou o tema não tenha encontrado alteração estatisticamente significativa nos valores de pic com a cabeceira em 15, 30 e 45 graus, assim como na posição supina, lateral direita e esquerda, o tamanho amostral de 30 pacientes foi considerado uma limitação da pesquisa (34). no entanto, outras pesquisas mostram que pacientes com aumento da pic se beneficiam da elevação da cabeceira em 10, 15, 30 e 45 graus quando comparados a zero grau (45-46). o outro procedimento descrito na literatura que contribui para o aumento da pic é a higiene oral. estudo que analisou a influência desse procedimento em 23 pacientes com monitorização de pic mostrou que houve um aumento estatisticamente significativo desse parâmetro durante a higiene bucal (p = 0,0031), porém sem repercussão clínica (38). embora esta revisão não tenha contemplado a inclusão de artigos sobre aspiração endotraqueal, faz-se imprescindível a contextualização desse procedimento, que também pode levar ao aumento da pic. estudo clínico que objetivou determinar a melhor técnica de aspiração (sistema aberto versus fechado) com 32 pacientes neurocirúrgicos mostrou que pacientes aspirados como sistema aberto tiveram significativamente menor média de pressão parcial de dióxido de carbono do que aqueles aspirados com sistema fechado, porém sem diferença significativa (47-50). estudo recente concluiu que, apesar de a maioria dos artigos mostrar um aumento da pic acima de 20 mmhg ao utilizar o sistema de aspiração aberto, ainda não está claro qual a melhor técnica para manter a adequada pressão de perfusão cerebral. para os autores, mais estudos são necessários para determinar a melhor técnica de aspiração endotraqueal para a prática de enfermagem (51-52). intervenções de enfermagem habilidades cognitivas raciocínio clínico práticas baseadas em evidência controle dos parâmetros neurofisiológicos e prevenção da hipertensão intracraniana administração da terapia farmacológica prescrita posição do paciente no leito higiene oral elevação da cabeceira 8 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1949 aquichan issn 1657-5997 eissn 2027-5374 a implementação de uma assistência pautada na pbe é fundamental para alcançar a eficácia, a confiabilidade e a segurança nas práticas em saúde (53-54). nesse contexto, o enfermeiro tem papel importante no planejamento da assistência ao paciente neurocrítico, pois este requer uma avaliação diária e sistematizada (35, 54). o enfermeiro deve ser muito cauteloso, já que a realização de procedimentos rotineiros pode agravar o quadro neurológico, em decorrência da elevação da pic e da diminuição da pressão de perfusão cerebral. para tanto, o profissional deve ser capacitado para prestar uma assistência segura e qualificada aos pacientes críticos, uma vez que há necessidade de atenção constante na aplicação das intervenções para a sua recuperação (20, 33, 55-59). assim, a avaliação neurológica é essencial para a identificação dos diagnósticos de enfermagem, etapa crucial para a elaboração de um plano de cuidados alicerçado em um referencial teórico, que guia e aprimora a prática, bem como direciona as intervenções de enfermagem e os resultados esperados (60-61). além disso, a decisão clínica subjacente aos cuidados é primordial para a qualidade e a excelência da prática da enfermagem em neurociência (62). como limitação desta pesquisa, pode-se mencionar a obtenção de estudos com reduzido tamanho amostral; portanto, faz-se necessário o desenvolvimento de estudos mais robustos sobre a temática. conclusões a hipertensão intracraniana é um evento de grande repercussão clínica. as complicações advindas desse evento podem ser minimizadas e controladas mediante intervenções de enfermagem específicas que compreendem o controle de parâmetros neurofisiológicos, hemodinâmicos, bem como a prevenção de aumento da pic, atreladas, muitas vezes, à realização de procedimentos de enfermagem. os resultados deste estudo também evidenciam a importância da prática 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evaluators article nursing leadership, associated sociodemographic and professional factors: the perception of leaders and evaluators* liderazgo en enfermería, factores sociodemográficos y profesionales asociados: percepción de líderes y clasificadores** liderança em enfermagem, fatores sociodemográficos e profissionais associados: percepção de líderes e enfermeiros classificadores*** 10.5294/aqui.2021.21.2.5 luz dalia valbuena-durán1 myriam ruiz rodríguez2 astrid nathalia páez esteban3 1 0000-0002-0577-6559.  health college, universidad industrial de santander, colombia. ldvaldur@correo.uis.edu.co 2 0000-0002-8598-3354. health college, universidad industrial de santander, colombia. myriam@uis.edu.co 3 0000-0003-0010-7564. health sciences college, universidad de santander, colombia. ast.paez@mail.udes.edu.co received: 23/08/2020 sent to peers: 31/08/2020 approved by peers: 26/03/2021 accepted: 28/04/2021 * this article derives from the master’s thesis entitled “nursing leadership styles and associated sociodemographic factors. perception of leaders and evaluators from a tertiary-level health care institution in the city of bucaramanga”, presented to the master’s degree program in health services management of universidad de santander in the city of bucaramanga-colombia. ** este artículo es derivado de la tesis de maestría titulada “estilos de liderazgo en enfermería y factores sociodemográficos asociados. percepción de líderes y clasificadores de una institución de salud de tercer nivel de atención de la ciudad de bucaramanga”, presentada al programa de maestría en gestión de servicios de salud de la universidad de santander de la ciudad de bucaramanga-colombia. *** este artigo deriva da dissertação de mestrado intitulada “estilos de liderança em enfermagem e fatores sociodemográficos associados. percepção de líderes e classificadores de uma instituição de saúde de terceiro nível de atenção da cidade de bucaramanga”, apresentada ao programa de mestrado em gestão de serviços de saúde da universidad de santander, bucaramanga, colômbia. theme: evidence-based practice. contribution to the subject: in its routine work, nursing has the responsibility of coordinating the tasks and the work team with which health professionals interact daily; it is for this reason that this research intends to be a model for the institutions to assess leadership styles in their collaborators to reap the benefits inherent to conducting work teams, especially in the health area, understanding leadership as one of the most booming competences nowadays, positioning itself as an important cornerstone in the organizations and seeking, through leadership, improvements in processes, performance, and work efficiency, leading them to the attainment of institutional goals and strategies, in addition to being related to work satisfaction and to a direct improvement in the provision of health services in aspects such as the patient safety programs, quality, and health management indicators. to reference this article / para citar este artículo / para citar este artigo: valbuena-durán ld, ruiz m, páez an. nursing leadership, associated sociodemographic and professional factors: the perception of leaders and evaluators. aquichan.  2021;21(2):e2125. doi: https://doi.org/10.5294/aqui.2021.21.2.5 abstract objective: to assess the leadership styles of the assistance nursing professionals and their associated sociodemographic and professional factors. materials and methods: an analytical and cross-sectional study. the sample comprised 75 nursing professionals and 170 nursing assistants selected for convenience. the multifactorial leadership questionnaire was applied to assess leadership and the organizational result variables. results: the predominant leadership styles were as follows: transformational (mean of 3.43) and transactional (3.40), which presented high correlation rates with satisfaction, efficacy and additional effort. the leadership style least perceived by the staff was corrective/avoidance (2.10). in transformational leadership, behavioral influence and inspirational motivation presented better scores in the leaders’ self-perception. age, marital status and having children evidenced statistically significant differences with the transformational and transactional leadership styles; work experience was significant with transactional leadership. conclusions: in their work, nursing professionals denote encouraging practices that are inherent to transformational leadership, which is related to changes in the organizational culture, leads to motivating and inspiring the subordinates to transcend the routines and increases their satisfaction and commitment to their duties, thus being an important factor in health institutions. keywords (source decs): leadership; nursing; hospital administration; health management; health personnel. resumen objetivo: evaluar los estilos de liderazgo de los profesionales de enfermería asistencial y sus factores sociodemográficos y profesionales asociados. materiales y métodos: estudio de corte transversal analítico. la muestra correspondió a 75 profesionales de enfermería y 170 auxiliares de enfermería seleccionados a conveniencia. se aplicó el instrumento multifactorial leadership questionnaire para la evaluación del liderazgo y las variables de resultado organizacional. resultados: los estilos de liderazgo predominantes fueron el transformacional (promedio 3,43) y transaccional (3,40), estos presentaron alta correlación con la satisfacción, eficacia y esfuerzo extra. el liderazgo correctivo/evitador fue el menos percibido por el personal (2,10). en el liderazgo transformacional, la influencia conductual y la motivación inspiracional presentaron mejores puntajes desde la autopercepción de los líderes. se evidenciaron diferencias estadísticamente significativas con la edad, estado civil y tener hijos con el liderazgo transformacional y transaccional; la experiencia laboral fue significativa con el liderazgo transaccional. conclusiones: los profesionales de enfermería denotan en su desempeño el estimular prácticas propias del liderazgo transformacional, lo cual está relacionado con cambios en la cultura organizacional, conlleva a motivar e inspirar a los seguidores para trascender lo rutinario, incrementa su satisfacción y compromiso en sus labores siendo un factor importante en las instituciones de salud. palabras clave (fuente decs): liderazgo; enfermería; administración hospitalaria; gestión en salud; personal de salud. resumo objetivo: avaliar os estilos de liderança dos profissionais de enfermagem assistencial e seus fatores sociodemográficos e profissionais associados. materiais e métodos: estudo de corte transversal analítico. a amostra correspondeu a 75 profissionais de enfermagem e 170 auxiliares de enfermagem selecionados por conveniência. foi aplicado o instrumento multifactorial leadership questionnaire para avaliar a liderança e as variáveis de resultado organizacional. resultados: os estilos de liderança predominantes foram o transformacional (média 3,43) e transacional (3,40), os quais apresentaram alta correlação com satisfação, eficácia e esforço extra. a liderança corretiva ou evitadora foi a menos percebida pela equipe (2,10). na liderança transformacional, a influência comportamental e a motivação inspiracional apresentaram melhores pontuações segundo a autopercepção dos líderes. foram evidenciadas diferenças estatisticamente significativas com idade, estado civil e ter filhos com a liderança transformacional e transacional; a experiência profissional foi significativa com a liderança transacional. conclusões: os profissionais de enfermagem denotam em seu desempenho o estímulo de práticas próprias da liderança transformacional, o que está relacionado com mudanças na cultura organizacional, leva a motivar e inspirar os seguidores para transcender a rotina, aumenta sua satisfação e comprometimento com o trabalho, sendo um fator importante nas instituições de saúde. palavras-chave (fonte: decs): liderança; enfermagem; administração hospitalar; gestão em saúde; pessoal de saúde. introduction the need to attain high-quality levels in health, globalization in medical technologies, the users’ preferences and the reforms of the health systems have led to the search for high-quality care and provision of services. these changes are innovating the organizational culture of health institutions, which requires new approaches and implies administrative challenges regarding the roles and putting skills into practice; mainly in essential aspects such as leadership by the nursing staff, which allows for better performance in care management and in the provision of care in the operative scope, without leaving aside the organizations’ technical and financial components, indispensable elements in the management of health services to face such changes. the adequate implementation of these changes will be determined by the context and by the leadership ability of their human talent (1-2). leadership is fundamental for the efficient development of the services, the provision of health care and, finally, for the health systems, thus becoming a basic component of health management and the most influencing factor in the organizational culture of such institutions, as asserted by the world health organization (who) (3). in addition, several research studies report a positive association between leadership and the results in health institutions, the following among them: the quality of the health outcomes, the institution’s financial performance and client satisfaction, as well as the staff’s satisfaction and commitment (4). it is for this reason that, in the last few decades, fostering efficient leadership practices has been encouraged to improve the health outcomes; research in this field has also been promoted because nursing is the cornerstone of any health system, has greater labor representation, and exerts a significant impact on patients’ health. for nursing, leadership is a basic competence that allows influencing, guiding, motivating and directing others to attain organizational effectiveness (5-6). in the international scope, most of the studies on nursing leadership focus on the styles (for example: transactional, transformational, autocratic, bureaucratic or democratic) and on how these influence the organizational culture, the work environment, the patients’ outcomes, and the relationships between leaders and subordinates (7-8). some studies conducted in hospitals show that nursing professionals prefer the transformational leadership style, which promotes satisfaction at work and professional performance and reduces job changes, which improves retention of the nursing staff in the organizations (5, 9-10). other studies have reported positive associations between transactional and transformational leadership styles and organizational commitment and work satisfaction (9). in méxico, hernández et al. (11) studied nursing leadership in public hospitals from different states of the country. the most important findings show a trend towards managerial practices of a transactional nature, where a greater correlation is evidenced between leadership and the seniority and staff shift variables. in south america, the number of recent studies reported on leadership in hospital nursing staff is scarce. in chile, cárcamo-fuentes and rivas-riveros (1) evidenced that assistance nursing professionals develop the transformational and transactional styles to a lesser extent. on the other hand, gonzález et al. (12) found that leadership is associated with work satisfaction in hospitalization services for adults in the areas of medicine and surgery. in brazil, and using qualitative methods, de souza (13) addressed the perception of nursing professionals in managerial positions in different health institutions and found that these professionals understand leadership as a process that exerts an influence on people and on behaviors, in addition to being a skill that can be learned. characteristics such as commitment, flexibility, effective communication, responsibility, good interpersonal relationships, creativity, organization and knowing how to listen are necessary to work in a leadership position. balsanelli et al. (14) also studied the association between the leadership styles and the nurse’s personal and professional profile with a member of their intensive care service team in brazil. they did not find statistically significant associations, but they reported predominance of the persuading style, followed by determining and by sharing in the leaders towards their subordinates. three recent studies were found in colombia. only one of them addressed leadership in nursing professionals working at the hospital level. valderrama (15) conducted a study on three successful cases of nursing leadership, all of them related to managerial positions in health and educational institutions. rozo and abaunza (2) studied the correlation between sociodemographic and work variables and the transformational and transactional leadership styles in nurse-professors; however, they did not find any relationship between the leadership styles and the variables studied. on the other hand, torres (16) investigated the situational leadership styles present in the nursing professionals from the hospitalization and intensive care services. in this study, there was a predominance of guiding in the hospitalization nurses’ style, and of participating in that of the intensive care nurses. in addition, it related the directing leadership style and the experience time in the clinical area, although without finding any association between the leadership style and the time working in the institution. when considering the importance of nursing leadership for personal and institutional performance, and given the limited number of research studies in colombia, it is necessary to deepen this topic in the hospital scope from the new leadership theories, as long as they are consistent with the changing and complex context faced by the care system in this realm. therefore, this study aims at assessing the leadership styles of the assistance nursing professionals according to the following research question: which are the nursing leadership styles and the associated sociodemographic and professional factors, from the perspective of leaders and evaluators from a tertiary-level health care institution in the city of bucaramanga, colombia? methodology an analytical and cross-sectional study. the sample comprised 75 nursing professionals (coordinating nurses or nurses working in the services) and 170 nursing assistants working in the assistance area of a tertiary-level public health care institution in bucaramanga, colombia, during the first four-month period of 2020. non-probabilistic and for convenience sampling was carried out, where a minimum sample size of 75 nursing professionals and 75 nursing assistants was calculated, considering a 95 % confidence interval, 80 % power, and an expected means difference of 0.33 with a variance of 0.25 in the leadership score. the following inclusion criteria were considered: assistance nursing professionals and assistants with employment contracts and a minimum work experience of four months in the institution, at least 6 months of personal experience of their own, and accepting to participate by signing the informed consent. no exclusion criteria were defined. the version validated in chile by vega and zavala (17) of the multifactor leadership questionnaire, short version (mlq-5x) was used for this research, with a version for the leaders and another for the evaluators or subordinates. this instrument is based on the full range leadership model comprised of 82 items, of which 65 are hierarchically organized by firstand second-order variables to assess leadership and 17 assess organizational results. it distinguishes three leadership styles or first-order variables: transactional, transformational, and corrective/avoidance. the second-order variables are sub-variables that allow valuing and identifying the three styles. the variables are assessed according to the score of the attitudes and behaviors perceived by the leaders themselves and their evaluators, through a likert-type scale with the following scores: 0 = never, 1 = rarely, 2 =sometimes, 3 = often; and 4 = frequently, if not always. each variable has a score, which means that the higher their score, the greater the presence of the behaviors and attitudes which characterize it. all the scores obtained are added up as a final step (17). on the other hand, the organizational consequences and results are effectiveness, additional effort and satisfaction, aspects which are generally associated with transformational leadership (16). each of them is defined below: • effectiveness: leader’s actions targeted at harmonic teamwork and at good use of the resources, which leads to the subordinates meeting the objectives efficiently and effectively. • additional effort: greater participation and motivation of the subordinates towards attaining the objectives thanks to the leader’s actions which stimulate participation through motivational rewards. • satisfaction: the extent to which the subordinates feel at ease with their work, environment and the entire organization. feeling at ease with their work environment and the positive relationship between their effort, results and work demands exert a positive influence on the results (16). the following sociodemographic and work variables were also assessed: age (< 30 years old, 31-40 years old, > 40 years old), gender (male and female), marital status (with and without a partner), number of children (with and without children), university schooling level (technician, undergraduate and postgraduate), type of contract (fixed-term and undefined), the current area of residence (rural or urban), workplace or hospital service (gynecology and delivery room, general surgery and surgical specialties, operating rooms, adult and pediatric urgencies, internal medicine, burns, adult and pediatric intensive care units, and external consultation), simultaneous work as a nurse in another institution (yes and no), and work experience (0-3 months, 1-3 years, 3-5 years, 5-15 years, and more than 15 years). after obtaining due to written informed consent, the information was collected through a link sent via whatsapp. the participants filled out the questionnaires via google forms, and the database was collected in excel to then contrast possible inconsistencies and refine the data. finally, the database was exported to the stata 14 statistical program for analysis. a univariate analysis was performed to describe the qualitative variables through proportions, in addition to assessing the distribution of the quantitative variables of the leadership style levels using the shapiro-wilk normality test. as normal distribution was not found, medians and the 25 and 75 percentile values were reported. in addition, non-parametric tests were performed in the bivariate analysis, as follows: wilcoxon’s to compare the scores in the dichotomous variables, kruskal-wallis’ in polytomous variables, and pearson’s correlation coefficient for quantitative variables, based on the following interpretation: r=1, perfect correlation; above 0.80, very strong; between 0.60 and 0.80, strong; between 0.40 and 0.60, moderate; between 0.20 and 0.40, low; between 0 and 0.20, very low; and r=0 null. a p-value below 0.05 was considered as statistical significance (18). regarding the ethical aspects, the guidelines issued by the council of international medical sciences organizations (consejo de organizaciones internacionales de las ciencias médicas, cioms) and the rules set forth by the colombian ministry of health in resolution 8,430 of october 4th, 199rs are graduated nu3, were taken into consideration. the research was approved by the ethics committee of santander’s university hospital (minute 9000-ssac-000020-2020). in addition, personal data were safeguarded according to colombian decree no. 1,377 of 2013. results regarding the identification of the leaders’ and evaluators’ sociodemographic characteristics, they were mostly women, with 80 % (leaders) and 91 % (evaluators). the predominant marital status was no partner, both among the leaders and among the evaluators and, regarding having children, it was identified in most of the evaluators. both the leaders and the evaluators live in the metropolitan area of the city, considered as bucaramanga, girón, floridablanca and piedecuesta. regarding schooling, 62.67 % of the leaders have graduated nursing professionals, 33 % have some specialization, and 4 % some master’s post-graduate degree. all the evaluators are nursing technicians. 92 % of the nursing staff working in the institution are nurses from general hospitalization services and 8 % act as coordinators. in the case of the evaluators, they are all nursing technicians. regarding their work experience, both the leaders and the evaluators mostly reported from 5 to 15 years and the nurse-leaders stated having no parallel job outside the institution; however, 7.65 % of the evaluators do have a second job. the institution’s staff has a fixed-term contract. in relation to the service in which they were working at the time of the survey, 46.66 % of the nurse-leaders and 55.87 % of the evaluators do so in hospitalization services (internal medicine, postoperative, pediatrics and gynecology/delivery room), 13.33 % of the leaders and 7.65 % of the evaluators work in intensive care units, 10.67 % of the leaders and 7.65 % of the evaluators work in adult and pediatric urgencies, 5.33 % of the leaders and 7.65 % of the evaluators work in surgery rooms (operating rooms) and 5.3 % of the leaders and 5.88 % of the evaluators work in the burns unit. the rest of the nurse-leaders, 18.67 %, and 15.89 % of the evaluators work in services related to intra-hospital support special programs. table 1 shows the scores obtained in the leadership scores, where the perception of transformational leadership stands out, followed by the transactional and corrective/avoidance styles. on the other hand, both in the transformational and transactional styles, the leaders’ perception was higher than the evaluators’. regarding corrective/avoidance leadership (1, 8), a lower median was evidenced in the answers obtained in both groups (leaders and evaluators). in the transformational leadership style, the third-order variables, behavioral influence and inspirational motivation, presented better scores in the leaders’ results. in the case of the evaluators, the results were similar in these two variables, and a third high score was obtained for idealized influence. table 1. leadership styles in nurses according to a hierarchy of variables first-order variables second-order variables third-order variables leader n=75 median (iqr) evaluator n=170 median (iqr) transformational leadership (tfl) charisma c/i idealized influence ii 3.57 (3.00, 4.00) 3.00 (2.29, 3.57) behavioral influence bi 3.63 (3.13, 3.88) 3.00 (2.38, 3.50) inspirational motivation im 3.63 (3.25, 4.00) 3.00 (2.38, 3.63) total 3.56 (3.24, 3.86) 3.01 (2.33, 3.54) intellectual stimulation is 3.25 (3.00, 3.63) 2.50 (2.00, 3.13) total (tfl) 3.43 (3.08, 3.74) 2.80 (2.15, 3.35) transactional leadership individualized consideration ic 3.50 (3.00, 3.75) 2.63 (2.00, 3.25) contingent reward cr 3.50 (3.17, 3.83) 2.83 (2.00, 3.50) total (trl) 3.40 (3.13, 3.75) 2.72 (2.00, 3.31) corrective/ avoidance leadership (c/al) active management by exception mbe active 3.00 (2.67, 3.50) 2.83 (2.17, 3.50) passive avoidance leadership pal passive management by exception mbe passive 1.00 (0.50, 1.50) 1.50 (0.83, 2.00) laissez-faire lf 1.25 (0.88, 1.75) 1.38 (0.75, 1.88) total 1.17 (0.75, 1.65) 1.47 (0.90, 1.85) total (c/al) 2.10 (1.79, 2.48) 2.10 (1.79, 2.41) source: own elaboration. in transactional leadership, the individualized consideration and contingent reward variables obtained the same score values from the leaders’ perspective; however, in the evaluators’ scores, it was evidenced that contingent reward scored higher although presenting lower median values when compared to those reported in the leaders’ results. in the case of corrective/avoidance leadership, in the leaders’ results it was evidenced that active management by exception obtained a higher score when compared to passive avoidance leadership comprised by passive management by exception and laissez-faire, with lower scores. regarding the variables considered as reactive and which assess the organizational consequences and results, it was found that satisfaction and additional effort obtained higher scores than effectiveness. likewise, from the evaluators’ perspective, the results were low in the three variables of organizational results (table 2). table 2. variables with organizational results variables with organizational results leader n=75  median (iqr) evaluator n=170 median (iqr) satisfaction 3.60 (3.20, 4.00) 3.00 (2.40, 3.60) effectiveness 3.33 (2.83, 3.83) 2.83 (2.17, 3.50) additional effort 3.50 (3.00, 3.67) 3.00 (2.17, 3.67) source: own elaboration. when exploring the correlation of these result variables with the leadership styles (table 3), it was found that the transformational and transactional styles presented a strong correlation with all the result variables when compared to corrective/avoidance leadership. likewise, transformational leadership presented a greater correlation with satisfaction, so did transactional leadership with efficacy. finally, statistically significant differences between the age, marital status and having children variables were found for the transformational and transactional leadership styles; whereas the transactional leadership style was only statistically significant with work experience (table 4). the other sociodemographic variables did not present statistically significant differences with the leadership styles under study. table 3. correlation between organizational variables and leadership styles variable satisfaction efficacy additional effort correlation coefficient correlation coefficient correlation coefficient transformational leadership 0.77* 0.77* 0.71* transactional leadership 0.70* 0.79* 0.71* corrective/avoidance leadership 0.19 0.30** 0.18 *p-value < 0.001 **p-value < 0.01. pearson’s correlation coefficient source: own elaboration. table 4. perception of the leadership styles by the nursing professionals according to age, gender, marital status, children, job position, schooling level and experience. socio-demographic variables transformational leadership p-value transactional leadership p-value corrective/ avoidance leadership p-value age <31 years old 3.35 (3.07, 3.61) 0.03* 3.32 (3.02, 3.59) <0.01* 2.09 (1.80, 2.43) 0.15 31-40 years old 3.22 (3.03, 3.75) 3.42 (3.06, 3.67) 1.99 (1.72, 2.27) >41 years old 3.62 (3.39, 3.80) 3.73 (3.38, 3.85) 2.33 (2.04, 2.56) gender male 3.09 (2.25, 3.39) 0.49* 3.00 (2.33, 3.42) 0.35* 2.01 (1.86, 2.36) 0.65* female 2.77 (2.15, 3.35) 2.67 (2.00, 3.25) 2.10 (1.78, 2.43) children no children 3.23 (3.02, 3.61) 0.03* 3.33 (2.97, 3.65) 0.01 2.06 (1.78, 2.37) 0.34* with children 3.58 (3.26, 3.77) 3.67 (3.29, 3.79) 2.13 (1.89, 2.50) marital status with a partner 3.22 (3.01, 3.58) <0.01 3.33 (3.02, 3.71) 0.02 2.06 (1.77, 2.33) 0.21 no partner 3.62 (3.37, 3.85) 3.64 (3.29, 3.85) 2.17 (1.92, 2.50) work experience <3 months 3.14 (3.04, 3.54) 0.20** 3.30 (3.00, 3.33) 0.02** 2.12 (1.86, 2.31) 0.94 1-3 years 3.46 (3.13, 3.62) 3.42 (3.02, 3.75) 2.04 (1.82, 2.23) 3-5 years 3.43 (3.00, 3.47) 3.13 (3.06, 3.35) 2.07 (2.00, 2.31) 5-15 years 3.36 (3.08, 3.79) 3.63 (3.19, 3.77) 2.06 (1.72, 2.66) >15 years 3.60 (3.38, 3.79) 3.71 (3.38, 3.85) 2.14 (1.97, 2.48) job position nurse 3.43 (3.08, 3.62) 0.52* 3.38 (3.23, 3.73) 0.64* 2.08 (1.77, 2.33) 0.17* coordinator 3.45 (3.03, 3.81) 3.59 (3.04, 3.85) 2.13 (1.90, 2.64)   *wilcoxon’s test **kruskal-wallis test source: own elaboration. discussion this research was conducted according to the full range leadership model framework, which explores three leadership styles considered as first-order variables, namely: transactional, transformational and corrective/avoidance. it was found that there is no predominant leadership style, since slightly higher scores were obtained in transformational leadership versus transactional leadership, and significantly higher when compared to the corrective/avoidance style in the nursing staff that self-evaluated themselves and that was evaluated by the subordinates or evaluators (nursing technicians). these results were consistent with what bass and avolio pointed out regarding the fact that an efficient leader will present all the full-range styles to some extent, along with a minimum frequency of laissez-faire and a gradual increase of the transactional variables to achieve a high frequency of transformational variables (2). authors like cárcamo-fuentes and rivas-riveros reported results without significant differences in their research. the first is the transformational leadership style, followed by transactional leadership in nursing professionals (1), findings which are similar to those of this research. in opposition to the results of other studies, where transformational leadership was predominant over transactional leadership in terms of management, the development of these two styles can vary and be related to the type, operation, context, environment and culture of the organization, in addition to how the achievement of objectives is planned (19). on the other hand, the findings by pucheu (20) and those of this research were in consonance, for obtaining better scores in this corrective/avoidance leadership style. this symbolizes that the perspectives on leadership assessed in the nursing staff in their field and performance as leaders are related to behaviors characterized by the low resolution of the teams’ problems without the adequate guidance and support of the activities to be performed. likewise, cárcamo and cols (1) found low values in the scores of the laissez-faire dimension, as was also the case in the study by hernández and duana (11). the results of this research evidenced that passive management by exception and laissez-faire presented the lowest values, in opposition to active management by exception, which obtained a higher score. based on the findings of the variables that comprise the transformational leadership style, charisma, behavioral influence, inspirational motivation and idealized influence presented high scores in various studies (5, 21-22-23), as was the case in our research. the preceding aspects must be strategically acknowledged from productivity and management, as transformational style leaders are often charismatic, which allows them to act as role models and to influence their subordinates based on trust towards the leader in the achievement of objectives and on admiration towards them, applied to the health assistance processes and leading teamwork. therefore, with these data we can deduce that the nursing leaders relate and identify themselves with transformational style attitudes; although there was no significant difference between these two styles, transformational leadership was slightly higher when compared to the transactional style. in this sense, the literature reports that the nursing practice and the transformational leadership style are related, and that such relationship can exert an impact on the quality of the care provided to the patient by creating work environments that empower the nursing professional in the management of work teams to offer optimum care. in addition, this style highlights the communication strengths as an aspect that is reflected on their subordinates, which inspires them and turns them into active participants of the organizations’ strategic planning (mission and vision) and, in turn, is related to the staff’s work satisfaction (10, 22, 24-25). in the case of the intellectual stimulation and idealized influence dimensions, hernández and duana (11) reported low scores, a finding that is correlated with the results of our research. this would be considered as an aspect to be improved and worked on from the organizational and management component, if the aim is to implement the development of leadership in the institution, since certain characteristics are strengthened in the leaders that will help them to offer the work teams the guidance and motivation needed towards high performance in their duties. a number of studies in which leadership was assessed reported high scores in one of these two dimensions: individualized consideration and reward (10-11, 21-22), results which were similar in our research. the aforementioned can be considered from the managerial scope as characteristics of the leaders and which are related to their work context. the literature has shown that this type of leadership is related to how companies operate: the starting point is achievement planning by means of numerical goals or objectives, in addition to being recognized as a fundamental cornerstone to which quality care is provided to people is attributed (26). therefore, the reward becomes the core of transformational leadership. although none of the leadership styles was predominant in our research, the transactional style also characterized our sample. it is therefore inferred that the nursing work and the management modality can be related to health recovery, maintenance and rehabilitation. the relationship between the transactional leadership factors, especially contingent reward, asserts that these leadership styles are active and positive forms of leadership dimensions (25). consistency in transactional leadership behaviors and the trust developed because of effort are the foundation for transformational leadership. regarding the correlation between the leadership styles and the organizational variables, it is noted that the transformational and transactional leadership styles were significantly correlated with all the result variables; however, in the case of transformational leadership, it was strongly correlated with satisfaction, whereas transactional leadership showed a correlation with efficacy (12). the literature on leadership determined that satisfaction is a high-impact factor in relation to leadership, especially to transformational leadership (8-9, 12-13, 15, 27). in this sense, and from the managerial perspective, it must be taken into account why such association yields good results on the health professionals in the organizations, particularly in the nursing staff, which corresponds to the majority of the permanent personnel in the institutions and are those who assume care and team management in the assistance and strategic processes. given the above, it is indispensable to have leadership and managerial competencies that allow guiding teamwork, decision-making, and the planning of activities to attain the mission objectives. in addition, becoming a role model through the motivation to be excellent professionals and care providers, committed to the institutions in full compliance of the mission activities, which were agreed upon and that, in turn, this can be verified in the quality and user’s satisfaction indicators. regarding the sociodemographic factors that were statistically associated with the perception of leadership by the leaders, it was found that gender and type of job position did not present statistically significant differences with any type of leadership. non-association of gender with leadership was also similar to the finding of a study conducted with saudi arabian female nurses (30). according to the findings in which leadership in the nursing staff was assessed, most of this population is made up by women, as shown by the results of our research, where it was evidenced that 80 % of the group of leaders and 91 % of the evaluators were women, as was the case with the data reported by several authors (1, 9, 10-11, 19, 27,29). in this sense, in the health area it can be extremely useful since in hospital centers human talent is generally made up by women, who can come to lead according to the characteristics of effective leadership depending on the context of their organization or on the type of leadership that is intended to develop. however, transformational leadership leads to the better attainment of organizational goals, team performance, work satisfaction, staff retention, and patient safety. regarding the time of performance, hernández and duana (11), just as in this research, found that the nursing staff mostly provides its services in two assistance areas: hospitalization and intensive care units. the health institutions’ internal organization is made up of these types of units in service provision, the reason why it is considered important to recognize the job position profiles and their initiative to establish a leadership style policy that is acknowledged both for the hospitalization area and for the critical care area. the aforementioned considering that both hospital contexts are different in relation to care and team management, and to goals attainment mediated by the care demand from nursing and the entire health team. the data obtained in this study regarding work experience showed that 41.33 % stated having from 5 to 5 years of experience in the assistance scope, differently from the results by naseer et al. (10), where only 16.4 % of the nursing staff had more than 5 years of experience. this fact was related in a statistically significant way only to the transactional leadership style in our research, as was the case with the studies by cárcamo-fuentes and rivas-riveros (1) and by hernández and duana (11). work experience must be understood as task learning and as the feedback which has provided over time; therefore, the leaders in the organizations must not only consider the attitudinal and behavioral aspect but also that of knowledge, which can have a bearing on the provision of pertinent, timely and quality services. on the other hand, regarding age, moon et al. (19) and pucheu (20) showed similar results to those of this research when positively relating them with the development and influence of the transformational and transactional leadership styles (31). this aspect is relevant when it comes to striking a balance in the institutions regarding the age of the human talent which allows favoring behaviors to conduct work teams, hierarchy, achievements and goals proposed in the development of the activities. as was the case with the results of the research by clavelle et al. (32), not having a partner and having children were predominant in this study. these variables showed a statistically significant relationship with the transformational and transactional styles; however, no other study was found reporting this type of association. this result can be related to the fact that people who do not have a partner create a stronger bond with the workplace, as it is there that they spend most of their time and can relate their job with a family setting, which could be related to staff retention, institutional commitment and work satisfaction (33-34). on the other hand, no relationship between the leadership styles and characteristics such as type of job position was found in this study, that is, whether the person is a nurse or a coordinator. a possible reason for this is that the nursing staff role is considered as one of service head or leader. in addition, to the identification of the nursing staff in the institutions as process leaders in the organization’s scheme, we must add an integral command structure where the nurse is part of the comprehensive care processes, support and strategic processes. based on the findings, it is recommended that, for future research, intervention studies aimed at strengthening transformational and transactional leadership are developed, based on the mlq-5x instrument for baseline and follow-up measurements. in addition, prospective studies for the follow-up of the leadership style and level of the nursing professionals can be conducted, as well as assessing the association of leadership with objectives results or hospital care and patient safety indicators. conclusions nursing leadership is a fundamental characteristic for work performance, which is directly determined by specific dimensions to be explored in each of the nursing professionals, either by themselves or by their subordinates, which result in the practice of transformational, transactional, or corrective/avoidance leadership. in this study, the transformational and transactional leadership styles were predominant. the perception of transformational leadership in this population group was related to dimensions such as charisma, comprised by the behavioral influence and inspirational motivation sub-variables. regarding transactional leadership, the contingent reward was predominant among the variables for the evaluators. the corrective/avoidance leadership style was the one with which the leaders and evaluators identified the least. this proves that the institutions’ nursing staff stands out for practicing effective and active leadership in the face of the mission and strategic processes in the integral command structure. the fact that no predominant leadership style has been found in this study can be due to the health assistance context where the outsourced nursing staff targets its leadership actions towards attaining concrete objectives in a certain time frame, which can lead to the maintenance of behaviors directed to the transactional leadership style during the provision of health services. contrary to what was expected, the transformational leadership style was the one that obtained the highest score. this finding is promising for the health institution under study since, although the nursing staff and in general the entire personnel is outsourced, the team of leaders is encouraging practices that are inherent to transformational leadership, which is related to changes in the organizational culture. transformational leadership motivates and inspires the subordinates to transcend the routines, increases their satisfaction and commitment levels, and allows leaders to gradually train new leaders. the transformational and transactional leadership styles presented a strong correlation with organizational results such as satisfaction, efficacy and additional effort. in addition, of the sociodemographic variables, age, marital status and having children presented significant differences with the transformational and transactional leadership styles; 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[internet]. 2018; 31(6):644-650. doi: https://doi.org/10.1590/1982 0194201800088 32. clavelle jt, drenkard k, tullai-mcguinness s, fitzpatrick jj. transformational leadership practices of chief nursing officers in magnet® organizations. j nurs adm. 2012; 42(4):195-201. doi: https://doi.org/10.1097/nna.0b013e31824ccd7b 33. asiri sa, rohrer ww, al-surimi k, da’ar oo, ahmed a. la asociación de estilos de liderazgo y empoderamiento con el compromiso organizacional de las enfermeras en un entorno de atención médica aguda: un estudio transversal. bmc nurs. 2016; 15:38. doi: https://doi.org/10.1186/s12912-016-0161-7 34. kodama y, fukahori h, sato k, nishida t. is nurse managers’ leadership style related to japanese staff nurses’ affective commitment to their hospital? j nurs manag. 2016; 24(7);887-92. doi: https://10.1111/jonm.12392 home 257 265 manejo de cateteres.indd 257 dora isabel giraldo-montoya1 alexandra quirós-jaramillo2 luz aída mejía-cadavid3 manejo de catéteres centrales de inserción periférica en recién nacidos 1 magíster en enfermería materno perinatal. especialista en enfermería neonatal. docente de investigación. universidad pontificia bolivariana. facultad de enfermería. campus de laureles circular 1 no. 70-01 medellín. colombia. doragimo@geo.net.co 2 especialista en cuidado crítico del niño. clínica universitaria bolivariana. carrera 72a no. 78b -50 medellín. colombia. amq@geo.net.co 3 enfermera unidad de cuidado intensivo neonatal. clínica universitaria bolivariana. carrera 72a no. 78b -50 medellín. ladricla@gmail.com recibido: 13 de mayo de 2008 aceptado: 1º de septiembre de 2008 resumen objetivo: describir los efectos de un protocolo de manejo de catéteres centrales de inserción periférica en recién nacidos, sobre la frecuencia de infección, flebitis, alteración de la coagulación y complicaciones mecánicas del catéter, en la unidad de cuidado intensivo neonatal de la clínica universitaria bolivariana. método: estudio cuantitativo de tipo descriptivo. se seleccionaron 50 recién nacidos, por muestreo no probabilístico. se excluyeron aquellos neonatos con catéteres insertados en otras unidades neonatales, con menos de 800 g por estar en mínima manipulación, neonatos con alteraciones de la coagulación sanguínea, y los que recibieron heparina por otras vías. los catéteres fueron insertados en cualquier edad gestacional, con peso superior a 800 g, y después de 24 horas de nacimiento. se utilizó un formulario que fue aplicado por las investigadoras y por enfermeras de la unidad. se analizó en el programa epi-info 2005. resultados: la principal causa de retiro del catéter fue por terminación del tratamiento en un 70%. la aparición de flebitis fue de 8%, y de infección sospechosa de 6%. la obstrucción del catéter fue de 4%. las puntas del catéter ubicadas a nivel central fueron 68 y 32% para las no centrales. la prueba de tiempo parcial de tromboplastina después de infundir heparina a 0,5 ui/ml/h, fue normal en 94%. conclusión: actualizar el protocolo usual y efectuar modificaciones relacionadas con la indicación de inserción y la frecuencia de la toma de rayos x, y enfatizar los cuidados de enfermería para prevenir complicaciones como infección, flebitis, obstrucción y desplazamiento. palabras clave cateterización, recién nacido, prueba de coagulación, nutrición parenteral, cuidado del lactante. (fuente: decs) peripheral insertion of central catheters in newborns abstract objective: to describe the effects of a management protocol for the peripheral insertion of central catheters in newborns, specifically the frequency of infection, phlebitis, coagulation alterations and catheter-related mechanical complications at the neonatal intensive care unit at the bolivariana university clinic. año 8 vol. 8 nº 2 chía, colombia octubre 2008 257-265 258 año 8 vol. 8 nº 2 chía, colombia octubre 2008 257-265 aquichan issn 1657-5997 method: this is a quantitative study of a descriptive nature. fifty (50) newborns were selected through non-probability sampling. neonates with catheters inserted in other neonatal units and with a body weight less than 800 g were excluded for reasons associated with minimal manipulation, as were neonates with blood coagulation alterations, and those that received heparin by other means. the catheters were inserted at any gestational age, in neonates with a body weight of more than 800 grams, and 24 hours after birth. the study used a form that was applied by the researchers and by the nurses in the unit. epi-info 2005 was employed to analyze the data. results: the main reason for removal of the catheter was termination of treatment (70%). other motives, in order of importance, were the appearance of phlebitis (8%) and suspicious infection (6%). the proportion of catheter obstruction was 4%. the central catheter points came to 68%, and the non-central points, 32%. the partial thromboplastin time test, after a heparin infusion of 0.5 iu/ml/h, was 94% normal. conclusion: the usual protocol will have to be updated and changes made with respect to directions for insertion and how often x-rays should be taken, in addition to emphasizing the importance of nursing care to prevent complications such as infection, phlebitis, obstruction and displacement. key words catheterization, newborn, coagulation test, parenteral nutrition, infant care. manejo de catéteres centrais de inserçao periférica nos recém nascidos resumo objetivo: descrever os efeitos de um protocolo de manejo de cateteres centrais de inserção periférica nos recém nascidos na freqüência de infecção, flebite, alteração da coagulação e complicações mecânicas do cateter na unidade de cuidado intensivo neonatal da clínica universitária bolivariana. método: estudo quantitativo descritivo. foram selecionados 50 recém nascidos por amostra não probabilística. foram excluídos os neonatos com cateteres insertados em outras unidades neonatais, com menos de 800 g, por estar em manipulação mínima; neonatos com alterações da coagulação sanguínea; e os que receberam heparina por outras vias. os cateteres foram insertados em qualquer idade de gestaçao, com peso acima de 800 g, depois de 24 horas de nascimento. foi usado um formulário aplicado pelas pesquisadoras e por enfermeiras da unidade. foi analisado em epiinfo 2005. resultados: em 70%, a principal causa de retiro do cateter foi a finalização do tratamento. a flebite apareceu no 8% dos casos; infecção suspeitosa no 6%. a obstrução do cateter ocorreu no 4%. as pontas do cateter situadas no centro foram 68, e 32% para as não centrais. a proba de tempo parcial de tromboplastina depois de infundir heparina a 0.5 ul/ml/h foi normal no 94%. conclusão: atualizar o protocolo usual e alterar a indicação de inserção, a freqüência da toma de raios x e enfatizar nos cuidados de enfermagem para prevenir complicações como infecção, flebite, obstrução e deslocamento. palavras-chave cateterização, recém-nascido, proba de coagulação, nutrição parenteral, cuidado do lactante. 259 manejo de catéteres centrales de inserción periférica en recién nacidos dora isabel giraldo-montoya, alexandra quirós-jaramillo, luz aída mejía-cadavid introducción el catéter venoso central de inserción periférica –llamado también epicutáneo– es un procedimiento de enfermería frecuente en unidades de recién nacidos en estado crítico de salud. la administración de soluciones hiperosmolares es una de las indicaciones más importantes para insertar el catéter, ya que por vía venosa periférica se dificulta su manejo. las contraindicaciones para la inserción son la bacteriemia, las coagulopatías y la trombosis. también se pueden generar complicaciones como: flebitis, infección, obstrucción y extravasación, entre otras (1). las venas más utilizadas son las basílica y cefálica de las extremidades superiores, temporal o posterior auricular de la cabeza, y las safenas de las extremidades inferiores (1). para insertar el catéter se debe medir desde el punto de inserción de la extremidad superior a la línea media del esternón, o si es insertado desde la extremidad inferior, desde el punto de inserción, hasta a menos de dos centímetros por encima del ombligo. todo el procedimiento es realizado bajo condiciones de esterilidad, y el catéter es introducido lentamente –1 cm cada vez– para reducir el riesgo de daño de la vena, flebitis o posición incorrecta del catéter. igualmente, el catéter no debe ser devuelto a través de la aguja guía, mientras ésta permanezca en la luz del vaso del neonato, para evitar la ruptura del mismo por el bisel y producir embolismos. de manera simultánea, el catéter es examinado con aspiración para el retorno de sangre. la localización de la punta del catéter es verificada radiológicamente; así mismo, el sitio de inserción y el recorrido de la vena deben ser monitorizados de rutina para determinar la presencia de eritema, extravasación o edema. esta vigilancia permite la detección temprana y corrección de infección, flebitis u otra complicación. además, se debe realizar curación del sitio de inserción semanalmente, o cuando esté sucio o el apósito se encuentre despegado. para mantener la permeabilidad del catéter se administra una infusión continua de heparina a 0,5 ui/ml/ h (2) en la unidad de cuidado intensivo neonatal de la clínica universitaria bolivariana en medellín (3) se utiliza el catéter central de inserción periférica en recién nacidos en estado crítico de salud, que requieren infusiones de soluciones hiperosmolares o de otros medicamentos de larga duración. igualmente, para la inserción y el manejo de este catéter se tiene un protocolo respaldado por la literatura científica y por experiencias de otras unidades neonatales. con el presente estudio se quiso encontrar los efectos de este protocolo sobre la frecuencia de infección, flebitis, alteración de la coagulación y complicaciones mecánicas del catéter. metodología en la unidad neonatal de la clínica universitaria bolivariana de medellín, colombia, se utilizan dos tipos de catéteres, uno es de poliuretano con diámetro menor de 2 fr, para la administración de soluciones hiperosmolares es una de las indicaciones más importantes para insertar el catéter, ya que por vía venosa periférica se dificulta su manejo. 260 año 8 vol. 8 nº 2 chía, colombia octubre 2008 257-265 aquichan issn 1657-5997 neonatos menores de 1000 g de peso, y el otro de silicona para neonatos mayores de 1000 g. el protocolo para la inserción y el manejo del catéter se implementó hace dos años. la primera parte contiene una introducción, las indicaciones, las contraindicaciones, los sitos de inserción ideales, la localización de la punta del catéter, y las complicaciones locales y sistémicas. una segunda parte describe el procedimiento para insertarlo, y el cuidado posterior para el catéter y el neonato. con el fin de observar los efectos de este protocolo sobre la frecuencia de infección, flebitis, alteración de la coagulación y complicaciones mecánicas del catéter, se desarrolló un estudio cuantitativo de tipo descriptivo. la muestra estuvo constituida por 50 recién nacidos que tuvieron catéter central de inserción periférica, entre agosto de 2005 y marzo de 2006, seleccionados con un muestreo no probabilístico, a conveniencia. se excluyeron los neonatos con catéteres que fueron insertados en otras unidades neonatales, los menores de 800 g por estar en protocolos de mínima intervención, los que tenían alteraciones de la coagulación sanguínea o coagulación intravascular diseminada, y los que recibieron heparina por otras vías. los catéteres fueron insertados a los neonatos en cualquier edad gestacional, con un peso superior a 800 g, y después de 24 horas de nacimiento. la recolección de la información se realizó a través de un formulario aplicado por las tres investigadoras (una enfermera docente y dos enfermeras de la unidad), y por las demás enfermeras del mismo servicio, quienes fueron entrenadas previamente para el diligenciamiento de éste. dicho formulario se aplicó para cada recién nacido durante el tiempo que duró el catéter. el instrumento contenía preguntas relacionadas con las variables peso, edad gestacional, procedencia y patología del recién nacido. igualmente, preguntaba por las variables relacionadas con la inserción y el manejo del catéter como tipo de catéter, vena canalizada, posición final de la punta, infusión administrada, frecuencia de manipulación del catéter por cualquier motivo, y duración del mismo. también se indagaron variables que tenían que ver con las causas de retiro del catéter como finalización del tratamiento, flebitis, sospecha de infección, obstrucción por trombos o alteración mecánica y, por último, se preguntó por dosis de infusión de heparina y resultados de las pruebas de coagulación de tiempo parcial de tromboplastina, antes y después de retirar el catéter. a todos los neonatos se les aplicó el protocolo de inserción y manejo del catéter central de inserción periférica que se lleva en la unidad de cuidado intensivo neonatal de la clínica universitaria bolivariana. para determinar alteraciones en las pruebas de la coagulación se realizaron dos test sanguíneos de tpt al recién nacido, antes de insertar y después de retirar el catéter. a los pacientes con infección probable se les realizó de rutina el cultivo de la punta del catéter, y uno o dos hemocultivos periféricos. se creó una base de datos en el programa epi info 2005, y allí se procesó la información a través de frecuencias absolutas y relativas. se aplicó una prueba piloto con diez recién nacidos que permitió realizar algula muestra estuvo constituida por 50 recién nacidos que tuvieron catéter central de inserción periférica, entre agosto de 2005 y marzo de 2006. 261 manejo de catéteres centrales de inserción periférica en recién nacidos dora isabel giraldo-montoya, alexandra quirós-jaramillo, luz aída mejía-cadavid nas modificaciones al formulario. el estudio tuvo la aprobación del comité de ética de la universidad pontifica bolivariana. los padres o el representante legal del neonato firmaron el consentimiento informado. resultados y discusión patología del recién nacido en este estudio se observa que la principal patología fue la enfermedad de membrana hialina con 24%, seguida de riesgo global con 18%, y riesgo séptico con 16%. igualmente, los estudios de unidad de cuidado intensivo del hospital universitario del valle (4), y de la unidad neonatal de la fundación santa fe de bogotá (5), coinciden en que la principal patología encontrada fue la enfermedad de membrana hialina con 69,8 y 45% respectivamente. peso y edad gestacional se observó que el peso más frecuente de los neonatos del estudio fue de 800 a 1300 g para el 34%, y la edad gestacional más común fue entre 31 a 35 semanas para el 50%. de igual manera lo expresa el estudio de la unidad de cuidado intensivo del hospital universitario del valle (4), donde reporta que la principal edad gestacional se ubicó entre las 30 y 33 semanas. se combinaron las variables de peso con causas de retiro por complicaciones, observándose que 8% de las flebitis, y todos los casos de infección sospechosa, estaban entre los pesos de 800 a 1300 g. esta información se asemeja a los datos reportados por otros estudios, como lo refiere neubauer (6) quien observó 535 catéteres una mayor aparición de sepsis en neonatos menores de 1000 g. el mismo autor reporta otro estudio de 250 catéteres en prematuros menores de 1500 g con una frecuencia de flebitis de 9,2%. tipo de catéter y peso el presente estudio identificó que el catéter de silicona fue el más común (80%), y con una mayor frecuencia en neonatos que tuvieron pesos superiores a 1000 g. un 80% del total de los catéteres de poliuretano se colocaron a neonatos con pesos de 800 a 1000 g. tipo de catéter y causa de retiro se analizó el tipo de catéter con las causas de retiro. se observó que 60% de los catéteres de poliuretano fueron retirados por: sospecha de infección (20%), flebitis (30%), fallecimiento (10%). el 40% restante fue retirado por finalización del tratamiento. el 77,5% de los catéteres de silicona fueron retirados por finalizar el tratamiento, y el resto (22,5%) fueron retirados por: defecto mecánico (2,5%), desplazamiento (2,5%), fallecimiento (5%), flebitis (2,5%), infección sospechosa (2,5%), obstrucción (5%,), y traslado (2,5%). las guías de los centres for disease control and prevention (cdc) (7), de 2002, asocian la aparición de infecciones con el tipo de catéter utilizado. refieren que los catéteres de poliuretano se han asociado con un menor número de complicaciones infecciosas, contrario a lo que reportó el presente estudio. igualmente, hacen referencia a que es importante escoger bien el catéter de acuerdo con el propósito y la duración, con conocimiento de las complicaciones (categoría ia). para determinar alteraciones en las pruebas de la coagulación se realizaron dos test sanguíneos de tpt al recién nacido, antes de insertar y después de retirar el catéter. 262 año 8 vol. 8 nº 2 chía, colombia octubre 2008 257-265 aquichan issn 1657-5997 infusión administrada por el catéter este estudio encontró que la principal infusión utilizada a través del catéter fue la nutrición parenteral total en el 84%, junto con la administración simultánea de una infusión continua de heparina en el 88%. esto se explica porque los neonatos en estado crítico de salud requieren de soporte nutricional y de una vía venosa segura y permeable, mientras se estabilizan en su función respiratoria y hemodinámica. los estudios de la unidad de cuidado intensivo del hospital universitario del valle, unidad neonatal de la fundación santa fe de bogotá y neubauer (4, 5, 6), muestran que la principal infusión administrada por el catéter fue la nutrición parenteral total. pruebas de coagulación e infusión de heparina se observó que después de retirar la infusión de heparina a dosis de 0,5 ui/ml/ h, ningún neonato tuvo alteraciones en el tiempo parcial de tromboplastina. también se identificó que dos catéteres se retiraron por obstrucción, a pesar de que tenían infusión continua de este medicamento. los estudios de neubauer (6), treas y cols. (2), y kamala y cols. (8) utilizan los bolos o la infusión continua de heparina a 0,5 ui/ml/h en los catéteres centrales de inserción periférica, y muestran que con esta dosis se disminuye la frecuencia de obstrucción, y se incrementa la duración del catéter. smith y miller (9) realizaron estudios con heparina a través de los catéteres y no reportan alteraciones del tiempo parcial de tromboplastina. duración del catéter en cuanto al tiempo de duración del catéter, la presente investigación reportó que la duración promedio fue de seis a once días, comparado con otros estudios que muestran una duración mayor. por ejemplo, los estudios de la unidad neonatal de la fundación santa fe de bogotá (5) y de la unidad de cuidado intensivo del hospital universitario del valle (4), refieren que la duración de los catéteres es de 15 a 24 días. es de anotar que en el presente estudio un importante porcentaje de la duración de los catéteres fue inferior a seis días (34%). al respecto, las guías de la cdc de 2002 (7), recomiendan la utilización de los catéteres de inserción periférica cuando el tiempo de la terapia se espera que exceda los seis días (categoría ib). venas canalizadas las principales venas periféricas canalizadas para la inserción del catéter fueron la cefálica y la basílica, porque su ubicación, facilidad y grosor favorecen el acceso a nivel central. igualmente, el estudio realizado en la unidad de cuidado intensivo del hospital universitario del valle (4) muestra que las venas periféricas más utilizadas para insertar el catéter son la basílica y la cefálica. de la misma manera, el estudio de frey (10) reporta que las venas de mayor frecuencia son la basílica y la cefálica, y que las venas safenas son utilizadas en niños mayores. racadio y cols. (11) reportan que la mayoría de los catéteres insertados son en las extremidades superiores en la fosa antecubital. neubauer (6) reporta como principal lugar de punción la vena basílica. ubicación de la punta del catéter la unidad de cuidado intensivo neonatal de la clínica universitaria bolivariase observó que después de retirar la infusión de heparina a dosis de 0,5 ui/ml/h, ningún neonato tuvo alteraciones en el tiempo parcial de tromboplastina. 263 manejo de catéteres centrales de inserción periférica en recién nacidos dora isabel giraldo-montoya, alexandra quirós-jaramillo, luz aída mejía-cadavid na (3) considera como ubicación central de la punta a los catéteres que se encuentren en la unión de la vena cava superior o inferior con la aurícula derecha, y aquellos ubicados en la subclavia. para el estudio se encontró que 68% de los catéteres quedaron a nivel central. el estudio de racadio y cols. (11) define como catéteres centrales a los ubicados en la vena cava superior, aurícula derecha, parte alta de la vena cava superior, o por encima del nivel del diafragma. los mismos autores consideran que ubicados allí tienen más duración, desarrollan menos complicaciones, y que de todos los catéteres, 87% se ubican a nivel central. el protocolo de la unidad de cuidado intensivo neonatal de la clínica universitaria bolivariana (3) refiere que la posibilidad de dejar la punta a nivel central puede estar relacionada con la vena canalizada. el mismo protocolo dice que de la vena basílica es fácil llegar a posición central y que la cefálica también, pero presenta una estrechez al llegar a la subclavia. la vena axilar tiene alto riesgo de producir neumotórax, las safenas son de riesgo para flebitis, y la poplítea, la auricular posterior y temporal superficial son difíciles para llegar a posición central. es por ello que la presente investigación cruzó las variables de ubicación de la punta y la vena canalizada, encontrándose que de todas las puntas de los catéteres ubicados en la vena cava superior, 62% eran de vena basílica, seguido 50% de la vena cefálica. el estudio también reportó que el 80,8% de las puntas ubicadas en la vena cava superior fueron catéteres de silicona, y 19,2% eran de poliuretano. manipulación del catéter en cuanto a la frecuencia en días para la manipulación del catéter se encontró que el 29,2% fue manipulado de tres a seis días, el 26,4% a las 24 horas, y el 15,3% en menos de 24 horas. los motivos de manipulación fueron por curación de rutina o porque estaba húmedo o despegado. se observa que la manipulación del catéter no coincide con la frecuencia estipulada por el protocolo, y sólo el 62,9% recibieron las curaciones aconsejadas por el mismo. la revisión de la literatura sobre la manipulación de los catéteres muestra que en la unidad neonatal de la fundación santa fe de bogotá (5) realizan curaciones cada semana o según necesidad, cuando hay humedad o presencia de sangre, y hacen énfasis en la mínima manipulación. el estudio de la unidad de cuidado intensivo del hospital universitario del valle (4) no habla de frecuencias de las curaciones, pero sí tienen en cuenta la mínima manipulación del catéter. las guías de la cdc de 2002 (7) refieren que varios factores influyen en la infección de los catéteres, como el tipo de catéter, la frecuencia de la manipulación y las condiciones del niño. las guías recomiendan que las normas de cambio de apósito se deben aplicar cuando hay humedad, está suelto o está sucio (categoría ia), o de lo contrario, hacer el cambio del apósito transparente cada siete días, excepto en los casos pediátricos en que la salida del catéter pese más que el cambio del apósito (categoría ib). causas de retiro y complicaciones los estudios realizados en la unidad neonatal de la fundación santa fe de bolas guías de la cdc de 2002, recomiendan la utilización de los catéteres de inserción periférica cuando el tiempo de la terapia se espera que exceda los seis días (categoría ib). 264 año 8 vol. 8 nº 2 chía, colombia octubre 2008 257-265 aquichan issn 1657-5997 gotá (5), en la unidad de cuidado intensivo neonatal del hospital universitario del valle (4), en el estudio de cartwright (12), y en la investigación del hospital de puerto montt (13), encuentran que la principal causa de retiro es la finalización del tratamiento. es así como el presente estudio reportó que la principal causa de retiro fue la finalización del tratamiento (70%). otras razones por las cuales se retiró el catéter son la flebitis (8%), que fue manifestada por dolor y eritema a lo largo del catéter, y la infección sospechosa (6%), con un cultivo positivo para coagulasa negative stafilococcus. el estudio sobre infección en catéteres centrales de inserción periférica, reportado en las guías de la cdc de 2002 (7), observó 106 recién nacidos, de los cuales encuentran que la frecuencia de colonización de los catéteres es de 15,1% para gérmenes como staphyloccocus aureus y coagulasa negativo en la punta, y s. aureus en el hemocultivo. igualmente, refieren que la exposición a los lípidos de la nutrición parenteral ha sido identificada como un factor de riesgo independiente para desarrollar coagulase negative staphylococci en los recién nacidos de bajo peso al nacer. otras causas de retiro encontradas en este estudio fueron la obstrucción por trombos en dos catéteres de silicona que recibieron infusión de heparina para un 4%, y el desplazamiento del catéter en el 2%. tres neonatos fallecieron, pero las causas de muerte no estaban relacionadas por complicaciones del catéter. la investigación de frey (10) demuestra que la obstrucción ocurre más frecuentemente en catéteres pequeños por su diámetro y resistencia, por ejemplo, ellos reportan que 23% de los catéteres de 1,9-2 french presentaron obstrucción. conclusiones de acuerdo con los reportes de la literatura científica acerca de la buena utilidad de los catéteres centrales de inserción periférica en unidades de cuidado intensivo neonatal, el presente estudio tiene similares resultados, considerando este procedimiento como una práctica de enfermería que mejora la calidad del cuidado del recién nacido. la investigación concluye que los efectos del protocolo de manejo de catéteres centrales de inserción periférica en recién nacidos muestra que las tendencias de complicaciones asociadas al catéter son bajas, hay mayor duración en la terapia con soluciones hiperosmolares, mayor permeabilidad del catéter con el uso de infusión continua de heparina a dosis de 0,5 ui/ml/h, y no hay alteraciones del tiempo parcial de tromboplastina. igualmente, hubo una mayor frecuencia de canalización de las venas basílica y cefálica, garantizando la ubicación de la punta del catéter a nivel central en la mayoría de los casos. en este estudio se observó que los recién nacidos prematuros menores de 1000 g, y con catéteres de poliuretano, tienen más riesgo de complicaciones como flebitis e infección. también, los resultados del estudio permitieron actualizar el protocolo usual y se realizaron modificaciones relacionadas con la indicación de inserción de acuerdo con el peso del neonato y el tipo de catélos motivos de manipulación de catéter fueron por curación de rutina o porque estaba húmedo o despegado. 265 manejo de catéteres centrales de inserción periférica en recién nacidos dora isabel giraldo-montoya, alexandra quirós-jaramillo, luz aída mejía-cadavid ter, insertar el catéter cuando la terapia se exceda más de seis días, realizar curación sólo semanal, y tomar nuevamente placa de rayos x después de reubicar la punta del catéter. adicionalmente, se le agregaron los cuidados de enfermería para prevereferencias 1. chock vy. therapeutic techniques: peripherally inserted central catheters in neonates. division of neonatal and developmental medicine, stanford university, palo alto. ca. neoreviews 2004; 5: 60-62. 2. treas ls. efficacy of heparin in peripheral venous infusion in neonates. j obstet gynecol neonatal nurs 1991; 21: 214-219. 3. clínica universitaria bolivariana. unidad de cuidado intensivo neonatal. manual de normas y procedimientos básicos para la atención de enfermería del recién nacido en la unidad de cuidado intensivo neonatal. medellín: clínica universitaria bolivariana; 2003. 4. herrera r, mayor y, vásquez m. el catéter venoso percutáneo: una opción económica y segura para niños pretérmino de muy bajo peso. unidad de cuidado intensivo del hospital universitario del valle. colombia médica 1996; 27: 11-5. 5. díaz, bc. experiencia con el catéter venoso central de inserción periférica en la unidad neonatal de la fundación santa fe de bogotá. actualidad en enfermería 1998; 1 (2): 9-14. 6. neubauer ap. percutaneous central iv access in the neonate: experience with 535 silastic catheters. acta pediatric 1995; 84: 756-60. nir complicaciones como infección, flebitis, obstrucción y desplazamiento. agradecimientos la investigación fue financiada por la facultad de enfermería, el centro integrado para el desarrollo de la investigación de la universidad pontificia bolivariana, y la clínica universitaria bolivariana en medellín. a estas instituciones, las autoras presentamos nuestros agradecimientos por su apoyo y aportes. 7. guias de centres for disease control and prevention (cdc). guidelines for the prevention of intravascular catheter-related infections. [internet]. atlanta; cdc; 2002. [fecha de consulta 18 de julio de 2006]. http:// www.cdc.gov/mmwr 8. kamala f, boo ny, cheah fc, birinder k. randomized controlled trial of heparin for prevention of blockage of peripherally inserted central catheters in neonates. acta paediatr 2002; 91(12): 1350-6. 9. smith gh, miller ml. heparin flushes for umbilical and peripheral catheters in new borns. micromedex inc. healthcare series 2000; 106 (12): 2-5. 10. frey am. picc complications in neonates and children. neonatal pediatric. j intraven nurs 1999; 18 (6): 280-91. 11. racadio j, doellman da, johnson nd, bean ja, jacobs br. pediatric peripherally inserted central catheters: complication rates related to catheter tip location. pediatrics 2001; 107: e28. 12. cartwright dw. línea venosa central en recién nacidos: un estudio de 2186 catéteres. arch dis child fetal neonatal ed 2004; 89 (6): f504-f508. 13. unidad de neonatología. accesos vasculares. instalación de catéter epicutáneo. [internet]. chile: hospital de puerto montt; 2004. [fecha de consulta 22 de julio de 2006]. http://www.sociedadmedicallanquihue.cl 139 145 primeras paginas.indd 142 aquichan issn 1657-5997 editorial con este número de aquichan, la facultad de enfermería y rehabilitación de la universidad de la sabana llega a la comunidad científica, a los diseñadores y ejecutores de las políticas públicas, y al público en general con los resultados de investigación de nuevos autores; de enfermeras y enfermeros que dan consistencia y solidez a la disciplina y a la práctica del cuidado de la salud. gracias a sus aportes teóricos, sociales, culturales, metodológicos, históricos o clínicos, la enfermería contribuye al desarrollo de soluciones globales. el mundo actual demanda de las ciencias un abordaje interdisciplinario de los fenómenos que estudian, y exige a los investigadores de una disciplina apoyarse en los métodos de otra, con lo cual surge un nuevo campo de saber (1). desde esta perspectiva, aquichan abre el espacio a investigadores de disciplinas afines, como lo establece en su misión: “esta revista nace como un medio de expresión de la facultad de enfermería y rehabilitación de la universidad de la sabana, orientado hacia la promoción y estímulo del desarrollo teórico de enfermería y de disciplinas afines…”. la interrelación de las ciencias amplía la mirada y enriquece la comprensión de los fenómenos de estudio. en ese sentido, la academia –desde sus facultades de salud– y los gobiernos tienen un enorme reto: promover la interacción y el encuentro de saberes a favor del desarrollo y crecimiento equitativo y equilibrado de la sociedad, la cual presenta serias falencias, como refleja la onu en sus objetivos del milenio. en este orden de ideas, es oportuno replicar y apoyar la declaración de río sobre información y conocimiento para la innovación en salud, emitida por los participantes en el 8º congreso regional de información científica en salud (crics8), realizado entre el 16 y el 19 de septiembre último en río de janeiro. en esta declaración se pone de manifiesto que “la innovación en salud es un proceso social, político y cultural de cambio en las formas como la sociedad organiza sus respuestas a los desafíos de salud”. considera, además, que los “procesos de cambio deben combatir las diferencias injustas y evitables en la situación de salud y en el acceso a la atención entre los diversos grupos sociales”. para ello, plantea la necesidad de fortalecer los vínculos entre la producción del conocimiento y su utilización en la definición de políticas de innovación en salud, y hace un llamado a la integración y a la retroalimentación entre los investigadores y los responsables de las políticas públicas. la misma declaración insta a los gobiernos de américa latina y el caribe a adoptar políticas explícitas, a cualificar el recurso humano, a dar pleno desarrollo a la gestión de la información y el conocimiento en salud, y a promover el acceso equitativo a esos bienes públicos. año 8 vol. 8 nº 2 chía, colombia octubre 2008 142-143 143 editorial haciendo eco a la declaración de río, los conocimientos producidos por los científicos e investigadores deben llegar a la sociedad e incidir en ésta en el menor tiempo posible. es un imperativo para las comunidades académicas informar a la sociedad sus avances y progresos, y para ello cuentan con su propio medio de comunicación: las revistas científicas. podríamos afirmar, entonces, que las publicaciones seriadas reflejan la madurez y el progreso de las disciplinas, de este modo, “el conocimiento se produce socialmente y el investigador al producir conocimiento sobre cualquier tiempo, trabaja la perspectiva del pasado con su presente, se cambia el enfoque de la relación entre pasado y presente y se admite que los planteamientos sobre el pasado se den en una serie de cuestiones que son el ahora” (2). y el ahora nos propone grandes desafíos. hoy, cuando aquichan ha sido reclasificada en el índice nacional publindex, en la categoría a2, y con la indexación en scielo, lilacs, doaj, fuente académica, hinari, redalyc, latindex-catálogo, cuiden, dialnet y en google académico el compromiso con la comunidad científica y con la sociedad es mayor, como mayor es nuestra voluntad para seguir creciendo. de ese crecimiento, en adelante, dará cuenta la nueva editora de aquichan, la profesora maría elisa moreno fergusson, candidata a doctora, decana de la facultad de enfermería y rehabilitación desde septiembre de 2008. a ella, a todo el equipo editorial de la revista, a sus comités, a los investigadores, árbitros y lectores, presento mis agradecimientos por sus deferencias a lo largo de estos años, en el desarrollo del proyecto aquichan. el nivel científico y editorial alcanzado en estos siete años permite vislumbrar su consolidación y el logro de nuevos retos como publicación de alta calidad que, sin duda, seguirá comprometida con el cuidado de la salud de nacionales y extranjeros. maría clara quintero laverde directora mariac.quintero@unisabana.edu.co el desarrollo del conocimiento y la información en salud referencias 1. gastaldo d. la interdisciplinariedad: cuestiones conceptuales y aplicadas. en: texto & contexto enfermagen. brasil: universidad federal de santa catarina; 2005. 2. souza ramos fr et ál. foucault y enfermería. index de enfermería 2007; xvi (57). 147 155 implicacoes para o.indd 147 claudia de carvalho-dantas1 marliete rodrigues-aguiar2 joséte luzia leite3 fernanda de carvalho-dantas4 patrícia dos santos claro-fuly5 implicações para o cuidar de enfermagem a partir de percepções do ser portador de neurofi bromatose 1. doutora em enfermagem. universidade federal fluminense. niterói, rio de janeiro, brasil. dantasclaudia@hotmail.com 2. enfermeira. membro da unidade de apoio mútuo a neurofibromatose. rio de janeiro, brasil. marlyette@hotmail.com 3. doutora em enfermagem. universidade federal do estado do rio de janeiro. rio de janeiro, brasil. joluzia@gamil.com 4. académica de enfermagem do ucl. bolsista da faperj. rio de janeiro, brasil. ffernandadantas@yahoo.com.br 5. doutoranda em enfermagem. universidade federal fluminense. niterói, rio de janeiro, brasil. claropatricia@yahoo.com.br recibido: 15 de marzo de 2009 aceptado: 17 de junio de 2009 resumo a neurofibromatose tipo 1 é uma síndrome genética autossômica muito freqüente no ser humano com crescimento de tumores benignos nos nervos; pode acontecer em qualquer parte do corpo. objetivos: identificar a percepção do paciente portador de neurofibromatose na condição de portador dessa morbidade; analisar os fatores intervenientes em sua vida pessoal ou profissional baseado em seus relatos; e discutir as implicações dessas percepções para assistência de enfermagem. trata-se de pesquisa qualitativa, descritivoexploratória, cujo cenário foi a unidade de apoio mútuo a neurofibromatose localizada no estado do rio de janeiro, vinculada ao centro nacional de neurofibromatose. a coleta de dados ocorreu em 2008 através de uma entrevista semi-estruturada, e os sujeitos foram 8 pacientes com idade superior a 18 anos. da análise, emergiu uma categoria central e cinco subcategorias. conclui-se que as percepções convergem para dificuldades cotidianas de cunho social, emocional, estético, físico e educacional, levando o portador a viver conflito da exclusão interna e da sociedade, determinado pela falta de informação quanto a sua própria doença. sugere-se a realização de outras pesquisas e investimentos em processos educativos/informação para portadores e sociedade em geral, bem como preparo de profissionais de saúde para intervir com orientações e diagnósticos corretos, corroborando para melhor qualidade de vida e inclusão desses portadores a sociedade. palavras-chave neurofibromatose 1, percepção, enfermagem, neurologia, cuidado. (fonte: decs, bireme). how the perception of being a neurofi bromatosis carrier affects nursing care abstract neurofibromatosis type 1 is an autosomal genetic syndrome found frequently in humans. characterized by the growth of benign tumors of the nervous system, it can occur in any part of the body. objectives: identify the perception of a patient with neurofibromatosis as a carrier of the disease, analyze the factors that intervene in the patient’s personal or professional life, based on his/her accounts, and discuss the implications those perceptions have for nursing care. año 9 vol. 9 nº 2 chía, colombia agosto 2009 147-155 148 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 this is a qualitative descriptive exploratory study conducted at the neurofibromatosis mutual support unit, which is associated with the national center for fibromatosis in río de janeiro. the data were collected in 2008 through semi-structured interviews of eight patients, all over 18 years of age. a main category and five sub-categories were established on the basis of the analysis. it was concluded that perceptions generate daily concerns of a social, emotional, esthetic, physical and educational nature that lead the carrier to experience conflicts involving internal and social exclusion due to a lack of information about the disease. it is suggested that other studies be done and an investment be made in educational-informative processes for carriers and society, along with training that would enable health professionals to offer counseling and correct diagnoses. this would improve the quality of life for carriers and aid their integration into society. key words neurofibromatosis type 1, perception, nursing, neurology, care. (source: decs, bireme). implicaciones de las percepciones de ser portador de neurofi bromatosis en el cuidado de enfermería resumen la neurofibromatosis 1 es un síndrome genético autosómico muy frecuente en el ser humano. se caracteriza por el crecimiento de tumores benignos de los nervios; puede presentarse en cualquier parte del cuerpo. objetivos: identificar la percepción del paciente con neurofibromatosis al ser portador de esta enfermedad; analizar los factores que intervienen en su vida personal o profesional con base en sus relatos; discutir las implicaciones de esas percepciones en la asistencia de enfermería. esta investigación, llevada a cabo en la unidad de apoyo mutuo a la neurofibromatosis –vinculada al centro nacional de fibromatosis en río de janeiro–, es cualitativa y descriptivo-exploratoria. la recolección de datos se realizó en 2008 mediante una entrevista semiestructurada a 8 pacientes mayores de 18 años. del análisis surgieron una categoría principal y 5 subcategorías. se concluyó que las percepciones originan preocupaciones cotidianas de corte social, emocional, estético, físico y educativo que conducen al portador a experimentar el conflicto de la exclusión interna y de la sociedad, debido a la falta de información respecto de su enfermedad. se sugiere realizar otras investigaciones e invertir en procesos educativo-informativos para los portadores y la sociedad, así como preparar profesionales de salud que puedan brindar orientaciones y diagnósticos correctos, lo cual redunda en el mejoramiento de la calidad de vida de los portadores y ayuda a integrarlos en la sociedad. palabras clave neurofibromatosis tipo 1, percepción, enfermería, neurología, cuidado. (fuente: decs, bireme). 149 implicações para o cuidar de enfermagem a partir de percepções do ser portador de neurofibromatose claudia de carvalho-dantas, marliete rodrigues-aguiar e outros. introdução a neurofibromatose é uma doença genética, com crescimento de tumores benignos nos nervos; pode acontecer em qualquer parte do corpo. não é contagiosa; a pessoa já nasce com o problema. alguns dos sinais e sintomas podem manifestar-se no primeiro ano de vida, enquanto outros somente mais tarde, no transcurso da vida (1, 2). “o termo neurofibromatose é utilizado para um grupo de doenças genéticas que afetam primariamente o desenvolvimento celular dos tecidos neurais”. esta doença produz alterações na pigmentação cutânea e tumores congênitos. apenas dois tipos são conhecidos desta patologia: o mais comum é a neurofibromatose do tipo 1 (nf-1, síndrome de von reclinghausen ou neurofibromatose periférica); a mais rara é a neurofibromatose do tipo 2 (nf-2, neurofibromatose acústica bilateral ou neurofibromatose central). a nf-1 afeta 1 em cada 3.000 indivíduos (3). a neurofibromatose na sua forma clássica é denominada de doença de von reclinghausen (nf-1); evidencia-se por manchas melanodérmicas e tumores cutâneos, eventualmente acompanhados por alterações mentais, endócrinas, neurológicas e ósseas (4, 5). calcula-se que há cerca de 1,5 milhões de indivíduos acometidos por nf no mundo, com uma estimativa de 80.000 pessoas portadoras de nf-1 no brasil. no mundo, a nf-1 tem uma variação de 1:2.000 a 1:5.000 dentre as populações estudadas (3). esta pesquisa visou perquirir questões inerentes a neurofibromatose tipo 1 (nf-1). trata-se de um recorte do projeto intitulado neurofibromatose tipo 1: fatores intervenientes no processo interpessoal de portadores com diagnóstico de nf-1. mediante a tal projeto, emergiram diversos recortes de pesquisa, entre os quais será trabalhado por esta investigação o seguinte objeto: as percepções de pacientes acerca de sua condição de portador de neurofibromatose. assim, o referido objeto justifica-se devido à escassez de literatura em enfermagem no âmbito da neurofibromatose, que fora constatada por meio de buscas em biblioteca das quatro principais universidades públicas do estado do rio de janeiro, bem como em bibliotecas digitais, com destaque para a bireme. justifica-se ainda, pela necessidade de trabalhar e divulgar conhecimento acerca dessa morbidade, em especial pelo fato do crescente número de novos casos que, pela nossa prática clínica, observamos o despreparo no tocante as formas de intervenção/tratamento; outrossim, o impacto que esta morbidade acarreta para a vida dos portadores, concernente à discriminação e os preconceitos. no tocante ao brasil, vale ressaltar que a nf-1 é uma síndrome genética autossômica muito freqüente no ser humano, ainda pouco divulgada nas literaturas brasileiras. mediante ao exposto, emergiram as seguintes questões norteadoras: que é para uma pessoa ser portador de neurofibromatose? que fatores interferem em sua vida pessoal ou profissional? visando alcançar respostas para tais inquietações, foram delineados três objetivos, os quais serão apresentados, a seguir. “o termo neurofibromatose é utilizado para um grupo de doenças genéticas que afetam primariamente o desenvolvimento celular dos tecidos neurais”. 150 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 objetivos identificar a percepção do paciente portador de neurofibromatose na condição de portador dessa morbidade; analisar os fatores intervenientes em sua vida pessoal ou profissional, baseado em seus relatos; e discutir as implicações dessas percepções para assistência de enfermagem a essa clientela. material e método a fim de atingir os objetivos propostos, realizou-se uma pesquisa qualitativa do tipo descritivo-exploratória. a pesquisa qualitativa replica questões particulares, preocupa-se nas ciências sociais, com uma realidade que não pode ser quantificada, ou seja, trabalha com o universo de significados, motivos, aspirações, crenças, valores e atitudes, correspondendo a um espaço mais profundo das relações, dos processos e dos fenômenos que não podem ser reduzidos à operacionalização de variáveis (6). dada a natureza do objeto em estudo, esta opção metodológica permite desvelar as percepções dos indivíduos sobre sua patologia face ao contexto da realidade na qual são produzidas. a pesquisa qualitativa possibilita o conhecimento dos fenômenos pouco explorados e, desta forma, dado as especificidades anteriormente elucidadas da nf-1, essa metodologia possibilitará explorar e descrever as percepções dos pacientes com nf-1 e assim corroborar com reflexões que possibilitem uma melhor assistência. este estudo foi realizado na unidade de apoio mútuo a neurofibromatose localizada no estado do rio de janeiro, vinculada ao centro nacional de neurofibromatose, situado em uma instituição filantrópica localizada no estado do rio de janeiro. o período de coleta de dados ocorreu no primeiro semestre de 2008, e os sujeitos desse estudo foram 8 pacientes com diagnóstico médico de nf-1, com idade superior a 18 anos, que participavam das reuniões do núcleo supracitado da referida instituição. tais pacientes foram identificados por nome fictício de “estrela”. cumpre ressaltar que para cada sujeito desse estudo foi fornecido um termo de consentimento livre e esclarecido conforme preceitua a resolução 196 de 1996 do conselho nacional (7), de modo a garantir o anonimato de cada pessoa que se propôs a participar voluntariamente deste estudo. para tal pesquisa utilizou-se como técnica de coleta de dados entrevista semiestruturada, gravada em fita magnética, que permitiu, através de um roteiro, caracterizar fatores intervenientes na condição de portador de neurofibromatose, a partir das percepções do paciente. a entrevista semi-estruturada favorece, além dos fenômenos sociais, também a sua explicação e a compreensão de sua totalidade, desde aspectos que contemple uma situação específica até as situações de dimensões maiores (8). no que tange a análise dos dados, esta foi submetida ao processo de categorização que aponta categorias nas quais se inserem as expressões enunciadas em relação ao tema. essas podem organizar-se conforme as palavras que costumam ser persistentes, proporcionando uma explicação de conformidade de sentimentos; pode ainda ocorrer categorização a partir de determinadas formas de como o antes e o depois de qualquer evento, o cultural e o familiar, o político e o econômico, e aineste estudo foi realizado na unidade de apoio mútuo a neurofibromatose localizada no estado do rio de janeiro, vinculada ao centro nacional de neurofibromatose, situado em uma instituição filantrópica. 151 implicações para o cuidar de enfermagem a partir de percepções do ser portador de neurofibromatose claudia de carvalho-dantas, marliete rodrigues-aguiar e outros. da subcategorias para a concentração dos dados (9). resultados e discussões os resultados que se seguem foram obtidos através da análise qualitativa de 8 portadores de nf-1 que se dispuseram a participar voluntariamente da pesquisa. visando uma melhor compreensão dos dados obtidos, inicialmente será apresentado o perfil da amostra dos sujeitos e, posteriormente, as categorias dessa pesquisa. caracterização da amostra das oito entrevistas colhidas, verificou-se que 3 dos participantes pertencem ao sexo feminino e 5 pertencem ao sexo masculino. foram entrevistados portadores atingindo uma faixa etária entre 22 e 72 anos de idade. em relação à naturalidade, verifica-se que 5 dos depoentes são do rio de janeiro, enquanto 1 do ceará, 1 de minas gerais e 1 de salvador. em termos do estado civil, 5 são solteiros, 2 casados e, por fim, um viúvo. ressalta-se ainda que 3 dos participantes tiveram filhos. dos 3, apenas 1 dos entrevistados teve 2 filhos sem nf-1; casa um teve 1 filho, ambos portadores de nf-1. no que se refere ao apoio familiar, 6 dos depoentes relataram receber apoio, seguidos de 2 onde se evidenciou, por meio de seu depoimento, certo descaso da família por conta da patologia. de acordo com o grau de escolaridade, observa-se que 2 dos entrevistados possuem o ensino superior completo, 1 o superior incompleto, 2 o ensino médio completo, 1 o ensino fundamental completo e 2 têm o ensino fundamental incompleto. de acordo à profissão, 2 são aposentados, 1é estudante, 1é psicólogo, 1é securitário, 1é taxista, e 1, zelador de condomínio. no tocante ao ano de diagnostico da doença, 1foi diagnosticado entre 9 e 10 anos de idade; 2 aos 15 anos; 1quando adolescente; 1aos 37 anos e 1aos 65 anos de idade. ao questionar sobre o tratamento para nf-1, somente 3 relataram fazer o tratamento prescrito pelo profissional de saúde. e, por fim, 6 dos 8 depoentes já foram submetidos a procedimento cirúrgico por conta da nf-1. processo de categorização a partir da análise sobre a percepção dos depoentes, no tocante sua condição de portador de nf-1, emergiu uma categoria central, fundamentada por subcategorias que caracterizaram a percepção dos sujeitos. a categoria central foi intitulada percebendo-se com neurofibromatose, fundamentada por 5 subcategorias, as quais serão apresentadas a seguir, com os respectivos critérios de inclusão: percepções de cunho social (depoimentos de portadores que ilustram como as demais pessoas e a sociedade se relacionam diante do portador e da doença), percepções de cunho estético (depoimentos de portadores que ilustram como encaram a sintomatologia externa e as modificações de seu corpo face à doença, concernentes a padrões de beleza), percepções de cunho emocional (depoimentos de portadores que ilustram aspectos relativos à psique, ao ego e ao superego), percepções de cunho físico (depoimentos de portadores que apresentam deformidades e deficiências decorrentes da doença) e percepções de cunho educacional (depoimentos de portadores que ilustram a necessidade de informação e os resultados que se seguem foram obtidos através da análise qualitativa de 8 portadores de nf-1 que se dispuseram a participar voluntariamente da pesquisa. 152 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 divulgação do conhecimento e realização de educação especifica sobre a doença para população leiga e profissional). percepções de cunho social segue alguns dos depoimentos que compuseram essa subcategoria: quando alguém me pergunta o que é, friso logo que não é contagioso, que é uma doença genética (estrela 7). por um lado é ruim, as pessoas olham e se afastam, têm medo, acham que a doença pega (estrela 8). é notório, através de alguns relatos, que há uma resistência da sociedade com relação à aparência dos portadores acometidos por tal síndrome. talvez por desconhecer a doença, se afasta dessas pessoas por medo de contraírem tal patologia e, dessa forma, causa no outro a sensação de estar discriminado e excluído do convívio social. complementando tais concepções, ressalta-se que é preciso reunir esforços –sejam da comunidade, pessoais ou organizacionais– na luta e no trabalho para prevenir as deficiências, promover a dignidade e os direitos dos indivíduos que portam algum tipo de imperfeição, bem como seus familiares. contempla-se ainda que nessa perspectiva, poderá se evitar que tais deficiências sejam causa de injustiça e pretexto para que haja discriminações (10). percepções de cunho estético nessa subcategoria, percebe-se que o portador de nf-1 sofre com os danos que esta causa em sua aparência física, segundo observação de seus relatos. os depoimentos selecionados para exemplificar essa subcategoria foram: tem impedido totalmente a minha vida, me atrapalha em tudo (estrela 3). não sei te dizer, é algo que atinge esteticamente (estrela 4). tais portadores tendem a se isolar, tornam-se introspectivos, sentem vergonha de sua própria imagem que, acometida pela doença, muitas vezes torna-se disforme em relação ao indivíduo que é tido como normal, ou seja, que não sofre de nenhuma síndrome, subtendendo-se que seguem o padrão de beleza aceitável pela sociedade. contudo, muitas vezes esses indivíduos que portam a nf-1 sentem-se deprimidos diante de tal situação tão inconstante em suas vidas (11). a estética traz consigo uma relação com o que é belo (12). a deficiência apresentase mais como uma diferença entre os seres humanos, mas não é fator para que se considere alguém “belo” ou “feio” (12). percepções de cunho emocional tendo em vista o fator emocional, pode se observar que os entrevistados enfrentam certas dificuldades que afetam seu aspecto emocional causando-lhes ansiedades e incertezas no que se refere a sua patologia e, subseqüentemente, ao seu prognóstico. a labilidade emocional apresenta-se quando o indivíduo depara-se numa situação de fragilidade; então mostrará uma instabilidade emocional aumentada. a pessoa torna-se mais suscetível ao choro; também pode tornar-se hostil e reivindicativa, pois a forma como a doença se manifesta pode tais portadores tendem a se isolar, tornam-se introspectivos, sentem vergonha de sua própria imagem que, acometida pela doença, muitas vezes torna-se disforme em relação ao indivíduo que é tido como normal, ou seja, que não sofre de nenhuma síndrome, subtendendo-se que seguem o padrão de beleza aceitável pela sociedade. 153 implicações para o cuidar de enfermagem a partir de percepções do ser portador de neurofibromatose claudia de carvalho-dantas, marliete rodrigues-aguiar e outros. fazer com que esse doente torne-se irritado e emotivo (13, 14). encontram-se a seguir alguns depoimentos: mexe com a emoção... no começo foi uma dificuldade, era muito difícil! (estrela 1). tem sido muito difícil (estrela 3). acho que mexe com a auto-estima (estrela 4) mexe muito com a auto-estima (estrela 5). tenho medo que meus filhos e netos venham a ter, me da tristeza (estrela 6) percepções de cunho físico alguns depoimentos subsidiaram a construção dessa subcategoria, os quais se encontram a seguir: limita-me pouca coisa (estrela 5). eu não consigo correr, me doe correr, eu tenho um cansaço (estrela 5). quanto ao fator físico, muitas vezes limita ao portador de nf-1 a exercer algumas atividades, visto que a referida patologia pode acometer os ossos, dificultando ou até mesmo impossibilitando muitos desses portadores realizarem certas atividades, como também, causando-lhes dores e desconforto, como pode observar-se nos relatos. a realidade do corpo referese ao aspecto físico originado pelo código genético e moldado pelas influências do estilo de vida (15). uma das complicações mais freqüentes, associadas à neurofibromatose tipo 1, é o neurofibroma plexiforme em qualquer localização. o neurofibroma plexiforme da pálpebra superior e da órbita está habitualmente associado a hiperplasia hemifacial lateral, cujas características, estudadas em quatro pacientes por especialistas (16) da área, conferem características físicas que contribuem para impactar a doença em termos não apenas físicos, mas estéticos, potencializando a segregação dessa clientela. percepções de cunho educacional com respeito ao fator educacional, esse tem uma importância primordial no que se refere à educação aos pacientes, bem como para os portadores de determinadas patologias que eles desconhecem. isto lhes causa angustias e tristezas, e ainda, faze com que esse portador simplesmente não busque ajuda para seu problema, por desconhecerem a gravidade que a referida patologia oferece. segue alguns depoimentos: eu particularmente não tinha conhecimento da nf (estrela 1). eu não tinha muito conhecimento da doença (estrela 2). já vim saber o que era essa doença muita tarde (estrela 6). é fundamental que o indivíduo portador de algum tipo de patologia tenha conhecimento sobre tal para que ele tome as devidas providências, busque um tratamento da melhor forma possível, que possa lhe oferecer qualidade vida, já que muitas vezes a doença o impossibilita. o interessante é perceber que para educar é necessário ter determinação, insistência e compaixão (17, 18). uma das complicações mais freqüentes, associadas à neurofibromatose tipo 1, é o neurofibroma plexiforme em qualquer localização. 154 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 vale ressaltar que a educação realizada não deve apenas se ater aos portadores e demais pessoas leigas, outrossim, deve incluir aos profissionais de saúde, tendo em vista as especificidades da doença. muitos profissionais encontram-se despreparados para diagnosticar e orientar a clientela em questão. considerações finais esta pesquisa permitiu conhecer as percepções de portadores de nf-1 sobre sua própria condição de portador, onde se observou que eles lidam com diversas dificuldades cotidianas, dentre as quais citamos as de cunho social, emocional, estético, físico e educacional. vale ressaltar que uma das percepções mais evidentes foi a falta de informação quanto a sua própria doença. por meio dos depoimentos, verificou-se que essa “doença” deixa-os absortos e com isso os tolhe a procurar um tratamento adequado. a maioria vive o conflito da exclusão. diversos foram os fatores intervenientes na condição de portador, emergidos através dos discursos dos depoentes, a partir de suas percepções. é importante frisar que tais fatores dificultam a inserção dessa clientela no âmbito da sociedade. estas dificuldades permeiam não apenas o universo dos portadores, mas também os dos não portadores que passam a discriminar muitas das vezes com o olhar de medo ou repulsa por não conhecer as transformações externas que a nf-1 causa (em termos da aparência física do portador). outro ponto a se destacar é a necessidade de maior divulgação dessa morbidade, não apenas para a clientela, mas também para os profissionais, porque, de acordo com a nossa prática, muitas instituições carecem de profissionais qualificados para assistirem aos portadores de nf-1. assim, a partir da existência de profissionais aptos para o diagnóstico e tratamento, haverá pessoas capacitadas para orientar a clientela em geral e contribuir para minimizar o impacto da doença no tocante a discriminação por meio da informação. por fim, sugerimos e enfatizamos a necessidade de realização de outras pesquisas nessa área do conhecimento não apenas dentro da enfermagem, outrossim, áreas afins, de modo a possibilitar a construção e disseminação do conhecimento, colaborando para uma assistência de melhor qualidade aos portadores de nf-1. 155 implicações para o cuidar de enfermagem a partir de percepções do ser portador de neurofibromatose claudia de carvalho-dantas, marliete rodrigues-aguiar e outros. referências 1. 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times 2004; 100 (27): 34-36. 14. cavalcante am. psiquiatria, outros olhares: perfil etnopsicológico do enfermo. psychiatry on-line brazil 2005; 1(9): 124-129. 15. pedrolo ft, zago mmf. a imagem corporal alterada do laringectomizado: resignação com a condição. url: http://www.inca.gov.br/rbc/n_46/v04/pdf/ artigo6.pdf [consulta em novembro de 2008]. 16. castroviejo p, pascual sip, burgueño m, pérez mm, palencia r, segura jmg, valero c. unilateral facial and cerebral hyperplasia associated with neurofibromatosis type 1. report of four patients. rev. neurol. 2006; 43: 346-352. 17. graciato a, gomes cj, echer ic, lorenzi pdc. grupo de orientação de cuidados aos familiares de pacientes dependentes. rev. bras. enferm. 2006; 59(1): 105-108. 18. kodra y, salerno p, agazio e, mirabella f, taruscio d. accessibility and quality of italian health and social services: the experiences of patients with neurofibromatosis type 1 and of their relatives. ann. ig. 2007; 19 (5): 443-450. 1 dewi gayatri1 elly nurachmah2 muchtaruddin mansyur3 pradana soewondo4 suriadi suriadi5 relationship between wound severity, discomfort, and psychological problems in patients with a diabetic foot ulcer in indonesia: a cross-sectional study* 1 https://orcid.org/0000-0003-1477-0033. universitas indonesia, faculty of nursing, indonesia. dewi_g@ui.ac.id 2 https://orcid.org/0000-0002-1299-6437. universitas indonesia, faculty of nursing, indonesia. elly-nrm@ui.ac.id 3 https://orcid.org/0000-0002-3100-3269. universitas indonesia, faculty of nursing, indonesia. muctaruddin.mansyur@ui.ac.id 4 https://orcid.org/0000-0003-3674-7934. universitas indonesia, faculty of nursing, indonesia. pradana.soewondo@ui.ac.id 5 https://orcid.org/0000-0002-5450-0874. muhammadiyah pontianak, school of nursing, indonesia. suriadi@stikmuhptk.ac.id * this paper is derived from a doctoral thesis dissertation. recibido: 02/09/2019 enviado a pares: 05/11/2019 aceptado por pares: 12/05/2020 aprobado: 13/07/2020 doi: 10.5294/aqui.2020.20.3.3 para citar este artículo / to reference this article / para citar este artigo gayarti d, nurachmah e, mansyur m, soewondo p, suriadi s. relationship between wound severity, discomfort, and psychological problems in patients with a diabetic foot ulcer in indonesia: a cross-sectional study. aquichan. 2020;20(3):e2033. doi: https://doi.org/10.5294/aqui.2020.20.3.3 abstract objectives: the purpose of this study is to identify the relationship between wound severity, discomfort, and psychological problems in patients with a diabetic foot ulcer in indonesia. methods: a cross-sectional study is conducted in three general hospitals and one clinic in indonesia. the bates-jensen wound assessment tool (bwat), the discomfort evaluation of wound instrument (dewi), and the depression, anxiety, and stress scale (dass) are used to measure the variables of interest. path analysis is performed to evaluate the association between wound severity, discomfort, and psychological problems. results: of 140 patients with diabetic foot ulcers who joined this study, the majority experienced immobilization (74.3 %), pain (69.3 %), and sleep disturbance (63.6 %). the means were as follows: discomfort año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2033 theme: chronic care contribution to the discipline: this study provides essential data to understand the factors that may affect wound severity. thus, nurses can use it to consider the psychological aspect of wound care. https://orcid.org/0000-0003-1477-0033 mailto:dewi_g@ui.ac.id https://orcid.org/0000-0002-1299-6437 mailto:elly-nrm@ui.ac.id https://orcid.org/0000-0002-3100-3269 mailto:muctaruddin.mansyur@ui.ac.id https://orcid.org/0000-0003-3674-7934 mailto:pradana.soewondo@ui.ac.id https://orcid.org/0000-0002-5450-0874 mailto:suriadi@stikmuhptk.ac.id https://doi.org/10.5294/aqui.2020.20.3.3 https://doi.org/10.5294/aqui.2020.20.3.3 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2033 (2.35 ± 0.33), depression (1.34 ± 0.41), stress (1.49 ± 0.48), anxiety (1.43 ± 0.40), and wound severity (31.35 ± 9.96). discomfort partially mediated the relationship between wound severity and psychological problems, which indirect effect was 0.11. conclusion: high prevalence of discomfort, both physical and psychological, was found in patients with a diabetic foot ulcer. discomfort mediates the relationship between wound severity and psychological problems. integrating comfort into wound care management may help to reduce the psychological burden. keywords (source: decs) chronic wound; diabetic foot ulcer; discomfort; psychological problems; wound severity. 3 relationship between wound severity, discomfort, and psychological problems in patients with a diabetic foot ulcer in indonesia... l dewi gayatri and others relación entre la gravedad de la herida, la molestia y los problemas psicológicos en pacientes con úlcera del pie diabético en indonesia: estudio transversal* resumen objetivos: el presente estudio tiene como objetivo identificar la relación entre la gravedad de la herida, la molestia y los problemas psicológicos en pacientes con úlcera del pie diabético en indonesia. métodos: se realizó un estudio transversal en tres hospitales generales y una clínica de indonesia. la herramienta de evaluación de heridas bates-jensen (bwat, por sus siglas en inglés), el instrumento de evaluación de molestia de la herida (dewi, por sus siglas en inglés) y la escala de depresión, ansiedad y estrés (dass, por sus siglas en inglés) se utilizaron para medir las variables de interés. se realizó un análisis de ruta para evaluar la asociación entre la gravedad de la herida, la molestia y los problemas psicológicos. resultados: de 140 pacientes con úlcera del pie diabético que participaron en este estudio, la mayoría experimentó inmovilización (74,3 %), dolor (69,3 %) y trastornos del sueño (63,6 %). las medias fueron las siguientes: molestia (2,35 ± 0,33), depresión (1,34 ± 0,41), estrés (1,49 ± 0,48), ansiedad (1,43 ± 0,40) y gravedad de la herida (31,35 ± 9,96). la molestia medió en parte la relación entre la gravedad de la herida y los problemas psicológicos, cuyo efecto indirecto fue de 0,11. conclusión: se encontró una alta prevalencia de molestias, tanto físicas como psicológicas, en pacientes con úlcera del pie diabético. además, la molestia media la relación entre la gravedad de la herida y los problemas psicológicos. la integración de la comodidad en el manejo del cuidado de las heridas puede ayudar a reducir la carga psicológica. palabras clave (fuente: decs) herida crónica; úlcera de pie diabético; molestia; problemas psicológicos; gravedad de la herida. año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2033 * este artículo es derivado de una tesis doctoral. 4 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2033 aquichan issn 1657-5997 eissn 2027-5374 relação entre gravidade da ferida, desconforto e problemas psicológicos em pacientes com úlcera diabética do pé na indonésia: um estudo transversal* resumo objetivos: o objetivo deste estudo é identificar a relação entre a gravidade da ferida, o desconforto e os problemas psicológicos en pacientes com úlcera do pé diabético na indonésia. métodos: foi realizado um estudo transversal em três hospitais gerais e uma clínica da indonésia. a ferramenta da avaliação de feridas bates-jensen (bwat, por sua sigla em inglês), o instrumento de avaliação do desconforto da ferida (dewi, por sua sigla em inglês) e a escala de depressão, ansiedade e estresse (dass, por sua sigla em inglês) foram utilizados para medir as variáveis de interesse. uma análise de rota foi realizada para avaliar a associação entre a gravidade da ferida, o desconforto e os problemas psicológicos. resultados: de 140 pacientes com úlcera diabética do pé que participaram deste estudo, a maioria experimentou imobilização (74,3 %), dor (69,3 %) e transtornos do sono (63,6 %). as médias foram: desconforto (2,35 ± 0,33), depressão (1,34 ± 0,41), estresse (1,49 ± 0,48), ansiedade (1,43 ± 0,40) e gravidade da ferida (31,35 ± 9,96). o desconforto foi o mediador em parte da relação entre a gravidade da ferida e os problemas psicológicos, cujo efeito indireto foi de 0,11. conclusões: verificou-se alta prevalência de desconforto, tanto físico quanto psicológico, em pacientes com úlcera diabética do pé. além disso, o desconforto intermedeia a relação entre a gravidade da ferida e os problemas psicológicos. a integração do conforto na gestão do cuidado das feridas pode ajudar a reduzir a carga psicológica. palavras-chave (fonte: decs) ferida crônica; úlcera diabética do pé; desconforto; problemas psicológicos; gravidade da ferida. * este artigo é derivado de uma tese de doutorado. 5 relationship between wound severity, discomfort, and psychological problems in patients with a diabetic foot ulcer in indonesia... l dewi gayatri and others introduction diabetes mellitus (dm) is a significant public health issue and a socioeconomic burden in indonesia. in 2019, approximately 463 million adults around the world had diabetes; it is estimated to increase to 700 million by 2045 (1). about 79 % of adults with diabetes lived in lowand middle-income countries (1). indonesia is ranked as having the seventh-largest number of dm patients in the world, and the number of people with diabetes was 10.7 million (6.2 %) of the total population in 2019 (1). dm caused 4.2 million deaths and at least usd 760 billion in health expenditure in 2019—10 % of total spending on adults (1). diabetic foot complications constitute a major health burden, amounting to the single most substantial reason for hospitalization among diabetic patients. up to 2–3 % of dm patients are thought to have an active foot ulcer with a lifetime risk of developing complications (2, 3). the international diabetes federation states that 9.1 to 26.1 million people with diabetes will suffer from a diabetic foot ulcer (dfu) each year (4, 5). dfu is described as a full-thickness lesion appearing on the skin on the feet of people with diabetes, along with infection, and destruction of tissues due to neuropathy or peripheral artery disease (pad) (6). concerning long-term conditions, a dfu may ultimately prompt lower extremity amputation (lea), thus reducing patients’ quality of life (7). dm had increased 11 times the incidence of foot ulcers, accounted for more than 80 % of all amputations, and risen hospital costs more than 10-fold (8–10). most dfus are asymptomatic at the beginning, and patients start to recognize it until non-healing ulcers become evident (11). therefore, wound healing becomes longer and cause high medical costs. the improvement, innovation, and prevention agenda further highlights the need for better efforts on active chronic disease management to optimizing the utilization of healthcare resources. the previous study reported that discomfort due to a dfu is the most common complaint among patients and significantly impacts the wound healing process (12). discomfort refers to the attributes of communication, family and relationship, functionality, self-identity, physical and psychosocial symptom relief, spiritual activities and states, safety and security (13). discomfort means unfulfilled human basic needs individually and holistically (14). pain, stress, bad smell, sleep disorder, and daily activities disturbances were the most common complaints by patients with a dfu (11, 12). previous studies reported that feeling discomfort could affect the wound healing process (14, 15). however, discomfort receives less attention from health care providers. therefore, achieving a good quality of wound care requires that the nurse care for patients physically and psychologically. the purpose of this study is to explore wound severity, discomfort, and psychological problems (stress, anxiety, and depression) and its interaction in patients with a dfu. methods study design the cross-sectional study design was employed to explore wound severity, discomfort, and psychological problems of patients with a dfu. this study was conducted at the inpatient of three public hospitals in jakarta and one wound care clinic in indonesia from january 2018 to september 2018. the hospitals in jakarta take care of 300–350 dm patients (with or without dfus) daily. participants the study sample consisted of 140 patients with a dfu. the sample size was calculated using a rule of thumb, namely, 5 to 50 respondents for each variable being researched (16). the inclusion criteria were patients with a dfu, having a stable hemodynamic status, able to communicate in bahasa, and willing to be respondents. a convenience sampling technique was used to select the participants. measures demographic characteristics and clinical information were collected, including age, gender, education level, marital status, working status, monthly income, body mass index, duration of the dfu, type of wound dressing, and smoking status. the bates-jensen wound assessment tool (bwat) was used to measure a chronic wound. this instrument consists of 13 indicators: wound size, depth, edges, undermining, necrotic tissue type and amount, exudate type and amount, skin color surrounding wound, peripheral tissue edema and induration, granulation tissue, and epithelialization. this instrument uses a likert scale from 1 to 5 (1 being the healthiest and 5 the unhealthiest attribute for each characteristic). a score ranging from 1 to 12 indicates a good condition of the wound, 13 to 56 regeneration stage, and more than 60 wound degeneration (17). the reliability in the current study was 0.763. 6 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2033 aquichan issn 1657-5997 eissn 2027-5374 the discomfort evaluation of wound instrument (dewi) was used to evaluate the discomfort of patients with a dfu. the authors and colleagues developed this instrument in 2015. it consists of 11 items including the general perception of discomfort, physical discomfort (wound severity, pain, itching, fluid, odor), the physical impact of discomfort (immobility, frequency of changing dressing), the psychological impact of discomfort (frustration, anxiety due to injury), and worship disruption. in the current study, the content validity index was 0.83, and the factor loading ranged from 0.257 to 0.658. the depression, anxiety, and stress scale (dass) is a questionnaire that contains 21 items to measure negative emotional states: depression, anxiety, and stress. the total score was categorized as follows; normal (0-19), mild (30-59), moderate (60-89), severe (90-119), and very severe (> 120) (18). the reliability in the current study was 0.815. data collection procedure ethical approval was obtained from the ethical committee of the faculty of nursing, universitas indonesia, before data collection (e234o20). one research assistant was mutually trained for data collection. participants were invited to join the study during their clinical visits and while hospitalized in the studied hospitals. written informed consent was obtained from the participants involved. the researcher personally provided a questionnaire to the respondents and filled it out according to their answers. the time needed to fill out all questions was 10 to 20 minutes. all data were collected anonymously, and no personal identifiers were recorded. data analysis descriptive statistics were used to explore the discomfort of patients with a dfu. categorical data were represented as count and proportion, while continuous data were indicated as mean and standard deviation or as median and interquartile range. a bivariate analysis was performed before path analysis to evaluate the correlation among variables. a path analysis was carried out to examine the interaction between wound severity, discomfort, and psychological problems. the statistical package for social sciences (spss 22.0, ibm, chicago, illinois) software was used for statistical analysis. results of 140 participants included in this study, 53.6 % were female and 91 % were married. more than half (52.2 %) were 55 and older, the mean age being 50.23 (sd: 7.82). of the patients, 60 % had an educational level above senior high school and 51.1 % were government officers, with more than 60 % earning less than usd 341 or 5 million rupiahs a month. for the clinical indicators, more than half were overweight to obese, non-smokers, and having a dfu of less than four weeks (table 1). the means were as follows: discomfort 2.35 (sd = 0.33), depression (1.34 ± 0.41), stress (1.49 ± 0.48), and anxiety (1.43 ± 0.40) (table 2). the average score of wound severity was 31.35 ± 9.96. table 1. demographic and clinical information of patients with a dfu (n = 140) variables n (%) age (year, mean ± sd) 50.23 ± 7.82 < 55 years 67 (47.8) > 55 years 73 (52.2) gender male 65 (46.4) female 75 (53.6) education level not at all 7 (5) under senior high school 49 (35) above senior high school 84 (60) marital status single 13 (9.3) married 127 (90.7) working status unemployed 78 (55.7) government officer 52 (44.3) monthly income (rupiah) rp 0 3 million 88 (62.8) rp 3 5 million 38 (27.1) > rp 5 million 14 (10.1) 7 relationship between wound severity, discomfort, and psychological problems in patients with a diabetic foot ulcer in indonesia... l dewi gayatri and others variables n (%) age (year, mean ± sd) 50.23 ± 7.82 < 55 years 67 (47.8) > 55 years 73 (52.2) body mass index underweight-normal 66 (47.8) overweight-obesity 72 (52.2) duration to date < 4 weeks 82 (59.4) > 4 weeks 56 (41.6) type of wound dressing conventional 65 (46.4) modern 75 (53.6) smoking status yes 49 (35) no 91 (65) source: own elaboration. table 2. score of discomfort, depression, stress anxiety, and wound severity among patients with a dfu (n = 140) variables mean sd 95 % ci discomfort 2.35 0.33 2.29–2.41 depression 1.34 0.41 1.28–1.41 stress 1.49 0.48 1.41–1.57 anxiety 1.43 0.40 1.37–1.50 wound severity 31.4 9.96 29.7–33.0 source: own elaboration. figure 1 depicts the top three prevalence of discomfort experienced by patients with a dfu. mobility problems were identified as the most frequent discomfort, followed by sleep disturbance and pain. more specifically, patients have reported difficulty in walking (52.6 %), difficulty in doing daily activities (48.6 %), waking up easily (32.9 %), and throbbing pain (50 %). figure 1. top three prevalence of physical discomfort characteristics of patients with diabetic foot ulcer (n=140) source: own elaboration. the analysis showed a significant correlation between wound severity, discomfort, and psychological problems (p < 0.005). the discomfort was significantly associated with psychological problems, including stress, depression, and anxiety (p < 0.005). table 3 shows that discomfort partially mediated the relationship between wound severity and psychological problems. in step 1, wound severity was significantly associated with discomfort, whose total effect was 0.41. in step 2, the impact of wound severity on psychological problems reduced but continue to be significant when the discomfort was entered in the model. the indirect effect of wound severity and psychological problems, as mediated by discomfort, was 0.11. in step 3, psychological problems were significantly associated with discomfort, whose direct effect was 0.72. table 3. interaction between wound severity, dass, and discomfort in patients with a dfu (n = 140) coeff. 95 % ci p-value wound-discomfort 0.41 0.24–0.55 < 0.001 wound-discomfort-dass 0.11 -0.05–0.26 0.05 dass-discomfort 0.72 0.54–0.87 < 0.001 note: dass=depression, anxiety, and stress scale source: own elaboration. sore sick oulsating piercing pain waking up easily not sleeping soundly difficulty in falling asleep needing help sleep disturbance needing help difficulty in walking motion limitation difficulty in activities difficulty in self-care mobilization 29.3 30 50 14.3 32.9 69.3 23.6 28.5 22.1 63.6 42.1 52.6 42.9 48.6 47.9 74.3 0 10 20 30 40 50 60 70 80 8 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2033 aquichan issn 1657-5997 eissn 2027-5374 discussion most subjects in this study were at a moderate level of wound severity. this study was supported by a previous study that reported a high prevalence of moderate level of wound severity in patients with a dfu (19). a dfu is a chronic wound that occurs due to vascular disorders, neuropathy, and immunosuppression and entails a high medical cost (20, 21). dfus could quickly develop into infections because high blood glucose becomes the right place for microorganism growth (22). over 85 % of major amputations in patients with diabetes are preceded by foot ulceration (23). a moderate level of wound severity could affect the individual’s daily activity and may need some help from caregivers or family. health care professionals need to provide an education to them regarding how to do their daily activities and increase social support to help patients with dfu. also, preventative strategies, including annual diabetic foot screening and diabetic foot care interventions facilitated by a multidisciplinary team, should be implemented to enable early identification of diabetic patients at high risk of diabetic foot complications. patients with dfu experienced discomfort, specifically immobilization, sleep disturbance, and pain. the previous study reported that chronic wounds caused discomfort, including pain and difficulty in doing daily activities (24). the previous study suggested that providing physical comfort was necessary, and the main factors disrupting physical comfort were pain, noise, sleep disturbance, and immobilization (25). although comfort may have a different meaning to different people, the previous study highlighted comfort significantly affected wound healing, reduced symptom burden, and improved daily activities and quality of life (26). however, the feeling of discomfort may be affected by cultural differences and gender issues; e.g., in indonesia, men are expected to be strong, thus if they complain about something like discomfort, they may be considered weak. the interventions to manage a wound in patients with dfus should enhance comfort level and consider the discomfort in male patients. this study found that psychological problems, including anxiety and stress, were also reported by the patients with a dfu. several studies have reported that patients with chronic wounds feel fear and anxiety about a long process of wound healing or even getting an amputation (15, 25). however, previous studies did not include stress as an independent factor. the previous study also found that stress and depression are independent risk factors for the development of diabetic ulcers and increase the risk of death in patients with diabetic ulcers despite controlling glucose levels, diabetic ulcer severity, smoking, socioeconomic conditions, and other factors (15). patients can feel stressed because of the pressure and situations they experience. therefore, support from family is critical to helping patients to adjust and be more confident to take care of themselves. the relationship between wound severity and psychological problems was mediated by discomfort. no previous study has been conducted to explore the mediating effect of discomfort on stress and psychological problems. respondents experienced stress from moderate to severe, associated with higher degeneration of diabetic ulcers (19). there is a difference between discomfort and psychological problems. discomfort is a direct and immediate feeling or general perception about the environment, while psychological problems are a feeling or perception that takes long to be perceived or experienced (11). according to nurachmah et al. (26), someone who is injured will feel an imperfection, which ultimately results in emotional disturbances such as stress, anxiety, and depression. wound care for patients with diabetic foot also needs to focus not only on the wound healing but also on the psychological problems and discomfort of patients. a comprehensive assessment of the psychological aspect should be integrated into wound care intervention. limitation the limitation of this study is that the findings may not be generalized to the various patients in indonesia because this study only collected data from three referral hospitals in indonesia, and the country has 34 provinces distributed in more than seven big islands. nonetheless, although selection bias in this research cannot be ruled out, our study recruited participants from two tertiary hospitals, which have similar demographic characteristics as to patients with a dfu across indonesia. conclusion in conclusion, this study indicated that patients with dfu experienced physical discomfort and psychological problems. the relationship between wound severity and psychological problems was mediated by discomfort. future studies should explore more interaction models of discomfort in patients with dfus using a longitudinal follow-up. early identification of dfu severity and psychological problems should be integrated into wound care management. conflict of interest: none declared. 9 relationship between wound severity, discomfort, and psychological problems in patients with a diabetic foot ulcer in indonesia... l dewi gayatri and others references 1. international diabetes federation. idf diabetes atlas ninth edition 2019. available from: http://www.diabetesatlas.org 2. hscic. clinical audit and registries management service. national diabetes foot care audit report 2014-2015. england and wales; 2016 mar. available from: http://diabetestimes.co.uk/wp-content/uploads/2016/03/national_diabetes_ foot_care_audit_ndfa_-_2014-2015_report.pdf 3. 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http://journal.ui.ac.id/index.php/health/article/ view/939 https://doi.org/10.1177/1534734610371600 https://doi.org/10.12968/jowc.2010.19.3.47280 https://doi.org/10.1111/j.1365-2702.2012.04092.x https://doi.org/10.1111/j.1742-481x.2008.00483.x https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3696216/ http://journal.ui.ac.id/index.php/health/article/view/939 http://journal.ui.ac.id/index.php/health/article/view/939 197 211 cuidando.indd 197 amparo montalvo-prieto1 inna e. flórez-torres2 diana stavro de vega3 cuidando a cuidadores familiares de niños en situación de discapacidad 1 magíster en enfermería con énfasis en cuidado al paciente crónico. especialista en enfermería médico-quirúrgica. docente. universidad de cartagena. facultad de enfermería. centro cr 6 36 -100 calle de la universidad. cartagenabolívar. colombia. denfermeria@unicartagena.edu.co 2 magíster en enfermería con énfasis en cuidado al paciente cardiovascular. especialista en enfermería médico-quirúrgica. docente. universidad de cartagena. facultad de enfermería. centro cr 6 36 -100 calle de la universidad. cartagena bolívar. colombia. iflorezt@unicartagena.edu.co 3 especialista en epidemiología. docente. universidad de cartagena. facultad de enfermería. centro cr 6 36 -100 calle de la universidad. cartagena bolívar. colombia. dianastavro@gmail.com recibido: 19 de marzo de 2008 aceptado: 12 de septiembre de 2008 resumen objetivo: evaluar la efectividad del programa cuidando a los cuidadores, diseñado para fortalecer la habilidad de cuidado de los cuidadores familiares de niños en situación de discapacidad en la ciudad de cartagena, colombia. método: estudio cuasiexperimental, muestra intencional de 47 cuidadores para dos grupos, el experimental conformado por 27 y el control por 40. se evaluó la habilidad de cuidado de ambos grupos con el instrumento inventario de habilidad de cuidado (cai), de ngozi o. nkongho, autorizado y validado en su versión en español. con el grupo experimental se desarrolló el programa cuidando a los cuidadores. resultados: se describen y comparan las características sociodemográficas y de relación de cuidado de cada uno de los grupos de cuidadores estudiados. ambos grupos presentan una alta habilidad de cuidado en la preprueba y en la posprueba, en especial en el grupo experimental. conclusiones: el análisis estadístico reveló que el programa cuidando a los cuidadores no afectó la habilidad de cuidado de los participantes del estudio. los participantes mostraron desde el inicio una alta habilidad de cuidado, la mayoría cuida desde el momento del diagnóstico. el valor fue la dimensión donde se obtuvo la más baja puntuación al iniciar y finalizar el programa. palabras clave cuidadores, evaluación, enfermedad crónica, discapacidad. (fuente: decs) caring for family care-givers who are responsible for disabled children abstract objective: to assess the effectiveness of the “caring for caregivers” program, which is designed to reinforce the ability of family caregivers in the city of cartagena (colombia) who attend to disabled children. año 8 vol. 8 nº 2 chía, colombia octubre 2008 197-211 198 año 8 vol. 8 nº 2 chía, colombia octubre 2008 197-211 aquichan issn 1657-5997 method: this is a quasi-experimental study with an intentional sample of 47 caregivers divided into two groups: 27 in the experimental group and 40 in the control group. the ability of both groups to provide care was assessed with the authorized and validated spanish version of ngozi o. nkongho’s caring ability inventory (cai). the “caring for caregivers” program was developed with the experimental group. results: the socio-demographic characteristics and the care relationship are described and compared for each group of caregivers. both groups demonstrated considerable ability for care in the pre-test and the post-test, particularly the experimental group. conclusions: the statistical analysis showed the “caring for caregivers” program had no effect on the caring ability of those who took part in the study. they demonstrated a high degree of caring ability from the beginning; most of them had provided care from the moment of diagnosis. value was the dimension with the lowest score at the start and at end of the program. key words caregivers, assessment, chronic illness, disability. cuidado a cuidadores familiares de meninos em situação de discapacidade resumo objetivo: avaliar a efetividade do programa cuidado a cuidadores, planejado para melhorar a capacidade de cuidado dos cuidadores familiares de meninos em situação de discapacidade na cidade de cartagena. método: estudo quase experimental, amostra intencional de 47 cuidadores para dois grupos: o experimental, conformado por 27, e o de controle, por 40. foi avaliada a habilidade de cuidado dos dois grupos com o instrumento inventário de habilidade de cuidado (cai), de ngozi o. nkongho, autorizado e validado em sua versão em espanhol. o programa cuidado a cuidadores foi desenvolvido com o grupo experimental. resultados: são descritas e comparadas as características socio-demográficas e de relação de cuidado de cada grupo de cuidadores estudados. os dois grupos apresentam grande habilidade de cuidado na pré-proba e na pós-proba, sobretudo no grupo experimental. conclusões: a análise estatística indicou que o programa cuidado a cuidadores não afetou a habilidade de cuidado dos participantes no estudo. desde o começo mostraram grande habilidade para o cuidado. a maioria cuida desde o diagnóstico. a mais baixa qualificação foi obtida no valor ao começo e ao final do programa. palavras-chave cuidadores, avaliação, doença crónica, discapacidade. 199 cuidando a cuidadores familiares de niños en situación de discapacidad amparo montalvo-prieto, inna e. flórez-torres, diana stavro de vega introducción el vivir con una enfermedad crónica discapacitante hace referencia a la experiencia de padecer un trastorno orgánico y funcional que provoca alteraciones en las funciones o estructuras corporales, y algún grado de limitación en la actividad de la persona, lo que puede requerir de largos periodos de cuidado, tratamiento paliativo y control, por lo cual la persona debe modificar su estilo de vida (1). la discapacidad que afecta a la población, sobre todo a la infantil, se constituye en un problema de salud pública, si se considera el impacto negativo que determina sobre el niño, la familia, la comunidad y los enormes recursos que deben ser destinados para dar respuesta a esas necesidades especiales que surgen como consecuencia de la misma (2). la discapacidad ha sido vista como un término genérico que incluye déficit, deficiencias o alteraciones en las funciones o estructuras corporales, limitaciones en la actividad y restricciones en la participación, que indican los aspectos negativos de la interrelación entre un individuo (con una condición de salud) y sus factores contextuales (3). limita la integración social de las personas, afecta el reconocimiento, el desarrollo de las actividades y funcionalidades como individuos pertenecientes a la sociedad. en el departamento de bolívar, y en la ciudad de cartagena, colombia, no hay estadísticas que permitan conocer el número de personas en situación de discapacidad. se presenta subregistro en lo referente a los pacientes crónicos, lo que impide conocer la dimensión del problema. al no conocer el número y tipo de afección que presentan estas personas se hace menos visible la situación de sus cuidadores y la experiencia de cuidado (4). en cartagena, la fundación rei busca la rehabilitación integral de las personas discapacitadas de todas las edades. la población beneficiada corresponde a niños y adultos con escasos recursos económicos, que presentan discapacidad física, cognitiva, sensorial, multidéficit, o están en riesgo de adquirir una discapacidad. agrupa un sector de la población que presenta algún tipo de discapacidad, brinda asistencia a los niños con déficit en la esfera cognitiva, auditiva, visual, de habla, de lenguaje y de destreza motora. en el cuidado de los niños con algún grado de discapacidad la responsabilidad la asume su familia. la condición de los cuidadores de los niños en situación de discapacidad que asisten a los programas de la fundación rei es similar a la de los cuidadores de otras regiones de colombia y de américa latina (5, 6, 7). se denomina cuidador familiar a la persona que tiene un vínculo de parentesco o cercanía y asume la responsabilidad del cuidado de un ser querido que vive con enfermedad crónica y participa en la toma de decisiones, y supervisa y apoya la realización de las actividades de la vida diaria para compensar la disfunción existente en la persona con la enfermedad (8). los cuidadores familiares son en su mayoría mujeres de edad intermedia, menores que el receptor del cuidado, con estados civiles variados, algunas empleadas y otras amas de casa, con niveles de educación y socioeconómicos heterogéneos, quienes por lo general cuidan al ser querido desde el momento de su diagnóstico y llevan cuidándolo más de seis meses. estas personas sienten que la actividad ocupa la mayor parte del día y, por lo general, desconocen el rol que asumen (8). la discapacidad que afecta a la población, sobre todo a la infantil, se constituye en un problema de salud pública, si se considera el impacto negativo que determina sobre el niño, la familia y la comunidad. 200 año 8 vol. 8 nº 2 chía, colombia octubre 2008 197-211 aquichan issn 1657-5997 el cuidador experimenta cambios importantes en el desempeño de sus roles habituales; el grado de compromiso depende de la demanda de cuidado que el paciente requiere, así como de las características del cuidador. en la forma como el cuidador se adapta a estos cambios influyen factores específicos como sus características personales, la severidad de la enfermedad del paciente, y los ajustes que debe hacer en su estilo de vida y en el rol familiar para satisfacer las demandas de cuidado (9). en diferentes contextos se han documentado las implicaciones de la experiencia de cuidado de los cuidadores sobre su calidad de vida, relacionadas con el estrés permanente al que se ven sometidos, alteraciones de la salud física en general, del patrón del sueño, fatiga, incertidumbre, depresión y ansiedad, aislamiento social, alteración de la ejecución habitual del rol, y la percepción de la falta de soporte social y de apoyo de los sistemas de cuidado de la salud (6, 10, 11, 12, 13). ngosi nkongo identificó conceptualmente que el cuidado es multidimensional, con componentes cognoscitivos y de actitud, en donde el potencial para cuidar está presente en todos los individuos, es cuantificable y se puede aprender. así mismo, la habilidad de cuidado es el potencial que tiene la persona adulta que incluye dimensiones cognoscitivas y actitudinales, identificadas y medidas con indicadores de conocimiento, valor y paciencia; la habilidad, vista así, puede evaluarse a través de la comunicación directa con cada persona (14). los cuidadores familiares, como una fuente importante de cuidado informal, experimentan situaciones ignoradas tanto por el actual sistema de seguridad social como por la familia, ya que no cuentan con un servicio oportuno y eficiente para el fortalecimiento de la habilidad de cuidado en casa y el reconocimiento de la labor que cumplen. estas situaciones le han permitido a enfermería la indagación de algunos aspectos básicos como la caracterización, la importancia de su labor, las necesidades, la calidad de vida y la forma de vivir esa experiencia (8). el programa cuidando a los cuidadores aborda el estudio de estas condiciones, lo que le ha permitido formular algunas sugerencias para las enfermeras que cuidan personas con enfermedad crónica en el ambiente hospitalario y comunitario (8). este programa pretende que el cuidador descubra su experiencia de cuidado y la analice, identifique sus potencialidades y limitaciones, las ganancias que el proceso de ser cuidador le genera, y se empodere dentro de su rol. consta de una sesión de inducción general y tres módulos que trabajan temas de conocimiento, valor y paciencia (15). el objetivo del presente estudio es evaluar la efectividad del programa cuidando a los cuidadores, diseñado para fortalecer la habilidad de cuidado de los cuidadores familiares de niños en situación de discapacidad, en la ciudad de cartagena. materiales y métodos se desarrolló un estudio de tipo cuasiexperimental durante los años 2006 y 2007. la población la conformaron los cuidadores familiares de niños en situación de discapacidad que asistían a los programas desarrollados por la fundación rei, de la ciudad de cartagena. la muestra fue seleccionada en forma intencional, tenienngosi nkongo identificó conceptualmente que el cuidado es multidimensional, con componentes cognoscitivos y de actitud, en donde el potencial para cuidar está presente en todos los individuos, es cuantificable y se puede aprender. 201 cuidando a cuidadores familiares de niños en situación de discapacidad amparo montalvo-prieto, inna e. flórez-torres, diana stavro de vega do en cuenta los siguientes criterios: cuidadores familiares principales de niños en situación de discapacidad, usuarios de la institución, que aceptaran participar en la investigación firmando su consentimiento. los sujetos seleccionados fueron distribuidos en forma no aleatoria a los grupos de intervención y control, teniendo como criterio la periodicidad con que asistían a la institución. de esta forma, el grupo experimental estuvo constituido por 27 cuidadores de niños en situación de discapacidad, que cumplían cada semana con este criterio, y el grupo control por 40, que asistían con una frecuencia menor. para la caracterización se aplicó la encuesta caracterización de los cuidadores, diseñada por el grupo de cuidado del paciente crónico de la universidad nacional de colombia, el cual consta de 13 ítems que evalúan datos sociodemográficos y de relación de cuidado. la habilidad de cuidado se midió con el inventario de la habilidad de cuidado (cai) de ngozi o. nkongho (14), herramienta integrada por 37 ítems con respuesta tipo lickert, y se compone de tres subescalas: conocimiento, valor y paciencia. las respuestas van de 1 a 7, con los puntajes más altos indicando mayor grado de habilidad de cuidado para un ítem positivamente formulado; para los ítems negativamente formulados el puntaje se invierte. las respuestas a los ítems se suman para cada subescala, dando un puntaje total para cada una de ellas. el instrumento arroja un puntaje para la habilidad total y para cada uno de sus componentes. la subescala “conocimiento” consta de 14 ítems, la de “valor” de 13 ítems y la de “paciencia” de 10. su validez de 0,80, y confiabilidad de 0,84, fue ratificada con pruebas psicométricas en población colombiana. a ambos grupos se les evaluó su habilidad de cuidado, en el grupo experimental se implementó el programa cuidando a los cuidadores y, una vez finalizado éste, se aplicó nuevamente el cai; a los participantes del grupo control se les administró el mismo instrumento en dos momentos diferentes, aunque éstos no fueron expuestos a la intervención. el programa cuidando a los cuidadores, tuvo una inducción general en donde se establecieron los grupos para trabajar, se hizo una sensibilización y se entregó el material que se debía utilizar. en el módulo de la dimensión conocimiento se desarrollaron los temas, la experiencia de ser cuidador, la experiencia del receptor de cuidado y el conocimiento que se requiere para comprender y facilitar el rol de cuidador. en el módulo relativo al valor se trabajaron los temas, las ganancias del proceso de cuidado a personas con enfermedad crónica, las habilidades sociales y la importancia de que el cuidador se empodere de su función y de la toma de decisiones en la tarea de cuidar. la temática del módulo de la paciencia contempló esta cualidad como una característica esencial para el cuidador, la experiencia de crecer siendo cuidador y el hecho de que un cuidador hábil piensa en el futuro. al finalizar cada uno de los módulos los participantes realizaron una evaluación escrita (15). la información obtenida mediante la encuesta fue procesada y organizada para describir las características generales de los participantes. los datos obtenidos con la aplicación del cai fueron clasificados inicialmente en una de dos categorías: baja y alta habilidad de cuidado. se consideraron las puntuaciones tanto globales en el cai como en cada una de las tres dimensiones. se realizó un análisis descriptivo en en el módulo de la dimensión conocimiento se desarrollaron los temas, la experiencia de ser cuidador, la experiencia del receptor de cuidado y el conocimiento que se requiere para comprender y facilitar el rol de cuidador. 202 año 8 vol. 8 nº 2 chía, colombia octubre 2008 197-211 aquichan issn 1657-5997 cada grupo con respecto a las dimensiones objeto de estudio, utilizando medidas de tendencia central y dispersión. para establecer si la distribución de los datos obtenidos era normal se utilizó el test de kolmogorov-smirnov, y para comparar los resultados de preprueba y posprueba entre los dos grupos se aplicó la prueba t student, asumiendo como significativos los valores de p inferiores a 0,05. además, se aplicó la prueba chi cuadrado para probar las diferencias entre las proporciones obtenidas con los dos grupos con respecto a la habilidad de cuidado. la investigación conservó los parámetros éticos para estudios con seres humanos incluyendo el consentimiento informado, la participación voluntaria, el manejo confidencial de la información, el empleo de la evidencia disponible para la intervención terapéutica a los cuidadores familiares, y la autorización para el uso de los instrumentos y de las instancias pertinentes. la información del estudio se consideró importante para cualificar el cuidado de enfermería y la investigación sin riesgos previsibles para los participantes. de ser identificado lo contrario, el estudio sería ajustado o suspendido. el costo-beneficio contempló el empleo de los recursos humanos para la investigación, al igual que los recursos financieros, que se justificaron por el fortalecimiento de la habilidad de cuidado de los cuidadores mediante la implementación del programa, el reconocimiento de los cuidadores y de su labor, y la conformación como grupo de apoyo. para la fundación rei representó una fortaleza el reconocer en los cuidadores la necesidad de apoyo y respaldo institucional. en el campo ambiental se consideró un estudio de impacto neutro que, aunque no abordó aspectos relativos al medio, se espera que al reunir cuidadores de personas con enfermedad crónica puedan surgir propuestas tendientes a evitar barreras ambientales y riesgos innecesarios para este grupo. resultados características generales de los cuidadores género del cuidador porcentaje masculino 6 femenino 94 total 100 edad del cuidador 17 años o menos 1 entre 18 y 35 años 52 entre 36 y 59 años 45 60 años o más 1 total 100 sabe leer y escribir el cuidador sí 97 no 3 total 100 escolaridad del cuidador primaria completa o incompleta 25 bachillerato completo o incompleto 57 técnico o más 18 total 100 estado civil del cuidador soltero(a) 24 casado(a) 21 separado(a) 10 viudo(a) 1 unión libre 43 total 100 ocupación del cuidador hogar 76 empleado(a) 4 trabajador independiente 15 estudiante 1 otros 3 total 100 estrato del cuidador estrato 1 67 estrato 2 28 estrato 3 4 total 100 tabla 1. características sociodemográficas de los 67 cuidadores la información del estudio se consideró importante para cualificar el cuidado de enfermería y la investigación sin riesgos previsibles para los participantes. 203 cuidando a cuidadores familiares de niños en situación de discapacidad amparo montalvo-prieto, inna e. flórez-torres, diana stavro de vega del total de los 67 cuidadores, el 94% es de género femenino, el 6% correspondió al género masculino. el 53% de los participantes tienen 35 años o menos, mientras que el 46% tiene 36 años o más. aunque la mayoría sabe leer y escribir (97%), es preciso advertir que un 25% cuenta con primaria (completa o incompleta); el 57% tiene bachillerato (completo o incompleto), y el 18% tiene una formación técnica o un nivel superior. en cuanto al estado civil el mayor grupo de participantes se encuentran en unión libre (43%), seguido por los participantes solteros que agrupan al 24%, y casados el 21%. la mayoría de los cuidadores está dedicada al hogar (76%), el 15% corresponde a trabajadores independientes. con relación al estrato socioeconómico, el 67% de los cuidadores pertenece al estrato 1, seguido del estrato 2 que equivale al 28%. en cuanto al tiempo de experiencia como cuidador, el 78% lleva más de 37 meses dedicado a su tarea de cuidado, y el 91% de los cuidadores cuida al paciente desde el momento del diagnóstico. con respecto al tiempo de dedicación, el 61% reportó 24 horas al día, mientras que el 37% de los cuidadores le dedica diariamente al cuidado del paciente entre 7 y 23 horas. las características de cada uno de los grupos se presentan en la tabla 2. tabla 2. características sociodemográficas de acuerdo con los grupos de estudio características experimental % control % género masculino 0 10 femenino 100 90 total 100 100 edad 17 años o menos 3,7 0 entre 18 y 35 años 40,74 60 entre 36 y 59 años 51,86 40 60 años o más 3,7 0 total 100 100 sabe leer y escribir no 0 2,5 sí 100 97,5 total 100 100 escolaridad primaria completa o incompleta 22,22 27,5 bachillerato completo o incomp. 37,03 70 técnico o más 40,75 2,5 total 100 100 estado civil soltero(a) 11,11 32,5 casado(a) 22,22 20 separado(a) 22,22 2,5 viudo(a) 3,7 0 unión libre 40,75 45 total 100 100 ocupación hogar 81,48 72,5 empleado(a) 0 7,5 trabajador independiente 11,11 17,5 estudiante 0 2,5 otros 7,5 0 total 100 100 estrato del cuidador estrato 1 74,08 62,5 estrato 2 22,22 32,5 estrato 3 3,7 5 total 100 100 con respecto al tiempo de dedicación, el 61% de los cuidadores reportó 24 horas al día. 204 año 8 vol. 8 nº 2 chía, colombia octubre 2008 197-211 aquichan issn 1657-5997 los resultados de la habilidad de cuidado total y por dimensiones, en los dos control n=40 experimental n=27 preprueba posprueba preprueba posprueba % % % % baja habilidad de cuidado 48 30 41 11 alta habilidad de cuidado 52 70 59 89 bajo conocimiento 5 8 15 0 alto conocimiento 95 92 85 100 baja paciencia 2 2 0 0 alta paciencia 98 98 100 100 bajo valor 93 95 93 81 alto valor 7 5 7 19 total 100 100 grupos de cuidadores antes y después de la intervención, se presentan en la tabla 3. tabla 3. habilidad de cuidado de los participantes de los grupos control y experimental en las dos pruebas *cai general conocimiento paciencia valor *p=0,24. según el puntaje obtenido en el cai general, la habilidad de cuidado de los cuidadores se reporta como alta en la preprueba en ambos grupos, 52% en el grupo control y 59% en el experimental. en el análisis a través de la prueba chi cuadrado no se encontraron diferencias estadísticamente significativas entre la ocurrencia de la habilidad observada en los dos grupos (p=0,24), es importante resaltar que para las otras dimensiones no fue posible aplicar la prueba. de acuerdo con los resultados anteriores, la habilidad general de cuidado contrasta con las habilidades específicas que miden las dimensiones conocimiento, paciencia y valor. del grupo control, 48% de los participantes presentaron baja habilidad en el cai general, 5% puntuaron con un bajo nivel de conocimiento, 2% con un bajo nivel de paciencia y 93% con un bajo nivel de valor. en el grupo experimental, 41% de los cuidadores presenta baja habilidad en el cai general, 15% puntúa un bajo nivel de conocimiento y 93% revela un bajo valor. la dimensión “valor” se encontró más afectada en los participantes en ambos grupos. con relación al conocimiento y la paciencia, la mayoría de los cuidadores iniciaron el estudio con una alta habilidad de cuidado. de acuerdo con los datos del cai general, en el grupo experimental se observa que posterior a la intervención, el 89% mejoró su puntuación en la habilidad de cuidado. en la dimensión valor se presentó un aumento en el 19% de los cuidadores. en la paciencia, el 100% de los cuidadores mantuvieron un alto nivel. en la dimensión conocimiento el 100% de los cuidadores presentaron un alto nivel. de acuerdo con los resultados anteriores, la habilidad general de cuidado contrasta con las habilidades específicas que miden las dimensiones conocimiento, paciencia y valor. 205 cuidando a cuidadores familiares de niños en situación de discapacidad amparo montalvo-prieto, inna e. flórez-torres, diana stavro de vega figura 1. representación de la habilidad de cuidado general de los dos grupos en la preprueba y en la posprueba la figura 1 representa la distribución del cai total del grupo experimental en la preprueba. los cuidadores en el cai total tuvieron puntuaciones que van desde 155 hasta 233 aproximadamente, lo que significa que el 50% tuvo puntajes inferiores a 195, y el 25% de los cuidadores obtuvo los mínimos y los máximos puntajes. a partir de esta información de la preprueba en los dos grupos del estudio se puede apreciar que la principal diferencia tiene que ver con la mayor longitud de la línea vertical del grupo control, lo que significa que este grupo inició con una mayor dispersión que el grupo experimental. por otra parte, al comparar los diagramas de caja que representan los resultados de la segunda aplicación del cai general en ambos grupos, se puede observar que la barra negra horizontal parte en dos cada diagrama de cajas y es más alta en el grupo experimental que en el grupo de control. en este sentido, se observa un leve aumento en las puntuaciones máximas obtenidas por el grupo experimental en la posprueba al comparar los extremos superiores de los dos diagramas de este grupo, mientras que aparece una considerable baja en las puntuaciones máximas del grupo control en la posprueba. hubo un notable cambio en el grupo experimental como se puede constatar al ver que aumentaron en la posprueba las puntuaciones mínimas, mientras que tal cambio es ligero en el grupo control. sin embargo, no se encontró evidencia estadística suficiente para establecer que el programa cuidando a los cuidadores aumentó significativamente la habilidad de cuidado. no se encontró evidencia estadística suficiente para establecer que el programa cuidando a los cuidadores aumentó significativamente la habilidad de cuidado. 206 año 8 vol. 8 nº 2 chía, colombia octubre 2008 197-211 aquichan issn 1657-5997 figura 2. representación de las puntuaciones en la dimensión del valor de los dos grupos en la preprueba y en la posprueba las puntuaciones en la dimensión valor se encontraron relativamente bajas, oscilando entre el 22 y el 90%. por otra parte, sobresale el considerable aumento en las puntuaciones máximas del grupo experimental, al constatar la mayor longitud del diagrama de caja de la posprueba. en la segunda medición de la habilidad de cuidado hubo cuidadores en los dos grupos que aumentaron su valor, siendo mayor en los cuidadores del grupo control. no obstante, no se encontró evidencia estadística suficiente para establecer que el programa cuidando a los cuidadores aumentara significativamente el valor de estos últimos. figura 3. representación de las puntuaciones en la dimensión del conocimiento de los dos grupos en la preprueba y en la posprueba no se encontró evidencia estadística suficiente para establecer que el programa cuidando a los cuidadores aumentara significativamente el valor de estos últimos. 207 cuidando a cuidadores familiares de niños en situación de discapacidad amparo montalvo-prieto, inna e. flórez-torres, diana stavro de vega en esta dimensión se presentaron puntuaciones altas en ambos grupos y pruebas. las puntuaciones mínimas oscilan entre 60 y 70, y la máxima fue 100. se observa que el límite inferior de los diagramas de caja de la posprueba es superior al encontrado en la preprueba. los principales cambios en las puntuaciones del grupo experimental están concentrados en el aumento de las puntuaciones mínimas, considerando que éstas estaban inicialmente alrededor de los 63 puntos y pasaron a 73. este cambio no se observa en el grupo control, pero la diferencia no fue estadísticamente significativa. figura 4. representación de las puntuaciones en la dimensión de la paciencia de los dos grupos en la preprueba y en la posprueba en la dimensión paciencia se observa que los cuidadores del grupo control presentan en la preprueba puntuaciones más bajas que el grupo experimental. al revisar la posprueba hubo un aumento considerable en las puntuaciones mínimas de los cuidadores del grupo control. en los dos grupos se encontró semejanza en las puntuaciones máximas de los cuidadores. discusión al comparar el género de los grupos de cuidadores se encontraron diferencias. en el grupo control hubo representación del género masculino, a diferencia del grupo experimental donde todas las cuidadoras fueron mujeres. similar a lo reportado en la literatura, el rol de cuidador es asumido por la mujer (16, 17, 18, 19, 20). históricamente a la mujer se le ha asignado el papel de cuidadora aduciendo condiciones inherentes a su naturaleza que la preparan para cuidar y ser más abnegada (5). en el entorno colombiano es frecuente que los familiares, en especial las mujeres, asuman el papel de cuidadores de los enfermos crónicos, mucho más si éste es un niño (21). en el entorno colombiano es frecuente que los familiares, en especial las mujeres, asuman el papel de cuidadores de los enfermos crónicos, mucho más si éste es un niño. 208 año 8 vol. 8 nº 2 chía, colombia octubre 2008 197-211 aquichan issn 1657-5997 en cuanto a la edad, la mayor concentración de cuidadores del grupo experimental se encuentra en el rango de los 36 a 59 años, y en el grupo control entre 18 a 35 años. este hallazgo es referido en la literatura como las dificultades de una generación intermedia o “sándwich” sobre la cual recae, además de la crianza de los hijos, el cuidado de las personas dependientes y mayores (8, 22). a su vez, griffin anota que los cuidadores familiares son en su mayoría mujeres de edad intermedia, quienes cuidan al ser querido desde el momento de su diagnóstico, y llevan cuidándolo más de seis meses. en el presente estudio, el rol de cuidador es asumido principalmente por la madre dado que los sujetos de cuidado son niños que viven en situación de discapacidad (23). los datos obtenidos en el presente estudio reportan desde su inicio una alta habilidad de cuidado de los cuidadores en ambos grupos; este hecho podría estar relacionado con el tiempo que los cuidadores han dedicado a la tarea de cuidar a los niños en situación de discapacidad; una entrega casi absoluta, a pesar de no ser los únicos cuidadores. dadas las anteriores características se podría interpretar, como lo reporta venegas, como una fortaleza, ya que entre más tiempo se tenga como cuidador se esperaría una mayor habilidad (24). a pesar de que en los resultados obtenidos en cuanto a la habilidad de cuidado de los cuidadores hubo cambios en los dos grupos, éste fue importante en el grupo experimental, lo anterior se encuentra referido en la literatura por sánchez; la experiencia de ser cuidadora de una persona en situación de enfermedad crónica es vivir de una manera diferente, modificando las funciones a las que se está acostumbrado, tomando decisiones, asumiendo responsabilidades y realizando tareas y acciones de cuidado físico, social, psicológico y religioso, para atender las necesidades cambiantes de la persona cuidada, en las que progresivamente se va adquiriendo habilidad hasta superar muchas veces a los más conocedores (17). con relación a las dimensiones de conocimiento y paciencia el estudio reportó que los cuidadores presentaron una alta puntuación. algunos autores han referido que la paciencia y el conocimiento pertinentes en la relación personal de cuidado se encuentran disponibles en cualquier cuidador potencial, y se desarrollan de manera casi “natural” a lo largo de la experiencia, en virtud del vínculo entre cuidador y sujeto cuidado, mientras que el valor puede constituir una cualidad que requiere condiciones particulares para su desarrollo. en la dimensión valor se encontraron puntuaciones bajas en ambos grupos inicialmente. en la segunda medición en los dos grupos hubo cuidadores que aumentaron su puntuación. el grado de valor puede estar afectado por el conocimiento limitado que se tiene en cuanto a las intervenciones como cuidador, lo cual restringe y genera un estado de incertidumbre frente a las experiencias de cuidado (25). a través del desarrollo de los diferentes talleres se evidenciaron los cambios generados en las cuidadoras al despertarles intereses, motivaciones hacia su propia valoración como seres humanos que tienen a su cargo una labor no reconocida por su pareja, familia e incluso por ellas mismas, quienes por su edad y su otro de los cambios observados fue el hacer evidente su necesidad de autocuidado, como también asignar responsabilidades a su familia en el rol de cuidador, y el poder reconocer y orientar las necesidades de afecto de los otros miembros de su familia. 209 cuidando a cuidadores familiares de niños en situación de discapacidad amparo montalvo-prieto, inna e. flórez-torres, diana stavro de vega condición de género requieren del reconocimiento social que les permita el desempeño de roles en espacios diferentes al de cuidador. otro de los cambios observados fue el hacer evidente su necesidad de autocuidado, como también asignar responsabilidades a su familia en el rol de cuidador, y el poder reconocer y orientar las necesidades de afecto de los otros miembros de su familia. esto es similar a lo reportado por giraldo y franco (26) quienes indican que el cuidado familiar y ser cuidador o cuidadora pasa inadvertido o invisible no solo para las personas que no tenían relación directa o indirecta con ello, sino aún para las mismas cuidadoras. los resultados obtenidos en el presente estudio contrastan con los hallazgos de barrera y cols. (20), quienes en un estudio que evaluó la efectividad del programa cuidando a los cuidadores, el cual incluyó la participación de cuidadores de personas adultas con enfermedad crónica, reportan un incremento en la habilidad de cuidado y en cada una de las dimensiones, en los grupos experimental y control, posterior a la implementación del programa. sin embargo, las narrativas de quienes participaron en el programa señalan un cambio más significativo que el reflejado por los datos numéricos de la aplicación del cai. conclusiones • los cuidadores del grupo experimental y del grupo control mostraron desde el inicio una alta habilidad; puede resultar útil considerar que en su mayoría los cuidadores le han dedicado a esta tarea una entrega casi absoluta, a pesar de no ser los únicos cuidadores. • los participantes del grupo experimental claramente mejoraron en términos generales sus puntuaciones en la habilidad de cuidado. el grupo control presentó cambios favorables a pesar de no participar en el programa. • la dimensión valor presentó las más bajas puntuaciones iniciales y, a su vez, fue la que se mostró más insensible a la intervención del programa. • no existe evidencia suficiente para concluir que el programa cuidando a los cuidadores aumentara significativamente el nivel de conocimiento, de valor y de paciencia de los cuidadores de la ciudad de cartagena. recomendaciones • a pesar de ser el único instrumento disponible en nuestro medio para medir la habilidad de cuidado de los cuidadores, se evidenció la necesidad de diseñar, proponer y evaluar un instrumento que sea de fácil manejo y comprensión para los futuros investigadores en nuestro medio. • para explicar los hallazgos relativos a la dimensión valor se recomienda no desestimar la posibilidad de problemas metodológicos asociados con el instrumento. • idealmente, futuros estudios deben contar con grupos de participantes cuya habilidad de cuidado sea claramente insuficiente y pueda por tanto verse favorecida con la intervención prevista. agradecimientos al grupo de cuidado al paciente crónico de la universidad nacional por su apoyo al desarrollo de la investigación en la costa atlántica. la dimensión valor presentó las más bajas puntuaciones iniciales y, a su vez, fue la que se mostró más insensible a la intervención del programa. 210 año 8 vol. 8 nº 2 chía, colombia octubre 2008 197-211 aquichan issn 1657-5997 referencias 1. barrera l, et ál. la habilidad de cuidado de los cuidadores familiares de personas con enfermedad crónica. invest. educ. enferm 2006; 24 (1): 36-46. 2. organización mundial de la salud. clasificación internacional de deficiencias, discapacidades y minusvalías (ciddm); 1980. disponible en http:// portal.educ.ar/debates/eid/docenteshoy/gruposheterogeneos/discapacidad-y-singularidad.php [fecha de consulta: febrero de 2007). 3. departamento nacional de estadísticas. disponible en http:// www.discapacidad.gov.co/estadisticas/ capacitacion.doc [fecha de consulta: febrero de 2007). 4. montalvo a, flórez i, stavro d. una mirada a la experiencia de cuidado de los cuidadores de niños en situación de discapacidad de la ciudad de cartagena. rev. unicarta 2007; 105 (1): 73-78. 5. barrera l. el cuidado del cuidador que afronta enfermedades crónicas. en: cuidado y práctica de enfermería. bogotá: unibiblos; 2000. p. 223-225. 6. merino s. calidad de vida de los cuidadores familiares que cuidan niños en situación de enfermedad crónica. avances en enfermería 2004; 22 (1): 39-46. 7. blanco d. habilidad de cuidado de los cuidadores principales de niños en situación de enfermedad crónica que consultan en la clínica colsánitas. avances en enfermería 2007; 25 (1): 19-32. 8. pinto n, barrera l, sánchez b. reflexiones sobre el cuidado a partir del programa “cuidando a los cuidadores”. aquichan 2005; 5 (1): 128-137. 9. pinto n. el reto de los cuidadores familiares de personas en situación crónica de enfermedad. en: cuidado y práctica de enfermería. bogotá: unibiblos; 2000. 172-183. 10. álvarez b. comparación de la calidad de vida de cuidadores familiares de personas que viven con el vih/sida y reciben terapia antirretroviral con la calidad de vida de los cuidadores familiares de personas con el vih/sida y no reciben terapia antirretroviral de honduras. avances en enfermería 2004; 22 (2): 6-18. 11. moreno me, nader a, lópez c. relación entre las características de los cuidadores familiares de pacientes con discapacidad y la percepción de su estado de salud. avances de enfermería 2004; 22 (1): 27-38. 12. escuredo b. cuidadores informales, necesidades y ayudas. rol de enfermería 2001; 24 (3): 26. 13. giraldo c, franco g. calidad de vida de los cuidadores familiares. aquichan 2006; 6 (1): 38-56. 14. nkongho n. the caring ability inventory. en: stricklan ol, waltz cf. measurement of nursing outcomes: measuring client self-care and coping skills. new york: springer; 1990. pp. 3-16. 15. sánchez b, barrera l, pinto n. colciencias y universidad nacional de colombia. programa “cuidado a los cuidadores”; 2004. 16. zabala m, et ál. características sociodemográficas de los cuidadores de ancianos. en: simposio antropología de la vejez. chile; 2001. 17. sánchez b. habilidad de cuidado de los cuidadores de personas en situación de enfermedad crónica. en: grupo de cuidado. el arte y la ciencia del cuidado. bogotá: unibiblos; 2002. p. 373-855. 18. barrera l, pinto n, sánchez b. habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica: comparación de géneros. actualizaciones en enfermería 2006; 9 (2): 9-13. 19. garcía et ál. el impacto de cuidar en la salud y la calidad de vida de las mujeres. disponible en: http:// www.scielosp.org/scielo.php. 18 (supl. 2): 83-92. [fecha de consulta: abril de 2008]. 20. barrera l, pinto n, sánchez b. evaluación de un programa para fortalecer a los cuidadores familiares de enfermos crónicos. revista de salud pública 2006; 8 (2): 141-152. 21. díaz l. cómo perciben los cuidadores la situación crónica de enfermedad del niño. en: el arte y la ciencia del cuidado. bogotá: unibiblos; 2002. p. 227-229. 22. sánchez b. la cronicidad y el cuidado familiar, un problema de todas las edades: los cuidadores de ancianos. avances en enfermería 2004; (22): 153-59. 23. griffin, m. cuidando a los cuidadores: el rol de enfermería en un establecimiento corporativo. geriar nurs 1993; 14 (4): 200-204. 211 cuidando a cuidadores familiares de niños en situación de discapacidad amparo montalvo-prieto, inna e. flórez-torres, diana stavro de vega 24. venegas b. habilidad del cuidador y funcionalidad de la persona cuidada. rev. aquichan 2006; 6 (1): 133-147. 25. montalvo a. los cuidadores de pacientes con alzheimer y su habilidad de cuidado en la ciudad de cartagena. avances en enfermería 2007; 25 (2): 90-100. 26. giraldo c, franco g. calidad de vida de los cuidadores familiares. rev. aquichan 2006; 6 (1): 38-53. 1 edison vitório de souza júnior1 cristiane dos santos silva2 poliana souza lapa3 laís emily souza trindade4 benedito fernandes da silva filho5 namie okino sawada6 influência da sexualidade na saúde dos idosos em processo demencial: revisão integrativa 1 https://orcid.org/0000-0003-0457-0513. universidade de são paulo, brasil. edison.vitorio@usp.br 2 https://orcid.org/0000-0003-3822-1397. universidade norte do paraná, brasil. 3 https://orcid.org/0000-0002-9262-7745. universidade estadual do sudoeste da bahia, brasil. 4 https://orcid.org/0000-0002-8760-5736. universidade estadual do sudoeste da bahia, brasil. 5 https://orcid.org/0000-0003-2464-9958. universidade estadual do sudoeste da bahia, brasil. 6 https://orcid.org/0000-0002-1874-3481. universidade federal de alfenas, brasil. recebido: 29/10/2019 submetido: 19/11/2019 aceito por pares: 14/01/2020 aceito: 23/01/2020 doi: 10.5294/aqui.2020.20.1.6 para citar este artículo / to reference this article / para citar este artigo souza júnior ev, silva cs, lapa os, trindade les, silva filho bf, sawada no. influence of sexuality on the health of the elderly in process of dementia: integrative review. aquichan. 2020;20(1):e2016. doi: https://doi.org/10.5294/aqui.2020.20.1.6 resumo objetivo: verificar a influência da sexualidade na saúde dos idosos em processo demencial. materiais e métodos: trata-se de uma revisão integrativa. realizou-se uma busca criteriosa em nove bases de dados, no entanto somente cinco delas disponibilizaram artigos que atendessem ao escopo do estudo: medline, lilacs, bdenf, scopus e wos. adotaram-se os descritores em ciências da saúde (decs): “sexualidade”, “demência” e “idoso”, e os descritores catalogados no medical subject headings (mesh): “sexuality”, “dementia” e “aged”. após a aplicação dos critérios de inclusão, foram selecionados oito artigos que compuseram a amostra do estudo. resultados: o exercício da sexualidade influencia, com alguns efeitos benéficos, a saúde de idosos com demência por proporcionar, especialmente, melhor percepção de qualidade de vida e bem-estar. contudo, não se pode generalizar em virtude da insuficiência metodológica evidenciada nos año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2016 temática: promoção e prevenção. contribuições para a disciplina: fica evidente a implicação do estudo para o aprimoramento das práticas assistenciais em saúde da população idosa. os resultados aqui revelados indicam que o exercício da sexualidade entre os idosos com demência apresenta alguns efeitos benéficos para a saúde. no entanto, não se pode generalizar, em virtude da insuficiência metodológica evidenciada nos estudos encontrados para a construção desta revisão. todavia, os profissionais de saúde podem orientar e incentivar o exercício da sexualidade sempre que for desejado pelos idosos como cumprimento da proposta do envelhecimento ativo, que inclui a temática em seus planos de cuidado. assim, será possível agregar melhor qualidade aos anos de vida, especialmente nos indivíduos que cursam com algum tipo de demência. espera-se que este estudo estimule o desenvolvimento de mais pesquisas com maior rigor metodológico para garantir a reprodutibilidade dos resultados. https://orcid.org/0000-0003-0457-0513 https://orcid.org/0000-0003-3822-1397 https://orcid.org/0000-0002-9262-7745 https://orcid.org/0000-0002-8760-5736 https://orcid.org/0000-0003-2464-9958 https://orcid.org/0000-0002-1874-3481 https://doi.org/10.5294/aqui.2020.20.1.6 https://orcid.org/0000-0003-0457-0513 https://orcid.org/0000-0003-3822-1397 https://orcid.org/0000-0002-9262-7745 https://orcid.org/0000-0002-8760-5736 https://orcid.org/0000-0003-2464-9958 https://orcid.org/0000-0002-1874-3481 https://doi.org/10.5294/aqui.2020.20.1.6 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2016 estudos encontrados para a construção desta revisão. conclusões: devido à limitação de estudos que abordassem a temática e à insuficiência metodológica dos que foram incluídos na presente revisão, torna-se necessário o desenvolvimento de pesquisas que demonstrem com profundidade a influência da sexualidade nessa população, pois poderá se constituir como mais uma abordagem de promoção e proteção da saúde para os idosos com demência. palavras-chave (fonte: decs) saúde pública; saúde do idoso; demência; qualidade de vida; promoção da saúde. influencia de la sexualidad en la salud del anciano con demencia: revisión integradora resumen objetivo: averiguar la influencia de la sexualidad en la salud de los ancianos con demencia. materiales y métodos: se trata de una revisión integradora. se realizó una búsqueda cuidadosa en nueve bases de datos; sin embargo, solo cinco bases de datos proporcionaron artículos que cumplían con el alcance del estudio: medline, lilacs, bdenf, scopus y wos. se adoptaron los descriptores en ciencias de la salud (decs): “sexualidad”, “demencia” y “ancianos”, y los descriptores catalogados en los medical subject headings (mesh): “sexuality”, “dementia” y “aged”. luego de aplicar los criterios de inclusión, seleccionamos ocho artículos que comprendían la muestra del estudio. resultados: el ejercicio de la sexualidad influye en la salud de los ancianos con demencia con algunos efectos beneficiosos, ya que proporciona, especialmente, una mejor percepción de la calidad de vida y el bienestar. sin embargo, no se puede generalizar en razón de la insuficiencia metodológica evidenciada en los estudios encontrados para la construcción de esta revisión. conclusiones: debido a la limitación de los estudios que abordan el tema y la insuficiencia metodológica de los incluidos en la presente revisión, es necesario desarrollar investigaciones que demuestren con profundidad la influencia de la sexualidad en esta población, ya que se puede constituir como otro enfoque para la promoción y protección de la salud de los ancianos con demencia. palabras clave (fuente: decs) salud pública; salud del anciano; demencia; calidad de vida; promoción de la salud. 3 influência da sexualidade na saúde dos idosos em processo demencial: revisão integrativa l edison vitório de souza júnior e outros influence of sexuality on the health of the elderly in process of dementia: integrative review abstract objective: this work sought to inquire on the influence of sexuality on the health of the elderly during dementia. materials and methods: this was an integrative review. a careful search was conducted in nine databases; however, only five databases provided articles fulfilling the scope of the study: medline, lilacs, bdenf, scopus, and web of science (wos). the health science descriptors (decs) were adopted: “sexualidad”, “demencia” and “anciano”, and the descriptors cataloged in the medical subject headings (mesh): “sexuality”, “dementia” and “aged”. after applying the inclusion criteria, eight articles were selected to comprise the study sample. results: the practice of sexuality influences upon the health of the elderly with dementia with some beneficial effects, given that it provides, especially, better perception of quality of life and wellbeing. nevertheless, it cannot be generalized due to methodological insufficiency evidenced in the studies found to construct this review. conclusions: due to the limitation of studies addressing the theme and the methodological insufficiency of those included in this review, it is necessary to conduct research that shows in depth the influence of sexuality on this population, given that it can be constituted as another approach for the promotion and protection of health in the elderly with dementia. keywords (source: decs) public health; health of the elderly; dementia; quality of life; health promotion. año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2016 4 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2016 aquichan issn 1657-5997 eissn 2027-5374 introdução a sexualidade é definida como um constructo multidimensional em que o indivíduo expressa sentimentos, pensamentos e cognição, como as demonstrações de intimidade, o carinho, o amor, o toque, o afeto, o abraço, inclusive o contato sexual propriamente dito (1-5). o erotismo se destaca como o maior atributo da sexualidade (6), mas não está ligado somente a ela, uma vez que indica também a exaltação do sexo no contexto das artes, por meio da pintura e da literatura, por exemplo. essa característica distingue o erotismo da pornografia, visto que esta última tem maior preocupação com o ato sexual do que com os aspectos estéticos, presentes no erotismo (7). nesse sentido, “o erotismo é uma arte que tem como matéria-prima o ato sexual, visto de maneira produzida e bela, sem vulgaridade, ou seja, sem tratar o sexo de forma banal ou medíocre, e sim de maneira bonita e elegante” (8:30). desse modo, há uma separação entre ele e o ato sexual, além de estar associado a uma dimensão de fantasias que revela todas as atividades amorosas e sexuais do indivíduo (9). além disso, vale destacar que o erotismo também está incluso no campo da sexualidade (10). considera-se que a sexualidade seja uma necessidade humana básica, essencial para a saúde (11, 12), para a qualidade de vida (13-17) e para o bem-estar (18, 19), cuja expressão se inicia no nascimento (19), permanece na velhice (1, 20, 21) e se encerra apenas com a morte do indivíduo (22). diante disso, não há faixa etária em que a sexualidade é extinta. pelo contrário, a maioria dos idosos refere manutenção dos interesses sexuais, ainda que sua expressão possa sofrer influência do declínio hormonal observado fisiologicamente na velhice (23). isso quer dizer que, embora os idosos sofram declínio de suas funções hormonais e orgânicas, que refletem no desempenho sexual, como a falta de lubrificação vaginal e a dificuldade de ereção, eles continuam capazes de desfrutar a sexualidade de forma satisfatória. define-se como idoso o indivíduo com idade igual ou superior a 65 anos em países economicamente desenvolvidos e 60 anos ou mais em países em desenvolvimento (24). a transição demográfica da população idosa está sendo modificada e um dos fatores determinantes é a redução das taxas de mortalidade, em virtude, principalmente, da implementação de políticas públicas de proteção e promoção da saúde. em decorrência disso, há um aumento na proporção de idosos, o que provoca significativas alterações na estrutura etária da população (25), estimando-se que, até 2050, o quantitativo de idosos aumentará de 12,3 % para 21,5 % da população mundial (26). com o processo do envelhecimento, volta-se a atenção à saúde dessa população, com a inclusão de todos os aspectos que determinam e condicionam a sua saúde, como a sexualidade (27). há algumas décadas, pensava-se que os idosos, mesmo que saudáveis, não tinham interesse em relacionar-se sexualmente. entretanto, nos últimos anos, esse pensamento vem sendo modificado, visto que são amplamente divulgados os benefícios da atividade sexual como a promoção do bem-estar físico e psicológico, além da redução de problemas físicos e mentais associados ao envelhecimento (28). os idosos revelam que a sexualidade se constitui em parte integrante de sua identidade, relações sociais e saúde mental. a intimidade e as relações interpessoais, além de promoverem benefícios quanto à manutenção do humor e à redução das incapacidades, promovem melhor percepção de qualidade de vida e atuam como fator protetor para diversas doenças, como a artrite (23). entretanto, ao contrário do que se proclamou durante tanto tempo, a capacidade de viver plenamente a sexualidade não se perde com a idade, apenas se modifica (24). todavia, devido ao julgamento e à vigilância que a sociedade mantém sobre os idosos, imputando-os que somente as pessoas mais jovens são condicionadas a vivenciar a sexualidade, eles acabam inibindo sua identidade sexual, que deveria ser expressa com naturalidade. em decorrência dessa inibição, a saúde mental do indivíduo pode ser afetada por não se sentir permitido em realizar tal ato (29). a crença de que os idosos são assexuados e não possuem desejos sexuais está fortemente presente na sociedade (23, 30-38), inclusive entre os profissionais da saúde (23, 30). diante disso, justifica-se, em partes, a limitação quantitativa de estudos que abordam a sexualidade na velhice. além disso, quando se trata da sexualidade entre idosos com demência, a limitação se torna mais evidente (31). destaca-se que o envelhecimento populacional se torna um problema no momento em que a sociedade não está apta a encarar seu próprio processo de envelhecimento e, como consequên5 influência da sexualidade na saúde dos idosos em processo demencial: revisão integrativa l edison vitório de souza júnior e outros cia, exprime posturas negativas em relação a essa etapa do ciclo vital. desse modo, torna-se imprescindível incrementar os estudos voltados aos preconceitos contra a velhice, além dos estereótipos vinculados à sexualidade nessa idade, por serem temas de relevância para a saúde pública e pouco abordados no meio científico (26). os idosos que vivem com algum tipo de demência são erroneamente considerados inaptos para a prática de qualquer tipo de ato sexual e incapazes de sentir prazer. além do mais, a maioria dos estudos que se aproxima dessa temática se refere ao chamado “comportamento sexual inadequado” (39), decorrente de perturbações cerebrais que desencadeiam processos de hipersexualidade, que leva o indivíduo a praticar atos libidinosos, como a pedofilia e a promiscuidade (40). nesse sentido, uma maior compreensão sobre a vivência da sexualidade na velhice apresenta potencial significativo para promover melhor qualidade de vida das pessoas com demência (30). considerando a importância da temática, a limitação de estudos publicados e a necessidade de reorientar as práticas profissionais para a promoção e proteção da saúde do idoso, elaborou-se a seguinte questão de pesquisa: há influência da sexualidade na saúde dos idosos em processo demencial? no intuito de responder a ela, objetivou-se, por meio deste estudo, verificar a influência da sexualidade na saúde dos idosos em processo demencial. materiais e métodos trata-se de uma revisão integrativa da literatura, caracterizada por representar o mais alto grau de abrangência dentre as revisões, pois permite a inclusão de artigos com diferentes delineamentos metodológicos para promover a compreensão completa do objeto estudado, o que inclui informações da literatura teórica e empírica (41). a revisão foi construída por meio da estratégia pico — sigla metodológica para se referir aos seguintes elementos: problema, intervenção, controle ou comparação e desfecho. trata-se de um método sistemático que auxilia na identificação de palavras-chave relevantes para a temática e, por consequência, aumenta a possibilidade de encontrar estudos estritamente relacionados à questão de pesquisa, o que reduz vieses e evita a realização de buscas desnecessárias (42, 43). desse modo, no presente estudo, o primeiro elemento (p) consistiu em idosos com demência; o segundo (i), na vivência da sexualidade e o quarto elemento (o), na influência da sexualidade na saúde. destaca-se que o terceiro elemento (c) não foi adotado neste estudo pelo fato de se referir à comparação/controle. o levantamento bibliográfico foi realizado em setembro de 2019 em nove bases de dados: biblioteca virtual em saúde (bvs), medical literature analysis and retrieval system online (medline), scopus, scientific electronic library online (scielo), literatura latino-americana e do caribe em ciências da saúde (lilacs), base de dados em enfermagem (bdenf), índice bibliográfico espanhol de ciências de saúde (ibecs), science direct e web of science. adotaram-se os descritores em ciências da saúde (decs): “sexualidade”, “demência” e “idoso”, além dos descritores catalogados no medical subject headings (mesh): “sexuality”, “dementia” e “aged”, ambos intercalados com o operador booleano and. a busca, seleção e extração dos artigos foram realizadas pelos cinco primeiros autores. para a busca, os autores foram submetidos a duas etapas de sorteio presenciais, para que todos os integrantes tivessem a mesma probabilidade, diferente de zero, de serem escolhidos. a primeira etapa consistiu em sortear as bases de dados entre os autores, o que levou a cinco bases definidas para o autor correspondente realizar a busca, a seleção e a extração. ainda assim, restaram-se quatro bases que foram alocadas para a segunda etapa do sorteio. nesta, as bases restantes foram elencadas em ordem alfabética e foram sorteados os autores que assumiriam a segunda responsabilidade de buscar, selecionar e extrair os artigos. após os autores notificarem o término da busca, da seleção e da extração, os artigos foram submetidos à leitura crítico-reflexiva, e os principais elementos foram registrados em dois quadros sinópticos. logo após, foi realizado um rodízio, de tal forma que 100 % dos artigos foram lidos por todos os autores, com suas respectivas contribuições nos quadros citados. ressalta-se que a última autora contribuiu na revisão do conteúdo, na adequação científica, na análise geral e na aprovação da versão final. para sistematizar o percurso metodológico, foi utilizado o fluxograma prisma (44) e incluídos os estudos que contemplaram os seguintes critérios de inclusão: artigos de diferentes abordagens metodológicas publicados nos últimos seis anos 6 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2016 aquichan issn 1657-5997 eissn 2027-5374 (2014-2019), sem restrições idiomáticas, disponíveis para download e que abordassem informações relevantes sobre como a sexualidade influencia na saúde dos idosos com demência. ressalta-se que foram excluídos todos os estudos que abordassem a hipersexualidade decorrente de demências, por entender que tal situação se configura como um estado mórbido de alterações comportamentais (45), o que se desvia totalmente do tema estudado. após a aplicação dos critérios e a triagem dos artigos, selecionaram-se nove estudos para a discussão, conforme ilustrado na figura 1. figura 1. prisma — fluxograma do percurso metodológico (44) resultados a análise dos estudos selecionados mostrou uma lacuna científica sobre a temática, visto que apenas 2,5 % foram elegíveis para responder ao objetivo proposto (23, 47, 48, 49-53). identificou-se, ainda, que a maioria das pesquisas (75 %) abordou a sexualidade de idosos com ou sem demência que vivem em lares residenciais (23, 48, 49-52). as demais características dos estudos estão descritas nos quadros 1 e 2. discussão considera-se a sexualidade um componente vitalício do ser humano (54, 55) e, quando é vivenciada de forma satisfatória pelos idosos com demência, proporciona saúde e qualidade de vida (49, 51, 53), preserva a identidade e a autonomia, reduz as taxas de solidão e os sentimentos de medo (23), diminui a sensibilidade dolorosa, aumenta a capacidade de relaxamento e reduz os índices de depressão (48); além disso, melhora a saúde mental e aumenta o desempenho em algumas dimensões cognitivas avaliadas por meio de testes funcionais (52, 56, 57). trata-se, portanto, de um aspecto fundamental da experiência humana (48, 58), além de ser considerada uma vivência indispensável para o envelhecimento ativo (59). nessa perspectiva, é possível afirmar que a sexualidade se constitui em uma necessidade universal que transcende faixa etária, incapacidades ou declínios cognitivos (48). divulga-se, no âmbito científico, que a sexualidade e as relações íntimas são únicas e não há, até o momento, algo que possa substituí-las, nem mesmo as relações sociais ou as amizades de maneira geral (60). essa inferência aponta para a necessidade de valorizar a sexualidade na população idosa com demência, visto que sua experiência é única e obedece a uma necessidade fisiológica e emocional de cada indivíduo, influenciando nos aspectos de autoimagem, saúde mental e relações sociais (34). corroborando essa afirmação, estudos (61, 62) revelam que, para muitos idosos com e sem demência, a sexualidade ainda é importante. além do mais, os direitos à privacidade e à expressão sexual estão recebendo maior reconhecimento e aceitação científica, visto que são partes importantes na vida dos idosos em processo demencial (63). fonte: elaboração própria. vale destacar que a construção deste estudo se pautou nas seguintes etapas: identificação do tema e seleção da questão de pesquisa; estabelecimento de critérios para a inclusão e exclusão de estudos/amostragem ou busca na literatura; definição das informações a serem extraídas dos estudos selecionados/ categorização dos estudos; avaliação dos estudos incluídos; interpretação dos resultados; apresentação da revisão/síntese do conhecimento (46:9). por se tratar de um estudo que não envolve a participação de seres humanos e que foi construído por meio de revisão da literatura, dispensou-se a avaliação por um comitê de ética em pesquisa, conforme estabelece a resolução 510, de 7 de abril de 2016, do conselho nacional de saúde do brasil. bvs (n = 71) medline (n = 461) scopus (n = 4) scielo (n = 1) lilacs (n = 9) bdenf (n = 1) ibecs (n = 0) (n = 1.538) (n = 1) science direct web of science artigos encontrados após a aplicação dos criterios de inclusão bvs (n = 15) medline (n = 297) scopus (n = 1) scielo (n = 0) lilacs (n = 1) bdenf (n = 1) ibecs (n = 0) (n = 0) (n = 1) science direct web of science artigos availados com a leitura do título, do resumo e do ano (n = 316) artigos availados na íntegra para elegibilidade (n = 11) artigos incluídos no estudo (n = 8) artigos excluídos por duplicação e/ou inadequação aos critérios de inclusão após a leitura completa do título e do resumo (n = 316) artigos excluídos por inadequação ao tema após a leitura do texto completo (n = 3) in cl us ão el eg ib ili da de s el eç ão id en ti fi ca çã o 7 influência da sexualidade na saúde dos idosos em processo demencial: revisão integrativa l edison vitório de souza júnior e outros quadro 1. características dos estudos selecionados autores (ano) título objetivos metodologia participantes do estudo wilkins jm (2015) more than capacity: alternatives for sexual decision making for individuals with dementia (23) não informado. fórum. não possui. lima cfm, trotte lac, souza ta, ferreira amo, caldas gp (2017) sexualidade do cônjuge que cuida do idoso demenciado: revisão integrativa da literatura (47) identificar e analisar a produção científica da sexualidade do cônjuge que cuida do idoso em processo demencial. revisão integrativa de artigos científicos indexados nas bases lilacs, medline, cinahl e web of science. não possui. grigorovich a, kontos p (2018) advancing an ethic of embodied relational sexuality to guide decision-making in dementia care (48) não possui. fórum. não possui. roelofs ts, luijkx kg, embregts pj (2015) intimacy and sexuality of nursing home residents with dementia: a systematic review (49) fornecer uma visão geral estruturada de todos os elementos da intimidade em todo o espectro de intimidade e sexualidade em pessoas com demência, no contexto de atendimento residencial especializado. revisão sistemática com artigos indexados na pubmed, psychinfo, e medline. não possui. iacub r, rodríguez r (2015) the eroticism of persons with dementia in nursing homes for the elderly (50) apresentar os modelos com os quais as instituições de repouso organizam o erotismo de seus moradores, principalmente para aqueles que sofrem de demências. não informado. não informado. roelofs ts, luijkx kg, embregts pj (2019) love, intimacy and sexuality in residential dementia care: a spousal perspective (51) explorar as experiências e necessidades dos cônjuges do lar de idosos residentes com demência, relacionados a amizade, amor, intimidade e sexualidade. pesquisa qualitativa. nove cônjuges de pessoas com demência. lindau st, dale w, feldmeth g, gavrilova n, langa km, makelarski ja et al. (2018) sexuality and cognitive status: a u.s. nationally representative study of home-dwelling older adults (52) determinar padrões e prevalência de comportamento sexual, problemas e atitudes em indivíduos com diferentes condições cognitivas. estudo longitudinal que usa dados da national social life, health, and aging project. 3.196 participantes. cindy laj, wendy m (2016) sexuality & dementia: an elearning resource to improve knowledge and attitudes of aged-care staff (53) avaliar a facilidade de uso, a qualidade e a eficácia de uma intervenção educacional para aumentar o conhecimento e melhorar as atitudes dos funcionários em relação à expressão da sexualidade por pessoas com demência que vivem em instalações residenciais para idosos. estudo de método misto que utiliza intervenções e questionários educacionais on-line, seguido de uma entrevista semiestruturada. estudantes de graduação em enfermagem, enfermeiros, cuidadores e terapeutas. fonte: elaboração própria. 8 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2016 aquichan issn 1657-5997 eissn 2027-5374 diante da diversidade de desejos sexuais presentes nos idosos com demência, deve-se, então, distinguir quando o comportamento sexual é apropriado ou inapropriado. as expressões consideradas apropriadas são as que devem ser estimuladas, enquanto os comportamentos inapropriados devem ser reprimidos para evitar danos aos envolvidos, com destaque para o idoso em processo demencial. logo, o desafio deve ser focado no exercício saudável e seguro da sexualidade desses indivíduos e acompanhar suas repercussões na sua saúde. os comportamentos inapropriados são definidos como aqueles caracterizados como inseguros, perturbadores e que prejudicam o cuidado, como as expressões verbais sexualmente explícitas e os atos libidinosos (agarrar, expor genitália, tocar, masturbar-se em público, dentre outros) (23, 64, 65). de outro modo, evidencia-se que a expressão sexual entre idosos com demência caracteriza-se por ser uma vivência saudável e que pode ser incentivada se assim o desejarem. entretanto, no intuito de evitar abusos, respeitar a sua autonomia e garantir a segurança no exercício da sexualidade (23), esse incentivo deve ser acompanhado de mecanismos capazes de avaliar o grau de consentimento dos envolvidos. a dúvida central é definir o momento exato em que o declínio cognitivo indica a necessidade de limitar a vivência da sexualidade (50). para isso, os aspectos éticos relacionados à tomada de decisão podem ser úteis na prática em que há essa situação (30). o princípio que direciona o cuidado aos idosos com demência ante a sexualidade é a proteção e observa-se que tanto as equipes de saúde quanto os familiares adotam esse comportamento protetor no intuito de prevenir abusos físicos ou mentais (49). além do mais, existem relatos na literatura que o parceiro saudável demonstra constrangimento em exercer práticas sexuais com o cônjuge que, em decorrência do processo demencial, não é mais capaz de reconhecê-lo. cita-se também que o cônjuge quadro 2. categorização dos estudos selecionados artigo principais resultados dos autores a (23) a intimidade sexual pode contribuir para o alívio da solidão e do medo relacionados ao processo de demência, além de preservar a identidade do idoso em sua família, diante dos prejuízos decorrentes do processo demencial como a tomada de decisões financeiras. b (47) há a redução dos impactos da demência na vida de um casal de idosos que vivenciam as práticas sexuais, e o paciente evolui de forma mais satisfatória quando se encontra sexualmente ativo, ou seja, o sexo pode influenciar como um fator de equilíbrio a partir da boa compreensão emocional entre o casal. c (48) a sexualidade também tem efeitos benéficos para os idosos, como prazer e intimidade, diminuição da sensibilidade à dor, aumento do relaxamento e níveis mais baixos de depressão. e (49) a expressão da intimidade e da sexualidade é considerada um elemento vitalício do ser humano e é reconhecida cientificamente sua influência na qualidade de vida. a abertura de discussão e uma visão mais liberal entre as partes interessadas sobre a temática são pré-requisitos para alterar a subcultura das equipes de atendimento. isso permitiria que os equívocos sobre intimidade e sexualidade nos idosos com demência fossem abordados com mais facilidade e, dessa forma, promoveria melhorias na qualidade de vida dos idosos que vivem em lares residenciais. f (50) o foco na pessoa com demência deve investigar todos os aspectos que melhoram sua qualidade de vida, entre os quais o erotismo certamente é relevante. nesse sentido, o papel das residências é garantir o direito de manifestar o erotismo e a sexualidade, por meio de um controle que proteja os residentes que sofrem de demência e permita qualidade de vida para eles. desse modo, a sexualidade e suas variáveis quanti-qualitativas, como o erotismo, influenciam na melhor percepção de qualidade de vida dos idosos. g (51) a amizade, o amor, a intimidade e a sexualidade ainda estão incorporados na vida dos casais. ressalta-se que são necessários programas educacionais para a equipe de cuidados residenciais no intuito de aprimorar os conhecimentos e habilidades adequados e, com isso, otimizar a qualidade de vida das pessoas com demência e seus cônjuges por meio da assistência integral, a qual envolve o estímulo e o apoio à sexualidade. h (52) nosso estudo revelou dados semelhantes a um de base populacional realizado na europa, no qual se verificou que a atividade sexual na velhice está associada a melhores condições de saúde mental, a melhor qualidade de vida, a menores taxas de solidão e, nos homens ingleses, a melhor desempenho em alguns aspectos do teste da função cognitiva. i (53) a facilitação de um ambiente de assistência que apoie a verbalização e expressão de preferência sexual, necessidade e desejo de pessoas com demência pode melhorar a sua qualidade de vida, a saúde e o bem-estar, bem como reduzir as tensões em potencial entre funcionários, idosos e familiares. fonte: elaboração própria. 9 influência da sexualidade na saúde dos idosos em processo demencial: revisão integrativa l edison vitório de souza júnior e outros do sexo masculino relata sentimentos de culpa por se relacionar sexualmente com sua esposa sem ter o conhecimento de sua real vontade ou consentimento, uma vez que há o declínio da capacidade decisória à medida que a demência avança. portanto, notam-se dilemas referentes a conflitos entre a proteção dos envolvidos e a satisfação dos desejos sexuais dos casais (39). no caso dos lares residenciais, apoiar a sexualidade entre os idosos implica diversos dilemas éticos (66), uma vez que se trata de um ambiente laboral para profissionais e doméstico para os idosos residentes. quando se trata de pessoas com demência, a complexidade da temática aumenta, no sentido de equilibrar a proteção contra danos e respeitar a autonomia dos envolvidos (48). além do mais, tais vivências tornam-se ainda mais complicadas, visto que, nesses locais, a sexualidade e a atividade sexual raramente são incentivadas. justifica-se tal fato, pois alguns profissionais ainda são adeptos à percepção de que sua vivência deve ser evitada (48, 67). no entanto, ressalta-se que o objetivo do cuidado em longo prazo deve-se pautar na preservação e restauração das capacidades comunicativas e dignificar a identidade do idoso com demência. nessa perspectiva, torna-se necessária a criação de diretrizes nas instituições residenciais no intuito de sistematizar e direcionar o cuidado aos idosos nesse contexto (48). além disso, as equipes que atuam nesses locais devem receber capacitações com o objetivo de aperfeiçoar conhecimentos e habilidades para que, desse modo, possam otimizar a qualidade de vida e o bem-estar das pessoas com demência e seus cônjuges (51, 53). outro aspecto importante a ser considerado diz respeito à formação profissional na temática. o corpo docente deve incluir a sexualidade, o envelhecimento e a demência na grade curricular de formação e no treinamento profissional, a fim de evitar a centralidade assistencial nos aspectos patológicos e proporcionar uma visão holística da pessoa idosa (30, 32). nesse cuidado holístico, destaca-se a sexualidade por esta se constituir fator de equilíbrio entre o casal que vivencia a demência (47), pelo fato de a maioria desses idosos ser sexualmente ativa (56) e pela importância da sexualidade na sua reafirmação na sociedade, o que melhoraria a autoestima e a saúde mental deles (23). um estudo que sustenta a inferência de que os profissionais não estão preparados para abordar a temática é o que foi realizado em nottingham, reino unido. os pesquisadores investigaram atitudes de enfermeiros e cuidadores ante a sexualidade de idosos que vivem em lares residenciais. os resultados apontaram que as variáveis “idade jovem” e “tempo de experiência laboral menor que cinco anos” foram as que mais se associaram às posturas negativas e restritivas quando o assunto foi sexualidade na velhice (68). no entanto, reconhece-se que a educação e a formação sobre o envelhecimento devem ser realizadas desde os anos iniciais de vida, o que contribuirá para a redução dos preconceitos contra os idosos (26). além do mais, é imprescindível incrementar a atuação das equipes de saúde junto aos idosos no intuito de reconstruir paradigmas e reduzir atitudes não permissivas para que se aumente a qualidade de vida dessa população (26). os idosos precisam liberar-se das normas sexistas e que desvalorizam a velhice no contexto da sexualidade, preestabelecidas pela sociedade e pelas redes midiáticas (69). em compensação, aspectos biológicos, psicológicos e sociais devem ser considerados quando se trata da sexualidade dos idosos, a fim de que estes possam desfrutá-la de forma integral e natural (69). vale destacar que a temática é promissora e aponta para a necessidade de mais estudos que contribuam para a inovação de intervenções científicas no cuidado aos idosos com demência quanto à sexualidade (47). além do mais, as evidências éticas, políticas e legais no tocante à sexualidade de pessoas com e sem demência sustentam a ideia de que a sexualidade entre essa população consiste em uma necessidade integral e legítima (1). talvez, na perspectiva de reconhecer a importância da sexualidade na vida dos idosos, nos últimos anos, a ciência tenha avançado nas opções terapêuticas para combater a disfunção sexual. citam-se, como exemplo, os métodos cirúrgicos, as próteses penianas, o tratamento hormonal, a psicoterapia e os medicamentos orais ou medicamentos injetáveis diretamente no órgão genital masculino (70). por fim, revelou-se limitação quantitativa de artigos sobre a temática. a maioria dos estudos tem enfoque nos comportamentos sexuais inapropriados e na hiper ou hipossexualidade decorrente do processo demencial, contribuindo com restritas reflexões sobre os benefícios da sexualidade entre idosos que vivem com demência. uma pesquisa (39) evidenciou poucos estudos com delineamento metodológico significativo e ausência de instrumentos fidedignos para a avaliação, sendo que a maioria dos estudos 10 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2016 aquichan issn 1657-5997 eissn 2027-5374 encontrados se referiu a fóruns e a revisões da literatura. assim, torna-se necessário o desenvolvimento de pesquisas que demonstrem com profundidade a influência da sexualidade nessa população, pois poderá se constituir como mais uma abordagem de promoção e proteção da saúde para os idosos com demência. conclusões os resultados indicam que o exercício da sexualidade entre os idosos com demência apresenta alguns efeitos benéficos para a saúde. no entanto, não se pode generalizar, em virtude da insuficiência metodológica evidenciada nos estudos encontrados para a construção desta revisão. todavia, os profissionais de saúde podem orientar e incentivar seu exercício sempre que for desejado pelos 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https://doi.org/10.1111/j.1743-6109.2011.02511.x https://doi.org/10.1016/j.jaging.2017.01.002 https://doi.org/10.1016/j.jsxm.2017.05.010 https://doi.org/10.1016/j.jsxm.2017.05.010 https://doi.org/10.3109/07380577.2013.865858 https://doi.org/10.1080/19419899.2012.713869 https://www.ncbi.nlm.nih.gov/pubmed/31482865 https://www.ncbi.nlm.nih.gov/pubmed/31482865 https://doi.org/10.1111/ijn.12317 https://doi.org/10.1007/s11940-016-0425-2 https://doi.org/10.1007/s11195-010-9187-z https://doi.org/10.1007/s11195-010-9187-z https://doi.org/10.1007/s10728-014-0287-2 https://doi.org/10.1111/hex.12509 https://doi.org/10.1111/hex.12509 https://doi.org/10.1080/14681990600637630 https://doi.org/10.1080/13691058.2018.1465203 http://www.dst.uff.br/revista20-1-2008/9.pdf http://www.dst.uff.br/revista20-1-2008/9.pdf nursing care for kidney transplant patients: a scoping review article nursing care for kidney transplant patients: a scoping review* cuidados de enfermería al paciente trasplantado renal: scoping review** cuidados de enfermagem ao paciente transplantado renal: scoping review*** 10.5294/aqui.2021.21.3.6 cintia capistrano teixeira rocha1 alcides viana da lima neto2 ana beatriz pereira da silva3 victor alexandre silva farias4 aurean d'eca junior5 richardson augusto rosendo da silva6 1 0000-0002-3755-8978. universidade federal do rio grande do norte, brazil. cintia.capistrano@ebserh.gov.br 2 0000-0001-6191-9465. universidade federal do rio grande do norte, brazil. alcides.neto@ebserh.gov.com 3 0000-0001-8339-6482. universidade federal do rio grande do norte, brazil. ana.beatriz.pereira.700@ufrn.edu.br 4 0000-0002-5173-7331. universidade federal do rio grande do norte, brazil. victor.farias.091@ufrn.edu.br 5 0000-0002-7675-412x. universidade federal do rio grande do norte, brazil. aurean.junior@ufma.br 6 0000-0001-6290-9365. universidade federal do rio grande do norte, brazil. richardson.augusto@ufrn.br * this article is derived from the ongoing doctoral thesis entitled “construction and validation of an educational technology for nursing care in renal transplant recipients”, which will be presented to the graduate program in nursing at the federal university of rio grande do norte, brazil. ** este artículo se deriva de la tesis doctoral en construcción titulada "construcción y validación de una tecnología educativa para el cuidado de enfermería en receptores de trasplante renal", que se presentará al programa de posgrado en enfermería de la universidade federal do rio grande do norte, brasil. *** este artigo é derivado da tese de doutorado em andamento intitulada "construção e validação de uma tecnologia educativa para o cuidado de enfermagem em receptores de transplante renal", que será apresentada ao programa de pós-graduação em enfermagem da universidade federal do rio grande do norte, brasil. received: 01/03/2021 sent to peers: 15/06/2021 approved by peers: 01/07/2021 accepted: 13/08/2021 theme: chronic care. contribution to the discipline: in this study, knowledge for nursing care to transplanted patients is mapped, in which a care practice based on scientific evidence, quality, and safety, is mapped, which allows better decision-making of the nurse. added to the importance of this theme is the identification of nursing care that permeates the three levels of complexity in health: primary, secondary tertiary, considering the different scenarios of the nursing team's performance. therefore, it is configured as an instrument that induces co-responsibility and care quality with the objective of continuous improvement of health effects, essential for the maintenance of the graft in the transplanted patient. para citar este artículo / to reference this article / para citar este artigo: rocha cct, neto avl, da silva abp, farias vas, d'eca junior a, silva rar. nursing care for kidney transplant patients: a scoping review. aquichan. 2021;21(3):e213x. doi: https://doi.org/10.5294/aqui.2021.21.3.6 abstract objectives: mapping nursing care in kidney transplant patients. materials and method: a scoping review was conducted according to the recommendations of the joanna briggs institute reviewers' manual. data were collected through 13 national and international databases from december 2020 to january 2021, following scientific rigor in the selection of the material. the pre-selection was made by reading the title, abstract and introductory text in advance; the materials included in this stage were read in full to define the content for the study. results: fifteen studies were included. of these, 60% are articles; dissertations, manuals, protocols, guidelines and bulletins totaled 40%> of the material studied. 86.6% of the material has a quantitative approach. regarding the methodological design, 73.3% were descriptive/transversal character studies. regarding the mapping of nursing care, it was possible to divide them into two categories: nursing care after kidney transplantation (immediate, mediated and late) and nursing care after kidney transplantation in primary health/ extra-hospital care. conclusions: it is concluded that the study allowed mapping nursing care to kidney transplant patients in the immediate, late and primary health care periods. keywords (source deos): kidney transplantation; nursing; nursing care; postoperative period; review literature as topic. resumen objetivos: mapear los cuidados de enfermería en pacientes trasplantados renais. materiales y método: scoping review conducida conforme las recomendaciones del joanna briggs institute reviewers' manual. se recolectaron los datos por medio de 13 bases de datos nacionales e internacionales de diciembre del 2020 a enero del 2021, siguiendo rigor científico en la selección del material. la preselección se dio mediante lectura previa de título, resumen y texto introductorio; los materiales incluidos en esta etapa se leyeron en la íntegra con el fin de definir el contenido para el estudio. resultados: se incluyeron 15 estudios. de estos, el 60 % es artículo; tesis, manuales, protocolos, directrices y boletines suman 40 % del material estudiado. el 86,6 % del material presenta enfoque cuantitativo. en cuanto al diseño metodológico, el 73,3 % son estudios de tipo descriptivos/transversales. con relación al mapeo de los cuidados de enfermería, se logró dividirlos en dos categorías: cuidados de enfermería post trasplante renal (inmediato, mediato y tardío) y cuidados de enfermería post trasplante renal en la atención primaria a la salud/extra hospitalaria. conclusiones: se concluye que el estudio permitió mapear los cuidados de enfermería al paciente trasplantado renal en los posoperatorios inmediato, mediato, tardío y en la atención primaria a la salud. palabras clave (fuente deos): trasplante de riñón; enfermería; atención de enfermería; periodo posoperatorio; literatura de revisión como asunto. resumo objetivos: mapear os cuidados de enfermagem em pacientes transplantados renais. materiais e método: scoping review conduzida conforme as recomendações do joanna briggs institute reviewers' manual. os dados foram coletados por meio de 13 bases de dados nacionais e internacionais de dezembro de 2020 a janeiro de 2021, seguindo rigor científico na seleção do material. a pré-seleção se deu mediante a leitura prévia de título, resumo e texto introdutório; os materiais incluídos nessa etapa foram lidos na íntegra a fim de definir o conteúdo para o estudo. resultados: foram incluídos 15 estudos. destes, 60 % são artigos; dissertações, manuais, protocolos, diretrizes e boletins somaram 40 % do material estudado. 86,6 % do material apresenta abordagem quantitativa. quanto ao desenho metodológico, 73,3 % eram estudos de tipo descritivos/transversais. quanto ao mapeamento dos cuidados de enfermagem, pôde dividi-los em duas categorias: cuidados de enfermagem póstransplante renal (imediato, mediato e tardio) e cuidados de enfermagem póstransplante renal na atenção primária à saúde/extra-hospitalar. conclusões: conclui-se que o estudo permitiu mapear os cuidados de enfermagem ao paciente transplantado renal nos pós-operatórios imediato, mediato, tardio e na atenção primária à saúde. palavras-chaves (fonte deos): transplante de rim; enfermagem; cuidado de enfermagem; período pós-operatório; literatura de revisão como assunto. introduction chronic kidney diseases (ckd) are quickly increasing worldwide and represent important events for public health, as a significant percentage of affected individuals progress to death. thus, this population demands a health system organized in terms of the appropriate process and structure, so that qualified care occurs, with treatment for such diseases, according to their needs (1). in the publication of ordinance 389/2014, which defines the criteria for the organization of the care line of the person with ckd, replacement therapies for kidney function are peritoneal dialysis, hemodialysis and kidney transplantation, when the individual has advanced ckd (2). kidney transplantation is a safe and successful surgical strategy consisting of the removal of a healthy kidney from one individual (living or deceased donor) to another (recipient), to maintain lost or ineffective kidney functions. kidney transplantation, although not the definitive "cure" for the disease, provides, among the therapeutic options, a better quality of life for chronic kidney patients (3-9). thus, considering kidney transplantation a substitute therapy, that is, a treatment for ckd, the kidney transplant recipient is still a person living with ckd. thus, it is necessary to understand that, throughout its treatment, it permeates the three levels of complexity of health care: primary, secondary and tertiary, according to the organization of the care line of the person with ckd. the success of kidney transplantation is directly linked to the health and support network in which the transplanted person is inserted. thus, during therapy, hospital admissions, high complexity procedures, follow-up of the specialized outpatient clinic and follow-up of primary care in its home location may be necessary (2, 10, 11). in this perspective, because it is a highly complex treatment, kidney transplantation requires specificities from the nursing team during their care (12-14). for this, nurses must systematize their actions, their care provided and interventions with periodic evaluation of patients. thus, the health care provided to the transplanted becomes quality and safe care, since this performance is based on scientific evidence (15, 16). in this sense, the nurse, being the leader of the nursing team, actively participates in all stages of the organ transplantation process, since his activities are broad and specialized, and the satisfactory evolution of the patient is related to the care provided to him and directly to the technical-scientific quality of the professional nurse. it has the task of coordinating the nursing service, early diagnosing problems, proposing solutions and developing health education activities in daily work focusing on technical-scientific deficiencies (17-23). when we think of nursing care for transplanted patients, the entire postoperative period stands out until outpatient and home care for graft maintenance (24). it is emphasized that, in this process, health professionals, patients and their families are involved. it is believed that follow-up should be performed both in primary health care (phc) and in specialized care. however, it is perceived, in practice, that transplanted patients are followed by phc from their municipalities in a non-effective way and that many professionals have disabilities regarding the competencies and skills in this theme. this care, besides being important for the strengthening of phc and being configured as an instrument that induces co-responsibility and quality to continuously improve health outcomes, is essential for the maintenance of the graft in the transplanted patient, because it allows better adhering to drug treatment as an action to protect health; promotion and prevention actions for diseases such as opportunistic infectious diseases; promotion of sexual health; health recovery actions such as reducing anxiety about doubts and treatment difficulties, and greater emotional support for the user and family involved; health rehabilitation actions (25-27). therefore, research on this theme is of great relevance to the health area, especially for nursing because they contribute to the quality of care provided to this patient audience, assistance that is still very specialized and little widespread in undergraduate studies. thus, it is essential to awaken, in nursing professionals, the care of the transplanted patient at any level of complexity in health. from the above, the study aims to map nursing care in kidney transplant patients through the scoping review. materials and method a scoping review was carried out that followed the methodology recommended by the joanna briggs institute (28). this methodological strategy is considered a robust approach to synthesize the relevant literature on health, being used to answer comprehensive questions and map evidence for practical decision-making and research (29). to this end, the following steps were performed in the study: 1) elaboration of the guiding question of the scoping review; 2) identification of relevant studies; 3) sorting of studies; 4) analysis of the collected data and 5) treatment, synthesis and presentation of the results. a protocol was elaborated for the structuring and development of the research, which contained the objective of the study, the research question, the eligibility criteria, the research strategy, the databases used for data collection, the definition of variables for data extraction and how the data would be presented. the entire protocol was based on the parameters of the participants, concept and context (pcc) strategy, in which "p" is population, "c", concept and "c", context. the scoping protocol was registered in the public domain (https://osf.io). thus, for the study in question, the defined population consisted of patients submitted to kidney transplantation; the concept is related to nursing care in kidney transplant recipients, and the context, to the postoperative period of kidney transplantation in hospitals and phc. all the results found in the scoping review on the subject were included from the pcc strategy. thus, the study has as a guiding question to identify which nursing care is described in the national and international literature to patients undergoing kidney transplantation. in addition, it has as inclusion criteria texts available in full in portuguese, spanish and english and texts that address nursing care in kidney transplant patients. initially, the descriptors were identified through the descriptors in health sciences (decs) — words in portuguese — and the medical subject headings (mesh) — terms in english — which make up the mnemonic pcc of this research. they are: (p) kidney transplantation or (c) nursing or nursing care and (c) postoperative period. the second and third stage of the scoping review that corresponds to the identification and selection of studies that fall under the research occurred from december 2020 to january 2021. pubmed, cumulative index of nursing and allied health (cinahl), web of science, latin american and caribbean health sciences (lilacs) and scielo databases were performed in the databases. for the research of studies in the grey literature, such as theses,  dissertations, manuals, protocols, guidelines and bulletins, we use the scientific repository of open access of portugal (rcaap), the thesis bank of the coordination for the improvement of higher education personnel (capes), to the national etd portal, theses canada, the national health surveillance agency (anvisa), the brazilian ministry of health, the federal nursing council, the brazilian organ transplant association and the brazilian society of nephrology. as a search strategy used for the research, we have (kidney transplantation) or (nursing or nursing care) and (postoperative period) for the databases in portuguese and (kidney transplantation) or (nursing or nursing care) and (postoperative period) for the international databases. scientific articles, dissertations, theses, manuals, guidelines, protocols and bulletins were defined as eligibility criteria; published and available in full online; in portuguese, spanish and english; and that address nursing care in kidney transplant patients. in turn, they were not included in the editorial scope and experience reports. there was no temporal delimitation in the search performed. by evaluating the titles and abstracts of the identified studies, the preliminary selection was made. then, the selected publications were read in full, according to figure 1. the relevance of the articles for the review was analyzed by two independent reviewers. figure 1. scheme of the study selection process.natal, brazil, 2021. souce: flowchart for the scoping review (adapted from prisma) the fourth stage of the scoping review aimed at the treatment, synthesis and presentation of the results was performed by collecting the data contained in the publications included in the final sample, in a spreadsheet built-in microsoft excel office 365, with support for the variables listed in the research protocol: type of document, year of publication, journal, country of origin, language, study objective, type of research, study sample, main results about nursing care in kidney transplant patients identified and conclusion of the study. after data analysis, they were synthesized and presented using tables. to facilitate the understanding and visualization of the data, the studies were coded as follows: "e" (study), followed by arabic numerals 1, 2, 3, ... 15, to assume representation e1, e2, e3, ... e15. the level of evidence and the level of recommendation of the studies were classified according to the proposal of the joanna briggs institute (28). to facilitate the reader's understanding and through the materials selected in the scoping review, nursing care for kidney transplant patients was classified as: nursing care to kidney transplant recipients in the immediate, middle, and late postoperative periods, and nursing care for kidney transplant recipients in phc. results the final sample of the scoping review consisted of 15 publications (100%). among these, there are articles (60 %), manuals (6.6 %), dissertations (6.6 %), protocols (6.6 %), guidelines (13.6 %) and bulletins (6.6 %). most publications have a quantitative approach (86.6 %); on methodological design, 60% of the studies are descriptive, 13.3 %, transversal character, 6.6 %, observational and 20.1 %, others. as for the country of origin, 93.3 % of the material comes from brazilian studies. in view of the sample found, the publications started in 2006 and ended in 2021. most publications were in 2006, followed by 2007, 2013 and 2016, each year with two publications on the subject, according to table 1. table 1. characterization of the included studies. natal, rio grande do norte, brazil, 2021. study code (reference) study aim country (year) type of study/ approach/type of publication/level of evidence e1 have evidence-based recommendations on covid-19 vaccination for kidney transplant recipients. brazil (2021) descriptive/qualitative/ bulletin/5a e2 evaluate the knowledge of nurses in patient care in the immediate postoperative period of kidney transplantation. brazil (2020) exploratory, descriptive/ qualitative/article/4b e3 to know the complications that led patients to re-intern in the first year after kidney transplantation and develop strategies to reduce them. brazil (2018) retrospective/ quantitative/dissertation e4 identify the care performed by people with kidney transplantation for the maintenance of the transplanted organ. brazil (2017) descriptive/qualitative/ article/4b e5 to recognize the facilities and difficulties that people with ckd experience after kidney transplantation. brazil (2016) descriptive/qualitative/ article/4b e6 to analyze the perceptions of transplant patients and health professionals about kidney transplantation. brazil (2016) exploratory, descriptive/ qualitative/article/4b e7 review sorting parameters, prevention and management strategies for diabetes mellitusbefore and after transplantation. brazil (2014) descriptive/bibliographic review/article/4a e8 to analyze the quality of life of people with chronic kidney failure undergoing hemodialysis compared to transplant patients. brazil (2013) descriptive, cross/ quantitative/article/4b e9 clarify the basic doubts that occur in the period after kidney transplantation. brazil (2013) descriptive/qualitative/ manual/5a e10 conduct a bibliographic survey about the role of care and educator of nurses in kidney transplantation. brazil (2012) descriptive, retrospective/ bibliographic review/ article/4a e11 systematize the actions and planning of care provided to patients submitted to kidney transplantation by the nurse professional. brazil (2008) descriptive/qualitative/ protocol/5a e12 to identify nursing diagnoses in the immediate postoperative period of patients undergoing kidney transplantation and to raise nursing actions proposed by the nursing interventions classification for nursing diagnoses identified in patients undergoing kidney transplantation. brazil (2007) descriptive, transversal character/qualitative/ article/4b e13 identify nursing care recorded in the medical records of clients in the postoperative period of kidney transplantation; discuss the implications of records for nursing care; evaluate nursing care. brazil (2007) descriptive/ observational study/ article/4b e14 to present recommendations for the practice of kidney transplantation, based on evidence published in the literature and clinical experience. brazil (2006) descriptive/qualitative/ guideline/5a e15 to present recommendations for the practice of kidney transplantation, based on evidence published in the literature and clinical experience. brazil (2006) descriptive/qualitative/ guideline/5a source: own elaboration. table 2 gathers the main findings, classifying them in nursing care after kidney transplantation (immediate, mediated and late) and phc. table 2. main nursing care in kidney transplant patients mapped in the scoping review. natal, rio grande do norte, brazil, 2021. classification of post-kidney transplant nursing care main results immediate post-operative nursing care • carrying out the systematization of nursing care (30). • maintaining bed rest for the first 24 hours and guiding the patient not to exert physical effort (1-5, 15, 22, 23, 27-32). • clinical evaluation of the sign and symptoms of sudden anuria, for the prevention of kidney artery thrombosis (29-31). • monitoring the level of consciousness and cough reflex (30, 33). • monitoring of systemic signs and symptoms and sites of infection such as the surgical wound (15, 32, 34). • carrying out medication handling (15, 33). • control of hemodynamic status, blood pressure, respiratory function and capillary blood glucose levels (31, 33, 35-37). • monitoring the hydration situation, performing volume replacement, controlling diuresis every hour, weighing in fasting, assessing waist circumference and laboratory results regarding fluid retention (4, 15, 30, 36, 38-40). • care with an indwelling urinary catheter for the prevention of urinary tract infections (15, 33). • care with surgical drains (15, 33, 36). administration of a light diet after 8 to 12 hours of fasting if clinical conditions exist (15). • limiting the number of visits (15, 30, 33). immediate post-operative nursing care • carrying out the systematization of nursing care (30). • monitoring of systemic signs and symptoms and sites of infection such as the surgical wound (15, 30, 31, 34). • carrying out medication administration (15, 33). • control of hemodynamic status, blood pressure, respiratory function and capillary blood glucose levels. continuous monitoring of vital signs, patient weight in fasting (4, 15, 16, 30, 38-40 ). • recording and evaluation of diet acceptance; maintenance of care with indwelling bladder catheter, with the removal of the bladder catheter on the 4th postoperative day (1, 3). • monitoring the hydration situation; performing volume replacement; diuresis control every hour; weighs in fasting; evaluation of waist circumference and laboratory results regarding fluid retention (1, 30, 31, 34). • beginning of guidance on adherence to treatment/follow-up and information on side effects resulting from immunosuppressive agents or rejection (15, 36, 38). • exercise of the caregiving and educator role (36). early detection of complications related to the surgical procedure (33, 36, 37, 39). • assessment of the presence of hemorrhage, hematomas in the surgical wound and dressing changes (31, 33, 38). • encouragement to walk as early as possible (33). late postoperative nursing care • prevention of surgical wound infection and urinary infection, in addition to the removal of surgical stitches (30, 31, 40). • offering recommendations on the correct use of immunosuppressants and other necessary medications (15, 36, 38). • guidance on the importance of attending scheduled outpatient appointments; exams scheduled weekly during the first 30 days; monitoring of vital signs, capillary blood glucose; dietary recommendations; regular physical activity; obesity prevention; avoidance of alcohol and tobacco (15, 31, 37). • exercise of the caregiving and educator role (36). • advice on staying away from people with contagious diseases or animals and frequent hand washing (40). • avoidance of lifting heavy objects, pulling or pushing large objects, because between the 6th and 8th week, the surgical wound must heal completely (15, 30). • clinical evaluation of the emergence of lymphoceles; evaluation for the presence of a palpable mass, hydronephrosis and edema of the lower limb on the transplant side (38). nursing care for kidney transplant recipients in phc • regular maintenance of follow-up with consultations by the multidisciplinary team (36, 40). • exercise of the caregiving and educator role (36). • encouragement of scheduled exams; monitoring of vital signs; regular physical activity; obesity prevention (36, 40, 41). • encouraging healthy habits, such as eating less sodium and protein, with lots of fiber and fluid intake (27). • guidance on avoiding alcohol and smoking, as well as hygiene care and infection control (40). • guidance on medication care and the importance of adherence to the use of medications, especially immunosuppressants (31, 36, 37, 39, 40). • guidance on returning to sexual activity and family planning (4, 16). • avoidance of abdominal exertion and exercises in the first months after surgery (39). • guidance on the use of sunscreen and avoiding the sun (16, 35). • monitoring the patient from the beginning of the evolution of their disease to a better quality of life after the procedure (16, 33, 34, 37). • orientation of the patient to always walk with their identification card about their transplant condition, in addition to their medication (15, 32, 34, 36). • updated vaccination card — including covid-19 vaccination (41). • evaluation of signs and symptoms suggestive of cytomegalovirus infection, especially in the first three months (37). • evaluation of signs and symptoms of chronic rejection (progressive worsening of kidney function, presence of proteinuria, less than 1.0 g/day in 50% of cases), presence of arterial hypertension (> 90%)(15, 34-36 ). source: own elaboration. among nursing care after kidney transplantation (immediate, mediated, late), the material studied has as main findings to control hemodynamic status, blood pressure, respiratory function and capillary glucose levels; monitor the hydration situation; perform volume replacement, diuresis control every hour; fasting weigh; evaluate abdominal circumference and laboratory results related to fluid retention; monitor systemic signs and symptoms and sites of infection such as the surgical wound; care with an indwelling urinary catheter for the prevention of urinary tract infections; detect early complications related to the surgical procedure; initiate guidance on treatment/follow-up and inform about side effects resulting from immunosuppressive agents or rejection (table 2). on the extra-hospital care that also involves phc, it was identified to encourage healthy habits, such as feeding with less sodium and proteins, with many fibers and fluid intake; guide to avoiding alcohol and smoking, in addition to hygiene care and infection control; guide care with medications and the importance of adhering to the use of medications, especially immunosuppressants; check the vaccine card and guide the one that is up to date; evaluate signs and symptoms suggestive of cytomegalovirus infection, especially in the first three months; evaluate signs and symptoms of chronic rejection (progressive worsening of kidney function, presence of proteinuria, less than 1.0 g/day in 50% of cases); the presence of hypertension (> 90°%), as observed in table 2. discussion given the predominance of descriptive studies developed in brazil, in the final sample of the scoping review, it is evident the need for studies related to this theme focused on clinical practice and with scientific productions with a better level of evidence, making reliable publications that empower the care nurse and assist him in decision making. nursing care for kidney transplant patients is essential for the maintenance and preservation of the graft and quality of life of the patient. this care constitutes the basic structure for the patient in the post-transplant period because nursing is the category that is present 24 hours next to the patient during hospitalization and that also monitors and monitors the responses of the organism along with the three levels of health complexity (40). research developed on the culture of patient safety in kidney transplantation showed the need for continuous improvement of the nursing professional in the face of theoretical and practical knowledge related to transplantation. it is noteworthy that the nursing professional must be trained and have the skills and competence to assist the transplanted patient to enable safe care for patients and staff, a better quality of care provided, a higher graft survival and better quality of life for kidney transplant recipients (42). considering the classification used in the review of the scope in question for nursing care for kidney transplant recipients in the immediate, middle and late postoperative periods, and nursing care for kidney transplant recipients in phc, results were found for each classification. for this, nursing care in the immediate postoperative period is vital, being considered a care for critical care. in the first 24 hours after kidney transplantation, nursing actions aim to prevent complications and prioritize the continuous evaluation of general health status with noninvasive monitoring of vital signs and evaluation of the nursing team of 1 hour/1 hour in the first 12 postoperative hours, which allows early and appropriate interventions for each type of worsening. this period of great potential for hemodynamic instability, cardiovascular and neurological complications, important metabolic alterations and the need for replacement of parenteral fluids in large volumes that require intensive care for the maintenance of life (5, 23, 43, 44-49). the main complications of this period are related to the surgical procedure of kidney transplantation, such as: kidney artery thrombosis, hemorrhage, kidney surgery, urinary obstruction; and non-surgical complications such as acute graft rejection (37, 41). therefore, the care of the nursing team should be based on clinical evaluation based on physical examination and laboratory tests for monitoring kidney function, pulmonary and cardiovascular function, with emphasis on monitoring the hydroelectrolytic balance and signs and symptoms of kidney injury (5, 23, 33, 50). nursing care in the middle postoperative period is a continuity of the surveillance of these patients. the main complications in this period are kidney vein thrombosis, bladder fistula, urinary fistula, kidney shop hematoma, urinary infection and hypertension. the emphasis of care in this period is the monitoring of the hydro-electrolytic balance, care for infection prevention, pain control, maintenance and stimulation of pulmonary function, early ambulation, restoration of gastrointestinal functions and restoration of kidney function (37, 51-53). in this moment of care still in the hospital environment, it is extremely important to create the bond between professionals and the patient, because the longevity of the graft, the quality of life of the recipient and self-care are associated with his/her treatment' and the latter, directly linked to the relationships established throughout the health network. thus, the professional must establish a dialogical relationship with the client, with a clear language, holistic treatment, individualized, considering their socioeconomic, cultural, religious and cognitive condition (37, 41, 53-58). how far from the surgical procedure, surgical complications are more difficult to happen, but they may still be present, coming to light, more predominantly, clinical complications (59). thus, we can say that, in the late postoperative period, the most common complications are lymphocele, urinary infection, cytomegalovirus infection, systemic arterial hypertension, diabetes mellitus, rejection of the acute or chronic graft (32, 37, 41, 60-65). however, late nursing care is based on the care of the surgical wound, the scores of laboratory results of the general state of health and kidney function, but the care of guidance to the recipient and family members regarding the use of immunosup-pressants, the importance of returning to consultations and the performance of scheduled tests, maintenance of dietary recommendations and physical activity, among others (15, 32). this study highlights the inclusion of nursing care for kidney transplant recipients in phc. as important as the follow-up of kidney transplant recipients in secondary care, that is, in the specialized outpatient clinic, it is the follow-up of it in phc in the basic units and in the family health strategy in the municipalities of origin. it is important to highlight that the kidney transplant patient is still a patient with ckd and should be inserted in the health care network at the three levels of complexity, according to their need. published in march 2014, ordinance 389 defines the criteria for the organization of the care line of the person with ckd. thus, it is the responsibility of phc to perform educational activities and support self-care, expanding the autonomy of the person with ckd, such as stimulating and guiding therapeutic adherence, updating the vaccination card, personal and home hygiene care, and care for the prevention of opportunistic infections due to immunosuppression (2). it is the responsibility of specialized outpatient care to maintain communication with the multidisciplinary teams of the other components of the health care network (2). this shows that networking among the levels of complexity of care for patients with ckd is extremely important. moreover, the potential of studies of this nature is considered by synthesizing and mapping knowledge that ensures a care practice based on scientific evidence and allows decision-making. added to this theme and the evidence summed up for nursing professionals working with kidney transplant patients in a perspective of guidance and support to safe nursing care practices. the heterogeneity of the selected studies and even the possibility of vice-studies in individual studies described are uncontrolled characteristics in this type of study and is considered as a limitation of the research. another limiting feature would be the non-inclusion of material published and available in full in a non-free online medium that could add scientific value to this scoping review. the scarcity of studies focused on nursing care in the international literature was listed as a complicating feature, but not controlled in this type of study. conclusion it was concluded that the study allowed mapping nursing care to kidney transplant patients in the immediate, immediate, late and phc postoperative periods. the mapping of nursing care to kidney transplant recipients provides the strengthening of the care offered in the health care network and is configured as an instrument that induces co-responsibility and quality intending to continuously improve health outcomes. an important driver for the praxis (action-reflection-action) of science and for the valorization of nursing. given the complexity that the patient submitted to kidney transplantation presents, it is necessary that the nurse who assists this public be trained to conduct care efficiently in the face of the complex situations resulting from the clinical profile of patients, developing their practice of competent care for safe decision-making, ensuring patient safety and based on scientific evidence. the insertion of primary health care in the care of kidney transplant patients becomes a differential of this study. in addition, this care is considered essential in the process for graft maintenance in transplanted patients, as it allows better treatment support, promotion and prevention of diseases such as opportunistic infectious diseases, reduction of anxiety regarding doubts and 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gluba-brzózka a. diabetes and cardiovascular risk in renal transplant patients. int. j. mol. sci. 2021;22(7):3422. doi: https://doi.org/10.3390/ijms22073422 63. ponticelli c, favi e, ferraresso m. new-onset diabetes after kidney transplantation. medicina. 2021;57(3):250. doi: https://doi.org/10.3390/medicina57030250 64. bach pa, martínez sa, martínez dy, sobrado so, redondo pmd, junyent ie. obesidad, diabetes y trasplante. enferm nefrol. 2017;20(1):82-7. disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s2254-28842017000100011&lng=es 65. kinnunen s, karhapàà p, juutilainen a, finne p, helanterà i. secular trends in infection-related mortality after kidney transplantation. clin j am soc nephrol. 2018;13:755-62. doi: https://doi.org/10.2215/cjn.11511017 home preparation of a scale for assessing nursing care needs in dependent people article preparation of a scale for assessing nursing care needs in dependent people construcción de una escala para la valoración de necesidades de cuidado de enfermería en personas dependientes construção de uma escala para avaliação das necessidades de cuidados de enfermagem em pessoas dependentes 10.5294/aqui.2022.22.3.5 maite catalina agudelo-cifuentes 1 dedsy yajaira berbesi-fernández 2 ángela maría salazar-maya 3 1 0000-0003-1501-9452. nursing school, universidad ces, colombia. magudeloc@ces.edu.co 2 0000-0002-1716-957x. nursing school, universidad ces, colombia. dberbesi@ces.edu.co 3 0000-0001-7599-1193. nursing school, universidad ces, colombia. asalazar@ces.edu.co received: 06/02/2021 sent to peers: 10/24/2021 approved by peers: 03/02/2022 accepted: 03/17/2022 theme: evidence-based practice. contribution to the subject: it is necessary to submit a measuring scale to a validation process that supports its proper use in research or clinical scope. it is in this fact that the main contribution of this research lies, providing the scientific support required for the appropriate application of the theories addressed in the diagnosis and follow-up of dependent patients. in addition, it promotes nurses' use and recognition of maslow's theory in their clinical practice and research. this scale, which showed good reliability and validity, allows the implementation of care models based on virginia henderson's theory and their coordination with the nanda-i, noc, and nic (nnn) standardized languages, which have gained increasing relevance in the nurses' practice. to reference this article / para citar este artículo / para citar esteartigo: agudelo-cifuentes mc, berbesi-fernández dy, salazar-maya am. preparation of a scale for assessing nursing care needs in dependent people. aquichan [internet]. 2022;22(3):e2235. doi: https://doi.org/10.5294/aqui.2022.22.3.5 abstract objective: to prepare and validate a scale for assessing care needs in dependent people, based on all fourteen needs included in virginia henderson's theory and maslow's theory of human needs. materials and methods: an observational study was conducted to validate a scale with a sample of 776 care-dependent individuals. nursing professionals were in charge of writing the items. correlations between items and factor structure were evaluated using a structural equation model. reliability was assessed through cronbach's alpha and mcdonald's omega. results: the correlations between all fourteen needs were satisfactory. the structure with three dimensions (physiological needs, need for safety and belonging, and need for independence) was satisfactory: cfi = 0.95, tli = 0.94, srmr = 0.04, and rmsea = 0.06 (95 % ci: 0.05-0.07). the scale's reliability was satisfactory, with cronbach's alpha = 0.870 and mcdonald's omega = 0.871. conclusions: this scale allows obtaining a classification score to determine the nursing assistance needs of dependent people. it contributes to the standardization and use of the theories about care and human needs. keywords (source: decs): validation study; nursing assistance; nursing care; people with disabilities; nursing theory. resumen objetivos: construir y validar una escala para la valoración de la necesidad de cuidados de personas dependientes con base en las catorce necesidades de la teoría de virginia henderson y la teoría de las necesidades humanas de maslow. metodología: estudio observacional de validación de escala con una muestra de 776 personas dependientes de cuidado. construcción de los ítems a cargo de profesionales de enfermería. se evaluaron correlaciones entre ítems y estructura factorial por medio de un modelo de ecuaciones estructurales. análisis de fiabilidad mediante alfa de cronbach y omega de mcdonald. resultados: las correlaciones entre las catorce necesidades fueron satisfactorias. la estructura de tres dimensiones (necesidades fisiológicas, necesidad de seguridad y afiliación y necesidad de independencia) fue satisfactoria: cfi = 0,95; tli = 0,94; srmr = 0,04 y rmsea = 0,06 (ic 95 %>: 0,05-0,07). la fiabilidad de la escala fue satisfactoria, con alfa de cronbach = 0,870 y omega de mcdonald = 0,871. conclusiones: esta escala permite obtener un puntaje de clasificación para conocer la necesidad de ayuda por parte de enfermería de la persona dependiente. por lo tanto, es un aporte a la estandarización y el uso objetivo de las teorías sobre el cuidado y las necesidades humanas. palabras clave (fuente decs): estudio de validación; atención de enfermería; cuidado de enfermería; personas con discapacidad; teoría de enfermería. resumo objetivos: construir e validar uma escala de avaliação das necessidades de cuidado de pessoas dependentes, com base nas quatorze necessidades da teoria de virginia henderson e na teoria das necessidades humanas de maslow. metodologia: estudo observacional de validação de escala com amostra de 776 pessoas dependentes de cuidados. construção dos itens pelos profissionais de enfermagem. as correlações entre os itens e a estrutura fatorial foram avaliadas por meio de um modelo de equação estrutural. análise de confiabilidade com utilização dos coeficientes alfa de cronbach e ômega de mcdonald. resultados: as correlações entre as quatorze necessidades foram satisfatórias. a estrutura de três dimensões (necessidades fisiológicas, necessidade de segurança e afiliação e necessidade de independência) foi satisfatória: cfi = 0,95; tli = 0,94; srmr = 0,04 e rmsea = 0,06 (ic 95 °%: 0,05-0,07). a confiabilidade da escala foi satisfatória, com alfa de cronbach = 0,870 e ômega de mcdonald = 0,871. conclusões: esta escala permite obter um escore de classificação para avaliar as necessidades de cuidados de enfermagem de pessoas dependentes. implica uma contribuição para a padronização e o uso objetivo de teorias sobre o cuidado e as necessidades humanas. palavras-chave (fonte decs): estudo de validação; assistência de enfermagem; cuidados de enfermagem; pessoas com deficiências; teoria de enfermagem. introduction one of the main pillars of nursing is to provide care according to patients' and communities' needs. nursing is a discipline that grounds its performance on theoretical models that support the elaboration of a diagnosis based on the patient's needs and favor decision-making, planning, and evaluation of the interventions (1). using theoretical models allows for a common language among professionals and grounding the decisions on updated evidence (2). in turn, the concept of "need" has been present in different disciplines. in the social sciences, abraham maslow stands out with the sequential notion of needs (3) since, according to this author, specific human needs prevail over others. consequently, he identifies five major groups of human needs according to their differences regarding relevance. he allocates the priority ones to the first four places and those related to self-improvement to the fifth place. the first group consists of physiological needs related to the person's survival; therefore, maslow places them at the pyramid base. upon a deficit of all needs, the body will be dominated by the physiological ones, whereas the others will be moved to the background. the second group of needs is related to the person's safety. although it can be more relevant during childhood, it is not exclusive to this stage because the very nature of human beings requires protection against danger and vulnerability. subsequently, we find the social and affiliation or belonging needs framed in the scope of interpersonal relationships. in the fourth group, maslow places the needs related to esteem and concern about achieving skills and status. this group includes the need for self-assessment and evaluating others or social success. meeting this group of needs provides self-confidence and a feeling of usefulness and sufficiency to a person. finally, according to maslow's theory, the pyramid summit comprises the self-fulfillment or self-improvement needs to be met by opportunities to develop each person's maximum potential (4). in the work entitled nursing: the philosophy and science of caring (5), watson describes how care-related factors assist in meeting human needs. she identifies the biophysical and psychophysical needs as lower order, the psychosocial needs as higher-order, and the intraand interpersonal needs as top order (5). according to the theory, there are four human conservation principles and basic needs: energy conservation, structural integrity conservation, personal integrity conservation, and social integrity conservation (6). in turn, roy focuses on four adaptation modes of the person as a system: physiological, self-concept, role, and interdependence (7). on the one hand, orlando acknowledges the need for help in people, and nurses are the individuals who will have to meet them (8). wiedenbach indicates that it is necessary to "identify the patient's need for help, provide the help required, and verify that the need for help has been met" (9). on the other hand, although leininger does not delve further into the concept of "need," she implicitly accepts the basic need when she acknowledges universal care and defines it as "help, support, or stimulating behaviors that ease or improve a person's situation" (10). one of the primary care models on which nurses' performance is grounded is virginia henderson's, which has practical application and is framed within the human needs model. according to this theory, individuals are comprehensive beings with biological, psychological, sociocultural, and spiritual components that require complete satisfaction of fourteen basic needs to attain their highest potential. when one of these needs cannot be met independently, help from others is necessary to maintain harmony and integrity (2). at that moment, nurses play a complementary role in meeting these needs through the care provided (1). these needs interact with each other, for which they cannot be analyzed in isolation; in addition, although inherent to all human beings, how they are met differs according to each person's characteristics (2). the number of people with care needs tends to increase, mainly potentiated by the demographic changes that have led to accelerated population aging in latin america. added to the unhealthy conditions under which the population is aging, this rapidly increases the number of frail or dependent individuals who require care and support to perform their basic activities. however, the need for care is not a condition exclusively inherent to old age (11-13). the approach to a nursing care plan must be anchored in the identification of a person's priority needs; for this reason, applying valid and reliable scales to support these decisions enables professionals to provide care grounded on an objective diagnosis that directs not only the implementation of the interventions but also their subsequent evaluation (14,15). currently, few instruments are used in nursing to assess care needs in dependent people. three tools stand out among them: the cardiovascular nursing assessment instrument with virginia henderson's approach, validated by montesinos jiménez et al. (16); the nursing assessment instrument on palliative care needs for pediatric patients by instituto nacional de salud del niño, validated in 2017 by cairo (17); and the scale designed by jorge, which allows assessing patients' needs and satisfying factors in end-of-life care, based on max neef's needs (18). other validated instruments employed by nursing professionals focus on the prevention of pressure ulcers in hospitalized patients (19), the nursing professionals' communication skills (20), and the nursing care protocol for newborns regarding pain treatment (21). this research aimed to elaborate and validate a scale for assessing the care needs of dependent people based on all fourteen needs included in virginia henderson's theory and maslow's theory of human needs. materials and methods an analytical, empirical, and observational study was conducted to validate a scale. the study population consisted of 776 care-dependent individuals. regarding the inclusion criteria, the study participants were care-dependent individuals from the municipality of envigado, antioquia, registered in the caregiver program database in 2020. those who refused to participate in the program or give their informed consent were excluded. an official sampling framework with information about the families who benefited from the program was used for data collection. previously trained and standardized nursing professionals assessed all fourteen needs. the assessment was conducted on the individuals who accepted to participate in the caregiver program. such assessment was accompanied by a questionnaire that included sociodemographic questions about the care-dependent individuals and the delta test to evaluate functional dependence, answered by the care-dependent person or the caregiver, depending on the patient's clinical condition. preparation and validation of the instrument nursing professionals were responsible for writing the questions for assessing all fourteen needs, taken from virginia henderson's theory. the measuring instrument was reviewed and tested as a pilot to control information biases. the research team performed due quality control of the information collected. the starting points were virginia henderson's theory and maslow's theory of human needs to validate the scale proposed with fourteen needs. three dimensions were structured in this sense: physiological needs (six items), need for safety and belonging (five items), and need for independence (three items). the items were measured on an ordinal categorical scale: 1. no difficulty; 2. some difficulty; and 3. needs help or does not do it. according to maslow's theory, the first dimension corresponds to physiological or basic needs. it includes breathing, eating and drinking, urinary and fecal eliminations, sleep and good rest, body temperature maintenance, and staying conscious and oriented. the second dimension is divided into two groups from maslow's pyramid: the need for safety and protection and the need for affiliation or belonging. consequently, this second dimension included family support, ability to communicate, preservation of social life, engagement in recreational activities, and participation in learning activities. in turn, the third dimension, called "need for independence," is delimited by the need for high esteem proposed by maslow. it refers to self-confidence, competence, and independence, where the ability to move, get dressed and undressed without help, and perform self-hygiene was included (3). a valid and reliable instrument to measure functional dependence (delta test) was used for construct validation of the scale with fourteen needs. data analysis regarding statistical data, the care-dependent individuals were characterized using absolute and relative frequencies and central tendency and dispersion measures. additionally, the chi-square statistical test and its respective p-value were used to identify significant differences between some characteristics. in addition, exploratory factor analysis was developed to approach the dimensionality of the "needs" construct. as a sample adequacy measure, the kaiser-meyer-olkin index was calculated, also performing bartlett's sphericity test. similarly, the polychoric correlation matrix was prepared (22), considering the ordinal level at which all fourteen needs were measured (23,24). confirmatory factor analysis was performed to test the theoretical construct of all three dimensions, based on virginia henderson's and abraham maslow's theoretical frameworks. thus, a structural equation model was developed using the maximum likelihood method. the following goodness-of-fit indices were obtained to determine the statistical efficiency of the model: standardized rood mean residual (srmr); root mean square error of approximation (rmsea), with its confidence interval (95 % ci); comparative fit index (cfi); and tucker-lewis index (tli) (25). the weights of variables, correlations between the latent variables, and variance percentage explained by each factor were analyzed. in addition, the modification indices were obtained, and, based on them, some correlations were established between the error terms to improve the model fit. likewise, the model reliability was analyzed through cronbach's alpha and mcdonald's omega (26). the dependent people's scores were also obtained for each dimension and the total scale. all the items were considered and weighted according to each dimension, following maslow's theory, in which the needs located at the pyramid base are more relevant. these items were assigned higher weights (doubled) than the others. this way, scores between 20 and 60 are obtained; the higher the score, the greater the care need. for construct validation of the care need scale, the final scores were correlated to those obtained in the delta scale. the statistical analyses were performed with the aid of the jamovi free-use program (27). this project was evaluated and approved by the ethics committee of universidad ces, medellin, colombia. results sociodemographic characterization of the care-dependent people most of the 776 care-dependent individuals were women (66.9 %); 58.9 % were 80 years old or older, and only 1.8 % were under 20. age distribution behaved differently between men and women (x2 = 27.6; p < 0.001), as 91.5 % of the women were over 60 years old, whereas the men over that age represented 78.6 % (figure 1). figure 1. distribution according to the gender and age of the care-dependent people from the caregiver program. source: own elaboration basic needs of the care-dependent people according to virginia henderson's theory and abraham maslow's human needs regarding the "physiological needs" component, one-third of the care-dependent individuals required help for urinary or fecal eliminations. in addition, 26.9 % had difficulties staying conscious or oriented. the need for help to breathe and maintain body temperature was found in less than 10 % of the participants. on the other hand, nearly half of the participants needed help moving, performing body hygiene, and getting dressed and undressed (table 1). table 1. characterizing the care-dependent people's needs according to all fourteen needs included in virginia henderson's theory and abraham maslow's human needs dimension need needs help/ does not do it does it with difficulty no difficulty n % n % n % physiological needs breathing (n1) 72 9.3 157 20.2 547 70.5 eating and drinking (n2) 186 24.0 192 24.7 398 51.3 eliminations (urinary and fecal) (n3) 245 31.6 193 24.9 338 43.6 sleeping (rest-related problems) (n6) 152 19.6 276 35.6 348 44.8 maintaining body temperature (n7) 63 8.1 133 17.1 580 74.7 staying conscious and oriented (n10) 209 26.9 202 26.0 365 47.0 need for safety and belonging having family support (n9) 112 14.4 154 19.8 510 65.7 ability to communicate (n11) 154 19.8 201 25.9 421 54.3 preserving social life (n12) 311 40.1 206 26.5 259 33.4 engaging in recreational activities (n13) 440 56.7 177 22.8 159 20.5 participating in learning activities (n14) 466 60.1 164 21.1 146 18.8 need for independence motion (moves) 403 51.9 219 28.2 154 19.8 getting dressed and undressed 380 49.0 169 21.8 227 29.3 body hygiene (to have a bath) 391 50.4 150 19.3 235 30.3 source: own elaboration validation of the care need scale according to virginia henderson's theory and maslow's human needs the correlations between all fourteen needs were satisfactory, and the strongest ones were observed in the items from the "need for independence" dimension. consequently, the need for help to get dressed and undressed and to perform self-hygiene (correlation coefficient = 0.94) and the need to engage in recreational activities and participate in learning activities (correlation coefficient = 0.93) had a high correlation (figure 2). figure 2. polychoric correlation between all fourteen needs included in virginia henderson's theory and maslow's human needs. source: own elaboration regarding the scale's factor structure, the kaiser-meier-olkin test yielded a satisfactory score of 0.86, which indicates sample adequacy. likewise, the result of bartlett's sphericity test was significant (x2 = 5.343, p < 0.001). the scale's reliability was satisfactory, with cronbach's alpha = 0.870 and mcdonald's omega = 0.871 in the scale's total score. the mean score of the items was 2.1, with a standard deviation of 0.48. the homogeneity of the scale was determined based on the correlation between each item and the total scale. most correlations had values from 0.4 to 0.7, indicating that the scale has a good discriminant ability and that the items are targeted at measuring the same construct (table 2). table 2. descriptive statistical data for all 14 items of the care need scale         if the item is removed   mean sd v α ω item-scale correlation n1. breathing 2.61 0.651 0.424 0.88 0.88 0.13 n2. eating and drinking 2.27 0.824 0.679 0.86 0.86 0.66 n3. eliminations (urinary and fecal) 2.12 0.859 0.738 0.86 0.86 0.61 n4. motion (moves) 1.68 0.785 0.616 0.86 0.86 0.62 n5. getting dressed and undressed 1.80 0.863 0.744 0.85 0.85 0.72 n6. sleeping (rest-related problems) 2.25 0.762 0.581 0.87 0.87 0.41 n7. maintaining body temperature 2.67 0.621 0.385 0.87 0.87 0.38 n8. body hygiene (to have a bath) 1.80 0.876 0.767 0.85 0.85 0.69 n9. having family support 2.51 0.734 0.539 0.87 0.87 0.32 n10. staying conscious and oriented 2.20 0.837 0.700 0.86 0.86 0.60 n11. ability to communicate 2.34 0.790 0.623 0.86 0.86 0.61 n12. preserving social life 1.93 0.855 0.731 0.86 0.86 0.60 n13. engaging in recreational activities 1.64 0.801 0.642 0.86 0.87 0.48 n14. participating in learning activities 1.59 0.787 0.619 0.86 0.87 0.48 sd: standard deviation; v: variance; α: cronbach's alpha; ω:: mcdonald's omega. source: own elaboration confirmatory factor analysis was performed to confirm the three-dimension factor structure according to maslow's theory of human needs, yielding the following initial fit indices: cfi = 0.83, tli = 0.79; srmr = 0.122, and rmsea = 0.127 (95 % ci: 0.120-0.134). although all the correlation coefficients between the error terms were set to zero, some were freed to favor the model fit, considering the resulting modification indices (figure 3). figure 3. confirmatory factor analysis for validation of the three-dimension theoretical model of the scale to assess care needs in dependent people. source: own elaboration after assigning the residual covariances, the fit indices of the model were satisfactory; for example, cfi showed a good fit (cfi = 0.95). similarly, tli, a comparative index between the proposed model and a naive one, also showed a good fit (tli = 0.94). srmr, which evaluates the plausibility that the sample and estimated matrices are identical, showed a good fit (srmr = 0,04), and so did rmsea = 0.06 (95 % ci: 0.05-0.07). as expected, the residual covariance matrix yielded small and satisfactory values, indicating slight differences between the matrix of population covariances estimated by the model and the sample matrix. good covariation is also observed between all three dimensions: covariance is higher between the "physiological needs" and "need for independence" dimensions (standardized correlation = 0:83) (table 3). all the standardized and non-standardized factor loadings were within the expected ranges. likewise, their standard errors were minor and satisfactory. regarding the t statistical value, it was significant for all the variables. table 3. estimation of the factor loadings   95 % confidence interval   factor variable factor loading standard error lower upper z p standardized loading physiological needs n1 0.0793 0.0252 0.0299 0.129 3.15 0.002 0.122 n2 0.6386 0.0268 0.5861 0.691 23.86 < 0.001 0.776 n3 0.6250 0.0285 0.5691 0.681 21.93 < 0.001 0.728 n6 0.3119 0.0284 0.2563 0.367 11 < 0.001 0.409 n7 0.2602 0.023 0.2151 0.305 11.3 < 0.001 0.42 n10 0.453 0.0306 0.3929 0.513 14.78 < 0.001 0.548 need for safety and belonging n9 0.2309 0.0288 0.1743 0.287 8 < 0.001 0.315 n11 0.5205 0.0295 0.4628 0.578 17.67 < 0.001 0.67 n12 0.6183 0.0314 0.5568 0.68 19.72 < 0.001 0.73 n13 0.4133 0.0309 0.3528 0.474 13.39 < 0.001 0.516 n14 0.3726 0.0306 0.3126 0.433 12.17 < 0.001 0.474 need for independence n4 0.6139 0.0239 0.567 0.661 25.63 < 0.001 0.783 n5 0.8244 0.0235 0.7784 0.87 35.09 < 0.001 0.956 n8 0.7729 0.0251 0.7236 0.822 30.75 < 0.001 0.883 source: own elaboration for the "physiological needs" dimension, the "eating and drinking" and "urinary and fecal eliminations" variables were the ones with the highest factor loadings (standardized) regarding the dimension (0.77 and 0.74, respectively). in contrast, the "breathing" need had low loading with the factor (0.12); however, its loading was significant (z = 3.15; p = 0.002). in the case of the "need for independence" dimension, satisfactory loadings were observed in all its variables, with the highest being the "need for help to get dressed and undressed" (0.96). regarding the "need for safety and belonging" dimension, the variable that most strongly loaded the factor was the "need for help to preserve social life" (0.73). as to the covariances between the factors (standardized estimation), all three dimensions are satisfactorily correlated (table 3). reliability of the scale as a first step, reliability was analyzed for the dimensions proposed, finding that the dimension with the highest internal consistency was the "need for independence" (cronbach's alpha = 0.904; mcdonald's omega = 0.908), immediately followed by the "need for safety and belonging" dimension (cronbach's alpha = 0.752; mcdonald's omega = 0.773). in turn, although with the lowest internal consistency, the "physiological needs" dimension had some satisfactory values, showing that its items are targeted at measuring the same construct (cronbach's alpha = 0.691; mcdonald's omega = 0.699). final score the mean score for the "physiological needs" dimension was 19.8 (sd = 5.75). for the second dimension, "need for safety and belonging," the mean score was 10 (sd = 2.81). for the third dimension, "need for independence," the mean score was 7 (sd = 2.31). a typification process was conducted to standardize the result of all three dimensions of the scale with fourteen needs, and, subsequently, a score between 1 and 5 was assigned according to the typified value: 1 = z scores below -1.5; 2 = z scores below -0.5; 3 = z scores below 0.5; 4 = z scores below 1.5; and 5 = z scores above 1.5, where 1 indicates little care need and 5 total care need. construct validity the overall mean score of the scale was 36 (sd = 9.43). in turn, the delta test had a mean score of 23 (sd = 12.5). the correlation between these two scales, expected to be positive, yielded a satisfactory value (spearman's correlation coefficient = 0.84; p < 0.01). the final scale is presented in figure 4. table 4. scale for assessing nursing care needs in dependent people. scale for assessing nursing care needs in dependent people this scale was developed according to virginia henderson's theory and maslow's theory of human needs. it must be used by a nursing professional who responds to each item according to the assessment of the patient.     score dimension need no difficulty / needs little help does it with difficulty / needs help does not do it / needs help physiological needs breathing 2 4 6 eating and drinking 2 4 6 eliminations (urinary and fecal) 2 4 6 sleeping (rest-related problems) 2 4 6 maintaining body temperature 2 4 6 staying conscious and oriented 2 4 6 need for safety and belonging having family support 1 2 3 ability to communicate 1 2 3 preserving social life 1 2 3 engaging in recreational activities 1 2 3 participating in learning activities 1 2 3 need for independence motion (moves) 1 2 3 getting dressed and undressed 1 2 3 body hygiene (to have a bath) 1 2 3 source: own elaboration discussion nursing has become the care science (2) thanks to the adoption of several theories, the development of nursing care models, and the inclusion of the scientific method in professional practice. understood as an organized set of diverse knowledge endorsed by the scientific community, theories provide the nursing profession with fundamental grounds to understand the reality in which care is contextualized and guide the identification of the specific action to be taken in each situation (28). using the scientific method in care has enabled nurses to apply a systematic work system, standardize care, and evaluate and follow up on the therapeutic interventions or programs aimed at health recovery or at support and assistance in the face of a lack of independence in a person to meet basic needs (29). nursing is grounded on multiple theories and conceptual models, both of its own and derived from other sciences; some have historical importance, such as virginia henderson's theory of fourteen needs, which focused on humanistic nursing and the needs models. this theory is currently used globally in higher education and clinical activity (28). such theory is the basis of the current research, which also incorporates abraham maslow's theoretical proposal, grounded on humanistic psychology, to achieve nursing diagnoses based on human needs. this proposal also contemplates the author's postulates, which indicate that some of these needs, which are essential or elementary, prevail over others (4). accordingly, a theoretical model was put to the test that incorporates virginia henderson's fourteen needs coordinated with maslow's theory of basic needs, which sustains the existence of a natural hierarchy among the different needs. the statistical model corroborated the covariation among all three dimensions proposed, where the predominance of covariation between "physiological needs" and the other two dimensions ("need for safety and belonging" and "need for independence") is also noted, as supported by the sequential notion of needs proposed by the theorist (30). according to maslow's postulates, the pyramid summit represents the need for self-fulfillment or self-improvement. these needs are considered of a higher or developmental order, and their importance is only realized after meeting the necessities. considering that this research sought to assess a scale to measure care needs in dependent people, where meeting the priority needs prevails, the need for self-fulfillment was not contemplated. if a person does not have their needs from the first stage met, they will hardly be able to reach the higher-order ones (31). according to maslow, for a person to be able to initiate a self-fulfillment process, they must have previously met many needs, among which independence and self-functional ability prevail (32). consequently, this scale is focused on the deficit or lower-order needs, which, according to maslow, are the "physiological," "safety and belonging," and "esteem" needs. the importance of this group of needs lies in the fact that, if any distortion occurs in them, psychological or physiological problems can arise in the person (32). the findings from the current research show that the assessment of all fourteen needs yielded satisfactory results for consistency and correlation. although most needs are satisfactorily correlated with each other, such correlation was much more robust in some, such as the need for help to get dressed and undressed and to perform body hygiene, both belonging to the "need for independence" dimension. the strong correlation between them reflects the need for help resulting from a lack of physical or mental autonomy, which can be due to age, disease, or disability, making the person require assistance and help for these two essential activities in daily living (31). furthermore, there was a high correlation between the need for help to engage in recreational activities and to participate in learning activities. it should be emphasized that the current scale is guided towards assessing the care needs of people with some dependence degree, where it is possible to find deficits to adequately meet the needs that prevail over them, such as the physiological ones. a high correlation was also observed between the need for help to stay conscious and oriented and the need for help to commu­nicate. despite belonging to different dimensions, they reflect the dependence degree of the "need for safety and belonging" and the "need for independence" with the elementary ones, which are the physiological needs, the group that includes the need for help to stay conscious and oriented. in addition, this is a fundamental condition for maintaining proper communication with others (31). in line with the above, it was observed that, in the initial confirmatory factor model, the modification indices suggested the need to establish correlations between the error terms of the previously discussed needs to favor the model fit. it was satisfactorily attained after adding such correlations that are not only supported in the statistical aspect (33) but also in the theoretical one, already discussed. strikingly, the need for help to breathe, included in the "physiological needs" dimension, had low correlations compared to the others, mainly referring to the "need for independence." likewise, when evaluating the item-scale correlation, it was the one with the lowest value, differing substantially from the rest of the needs. however, the need for help to breathe was detected in less than 10 % of the dependent people used for this validation. nonetheless, when evaluating the consistency of the measurements, it was satisfactory (cronbach's alpha = 0.87) and did not show any substantial improvement when removing the first need (cronbach's alpha = 0.88). when scale validation procedures are performed, quantifying the existing correlations between the items is an initial step, indicating whether the scale has a valid underlying construct (26,34). in this sense, the scale's internal consistency with fourteen needs proposed yielded values within the ranges suggested by various authors (34). it is worth clarifying that, although the need for help to breathe has not shown adequate consistency with the measurements of the other needs, it is indeed part of the vital and physiological needs presented by maslow, and its presence in the scale is fundamental (4). as expected, the consistency of the measurements within each dimension was high, reflecting the coherence of these dimensions with the underlying theory (34,35). in this sense, the "need for independence" was the dimension that showed the highest consistency in its measurements (cronbach's alpha = 0.90; mcdonald's omega = 0.90), despite being the one represented by the fewest number of needs. this dimension is followed by the "need for safety and belonging" and "physiological needs"; in the latter, internal consistency may have been affected by the low variability and correlation of the need for help to breathe, as previously discussed. the three-dimension model proposed for assessing care needs in dependent people showed a satisfactory fit to its underlying theory. the tests to evaluate if the model is adequate or not were sat­isfactory; such tests are mainly based on comparing the model proposed with a naive one, where the greatest similarity possible is sought between them (33). consequently, in addition to obtaining satisfactory values in the indices analyzed, comparing the residual and estimated matrices of population covariances yielded small values that indicate minor differences (33). in the "physiological needs" dimension, the needs for help to eat and drink and in urinary and fecal eliminations were the ones with the highest weight for the dimension. on the one hand, regarding the "need for independence" dimension, the needs for help to get dressed and undressed and to perform body hygiene were the ones with the highest weight in the dimension representation, mainly explained by the high number of older adults in whom the need for help to perform basic activities of daily living increases with age (36). concerning this last dimension, it is part of what maslow calls the "need for high esteem," which refers to the search for self-recognition, self-confidence, self-value, and self-acceptance, aspects that can be strongly affected by dependence to carry out these two essential activities of daily living that prevailed in this dimension (32). on the other hand, regarding the "safety and belonging" group of needs, the need for help to preserve social life is the one that most strongly represents the dimension. it is worth emphasizing that once the physiological needs are met, the one related to feeling rooted in a place and socially integrated becomes the strength that dominates an individual's personality (32). the scale proposed to evaluate the care needs in dependent people includes the assessment of each of the fourteen needs on a scale that assigns a score varying from little need for help (1) to total need for assistance by nursing professionals (3). the final sum of the scores is grouped into the three dimensions proposed according to maslow's theory: physiological needs, need for safety and belonging and need for independence. according to maslow's postulates, the current scale suggests assigning double weight to the score of the physiological needs, as they are predominant in human beings and, similarly, that the search to meet them should prevail over the others (4), as they are fundamental for the very survival of the person (31). nursing plays a fundamental role in meeting the basic needs of dependent people and in helping to optimize internal and external resources; in addition, it assists in compensating deficits and defines the interventions to be implemented during the care and recovery of patients (37). standardization and objective use of the different theories about care and human needs allows the nursing profession to employ objective measurements to quantify the care needs and follow up on patients. in addition, it contributes to the development and strengthening of the discipline (2). measuring scales allow for quantifying the different states related to people's health and providing care centered on needs while monitoring patients' evolution. however, to ensure the proper use of a measuring scale, it is necessary to submit it to a validation process that supports its use, whether in research or clinical scope (34). it is in this fact that the main contribution of this research lies, providing the scientific support required for the proper use of both theories addressed in the diagnosis and follow-up of dependent patients. in addition, it promotes nurses' use and recognition of maslow's theory in their clinical practice and research (38). in addition, this scale, which showed good reliability and validity and is grounded on both theories presented, allows the implementation of care models based on virginia henderson's theory and their coordination with the nanda-i, noc, and nic (nnn) standardized languages, which have gained increasing relevance in the nurses' practice (2,39,40). finally, for future research studies, we suggest validating the instrument content with experts from different countries to officially authorize its use in various contexts. conclusions the scale prepared and validated for assessing care needs in dependent people, based on all fourteen needs included in virginia henderson's theory, consists of three dimensions whose grounds and sequentiality are anchored in maslow's theory of human needs. the items had satisfactory correlations with each other, as was also the case in the dimensions. this scale allows obtaining a classification score to determine the nursing assistance needs of dependent people. this scale represents a contribution to standardization and objective use of the theories 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[internet]. 2009 en. 06;15(3):163-166. doi: https://doi.org/10.1016/s1130-8621(05)71103-7 home 09 validacion del instrumento.indd 116 aquichan issn 1657-5997 margarita lazcano-ortiz1 bertha cecilia salazar-gonzález2 marco vinicio gómez-meza3 validación del instrumento: afrontamiento y proceso de adaptación de roy en pacientes con diabetes mellitus tipo 2 recibido: 27 de mayo de 2007 aceptado: 6 de noviembre de 2007 1 doctora en ciencias de enfermería. profesora tiempo completo. universidad autónoma del estado de hidalgo, méxico. magos1000@hotmail.com 2 ph. d. profesora tiempo completo. universidad autónoma de nuevo león, méxico. bsalazar@fe.uanl.mx 3 ph.d. profesor tiempo completo. universidad autónoma de nuevo león, méxico. mgomez@ccr.dsi.uanl.mx resumen objetivo: valorar las propiedades psicométricas de la escala de afrontamiento y proceso de adaptación de roy en población mexicana. materiales y métodos: la escala se aplicó a 200 participantes con diabetes mellitus tipo 2. para validar el constructo se realizó la extracción de factores con componentes principales y rotación varimax, con eigenvalores por arriba de 1 y cargas de factor mayores a ,30. resultados: seis reactivos fueron eliminados del análisis por mostrar correlación negativa con la correlación total de la escala. el análisis de componentes principales inicial reveló nueve factores con una variación explicada de 65,29%. sin embargo, no se consideraron tres factores por contener cada uno de ellos solamente un reactivo. por tanto, la escala final se acepta con 38 reactivos. el coeficiente de confiabilidad alfa de cronbach fue de, 93. discusión: el análisis reveló seis factores, uno más de lo reportado por roy, y con mayor variación explicada. algunos reactivos parecen no ser bien comprendidos por los participantes. conclusiones: este artículo aporta una aproximación metodológica para explorar la adecuación de un instrumento a una población diferente para la que originalmente fue diseñado. se concluye que la escala tiene consistencia interna y validez de constructo incipiente, los datos reportados en este estudio deben tomarse en cuenta con cautela. es conveniente revisar de nuevo los reactivos y adecuarlos a la cultura particular, y probar la escala de nuevo con pacientes con enfermedades crónicas degenerativas a fin de contar con instrumentos culturalmente equivalentes. palabras clave adaptación, diabetes mellitus tipo 2, confiabilidad, validez. año 8 vol. 8 nº 1 chía, colombia abril 2008 116-125 117 validación del instrumento: afrontamiento y proceso de adaptación en pacientes con diabetes mellitus tipo 2 instrument validation: roy´s coping and adaptation process in patients with type 2 diabetes mellitus abstract: aim: to assess the psychometric properties of roy’s coping and adaptation process scale among mexican nationals. materials and methods: the scale was applied to 200 participants with type 2 diabetes mellitus. to validate the construct, factor extraction was done with main components and varimax rotation. the eigenvalues were above 1 and factor loadings, above 0.30. results: six items were eliminated from the analysis because they showed a negative correlation with the total correlation of the scale. the initial main-components analysis revealed nine (9) factors with an explained variation of 65.29�. however, three factors were not taken into account, because each had only one item. consequently, final scale was accepted with 38 items. cronbach’s alpha, which is a numerical coefficient of reliability, was .93. discussion: the analysis revealed six factors, one more than reported by roy, and with more explained variation. some items do not appear to be understood fully by the participants. conclusions: the article offers a methodological approach to exploring how this instrument might be adapted for use with populations other than the one for which it was designed. the scale has good inner consistency and validity as an incipient construct. the data reported in the study should be used with caution. it is advisable to review the items once again, and to adapt them to the culture in question. to achieve culturally equivalent instruments, the scale should be retested with patients who have chronic degenerative illnesses. key words adaptation, type 2 diabetes mellitus, confiability, validity. validação do instrumento: afrontamento e processo de adaptação de roy nos pacientes com diabetes mellitus tipo 2 resumo objetivo: valorar as propriedades psicométricas da escala de afrontamento e processo de adaptação de roy na população mexicana. materiais e métodos: a escala foi aplicada a 200 participantes com diabetes mellitus tipo 2. para validar o constructo, foram extraídos fatores com componentes principais e rotação varimax, com eigenvalores acima de 1e cargas de fator maiores do que 30. resultados: da amostra foram eliminados seis reativos por amostrar correlação negativa com a correlação total da escala. a análise inicial de componentes principais amostrou nove fatores com uma variação explicada de 65.29%: no entanto, não foram considerados três fatores conterem só um reativo. portanto, a escala final e aceitada com 38 reativos. o coeficiente de confiabilidade alfa de cronbach foi 0,93. discussão: a análise revelou seis fatores, uno mais do que reportado por roy, mesmo se com maior variação explicada. alguns reativos parecem não ser bem compreendidos pelos participantes. conclusões: este artigo aporta um enfoque metodológico para explorar a adequação de um instrumento a uma população distinta da que foi tida em conta originalmente. a escala tem consistência interna e validez incipiente de constructo. os dados reportados neste estudo se devem tomar com cautela. é conveniente revisar de novo os reativos e adequá-los á cultura particular, e provar outra vez a escala com pacientes com doenças crônicas degenerativas para contar com instrumentos culturais equivalentes. palavras-chave adaptação, diabetes mellitus tipo 2, confiabilidade, validez. 118 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 introducción el riesgo de un evento extremo, cuyas consecuencias pueden ser extremadamente peligrosas, es una condición con la cual el hombre ha vivido a lo largo de su historia. la forma como enfrentamos el peligro va a depender de muchos factores que pueden ser resumidos en la evaluación cognitiva que los individuos realizan frente a un evento (1). en la práctica de enfermería a menudo se observa que los pacientes y sus familias hacen frente a enfermedades crónicas degenerativas de diferentes formas, positivas o negativas. roy (2) reconoce que el afrontamiento constituye una variable crucial para comprender el efecto del estrés sobre la salud y la enfermedad; el afrontamiento es clave para el manejo de la enfermedad, el mantenimiento de la salud o bien la recuperación. roy (2) alerta sobre la controversia sostenida entre psicólogos que defienden al afrontamiento como estilo frente a procesos. la revisión crítica de varios autores de enfermería (3, 4) acerca de los instrumentos existentes de afrontamiento hace notar que éstos carecen de procesos cognoscitivos y de conductas. su argumento es que justamente las estrategias o conductas de las personas ofrecen la pauta para las intervenciones de enfermería. por esta razón, roy se dio a la tarea de construir un instrumento que diera cuenta de lo anterior, y se basó en su modelo de adaptación y los resultados de investigaciones. la importancia de tener un instrumento validado nos permite conocer mejor el comportamiento de las personas que viven o se enfrentan a un evento, y así pensar mejor en una posible intervención. es todavía más importante contar con instrumentos culturalmente válidos en la población sobre la que estamos reportando o interactuando, dado que los reactivos y términos empleados originalmente responden a un determinado contexto además del constructo. en ocasiones, algunas situaciones contenidas en los reactivos no tienen sentido para otras culturas o regiones geográficas; en consecuencia, los resultados no reflejan la realidad del grupo estudiado. roy postula que el subsistema cognoscitivo es el proceso de afrontamiento principal de la persona, y se manifiesta en la conducta bajo la respuesta o modo fisiológico deauto concepto, función de rol e interdependencia (5). se refiere al “afrontamiento y procesos de adaptación” como a un constructo multidimensional que representa las respuestas o modos fisiológico y psicosocial. como sistema posee niveles jerárquicos pues abarca procesamientos cognoscitivos tanto a nivel de entradas o estímulos, procesos internos o centrales, como de salidas o respuestas. entradas las entradas son experiencias sensoriales o estímulos inmediatos o mediatos a la persona; los estímulos focales, contextuales y residuales provocan una respuesta procesada internamente, y constituyen el punto de vinculación entre el sistema de la persona y su entorno. además, los factores ambientales internos y externos, así como el tipo de experiencias, información sensorial y duración de la exposición al evento, afectan la entrada sensorial. 119 validación del instrumento: afrontamiento y proceso de adaptación en pacientes con diabetes mellitus tipo 2 procesos centrales el modelo de roy conceptualiza la dinámica interna de la persona como los procesos de afrontamiento que se llevan a cabo a través de los subsistemas regulador o innato y cognator4 o adquirido. el subsistema regulador comprende los procesos bioquímicos, neurológicos, independientes de la voluntad de la persona. los procesos de afrontamiento adquiridos son desarrollados a través de estrategias como el aprendizaje, el juicio y las emociones. salidas las respuestas o conductas para roy son el producto de los estímulos y del nivel de adaptación de la persona. para la autora sólo las respuestas que son creadas pueden ser observadas. las conductas que resultan de los procesos pueden ser observadas en cuatro modos adaptativos: fisiológico, autoconcepto, desempeño del rol e interdependencia (5). este constructo de afrontamiento describe las estrategias mediante las que la persona responde a influencias y cambios del ambiente a fin de crear una integración humana y ambiental (2). el desarrollo de los reactivos de la escala de afrontamiento y proceso de adaptación (caps por sus siglas en inglés) se llevó a cabo mediante procesos de indagación inductivos y deductivos que, a su vez, tuvieron como base el modelo de adaptación de roy. el trabajo inductivo se llevó a cabo mediante entrevistas con 10 pacientes y análisis de contenido de 36 planes de cuidado de enfermería, a fin de inferir las estrategias de afrontamiento de acuerdo con los modos adaptativos. producto de ello, roy identificó 45 estrategias de afrontamiento, que fueron revisadas y ratificadas por cuatro expertas, dos en afrontamiento y teoría de adaptación; las otras dos en proceso cognitivo. posteriormente, en forma deductiva, identificaron 26 categorías de procesamiento (entradas, procesos y salidas) con base en el modelo de procesamiento cognoscitivo. se generaron 73 enunciados como producto de estos trabajos, pero se eliminaron 26 reactivos debido a la redundancia y a que no obtuvieron cargas significativas en una primera prueba. por lo anterior, se sometió a prueba de nuevo la escala con 47 reactivos. las propiedades psicométricas fueron analizadas con 349 casos procedentes de dos grupos: miembros de la asociación de daño espinal y de la asociación de neuroma acústico. el criterio empleado fue el de contar entre 5 a 10 participantes por reactivo; dado que se eliminaron cuestionarios incompletos, quedaron poco más de 7 participantes por reactivo. de la extracción de factores con componentes principales con rotación varimax, con eigenvalores iguales o mayores de 1, y cargas mayores a ,30 se obtuvieron cinco factores. la interpretación conceptual es la siguiente: factor 1, con recursos y enfocado, con diez reactivos; factor 2, físico y estable, con catorce reactivos; factor 3, procesos de alerta con nueve reactivos; factor 4, procesamientos sistemáticos, con seis reactivos; factor 5, conociendo y relacionando, con ocho reactivos. los factores explicaron 45,3% del total de la varianza. el coeficiente de cronbach fue de, 94, las subescalas variaron de ,86 a ,78. la autora concluye que esta validación es apenas inicial; recomienda continuar analizando sus propiedades. 4 el constructo “cognator” acuñado por roy se refiere a procesos mentales complejos resultantes de la percepción, información, aprendizaje, juicio y emociones de cada persona; por tanto, no se le puede reducir a procesos cognoscitivos meramente. es a través de las emociones que la persona usa sus defensas para buscar alivio a su ansiedad y crear valores positivos, y vínculos o lazos. los procesos de afrontamiento adquiridos son desarrollados a través de estrategias como el aprendizaje, el juicio y las emociones. 120 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 por tanto, el objetivo del presente estudio fue valorar las propiedades psicométricas del caps en población mexicana. la versión en español fue aplicada a 200 participantes con diabetes mellitus tipo 2. antes de analizar las propiedades psicométricas se obtuvo el coeficiente de confiabilidad alfa de cronbach de la escala total. para validar el constructo se realizó extracción de factores con componentes principales y rotación varimax, con eigenvalores o raíces características por arriba de 1, y cargas factoriales mayores a ,30. se utilizó el programa spss versión 13. instrumento como se señaló, la escala de afrontamiento y proceso de adaptación aplicado (caps) consta de 47 reactivos con cinco dimensiones de acuerdo con roy. el patrón de respuesta es de cuatro puntos, que va desde 1 = nunca, a 4 = siempre. el puntaje puede oscilar entre 47 a 188 puntos, a mayor puntaje significa un uso más consistente de estrategias de afrontamiento. la puntuación total de caps se obtiene invirtiendo los valores de las preguntas negativas 5, 8, 11, 13, 15, 20, 23, 24, 33, 35, 39, 42, 43, 45, 47 (2). el instrumento fue elaborado por callista roy, (versión inglés) con la finalidad de identificar las estrategias que la persona utiliza para afrontar situaciones difíciles (2). actualmente existen dos estudios de investigación en español y tailandés. el primer estudio fue realizado por gutiérrez y colaboradores (6) de la universidad de la sabana, aplicado a 417 sujetos mayores de 50 años con una función mental intacta. la confiabilidad se evaluó a través de la consistencia interna, con un alfa de cronbach de 0,88. la estabilidad se midió a través del coeficiente de correlación de spearman (r = 0,94). los resultados confirman la validez y la confiabilidad de la escala de medición del proceso de afrontamiento y adaptación en la versión español (6). el segundo estudio fue realizado por chayaput (7), versión tailandesa de la escala de afrontamiento y proceso de adaptación (tcaps), y fue aplicado a 554 pacientes hospitalizados con enfermedades agudas. el tcaps obtuvo alta confiabilidad con un coeficiente alfa de cronbach de ,93 y arrojó cuatro factores, con una explicación de 42,3% de varianza explicada. los resultados mostraron equivalencia semántica, conceptual y técnica (7). el método utilizado para la traducción en español y tailandés fue la retrotraducción. este método es preferible y recomendable para la traducción de instrumentos de otro idioma (8). varios autores señalan que algunas de las recomendaciones para lograr buena retrotraducción y propiedades psicométricas son: a) la persona que traduce debe estar familiarizada con el contenido del origen del lenguaje del instrumento; b) el material traducido no debe tener errores de significado; c) la habilidad y el conocimiento de las personas que traducen es uno de los más importantes factores para una buena calidad de material traducido (9). las anteriores recomendaciones se cubrieron en la traducción de este instrumento (contacto personal con una profesora de la universidad la sabana). además, el instrumento fue revisado y autorizado para aplicarlo en población mexicana por roy. resultados el promedio de edad de los participantes fue de 52,2 años (de = 7,5) con un valor mínimo de 32 y máximo de 65 años. el el objetivo del presente estudio fue valorar las propiedades psicométricas del caps en población mexicana. la versión en español fue aplicada a 200 participantes con diabetes mellitus tipo 2. 121 validación del instrumento: afrontamiento y proceso de adaptación en pacientes con diabetes mellitus tipo 2 72% correspondió al sexo femenino. los participantes mostraron un nivel de escolaridad de 6,19 años (de = 6,98) con un mínimo de 0 y máximo de 20 años. la media del índice de afrontamiento y proceso de adaptación fue de 64,19 (de =11,42). el primer análisis de componentes principales arrojó 11 factores, se analizaron las correlaciones de cada reactivo con la escala total, y se eliminaron seis por presentar correlación negativa (23, 29, 39, 42, 43 y 47). se volvió a aplicar el análisis de componentes principales y rotación varimax con normalización kaiser, con raíces características por arriba de 1 con cargas por encima de ,30, el cual arrojó nueve factores con una variación explicada de 65,29%. sin embargo, se observó que los últimos tres factores contenían sólo un reactivo cada uno de ellos (reactivos 8, 27 y 35), permaneciendo 38 reactivos para el análisis. el coeficiente de confiabilidad alfa de cronbach para toda la escala fue de ,92 con los 47 reactivos, y con 38 reactivos fue de ,93. para el primer factor fue de ,94, para el segundo ,80, para el tercero ,82, para el cuarto factor ,85, para el quinto ,61, y para el sexto fue de ,52. en la tabla 2 se presenta la estadística descriptiva de la escala de proceso de afrontamiento y adaptación original. discusión la validez de constructo se llevó a cabo a través de análisis factorial con el método de extracción, el análisis de los componentes principales, y el método de rotación varimax y normalización kaiser aplicados a la matriz de estructura de los reactivos. la extracción de factores de este estudio resultó en seis, uno más de lo reportado por roy, a diferencia de zhan (10) que obtuvo cinco factores y de chayaput (7) que obtuvo cuatro. el coeficiente alfa de cronbach general de este estudio fue de ,93, con una puntuación más alta que el alfa de cronbach del análisis de factor de zhan en el que obtuvo ,85 con una explicación de 38,1% de varianza, y similar con chayaput con un alfa de ,93 con una explicación de 42,3% de varianza explicada. de los 24 reactivos que cargaron en el primer factor de este estudio, ocho de ellos coinciden con el primer factor de la autora del instrumento. el resto de los reactivos se relacionaron con todos los otros factores de la autora, por tanto, se observa una mezcla de factores y no se puede concluir que tenga interpretación conceptual, a diferencia de chayaput (7) en donde se agruparon 17 reactivos en el primer factor llamado ingenio y sistemático. dos reactivos del segundo factor corresponden al factor procesos sistemáticos y un reactivo al físico-estable, en contraparte a 14 reactivos de roy de este último factor. similar a chayaput (7), se agruparon 13 reactivos denominados factor físico-estable. el tercer factor de este estudio comprende tres reactivos que correspondieron al factor llamado conociendo y relacionando, la autora reportó ocho reactivos. a diferencia de chayaput (7), en donde reportaron 10 reactivos con el nombre del factor positivo y conocer. el cuarto factor de este estudio sólo agrupa dos reactivos que correspondieron al factor proceso de alerta, la autora reportó nueve reactivos. a diferencia de la validez de constructo se llevó a cabo a través de análisis factorial con el método de extracción, el análisis de los componentes principales, y el método de rotación varimax y normalización kaiser aplicados a la matriz de estructura de los reactivos. 122 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 chayaput (7), en donde siete reactivos cargaron para el factor llamado proceso de alerta. en el quinto factor en este estudio, un reactivo corresponde a recurso y enfocado de roy, y tres reactivos con el factor físico-estable. finalmente, el sexto factor agrupó dos reactivos que correspondieron a los factores físico-estables y proceso de alerta. los reactivos que cargaron negativamente pueden tener diversas explicaciones. una posibilidad es el bajo nivel de escolaridad de los participantes con un promedio de seis años, y tal vez con escasas habilidades para toma de decisiones y solución de problemas. de acuerdo con roy, el afrontamiento como proceso cognitivo y como forma de pensamiento y proceso de información requiere de habilidades cognitivas. otra posible explicación es la complejidad de los reactivos o que no hayan sido bien entendidos debido a que los términos utilizados no son de uso frecuente por los participantes, como por ejemplo: “sólo puedo pensar en lo que me preocupa”, “tiendo a reaccionar con exageración al comienzo”, “tiendo a paralizarme y confundirme al menos por un momento”, “por alguna razón no parezco beneficiarme de mis experiencias pasadas”. es probable que la diferencia cultural y situacional sea un elemento que explique las diferencias, o bien la escolaridad. un comentario planteado por los participantes fue que algunas preguntas se repiten. cabe señalar que son escasos los reactivos con cargas por debajo de ,50. aparentemente 38 de estos reactivos son válidos en la población estudiada. conclusiones se concluye que la escala posee consistencia interna adecuada y validez de constructo incipiente, los datos reportados en este estudio deben tomarse en cuenta con cautela. el hecho de que algunos reactivos hayan presentado correlación negativa y otros hayan cargado en un solo factor, no significa que deban eliminarse. por tanto, se recomienda revisar y adecuar la redacción de todos los reactivos a fin de que tengan mejor sentido cultural. se sugiere probar la escala incluyendo todos los reactivos con otras poblaciones de pacientes adultos con enfermedades crónicas degenerativas para poder concluir si es culturalmente equivalente. se recomienda que el instrumento sea aplicado en pacientes con mayor escolaridad y homogeneidad al respecto. tabla 1 ponderación de factores y comunalidades5 de la escala de afrontamiento y proceso de adaptación reactivo factor factor factor factor factor factor c* 1 2 3 4 5 6 me siento bien al saber que estoy manejando el problema ,799 ,728 miro la situación positivamente como un reto ,798 ,685 miro la situación desde diferentes puntos de vista ,797 ,735 trato de usar mis habilidades para enfrentar la situación** ,796 ,770 reorganizar mis sentimientos positivamente** ,782 ,706 planteo soluciones aunque sean difíciles de alcanzar ,769 ,730 estoy atento a la situación** ,750 ,707 trato de ser creativo y propongo soluciones** ,710 ,656 llamo al problema por su nombre ,699 ,545 obtengo buenos resultados con problemas complejos ,675 ,646 analizo los detalles tal como sucedieron ,634 ,657 identifico cómo quiero que resulte la situación** ,610 ,673 obtengo información para aumentar mis opciones** ,598 ,598 adopto una nueva destreza si resuelve mi dificultad ,593 ,608, estoy activo durante el día cuando estoy en crisis ,589 ,535 trato de hacer que todo funcione a mi favor** ,567 ,581 soy realista con lo que sucede ,558 ,673 aprendo de las soluciones de otros ,534 ,658 5 comunalidades: es la varianza compartida de una variable (reactivo) entre los factores. 123 validación del instrumento: afrontamiento y proceso de adaptación en pacientes con diabetes mellitus tipo 2 reactivo factor factor factor factor factor factor c* 1 2 3 4 5 6 me rindo fácilmente ,523 ,553 utilizo el humor para manejar la situación ,484 ,553 desarrollo un plan para enfrentar la situación** ,482 ,685 mantengo equilibrio entre actividad y descanso ,471 ,628 encuentro la crisis demasiado complicada ,426 ,626 pienso en el problema paso a paso ,382 ,663 tiendo a reaccionar con exageración al comienzo ,781 ,656 no actúo hasta que tengo comprensión de la situación ,719 ,798 trato de aclarar cualquier duda antes de actuar ,649 ,726 trato de recordar soluciones que me han servido antes ,818 ,766 puedo relacionar lo que sucede con experiencias pasadas ,807 ,794 recuerdo cosas que me ayudaron en otras situaciones ,675 ,726 soy más eficaz bajo estrés ,858 ,802 soy menos eficaz bajo estrés ,835 ,809 encuentro difícil explicar el verdadero problema ,685 ,776 propongo soluciones para problemas nuevos ,603 ,687 parece que actúo con lentitud sin razón aparente ,473 ,667 tiendo a culparme por cualquier dificultad que tengo ,416 ,497 puedo hacer varias actividades al mismo tiempo ,632 ,640 cuando estoy preocupado tengo dificultad para realizar tareas ,567 ,586 eigenvalores 15,65 2,94 1,70 1,64 1,37 1,33 varianza explicada (%) 36,41 6,85 3,96 3,82 3,19 3,11 varianza explicada acumulada (%) 36,41 43,26 47,22 51,04 54,23 57,34 * comunalidades. ** reactivos que coinciden con el primer factor de roy. tabla 2 estadística descriptiva de la escala de proceso de afrontamiento y adaptación original 1. puedo hacer varias actividades al mismo tiempo 3,13 ,84 2. propongo soluciones para problemas nuevos 3. llamo al problema por su nombre y trato de verlo todo 4. obtengo información para aumentar mis opciones 5. cuando estoy preocupado tengo dificultad para realizar tareas 2,56 ,93 6. trato de recordar soluciones que me han servido antes 7. trato de que todo funcione a mi favor 8. solo pienso en lo que me preocupa 2,28 ,94 9. me siento bien de saber que estoy manejando el problema 10. identifico cómo quiero que resulte la situación media de tabla 1 ponderación de factores y comunalidades5 de la escala de afrontamiento y proceso de adaptación reactivo 124 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 11. soy menos eficaz bajo estrés 12. no actúo hasta que tengo comprensión de la situación 13. encuentro la crisis demasiado complicada 2,68 ,88 14. pienso en el problema paso a paso 15. parece que actúo con lentitud sin razón aparente 2,55 ,87 16. trato de reorganizar mis sentimientos positivamente 17. estoy activo durante el día cuando estoy en crisis 18. soy realista con lo que sucede 19. estoy atento a la situación 20. tiendo a reaccionar con exageración al comienzo 2,61 1,06 21. recuerdo cosas que me ayudaron en otras situaciones 22. miro la situación desde diferentes puntos de vista 23. tiendo a quedarme quieto por un momento 2,44 ,86 24. encuentro difícil explicar el verdadero problema 2,52 ,86 25. obtengo buenos resultados con problemas complejos 26. trato de usar mis habilidades para enfrentar la situación 27. puedo desenvolverme mejor cuando tengo que ir a lugares desconocidos 28. utilizo el humor para manejar la situación 29. con tal de salir de la crisis estoy dispuesto a modificar mi vida 30. mantengo equilibrio entre la actividad y el descanso 31. soy más eficaz bajo estrés 32. puedo relacionar lo que sucede con experiencias pasadas 33. tiendo a culparme por cualquier dificultad que tengo 2,78 ,91 34. trato de ser creativo y propongo soluciones 35. por alguna razón no me beneficio de mis experiencias pasadas 2,99 ,76 36. aprendo de las soluciones de otros 37. miro la situación positivamente como un reto 38. planteo soluciones aunque parezcan difíciles de alcanzar 39. experimento cambios en la actividad física 2,28 1,02 40. analizo los detalles tal como sucedieron 41. trato de aclarar cualquier duda antes de actuar 42. trato de hacer frente la crisis desde el principio 1,66 ,59 43. me doy cuenta de que me estoy enfermando 1,71 ,73 44. adopto una nueva destreza cuando resuelvo mi dificultad 45. me rindo fácilmente 3,16 ,84 46. desarrollo un plan para enfrentar la situación 47. al parecer me hago ilusiones de cómo resultarán las cosas 2,07 ,84 tabla 2 estadística descriptiva de la escala de proceso de afrontamiento y adaptación original media dereactivo 125 validación del instrumento: afrontamiento y proceso de adaptación en pacientes con diabetes mellitus tipo 2 referencias 1. lópez e, marvan ml. validación de una escala de afrontamiento frente a riesgos extremos. salud pública de méxico 2004; 46 (3): 216-221. 2. roy c. coping and adaptation processing scale (caps), 2004. en prensa. 3. oakland s, ostell a. measuring coping: a review and critique. human relations 1996; 49 (2): 133-155. 4. mishel m, sorenson d. revision of the ways of coping checklist for a clinical population. western journal of nursing research 1993; 15 (1): 59-79. 5. roy c, andrews h. the roy adaptation model. 2 ed. stanford, ct: appleton & lange;1999. p. 31-48. 6. gutiérrez c, veloza m, moreno m, durán m, lópez c, crespo o. validez y confiabilidad de la versión en español del instrumento escala de medición del proceso de afrontamiento y adaptación de callista roy. revista aquichán 2007; 7 (1): 54-63. 7. chayaput p. development and psychometric evaluation of the thai version of the coping and adaptation processing scale. [tesis doctoral]. massachusetts; 2004. 8. beck c, bernal h, froman r. methods to document semantic equivalence of a translated scale. research in nursing and health 2003; 26: 64-73. 9. nunnally j, bernstein i. psychometric theory. 3 ed. new york. en chayaput p. development and psychometric evaluation of the thai version of the coping and adaptation processing scale. [tesis doctoral]. massachusetts; 2004. 10. zhan l. cognitive adaptation processing and selfconsistency in hearing-impaired elderly. dissertation abstracts international, 54 (08b), 4086 (umino. puz9402783). 07 actualizacao do cuidar.indd 85 atualização do cuidar atualização do cuidar recibido: 28 de enero de 2008 aceptado: 3 de abril de 2008 resumo o presente artigo tem como objetivo divulgar uma série de idéias acerca do cuidado, a fim de contribuir para uma reflexão sobre a prática do cuidar no cenário da enfermagem. é uma síntese sobre os aspectos que fundamentam a natureza e o conhecimento do cuidar desde uma perspectiva filosófica e propõe algumas definições, como cuidado humano, cuidado na enfermagem, relações de cuidado, entre outras. palavras-chave: enfermagem, cuidado, cuidar. nuevas ideas sobre el cuidado resumen el presente artículo tiene como objetivo difundir una serie de ideas acerca del cuidado, pretendiendo con esto, contribuir para una reflexión sobre la práctica del cuidar en el cotidiano del escenario de la enfermería. presenta una síntesis sobre los aspectos que fundamentan la naturaleza y el conocimiento del cuidar bajo la perspectiva filosófica y plantea algunas definiciones tales como: cuidado humano, cuidado de enfermería, relaciones de cuidado, entre otras. palabras clave enfermería, cuidado, cuidar. new ideas about care abstract the aim of this article is to circulate a series of ideas on care in the hope of fostering reflection on care practices in everyday nursing scenarios. it offers a summary of the aspects that substantiate the nature and understanding of care from a philosophical point of view, and proposes definitions of human care, nursing care and care relationships, among others. key words nursing, attention, care issn 1657-5997 año 8 vol. 8 nº 1 chía, colombia abril 2008 85-96 vera regina waldow1 1 profesora jubilada por la universidad do rio grande do sul. porto alegre, brasil. doctora en educación-enfermería. waldowvr@portoweb.com.br 86 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 introdução as idéias emitidas no presente texto são de autoria e, portanto, de inteira responsabilidade da autora que, ao longo de quase duas décadas, vem pesquisando e estudando sobre o tema do cuidado. primeiramente houve uma preocupação em divulgar o tema cuidar/cuidado (1, 2), inspirado em alguns trabalhos de teoristas e estudiosas do tema, como madeleine leininger (3), jean watson (4) e sister simone roach (5), entre outras. após algum tempo, a autora iniciou a publicar trabalhos nos quais expunha suas próprias idéias (6), as quais, por sua vez, evoluíram com o passar do tempo. a sua trajetória pode ser constatada nas suas publicações mais recentes (7, 8, 9). contribuíram para muitas das idéias, igualmente, discussões com grupos de colegas de pesquisa, seminários e cursos realizados, além de constante investigação sobre a temática. atualmente seu trabalho é orientado pela linha filosófica, sendo heidegger (10) seu referencial de partida; assim mesmo com pelas contribuições de outros autores, da mesma linha, como boff (11); mayeroff (12); noddings (13) e torralba (14, 15). neste texto, o cuidar será analisado buscando captar o seu sentido mais amplo: o cuidado como uma forma de ser, de se expressar, de relacionar-se consigo mesmo, com o outro ser e com o mundo (6, 8). o que se propõe é uma releitura ou uma resignificação do cuidado, visualizando-o como uma ação moral, portanto permeado de valores, e também como um sentimento. envolve, conforme griffin (16), além de atividade, o aspecto de atitude em que são expressos os sentimentos. para a autora, as atividades de cuidar só podem ser realmente cuidado ao serem desempenhadas quando estão acompanhadas de um comportamento emocional. como se verá a seguir, o cuidado é um fenômeno existencial, relacional e contextual. existencial porque faz parte do ser, lhe confere a condição de humanidade; relacional porque ocorre em relação com outro ser, se revela na co-existência com outros seres; contextual porque assume variações, intensidades, diferenças nas maneiras e expressões de cuidar conforme o meio em que ocorre (8). gênese do cuidar uma curiosidade em saber como se originou, se desenvolveu e como tem se manifestado o cuidar na humanidade, fez com que se investigasse a respeito. contudo, o que se conseguiu são apenas aproximações, suposições daquilo que se infere e acredita serem hábitos e comportamentos de cuidar. de modo informal e rudimentar, o cuidar inicia-se de duas formas: como um modo de sobrevivência e como uma expressão de interesse e carinho em relação com outro ser; portanto, relacional (6, 8). a história das civilizações nos brinda alguns registros. nos diferentes períodos imprimiram, em forma de arte, muitos dos seus hábitos e rituais de seu cotidiano, de sua 87 atualização do cuidar cultura. através de algumas disciplinas, como a arqueologia e a antropologia, consegue-se deduzir algumas evidências de como os povos se desenvolveram através dos tempos, se movimentando entre hábitos, ações e comportamentos de cuidado e não-cuidado. o ser humano é um ser de cuidado; o ser nasce com este potencial, portanto, todas as pessoas são capazes de cuidar (5) e necessitam, igualmente, de serem cuidadas. porém, esta capacidade será mais ou menos desenvolvida de acordo com as circunstâncias, dependerá da forma como as pessoas foram cuidadas durante as etapas da vida. vários fatores intervêm neste processo: ambiente, cultura, economia, política, religião, entre outros. ao pinçar alguns momentos da evolução humana e os sucessivos eventos através dos séculos não se consegue caracterizar, de forma fidedigna, o comportamento das pessoas nas suas culturas, em termos de cuidado. atualmente já é possível resgatar muitas informações através da tecnologia, das descobertas e métodos exploratórios, assim como de estudos e investigações utilizando metodologias variadas. no entanto, o que ficou no passado permanece um mistério e é fonte de suposições e especulações. muitos segredos, ainda sobre antigas civilizações, estão sendo descobertos. a autora do presente trabalho oferece uma visão histórica sobre o cuidado, buscando resgatar informações sobre esta categoria, desde o início da humanidade, as primeiras civilizações, antes e após o cristianismo e nos tempos mais modernos (6, 8). pode-se considerar que o ser humano foi progredindo nas suas necessidades, através dos tempos, as quais lhe exigiram o desenvolvimento de habilidades e capacidades não só físicas e biológicas para a adaptação ao meio e às circunstâncias, mas também mentais, emocionais e sociais. os recursos e os comportamentos de cuidado à sobrevivência assumem assim características estéticas, pois os seres humanos imprimem cultura e história nas suas pinturas e esculturas de figuras e objetos de uso doméstico, os quais descrevem eventos do dia-a-dia, crenças, devoções, etc. além da expressão artística, o ser humano tenta comunicar experiência, conhecimento e sentimentos. dessa maneira, a arte como forma de expressão cultural, de comunicação e de expressão de sentimentos, registra a história, a cultura de um povo e as formas e rituais de cuidado. o que se pode concluir é que o ser humano, infelizmente, em sua história, apresenta paradoxos e ambigüidades entre comportamentos de cuidado e não-cuidado: as guerras, os progressivos e cada vez mais sofisticados arsenais para uso militar, verdadeira obsessão dos homens, são responsáveis pela dizimação de milhares e milhares de pessoas. as descobertas científicas e o avanço industrial e tecnológico, de um lado, têm beneficiado populações no mundo inteiro, e de outro, acarretam tragédias em função do prazer do ser humano em exercitar seu poder. foley (17) recorda que, desde o final do pleistoceno, há cerca de 10.000 anos, o meio ambiente tem sido transformado pela atividade humana. ele menciona a destruição de florestas; a modificação do curso ou o desaparecimento de rios em função das necessidades humanas; o incrível aumento da população e a alteração de tamanho e forma das plantas e animais; a criação, inclusive de novas espécies. a engenharia genética e a biotecnologia têm acelerado esse processo e possibilio ser humano é um ser de cuidado; o ser nasce com este potencial, portanto, todas as pessoas são capazes de cuidar (5) e necessitam, igualmente, de serem cuidadas. 88 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 tado coisas inimagináveis até certo tempo atrás, como clonagem, entre outras técnicas. em outro sentido, observa foley, o desaparecimento crescente de muitas espécies e a redução da biodiversidade parece não só uma ameaça, mas sim uma realidade. em contrapartida, doenças têm sido erradicadas, a mortalidade tem sido reduzida, o trabalho se tornado simplificado, e as oportunidades de realização parecem ter-se ampliado. a violência, contudo permanece ou aumenta, ou ainda simplesmente assume nova cara; novas doenças surgem, outras reaparecem. a população envelhece e os jovens morrem vítimas de acidente, de homicídio e de drogas. os governos tornam-se cada vez mais corruptos, a ética torna-se questionável. considerando-se a idéia de caracterizar o cuidar como um modo de sobrevivência, a humanidade ainda demonstra essa forma de cuidado, agora bastante mais exigente e sofisticada. por vezes não mede conseqüências, pois a luta agora é bem mais competitiva, e o ser humano é mais individualista. o bem-estar passou a significar ter, possuir coisas, adquirir bens e, por vezes, não importa a que custo. quanto ao cuidar como uma forma de se relacionar, parece que vivemos um paradoxo. a hostilidade, o ódio, a violência, a desonestidade e o medo convivem com a solidariedade, a afetividade, o amor, a luta pela paz, pelo respeito, pela esperança. no final quem vence? pensa-se que o cuidado “humano” é “uma atitude ética em que seres humanos percebem e reconhecem os direitos uns dos outros”. as pessoas se relacionam numa forma a promover o crescimento e o bem-estar dos outros (6: 43). considerando-se dessa forma, pode se questionar qual é a ética que impera atualmente. o cuidar sob a perspectiva filosófica o ser humano, além de atuar no mundo, sente a necessidade de explicar o porquê de suas ações, a razão de seus atos, e pensar as razões de cuidar, assim como justificar tal atividade. isso constitui uma tarefa básica não somente para compreender-se a si próprio, mas também para exigir de si mesmo e de seus semelhantes uma ação compatível com sua dignidade moral. a interpretação filosófica do cuidar tem sua fundamentação em martin heidegger. para entender sua interpretação, é necessário falar brevemente antes do ser que habita o cuidar. ser implica que alguém está em vias de tornar-se algo, um “vir a ser”. o homem é entendido como um projeto inacabado, um “sendo” que se interroga acerca do ser, entidade que está em condições de refletir sobre seu próprio ser. a presença é o ente do ser, e o sentido existencial da presença é a cura ou cuidado. o ser é uma realidade difícil de definir; por exemplo, é mais fácil compreender que não se é um outro. “sendo-com-os outros” é a característica fundamental que heidegger (10) descobre no existir do ser humano. o ser humano só pode definir-se a partir do seu existir, de sua possibilidade de ser ou não ser o que ele é. dasein, que significa o ser-aí, quer dizer o modo de existir do homem, único entre os existentes. é a compreensão de ser e a sua revelação. dasein está em relação básica com o ser, cuja filosofia é a explicitação da compreensão do existir considerando-se a idéia de caracterizar o cuidar como um modo de sobrevivência, a humanidade ainda demonstra essa forma de cuidado, agora bastante mais exigente e sofisticada. 89 atualização do cuidar pelo existente. na análise do dasein, verifica-se que ele é essencialmente estar no mundo. o mundo e o dasein estão em relação interna, não havendo sentido em conceber dasein fora do mundo. dasein está sempre criando, cuidando, preocupado e em desassossego com o mundo num estado de busca constante e jamais alcança a totalidade. a existência autêntica é sempre uma inquietude de ser, uma luta com o não-ser (10). ser-no-mundo é essencialmente zelar, cuidar, existir ao lado das coisas e dos seres, ter interesse, ser-com-os-outros que encontramos no mundo, o que corresponde ao que heidegger denomina de “solicitude”. a relação de ser com os outros se caracteriza pela maneira como age, sente e pensa no convívio com seus semelhantes. o cuidar, o relacionar-se com outro é a estrutura fundamental do ser-aí. cuidar se expressa pela relação com o outro dentro do mundo. existencialmente falando, significa “zelar”; é o desvelar do outro, orientado pela consideração e paciência. o cuidar põe em evidência o serlivre. o ser humano sem “cuidado” não pode ser livre. as duas partes envolvidas na relação, ser cuidado e cuidador, contribuem para ele; existe responsabilidade, compromisso. o cuidado deve ser, de alguma forma, completado no outro para assim ser descrita como uma relação de cuidado. a relação é o reconhecimento do encontro humano que implica uma resposta afetiva. o cuidar, o relacionar-se de forma envolvente e significante com o outro ser corresponde à solicitude e esta solicitude que representa a “preocupação com” é o cuidado (10). concluindo esta parte, podese dizer que “o ser-ai-no-mundo se define pelas formas ou maneiras de experienciar cuidado e pelas relações (de cuidado) que estabelece consigo mesmo, com os outros e com o meio que o cerca” (8: 37). a figura abaixo representa, de forma gráfica o cuidado humano que para waldow é compreendido como uma forma de viver, de ser e de se expressar: ”consiste em uma postura ética e estética frente ao mundo e contribuir com o bem-estar geral, na preservação da natureza, na promoção das potencialidades, da dignidade humana e da nossa espiritualidade; é contribuir na construção da história, do conhecimento, da vida” (8: 89). a figura é representada por círculos que se interconectam e por isso se apresentam por linhas abertas, tracejadas, que compõem o eu –ou self–, o outro e o cosmos. estas dimensões são permeadas por elementos que variam: valores, conhecimento, felicidade, respeito, ética, entre outros. as linhas onduladas representam a dinamicidade dessas variáveis; constituem o fluxo energético entre as dimensões e os elementos que variam. figura 1. representação gráfica do cuidado humano conforme waldow (6, 8). o cuidado na enfermagem em sua trajetória, a enfermagem tem sido associada ao termo cuidar, assim como ao termo assistir. os termos são utilizados de forma indiferenciada, mas algumas diferenças podem ser observadas (18). o cuidar é anterior à enfermagem e, através da história, se constata que havia uma estreita ligação com a prática religiosa no sentido de oferecer conforto, tanto físico quanto espiritual, aos necessitados (pode-se dizer que mais espiritual), além de abrigo e alimento. pessoas que se dedicavam a exercer práticas de caridade tratavam também feridas; durante as guerras havia voluntários para cuidar dos guerreiros. com a construção dos hospitais, se utilizavam pessoas sem formação para “cuidar” dos enfermos, e houve época em que estas pessoas, sendo as religiosas expulsas destes locais, eram de caráter duvidoso, prostitutas e bêbados. esta época foi considerada o período negro na enfermagem. com o movimento reformista de nightingale, o cuidar assume uma nova face. higiene, a importância do ambiente, a preocupação em fazer as ações com conhecimento são características que florence nigthingale imprimiu à enfermagem. assim mesmo, o comportamento e a atitude das enfermeiras eram caracterizados por uma dualidade: obediência, servilismo, docilidade, mas também autoritarismo. com o advento da revolução industrial e da era científica, as especialidades médicas adquiriram uma importância refletida na enfermagem. há uma idolatria pela técnica. a cura e as atividades de cuidar passam a ter privilégio. importam aquelas atividades de cunho terapêutico, 90 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 enfocando a doença; a pessoa passa a ser secundarizada. ações básicas de cuidar são menosprezadas e delegadas. a enfermagem tenta auferir status se mirando no modelo biomédico e busca se caracterizar como ciência. a década de sessenta se caracteriza pelo início do desenvolvimento de teorias de enfermagem nos estados unidos e se propagam aos outros países. a maioria dessas teorias foi desenvolvida por enfermeiras norte-americanas, com ênfase em aspectos biomédicos, como adaptação, homeostase, necessidades básicas. algumas buscam apoio em outras áreas de conhecimento e seu enfoque predominante é o aspecto psicológico ou social. é comum, mesmo utilizando um enfoque oriundo do paradigma positivista, considerarem-se “holísticas”, o que revela ambigüidade e, inclusive, contradições. o processo de enfermagem é uma conseqüência das teorias, o que parece organizar o trabalho de enfermagem e lhe conferir prestígio. algumas teorias propõem o cuidar como foco central, como as de leininger (3), watson (4) e de boykin e schoenhofer (19). parece que a fase atual por que passa a enfermagem é justamente discutir e questionar seu conhecimento adotando abordagens plurais. há certa diversidade, embora o modelo norte-americano ainda exerça certa influência; a classificação por diagnósticos é uma delas. contudo, já se observam peculiaridades próprias de cada país. as teorias e modelos fora dos estados unidos perdem o seu glamour (9). uma tendência observada e já evidenciada nas abordagens das pesquisas mais recentes é a de um enfoque mais humanista na enfermagem. observa-se uma tendência de privilegiar uma pluralidade de abordagens, o que equivale permitir que se discuta diferentes maneiras de pensar, fazer e ensinar enfermagem. em conseqüência visualiza-se uma era de desafios, pois conduz os profissionais a conviverem com uma heterogeneidade de idéias nos processos de cuidar. o pluralismo, a diversidade, a interdisciplinaridade são algumas das tônicas para o novo milênio e, entre elas, também o resgate do cuidado humano contrariamente ao que algumas pessoas pensam, o resgate do cuidado na enfermagem não é uma rejeição aos aspectos técnicos, tampouco ao aspecto científico. o que se pretende ao relevar o cuidar é enfatizar a característica de processo interativo, assim como do componente emocional, da intuição que caracterizam a sua dimensão artística, além da dimensão moral que contém (6). uma das dificuldades no cuidar ser aceito, em seu caráter humanístico, reside na idéia de que, visto desta forma, não apresentaria características de cientificidade e de ações sistemáticas e tecnologizadas que tragam “resultados pertinentes”. no entanto, há quem rejeite a compreensão preconceituosa do cuidado que desqualifica o cuidar ao transmitir sentimentos (20). o cuidado compõe a linguagem da enfermagem e ao visualizá-lo como um modo de ser, relacional e contextual, caracterizase por ser a única ação verdadeiramente independente da enfermagem. o cuidado não pode ser prescrito; terapêuticas, técnicas, intervenções e procedimentos podem ser prescritos. não se prescreve um modo de ser, não se ditam ou criam regras ou normas de cuidar, ou maneiras de se comportar. eles podem ser sugeridos, aconselhados, recomendados, não prescritos (8). na enfermagem, o cuidar “compreende os comportamentos e atitudes demonstradas nas ações que lhe são pertinentes e asseguradas por lei e desenvolvidas com competência no sentido de favorecer as potencialidades das pessoas para manter ou melhorar a condição humana no processo de viver e morrer” (8: 87). por competências entende-se as qualidades necessárias ao desenvolvimento das atividades de enfermagem e se traduzem por conhecimento, habilidades e destreza manual, criatividade, sensibilidade, pensamento crítico, julgamento e capacidade de tomada de decisão (veja-se representação gráfica do processo de cuidar e sua descrição). os comportamentos e as atitudes são entendidos como de cuidado e são compostos por uma vasta lista, onde se destacam: respeito, gentileza, amabilidade, compaixão, responsabilidade, disponibilidade, segurança, oferecimento de apoio, conforto (8). momento de cuidar o cuidar implica um movimento em direção a algo ou alguém que é motivo de interesse ou preocupação. o exercício de cuidar é, portanto, uma ação que possui direcionalidade concreta e determinada (14). é uma ação que nos move a fazer algo, que nos impulsiona. é uma ação moral que objetiva, como referido anteriormente, aliviar, satisfazer, ajudar, confortar, apoiar. a ação de cuidar tem sempre uma conotação para prover, favorecer o bem para outro ser. é, portanto, uma ação bastante peculiar. a finalidade é algo ou alguém que necessita a ação de cuidar; na enfermagem, do ser que padece, que 91 atualização do cuidar se encontra carente, vulnerável. a vulnerabilidade é uma condição que solicita o cuidado (14). a cuidadora responde a uma necessidade manifesta ou inferida; ocorre uma troca e o encontro de cuidar entre cuidadora e ser cuidado é sempre transformativo. o ser implica em algo mais do que simplesmente estar com. o estar com pode dar-se de forma a não haver um real envolvimento, em não se caracterizar como verdadeira presença. esta presença real, de corpo e alma, significa ser com. cuidar é um compromisso, é ajudar o outro ser a crescer promovendo sua integridade e unidade, mantendo sua dignidade, sua singularidade. o cuidado não é exatamente a técnica que se faz, o procedimento, por exemplo, um curativo, uma troca de decúbito. o que diferencia o cuidar de um procedimento é a preocupação, o interesse, a motivação, expressos em um movimento, como já mencionado. consiste em um impulso que nos dirige no sentido de fazer algo para ajudar. aí se realiza a ação. no caso de um procedimento, ela só se concretiza plenamente como cuidar na forma como é realizada a ação. esta é interativa. interage-se com o ser, seja através de palavras, de gestos, de olhares; há envolvimento não só no que se faz, mas também com a pessoa em quem se realiza a ação. portanto, o que diferencia o cuidar é como se faz, ou seja, com gentileza, com respeito, com consideração, pois está se prestando uma ajuda a um ser humano que é digno de atenção e para quem se tem um compromisso, uma responsabilidade. além disso, existe a intenção de promover o bem-estar, de manter o ser seguro e confortável, oferecendo apoio e minimizando os riscos, e reduzindo a sua vulnerabilidade. existe um sentimento, é uma ação e uma atitude moral (9). processo de cuidar por processo de cuidar entende-se “todas as atividades desenvolvidas pela cuidadora para e com o ser cuidado com base em conhecimento científico, habilidade, intuição, pensamento crítico, criatividade, acompanhadas de comportamentos e atitudes de cuidado no sentido de promover, manter e/ou recuperar sua dignidade e totalidade humanas. essa dignidade e totalidade englobam o sentido de integridade e a plenitude física, mental, moral, emocional, social e espiritual nas fases do viver e do morrer, constituindofigura 2. representação gráfica do processo de cuidar segundo waldow (6, 8). se, em última análise, em um processo de transformação de ambos, cuidadora e ser cuidado” (8: 113). a seguir descreve-se o processo de cuidar, conforme visualizado pela autora (6, 8). embora a figura privilegie o cuidado no contexto hospitalar, ele pode ser viabilizado em outros contextos e mesmo que não na sua íntegra, mas de acordo como a situação se apresentar no momento do encontro. a cultura organizacional é composta por variáveis ou fatores que influenciam 92 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 a forma como se processará o cuidado, as quais foram denominadas de componentes da cultura organizacional. entre os componentes destaca-se o meio ambiente organizacional, composto, por seu turno, pelo meio ambiente físico, o meio ambiente administrativo, o meio ambiente social e o meio ambiente tecnológico. os dois primeiros constituem os componentes estruturais: o social, o componente afetivo, porque responde pela valorização do cuidado na instituição. o ambiente tecnológico responde pela parte tecnológica, tão presente nos dias de hoje nas áreas de prevenção, diagnóstico e tratamento e, inclusive, do cuidado. por meio ambiente físico, entende-se a estrutura física e suas condições: instalações adequadas, equipamentos e material suficiente e em condições de uso com segurança. por meio ambiente administrativo entende-se a direção hospitalar e todas as chefias de serviços e equipes. espera-se dos setores administrativos, a provisão de material e pessoal em todos os locais e níveis, de forma a favorecer o preparo e a atualização técnica e científica, visando à qualidade do atendimento. inclui, ainda, apoio no planejamento e no desenvolvimento das atividades de enfermagem, um dos serviços com maior número de funcionários na prestação do cuidado. por meio ambiente social, entende-se a socialização e valorização do cuidado, ou seja, o reflexo, em todos os setores da instituição, de atitudes e relações harmônicas, ou de cuidado as quais são definidas em outro momento. representa a polidez, a solicitude, o respeito, a consideração, a boa vontade, o bom humor e a paciência no encaminhamento de todas as questões da organização. por meio ambiente tecnológico, entende-se todas as atividades que corroboram para o cuidado ao paciente e que incluem desde as de comunicação e informação na prevenção, diagnóstico e tratamento, como as de ajuda funcional e processamento de dados e pesquisa*. o momento de cuidar, como pode ser observado na figura, está representado por um movimento ondular, significando tempo e espaço indefinidos; é um movimento evolutivo, energético, transformativo, por isso, estético. para o cuidado ocorrer, a cuidadora primeiramente percebe a situação e o paciente como um todo. o pensamento crítico, representado pela reflexão, deve ser acionado. ao refletir sobre a situação, alguns questionamentos e hipóteses são levantados; por exemplo, como se caracteriza esta situação? quem é este paciente? o que preciso saber sobre sua história e sua condição? como posso ajudá-lo? em seguida, a cuidadora identifica a necessidade de cuidado e verifica os meios disponíveis para que o mesmo se realize. essa fase inclui desenvolvimento da interação interpessoal; deve incluir iniciativas para oferecer um ambiente adequado (limpeza, privacidade, segurança, condições térmicas adequadas, etc.) e expressar reconhecimento do paciente, sua família demonstrando aceitação que pode ser por intermédio de palavras, toques, olhares, gestos. a presença é importante, demonstrando segurança e eficiência no desempenho das intervenções necessárias. durante a ação, a cuidadora também deve se comunicar, mesmo que no silêncio. a ação é também reflexiva. enquanto desempenha a ação, levanta questões e hipóteses, que serão, ao mesmo tempo, acompanhadas de avaliação do que está ocorrendo no momento: como se apresenta a situação? os meios estão sendo adequados? precisarei modificá-los? como o paciente e sua família estão reagindo? o que mais posso fazer para tornar a situação, condição do paciente mais confortável? durante e após a ação, a cuidadora checa a reação do paciente e, nessa fase a reflexão é bem mais objetiva. a cuidadora reflete sobre o que foi feito, como foi feito, quem executou a ação, as reações do paciente e condições do meio ambiente, do material, assim como reflete também sobre seus valores e sentimentos em relação ao paciente e ao cuidado. faz uma avaliação geral do evento e vê como se comportou cada componente envolvido: paciente, equipe de enfermagem, família, equipe de saúde. o objetivo dessa avaliação reflexiva é auxiliar no aprendizado, na atualização dos cuidadores e na melhoria do cuidado. as respostas e as atitudes em relação ao cuidado são analisadas para verificar se o paciente obteve algum benefício ou bem-estar. as ações de enfermagem de ordem técnica, planejadas pela própria enfermagem ou prescritas pela equipe médica, são avaliadas de forma objetiva, em geral por meio de reações físico-químicas de praxe, valores e níveis padronizados de monitorização das funções vitais e das informações obtidas pelo próprio paciente. as ações de ordem expressiva, tais como ações educativas, apoio emocional, conforto espiritual, entre outras, são averiguadas junto do próprio paciente ou da família e pela observação de sinais subjetivos, tais como: relaxamento muscular, diminuição da dor, desconforto e ansiedade, expressão facial e corporal, tom de voz, etc. de forma geral, o processo de cuidar envolve transformação de ambos: o ser cuidado e os cuidadores. no que se refere 93 atualização do cuidar à cuidadora, o crescimento traduz-se por satisfação, sensação de dever cumprido, realização, melhora da auto-estima, mais segurança e confiança, prazer e bem-estar. mesmo constatando que o cuidado possibilita crescimento para o ser cuidado e para a própria cuidadora, é freqüente esta vivencie estresse, o qual, dependendo da situação, do envolvimento e da responsabilidade, pode ser maior ou menor. se as condições do meio ambiente não forem favoráveis, pode haver insatisfação, e a vulnerabilidade aumenta, tornando a profissão fonte de frustração. em relação ao ser cuidado, é possível perceber que está vivenciando uma experiência única. ele reflete sobre sua situação e vários questionamentos, dúvidas e hipóteses são levantadas, mesmo que nem sempre verbalizadas: o que estou fazendo aqui? o que está acontecendo comigo? estou com algo grave? o que farão comigo? como vou fazer com a minha família, minha casa, meu trabalho? será que vai doer? estas pessoas serão competentes? e assim por diante. a hospitalização é um evento bastante atemorizante para algumas pessoas. a doença é uma ameaça; o sentir-se doente ou estar doente caracteriza-se por uma ruptura na relação do ser humano com o mundo. o paciente se vê privado de uma série de elementos, inclusive de sua própria identidade, privacidade e autonomia. a primeira fase que o ser cuidado apresenta, conforme pode ser acompanhado pela figura, é a percepção de sua condição de paciente. a aceitação está relacionada à disponibilidade do paciente e à sua decisão de hospitalizar-se, aceitar o tratamento, o cuidado, a sua situação. essa aceitação torna-se mais fácil se o paciente possuir conhecimento e for informado sobre seu estado, assim como na confiança que deposita em seus cuidadores. o fato de aceitar o cuidado é uma decisão, não querendo significar que o paciente aceite passivamente tudo o que façam com ele. nesse sentido, a colaboração é outro fator que pode denotar a aceitação ou não, e evidentemente depende do nível de compreensão, da consciência, do quanto foi informado e solicitado para tal, assim como pela maneira como foi abordado e do seu desejo e motivação para vencer as adversidades. a resposta do ser cuidado pode ser observada através de vários sinais subjetivos, tais como queixas, dúvidas e perguntas, ou pelo silêncio, além das respostas objetivas. a reflexão também está presente, assim como em todos os demais momentos, relacionada a dúvidas e questões concernentes à sua futura condição e ao seu desempenho. o crescimento é considerado, por parte do ser cuidado, uma atitude mais positiva e serena frente às experiências de doença, perda, incapacidade ou morte. o conhecimento de si e de suas potencialidades traz melhor auto-estima, confiança em si e na situação que está vivenciando e coragem, trazendo auto-satisfação. além desses, ocorre o alívio da dor, o conforto, a tranqüilidade, o relaxamento, a preservação da identidade, o bem-estar, entre outros. o sentir-se bem cuidado e acolhido irá influenciar, sobremaneira, para que a experiência se torne positiva, possibilitando que o paciente enfrente melhor a sua situação. as variáveis circunstanciais do ser cuidado constituem fatores importantes para que o processo de cuidar ocorra, e a cuidadora deve ter, na medida do possível, conhecimento dessas variáveis ou circunstâncias. as expectativas incluem a história de vida do paciente, sua história de saúde, seus valores, hábitos, enfim, tudo aquilo que possa interessar para o processo de cuidar no momento. porém, convém saber discernir que dados serão realmente necessários, principalmente tendo em conta o tempo que se dispõe com o paciente. mais importante de tudo é saber sobre as condições atuais e o que motivou a internação, e como o paciente está se sentindo, ou seja, encorajando-o a verbalizar seus sentimentos e o que relaciona à sua condição atual. o conhecimento da cuidadora sobre o paciente contribuirá para o processo de cuidar, influenciando as respostas do mesmo no presente, assim como a motivação e suas expectativas. o conhecimento do paciente é outra variável importante quanto a sua situação atual, seu tratamento e sobre os exames e procedimentos a que será submetido. ao identificar que o paciente não está informado suficientemente, a enfermeira poderá sanar essa falha. a motivação é considerada como a disposição para ser cuidado, para ajudar, colaborando na medida do possível, e o seu desejo de crescer, incluindo desejo e vontade de viver, aumento de conhecimento e aceitação frente ao inevitável, aos mistérios da vida e da morte. as expectativas e a motivação estão intimamente relacionadas ao conhecimento das experiências prévias do ser cuidado: com saúde, doença, hospitalização e cuidadores. elas podem ajudar ou dificultar o cuidado, e o seu conhecimento poderá auxiliar a amenizar estados de ansiedade, medo e angústia no caso de terem sido negativas. serenidade, bom humor, carinho, competência, entre outros, contribuem para as expectativas positivas e 94 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 como resultado, uma melhor aceitação e colaboração com respostas bem mais rápidas no sentido de restabelecimento. os rituais de cuidado constituem os hábitos de saúde e de cuidado, de higiene corporal, mental e englobam os valores pessoais e aqueles que fazem parte de sua história, sua cultura; conhecê-los é importante para assegurar que o cuidado atual seja significativo e personalizado. a família é outra variável de extrema importância. sua presença junto do paciente e o seu carinho são fundamentais, e a equipe deve estar atenta, esclarecendo, informando, dando apoio, pois assim haverá grande ajuda para o crescimento do ser cuidado. famílias ansiosas, em função da gravidade da situação do paciente, ou por falta de informação, por vezes provocam reações negativas por parte da equipe de saúde e podem prejudicar o processo de cuidar. na verdade, na maioria das vezes, a família também necessita de cuidado e pode, através de seu comportamento, estar expressando e solicitando isso. se a organização valoriza o cuidado, pacientes e familiares reconhecem isso e comportam-se de forma bastante tranqüila, pois se sentem seguros, respeitados, informados e sabem que serão tratados com dignidade e consideração. as variáveis da cuidadora, são as competências, como pode se ver pela figura e incluem a motivação, a experiência, o conhecimento, as habilidades técnicas, a capacidade para cuidar e o pensamento crítico. a motivação consiste no desejo de cuidar, nos valores, no comprometimento e na ética da cuidadora. está bastante relacionada à experiência e pode ser influenciada pelo meio ambiente da organização, pelas relações, pela valorização e pelo apoio dado à enfermagem, assim como pela valorização do cuidado e pela remuneração, etc. a experiência é conformada pela experiência educacional acerca do cuidado, fornecida pela instituição formadora, que influenciará a maneira de cuidar; pelas experiências anteriores adquiridas em relação ao sistema de saúde, a relação com superiores imediatos e com a equipe, ou seja, o manejo com a autoridade; experiências prévias de cuidar (e também como ser cuidado, quando é o caso). no concernente ao tempo de prática, a experiência é relevante. estreitamente relacionado a ela, menciona-se o desenvolvimento da intuição como um componente essencial. o conhecimento representa não só aquele adquirido na academia, como também a relação deste com a experiência e o interesse em manter-se atualizada. as escolas fornecem o conhecimento básico, sendo sugerido que cuidadoras busquem a complementação do conhecimento, atualizando-o e aprimorando-o. a reflexão que ocorre antes, durante e após a ação de cuidar revela esse comprometimento com o conhecimento. a cuidadora, a cada novo encontro, se enriquece e sua experiência torna-se mais rica, pois cada ser é um universo com singularidades próprias. por isso é importante cuidar fora dos parâmetros do modelo tradicional, das estandardizações e classificações, para perceber que cada ser reage à experiência vivida e não à patologia e a ela de forma bastante peculiar. as habilidades técnicas compõem uma das competências com a qual a cuidadora está bastante familiarizada. no entanto, vale lembrar que realizar procedimentos no paciente é diferente de realizar procedimentos para e com o paciente, interagindo com o mesmo. a capacidade para cuidar inclui o autoconhecimento da cuidadora. somente com o conhecimento do que se é pode-se mostrar o que se quer ser. em adição a isso, o autoconhecimento favorece conhecer o outro ser. outras capacidades envolvem a responsabilidade, a obrigação moral e a energia. as cuidadoras necessitam de energia para cuidar, pois, além de se fortalecerem a si próprias, podem atuar como meios facilitadores para mobilizar as energias dos pacientes e de seus familiares. a honestidade é um atributo importante que capacita para o cuidado, além de sentimentos; entre estes, podese mencionar a compaixão, o amor, o respeito, a tolerância e a solidariedade. o pensamento crítico é uma competência que se sugere que seja desenvolvida no período de formação, contudo pode também ser desenvolvida em qualquer momento. o pensamento crítico compreende a capacidade de questionar, analisar, emitir hipóteses, refletir e criticar alternativas, além de facilitar a criatividade, a flexibilidade, a confiança e a intuição. relações de cuidado o sucesso no processo de cuidar deve-se, em grande parte, às relações de cuidado que são travadas em todas as instâncias da cultura organizacional, ou seja, desde a recepção até a unidade de internação e em todos os setores. engloba não só as relações entre cuidadora e ser cuidado, mas de todas as pessoas que entram em contato com o paciente e sua família, assim como entre as equipes (7). as relações de cuidado compreendem “aquelas que se distinguem pela expressão de comportamentos de cuidar, que as pessoas compartilham, tais como con95 atualização do cuidar fiança, respeito, consideração, interesse, atenção, entre outros” (7: 133). as relações de cuidado podem se caracterizar por relações em nível de sujeito-sujeito e sujeito-isto ou sujeito-coisa, considerando-se que não se cuida apenas de pessoas, mas de coisas, objetos, animais, plantas. as relações de cuidado na dimensão sujeito-sujeito podem se apresentar de duas formas: sujeito-self e sujeito-outro. o sujeito-self se caracteriza pelo cuidado pessoal e compreende o cuidar de si. esse cuidar de si inclui o conhecimento de si, de suas potencialidades, necessidades e limitações. compreende também o cuidar da saúde, do espírito, do intelecto, de seu tempo, do lazer e assim por diante. ainda no âmbito pessoal ou privado, encontra-se a forma de relação sujeito-outro e que incluem as relações genuínas ou de cuidado natural e que se caracterizam por relacionamentos mais íntimos, com a família e amigos. a forma de relação sujeito-outro pode ser de tipo social ou público e compreende as relações dirigidas a pessoas com as quais não existe nenhum vínculo de parentesco ou afetivo, mas nelas se evidenciam o respeito, a consideração e a solidariedade, por exemplo. também neste tipo de relação encontram-se as relações de cuidado profissional, caracterizadas por ocorrer entre ser que necessita de cuidado e ser que tem, legalmente, a obrigação moral de cuidar, implicando um comportamento de responsabilidade e o uso de conhecimento e habilidades aprendidas formalmente em uma instituição formadora. pode ocorrer uma forma de relação sujeito-objeto e nesta, o ser que cuida não estará visualizando o ser cuidado como um ser integral, genuíno e digno. nesta forma pode ocorrer uma relação de não cuidado, já que o ser está sendo considerado um objeto. ao se criarem relações de cuidado e ao serem exercitadas, cria-se automaticamente, um ambiente ou clima de cuidado, no qual os valores de cuidado são enaltecidos. em um ambiente de cuidado, “as pessoas sentem-se bem, reconhecidas e aceitas como são; conseguem se expressar de forma autêntica e se preocupam umas com as outras no sentido de atualizar informações, fornecendo e trocando idéias, oferecendo apoio e ajuda e se responsabilizando e comprometendo com a manutenção desse clima de cuidado” (7: 131-2). considerações finais exposto neste artigo, uma síntese das idéias da autora acerca do cuidado humano, processo de cuidar e cuidado em enfermagem. o cuidado humano é visto como uma forma de cuidar que os seres humanos expressam, consigo mesmos, entre si e com o universo. para a autora o ato de cuidar humaniza o ser, significando com isso, que é através do cuidado que o ser se distingue como humano. o cuidado, visto dessa forma, pressupõe valores e elementos que são imprescindíveis no sentido de ser exercido de forma plena, tais como o respeito pelo outro, pela natureza, pela vida, a compaixão, a solidariedade, entre outros que compõem atitudes éticas. também são imprescindíveis a busca, a criação e o aprimoramento do conhecimento, a valorização da cultura e da história, o amor, a fraternidade, e assim por diante. na enfermagem o cuidado se profissionaliza e é exercido, tendo em vista aquilo que é previsto por lei e engloba uma série de competências, entre as quais: habilidades manuais ou técnicas, pensamento crítico, além de conhecimento e intuição. contudo, estas competências não são suficientes para que o profissional seja um verdadeiro cuidador, dado que ele necessita um componente afetivo, relacional, de maneira que interaja, se relacione com o ser cuidado, seja através de palavras, seja através do silêncio, por meio do toque, de um olhar, de um gesto. o cuidado prescinde a preocupação, o interesse, o envolvimento, a solicitude, conforme martin heidegger. como visto no texto, a ação de cuidar tem, ou deveria ter sempre, uma conotação no sentido de prover, de favorecer o bem para o outro ser. é necessário, todavia, discernir o que é melhor para o paciente, pois nem sempre coincide com o que ele gostaria. por vezes, a necessidade de cuidado não é reconhecida pelo ser e quem está próximo ou habilitado para cuidar identifica a necessidade e se movimenta em direção à satisfação da mesma. para que o cuidado ocorra é necessário “consciência de cuidado” (9). a consciência de cuidado engloba discernimento, intuição, pensamento crítico, decisão e sensibilidade. o ser que cuida precisa conquistar a confiança do paciente para que ele aceite e colabore no cuidado. como também apresentado no texto, o cuidado, no seu real sentido, promove o crescimento de ambos: o ser que cuida e o ser que é cuidado. na enfermagem, o cuidado como sua ação primordial, pode ser considerado sua essência. 96 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 referências 1. waldow vr. cuidado: uma revisão teórica. rev gaúcha de enferm 1992; 13(2): 29-35. 2. waldow vr. cuidar/cuidado: o domínio unificador da enfermagem. in: waldow vr et al., organizadores. maneiras de cuidar, maneiras de ensinar: a enfermagem entre a escola e a prática profissional. porto alegre: artes médicas; 1995. p. 7-30. 3. leininger m. culture care diversity and universality: a theory of nursing. new york: national league for nursing; 1991. 4. watson j. nursing: human science and human care. a theory of nursing. new york: national league for nursing; 1988. 5. roach ss. the human act of caring: a blueprint for the health professionals. ottawa: canadian hospital; 1993. 6. waldow vr. cuidado humano: o resgate necessário. porto alegre: sagra luzzatto; 1998. 7. waldow vr. o cuidado na saúde: as relações entre o eu, o outro e o cosmos. petrópolis, rio de janeiro: vozes; 2004. 8. waldow vr. cuidar: expressão humanizadora da enfermagem. petrópolis, rio de janeiro: vozes; 2006. 9. waldow vr. bases e princípios do conhecimento e da arte da enfermagem. petrópolis, rio de janeiro: vozes; 2008 (no prelo). 10. heidegger m. ser e tempo (parte 1 e 2). petrópolis, rio de janeiro: vozes; 2001. 11. boff l. saber cuidar: ética do humano –compaixão pela terra. petrópolis, rio de janeiro: vozes; 1999. 12. mayeroff m. on caring. new york: harper; 1971. 13. noddings n. o cuidado: uma abordagem feminina à ética e à educação moral. são leopoldo: unisinos; 2003. 14. torralba f. antropología del cuidar. madrid: institut borja de bioética/fundación mapfre medicina; 1998. 15. torralba f. ética del cuidar: fundamentos, contextos y problemas. madrid: institut borja de bioética/ fundación mapfre/medicina; 2002. 16. griffin ap. a philosophical analysis of caring in nursing. journal of advanced nursing 1983; 8: 89295. 17. foley r. humans before humanity. cambridge (ma): blackwell; 1995. 18. waldow vr. definições de cuidar e assistir: uma mera questão de semântica? rev gaúcha de enferm 1998; 19 (1): 20-32. 19. boykin a, schoenhofer s. nursing as caring: a model for transforming practice. new york: national league for nursing; 1993. 20. pessini l. a filosofia dos cuidados paliativos: uma resposta diante da obstinação terapêutica. in: pessini l, bertachini l, organizadores. humanização e cuidados paliativos. são paulo: loyola; 2004. p. 181-208. 287 304 diversidad cultural de sanadores.indd 287 lucero lópez1 nhora cataño2 heddy lópez3 vilma velásquez4 diversidad cultural de sanadores tradicionales afrocolombianos: preservación y conciliación de saberes5 1 ph.d. profesora asociada, universidad nacional de colombia. allopezdi@bt.unal.edu.co 2 m.sc. profesora asociada, universidad nacional de colombia. ncatano@bt.unal.edu.co 3 integrante del grupo de investigación cuidado cultural de la salud; psicóloga, universidad católica de colombia. helopd@gmail.com 4 m.sc. profesora asociada, universidad nacional de colombia. vvelasquez@unal.edu.co 5 trabajo enmarcado en los proyectos del grupo de investigación cuidado cultural de la salud, con el apoyo financiero de la división de investigación bogotá (dib) de la universidad nacional de colombia, 2008-2010, código 8007033 y 8007039. además, se contó con el apoyo logístico de fundamor y la alcaldía de guapi. recibido: 8 de junio de 2010 aceptado: 2 de octubre de 2011 resumen la diversidad afrocolombiana entreteje prácticas culturales en salud específicas. los sanadores tradicionales son poseedores de una costumbre milenaria en el cuidado de la salud. gozan del reconocimiento, la confianza y el respeto de sus comunidades, pero son desconocidos o ignorados en las instituciones de salud y en el mundo profesional. objetivo: describir las prácticas de cuidado realizadas por los sanadores tradicionales (remedieros y parteras) en una comunidad afrocolombiana en guapi, cauca, colombia. método: el estudio etnográfico utiliza observación participante y entrevistas en profundidad con tres remedieros y tres parteras. el análisis se realizó de forma inductiva e interpretativa. resultados: los hallazgos evidencian diversos métodos de curación relacionados con el uso de hierbas, maniobras, fórmulas especiales y rezos, entre otros. esta diversidad de métodos implica que las personas sean vistas de manera holística adoptándose diferentes maneras de sanar y cuidar la salud. conclusiones: la importancia de conocer y preservar estos conocimientos es una forma de expresar el compromiso por proteger, rescatar y favorecer el diálogo entre los saberes profesional y popular. es una invitación a conocer y reconocer el papel que pueden jugar los sanadores tradicionales en los sistemas de salud. palabras clave diversidad cultural, curación, medicina tradicional, enfermería transcultural (fuente: decs, bireme). año 11 vol. 11 nº 3 chía, colombia diciembre 2011 l 287-304 288 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 cultural diversity of afro-colombian traditional healers: preservation and conciliation of knowledge abstract afro-colombian diversity is interwoven with specific cultural health-care practices. traditional healers possess a thousand-year-old tradition regarding health care. they enjoy the recognition, trust and respect of their communities, but are unknown to health institutions and the professional world, or ignored by them. objective: the study describes health-care practices performed by traditional healers; specifically, remedieros (non-professional apothecaries) and parteras (midwives) in an afro-colombian community in guapi, a town located in the cauca region of colombia. methodology: this ethnographic study relied on participant observation and in-depth interviews with three remedieros and three parteras. the analysis was conducted in an inductive and interpretative way. results: the results demonstrate different healing methods associated with the use of herbs, maneuvers, special formulas and prayers, among other elements. this diversity of methods implies the person is viewed in a holistic manner that is conducive to the adoption of diverse ways to heal and protect health. conclusions: the importance of being aware of this knowledge and preserving it is a way to express a commitment to protecting, rescuing and favoring dialogue between professional and traditional healers. it also is an invitation to understand and acknowledge the role traditional healers can play in health care systems. key words cultural diversity, cure, medicine traditional, transcultural nursing (source: decs, bireme). diversidade cultural dos curandeiros tradicionais afro-colombianos: preservação e conciliação de saberes resumo a diversidade afro-colombiana entretece práticas culturais específicas em saúde. os curandeiros tradicionais são possuidores de um costume milenar no cuidado da saúde. desfrutam do reconhecimento, da confiança e do respeito de suas comunidades, mas são desconhecidos ou ignorados nas instituições de saúde e no mundo profissional. objetivo: o estudo descreve as práticas de cuidado realizadas pelos curandeiros tradicionais (“ervateiro” e parteiras) em uma comunidade afro-colombiana em guapi, cauca, colômbia. método: o estudo etnográfico utiliza observação participante e entrevistas em profundidade com três “ervateiros” e três parteiras. a análise se realizou de forma indutiva e interpretativa. resultados: os resultados encontrados evidenciam diversos métodos de cura relacionados com o uso de ervas, manipulações, fórmulas especiais e rezas, entre outros. essa diversidade de métodos implica que as pessoas sejam vistas de maneira holística, adotando diferentes maneiras de curar e cuidar a saúde. conclusões: a importância de conhecer e preservar esses conhecimentos é uma forma de expressar o compromisso por proteger, resgatar e favorecer o diálogo entre os saberes profissional e popular. é um convite a conhecer e reconhecer o papel que os curandeiros tradicionais podem ter nos sistemas de saúde. palavras-chave diversidade cultural, cura, medicina tradicional, enfermagem transcultural (fonte: decs, bireme). 289 diversidad cultural de sanadores tradicionales afrocolombianos: preservación y conciliación de saberes l lucero lópez, nhora cataño, heddy lópez, vilma velásquez introducción sanadores tradicionales la sanación es un fenómeno holístico o tridimensional que envuelve la recuperación del equilibrio, la armonía en el cuerpo, la mente y el espíritu, o entre la persona y el ambiente (1). no se enfoca en síntomas o enfermedades, sino que trata al ser humano en su totalidad. desde esta perspectiva, la curación es dirigida a la persona y no a la enfermedad. los sanadores tradicionales reciben enseñanzas especiales de sus ancestros y transmiten tradiciones curativas de una generación a la siguiente. son reconocidos en la comunidad donde viven por su capacidad de sanación (2). el “don de curar” puede ser recibido por cuatro medios: a) desde el nacimiento, cuando se ha determinado que tendrá ese don o se sabe que se posee un don especial; b) por aprendizaje, cuando es enseñado por otro sanador; c) por recibir una “llamada”, lo que generalmente ocurre durante un sueño, trance o visión de un ser considerado con dones especiales, y d) por percibir de otro sanador su potencial por medio de la “luz” que una persona irradia y hacérselo saber (1). el artículo se centra en los practicantes populares guapireños —oriundos del municipio de guapi, cauca, colombia—. en este documento serán denominados como “sanadores tradicionales” (st), término acuñado por spector (1) para referirse a las prácticas tradicionales del curanderismo en españa. consideramos que el término st da cuenta del objetivo de la actividad —sanar— y el origen de la acción —la tradición oral que enseña el uso del saber mágico, las plantas y las técnicas—. en otras culturas y estudios se hace referencia a este grupo como practicantes culturales en salud. en el sur de chile se denominan “machi” —sana problemas de salud en general— y representan una figura de espiritualidad (3). en oaxaca, méxico, “hueseros, sanadores, espiritualistas y curanderos” (4). en costa rica y otros lugares de centroamérica y suramérica se les llama “chamanes” y poseen poderes extraordinarios, contribuyen a la curación del paciente y al mismo tiempo sirven como guía espiritual (5). el st es un fenómeno sociocultural tan antiguo como la historia del hombre (6). coexisten con el desarrollo cultural y tecnológico de los pueblos (7). se estima que el 80% de los habitantes de los países en desarrollo confían principalmente en la medicina tradicional para satisfacer sus necesidades de atención primaria en salud, y aunque en la mayoría de los países se desconoce el número real de st, estos constituyen un grupo significativamente amplio. gozan del reconocimiento, la confianza y el respeto de sus respectivas comunidades. son reconocidos por la atención personalizada, adaptada a las necesidades y expectativas de sus pacientes. de esta manera, son potentes agentes de comunicación para cuestiones sociales y de salud. poseen mayor credibilidad que los agentes que provienen de las instituciones (8). cobran fuerza en los entornos de recursos limitados porque las alternativas de curación proporcionadas son de fácil y rápido acceso. en algunos estudios se reporta que los métodos utilizados por sanadores tradicionales son eficaces (9, 10). 290 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 cuidar desde una perspectiva cultural diversos estudios muestran que grupos étnicos, sociales y económicos presentan patrones distintos en cuanto a la forma como perciben la salud/enfermedad y como actúan frente a ella. las subculturas populares, resultado de una mezcla de diversos elementos culturales, tienen modelos conceptuales para explicar el origen de la enfermedad; estos van, desde concepciones mágico-religiosas, hasta el extremo positivista. pasan por el espectro de variadas interpretaciones y prácticas de diagnóstico, prevención, tratamiento y rehabilitación acordes con esa cosmovisión (11). por ello, es necesario reconocer esa comprensión de la salud y la vida desde la cultura de las comunidades, tal entendimiento, y el de la discapacidad y la muerte desde esa perspectiva, ayudaría a evitar el etnocentrismo de los profesionales de la salud y sería el camino para lograr ofrecer un cuidado culturalmente competente (12). asimismo, los estudios de enfoque cultural recomiendan que a nivel institucional se deben tomar en consideración las percepciones, creencias y necesidades de los usuarios con el objetivo de optimizar los resultados, así como de evitar los efectos negativos que emergen de los flujos de información incorrectos, del abismo que se da entre las metas institucionales y las de los usuarios, así como del suministro de servicios que no conceden un rol activo a los usuarios (13). como aporte a esta comprensión, diferentes autores de la enfermería transcultural y la antropología de la salud han aportado en la comprensión de la influencia cultural en el cuidado de la misma. sin embargo, tomó relevancia la propuesta de la enfermera spector, con su modelo de tradiciones en salud, cuya premisa es considerar la salud como un equilibrio entre “el ser de la persona — físico, mental y espiritual— y su mundo exterior —naturaleza, familia, comunidad y metafísica—” (1). para spector, la salud en ese contexto tradicional posee nueve facetas interrelacionadas representadas por métodos para mantener, proteger y restaurar la salud física, mental y espiritual. los st son parte de los métodos tradicionales de los guapireños, por tanto, algunas de sus prácticas fueron analizadas desde esta propuesta. consideramos que los profesionales de la salud, formados bajo el poder del mundo científico, clínico o tecnológico, están poco entrenados en reconocer el “proceso por el cual las enfermedades populares son adquiridas y manifestadas y cómo eso puede afectar el comportamiento del paciente y el diagnóstico del problema de salud” (14). el universo popular atribuye gran credibilidad a los sanadores tradicionales. como profesionales, podríamos aproximarnos a ese saber y reconocer el potencial que tienen para contribuir en la salud de las comunidades. un diálogo abierto y horizontal con los st puede potencializar las capacidades instaladas en las comunidades y la posibilidad de beneficio y realimentación para la ciencia. en este sentido, el grupo de investigación cuidado cultural de la salud (gccs), de la facultad de enfermería de la universidad nacional de colombia, viene adelantando trabajos investigativos que permiten comprender la forma como las personas construyen patrones de signos, síntomas y medidas de tratamiento, donde los st ocupan un lugar importante (15-23). diversos estudios muestran que grupos étnicos, sociales y económicos presentan patrones distintos en cuanto a la forma como perciben la salud/enfermedad y como actúan frente a ella. 291 diversidad cultural de sanadores tradicionales afrocolombianos: preservación y conciliación de saberes l lucero lópez, nhora cataño, heddy lópez, vilma velásquez los estudios revelan las divergencias con el profesional de salud frente a la explicación de su situación y manejo, y el cansancio por los tratamientos prolongados y divergentes de su universo de valores y creencias. se muestra cierta aversión a las instituciones de salud por la tramitología, el trato despectivo y la poca solución de sus problemas. se hace un llamado a la importancia de la atención humanizada y particularizada desde una mirada cultural que surge como alternativa ante los patrones normalizados que reducen el bienestar de las personas y la conformidad de los servicios (24); asimismo, es necesario construir un diálogo entre el saber popular y el profesional que establezca salidas terapéuticas negociadas y de fácil aceptación por el grupo para que puedan favorecer la efectividad y adherencia terapéuticas (25). la cultura y la estructura sociopolítica influyen en la salud y en la manera como las poblaciones construyen las decisiones del cuidado de la salud y las demandas de los servicios. es necesaria la capacitación y el entrenamiento de los profesionales de la salud para apreciar y ser sensibles a la forma como las personas comprenden y enfrentan los procesos de salud/enfermedad, y al reconocimiento de un diálogo horizontal entre las comunidades y los st que pueda llegar a repensar las estructuras burocráticas y de poder de los servicios de salud y así mejorar el impacto en los indicadores. guapireños: un entramado de particularidades la diversidad afrocolombiana entreteje prácticas culturales en salud muy específicas que las distinguen como un grupo étnico, con rasgos propios de identidad cultural, etnohistoria, organización social, estructura de parentesco, entre otros elementos. en este sentido, podemos hablar que existe una diversidad en el mundo afro (26). los afrocolombianos llegaron por diferentes corrientes migratorias. en colombia, se estima que representan el 30% del total de la población, es decir, 12’000.000 de personas. se ubican en las regiones del pacífico, del caribe, del sur del valle, en el norte y sur del cauca, en el magdalena medio y en urabá (27). los guapireños se encuentran en el departamento del cauca, en el municipio de guapi, bañado por el río de su mismo nombre. el acceso a la región se hace por vía aérea, fluvial y marítima, no hay acceso directo por vía terrestre (28). tiene una extensión de 2.688 kilómetros cuadrados y aproximadamente 30.527 habitantes. la mayoría son afrocolombianos y, en menor proporción, indígenas, mestizos y blancos. un gran porcentaje de los pobladores de guapi vive en condiciones de deprivación social, baja escolarización en mujeres jóvenes, inseguridad alimentaria, condiciones precarias de vivienda y saneamiento básico, y desempleo (29). la anterior inequidad social de la población afrocolombiana los ubica en el segundo lugar de los mayores índices de pobreza —línea de pobreza, línea de indigencia, necesidades básicas insatisfechas (nbi) e índice de condiciones de vida (icv)—, comparados con los hogares de población no étnica (población mestiza y blanca) (30). en el aspecto cultural se manifiestan contrastes enmarcados en sus ritmos musicales, el baile, las prácticas ancestrales de curación basadas en el uso de plantas medicinales, diversos ritos y tradición arla cultura y la estructura sociopolítica influyen en la salud y en la manera como las poblaciones construyen las decisiones del cuidado de la salud y las demandas de los servicios. 292 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 tesanal. los ritos de los ancianos se han convertido en normas sociales que también hacen parte de su religiosidad. la religión católica tiene una fuerte expresión, los festejos decembrinos se revisten de gran colorido. la economía se basa en la producción agrícola (coco, arroz, naidí, chontaduro, papachina, plátano, maíz), la pesca (camarón, piangua y pesca blanca), la minería y la explotación maderera (31). en el cuidado de la salud, los sanadores tradicionales son un eje importante en guapi. la asociación juntos por el progreso (jumpro) y otros actores sociales han realizado un esfuerzo sistemático por mantener las prácticas de los st en el municipio. la asociación los denomina como “sabios ancestrales” y los subdivide en: curanderos (sana mordeduras y picaduras venenosas), comadronas o parteras (encargadas de la gestación, el parto y el posparto), sobanderos (quinesiólogo), y remedieros (sana enfermedades, heridas e infecciones) (32). estos hombres y mujeres son reconocidos como conocedores de la enfermedad y la salud —sabios—. los st constituyen un valioso recurso en salud porque permiten interpretar y comprender los procesos de salud-enfermedad, las formas de sobrevivencia y cuidado, y la construcción de identidad de los diversos pueblos. son potencial de desarrollo dentro de las comunidades, en especial las excluidas socialmente, y una oportunidad para el sistema de salud. por lo anterior, el objetivo del estudio es describir las prácticas de cuidado realizadas por los sanadores tradicionales (remedieros y parteras) en el municipio de guapi, cauca. de esta manera, el gccs expresa el compromiso por proteger, rescatar y favorecer el diálogo entre el saber profesional y popular, e invita a conocer y reconocer el papel que pueden jugar los st en los sistemas de salud. método el estudio cualitativo de tipo etnográfico se realizó con observación participante (op) y entrevistas en profundidad. la inserción al campo se realizó en el segundo semestre de 2008, donde se establecieron vínculos con diversos sectores de la comunidad. se realizaron seis entrevistas con los sanadores (tres remedieros y tres parteras). las edades oscilaron entre los 59 y 78 años. las entrevistas suman 598 minutos, algunas realizadas en varios encuentros. el trabajo de campo fue realizado por dos docentes de enfermería y siete estudiantes de último año con entrenamiento previo. la observación se realizó durante el mes de febrero de 2009, y fue condensada en un diario de campo grupal. en encuentros con el grupo investigador se analizaban los registros, se contrastaban los datos y se identificaban preguntas de indagación para las posteriores entrevistas. los datos recogidos se analizaron de forma manual desde la lógica inductiva e interpretativa (33) construyéndose descriptores culturales (designación del grupo investigador que sintetiza los diálogos provenientes de las entrevistas y de los diarios de campo), posteriormente, en una matriz se organizaron por similaridad las subcategorías y luego se construyeron las categorías. el rigor metodológico tuvo en cuenta la realización de sesiones grupales de análisis donde se ponía de manifiesto la reflexividad de los investigadores y se contrastaban las subcategorías emergentes, alcanzándose consensos grupales sobre la interpretación de las mismas, estos aspectos respondieron a los criterios de credibilidad y auditabilidad. los resultalos sanadores tradicionales constituyen un valioso recurso en salud porque permiten interpretar y comprender los procesos de salud-enfermedad, las formas de sobrevivencia y cuidado, y la construcción de identidad de los diversos pueblos. 293 diversidad cultural de sanadores tradicionales afrocolombianos: preservación y conciliación de saberes l lucero lópez, nhora cataño, heddy lópez, vilma velásquez dos muestran quiénes son los sanadores tradicionales, qué hacen y qué usan para mantener, proteger o recuperar la salud, siguiendo la propuesta de spector en el modelo de tradiciones en salud (1). fueron considerados todos los cuidados éticos de acuerdo con la resolución 8430 de 1993 del ministerio de salud de colombia, considerándose una investigación “sin riesgo” ya que no hubo intencionalidad de modificación o intervención en las variables indagadas en los participantes. además, se contó con el aval de comité de ética de la facultad de enfermería de la universidad nacional. los hallazgos fueron presentados a la comunidad y fueron la base para la construcción de dos programas culturalmente sensibles de visita domiciliaria y de educación con personas ancianas en situación de discapacidad y sus familiares, realizados en el segundo semestre de 2010. resultados y discusión las prácticas del st: “remediero” remediero es el nombre local que se le da a los sanadores tradicionales con capacidad para sanar enfermedades, heridas e infecciones. conjugan diversas formas de sanar utilizando hierbas, oraciones secretas, actos de hechicería y adivinación, entre otros (34). en guapi, los remedieros son personas de estrato medio bajo, que proceden de municipios aledaños como timbiquí, lópez de micay e iscuandé (nariño). aprendieron su oficio desde la infancia y ahora forman parte del grupo de adultos y adultos mayores del municipio (32). curan enfermedades como el “mal de ojo”, el “pasmo” y el “espanto”. consideran que hay “males” (enfermedades o daños) puestos por otros, fruto de la envidia, los celos, la hechicería. usan los “bebedizos” para la cura o protección, y manifiestan haber curado enfermedades como el cáncer, el paludismo, la malaria y las diarreas. actúan bajo una organización de signos y síntomas aprendidos por tradición oral. tienen una forma particular de considerar el funcionamiento del cuerpo y la vida. de acuerdo con esas lógicas adoptan diversas formas de sanar, como se muestra en los cuadros 1 y 2. este es un saber con el que la medicina alopática puede dialogar. la gran mayoría de los sanadores tradicionales de la medicina negra —“sabios”— realizan sus labores de manera integral, es decir, pueden ser al mismo tiempo sobanderos, curanderos, remedieros, parteros, o pueden tener más conocimiento acerca de una de las especialidades (32). el costo de los servicios del sanador se basa en una práctica de trueque o de voluntades. es decir, el st algunas veces asume la actividad como un favor para alguien que necesita de ayuda, o deja a consideración del usuario lo que pueda pagarle u ofrecerle. pueden recibir cosas a cambio como alimentos o colaboración en algunos quehaceres, “yo hago remedios a muchas personas, a gente que los necesite a veces les cobro a veces no… no me gusta cobrarle a nadie sino hacer servicio”. aquellos que tienen una tarifa cobran de acuerdo con la complejidad de la situación. los costos pueden oscilar entre los $2.000 y $50.000 pesos colombianos (menos de un euro o hasta 20 euros). el sanador tradicional trabaja generalmente en la casa. cuando alguien lo requiere lo atiende en el domicilio. de remediero es el nombre local que se le da a los sanadores tradicionales con capacidad para sanar enfermedades, heridas e infecciones. conjugan diversas formas de sanar utilizando hierbas, oraciones secretas, actos de hechicería y adivinación, entre otros. 294 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 esta manera, el acceso a estos servicios resulta económico e integral. los servicios de salud en la zona son de difícil acceso y, de acuerdo con la situación, deben desplazarse a otras ciudades para realizarse exámenes, ser evaluados por especialistas o acceder a medicamentos. el conocimiento de los remedieros y su particular manera de abordar los asuntos de salud debería interesar los paradigmas previstos por la medicina alopática, ya que este trasciende las barreras de los ambientes poco comunes, lo que sugiere robustecer una experiencia científica compartida donde se armonicen experiencias, métodos y resultados de los practicantes populares con el saber de la medicina alopática. la gestación y el nacimiento: “parteras” se estima que en nuestro país las parteras asisten aproximadamente el 30% de los partos que se presentan en las zonas urbanas marginadas y en las áreas rurales donde los servicios de salud prestan bajas coberturas y el acceso a las instituciones es complicado (35). el rol es ejercido mayoritariamente por mujeres, con un promedio de edad superior a los 55 años (36). este tipo de sanadores tradicionales se sitúa dentro de la cotidianidad e informalidad (37), lo que revela una proximidad a la población, y el conocimiento de sus creencias, valores y representaciones del mundo. su conocimiento es un legado cultural incorporado a la herencia familiar, que mantiene una sólida identificación social y cultural entre los usuarios de la medicina tradicional y la partería; sus practicantes ejercen un importante liderazgo en la comunidad (38). la actividad implica asistencia a los procesos de gestación, parto y posparto (cuadro 3), estas st ofrecen sus servicios con características relacionadas con el oficio del remediero, es decir, tienen conocimientos acerca del manejo de otras enfermedades, por tanto, no solo enfocan su servicio en los procesos relacionados con la partería sino que también aseguran la atención en otros aspectos de la salud. manejan dos momentos en la atención descritos como el momento del parto y el nacimiento del niño (37). el parto es considerado como una enfermedad a la que debe dársele tratamiento, no se concibe como un proceso natural en las mujeres (36). se propone que la intervención profesional encaminada a la reestructuración y negociación de las prácticas con evidencia científica deba tener una actitud de respeto por los saberes de las parteras así como de las condiciones en que desarrollan su quehacer. resulta interesante contemplar la posibilidad de incluir prácticas que han resultado efectivas como la posición vertical durante el expulsivo (37) las cuales, en últimas, aciertan con la capacidad para cuidar de la vida y con la prolongación de la misma con vitalidad. en circunstancias donde el acceso a los servicios de salud es restringido, sectorizado y monopolizado, los sanadores tradicionales (remedieros y parteras) en poblaciones apartadas de nuestro país realizan una importante función social que ha permitido a sectores menos favorecidos recibir atenciones y cuidados de la salud, aun sin recibir un digno reconocimiento por desempeñar ese trabajo tan indispensable. se encuentran en un mundo invisible, sin el meritorio reconoel costo de los servicios del sanador se basa en una práctica de trueque o de voluntades. es decir, el sanador tradicional algunas veces asume la actividad como un favor para alguien que necesita de ayuda, o deja a consideración del usuario lo que pueda pagarle u ofrecerle. 295 diversidad cultural de sanadores tradicionales afrocolombianos: preservación y conciliación de saberes l lucero lópez, nhora cataño, heddy lópez, vilma velásquez cimiento por parte de las instituciones de salud y del estado. sin embargo, gozan de un estatus en sus comunidades por la importante labor que cumplen. estos sanadores mantienen la confianza, la fe y la valoración por parte de la comunidad. es un desafío para las instituciones de salud y para el mismo gobierno buscar, proteger y armonizar dichos saberes en el campo de la intervención, promoción y prevención de la salud. consideraciones finales los hallazgos muestran semejanzas de los sanadores tradicionales (remedieros y parteras) guapireños con otros estudios donde se mantiene un ambiente eminentemente místico-religioso (imágenes, altares, flores, oraciones), de imposición de manos, donde se le da gran valor al contacto personal con el cuerpo y el mundo espiritual de la persona atendida (39-41). los tratamientos combinan la ingesta de infusiones, el uso de calor seco, lavarse o frotar la zona con preparados de diferentes hierbas (7). para estos sanadores el mundo mágico de los ancestros africanos y el uso de plantas constituyen el recurso básico de tratamiento. la diversidad de plantas utilizadas es favorecida por un ecosistema regional rico en diversidad, de fácil acceso y bajo costo. sin embargo, los procesos de producción industrial de palma y otros cultivos vienen deteriorando el entorno selvático y, en consecuencia, estas prácticas sufrirán transformaciones. enfatizamos en la señal de alarma de jumpro por los “sabios ancestrales” ya que consideran que los st se han venido extinguiendo por causas que pueden estar relacionadas con el poco interés de las nuevas generaciones por conservar estos conocimientos, la brecha generacional cada vez más distante entre los st y la juventud, así como la frecuente imposición de la medicina alopática que según lo reportado comienza a finales de 1940 en la costa caucana del pacífico y que da inicio al proceso de extinción de las prácticas ancestrales. se ha venido considerando que estos sanadores se están quedando solos con la dificultad de continuar el ciclo de transmisión de conocimiento ancestral, se están envejeciendo, muriendo y, con ellos, se sepultan los saberes ancestrales (32). por lo anterior, es urgente reivindicar este cúmulo de conocimientos y sus practicantes por medio de encuentros de saberes, como lo ha venido haciendo jumpro, y el reconocimiento legítimo por parte de las instituciones de salud, puesto que estos conocimientos han venido siendo objeto del saqueo permanente produciéndose la deslegitimación de sus practicantes, lo que los hace cada vez más vulnerables y próximos a la extinción. finalmente, como estrategia de continuidad con lo que ha venido realizando jumpro con los “sabios”, convendría enfocar capacitaciones constantes por parte de las instituciones de salud (apoyadas con recursos del gobierno) para lograr adoptar sus saberes y, con el conocimiento de la medicina alopática, ofrecer mejores alternativas en salud; como consecuencia de ello, estarían en condiciones de certificarse y pertenecer a asociaciones inscritas ante la secretaría de salud que a su vez podría establecer mecanismos de vigilancia y control al ejercicio de estas prácticas en beneficio de la seguridad de los usuarios. los tratamientos combinan la ingesta de infusiones, el uso de calor seco, lavarse o frotar la zona con preparados de diferentes hierbas. para estos sanadores el mundo mágico de los ancestros africanos y el uso de plantas constituyen el recurso 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(ed.). sistemas de salud de las comunidades indígenas y negras de colombia estudiadas por la gran expedición humana. terrenos de la gran expedición humana. serie reportes de investigación bogotá: universidad javeriana; 1996. 12. castellanos f, lópez l. discapacidad y cultura: desafío emergente en investigación. avances en enfermería 2009; xxvii (1): 110-123. 13. cárdenas a, lópez l. resiliencia ante la vejez, la discapacidad y la pobreza: historia oral de vida. iii congreso iberoamericano de investigación cualitativa en salud. escuela graduada de salud pública, recinto de ciencias médicas, universidad de puerto rico. libro de resúmenes; 2008 may 6-9; 122-123. 14. helman g. culture, health and illnes. london: hodder education; 2007. 15. vargas ca. efecto del modelo de cuidado cultural para personas ancianas en situación de discapacidad y pobreza residentes en el área rural del municipio de cáqueza, cundinamarca. tesis maestría. bogotá: facultad de medicina, universidad nacional de colombia; 2008. 16. alzate ml, lópez l, velásquez v. una mirada de la rehabilitación desde enfermería. avances en enfermería 2010; xxviii (1): 152-165. 17. mejía ld, lópez l, velásquez v. hierbas medicinales: un asunto más allá de las prácticas populares. en avances en el cuidado de enfermería. colombia: universidad nacional de colombia, unibiblos; 2010. p. 383-401. 18. cárdenas a, lópez l. analysis matrix of resilience in the face of disability, old age and poverty. international journal of disability, development and education 2010; 57 (2): 175-189. 19. mejía ld, lópez l. la familia y la cultura: una coagradecimientos las autoras expresan su agradecimiento a los integrantes del semillero de investigación del grupo de investigación en cuidado cultural de la salud, que en diferentes momentos hicieron algún aporte para la realización de este trabajo: esperanza muñoz, martha alzate, yenny barreto, alexandra maluche, franci madera, yurany zúniga, william lópez, jeimmy puentes y beatriz soto. 297 diversidad cultural de sanadores tradicionales afrocolombianos: preservación y conciliación de saberes l lucero lópez, nhora cataño, heddy lópez, vilma velásquez nexión innovadora para el cuidado de la salud. index de enfermería 2010; 19 (2-3): 138-142. 20. melguizo e, alzate ml. creencias de cuidado de la salud de los ancianos. rev paraninfo digital [revista en internet] 2009 [consultado el 5 de octubre de 2010]; 7. disponible en: http://www.index-f.com/ para/n7/128o.php 21. castellanos f, lópez l. mirando pasar la vida desde la ventana: significados de la vejez y la discapacidad de un grupo de ancianos en un contexto de pobreza. investigación en enfermería: imagen y desarrollo 2010; 12 (2): 37-53. 22. lópez l, alzate ml, velásquez v. poverty, disability and old age in colombia: a cultural care perspective. 33rd annual conference of the transcultural nursing society. bournemouth university. abstract book; 2007 sep 15-21; bournemouth, inglaterra; 2007. 23. lópez l, gualda dm. modelo cultural para cuidar a personas ancianas. 23º congreso cuadrienal del cie. programa; 2005 may 21-27; taipei, taiwán. 24. osorio mb, lópez l. competencia cultural en salud: necesidad emergente en un mundo globalizado. index de enfermería 2008; 17 (4): 266-270. 25. cataño n, lópez l, lópez h. el saber popular: puente para la adherencia terapéutica en la población anciana. memorias ix congreso colombiano de gerontología y geriatría 2010, abr 28-29 y may 1; bogotá, colombia [fecha de consulta: 17 de mayo de 2010]. disponible en: http://www.acgg.org.co/ memorias_ix_congreso_colombiano/p_sciencsoc/ saber-popular.pdf 26. sánchez ja. curanderos afrocolombianos y el territorio como escenario religioso. en ferro g (ed.). religión y etnicidad en américa latina. bogotá: instituto colombiano de antropología, tomo iii; 1998. 27. castro r. el confinamiento y la resistencia pacífica de los afrocolombianos. comisionado especial derechos étnicos afrocolombianos. consultoría para los ddhh y el desplazamiento (codhes). proyecto pasos; 2004. 28. delgado m, tabares e, bedoya lm, del cairo c, calvache ja. informe final del proyecto: signos de alarma en enfermedad neonatal: percepciones de los cuidadores y trabajadores de la salud. presentado a childnet inclen; 2004. 29. alvarado b, tabares e. epidemiología del crecimiento infantil. estudio longitudinal de los determinantes sociales y biológicos en niños de 6 a 18 meses de la costa pacífica colombiana. revista antropacífico 2005; 3 (1-2): 7-21. 30. urrea f, viáfara c. pobreza y grupos étnicos en colombia: análisis de sus factores determinantes y lineamientos de políticas para su reducción. misión para el diseño de una estrategia para la reducción de la pobreza y la desigualdad, dnp-bid; grupo de investigación cidse-ird sobre estadísticas étnicoraciales; 2005. 31. alcaldía municipal de guapi, cauca. plan de desarrollo municipal de guapi 2008-2011: trabajando con experiencia. guapi, cauca; 2008. 32. pantoja, j. (comp.). tras el conocimiento ancestral afrocolombiano. encuentros de saberes en medicina tradicional del pacífico colombiano. asociación jumpro, guapi, cauca; 2008. 33. leininger m. culture care diversity and universality: a theory of nursing. 2 ed. new york: hudson street; 1991. 34. kroeger a, ruiz w. conceptos y tratamientos populares de algunas enfermedades en latinoamerica. cptp divina andina; 2009. 35. villa ma, falla mn. manual programa para complementación de parteras tradicionales. bogotá: ministerio de salud; 1997. 36. eslava d. los agentes tradicionales de salud: otras alternativas para las comunidades campesinas. el caso de cundinamarca y santander. investigación y educación en enfermería 1998; xvi (2): 57-71. 37. laza c, ruiz c. el saber de la partera tradicional del valle del río cimitarra: cuidando la vida. avances en enfermería 2009; xxvii (2): 116-118. 38. hincapié e, valencia c. capacitación de las parteras y su relación con la mortalidad perinatal en el municipio de quinchía, colombia. colombia médica 2000; 31 (1): 11-15. 39. castro e, muñoz sf, plaza gp, rodríguez m, sepúlveda lj. prácticas y creencias tradicionales en torno al puerperio, municipio de popayán. rev infancia, adolescencia y familia 2006; 1 (1): 141-152. 40. gubler r. el papel del curandero y la medicina tradicional en yucatán. alteridades 1996; 6 (12): 11-18. 41. alcaraz gm, yagari l. la concepción de la curación chamánica entre los indígenas embera de colombia: un proceso de comunicación socio-cultural y fisiológico. investigación y educación en enfermería 2003; 21 (2): 60-78. 298 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 glosario baños de asiento: baño caliente que se realiza en la zona genital con mezcla de plantas medicinales. bebedizos: bebidas preparadas con plantas medicinales u otras sustancias, suelen tener secretos de preparación a los que le atribuyen poderes inmateriales. botellas curadas: botellas con diferentes plantas medicinales que previenen enfermedades, energizan y curan diferentes tipos de males o enfermedades. espanto: “maleficio inmaterial que se introduce al cuerpo de las personas por causas asociadas con fenómenos naturales, accidentes o amenazas que alteran el sistema nervioso. puede afectar seriamente órganos del cuerpo”. mal de ojo: es una energía que tiene la vista para causar daño a otro. pasmo: se relaciona con problemas de frigidez o infertilidad. sin embargo, en otros contextos tiene la connotación de un enfriamiento que entra al cuerpo de múltiples formas y se debe contrarrestar con calor directo o con el consumo de sustancias que lo produzcan. pringues: golpes suaves sobre la zona afectada con plantas medicinales que estaban en agua previamente preparada. sobijos: masajes suaves realizados con las manos, algunas veces pueden tener preparativos de plantas. tocada: maniobras manuales realizadas por las parteras a la gestante para conocer la posición del bebé. tomas: bebidas preparadas con plantas medicinales. las parteras mencionan las tomas como una bebida que ayuda a estimular las contracciones del parto o a mejorar el estado de la parturienta. 299 diversidad cultural de sanadores tradicionales afrocolombianos: preservación y conciliación de saberes l lucero lópez, nhora cataño, heddy lópez, vilma velásquez cuadro 1. manifestaciones de algunas enfermedades reconocidas por los remedieros guapireños enfermedad manifestaciones diabetes mareos, orina amarilla oscura y dulce, resequedad en los labios. espanto es cuando la persona se asusta, ve y siente cosas, se siente desesperada, se altera el sistema nervioso. se mide con un ramo bendito alrededor del tórax, esto va indicando el grado de complicación. “… le va dando fiebre, se pierde el apetito, se va deprimiendo”. gastritis ardor en la “boca del estómago”. hígado dolor de cabeza, náuseas, escalofríos, fiebre, piel de color amarilla y pálida, mal aliento. mal de ojo dolor en el ombligo, planta del pie fría. “…usted no se da cuenta de que pueden odiar al niño, cuando usted ve, el niño le agarró una lloradera, vómito, sudadera y se murió…”. pasmo se presenta cuando las mujeres no se cuidan en el posparto o están con la menstruación. picazón y delgadez de la mujer. sarampión fiebre, boca roja, brote en la piel. tiricia color amarillo y pálido, falta de ánimo. 300 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 cuadro 2. prácticas de mantenimiento, protección y recuperación de la salud de los remedieros guapireños prácticas mantenimiento protección recuperación la “botella curada” es un remedio preparado a base de bejucos (tallos), hierbas medicinales y aguardiente. es utilizada para el manejo de diferentes enfermedades. para el control de la presión arterial se usa el cidrón, casco de vaca y la yerbabuena. purgante a base de hierbas para el pasmo. tomas con mata ratón; espíritu santo tres veces con tres, seis y nueve hojas, quinigua y vinagre para el hígado. cocción de cáscara de plátano, hoja de pepa de pan y de almendra, pepa de aguacate y hoja de marañón para la diabetes. hierbas machacadas, toma de sumos, y se restringe el consumo de dulces para el espanto. tomas de la hierba llantén, tapao de chanchullo con banano para la gastritis. hoja de majagua, achiote y tiatino. jugos de pringamosa para la tiricia. preparados con gallinazo, flor de gallo, la hierba de chivo para el dolor en las articulaciones. hoja de majagua y de achiote, tiatino, verdolaga, cresta de gallo y canutillo para el tabardillo (tifus). cocción de heliotropo machacado, se deja reposar en el sol y luego se toma para las dolencias en las articulaciones. espíritu santo y cocción de pobeda con panela para la tos. para mantener los periodos de sueño se usa la raíz de limoncillo machacada, se cocina y se bebe esta agua. hierbas 301 diversidad cultural de sanadores tradicionales afrocolombianos: preservación y conciliación de saberes l lucero lópez, nhora cataño, heddy lópez, vilma velásquez prácticas mantenimiento protección recuperación cocción de arroz en bastante agua con gotas de limón para el sarampión. cocción de la cáscara de plátano, pepino licuado con gotas de limón para el colesterol. limón partido en cruz cocinado en poca agua con cuatro cucharadas de azúcar para la tos. para la migraña, se deja piña picada en un recipiente de un día para otro. banano verde licuado tomado en ayunas para la gastritis. sobijos con hierbas machacadas para el mal de ojo. sobijos, tomas y baños con mata ratón para el hígado. se realizan sobijos para el espanto. sobijos de limón con ajo para la diarrea causada por parásitos. para las dolencias en las articulaciones se realizan sobijos preparados con gallinazo, flor de gallo, la hierba de chivo, alcohol y orines. alimentos evitar la combinación de bebidas alcohólicas con ciertos alimentos como el chontaduro, manzano y naidí, ya que se estima que es perjudicial para la salud. sobijos el “bebedizo”, preparado a base de licor o viche, se utiliza para mantener la potencia sexual o para mejorar problemas de frigidez así como la impotencia en hombres. bebedizos 302 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 cuadro 3. prácticas de mantenimiento, protección y recuperación de la salud de las parteras guapireñas prácticas mantenimiento protección recuperación baño con mata ratón, zapatito, hierba de sapo, quinigua y vinagre para el hígado. baño con hoja de majagua, hoja de achiote, tiatino, verdolaga, cresta de gallo y canutillo para el tabardillo (tifus). baños con hoja de majagua, achiote y tiatino para la tiricia. se realizan nueve baños con el agua de cinco piñas que se han dejado de un día para otro picadas en un recipiente para la migraña. baños prácticas mantenimiento protección recuperación el anamú sirve para los dolores de parto, se deben contar las hojas para la toma, si posterior a esta los dolores persisten, indica que hay parto. tomas de bejucos y hierba de la virgen para tratamiento de venéreas o hemorroides. toma de hierba contenedora, almeja, gallinazo, estopa quemada y molida, para amenaza de aborto. en el posparto se le recomienda a la madre el consumo de gallina, pescado de mar o de agua dulce. agua de arroz tostado para la diarrea del recién nacido. en los últimos días de la gestación se hacen tomas de brevo y nacedera para “ablandar las carnes” (facilitar el trabajo de parto). hierbas alimentos el calostro es recomendado a las madres como alimento inicial en los recién nacidos y lo consideran como primera vacuna. evitar el consumo de carne de animales de monte como el armadillo, el venado o el guatil ya que se consideran perjudiciales para el bebé. 303 diversidad cultural de sanadores tradicionales afrocolombianos: preservación y conciliación de saberes l lucero lópez, nhora cataño, heddy lópez, vilma velásquez prácticas mantenimiento protección recuperación para el alumbramiento con sobijos introducen las manos en la matriz y ayudan a sacar la placenta así como los coágulos de sangre. durante el parto, con maniobras (tocadas) ayudan a girar el feto boca arriba y boca abajo. también, ayudan a la salida de flemas y para la respiración. aceite de ricino, de almendras o de cocina al recién nacido para “curar el estómago”, es decir, que no le haga daño ningún alimento. sobijos detectan el embarazo colocando las manos sobre el abdomen donde perciben un pulso diferente con respecto a épocas normales; asimismo, aprecian un punto o bolita. durante el control mensual realizan actividades de “tocada”, que consiste en masajes sobre el vientre para hacer girar el feto cuando se encuentra en posición contraria. bebedizos cuando la mujer tiene problemas para concebir le proporcionan bebedizos preparados con hierbas comunes. a una toma elaborada con miel o panela, canela, clavos y anís le ponen una copita de aguardiente y se la dan a tomar a la madre para que no siga sangrando y que el útero se contraiga, esto se debe hacer después de que haya salido la placenta. 304 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 prácticas mantenimiento protección recuperación para la anemia de la parturienta.vitaminas o pringues rituales para prevenir embarazos realizan un ritual que consiste en cortar la placenta del ombligo. se toma un pedazo, voltean la placenta y la doblan de un lado y del otro y la introducen dentro de una chuspa (bolsa) y la entierran. la embarazada no debe realizar labores hogareñas relacionadas con hacer nudos, clavar puntillas, tapar un recipiente, pasar por debajo de las escaleras ya que ocasionan la “trama”, es decir, un parto difícil. baños baño de asiento preparado con plantas medicinales calientes. la gestante se sienta en un platón y baña sus genitales para facilitar el parto. baños vaginales con plantas medicinales calientes. 1 johana enyd cifuentes rodriguez1 sandra guerrero gamboa2 intervenciones de enfermería dirigidas a las personas con úlceras venosas: una revisión integrativa* 1 https://orcid.org/0000-0001-5384-3480. universidad nacional de colombia, colombia. jecifuentesr@unal.edu.co 2 https://orcid.org/0000-0002-0893-0478. universidad nacional de colombia, colombia. nsguerrerog@unal.edu.co * artículo derivado del proyecto de investigación doctoral titulado: "m.a.t.e.o. viabilidad y efecto de una intervención de automanejo para pacientes con úlceras venosas". recibido: 10/08/2019 enviado a pares: 12/09/2019 aceptado por pares: 11/12/2019 aprobado: 18/12/2019 doi: 10.5294/aqui.2020.20.1.7 para citar este artículo / to reference this article / para citar este artigo cifuentes je, guerrero s. nursing interventions aimed at persons with venous ulcers: an integrative review. aquichan. 2020;20(1):e2017. doi: https://doi.org/10.5294/ aqui.2020.20.1.7 resumen objetivos: identificar y describir los fundamentos teóricos, los componentes, la duración, el modo de entrega y los resultados de las intervenciones de enfermería dirigidas a personas con úlceras venosas disponibles en la literatura. materiales y método: revisión integrativa entre los años 2000 y 2018 en las bases de datos electrónicas pubmed, ovidnursing y ebscohost. resultados: esta revisión incluye dieciséis artículos. en su mayoría, las intervenciones fueron de carácter educativo, tres se desarrollaron en la comunidad (bajo el modelo leg club) y el resto de intervenciones fueron entregadas personalmente, cara a cara, por una enfermera profesional. el tiempo mínimo de duración de aquellas fue de ocho semanas, con seguimientos telefónicos. las variables de resultados más comunes fueron la cicatrización de la úlcera venosa y la reducción del área de la herida. conclusiones: hubo diversidad en relación con los componentes de las intervenciones y los resultados esperados. se debe reforzar el reporte de las intervenciones y el uso de teorías de enfermería que respalden su diseño. palabras clave (fuente: decs) úlcera varicosa; úlcera de la pierna; atención de enfermería; estudios controlados antes y después; enfermería práctica. año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2017 temática: práctica basada en la evidencia. aporte a la disciplina: identificar los elementos que dieron forma a las intervenciones de enfermería en otras culturas y los fundamentos que las subyacen permite conocer los avances en el área, así como las fortalezas y debilidades en su desarrollo y ejecución. a la vez, poner a prueba intervenciones de enfermería acordes con nuestro contexto, es decir, que aborden al ser humano con sus necesidades, dudas y temores, a través de espacios de aprendizaje y construcción mutua que favorezcan una experiencia de cuidado positiva. proporcionar cuidados de calidad y costo-efectivos requiere intervenciones de enfermería viables, eficaces, fácilmente replicables y con un importante impacto social, que transformen la práctica de enfermería y demuestren su autonomía y jurisdicción. https://orcid.org/0000-0001-5384-3480 mailto:jecifuentesr@unal.edu.co https://orcid.org/0000-0002-0893-0478 mailto:nsguerrerog@unal.edu.co https://doi.org/10.5294/aqui.2020.20.1.7 https://orcid.org/0000-0001-5384-3480 https://orcid.org/0000-0002-0893-0478 https://doi.org/10.5294/aqui.2020.20.1.7 https://doi.org/10.5294/aqui.2020.20.1.7 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2017 nursing interventions aimed at persons with venous ulcers: an integrative review* abstract objectives: this work sought to identify and describe the theoretical foundations, components, duration, delivery mode, and results of the nursing interventions aimed at persons with venous ulcers as available in the literature. materials and method: integrative review between 2000 and 2018 in the pubmed, ovidnursing, and ebscohost electronic databases. results: this review includes 16 articles. most of the interventions were of educational nature; three were developed in the community (through the leg club model) and the other ones were delivered by a nursing professional, face to face. the minimum time of duration for these was eight weeks, with telephone follow up. the most-common result variables were venous ulcer healing and reduction of the wound area. conclusions: diversity existed in relation with the components of the interventions and the results expected. report of the interventions must be reinforced, along with the use of nursing theories that support their design. keywords (source: decs) varicose ulcer; leg ulcer; nursing care; controlled before-after studies; practical nursing. * this work is derived from the doctoral research proyect named: "m.a.t.e.o. viabilidad y efecto de una intervención de automanejo para pacientes con úlceras venosas". 3 intervenciones de enfermería dirigidas a las personas con úlceras venosas: una revisión integrativa l johana enyd cifuentes rodriguez y otra intervenções de enfermagem dirigidas às pessoas com úlceras varicosas: uma revisão integrativa* resumo objetivos: identificar e descrever os fundamentos teóricos, os componentes, a duração, o modo de entrega e os resultados das intervenções de enfermagem dirigidas a pessoas com úlceras varicosas disponíveis na literatura. materiais e método: revisão integrativa entre 2000 e 2018 nas bases de dados eletrônicas pubmed, ovidnursing e ebscohost. resultados: esta revisão inclui 16 artigos. em sua maioria, as intervenções foram de caráter educativo; três foram desenvolvidas na comunidade (com o modelo leg club) e o restante foi entregue pessoalmente por uma enfermeira profissional. o tempo mínimo de duração foi de oito semanas, com seguimento telefônico. as variáveis de resultados mais comuns foram a cicatrização da úlcera varicosa e a redução da área da ferida. conclusões: houve diversidade quanto aos componentes das intervenções e dos resultados esperados. deve-se salientar o relato das intervenções e o uso de teorias de enfermagem que apoiem seu desenho. palavras-chave (fonte: decs) úlcera varicosa; úlcera da perna; cuidados de enfermagem; estudos controlados antes e depois; enfermagem prática. año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2017 * artigo derivado do projeto de pesquisa de doutorado chamado "m.a.t.e.o. viabilidad y efecto de una intervención de automanejo para pacientes con úlceras venosas". 4 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2017 aquichan issn 1657-5997 eissn 2027-5374 introducción las úlceras venosas (uv), también conocidas como úlceras varicosas, son lesiones cutáneas abiertas que, generalmente, se presentan en el lado medial de la parte inferior de la pierna, entre el tobillo y la rodilla, como resultado de la insuficiencia venosa crónica y la hipertensión venosa ambulatoria. su curación puede tardar entre cuatro y seis semanas, desde su aparición inicial (1). entre el 75 y el 80 % de la totalidad de las úlceras de los miembros inferiores es de etiología venosa, su prevalencia oscila entre el 0,5 y el 2,7 %, y esta aumenta con la edad (2, 3). se ha estimado que las uv activas tienen una edad media de 210 días, con periodos de menos de 1 a más de 67 años y una tasa de recurrencia de hasta el 70 % dentro de los 3 meses posteriores al cierre de la herida (4-6). estos aspectos las convierten en una condición crónica compleja, no solo para los pacientes y sus familias, sino también para los sistemas de salud. el papel que la disciplina de enfermería ha tenido en el cuidado de estos pacientes ha sido fundamental para comprender hoy en día la complejidad de vivir con uv en miembros inferiores y su impacto negativo en todas las dimensiones de la calidad de vida de las personas. entre los problemas comunes que enfrentan los pacientes con uv, se encuentran: dolor, exudado, olor, limitaciones en la movilidad, depresión, ansiedad, aislamiento social, sentimientos de tristeza y alteraciones del sueño (7-9). las uv, como cualquier otra condición crónica, demandan cuidados de enfermería prolongados, significativos cambios del estilo de vida y adherencia a regímenes terapéuticos por parte de los pacientes. estos incluyen uso de terapia compresiva de por vida (el gold standard para el cuidado y el manejo de las uv) y estrategias de prevención y mantenimiento para evitar la recurrencia, como elevación de las piernas, control del peso, actividad física, cuidados de la piel, protección contra lesiones, entre otras (10, 11). por tales razones, desde hace algunos años, las enfermeras han empezado a diseñar intervenciones con el fin de investigar si estas podrían contribuir en la cicatrización, diminución de la recurrencia o mejora de la calidad de vida de los pacientes con uv, además de otras variables físicas y psicosociales. identificar en la literatura las intervenciones de enfermería disponibles para pacientes con uv permite conocer los elementos que las conforman y cómo estos producen resultados beneficiosos. por lo tanto, el objetivo de la presente revisión es identificar y describir los fundamentos teóricos, los componentes, la duración, el modo de entrega y los resultados de las intervenciones de enfermería dirigidas a personas con uv disponibles en la literatura. materiales y métodos revisión integrativa de la literatura, con base en el método propuesto por whittemore y knafl (12). incluye las siguientes etapas: 1. definición del propósito de la revisión: identificar y describir los fundamentos teóricos, los componentes, la duración, el modo de entrega y los resultados de las intervenciones de enfermería dirigidas a personas con uv disponibles en la literatura. 2. búsqueda de la literatura: se efectúo una búsqueda de artículos en las bases de datos electrónicas pubmed, ovidnursing y ebscohost, entre el 2000 y el 2018, debido a la limitada investigación en el área antes de este rango de tiempo. las palabras clave fueron venous leg ulcer o varicose ulcer, nursing, interventions y wound healing, en inglés, portugués y español. se hicieron combinaciones con los operadores boléanos (and, or). la búsqueda se realizó entre el 1.º de enero y el 31 de abril del 2018, y se actualizó en febrero del 2019. los criterios de inclusión fueron: 1) artículos publicados en revistas indexadas; 2) estudios descriptivos, experimentales y cuasiexperimentales, desarrollados exclusivamente por enfermería; y 3) artículos que presentan de manera clara el desarrollo o la implementación de la intervención. se excluyeron revisiones, tesis de maestría o doctorado y artículos no publicados; también estudios centrados en métodos diagnósticos, o estudios de intervención con productos de laboratorio o casas farmacéuticas. 3. evaluación de los datos: en esta etapa, con el objeto de estimar su calidad metodológica, se realizó la lectura crítica de los artículos seleccionados, bajo los criterios propuestos por el instituto joanna briggs (13). en consecuencia, los revisores examinaron los títulos de forma independiente, en función del resumen, excluyendo estudios irrelevantes. posteriormente, seleccionaron los artículos según los criterios de inclusión, y examinaron cada uno de los artículos de forma independiente. 4. análisis de los datos: se diseñó un instrumento de trabajo para extraer las características principales de los estudios incluidos en el análisis. el instrumento estuvo conformado por los siguientes apartados: 1) datos de identificación del estudio, 5 intervenciones de enfermería dirigidas a las personas con úlceras venosas: una revisión integrativa l johana enyd cifuentes rodriguez y otra autor, año y país; 2) objetivo del estudio; 3) diseño del estudio y muestra; 4) descripción de la intervención: tipo de intervención, fundamento teórico, componentes, duración y modo de entrega; y 5) variables del resultado de la intervención. para la clasificación según su nivel de evidencia, se siguieron los criterios propuestos por el instituto joanna briggs (13). la etapa final de la revisión describe los hallazgos mediante la síntesis de la información y se presenta a continuación. resultados según su contenido, se hallaron 207 estudios, de los cuales se descartaron 42 por duplicación en las bases de datos; luego, se revisaron los títulos y los resúmenes de los artículos restantes, de acuerdo con los criterios de inclusión y exclusión; finalmente, tres revisores por consenso mantuvieron 16 artículos en la revisión. la figura 1 presenta los detalles del proceso de selección de estudios. en esta revisión, 16 artículos cumplieron los criterios de búsqueda y fueron incluidos. de estos, el 50 % (8) se realizó en países de oceanía; 25 % (4), en europa; 12,5 % (2), en américa del norte; 6,25 % (1), en asia; y 6,25 % (1), en américa del sur (tabla 1). de acuerdo con su diseño, los estudios fueron: cuantitativos, de tipo ensayo clínico aleatorizado (10); pre y postest, con un solo grupo (3); cuasi experimental (1); prospectivo con un grupo control (1); y comparativo (1). los niveles de evidencia predominaron en los niveles i y ii (tabla 1). los 16 artículos incluyeron un total de 1249 pacientes de diferentes centros de atención de enfermería comunitarios, clínicas de heridas ambulatorias, de dermatología y de servicios de atención a pacientes con alteración en sus tejidos en hospitales universitarios. dentro de los participantes, el sexo femenino fue el de mayor prevalencia, y el rango de edades osciló entre los 54 y los 80 años. población diana el 100 % de las intervenciones estuvo dirigido a los pacientes con uv. los familiares o cuidadores no se tuvieron en cuenta. identificación selección elegibilidad inclusión estudios identificados a través de la búsqueda en bases de datos (n = 207): pubmed (n = 53) ovidnursing (n = 85) ebscohost (n = 69) estudios excluidos por duplicación (n = 42) estudios que se retuvieron después de la eliminación de los duplicados y se analizaron según el título y el resumen (n = 165) artículos completos evaluados por elegibilidad (n = 17) estudios que cumplen con los criterios de revisión (n = 16) estudios excluidos por título y resumen (n = 148) no desarrollados por enfermería (n = 89) no incluían úlceras de etiología venosa (n = 13) centrados en métodos diagnósticos (n = 17) estudios con productos farmacéuticos o de laboratorio (n = 29) artículos excluidos: revisión de la literatura (n = 1) figura 1. proceso de selección de los estudios fuente: elaboración propia. 6 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2017 aquichan issn 1657-5997 eissn 2027-5374 tipo de intervención y fundamento teórico de las dieciséis intervenciones halladas en los diferentes estudios, once fueron educativas (14-24); dentro de estas, cuatro fomentaron el desarrollo de ejercicios de resistencia progresiva (14, 18, 19, 21); dos, de características clínicas, evaluaron el cambio en la calidad de vida de los pacientes a quienes se les instauraba un sistema de vendaje compresivo de cuatro capas y de estiramiento corto; tres fueron de tipo comunitario (25, 26). la teoría social cognitiva de bandura respaldó cuatro intervenciones educativas (14, 18, 22, 24). dos estudios adicionaron elementos de la teoría de establecimiento de objetivos de locke, además de utilizar la entrevista motivacional de miller y rollnick como técnica para facilitar el cambio de comportamiento entre los participantes durante sus encuentros (22, 24). las tres intervenciones comunitarias propuestas se basaron en el modelo de cuidado denominado leg club, que propone que el cuidado de las heridas se realice en un entorno informal (no clínico), de propiedad de la comunidad (como salones comunitarios), que fomente la interacción social, el apoyo entre pares, el intercambio de información, la promoción de la salud, la educación y la atención continua para todos los grupos de edad que tienen problemas relacionados con sus piernas (27-29) (tabla 1). componentes de las intervenciones de las intervenciones identificadas, el 87,5 % (14/16) mencionaron un componente educativo en el desarrollo de las mismas (14-24, 27-29), mientras que el 12,5 % (2/16) no realizó ningún tipo de educación, ya que solo observó el cambio en la tasa de cicatrización de las uv como respuesta al uso de sistemas compresivos de cuatro capas y de estiramiento corto (25, 26). entre los temas de educación, se encontraron: estilos de vida, causas, desarrollo, progreso y prevención de las uv, importancia de los vendajes de compresión, adherencia, actividades de autocuidado y ejercicio. este último es el aspecto que con mayor frecuencia se impartió por las enfermeras, en un 62,5 % (10/16) (14-19, 21-24). las intervenciones comunitarias incluyeron: evaluación del estado de salud, medición índice, tobillo-brazo, tratamiento de uv, aplicación de un sistema de vendaje de compresión de estiramiento corto, consejería y soporte en relación con las uv, seguimiento y asistencia al leg club de la comunidad (27-29). todas las intervenciones consideraron un elemento clínico esencial, y fue la valoración clínica del área de la herida (tabla 1). modo de entrega y duración todas las intervenciones se realizaron cara a cara; sin embargo, se entregaron trece de manera individual, y tres de, forma colectiva (27-29). cuatro estudios hicieron seguimiento telefónico a los participantes (14, 17, 18, 20). el primero realizó seis llamadas de diez a quince minutos, con el objeto de reforzar el desarrollo de los ejercicios de resistencia (14); el segundo indicó un seguimiento telefónico regular durante la primera, cuarta y última semana, sin estipular el tiempo (16); el tercero hizo llamadas solo cuando el paciente lo requirió (18); y el cuarto señaló que las dos llamadas de rastreo fueron de 30 minutos (20). en relación con el material empleado para entregar la intervención, el 43,7 % (7/16) de los estudios se apoyó en cartillas y folletos (14, 15, 17, 18, 20, 21, 24), mientras que el 31,5 % (5/16) no describió este aspecto (19, 22, 27, 28). el tiempo mínimo de las intervenciones fue de 8 semanas, y el máximo fue de 72 (18 meses). sin embargo, el 50 % (8/16) de las intervenciones duraron 12 semanas (14, 16-19, 28, 29). respecto al seguimiento, solo un estudio no siguió a los participantes (23); los demás presentaron diversidad frente al tiempo y finalidad de aquel, que osciló entre semanal, quincenal y mensual. sobre el tiempo dedicado a cada sesión con el paciente, este varió entre 20 y 60 minutos, para la primera sesión; las subsecuentes, entre 10 y 30 minutos (14, 17, 20-23). el 62,2 % (10/16) de las intervenciones se entregaron en contextos clínicos; el 18,7 % (3/16), en el hogar de los pacientes; y el 18,7 % (3/16), en el leg club de la comunidad (tabla 1). variables de resultado entre las variables de resultado evaluadas con mayor frecuencia, se encontró: 1) medición del área de la herida (11/16) (14,16-19, 22, 24-26, 28); 2) evaluación del proceso de cicatrización con la escala denominada the pressure ulcer scale for healing, mediante los aspectos de área de la herida, cantidad de exudado y el tipo de tejido (6/16), 3); dolor (7/16) (16, 17, 21, 24, 26-28); y 4) calidad de vida (5/16) (14,17,25-27). frente a los instrumentos utilizados para la evaluación de los resultados mencionados, solo cuatro estudios reportaron las propiedades psicométricas correspondientes (21, 25-27). 7 intervenciones de enfermería dirigidas a las personas con úlceras venosas: una revisión integrativa l johana enyd cifuentes rodriguez y otra tabla 1. descripción de las intervenciones de enfermería dirigidas a personas con úlceras venosas autor, año, país nivel de evidencia diseño del estudio y muestra descripción de la intervención: tipo de intervención, fundamento teórico, componentes, duración, modo de entrega variables del resultado 1. o’ brien et al., 2012, australia (18). i eca n = 11pacientes gc:5 pacientes. gi:6 pacientes. intervención educativa, programa de ejercicios de resistencia progresiva en el hogar. teoría: no se menciona. componentes: educativo y de valoración de la función de la bomba muscular de la pantorrilla. duración: 12 semanas. modo de entrega: semanalmente, cara a cara, durante la consulta ambulatoria de enfermería o por teléfono, si el paciente requería apoyo adicional. material adicional: protocolo de ejercicios. lugar: clínica ambulatoria de úlceras venosas. seguimiento: quincenal, durante las doce semanas. the pressure ulcer scale for healing. área de la úlcera por planimetría digital portátil visitrak digital. función de la bomba muscular de la pantorrilla mediante pletismografía de aire. rango de movimiento del tobillo por medio de goniómetro. incidencia del cierre completo de la herida al finalizar el estudio. 2. edwards h et al., 2005, australia (29). i eca n = 56 pacientes gc: 28 gi: 28 intervención: comunitaria. teoría: modelo de cuidado denominado leg club. componentes: a) evaluación del estado de salud, medición del índice brazo-tobillo; b) remisión a una valoración circulatoria, de ser necesario; c) tratamiento de la úlcera venosa según las guías de práctica clínica, con el uso de un sistema de vendaje de compresión de corto estiramiento; d) consejería y soporte en relación con las úlceras venosas; e) seguimiento del manejo; y e) asistencia al leg club de la comunidad para promover la interacción social y el establecimiento de metas, modificación de actividades diarias y adopción de estrategias de afrontamiento. duración: 12 semanas. modo de entrega: en grupo, semanalmente. material: no se describe. lugar: leg club. seguimiento: al inicio y a las 12 semanas. nivel de dolor según las medical outcomes study pain measures. the pressure ulcer scale for healing. cálculo del área de la herida por el método punto a punto. 3. finlayson k et al., 2012, australia (25). i eca n = 87 pacientes grupo sistema de compresión de 4 capas: 45 grupo sistema de medias de compresión clase 3 (30-35 mmhg): 42 intervención: clínica. teoría: no se menciona. componentes: no descritos. duración: 24 semanas. modo de entrega: cara a cara. material: sistema de compresión de 4 capas y medias con un sistema de compresión clase 3. lugar: clínica ambulatoria para pacientes con úlceras en las piernas. seguimiento: al inicio del estudio, a las 12 semanas y a las 24 semanas desde el reclutamiento. the pressure ulcer scale for healing. mediciones de la circunferencia del tobillo y la pantorrilla. medición del área de la úlcera a partir de trazados de acetato y el uso de un dispositivo de planimetría digital portátil. quality life index. pain measure. depression geriatric scale. 4. edwards h et al., 2005, australia (28). i eca n = 33 pacientes gc: 17 gi: 16 intervención: comunitaria. teoría: modelo de cuidado denominado leg club. componentes: iguales. edwards et al. (1). duración: 12 semanas. modo de entrega: en grupo, semanalmente. material: no se menciona. lugar: leg club. seguimiento: al inicio del estudio y 12 semanas después. área de la herida: trazado de la herida y medición punto a punto. the pressure ulcer scale for healing. -tasa de cicatrización de la herida. 8 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2017 aquichan issn 1657-5997 eissn 2027-5374 autor, año, país nivel de evidencia diseño del estudio y muestra descripción de la intervención: tipo de intervención, fundamento teórico, componentes, duración, modo de entrega variables del resultado 5. jull a et al., 2009, nueva zelanda (19). i eca n = 39 pacientes gc: 19 gi: 20 intervención: educativa, en relación con los ejercicios por realizar de manera progresiva. teoría: no se menciona. componentes: no descritos. duración: 12 semanas. modo de entrega: individualmente, los ejercicios se prescribían de manera progresiva, según la valoración de la enfermera. material: no se menciona. lugar: servicio de atención de pacientes con úlceras en las piernas. seguimiento: al inicio y después, en las semanas 3, 6 y 9. cambios en la función muscular de la pantorrilla. área de la úlcera (medida con el dispositivo silhouette mobile, aranz). curación de la úlcera. tiempo para completar la curación. pletismografía de aire para medir: volumen venoso, volumen de eyección, fracción de eyección, volumen residual, fracción de volumen residual e índice de llenado venoso. 6. edwards h et al., 2009, australia (27). i eca n = 67 pacientes gc: 33 gi: 34 intervención: comunitaria. teoría: modelo de cuidado denominado leg club. componentes: iguales. edwards et al. (1). duración: 24 semanas. modo de entrega: en grupo, semanalmente. material: no descrito. lugar: leg club. seguimiento: inicio, 12 y 24 semanas desde el reclutamiento. índice de calidad de vida de spitzer. escala de depresión geriátrica de yesavage. escala de autoestima de rosenberg. medida del nivel de dolor de sherbourne. escala de soporte social de sherbourne & stewart. índice de actividades de la vida diaria de katz y akpom. the medical outcomes study, para medir el dolor. 7. o’brien et al., 2016, australia (14). i eca n = 59 pacientes gc: 30 gi: 29 intervención: educativa, de cambio de comportamiento. teoría: autoeficacia. componentes: educación en ejercicios de resistencia de los miembros inferiores (caminar); registro de ejercicios y educación en cambios de comportamiento; seguimiento telefónico (6 llamadas de 10 a 15 minutos); adherencia al programa. duración: 12 semanas. modo de entrega: primer encuentro, cara a cara, durante 20-30 minutos. posteriormente, vía telefónica. material: cartilla de ejercicios para personas con úlceras venosas, podómetro, hojas de registro de sus series de ejercicios y repeticiones. lugar: servicio comunitario de enfermería. seguimiento: semanal (semanas 1, 2, 4, 6, 8 y 12), vía telefónica. primarios curación de la herida (sí/no). área de la úlcera, mediante dispositivo de planimetría digital. the pressure ulcer healing score. secundarios encuesta de actividad física de yale. habilidad funcional: medición de marcha y equilibrio de tinetti y del rango de movimiento del tobillo. formulario corto de calidad de vida sf8. adherencia al ejercicio. 8. domingues et al., 2018, brasil (17). i eca n = 71 pacientes gc: 36 gi: 35 intervención: educativa, sobre estilos de vida. teoría: no se menciona. componentes: ejercicio físico de los miembros inferiores, terapia compresiva, orientación sobre estilos de vida y descanso. duración: 12 semanas. modo de entrega: cara a cara, por 40 minutos. posteriormente, reuniones cada 4 semanas para reforzar las instrucciones iniciales y despejar dudas. material: folleto informativo. lugar: unidad especializada en tratamiento de heridas. seguimiento: cuatro encuentros por mes para reforzar el estilo de vida y resolver dudas, y dos seguimientos telefónicos. primarios reducción del área de la herida en centímetros cuadrados. pressure ulcer scale for healing. secundarios escala numérica de percepción del dolor. calidad de vida, freiburg life quality assessment for wounds. 9 intervenciones de enfermería dirigidas a las personas con úlceras venosas: una revisión integrativa l johana enyd cifuentes rodriguez y otra autor, año, país nivel de evidencia diseño del estudio y muestra descripción de la intervención: tipo de intervención, fundamento teórico, componentes, duración, modo de entrega variables del resultado 9. brooks j et al., 2004, reino unido (15). ii estudio cuasiexperimental n = 102 pacientes gc: 60 gi: 42 intervención: educativa. teoría: no se menciona. componentes: causas, prevención, importancia del sistema de compresión, nutrición, ejercicio, manejo del dolor, cuidados de la piel, consulta temprana en caso de rotura de la piel y evitación de traumas en las piernas. duración: 52 semanas. modo de entrega: cara a cara, durante la consulta. refuerzo de educación cada 3 meses. material: folletos informativos con medidas preventivas, ejercicios e importancia de las medias de compresión. lugar: servicio. seguimiento: semanal, durante 52 semanas. primarios tasa de recurrencia de úlcera venosa. secundarios tiempo de uso de medias de compresión. diferencia en las tasas de recurrencia entre los pacientes que eran completamente móviles (móviles sin ayuda) y tenían movimiento completo del tobillo y aquellos con menos movimiento y movilidad del tobillo. 10.wong et al., 2012, hong kong (26). i eca n = 276 pacientes grupo 1:87 grupo 2:95 grupo 3 (control): 94 intervención: clínica. teoría: no se menciona. componentes: aplicación del sistema de compresión. duración: 24 semanas. modo de entrega: no se describe. material: vendajes de compresión de 4 capas y de estiramiento corto. lugar: servicio de atención a pacientes con úlceras venosas. seguimiento: inicio, 12 y 24 semanas desde el reclutamiento. inventario corto de dolor brief pain inventory (versión china). índice del estatus funcional de frenchay the frenchay activities index (versión china). encuesta corta de calidad de vida sf-12. the short form-12-item health survey sf-12. cuestionario de calidad de vida para pacientes con úlceras venosas. charing cross venous ulcer questionnaire. tiempo de curación de la herida y área de la misma por planimetría digital. 11. gonzález a, 2014, estados unidos (20). ii diseño de un solo grupo con pretest y postest n = 30 pacientes intervención: educativa. teoría: no se menciona. componentes: desarrollo y progreso de la enfermedad, actividades de autocuidado para favorecer la curación de la úlcera venosa y prevenir su recurrencia. duración: 9 semanas. modo de entrega: individual, por 45 minutos; vía telefónica, por 30 minutos. material: cartilla y folleto con información respecto a los componentes de la intervención. lugar: hogares de los pacientes con úlceras venosas que asistían a un centro especializado en cuidado de heridas. seguimiento: vía telefónica, durante 30 minutos en las semanas 2 y 9, desde el reclutamiento. una lista de chequeo ad-hoc que midió el proceso de la enfermedad y las actividades de autocuidado. curación de la úlcera venosa. recurrencia de la herida a las 9 semanas. 10 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2017 aquichan issn 1657-5997 eissn 2027-5374 autor, año, país nivel de evidencia diseño del estudio y muestra descripción de la intervención: tipo de intervención, fundamento teórico, componentes, duración, modo de entrega variables del resultado 12. kelechi et al., 2014, estados unidos (21). iv diseño comparativo n = 21 pacientes gi:12 gc:9 intervención: educativa. teoría: enfoque de entrevista motivacional. componentes: entrevista motivacional y actividades de acondicionamiento para la función de la parte inferior de la pierna. duración: 8 semanas. modo de entrega: individualmente, cada semana hasta la número 6. la entrevista motivacional tuvo una duración de 10 minutos. material: folleto. lugar: centros de atención a personas con heridas. seguimiento: al inicio y a las 8 semanas. escala visual análoga del dolor y leg pain questionnaire. depresión: primary care evaluation of mental disorders. patient health questionnaire. fuerza: dinamómetro de fuerza para dorsiflexión de tobillo y flexión plantar. rango de movimiento: goniometría para dorsiflexión, flexión plantar, inversión, eversión en grados. questionnaire for physical activity and confidence and exercise. función de actividad física: timed chair rise test, timed up and go y community healthy activities model for program for seniors. 13. heinen m et al., 2012, países bajos (22). i eca multicéntrico n = 184 pacientes de 11 clínicas ambulatorias. gi:92 gc:92 intervención: programa de automanejo denominado lively legs. teoría: social cognitiva de bandura. incluyó elementos de la teoría del establecimiento de objetivos de locke y latham y del modelo de proceso de adopción de precaución de westein y colaboradores. además, se utilizó el abordaje de entrevista motivacional de miller y rollnick como técnica para discutir conductas de salud. componentes: 6 sesiones en las que se evaluaron el estilo de vida, el cambio de comportamiento, las creencias en salud y la educación. incluyeron la demostración y ejercicios. duración: 18 meses. la primera sesión fue de 45-60 minutos. de la segunda a la sexta, de 20-30 minutos. modo de entrega: la primera sesión, al inicio; la segunda, de 2 a 4 semanas después de la primera; y la sexta sesión, 6 meses después de la primera sesión. material: no se describe. lugar: clínicas de dermatología. seguimiento: al inicio, a los 6, a los 12 y a los 18 meses. primarios adherencia con la terapia compresiva. actividad física: physical activity recall (ipaq) de craig. monitor de actividad física: acelerómetro. the seven-day physical activity recall inventory. secundarios medición de la herida mediante una lámina de plástico con celdas de un centímetro cuadrado. 14. kapp et al., 2010, australia (23). ii estudio de un solo grupo con pretest y posttest n = 152 pacientes intervención: educativa, mediante el programa de prevención de úlcera de pierna. teoría: no se menciona. componentes: 1) rol del vendaje compresivo y medias de compresión para favorecer la cicatrización de la úlcera y evitar la recurrencia. 2) tratamiento de la úlcera venosa. 3) ejercicio y su impacto en la función de la bomba del músculo de la pantorrilla y elevación de las piernas para manejar el edema. 4) alimentación saludable. 5) cuidado de la piel. 6) refuerzo del uso de medias compresivas y del mantenimiento de la úlcera cicatrizada. duración: 20 a 60 minutos por sesión. las seis sesiones tomaron un tiempo total de tres horas. modo de entrega: semanal, cara a cara al paciente, en la visita domiciliaria de enfermería para el cuidado de la herida. material: tecnología de aprendizaje en línea y material educativo impreso. lugar: el hogar de los pacientes. seguimiento: no se describe. cuestionario diseñado para este estudio, conformado por conocimientos, comportamientos, actitudes, adopción y adherencia de las recomendaciones. 11 intervenciones de enfermería dirigidas a las personas con úlceras venosas: una revisión integrativa l johana enyd cifuentes rodriguez y otra autor, año, país nivel de evidencia diseño del estudio y muestra descripción de la intervención: tipo de intervención, fundamento teórico, componentes, duración, modo de entrega variables del resultado 15.van hecke et al., 2011, bélgica (24). ii evaluación pretest y posttest de un solo grupo con aproximación cualitativa n = 26 pacientes intervención: educativa, cognitiva y comportamental, denominada adherence to leg ulcer lifestyle advice. teorías: de autoeficacia, de establecimiento de metas, de constructo de representaciones de la enfermedad de leventhal et al., 1997, y entrevista motivacional como técnica para facilitar el cambio de comportamiento. componentes: adherencia a terapia compresiva, actividad física y elevación de las piernas. duración: 12 semanas. modo de entrega: cara a cara al paciente. material: un folleto y un cuaderno de trabajo de enfermería para el registro de los pacientes. lugar: el hogar de los pacientes. seguimiento: para la recolección de datos cuantitativos, al inicio de la intervención, una semana después de finalizar la intervención y tres meses después. para la recolección de datos cualitativos, una semana después de finalizada la intervención. entrevistas semiestructuradas una semana después de finalizada la intervención. observación participante durante las consultas de las enfermeras en los hogares. registro del número de horas de compresión, frecuencia y duración de los ejercicios para las piernas. nivel de actividad mediante el uso del acelerómetro. dolor mediante la escala verbal. medición de la tasa de curación de la herida mediante rastreo con acetato y conteo asistido por computadora de centímetros cuadrados. 16. meagher h, et al., 2012, irlanda (16) iv estudio prospectivo, comparativo n = 35 pacientes gi: 18 gc: 17 intervención: educativa. teoría: no se menciona. componentes: promoción de la actividad física, específicamente caminar. duración: 12 semanas. modo de entrega: cara a cara al inicio y, posteriormente, por vía telefónica, si se requería. material: monitor de actividad física activpal. lugar: hospital universitario. seguimiento: al inicio, y en las semanas 4 y 12. posteriormente, mediante contacto telefónico regular, para responder preguntas y aclarar dudas. cuestionario sociodemográfico. escala análoga visual del dolor. tamaño de la úlcera por medio de planimetría digital. número de pasos por cada participante, mediante un monitor externo de medición de actividades y un podómetro. *eca: ensayo clínico aleatorizado; †n: muestra; ‡ gc: grupo de control; § gi: grupo de intervención. fuente: elaboración propia. con base en esta revisión integrativa de la literatura, se recomienda fortalecer el diseño y el reporte de las intervenciones en esta área específica del conocimiento de enfermería. para ello, existen entes como el consejo de investigación médica (medical research council), que ofrece lineamientos para su construcción, o la guía tidier (template for intervention, description, and replication checklist and guide) (30), entre otros. discusión el objetivo de esta revisión fue identificar y describir los fundamentos teóricos, los componentes, la duración, el modo de entrega y los resultados de las intervenciones de enfermería dirigidas a personas con uv disponibles en la literatura. los hallazgos descritos confirman la variedad de intervenciones de enfermería que buscan mejorar la atención y potencializar los cuidados dirigidos a esta población. si bien la mayoría de las intervenciones fueron educativas, pocas mencionaron la teoría, los conceptos o las proposiciones que guiaron su construcción. el uso de modelos conceptuales y teorías de enfermería facilitan la compresión de problemas comunes en la práctica desde una perspectiva única. esto permite probar conocimiento disciplinar, demostrar resultados positivos en la salud de las personas y adquirir autonomía y jurisdicción en la práctica (31). tal como se ha reportado con el uso del modelo 12 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2017 aquichan issn 1657-5997 eissn 2027-5374 de atención de enfermería para pacientes con uv en australia, denominado leg club, este modelo está basado en la comunidad; los pacientes son tratados colectivamente, funciona sin cita previa e incorporan un régimen well leg, programa de educación y consejería preventiva, una vez la úlcera cicatriza. su objetivo es empoderar a los pacientes y hacerlos particípes en su tratamiento, mediante la modificación de comportamientos que disminuyan la recurrencia de uv (32-34). ha sido reconocido como un modelo viable, replicable y rentable en el reino unido, australia y otros países europeos (35). frente a los componentes de las intervenciones, la promoción de la actividad física y el ejercicio fue el tópico central de los estudios donde fue prescrito y se motivó a los pacientes para que caminaran y elevaran las piernas. existe evidencia que demuestra el efecto positivo del ejercicio en la mejora de la función de la bomba muscular de la pantorrilla y sus subsecuentes efectos en la curación de las uv, además de utilizarse como terapia complementaria de los sistemas de compresión que, hasta el momento, son considerados gold standard en el tratamiento de este tipo de heridas crónicas (36-40). más del 50 % de los autores consideraron la valoración de la herida un componente esencial y un efecto positivo de sus intervenciones (14-19, 21, 22, 26-29). el modo de entrega fue cara a cara; quince estudios realizaron seguimiento, pero solo cuatro especificaron que este fue telefónico, y su objetivo fue reforzar la educación impartida (14, 16, 17, 20). algunas revisiones sistemáticas de la literatura han validado la eficacia del soporte telefónico en intervenciones desarrolladas por diferentes profesionales de la salud y han reportando resultados positivos en los pacientes, como la calidad de vida y una reducción de las tasas de hospitalización y de los costos en los sistemas de salud (41, 42). en consecuencia, las llamadas telefónicas podrían ser una herramienta útil y más efectiva que otros dispositivos de comunicación para brindar atención y cuidados a los pacientes con uv, considerando que el deterioro de la movilidad es uno de los efectos negativos más comunes en esta población. el tiempo invertido en la entrega de las intervenciones es clave para identificar las prácticas de enfermería costo-efectivas. no obstante, pocas mencionaron el tiempo específico invertido en cada sesión con los pacientes y sus seguimientos. frente al material de apoyo, apenas un estudió utilizó presentación multimedia (23). probablemente, el uso de medios digitales resulta problemático para pacientes de la tercera edad, quienes a menudo carecen de los conocimientos y las habilidades necesarias para utilizar recursos electrónicos (43). sin embargo, las intervenciones de alfabetización en salud (ehealth literacy) podrían ofrecer una oportunidad para los adultos mayores con uv, al permitir el acceso a recursos como registros de salud electrónicos, grupos de apoyo en línea y herramientas de automanejo que orientan a los pacientes a solucionar problemas habituales, tomar decisiones informadas y comunicarse con sus proveedores de salud (44, 45). asimismo, el involucramiento de familiares y cuidadores contribuiría en la identificación, seguimiento y control oportuno de complicaciones relacionadas con la úlcera venosa (46). respecto a las variables de resultado, llaman la atención dos aspectos. el primero tiene que ver con las propiedades psicométricas de los instrumentos utilizados para la medición de las variables de resultado propuestas, ya que solo cuatro estudios lo hicieron, y la mayor parte de las escalas utilizadas no eran específicas para los pacientes con úlceras venosas. esto podría explicarse por el número limitado de instrumentos disponibles específicos para pacientes con uv. en concreto, se han identificado seis instrumentos para este tipo de población, pero han demostrado una validez de criterio y de constructo pobre. por otra parte, cuestionarios genéricos como el eq-5d y el sf-36 de calidad de vida evidenciaron una capacidad de respuesta débil, o que no se apoyaba su uso en pacientes con uv (47). estos aspectos tuvieron importantes repercusiones en la validez de los datos reportados. el segundo se relaciona con el hecho de que primen aspectos clínicos como la curación de la herida y el proceso de cicatrización frente a otras variables. existe evidencia empírica que sostiene que los procesos de curación de las heridas son complejos, y en estos inciden factores físicos, psicológicos, e incluso sociológicos, de manera favorable o desfavorable (5, 48-53). con esto, se quiere decir que, si bien las variables de tipo clínico como objetivos son importantes, incluir variables de comportamiento también lo es. es probable, en muchos casos, lograr cambios de comportamiento significativos, pero no clínicos a corto plazo. en consecuencia, no es posible dictaminar que una intervención de enfermería sea eficaz si no logró que los pacientes con uv cicatrizaran sus heridas en cierto tiempo estipulado, pero sí quizá si contribuyeron en mejorar la forma como viven y afrontan esta condición crónica de salud. así, habría que preguntarse si es pertinente establecer como resultados solo variables clínicas en este tipo de población. 13 intervenciones de enfermería dirigidas a las personas con úlceras venosas: una revisión integrativa l johana enyd cifuentes rodriguez y otra limitaciones los artículos incluidos se publicaron solo en inglés, de manera que estudios en otros idiomas y contextos podrían ratificar o contradecir la forma en que se desarrollan las intervenciones y los resultados esperados. la falta de instrumentos específicos para pacientes con uv y el uso de otros cuestionarios genéricos sin pruebas de validez satisfactorias podrían limitar la interpretación de los resultados. esta revisión no incluyó en su búsqueda intervenciones dirigidas a cuidadores o familiares de pacientes con uv. conclusiones los hallazgos presentados en esta revisión integrativa permiten identificar que existen pocas intervenciones de enfermería dirigidas a las personas con úlceras venosas, a pesar de que estas padecen una condición crónica que tiende a aumentar su incidencia y prevalencia. desafortunadamente, menos de la mitad de los estudios mencionó el fundamento teórico que sustentó la intervención, y aquellos que lo hicieron no expusieron cuáles proposiciones o conceptos fueron seleccionados como orientadores para el desarrollo de aquella hubo diversidad en relación con el tiempo de entrega de la intervención y las dinámicas de los encuentros cara a cara, así como en los seguimientos realizados. pocos estudios reportaron el contenido temático de sus intervenciones, hecho que impide comprender si estos generan impacto o no en los resultados primarios establecidos, siendo el prioritario la curación de la úlcera venosa. se considera necesario replantear el enfoque de las intervenciones de enfermería en esta área del conocimiento, ya que priman las personas como seres holísticos, y el objeto de la enfermería es el cuidado de la experiencia de la salud humana. conflicto de intereses: ninguno declarado. agradecimientos: johana cifuentes agradece a la dirección académica de la universidad nacional de colombia, por la beca otorgada para realizar sus estudios 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(source: decs, bireme). año 10 vol. 10 nº 3 chía, colombia diciembre 2010 l 192-203 193 political systems and the perspective on nursing education during the spanish transition ... l josé siles, maría del carmen solano-ruiz, genival fernández de freitas, taka oguisso sistemas políticos y perspectiva de la educación de enfermería en la transición española (del franquismo a la democracia). una contribución desde la historia de la enfermería resumen el objetivo del estudio consiste en describir los cambios que afectan a enfermería dentro del sistema educativo durante el proceso previo y posterior al establecimiento de la democracia en españa. se parte de la siguiente hipótesis: las diferencias en la organización social y política influenciaron la evolución de la enfermería española manteniéndola dentro de los esquemas del neopositivismo y los enfoques exclusivamente técnicos hasta la llegada de la democracia. la relación entre los sistemas de organización social y política en españa ha determinado la evolución de un perfil específico de enfermería en el sistema educativo. para comprender la integración de asignaturas como la antropología del los cuidados en los programas educativos de la enfermería española hay que se considerar los factores culturales, interculturales y transculturales que constituyen las claves para el entendimiento de los cambios en la educación enfermera haciendo posible la adopción de una perspectiva holística en los currículos. hasta la llegada del sistema democrático en 1977, la educación en la enfermería española fue solamente de naturaleza técnica y los roles de las enfermeras se limitaban al cumplimiento de tareas y procedimientos definidos por el pensamiento burocrático característico del paradigma racional tecnológico. conclusiones: durante el largo período predemocrático la enfermería española estuvo bajo la influencia del pensamiento neopositivista y técnico, lo cual se plasmaba en los currículos educativos. la integración en los currículos de materias humanísticas y antropológicas que facilitaban el enfoque holístico se produjo tras la integración de la enfermería en la universidad en 1977 coincidiendo con los inicios de la democracia en españa. palabras clave enfermería, cuidado, historia de la enfermería, sistemas políticos, españa. (fuente: decs, bireme). 194 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 sistemas políticos e perspectiva de ensino da enfermagem na transição espanhola (do regime de franco à democracia). uma contribuição da história da enfermagem resumo objetivo: descrever as mudanças que afetam a enfermagem no sistema de ensino durante o período pré e pós-estabelecimento da democracia na espanha. a hipótese de partida é: as diferenças na organização social e política influenciaram a evolução da enfermagem espanhola mantendo-a dentro do positivismo e das abordagens puramente técnicas até a chegada da democracia. a relação entre os sistemas de organização social e política em espanha determinou o desenvolvimento de um perfil específico da enfermagem no sistema de ensino. para compreender a integração de disciplinas como a antropologia do cuidado nos programas de educação da enfermagem espanhola é necessário considerar factores culturais, interculturaisl e transculturais fundamentais para a compreensão das mudanças no ensino de enfermagem. isso permites a adoção de uma perspectiva holística nos currículos. até o advento da democracia em 1977, o ensino da enfermagem na espanha era apenas de natureza técnica e os papéis dos enfermeiros eram limitados ao cumprimento de tarefas e procedimentos definidos pelo pensamento burocrático característico do paradigma racional da tecnologia. conclusões: durante o longo período pré-democrático, a enfermagem espanhola esteve sob a influência do pensamento técnico neo-positivista, que foi incorporado nos currículos educacionais. a integração de matérias humanísticas e antropológicas no currículo, que facilitou a abordagem holística, chegou depois a integração da enfermagem na universidade em 1977, o qual coincide com o início da democracia em espanha. palavras-chave enfermagem, cuidado, história da enfermagem, sistemas políticos, espanha. (fonte: decs, bireme). 195 political systems and the perspective on nursing education during the spanish transition ... l josé siles, maría del carmen solano-ruiz, genival fernández de freitas, taka oguisso introduction power differences in a society are linked to diversities in the evolution of education and educational strategies. the essential and existential dimensions of education are influenced by power relationships in society. the aim of this study is to describe the changes in nursing education during the process prior to and following the establishment of democracy in spain. it work begins with the hypothesis that the differences in social and political organization influenced the way the system of nursing education evolved, keeping it in line with neopositivistic schemes and exclusively technical approaches up until the advent of democracy. the relationship between the systems of social and political organization in spain has shaped the evolution of a specific profile for nursing within the educational system. to examine the insertion of subjects such as the anthropology of healthcare into education programs for the spanish nursing, one must consider the cultural, intercultural and transcultural factors that are key to understanding the changes in nursing education that allowed for the adoption of a holistic approach in the curricula. background the nature of power and ideology, their link to education, and the strategies developed for their perpetuation have influenced the way the education system has been structured (1,2). furthermore, the transmission mechanisms for learning have been influenced strongly by power and politics (3, 4, and 5). integrating political involvement and nursing education emphasizes the need for nurses to develop health policy skills. education systems also are influenced by religious political power (6, 7). in spain, literature concerning the influence of political power on education is scarce (8, 9). a number of authors identified the false neutrality of scientific paradigms and the hierarchical and authoritarian bureaucratization of disciplines (10). other works analyze the dogma in scientific production and deal with the subject of power and its relationship to science within the specific scope of nursing (11, 12, 13, 14, 15, and 16). historical and anthropological work on spanish nursing was begun in the 80’s. the first publication on the anthropology of healthcare appeared in the 90´s. as the decade progressed, the anthropological view of nursing in spain continued to evolve. these publications dealt with specific topics such as pregnancy, nurses’ image in the media during the spanish civil war, and mental health (1718). methodology this historical study was conducted in two parts. the first involved a historical study of spanish nursing education under the social, labour and scientific conditions that existed before (1939-1976) and after (1977-1998) the arrival of a democratic system. the rationaltechnological, hermeneutic and socio-critical paradigms were used to analyze the features of the period prior to and after democracy was established. it work begins with the hypothesis that the differences in social and political organization influenced the way the system of nursing education evolved, keeping it in line with neopositivistic schemes and exclusively technical approaches up until the advent of democracy. 196 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 the second historical study involved a bibliographic review focused primarily on journals and monographs on spanish nursing education. the more relevant periodical publications were reviewed, such as rol, enfermería clínica, index and cultura de los cuidados. the spanish database cuiden (published by the index foundation) also was used, as was cuidatge (universidad rovira y virgil), and the isbn database published by the ministry of culture. results after the end of the spanish civil war in 1939, nurses returned to their old activities and traditional values, abandoning a great many of the achievements secured during the ii republic. the number of religious leaders and their impact on nursing and nursing education increased. in fact, religious leaders regained the influence lost before and during the spanish civil war. nursing returned to a working situation directly related to a gender-dependant distribution of tasks and regained its condition as a predominantly female profession. sección femenina (the women’s division) was founded in 1933; directly dependent on the falange, its members specialised in the task of assistance. in 1936, winter aid was founded; its primary function was care of the wounded and sick in military hospitals. consequently, it became necessary to endow these organizations with the most basic and indispensable knowledge. in 1937, social aid was founded and its first by-laws established three delegations: education, social aid and hospitals. the future directors of nursing schools were selected from among the most outstanding students. in 1942, traditionalist spanish falange nurses was constituted in four sections. a high degree of ideological and religious indoctrination was customary. because of the unavoidable requirement of being a member of sección femenina in order to study nursing or to become a teacher, an important part of education for teachers and nurses was dedicated to religion and prayer. ibáñez martín was the minister of education from 1939 to 1951, a period characterised by immobility and religious and ideological predominance (falange) in primary, secondary and university education. the beginning of the technocratic period the shift from education based on religious and political ideas to education that was more technocratic and utilitarian took place when ruiz giménez was in charge of the ministry of education. at this opening stage, secondary education continued to polarize the educational system. in 1953, two levels (elementary and higher) were established in secondary school. at the elementary secondaryschool level, one could begin to study for a short degree, i.e. nursing. during ruiz giménez’s time, studies for practicantes (interns) and nursing were combined. ultimately, this period led to the creation of the degree of technical health assistant (a.t.s.) in 1955. in this context of technological medicine and technocratic scientific development, nursing was regarded solely as an auxiliary profession subordinate to the figure of the physician. technocracy, with its limitations, influenced nursing progress by hindering the secularisation of hospital workers (tables 1 and 2). however, to understand this process of technification within the context nursing returned to a working situation directly related to a gender-dependant distribution of tasks and regained its condition as a predominantly female profession. 197 political systems and the perspective on nursing education during the spanish transition ... l josé siles, maría del carmen solano-ruiz, genival fernández de freitas, taka oguisso of nursing, it is important to bear in mind one of the most decisive factors in the development of the health system. parallel to the improvements in education, technocrats favoured a politically-influenced development of hospitals and encouraged the construction of healthcare facilities through several development plans implemented during the franco regime (i.e. the first and second development plans). the role of nursing according to the rational-technological paradigm: nurse: executor of techniques and subordinate to other professionals. (...) patient as a “passive recipient” of procedures and educational advice nursing dependent on research in other disciplines. later, with publication of the laws on hospital regulation (1962), the number of hospitals tripled to more than one hundred, and the number of hospital assistants came to approximately 70,000 by 1970. in 1953, the total number of people with social security surpassed 29%; in 1968, the proportion of spanish state beneficiaries who were insured was 72%. the same developmental movement influenced nursing education, inasmuch as a considerable effort was made to endow new and previously existing hospitals with a technically trained nursing staff and to substitute or recycle the religious staff (nuns) working as nurses at health centres. this was an extremely important period in nursing history, because it was when the foundation for the leap towards a professional situation was laid. parallel to this, the education system improved while lora tamayo was head of the ministry of education. he extended the compulsory school age to 14 years (1964) and made a “bachiller superior” (upper secondary) degree a mandatory prerequisite for studying to become a teacher (magisterial). during those years, a person’s profession was determined largely by their gender. male a.t.s. picked up where the old practicantes left off (most were men). these professionals obtained their detable 1 moral dimension of the practice “the rational technological reduces the practical activity to a mere instrumental one, to the analysis of the resources adapted for certain aims, avoiding the moral and ethical problem of the objetives in every professional initiative that tries to solve human problems (…)” source: habermas j. ciencia y técnica como ideología. madrid: tecnos; 2007 “the rational-technological regime reduces practical activity to merely an instrumental role and to the analysis of resources adapted for certain aims. it avoids the moral and ethical problems of the objectives in every professional initiative that attempts to resolve human problems (...)“ table 2 nursing rol from rational technological paradigm l neutrality and objectivity of science. l nurse: executor of techniques and subordinated to other professionals. external controller of the health process. l patient as" receiving passive object " of procedures and educative advice. l concept of health: empty /negative(no symptoms) nursing dependending of the investigation of other disciplines. l standardized, experimental scientific production with statistical instruments. source: epistemología y enfermería: por una fundamentación científica y profesional de la disciplina. enfermería clínica. enfermería clínica 1997; 7: 188-94. “the rationaltechnological regime reduces practical activity to merely an instrumental role and to the analysis of resources adapted for certain aims. it avoids the moral and ethical problems of the objectives in every professional initiative that attempts to resolve human problems (...)”. 198 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 grees from medical schools where they received a fundamentally theoretical education with a technical orientation. as to their destination, they worked essentially in local healthcare settings and the old a.p.d. (atención publica domiciliariapublic home care). female a.t.s. were educated in schools integrated into hospitals, receiving mostly practical training, although the technological aspect was emphasized. the increase in this type of personnel was closely linked to the development of health institutions. the curricula during the 60’s and 70’s included subjects that had little to do with the needs of the profession and were concerned more with religious and ideological matters (religion, the development of a nationalistic spirit and in the schools for women subjects related to house management and domestic tasks). however, these matters were deliberately ignored in many schools, thanks to the good will of a number of professors (table 3). a historical fact: the option of university integration in 1968, villar palasi took over as head of the ministry of education and science. soon after, in 1970, a decisive law for the future of nursing would result in nursing becoming a field of study at the university level. this legislation represented an attempt to answer the propositions established by moyano´s hundred-year-old law (1857), which continued to persist in the spanish education system and particularly in spanish nursing, which was being moulded professionally and academically by it. the general education act provided for diploma studies at the university level. in this context, nurses were able to choose between vocational training, and studies for a university degree. in february 1976, the comisión interministerial (cross-ministerial commission) was constituted to reform a.t.s. studies. it was comprised of representatives from a number of official agencies (dirección general table 3. distribution of contents in “nursing study programs” spain, 1 first course second course third course religion professional ethics functional anatomy biology-histology microbiology general hygiene general pathology building a national spirit physical education practice religion professional ethics pathology and prescription surgical pathology general psychology history of the profession building a national spirit physical education practice religion professional ethics surgical specialities medical/surgical causalities hygiene and prevention obstetrics and genecology newborns-infants social medicine differential psychology physical education practice source: (siles, 1999): study programs in 1968, villar palasi took over as head of the ministry of education and science. soon after, in 1970, a decisive law for the future of nursing would result in nursing becoming a field of study at the university level. 199 political systems and the perspective on nursing education during the spanish transition ... l josé siles, maría del carmen solano-ruiz, genival fernández de freitas, taka oguisso de sanidad, ministerio de educación y ciencia, instituto nacional de previsión, sindicato de actividades sanitarias and the three branches of the consejo general de a.t.s.), in addition to two doctors and two nurses as advisory members. to justify their decision to include studies at the university level, the experts used the european council guidelines on the activities of nurses responsible for general care (77/453/cee). the strain imposed by the work force, mainly from the hospital sector, and the pressure brought to bear by professionals who were part of the provincial a.t.s. associations brought them all together to form a national co-ordinating committee, ultimately achieving the addition of nursing at the university level. a bachelor’s degree in nursing (as at the university of alicante) became a reality during the 1998-99 academic year, after a long struggle and with the hope that this experience would serve as model and be implemented nationwide. historical evolution of studies in spain to become “practicantes,” midwives, nurses (1942-43 / 195556) and a.t.s. (195657/1976-77) after world war ii and as a consequence of the international isolation that totalitarian spain experienced, the transformation regarding authoritarianism was slow, but irreversible. between the course” in 1942-43 to the one in 1955-56, a total of 57, 496 students were enrolled (table 4). the course in 1951-52 had the highest enrolment. course/year schools total males % males females % females degrees 1942-43 1943-44 1944-45 1945-46 1946-47 1947-48 1948-49 1949-50 1950-51 1951-52 1952-53 1953-54 1954-55 1955-56 10 10 10 10 10 10 10 10 10 10 10 10 10 10 2241 2277 2716 2835 3031 4052 5727 6240 6354 6733 4874 5745 3588 1113 1758 1791 2029 2081 2168 2797 3872 4305 4723 4970 3307 3823 2263 752 78,4 78,7 74,7 73,4 71,5 69,0 67,6 69,0 74,7 73,8 67,8 66,5 63,1 67,6 483 486 687 754 863 1255 1855 1935 1601 1763 1567 1922 1325 361 21,6 21,3 25,3 26,6 28,5 31,0 32,4 31,0 25,3 26,2 32,2 33,5 36,9 32,4 822 1245 717 872 1016 1850 1541 1850 2128 2121 2108 1751 1844 1493 table 4. distribution of men and women in the nursing course between 1942 and 1956. spain, 1957 midwives this period witnessed a clear evolution in midwifery studies. with unification of the curricula and the creation of the title and profession of technical health assistant (a.t.s.), midwifery was established source: anuario nacional de estadística, 1957: 801. as an a.t.s. specialty. during this academic period, a total of 12.567 students were enrolled (897 per course) (table 5). the following table shows the total number of students enrolled to study midwifery during the period between 1942 and 1956. table 5. total number of nursing students studying midwifery between 1942 and 1956. spain, 1957 course schools total degrees 1942-43 1943-44 1944-45 1945-46 1946-47 1947-48 1948-49 1949-50 1950-51 1951-52 1952-53 1953-54 1954-55 1955-56 source: anuario nacional de estadística, 1957: 801. 10 10 10 10 10 10 10 10 10 10 10 10 10 10 432 469 572 731 760 779 1038 1117 1333 1326 1008 1133 1171 698 122 152 190 243 233 329 316 537 379 456 406 385 385 382 200 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 nurses nursing studies began in 1915 and reached their peak of development during the ii republic, when there was a massive influx of women. between 1942-43/195556, a total of 49,816 students were enrolled (3,558 per course) (table 6). the following table shows the number of students enrolled between 1942 and 1956. the university stage and nursing graduates the democratic transition in spain was important to improving academic teaching. in 1989-90, 20,228 students were enrolled and 5,973 degrees were granted by a total of 31 university schools, three of them private. the following table shows the universities and the total number of nursing students enrolled in spain during the period from 1989 to 1990 (table 7). the origin of nursing research in spain híades is the first spanish journal dedicated exclusively to the history of nursing. it first appeared in august 1994, encouraged by the efforts of the andalusian group for research on nursing history (gaihe). the first issue of cultura de los cuidados appeared in august 1997. this journal is characterized by a zeal for the development of humanistic nursing in four fundamental areas: phenomenology, anthropology, history and theory, and nursing ideas and principles pursuant to the hermeneutic and sociocritical paradigms (tables 8 y 9). moreover, the first spanish association of history and the anthropology of healthcare was established as a result of this publication. 1942-43 1943-44 1944-45 1945-46 1946-47 1947-48 1948-49 1949-50 1950-51 1951-52 1952-53 1953-54 1954-55 1955-56 10 10 10 10 10 10 10 10 10 10 10 10 10 10 869 1217 1891 1749 2024 2811 4274 5277 6464 7066 11586 2805 496 1242(2) 186 419 229 440 620 755 773 1656 1478 1912 2352 3069 1699 930 course schools female students(1) degrees source: anuario nacional de estadística, 1957: 801. (1) external and “official” students. (2) included 237 males (a.t.s. students). in spain, the a.t.s were known as “technical health assistants”. table 7. universities and total number of nursing students in spain during 1989 1990. spain, 1992 public and private universities public universities alcala henares alicante baleares autonoma barcelona barcelona cantabria cadiz castilla la mancha cordoba coruña extremadura granada la laguna leon universities enrolment females degrees total students 20228 19064 130 198 164 340 1342 190 561 658 252 189 855 1354 289 179 17036 15931 117 165 143 316 1197 157 371 567 187 168 696 1040 225 168 5973 5537 37 55 42 101 357 63 135 280 74 259 512 148 41 table 6. distribution of female students enrolled in the nursing course during 1942-1956, spain, 1957 201 political systems and the perspective on nursing education during the spanish transition ... l josé siles, maría del carmen solano-ruiz, genival fernández de freitas, taka oguisso source: anuario estadístico de 1992, ine, madrid: 571 l possibility of admitting the subjective dimension in research. l nurse works like agent of comprehensive and interactive communication l patient exerts the roll of subject signaller of his state and expectations l the health concept is processed interactively l scientific knowledge: phenomenology, symbolic interactionism, anthropology, lifes histories, etc. table 8 hermeneutic paradigm source: siles j. epistemología y enfermería: por una fundamentación científica y profesional de la disciplina. enfermería clínica. enfermería clínica 1997; 7: 188-94. table 7. universities and total number of nursing students in spain during 1989 1990. spain, 1992 universities enrolment females degrees total students madrid (autonoma madrid (complutense) malaga murcia oviedo pais vasco las palmas salamanca santiago sevilla valencia valladolid vigo zaragoza private universities navarra pontificia de comillas pontificia de salamanca 257 966 567 372 524 1220 214 547 590 682 1127 928 373 1125 642 257 265 233 788 434 307 457 1086 166 482 506 525 901 841 311 1003 642 208 255 97 488 137 109 138 367 50 133 290 146 286 236 249 173 83 continue. l necessity of developing the historical conscience. l interpret subjectively nurse as agent of change. l the patient acts like subject involved in the control and dynamics of his process of health l positive concept of health: reelaboration of the same one on the part of the subject. l constructed knowledge dialectically critical investigation, study of contexts and consideration of the subjet-patient (anthropology, history, critical sociology). table 9 sociocritical paradigm source: siles j. epistemología y enfermería: por una fundamentación científica y profesional de la disciplina. enfermería clínica. enfermería clínica 1997; 7: 188-94. 202 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 hermeneutic paradigm: possibility of permitting a subjective dimension in research. the nurse functions as an agent for comprehensive and interactive communication. the patient is a subject who signals his/ her state of health and expectations. socio-critical paradigm: need to develop a historical conscience. subjectively interprets the nurse’s role as an agent of change. patients behave as subjects involved in the control and dynamics of their health process. positive concept of health: reworking of that concept on the part of the subject. constructed knowledge, dialectically critical research, study of contexts, and consideration of the subject-patient (anthropology, history, critical sociology). among other results, this study found only one spanish journal that dedicates a section to the anthropology of healthcare (cultura de los cuidados in 1997); while another publication often includes articles on the subject (index, in 1988). the other journals consulted only occasionally contain articles on the anthropology of healthcare. the characteristics of the articles published in cultura de los cuidados and index point to an evident change of paradigm. thus, three different periods can be distinguished, given the political system at the time and the characteristics of spanish nursing education. the first stage is dominated by the rational-technological paradigm (figure i). it coincides with the authoritarian period (1855-1977) when nurses were not regarded as independent professionals, but as physicians’ assistants with no scientific knowledge. during this period, nurses performed only simple tasks, with the patient as the recipient. in other words, it is possible to say that the moral dimension of nursing practice was not taken into account during that time. the hermeneutic paradigm pertains to a shorter period, which began when nursing became a field of study for a university degree (coinciding with the beginning of the democratic transition in 1977) and lasted up until enactment of the general health act in 1986. during that period, the nurse became an interpreter of the patient’s situation, as it was the nurse who had a command of know-how, communication skills and psychology, and a historical, sociological and anthropological education. yet, nurses were unable apply all of this in practice, because the labour system was not structured for universitytrained nurses. finally, the phase when the sociocritical paradigm began coincides with enactment of the general health act and continues to this day. in this phase, nurses are agents of socio-health change and their knowledge can be applied in practice, since the general health act recognizes them as university-trained health professionals. conclusions during the long pre-democratic period, spanish nursing was governed by positivistic logic and a technical approach, which influenced educational curricula. the addition of humanistic and anthropological subjects to the curricula facilitated a holistic approach and occurred in 1997, when nursing became a field of study at the university level. this coincided with the onset of democracy in spain. the variability of the political and social system has had a strong influence on the adoption of nursing paradigms in education, and on development of the anthropology of healthcare. the false neutrality of the scientific paradigms and the hierarchical and authoritarian bureaucratization of the disciplines are evident, particularly on the part of specialists in the so-called emerging, new or developing disciplines, which is the case of nursing education. practicantes, midwives and nurses suffered an educational system in which ideology, political indoctrination and religious ideas played a paramount role. with the arrival of democracy in spain, nursing finally became a field of study for a university degree 1977. this did away with the nurse’s image as a mere technician. after being incorporated into the university curriculum, nursing began an evolution that culminated with adoption of the hermeneutic and socio-political paradigms. historical, sociological and anthropological research acquired a prominent role (in curricula) following the adoption of approaches endorsed by the hermeneutic and socio-political paradigms. the interest in nursing anthropological studies and their development were preceded by a period of historiographic development. 203 political systems and the perspective on nursing education during the spanish transition ... l josé siles, maría del carmen solano-ruiz, genival fernández de freitas, taka oguisso references 1. foucault m. un diálogo sobre el poder y otras conversaciones. madrid: alianza; 2008. 2. foucault m. estrategias de poder. barcelona: paidós; 1999. 3. suchodolski b. pedagogia de l’essència i pedagogia de l’existència. barcelona: eumo; 1986. 4. siles j y solano c. (ed.) antropología educativa. alcoy: marfil/ instituto ciencias de la educación. universidad de alicante; 2009. 5. habermas j. ciencia y técnica como ideología. madrid: tecnos; 2007. 6. conger c.& johnson p. integrating political involvement and nursing education. nurse educator 2000; 25(2): 99-103. 7. bonald la. teoría del poder político y religioso. madrid: tecnos; 1988. 8. puelles m. educación e ideología en la españa contemporánea. madrid: tecnos; 2001. 9. viñao a. política y educación en los orígenes de la españa contemporánea. madrid: siglo xxi; 1982.9. kuhn ts. qué son las revoluciones científicas? barcelona: paidós: barcelona; 1995. 10. powkewitz ts. las tecnologías culturales como control. prácticas culturales: revista educación y pedagogía 2003; 15(37): 33-51. 11. kuhn ts. la estructura de las revoluciones científicas. madrid: fondo de cultura económica; 2005. 12. medina jl & sandín mp. fundamentación epistemológica de la teoría del cuidado. enfermería clínica 1994; 5: 221-225. 13. medina jl & sandín mp. epistemología y enfermería: paradigmas de investigación en enfermería. enfermería clínica 1995; 5: 40-52. septemberoctober. 14. siles j. & garcía e. las características de los paradigmas científicos y su adecuación a la investigación en enfermería. enfermería científica 1995; 160: 10-15. july-august. 15. siles j. historia de la enfermería. alicante: aguaclara; 1999. 16. siles j. epistemología y enfermería: por una fundamentación científica y profesional de la disciplina. enfermería clínica1997; 7: 188-94. 17. siles j. historia de la enfermería comunitaria en españa. un enfoque social, político, científico e ideológico de la evolución de los cuidados comunitarios. index de enfermería 1997; 24: 25-31. 18. eseverri c. historia de la enfermería española e iberoamericana. madrid: universitas; 1995. 170 182 instrumento.indd 170 aquichan issn 1657-5997 yariela gonzález-ortega1 instrumento cuidado de comportamiento profesional: validez y confi abilidad 1 candidata a doctora en enfermería. universidad nacional de colombia. docente. universidad de panamá. facultad de enfermería. campus central. panamá república de panamá. yagonzalez@ancon.up.ac.pa recibido: 13 de febrero de 2008 aceptado: 5 de agosto de 2008 resumen propósito: determinar la validez y confiabilidad en español del instrumento cuidado de comportamiento profesional “forma a”, elaborado por la doctora sharon horner, con el fin de conocer, desarrollar y medir los fenómenos de enfermería relacionados con el cuidado en el contexto panameño. método: investigación de tipo metodológico realizada en cuatro fases: proceso de traducción, en el cual se utilizó una muestra de tres expertos; fase de validación facial o aparente, con una muestra de diez docentes de la facultad de enfermería de la universidad nacional de colombia, y diez docentes de la facultad de enfermería de la universidad de panamá; fase preliminar de ajuste, tomando una muestra de diez pacientes hospitalizados, y fase de confiabilidad, cuya muestra fue de 284 pacientes hospitalizados. en el proceso de traducción hubo corrección de escritura en los ítems 12 y 21, y reestructuración del ítem 20. en la validez facial se realizaron cambios de redacción de los ítems, sin perder el sentido original de los mismos, y se reemplazó la escala original por: siempre, casi siempre, algunas veces y nunca. resultados: la prueba preliminar de ajuste indicó comprensión por parte de los pacientes. en la prueba de confiabilidad se obtuvo un coeficiente de confiabilidad alfa de cronbach de 0,80 con factores que oscilaron entre 0,25 y 0,69, y por ítem se obtuvieron alfas entre 0,78 y 0,80. conclusión: el instrumento presenta validez facial o aparente y consistencia interna, lo que demuestra que es apto para ser utilizado en el contexto panameño. palabras clave validez, confiabilidad, instrumento de cuidado, atención de enfermería, ética de enfermería. (fuente: decs) validity and reliability of “caring for professional performance” abstract purpose: to determine the validity and reliability of the spanish version of caring for professional performance – “form a”, an instrument designed by dr. sharon horner to understand, develop and measure the nursing phenomena associated with care in the panamanian context. año 8 vol. 8 nº 2 chía, colombia octubre 2008 170-182 171 instrumento cuidado de comportamiento profesional: validez y confiabilidad yariela gonzález-ortega method: this is a methodological study conducted in four phases: the translation process, in which a sample of three experts was used; the facial or apparent validation phase, with a sample of ten teachers from the national university of colombia school of nursing and ten teachers from the university of panama school of nursing; the preliminary adjustment phase, with a sample of ten hospitalized patients, and the reliability phase, with a sample of 284 hospitalized patients. in the translation process, the wording of items 12 and 21 was corrected and item 20 was restructured. the wording of the items concerning facial validity was modified, without changing the initial meaning, and the original scale was replaced with: always, almost always, sometimes and never. results: the preliminary adjustment test indicated an understanding on the part of the patients. the reliability test produced a cronbach alpha reliability coefficient of 0.80 with factors that oscillated between 0.25 and 0.69. the alphas per item were between 0.78 and 0.80. conclusion: the instrument shows facial or apparent validity and internal consistency, which demonstrates its suitability for use in the panamanian context. key words validity, reliability, care instrument, nursing care, nursing ethics. instrumento cuidado de comportamento profi ssional: validade e confi abilidade resumo objetivo: estabelecer a validade e a confiabilidade, em espanhol, do instrumento cuidado de comportamento profissional, forma a, elaborado por sharon horner para conhecer, desenvolver e medir os fenômenos de enfermagem relacionados com o cuidado no contexto de panamá. método: pesquisa de tipo metodológico, realizada em quatro estágios: processo de tradução, no qual foi utilizada uma amostra de três expertos; validação facial ou aparente, na qual foi usada uma amostra de 10 docentes da faculdade de enfermagem da universidad nacional de colombia e 10 docentes da faculdade de enfermagem da universidad de panamá; ajuste preliminar, na qual foi utilizada uma amostra de 10 pacientes hospitalizados; e confiabilidade, na qual foi usada uma amostra de 284 pacientes hospitalizados. no processo de tradução, foi corregida a redação dos itens 12 e 21, e foi restruturado o item 20. na validade facial foram realizadas alterações na redação dos itens, sim perder o senso original. a escala original foi substituída por sempre, casi sempre, algumas vezes, nunca. resultados: a proba preliminar de ajuste amostrou compreensão dos pacientes. na proba de confiabilidade, se logrou um coeficiente de confiabilidade alfa de cronbach de 0.80, com fatores entre 0.25 e 0.69. por itens foram obtidos alfas entre 0.78 e 0.80. conclusão: o instrumento apresenta validade facial ou aparente e consistência interna; isto sugere que é apto para utilizá-lo no contexto de panamá. palavras-chave validade, confiabilidade, instrumento de cuidado, cuidado de enfermagem, ética de enfermagem. 172 año 8 vol. 8 nº 2 chía, colombia octubre 2008 170-182 aquichan issn 1657-5997 introducción la validez y confiabilidad del instrumento de cuidado de comportamiento profesional se realizó como parte del proyecto de investigación “cuidado de relación interpersonal según experiencia práctica de la enfermera”, en el doctorado de enfermería de la universidad nacional de colombia. el tener este instrumento válido y confiable en idioma español se convirtió en un marco de referencia que contribuyó a conocer y medir el cuidado de enfermería en el contexto panameño, donde no se cuenta actualmente con instrumentos confiables y validados. es por ello que surgió la necesidad de responder a la pregunta: ¿cuál es la validez y confiabilidad de la versión en español del instrumento cuidado de comportamiento profesional “forma a”, elaborado por la doctora sharon horner? para responder a esta interrogante se trazó el objetivo de determinar la confiabilidad a través de la consistencia interna de la versión en español del instrumento cuidado de comportamiento profesional “forma a”, y de determinar su validez facial o aparente. cuidado de enfermería el cuidado como tema central de la atención de enfermería es proporcionado en sus diferentes dimensiones dentro de un proceso de interacción, y se basa fundamentalmente en las necesidades biopsicosociales, culturales y espirituales del paciente (1) . este comportamiento de dar y recibir cuidado denota conductas recíprocas que producen un efecto en la experiencia subjetiva del paciente (2) . es por ello que la práctica de cuidado que proporciona la enfermera es fundamental para aliviar las respuestas humanas ante situaciones amenazantes o para prevenir las mismas, por lo que es importante medir el comportamiento de cuidado tanto de la enfermera como del paciente, ya sea de forma individual o colectiva, y de correlacionarlos, para conocer finalmente cómo la enfermera proporciona el cuidado de enfermería en cada una de sus dimensiones. de aquí la importancia de medir el cuidado a través de instrumentos confiables y válidos que ayuden a identificar a la ciencia de enfermería y permitan conocer más sobre cómo los pacientes perciben este acto de cuidar, y cómo la enfermera lo realiza. en este sentido, para tratar de explicar la percepción del comportamiento de cuidado, brown, citado por znyder (3) dividió la conducta del cuidado y sus características en dos dimensiones: la instrumental y la afectiva. la dimensión instrumental evalúa el conocimiento del profesional de enfermería midiendo el confort, la asistencia, la información, la protección y el apoyo proporcionado. la dimensión afectiva incluye la sensibilidad del paciente y de los otros, necesidades de reconocimiento individual, apoyo emocional, promoción de la autonomía, contacto y presencia. el cuidado como tema central de la atención de enfermería es proporcionado en sus diferentes dimensiones dentro de un proceso de interacción, y se basa fundamentalmente en las necesidades biopsicosociales, culturales y espirituales del paciente. 173 instrumento cuidado de comportamiento profesional: validez y confiabilidad yariela gonzález-ortega así surgieron instrumentos pioneros de medición del cuidado tales como el de larson, citado por watson (4), que mide la conducta del cuidado de la enfermera en seis subescalas: accesibilidad, explicación, facilitación, confort, relación de confianza y seguimiento por supervisión; el instrumento de wolf (5) de caring behaviors inventory (inventario de comportamientos de cuidado), el cual mide diez comportamientos: escuchar atento, consuelo, honestidad, paciencia, responsabilidad, proporcionar información, contacto, sensitividad, respeto, llamar al paciente por su nombre. cronin y harrison citados por snyder (3) desarrollaron un instrumento de medición llamado caring behaviors assessment, basado en los planteamientos de watson. el mismo consta de 63 conductas del cuidado de enfermería desarrolladas en siete subescalas. larson y ferketich (6) desarrollaron un instrumento de medición de satisfacción del paciente sobre el cuidado de enfermería el care/satisfaction questionarie (care/sat). a través del tiempo se han desarrollado otros instrumentos que miden aspectos particulares de cuidado, lo relevante es que cada uno de ellos responde a pruebas psicométricas que le dan la validez y confiabilidad para poder utilizarlos dentro del contexto donde fueron elaborados, por lo que el instrumento de cuidado de comportamiento profesional no escapa a ello. el mismo fue sometido a pruebas psicométricas en idioma inglés, por tal motivo, al traducirlo al idioma español también se hace necesario realizar este proceso de validación. pruebas de adaptación del instrumento existen dos requisitos que por su relevancia son fundamentales en un instrumento de medición, estos son: confiabilidad y validez (7), cuya finalidad es determinar si el instrumento cumple con la función para la cual fue elaborado. de acuerdo con los estándares de la american psychological association (8), cuando a un instrumento se le hacen cambios sustanciales en el formato, modo de aplicación, idioma o contenido, se debe revalidar la escala para las nuevas condiciones o grupos en los que se aplique. este proceso de validación requiere de una serie de pasos tales como la selección del instrumento, traducción, prueba preliminar de ajuste (ítems), pruebas de su validez, prueba de confiabilidad y determinación de su utilidad (8) . en cuanto a la traducción el énfasis no es la traducción textual o literal, sino del sentido conceptual que cada ítem persigue. la fase preliminar de ajuste tiene como finalidad analizar aspectos relacionados con los ítems y la utilidad de la escala. la validez se refiere al grado en que un instrumento mide realmente la variable que pretende medir. la evaluación de la validez de un instrumento busca responder a la validez facial o aparente, de contenido y de criterio (8). la validez facial o aparente es el juicio de quien toma la prueba y siente que el instrumento mide lo que se pretende medir, es decir, se emite un juicio acerca de los reactivos después de que ha sido construido (9). la confiabilidad de un instrumento se refiere al grado en que su aplicación repetida al mismo sujeto u objeto produce iguales resultados (10). la confiabilidad puede ser medida a través de la consistencia interna por medio del coeficiente de alfa de cronbach, el cual es considerado como un estimador estable de la confiabila dimensión afectiva incluye la sensibilidad del paciente y de los otros, necesidades de reconocimiento individual, apoyo emocional, promoción de la autonomía, contacto y presencia. 174 año 8 vol. 8 nº 2 chía, colombia octubre 2008 170-182 aquichan issn 1657-5997 lidad calculada por mitades de una prueba. este coeficiente analiza el alcance con que los ítems del instrumento miden el constructo de manera coherente (2). su valor fluctúa entre 0,00 y + 1,00. los valores que se recomiendan para estos índices son entre 0,70-0,90 (9, 6). valores bajos indican que el instrumento no muestra consistencia ante diferentes condiciones de aplicación, y su valor más alto refleja un mayor grado de congruencia interna. por consiguiente, para que se hable de que el instrumento es idóneo, y que se pueda utilizar con toda la confianza se requiere que cumpla con los dos requisitos: confiabilidad y validez. marco de diseño tipo de estudio esta investigación se desarrolló bajo el marco de un estudio de tipo metodológico. este tipo de estudio aborda el desarrollo, la validación y la evaluación de instrumentos, siendo su objetivo principal el desarrollar instrumentos confiables, eficaces y funcionales que se puedan utilizar en otras investigaciones (11). este tipo de estudio permitió aplicar pruebas psicométricas para establecer la validez y confiabilidad del instrumento de cuidado de comportamiento profesional “forma a”, traducido al español. descripción del instrumento cuidado de comportamiento profesional “forma a”, en su versión original (inglés) el instrumento de cuidado de comportamiento profesional “forma a” fue elaborado por la doctora sharon horner (12) con el objetivo de valorar la percepción del cuidado de comportamiento de las enfermeras en pacientes adultos hospitalizados, y cuyo marco conceptual fue basado en el cuidado. su contenido se derivó de la teoría sobre cuidado, la literatura y las investigaciones de enfermería realizadas, definiendo éste desde una base teórica y práctica (13). desde la perspectiva teórica, el cuidado lo describe como un valor fundamental que guía a la enfermera en las decisiones éticas, haciendo y promoviendo las bases para las acciones de enfermería. por esto, lo identifica como una característica personal y una herramienta terapéutica para la interacción enfermera-paciente. desde el punto de vista práctico lo describe como lo identificable y medible del comportamiento, lo cual ayuda a evitar improvisaciones. desde el punto de vista de las investigaciones, identifica comportamientos y actividades asociadas con el cuidado de enfermería. estas investigaciones aportaron puntos de vista divergentes y convergentes del comportamiento del cuidado, expresados por los pacientes y las enfermeras, que son necesarios tomar en cuenta al definir más exactamente los cuidados. en este sentido, la doctora horner desarrolló el instrumento tomando en consideración las respuestas de 356 pacientes, a los que se hicieron preguntas abiertas y cerradas acerca del cuidado que proporciona la enfermera, y de las que se extrajeron 56 ítems, los cuales se dividieron en dos formas, la forma a y la forma b, ambos con 28 ítemes, tanto positivos como negativos (4). la versión original del instrumento en la versión en inglés utilizó una escala de para que se hable de que el instrumento es idóneo, y que se pueda utilizar con toda la confianza se requiere que cumpla con los dos requisitos: confiabilidad y validez. 175 instrumento cuidado de comportamiento profesional: validez y confiabilidad yariela gonzález-ortega likert con cuatro categorías, con un rango de 4-1 puntos, que va de un grado de total acuerdo a uno de total desacuerdo, y cuenta con un total de 28 ítems, relacionados con aspectos de percepción de cuidado. los factores que presenta son cuatro (12): el primero “no comprometido”, que incluye todos los ítems negativos, hacen un total de 10 ítems; el segundo, “interacción con la familia/paciente”, contiene un total de siete ítems; el tercero, llamado “cortesía”, contiene cinco ítems; el cuarto fue llamado “relación” y contiene seis ítems (ver tabla 1). tabla 1. descripción de los factores del instrumento de cuidado de comportamiento profesional “forma a” en su versión original (11) factores ítems total de ítems no comprometido 1, 5, 6, 7, 10 13, 19, 20, 15, 23, 27 interacción con 9, 16, 17, 21, 7 la familia 22, 24, 25 cortesía 10, 11, 14, 18, 26 5 relación 2, 3, 4, 8, 12, 28 6 la razón de validez de contenido fue dada a través de un panel de cuatro enfermeras expertas en el concepto de cuidado a los enfermos. las expertas consideraron un acuerdo del 90%, es decir, una razón de validez de contendido (rvc) de 0,90 (13). para la validez del constructo se usó una muestra de 394 personas, utilizando el método de análisis factorial presentando cargas factoriales por ítems entre 0,46 y 0,68. considerando que cada ítem representa una frase de cuidado, estos resultados revelaron una relación aceptable. el método utilizado para derivar los factores fue el análisis de factor de componentes principales (prc) de eje principal o de autovalores (9). los cuatro factores producidos por este método fueron: el primer factor, llamado “no comprometido”, presentó un valor propio de 9.416, cuya varianza explicada fue de 33,6%; el segundo factor, llamado “interacción con la familia-paciente”, presentó un valor propio de 1,60 con varianza explicada de 5,7%; el tercer factor, llamado “cortesía”, presentó un valor propio de 1,40 cuya varianza explicada fue de 5%. el cuarto factor fue llamado “relación” con un valor propio de 1,15 y una varianza explicada de 4,1% (12). la consistencia interna se determinó a través del coeficiente de alfa de cronbach, el cual dio como resultado un valor de 0,92 y la estabilidad a través de test-retest reportó un valor de 0,81, con un α 0,05. a este instrumento también le fue aplicado el método de las formas paralelas. para ello se utilizaron la forma a y la forma b del instrumento. la forma b está compuesta por similares contenidos, estructura y escala de la forma a. el análisis de confiabilidad para estos instrumentos reportó para la forma a un valor de 0,92, y para la b un valor de 0,94. además, fue valorado con una prueba de correlación de pearson, cuyo resultado fue una correlación fuerte 0,90 y valores p menores de 0,001, para cada uno de los 28 pares de ítems. la razón de validez de contenido fue dada a través de un panel de cuatro enfermeras expertas en el concepto de cuidado a los enfermos. 176 año 8 vol. 8 nº 2 chía, colombia octubre 2008 170-182 aquichan issn 1657-5997 tabla 2. resumen de las pruebas de confiabilidad del instrumento de cuidado de comportamiento profesional “forma a” en su versión original pruebas de confiabilidad valores alfa de cronbach 0,92 prueba-reprueba 0,81 formas paralelas (correlación de pearson) 0,90 fases de validez y confiabilidad del instrumento de cuidado de comportamiento profesional “forma a”, versión en español fase de traducción muestra. se conformó un comité de tres profesoras de enfermería, con experiencia en aplicación de instrumentos, y con conocimiento del idioma inglés. dos de ellas formaron parte de la cultura panameña en la cual se aplicó el instrumento, con el objetivo de realizar una traducción directa (traducción del instrumento del idioma original al idioma de aplicación). procedimiento. el proceso de traducción se inició con la solicitud a la autora del instrumento, doctora sharon horner, de su autorización para la utilización y traducción al idioma español. cada uno de los miembros del comité tradujo el instrumento original al idioma español, y se llegó a un acuerdo en los ítems discordantes, quedando una sola versión en idioma español. posteriormente se entregó el instrumento a un cuarto evaluador, que no pertenecía al comité, para su revisión final. la versión final en español fue traducida nuevamente al inglés por un profesor experto en este idioma y enviada nuevamente a su autora. resultados. la versión final del instrumento traducido al idioma inglés fue evaluada por la autora, la cual sugirió corregir un error de escritura en el ítem 12, colocar en negativo el ítem 21, y reestructurar la redacción del ítem 20, ya que la redacción presentada cambiaba el sentido del mismo. fase de validación facial o aparente la validación facial se realizó con el objetivo de evaluar los ítems, emitir un juicio sobre la comprensión de los mismos, y comprobar si eran comprendidos en el contexto y lenguaje panameño, para así obtener la aceptación del instrumento por parte de los usuarios. muestra. en esta validación participaron diez enfermeras colombianas, expertas en cuidado y en manejo de instrumentos, así como diez enfermeras panameñas, docentes que se encuentran en el contexto panameño, donde se aplicó el instrumento. procedimiento. a cada docente se le entregó un formato que contaba con una introducción, objetivos e instructivo con respecto al procedimiento de validez facial o aparente del instrumento. su estructura estaba conformada por dos columnas, la primera contenía los 28 ítems del instrumento y la segunda presentaba un enunciado de observaciones, donde el docente pondría las suyas con respecto a la redacción del ítem de acuerdo con el contexto. la validación facial se realizó con el objetivo de evaluar los ítems, emitir un juicio sobre la comprensión de los mismos, y comprobar si eran comprendidos en el contexto y lenguaje panameño. 177 instrumento cuidado de comportamiento profesional: validez y confiabilidad yariela gonzález-ortega resultados. se obtuvieron recomendaciones de cada experto con respecto a la redacción y clarificación de conceptos abstractos que pudieran no ser comprendidos por los pacientes, tales como: cálidamente, respuesta cuidadosa, personas reales, interés real, expresión del rostro, creencias espirituales, automáticamente y sentimiento real. con estas recomendaciones se hizo un compendio por ítems, dando como resultado pequeños cambios de redacción en cada ítem, sin que se perdiera el sentido original de los mismos. otro ajuste que sufrió el instrumento fue su escala original de total acuerdo, de acuerdo, desacuerdo y total desacuerdo, que fue reemplazada por la escala de siempre, casi siempre, algunas veces y nunca. fase de prueba preliminar de ajuste posterior a las recomendaciones efectuadas por los expertos en la validación facial o aparente, se procedió a realizar una prueba preliminar de ajuste. muestra. se utilizó una muestra de diez pacientes de un hospital de tercer nivel de atención ubicado en la ciudad de panamá, de los cuales cinco pertenecían al servicio de medicina y cinco al servicio de cirugía, y cuyos criterios de inclusión fueron pacientes hospitalizados adultos, sin patologías que afectaran su estado mental y cognitivo, y que no hubiesen llegado recientemente de un procedimiento. procedimiento. el instrumento fue aplicado en un horario de 7:00 a.m. a 3:00 p.m. y en forma de entrevista. resultado. se obtuvo una buena interpretación de los ítems por parte de los pacientes, ya que no hubo ninguna observación en cuanto a su comprensión. una vez realizadas estas tres primeras fases, se entregó nuevamente el instrumento a la autora, la cual le dio la revisión y aprobación. fase de confiabilidad muestra. para realizar la confiabilidad del instrumento, éste se aplicó a una muestra aleatoria de 284 pacientes hospitalizados en una institución de tercer nivel de atención en la ciudad de panamá. el tamaño muestral se determinó utilizando lo referido por nunnally y bernstein citados por mahon (14), quienes manifiestan que para validar un instrumento se requieren diez participantes por cada ítem. criterios de inclusión. el instrumento se aplicó a pacientes que cumplían con los criterios de ser adultos hospitalizados, sin patologías que afectaran su estado mental y cognitivo, con un mínimo de tres días de hospitalización, y que no hubiesen llegado recientemente de un procedimiento. consideraciones éticas. para dar inicio a la investigación se solicitó autorización a la administración del hospital donde se realizó la investigación: director médico, director de docencia e investigación médica, directora del departamento de enfermería, y al comité de ética del hospital donde se realizó el estudio. se describió a los pacientes el propósito del estudio, los beneficios, el derecho a la confidencialidad, al anonimato y a abandonar el estudio al momento de la aplicación del instrumento. se solicitó a los participantes su autorización con la firma del consentimiento informado, antes de aplicar el instrumento. procedimiento el instrumento fue aplicado en los turnos de 7:00 a.m. a 3:00 p.m. y de 3:00 otro ajuste que sufrió el instrumento fue su escala original de total acuerdo, de acuerdo, desacuerdo y total desacuerdo, que fue reemplazada por la escala de siempre, casi siempre, algunas veces y nunca. 178 año 8 vol. 8 nº 2 chía, colombia octubre 2008 170-182 aquichan issn 1657-5997 p.m. a 11:00 p.m., de lunes a viernes y días festivos. la aplicación del instrumento se dio en forma de entrevista, donde se leyeron las preguntas y alternativas de respuesta al paciente y se anotó lo que éste contestó, según su preferencia. para determinar la confiabilidad se utilizó como procedimiento estadístico el coeficiente de consistencia interna de alfa de cronbach, mediante el paquete estadístico spss versión 11.5. este coeficiente analiza el alcance con que los ítems del instrumento miden el constructo de manera coherente (2). una vez aplicado el instrumento se codificaron los datos tomando en cuenta la inversión de respuesta (9). se asignó la puntuación de 4 a 1 a las preguntas enunciadas de forma positiva conforme fue contestada, y a las preguntas negativas se les asignaron los puntos de manera inversa conforme fueron contestadas. a la categoría 1 se le asignó un valor de 4 puntos, a la 2 un valor de 3 puntos, a la 3 uno de 2 puntos, y a la categoría 4 un punto. análisis de resultados tabla 3 distribución de la muestra según sexo en un hospital de tercer nivel. fuente: instrumento aplicado a los pacientes hospitalizados en una institución de tercer nivel de atención de la ciudad de panamá. febrero-marzo de 2006. total 284 100,0 masculino 136 47,9 femenino 148 52,1 la tabla 3 muestra que el 52,1% corresponde al sexo femenino y el 47,9% al sexo masculino, lo que indica que la muestra estuvo bien representada por pacientes de ambos géneros. tabla 4 distribución de los pacientes según servicio de hospitalización en un hospital de tercer nivel. figura distribución de la muestra según sexo, en un hospital de tercer nivel de la ciudad de panamá. febrero marzo 2006 especialidad fr % total 284 100,0 ortopedia 48 16,9 neurocirugía 22 7,7 urgencias 27 9,5 cirugía general 36 12,7 cirugía de especialidades 52 18.3 ginecología 20 7,0 hematología 7 2,5 gastroenterología 21 7,4 medicina 51 17,9 fuente: instrumento aplicado a los pacientes hospitalizados en una institución de tercer nivel de atención de la ciudad de panamá. febrero-marzo de 2006. la tabla 4 muestra que los pacientes estaban distribuidos en diferentes servicios de especialidad, siendo el servicio de cirugía de especialidades el de mayor concentración de pacientes, representando un 18,3%, seguido de un 17,9% en el servicio de medicina, y en tercer lugar el de ortopedia con un 16,9%. por otra parte, los servicios de menor concentración fueron hematología con un 2,5%, ginecología con el 7,0%, y gastroenterología con 7,4%. estos resultados indican que la muestra de pacientes está distribuida en diferentes servicios. tabla 5 descripción de la edad de los pacientes. hospital de tercer nivel. n válidos 281 perdidos 3 media 55,4 mediana 58.0 moda 65 desv. típ. 17,9 mínimo 15 máximo 88 fuente: instrumento aplicado a los pacientes hospitalizados en una institución de tercer nivel de atención de la ciudad de panamá. febrero-marzo de 2006. la tabla 5 presenta una población conformada por 281 pacientes, cuyo promedio de edad es de 55,4 años, una mediana de 58 años, lo que indica que el 50% de la población se encuentra por encima de esta edad, y el resto se encuentra por debajo. la moda o valor más frecuente corresponde a los 65 años de edad, con una desviación estándar de 17,9 y un rango de edad de 15 años a 88 años. esto indica que los pacientes se encontraban en un promedio de edad adulta. tabla 6 confiabilidad global del instrumento de cuidado de comportamiento profesional. hospital de tercer nivel. alfa de alfa de cronbach n cronbach basado en los de ítems elementos tipificados 0,79 0,797 = 0,80 28 fuente: instrumento aplicado a los pacientes hospitalizados en una institución de tercer nivel de atención de la ciudad de panamá. febrero-marzo de 2006. 179 instrumento cuidado de comportamiento profesional: validez y confiabilidad yariela gonzález-ortega el coeficiente alfa obtenido (0,80) es alto, indicando que el instrumento tiene alta consistencia interna y que los ítems del mismo miden el constructo de manera coherente. tabla 7 estadístico descriptivo de los ítems del instrumento de cuidado de comportamiento profesional, “forma a”, versión en español. hospital de tercer nivel. no item. correlación alfa de ítem total corregido cronbach si se elimina el ítem 1 0,25 0,79 2 0,38 0,78 3 0,03 0,80 4 0,40 0,78 5 0,47 0,78 6 0,34 0,78 7 0,46 0,78 8 0,06 0,80 9 0,26 0,79 10 0,46 0,78 11 0,50 0,77 12 0,28 0,78 13 0,39 0,78 14 0,44 0,78 15 0,51 0,78 16 0,32 0,79 17 0,10 0,80 18 0,90 0,79 19 0,45 0,78 20 0,41 0,78 21 0,007 0,80 22 0,47 0,77 23 0,14 0,79 24 0,19 0,79 25 0,42 0,78 26 0,15 0,79 27 0,27 0,79 28 0,35 0,78 fuente: instrumento aplicado a los pacientes hospitalizados en una institución de tercer nivel de atención de la ciudad de panamá. febrero-marzo de 2006. el tabla 7 presenta la relación entre cada ítem y el instrumento en general, la columna dos refleja la correlación del ítem total corregido, observándose una mayor correlación en el ítem 18 (0,90), seguido del ítem 15 con un valor de 0,51 y el ítem 11 con valor de 0,50. las correlaciones más bajas se presentaron en el ítem 21, con un valor de 0,007, seguido del ítem 3 con un valor de 0,03, y el ítem 8 con un valor de 0,06. en la tercera columna se muestra el alfa de cronbach si se elimina el ítem del instrumento, lo que demuestra una consistencia entre cada ítem y el alfa total, esto revela que no es necesario eliminar ningún ítem. no compromiso 1 cuando la enfermera le explica las cosas usted no logra comprenderla. 0,69 17,21 5 al atenderlo considera que la enfermera es desorganizada en su labor. 6 cuando siente algún dolor la enfermera lo examina de forma brusca. 7 la enfermera se mueve mecánicamente, sin expresar sus sentimientos. 13 la enfermera le habla de manera disgustada. 15 la enfermera no muestra un verdadero interés por sus problemas. 19 al atenderlo, la enfermera actúa de manera brusca y apresurada. 20 al atenderlo la enfermera es poco amigable. 23 la enfermera deja la ropa sucia y el material de las curaciones usado, en su cuarto. 27 la enfermera no le presta atención cuando usted le habla de su problema sus y preocupaciones. interacción 9 la enfermera entra al cuarto sin avisar. 0,39 9,68 con la 16 la enfermera le dedica tiempo a sus familiares. familia/paciente 17 la enfermera ignora sus creencias religiosas. 21 la enfermera no le dedica tiempo a sus familiares. 22 la enfermera no se interesa por sus problemas. 24 al tocarlo la enfermera lo hace de forma apropiada. 25 la enfermera da respuestas satisfactorias a sus preguntas. cortesía 10 la enfermera escucha atentamente cualquier queja suya. 0,50 5,42 11 la enfermera está pendiente de sus necesidades especiales. 14 la enfermera expresa preocupación por su condición. 18 la enfermera lo llama por su nombre. 26 la enfermera respeta sus necesidades religiosas. relación 2 cuando la enfermera le realiza un procedimiento le habla con un tono de voz suave. 0,25 5,33 3 la enfermera solo se toma unos minutos para hablar con usted. 4 la enfermera que lo cuida comprende la experiencia de su enfermedad y la comparte. 8 la enfermera arregla la unidad de los pacientes para que se vea bien. 12 la enfermera le pone las inyecciones de tal manera que le producen menos temor y dolor. 28 cuando le sonríe, la enfermera lo hace en forma cariñosa. tabla 8 confiabilidad del instrumento de cuidado de comportamiento profesional por factores “forma a”, versión en español. hospital de tercer nivel. factores ítems alfa de varianza cronbach basado en los elementos tipificados fuente: instrumento aplicado a los pacientes hospitalizados en una institución de tercer nivel de atención de la ciudad de panamá. febrero-marzo de 2006. 180 año 8 vol. 8 nº 2 chía, colombia octubre 2008 170-182 aquichan issn 1657-5997 la tabla 8 muestra un alfa de cronbach distribuido en los diferentes factores que componen el instrumento, observándose para el factor de no compromiso un alfa de 0,69, en el factor de interacción con la familia y el paciente de 0,39, para el factor de cortesía de 0,50 y el factor de relación 0,25, lo que muestra una variabilidad en el coeficiente de alfa de cronbach probablemente debido a la carga factorial de los ítems (13), ya que según cortina, citada por cervantes (15), una de las condiciones de las que depende el coeficiente de alfa de cronbach es la cantidad de ítems o partes que conforman la prueba, pues se observan varianzas de 19,65 para el primer factor, para el segundo factor de 9,36, el tercer factor con 5,42, y el cuarto factor con 5,33. conclusiones el instrumento cuidado de comportamiento profesional “forma a” de la doctora sharon horner, versión en español, presenta validez facial o aparente, pues al aplicarlo en una prueba preliminar a los pacientes sus ítems fueron claramente comprendidos, lo que demuestra la relación entre la redacción de las preguntas y la comprensión del paciente. el instrumento de cuidado de comportamiento profesional “forma a”, versión en español, presenta un alfa de cronbach alto, de 0,80, por lo que es evidente la consistencia interna entre los 28 ítems que lo constituyen. los factores, en términos generales, oscilaron entre 0,25 y 0,69, y por ítem fue moderadamente alta, entre 0,78 y 0,80. de acuerdo con los resultados de validez y confiabilidad, se demuestra que el instrumento es apto para ser utilizado en el contexto panameño a fin de medir la percepción del paciente acerca de las prácticas de cuidado de comportamiento profesional que realizan las enfermeras en las diferentes especialidades del contexto hospitalario. esta validez y confiabilidad se convierte en una herramienta de utilidad para evaluar cómo el paciente percibe el cuidado que le proporciona la enfermera, sobre todo en el ámbito de las relaciones interpersonales. al mismo tiempo, da pautas para iniciar nuevos campos de investigación con el fin de orientar la práctica enfermería. este instrumento, en la versión en español, tendrá una trascendencia social, ya que al identificar la percepción que tienen los pacientes sobre el cuidado que proporcionan las enfermeras, servirá de base para implementar programas educativos, encaminados a mejorar la relación enfermera-paciente, pues sus ítems incluyen actitudes verbales y no verbales basadas en las relaciones interpersonales (73% de los ítems). después de haber realizado las pruebas de validez y confiabilidad, el instrumento en la versión en español fue la siguiente: comportamientos del cuidado profesional el llenado de este instrumento implica que se ha dado el consentimiento para responderlo. edad _________ masculino_________ femenino__________ registro de seguro social ______________. instrucciones: lea cada enunciado e indique el grado de acuerdo o desacuerdo si el enunciado representa el cuidado profesional. una de las condiciones de las que depende el coeficiente de alfa de cronbach es la cantidad de ítems o partes que conforman la prueba. 181 instrumento cuidado de comportamiento profesional: validez y confiabilidad yariela gonzález-ortega escala: siempre = 4; casi siempre = 3; algunas veces = 2; nunca = 1 nota. en el espacio inmediatamente inferior, describa otros comportamientos de cuidado que se le ocurran. enunciado siempre casi algunas nunca siempre veces 4 3 2 1 1. cuando la enfermera le explica las cosas usted no logra comprenderlas. 2. cuando la enfermera le realiza un procedimiento le habla con un tono de voz suave. 3. la enfermera solo se toma unos minutos para hablar con usted. 4. la enfermera que lo cuida comprende sus experiencias y las comparte. 5. al atenderlo considera que la enfermera es desorganizada en su labor. 6. cuando siente algún dolor la enfermera lo examina de forma brusca. 7. la enfermera se mueve mecánicamente, sin expresar sus sentimientos. 8. la enfermera arregla la unidad de los pacientes para que se vea bien. 9. la enfermera entra al cuarto sin avisar. 10. la enfermera escucha atentamente cualquier queja suya. 11. la enfermera está pendiente de sus necesidades especiales. 12. la enfermera le pone las inyecciones de tal manera que le producen menos temor y dolor. 13. la enfermera le habla de manera disgustada. 14. la enfermera expresa preocupación por su condición. 15. la enfermera muestra un verdadero interés por sus problemas. 16. la enfermera le dedica tiempo a sus familiares. 17. la enfermera ignora sus creencias religiosas. 18. la enfermera lo llama por su nombre. 19. al atenderlo, la enfermera actúa de manera brusca y apresurada. 20. a l atenderlo, la enfermera presenta cara de pocos amigos. 21. la enfermera no le dedica tiempo a sus familiares. 22. la enfermera no se interesa por sus problemas. 23. la enfermera deja la ropa sucia y el material de las curaciones usado en su cuarto. 24. al tocarlo la enfermera lo hace de una forma adecuada. 25. la enfermera le da respuestas adecuadas a sus preguntas. 26. la enfermera respeta sus necesidades religiosas. 27. la enfermera no le presta atención cuando usted le habla de su problema y preocupaciones. 28. cuando le sonríe la enfermera lo hace en forma cariñosa. 182 año 8 vol. 8 nº 2 chía, colombia octubre 2008 170-182 aquichan issn 1657-5997 referencias 1. fawcett j. analysis and evaluation of contemporary nursing knowledge: nursing models and theories. usa: davis company; 2000. 2. burns n, grove ks. investigación en enfermería. 3 ed. españa: grafos s.a; 2004. p. 554. 3. snyder m, brandt cl, tseng hy. measuring intervention outcomes: impact of nurse characteristics. international journal for human caring 2000; 4 (1): 35-42. 4. watson j. assessing and measuring caring in nursing and health science. usa: springer publishing company; 2002. p. 100-106. 5. wolf z. the caring concept and nurse identified caring behaviours. en clinical nursing. usa. july, 1986; p. 84-93. 6. larson p, ferketich. patients satisfaction with nurses caring during hospitalization. journal of nursing research 1993; 15 (6): 690-707. 7. canales f. metodología de la investigación. 2 ed. usa: ops-oms; 1994. p. 225. 8. sánchez r, echeverry j. validación de escalas de medición. revista de salud pública 2004; 6 (3): 302-317. 9. nunnally cb. teoría psicométrica. 3 ed. méxico: mcgraw-hill interamericana; 1995, p. 532. 10. hernández r, fernández c, batista p. metodología de la investigación. 3 ed. méxico: mcgraw-hill; 2003. p. 505. 11. polit d, hungler b. investigación científica en ciencias de la salud. 6 ed. méxico: mcgraw-hill interamericana; 2000. p. 715. 12. horner s. información sobre la validez y confiabilidad del instrumento de comportamiento de cuidado professional. university of texas at austin. school of nursing; 2005. 13. harrison e. nurse caring and the new health care paradigm. journal nurses care qual 1995; 9 (4): 14-23. 14. mahon n, yarcheski t, yarcheski a. the revised personal lifestyle questionnaire for early adolescents wester. journal of nursing research 2002; 25 (5): 538. 15. cervantes vh. interpretaciones del coeficiente alfa de cronbach. avances en medición 2005; 3: 19. 146 aquichan issn 1657-5997 joséte luzia leite1 fernanda de carvalho-dantas2 claudia de carvalho-dantas3 alacoque lorenzini-erdmann4 suzinara beatriz soares de lima5 priscila de oliveira-barros6 delineando un modelo de cuidado a partir del análisis sistemático de la actividad diaria del enfermero en un hospital universitario de rio de janeiro 1 doctora. profesora titular emérita de la universidad federal del estado de río de janeiro (unirio) rio de janeiro, brasil. joluzia@gmail.com 2 académica de enfermería del centro universitario celso lisboa, becaria de la fundación de apoyo a la investigación del estado de río de janeiro (faperj), brasil. ffernandadantas@yahoo.com.br 3 doctora por la escuela de enfermería anna nery de la universidad federal do rio de janeiro (eean/ufrj), rio de janeiro, brasil. profesora de la universidad federal fluminense (uff), niterói, brasil. dantasclaudia@hotmail.com 4 doctora en filosofía de la enfermería. profesora titular de la universidad federal de santa catarina (ufsc), florianópolis, brasil. alacoque@newsite.com.br 5 doctora por la escuela de enfermería anna nery de la universidad federal do rio de janeiro (eean/ufrj), rio de janeiro, brasil. profesora de la universidad federal de santa maria, santa maria, brasil. suzibslima@yahoo.com.br 6 académica de biomedicina del 6º período de la universidad federal del estado de rio de janeiro (unirio), rio de janeiro, brasil. integrante del gespen: núcleo de investigación, gestión en salud y práctica profesional de enfermería de la eean/ufrj. recibido: 15 de marzo de 2009 aceptado: 21 de julio de 2010 resumen esta investigación deriva del proyecto titulado “el análisis sistemático del cuidado a las personas con vih / sida: la construcción de un modelo nacional”, apoyado por el consejo nacional de desarrollo científico y tecnológico. este proyecto integra el núcleo de investigación "gestión en salud y práctica profesional de la enfermería" del departamento de metodología de la escuela de enfermería anna nery de la universidade federal do rio de janeiro, en la línea de investigación "modelos asistenciales, conocimientos y paradigmas". esta es una investigación cualitativa del tipo descriptivo-exploratorio que tiene como objetivos analizar las formas de cuidado prestado a los pacientes seropositivos para el vih a partir de declaraciones de algunos enfermeros, y proponer un modelo de cuidado basado en la información obtenida. los datos fueron recolectados después de la autorización del comité de ética con respecto al protocolo 10/2006. se concluye que la construcción de un modelo de cuidado para los pacientes con el vih se construye a partir del cuidado como competencia / actualización del profesional enfermero, en el conocimiento acerca de los progresos y las implicaciones de la patología / sida, y en las condiciones del ser humano / paciente con vih. se comprende que el modelo indica al enfermero la importancia de la competencia técnico-científica y política, y la postura ética crítica-reflexiva acerca de las intervenciones del cuidado al paciente con el vih. palabras clave vih, sida, modelos, enfermero, enfermería. (fuente: decs, bireme). año 10 vol. 10 nº 2 chía, colombia agosto 2010 l 146-156 147 delineando un modelo de cuidado a partir del análisis sistemático de la actividad diaria del enfermero... l joséte luzia leite, fernanda de carvalho-dantas y otros. outlining a model of care based on a systematic analysis of the daily activities of nurses at a university hospital in rio de janeiro abstract this study is derived from the project “systematic analysis of care for persons with hiv / aids: building a national model,” a project that was supported by the national council for scientific and technological development and is part of core research on health management and professional nursing practice done by the methodology department of the anna nery school of nursing at the universidade federal do rio de janeiro, specifically with respect to care models, know-how and paradigms. it is a qualitative, descriptiveexploratory study designed to analyze the kinds of care provided to hiv seropositive patients, based on statements from nurses, and to propose a model of care based on the data gathered. the information was collected following authorization of protocol 10/2006 by the ethics committee. the conclusion is that construction of a care model for patients with hiv must be founded on professional nursing competence/updating with respect to knowledge about the progress and implications of the pathology / aids, and the conditions of the human being / hiv patient. the model emphasizes to nurses the importance of technical-scientific and policy competence and a critical-thoughtful ethical position on care for patients with hiv. key words hiv, aids, models, nurse, nursing (source: decs, bireme). delinear um modelo de cuidado a partir da análise sistemática das atividades diárias do enfermeiro em um hospital universitário no rio de janeiro resumo esta pesquisa decorre do projeto análise sistemática do cuidado de pessoas com vih/sida: a construção de um modelo nacional, apoiado pelo conselho nacional de desenvolvimento científico e tecnológico. este projeto integra o núcleo de pesquisa de gestão de saúde e a prática profissional de enfermagem do departamento de metodologia da escola anna nery de enfermagem da universidade 148 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 federal do rio de janeiro, na linha de pesquisa de atendimento modelos assistenciais, conhecimentos e paradigmas. este estudo qualitativo de tipo descritivo e exploratório para analisar as formas de assistência aos pacientes vih-positivos, com base em declarações de alguns enfermeiros e propor um modelo de atenção com base nas informações recolhidas. os dados foram coletados após aprovação do comitê de ética para o protocolo 10/2006. conclui-se que a construção de um modelo de cuidado para pacientes com vih é construído a partir do cuidado como competencia/atualização do profissional enfermeiro no conhecimento sobre a evolução e as repercussões da patologia sida e nas condições do humano/paciente com vih. o modelo indica a importância da competência técnico-científica e política, e a posição ético-reflexiva das intervenções sobre o cuidado de intervenções para pacientes com vih. palavras-chave vih, sida, modelo, enfermeira, enfermagem. (fonte: decs, bireme). 149 delineando un modelo de cuidado a partir del análisis sistemático de la actividad diaria del enfermero... l joséte luzia leite, fernanda de carvalho-dantas y otros. introducción esta investigación deriva del proyecto titulado “el análisis sistemático del cuidado a las personas con vih / sida: la construcción de un modelo nacional”, apoyado por el consejo nacional de desarrollo científico y tecnológico (cnpq). se destaca que el proyecto integra el núcleo de investigación gestión en salud y práctica profesional de enfermería (gespen) del departamento de metodología de la escuela de enfermería anna nery de la universidade federal do rio de janeiro (eean/ufrj), en la línea de investigación modelos asistenciales, conocimientos y paradigmas. el objeto de la investigación fue la construcción de un modelo de cuidado al portador de vih/sida a partir de la vivencia / experiencia de los enfermeros de un hospital universitario de rio de janeiro. su realización se justifica por la necesidad de avanzar en el ámbito del cuidado a los portadores de vih en lo que concierne a las actividades de los enfermeros y, análogo a ello, el hecho de que, aún en el siglo xxi, el sida es una morbilidad con altas tasas de incidencia y prevalencia. las siglas aids / hiv vienen del inglés acquired immune deficiency syndrome y human immunodeficiency virus respectivamente, que han sido traducidas al portugués para síndrome da imunodeficiência adquirida (sida) y vírus da imunodeficiência humana (vih). los índices de prevalencia e incidencia registrados indican que la epidemia del sida es un desafío sin precedentes para la salud mundial, y que el vih ha causado cerca de 25 millones de muertes y ha generado profundos cambios demográficos, económicos y sociales en la mayoría de los países más afectados. otro dato relevante indica que alrededor de 6.800 personas están infectadas con el vih y 5.700 mueren a causa del sida en el mundo, la mayoría debido a la falta de acceso a los servicios de tratamiento y atención (1). se estima que 33 millones de personas vivan con el vih en todo el mundo. entre las regiones más afectadas por la enfermedad están la sahariana y la subsahariana del áfrica del sur. en la región del sahara se presentaron el 35% de las infecciones por el vih y el 38% de las muertes por sida en 2007. por otro lado, el 67% de todas las personas que viven con el vih están en el áfrica subsahariana. aún se subraya que con respecto al género, las mujeres representan la mitad de las personas que viven con el vih en todo el mundo, con números cada vez mayores en muchos países (2). las tasas de prevalencia en brasil están estabilizadas en 0,6% desde el año 2000. aproximadamente 630 mil personas viven con el vih y, según los parámetros internacionales adoptados, brasil tiene una epidemia concentrada. en promedio, alrededor de 30 mil nuevos casos de sida son identificados cada año, con un número cada vez mayor entre las mujeres y personas de más de 50 años de edad (1). la región con mayor tasa de notificación es el sudeste con el 60,4%, o sea, 305.725 casos. el sur concentra el 18,9% (95.552), el nordeste un 11,5% (58.348), el centro-oeste el 5,7% (28.719) y el norte el 3,6% (18.155) (2). los índices de prevalencia e incidencia registrados indican que la epidemia del sida es un desafío sin precedentes para la salud mundial, y que el vih ha causado cerca de 25 millones de muertes y ha generado profundos cambios demográficos, económicos y sociales en la mayoría de los países más afectados. 150 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 según el ministerio de la salud, los primeros casos de vih / sida surgieron en los estados unidos, haití y áfrica central entre 1977-1978, pero sólo fueron definidos como sida en 1982 cuando este nuevo síndrome fue clasificado con el nombre temporario de enfermedad de los 5h —homosexuales, hemofílicos, haitianos, heroinómanos (usuarios de heroína inyectable) y hookers (trabajadoras del sexo en inglés)—; en el mismo año se descubrieron los posibles factores de transmisión de la enfermedad que serían el contacto sexual, el consumo de drogas o la exposición a la sangre y sus derivados (3). en brasil, el primer caso informado ocurrió en 1980 en são paulo, pero sólo fue clasificado en 1982. otro hito importante en la historia de esta enfermedad fue el primer caso de notificación de sida en los niños, estableciendo así que dicha enfermedad no sólo era diseminada entre los homosexuales sino que también era posible la transmisión heterosexual (4). de todos los temas relativos a la investigación y los estudios sobre el vih, se destaca el avance en lo que concierne a las acciones médicas dirigidas al portador. por otra parte, las investigaciones de carácter social no se han desarrollado en las mismas proporciones. así, urge la necesidad de considerar un modelo base para fundamentar el cuidado a la persona con vih en los aspectos clínicos (la enfermedad, el tratamiento y la medicación) y sociales (los prejuicios y la discriminación), que permita una asistencia holística que abarque todos los aspectos de este síndrome permitiendo al usuario una atención de mejor calidad. considerando lo expuesto, surge el siguiente interrogante: ¿cómo es el cuidado prestado por el enfermero al portador de vih en un hospital universitario del rio de janeiro? teniendo en cuenta esta cuestión, trazamos los siguientes objetivos: • analizar las maneras de cuidado prestado a los pacientes con el vih/ sida a partir de declaraciones de enfermeros de un hospital universitario. • proponer un modelo de cuidado basado en declaraciones de enfermeros para el paciente con vih. este estudio hizo posible crear principios y aportes para las reflexiones acerca del cuidado prestado a los pacientes seropositivos, además de la enseñanza, la investigación y la asistencia en el ámbito de los servicios de enfermería y afines al portador del vih, por medio de la construcción de un modelo de cuidado realizado por los enfermeros que han posibilitado las reflexiones y los cambios de paradigmas en el proceso de cuidar a esos pacientes. metodología se trata de una investigación cualitativa de tipo descriptivo y exploratorio. la opción por la investigación cualitativa se basó en el hecho de que su objetivo es sacar a la luz los datos, los indicadores y las tendencias observables o producir modelos teóricos de gran abstracción con aplicabilidad práctica (5). los investigadores utilizan la investigación cualitativa cuando existe un vacío en el conocimiento, o cuando se sabe poco acerca de un determinado fenómeno, experiencia o concepto (6). los estudios que emplean una metodología cualitativa describen la complejidad de un determinado problema, analizan la interacción de algunas variables, comprenden y clasifican los procesos dinámicos vividos por los grupos sociales, y contribuyen en el proceso de cambio de determinado grupo (7). los estudios que emplean una metodología cualitativa describen la complejidad de un determinado problema, analizan la interacción de algunas variables, comprenden y clasifican los procesos dinámicos vividos por los grupos sociales, y contribuyen en el proceso de cambio de determinado grupo. 151 delineando un modelo de cuidado a partir del análisis sistemático de la actividad diaria del enfermero... l joséte luzia leite, fernanda de carvalho-dantas y otros. con respecto a la naturaleza descriptivo-exploratoria, la utilizamos porque conlleva las siguientes características: en el caso de la investigación exploratoria, tiene como principal objetivo desarrollar, aclarar y cambiar conceptos e ideas a fin de formular problemas más precisos o hipótesis investigables para estudios posteriores (8). con respecto a la investigación descriptiva, su elección se dio por su estudio de la investigación empírica, cuyo objetivo principal es el delineamiento o el análisis de las características de los hechos o fenómenos, la evaluación de programas, o el aislamiento de las variables principales o claves (9). el escenario de este estudio fue un hospital universitario ubicado en la provincia de rio de janeiro, el cual concedió permiso para recoger los datos según el protocolo 10/2006, subvencionados según la resolución 196/96 del consejo nacional de salud/ ministerio de la salud de brasil; cada uno de los sujetos del estudio firmó un formato de consentimiento libre e informado, con el fin de preservar su identidad, garantizando el anonimato y el uso de las declaraciones sólo con fines de investigación y la posibilidad de desvincularse en cualquier etapa del estudio sin ningún gravamen. los sujetos de este estudio fueron los enfermeros, cuyos criterios de selección de la muestra fueron: estar de acuerdo con participar del estudio, ser enfermero, tener al menos dos años de experiencia profesional con pacientes vih positivos y trabajar en el hospital universitario escenario de la investigación. la recolección de los datos se realizó en enero de 2007 a través de una entrevista abierta, grabada en cinta magnética; posteriormente, estos fueron sometidos a sucesivas lecturas buscándose los puntos de confluencia a fin de hacer posible su categorización. el proceso de categorización se refiere a cualquier tipo de razonamiento, de los más sencillos a los más complejos, que lleve a realizar una categorización sin la cual no se podría concluir el trabajo, sea en el mundo físico, en la vida social o intelectual (10). presentación y discusión de los resultados los resultados que se presentan a continuación son el fruto del análisis cualitativo de las entrevistas en profundidad de cinco enfermeros que estaban dispuestos a participar voluntariamente con su vivencia / experiencia para contribuir al delineamiento de un modelo sistemático de cuidado a las personas portadoras del vih. así, después de recoger las entrevistas y transcribirlas, se sometieron a sucesivas lecturas y a un posterior proceso de categorización, de lo cual surgieron tres categorías, que serán presentadas y discutidas a continuación. categoría 1: desarrollando el cuidado al portador de vih / sida enfocado en lo profesional esta categoría fue integrada por las declaraciones de los enfermeros que han fundamentado que el cuidado al portador del vih, bajo la perspectiva de la creación de modelo, debe pasar en primer lugar por el perfeccionamiento profesional. el cuadro 1 se refiere a los principales significados que el enfermero atribuye al modelo de cuidado al portador, enfocado en el profesional. mediante la identificación de las actividades desarrolladas por los profesionales de enfermería en el desempeño de sus funciones se verifica la necesidad de reafirmar la cuestión educativa como compromiso con el crecimiento personal y profesional, con el objetivo de mejorar la calidad de la práctica laboral. 152 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 en este cuadro se observa la preocupación de los enfermeros por las competencias / actualizaciones profesionales, las cuales se deben dar a través de conferencias y entrenamientos para proporcionar a los sujetos —profesionales que tratan diariamente con el paciente— la base teórica necesaria para cuidar. esta afirmación se fundamenta en la educación de los profesionales de enfermería, que merece más atención, ya que existe la necesidad de preparar a las personas para los cambios en el mundo y en el entorno laboral, buscando conciliar las necesidades de desarrollo personal y grupal con las institucionales y las de la sociedad. mediante la identificación de las actividades desarrolladas por los profesionales de enfermería en el desempeño de sus funciones se verifica la necesidad de reafirmar la cuestión educativa como compromiso con el crecimiento personal y profesional, con el objetivo de mejorar la calidad de la práctica laboral (11). en la misma línea de razonamiento, vemos que la competencia profesional es un concepto político-educativo amplio, un proceso de articulación y movilización gradual y continuo de los conocimientos generales y específicos, de habilidades teóricas y prácticas, de hábitos y actitudes, y de valores éticos, que permiten al individuo el ejercicio eficaz de su trabajo, la participación activa, consciente y crítica en el mundo laboral y en la esfera social, además de su autorrealización (12). así, las declaraciones de los enfermeros basadas en sus experiencias profesionales apuntan que el modelo de cuidado comienza por el profesional en el lugar en que ejerce sus actividades laborales, el cual debe obtener la base teórica necesaria para ofrecer un cuidado de calidad en consonancia con el progreso de los preceptos de la ciencia. la siguiente es la declaración de uno de los sujetos que integraron esa categoría. […] mi equipo siempre los trató bien, una cosa que nosotras nos propusimos fue establecer un vínculo de amistad y calor humano con los pacientes. nunca los discriminamos. por lo tanto, en la medida de lo posible, hemos tratado de ser amigas, hermanas, madres, la familia que no despreciaba, que ayudaba. nunca hubo discriminación, éramos nosotras las que tratábamos a los pacientes seropositivos. incluso dentro de la institución sufríamos discriminación (entrevista 1). categoría 2: desarrollando el cuidado al portador de vih / sida enfocado en la patología la otra categoría que ha fundamentado la construcción del modelo fue aquella relativa a la patología de estos pacientes, o sea, el sida. en consecuencia, desde las declaraciones de los enfermeros se percibió una preocupación con la patología en lo referente a los conocimientos acerca de los avances y las implicaciones de la encuadro 1. enfoque en lo profesional l producción de herramientas para el incremento del cuidado. l participación en congresos y realización de conferencias. l coordinación, soporte y prestación de ayuda al paciente de gran complejidad. l enfermera multiprofesional con actividades en todos los niveles. l cuidado de las normas de bioseguridad / prevención. l miedo que tienen los profesionales y estudiantes de cuidar al paciente. l programa de entrenamiento / educación continuada a los profesionales de salud del hospital. fuente: entrevistas. 153 delineando un modelo de cuidado a partir del análisis sistemático de la actividad diaria del enfermero... l joséte luzia leite, fernanda de carvalho-dantas y otros. fermedad (sida) en los aspectos relacionados con la terapia antirretroviral (tar) y su consecuente adhesión a la misma. entre las dificultades de adhesión a la tar se subrayan las inherentes al tratamiento, a la complejidad de la vida de las personas con el vih, a los contextos socioeconómicos desfavorables, al acceso limitado a la terapia que sufren las poblaciones marginadas y la falta de intervenciones eficaces para ayudar a que los pacientes la mantengan y alcancen niveles adecuados de adhesión (13). se subraya que las diferencias fisiológicas entre los pacientes pueden alterar los niveles plasmáticos de los antirretrovirales, lo que causa variaciones en la eficacia de los diferentes esquemas terapéuticos. el éxito en la adhesión depende de la responsabilidad de los profesionales de salud y de los pacientes, así como de los servicios de salud (14). acerca del enfoque dado a la enfermedad con énfasis en la adhesión a la terapéutica antirretroviral, en el cuadro 2 se presentan los principales significados que los sujetos han señalado en sus discursos. el sida, como una enfermedad incurable —a pesar de los muchos avances de la ciencia en este campo de actividad—, todavía produce una gran preocupación en la comunidad científica y académica, y aún manifiesta las dificultades de orden social en lo tocante a prejuicios y exclusión social. algunos autores aclaran que el sida incluye estigmas que hacen necesarias más investigaciones en este ámbito, a fin de optimizar la calidad de la asistencia prestada a los portadores del vih quienes se esfuerzan por minimizar la exclusión social (4). a continuación se presenta una declaración que fundamenta esta categoría: […] con el virus, nosotros no podemos bajar la guardia. en primer lugar, el virus de hoy no es el virus de mañana, puede haber una mutación que cruce algunas barreras, ciertas dificultades que no pasaban anteriormente que pueden aparecer en un futuro muy cercano (entrevista 2). categoría 3: desarrollo del cuidado al portador de vih / sida enfocado en el paciente la próxima categoría tiene como fundamento el foco en el paciente, en sus condiciones y características como portador del vih que forman uno más de los principales pilares del modelo de cuidado. el siguiente testimonio fundamenta esa categoría: […] con la aparición del sida en toda la sociedad, disminuyó considerablemente la idea prejuiciosa acerca de la cuestión de los homosexuales, los drogadictos... que este estigma ha hecho mucho daño, mucho... después empezamos a conocer mejor los problemas, una inmediata terapéutica para asustar la agresión de las enfermedades oportunistas y otras cuadro 2. enfoque en la patología l preocupación con las infecciones y las subclases de vih. l uso de terapia múltiple o cóctel, que aumenta la sobrevida. l minimización de los efectos colaterales. fuente: entrevistas. entre las dificultades de adhesión a la terapia antirretroviral se subrayan las inherentes al tratamiento, a la complejidad de la vida de las personas con el vih, a los contextos socioeconómicos desfavorables, al acceso limitado a la terapia que sufren las poblaciones marginadas y la falta de intervenciones eficaces para ayudar a que los pacientes la mantengan y alcancen niveles adecuados de adhesión. 154 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 sobre de la terapia antirretroviral que empezó con el azt, y ahora se hace con la terapia múltiple (entrevista 3). esta categoría tiene un valor fundamental, ya que en las declaraciones de los sujetos se observó la importancia de la humanización de la asistencia, especialmente aquella relativa a la contribución y al factor psicológico del paciente, donde las intervenciones psicológicas ayudan a mejorar la calidad de vida de las personas con vih (15). algunos investigadores presentaron estudios acerca de la influencia de los factores psicológicos en diversas enfermedades orgánicas, así como la relación entre aspectos psicológicos y biológicos. ellos descubrieron que ciertos estados mentales se relacionan con el aumento de la vulnerabilidad biológica. aunque estos estados no sean la causa de la enfermedad, pueden ser condiciones necesarias para su aparición. el cuadro 3 representa la distribución de los significados atribuidos por los enfermeros con enfoque en el paciente. así, a través del análisis de los discursos, se apuntaron los factores bajo la óptica de la humanización, aporte emocional y psicológico, los cuales deben interponerse a la asistencia de enfermería a los portadores del vih, tomando en cuenta las repercusiones de este síndrome en el ámbito de la sociedad. el concepto de la humanización de la atención “se constituye en una directriz de trabajo, que aspira a una nueva ‘praxis’ para la atención a la salud” (16). esta innovación, de carácter procesal y complejo, prevé qué cambios pueden generar inseguridad y resistencia de los profesionales de la salud, ya que no son posibles de ser estandarizados ni tampoco son generalizables, enfatizando la singularidad de los procesos de atención a la salud (17). al examinar la cuestión de la humanización en el ámbito específico de la atención a la salud de las personas que viven con el vih / sida, se percibe una condición privilegiada, especialmente cuando se la compara con la red de salud pública en su conjunto, tanto en la provisión de insumos para el tratamiento, como en los llamados “factores humanos” de la atención (18). con estos resultados nos dirigimos hacia la estructura de un modelo de cuidado del enfermero al portador de vih / sida apoyado en el trípode: el cuidado como la competencia / actualización del profesional de enfermería, el conocimiento del enfermero acerca de los progresos e implicaciones de la patología (sida), y el reconocimiento por el enfermero de las condiciones y características de los pacientes con el vih y sus consecuencias para el cuidado. por tanto, se reconoce la importancia de la competencia técnico-científica y política del enfermero para el cuidado en enfermería y salud, y su postura ética y crítica-reflexiva acerca de las intervenciones que hace en las esferas del cuidado al portador del vih. en las declaraciones de los sujetos se observó la importancia de la humanización de la asistencia, especialmente aquella relativa a la contribución y al factor psicológico del paciente, donde las intervenciones psicológicas ayudan a mejorar la calidad de vida de las personas con vih. cuadro 3. enfoque en el paciente l preocupación con la adhesión a la terapia. l soporte psicológico a los pacientes. l cuidado diferenciado al anciano. l respeto al ser humano. l apoyo al paciente buscando el desarrollo de su religiosidad. fuente: entrevistas. 155 delineando un modelo de cuidado a partir del análisis sistemático de la actividad diaria del enfermero... l joséte luzia leite, fernanda de carvalho-dantas y otros. modelo de cuidado del enfermero al ser humano / paciente portador del vih / sida así, la enfermería debe dirigirse a las acciones que contemplen al ser humano como un todo, una persona internada en un hospital en la condición de paciente con una enfermedad crónica. las bases para la construcción de un modelo de cuidar deben basarse en valores éticos y profesionales que deben ser una rutina constante en el desempeño cotidiano de las instituciones de salud para permitir un cuidado integral que responda a las reales necesidades del paciente. conclusiones se concluye que el proceso de construcción de un modelo de cuidado para el portador del vih se caracteriza por el cuidado como competencia / actualización del profesional enfermero en el conocimiento acerca de los avances y las implicaciones de la patología (sida), y en las condiciones y características del paciente portador del vih. con respecto al profesional de enfermería, la competencia / actualización debe ser una preocupación constante que el profesional debe buscar por sí mismo, así como incentivar y apoyar a su equipo para que participe en conferencias, seminarios, simposios y capacitaciones que ayudarán a instrumentalizar la práctica en cualquier área del cuidado. en lo referente al sida, este se encuentra rodeado de varios paradigmas, a saber: que el profesional, junto con la el cuidado al portador del vih / sida con enfoque en el profesional. desarrollando el cuidado al portador de vih / sida con enfoque en la patología. desarrollando el cuidado al portador de vih / sida con enfoque en el paciente. familia y la sociedad, deben superar los prejuicios para que el paciente se sienta seguro y estimulado a luchar contra su enfermedad. las dificultades de la patología favorecen que el paciente se vea más dependiente de la terapia con medicamentos para minimizar los efectos colaterales y adversos de la tar necesaria al tratamiento. otro principio para el delineamiento de un modelo de cuidado se refiere al énfasis en los aspectos psicológicos, emocionales y humanos, teniendo en cuenta las particularidades de cada paciente. estos aspectos merecen especial atención para que los profesionales de enfermería puedan prestar un cuidado que incluya acciones no sólo dirigidas a las enfermedades y a la medicina, sino también, a la esfera emocional / social. finalmente, destacamos que las bases de construcción de este modelo incluyen principios aplicables a cualquier patología, ya que el cuidado de enfermería debe estar fundamentado en las necesidades que tiene el paciente, independientemente de su enfermedad. así, aunque sea escena de un macroproyecto auspiciado por el cnpq (consejo nacional de desarrollo científico y tecnológico), la presentación de este estudio favorece la reflexión acerca del cuidado prestado a los pacientes seropositivos, la importancia de la competencia técnico-científica y política, y la postura ética y crítico-reflexiva del profesional en enfermería. 156 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 referencias bibliográficas 1. organização das nações unidas (onu). número de mortos por aids tem leve queda no mundo. disponible en: http://www.onu-brasil.org.br/levantese. php [consultado el 10 de enero de 2009]. 2. organização mundial de saúde (oms). aids. disponible en: www.who.int [consultado el 10 de enero de 2009]. 3. ministério da saúde (br). boletim epidemiológico aids. disponible en: http://www.aids.gov.br/ 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el estado emocional de pacientes con infección por vih/ sida. oviedo: psicothema 2003. p. 517-523. 16. deslandes sf. análise do discurso oficial sobre a humanização da assistência hospitalar. ciência e saúde coletiva 2004; 9 (1): 7-14. 17. martins mcfn. humanização da assistência e formação do profissional de saúde. disponible en: www.polbr.med.br/arquivo/artigo0503_1.htm [consultado el 5 de enero de 2009]. 18. nemes mib. avaliação em saúde: questões para o programa de dst/aids no brasil. associação brasileira interdisciplinar de aids (abia), rio de janeiro; 2001. 22 31 validez y confiabilidad.indd 22 aquichan issn 1657-5997 maría de los ángeles rodríguez-gázquez1 edith arredondo-holguín2 validez y confi abilidad de una escala de valoración de comportamientos de autocuidado en personas con falla cardiaca 1 doctora en salud pública. universidad de antioquia, colombia. marodriguez@tone.udea.edu.co 2 magíster. universidad de antioquia, colombia. tapua412@tone.udea.edu.co recibido: 11 de marzo de 2011 aceptado: 2 de febrero de 2012 resumen objetivo: determinar la validez y confiabilidad, en el contexto colombiano, de la escala de valoración de comportamientos de autocuidado en personas con falla cardiaca (fc) diseñada por nancy artinian. método: estudio de validación de la escala revised heart failure self care behavior. se realizó validación cultural (n = 13 enfermeros expertos en cuidado cardiovascular y 12 pacientes con fc), validación factorial y análisis de la confiabilidad (n = 206 pacientes con fc). resultados: la validación cultural de la escala fue adecuada. la validación factorial mostró que la versión en español tenía cuatro dominios (solicitud de ayuda, adaptación a vivir con la enfermedad, adherencia al tratamiento farmacológico y adherencia al tratamiento no farmacológico) que explicaron el 34,2% de la varianza del constructo latente en la escala. se eliminaron siete ítems por explicar menos del 0,2% de la varianza, quedando la escala final reducida a 21 ítems. el coeficiente de confiabilidad alfa de cronbach para la escala total fue aceptable (0,75). conclusión: la nueva versión de la escala tiene adecuadas propiedades psicométricas en términos de confiabilidad y validez, lo que permitirá su utilización por enfermeros en la detección de cambios de comportamientos de autocuidado clínicamente importantes en los pacientes con fc. palabras clave estudios de validación, autocuidado, modelos de enfermería, enfermedades cardiovasculares. (fuente: decs, bireme). validity and reliability of a scale for rating self-care in persons with heart failure abstract objective: the purpose of this study is to determine the validity and reliability, in the colombian context, of a scale designed by nancy artinian to rate self-care among persons with heart failure (hf). method: this is a validation study of the revised heart failure self-care behavior scale. a cultural validation was done (n = 13 nurses who are experts in cardiovascular care and 12 patients with hf), along año 12 vol. 12 nº 1 chía, colombia abril 2012 l 22-31 23 validez y confiabilidad de una escala de valoración de comportamientos... l maría de los ángeles rodríguez-gázquez, edith arredondo-holguín with factor validation and a reliability analysis (n = 206 patients with hf). results: the cultural validation of the scale was adequate. the factor evaluation showed the spanish version had four domains (asking for help, adapting to living with the disease, adherence to pharmacological treatment, and adherence to non-pharmacological treatment) that explained 34.2% of the latent construct variance in the scale. seven items that account for less than 0.2% of the variance were eliminated, leaving the final scale reduced to 21 items. the cronbach alpha reliability coefficient for the entire scale was acceptable (0.75). conclusion: the new version of the scale has adequate psychometric properties in terms of reliability and validity, allowing for its use by nurses to detect clinically important behavioral changes in self-care among patients with hf. key words validation studies, self-care, nursing models, cardiovascular diseases (source: decs, bireme). validade e confiabilidade de uma escala de valoração de comportamentos de autocuidado em pessoas com falha cardíaca resumo objetivo: determinar a validade e confiabilidade, no contexto colombiano, da escala de valoração de comportamentos de autocuidado em pessoas com falha cardíaca (fc) desenhada por nancy artinian. método: estudo de validação da escala revised heart failure self care behavior. realizou-se validação cultural (n = 13 enfermeiros especialistas em cuidado cardiovascular e 12 pacientes com fc), validação fatorial e análise da confiabilidade (n = 206 pacientes com fc). resultados: a validação cultural da escala foi adequada. a validação fatorial mostrou que a versão em espanhol tinha quatro domínios (solicitação de ajuda, adaptação para viver com a doença, aderência ao tratamento farmacológico e aderência ao tratamento não farmacológico) que explicaram os 34,2% da variação do construto latente na escala. eliminaram-se sete itens por explicar menos de 0,2% da variação, ficando a escala final reduzida a 21 itens. o coeficiente de confiabilidade alfa de cronbach para a escala total foi aceitável (0,75). conclusão: a nova versão da escala tem adequadas propriedades psicométricas em termos de confiabilidade e validade, o que permitirá sua utilização por enfermeiros na detecção de mudanças de comportamentos de autocuidado clinicamente importantes nos pacientes com fc. palavras-chave estudos de validação, autocuidado, modelos de enfermagem, doenças cardiovasculares (fonte: decs, bireme). 24 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 introducción la organización mundial de la salud (oms) (1) ubica a la enfermedad cardiovascular, entre ellas la insuficiencia o falla cardiaca (fc), dentro de las primeras cinco causas de mortalidad en adultos de ambos sexos a nivel mundial, proyectando que para 2030 producirá más de ocho millones de muertes en población mayor de 30 años. colombia presenta una problemática similar, encontrándose la fc dentro de las primeras diez causas de morbilidad y mortalidad de personas en edad económica y socialmente productiva (2), asociándose esta enfermedad, entre otros, a estilos de vida poco saludables adquiridos desde la niñez (3). la fc puede ser extremadamente debilitante, y es causante de frecuentes admisiones hospitalarias durante los periodos de descompensación (4, 5), lo que lleva al deterioro de la calidad de vida por la falta de capacidad para satisfacer las necesidades humanas básicas y la pérdida de autonomía para sentirse realizado (6, 7), aportando un volumen importante de años de vida saludables perdidos (8). el cuidado de la persona con fc plantea retos importantes a los profesionales del área de la salud en general, y de enfermería en particular, en la medida que es una enfermedad que altera la capacidad de cuidar de sí, por lo que el autocuidado ayudaría a estas personas a desarrollar actividades tendientes a mejorar la calidad de vida (9). hay varias conceptualizaciones de lo que es el autocuidado. la oms (10) describe el autocuidado como un proceso de desarrollo que los individuos, las familias y la comunidad asumen con responsabilidad para el manejo de su propia salud, adoptando conductas que ayudan a prevenir la enfermedad y a restaurar la salud. asimismo, dorothea orem (11) reconoce que las necesidades de autocuidado de las personas crecen con los problemas de salud y con las etapas específicas de la vida, lo que requiere para su satisfacción no solo de un funcionamiento biológico, sino de unas condiciones saludables del entorno y un desarrollo personal del individuo que le permita tomar la decisión de cuidarse. levin (12) decía que “el autocuidado en enfermedades crónicas exige que las personas que las sufren tengan capacidades para cambiar su propio cuidado”, lo cual es un proceso complejo que envuelve la práctica de conductas, algunas de ellas acerca de cómo reconocer, interpretar y tratar los síntomas de deterioro del estado de salud a causa de su enfermedad (13). una de las consecuencias favorables del autocuidado es que los pacientes monitorean sus síntomas, toman decisiones y evalúan el impacto de las mismas, pasando de ser simples “seguidores de instrucciones” a colaborador en su propio cuidado (14). es en este contexto, en el que el autocuidado se convierte en un método de empoderamiento de los pacientes que los ayuda a ser más sanos y felices, y que prolonga la vida a causa del cambio en sus estilos de vida (15). los comportamientos de autocuidado en la fc incluyen, entre otros, la adecuada adherencia al tratamiento farmacológico, al no farmacológico (recomendaciones sobre la dieta, ejercicio, descanso y control diario de peso), y la búsqueda de ayuda asistencial cuando sea necesario (16); para esto, los pacientes deben tener, como mínimo, los conocimientos adecuados acerca del autocuidado (17), que pueden ser enseñados a través programas educativos que tengan por objetivo la mejoría en las conductas del cuidado propio y el reconocimiento temprano de síntomas de descompensación (18). con el solo conocimiento no es suficiente, como dice thompson (19), los pacientes con fc deben hacer el compromiso de vivir saludablemente. para los servicios de salud es una gran necesidad la valoración permanente de las conductas de autocuidado en las personas con fc (20), no solamente como indicador de éxito del componente educativo brindado dentro del tratamiento de la enfermedad (21), sino porque es un excelente factor predictivo del curso de la enfermedad del paciente (22, 23). el desarrollo y la validación de escalas derivadas de la teoría del déficit de autocuidado ha interesado a los profesionales de enfermería desde los años setenta (24-26). una de las más conocidas es the heart failure self care behaviur scale, desarrollada por jaarsma (16) con base en la teoría de orem sobre déficit de autocuidado, que ha sido validada en diversas lenguas (27, 28). este instrumento de 20 ítems contenidos en tres dominios (cumplimiento del régimen terapéutico, solicitud de ayuda y adaptación a actividades de la vida) tiene opciones de respuesta de sí o no. en 2002 artinian (29) realiza una versión modificada para estados unidos (revised heart failure self care behavior scale), aumentando los dominios del instrumento de tres a cinco —buscar y obtener asistencia médica adecuada (seis ítems), vigilar y atender los síntomas de la enfermedad (cinco ítems), cumplir con la prescripción médica y con las medidas dirigidas a la prevención de las complicaciones (doce ítems), modificar el autoconcepto (dos ítems) y aprender a vivir con la enfermedad (cuatro ítems), con lo que el número de ítems sube a 29, y cambia la opción de res25 validez y confiabilidad de una escala de valoración de comportamientos... l maría de los ángeles rodríguez-gázquez, edith arredondo-holguín puesta sí/no a una tipo likert de seis opciones (“none of the time” a “all of the time”, codificados de 0 a 5); dicha escala tiene una confiabilidad de 0,84 y una buena validación de expertos. para la puntuación de la frecuencia de comportamientos de autocuidado se hace la sumatoria de la calificación de cada ítem, pudiendo alcanzar la escala de 0 a 84 puntos, donde los valores más altos corresponden a una mejor frecuencia de estos comportamientos. como el autocuidado es un importante componente en la vida de los pacientes con fc, y es indispensable que los enfermeros y otros profesionales de la salud cuenten con instrumentos que ayuden a detectar de manera eficiente los cambios clínicamente importantes que serán objeto de intervenciones en salud, realizamos un estudio que tuvo como objetivo determinar la validez y confiabilidad en el contexto de colombia de la escala nancy artinian para la valoración de comportamientos de autocuidado en personas con fc. método se realizó un estudio de validación en tres fases: fase 1. validación cultural. el uso de la escala revised heart failure self care behavior scale (29) para su traducción y validación al contexto de colombia se hizo con autorización de su autora, nancy artinian. la traducción del inglés al español fue hecha por un traductor oficial. posteriormente, esta versión fue revisada por un comité de expertos en el tema de comportamientos de autocuidado en pacientes cardiovasculares, el cual hizo ajustes semánticos y de estructura al instrumento. para el ajuste semántico final, la escala traducida fue aplicada en forma autodiligenciada en trece enfermeros expertos en cuidado cardiovascular, y en un grupo de doce pacientes con enfermedad cardiovascular. a la escala se le adicionó un espacio para la evaluación de cada ítem de los criterios de quesada (30), así: a) precisión: el lenguaje es exacto y no se presta a dudas; b) comprensión: el lenguaje usado es sencillo y puede ser entendido al ser leído, y c) claridad: las palabras y la construcción de las oraciones es acertada. cada uno de estos criterios fueron calificados con 0 si no cumplía o cumplía parcialmente, y con 1 si cumplía totalmente. los ítems que en cualquiera de los criterios tuviera valores promedios inferiores a 0,75 fueron estudiados nuevamente para la modificación semántica final de su enunciado. fase 2. validación factorial. el instrumento con las modificaciones realizadas en la fase anterior fue aplicado a una muestra por conveniencia de 206 personas con insuficiencia cardiaca confirmada por diagnóstico médico, ecocardiografía y sintomatología clínica, que consultaron entre mayo de 2007 a mayo de 2008 en una clínica cardiovascular de origen privado de la ciudad de medellín. los pacientes, además, deberían cumplir con los siguientes requisitos: estar en estadio funcional según clasificación nyha —clases i y ii o iii compensada—, no tener alteración del estado mental —evaluada esta con el mini mental state examination (31)—, y haber firmado el consentimiento informado. la información suministrada fue manejada con confidencialidad (32). el análisis factorial de la escala modificada se realizó utilizando el método de componentes principales. para esto se introdujeron las 28 variables correspondientes a la totalidad de los ítems de la escala traducida y modificada, luego se corrió la matriz de correlación, y posteriormente se identificaron los componentes principales. las combinaciones lineales de las variables fueron analizadas con el objeto de identificar cuáles explicaban la mayor proporción de varianza. a los componentes principales (factores, dominios o subescalas) se les estimó la correlación de cada variable con cada uno de ellos, es decir, su carga factorial. para clarificar las relaciones entre las variables y los componentes se utilizó la rotación de los factores por el método varimax con normalización kaiser, teniendo como criterio de selección del factor si su autovalor era igual o mayor a 1. se consideró que cuando un ítem tenía una carga factorial mayor a 0,4, estaba altamente correlacionada con el factor. cuando un ítem no compartió al menos 0,4 de carga factorial con un factor se tomó la decisión de eliminarlo de la escala. por último, con base en el constructo latente que subyacía en cada combinación de ítems, se asignó un nombre a cada componente. fase 3. confiabilidad de la escala. se hizo la evaluación de la consistencia interna del instrumento por medio del estadístico alfa de cronbach, el cual es un coeficiente de correlación al cuadrado que mide la homogeneidad de las preguntas promediando todas las correlaciones entre todos los ítems para evaluar si efectivamente se parecen. se calcularon coeficientes alfa para el total de la escala y para cada sexo, grupo de edad y subescala. resultados fase 1. validación cultural. en el cuadro 1 se describe el puntaje promedio para los criterios de la calificación (claridad, precisión y comprensión) de cada ítem por tipo de evaluador, 26 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 apreciándose que en el grupo de enfermeros los ítems 2, 6, 8, 14, 16, 22 y 27 tuvieron por lo menos uno de los tres criterios por debajo de 0,75, al igual que el ítem 18 en los pacientes. todos estos ítems fueron analizados y modificados semánticamente con el fin de mejorar el criterio de evaluación que no fue adecuado. las modificaciones realizadas a la escala después del análisis de los expertos fueron: a) como los ítems 17 y 18 son iguales en su significado para las personas que realizaron la prueba piloto, se unen reduciendo la escala de 29 a 28 ítems; b) las cinco opciones de respuesta original (nunca, pocas veces, algunas veces, una buena parte del tiempo y la mayor parte del tiempo) se reducen a cuatro (nunca, pocas veces, la mayor parte del tiempo, todo el tiempo); c) se elimina el pronombre “yo” de todos los ítems que comienzan con él; d) en los ítems 2, 3, 4 y 11, en lugar de disnea se cambia por los sinónimos “fatiga”, “falto de aire” y “sensación de ahogo”; y e) el ítem 19 se modifica así: “compro/solicito la medicación o los remedios a tiempo”. a partir de este momento, este instrumento se llamará escala modificada de comportamientos de autocuidado en pacientes con falla cardiaca (emcafc). cuadro 1. calificación promedio por criterio de los ítems de la escala traducida según tipo de evaluador 1 me peso todos los días de la semana. 1,00 1,00 1,00 1,00 1,00 1,00 2 cuando estoy corto de la respiración (disnea) descanso. 1,00 0,92 0,92 0,92 0,85 0,69 3 cuando estoy corto de respiración o cansado pido ayuda para realizar lo que no puedo hacer. 0,92 1,00 0,92 0,92 0,92 0,92 4 yo consulto a mi doctor cuando me siento muy ahogado de la respiración (disnea). 1,00 1,00 1,00 0,85 0,85 0,85 5 yo contacto a mi doctor cuando veo que mis pies, tobillos, piernas o estómago se hinchan. 1,00 0,92 0,92 0,77 0,69 0,77 6 yo consulto a mi doctor cuando he aumentado un kilo en un día o un kilo y medio desde la 1,00 1,00 0,92 0,77 0,69 0,77 última visita al doctor. 7 yo mido la cantidad de orina que elimino cada día. 1,00 1,00 1,00 0,92 0,92 0,92 8 yo me cuido de ingerir demasiados líquidos cada día. 1,00 0,75 0,92 0,69 0,85 0,85 9 cuando me siento ansioso por el empeoramiento de los síntomas de la falla cardiaca hablo 0,92 0,92 0,92 1,00 1,00 1,00 con mi doctor acerca de ello. 10 yo consulto a mi doctor cuando siento náuseas o no siento ganas de comer. 1,00 0,83 0,92 0,92 0,92 0,92 11 para ayudar a reducir síntomas como: fatiga, ahogo en la respiración (disnea), yo limito las 0,92 0,92 1,00 0,92 0,92 0,92 actividades que son difíciles para mí. 12 yo creo que tener falla cardiaca es una condición a la cual me puedo adaptar. 1,00 1,00 1,00 1,00 1,00 1,00 13 yo distribuyo las actividades del día para no cansarme demasiado. 1,00 1,00 1,00 1,00 1,00 1,00 14 yo descanso durante el día. 1,00 1,00 1,00 0,92 0,69 0,92 15 yo consulto a mi doctor cuando me siento cansado todo el día. 1,00 1,00 0,92 0,92 0,92 0,92 16 yo me cuido de no comer enlatados ni comidas rápidas. 0,75 0,83 0,75 0,69 0,69 0,69 17 yo tomo la medicación para la falla cardiaca todos los días. 1,00 0,75 0,83 0,92 0,92 0,92 18 yo tomo la medicación y las dosis completas que me prescribe el doctor. 1,00 0,67 1,00 0,92 0,85 0,92 19 yo siempre repito la compra de la medicación a tiempo. 1,00 1,00 0,92 0,85 0,85 0,92 20 yo tengo un sistema para recordar cuándo debo tomar la medicación 0,92 0,83 0,83 0,92 1,00 1,00 21 yo me mantengo alejado de las personas que tienen gripa. 1,00 1,00 1,00 1,00 0,85 0,92 22 yo realizo actividad física (por ejemplo, camino o monto en bicicleta de 3 a 4 días a la semana). 1,00 0,92 1,00 0,85 0,69 0,85 23 yo me vacuno contra la gripa todos los años. 1,00 1,00 1,00 0,85 0,85 0,85 24 yo limito la ingesta de licor a un vaso de cerveza o vino al día. 0,83 0,83 0,83 0,77 0,83 0,77 25 yo no fumo. 1,00 1,00 1,00 0,92 0,92 0,92 26 yo cumplo mis citas con el doctor. 1,00 1,00 1,00 1,00 1,00 1,00 27 yo levanto las piernas cuando me siento en una silla. 0,92 0,92 1,00 0,85 0,69 0,85 28 yo hablo con el doctor y mi familia acerca de mi condición con el fin de hacer cambios y planes 1,00 1,00 1,00 0,85 0,85 0,85 para el futuro. 29 yo pienso que una persona puede vivir bien y feliz aun teniendo falla cardiaca. 0,92 0,92 0,92 1,00 1,00 1,00 evaluador paciente enfermo claridad precisión comprensión claridad precisión comprensión ítem 27 validez y confiabilidad de una escala de valoración de comportamientos... l maría de los ángeles rodríguez-gázquez, edith arredondo-holguín fase 2. validación factorial. la muestra en la que se evaluó la emcafc estuvo compuesta por 206 personas. las características generales de estos pacientes son: el promedio de edad es de 60,6 ± 13,5 años (edad mínima 19 y edad máxima 94), un 65,5% son hombres y un 58,7% tenía como nivel máximo de escolaridad el de primaria. por clasificación funcional nyha predominaron las clases i (59,7%) y ii (33,0%). con el fin de evaluar si la emcafc era unidimensional se examinó la estructura factorial de la matriz de correlación policórica de los 28 ítems que la componen, encontrando que en la escala hay multidimensionalidad. se identificaron cuatro factores con autovalores por encima de 1, de los cuales el primer factor explica el 15,5% de la varianza, siguiéndole los factores 2, 3 y 4 que explican el 7, 6, 5, 7 y 5, 4%, respectivamente. la varianza explicada acumulada de los cuatro factores alcanza a ser de 34,2%. la distribución de los ítems según factor de la emcafc, así como la varianza que comparte con el correspondiente factor pueden observarse en el cuadro 2. siete ítems explicaron menos de 0,2%, razón por la que no aparecen en ninguno de los factores, reduciendo la escala de 28 a 21 ítems. aquellos que se quitaron fueron: me peso todos los días de la semana, consulto a mi doctor cuando he aumentado un kilo en un día o un kilo y medio en una semana, restrinjo la cantidad de líquidos ingeridos cada día según lo prescrito por el doctor, me vacuno contra la gripa todos los años, limito la ingesta de licor a un vaso de cerveza o vino al día, cumplo mis citas con el doctor, y fumo. en la emcafc, de 21 ítems se encontró que subyacían cuatro dominios: solicitud de ayuda (seis ítems), adaptación a la enfermedad (tres ítems), adherencia al tratamiento farmacológico (tres ítems) y adherencia al tratamiento no farmacológico (nueve ítems). cuadro 2. varianza explicada de los ítems que componen los factores de la emcafc de 21 ítems factor ítems por factor varianza explicada consulto a mi doctor cuando me siento con sensación de ahogo. 0,72 contacto a mi doctor cuando veo que mis pies, tobillos, piernas o estómago se hinchan. 0,71 solicitud de ayuda consulto al doctor cuando me siento cansado. 0,69 consulto a mi doctor cuando siento náuseas y pérdida del apetito. 0,60 hablo con mi doctor por el empeoramiento de mis síntomas. 0,56 pido ayuda cuando estoy con sensación de ahogo. 0,50 adaptación me adapto a la condición de tener falla cardiaca. 0,78 a la enfermedad puedo vivir feliz teniendo falla cardiaca. 0,74 hablo con el doctor y mi familia de cambios y planes para el futuro. 0,48 adherencia al tomo la medicación y las dosis completas que me prescribe el doctor para la falla cardiaca todos los días. 0,76 tratamiento siempre compro o solicito la medicación a tiempo. 0,64 farmacológico tengo un sistema para recordar cuándo debo tomar la medicación. 0,55 distribuyo las actividades del día para no cansarme demasiado. 0,65 me mantengo alejado de las personas que tienen gripa. 0,54 me cuido de comer enlatados y alimentos ricos en sal. 0,47 adherencia al para ayudar a reducir síntomas como la sensación de ahogo, yo limito las actividades que son difíciles para mí. 0,44 tratamiento no levanto las piernas 30 grados cuando me siento en una silla. 0,42 farmacológico descanso en cama tres veces al día y después de las actividades que me generan esfuerzo. 0,41 cuando estoy con sensación de ahogo descanso hasta que disminuya el síntoma. 0,40 mido la cantidad de orina que elimino cada día. 0,40 realizo actividad física (por ejemplo, camino o monto en bicicleta, tres a cuatro veces por a semana). 0,40 28 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 con el fin de evaluar la interdependencia de las cuatro subescalas se estimaron los coeficientes de correlación interdominio, encontrándose correlaciones significativas (p < 0,01) entre la subescala de solicitud de ayuda con las de adherencia al tratamiento farmacológico y no farmacológico, compartiendo el 26 y el 7% de la varianza, respectivamente; y de la subescala de adherencia al tratamiento farmacológico con la de adherencia al tratamiento no farmacológico con la de adaptación a la enfermedad (3 y 8% de varianza compartida, respectivamente). hubo independencia interdominio entre la subescala de adaptación a la enfermedad con las de solicitud de ayuda y adherencia al tratamiento no farmacológico (varianzas compartidas de 1 y 0,8%). fase 3. análisis de confiabilidad. la emcafc de 21 ítems tiene un alfa de cronbach de 0,75, siendo un poco mayor la confiabilidad en hombres que en mujeres (0,79 frente a 0,71). por subescala, la de solicitud de ayuda tuvo el mejor valor (0,77), seguida por las de adaptación a la enfermedad (0,58), adherencia al tratamiento farmacológico (0,47) y adherencia al tratamiento no farmacológico (0,39). discusión el proceso de traducción y adaptación de instrumentos en nuestro contexto para la medición de autocuidado en pacientes con enfermedad cardiovascular suele tener inconvenientes relacionados principalmente con la adaptación de los conceptos evaluados para que sean expresados adecuadamente en sus ítems, con el fin de que reflejen lo más fielmente posible a la versión original (33, 34); por esta razón es tan importante la adaptación cultural de un instrumento, que no tiene que ver solamente con la traducción a otro idioma, sino también con la contextualización al medio en que se vaya a aplicar (35); posteriormente, es necesario analizar las propiedades psicométricas de la nueva versión (36-38). en este estudio de evaluación de la validez y confiabilidad de la escala de valoración de comportamientos de autocuidado en personas con fc diseñada por nancy artinian (29, 39) encontramos que la emcafc presentó una adecuada validez cultural que fue evidente al aplicar la versión traducida en la prueba preliminar a enfermeros especialistas en cuidado cardiovascular y al grupo de pacientes con fc, cuando la mayor parte de sus ítems fueron calificados como claros, precisos y comprensibles; los ocho que no cumplieron con alguno de estos criterios fueron analizados y modificados semánticamente. la versión modificada fue aplicada a la muestra de 206 pacientes con fc. en la fase de validación factorial se pudo comprobar que la emcafc de 28 ítems tenía cuatro dominios (solicitud de ayuda, adaptación a la enfermedad, adherencia al tratamiento farmacológico y adherencia al tratamiento no farmacológico), que juntos explicaron el 34,2% de la varianza del constructo latente en la escala, siendo la subescala de solicitud de ayuda la más importante al tener varianza de 15,5%. como siete ítems no aparecieron en ninguno de los factores, fueron eliminados quedando la escala final reducida a 21 ítems. al comparar la distribución de los 21 ítems en las subescalas de la emcafc con lo reportado por artinian (39) se encontró lo siguiente: dominio de solicitud de ayuda: cinco de los seis ítems (consulto a mi doctor cuando me siento con sensación de ahogo; contacto a mi doctor cuando veo que mis pies, tobillos, piernas o estomago se hinchan; consulto al doctor cuando me siento cansado; consulto a mi doctor cuando siento náuseas y pérdida del apetito, y hablo con mi doctor por el empeoramiento de mis síntomas) se corresponden con la subescala de artinian de buscar y obtener asistencia médica adecuada, y el sexto ítem, pido ayuda cuando estoy con sensación de ahogo, se encuentra en el dominio de vigilar y atender los síntomas de la enfermedad en la de la autora. dominio de adaptación a la enfermedad: dos de los tres ítems (me adapto a la condición de tener insuficiencia cardiaca y puedo vivir feliz teniendo insuficiencia cardiaca) hacen parte del dominio de modificar el autoconcepto en la escala original, y el tercero (hablo con el doctor y mi familia de cambios y planes para el futuro) en la escala de artinian pertenece al dominio aprendiendo a vivir con la enfermedad. dominio de adherencia al tratamiento farmacológico: en la emcafc está compuesto por tres ítems (tomo la medicación y las dosis completas que me prescribe el doctor para la insuficiencia cardiaca todos los días, siempre compro o solicito la medicación a tiempo, y tengo un sistema para recordar cuándo debo tomar la medicación), los que hacen parte del dominio cumplir con la prescripción médica y con las medidas dirigidas a la prevención de las complicaciones. 29 validez y confiabilidad de una escala de valoración de comportamientos... l maría de los ángeles rodríguez-gázquez, edith arredondo-holguín referencias bibliográficas 1. world health organization. world health statistics 2007. geneve: world health organization; 2007. 2. departamento administrativo nacional de estadística. estadísticas vitales: mortalidad. bogotá: departamento administrativo nacional de estadística; 2004. 3. organización panamericana de la salud, alcaldía de medellín. situación de salud en medellín. medellín: organización panamericana de la salud; 2004. 4. krumholz hm, chen yt, wang y, vaccarino v, radford mj, horwitz ri. predictors of readmission among elderly survivors of admission with heart failure. am heart j 2000; 139 (pt 1): 72-7. 5. stewart s, macintyre k, macleod m, bailey a, capewell s, mcmurray j. trends in hospitalization for heart failure in scotland, 1990-1996. an epidemic that has reached its peak? eur heart j 2001; 22 (3): 209-17. 6. riedingger m. quality of life in women with heart failure, normative group and patients with other chronic conditions. am j crit care 2002; 11 (3): 211-9. 7. bosworth h. congestive heart failure patients of quality of life; the integration of physical and psychosocial factors. aging ment health 2004; 8 (1): 83-9. 8. goldberg rj, ciampa j, lessard d, meyer te, spencer fa. long-term survival after heart failure: a contemporary population-based perspective. arch intern med 2007; 167 (5): 490-6. 9. baas l. self care resources and activity as predictors of quality of life in persons after myocardial infarction. dimens crit care nurs 2004; 23 (3): 131-8. 10. world health organization. report of a scientific consultation. health education in self-care: possibilities and limitation. geneva: world health organization; 1983. adherencia al tratamiento no farmacológico: de los nueve ítems que conforman esta subescala, cuatro pertenecen al dominio vigilar y atender los síntomas de la enfermedad en la de artinian (distribuyo las actividades del día para no cansarme demasiado; para ayudar a reducir síntomas como la sensación de ahogo, limito las actividades que son difíciles para mí; descanso en cama tres veces al día y después de las actividades que me generan esfuerzo, y cuando estoy con sensación de ahogo descanso, hasta que disminuya el síntoma); otros cuatro hacen parte del dominio cumplir con la prescripción médica y con las medidas dirigidas a la prevención de las complicaciones (me mantengo alejado de las personas que tienen gripa, me cuido de comer enlatados y alimentos ricos en sal, mido la cantidad de orina que elimino cada día, y realizo actividad física tres a cuatro veces por semana), y el restante (levanto las piernas 30 grados cuando me siento en una silla) es del dominio aprendiendo a vivir con la enfermedad. la correlación significante observada entre la subescala de solicitud de ayuda con las de adherencia al tratamiento farmacológico y no farmacológico, y la de adherencia al tratamiento farmacológico con las de adherencia al tratamiento no farmacológico y adaptación a la enfermedad, muestra que no son independientes, situación que ya ha sido documentada en los estudios (32, 40, 41). en este estudio se encontró que la consistencia interna de la emcafc de 28 ítems fue de 0,76, que puede ser considerada como aceptable, la cual solo rebajó a 0,75 cuando la escala se redujo a 21 ítems. esta confiabilidad es menor a la reportada por artinian (39) cuando encontró un alfa de cronbach de 0,84. la subescala de solicitud de ayuda tuvo el mejor valor de confiabilidad (0,77), lo que puede ser explicado porque es el dominio que más varianza manifestó de la escala analizada. como conclusión de este estudio se puede decir que la emcafc tiene una adecuada validación cultural y buenas propiedades psicométricas en términos de confiabilidad y validez, lo que permitirá que este instrumento pueda ser utilizado por enfermeros y otros profesionales de la salud en la detección eficiente de los cambios clínicamente importantes que sean objeto de intervenciones en salud en los pacientes con fc. 30 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 11. orem d. nursing concepts of practice. 6th ed. philadelphia: mosby; 2001. 12. levin l. self-care: toward fundamental changes in national strategies. int j health educ 1981; 24: 219-28. 13. sethares ka. supporting the self-care behaviors of women with heart failure through an individualized nursing intervention. massachusetts: boston college; 2003. 14. holman h, lorig k. patients as partners in managing chronic disease: partnership is a prerequisite for effective and efficient health care. br med j 2000; 320 (7234): 526-7. 15. lorig k, holman h. self-management education: history, definition, outcomes, and mechanisms. ann behav med 2003; 26 (1): 1-7. 16. jaarsma t, stromberg a, martenssen j, dracup k. development and testing of the european heart failure self-care behaviour scale. eur j heart fail 2003; 5: 363-70. 17. hope c, wu j, tu w. association of medication adherence, knowledge, and skills with emergency department visits by adults 50 years or older with congestive heart failure. am j health syst pharm 2004; 61 (19): 2043-9. 18. gonseth j, guallar-castillon p, banegas jr, rodrigues-artalejo f. the effectiveness of disease management programmes in reducing hospital re-admission in older patients with heart failure: a systematic review and meta-analysis of published reports. eur heart j 2004; 25: 1570-95. 19. thompson dr, stewart s. nurse directed services: how can they be made more effective? eur j cardiovasc nurs 2002; 1: 7-10. 20. mcalister f, stewart s, ferrua s, mcmurray j. multidisciplinary strategies for the management of heart failure patients at high risk for admission. a systematic review of randomized trials. j am coll cardio 2004; 44: 810-9. 21. albert nm. promoting self-care in heart failure: state of clinical practice based on the perspectives of healthcare systems and providers. j cardiovasc nurs 2008; 23 (3): 277-84. 22. achury dm. autocuidado y adherencia en pacientes con falla cardiaca. aquichán 2007; 7 (2): 139-60. 23. carlson b, riegel b, moser d. self-care abilities of patients with heart failure. heart lung 2001; 30: 351-9. 24. muñoz cl, cabrero j, richart m, orts mi, cabañero mj. la medición de los autocuidados: una revisión de la bibliografía. enferm clin 2005; 15 (2): 76-8. 25. deaton c, grady lk. state of the science for cardiovascular nursing outcomes heart failure. j cardiovasc nurs 2004; 19 (5): 229-38. 26. bonilla c. diseño de un instrumento para evaluar los factores que influyen en la adherencia a tratamientos en personas que presentan factores de riesgo de enfermedad cardiovascular. rev avances enf 2007; 15 (1): 46-50. 27. jaarsma t, halfens r, tan f, abu-saad h, dracup k, diederiks j. self-care and quality of life in patients with advanced heart failure: the effect of a supportive educational intervention. heart lung 2000; 29 (5): 319-30. 28. shuldham c, theaker c, jaarsma t, cowie m. evaluation of the european heart failure self-care behaviour scale in a united kingdom population. adv nurs 2007; 60 (1): 87-95. 29. artinian tn, magnan m, christian w, lange mp. what do patients know about their heart failure? appl nurs res 2002; 15 (14): 200-8. 30. quesada-vargas m. cualidades estilísticas del texto escrito. enf costa rica 2005; 26 (1): 31-6. 31. folstein fm, folstein es, mchugh rp. mini-mental state: a practical method for grading the cognitive state of patients for the clinician. j psychiatr res 1975; 12 (3): 189-98. 32. arredondo e. comportamientos y capacidad de agencia de autocuidado de adultos con insuficiencia cardiaca. avances enf 2010; 28 (1): 21-30. 33. goodwin l. changing conceptions of measurement validity: an update on the new standards. j nurs edu 2002; 41: 100-6. 34. guillemin f, bombardier c, beaton d. cross-cultural adaptation of health-related quality of life measure: literature review and proposed guidelines. j clin epidemiol 1993; 46: 1417-32. 31 validez y confiabilidad de una escala de valoración de comportamientos... l maría de los ángeles rodríguez-gázquez, edith arredondo-holguín 35. guyatt g, patrick d, editors. evaluation of translation and cultural adaptation in global clinical trials included in cochrane reviews. xv cochrane colloquium 2007 oct 23-27; são paulo, brazil. 36. acquadro c, conway k, ciroudet c. linguistic validation manual for patient-reported outcomes (pro) instruments. lyon: mapi research institute; 2004. 37. beaton ed, bombardier c, guillemin f. guideline for the process of cross-cultural adaptation of self-report measures. spine 2000; 24: 3186-91. 38. wild d, grove m, martin m, eremenco s, mcelroy s, et al. principles of good practice for the translation and cultural adaptation process for patient-reported outcomes (pro) measures: report of the ispor task force for translation and cultural adaptation. value health 2005; 8: 95-105. 39. artinian nt, magnan m, sloan m, lange mp. self-care behaviors among patients with heart failure. heart lung 2002; 31: 161-72. 40. leguizamón m. factores relacionados con la adherencia al tratamiento farmacológico y no farmacológico en pacientes con posinfarto agudo del miocardio en una institución de cuarto nivel de bogotá. bogotá: pontificia universidad javeriana; 2008. 41. heath wg. physical activity transitions and chronic disease. am j lifestyle med 2009; 3 (3): suppl, 27s-31s. 6 espacio y territorio.p65 espacio y territorio en la práctica de enfermería comunitaria 189 año 7 vol. 7 nº 2 • chía, colombia octubre 2007 • 189-198 yaira yohanna pardo mora1 marlon mauricio gonzález ballesteros2 1 universidad nacional de colombia. ciudad universitaria bogotá d.c., colombia yypardom@unal.edu.co 2 universidad nacional de colombia. ciudad universitaria bogotá d.c., colombia mmgonzalezb@unal.edu.co recibido: 28 de mayo de 2007 aprobado: 22 de julio de 2007 resumen la práctica diaria de las enfermeras comunitarias se determina por la dinámica del cumplimiento de metas y resultados de los programas, sin tener en cuenta que el éxito o el fracaso de los mismos depende en parte de variables socioespaciales que las enfermeras desconocen. sin embargo, para que exista un desarrollo del conocimiento en enfermería en esta área, dentro del desarrollo del concepto metaparadigmático de ambiente de la disciplina de enfermería se deberían incluir estas variables, necesarias para el diseño, la implementación y la evaluación de los programas, y que determinan las relaciones terapéuticas de cuidado introduciendo al pensamiento cotidiano de la práctica los conceptos de espacio y territorio como categorías de análisis que aportan una serie de métodos y teorías para la comprensión de los procesos de salud-enfermedad y cuidado. estas categorías, junto con un pensamiento teórico de los modelos en enfermería, aporta nuevas herramientas que permiten planificar las actividades propias del trabajo comunitario, así como el uso de técnicas como la cartografía y los análisis espaciales en salud, elementos esenciales para el establecimiento y la distribución del personal en salud, el desarrollo de programas comunitarios y una explicación de causalidad de los procesos colectivos de cuidado. palabras clave cartografía, enfermería en salud comunitaria, geografía, métodos. (fuente: decs bireme). aquichan issn 1657-5997 espacio y territorio en la práctica de enfermería comunitaria espacio y territorio en la práctica de enfermería comunitaria aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007190 space and territory in community nursing practice abstract daily practice in community nursing is determined by compliance with targets and the results of programs, without taking into account the fact that their success or failure depends, in part, on socio-spatial variables nurses are unfamiliar with. nonetheless, these variables should be included if knowledge on community nursing is to be developed as part of the metaparadigmic concept of environment in the discipline of nursing. they also are necessary to design, implement and evaluate programs, and determine therapeutic relations with respect to care, by introducing the concepts of space and territory into everyday thinking about nursing practice, as analytical categories that contribute a series of methods and theories for understanding processes related to health-illness and care. these categories, together with theoretical thinking on the models used in nursing, contribute new tools that allow for planning activities particular to community work, as well as the use of techniques such as mapping and spatial analysis in health, which are essential elements for the establishment and distribution of health personnel, the development of community programs, and an explanation of the cause of collective processes for care. key words cartography, community health nursing, geography, methods. espaço e território na prática da enfermagem comunitária resumo a prática cotidiana das enfermeiras comunitárias é determinada por a dinâmica do cumprimento de metas e resultados dos programas, mas não é tido em conta que o êxito ou o fracasso destes depende de variáveis espaciais desconhecidas por elas. para um avanço do conhecimento da enfermagem nesta área, dentro do desenvolvimento do conceito metaparadigmático de entorno nesta disciplina, é necessário incluir estes variáveis no desenho, na implantação e avaliação dos programas que determinam as relações terapêuticas de cuidado, integrando ao pensamento diário da prática os conceitos de espaço e território como categorias de análise que aportam métodos e teorias para a compreensão dos processos de saúde-doença e cuidado. junto com um pensamento teórico dos modelos da enfermagem, estes categorias aportam novos instrumentos para o planejamento das atividades próprias das labores comunitárias e técnicas, como a cartografia e as análises espaciais na saúde, elementos essenciais para situar e distribuir o pessoal da saúde, desenvolver programas comunitários e explicitar as causas dos processos coletivos de cuidado. palavaras-chaves cartografia, enfermagem em saúde comunitária, geografia, métodos. espacio y territorio en la práctica de enfermería comunitaria 191 introducción a práctica disciplinar de las enfermeras comunitarias está involucrada íntimamente con el territorio y el espacio donde se desarrollan la mayoría de sus acciones y actividades, puesto que el ejercicio disciplinar integra los conceptos de salud y enfermedad como procesos de cuidado, estableciendo una relación causal y determinante de los espacios y los territorios con las acciones y respuestas al cuidado de la salud. sin embargo, dentro de la teorización y conceptualización de la práctica disciplinar de enfermería en este ámbito, poco se ha tenido en cuenta esta relación o se han definido parámetros de entorno y ambiente con una conceptualización clara y una operacionalización concreta (1). en este sentido, la práctica en la enfermería comunitaria se ha determinado como una extensión más de la práctica asistencial tradicional clínica de cuidado relacionada con la rehabilitación y la curación, razón por la cual los procesos, las motivaciones, las razones y las acciones que se llevan a cabo dentro de los equipos interdisciplinarios en salud se desconocen, y la práctica disciplinar de enfermería se mimetiza dentro de las prácticas y los saberes en salud pública (2). lo anterior se ha convertido en un vacío dentro del conocimiento en enfermería y la práctica disciplinar de las enfermeras comunitarias fuente de investigación, situación que permite profundizar sobre los aspectos teórico-conceptuales que le den piso a las múltiples acciones de las enfermeras comunitarias y así mismo, determinar el núcleo disciplinar de enfermería dentro del gran universo de consideraciones de la salud pública (3-5). las reflexiones sobre la importancia de la derivación, la utilización y el manejo de los conceptos geográficos de espacio y territorio para la práctica disciplinar de enfermería surge de la preocupación de la comunidad científica de la disciplina por dar un paso en la construcción de un cuerpo teórico para las enfermeras comunitarias (6), y de la revisión y reflexión que se ha generado a partir de la investigación sobre la �evaluación del impacto social de las enfermeras comunitarias dentro de la experiencia en un modelo de atención primaria en salud�, de la facultad de enfermería de la universidad nacional de colombia. en este marco de análisis se ha determinado que la práctica diaria de las enfermeras comunitarias gira en torno a la dinámica del cumplimiento de metas y resultados de los programas de promoción de la salud y prevención de la enfermedad, regidos únicamente por las normas legales sin tener en cuenta que el éxito o el fracaso de los mismos depende en parte de una serie de variables de índole socioespacial que en la mayoría de los casos las enfermeras desconocen (7). sin embargo, para que exista un desarrollo del conocimiento de enfermería en esta área, se considera que el manejo conceptual y teórico del espacio y el territorio se puede hacer dentro de los parámetros del concepto metaparadigmático de ambiente de la disciplina de enfermería, puesto que éste contempla dentro su definición la relación entre las personas (individuos, familias o comunidades), sus condiciones y las sociedades en general (8). es por esto que para el análisis de las realidades socioespaciales que determinan las relaciones terapéuticas de cuidado �objeto social de la disciplina de enfermería� es necesario introducir al pensamiento cotidiano de la práctica conceptos como el espacio, el territorio y el lugar, como categorías de análisis determinantes que aportan una serie de métodos y teorías para una mejor comprensión de las comunidades y los colectivos y de los procesos de salud-enfermedad y cuidado por parte de las enfermeras, y no solamente de las circunstancias particulares de los individuos que los conforman (9-11). aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007192 la comprensión de estas categorías, junto con un pensamiento conceptual-teóricoempírico de los modelos y las teorías de enfermería, da a las profesionales nuevas herramientas para comprender los procesos de salud en una forma integral, y permiten planificar las actividades propias del trabajo comunitario y colectivo, así como el aprendizaje de algunas técnicas utilizadas ampliamente en el mundo, como la cartografía social y los análisis espaciales en salud, que se constituyen como una herramienta para el establecimiento y la distribución, no sólo del personal para el desarrollo de los programas de promoción de la salud y prevención de la enfermedad, sino que permite una explicación de causalidad de los procesos colectivos de cuidado (12, 13). hasta una década atrás, los conceptos de lo que se determina como el espacio y el territorio hasta una década atrás se desconocían por las ciencias de la salud, en especial por enfermería, como un elemento fundamental para comprender los procesos de cuidado y salud tanto de individuos como de colectivos y comunidades, en donde se circunscriben sus habitantes (14). concepto geográfico de espacio milton santos (15) da una definición clara de espacio como �una instancia de la sociedad, al mismo nivel que la instancia económica y la cultural-ideológica�. esto significa que, en tanto que instancia, el espacio contiene y está contenido por las demás instancias, del mismo modo que cada una de ellas lo contiene y es por ellas contenida. la economía está en el espacio, así como el espacio está en la economía. lo mismo ocurre con lo políticoinstitucional y con lo cultural-ideológico. eso quiere decir que la esencia del espacio es social. en ese caso, el espacio no puede estar formado únicamente por las cosas, los objetos geográficos, naturales o artificiales, cuyo conjunto nos ofrece la naturaleza. el espacio es todo eso más la sociedad: cada fracción de la naturaleza abriga una fracción de la sociedad actual. en principio, el espacio geográfico es el espacio accesible a la sociedad, es cualquier punto de la superficie terrestre que se vea afectado o que afecte de alguna manera a la humanidad. el objeto de la geografía es interpretar las relaciones, los procesos y las funciones que se dan entre los distintos objetos geográficos, desde la historia y las transformaciones que se han ocasionado al espacio, entendiendo las relaciones y los flujos (16). esas relaciones que dan origen a los procesos, resueltos en funciones, se materializan a través de formas, cuyas cargas histórica y simbólica configuran un entramado mayor de relaciones y funciones entre otras formas espaciales. esta secuencia de análisis permite un acercamiento a una totalidad social (17). en la ciencia geográfica han existido un sinnúmero de debates en torno al concepto de espacio, venidos de cada una de las corrientes epistemológicas dominantes a lo largo del siglo xx. las primeras aproximaciones se dieron alrededor de los años cincuenta con la aparición de la nueva geografía, corriente de origen positivista cuantitativita que se preocupó por las localizaciones absolutas de los elementos del espacio, y la interpretación de éstas a partir de modelos matemáticos, en los que se modelaban procesos económicos y físicos para su explicación y predicción (18). en esta corriente el espacio es observado como un mero contenedor de una serie de elementos físicos y sociales que se localizan por circunstancias específicas, en determinado lugar y su relación pasa por la distancia, en pocas palabras, el espacio es ahistórico. una de las principales críticas a este concepto tan ampliamente conocido, es el desconocimiento de la existencia de un sinnúmero de realidades que dinamizan el espacio y lo transforman �no sólo los fenómenos naturales�, en este caso la sociedad en sí misma representa un agente transformador. estas carencias fueron interpretadas y conjugadas por una corriente que en palabras de delgado (16) fue primero de corte liberal, posteriormente socialista y, por último, acogió la teoría marxista para la producción de conocimiento geográfico. este nuevo discurso privilegia la dimensión social del espacio, donde las relaciones espaciales se definen como manifestaciones de las relaciones sociales de clase en el espacio geográfico producido y reproducido por el modo de producción. esta posición excluye el concepto de espacio como contenedor de objetos y lo traslada hacia un sistema abstracto de elementos, movimientos y formas espaciales, y adopta un concepto del mismo como la construcción social de los agentes y las sociedades entre sí y las relaciones de estos agentes con la naturaleza tanto natural como antrópica (16). este espacio social es históricamente construido por la dinámica natural de los modos de producción. bajo esta óptica, harvey (19), propone una aproximación dialéctica del estudio del espacio geográfico en donde el espacio privilegia los procesos, flujos y cambios permanentes, y las relaciones sobre análisis de elementos y estructuras de los sistemas organizados, teniendo en cuenta que los elementos, cualquiera que éstos sean, son interel espacio geográfico es el espacio accesible a la sociedad, es cualquier punto de la superficie terrestre que se vea afectado o que afecte de alguna manera a la humanidad. espacio y territorio en la práctica de enfermería comunitaria 193 namente contradictorios en virtud de los múltiples procesos que los constituyen. a finales de los años setenta ciertos círculos de geógrafos inconformes con las visiones positivistas y marxistas del espacio, buscaron otras alternativas de acercamiento al conocimiento tales como el existencialismo y la fenomenología. desde esta tradición, la experiencia práctica es la fuente de las nociones científicas que se dan en espacios concretos con una carga de significación simbólica muy fuerte (lugar, vivienda, barrio, esquinas); en pocas palabras la experiencia de la vida en y de los lugares. posteriormente, la geografía humanista revaloriza el cuerpo y su simbología. tuan (20) advierte que el cuerpo es un objeto que vive en el espacio y a través de esta situación el hombre y su entorno se integran en el mundo; el cuerpo se convierte en un elemento productor de conocimiento a través de la experiencia de sus propias formas de vivirlo. por ende, el hombre transforma y recrea su entorno de acuerdo a sus necesidades tanto biológicas como sociales. concepto geográfico de territorio el concepto de territorio nos habla, en principio, del poder que se ejerce sobre el espacio. al referirnos a un territorio estamos hablando de los diversos poderes que ejercen diferentes actores sobre un espacio, delimitándolo y diferenciándolo de otros espacios. este poder ejercido por los distintos agentes sociales que lo ocupan, conlleva una construcción histórica de los procesos de territorialización en donde lo económico, desde una postura marxista, hasta lo vivido desde las teorías fenomenológicas, construyen y reconstruyen el concepto de territorio (21). montañés y delgado (22) hacen referencia a la importancia del territorio como escenario de toda relación social, y de distintos actores, tanto externos como internos, y cómo éstos, investidos por un poder, ejercen una territorialidad o generan territorios que se yuxtaponen a otros territorios, esto hace de este concepto una construcción social de carácter histórico, que conlleva el conocimiento del modo de producción dominante y de las relaciones vivenciales de los individuos o las comunidades que se organiza de distintas formas (redes, áreas, conductos, etc.). es el poder que se ejerce en los territorios el que da la significancia y las características a los agentes sociales que las habitan, así como la forma de relacionarse con el territorio físico y todas sus características ambientales. es en este punto donde algunos especialistas en salud pública lo han denominado como empoderamiento y lo han utilizado como forma de ejercicio del poder de una comunidad hacia su salud, el cual se puede considerar como una acción política que demarca un punto de partida para quien establece el análisis en salud (23). en las ciencias de la salud se ha extendido la concepción natural del territorio, en el que se considera que los espacios enferman o curan. esta visión epidemiológica y reduccionista de los espacios y los territorios se ha convertido en un arma política para devaluar ciertos territorios que no cumplen con los estándares geográficos europeos y norteamericanos (24). en realidad, el territorio es un todo que comprende lo natural (formas, recursos hídricos, vegetación), lo humano y las relaciones que se dan entre los agentes sociales que reconfiguran nuevas espacialidades y recrean nuevas relaciones de salud y de cuidado (25-27). como señalan sánchez y león (24), la aproximación territoriosalud va más allá de lo elemental de la distribución espacial o de las características ambientales que inciden en los perfiles epidemiológicos, y aporta la comprensión del hombre concebido en su incesante proceso de totalización, cuyo fin es la realización de su ser social, en busca de su propia satisfacción y la de su comunidad. espacio, territorio y enfermería la relación de los aspectos espaciales con la práctica disciplinar de enfermería en general es considerada como una nueva corriente epistemológica desde comienzo de la década pasada, en la cual investigadores de origen británico y canadiense se han interesado por la relación entre la enfermería, el espacio y el territorio. tal interés se ha dado por el auge del cuidado de la salud como factor principal de organización y atención en los sistemas de salud, y el incremento de las acciones de enfermería en el ámbito comunitario (14, 28). en este sentido geográfico del cuidado, la comunidad es vista como un grupo social determinado por límites geográficos y valores e intereses comunes, en donde sus miembros se conocen e influyen mutuamente. la comunidad se enmarca dentro de una determinada función social condicionada por un modo de producción concreto, un sistema de estratificación social y un conjunto de normas, instituciones y valores sociales (29). el territorio es un todo que comprende lo natural (formas, recursos hídricos, vegetación), lo humano y las relaciones que se dan entre los agentes sociales que reconfiguran nuevas espacialidades y recrean nuevas relaciones de salud y de cuidado. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007194 la comunidad constituye una fuerza social dinámica, con características demográficas, instituciones, condiciones ambientales y recursos bien definidos, que entre otras cosas promueven o impiden la salud y el bienestar de la población que aquélla abarca. la enfermera comunitaria, en este ámbito, se acerca y mantiene contactos regulares con los grupos sociales, los hogares, los centros de trabajo, las escuelas, es decir, lugares donde los grupos viven y trabajan, se relacionan, ponen de manifiesto las necesidades reales o potenciales de salud, y en los cuales se encuentra la mayoría de los factores de riesgos que inciden negativamente sobre ella (30). específicamente en los sistemas de salud actuales en los contextos latinoamericanos, las acciones que realiza enfermería comunitaria implican una amplia gama de actividades dentro de estos lugares entre las que se encuentran (8): · actividades de atención directa a la persona y a la familia; en la que la integración sitúa al profesional como nexo entre la persona, la familia y el sistema de salud. · actividades de atención directa a los grupos. · acciones de organización a la comunidad con el fin de aprovechar los recursos disponibles para las acciones preventivas. · actividades de coordinación y enlace con los equipos multidisciplinarios. · actividades de educación en salud: educación directa a personas, familias y grupos, como directivo en la formación del talento humano. · actividades de administración del recurso tanto humano como físico. sin embargo, estas acciones aún no se conocen a profundidad, y su desarrollo y ejecución se realizan por medio de parámetros normativos y la planeación de las acciones públicas en salud; a su vez, los diagnósticos en salud se realizan de acuerdo con los intereses de los sistemas de salud y no a las necesidades percibidas y sentidas por los colectivos o las comunidades dentro de sus espacios y sus territorios, razón por la cual no se ha podido medir el impacto social ni la utilidad específica de la práctica de enfermería y de la salud pública en general (31). aún así, el fin último de enfermería como práctica social siempre será buscar la salud de la comunidad vista como el resultado de una relación recíproca saludable del hombre con su territorio, y el impacto de los servicios de salud sobre éstos. en consecuencia, desde la perspectiva geográfica del cuidado, la salud de la comunidad es algo más que la suma de la salud de cada uno de sus miembros (3). para lograr este objetivo, dentro de la geografía del cuidado, éste se considera como el interés proactivo de una persona en el bienestar de la otra, lo que implica enmarcar la práctica de cuidado dentro de unas conexiones del hombre con su espacio y sus lugares específicos, teniendo en cuenta desde la accesibilidad a ese cuidado hasta el momento de la actuación del mismo. esto requiere de las enfermeras comunitarias una mirada crítica, amplia y objetiva sobre la pluralidad de los fenómenos que ocurren y la función de reciprocidad de los mismos en las relaciones de cuidado, teniendo en cuenta los aspectos económicos, políticos, culturales y sociales de las comunidades (32). discusión las consideraciones teóricas tradicionales en el manejo del análisis espacial y territorial en salud han girado alrededor de lo que se denomina geografía médica, cuyo enfoque es hacia los patrones espaciales de la medicina y la enfermedad, y lo que se considera geografía de la salud, cuya concepción es de corte posmoderno y se ha centrado en la dinámica entre salud, bienestar y lugar (33) por consiguiente, estos aspectos se han reducido a elementos de la medicina exclusivamente. el punto de desencuentro entre estas posiciones y el cuidado de la salud radica en que las ciencias naturales y biomédicas se fundan en la premisa de que el hombre es un producto de la naturaleza y un organismo determinado biológicamente que se puede y debe ser estudiado como cualquier otro objeto natural, en cambio, dentro del cuidado de la salud se ve al hombre como sujeto humano que se desenvuelve dentro de unos espacios cotidianos. aunque enfermería como actividad esté atravesada por su dependencia práctica con medicina, esto no implica que los análisis teóricos del espacio en que se encuentre su práctica, tengan que coincidir con las posiciones biomédicas y epidemiológicas, ya que el cuidado de la salud implica una relación hermenéutica de los espacios con los seres humanos (29). los diagnósticos en salud se realizan de acuerdo con los intereses de los sistemas de salud y no a las necesidades percibidas y sentidas por los colectivos o las comunidades dentro de sus espacios y sus territorios, razón por la cual no se ha podido medir el impacto social ni la utilidad específica de la práctica de enfermería y de la salud pública en general. espacio y territorio en la práctica de enfermería comunitaria 195 si bien dentro de las bases epistemológicas de enfermería como ciencia y de los límites metaparadigmáticos se habla de un ambiente �o, como se denomina en textos traducidos al español, entorno� como dominio de enfermería, cuya concepción fue establecida por florence nightingale en 1946 éste ha sido considerado como el listado o inventario de elementos que rodean a un individuo (34). desde el punto de vista geográfico, el entorno es una categoría de análisis espacial que se refiere a un espacio euclidiano en el que se definen y se hace inventario de los elementos geográficos cercanos en los que no se precisa su origen, su historia y sus relaciones internas y externas, y en el que las funciones de cada uno de los elementos espaciales se invisibilizan dando prioridad a la descripción de éstos (35, 36). con la revolución tecnológica surgida a la luz del derrumbamiento del modelo de producción fordista, las características del espacio se fueron cambiando. internet dio paso a una compresión del espacio-tiempo que permitió una mayor cantidad de flujos de interacción de los elementos espaciales en tiempo real, con lo cual la proximidad, la co-presencia física y la visibilidad, que siempre han sido elementos constitutivos de la identidad del trabajo de la enfermera, han ido revaluándose. es aquí donde el concepto de entorno carece de utilidad para explicar las nuevas características del cuidado bajo las nuevas condiciones que recrea el modelo de producción dominante (36). como afirma meleis (34), el desarrollo del concepto se vio perdido durante los años de influencia fuerte del dominio de los sistemas biológicos sobre las teorías de enfermería, por lo que sólo algunas teóricas contemporáneas (37, 38), poseen un concepto claro y definido de lo que es el ambiente o el entorno, cuyos elementos en común giran alrededor de ver el ambiente como un campo de energía con unos límites espaciales definidos; específicamente, hablan de la relación inseparable del hombre con el ambiente (37). el concepto de ambiente o entorno que se desarrolla en otras teorías de enfermería sólo se nombra, por lo que no es explícita su definición y sus implicaciones, por esta razón muchos de estos conceptos se toman como implícitos dentro de la operacionalización de las teorías. en cambio, cuando se habla de espacio y territorio para la práctica de enfermería, conteniendo las definiciones y operacionalizaciones de la geografía como ciencia del espacio, éstos toman relevancia para abarcar la complejidad de la práctica disciplinar, ya que como afirma meleis, citando a chopoorian, en el ejercicio de la práctica de enfermería �las enfermeras desarrollan una conciencia del ambiente social, económico y de las estructuras políticas� así como las relaciones humanas sociales en el cotidiano de la vida� (34). por esta razón, la corriente de la geografía del cuidado ha realizado un ejercicio de derivación de conceptos para ubicarlos en el cotidiano de la práctica de enfermería; es así como los lugares se entienden no sólo como contenedores físicos de actividades humanas, sino como interacciones complejas de características físicas y sociales, a las cuales se les atribuyen sentimientos, identidades y simbolismos, tanto a nivel individual como comunitario; además, los lugares dan significado, por medio de sus espacios sociales, a actividades, rituales e interacciones de cuidado. es así como se considera que el análisis de los aspectos espaciales que corresponden a enfermería proveen una base de conexión entre lo concerniente a la geografía de la salud, los asuntos profesionales prácticos y las realidades en que viven las personas desde una perspectiva multimetódica y potencialmente crítica. las suposiciones teóricas de la geografía del cuidado están determinadas por las corrientes humanistas del espacio en las cuales éste es definido como el lugar en donde los fenómenos y las personas están distribuidos, y el lugar como un punto, o nodo, en donde los fenómenos o las personas pueden estar ubicados, cuyo estudio está liderado por un acercamiento sensitivo a las personas y al territorio al cual pertenecen. este acercamiento a las relaciones de las personas con los lugares está determinado por la filosofía heideggeriana de estar-en-el-mundo, cuya intencionalidad es ser consecuente con el �porqué� de las cosas, ya que los lugares y los espacios no son sólo físicos y envuelven una intención humana (38). de esta manera, los lugares y los espacios tienen un significado esencial con la cura y el cuidado, con las emociones y los sentimientos; sin embargo, no hay que confundir los valores sociales involucrados en la relación de un grupo, un individuo o una comunidad, con la identidad de clase, con el pensar y el actuar de estos mismos en el espacio que es la esencia de las relaciones de cuidado. así, los lugares son un punto de vista de inicio para el conocimiento humano del mundo y de las actitudes y acciones de cuidado de las personas en el mismo (39, 40). desde el punto de vista geográfico, el entorno es una categoría de análisis espacial que se refiere a un espacio euclidiano en el que se definen y se hace inventario de los elementos geográficos cercanos en los que no se precisa su origen, su historia y sus relaciones internas y externas. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007196 conocer la relevancia del papel que desempeña la comprensión de la categoría de lugar en los procesos de salud-enfermedad determina un espectro total en el campo del cuidado contemporáneo de la salud, ya que las relaciones existentes entre los lugares y las personas determinan patrones de cuidado y poder (41). en este sentido, la contribución de la geografía del cuidado es dar una visión cualitativa de los territorios, teniendo en cuenta los asuntos profesionales y prácticos de enfermería, y las necesidades particulares de las personas. de por sí la enfermería como profesión está en sí misma involucrada en los patrones espaciales históricos cambiantes en la provisión de cuidado, al mismo tiempo que el conocimiento que tienen las personas sobre el cuidado de su salud está íntimamente involucrado con los eventos que suceden en su espacio específico (42, 43). por esta razón, el análisis del espacio y el territorio está dado por la combinación de las perspectivas cualitativas-sensitivas de los territorios, los acercamientos cuantitativos de los modelos cartográficos, y los rasgos distributivos espaciales de enfermería, que se mezclan con un serie de problemas relacionados con la práctica como la educación en enfermería, la fuerza de trabajo (contratación y retención), los recursos financieros, la distribución del personal de enfermería según las necesidades de la población, y la efectividad y los resultados de los procesos de enfermería (44-46). de esta forma, el análisis del espacio y el territorio para la práctica disciplinar de enfermería comunitaria es una herramienta fundamental en la planeación, ejecución y medición de las acciones de enfermería, dado que éstas deben corresponder a cuatro aspectos fundamentales en el ejercicio de la enfermería comunitaria (8): 1. el cambio de consideración de los problemas de salud individuales hacia la acción en salud colectiva. 2. el estudio de los problemas de salud parte de la idea de que las raíces de los procesos de enfermar están en las diferentes estructuras que componen la formación de una sociedad. 3. la elaboración de planes de actuación debe estar encaminada fundamentalmente a modificar y controlar los factores sociales que generen riesgos para la salud comunitaria. 4. los diagnósticos en salud deben permitir conocer la situación global de la comunidad, y no exclusivamente los aspectos y problemas sanitarios. para realizar este tipo de análisis, la geografía del cuidado ofrece diferentes herramientas como la cartografía social, la cartografía temática, las bases de datos cartográficas, los sistemas de información geográfica, cuya construcción se deriva de una valoración de los subsistemas que conforman una comunidad (estructura demográfica, aspectos culturales, sociales, medioambientales, productivos), con datos tanto cualitativos como cuantitativos, que permiten tener información en tiempo real de las comunidades y los procesos, para que la enfermera pueda ejecutar las prácticas inherentes a su quehacer disciplinar en cada uno de los miembros de una comunidad específica. como complemento permite la explicación y el análisis de factores de riesgo en salud que pueden afectar o no los procesos de salud de las poblaciones y realizar intervenciones oportunas (47-50). esta serie de herramientas permite a la enfermera tener una globalidad de los espacios de intervención, abrir los panoramas de conocimiento y no centrarse en meras acciones que, en últimas, al ser tan descontextualizadas no generan el impacto esperado en los distintos programas comunitarios y colectivos que tengan lugar en los espacios de apropiación territorial de las comunidades, llámense manzanas, barrios, veredas, localidades y estados (50, 51). agradecimientos a todas las enfermeras jóvenes que han inspirado este nuevo análisis de la realidad en que vivimos gracias a su empeño y esfuerzo cotidiano en trabajar en un área que trae profundas satisfacciones personales y profesionales. el análisis del espacio y el territorio está dado por la combinación de las perspectivas cualitativas-sensitivas de los territorios, los acercamientos cuantitativos de los modelos cartográficos, y los rasgos distributivos espaciales de enfermería, espacio y territorio en la práctica de enfermería comunitaria 197 referencias bibliográficas 1. parker me. nursing theories and nursing practice. 1st ed; philadelphia (usa) fa: davis 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microbióloga; profesora asistente, departamento de medicina interna, facultad de ciencias de la salud, universidad del cauca, colombia. 3 enfermera graduada, departamento de enfermería, facultad de ciencias de la salud, universidad del cauca. 4 enfermera graduada, departamento de enfermería, facultad de ciencias de la salud, universidad del cauca. 5 enfermera graduada, departamento de enfermería, facultad de ciencias de la salud, universidad del cauca. recibido: 13 de febrero de 2008 aceptado: 5 de agosto de 2008 resumen en las vías urinarias de las mujeres embarazadas se producen cambios importantes, uno de ellos es ser propensas a padecer infección de vías urinarias. tanto la bacteriuria asintomática, como la infección de vía urinaria (ivu) requieren detección y tratamiento oportunos para evitar complicaciones, y es en estos procesos en los cuales el papel activo y decidido de la actitud de la gestante frente a su cuidado y el apoyo del personal de enfermería son relevantes. objetivo: describir las creencias, prácticas y actitudes de mujeres embarazadas frente a las infecciones urinarias en el centro de salud alfonso lópez, popayán, colombia. método: se realizó un estudio a través del método cualitativo etnográfico, con 21 mujeres embarazadas que asistían a control prenatal al centro de salud alfonso lópez. resultados: la investigación permitió conocer el impacto que tiene el saber cultural sobre la práctica consciente del autocuidado durante la etapa de la gestación. así mismo, la resistencia marcada hacia el uso o tratamiento con antibióticos, por pensar en los efectos dañinos que estos medicamentos pueden causar en el bebé. palabras clave infección urinaria, cuidado, prácticas, creencias, actitudes, cultura. (fuente: decs) beliefs, practices and attitudes of pregnant women concerning urinary infections abstract in the urinary tract of pregnant women important changes take place, are prone to suffer from infections of the urinary ways. both asymptomatic bacteriuria and urinary tract infection (u.t.i) require a right detection and an appropriate treatment in order to avoid complications, and it is in these processes when an active care of the expectant mother and the support from the nursing staff become relevant. año 8 vol. 8 nº 2 chía, colombia octubre 2008 183-196 184 año 8 vol. 8 nº 2 chía, colombia octubre 2008 183-196 aquichan issn 1657-5997 objective: to describe the beliefs, practices and attitudes of the expectant women regarding the urinary infections, alfonso lopez healthcare centre, popayán – colombia. method: the study was carried out through a qualitative ethnographic method, with twenty one pregnant women who attended the prenatal check-up at alfonso lopez healthcare centre. results: the research allowed knowing the impact that the cultural knowledge has upon the self-care practice over the course of the gestation stage. likewise, it was possible to see a strong disagreement about the use and treatment with antibiotics; given that some people think that those medications may have harmful effects on the baby. key words urinary infections, care, practices, beliefs, attitudes, culture. crenças, práticas e atitudes de mulheres grávidas frente as infecções urinárias resumo entre as mudanças importantes que experimentam as mulheres grávidas nas vias urinárias está a propensão a sofrer infecção. tanto a bacteriúria assintomática como a infecção de via urinária (ivu) necessitam detecção e tratamento oportunos para evitar complicações. nestes processos, são importantes o papel ativo e decidido da gestante respeito do seu cuidado e o apoio do pessoal de enfermagem. objetivo: descrever as crenças, práticas e atitudes das mulheres grávidas frente as infecções urinárias no centro de saúde alfonso lópez, popayán, colombia. método: foi realizado um estudo qualitativo etnográfico com 21 mulheres grávidas que iam a controle pré-natal no centro de saúde alfonso lópez. resultados: a pesquisa permitiu conhecer o impacto do saber cultural na prática consciente do auto cuidado na etapa da gestação. além disso, a resistência notória para o tratamento com antibióticos, pensando nos efeitos nocivos que podem causar no bebê. palavras-chave trato urinário, doenças urogenitales femininas e complicações durante a gravidez, atenção prenatal, cultura. 185 creencias, prácticas y actitudes de mujeres embarazadas frente a las infecciones urinarias. édgar castro f., liliana caldas a., carmita cepeda, briseida huertas, nini jiménez introducción durante el embarazo ocurren ciertos cambios en el sistema urinario que favorecen el desarrollo de infección de vías urinarias (ivu). la ivu es ocasionada por bacterias que invaden el sistema urinario y se multiplican, la infección puede ocurrir en cualquier parte del sistema urinario, aunque generalmente se inicia en la uretra. la mayoría de las infecciones de vías urinarias son ocasionadas por una bacteria denominada escherichia coli, que normalmente vive en el área del colon y recto. en las mujeres el recto y la uretra están muy cerca, motivo por el cual las bacterias logran migrar hacia ella infectándola. de ahí la importancia de practicar adecuados hábitos higiénicos como medida preventiva para disminuir la aparición de estas infecciones. este estudio surgió por el interés de realizar un trabajo interdisciplinario entre enfermería, bacteriología y antropología sobre una situación que afecta a las mujeres durante el embarazo, y que trae consigo complicaciones tanto maternas como fetales. el trabajo se inició en el mes de enero del 2005, y culminó en el mes de agosto del 2006. este trabajo se realizó a través de un método cualitativo con el objetivo de conocer las prácticas y actitudes de las embarazadas frente a la ocurrencia de ivu en el centro de salud alfonso lópez, de popayán, colombia. el método de investigación cualitativa muestra la importancia de conocer aún más las características culturales de la población –en este caso de las mujeres gestantes– en relación con su autocuidado durante este periodo, lo cual facilita encaminar de manera más acertada una serie de actividades tempranas y oportunas que disminuyan el riesgo de complicaciones tanto para la madre como para el bebé cuando ocurren estos procesos infecciosos, de tal manera que se logren fortalecer y modificar de forma positiva aspectos tan sencillos y a la vez tan complejos como son las características culturales arraigadas en la población, y que pueden convertirse en ayuda o barreras en el momento de acceder a los servicios de salud. método el estudio se realizó a través de un método cualitativo etnográfico que permitió describir un aspecto selecto de la cultura, en este caso en torno a las creencias, prácticas y actitudes de mujeres embarazadas frente a las infecciones de vías urinarias. en la etnografía se da un proceso de interacción directa con los sujetos investigados, donde se connotan significados o interpretaciones de las acciones cotidianas que se presentan en la cultura. las técnicas de recolección utilizadas fueron, en primer lugar, la observación, que permitió interactuar con las gestantes que asistían al centro de salud con el fin de ganar su confianza para que la información fuera real; las mujeres en principio mostraron cierta resistencia y desconfianza hacia los investigadores lo cual cambió en el proceso mismo de la investigación. en segundo lugar, la entrevista informal o los diálogos directos realizados a las 21 gestantes permitió fortalecer la interacción y realización de preguntas dirigidas al tema especíla infección de vías urinarias es ocasionada por bacterias que invaden el sistema urinario y se multiplican, la infección puede ocurrir en cualquier parte del sistema urinario, aunque generalmente se inicia en la uretra. 186 año 8 vol. 8 nº 2 chía, colombia octubre 2008 183-196 aquichan issn 1657-5997 información), y la autonomía (que le confiere a las mujeres embarazadas sujeto de estudio escoger libremente su participación en el estudio sin ser sometidas a coacción alguna). igualdad, a todas las mujeres se les brindó un trato respetuoso y tuvieron el beneficio adicional del urocultivo cuyo costo fue asumido por la dirección departamental de salud para las pacientes vinculadas, y eps y ars para las pacientes que posean seguridad social, a quienes se les tramitará orden de apoyo con la entidad correspondiente; sumado a esto se sugirió la implementación de un programa para la prevención de las infecciones urinarias en el centro de salud alfonso lópez. estos principios éticos están consignados en el consentimiento informado que diligenció cada una de las embarazadas sujetos de estudio. resultados características sociodemográficas la edad de la población sujeto de estudio estuvo comprendida desde los 18 hasta los 43 años de edad. dentro del grupo poblacional se encontró que en un alto porcentaje, la edad estaba comprendida entre los 20 y 30 años de edad. el 61,9% (13 participantes) de la población esta entre los 21 y 30 años. el 19% (4) de la población se encuentra entre los 18 y 20 años. el 14,3% (3) de la población tiene entre 31 y 40 años de edad. la población restante, que corresponde a un 4,8% (1) tiene 41 años. las frecuencias y los porcentajes más significativos en cuanto a origen y fico, con las entrevistas abiertas se logró especificar los conocimientos, las prácticas y las actitudes sobre la temática. por último, la entrevista semiestructurada también aplicada a las 21 mujeres embarazadas tuvo como objetivo conocer características sociales generales de las participantes en el estudio. los grupos focales se constituyeron en una técnica de recolección de información que permitió verificar, confrontar y ampliar los datos obtenidos a través de las otras técnicas mencionadas; se hicieron dos grupos focales, uno con ocho participantes y otro con seis, la conformación de los grupos fue voluntaria y se trabajó en dos sesiones, una sesión por cada grupo focal. la reiteración de los conocimientos, las prácticas y las actitudes de las participantes en el estudio a partir de las técnicas aplicadas y culminadas específicamente con el grupo focal permitieron llegar al nivel de saturación de la información. adicionalmente al interés cualitativo del estudio se realizó un urocultivo que permitiera detectar la presencia de bacteriuria asintomática o ivu a las 21 mujeres participantes. el universo de investigación estuvo constituido por 21 informantes claves que aceptaron participar voluntariamente en esta investigación. las expresiones de cada una de las gestantes se citarán de forma textual, con el objetivo de no omitir ni alterar ninguna de sus opiniones. consideraciones éticas en este trabajo se tienen en cuenta los principios éticos de respeto hacia las demás personas (confidencialidad de la en la etnografía se da un proceso de interacción directa con los sujetos investigados, donde se connotan significados o interpretaciones de las acciones cotidianas que se presentan en la cultura. 187 creencias, prácticas y actitudes de mujeres embarazadas frente a las infecciones urinarias. édgar castro f., liliana caldas a., carmita cepeda, briseida huertas, nini jiménez procedencia son: 61,9% (13) que proceden de popayán, seguido del 9,5% (2) que proceden de bolívar-cauca. el porcentaje restante corresponde al 28,8% (6) que proceden de diferentes municipios del departamento del cauca (argelia, el tambo, sotará), quindío (armenia), y de nariño (pasto, san pablo). las frecuencias y los porcentajes de acuerdo con el estado civil son: 57,1% (12) viven en unión libre, seguido de un 28,6% (6) que son solteras; el porcentaje restante, 14,3% (3), están casadas. las frecuencias y los porcentajes de acuerdo con la escolaridad son: 38,1% (8) han cursado secundaria completa, seguido del 28,6% (6) quienes han cursado secundaria incompleta, y un 14,3% (3) con nivel técnico completo. el porcentaje restante, 9,5% (2), han cursado primaria completa y en igual porcentaje han cursado universidad incompleta. las frecuencias y los porcentajes de acuerdo con la seguridad social: 95,2% tienen algún tipo de seguridad social, y de estos el 85,7% corresponde al régimen subsidiado, seguido del 9,5% pertenecientes al régimen contributivo, y el 4,8% restante son particulares. características ginecobstétricas las frecuencias y los porcentajes del número de gestaciones son: 47,6% (10) corresponde a su primer embarazo, seguido de 38% (8) las cuales presentan su segunda gestación, 4,8% (1) han tenido 3 gestaciones, 4,8% (1) han tenido 5 gestaciones, y 4,8% (1) han tenido 9 gestaciones. la frecuencia y el porcentaje de la edad gestacional: 33,3% (7) se encuentran en su cuarto mes de gestación, seguido del 28,6% (6) que se encuentran en su sexto mes de gestación, el 14,3% (3) en su séptimo mes, el 9,5% (2) en el quinto mes de gestación, y el 9,5% (2) en el octevo mes de gestación; el porcentaje restante, 4,8% (1), está en su segundo mes de gestación. frecuencia y porcentajes de abortos: el 81% (17) no han presentado abortos, el porcentaje restante 19% (4) presentaron aborto en alguna ocasión. infección de vías urinarias la mayoría de las infecciones de vías urinarias son ocasionadas por bacterias que invaden y se multiplican en el sistema urinario. las bacterias generalmente provienen del sistema digestivo, empiezan a colonizar la uretra y pueden producir uretritis o cistitis, que si no son tratadas oportunamente, pueden ocasionar pielonefritis. las ivu representan el 10% de las consultas médicas por parte de las mujeres. el 15% las padecen en algún momento de su vida, con una incidencia del 8% durante el embarazo y prevalencia entre 4-7% (1). es importante detectar la bacteriuria asintomática en las pacientes embarazadas debido a que aproximadamente el 30% de las gestantes desarrollaran pielonefritis, en comparación con las no embarazadas que es menor del 1%. al ser el tracto urinario un sistema conformado por distintos órganos, se concluye que hay total desconocimiento de este sistema, ya que solo relacionan infecla mayoría de las infecciones de vías urinarias son ocasionadas por bacterias que invaden y se multiplican en el sistema urinario. 188 año 8 vol. 8 nº 2 chía, colombia octubre 2008 183-196 aquichan issn 1657-5997 ción de vías urinarias con problemas en los riñones, nunca con otras partes, a lo que las participantes refieren “una infección de vías urinarias es una afección de los riñones durante el embarazo” causada por microorganismos a los que se refieren como “una infección por bacterias” (informante cultural, centro de salud alfonso lópez, 2005). las participantes del estudio tienen un concepto muy general de las ivu, sin embargo, desconocen que la pielonefritis trae serios problemas como sepsis materna y amenaza de parto prematuro. se reconoce que esta infección es causada por bacterias, lo que coincide con lo descrito en la literatura ya que durante el embarazo los microorganismos más comunes son escherichia coli (80-90%) y otros bacilos gram negativos como proteus mirabilis y klebsiella pneumoniae, bacterias gram positivas como streptococcus del grupo b y staphylococcus saprophyticcus, y organismos menos comunes como enterococci, y urea plasma urealyticum (2). la infección urinaria la definen en la mayoría de los casos como “molestias al orinar”, que produce ciertos síntomas como “infección urinaria que es cuando hay dolor al orinar”; otro signo es el cambio del color normal de la orina que definen como “color coca-cola”, un cambio evidente, ya que la orina normal es una sustancia de color amarillo claro. referentes de información las mujeres embarazadas son las más propensas a padecer de ivu debido a los cambios que ocurren durante el embarazo; además, el ser mujer aumenta la probabilidad porque “el recto y la uretra están bastante próximos, motivo por el cual las bacterias logran migrar hacia la uretra”. al presentarse el embarazo las mujeres se enteran de este proceso infeccioso cuando refieren “conocí de su existencia durante el embarazo”. obtienen información de diferentes maneras: “lo supe por información de una amiga que sabe qué es infección de vías urinarias”. solo unas pocas manifiestan haber obtenido la información a través del personal de salud: “me enteré por información que me dio una enfermera”, y en muy pocos casos “por información dada durante el control prenatal” (informante cultural, centro de salud alfonso lópez, 2005). esto permite apreciar que se está brindando poca información por parte del personal de salud, especialmente en el área de la prevención, ya que sólo se limita a interrogar, a ordenar exámenes y realizar procedimientos, y pocas veces a brindar educación clara y oportuna; lo anterior se constituye en un grave problema de comunicación, ya que muchas gestantes, después de haber padecido ivu, no saben en qué consiste: “no sé qué es infección urinaria”, solo nombran algunos de sus síntomas, y los confunden con los que se presentan en una infección del tracto reproductor. además, no tienen claro cuáles son las causas, las complicaciones y las formas de prevención de ivu, a lo que dicen: “por haberla padecido sé en qué consiste”, lo que dificulta adquirir hábitos saludables y de autocuidado. complicaciones existen muchas concepciones culturales respecto a las complicaciones que pueden producir las ivu, entre ellas se encuentran “formación de un hematoma que no deja salir la orina y obliga a usar sonda”, esta creencia popular demuestra desconocimiento sobre las complicaciolas participantes del estudio tienen un concepto muy general de las ivu, sin embargo, desconocen que la pielonefritis trae serios problemas como sepsis materna y amenaza de parto prematuro. 189 creencias, prácticas y actitudes de mujeres embarazadas frente a las infecciones urinarias. édgar castro f., liliana caldas a., carmita cepeda, briseida huertas, nini jiménez nes que se pueden presentar, tanto a la madre como al bebé. la fiebre es uno de los síntomas que indica el desarrollo de pielonefritis, a lo que refieren, “la fiebre hace que la temperatura aumente en el líquido amniótico produciendo la muerte del bebé”. la fiebre es un indicador de un proceso infeccioso que puede presentarse a la diada madre-bebé, en tal sentido, “pueden haber malformaciones”, o también “una complicación es que el bebé salga enfermo”, al respecto no existe literatura que argumente esta afirmación, pero sí otras como: amenaza de parto pretérmino, bajo peso al nacer, retardo en el crecimiento intrauterino. además, en etapas tempranas de la gestación, amenaza de aborto, a lo que refieren: “es algo que puede producir un aborto”, un suceso que puede presentarse durante los primeros meses al no detectarse y tratarse la infección oportunamente. síntomas de infección de vías urinarias los síntomas característicos de la infección de vías urinarias dependen del órgano afectado. si se presenta cistitis, uno de los síntomas es disuria que se asume como “ardor al orinar”; polaquiuria y urgencia urinaria que ellas definen como: “aumento de las ganas de orinar” o también “orinar en poca cantidad”. si la infección urinaria es alta, los síntomas característicos son fiebre, que ellas expresan como “tener mucha fiebre” o como “calor en los pies”, y dolor lumbar nombrado como “dolor de cintura que impide caminar”. otros síntomas nombrados son por ejemplo náuseas, vómito y el cambio de las características normales de la orina, las cuales son descritas como “cambios en el color de la orina” o “color de orina oscuro y espeso”, acompañado de “mal olor de la orina”, cambios que se dan por la presencia de proteínas, hormonas, glucosa y bacterias. síntomas referidos frecuentemente y no propios de ivu, son “la presencia de flujo de mal olor”, “rasquiña en el área genital” y “molestias vaginales” que corresponden a infecciones vaginales. las infecciones del tracto reproductor (itr) son infecciones del tracto genital. algunas itr, como sífilis y gonorrea, son de transmisión sexual, pero otras no lo son. en las mujeres, el crecimiento excesivo de microorganismos endógenos que habitualmente se encuentran en la vagina pueden causar itr como candidiasis o vaginosis bacteriana. esto demuestra la confusión que existe entre estas dos patologías que, sumada a la no realización de prácticas y hábitos higiénicos adecuados, aumenta la frecuencia de tales manifestaciones. causas de infección de vías urinarias la mayoría de las infecciones tienen como causa la bacteria escherichia coli, que normalmente vive en el área del colón y del recto (2, 3), lo que aumenta los riesgos de una autoinfección, es decir, que las bacterias se desplacen desde el área perianal hacia la perineal y uretral; al respecto las gestantes manifiestan que “secar el área genital de atrás hacia delante”, y la “mala higiene genital”, aumentan el riesgo de desarrollar ivu. las gestantes expresan que “las relaciones sexuales durante el embarazo” o “las relaciones sexuales promiscuas” son causa de ivu, situación que se correlaciola mayoría de las infecciones tienen como causa la bacteria escherichia coli, que normalmente vive en el área del colón y del recto, lo que aumenta los riesgos de una autoinfección, es decir, que las bacterias se desplacen desde el área perianal hacia la perineal y uretral. 190 año 8 vol. 8 nº 2 chía, colombia octubre 2008 183-196 aquichan issn 1657-5997 na con lo descrito en la literatura, ya que las mujeres después de los 20 años son hasta 60 veces más propensas a desarrollar una infección de vías urinarias dentro de las 48 horas posteriores a una relación sexual con penetración vaginal, que las mujeres de la misma edad que no tienen relaciones sexuales (1, 4). durante el embarazo el útero aumenta de tamaño y comprime la vejiga y los uréteres obstruyendo el flujo de la orina, lo que aumenta el riesgo de ivu, percibido por ellas como “aguantar deseos de orinar” o “retener líquidos”, generado por diferentes motivos entre los que se destacan el trabajo, el estudio y los oficios en el hogar. “la mala alimentación” y “no tomar líquidos”, son otras causas nombradas, y aunque no tienen relación directa con ivu, pueden producir problemas graves para la madre y el feto al no aportar los elementos nutricionales que se requieren durante esta época, debido a la alteración que existe del metabolismo de carbohidratos, lípidos y proteínas. estas connotaciones culturales pueden desviar en gran medida la prevención y el autocuidado, y contribuir al progreso de la ivu considerado como una complicación médica muy común del embarazo que, de no ser tratada, puede provocar problemas más serios (2). el “sudor y polvo”, “dejar jabón en los genitales del hombre”, y “compartir el baño con muchos hombres”, “sentarse en baños usados previamente por hombres o en un andén caliente” y “usar papel higiénico de colores”, las consideran como causas para adquirir ivu; sin embargo, hasta el momento no se tiene una base científica que las catalogue como factores predisponentes para el desarrollo de esta infección. actitudes frente a las infecciones de vías urinarias “después de haber padecido infección urinaria no he cambiado mi estilo de vida”, es una de las expresiones más mencionadas por las mujeres embarazadas. muchos factores pueden influir para que esto ocurra, uno de ellos es la no asistencia al control prenatal, que es el momento más apropiado para recibir o solicitar la información necesaria. la no asistencia se puede deber a múltiples causas, como por ejemplo: la utilización y mayor facilidad de acceso a la medicina tradicional que a la facultativa, haciendo tardía la consulta y trayendo como consecuencia el desarrollo de complicaciones graves en estadios ya avanzados, lo que implica mayores costos y prolongadas hospitalizaciones; aunado a esto, el personal de salud solo se dedica a ordenar y realizar exámenes y procedimientos sin tratar de entablar una relación más dinámica y cordial que permita brindar educación, por lo que ellas refieren: “no me explican los procedimientos ni los exámenes que me van a realizar”, además, “la presencia de muchos estudiantes practicantes durante el examen me incomoda”, situación que conduce a “no asisto a control prenatal por pena a hacer preguntas”; todo esto constituye una barrera de acceso a los servicios de salud o a la consulta cuando las enfermedades se encuentran en estadios tardíos. así mismo, la desinformación hace que se adopten actitudes negativas como actualmente, el diagnóstico de ivu se realiza con la historia clínica completa y el uroanálisis, pero el estándar de oro según el american college of obstetrics and gynecology es la realización del urocultivo en la primera visita prenatal, o entre las semanas 12 a 16 de gestación. 191 creencias, prácticas y actitudes de mujeres embarazadas frente a las infecciones urinarias. édgar castro f., liliana caldas a., carmita cepeda, briseida huertas, nini jiménez “soporto los síntomas por miedo a consumir medicamentos durante el embarazo”, en especial antibióticos; esta percepción de las gestantes se justifica en parte, ya que algunos antibióticos como las fluoroquinolonas y las tetraciclinas están contraindicados por la toxicidad fetal que producen, y las sulfonamidas durante el tercer trimestre pueden ser causantes de kernicterus; sin embargo, también es cierto que existen algunos medicamentos necesarios y seguros durante el embarazo, como la ampicilina, para tratar las infecciones de vías urinarias (4). práctica de autocuidado en la toma de urocultivo actualmente, el diagnóstico de ivu se realiza con la historia clínica completa y el uroanálisis, pero el estándar de oro según el american college of obstetrics and gynecology es la realización del urocultivo en la primera visita prenatal, o entre las semanas 12 a 16 de gestación como recomienda la u.s. preventive services task force (4). el urocultivo permite diagnosticar certeramente la presencia de ivu como también la bacteriuria asintomática que se presentan en muchas gestantes, como etapa inicial al desarrollo de la infección. para la toma adecuada de la muestra de orina previa a la realización de este examen las gestantes refieren tener alguna información como: “tomar la muestra de orina previo lavado de genitales en las horas de la mañana y en ayunas”, y otra aún más completa, “tomar la muestra de orina previo aseo genital con jabón, dejando caer la primera orina, recoger del chorro medio y en la mañana”, que coincide con la recomendación dada de lavarse con abundante agua y jabón el área genital, e iniciar la micción, la primera micción del flujo de orina se descarta por la posibilidad de contaminación de la vulva y la porción final de la uretra con bacterias. para el examen se toma la muestra de la segunda porción de la micción. en el laboratorio se busca la detección del agente etiológico, además de una prueba de sensibilidad a los antibióticos (antibiograma) que orienta sobre un tratamiento más específico. el no entendimiento de la forma correcta de recoger la muestra de orina, necesaria y vital para la realización del examen, puede ser causado por la falta de información oportuna por parte del personal de salud, o por los diferentes niveles culturales y educativos de cada una de las gestantes, que hace que se manejen distintos niveles de comprensión. prácticas de prevención la prevención se ha constituido hoy en día en la principal herramienta para el mantenimiento de la salud y el mejoramiento de las condiciones de vida de la población, esta teoría va dirigida a orientar acciones que eviten la aparición de eventos que desencadenen el desequilibrio entre el medioambiente y el sujeto en su entorno físico, mental o social, afectando principalmente la salud. dentro de esta lógica, y más aún en el periodo de gestación las mujeres deben practicar la prevención y el autocuidado como estrategias para el mejoramiento de su calidad de vida y la de su hijo. las ivu son prevenibles, y aunque en el embarazo hay una mayor predisposición para contraerlas, no necesariamente quiere decir que las mujeres gestantes deban el urocultivo permite diagnosticar certeramente la presencia de ivu como también la bacteriuria asintomática que se presentan en muchas gestantes, como etapa inicial al desarrollo de la infección. 192 año 8 vol. 8 nº 2 chía, colombia octubre 2008 183-196 aquichan issn 1657-5997 padecerlas; es así como en el presente estudio se indagó acerca de las prácticas encaminadas a la prevención de este tipo de infecciones, encontrando actitudes tan acertadas como “tomo mucho líquido para limpiar los riñones”, y otras influenciadas por la desinformación y las creencias populares que llevan al abandono del tratamiento principalmente antibiótico, afirmando que: “no se debe tomar antibióticos durante el embarazo, ya que pueden causar daño al bebé, como malformaciones” (informante cultural, centro de salud alfonso lópez, 2005). de esta manera se encuentra que el saber cultural y la lógica connotada por las mujeres hacen que estas prácticas de autocuidado sean en un alto porcentaje adecuadas; sin embargo, no se puede dejar de lado que la falta de información y educación predispone a los sujetos de estudio a aplicar estas prácticas de forma errada. por otra parte, las creencias culturales acerca de la prevención de las ivu en las gestantes que hicieron parte del estudio son algo confusas respecto a la diferenciación entre la infección del tracto urinario y la infección del aparato reproductor; esto las lleva a asociar la aparición de una u otra como la misma entidad, y hablan de prevención en general como si se tratara de lo mismo, expresando que: “el colocarse óvulos en la vagina evita que el niño quede ciego por el flujo”, o también que: “el hombre tiene en el pene bacterias que pueden causar infección en la mujer” y por ello se hace necesario “orinar después de la relación sexual, ya que barre con todas las bacterias que mi compañero sexual me pasa” (informante cultural, centro de salud alfonso lópez, 2005). la gestación es vista también como un periodo de mayor cuidado, esto hace que las gestantes de cierta manera cambien el estilo de vida ya sea de forma positiva o negativa, y se atienda a las recomendaciones dadas por las personas más cercanas a ellas como son la madre, las hermanas, la pareja o las amigas, así ellas refieren que: “aguanto las ganas de orinar cuando el baño no está limpio... todos los días limpio muy bien mis partes íntimas” (informante cultural, centro de salud alfonso lópez, 2005). la experiencia de la madre y la confianza que las gestantes depositan en referentes familiares hacen que muchas de las creencias perduren en el tiempo, formal igual que las prácticas asociadas a éstas, como por ejemplo: “se tiene en cuenta el número de veces que se va al baño para saber el estado en el que se encuentra el bebé, cuando se va pocas veces es por falta de líquido y cuantas más veces se va, se va limpiando la matriz”, “en el embarazo no debe tomarse ni ruda, ni perejil porque son plantas abortivas” (grupo focal, centro de salud alfonso lópez, 2005). respuestas al tratamiento el tratamiento de las ivu debe ser individualizado, teniendo en cuenta el resultado del urocultivo y del antibiograma. éste debe tener como objetivos erradicar la infección, prevenir las recidivas y preservar la función renal. la elección del antimicrobiano debe estar dirigida a los agentes etiológicos más frecuentes, y debe ser seguro para la madre y el feto. la droga de elección es la ampicilina (presenta 20-30% de resistencia), la nitrofurantonina, cefalosla prevención se ha constituido hoy en día en la principal herramienta para el mantenimiento de la salud y el mejoramiento de las condiciones de vida de la población. 193 creencias, prácticas y actitudes de mujeres embarazadas frente a las infecciones urinarias. édgar castro f., liliana caldas a., carmita cepeda, briseida huertas, nini jiménez porinas, fosfomicina (en única dosis), y sulfonamidas solo en el primer y segundo trimestre (2). el tratamiento más usado es con ampicilina, que infortunadamente es abandonado por efectos secundarios que las gestantes refieren como: “no completé el tratamiento porque me producía dolores de cabeza”; además, “no continué el tratamiento por miedo a que el bebé tuviera malformaciones”. todo esto deja ver la poca información brindada acerca del uso de los medicamentos durante el embarazo por parte del personal de salud, y la gran influencia de la medicina tradicional, que refuerzan actitudes negativas de las gestantes hacia el tratamiento terapéutico. el principal problema es el abandono del tratamiento antibiótico que conlleva la aparición de resistencia bacteriana, obstaculizando el tratamiento de ivu por las características específicas de este grupo poblacional. hábitos higiénicos durante la gestación existe gran influencia de los medios de comunicación y de la publicidad, ya que algunas gestantes expresan que: “el uso de ciertas marcas de jabón hacen que se combatan las bacterias”, o también que: “no debe usarse papel higiénico de color ni de olor, ya que produce alergias”, “el papel higiénico de color y de bajo costo, es papel reciclable que produce enfermedad” “no debe usarse protectores de ropa interior con aroma”, “los protectores de ropa interior con aroma producen flujo” (grupo focal, centro de salud alfonso lópez, 2005). dentro del significado que las gestantes tienen sobre esta etapa se resalta que el embarazo no es considerado como un proceso de enfermedad sino de salud que implica un mayor autocuidado, y la prevención suele tornarse en ocasiones muy drástica. así, alguna gestante refiere: “uno no puede entrar a baños públicos, ya que uno no conoce las prácticas sexuales de las demás personas que usan el baño y las enfermedades que puedan tener, ya que le pueden transmitir a uno bacterias o infecciones”, “al usar baños públicos uno tiene que tratar de orinar parada, para evitar que se le peguen infecciones o bacterias” (informante cultural, centro de salud alfonso lópez, 2005). el autocuidado como parte de la vida de las mujeres en esta época se ve claramente influenciado por el saber tradicional y los consejos de quienes la rodean; de esta manera, y en torno no solo a las ivu, ellas expresan: “se debe consumir cerveza, ya que esto ayuda a aumentar la producción de orina y así se elimina la infección”, “para prevenir las ivu, se debe hacer un baño vaginal con bicarbonato”, “el vinagre quita los granos que salen en los genitales” (informante cultural, centro de salud alfonso lópez, 2005). esto nos lleva a deducir la falta de información y la urgente necesidad de educación para esta población. debe implementarse el autocuidado como una práctica individualizada y aplicada según las costumbres y las creencias de la población, ello agregado al conocimiento científico del personal de salud. la negociación de saberes es una buena estrategia para modificar algunas actitudes negativas que las gestantes tienen frente al tratamiento. el principal problema es el abandono del tratamiento antibiótico que conlleva la aparición de resistencia bacteriana, obstaculizando el tratamiento de ivu por las características específicas de este grupo poblacional. 194 año 8 vol. 8 nº 2 chía, colombia octubre 2008 183-196 aquichan issn 1657-5997 actitudes frente al control prenatal las gestantes asistentes al control prenatal en el centro de salud alfonso lópez, deben cancelar una cuota estándar por cada control que realicen, debido a que este centro es de carácter privado y actualmente no tiene convenios con ninguna eps o ars; esta situación determina, en parte, la asistencia cumplida al control para la mayoría de la mujeres embarazadas de esta comuna. también se logró determinar que a pesar del costo del servicio, un grupo mayoritario de gestantes considera prioritario el hecho de acceder y asistir a este servicio, con la periodicidad según criterio del médico, puesto que consideran que solo de esta forma pueden conocer sobre el bienestar del bebé y el de ellas mismas, y en caso de alguna complicación, van a tener el tratamiento adecuado; así lo argumentan: “para mí es muy importante lo que el médico me recomienda; y trato de venir a control para saber cómo está mi bebé... voy a entrar al curso de psicoprofilaxis para aprender a respirar en el momento del parto... ” (informante cultural, centro de salud alfonso lópez, 2005). llama la atención que algunas de las gestantes tienen una actitud de apatía y descuido hacia el control prenatal y todo lo relacionado con el proceso de embarazo, lo cual puede estar asociado en parte con el grado de escolaridad –que llega a la básica primaria–, sumado a la precaria situación económica para acceder a los servicios médicos, y el déficit de autocuidado que estas mujeres tienen de la salud en general, y así lo refieren: “vengo a control prenatal cuando puedo, el médico me mandó a tomarme unos exámenes pero todavía no los he realizado... es que en la mañana tengo que hacer el almuerzo y en las tardes me da mucha pereza” (informante cultural, centro de salud alfonso lópez, 2005). actitudes frente al tratamiento de las ivu dado que durante la gestación las mujeres están predispuestas a desarrollar bacteriuria significativa asintomática, se conoció que algunas de éstas buscan encontrar respuestas a los cambios fisiológicos que están atravesando por medio de la observación frecuente del cuerpo y su fisiología normal, esto aplica para la micción y sus características, y adoptan esto como una medida protectora para informarse si hay algún cambio anormal que augure el principio de una infección: “cuando el color de la orina cambia yo pienso que estoy enferma, porque lo normal es que la orina sea de color amarillo claro... ahora en el embarazo estoy orinando más veces” (informante cultural, centro de salud alfonso lópez, 2005). otras gestantes participantes asumen una actitud de total desinterés hacia los cambios fisiológicos en este periodo, al igual que no acostumbran a observar la micción, por ende, este desconocimiento se convierte en un factor de riesgo al momento de poder detectar una anormalidad en su cuerpo, y así lo refieren: “me imagino que el color de la orina puede cambiar por las comidas que uno consume... realmente no me pongo a ver cuántas veces orino en el día” (informante cultural, centro de salud alfonso lópez, 2005). según la normatividad vigente (resolución 412 de 2000), toda embarazada debe realizarse tres uroanálisis, uno en cada trimestre de la gestación, con el objetivo de dentro del significado que las gestantes tienen sobre esta etapa se resalta que el embarazo no es considerado como un proceso de enfermedad sino de salud que implica un mayor autocuidado, y la prevención suele tornarse en ocasiones muy drástica. 195 creencias, prácticas y actitudes de mujeres embarazadas frente a las infecciones urinarias. édgar castro f., liliana caldas a., carmita cepeda, briseida huertas, nini jiménez divisar en forma temprana los indicios de una infección urinaria en curso, pero el sistema de salud actual debe tener en cuenta la mayor sensibilidad del urocultivo para que este examen le cubra a las embarazadas el respectivo antibiograma además del uroanálisis correspondiente. en el estudio se determinó que las gestantes tienen una actitud reacia a seguir el tratamiento farmacológico, y en especial de antibióticos, prescrito por el médico, debido a que el profesional da poca información sobre la utilidad de estos medicamentos para eliminar la infección del cuerpo; además, las gestantes asumen que los antibióticos le causan malformaciones al bebé; entonces se observa que prima para ellas el bienestar de su hijo y así lo manifiestan: “recogí la muestra de orina porque el médico me lo pidió... cuando el médico me manda a tomar antibióticos, yo prefiero no hacerlo pues me da miedo que el niño salga enfermo...” (informante cultural, centro de salud alfonso lópez, 2005). implicaciones de enfermería la investigación sobre prácticas y actitudes de mujeres embarazadas que asisten a control prenatal al centro de salud alfonso lópez de la ciudad de popayán, frente a sus conocimientos de ivu, permitió identificar el impacto que tiene el saber cultural sobre la práctica consciente del autocuidado durante la etapa de la gestación. de acuerdo con su interiorización y vivencias personales (creencias, prácticas y actitudes), la mujer adopta un estilo de vida adecuado para ella y su hijo; aunque algunas de ellas también podrían tener coincidencias negativas. el autocuidado se aprende a lo largo de la vida, y cada persona aprende a cuidarse de acuerdo con el medio que lo rodea, generando las necesidades propias para cada individuo, poniendo en juego la lógica y el sentido común como herramienta para dar solución a los retos del diario vivir. sin embargo, es evidente que estos elementos no son suficientes para desarrollar estilos de vida saludables, ya que se requiere de conocimientos precisos basados en la evidencia que permitan definir medidas preventivas para preservar la salud y evitar la enfermedad. el papel del profesional de enfermería logra trascender cuando brinda los cuidados necesarios a la mujer gestante y su futuro hijo, ya que de esta forma contribuye a la realización personal de muchas mujeres a través de la maternidad. la labor de enfermería tiene implicaciones en los cuidados que se brinda a la mujer gestante, los cuales se encaminan a la atención integral desde la etapa preconcepcional, desarrollo del autocuidado consciente, la culminación del proceso de gestación con éxito, y la adaptación del nuevo ser a la vida extrauterina, de manera óptima, garantizando el desarrollo de sus potencialidades en el futuro. razones éstas para hacer de la atención en salud de la gestante una acción prioritaria y de calidad, garantizando que sea accesible, oportuna, suficiente, pertinente y continua. esta tarea debe ser asumida por el personal de enfermería, el cual debe adaptar los programas actuales de control prenatal y atención del parto a las necesidades individuales de cada mujer gestante, teniendo en cuenta el componente socioculen el estudio se determinó que las gestantes tienen una actitud reacia a seguir el tratamiento farmacológico, y en especial de antibióticos, prescrito por el médico, debido a que el profesional da poca información sobre la utilidad de estos medicamentos para eliminar la infección del cuerpo. 196 año 8 vol. 8 nº 2 chía, colombia octubre 2008 183-196 aquichan issn 1657-5997 tural, psicológico y económico que son las principales limitantes para el acceso a los servicios de salud. retomando este principio de las teóricas de enfermería dorotea orem y madeleine leininger, las cuales han dejado como legado un encuentro de saberes que percibieron a través del ejercicio diario de la profesión, y que hoy día cobran importancia, al ser la base para guiar y aplicar los cuidados de enfermería a un grupo poblacional determinado. es así como la teoría de cuidado transcultural y del autocuidado convergen con un fin único: brindar cuidados coherentes a las necesidades sentidas de un individuo o grupo poblacional, que puede ser ejecutado a través de la capacidad para desarrollar empatía, trato humano y considerado, respeto por el saber cultural y manejo de la concertación como estrategia para modificar conductas o prácticas riesgosas, promoviendo la interacción y adopción de saberes culturales y facultativos que faciliten en las gestantes acciones propias de autocuidado, que las hagan sentir que son partícipes de su propio cuidado. para lograrlo se requiere del compromiso de todo el equipo de salud, y en especial del profesional de enfermería, educador natural, quien juega un papel decisivo en el empalme entre lo cultural y lo facultativo. una de las herramientas de comunicación bidireccional, que permitirán mejorar las prácticas, creencias y actitudes de las mujeres gestantes con respecto al autocuidado de su salud, es la comunicación asertiva, en que la mujer participe e referencias 1. infecciones del tracto urinario durante el embarazo [citado en julio de 2005].disponible en: http:// www.intermedicina.com/avances/ginecologia/ ago21.htm 2. delzell je, lefevre ml. urinary tract infections during pregnancy. [citado en julio de 2005]. disponible en: http://www.aafp.org.afp/20000201/.html. interactúe con el personal de salud de una manera efectiva. una de las estrategias que cumple con estos postulados es la iec (información, educación y comunicación). es el profesional de enfermería, durante el control prenatal, quien empieza a liderar estos procesos a través del cumplimiento oportuno y eficaz de la normatividad vigente, además de la toma de exámenes de laboratorio, de diagnóstico y seguimiento –idealmente el urocultivo para detección temprana de ivu–, prevención de las complicaciones, y educación pertinente sobre los comportamientos y estilos de vida saludable que deben adoptar las gestantes durante esta etapa, que se traducen en la disminución de las tasas de morbi-mortalidad materna y perinatal. 3. infecciones de transmisión sexual y otras infecciones del tracto reproductor. organización mundial de la salud; 2005. 4. infección de vías urinarias crónica o recurrente. [citado en julio de 2005]. disponible en: www.virginia hospitalcenter.com. coping and adaptation of adults with cancer: the art of nursing care.   article coping and adaptation of adults with cancer: the art of nursing care* afrontamiento y adaptación del adulto con cáncer: el arte del cuidado de enfermería** enfrentamento e adaptação do adulto com câncer: a arte do cuidado de enfermagem*** 10.5294/aqui.2022.22.1.7 lina marcela cepeda-trujillo 1 jesús miguel mosquera-aguirre 2 yurani rojas-atehortua 3 alix yaneth perdomo-romero 4 1 0000-0002-4136-5781 universidad surcolombiana, neiva, colombia. u20161147749@usco.edu.co 2 0000-0001-9238-8978 universidad surcolombiana, neiva, colombia. u20161146418@usco.edu.co 3 0000-0002-5824-752x universidad surcolombiana, neiva, colombia. u20161145396@usco.edu.co 4 0000-0003-1390-9718 universidad surcolombiana, neiva, colombia. alixyaneth.perdomo@usco.edu.co received: 16/10/2020 sent to peers: 17/11/2020 approved by peers: 08/06/2021 accepted: 27/09/2021 * article financed by the bank of projects for fostering research and technological development and innovation, in the funding modality no. psem01-2019. ** artículo financiado por el banco de proyectos de semilleros de investigación y desarrollo tecnológico e innovación, en la modalidad de financiación no. psem01-2019. *** artículo financiado por el banco de proyectos de semilleros de investigación y desarrollo tecnológico e innovación, en la modalidad de financiación no. psem01-2019. subject: chronic care. contribution to the subject: applying a nursing theory enables a better understanding of the human experiences that are lived in the process of coping and adaptation to cancer, identifying which strategies favor and undermine the new situation that patients are going through. it is a priority for nursing as a whole to strengthen coping and adaptation, through knowledge that guides a comprehensive approach and quality care to patients. para citar este artículo / to reference this article / para citar este artigo: cepeda-trujillo lm, mosquera-aguirre jm, rojas-atehortua dy, perdomo-romero ay. coping and adaptation of adults with cancer: the art of nursing care. aquichan. 2022;22(1):e2217. doi: https://doi.org/10.5294/aqui.2022.22.1.7 abstract objective: to determine the coping and adaptive capabilities in patients with cancer undergoing treatment. methodology: this was a quantitative and descriptive cross-sectional study; the sample consisted of 100 patients with a cancer diagnosis who received chemotherapy and/or radiotherapy treatment between june and august 2019, meeting the inclusion criteria. the coping and adaptation processing scale (caps) was used. results: 53 % of the patients participating in the study presented high coping and adaptive capabilities; 40 % presented medium capabilities, and 7 % presented low capabilities. conclusion: continuous follow-up is extremely important throughout the disease process; having a romantic partner becomes a protective factor since patients feel heard and cared for, which motivates them to follow through with the treatment. in the nursing field, knowing the experience of those who live with an illness allows for transcending and impacting care by providing holistic attention to patients. keywords (source mesh, decs): nursing; caregivers; cancer; neoplasms; chemotherapy; radiotherapy. resumen objetivo: determinar la capacidad de afrontamiento y adaptación en personas con cáncer en tratamiento. metodología: estudio cuantitativo y descriptivo de corte transversal; la muestra fue conformada por 100 pacientes con diagnóstico de cáncer que asistieron a tratamiento de quimioterapia y/o radioterapia entre junio y agosto del 2019, cumpliendo los criterios de inclusión. se utilizó la escala de medición del proceso de afrontamiento y adaptación (escaps). resultados: 53% de los pacientes estudiados poseen una capacidad de afrontamiento y adaptación alta; 40% obtuvo capacidad media y 7% una capacidad baja. conclusión: el acompañamiento continuo es de gran importancia en todo el proceso de la enfermedad; tener una pareja sentimental se convierte en un factor protector pues los pacientes se sienten escuchados y atendidos, lo cual los motiva a continuar con el tratamiento. en el área de enfermería, conocer la experiencia de quienes viven una enfermedad permite trascender e impactar el cuidado brindando una atención holística. palabras clave (fuente mesh, decs): enfermería; cuidadores; cáncer; neoplasias; quimioterapia; radioterapia. resumo objetivo: determinar a capacidade de enfrentamento e adaptação em pessoas com câncer em tratamento. materiais e método: estudo quantitativo e descritivo, de corte transversal; a amostra foi conformada de 100 pacientes com diagnóstico de câncer que passaram por tratamento de quimioterapia e/ou radioterapia entre junho e agosto de 2019, cumprindo com os critérios de inclusão. foi utilizada a escala de medição do processo de enfrentamento e adaptação. resultados: 53 % dos pacientes estudados apresentaram capacidade de enfrentamento e adaptação alta; 40 % obtiveram capacidade média e 7 %, capacidade baixa. conclusões: o acompanhamento contínuo é de grande importância em todo o processo da doença; ter um parceiro(a) sentimental se torna um fator protetor, pois os pacientes se sentem escutados e atendidos, o que os motiva a continuar com o tratamento. na área de enfermagem, conhecer a experiência de quem vive uma doença permite transcender e impactar o cuidado, oferecendo uma atenção holística. palavras-chave (fonte mesh, decs): enfermagem; cuidadores; câncer; neoplasias; quimioterapia; radioterapia. introduction cancer is a disease that causes more than eight million deaths each year worldwide (1) and causes the largest number of premature deaths (2). in america, it is the second leading cause of death; during 2018, 3.8 million cases were diagnosed, and 1.4 million people aged 69 years or under died from cancer (3). the diagnosis of cancer has a significant impact on biological, psychological, physical, and social aspects. it involves multiple challenges and, therefore, the experience of having cancer is highly distressing since it forces individuals to deal with affliction, deterioration, death, transcendence, concepts for each of which they must seek a personal meaning. it is at that moment where coping becomes the main intermediary mechanism in the presence of crisis or in difficult situations involving stress; it is recognized that the behaviors used as coping strategies can promote adaptation (4). callista roy defines coping capability as the innate or acquired ability to generate a response, using new strategies to adapt effectively to challenging changes (5). cancer leads patients to face various changes in their lives which generate negative feelings and emotions in those who suffer from it and in their families; likewise, if effective coping strategies are used, the psychosocial effects produced by this disease can be mitigated (6). the nursing field needs to know how to promote health for its patients, but also how to help them cope with the changing episodes and challenges posed by their disease (7). consequently, the present research aims to determine the coping and adaptive capabilities of patients undergoing cancer treatment. methodology this was a quantitative and descriptive cross-sectional study whose population consisted of users who received chemotherapy and/or radiotherapy treatment between june and august 2019 in a cancer unit. a total of 100 users with a diagnosis of cancer participated, who were chosen non-probabilistically and by convenience, and who met the following selection criteria: i) being over 18 years of age, ii) having a diagnosis of cancer recorded in the clinical history for more than three months, iii) undergoing active chemotherapy and/or radiotherapy treatment, and iv) expressing their voluntary acceptance to participate by signing the informed consent form. the study was submitted to the hospital's ethics committee, in accordance with resolution 8430 of 1993, as well as laws 911 of 2004 and 1581 of 2012, decree 1377 of 2013, the declaration of helsinki, and the ethical principles of confidentiality, beneficence, nonmaleficence, and autonomy. sociodemographic variables included age, gender, marital status, socioeconomic stratum, educational level, occupation, income, number of people in the household, number of dependents, main support person, place of origin, place, and area of residence, and difficulty of mobility. the clinical variables were the type of cancer, stage, time of diagnosis, type, and duration of treatment, the latter collected from the patients' medical history. additionally, the coping and adaptation processing scale (caps) was used, which is suitable for measuring coping processes, designed by callista roy in 2004; this instrument consists of 47 items that, by using short statements, describe the way individuals respond to a crisis or a difficult event and is scored on a likert scale (8). the instrument was translated into spanish, with apparent face validity, reliability between 0.90 and 0.94, and stability of 0.8 (9). it was subsequent­ly validated by paola sarmiento, johana botero, and gloria carvajal, who provided continuity to the construct validity and generated a final version of the caps scale composed of 33 items, with a cronbach alpha of 0.71, face validity of 95 %, and content validity of 0.83. the response options range from 0 (never) to 3 (always), with a minimum score of 0 and a maximum of 99 points; the level of coping and adaptation will be considered low (from 0 to 56 points), medium (from 57 to 70 points) and high (from 71 to 99 points) (10). the researchers collected the information by applying and filling out the instrument manually and then transferring it to a google® form which generated a database in the excel® 2019 program where the data were tabulated, coded, and exported to the stata® 2015 version 14.0 program. absolute and relative frequencies were used to describe the quantitative variables of the study. the normality of the continuous variables was determined with the shapiro wilk test, using the mean or median in the corresponding case; subsequently, the association between the sociodemographic/clinical variables and the coping and adaptation scale was established using the chi-squared test and considering a statistical significance of p<0.05. results most participants were female (75 %), in the adult age range (61 %), with a median age of 54 years, a minimum age of 21 years, and a maximum age of 81 years, from a low socioeconomic standing (89 %) and receiving support from their partner (50 %) and their children (28 %) (table 1). table 1. sociodemographic characterization of cancer patients, n=100 variable n % age 18-28 years 3 3 29-59 years 61 61 60 years or older 36 36 sex male 25 25 female 75 75 marital status married 48 48 free union 15 15 widow/widower 6 6 divorced or separated 3 3 single 28 28 socioeconomic stratum low 89 89 medium 11 11 level of education primary 41 41 bachelor's degree 30 30 technician/technologist 16 16 undergraduate 10 10 postgraduate 3 3 occupation housekeeper 45 45 farmer 4 4 unemployed 13 13 employed 12 12 freelancer 14 14 retired 12 12 primary supporting person partner 50 50 son/daughter 28 28 parents 15 15 sibling 3 3 cousin 1 1 nobody 3 3 source: own elaboration. most of them live in urban areas (78 %), some of them live with two people in their household (42 %), some have a dependent (33 %), and some stated that they face financial difficulties in commuting to the healthcare institution (42 %). the participants have been diagnosed primarily with breast cancer (43 %), as well as gynecologic (17 %), hematologic (11 %), and gastrointestinal (10 %) cancers (table 2). table 2. clinical characterization of cancer patients, n =100 variable n % type of cancer breast 43 43 gynecologic (cervix, endometrium and ovary) 17 17 hematologic (acute lymphoblastic leukemia, non-hodgkin's lymphoma, hodgkin's lymphoma, and multiple myeloma). 11 11 gastrointestinal (gastric, ampulla of vater, colon and rectum) 10 10 head and neck (nasal cavity, thyroid, pharynx, oropharynx, and parotid gland) 7 7 prostate 5 5 soft tissue (mesenchymal angiosarcoma, leiomyosarcoma, abdominal wall) 3 3 lung 2 2 skin 2 2 stage of cancer i 8 8 ii 25 25 iii 38 38 iv 18 18 na 11 11 type of treatment chemotherapy 58 58 radiotherapy 33 33 chemotherapy and radiotherapy 9 9 source: own elaboration. participants demonstrated to have the following capabilities: high coping and adaptive capabilities (53 %), medium (40 %), and low (7 %) capabilities. participants felt comfortable handling the situation in the best possible way (84 %) and seek all means available to cope with the situation (75 %); likewise, they accepted the situation as it presented itself (72 %), had expectations of how it would be resolved (67 %), were attentive to any related issue (65 %), took the necessary time before acting (65 %), clarified any doubts (64 %), never gave up easily (68 %), felt they could handle the situation (55 %), adopted new skills to resolve it (50 %), never felt guilty, never overreacted, and never became stuck and confused (49 %). while they focused their feelings and emotions in a helpful way (44 %), they had difficulties in completing activities, tasks, and projects (37 %), never thought about the problem (33 %), and made drastic changes in their lives (28 %). regarding the associations between coping capabilities with the different variables, two were found to be statistically significant. the first identified that participants who had a partner presented high coping and adaptive capabilities (55 %), which is evidenced by a p=0.020 (table 3). table 3. the association of the coping and adaptation level according to the primary support person, n=100 variable low coping medium coping high coping p n % n % n % parents 0 0 9 23 6 11 0,020 sibling 1 14 1 3 1 2 partner 3 43 18 45 29 55 son/daughter 2 29 10 25 16 30 cousin 1 14 0 0 0 0 nobody 0 0 2 5 1 2 source: own elaboration. the second association demonstrated that patients with high coping capabilities were undergoing chemotherapy (68 %), and those with low coping capabilities were undergoing radiotherapy treatment (71 %) (p=0.005) (table 4). table 4. the association between the coping and adaptation levels according to the type of treatment, n=100 variable low coping medium coping high coping p n % n % n % chemotherapy 2 29 20 50 36 68 0,005 radiotherapy 5 71 12 30 16 30 chemotherapy and radiotherapy 0 0 8 20 1 2 source: own elaboration. discussion breast cancer was the most prevalent (11), followed by cervical and endometrial cancer, which accounted for the greater participation of the female gender in this study; regarding the male gender, the types of cancer with the greatest presentation were prostate and head and neck cancers. in both sexes, stages ii and iii were prevalent, while the effects of treatment were significantly more common in adults who received radiotherapy (12). women with breast cancer applied active coping strategies, which is expressed through positive reframing, acceptance, and the use of emotional support (13), strategies that are similar to others also used, such as expecting a solution, accepting reality, and the presence of support, without these strategies being influenced by the type of cancer. in addition, high expectancy and difficulty in completing activities were presented; this phenomenon has been described in a study in which, even in treatment, they esteem themselves and feel useful in society which demonstrates, with positive coping, high levels of hope (14). with a positive approach and orientation, it has also been demonstrated that such patients accept the diagnosis and adopt an optimistic posture (15). however, they may sometimes feel weak in 1 performing daily life activities, become disinterested, fearful, and performing daily life activities, become disinterested, fearful, and worried that they will get worse (16). one of the coping strategies most commonly employed by oncology patients is emotional orientation, while the least used is avoidance (17). these are feelings that resemble feeling good when dealing with the situation as best as possible, never giving up easily, taking charge quickly, and accepting the disease without avoiding it. other coping strategies that have been applied are the following ones: religiosity, positive re-assessment, problem-solving, and seeking professional support, which are similar to accepting the event, clarifying doubts, and seeking all possible means for its solution. therefore, some report that the more these types of strategies are used, the lower the levels of anxiety and depression experienced by oncologic patients (18). additionally, they deploy strategies such as accepting their diagnosis, participating in different activities, seeking information, and expressing their emotions (19), which are related to those handled by the participants in this study in the search for all possible means to cope with the situation, viewing difficult situations as an opportunity or a challenge, proposing different solutions to resolve it and trying to clarify any doubts before acting, all of which contribute to improving the level of coping. it is worth noting that no statistically significant difference was found between men and women in the use of coping strategies (20). those who retain high coping and adaptive capabilities are mostly adults aged over 65 who use strategies such as a favorable and positive approach to decision-making (21), which does not correspond to this study's results, since no association with age was found. it has been demonstrated that a relationship exists between strong family support and effective coping strategies (22); in effect, patients' families promote an adequate adaptation and their partners are identified as the most significant source of support in order to be able to talk openly on the topic. even the support received is considered by some authors as the most important variable to value (23); thus, a stable partner is associated with support and daily care activities that influence especially the elderly (24). this is reflected in cases where the primary support person belongs to a consanguineous line and where those with high coping capabilities rely on their intimate partners for support. it is relevant to mention the importance of assertive communi­cation between the nursing staff and the companions, regarding which patients recognize their effectiveness —whether in the waiting room or virtually—, which allows them to be involved in the entire disease process in order to be able to identify discomfort and intervene promptly. meanwhile, other studies have found several restrictions in daily activities generated by cancer treatments (25, 26), which were especially evident in participants undergoing radiotherapy, who developed a low coping capability; one of the reasons for this lies in the lack of information provided by healthcare personnel regarding the treatment, the most important care needed by patients, or the changes that occur at the physical level (27). the length of time from diagnosis was not associated with coping capabilities, but those who used strategies such as expressing positive emotions, reframing the experience positively, and cultivating a sense of peace and meaning in their lives reported greater stability during their diagnosis (28). furthermore, acinas (29) observed that by delaying coping and not taking charge, the probability of feeling guilty and increasing distress increases; in this regard, the results of this research indicate that most participants have never felt guilty and have always taken charge of the problem quickly. likewise, it has been reported that one of the most commonly used strategies is to implement radical changes six months after diagnosis (30), similar to what was found in our study in which some cancer patients made drastic changes in order to overcome the situation. similarly, it was evident that in the initial phase of treatment patients apply coping strategies focused on the event and the pursuit of religious practices or unrealistic thoughts (31), which did not demonstrate any dependence between the duration of treatment and the strategies used. the responsibility of being in charge did not demonstrate any relationship with coping capabilities; however, if the patient is a direct caregiver, some degree of anxiety, stress, or extra burden may be generated, which limits the effective fulfillment of tasks related to the patient's occupation and treatment, and also affects the patient's level of adaptation (32). despite not evidencing concordance between occupation and coping in this study, a small group of housekeepers with breast cancer in indonesia were found to be more likely to apply problem-focused coping strategies by positively re-assessing themselves and seeking social support, thus lessening the burden of their illness; on the other hand, those who demonstrated low levels of coping were those who used emotional strategies, that is, they distanced themselves and avoided their situation (33). in addition to the physical and emotional impacts, patients with cancer must face challenges and threats related to the loss of financial security and the lifestyle changes they must make; although no relationship was found between their income and their level of coping capabilities, interventions should be implemented to support their financial management during their illness (34). the presence or absence of physical and/or economic difficulties was not relevant regarding coping levels; however, any barrier — whether of physical, social, psychological or spiritual origin— has the potential to generate suffering when it is perceived as a threat and will not allow patients to cope and adapt (35). other variables that were not associated with the results of the coping levels in this study were the place of origin and residence, factors that have been considered as barriers in the literature, given that not only were the sociodemographic aspects, distance, or lack of regional services the factors identified as obstacles, but also cultural factors, communication, coordination and the limitation of means for diagnosis, all of which were considered disadvantages for oncologic patients (36). performing a timely nursing diagnosis in the care process allows for the implementation of interventions aimed at eliminating, increasing, decreasing, or altering the stimuli that threaten the objective of adaptation, where the most important aspect is for patients to never lose their resilience and to become stronger along with their support network. finally, cancer involves a process that is characterized by a series of stages that, as the disease and treatment progress, changes will be carried out in order to assist patients in adapting to the new situation. healthcare personnel, and especially the nursing team that interacts with patients in a close and prolonged manner, must act responsibly and competently in a process that is becoming increasingly complex, due to new treatments, medications, and side effects; in fact, not having such assertiveness would trigger discomfort, frustration, or feelings of incompetence in healthcare providers and in their patients (37). conclusions permanent support is essential for patients with cancer, who demonstrate improvements by having partners and by allowing them to be accompanied during treatment sessions, which strengthens their adaptation to their new process. although the participants in this study presented high levels of adaptation, it is essential for healthcare providers especially nursing personnel to be aware of the processes that each patient goes through in order to cope with and adapt to a new situation such as the emergence of cancer; therefore, when talking to patients, it is necessary to inquire about stressful events in order to guide them towards stress reduction by promoting the active search for solutions, satisfaction with their actions and acceptance of the current situation, which allows patients to develop coping and adaptation capabilities regarding the process they are undergoing. therefore, care is transcendent, leaving aside the intervention focused on pathology to focus on providing holistic, constant, humane, and professional care. in light of the above, the nursing field, being aware of the impact that the diagnosis of cancer has on individuals, which is viewed by them as a life-threatening event, should lead a multidisciplinary management support network, in which the providers identify the adaptation needs according to the effects that occur at the physiological level, self-concept, interdependence, and the performance of their role. by performing a behavioral analysis and the internal and external stimuli that influence patients' health, a timely, continuous, and comprehensive management can be achieved, which subsequently allows sharing the benefits of the process with other patients. acknowledgments to the universidad surcolombiana for its initiative and support in the research; 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(fuente: decs, bireme). application of callista roy’s adaptation model in latin america: a review of the literature abstract literature published during the period from 1996 to 2009 was reviewed to identify progress towards applying callista roy’s adaptation model in latin america. of the 163 documents found, 45 were selected and classified by the authors into seven categories, according to the purpose of the studies. the findings indicate the model has been applied primarily in brazil, mexico and colombia. most of the reported studies are descriptive; they feature intentional samples and were conducted with chronically ill persons and their caregivers. the results año 9 vol. 9 nº 1 chía, colombia abril 2009 62 72 maría elisa moreno-fergusson1 alejandra maría alvarado-garcía2 63 aplicación del modelo de adaptación de callista roy en latinoamérica: revisión de la literatura maría elisa moreno-fergusson, alejandra maría alvarado-garcía show a change in a particular mode of adaptation affects all the others, and that some stimuli influence the individual’s adaptation process. this analysis demonstrates the need to reinforce the development of qualitative and quantitative studies intended to expand what is known about the phenomenon of adaptation; it also underscores the importance of consolidating networks of researchers in latin america to strengthen progress towards developing the roy model and to measure its application in practice. key words nursing theory, adaptation, nursing, review of literature. (source: mesh, bireme). aplicação do modelo de adaptação de callista roy em latino-américa: revisão da literatura resumo foi revisada a literatura escrita entre 1996 e 2009, para conhecer o progresso na aplicação do modelo de adaptação callista roy em latino-américa. de 163 documentos achados, foram selecionados 45, que os autores classificaram em sete categorias de acordo com o objetivo do estudo. os achados indicam que o modelo tem sido aplicado no brasil, em méxico e na colômbia. os estudos reportados, em sua maioria, são descritivos com amostras intencionais, e têm sido realizados com pessoas que sofrem doença crônica e os seus cuidadores. os achados indicam que a modificação de um modelo adaptativa afeta os demais modos e que alguns estímulos influenciam no processo de adaptação dos indivíduos. a análise mostra a necessidade de incrementar o desenvolvimento de estudos qualitativos e quantitativos para aprofundar no conhecimento do fenômeno da adaptação e a importância de consolidar os progressos no desenvolvimento do modelo e mensurar a sua aplicação prática. palavras-chave teoria de enfermagem, adaptação, enfermagem, literatura da revisão. (fonte: decs, bireme). 64 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 introducción uno de los retos que tiene la enfermería es la producción y consolidación de conocimiento propio que permita fortalecer la autonomía de las enfermeras, mejorar la calidad del cuidado que se presta a las personas y grupos de la comunidad y promover su reconocimiento como disciplina profesional. este conocimiento se ve reflejado en los modelos conceptuales y teorías, producto de la observación en la práctica, de la investigación y de la indagación filosófica de sus autoras. los modelos conceptuales son esquemas mentales que muestran una visión particular de la práctica, sustentada en principios científicos y filosóficos y en unos valores (1). por su complejidad, requieren ser analizados para comprender su significado y alcance y de esta manera facilitar su aplicación en el cuidado del paciente. uno de los que ha tenido mayor aceptación es el modelo de adaptación de callista roy. presentado por primera vez en 1970, desde ésa época ha mostrado un proceso permanente de expansión acorde con el desarrollo de la disciplina de enfermería (2). el desarrollo que ha tenido este modelo ha motivado su aplicación por las enfermeras en diferentes países alrededor del mundo, entre ellos, algunos latinoamericanos, y sus resultados son evidentes a través de los productos de investigación publicados en revistas de enfermería. la boston based adaptation research in nursing society (bbarns) (3) realizó un análisis de los primeros 25 años de desarrollo de la investigación basada en el modelo de roy, en el período comprendido entre 1970 y 1994. de los 434 títulos encontrados, el grupo analizó 163 estudios, que se clasificaron teniendo en cuenta los modos y procesos de adaptación, estudios relacionados con los estímulos, estudios de intervención y desarrollo de instrumentos. los resultados de este análisis permiten confirmar algunas proposiciones que plantean directrices para la aplicación del modelo en la práctica de enfermería, relacionadas con la valoración de comportamientos y de estímulos, la rotulación de diagnósticos de enfermería y el establecimiento de metas e intervenciones de enfermería. en el análisis mencionado no se incluyeron las publicaciones realizadas en habla hispana; sin embargo, al realizar una búsqueda en las bases de datos y en las publicaciones de enfermería de la región, se pudo establecer que el modelo de adaptación de roy es uno de los más utilizados en brasil, méxico, colombia, chile y perú. en esta indagación preliminar no se encontró una recopilación y análisis de los resultados de la aplicación del modelo en américa latina, lo cual adquiere importancia cuando se desean conocer los avances en su estudio y aplicación, para fundamentar la práctica profesional, señalar vacíos del conocimiento, generar preguntas de investigación e identificar las personas interesadas en el conocimiento del modelo para fortalecer las redes de investigadores (4). el propósito de este artículo es analizar los avances en el desarrollo del conocimiento sobre la aplicación del modelo de adaptación de callista roy en la práctica de enfermería en américa latina, evidenciado en la publicación de libros, artículos y trabajos de posgrado editados por revistas científicas de enfermería y visibles en bases de datos. los modelos conceptuales son esquemas mentales que muestran una visión particular de la práctica, sustentada en principios científicos y filosóficos y en unos valores. 65 aplicación del modelo de adaptación de callista roy en latinoamérica: revisión de la literatura maría elisa moreno-fergusson, alejandra maría alvarado-garcía los resultados de esta revisión permiten conocer las fortalezas y debilidades en la aplicación del modelo en la práctica disciplinar, en la investigación y en la docencia en esta región y, así mismo, identificar oportunidades para replicar ó refinar estudios realizados en éstos países. método los criterios de inclusión que se tuvieron en cuenta en el proceso de recolección de la información para esta revisión de la literatura fueron: 1. artículos originales publicados en las siguientes revistas de enfermería: actualizaciones en enfermería; aquichan, avances en enfermería, investigación y educación en enfermería, enfermería hoy, ciencia y enfermería, cultura de los cuidados, cogitare enfermagem, revista latinoamericana de enfermagem, y en las bases de datos cuiden, lilacs y scielo; 2. publicaciones en español y portugués realizadas por autores o coautores de lengua hispana entre 1996 y 2009; y 3. que las fuentes mencionaran explícitamente el modelo de adaptación de callista roy. las palabras clave que se utilizaron para hacer la búsqueda fueron: enfermería, adaptación, modelo conceptual y callista roy. de los 163 artículos y tesis de grado encontrados se seleccionaron 45 que reúnen los criterios de inclusión establecidos, los cuales se clasificaron en artículos de investigación, de revisión, de reflexión, artículos cortos y revisión de temas en las fuentes mencionadas. en esta clasificación se incluyó, además, la categoría denominada “casos clínicos de enfermería”, en la cual los autores describen cada una las etapas del proceso de enfermería según el modelo de adaptación de roy en el análisis de una situación particular de un paciente. esta se diferencia de los estudios de caso, en que los autores no presentan una descripción profunda de las dimensiones esenciales y procesos del fenómeno estudiado. resultados con el propósito de facilitar el análisis de la información, los artículos seleccionados se agruparon en seis categorías según el propósito de los mismos: diseño y validación de instrumentos; análisis de los conceptos centrales del modelo; análisis del proceso de adaptación; análisis de los estímulos que influyen en el proceso de afrontamiento y adaptación; aplicación del proceso de enfermería; aplicación del modelo en la práctica. enseguida se describen los hallazgos relevantes. diseño y validación de instrumentos el diseño y la validación de instrumentos para valorar a las personas y para la medición de algunos conceptos del modelo tienen relevancia cuando se trata de aplicar un modelo de enfermería en un contexto cultural determinado o de contribuir al desarrollo del mismo a través de procesos de investigación. en la revisión se encontraron cuatro artículos relacionados con el diseño y validación de instrumentos que permiten valorar los cuatro modos de adaptación en niños hospitalizados en unidades de cuidado intensivo pediátrico (5), determinar los niveles de adaptación del modo de interdependencia y del incumplimiento del tratamiento en personas con hipertensión arterial (6), valorar el autoconcepto de personas con enfermedades crónicas, degenerativas o terminales (7) y estableel análisis de los conceptos del modelo por parte de los enfermeros latinoamericanos ha tenido como propósito determinar la esencia del mismo y unificar el enfoque desde una perspectiva cultural para facilitar su aplicación. 66 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 cer la validez y confiabilidad de la versión en español de la escala de medición del proceso de afrontamiento y adaptación (caps) de callista roy (8). cabe resaltar la utilidad que tiene el desarrollo y validación de instrumentos, que se evidencia en la aplicación de la versión en español del caps, para medir la capacidad de afrontamiento y adaptación, en un estudio que se realizó con el propósito de evaluar la eficacia de dos intervenciones de enfermería dirigidas a pacientes con cardiopatía isquémica (9). la necesidad de medir los resultados, llevó a la autora a realizar un análisis más profundo del instrumento y a organizarlo teniendo en cuenta el modelo de enfermería para el procesamiento cognitivo propuesto por roy (2) y a categorizar los puntajes obtenidos en alta y baja capacidad de afrontamiento y adaptación (10). posteriormente, la escala re organizada se utilizó en un estudio con personas mayores de 50 años en el cual, las autoras fundamentadas en el análisis estadístico de la misma, identifican 4 categorías muy alta, alta, mediana y baja capacidad, lo cual permite obtener una medición más precisa de los resultados y favorece la toma de decisiones para la planeación del cuidado de enfermería fundamentado en el modelo de roy (11). análisis de los conceptos centrales del modelo el análisis de los conceptos del modelo por parte de los enfermeros latinoamericanos ha tenido como propósito determinar la esencia del mismo y unificar el enfoque desde una perspectiva cultural para facilitar su aplicación (12). algunos de los conceptos del modelo que han sido analizados son: el concepto de grupo y de cada uno de sus componentes (13), el de persona (14), la evolución del concepto de ambiente (15); el análisis del subsistema cognitivo en la etapa preescolar (16) y el análisis del modo fisiológico (17-18). este último permitió identificar los aspectos a valorar, los indicadores de adaptación positiva y los estímulos asociados con cada uno de los componentes de este modo. los análisis mencionados han facilitado la comprensión de los conceptos, esencial para unificar criterios y facilitar la aplicación del modelo en la práctica profesional. análisis del proceso de adaptación los resultados muestran el interés de las enfermeras latinoamericanas por comprender el proceso de adaptación de los individuos y familiares que se encuentran en condición de enfermedad crónica. esto es evidente en un estudio realizado con pacientes con anemia falciforme en que se concluyó que esta situación no solo altera el modo fisiológico, sino el de autoconcepto, en la medida en que afecta la autoestima y ocasiona cambios en el rol (19). así mismo, en un estudio cualitativo realizado para conocer la percepción que tenía un grupo de adolescentes sometidos a trasplante renal, se evidenciaron respuestas inefectivas en el modo fisiológico, como la limitación física, y en el modo de autoconcepto, con sentimientos de vergüenza, miedo al rechazo e impotencia (20). los resultados de este estudio muestran que la percepción que tienen las personas de su situación influye en el proceso de adaptación. un estudio, cuyo objetivo fue desmitificar las repercusiones de la mastectomía en el autoconcepto de un grupo de mujeres, describe cómo las respuestas del prose encontraron estudios relacionados con el proceso de adaptación de los familiares ante la enfermedad crónica, entre los cuales vale la pena mencionar uno realizado con madres de niños con síndrome de down, uno con familiares de mujeres con cáncer de seno y otro sobre el proceso de adaptación del cuidador familiar ante la agonía de uno de sus padres. 67 aplicación del modelo de adaptación de callista roy en latinoamérica: revisión de la literatura maría elisa moreno-fergusson, alejandra maría alvarado-garcía ceso de duelo se debían al diagnóstico de cáncer, a la desfiguración, a la incertidumbre por el pronóstico, a la preocupación por la familia y a las condiciones de vida (21), aspectos que constituyen estímulos contextuales y afectan el proceso de adaptación. el estudio de correlación realizado por garcía et ál., con el propósito de analizar el nivel de adaptación del paciente oncológico en quimioterapia ambulatoria, mostró que los pacientes ambulatorios tuvieron menos afectación en el modo fisiológico y la representación de rol, pero presentaron una adaptación menor en el autoconcepto (22). por último, los resultados del estudio descriptivo exploratorio realizado por tafolla et ál., en pacientes con diabetes mellitus, permiten concluir que la alteración del modo fisiológico afecta el modo de autoconcepto, y no muestran asociación entre el tiempo de evolución y las complicaciones con este modo de adaptación (23). también se encontraron estudios relacionados con el proceso de adaptación de los familiares ante la enfermedad crónica, entre los cuales vale la pena mencionar uno realizado con madres de niños con síndrome de down (24), uno con familiares de mujeres con cáncer de seno (25) y otro sobre el proceso de adaptación del cuidador familiar ante la agonía de uno de sus padres (26). los resultados muestran alteración en los modos adaptativos psicosociales de los cuidadores. es importante anotar que los familiares de las mujeres con cáncer de seno expresaron una mejoría en las relación familiar, en la medida en que aumentó en ellos la confianza, la cercanía y el afecto, lo cual fue un estímulo contextual positivo que favoreció la adaptación de la paciente y la familia. los resultados de los estudios mencionados muestran la interrelación que existe entre los cuatro modos de adaptación, por lo cual la alteración en uno de ellos, como el modo fisiológico, afecta el proceso de adaptación en los modos de autoconcepto, de función del rol y de interdependencia, en las personas con enfermedad crónica y en sus familiares. esto a su vez se relaciona con la articulación que existe entre los procesos de afrontamiento regulador y cognitivo. análisis de los estímulos que influyen en el proceso de afrontamiento y adaptación los resultados de la revisión permiten identificar algunos estímulos que intervienen en el proceso de adaptación de las personas con enfermedades crónicas y de sus familias. es así como el apoyo social ha sido identificado como un estímulo contextual positivo para la recuperación de mujeres con cáncer de seno (27). de los resultados del estudio se puede deducir que el lugar de residencia es también un estímulo contextual que afecta el proceso de adaptación, en la medida en que las mujeres del área urbana les dan mayor trascendencia a los cambios en su cuerpo que las mujeres del área rural. así mismo, el apoyo a la familia y su preparación para afrontar situaciones difíciles como el cáncer de seno en uno de sus integrantes se constituye en una intervención que contribuye positivamente al proceso de adaptación, por ello se recomienda continuar desarrollando estudios longitudinales encaminados a determinar las repercusiones que tienen estas en el estado de salud de las personas (28). lugar de residencia es también un estímulo contextual que afecta el proceso de adaptación, en la medida en que las mujeres del área urbana les dan mayor trascendencia a los cambios en su cuerpo que las mujeres del área rural. 68 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 tener conocimiento de la enfermedad, de sus manifestaciones y de las razones del tratamiento prescrito es también un estímulo que promueve la adaptación, en la medida en que ayuda a las personas a comprender los cambios que deben realizar en su estilo de vida para afrontar la situación y adaptarse a ella (29-30). otros estímulos positivos identificados son el bienestar espiritual y la fortaleza relacionada con la salud, que se correlacionan entre sí y tienen un efecto positivo en el nivel de adaptación en personas mayores de 65 años (31). esta conclusión ha sido evidente en otros estudios con grupos etáreos diferentes (32-33), en los cuales se encontró una relación inversa entre los niveles de ansiedad y la espiritualidad y la fortaleza ligada con la salud en pacientes adultos y ancianos en situación de enfermedad crónica. a diferencia de los estímulos positivos mencionados, se identificaron estímulos contextuales negativos, como el estrés percibido en pacientes con diabetes mellitus tipo 2 (34), que compromete las habilidades para la solución de problemas, el juicio, la emoción, la búsqueda de resultados, la creatividad y el manejo de situaciones, lo cual afecta los modos de autoconcepto, función del rol e interdependencia en las personas. por otra parte, la edad y la hospitalización se constituyen en un estímulo contextual en los niños, es así como un estudio realizado en méxico con niños hospitalizados de 7-11 años de edad evidenció una correlación negativa entre la edad y el nivel de ansiedad, por lo cual los autores concluyen que los niños mayores cuentan con mejores recursos para afrontar las situaciones que producen ansiedad durante la hospitalización (35). los resultados de los estudios mencionados muestran la influencia de los estímulos en los procesos de afrontamiento regulador y cognitivo, cuyas respuestas se reflejan en los cuatro modos adaptativos, y según las características de la situación, estos estímulos constituyen estímulos focales, contextuales o residuales. aplicación del proceso de enfermería en esta revisión, se encontraron casos clínicos relacionados con el cuidado de pacientes con artritis reumatoidea (36), infarto agudo del miocardio (37) y ostomizados (38), cuyo propósito fue describir y explicar la aplicación del proceso de enfermería basado en el modelo. también se hallaron estudios que han analizado la utilidad de la taxonomía de diagnósticos de enfermería de la nanda y su relación con los modos adaptativos (39). así mismo se ha utilizado en la valoración y análisis de situaciones específicas y estudios de caso con pacientes hipertensos (40), con mujeres mastectomizadas (41), en pacientes con ventilación mecánica domiciliaria (42) y para rotular los problemas de adaptación fisiológica en pacientes con angina de pecho (43). aplicación del modelo en la práctica clínica un aspecto que se ha identificado como esencial para el desarrollo de enfermería ha sido el de fundamentar la práctica en el conocimiento disciplinar, como una estrategia para fortalecer la autonomía y mejorar la visibilidad del cuidado de enfermería. en la revisión se registraron algunas reflexiones teóricas sobre la aplicación del modelo de adaptación en condiciones específicas, como el cuidado de adolescentes con problemas de salud (44), el cuidado de los familiares de niños en la revisión se registraron algunas reflexiones teóricas sobre la aplicación del modelo de adaptación en condiciones específicas, como el cuidado de adolescentes con problemas de salud, el cuidado de los familiares de niños con cardiopatías congénitas y tres experiencias institucionales relacionadas con la aplicación del modelo en hospitales colombianos. 69 aplicación del modelo de adaptación de callista roy en latinoamérica: revisión de la literatura maría elisa moreno-fergusson, alejandra maría alvarado-garcía con cardiopatías congénitas (45) y tres experiencias institucionales relacionadas con la aplicación del modelo en hospitales colombianos, como el servicio de rehabilitación de la clínica universitaria teletón (46), la unidad de cuidado intensivo pediátrico de la fundación cardio infantil instituto de cardiología (47) y en la facultad de enfermería de la universidad de la sabana (48). en estos tres artículos se destacan las etapas que se siguieron para lograr su implementación y los logros en reconocimiento social y académico, autonomía y calidad del cuidado en cada una de las instituciones donde se aplica el modelo como marco de referencia teórico. conclusiones en la literatura reciente de enfermería, se evidencia un incremento en las publicaciones relacionadas con el estudio y la aplicación del modelo de adaptación de roy, especialmente en brasil, méxico y colombia, cuyos autores en la mayoría de los casos son egresados de estudios de post grado y docentes. estas publicaciones dan cuenta de los resultados de estudios de investigación en los cuales se aprecia el interés de los profesionales de enfermería por indagar sobre el proceso de adaptación fisiológica y psicosocial en condiciones de enfermedad crónica, por el desarrollo y validación de instrumentos, por evaluar la aplicación del proceso de enfermería a través de casos clínicos y verificar la relación entre los diagnósticos de enfermería de la nanda y los problemas de adaptación. con base en los resultados del análisis, se puede establecer que los problemas de afrontamiento y adaptación se pueden relacionar con ésta taxonomía de enfermería, y por lo tanto su aplicación favorece la operacionalización del proceso de enfermería. el análisis de los conceptos del modelo ha sido interesante, porque favorece la comprensión de sus elementos estructurales y facilita su aplicación en la práctica. los resultados de estos estudios latinoamericanos permiten identificar algunos estímulos que influyen en el proceso de adaptación. los estímulos negativos identificados en las personas adultas y ancianas con enfermedad crónica son la alteración del estado de salud, los cambios en el cuerpo, el estrés percibido, y en los niños, la edad y la hospitalización. los estímulos positivos que favorecen el proceso de adaptación son: el apoyo familiar y social, la fortaleza relacionada con la salud, el apoyo en las creencias religiosas y el bienestar espiritual. también es un estímulo positivo el conocimiento de la enfermedad, de sus manifestaciones y de las razones del tratamiento prescrito, puesto que ayuda a las personas a comprender los cambios que deben realizar en su estilo de vida, para afrontar la situación y adaptarse a ella. así mismo, el apoyo a la familia y su preparación para afrontar situaciones difíciles como el cáncer de seno en uno de sus integrantes se constituye en una intervención que contribuye al proceso de adaptación, por ello se recomienda continuar desarrollando estudios longitudinales encaminados a determinar las repercusiones que tienen estas sobre el estado de salud de las personas. los resultados de esta revisión de la literatura muestran algunas prioridades de investigación para la aplicación del modelo de roy en latinoamérica, como son el estudio del proceso de afrontamiento y adaptación en grupos como familias o comunidades, el cual es incipiente, a pesar de la importancia que tiene este aspecto en el contexto latinoamericano. algunas de las estrategias que se deben desarrollar son la ejecución de proyectos de investigación multicéntricos y la creación de centros de investigación, a los cuales se vinculen profesionales de enfermería del área asistencial y docente. 70 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 la investigación en latinoamérica se ha realizado básicamente con diseños descriptivos cuantitativos. las muestras utilizadas son en su mayoría intencionales, no probabilísticas, y con poblaciones pequeñas, lo cual reduce el poder estadístico de los resultados. por lo cual, dada la complejidad del proceso de afrontamiento y adaptación en el cual influyen múltiples factores, es necesario: 1. realizar estudios cualitativos que permitan describir este proceso (49) desde la perspectiva de las personas y los grupos. 2. fortalecer el desarrollo de la investigación clínica, con estudios sobre el modelo de tipo longitudinal, cuasi experimental y experimental que permitan: validar o desarrollar instrumentos de medición más precisos y culturalmente congruentes, así como determinar el nivel de adaptación de las personas y grupos. ampliar el conocimiento sobre la relación entre los estímulos focales y contextuales y el nivel de adaptación. evaluar el efecto de las intervenciones de enfermería en el proceso de adaptación en condiciones de enfermedad aguda y crónica. medir la contribución del modelo en la práctica de enfermería en latino américa. algunas de las estrategias que se deben desarrollar son la ejecución de proyectos de investigación multicéntricos (50) y la creación de centros de investigación, a los cuales se vinculen profesionales de enfermería del área asistencial y docente que busquen, a través del desarrollo de proyectos solucionar los problemas de la práctica. los resultados de las experiencias relacionadas con la aplicación del modelo en la docencia y la asistencia así como los productos de investigación son una contribución necesaria para el desarrollo y la expansión del modelo de adaptación de roy y del conocimiento disciplinar de enfermería. por ello es necesario continuar fortaleciendo su desarrollo en el contexto 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5(5): 44-55. 49. ailinger, r. l., contributions of qualitative research to evidence-based practice in nursing. rev. latino-am. enfermagem [online]. 2003, v. 11, n. 3, pp. 275-279. issn 0104-1169. 50. castrillon a., m. trends and priorities in nursing research. rev. latino-am. enfermagem [online]. 2004, vol.12, n.4, pp. 583-588. issn 0104-1169. doi: 10.1590/s0104-11692004000400002 1 valoración.p65 aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007120 1 fundación cardio infantil, instituto de cardiología, calle 163a no 28 60, bogotá, colombia aidav87@hotmail.com 2 fundación hospital de la misericordia, av. caracas no 1-13, bogotá, colombia monica27@terramail.com 3 fundación cardio infantil, instituto de cardiología, calle 163a no 28 60, bogotá, colombia marybepa@gmail.com 4 fundación cardio infantil, instituto de cardiología, calle 163a no 28 60, bogotá, colombia normacleloso@hotmail.com 5 fundación cardio infantil, instituto de cardiología, calle 163a no 28 60, bogotá, colombia cristinapabon@gmail.com año 7 vol. 7 nº 2 • chía, colombia octubre 2007 • 120-129 aída liliana villamil gonzález1 mónica marcela ríos gutiérrez 2 mary stella bello pacheco 3 norma clemencia lópez soto 4 isabel cristina pabón sánchez 5 recibido: 9 de marzo de 2007 aceptado: 26 de mayo de 2007 resumen el propósito del estudio fue aplicar la escala de valoración de la intensidad de dolor de susan givens bell en la uci neonatal. se valoró la intensidad del dolor de 47 neonatos de la unidad neonatal de la fundación cardio infantil, sometidos a punciones arteriovenosas y de talón utilizando la escala antes y después de los procedimientos. la información se procesó por medio del paquete estadístico spss, y se utilizaron las pruebas estadísticas anova 1 factor y la u mann whithey para variables no paramétricas, que generó una significancia estadística de p<0,05. encontrándose una relación entre los signos fisiológicos y conductuales sobre el total de la escala. se concluyó que la escala de susan givens es adecuada para la valoración del dolor en neonatos, ya que se obtienen probabilidades significativas del 95,7%. palabras clave dolor, dimensión del dolor, recién nacido. (fuente: decs, bireme). valoración del dolor neonatal: una experiencia clínica valoración del dolor neonatal: una experiencia clínica valoración del dolor neonatal: una experiencia clínica 121 neonatal pain assessments a clinical experience abstract the purpose of this study was to apply the valuation scale in susan givens bell�s pain intensity at the neonatal uci. the intensity of the pain was values in 47 neonates, who were submit to artery vein and heel punctures, using the scale before and after the procedure. the information was process by the spss statistical packet and the statistical tests anova 1 factor and the u mann whitney for the no parametric variables this get a significant statistical of p<0.05. finding an existent relation between the physiological signs and conductions about the total of the scale. the conclusion was that the susan givens� scale is adequate for the pain value in neonates, because it gets significant probabilities: 95.7%. key words pain, pain measurement, newborn. valoração da dor neo-natal: uma experiência clínica resumo neste estudo foi aplicada a escala de valoração da intensidade da dor de susan givens bell na uci neonatal. foi avaliada a intensidade da dor de 47 neonatos da unidade neonatal da fundación cardio infantil, sujeitos a punções arteriovenosas e do talão usando a escala antes e depois de dos procedimentos. a informação foi processada com o paquete estatístico spss. foram usadas as provas estatísticas anova 1 e u mann whitney para variáveis não paramétricas, gerando uma significância estatística de p < 0,05. foi encontrada uma relação entre signos fisiológicos e de conduta sobre o total da escala. em breve, a escala de susan givens é apropriada para avaliar a dor nos neonatos, no sentido que são obtidas probabilidades significativas do 95,7%. palavras-chaves dor, medição da dor, recém-nascido. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007122 introducción l principal problema que se plantea en el tratamiento del dolor neonatal es el de su valoración. los neonatos, y sobre todo los prematuros hospitalizados en la unidad de cuidados intensivos neonatales, son sometidos a numerosos procedimientos diagnósticos y terapéuticos la mayoría de los cuales son dolorosos. la frecuencia de estos procedimientos es variable según las unidades de cuidados intensivos como lo evidencian algunos estudios como los realizados por annad y cols. en el canadian neonatal intensive care unit en 1997, donde muestra la incidencia de tres procedimientos invasivos por hora y 9 por semana que generan dolor y molestia en el paciente (1). en 1998, granau y cols. publicaron un estudio en el research and clinical forum, donde se tomó una muestra de 144 neonatos a los cuales se les cuantificaron 7000 procedimientos, 6000 de los cuales eran punciones de talón (2). en la práctica diaria, en las unidades neonatales se realizan procedimientos rutinarios, como son las punciones arteriovenosas y de talón que se consideran dolorosos para los recién nacidos. debido a la incapacidad de éstos para verbalizar conceptos, se depende de la interpretación de sus conductas por parte de los profesionales de la salud encargados de su cuidado. esta situación ha condicionado la lenta incorporación de técnicas de prevención y manejo del dolor en las uci neonatales, o simplemente la ausencia y falta de entrenamiento del personal para su identificación y posterior tratamiento. lo dicho anteriormente explica la necesidad de valorar el dolor neonatal, así como lo hacemos en otras situaciones clínicas. a pesar de que se piense que un recién nacido presente este síntoma, a menudo éste no es evaluado de una manera objetiva. no medir el dolor puede impedir tratarlo de la manera más adecuada, ya que si no es medible es muy fácil ignorarlo. el dolor neonatal se puede medir valorando cambios en el comportamiento, los cuales se manifiestan en la expresión facial, actividad motora, llanto, capacidad de conciliar el sueño, consuelo difícil después del procedimiento, o en medidas fisiológicas representadas en la frecuencia cardiaca, frecuencia respiratoria, presión arterial, saturación de oxígeno, sudoración palmar, niveles en plasma de cortisol y catecolamina (3, 4). hay que tener en cuenta que no todos los síntomas son ocasionados por estímulos dolorosos sino también por molestia (5, 6), por eso es importante identificar el origen del dolor, y esto se logra mediante la aplicación de una escala de valoración de su intensidad. existen múltiples trabajos que investigan la validez y fiabilidad de escalas de medida del dolor en el recién nacido a término o prematuro, ante distintos estímulos dolorosos fundamentalmente agudos o posquirúrgicos, de los cuales nos remitimos a los más concluyentes (5-9). existe la escala de susan givens bell denominada �escala de valoración del dolor� (10, 11), mediante la cual se valora la intensidad del dolor a través de cambios en parámetros conductuales y fisiológicos, que permiten evidenciar de manera objetiva y cuantificable la aparición e intensidad del dolor al realizar procedimientos considerados dolorosos. valoración del dolor neonatal: una experiencia clínica 123 en diferentes instituciones de salud de bogotá donde se ofrece atención a neonatos no se aplica ninguna escala para valorar la intensidad del dolor en los niños de este grupo de edad. en la unidad neonatal de la fundación cardio infantil, las mediciones que se realizan para valorar el dolor en niños sometidos a procedimientos dolorosos, como son las punciones arteriovenosas y de talón, son subjetivas, no cuantificables y en ocasiones confusas, debido a que no existe una herramienta que permita medirlo, clasificarlo e identificar si su origen es por un estímulo doloroso o por molestia. esta situación dificulta la valoración del dolor, y la planeación y ejecución del cuidado de enfermería de acuerdo con la situación que vive el neonato. en este estudio se aplicó escala de valoración de dolor en neonatos y se estableció su sensibilidad para implementarla como parte de la historia clínica, convirtiéndose en una herramienta en la planeación del cuidado de enfermería dentro de la unidad de cuidados intensivos neonatal de la fundación cardio infantil. cabe resaltar que además de la aplicación de la escala de valoración de dolor de susan givens bell se tuvo un acercamiento científico con fernández ibarra, enfermero coordinador del �estudio multicéntrico sobre la valoración del dolor en niños preverbales�, donde se compartieron vivencias y fundamentos teóricos y científicos que nos ayudaron a terminar esta primera parte de nuestra investigación; además, nos incentivó a compartir nuestras experiencias con otras instituciones para crear a nivel nacional un estudio multicéntrico de la valoración del dolor en neonatos. métodos y materiales el estudio tiene un abordaje cuantitativo con un diseño de tipo prospectivo compael modelo conceptual basado en la teoría de transiciones comprende la naturaleza, las condiciones y los patrones de respuesta de la transición, los cuales guían la terapéutica de enfermería. rativo. la muestra fue seleccionada al azar y la conformaron 47 neonatos de la unidad de recién nacidos de la fundación cardio infantil hospitalizados en las unidades de básicos e intermedios, y sometidos a punciones arteriovenosas y de talón. la muestra fue tomada del 10% del total de egresos de la uci neonatal del año 2005. los recién nacidos que fueron excluidos estaban bajo ventilación mecánica o sedación. el instrumento utilizado para la recolección de información fue la escala de valoración de dolor de susan givens, utilizada en el estudio multicéntrico de valoración de dolor en niños preverbales realizada por fernando ibarra en españa, la cual fue aplicada por el grupo investigador y aprobada por el comité de investigación de la fundación cardio infantil. para tener más claridad en el análisis de datos el comité de investigación de la institución sugirió la inclusión de edad y peso a fin de tener mayor veracidad y objetividad en la recolección de los datos; esta escala se aplicó antes y después de los procedimientos mencionados (punciones arteriovenosas y de talón). la escala de susan givens cuenta con 10 variables, 6 variables conductuales (acción de dormir, expresión facial, actividad motora espontánea, tono global, consuelo y llanto), y 4 variables fisiológicas: frecuencia cardiaca, presión arterial (sistólica), frecuencia respiratoria, y cualidades y saturación de oxígeno. esta escala permite valorar de forma rápida la intensidad del dolor. las variables van de 0 a 2, donde 0 es ausencia de dolor, y 2 máxima expresión de dolor, obteniéndose en total una puntuación de 0 a 20 donde: • [< 4] (no dolor) • [5-8] (dolor moderado) • [>9] (dolor intenso) aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007124 escala de susan givens bell signos conductuales 2 1 0 1. duerme durante ninguno duerme entre 5-10 minutos duerme más de 10 minutos la hora precedente 2. expresión facial de dolor marcado constante menos marcado intermitente calmado, relajado 3. actividad motora agitación incesante o agitación moderada o normal espontánea ninguna actividad actividad disminuida 4. tono global hipertonicidad fuerte o hipertonicidad moderada o normal hipotonicidad, fláccido hipotonicidad moderada 5. consuelo ninguno después de 2 consuelo después de 1 consuelo dentro minutos minuto de esfuerzo de 1 minuto 6. llanto llanto vigoroso quejido no llora ni se queja signos fisiológicos 2 1 0 1. frecuencia cardiaca > 20% aumento 10-20% aumento dentro de la normalidad 2. presión arterial >10 mm/hg de aumento 10 mm/hg de aumento dentro de la normalidad (sistólica) 3. frecuencia respiratoria y apnea o taquipnea pausas de apnea dentro de la normalidad cualidades 4. sao 2 10% de aumento de fio 2 = al 10% de > aumento de fio 2 ningún aumento en fio 2 procedimiento la aplicación del instrumento se realizó de la siguiente manera: 1. se identificaron los neonatos a los cuales se le iban a realizar punción arteriovenosa y de talón, teniendo en cuenta criterios de inclusión: recién nacidos a término o cercanos al término, recién nacidos de intermedios y básicos, recién nacidos que vayan a ser sometidos a los siguientes procedimientos: punciones arteriovenosas y punciones de talón. 2. estos procedimientos se realizaron cuando fue necesario manipular al recién nacido, siguiendo la rutina de la unidad. 3. se evaluó que el recién nacido tuviera sus necesidades básicas satisfechas (sueño, hambre, pañal seco, termorregulación), para evitar sesgos en la aplicación de la escala. valoración del dolor neonatal: una experiencia clínica 125 4. un primer investigador aplicó la escala antes del procedimiento y registró los datos en la lista de chequeo diseñada para tal fin. 5. un segundo investigador realizó el procedimiento, mientras el primero aplicó la escala nuevamente; para evaluar el grado de dolor que presentaba el recién nacido al realizar el procedimiento. 6. nuevamente se registró en la lista de chequeo 7. se analizaron y graficaron los resultados. 8. en cada paciente la aplicación de la escala duró aproximadamente 5 minutos. el análisis de los datos se realizó incorporando los datos en una tabla de excel y se procesaron en el software estadístico spss donde la información se presenta en gráficas; además se utilizaron las pruebas estadísticas anova 1 factor y u mann whitney para variables no paramétricas considerando una significancia de p <0,05. el análisis generó frecuencias absolutas y porcentajes, así como promedios, valores mínimos y máximos, y comparaciones entre variables conductuales y fisiológicas, donde se evidenciaron los mayores cambios en las variables fisiológicas; se contó con el apoyo directo de la asesora de investigación y profesional en estadística. cabe resaltar que no se requirió consentimiento informado ya que los procedimientos realizados a los recién nacidos hacen parte de la atención médica y de enfermería diaria de la unidad (sugerencia suministrada por el comité de ética de la institución). las consideraciones éticas que se tuvieron en cuenta fueron: • la información que fue recolectada es totalmente confidencial, además de relevante para cualificar el cuidado de enfermería en la valoración del dolor neonatal. • los pacientes incluidos cumplían los siguientes criterios: ♦ que fueran a ser sometidos a los procedimientos de punción arteriovenosa y de talón. ♦ que estuvieran en las unidades de básicos e intermedios de la uci neonatal. ♦ que los riesgos que corrieran fueran mínimos. se contó con el aval de la universidad de la sabana y la fundación cardio infantil, instituto de cardiología, después de ser presentados en el comité ético y de investigación de la institución al cabo del cual se realizó la recolección de la información durante un mes (17 de enero a 17 de febrero de 2007). resultados ingresaron al estudio 47 pacientes, quienes cumplieron los criterios de selección, con promedio de edad gestacional corregida de 41,9 ± 2,7 semanas (rango: 36-47), y con un peso promedio al nacer de 2.931 ± 563 gramos (rango 1.3604.360). momento de la toma de muestra: en el 63,8% (n=30) de los casos la toma se realizó en la extracción de muestras de laboratorio, y el 36,2% (n=17) en la punción del talón. evaluación de presión arterial: en la figura 1 se observan aumentos de la presión arterial, tanto sistólica como diastólica, en donde los cambios son estadísticamente significativos (p<0,01). en la figura 2 se observan los cambios en la frecuencia cardiaca y respiratoria antes y después del procedimiento. se evidenció un aumento significativo en los valores, tanto de la frecuencia cardiaca como respiratoria. se evaluó que el recién nacido tuviera sus necesidades básicas satisfechas (sueño, hambre, pañal seco, termorregulación), para evitar sesgos en la aplicación de la escala. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007126 saturación de oxígeno: al igual que en las anteriores variables se observó una variación significativa, disminuyendo los niveles de saturación de oxígeno después de realizado el procedimiento (figura 3). en la figura 4 se muestran los puntajes obtenidos según la escala de susan givens, en donde hay una diferencia estadísticamente significativa (p<0,01) al comparar los puntajes antes y después del procedimiento en relación con los signos conductuales. en cuanto a los signos fisiológicos el puntaje está dado por las variaciones de los signos vitales antes y después de los procedimientos, los cuales tuvieron puntajes elevados que, al sumarlos, dan en promedio 17 +/3 puntos sobre un total de 20 puntos. en la figura 5 se presenta la evaluación global según la escala de susan givens, en donde el 4,3% presentó dolor moderado y en el 95,7% el dolor fue calificado como intenso. figura 2. comparación de los valores promedio de frecuencia respiratoria y cardiaca antes y durante el procedimiento figura 1. comparación de los valores promedio de presión arterial sistólica y diastólica antes y durante el procedimiento frecuencia cardfiaca p<0,01 frecuencia respiratoria p<0,01 9 5 % i c antes del procedimiento durante el procedimiento observación 180 150 120 90 60 sistólica p<0,01 diastólica p<0,01 p re s ió n a rt e ri a l (m m h g ) 9 5 % i c antes del procedimiento durante el procedimiento observación 90 80 70 60 50 40 valoración del dolor neonatal: una experiencia clínica 127 figura 3. comparación de los valores promedio de saturación de oxígeno antes y durante el procedimiento figura 4. comparación del puntaje de los signos conductuales y fisiológicos durante el tiempo de observación figura 5. comparación de los valores promedio de la intensidad de dolor obtenidos al aplicar la escala p o rc e n ta je d e n e o n a to s dolor moderado dolor intenso escala susan givens 100 80 60 40 20 0 4,3% 95,7% p<0,001 p u n ta je o b te n id o s e g ú n s ig n o s 9 5 % i c puntos signos conductuales antes del procedimiento 20 15 10 5 0 puntos signos conductuales durante el procedimiento puntos signos fisiológicos durante el procedimiento total puntaje p<0,01 9 5 % i c s a tu ra ci ó n 0 2 antes del procedimiento durante el procedimiento observación 100 90 80 70 60 aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007128 conclusiones • la aplicación de la escala de valoración de intensidad de dolor en los neonatos de la uci neonatal de la fundación cardio infantil pudo realizarse fácilmente, es práctica, objetiva, y permite la valoración rápida del dolor por parte de enfermería. • se evidenció dolor mediante las variaciones de los signos vitales teniendo éstas una significancia estadística importante. • los signos conductuales también se modificaron estadísticamente por medio de una significancia representativa. • de los 47 neonatos sometidos a la aplicación de la escala el 95,3% presentó dolor intenso durante el procedimiento, y el 4,7% presentó dolor moderado. • el dolor intenso evidenciado en el 97,3% de los neonatos demuestra la sensibilidad de la escala, para que sea incluida en el plan de cuidados de enfermería de la uci neonatal. • la implementación y utilización de la escala de valoración de dolor, además de evaluar de manera objetiva y rápida este síntoma, permitirá que enfermería tenga un papel activo dentro del grupo interdisciplinario de las unidades de cuidado intensivo al poder gestionar el cuidado que debe realizarse en los pacientes neonatales en la prevención y el manejo del dolor de este grupo de edad. • la aplicación de la escala de dolor de susan givens bell en neonatos de las uci neonatales permite justificar la aplicación de medidas terapéuticas al neonato antes de la realización de procedimientos dolorosos por parte del equipo interdisciplinario de salud. • permite justificar el trabajo de enfermería como proceso, fortaleciéndose en el conocimiento del hacer y quehacer de la profesión. • para los neonatos el alivio del dolor favorece su rápida evolución y sus posibles complicaciones. recomendaciones incentivar en los profesionales de enfermería la necesidad de valoración del dolor mostrando la importancia de ésta para la planeación y el cuidado de la disciplina en los neonatos sometidos a procedimientos dolorosos. incluir la escala en el plan de cuidado de enfermería de la uci neonatal de la fundación cardio infantil. continuar la ejecución de este trabajo con la elaboración de guías de manejo de enfermería para el alivio del dolor con la utilización de medidas no farmacológicas y el manejo claro de las medidas farmacológicas cuando las primeras no generen disminución en la intensidad del dolor. realizar un estudio multicéntrico a nivel local y nacional en la aplicación de la escala de dolor de susan givens bell en neonatos de las uci neonatales. la implementación y utilización de la escala de valoración de dolor, además de evaluar de manera objetiva y 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http://st.petersburgbeach.www.vachss.com/ guest_dispatches/neonatal_pain.html 115 daniele fernandes de aguiar1 marluci andrade conceição-stipp2 joséte luzia leite3 valéria zadra de mattos4 karla biancha silva de andrade5 gerenciamento de enfermagem: situações que facilitam ou dificultam o cuidado na unidade coronariana 1 mestranda da escola de enfermagem anna nery da universidade federal do rio de janeiro, rio de janeiro, brasil. danifaguiarufrj@yahoo.com.br 2 doutora em enfermagem. docente da escola de enfermagem anna nery. universidade federal do rio de janeiro, rio de janeiro, brasil. marlustipp@gmail.com 3 doutora em enfermagem. docente da escola de enfermagem anna nery. universidade federal do rio de janeiro, rio de janeiro, brasil. joluzia@gmail.com 4 doutora em enfermagem. enfermeira chefe da educação continuada. hospital procardíaco, rio de janeiro, brasil. valzadra@uol.com.br 5 doutoranda em enfermagem. enfermeira chefe do setor de emergência do hospital procardíaco, rio de janeiro, brasil. k.biancha@ig.com.br recibido: 14 de abril de 2009 aceptado: 6 de mayo de 2010 resumo a assistência de enfermagem na unidade coranariana requer uma equipe de saúde especializada, equipamentos de alta tecnologia e uma liderança atenta as facilidades e dificuldades do cotidiano do cuidado de enfermagem. objetivo: discutir os aspectos que facilitam ou dificultam o gerenciamento de enfermagem na unidade coronariana. métodos: realizou-se pesquisa bibliográfica na base de dados scielo e coleta de dados, utilizando um roteiro de entrevista semi-estruturada com 6 enfermeiras líderes do setor de unidade coronariana do hospital universitário da universidade federal do rio de janeiro. resultados: quanto aos aspectos facilitadores do gerenciamento de enfermagem, os estudos selecionados e as enfermeiras apontaram fatores objetivos e subjetivos, respectivamente, como a utilização de instrumentos de distribuição da equipe e boa comunicação e relacionamento interpessoal. sobre os aspectos dificultadores, concordaram quanto à mecanização da enfermeira, à complexidade de uma unidade de cuidados críticos e à escassez de recursos materiais. conclusões: diante disso, cabe à gerência de enfermagem identificar estes fatores, a fim de possibilitar melhor desempenho dos profissionais e, conseqüentemente, uma assistência mais eficaz e segura ao paciente e sua família. palavras-chave enfermagem, gerência, unidades de cuidados coronarianos. (fonte: decs, bireme). año 10 vol. 10 nº 2 chía, colombia agosto 2010 l 115-131 116 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 nursing administration: aspects that can facilitate and hinder care in a coronary unit abstract nursing care in a coronary unit requires a team of specialized health-care professionals, high-tech equipment and leadership that is alert to the daily possibilities and difficulties of nursing care. objective: to discuss the aspects that can facilitate and hinder nursing administration in a coronary care unit. methods: this is a bibliographic study based on scielo and data collection, using semi-structured interviews with six head nurses from the coronary care unit at the universidade federal do rio de janeiro university hospital. results: as to the aspects that facilitate nursing administration, the selected studies and the nurses interviewed point to objective and subjective factors, respectively, such as the use of instruments, distribution of the team and good communication and interpersonal relations. concerning the aspects that hinder nursing administration, they were in agreement with respect to the mechanization of nursing, the complexity of a critical care unit and the shortage of material resources. conclusions: it is, therefore, the duty of nursing administration to identify these factors in order to help nursing professionals perform better. this will result in safer and more effective care for patients and their families. key words nursing, administration, coronary care units. (source: decs, bireme). administración de la enfermería: aspectos que facilitan o dificultan el cuidado en unidad coronaria resumen la asistencia de enfermería en la unidad coranariana requiere un equipo de cuidados de salud especializado, equipamientos de alta tecnología y un liderazgo atento a las facilidades y dificultades diarias del cuidado de enfermería. objetivo: discutir los aspectos que facilitan y dificultan la administración de enfermería en la unidad coronariana. métodos: se realizó una investigación bibliográfica en la base de datos scielo y recolección de datos, utilizando un plan de entrevista semiestructurada con 6 enfermeras líderes del sector de la 117 gerenciamento de enfermagem: situações que facilitam ou dificultam o cuidado na unidade coronariana l daniele fernandes de aguiar, marluci andrade conceição-stipp y otros. unidad coronaria del hospital universitario de la universidad federal de río de janeiro. resultados: acerca de los aspectos que facilitan la administración de enfermería, los estudios seleccionados y las enfermeras apuntaron factores objetivos y subjetivos, respectivamente, como el uso de instrumentos de la distribución del equipo y la buena comunicación y relación interpersonal. sobre los aspectos que la dificultan, han señalado la mecanización de la enfermera, la complejidad de una unidad de cuidados críticos y la escasez de recursos materiales. conclusiones: es deber de la administración de enfermería identificar estos factores, para permitir mejor desempeño de los profesionales y, en consecuencia, asistencia más eficaz y segura para los pacientes y sus familias. palabras clave enfermería, gerencia, unidadeds de cuidados coronarios. (fuente: decs, bireme). 118 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 introdução a unidade coronariana é um setor diferenciado por exigir equipamentos de alta tecnologia e cuidados especializados desenvolvidos pelos profissionais que a ocupam. além do aprimoramento científico da equipe, é necessário o desenvolvimento de habilidades em prol da dinamização do cuidado ao paciente crítico (1). logo, é uma unidade de terapia intensiva capaz de prestar cuidados voltados ao indivíduo coronariopata, o qual requer da enfermeira uma multiplicidade de conhecimento em cardiologia e versatilidade na sua atuação, enquanto gerente ou líder de equipe. a unidade coronariana deve ser provida adequadamente, em sua estrutura física, de recursos humanos e materiais, constituindo-se em suporte para implantação de uma assistência efetiva ao paciente hospitalizado, em função da sua elevada especificidade. nesse contexto, é uma unidade onde se concentram recursos humanos e tecnológicos altamente especializados, que proporcionam assistência considerada das mais complexas, sofisticadas e onerosas do sistema de atendimento à saúde (1,2). a equipe de enfermagem representa, na maioria das instituições de saúde, o percentual quantitativo e orçamentário mais significativo, tornando-se a equipe mais visada quando o problema é redução de custos (3). nesse sentido, a inadequação numérica e qualitativa dos recursos de enfermagem lesa a clientela no seu direito de assistência à saúde livre de riscos e pode comprometer legalmente a instituição pelas falhas ocorridas, devido à sobrecarga de trabalho e à deficiência da qualidade da assistência prestada. por tanto, os recursos humanos são o primeiro foco de atenção da enfermeira gerente ou líder de unidade coronariana (4). contar com uma equipe qualificada é condição vital para a atuação efetiva do trabalho da enfermeira. o desenvolvimento de pesquisas e grupos de interesse na área do saber do cuidado crítico aprimora o aspecto técnico-científico dos profissionais e promove o aperfeiçoamento contínuo (5), refletido na execução do cuidado. outro aspecto que envolve os recursos humanos refere-se ao dimensionamento da equipe de enfermagem (4). ao gerenciar a unidade coronariana, a enfermeira faz uma conexão assistencial entre as equipes de enfermagem, pois está presente de forma contínua durante a rotina dos cuidados, momento em que se tomam as decisões mais importantes na condução do programa de tratamento, seja ele clínico ou cirúrgico. a qualidade do cuidado é preservada quando se considera também a disponibilização de recursos materiais adequados à prática assistencial, sejam eles de consumo ou permanentes (4). este é o segundo foco gerencial para a construção da estratégia assistencial adequada. o terceiro foco que deve preponderar na manutenção do nível de assistência prestada é a disposição do espaço físico da unidade (4). deve seguir normas exigidas para a construção de instituições de saúde, respeitando-se as necessidades da equipe de enfermagem, tornando fácil e segura a implementação da assistência e com conseqüências positivas para o paciente. os recursos humanos são o primeiro foco de atenção da enfermeira gerente ou líder de unidade coronariana. contar com uma equipe qualificada é condição vital para a atuação efetiva do trabalho da enfermeira. 119 gerenciamento de enfermagem: situações que facilitam ou dificultam o cuidado na unidade coronariana l daniele fernandes de aguiar, marluci andrade conceição-stipp y otros. diante destes fatores, objetivamos discutir os aspectos que facilitam ou dificultam o gerenciamento de enfermagem na unidade coronariana. metodologia trata-se de um recorte da dissertação de mestrado intitulada estratégias gerenciais do cuidado de enfermagem na unidade coronariana: avaliação em três hospitais públicos universitários do estado do rio de janeiro, desenvolvida na escola de enfermagem anna nery, da universidade federal do rio de janeiro. a fim de atender o objetivo do estudo, houve necessidade de dividi-lo em duas fases. a primeira consistiu em uma revisão da literatura através de pesquisa bibliográfica computadorizada, na qual foram utilizadas fontes secundárias em forma de artigos de enfermagem publicados em periódicos nacionais com circulação internacional. nesta fase, foi estabelecido como recorte temporal os anos de 2003 a 2008, com a finalidade de acessar a literatura mais recente publicada sobre o gerenciamento de enfermagem em unidade coronariana. a pesquisa se levou a cabo em abril de 2008 na base de dados scielo, utilizando-se o formulário avançado com os descritores “enfermagem” e “unidade coronariana”. encontraram-se apenas 2 publicações. ao trocar o segundo termo por “unidades de cuidados críticos”, não surgiu nenhuma produção científica. optou-se então por utilizar os descritores “enfermagem” e “unidades de terapia intensiva”, com os quais foram encontradas 29 publicações distintas da área da enfermagem acerca do tema. como critério de inclusão foram selecionados os artigos que abordavam gerenciamento de enfermagem nesta unidade, enfatizando os seguintes aspectos administrativos: recursos humanos e materiais. assim, através da análise dos resumos e, em alguns casos, das introduções dos estudos, incluíram-se 15 artigos. a segunda fase configurou um estudo de caso, do tipo único, com análise descritivo-exploratória e abordagem qualitativa, através de pesquisa de campo com todas as enfermeiras líderes: 6 enfermeiras responsáveis pelo gerenciamento do cuidado direto de enfermagem, do setor de unidade coronariana do hospital universitário clementino fraga filho (hucff), da universidade federal do rio de janeiro. utilizou-se um roteiro de entrevista semiestruturada. a coleta dos dados no hucff ocorreu no período de 20 de maio a 18 de junho de 2008, após a aprovação pelo comitê de ética em pesquisa da própria instituição (protocolo 012/08). houve consentimento dos sujeitos com assinatura do termo de consentimento livre e esclarecido, respeitando-se os preceitos da resolução 196/96 do conselho nacional de saúde do ministério da saúde. as entrevistas foram gravadas em fitacassete e, posteriormente, transcritas e validadas pelas enfermeiras. a fim de manter o anonimato dos sujeitos, os seus discursos foram identificados por números: “líder 1”, “líder 2”, “líder 3” e assim em diante, obedecendo à ordem de citação. a análise dos resultados foi realizada através de agrupamento, classificação e avaliação dos dados por meio de unidades temáticas (7). 120 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 resultados e discussão dos dados no quadro 1, apresentamos a identificação dos artigos encontrados. verificamos que a maioria dos autores se repete nas diversas publicações, o que demonstra que os profissionais de enfermagem estão cada vez mais se aprimorando e elaborando estudos em áreas de campo específicas da enfermagem, como nas unidades de cuidados críticos. dentre as 15 publicações selecionadas, 46,7% foram publicadas na revista da escola de enfermagem da usp; 26,7% na acta paulista de enfermagem; 13,3% na texto & contexto enfermagem; e outros 13,3% na revista latino-americana de enfermagem. notou-se, portanto, que há predominância de artigos publicados em revistas do estado de são paulo. cabe destacar que todos os periódicos referidos possuem qualis a2 no momento (8), que representa o segundo estrato mais elevado de qualidade. quadro 1. distribuição dos artigos. nº título autores periódico ano 01 tecnobiomedicina: implicações naquilo e daquilo que a enfermagem faz vargas mao, texto & em terapia intensiva ramos frs contexto 2008 enfermagem 02 qualidade de vida dos trabalhadores de enfermagem de unidades de paschoa s, acta paulista terapia intensiva zanei ssv, de 2007 whitaker iy enfermagem 03 nursing activities score (nas) como instrumento para medir carga de trabalho conishi rmy, revista da de enfermagem em uti adulto gaidzinski rr escola de 2007 enfermagem da usp 04 número de horas de cuidados de enfermagem em unidade de terapia intensiva tranquitelli revista da de adultos am, escola de 2007 ciampone enfermagem mht da usp 05 fatores associados à carga de trabalho de enfermagem em unidade de gonçalves la, revista da terapia intensiva padilha kg escola de 2007 enfermagem da usp 06 sistemas de classificação de pacientes como instrumentos de gestão tranquitelli revista da em unidades de terapia intensiva am, escola de 2007 padilha kg enfermagem da usp 121 gerenciamento de enfermagem: situações que facilitam ou dificultam o cuidado na unidade coronariana l daniele fernandes de aguiar, marluci andrade conceição-stipp y otros. 07 o processo de morrer e a morte no enfoque dos profissionais de enfermagem gutierrez revista da de utis bao, escola de 2007 ciampone enfermagem mht da usp 08 necessidades de cuidados de enfermagem e intervenções terapêuticas em ciampone jt, acta paulista unidade de terapia intensiva: estudo comparativo entre pacientes idosos e gonçalves la, de 2006 não idosos maia fom, enfermagem padilha kg 09 sistematização da assistência de enfermagem ao paciente crítico: proposta de bittar db, texto & instrumento de coleta de dados pereira lv, contexto 2006 lemos rca enfermagem 10 as cores no ambiente de terapia intensiva: percepções de pacientes e boccanera nb, revista da profissionais boccanera sfb, escola de 2006 barbosa ma enfermagem da usp 11 percepção do estresse entre enfermeiros que atuam em terapia intensiva ferrareze mvg, acta paulista ferreira v, de 2006 carvalho amp enfermagem 12 profissionais de enfermagem frente ao processo de morte em unidades de gutierrez bao, acta paulista terapia intensiva ciampone de 2006 mht enfermagem 13 re-significações do humano no contexto da ‘ciborguização’: um olhar sobre as vargas mao, revista da relações humano-máquina na terapia intensiva meyer de escola de 2005 enfermagem da usp 14 dificuldades vivenciadas pela equipe multiprofissional na unidade de terapia leite ma, revista intensiva vila vsc latino2005 americana de enfermagem 15 as representações dos técnicos e auxiliares de enfermagem acerca do trabalho shimizu he, revista em equipe na unidade de terapia intensiva ciampone latino2004 mht americana de enfermagem nº título autores periódico ano quadro 1. distribuição dos artigos. (continuação) 122 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 no que se refere ao ano de publicação, 40% foram publicados em 2007; 33,3% em 2006; 13,3% em 2005; 6,7% em 2008; e 6,7% em 2004. segundo estes dados, consideramos que o gerenciamento de enfermagem em unidades de cuidados críticos vem sendo amplamente discutido por profissionais de enfermagem, reforçando a necessidade de capacitação técnica e científica para prestar melhor assistência ao paciente em suas diversas necessidades. apesar de 2003 fazer parte do recorte temporal estipulado, não foi selecionado nenhum artigo por não se adequar ao tema proposto. ocorreu unanimidade na prevalência do sexo feminino entre os sujeitos, o qual demonstra novamente que a enfermagem é uma profissão composta em sua maioria por mulheres (tabela 1). devido à constante insatisfação salarial, a maioria das enfermeiras mantém outros empregos para complementar a renda. das 4 enfermeiras que possuíam outros vínculos empregatícios, 2 também eram enfermeiras líderes em outros locais de trabalho, 1 era enfermeira chefe e 1 trabalhava com acupuntura. assim mesmo, verificou-se a preocupação por quase todas as enfermeiras de tabela 1. perfil dos sujeitos de estudo. características casos n % sexo feminino 6 100,0 masculino 0 0,0 faixa etária 30 |--40 3 50,0 40 |--50 2 33,3 50 |--60 1 16,7 turno de serviço diurno 3 50,0 noturno 3 50,0 tempo de profissão como enfermeira líder (anos) 05 |--15 3 50,0 15 |--25 3 50,0 existência de outro vínculo empregatício sim 4 66,7 não 2 33,3 realização de pós-graduação lato/stricto sensu sim 5 83,3 não 1 16,7 123 gerenciamento de enfermagem: situações que facilitam ou dificultam o cuidado na unidade coronariana l daniele fernandes de aguiar, marluci andrade conceição-stipp y otros. realizarem curso(s) de pós-graduação, a fim de manter contínua capacitação profissional, em virtude dos avanços tecnológicos e diversas necessidades específicas da clientela. das 5 enfermeiras que fizeram/fazem curso(s) de pós-graduação lato/stricto sensu, 1 fez mestrado em enfermagem. das que fizeram/fazem residência em enfermagem, 2 optaram pelo programa de enfermagem médico-cirúrgica (sendo que 1 incompleta, por trancamento da matrícula) e 1 pela clínica cirúrgica. quanto aos cursos de especialização, 4 optaram por enfermagem em cardiologia (sendo que 01 incompleta, pois está em fase final), 2 por enfermagem do trabalho, 1 por enfermagem em terapia intensiva e 1 por acupuntura. unidade temática 1. aspectos facilitadores do gerenciamento de enfermagem em unidade coronariana neste item, foram analisados os fatores que facilitavam o gerenciamento de enfermagem em cenário de unidade coronariana, segundo a revisão bibliográfica e os relatos das enfermeiras. nos artigos 3, 4, 5, 6 e 8, o nas (nursing activities score), instrumento que visa medir o tempo de assistência de enfermagem em unidades de terapia intensiva (9), apresentou-se como interessante e valioso instrumento para classificação de pacientes e avaliação da carga de trabalho da equipe de enfermagem neste setor. o nas foi desenvolvido a partir do therapeutic intervention scoring system (tiss-28) para torná-lo mais representativo das atividades realizadas pela enfermagem na uti (10) e, posteriormente, traduzido para o português e validado (11). a mudança mais substancial ocorreu na categoria das atividades básicas, subcategorizada em: monitorização e controles; procedimentos de higiene; mobilização e posicionamento; suporte e cuidados aos familiares e pacientes; e tarefas administrativas e gerenciais (2). o instrumento resultante consta de 7 grandes categorias e 23 itens. cada item possui uma pontuação, portanto o escore atribuído a um paciente resulta da soma das pontuações dos itens que correspondem às suas necessidades de assistência direta e indireta. esse escore representa quanto tempo o paciente necessitou de um profissional de enfermagem nas últimas 24 horas (2). assim, se a pontuação for 100, interpretase que o paciente precisou 100% do tempo de um profissional de enfermagem no seu cuidado nas últimas 24 horas. portanto, é um recurso que serve para identificar a gravidade dos doentes, avaliar a carga de trabalho de enfermagem, quantificar as necessidades de cuidados dos pacientes e estimar a real necessidade de profissionais de enfermagem por paciente. no artigo 4, concluiu-se que o cálculo do número de horas de assistência de enfermagem, em unidades em que o sistema de classificação de pacientes esteja implantado, evidencia-se como importante ferramenta de gerenciamento da assistência, além de ser um fator essencial para o dimensionamento mais adequado do pessoal de enfermagem. a sistematização da assistência de enfermagem (sae) foi citada no artigo 9 a mudança mais substancial ocorreu na categoria das atividades básicas, sub-categorizada em: monitorização e controles; procedimentos de higiene; mobilização e posicionamento; suporte e cuidados aos familiares e pacientes; e tarefas administrativas e gerenciais. 124 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 como um meio de aprimorar habilidades cognitivas e psicomotoras do profissional de enfermagem que a utiliza, pois se torna capaz de associar teoria e prática, já que está sempre à luz de um referencial teórico de enfermagem, relacionando conhecimentos multidisciplinares e estabelecendo relações de trabalho mais profundas e produtivas. embora as enfermeiras do setor de unidade coronariana do hucff não utilizarem o nas e não mencionarem a sae, elas avaliavam a complexidade de cada paciente de acordo com o olhar experiente e o saber técnico-científico e, a partir daí, priorizavam os que necessitavam de cuidados mais urgentes: [...] a gente faz por complexidade de cada paciente... então a gente vê por características mesmo de cada paciente. (...) a gente sempre tenta, assim, priorizar os cuidados, né... com certeza o que tiver, assim, de mais urgência vai ser feito primeiro. eu não vou estar conferindo material, se tem um paciente passando mal, paciente fazendo arritmia... então a gente tem que realmente ter discernimento, né. a gente tá sempre gerenciando (líder 1). priorizar o atendimento de emergência ao paciente em situação crítica. por exemplo, hoje eu larguei tudo e fiz a medicação rapidinho. começaram a fazer a pam na paciente, eu larguei tudo e já fui pra paciente crítico. que normalmente quando tem paciente crítico aqui, a gente é prioritário dela. (líder 2). a líder 1 complementou: então essas coisas assim, esse olhar crítico, é o enfermeiro que tem né... pra que não seja feita aquela coisa, assim, de rotina, sem pensar. tem que ser uma coisa questionada. então eu acho que o enfermeiro, a função, assim, primordial dele em relação à gerência é esse: ter olhar crítico e observar prioridades. entendeu-se, pelos argumentos das enfermeiras, que elas mesclavam o conhecimento científico adquirido durante os cursos de capacitação profissional, relatados anteriormente, com as formas de lidar com a equipe e os pacientes, desenvolvidas na vivência prática. isso pode ser explicado pelo tempo prolongado de experiência profissional e pela faixa etária. quanto à assistência de enfermagem, é fundamental traçar um planejamento diário e estabelecer as reais prioridades – as quais variam com as características da instituição e as necessidades específicas da clientela assistida–, a fim de proporcionar um cuidado individualizado e de qualidade, principalmente quando se trata de um paciente que inspira cuidados críticos. em um setor de unidade coronariana, o cuidado de enfermagem requer, dentre outras atividades, vigília e atenção permanentes ao paciente e às suas diversas respostas orgânicas. é aí que surge a necessidade de ter sistemas de monitorização neste ambiente, pois eles fornecem informações sobre as variáveis fisiológicas do paciente crítico com exatidão e precisão adequadas, o que permite o acompanhamento e a tomada de decisões em tempo hábil. outro ponto destacado na literatura, porém não referenciado pelas depoentes, foi a influência das cores utilizadas no ambiente, apresentada no artigo 10 como um fator que pode facilitar gerenciamento de enfermagem, reduzindo tensões não somente do paciente, como também da equipe que lhe presta cuidados. em um setor de unidade coronariana, o cuidado de enfermagem requer, dentre outras atividades, vigília e atenção permanentes ao paciente e às suas diversas respostas orgânicas. é aí que surge a necessidade de ter sistemas de monitorização neste ambiente, pois eles fornecem informações sobre as variáveis fisiológicas do paciente crítico. 125 gerenciamento de enfermagem: situações que facilitam ou dificultam o cuidado na unidade coronariana l daniele fernandes de aguiar, marluci andrade conceição-stipp y otros. neste estudo, os profissionais que se encontravam trabalhando e os pacientes internados nas unidades referiram que as cores mais agradáveis e presentes neste ambiente eram o azul claro, o branco e o verde claro. além das cores existentes, apontaram as cores amarelo claro, palha, cinza, rosa e goiaba como aquelas que também gostariam de estar em contato no. cores como o preto e o vermelho foram consideradas, tanto por pacientes quanto por profissionais, desagradáveis e impróprias para uma unidade coronariana. além disso, alguns doentes referiram que a cor branca, usualmente utilizada nos serviços de saúde, torna-se desagradável dentro do ambiente de cuidados críticos. desta forma, a cor é um evento que pode estar sendo ou não interpretado e codificado pelo indivíduo. tanto em um como em outro momento, a cor pode ser um fator estressor. pois ela pode estar agindo como um estímulo insistente sobre a pessoa, causando estresse pela sua constância (12). por conseqüência, já no processo de construção dos serviços de saúde, deve haver especial atenção voltada à aplicação de cores e suas diferentes tonalidades no cenário de cuidados críticos, considerando, inclusive, que as cores com seus campos de onda não somente decoram, mas também podem contribuir para o bem-estar das pessoas que estão em contato com este ambiente. este fato facilita muito o gerenciamento deste serviço. as enfermeiras do hucff também mencionaram outros aspectos que facilitam a gerência de enfermagem: o bom relacionamento e a comunicação eficiente entre a equipe. quando tem paciente crítico... os técnicos aqui são excelentes. então, quer dizer, eu não preciso nem mandar, eles já sabem o que fazer. então fica até mais tranqüilo pra gente, pro nosso trabalho. todo mundo fica em sintonia. (líder 2) pra ter noção de tudo o que acontece dentro de uma unidade, você tem que ter a cooperação dos técnicos. então, se acontece alguma coisa, por exemplo, o paciente tem o débito cardíaco diminuído, e se você tiver só e com paciente grave, se o técnico não chegar pra você e disser: ”ó, tá caindo a pressão, diurese tá caindo”, passa despercebido. porque é impraticável você ter noção de seis pacientes graves em uma unidade que tem alta rotatividade. (líder 3) é muito bom trabalhar aqui. aqui as pessoas trabalham e as coisas funcionam muito bem. por exemplo, quando tem uma intercorrência, a gente se divide e já vê quem vai fazer o que primeiro... somos realmente uma equipe. (líder 4) [...] eu não preciso ficar observando, acompanhamento em tudo. eu sei como o funcionário trabalha, conheço o trabalho dele. e aí entro na hora exatamente que eu preciso entrar, na hora do cuidado mais elaborado. ajudo o funcionário em tudo o que for necessário. então, tem que ter bom relacionamento com a equipe. saber falar, saber pedir, entendeu, nunca mandar. isso sempre deu certo no meu trabalho. (líder 5) a enfermeira necessita o apoio de sua equipe, mas, para tal, deve oferecer o seu apoio, demonstrando conhecimento, acessibilidade, compreensão, segurança e interesse, além de nutrir o poder individual de cada membro, tornando o poder compartilhado (13). assim, se não existir clima harmonioso no exercício das funções, ou se não houver a cor é um evento que pode estar sendo ou não interpretado e codificado pelo indivíduo. tanto em um como em outro momento, a cor pode ser um fator estressor. 126 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 respeito e confiança entre os profissionais da equipe, a desmotivação e insatisfação será comum, o que trará conseqüências negativas para as relações de trabalho e no cuidado ao paciente. do contrário, um grupo forte e unido, com um mesmo objetivo, terá maior prazer em cuidar do outro e se encherá de auto-estima, refletindo-se nas suas ações e comportamentos. além disso, reforçaram a importância de ter o apoio de seus superiores: a chefe da unidade ocupa o tempo dela bastante com as burocracias da unidade, de reposição, justamente pra gente estar junto com o paciente integralmente, né, durante o plantão. (líder 1) a chefia ajuda na administração dos recursos da unidade, ela tem um controle e consegue remanejar esse material. então isso aí é direcionado através da chefia. ela tá todo dia aí vendo e organizando isso. (líder 3) normalmente é tudo sempre muito bem organizado, tudo muito bem controlado. a chefia, em qualquer coisa, a gente tem um suporte muito grande, tanto que a gente fica praticamente liberado pra assistência. (...) a gente tem uma chefia que cobra direitinho. ela organiza muito bem, ela gerencia, ela controla muito bem, felizmente. então, você fica tranqüilo, porque você tem respaldo. então você sente que está apoiado. (líder 4) então, de nada adianta cuidadoras serem sensíveis às necessidades dos pacientes, se não existir apoio e coleguismo, ou se outros valores como produtividade e competitividade predominarem no ambiente de trabalho. e, ainda, o uso da internet no ambiente de trabalho mostrou-se necessário a fim de manter a equipe informada sobre a atualização do conhecimento: a presença da internet no setor é muito importante, porque mantém você atualizado e permite tirar muitas dúvidas que surgem durante o plantão. especialmente quando se trata de um hospital universitário, aonde os alunos vêm com um conhecimento teórico muito grande. então a gente precisa cada vez mais se aperfeiçoar pra atender as expectativas. (líder 4) através da internet, podemos estar ligados aos grandes centros de pesquisa, às grandes bibliotecas e interagir com colegas da profissão em todas as partes do país e do mundo de maneira eficiente, portanto constitui uma importante ferramenta para a enfermagem. unidade temática 2. aspectos dificultadores do gerenciamento na unidade coronariana, a equipe multiprofissional convive com diversos fatores desencadeadores de estresse, como a dificuldade de aceitação da morte, a escassez de recursos materiais –leitos e equipamentos– e humanos, assim como a tomada de decisões conflitantes relacionadas com a seleção dos pacientes que serão atendidos. resultados de pesquisas têm demonstrado que a má utilização dos recursos tecnológicos e a falta de compromisso de alguns profissionais tornam a assistência mecanicista, ou seja, afastam o paciente/a família da equipe multiprofissional, descaracterizando o cuidado como ação humana (13-14). os artigos 1 e 13 discutiram a tecnobiomedicina e as relações humano-máquina unidade coronariana, a equipe multiprofissional convive com diversos fatores desencadeadores de estresse, como a dificuldade de aceitação da morte, a escassez de recursos materiais e humanos, assim como a tomada de decisões conflitantes relacionadas com a seleção dos pacientes que serão atendidos. 127 gerenciamento de enfermagem: situações que facilitam ou dificultam o cuidado na unidade coronariana l daniele fernandes de aguiar, marluci andrade conceição-stipp y otros. na do processo denominado ‘ciborguização da enfermeira’ na terapia intensiva. houve também relatos de uma das enfermeiras do hucff que demonstraram este fato: no começo até dava mais atenção aos pacientes, mas agora a gente tá mais robotizada. porque ou eu faço o que tem que ser feito de imediato e prontamente ao paciente, ou eu dou atenção e converso com ele. (líder 2) aí fica aquela história, de você já ficar acostumada, que você já entra no ritmo. então às vezes você pode conversar com o paciente, e quando tá calmo não conversa. que você já tá tão cansada, na batida de vai lá e pra cá... e acaba não dando. (líder 2) na perspectiva da ciborguização, o humano deixa de ser o eu, mas também não seria o outro. a máquina, por sua vez, não é o outro, mas também não assumiria qualquer privilégio. a tecnologia deveria deixar de ser descrita como condição externa à constituição humana. a condição humana, por sua vez, deveria deixar de ser descrita como essência e de assumir uma posição privilegiada para a constituição de qualquer subjetividade. teríamos então um ciborgue, um híbrido. nem humano, nem máquina: irredutível a qualquer condição de dualismo e de hierarquia. os artigos 7, 12 e 14 trataram da morte na visão dos profissionais de enfermagem em unidades de cuidados críticos, pois eles se deparam cotidianamente em seu trabalho com o sofrimento dos pacientes e familiares no enfrentamento do processo de morrer, visto que, pelas características dessas unidades, os pacientes apresentam quadros graves e muitas vezes irreversíveis, tornando o ambiente estressante e gerador de uma atmosfera emocionalmente comprometida para todos os que o habitam. as enfermeiras da unidade coronariana do hucff não refletiram sobre a morte, muito evidenciada neste setor, mas o reconheceram como um ambiente gerador de muitas tensões e conflitos, nem sempre tão evidentes e de fácil resolução: ali, por ser um setor complexo, é bem traumatizante. na supervisão dos alunos em campo de estágio, eu vou junto o tempo todo. (...) ou ele tá comigo, ou ele tá com o técnico. ele não fica sozinho. ele não mete a mão em nada sozinho aqui. uma coisa que eu me preocupo é dele, antes de exercer a profissão, ficar traumatizado por uma situação que ele fez alguma coisa errada. e aí, já pensou, você ainda tá pensando em ser enfermeiro e já acontece uma tragédia... fica marcado pro resto da vida. (líder 4) verificou-se que os profissionais de saúde, inclusive os de enfermagem, estão despreparados para lidar com as questões relacionadas à morte e ao processo de morrer. além disso, este tende a ser considerado um assunto menos importante nas instituições de saúde, já que a imagem do hospital é vinculada a um local de cura, tanto pelos pacientes quanto pelos profissionais, pois os primeiros o procuram com a esperança de sair curados e, os segundos, de proporcionar a cura a alguém. segundo os depoimentos de enfermeiras, técnicos e auxiliares de enfermagem no estudo do artigo 7, foi evidenciado que os profissionais de enfermagem buscam na espiritualidade e nas crenças religiosas subsídios para tentar aliviar o sofriverificou-se que os profissionais de saúde, inclusive os de enfermagem, estão despreparados para lidar com as questões relacionadas à morte e ao processo de morrer. 128 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 mento dos pacientes e, indiretamente, os seus próprios, pois é a enfermagem que permanece ao lado desses pacientes, cuidando e amparando-os. por isso, freqüentemente, são esses profissionais que presenciam o ato de morrer, oferecendo algum suporte espiritual, de acordo com as crenças e valores cultivados quando estes são expressos pelos enfermos. assim, as organizações e os profissionais que nelas trabalham precisam desenvolver uma dinâmica de aprendizagem e inovação, melhorando sua capacidade de se adaptar às novas situações que acarretam muitas vezes dilemas bioéticos, como no caso do prolongamento da vida por meios artificiais. é importante que pessoas com cargo de gerência ou forte liderança desenvolvam nessas organizações espaços para debates a respeito dos conhecimentos e práticas, visando a troca de experiências e o suporte necessário para que os profissionais de saúde acompanhem as transformações, integrando o conhecimento científico em suas práticas, ampliando-as ao âmbito do social e espiritual. os profissionais também enfrentam grandes problemas causados pelo fato de alguns membros não saberem atuar em equipe, segundo os artigos 14 e 15. essa situação desencadeia mais um tipo de estresse e a frustração no grupo de trabalho, o que produz desmotivação e, por conseguinte, relações de trabalho inadequadas. desta forma, é necessário dar ênfase às relações humanas. assim, será possível assegurar a reintegração da equipe multiprofissional, possibilitar a discussão e a reflexão sobre os dilemas da prática profissional, onde os sujeitos possam verbalizar os sentimentos de ansiedade, insatisfação, dor, insegurança e conflito, vivenciados nas relações com os pacientes, familiares, equipe de trabalho e com a instituição. verifica-se também que a estrutura do serviço de enfermagem rigidamente hierarquizada, onde a enfermeira assume postura autoritária e centralizadora junto aos demais elementos, contribui muito para dificultar o desenvolvimento do trabalho em equipe. portanto, é necessário que as enfermeiras repensem e modifiquem o modelo de gerenciamento de recursos humanos que desenvolvem. adotar um modelo mais flexível é o mais desejável, ocorrendo maior horizontalidade nas decisões e poderes, bem como maior participação de todos os trabalhadores de enfermagem. quanto à estrutura, os estudos também apontaram para a falta de recursos materiais, que dificulta e interfere na qualidade da assistência prestada ao paciente crítico (artigo 14), gerando outro fator estressante no ambiente de unidade coronariana (artigo 11) e baixa qualidade de vida (artigo 2). da mesma maneira, enfermeiras do setor de unidade coronariana do hucff identificaram a insuficiência de recursos materiais como um aspecto dificultador da gerência: a gente tenta poupar ao máximo. é difícil, mas... é o que a gente fala... a enfermagem é tudo... magiver da vida... inventa e reinventa. a única coisa que a gente não pode é... não fabrica agulha, não fabrica seringa, lençol. a gente tenta remediar o mais que possa com a nossa capacidade de inteligência de tentar adequar pro paciente. mas é difícil... e fica triste. (líder 2) as organizações e os profissionais que nelas trabalham precisam desenvolver uma dinâmica de aprendizagem e inovação, melhorando sua capacidade de se adaptar às novas situações que acarretam muitas vezes dilemas bioéticos, como no caso do prolongamento da vida por meios artificiais. 129 gerenciamento de enfermagem: situações que facilitam ou dificultam o cuidado na unidade coronariana l daniele fernandes de aguiar, marluci andrade conceição-stipp y otros. agora realmente a gente tá com dificuldade. não tem sabão adequado pra lavar a mão em terapia intensiva, que seria clorexidina degermante... a gente não tem papel toalha... então agora realmente tá uma fase complicada, mas a gente consegue lidar. (líder 6) assim, impõe-se a necessidade dos serviços de saúde aprimorarem os sistemas de gerenciamento desses recursos, a fim de garantirem uma assistência contínua de qualidade a um menor custo e assegurarem quantidade e qualidade dos materiais necessários para que os profissionais realizem suas atividades sem riscos para si mesmos e para os pacientes (15). considerações finais este estudo foi relevante por comprovar, mediante dados teóricos e práticos, a existência de vários fatores que interferem no gerenciamento de enfermagem em unidade coronariana e outros que podem facilitar/amenizar as situações conflitantes vivenciadas no ambiente de trabalho. quanto aos pontos facilitadores, não houve concordância entre os estudos selecionados e as enfermeiras da unidade coronariana. os artigos apontaram aspectos objetivos, como a utilização de instrumentos para distribuir quanti-qualitativamente a equipe de enfermagem e a aplicação de cores leves em ambiente de cuidados críticos. além disso, as enfermeiras refletiram sobre aspectos subjetivos, como a manutenção de um bom relacionamento interpessoal e a comunicação eficiente entre a equipe. cabe ressaltar a importância de utilizar instrumentos como o nas (nursing activities score) e o tiss-28 (therapeutic intervention scoring system), que facilitam a classificação do tempo de assistência de enfermagem aos pacientes das unidades de cuidado intensivo e, conseqüentemente, facilitam o cálculo de pessoal de enfermagem necessário. ressaltamos o frágil momento em que as enfermeiras da unidade coronariana do hucff se encontravam, pois o hospital estava enfrentando uma grave crise financeira, a qual teve repercussão nacional e se refletiu na realização de procedimentos (como a realização de cirurgias), na formação acadêmica e no reajuste de funcionários (desligamento temporário de alguns cooperativados e remanejamento de outros funcionários para diferentes setores). por isso, estavam, mais do que em qualquer outra situação, valorizando as relações interpessoais, a fim de obterem suporte mútuo às diversas dificuldades. universidade federal do rio de janeiro ufrj escola de enfermagem anna nery eean roteiro de entrevista semi-estruturada 1ª parte. dados objetivos: 1. nome: 2. idade: 3. sexo: 4. instituição na qual trabalha: 5. serviço diurno ou noturno? 6. tempo de exercício na profissão como líder de equipe: 7. possui outro vínculo empregatício? que função desenvolve? 8. possui algum curso de pós-graduação (lato e/ou stricto sensu)? qual? 2ª parte. dados subjetivos: 1. quais são as suas atividades desenvolvidas no setor de unidade coronariana des te hospital? 2. comente sobre como você gerencia o cuidado de enfermagem no setor de uni dade coronariana, enquanto profissional de um hospital público universitário. já nos pontos dificultadores, houve concordância no que se refere à mecanização das relações entre paciente/família e equipe, ao fato do ambiente da unidade coronariana ser um setor complexo e de difícil enfrentamento dos conflitos internos e externos para todos os envolvidos e ao déficit de recursos, principalmente de materiais. diante desta evidência, cabe à gerência de enfermagem, enquanto enfermeira chefe ou líder de equipe, identificar estes fatores dificultadores e discutir em grupo formas de melhoria, a fim de proporcionar na medida do possível melhores condições de trabalho e de permanência em um setor fechado. isto possibilitará melhor desempenho dos profissionais e, conseqüentemente, uma assistência mais eficaz e segura ao paciente e sua família. 130 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 referencias bibliográficas 1. tranquitelli am, ciampone mht. número de horas de cuidados de enfermagem em unidade de terapia intensiva de adultos. rev. esc. enferm. usp 2007; 41(3): 371-7. 2. conishi rmy, gaidzinski rr. nursing activities score (nas) como instrumento para medir carga de trabalho de enfermagem em uti adulto. rev. esc. enferm. usp 2007; 41(3): 346-54. 3. kurcgant p (coord). administração em enfermagem. 7ª reimpressão. são paulo (sp): epu; 2006. 4. nascimento mtf, stipp mac. gerência de unidade de cuidado crítico. esc. anna nery r. enferm. 2002; 6(2): 189-94. 5. simões ala, fávero n. o desafio da liderança para o enfermeiro. rev. latino-am. enfermagem 2003; 11(5): 567-73. 6. yin rk. estudo de caso: planejamento e métodos. tradução: daniel grassi. reimpressão 2006. 3ª edição. porto alegre (rs): bookman; 2005. 7. minayo mcs, deslandes sf, cruz neto o, gomes r. pesquisa social: teoria, método e criatividade. 24ª edição. petrópolis (rj): vozes; 2005. 8. capes. webqualis – consulta periódicos. classificação de periódicos, anais, revistas e jornais. 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não idosos. acta paul enferm. 2006; 19(1): 28-35. 24. bittar db, pereira lv, lemos rca. sistematização da assistência de enfermagem ao paciente crítico: proposta de instrumento de coleta de dados. texto contexto enferm. 2006; 15(4): 617-28. 131 gerenciamento de enfermagem: situações que facilitam ou dificultam o cuidado na unidade coronariana l daniele fernandes de aguiar, marluci andrade conceição-stipp y otros. 25. boccanera nb, boccanera sfb, barbosa ma. as cores no ambiente de terapia intensiva: percepções de pacientes e profissionais. rev. esc. enferm. usp 2006; 40(3): 343-9. 26. ferrareze mvg, ferreira v, carvalho amp. percepção do estresse entre enfermeiros que atuam em terapia intensiva. acta paul enferm. 2006; 19(3): 310-15. 27. gutierrez bao, ciampone mht. profissionais de enfermagem frente ao processo de morte em unidades de terapia intensiva. acta paul enferm. 2006; 19(4): 456-61. 28. vargas mao, meyer de. re-significações do humano no contexto da ‘ciborguização’: um olhar sobre as relações humano-máquina na terapia intensiva. rev. esc. enferm. usp 2005; 39(2): 211-9. 29. leite ma, vila vsc. dificuldades vivenciadas pela equipe multiprofissional na unidade de terapia intensiva. rev. latino-am. enfermagem 2005; 13(2): 145-50. 30. shimizu he, ciampone mht. as representações dos técnicos e auxiliares de enfermagem acerca do trabalho em equipe na unidade de terapia intensiva. rev. latino-am. enfermagem 2004; 12(4): 623-30. 139 145 primeras paginas.indd 144 año 8 vol. 8 nº 2 chía, colombia octubre 2008 144-145 correo del lector formando docentes la investigación incorporada en el último número de la revista, titulada “formando docentes. una experiencia desde el constructivismo”, de cerezo-bautista y hernández-álvarez, nos motiva a reflexionar sobre nuestras prácticas pedagógicas en la enseñanza de la enfermería. los resultados son destacables ya que confirman que la productividad en el aula se incrementa con un diseño constructivista de aprendizaje. el trabajo fue realizado con profesores de enfermería y se fundamenta en las concepciones constructivistas de mayer. a través de un diseño descriptivo y de intervención, aplicando pre y posprueba, las investigadoras concluyen que este abordaje permitió incrementar los porcentajes de aprovechamiento del grupo de docentes participantes. las autoras refuerzan el trabajo del docente quien tiene que crear condiciones óptimas para que los estudiantes desplieguen una actividad mental constructiva. fortalecen su papel de orientador y guía, minimizando el ejercicio de la autoridad y el control excesivo, favoreciendo un clima de confianza en las propias capacidades del estudiante sin penalizar sus errores. el académico debe crear incentivos para volver el estudio más racional, más sensible, a fin de ir más allá de la simple memorización. esto demanda del profesor una actitud de apertura al cambio, donde se asuma el compromiso de trabajar con modelos de educación que potencien todas las dimensiones del estudiante, que le permitan “aprender a aprender”. es menester también destacar, en sintonía con las investigadoras, que en la práctica docente los académicos debemos ser coherentes y claros en nuestros principios, creencias y valores. no debe faltar la congruencia en el cumplimiento de nuestra función docente entre lo que se dice, se siente y se hace. aspectos como el desarrollo de la autonomía, el pensamiento crítico, la capacidad de reflexión sobre uno mismo y sobre el propio aprendizaje, la motivación y responsabilidad por el estudio, la disposición para aprender significativamente y para cooperar buscando el bien colectivo, entre otras características que se asocian a los postulados constructivistas, son así mismo factores que indicarán si la educación (sus procesos y resultados) es o no de calidad. desde esta concepción, la calidad de un proyecto curricular y de una unidad educativa se relaciona con su capacidad de atender a las necesidades especiales que plantean los estudiantes. así, una escuela de calidad será aquella que sea capaz de atender a la diversidad de individuos que aprenden. y que ofrece una enseñanza adaptada y rica, promotora del desarrollo. el constructivismo se destaca como un paradigma educativo humanista, importante para enfermería, que estimula la creatividad y el respeto a la individualidad durante la planificación y ejecución de cualquier actividad. la filosofía educativa que subyace a estos planteamientos indica que la institución educativa, en este caso la universidad, debe promover el doble proceso de socialización y de individualización, debe permitir a los estudiantes construir una identidad personal y profesional, en el marco de un contexto social y cultural determinado. 145 correo del lector en un momento en el cual muchas escuelas y facultades de enfermería revisan sus currículos, reflexionan para renovarlos, perfeccionarlos y responder así a las demandas educativas y a la calidad que las universidades buscan en los procesos de acreditación o certificación, una investigación como la presentada por nuestras colegas mexicanas nos muestra evidencias que apreciamos y destacamos como un importante aporte a estos procesos y a la docencia en enfermería. sandra valenzuela suazo doctora en enfermería directora de la revista ciencia y enfermería departamento de enfermería universidad de concepción, chile me gustaría felicitar a las colegas enfermeras y docentes de la facultad de enfermería de la universidad de la sabana por el emprendimiento en publicar una revista de nombre tan sugestivo. aquichan (cuidado), y principalmente por ofrecer la oportunidad para que colegas de otros países escriban, tornándola una revista intercultural. me llamó la atención en esa edición el artículo de campbell. “gaining insight into student nurses’ clinical decision-making process”. pienso que es una excelente contribución en el sentido de difundir y dar coraje a colegas para introducir actividades como ésta en las escuelas de enfermería, aún más entre los docentes que deben estar preparados para nutrir la capacidad de reflexionar, pensar, hacer juicios clínicos y tomar decisiones que sean justas, adecuadas y competentes. la toma de decisiones clínicas es una actividad bastante popular en estados unidos, como la autora refiere, así como las actividades de pensamiento crítico y juicio clínico. en mi opinión, éstos son enfoques aún poco trabajados en enfermería de america latina, pero muy necesitados. mi duda, talvez por falta de información, es cómo nutrir la toma de decisión clínica, o sea, cómo hacer para que los alumnos adquieran esa capacidad. por otro lado, no me parece que haya una clara distinción entre la toma de decisiones clínicas y el juicio clínico. por eso se necesitan más estudios. el pensamiento crítico, en especial, cuenta con diversas estrategias para su desarrollo con los estudiantes. en brasil, por ejemplo, ya tenemos algunos libros traducidos y algunos trabajos publicados, pero las experiencias prácticas son raras. mi experiencia está más dirigida al desarrollo del pensamiento crítico, y tengo una especial preocupación con la práctica reflexiva, con lo que se denomina “reflexión en la acción”, que significa pensar acerca de lo que se hace en cuanto se hace. que todas podamos inspirarnos en estudios que utilicen tales abordajes. le deseo mucho éxito a la revista aquichan. vera regina waldow doctora en educación-enfermería profesora jubilada por la escuela de enfermeria universidade do rio grande do sul/porto alegre/rsbrasil la toma de decisiones clínicas ���������� � � ��������� �������� ������ ��� ����������� ����� � �� �� ���������� � � ��������� �� ����� ������ � � ����������� ����� � �� ���������� � � ��������� �� ����� ������ � � ����������� ����� � �� ���� �� �� ��� � �� �� �� •� ����� �������� �� ������ ���� ������������ ���� ��� � ��������� ��������� ������ ��� � ��������� � �� �� ������� �� ��� � ������� � �� ��������� �� ��� � �������� � � ����� � ��� 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portuguese adaptación y validación de la tuberculosis related stigma scale en portugués adaptação e validação da tuberculosis related stigma scale para português 10.5294/aqui.2022.22.2.6 maria isabel pereira da silva 1 beatriz rodrigues araújo 2 joão manuel costa amado 3 1 0000-0003-3817-1721. universidade católica portuguesa. interdisciplinary health investigation center. institute of health sciences. porto, portugal. misabelsilva101@gmail.com 2 0000-0003-0266-2449. universidade católica portuguesa. interdisciplinary health investigation center. institute of health sciences. porto, portugal. baraujo@ucp.pt 3 0000-0003-0358-7970. universidade católica portuguesa. interdisciplinary health investigation center. institute of health sciences. porto, portugal. jcamado@ucp.pt received: 04/02/2021 sent to peers: 10/12/2021 approved by peers: 07/03/2022 accepted: 11/03/2022 theme: evidence-based practice. contribution to the subject: this article presents a tuberculosis-related stigma scale for people with pulmonary tuberculosis undergoing treatment, with two dimensions and psychometric characteristics that ensure its reliability and validity in assessing the presence of stigma. it constitutes an instrument to support nurses' decision-making for an early intervention in people with pulmonary tuberculosis, so as to minimize the adverse effects of the social stigma associated with the disease. para citar este artículo / to reference this article / para citar este artigo: silva mip, araújo b, costa amado jm. adaptation and validation of the tuberculosis related stigma scale in portuguese. aquichan. 2022;22(2):e2226. doi: https://doi. org/10.5294/aqui.2022.22.2.6 abstract objective: to adapt and validate the tuberculosis related stigma scale (trss) in european portuguese. materials and method: a methodological study in a sample of 204 individuals being treated for pulmonary tuberculosis in portuguese pulmonary diagnostic centers, with at least one month of treatment or in follow-up. the evaluation process of linguistic and conceptual equivalence involved translation, the consensus among judges, back-translation, semantic validation, and pre-testing of the trss. the scale's psychometric properties were assessed by verifying the reliability and validity of the results and calculating cronbach's alpha coefficient and the exploratory factor analysis of principal components, with varimax rotation of the scale items. results: the portuguese version of the trss has a cronbach's alpha coefficient of 0.94 and has 23 items distributed in two dimensions: "community's perspectives on tuberculosis" (11 items) and "person's perspectives on tuberculosis" (12 items). its psychometric characteristics ensure adequate reliability and validity for the portuguese population. conclusions: the trss is a valid and reliable instrument to assess stigma in people with pulmonary tuberculosis and, to date, the only scale validated in this domain for the portuguese population, which allows nurses to make an integrated intervention. keywords (source decs): nursing; social stigma; tuberculosis; validation study; surveys and questionnaires. resumen objetivo: adaptar y validar la tuberculosis related stigma scale (trss) en el portugués de portugal. materiales y método: estudio metodológico, en una muestra de 204 personas en tratamiento de tuberculosis pulmonar, en centros de diagnóstico neumológico portugueses, con por lo menos un mes de tratamiento o en seguimiento. el proceso de evaluación de la equivalencia lingüística y conceptual implicó traducción, consenso entre expertos, retrotraducción, validación semántica y preprueba de la trss. las propiedades psicométricas de la escala se evaluaron a partir de la verificación de la fiabilidad y validez de los resultados, mediante el cálculo del coeficiente alfa de cronbach y el análisis factorial exploratorio de componentes principales, con rotación varimax de los ítems de la escala. resultados: la versión portuguesa de la trss tiene un coeficiente alfa de cronbach de 0,94 y quedó con 23 ítems distribuidos en dos dimensiones: "perspectivas de la comunidad en relación con la tuberculosis" (11 ítems) y "perspectivas de la persona en relación con la tuberculosis" (12 ítems). las características psicométricas le garantizan confiabilidad y validez adecuadas para la población portuguesa. conclusiones: la trss constituye un instrumento válido y fiable para medir el estigma en la persona con tuberculosis pulmonar y es, hasta ahora, la única escala validada en este dominio para la población portuguesa, lo que le permite al profesional de enfermería una intervención integrada. palabras clave (fuente: decs): enfermería; estigma social; tuberculosis; estudio de validación; encuestas y cuestionarios. resumo objetivo: adaptar e validar a tuberculosis related stigma scale (trss) para o português de portugal. materiais e método: estudo metodológico, numa amostra de 204 pessoas em tratamento de tuberculose pulmonar, em centros de diagnóstico pneumológico portugueses, com pelo menos um mês de tratamento, ou em follow-up. o processo de avaliação da equivalência linguística e conceptual envolveu tradução, consenso entre juízes, retrotradução, validação semântica e pré-teste da trss. as propriedades psicométricas da escala foram avaliadas através da verificação da confiabilidade e validade dos resultados, recorrendo ao cálculo do coeficiente alfa de cronbach e da análise fatorial exploratória de componentes principais, com rotação varimax dos itens da escala. resultados: a versão portuguesa da trss tem um coeficiente alfa de cronbach de 0,94 e ficou com 23 itens distribuídos por duas dimensões: "perspetivas da comunidade em relação à tuberculose" (11 itens) e "perspetivas da pessoa em relação à tuberculose" (12 itens). as características psicométricas garantem-lhe confiabilidade e validade adequadas para a população portuguesa. conclusões: a trss constitui um instrumento válido e confiável para avaliar o estigma na pessoa com tuberculose pulmonar sendo, até ao momento, a única escala validada nesse domínio para a população portuguesa, o que permite ao enfermeiro uma intervenção integrada. palavras-chave (fonte decs): enfermagem; estigma social; tuberculose; estudo de validação; inquéritos e questionários. introduction pulmonary tuberculosis (tb) is an infectious disease caused by mycobacterium tuberculosis complex, with the potential to affect any organ, being the most frequent the pulmonary form with the most public health implications. sick people expell the bacilli, mainly through coughing and speech, and can later be inhaled by others (1). in this context, one of the challenges of the world health organization (who) is to eliminate tb. therefore, to eradicate the disease by 2050, they have planned and implemented strategies to reduce mortality rates by 90 % and incidence rates by 80 % by 2030 (2-3). already in 2015, the who proposed, in the end tb strategy, additional targets so that no person with tb needs to bear the catastrophic costs or social repercussions caused by the disease (4). although there has been a decrease in its incidence rate in recent years, this reduction is considered insufficient in view of the desired goals. it is estimated that in 2019, worldwide, about ten million people will have contracted the disease. it remains a serious global public health problem (3). in portugal, the national program for the fight against tuberculosis foresees that the planning and provision of care related to tb tend to be centered on primary health care, whose pillars are the centers for pneumological diagnosis (cpd). in the last ten years, portugal has been showing a decrease in its incidence rate, with an annual reduction of about 5 % of new cases (5). however, this figure is clearly insufficient, and needs to be doubled in order to meet the targets proposed by who (3). in 2017, about 1,244 new cases were diagnosed, and in 2018, 1,703 new cases were reported. this figure refers to an incidence rate of approximately 15.6/100,000 inhabitants (6). it is also known, through data from may 2020, that in portugal and in the north region, the percentage of completed treatments was 82.4 % (7). despite the positive evolution, portugal still does not meet the targets set by the who for 2030 (3). the type of treatment to be instituted and the measures recommended for its follow-up are essential for therapeutic success. this is intrinsically related to the measures adopted, which contribute to reducing exposure to cases of drug resistance and relapse, motivated by interruption or abandonment of treatment. in public health terms, treatment failure can lead to relapses, failure to interrupt the chain of transmission of the disease, and even to multidrug-resistant tb, which are very important problems in terms of public health (2, 8, 9). related to the commitment and coordination between the various structures and intervention programs in the fight against pulmonary tb, priorities for action on social risk factors, such as stigma, are also included (3). in recent years, there has been a growing concern with understanding the stigma associated with tb, with the aim of identifying and implementing interventions that can minimize its impact on people with this disease (10-13). within the healthcare system, stigma in a person living with a specific disease leads to delayed diagnosis, treatment, and successful health outcomes (14). however, stigma reduction has not been a priority in health policies, nor is it widely stated in how health services are delivered or evaluated, nor is it a standard part of the initial and continuing training of all health professionals (12). stigma is described as a powerful social process characterized by labeling and stereotyping an individual, relating him/her to a deeply undesirable or derogatory attribute in the eyes of society, and can lead to marginalization, isolation, and exclusion from social relationships. stigma presents itself as a sign of shame or disapproval, resulting in an individual being rejected, the object of discrimination, and even excluded from participation in various areas of society (15). if related to health care facilities, stigma negatively affects people who seek health care services when they are in a situation of greater vulnerability. in this context, some of the manifestations of stigma include: the denial of care, the provision of care with a lower standard of quality than desirable, physical and verbal abuse, even more bizarre forms, such as purposely increasing waiting times for care. it thus emerges as a barrier to care for people seeking health services for disease prevention, treatment of acute or chronic conditions, or support to maintain a healthy lifestyle (12). therefore, the social stigma of tb poses a challenge to the management of care for people with pulmonary tb. the literature review allowed us to identify the tuberculosis related stigma scale (trss) administered specifically to people with tb and seems to be a scale capable of assessing and measuring stigma in people with pulmonary tb. it is a scale that quantifies the stigma associated with this disease and was developed in southern thailand, with internal consistency considered adequate by the author (cronbach's alpha greater than 0.70) (16). the scale consists of 23 items divided into two dimensions: the first dimension is related to the "community's views on tuberculosis" and consists of 11 items, which assess the individual's perception of the community's behavior towards people with tb (negative feelings, isolation, discrimination and disclosure, among others); the second dimension is related to the "person's views on tuberculosis". consisting of 12 items, it assesses the individual's perception of the disease and includes feelings related to fear of disease transmission, guilt, shame, and grief when confronted with the disease (16). each item is answered on a likert-type scale, with four response options: 1 strongly disagree; 2 disagree; 3 agree; and 4 strongly agree. in the dimension "community perspectives on tuberculosis", the calculation of final scores may vary between 11 and 44. on the other hand, in the dimension "person's perspectives on tuberculosis", scores may vary between 12 and 48. in both dimensions, the higher the score, the greater the stigma related to the disease. therefore, the application of this scale in the portuguese cultural context is justified by the potential to obtain knowledge about the patient's perception of the stigma associated with the disease. as a contribution to nursing care, the added value through the knowledge obtained may have a broad impact on improving the quality of nursing practice, as well as on the potential for a person-centered approach to nursing care. thus, this study aims to adapt and validate the trss for european portuguese. materials and methods for the process of adaptation and analysis of the psychometric properties of the trss, a methodological study of cross-sectional nature was carried out using a qualitative and quantitative analysis of the items (17-21). procedures this study was conducted in two stages: evaluation of linguistic and conceptual equivalence, which included translation, the consensus among judges, back-translation, semantic validation, and pre-test of the trss, and evaluation of the psychometric properties of the scale (17). after the authors' authorization, the linguistic and conceptual equivalence was assessed, starting with the translation of the trss from english into portuguese. the translation was carried out independently and autonomously by two bilingual translators: one, whose native language was english and who was familiar with the cultural and linguistic singularities of the portuguese language; and another, whose native language was portuguese and who was familiar with the construct to be evaluated. the two translations were synthesized, reducing the differences found in the translations and choosing the best expressions and words for each item. the text was adapted to the portuguese cultural knowledge through a consensus process, harmonizing and producing a common translation, and a written report was prepared documenting the synthesis process, with a record of the proposed changes. next, a copy of the portuguese version of the trss was sent to two other english translators, who did not know the original text in order to avoid any influence on the translation of the words and did the scale's back-translation. the researchers and the translators performed a new evaluation of the two versions and produced a single consensus document. this step verified the validity of the translation in its semantic equivalence, providing assurance that the translation process of the first consensus version reflects the items of the original version. this document, as well as the specified report of the results associated with the translations and back-translations, was sent to the first author of the original trss, who accepted the proposed suggestions. this process minimized the possibility of conceptual errors in the translation (17-20). subsequently, and for the purpose of cultural validation, we submitted the last translated version to a panel of five experts, two of whom were nurses with experience in caring for tb patients in a cpd, a physician with experience in the treatment and follow-up of tb patients, a methodologist, a professor of sociology with expertise in the cultures and behaviors of asian populations, and a professor of portuguese and english (native speaker of an english-speaking country), who analyzed the trss and suggested minor adjustments regarding clarity and comprehension. after revision, the final version of the trss was produced and administered to a group of 30 people already undergoing tb treatment, followed by spoken reflection, with the suggestion of changing some words to others more commonly used in the portuguese language and culture and replacing the word "nojo" (present in item #5) by "fear". in the second stage, we assessed the psychometric characteristics of the final version of the trss in a sample of 204 patients with pulmonary tb being treated at a cpd in the northern region of portugal. when calculating the sample, we considered that the number of five to eight respondents per item would be sufficient for exploratory factor analysis (21). the inclusion criteria were age of majority, pulmonary tb, and at least one month of treatment or follow-up. data was collected after the favorable opinion of the ethics committee for health of the regional health administration of the north, i. p., porto, under number 021/2019. all participants, of legal age, who agreed to participate in the study, signed the informed consent form, ensuring data anonymity and confidentiality. psychometric properties were assessed by determining the accuracy or reliability and validity of the results. to test reliability, we used the sense of internal consistency given by cronbach's alpha coefficient of the scale. for construct validation, we performed an exploratory factor analysis of principal components with varimax rotation of the scale items, to identify the underlying factors. for factor retention, we took into consideration eigenvalues greater than one. we performed the kaiser-meyer-olkin test (kmo) and bartlett's test of sphericity (bts) to assess the adequacy of the sample for factor analysis. for the factor analysis to be smooth and reliable, we assumed not to accept saturations below 40 % (21-23). data was analyzed using the statistical package for social sciences (spss) for windows, version 26.0. a confidence interval of 95 % was set, with a margin of error of 0.05. results in this study, 204 patients treated for pulmonary tb in portuguese cpds participated, mostly males (61.7 %), aged between 18 and 68 years (m = 42.7 years; sd = 11.8 years). the average age of males was 45.5 years and of females 38.6 years. most participants in the sample were married (n = 99 [48.5 %]), the professional status of employed prevails (n = 148 [72.5 %]), followed by unemployed status (n =30 [14.7 %]). as for education, about 45.1 % (n = 92) of the participants had completed the 1st, 2nd, and 3rd cycles of basic education, 26.5 % (n = 54) had completed secondary education, and 26.9 % (n = 55) had completed high school or college. the entire sample had started treatment at least one month ago or was in follow-up. to assess the scale's reliability or internal consistency, cronbach's alpha coefficient was calculated both for each item and for the totality of items. table 1 presents the results of the internal consistency and homogeneity analysis for the 23 items of the trss. along with the mean and standard deviation, we describe the respective correlation of the item with the total of its belonging scale (corrected coefficient) and the alpha value if this same item was deleted, considering the total sample (n = 204). table 1. internal consistency analysis and homogeneity of the trss items items mean standard deviation r itc (corrected) cronbach's alpha if eliminated item some people may not want to eat or drink with friends who have tb. 3.05 0.65 0.63 0.94 some people feel uncomfortable being around someone with tb. 3.26 0.67 0.67 0.94 if a person has tuberculosis, other people behave differently towards him. 3.21 0.65 0.64 0.94 some people don't want their children to play with someone who has tuberculosis. 2.98 0.54 0.44 0.94 some people stay away from people with tb. 3.48 0.71 0.81 0.94 some people think that they should not go near people who have tuberculosis. 3.48 0.69 0.78 0.94 some people don't want to talk to someone who has tb. 3.35 0.70 0.74 0.94 some people are afraid of those who have tuberculosis. 3.55 0.60 0.80 0.94 some people avoid touching someone with tb. 3.46 0.73 0.78 0.94 some people may not want to eat or drink with relatives who have tuberculosis. 3.07 0.63 0.67 0.94 some people prefer that someone with tb not live near them. 2.98 0.69 0.65 0.94 people with tuberculosis feel hurt by the way others react when they know they have the disease. 3.25 0.64 0.68 0.94 people with tuberculosis lose friends when they tell them they have the disease. 2.51 0.66 0.47 0.94 people with tuberculosis feel lonely. 2.50 0.71 0.33 0.94 people who have tuberculosis keep away from others to avoid spreading the disease. 3.54 0.71 0.67 0.94 people with tuberculosis are afraid to tell people outside their family that they have the disease. 3.53 0.73 0.79 0.94 people with tb are afraid to go to the tb treatment unit (cpd) because other people might see them there. 3.22 0.90 0.73 0.94 people with tuberculosis are afraid to tell others that they have the disease because they might think they also have aids. 2.53 0.78 0.44 0.94 people with tb feel guilty because they feel they are a burden to their family. 2.50 0.71 0.42 0.94 people with tuberculosis choose carefully whom they tell about their disease. 3.47 0.73 0.75 0.94 people with tuberculosis think they may have contracted the disease due to addiction to tobacco, alcohol or other risky behaviors. 2.50 0.73 0.39 0.94 people with tuberculosis fear that they have also contracted hiv. 2.26 0.72 0.43 0.94 people with tb are afraid to tell their families that they have the disease. 3.27 0.93 0.71 0.94 global alpha 0.94 source: own elaboration. from values in table 1, we found that the cronbach's alpha coefficients of each item related to the total scale were 0.94, obtaining a "very good" internal consistency (22). these values indicate a very good correlation among all items and a good homogeneity of the items. we tried to evaluate the internal consistency in case any item was removed from the analysis and we verified that all items present correlations higher than 0.20. analyzing the correlation of each item with the total scale, we verified that the values oscillate between 0.33 and 0.81. it should be noted that, the value found refers to the correlation of the item with the sum of the other items, that is, the item itself was excluded from the sum of the scale. the next step was to analyze the validity of the measurement instrument, more specifically its internal structure. we used factor analysis, which aims to establish correlations between statements and groups of statements in order to highlight factors that explain these correlations. the factor analysis allows assessing the adjustment of the structure obtained based on the observed data with the dimensional organization rationally derived from the conceptual definition of the variable. the factor loading of an item translates the extent to which this item represents, at the behavioral level, a given latent trait, i.e., the percentage of covariance between this item and the respective factor (21-23). table 2 shows the values resulting from the dimensionality analysis of the trss. we used the principal components factor analysis with orthogonal rotation by the varimax method of the 23 scale items the underlying factors. from this analysis, we retained the items with eigenvalues equal to or greater than unity and the factorial saturations of the items greater than 0.40. this index will be lower when the assumption of the 0.40 threshold implies the elimination of the item from any of the isolated factors. the eigenvalues and the percentage of variance are explained by each factor, the communalities (h2), the total variance explained, the measure of sample adequacy via the kmo test, and the bts. table 2. trss factor analysis results items factors h2 1 2 community perspectives on tuberculosis a = 0.94 some people may not want to eat or drink with friends who have tb. 0.68   0.45 some people feel uncomfortable being around someone with tb. 0.81   0.60 if a person has tuberculosis, other people behave differently towards them. 0.78   0.55 some people don't want their children to play with someone who has tuberculosis. 0.54   0.24 some people stay away from people with tb. 0.93   0.89 some people think that they should not go near people who have tuberculosis. 0.90   0.85 some people don't want to talk to someone who has tb. 0.84   0.74 some people are afraid of those who have tuberculosis. 0.87   0.81 some people avoid touching someone with tb. 0.86   0.78 some people may not want to eat or drink with relatives who have tuberculosis. 0.79   0.52 some people prefer that someone with tb not live near them. 0.73   0.48 patient perspectives on tuberculosis a = 0.89 people with tuberculosis feel hurt by the way others react when they know they have the disease.   0.69 0.52 people with tb lose friends when they tell them they have the disease.   0.62 0.64 people with tuberculosis feel lonely.   0.50 0.60 people who have tuberculosis keep away from others to avoid spreading the disease.   0.68 0.54 people with tuberculosis are afraid to tell people outside their family that they have the disease.   0.80 0.70 people with tb are afraid to go to the tb treatment unit (cpd) because other people might see them there.   0.77 0.59 people with tuberculosis are afraid to tell others that they have the disease because they might think they also have aids.   0.59 0.41 people with tb feel guilty because they feel they are a burden to their family.   0.61 0.63 people with tuberculosis choose carefully whom they tell about their disease.   0.82 0.61 people with tuberculosis think they may have contracted the disease due to addiction to tobacco, alcohol or other risky behaviors.   0.53 0.44 people with tuberculosis fear that they have also contracted hiv.   0.62 0.51 people with tb are afraid to tell their families that they have the disease.   0.78 0.56 total variance explained — 59.23 % 46.68 % 12.55 %   eigenvalue 10.74 2.89   kmo measure of sample adequacy — 0.927 bts — 3847.599; p = 0.000 source: own elaboration. from the analysis of the results in table 2, we found that the kaiser-meyer-olkin (kmo) test value was 0.927, reflecting a good adequacy of the sample for the analysis. in turn, the bts value was 3847.599; p < 0.001, which ensured the adequacy of the factor model to this correlation matrix to perform the factor analysis (21-23). the analysis of the correlation matrix between the 23 items and the total scale showed significant indices (p < 0.001) with significant correlations. the factorial organization of the items in two dimensions ("community perspectives on tuberculosis" with 11 items and "patient perspectives on tuberculosis" with 12 items, respectively) together, explain 59.23 % of the total variance of the scale. the saturation coefficients present values greater than 0.50. the communality values are good for most items, being almost all of them higher than 0.45, except for items 4, 18, and 21. table 3 shows responses to the 23 items of the trss, grouped into the two dimensions. along with the means and standard deviations, we described their correlation with the total of their belonging dimension (corrected coefficient) and the alpha value of the dimension if this same item were eliminated. table 3. results of the internal consistency and homogeneity analysis of the items per dimension of the trss dimensions no. items variation of means variation of standard deviations r itc (corrected) m scale sd scale alpha value community perspectives on tuberculosis 11 2.98 3.46 0.54 0.73 0.44 0.81 35.87 5.80 0.89 people's perspectives on pulmonary tuberculosis 12 2.26 3.54 0.64 0.93 0.33 0.79 35.06 6.024 0.94 source: own elaboration. the two dimensions of the trss showed good internal consistency (values equal to or higher than 0.89), with the dimension "community perspectives on tuberculosis" being more consistent (0.94). means ranged from 2.26 to 3.54 and standard deviations from 0.54 to 0.93. as for the corrected correlation coefficients of each item with the total dimension of belonging, the values were very satisfactory (between 0.44 and 0.81 for the dimension "community perspectives on tuberculosis" and between 0.33 and 0.79 for the dimension "person's perspectives on pulmonary tuberculosis"). next, table 4 presents the results of the correlation between the dimensions and the global scale. table 4. results of the correlation between the dimensions and the global scale dimensions/scale community perspectives on tuberculosis people's perspectives on pulmonary tuberculosis community perspectives on tuberculosis   0.67** people's perspectives on pulmonary tuberculosis 0.67**   global scale 0.91** 0.92** ** the correlation is significant at the 0.01 level. source: own elaboration. analyzing globally the values in table 4, there was a moderate relationship between the two dimensions, and they are strongly correlated with the global scale in a statistically significant way. discussion in the initial phase, after translation, semantic, idiomatic, conceptual and cultural equivalence, and the consensus among judges were obtained through the methodological process. considering the specificity of some of the terms applied and their cultural and linguistic meaning, the initial translation procedure, the synthesis of the two translations, the back-translation, the panel of experts, and the pretest were crucial to ensure the equivalence of the trss. the trss is a short and reliable scale that quantitatively measures stigma associated with tb. it has an "excellent" internal consistency with an overall cronbach's alpha of 0.94 (21). the 23-item scale is structured in two dimensions: "community perspectives on tuberculosis" (with 11 items), which identifies negative feelings and emotional reactions toward affected individuals, isolation, discrimination, and disclosure, and "patient perspectives on tuberculosis" (with 12 items), which identifies feelings such as fear of casual transmission, moral values of guilt, responsibility, shame, and grief in coping with tb (16). the first dimension obtained a cronbach's alpha of 0.94 and the second, 0.89. when we compared the reliability or internal consistency indices obtained in our study with those obtained by the authors of the original scale, we found higher values both in the global scale (a = 0.91) and in the two dimensions (a = 0.88 and a = 0.82, respectively), demonstrating its robustness (16). this scale assesses stigma from two perspectives: the community's response to those who have tb and how stigma is experienced by people with pulmonary tb. thus, it is an instrument of great interest (11) and has contributions to the area of care planning for patients, enhancing adherence and completion of the treatment instituted (10-13). conclusions the adaptation of the trss into the portuguese language and culture of portugal showed an excellent internal consistency, with a cronbach's alpha of 0.94, reproducibility and overlapping with the results of other studies carried out by the author of the original scale. it is a short (23-item) and reliable scale that quantitatively measures the stigma associated with tb. in addition, stigma was assessed from the community's and the patient's perspectives of pulmonary tb. thus, it is an instrument of great interest, with contributions to the area of care planning for patients, enhancing adherence and completion of the treatment instituted. the entire adaptation and validation process was conducted according to international guidelines, as was the analysis of the psychometric properties of construct validity and internal consistency. this study translated, adapted and validated the trss into the portuguese language and culture of portugal, as an instrument to assess stigma in patients with pulmonary tb from the patient's own perspective. its psychometric characteristics ensure adequate reliability and validity for the portuguese population. since it is a short and easy-to-understand instrument, its application to patients with tb will allow us to identify the main causes and consequences of the stigma that may lead to non-adherence to and completion of treatment in patients with pulmonary tb. thus, the trss is a valid and reliable instrument for nurses to use in the diagnosis of stigma in people undergoing treatment for pulmonary tb, being, so far, the only scale validated in this field for the portuguese population, which allows nurses to make their intervention comprehensive. thus, we believe that it will add scientific knowledge to nursing, and may provide greater accuracy to clinical practice. study limitations one of the limitations of this study refers to the perceptions of people with pulmonary tb undergoing treatment in the northern region of portugal. further research should be conducted with people with other types of tb, at different stages of the disease and from other regions of the country. however, the results of this study show that the trss is an 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[internet]; 2017[internet]; 2018[citado 22 nov. 2020]. disponível em: https://www.intestcom.org/files/guideline_test_adaptation_2_brasilian_portuguese.pdf 18. ximenes rrc, carvalho zmf, coutinho jfv, braga dco, coelho jma, studart rmb, et al. cross-cultural adaptation and validation of the intermittent self-catheterization questionnaire. rene.2018;19:e3315. doi: https://doi.org/10.15253/2175-6783.2018193315 19. reis lr, donato m, sousa r, et al. tradução, adaptação cultural e validação da escala satisfaction with amplification in daily life para o português de portugal. acta médica portuguesa. 2017;30(2):115-21. doi: https://doi.org/10.20344/amp.7794 20. epstein j, santo rm, guillemin f. a review of guidelines for cross-cultural adaptation of questionnaires could not bring out a consensus. j clin epidemiol. 2015;68(4):435-41. doi: https://doi.org/10.1016/j.jclinepi.2014.11.021 21. almeida l, freire t. metodologia da investigação em psicologia e educação. 5a ed. braga: psiquilíbrios; 2017. 22. marôco j. análise estatística com o spss statistics. 8a ed. pêro pinheiro: reportnumber, editor; 2021. 23. watson jc. establishing evidence for internal structure using exploratory factor analysis. measurement and evaluation in counseling and development. 2017;50:232-8. doi: https://doi.org/10.1080/07481756.2017.1336931 home 06 percepcion de la calidad del cuidado.indd 74 aquichan issn 1657-5997 luz marina bautista r.1 percepción de la calidad del cuidado de enfermería en la ese francisco de paula santander recibido: 23 de octubre de 2007 aceptado: 29 de enero de 2008 1 enfermera. magíster en enfermería con énfasis en gerencia en servicios de salud. docente, universidad francisco de paula santander. cúcuta, colombia. bautrod@gmail.com. resumen objetivo: describir la forma como algunos usuarios de la empresa social del estado francisco de paula santander, de cúcuta, colombia, hospitalizados en el servicio de especialidades médicas, percibieron la calidad del cuidado del personal de enfermería durante el segundo semestre de 2004. muestra: 202 usuarios del servicio de especialidades médicas que cumplieran con los criterios de inclusión y aceptaran participar mediante firma de consentimiento informado. el estudio es de tipo cuantitativo descriptivo transversal. método: se utilizó el instrumento caring assessment questionare (care-q) de patricia larson, integrado por cincuenta preguntas divididas en las siguientes subescalas del comportamiento de la enfermera: accesible, explica y facilita, conforta, se anticipa, mantiene relación de confianza, y monitorea y hace seguimiento. resultados: los comportamientos más importantes percibidos por los usuarios están relacionados con habilidades del personal como: administrar al paciente los tratamientos y las medicinas oportunamente, saber aplicar inyecciones, manipular equipos de uso parenteral (sueros), las máquinas de succión y otros equipos. los comportamientos menos importantes son: preguntar al paciente cómo prefiere que lo llamen, sentarse con éste, ser jovial, ofrecer alternativas razonables y encontrar la mejor oportunidad para hablarle sobre los cambios de su estado de salud. conclusión: conocer la percepción de los usuarios permite evaluar la calidad de los cuidados ofrecidos en los servicios de salud, para ser más competitivos y satisfacer las necesidades y expectativas de cuidado del paciente hospitalizado en el servicio de clínicas médicas. palabras clave atención al paciente, cuidado, personal de enfermería, servicios de salud. año 8 vol. 8 nº 1 chía, colombia abril 2008 74-84 75 percepción de la calidad del cuidado de enfermería en la ese francisco de paula santander perception of the quality of nursing care at the francisco de paula santander social service center abstract: aim: to describe how a group of hospitalized users of medical specialties at the francisco de paula santander social service center, a state-run institution in cúcuta (colombia), perceived the quality of nursing care during the second half of 2004. sample: 202 users of medical specialties, who met the criteria for participating in the study and agreed to participate by signing an informed consent form. this was a descriptive, cross-sectional study with a quantitative focus. method: patricia larson’s caring assessment instrument (care-q) was used. it included 50 questions divided into the following subitems related to the nurse’s behavior: he/she is accessible, explains and facilitates, comforts, is ahead of the patient’s needs, keeps a faithful relationship, monitors and follows up. results: the most important conduct perceived by users concerns the nurse’s ability to administer treatment and to give patients their medication on time, knowing how to inject and how to use parenteral equipment (for administering intravenous fluids), as well as suction machines and other equipment. less important conduct includes asking the patient how he/she wishes to be called, sitting beside the patient, being good humored, offering reasonable choices and finding the best moment to talk about changes in the patient’s state of health. conclusion: knowledge of the user’s perception makes it possible to evaluate the quality of care provided at health care facilities, so it can be improved, become more competitive and satisfy the hospitalized patient’s needs and expectations from the standpoint of clinical medicine. key words: attention, care, nursing staff, health services. percepção da qualidade do cuidado de enfermagem na empresa social do estado francisco de paula de santander resumo objetivo: descrever a percepção dos usuários hospitalizados sobre a qualidade do cuidado de enfermagem no serviço de especialidades médicas na empresa social do estado francisco de paula santander da cidade de cúcuta, colômbia, durante o segundo semestre de 2004. amostra: 202 usuários do serviço de especialidades médicas que cumpriram os critérios de inclusão e aceitaram participar firmando o consentimento informado. o estudo é quantitativo descritivo transversal. método: foi utilizado o caring assessment instrument (care-q) de patricia larson, formado por 50 perguntas divididas nas seguintes sub-escalas do comportamento da enfermeira: acessível, explica y facilita, conforta, se antecipa, mantém relação de confiança, e faz monitoramento e seguimento. resultados: os comportamentos mais importantes percebidos pelos usuários se relacionam com habilidades do pessoal, como administrar o paciente os tratamentos e medicinas oportunamente, saber como aplicar injeções, manejar equipes de uso parenteral (soros), máquinas de absorção e outras equipes. os comportamentos menos importantes são: perguntar ao paciente como prefere ser chamado, se sentar com ele, ser jovial, oferecer alternativas razoáveis, e encontrar a melhor oportunidade para falar-lhe das alterações do seu estado de saúde. conclusão: conhecer a percepção dos usuários permite avaliar a qualidade dos serviços oferecidos nos sistemas de saúde para ser mais competitivos e cobrir as necessidades e expectações do cuidado do paciente hospitalizado no serviço de clínicas médicas. palavras-chave atenção ao paciente, cuidado, pessoal de enfermagem, serviços de saúde. 76 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 introducción el marco establecido en el sistema de salud colombiano ha favorecido el creciente interés en considerar la opinión de los usuarios como indicador importante de la calidad de la atención, a fin de brindar una atención acorde con las necesidades y expectativas de éstos. a nivel nacional se han realizado estudios que muestran el grado de satisfacción que tienen los usuarios de los servicios de salud; sin embargo, se puede observar que la satisfacción de los usuarios como indicador de calidad ha sido evaluada desde una perspectiva global en la atención en salud, donde el cuidado que brinda enfermería no ha sido valorado específicamente. las instituciones de salud del país tienen hoy, más que nunca, la responsabilidad de establecer las herramientas que propicien la evaluación de la atención de los servicios que ofrecen, respondiendo efectivamente a las metas de salud y al reto de la competitividad; sin embargo, son escasos los logros en este campo, por la ausencia de metodologías prácticas y sencillas que puedan aplicarse a todas las instituciones, y mejor aún, que puedan ser utilizadas de manera específica por los diferentes servicios o profesionales que conforman la atención en salud. evaluar la calidad de la atención desde la perspectiva del usuario es cada vez más común, a partir de ello, es posible obtener del entrevistado un conjunto de conceptos y actitudes asociados con la atención recibida, con los cuales se adquiere información que beneficia a la organización otorgante de los servicios, a los prestadores directos y a los usuarios mismos en sus necesidades y expectativas. enfermería es fundamental en la atención que se brinda en cualquier institución de salud, conocer la percepción del usuario sobre la calidad del cuidado que se ofrece es de vital importancia en la práctica de enfermería en el actual modelo de seguridad social, que ha dado información y educación a los usuarios. el presente estudio tiene como objetivo describir la percepción de la calidad del cuidado del personal de enfermería que tienen los usuarios hospitalizados del servicio de especialidades médicas de la clínica perteneciente a la ese francisco de paula santander de cúcuta. las instituciones de salud del país tienen hoy más que nunca la responsabilidad de establecer las herramientas que propicien la evaluación de la atención de los servicios de salud, respondiendo efectivamente a las metas de salud y al reto de la competitividad; sin embargo, son escasos los logros en este campo, por la ausencia de metodologías prácticas y sencillas que puedan aplicarse a todas las instituciones, y mejor aún, que puedan ser utilizadas de manera específica por los diferentes servicios o profesionales que conforman la atención en salud. el presente trabajo se realiza con el propósito de contar con información que permita la cualificación del cuidado ofertado, que favorezca la orientación de éste primordialmente para satisfacer las necesidades y expectativas del paciente con calidad, de tal manera que contribuya a mejorar la atención de enfermería en las instituciones de salud. 77 percepción de la calidad del cuidado de enfermería en la ese francisco de paula santander materiales y métodos el estudio es de tipo cuantitativo descriptivo transversal, se realizó en el servicio de especialidades médicas de la clínica de la ese francisco de paula santander de la ciudad de san josé de cúcuta. los criterios de inclusión para seleccionar la muestra fueron los siguientes: a) diagnóstico de hospitalización para medicina interna en las subespecialidades de cardiología, oncología, dermatología, nefrología, gastroenterología, hematología y nutrición; b) estancia hospitalaria mínima de tres días; c) encontrarse hospitalizado en el momento de aplicar el instrumento; d) no referir alteración en su estado anímico durante las 24 horas anteriores. la población la constituyen 864 usuarios que egresaron del servicio durante el año 2003, los seleccionados para la muestra corresponden a 202 pacientes hospitalizados durante el segundo semestre de 2004. la muestra se obtuvo mediante muestreo probabilístico sistemático realizando listado general de usuarios hospitalizados en el servicio de especialidades médicas de la ese francisco de paula santander, y después seleccionando cada cuatro pacientes de acuerdo con el universo y la muestra del estudio. el instrumento utilizado para recolectar la información fue el caring assessment instrument (care-q), el cual está integrado por 50 preguntas divididas en las siguientes subescalas del comportamiento de la enfermera: accesible, explica y facilita, se miden a través de 6 preguntas cada uno; conforta, mediante 9 preguntas; se anticipa, con 5; mantiene relación de confianza incluye 16 preguntas, y monitorea y hace seguimiento, con 8 preguntas. estas subescalas constituyen las variables que permiten determinar cómo enfermería desarrolla acciones para enseñar, ayudar, establecer confianza y realizar seguimiento. el instrumento fue diseñado por la enfermera patricia larson y validado por la autora en el estudio realizado como disertación doctoral (1). la validez de contenido del instrumento se obtuvo por medio de dos paneles de expertos, y la confiabilidad mediante dos estudios realizados de prueba-contraprueba, obteniendo en el primero una correlación perfecta entre el test 1 y el test 2 de r: 1,0. en el segundo se reveló la consistencia de la clasificación de ítems, encontrando como el más importante (límite 5) del 79% del test 1 al test 2, y menos importantes (cinco últimos) con una relación de consistencia del 63,4%. este instrumento ha sido empleado y validado en otras investigaciones con los mismos propósitos, como en el estudio realizado en méxico donde se determinó la confiabilidad del instrumento care-q y se obtuvo un alpha de cronbach de 0,90 (2). el coeficiente alpha de cronbach produce valores que oscilan entre 0 y 1, indicando mayor estabilidad de la medición los valores que se acercan a 1 (3). en este caso el nivel de confiabilidad es satisfactorio. las variables que plantea el instrumento permiten conocer claramente lo que el usuario percibe y expresa con relación a la interacción que se establece en el cuidado entre personal de enfermeríausuario. por otra parte, al aplicar el instrumento se podrá determinar cuáles son los aspectos que el paciente considera relevantes en la interacción personal que se establece con él, conociendo las acciones realizadas por el personal de enfermería y percibidas por el paciente como significativas o importantes para que se piense en calidad de los cuidados. las variables que plantea el instrumento permiten conocer claramente lo que el usuario percibe y expresa con relación a la interacción que se establece en el cuidado entre personal de enfermería-usuario. 78 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 para obtener la percepción que tiene el usuario sobre las acciones que indican calidad en los cuidados brindados, se estableció una escala de clasificación de 1 a 7, donde 1 es nada importante, y 7 es importantísimo, la cual permitió al paciente opinar según la significancia que tienen para él las acciones realizadas por enfermería. el método seleccionado es el denominado metodología q que permite, mediante elección forzosa, clasificar los comportamientos seleccionando un número prederminado de ítems por cada una de las categorías, los cuales se depositan en sobres marcados con la escala de clasificación; se indicó al usuario que ordenara 1 como la más importante, 4 como bastante importante, 10 como importante en alguna forma, 20 como ni importantes ni sin importancia, 4 como menos importantes, y 1 como la menos importante. finalizada la recolección de información se digitó inicialmente en una base de datos de excel y luego, para obtener la estadística requerida de promedios, desviación estándar y coeficiente de variación en una base de datos epi-info 2000. resultados y discusión la recolección de información en la muestra definida permitió obtener los siguientes resultados que se especifican por categorías según la importancia percibida por los usuarios para cada comportamiento. la categoría “es accesible” comprende los comportamientos relacionados con acercarse, responder a los llamados y realizar cuidados específicamente de habilidad de manera oportuna; de acuerdo con las respuestas obtenidas en esta categoría, se encuentra que la mayor parte de los pacientes percibe como de alta importancia el comportamiento de administrar tratamientos y medicinas oportunamente, el cual obtuvo una calificación promedio de 6,05 siendo percibido como muy importante. los hallazgos obtenidos sobre los comportamientos percibidos como importantes por los usuarios en esta categoría indican el valor que tiene para ellos que el personal de enfermería posea conocimientos y destrezas que favorezcan el cuidado, específicamente en acciones técnicas que den cumplimiento a órdenes médicas, y respuesta a algunas necesidades sentidas por el usuario. estos hallazgos se fundamentan en lo planteado por jean watson (4) en la teoría de los cuidados humanos, donde define la enfermería como una ciencia humana de experiencias de salud-enfermedad-curación que deben ser abordadas desde dos vertientes, la instrumental y la expresiva. las actividades instrumentales comprenden las necesidades físicas como pueden ser la administración de medicamentos y la realización de procedimientos, las expresivas se refieren a necesidades psicosociales orientadas al comportamiento. la categoría “explicar y facilitar” hace referencia a la información y educación que requiere el paciente para entender la situación actual de enfermedad y tratamiento, los resultados obtenidos muestran que la mayoría de las calificaciones promedio de los comportamientos en esta categoría están por debajo de 5, es decir, de mediana importancia. el ser honesto(a) con el paciente sobre su condición médica, es el comportamiento más importante para el paciente, ya que presentó la calificación ponderada más alta del grupo percibiéndolo como muy importante. la categoría “es accesible” comprende los comportamientos relacionados con acercarse, responder a los llamados y realizar cuidados específicamente de habilidad de manera oportuna. 79 percepción de la calidad del cuidado de enfermería en la ese francisco de paula santander el hallazgo de “ser honesto” tiene relación con lo planteado por nightingale respecto a las actitudes que había que desarrollar para cuidar correctamente a los pacientes, señalando lo siguiente: “una enfermera debe ser una persona en la que se pueda confiar, en otras palabras, capaz de ser enfermera de confianza... no puede ser ligera habladora; nunca debe contestar preguntas sobre su enfermo; debe ser estrictamente moderada y honesta” (5). estos resultados encontrados demuestran la importancia que tiene para el usuario el que se explique o se informe sobre su condición actual, implicando la necesidad de fortalecer el rol funcional de educar en el proceso de formación, en el cual se deben brindar los elementos teórico-prácticos necesarios que favorezcan la adquisición de esta habilidad. así mismo, el profesional de enfermería de la asistencia deberá incluirlo como una de las intervenciones prioritarias que se planean en el proceso de enfermería. la categoría “conforta” plantea comportamientos que permiten dar ánimo, involucrar a familiares y brindar las mejores condiciones para que el paciente se sienta bien. los comportamientos más importantes para el usuario, que son percibidos como de mediana importancia, tienen que ver con: tener paciencia aún con los pacientes difíciles; procurar medidas básicas de confort, tales como iluminación adecuada, control de ruido y sábanas adecuadas, entre otros, e involucrar a la familia del paciente o a otros allegados en su cuidado. los resultados anteriores se pueden sustentar con lo escrito por escobar saldarriaga y cols. (6) en su investigación de la calidad de enfermería en salas de parto, donde se plantea que la relación interpersonal no se mide exclusivamente por la comunicación verbal. también hace referencia al interés que se tiene por las personas usuarias, el cual se demuestra por la comodidad, la privacidad y por el ambiente que se les proporciona en los diferentes lugares donde se presta la atención en salud. los resultados indican que brindar medidas de confort es un aspecto fundamental para contribuir a la satisfacción de la persona usuaria del servicio de enfermería y de salud. proporcionar estas medidas no solo implica para enfermería tener unas condiciones ambientales y estéticas favorables, sino se constituye en un espacio para conocer, establecer empatía, dialogar y educar al usuario. la categoría “anticiparse” hace referencia a los comportamientos que se deben realizar para prever necesidades y complicaciones. al revisar los resultados se encuentra que los comportamientos de esta categoría se clasificaron como de mediana importancia, siendo percibidos como ni importantes ni sin importancia, destacándose entre los de promedio más elevado prever que las “primeras veces” son las más difíciles y por lo tanto dedicar atención especial al paciente durante estas oportunidades, tomar conciencia de que la noche es a menudo el tiempo más difícil para el paciente, anticiparse al impacto con relación al diagnostico y planificar actividades al respecto. estos hallazgos se relacionan con lo planteado por lock (7) en el libro como gerenciar la calidad total, en el cual se consideran las dimensiones que comprende la calidad, específicamente la del servicio, considerada como la oportunidad y continuidad en que se presta la atención. la categoría “anticiparse” hace referencia a los comportamientos que se deben realizar para prever necesidades y complicaciones. 80 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 estos resultados sugieren que para el usuario es importante que el personal de enfermería le brinde el cuidado necesario cuando se ingresa por primera vez, sin querer decir que este cuidado no sea tenido en cuenta con pacientes que reinciden en el ingreso. así mismo, el personal de enfermería debe tener en cuenta las necesidades del usuario para planear las acciones de cuidado. la categoría “mantiene la relación de confianza” comprende comportamientos que favorecen la relación terapéutica y demuestran el interés y la preocupación por el paciente. esta categoría posee el mayor número de comportamientos, 16 en total. de acuerdo con lo expresado por los entrevistados, el presentarse ante el paciente y explicarle el procedimiento que se va a realizar, así como el trato con alto sentido humano, son los comportamientos con mayor promedio: 4,69 y 4,35 respectivamente, percibidos como de mediana importancia. estos resultados tienen relación con lo descrito por martínez y cols. (8) en el artículo “prospectiva de la enfermería en méxico”, donde se relaciona el modelo de evaluación de la calidad planteado por donabedian, de estructura, proceso y resultado, indicando que el proceso son las acciones que se llevan a cabo por el personal de enfermería, interactuando con el usuario (persona, familia, colectivo), y con otros profesionales de la salud. en otras palabras durante el proceso, en el caso de la práctica de enfermería, se refiere a la planeación y ejecución de intervenciones donde el profesional establece una relación de confianza necesaria y primordial para aplicar con éxito los conocimientos y las habilidades que permitan satisfacer las necesidades del usuario desde la integralidad (9). la relación de confianza constituye un elemento central en el arte de cuidar. sólo es posible cuidar a un ser humano vulnerable si entre el agente cuidador y el sujeto cuidado se establece una relación de confianza, un vínculo presidido por la fidelidad, es decir, de fe en la persona que interviene en su acción y en el dominio que tiene de dicho arte (10). la categoría “monitorea y hace seguimiento” está relacionada con los comportamientos que demuestran la capacidad científica, humana y técnica del personal. en esta categoría se encuentra que los pacientes entrevistados consideran de alta importancia el comportamiento relacionado con habilidades y destrezas de personal de enfermería; dentro de estos comportamientos se encuentra el saber aplicar inyecciones, manipular equipos de uso parenteral (sueros), las máquinas de succión y otros equipos que haya en el servicio, percibido como muy importante con un promedio de 5,65. este hallazgo se puede sustentar con lo expresado por rosello torralba (10) en la filosofía del cuidar, donde se “considera que la competencia profesional constituye una virtud básica de la deontología”. la tarea de cuidar requiere de varios constructos básicos, entre los que se encuentra la competencia profesional, “sólo es posible cuidar adecuadamente a un ser humano si se cuenta con la competencia desde el conocimiento, la experiencia y la destreza que permitan ver al ser que se cuida desde una perspectiva holística”. de igual manera, los resultados pueden fundamentarse con lo expresado por orrego sierra y ortiz zapata (11) en relación con las dimensiones de la calidad del cuidado de enfermería, específicamente con la dimensión técnica de la calidad, la categoría “mantiene la relación de confianza” comprende comportamientos que favorecen la relación terapéutica y demuestran el interés y la preocupación por el paciente. 81 percepción de la calidad del cuidado de enfermería en la ese francisco de paula santander referida como la aplicación de los conocimientos y la adecuada utilización de la tecnología, cuya función científico-técnica favorece la aplicación del conocimiento con criterios unificados, probados y evaluados sistemáticamente. se puede observar que los comportamientos de mayor importancia están relacionados con aspectos técnicos, donde las habilidades son significativas para el paciente, seguramente condicionados por la alta interacción con personal vocacional. igualmente, los resultados resaltan la necesidad de realizar identificación, priorización y planeación de cuidados según las necesidades y expectativas del paciente. la gráfica permite visualizar de manera global cada categoría según el nivel de importancia percibido por los pacientes. dentro de los comportamientos que los pacientes encuestados percibieron como los más importantes, es decir, como “muy importante e importantísimo”, se encuentra que el 81,7% de los usuarios considera que es administrar al paciente los tratamientos y las medicinas oportunamente; el 65,8% de los usuarios percibe que es el saber aplicar inyecciones, manipular equipos de uso parenteral (sueros), las máquinas de succión y otros equipos que haya en el servicio y, finalmente, el 64,4% de los usuarios considera que es ser honesto en cuanto a su condición médica. los comportamientos clasificados por los usuarios como de mediana importancia fueron percibidos como “ni importantes ni sin importancia” y como “algo importante”, dentro de estos se encuentra que el 83,2% de los usuarios percibe que es lograr tratar al paciente como una persona, el 82,2% considera que es escuchar al paciente, el 80,7% expresa que tiene que ver con tomar al paciente de la mano, cuando él necesita que alguien lo anime, el 79,2% manifiesta que es ser bien organizado(a) y, en última instancia, entre los de porcentaje más alto está el presentarse al paciente y explicar el procedimiento que se va a realizar, con el 78,2%. los comportamientos menos importantes para los usuarios entrevistados y, por tanto, con calificación cualitativa entre “nada fuente: instrumento caring assessment instrument (care-q). importante y poco importante” de mayor frecuencia son preguntar al paciente cómo prefiere que lo llamen, con el 87,1%, el 75,2% manifiesta estar de acuerdo con sentarse con el paciente, el 63,9% expresa que es el ser jovial, el 54% considera que está relacionado con ofrecer alternativas razonables y, finalmente, el 53,5% de los usuarios expresa que es comprobar la mejor oportunidad para hablarle sobre los cambios de su estado de salud. tabla. distribución de la percepción de comportamientos de cuidado de los usuarios de la ese francisco de paula santander por categorías categoría es accesible explica y facilita monitorea y hace seguimiento conforta se anticipa mantiene relación de confianza total promedio 4,39 4,32 4,08 3,98 3,95 3,72 4,07 fuente: care-q. los usuarios hospitalizados en el servicio de especialidades médicas de la clínica perteneciente a la ese francisco de paula santander de cúcuta perciben, según las calificaciones dadas a los diferentes comportamientos de las seis categorías planteadas en el instrumento care-q, que las categorías de es “accesible y explica y facilita” son consideradas de mediana importancia; estos resultados son parcialmente semejantes con los obtenidos en méxico en el estudio realizado por moreno monsiviadis (12), en donde se encontró que en la institución pública se reportaron medias más altas en relación con las características del cuidado de la enfermera tales como “conforta”, “explica y facilita” y “mantiene relación de confianza”, mientras que en institución privada reportó medias mayores en las caractegráfica. distribución de los grupos de comportamientos de acuerdo con la importancia percibida por los usuarios de la ese francisco de paula santander segundo semestre de 2004 82 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 rísticas de “accesibilidad de la enfermera”, “monitorea y hace seguimiento”. de igual manera, los resultados reportados son parcialmente semejantes con los del estudio realizado por cuervo (13) en colombia, el cual reportó como comportamientos de mediana importancia los pertenecientes a las categorías “mantiene relación de confianza, es accesible y conforta”. los hallazgos encontrados se fundamentan en lo planteado por orrego sierra y ortiz zapata (11); una de las dimensiones de esta calidad tiene que ver con la ética, la cual para ser tangible requiere establecer normas de calidad en todos los niveles, desde el conocimiento científico hasta las relaciones interpersonales, por tanto, acciones concretas como la información oportuna, la explicación verdadera de la condición de salud actual, la explicación de los procedimientos y la solicitud de autorización escrita (consentimiento informado) la hacen tangible (11). por otra parte, se pueden sustentar con lo planteado por milton mayeroff en la filosofía del cuidar, en donde la competencia profesional implica contar con la “competencia desde el conocimiento, la experiencia y la destreza permitiendo ver al ser humano que se cuida desde una perspectiva holística” (14). en este sentido, se puede observar que para los usuarios hospitalizados del servicio de especialidades médicas de la clínica perteneciente a la ese francisco de paula santander de cúcuta, lo más significativo en el cuidado que brinda enfermería es lo relacionado con la parte procedimental, y el manejo del tratamiento, es decir, habilidades, lo que puede indicar que en el cuidado el personal de enfermería enfatiza en los aspectos técnicos y da menor relevancia a la interacción que se debe establecer con el paciente como consecuencia probable de un alto contenido de funciones de tipo administrativo. conclusiones según la percepción de los usuarios del servicio de especialidades médicas de la ese francisco de paula santander, durante el segundo semestre de 2004 las categorías de mayor promedio son “es accesible, y explica y facilita”, “monitorea y hace seguimiento”. así mismo, los comportamientos percibidos como de mayor importancia tienen que ver con aquellos relacionados con la habilidad, como la administración de medicamentos y el manejo adecuado de los equipos. los comportamientos de mayor importancia para los usuarios hospitalizados del servicio de especialidades médicas de la clínica perteneciente a la ese francisco de paula santander de cúcuta están relacionados con las habilidades que debe tener el personal de enfermería, seguramente como resultado del sistema de salud actual, y el enfoque de cuidado que predomina en la región del norte de santander, donde el profesional de enfermería realiza en su mayor parte acciones administrativas relacionadas con la planeación y gestión de recursos para brindar el cuidado, sin olvidar que también lleva a cabo algunos procedimientos complejos y especializados; en cambio, el personal auxiliar desarrolla acciones procedimentales propias de su nivel de formación, lo cual parece ser más visible para el usuario. la enfermería, como ciencia social y humana, requiere de constructos éticos que fundamenten el cuidar con calidad, los los comportamientos percibidos como de mayor importancia tienen que ver con aquellos relacionados con la habilidad, como la administración de medicamentos y el manejo adecuado de los equipos. 83 percepción de la calidad del cuidado de enfermería en la ese francisco de paula santander cuales se deben considerar como virtudes básicas e ineludibles que se requieren para cuidar a un ser humano con excelencia profesional, éstas se deben constituir en hábitos personales y profesionales que día a día se utilicen con mayor frecuencia y generen la diferenciación de los cuidados que brinda el personal de enfermería. dentro de los comportamientos de la categoría “establece una relación de confianza”, el hecho de cuidar de una persona con trato humano es lo percibido con mayor importancia. desde la orientación humanista sólo tiene sentido cuidar si este cuidado se integra a un proceso de relación. de este modo, “cuidar” se convierte en un acto de reciprocidad cuando, temporal o definitivamente, se tiene que recibir ayuda de otra persona para poder llevar a cabo las necesidades más básicas. en el caso de los pacientes, los cuidados ayudan y confortan en la medida en que se tiene a alguien que se preocupa por ellos, que confía y ofrece atención y consuelo, esperanza y ayuda. pero también como profesionales, cuidar de alguien enriquece como personas, porque es en la relación de ayuda cuando mejor se aprende a conocerse y a conocer las fuerzas y los límites. conocer cuáles son los comportamientos que perciben los usuarios como importantes es relevante para las enfermeras (os) en servicio, debido a que permite identificar los aspectos significativos para alcanzar la calidad en el cuidado que se brinda, lo que favorecerá el fortalecimiento o la mejora de estos comportamientos mediante el establecimiento de acciones de mejoramiento en los servicios. los resultados obtenidos permiten que el personal profesional de enfermería que planifica los cuidados reflexione acerca de los comportamientos que se realizan diariamente y los comportamientos percibidos por el usuario como de mayor imporreferencias 1 larson p. percepciones del cuidado de pacientes con cáncer por enfermeras oncológicas [tesis doctoral]. san francisco: universidad de california; 1981. 2 moreno mg, bentancourt md, solis a, barron gl, gomez js. percepción de la calidad del cuidado de enfermería. desarrollo científico enfermería 1998; 6 (9): 267-271. 3 polit df, hungler bp. investigación científica en ciencias de la salud. 6 ed. méxico: mcgraw hill interamericana; 2000. 4 watson j. filosofía y teoría de los cuidados humanos. 3 ed. california: universidad de colorado; 1999. 5 paez r. la ética de las virtudes y enfermería. revista mexicana de enfermería cardiológica 2000; 8 (1-4): 62. 6 escobar i, castrillon mc, pulido s. calidad de atención de enfermería en salas de parto. revista de tancia. esta reflexión favorecerá mejorar los comportamientos realizados y, de esta manera, dar una mejor respuesta a las expectativas que tienen los usuarios. para los servicios de enfermería como parte de una institución de salud, es importante desempeñar con calidad el cuidado brindado a los pacientes; para lograrlo es indispensable pensar que el proceso de la calidad es un estímulo para el desarrollo personal de la profesión, y no una actividad para juzgarlo. agradecimientos a las directivas y el personal de enfermería de la clínica de la ese francisco de paula santander por su colaboración incondicional que favoreció los espacios y tiempos necesarios para el desarrollo de la investigación como una meta personal y profesional planeada. investigación y educación en enfermería de la universidad de antioquia 1992; 10 (2): 28. 7 lock d, smith d. cómo gerenciar la calidad total: estrategias y técnicas. bogotá: legis; 1992. 8 martínez l, avalo m, quintero al. calidad de los servicios de enfermería: ¿utopía o realidad? revista desarrollo científico en enfermería 2001; 9 (3): 68-75. 9 valdez me, jiménez gm. prospectiva de la enfermería en méxico. educación médica y salud. 3 ed. méxico: mcgraw-hill; 1991. 10 rosello, torralba. filosofía del cuidar. en: mapfre medicina. barcelona; 2000. 11 orrego s, ortiz ac. calidad de atención en enfermería. revista investigación y educación en enfermería de la universidad de antioquia 2001; 19 (2). 84 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 12 moreno mg, bentancourt md, solis a, barron gl, gómez, js. percepción de la calidad del cuidado de enfermería. desarrollo científico enfermería 1998; 6 (9): 267-271. 13 cuervo n. relación entre la percepción de los comportamientos de cuidado de los pacientes y el personal de enfermería. actualización en enfermería 1999; 2 (3). 14 cescatto mc. identificación de comportamientos expresivos de cuidado afectivo. comentado. brasil: universidad de são paulo; 2003. a glance at the barriers and enablers of the nursing role in pandemics: an integrative review article a glance at the barriers and enablers of the nursing role in pandemics: an integrative review una mirada a las barreras y los factores facilitadores del rol de la enfermería en las pandemias: revisión integrativa uma visão às barreiras e aos fatores facilitadores do papel da enfermagem nas pandemias: revisão integrativa 10.5294/aqui.2022.22.1.4 juan domingo reyes-luna 1 , patricia del tránsito jara-concha 2 1 0000-0002-4862-9700 universidad de concepción, chile. jreyesl@udec.cl 2 0000-0003-1580-3976 universidad de concepción, chile. pjara@udec.cl received: 19/10/2020 sent to peers: 16/12/2020 approved by peers: 27/09/2021 accepted: 30/09/2021 subject: evidence-based practice. contribution to the subject: it is relevant in that it identifies specific phenomena and more general aspects of nursing practice during pandemics, which can be transformed into research opportunities using diverse theoretical references. among the specific phenomena are nurses' fear of contagion and death in their personal and family environments; among the general aspects are the barriers, enablers, and ethical dilemmas that these professionals have faced in carrying out their role during the pandemic that is currently challenging humanity. the information in this article is a contribution to be contemplated by nursing professionals to address the development of their role in an emergency situation in a proactive, immediate, collaborative and multidisciplinary way. para citar este artículo / to reference this article / para citar este artigo: reyes-luna jd, jara-concha p. a glance at the barriers and enablers of the nursing role in pandemics: an integrative review. aquichan. 2022;22(1):e2214. doi: https://doi.org/10.5294/aqui.2022.22.1.4 abstract objective: to analyze the enablers and barriers to nurses' professional role fulfillment during pandemics and disasters. materials and methods: this was an integrative review based on the salsa analytical method, carried out in eight databases, namely: medline, proquest, cinahl, web of science, bvs, springerlink, scopus, and pubmed. the descriptors used were the following: 'nurse's role' and 'pandemic' and 'patient' and 'coronavirus infection', in english, spanish and portuguese. filters along with inclusion and exclusion criteria were applied to the 11,031 articles found, after which the final sample consisted of a total of 32 articles. results: considering the objectives set and the results obtained, it is noted that all actions focused on three main instances, namely: a) training and updating for role performance; b) predictors, enablers, and barriers for exercising the role in the face of a pandemic; and c) evidence of the role in the face of pandemics. conclusion: this study allowed understanding both the barriers and the enablers that allow the fulfillment of nurses' professional role in the face of pandemics or catastrophes. it also clarified that emerging infectious diseases must be addressed in an immediate, collaborative, and multidisciplinary way. nurses' experience, leadership, and professional training are key attributes that these professionals possess to enable their role to be more proactive during an emergency situation. keywords (source decs): nurse's role; pandemics; community health nursing; nurse clinicians; coronavirus infections. resumen objetivo: analizar los factores facilitadores y las barreras para el cumplimiento del rol profesional de las enfermeras y enfermeros en tiempos de pandemia y desastres. material y método: revisión integrativa según método analítico salsa, realizada en ocho bases de datos: medline, proquest, cinahl, web of science, bvs, springerlink, scopus y pubmed. los descriptores utilizados fueron: 'rol de la enfermera' and 'pandemia' and 'paciente' and 'infección por coronavirus', en idiomas inglés, español y portugués. a los 11.031 artículos encontrados se aplicaron filtros y criterios de inclusión y exclusión; después de ello un total de 32 artículos conformaron la muestra final. resultados: considerando los objetivos planteados y los resultados obtenidos, se advierte que todas las acciones se enfocaban en tres instancias principales: a) formación y actualización para el desempeño del rol; b) factores predictores, facilitadores y barreras para ejercer el rol frente a una pandemia; y c) evidencia el rol frente a pandemias. conclusión: este estudio hizo posible conocer, tanto las barreras, como los aspectos facilitadores que permiten el cumplimiento del rol profesional de enfermería frente a pandemias o catástrofes. además, dejo claro que las enfermedades infecciosas emergentes deben abordarse en forma inmediata, colaborativa y multidisciplinaria. la experiencia, el liderazgo y la formación profesional de enfermeras y enfermeros son atributos claves que estos profesionales poseen, para permitir que su rol sea más proactivo durante una situación de emergencia. palabras clave (fuente decs): rol de la enfermera; pandemias; enfermería en salud comunitaria; enfermeras clínicas; infecciones por coronavirus. resumo objetivo: analisar os fatores facilitadores e as barreiras para o cumprimento do papel profissional de enfermeiros e enfermeiras em tempos de pandemia e desastres. materiais e método: revisão integrativa segundo método analítico salsa, realizada em oito bases de dados: medline, proquest, cinahl, web of science, bvs, sprin-gerlink, scopus e pubmed. os descritores utilizados foram: "papel da enfermeira" and "pandemia" and "paciente" and "infecção por coronavírus", em inglês, espanhol e português. aos 11 031 artigos encontrados, foram aplicados filtros e critérios de inclusão e exclusão. depois disso, 32 artigos conformaram a amostra final. resultados: considerando os objetivos propostos e os resultados, constata-se que todas as ações se enfocavam em três instâncias principais: a) formação e atualização para o desempenho do papel; b) fatores preditores, facilitadores e barreiras para exercer o papel ante uma pandemia e c) evidência do papel profissional ante pandemias. conclusões: este estudo torna possível conhecer tanto as barreiras quanto os aspectos facilitadores que permitem o cumprimento do papel do profissional de enfermagem ante pandemias e catástrofes. além disso, deixa claro que as doenças infecciosas emergentes devem ser abordadas de forma imediata, colaborativa e multidisciplinar. a experiência, a liderança e a formação profissional de enfermeiras e enfermeiros são atributos-chave desses profissionais para permitir que seu papel seja mais proativo durante uma emergência. palavras-chave (fonte decs): papel do profissional de enfermagem; pandemias; enfermagem em saúde comunitária; enfermeiras clínicas; infecções por coronavirus. introduction global health issues (ghi) demand interinstitutional and interprofessional work and collaboration for adequate planning, prevention, and care to address health equity issues among nations (1). emerging infectious diseases, such as epidemics, are ghi problems as they cross country boundaries in a matter of hours or days. in this context, the deficit of healthcare resources, as well as healthcare providers and infrastructure, will negatively impact the prevention of emerging ghi in the population (1), which raises a major issue of social justice, an essential concept for the nursing field (2). in human history three deadly epidemics have affected the population: the yellow fever of 1853 in new orleans, cholera in 1832, and the spanish flu (1918-1920) (3); the latter caused a mortality rate ranging from 60 % to 70 % (4), with more than 40 million deaths worldwide (5). later, the asian influenza (1957-1958) and the hong kong influenza (1968-1968) were less catastrophic, although they caused deaths along with economic and social issues (6). currently, humanity is facing a pandemic as declared by the who (7); it is a respiratory disease named covid-19, with characteristics similar to influenza in mild cases, which is transmitted from person to person and in severe cases can cause death (8), spreading to more than 200 countries and causing 5,087,688 deaths so far (november 11, 2021) (9). one of the main concerns regarding emerging infectious diseases is the prevention of the spread of these agents within healthcare settings (10). there is no doubt that, throughout history, only a few pandemics have struck the world and —despite the fact that experience along with oral and written traditions are lost in time—, evidence has demonstrated that nursing professionals have been paramount in the recognition and response to emerging disease threats (1), given that they occupy and assume vital positions and roles in care due to their expertise and unique professional roles with patients. the international council of nurses (icn) states that nurses are uniquely positioned to assist government healthcare agencies in implementing and evaluating disaster prevention and response measures internationally (11). on the other hand, the american nurses association (ana) provides valuable information and digital resources related to covid-19 for use by nurses in all settings (12). despite the wealth of information currently available, the review of the literature on nursing roles during pandemics is scarce up until 1968; subsequently, the number of references increases until information becomes plentiful in the current covid-19 setting. some studies report on the organizational aspect commenting on nursing care in typhoid fever (13), while other studies perform an evolutionary analysis of the influenza pandemic, and others focus on personal experience, providing very modest information on feelings of fear, isolation, and resentment during public health crises (3, 14) making it evident that, in the face of infectious diseases for which no treatment or vaccine is available, the healthcare teams' rates of unwillingness to work were higher (15, 16). however, although few studies have directly demonstrated how nurses have coped with these epidemic diseases (3), since the current pandemic context of covid-19, plenty of varied and abundant information has become available. in this context, and in the midst of the contingency that is currentlbeing experienced worldwide, it is essential to expose the true impact of pandemics on the role of nursing professionals. in light of this, a study was carried out with the objective of finding out what are the enablers and barriers to the fulfillment of nurses' professional role in times of pandemics and disasters. methodology an integrative review was carried out aiming to obtain the best evidence and a summary of the literature that was objective, concise, and logical on the current knowledge of a particular topic (17, 18), for the specific case of this study, the covid-19 pandemic. the information searched had no publication year limits up to 2021 in the medline, proquest, cinahl, web of science, bvs, springerlink, scopus, and pubmed databases. to formulate the research question, the pico methodology (19) was used, resulting in the following question: what were the barriers and enablers for the fulfillment of the nursing role in the face of pandemics and disasters? to answer this question, the terms controlled and referenced in the thesaurus of health sciences descriptors — decs— were used, with the simple analytical method named salsa (search, appraisal, analysis and synthesis) for systematic reviews (20) (figure 1) and using the following descriptors: nursing and pandemic and disaster and coronavirus infection, in english, spanish, and portuguese. using this method, 11,027 potential research studies were compiled for this study. figure 1. flowchart of the information selection process according to the salsa method source: own elaboration. once the studies had been selected, it was necessary to evaluate and classify the best existing evidence in the healthcare field for decision-making (21). for this purpose, a large number of proposals currently exist that rank the evidence accordingly, and one of them is the one proposed by the agency for healthcare research and quality (ahrq) (22), which allows the levels of evidence to be classified using quantitative and qualitative approaches. results the search strategy used achieved an initial retrieval of 11,031 potential articles for the study, out of which 32 articles were finally included in the final sample (table 1). table 1. distribution of studies by title, journal, impact factor, design, level of evidence, country, and year   article title journal / impact factor 2019 (according to scimago journal rank -sjror journal citation reports -jcr-) design / evidence country / year 1 educating nursing students about quality care and safe practices in the aids epidemic (23) public health rep sjr 1.04 not stated the usa 1988 2 community health nursing and the aids pandemic: case report of one community's response (24) journal of community health nursing sjr 0.22 case study 4 the usa 1991 3 godzilla in the corridor: the ontario sars crisis in historical perspective (3) intensive and critical care nursing sjr 0.74 not stated canada 2006 4 pandemic containment and management (6) australian nursing journal sjr 0.11 not stated australia 2006 5 avian influenza: are we ready? (25) critical care nursing of north américa sjr 0.28 not stated the usa 2007 6 when the city is a great field hospital': the influenza pandemic of 1918 and the new york city nursing response (26) journal of clinical nursing jcr 1.757 social history framework 4 the usa 2009 7 will the community nurse continue to function during h1n1 influenza pandemic: a cross-sectional study of hong kong community nurses (14) bmc infectious diseases jcr 2.565 cross-sectional study 4 honk kong 2010 8 incorporating bioterrorism content in the nursing curriculum: a creative approach (27) journal of nursing education jcr 1.070 not stated the usa 2010 9 predictors of nurses' intentions to work during the 2009 influenza a (h1n1) pandemic (28) american journal of nursing jcr 1.355 not stated the usa 2013 10 forensic nursing: key to disaster preparedness strategy (29) forensic examiner not stated the usa 2013 11 disasters, nursing, and community responses: a historical perspective (30) nursing history review sjr 0.12 caso estudio 4 the usa 2015 12 managing boundaries between professional and lay nursing following the influenza pandemic, 1918-1919: insights for professional resilience today? (31) journal of clinical nursing jcr 1.757 historical research 4 new zealand 2016 13 nurses' fears and professional obligations concerning possible human-to-human avian flu (32) nursing ethics jcr 1.957 quantitative cross-sectional study 4 taiwan 2016 14 registered nurses' perceptions regarding nurse-led antiretroviral therapy initiation in hhohho region, swaziland (33) international nursing review jcr 1562 phenomenological qualitative study 4 swaziland 2017 15 a multi-faceted approach of a nursing led education in response to mers-cov infection (10) journal of infection and public health jcr 2.487 not stated saudi arabia 2017 16 emerging global health issues: a nurse's role (1) online journal of issues in nursing jcr 0.37 not stated the usa 2017 17 the eighteen of 1918-1919: black nurses and the great flu pandemic in the united states (34) american journal of public health jcr 5.381 case study 4 the usa 2019 18 call to action for advocacy of immigrant nurses during covid-19 pandemic (35) journal of advanced nursing jcr 2.376 editorial canada 2020 19 nursing situacion in america, in front of the covid -19 pandemic (36) revista salud y bienestar colectivo narrative-qualitative documentary 5 the americas 2020 20 increasing critical care nurse engagement of palliative care during the covid-19 pandemic (37) critical care nurse jcr 1.484 not stated 5 the usa 2020 21 the perception of nurses towards their roles during the covid-19 pandemic (38) international journal of clinical practice jcr 2.444 qualitative study 6 jordan 2020 22 mitigating strategies and nursing response for cancer care management during the covid-19 pandemic: an italian experience (39) international nursing review jcr 1562 not stated 6 italy 2020 23 role of anesthesia nurses in the treatment and management of patients with covid-19 (40) journal of perianesthesia nursing jcr 1084 not stated 6 china 2020 24 nurses' core disaster-response competencies for combating covid-19—a cross-sectional study (41) plos one jcr 2.74 cross-sectional study 5 slovenia 2021 25 nurses' experiences of caring for people with covid-19 in hong kong: a qualitative enquiry (42) bmj open jcr 2496 qualitative study 4 hong kong 2021 26 nurses' grief counseling for bereaved family members of covid-19 patients in wuhan, china: a cross-sectional survey (43) journal of psychosocial nursing sjr o.25 qualitative study 4 china 2021 27 experiences of nurses amidst giving care to covid-19 patients in clinical settings in iraqi kurdistan: a qualitative descriptive study (44) journal of clinical nursing jcr 1.757 qualitative study 4 iraq 2021 28 improving adult coping with socialisolation during covid-19 in the community through nurse-led patient-centered telehealth teaching and listening interventions (45) nursing forum jcr 1.89 pilot study 4 the usa 2021 29 experiences of nurses caring for respiratory patients during the first wave of the covid-19 pandemic: an online survey study (46) bmj open respiratory research jcr 3.16 not stated 5 the uk 2021 30 trabalho do enfermeiro no contexto da pandemia de covid-19 (47) i revista brasileira de enfermagem jcr o.534 reflective study 6 brazil 2021 31 australian critical care nurses' knowledge, preparedness, and experiences of managing sars-cov-2 and covid-19 pandemic (48) australia critical care jcr 2.727 exploratory cross-sectional study 4 australia 2021 32 "new normal" home chemotherapy in thailand: how the challenging roles of nurses are changing? (49) asia pacific journal oncology nursing sjr 0,542 brief report 6 thailand 2021 source: own elaboration. once the 32 selected studies had been evaluated (table 1), it was observed that more than half of the articles stemmed from the americas: canada (3, 35), the usa (1, 2330, 34, 37, 45), brazil (47) and one article that refers to the american continent in general (3); the rest of the evidence is distributed across studies from asia (10, 14, 32, 38, 40, 42, 43, 44, 49), europe (39, 41, 46), oceania (6, 31, 48), and africa (33); therefore, all the articles are written in english. regarding the journals where these articles were published, it was noted that all were published in journals indexed in the proquest, scopus, and pubmed databases. in addition, it was evident that a large percentage of the retrieved articles did not state their design, and those articles that did had a level of evidence of 4 (14, 24, 26, 3034, 4245, 48). considering the objectives set and the results obtained, it is noted that all actions were focused on three main instances: a) training and updating for role performance; b) predictors, enablers, and enabling factors for exercising the role in the face of a pandemic; and, c) evidence of the role in the face of pandemics. in light of this information, a synthesis of the evidence is presented in tables 2, 3, and 4. results regarding training and updating for the performance of the nursing role in the face of a pandemic following a thorough search, a number of 10 articles that demonstrated aspects of nursing education and updating of knowledge for the performance of the professional role in the face of a pandemic were described (table 2). table 2. studies that focused on the training and updating of knowledge for the performance of the role in the face of a pandemic. no. author objectives conclusions s1 spero jr (23) to educate nursing students on quality care and safe practices in the aids epidemic. the nursing schools, colleges, and universities can be key resources for developing curricula, policies, and practice guidelines that will support the nursing community and the public in responding to the aids epidemic. s2 gardner a (6) to provide up-to-date information on the avian influenza virus (h5n1) and its means of transmission, principles of containment and management, and key knowledge in the event of a pandemic. nurses will face difficult ethical dilemmas in the event of a flu pandemic. these professionals will have to consider how to balance their responsibilities towards their families, their patients, and their own health. they are encouraged to think about these issues now and discuss them with their families and coworkers before a pandemic arises, as they will have to make sound decisions and, although these are personal, they should be discussed beforehand. s3 krau sd, parsons lc (25) to understand the current status of avian influenza (h5n1), vaccine research, recommendations, and ethical issues that could be raised by this pandemic. it is worth considering different aspects of a pandemic before it occurs so that a plan of action is in place. as this plan develops and evolves, it is imperative that critical care nurses contribute to informed healthcare practices. this can only be accomplished when there is a deliberate effort to understand the virus, its implications, current research, and consider the ethical issues that this pandemic might raise. s4 carter mr, gaskins sw (27) to design a creative educational experience for community health science students concerning bioterrorism and disaster preparedness. the students have evaluated the experience positively. although students do not experience firsthand the consequences of a bioterrorist attack and the nursing care of patients with an exposure, this experience provided the opportunity to recognize the signs and symptoms of exposure, practice procedures, increase confidence, develop critical thinking skills in a safe environment, and potentially improve personal and public health. s5 doyle l (29) the purpose of this article was to introduce forensic nurses to a novel and exciting field to pursue. knowledge learned from past disasters to predict the types of trauma likely to occur in similar future situations grants forensic nurses the ability to take preventative measures and be proactive rather than just reactive. assessment skills, the ability to anticipate potential problems based on risk, and the aptitude to recognize causes and possible interventions are all factors that should compel disaster managers to include forensic nurses in all preparedness and prevention activities. forensic nurses, in addition to contributing to disaster preparedness and prevention, contribute to disaster response, although some argue that the contribution to preparedness is even more important. s6 wall bm (30) to improve the understanding of the social and political powers that have informed nurses' actions and of the tensions and inconsistencies that have arisen at particular times and places. instead of strictly reacting to disasters with firefighters, search and rescue teams, and emergency medical care, attention was focused on disaster forecasting and prevention. city mayors and other disaster responders can also benefit from observing nurses and physicians in their regular work, as they cooperate and communicate daily with many other healthcare personnel under situations of extreme pressure. nurses and physicians are ready for contingencies. to understand and deal effectively with disasters, multidisciplinary approaches are needed that include meteorologists, engineers, anthropologists, lawyers, political scientists, economists, journalists, and other professionals. s7 edmonson c, mccarthy c, trent-adams s, mccain c, marshall j (1) to examine the response to issues posed by emerging infectious diseases, human trafficking, as well as maternal and newborn health; preparedness to mitigate health inequities within a framework of social justice, equity and countering a disproportionate distribution of the global healthcare workforce. global health issues (ghi) do not exist in a vacuum chamber; they are highly complex issues that must be examined in a comprehensive and holistic way. nurses are positioned in settings such as governmental roles, public health, academia, clinical care, leadership, and private industries with the ability to develop a creative and effective network to respond to multifaceted issues. there is a clear need for increasing nurses' awareness and education on ghi, including, but not limited to emerging infectious diseases, human trafficking, and maternal and newborn health. professional nurses can contribute as global leaders of change by actively participating in communities, professional nursing organizations, health policy-making and advocacy organizations, and in their workplaces. s9 rosa w, ferrell b, wiencek c. (37) to promote palliative care involvement in critical care; share palliative care resources to assist critical care nurses in alleviating suffering during the 2019 coronavirus disease pandemic; and formulate recommendations to strengthen nursing capacity to deliver high-quality, person-centered critical care. the covid-19 pandemic has rendered explicit the need for the integration of palliative care into hospital and community settings worldwide as the suffering of patients and their families worsens. it calls for the integration of palliative care into all high-quality critical care practices to ensure that the comprehensive needs of patients and their families are met in these uncertain times. achieving this ideal will require leadership, advocacy, perseverance, and rapid change in perspectives and protocols. palliative care is critical care; and critical care nurses are in an ideal position to ensure that this congruence is carried out, disseminated, and empathically translated into practice geared towards improved quality outcomes and person-centered care. s10 karnjus i, prosen m, licen s. (41) to explore how registered nurses perceive the core competencies involved in disaster nursing, their role in disaster management, and potential barriers towards the development of disaster nursing in slovenia. registered nurses perceive the core competencies listed as fundamental to their disaster preparedness; however, they lack adequate education, training programs, and experience in disaster nursing. registered nurses working in nursing homes and nurse managers in leadership positions are more aware of the active role of nurses and their responsibilities in disaster management. as the frequency and impact of disasters increase worldwide, there is a need to integrate disaster management into nursing education programs in both formal and continuing education. the core competencies of disaster nursing should be included in future research, as the framework of disaster nursing competency is under the influence of several contextual factors that need to be investigated. source: own elaboration. it can be noted that the objectives of the articles collected are focused on providing and updating the knowledge of nurses in the face of global health issues, including emerging infectious diseases, providing information on pandemics experienced by humanity such as the avian flu or the chaos in the face of a bioterrorist attack (27); in addition, updating the knowledge in healthcare that the team and nurses could face in the event of a possible pandemic (6, 25). it should be noted that the evidence recovered also reports new fields of action for nursing professionals regarding disaster preparedness; an example is the "forensic nursing" field (29). however, although they have the basic competencies to deal with disasters, these professionals lack sufficient experience as well as adequate and specific preparation for disasters, which is evident in the lack of continuous training programs in this field (41). in this context, it is also suggested to promote the participation of palliative care in other fields of nursing in which it was not present, such as intensive care, with the aim of assisting nurses to provide care for the pain of patients and their families (37). another topic raised by the selected articles focuses on describing the experiences lived by students in the process of implementing curricula that address safe care and practices for patients and their families in the face of epidemics such as the hiv epidemic (23), exploring, in addition, the understanding and interaction of political, social, and nursing actors in the event of a disaster (30). in light of the above, the results were conclusive regarding the existence of key strategies for the preventive preparation of nurses in the face of a catastrophe and/or epidemic, which corresponds to the training role of universities and nursing schools as an essential resource in the development of curricula, policies, practice guidelines, and simulation experiences; this would allow the development of skills, increase confidence and communication to face a potentially unsafe environment in order to provide care in personal and public health contexts. this innovation in education could also be extended to professionals currently working in this field, thus taking advantage of the knowledge they have acquired from previous disasters, their assessment skills, their ability to anticipate potential issues based on risk so that nursing professionals can play a proactive rather than a reactive role. it is necessary for nursing professionals to talk about and discuss this theme with their families and coworkers before a catastrophe happens, so that, when the time comes to make decisions, they are informed, also understanding that these professionals will face ethical dilemmas in the performance of their duties and that, simultaneously, they must face responsibilities regarding their families, the people they care for and their own health. finally, emerging global health issues should be viewed from a comprehensive and multidisciplinary perspective, under which nurses are the most suitable professionals to respond effectively since in their routine they are positioned in management, care, academic, and public health roles; with this experience, they are able to develop a creative and effective network to respond to an emerging health issue. results regarding predictors, enablers, and barriers in the exercise of the nursing role in a pandemic from the totality of findings recovered in this research, this section describes the objectives and conclusions of 16 articles that demonstrate factors that predict, enable, and/or hinder the exercise of the role in the face of a pandemic (table 3). table 3. studies developed concerning predictors, enablers, and barriers to the performance of the nursing role in the face of a pandemic. no. author objectives conclusions s1 rankin j (3) the objective was to determine whether the sars outbreak was a unique experience for nurses or whether nurses shared similar experiences in the past. nurses' reactions to the possibility of contracting a deadly disease remain human: two of these are fear and isolation, as well as leadership in the face of this situation not unlike in the past or present. nurses' responses to sars can be meaningfully studied, and information or impressions from previous crises may be of interest to the nursing profession as a whole. s2 wong sys, wong ely, et al. (14) to study the willingness of hong kong community nurses to work during the h1n1 influenza pandemic. a high rate of nurses working for community nursing services were found to be unwilling to work with patients suspected of being infected with h1n1 influenza. interventions to provide infection management training and to address the psychological needs of community nurses could increase their willingness to provide care to patients during the h1n1 influenza pandemic. this would support an effective and appropriate health system response during a pandemic triggered by the aforementioned virus. s3 martin sd, brown lm, reid wm (28) to examine possible predictors of nurses' intentions to work during the 2009 influenza a (h1n1) pandemic. to maintain an adequate nursing workforce during an influenza pandemic, employers should ensure that policies and procedures include providing appropriate ppe (personal protective equipment) and ensuring the health of nurses and their families. the level of perceived threat is likely to affect the proportion of nurses willing to work. some nurses will refuse to work during an influenza pandemic, regardless of the protections and incentives offered. efforts to force or entice all nurses to work are unlikely to be successful. s4 tzeng hm, yin cy (32) to explore the factors contributing to nurses' fear of a potential avian influenza pandemic with human-to-human transmission and their professional duties. the nurses' fear of an unknown infectious disease, such as the h5n1 influenza virus, the lack of infection management measures and equipment to prevent nosocomial infection, as well as the fear of infecting their families, are factors contributing to the fear experienced by them, and these could easily rise to levels higher than those that occurred during the 2003 sars outbreak in taiwan. s5 mavhandu-mudzusi ah, sandy pt, hettema a (33) to analyze graduate nurses' perceptions of the nurse-led antiretroviral therapy initiation program (nartis) in the hhohho region of swaziland. the study findings have generated information concerning this program that is useful in providing care for patients living with hiv/aids in swaziland. despite this, there are negative factors such as a low number of clinic wards and nurses, as well as nurses' limited knowledge on this theme, which may sometimes affect the nartis program's effectiveness. nurses need regular, ongoing, and updated educational support to ensure effective implementation of their practices. support is also needed for nurses in resource fields. s6 al-tawfiq ja, rothwell s, mcgregor ha, khouri za (10) to develop a nurse-led program to evaluate and screen patients with mers-cov infection. the implementation of specific protocols minimizes the risks of cross-infection, emphasizing patient and staff safety, and expediting patients towards definitive treatment. nurse educators have a critical role in training nurses and other healthcare providers on the details needed to identify, contain, and manage patients presenting with mers-cov. s7 tayaben jl, younas a (35) to call for action in advocating for rights and assisting immigrant nurses with transition and registration. during the current covid-19 crisis, immigrant nurses who are considered less competent and skilled are an essential part of the workforce and perform a vital role in alleviating the workload of the healthcare workforce in high-income countries. immigrant nurses want to support their countries of residence, but they would not be able to do their part if restrictive and differential policies and requirements are in place. therefore, equal privileges and respect are needed for all immigrant and non-immigrant nurses during this public health crisis; nursing associations have an important role to perform in this regard. s8 zeneli et al. (39) to describe the emergency response to covid-19 in a cancer center to enable other nursing organizations to determine what elements might be useful in managing a surge of patients in their own setting. our institute's nursing staff provided invaluable support in numerous areas during the first phase of the covid-19 pandemic; namely, patient assessment and treatment schedule planning; patient and family support, information, and education; and participation in patient care, research, and education. in addition, they performed an active role in ensuring the appropriate use of healthcare resources and increasing the benefit to patients and the community. key policies will be needed for an action plan: health policies, coordinated planning and communication strategies, technology and health it, nursing organization and safety culture. s9 abuhammad s, alazzam m, mukattash t. (38) the study aimed to evaluate, in local jordanian facebook nursing groups, the perception of their roles during the coronavirus pandemic. the jordanian nurses perceived that their role during the covid-19 outbreak was constructive and not limited to their usual roles during the outbreak. indeed, they performed the task of supporting and advocating for the sick and their families. despite these efforts during the outbreak, the lack of awareness and underestimation of nurses' essential work compared to physicians and other healthcare providers persists. improving the prestige of nursing professionals and their social standing, including providing opportunities for creativity and innovation in nursing practice, will change the perception of nurses, promoting effective and permanent changes in the notion of nursing. s10 chau jpc et al (42) this study aimed to explore the experiences of registered nurses providing care to patients with suspected or diagnosed covid-19 during the first 6 months of the ongoing global pandemic. our study found that nurses were resilient, were capable of self-care, and were adaptable in the face of resource shortages, changes in nursing protocols, and threats to physical and mental health during the covid-19 pandemic. however, coordinated support from the clinical setting, local authorities, and the community, in addition to advanced preparedness, would likely improve nursing responses to future pandemics. su abdulah d, mohammedsadiq h, liamputtong p. (44) we have explored the experiences of nurses who provided care to patients with the 2019 coronavirus disease in iraqi kurdistan. the patients had some concerns regarding their health and their stay in the hospitals, and some of them displayed aggressive behaviors towards the nurses in the corona hospitals. the public, close friends, and relatives of the nurses feared contracting the virus infection from the nurses. however, the nurses tried to protect themselves, their colleagues, and their family members and provide the best care for patients with the 2019 coronavirus disease. the findings have implications for healthcare administrators who need to be sensitive to the psychological well-being of nurses. better support needs to be established as this would provide more effective and safer work practices. s12 robert nj, kelly ca, lippiett k et al. (46) to identify and characterize self-reported issues that exacerbated or relieved their concerns during the first wave of the covid-19 pandemic. there are concerns regarding the work environment, availability of ppe, quality of care, changing environment patterns, the impact on the mental health of nurses and their families. support for staff is essential, both during and after the pandemic, and it is essential to recognize the preparedness of individuals regarding the development of resilience. it is also clear that psychological support and services for nurses and the healthcare team in general must be available and rapidly called upon in the event of similar major incidents, whether globally or locally. s13 silva vgf, silva bn da, pinto esg, meneses rpm (47) to reflect on the work experienced by nurses responding to the covid-19 pandemic in a public hospital in the state of rio grande do norte. the role of nurses is highlighted, since their role in the organization of front-line services and in the exercise of care management demonstrates their relevance. however, the existence of several factors that often lead to burnout in the nursing team's work was identified, especially those related to low professional recognition, material and personnel deficits in the care services, as well as psychosocial and interpersonal aspects. from this perspective, it is necessary to acknowledge the work of nurses in all its attributes, as well as to strengthen interdisciplinary work processes that collaborate to overcome the crisis caused by the pandemic. s14 nahidi s, sotomayor-castillo c, li c, et al. (48) to explore the knowledge, preparedness, and experiences of australian intensive care nurses in managing patients diagnosed with severe acute respiratory syndrome, coronavirus 2 infection (sars-cov-2), and covid-19. while most nurses expressed sufficient preparation for managing patients with covid-19, specific education had been conducted and experiential learning was evident. fears of inadequate or lack of adequate ppe and the provision of support in the face of contracting the disease hindered the nurses' and the community's response to the pandemic. preparedness and psychological support to counteract anxiety and mental exhaustion are critical factors for the successful management of the covid-19 pandemic and future outbreaks of emerging infectious diseases. s15 ross l, meier n. (45) to improve the adult population's response to the covid-19 pandemic in the community by 80 % within 8 weeks. telehealth interventions programmed to be patient-centered can provide isolated populations with meaningful social contact. s16 encalada g, yancha c, guerrero g. et al. (36) to describe the nursing situation in the americas facing the covid-19 pandemic. the current pandemic demonstrates the importance of having an adequate number of healthcare providers according to the needs and care required by each patient; for this reason, countries need to invest in improving the working conditions of nursing professionals, including individual protective equipment, support for teamwork and continuing nursing education, which will lead to significant achievements, demonstrating the professionalism of nurses and their absolute dedication, by applying their four fundamental roles in order to protect the health and improve the lives of people, despite the obvious real and potential risks they face at the workplace. source: own elaboration. in the selected evidence, the predictors, enablers, and barriers to the professional role of nurses can be noted. it is concluded that in order to maintain a nursing workforce in the face of a pandemic, there are predictors that should be considered to carry out this role, one of them being the need for support from local authorities and the community (42), providing training in infection control and addressing the psychological needs of nursing professionals in the community, with the aim of increasing their willingness to care for patients during times of crisis (14). on the other hand, the evidence also reports that there are enabling factors for the performance of the role, firstly, when it is considered that these professionals provide "constructive" support with their work (38); in addition, they are resilient, capable of self-care and adaptability towards the continuous changes in protocol and scarcity of resources (42), as well as their capacity for planning, support, information, active participation in research and adequate use of resources (39), relevant aspects that should be considered by the employers of healthcare services, since they must ensure clear practices in the care to be provided, control measures for infections and personal protection equipment that is adequate for the use of healthcare providers, which are all indispensable variables to en­sure the health of healthcare providers and their families (28); in addition, the need for psychological support for these professionals is also evident (48), as well as the need for their continuing education. this need should not only satisfy nurses but also other healthcare providers who are for the implementation of programs and protocols with the objective of minimizing cross-infection for patient and staff safety in the face of a pandemic (10, 33, 48), strengthening interdisciplinary work (46). one strategy reported in this review that will undoubtedly support their performance in improving communication with isolated populations is telehealth. among the factors that hinder the performance of their role were the fear of working with patients with infectious diseases experienced by nursing professionals (32) — and therefore, the need for support in case of contracting the disease (48) —, the insecurity of not having adequate personal protective equipment (46, 48), the fear of contam­inating members of their family, the social isolation that these profes­sionals must face (3, 46), as well as the limited infrastructure and the deficit of nursing professionals (33), the feeling of ignorance and underestimation of the efforts of nurses compared to physicians (38), and the lack of social recognition (46), all of which undoubtedly affect their willingness to work with and provide care for patients with infectious diseases (28); in addition, the crucial contribution and work of immigrant nurses in support of the existing workforce is often overlooked, since despite the different nature and environment of their jobs, they can play a key role during times of crisis such as what has been witnessed in the covid-19 pandemic (35). finally, a study that unveils the reality of nursing in the americas comments that, in order to have adequate nursing professionals, countries need to invest in improving their working conditions, ensuring the provision of personal protective equipment, and continuing education (36). results found in the evidence dimension of the professional role in pandemics regarding the results found in the dimension 'evidence of the professional role in pandemics', nine articles were found. their objectives and conclusions are detailed below (table 4). table 4. studies developed regarding role performance during pandemics and disasters no. author objectives conclusions s1 kuehnert pl (24) to present the development of a program in response to the aids epidemic in a midwestern community in the usa. the dynamic interaction of community health nursing activities with individuals, families, and community, guided by the nursing process, has been used to demonstrate the roles of community health nurses (chns). chn roles may include the following: direct caregiver, advocate, case manager, health educator, program planner, program coordinator, and policy advocate. the community-based approach to aids allows for a caring and compassionate response, as well as improving the public image of chns as innovators and enablers of change. s2 keeling aw (26) to describe and analyze the role of nurses in the response to the influenza epidemic in new york city in 1918. in 1918, close cooperation between a previously established network of nursing and other social organizations, as well as early cooperation with the american red cross and the u.s. public health service, were essential to new york city's response to the crisis. s3 wood pj (31) to examine the boundaries of the nursing profession in new zealand after the 1918-1919 influenza pandemic. this historical example demonstrates how the nursing profession faced a perceived threat to its professional boundaries. it also demonstrates how the competing goals of building "lay", secular, community-based nursing capacity and protecting professional boundaries can be effectively managed. s4 jones mm, saines m (34) to examine the role of african american nurses during the influenza pandemic of 1918­1919 and the aftermath of world war i. this analysis demonstrates that the pandemic progressively increased civil rights in the army nurse corps and red cross, while providing ephemeral opportunities for black nurses in general. this case study reframes the response to epidemics and other public health emergencies as potential opportunities for advancing health equity. s8 chen et al. (40) to evaluate the role and responsibility of nurses in the treatment of covid-19 patients. nurse anesthetists have skills and experience in the management of the respiratory tract and can adapt quickly to the treatment and management of patients with covid-19. however, they lack experience in infectious disease prevention and management. they may also lack expertise in nursing procedures and patient communication, which are two deficiencies. therefore, nurse anesthetists require training in emotional management and communication. s9 kong et al. (43) to evaluate nurses' actions and skills regarding bereavement counseling for bereaved family members of patients who died of coronavirus disease 2019 (covid-19) in wuhan, china. nurses' actions and skills regarding bereavement counseling in wuhan were poor. educational level, communication skills, and training related to bereavement counseling were the main factors affecting nurses' actions in wuhan (china). responsibilities and roles, frequency of contact with the bereaved, and positive view of counseling were the main factors affecting nurses' bereavement counseling skills. hospitals should establish bereavement counseling committees, staff training, and the organization of related activities. considering that the covid-19 pandemic is ongoing, short videos, webcasts, and open online courses are recommended for this type of training. s9 srithumsuk w, wangnum k (49) to describe the lessons learned from oncology nurses in administering home chemotherapy to cancer patients during the covid-19 pandemic and the new normal situation in thailand. during the covid-19 pandemic oncology and home health care (hhc) nurses have been challenged in this new normality to care for cancer patients using home chemotherapy. oncology and hhc nurses must focus on effective ways to prevent covid-19 infections in those cancer patients undergoing home chemotherapy, as well as appropriate nursing practices in the fight against this developing health crisis, which has the potential to cause serious and life-threatening issues for patients' conditions. source: own elaboration. regarding the evidence on the role of nursing professionals in times of pandemic crisis, the first articles retrieved reported the role of american (26) and african-american nurses in outbreaks such as the 1918 "spanish flu" as a model of past pandemic experiences that occurred in periods of history with racial segregation and violence in which people of color were denied access to health, educational, and political institutions; nevertheless, these borderline situations that humanity experienced provided ephemeral opportunities for these professionals of color to deliver nursing care in response to public health emergencies (34). other articles have also demonstrated how nursing professionals coped with the formation of a lay nursing force without threatening their professional boundaries in times of pandemics. as a consequence of the exposed results, it can be interpreted that nursing professionals in past pandemic experiences had a more reactive role, since, in the midst of pandemic crises, such as the aids crisis, for example, they promoted the interaction between community health nursing activities with individuals, families, and community, through the nursing process, managing to play diverse roles such as direct caregiver, advocate, case manager, health educator, program planner, program coordinator, which allowed these professionals to be considered agents of change (24). another role that was evident in the retrieved bibliography was the immediate reaction and cooperation of nursing professionals with the assistance of local community organizations in the face of a pandemic disease such as the influenza of 1918, since in the face of a shortage of supplies and medicines, and a rapid spread of the disease, "nursing home care" represented the only response and treatment that could be offered to the population in the midst of these crises (26). after a century, this same strategy was used again, bringing oncology care to patients' homes with the aim of minimizing the risk of infection in patients undergoing chemotherapy (49). in a context of the low global availability of nursing professionals and the need for home care in the midst of the pandemic crisis, in the past it was necessary to consider the formation of a second line of lay or volunteer nurses in response to this need, with caution and keen avoidance of crossing professional boundaries regarding the basic instruction that non-professional nurses should receive; this consideration had to be taken into account, since in the future it could constitute a risk for the population to become dependent on these volunteers with precarious knowledge, in situations in which the nursing professionals became massively ill (31). currently, the evidence reports some experiences that were necessary to address the need for care professionals; one of them was the need for a change of professional role that had to be experienced, for example, by nurse anesthetists, who used their experience, competencies, and skills in the management of the respiratory tract to contribute to the care of patients with pathologies derived from covid-19 (40). on the other hand, there was also an urgent need to improve bereavement counseling as a way of focusing attention not only on patients but also on their families (43). discussion in the study's integral analysis, it was found that all the articles retrieved were published in scientific journals indexed in the databases, which meet methodological quality standards and enjoy greater international recognition (50). however, due to the historical characteristics of the information found in the first stage of collection, these articles presented a low level of evidence and used traditional historical methods for data collection, such as case studies and critical analysis of the social, political, and economic context in times of pandemics and disasters. subsequently, the highest percentage of the information retrieved in the current covid-19 pandemic context was mainly of a qualitative nature, being worth mentioning that the articles in these journals, originating from 16 countries worldwide, are in english, making the mastery of this language a pressing need and one of the main challenges for our profession since it is one of the tools that nursing professionals must possess to train and exchange knowledge (51, 52). it should be noted that a significant percentage of the evidence collected was obtained from databases with restricted access and in agreement with higher education centers; therefore, it is urgent to make effective agreements with healthcare professors to grant them access to these databases from healthcare centers, if research is to be done from a healthcare perspective. regarding the information obtained in this review, it is noted that the first studies found date back to the 1980s and contain little information regarding the role of nurses; later, in the current circumstances of the pandemic that humanity is experiencing, it is noted the report of sufficient and varied information that was useful in answering the research question. according to the interpretation of the evidence collected, nursing professionals have had a reactive role in the face of emerging infectious diseases, that is, a rapid and immediate response in which they mainly fulfilled an assistance role, providing nursing care at home to families and the community in the face of an unexpected emerging public health issue. it should be noted that this reactive role also had its expressions inside the hospitals, carrying out its competencies to different services, but understanding that the preparation and experience were deficient in disasters and pandemics. unfortunately, this action was deployed when emerging pandemic diseases were already present and their dissemination was imminent, both within and outside the borders of a country and/or continent. currently, as empirical knowledge advances along with the development of technologies, nursing graduates are starting to evolve in their professional work and in their visibility to society, managing direct care roles, becoming chaos managers, pandemic planners, health educators, and so on (24), benefiting from their experience, knowledge and direct contact with the issue; these characteristics will undoubtedly be useful for the effective management of a recent emerging event and, of course, those to come. it is undoubted, and the bibliography reports it, that in order to effectively perform the nursing role, it is necessary to invite nurses to reflect upon some ethical dilemmas that they must face in times of pandemics in their workplaces, first of all, questioning where their professional responsibilities begin and end, the existence of care protocols, work and contingency plans that the facility has in case of a pandemic, and the need for training and updates that should be provided by their employers since there is evidence reporting that nurses with limited training are less likely to stay on the job (14). regarding the evidence found, the results of this review coincide with other reviews retrieved (53, 54) regarding the barriers to the performance of their professional role; some of the relevant factors, which have been developed by several authors, are "fear" (3, 14, 46), uncertainty (55), psychological stress and the reluctance of healthcare professionals —especially nurses and nursing assistants (56)— to work with patients infected with emerging infectious diseases in an environment of scarce personal protective equipment (46, 48) and, therefore, the fear of bringing the infection to their homes and families (48, 57, 58). this situation has not been addressed by governmental and health agencies, nor by the icn (international council of nurses); the aforementioned institution, although it has recently published the 12 main priorities for the covid-19 pandemic (59), did not consider in any of the points of the declaration the protection of the fundamental pillar of every human being, and of course, of a healthcare professional, namely, their families. failure to address this situation could lead to a setback in the effort to mitigate absenteeism and the deficit of human and material resources currently available to health systems (60) since it is unquestionable that the nursing professionals' unwillingness to work is clearly related to the scarcity of personal protective equipment (ppe) (61), as well as to their personal safety and that of their families. thus, a debatable ethical dilemma arises in the field of nursing regarding the moral obligation to provide care under any circumstances. the icn (62), in the code of ethics that governs nursing practice, emphasizes in the section "the nurse and practice", the moral autonomy that nursing professionals have in the development of their professional practice, mentioning that they "will maintain a level of personal health that does not compromise their ability to provide care". in this sense, the american nursing association (ana) (2) also develops the idea of autonomy in the practice of nursing without compromising health, stating in its provision number 5: "nurses owe the same duties to themselves as they owe to others, including the responsibility to promote health and safety". an enabling element for the implementation of the professional role in times of pandemic is to consider, on one hand, nursing professionals as "constructive" support that has characteristics of resilience, self-care, and adaptability; and on the other hand, the aspect raised by some authors (1) stating that if nursing professionals want to have a successful impact in the fight against emerging global health issues, they must develop leadership skills and strengthen interdisciplinary work (46), directing their focus beyond the hospital wards and healthcare settings, with an understanding of the broader context. this is stated by the canadian nurse association (63), an organization that proposes eight essential competencies for nurse leaders in 2020; they approach leadership from a global perspective in the face of health and professional nursing issues. this approach allows the dynamic interaction of nurses at all levels of care, preferably in community health nursing activities with individuals, families, and the community, granting them the opportunity to become innovative agents of change (1, 24). in this context, one author (64) argues that it is imperative to support a change agent by evidence-based practice, this being the framework in which nurses begin prevention, early recognition, intervention, and implementation of practices and programs to address these issues, actions that in the perspective of the results achieved in this study, and the onsite experience of the authors, should be worked upon immediately. another element that the literature reports as an enabler, and that conditions the development of the professional role, is related to the training that future nurses receive in nursing schools and colleges (65); these should encourage a change in curricular innovation, incorporating in their curricula policies, guidelines, and experiences in the simulation of epidemics and/or catastrophes, and even in preparation for bereavement counseling since the community and patients expect expert care and specific training in such areas, which can reassure them regarding the competencies of nurses. this training in times of pandemics, not only can be contemplated from the formal academic environment, but also from the need to constitute a non-professional nursing capacity whose objective would be to have a second line of nurses with basic training to provide care, as a viable alternative if there is a need for additional human resources to provide care to the community. in this regard, some authors state (31) that, although "informal" training is necessary in times of pandemics, it must be strongly protected so as to not cross professional boundaries since in the future there could be a serious risk of becoming dependent on these volunteers with basic knowledge in situations in which nurses become massively ill or decide to refuse to work. faced with this issue, the authors agree with some studies (35) which suggest that, faced with a deficit of nurses in times of pandemics, a call should be made to allow the arrival of immigrant nursing professionals from countries less affected by the pandemic; this would respond to one of the 12 priorities of the icn in the face of the covid-19 pandemic (59), since in its priority number 6 they comment that when faced with a deficit of nursing professionals, "an effective response in terms of registration and regulation should be provided by rapidly increasing the nursing staff". in addition, they demand that, in order to rapidly increase the number of nurses, the graduation of students or the reinstatement of retired nurses should be accelerated, ignoring the fact that this skilled workforce of immigrant nurses may be better prepared than students and retired nurses. ultimately, to ensure that an adequate frontline nursing workforce is in place, while simultaneously ensuring that the autonomous role of the frontline nurses is fulfilled during a pandemic and/or disaster, a number of issues need to be addressed: pre-planning by employers, training, and updates prior to and during pandemic crises, provision of full personal protective equipment to provide safety for frontline staff, ensuring a safe environment for the nursing team and a holistic environment in their workplace by providing resting and feeding areas, shift rotation of work teams, psychological support, incentives, and life insurance, religious facilities, transportation in case of social restrictions, ensuring the frontline nursing team and their families easy access to medications, vaccinations, nursing homes, and psychological support; and finally, to provide incentives and life insurance for frontline staff. conclusion this study allowed, firstly, to identify the barriers and enablers that allow or hinder the fulfillment of nurses' professional role in the face of pandemics or catastrophes; secondly, to understand that emerging infectious diseases should be addressed immediately and collaboratively by governmental and local agencies and, ideally, in a preventive manner once they emerge, with a complex and multidisciplinary approach. with the information collected, it is possible to change the paradigm that nursing is only a technical and reactive profession in the face of emerging health crises since the work of nurses goes beyond care: it encompasses management, education, and research, so that the community recognizes the importance of nursing and can be confident that these professionals will be there to take care of them in the event of an unexpected pandemic event, thus developing a much more proactive and visible professional role in their social actions. limitations a relevant limitation to consider is that the articles retrieved in this review were evaluated by a single researcher; 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https://www.medigraphic.com/pdfs/enfermeriaimss/eim-2017/eim172b.pdf 63. canadian nurses association. nursing leadership position statemen [internet]. 2009. disponible en: https://www.cna-aiic.ca/en/download-buy/leadership 64. oulton ja. leading nursing globally. heal emerg disaster nurs [internet]. 2014;1(1):29-33. doi: https://doi.org/10.24298/hedn.2014-1.29 65. gerbotto m, saez nb, gattari mdlá, daro mv. prácticas y representaciones de estudiantes de enfermería en torno al rol enfermero. rev uruguaya enferm [internet]. 2019;14(1):28-37. doi: http://doi.org/rue2019v14n1a3. disponible en: http://rue.fenf.edu.uy/index.php/rue/article/view/268/271 home desgaste profesional y factores asociados en personal de enfermería cartagena, colombia de servicios de urgencias de 43 zuleima cogollo-milanés1 edith batista2 chanelly cantillo2 alicia jaramillo2 dalys rodelo2 gary meriño2 desgaste profesional y factores asociados en personal de enfermería cartagena, colombia 1 enfermera. maestra en salud pública. profesora titular, facultad de enfermería, universidad de cartagena, cartagena, colombia. zcogollom@unicartagena.edu.co, zcogollo@yahoo.com.mx 2 estudiantes. facultad de enfermería. universidad de cartagena, colombia. recibido: 2 de julio de 2009 reenviado: 28 de septiembre de 2009 aceptado: 19 de marzo de 2010 resumen objetivo: determinar la prevalencia del desgaste profesional y factores asociados en personal de enfermería de servicios de urgencias de cuatro instituciones de salud de cartagena, colombia. método: se diseñó un estudio analítico transversal. el desgaste profesional se cuantificó con la versión española de la escala maslach burnout inventory. mediante regresión logística se controlaron las variables asociadas a desgaste profesional. resultados: un total de 173 personas completaron en forma satisfactoria el cuestionario. la edad promedio del grupo fue 34,5 años (de=8,6). un total de 126 (72,4%) auxiliares de enfermería y 47 (27,6%) profesionales de enfermería. la prevalencia del desgaste profesional fue 26,6%. insatisfacción laboral (or=22,80; ic95% 3,02-172,2) y edad menor de 40 años (or=2,84; ic95% 1,28-8,82) se asociaron a desgaste profesional. conclusión: la prevalencia del desgaste profesional es alta en el personal de enfermería que labora en servicios de urgencias de cartagena. la insatisfacción laboral se asocia significativamente a desgaste profesional. se necesita más investigación en este campo. palabras clave desgaste profesional, personal de enfermería, estudios transversales (fuente: decs, bireme). professional attrition and related factors among emergency nursing staff in cartagena, colombia abstract objective: determine the prevalence of professional attrition and related factors among the emergency nursing staff at four health facilities in cartagena, colombia. method: a transversal analytical study was designed. professional attrition was measured with the spanish version of the maslach burnout inventory scale. the variables associated with professional attrition were controlled through loaño 10 vol. 10 nº 1 chía, colombia abril 2010 l 43-51 de servicios de urgencias de 44 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 gistic regression. results: a total of 173 persons completed the questionnaire satisfactorily. the average age of the group was 34.5 years (de=8.6). a total of 126 (72.4%) nurse’s aides and 47 (27.6%) professional nurses took part. the prevalence of professional attrition was 26.6%. job dissatisfaction (or=22.80; ic95% 3.02-172.2) and under age 40 (or=2.84; ic95% 1.28-8.82) were associated with professional attrition. conclusion: the prevalence of professional attrition is high among the nursing staff at emergency services in cartagena. job dissatisfaction is associated to a great degree with professional attrition. more research in this field is needed. key words burnout, professional, nursing staff, cross sectional studies (source: decs, bireme). burnout e fatores associados em trabalhadores de enfermagem em serviços de emergência em cartagena (colômbia) resumo objetivo: determinar a prevalência de burnout e fatores associados em trabalhadores de enfermagem nos serviços de emergência de quatro instituições de saúde em cartagena, colômbia. método: estudo analítico transversal. burnout foi medido com a versão espanhola da escala maslach burnout inventory. por regressão logística, se controlaram as variáveis associadas com burnout. resultados: 173 pessoas responderam ao questionário de forma satisfatória: 126 (72,4%) auxiliares de enfermagem e 47 (27,6%) enfermeiros. a faixa etária média foi 34,5 anos (dp = 8,6). a prevalência de burnout foi 26,6%, a insatisfação no trabalho (or = 22,80, 95% 3,02-172,2) e idade inferior a 40 anos (or = 2,84, ic 95% 1,28-8,82) foram associados com burnout. conclusão: a prevalência de burnout é elevada nos profissionais de enfermagem que trabalham em serviços de emergência em cartagena. a insatisfação no trabalho é significativamente associada com burnout. é necessária mais investigação nesta área. palavras-chave burnout, profissional de enfermagem, estudos transversais (fonte: decs, bireme). 45 desgaste profesional y factores asociados en personal de enfermería de servicios de urgencias de cartagena, colombia l zuleima cogollo-milanés, edith batista, y otros. introducción el concepto de desgate o agotamiento profesional (professional burnout, en inglés) hace referencia a la respuesta de estrés excesiva en relación con el ambiente laboral o profesional. el desgaste profesional es frecuente en profesionales que mantienen una relación constante y directa con otras personas (1). el desgaste profesional es una condición multidimensional compuesta por el agotamiento o cansancio emocional, la despersonalización y el abandono de la realización personal (2, 3, 4). el desgaste profesional es muy frecuente en profesionales de la enfermería. este problema es el segundo en frecuencia de salud laboral, después del dolor de espalda; se presenta en todos los oficios, especialmente en aquellas labores asistenciales que demandan un trato directo y cercano con otras personas, como la enfermería (5). entre profesionales de la enfermería es más prevalente en el personal que labora con personas en situación crítica, como los servicios de urgencias (6). en colombia existen pocos estudios sobre la prevalencia y los factores asociados a desgaste profesional en personal de enfermería. en una investigación realizada en barranquilla se observó que el 1,9% reunía criterios para desgaste profesional, medido con la escala de maslach (7). otro estudio en bogotá mostró que el 21,7% del personal de enfermería mostraba puntuaciones en el rango medio, y un 15,7%, altas puntuaciones para desgaste profesional en la escala de maslach (8). en otros países se encontró que el desgaste profesional puede afectar entre 14,0 y 63,3% del personal de enfermería (9, 10, 11, 12, 13). en diferentes grupos de profesionales, la edad, el sexo, el estado civil, el estrato socioeconómico, el salario y la satisfacción laboral se relacionan con la presencia de desgaste profesional (7, 12, 14-24). el desgaste profesional tiene repercusiones emocionales y comportamentales en el profesional que lo padece, en su vida familiar y social, y en el desempeño laboral. asimismo, deteriora la calidad de los cuidados de enfermería que se brindan (25). sin embargo, se carece de estudios que informen la prevalencia de desgaste profesional en personal de enfermería de cartagena, colombia. en un estudio precedente se investigaron algunas variables relacionadas con satisfacción laboral. sin embargo, en éste no se incluyó la asociación con desgaste profesional (26). conocer la prevalencia de desgaste profesional y explorar otras variables relacionadas en personal de enfermería con mayores niveles de insatisfacción profesional, como las personas que laboran en servicios de urgencias, permite diseñar estrategias para prevenir y reducir la frecuencia y el impacto negativo en este grupo de profesionales, lo que a su vez mejorará la calidad de la atención que presta el personal de enfermería (27). el objetivo del estudio fue determinar la prevalencia del desgaste profesional y algunos factores asociados en personal de enfermería que laboraba en servicios de urgencias de cuatro hospitales de cartagena, colombia. el desgaste profesional es una condición multidimensional compuesta por el agotamiento o cansancio emocional, la despersonalización y el abandono de la realización personal. 46 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 método se realizó un estudio analítico transversal que aprobó el comité de investigación de la facultad de enfermería de la universidad de cartagena. según las normas para la investigación en salud en colombia, se informó el objetivo de la investigación, se señaló que la participación era voluntaria y se respetaba la confidencialidad (28). población se solicitó la participación del personal de enfermería de doce instituciones con servicios de urgencias generales en la ciudad, y la participación de personal de enfermería mayor de edad que laboraba en el servicio de urgencia. con una prevalencia esperada de 12,0% de desgaste profesional con margen del error de 5,0 y una probabilidad de error alfa del 5%, se calculó una muestra de 162 personas. a partir de este tamaño de muestra se podían explorar en un modelo multivariado con alta confiabilidad hasta cuatro variables (29). instrumentos los participantes diligenciaron un cuestionario anónimo en el sitio de trabajo, previa información de los objetivos del estudio y la forma de diligenciamiento. el cuestionario solicitaba información demográfica e incluyó la escala de satisfacción en el trabajo (30) y una versión modificada de la escala de maslach para desgate profesional. la escala cuantifica agotamiento emocional, despersonalización y ausencia de realización en el área profesional (maslach burnout inventory) (31). la escala de satisfacción en el trabajo consta de quince puntos que indagan sobre la satisfacción personal, intrínseca y extrínseca, con la práctica laboral. la escala brinda un patrón de respuesta politómico, con siete opciones de respuesta que da puntuaciones entre 1 y 7. las puntuaciones totales son entre 15 y 105, a mayor puntuación mayor satisfacción. se aceptó que las puntuaciones a partir de 80 o más indicaban alto grado de insatisfacción laboral (30). esta escala mostró excelente desempeño psicométrico en otras poblaciones. para corroborar las propiedades psicométricas de la escala se calculó el coeficiente de alfa de cronbach (32). la versión modificada de la escala de maslach para desgaste profesional cuenta con quince puntos con respuestas dicotómicas. da puntuaciones entre 0 y 15, a mayor puntuación mayor desgate profesional, y se aceptó que las puntuaciones a partir de 9 o más indicaban desgaste profesional (31). el inventario original muestra un desempeño psicométrico adecuado en otras poblaciones. para confirmar ese desempeño, en el presente estudio se calculó el coeficiente de la fórmula 20 de kuder-richardson que es la técnica más adecuada para estimar la consistencia interna de una escala con respuestas dicotómicas (33). análisis estadístico los datos se procesaron en el paquete estadístico para ciencias sociales para windows (ssps 13.0) (34). todas las variables se dicotomizaron para el análisis. se realizó análisis descriptivo, bivariado y multivariado. se usó regresión logística no condicionada para ajustar las asociaciones. se aceptaron como asociaciones significativas las que mostraron intervalos de confianza del 95% (ic95%) que no superaban la unidad. para el modelo multivariado se siguieron las recomendaciones de greenland (35). al modelo final se le estimó la bondad del ajuste con la prueba de hosmer-lemeshow (36). se realizó un estudio analítico transversal que aprobó el comité de investigación de la facultad de enfermería de la universidad de cartagena. 47 desgaste profesional y factores asociados en personal de enfermería de servicios de urgencias de cartagena, colombia l zuleima cogollo-milanés, edith batista, y otros. resultados participó personal de enfermería que laboraba en cuatro instituciones. un grupo de 173 participantes completaron los cuestionarios. las edades del personal participante se encontraban entre 20 y 53 años, la media fue 34,0 años (de=8,5). otras características se presentan en la tabla 1. las puntuaciones en la escala de satisfacción en el trabajo se hallaron entre 25 y 99 puntos, la media fue 69,4 (de=13,2). un total de 44 personas (25,4%) informó satisfacción con el trabajo. la consistencia interna de la escala fue alta, 0,86. las puntuaciones en la escala de maslach para desgate se encontraron entre 0 y 15 puntos, la media fue 7,7 (de=1,5). un total de 46 personas (26,6%) puntuaron para desgaste profesional. la consistencia interna para la escala fue adecuada, 0,83. en el análisis bivariado y multivariado se tomó como grupo de referencia aquel que no presentó síntomas de desgaste. en la tabla 2 se presenta el análisis bivariado y en la tabla 3 el ajuste en las asociaciones (or e ic95%) sólo para cuatro variables que se incluyeron en el modelo. discusión en el presente estudio se encontró que el 26,6% del personal de enfermería informó desgate profesional. y fue más frecuente en personas menores de 40 años de edad y en quienes informaron insatisfacción laboral. consistente con esta observación, novoa y cols. observaron puntuaciones medianas y altas en 37,5% de personal de enfermería colombiano (8); y albaladejo y cols. hallaron una prevalencia de 30,5% en profesionales españoles (9). otros estudios documentaron prevalencias menores: en colombia, tuesca-molina, 1,9% (7); en méxico, hernández y cols., 14,0% (10); y en españa, del río y cols., 17,8% (11). prevalencias mayores observaron investigadores de: en españa, atence, 47,4% (12); y de argentina, reyes y cols., 63,3% (13). en relación con el sexo, en la presente investigación se observó que la presencia de desgaste profesional era independiente del sexo del profesional. esta observación es consistente con estudios previos. tuesca-molina y cols. informaron la ausencia de relación (7). lee y henderson observaron una frecuencia mayor de desgaste profesional en mujeres que en varones (14). en tanto que cooper y cols. señalaron que variable total % sexo mujeres 155 89,6 varones 18 10,4 edad menor de 40 años 124 71,7 mayor de 40 años 49 28,3 pareja estable con pareja 112 64,8 sin pareja 61 35,2 estrato socioeconómico estrato 1 48 27,7 estrato 2 o más 125 72,3 nivel de formación auxiliar 126 72,8 profesional 47 27,2 institución bajo número de urgencias 115 66,5 alto número de urgencias 58 33,5 salario mínimo uno 126 72,8 más de uno 47 27,2 tabla 1. variables sociodemográficas del personal de enfermería en el presente estudio se encontró que el 26,6% del personal de enfermería informó desgate profesional. y fue más frecuente en personas menores de 40 años de edad y en quienes informaron insatisfacción laboral. 48 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 el desgaste era mayor en hombres que en mujeres (15). estas explicaciones están relacionadas con los roles de género (37). sin embargo, es necesario considerar otros factores –biológicos, culturales y sociales– que pueden relacionarse con el desgaste profesional y que se omitieron en los estudios realizados a la fecha (1, 6). los datos tabla 3. modelo de regresión logística para desgaste profesional en el personal de enfermería de cartagena, colombia tabla 2. comparación de las variables cualitativas investigadas y presencia de desgaste profesional discrepantes sugieren la necesidad de mayor investigación en esta área. la edad menor de 40 años se asoció a la presencia de desgaste profesional. datos similares se encontraron en publicaciones precedentes. parada y cols. observaron que las personas menores de 40 años presentaban un riesgo mayor para desgaste profesional (16). asimismo, bustinza y cols. y ilham y cols. concluyeron que los profesionales más jóvenes mostraban mayor susceptibilidad al desgate profesional (17, 18). no obstante, otros investigadores señalaron hallazgos divergentes. atence informó que la prevalencia de desgaste profesional era superior en personas mayores de 45 años (11). estas discrepancias sugieren diferentes explicaciones. hillhouse y adler, escribá y cols. y gil-monte propusieron que los profesionales con mayor edad eran menos vulnerables a los eventos estresores dadas las estrategias de afrontamiento que aprendieron durante la vida, y que mostraban expectativas laborales más realistas (19-21). en el estudio que se presenta se observó que el desgaste profesional no se relaciona con el hecho de contar con una pareja estable. tuesca-molina y cols. informaron que el estado civil no guarda asociación con la presencia de desgaste profesional (7). parada y cols. encontraron que las personas con una pareja habitual mostraron mayor frecuencia de desgaste emocional (16). gil-monte planteó que es más importante la calidad de la relación de pareja que el estado civil (21). en lo que atañe al estrato socioeconómico, se encontró que el desgaste profesional era independiente del estrato de residencia. consistente con esta observación, vinnacia y albaran no encontraron relación significativa entre estrato y desgas49 desgaste profesional y factores asociados en personal de enfermería de servicios de urgencias de cartagena, colombia l zuleima cogollo-milanés, edith batista, y otros. te profesional (22). sin duda, el desgaste profesional es un problema complejo al parecer más relacionado con las condiciones laborales que socioeconómicas (1, 6). también, se halló que el nivel de formación (auxiliares frente a enfermeras) era independiente de la presencia de desgate profesional. esta asociación se omitió en los estudios precedentes. esta falta de relación entre el nivel de formación y la presencia de desgaste profesional sugiere que, en urgencias, los estresores afectan por igual a todas las personas que laboran en estos servicios (1, 18, 26). no se observó, en cambio, una asociación significativa entre el número de pacientes que ingresan a urgencias en la institución y la presencia de desgate profesional. estudios previos no exploraron la asociación de esta variable. se esperaría que el personal de enfermería que maneja mayor número de urgencias durante la jornada de trabajo muestre mayor desgaste profesional (6). esta variable debe evaluarse cuidadosamente en futuras investigaciones. los hallazgos mostraron una falta de relación estadísticamente significativa entre el salario y la presencia de desgaste profesional. en forma similar, tuesca-molina y cols. y parada y cols. hallaron que el salario no se asociaba con esta variable (7, 16). shirom y cols. plantearon que, en teoría, el salario puede ser un factor favorecedor para la aparición de desgaste profesional, que los estudios no confirman, y sugirieron que se necesita más investigación de esta variable para llegar una conclusión más definitiva (23). no hubo asociación entre las personas a cargo y la presencia de desgaste profesional. contrario a esto, de la fuente y de la fuente observaron que el personal con más de dos hijos mostraba una mayor presencia de desgaste profesional (24). la relación del número de hijos y el desgaste profesional debe estudiarse a profundidad. del río y cols. y grau y cols. observaron que la presencia de hijos se asociaba a menor desgaste profesional dado que el apoyo que los hijos brindan ayuda a afrontar problemas laborales (10, 38). en el presente estudio se detectó una asociación significativa entre insatisfacción laboral y desgaste profesional. consistente con datos similares, albaladejo y cols. concluyeron que el alto grado de insatisfacción laboral se relacionaba con desgaste profesional (8). sin embargo, es posible que el desgaste profesional explique la insatisfacción laboral y no viceversa (1, 6, 38). la asociación parece bidireccional. hillhouse y adler señalaron que la disminución en la satisfacción laboral es una variable importante para la presentación del desgaste profesional (19). para zambrano es un proceso progresivo en el que la insatisfacción laboral es un paso al desgaste profesional (5). el desgaste profesional es un problema de salud laboral complejo que se relaciona con múltiples factores individuales y ambientales (1, 6). sin duda, el personal de enfermería en todos los contextos del desempeño profesional presenta alto riesgo debido en algunos casos a la sobrecarga laboral, la realización de turnos, relaciones difíciles con pacientes y familiares, falta de reconocimiento profesional, falta de autonomía y autoridad en el trabajo para poder tomar decisiones, y al contacto directo con la enfermedad, el el desgaste profesional es un problema de salud laboral complejo que se relaciona con múltiples factores individuales y ambientales. 50 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 dolor y la muerte, entre otros (1, 18). el desgaste profesional tiene implicaciones no sólo laborales sino personales y familiares por lo que son necesarios programas de prevención en el contexto laboral y la vida privada (1, 6). igualmente, las instituciones deben diseñar estrategias para la identificación temprana de posibles casos en el personal de enfermería, y asegurar el manejo indicado. sería importante que los programas de formación de profesionales de la enfermería incluyeran en sus currículos elementos para la prevención y el abordaje clínico del desgaste profesional (39, 40). conclusiones este estudio es un aporte a la comprensión del desgaste profesional en el personal de enfermería que labora en servicios de urgencias en cartagena, colombia, en el que se estudiaron variables no investigadas a la fecha, como el nivel de formación. sin embargo, tiene la limitación de un diseño transversal que no permite establecer una dirección de causalidad entre las variables estudiadas, además de no contar con suficiente información acerca del desempeño psicométrico de las escalas que se usaron en poblaciones colombianas. asimismo, se omitió la evaluación de otras variables que pueden relacionarse o matizar el informe de síntomas del desgaste profesional, como la presencia de síntomas depresivos o de ansiedad. se concluye que la prevalencia del desgaste profesional es alta en el personal de enfermería que labora en servicios de urgencias de cartagena. la insatisfacción laboral y la edad menor de 40 años se asocian significativamente a desgaste profesional. se necesitan más investigaciones en este campo con muestras más amplias y que exploren un mayor número de variables personales y laborales. referencias bibliográficas 1. vega nv, sanabria a, 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transnacionales en el síndrome de burnout en personal sanitario hispanoamericano y español (2007). rev esp salud pública 2009; 83: 215-30. 39. maslach c, schaufeli wb, leiter mp. job burnout. annu rev psychol 2001; 52: 397-422. 40. van rhenen w, blonk rwb, van der klink jjl, van dijk fjh, schaufell wb. the effect of a cognitive and physical stress-reducing programme on phychological complaints. int arch occup environ health 2005; 78: 138-49. translation and cross-cultural adaptation of the system usability scale to brazilian portuguese article translation and cross-cultural adaptation of the system usability scale to brazilian portuguese traducción y adaptación transcultural de la system usability scale al portugués de brasil tradução e adaptação transcultural da system usability scale para o português do brasil 10.5294/aqui.2022.22.2.8 douglas fabiano lourenço 1 elenice valentim carmona 2 maria helena baena de moraes lopes 3 1 0000-0001-8305-8950 nursing school, unicamp, brasil, d210044@dac.unicamp.br 2 0000-0001-9976-3603 nursing school, unicamp, brasil carmona@unicamp.br 3 0000-0001-7747-1140 nursing school, unicamp, brasil, mhbaena@unicamp.br received: 12/05/2021 sent to peers: 17/01/2022 approved by peers: 19/03/2022 accepted: 22/03/2022 theme: promotion and prevention. contribution to the discipline: it is expected that the translation and cultural adaptation of the system usability scale will contribute to teaching and researching health sciences, leading to new knowledge, and make available tools widely used in the healthcare field to improve the measurement of the usability of systems, software, and applications. furthermore, it is essential to further research in this field, aiming to translate usability scales into other languages. para citar este artículo / to reference this article / para citar este artigo: lourenço df, carmona ev, lopes mhbm. translation and cross-cultural adaptation of the system usability scale to brazilian portuguese. aquichan. 2022;22(2):e2228. doi: https://doi.org/10.5294/aqui.2022.22.2.8 abstract objective: to adapt culturally the system usability scale to brazilian portuguese and assess its internal consistency and structural construct validity. materials and methods: this methodological study of a measurement instrument's cultural adaptation included the initial translation, the translations' synthesis, the back-translation, the evaluation by a committee of eight experts, testinh with a sample of 100 students, who evaluated the usability of the whatsapp application, and the evaluation of structural construct validity by exploratory factor analysis. results: the judges validated the brazilian version of the system usability scale in the second round. it was revealed that, following the structural construct validation, the version had a unidimensional structure and an acceptable level of reliability (cronbach's alpha of 0.76). besides, in the usability test, no suggestions for change were made. conclusions: it is worth noting that the brazilian version of this scale was semantically, idiomatically, conceptually, and culturally equivalent to the original english version and showed adequate reliability and structural construct validity. keywords (source decs): translating; mobile applications; software; data accuracy; evaluation of research programs and tools. resumen objetivo: realizar la adaptación cultural de la system usability scale al idioma portugués, variante brasileña, y evaluar su consistencia interna y su validez de constructo estructural. materiales y métodos: se trata de un estudio metodológico de adaptación cultural de un instrumento de medición, que contempló traducción inicial, síntesis de traducciones, retrotraducción, evaluación por ocho expertos, prueba con una muestra de 100 estudiantes, quienes evaluaron la usabilidad de la aplicación whatsapp, y evaluación de la validez de constructo estructural mediante análisis factorial exploratorio. resultados: los expertos en la segunda ronda validaron la versión brasileña de la system usability scale. se reveló que, luego de la validación de constructo, la versión presentó una estructura unidimensional y un nivel aceptable de confiabilidad (alfa de cronbach de 0,76). además, en la prueba de usabilidad, no hubo sugerencia de cambio. conclusiones: se informa que la versión brasileña de la escala presentó equivalencia semántica, idiomática, conceptual y cultural con la versión original en inglés, así como una confiabilidad y validez de constructo estructural adecuadas. palabras clave (fuente decs): traducción; aplicaciones móviles; programas informáticos; exactitud de los datos; evaluación de programas e instrumentos de investigación. resumo objetivo: realizar a adaptação cultural da system usability scale para a língua portuguesa do brasil e avaliar a sua consistência interna e a validade estrutural de constructo. materiais e método: trata-se de um estudo metodológico, de adaptação cultural de instrumento de medida, que contemplou a tradução inicial, a síntese das traduções, a retrotradução, a avaliação por comitê de oito especialistas, o teste com uma amostra de 100 estudantes, que avaliaram a usabilidade do aplicativo whatsapp, e a avaliação da validade de constructo estrutural por análise fatorial exploratória. resultados: validou-se a versão brasileira da system usability scale pelos juízes na segunda rodada. revela-se que, após a validação de constructo estrutural, a versão apresentou estrutura unidimensional e nível aceitável de confiabilidade (alfa de cronbach de 0,76). acrescenta-se que, no teste de usabilidade, não houve sugestão de mudança. conclusões: informa-se que a versão brasileira dessa escala apresentou equivalência semântica, idiomática, conceitual e cultural com a versão original em inglês, bem como adequada confiabilidade e validade de constructo estrutural. palavras-chave (fonte decs): tradução; aplicativos móveis; software; confiabilidade dos dados; avaliação de programas e instrumentos de pesquisa. introduction it is known that the use of software and applications for mobile devices is growing daily (1), and one of the fields in which this advancement stands out is healthcare (2). when creating a computer system for use on computers or mobile devices, the developer is expected to evaluate the usability, that is, investigates the ease with which users can perform specific tasks when interacting with such systems. therefore, it is necessary to use appropriate methods and tools to improve what has already been developed and provide broader access to these resources (3). more than 242 million mobile phone lines currently exist in brazil (4), demonstrating the need to develop solutions based on mobile devices and advancing studies to measure usability, specifically for computer tools (5). considering the significant amount of software and applications, it is necessary to evaluate their usability by instruments that can be widely used and adapted to the brazilian portuguese language and culture. the usability scales employed internationally include the usability measurement inventory software, which measures user perception of usability and compares software versions (2); the standardized user experience percentile rank questionnaire, which evaluates usability, trust, appearance, and loyalty (6), and the questionnaire for user interaction satisfaction, which considers subjective user satisfaction with specific aspects of the human-computer interface. in brazil, the questionnaire for user interaction satisfaction and the system usability scale measure software usability; both are used through free translation (7), lacking professional translation and cross-cultural validation procedures. therefore, it is relevant to translate and cross-culturally validate into brazilian portuguese, with adaptation to the brazilian context, a usability scale with psychometric properties previously evaluated in other contexts and that proves to be valid and reliable, as well as simple and easy to use. we found that a scale with such characteristics exists, used internationally to measure software usability, including the nursing field (8): the system usability scale (9), which has already been translated and validated into european portuguese (10). this version has also been used in brazil. it should be noted that the system usability scale is simple, consisting of only ten objective statements. they provide an overview of the user's usability evaluation and can be applied to several products and services, such as websites, mobile applications, and clinical systems. within the usability evaluation methods described in the literature, questionnaires assume significant importance for collecting self-reported qualitative data on users' characteristics, thoughts, feelings, perceptions, behaviors, or actions (10). this scale has drawn the attention of researchers for its benefits, such as ease of use, evaluation of different tasks within the same interface (system screens), compar­ison of versions of the same system, and comparison of competing implementations (8-11). a growing number of health care researchers, especially in nursing, have been involved in the development of software, systems for the electronic registration of care, and mobile devices for use by professionals, patients, and the public. however, it is crucial to evaluate the usability of these systems and applications, depending on their type or purpose. the literature indicates that usability assessment though the system usability scale questionnaire is a valuable strategy to verify the interaction between application and system users and used in several fields, including nursing (12). it is worth noting that the system usability scale can be applied to evaluate usability in any system or application, not only in healthcare. thus, this study aims to perform the cultural adaptation of the system usability scale for the brazilian portuguese language and evaluate its internal consistency and structural construct validity. materials and methods type of study this methodological study aims to translate and culturally adapt the system usability scale into brazilian portuguese. population and sample in the cultural adaptation stage, a committee of specialists (13) evaluated the translated version. therefore, a minimum of five and a maximum of ten people are recommended for content validation (14). thus, the committee was composed of eight specialists: three methodologists, one linguist, one it professional, two translators, and one representative of the target audience (a professional who uses software and applications, in this case, a nurse). following the system usability scale translation, the structural construct validation and testing of the scale were carried out with students from the systems analysis and development and nursing courses attending a private university in the state of são paulo, brazil; this was a convenience sampling. for the test, 30 to 40 participants are recommended (14). based on literature recommendations (15), we verified that 100 participants would be necessary for structural construct validity: ten per scale item. criteria to select specialists and undergraduates for selecting specialists, we considered training and qualificationd (13, 16). thus, english language knowledge was assumed, as stated by all the invited specialists, with no need for certification, and reading skills were expected of them. knowledge of the culture of the country where the scale was built was assumed for the invited translators (private english teachers who had lived for one year or more in england, the native country of the system usability scale's author); a minimum of two years' experience in computer science for information technology professionals (analysts and system developers with expertise and currently working in this sector); a minimum of two years' experience in linguistics for linguists (professionals with a degree in linguistics and presently working in this sector) and, for methodologists, the conduct and publication of research about validation. specialists who failed to carry out the evaluations in full were excluded. to evaluate the system usability scale translated into brazilian portuguese, we included nursing and systems analysis students. the evaluation by nursing students is vital, as the objective is to use this scale to evaluate the usability of systems and applications in the health field, especially nursing. the participation of system analysis and development students is relevant since they can identify some critical aspects of the evaluated system that are not contemplated in the system usability scale. the students included used whatsapp on mobile devices daily to send and receive text or audio messages and images or photos. those who failed to complete any item of the system usability scale, even with the primary researcher's support and guidance, were excluded. system usability scale the scale presents items with sentences that denote positive evaluations and other items with negative evaluations alternately to minimize the possibility of responses that lack reflection by those who apply the system usability scale to evaluate the usability of a given system or tool. for each statement present in this scale, a five-point likert scale is used, where one means "strongly disagree" and five means "strongly agree." to obtain the final score, the researcher must perform the calculation described as follows: for the odd-numbered statements (1, 3, 5, 7, and 9), the individual score is obtained by subtracting one from the score given by the evaluator. for even-numbered statements (2, 4, 6, 8, and 10), the individual score is obtained by subtracting five from the score given by the evaluator. the obtained values are added, and the result of this sum is multiplied by 2.5, obtaining the total value of the system usability scale. regarding this total value, it is possible to consider the evaluated system as follows: worst imaginable (up to 20.5); poor (21 to 38.5); average (39 to 52.5); good (53 to 73.5); excellent (74 to 85.5); best imaginable (86 to 100) (8, 9). cross-cultural adaptation process for a reliable cultural adaptation, the literature recommends the following steps: initial translation, synthesis of translations; back-translation; evaluation by a committee of specialists, and testing (13). in the initial translation stage, two translators independently performed the translation, both native to the country to which the scale was translated (brazil) and proficient in the original scale language (british english), in addition to being knowledgeable of the culture of the country where the instrument was produced (england). two portuguese scale versions were obtained: translation 1 (t1) and translation 2 (t2). then, the translations were synthesized, producing a single version in portuguese, the t1-2. this version was forwarded to two native translators . from the scale's country of origin (england) with proficiency in the language and culture of both countries involved in the adaptation process (brazil and england) for the back-translation process. the objective was to verify if the t1-2 version reflected the content of the original english version. the material produced was referred to as "back-translation 1" (rt1) and "back-translation 2" (rt2). a committee of eight specialists carried out the evaluation stage. to this end, each of them received the original instrument, the two initial translations (t1 and t2), the synthesis of the translations (t1-2), and the two back-translations (rt1 and rt2). the specialists' committee met twice to reach a consensus on whether semantic, idiomatic, conceptual, and cultural equivalences were present (13). it is known that the pre-test is the final stage of the cultural adaptation process. this stage included a sample of 100 undergraduate students (14), distributed between the system analysis and nursing courses, to evaluate the comprehension of the portuguese version of the system usability scale. from the demographic point of view, the sample consisted of undergraduate students aged 17 to 45 years, with a mean age of 22.68, a variance of 32.02, and a standard deviation of 5.66. among the participants, 61 undergraduates were nursing students, and 39 were system analysis students. among the undergraduate nursing students, 50 were male, 11 were female, and among the undergraduate systems analysis students, 30 were male, and nine were female. the participants were invited and oriented to use this scale to evaluate the whatsapp application for mobile devices. construct validity and internal consistency of the system usability scale — brazilian version the structural construct validity was evaluated using the exploratory factor analysis (15), using two factor extraction methods: principal components and common factors. the common factors method is more suitable when the objective is to identify latent factors in the analyzed variables. in contrast, the primary com­ponents method is more convenient when the aim is to obtain the minimum number of factors necessary to summarize most of the total variance of the variables (16). by definition, the common factors method may be the most suitable when the objective is the structural construct validity of a measurement instrument. still, this method may present issues in its application, for instance, factor indeterminacy (16). since several studies in the literature apply the two methodologies, the decision made was to apply the two extraction methods to compare the results obtained. for the analysis, we used the varimax rotation method for the primary components, and the direct oblimin rotation for common factors. this choice was defined by analyzing the correlation matrix between the factors. thus, in the case of the principal component method analysis, correlations lower than 0.32 were observed between factors (17). in the case of the common factor method analysis, values higher than 0.32 were observed. we employed the statistical package for the social sciences (spss) software, version 23, to implement these analyses. the kaiser-meyer-olkin (kmo) index was initially calculated to verify the data fitting to the factor analysis, applying bartlett's test of sphericity. in this study, kmo values < 0.50 are considered unacceptable; > 0.50 and < 0.60 are poor, but still acceptable; > 0.60 and < 0.70 are mediocre; > 0.70 and < 0.80 are average; > 0.80 and < 0.90 are good; and > 0.90 are excellent (18). to define the number of factors extracted, we observed the factors that presented eigenvalues greater than 1.0 if they represented at least 60 % of the total variance explained. factor load values greater than or equal to 0.50 were considered satisfactory (15). the system usability scale's internal consistency was evaluated using cronbach's alpha. an adequate good alpha value ranges from 0.70 to 0.90 (15). ethical aspects the author of the system usability scale was previously contacted, and formal authorization was obtained for the translation and cultural adaptation of the instrument. the research ethics committee og the university of campinas (unicamp) approved the research under the certificate of ethical appraisal no. 95580318.2.0000.5404 and legal opinion no. 3.004.013/2018. after the necessary clarifications and orientations, the specialists and undergraduate students agreed to participate and signed the informed consent form, keeping one copy in their possession. the study was conducted between november 2018 and august 2019. results two rounds of evaluation with the experts were necessary. in the first round, four items required discussion to reach a consensus. item 1 of the system usability scale, "i think that i would like to use this system frequently," translated as "eu gostaria de usar esse sistema frequentemente," was considered non-equivalent to the original by one of the specialists for lacking the phrase "eu acho que." item 4, "i think that i would need the support of a technical person to be able to use this system," demanded adjustments, as the portuguese version included the word "eu" twice, just as the english version, which was considered unnecessary by a specialist. regarding item 7, "i would imagine that most people learn to use this system very quickly," approaching semantic equivalence and considering the grammar (partitive collective), the consensus among researchers and specialists led to the wording of "eu imagino que a maioria das pessoas pode aprender a usar esse sistema muito rapidamente." for item 9, "i felt very confident using the system," the final wording was "eu me senti muito seguro usando o sistema." following the adjustments made by the specialists, the modified version was sent to everyone for a second round and approved. this version, considered the pre-final version of the system usability scale in brazilian portuguese, is presented in table 1 and was used in the test. at the end of this process, the proposed title for the adapted version was "escala de usabilidade de sistema versão brasileira" (system usability scale brazilian version). table 1. pre-final version of the system usability scale, translated into brazilian portuguese item original instrument in english consensus version in portuguese 01 i think that i would like to use this system frequently. eu acho que gostaria de usar esse sistema frequentemente. 02 i found the system unnecessarily complex. eu achei esse sistema desnecessariamente complexo. 03 i thought the system was easy to use. eu achei esse sistema fácil de usar. 04 i think that i would need the support of a technical person to be able to use this system. eu achei que precisaria de ajuda de uma pessoa técnica para ser capaz de usar esse sistema. 05 i found the various functions in this system were well integrated. eu achei que as várias funções desse sistema foram bem integradas. 06 i thought there was too much inconsistency in this system. eu acho que o sistema apresenta muita inconsistência. 07 i would imagine that most people would learn to use this system very quickly. eu imagino que a maioria das pessoas pode aprender a usar esse sistema rapidamente. 08 i found the system very cumbersome to use. eu achei esse sistema muito pesado para usar. 09 i felt very confident using the system. eu me senti muito seguro usando o sistema. 10 i needed to learn a lot of things before i could get going with this system. eu precisei aprender muitas coisas antes que pudesse utilizar esse sistema. source: own elaboration. it is reported that no suggestions for changes or comments regarding difficulties in comprehension were made. the brazilian version of the system usability scale presented an acceptable level of reliability, with cronbach's alpha equal to 0.76. a kmo value of 0.73 for the instrument and a p-value lower than 0.0001 in bartlett's test of sphericity were obtained for structural construct validity, indicating that the exploratory factor analysis was adequate. the results suggested a structure composed of three domains, which combined would explain 64.64 °% of the variance in the principal component analysis and 51.55 °% in the common factor analysis (table 2). table 2. values of explained variance obtained using the principal component and common factor extraction methods. campinas (sp), brazil, 2019 factor explained variance   principal components common factors 1 36.33 % 32.62 % 2 17.40 % 12.76 % 3 10.91 % 6.17 % cumulative total 64.64 % 51.55 % source: own elaboration using research data (2019). table 3 presents the factor loadings of the items in each factor of the principal component analysis after applying the varimax rotation method. table 4 presents the factor loadings of the structure matrix and the standard matrix obtained by the common factor method after applying the direct oblimin rotation. the results obtained suggest the same distribution of items among the three factors. table 3. factor loadings of the system usability scale items brazilian version, obtained using the principal component extraction method. campinas (sp), brazil, 2019 scale items factor 1* factor 2* factor 3* 1 ** 0.61 ** 2 0.82 ** ** 3 ** 0.40 0.71 4 0.87 ** 0.32 5 ** 0.77 ** 6 ** 0.68 ** 7 0.72 0.44 ** 8 0.38 0.55 ** 9 ** ** 0.83 10 0.69 ** 0.54 * varimax rotation method. ** factor loading values lower than 0.30 were removed from the table. source: own elaboration using research data (2019). table 4. factor loadings of the system usability scale items brazilian version, obtained using the common factor extraction method. campinas (sp), brazil, 2019 scale items structure matrix standard matrix factor 1* factor 2* factor 3* factor 1* factor 2* factor 3* 1 ** 0.50 -0.44 ** 0.39 ** 2 0.69 ** ** 0.72 ** ** 3 ** 0.46 -0.90 ** ** -0.87 4 0.94 ** -0.51 0.86 ** ** 5 ** 0.74 ** ** 0.75 ** 6 ** 0.45 ** ** 0.44 ** 7 0.63 0.44 ** 0.60 0.39 ** 8 0.35 0.51 -0.40 ** 0.42 ** 9 ** ** -0.47 ** ** -0.45 10 0.70 ** -0.65 0.54 ** -0.53 * direct oblimin rotation method. ** factor loading values lower than 0.30 were removed from the table. source: own elaboration using research data (2019). in table 5, where the communality values obtained for each of the methods used are presented, it can be noted that some items have low communality values. table 5. communality values of the system usability scale items brazilian version, using the principal component and common factor extraction methods. campinas (sp), brazil, 2019   communalities variable principal components common factors q1 0.46 0.32 q2 0.68 0.49 q3 0.71 0.83 q4 0.86 0.93 q5 0.61 0.56 q6 0.48 0.22 q7 0.71 0.54 q8 0.48 0.36 q9 0.70 0.22 q10 0.78 0.71 source: own elaboration using research data (2019). we verified that the evaluations of the factorial solutions obtained were not satisfactory, either through the indexes obtained or through the domain structure formed, which was not adequate from a practical point of view. based on this, the decision was to keep the instrument's original version (unidimensional). the internal consistency was also evaluated through cronbach's alpha coefficient. this coefficient varies from 0 to 1, where values greater than 0.7 indicate reliability between measures. discussion the translation process carried out with the method recommended by the literature enabled the achievement of a final version entirely understandable by the test participants. this study also confirmed the unidirectionality of the scale and an indication of the well-defined structure as proposed initially. we believe that this study came across the need for a brazilian version of the system usability scale, as it is a helpful instrument that has been applied in the brazilian context (3, 8), but without a version that had formally undergone the cross-cultural adaptation process. the specialists' committee proved to be consistent with the study's objectives and the context of the system usability scale, as recommended by the literature (13). the psychological test adaptation procedure was performed to translate the system usability scale into polish (18). a cronbach's alpha value of 0.805 was also identified, with high correlations between the polish and english versions' items and the total score. the malaysian version of the system usability scale (19) was developed from a front-to-back translation of the scale. the final version was reached through consensus and cross-cultural adaptation with ten specialists in mobile application development. the content validity index was found to be 0.91, indicating the relevance of the ten items of the system usability scale to evaluate the usability of mobile device applications. face validity was also analyzed with ten cell phone users, obtaining a value of 0.94, indicating that the scale was easily understood. reliability was assessed among 54 cell phone users, reaching a cronbach's alpha value of 0.85 (95 % confidence interval; 0.79-0.91), which denotes a reliable version for its proposed assessment (19). on the one hand, the system usability scale provides a usability score easily understood by many people: project managers, computer programmers, and application users. it becomes apparent, on the other hand, as its author rightly puts it, that the scores for the items are not meaningful by themselves (9). therefore, the usability evaluation should be understood based on the set of answers to the items of the system usability scale. it has been noted; however, that software users and it professionals tend to ignore this recommendation provided by the scale's author (20-22) and often consider, in isolation, information regarding the quality of specific aspects of usability, viewing the evaluation obtained through some items of the scale. this study confirmed the one-dimensionality of the system usability scale, which reaffirms the original author's recommendation that its items should not be analyzed separately. a recent study (23) has found that the use of mobile devices by nurses is increasing, considering a sample of 24 studies (19 master's theses and five dissertations) that verify the development and use of applications: 16 (66.7 %%) of them with a care focus, six (25 %%) with an educational focus, and two (8.3 %%) with a management focus. from the automotive sector to space and industrial research, from people with different disabilities to voters, many sectors are interested in conducting usability research (9, 10). in nursing care and in light of the swift technological development in healthcare, it is believed that this scale can be used in different contexts. conclusions the system usability scale cross-cultural adaptation process into brazilian portuguese was conducted according to the steps recommended by the literature. for the adapted version, the title "escala de usabilidade de sistema — versão brasileira" (system usability scale — brazilian version) was adopted. the cultural adaptation process demanded only a few adjustments in some terms concerning the original version. the brazilian version of the system usability scale was user-friendly and easy to understand, confirming its functionality. it also presented construct validity, being equivalent to the original english version. as a limitation, the test was carried out at a single private university, with students from two courses, and focused only on the whatsapp application. studies involving the testing of other systems and other target audiences are suggested to confirm this version's adequacy, considering the country's cultural diversity. another limitation of the study is that the participants were not randomly selected. furthermore, as the results suggested a one-dimensional factor structure, it is recommended that the structural construct validity be assessed again using the item response theory technique in a future study. therefore, it is believed that the system usability scale can be used to evaluate new technological tools, such as computer programs and software for teaching and care in healthcare and nursing. conflicts of interest: none declared. references 1. odgers c. smartphones are bad for some teens, not all. nature. 2018554(7693):432-4. doi: https://doi.org/10.1038/d41586-018-02109-8 2. pérez lsv, tornés afg, riverón emf, hernández ams, galeana nip. software quality methodology to train engineers as evaluators of information systems development tools. universal j educ res. 2018;6(12):2942-51. doi: https://doi.org/10.13189/ujer.2018.061230 3. hodrien a. a review of post-study and post-task subjective questionnaires to guide assessment of system usability. j usability stud. 2021;16(3):203-32. http://usir.salford.ac.uk/id/eprint/60928/4/hodrien_jus_may2021.pdf 4. agência nacional de telecomunicações. histórico: acessos [internet]. brasília: anatel; 2017. https://www.anatel.gov.br\dados-abertos\pda\historico_acessos\historico_acessos.csv 5. barra dcc, paim sms, sasso gt, colla gw. methods for developing mobile apps in health: na integrative review of the literature. texto contexto enferm. 2017; 26(4):e2260017. doi:  https://doi.org/10.1590/0104-07072017002260017 6. reichenpfader d, glauser r, dugas m, denecke k. assessing and improving the usability of the medical data models portal. stud health technol inform. 2020;271:199-206. doi: https://doi.org/10.3233/shti200097 7. narcizo jcm, silva la. qualidade de software: melhorando a qualidade de serviços computacionais, baseado na percepção do usuário [dissertação de mestrado] [internet]. anápolis: centro universitário de anápolis; 2018. http://repositorio.aee.edu.br/bitstream/aee/1103/1/tcc2_2018_02_josimar_candido_e_lucas_andrade.pdf 8. padrini-andrade l, balda rcx, areco kcn, bandiera-paiva p, nunes mv, marba stm et al. evaluation of usability of a neonatal health 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beaton de, bombardier c, guillemin f, ferraz mb. recommendations for the cross-cultural adaptation of health status measures. spine (phila pa 1976). 2000; 25(24):3186-91. doi: https://doi.org/10.1097/00007632-200012150-00014 14. hair jf, black wc bj, anderson re. multivariate data analysis. 9a ed. hampshire: cengage learning; 2019. 15. lynn mr. determination and quantification of content validity. nurs res. 1986;35(6):382-5. 16. hair junior jf, black wc, babin bj, anderson re, tatham rl. análise multivariada de dados. 6a ed. porto alegre: bookman; 2009. 17. tabachnick bg, fidell ls. using multivariate statistics. 5a ed. upper saddle river, nj: pearson allyn & bacon; 2007. 18. alexandre nmc, coluci mzo. content validity in the development and adaptation processes of measurement instruments. ciênc saúde colet. 2011;16(7):3061-8. doi: https://doi.org/10.1590/s1413-81232011000800006 19. marôco j. análise estatística com o pasw statistics (ex-spss). lisboa: reportnumber; 2010. 20. gao m, kortum p. m. borkowska aj jach k. multi-language toolkit for the system usability scale. int j human-comput interact. 2020;36(20):1883-901. https://doi.org/10.1080/10447318.2020.1801173 21. marzuki mfm, yaacob na, yaacob nm. translation, cross-cultural adaptation, and validation of the malay version of the system usability scale questionnaire for the assessment of mobile apps. jmir hum factors. 2018;5(2):e10308. doi: https://doi.org/10.2196/10308 22. bloom bm, pott j, thomas s. usability of electronic health record systems in uk eds. emerg med j. 2021;38(6):410-5. doi: https://doi.org/10.5061/dryad.7h44j0zsq 23. lima csp, barbosa sdff. aplicativos móveis em saúde: caracterização da produção científica da enfermagem brasileira. rev eletr enferm. 2019;21. doi: https://doi.org/10.5216/ree.v21.53278 home microcephaly diagnosis: maternal perspectives about the organization of the health care network article microcephaly diagnosis: maternal perspectives about the organization of the health care network* diagnóstico de la microcefalia: perspectivas maternas acerca de la organización de la red de atención a la salud** diagnóstico da microcefalia: perspectivas maternas sobre a organização da rede de atenção à saúde*** 10.5294/aqui.2021.21.1.7 hosana mirelle goes e silva costa1 bárbara daniely dos santos silva2 jussara rodrigues de alcantara3 cintia mikaelle cunha de santiago nogueira4 fátima raquel rosado morais5 1 0000-0003-3402-5065. universidade do estado do rio grande do norte, brasil. hosanamirelle@uern.com 2 0000-0003-1165-3931. universidade do estado do rio grande do norte, brazil. barbaradaniely@alu.uern.br 3 0000-0002-7340-5012. universidade do estado do rio grande do norte, brazil. jussaraalcantara@alu.uern.br 4 0000-0002-6513-120x. universidade do estado do rio grande do norte, brazil. cintiamikaelle@uern.br 5 0000-0001-8052-4725. universidade do estado do rio grande do norte, brazil. fatimaraquel@uern.br * this article derives from the master’s thesis entitled “care network for children diagnosed with microcephaly due to zika virus: maternal perspectives”, presented at universidade do estado do rio grande do norte, brazil. available from:         http://www.uern.br/controledepaginas/ppgss-dissertacoes-concluidas-em-2019/arquivos/3457dissertacao_concluida_ppgss_hosana_mirelle_goes_e_silva_costa.pdf ** el artículo proviene de la tesis de maestría “red de atención a los niños diagnosticados con microcefalia resultante del zika virus: perspectivas maternas”, presentada en la universidade do estado do rio grande do norte, brasil. disponible en: http://www.uern.br/controledepaginas/ppgss-dissertacoes-concluidas-em-2019/arquivos/3457dissertacao_concluida_ppgss_hosana_mirelle_goes_e_silva_costa.pdf *** este artigo é derivado da dissertação de mestrado intitulada “rede de atenção às crianças diagnosticadas com microcefalia decorrente do zika vírus: perspectivas maternas”, apresentada na universidade do estado do rio grande do norte, brasil. disponível em: http://www.uern.br/controledepaginas/ppgss-dissertacoes-concluidas-em-2019/arquivos/3457dissertacao_concluida_ppgss_hosana_mirelle_goes_e_silva_costa.pdf received: 13/06/2020 sent to peers: 13/07/2020 approved by peers: 09/11/2020 accepted: 07/12/2020 to reference this article / para citar este artículo / para citar este artigo: costa hmgs, silva bds, alcantara jr, nogueira cmcs, morais frr. microcephaly diagnosis: maternal perspectives about the organization of the health care network. aquichan. 2021;21(1):e2117. doi: https://doi.org/10.5294/aqui.2021.21.1.7 abstract objective: to understand the organization of the health care network (rede de atenção à saúde, ras) from the experiences of mothers and family members in the assistance process for the diagnosis of microcephaly. materials and methods: a descriptive and exploratory research study with a qualitative approach, conducted with 14 mothers of children with microcephaly. for the definition of the sample, the following inclusion criteria were listed: being a mother of a child diagnosed with microcephaly due to zika virus, having given birth, and being a resident of the municipality of mossoró, rio grande do norte, brazil. regarding the exclusion criterion, the following was specified: mothers who did not accept to participate in the study. the population of this research was defined in 2018. minayo’s method of thematic content analysis was employed for data analysis. results: the results were divided into the following categories: 1. access to the services, exams, and professional monitoring; 2. perception of the mothers about follow-up in the ras. it was possible to apprehend the obstacles experienced in the ras for the diagnosis and follow-up of children with congenital syndrome due to the zika virus. conclusions: the difficulty of operationalizing the proposed protocol for the ras was evidenced, either due to insufficient knowledge about the syndrome, making it impossible to maintain the organizational flow established by the protocol, or to the scarcity of hard technologies that assist in the implementation of this assistance. keywords (source decs): microcephaly; zika vírus; nursing; delivery of health care; diagnosis. resumen objetivo: entender la organización de la red de atención a la salud (ras) desde vivencias de madres y de familiares en el proceso asistencial para el diagnóstico de microcefalia. materiales y métodos: investigación descriptiva y exploratoria, de enfoque cualitativo, realizado con 14 madres de niños con microcefalia. para definir la muestra, se consideraron los siguientes criterios de inclusión: ser madre de niño diagnosticado con microcefalia resultante del virus zika, haber parido y ser residente del municipio de mossoró, rio grande do norte, brasil. como criterios de exclusión, se especificaron: madres que no aceptaron a participar en el estudio. la población del estudio se definió en el 2018. para analizar los datos, se empleó el método de análisis temático de contenido de minayo. resultados: los resultados se dividieron en las categorías: 1. acceso a los servicios, a las pruebas y al seguimiento profesional; 2. percepción de las madres acerca del seguimiento en la ras. se logró aprehender los obstáculos vivenciados en la ras para o diagnóstico y el seguimiento de los niños con síndrome congénito resultante del virus zika. conclusiones: se evidenció la dificultad de operacionalización de protocolo propuesto para la ras, ya sea por el conocimiento insuficiente acerca del síndrome, imposibilitando el mantenimiento del flujo organizacional establecido por el protocolo, ya sea por la escasez de tecnologías duras que auxilien en la efectuación de esta asistencia. palabras clave (fuente decs): microcefalia; virus zika; enfermería; prestación de atención de salud; diagnóstico. resumo objetivo: entender a organização da rede de atenção à saúde (ras) a partir de vivências de mães e de familiares no processo assistencial para o diagnóstico de microcefalia. materiais e métodos: pesquisa descritiva e exploratória, de abordagem qualitativa, realizada com 14 mães de crianças com microcefalia. para a definição da amostra, foram elencados os seguintes critérios de inclusão: ser mãe de criança diagnosticada com microcefalia decorrente do zika vírus, ter parido e ser residente do município de mossoró, rio grande do norte, brasil. enquanto critérios de exclusão, foram especificados: mães que não aceitaram participar do estudo. a população desta investigação foi definida no ano de 2018. para a análise dos dados, foi empregado o método da análise temática do conteúdo de minayo. resultados: os resultados foram divididos nas seguintes categorias: 1. acesso aos serviços, aos exames e ao acompanhamento profissional; 2. percepção das mães acerca do seguimento na ras. foi possível apreender os obstáculos vivenciados na ras para o diagnóstico e o seguimento das crianças com síndrome congênita decorrente do zika vírus. conclusões: evidenciou-se a dificuldade de operacionalização de protocolo proposto para a ras quer seja pelo conhecimento insuficiente acerca da síndrome, impossibilitando a manutenção do fluxo organizacional estabelecido pelo protocolo, quer seja pela escassez de tecnologias duras que auxiliem na efetivação dessa assistência. palavras-chave (fonte decs): microcefalia; zika vírus; enfermagem; assistência à saúde; diagnóstico. introduction the first record of zika virus (zikv), transmitted through aedes aegypti, took place in uganda in 1947. however, it was only 60 years later that the first outbreak occurred, in micronesia and french polynesia and, at the time, it was not considered a risk to public health, as it mildly manifested itself, with a benign evolution. in brazil, zikv had its first identification in april 2015 (1). the situation for facing zikv cases in the country was worsened when noticing that, after the occurrence of the rash disease in pregnancy, there was a significant increase in cases of microcephaly, which is defined as a congenital malformation where the head circumference of the newborns (nbs) is below the standard for their age and gender (2). during the diagnostic research, a study conducted and coordinated by celina turchi in 2016 identified a possible relationship between zikv infection during pregnancy and the occurrence of microcephaly in nbs (3). thus, from november 2015 to february 2020, approximately 18,687 cases of microcephaly associated with zikv were notified in brazil. of these, 22 % (4,111 cases) are still under investigation, 59.2 % (11,064 cases) were discarded, and 18.7 % (3,512 cases) are confirmed (4). these data, in turn, are characterized as alarming since, between 2000 and 2014, there were 2,464 cases of microcephaly in live births in brazil, with an annual mean of 164 cases (5). at the same time, from november 2015 to february 2020, in rio grande do norte, 558 suspected cases of microcephaly and/or other malformations related to congenital infections were notified. of this total, 19.3 % (108 cases) are under investigation, 29.6 % (165 cases) were confirmed, and 51.1 % (285 cases) were discarded (6). in this state, until the outbreak occurred, the proportion of cases was two cases in 2010, two in 2011, four in 2012, no cases in 2013, and one case in 2014 (7). in the municipality of mossoró, rio grande do norte, epidemiological bulletin no. 7/2020 records 87 cases in the city, of which 19.5 % (17 cases) were confirmed, 71.3 % (62 cases) were discarded and 9.2 % (8 cases) are under investigation (6). given the alarming initial data on microcephaly, in november 2015, the brazilian ministry of health classified the occurrence of this situation as a public health emergency of national importance. therefore, with the increase in the proportion of cases, in february 2016, the world health organization also declared the situation as a public health emergency of international importance (1). to assist in facing and controlling the epidemic in brazil, the brazilian ministry of health published two protocols: the protocol for surveillance and response to the occurrence of microcephaly and the protocol for health care and response to the occurrence of microcephaly related to zikv infection. there was even concerned with the formatting of the health care network (ras) in the perspective of states and municipalities being organized, agreeing on the steps to be taken for the diagnostic closure of suspected cases (7). however, in rio grande do norte, there were difficulties in operationalizing this network, either due to technical and scientific limitations of the working team or to the limitation of supplies and equipment to cope with the large demand. this assertion is corroborated by the fact that, even after five years since the outbreak, there are still items pending compliance with the protocol in the state, with 22 % of the children still lacking diagnostic closure (6). the decision to develop this research was taken given the issues observed preliminarily and assuming that the ras is fragile and not very resolute, particularly in the occurrence of microcephaly due to zikv. in the course of the study, it was sought to understand the organization of the ras based on the experiences of mothers and family members in the care process for the diagnosis of microcephaly. materials and methods this is a descriptive and exploratory research, as it seeks to portray the organization of the ras for the diagnosis of children with microcephaly due to zikv, from their mothers’ experiences. the research was carried out in the municipality of mossoró, the second in the state with the largest number of confirmed microcephaly cases. the population of this research was defined in 2018 based on the number of notified cases and the non-probabilistic sample of the total number of cases for that year, delimited from the cases that had already completed the stages for diagnosis based on the ministerial protocols. consequently, notification of 94 cases was identified, with a total of 14 cases with an already defined diagnosis. thus, to define the sample of mothers who would be part of the research, the following inclusion criteria were listed: being the mother of a child diagnosed with microcephaly due to zikv, having given birth and being a resident of the municipality of mossoró. regarding the research exclusion criterion, the mothers who did not accept to participate in the study were not considered. the data collection instrument was of the semi-structured interview type. the closed questions were asked to define the sociodemographic profile of the research subjects and the open ones were intended to analyze the perception of the target audience about their trajectory through the ras and their feelings about this path. for data analysis, minayo’s method of thematic content analysis (8) was used, in which the speeches were organized, transcribed and separated by guiding questions, proceeding to a floating reading to apprehend the meaning of the whole. subsequently, the material was explored with an exhaustive reading of the statements, with the purpose of categorization. regarding this stage, first, the nuclei of meaning (words or expressions that answered the guiding question) were extracted. with the nuclei of meaning highlighted in the speeches, these were clipped, without losing the context, obtaining excerpts from the interviews that answered the question. the interviewees were identified with the word “mother”, followed by a number indicating the chronological order of the interviews. after that, the categories were divided and their respective discussions were carried out. the following categories were defined: 1. access to the services, exams and professional monitoring; 2. perception of the mothers about follow-up in the ras. the research observed all the ethical aspects recommended by resolution 466/2012 of the brazilian national health council. the research in question is an excerpt from a master’s dissertation carried out by hosana mirelle goes silva costa, in which it was submitted to a previous evaluation by the research ethics committee of universidade estadual do rio grande do norte, approved according to opinion no. 2,080,033, and performed as prescribed by that collegiate body. results the study participants and the categories generated from data analysis are presented below. characterization of the study participants for a better understanding of the categories of this research, the importance is understood of presenting the mothers, subjects of this research, to facilitate the reading of the life context and the health needs presented by the group under consideration. thus, the description of the group of mothers of children with microcephaly due to zikv follows. the study had the participation of 14 mothers of children diagnosed with microcephaly, through the care network organized in the municipality of mossoró. of the 14 mothers who participated in the research, 71.4 % (n = 10) were 29 years of age or younger, 42.9 % (n = 6) of these women had only completed elementary school, and 71.4 % (n = 10) were married or in a stable union. in terms of personal income, 64.3 % (n = 9) of these women carried out only activities in their homes, without participating in the productive sector, as well as in 64.3 % (n = 9) of these families, in which incomes fluctuated between one and three minimum wages. it is noteworthy that, in this income, 78.6 % (n = 11) of the sample is already included, mothers who perceive the continuous provision benefit, an aid that complements income and allows reaching this data. the results are divided into categories of analysis, to understand the obstacles that women with children diagnosed with microcephaly due to zikv had to face within the ras, namely: 1. access to the services, exams, and professional monitoring; 2. perception of the mothers about follow-up in the ras. access to the services, exams and professional monitoring although all mothers in this study performed some prenatal consultations, the data show that only 50 % attended at least six consultations, as recommended by the brazilian ministry of health. in this context, it was found that it was the pregnant women who made six or more consultations (50 % of the cases investigated) who early detected the occurrence of microcephaly while still pregnant. it is worth mentioning that even the pregnant women who detected microcephaly during pregnancy had much of their time consumed with the difficulty in accessing the service: prenatal care was initiated with two months. i went to the appointments very well, but i only managed to do the ultra with thirty-nine weeks and four days, the day she was born was that i managed. at that moment i discovered the micro, in this ultrasound. (mother 5) because the health center was always lacking the nurse, when it wasn’t that, it was because it was a holiday, it wasn’t working, a strike… these things like that. (mother 4) the aforementioned difficulty persisted, even after pregnancy, when the child needed to undergo a series of procedures foreseen in the protocols for diagnostic closure of the complication. then there was this task force. a lot of children were discarded, so with this task force a lot of exams were done, they gave the exams in a private clinic because it had to be soon, in a week we did, i think, like six exams. (mother 4) once the difficulties related to the preliminary diagnosis were overcome, according to the guidelines in the protocol, specialized consultations become indispensable for diagnostic precision concerning the syndrome itself. this other aspect was severely impaired in the organization of the network: [...] my son has been in the waiting list for a year, got it? for an appointment with a neuropediatrician here in mossoró. until today, he has been in this for a year, waiting his turn. (mother 1) also in the ras and from the maternal speeches, lack of knowledge and/or unpreparedness of the professionals regarding the referrals and the need to carry out tests for diagnostic closure was observed: [...] i did ultrasounds every fifteen days, because it presented a change and nobody knew what that change was. so, with almost seven months [of pregnancy], we really came to discover my son’s microcephaly. (mother 3) however, there were cases in which the mother, aware of the child’s diagnosis, received more attentive care, thus evidencing the sensitivity of the professionals in the face of this situation: as we already knew about microcephaly, the team was ready to receive her, they had already guided me since i was pregnant... i was afraid... but i trusted the team. we had all the support of the procedures, i was very well assisted. (mother 3) in the group of this study, the cases that were not identified, even during pregnancy, were mostly detected during follow-ups c and d: the nurse found out when i went to do c and d at the health center, as usual. she was already eight months old. i was seeing a few different things about her, only that i thought she didn’t have any condition. because there is no way for a child to leave a large hospital and not diagnose, neither a pediatrician nor a doctor to diagnose my daughter’s microcephaly. (mother 6) i discovered his microcephaly with a routine consultation, when he was seven months old, there in the health center. (mother 8) also concerning to the ras, when asked about the laboratory and imaging tests for diagnosis, performed at the time of birth, the data show that only three mothers reported that immediate blood collection from the umbilical cord of the children was carried out. seven mothers reported that such examinations were not performed, and four did not know how to inform. the data further reinforce the unenforceability of the network in the region because, with the increase in the complexity of the exams for diagnostic closure, the more difficult its performance. this was noticed when one of the mothers reported the need for a placental biopsy and collection of cerebrospinal fluid. in the cases of this research, ten mothers reported not having performed this collection, while four did not know how to inform: no exam was done, in the maternity they passed only an ultra, a transfontanellar ultra for the child. but, as they didn’t do it there, i asked for permission to do it out here. (mother 5) if it is impossible to perform transfontanellar ultrasonography (tf-us) while still in the maternity hospital, whether due to the absence of the necessary instruments or to the reduction of the fontanelle, it is possible to perform it later, within the child’s first year of life (9). when diagnostic confirmation is not performed through laboratory tests and tf-us, the brazilian ministry of health indicates that a skull computed tomography (ct) without contrast (1) should be performed. in fact, the reports of mothers who managed or, at least, tried to carry out these exams through the public network demonstrate the obstacles to its performance: since she was born, the ct is there in that office and has never been scheduled. (mother 4) i only did an exam by the sus, which was to detect the zika virus, i collected the blood with a mean of 15 days after my daughter was born, the exam only came later, with a year. (mother 9). perceptions of the mothers about follow-up in the ras regarding this category, the mother’s speeches reinforce the network’s deficiency in establishing this essential link for care continuity: we left the hospital with a report, with a report stating that he had microcephaly, but the doctors, they didn’t say anything, i even made a scandal there in the hospital, inside the hospital director’s office because they didn’t say anything to me that it had to be done. (mother 1) such data can be a sample of how much the network was not yet understood and inserted in daily work, emphasizing the importance of unveiling the knowledge of the professionals regarding this organization. concerning this variable, the research data show that only five mothers were referred, upon discharge from the maternity hospital, to the health services responsible for care continuity. all these doubts, anchored to the disjointed reference services, aroused a feeling of helplessness in the mothers. such feeling can be illustrated with the following speeches: to the health center... i went... my daughter was not ten days old, but i had no answer there, i was not advised by the health center. (mother 3) only after a year did i start going to the health center, we went to the center, but we never received a home visit, and i was never advised about anything. (mother 7) the reports reinforce the weakness in the services and in the operational dynamics of management, with the need to promote strategies that better assist the users of the public service regarding the understanding of the organization of assistance. discussion by focusing on the diagnosis of zikv infection and detection of microcephaly, from the analysis, it was found that prenatal care is the action that aims to monitor pregnancy for guidelines and early diagnosis of complications (10). consequently, it is expected that the diagnosis is made in the initial stages of pregnancy. it is a fact that prenatal care is important, especially when all consultations and examinations provided for in this process are carried out. thus, it is possible that early discovery and good guidance within the context of prenatal care can contribute in a uniquely to the preparation and acceptance of the condition by the mother and all the family members (11). however, the speeches reveal the inability of the network to be resolute, to give precise answers, and to meet the demands of the population in the face of this demand. so much so that, in the municipality of mossoró, emergency actions were taken for capture and diagnosis of possible microcephaly cases. the main action in this regard was a “task force” to assist suspected cases, to minimize the delay in the consultations and exams necessary for this research (12). prenatal care incapable of making the microcephaly diagnosis during the gestational period plus the failure to perform fundamental tests promptly requires the presence of a neuropediatrician for late diagnostic confirmation. given the alleged organization of the ras, as well as due to the assistance protocols for the diagnosis and follow-up of the child with microcephaly due to zikv, the absence of the neuropediatrician can be associated with the inefficiency of the network concerning the necessary services and actions before that moment. as the focus of this research is the knowledge of the aspects involved in the dynamics of the ras for the diagnosis of microcephaly due to zikv, it is important to discuss welcoming and empathy in the face of the problems experienced by each family. so, in parallel with all the technical stages for diagnosis, it would be up to each professional to welcome and guide the mother and her family (13). however, even with the detection of the syndrome during follow-ups c and d by the health professionals, the delay in the perception of the situation is evident since only after several follow-ups there was a referral for diagnostic closure. in these cases, it is worth reflecting on how much the monitoring of growth and development has been occurring within its predicted meaning or if the emphasis does not focus primarily on the evaluation of the child growth chart, disregarding, or underestimating, the development milestones. in some situations, it was the mothers themselves, without having scientific knowledge, who began to notice changes in the child’s development. it seems that the clinical evaluation, with the identification of the changes, tended to go unnoticed by the multi-professional team responsible for providing this service. children with microcephaly due to zikv tend to perform poorly in the areas of physical, motor, cognitive, visual development and anthropometric measurements. such characteristics can, for example, cause impairment in their growth, and development when compared to children who do not present this congenital syndrome. in this perspective, such impairments must be evaluated early in the c and d consultations for better follow-up of these children to the rehabilitation and early stimulation services (14). follow-ups c and d seem to tend to fail to capture nuances of the child’s clinical and physical changes. this condition may be related to the emphasis on growth, with a focus and concern on weight and height, disregarding, among others, aspects related to child development (15). thus, it can be observed that the reorganization of a ras aimed at children diagnosed with microcephaly, based on the assistance already offered to the population, evidenced the weaknesses and deficiencies in the availability of these services. the lack of specific professional knowledge on this situation, associated with the delay in its qualification and the recruitment of qualified professionals, has worsened the complications (16). in addition to that, the structural context of the services, as well as the difficulty in knowing and learning how to deal with the ras, contributed greatly to the difficulty in diagnosing and monitoring these children. also concerning to the organization of the ras for diagnosis, the protocol for health care and response to the occurrence of microcephaly related to infection by zikv states that, at the time of birth and through laboratory and imaging exams, the diagnostic investigation has as its main objectives to confirm the diagnosis of congenital microcephaly and to rule out other etiologies that cause microcephaly (1). some of these exams must be performed in the delivery room, such as the following collections in the nb: blood from the umbilical cord (3 ml) and the placenta (3 fragments of 1 cm3 each) and cerebrospinal fluid from the nb (1 ml) (17). based on the negatives regarding the performance of the exams and also due to the considerable percentage of mothers who did not know how to inform about it, it is possible to infer the mother’s lack of knowledge regarding the exams and the stages for diagnosis. some of the mothers went through the network without the slightest notion of what each stage of this process represented. however, the materials published by the brazilian ministry of health (17) emphasized the importance of care beyond the biological scope, based on the formation of a bond between the professionals and the mothers of these children. this would tend to make the network accessible, by promoting the necessary supplies and logic, in which these women could understand it and solve their doubts about the diagnosis stages.   as an aggravating factor for maternal lack of knowledge, regarding the need to perform laboratory exams, the transmission of scarce information by the health team professionals can be mentioned. this is linked to a lack of knowledge or even to the establishment of an environment that does not allow for dialog between professionals and mothers (18). to facilitate diagnosis, after discharge from the maternity hospital, the ministry of health recommends that the tf-us be performed as a priority. this exam is defined as the first choice, as ct uses radiation at high levels and even generates the need for sedation of the nb for its conduction (1). however, the data demonstrate the weakness of the public services in relation to the availability of these exams on time. this, in turn, enhances, for those who have resources, the search for private means for timely diagnosis; and thus, the initiation of early stimulation. given the reports, there is evidence of the unpreparedness of the public bodies to deal with certain situations that require more complex assistance and the use of many technologies. since the exams considered as basic for diagnostic definition were not prioritized, fast closure of this diagnosis became impossible, which would contribute to faster and more effective performance, especially concerning development stimulation and to the minimization of possible sequelae (19). the public health emergency installed with microcephaly resulting from zikv showed the current difficulty in the articulation of the health services, at different complexity levels. according to the ministry of health (20), when a clinical condition is declared a public health emergency, it is necessary to urgently install risk prevention and control measures to reduce public health problems. the arrival of these children at the service was felt with insecurity, due to diagnostic uncertainty and to the obscurity in the assistance follow-up. the families sought guidelines to understand what was happening and to know which path should be outlined (21). in this context, the care network must encourage health promotion strategies to try to reduce and overcome the impact within the family nucleus (1). thus, it is important to know the network, reflecting on its organization and seeking to eliminate the frequent fragmentation present in this system, as well as in the recurrent conducts by the professionals, culminating in the guarantee of its articulation, with a view to comprehensive and resolute care (22). only in this way would it be possible to foresee care organization in an effective and expanded way, favoring access and more resolute, qualified and welcoming care for the population. conclusions zikv increased the fragility of the organization of the services that make up the ras in the services and in the study centers. when the demands arose, the focus was only on biological control, not paying attention to other problems. such congenital malformation requires humanized attention from the health services, because of the social profile reached by zikv. this flow requires assistance demands that range from conception to the rehabilitation of the children and their families. the aim is a network that guarantees the integrality of the care provided to this population, through the articulation of the different sectors and the commitment of the working professionals. however, it was noticed that, according to the maternal perspective, the care network in question presented various failures in complying with the entire protocol recommended for the care of the children, pointing out the need to build a ras directed to meet emerging demands, which require continuous and comprehensive assistance, not only focal and temporary, like the existing ones. due to the lack of studies that relate the functioning of a ras to children with zikv, in addition to the particularities experienced by the mothers during the period of microcephaly diagnosis and treatment, data collection and research directed to the organization of the ras in the context of endemic diseases will continue to be important for the academic environment and society, due to the need to reorganize all the nuances that make up the ras, to guarantee the control of the disease in question. as study limitations, the size of the study sample and the restrictions in the interviewees’ speeches are highlighted. thus, it is necessary to address this theme in other studies, to obtain more information and to sensitize professionals and managers about the problems found in the ras that assist these children, in addition to encouraging the welcoming of these families. it is also suggested that future studies related to zikv do not focus only on its biological and clinical aspects, but that they assist the services in building a service network capable of remedying the needs still left by the outbreak that occurred. conflict of interests: none declared. references 1. brasil. portaria interministerial n.o 405. institui, no âmbito do sistema único de saúde (sus) e do sistema único de assistência social (suas), a estratégia de ação rápida para o fortalecimento da atenção à saúde e da proteção social de crianças com microcefalia; 2016. disponível em: http://portalarquivos2.saude.gov.br/images/pdf/2016/marco/23/portaria-interministerial n-405-ms-e-mds-de-15.03.2016.pdf. 2. world health organization. pregnancy management in the context of zika virus infection. interim guidance update; 2016. available from: http://apps.who.int/iris/bitstream/10665/204520/1/who_zikv_moc_16.2_eng.pdf?ua=1 3. miranda-filho db, martelli cmt, de alencar ximenes ra, araújo tvb, rocha maw, ramos rcf et al. initial description of the presumed congenital zika syndrome. american journal of public health. 2016;106(4):598-600. available from: 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2014;22(1):15-23. doi: https://doi.org/10.4322/cto.2014.003 14. frança tlb, medeiros wr, souza nl, longo e, pereira sa, frança tbo et al. growth and development of children with microcephaly associated with congenital zika virus syndrome in brazil. international journal of environmental research and public health; 2018. doi: https://doi.org/10.3390/ijerph15091990 15. da silva reichert ap. vigilância do crescimento e desenvolvimento: análise dos registros na caderneta de saúde da criança. cogitare enfermagem. 2016;21(4):1-9. doi: https://doi.org/10.5380/ce.v21i4.45256 16. mestriner rg. uma realidade revisitada em tempos de zika vírus e microcefalia: estamos preparados para comunicar um diagnóstico de deficiência? ciência & saúde. 2016;8(3):98. doi: https://doi.org/10.15448/1983-652x.2015.3.22927 17. brasil. orientações integradas de vigilância e atenção à saúde no âmbito da emergência de saúde pública de importância nacional. ministério da saúde; 2017. disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/orientacoes_integradas_vigilancia_atencao_emergencia_saude_publica.pdf 18. cerqueira mmf, de oliveira alves r, aguiar mgg. experiências vividas por mães de crianças com deficiência intelectual nos itinerários terapêuticos. ciência & saúde coletiva. 2016;21(10):3223-32. doi: http://dx.doi.org/10.1590/1413-812320152110.17242016 19. garcia lp. epidemia do vírus zika e microcefalia no brasil. brasília: instituto de pesquisa econômica aplicada; 2018. disponível em: https://www.ipea.gov.br/portal/index.php?option=com_content&view=article&id=32492. 20. brasil. plano de resposta às emergências em saúde pública [internet]. brasília: ministério da saúde; 2014. disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/plano_resposta_emergencias_saude_publica.pdf 21. hasue rh. a síndrome congênita do vírus zika: importância da abordagem multiprofissional. fisioterapia e pesquisa. 2017;24(1). disponível em: https://www.scielo.br/scielo.php?pid=s1809-29502017000100001&script=sci_arttext 22. montenegro lc. a integralidade sob a ótica dos profissionais dos serviços de saúde de belo horizonte. revista da escola de enfermagem da usp. 2010;9(44):649-56. disponível em: http://www.scielo.br/scieloorg/php/articlexml.php?lang=ptpid=s0080-62342010000300014. home 227 242 las tic.indd 227 óscar boude-figueredo1 mónica ruiz-quintero2 las tic: propuesta para el aprendizaje de enfermería basado en problemas 1 ingeniero electrónico. candidato a doctor en modelos didácticos e interculturalidad de las tic en la educación. universidad de la sabana. campus universitario puente del común. chía, colombia. oscarbf@unisabana.edu.co 2 licenciada en ciencias sociales. magíster en educación. especialista en teorías métodos y técnicas de investigación social. universidad de la sabana. campus universitario puente del común chía. colombia. monicarq@unisabana.edu.co recibido: 20 de junio de 2008 aceptado: 25 de agosto de 2008 resumen este artículo presenta el análisis de un proceso de investigación cuyo objetivo fue identificar las competencias sobre redes de computadores que alcanzan los estudiantes de enfermería a través del trabajo independiente, en un ambiente de aprendizaje (aa) que hace uso de un material educativo digital basado en problemas. en el estudio participaron 22 estudiantes de enfermería de la universidad de la sabana, que cursaron la materia telemática durante el segundo semestre de 2007. se recurrió al estudio de caso, ya que éste permite ver un aa desde todas sus aristas, así como comprender las prácticas y los imaginarios de los actores que intervienen, sus relaciones, tensiones y transformaciones. el 27% de los estudiantes superaron los niveles esperados en el desarrollo de las competencias planteadas, el 63% alcanzó los niveles esperados, y el 14% sólo llegó a los niveles mínimos. estos logros estuvieron relacionados con las metodologías desarrolladas por cada pareja para solucionar los casos, y con factores tales como el intercambio de saberes con pares, los esquemas de pensamiento propios, la disposición y la actitud de los estudiantes. palabras clave estudiantes de enfermería, aprendizaje, aprendizaje basado en problemas, educación basada en competencias. (fuente: decs) tic: a problem-based proposal for nursing education abstract this article offers an analysis of a research project designed to identify the computer network competence acquired by students through independent work in a learning environment (le) that makes use of problem-based, digital educational material. twenty-two (22) nursing students who were enrolled in a telematics course at the universidad de la sabana during the second half of 2007 participated in the study. a case-study methodology was used, as it permits an overview of all the problems in a le and facilitates an understanding of the practices and concepts of those who take part, their relations, tensions and transformations. twenty-seven percent (27%) of the students surpassed the expected levels of development in terms of the proposed competence, 63% achieved the expected levels, and only 14% reached the minimum levels. these accomplishments were related to the methods each pair developed to solve the case studies and to factors such as an exchange of knowledge with peers, individual ways of thinking, and each student’s willingness and attitude. key words nursing students, learning, problem-based learning, competence-based education. año 8 vol. 8 nº 2 chía, colombia octubre 2008 227-242 228 año 8 vol. 8 nº 2 chía, colombia octubre 2008 227-242 aquichan issn 1657-5997 as tics: uma proposta para a aprendizagem de enfermagem baseado nos problemas resumo neste artigo é analisado um processo de pesquisa dirigido a identificar as competências sobre redes de computadores que logram os estudantes de enfermagem mediante o trabalho independente em um meio de aprendizagem (ma) que utiliza material educativo digital baseado nos problemas. participaram 22 estudantes de enfermagem da universidad de la sabana que cursaram a matéria telemática no segundo semestre de 2007. foi empregado o estudo de caso, já que permite ver um ma desde diversas perspectivas e compreender práticas e imaginários dos intervenientes, assim como suas relações, tensões e transformações. o 27% dos estudantes ultrapassou os níveis desejados no desenvolvimento das competências apresentadas; 63% chegou aos níveis desejados e 14% só alcançou os níveis mínimos. estes logros se relacionam com as metodologias usadas aos pares para resolver os casos e com fatores como o intercâmbio de conhecimento com pares, esquemas de pensamento próprio, disposição e atitude dos estudantes. palavras-chave estudantes de enfermagem, aprendizagem, aprendizagem baseado nos problemas, educação baseada nas competéncias. 229 las tic: propuesta para el aprendizaje de enfermería basado en problemas óscar boude-figueredo, mónica ruiz-quintero introducción a partir del decreto 808 del 25 de abril de 2002, que estableció el crédito académico como mecanismo de evaluación de calidad, transferencia estudiantil y cooperación interinstitucional (1), la educación superior en colombia empezó un proceso de transformación al cual la facultad de enfermería de la universidad de la sabana no ha sido ajena. como resultado de estas acciones se desarrolló un proceso de resignificación del plan de estudios, integrando las tic como una herramienta mediadora y facilitadora de los procesos de aprendizaje a través del trabajo independiente (ti) de los estudiantes. ahora bien, dicha integración instaló un nuevo reto al centro de tecnologías para la academia, ya que éste debía no solo asesorar a la facultad en el proceso de integración, sino dar respuesta a preguntas como: ¿qué estrategias didácticas se pueden implementar para desarrollar competencias en los estudiantes a través del ti? ¿es posible lograrlo con la mediación de las tic? ¿cuál es el rol del docente y del estudiante? interrogantes que no solo plantean la necesidad de desarrollar diferentes estrategias didácticas enfocadas al ti, sino que evidencian la necesidad de validar si éstas favorecen el desarrollo de competencias en los estudiantes. al respecto, una investigación realizada por la universidad de la sabana y la escuela de ingeniería, denominada “integración de tic en la educación superior”, encontró en su primera fase cerca de cien usos diferentes de las tic reportados por 117 profesores que participaron, usos que van desde el apoyo a los procesos administrativos del curso hasta la integración de las mismas en el aula de clase (2). en la segunda fase observaron que aunque los profesores expresaban que las estrategias de integración utilizadas desarrollaban en sus estudiantes las competencias planteadas, esto no estaba ocurriendo, debido en gran medida a que en sus discursos y prácticas pedagógicas persisten concepciones tradicionales del cómo, qué y para qué se aprende; ejemplo de ellas es la insistencia de un rol protagónico del docente frente al pasivo de los estudiantes (3). sumado a lo anterior, es preocupante observar que la integración de las tic en las aulas se da en algunos casos porque alguien les contó que funcionaban, porque quieren experimentar o simplemente porque es una exigencia de la institución educativa, y no surge como producto de una reflexión acerca del qué, para qué y cómo se van a integrar las tic. marco contextual el marco de referencia que orienta este trabajo gira en torno a los diferentes hallazgos y discusiones que se están dando en la educación superior sobre la integración de las tic en el aula, y las transformaciones que esto está generando, por lo que de manera articulada se profundizará en conceptos como: aa, aprendizaje basado en problemas (abp), aprendizaje colaborativo (ac), ti y material educativo digital o computarizado (med). un aa es un espacio construido por el profesor con la intención de lograr unos objetivos de aprendizaje concretos, esto significa un proceso reflexivo en el que se atiende a las prela integración de las tic en las aulas se da en algunos casos porque alguien les contó que funcionaban, porque quieren experimentar o simplemente porque es una exigencia de la institución educativa, y no surge como producto de una reflexión acerca del qué, para qué y cómo se van a integrar las tic. 230 año 8 vol. 8 nº 2 chía, colombia octubre 2008 227-242 aquichan issn 1657-5997 guntas del qué, cómo y para qué enseño. en los ambientes intervienen diferentes actores teniendo en cuenta las concepciones pedagógicas del profesor; en él, los mismos desempeñan roles diversos. para este caso los actores son: los estudiantes, el profesor y un material educativo computarizado basado en problemas. jaramillo (4) plantea que los aa involucran la actuación de tres sujetos: los estudiantes, el profesor y las tic. estudiante y profesor participan en el ambiente a partir de unos imaginarios sobre lo que significa para ellos enseñar y aprender, sobre las tic y sobre el papel que debe jugar en este espacio; en este sentido los dos ponen en juego sus saberes, concepciones y prácticas que en muchas ocasiones son contradictorios y generan tensiones en el ambiente. ahora bien, ¿qué es esto de las tic?, ¿cuál es el sentido de un material educativo digital integrado al ambiente de aprendizaje? para este trabajo tomaremos la definición sobre tic dada por adell (5), quien las define como: “el conjunto de instrumentos y procedimientos que permiten la adquisición, producción, almacenamiento, tratamiento, comunicación, registro y presentación de informaciones, en forma de voz, imágenes y datos contenidos en señales de naturaleza acústica, óptica o electromagnética”. las tic incluyen la electrónica como tecnología base que soporta el desarrollo de las telecomunicaciones, la informática y el audiovisual. sin embargo, lo que le da un verdadero potencial dentro del aula es el sentido pedagógico que les imprime el docente, por tanto su incorporación debe ser el producto de una reflexión constante del docente sobre varios aspectos, entre ellos, la estrategia didáctica que se va a utilizar, las competencias por desarrollar, la temática, la problemática que se debe solucionar, etc. por otro lado, es posible incorporar las tic en el aula a través del uso de med. según galvis (6) un med es la denominación otorgada a las diferentes aplicaciones informáticas cuyo objetivo terminal es apoyar el aprendizaje. se caracterizan además porque es el alumno quien controla el ritmo del aprendizaje. este estudio se planteó el uso de un med basado en la metodología abp como apoyo al aa diseñado, debido a que en esta metodología el estudiante se convierte en el centro del proceso de aprendizaje, se transforma el rol del profesor que pasa de protagonista a coordinador del proceso de investigación y de resolución del problema de los estudiantes gracias a que el alumno debe resolver escenarios de problemas antes que tópicos; ayuda a generar un desarrollo intelectual y cognitivo más avanzado (7), así como a alcanzar altos niveles de comprensión (8). aunque este promueve el aprendizaje individual, puede ser construido a partir de la interacción con los otros. a esto le llamamos ac. en los ambientes colaborativos el proceso de ajuste de las estructuras mentales es permanente, no sólo se tiene la visión individual, ésta es contrastada con las múltiples visiones de los demás. cada miembro tiene responsabilidades específicas en la búsqueda, articulación, valoración y acomodación de ideas. la participación dinámica del individuo es fundamental para garantizar la dinámica del grupo. el conocimiento individual es constantemente contrastado, evaluado y ampliado por el grupo. el docente es el facilitador del en esta metodología el estudiante se convierte en el centro del proceso de aprendizaje, se transforma el rol del profesor que pasa de protagonista a coordinador del proceso de investigación y de resolución del problema de los estudiantes. 231 las tic: propuesta para el aprendizaje de enfermería basado en problemas óscar boude-figueredo, mónica ruiz-quintero proceso, plantea retos y genera situaciones de desequilibrio que motivan al grupo a iniciar una actividad colaborativa (9). ahora bien, es necesario hacer un alto en el camino e introducir lo que entendemos por competencia. una competencia es un proceso complejo mediante el cual la persona realiza actividades y resuelve problemas con la articulación del saber, el saber hacer y el saber ser, con autonomía, crítica y creatividad (10). ésta involucra simultáneamente conocimientos, desempeños y actitudes. los conocimientos se relacionan con la dimensión del saber; los desempeños con el hacer, involucran procedimientos, desarrollo de productos y estrategias; y las actitudes están ubicadas en la dimensión del ser junto a la motivación, la iniciativa, la disposición y otras características que pueden identificarse en la personalidad de quien tiene la competencia. de manera redundante se puede decir que al tener una competencia la persona es competente para realizar una actividad. esto significa que integra sus conocimientos, habilidades, disposiciones y conductas específicas para llevarla a cabo. si falla en alguno de estos aspectos no se puede decir que la persona es competente. esta concepción de las competencias como un saber hacer en contexto ha sido acompañada en la experiencia escolar por diversas estrategias con la intención de generar su desarrollo. precisamente en el campo de la salud los estudios de casos o la resolución de problemas han sido privilegiados en el proceso de aprendizaje de los estudiantes. dueñas (11) explica que este enfoque pedagógico abp se encauza en el autoaprendizaje y la autoformación, y se enseña y aprende a partir de problemas con significado para el estudiante. dice además que, con este enfoque el estudiante se encarga de seleccionar los contenidos o temas pertinentes en la solución del problema. a nuestro modo de ver lo interesante del abp es que permite al estudiante ser gestor de su proceso de aprendizaje asumiendo dentro de este un rol activo. metodología este proyecto se desarrolló a partir de las siguientes preguntas: ¿en qué medida los estudiantes alcanzan las competencias esperadas? ¿cuáles son las razones para que esto ocurra? ¿la estrategia basada en problemas apoya el ti? para dar respuesta a estas preguntas se recurrió al estudio de caso, ya que éste permite ver un aa desde todas sus aristas, comprender las prácticas y los imaginarios de los actores que intervienen, sus tensiones, relaciones y transformaciones. participaron 22 estudiantes de la facultad de enfermería que cursaron la asignatura telemática durante el segundo semestre de 2007, distribuidos así: tres estudiantes de noveno semestre, dos de octavo, uno de quinto y dieciséis de tercer semestre. los estudiantes interactuaron con el med en parejas (seleccionadas por ellos), con el fin de resolver los cuatro casos planteados y enviar el reporte de los mismos. la comunicación con el profesor se dio a través de un foro virtual. los datos fueron recolectados entre octubre y noviembre de 2007, mediante observaciones no participativas, foros de discusión, la aplicación de una línea de base pre-pos, reportes y entrevistas semiestructuradas, diseñadas con el fin de conocer comportamientos, maneras de hacer, percepciones, concepciones y reflexiones de los estudiantes sobre la experiencia. el en los ambientes colaborativos el proceso de ajuste de las estructuras mentales es permanente, no sólo se tiene la visión individual, ésta es contrastada con las múltiples visiones de los demás. 232 año 8 vol. 8 nº 2 chía, colombia octubre 2008 227-242 aquichan issn 1657-5997 análisis de los datos cualitativos se realizó utilizando las categorías que surgieron a partir del marco teórico, y otras que surgieron a partir del análisis de las entrevistas. los datos recolectados en la línea de base fueron analizados mediante estadística descriptiva. con el fin de determinar los niveles de competencia alcanzados por los estudiantes y dar respuesta a las preguntas de investigación, se triangularon los datos recolectados en el reporte, la línea de base, entrevistas y foros. resultados con el fin de contribuir al desarrollo de las competencias planteadas en la asignatura, se diseñó un aa conformado por cuatro elementos: los estudiantes, el profesor, un material educativo digital basado en problemas y un foro virtual. en él, los estudiantes debieron interactuar con el material educativo en parejas en los tiempos destinados al trabajo independiente, con apoyo del profesor a través del un foro virtual. el material estaba dividido en cuatro casos en los cuales el grado de dificultad aumentaba en la medida que los estudiantes avanzaban. cada caso tenía seis recursos que el estudiante podía utilizar para solucionarlo. el primero, “información”, tenía como fin permitir al estudiante ver el contenido del caso. el segundo, “material”, contenía el marco conceptual en el cual se fundamentaban los casos. los siguientes tres recursos, “pasos, preguntas y autoevaluación”, tenían como fin orientar a los estudiantes en la solución de los casos, y el último recurso, “reporte”, tenía como fin permitir enviar las soluciones del caso al profesor. los objetivos que se proponía este aa fueron: • contribuir al desarrollo de competencias sobre redes de computadores en los estudiantes. • incentivar a los estudiantes a ser el centro de su proceso de aprendizaje. • favorecer el desarrollo e implementación de estrategias de aprendizaje que puedan ser utilizadas a través del trabajo independiente de los estudiantes. en la gráfica puede observarse el aa diseñado, así como las diferentes interacciones que se esperaba ocurrieran entre los actores que lo conformaban, las cuales serían más o menos frecuentes en la medida que los estudiantes fueran desarrollando sus competencias. gráfica ambiente de aprendizaje desarrollado 233 las tic: propuesta para el aprendizaje de enfermería basado en problemas óscar boude-figueredo, mónica ruiz-quintero a partir de dichas interacciones se esperaba que los estudiantes: • interactuaran con el material a fin de obtener los conocimientos necesarios para resolver el caso. • compartieran entre ellos lo que entendieron o les era confuso. • participaran en el foro virtual de forma activa a través del intercambio de saberes con el asesor (para comprender aquello que no quedó claro). • participaran en el foro de forma pasiva leyendo las discusiones generadas con las demás parejas, optimizando así el tiempo utilizado para resolverlas. • intercambiaran información y conocimiento con las otras parejas a través del foro, con el fin de validar sus conocimientos. • generaran sus propias dinámicas de interacción, de tal forma que el aprendizaje se tornara más significativo para ellos. así mismo se esperaba que éstas se hicieran más evidentes y fáciles de reconocer en la medida que avanzaban en el proceso. teniendo claro las principales características del aa diseñado, a continuación se expondrán los resultados obtenidos en este estudio de caso con respecto a: los niveles de competencia alcanzados por las parejas y los estudiantes, las metodologías utilizadas para solucionar los casos, y los efectos que éstas tuvieron en los aprendizajes generados. en la tabla se presentan las competencias que de manera intencional el aa proponía desarrollar en los estudiantes, así como los niveles alcanzados durante la investigación por las parejas: competencias para desarrollar por las parejas porcentaje de parejas que alcanzaron los diferentes niveles de competencia nivel nivel nivel alto medio bajo interpreta documentos relacionados con redes de computadores con el fin de manejar el vocabulario básico acorde con los avances tecnológicos. 45,40% 54,60% 0% soluciona problemas hipotéticos sobre redes de computadores en sus contextos de práctica, con criterios de eficiencia. 36,40% 63,60% 0% identifica con precisión las características y aplicaciones de los diferentes tipos de redes de computadores con el fin de comprender las actividades que puede realizar en cada uno de ellos. 27,30% 45,40% 27,30% manifiesta una actitud ética ante diversas situaciones de trabajo en equipo. 18,20% 68,20% 13,60% tabla porcentajes alcanzados por las parejas en las competencias planteadas al realizar un análisis individual de los datos recolectados durante la investigación, fue posible evidenciar que el 27% de los estudiantes alcanzó el nivel más alto en el desarrollo de las competencias, el 63% alcanzó el nivel de competencia esperado (nivel medio), y el 10% restante alcanzó el nivel bajo. lo cual nos indica que un 90% de los estudiantes logró las competencias planteadas para esta temática. así mismo, se encontró una relación entre los niveles alcanzados por los estudiantes y la metodología utilizada por estos para solucionar los casos; aquellos estudiantes que desarrollaron una estrategia basada en el trabajo colaborativo alcanzaron niveles superiores frente a los que utilizaron una estrategia de trabajo en grupo o individual. para entender como influyó la metodología utilizada por las parejas en el desarrollo de las competencias planteadas, se mostrarán las metodolo234 año 8 vol. 8 nº 2 chía, colombia octubre 2008 227-242 aquichan issn 1657-5997 gías utilizadas y los resultados obtenidos por las parejas. metodología 1. “en el hospital estaremos solos” bajo esta metodología se orientaron tres de las once parejas que formaron parte de la experiencia, las características principales de estas parejas fueron: • revisar el material en un solo computador entre los dos. • utilizar la mayoría de recursos del material. • intercambiar opiniones acerca de los contenidos del material aunque las tres parejas utilizaron la misma metodología, los resultados obtenidos indicaron que dos de ellas alcanzaron el nivel medio en todas las competencias, mientras que una de ellas alcanzó el nivel medio en las dos primeras y bajo en las demás. esto se debió a que durante la intervención esta pareja acababa treinta minutos antes que los demás; no participaba del proceso de intercambio de saberes, ni generó discusiones al interior de la pareja. según sus palabras: investigador: cuéntenos un poco acerca de las preguntas que mandaron al foro, ¿que pasó? estudiante: nunca le mandamos una pregunta. porque nosotros la tomamos como bueno si estamos solas y si no hay un foro, no hay algo donde hay que mandarle a un profesor, entonces ¿cómo nos vamos a desenvolver en eso?, no, tenemos que hacerlo solas… porque si no tenemos al profesor al lado entonces qué vamos a hacer. investigador: ¿leyeron las preguntas que se enviaron al foro para usarlas como insumo? estudiantes: si nos poníamos a leer esas preguntas era para que nos confundiéramos, si ya lo teníamos claro para qué nos íbamos a confundir y a complicar con algo que ellos están preguntando... van es a confundir a todo el mundo. este es un buen ejemplo de por qué es necesario concientizar a los estudiantes acerca de la importancia del trabajo colaborativo, de trabajar por un bien común y no por objetivos individuales, así como comparar lo que creen saber con otros pares que puedan certificar o corregir lo que se sabe. metodología 2. “divide y vencerás” bajo esta metodología se orientaron todos los grupos que tuvieron las siguientes características: • revisar el material de forma individual. • unificar los conceptos y conocimientos con el compañero. • uno plantea hipótesis a través del foro virtual, mientras el otro lee las preguntas y respuestas dadas en el foro a las demás parejas. investigador: ¿usaron el foro para esos casos especiales? estudiante: claro, se comentaba como la idea que se tenía para resolver el caso… comparábamos también las preguntas con las de los compañeros y las correlacionábamos. se encontró una relación entre los niveles alcanzados por los estudiantes y la metodología utilizada por éstos para solucionar los casos; aquellos estudiantes que desarrollaron una estrategia basada en el trabajo colaborativo alcanzaron niveles superiores frente a los que utilizaron una estrategia de trabajo en grupo o individual. 235 las tic: propuesta para el aprendizaje de enfermería basado en problemas óscar boude-figueredo, mónica ruiz-quintero investigador: ¿a partir de eso podían encontrar respuestas a sus preguntas? estudiante: pues de ahí sacamos la respuesta, pero si quedó totalmente acertada queda la duda. investigador: ¿concretamente sobre qué le preguntaban al profesor en el foro? estudiante: digamos soluciones de cómo se conectaban las redes, si estaban bien, cómo creíamos que se conectaba… dónde estaba el daño… por deducción sacábamos eso. investigador: ¿y ustedes preguntaron a sus compañeros? estudiante: a los compañeros no, pero como estábamos en el foro, uno veía las respuestas o las preguntas que le hacían nuestros compañeros al profesor y las respuestas que él les daba… uno se daba cuenta que también tenía como la misma idea... ya sabía como por donde guiarse. el nivel alcanzado por estos grupos en el desarrollo de las competencias fue el esperado por el profesor-investigador. sin embargo, en las observaciones realizadas fue posible evidenciar que las discusiones y comparaciones que ayudaron a la comprensión de los estudiantes se generaron en cada pareja, dejando por fuera de este importante proceso a sus demás pares. aunque se esperaba que los estudiantes fueran el centro de su aprendizaje se observó que para algunos este esquema fue difícil de asimilar y asumieron que el profesor era quien sabía todo y, por tanto, quien debía dar el visto bueno a sus conocimientos. louis not (12) explica que hoy en día persisten diferentes tradiciones pedagógicas que se yuxtaponen, esto quiere decir que mientras el profesor intenta cambiar los roles respecto a él mismo y a los estudiantes, se encuentra en un momento de tensión cuando recibe resistencia de los estudiantes que consideran que su rol debe ser el de proveedor de conocimiento. no todas las parejas se caracterizaron por este tipo de concepciones, asumiendo desde el principio un rol protagónico. metodología 3. “el que busca y pregunta encuentra” esta metodología fue la más exitosa de las desarrolladas por las parejas, ya que todos los que utilizaron este método alcanzaron niveles superiores a los previstos. las características principales de estas parejas fueron: • revisar el material de forma individual. • unificar los conceptos y conocimientos con el compañero. • utilizar el proceso de intercambio de saberes con el profesor para aclarar las dudas referentes a conceptos e hipótesis. • comprobar la validez de los contenidos a través de búsquedas en internet. • utilizar el proceso de intercambio de saberes con sus pares para comparar hipótesis, construir soluciones y reforzar los conocimientos adquiridos. de las tres parejas que utilizaron esta metodología la que obtuvo los mejores resultados fue aquella que inició este importante proceso de colaboración. particularmente esta pareja evidenció una gran comprensión del tema, los niveles de louis not explica que hoy en día persisten diferentes tradiciones pedagógicas que se yuxtaponen, esto quiere decir que mientras el profesor intenta cambiar los roles respecto a él mismo y a los estudiantes, se encuentra en un momento de tensión cuando recibe resistencia de los estudiantes que consideran que su rol debe ser el de proveedor de conocimiento. 236 año 8 vol. 8 nº 2 chía, colombia octubre 2008 227-242 aquichan issn 1657-5997 competencia alcanzados fueron altos, los resultados obtenidos en la línea de base, quince días después de terminar la experiencia, muestran un 90% de acierto en las preguntas abiertas y un 57% de acierto en las preguntas de selección múltiple, en contraste con los resultados obtenidos en la misma prueba al inicio de la experiencia, los cuales muestran un 0% y un 14,3% de acierto respectivamente. éste es un buen ejemplo de lo que se puede lograr cuando en un aa centrado en el estudiante éste se vuelve protagonista de su proceso de aprendizaje. metodología 4. “uno más uno es… dos más o menos uno” esta metodología fue utilizada por dos parejas de la experiencia, y es una muestra de lo que suele suceder en el aula cuando un estudiante que tiene dificultades para comprender la temática del curso estudia con un estudiante al que se le facilita. generalmente el resultado es que el estudiante que mejor comprende las temáticas potencia el desarrollo de sus competencias y sus conocimientos, mientras que el otro puede comprender un poco más en el mejor de los casos, o terminar más confundido. en el caso particular de este estudio, la situación se presentó entre dos parejas conformadas por estudiantes de tercer semestre; una de las parejas le explicó a otra lo que habían comprendido y cómo solucionaron el caso. la pareja que recibió la explicación no puso en duda lo que sus compañeras les explicaban, lo cual trajo consigo, como diría senge un desplazamiento de carga (13). bajo esta teoría, quien realiza el desplazamiento deja a un lado un problema que es difícil de resolver adoptando una solución fácil, esta solución es solo temporal ya que el problema inicial sigue intacto (13). en este caso, la falta de comprensión de la pareja que tomó las explicaciones de sus compañeros sin cuestionarlas siguió ahí, y se hizo evidente tanto en los reportes presentados, como en la línea de base aplicada quince días después de la intervención. solución presentada por la pareja al caso 2 el hospital simón bolívar tiene implantada la topología de estrella ya que como nos refiere el caso toda la red está instalada de un mismo servidor central. la solución implantada es implementar un servidor paralelo el cual me va a permitir que en caso de que se me dañe o esté en mantenimiento el servidor central lo puedo reemplazar con el servidor paralelo así no me deja de funcionar la red. los registros de los pacientes no se pueden modificar porque los computadores poseen el hub pasivo en que ciertas áreas del hospital que se quieran modificar se utiliza el componente hub activo. para logra mayor eficacia, ya que estos llegan al destino de forma rápida, se utiliza el componente switch. para logar que los recursos sean utilizados en las áreas asignadas utilizamos las subredes… como se puede observar, la solución es el resultado de unir frases que responden a soluciones puntuales, no es posible evidenciar más que el manejo adecuado de algunos conceptos. al realizar el desplazamiento de carga estas estudiantes transcribieron la información que se les suministró por parte de otro grupo, sin llevar a cabo los procesos de análisis, interpretación y argumentación tan importantes a la hora de comprender un tema. otros aprendizajes además de las competencias planteadas se esperaba estimular en los estudiantes el desarrollo de otros aprendizajes que contribuyeran tanto con su proceso de formación, como con la comprensión de la temática tratada en este estudio de caso. a continuación se indicarán los resultados obtenidos al respecto. metodológicos con este aa se pretendía que los estudiantes aprendieran a analizar y solucionar de una forma sistemática los casos que se les presentaba, para esto se diseñaron tres recursos dentro del material con los que se esperaba enseñar a los estudiantes el proceso que se debe seguir a la hora de analizar un caso, y los elementos que se deben tener en cuenta a la hora de solucionarlo. el análisis de los datos recolectados evidenció que algunas de las parejas utilizaron estos recursos para orientar la solución de los casos, pero que la mayoría incorporó algunos recursos dentro de la metodología utilizada. por tanto, es necesario reconocer que así como los estudiantes traen consigo unos conocimientos previos sobre un tema en especial, también traen consigo esquemas de acción diversos que no suelen corresponder con los del profesor, lo cual implica reconocer que las estructuras de los jóvenes obvian, yuxtaponen e inventan otros recursos de acción que pueden ser más eficaces o no. sin embargo, muchas parejas reconocieron que estos recursos les sirvieron de guías para resolver los problemas de los 237 las tic: propuesta para el aprendizaje de enfermería basado en problemas óscar boude-figueredo, mónica ruiz-quintero el análisis de los datos recolectados evidenció que algunas de las parejas utilizaron estos recursos para orientar la solución de los casos, pero que la mayoría incorporó algunos recursos dentro de la metodología utilizada. casos o para identificar aquellos conocimientos que aún no manejaban. un ejemplo de esto se puede ver en las observaciones y entrevistas: investigador: de los link que habían en ese material: preguntas, pasos que se deben seguir, reporte, autoevaluación, ¿cómo lo usaron?, ¿cuál fue el que más usaron y el que menos usaron y por qué? estudiante: del material, pasos que se deben seguir ya que queda más fácil entender el caso y las preguntas pues si las resolvíamos bien, nos daban más pautas para el desarrollo. estudiante: el que más usamos, pasos que se deben seguir y materiales. pues primero necesitamos como una guía… miramos la preguntas porque ahí hacían preguntas, después (…) mirábamos el material que nos ayuda a resolver con esas preguntas que tengo. comunicativos parte de los aprendizajes que se querían reforzar están relacionados con el desarrollo de competencias comunicativas, para lo cual se orientó a los estudiantes sobre cómo comunicarse en el foro y plantear las preguntas de forma clara sin lugar a dobles interpretaciones. así mismo, se esperaba que los estudiantes fueran capaces de expresar la solución del caso de forma escrita utilizando un lenguaje acorde al tema tratado. los datos recolectados indicaron que el 70% de los estudiantes mejoraron la redacción de sus informes (tomando como base el primer reporte presentado frente al último), estructuraron de forma adecuada las hipótesis planteadas en el foro, y se expresaron en las entrevistas utilizando la terminología adecuada. por otro lado, los estudiantes reconocieron la importancia del uso de los foros no solo como medios de comunicación, sino como espacios ideales para el intercambio de conocimiento. investigador: bueno, y por último, ¿qué otras cosas creen que aprendieron? estudiante: yo creo que hacer uso del foro, eso es algo que uno constantemente no hace, o sea a pesar de que es un medio muy bueno, debería no ser solamente a nivel de telemática, sino a nivel de las materias troncales que nosotros vemos en enfermería, sería bueno que hubiera foros abiertos, o digamos en los temas que hayan, crear foros que uno pueda exponer sus experiencias como estudiante… el uso del foro es bueno, y debería ser más constante. igualmente, indicaron la importancia de realizar reportes de forma escrita, ya que es una falencia que tienen, y tendrán que hacerlo a diario en su práctica profesional. investigador: ¿cómo se sintieron escribiendo los reportes? estudiante grupo 6: no sé, creo que uno como estudiante y más como estudiante de enfermería siempre le causa como temor redactar, porque no estamos acostumbrados a hacerlo, a veces uno quiere expresar algo pero las palabras no salen o no son las más adecuadas para redactarlo, pero igual siento que es un ejercicio bueno y que se debe hacer constantemente para que uno como estudiante sea más fluido a la hora de comunicarse de manera escrita. 238 año 8 vol. 8 nº 2 chía, colombia octubre 2008 227-242 aquichan issn 1657-5997 estudiante grupo 2: pienso que el ejercicio de redactar nos sirve en nuestro día a día, ya que nosotros tenemos que hacer los reportes de enfermería y tienen que ser muy claros y concisos… interpretativos en este caso se pretendía que los estudiantes concibieran, ordenaran y expresaran de un modo personal los problemas que había en los casos que tenían que solucionar, con el fin de asimilarlos y entender no solo las circunstancias en las que se estaban desarrollando, sino los efectos que estas podían generar en sus pacientes. es así como la competencia “interpreta documentos relacionados con redes de computadores con el fin de manejar el vocabulario básico acorde con los avances tecnológicos” se diseñó para ayudar a valorar la capacidad de interpretación de los estudiantes. los datos recolectados permitieron confirmar el nivel de interpretación alcanzado por los estudiantes. a continuación se indicarán algunos ejemplos: análisis realizado por un grupo en el foro sobre el caso “hospital simón bolívar”: estudiante: bueno, es un hecho que la red del hospital es lan y que su topología es de estrella. la lan conecta todas las redes de los computadores pero cuando hay muchos computadores se vuelve lenta entonces la solución sería crear subredes conectándolas por switch o router, creo que es lo más conveniente para enrrutar el tráfico de tanta información. análisis generado por otro grupo en el foro sobre el caso “enfermera rural”: estudiante: profe, es posible que el daño esté en switch pues no existe conexión entre las diferentes estaciones de origen y destino; por otro lado, el router interconecta una red lan con una man relacionada con eps e internet, o sea el pueblo y medellín, y esta no está funcionando porque no pudo encontrar información del paciente ni entrar a internet, y por otro lado está conectada por una topología estrella la cual cuenta con un hub que posiblemente está dañado porque hay un problema de reenvío en la red. planteamiento de soluciones no esperadas una de las evidencias que nos impactó como investigadores fue encontrar que los estudiantes plantearon una solución que no había sido concebida, y comprobar que ésta no solo era válida, sino que era utilizada por uno de los principales bancos de colombia. al reflexionar al respecto encontramos que la forma en que fue diseñado el aa brinda a los estudiantes la oportunidad de organizar sus ideas y confrontarlas, comprender las temáticas y sus interrelaciones, desarrollar diferentes tipos de imaginarios, plantearse hipótesis y llegar a conclusiones con las que él se sienta cómodo, de tal forma que se posibilite que este tipo de situaciones se pueda presentar. discusión si bien es cierto que en el mundo son muchas y variadas las experiencias que dan fe de la implementación de aa que han logrado integrar con éxito las tic al aula de clases, no es posible afirmar que hoy en día éstas han transformado el aula, por el contrario, en muchos casos son simplemente el apoyo que tiene el profeparte de los aprendizajes que se querían reforzar están relacionados con el desarrollo de competencias comunicativas, para lo cual se orientó a los estudiantes sobre cómo comunicarse en el foro y plantear las preguntas de forma clara sin lugar a dobles interpretaciones. 239 las tic: propuesta para el aprendizaje de enfermería basado en problemas óscar boude-figueredo, mónica ruiz-quintero sor para agilizar algunos procesos de su cátedra. para confirmar esto solo basta ir al salón de clases y ver cómo se da una cátedra. seguramente encontraríamos que aunque se hace uso de diferentes tic, la metodología y la estrategia didáctica que se utiliza sigue siendo la misma que se tenía cuando no se hacía uso de ellas. al respecto hay varios autores que se han pronunciado, entre ellos natriello (14), para quien las transformaciones que las tic están generando en la educación a nivel de cambios profundos en los paradigmas educativos son modestas y poco generalizadas. por su parte, para barrón (15), la principal tendencia en la incorporación de las tic a la educación está marcada por una extensión de los modelos transmitivo-receptivo de la educación presencial. según díaz (16) esta situación hace pensar que la visión inicial que se tenía sobre las transformaciones que las tic iban a generar en la educación mexicana están muy alejadas de lo que sucede en la realidad. por su parte, en un estudio de caso realizado en dos cursos de tercer grado de dos instituciones de educación básica en bogotá se encontró que la integración se daba en el terreno de lo tecnológico-instrumental y no basada en sus potenciales pedagógicos. los profesores reconocen la importancia de las tic pero no saben cómo usarlas (17). por tanto, es necesario desarrollar proyectos de investigación que den respuesta a esta problemática, que planteen soluciones, que estas no solo sean validadas de forma rigurosa sino que se desarrollen mecanismos para que los hallazgos sean implementados por la comunidad académica. los hallazgos encontrados en este estudio indican que el 27% de los estudiantes que participaron superaron los niveles esperados por el profesor-investigador en el desarrollo de las competencias planteadas, mientras que el 63% logró alcanzar los niveles esperados y el 14% restante alcanzó los niveles mínimos. al analizar los datos recolectados se puede concluir que la diferencia se debió a la capacidad de razonamiento de los estudiantes, al tipo de motivación que tenían, ya sea intrínseca o extrínseca, y a la actitud tomada al asumir el rol de protagonistas de su proceso de aprendizaje; aquellos que asumieron un rol pasivo en este proceso alcanzaron los niveles más bajos, frente a aquellos que asumieron un rol más activo. los estudiantes que alcanzaron los niveles más altos en las competencias planteadas fueron aquellos que tenían una mayor capacidad de razonamiento, lo cual concuerda con los datos encontrados por araz (18), quien indica que la capacidad de razonamiento tiene un efecto directo e indirecto en los logros de los estudiantes. asímismo, alcanzaron los niveles más altos en las competencias planteadas aquellos que asumieron de forma positiva el rol de protagonistas en su proceso de aprendizaje, y que participaron del proceso de intercambio de saberes con el profesorinvestigador y con sus compañeros de manera presencial. lo cual concuerda con los hallazgos de becerra (19) quien encontró que compartir inquietudes y resolver dudas con sus pares es uno de los factores fundamentales que afecta la comprensión de conceptos. ahora bien, en las parejas no se observaron diferencias significativas en los niveles de competencias alcanzados por cada uno de los integrantes, a excepción de una pareja en donde uno de los miembros alcanzó niveles inferiores en desapara barrón, la principal tendencia en la incorporación de las tic a la educación está marcada por una extensión de los modelos transmitivoreceptivo de la educación presencial. 240 año 8 vol. 8 nº 2 chía, colombia octubre 2008 227-242 aquichan issn 1657-5997 rrollo de las competencias. esto se debió a dos razones, la primera es que la estudiante no asumió el rol de protagonista de su proceso de aprendizaje, dejando esta responsabilidad en manos de su compañero. la segunda razón se debió a que el único proceso de intercambio de saberes que realizó el grupo fue con el profesorinvestigador, y en este proceso se dedicaron a “adivinar” la respuesta, para lo cual incluyeron en sus preguntas opciones tales como: esta bien, mal o más o menos. de igual manera, las parejas desarrollaron diversas metodologías para abordar y solucionar los diferentes casos planteados. dentro de estas cada estudiante asumió diferentes tipos de roles que afectaron de forma directa e indirecta los niveles de competencia alcanzados. cuando estos asignan responsabilidades a las dos personas, y existe un verdadero trabajo colaborativo, las dos personas alcanzan niveles parecidos en sus competencias, pero cuando en estos acuerdos se generan roles activos y pasivos en las parejas, la persona que asume la posición pasiva presenta niveles inferiores en el desarrollo de las competencias. por tal razón es necesario desarrollar estrategias que contribuyan a incentivar la participación de los estudiantes. por otro lado, aunque se esperaba que los estudiantes fueran el centro de su aprendizaje es posible evidenciar, por los datos registrados en los foros y en las entrevistas, que esto no sucedió así, y que tal y como afirma louis not (12), cuando se intentan cambiar los roles de profesor y estudiante, se dan momentos de tensión en los que se genera resistencia de los estudiantes que aún consideran que el rol del profesor debe ser el de proveedor de conocimiento. esto no quiere decir que se haga un juicio de valor hacia el estudiante, más bien lo ponemos en discusión puesto que nos muestra que las prácticas pedagógicas aún siguen siendo tradicionales y los estudiantes actúan bajo estos imaginarios. el uso de este tipo de ambientes de aprendizaje no solo ayuda a evidenciar los diferentes estilos de aprendizaje de los estudiantes, sino que favorece el desarrollo de la autonomía de los mismos. así mismo, ayuda al desarrollo de competencias comunicativas estimulando a los estudiantes a expresar sus ideas de diferentes formas, escrita a través del reporte y en el intercambio de saberes en el foro con el profesor, y oral a través del intercambio de saberes con su compañero de grupo y con los demás grupos. gracias a los fundamentos en los que se basó el diseño del material educativo, es posible que éste se convierta en un apoyo para que el estudiante pueda ser el centro de su aprendizaje, dándole así la libertad de organizar y confrontar sus ideas, comprender las temáticas y sus interrelaciones, desarrollar diferentes tipos de imaginarios, plantearse hipótesis y llegar a conclusiones con las que él se sienta cómodo, haciendo que sea más significativo el aprendizaje adquirido. en su práctica profesional, los estudiantes no solo se hicieron más conscientes del apoyo que les brindan las tic y de cómo pueden utilizarlas para fortalecer su proceso de formación, sino que al asumir el rol que tenían los profesionales de enfermería en los casos reflexionaron sobre su papel cuando sean profesionales y las responsabilidades que tendrán. y aunque seguramente no tendrán que solucionar un problema sobre redes de computadores, hacer evidente que pueden existir faclos hallazgos encontrados en este estudio indican que el 27% de los estudiantes que participaron superaron los niveles esperados por el profesor-investigador en el desarrollo de las competencias planteadas, mientras que el 63% logró alcanzar los niveles esperados y el 14% restante alcanzó los niveles mínimos. 241 las tic: propuesta para el aprendizaje de enfermería basado en problemas óscar boude-figueredo, mónica ruiz-quintero invitados, generen procesos de reflexión compartida (20). este tipo de ambientes no solo contribuye a la comprensión de una temática particular, sino facilita el desarrollo de procesos de metacognición en los estudiantes, con lo cual se contribuye al proceso de formación integral de los mismos. igualmente, este tipo de experiencias ayuda a los estudiantes a ser conscientes de que el conocimiento se construye de la mano de otros y no como producto de una reflexión personal. tores externos a ellos que pueden poner en riesgo la vida de sus pacientes ayuda a que sean más conscientes de las realidades que van a encontrar y que por encima de todo estará la vida de su paciente. los estudiantes no están acostumbrados a ver los foros como el punto de encuentro entre ellos y el profesor, o como un espacio donde es posible no solo comprobar sus conocimientos, o aclarar sus dudas, sino un sitio en el que entre todos se puede construir conocimiento, gracias a las interacciones que allí se desarrollan. por tanto, se sugiere en primera instancia a la facultad de enfermería la necesidad de generar un plan de sensibilización dirigido a estudiantes y profesores acerca de los beneficios que pueden obtener con el uso crítico de los foros de discusión. así mismo, incorporar de forma paulatina en todas las asignaturas de la carrera la utilización de foros de discusión como espacios de generación de conocimiento. los foros tienen una alta potencialidad formativa que pueden y deben ser conducidos al éxito de un proceso en el que los diálogos compartidos de estudiantes, docentes e referencias 1. ministerio de educación nacional, decreto 808 del 25 de abril de 2002, república de colombia. 2. jaramillo p, castañeda p, pimienta m. inventario de usos de las tic para aprender y enseñar. informe final del proyecto integración de tic en educación superior, fase 1. no publicado; 2007. 3. jaramillo p, ruiz m. cómo integrar muchas tic y obtener pobres aprendizajes un estudio de caso. no publicado; 2008. 4. jaramillo p, ordóñez c, castellanos s, castañeda p. informática, todo un reto. ambientes de aprendizaje en el aula de informática: ¿fomentan el manejo de la información? bogotá: ediciones uniandes; 2005. 5. adell j. tendencias de investigación en la sociedad de las tecnologías de la información. edutec: revista electrónica de tecnología educativa [internet]. 1997 [acceso 2 de junio de 2008] (7). disponible en: http://www.uib.es/depart/gte/revelec7.html. 6. galvis a. ingeniería de software educativo. bogotá: ediciones uniandes; 1992. p. 3-47. 7. muñiz so. aprendizaje basado en problemas (pbl): beneficios y riesgos. geotrópico 2004; 2: 51-60. 8. rhem j. problem-based learning: an introduction. the national teaching & learning forum 1998; 8 (1): 1-4. 9. osorio la. ambientes colaborativos en ludomática. revista informática educativa uniandes-lidie 2000; 13 (1): 41-57. 10. tobón s. formación basada en competencias. guía rápida. 2 ed. bogotá: ecoe ediciones; 2006. p. 1-20. 11. dueñas v. el aprendizaje basado en problemas como enfoque pedagógico en la educación en salud. colomb med 2001; 32 (4): 189-196. 12. not l. las pedagogías del conocimiento. bogotá: fondo de cultura económica; 2000. 13. senge p. la quinta disciplina: cómo impulsar el aprendizaje en la organización inteligente. 2 ed. barcelona: ediciones juan granica; 1993. p. 30-60. 14. natriello g. modest changes, revolutionary posibilities: distance learning and the future of education. teachers college record 2005; 107 (8): 1885-1904. 15. barrón c. proyectos educativos innovadores. construcción y debate. colección pensamiento universitario 99, tercera época. méxico: cesu; 2006. 16. díaz f. la innovación en la enseñanza soportada en tic. una mirada al futuro desde las condiciones actuales. organización de estados iberoamericanos [internet] [acceso 5 de junio de 2008]. disponible en: http://www.oei.es/tic/santillana/barriga.pdf 17. jaramillo p. uso de tecnologías de información en el aula. ¿qué saben hacer los niños con los com242 año 8 vol. 8 nº 2 chía, colombia octubre 2008 227-242 aquichan issn 1657-5997 putadores y la información? revista de estudios sociales 2005; 20: 27-44. 18. araz g, sungur s. the interplay between cognitive motivational variables in a problem-based learning emviroment. journal of psychology and education 2007; 17 (4): 291-297. 19. becerra f. aprendizaje en colaboración mediado por simulación en computador. efectos en el aprendizaje de procesos termodinámicos. revista de estudios sociales 2005; 20: 13-26. 20. perez r, álvarez e, garcía ms, pascual m, fombona j. foro virtual: sus límites y posibilidades en el proceso de enseñanza-aprendizaje. edutec 2004, educar con tecnologías, de lo excepcional a lo cotidiano [internet] [acceso 5 de junio de 2008]. disponible en: http://www.edutec2004.lmi.ub.es/pdf/183.pdf 1 jessica pamela noack-segovia1 antonio manuel sánchez-lópez2 inmaculada garcía-garcía3 raquel rodríguez-blanque4 ximena alejandra león-ríos5 maría josé aguilar-cordero6 ejercicio físico y fuerza de agarre en pacientes intervenidos de cirugía bariátrica 1 orcid.org/0000-0002-3463-9991. escuela de enfermería, universidad de santo tomas, chile. jnoack@santotomas.cl 2 orcid.org/0000-0001-5482-226x. grupo de investigación cts 367, junta de andalucía, españa. asanchez47@us.es 3 orcid.org/0000-0003-0500-7175. facultad de ciencias de la salud, universidad de granada, españa. igarcia@ugr.es 4 orcid.org/0000-0003-2086-1222. complejo hospitalario universitario de granada, españa. rarobladoc@ugr.es 5 orcid.org/0000-0002-3494-331x. grupo de investigación cts 367, junta de andalucía, españa. ximenalr@correo.ugr.es 6 orcid.org/0000-0002-6268-0975. facultad de ciencias de la salud, universidad de granada, españa. mariajoseaguilar@ugr.es recibido: 21/03/2019 enviado a pares: 22/04/2019 aceptado por pares: 09/07/2019 aprobado: 17/07/2019 doi: 10.5294/aqui.2019.19.3.6 para citar este artigo / para citar este artículo / to reference this article noack-segovia jp, sánchez-lópez am, garcía-garcía i, rodríguez-blanque r, león-ríos xa, aguilar-cordero mj. physical exercise and grip strength in patients intervened through bariatric surgery. aquichan 2019; 19(3): e1936. doi: https://doi.org/10.5294/aqui.2019.19.3.6 resumen objetivo: evaluar un programa de ejercicio físico de intensidad moderada en pacientes operados de cirugía bariátrica y su influencia en la fuerza muscular. método: ensayo clínico aleatorizado, con un grupo de intervención y un grupo control. cuarenta y tres pacientes fueron operados de cirugía bariátrica. al grupo de intervención se le aplicó un programa de actividad física moderada durante seis meses. la fuerza de agarre y la bioimpedancia se midieron en su forma basal, al mes y a los seis meses después de la cirugía. se realizó un estudio de bivariante para observar los cambios de las variables. resultados: al realizar la prueba de t de student para muestras independientes en todas las variables (peso, índice de masa corporal, fuerza de agarre, masa magra, masa grasa y metabolismo), el resultado es que no hay diferencias significativas entre el grupo de intervención y el grupo control con p>0,05. conclusión: un programa de actividad física moderado de seis meses de duración en pacientes intervenidos de cirugía bariátrica no tiene resultados significantes en el desarrollo de la masa muscular evaluada a través de la dinamometría manual y la bioimpedancia. palabras clave (fuente: decs) cirugía bariátrica; fuerza de la mano; ejercicio; terapia por ejercicio; obesidad; condición física; obesidad mórbida; actividad física; actividad motora; índice de masa corporal. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1936 temática: promoción y prevención. aporte a la disciplina: esta investigación contribuye a la asistencia de personal sanitario experto en pacientes operados de cirugía bariátrica, ya que identifica problemas comunes y propone intervenciones que permitan mejoras en su condición de salud, como la adquisición de hábitos saludables para aquellos y su familia. la reganancia de peso en los pacientes operados de cirugía bariátrica es muy frecuente a partir de los dos años, como lo indica la bibliografía consultada, razón por la cual el paciente y su familia requieren apoyo por parte de un equipo multidisciplinario que les permita establecer una relación de confianza. https://orcid.org/0000-0002-3463-9991 https://orcid.org/0000-0001-5482-226x https://orcid.org/0000-0003-0500-7175 https://orcid.org/0000-0003-2086-1222 https://orcid.org/0000-0002-3494-331x https://orcid.org/0000-0002-6268-0975 https://doi.org/10.5294/aqui.2019.19.3.6 https://orcid.org/0000-0002-3463-9991 https://orcid.org/0000-0001-5482-226x https://orcid.org/0000-0003-0500-7175 https://orcid.org/0000-0003-2086-1222 https://orcid.org/0000-0002-3494-331x https://orcid.org/0000-0002-6268-0975 https://doi.org/10.5294/aqui.2019.19.3.6 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1936 physical exercise and grip strength in patients intervened through bariatric surgery abstract objective: this work sought to evaluate a physical exercise program of moderate intensity in patients operated of bariatric surgery and its influence on muscle strength. method: randomized clinical trial, with an intervention group and a control group. forty three patients were operated of bariatric surgery. the intervention group was applied a program of moderate physical activity during six months. grip strength and bioimpedance were measured at their baseline form, at one month, and six months after surgery. a bivariate study was conducted to observe variable changes. results: upon conducting student´s t for independent samples in all the variables (weight, body mass index, grip strength, lean mass, fat mass, and metabolism), the result is that no significant differences exist between the intervention group and the control group with p > 0.05. conclusion: a program of moderate physical activity lasting six months in patients intervened of bariatric surgery has no significant result in the development of muscle mass evaluated through manual dynamometry and bioimpedance. keywords (source: decs): bariatric surgery; hand strength; exercise; exercise therapy; obesity; physical condition; obesity, morbid; physical activity; motor activity; body mass index. 3 ejercicio físico y fuerza de agarre en pacientes intervenidos de cirugía bariátrica l maría josé aguilar-cordero y otros exercício físico e força muscular em pacientes submetidos à cirurgia bariátrica resumo objetivo: avaliar um programa de exercício físico de intensidade moderada em pacientes submetidos à cirurgia bariátrica e sua influência na força muscular. materiais e método: ensaio clínico randomizado, com um grupo de intervenção e um grupo controle. quarenta e três pacientes foram operados de cirurgia bariátrica. ao grupo de intervenção, foi aplicado um programa de atividade física moderada durante seis meses. a força muscular e a bioimpedância foram medidas em sua forma basal em um mês e aos seis meses depois da cirurgia. foi realizado um estudo de bivariante para observar as mudanças das variáveis. resultados: ao realizar o teste t de student para amostras independentes em todas as variáveis (peso, índice de massa corporal, força muscular, massa magra, massa gordurosa e metabolismo), não se verificam diferenças significativas entre o grupo de intervenção e o grupo controle com p > 0,05. conclusão: um programa de atividade física moderada de seis meses de duração em pacientes submetidos à cirurgia bariátrica não apresenta resultados significantes no desenvolvimento da massa muscular avaliada por meio da dinamometria manual e da bioimpedância. palavras-chave (fonte: decs) cirurgia bariátrica; força da mão; exercício; terapia por exercício; obesidade; condição física; obesidade mórbida; atividade física; atividade motora; índice de massa corporal. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1936 4 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1936 aquichan issn 1657-5997 eissn 2027-5374 introducción la obesidad mórbida se ha convertido en una pandemia; no se restringe a los países desarrollados ni en vías de desarrollo, sino que abarca todos aquellos con sistemas de economía de libre mercado (1). este problema, propio de las últimas décadas, es una consecuencia de los hábitos poco saludables de la población (2). al sedentarismo, resultado —en parte— del desarrollo de las telecomunicaciones, se suma un aumento en la ingesta de alimentos con alto contenido en grasas saturadas. en la actualidad, en los estados unidos, uno de cada cuatro niños o adolescentes padece obesidad, y uno de cada tres tiene riesgo de adquirirla (3). así, uno de cada cuatro niños con sobrepeso, en el rango de 6 a 12 años, padece intolerancia a la glucosa, y un 60 % de ellos tiene al menos un factor de riesgo para padecer una enfermedad cardiovascular (4). la obesidad infantil se asocia a una mayor probabilidad de muerte prematura y discapacidad en la edad adulta, y en la adolescencia puede reducir la expectativa de vida de 5 a 20 años (5). la cirugía bariátrica (cb) ha significado una solución temporal para aquellos casos en que, sumado a un peso extremo, los individuos desarrollan patologías asociadas como diabetes mellitus 2, hipertensión y problemas locomotores, entre otras (6-9). después de esta intervención, los pacientes experimentan una rápida pérdida de peso debida a una notable disminución de la masa libre de grasa (mlg) (10). la mala absorción de nutrientes en el organismo, sumada a una ingesta inadecuada de proteínas producen una pérdida de tejido muscular y una reducción considerable de la fuerza de los músculos (11). el grado de restricción calórica, el peso preoperatorio, una edad avanzada, diabetes tipo ii, el ejercicio y el tipo de cb son predictores ya conocidos de la pérdida postoperatoria de masa grasa (mg) (10) (12). todos los pacientes operados de cb llevan un seguimiento estricto durante el postoperatorio para evitar recuperar el peso perdido y controlar posibles alteraciones (11). lo que se busca es la pérdida de grasa corporal, mientras se preserva la masa corporal magra (mcm), conformada por minerales, músculos, proteínas y hueso (13); en particular, la masa celular del cuerpo, que forma parte de la mcm. en promedio, la mcm corresponde al 60-90 % del peso corporal total. la pérdida de mcm puede ser indeseable, ya que este tejido es necesario para la actividad metabólica, la regulación de la temperatura corporal, la preservación de la integridad del esqueleto, el mantenimiento del equilibrio hormonal y la percepción de la calidad de vida (14). evitar la atrofia muscular después de la cb es una parte esencial de la atención postoperatoria y una de las razones por las que se utiliza la bioimpedancia (bia), una técnica simple, rápida y no invasiva que permite la estimación del agua corporal total (act). por asunciones basadas en las constantes de hidratación de los tejidos, se obtiene la mlg y, por derivación, la mg, mediante la simple ecuación basada en dos componentes (mlg kg = peso total kg – mg kg). en el área de las ciencias del deporte, es posible medir el act en diferentes situaciones, tanto en estados de hidratación normal, como de deshidratación, así como evaluar la composición corporal en diversos estados clínicos y nutricionales relacionados con la actividad física y el entrenamiento (15). la fuerza de agarre, que mide fuerza muscular estática, se ha utilizado como predictor de capacidad funcional para varias patologías, debido a su fácil aplicación y bajo costo. este test se ha utilizado para predecir mortalidad en pacientes con enfermedad pulmonar obstructiva crónica (epoc) y complicaciones en pacientes dializados, así como para evaluar la desnutrición en pacientes hospitalizados (16) (17). hipótesis h0: un programa de actividad física moderada no produce cambios significativos en el grupo de intervención. h1: un programa de actividad física moderada produce diferencias significativas entre el grupo de intervención y el grupo control. objetivo evaluar un programa de ejercicio físico de intensidad moderada en pacientes operados de cb y su influencia en la fuerza muscular. objetivos específicos los objetivos específicos de este estudio son los siguientes: • valorar la fuerza muscular de pacientes operados de cb antes y un mes después de la intervención. • evaluar la composición corporal de pacientes operados de cb antes, un mes después de la intervención y luego de un programa de ejercicios de tipo moderado. • comparar la fuerza muscular y la composición corporal en los grupos de intervención y en los grupos de control. 5 ejercicio físico y fuerza de agarre en pacientes intervenidos de cirugía bariátrica l maría josé aguilar-cordero y otros metodología ensayo clínico aleatorizado. los pacientes se dividieron en dos grupos: un grupo de intervención (gi) y un grupo control (gc). la aleatorización se llevó a cabo por un generador de números aleatorios en excel. luego, se realizó una comparación de medias basales de ambos grupos, a través de la t de student: se obtuvieron valores de p>0.05 y se comprobó la homogeneidad de los valores basales de las muestras. los criterios de inclusión consideraron pacientes entre 18 y 50 años, que hayan firmado el consentimiento informado, no padecieran contraindicaciones médicas, infarto agudo al miocardio, insuficiencia cardiaca, patologías crónicas con compromiso del estado general, complicaciones postoperatorias, y que tuvieran un peso menor de 180 kilos. la investigación fue dirigida por una enfermera, ayudada por un equipo conformado por un médico, un nutricionista y un fisioterapeuta de la clínica lircay, donde se realiza un programa de cb en la que, anualmente, se opera un número aproximado de cien pacientes. la clínica es privada y está ubicada en la ciudad de talca, chile. se diseñó un protocolo de intervenciones educativas y de ejercicios de intensidad moderados. a todos los pacientes, se les realizó una evaluación inicial (anamnesis, medidas antropométricas, bia, dinamometría). el gi participó en un programa de ejercicios físicos moderados, a partir del primer mes de la cirugía, y al gc se le realizó la atención de rutina, con un control mensual por parte del médico y del nutricionista. la intervención tuvo una duración de veinticuatro semanas (18) (19) y estuvo constituida por un plan de educación que incluyó dieta, ejercicios físicos y apoyo familiar en el proceso. la enfermera realizaba una vez al mes los controles, en conjunto con las mediciones antropométricas llevadas a cabo por la nutricionista y la fisioterapeuta. además, se planificaron ejercicios de tipo aeróbico y trabajo de fortalecimiento muscular, tres veces a la semana, de una hora y media cada sesión. se indicó a los participantes que debían acudir al 75 % de las horas de entrenamiento para poder continuar con el estudio. protocolo de ejercicios para el grupo de intervención el protocolo que se describe a continuación inició con una etapa de adaptación durante dos semanas, y después con una etapa continua, con la misma rutina, pero en la cual la intensidad y las repeticiones aumentaron de forma paulatina, bajo la supervisión de un fisioterapeuta. los pacientes realizaron una caminata al 54 % de su capacidad y frecuencia de resistencia (fcdres) en la caminadora (hp cosmos®). se modificó la intensidad del entrenamiento al 59 % de dicha frecuencia hasta completar el programa de ejercicio físico, con una duración de entrenamiento aeróbico de treinta minutos en la caminadora. el fortalecimiento muscular de bíceps, tríceps, deltoides y pectorales se realizó de forma progresiva en intensidad y número de repeticiones, determinados por la evaluación de 1 rmax. el entrenamiento en el cicloergómetro (monark®) se llevó a cabo sin carga durante quince minutos. cuando el paciente no era capaz de realizar al menos diez minutos de forma constante, se fraccionaba en dos o tres etapas, intercaladas con ejercicios de fortalecimiento o de elongación. para finalizar la rutina, se realizaron ejercicios de elongación del tren superior e inferior, más ejercicios respiratorios (inspiración, espiración profunda y diafragmática). las medidas fueron tomadas 72 horas después de la última sesión de ejercicios, en el mismo orden y con el mismo personal fisioterapeuta que en la evaluación de línea de base. todos los sujetos fueron instruidos para no llevar a cabo cualquier otro tipo de actividad física durante la intervención. el peso de los pacientes se evaluó con una balanza tipo seca, la estatura se midió con un podómetro y se calculó el índice de masa corporal (imc). aspectos éticos el proyecto ha sido aprobado por el comité de ética para la investigación de la universidad santo tomas, chile, el 28 diciembre de 2015. todos los pacientes firmaron un consentimiento informado antes del estudio, de acuerdo con la declaración de helsinki y las normas revisadas por el secretariado de la asociación médica mundial respecto al consentimiento informado. el estudio está registrado en la web clinicaltrials.gov con el número nct03159312. instrumentos de medida la bia se ha utilizado para medir la composición corporal; en este caso, se llevó a cabo mediante la tanita bc-418 ma. los pacientes fueron evaluados después de un ayuno nocturno, y según el protocolo establecido para esta prueba. la bia se basa en el hecho de que el tejido magro tiene más contenido de electrolitos y agua que la grasa. esta diferencia en el contenido de electrolihttp://clinicaltrials.gov/ 6 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1936 aquichan issn 1657-5997 eissn 2027-5374 tos permite una estimación de la mlg, que mide la cantidad de electricidad que fluye a través del cuerpo desde la fuente hasta los electrodos (20). el examen de bia fue evaluado por el mismo profesional nutricionista en todas las oportunidades, para disminuir posibles sesgos. la fuerza de agarre se midió en ambos lados (dominante y no dominante), y de ello se encargó el mismo investigador en todas las pruebas, mediante un dinamómetro hidráulico manual (dinamómetro smedley spring ee.uu.), según las recomendaciones de la asociación americana de terapeutas de manos (21). antes de usar el dinamómetro manual, se adaptó al tamaño de la mano, en una posición cómoda para el paciente. este se lo puso en forma erguida, con el hombro aducido y rotando hacia una posición neutra; el brazo extendido, el antebrazo en posición neutra y la muñeca en extensión leve (entre 0 y 30°). se les pidió a los pacientes comprimir el dinamómetro con la máxima fuerza posible, mediante una contracción máxima breve y sin realizar movimientos corporales adicionales. se hicieron tres pruebas con cada mano, con un minuto de descanso entre cada una, y se utilizó la mejor puntuación como la fuerza básica del paciente (22). cálculo del tamaño de la muestra el tamaño de la muestra se calculó a partir de los cambios basados en la fuerza de agarre medida por dinamometría en población bariátrica (23), en el que se propone una diferencia de medias de 2,88 kg, con una desviación estándar de 2,3 kg como la mínima diferencia requerida para obtener cambios clínicos sustanciales. el cálculo arrojado señala que para cada grupo se requiere un mínimo de dieciséis participantes, considerando un nivel de significancia de 0,05, 90 % de poder estadístico y una pérdida esperada de un 15 %. habrá que aumentar el tamaño seleccionado en un 15-20 %, para prevenir posibles pérdidas o abandonos durante el seguimiento (figura 1). análisis estadístico se contrastaron las diferencias de medias entre cada grupo para cada variable y tiempo por separado. en este caso, se procedió igualmente a un estudio descriptivo, calculando medidas de tendencia central y dispersión. la normalidad de los datos se ha contrastado con el test de shapiro-wilks. para analizar las variables que se relacionaron, se llevó a cabo un análisis bivariante, aplicando el test t de student para las variables numéricas, o el de figura 1. diagrama de flujo de participantes del estudio durante seis meses 67 pacientes evaluados l 10 pacientes rechazaron la participación l 4 pacientes con patologías incompatibles con el programa (linfoma y desprendimiento de retina) l 4 pacientes posoperadas embarazadas en el primer trimestre de gestación l 4 pacientes mayores de 60 años 45 pacientes para ingreso a un grupo de investigación 2 pacientes interrumpieron el programa por cambio de domicilio grupo control 22 grupo experimental 21 fuente: elaboración propia. mann-whitney, en los casos en los que no se cumplió la hipótesis de normalidad. el valor de significación considerado fue p<0.05. los datos se han analizado con el software ibm spss statistics 19. el sesgo estadístico está controlado, ya que la investigación se realizó con un grupo experimental y un grupo control. resultados el estudio se realizó entre marzo de 2015 y marzo de 2018, en la consulta de especialidades quirúrgicas de la clínica lircay, en la ciudad de talca, chile. la asistencia de los pacientes 7 ejercicio físico y fuerza de agarre en pacientes intervenidos de cirugía bariátrica l maría josé aguilar-cordero y otros al programa de intervención fue de un 80 %, luego de abandonar el programa dos del gi por razones de domicilio lejano. el gi asistió al 97 % de las evaluaciones programadas, y el gc, al 100 %. el grupo, en su totalidad, estuvo formado por 32 mujeres (74,4 %) y 11 hombres (25,6 %). el gi estuvo constituido por 21 pacientes, y el gc por 22. la edad promedio fue de 33 ± 6,9. el peso preoperatorio de los pacientes fue de 95,66 ± 13 y de 103,04 ±14,4 en los grupos de intervención y de control, respectivamente. el imc fue de 35,5 ± 3,3 en el gi, y de 36,7 ± 3,3 en el gc. al evaluar la fuerza de agarre en el basal, el gi y el gc tuvieron valores de 34,19 kg y de 34,18 kg, respectivamente. los valores que se presentan en la tabla 1 son del preoperatorio (un mes y seis meses antes de la cirugía). tabla 1. descripción de la media y de la desviación estándar del peso, del índice de masa corporal y de la fuerza de agarre estadísticos de grupo grupo preoperatorio 1 mes 6 meses peso intervención 95,66 kg (13,07) 83,143 kg (11,35) 69,85 kg (9,16) control 103,04 kg (14,40) 88,273 kg (14,63) 68,409 kg (11,31) imc intervención 35,52 (3,34) 30,95 (3,26) 26,05 (2,95) control 36,73 (3,31) 31,41 (3,75) 24,32 (3,16) fuerza de agarre intervención 34,19 kg (7,32) 34,26 kg (7,42) 31,57 kg (6,72) control 34,18 kg (8,91) 32,86 kg (5,42) 31,91 kg (9,12) nota: entre paréntesis, bajo la media, se encuentra la desviación estándar (de). fuente: elaboración propia. la bia reveló una cantidad promedio de grasa corporal preoperatoria de 44 kg. durante el curso del estudio, los participantes pudieron reducir significativamente su grasa corporal: seis meses después de la cirugía, obtuvieron un promedio de 23,9 kg de grasa, lo que representa una reducción de 20 kg. los pacientes tenían una mcm media preoperatoria de 59 kg, y luego de seis meses obtuvieron una medición de 13,9 kg. el metabolismo basal preoperatorio fue de 1974, y disminuyó a los seis meses de operado a 1331, con una diferencia de 642,21 (tabla 2). tabla 2. resultado de bioimpedancia grupo preoperatorio 6 meses masa magra corporal intervención 57,37 (11) 49,257 (8,7) control 61,45 (13,51) 51,17 (11,73) masa grasa corporal intervención 47,16 (15,23) 26,94 (10,95) control 41,0 (6,41) 21,20 (3,82) metabolismo intervención 2456,3 1297,85 control 1492,72 1365,72 nota: entre paréntesis, bajo la media, se encuentra la desviación estándar (de). fuente: elaboración propia. al realizar la prueba de t de student para muestras independientes en todas las variables (peso, imc, fuerza de agarre, mcm, mg y metabolismo), el resultado es que no hay diferencias significativas entre el gi y el gc con p>0,05. discusión el objetivo del estudio fue determinar la influencia que ejerce un programa de ejercicios de moderada intensidad en la fuerza de agarre en los pacientes operados de cb. en relación con la tasa de abandono, el 20 % de la muestra seleccionada dejó de asistir a entrenamiento o a control. estos valores se encuentran por debajo de la cifra que se estima en la falta de adherencia a los programas de actividad física y de control postquirúrgico (60-70 % de abandono) (24). este estudio coincide con las investigaciones que revelan que las mujeres se realizan con mayor frecuencia la cb. según los hallazgos, la idealización del cuerpo femenino lleva a la mujer a intervenir su cuerpo, así como otros factores: dificultad para perder peso después del embarazo, malos hábitos y falta de actividad física (25). el programa de ejercicio moderado produjo una pérdida de peso, a los seis meses, del 28,53 % del peso inicial, y ambos grupos presentaron una baja importante a partir del tercer mes. estos resultados son similares a los estudios realizados por coleman et al. (18) y por trofa et al. (26), que encontraron una correlación positiva entre la actividad física postoperatoria y el grado 8 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1936 aquichan issn 1657-5997 eissn 2027-5374 de pérdida de peso, así como una diferencia significativa en la pérdida de peso entre los grupos activos e inactivos. estos estudios también relacionaron el imc preoperatorio con la reganancia de peso a largo plazo, pero metcalf et al. concluyen que no hay diferencia en la pérdida de peso entre el grupo de ejercicio y los que no lo realizan, aunque hay una disminución de mg y lgm en los primeros meses (p <0,05) (27). en relación con el trabajo de investigación realizado por stegen et al., la fuerza muscular estática, medida como la fuerza de agarre, establece que esta disminuyó el 18 y el 7 % en el grupo control y en el grupo experimental, respectivamente, a los cuatro meses después de haber realizado la cb (28). por su parte, el estudio realizado por hassannejad et al. muestra que no hubo cambios en la fuerza muscular ni en la composición de la mcm, pero sí un aumento importante en la capacidad aeróbica del gi (9). la muestra de este estudio presenta resultados similares, ya que a pesar de que el gi realizó trabajos musculares específicos, hubo una disminución de la mcm, resultado que puede atribuirse a la baja ingesta de proteínas por la dieta postoperatoria y, por lo tanto, a la pérdida de mg y mcm. otro estudio demostró que aunque los pacientes con obesidad mórbida experimentaron una pérdida significativa de la fuerza muscular después de la cirugía, su cuerpo podría adaptarse bien a este cambio, debido a la pérdida de peso corporal en relación con una fuerza incluso reducida (29). un estudio que sometió a un entrenamiento con ejercicios de fuerza prescritos a ocho pacientes con cb y descubrió que, si bien la pérdida de masa sin grasa es inevitable, los programas de ejercicios postoperatorios no solo pueden conservar la fuerza muscular, sino que también tienen un impacto significativo en el aumento de la fuerza dinámica de la mayoría de los músculos. según el estudio de huck, doce semanas de entrenamiento de resistencia supervisado mejoraron la fuerza funcional (prueba de sentarse y pararse), tanto en el gc, como en gi, y hubo cierta progresión en la flexibilidad y en la fuerza de agarre, pero sin cambios significativos (30). el estudio realizado por nuestro equipo de investigación fue de veinticuatro semanas, con resultados similares a los del estudio mencionado, lo cual supone que el tiempo de ejercicios debería aumentarse en semanas de ejercicios. finalmente, un estudio describió que la fuerza de agarre preoperatoria tiene una relación directa con la composición corporal postoperatoria. la importancia de este estudio radica en poder supervisar la evolución de los pacientes en los que disminuye la fuerza de agarre y, por lo tanto, la mcm. estos resultados concuerdan con los de esta investigación, que demostró la disminución postoperatoria de la masa muscular y de la fuerza de agarre, pese al componente de ejercicios físicos (23). limitaciones del estudio la asistencia de los pacientes al programa de intervención fue de un 80 %, pues abandonaron el programa por razones de domicilio lejano, y el tamaño muestral, a pesar de tener un nivel de significancia de 0,05, fue de solo 43 pacientes. no obstante, se observa que el ejercicio físico sí ha sido eficaz en la reducción de peso y en el mantenimiento de este a mediano plazo, sin efecto rebote. conclusiones un programa de actividad física moderado de seis meses de duración en pacientes intervenidos de cb no tiene resultados significantes en el desarrollo de la masa muscular evaluada a través de la dinamometría manual. sin embargo, el ejercicio físico sí ha sido eficaz en la reducción de peso y en el mantenimiento de este a mediano plazo, sin efecto rebote. se recomienda seguir con el programa de intervención de actividad física para impedir la reganancia de peso en estos pacientes, que suele producirse a partir de los dos años, según otros estudios realizados. la atención de enfermería prescrita incluye tomar el peso de los pacientes, estimularlos a realizar ejercicios de forma rutinaria, brindarles información sobre el manejo de una dieta adecuada y educar a la familia (o el entorno) para que contribuya en el proceso de adaptación del paciente, pues los cuidados postoperatorios son esenciales. con el programa de intervención llevado a cabo, se ha comprobado una mejora de la calidad de vida de estos pacientes, al disminuir las limitaciones producidas por el exceso de peso. conflicto de interés: ninguno declarado. financiación: el estudio no ha recibido financiación externa. 9 ejercicio físico y fuerza de agarre en pacientes intervenidos de cirugía bariátrica l maría josé aguilar-cordero y otros referencias 1. eduardo-atalah s. epidemiología de la obesidad en chile. revista médica clínica las condes. 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[2008 sept. 1];18(9):1112-8. doi: https://doi.org/10.1007/ s11695-008-9597-5 30. sjöström l. review of the key results from the swedish obese subjects (sos) trial–a prospective controlled intervention study of bariatric surgery. journal of internal medicine. 2013;273(3):219-34. doi: https://doi.org/10.1111/joim.12012 https://doi.org/10.1016/j.eurger.2015.11.009 https://doi.org/10.1016/j.eurger.2015.11.009 https://doi.org/10.1007/s11695-016-2240-y https://doi.org/10.1007/s11695-016-2240-y https://doi.org/10.1038/ijo.2017.60 https://doi.org/10.1007/s11695-014-1182-5 https://doi.org/10.1186/s12891-018-1971-4 https://doi.org/10.1016/j.jht.2016.10.009 https://doi.org/10.1016/j.jht.2016.10.009 https://doi.org/10.1007/s11695-014-1299-6 https://doi.org/10.1007/s11695-017-2618-5 https://doi.org/10.1186/s12893-017-0318-7 https://doi.org/10.1016/j.soard.2013.09.011 https://doi.org/10.1381/0960892053268381 https://doi.org/10.1007/s11695-009-0045-y https://doi.org/10.1007/s11695-009-0045-y https://doi.org/10.1007/s11695-008-9597-5 https://doi.org/10.1007/s11695-008-9597-5 https://doi.org/10.1111/joim.12012 212 226 conocimiento.indd 212 aquichan issn 1657-5997 ma. del refugio zavala-rodríguez1 j. fernanda gonzález-salinas2 conocimiento y manejo del dolor en alumnos de enfermería 1 doctora en educación. profesora de tiempo completo. universidad autónoma de tamaulipas. facultad de enfermería. campus tampico. matamoros sn victoria centro. juan b. tijerina y c. colón victoria tamaulipas. méxico cp 87000. mzavala07@hotmail.com 2 magíster en ciencias de la enfermería. profesora de tiempo completo. facultad de enfermería campus tampico. universidad autónoma de tamaulipas. matamoros sn victoria centro. juan b. tijerina y c. colón victoria tamaulipas. méxico cp 87000. fgonzale@uat.edu.mx recibido: 10 de diciembre de 2007 aceptado: 25 de agosto de 2008 resumen objetivo: identificar el nivel de conocimiento en el manejo del dolor de los alumnos de la facultad de enfermería, campus tampico, de la universidad autónoma de tamaulipas, méxico. método: investigación descriptiva, transversal y correlacional. se integró una muestra con 139 alumnos, de sexto a octavo periodo académico, en el 2006. además, otra muestra de 30 docentes del área de enfermería para conocer su opinión en cuanto al conocimiento de los alumnos. se diseñaron dos cuestionarios, uno para los alumnos con 33 reactivos clasificados en tres dimensiones: clasificación del dolor, valoración y cuestiones farmacológicas. para los docentes el cuestionario incluyó 25 reactivos derivados de dichas dimensiones. estos instrumentos obtuvieron un alpha de cronbach de 0,85 y 0,82 respectivamente. los datos se procesaron y analizaron a través del paquete estadístico spss versión 13, se utilizó estadística descriptiva e inferencial. resultados: el 41% de los alumnos se ubicó en el grupo de edad de 22 a 24 años; el 65% correspondió al séptimo periodo. el 70% de los alumnos se situó en un nivel alto de conocimiento. respecto a los docentes, el 53% son profesores de tiempo completo, el 47% tienen una antigüedad laboral entre 12 y 21 años. el 70% refirió que los alumnos tienen moderado conocimiento en el manejo del dolor. la correlación de pearson arrojó relación significativa entre el índice general de conocimiento y las tres dimensiones de variables. conclusión: se requiere analizar, a través de trabajo colegiado, el contenido y la metodología en las asignaturas de enfermería que conlleva la formación profesional esencial que se exige a enfermería en medidas terapéuticas para el manejo del dolor del usuario de los servicios de salud, dentro de un marco de seguridad técnico, científico, ético y legal. palabras clave diagnóstico de enfermería, dolor, alumnos de enfermería, atención al paciente. (fuente: decs) nursing students’ knowledge and management of pain abstract objective: to identify what students at the universidad autónoma de tamaulipas school of nursing in tampico, méxico know about pain management. año 8 vol. 8 nº 2 chía, colombia octubre 2008 212-226 213 conocimiento y manejo del dolor en alumnos de enfermería ma. del refugio zavala-rodríguez, j. fernanda gonzález-salinas method: this is a descriptive, transverse and correlational study based on a sample of 139 students from academic periods six to eight during 2006. a sample of 30 nursing teachers was used as well, for an insight into their opinion on what students know. two questionnaires were designed. one was for the students, with 33 reactions classified into three dimensions: pain classification, assessment and pharmacological questions. the questionnaire for the teachers included 25 reactions derived from those dimensions. the respective cronbach alphas obtained for these instruments were .85 and .82. the data were processed and analyzed with the spss statistical package (version 13). descriptive and inferential statistics were used. results: forty-one percent (41%) of the students were in the 22 to 24 age group, and 65% were in their seventh academic period. seventy percent (70%) had a high degree of knowledge. as to the teachers, 53% are full-time professors and 47% have 12 to 21 years of experience. seventy percent (70%) said the students have a moderate knowledge of pain management. the pearson correlation showed a significant relationship between the general knowledge index and the three variable dimensions. conclusion: the contents and methodology of the nursing subjects taught as part of essential professional training will have to be analyzed through collegiate work, specifically in terms of therapeutic pain management measures for those who use health services, based on a framework of technical, scientific, ethical and legal security. key words nursing diagnosis, pain, nursing students, patient care. conhecimento e manejo da dor nos alunos de enfermagem resumo objetivo: identificar o nível de conhecimento no manejo da dor dos alunos da faculdade de enfermagem, tampico da universidad autónoma de tamaulipas, méxico. método: descritiva, transversal e correlacional. a amostra constou de 139 alunos de sexto a oitavo período acadêmico em 2006. além disso, foi conformada outra amostra com 30 docentes da área de enfermagem para saber a sua opinião sobre o conhecimento dos alunos. foram desenhados dois questionários: um para os alunos, com 33 reativos classificados em três dimensões: classificação da dor, valoração e assuntos farmacológicos. para os docentes, o questionário incluiu 25 reativos derivados dessas dimensões. estes instrumentos lograram um alfa de cronbach de 0.85 e 0.82, respectivamente. os dados foram processados e analisados mediante o pacote estatístico spss, versão 13. utilizou-se estatística descritiva e inferencial. resultados: o 41% dos alunos foi situado no grupo de idade de 22 a 24 anos; o 65% correspondeu ao sétimo período. o 70% dos alunos foi localizado em um nível alto de conhecimento. respeito aos docentes, o 53% são professores de tempo completo; o 47% tem uma antigüidade de trabalho de 21 anos. o 70ª% contou que o conhecimento dos alunos no manejo da dor é moderado. a correlação de pearson mostrou uma relação significativa entre o índex geral de conhecimento e as três dimensões de variáveis. conclusão: é necessário analisar, mediante trabalho colegiado, o conteúdo e a metodologia nas matérias de enfermagem, que acarretam a formação profissional essencial exigida a enfermagem em medidas terapêuticas para o manejo da dor do usuário do serviço de saúde em um ambiente de seguridade técnico, científico, ético e legal. palavras-chave diagnóstico de enfermagem, dor, alunos de enfermagem, atenção ao paciente. 214 año 8 vol. 8 nº 2 chía, colombia octubre 2008 212-226 aquichan issn 1657-5997 introducción la facultad de enfermería, campus tampico, de la universidad autónoma de tamaulipas, méxico, en un esfuerzo por formar profesionales competitivos, a partir del 2002 implantó un diseño curricular sustentado en el paradigma del constructivismo, lo que representó un cambio en la estructura organizacional y operacional del proceso enseñanzaaprendizaje que guía el desarrollo de habilidades cognitivas, técnicas e interpersonales en los estudiantes, y les permite conjugar su saber y hacer en el cuidado que brindan al individuo sano o enfermo. por tanto, la profesión de enfermería se basa en la teoría y la práctica que fundamentan la responsabilidad en las diversas actividades que realiza en la atención de los pacientes, una de esas actividades es la que se relaciona con el manejo del dolor, y según mccloskey (1) se define como el alivio o la disminución del dolor a un nivel de tolerancia que sea aceptable para el paciente. el dolor como diagnóstico enfermero está considerado dentro del marco conceptual de enfermería desarrollado por la asociación de diagnósticos de enfermería de norteamérica (nanda), y fue aprobado en 1998. se ubica dentro del patrón cognitivo-perceptual; de las ocho categorías diagnósticas aprobadas en este patrón, todas describen patrones disfuncionales sensorio-perceptuales y cognitivos (2). el dolor como respuesta humana se define como el estado en el que el individuo experimenta y se queja de una molestia grave o una sensación desagradable (2). lo ideal en el control del dolor es mantener la concentración plasmática sostenida del fármaco, cualquiera que sea su vía de administración, por lo que es necesario que las enfermeras conozcan lo relativo a la farmacocinética y farmacodinamia como sustento de sus acciones (3), pues es enfermería la que se responsabiliza de la adecuada valoración del dolor, el control de los fármacos, su administración, la respuesta de los mismos, y de proporcionar información y educación tanto al paciente como a la familia, de tal forma que el enfermo reciba el máximo beneficio del tratamiento y se genere la adecuada comunicación interdisciplinaria. uno de los métodos para valorar la efectividad de los tratamientos antiálgicos es la medición del dolor, lo cual permite ajustar dosis, horarios e incluso modificar el esquema terapéutico si el paciente no responde positivamente al manejo (3). sin embargo, los resultados de estudios realizados por espinosa (4) y zavala y cols. (5) evidencian la no utilización por parte de las enfermeras de escalas de medición que permitan calificar junto con los pacientes el grado de dolor que experimentan, por consiguiente esta característica del dolor no se registra como un parámetro para el uso apropiado de fármacos a fin de mitigarlo. asociado a esto, morrison (cit. por jiménez) (6), peñarrieta y cols. (7), mccafery y beebe (cit. por espinosa) (4) indican la escasa enseñanza del profesional sanitario en el manejo del dolor; otro elemento es la limitada capacitación institucional (5), factores que repercuten en el tratamiento efectivo de este síntoma. la realidad en muchos casos es que los estudiantes y los egresados de enfermería van aprendiendo directamente en las instituciones de salud en donde realizan las prácticas de pregrado o el servicio social, donde los criterios para la aplicación y utilización la profesión de enfermería se basa en la teoría y la práctica que fundamentan la responsabilidad en las diversas actividades que realiza en la atención de los pacientes, una de esas actividades es la que se relaciona con el manejo del dolor. 215 conocimiento y manejo del dolor en alumnos de enfermería ma. del refugio zavala-rodríguez, j. fernanda gonzález-salinas de medicamentos varían de una a otra (8). un gran porcentaje de enfermeras en el campo clínico carecen de tiempo, habilidad o conocimiento para valorar y ayudar al paciente con dolor (4). considerando la magnitud de la situación anterior se formuló la siguiente pregunta de investigación: ¿cuál es el nivel de conocimientos en el manejo del dolor de los alumnos de la facultad de enfermería en tampico, de la universidad autónoma de tamaulipas? el propósito del estudio fue describir el grado de conocimiento sobre el manejo del dolor en cuanto a clasificación, características, valoración y algunas medidas terapéuticas, que poseen los alumnos de licenciatura en enfermería, y determinar la percepción de los docentes al respecto, a fin de que sirva como referencia para los acuerdos académicos necesarios en esta área del cuidado de enfermería. revisión de literatura en las diferentes modalidades de programas de estudio para la formación de recursos humanos en enfermería frecuentemente se contempla un curso de farmacología como parte de los fundamentos teóricos necesarios para brindar atención de calidad a los pacientes. la farmacología es la rama de la medicina que estudia la interacción de los fármacos con el organismo humano, tiene bien definidos dos componentes: la farmacocinética y la farmacodinamia, que en términos generales estudian “lo que el cuerpo le hace al fármaco” (absorción, eliminación, metabolismo), la primera, y la segunda “lo que el fármaco le hace al cuerpo” (células blanco, cambios bioquímicos y celulares, efectos esperados) (6). la organización mundial de la salud (oms) unificó la terapéutica antiálgica a nivel internacional basándose en una escalera de tres peldaños de la cual se deben conocer los fármacos, su uso, los efectos secundarios y las complicaciones (3). esta misma organización internacional, en el 2002, expide una resolución para mejorar la seguridad de los pacientes, la cual se concreta en el 2004 con el establecimiento de la alianza mundial por la seguridad de los pacientes, como una de las prioridades de salud pública. esta alianza define 21 indicadores para vigilar y evaluar el desempeño de los sistemas de salud en esta temática; en la categoría de eventos centinelas, uno de esos indicadores son los errores de medicación (8). la administración de medicamentos por vía parenteral es de las más utilizadas en el campo hospitalario por sus ventajas, como es el rápido aumento de las concentraciones plasmáticas de un fármaco, pero en la mayoría de los casos, el personal de enfermería carece de información con relación a los diluyentes adecuados, velocidad de infusión y la estabilidad de las diluciones ya preparadas, lo que puede contribuir a errores de medicación que, adicionados a los cálculos de dosis en relación con la edad, ocasionan mayor riesgo de producir un error que pueda poner en peligro la vida yo calidad de vida de los pacientes (american society of hospital pharmacy y konick) (cit. por peña) (9). bruce y wong (cit. por tena) (10) señalan los errores por medicación como un problema persistente asociado con la práctica de enfermería, estos autores afirman que se requiere un enfoque interprofesional para reducir la frecuencia de error por medicación. la farmacología es la rama de la medicina que estudia la interacción de los fármacos con el organismo humano. 216 año 8 vol. 8 nº 2 chía, colombia octubre 2008 212-226 aquichan issn 1657-5997 con relación a los sustentos teóricos existen múltiples teorías que tratan de explicar la experiencia dolorosa, una de ellas, y dentro del ámbito de enfermería, es la teoría de mediano rango de los síntomas desagradables de lenz (cit. por sánchez) (11), la cual considera la compleja naturaleza de los síntomas desagradables, identificando tres componentes: el primero describe factores relacionados, en donde se integran los factores fisiológicos, psicológicos y los situacionales. el segundo se refiere a una forma de expresión particular, en donde se considera la duración y frecuencia del síntoma, su calidad, intensidad y la angustia. como tercer componente se determinan las implicaciones de la experiencia a nivel funcional, físico y cognitivo. sánchez (11) señala que esta teoría contextualiza la experiencia dolorosa desagradable y le da una connotación que a la vez tiene unicidad y totalidad, por lo que se puede hacer un análisis en cada situación en la que se maneje el cuidado de la experiencia dolorosa relacionada con la salud. si bien es el médico el que prescribe los fármacos, la enfermera debe valorar la efectividad y los efectos secundarios de éstos así como también comunicar por escrito de manera apropiada los resultados del tratamiento. estas acciones, de acuerdo con maccaffery, apoyan la titulación analgésica cuyo objetivo es usar la menor dosis posible de analgésicos que proporcione control efectivo del dolor con los menores efectos secundarios. es notoria la responsabilidad de enfermería en la ejecución de tratamientos para disminuir o eliminar el dolor, las posibilidades de los profesionales de esta disciplina se amplían desde la perspectiva de su función propia e independiente que es la de cuidar (2). por tanto, el rol de enfermería como miembro de un equipo multidisciplinario de salud, requiere de conocimientos tanto de intervenciones farmacológicas como no farmacológicas, y la aplicación de este conocimiento mediante acciones como valoración, enseñanza y monitoreo de automanejo del paciente (12). sin embargo, el alivio del dolor adquiere a menudo un papel secundario en numerosas situaciones clínicas y tratamientos, generando en el paciente múltiples efectos negativos que van desde el retraso en la recuperación y el desarrollo de complicaciones, hasta síndromes depresivos (2). partiendo del significado del dolor, y teniendo en cuenta que es subjetivo, ya que cada individuo lo expresa y experimenta de diferente forma, la asociación internacional para el estudio del dolor (iasp), unifica la idea de un método fidedigno que cuantifique el dolor de cada paciente, por lo que se instituyeron diferentes modalidades de escalas: numéricas, de colores, o bien de expresiones faciales (3). cada una de ellas tiene su objetividad y validación, pero se deben elegir de acuerdo con el tipo de paciente. las más utilizadas son la escala numérica, en donde 0 es ausencia y 10 el máximo dolor soportable, y la escala visual análoga (eva) (11). respecto a nuestro país, méxico, en septiembre del año en curso, el pleno de la cámara de diputados aprobó por mayoría de votos la adición de un artículo (28bis) a la ley general de salud a fin de permitir, aparte de los médicos, también a los licenciados en enfermería prescribir medicamentos (13). el dictamen especifica que dichos profesionales sólo podrán prescribir medicamentos comprendidos en un cuadro básico de insumos para el primer nivel de la organización mundial de la salud (oms) unificó la terapéutica antiálgica a nivel internacional basándose en una escalera de tres peldaños de la cual se deben conocer los fármacos, su uso, los efectos secundarios y las complicaciones. 217 conocimiento y manejo del dolor en alumnos de enfermería ma. del refugio zavala-rodríguez, j. fernanda gonzález-salinas atención a la salud. en cuanto al segundo y tercer nivel de atención, se deberá contar con un catálogo de insumos elaborado por el consejo de salubridad general, a los cuales se ajustarán las instituciones públicas del sistema nacional de salud. el dictamen enfatiza en datos emitidos por la organización de cooperación para el desarrollo económico (ocde) sobre los sistemas de salud en méxico, y de la encuesta nacional de salud (13); uno de esos datos especifica que cerca del 4% de la población no fue atendida por un médico porque geográficamente no tenía acceso a dicho servicio. el documento se encuentra en el senado de la república para sus efectos constitucionales. estudios relacionados los artículos científicos relacionados con el objeto de estudio, en su gran mayoría fueron realizados con personal de enfermería que labora en hospitales; no obstante, se retomaron como marco referencial para el presente trabajo de investigación. en un estudio realizado por mccaffery y ferrel (1992, cit. por espinosa) (4) al preguntar a 456 enfermeras cómo valorarían el dolor en dos pacientes hipotéticos, en donde uno tenía manifestaciones conductuales y el otro no, valoraron con puntuación más alta al paciente con respuesta conductual; esto muestra que las enfermeras están influidas por el comportamiento del paciente, y no necesariamente hay respuestas conductuales o físicas en pacientes con dolor. otros estudios efectuados por mccaffery y beebe (1992), y martínez i. (1997) (cit. por espinosa) (4), señalan que el equipo de salud no tiene suficientes conocimientos sobre el dolor, lo que repercute directamente en la efectividad o no del tratamiento, por ello coinciden en que se requiere la reeducación de todos los miembros del equipo de salud, y en especial de las enfermeras, ya que son las que pasan más tiempo con el paciente. en estados unidos, al surgir la figura de la enfermera facultativa avanzada (anp), estos profesionales tuvieron autoridad legal para prescribir medicamentos en la mayoría de los estados de aquel país. para reforzar la preparación de los anp, la asociación estadounidense de colegios de enfermería (cit. por jiménez) (6) estableció en 1996 que todos los graduados de anp deben saber con fundamento los principios básicos de farmacología, lo que incluye las respuestas a nivel celular, además de la farmacoterapia y farmacocinética de una amplia variedad de agentes farmacológicos. por su parte, en méxico la comisión nacional de arbitraje médico (conamed) (cit. por tena) (10), realizó un análisis de las quejas recibidas en el periodo de 1996 a 2001, en relación con los servicios de enfermería; en el caso concreto, con la administración de medicamentos se identificaron las siguientes inconformidades: extravasación de medicamento por medio de canalización intravenosa, administración de medicamento por vía intramuscular con técnica inadecuada, y aplicación errónea de medicamento por vía endovenosa. situaciones más asociadas con el desarrollo de procedimientos para la administración de medicamentos por vía intravenosa y ausencia de vigilancia. campos yáñez et ál. (14), desarrollaron un estudio descriptivo para identificar si la actitud empática de la enfermera los artículos científicos relacionados con el objeto de estudio, en su gran mayoría fueron realizados con personal de enfermería que labora en hospitales. 218 año 8 vol. 8 nº 2 chía, colombia octubre 2008 212-226 aquichan issn 1657-5997 favorece la disminución del dolor en el paciente posquirúrgico, participaron 88 pacientes y una misma cantidad de enfermeras de servicios de hospitalización. como parte de los resultados se encontró que el 100% de las enfermeras se interesó por el comentario del paciente sobre la intensidad del dolor, coincidiendo con la opinión de los pacientes. sin embargo, se encontró diferencia de valores respecto a la evaluación de esta característica del dolor, ya que el 70% de las enfermeras asignaron menor intensidad al dolor, y el 53% de los pacientes lo manifestaron de intenso a insoportable. esta divergencia se asocia al porcentaje (39%) de enfermeras que comentaron que el paciente exagera al referir dolor. espinoza meneses (4) realizó un estudio descriptivo con el propósito de identificar los conocimientos en cuanto a la valoración del dolor en 102 enfermeras que laboraban en un hospital de segundo nivel. los resultados reportaron que más del 50% eran enfermeras generales, y solamente el 10% licenciadas en enfermería; la mayoría desconocía la clasificación del dolor, menos del 40% conocían que la característica denominada “cualidad del dolor” requiere registrar la palabra exacta que dice el paciente con el fin de evitar interpretaciones propias, más del 75% no conocía un método adecuado para valorar la intensidad del dolor, más del 50% opinó que no siempre hay respuestas fisiológicas y conductuales ante el dolor. se concluye que la población participante tiene un conocimiento del dolor superficial e incompleto. morrison y cols. (cit. por jiménez) (6) investigaron acerca de las expectativas de conocimiento en farmacología relacionadas con las tareas que se espera realicen los enfermeros, para ello enviaron un cuestionario a todas las instituciones de educación en enfermería localizadas en inglaterra. los autores mencionaron que de acuerdo con la revisión bibliográfica los enfermeros no están preparados para la administración de medicamentos. además, los resultados apoyan la noción de que muchos enfermeros pueden estar inadecuadamente preparados para los roles que se espera realicen una vez que son graduados y titulados. los autores opinan que las razones al respecto parecen ser complejas, y proponen incluir guías de acción suficientes por parte de los cuerpos de regulación en enfermería, así como mejorar los programas de estudio. otro estudio relacionado con necesidades de educación en farmacología fue el de king (2004) (cit. por jiménez) (6), que encuestó a enfermeros de la parte norte de inglaterra, los resultados reportaron que existía un limitado entendimiento de la materia, insatisfacción con la enseñanza en farmacología, y estados de ansiedad como consecuencia. las tareas de mayor conocimiento fueron: administración de medicamentos, valoración de pacientes, prescripción de medicamentos y educación a los pacientes en este tópico. zavala y cols. (5) efectuaron un estudio descriptivo con el propósito de identificar el nivel de conocimiento en el manejo del dolor en 91 enfermeras asignadas a los servicios de hospitalización de adultos y pediatría de una institución de segundo nivel de atención. con relación a los resultados, clasificados en tres subescalas de acuerdo con el instrumento de medición, en la subescala valoración del dolor el 80% indicó que siempre toma en cuenta el reporte verbal del paciente. en cuanto a la subescala administración de medicamense requiere la reeducación de todos los miembros del equipo de salud, y en especial de las enfermeras, ya que son las que pasan más tiempo con el paciente. 219 conocimiento y manejo del dolor en alumnos de enfermería ma. del refugio zavala-rodríguez, j. fernanda gonzález-salinas tos, el 93% de las enfermeras especificó que siempre valoran los signos vitales, la posibilidad de una reacción alérgica y las características del dolor previo a la administración de analgésicos. con relación a la subescala orientación al paciente, el 82% contestó que siempre orienta al paciente sobre el medicamento que le administra. en el 52% de las enfermeras se encontró un conocimiento entre muy bueno y bueno, con predominio de este último nivel. peñarrieta y cols. (7) realizaron un estudio descriptivo con el propósito de describir la experiencia del dolor y la satisfacción frente a su manejo en 180 pacientes posoperados; se utilizó el cuestionario, adaptado, de la asociación americana del dolor, y el index de manejo del dolor. el 54% de los pacientes reportaron haber experimentado el peor dolor imaginable, el 60% presentó un index inefectivo, es decir, recibió medicación analgésica más baja con relación al nivel de dolor alto del paciente. el 56% refirió estar totalmente insatisfecho con la información recibida sobre el manejo del dolor. este aspecto, junto con las creencias del paciente y el efecto sobre el sueño, fueron las variables con mayor relación estadísticamente significativa con la satisfacción de los cuidados ante el dolor del paciente. se encontró alta correlación entre satisfacción de los cuidados con la información recibida, y ninguna relación con el manejo del dolor, no obstante que éste fue inadecuado. ramsey (2005, cit. por gómez) (8), señala que en un artículo del american journal of nursing realizado en el transcurso de tres años, en donde se estudió la cultura organizacional, las actitudes y la asignación de la responsabilidad en hospitales respecto a la seguridad del paciente, se evidenció que la mayor parte de los errores caían dentro del ámbito de la práctica de enfermería, y que los médicos, los administradores y las enfermeras veían, en gran parte, la seguridad del paciente como una responsabilidad de enfermería; solamente el 22% de los encuestados opinaron que los profesionales antes mencionados y los farmacéuticos compartían esta responsabilidad de manera equitativa. gómez y fernanda (8), a través del análisis del concepto de evento adverso, enfatizan la importancia del cuidado de enfermería en un proceso específico de atención como es la administración de medicamentos. de acuerdo con la literatura analizada, el evento adverso asociado con este tipo de intervención es definido como “cualquier evento previsible que puede ser causado por el uso inconveniente o la falta de una medicación y que puede causar perjuicio al paciente, mientras la medicación está bajo control de los profesionales de la salud o el paciente”. el error se puede presentar en las etapas de prescripción, trascripción, administración y monitoreo. los autores resaltan la expresión de “pensar es cuidar”, por ello, no obstante existir una prescripción médica, debe ser analizada por parte de la enfermera con la finalidad de advertir dosis, vías, frecuencia e interacciones que pongan en peligro la integridad del paciente. metodología se realizó un estudio de corte cuantitativo con un diseño descriptivo, transversal y correlacional. se integró una muestra poblacional de 139 alumnos, y otra con 30 docentes de la facultad de enfermería, campus tampico, de la universidad autónoma de tamaulipas (uat), país méxico. con relación a los alumnos se consideraron como criterios de inclusión los que cursaban del sexto al octavo periodo académico porque ya habían cursado la materia de farmacología (4º periodo), además de cuatro asignaturas propias de enfermería en donde se contemplan aspectos relacionados con el manejo del dolor. la muestra representa el 90% de los alumnos inscritos en dichos periodos. respecto a los docentes se incluyeron los que impartían farmacología y las asignaturas del área de enfermería en su enfoque teórico-práctico. se eliminaron tres cuestionarios de los maestros por respuestas incompletas. la muestra representó el 40% de la plantilla docente. para la recolección de los datos se diseñó un cuestionario para la medición del conocimiento básico en el manejo del dolor que poseen los alumnos; en un primer apartado se recabó la edad, el género y el periodo académico; el segundo apartado se integró con 33 reactivos, con una escala de tres opciones de respuesta, en donde 3 = totalmente de acuerdo y 1 = en desacuerdo. la puntuación fluctúa de 33 puntos como mínimo y 99 puntos como máximo, en donde a mayor puntuación mayor conocimiento. los reactivos se agruparon en tres dimensiones: clasificación del dolor, valoración del dolor y medidas terapéuticas. con base en el puntaje total del cuestionario se categorizaron los valores en tres niveles (bajo, regular y alto). previo al estudio se efectuó una prueba piloto con 30 alumnos del quinto periodo con la finalidad de medir la confiabilidad del cuestionario dirigido a los alumnos, alcanzó un valor alpha de cronbach de ,801, y se redefinieron tres reactivos para su mejor comprensión. con el fin de conocer la opinión de los docentes sobre la frecuencia con que 220 año 8 vol. 8 nº 2 chía, colombia octubre 2008 212-226 aquichan issn 1657-5997 los alumnos aplican el conocimiento en el manejo del dolor durante las sesiones de clase, se diseñó un cuestionario, iniciando con datos demográficos relacionados con la antigüedad laboral, el nivel académico, la categoría, y el área en que se desempeña; se continuó con la formulación de 25 reactivos para lo cual se tomaron en cuenta las tres dimensiones antes mencionadas. se especificaron tres opciones de respuesta, en donde 1 = nunca y 3 = casi siempre. la puntuación mínima es de 25 y la máxima de 75, en donde a mayor puntuación mejor opinión de los docentes respecto al conocimiento en el manejo del dolor por parte de los alumnos. al realizar el estudio se consideraron los aspectos éticos señalados en el reglamento de la ley general de salud (1987) en materia de investigación, donde se incluye el anonimato de los sujetos, la confidencialidad de la información brindada por los mismos, y el derecho a información con respecto al estudio y a retirarse en el momento que lo deseen. tanto a los alumnos como a los maestros se les explicó la finalidad del estudio y cuál sería su participación, en ese momento se obtuvo el consentimiento informado de forma verbal por considerarse el estudio sin riesgo para los participantes dado que no se realizó ninguna intervención, pero siempre respetando el anonimato de la información como parte de la ética del estudio, el cual se llevó a cabo en el periodo de septiembre de 2006 a agosto de 2007. la información recabada se procesó a través del paquete estadístico spss, versión 13, se analizó mediante estadística descriptiva a través de frecuencias absoluta y relativa, índices, medidas de tendencia central y desviación estándar. también se efectuó análisis inferencial mediante la correlación de pearson debido a que los datos no mostraron normalidad en su distribución reportada por la prueba de kolmogorov-smirnov. resultados este apartado se inicia con el análisis de los datos de los alumnos y enseguida se presentan los resultados derivados del cuestionario de los docentes, confrontándolos con los de los alumnos. la tabla 1 muestra el perfil demográfico de los alumnos, como se puede observar predominó el género femenino, el rango de edad fue de 19 a 28 años, la media fue de 21,8, desviación estándar (de) de 1,54, mediana y moda de 21; el grupo de edad estuvo entre 19 a 21 años con más del 50%. respecto al semestre académico, el 65% de los alumnos cursaban el séptimo periodo. tabla 1. perfil demográfico de los alumnos variable f % género femenino 127 91,3 masculino 12 8,6 grupo de edad 19-21 75 53,9 22-24 57 41,0 25-28 7 5,0 periodo académico sexto 20 14,4 séptimo 90 64,7 octavo 29 20,9 fuente: ccmde n= 139. con el fin de conocer la opinión de los docentes sobre la frecuencia con que los alumnos aplican el conocimiento en el manejo del dolor durante las sesiones de clase se diseñó un cuestionario, iniciando con datos demográficos relacionados con la antigüedad laboral, el nivel académico, la categoría, y el área en que se desempeña. 221 conocimiento y manejo del dolor en alumnos de enfermería ma. del refugio zavala-rodríguez, j. fernanda gonzález-salinas tabla 2. datos descriptivos del conocimiento en el manejo del dolor por alumnos indicador n valor x md moda de mín. máx. puntaje 139 53 98 81,7 85 85 8,9 índice 139 30,3 98,5 73,8 75,7 75,7 13,5 fuente: ccmde n= 139. en la tabla 2 se puede detectar que el grado de conocimiento en el manejo del dolor en la población de alumnos participantes es bueno, ya que de los 99 puntos en total del cuestionario obtuvieron un promedio de 82, es decir, los 139 alumnos tuvieron un 74% (índice) de conocimiento relacionado con el manejo del dolor. el máximo valor encontrado fue de 98,5%, mientras que el mínimo índice de conocimiento fue de 30%. tabla 3. distribución de alumnos por niveles de conocimiento en el manejo del dolor nivel puntaje f % bajo 33 54 1 ,7 regular 55 77 41 29,5 alto 78 99 97 69,8 fuente: ccmde n= 139. los valores del cuestionario relativo al conocimiento en el manejo del dolor se categorizaron en tres niveles, encontrándose el 70% de los alumnos en el nivel alto. la tabla 3 especifica el puntaje por nivel. tabla 4. aspectos por considerar en la valoración del dolor, según opinión de alumnos indicador en parcialmente totalmente desacuerdo de acuerdo de acuerdo f % f % f % mediante la localización del dolor se especifica 3 2,1 29 20,9 107 77,0 si es delimitado o se irradia. las escalas de medición permiten traducir la 8 5,7 23 16,5 108 77,7 intensidad del dolor. la escala frutal se puede usar en personas con 33 23,7 30 21,6 76 54,7 poca escolaridad. eva: el cero indica ausencia de dolor y el 10 10 7,1 42 30,2 87 62,6 dolor severo. escala de 9 caritas se usa en niños. 13 9,3 45 32,4 81 58,3 en la evaluación se considera la historia clínica, 8 5,7 37 26,6 94 67,6 severidad del síntoma y reporte verbal del paciente. signos vitales, fascies y movilización, se consideran 3 2,1 39 28,0 97 69,8 para evaluar efecto de la analgesia en el paciente. se solicita al paciente que explique alguna 3 2,1 22 15,8 114 82,0 cualidad del dolor en sus propias palabras. se toma en cuenta el estado emocional y 10 7,2 49 35,2 80 57,6 espiritual del paciente. en la experiencia del dolor influye su significado, 20 14,4 40 28,8 79 56,8 edad y género del paciente. el umbral del dolor es la mínima sensación que 22 15,8 51 36,7 66 47,5 un individuo reconoce como dolorosa. se consideran las creencias del paciente y la 24 20,9 52 28,8 63 45,3 familia. si el paciente no reporta el dolor, influye en que 39 28,0 55 39,6 45 32,4 no le creen. respuestas humanas, intervenciones y respuesta 3 2,2 16 11,5 120 86,3 del paciente, se valoran para elaborar una nota de enfermería. fuente: ccmde n= 139. 222 año 8 vol. 8 nº 2 chía, colombia octubre 2008 212-226 aquichan issn 1657-5997 con base en las frecuencias de respuesta para cada uno de los indicadores contemplados en el cuestionario para los alumnos, en 29 de un total de 33 la mayoría eligió la opción tres (totalmente de acuerdo). en la tabla 4 se muestra lo referente a la dimensión valoración del dolor; de 14 reactivos en 13, los alumnos marcaen la tabla 5 se presenta la estadística descriptiva de puntaje e índice de la opinión de los docentes sobre el conocimiento en el manejo del dolor por parte de los ron la opción tres, con un porcentaje que va del 45 al 86,3%. respecto al perfil demográfico de los docentes, el 63% cuenta con estudios de maestría, el 37% está en licenciatura; respecto a la categoría laboral, el 53% son profesores de tiempo completo, el resto indicador n valor x md moda de mín. máx. puntaje 30 43 69 55,6 54 51 7,2 índice 30 36 88 61,2 58 52 14,5 fuente: ccmdd n= 30. tabla 5. datos descriptivos de la opinión de los docentes son de horario libre. con relación a la antigüedad laboral, el rango fue de 2 a 43 años, predominó el grupo con 12 a 21 años de antigüedad; la media fue de 18,3, de de 10,5, mediana y moda de 15. el 47% se desempeña en el área teórica, y un porcentaje equivalente labora tanto en el área antes señalada como en el área clínica. alumnos. se observa que la percepción de los 30 docentes participantes fue regular, pues de los 75 puntos en total del cuestionario obtuvieron un promedio de 56, equivalente al 61% (índice). el máximo valor encontrado fue de 88%, es decir, ningún maestro consideró que los alumnos tengan el 100% de conocimiento. tabla 6. conocimiento de tipos-características del dolor y escalas de medición que aplican los alumnos en clase, según opinión de los docentes variable casi siempre algunas veces nunca f % f % f % diferencian tipos de dolor: agudo-crónico 21 70 9 30 somático-vegetativo 7 23,3 18 60 5 16,7 agudo-neuropático 4 23,3 13 43,3 13 43,3 diferencian características del dolor: frecuencia-duración 14 46,7 16 53,3 intensidad-calidad 15 50,0 12 40,0 3 10,0 localización-intensidad 14 46,7 14 46,7 2 6,7 describen escalas de medición: escala visual análoga 11 36,7 11 36,7 8 26,7 escala frutal 5 3,3 15 50,0 14 46,7 escala de caritas 1 16,7 13 43,3 12 40,0 fuente: ccmdd n= 30. 223 conocimiento y manejo del dolor en alumnos de enfermería ma. del refugio zavala-rodríguez, j. fernanda gonzález-salinas la tabla 6 muestra la frecuencia con que los docentes señalaron que los alumnos refieren estos elementos en torno al manejo del dolor, durante las sesiones de clase; el 70% registró que casi siempre saben diferenciar entre el dolor agudo y crónico, algunas veces lo hacen para los demás tipos de dolor. en este sentido se encontró coincidencia con las respuestas reportadas por los alumnos, ya que la mayoría contestó estar entre parcialmente de acuerdo y en desacuerdo con la concepción formulada respecto al dolor vegetativo (75%) y al dolor neuropático (56%); situación diferente se encontró con la definición de dolor somático, en donde el mayor porcentaje de alumnos (52,5%), señaló estar totalmente de acuerdo con el enunciado correspondiente. respecto a las características del dolor, el 50% de los docentes indicaron que casi siempre detallan lo referente a intensidad y calidad del dolor, coincidiendo con la opinión de la mayoría de los alumnos, y un poco más de este porcentaje indicó que algunas veces especifican la frecuencia-duración del dolor. la mayoría de los docentes manifestó que algunas veces o nunca los alumnos describen la escala frutal y la escala de intervalos de nueve caritas. lo anterior difiere con lo registrado por los alumnos, ya que el 55 y 58%, respectivamente, indicó estar totalmente de acuerdo con la concepción formulada para dichas escalas. es posible que los alumnos tengan el conocimiento declarativo en estos aspectos pero no lo manifiestan en las sesiones de clase, o bien no se les solicita o no se aplican en el contenido temático. tabla 7. conocimiento de la escalera analgésica, conceptos, medidas paliativas y aspectos contemplados en el paciente variable casi siempre algunas veces nunca f % f % f % diferencian la escalera analgésica de la oms: uso de aines 17 56,7 11 36,7 2 6,7 opioides 7 23,3 12 40 11 36,7 adyuvantes 6 20 11 36,7 13 43,3 diferencian conceptos: tolerancia 11 36,7 15 50 4 13,3 dependencia 8 26,7 17 56,7 5 16,7 umbral del dolor 11 36,7 14 46,7 5 16,7 contemplan medidas paliativas en el plan de cuidados: masaje-cambio de posición 19 63,3 9 30 2 6,7 aplicación de calor-frío 12 40 17 56,7 1 3,3 técnicas de relajación 6 20 12 40 12 40 aspectos considerados en el paciente: edad-género 18 60 9 30 3 10 creencias 9 30 14 46,7 7 23,3 estado emocional 8 26,7 18 60 4 13,3 fuente: ccmdd n= 30. la tabla 7 muestra aspectos asociados con cuestiones de tratamiento, de 12 indicadores, en nueve de ellos la mayoría de los docentes registró que algunas veces los alumnos los aplican en clase, la frecuencia oscila entre 40 y 57%, difiriendo con lo manifestado por los alumnos, ya que la mayoría contestó en forma adecuada los 14 indicadores correspondientes a esta dimensión, con excepción del término “dependencia física”, pues el 45% señaló estar parcialmente de acuerdo con la concepción planteada, y el 38% indicó estar totalmente de acuerdo. cabe señalar que los tres últimos aspectos incluidos en esta tabla se ubican en la dimensión valoración del dolor, y que inciden en el tratamiento, y sólo lo inherente a las creencias del paciente coincide con lo registrado por los alumnos ya que el 55% señaló estar entre parcialmente de acuerdo y en desacuerdo 224 año 8 vol. 8 nº 2 chía, colombia octubre 2008 212-226 aquichan issn 1657-5997 en que estos aspectos se deben tomar en cuenta en el manejo del dolor. a la pregunta de si los alumnos describen la farmacoterapia de mayor uso de acuerdo con el contenido temático por programas de estudio, el 57% de los docentes contestó que casi siempre lo efectúan. en lo concerniente a la etapa del proceso enfermero en la que los alumnos enfatizan sobre el manejo del dolor, la mayoría de los docentes indicó las etapas de valoración, diagnóstico enfermero, plan de cuidados y evaluación, con un porcentaje que va del 67 al 70%. tabla 8. consistencia interna de los instrumentos de medición instrumento/ dimensión no. de r a. de eactivos cronbach cuestionario para alumnos 33 ,85 por dimensión clasificación del dolor 5 ,52 valoración del dolor 14 ,71 medidas terapéuticas 14 ,76 cuestionario para docentes 25 ,82 fuente: ccmde, ccmdd n= 139 alumnos, 30 docentes. la tabla 8 especifica la confiabilidad de los dos cuestionarios diseñados para efectos del presente estudio, el valor total de ambos instrumentos apoya su consistencia interna determinada a través del coeficiente alpha de cronbach. con el propósito de determinar si existe relación estadísticamente significativa entre las tres dimensiones estructuradas y el índice general del cuestionario para los alumnos, se efectuó un análisis de correlación de pearson. la relación lineal resultó significativa: para la dimensión clasificación del dolor fue de ,895, en la de valoración del dolor fue de ,884, y para la dimensión medidas terapéuticas fue de ,895, con valor p= ,000 por cada dimensión. las correlaciones fueron significativas al nivel del ,01. discusión la mayoría de los alumnos concordaron en considerar las palabras del paciente para describir la cualidad del dolor, a diferencia del estudio de espinosa, en donde menos del 40% de las enfermeras asociaron esta característica con expresiones del paciente; en cuanto al desconocimiento de un método de medición del dolor, también difiere con lo reportado conceptualmente por los alumnos, ya que ellos indicaron en forma correcta escalas de mayor uso. lo anterior coincide parcialmente en el aspecto de clasificación del dolor, pues el mayor porcentaje de los alumnos no identificó la definición de dolor vegetativo. menos del 50% de los alumnos señalaron que en la valoración del dolor se deben tomar en cuenta las creencias del paciente y la familia, a pesar de que es una de las variables que influye en la satisfacción del paciente en el manejo del dolor, como está reportado en el estudio de peñarrieta. por otro lado, consideraron importante tomar en cuenta el reporte verbal del paciente acerca del dolor, ello coincide con lo encontrado por campos (14) y zavala (5). referente a las etapas del proceso enfermero, los resultados del estudio reflejan que los alumnos identifican su importancia, ya que el 86% indicó estar totalmente de acuerdo en la valoración de las respuestas humanas, las intervenciones y respuescon el propósito de determinar si existe relación estadísticamente significativa entre las tres dimensiones estructuradas y el índice general del cuestionario para los alumnos, se efectuó un análisis de correlación de pearson. 225 conocimiento y manejo del dolor en alumnos de enfermería ma. del refugio zavala-rodríguez, j. fernanda gonzález-salinas tas del paciente, y en considerarlos como indicadores para el registro de notas de enfermería. al igual que los maestros, manifestaron que los alumnos enfatizan en todas las etapas del proceso en los temas inherentes al manejo del dolor. de acuerdo con el puntaje de respuestas, el mayor porcentaje (70%) de alumnos se localizó en el nivel alto de conocimientos básicos en el manejo del dolor; situación inversa se encontró con los maestros, la mayoría opinó que cuentan con un nivel regular de conocimiento. esto podría relacionarse con el grado de vinculación entre las materias biomédicas y las enfermerías que se exige o se aplica en las sesiones de clase tanto por maestros como por los alumnos. de otro lado, con base en la información derivada de las inconformidades en la conamed, en méxico, vinculadas con la práctica de enfermería, la administración errónea de medicamentos se puede considerar como un reflejo de la problemática que se menciona en la literatura internacional, ello podría ser un indicador para prestar atención a los problemas con mayor incidencia y establecer las estrategias necesarias tanto en el ámbito formativo como asistencial para que disminuyan, y poder contribuir de manera significativa en la calidad de la atención en los sistemas la salud. conclusiones y recomendaciones la divergencia de opiniones entre alumnos y docentes respecto al nivel de conocimiento en el manejo del dolor invita a reflexionar, a través del trabajo participativo, en el contenido de los programas del área biomédica y el área de enfermerías, así como también en las estrategias de enseñanza-aprendizaje en relación a lo establecido en el método pedagógico del constructivismo en el sentido de guiar y orientar al alumno en la adquisición del conocimiento según sus saberes previos y capacidades cognitivas, a fin de que adquieran los fundamentos teórico-prácticos necesarios para el desempeño efectivo de las intervenciones, en este caso concreto, en terapia farmacológica, para empezar a construir bases sólidas para ejercer en un futuro próximo, en nuestro país, la prescripción de medicamentos por enfermeras (os) con la pericia y responsabilidad que esto representa. en forma global los cuestionarios diseñados alcanzaron consistencia interna aceptable, sin embargo, se recomienda investigar sobre el objeto de estudio con instrumentos validados, así como también indagar respecto a las experiencias y los aprendizajes en el manejo del dolor en el campo clínico por parte de los alumnos, ya que es un aspecto no contemplado en el presente estudio, y así poder articular resultados e implementar estrategias en los aspectos educativos requeridos con la firme convicción de fortalecer la formación profesional en la disciplina de enfermería en áreas básicas de la salud. la administración errónea de medicamentos se puede considerar como un reflejo de la problemática que se menciona en la literatura internacional. 226 año 8 vol. 8 nº 2 chía, colombia octubre 2008 212-226 aquichan issn 1657-5997 referencias 1. mccloskey j, bulechek g. clasificación de intervenciones de enfermería (nic). 4 edición. madrid: mosby; 2005. 2. romero b, jordán j. dolor: diagnóstico de enfermería en un caso clínico. revista desarrollo científico de enfermería 2004; 12 (10): 304-308. 3. reyes m. guía básica para el manejo del dolor por enfermería. el quinto signo vital. méxico: jgh editores; 1999. 4. espinosa. las enfermeras en la valoración del dolor. revista desarrollo científico de enfermería 2002; 10 (9): 260-264. 5. zavala, fang, ortega, rivera. manejo del dolor por el personal de enfermería. revista mexicana de algología 2005; 4 (1): 11, 14-16. 6. jiménez 0. farmacología o administración de medicamentos: preparando el camino hacia la prescripción enfermera (sección práctica clínica). revista desarrollo científico de enfermería 2006; 14 (10): 415-418. 7. peñarrieta, del ángel, garcía, vergel, gonzález, zavala. manejo del dolor y la satisfacción de pacientes post operados hospitalizados: el caso de perú y méxico. revista desarrollo científico de enfermería 2006; 14 (1): 20-26. 8. gómez, fernanda. dilemas éticos frente a la seguridad del paciente. cuidar es pensar. revista aquichan 2006; 6 (1): 54-67. 9. peña m. recomendaciones para la administración de medicamentos por vía intravenosa (sección procedimientos). revista desarrollo científico de enfermería 2007; 15 (4): 172-174. 10. tena, arroyo, jiménez, mejía, fonseca, gutiérrez. recomendaciones para mejorar la atención de enfermería (sección información general). revista desarrollo científico de enfermería 2005; 13 (1): 21-27. 11. sánchez b. abordajes teóricos para comprender el dolor humano. revista aquichan 2003; (3): 3: 32-41. 12. davis g, white t. papel de la enfermera en el manejo del dolor crónico con adultos mayores. college of nursing, texas woman’s university. denton; 2005. 13. medina. los licenciados en enfermería podrán recetar medicamentos (sección de noticias). revista desarrollo científico de enfermería 2007; 15 (9): 389. 14. campos, garcía, marmolejo, santillán, violante. la empatía de la enfermera, factor relacionado con el dolor (sección investigación). revista desarrollo científico de enfermería 1997; 5 (6): 185-188. 10 reseñas.p65 reseñas 227 año 7 vol. 7 nº 2 • chía, colombia octubre 2007 nursing care is a practice that is guided by knowledge and by love when i think what the essence of nursing practice is, i realize that our delivery of care is based on love for humanity and knowledge that is guided by theory and research. to elaborate a little as an educator, i know that nurses learn theory as some sort of a road map to guide their research and practice, which facilitates the acquisition of their mission: to insure patients� well-being. adaptacion y cuidado en el ser humano. una vision de enfermeria is a wonderful tool for teaching under-graduate and graduate nurses how to build delicate structures of logic, in order to comprehend the pivotal role that theory plays in our practice. in this book, the roy adaptation model is an excellent example in how to integrate nursing theory into our practice. the purpose of this book is to help nurses comprehend that, through the use of theory, our visions broaden. its readers see many things differently and envision many different ways to impart bedside care. they will also learn to critically create nursing interventions whose existence they were unaware of and to evaluate many relationships that we could not have possibly done without the use of theory. the group of la sabana school of nursing began this project with the conviction that the roy adaptation model (ram) has the breadth, scope, and adaptability to be used with south american populations. furthermore, this group believes that nursing practice, based on the model, has created a higher level of knowledge that it is particularly efficient for nursing practice, and also aids in establishing guidelines for critical analyses and processes to evaluate the relationships of its practice to the model. the book is divided in nine chapters. chapter one deals with historical and philosophical bases, and visions for the 21st century written by dr. callista roy. chapter 2 describes the roy adaptation model and processes of adaptation and cognition taking sociological and psychological nursing references to conclude that the cognitive process can determine the parameters that can guide the nursing process. chapter 3 addresses pre-natal and post-partum care while chapter 4 covers newborn care. chapter 5 presents the infant care. the next chapter discusses the adaptation of the adolescent. chapter 7 focuses on the young adult care while chapter 8 elaborates the adaptation of the older healthy adult. the final chapter talks about experiences and application of the model to research, education, and practice. i believe that the dream and the vision in writing this book has been to make theory more relevant for the practice of nursing in south america and also to stimulate further use of the model maría del carmen gutiérrez, coordinadora editorial universidad de la sabana, manual moderno, 2007 aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007228 by leading the way to the development of better nursing practice and establishment of evidence-based practice. this book is unique in that it is comprehensive and moves beyond the description of the model, and it gives direction for its utilization in practice settings. nurses in academia and in practice will benefit from the many examples of the use of the model that are provided. the members of the college of nursing of la sabana university are indebted to sr. callista roy, and to all who have encouraged and assisted in the development of this project. martha v. whetsell, phd, rn, arnp doctora en enfermería profesora lehmon college of nursing new york, ee.uu. reflexiones y perspectivas de la educación superior en américa latina el proyecto tuning-américa latina, en el que se comprometieron 19 países del área, ofrece un marco referencial de trabajo conjunto y construcción de lenguajes comunes que permiten la comprensión de los sistemas de enseñanza superior en varias disciplinas, en lo relacionado con competencias (genéricas y específicas de las áreas temáticas seleccionadas); enfoque de enseñanza, aprendizaje y evaluación de estas competencias, créditos académicos y calidad de los programas. este texto hace relación a un proceso de reflexión y debate colectivo llevado a cabo por más de 200 académicos de 190 universidades que en latinoamérica, en las áreas temáticas específicas de administración, arquitectura, derecho, educación, enfermería, física, geología, historia, ingeniería civil, matemáticas, medicina y química, adelantaron en sus respectivos países abordando la metodología propuesta por el proyecto, y que se encuentra anexada a la obra, en donde se consultaron a los académicos (docentes universitarios), graduados, estudiantes y empleadores cuyos aportes en cada institución sirvieron de base para construir las competencias genéricas y específicas en el campo de estudio. sus resultados fueron analizados y comparados, y su priorización permitió determinar las conclusiones y proyecciones pertinentes en cada una de las disciplinas consultadas, aspectos que se podrán apreciar detalladamente en este libro. son de interés general para todos los académicos las reflexiones sobre las unidades de medida de trabajo del estudiante, cuyas conclusiones preliminares ofrecen una herramienta que enmarca en un futuro los estudios de movilidad, homologación y convalidación para estudiantes y profesionales de los diferentes países, los que están complementados por las fichas descriptivas de las características educativas que se tienen en cada lugar de los participantes del proyecto, y que se encuentran en el anexo ii. esta obra recoge una importante experiencia y significativos aportes que los participantes en el proyecto tuning-américa latina hicieron desde su visión de la educación superior, y se convierte en un medio de consulta para quienes deseen ahondar en los sistemas educativos que se siguen en latinoamérica. maría del carmen gutiérrez agudelo profesora asociada facultad de enfermería universidad de la sabana informe final. proyecto tuning-américa latina 2004-2007 4 aquichan issn 1657-5997 editorial la templanza es la virtud del equilibrio. en este sentido, es necesario resaltar que la enfermería, para aumentar su bagaje de conocimiento científico, debe mantener ese equilibrio en la investigación, ya que dada la naturaleza de los fenómenos disciplinares de interés, se requiere incorporar a nuestras metodologías todos aquellos procesos que facilitan múltiples miradas, indispensables para el crecimiento y la clarificación del conocimiento. la disciplina dio legitimidad a la investigación cualitativa tiempo atrás (1); sin embargo, hoy en día, numerosas académicas, publicaciones científicas periódicas y agencias de financiación exigen los mismos estándares derivados de la metodología científica tradicional, al tener en cuenta las propuestas enmarcadas dentro de los cánones de la investigación cualitativa. este hecho, a mi juicio, contribuye a restar significado, validez e importancia a la “forma externa” como se presenta la investigación cualitativa. pero ustedes se preguntarán, ¿por qué razón el editorial de la revista aquichan trae a colación un tema trillado y, sobre todo, discutido en los diversos ámbitos académicos? la respuesta es simple. porque, como miembro del comité editorial de aquichan, pasan por mis manos manuscritos, resultantes de investigaciones cualitativas, algunos de los cuales gravitan alrededor de la incoherencia y otros de la superficialidad, y ello puede tener explicación en la forma de presentación adaptada de los artículos de investigación cuantitativa, utilizada en la mayoría de las revistas científicas. si aceptamos la propuesta de que la investigación cualitativa enfatiza en el lenguaje y los significados para comprender nuestra experiencia, es precisamente alrededor de esos significados y lenguaje sobre los cuales debe girar la escritura de los reportes cualitativos aunque se rompa un tanto con las exigencias ortodoxas de los reportes de investigación de este tipo. de acuerdo con morse (2) “estos estándares deben ser revisados y resaltados”, ya que muchas veces los pares evaluadores y los lectores suponen que los artículos cualitativos deben incluir todos los requisitos delineados para los cuantitativos y, por tanto, si se omiten o se incluyen aspectos pertinentes a lo cualitativo, son juzgados de manera inadecuada. el lenguaje de la investigación científica es un lenguaje aprendido libremente o inducido en una u otra dirección, y puede presentarse como un relato coloquial, o mostrar tales año 10 vol. 10 nº 1 chía, colombia abril 2010 l 4-7 apuntes sobre la presentación de artículos cualitativos 5 editorial niveles de abstracción que se puede tornar incomprensible. desde una perspectiva cualitativa, la habilidad para expresarse a sí mismo o expresar el discurso de los otros debe hacerse de forma parsimoniosa, sin llegar a la economía totalmente neutra del lenguaje utilizado en la cuantitativa. recordemos que el lenguaje que manejan los informantes y, posteriormente, el discurso que maneja el investigador, son los elementos claves en los procesos cualitativos. por ello el énfasis de los discursos debe centrarse más en la información de los otros y menos en los elementos generales teóricos existentes. la investigación cualitativa gira fundamentalmente alrededor del lenguaje y del lenguaje de las personas. rodgers (3) cita a heidegger y explica que el fundamento ontológico de los lenguajes es el discurso o la palabra, y es esta última la que permite articular las expresiones, de acuerdo con el significado de “ser y estar en el mundo”, que le adjudican las personas. lo anterior nos lleva, entonces, a reconocer que, de acuerdo con el origen de cada método y de la forma como utiliza el lenguaje, pueden variar algunos aspectos, que se tornan importantes a la hora de hacer los reportes escritos (manejo de discurso) para las revistas científicas, y recordemos que los resultados, generalmente, proveen una descripción, en forma de narrativa, derivada de las experiencias o cultura de las personas. teniendo en cuenta estos planteamientos, y utilizando lo propuesto por morse (2), podemos proponer algunos elementos que deben reforzarse en los reportes cualitativos para hacerlos más ricos en contenido y dejar ver a través de ellos la verdadera esencia y propósito de este tipo de indagación. 1. estilo de la escritura. el hábito más incorporado en los reportes es la eliminación de la primera persona. la tercera persona desapasionada de los reportes cuantitativos se incorporó y se “tomó” los cualitativos. no existe una política clara sobre cómo presentar los manuscritos, lo cual hace urgente que se estandaricen formatos para tal fin. entre tanto, se debe tener en cuenta que los autores deben mantener normas básicas gramaticales que eliminen textos aburridos tendientes a mostrar los resultados en términos neutros e impersonales, o a convertirlos en narrativas coloquiales (2). recomments on the presentation of qualitative articles anotações sobre a presentação de artigos qualitativos 6 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 cordemos que los manuscritos son de los investigadores y no de los pares evaluadores, y es un tanto arriesgado que el evaluador desee, a toda costa, que el investigador modifique el manuscrito sólo porque no se ajusta a parámetros cuantitativos. 2. descripción de las muestras. los reportes cuantitativos expresan las muestras en términos cuantitativos porque así se permite comparar la muestra con la población general de la cual se extrajo en términos aleatorios para eliminar sesgos, propender por la generalización y poder comparar los resultados con los de otros estudios. pero lo cualitativo no cae dentro de esta descripción, y si se pretende asimilar la muestra cualitativa a la cuantitativa, aquella pierde legitimidad. lo que se requiere en el caso presente es la descripción de los participantes, lo cual facilita evaluar la “representación teórica” de éstos. para lograr este fin se necesita demostrar cuál ha sido la experiencia o el papel que han jugado dentro del fenómeno de estudio, lo que les permite generar información pertinente y suficiente para los análisis posteriores y así “el reporte se puede evaluar de acuerdo con requisitos tales como integralidad, grado de saturación y sesgos indeseables” (2). la experiencia nos muestra, al contrario de lo descrito, que los manuscritos hacen énfasis en características demográficas como género, estatus marital, ocupación, enfermedades, entre otros, pero el énfasis debe ponerse en las características relacionadas con la experiencia; y aunque estos aspectos demográficos pueden ser importantes, algunas veces no ayudan a explicar el uso apropiado del muestreo teórico representativo útil para comprender el concepto de saturación de muestreo requerido para la investigación cualitativa. y más grave aún, cuando se expresan las metodologías de análisis se hace un listado de pasos, tan cual aparecen en los textos, y no se demuestra sustantivamente cómo se llegó a la saturación teórica de la muestra (información). no me parece suficiente que en los reportes se mencione que se llegó a la saturación teórica que es el eje central del análisis. creo necesario que se explique de manera descriptiva cómo se logró la meta de la saturación. 3. presentación de marcos de referencia, análisis y conclusiones. debemos recordar que los fines de la investigación cualitativa apuntan a la comprensión de lo existencial, vivencial, a la experiencia y a lo cultural. y estas descripciones no requieren marcos de referencia que puedan generar problemas de sesgo (desde el punto de vista etic), y mucho menos marcos teóricos que delimiten los análisis a partir de premisas determinadas a priori. por el contrario, si el análisis nos conduce al planteamiento de un concepto, a un planteamiento hipotético, o al planteamiento de una teoría emergente, esto significa que los resultados se pueden considerar aspectos nuevos del conocimiento, aunque tengan una esencia descriptiva. entonces, ¿por qué razón el análisis se debe plantear en términos deductivos, como si quisiéramos ajustar el fenómeno o la experiencia a propuestas predefinidas? los resultados cualitativos se articulan a partir del desarrollo de significados, y si hemos desarrollado los conceptos ciñéndonos al rigor analítico, esos conceptos son susceptibles de transferirse a otras personas, grupos o situaciones. tampoco es válido el argumento de que “algo se debe probar como resultado de la investigación”. nuevamente, si el análisis deri7 vado de la recolección, el despliegue, la síntesis y la diagramación de información, de la comparación constante y acompañado de saturación de muestra, nos conduce a la obtención de resultados teóricos, es suficiente para concluir con satisfacción la investigación (4). si, además, en investigaciones posteriores, se desea un movimiento hacia la demostración y generalización posible de los resultados, se procederá de conformidad con los cánones investigativos requeridos para tal fin. no sobra recordar que los aspectos que debe buscar un evaluador de reportes de investigación cualitativa giran alrededor de la credibilidad, confianza, capacidad de confirmación y del poder de transferencia de los resultados. estos elementos los garantiza un manuscrito que exprese claridad, credibilidad y seguridad en el valor de los datos, resultado del manejo de la información. un texto que muestre un “retrato auténtico de lo que se indaga” (4). además, la confianza nos indica la consistencia entre la información bruta y los resultados finales. esta es una característica sustantiva ya que durante el proceso de codificación primaria (sustantiva y nominal), y luego de la codificación axial puede perderse el verdadero significado de las informaciones (4). el tercer aspecto o capacidad de confirmación debe ser visible dada la “neutralidad y la libertad relativas que maneja el investigador y que generan sesgos” (4). esta transparencia se opaca con descripciones gruesas o burdas, cuando los procesos de análisis no reportan auditorías y, sobre todo, cuando en aras de la independencia no se permiten revisiones de pares internos y externos a la investigación. y la posibilidad de transferencia, que es uno de los aspectos más discutidos de lo cualitativo y que no debemos confundir con la generalización cuantitativa, nos permite analizar o determinar el grado de transferencia de los hallazgos cuando éstos pueden “trasladarse” a otras poblaciones, ambientes y contextos (5). con estos apuntes he querido enfatizar en la importancia que debemos dar a los manuscritos cualitativos, y en los esfuerzos que bebemos llevar a cabo para que los resultados de la indagación cualitativa cumplan con la meta de aportar al crecimiento de los contenidos disciplinares de enfermería. maría mercedes durán de villalobos maria.duran1@unisabana.edu.co referencias bibliográficas 1. munhall pl. language and nursing research: the evolution. en pl munhall. nursing research: a qualitative perspective. 4 edition. 2007; sadburry, mass: jones and bartle publishers. 2. morse j. editorial: qualitative influences on the presentation of qualitative articles. qualitaive health research 2007; 17 (2): 147-148. 3. rodgers b. developing nursing knowledge: philosophical traditions and influences. 2005; philadelphia: lippincott, williams & wilkins. 4. huberman m, miles m. data management and analisis methods. en denzing n, lincoln y. editors. handbook of qualitative research. 1994; thausand oaks, ca. 5. denzing n. the art and politics of interpretation. en denzing n, lincoln, y. editors. handbook of qualitative research. 1994; thausand oaks, ca. 96 aquichan issn 1657-5997 editorial en este número de aquichan los lectores encontrarán, entre otros, artículos de investigación relacionados con el cuidado de enfermería a personas en condición de enfermedad crónica como el cáncer y el vih. y artículos relacionados con aspectos administrativos del cuidado de personas que han sufrido un evento coronario o que han sido sometidas a cirugía cardiovascular. del análisis de los resultados que presentan los autores se puede inferir que los participantes de los estudios esperan que los profesionales de enfermería les den información precisa sobre los cambios en el estilo de vida, el tratamiento y las medidas de cuidado que demanda su estado de salud, el apoyo emocional y la ayuda que requieren para no abandonar el tratamiento. esos mismos participantes anhelan que los enfermeros (as) generen espacios que les permitan compartir experiencias con otros pacientes y con sus familias, por lo cual es fundamental que los responsables de brindar cuidado no solo tengan conocimientos actualizados de las características de la enfermedad, sino que comprendan su condición humana, en momentos difíciles de manejo y de aceptación. desde el punto de vista administrativo del cuidado, uno de los indicadores de calidad en la prestación de los servicios de salud es la satisfacción de los pacientes con las relaciones interpersonales que les proporcionan confianza y credibilidad en el personal de salud (1); asimismo, se debe tener en cuenta la importancia de ser eficientes con la administración de los recursos necesarios que garanticen una atención diligente y oportuna. es importante anotar que estar enfermo altera el estado emocional de las personas, por ello para brindar cuidado de enfermería no basta con tener conocimientos de las ciencias básicas y habilidades en la ejecución de procedimientos. el fundamento del cuidado es la relación que establece la enfermera con el paciente y con su familia. la forma como se plantea esta relación depende fundamentalmente de la filosofía que respalda la práctica, la cual puede tener dos perspectivas, una mecanicista y otra naturalista. la visión mecanicista, o visión recibida, tiene su origen en el positivismo lógico, y desde este punto de vista se considera que los seres humanos responden al ambiente año 10 vol. 10 nº 2 chía, colombia agosto 2010 l 96-98 ¿qué esperan las personas del cuidado de enfermería? 97 editorial en una relación causa-efecto, de tal manera que sus respuestas son predecibles y por ello pueden ser controladas. lo esencial desde este enfoque es el estudio de las partes, porque lo real es físico y objetivo, y por ello puede medirse y observarse. el profesional de enfermería que tiene esta visión de la práctica se centra en el síntoma, en la patología y en los procedimientos que requieren los pacientes para atender el problema de salud, sin preocuparse por otros factores del contexto que pueden influir en la situación que la persona está viviendo. la visión naturalista tiene su origen en las ciencias humanas y sociales, por ello se enfoca en explicar el comportamiento de la persona como un ser holístico, que otorga un significado a las situaciones que vive, con base en su conocimiento y experiencias previas. por ello, el comportamiento de cada persona es diferente, la suma de las partes no representa el todo, la realidad es dinámica y no puede prescribirse. desde este punto de vista cada persona es única, y la percepción que tiene de su condición es individual, está determinada por factores internos y externos que van más allá de las condiciones patológicas que la aquejan (2). esta visión reconoce que hay un propósito en la existencia humana, y que las personas tienen autonomía y capacidad de decisión. el profesional de enfermería que tiene esta visión de la práctica se enfoca en la persona como sujeto de cuidado, se preocupa por conocer cómo está viviendo la situación para, de esta manera, centrarse en atender las necesidades particulares. según webb et ál. (3), algunas enfermeras han cuestionado este énfasis en la importancia de la relación enfermera-paciente y en los aspectos psicosociales del cuidado. la realidad es que estos aspectos son inseparables de las competencias y habilidades clínicas que como profesionales deben tener. los participantes de los estudios mencionados esperan que los profesionales de enfermería tengan una visión naturalista de la práctica, para que brinden un cuidado humano, competente y eficaz. un cuidado humano por el cual sean atendidos como personas, no como un síntoma, una patología o un procedimiento; un cuidado competente y eficaz, brindado por profesionales de enfermería expertos, con una fundamentación sólida en las ciencias básicas y en el conocimiento disciplinar, que garantice la eficiencia en la administración de los recursos humanos y materiales requeridos. para los profesionales de enfermería, asumir el desafío de fortalecer la interrelación what do patients expect in terms of nursing care? que desejam as pessoas do cuidado de enfermagem? 98 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 con los pacientes y sus familias es ventajoso desde todo punto de vista. a través de las interacciones de cuidado podrán incrementar el conocimiento de la disciplina, demostrar su contribución a la recuperación del estado de salud de las personas y, por consiguiente, su autonomía e independencia frente a otros profesionales; además, registrar la satisfacción de las personas cuidadas y de sus familias. maría elisa moreno fergusson editora mariae.moreno@unisabana.edu.co referencias 1. ministerio de la protección social. sistema obligatorio de garantía de la calidad en salud. primer informe nacional de calidad de la atención en salud, incas colombia; 2009. p. 321. 2. munhall p. nursing research a qualitative perspective. 4 edition. boston: jones and bartlett publishers; 2007. pp. 47-51. 3. webb c, hope k. what kind of nurses do patients want? journal of advanced nursing 1995; 4: 101-108. 10 ultimas paginas.indd reseñas enfermería cardiovascular durante las últimas dos décadas el cuidado de enfermería ha enfrentado una serie de retos importantes derivados de los cambios de los sistemas de salud y, más que todo, de la utilización y el manejo claro del conocimiento y la teoría de enfermería para solucionar los problemas de la práctica cotidiana. en concordancia con estas exigencias, las enfermeras han propuesto formas de trabajo que hacen énfasis en dos elementos fundamentales del cuidado de enfermería: el fomento de la proactividad y autonomía de los pacientes, y el manejo profundo y experto del conocimiento científico que respalda sus decisiones de cuidado combinado con la humanización del mismo. en nuestro medio, las enfermeras pioneras de la enfermería cardiovascular, continúan ocupando un lugar fundamental en la memoria del presente trabajo ya que fueron ellas quienes en los años setenta sentaron las bases de nuestro trabajo actual. sin embargo, y cómo se verá a lo largo del texto enfermería cardiovascular, su contenido nos facilita la comprensión y el tránsito por una serie de aspectos que, hoy en día, son fundamentales para el trabajo del área en discusión, y que combinan no solamente los fundamentos tecnológicos y científicos pertinentes, sino que dejan ver de manera clara el aporte de los conocimientos de enfermería que se requieren para la solución de los múltiples problemas de la compleja y crítica área del cuidado cardiovascular. enfermería cardiovascular es un compendio ambicioso que pretende mostrar todos los aspectos importantes relacionados con el tema. es posible que a juicio del ojo crítico, se hayan omitido algunos contenidos que habrían debido incluirse, pero en términos generales las sesiones abarcan de forma integral y experta la mayoría de planteamientos conceptuales y teóricos que se requieren para manejar y abordar los problemas que nos ocupan. de esta manera, y a partir de propuestas sobre la problemática de la salud cardiovascular en colombia, y su impacto y costo en el manejo de la misma, las autoras nos conducen por los campos de la fisiopatología, medios diagnósticos, tratamientos clínicos y autor: comité editorial capitulo de enfermería sociedad colombiana de cardiología editorial: distribuna editorial año: 2008 127 reseñas quirúrgicos, pero tal vez lo más importante, nos aclaran la importancia del cuidado de enfermería para el trabajo con las personas en riesgo y rehabilitación, y con los pacientes sometidos a tratamientos, haciendo del trabajo de enfermería algo totalmente insustituible. la experiencia y productividad de las autoras permitió esta mirada integral del problema. así mismo, los textos facilitan una visión amplía para el trabajo de la enfermera, un campo promisorio en donde la imaginación e innovación permitirán la extensión de su trabajo hacia ámbitos que posiblemente hace algún tiempo no se imaginaban, formas de ejercicio liberal que expandan el rol y promuevan la consultoría de la enfermera. en fin, enfermería cardiovascular no solo trata profundamente lo que se conoce, propone el trabajo futuro aún sin habérselo propuesto ya que nos plantea una perspectiva profesional gratificante y rica en posibilidades. con las características expuestas es casi mandatorio la utilización de enfermería cardiovascular como texto de consulta de las enfermeras que trabajan dando cuidado cardiovascular, igualmente para docentes y estudiantes de pre y post grado porque no solo aporta con sus contenidos elementos precisos y claros de conocimiento, sino por la riqueza de las referencias bibliográficas que permiten profundizar en aquellos aspectos que así lo requieran. felicitaciones por este aporte intelectual de enfermería a la comunidad de la salud. gracias a las autoras por permitirnos compartir sus reflexiones conceptuales y teóricas, gracias a las editoras del libro por lograr una compilación de material rico, claro y profundo pero a la vez traducible a términos de nuestro diario vivir, y gracias a los pacientes que dieron su autorización a las autoras investigadoras para mostrarnos resultados que aportan a la comprensión y solución de sus problemáticas de salud. maría mercedes durán de villalobos profesora titular y emérita facultad de enfermería universidad nacional de colombia, bogotá guías de valoración de enfermería este manual constituye un práctico e interesante texto en donde el lector encuentra un detallado abordaje sobre las técnicas y los conceptos para la valoración del ser humano, según el modelo de adaptación de callista roy. igualmente, describe los procedimientos que apoyan el cuidado de enfermería. el texto, además, no es solo para estudiantes, ya que su contenido lo hace pertinente también para profesionales. es tan clara la intencionalidad del manual, que no pierde detalle a fin de guiar al lector por los pasos que se deben seguir para lograr una completa y correcta valoración y así satisfacer las necesidades del paciente. en la introducción las autoras afirman que “el deber ser de la enfermería como disciplina dinámica se concentra en el cuidado del paciente, la familia, la comunidad y su entorno; este cuidado no se brinda dentro de un esquema rígido e impersonal sino, por el contrario, en un esquema sistémico y flexible que permite abordar a la persona de manera holística”. 128 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 de otro lado, reafirma el interés y el empeño de las autoras por lograr un manual didáctico, que apoye el ejercicio docente y promueva el trabajo autónomo en el estudiante. una característica de este manual es la manera como las autoras integran desde una perspectiva teórica (modelo de adaptación de roy) las técnicas y los procedimientos para una valoración. igualmente, resulta interesante la presentación de situaciones de enfermería en cada uno de los capítulos, facilitando al lector el análisis y la comprensión de la misma. el texto está subdividido en diecinueve guías, cada una correspondiente a las funciones y necesidades planteadas en el modelo de adaptación para la valoración del ser humano. el lector inicia con algunos conceptos teóricos necesarios como son: la entrevista, las técnicas de valoración física y los registros; continúa con la valoración del modo psicosocial, pasando por cada uno de los modos fisiológicos, y finaliza con la valoración de la función endocrina y reproductiva. el desarrollo de cada uno de los capítulos se complementa con las intervenciones de enfermería. finalmente, vale la pena resaltar que este manual responde a una necesidad expresada de algunos docentes, profesionales y estudiantes, que han estado a la espera de un apoyo didáctico que facilite el entendimiento de la etapa fundamental de valoración para el buen planteamiento de diagnósticos de enfermería. magda castro-sánchez profesora asistente universidad de la sabana, chía, colombia autoras: yolanda gonzález de acuña blanca cecilia venegas editorial: universidad de la sabana año: 2008 psychosocial risks and job satisfaction: a meaningful relationship for oncology workers article psychosocial risks and job satisfaction: a meaningful relationship for oncology workers* riesgos psicosociales y satisfacción laboral: una relación significativa para los trabajadores de oncología** riscos psicossociais e satisfação profissional: uma relação significativa para os trabalhadores da oncologia*** 10.5294/aqui.2021.21.1.4 flérida rivera-rojas1 paula ceballos-vásquez2 yanni gonzález-palacios3 1 0000-0003-2542-8751. universidad católica del maule, chile. frivera@ucm.cl 2 0000-0002-3804-5146. universidad católica del maule, chile. pceballos@ucm.cl 3 0000-0002-1398-1560. universidad católica del maule, chile. ygonzalez@ucm.cl received: 24/06/2020 sent to peers: 21/07/2020 accepted by peers: 03/10/2020 approved: 16/10/2020 * it was financed by the regular internal project, ucm434194, pmi-oncology subline, of the universidad católica del maule, chile, called “intervention in psychosocial risks to improve the quality of life of the oncologic health team”. ** se contó con el financiamiento del proyecto interno regular ucm434194, sublínea pmi-oncología, de la universidad católica del maule, chile, denominado “intervención en riesgos psicosociales para la mejora de la calidad de vida del equipo de salud de oncología”. ***   financiamento de projeto interno regular ucm434194, sublinha pmi-oncologia, da universidad católica del maule, chile, chamado “intervenção em riscos psicossociais para melhorar a qualidade de vida da equipe de saúde de oncologia”. to reference this article / para citar este artículo / para citar este artigo: rivera-rojas f, ceballos-vásquez p, gonzález-palacios y. psychosocial risks and job satisfaction: a meaningful relationship for oncology workers. aquichan. 2021;21(1):e21114. doi: https://doi.org/10.5294/aqui.2021.21.1.4 abstract objective: to determine the relationship between psychosocial risk factors and professional satisfaction of workers working in oncology and palliative care units in a region of chile. material and method: non experimental, cross-sectional, correlational study with quantitative approach. in the last semester of 2016, the census of health workers was carried out, using an instrument composed of three parts for data collection: a) bio-sociodemographic history, b) suseso-istas 21 questionnaire for psychosocial risks, and c) for work satisfaction. international bioethical principles were respected throughout the research. results: there is a relationship with statistical significance (p≤0,05) between psychosocial risks and job satisfaction at work, the dimension of psychosocial risk with higher risk is psychological demand (x:11,24; dp: 3,06) and dual presence (x: 3,23; dp: 1,90) and the factor in which less satisfaction is perceived is the physical work environment (x: 4,32 dp: 1,77). conclusion: with the results obtained, it can be affirmed that the workers who work in oncologic units and perceive greater psychosocial risk at work present less satisfaction at work, which can impact on the quality of assistance. keywords (source decs): occupational risks; occupational health nursing; health personnel; oncology service, hospital; job satisfaction. resumen objetivo: determinar la relación entre los factores de riesgo psicosocial y satisfacción laboral de los trabajadores que se desempeñan en unidades de oncología y cuidados paliativos de una región de chile. material y método: estudio no experimental, transversal, correlacional con abordaje cuantitativo. durante el último semestre 2016, se realizó un censo a 110 trabajadores sanitarios, usando para la recolección de datos un instrumento que consta de tres partes: a) antecedentes biosociodemográficos, b) el cuestionario suseso-istas 21 para riesgos psicosociales y c) s20/23 para satisfacción laboral. durante toda la investigación, se respetaron principios bioéticos internacionales. resultados: existe relación con significancia estadística (p≤0,05) entre riesgos psicosociales y satisfacción laboral en el trabajo, la dimensión de riesgo psicosocial con mayor riesgo es exigencias psicológicas (x: 11,24; de:3,06) y doble presencia (x: 3,23; de:1,90) y el factor en que se percibe menor satisfacción es el ambiente físico de trabajo (x: 4,32 de:1,77). conclusión: con los resultados obtenidos se puede afirmar que los trabajadores que se desempeñan en unidades de oncología y perciben mayor riesgo psicosocial en el trabajo tienen menor satisfacción laboral, lo que podría impactar en la calidad de la atención. palabras clave (fuente decs): riesgos laborales; enfermería del trabajo; trabajadores de la salud; servicio de oncología en hospital; satisfacción en el trabajo. resumo objetivo: determinar a relação entre os fatores de risco psicossocial e a satisfação profissional dos trabalhadores que atuam em unidades de oncologia e cuidados paliativos, em determinada região do chile. materiais e método: estudo não experimental, transversal, correlacional de abordagem quantitativa. no último semestre de 2016, foi realizado um censo com 110 trabalhadores da área da saúde. para a coleta de dados, foi utilizado um instrumento que apresenta três partes: a) antecedentes biossociodemográficos; b) questionário suseso-istas 21 para riscos psicossociais e c) s20/23 para satisfação profissional. durante toda a pesquisa, foram respeitados os princípios bioéticos internacionais. resultados: existe relação com significância estatística (p ≤ 0,05) entre riscos psicossociais e satisfação profissional no trabalho; a dimensão de risco psicossocial mais prevalente são exigências psicológicas (x: 11,24; dp = 3,06) e presença dupla (x: 3,23; dp = 1,90); o fator em que é percebida menor satisfação é o ambiente físico de trabalho (x: 4,32 dp = 1,77). conclusão: com os resultados obtidos, pode-se afirmar que os trabalhadores que realizam atividades em unidades de oncologia e percebem maior risco psicossocial no trabalho têm menor satisfação profissional, fato que impacta na qualidade da atenção. palavras-chaves (fonte decs): riscos profissionais; enfermagem do trabalho; trabalhadores da saúde; serviço de oncologia em hospital; satisfação no trabalho. introduction the conditions inherent to the work are related to the type of organization and the content and execution of the task, which affect the health and well-being of the worker. they are called psychosocial risks of work (1) and are affecting many people around the world. there are countless studies that show the level of risk in the various locations, but most are descriptive and are not associated with other variables of interest such as job satisfaction (2-5), defined as an attitude or set of attitudes developed by the person in relation to his or her work situation that can be referred to the work in general itself or to its facets (6). this association is relevant to nursing given the theoretical relationship between job satisfaction and quality care (7,8). experts postulate that a healthy working environment is an important factor that improves job satisfaction and care for people. in addition to the above, it is important to point out that precarious working conditions generate exposure to psychosocial risks, work overload and imbalance between family and professional life, which affects productivity and care provision (9). on the other hand, the characteristics of work and dissatisfaction compromise the efficiency of work, causing errors, problems in exercise and depersonalization in providing care to users and family members, which in turn generates dissatisfaction and discontent (10). working conditions with high demands, little control and emotional support would result in what herzberg’s model states, which points to external causes as the root of dissatisfaction at work (11), however, no empirical evidence was found to support such a statement. the world health organization (who) states that work environments with higher psychosocial, quantitative, emotional and dual presence demands (work-family conflict) are associated with lower job satisfaction and lower quality of assistance provided (12). at the national level, since the 2013, psychosocial risk protocol evaluated their presence, however, no studies were carried out that show the importance of relating them to performance. for all these reasons, this document arises with the objective of determining the relationship between the two variables in oncology units and palliative care in a region of chile, which will contribute to the strengthening of the nursing discipline since imogene king’s interaction systems model (ism) was used as theoretical support (13). this model is composed of three systems: personal, interpersonal and social. this author highlights that each system is open and interrelated, showing that any change in one of them can impact the others through processes of action, reaction, interaction and transaction (13). material and method a non-experimental, cross-sectional and correlational study was performed, with a quantitative approach (14). in the last semester of the year 2016, 110 health professionals (professionals, technicians and administrators) from the oncology and palliative care units of the maule region, chile, were registered, corresponding to 91.66% of the total population. the participants of the study should meet the following inclusion criteria: be a member of the health team and work in oncology and palliative care units of health institutions. the following exclusion criteria were considered: being on medical leave, legal holiday or administrative permission during the data collection period. a self-applicable tool was applied in the work environment, accompanied by the responsible researcher, to solve doubts and questions. this instrument was composed of three parts: 1) bio-sociodemographic factors, elaborated by the research team; 2) the work satisfaction scale for which the s20/23 (15) was used, validated in chile and with global cronbach’s alfa of 0.92 and factors that vary between 0.76 and 0.89. this has five factors that allow us to evaluate the intrinsic satisfaction with the work, with supervision, with the physical environment, with participation in decisions and with participation in general. it is answered using a likert seven point scale format (from 1 = very unsatisfied to 7 = very satisfied). the last part is the suseso-istas 21 (16) questionnaire, adapted and validated in chile in 2008 by the school of public health of the university of chile. it is a multidimensional instrument that allows identifying and measuring the existence of psychosocial risk, its use is public for the summarized version, it is composed of 20 questions and evaluates five dimensions: psychological demands α: 0.86; active work and development of skills α: 0.86; social support in the company and quality of leadership α: 0.92; α: 0.83 and compensations of double presence α: 0.64. for the descriptive analysis of the data frequencies, intervals, means and measures of central tendency were used and to determine the relationship between s20/23 and psychosocial risk factors, pearson’s correlation was used. this research was approved by the scientific ethics committee of the catholic university of maule, chile (approval certificate num. 10/2015) and by the scientific ethics committee of the health service of maule, chile (08th october 2015 minutes). it is indicated that all ethical aspects were duly considered in order to guarantee the anonymity of the participants and the secrecy of the data obtained in this research. results in the data analysis, the spss version 23 for windows xp and the kolmogorov-smirnov (k-s) test were used to evaluate the normality of the data. regarding the descriptive data, it was obtained that the mean age of the workers participating in the study was 38 years (sd: 11.66) with variation from 22 to 65 years; 75.45% correspond to women, 73.63% have a partner and 58.18% have children; regarding the degree of schooling, 61.81% have university education (doctors, nurses, psychologists, among others) and 38.18% have non-university education (nursing and administrative technicians); finally, 48.18% had medical habilitation and 68.18% consulted a doctor in the last twelve months. table 1 shows the results regarding the psychosocial risk perceptions of health professionals participating in the study. it is observed that the workers report perception of high exposure to psychosocial risks in the dimensions psychological demands and double presence and medium perception of exposure to risks in the other dimensions. table 1. perception of psychosocial risk by dimension in oncology and palliative care workers (n =110). factors mean standard deviation risk level psychological demands 11.24 3.06 high active work and skill development 5.66 2.48 average social support in the company and quality of leadership 5.34 3.05 average compensation 3.70 2.51 average double presence 3.23 1.90 high source: own elaboration based on the research data, 2017. table 2 reports the results regarding health care workers satisfaction perception participating in the study of each dimension of the scale. the intrinsic work satisfaction factor is the one that presents the highest satisfaction with 6.87 mean (sd: 1.44). on the other hand, the satisfaction factor with the physical work environment is the lowest with 4.32 mean (sd: 1.77) table 2. oncology workers work satisfaction perception (n =110). work satisfaction factors score half standard deviation satisfaction level with supervision 5.24 1.37 a little bit satisfied with the physical work environment 4.32 1.77 indiference with decision making 5.08 1.36 a little bit satisfied intrinsic to their work 6.87 1.44 very satisfied with recognition 4.34 1.56 indiference source: own elaboration from survey data, 2017. in the table 3 shows correlations with statistical significance (p≤0.05) between the perception of psychosocial risk and work satisfaction. psychological demands, whether emotional, sensory or related to the amount of work, the necessary knowledge or the need to hide emotions (1), are related to satisfaction with recognition. table 3. pearson’s correlation between psychosocial risk factors and work satisfaction of health workers who work in oncology units (n: 110). items satisfaction with recognition satisfaction with supervision satisfaction with the physical work environment satisfaction with decision making intrinsic to work psychological demands -.189* -.065 -.132 -.144 -.142 active work -.247** -.043 -.064 -.223* -.168 social support -.272** -.563** -.198* -.260** -.153 compensation -.326** -.297** -.053 -.369** -.295** double presence -.084 -.019 .094 .008 .017 *p≤0,05 **p≤0,01. source: own elaboration from research data, 2017. the dimension of active work and the competencies development are correlated with decision making satisfaction and with recognition satisfaction. on the other hand, there is an association between the social support dimension in the company and the quality of leadership with recognition satisfaction, satisfaction with supervision, satisfaction with the physical working environment and satisfaction with decision making. the dimension of remuneration is related to recognition satisfaction, satisfaction with superiors, satisfaction with decision making and work satisfaction. regarding the double presence dimension, no correlations of statistical significance with job satisfaction factors were observed. discussion to answer the objective, the results obtained will be discussed with other studies published in health workers and with the imogene king’s interaction systems model (ism) which proposes that it is the responsibility of nursing professionals to use their knowledge and skills to help individuals to face their existential problems and to know the different ways of adapting to the daily life changes (13). another of their proposals is that each system is in balance and exchange and what can affect each of them, in this case, is the perception of the psychosocial environment. in this sense, within the psychosocial occupational risks, it is evident that the psychological demands (quantitative, emotional and cognitive) are the product of experiences related to making difficult decisions and working with users of poor prognosis such as oncologic patients and, likewise, to the double presence that is evident when the concerns of the home plus those of work fall on the same person (5, 17). both dimensions are those that the workers participating in the study perceive as the greatest exposure to psychosocial risk. as mentioned, this high level of risk is usually due to the service to oncologic users, who, due to their complexity, are generators of high physical and psychological demand (2). a similar result was reported in a study conducted in cuba where interaction with patients with poor prognosis and critical attitude towards the team, associated with cognitive demands such as healing injuries and facing clinical situations specific to the oncology specialty, increase psychological demands. similarly, ism states that high demands can affect interaction and transaction, since it is necessary for the nurse and patient to perceive a coherence of roles that contributes to the achievement of care objectives (13). on the other hand, specialists indicate that the oncology worker is exposed to stressful situations that generate diseases that would cause work absenteeism, which is reflected in the high percentage of medical consultations in the last twelve months that have caused absenteeism due to medical leave (5). another study conducted in chile reported absenteeism due to medical leave in 57.8% of the workers (17). some authors state that absenteeism should be considered as a consequence of low satisfaction, because it is associated with the overload of employees who are in replacement, which leads to lower performance, lower satisfaction and lower care quality (10,18). it is relevant to deal with high work demands, since specialists indicate that these may be associated with work accidents and occupational diseases. in this sense, the pan american health organization and the world health organization (paho/who) propose a strategic plan for the health and well-being of health professionals, whose objective is to develop programs for the identification and control of dangerous agents and risk conditions (19). it is relevant for organizations to understand the interaction systems proposed by king’s ism (personal, interpersonal and social) to facilitate transactions and decision-making with common interests (13). on the other hand, it is indicated that, due to their characteristics, this group of workers are more likely to perceive high exposure to psychosocial risks of double presence. in general, high percentages are women (75.45% in this study). due to cultural and gender aspects, domestic work and child care in latin america are the responsibility of independent women, so they have a double workload that causes fatigue and a feeling of guilt for the lack of attention to children, family and friends (20). being aware of this, the world health organization (who), concerned about the problem, recommends the reduction of working hours and flexible working hours (18), however, due to the characteristics of health work, this solution is still pending, limiting the possibility of greater participation in social and family activities (21). it is relevant to think about the future and not only increase time flexibility, but also propose public, national and international policies focused on education, in order to reduce patriarchal structures present in the education of children and to be able to grow up in equal conditions (22). as previously indicated, job satisfaction presents the best levels in the perception of intrinsic job satisfaction, which refers to performance in what you like and what stands out; similar results were reported in brazil, where the main motivation was to work as a specialist in oncology (23), a situation that is repeated in spain with people working in a university hospital (24). on the other hand, the lowest reported satisfaction is presented with the working environment conditions; this result coincides with the perception of peruvian and mexican nurses, who express dissatisfaction with the space and physical conditions (25,26). similar results are evidenced in a chilean study in which it is stated that the few or sometimes non-existent spaces assigned, without natural lighting, with regular ventilation and annoying noises caused by the equipment (27), generate dissatisfaction at work. according to the open interaction systems model, personal experiences that include concepts of self-perception, space and time, affect the process of action, reaction, interaction and personal transaction, because they must be in balance to provide care (13). in relation to the correlational analysis, the bibliographical survey shows few studies that relate the variables of psychosocial risk factors and job satisfaction in workers who work in oncology and palliative care units, which includes different groups of workers (doctors, nurses, nursing technicians and psychologist, among other professionals). by observing the results, one can affirm that workers exposed to greater psychosocial risk perceive less satisfaction at work, which coincides with the assumption made. specifically, some studies show that the greater the psychological demands, the lower the satisfaction at work with recognition. in this sense, it is proposed that the low satisfaction at work is related to characteristics of the organization such as inequality in work overload, lack of recognition (28), cognitive psychological demands and work characteristics, which compels the development of specific skills and competencies in providing care (29). this could increase the cognitive and emotional demands of workers, who also experience painful experiences of the user and suffer from stress, causing emotional wear and tear (30). according to ism, if nurses with specific knowledge and skills convey the appropriate information to the people in their care, a transaction proposal and the achievement of the objectives will be presented (13). moreover, working with insufficient material exposes the professional to make rational use of resources or to improvise, using inadequate inputs and having to resort, occasionally, to looking for them in other sectors, generating waste of time that could be used in the care of users (8). on the other hand, dissatisfaction can be generated in the worker mainly when his/her effort is not recognized by his/her superiors, when he/she perceives vulnerability of his/her rights when receiving low or unfair remuneration or when he/she works in a work environment with highly hierarchical and conflictive, authoritarian and rigid relationships, producing feelings of dissatisfaction (8). another relationship to highlight is that which arises when we perceive a greater exposure to psychosocial risk due to active work and the development of skills that include autonomy in terms of working conditions, opportunities for the development of skills, control of working hours and the importance that the company has (1), which report less satisfaction with the recognition and decision making. in this sense, in a study conducted in brazil, nurses attach great importance to autonomy in decision making because they consider they have the knowledge and technical-scientific skills necessary for a more independent performance that allows them to make decisions with clinical judgment in benefit of the user; this generates great satisfaction with the care provided (23,31). other authors point out that to achieve this behavior requires an effort by the organization, since nursing professionals must be trained in specialized technical competence in order to be committed to the management process in order to facilitate the achievement of institutional objectives (32). today, the training of these professionals is fundamental (33), considering that, due to the covid-19 pandemic, the health organizations presented deficiencies in their effective support and the health institutions have few specialists to attend the users in critical units such as oncology, emergency and intensive care. the social support dimension in the company and the quality of leadership speak of the demands of support from colleagues and superiors and the clarity of the role at work (1) and correlate with almost all dimensions of job satisfaction (recognition, superiors, physical conditions and decision-making), which shows the importance of an organizational culture that generates collaborative interdisciplinary relationships. this result shows that workers who perceive less psychosocial risk in the social support dimension have greater satisfaction at work with superiors and with the task. karasek and theorell suggest that social support acts as a buffer and indicate that it has two components: socio-emotional support, which is related to integration and trust between co-workers and supervisors, and socio-instrumental support, which is related to additional resources to help in work tasks between colleagues and supervisors (34). similar results were reported by nurses in portugal who pointed out that having social support (from supervisors and colleagues) generated positive feelings and emotions regarding their work, producing an efficient interaction and communication between doctors and nurses, which translates into providing safe care to the user (35). on the other hand, there is the social support relationship that facilitates the expression of negative feelings, minimizing feelings of loneliness and suffering and that works as a protector of the work environment. therefore, it is necessary that health professionals allocate financial and managerial resources in the training of supervisors for the development of competencies in this sense (management, advisory and supervision) (36). in a study conducted in colombia, with heads of five health centers, it was found that all levels of intra-occupational psychosocial risks lead to non-participatory leadership styles that do not favor the motivation of the subordinates, making it difficult to face the work day and producing problems in customer service (37). in addition to the above, workers who perceive insecurity regarding their employment contract and fear of the probability of not continuing perceive less satisfaction with the recognition (promotion opportunity, training and salary); this result coincides with the perception of nurses in a hematological hospital that they report few promotion opportunities (38). finally, the results report that the participating workers who perceive greater exposure to risk in the dimension of remuneration also perceive less satisfaction with their work and with their superiors. this may be related to the lack of professional rewards related to the organization of work, which require preventive measures to reduce the burden, since these workers are in permanent contact with death and suffering. studies in spain, portugal, and brazil, show that health professionals often receive compensation only when they interact with their patients, who often report pain and struggle to avoid death (36,39), and receive no economic reward or recognition from their co-workers or superiors (36,37). on the other hand, brazilian nurses express the few opportunities for promotion and the scarce endowment versus the number of users, which creates an imbalance in the effort-reward relationship and causes professional dissatisfaction, emotional exhaustion and difficulty to give assistance in a holistic and quality manner (37), affecting the interaction and transaction between nurses and patients (13). conclusions the results obtained in this research allow us to affirm that there is an association between the perception of psychosocial risk and job satisfaction, showing that the greater the exposure to psychosocial risks, the greater dissatisfaction is perceived by oncology workers, which affects work environments. this highlights the importance of a nursing professional capable of managing development and promotion activities, for which there are different theoretical models of nursing, as the open systems of interaction of imogene king. this research contributes to the identification of psychosocial risks such as high psychological demand and double presence, which reinforces existing knowledge and provides evidence for nurses responsible for care management to take preventive measures, such as the development of intervention programs in vulnerable groups through interaction, communication and transaction. on the other hand, determining the factors that generate greater job satisfaction will help nursing care managers, along with the organization, to favor conditions that increase intrinsic job satisfaction and the relationship with superiors. as a recommendation of the research team, it is suggested to broaden the analysis from a qualitative approach, from which workers can present their own experiences or meanings when working in these units. as a limitation of the study, it is recognized the difficulty of generalizing the results of the research to other latitudes or work contexts, since it is only evident the reality of the workers of oncology units that work in the public services with characteristics of work different from private and other clinical units. acknowledgements: the authors thank oncology health teams that participated in the study and the uc maule care research center for their collaboration in the development of this 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lima gomes1 pétala tuani candido de oliveira salvador2 clarissa fernandes goulart3 sumaya giarola cecilio4 maria flávia gazzinelli bethony5 metodologias inovadoras para o ensino da segurança do paciente na graduação em enfermagem: scoping review 1 https://orcid.org/0000-0003-0505-5783. universidade federal de minas gerais, brasil. andreatayse@ufmg.br 2 https://orcid.org/0000-0002-3208-6270. escola de enfermagem de natal, universidade federal do rio grande do norte, brasil. 3 https://orcid.org/0000-0002-9744-8658. universidade federal de minas gerais, brasil. 4 https://orcid.org/0000-0002-4571-8038. universidade federal de minas gerais, brasil. 5 https://orcid.org/0000-0003-0523-3973. universidade federal de minas gerais, brasil. recebido: 18/07/2019 submetido: 15/09/2019 aceito por pares: 29/11/2019 aceito: 06/12/2019 doi: 10.5294/aqui.2020.20.1.8 para citar este artigo / para citar este artículo / to reference this article gomes atl, salvador ptco, goulart cf, cecilio sg, bethony mfg. innovative methodologies to teach patient safety in undergraduate nursing: scoping review. aquichan 2020;20(1):e2018. doi: https://doi.org/10.5294/aqui.2020.20.1.8 resumo objetivo: identificar as metodologias inovadoras utilizadas para o ensino da segurança do paciente na graduação em enfermagem. materiais e método: scoping review conduzida conforme as recomendações do joanna briggs institute reviewers’ manual, por meio das bases de dados: medline/pubmed, cumulative index of nursing and allied health, scopus, web of science, education resources information center, literatura latino-americana e do caribe em ciências da saúde, catálogo de teses e dissertações da coordenação de aperfeiçoamento de pessoal de nível superior, the national library of australia’s, academic archive online, digital access to research theses europe e-theses portal, electronic theses online service, repositório científico de acesso aberto de portugal, national etd portal e theses canada. resultados: foram incluídos 19 estudos; a maioria do tipo descritivo (n = 8; 42,1 %) e quase experimental año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2018 temática: promoção e prevenção. contribuição para a disciplina: a mitigação de eventos adversos e a melhoria da segurança do paciente são objetivos fundamentais da formação em enfermagem, já que o ponto-chave é a inserção de enfermeiros capacitados para a prestação de cuidado de excelência, e pautada na prevenção de agravos. a qualidade, o conteúdo e a forma como essa educação é oferecida podem ter um impacto significativo nos comportamentos de segurança dos estudantes em seus vindouros ambientes clínicos. nesse panorama, lança-se como principal desafio a educação dos estudantes em relação aos fundamentos do cuidado seguro, de modo a favorecer o desenvolvimento de saberes e fazeres específicos, independentemente da formação técnica pretendida. portanto, é imprescindível que tal ação educativa perpasse pelo panorama clínico e pela experimentação das melhores práticas, de maneira contínua, considerando os diferentes cenários de atuação no percurso formativo dos futuros enfermeiros. https://orcid.org/0000-0003-0505-5783 mailto:andreatayse@ufmg.br https://orcid.org/0000-0002-3208-6270 https://orcid.org/0000-0002-9744-8658 https://orcid.org/0000-0002-4571-8038 https://orcid.org/0000-0003-0523-3973 https://doi.org/10.5294/aqui.2020.20.1.8 https://orcid.org/0000-0003-0505-5783 https://orcid.org/0000-0002-3208-6270 https://orcid.org/0000-0002-9744-8658 https://orcid.org/0000-0002-4571-8038 https://orcid.org/0000-0003-0523-3973 https://doi.org/10.5294/aqui.2020.20.1.8 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2018 (n = 7; 36,8 %); com abordagem quantitativa (n = 11; 57,9 %); realizados nos estados unidos (n = 4; 21,1 %), em 2013 (n = 4; 21,1 %) e em 2017 (n = 4; 21,1 %). as metodologias inovadoras utilizadas para o ensino da segurança do paciente na graduação em enfermagem que se destacaram foram o cenário de prática assistencial simulada em laboratório (n = 14; 73,7 %) e os vídeos educacionais (n = 7; 36,8 %). conclusões: identificou-se que as metodologias inovadoras utilizadas para o ensino da segurança do paciente na graduação em enfermagem foram simulação, vídeos, encenação/dramatização e filmes, todas aplicadas na modalidade de ensino presencial. palavras-chave (fonte: decs) ensino; segurança do paciente; metodologia; tecnologia educacional; educação em enfermagem. 3 metodologias inovadoras para o ensino da segurança do paciente na graduação em enfermagem: scoping review l andréa tayse de lima gomes e outros metodologías innovadoras para la enseñanza de la seguridad del paciente en el pregrado de enfermería: scoping review resumen objetivo: identificar las metodologías innovadoras utilizadas para la enseñanza de la seguridad del paciente en el pregrado de enfermería. materiales y método: scoping review realizada de acuerdo con las recomendaciones del joanna briggs institute reviewers’ manual, por medio de las bases de datos: medline/pubmed, cumulative index of nursing and allied health, scopus, web of science, education resources information center, literatura latinoamericana y del caribe en ciencias de la salud, catálogo de tesis de la coordenação de aperfeiçoamento de pessoal de nível superior, the national library of australia’s, academic archive online, digital access to research theses europe e-theses portal, electronic theses online service, repositório científico de acesso aberto de portugal, national etd portal y theses canada. resultados: se incluyeron 19 estudios; la mayoría de tipo descriptivo (n = 8; 42,1 %) y casi experimental (n = 7; 36,8 %); con enfoque cuantitativo (n = 11; 57,9 %); realizados en los estados unidos (n = 4; 21,1 %), en el 2013 (n = 4; 21,1 %) y el 2017 (n = 4; 21,1 %). las metodologías innovadoras utilizadas para la enseñanza de la seguridad del paciente en el pregrado de enfermería que se destacaron fueron: el escenario de práctica asistencial simulada en laboratorio (n = 14; 73,7 %) y los videos educacionales (n = 7; 36,8 %). conclusiones: se identificó que las metodologías innovadoras utilizadas para la enseñanza de la seguridad del paciente en el pregrado de enfermería fueron simulacro, videos, escenificación/dramatización y películas, todas aplicadas en la modalidad de enseñanza presencial. palabras clave (fuente: decs) enseñanza; seguridade del paciente; metodología; tecnología educacional; educación en enfermería. año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2018 4 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2018 aquichan issn 1657-5997 eissn 2027-5374 innovative methodologies to teach patient safety in undergraduate nursing: scoping review abstract objective: this work sought to identify the innovative methodologies used to teach patient safety in undergraduate nursing. materials and method: this is a scoping review conducted according to the recommendations by the joanna briggs institute reviewers’ manual, through the databases: medline/pubmed, cumulative index of nursing and allied health, scopus, web of science, education resources information center, latin american and caribbean literature on health sciences, catálogo de tesis de la coordenação de aperfeiçoamento de pessoal de nível superior, the national library of australia’s academic archive online, digital access to research theses europe e-theses portal, electronic theses online service, repositório científico de acesso aberto de portugal, national etd portal, and theses canada. results: the study included 19 studies, most of descriptive type (n = 8; 42.1 %) and quasi-experimental (n = 7; 36.8 %) with quantative approach (n = 11; 57.9 %), conducted in the united states (n = 4; 21.1 %), in 2013 (n = 4; 21.1 %) and 2017 (n = 4; 21.1 %). the innovative methodologies used to teach patient safety in undergraduate nursing that were highlighted included the scenario of the care practice simulated in the laboratory (n = 14; 73.7 %) and educational videos (n = 7; 36.8 %). conclusions: it was identified that innovative methodologies used to teach patient safety in undergraduate nursing were simulation, videos, staging/role playing, and films, all applied in the classroom teaching modality. keywords (source: decs) teaching; patient safety; methodology; educational technology; nursing education. 5 metodologias inovadoras para o ensino da segurança do paciente na graduação em enfermagem: scoping review l andréa tayse de lima gomes e outros introdução desde a publicação do relatório to err is human, pelo institute of medicine (iom) dos estados unidos da américa (eua), em 1999, a questão da segurança do paciente tem adquirido relevância mundial. o documento aponta que, aproximadamente, 100.000 pessoas morrem a cada ano em hospitais norte-americanos, decorrentes de eventos adversos preveníveis (1). as práticas dos profissionais de saúde têm sido marcadas por elevadas taxas de eventos adversos relacionados a procedimentos cirúrgicos, administração de medicamentos, infecções adquiridas em hospitais, lesões provocadas em pacientes, falhas nos sistemas de atendimento hospitalar, danos permanentes e mortes. práticas inadequadas, inseguras e negligentes afetam entre 3 e 16 % dos pacientes hospitalizados em países desenvolvidos (2-5). o reconhecimento dessa problemática e dos danos não intencionais causados pelos cuidados de saúde tem desencadeado múltiplas reflexões, principalmente, acerca da formação dos profissionais de saúde, que, em alguns momentos, se apresenta fragilizada por não acompanhar o ritmo acelerado de inovações na prática, as mudanças nas condições, nas diversidades e na força de trabalho impostas nas últimas décadas (6). nesse contexto, assente-se que a prevenção de eventos adversos e a melhoria da segurança do paciente são importantes aspectos a serem tratados na formação em enfermagem. a qualidade, o conteúdo e a forma como essa educação é oferecida podem ter um impacto significativo nos comportamentos de segurança dos estudantes em seus futuros ambientes clínicos (7, 8). a segurança do paciente deve ser discutida e, sobretudo, compreendida desde a graduação, lançando mão de metodologias inovadoras capazes de suscitar o pensamento crítico e reflexivo dos estudantes, uma vez que essa perspectiva é abordada pelo ministério da saúde brasileiro desde o lançamento da portaria 529, de 2013, ao relatar, em um dos seus objetivos específicos, a relevância da fomentação da inclusão do tema “segurança do paciente” no ensino técnico, no de graduação e no de pós-graduação na área da saúde (9). diante dessa realidade, em 2011, a organização mundial de saúde (oms) definiu, dentre as suas atividades, aquelas destinadas a promover o ensino relacionado aos princípios do cuidado seguro na formação dos estudantes das áreas da saúde, com o objetivo geral de realizar um atendimento clínico centrado no paciente. como objetivos específicos, foram estabelecidos: 1) preparar os estudantes da área de saúde para uma prática segura; 2) informar as instituições de ensino sobre as principais questões de segurança; 3) aprimorar os aspectos basilares atrelados à segurança do paciente como tema de todos os cursos da área de saúde; 4) fornecer um programa abrangente para auxiliar o ensino e a integração da aprendizagem da segurança do paciente; 5) incentivar o desenvolvimento de treinamento na segurança do paciente (10). para atingir esses objetivos, é imprescindível que se façam revisões críticas dos currículos para incluir, nos procedimentos aplicados ao ensino-aprendizagem, atividades voltadas à segurança do paciente, a fim de gerar mudanças disciplinares, com ênfase na integração de estratégias que colaborem para o aprimoramento de habilidades de raciocínio e para o julgamento clínico dos estudantes (10, 11). discute-se, dessa forma, a necessidade de alterações nas diretrizes curriculares nacionais (dcn) dos cursos de enfermagem do brasil que orientem a formação superior de forma abrangente às evidências contemporâneas sobre a segurança do paciente. em paralelo à relevância de atualização dos conteúdos curriculares, compreende-se a importância de as instituições de ensino superior acompanharem, também, as inovações pedagógicas que ultrapassam as formas tradicionais de ensino (12-14). essas inovações representam não somente a inserção de novidades e tecnologias no ensino, mas também incluem uma mudança na forma de entender o conhecimento. dentre as características de inovações pedagógicas, destacam-se: a ruptura com a forma tradicional de ensinar e aprender; a participação dos estudantes na definição de percursos e critérios no processo de ensino e aprendizagem; a reconfiguração de saberes, competências e vivências pessoais; a reorganização da relação entre a teoria e a prática; a transição da percepção da concepção, do desenvolvimento e da avaliação da experiência no ensino-aprendizagem (15, 16). as metodologias inovadoras envolvem o ato de oferecer, ao fazer pedagógico, novas possibilidades, atitudes e tomadas de decisão em sala de aula. ao se optar por esse tipo de recurso pedagógico, o educador poderá romper com modelos que simplesmente depositam informações e conhecimentos em seus 6 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2018 aquichan issn 1657-5997 eissn 2027-5374 estudantes. desse modo, faz-se relevante discutir sobre as metodologias de ensino inovadoras que sejam capazes de facilitar a compreensão sobre os pilares da segurança do paciente na formação em enfermagem (17, 18). diante disso, esta pesquisa teve como objetivo identificar as metodologias inovadoras utilizadas para o ensino da segurança do paciente na graduação em enfermagem. materiais e método a scoping review conduzida conforme as diretrizes do joanna briggs institute reviewers’ manual, segundo o cenário teórico levantado por autores da área (19, 20). as etapas seguidas foram: 1) elaboração da questão norteadora da scoping review; 2) identificação dos estudos pertinentes; 3) triagem dos estudos; 4) análise dos dados coletados e 5) tratamento, síntese e apresentação dos resultados. para a estruturação e execução da pesquisa, preparou-se um protocolo que continha informações concernentes ao objetivo do estudo, à população envolvida na pesquisa, à formulação da questão de pesquisa, aos critérios de elegibilidade, à estratégia e bases utilizadas para a coleta de dados, à definição de variáveis para a extração dos dados e à forma como os dados seriam sintetizados. o delineamento do objetivo e da questão de pesquisa, bem como a seleção dos descritores, das sinonímias e das palavras-chave utilizadas na coleta de dados seguiu os parâmetros da estratégia p (população), c (conceito) e c (contexto). neste estudo, a população diz respeito às metodologias inovadoras; o conceito está atrelado ao ensino da segurança do paciente, e o contexto é a graduação em enfermagem. nesse sentido, a pesquisa foi orientada pelo questionamento: quais metodologias inovadoras têm sido utilizadas para o ensino da segurança do paciente na graduação em enfermagem? inicialmente, foi realizada uma busca preliminar de possíveis estudos semelhantes nas bases de dados jbi connect+, the cochrane library e prospero, em janeiro de 2019, nas quais não foram detectados protocolos e/ou revisões publicados enquadrados em temática análoga. em seguida, buscou-se identificar as palavras-chave e as sinonímias disponíveis na literatura por meio da combinação dos descritores em ciências da saúde (decs) — palavras em português — e em medical subject headings (mesh) — termos em inglês —, componentes do mnemônico pcc desta pesquisa, em que: (p) metodologia/methodology and tecnologia educacional/ educational technology and (c) ensino/teaching and segurança do paciente/patient safety and (c) educação em enfermagem/ education, nursing. esse momento envolveu três bases de dados, a saber: literatura latino-americana e do caribe em ciências da saúde (lilacs), medline/pubmed e cumulative index of nursing and allied health (cinahl). a segunda e a terceira etapas desta scoping review (identificação e seleção dos estudos relevantes) foram executadas de janeiro a fevereiro de 2019, por intermédio das bases de dados medline/pubmed, cinahl, scopus, web of science, education resources information center (eric), lilacs, catálogo de teses e dissertações da coordenação de aperfeiçoamento de pessoal de nível superior (capes), the national library of australia’s (trove), academic archive online (diva), digital access to research theses (dart), europe e-theses portal, electronic theses online service (ethos), repositório científico de acesso aberto de portugal (rcaap), national etd portal e theses canada, a fim de pesquisar artigos, dissertações e teses que retratassem a utilização de metodologias inovadoras voltadas ao ensino do cuidado seguro na graduação em enfermagem. as estratégias de busca utilizadas nessa investigação foram: 1) para as bases de dados em língua portuguesa — (ensino or educação) and (segurança do paciente or melhoria da qualidade) and (metodologia or métodos de ensino) and (tecnologia educacional or simulação por computador or aprendizagem baseada em simulação or jogos de vídeo or tecnologia de aprendizagem or vídeo or recurso educacional aberto or filmes instrutivos e vídeo or inovações or simulação or encenação or paciente virtual or ambiente baseado em simulação) and (educação em enfermagem or estudantes de enfermagem) e 2) para as bases de dados internacionais — (teaching or education) and (patient safety or quality improvement) and (methodology or teaching methods) and (educational technology or computer simulation or simulation-based learning or video game or learning technology or video or open education resource or instructional films and video or innovations or simulation or role-play or virtual patient simulation-based environment) and (education, nursing or nursing students). 7 metodologias inovadoras para o ensino da segurança do paciente na graduação em enfermagem: scoping review l andréa tayse de lima gomes e outros os estudos foram selecionados com suporte nos respectivos critérios de elegibilidade: incluíram-se artigos científicos, dissertações e teses; publicados na íntegra em meio on-line; que discorressem sobre a utilização de metodologias inovadoras voltadas ao ensino da segurança do paciente na graduação em enfermagem. por sua vez, foram excluídos editoriais, relatos de experiência, ensaios teóricos, reflexões e revisões. não foi traçado limite temporal na busca realizada. preliminarmente, avaliaram-se o título e o resumo dos estudos identificados, com fundamentação nos critérios de elegibilidade preestabelecidos; em seguida, as publicações selecionadas foram recuperadas para a leitura completa, conforme o esquema exposto na figura 1. figura 1. esquema do processo de seleção dos estudos. belo horizonte-mg, brasil, 2019 por fim, os dados foram sintetizados de forma descritiva (n e %), com a utilização de tabelas e quadros. igualmente, os estudos foram codificados, a fim de facilitar a compreensão da disposição final dos dados, da seguinte maneira: “e” (estudo), seguido pelos algarismos arábicos 1, 2, 3, ... 19, de modo a assumir a representação e1, e2, e3, ... e19. resultados foram incluídos 19 estudos; a maioria do tipo descritivo (n = 8; 42,1 %) e quase experimental (n = 7; 36,8 %); com abordagem metodológica quantitativa (n = 11; 57,9 %); realizados nos estados unidos (n = 4; 21,1 %), na austrália (n = 3; 15,8 %) e na turquia (n = 3; 15,8 %); em 2013 (n = 4; 21,1 %) e em 2017 (n = 4; 21,1 %). o tabela 1 descreve a caracterização dos estudos que compuseram a amostra desta scoping review conforme os respectivos códigos identificadores (e1, e2, e3, ... e19), o objetivo do estudo, o país e o ano em que a pesquisa foi realizada, o tipo de pesquisa, o nível de evidência (ne) e a abordagem metodológica. todos os estudos envolveram a aplicação de metodologias inovadoras para o ensino do cuidado seguro aos estudantes da graduação em enfermagem em sua modalidade presencial, e a inovação usada com maior frequência foi a simulação (n = 14; 73,7 %), conforme apresentado na tabela 1. a tabela 2 expõe, quantitativamente, as metodologias inovadoras utilizadas, associando-as aos respectivos estudos que fizeram parte do escopo da pesquisa. tabela 1. metodologias inovadoras aplicadas ao ensino da segurança do paciente (n = 19). belo horizonte-mg, brasil, 2019 metodologias utilizadas (códigos dos estudos) n6 % cenário de prática assistencial simulada em laboratório (e1, e6, e8-e9, e10-e19) 14 73,7 vídeos educacionais (e2-e4, e7, e11, e16-e17) 7 36,8 encenação/dramatização (e3, e5, e19) 3 15,8 filmes (e8) 1 5,3 fonte: elaboração própria. 6 alguns estudos abordaram o uso de mais de uma metodologia. estudos excluídos, por não respondem á questão de pesquisa (n = 32) id en ti fi ca çã o s el eç ão el eg ib ili da de in cl uí do s estudos identificados nas bases de dados (n = 568) estudos excluídos por duplicação (n = 3) estudos selecionados para a leitura de titulo e resumo (n = 565) estudos selecionados para leitura na integra (n = 54) estudos incluidos na amostra final (n = 19) estudos excluídos por não atenderem criterios de elegibilidade (n = 511) fonte: prisma — fluxograma para scoping review (adaptado) (19). no que concerne à quarta etapa desta investigação (análise dos dados), procedeu-se à extração dos dados dos estudos incluídos na amostra final em uma planilha construída no microsoft excel 2016, de acordo com as variáveis: ano em que o estudo foi publicado, país onde a pesquisa foi realizada, objetivo da investigação, tipo de estudo, abordagem metodológica, nível de evidência (21), metodologia inovadora abordada, modalidade de ensino em que a metodologia foi utilizada, fragilidades e potencialidades inerentes à metodologia inovadora aplicada. 8 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2018 aquichan issn 1657-5997 eissn 2027-5374 tabela 2. caracterização dos estudos incluídos. belo horizonte-mg, brasil, 2019 código do estudo (referência) objetivo do estudo país (ano) tipo/ne/abordagem e1 (22) avaliar a eficácia do treinamento teórico relacionado a erros médicos e à segurança do paciente e do treinamento de simulação prática sobre os conhecimentos e níveis de habilidades dos estudantes. turquia (2018) experimental/1/ quantitativa e2 (23) determinar se o uso de um vídeo simulado por especialistas durante a pré-aprendizagem melhorou o desempenho de habilidades na simulação. estados unidos (2018) quase-experimental /2/quantitativa e3 (24) explorar a avaliação dos estudantes de bacharelado em enfermagem sobre os métodos de aprendizagem combinados para melhorar as habilidades de comunicação em enfermagem em saúde mental. noruega (2018) exploratório/2/ quantitativa e qualitativa e4 (25) examinar os efeitos do uso de vídeos educativos sobre as habilidades do estudante de enfermagem para administrar medicação parenteral. turquia (2017) quase-experimental /2/quantitativa e5 (26) descrever as respostas de estudantes de graduação de enfermagem sobre uma experiência de encenação que simulou o gerenciamento de interrupções durante a administração de medicação. austrália (2017) descritivo/4/ qualitativa e6 (27) descrever como os acadêmicos de enfermagem apreendem o cuidado voltado a pacientes em situações agudas por meio de exercícios de simulação, observação e debriefing. suécia (2017) descritivo/4/ qualitativa e7 (28) avaliar a eficácia de um programa de intervenção educacional no conhecimento de questões básicas de segurança do paciente em estudantes de graduação de uma escola de enfermagem privada que frequentam sua primeira prática clínica. chile (2017) quase-experimental /2/quantitativa e8 (29) determinar se a exposição simulada a situações de erros muda as atitudes de uma forma que pode ter um impacto positivo sobre os comportamentos de prevenção de erros. estados unidos (2016) quase-experimental /2/quantitativa e9 (30) investigar a viabilidade de gravações audiovisuais para aumentar o feedback após as simulações agudas de deterioração do paciente. austrália (2016) descritivo /4/ quantitativa e10 (31) comparar a eficácia do debriefing oral assistido por vídeo e do debriefing oral sozinho sobre comportamentos por estudantes de enfermagem de graduação durante a simulação de alta fidelidade. estados unidos (2014) quase-experimental /2/quantitativa e11 (32) avaliar o uso de um modelo de melhores práticas on-line como um complemento ao ensino de habilidades clínicas de administração de medicação oral a estudantes de graduação em enfermagem. escócia (2013) coorte/3/mista e12 (33) explorar os resultados de desenvolvimento e avaliação de um pacote de habilidades simuladas que usam uma abordagem de aprendizagem baseada em problemas com estudantes de enfermagem em geral. irlanda (2013) descritivo/4/quantitativa e13 (34) avaliar a eficácia de um workshop de habilidades clínicas sobre a administração de medicamentos para melhorar as habilidades de cálculo de dose-droga de estudantes de enfermagem do segundo ano, com o objetivo de promover a segurança na administração de medicamentos. itália (2013) descritivo/2/quantitativa e14 (35) determinar se o treinamento em simulação é um método de ensino apropriado e afetivo a ser usado para o ensino do cuidado seguro em enfermagem perinatal. turquia (2013) quase-experimental/2/quantitativa e15 (36) fornecer aos estudantes do terceiro ano do curso de graduação em enfermagem uma exposição cuidadosamente planejada para um cenário que simula uma mudança típica em um ambiente de prática. país de gales (2012) coorte/3/mista e16 (37) explorar e descrever os modos comunicativos que os estudantes empregam para coordenar a equipe em um ambiente de simulação projetado para o treinamento da equipe de ressuscitação. noruega (2011) descritivo/4/qualitativa e17 (38) investigar os processos utilizados por estudantes de enfermagem do final do curso para reconhecer e agir sobre pistas clínicas de deterioração em um ambiente simulado. austrália (2010) descritivo/4/qualitativa e18 (39) investigar os recursos de aprendizagem de um programa de simulação de computador cathsim usado para a ministração de treinamento de habilidades de cateterização intravenosa. suécia (2010) quase-experimental/2/quantitativa e19 (40) descrever como uma faculdade de enfermagem começou a integrar o ensino de segurança do paciente em experiências de simulação para estudantes de graduação em enfermagem. estados unidos (2009) descritivo/4/qualitativa fonte: elaboração própria. 9 metodologias inovadoras para o ensino da segurança do paciente na graduação em enfermagem: scoping review l andréa tayse de lima gomes e outros a tabela 3 detalha as potencialidades e as fragilidades relacionadas às metodologias inovadoras, abordadas pelos estudos analisados, usadas para o ensino do cuidado seguro aos estudantes em enfermagem. tabela 3. potencialidades e fragilidades inerentes às metodologias inovadoras utilizadas para o ensino da segurança do paciente. belo horizonte-mg, brasil, 2019 metodologias inovadoras potencialidades e fragilidades (códigos dos estudos) cenário de prática assistencial simulada em laboratório potencialidades • os estudantes podem praticar as habilidades repetidamente, até que se sintam seguros (e15, e18-e19). • permite que os estudantes desenvolvam as habilidades, com integração da teoria e da prática, e refletindo criticamente sobre seu desempenho, individual e coletivo, em um ambiente seguro (e1, e12-e13, e11, e15). • os estudantes tornam-se conscientes quanto às lacunas em seu conhecimento, o que é reconhecido durante as observações e em grupos de debriefing (e6). • permite o treinamento prático dos estudantes por meio de uma aprendizagem ativa e independente, com multimídia interativa e ferramenta de simulação de fácil manuseio. os estudantes podem ter a confiança aumentada em relação a uma habilidade específica (e18). • melhora as habilidades de comunicação entre os estudantes (e14). fragilidades • diferentes e complexos ambientes clínicos, redução do controle sobre as condições ambientais, necessidade de garantir a segurança do paciente versus necessidades de melhoria das habilidades e estresse podem afetar negativamente o processo formativo (e1). • a utilização dessa metodologia no currículo de graduação em enfermagem é demorada e requer um investimento significativo em pessoal e recursos (e8, e12). • requer uma abordagem cautelosa e cuidadosamente planejada, com tempo suficiente para que cada estudante seja observado e receba feedback (e3). • não é uma abordagem de ensino adequada a todos os estudantes. esse método não é capaz de trazer benefícios aos participantes nem aumento da confiança para a atuação em ambiente prático real (e15). vídeos educacionais potencialidades • contribuições positivas para o treinamento de habilidades com grandes grupos de estudantes (e2, e4). • o acesso ilimitado a vídeos on-line como complemento ao ensino da prática clínica está associado a uma maior aquisição de habilidades e à satisfação do estudante (e11). fragilidades • o uso pode ser associado aos métodos de ensino tradicionais, sem substituí-los no treinamento prático de habilidades clínicas. embora a eficácia do modelo de treinamento apoiado em multimídia esteja bem-estabelecida, seu uso permanece limitado (e4). encenação/dramatização potencialidades • é uma forma válida de ensino e de fácil acesso, que não é apenas agradável para a maioria dos estudantes, mas pode fornecer-lhes as conexões necessárias para usar o pensamento crítico e os julgamentos clínicos sólidos (e5). • é um método relevante, especialmente no que diz respeito à aprendizagem ativa. a filmagem da dramatização oferece uma oportunidade única para refletir sobre o próprio desempenho (e3). fragilidades • não foram apontadas fragilidades quanto ao recurso de encenação/dramatização para o ensino do cuidado seguro aos estudantes de graduação em enfermagem entre os estudos incluídos na amostra final. filmes potencialidades • a educação cinematográfica tornou os participantes mais conscientes quanto às consequências devastadoras dos erros durante a assistência à saúde. a exposição a erros por meio de filmes pode sensibilizar quanto ao risco daqueles e as possibilidades de evitá-los (e8-e9). fragilidades • não foram apontadas fragilidades quanto ao uso de filmes para o ensino de segurança do paciente aos estudantes de graduação em enfermagem entre os estudos incluídos na amostra final. fonte: elaboração própria. 10 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2018 aquichan issn 1657-5997 eissn 2027-5374 as metodologias inovadoras utilizadas para o ensino da segurança do paciente aos estudantes do ensino superior em enfermagem favorecem significativamente ao desenvolvimento de habilidades em um ambiente seguro e de forma crítica e reflexiva, desde que a execução da estratégia de ensino seja cuidadosamente planejada, principalmente em termos de tempo, pessoal e recursos materiais. discussão destaca-se que a predominância de estudos do tipo descritivo entre as pesquisas analisadas na amostra final dessa scoping review realça a recorrente necessidade de descrever a realidade de determinados fenômenos no meio científico. entretanto, isso revela a importância da produção investigativa com melhor nível de evidência, a fim de tornar os dados publicados mais confiáveis e passíveis de generalização para a aplicação no campo prático. quanto ao ensino em enfermagem, é notório que o não aprendizado das habilidades básicas dessa disciplina, associado à inexperiência, pode repercutir no aumento do risco de eventos adversos aos pacientes. logo, é evidente que os estudantes de enfermagem podem contribuir para o acontecimento de episódios indesejados, mas evitáveis, nos serviços de saúde, como morte, lesão, incapacidade ou atraso no tratamento dos pacientes, devido a erros executados durante a assistência à saúde (41, 42). tal possibilidade tem potencial para gerar medo, ansiedade, sentimento de culpa e tristeza entre os estudantes de enfermagem, afetando negativamente o seu bem-estar. também pode diminuir a motivação e o sucesso durante o transcorrer do curso, levar à alienação ou ao afastamento da profissão ou, até mesmo, resultar na saída da escola ou da profissão ainda durante o primeiro ano (42). no entanto, a busca por melhores práticas de ensino pode tornar esse processo mais prazeroso e facilitar a aprendizagem. destarte, denota-se que, ao oferecer a todos os estudantes uma oportunidade ativa de aprendizado, é possível proporcionar a experimentação de experiências consistentes e comparáveis, além de ajudar a integrar os conhecimentos teórico-práticos e as habilidades. ademais, é imprescindível que os estudantes tenham a oportunidade de repetir o treinamento com frequência, a fim de reduzir o número de erros na prática clínica e garantir a segurança do atendimento ao paciente (43). nesse panorama, lança-se a proposta de proporcionar uma educação que envolva a segurança no cuidado em saúde aos estudantes da graduação em enfermagem, de modo a favorecer o desenvolvimento de saberes e fazeres específicos, independentemente da formação técnica pretendida. esse processo educativo precisa estar presente em suas abordagens clínicas e na demonstração das melhores práticas, devendo ser permanente durante o desenvolvimento dos estudantes nos diferentes cenários que contribuem para a sua formação (9, 10, 44). diante da necessidade de atender às demandas de aprendizagem dos estudantes de enfermagem com o fim de contribuir para o cuidado seguro na assistência à saúde, tem-se a consolidação de metodologias inovadoras voltadas ao ensino, as quais, como pontua autor da área (45), possibilitam novas estratégias, mais dinâmicas e participativas, que posicionam os estudantes como atores ativos na construção de seu próprio conhecimento, apoiados por ferramentas educacionais inovadoras, como simulações, filmes, vídeos, encenações, dramatizações, entre outras. o cenário da prática assistencial simulada em laboratório ou da simulação, o qual sobressaiu entre as metodologias inovadoras utilizadas nos estudos analisados na presente pesquisa, pode ser definido como uma tentativa de simular determinada situação clínica real. a simulação é um processo de educação cognitiva e comportamental que recria uma situação real em um ambiente artificial, com o intuito de promover uma aprendizagem significativa ao estudante, livre de danos ao paciente, com custo reduzido e maior segurança e eficácia no desenvolvimento de tarefas antes nunca realizadas pelo estudante (45-48). o principal objetivo da utilização da simulação no ambiente de ensino voltado à segurança do paciente é criar ambientes reais para que os estudantes possam atuar e construir seu aprendizado simulando a execução de determinado cuidado ou ação, quantas vezes forem necessárias, seja em manequim, seja em paciente simulado, a fim de aperfeiçoar suas habilidades técnicas e gerenciais (46, 48, 49). a formação em simulação como método de ensino inovador desempenha um papel de suma importância na aprendizagem dos estudantes de enfermagem. assim, o processo formativo embasado em competências clínicas pode efetivar-se mediante a possibilidade de treinar o estudante lançando mão de técnicas e procedimentos relacionados à disciplina da enfermagem, de 11 metodologias inovadoras para o ensino da segurança do paciente na graduação em enfermagem: scoping review l andréa tayse de lima gomes e outros modo seguro, e com o apoio de docentes capacitados e disponíveis para fornecer um retorno imediato. ademais, ao experimentar a vivência nos diversos cenários da prática, os estudantes podem visualizar, executar e atribuir uma (re)significação ao que se dispuseram a aprender (50). a simulação oferece uma oportunidade para amenizar as limitações e variações nas experiências de aprendizado dos estudantes, que ocorrem durante os estágios clínicos, porquanto fornece acesso a “pacientes” padronizados de complexidade variável, de maneira a oferecer oportunidades aos estudantes de aplicar e integrar o pensamento crítico, o conhecimento e as habilidades, dentro de uma variedade de contextos e situações clínicas simuladas (51). posto isso, constata-se que o treinamento fundamentado em cenário de prática assistencial simulada em laboratório é capaz de melhorar os conhecimentos e as habilidades profissionais dos estudantes, aumentar a sensibilidade e a atenção para um comportamento direcionado a evitar erros nos serviços de assistência à saúde e a melhorar a qualidade e a segurança do paciente na assistência fornecida, o que, por consequência, colabora substancialmente para reduzir a taxa de eventos adversos evitáveis em suas práticas (22). embora essa aproximação dos estudantes com a realidade da assistência de enfermagem por meio da simulação clínica seja fundamental, ainda existem certos desafios, a começar pelo treinamento dos docentes/educadores e dos centros de ensino na busca pela excelência do ensino de enfermagem, cujo intuito final é formar enfermeiros que atendam às dcn brasileiras e que possam exercer suas habilidades de forma plena e com qualidade no cuidado e na assistência de enfermagem (48). no tocante ao uso de vídeos e filmes como apoio ao ensino da segurança do paciente na graduação em enfermagem, trata-se de tecnologias multimídias, as quais permitem demonstrar aos estudantes um conjunto de técnicas audiovisuais que facilitam uma maior e mais rápida compreensão e interpretação das ideias. além do mais, proporcionam um ambiente de aprendizado mais sensorial de forma a garantir que as informações aprendidas possam ser retidas por períodos mais longos (52, 53). apesar de os recursos multimídias apresentarem inúmeras possibilidades e potencialidades atreladas a estratégias de ensino sobre a segurança do paciente, o seu uso dispõe de algumas limitações, como a falta de feedback dos questionamentos e das dúvidas dos estudantes e a possibilidade de problemas técnicos no decurso do uso (54). quanto à utilização da encenação/dramatização no ensino da segurança do paciente aos estudantes do ensino superior em enfermagem, entende-se que é uma maneira válida e eficaz de reproduzir, com segurança, situações clínicas complexas. essa metodologia de ensino pode colaborar para uma melhor preparação dos estudantes e torná-los mais confiantes para atender pacientes em configurações reais (24, 26, 55). as metodologias inovadoras podem auxiliar expressivamente o ensino teórico-prático da segurança do paciente aos estudantes em enfermagem, conferindo-lhes a oportunidade de desenvolverem com maior efetividade e eficácia os conhecimentos e as habilidades na temática, o que reduziria os índices de eventos adversos durante os cuidados prestados ao paciente. isso porque uma das motivações para o advento de incidentes durante a assistência à saúde é a insuficiência ou a fragilidade dos componentes conhecimentos e habilidades do fator humano (56). além do desenvolvimento de competências na formação dos futuros profissionais de enfermagem, para que o cuidado seja efetivamente seguro, também se devem considerar o processo e a estrutura disponível nos serviços de saúde, tendo em vista que a ocorrência de eventos adversos é um fenômeno de ordem multifatorial e multicausal, bem como está intrinsecamente relacionada a falhas no sistema de saúde. nesse contexto, compreende-se que o ensinar e o aprender por meio de metodologias inovadoras não dependem somente de como a tecnologia é usada, ou seja, não adianta apenas trocar as tecnologias já utilizadas por elementos digitais de última geração, se não houver ponderação sobre as estratégias e os conteúdos dinamizados para sua utilização. daí, denota-se o planejamento docente como elemento fundamental para tornar o processo de ensino e aprendizagem mais fluído e efetivo (56). logo, é significativamente importante levar em consideração que a utilização da tecnologia de maneira isolada não garante uma melhor aprendizagem, já que há a necessidade de se desenvolverem ações pedagógicas que possibilitem um fazer crítico vinculado à realidade, construído na autonomia e na cooperação dos estudantes (15). 12 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2018 aquichan issn 1657-5997 eissn 2027-5374 esta scoping review foi realizada com enfoque específico no ensino da graduação em enfermagem. portanto, recomenda-se que estudos que incluam outras áreas da saúde sejam realizados, de maneira a tomar como escopo uma abordagem multiprofissional, que considere os profissionais já atuantes na prática assistencial e/ou gerencial. conclusão conclui-se que as metodologias inovadoras utilizadas para o ensino efetivo da segurança do paciente na graduação em enfermagem foram simulação, vídeos, encenação/dramatização e filmes, todas aplicadas na modalidade de ensino presencial. além do mais, observou-se que o uso de metodologias inovadoras voltadas ao ensino do cuidado seguro na graduação em enfermagem, com destaque para o cenário de prática assistencial simulada em laboratório, o qual foi predominante nesta scoping review e apresentou grande potencial para a efetividade e eficácia do processo de ensino-aprendizagem do tema. conflitos de interesses: nenhum declarado. referências 1. gonçalves n, siqueira ldc, caliri mhl. teaching patient safety in undergraduate courses: a bibliometric study. rev enferm uerj. 2017;25:e15460. doi: http://dx.doi.org/10.12957/reuerj.2017.15460 2. mendes w, pavão alb, martins m, moura mlo, travassos c. the feature of preventable adverse events in hospitals in the state of rio de janeiro, brazil. rev assoc med bras. 2013;59(5):421-8. doi: https://doi.org/10.1016/j.ramb.2013.03.002 3. sousa 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https://doi.org/10.3928/01484834-20090918-10 https://doi.org/10.1186/s12909-016-0672-7 https://www.researchgate.net/publication/277560127 https://www.researchgate.net/publication/277560127 https://doi.org/10.1186/s12909-016-0672-7 https://doi.org/10.1590/1807-57622015.0699 https://doi.org/10.11606/issn.2525-376x.v2i2p55-63 https://doi.org/10.1590/1518-8345.0000.2791 https://doi.org/10.12707/riv16074 https://periodicos.ufjf.br/index.php/enfermagem/article/view/3842 https://doi.org/10.1186/s41077-016-0009-y 15 metodologias inovadoras para o ensino da segurança do paciente na graduação em enfermagem: scoping review l andréa tayse de lima gomes e outros 50. costa rro, medeiros sm, vitor af, lira albc, martins jca, araujo ms. tipos e finalidades da simulação no ensino de graduação em enfermagem: revisão integrativa da literatura. rev. baiana enferm. 2016;30(3):1-11. doi: https://doi. org/10.18471/rbe.v30i3.16589 51. motola i, devine la, chung hs, sullivan je, issenberg bs. simulation in healthcare education: a best evidence practical guide. med teach. 2013;35(10):e1511-30. doi: https://doi.org/10.3109/0142159x.2013.818632 52. sowan ak. multimedia applications in nursing curriculum: the process of producing streaming videos for medication administration skills. int j med inform. 2014;83(7):529-35. doi: https://doi.org/10.1016/j.ijmedinf.2014.04.004 53. cooper e. nursing student medication errors: a snapshot view from a school of nursing’s quality and safety officer. j nurs educ. 2014;53(3):s51-4. doi: https://doi.org/10.3928/01484834-20140211-03 54. delen e, liew j, willson v. effects of interactivity and educational scaffolding on learning: self-regulation in online videobased environments. computers & education. 2014;78:312-20. doi: https://doi.org/10.1016/j.compedu.2014.06.018 55. lubbers j, rossman c. the effects of pediatric community simulation experience on the self-confidence and satisfaction of baccalaureate nursing students: a quasi-experimental study. nurse educ today. 2016;39:93-8. doi: https://doi. org/10.1016/j.nedt.2016.01.013 56. saygin t, keklik b. a study about causes of medical errors: isparta province sample. hacettepe journal of health administration. 2014;17(2):99-118. https://doi.org/10.18471/rbe.v30i3.16589 https://doi.org/10.18471/rbe.v30i3.16589 https://doi.org/10.3109/0142159x.2013.818632 https://doi.org/10.1016/j.ijmedinf.2014.04.004 https://doi.org/10.3928/01484834-20140211-03 https://doi.org/10.1016/j.compedu.2014.06.018 https://doi.org/10.1016/j.nedt.2016.01.013 https://doi.org/10.1016/j.nedt.2016.01.013 1 thaís araújo da silva1 maria del carmen solano ruiz2 josé siles gonzález3 genival fernandes de freitas4 identidade profissional do enfermeiro gestor à luz do modelo estrutural dialético dos cuidados 1 orcid.org/0000-0002-1218-9096. escola de enfermagem, universidade de são paulo, brasil. taarsi2@usp.br 2 orcid.org/0000-0001-8720-8397. departamento de enfermería, universidad de alicante, espanha. carmen.solano@ua.es 3 orcid.org/0000-0003-3046-639x. departamento de enfermería, universidad de alicante, espanha. jose.siles@ua.es 4 orcid.org/0000-0003-4922-7858. escola de enfermagem, universidade de são paulo, brasil. genivalf@usp.br recebido: 05/02/2019 submetido: 07/03/2019 aceito por pares: 14/05/2019 aceito: 12/06/2019 resumo objetivos: identificar, na literatura científica, as configurações identitárias inerentes às práticas gerenciais do enfermeiro que atua em ambiente hospitalar e analisá-las à luz do modelo estrutural dialético dos cuidados (medc). materiais e método: trata-se de uma pesquisa qualitativa. foi realizada uma revisão integrativa que possibilitou selecionar 15 artigos, analisados à luz do medc. resultados: a partir dos 15 artigos selecionados, foram estabelecidos três eixos temáticos: liderança, cuidado e conflitos. conclusões: conclui-se que o medc possibilitou averiguar os modelos identitários do enfermeiro, como agente gestor, nas diversas pluralidades articuladas aos processos identitários desse profissional. palavras-chave (fonte: decs) papel do profissional de enfermagem; administração de enfermagem; pesquisa em administração de enfermagem; enfermeiras e enfermeiros; enfermagem; organização e administração. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e193x tema: epistemologia. contribuição para a disciplina: esta revisão pretende promover a compreensão mais ampliada a respeito da identidade profissional do enfermeiro em seu papel gestor à luz do modelo estrutural dialético dos cuidados, o que possibilita refletir sobre suas atividades, características e singulares matizes identitárias na tentativa de contribuir em sua visibilidade na sociedade. este estudo poderá ter implicações para a gestão, para a docência e para a assistência em enfermagem. identificam-se lacunas na literatura quanto à evidência de seu papel como gestor em ambiente hospitalar. as configurações identitárias discutidas pautaram-se nas competências de liderança, no cuidado e na gestão de conflitos. esses achados revelam um vasto campo a ser explorado, uma vez que se suscita a necessidade de estudos que aprofundem a temática em questão para uma (re)definição da imagem ideal para esse profissional. doi: 10.5294/aqui.2019.19.3.5 to reference this article / para citar este artículo / para citar este artigo da silva ta, solano mdc, siles j, de freitas gf. professional identity of nurse manager in the light of the structural dialectic care model. aquichan 2019; 19(3): e1935. doi: https://doi.org/10.5294/aqui.2019.19.3.5 https://orcid.org/0000-0002-1218-9096 mailto:taarsi2@usp.br https://orcid.org/0000-0001-8720-8397 mailto:carmen.solano@ua.es https://orcid.org/0000-0003-3046-639x mailto:jose.siles@ua.es https://orcid.org/0000-0003-4922-7858 mailto:genivalf@usp.br https://doi.org/10.5294/aqui.2019.19.3.5 https://orcid.org/0000-0002-1218-9096 https://orcid.org/0000-0001-8720-8397 https://orcid.org/0000-0003-3046-639x https://orcid.org/0000-0003-4922-7858 https://doi.org/10.5294/aqui.2019.19.3.5 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e193x identidad profesional del enfermero gestor a la luz del modelo estructural dialéctico de los cuidados resumen objetivos: identificar en la literatura científica las configuraciones identitarias inherentes a las prácticas gerenciales del enfermero, que actúa en el entorno hospitalario, y analizarlas a la luz del modelo estructural dialéctico de los cuidados (medc). materiales y método: investigación cualitativa en la que se realizó una revisión integrativa que posibilitó seleccionar 15 artículos, analizados desde el medc. resultados: a partir de los artículos seleccionados, se establecieron tres ejes temáticos: liderazgo, cuidado y conflictos. conclusiones: el medc ha posibilitado averiguar los modelos identitarios del enfermero como agente gestor en las diversas pluralidades articuladas a los procesos identitarios de dicho profesional. palabras clave (fuente: decs) rol del profesional de enfermería; administración de enfermería; investigación en administración de enfermería; enfermeras y enfermeros; enfermería; organización y administración. 3 identidade profissional do enfermeiro gestor à luz do modelo estrutural dialético dos cuidados l thaís araújo da silva e outros professional identity of nurse manager in the light of the structural dialectic care model abstract objectives: to identify in the scientific literature the identity-related configurations inherent to the nurse’s managerial practices of a professional that works in a hospital setting, and to analyze them in the light of the structural dialectic care model (sdcm). materials and method: the article concerns about a qualitative research where an integrative review was made enabling the selection of 15 articles, analyzed in light of the sdcm. results: from the 15 selected articles, three thematic axes were established: leadership, care and conflicts. conclusions: it was concluded that the sdcm has made it possible to discover the nurse’s identity models as a managerial agent in the diverse pluralities articulated to the identity-related processes of such professional. keywords (source: decs): nurse’s role; nursing management; nursing administration research; nurses; nursing; organization and administration. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e193x 4 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e193x aquichan issn 1657-5997 eissn 2027-5374 introdução as profissões são atividades que surgiram por meio da singularidade dos grupos ocupacionais. estes constroem uma identidade profissional característica por intermédio de um movimento entre elementos internos e externos que incluem a trajetória histórica de cada profissão, a cultura laboral peculiar, o conhecimento específico e a linguagem peculiar (1). a identidade de uma profissão está ancorada na identificação social e está situada nos intervalos dinâmicos entre a identidade social atribuída pelos outros e a identidade social atribuída para os outros. para tanto, ela não pode ser confundida com a identidade pessoal ou com a identidade de grupo (identidade de pertença coletiva) (2, 3). tal conceito, quando levado para a área da enfermagem, mais em específico para os profissionais enfermeiros que atuam em cargos de chefia, deriva-se em uma pluralidade identitária em torno desse profissional. ao longo da trajetória histórica da enfermagem, seus pressupostos epistemológicos foram e vêm sendo transformados na tentativa de (re)modelar o contexto da saúde e do cuidado (4, 5). nesse aspecto, muito se discute acerca das configurações identitárias do enfermeiro atuante em diversos contextos, visto que abordar a referida temática “implica transitar por uma série de acontecimentos conjugados ao longo do tempo” (6:2), o que possibilita avistar as incompreensões acerca das atividades desenvolvidas pelos enfermeiros (7, 8). as nuances identitárias do enfermeiro estiveram alicerçadas na simbologia da vocação, uma vez que sua formação esteve voltada para a conduta moral, por vezes, até em detrimento do conhecimento (9). as atividades do enfermeiro confluem em ações não somente cuidativas, mas também nas condutas gerenciais que, de certa forma, estão relacionadas ao papel e às atribuições do referido profissional. estruturar os atributos identitários do enfermeiro gestor requer minuciosas análises fundamentadas em metodologias científicas. nessa direção, é possível utilizar os conceitos do modelo estrutural dialético dos cuidados (medc), visto que seus princípios se fundam em estruturas sociais por meio do processo de socialização; portanto, é possível averiguar os padrões estéticos dos cuidados pela ótica do profissionalismo, do humanismo, do tecnologicismo, entre outros, e, assim, transpor tais conceitos para a lógica da identidade profissional (10), o que possibilita refletir acerca do objeto de estudo em uma dimensão cultural históricocontemporânea. isso posto, este estudo tem como objetivo identificar, na literatura científica, as configurações identitárias inerentes às práticas gerenciais do enfermeiro que atua em ambiente hospitalar e analisá-las à luz do medc. materiais e método trata-se de uma pesquisa qualitativa. foi realizada uma revisão integrativa como método para atingir o objetivo do estudo, uma vez que ela permite criticar, avaliar, sintetizar e vislumbrar evidências inerentes às temáticas (11). dessa maneira, foram realizadas seis etapas. a primeira foi a identificação do tema e a seleção da questão de pesquisa: “de acordo com as contribuições estruturais do medc, quais são os modelos identitários de enfermeiros que desempenham ações gerenciais em instituições hospitalares?” a segunda etapa consistiu nos critérios de inclusão e exclusão (figura 1). assim, foram considerados critérios de inclusão: publicações em português, inglês ou espanhol, sem restrição de tempo de publicação. como critérios de exclusão: publicações repetidas, estudos reflexivos, resumos, editoriais, capítulos e livros, teses, dissertações, trabalhos de conclusão de curso e estudos que não abordassem o tema proposto. as demais etapas consistiram em definir as informações a serem extraídas dos estudos selecionados, avaliar os estudos eleitos, interpretá-los e apresentar os dados encontrados (11). o levantamento das produções foi realizado em novembro de 2018 por meio da consulta ao portal da biblioteca virtual em saúde (bvs), na base de datos bibliográfica sobre cuidados de salud en iberoamérica (cuiden) e na pubmed; em fevereiro de 2019, nas bases de dados da scopus e web of science. para a seleção dos estudos, foram utilizados os descritores em ciências da saúde (decs) e as palavras-chave, com os quais foi possível realizar uma busca avançada a partir do operador 5 identidade profissional do enfermeiro gestor à luz do modelo estrutural dialético dos cuidados l thaís araújo da silva e outros booleano “[and]”, com os descritores em espanhol para a cuiden e a bvs: rol de la enfermera, administración de enfermería and enfermeros; com filtro: disponível e como assunto principal: papel do profissional de enfermagem. na pubmed, a estratégia de busca ocorreu com os seguintes descritores: nurse’s role, hospital administration, hospitals e nurses. já na scopus, a estratégia foi feita dessa forma: nurse’s and role and organization and administration and nurses; com os filtros: enfermagem; somente artigos; disponíveis na íntegra e com a palavra-chave: “organization and management”. na web of science, a estratégia foi realizada da seguinte maneira: nurse’s role and (“hospital administration” or “hospitals administration” or “hospital management” or “hospitals management”) and nurses. dessa forma, foram encontrados 226 artigos, dos quais foram selecionados 15 que compuseram os critérios de inclusão previamentes estabelecidos (figura 1). figura 1. esquema representativo do processo de busca e exclusão de artigo após busca, exclusão e seleção de artigos, houve a codificação e a identificação dos selecionados, como apresentado no quadro 1. os artigos selecionados foram analisados sob a ótica do medc. tal modelo foi construído fundamentando-se nas contruibuições do funcionalismo e do estruturalismo. todavia, sua origem advém da tese intitulada estrutura familiar e função social da mulher em alicante 1868-1993. os eixos do referente método, para a análise dos dados, são subdivididos em unidade funcional (uf), marco funcional (mf) e elemento funcional (ef) (10). a uf se detém na estrutura social básica de socialização, na qual congrega elementos referentes às crenças, aos valores, aos sentimentos e aos conhecimentos. “cada um deles incide em uma forma determinada de organizar e fundamentar a enfermagem: doméstica, religiosa, técnica, profissional humanista” (10:303). no mf, reúnem-se as informações relacionadas aos cenários, aos espaços ou aos lugares onde são desenvolvidas as atividades de enfermagem, como: hospitais, ambulatório, clínicas, entre outros (10). o ef agrupa os dados referentes às pessoas envolvidas no cenário socializador e que são responsáveis pelo cuidado (10). as estruturas do medc estão agrupadas no quadro 2 e representam os padrões estéticos na história cultural da enfermagem. nesse sentido, após a leitura e a releitura dos artigos eleitos, foi possível responder à questão norteadora proposta neste estudo. resultados quinze artigos compuseram a amostra desta revisão de literatura. a partir deles, foi possível identificar os componentes da metodologia do medc — a uf, o mf e o ef —, como apresentado no quadro 3. dos 15 artigos eleitos, 9 tiveram como enfoque central a liderança; 5, o cuidado, e 4, os conflitos. os estudos que abordam a temática liderança (t1, t2, t3, t4, t5, t6, t7, t14 e t15) trazem matizes acerca da referida competência, o que evidencia que a maioria dos enfermeiros que atua em cargo de chefia e de liderança é do sexo feminino, e que boa parte tem um ou nenhum filho. alguns estudos apresentam aspectos positivos e negativos relacionados às deficiências na liderança ou à falta dela. artigos identificados nas bases de dados consultadas (n = 226) cuiden: (n = 52) bvs: (n = 101) pubmed: (n = 50) scopus: (n = 21) web of science: (n = 2) 1ª exclusão: registros duplicados (6) (n = 220) 2ª exclusão mediante leitura dos títulos e dos resumos que não atenderam aos objetivos do presente estudo (79) (n = 141) 3ª exclusão após a leitura dos textos completos. foram excluídos artigos que não respoderam à questão norteadora (126) (n = 15) fonte: elaboração própria. 6 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e193x aquichan issn 1657-5997 eissn 2027-5374 quadro 1. codificação e apresentação dos artigos selecionados, seguidos do número apresentado pela ordem da seleção cód. autor/título periódico / ano base de dados país t1 fabriz la, eduardo ea, poliquese cb, veran mp, oliveira vc, bernardino e. competências necessárias para o gerenciamento na prática do enfermeiro: revisão integrativa (12) rev enferm ufpe. 2014 cuiden brasil t2 almeida ml, segui mlh, maftum ma, labronici lm, peres am. instrumentos gerenciais utilizados na tomada de decisão do enfermeiro no contexto hospitalar (13) texto contexto enferm. 2011 cuiden brasil t3 kian ko, matsuda lm, waidmann map. compreendendo o cotidiano profissional do enfermeiro-líder (14) rev rene. 2011 cuiden brasil t4 santos i, castro cb. características pessoais e profissionais de enfermeiros com funções administrativas atuantes em um hospital universitário (15) rev esc enferm usp. 2010 cuiden brasil t5 alecrim js, campos lf. visão dos técnicos e auxiliares de enfermagem sobre o estilo de liderança do enfermeiro (16) cogitare enferm. 2009 cuiden brasil t6 castro cb, santos i. estilos e dimensões do comportamento de liderança de enfermeiros líderes do cuidar em saúde (17) rev min enferm. 2008 cuiden brasil t7 gindri l, medeiros hmf, zamberlan c, costenaro rgs. a percepção dos profissionais da equipe de enfermagem sobre o trabalho dos enfermeiros (18) cogitare enferm. 2005 cuiden brasil t8 silva rcc, mendes da, ximenes neto frg, cunha icko. gerenciamento em enfermagem: atividades exercidas por enfermeiros que atuam nas unidades de cuidado (19) paraninfo digital. 2011 cuiden brasil t9 nóbrega-therrien sm. a enfermeira e o exercício do poder da profissão: a trama da ambiguidade (20) acta paul enferm. 2004 bvs brasil t10 giordani jn, bisogno sbc, silva laa. percepção dos enfermeiros frente às atividades gerenciais na assistência ao usuário (21) acta paul enferm. 2012 bvs brasil t11 santos jlg, lima mads, klock p, erdmann al. concepções de enfermeiros sobre gerência do cuidado em um serviço de emergência: estudo exploratório-descritivo (22) study online brazilian journal of nursing. 2012 bvs brasil t12 lampert na, kinalski ddf, machado bp, lima sbs. conflitos gerenciais: dificuldades para o enfermeiro gerente (23) reas. 2013 bvs brasil t13 musa mb, rashid mdo, sakamoto j. nurse managers’ experience with ethical issues in six government hospitals in malaysia: a cross-sectional study (24) bmc medical ethics. 2011 pubmed malásia t14 stetler cb, ritchie ja, malone jr, charns mp. leadership for evidence-based practice: strategic and functional behaviors for institutionalizing ebp (25) worldviews evid based nurs. 2014 scopus estados unidos t15 weber e, ward j, walsh t. nurse leader competencies: a toolkit for success (26) nurs. manage. 2015 scopus estados unidos fonte: elaboração própria. 7 identidade profissional do enfermeiro gestor à luz do modelo estrutural dialético dos cuidados l thaís araújo da silva e outros quadro 2. estruturas e padrões estéticos na história cultural da enfermagem quadro 3. artigos selecionados dentro dos critérios de inclusão, sob a perspectiva do medc fonte: siles (27). cód. autor/ano unidade funcional (uf) marco funcional (mf) elemento funcional (ef) t1 fabriz la, eduardo ea, poliquese cb, veran mp, oliveira vc, bernardino e, 2014 identidade profissional / competências — liderança hospitais privados e públicos enfermeiro gestor t2 almeida ml, segui mlh, maftum ma, labronici lm, 2011 identidade profissional / instrumentos gerenciais: liderança, mediação de conflitos hospital de ensino público enfermeiros assistenciais e gerenciais t3 kian ko, matsuda lm, waidmann map, 2011 identidade profissional/percepção do trabalho do enfermeiro-líder hospital de ensino enfermeiros que exerceram cargo de chefia e/ou supervisão t4 santos i, castro cb, 2010 identidade profissional/liderança hospital universitário enfermeiros que exercem funções administrativas t5 alecrim js, campos lf, 2009 identidade profissional/estilos de liderança hospital filantrópico enfermeiros t6 castro cb, santos i, 2008 identidade profissional/ comportamento de liderança hospital federal enfermeiros t7 gindri et al., 2005 identidade profissional/articulação assistencial e administrativa hospital filantrópico enfermeiro t8 silva et al., 2011 identidade profissional/trabalho gerencial com enfoque no cuidado hospital enfermeiros t9 nóbrega-therrien, 2004 identidade profissional/apreensão e compreensão do poder no cuidado e na gestão hospital enfermeiras com experiência na assistência e em cargos de gestão unidade funcional marco funcional elemento funcional padrão estético de cuidados e sentimentos nos quais se fundamenta evolução histórica tribo animismo acampamento/ caverna mulher feiticeiro bruxa tribal (maternidade, magia) pré-história família lar mulher familiar (maternidade) antiguidade mitos religião templo hospital religioso sacerdote/sacerdotisa deus/deuses religiosos/religiosas religioso (caridade, altruísmo) idade média renascimento corporação/família/ profissional ambulatorial hospital profissional centro de saúde profissão profissional (tecnicismo, cientificismo, profissionalismo) século xviii revolução industrial contemporaneidade 8 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e193x aquichan issn 1657-5997 eissn 2027-5374 na categoria cuidado, foram encontrados os estudos t7, t8, t9, t10 e t11, que trazem outra dimensão identitária encontrada nas atividades do enfermeiro gestor. boa parte aponta a importância do enfermeiro de articular assistência e gestão. o eixo conflitos foi evidenciado em quatro estudos (t2, t11, t12 e t13). alguns apontaram para a necessidade e as dificuldades das relações interpessoais, que impactam no gerenciamento dos conflitos. as categorias citadas (liderança, cuidado e conflitos) foram subsidiadas pelo medc, o qual auxiliou na identificação das nuances identitárias do enfermeiro como agente gestor. discussão a identidade profissional do enfermeiro gestor tem sido colocada aqui como principal objeto de investigação da uf, articulada ao contexto hospitalar (mf) e ao ef — enfermeiro gestor/assistencial. o tema liderança é largamente discutido, visto que a maioria dos artigos eleitos denotou tal competência, o que salienta que esse saber integra consideravelmente as habilidades vitais e essenciais do enfermeiro. a liderança, tratada aqui como uma das nuances identitárias do enfermeiro, atém-se à uf que, como visto, constituti uma estrutura básica social que congrega, nesse caso, valores, sentimentos e conhecimentos. para liderar, é necessário possuir habilidades que permitam que o grupo busque objetivos comuns, exercendo influência com ações intencionais sobre seus seguidores, o que propicia transformações no ambiente de trabalho (28-30). os valores são qualidades percebidas pela essência manifestada, como por exemplo, em uma obra de arte, a melodia de uma música, a ternura de uma mãe que cuida de seus filhos (31) e, nesse caso, no profissionalismo do enfermeiro que detém o conhecimento técnico-científico para poder liderar. assim, o conjunto de valores pelo qual a liderança perpassa concentra-se em autodisciplina, honestidade, compromisso e crescimento mútuo, e não deve ser confundida com postura de poder e de autoridade (32). a práxis da liderança auxilia o enfermeiro na tomada de decisão (33) e no reconhecimento profissional (13), embora isso possa estar voltado a ser aceito pelas pessoas e à popularidade do líder (16). importante salientar que as competências do enfermeiro no brasil, reconhecidas pelas diretrizes curriculares nacionais (dcn), consideram a educação permanente, a comunicação, a administração e o gerenciamento, a tomada de decisão, a atenção à saúde e a liderança como habilidades gerais e específicas para o trabalho do enfermeiro (34). cód. autor/ano unidade funcional (uf) marco funcional (mf) elemento funcional (ef) t10 giordani jn, bisogno sbc, silva laa, 2012 identidade profissional/cuidado direto e indireto hospital geral enfermeiros t11 santos et al., 2012 identidade profissional/gerência do cuidado e dos conflitos hospital universitário enfermeiros t12 lampert na, kinalski ddf, machado bp, lima sbs, 2013 identidade profissional/conflitos gerenciais hospitais enfermeiros t13 musa mb, rashid mdo, sakamoto j, 2011 identidade profissional/conflitos éticos hospitais enfermeiro gerente t14 stetler cb, ritchie ja, malone jr, charns mp, 2014 identidade profissional/estratégias de liderança hospital enfermeiros t15 weber e, ward j, walsh t, 2015 identidade profissional/modelo de liderança hospital enfermeiros fonte: elaboração própria. 9 identidade profissional do enfermeiro gestor à luz do modelo estrutural dialético dos cuidados l thaís araújo da silva e outros nesse sentido, denota-se que o enfermeiro necessita possuir e desenvolver características identitárias pautadas na liderança, uma vez que essa competência é abordada antes mesmo de ele atuar efetivamente em sua área. acredita-se que o trabalhador da enfermagem desenvolve sua identidade profissional antes mesmo de entrar na enfermagem, sendo transformada com anos de estudos e experiência clínica, evoluindo ao longo da carreira. a educação e a pesquisa científica são retratos dessa identidade manifestada e, simultaneamente, influenciam tal construção. a constituição de um conjunto de conceitos, desenvolvidos por cada profissional referentes ao papel da enfermagem na sociedade pode ser trabalhada para a conservação de alunos e enfermeiros nos serviços de saúde. (35:2) cabe evocar que a identidade profissional dos enfermeiros inicia na graduação, mas é construída e consolidada a partir da sua atuação no campo do seu saber, diante das interações realizadas no espaço pelo qual exerce sua função, ao interagir com os demais atores inseridos no mesmo cenário (36), pois, ao atuar, o profissional aflora modelos identitários que são mediados pela dinâmica das transações biográficas e relacionais (2, 3, 37). logo, “a identidade nunca é dada, ela sempre é construída e deverá ser (re)construída em uma incerteza maior ou menor e mais ou menos duradoura” (2:135). o ef, na categoria liderança, aponta para os atores sociais responsáveis pelas atividades desenvolvidas pelos profissionais. a maioria dos estudos eleitos no presente estudo indica que é o enfermeiro quem possui adequada competência para liderar, mesmo na visão dos componentes que interagem com ele durante sua atuação, como, no caso, os auxiliares e os técnicos de enfermagem, como demonstram os estudos t5 e t7. cabe pontuar que os auxiliares e os técnicos de enfermagem são profissionais com formação escolar completa que realizaram curso específico para atuar na referida profissão. os auxiliares exercem atividades de nível médio que envolvem “serviços auxiliares de enfermagem sob supervisão, bem como a participação em nível de execução simples, em processos de tratamento”. o técnico de enfermagem também exerce atividade de nível médio, porém realiza atividades que envolvem “orientação e acompanhamento do trabalho de enfermagem em grau auxiliar, e participação no planejamento da assistência de enfermagem” (38:9273). como dito dantes, a maioria dos estudos selecionados na uf liderança apontou para o grande contingente de enfermeiro do sexo feminino. nesse sentido, é indispensável rememorar fatores relacionados ao gênero que podem, de certa forma, contribuir para os problemas no processo de liderança e da identidade profissional. as questões de gênero no contexto da enfermagem definem, muitas vezes, o padrão estético profissional por conta do “conformismo lógico” que se estabeleceu ao longo da trajetória histórica da referida área em uma perspectiva cultural (31) em que o cuidado era adequado somente para as mulheres, pois, muitas vezes, foram enfatizadas as características da mulher/enfermeira no quesito subserviência, doçura e feminilidade, ora legitimadas pela igreja, ora pelo estado, contribuindo, portanto, para a invisibilidade do trabalho profissional do enfermeiro por estar atrelado às vicissitudes causais em virtude do gênero. sob essa ótica, a história da enfermagem foi contada por meio das variadas disciplinas como a sociologia, a medicina e a história, que ora enfatizavam os caracteres de cunho religioso e de subalternidade, ora de imoralidade e profanidade. tal história não havia ainda sido contada pelas mulheres que atuavam efetiva e ativamente na profissão, o que ocasionou um imaginário social que levou ao irreconhecimento identitário da profissão do enfermeiro (39). sabe-se que as concepções de gênero, as percepções e as identidades muitas vezes são construídas por meio de estereótipos. dessa forma, ações e habilidades são designadas para cada indivíduo dentro de uma sociedade e cultura; o papel de líder é um deles, visto que muitas sociedades apontam o indivíduo do sexo masculino com maior capacidade para atuar nessa posição, e que as mulheres devem estar voltadas para os cuidados (40, 41). é relevante destacar que há grande presença de mulheres em cursos voltados para a saúde e a educação (áreas biológicas e humanas), enquanto há um maior contigente de homens nas áreas exatas (42, 43). destarte, no cerne liderança, articulando o objeto de estudo identidade profissional ao medc, a uf revela que tal prática é tratada como imprescindível competência do enfermeiro, que necessita de compreensão e percepção dessa habilidade por parte dos atores que se socializam com ele, para que desempenhe essa incumbência em consonância com um adequado modelo, estilo, 10 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e193x aquichan issn 1657-5997 eissn 2027-5374 comportamento e estratégias liderais, de acordo com a realidade prescrita, independentemente da área de sua atuação nos diversos mfs, públicos, de ensino, universitários, filantrópicos ou federais, e independentemente se ele realiza atividades gerenciais ou assistenciais, como visto no ef. adentrando na categoria cuidado, é relevante evidenciar que a enfermagem, considerada uma das artes mais antigas e a ciência mais moderna, é conhecida pelos marcos pré-profissionais e profissionais (44). a enfermagem está intrinsecamente enredada no campo dos cuidados, os quais, inicialmente, foram denotados por meio das ações de sobrevivência para perpetuar e preservar a espécie (45). os cuidados foram moldados de acordo com o padrão social de cada época e de cada cenário, que trouxeram lacunas na perspectiva do profissionalismo, uma vez que a gênese das práticas dessa área se reclinava às ideologias religiosas e maternais (46). tal cenário é observado desde os primórdios da conclamada enfermagem moderna (45), quando florence nightingale alegou ter recebido um “chamado de deus” para cuidar dos soldados feridos em um hospital militar inglês (47). o processo histórico-cultural do cuidado na enfermagem passou por diversas transformações. inicialmente, os sentimentos e os valores nessa área estavam alicerçados na estética dos cuidados maternos. com o advento do pensamento crítico e feminista, a referida profissão passou por um processo de desconstrução (48) no qual, progressivamente, sentimentos e valores se assentaram na ciência, na tecnologia e no profissionalismo (31). o hospital, no prisma do mf, constitui espaço primordial quando se trata da ideologia do cuidar em enfermagem, cuja estética responde às características da uf. a própria sociedade associa a imagem do enfermeiro como agente cuidador que atua prioritariamente em ambiente hospitalar. é certo que muitos enfermeiros desenvolvem suas atividades profissionais nesse âmbito, mas o cuidado não deve remeter somente a esse mf, seja ele filantrópico, geral, seja universitário, haja vista que o enfermeiro pode desempenhar as atividades assistenciais em diversas áreas, inclusive no âmbito da promoção e da prevenção à saúde. a uf, nesse eixo, aponta para as matizes identitárias do enfermeiro na lógica da articulação da assistência com a gerência e do cuidado direto e indireto, dado que o cuidado representa uma forma de “poder curativo”, conforme elencado nesse componente do medc, especificamente realçado no estudo t9. é relevante destacar que a compreensão do “poder” dos enfermeiros no estudo t9 elenca que atuar na gestão traz visibilidade ao enfermeiro, contudo isso somente ocorre porque este exerce uma atividade administrativa que o legitima. sua ação na assistência também elenca o sentido do “poder da cura”, porém, ainda assim, tal elemento é quase invisível no presente mf — o hospital. o ef, nessa categoria, revela que o cuidado é desenvolvido e percebido pelos pares sociativos envolvidos no protagonismo do enfermeiro em ação. tal unidade exprime “a motivação dos cuidados pré-profissionais e profissionais, a partir de uma estética que é produto da convivência e do processo de socialização do grupo” (31:6), o que permite desvendar os papéis, as normas, os valores, as crenças, dentre outros. na vertente conflitos, de um modo geral, inserem-se as relações interpessoais, visto que as ações atitudinais e dialógicas podem entrar em divergência. para tanto, a uf revela que uma das características identitárias do enfermeiro é mediar/gerenciar os conflitos no mf proposto — hospital — seja ele universitário, seja de ensino público. os conflitos ocorrem quando existem incompatibilidades externas e internas, pelo fato de haver diversas formas de pensar e diversos sentimentos, valores e crenças em cada indivíduo (49-51). por ser o profissional incumbido da gerência dos serviços e da mediação da relação entre os profissionais, em seu ambiente de trabalho, o enfermeiro está passível de se ver diante de conflitos entre os profissionais geridos e vir a ser o mediador da resolução destas situações. (49:420) os conflitos sociais estão associados aos atores sociais que configuram o ef, fundalmentamente relacionados às identidades culturais e não somente por seus interesses estratégicos. muitas vezes, o gerenciamento de conflitos dentro do respectivo mf (hospital) pode levar o enfermeiro ou sua equipe à insatisfação e à frustração. isso pode impactar na identidade profissional do enfermeiro, pois podem sobressair sentimentos duais no sentido de saber que profissional ele é e qual é o lugar 11 identidade profissional do enfermeiro gestor à luz do modelo estrutural dialético dos cuidados l thaís araújo da silva e outros dele em um determinado espaço, além de surgir questionamentos internos relacionados à carência da necessidade de realizar suas aspirações assistenciais e gerenciais (52). são momentos como os apresentados acima que o profissional pode vir a experenciar uma crise identitária (2), visto que suscita uma sensação de desvalorização. portanto, é fundamental compreender como ocorrem os movimentos transacionais inerentes à representação de uma profissão na tentativa de evidenciar uma imagem identitária ideal do enfermeiro. conclusões este estudo teve como principal objetivo identificar, na literatura científica, as configurações identitárias inerentes às práticas gerenciais do enfermeiro que atua em ambiente hospitalar e analisá-las à luz do medc. a partir disso, conclui-se que o medc e seus constructos estruturais (uf, mf e ef) oferecem subsídios para compreender a temática em questão, visto que, sem a ação socializadora das referidas unidades vinculadas entre si, muitas vezes, não é possível perceber as nuances identitárias pelas quais perpassam as singularidades do enfermeiro em seu papel gerencial e cuidativo. assim, a análise na ótica do medc possibilitou despontar três temáticas (liderança, cuidado e os conflitos), o que permitiu realizar uma discussão crítico-reflexiva sobre o trabalho e a identidade profissional do enfermeiro gestor. assim, conclui-se que o medc possibilitou averiguar as matizes identitárias do enfermeiro, enquanto agente gestor, nas diversas pluralidades articuladas ao processo de trabalho desse profissional. conflito de interesse: nenhum declarado. referências 1. diniz m. os donos do saber: profissões e monopólios profissionais. 1ª ed. rio de janeiro (rj): revan; 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this article derives from the dissertation entitled "competencia interpersonal del docente de enfermería: génesis e influencias mutuas en la formación del estudiante de enfermería", doctorate program in nursing, nursing school, universidad nacional de colombia. available from: https://repositorio.unal.edu.co/handle/unal/78501 received: 05/01/2021 sent to reviewers: 25/05/2021 approved by reviewers: 20/09/2021 accepted: 01/10/2021 topic: epistemology. contribution to the discipline: concept analyses are considered theoretical research because they contribute to advancing nursing knowledge. in this case, the concept of interpersonal skills in nursing makes the core relational aspects of nursing visible and defines the characteristics of a professional within practice. para citar este artículo / to reference this article / para citar este artigo: rojas j, rivera ln. concept analysis of interpersonal skills in nursing. aquichan. 2022;22(1):e2213. doi: https://doi.org/10.5294/aqui.2022.22.1.3 abstract objective: to determine a broad definition of the term interpersonal skills in nursing. materials and methods: this theoretical study follows walker and avant's method of concept analysis to examine the defining attributes of the concept. a literature search on interpersonal aspects of nursing was conducted in databases, e-books, and institutional repositories to recognize the uses, attributes, antecedents, consequences, and empirical referents of the concept. experts on professional and relationship skills were consulted between 2009 and 2019. results: this information was analyzed, concluding that interpersonal skills in nursing are defined as the abilities of professional nurses to express their knowledge, abilities, attitudes, and values in relationships with colleages, patients, and their relatives and achieve a humane and person-centered practice. conclusion: the concept of interpersonal skills in nursing is limited, given a lack of clarity in practice and research on the indistinct use of terms related to interpersonal skills and interpersonal knowledge. this analysis advances nursing theory towards practice and research. keywords (source mesh): nursing theory; professional competence; nursing; interpersonal skills; interpersonal relations; nursing research. resumen objetivo: determinar una definición amplia del término competencia interpersonal en enfermería. materiales y métodos: en el presente estudio teórico, se aplica el método de análisis de conceptos de walker y avant para examinar los atributos definitorios del concepto. se realizó una búsqueda bibliográfica sobre aspectos interpersonales de la enfermería en bases de datos, libros electrónicos y repositorios institucionales para reconocer los usos, los atributos, los antecedentes, las consecuencias y las referencias empíricas del concepto. además, se consultó a expertos en habilidades profesionales y relacionales entre 2009 y 2019. resultados: se analizó esta información y se concluyó que la competencia interpersonal en enfermería se define como la habilidad de los enfermeros profesionales para expresar sus conocimientos, destrezas, actitudes y valores en las relaciones con los colegas, los pacientes y sus familiares a fin de lograr una práctica humana y centrada en la persona. conclusión: el concepto de competencia interpersonal en enfermería es limitado, dada la falta de claridad en la práctica y la investigación sobre el uso indistinto de términos relacionados con la competencia interpersonal y el conocimiento interpersonal. el presente análisis lleva la teoría de la enfermería hacia la práctica y la investigación. palabras clave (fuente: mesh): teoría de enfermería; competencia profesional; enfermería; habilidades interpersonales; relaciones interpersonales; investigación en enfermería. resumo objetivo: determinar uma definição ampla da expressão "competência interpessoal em enfermagem". materiais e métodos: neste estudo teórico, é aplicado o método de análise de conceitos de walker e avant para examinar os atributos que definem o conceito. foi realizada busca bibliográfica sobre aspectos interpessoais da enfermagem em bases de dados, livros eletrônicos e repositórios institucionais para reconhecer os usos, os atributos, os antecedentes, as consequências e as referências empíricas do conceito. além disso, especialistas em habilidades profissionais e relacionais foram consultados entre 2009 e 2019. resultados: as informações foram analisadas e concluiu-se que a competência interpessoal em enfermagem é definida como a habilidade dos enfermeiros profissionais de expressar seus conhecimentos, destrezas, atitudes e valores nas relações com os colegas, com os pacientes e seus familiares a fim de atingir uma prática humana e focada na pessoa. conclusões: o conceito de competência interpessoal em enfermagem é limitado, tendo em vista a falta de clareza na prática e na pesquisa sobre o uso indiscriminado de termos relacionados com competência interpessoal e conhecimento interpessoal. esta análise leva a teoria da enfermagem à prática e à pesquisa. palavras-chave (fonte mesh): teoria de enfermagem; competência profissional; enfermagem; relações interpessoais; pesquisa em enfermagem. introduction nursing competence comprise knowledge, abilities, attitudes, and behaviors integrated into and aimed at holistic care (1). this competence is not innate but developed in a complex process to which the environment and internal motivations contribute. nursing competence is a multidimensional concept; its attributes include professional values, critical judgment, leadership, and effective interpersonal relationships (1, 2), the latter being the most relevant considering the growing need for human care in the world. developing behaviors aimed at establishing optimum interpersonal relationships do not always occupy essential places in institutional or educational nursing programs (3), in addition to the fact that nursing professionals with little experience find it difficult to put into practice effective methods to build up relationships with care recipients (3). therefore, the need for interpersonally competent nurses is explicit. then, care as affection and interpersonal relationship (4) shows that these aspects are the most important for interpersonal skills in nursing. care as affection reflects the emotional commitment to the other, and care as an interpersonal relationship is the essence of caring; it is the means through which the other is reached, which requires a genuine interest in the welfare of the other (5, 6). in other words, the interpersonal dimension of care establishes the ontological and epistemological aspects of the relationships with the subjects of care, the interpersonal nursing skills being necessary. when inquiring about this topic within the literature and practice, concepts such as social skills, communicative aptitudes, communicative skills, relational knowledge, among others, are commonly used. however, the term "skill" is not fully grasped, and, as it is not clearly defined, a conceptual void is left. therefore, a concept analysis of interpersonal skills in nursing is required. for clarity purposes, concept analysis is a theoretical development strategy of the discipline, even being considered a form of theoretical research in nursing (7). it is a strategy that allows examining the attributes or characteristics of a term; it is a formal linguistic exercise that must be rigorous and precise to approach a definition, focusing on the potential and actual uses of words that convey the meanings of a concept (8). in this case, the term interpersonal skills in nursing arises from an attempt to narrow down the diversity of concepts on relational function in nursing found in the literature that are unclear to be used in research and applied in practice. this article aims to provide a broad definition of interpersonal skills in nursing as a theoretical approach that contributes to nursing research, practice, and education. materials and methods a concept analysis was carried out as the most suitable and rigorous method to define the concept of interpersonal skills in nursing. comparing the different forms of analysis, walker and avant's (8) methodology has fewer steps to follow than wilson's (8), which allows to exemplify what the concept is and is not; in contrast to rodger (9), which only includes the model case and it does not require explicit assumptions as proposed by meleis (7). walker and avant's steps were followed for concept analysis: 1) select a concept; 2) determine the aim and purpose of the analysis; 3) identify all uses of the concept; 4) identify the defining attributes of the concept; 5) construct a model case; 6) construct borderline, related, and contrary cases; 7) identify antecedents and consequences; 8) define empirical referents. two strategies were employed to gather information on the concept and perform the analysis: literature search and consultation with an expert in the field. both strategies are described below: literature search: it was conducted in science direct, pubmed, medline, academic search complete, psycarticles, bvs, and scopus databases. we narrowed down the search to articles written in english, spanish, and portuguese and published between 2009 and 2019. this time range is adequate to cover the theoretical-conceptual evolution and the current state of the topic because the initial search yielded results per year, with a marked increase in articles related to professional competence and interpersonal skills in nursing since 2009. decs and mesh terms 'nursing research,' 'nursing education research,' 'nursing practice,' 'professional competence,' and 'interpersonal skills' were searched using the boolean operators and and or. the literature review only included research articles, dissertations, thesis, and books addressing interpersonal aspects in nursing. critical appraisal of manuscripts that presented research results was conducted using caspe tools (10). the search and selection strategy of manuscripts is described in figure 1. figure 1. literature search and selection diagram source: adapted from prisma flow diagram for scoping review (11) subject experts: although the concept analysis methodology does not explicitly consider nurses' experiences regarding the conception and uses of the concept, we decided to include two nurses. they were part of the main study of the dissertation in which this analysis is immersed and were interested (voluntarily) in talking about the subject. thus, from their experience, they fed what was found in the literature. given the scope and uses of the concept, knowing the nurses' definition of interpersonal skills was considered relevant. with their prior consent, these nurses with graduate degrees in nursing and education were invited to participate in a semi-structured interview. they have researched into professional competence and communication skills; both have extensive practical experience, and nowadays, they work as lectures in nursing schools and departments in spain and colombia. they were asked about their knowledge, perception, and definition of competence and interpersonal skills; the main questions asked were the following: "when talking about the concept of interpersonal skills in nursing, what is the first thing that comes to your mind? how do you define it? what aspects make it up? answers were audio-recorded, transcribed, and analyzed according to relevant themes and attributes using atlas ti. data analysis: the analysis of the information collected aims to follow the steps proposed in the concept analysis methodology, the literature review, and the consultation of subject experts. however, the review process is described according to whittemore and knafl (12), and the interviews with the experts were subjected to thematic analysis (13), as presented in table 1. they were then compared with each other to define the critical attributes of the concept, as shown in the results. table 1. analysis of the information collected integrative review of the literature thematic analysis of the interviews 1. problem identification: the concept of interest arises when conducting a limited search for the dissertation in which the concept analysis is included. phase 1. getting familiar with the data/information: the interviews are read during the transcriptions. 2. literature search: as presented in figure 1 phase 2. generation of categories or initial codes: in a detailed reading, the general topics are highlighted. 3. data assessment: critical reading is performed as presented in figure 1. phase 3. search for topics: the emerging codes related to the concept of interpersonal skills are gathered. 4. data analysis: the information is organized by common characteristics, in this case, by the attributes that represent the concept. phase 4. topic review: codes are merged and described from the data and part of the literature. 5. presentation of results: the antecedents, consequences, and characteristics of the concept are speciied. phase 5. topic definition and naming: the topics are named and defined according to the concept concerned. phase 6. production of the final report: the concept analysis is carried out, and the findings from the interviews and the literature review are contrasted. source: own elaboration in analyzing the information from the literature and interviews, attributes and concepts emerged repetitively, showing strength in the data and characterizing the concept with aspects such as empathy, confidence, emotional intelligence, and negotiated decision making. these aspects are expanded in the uses of the concept and the critical attributes. finally, to follow the ethical principles of research, this concept analysis is embedded within a dissertation endorsed by the ethics committee of the nursing school, universidad nacional de colombia. additionally, the participating experts signed informed consents for the interviews. this information is in possession of the first author, which will be retained and kept confidential for five years and then eliminated. results following the steps of concept analysis, the results are described below. concept selection and aim of the analysis multiple definitions of this term were found during the literature search on different nursing skills. however, when approaching the interpersonal aspects, we determined that the concept of interpersonal skills in nursing had not been clearly defined within the discipline since this concept tends to be confused with others, such as social skills, communication skills, empathy, or emotional intelligence, which, although linked, convey different meanings. then, it is essential to clarify the meaning of interpersonal skills in nursing by offering a constitutive and operating definition. uses of the concept the literature on the discipline and the experts in nursing skills were consulted to verify the uses of the concept. in this way, we could determine that the concept of interpersonal skills has been addressed mainly by nursing education research, clinical practice, and some nursing theories focused on interaction as a form of care. this section describes some aspects found in the literature review that can be divided into topics, as presented in table 2. table 2. integrated evidence from the literature topic characteristics beginnings and origin of the concept conceptually, interpersonal skills in nursing began to be addressed by the tuning project (14). it defined it as individual abilities to express one's feelings and to be critical and self-critical, social skills related to interpersonal skills, ability to work in a team or to express social and ethical commitment, and abilities that tend to facilitate social interaction processes in nursing (15). communication skills in nursing the most outstanding nurses' skills, strategies, and gestures to communicate effectively include empathy, negotiation skills; use of socio-culturally appropriate information; good intonation, volume, and rhythm of the voice, body language, and facial expression. according to these authors, all these aspects may be trainable (1618). regarding nursing education, some studies started from the positive teacher-student experience; that is, when they understand each other, students' anxiety levels are reduced in practice settings (19, 20). then, the relationship modifies the student's behavior (21). empathy and emotional intelligence interpersonal skills in nursing comprises emotional skills (emotion expression and control, anxiety management, among others) (22) and cognitive skills (interpreting the situation, perceiving others correctly), which enable nurses to observe, interpret, and integrate a situation, and take an empathic position (5). sociodemographic, labor, and academic variables seem to be related to emotional intelligence and empathy (23). for senior nursing students, proper empathy, respect, and assertiveness levels are associated with good performance during clinical practices (24, 25). then, student's education requires not only instrumental skills, but also affective skills (26, 27). negotiated decision-making in nursing care some authors determined in their studies that situational aspects for both patient and nurse may condition the quality of the established relationship, participation in care, and communication (2830). research on end-of-life care found that nurses seek consensus and emotional support during decision-making, which gives peace of mind to the person, the family, and the nurse (29). concept from nursing theories peplau affirms that nursing care is an interpersonal therapeutic process carried out through a relationship between the individual and the nurse (31, 32). for paterson and zderad, nursing is an intersubjective-transactional relationship between a nurse and a patient, where they share experiences that lead to intersubjectivity, characterized by real presence and authentic sharing (33, 34). then, humane practice becomes the purpose of interpersonal skills in nursing. source: own elaboration finally, the literature review shows no clearly defined concept of interpersonal skills in nursing to work with for research and practice. what is clear is that interpersonal skills delimit knowledge, abilities, attitudes, and values applied to interpersonal relationships that nurses establish with care recipients and integrated into practical situations of care to ensure human care provision. concept attributes the concept attributes allow us to approach a definition and recognize its characteristics. interpersonal skills in nursing are made up of the knowledge, abilities, attitudes, and values expressed by nurses in recognition of the other person, in an authentic encounter that provides the interaction with therapeutic properties and positive effects for mutual growth (35) and favors the development of negotiation capacity and shared decision-making (36). the development of interpersonal skills in nursing is mediated by attributes of interpersonal relationship such as trust, empathy, emotional intelligence, assertive communication, respect, openness towards others experiences, flexibility, social maturity, being in touch with one's and others' feelings, understanding, and negotiated decision-making (37). interpersonal skills are also influenced by the nurse's experience and other interpersonal relationships, such as those involved in teamwork and work settings (36, 38). findings from the literature are supported by the experts' opinions about the subject. they consider interpersonal skills related to the formation of the self in nursing, the ability to reflect on interactions, nurses' previous and personal experiences, and communication as the cross-cutting factors of interpersonal relationships. voices of the experts and topics discussed are shown in table 3. table 3. topics and voices of the experts interviewed topics voices of the experts formation of the self in nursing: that "self" includes professional and personal values, ethical principles, emotion management, and comprehension of the other person's experience and meaning of health. "if i don't work on all these aspects of the self, not just what has to do with values, but also, for example, what has to do with self-assurance, how will i tune up confidence and sureness in a student who is going to lead health care teams and decision-making processes in nursing care?" (expert 02) communication as a basis for interpersonal relationships: conveying an idea in which verbal and non-verbal expressions bear meanings for both parties to understand and help each other grow. "[interpersonal skills comprise] verbal language, non-verbal language, contact, empathy, and communication. i think that dialogue and communication are essential. these skills are just as crucial between teacher and student as among nurses and between doctor and nurse." (expert 01) source: data obtained from the analysis carried out by the authors in atlas ti for clarity purposes, critical attributes of the concept are presented in table 4. these attributes represent what we found in the literature review, complemented and validated by the interviews carried out. table 4. critical attributes and surrogate terms of the concept critical attributes definition expression of the self of nursing and its bioethical values, in which the relationship has a therapeutic or pedagogical aim (according to the role of nursing) that produces positive results. the self of nursing is abstract; however, it essentially provides care as an interpersonal relationship (4), in which the connection and interest in others' needs and vulnerable situations make nurses use their sensitivity, trust, active listening, and respect as a means of understanding and benefiting other people. ability to negotiate and make decisions together with the other person. communicating needs negotiated and jointly made care decisions foster horizontal relationships and give value and importance to what other people think about a situation. other people may be students, patients, families, communities, and work teams. identification and self-control of emotions derived from shared experiences nurses should reflect on their own emotions, which are often difficult to identify and control due to nurses' multiple adverse situations. so, emotional intelligence is part of interpersonal skills in nursing. understanding the context where other interpersonal relationships established by nurses take place it means that part of the nurses' attitude may depend on other relationships, such as those with colleagues and other professionals in the health team. literature shows that a good work environment fosters good interpersonal relationships. source: own elaboration the self of nursing identifies with the essence of care that is the interpersonal relationship, which allows understanding the human health experience; in this dynamic, the need to identify and control emotions emerges, especially because experiences such as pain or death are difficult to handle when caring behaviors are marked by empathy and ethical principles of caring (39, 40). consequently, the critical and reflective analysis of these situations helps the nurse understand the conceptions of health and care of people and the contexts in which care occurs, actively participating in decision-making. these characteristics enable us to recognize interpersonal skills in nursing. in summary, interpersonal skills describe nurses' abilities to be open to others and their own experiences in the caring process. it involves knowing how to listen and communicate assertively, regulate emotions, be empathetic, respect and understand situations, help make negotiated decisions, and show a humane practice (41, 42). besides, there are settings for teamwork that also affect the way interpersonal relationships are established. case construction subsequently, once exclusive characteristics of the concept are evident, the next step is taken, which is, at first sight, something simple but requires analytical thinking: case construction. the cases are constructed to illustrate what the concept is and is not, as follows: model case an emergency nurse is caring for an older adult dying on a gurney in the hall, accompanied by his relative. the nurse decides to approach them because when she started her shift, she noted the patient's condition and the sad expression of his relative, so she greets them amicably and warmly, introduces herself, and asks them what they need. the patient's relative breaks into tears, and the nurse comforts him with a purposeful touch. the patient's relative tells her that he does not understand what is going on with his father and does not know if he is suffering exposed to the sight of everyone. the nurse listens to the patient's relative, answers his questions, and helps him say goodbye to his father. then, understanding the situation and noting that there are no beds available in the inpatient unit, the nurse moves the patient to a more private area with an exclusive space for him and the relatives who wish to be there with him. the nurse informs the psychologist about the situation, and they together support the process of death and mourning, giving peacefulness to the family and dignity to the father's death. borderline case an emergency nurse is caring for an older adult going through the dying process in the hall, accompanied by his relative. the nurse decides to approach them as she does with all her patients on each shift, greeting them and asking them what they need. the patients' relative breaks into tears, and she keeps silent and leaves for a moment. then, she returns and informs the patient's relative that as there are no beds available in the inpatient unit, she will locate the patient in a more private place so that his family can say goodbye to him. then, understanding the situation, the nurse informs the psychologist about the situation and, they together support the process of death and mourning. related case an emergency nurse is caring for an older adult going through the dying process in the hall, accompanied by his relative. the nurse decides to approach them because she feels empathy, as she had liveda similar situation with her grandfather. she greets and asks them what they need, the patient's relative breaks into tears, and the nurse begins to talk to them about how important it is to say goodbye and be grateful for everything they shared and lived together. the nurse then informs the patient's relative that there are no beds available in the inpatient unit, but she will locate the patient in a more private place. there, the patient's relative expresses his feelings; the nurse listens to him and asks for support from the psychologist to support the process of death and mourning. contrary case an emergency nurse is caring for an older adult going through the dying process in the hall, accompanied by his relative. the nurse approaches to give the patient the medications and notes that the patient's relative is sad; so, she decides to avoid the situation and only informs them that she is giving medications that relieve pain. the patient's relative asks her to please relocate them. she moves the patient to a more private area and tells them again that there are no beds available. she informs the treating physician and says that it is his job to support them in this process of death and mourning. comparing the model case versus the contrary case, table 5 presents a specific analysis that makes explicit the differences between them. table 5. comparison between cases critical attributes model case contrary case expression of the self of nursing and bioethical values the ethical principle of beneficence, approaching others, and authentic presence minimum interest and responsibility for the person's situation ability to negotiate and make decisions together/ communication control of situations and decision-making considering the family superficial management of the problem, unable to mediate care decisions. identification and self-control of emotions she manages to empathize with the situation without being affected emotionally little control of emotions during attention, runs away from the situation. understanding the context of others interpersonal relationships good communication and relationship with the team and focuses attention on the patient there is no relationship with the patient care team source: own elaboration identification of antecedents and consequences antecedents are those aspects present before competence achievement, and consequences are those aspects that result from such competence. as antecedents, nurses ought to have theoretical knowledge of interpersonal relationships, which is acquired during their professional training and from previous experiences such as the school and family education they received, especially values, morals, and ethics. additionally, self-criticism and reflection on practical action should be strengthened to think and rethink the experiences derived from established relationships (43, 44). regarding the consequences of developing interpersonal skills, nurses will follow a humane practice, be genuinely present in the care they provide, be guided by bioethical principles, and efficiently work in teams (45, 46). empirical referents: methods and measurement instruments few validated instruments are available to measure interpersonal skills in english and spanish versions. some scales that may measure specific attributes or address interpersonal aspects are shown in table 6. research perspectives to approach this phenomenon show that experiences and the process of developing interpersonal skills in nursing have been researched from the qualitative point of view. quantitatively, researchers have come close to describing the characteristics and relating each attribute to this concept. table 6. measurement instruments related to the concept concept instrument validity and reliability caring behavior caring behaviors assessment (cba) (47). it is based on watson's theory. cronbach's alpha: 0.96 content validity (cvi): 0.93 (high) factor analysis with varimax rotation of 72 % explained variance caring interpersonal relationships assessment of nurse-patient interpersonal relationship vriep-icu (48). it is based on the hanc model (humanism, patient assistance, met need, and quality of care). content validity with kappa index of agreement of 0.86 (high) it needs tests for construct validity and reliability. caring interpersonal relationships nursing care interpersonal relationship questionnaire (49). it is based on imogene king's conceptual model. cronbach's alpha: 0.90 content validity: ≥ 0.78 (high) one factor explains 31.5 °% variance. attributes of care subjectivity caring assessment scale tool (cat-v). it is based on the theory of transpersonal human caring. cronbach's alpha: 0.95 three factors explain 59.3 % variance. source: own elaboration implications for research, practice, and education having conceptual clarity of the term interpersonal skills in nursing guides both the being and the duties of nursing professionals. evidence shows a growing need to include it within the training practices of students (51) since interpersonal skills has become essential to provide care recipients with authentic and humane care. despite being often intangible, interpersonal skills are perceptible to those who are receiving care. however, approaching more factual knowledge, it is expected that the attributes derived from this analysis will guide future translational research through interventions that favor the development of these skills in nursing professionals and psychometric research to create specific scales for its measurement. the real impact will be on the patient cared for and their families by having nurses that make them visible and participants in their care. conclusions after the literature review and the consultations with subject experts, we can affirm that interpersonal skills in nursing are the knowledge, abilities, attitudes, and values that nurses can express comprehensively during the interpersonal relationships they es­tablish with others, whether care recipients, family members, communities, colleagues, or other professionals. these skills are characterized by respect, openness to others' experiences, emotion management, commitment to others, empathy, negotiated and shared decision making, teamwork, and application of bioethical principles. their purpose is to develop a humane nursing practice in which positive results are obtained therapeutically or pedagogically depending on the role played by the nursing profession. hopefully, this concept analysis will guide future research on measurement and 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https://doi.org/10.1590/1518-8345.0920.2965 home 1 miguel ángel villegas-pantoja1 martha dalila méndez-ruiz2 maría de jesús de valle-alonso3 laura alicia garcía-perales4 nursing course on drug addiction and its effects on beliefs and intentions: a quasi-experimental study 1 https://orcid.org/0000-0001-9917-8439. universidad autónoma de tamaulipas, méxico. mapantoja@uat.edu.mx 2 https://orcid.org/0000-0002-4527-0296. universidad autónoma de tamaulipas, méxico. mdmendez@docentes.uat.edu.mx 3 https://orcid.org/0000-0001-9792-0425. universidad autónoma de tamaulipas, méxico. mjdevalle@docentes.uat.edu.mx 4 https://orcid.org/0000-0002-6424-0586. universidad autónoma de tamaulipas, méxico. lagarcia@docentes.uat.edu.mx received: 04/03/2020 sent to peers: 30/03/2020 approved by peers: 28/04/2020 accepted: 04/05/2020 doi: 10.5294/aqui.2020.20.2.7 para citar este artículo / to reference this article / para citar este artigo villegas-pantoja ma, méndez-ruiz md, de valle-alonso mj, garcía-perales la. nursing course on drug addiction and its effects on beliefs and intentions: a quasiexperimental study. aquichan. 2020;20(2):e2027. doi: https://doi.org/10.5294/aqui.2020.20.2.7 abstract objective: to determine the impact of a course aimed at the care of persons with drug dependence on the beliefs and intentions of drug use among bachelor nursing students. materials and methods: a quasi-experimental study conducted with a non-equivalent comparison group composed of 210 mexican students of both sexes. two likert-type instruments were used to measure the beliefs and intentions of drug use, before and after a semester-long course. results: at the end of the study, a significant interaction was found (f = 3.56, p = 0.050, η2p = 0.025), which suggests a greater decrease in beliefs in favor of drug use among students who took the course on drug addiction. regarding drug use intentions, a general decrease was observed in the entire sample (f = 10.13, p = 0.002, η2p = 0.059). conclusions: courses on the care of drug addiction can have beneficial effects on nursing students by modifying beliefs and intentions to carry out unhealthy behaviors such as the use of substances. these results demand to verify if the effects remain beyond the completion of university education. keywords (source: decs) intention; nursing education research; health promotion; substance-related disorders; mexico. año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2027 topic: promotion and prevention. contribution to the discipline: the plans of study in nursing not only influence the quality of patient care, but also promote the health of future professionals. this quasi-experimental research highlights the possible benefits to bachelor nursing students when they take a course aimed at promoting knowledge and skills for the care of drug-dependent patients. when comparing students who did not receive specific education on drug addiction with those who did, the results suggest that such training may have positive effects on a personal level, for example a decrease in the beliefs in favor of substance use and number of days they reported have used tobacco and marijuana. https://orcid.org/0000-0001-9917-8439 mailto:mapantoja@uat.edu.mx https://orcid.org/0000-0002-4527-0296 mailto:mdmendez@docentes.uat.edu.mx https://orcid.org/0000-0001-9792-0425 mailto:mjdevalle@docentes.uat.edu.mx https://orcid.org/0000-0002-6424-0586 mailto:lagarcia@docentes.uat.edu.mx https://doi.org/10.5294/aqui.2020.20.2.7 https://orcid.org/0000-0001-9917-8439 https://orcid.org/0000-0002-4527-0296 https://orcid.org/0000-0001-9792-0425 https://orcid.org/0000-0002-6424-0586 https://doi.org/10.5294/aqui.2020.20.2.7 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2027 asignatura de enfermería sobre drogodependencias y sus efectos sobre las creencias e intenciones: estudio cuasi experimental resumen objetivo: determinar el impacto de una asignatura orientada al cuidado de usuarios drogodependientes sobre las creencias e intenciones del uso de drogas en estudiantes de la licenciatura en enfermería. materiales y métodos: estudio cuasi experimental con un grupo de comparación no equivalente realizado en 210 estudiantes mexicanos de ambos sexos. se utilizaron dos instrumentos tipo likert para medir las creencias e intenciones del uso de drogas, antes y después de una asignatura con duración de un semestre. resultados: al final del estudio, se encontró una interacción significativa (f = 3,56, p = 0,050, η2p = 0,025), que sugiere una mayor disminución de las creencias a favor de las drogas entre los estudiantes que cursaron la asignatura sobre drogodependencias. respecto a las intenciones del uso de drogas, se apreció una disminución generalizada en toda la muestra (f = 10,13, p = 0,002, η2p = 0,059). conclusiones: las asignaturas sobre cuidados en las drogodependencias pueden tener efectos beneficiosos en los estudiantes de enfermería al modificar las creencias y las intenciones de llevar a cabo conductas no saludables como el uso de sustancias. los resultados demandan revisar si los efectos permanecen más allá de la finalización de los estudios universitarios. palabras clave (fuente: decs) intención; investigación en educación de enfermería; promoción de la salud; trastornos relacionados con sustancias; méxico. 3 nursing course on drug addiction and its effects on beliefs and intentions: a quasi-experimental study l miguel ángel villegas-pantoja and others disciplina de toxicodependências no curso de enfermagem e seus efeitos sobre crenças e intenções: estudo quase experimental resumo objetivo: determinar o impacto de uma disciplina orientada ao cuidado de pessoas toxicodependentes sobre as crenças e intenções do uso de drogas em estudantes de enfermagem. materiais e métodos: estudo quase experimental com um grupo de comparação não equivalente, realizado com 210 estudantes mexicanos de ambos os sexos. foram utilizados dois instrumentos tipo likert para medir as crenças e intenções do uso de drogas, antes e depois de terem aula da referida disciplina durante um semestre. resultados: no final do estudo, verificou-se uma interação significativa (f = 3,56; p = 0,050; h2p = 0,025) que sugere uma maior diminuição das crenças a favor das drogas nos estudantes da matéria sobre toxicodependência. quanto às intenções do uso de drogas, constatou-se uma diminuição generalizada em toda a amostra (f = 10,13; p = 0,002; h2p = 0,059). conclusões: as disciplinas sobre cuidados de pessoas toxicodependentes podem ter efeitos benéficos nos estudantes de enfermagem ao transformar as crenças e as intenções de realizar comportamentos não saudáveis como o uso de substâncias psicoativas. contudo, os resultados exigem revisar se os efeitos permanecem após a finalização dos estudos universitários. palavras-chave (fonte: decs) intenção; pesquisa em educação de enfermagem; promoção da saúde; transtornos relacionados ao uso de substâncias; méxico. año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2027 4 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2027 aquichan issn 1657-5997 eissn 2027-5374 introduction the use of psychoactive substances —both legal and illegal— represents unhealthy behavior that may have consequences for individual, family and social well-being (1-2). it is a growing problem, having become one of the leading causes of morbidity and mortality worldwide. in this regard, the united nations office on drugs and crime (2) points out in its most recent world report that nearly 35,000,000 people suffer from a substance use disorder, and that in 2017 alone, there were 42,000,000 healthy years of life lost due to disability and 585,000 deaths directly related to drug use. this situation requires that nursing and related sciences professionals adopt actions aimed at its effective incorporation in the fight against addictions, through prevention, treatment, and rehabilitation activities. in this connection, from the second half of the twentieth century, curriculum adjustments in the study plans were used as a strategy to promote the participation of nursing professionals in the care of drug-dependent people (3). international organizations (such as the inter-american drug abuse control commission, through the hemispheric drug strategy) (4) and national agencies have made curriculum adjustments to ensure that new graduates have specific knowledge and skills needed to provide effective care (5). this trend continues up to the present because of the persistent lack of training among nursing professionals (6). in the case of mexico, the mexican federation of associations of faculties and schools of nursing (femafee) established some basic guidelines to improve the training of new generations, such as the inclusion of contents on addictions, by means of courses and the development and incorporation of specialization courses on nursing care for persons with drug dependence (7-8). evidence indicates that taking study programs with specific courses and contents may be a strategy to improve the skills of nursing professionals and the quality of care for drug users (9-11); however, its protective effects on the behavior of nursing students have been the subject of very little studies (5). for example, some studies in developed countries suggest that taking courses on drug addiction could improve nurses’ negative attitudes related to the use of psychoactive substances (12-3). in addition, it has been documented that it could increase the perception of risk associated with drug addictions (14). in this regards, it is of particular interest to know if it could have effects on students’ beliefs and intentions related to substances use, since they have a critical role in the motivational system, which explains the use of drugs (15). it is stated that beliefs influence intentions and that intentions, in turn, may precede behaviors (16). this has been evaluated in studies on behaviors such as the use of addictive substances (15-16). in this respect, the literature suggests that when nursing professionals ignore the issue of drug addiction (for example, due to positive beliefs about drug use or because they are users of addictive substances), they are less inclined to care for drugdependent patients (17), and a worse performance as preventive agents is observed (18). this could contribute to the continuous increase in the number of cases of substance use among nursing professionals (14, 19). this is partly due to the characteristics of the profession and the stage of development in which they are in when pursuing their degree (the beginning of substances use usually occurs during the second decade of life, simultaneously with university education) (18, 20). the lack of studies conducted with the population of mexican nursing students is a knowledge gap, on which professors and health researchers should focus. furthermore, the search for well-being of the drug-dependent people and nursing students are important reasons for evaluating whether the courses on nursing care for persons with drug dependence —recently incorporated into the curriculum— have any effect on the beliefs and intentions related to drug use. the region in which tamaulipas is located, in mexico, on the border with the united states of america, is characterized by having prevalences above the national average of consumption of licit and illicit substances (21). for this reason, it was decided to conduct a research that would allow us to answer the following question: what is the impact of taking a course on the care of persons with drug dependence on the beliefs and intentions of drug use in mexican bachelor nursing students? methodology quasi-experimental study, in which a group of bachelor nursing students who took a course on the care for drug addiction was compared with a group that did not take this course (22). measurements were performed at the beginning and end of the semester-long course. sampling was considered non-probabilistic (all enrolled students were recruited). the final sample was 5 nursing course on drug addiction and its effects on beliefs and intentions: a quasi-experimental study l miguel ángel villegas-pantoja and others stratified as follows: 120 students distributed in four classrooms that took the nursing course on the care for drug addiction (called nursing for addictions [enfermería ante las adicciones], taught to students under a new study program), and 90 students distributed in four control classrooms that did not take the course (although they received information on this subject in the thesis seminar course, which they took during that period, when they were under another study program). the study was conducted during the second half of 2018, while they were in the seventh semester. the sample size was sufficient to detect a medium effect size (d = 0.5), with an alpha error set at 0.05 and 94.0 % power to perform comparative analyzes. the plan of study of the bachelor’s degree in nursing consists of 312 credits, with 7,648 hours in total, and is eight semesters long. the curriculum includes 63 courses divided into three cores: basic training, professional practice training, and disciplinary trainining. the course on the care for persons with drug dependence corresponds to the disciplinary training core (that is, courses aimed at promoting nursing skills). it is divided into six units that address the following topics: etiology, epidemiology, vulnerable groups, pharmacokinetics and pharmacodynamics, prevention, diagnosis and treatment, and nursing care. the class was taught at a rate of four theoretical hours per week (4 credits of the system of assignment and transfer of academic credits [satca, by its spanish abreviation]) by nursing professionals with postgraduate degree (master’s or doctorate degree) and with experience in the care for drug addiction or in addiction research. the methodology included lectures delivered by professors, analysis of documents, discussion groups and presentation of real-life experiences. among the didactic resources, the clinical cases, the practice of anamnesis and identification of risk factors in the population for convenience (such as individual assignments), the application of screening methods and the emergency care videos stand out. it should be noted that, because of the limited availability of specialized care centres where to practice the care of persons with drug dependence, compulsory hours of clinical practice have not been included. with respect to the comparison group, as part of this study, no specific training on addictions was provided during measurements. however, after the research (over the year of their social service), the comparison group received some speeches given by professors, on saturdays, in order to complement their training in this area. instruments a sociodemographic data sheet and two instruments were used to measure the study variables. the data sheet was composed of thirteen items grouped into two sections. the first section had questions designed to record sex, semester, age and experience in the care of drug-dependent patients. the second section included a table of prevalences of the use of licit (alcohol and tobacco) and illicit drugs (marijuana, cocaine, inhalants, heroin, and controlled drugs) in the last 30 days (that is, prevalence in the last month). the first instrument was the spanish version of the beliefs about substance abuse questionnaire (23). the instrument was used to find out young people’s beliefs about the consumption of psychoactive substances. the seven-point likert-type scale consists of 20 items, where 1 indicates strongly disagree and 7 indicates strongly agree. the score ranges from 20 to 140 points, where the higher the score, the stronger the beliefs in favor of drug use. this instrument has been reported to have acceptable reliability in the mexican population (α = 0.81). the second instrument was the drug use intentions scale (24). this scale applies to people who do not consume addictive substances and who do not have the intention to consume any substance, as well as to those who have already consumed them and have the intention to consume them again. it was developed based on the theory of planned behavior, which states that intentions can be predicted by measuring three constructs: attitude, subjective norm, and perceived behavioral control. thus, its 64 items allow measuring these constructs. attitude was indicated by the scores of the behavioral beliefs (13 items) and value attributed to beliefs (13 items) subscales; the subjective norm, by means of the scores of the normative beliefs (four items) and willingness to change (four items) subscales; and perceived behavioral control, through the consumption opportunities (15 items) and perceived behavioral control (15 items) subscales. as a last step, a total intention score was calculated, composed of the subtotals of the three constructs (attitude, subjective norm, and perceived behavioral control). therefore, the higher the score, the greater the intention to use drugs. this instrument has been reported to have sufficient level of global reliability (α = 0.91) in the mexican population, as well as its respective subscales. 6 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2027 aquichan issn 1657-5997 eissn 2027-5374 data collection procedures after approval of the study by the research ethics committees, the authorization of the management staff of the educational institution was requested. subsequently, the group of researchers visited each classroom to invite students. recruitment and initial measurement took place at the beginning of the academic period, just before students started classes. the interviewers were research assistants. the objective of the study was explained verbally and a written informed consent form was provided. it was specified that those who did not wish to participate in the research were free to not answer the instruments, without their academic status in the institution being affected. the instruments were the data card, the belief scale and the drug use intentions scale. their application in each corresponding classroom lasted approximately 25 minutes. six months later, just before the end of the academic period, the final measurement was performed, the classrooms (in some cases, laboratories or areas of clinical practice) were re-visited and the instruments were applied again. an alphanumeric code was used to match them between the initial and final measurements. research development is observed in figure 1. it is noteworthy that the general attrition was estimated at 22.38 % (f = 47) between the two measurements, mainly because some participants could not be found (18.09 %, f = 38) or because they refused to participate in the follow-up (4.29 %, f = 9). data analysis descriptive analyzes consisted of measures of central tendency and dispersion, percentages and frequencies. the kolmogorovsmirnov test with lilliefors correction was used, and it was found that the study variables did not present a normal distribution. thus, it was decided to normalize the variables (in this case, by logarithmic transformation, as there was a right-skewed asymmetry). this enabled to perform the two-way anova parametric test (2 × 2), where the time factor was the repeated measurement or intra-subject reliability measurement (initial measurement vs. final measurement), and the clustering factor was the inter-subject reliability measurement (students who took the course on the care for persons with drug dependence vs. comparison group). assumptions of sphericity (mauchly’s test with p > 0.05), homocedasticity (levene’s test with p > 0.05) and homogenefigure 1. consort flow diagram on the development of the quasi-experimental study source: own elaboration. ity of variance-covariance matrices (box’s m test with p > 0.05) were verified. in all cases, the requirements were met and the f-statistic was interpreted (the higher the value, the greater the probability of occurring significant differences). in the case of non-parametric variables, the chi-square test (χ 2; to compare proportions between two independent groups) and the wilcoxon test (to compare related groups) were used. finally, the reliability of the instruments was evaluated by calculating the cronbach’s alpha coefficient. all analyzes were performed with the spss statistical package version 24.0 for apple macintosh. ethical aspects the study was approved by the research ethics committees of the faculty of nursing (protocol ca-a017), universidad autónoma de tamaulipas, mexico. in addition, it complies with the guidelines of the general health law on health research in force in mexico, which is also based on the general principles of the declaration of helsinki. 7 nursing course on drug addiction and its effects on beliefs and intentions: a quasi-experimental study l miguel ángel villegas-pantoja and others results all instruments showed an acceptable reliability (α > 0.700), both in the initial and final measurements. table 1. instruments reliability instruments items reliability (cronbach’s alpha) initial measurement final measurement beliefs about substance abuse questionnaire 20 0.815 0.839 drug use intentions scale 64 0.951 0.962 attitude subscale behavioral beliefs 13 0.936 0.958 value attributed to beliefs 13 0.922 0.934 subjective norm subscale normative beliefs 4 0.805 0.859 willingness to change 4 0.886 0.881 perceived behavioral control subscale consumption opportunities 15 0.900 0.927 perceived behavioral control 15 0.970 0.961 source: own elaboration. although there was a greater representation of female students (78.3 %), participants from both curricula reported similar prevalences of the use of alcohol, tobacco, marijuana, and controlled drugs (p > 0.05). there were also no significant differences between the proportions of participants with previous experiences in the care of persons with drug dependence during their clinical practices in the previous semesters (p > 0.05) (table 2). the objective of this study was to identify changes in the beliefs and intentions of drug use among bachelor nursing students at the end of a course on the care of drug users. by means of the anova test (table 3), it was identified that in the case of beliefs about substance use, there was a significant main effect exerted by the time factor (f = 5.51, p = 0.020, η2p = 0.033), as a decrease in beliefs in favor of drugs was observed throughout the sample in the final measurement. however, an interaction between the time × clustering factors (f = 3.56, p = 0.050, η2p = 0.025) was also found, which indicates that, over time, the changes in beliefs about drug use were different between the two groups of students (table 3). in figure 2 (subsection a), it can be corroborated that, at the end of the study, the participants who took the course reported a decrease in their beliefs in favor of drugs. table 2. sociodemographic characteristics of participants in the initial measurement variables group that took the course comparison group chi-square test f % f % sex men 26 21.6 35 38.9 χ2 = 8.768 p = 0.012women 94 78.3 55 61.1 previous experiences in the care of persons with drug dependence yes 52 43.3 45 50.0 χ2 = 0.920 p = 0.402no 68 56.7 45 50.0 alcohol use (sometime in life) yes 107 89.2 78 86.7 χ2 = 0.306 p = 0.668no 13 10.8 12 13.3 tobacco use (sometime in life) yes 57 47.5 46 51.5 χ2 = 0.268 p = 0.676no 63 52.5 44 48.9 marijuana use (sometime in life) yes 25 20.8 20 22.2 χ2 = 0.059 p = 0.866no 95 79.2 70 77.8 use of controlled drugs (sometime in life) yes 11 9.2 9 10.0 χ2 = 0.041 p = 0.839no 109 90.8 81 90.0 note: f = frequencies; % = porcentages; χ2 = chi-square statistical test; p = statistical significance. source: own elaboration. regarding drug use intentions, only a significant main effect exerted by the time factor was identified (f = 10.13, p = 0.002, η2p = 0.059), as well as the absence of interaction between the time × clustering factors or the absence of the main effect of the clustering factor (table 3). that is, at the end of the study, there was a general decrease in drug use intentions, but without differences between the students in both groups (figure 1, subsection b). additionally, comparisons of the number of days (in the last month) of consumption of alcohol, tobacco, marijuana and controlled drugs were performed. since these were variables with low response rate and strong asymmetry, the wilcoxon non-parametric test was used. in the final measurement, the students who took the course showed a significantly lower number of days of tobacco use (z = –2.107, p = 0.035), and there was a reduction in the number of days of marijuana use with a tendency to significance (z = –1.890, p = 0.057). it is worth mentioning that no statistically significant differences were identified among the students in the comparison group. 8 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2027 aquichan issn 1657-5997 eissn 2027-5374 discussion the present study identified that education on the nursing care of drug-dependent patients changed positive beliefs about drugs in bachelor nursing students. thus, a decrease in positive beliefs among the students who took the course was registered table 3. changes in scores of beliefs and intentions of drug use among bachelor nursing students indicators group that took the course comparison group factors f η2 p pinitial measurement final measurement initial measurement final measurement m (sd) m (sd) m (sd) m (sd) beliefs about drug use 6.58 (0.89) 6.24 (0.87) 6.30 (0.99) 6.26 (1.05) time time × clustering clustering 5.51 3.56 1.08 0.033 0.025 0.007 0.020 0.050 0.299 drug use intentions 3.38 (0.31) 3.33 (0.30) 3.37 (0.29) 3.31 (0.30) time time × clustering clustering 10.13 0.36 0.29 0.059 0.002 0.002 0.002 0.569 0.589 note: f = analysis of variance statistical test; η 2p = partial eta squared; m = mean; sd = standard deviation; p = statistical significance. source: own elaboration. figure 2. profile graphs of beliefs and intentions of drug use as a function of the time and clustering factors source: own elaboration. in the final measurement. this suggests that the skills and knowledge acquired in the course could benefit students by modifying their personal beliefs about drugs. it is possible that changes in beliefs are due, in part, to increased knowledge about the consequences of drug use, since 9 nursing course on drug addiction and its effects on beliefs and intentions: a quasi-experimental study l miguel ángel villegas-pantoja and others on the other hand, the similarity in scores of drug use intentions between both groups could be because changes in the drug use intentions scale require changes in other antecedent elements. in this connection, they may be due to the planned manipulation of constructs such as the subjective norm, perceived behavioral control and attitudes –in addition to beliefs (16). different interventions have focused on changing intentions through the constructs mentioned above and, in general, are characterized not only by providing educational information, but also by being based on activities that strengthen behavioral control (role-playing scenarios) (27), and considering social norms (for example, including the participation of important people who have an influence on participants) (29-30). although the course program does not meet these attributes, it would be possible to include some activities that aim to strengthen the subjective norm by handling with social pressure or through the establishment of group commitments, for example. it is worth mentioning that, although the scores of drug use intentions are not good, it has been reported that people do not necessarily act according to their intentions (16). in this way, the significant decrease in the number of days of tobacco and marijuana use found among the students who attended the nursing course on the care for drug addiction could be an indication of change in their behavior. however, it would be necessary to confirm whether the intentions change over an extended period or in a larger sample. it has been reported that interventions aimed at modifying the intentions of substance use usually show small effect sizes (30) and, therefore, they have more requirements to be met. in addition, it would also be useful to analyze whether the decrease in the number of days of substance use remains beyond the end of the academic period. among the limitations of this study, the control of information to which participants have access stands out. as this is a research conducted in a natural environment, participants continued their day-to-day activities, which may include acquiring information or skills that improve beliefs or intentions related to drug use. although this bias can occur in both groups, it is not possible to identify if it occurs with greater intensity in any one in particular. in addition, the generalization of the results is limited due to the underrepresentation of male students, as there is evidence that men have a higher frequency and quantity of use of addictive substances (31-32) and their attitudes related to substances table 4. comparison of the number of days of consumption of addictive substances in the last month between the initial and final measurements days of substances use in the last month initial measurement final measurement wilcoxon test m sr m sr participants who took the course alcohol 1.37 600.50 1.08 575.50 z = –0.134; p = 0.894 tobacco 2.37 191.00 1.00 62.00 z = –2.107; p = 0.035 marijuana 0.24 2.50 0.18 10.00 z = –1.890; p = 0.057 controlled drugs 0.64 0.00 0.29 0.00 z = 0.001; p = 0.999 participants in the comparison group alcohol 1.63 236.00 1.88 325.00 z = –0.804; p = 0.422 tobacco 1.70 40.00 1.95 113.00 z = –1.743; p = 0.091 marijuana 0.65 1.00 0.06 0.00 z = –1.010; p = 0.317 controlled drugs 0.44 0.00 0.86 3.00 z = –1.342; p = 0.180 note: m = mean; sr = sum of ranks; z = wilcoxon statistical test. p = statistical significance. source: own elaboration. such information can contribute to the development of a more critical view of its benefits and a greater perception of risk (2526). in this sense, throughout the course, information is provided on the epidemiology of addiction, as well as the characteristics of vulnerable groups and the consequences of the abuse of different addictive substances. in addition to being informative, to approach these topics could have an impact by raising awareness of personal health, since it was also found that many students were users of addictive substances (for example, more than 20.0 % had used marijuana sometime in life). in fact, the significant decrease in the number of days of tobacco and marijuana use among course participants is a contribution of this research, since no studies were found focused on detecting changes in the self-reported substance use in this population due to the curriculum adjustments. instead, most of what has been reported in the literature was limited to describing changes in attitude, perception or skills (9-11, 13-14, 27-28). 10 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2027 aquichan issn 1657-5997 eissn 2027-5374 use differ from those of women (33). however, the low number of male participants did not allow further analysis without compromising the power of statistical tests. finally, a last limitation was the non-obligatory nature of taking the nursing course on the care practices for drug addictions, since it is likely that the application of the skills acquired in class can contribute to changes in beliefs and intentions (11). conclusions education and training in nursing care of drug-dependent patients —provided through specialized courses on this subject —can modify positive beliefs about drugs in bachelor nursing students. this indicates that, in addition to the acquisition of knowledge and skills frequently reported in the literature, taking the course could also have a positive impact on behavior, through the modification of personal beliefs about drugs. it is possible that the decrease in beliefs in favor of drugs will facilitate, in the future, the reduction of intentions or consumption of addictive substances in this population. however, it is still necessary that teachers and those responsible for curricular changes conduct follow-up studies to verify if the changes in beliefs remain in the medium term period. acknowledgments we thank the different institutional authorities for their contribution to the improvement of educational processes through research, as well as the participants for their availability. their collaboration was essential to the development of this manuscript. 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19(3): e1939. doi: https://doi.org/10.5294/aqui.2019.19.3.9 abstract objective: the aim of this research was to analyse the association between successful aging (sa) and subjective well-being (swb) in different domains. method: the study is quantitative and cross-sectional, with a sample consisting of 800 older people, including 569 indigenous (aymara and mapuche) participants living in northern and southern chile. results: domains associated with sa are satisfaction with health, satisfaction with social relationships, satisfaction with future security, and satisfaction with spiritual and religious experiences. sa is also positively associated with being a woman, being young, and not being indigenous. conclusion: the research has two main practical implications. first, swb domains may be incorporated into socio-health interventions as they relate to elements that can be changed or improved (health, social inclusion, security, and beliefs). second, this study suggests a situation of risk among older indigenous chileans, confirming the premise that the life paths of indigenous chileans at social risk give rise to a more socially unequal old age with; therefore, it is important to analyse positive aspects that promote better old age. keywords (source: decs): aging; health of the elderly; healthy aging; successful aging; subjective well-being; intercultural health; indigenous groups; health of indigenous people; chile. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1939 theme: promotion and prevention. contribution to the discipline: from the perspective of health and social sciences, it is necessary to conduct studies that incorporate diversity into an analysis of the aging process. in this regard, this study contributes to knowledge of the aging process among latin american indigenous ethnic minorities (aymara and mapuche). it is important to emphasise the scarce research analysing the aging process among native indigenous peoples in latin america, taking into account that these ethnic groups tend to be in positions of inequality and/or exclusion in comparison with the general population. results of this research can also be applied to intercultural intervention in socio-healthcare areas, particularly in healthcare devices that are used daily in working with the indigenous elderly. http://orcid.org/0000-0003-3297-2704 http://orcid.org/0000-0002-2978-9485 https://doi.org/10.5294/aqui.2019.19.3.9 https://www.orcid.org/0000-0003-3297-2704 https://orcid.org/0000-0002-2978-9485 https://doi.org/10.5294/aqui.2019.19.3.9 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1939 envejecimiento exitoso y bienestar personal en adultos mayores chilenos indígenas y no indígenas* resumen objetivo: el objetivo de esta investigación consistió en analizar la asociación entre envejecimiento exitoso (sa) y bienestar subjetivo (swb) en sus diferentes dominios. metodología: se trata de un diseño cuantitativo y transversal, con una muestra compuesta por 800 adultos mayores, incluidos 569 indígenas (aymaras y mapuches), que viven en el norte y sur de chile. resultados: muestran que los dominios asociados con la sa son satisfacción con la salud, satisfacción con las relaciones sociales, satisfacción con la seguridad futura y satisfacción con las experiencias espirituales y religiosas. la sa también se asocia positivamente con ser mujer, ser joven y no ser indígena. conclusión: la investigación tiene dos implicaciones prácticas principales. primero, estos dominios del swb pueden incorporarse a las intervenciones sociosanitarias, ya que se relacionan con elementos que se pueden cambiar o mejorar (salud, inclusión social, seguridad y creencias). en segundo lugar, este estudio sugiere una situación de riesgo entre los chilenos indígenas mayores, lo que confirma la premisa de que las trayectorias de vida de los indígenas chilenos que han enfrentado más riesgo social dan lugar a una vejez con más desigualdad social, por lo que es importante analizar aspectos positivos que promuevan un mejor envejecimiento. palabras clave (fuente: decs) envejecimiento; salud del anciano; envejecimiento saludable; envejecimiento exitoso; bienestar subjetivo; salud intercultural; grupos indígenas; salud de poblaciones indígenas. * este artículo fue financiado por el gobierno de chile (proyecto fondecyt 1170493). 3 successful aging and personal well-being among the chilean indigenous and non-indigenous elderly l lorena patricia gallardo-peralta and other envelhecimento bem-sucedido e bem-estar pessoal em idosos chilenos indígenas e não indígenas* resumo objetivo: analisar a associação entre envelhecimento bem-sucedido e bem-estar subjetivo em seus diferentes domínios. método: trata-se de um desenho quantitativo e transversal, com uma amostra composta por 800 idosos, incluídos 569 indígenas (aymaras e mapuches), que habitam no norte e no sul do chile. resultados: os domínios associados com o envelhecimento bem-sucedido são satisfação com a saúde, satisfação com as relações sociais, satisfação com a segurança futura e satisfação com as experiências espirituais e religiosas. além disso, associa-se de forma positiva com ser mulher, jovem e não indígena. conclusão: esta pesquisa tem duas implicações práticas principais. na primeira, esses domínios do bem-estar subjetivo podem ser incorporados às intervenções sociossanitárias, já que estão relacionados com elementos que podem ser mudados ou melhorados (saúde, inclusão social, segurança e crenças). em segundo lugar, este estudo sugere uma situação de risco entre os idosos chilenos indígenas, o que confirma a hipótese de que as trajetórias de vida dos indígenas chilenos que enfrentaram mais risco social levam a uma velhice com mais desigualdade social, razão pela qual é importante analisar aspectos positivos que promovam um melhor envelhecimento. palavras-chave (fonte: decs) envelhecimento; saúde do idoso; envelhecimento saudável; envelhecimento bem sucedido; bem-estar subjetivo; saúde intercultural; grupos indígenas; saúde de populaçoes indígenas. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1939 * este artigo foi financiado pelo governo do chile (projeto fondecyt 1170493). 4 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1939 aquichan issn 1657-5997 eissn 2027-5374 introduction in chile the gradual growth of the population aged over 60 has given rise to an increase in research activity focusing on this age segment. of note are the social science initiatives that have sought to analyse the variables and dimensions that promote aging in a manner that maintains well-being (1) with quality of life (2) or with success (3). in this regard, the promotion of good aging is a development strategy (4) that would improve well-being among the population at an advanced age. this study intends to contribute to an understanding of the dimensions associated with good aging. specifically, this research analyses how subjective well-being (swb) is associated with successful aging (sa) among the indigenous and non-indigenous elderly. conceptual and theoretical foundations: models for understanding successful aging and subjective well-being the sa model has its origins in rowe and khan’s proposal (5, 6), for whom sa was related to a low probability of disease and disease-related disability, high physical and cognitive functional capacity, and active engagement with life in terms of both interpersonal relations and productive activity. this model focuses on functionality (physical, psychological and social) and how this enables older people to adapt to the new conditions that are the outcome of the aging process. fundamental aspects for the consideration of sa have recently been added, including cognitive and psychological functionality (7). in broader terms, we currently find various multidimensional proposals whose bases transcend physical functionality and extend to the incorporation of areas such as gerotranscendence and spirituality (8, 9). therefore, the sa model does not consider aging exclusively as a stage of decline or of progressive and irreversible loss of capacities; rather, there is an emphasis on the possibility of aging with optimal physical, cognitive, psychological and social functioning. people can participate in actions to improve, change or transform their lifestyles, avoiding illnesses and thus increasing their prospects of better aging (10). in this study, we take as our basis the sa model proposed by troutman (formerly flood), who defines sa “as an individual’s perception of a favourable outcome in adapting to the cumulative physiological and functional alterations associated with the passage of time, while experiencing spiritual connectedness and a sense of meaning and purpose in life” (11). about successful aging: models and previous research it should be noted that empirical evidence regarding sa in latin american contexts shows that the theoretical models applied are based on the tenets originally proposed by the rowe and kahn’ model (5), focused on an individual process and assessing physical, cognitive and social functionality. also of note are two lines of research. first are those studies that evaluate sa as a dichotomous variable: a person ages successfully or unsuccessfully. in this regard, research conducted by arias-merino et al. (12) with the mexican population indicated that 12.6 % of the population under study would be classified as aging successfully, which means older people who do not report significant illnesses, do not have disabilities for purposes of basic and fundamental activities in daily life, have no more than one difficulty in their physical and cognitive functioning, and participate actively in their social environment. second, we found studies that evaluate this process in a multidimensional manner, and above all as a process of subjective assessment. in this regard, one may note the study carried out by olivera and tounier (13) among the peruvian elderly (aged between 65 and 80), which proposed a regression model for sa with the following predictive variables: being male, being young, being literate, being at work, having high levels of food security, being well-nourished, having normal arterial blood pressure, absence of disability, not smoking, empowerment, having good self-esteem, and enjoying regular contact with social networks. however, a specific sa model has not been developed in latin america that would consider the cultural, historical and social aspects of the region. this is because we are faced with a paradigm that has recently emerged in the region and remains in an initial phase of development. the sa model below has five domains (see figure 1), which evaluate various areas of the process of successful adaptation during aging. domain 1 (functional performance mechanisms) evaluates the older person’s awareness and choice capacity as an adaptive response to the physiological and physical losses resulting from aging. domain 2 (intrapsychic factors) notes the older persons capacity to adapt to changes and resolve problems inherent to aging. domain 3 (spirituality) evaluates the older person’s metaperspec5 successful aging and personal well-being among the chilean indigenous and non-indigenous elderly l lorena patricia gallardo-peralta and other tive; that is, the degree to which they revolve around an existential or transcendental worldview. religious actions carried out by the older person are included in domain 4 (gerotranscendence). finally, domain 5 (life purpose/satisfaction) emphasises the areas of well-being among the elderly such as having a purpose in life, concern for other generations, and life satisfaction (14). there is a medical context to the origins of the troutman’s model, whose field of specialisation is nursing. however, it is essential to note that the model emerges in this context with the objective of providing an alternative to the specific emphasis placed by previous models on the biomedical factors of sa. troutman’s proposal incorporates psychosocial processes as characteristic elements of good aging. subjective well-being and aging: models and empirical evidence furthermore, the term subjective well-being (swb) is associated with a state of being happy, healthy and prosperous (15). swb is made up of at least three interrelated dimensions: positive affect, negative affect and satisfaction. it is possible to add a fourth dimension, defined by the existence of a state of happiness (16). the concept of swb “explores the evaluations, both positive and negative, of how people experience their lives. this subjective appraisal includes a cognitive and an affective dimension” (17). from a psychosociological viewpoint, it is particularly important to analyse swb with the aim of identifying what the strengths are that lead a person to feel happy and satisfied with their life. what is certain is that swb is a measure of the general well-being of an individual, which permits its use as a global indicator of various areas that affect people (18). we can also note that there are three broad approaches to the measurement of swb: eudemonic, evaluative, and affective (4). this study takes an evaluative approach, implying the assessment of swb as a construct that examines the feeling of well-being among the elderly in various domains of their lives including standard of living, state of health, life achievements, personal relationships, feeling of safety, feeling of community connectedness, future security, and spiritual life/religious beliefs (19, 20). swb among the elderly is generally analysed as a dependent variable. available evidence shows that swb is positively associated with perceived health and generativity (21), participation in social activities (22), religiousness and spirituality (23), autonomy in activities of daily living (adl) (24), giving and receiving social support (25), and the structure of a diverse social support network, that is, one made up of family and non-family members (26). particularly, social networks made up of friends are associated with more happiness (27) and social support from friends is associated with more emotional well-being (28). specifically, in chile, life satisfaction is positively associated with financial income (among men), level of education (among women), social support, positive self-reporting of health and memory, being the head of the household, and not living alone. life satisfaction is also negatively associated with the diagnosis of chronic diseases such as diabetes and hypertension (29, 30). in the specific case of psychological well-being, there are also positive associations with social support, being a man, and being married or having a partner (31). how is successful aging associated with well-being and feeling happy? considering that aging is a psychosocial and heterogeneous process, there are various ways of aging successfully. if we focus figure 1. model of successful aging successful aging (sa) domain 1 functional performance mechanism domain 2 intrapsychic factors domain 5 life purpose/ satisfaction domain 4 gerotrascendence domain 3 spirituality source: own elaboration. 6 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1939 aquichan issn 1657-5997 eissn 2027-5374 only on the psychological and/or social domains, each older adult can make use of their own compensatory mechanisms (such as coping, adaptation, resilience and spirituality) that help them to foster and maintain a feeling of quality of life, personal realisation and well-being; in other words, successful aging (32). hence, sa and swb are related constructs; it could even be affirmed that they are inseparably associated. in fact, we can see that studies prior to the formulation of contemporary sa models, such as that conducted by palmore (33), concluded that the best predictors of successful aging were initial health and happiness, which together correctly predicted the success status of 74 % of the sample. along these lines, fisher (34) states that life satisfaction is a precursor to sa. the comprehensive review carried out by cosco et al. (8) also shows that for operational definitions of sa, 48.6 % (equivalent to 51 of the articles analysed by the author) include constructs of swb, by reference to affective status or lifesatisfaction/well-being. studies conducted in various cultural contexts show how wellbeing may be considered as a determinant of sa; for example, quantitative research by iwamasa and iwasaki (35) carried out with japanese-american older people states that one of the subcategories in the conceptualisation of sa is defined by positive affect and attitudes (“being happy”; “you’ve got to smile all the time and laugh”; “being optimistic”; “not to complain all the time”). similarly, a study conducted in two cultural contexts (germany and the united states) indicates that well-being occupies fifth position in assessing well-being, behind health (81.7 %), social resources (65.7 %), activities and interests (55.9 %), and virtues/attitudes/ beliefs (51 %). this study found that “well-being” was cited as a determinant for sa in 49.3 % of cases, by reference to the following terms: feeling good, being/remaining happy, satisfied with one’s life, having fun, living fully, and having a calm, stress-free life (36). in terms of research with the indigenous elderly, it is worth clarifying that there are few studies with indigenous ethnic minorities and even fewer if we restrict the scope to health/well-being in old age (37). we may highlight the current studies being conducted among indigenous populations in north america (38), and some research among indigenous brazilian (39) and chilean (40) populations. however, the empirical evidence that predominates about ethnic minorities tends to deal with migratory processes; that is, how migrant minorities age in developed countries (35, 37, 41). in general, this research warns us of processes involving social risk for ethnic minority groups (42). yet, when research is focused on ethnic minorities that have become “minorities” in their natural geographic environment, the results tend to be paradoxical in that various protective factors are observed (healthy lifestyles, positive coping through religious/spiritual practices, a system for family/community organisation, among others) that may improve certain aspects of physical health among the indigenous elderly (43). present research this study analyses the association between various domains of swb and sa in a sample of chilean indigenous and non-indigenous older people. the empirical evidence suggests that the elderly who positively evaluate their capacity to adapt to the process of aging well (sa) also provide a positive subjective evaluation of their well-being (swb) (44). but there is also a lack of research assessing the potential differences between aging as an indigenous person (native latin american ethnicities) and as a non-indigenous person (mestizo or caucasian). in chile, 9 % of the population is indigenous; this amounts to 1,585,680 people, with the two most populous indigenous ethnicities being mapuche (83.8 %) and aymara (6.8 %) (45). in this context, studies are required regarding the differentiated aging processes for indigenous and non-indigenous older people. it is necessary to highlight the importance of conducting research into indigenous cultural practices and their implications for the aging process (40). although this study is focused on two chilean indigenous ethnic groups, we hope it can be used as a point of reference by other latin american countries whose indigenous populations are experiencing very similar social processes to the chilean case. in this respect, some native indigenous groups in latin america —such as the aymara and mapuche in chile— have in recent decades become ethnic minorities, whether due to the low rates of demographic renewal among indigenous peoples, low inter-ethnic cultural transmission (language, religiousness, worldview, and so on), increased processes of ethnic intermarrying and reproduction, assimilation into the dominant culture (chilean) or acculturation, and even changes in interethnic relations (46). it is difficult to formulate a specific hypothesis since, as previously stated, there is little available literature offering a specific 7 successful aging and personal well-being among the chilean indigenous and non-indigenous elderly l lorena patricia gallardo-peralta and other analysis of the relationship between the different dimensions of swb and sa, especially in the chilean multi-ethnic context. undoubtedly, and within the scope of our aim, the only hypotheses that can be clearly formulated are related with demographic and socioeconomic variables. the association between social resources and sa is difficult to adjust to a classical hypothesis in the context of our aims. this is due to the characteristic family dynamics of multi-ethnic rural environments in chile that are increasingly putting the elderly in situations of solitude, which permits to assume that other dimensions are becoming progressively more significant for sa. as such, it is possible to hypothesise a lack of association between social resources (structural social support) and sa, especially when statistical models include variables such as satisfaction with social relationships or with community and psychosocial dimensions of swb. the latter, especially the dimensions that comprise it, causes the greatest difficulties for the formulation of hypotheses. there is a lack of prior empirical evidence, especially in terms of samples similar to that examined in this study. there are no pre-existing frames of reference for multi-ethnic samples that are characterised by the presence of indigenous ethnicities with notably divergent cultural features in comparison with those that are characteristic of the society in which they are located, as in this case. the fundamental aim of this study is precisely to contribute to creating this type of knowledge, through results that permit the identification of swb that are most sensitive to ethnic diversity. methods characteristics of participants and selection the study followed a quantitative and transversal approach with a sample consisting of 800 older people living in northern and southern chile. a sample stratified by sex, ethnicity and place of residence (municipal or rural areas) was used to ensure representativeness in each of these territories. the fundamental features of the sample are set forth in table 1. it is appropriate to highlight average age (72.07 years; sd=7.81) and that 71 % of the sample stated that they were indigenous (35 % aymara and 65 % mapuche). trained professionals administered the face-to-face questionnaire as interviews between august and october 2017. spanish was the main language used for the scale. the native population uses spanish on a daily basis, as it is the main language in chilean society. the ethics committee of university of tarapacá and the national council for science and technology of chile approved and monitored the ethical aspects of the study. table 1. characteristics of participants variable categories non-indigenous (n=231) aymara (n=201) mapuche (n=368) n (%) n (%) gender women 107 (46%) 106 (53 %) 180 (49 %) 393 (49 %) men 124 (54 %) 95 (47 %) 188 (51 %) 407 (51 %) age groups 60 – 69 years 82 (35 %) 97 (48 %) 162 (44 %) 341 (43 %) 70 – 79 years 102 (44 %) 75 (37 %) 134 (36 %) 311 (39 %) 80 + years 47 (21 %) 29 (15 %) 72 (20 %) 148 (18 %) married or cohabiting 112 (48 %)a 120 (60 %)c 202 (55 %) 434 (54 %) marital status single 47 (20 %)a 23 (11 %)c 54 (15 %) 124 (15 %) widow(er) 49 (21 %) 45 (22 %) 96 (26 %) 190 (24 %) divorced, separated 23 (11 %)b 13 (7 %) 16 (4 %)c 52 (7 %) 8 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1939 aquichan issn 1657-5997 eissn 2027-5374 measures successful aging. the successful aging inventory (sai) was used (11). this is made up of 20 items, divided into five dimensions: mechanisms of functional performance, intrapsychic factors, gerotranscendence, spirituality, and life purpose/satisfaction. this inventory has been validated in chilean indigenous and non-indigenous older people, proving to be a reliable and adequate instrument for this population (14). subjective well-being. the personal well-being index (pwi) was created from the comprehensive quality of life scale (47). a nine-item scale was used to evaluate satisfaction across the following factors: standard of living, health, achieving in life, relationships, safety, community-connectedness, future security, and spirituality/religion, with a question also included on the ninth item of overall life satisfaction. this questionnaire has been validated in the chilean population, including the indigenous elderly (20). social resources. having a partner (0=without partner, 1=with partner), living accompanied (0=living alone, 1=living accompanied) and number of cohabitants. control variables. sex (0=man, 1=woman), age, ethnicity (0=non-indigenous, 1=indigenous), literacy (0=illiterate, 1=literate). data analysis to fulfil the study aims, data analysis was completed in two phases. first, descriptive analyses were performed for the study variables, together with the bivariate correlations among the main study variables. second, a hierarchical regression analysis was carried out for the sa variable, entailing the production of three models. model 1 included control variables. model 2 included social resources. model 3 incorporated the nine dimensions of swb: overall life satisfaction, standard of living, health, achieving in life, relationships, safety, community-connectedness, future security, and spirituality/religion. version 23 of the ibm-spss programme was used to conduct the analyses. results pursuing the logic proposed in the foregoing paragraph, our results are grouped into two main blocks. the first, supported by tables 2 and 3, offers the results of the descriptive analysis conducted. the second block, supported by table 4, engages in a detailed multivariate analysis to test the proposed hypotheses. table 2 shows internal consistency indices (cronbach’s alpha), which are acceptable for both measures from .90 to .93, the total number of items per construct and ranges (potential and actual). table 3 sets forth the descriptive statistics and correlations of the main study variables. specifically, the results show a statistically significant association between sa and overall life satisfaction (r=.39; p<.01), standard of living (r=.35; p<.01), health (r=.36; p<.01), achieving in life (r=.42; p<.01), relationships (r=.45; p<.01), safety (r=.44; p<.01), community-connectedness (r=.41; p<.01), future security (r=.40; p<.01), and spirituality/religion (r=.37; p<.01). variable categories non-indigenous (n=231) aymara (n=201) mapuche (n=368) n (%) residence north (region of arica y parinacota) 110 (48 %) 201 (100 %) 0 311 (39 %) south (region of the araucanía) 121 (52 %) 0 368 (100 %) 489 (61 %) education primary school incomplete 56 (24 %)a,b 127 (63 %)c 250 (68 %)c 433 (54 %) primary school 120 (52 %)a,b 4-9 (24 %)c 76 (21 %)c 245 (31 %) high school or vocational education 48 (21 %)a,b 21 (10 %)c 39 (10 %)c 108 (13 %) higher education 7 (3 %)b 4 (3 %) 3 (1 %)c 14 (2 %) note. a different from aymara (p<.05); b different from mapuche (p<.05); c different from non-indigenous (p<.05) source: own elaboration. 9 successful aging and personal well-being among the chilean indigenous and non-indigenous elderly l lorena patricia gallardo-peralta and other table 2. reliability, number of items, and range of study variables variable α total number of items range potential actual successful aging .90 20 0-80 8-80 subjective well-being .93 8 0-10 1-10 source: own elaboration. table 3. mean, standard deviations, and correlations among study variables 1 2 3 4 5 6 7 8 9 10 m sd 1. successful aging 64.18 10.680 2. overall life satisfaction .386** 7.41 1.882 3. satisfaction with standard of living .346** .850** 7.31 1.968 4. satisfaction with health .360** .488** .502** 6.37 2.316 5. satisfaction with achieving in life .422** .689** .712** .540** 7.34 1.982 6. satisfaction with relationships .449** .652** .686** .488** .805** 7.40 2.013 7. satisfaction with safety .438** .593** .604** .486** .712** .727** 7.08 2.050 8. satisfaction with community-connectedness .411** .630** .666** .496** .726** .795** .697** 7.33 2.091 9. satisfaction with future security .398** .562** .537** .426** .561** .551** .767** .538** 6.85 2.115 10. satisfaction with spirituality/religion .367** .487** .486** .355** .589** .594** .571** .592** .508** 7.60 2.248 note. m stands for mean. sd stands for standard deviation. *p<.05, **p<.01, ***p<.001 source: own elaboration. table 4 presents the regression model for sa. included in model 1 (control variables) are sex (β=.096; p<.01), age (β=-.177; p<.001), and ethnicity (β=-.094; p<.01). model 2 (social resources) contains sex (β=.105; p<.01), age (β=-.167; p<.001), and ethnicity (β=-.085; p<.01). however, the variables of social resources included do not show an association with sa. finally, model 3 again incorporates the control variables of sex (β=.096; p<.05), age (β=-.136; p<.001), and ethnicity (β=-.077; p<.01), but it also adds satisfaction with health (β=.072; p<.05), satisfaction with relationships (β=.193; p<.01), satisfaction with future security (β=.137; p<.01), and satisfaction with religion/ spirituality (β=.098; p<.01). in accordance with the hypotheses subject to examination, the inclusion of the various swb domains (model 3) notably increased the explanatory power as regards sa, with 29.4 % of explained variance. in summary, sa is positively associated with being a woman, satisfaction with health, satisfaction with relationships, satisfaction with future security, and satisfaction with religion/spirituality. in contrast, it is negatively associated with age and being indigenous. 10 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1939 aquichan issn 1657-5997 eissn 2027-5374 discussion the following study is intended to offer a contribution to knowledge regarding the relationship between subjective wellbeing and successful aging. the most significant aspect of this contribution is the sample from which the data were obtained, which included population from indigenous ethnicities living in an indigenous environment in chile. the results partially confirm the proposed hypotheses. the discussion of findings will be divided into three main blocks: (1) demographic and socioeconomic variables and their association with sa; (2) absence of association between the variables relating to social resources and sa; and (3) relationship between subjective well-being and successful aging. first, the sociodemographic variables that were analysed and are positively associated with sa are being a woman, being young, and not being indigenous. for the latter two, our results table 4. hierarchical regression analyses for successful aging variable model 1 β model 2 β model 3 β step 1. control variable sex (1=female) .096** .105** .069* age -.177*** -.167*** -.136*** ethnicity (1=native) -.094** -.085** -.077** literacy (1=literate) .064 .060 .056 step 2. social resources having a partner .051 .038 living with someone else .070 .027 number of cohabitants .021 .024 step 3. subjective well-being overall life satisfaction .064 satisfaction with standard of living .032 satisfaction with health .072* satisfaction with achieving in life .054 satisfaction with relationships .193** satisfaction with safety .059 satisfaction with community-connectedness .063 satisfaction with future security .137** satisfaction with spirituality/religion .098** f 13.296*** 2.550* 30.817*** r2 .063 .072 .294 note. *p<.05, **p<.01, ***p<.001 source: own elaboration. 11 successful aging and personal well-being among the chilean indigenous and non-indigenous elderly l lorena patricia gallardo-peralta and other corroborate the results of previous studies with older people (9, 28, 42). our study therefore adds empirical evidence to the patterns of association that have been established in existing literature. in this regard, as aging takes place, the decline in physical and cognitive functions begins to negatively affect the capacity to adapt to the changes that come with it. additionally, belonging to an indigenous ethnicity that also constitutes an ethnic minority implies the accumulation of various situations of risk that result in a higher-risk old age. given the importance of this point, there will be a subsequent detailed discussion of its research implications and the impact of our results in this respect. successful aging, gender and social resources: the key role of indigenous communities unexpectedly, women showed a positive association with successful aging. our results underline depp and jeste’s arguments (48) that the effect of gender on sa is confusing. the metaanalysis conducted by these authors revealed that 50 % of the longitu dinal studies reviewed found that women were more likely to experience successful aging than men. additionally, this study could not corroborate the association between level of literacy (knowing how to read and write) and successful aging, despite the empirical evidence showing that sa is more likely at higher levels of educational qualification (9). second, the variables establishing availability of “social resources” (having a partner, not living alone, and number of cohabitants) did not show a statistically significant association with sa, though various studies indicate otherwise (49); for example, strawbridge, cohen, shema, and kaplan’s research (50) showed how having five or more close personal contacts increased the likelihood of sa. these findings prompt a more specific analysis concerning the influence of having a partner and living alone (or otherwise) on the well-being of chilean older people, particularly when changes in terms of demography and family structures mean that a high number of people will live alone in their old age. this study focused on rural and indigenous areas experiencing transformations in family structure due to migration from rural environments to cities. in highland areas where members of the aymara community live, there has been a change in household structure with a trend toward childless households and singleperson homes, due to an accelerated process of depopulation of many communities because of the migration of younger people. in the case of mapuche communities, a characteristic process is marked by the presence of households made up of grandparents caring for their grandchildren, while their adult children live in the city. these processes give rise to common aspects of community development in the rural areas of northern and southern chile, increasing the importance of community in the lives of the elderly. of key importance as support figures in the community are neighbours and the neighbourhood. in daily life, these sources of support help to resolve practical problems but also offer a source of emotional support and advice. in these community relationships, social, religious, cultural and indigenous groups stand out as a source of social support and, at the same time, a mechanism for social integration. this centrality of the community to the lives of indigenous older people in chile could contribute to explaining the importance of the relational and spiritual/religious dimensions of successful aging in subjective well-being. subjective well-being and successful aging: exploring the role of satisfaction with health, social relationships, future security, and spiritual experiences though the bivariate correlations statistically show significant associations between the various domains of subjective well-being and successful aging, only four dimensions were predictive of sa in the multivariate analyses (health, social relationships, future security and protection, and religion/spirituality). this demonstrates the specificity of the successful aging process to the cultural context that is subject to analysis (51). as expected, the perception of being satisfied with one’s state of health has a positive influence on sa. in this respect, as whitley, popham, and benzeval (52) argue, positive self-perception and satisfaction with health are associated with increased levels of sa, even among those older persons who have diseases or some level of disability. in other words, the capacity to adapt to and cope positively with adverse health conditions inherent to old age will be determinants of sa (9). a positive association was also hypothesised between satisfaction with social relationships and sa. this study confirms that key domains of subjective well-being are positively associated with successful aging. in this regard, various studies verify 12 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1939 aquichan issn 1657-5997 eissn 2027-5374 the potential value of social relationships in fostering good aging (49, 53), with the assumption of social support mobilisation in situations of need. in the specific case of chile, one of the most important social relationships is with family, and in this regard a study carried out by gallardo-peralta, barrón lópez de roda, molina, and schettini (54) showed how the quality of family relationships (satisfaction with family relationships) was associated with increased well-being. this result, moreover, helps to explain the lack of a statistically significant association between available social resources and sa. in line with previous research, functional social support and satisfaction with social relationships —and not the structure or structural aspects of the network— define the range of sociocultural variables that are related with the sa process (32, 35). another dimension that is positively associated with sa is satisfaction with future security and protection. though a very general evaluation of security, being able to perceive that one will have access to financial and non-financial resources arouses a feeling of well-being. along these lines, one of the areas of security with the greatest impact on sa is financial security (55), since it allows older people independence in having and using a certain amount of stable financial resources that are sufficient to ensure a good standard of living. finally, satisfaction with spiritual experiences and religious beliefs is positively associated with successful aging. in this respect, numerous studies confirm that religious and spiritual experiences produce a positive impact on adaptation to and coping with the various aging processes (8, 56). in other words, religion and spirituality offer the elderly guidelines, principles or strategies to cope with the various difficulties inherent to aging, such as deteriorations in health and declining functionality, losses in terms of roles and social networks and in cognitive functions, deteriorations in economic status, and experiencing feelings of loneliness, sadness or hopelessness (57). limitations certain limitations must be taken into account with relation to this research. first, the study design is cross-sectional. this invites a cautious interpretation of the potential existence of causal relationships. the interest of our analytical framework was to explore the potential impact of subjective well-being on successful aging, but to be able to identify the existence and direction of causal relationships, it is necessary to design longitudinal research. qualitative methodologies would also be useful for an in-depth examination of the potential associations between the sa process and the availability of social resources; of particular use would be participative methodologies, which would guide us on the specificity of these relationships in ethnically diverse populations. second, although the sample was representative for the regions in the north (arica and parinacota) and south (araucanía) of chile, it is not a national sample. the results cannot therefore be generalised for all chilean older people and should be understood/applied in the specific geographical context in which they were collected. however, the sample design does suggest that the results are representative of the two above-mentioned regions, as well as that the sample structure is a faithful reflection of the multi-ethnic character of the chilean older population. in summary, evaluating successful aging is a multidimensional process subject to life paths and cultural contexts. subjective well-being is a central element in understanding it. along these lines and as proposed by kahana and kahana (58), sa is a process composed of social and psychological resources, preventive and corrective adaptations, psychological, existential, and social wellbeing. well-being is one of the constituents of successful aging, and in this study, we have confirmed that 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baywood publishing; 2003. https://academic.oup.com/bjsw/article-abstract/45/suppl_1/i135/2472311 https://academic.oup.com/bjsw/article-abstract/45/suppl_1/i135/2472311 https://doi.org/10.1093/bjsw/bcv120 https://www.ncbi.nlm.nih.gov/pubmed/?term=expanding+the+circle+of+knowledge%3a+reconceptualizing+successful+aging+among+north+american+older+indigenous+peoples%27 https://doi.org/10.1093/geronb/gbw128 https://doi.org/10.1093/geronb/gbw128 https://www.interciencia.net/wp-content/uploads/2018/05/313-gallardo-43_5.pdf https://www.interciencia.net/wp-content/uploads/2018/05/313-gallardo-43_5.pdf https://doi.org/10.1093/geront/gny083 https://doi.org/10.1093/geront/gny083 https://doi.org/10.4067/s0719-09482014000200009 https://doi.org/10.1177/0013164494054002011 https://doi.org/10.1177/0013164494054002011 https://www.ncbi.nlm.nih.gov/pubmed/16407577 https://doi.org/10.1097/01.jgp.0000192501.03069.bc https://doi.org/10.1093/geront/gnu074 https://www.ncbi.nlm.nih.gov/pubmed/8678044 https://www.ncbi.nlm.nih.gov/pubmed/8678044 https://doi.org/10.1093/oxfordjournals.aje.a008900 https://doi.org/10.1017/s0144686x14001330 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5181386/ https://doi.org/10.1093/geront/gnv054 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3894851/ https://doi.org/10.1093/geront/gnt118 https://doi.org/10.1080/01634372.2018.1489928 https://doi.org/10.1016/j.eurger.2014.09.005 https://doi.org/10.1016/j.eurger.2014.09.005 https://www.ncbi.nlm.nih.gov/pubmed/29380710/ https://doi.org/10.1017/s1041610218000029 https://doi.org/10.1017/s1041610218000029 1 flor de maría cáceres-manrique1 claudia isabel amaya-castellanos2 carolina rivero-rubio3 gender inequalities in the health setting: the case of medicine* 1 orcid.org/0000-0002-4796-6190. school of medicine, universidad industrial de santander, colombia. fmcacer@uis.edu.co 2 orcid.org/0000-0002-4838-2226. school of medicine, universidad industrial de santander, colombia. ciamaya@uis.edu.co 3 orcid.org/0000-0002-5508-4286. school of medicine, universidad industrial de santander, colombia. carivrub@gmail.com * project: “feminization of medicine and its possible consequences in the colombian health job market”. funded by the vice-rectory of research and extension, universidad industrial de santander. convocatoria capital semilla 2016. code 2311. received: 19/01/2019 sent to peer reviewers: 05/02/2019 accepted by peers: 19/03/2019 approved submission: 24/04/2019 doi: 10.5294/aqui.2019.19.2.7 para citar este artículo / to reference this article / para citar este artigo cáceres-manrique fdc, amaya-castellanos ci, rivero-rubio c. gender inequalities in the health setting: the case of medicine. aquichan 2019; 19(2): e1927. doi: 10.5294/aqui.2019.19.2.7 abstract objective: to understand relationships of power according to gender experienced in scenarios of professional performance by colombian female physicians. materials and methods: qualitative study with phenomenological approach, from in-depth interviews to 33 female physicians, ranging in age between 29 and 60 years, and with over five years of professional exercise. between october 2017 and march 2018, with prior informed consent, the interviews were conducted with questions about the relationships of power and the inequalities experienced with their male colleagues in scenarios of professional performance. results: in the reports by the female physicians interviewed, it is possible to perceive gender inequalities in wages, forms of hiring, responsibilities assigned, recognition by the patients, and access to positions of power in comparison with their male colleagues. conclusions: medicine maintains a power structure centered on men, with differential opportunities by gender, and characterized by a lower wage, more responsibilities, lesser recognition, and limited access to positions of prestige for women. this phenomenon needs to be explored in other professionals from the health area. keywords (source: decs) health status disparities; physicians, women; feminization; health equity; gender and health; colombia. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1927 theme: promotion and prevention. contribution to the discipline: this work revealed gender inequalities in medicine, one of the most emblematic professions (along with nursing) and with the highest number of women from the health area. recognizing the inequalities confronted by health professionals opens the possibility of guiding efforts and progressing in the construction of a fairer society. http://orcid.org/0000-0002-4796-6190 mailto:fmcacer@uis.edu.co http://orcid.org/0000-0002-4838-2226 mailto:ciamaya@uis.edu.co http://orcid.org/0000-0002-5508-4286 mailto:carivrub@gmail.com http://dx.doi.org/10.5294/aqui.2019.19.2.7 http://orcid.org/000-0002-4796-6190 http://orcid.org/0000-0002-4838-2226 http://orcid.org/000-0002-5508-4286 http://dx.doi.org/10.5294/aqui.2019.19.2.7 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1927 inequidades de género en el ámbito de la salud: el caso de medicina resumen objetivo: comprender las relaciones de poder según el género, vividas en los escenarios de desempeño profesional por médicas colombianas. materiales y métodos: estudio cualitativo con enfoque fenomenológico, a partir de entrevistas en profundidad a 33 médicas, con edades entre 29 y 60 años, y más de cinco años de ejercicio profesional. entre octubre de 2017 y marzo de 2018, previo consentimiento informado, se realizaron las entrevistas con preguntas sobre las relaciones de poder y las desigualdades experimentadas con sus colegas hombres, en los escenarios de desempeño profesional. resultados: en los relatos de las médicas entrevistadas, se perciben inequidades de género en los salarios, las formas de contratación, las responsabilidades asignadas, el reconocimiento por parte de los pacientes y el acceso a cargos de poder, en comparación con sus colegas hombres. conclusiones: la medicina mantiene una estructura de poder centrada en los hombres, con oportunidades diferenciales por género, y caracterizada por un menor salario, más responsabilidades, menor reconocimiento y un acceso limitado a cargos de prestigio para las mujeres. se requiere explorar ese fenómeno en otros profesionales del área de la salud. palabras clave (fuente: decs) inequidad en salud; médicos mujeres; feminización; equidad en salud; género y salud; colombia. * proyecto: “feminización de la medicina y sus posibles consecuencias en el mercado laboral de salud colombiano”. financiado por la vicerrectoría de investigaciones y extensión, universidad industrial de santander. convocatoria capital semilla 2016. código 2311. 3 gender inequalities in the health setting: the case of medicine l flor de maría cáceres-manrique y otros inequidades de gênero no âmbito da saúde: o caso da medicina resumo objetivo: compreender as relações de poder segundo o gênero, vividas nos cenários de desempenho profissional por médicas colombianas. materiais e métodos: estudo qualitativo com abordagem fenomenológica, a partir de entrevistas em profundidade a 33 médicas, entre 29 e 60 anos de idade, e mais de cinco anos de exercício profissional. entre outubro de 2017 e março de 2018, com prévio consentimento informado, foram realizadas as entrevistas com perguntas sobre as relações de poder e as desigualdades experimentadas com seus colegas homens, nos cenários de desempenho profissional. resultados: nos relatos das médicas entrevistadas, são percebidas inequidades de gênero nos salários, nas formas de contratação, nas responsabilidades designadas, no reconhecimento por parte dos pacientes e no acesso a cargos de poder, em comparação com seus colegas homens. conclusões: a medicina mantém uma estrutura de poder centralizada nos homens, com oportunidades diferenciais por gênero, e caracterizada por um menor salário, mais responsabilidades, menor reconhecimento e um acesso limitado a cargos de prestígio para as mulheres. faz-se necessário explorar esse fenômeno em outros profissionais da área da saúde. palavras-chave (fonte: decs) disparidades nos níveis de saúde; mulheres médicas; feminização, equidade em saúde; gênero e saúde; colômbia. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1927 * projeto: “feminização da medicina e suas possíveis consequências no mercado de trabalho de saúde”. financiado pela vice-reitoria de pesquisas e extensão, universidad industrial de santander, colômbia. chamada capital semilla 2016. código 2311. 4 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1927 aquichan issn 1657-5997 eissn 2027-5374 introduction medicine, one of the health professions of greatest social recognition, had been practiced mostly by men until the past century (1, 2). in recent decades, the entry of women has had a major upswing, even surpassing the number of males in some countries (2, 3, 4, 5). this phenomenon, denominated feminization of medicine (4, 6), has not achieved major changes in its masculinized structural model, given that it continues presenting subtle exclusion of women from positions of higher authority, recognition, and prestige (2). in 1994, the united nations organization (un) held the convention on the elimination of all forms of violence against women (7), which advocates for the participation of women in equal conditions as men. in september 2015, the 2030 agenda was approved for sustainable development objectives (sdo), with 17 objectives and 169 goals centered on the people, which are summarized on the ideal of transforming the world into a better place; combating inequalities; constructing peaceful, fair, and inclusive societies; promoting equality between genders; and generating empowerment of women and girls, among others (8). with increased access of women to a professional career, and with progress of the sdo, a higher level of empowerment and gender equity are expected, so that they can strengthen the exercise of the profession with distinct contributions and styles (9), leadership alternatives (10), and freedom to develop their skills and potentialities (11) in equal conditions as their male colleagues. in this regard, research has been conducted to assess the influence of gender on the medical practice and differences have been found in the communication style and in the performance of preventive activities (10), but the experiences of the health professionals have not been explored related to the distribution of power according to sex. studies have also not delved into gender inequalities, defined as unnatural, unjust, and avoidable inequalities (12) between men and women in the professional exercise, which affect negatively, in this case, the female physicians (13). therein, the need to conduct this study, seeking to understand relationships of power according to gender, experienced by a group of women who practice one of the most valued and recognized health professions: medicine. materials and methods a qualitative study with phenomenological approach was carried out (14). it sought to explore the phenomenon of distribution of power according to sex, from the experiences of colombian female physicians from bucaramanga, bogota, or medellin. the selection criteria included being a female physician, having been working for over five years in any of the fields of the professional exercise of medicine, and authorizing their participation by signing the informed consent. the “snow-ball” strategy was used (15), starting with key informants. from the phenomenological perspective (16), the analysis sought to reach the essential structures to give meaning to the experiences of the women (17), stemming from two thematic axes defined a priori : 1) relationships of power (18, 19), understood as the experiences of female physicians expressed in reports that reveal the phenomenon of the distribution of power between men and women, with their origins, characteristics, implications, advantages, and disadvantages; and 2) gender equity (20), defined as the perception of fair and equitable distribution of opportunities, responsibilities, wages, and power between male and female health professionals, under equal conditions. to address the contents, in-depth interviews were conducted with 33 female physicians who gave their informed consent to participate in the study, between october 2017 and february 2018, with which saturation of the categories studied was achieved. the interviews lasted between 20 and 120 minutes and were led by one of the researchers (female physician, nurse, or psychologist), all with masters or phd studies, with experience in qualitative research and in conducting previously standardized in-depth interviews. each researcher kept a field diary with observations, experiences, and reflections that emerged during the work. during the first contact with the potential participants, they were introduced to the researchers’ curriculums and the study objectives. with those expressing interest, an appointment was set to meet face to face, at the place and time defined by them, to comply with the process of written informed consent, solve questions, and carry out the interviews. the places chosen were, mostly, their places of work, offices, or homes. additionally, their approval was obtained to audio record their narrations. to guarantee anonymity of the participants and safeguard their information, each experience was assigned an identification code. 5 gender inequalities in the health setting: the case of medicine l flor de maría cáceres-manrique y otros table 1. characteristics of participating female physicians source: own elaboration. categories defined a priori subcategories gender inequalities differences in labor wages. work overload because of being a woman. overburdened by work, child rearing, and caring for the family. relationships of power limited access to positions of leadership and power. lack of recognition by the patients. table 2. categories on relationships of power and gender inequalities perceived by some colombian female physicians source: own elaboration. the interviews were transcribed, read, and coded by the three researchers; thereafter, in consensus, the codes extracted were fine tuned to guarantee the credibility of the results. in total, 3125 codes were obtained related with the experience of relationships of power differential by gender. the information was processed through the nvivo10 program for qualitative analysis and interpreted by the researchers. the findings were validated in a meeting with participating and non-participating female physicians, in academic committees from the faculty of health at the university, and in conferences presented in three national and international events. the presentation and discussion of the findings in the aforementioned scenarios, and with said actors, is guarantee of the methodological rigor of the research. before starting the study, the research protocol was endorsed by the ethics committee in scientific research at universidad industrial de santander. the ethical principles were respected at all times for research with humans, as established in resolution 008423 of 1993 (21). characteristics of the women interviewed the study invited to participate 38 female physicians, of which 33 (86.8 %) were interviewed. the motives for their not participating were: two female physicians did not accept being interviewed, and with three, in spite of their accepting, it was impossible to set an appointment, given their occupations. participant age ranged between 29 and 60 years, with median age of 38 years, average of 39.6 years, and standard deviation of 6.7 years. they had been working between 6 and 35 years, with an average of 21 and a median of 19. other characteristics of the participants are presented in table 1. results the reports of experiences lived by the participants account for the disparities in the exercise of power that point to the existence of gender inequalities regarding labor wages, hiring terms, and responsibilities assigned. all this is conjugated into invisible barriers of access to positions of power and prestige, as well as the poor recognition by patients. table 2 summarizes the resulting categories and subcategories. the following describe the inequalities exposed, accompanied by testimonials from the participants. characteristic condition sample percentage (%) marital status single 6 18.2 married 21 63.6 common law 3 9.1 separated 3 9.1 number of chil-dren 0 12 36.4 1 6 18.2 2 12 36.4 3 3 9.1 level of for-mation general physician 7 21.2 gynecology or perina-tology 5 15.2 pathologist 3 9.1 epidemiologist 3 9.1 psychiatrist 3 9.1 occupational health 3 9.1 health worker 2 6.1 pediatrician 2 6.1 family physician 1 3 administrator 1 3 surgeon 1 3 anesthesiologist 1 3 geneticist 1 3 nature of the area of work public 19 57.6 private 4 12.1 public and private 10 30.3 6 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1927 aquichan issn 1657-5997 eissn 2027-5374 inequalities in labor wages most of those interviewed reported that the wages they earn are lower than those earned by their male colleagues in equal positions. they estimate differences between 30 % and 50 %. although they believe that the situation has improved, they state that it is a given that by merely being women they earn less than the men. they report that some managers, with the argument of hiring more personnel, not only pay them less, but make them responsible for “being willing” to receive less wages than the men. expressing it thus: “the woman’s labor is not valued in equal terms as the man’s, this is seen often in the administrative part. if she were a man, she would have to be paid more. that makes it easier to hire a female auditor or administrative assistant, but for less salary” (specialist in occupational health, 8 years of experience, private sector). “they say women ‘are willing’ to accept a lower wage than the men, in a rank even higher than that being offered them, and one remains concerned wondering: ‘how do we value the work we do that we allow them to take advantage of that situation?’” (health services administrator, 10 years of experience, private sector). regarding the difference in wages, some of the women opt for quitting: “in some institutions, while i am doing exactly the same as my colleague, he gets paid more than i do, 30 % or more. that is one of the reasons why i have had to quit: economic inequality” (gynecologist, 9 years of experience in public and private sectors). some consider that the income gap places them at a disadvantage, given that it implies their working more to obtain pay equivalent to the pay men get. additionally, the wage difference is used as a pretext to burden them with the household work, as expressed in the following: …my husband is also a specialist. never, even if i work the same time he works, will i earn the money he makes. that implies my having to spend more time at home, taking care of the girls, making lunch; given that he earns more, he works outside more. i would say that if i had more income, the burden of caring for the house would be the same. (occupational medicine, 12 years of experience, private sector) obstacles against hiring the women interviewed reported that, having been heard that the demands of maternity and child rearing imply women, employers see as an obstacle their hiring and, thus, tend to justify the preference for males, with excluding forms of hiring: “to hire a woman, there are many obstacles. i see the discrimination, for fear that women get married, request leaves to care for the children, get sick or request maternity leave” (general physician, 6 years of experience, private sector). discrimination to hiring is exerted subtly, as they report: “when you are going to be hired, you have to be interviewed, and the other candidate is a man, you note, as of the greeting, the difference in treatment. one knows it will be harder by the fact of being a woman” (psychiatrist, 5 years of experience, public and private sectors). work overload and caring for the family some professionals recognized that working in spaces dominated by men implies work overload, given the symbolic significance of certain tasks as exclusive responsibility of the women. thus, their male counterparts lead them to understand that because of their being women, they must execute tasks the men do not want to carry out, adducing that the women do them better. independent of the academic level reached, for being women they are assigned additional work, like making reports, writing letters, or organizing matters related with the wellbeing of others. thus, they expressed: “my coworkers are very uncooperative, they do not like to do anything; they are lazy. they only do what they have to do and what they like to do, but nothing more. a report, a form that needs to be filled out, or another thing, they say: ‘hey you (referring to a woman), do it; you do it perfectly” (sub-specialist, 15 years of experience, public and private sectors). those who are mothers are delegated with tasks of maternity and child rearing, which, on occasion, come into conflict with their work responsibilities, above all during fortuitous events, like sickness or disability. reported thus: …effectively, being a mother is indeed difficult to combine with the medical exercise: caring for the children, if they get sick, if you don’t have someone to help you with house chores, if your spouse is a physician, he continues working, as always, but you have to do things by yourself. (gynecologist, 6 years of experience, public and private sectors) besides working and caring for the children, they also sense they carry the responsibility of caring for the family and for orga7 gender inequalities in the health setting: the case of medicine l flor de maría cáceres-manrique y otros nizing matters of wellbeing at home, while men only work: “we, as women, have that responsibility of caring for our families. men go to work, they do not worry, come home and rest. but women go out to work and come home to care for her family: dads, children” (occupational medicine, 6 years of experience, private sector). these challenges require their investing greater efforts than men to keep up to date, besides complying with extra roles: “in such a demanding environment, where the men only worry about that which has to do with their work, never about the home, you as a female physician must dedicate greater physical and mental efforts to be at a competitive level” (general medicine, 12 years of experience, public and private sectors). “it is easier for men, without it sounding chauvinist, but the children are more attached to the mother. then, i do believe it is easier for men, and much more difficult for a woman, having 100 % of the fields solved: child rearing, the profession: double work” (pathologist, 15 years of experience, public and private sectors). limited access to positions of leadership and power the women consider that, in general, positions of leadership are held by men. they are the ones that figure in social events, business managers, directors of clinics and hospitals. but the women note that in the background there is a team, generally hidden, led by women, who do the most demanding work. i believe the leadership men have is very notorious. for example, the presidents of the association have always been men, and congress organizers are men. they are the speakers, they voice opinions, they state, and we “urge them”, but very few women end up having leadership. (pediatrician, 15 years of experience, public and private sectors) if the women have the opportunity to reach positions of power, sometimes, they feel relegated to a second plane, as they describe it: “when we sit there, we see it is a man’s world; we women are the secretaries, the advisors, the reporters. no matter how many women are there, the positions of leadership will always be in the hands of men” (sub-specialist, 20 years of experience, public and private sectors). some state with disdain the lack of gender solidarity in situations that imply exercises of power between men and women: we women are well-mannered, applied and have many biological advantages. the problem is that we have never achieved social advantage as a trade group. this happened with so and so, who was harassing me. my female co-workers got together and gave me the third degree. they asked me: “why is so and so in a bad mood? we think it is because of you, and you must solve the situation”. imagine, all of them women and defending the guy! (general physician, 14 years of experience, private sector) it is striking that some female physicians in positions of power assume authoritarian, cold, distant, or aggressive behaviors with their female co-workers, emulating their male colleagues, as adaptive response to the patriarchal system in which they work: “in positions of power and command is where some women end up adopting those patriarchal behaviors to keep their place in this heavily masculinized world” (health care worker, 26 years of experience, public and private sectors). the participants exposed cases in which the men establish tacit agreements to detract or minimize the arguments of the female physicians. the women, in their more conciliatory role, prefer not to argue to avoid controversy. some experience it thus: “in situations of crisis, of algid discussions, with mostly men, i felt they disrespected me that they did not consider what i thought only because i do not scream like they do; because i am a woman, moderate, i try to hold a dialogue, i try to exert the policy. but, basically, because of the fact of being a woman” (epidemiologist, 25 years of experience, public sector). nevertheless, knowing that the positions of power continue in the hands of men, they foresee, in the union as a trade group, hopes of reaching equality of opportunities: “that we really have the power of decision, we do not have it. if we were a trade group, we would have power, we would have positions of command, we would have equal wages, and we would have the same opportunities” (sub-specialist, 22 years of experience, public sector). lack of recognition by the patients from such social roots, it is possible to conceive the gender inequalities that women consider manage to permeate the behaviors of patients, who, on occasion, tend to not recognize their status. they state: “sometimes, the patients don’t address me as ‘doctor’, as they do say ‘doctor’ to the male co-worker. many times i ask them something and they barely respond. when my male co-worker arrives, who is my same age, with the same physician’s 8 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1927 aquichan issn 1657-5997 eissn 2027-5374 coat, then there they do start: ‘doctor, look at me here, doctor tell me such a thing…’, only because of being a woman” (occupational medicine, 9 years of experience, private sector). patients believe in men more. when i say something to patients, they say: “yes, the other doctor also told me the same”, like reaffirming that what the male doctor said is the truth. then, you have to make an effort to demonstrate that you are indeed good, that you do know. you have to gather arguments and read scientific articles for them to believe you because while the male physician’s word is the word of god, if you are a woman you have to reinforce it. (psychiatrist, 6 years of experience, public and private sectors) discussion the findings herein show that this group of health professionals experience gender inequalities regarding wages, forms of hiring, responsibilities assigned, access to positions of leadership and power, and recognition by their colleagues and patients, compared to men. that is, the distribution of power according to gender is not equitable. it is interesting that, in spite of efforts to achieve greater access to the career of medicine by women and, consequently, an academic level and equivalent social valuation in both sexes, said inequity continues. this phenomenon has been observed in prior studies (2), which also found that inequity is greater when wages are higher, independent of age and the educational level of the women (22). the results are consistent with three national studies about wage gaps according to gender. the first (23) found that women not only face a “glass ceiling”, but also a “quicksand floor”, given that inequities affect those earning a high or low wage, and estimated that if all colombian women worked, the wage gap would be nearly 50 % higher. another study concluded that between 25 % and 30 % of the wage differences by gender are associated to discrimination (24). one more holds that, although the educational level of women has improved, a high percentage receives lower wages than the men and works in less productive economic sectors (25). another of our findings were the subtle barriers to hiring female physicians. research conducted with medical students found, explicitly, discrimination based on gender (26). this contrast is of concern because, if as of the training women are discriminated, inequities will perpetuate in the professional performance. the participants also revealed that organizations maintain invisible barriers that keep women from holding leadership and power positions due to prejudice originated in social codes, as reported by previous studies, which demonstrate scarce participation by women in directive posts and a clear segregation by gender (27). consequently, female physicians occupy secondary positions due to gender discrimination, with lesser recognition, prestige, and power, as it occurred decades ago (1). such is the importance of the gender inequalities considered in a prior study, together with violence, political participation, and work, the spheres of greater magnitude of inequity against women, with indicators of lower power of decision, less opportunities for work, lower income, and double work shift (28). the participants in this study also accused work overload due to the work shift and caring for the family. in this sense, health care actions tend to be naturalized as appertaining to women (29), which shows asymmetric relationships of power and the symbolic efficacy that associates the act of caring with intrinsically feminine qualities (30). these constructions of gender permeate all the spheres of daily life and reinforce diverse inequalities (28), given that, as stated by foucault, the exercise of power is not limited to exclusion or repression, but acts also through normalization (18). the finding of women who, in positions of power, adopt macho behaviors was also reported (31). this behavior helps to maintain the gender inequality and the male ethic of the profession. under the pretext of gaining recognition from the patient, maintaining the status, and preserving the position, some women assume the dominant patriarchal discourse, add it and reproduce it onto their professional practice (2). furthermore, the lack of recognition by patients leads female physicians to limit their affective responses (32), given that they believe they lose power and that they are not taken seriously. it is fitting for female health professionals to internalize and communicate that their leadership style be distinguished from that of men because it promotes creativity, cooperation, and intuition in decision making; hence, it is convenient to become empowered and have confidence on the advantage of the values more culturally developed by women (9). finding gender inequalities in medicine is quite disappointing; it means that the historical exclusion of women from the profes9 gender inequalities in the health setting: the case of medicine l flor de maría cáceres-manrique y otros sion has turned into segregation, that the sexual division of work continues reproducing, and that the career is highlighted by its scarce female representation, both is specializations of greater prestige and power, as in high professional and academic levels (2). notwithstanding some advances, the persistence of gaps is undeniable between women and men (33). but the principal pitfall for empowerment is the macho culture that, as shown by our findings, crosses social life (34). this research was not exempt from limitations. in the first place, the representativeness of the sample: non-participation of five female physicians, two of them in key positions and with similar trajectories, limits the spectrum of testimonies without knowing if their points of view would coincide or disagree with those who did participate. the other three, two surgeons and an anesthesiologist, who were very busy, could have contributed with new experiences, precisely due to their situation of overburden, to the point of not having time to participate in the research. another limitation, in this case of the analysis performed, is not having compared the significance by age, specialty, or time of professional exercise, which would permit exploring how these variables affect the experience of inequality. the study opted for obtaining a general spectrum of the exercise of power by female physicians from various specialties, according to the general objective of the research. future work should address this comparative analysis. some of the strengths included that the field work was carried out by the researchers themselves and not by support staff, which ensured the necessary academic qualification and experience to guarantee its quality. likewise, the methodology used through interview techniques, face to face, and field diaries, which, due to the reflexivity, inter-subjectivity, and observational understanding they allow, are fundamental for the analysis, interpretation, and discussion of the findings. conclusion from the results of this study, it may be inferred that medicine maintains a power structure centered on men, with differential opportunities by gender, characterized by lower wages, more responsibilities, lesser recognition, and limited access to positions of prestige for women. as a complement to these results, said phenomenon should be explored in other health area professionals, like nursing, physical therapy, microbiology, or nutrition, seeking to continue constructing a fairer and more equitable society, in compliance with the sdo. conflict of interests: none declared. acknowledgments: to all the participants. references 1. rodríguez ac, castañeda gl. inicio de las mujeres en la medicina mexicana. revista de la facultad de medicina de la unam. 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[cited 2019 jan. 30]. 14 (02):73-87. doi: 10.15665/re.v14i2.792 https://www.elsevier.es/es-revista-educacion-medica-71-avance-resumen-la-mujer-medicina-del-siglo-s1575181318301232 https://www.elsevier.es/es-revista-educacion-medica-71-avance-resumen-la-mujer-medicina-del-siglo-s1575181318301232 http://www.scielo.org.mx/pdf/estsoc/v22n44/v22n44a10.pdf http://www.scielo.org.mx/pdf/estsoc/v22n44/v22n44a10.pdf https://doi.org/10.6018/eglobal.17.1.292331 http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s1132-12962004000200002&lng=es http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s1132-12962004000200002&lng=es http://dx.doi.org/10.1177/0891243209355978 http://https/doi.org/10.1097/acm.0b013e318248f718 http://www.eligered.org/wp-content/uploads/2017/06/unw16017-executive-summary-web-esp.pdf http://www.eligered.org/wp-content/uploads/2017/06/unw16017-executive-summary-web-esp.pdf http://dx.doi.org/10.15665/re.v14i2.792 1 daiana evangelista rodrigues fernandes1 marcelo medeiros2 walterlania silva santos3 mayara guimarães dos santos4 produção científica de enfermagem sobre a gravidez na adolescência: revisão integrativa 1 https://orcid.org/0000-0001-7238-5999. departamento de enfermagem, universidade federal de rondônia, brasil. daiana.rodrigues@unir.br 2 https://orcid.org/0000-0001-6979-3211. faculdade de enfermagem, universidade federal de goiás, brasil. marcelo@ufg.br 3 https://orcid.org/0000-0001-6266-8901. faculdade ceilândia, universidade de brasília, brasil. walterlania@unb.br 4 https://orcid.org/0000-0002-3340-3303. faculdade de enfermagem, universidade federal de goiás, brasil. recebido: 16/09/2019 submetido a pares: 30/10/2019 aceito por pares: 27/03/2020 aprovado: 16/04/2020 doi: 10.5294/aqui.2020.20.2.5 para citar este artículo / to reference this article / para citar este artigo fernandes der, medeiros m, santos ws, dos santos mg. nursing scientific production on teenage pregnancy: an integrative review. aquichan. 2020;20(2):e2025. doi: https://doi.org/10.5294/aqui.2020.20.2.5 resumo objetivo: identificar, na literatura científica nacional e internacional, as evidências produzidas pela enfermagem que forneçam subsídios para prevenir a gravidez na adolescência. material e método: estudo de revisão integrativa da literatura, a partir de artigos disponíveis nas metabases pubmed, bvs, scopus e web of science, e nas bases de dados lilacs e bdenf, em português, inglês e espanhol, produzidos de janeiro de 2013 a março de 2020. resultados: foram selecionados, de acordo com os critérios de inclusão, 13 artigos. os resultados obtidos são apresentados nas categorias “condições socioeconômicas desfavoráveis”, “conhecimentos, atitudes e aspectos culturais” e “educação sexual e serviços especializados”. conclusões: a gravidez na adolescência é fortemente associada à pobreza e a demais questões socioeconômicas. as relações de gênero, a comunicação sobre a educação sexual no âmbito familiar e outros aspectos culturais foram constatados nas discussões, o que indica sua influência sobre esse fenômeno. intervenções que envolvem a educação sexual se mostram como alternativa de enfrentamento. a presença do profissional enfermeiro nos ambientes que atendem ou concentram adolescentes pode ser um grande diferencial para reduzir os índices de gravidez nessa fase. palavras-chave (fonte: decs) adolescente; saúde do adolescente; gravidez na adolescência; educação sexual; saúde sexual e reprodutiva. año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2025 temática: promoção e prevenção. contribuição à disciplina: este estudo de revisão integrativa foi desenvolvido no intuito de identificar produções científicas da enfermagem a respeito da gravidez na adolescência, de modo a contribuir com a construção de um conjunto de conhecimentos sobre a temática que propicie subsídios para preveni-la. ao mesmo tempo, também foi possível identificar as lacunas do conhecimento acerca da temática. entendemos que os enfermeiros podem assumir papel de destaque no âmbito da saúde dos adolescentes e, especialmente, na questão da gravidez na adolescência. identificamos que a maioria dos estudos aborda adolescentes do sexo feminino com condições socioeconômicas menos privilegiadas. https://orcid.org/0000-0001-7238-5999 mailto:daiana.rodrigues@unir.br https://orcid.org/0000-0001-6979-3211 mailto:marcelo@ufg.br https://orcid.org/0000-0001-6266-8901 mailto:walterlania@unb.br https://orcid.org/0000-0002-3340-3303 https://doi.org/10.5294/aqui.2020.20.2.5 https://orcid.org/0000-0001-7238-5999%22 https://orcid.org/0000-0001-6979-3211 https://orcid.org/0000-0001-6266-8901 https://orcid.org/0000-0002-3340-3303 https://doi.org/10.5294/aqui.2020.20.2.5 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2025 producción científica de enfermería acerca del embarazo en la adolescencia: revisión integradora resumen objetivo: identificar, en la literatura científica nacional e internacional, las evidencias producidas por la enfermería que brinden subsidios para prevenir el embarazo en la adolescencia. material y método: estudio de revisión integradora de la literatura, con base en artículos disponibles en las metabases pubmed, bvs, scopus y web of science, y en las bases de datos lilacs y bdenf, en portugués, inglés y español, producidos entre enero de 2013 y marzo de 2020. resultados: se seleccionaron, de acuerdo con los criterios de inclusión, 13 artículos. los resultados se presentan por medio de las categorías “condiciones socioeconómicas desfavorables”, “conocimientos, actitudes y aspectos culturales” y “educación sexual y servicios especializados”. conclusiones: el embarazo en la adolescencia es fuertemente asociado a la pobreza y a otras cuestiones socioeconómicas. las relaciones de género, la comunicación acerca de la educación sexual en el contexto familiar y otros aspectos culturales se hallaron en las discusiones, lo que señala su influencia sobre el fenómeno. intervenciones que involucren la educación sexual se muestran como alternativa de afrontamiento. la presencia del profesional enfermero en los ambientes que atienden o concentran a adolescentes puede ser un gran diferencial para reducir los índices de embarazo en esta fase. palabras clave (fuente: decs) adolescente; salud del adolescente; embarazo en la adolescencia; educación sexual; salud sexual y reproductiva. 3 produção científica de enfermagem sobre a gravidez na adolescência: revisão integrativa l daiana evangelista rodrigues fernandes e outros nursing scientific production on teenage pregnancy: an integrative review abstract objective: to identify, in the national and international scientific literature, the evidence produced by nursing that provides subsidies to prevent teenage pregnancy. material and method: an integrative literature review study, based on papers available in the pubmed, bvs, scopus and web of science metabases, and in the lilacs and bdenf databases, in portuguese, english and spanish languages, published from january 2013 to march 2020. results: according to the inclusion criteria, 13 articles were selected. the findings are presented in the categories “lower socio-economic conditions”, “knowledge, attitudes and cultural aspects” and “sexual education and specialized services”. conclusions: teenage pregnancy is strongly associated with poverty and other socio-economic issues. gender relations, communication about sex education in the family and other cultural aspects were found in the discussions, which indicates their impact on this phenomenon. interventions involving sex education are shown as an alternative to cope. the presence of the nurse at the places that assist or concentrate adolescents can be a great element to reduce pregnancy rates in this phase. keywords (source: decs/mesh) adolescent; adolescent health; pregnancy in adolescence; sex education; sexual and reproductive health. año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2025 4 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2025 aquichan issn 1657-5997 eissn 2027-5374 introdução a taxa de gravidez na adolescência (ga) no brasil é superior à mundial. entre 2010 e 2015, segundo dados da organização pan-americana da saúde, para a qual a adolescência compreende a faixa etária de 15 a 29 anos, a taxa mundial de ga foi de 46 por 1.000 meninas. a ga pode repercutir negativamente sobre a saúde da mãe e do filho, além de poder apresentar complicações obstétricas. entretanto, não pode ser classificada como de risco somente pelo aspecto biomédico, mas também por todos os fatores biopsicossociais envolvidos. é consenso que a ga merece especial atenção no sentido de preservar a saúde materna, fetal e neonatal (2-10). precárias condições socioeconômicas, associadas à dificuldade de acesso aos serviços e à informação adequada contribuem para o problema (2-10). no sentido de desenvolver medidas de enfrentamento desse fenômeno, acreditamos que os profissionais enfermeiros têm significativa importância, visto que ocupam lugares estratégicos em todos os níveis de atenção à saúde. além disso, podem estar presentes não somente em serviços específicos de saúde, mas também em outros ambientes nos quais convivem adolescentes, especialmente, a escola. o enfermeiro qualificado tem potencial para ser um profissional de referência na defesa de práticas amigas da juventude (11, 12). para construir um corpus de conhecimentos que sirva de subsídio na atuação de enfermeiros e de outros profissionais, torna-se de essencial importância que a enfermagem se engaje na produção de evidências científicas sobre a saúde do adolescente e, em especial, sobre a ga. com isso, este artigo de revisão foi elaborado no sentido de verificar o estado da arte relacionado ao tema, com o objetivo de identificar, na literatura científica nacional e internacional, as evidências produzidas pela enfermagem que forneçam subsídios para prevenir a gravidez na adolescência, considerando a importância mundial do fenômeno e a necessidade de implementar medidas de abordagem diversificadas. material e método estudo de revisão integrativa da literatura, elaborado com base nas recomendações metodológicas do prisma statement (13). seguiram-se as etapas de: identificação dos relatos; eliminação dos duplicados; seleção dos relatos após a leitura do título e do resumo; seleção dos relatos após a leitura do texto na íntegra; seleção final dos relatos após a análise crítica (13). para atender ao objetivo proposto, desenvolveu-se, de acordo com a estratégia pico — acrônimo para paciente, intervenção, comparação e outcomes (desfecho) (14) —, a seguinte questão de pesquisa: qual a produção científica da enfermagem nacional e internacional no sentido de oferecer subsídios para a prevenção da gravidez na adolescência? as buscas foram realizadas nas metabases: public/publishmedline (pubmed), biblioteca virtual em saúde (bvs), scopus e web of science, estas duas últimas por meio do portal periódicos da coordenação de aperfeiçoamento de pessoal de nível superior, brasil. também foram realizadas buscas na base de dados literatura latino-americana e do caribe em ciências da saúde (lilacs) e base de dados de enfermagem (bdenf). a seleção dos estudos envolveu a combinação dos termos medical subject headings (mesh): “nursing” (and) “prevention and control” (and) “adolescence pregnancy”; além dos descritores em ciências da saúde (decs): “enfermagem” (and) “prevenção e controle” (and) “gravidez na adolescência”. foram incluídos, na pesquisa, artigos originais, provenientes de estudos experimentais, descritivos ou analíticos, quantitativos e qualitativos, disponíveis na íntegra, nos idiomas português, inglês e espanhol, realizados integralmente ou parcialmente por enfermeiros, publicados de janeiro de 2013 a março de 2020, que responderam à pergunta de pesquisa, o que demonstrou a produção científica de enfermagem nacional e internacional que oferece subsídios para prevenir a gravidez na adolescência. dessa forma, foram excluídos artigos de revisão, editoriais, dissertações, teses, relatos de experiência e outros gêneros textuais que não atendessem aos critérios de inclusão. os artigos foram avaliados primeiramente com base no título e no resumo, caso restasse alguma dúvida sobre a natureza do estudo ou sua adequação aos critérios de inclusão, procedia-se à leitura na íntegra. esses procedimentos foram realizados por dois pesquisadores de maneira independente, com comparação dos resultados ao final, para promover maior qualificação da revisão. após a seleção, os dados dos artigos foram extraídos para um formulário com os seguintes itens: identificação, objetivo, procedimentos metodológicos, principais resultados e conclusões. 5 produção científica de enfermagem sobre a gravidez na adolescência: revisão integrativa l daiana evangelista rodrigues fernandes e outros após a elaboração da questão de pesquisa, das buscas e extração dos dados dos artigos, demos continuidade ao processo com: categorização dos estudos encontrados, a partir dos seus principais resultados e contribuições; avaliação crítica dos estudos; interpretação dos resultados, com identificação das principais conclusões e implicações provenientes da revisão integrativa; elaboração da síntese da revisão, com descrição de todas as etapas realizadas, e apresentação dos resultados das análises (15). os dados são expostos de maneira a evidenciar os principais resultados dos artigos e discuti-los em categorias temáticas com outros autores. resultados inicialmente, foram encontrados 122 artigos e, destes, 35 foram excluídos por duplicidade. dos 87 artigos restantes, 30 foram excluídos devido à indisponibilidade do texto completo. após a leitura do título, do resumo e das credenciais dos autores, foram excluídos 41 artigos por não atenderem aos critérios de inclusão na pesquisa e, após a leitura na íntegra destes, outros três também foram excluídos. a seleção foi finalizada com 13 artigos (figura 1). figura 1. fluxograma de seleção dos artigos que compõem a revisão integrativa referente ao período de janeiro de 2013 a março de 2020 dentre os artigos selecionados, os estudos foram desenvolvidos em gana (n = 1), na áfrica do sul (n = 1), na nova zelândia (n = 1), no brasil (n = 2) e nos estados unidos da américa (n = 8). dez estudos foram desenvolvidos integralmente por enfermeiros e três estudos também tiveram a participação de profissionais de escolas médicas ou de saúde pública. os estudos brasileiros estavam disponíveis em português e em inglês; os demais estudos, apenas na língua inglesa. no quadro 1, podemos observar a listagem dos artigos selecionados com o código correspondente, a autoria, o periódico, o desenho do estudo, o nível de evidência e os principais resultados. as citações dos artigos que compõe os resultados desta revisão são acompanhadas do código do estudo, composto pela letra “e”, de estudo, e o número de ordem correspondente, estabelecido de acordo com o ano de publicação, do mais recente ao mais antigo. quanto aos aspectos gerais dos objetivos, identificamos que 46,1 % (n = 6) dos estudos se preocuparam em estudar fatores associados à ga. dois estudos de abordagem quantitativa e de desenho transversal (e4, e7), e dois estudos qualitativos (e11, e13) descrevem possíveis causas, conhecimentos sobre métodos contraceptivos e comunicação entre pais e filhos sobre sexo (16-19). outros dois estudos qualitativos exploraram opiniões e percepções, um deles (e9) com adolescentes do sexo feminino, nunca grávidas, sobre a ocorrência da gravidez e suas consequências para a vida do adolescente (20); outro (e2), com homens jovens sobre a ga (21). outra parte dos estudos, 38,5 % (n = 5), teve foco em intervenções; foram três (e1, e6, e12) ensaios clínicos randomizados (22-24), um (e10) estudo de coorte (25) para avaliar a efetividade de um ensaio clínico randomizado realizado anteriormente e um (e8) estudo qualitativo do tipo “grounded theory” (26). de maneira geral, todos os estudos realizados a partir de intervenções, foram direcionados à ampliação do conhecimento sobre métodos contraceptivos, gravidez, ists, mudanças de comportamentos e redução dos índices de ga (23-26). por fim, os outros estudos, 15,4 % (n = 2), preocuparam-se em avaliar, na perspectiva de adolescentes e de enfermeiros, a efetividade de centros de saúde escolares, um modelo americano de atenção à saúde dessa população. um deles (e3) avaliou, com abordagem quantitativa e um estudo transversal, o impacto do centro de saúde escolar sobre a saúde sexual de adolescentes; outro (e5) abordou, por meio de estudo fenomenológico, a experiência de enfermeiros em tais centros (27, 28). in cl us ão el eg ib ili da de s el eç ão id en ti fi ca çã o artigos identificados pubmed: 45 bvs: 31 scopus: 13 web of science: 4 artigos após a remoção dos duplicados (n = 87) artigos selecionados (n = 87) artigos com texto completo avaliados para a elegibilidade (n = 57) artigos incluídos na síntese qualitativa (n = 13) artigos incluídos na síntese quantitativa (n = 13) artigos excluídos (n = 30) artigos com texto completo excluídos com justificativa (n = 44) fonte: elaboração própria. 6 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2025 aquichan issn 1657-5997 eissn 2027-5374 quadro 1. listagem dos estudos com autoria, periódico, desenho do estudo, nível de evidência e principais resultados, nas metabases e bases de dados pubmed, bvs, scopus, web of science, bedenf e lilacs, de janeiro de 2013 a março de 2020 referência periódico desenho do estudo/nível de evidência principais resultados e1 — yakubu i, garmaroudi g, sadeghi r, tol a, yekaninejad ms, yidana a (2019) (22) reproductive health ensaio clínico randomizado/ nível de evidência: 1 intervenção educacional, baseada no health belief model, junto a adolescentes do sexo feminino, promoveu a redução da atividade sexual de adolescentes a curto prazo e aprimorou seus conhecimentos sobre a prevenção da gravidez. e2 — madlala st, sibiya mn, nqxongo tsp (2018) (21) african journal of primary health care & family medicine estudo de abordagem qualitativa/nível de evidência: 3 informações sobre sexo obtidas por meio de conversas com amigos, mídias digitais e revistas. responsabilização da mulher pelo conhecimento sobre reprodução. e3 — bersamim m, pachall mj, fisher d (2018) (27) the journal of school nursing quantitativo transversal/ nível de evidência: 4 adolescentes inseridos em centros de saúde escolares apresentam maior probabilidade de comportamentos sexuais saudáveis e uso de contraceptivos. e4 — grigsby sr (2018) (19) the journal of school nursing estudo de abordagem qualitativa/nível de evidência: 3 as participantes relataram basearem-se na fé, nos valores e experiências pessoais para comunicarem-se com suas filhas sobre sexo. e5 — daley am, polifroni c (2018) (28) the journal of school nursing estudo de abordagem qualitativa/nível de evidência: 3 os centros de saúde escolares são locais ideais para enfrentar ou minimizar barreiras aos cuidados contraceptivos por adolescentes, desde que sejam acessíveis e ofereçam confidencialidade. entretanto, alguns serviços apresentam restrições. e6 — chernick ls, stockwell ms, wu m, castaño pm, schnall r, westhoff cl et al. (2017) (23) journal of adolescent health ensaio clínico randomizado/ nível de evidência: 1 as adolescentes mais jovens responderam melhor à intervenção. acreditam que o desinteresse maior entre as adolescentes mais velhas foi devido ao contato anterior com as informações compartilhadas. e7 — harris al (2016) (16) journal of pediatric nursing quantitativo transversal/ nível de evidência: 4 a comunicação entre pais e filhos sobre sexo predominou entre mães e filhos. maior nível educacional dos pais não influenciou nos resultados. e8 — hoare kj, decker e (2016) (26) collegian estudo de abordagem qualitativa/nível de evidência: 3 a intervenção foi bem-recebida no estudo devido à sua discrição e abordagem da sexualidade de maneira positiva. 7 produção científica de enfermagem sobre a gravidez na adolescência: revisão integrativa l daiana evangelista rodrigues fernandes e outros verificamos que os estudos trazem importantes contribuições para o conhecimento científico relacionado ao tema, evidenciando aspectos sociais, culturais, familiares, e de intervencionais diante dos problemas relacionados. além disso, apesar de sua maioria (77 %) ter sido realizada exclusivamente por enfermeiros, percebemos que o conhecimento produzido é de interesse de toda a comunidade acadêmica e da sociedade em geral. discussão os estudos encontrados nos trazem importantes contribuições no sentido de conhecer o panorama atual de publicações produzidas por enfermeiros relacionadas à temática da ga. isso nos demonstra a tendência que os estudos têm seguido e quais são os pontos de maior relevância internacional, visto que se trata de um problema de abrangência global (1). verificamos que os dados obtidos se categorizam como apresentamos a seguir. condições socioeconômicas desfavoráveis nos estudos brasileiros (e11, e13), entre as adolescentes participantes das pesquisas e que apresentavam fatores que demonstravam maior risco de ocorrência da gravidez, ou que já referência periódico desenho do estudo/nível de evidência principais resultados e9 — child gd, knight c, white r (2015) (20) journal of pediatric nursing estudo de abordagem qualitativa/nível de evidência: 3 o uso do preservativo e a abstenção sexual como medidas para a prevenção da gravidez. ser bem-sucedido em suas atividades acadêmicas e esportivas foi um desejo que superou o de praticar sexo ou engravidar. e10 — serowoky ml, george n, yarandi h (2015) (25) worldviews on evidencebased nursing estudo de coorte/nível de evidência: 3 elevada satisfação com o programa que obteve retenção de 95,8 %. melhoria do conhecimento relacionado à prevenção de infecções sexualmente transmissíveis (ists) e de ga, além de atitudes e intenções direcionadas ao uso do preservativo e à redução na intenção de ter relações sexuais. e11 — ferreira eb, veras jla, brito as, gomes ea, mendes jpa, aquino jm (2014) (17) revista de pesquisa: cuidado é fundamental (on-line) quantitativo transversal/ nível de evidência: 4 participantes, na maioria pardas, católicas, estavam em relação consensual e apresentavam baixa renda familiar. demonstraram conhecimento dos principais métodos, com destaque para o preservativo de látex e o contraceptivo hormonal oral. e12 — sieving re, mcree al, secorturner m, garwick aw, bearinger lh, beckman kj et al. (2014) (24) perspectives on sexual and reproductive health ensaio clínico randomizado/ nível de evidência: 1 reduções em comportamentos sexuais de risco, agressão relacional e vitimização pela violência. e13 — assis mr, silva lr da, pinho am, moraes leo, lemos a (2013) (18) revista de enfermagem ufpe on-line estudo de abordagem qualitativa/nível de evidência: 3 sexarca entre 13 e 15 anos. não utilizavam preservativo ou outros métodos. a atividade sexual mostrou-se influenciada por variáveis sociais, culturais, econômicas e de gênero. fonte: elaboração própria. 8 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2025 aquichan issn 1657-5997 eissn 2027-5374 eram mães, verificou-se, com maior frequência, cor parda, religião católica, união consensual ou casamento, além de baixa escolaridade e baixa renda; por vezes, foi relatado o desejo de engravidar (18, 24). outros autores verificaram dados semelhantes: baixa escolaridade mostrou-se associada ao desejo de engravidar; além disso, entre algumas adolescentes de baixa renda, ser mãe pode representar um incremento no status social vivenciado. entretanto, a ocorrência da gravidez e o fato de ser mãe em contexto de baixa escolaridade e baixa renda são fatores de perpetuação da pobreza e de demais problemas socioeconômicos e educacionais (29-31). mulheres com oportunidade de desenvolvimento educacional também têm maiores chances de desenvolverem autoestima, empoderamento e motivação para evitar uma gravidez precoce. além disso, elas têm oportunidade de discutir os aspectos relacionados com a gravidez, sendo levadas a decisões conscientes e a comportamentos de proteção (29). corroborando de maneira perpetuadora com a baixa escolaridade e outros problemas socioeconômicos, um estudo demonstrou que as proles de mães adolescentes podem ter um desenvolvimento cognitivo mais deficitário, inclusive com redução significativa do quociente de inteligência, o que leva a maior necessidade de estímulos adequados para o desenvolvimento neurológico e educacional (32). além disso, a recorrência da ga na população também mostra-se associada com abandono escolar, baixa escolaridade e baixa renda (33, 34). apesar da união consensual ou do casamento ter se mostrado relevante nos estudos brasileiros, em outros países, a variável “estado civil” pode ser observada de maneira diferente. no japão, um estudo prospectivo verificou que o estado civil “solteiro” foi o mais frequente entre as mulheres que passaram por ga (35). os estudos descritivos norte-americanos (e7 e e9) desta revisão voltaram-se para a população negra e latina, visto que os índices de ga nessas populações são elevados quando comparados aos da população branca (16, 20). tais dados, juntamente com outros dados semelhantes quando se fala em ists, também foram observados por outros autores (34, 36). o estudo africano (e2) mostrou que precárias condições socioeconômicas podem levar à prática sexual insegura, com o objetivo de aliviar o estresse da vida cotidiana. além disso, o recebimento de auxílio social devido a uma gravidez foi visto como uma vantagem, o que leva alguns a desejarem ter filhos para obter o direito de receber tal benefício (21). jovens em condições sociais adversas, muitas vezes vítimas de intimidação, violência, usuários de álcool e de outras drogas, entre outros problemas, costumam negligenciar riscos e se expor de maneira significativa à ga e às ists (37). conhecimentos, atitudes e aspectos culturais entre os participantes dos estudos que compõe esta revisão, observou-se conhecimento sobre os principais métodos, com maior destaque para o preservativo de látex e o contraceptivo hormonal oral, entretanto, os próprios adolescentes referem não os utilizarem regularmente por descuido ou por desejo de engravidar; além disso, verificam-se vários equívocos sobre outros métodos contraceptivos. a abstinência sexual até o casamento foi citada como forma possível de evitar a gravidez indesejada (e2, e9, e11) (21, 20, 17). contudo, também foi reconhecida a prática cultural do coito interrompido, o que contribui para o risco de ga e de ists (e2) (21). a sexarca, primeira relação sexual, abordada em um dos estudos qualitativos (e13) com meninas, ocorreu com maior frequência entre 13 e 15 anos de idade; apesar disso, a maioria dos parceiros dessas mulheres adolescentes eram adultos e, em geral, não utilizavam preservativo ou outros métodos. a atividade sexual mostrou-se influenciada por variáveis sociais, culturais, econômicas e de gênero, além da imaturidade emocional das adolescentes (18). estudo realizado com base nos dados da pesquisa nacional de saúde escolar de 2016, pesquisa realizada pelo instituto brasileiro de geografia e estatística, confirma a iniciação sexual precoce de adolescentes escolares no brasil, com média de idade de 13,2 anos; ademais, entre os adolescentes que já haviam iniciado a vida sexual, 63 % eram do sexo masculino (38). em outro estudo qualitativo (e9), que tratou das opiniões, as adolescentes não perceberam nenhum benefício associado a ser uma adolescente grávida, pelo contrário, perceberam múltiplas consequências negativas. acreditavam que estar grávida quando adolescente afetaria negativamente sua educação, oportunidades 9 produção científica de enfermagem sobre a gravidez na adolescência: revisão integrativa l daiana evangelista rodrigues fernandes e outros esportivas e relacionamentos com seus pais e colegas. ser bem-sucedida em suas atividades acadêmicas e esportivas foi um desejo que superou o de praticar sexo ou engravidar (20). outro estudo já demonstrou que adolescentes podem ter consciência sobre a necessidade de métodos contraceptivos, entretanto não têm o conhecimento e esclarecimento necessários para sua utilização, embora os utilizem. fica evidente a necessidade de articular ações no âmbito das políticas públicas de saúde, da escola e da família, de modo a propiciar acesso aos serviços de saúde e à informação (39). o estudo qualitativo africano (e2) mostrou que a pressão dos amigos também foi um fator preponderante para a prática sexual; trata-se de uma necessidade para a confirmação do status do ser homem, considerando já a transição para a vida adulta. os anciões africanos do contexto estudado, com papel cultural muito importante, incentivam os jovens a manterem abstinência até o casamento, entretanto, o maior foco dessa estratégia é sobre as meninas. além disso, esses jovens reconheceram sua responsabilidade nos relacionamentos, mas acreditam que o conhecimento sobre a saúde reprodutiva é um domínio feminino (21). este resultado nos mostra a importância de discutir gênero no contexto das relações adolescentes, comportamentos de risco são altamente influenciados pelas relações de gênero, embasados no padrão heteronormativo, isto é, com dominação masculina. culturalmente, os meninos são altamente impulsionados ao namoro e às relações sexuais, quase que por obrigatoriedade, enquanto as meninas devem se resguardar: à mulher, cabe ser responsável e arcar com as consequências de seus atos (40-43). outro ponto quanto aos aspectos culturais que merece atenção é o casamento infantil, presente em alguns países. a prevenção de tal evento implica a prevenção de gestações precoces, isso porque, além de sofrerem com o casamento determinado pela família, essas meninas sofrem pressão para terem filhos (29, 44, 45). o casamento infantil/adolescente é um problema reconhecido por instituições internacionais, as quais recomendam o seu combate pela influência exercida sobre os indicadores de ga e pelas repercussões negativas para a vida da mulher (1). por sua vez, já foi demonstrado que a maternidade também pode ser um fator de proteção para as adolescentes que vivem o fenômeno das drogas, porque se tornar mãe preencheu um vazio emocional que elas tentavam ocupar com as drogas. para essas jovens, a maternidade representou salvação, uma vez que foram motivadas a resistir à tentação das drogas pelo desejo de serem pessoas melhores e pensarem em um futuro diferente com seus filhos (46-48). educação sexual e serviços especializados a comunicação a respeito da educação sexual foi vista como tabu, independentemente da configuração familiar (no que tange à presença paterna). os participantes utilizam como fontes de informação conversas com amigos, mídias digitais e revistas. o estudo que fez tais constatações (e2) também identificou a importante participação dos anciões no processo de iniciação dos homens à vida adulta e como forma de preenchimento da lacuna deixada pelas famílias no âmbito da educação sexual; contudo, o assunto ainda permanece um tabu nesse contexto (21). foi demonstrado que a comunicação entre pais e filhos (sexo masculino) sobre sexo predominou entre mãe e filhos, independentemente do contexto demográfico. apesar dos menores índices de comunicação do pai com os filhos, quando pensados em conjunto, pais (pai e mãe) de ambiente suburbano apresentaram maior comunicação sobre sexo com os filhos do que os pais de ambiente urbano. ainda que maior nível educacional dos pais não tenha interferido nos resultados (e7) (16), a influência daqueles na percepção dos adolescentes sobre a ga foi notória (e9) (20). um de nossos estudos (e4) preocupou-se em descrever fatores que influenciam na comunicação entre mães e filhas sobre saúde sexual e reprodutiva, e verificou que as mães participantes se basearam na fé, nos valores pessoais e nas experiências particulares nesse processo de comunicação. com isso, a partir de tais concepções, transmitem, às suas filhas, valores relacionados à vida e à feminilidade. referem, inclusive, grande dificuldade e constrangimento em falar sobre algumas questões, com destaque para as relações sexuais entre pessoas do mesmo sexo e para o sexo oral. entretanto, reconhecem que a comunicação deve ocorrer precocemente, de maneira adequada para cada idade (19). os estudos desta revisão trazem a importância de intervir mediante ações de educação sexual junto aos adolescentes, para interferir na condição de vulnerabilidade em relação à gravidez precoce, prevenindo sua ocorrência (17). 10 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2025 aquichan issn 1657-5997 eissn 2027-5374 cinco estudos dedicam-se a relatar intervenções ou avaliar seus resultados; dois, a conhecer aspectos relacionados a serviços voltados a adolescentes escolares. o primeiro estudo (e1) realizou intervenção educativa guiada pelo health belief model, o qual trabalha aspectos relacionados à suscetibilidade e à gravidade percebidas em relação à ga, bem como a possíveis consequências e benefícios em adiar uma gravidez. as participantes demonstraram maiores conhecimentos relacionados à prevenção da gravidez e à redução da atividade sexual devido à abstinência intencional (22). o segundo estudo (e6) desenvolveu-se a partir de mensagens de texto enviadas aos telefones de um grupo de adolescentes do sexo feminino. a ação mostrou-se viável e com aceitação alta; apesar disso, não foi unânime, e a iniciação contraceptiva foi limitada. verificaram que quanto mais jovens os participantes, melhores os resultados da intervenção (23). o terceiro estudo (e10) voltou-se a um programa de desenvolvimento para adolescentes, no qual os participantes demonstraram elevada satisfação, com adesão de 95,8 %. com isso, identificaram melhoria do conhecimento relacionado às ists e à ga, além de atitudes e intenções direcionadas ao uso do preservativo, bem como redução na intenção de ter relações sexuais (25). o quarto estudo (e12) verificou reduções em comportamentos sexuais de risco, agressão relacional e vitimização pela violência. acredita-se que tais achados se devem também a uma intervenção de desenvolvimento juvenil. além disso, o aumento nas matrículas em ensino pós-secundário e as habilidades intrapessoais identificadas em determinado ponto de acompanhamento sugerem que a intervenção tenha sido capaz de fomentar comportamentos saudáveis (24). o quinto estudo (e8) avaliou a efetividade de uma intervenção baseada na entrega de folheto informativo de maneira discreta, por meio de uma estratégia denominada “teabag”, na qual um folheto informativo sobre sexualidade foi colocado em um saquinho de chá e entregue no momento em que os adolescentes saíam de férias escolares. tal medida foi tomada após observarem aumento nos números de ga quando os adolescentes retornavam às aulas. na perspectiva dos adolescentes, o folheto promoveu empoderamento, visto que a abordagem utilizada foi positiva, reconhecendo a vida sexual ativa daqueles adolescentes, promovendo o sexo seguro e valorizando a comunicação entre os parceiros (26). um dos estudos (e3) que abordou a iniciativa dos centros de saúde escolares verificou associação entre a existência destes e os comportamentos sexuais saudáveis de adolescentes, assim como o uso de contraceptivos, especialmente entre adolescentes com condições socioeconômicas mais desfavoráveis e nos serviços onde há prescrição e dispensação de contraceptivos (27). ao mesmo tempo, outro estudo (e5) sobre a mesma temática verificou que enfermeiros consideram o centro de saúde escolar como local ideal para o enfretamento e a minimização de barreiras aos cuidados contraceptivos de adolescentes, desde que sejam acessíveis e ofereçam confidencialidade. entretanto, esbarram em dificuldades relacionadas à disponibilidade de contraceptivos e de restrições quanto à confidencialidade do atendimento e à liberdade do adolescente na utilização do serviço, visto que os pais podem restringir o acesso (28). intervenções para a prevenção da gravidez na adolescência devem incluir ações baseadas nas evidências provenientes da própria comunidade, com o envolvimento de atores e de aparelhos sociais, o treinamento das pessoas envolvidas, a assistência técnica sempre que necessário, o acesso aos serviços, a associação entre serviços de saúde e escola, a qualidade na assistência oferecida e a ênfase nas comunidades com maiores necessidades. tais intervenções levam tempo e esforço conjunto (49, 33). idealmente, devem ser desenvolvidos programas holísticos integrados com a preparação para a vida adulta, especialmente nas sociedades mais conservadoras (37). programas para a mudança de hábitos e comportamentos têm apresentado potencial de adesão dos adolescentes, não só para comportamentos seguros, mas também para abstinência; tais programas mostram-se fundamentais enquanto os índices de ga e de ists estiverem elevados (50). as intervenções, iniciativas ou programas, não podem ser realizadas da mesma forma para diferentes públicos; pelo contrário, precisam ser reconhecidos as normas locais, as relações de gênero, as estruturas familiares, o contexto cultural, os valores religiosos, os discursos compartilhados pelos jovens e os demais aspectos da realidade, de modo que o modelo educativo empreendido se mostre de fato pertinente àqueles adolescentes. mediante tais cuidados, há maior chance de sucesso (41, 51). aos adolescentes usuários de bebidas alcóolicas ou de outras substâncias, deve ser dada especial atenção, visto que os programas ou projetos voltados para a educação sexual podem 11 produção científica de enfermagem sobre a gravidez na adolescência: revisão integrativa l daiana evangelista rodrigues fernandes e outros conseguir efeitos positivos, apesar da resistência natural. porém, deverão ser insistentes e repetitivos no desafio de promover comportamentos sexuais seguros. mais uma vez, não podemos esquecer a importância da integração das ações com vistas ao desenvolvimento holístico desse adolescente. nesse sentido, é necessário implementar um processo educativo contínuo, planejado e monitorado que aborde tanto a ga e as ists quanto o uso de substâncias psicoativas (52). apesar das realidades das periferias, a comunicação frequente e de qualidade sobre sexualidade, gênero e comportamentos seguros, entre pais e filhos, e na escola com a participação dos professores, mostra-se fator fundamental para promover comportamentos seguros na prática sexual de adolescentes. contudo, nem sempre os pais estão preparados para orientar seus filhos adequadamente; portanto, faz-se necessário que os pais também recebam orientações que ampliem seus conhecimentos e os ajudem a romper possíveis barreiras (53). é primordial que os homens desde a adolescência também sejam envolvidos em ações para conhecer as necessidades de saúde dos adolescentes ou promover a saúde sexual e reprodutiva nessa população. a abordagem dos meninos é fundamental não só para a promoção da saúde, mas também para o desenvolvimento da paternidade responsável no futuro (54). adolescentes gestantes ou em maior risco de engravidar, assim como seus parceiros, devem ser atendidas tanto sob a perspectiva da vulnerabilidade quanto a da resiliência, com trabalhos voltados para o desenvolvimento de competências que as permitam buscar e encontrar o aporte social, econômico e cultural necessários às suas condições. os adolescentes podem ser vistos como agentes sociais ativos que não somente sofrem com as características do meio no qual estão inseridos, mas que também podem transformar suas realidades no âmbito doméstico e no comunitário (55). conclusões enfermeiros em diferentes países têm colaborado para a construção do conhecimento a respeito da saúde adolescente e da ga. os estudos demonstraram que o problema da ga é fortemente associado à pobreza e a demais questões socioeconômicas, além de ser influenciado por aspectos estruturais como oferta e acesso aos serviços de saúde, bem como informação adequada para adolescentes. as relações de gênero, a comunicação sobre a educação sexual no âmbito familiar e outros aspectos culturais estiveram presentes nas discussões, o que mostra sua influência sobre esse fenômeno. observamos que a maioria dos estudos se preocuparam em estudar a ga sob a perspectiva feminina, com o recrutamento de adolescentes exclusivamente do sexo feminino, o que aconteceu em 77 % dos estudos. um dos pontos a ser combatido na sociedade é o olhar de responsabilização de questões relacionadas à sexualidade somente sobre a mulher; nesse sentido, consideramos de suma importância envolver os adolescentes do sexo masculino em futuros estudos e ações que visem promover comportamentos seguros em relação ao sexo. da mesma forma, percebemos que os estudos não abordaram explicitamente adolescentes em escolas ou instituições de saúde privadas, o que demonstra uma lacuna do conhecimento em relação a essas pessoas, fato que chama a atenção, visto que a ga também pode ser observada na população desses contextos. a educação sobre saúde sexual e reprodutiva mostrou-se como caminho a ser seguido no sentido de enfrentar o problema da ga, bem como de outros eventos associados ao exercício da sexualidade. também ficou evidente que essa medida deve ser implementada o quanto antes na vida dos adolescentes, para que eles tenham acesso à informação adequada e assumam comportamentos saudáveis. além da prática sexual em si, outros aspectos da vida relacionam-se com desfechos indesejados para a adolescência, como a violência sexual e de gênero, a baixa autoestima e o abuso de substâncias psicoativas. por essas razões, a presença do profissional enfermeiro que realize um trabalho holístico nos ambientes frequentados por adolescentes, juntamente com outros profissionais, pode ser um grande diferencial para promover a saúde do adolescente e reduzir os índices de gravidez na adolescência. a enfermagem precisa se posicionar e mostrar a importância de sua atuação para a saúde e o bem-estar do adolescente. por último, considerando a proposta deste trabalho de identificar subsídios para prevenir a ga entre as publicações nacionais e internacionais de enfermagem, reconhecemos como limitação o número reduzido de estudos com adolescentes do sexo masculino e a não abordagem de populações com condições socioeconômicas diferentes. conflitos de interesse: nenhum declarado. 12 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2025 aquichan issn 1657-5997 eissn 2027-5374 referências 1. pan american health organization, united nations population fund and united nations children’s fund. accelerating progress toward the reduction of adolescent pregnancy in latin america and the caribbean. report of a technical consultation. 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and future fatherhood. j adolesc health. 2016;58(5):497-503. doi: https://doi. org/10.1016/j.jadohealth.2015.12.010 55. ahorlu ck, pfeiffer c, obrist b. socio-cultural and economic factors influencing adolescents’ resilience against the threat of teenage pregnancy: a crosssectional survey in accra, ghana. reprod health. 2015;12:1-11. doi: https://doi. org/10.1186/s12978-015-0113-9 http://doi.org/10.1097/jan.0000000000000167 https://doi.org/10.21149/7959 https://doi.org/10.1016/j.jadohealth.2015.12.010 https://doi.org/10.1016/j.jadohealth.2015.12.010 https://doi.org/10.1186/s12978-015-0113-9 https://doi.org/10.1186/s12978-015-0113-9 207 211 primeras paginas.indd 281 gloria carvajal-carrascal1 clara virginia caro-castillo2 soledad en la adolescencia: análisis del concepto 1 candidata a doctor en enfermería. universidad de la sabana. chía, colombia. gloria.carvajal@unisabana.edu.co 2 doctora en enfermería. universidad nacional de colombia. cvcaroc@unal.edu.co recibido: 21 de julio de 2009 aceptado: 13 de octubre de 2009 resumen la soledad es una experiencia conocida por todos los seres humanos, inherente a la necesidad de pertenecer y que actualmente es considerada como una epidemia de la sociedad moderna, un problema de salud pública que por sus consecuencias físicas, mentales y sociales requiere un abordaje desde múltiples perspectivas. así mismo, la adolescencia es una etapa especialmente vulnerable para experimentar sentimientos de soledad que son un factor significativo para la salud y la calidad de vida de los adolescentes y como tal es relevante para el cuidado de enfermería. este articulo tiene como objetivo analizar el concepto de soledad en la adolescencia a través de la metodología propuesta por walker y avant, estrategia a través de la cual se examinan las características que definen un concepto y sus atributos. el conocimiento de este fenómeno permitirá proponer estrategias de prevención e intervención, y guiar la práctica de cuidado en este grupo de edad. palabras clave soledad, adolescencia, salud mental, enfermería. (fuente: decs, bireme). loneliness during adolescence: analysis of the concept abstract loneliness is an experience known to all human beings. inherent in the need to belong, it is regarded as an epidemic in modern society, a public health problem that needs to be addressed from a variety of perspectives, given its physical, mental and social consequences. adolescence is a particularly vulnerable stage for experiencing feelings of loneliness, which are a significant factor for adolescent health and quality of life and , as such, it is relevant to nursing care. the purpose of this article is to analyze the concept of loneliness during adolescence through the method proposed by walker and avant, which is a strategy for examining the characteristics that define a concept and its attributes. an understanding of this phenomenon will make it possible to propose strategies for prevention and intervention, and to guide care for this age group. key words loneliness, adolescence, mental health, nursing. (source: decs, bireme). año 9 vol. 9 nº 3 chía, colombia diciembre 2009 281 296 282 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 solidão na adolescência: análise do contexto resumo a solidão é uma experiência familiar a todos os seres humanos, inerentes à necessidade de pertencer e agora é considerada uma epidemia da sociedade moderna, um problema de saúde pública cujo desenvolvimento físico, mental e social deve abordar-se desde múltiplas perspectivas. além disso, a adolescência é uma etapa especialmente vulnerável aos sentimentos de solidão – um fator significativo na saúde e qualidade de vida dos adolescentes e, como tal, relevante para a assistência de enfermagem–. este artigo tem como objetivo analisar o conceito de solidão na adolescência através da metodologia proposta por walker e avant, estratégia que permite examinar as características que definem um conceito e seus atributos. conhecimento deste fenômeno vai sugerir estratégias de prevenção e de intervenção e orientar a prática do cuidado neste grupo etário. palavras-chave solidão, adolescência, saúde mental, enfermagem. (fonte: decs, bireme). 283 soledad en la adolescencia: análisis del concepto gloria carvajal-carrascal, clara virginia caro-castillo introducción porque la soledad está dentro de nosotros y fuera de nosotros, porque cada uno de nosotros contiene su propia soledad y también aumenta la soledad de los demás, porque hay características de nuestra sociedad que exacerban la soledad, y porque no podemos manejarla o verla, sino sentirla, la soledad se ha convertido en el vehículo de nuestra miseria (1). la soledad es un tema que ha estado presente a lo largo de la historia a través de la música, la poesía y la literatura (2). sin embargo, a pesar de que es una experiencia conocida universalmente por todos los seres humanos, es difícil de definir, casi imposible de cuantificar y, muchas veces, penosa para los individuos, a quienes se les dificulta revelar abiertamente este sentimiento a otros (3). karnick (2) afirma que la soledad es un problema que ha sido sistemáticamente negado como un trastorno que requiere atención seria, tal vez porque quienes lo sufren no siempre admiten que puede ser la raíz de otros problemas, o porque no se ve como una entidad separada. las personas que sufren de soledad no quieren reconocerse como “solas”, debido a que experimentan sentimientos de vergüenza o dificultad para superar el aislamiento. además, refiere que quizá los seres humanos son capaces de identificar sus propios sentimientos de soledad cuando ellos reconocen los sentimientos de soledad en otros. otros hallazgos indican que esta problemática no se asocia con búsqueda de ayuda especializada porque no se percibe por las personas como algo patológico, sino como una característica normal de la vida (4). actualmente, el aumento en las tasas de soledad puede ser justificado como consecuencia de los cambios en la distribución de edad de la población, cambios en la estructura de las relaciones sociales, aumento de las familias monoparentales, aumento en el número de personas que desean vivir solas, aumento de las demandas sociales que implican aislamiento, y disminución de la probabilidad de satisfacer las necesidades emocionales y sociales (5). la soledad es un potente, pero poco conocido, factor de riesgo que se asocia con morbimortalidad (4, 6). dentro de sus efectos cabe mencionar alteraciones en la salud física (enfermedades cardiovasculares, trastornos de la alimentación, problemas de sueño), y alteraciones en la salud mental (depresión, suicidio y abuso de alcohol y drogas, entre otros) (7). holmen y cols. (8) sugieren que un aumento en la mortalidad general puede ser asociado con el aislamiento social que a menudo acompaña la soledad. es necesario diferenciar las características de los términos soledad, estar solo, aislamiento, enajenación y soledad positiva, que se utilizan indistintamente en la literatura de enfermería para referirse a la “experiencia de soledad”, pero que enmarcan significados distintos (2, 4, 7, 9, 10, 11, 12). a continuación se presenta el análisis del concepto “soledad”, haciendo énfasis en la etapa de la adolescencia. el estudio de este concepto, aunque de gran interés por los karnick afirma que la soledad es un problema que ha sido sistemáticamente negado como un trastorno que requiere atención seria, tal vez porque quienes lo sufren no siempre admiten que puede ser la raíz de otros problemas, o porque no se ve como una entidad separada. 284 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 efectos que produce a nivel físico, mental y social, ha estado vinculado a otros conceptos como depresión o ansiedad, lo que dificulta la definición de sus atributos específicos y sus necesidades de cuidado. el conocimiento del fenómeno permitirá proponer estrategias de prevención e intervención, y guiar la práctica de cuidado para este grupo de edad (13). la metodología utilizada para este análisis es la propuesta por walker y avant (14), quienes afirman que el análisis de conceptos es una vía para el desarrollo de la teoría, que proporciona una oportunidad para explicar y describir fenómenos de interés para la práctica. es una estrategia a través de la cual se examinan las características que definen el concepto y los atributos que permiten decidir qué fenómeno es buen ejemplo del mismo y cuál no. así, el análisis de conceptos es un ejercicio lingüístico para determinar sus atributos, y aunque es un proceso riguroso y preciso, el producto final siempre será tentativo (14). importancia del análisis del concepto de soledad en la adolescencia actualmente, la población se ve afectada por factores como inseguridad, un bajo nivel educativo, vivienda inadecuada, mala nutrición, abuso de alcohol y otras sustancias, maltrato, y conflictos familiares que alteran de forma significativa la calidad de vida en las esferas física, social, emocional y mental. estos factores ocasionan en los individuos y las familias experiencias de inseguridad, desesperanza, soledad, riesgos de violencia y problemas en la salud física (15). de la misma forma, afectan de manera directa a los adolescentes en una etapa que generalmente es descrita como una fase de transición en el desarrollo del ser entre la niñez y la adultez, que se inicia por los cambios puberales y se caracteriza por profundas transformaciones biológicas, psicológicas y sociales, muchas de ellas generadoras de crisis, conflictos y contradicciones (16, 17, 18). así, muchos de los problemas de los adolescentes se encuentran relacionados con sus comportamientos y con el contexto social que los rodea. aunque en la mayoría de los casos la adolescencia representa una etapa de crecimiento y maduración con buenos resultados, en algunas oportunidades se convierte en una época conflictiva, con comportamientos que pueden ocasionar resultados devastadores como la enfermedad y la muerte. la necesidad de adaptación a los cambios físicos, psicosociales y a los factores del contexto convierten a la adolescencia en un periodo de mayor vulnerabilidad para la aparición de problemas de salud, incluyendo aquellos de la esfera mental, emocional y social, especialmente si a ello se le suman acontecimientos que aumentan la carga emocional, como rechazo por parte de la pareja, falta de comunicación con los padres, dificultades para alcanzar las aspiraciones propias o las expectativas de los padres, y conflictos familiares. morrison (19) afirma que la salud mental de los adolescentes está influenciada por los sentimientos de bienestar que incluyen la capacidad de interactuar socialmente, afrontar el estrés en los periodos difíciles, e implicarse en relaciones y actividades con los demás. la soledad puede ser una experiencia que se espera en cierto grado durante la adolescencia, teniendo en cuenta que ésta aunque en la mayoría de los casos la adolescencia representa una etapa de crecimiento y maduración con buenos resultados, en algunas oportunidades se convierte en una época conflictiva, con comportamientos que pueden ocasionar resultados devastadores como la enfermedad y la muerte. 285 soledad en la adolescencia: análisis del concepto gloria carvajal-carrascal, clara virginia caro-castillo es una etapa en la cual las expectativas, los roles, las relaciones y las identidades sufren cambios significativos. la revisión de literatura de heinrich y gullone (7) muestra que el paso a la adolescencia implica para los jóvenes el desarrollo de expectativas hacia sus relaciones sociales, esperando lealtad, apoyo e intimidad; y que sufren, además, un cambio frente a las creencias, los valores y ideologías de los amigos, con los que antes solo compartían ciertas actividades. así, la soledad puede surgir si los adolescentes no han adquirido la aptitud necesaria para la interacción social y para enfrentarse con un ambiente social cambiante, o si ellos tienen esperanzas poco realistas con respecto a sus relaciones sociales (7). la transición hacia esta etapa también implica que los adolescentes dediquen menos tiempo a la familia y más a sus pares, reemplazando las figuras primarias de contacto (20). simultáneamente, los adolescentes tratan de definirse a sí mismos entre los cambios fisiológicos, emocionales e intelectuales que pueden alterar su autoconcepto; ellos pueden definirse de una manera cada vez más compleja y abstracta. esto implica la formación de la identidad no sólo por sus características físicas, sino también por las psicológicas (por ejemplo, los rasgos, los pensamientos, las creencias y los valores), y con respecto a sus relaciones sociales. sin embargo, en ese camino para lograr autonomía, individualidad y formación de la identidad, aparece el riesgo de experimentar los sentimientos de separación y responsabilidad, y de ahí una necesidad más fuerte para la afiliación, y vulnerabilidad a la soledad emocional y social. la adolescencia, entonces, es un periodo de alto riesgo para la soledad. sin embargo, mientras durante este periodo es de esperar algún grado de soledad, los sentimientos persistentes y dolorosos de este sentimiento no son normales. además, el fracaso para resolver la soledad antes terminar la adolescencia puede alterar en forma significativa las relaciones sociales futuras y la salud mental (7, 20). un factor que se asocia con frecuencia a la soledad durante la adolescencia está dado por los cambios en la estructura familiar y las características de la relación padres-hijos. los cambios en la estructura familiar pueden hacer difícil para los adolescentes obtener apoyo, guía y satisfacción de las necesidades interpersonales básicas. aspectos como desintegración familiar, familias reconstituidas, entre otros, disminuyen las relaciones familiares y aumentan comportamientos como abuso de drogas, problemas emocionales y de la conducta, y bajo desempeño escolar (21). otros factores asociados a la soledad son los sentimientos negativos de tristeza y desesperanza, este último entendido como una sensación de “no futuro” o de pesimismo hacia el mismo (22). por ejemplo, la literatura muestra que los sentimientos de soledad y desesperanza se asocian con conducta suicida entre adolescentes (23, 4, 24, 25, 11, 12, 26, 27, 28, 29). adicionalmente, se observa una fuerte relación entre soledad, desesperanza y conflicto familiar; estos factores, en combinación, juegan un papel importante en la adopción de conductas de riesgo y autodestrucción entre los adolescentes (30, 31). los sentimientos de desesperanza, fracaso, relaciones interpersonales deficientes, soledad, aislamiento y culpa son factores relacionados con el comportamiento suicida en jóvenes (32). un factor que se asocia con frecuencia a la soledad durante la adolescencia está dado por los cambios en la estructura familiar y las características de la relación padres-hijos. 286 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 si la adolescencia es un tiempo de riesgo para experimentar sentimientos de soledad, analizar el concepto se hace fundamental debido a que se ha observado un aumento en sus niveles de presentación en esta etapa de la vida, y una asociación como factor de riesgo importante de estudio, derivado de condiciones socioeconómicas, culturales y familiares adversas que ocasionan desenlaces fatales que incluyen enfermedad, muerte y comportamiento antisocial en el adolescente (7, 21, 25, 12). sólo en lo últimos años la soledad ha sido considerada como un problema de salud, que requiere intervención desde múltiples aproximaciones y perspectivas. actualmente se considera que es una epidemia de la sociedad moderna, que con el paso de los años ha aumentado sus tasas en todas las edades, pero que acentúa sus picos de presentación en etapas de la vida como la adolescencia (11, 12). dado que la soledad es un factor significativo para la salud y la calidad de vida, es relevante para el cuidado de enfermería (2). definiciones y usos del concepto algunas frases célebres que ilustran el concepto de soledad el infierno está todo en esta palabra: soledad. víctor hugo (novelista francés). sólo salgo para renovar la necesidad de estar solo. lord byron (poeta británico). la soledad se admira y desea cuando no se sufre, pero la necesidad humana de compartir cosas es evidente. carmen martín gaite (novelista española). ¿por qué, en general, se rehuye la soledad? porque son muy pocos los que encuentran compañía consigo mismos. carlo dossi (escritor italiano). el instinto social de los hombres no se basa en el amor a la sociedad, sino en el miedo a la soledad. arthur schopenhauer (filósofo alemán). la soledad no significa estar solo. noel pierce coward (escritor británico). definiciones a partir de diccionarios la soledad es definida por el websters new universal unabridged dictionary (33) como un estado o calidad de ser solitario, estar apartado de otros, aislamiento, ser infeliz estando solo; o anhelo de amigos o de compañía. el oxford english dictionary (34) define soledad como la calidad o condición de estar solitario; la necesidad de la sociedad o la compañía; el sentimiento de estar solo; el sentido de soledad; o el desaliento que surge de la necesidad de compañía. revisión de la literatura la soledad es un fenómeno multidimensional que varía en intensidad, causas y circunstancias en las que se presenta, y que no distingue entre edad, género, raza, nivel socioeconómico o estado civil (7). a continuación se presentan, en orden cronológico, las diversas definiciones de soledad que se encuentran a través de la revisión de la literatura. en nilsson et ál. (9) se define la soledad desde tres perspectivas: 1) soledad física, cuando se presenta ruptura física con otros; 2) sentimiento de soledad cuando se es excluido por otros; 3) sentimienla soledad es un fenómeno multidimensional que varía en intensidad, causas y circunstancias en las que se presenta, y que no distingue entre edad, género, raza, nivel socioeconómico o estado civil. 287 soledad en la adolescencia: análisis del concepto gloria carvajal-carrascal, clara virginia caro-castillo tos de aislamiento de uno mismo y deseo de soledad. el análisis del concepto desarrollado por brown (1) presenta la soledad como un espacio con pérdida de los puntos de referencia, sufrimiento con respecto al destino de la persona, crisis de identidad y enajenación de sí mismo. este análisis, además, identificó dos tipos de soledad, una causada por pérdida de un objeto o propósito, también llamada soledad secundaria, y soledad por sí misma, caracterizada por sentimientos de estar solo y sin ayuda en el mundo, también llamada soledad primaria (1). lopata (35), en un artículo basado en descripciones de personas que experimentaban situaciones de soledad, la definió como un sentimiento de interacción inadecuado experimentado por la persona. este sentimiento involucra pasado (situación de soledad ocasionada por una persona, objeto o evento anteriores), presente (ausencias o pérdidas actuales, o patrones de interacción diferentes), y futuro (ansiedad por el futuro). weiss (36) afirma que los sentimientos de soledad son considerados como una deficiencia en los sistemas de interacción interpersonal. diferenció entre soledad de tipo emocional y soledad de tipo social. la soledad emocional aparece en ausencia de apego emocional, y ocurre como resultado de la pérdida de intimidad con personas cercanas como padres, pareja o hijos; por el contrario, la soledad social aparece en ausencia de una red social de apoyo, por ejemplo, como consecuencia de la pérdida de amigos, vecinos y colegas. la soledad de tipo social puede guiar hacia la aparición de soledad emocional. en los niños y adolescentes la soledad emocional puede verse reflejada en la relación con los padres, y la social en la relación con los pares; es decir, la soledad ocurre en dos contextos. frente a este aspecto se resalta que la carencia de un tipo de relación no puede ser sustituido o aliviado por otro, porque representan diferentes necesidades de contacto no satisfechas (37). otros autores definieron la soledad como un estado psicológico que resulta de la diferencia entre una relación deseada y una relación actual, una experiencia estresante y negativa que ocurre en la relación social de la persona y que está apoyada en una necesidad de seguridad psicológica. la soledad, por tanto, no es sinónimo de aislamiento social objetivo. estos autores también afirman, que aunque la soledad tiene un elemento afectivo, porque es una experiencia emocionalmente desagradable, también tiene un elemento cognitivo que indica que requiere la percepción de que existe una disminución en las relaciones sociales o que éstas son inadecuadas (7). se ha observado que los niveles de satisfacción subjetiva en las relaciones sociales y el contacto son mejores predictores de soledad que la frecuencia del contacto (7). mcwhirter (12) incluye tres características importantes cuando se refiere al concepto de soledad: 1) experiencia estresante, que causa aversión y puede estar acompañada de tristeza, ansiedad y sentimientos de marginalización; 2) puede ocurrir en presencia o ausencia de relaciones sociales; 3) es un sentimiento relacionado con la temporalidad. es decir, que la soledad debe ser entendida como una dimensión misteriosa y compleja de la vida de las personas que puede ser experimentada en diferentes niveles. kraus et ál. (38) definen soledad como una percepción desagradable y penosa de en los niños y adolescentes la soledad emocional puede verse reflejada en la relación con los padres, y la social en la relación con los pares; es decir, la soledad ocurre en dos contextos. 288 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 ser desconectado de relaciones sociales significativas. otros autores la definen como “el sentimiento de sentirse solo a pesar de estar con otros” (39). o como una parte natural e integral del ser humano; como cualquier necesidad o sentimiento, considerando que los seres humanos nacen solos, mueren solos y experimentan soledad a lo largo de la vida (40). esta última definición se complementa con la afirmación de ebersole (10), quien refiriéndose a la soledad en experiencias vitales como la enfermedad y la muerte afirma que: “las relaciones íntimas pueden estar aliviando y proporcionando un sentido de seguridad, pero en la mayoría de las experiencias profundas de la vida, se está esencialmente solo”. nilsson et ál. (9) afirman que la soledad puede presentarse como consecuencia de: 1) aislamiento interpersonal como resultado de factores geográficos, disminución de la experiencia social y tipo de personalidad; 2) aislamiento intrapersonal, como una dimensión central de psicopatología; 3) aislamiento existencial como resultado de una separación del mundo. puede ser definida, además, como una experiencia subjetiva de aislamiento social, que existe cuando el número de relaciones es menor al deseable, y también cuando no se logra un nivel individual de intimidad (41). killeen (11), en un artículo de revisión, la definió como una condición penetrante, presionante y debilitante, que puede afectar toda la vida de un individuo. consiste en una sensación de ser la única persona en el mundo, un deseo de no querer vivir más, una sensación de aislamiento e inutilidad, de vida sin propósito, condición destructiva que puede originar un círculo vicioso de enfermedad, y que por considerar que genera sensaciones negativas y atemorizantes puede verse como tabú o estigma. roy y andrews (42) afirman que la soledad es una respuesta inefectiva en el modo de interdependencia. este modo involucra la interacción con otros, examina las relaciones significativas y los sistemas de apoyo. a través de éste, los individuos comparten sus necesidades afectivas. una respuesta adaptativa en el modo de interdependencia se da cuando se establecen relaciones mutuamente efectivas o se escoge libremente “estar solo”, mientras que las respuestas inefectivas pueden incluir soledad, separación o enajenación (43). para roy, la soledad existe como un problema común para lograr la adaptación desde la niñez hasta la vejez. además, afirma que nadie está inmunizado contra ella, y durante toda la vida se lucha por mantener una integridad relacional. sin embargo, incluso las personas que tienen relaciones mutuamente satisfactorias experimentan periodos de soledad y enajenación. afirma además que la persona que no alcanza un apego emocional adecuado, y que no puede tener o tiene muy pocas relaciones satisfactorias sufre un gran dolor emocional (42). además, define enajenación como una condición o sentimiento de estar separado de sí mismo y los demás. esta sensación se produce cuando los seres o las relaciones significativas no proveen la afiliación afectiva esperada. esta deprivación de presencia o contacto guía hacia sentimientos de no sentirse necesario, valorado o apreciado por otros, y es allí donde se encuentran las raíces de la soledad (42). investigaciones realizadas utilizando el modelo de adaptación evidencian que cuando aumentan los niveles de soledad, disminuyen los niveles de adaptación; y cuando aumentan los nivepara roy, la soledad existe como un problema común para lograr la adaptación desde la niñez hasta la vejez. además, afirma que nadie está inmunizado contra ella, y durante toda la vida se lucha por mantener una integridad relacional. 289 soledad en la adolescencia: análisis del concepto gloria carvajal-carrascal, clara virginia caro-castillo les de apoyo social, disminuyen los sentimientos de soledad (44, 45). asher y paquette (46) afirman que aunque la soledad está influenciada por características objetivas de las relaciones sociales (frecuencia del contacto social y número de amigos), es más influenciada por características subjetivas como la satisfacción con las relaciones sociales y la aceptación social percibida. finalmente, la definición de carpenito (47) se da en términos de “riesgo de soledad”, como un estado en el cual la persona está en riesgo de experimentar malestar asociado al deseo o a la necesidad de tener contacto con los demás. es un estado subjetivo, presente cuando la persona afirma encontrarse sola y lo describe cómo algo impuesto por los demás. conceptos relacionados la soledad es una experiencia claramente distinta a otros términos como aislamiento social, o estar solo; a continuación se presentan las diferencias con los conceptos a los que comúnmente se relaciona. estar solo y soledad: “la persona puede sentirse sola en una multitud o feliz estando sola” (11). estar solo: la persona que está sola, es solitaria, pero que no tiene sentimientos de soledad. no todas las personas que viven solas se sienten solas. este estado puede ser voluntario, la persona lo elige porque quizás prefiera realmente estar sola que estar con otras personas. se encuentra estrechamente relacionado con el concepto de aislamiento social (7, 11). soledad y aislamiento social: el aislamiento social con elección es “estar solo”, mientras el aislamiento social sin elección es la soledad (11). aislamiento social: estado en el cual el individuo experimenta una necesidad o deseo de contacto con otros, pero es incapaz de realizar ese contacto. incluye sentimientos expresos de soledad y deseo de contacto con otros. en el aislamiento social se observan manifestaciones de inseguridad en situaciones sociales. no es una respuesta, es más bien una causa o factor contribuyente a la soledad. tiene características como: sentimientos de inutilidad, de rechazo, falta de ánimo, escaso contacto ocular, hipoactividad, fracaso en la interacción social con otros (47). enajenación: describe un sentimiento de vacío interior, una separación de sí mismo y de un centro de identidad (42, 48, 49). younger (39) describe la enajenación como una experiencia de desconexión consigo mismo, con otros, con un dios, la naturaleza o un reino trascendente. no es ausencia de conexión sino conexión negativa. también se define como un patrón de interrelación negativa con otros (11). soledad positiva: es vista como una forma de descansar, de respirar (9). la soledad en sentido positivo es referida como una experiencia agradable, que conduce a abastecer de energía y recursos, y proporciona tiempo y espacio para el descanso. implica un deseo positivo, una elección personal (40). la soledad se considera positiva cuando es vista como un espacio que promueve la creatividad (50). la soledad en sentido positivo es referida como una experiencia agradable, que conduce a abastecer de energía y recursos, y proporciona tiempo y espacio para el descanso. implica un deseo positivo, una elección personal. 290 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 atributos del concepto sentimiento único, individual. experiencia subjetiva, involuntaria, negativa, atemorizante, avergonzante. afecta la esfera emocional, la esfera social, o ambas. está basado en la calidad de las relaciones con otros, no en el número. se relaciona con una ausencia, real o percibida, de relaciones sociales satisfactorias, o con relaciones interpersonales adversas (aislamiento o dependencia). se relaciona con disminución en la autoestima, timidez, tristeza, desinterés por la vida. definición de soledad en la adolescencia la soledad en la adolescencia es un sentimiento subjetivo, emotivo, variable, negativo e involuntario experimentado por el adolescente, que involucra una insatisfacción social, emocional, de afecto y de apoyo, asociada con una necesidad real o percibida de relaciones interpersonales insatisfactorias que afectan su esfera emocional y social, y que puede ser antecedente, predictor o desencadenante de resultados negativos a nivel físico y mental. a continuación se presentan una serie de casos que ilustran el concepto: caso modelo juan es un adolescente de 16 años que asiste a la escuela y se encuentra en décimo grado. la directora de curso lo ha observado desarreglado, apático, distraído, poco participativo y con escasa relación con sus compañeros de clase. además, los profesores han reportado que juan ha desmejorado su desempeño escolar. le ha preguntado frente a sus compañeros si le ocurre algo y juan responde enojado que “no pasa nada”, “todo está bien”. durante una actividad en clase de educación física, juan se enfrenta a uno de sus compañeros quien le da un golpe en la cara, razón por la cual es llevado a la enfermería. la enfermera pregunta a juan qué ocurrió, a lo que él responde: “todos mis compañeros son antipáticos, no me gusta el salón de clase, no tengo amigos, quiero que el año termine pronto, o mejor que la vida se termine pronto y así ya no molestaré a nadie más y nadie me molestará a mí”. la enfermera le pregunta por qué piensa así, si es tan joven y tiene tantas oportunidades, y él contesta: “la vida no es agradable, hay muchos problemas y pocas soluciones, y además yo no soy feliz, lo tengo todo pero a la vez no tengo nada”. indaga con juan acerca de lo que opinarán sus padres respecto a la pelea con su compañero y él responde que “ni siquiera se enterarán pues no están nunca en casa, casi nunca se ven y como están tan preocupados por sus problemas no me prestan mucha atención, así que no me preocupa porque yo no les contaré, y si la profesora llama a la casa nadie le va a responder…” . caso límite camilo es un estudiante universitario de 19 años que manifiesta a sus padres que quiere cambiar de universidad porque se siente aburrido con sus compañeros y con sus profesores, “todos son unos ineptos”; sus padres le manifiestan que están preocupados pues es la tercera vez que decide abandonar la universidad, que la soledad en la adolescencia es un sentimiento subjetivo, emotivo, variable e involuntario que puede ser antecedente, predictor o desencadenante de resultados negativos a nivel físico y mental. 291 soledad en la adolescencia: análisis del concepto gloria carvajal-carrascal, clara virginia caro-castillo por qué no les cuenta qué pasa, a lo que él en forma grosera contesta: “ustedes no me comprenden, no quiero estar ahí, no me siento bien, no me interesa tener amigos, mucho menos amigas, eso no sirve para nada”. los padres de camilo, preocupados, le proponen que asista a una consulta psicológica de orientación antes de tomar una decisión, a lo que él responde: “yo me siento bien, acaso creen que estoy loco, solamente porque no quiero tener amigos y porque me caen mal las profesoras, creen que estoy enfermo, los enfermos son ustedes…”. caso contrario gabriela es una adolescente de 18 años, estudia economía, y es amante de la pintura y la música, vive con sus padres, y aunque comparte todas las actividades familiares y disfruta de su compañía, ha acordado un espacio en el cual se encierra en su habitación a pintar, a leer y a escuchar música. gabriela es alegre, extrovertida. le encanta hacer amigos. considera que el espacio que tiene para encontrarse con ella misma le permite descansar, y disfruta de sus pasatiempos, además agradece mucho a sus papás que respeten sus decisiones y le permitan actuar con autonomía. antecedentes del concepto de soledad en la adolescencia las causas que favorecen la aparición de sentimientos de soledad en la adolescencia incluyen factores relacionados con los cambios físicos propios de la edad, que pueden generar sentimientos de timidez, rechazo, minusvalía, y conducir al aislamiento del adolescente. si no son manejados adecuadamente por una red de apoyo pueden generar sentimientos de soledad. los resultados de un estudio que utiliza la teoría de la soledad desarrollada por de jong gierveld y kamphuis, muestran que la soledad es un fenómeno común, y que sus factores de riesgo en población general incluyen violencia doméstica, desempleo, tener niños menores de 18 años dentro del hogar, tipo de relación marital (éstos, dentro de intervalos de confianza significativos). los resultados también apoyan hallazgos previos de la literatura que mencionan posible relación entre factores socioeconómicos, soledad y suicidio. dentro de las variables que predicen menores niveles en los sentimientos de soledad se encuentran: ser casado y tener empleo (4). otros autores mencionan como causas de la soledad a las condiciones sociodemográficas y culturales adversas, que ocasionan disminución en las oportunidades de interacción social; psicopatología del adolescente o de los padres, especialmente depresión y abuso de alcohol y drogas; violencia doméstica, tipo de relación marital y dinámica familiar, historia de abuso o maltrato; alteraciones en las relaciones con los familiares y amigos (pérdidas, rupturas, muerte, enfermedad, viajes, mala comunicación entre padres e hijos, peleas con los amigos); ambiente social y familiar de la persona (hijos con hogar, pero solos) (51, 16, 52, 31, 18). la muerte de personas significativas es la pérdida con más influencia en los sentimientos de soledad (11). un estudio de correlación realizado por antognoli-toland (21) mostró que la conexión entre padres y adolescentes es un predictor independiente de soledad en la adolescencia que covaría con edad y género. la conexión entre padres e hijos y la estructura familiar son predictores significativos de soledad durante la adolescenla conexión entre padres e hijos y la estructura familiar son predictores significativos de soledad durante la adolescencia. 292 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 cia. los hallazgos del estudio respaldan la afirmación de cómo un déficit en las redes de apoyo relacionadas con la estructura familiar hace difícil para el adolescente obtener el apoyo y la afirmación que ellos necesitan para satisfacer sus necesidades interpersonales. por el contrario, los adolescentes con mayor apego con los padres reportan menor soledad (53). un meta-análisis realizado por mahon et ál. (13) concluyó que algunos predictores que pueden aumentar la vulnerabilidad en la adolescencia para experimentar sentimientos de soledad incluyen depresión, bajo apoyo social, baja autoestima, ansiedad social, timidez, disminución en la expresividad materna, disminución en la expresividad paterna, edad y género. consecuencias del concepto de soledad en la adolescencia la revisión de la literatura realizada por heinrich y gullone (7) muestra que la soledad se asocia a problemas psicosociales, de la salud mental y del bienestar físico. la soledad se encuentra asociada a sentimientos de tristeza, ansiedad, depresión, baja autoestima, conducta suicida, abuso de drogas y restricciones dietéticas. también se encuentra asociada a síntomas como náuseas, dolor de cabeza, problemas de sueño y pobre funcionamiento cardiovascular. la justificación para los problemas físicos se encuentra en que las personas que experimentan sentimientos de soledad tienen cambios en los estilos de vida, prácticas menos saludables y menor número de comportamientos que promueven la salud: uso de alcohol, hábito de fumar, menos ejercicio, menos relajación, pobre nutrición. estos hallazgos son confirmados por los trabajos de otros autores (4, 6, 54, 11, 55). también se ha encontrado que la soledad, y el aislamiento social que la acompaña, han sido descritos como una causa principal de depresión, comportamientos autodestructivos y suicidio en el adolescente (56, 57, 58, 12). los autores afirman que el suicidio es el efecto terminal de la soledad porque los individuos que se perciben solos sienten que esta es la única vía para escapar (11, 12, 25). los hallazgos de boergeors et ál. (59) muestran la soledad como la razón que los adolescentes dan para intento de suicidio. estos hallazgos son confirmados por robert et ál. (57). la soledad aumenta la carga de estrés psicológico de los adolescentes y el riesgo de alteraciones en su esfera mental (60). la soledad afecta el bienestar general del adolescente, los programas educativos que se focalizan en la prevención y el manejo de la soledad pueden interrumpir la vía por la que se llega al uso de drogas y al suicidio (61). sin embargo, es importante aclarar que aunque soledad y depresión comparten algunas características comunes como pobres herramientas sociales y tristeza, son fenómenos distintos, que requieren diferentes niveles de intervención (62). page et ál. (61) afirman que existe asociación entre soledad, sentimientos de desesperanza y uso de sustancias psicoactivas. además, se evidencia relación entre soledad y baja autoestima, hostilidad, abuso de sustancias, restricciones dietéticas y comportamiento delictivo (63, 64, 55, 12). finalmente, los resultados de un estudio de correlación entre adolescentes sin hogar y resiliencia, desarrollado por rew (24), que incluyó la soledad como variable de estudio, confirmaron investigaciones previas en adolescentes que han mostrado relación inversa entre soledad y sentimientos de salud y bienestar (65), relación inversa entre soledad y comunicación con la familia (64), y relación directa entre soledad e historia de abuso sexual en mujeres jóvenes (66). referentes empíricos para realizar una medición objetiva de la soledad se ha utilizado ampliamente la revised ucla loneliness scale (ucla-r) desarrollada por rusell, peplau y cutrona (67). consiste en una medición de autorreporte con validez ampliamente demostrada, compuesta por 20 ítems que reflejan el grado de satisfacción o insatisfacción con las relaciones sociales. evalúa además sentimientos subjetivos de soledad o aislamiento social. la versión inicial de esta escala de 20 ítems fue desarrollada por rusell, peplau y fergusson (68), que en estudios con muestras de estudiantes reportaron buena consistencia interna (alfa de 0,96), y confiabilidad prueba-reprueba de 0,73, en un periodo de tiempo de dos meses. la validez concurrente indicó relación de los puntajes de las escalas con otros indicadores de soledad, relaciones sociales y estados afectivos. adicionalmente, y con respecto a validez de criterio, se ha demostrado que la ucla loneliness scale es un buen criterio para probar diferencias en la experiencia subjetiva de soledad emocional y social (69). posteriormente, russell (70) reportó los datos de validez, confiabilidad y dimensionalidad de la escala para la versión 3. esta versión se ha desarrollado para tratar de corregir algunas limitaciones de la escala que pueden alterar su confiabilidad. la versión está compuesta por 9 ítems expresados en positivo y 11 en negativo; a través de la literatura repor293 soledad en la adolescencia: análisis del concepto gloria carvajal-carrascal, clara virginia caro-castillo ta amplia utilización en muestras de adolescentes y adultos, y buenas cualidades psicométricas. conclusiones 1. la soledad es un fenómeno universal inherente a la necesidad humana de pertenecer. constituye una experiencia subjetiva que varía de persona a persona, ocurre por diversidad de causas, y produce una gran variedad de consecuencias físicas y psicosociales. aunque la soledad puede ser definida de manera objetiva, esta experiencia subjetiva no puede ser directamente observada. así, la soledad es un resumen abstracto de un conjunto de sentimientos, pensamientos y comportamientos (7). 2. aunque la adolescencia es un periodo de riesgo para experimentar sentimientos de soledad, también representa un espacio ideal para cultivar herramientas sociales y actitudes que mejoren el desarrollo emocional; de esta manera, la adolescencia constituye un tiempo especial para focalizar esfuerzos en investigación e intervención. se requiere identificar problemas de investigación que permitan explorar el fenómeno de soledad en la adolescencia y sus resultados en la salud mental y física, determinar su prevalencia y determinar relaciones causales. 3. la soledad como problema que afecta la salud y la calidad de vida de los adolescentes representa un reto para los profesionales de enfermería, quienes deben jugar un rol fundamental en su prevención, pero también un papel activo en la implementación de intervenciones que se construyan a partir de teorías disciplinares y puedan facilitar el entendimiento y abordaje de este fenómeno. aunque es fundamental que las enfermeras trabajen en la detección e intervención oportuna de factores de riesgo personales, familiares y sociales que hacen vulnerable al adolescente, también es prioritario que mejoren sus habilidades para trabajar una relación terapéutica que transmita al adolescente confianza, y en la construcción de herramientas que favorezcan una comunicación empática. 4. los espacios creados por las enfermeras(os) para la interacción y el cuidado pueden apuntar a disminuir los sentimientos de desesperanza, soledad y sufrimiento que vive el adolescente. comunicar esperanza y enseñar nuevas formas de afrontamiento también representan herramientas para el trabajo con los jóvenes. el cuidado de enfermería para los adolescentes que sufren de soledad es un proceso interpersonal que se fundamenta en el establecimiento de una atmósfera cálida que transmita preocupación e interés, y que demuestre empatía hacia el paciente, su situación y su familia, sumado a otros aspectos importantes en el cuidado como el respeto por sus opiniones y sentimientos, y la protección de la autonomía. finalmente, no deben olvidar la creación y el 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and gender. public health nurs 1994; 11 (5): 361-8. 66. gibson rl, hartshorne ts. childhood sexual abuse and adult loneliness and network orientation. child abuse negl 1996; 20 (11): 1087-93. 67. russell d, peplau l, cutrona c. the revised ucla loneliness scale. concurrent and discriminant validity evidence. journal of personality and social psychology 1980; 39: 472-80. 68. russell d, peplau l, fergusson m. developing a measure of loneliness. en: journal of personality assessment 1978; 42 (3): 290-294. 69. russell d, cutrona c, rose j, yurko k. social an emotional loneliness: an examination of weiss ´s typology of loneliness. journal of personality and social psychology 1984; 46 (6): 1313-1321. 70. russell d. ucla loneliness scale (version 3): reliability, validity, and factor structure. journal of personality assessment 1996; 66 (1): 20-40. 1 editorial leadership mentoring needed! ¡necesitamos tutoría en liderazgo! precisamos de assessoria em liderança! ellen b. buckner1 1 https://orcid.org/0000-0001-9676-2445. samford university, usa. ellen.buckner@samford.edu doi: 10.5294/aqui.2019.19.4.1 para citar este editorial / to reference this editorial / para citar este editorial buckner eb. leadership mentoring needed! aquichan. 2019;19(4):e1941. doi: https://doi.org/10.5294/aqui.2019.19.4.1 keywords (source: decs) leadership; cultural competency; organization and administration; mentoring; nursing. palabras clave (fuente: decs) liderazgo; competencia cultural; organización y administración; tutoría; enfermería. palavras-chave (fonte: decs) liderança; competência cultural; organização e administração; tutoria; enfermagem. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1941 https://orcid.org/0000-0001-9676-2445 https://doi.org/10.5294/aqui.2019.19.4.1 https://orcid.org.0000-0001-9676-2445 https://doi.org/10.5294/aqui.2019.19.4.1 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1941 leadership mentoring is valuable! it is built on the richness of our nursing experience, the depth of our relationships, and the breadth of our nursing presence. it exercises our engagement, expands our scholarship, refines our passion, and ignites the next generation of nurse leaders. leadership mentoring requires the selfless giving of our time and insight while encouraging us to be open to a new generation of nurses and nursing vision. in addition, leadership mentoring provides us with opportunities for advocacy for our profession and its worldwide mission. leadership mentoring in nursing can take many forms. it can be as informal as those moments when a simple hallway conversation encourages or inspires a colleague. it can be a formal program that engages scholars, frontline practicing nurses, or global acquaintances in planned activities for leadership development. leadership mentoring challenges nurses to create and implement a vision of nursing excellence. what is that vision and how can it be enacted? leadership mentoring helps nascent researchers to frontline clinicians envision change outside of their current role or “comfort zone.” new leadership then catalyzes growth in nursing education, administration, and practice. so, what are leadership mentoring attributes? hodgson and scanlon (1) conducted a concept analysis of mentoring for nursing leadership and found defining attributes of mentoring to include a relationship between two individuals with differing levels of experience, based on mutual respect and common goals, with a willingness by mentor and mentee to engage in the relationship, and sharing of knowledge. cardiff and colleagues (2) utilized a person-centered leadership approach that included reflection, leading/evaluating a leadership practice change, and developing insight into leadership development. cardiff and colleagues’ attributes were being person-centered and authentically other-centered and caring. they found self-awareness emerged from reflections and that being open, patient and optimistic fostered a sense of tranquility as leaders listened and supported mentees’ progress toward goals. additional characteristics were awareness of context and presence in the participants. thus, an essential criterion was to be engaged in a responsive relationship. formal mentoring programs are available through the international council of nurses (icn), sigma theta tau international (sigma), and others, but most of these are for a short to intermediate term and face-to-face format, limiting accessibility. morin and colleagues (3) evaluated 100 dyads from the maternal child leadership academy (sigma) and found enhanced leadership skills and behaviors, with additional needs to develop mentoring skills as a primary finding. i was an unlikely convert to the significance of leadership mentoring. as a young or even mid-career nurse, i would have said leadership is an innate trait not a learned skillset. however, through the transformational experience of several leadership programs, i have discovered leadership mentoring as the most meaningful and authentic role i have held in nursing. through it, i have found my calling. participation in three sigma leadership academies led me to understand more fully the significance of a formal structure, organizational context, team-focused methodology, and tangible outcomes-facilitated leadership growth. in 2012, following the initiation of global regions in sigma, several of us, including dr. nelly garzón from colombia, began a discussion on global nursing leadership (4). that discussion led to the formation of the global leadership mentoring community, a sigma community of interest (5, 6). now beginning its third cohort, we have realized mentoring relationships across nursing education, leadership, and scholarship. we have connected across 16 time zones using freely available technology. mentors have included former aquichan editor dr. maria elisa moreno fergusson from colombia, and global nurse leaders from australia, hong kong, philippines, england, the netherlands, south africa, pakistan, the usa and others. outcomes have included growth in sigma chapter leadership, participation in biennial convention, manuscript preparation, and the formation of new and lasting friendships. in the most recent sigma biennial convention, mentors and mentees met for the first time, and one example of shared joy was the beautiful pakistani shalwar kameez brought to her mentor, beth chiatti, by mentee salima farooq (figure 1). through technology, community can be created across seemingly impossible expanse of geographic distance and time (figure 2). through these professional conversations and gifts of the heart, a community was formed. in 2019, we began another journey of leadership mentoring and while it is still a fledgling venture, the potential for influencing nurses and nursing leadership is there. this group began as part of the roy adaptation association international (raa-i) with mentors and mentees from colombia, mexico, and several states in the usa, with potential to include others. we connect as roy 3 leadership mentoring needed! l ellen b. bucknera the formal structure of leadership mentoring which i experienced and have used in developing new programs was the cohort approach with a beginning, middle, conclusion, and committed relationships during the journey. the team-focused method encouraged the mentee to create a team at his/her home base, with team development at the core of leadership development. the organizational context—such as sigma or the roy adaptation association—was the structure for enacting new leadership skills. the tangible outcome, while a driving passion for the mentee, was also the vehicle for building their leadership skills. outcome development fueled leadership growth. benefits to mentees are support for problem solving in organizational roles, encouragement to take the next step in education, reviewing/editing a manuscript to improve a scholarly work, and collaboration through sharing of interests and expertise. benefits for mentors are rewards of forming new relationships in nursing, applying their lifetime experience to support learning and professional growth, and seeing the mentees reach their goals. why is this so transformative? the continuity and influence brought to the relationship empowers the mentee to lead change and grow in their own context. the role of the mentor is not to answer questions but help the mentee seek out who to ask and how. the investment of time in a mentee and his/her work is returned multiple times as the mentor grows, learns skills of team development, applies concepts of leadership, and strengthens his/her own philosophy in making a difference. the formal, structured approach makes it possible to develop leadership across global contexts, and the strength of relationships creates the sense of community. within that community, much is possible. the outcomes have and will document the power of these intentional experiences. nursing needs leadership mentoring to provide connections for the next generation of nurses to create environments for a culture of health, safety, and well-being. we need mentoring to teach how to develop collegiality in a stressful profession. nursing can welcome and nurture its own novice nurses into future leadership roles. global leadership means not only connecting through global relationships but also making a difference across the spectrum of nursing activity. from frontline clinical practice, to nursing organizational leadership, to health policy development, leadership mentoring means engaging nursing voice. it means investing the time and talent to nurture and teach leadership in new ways with the next generation. seeking out opportunities for leadership mentoring is the first step! figure 1. beth chiatti (mentor, usa) wears a pakistani shalwar kameez brought by mentee salima farooq (pakistan). figure 2. global leadership mentoring community (glmc2) meets on a video conference across 16 time zones. scholars while developing goals such as contributing to raa-i leadership through peer-review for journals, consultations, next generation presentations on the roy adaptation model, and more. mentoring mentors is part of the skill i have learned, and while not yet fully established, it is a significant part of any mentoring community. likewise, mentees express a need for getting to know other mentees, having mentoring conversations even if no formal agenda, and collaborating together to set goals and plans. thus, part of the format is conducting group calls for mentors and for mentees along the way. source: author's photo. source: author’s screenshot. 4 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1941 references 1. hodgson ak, scanlan jm. a concept analysis of mentoring in nursing leadership. open journal of nursing. 2013;3:384– 94. doi: https://doi.org/10.4236/ojn.2013.35052 2. cardiff s, mccormack b, mccance t. person-centred leadership: a relational approach to leadership derived through action research. journal of clinical nursing. 2018;27:15–6. doi https://doi.org/10.1111/jocn.14492 3. morin k, small l, spatz dl, solomon j, lessard l, leng sw. preparing leaders in maternal-child health nursing. jognn: journal of obstetric, gynecologic & neonatal nursing. 2015;44(5):633–643. doi: https://doi.org/10.1111/15526909.12730 4. buckner eb, anderson dj, garzon na, lai ck, hafsteinsdóttir tb, roshan r. perspectives on global nursing leadership: international experiences from the field. international nursing review. 2014 dec;61(4):463–471. 5. buckner eb, lai c. symposium: global leadership mentoring community: online stti community of interest for mentoring emerging global nurse leaders. sigma theta tau international’s 44th biennial convention [internet]; 2017 oct 28–nov 1; indianapolis, indiana, usa. available from: http://hdl.handle.net/10755/623038 6. buckner eb, lai c, welk d. symposium: global leadership mentoring community (glmc): expanding and focusing in cohort 2. sigma theta tau international’s 45th biennial convention [internet]; 2019 nov 16–20; washington, d.c., usa. available from: http://hdl.handle.net/10755/18948 https://doi.org/10.4236/ojn.2013.35052 https://doi.org/10.1111/jocn.14492 https://doi.org/10.1111/1552-6909.12730 https://doi.org/10.1111/1552-6909.12730 http://hdl.handle.net/10755/623038 http://hdl.handle.net/10755/18948 1 glenda agra1 nilton soares formiga2 simone helena dos santos oliveira3 alana tamar oliveira sousa dos santos4 maria júlia guimarães oliveira soares5 marta miriam lopes costa6 validação de instrumento sobre o saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral maligna cutânea 1 https://orcid.org/0000-0002-7628-9029. unidade acadêmica de enfermagem. universidade federal de campina grande, brasil. glenda.agra@ufcg.edu.br 2 https://orcid.org/0000-0003-4907-9736. universidade potiguar, brasil. 3 https://orcid.org/0000-0002-9556-1403. universidade federal da paraíba, brasil. 4 https://orcid.org/0000-0002-1683-2851. universidade federal de campina grande, brasil. 5 https://orcid.org/0000-0001-8025-9802. universidade federal da paraíba, brasil. 6 https://orcid.org/0000-0002-1910-3486. universidade federal da paraíba, brasil. recebido: 22/05/2019 submetido: 24/06/2019 aceito por pares: 25/08/2019 aceito: 24/09/2019 doi: 10.5294/aqui.2020.20.1.2 para citar este artigo / para citar este artículo / to reference this article agra g, formiga ns, oliveira shs, sousa ato, soares mjgo, lopes mm. instrument validation on nurses’ knowledge and practice in palliative care for people with cutaneous malignant tumor wound. aquichan 2020;20(1):e2012. doi: https://doi.org/10.5294/aqui.2020.20.1.2 resumo objetivo: apresentar o processo de construção e validação de um instrumento para avaliar o saber e o fazer de enfermeiros nos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea. materiais e método: estudo metodológico, quantitativo, com aplicação da técnica delphi, realizada em duas etapas. a primeira realizada com 30 juízes; a segunda, com 17. para a análise, utilizaram-se o coeficiente de lambda 2 guttman, o índice kappa e o índice de validade de conteúdo (ivc). resultados: dos 112 itens do instrumento original, 28 foram excluídos, pois os percentuais de lambda 2 guttman, o kappa e o ivc apresentaram escores menores do que o aceitável; desse modo, a segunda versão do instrumento resultou em 84 itens, o qual apresentou aceitação em 100 % na fase delphi 2. conclusões: a partir da avaliação dos juízes, foi definida uma versão do instrumento com índice de concordância e validade de conteúdo adequados, que poderá contribuir para a avaliação do saber e do fazer de enfermeiros nos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea. palavras-chave (fonte: decs) validação; estudos de validação; cuidados paliativos; úlcera cutânea; neoplasias. año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2012 temática: cuidado crônico. contribuição científica para a disciplina: espera-se que o instrumento possa contribuir para o ensino e para a pesquisa, bem como facilitar o processo de trabalho da prática diária e fornecer uma direção mais consistente para os registros de enfermagem. outrossim, é indispensável a continuidade de pesquisas nessa área, a fim de identificar as especificidades do saber e do fazer na enfermagem, e, desse modo, diminuir as lacunas na educação em enfermagem, sobretudo na área de cuidados paliativos. https://orcid.org/0000-0002-7628-9029 mailto:glenda.agra@ufcg.edu.br https://orcid.org/0000-0003-4907-9736 https://orcid.org/0000-0002-9556-1403 https://orcid.org/0000-0002-1683-2851 https://orcid.org/0000-0001-8025-9802 https://orcid.org/0000-0002-1910-3486 https://doi.org/10.5294/aqui.2020.20.1.2 https://orcid.org/0000-0002-7628-9029 https://orcid.org/0000-0003-4907-9736 https://orcid.org/0000-0002-9556-1403 https://orcid.org/0000-0002-1683-2851 https://orcid.org/0000-0001-8025-9802 https://orcid.org/0000-0002-1910-3486 https://doi.org/10.5294/aqui.2020.20.1.2 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2012 validación de instrumento sobre el saber y el quehacer de enfermeros en los cuidados paliativos hacia la persona con herida tumoral maligna cutánea resumen objetivo: presentar el proceso de construcción y validación de un instrumento para evaluar el saber y el quehacer de enfermeros en los cuidados paliativos hacia la persona con herida tumoral maligna cutánea. materiales y método: estudio metodológico, cuantitativo, con aplicación de la técnica delphi, realizada en dos etapas. la primera se realizó con 30 jueces y la segunda, con 17. para el análisis, se emplearon coeficiente de lambda 2 guttman, índice kappa y índice de validez de contenido (ivc). resultados: de los 112 ítems del instrumento original, 28 fueron excluidos, pues los porcentuales de lambda 2 guttman, el kappa y el ivc presentaron indicadores menores que el aceptable; así, la segunda versión del instrumento resultó en 84 ítems, lo que presentó aceptación en 100 % en la fase delphi 2. conclusiones: a partir de la evaluación de los jueces, se definió una versión del instrumento con índice de concordancia y validez de contenido adecuados, que podrá aportar a la evaluación del saber y del quehacer de enfermeros en los cuidados paliativos hacia la persona con herida tumoral maligna cutánea. palabras clave (fuente: decs) validación; estudios de validación; cuidados paliativos; úlcera cutánea; neoplasias. 3 validação de instrumento sobre o saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral maligna cutânea l glenda agra e outros instrument validation on nurses’ knowledge and practice in palliative care for people with cutaneous malignant tumor wound abstract objective: to present the construction and validation process of an instrument to evaluate the knowledge and practice of nurses in palliative care toward the person with cutaneous malignant tumor wound. materials and methods: methodological, quantitative study with applying the delphi technique, conducted in two stages. the first was carried out with 30 judges and the second with 17. the analysis used the lambda 2 guttmann coefficient, kappa index, and content validity index (cvi). results: of the 112 items of the original instrument, 28 were excluded, given that the percentiles of lambda 2 guttmann, kappa, and cvi had indicators lower than acceptable; thus, the second version of the instrument resulted with 84 items, which presented 100 % acceptance in the delphi 2 phase. conclusions: from the evaluation by the judges, a version of the instrument was defined with adequate content validity and concordance indices, which could contribute to the evaluation of knowledge and practice of nurses in palliative care toward the person with cutaneous malignant tumor wound. keywords (source: decs) validation; validation studies; palliative care; skin ulcer; neoplasm. año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2012 4 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2012 aquichan issn 1657-5997 eissn 2027-5374 introdução as feridas tumorais malignas são infiltrações cutâneas de células cancerígenas, que se desenvolvem em decorrência do crescimento de um tumor primário de pele ou de metástases de qualquer tumor maligno (1). a prevalência dessas lesões não é bem documentada, mas se estima, a partir de estudos internacionais, que de 5 a 15 % das pessoas com câncer desenvolvem feridas malignas (2-4). as feridas tumorais malignas cutâneas constituem um agravo na vida da pessoa com câncer, porquanto, progressivamente, desfiguram o corpo, tornando-se friáveis, dolorosas, exsudativas e fétidas. ainda, apresentam efeitos psicológicos e sociais que podem interferir nas relações interpessoais, uma vez que a pessoa apresenta sentimentos de rejeição, isolamento social, ansiedade, tristeza e solidão (1-2). além disso, essas feridas remetem à pessoa uma constante lembrança visível da sua enfermidade incurável, do mau prognóstico e, na maioria das vezes, da condição inevitável da morte que se aproxima; este último sentimento percebido no seu discurso, durante o entorno relacional do tratamento. ante tal situação, a pessoa necessita de cuidados paliativos para o controle dos sinais e sintomas dessas lesões. a atenção em saúde das pessoas com esse tipo de ferida exige cuidados paliativos sistematizados, prestados pela equipe multiprofissional e orientados por protocolos assistenciais, disponibilidade de recursos materiais e produtos farmacológicos, articulação entre os níveis de complexidade da assistência, bem como participação efetiva da pessoa com a ferida, dos familiares e dos cuidadores (1-3). o tratamento das feridas tumorais malignas cutâneas é complexo, pois exige avaliação de etiologia oncológica, da lesão, da pessoa nas suas dimensões biopsicossocial e espiritual, da condição econômica da família, do controle dos sinais e sintomas, bem como planejamento e orientações dos cuidados a serem executados pela própria pessoa e pela família em seu domicílio, uma vez que a cura da doença e a cicatrização da ferida já não são mais possíveis (1-4). o enfermeiro é o membro da equipe de saúde que avalia e gerencia o manejo clínico de feridas e realiza curativos, por isso cabe a ele desenvolver competências e habilidades que lhe permitam conhecer e identificar características individuais e/ou sociais de pessoas com feridas tumorais, além de implementar ações específicas às necessidades identificadas. nesse sentido, realizar curativos funcionais, estéticos e confortáveis é um desafio para o profissional, que pode contribuir, a partir do cuidado prestado, para uma apresentação mais aceitável da pessoa em relação à sua imagem social. portanto, é importante validar instrumentos de medida baseados em situações de realidade e que reproduzam a rotina das atividades do enfermeiro na vida profissional, fundamentados em estudos científicos e que contemplem a sistematização da assistência, a fim de homogeneizar e assegurar condutas eficientes no ensino, na pesquisa e na prática clínica (5). nessa perspectiva, vale ressaltar estudo de validação realizado com 78 enfermeiros da atenção básica do município de joão pessoa, paraíba, brasil, cujos resultados não só contribuíram para explicar como se aplicaram os conhecimentos teóricos e práticos no cuidado voltado para pessoas com feridas, com base na educação e na gestão para a saúde, como também garantiram a organização teórico-empírica na proposta de uma medida capaz de avaliar o saber e o fazer do enfermeiro em relação à pessoa com úlcera venosa (6). diante desse cenário, este estudo objetivou apresentar o processo de construção e validação de um instrumento direcionado aos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea. materiais e métodos trata-se de um estudo metodológico que apresenta a construção e validade de conteúdo e concordância de um instrumento de coleta de dados, em duas etapas, realizadas no período de janeiro a julho de 2017. a coleta de dados iniciou-se em março de 2017, quando do início da primeira avaliação delphi, após a aprovação do comitê de ética em pesquisa da universidade federal da paraíba, protocolo 031/2017, e a emissão do certificado de apresentação para apreciação ética (caae) 64122116.1.0000.5188, e seguiu até julho de 2017, época da conclusão da segunda avaliação delphi, segundo as normas da resolução 466/2012 do conselho nacional de saúde do ministério da saúde do brasil para pesquisas que envolvem seres humanos. primeira etapa — construção do instrumento o procedimento teórico do processo de desenvolvimento do instrumento envolveu uma busca dos itens representativos 5 validação de instrumento sobre o saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral maligna cutânea l glenda agra e outros do constructo em investigação, mediante uma revisão do manual do instituto nacional do câncer de tratamento e controle de ferida tumorais e úlceras por pressão no câncer avançado (7) e da construção de uma revisão integrativa da literatura em artigos científicos (8). desse processo de análise da literatura, foi construído um instrumento que apresenta 112 itens, com o objetivo de avaliar o saber e o fazer de enfermeiros nos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea. o instrumento é composto por cinco categorias: 1) avaliação da lesão e das necessidades da pessoa com ferida tumoral maligna cutânea; 2) cuidados básicos realizados com a ferida tumoral maligna cutânea; 3) cuidados específicos realizados com a ferida tumoral maligna cutânea (essa categoria subdivide-se em oito subcategorias, relacionadas ao controle dos sinais e sintomas: a) controle da dor, b) do exsudato, c) do prurido, d) da necrose, e) da fístula, f) do sangramento, g) do odor e h) da infestação por miíases); 4) registros das ações de enfermagem e 5) orientações para a alta hospitalar. segunda etapa — validação do conteúdo do instrumento escolha da técnica de validação a técnica delphi é uma estratégia metodológica que visa obter um máximo de consenso de um grupo de especialistas sobre um determinado tema, quando a unanimidade de opinião não existe em virtude da falta de evidências científicas ou quando há informações contraditórias (9). a técnica apresenta algumas vantagens: viabilidade econômica, possibilidade de reunir a opinião de profissionais qualificados, participação de juízes de localidades geográficas diferentes, eliminação de vieses inerentes a encontros presenciais (10). por tais motivos, tem sido amplamente utilizada na pesquisa em saúde (5, 10). seleção dos juízes a validação de conteúdo pressupõe um julgamento subjetivo sobre se uma medida faz sentido intuitivamente e se refere ao grau em que um instrumento representa um domínio ou a relevância de seus itens. para o quantitativo dos juízes, é recomendado de 6 a 20 sujeitos (11). para a seleção dos juízes, foi utilizada a amostragem por conveniência do tipo bola de neve, que possibilita a definição de pessoas com características comuns ao interesse da pesquisa. é solicitado aos primeiros membros da amostra que indiquem outras pessoas que atendam aos critérios para a composição da amostra da pesquisa (12). foram convidados 57 profissionais com base no atendimento aos seguintes critérios de inclusão: enfermeiros com nacionalidade brasileira; doutores e mestres com atuação em ensino e pesquisa, e especialistas em dermatologia/estomaterapia, com experiência prática. os enfermeiros selecionados foram contatados por correio eletrônico e convidados a participar como juízes da pesquisa, por meio de uma carta convite, que continha os objetivos e a metodologia do estudo, o instrumento a ser validado e o termo de consentimento livre e esclarecido, o qual contava com o prazo de 30 dias para sua devolução. em relação ao cálculo da amostra, utilizou-se o pacote estatístico g*power 3.1 para verificar a significância da amostra para o estudo pretendido. esse software destina-se ao cálculo do poder estatístico, que tem como base verificar não apenas o “n” necessário para o tipo de pesquisa, mas também o tipo de cálculo a ser realizado (13). assim, considerou-se uma probabilidade de 95 % (p < 0,05), magnitude do efeito amostral (r ≥ 0,25) e padrão de poder hipotético (π ≥ 0,80). gerado o cálculo amostral com base nesses critérios, a amostra de 30 sujeitos revelou-se suficiente para o que se pretendia realizar, com indicadores: r ≥ 1,98; π 0,98; p < 0,05. no que diz respeito à normalidade da amostra, realizou-se o cálculo de shapiro-wilk (s-w), que é adequado quando o tamanho da amostra é menor que 50 sujeitos, bem como não exige que os parâmetros da distribução sejam especificados (14-15). o formulário enviado aos juízes era composto por duas partes: a primeira direcionada à caracterização dos participantes do estudo, com questões sobre sexo, idade, qualificação profissional, área de atuação e local de trabalho; a segunda parte referiu-se à apresentação do instrumento estruturado com 112 itens e às instruções para o seu preenchimento. análise de concordância os juízes foram solicitados a avaliar a adequação em relação à clareza e pertinência dos itens, os quais foram dispostos em quadros, seguidos de duas colunas: uma delas destacava a cla6 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2012 aquichan issn 1657-5997 eissn 2027-5374 reza dos itens apresentados; a outra, sua pertinência. os juízes deveriam indicar, por meio de uma resposta binomial para cada uma das questões, o quanto concordavam quanto à categoria, subcategorias e especificidade do item. no caso de inadequações nos itens, reservou-se espaço para comentários, justificativas e sugestões que os juízes julgassem pertinentes. as sugestões também foram consideradas, o que resultou em alterações realizadas pelos autores, posteriormente justificadas. uma concordância de pelo menos 80 % entre os juízes pode servir de critério de decisão sobre a pertinência e/ou aceitação do item que teoricamente se refere (13). por isso, considerou-se a concordância mínima de 80 % para a validação do instrumento. a segunda avaliação pelos juízes foi enviado um formulário que continha as duas versões do instrumento, a original e a modificada. nessa fase, os juízes teriam que avaliar o instrumento original e o modificado de acordo com suas sugestões e com o tratamento analítico, atribuindo a qualidade de avaliação entre os instrumentos relacionados aos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea. após a avaliação do instrumento, foram aplicados os seguintes cálculos: lambda 2 guttman como melhor estimativa de confiabilidade de instrumentos que formam categorias e que são respondidos por uma amostra igual ou menor que 30 sujeitos; rhô de kurder-richardson, que se destina à verificação da confiabilidade do grau de concordância entre avaliadores numa medida dicotômica; o coeficiente kappa e o índice de validade de conteúdo (ivc), para verificar o nível de concordância dos juízes em relação aos itens avaliados. resultados participaram, na condição de juízes, 30 enfermeiros (assistenciais, professores e pesquisadores), sendo 28 mulheres e 2 homens, com idade de 29 a 58 anos (média = 39,82 anos; dp = 8,17). considerando o cálculo de shapiro-wilk (s-w), observou-se a existência de normalidade amostral (s-w = 0,96, p > 0,27) (14-15). ainda sobre a caracterização da amostra, quanto à titulação, 11 eram especialistas em dermatologia/estomaterapia, 9 eram mestres e 10 eram doutores; quanto à área de atuação, 15 trabalhavam na assistência hospitalar e, destes, 9 exerciam atividades assistenciais diretamente com pessoas com feridas tumorais malignas cutâneas; 11 eram docentes e 4 eram assessores técnicos. em relação ao local de trabalho, 12 exerciam atividades laborais em hospitais públicos, 8 em universidades públicas, 4 eram autônomos, 2 trabalhavam em ambulatórios para o tratamento de feridas vinculados às secretarias municipais de saúde, 2 em clínicas particulares para o tratamento de feridas, 1 em hospital privado e 1 em faculdade particular. a seguir, a tabela 1 destaca o instrumento (primeira e segunda versões) e alguns indicadores estatísticos (lambda 2 gutmann e índice kappa) acerca dos cuidados paliativos destinados às pessoas com feridas tumorais malignas cutâneas e seus respectivos cinco domínios e oito subdomínios. discussão considerando o instrumento em questão, observou-se que a maioria dos itens apresentou um percentual igual ou maior que 80 % quanto ao grau de concordância na clareza bem como na pertinência (16); por esse motivo, permaneceram na escala de medida proposta, contudo os itens 4, 5, 6, 22, 24, 44, 45, 46, 47, 56, 58, 71, 74, 75, 76, 79, 91, 94, 96, 97 e 98 não apresentaram percentuais desejados, os quais foram excluídos das respectivas categorias. vale mencionar que alguns desses resultados estão relacionados ao desconhecimento por parte dos juízes acerca dos produtos e coberturas destacados nesses itens, visto que os próprios avaliadores o explicitaram no espaço para sugestões e comentários; por esse motivo, optou-se pela exclusão deles. ainda, todos os itens com percentual igual ou maior que 80 % foram significativos com p < 0,001. a intenção no uso do cálculo do lambda 2 (λ) de guttman se deve ao fato de se encontrarem alguns estudos (17-18) que utilizaram o lambda como melhor estimativa de confiabilidade quando o instrumento avaliado é composto por poucos itens que formam categorias ou por uma amostra igual ou menor que 30 sujeitos (19-21). o lambda 2 (λ) de guttman deste estudo revelou (para o conjunto dos itens sobre a avaliação da clareza e da pertinência λ2 = 0,84 e 0,81, respectivamente) um escore superior exigido pela literatura estatística (19-22), que é de 0,80, que é destinado para avaliações de baixa participação, bem como instrumentos 7 validação de instrumento sobre o saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral maligna cutânea l glenda agra e outros que exigem comentários de instrução. com isso, quanto maior for o λ estatisticamente exigido, melhor o teste é capaz de diferenciar dos resultados reais e dos erros de medida. considerando esses resultados, os lambdas apresentados significam o percentual da variação real da medida, isto é, os lambdas explicam os valores acima de 80 %. a adequabilidade quanto ao grau de clareza e relevância dos itens do instrumento em questão apontada pelos juízes poderá ser usada para a respectiva avaliação sobre o fenômeno “o saber e o fazer de enfermeiros nos cuidados paliativos destinados às pessoas com feridas tumorais malignas cutâneas”. além disso, a análise gerou uma versão com alterações no conteúdo do instrumento, a partir dos comentários e sugestões dos juízes, a saber: o item 28 foi excluído, mas a frase foi direcionada ao item 27, uma vez que os juízes entenderam que as informações contidas nesses itens se complementavam; os itens 38, 43 e 49 foram direcionados da categoria 3 para a 2, uma vez que os juízes compreenderam que estariam mais bem articulados nos cuidados básicos; já os itens 42, 81, 83 e 84 foram excluídos das categorias 3 e 8, pois os juízes perceberam que as informações eram repetidas e compreenderam que deveriam permanecer somente nos cuidados básicos realizados com a lesão. o rhô (ρ) de kurder-richardson, que se destina à verificação da confiabilidade do grau de concordância entre avaliadores numa medida dicotômica, deve apresentar um escore acima de 0,70 (22), apresentou os seguintes resultados para a condição de clareza do instrumento: categoria 1, ρ = 0,80; categoria 2, ρ = 0,73; a categoria 3 (total, ρ = 0,71) foi subdividida em oito subcategorias: subcategoria 1, ρ = 0,71; subcategoria 2, ρ = 0,72; subcategoria 3, ρ = 0,73; subcategoria 4, ρ = 0,78; subcategoria 5, ρ = 0,78; subcategoria 6, ρ = 0,76; subcategoria 7, ρ = 0,75; subcategoria 8, ρ = 0,77; categoria 4, ρ = 0,73 e categoria 5, ρ = 0,75. o índice kappa (k), que trata de uma medida de concordância interobservador e que mensura o grau de concordância e consistência dos juízes em relação à permanência ou não dos itens do instrumento, levando em consideração as indicações de “inadequado” para estes, varia de “menos 1” a “mais 1”; com isso, quanto mais próximo de 1, melhor o nível de concordância entre os observadores. como critério de aceitação, foi estabelecida a concordância igual ou superior a 0,61 entre os juízes, que apresenta nível bom (23). o instrumento submetido para a primeira avaliação dos juízes contemplava os aspectos relacionados aos cuidados paliativos esperados para sua execução pelo enfermeiro na assistência paliativa à pessoa com ferida tumoral maligna, todavia os procedimentos envolvidos no processo de cuidar não contemplavam a descrição detalhada da técnica. essa configuração inicial influenciou os valores de kappa e subsidiou as reformulações no instrumento para a segunda avaliação dos instrumentos (original e modificado), contudo alguns foram mantidos, uma vez que são cuidados paliativos considerados imprescindíveis e respaldados pela literatura pertinente, a saber: os itens 2, 3 e 12, no que se refere à clareza (7-8). por fim, verificou-se validade aparente (nesta, considera-se a definição teórica de uma variável que, de fato, parece mensurar o item proposto. concretamente, refere-se ao que o item, pelo tipo de questões ou de situações apresentadas, aparenta avaliar); para isso, efetuou-se o ivc (12, 16) relacionado à qualidade da concordância e do conteúdo dos itens na concepção dos juízes para a clareza e a importância, e observou-se que esse indicador variou de 0,91 a 1,00; para os itens da medida, ficou entre 0,85 e 1,00. apesar de os itens 2, 3 e 12 não terem apresentado um kappa com valor aceitável, optou-se pela permanência destes, porque, no item 2, o tamanho se refere à mensuração da lesão, ou seja, é um parâmetro avaliativo que confere a evolução da ferida. recomenda-se medir o comprimento e a largura, e, se possível, medir a profundidade e/ou abaulamento, já que as feridas tumorais malignas também apresentam aspecto vegetativo (1, 7-8). no que se refere à permanência do item 3, vale ressaltar que o estadiamento é outro método avaliativo para as feridas tumorais e trata-se de uma classificação proposta pelo manual do ministério da saúde do brasil (7) e pela literatura pertinente (1-3, 8), cuja finalidade é classificar a ferida conforme o grau de comprometimento tecidual e sinais e sintomas predominantes. o item 12, que está relacionado à avaliação da borda e da pele periferida, também foi mantido, visto que a borda e a área perilesional apresentaram, além da descamação, problema comum encontrado nas feridas tumorais, maceração, escoriação, fragilidade e hiperqueratose. esses danos causam dor e desconforto nas pessoas, além de afetar negativamente sua qualidade de vida (24). já os itens 36 e 58 foram excluídos, pois não apresentaram um kappa com percentual aceitável, mesmo sendo respaldados pela literatura pertinente (1-3, 7-8). 8 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2012 aquichan issn 1657-5997 eissn 2027-5374 tabela 1. cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea. joão pessoa-pb, 2017 primeira versão clareza pertinência segunda versão sim não kappa sim não kappa categoria 1. avaliação da lesão e das necessidades da pessoa com ferida tumoral maligna cutânea 1. localização 87 % 13 % 0,74 97 % 3 % 0,94 1. localização anatômica da lesão 2. tamanho 80 % 20 % 0,60 93 % 7 % 0,86 2. tamanho — mensuração da lesão (altura, largura, profundidade ou abaulamento) 3. estadiamento 80 % 20 % 0,60 97 % 3 % 0,94 3. estadiamento (1, 1n, 2, 3 e 4) 4. área de envolvimento 43 % 57 % 0,14 50 % 50 % 0 4. excluído 5. coloração 80 % 20 % 0,60 73 % 27 % 0,46 5. excluído 6. extensão 57 % 43 % 0,14 73 % 27 % 0,46 6. excluído 7. odor (classificação) 97 % 3 % 0,94 100 % 0 1,00 7. intensidade do odor (grau i, ii e iii) 8. exsudato (tipo, cor e consistência) 93 % 7 % 0,86 100 % 0 1,00 8. exsudato (tipo e quantidade) 9. sangramento (classificação) 83 % 17 % 0,66 100 % 0 1,00 9. intensidade do sangramento (leve, moderado e intenso) 10. dor (intensidade) 97 % 3 % 0,94 100 % 0 1,00 10. intensidade da dor na ferida (leve, moderada, intensa, excruciante), usando a escala visual analógica ou a escala visual numérica 11. prurido 100 % 0 1,00 97 % 3 % 0,94 11. não houve alteração 12. descamação 90 % 10 % 0,80 80 % 20 % 0,60 12. borda e área perilesional 13. sinais de infecção 93 % 7 % 0,86 90 % 10 % 0,80 13. sinais de infecção locais (calor, rubor, edema e dor) 14. tipo de tecido (cicatrização, granulação, liquefação, coagulação) 83 % 17 % 0,66 90 % 10 % 0,80 14. tipo de tecido (necrose de coagulação, necrose de liquefação, granulação, epitelização) 15. presença de miíases 100 % 0 1,00 97 % 3 % 0,94 15. não houve alteração 16. fístulas 97 % 3 % 0,94 93 % 7 % 0,86 16. presença de fístulas e quantidade drenada 17. sinus 87 % 13 % 0,74 83 % 17 % 0,66 17. sinus (túneis) 18. cavidade 93 % 7 % 0,86 93 % 7 % 0,86 18. classificação morfológica da lesão (nodular, cavitária e vegetante) 19. acometimento ou invasão de órgãos ou sistemas 87 % 13 % 0,74 93 % 7 % 0,86 19. não houve alteração 20. avaliação dos aspectos social, psíquico e espiritual 87 % 13 % 0,74 93 % 7 % 0,86 20. avaliação dos aspectos social, psíquico, espiritual e econômico 21. progressão ou mudança da ferida 83 % 17 % 0,66 90 % 10 % 0,80 21. não houve alteração 22. produtos necessários/apropriados para a ferida 75 % 15 % 0,60 80 % 20 % 0,60 22. excluído 23. identificação das necessidades educacionais da pessoa ou do cuidador quanto aos cuidados com a ferida após a alta 98 % 2 % 0,96 97 % 3 % 0,94 23. não houve alteração categoria 2. cuidados básicos realizados com a ferida tumoral maligna cutânea 24. calçar luvas estéreis para proceder com o curativo 90 % 10 % 0,80 73 % 27 % 0,46 23. excluído 25. retirar gazes anteriores com irrigação abundante utilizando solução salina 97 % 3 % 0,94 87 % 13 % 0,74 25. retirar gazes aderidas ao leito da lesão com irrigação abundante utilizando solução salina 26. irrigar o leito da ferida com solução salina em jato com seringa de 20 ml e agulha 40 x 12 cm 97 % 3 % 0,94 90 % 10 % 0,80 26. irrigar o leito da ferida com solução salina 9 validação de instrumento sobre o saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral maligna cutânea l glenda agra e outros primeira versão clareza pertinência segunda versão sim não kappa sim não kappa 27. lavar a ferida com sabonete antisséptico (clorohexidine ou phmb) 93 % 7 % 0,86 83 % 17 % 0,74 27. lavar a ferida com antisséptico (clorohexidine degermante ou phmb sabonete) para a remoção superficial de bactérias e debris 28. limpar a ferida para a remoção superficial de bactérias e debris 93 % 7 % 0,86 83 % 17 % 0,74 28. excluído e direcionado para o item 27 29. empregar técnica asséptica 97 % 3 % 0,94 87 % 13 % 0,74 29. não houve alteração 30. conter/absorver o exsudato 87 % 17 % 0,74 90 % 10 % 0,80 30. utilizar coberturas absorventes 31. manter úmido o leito da ferida 100 % 0 1,00 90 % 10 % 0,80 31. manter úmido o leito da ferida, a fim de evitar aderência de gazes 32. eliminar o espaço morto (preenchê-lo com curativo) 97 % 3 % 0,94 93 % 7 % 0,86 32. não houve alteração 33. promover os curativos simétricos com a aparência do paciente) 100 % 0 1,00 100 % 0 1,00 33. promover as coberturas em conformidade com contornos da área para oferecer conforto à pessoa 34. proteger o curativo com saco plástico durante o banho de aspersão e abri-lo para a troca somente no leito (o que evita a dispersão do exsudato e micro-organismos no ambiente) 100 % 0 1,00 90 % 10 % 0,80 34. proteger o curativo com saco plástico ou filme transparente durante o banho de aspersão e abri-lo para a troca somente no leito (o que evita a dispersão do exsudato e micro-organismos no ambiente) categoria 3. cuidados específicos realizados na ferida tumoral maligna cutânea subcategoria 1. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle da dor 35. monitorar o nível de dor pela escala visual analógica 100 % 0 1,00 100 % 0 1,00 35. monitorar o nível de intensidade da dor pela escala visual analógica ou escala visual numérica 36. considerar o uso de gelo e medicação analgésica, conforme prescrição médica 80 % 20 % 0,60 80 % 20 % 0,60 36. excluído 37. iniciar o curativo após 30 minutos da analgesia via oral; 5 minutos da analgesia subcutânea ou endovenosa e início imediato para via tópica, conforme prescrição médica 97 % 3 % 0,94 97 % 3 % 0,94 37. não houve alteração 38. retirar os adesivos cuidadosamente 100 % 0 1,00 93 % 7 % 0,94 38. retirar os adesivos cuidadosamente usando solução removedora (solução salina ou vaselina ou óleo mineral). direcionado para o domínio 2 39. adequar o horário da troca de curativos após o paciente já estar medicado 100 % 0 1,00 93 % 7 % 0,94 39. adequar o horário de troca de curativos após a pessoa já estar medicada, respeitando o intervalo de acordo com o tipo de analgesia 40. avaliar a necessidade de analgesia tópica com lidocaína gel a 2 % 93 % 7 % 0,94 87 % 13 % 0,84 40. avaliar a necessidade de analgesia tópica com lidocaína gel a 2 %, conforme prescrição médica 41. evitar friccionar com força o leito da ferida 97 % 3 % 0,94 83 % 17 % 0,66 41. não friccionar com força o leito da ferida 42. irrigar o leito da ferida com solução salina 100 % 0 1,00 80 % 20 % 0,60 42. excluído. já está contemplado no domínio 2 43. utilizar coberturas antiaderentes (gaze de rayon, gaze impregnada de petrolatum, gaze embebida de óleo mineral ou vaselina) 97 % 3 % 0,94 97 % 3 % 0,94 43. utilizar coberturas antiaderentes. direcionado para o domínio 2 44. considerar coberturas à base de ibuprofeno 90 % 10 % 0,80 73 % 27 % 0,46 44. excluído 45. considerar a aplicação sobre a lesão de comprimidos de morfina (10 mg ou 30 mg) macerados e misturados com hidrogel (15 g) 83 % 17 % 0,66 60 % 40 % 0,20 45. excluído 46. considerar o uso de hidrogel se a ferida estiver seca ou com baixa exsudação 93 % 7 % 0,94 80 % 20 % 0,60 46. excluído 10 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2012 aquichan issn 1657-5997 eissn 2027-5374 primeira versão clareza pertinência segunda versão sim não kappa sim não kappa 47. aplicar pomada de óxido de zinco nas bordas e ao redor da ferida 90 % 10 % 0,80 67 % 33 % 0,30 47. excluído 48. observar a necessidade de analgesia após a realização do curativo 100 % 0 1,00 100 % 0 1,00 48. não houve alteração 49. considerar a redução de trocas frequentes de curativos utilizando compressas cirúrgicas, absorventes íntimos geriátricos descartáveis ou fraldas infantis descartáveis 93 % 7 % 0,94 83 % 17 % 0,66 49. excluído e direcionado para o domínio 2 50. verificar a necessidade de alteração do esquema analgésico prescrito 100 % 0 1,00 87 % 13 % 0,74 50. reavaliar, junto à equipe médica, a necessidade de alteração do esquema analgésico prescrito 51. considerar, junto à equipe médica, a necessidade de anti-inflamatórios, radioterapia antiálgica ou cirurgia 100 % 0 1,00 97 % 3 % 0,94 51. não houve alteração 52. registrar a avaliação da dor pela escala visual analógica e a analgesia antes e depois do curativo 97 % 3 % 0,94 97 % 3 % 0,94 52. registrar a avaliação da intensidade dor pela escala visual analógica ou escala visual numérica e a analgesia antes e depois do curativo 53. comunicar, à equipe médica, os casos de sofrimento álgico que fujam do controle da conduta preconizada 90 % 10 % 0,80 93 % 7 % 0,94 53. não houve alteração subcategoria 2. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle do exsudato 54. coletar material para cultura (aspirado ou swab) 90 % 10 % 0,80 93 % 7 % 0,94 54. coletar material para cultura (aspirado/swab pela técnica de levine) com limpeza prévia da lesão 55. empregar carvão ativado/alginato de cálcio/ copolímero de amido/ espumas com ou sem prata/ hidrofibra e compressas/gaze como cobertura secundária. 97 % 3 % 0,94 97 % 3 % 0,94 55. empregar carvão ativado/alginato de cálcio/copolímero de amido/ espumas com ou sem prata/hidrofibra como cobertura primária e compressas/gazes como cobertura secundária 56. empregar óxido de zinco, hidrocoloide, creme barreira na pele macerada e nas bordas da ferida antes da utilização de antissépticos 77 % 23 % 0,54 53 % 47 % 0,06 56. excluído subcategoria 3. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle do prurido 57. investigar a causa do prurido 97 % 3 % 0,94 97 % 3 % 0,94 57. não houve alteração 58. realizar crioterapia (uso de gelo) para bloquear o estímulo nervoso 87 % 13 % 0,74 80 % 20 % 0,60 58. excluído 59. considerar o uso de adesivos hipoalergênicos (micropore) 100 % 0 1,00 97 % 3 % 0,94 59. utilizar adesivos hipoalergênicos 60. utilizar dexametasona creme 0,1 % nas áreas do prurido, conforme prescrição médica 97 % 3 % 0,94 97 % 3 % 0,94 60. não houve alteração 61. investigar presença de infecções fúngicas 93 % 7 % 0,86 100 % 0 1,00 61. não houve alteração 62. utilizar nistatina ou sulfadiazina de prata com 1 % ou sem cério, conforme prescrição médica para candidíase cutânea nas áreas de hiperemia ao redor da ferida associada a manchas esbranquiçadas 93 % 7 % 0,86 93 % 7 % 0,86 62. utilizar nistatina ou sulfadiazina de prata 1 % com ou sem nitrato de cério, conforme prescrição médica para candidíase cutânea nas áreas de hiperemia ao redor da ferida associada a manchas esbranquiçadas 11 validação de instrumento sobre o saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral maligna cutânea l glenda agra e outros primeira versão clareza pertinência segunda versão sim não kappa sim não kappa 63. considerar a redução do intervalo dos curativos, para evitar esse sintoma 83 % 17 % 0,66 93 % 7 % 0,86 63. considerar a redução do intervalo dos curativos, para evitar esse sintoma e investigar reação alérgica a cobertura utilizada 64. caso o prurido persista, considerar, junto à equipe médica, a introdução de terapia sistêmica 97 % 3 % 0,94 97 % 3 % 0,94 64. não houve alteração 65. considerar cremes à base de desonida para os casos de alergia ao corticoide tópico, conforme prescrição médica 97 % 3 % 0,94 87 % 13 % 0,74 65. utilizar cremes à base de desonida para os casos de alergia, conforme prescrição médica subcategoria 4. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle da necrose 66. avaliar as necessidades de debridamento, de acordo com a capacidade do paciente 90 % 10 % 0,80 87 % 13 % 0,74 66. avaliar as necessidades de debridamento, de acordo com a condição clínica da pessoa e as características da lesão (por exemplo, friáveis) 67. eleger a forma de debridamento (autolítico, químico, mecânico e instrumental conservador) 97 % 3 % 0,94 93 % 7 % 0,94 67. não houve alteração 68. considerar o debridamento autolítico pelo uso de hidrogel ou alginato 93 % 7 % 0,86 83 % 17 % 0,66 68. considerar, prioritariamente, o debridamento autolítico subdomínio 5. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle da fístula 69. aplicar óxido de zinco/hidrocoloide/creme barreia/solução polimérica na pele ao redor da fístula 93 % 7 % 0,86 93 % 7 % 0,86 69. não houve alteração 70. adaptar, quando possível, uso de bolsas coletoras nas fístulas de alta drenagem, com placas de hidrocoloide ao redor da pele 90 % 10 % 0,80 100 % 0 1,00 70. adaptar, quando possível, bolsas coletoras nas fístulas de alta drenagem e proteger a área perifistular 71. realizar curativo absortivo com carvão ativado e/ ou alginato de cálcio com compressa/gaze como cobertura secundária 90 % 10 % 0,80 77 % 23 % 0,54 71. excluído subcategoria 6. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle do sangramento 72. aplicar pressão diretamente sobre os vasos sangrantes com o amparo de gazes, compressas ou toalhas 93 % 7 % 0,86 93 % 7 % 0,86 72. aplicar pressão diretamente sobre os vasos sangrantes com o emprego de gazes, compressas ou toalhas de cores escuras por 10 a 15 minutos 73. considerar aplicação de solução salina gelada por meio de gaze ou compressa gelada ou compressão manual por 10 a 15 minutos 93 % 7 % 0,86 100 % 0 1,00 73. considerar aplicação de solução salina gelada com o emprego de gazes e/ou compressas 74. considerar aplicação de nitrato de prata para sangramentos pequenos 87 % 13 % 0,74 77 % 23 % 0,54 74. excluído 75. considerar aplicação de solução de alumínio para sangramentos pequenos a moderados 87 % 13 % 0,74 77 % 23 % 0,54 75. excluído 76. considerar aplicação de comprimidos macerados ou solução de sucralfato 1 % (comprimido diluído em 5 ml de gel aquoso ou água destilada ou salpicado sobre a lesão, conforme prescrição médica) 80 % 20 % 0,60 77 % 23 % 0,54 76. excluído 77. considerar curativo hemostático à base de gelatina suína (gelfoam) 97 % 3 % 0,94 97 % 3 % 0,94 77. não houve alteração 78. considerar alginato de cálcio 100 % 0 1,00 90 % 10 % 0,80 78. aplicar alginato de cálcio 12 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2012 aquichan issn 1657-5997 eissn 2027-5374 primeira versão clareza pertinência segunda versão sim não kappa sim não kappa 79. considerar aplicação de curativo de celulose oxidada 93 % 7 % 0,94 73 % 27 % 0,46 79. excluído 80. considerar adrenalina (solução injetável) topicamente sobre os pontos sangrantes 1:1000, conforme prescrição médica 93 % 7 % 0,86 90 % 10 % 0,80 80. não houve alteração 81. manter o meio úmido para evitar a aderência de gaze no local da ferida 100 % 0 1,00 97 % 3 % 0,94 81. excluído. já está contemplado no domínio 2 82. verificar, junto à equipe médica, a possibilidade de tratamento com coagulante sistêmico como ácido aminocaproico (comprimidos ou em solução injetável) ou ácido tranexâmico (comprimidos ou em solução injetável) 97 % 3 % 0,94 97 % 3 % 0,94 82. não houve alteração 83. considerar o uso de coberturas antiaderentes (gaze de rayon ou gaze impregnada de petrolatum, óleo mineral, vaselina) 93 % 7 % 0,86 87 % 13 % 0,74 83. excluído. já está contemplado no domínio 3 84. considerar a redução das trocas frequentes de curativos utilizando compressas cirúrgicas, absorventes íntimos geriátricos descartáveis, fraldas infantis descartáveis 97 % 3 % 0,94 90 % 10 % 0,80 84. excluído. já está contemplado no domínio 3 85. verificar, junto à equipe médica, a possibilidade de tratamento com intervenção cirúrgica 93 % 7 % 0,86 93 % 7 % 0,86 85. verificar, junto à equipe médica, a possibilidade de tratamento com intervenção cirúrgica nos sangramentos persistentes ou resistentes às terapias convencionais 86. verificar, junto à equipe médica, a possibilidade de tratamento com radioterapia anti-hemorrágica 93 % 7 % 0,86 90 % 10 % 0,80 86. não houve alteração 87. verificar, junto à equipe médica, a possibilidade de tratamento com sedação paliativa para os casos de sangramento intenso acompanhado de agitação, desespero e angústia da pessoa 97 % 3 % 0,94 97 % 3 % 0,94 87. não houve alteração 88. em casos de agitação e angústia do paciente por causa do sangramento intenso, considerar o uso de toalhas pretas para conter a hemorragia 83 % 17 % 0,66 83 % 17 % 0,66 88. em casos de agitação e angústia da pessoa por causa do sangramento intenso, considerar o uso de toalhas de cores escuras para conter a hemorragia subcategoria 7. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle do odor 89. proceder à limpeza com solução salina e antissepsia com clorohexidina degermante ou phmb (polihexanidametilbiguanida) 97 % 3 % 0,94 97 % 3 % 0,94 89. considerar a aplicação de solução de phmb 90. retirar antisséptico com jato de solução salina e manter gazes embebidas em hidróxido de alumínio no leito da ferida 97 % 3 % 0,94 87 % 13 % 0,74 90. considerar o uso de gazes embebidas em hidróxido de alumínio no leito da ferida para odor grau i 91. empregar sulfadiazina de prata em gaze e ocluir com gaze embebida em vaselina líquida 78 % 22 % 0,56 70 % 30 % 0,40 91. excluído 92. empregar carvão ativado em gaze umedecida com solução salina. 93 % 7 % 0,94 90 % 10 % 0,80 92. considerar o uso de carvão ativado 93. aplicar gel de metronidazol 0,8 %, conforme prescrição médica, em gaze embebida em vaselina e aplicar no leito da ferida 90 % 10 % 0,80 83 % 17 % 0,66 93. aplicar gel ou solução de metronidazol 0,8 % para odor grau ii, conforme prescrição médica 94. se houver necessidade, fazer escarotomia em tecido necrótico e proceder à aplicação de gel de metronidazol 87 % 13 % 0,74 77 % 23 % 0,54 94. excluído 13 validação de instrumento sobre o saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral maligna cutânea l glenda agra e outros primeira versão clareza pertinência segunda versão sim não kappa sim não kappa 95. considerar, junto à equipe médica, a possibilidade de associação de metronidazol sistêmico (endovenoso ou oral) ao uso tópico 93 % 7 % 0,86 93 % 7 % 0,86 95. considerar, junto à equipe médica, a possibilidade de associação de metronidazol sistêmico (endovenoso ou oral) ao uso tópico para odor grau iii 96. considerar curativo impregnado de cloreto de sódio 97 % 3 % 0,94 67 % 33 % 0,34 96. excluído 97. considerar o uso de copolímero de amido 83 % 17 % 0,74 67 % 33 % 0,34 97. excluído 98. considerar o uso de cadexômero de iodo 83 % 17 % 0,74 67 % 33 % 0,34 98. excluído subcategoria 8. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle de infestação por miíases 99. considerar a aplicação lidocaína tópica a fim de reduzir a dor durante a retirada manual das larvas 93 % 7 % 0,86 90 % 10 % 0,80 99. considerar a aplicação de lidocaína tópica, conforme prescrição médica, a fim de reduzir a dor durante a retirada manual das larvas 100. aplicar vaselina líquida a fim de sufocar as larvas e facilitar a remoção 100 % 0 1,00 87 % 13 % 0,74 100. aplicar vaselina líquida a fim de impedir que as larvas respirem, o que facilita sua remoção 101. realizar a retirada manual (com pinças) das larvas 97 % 3 % 0,94 97 % 3 % 0,94 101. não houve alteração 102. administrar ivermectina sistêmico, conforme prescrição médica 100 % 0 1,00 90 % 10 % 0,80 102. não houve alteração categoria 4. registro das ações de enfermagem 103. documentar a avaliação da ferida e do paciente 97 % 3 % 0,94 97 % 3 % 0,94 103. documentar a avaliação das características da ferida e as necessidades da pessoa 104. documentar todas as intervenções realizadas 100 % 0 1,00 97 % 3 % 0,94 104. documentar todas as intervenções realizadas com a ferida e com a pessoa 105. documentar a educação realizada ao paciente e/ ou à família, sinalizando os pontos de dificuldades de entendimento e habilidade 97 % 3 % 0,94 93 % 7 % 0,86 105. documentar a educação realizada com a pessoa e/ou a família, sinalizando os pontos de dificuldades de entendimento e habilidade 106. documentar os resultados obtidos 97 % 3 % 0,94 93 % 7 % 0,86 106. não houve alteração 107. realizar registro fotográfico das feridas 97 % 3 % 0,94 93 % 7 % 0,86 107. considerar registro fotográfico das feridas após a autorização da pessoa e/ou do familiar categoria 5. orientações para a alta hospitalar 108. identificar e contatar o cuidador principal para a capacitação na realização dos curativos em domicílio 97 % 3 % 0,94 100 % 0 1,00 108. não houve alteração 109. identificar, com a família, a rede de atendimento público que poderá ser acessada para a parceria nos cuidados com relação à ferida 97 % 3 % 0,94 100 % 0 1,00 109. identificar e contatar, com a família, a rede de atendimento público que poderá ser acessada para a parceria nos cuidados com relação à ferida e capacitar esse profissional, se necessário 110. realizar relatório de enfermagem sumarizado com relação à alta hospitalar e aos cuidados com a ferida 100 % 0 1,00 97 % 3 % 0,94 110. realizar relatório de enfermagem sumarizado com relação à alta hospitalar e aos cuidados com a ferida, os produtos utilizados, os resultados obtidos e esperados e o processo de educação da família 111. orientar vestuário: roupas mais confortáveis e adaptadas ao melhor acesso à ferida para as trocas de curativos 97 % 3 % 0,94 100 % 0 1,00 111. não houve alteração 112. orientar melhores condições para dormir, considerando o uso de coxins e outros artefatos para melhorar o posicionamento 97 % 3 % 0,94 100 % 0 1,00 112. não houve alteração fonte: dados da pesquisa, 2017. 14 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2012 aquichan issn 1657-5997 eissn 2027-5374 todos os comentários e sugestões dos juízes foram acatados, bem como os itens foram reformulados, no sentido de atendê-los na sua totalidade. para não deixar dúvida, solicitou-se uma segunda avaliação dos juízes; para isso, foram enviados o instrumento original e o modificado, para que eles analisassem e atribuíssem a qualidade de avaliação entre as versões. dos 30 juízes que participaram da primeira avaliação do instrumento, mais de 50 % (17) responderam à segunda versão em sua totalidade e a aceitaram. vale ressaltar que a perda de participantes é um fato esperado a cada avaliação da técnica delphi, embora não represente um fator limitante para a análise dos dados da pesquisa (25). de forma geral, apesar de esses resultados garantirem a qualidade inicial do instrumento, ressalta-se a importância de estudos posteriores para a determinação da confiabilidade dele, seja na perspectiva psicométrica mais clássica, seja na mais complexa, que vise à qualidade do constructo teórico pretendido, condição essa que possibilitará determinar o grau de coerência com que o instrumento mede o atributo teórico em estudo. diante do exposto, o instrumento definitivo, que segue a conformidade dos juízes e está de acordo com o tratamento analítico, permaneceu com cinco categorias e 84 itens, como se pode observar no quadro 1. conclusões de forma geral, o presente estudo teve como objetivo descrever o processo de validação de uma medida que contribui para a avaliação dos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea, realizados em unidades de oncologia clínica e cuidados paliativos. a partir dos resultados observados, é possível afirmar que, nesta primeira etapa da análise da medida, o instrumento se mostrou adequado para o que se pretendia mensurar, uma vez que os indicadores estatísticos revelaram percentuais iguais ou superiores ao exigido pela literatura, bem como foram significativos nas categorias e subcategorias relacionadas aos cuidados paliativos. nesse sentido, acredita-se que a construção de instrumentos com tal perspectiva teórica e prática seja válida para a área da saúde e, especificamente, para a enfermagem; condição essa que, provavelmente, contribui para avaliar a qualidade do cuidado e, dessa forma, direcionar mudanças necessárias no processo de cuidar da equipe de enfermagem, que tem como objetivo principal ampliar a qualidade da assistência e do cuidado no contexto da realidade local. com isso, de forma prática, as reduzidas perdas de dados, o refinamento das opiniões e o consenso dos juízes em relação aos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea visaram à uniformização da medida e de atitudes intervencionistas mais claras, a partir do “lugar” em que os respondentes apontaram o grau de importância dos itens e das categorias na área da enfermagem, o que indicou que o instrumento em questão é aplicável. agradecimentos: os autores expressam os seus agradecimentos aos juízes que colaboraram na avaliação do instrumento. conflitos de interesse: nenhum declarado. quadro 1. instrumento definitivo para avaliar o saber e o fazer de enfermeiros nos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea. joão pessoa-pb, 2017 categoria 1. avaliação da lesão e das necessidades da pessoa com ferida tumoral maligna cutânea 1. localização anatômica da lesão. 2. tamanho — mensuração da lesão (altura, largura, profundidade ou abaulamento). 3. estadiamento (1, 1n, 2, 3, 4). 4. intensidade do odor (grau i, ii, iii). 5. exsudato (tipo e quantidade). 6. intensidade do sangramento (leve, moderado e intenso). 7. intensidade da dor na ferida (leve, moderada, intensa e excruciante), usando a escala visual analógica ou escala visual numérica. 15 validação de instrumento sobre o saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral maligna cutânea l glenda agra e outros 8. prurido. 9. borda e pele perilesional. 10. sinais de infecção locais (calor, rubor, edema, dor). 11. tipo de tecido (necrose de coagulação, necrose de liquefação, granulação, epitelização). 12. presença de miíases. 13. fístulas e quantidade drenada. 14. sinus (túneis). 15. classificação morfológica da lesão (nodular, cavitária, vegetante). 16. acometimento ou invasão de órgãos-alvo. 17. avaliação dos aspectos social, psíquico, espiritual e econômico. 18. progressão ou mudança da forma da ferida. 19. identificação das necessidades educacionais da pessoa ou do cuidador quanto aos cuidados com a ferida após a alta. categoria 2. cuidados básicos realizados na ferida tumoral maligna cutânea 20. retirar os adesivos cuidadosamente usando solução removedora (solução salina ou vaselina ou óleo mineral). 21. retirar gazes aderidas ao leito da lesão com irrigação abundante utilizando solução salina. 22. irrigar o leito da ferida com solução salina. 23. lavar a ferida com antisséptico (clorohexidine degermante ou phmb sabonete), para a remoção superficial de bactérias e debris. 24. empregar técnica asséptica. 25. manter úmido o leito da ferida a fim de evitar aderência de gazes. 26. eliminar o espaço morto (preenchê-lo com curativo) antes da cobertura selecionada. 27. utilizar coberturas absorventes. 28. considerar o uso de coberturas antiaderentes. 29. considerar a redução das trocas frequentes de curativos utilizando compressas cirúrgicas como coberturas primárias e absorventes íntimos geriátricos descartáveis ou fraldas infantis descartáveis como coberturas secundárias. 30. promover as coberturas em conformidade com os contornos da área para oferecer conforto à pessoa. 31. proteger o curativo com saco plástico ou filme transparente durante o banho de aspersão e abri-lo para a troca somente no leito (o que evita a dispersão de exsudato e micro-organismos no ambiente). categoria 3. cuidados específicos realizados na ferida tumoral maligna cutânea subcategoria 1. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle da dor 32. monitorar o nível de intensidade da dor pela escala visual analógica ou escala visual numérica. 33. iniciar o curativo após 30 minutos da analgesia via oral; 5 minutos da analgesia subcutânea ou endovenosa; e início imediato para a via tópica, conforme prescrição médica. 34. adequar o horário de troca de curativos após a pessoa já estar medicada, respeitando o intervalo de acordo com o tipo de analgesia. 35. avaliar a necessidade de analgesia tópica com lidocaína gel a 2 %, conforme prescrição médica. 36. não friccionar com força o leito da ferida. 16 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2012 aquichan issn 1657-5997 eissn 2027-5374 37. verificar a necessidade de alteração do esquema analgésico prescrito. 38. considerar, junto à equipe médica, a necessidade de anti-inflamatórios, radioterapia antiálgica ou cirurgia. 39. registrar a avaliação da dor pela escala visual analógica ou escala visual numérica e a analgesia antes e depois do curativo. 40. comunicar, à equipe médica, os casos de sofrimento álgico que fujam do controle da conduta preconizada. subcategoria 2. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle do exsudato 41. coletar material para cultura (aspirado/swab pela técnica de levine) com limpeza prévia da lesão. 42. empregar carvão ativado/alginato de cálcio/copolímero de amido/espumas com ou sem prata/hidrofibra como cobertura primária e compressas/gazes como cobertura secundária. subcategoria 3. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle do prurido 43. investigar a causa do prurido. 44. utilizar adesivos hipoalergênicos. 45. utilizar dexametasona creme 0,1 % nas áreas do prurido, conforme prescrição médica. 46. investigar presença de infecções fúngicas. 47. utilizar nistatina ou sulfadiazina de prata 1 % com ou sem nitrato de cério para candidíase cutânea nas áreas de hiperemia ao redor da ferida associada a manchas esbranquiçadas, conforme prescrição médica. 48. considerar a redução do intervalo dos curativos, para evitar esse sintoma e investigar reação alérgica à cobertura utilizada. 49. caso o prurido persista, considerar, junto à equipe médica, a introdução de terapia sistêmica. 50. utilizar cremes à base de desonida para os casos de alergia, conforme prescrição médica. subcategoria 4. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle da necrose 51. avaliar as necessidades de debridamento, de acordo com a condição clínica da pessoa e as características da lesão (por exemplo, friáveis). 52. eleger a forma de debridamento (autolítico, químico, mecânico e instrumental conservador). 53. considerar, prioritariamente, o debridamento autolítico. subcategoria 5. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle da fístula 54. aplicar óxido de zinco/hidrocoloide/creme barreia/solução polimérica na pele ao redor da fístula. 55. adaptar, quando possível, bolsas coletoras nas fístulas de alta drenagem e proteger a área perifistular. subcategoria 6. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle do sangramento 56. aplicar pressão diretamente sobre os vasos sangrantes com o emprego de gazes por 10 a 15 minutos. 57. considerar aplicação de solução salina gelada com o emprego de gazes e/ou compressas. 58. considerar o uso de curativo hemostático à base de gelatina suína (gelfoam). 59. aplicar alginato de cálcio. 60. considerar o uso de adrenalina (solução injetável) topicamente sobre os pontos sangrantes 1:1000, conforme prescrição médica. 61. verificar, junto à equipe médica, a possibilidade de tratamento com coagulante sistêmico como ácido aminocaproico (comprimidos ou em solução injetável) ou ácido tranexâmico (comprimidos ou em solução injetável). 62. verificar, junto à equipe médica, a possibilidade de tratamento com intervenção cirúrgica nos sangramentos persistentes ou resistentes às terapias convencionais. 63. verificar, junto à equipe médica, a possibilidade de tratamento com radioterapia anti-hemorrágica. 64. verificar, junto à equipe médica, a possibilidade de tratamento com sedação paliativa para os casos de sangramento intenso acompanhado de agitação, desespero e angústia da pessoa. 65. em casos de agitação e angústia da pessoa por causa do sangramento intenso, considerar o uso de toalhas de cores escuras para conter a hemorragia. 17 validação de instrumento sobre o saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral maligna cutânea l glenda agra e outros subcategoria 7. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle do odor 66. considerar a aplicação de solução de phmb (polihexanidametilbiguanida). 67. considerar o uso de gazes embebidas em hidróxido de alumínio no leito da ferida para odor grau i. 68. considerar o uso de carvão ativado. 69. aplicar gel ou solução de metronidazol 0,8 % para odor grau ii, conforme prescrição médica. 70. considerar, junto à equipe médica, a possibilidade de associação de metronidazol sistêmico (endovenoso ou oral) ao uso tópico para odor grau iii. subcategoria 8. cuidados específicos realizados na ferida tumoral maligna cutânea para o controle da infestação de miíases 71. considerar a aplicação de lidocaína tópica a fim de reduzir a dor durante a retirada manual das larvas, conforme prescrição médica. 72. aplicar vaselina líquida a fim de impedir que as larvas respirem, o que facilita sua remoção. 73. realizar a retirada manual (com pinças) das larvas. 74. administrar ivermectina sistêmico, conforme prescrição médica. categoria 4. registro das ações de enfermagem 75. documentar a avaliação das características da ferida e as necessidades da pessoa. 76. documentar todas as intervenções realizadas com a ferida e com a pessoa. 77. documentar a educação realizada com a pessoa e/ou a família, sinalizando os pontos de dificuldades de entendimento e habilidade. 78. documentar os resultados obtidos. 79. considerar registro fotográfico das feridas após a autorização da pessoa e/ou do familiar. categoria 5. orientações para a alta hospitalar 80. identificar e contatar o cuidador principal para a capacitação na realização dos curativos no domicílio. 81. identificar e contatar, com a família, a rede de atendimento público que poderá ser acessada para a parceria nos cuidados com relação à ferida e capacitar esse profissional, se necessário. 82. realizar relatório de enfermagem sumarizado com relação à alta hospitalar e aos cuidados com a ferida, os produtos utilizados, os resultados obtidos e esperados e o processo de educação da família. 83. orientar vestuário: roupas mais confortáveis e adaptadas ao melhor acesso à ferida para as trocas de curativos. 84. orientar melhores condições para dormir, considerando uso de coxins e outros artefatos para melhorar o posicionamento. fonte: dados da 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(fonte: decs, bireme). modelo de enfermería como sistema adaptativo complejo resumen el surgimiento y el uso de los sistemas complejos adaptativos suplieron la necesidad de contar con una nueva alternativa, recurriendo a los paradigmas existentes. en cuanto al sistema de salud y de enfermería, ambos pueden verse como sistemas complejos adaptativos al aplicar un modelo visual que debe ser explorado para potenciar la complejidad de la ciencia de enfermería y de cuidados de salud. desde esta perspectiva, el/la enfermero/a es un sistema complejo adaptativo, dinámico que interactúa, pero también es agente de un sistema complejo adaptativo en una unidad de enfermería, que a la vez es un sistema complejo adaptativo en una organización de la salud. hoy en día la/el profesional de enfermería busca actualizarse y cualificarse en diversas especialidades, que van desde enfermería neonatal hasta cuidados geriátricos, para ejecutar sus actividades y visualizar su ambiente laboral desde la perspectiva de un sistema complejo. en año 9 vol. 9 nº 3 chía, colombia diciembre 2009 212 221 213 um modelo de enfermagem como sistema complexo adaptativo mariana vieira, patrícia klock, roberta costa, alacoque lorenzini-erdmann consecuencia, la organización del sistema de cuidados permite, mediante los sistemas complejos, apoyarse en el saber compartido de los diversos profesionales y en el trabajo en equipo para disfrutar la complicidad de la cadena cliente-usuario-profesionales. palabras clave organización y administración, salud, modelos de enfermería. (fuente: decs, bireme). a model of nursing as a complex adaptive system abstract the emergence and use of complex adaptive systems remedied the need for a new alternative by resorting to existing paradigms. both the health care system and nursing can be regarded as complex adaptive systems by applying a visual model that should be explored to empower the complexity of the science of nursing and health care. viewed from this perspective, a nurse is a complex adaptive system, one that is dynamic and interacts, but is also an agent of a complex adaptive system in a nursing unit, which in turn is a complex adaptive system in a health organization. today, nursing professionals seek to be current in terms of training and skilled in a variety of special fields, ranging from neonatal nursing to geriatric care, in order to do their job and to envision a working environment from the perspective of a complex system. consequently, through complex systems based on shared knowledge among various professional and teamwork, organization of the health-care system is able to enjoy the support of the client-user-professional chain. key words organization and management, health, nursing models. (source: decs, bireme). 214 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 o surgimento e a utilização dos sistemas complexos adaptativos vieram ao encontro da necessidade de dispormos de uma nova alternativa mediante os paradigmas já conhecidos. tal sistema possui como características marcantes o enraizamento, a auto-organização, a não-linearidade, a imprevisibilidade. o objetivo deste estudo é refletir sobre a enfermagem como um sistema complexo, tangenciado por alguns autores: chaffee e mcneill (1), morin (2) e erdmann (3). a complexidade, sob este enfoque, incorpora em seu princípio uma forma dialética de compreender as oposições entre ordem-desordem, unidade-diversidade, acaso-necessidade, quantidade-qualidade, sujeito-objeto e por que não cuidado-descuidado e assim por diante. desse modo, essa nova forma de encarar a ciência, a sociedade e suas interações humanas não prioriza nem o objeto nem o sujeito. também não deixa de promover a redução para buscar o todo, o que faria da complexidade outra forma dicotômica de encarar a realidade. busca, ao contrário, uma forma de unidade complexa que compreende como interagem com o ambiente e como respondem à interação. o sistema de saúde e a enfermagem são sistemas complexos adaptativos que passam a ter novo enfoque, aplicando um modelo visual que necessita explorar-se, e avançam, potencializando assim a complexidade da ciência de enfermagem e de cuidados de saúde. a ciência de sistemas adaptativos complexos, é caracterizada por anderson e mcdaniel (4) como um conjunto de elementos que interagem localmente numa dinâmica ou maneira não-linear. interações no sistema estão intrínsecas: sistema de atividades é uma função do que já aconteceu anteriormente e está aberta a energia e as informações do ambiente. a complexidade como ciência os sistemas adaptativos complexos distinguem-se da visão de “complicado”. um automóvel, por exemplo, é composto de muitas partes que, aparentemente complicadas, influenciam, como um todo, em diversas áreas, quando pensamos na sua função de transporte de pessoas: sua influência na sociedade, na saúde, nos direitos, nas formas de comportamento, nas seguradoras e em outros sistemas (5). portanto, a teoria da complexidade busca explicar o comportamento complexo que emerge da dinâmica não-linear dos sistemas (1). como ciência, a complexidade baseia-se nos padrões de relacionamento entre si, bem como em que se sustentam, como se auto-organizam e nos resultados que emergem destes relacionamentos. caracteriza-se por englobar diferentes disciplinas científicas e por assumir um papel multi e interdisciplinar na busca de respostas a algumas perguntas fundamentais sobre a vida. descrição, propriedades e características de um sistema adaptativo a complexidade oferece uma nova forma de olhar e vislumbrar os sistemas que possuem comportamentos perplexos (os quais muitas vezes rotulam-se por caos e desordem, porém através do olhar complexo, assumem formas incertas que remetem e convidam a o sistema de saúde e a enfermagem são sistemas complexos adaptativos que passam a ter novo enfoque, aplicando um modelo visual que necessita explorarse, e avançam, potencializando assim a complexidade da ciência de enfermagem e de cuidados de saúde. 215 um modelo de enfermagem como sistema complexo adaptativo mariana vieira, patrícia klock, roberta costa, alacoque lorenzini-erdmann adaptações –por isso a não-linearidade– e interações contínuas, permitindo assumirem uma conotação de incompletude). para a compreensão e a existência dos sistemas complexos, os relacionamentos tornam-se primordiais. os elementos (ou agentes) que os constituem são independentes, porém interligados a outros agentes (por exemplo, colméias de abelhas). tais agentes podem ser uma pessoa, uma célula ou uma organização, onde suas reações, muitas vezes imprevisíveis e subestimadas, influenciam todo o sistema, uma vez que a interligação se faz presente. desta forma, as interligações são essenciais, pois permitem um vasto sistema de resposta adaptativa em um curso, proporcionando que as interconexões tornem o aprendizado e co-evolução possíveis(1) e criativos. em um sistema complexo adaptativo regido por regras simples não existe a possibilidade de controle por uma autoridade central, pois se caracteriza por auto-organização, assumindo um movimento não-linear e dinâmico que oportuniza a manifestação de comportamentos emocionantes e inovações, oferecendo assim múltiplos caminhos criativos para a realização das ações. neste enfoque, o enfermeiro assume a forma de um sistema complexo,adaptativo (1) e dinâmico que interage, e de agente de um sistema complexo e adaptativo em uma unidade de enfermagem que, por sua vez, é um sistema complexo adaptativo dentro de uma organização de saúde. esta é também um sistema complexo, adaptativo e um agente dentro do mais amplo sistema de saúde. tais fronteiras entre estes elementos são porosas e encontram-se mal definidas; portanto, permitem troca, interação (6). neste comportamento, emergem fenômenos imprevisíveis, resultantes das interações e da auto-organização dos agentes que o constituem. estas relações estabelecem-se entre os agentes e entre suas interações com o ambiente. a complexidade na saúde e na enfermagem o ser humano vive em um sistema complexo adaptativo ao visualizar a vida com uma lente diferente das tradicionais. a maneira como o homem visualiza a vida a caracteriza como um sistema complexo adaptativo, ou seja, um ambiente que vai além do ciclo nascer, viver e morrer. a vida visualizada com lentes de um sistema complexo é algo a mais, e os eventos da vida, como o pôr do sol, as ondas do mar, o sopro do vento, são vistos a como agentes complexos, em constante movimento e interação com o homem, que fazem a vida evoluir. ainda neste contexto, outro agente que faz parte da vida e que é caracterizado como um sistema complexo adaptativo é a saúde, a qual se encontra em constante evolução. em tempos passados, os cuidados à saúde eram bastante simples, as estratégias para lidar com a diversidade das doenças e traumas eram poucas. mas através de inúmeros estudos e descoberta de microorganismos nocivos à saúde, inovações e desenvolvimento de técnicas anestésicas e procedimentos cirúrgicos, a transição do médico generalista para o especialista, assim como a qualificação dos profissionais de enfermagem fizeram com que os cuidados à saúde se tornassem mais completos e complexos (1). além destes, vários são os eventos que caracterizam a saúde como um sistema compleneste comportamento, emergem fenômenos imprevisíveis, resultantes das interações e da auto-organização dos agentes que o constituem. estas relações estabelecemse entre os agentes e entre suas interações com o ambiente. 216 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 xo, desde atividades de atenção primária com ações de prevenção e educação para e em saúde, a exemplo da introdução da vacinação, dos programas e medidas de saúde pública, das visitas domiciliares pela equipe multidisciplinar de saúde, até as atividades de cunho secundário e terciário. estas evoluem em grandes proporções desde o nascimento e crescimento dos hospitais, constituídos por sofisticadas tecnologias, assim como por profissionais qualificados para a reabilitação e tratamento dos pacientes. há de se ressaltar ainda a presença das políticas do estado em saúde, com suas leis federais e estaduais para o fortalecimento desta área como um sistema complexo, mediante o financiamento da assistência ao paciente, dos custos em investigação, ensino e pesquisas que perpassam os diversos locais da saúde, como os centros ambulatoriais, de diálise, obstétricos e institutos de saúde mental. enfim, com todo este processo de evolução podemos afirmar que a saúde é um enorme sistema complexo adaptativo que fornece hoje subsídios para a prática do cuidado, conseqüentemente para o serviço de enfermagem. em relação à enfermagem, esta é caracterizada também como um sistema complexo, só que em menor tamanho, uma vez que tal serviço encontra-se inserido em um sistema complexo maior: a saúde. assim como a saúde com sua evolução, a enfermagem hoje é vista como um sistema complexo em constante interação com os outros sistemas, ou seja, com os serviços médicos, odontológicos, psicológicos, entre outros. tais interações, intercâmbios de idéias e flexibilidade entre o serviço de enfermagem com os demais serviços fazem hoje a enfermagem crescer e evoluir técnica-cientificamente e se caracterizar como um sistema complexo adaptativo. atualmente, o profissional enfermeiro busca manter-se atualizado e qualificado para a execução de suas atividades, assim como para visualizar seu ambiente de trabalho com as lentes de um sistema complexo; portanto tem procurado qualificarse em diferentes especialidades, desde enfermagem neonatal até os cuidados geriátricos. ainda nesta linha de pensamento, há de se ressaltar que a enfermagem como um sistema complexo pode encontrar-se em diferentes locais e com diversos papéis, como nos ambulatórioshospitais com a prestação do cuidado ao paciente; nas empresas mediante atividades de promoção à saúde e segurança do trabalhador; até nos meios acadêmicos, a partir das atividades de ensino, pesquisa e extensão. a enfermagem como sistema complexo adaptativo a enfermagem assume-se como um sistema complexo adaptativo, uma vez que a profissão apresenta uma série de características identificáveis a este tipo de sistema. dentre as características citamos o relacionamento ou as interações entre os agentes, a exemplo dos profissionais de enfermagem de um mesmo sistema, assim como com os demais sistemas. pois, apesar destes profissionais serem independentes com diferentes pensamentos, eles interage e intercambiam experiências entre si. estas interconexões são fundamentais para o aprendizado e a expansão dos variados sistemas que os compõe e conseqüentemente para a evolução de um sistema complexo maior: a saúde, onde se encontra inserido o serviço de enfermagem. a não-linearidade, possível de visualizá-la na enfermagem, é outra caracterísem relação à enfermagem, esta é caracterizada também como um sistema complexo, só que em menor tamanho, uma vez que tal serviço encontra-se inserido em um sistema complexo maior: a saúde. 217 um modelo de enfermagem como sistema complexo adaptativo mariana vieira, patrícia klock, roberta costa, alacoque lorenzini-erdmann tica relevante em um sistema complexo, é, porque os efeitos de uma ação, além dos resultados esperados, propagam-se em diferentes ambientes e contextos. por exemplo, uma ação simples de enfermagem, como os procedimentos de higienização e conforto ao paciente, muitas das vezes até menosprezada pelos profissionais, causa uma variedade de ações subseqüentes. há de se ressaltar também que a enfermagem como sistema complexo não apresenta um único e autoritário líder, com normas e um compêndio de diretrizes a serem seguidas, senão que aprende e, como um todo, oferece aos agentes do sistema, ou seja, aos profissionais de enfermagem, múltiplos caminhos criativos para ação e evolução do sistema. ainda neste contexto, para visualizarmos a enfermagem como um sistema complexo adaptativo é necessário vermos através das lentes de um sistema complexo. pois somente assim será possível conhecermos os pontos-chave e as relações-interações que se estabelecem dentro de um sistema e desenvolver novas abordagens de enfermagem, no campo da prática, pesquisa e ensino (1). o modelo conceitual e o seu valor. um modelo de enfermagem como sistema complexo adaptativo cabe neste momento descrever que o modelo conceitual é uma ferramenta poderosa para organizar, moldar e orientar o pensamento. assim como um microscópio oferece uma vista de micróbios, um modelo conceitual fornece uma lente através da qual entram em foco (1) idéias e relacionamentos. fawcett (7) define modelo conceitual como um conjunto de conceitos, relativamente abstratos e gerais, que abordam os fenômenos de interesse central, as proposições que descrevem os conceitos e as proposições de estado, relativamente abstratos e gerais, das relações entre dois ou mais dos conceitos. quanto ao sistema complexo adaptativo como modelo aplicado à enfermagem, este é elaborado pelo new england complex systems institute (necsi), uma instituição educacional independente e de pesquisa dedicada a promover o estudo de sistemas complexos. uma das iniciativas da necsi é promover a compreensão, a divulgação e a promoção de sistemas complexos, apresentando os conceitoschave, a partir de um modelo visual, o qual ilustra eficazmente as propriedades presentes em um sistema complexo adaptativo na enfermagem (8). embora seja de relevante importância a existência de um sistema complexo adaptativo como modelo conceitual para se pensar em saúde e enfermagem, há muito ainda que se avançar, uma vez que o aparecimento da temática complexidade nas literaturas de cuidados e enfermagem aparece ainda de maneira tímida e esporádica. este episódio é preocupante, pois a complexidade, principalmente enquanto modelo conceitual, poderá ser um adequado enquadramento teórico para pesquisa, assim como para a prática em enfermagem. a utilização de um sistema complexo adaptativo como modelo conceitual na prática de enfermagem permite que o enfermeiro enquanto responsável pela unidade a qual gerencia, olhe sua equipe, assim como, o comportamento organizacional das atividades, através de lentes da complexidade, já que a utilização de tal modelo contribuíra para tomada de a enfermagem como sistema complexo não apresenta um único e autoritário líder, com normas e um compêndio de diretrizes a serem seguidas, senão que aprende e, como um todo, oferece aos agentes do sistema, ou seja, aos profissionais de enfermagem, múltiplos caminhos criativos para ação e evolução do sistema. 218 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 decisões e para compreender melhor o ambiente em que trabalha. contudo enfatizamos que o sistema complexo adaptativo (sca) como modelo conceitual para a enfermagem é de grande valia, pois os sistemas adaptativos complexos estão embutidos em outros scas (9). e quando agente e sistema estão unidos dentro de outros sistemas, todos evoluem e interage uma única entidade que não pode compreender-se sem considerar as outras. é preciso interagir, intercambiar informações, matéria e energia. visualizando a enfermagem como um sistema complexo adaptativo usando a teoria da complexidade, percebemos claramente a enfermagem como um sistema que contém subsistemas e que cada um, por sua vez, contém outros subsistemas. todos estes exibem as propriedades do sistema complexo adaptativo. um sistema maior é composto por sistemas menores que estão sempre em prol da totalidade (10). ao visualizar a enfermagem como um sistema complexo adaptativo, têm-se os conceitos que formam o metaparadigma de enfermagem: ser humano: a maioria dos modelos de enfermagem aponta o indivíduo como o principal foco da profissão (11). o cuidado, exercido por meio dos processos de relação, interativos e associativos, está presente na vida humana, em seu processo vital, nas condições naturais e sociais desde a concepção, nascimento, crescimento, envelhecimento, morte e transcendência (12). compreender o ser humano como um ser de cuidado, cognoscente, construtor do futuro, que aprende a estabelecer estruturas sociais, políticas e econômicas mais orgânicas e flexíveis, implica avançar nas concepções de novas práticas de saúde na perspectiva do cuidado complexo: auto-organizador, dialógico, plural, interconectivo e potencializador de ações de cuidado. enfermagem: muitas definições de enfermagem têm evoluído desde a primeira posta por florence nightingale em 1859, e muito debate tenha ocorrido. thorne et al (12) propôs uma definição unificadora que reflete um meio termo filosófico. enfermagem é o estudo da saúde humana e dos processos de doença (1). enfermagem prática é facilitar, apoiar e ajudar os indivíduos, famílias, comunidades ou sociedades para promover, manter e recuperar saúde, e para reduzir e melhorar os efeitos da doença. enfermagem da prática relacional e ciência são voltadas para o resultado explícito de saúde relacionado com a qualidade de vida no ambiente imediato e maiores contextos. saúde: a definição de saúde tem sido a fonte de um debate importante e evoluiu como um conceito dentro da literatura de enfermagem (1). a saúde tem sido um fenômeno de interesse central para enfermagem. em seu metaparadigma de enfermagem, fawcett amplamente define saúde como os processos da vida e morte humana (7). ambiente: inicialmente identificado como “sociedade”, “ambiente”, foi o sentido que melhor descreve fenômenos relevantes para o “ser humano” (7). duas visões do conceito de ambiente podem existir no metaparadigma da enfermagem. a primeira é uma visão estreita do ambiente como usando a teoria da complexidade, percebemos claramente a enfermagem como um sistema que contém subsistemas e que cada um, por sua vez, contém outros subsistemas. todos estes exibem as propriedades do sistema complexo adaptativo. 219 um modelo de enfermagem como sistema complexo adaptativo mariana vieira, patrícia klock, roberta costa, alacoque lorenzini-erdmann as imediações ou circunstâncias de um indivíduo. a segunda é uma visão mais ampla que apresenta a pessoa e o meio ambiente como contínuos (11). o desafio da complexidade em saúde requer um novo olhar à academia, serviços, usuários e gestores como forma de possibilitar um campo transdisciplinar que esteja sempre interagindo e trocando saberes, numa dinâmica construtiva e criativa (13). um sistema é visto como uma entidade social, na qual o comportamento num sistema adaptativo complexo ocorre devido às interações entre os agentes do sistema. desta forma, ao pensarmos na enfermagem e no cuidado, devemos vêlos como um processo de relações, interações, associações, retroações entre os seres, em vários planos. é auto-organizador e organizador do sistema de saúde a que pertence, por meio das práticas e atitudes. ademais, se co-organiza em simbiose com outros sistemas sociais (3). a qualidade das relações entre os agentes necessita de mais atenção do que a qualidade dos agentes no sistema (14). os líderes que adotam a complexidade pensam em criar e fortalecer as relações com os seus colegas (15). as fronteiras de um sistema adaptativo complexo são porosas. intercambio de pessoas, de energia, dos recursos e doutros elementos que compõem os elementos de um sistema adaptativo complexo vão acontecer, qualquer que seja o elemento que terá repercussões noutros locais do sistema –e isso vai acontecer de forma não-linear. por exemplo, alterar a rotina de medicação numa unidade terá óbvio impacto sobre a farmácia. ela pode não ser tão evidente que o calendário dos exames laboratoriais pode ter de ser ajustado, o que terá um impacto na programação doutro departamento, o que poderia causar descontentamento, diminuição de retenção, bem como aumentar os custos (1). questões como interdependência, auto-organização, autopoiese (a complementaridade fundamental entre estrutura e função), caos, dentre outras, começam a ser debatidas em diversos meios e a configurar novas concepções, buscando embasar diferentemente a forma como o ser humano relaciona-se consigo mesmo e com o mundo, e como percebe e analisa os fenômenos que o cercam (10). a complexidade é uma ciência muito diferente no método de análise de enfermagem e em sua função no sistema de saúde. oferece aos enfermeiros uma poderosa oportunidade para projetar investigação, liderança, decisões, política e prática clínica de novas formas. adotar a ciência da complexidade para pensar em enfermagem pode ser vital para a sobrevivência da profissão, já que enfermagem é muitas vezes intransigente e realizada no local por forças inerciais (1). ainda que algumas profissões estejam abraçando os conceitos de complexidade da ciência, eles são poucos. enfermagem tem uma extraordinária oportunidade de aprovar e alterar a sua complexidade pensamento do mundo (4), (17), (18), (19), (20). o cuidado ao recémnascido como um sistema complexo adaptativo5 neste momento, procuramos representar o sistema de cuidado ao recém-nascido. entendendo este como uma unidade comple5 esta etapa do estudo utilizou como texto de base o artigo construindo um modelo de sistema de cuidados (erdmann, sousa, backes, mello) (21). ao pensarmos na enfermagem e no cuidado, devemos vêlos como um processo de relações, interações, associações, retroações entre os seres, em vários planos. é auto-organizador e organizador do sistema de saúde a que pertence, por meio das práticas e atitudes. 220 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 xa que liga, transforma, mantém ou produz acontecimentos, componentes e indivíduos. remete-nos ao plano dinâmico da interação. focalizar o sistema de cuidado ao recémnascido desta forma significa produzir um conhecimento complexo em saúde neonatal e compreender o cuidado como sistema vital e dinâmico que implica a construção de redes não-lineares. neste sentido, o sistema de cuidados é um coletivo constituído pela totalidade das práticas, das atitudes e do conhecimento dos vários profissionais que dão sustentação à dinâmica do cuidado, conforme mostra a figura 1: figura 1. sistema complexo de cuidado ao recém nascido. baseada no modelo de chaffee e mcneill, 2007. sendo assim, elaborar um sistema de cuidado ao recém-nascido a partir do sistema adaptativo complexo pressupõe atribuir um novo significado às práticas de saúde, em um olhar que compreende a complexidade das relações, dos intercâmbios e do próprio processo de cuidar, portanto não pode ser apreendido como algo pronto, estático ou como fim em si mesmo. por caracterizar um movimento dinâmico e interativo, o fenômeno demanda um processo dialógico e reflexivo dos profissionais de saúde, dos usuários, das instituições e dos pesquisadores. determinar o cuidado a partir de um processo interativo e dinâmico significa produzir um conhecimento complexo em saúde, a fim de alcançar a compreensão do cuidado da vida humana como um fenômeno que transcende a dimensão física e o enfoque assistencialista. significa compreender o cuidado enquanto sistema que implica a construção de redes não-lineares que atravessam as diversas áreas do saber. significa reconhecer a força criativa, dinâmica e transformadora do cuidado, presente nas mais variadas formas, dimensões e saberes do agir humano. a organização do sistema de cuidados deve, portanto, sustentar-se na ação e no saber compartilhado dos vários profissionais e no trabalho em equipe que se expresse na cumplicidade da teia entre usuários-clientes e profissionais. elaborar um sistema de cuidado ao recémnascido a partir do sistema adaptativo complexo pressupõe atribuir um novo significado às práticas de saúde, em um olhar que compreende a complexidade das relações, dos intercâmbios e do próprio processo de cuidar, portanto não pode ser apreendido como algo pronto, estático ou como fim em si mesmo. 221 um modelo de enfermagem como sistema complexo adaptativo mariana vieira, patrícia klock, roberta costa, alacoque lorenzini-erdmann referências bibliográficas 1. chaffee mw, mcneill mm. a model of nursing as a complex adaptive system. nursing outlook 2007; 55 (5): 232-41. 2. morin e. ciência com consciência. 7 edição. rio de janeiro: bertrand brasil; 2003. 3. erdmann al. sistemas de cuidados em enfermagem. pelotas (rs): editora universitária, ufpel; 1996. 4. anderson r, issel l, mcdaniel r. nursing homes as complex adaptive systems: relationship between management practice and resident outcomes. nurs res 2003; 52 (1): 12-21. 5. glouberman s, gemar m, campsie p, miller g, armstrong j, newman c et ál. a framework for improving health in cities: a discussion paper. j urban health 2006; 83 (2): 325-38. 6. minas h. leadership for change in complex systems. australas psychiatry 2005; 13 (1): 33-9. 7. fawcett j. contemporary nursing knowledge: analysis and evaluation of nursing models and theories. 2 ed., philadelphia (pa): f.a. davis co; 2005. 8. new england complex systems institute, interactive and visual representations (2000) available at: http://www.necsi.org/visual/index.html [acesso em 27 de agosto de 2008]. 9. plsek pe, greenhalgh t. complexity science: the challenge of complexity in health care. bmj 2001; 323:625-8. 10. terra mg, camponogara s, silva lc, girondi jbr, nascimento k, radünz v et ál. o significado de cuidar no contexto do pensamento complexo: novas possibilidades para a enfermagem. texto contexto enferm, florianópolis, 2006; 15 (esp): 164-9. 11. thorne s, canam c, dahinton s, hall w, henderson a, kirkham s, nursing’s metaparadigm concepts: disimpacting the debates. j adv nurs 1998; 27 (6): 1257-68. 12. erdmann al, bettinelli la. el ser humano y sus posibilidades de construcción desde el cuidado. aquichan 2003; 3: 48-51. 13. rowe a, hogarth a. use of complex adaptive systems metaphor to achieve professional and organizational change. j adv nurs 2005; 51 (4): 396-405. 14. stroebel ck, mcdaniel rrj, crabtree bf, miller wl, nutting pa, stange kc. how complexity science can inform a reflective process for improvement in primary care practices. jt comm j qual patient saf 2005; 31 (8): 438-46. 15. plexus institute. the plexus story. available at: www.plexusinstitute.com/about/index.cfm (acesso em 27 de agosto de 2008]. 16. begun jw, white kr. the profession of nursing as a complex adaptive system: strategies for change. res sociol health care 1999; 16: 189-203. 17. mcdaniel rrj, jordan me, fleeman bf. surprise, surprise, surprise! a complexity science view of the unexpected. health care manage rev 2003; 28 (3): 266-78. 18. brown c. the application of complex adaptive systems theory to clinical practice in rehabilitation. disabil rehabil 2006; 28 (9): 587-93. 19. walls m, mcdaniel rrj. mergers and acquisitions in professional organizations: a complex adaptive systems approach. semin nurse manag 1999; 7 (3): 117-24. 20. sitterding m. clinical nurse specialist integration of complex adaptive systems theory to positively influence the achievement and sustainability of surgical site infection prevention. clin nurse spec 2005; 19 (2): 82. 21. erdmann al, sousa fgm, backes ds, mello alsf. construyendo un modelo de sistema de cuidados. acta paul enferm 2007; 20 (2): 180-5. repercussions of the covid-19 pandemic from the childrens' perspective article repercussions of the covid-19 pandemic from the childrens' perspective repercusiones de la pandemia de la covid-19 desde la perspectiva de los niños repercussões da pandemia da covid-19 na perspectiva das crianças jeane barros de souza 1 tassiana potrich 2 crhis netto de brum 3 ivonete teresinha chülter buss heidemann 4 samuel spiegelberg zuge 5 ana lucia lago 6 1 0000-0002-0512-9765 universidade federal da fronteira sul, brazil. jeane.souza@uffs.edu.br 2 0000-0002-5180-5736 universidade federal da fronteira sul, brazil. tassiana.potrich@uffs.edu.br 3 0000-0002-2970-1906 universidade federal da fronteira sul, brazil. crhis.brum@uffs.edu.br 4 0000-0001-6216-1633 universidade federal de santa catarina, brazil. ivonete.heidemann@ufsc.br 5 0000-0002-0420-9122 universidade comunitária da região de chapecó, brazil. samuel.zuge@unochapeco.edu.br 6  0000-0003-0758-3790 universidade federal da fronteira sul, brazil. analago@unochapeco.edu.br 10.5294/aqui.2020.20.4.2 received: 24/08/2020 sent to peers: 04/09/2020 approved by peers: 13/10/2020 accepted: 23/10/2020 theme: promotion and prevention. contribution to the discipline: the article is relevant to the construction of nursing knowledge, considering the current public health situation in brazil and worldwide, and the impact of the covid-19 pandemic, in particular of social isolation, on child health. the scientific text brings visibility to the repercussions of the pandemic from the perspective of schoolchildren. when giving them a voice to pronounce on their experience, possibilities are pointed out to establish support strategies for this population, as well as to sensitize health professionals, mainly from nursing, in the prevention and promotion of care directed to the child's specificities in the midst of a pandemic scenario. in addition, this paper represents an innovation in the ways of developing paulo freire's culture circle in the virtual environment, being a light technology, which helps in responding to the growing demands of society to face covid-19. to reference this article / para citar este artigo / para citar este artículo: souza jb, potrich t, brum cn, heidemann itsb, zuge ss, lago al. repercussions of the covid-19 pandemic from the childrens' perspective. aquichan. 2020;20(4):e2042. doi: https://doi.org/10.5294/aqui.2020.20.4.2 abstract objective: to understand the repercussions of coronavirus disease 19 (covid-19) from the perspective of schoolchildren. materials and method: a qualitative study, of the participant action type, based on paulo freire's theoretical and methodological precepts. the participants were 10 children living in the coastal area of santa catarina, brazil, from a virtual culture circle held in july 2020. an analogy was made with the colored pencil to go through the stages of the research itinerary. results: two generative themes emerged for discussion: the good things of the covid-19 pandemic and the "cannots" of the pandemic. in the first theme, they highlighted more time with the family and strengthening family ties, proximity to pets, and self-care. in the second, they pointed out the impossibility of playing with friends, celebrating birthdays and hugging people. conclusions: the children identified positive and negative points experienced during the pandemic and unveiled the challenges of transforming moments of social isolation into spaces of family proximity, although restricted to their homes. keywords(source decs): social isolation; coronavirus infections; pandemics; pediatric nursing; qualitative research. resumen objetivo: comprender las repercusiones de la coronavirus disease19 (covid-19) desde la perspectiva de niños en edad escolar. materiales y método: estudio cualitativo, tipo acción participante, fundamentado en los supuestos teórico-metodológicos de paulo freire. participaron 10 niños residentes en la costa de santa catarina, brasil, a partir de un círculo de cultura virtual realizado en julio de 2020. se realizó analogía con el lápiz de color para recorrer las etapas del itinerario de investigación. resultados: han emergido dos temas generadores para la discusión: las cosas buenas de la pandemia de la covid-19 y los "nos" de la pandemia. en el primer tema, destacaron más tiempo con la familia y fortalecimiento de los vínculos familiares, cercanía con mascotas y autocuidado. en el segundo, señalaron la imposibilidad de jugar con los amigos, celebrar los cumpleaños y abrazar a las personas. conclusiones: los niños identificaron puntos positivos y negativos vividos durante la pandemia y desvelaron los retos de transformar los momentos de aislamiento social en espacios de cercanía familiar, aun restrictos a sus hogares. palabras clave (fuente decs): aislamiento social; infecciones por coronavirus; pandemias; enfermería pediátrica; investigación cualitativa. resumo objetivo: compreender as repercussões da coronavirus disease 19 (covid-19) na perspectiva de crianças em idade escolar. materiais e método: estudo qualitativo, tipo ação participante, fundamentado nos preceitos teórico-metodológicos de paulo freire. participaram 10 crianças residentes no litoral de santa catarina, brasil, a partir de um círculo de cultura virtual realizado em julho de 2020. realizou-se analogia com o lápis de cor para percorrer as etapas do itinerário de pesquisa. resultados: emergiram dois temas geradores para a discussão: as coisas boas da pandemia da covid-19 e os "nãos" da pandemia. no primeiro tema, destacaram maior tempo com a família e fortalecimento dos laços familiares, proximidade com animais de estimação e autocuidado. no segundo, apontaram a impossibilidade de brincar com os amigos, comemorar os aniversários e abraçar as pessoas. conclusões: as crianças identificaram pontos positivos e negativos vividos durante a pandemia e desvelaram os desafios de transformar os momentos de isolamento social em espaços de aproximação familiar, embora restritas às suas residências. palavras-chave (fontedecs): isolamento social; infecções por coronavírus; pandemias; enfermagem pediátrica; pesquisa qualitativa. introduction the coronavirus disease 2019 (covid-19) is considered a public health emergency, according to the world health organization, and imposes changes in people's daily life(1). since its outbreak, children began to live intensely with their families, in a scenario permeated by rearrangements concerning the needs of social isolation, as a possibility to minimize the spread of the new virus. the social isolation caused by the covid-19 pandemic brought uncertainties, fears and approximations in the daily lives of children and families as a whole(2). although children are below the infection rates indicated by the epidemiological scenario, in relation to adults and older adults, it is urgent to insert them in the context of care by their families and by health professionals, considering the other limitations that a pandemic imposes on child health(3). thus, in general, during the covid-19 pandemic, children experienced distancing from their routine, started taking remote classes, using technologies more intensively, creating coping strategies and, many times, were exposed to mental health problems. added to this are the questions surrounding the losses caused by the disease, which can cause dubious feelings and are difficult to manage. examples of these feelings can be anger, anxiety about the loss of bond with people around them —due to social isolation, illness or even the death of a loved one—, which impairs the children's reflexive function(4). relationships between children, family and friends end up suffering impairments due to dismay and increased concerns. in view of this, it is relevant to pay attention to the reactions of the children presented in this period, being important to support them, motivating them to experience the moments of crisis and providing opportunities to face the adversities(5). with so many uncertainties and challenges, it is important to guarantee children moments of listening and dialog that pay attention to their desires, in order to subsidize strategies to improve and strengthen their resilience mechanisms. from this recent context, research studies that address the repercussions of the pandemic on child health become important, in view of the manifestations that demand attention and care from all those involved with this population. therefore, the following research question emerged: what are the repercussions of covid-19 from the perspective of schoolchildren? in view of that, the aim of the study was to understand the repercussions of covid-19 from the perspective of schoolchildren. materials and method a qualitative study, of the participant action research type(6), based on paulo freire's theoretical and methodological precepts. the freirean research itinerary was used, which comprises three interdependent stages, namely: (a) thematic investigation: it is the initial dialog to identify the generating themes, which are extracted according to the reality of the research participants; (b) coding and decoding: it is the phase in which the generating themes are reflexive, representing the existential situations in a critical manner about the lived reality; (c) critical unveiling: it is the critical awareness of the existential situation, in which the limits and possibilities of reality are evidenced(7). the research itinerary takes place in a space, called by paulo freire as a "culture circle", which promotes the sharing of feelings and experiences combined with the construction of knowledge. it is a group of individuals who discuss common themes by means of horizontal and participatory dialog, fostering collective knowledge in search of the transformation of reality(8). faced with the pandemic situation, the virtual culture circle (vcc) has become a necessary and innovative practice. to conduct it, the zoom® application was used, through the cameras of electronic devices, in order to provide interaction and dialog among the study participants. the research participants were 10 children living in the coastal area of santa catarina, southern brazil, with only one vcc being carried out which, being a participatory action technique, allowed exploring data saturation during the dynamics. two children and their guardians, from the researchers' social network, were contacted and invited via telephone to join the research. then, using the snowball sampling method (9), these children and families invited the other participants to join the vcc. it is noteworthy that the snowball method favors the selection of participants with close ties, since they tend to indicate people close to them. the inclusion criteria were as follows: schoolchildren, between 7 and 9 years, 11 months and 29 days old. the exclusion criteria considered were not having access to the internet and electronic devices to participate in the vcc. in the week before the vcc, a message was sent via whatsapp to the guardians of the children participating in the study, in order to explain the objective of the research and the need to sign and explain the free and informed consent form (ficf) and the free and informed assent form (fiaf). the ficf and fiaf were sent via e-mail to those responsible, who signed them and forwarded them to the researchers, and to the children. at that time, the children were also asked to provide blank sheets of paper and colored pencils for participation in the vcc. the vcc took place in july 2020, lasting approximately two hours, and being recorded on an electronic device. the children's parents helped them to virtually enter the application, and the mediator (lead researcher) supported them in explaining how to use audio and video. after that first moment, the parents withdrew, and the children participated in the activity in the company of the vcc mediator, in order to provide greater freedom of expression for the study participants. in order to go through the stages of paulo freire's research itinerary in an interactive, critical, creative and playful way for the children, an analogy was made with colored pencils, which is something concrete in childhood experience (figure 1). figure 1. paulo freire's research itinerary: analogy with colored pencils source: image adapted by the authors from https://gartic.com.br/amanda_sccp/desenho-jogo/lapis-de-cor to start the vcc and go through the first phase of the freirean itinerary, which is thematic investigation, the mediator shared her taste for painting drawings and, from there, with a colored pencil in her hands, she urged the participants to investigate the parts of a pencil. after some discussions, she invited the children to use their colored pencils to symbolize their life during the covid-19 pandemic, by means of drawings or colorful words. then, each child presented their productions to the group, while the mediator wrote down their testimonies, using keywords, on a cardboard. the mediator read all the keywords for the children and encouraged them to organize these testimonies, according to the subject matters covered by the group. thus, two generating themes emerged for discussion in the vcc: (a) the good things about the covid-19 pandemic; (b) the "cannots" of the covid-19 pandemic. for coding and decoding, the second stage of the research itinerary, the mediator pointed to the children the graphite with the color mine that is inside the pencil wood, which allows them to have several tone options to make the drawings. in addition, she explained that colors, in the illustrations they presented, also had many meanings, which needed better understanding. subsequently, she posed the following questions: what are the good things that covid-19 brought to your life? what are the "cannots" of the covid-19 pandemic? the children discussed intensely about these questions in a welcoming space to share their perceptions, experiences and knowledge. then, the meanings of their perceptions were recorded by means of phrases, which were coded and decoded (figure 2). figure 2. representation of the coding and decoding of the generating themes source: extracted from the vcc with the children. image adapted by the authors from https://br.pinterest.com/pin/508273507933758187/ to validate these records, all the phrases were re-read to the children in order to motivate them to continue reflecting on the proposed themes, with a view to validating the action-reflection-action process, encouraging them to understand their ability to cope with the challenges raised and share proposals that would make it possible to transform their reality(7). the vcc dialogs were transcribed and organized, according to the two generating themes. for critical unveiling, it was addressed that the colored pencil made it possible to draw many meanings, such as those that occurred during the vcc, inviting children to reflect on everything they said and heard, in order to unveil the real possibilities of living healthily and overcoming the challenges of covid-19 in childhood, seeking to transform negative situations, in a process of awareness and resilience, strengthening them between each other. finally, the children were asked about the meaning of having participated in the vcc. the process of unveiling the themes occurred concurrently with thematic investigation, according to the assumptions of paulo freire's research itinerary, which provides for the analytical process(7). this moment, called "data analysis" in the freirean research itinerary, occurs continuously and with the participation of everyone involved in the culture circle. after the vcc, the transcriptions of the speeches were carried out. their coding was done by choosing the name of a color preferred by the children, in order to maintain their privacy and anonymity. the study was started after being approved by the committee of ethics in research with human beings of a public university in southern brazil, with opinion number 4,111,692 and certificate of presentation for ethical appreciation number 33736920.3.0000.5564. results the children participating in the study attended elementary school between the second and fifth grades; four of them studied in public schools and six in private schools. the participants were subjected to social distancing, with remote classes and/or online activities, due to the pandemic situation. six boys and four girls participated, living in the company of their parents, in different municipalities on the santa catarina coastal area, brazil. when talking about the repercussions of covid-19 in their lives, the first perceptions pointed out were the positive fruits provided by the pandemic, such as the union of the family and more time and presence of the parents, especially the father, in this daily life: our family became more united. (blue) dad now has lunch with us every day and works here at home. (yellow) dad is working at home and is very cool because he has more time to play with me. (black) the effective presence of the family members in the home made the children realize that, due to the quarantine, their parents started to have more time to assist them in carrying out school tasks and developing joint activities, such as riding a bicycle, painting screens and cooking: my mom bought several canvases and paints and we started to paint beautiful pictures. do you want to see? (pink) my dad now has time to help me with my homework because my dad is much better than my mom in math. (brown) we are going out, the whole family, to ride a bicycle wearing masks. it's really cool and we only started doing it in the pandemic. (blue) my mom is teaching me how to cook. i've already made wonder­ful and delicious cakes. we can even participate in the master-chef now. (purple) some participants raised the situation that, for some time, they wanted a dog, but their parents said that they did not have time to care for the animal. however, with the quarantine situation, the family finally decided to have a dog, which brought joy to the house: i've been asking for a dog for a long time, since i was a little boy. but my parents never gave it to me. and now, i won a beautiful one. i'll get it for you to see... thor is cheering our house up, he's a lot of fun and everyone likes him, look how beautiful! (red) i also finally got a dog. she is called pipoca and everyone here at home likes her, especially me. (pink) the children discussed that they learned some lessons from the pandemic, such as the importance of washing their hands and maintaining hygienic care for individual and collective well-being: with the pandemic, we learned more about the importance of always washing our hands and having hygiene. (orange) i learned that we have to respect people, that we have to take care of ourselves, in order to take care of others around us too. so, everyone has to do their part, mom always says that to me, for this pandemic to go away... (green) despite the need for social distancing, imposed by covid-19, the children revealed that they are talking more with their family members today, especially with their grandparents, through electronic devices: now i talk a lot more with my grandparents than before the pandemic, because every day mom calls them and i talk to them, so they don't feel homesick. (pink) here at home my mom and dad also call the whole family every day to talk to my two grandpas and my two grandmas. so, i think we talk a lot, even in this pandemic. (purple) the children also stated that they appreciated the idea of online classes, due to the impossibility of attending school, and praised the activities of the teachers: i think online classes are really cool because we don't even have to leave the house to take classes. i'm really enjoying it! my teachers are very nice and do some fun activities on the computer. (red) i also like computer classes and my teachers also make some really cool classes. and the cool thing is that we can attend the class even in pajamas, with a blanket, right? at school it couldn't be like that. (green) however, the children also felt some challenges in coping with covid-19. when discussing the second generating theme, they pointed out the impossibilities, the "cannots" in the experience of the pandemic, as they called it, such as not being able to play with friends, not having pajamas parties at home and not celebrating birthdays: now i can no longer go to play to my friends' house and they don't even come here to play with me. (black) mom said that she can't do pajama parties with friends at all. (orange) this year my birthday was very boring, because i couldn't call my friends. my mom made a cake, but it wasn't cool because it wasn't as fun as last year. (brown) with covid-19, some weekly activities were canceled, such as school, soccer and ballet classes. in addition, the children reported not being able to go to the pizzeria and cinema with the family, feeling homesick for strolling in the shopping center: my school is closed. there are no students there. (white) i can't go to soccer anymore. everything has been canceled and mom is not going to her ballet either. (green) i never again went to a pizzeria and to the cinema with my family. all because of covid-19. (blue) i miss going to the mall with my parents and going out to eat something outside the house, as we did before. (yellow) the children said that they will not be able to travel on vacation this year and stated that several other schedules have been canceled, such as the school's june party. as a consequence of preventive actions, they also revealed that they cannot leave the house without a mask or hug people who do not live in their house: every year my school has a very big june party and this year it didn't happen and i was sad. (black) this year we won't have july vacations. we travel and now, it won't work because of covid. (orange) we can't hug people who don't live with us. my mom always tells me that even though i know a lot and like other people, if we meet them somewhere, i can't hug them, i like to hug people and now, i can't. (pink) we can't leave the house without a mask. but wearing a mask is really bad because it keeps dropping all the time and doesn't let us breathe properly. (brown) as for participation in the vcc, the children shared that they found it a fun moment and that they learned together, revealing it to be a special moment: i thought it was really cool for us to meet on the computer, because now we have to meet anyway. tomorrow i will tell my teacher. (white) it was really fun, there was only one thing missing for us to eat together, right, guys? (purple) i thought it was cool because i learned a lot about the pandemic from everyone. (black) it was really cool that we participated and also very special because everything we talked about here is very important for the world. (green) i liked it very much because i hadn't talked to anyone about these pandemic things and it was good to have talked here today. (yellow) discussion the pandemic caused by covid-19 has transformed the life and routine of all population segments. with regard to the child population, it is known that the infection rarely develops and, when this happens, the manifestations of symptoms are generally mild(10-12). however, despite the fact that the child population is less affected than the adult population and presents, in most cases, the asymptomatic form, they are considered transmission vehicles(13). in this scenario, the need for social isolation is present and has conditioned families to a new reality. the development of work activities at home, added to the child's inability to attend school spaces in person, has had an impact on the narrowing of family life. from the children's perspective, this reality was positive, as it enabled parents to be more present in daily activities, be them educational or recreational, a reality that was not possible in a normal routine. in this sense, social isolation can become an opportunity to improve the interaction between parents and children, with the involvement of children in family activities and with the improvement of their self-management skills(14). difficult times such as what society is currently experiencing can allow for creative opportunities, as well as build stronger relationships(15). with the inability to attend school, the parents are asked to assist school learning in a way not previously seen. transporting learning from the classroom to the home, on a large scale and with such speed, can present human and technical challenges, and it is up to the families to circumvent them(16, 17). parental engagement in the children's educational process is an indicator for children's good school performance, while parents and teachers play different roles in the educational process, not to mention the increased workload on both and the structural and objective conditions of each family(18). in this sense, it is believed that creating schedules of tasks and activities with texts and interactive figures, as well as including the child in the organization of these schedules, helps in structuring the necessary transitions between daily tasks(17). with the changed routine and accumulated work demands, in view of the activities inherent to home and family life, parents end up giving in to some requests previously denied to their children, such as adopting a pet. family pets can act as enhancers to strengthen bonds in family life, reframe attention under the current context, and help children overcome challenging situations(17, 19). another positive point listed by the children in the study was the lessons learned from the advent of the pandemic. understanding the importance of hygiene measures and respiratory etiquette, not only for their own health, but for the maintenance of collective well-being, are significant premises in the daily lives of these children. in this situation, it is essential to establish communication compatible with their level of understanding, with reflection on the current pandemic context, so that, they are thus able to contribute, in their own way, to overcome this moment(20). it is also essential to listen to what the children believe about the transmission of covid-19 and to provide an accurate and meaningful explanation because, from that and from what they have access to in the media, they will be able to formulate their own conclusions(20, 21). the perception about the negative points that the pandemic brought to the children's lives was referred to as the "cannots" that are present in their daily lives. the impossibility of going to school, meeting with friends, and practicing outdoor activities are some examples of the experiences during the pandemic. the pandemic situation caused by covid-19 is changing the organization and the lives of families. the united nations educational, scientific and cultural organization estimates that 1.3 billion children are out of school or daycare, without access to group activities, team sports or playgrounds(15). even if school activities are maintained remotely by the educational institutions, it is imperative to look beyond the learning issues, noting the absence of social interactions that this scenario represents. in a similar study carried out with children who had the same experience, they stated that they miss school because, in addition to studying, the environment allows them to play with their colleagues and perform physical activities. the school institution has both an educational function and is essential for children to be in contact with their peers, developing their potential(20). isolation in the family environment can cause loss of external references, represented by the school and by the interactions with other family members: uncles, cousins and grandparents. this adaptive need requires increased surveillance of the family's internal organization, both in terms of structuring the domestic environment and in strengthening personal resources and the family network(4). the routine changes, the limitations of social contact with friends and family, even though they are accepted by the children, may not be well understood, deserving special attention from the nursing professionals who work in the pediatric area. although attention focused on reducing the transmission of the new coronavirus is essential, attention to children is necessary because, in view of various information and abrupt changes in their social and leisure routine(21), they are exposed to developing high levels of stress and anxiety. this will demand from nursing professionals a careful and sensitive view of the situation in order to offer care that meets these needs. the future of children requires a holistic strategy in view of all the uncertainties they are facing, and this will be the new challenge for the families and the nursing professionals who work in the care of this group. in addition to monitoring the child's performance and behavior, the parents also need to respect their identity and needs, seeking to help them develop self-discipline skills(14). health outcomes, both for children and adults, depend on coping resources, as the covid-19 pandemic requires the individual to adapt strategies to cope with stress (coping) in an adaptive manner(4). to make up for the absence of family and social interactions, children and adults began to use technologies and social media more frequently to establish contact and create interactive communication channels. such technological resources have become the only alternative to minimally guarantee what would be a fundamental right for family and social interaction and coexistence(22). in this context, it is evidenced that the use of technologies has shown an important rise in the daily lives of children and families during the pandemic. new ways of learning, communicating and interacting needed to be rethought and reformulated in order to maintain educational, personal and social needs, which are crucial for the child's full development, even in conditions of social distancing. this scenario leads us to a possibility that can be inserted in nursing care, that is, using technologies and/or social media to approach this population, creating bonds, and aiming at therapeutic care relationships. as a limitation of the study, the challenge of mediating the vcc with the children is mentioned, as they are active and easily dispersed; therefore, the mediator needed to resume data production frequently. however, the children were already participating in remote classes, which helped to minimize dispersions and allowed them to participate in the progress of all phases of the research itinerary in a reflective and dialogical manner. another limitation was to find brazilian studies that addressed childhood in the fight against covid-19, which highlights the relevance of this research proposal in giving visibility to the children's view of the pandemic moment. although it may seem like a limitation, the small group of children participating in the study is consistent with the method chosen, which provides for a small number, in order to promote dialog and interaction between those involved. conclusions in this study, through dialog and reflection, the positive and negative points experienced and highlighted by the children during the pandemic moment were identified. in addition, they unveiled the challenges of transforming moments of social isolation, as spaces of family proximity, although restricted to their homes. the freirean research itinerary used made it possible to achieve the proposed objective. in turn, the development of the culture circle in a virtual manner revealed its potential for the performance of nursing in health-promoting actions in the field of childhood, as well as for individuals and collectives of different age groups. thus, it is recommended to carry out participatory research studies in order to integrate the participants into research, allowing a space for the exchange of knowledge in a conscious and critical action on the theme of the study. in addition, it is suggested to continue studies to analyze the impacts of covid-19 on child health, since the conclusions are limited, for presenting a new and challenging situation in the lives of children and their families. conflict of interests: none declared. references 1. world health organization (who). coronavirus disease 2020 (covid-19). situation report — 67. geneva: who; 2020. 2. fundação oswaldo cruz. ministério da saúde. crianças na pandemia covid-19 [on-line]. 2020; [20 telas]. disponível em: https://www.fiocruzbrasilia.fiocruz.br/wp-content/uploads/2020/05/crianc%cc%a7as_pandemia.pdf 3. ministério da mulher, da família e dos direitos humanos. brasil. conselho nacional dos direitos da criança e do adolescente. recomendações da conanda para a proteção integral à criança e adolescentes durante a pandemia do covid-19 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(campinas) 2020;37:1-4. doi: https://doi.org/10.1590/1982-0275202037200110e 5. comitê científico do núcleo ciência pela infância. edição especial: repercussões da pandemia de covid-19 no desenvolvimento infantil [on-line]. 2020;[41 telas]. disponível em: http://www.ncpi.org.br/publicacoes/wp-pandemia/ 6. felcher cdo, ferreira ala, folmer v. da pesquisa-ação à pesquisa participante: discussões a partir de uma investigação desenvolvida no facebook. experiências em ensino de ciências. 2017;12(7):1-18. 7. heidemann itsb, dalmolin is, rumor pcf, cypriano cc, costa mfbna, durand mk. reflexões sobre o itinerário de pesquisa de paulo freire: contribuições para a saúde. texto contexto — enferm.. 2017;26(4):1-8. doi: https://doi.org/10.1590/0104-07072017000680017 8. dalmolin is, heidemann ttsb, freitag vl. práticas integrativas e complementares no sistema único de saúde: desvelando potências e limites. rev. esc. enferm. usp. 2019; 53:1-8. doi: https://doi.org/10.1590/s1980-220x2018026603506 9. naderifar m, goli h, ghaljaie f. snowball sampling: a purposeful method of sampling in qualitative research. strides dev med educ. 2017;14(3):1-6. doi: https://doi.org/10.5812/sdme.67670 10. christofel mm, gomes alm, souza tv, ciuffo ll. a (in)visibilidade da criança em vulnerabilidade social e o impacto do novo coronavírus (covid-19). rev. bras. enferm.. 2020;73(suppl 2):1-5. doi: https://doi.org/10.1590/0034-7167-2020-0302 11. ghosh r, dubey mj, chatterjee s, dubey s. impact of covid-19 on children: special focus on the psychosocial aspect. minerva pediatr. 2020;72(3):226-35. doi: https://doi.org/10.23736/s0026-4946.20.05887-9 12. sociedade brasileira de pediatria. chegada do inverno favorece intercorrências de infecções de vias aéreas superiores. [on-line]. 2020. disponível em: https://www.sbp.com.br/imprensa/detalhe/nid/chegada-do-inverno-favorece-ocorrencias-de-infeccoes-de-vias-aereas-superiores/ 13. pacheco sta, nunes mdr, victória jz, xavier ws, silva já, costa cia. recomendações para o cuidado à criança frente ao novo coronavírus. cogitare enferm. 2020;25:1-12. doi: http://dx.doi.org/10.5380/ce.v25i0.73554 14. wang g, zhang y, zhao j, zhang j, jiang f. mitigate the effects of home confinement on children during the covid-19 out break. the lancet. 2020;395:3-5. doi: https://doi.org/10.1016/s0140-6736(20)30547-x 15. cluver l, lachman jm, sherr l, wessels i, krug e, rakotomalala s et al. parenting in a time of covid-19. the lancet. 2020;395:e64. doi: https://doi.org/10.1016/s0140-6736(20)30736-4 16. berg j, vestena clb, costa-lobo c. criatividade e autonomia em tempo de pandemia: ensaio teórico a partir da pedagogia social. revista internacional de educación para la justicia social. 2020;9(3):1-13. disponível em: https://revistas.uam.es/riejs/article/view/12180 17. szabo tg, richling s, embry dd, biglan a, wilson kg. from helpless to hero: promoting values-based behavior and positive family interaction in the midst of covid-19. behav anal pract. 2020;1-9. doi: https://doi.org/10.1007/s40617-020-00431-0 18. ortega lmr, rocha vf. o dia depois de amanhã — na realidade e nas mentes — o que esperar da escola pós-pandemia? pedagogia em ação. 2020;13(1):302-14. disponível em: http://200.229.32.43/index.php/pedagogiacao/article/view/23782 19. silva k, lima m, santos-magalhães a, fafiães c, sousa l. can dogs assist children with severe autism spectrum disorder in complying with challenging demands? an exploratory experiment with a live and a robotic dog. j altern complement med. 2018;24(3):238-42. doi: https://doi.org/10.1089/acm.2017.0254 20. dutra jlc, carvalho ncc, saraiva tar. os efeitos da pandemia de covid-19 na saúde mental das crianças. pedagogia em ação. 2020;13(1):293-301. 21. dalton l, rapa e, stein a. protecting the psychological health of children through effective communication about covid-19. lancet child adolesc health. 2020;4(5):346-7. doi: https://doi.org/10.1016/s2352-4642(20)30097-3 22. oliveira mrh. medidas de exceção na pandemia para causas permanentes da família e suas repercussões no futuro. rbdcivil. 2020;24:227-39. disponível em: https://rbdcivil.ibdcivil.org.br/rbdc/article/view/556 home 7 red de investigación.p65 red de investigadores en: cuidado a cuidadores de pacientes crónicos 199 año 7 vol. 7 nº 2 • chía, colombia octubre 2007 • 199-206 lucy barrera1 natividad pinto2 beatriz sánchez3 resumen el presente artículo muestra cómo se ha construido una red de investigadores en el campo del cuidado a cuidadores de pacientes con enfermedad crónica. presenta los principios y conceptos de las redes reconociendo el proceso, la aplicación y articulación a partir de las experiencias realizadas por el grupo académico �cuidado al paciente crónico� de la facultad de enfermería de la universidad nacional, que genera un estudio multicéntrico de investigación. palabras clave cuidadores, investigadores, enfermedad crónica. (fuente decs bireme). recibido: 12 de abril de 2007 aprobado: 15 de junio de 2007 1 universidad nacional de colombia. ciudad universitaria bogotá d.c., colombia lbarrerao@unal.edu.co 2 universidad nacional de colombia. ciudad universitaria bogotá d.c., colombia rnpintoa@unal.edu.co 3 universidad nacional de colombia. ciudad universitaria bogotá d.c., colombia cbsanchezh@unal.edu.co aquichan issn 1657-5997 red de investigadores en: cuidado a cuidadores de pacientes crónicos red de investigadores en: cuidado a cuidadores de pacientes crónicos aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007200 network of researchers on caring for chronic patient caregivers abstract this article shows how a network of researchers was constructed in the area of caring for chronic patient caregivers. it presents the principles and concepts of such networks, examining the process in question, its application and articulation, based on experiences developed by the �caring for chronic patient caregivers� academic group at the universidad nacional de colombia school of nursing, which is involved in a multi-centric research study. key words caregivers, research personnel, chronic disease. rede de pesquisadores em cuidado a cuidadores de pacientes crônicos resumo este artigo mostra como é construída uma rede de pesquisadores no campo do cuidado a cuidadores de pacientes com doença crônica. também apresenta os princípios e conceitos das redes reconhecendo o processo, a aplicação e articulação partindo das experiências do grupo acadêmico cuidado ao paciente crônico, da faculdade de enfermagem da universidade nacional de colômbia, que gera um estudo multi-central de pesquisa. palavras-chaves cuidadores, pesquisadores, doença crônica.  red de investigadores en: cuidado a cuidadores de pacientes crónicos 201 introducción as redes representan las capacidades colectivas e individuales para asociarse con un fin común, por tanto, su conformación es significativa para las comunidades profesionales, académicas y sociales como la enfermería. estableciendo dicho significado se inicia la reflexión acerca del concepto de red. según coltell (1) este concepto toma connotación de acuerdo con el contexto en el cual surge: como herramienta para integración, cuando vincula sectores académicos, científicos, tecnológicos y culturales; como sistema de canal de comunicación cuando integra individuos, organizaciones con vínculos sociales y objetivos comunes; como proceso de construcción permanente incluyendo lo individual y colectivo; como sistema abierto de intercambio dinámico que potencializa recursos; como conjunto de componentes cuando interactúan entre sí para facilitar la transferencia de información y, finalmente, como proceso de expansión que une esfuerzos. para eran (2), la red se define según sus objetivos de conformación: la red de información es aquella que se encarga de recoger, sistematizar y difundir información con el objetivo de abordar el problema de la carencia de comunicación funcional entre las organizaciones y mejorar así el proceso de toma de decisiones; la red de acción representa la más numerosa, se conforma espontáneamente y a pesar de sus logros, como es el caso de las organizaciones comunitarias que no cuentan con apoyos financieros, por tal razón su impacto es limitado; la red de concientización busca influir o inducir cambios de arriba hacia abajo; la red de financiación está conformada por proyectos o grupos que comparten recursos, financiamientos y experiencias; la red de investigación posee un carácter de especialización mayor que el de una asociación profesional, se construye en torno a un problema o línea de investigación. para describir lo que es una red, gómez (3) establece unas características que la identifican: sistémica, porque se organiza, adquiriendo formas distintas dependiendo de los asuntos que la ocupen, por ejemplo, la red de investigación; comunicativa, pues permite la socialización de sus objetivos, actividades, propuestas, proyectos, servicios; constructiva, dado que su comunicación se vive a partir de lazos interactivos; compleja, porque tiene una configuración abierta, crece y diversifica vínculos en su interior y al exterior; es un sistema abierto, porque puede contener otras redes parciales dentro, que igualmente pueden ir desapareciendo es decir, incluye y excluye; legitimiza y avala, trabaja con pares académicos; conecta para unir esfuerzos, definir estrategias y ampliar áreas de conocimiento; tiene como eje el principio de reciprocidad, se está dispuesto a dar y recibir. se puede concluir que una red facilita los procesos consolidando grupos, dando sostenibilidad en el tiempo, induciendo a la colaboración con estrategias de arrastre para desarrollo de servicios sociales, académicos e investigativos, y brinda oportunidades de comunicación permanente, compartir experiencias, iniciativas, para plantear metas, generar y ejecutar políticas de programas, conocer contactos, fortalecer conocimiento, promover apoyos, servicios y, lo más relevante, une esfuerzos. después de este breve recorrido conceptual se finaliza con la definición de arvantis (4), quien determina la red como un modelo de acción humana, una práctica social que describe relaciones e interacciones, que tiene como característica fundamental el flujo de información que circula en todas las direcciones. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007202 reconociendo el concepto de red, a continuación se presenta el proceso de conformar una red a partir de la experiencia del grupo académico de enfermería �cuidado al paciente crónico�. antecedentes como una expresión de las inquietudes que surgen a partir del trabajo con personas que viven con enfermedad crónica, y de los cuidadores familiares en el país, en la facultad de enfermería de la universidad nacional de colombia, sede bogotá, se propuso buscar alternativas de vida y salud para ellas, entendiendo que cada una de estas situaciones implica no solamente a quien tiene la enfermedad sino además a quienes interactúan en su cuidado a nivel familiar y social. a continuación se hace un recuento de los principales trabajos adelantados dentro de esta línea de investigación, y de cada uno de sus aportes, que llevan al planteamiento del actual problema de investigación, que confluirá en la red para el desarrollo de la investigación. sánchez (5) desarrolló un estudio fenomenológico con el método de colaizzi en el cual describió exhaustivamente la experiencia de mujeres cuidadoras de personas en situación de enfermedad crónica. para ello tomó un grupo de 18 mujeres, mayores de 15 años, residentes en la sabana de bogotá, que hubieran tenido a su cargo por más de 1 año, durante los últimos 5 años, a una persona en esa situación de enfermedad. el estudio incluyó cuidadoras residentes en áreas rurales y urbanas, y a personas de diferentes edades y niveles socioeconómicos; sus hallazgos muestran que ser cuidadora va más allá de tener una tarea o responsabilidad, genera una forma de vida y relación diferente consigo misma, con la persona cuidada y con el mundo. por ese motivo, se requiere de una intención de compromiso para interactuar de manera simultánea con el binomio cuidador-cuidado, y comprender la habilidad del cuidador como una forma de vivir y no como una tarea colateral que altera la vida y la destruye. pinto (6) realizó un estudio en el instituto de seguros sociales regional cundinamarca a fin de proponer un modelo de cuidado en el hogar para pacientes que viven con enfermedad crónica; señala que estos cuidadores, en su mayoría mujeres, requirieron una orientación para mejorar el cuidado que dan porque en su mayoría no saben cómo hacerlo; los pacientes señalaron que sus cuidadores sentían gran alivio con las llamadas y el seguimiento de las instituciones de salud, las cuales significaban en muchos casos un aliento importante en las tareas que debían cumplir. barrera (7), en sus múltiples trabajos para desarrollar la habilidad de cuidado en cuidadores familiares de niños con fibrosis quística, señala cómo los padres se refieren a la ayuda brindada por la enfermera en cuanto a sentir que se preocupa por ellos, que los orienta en cómo manejar las situaciones de enfermedad, cómo afrontarla, y qué hacer para mejorar la autoestima. barrera también señala que las madres manifiestan angustia por la muerte del menor, se descuidan a sí mismas, e incluso descuidan a otros miembros de la familia, pierden en muchas ocasiones la relación de pareja, y dejan de hacer vida social (7). en la construcción de la experiencia es significativo el estudio realizado en bogotá entre los años 2004-2005 con 250 cuidadores familiares de personas con enfermedad crónica, una investigación cuantitativa de tipo cuasi-experimental, con grupos de muestra y control, y medición de la habilidad de cuidado antes y después de la intervención. los resultados encontrados en esta investigación sugieren la efectividad de un programa de apoyo de habilidades de cuidado de los cuidadores familiares de personas en situación de enfermedad crónica que surge como respuesta a las necesidades del cuidado de los mismos. al comparar los componentes de la habilidad se encontró que en el grupo muestra todos se incrementaron, y en el grupo ser cuidadora va más allá de tener una tarea o responsabilidad, genera una forma de vida y relación diferente consigo misma, con la persona cuidada y con el mundo. red de investigadores en: cuidado a cuidadores de pacientes crónicos 203 control incrementaron la habilidad total, el conocimiento y el valor mientras el componente paciencia disminuyó. se encontró significancia estadística en el incremento de la habilidad total de cuidado y el componente valor para el grupo muestra, este último componente se incrementó también en el grupo control, y se detectó disminución del componente paciencia para este mismo grupo. puede afirmarse, con base en el estudio, que tuvieron más efectos positivos frente a la habilidad de cuidado en general y por componentes las personas que recibieron el programa �cuidando a los cuidadores�®, que quienes no lo hicieron. los resultados aportan al conocimiento por cuanto ofrecen a los cuidadores de américa latina una alternativa aplicable, sencilla y viable, que tiene poco costo y puede significar un cambio en el nivel de habilidad que requieren para cuidar a un familiar con enfermedad crónica, condición que nos invita a proyectar el proceso con grupos de cuidadores en escenarios diferentes. convocar a las colegas de otras regiones del país y de países de américa latina para participar en la definición del nivel de habilidad de cuidado de los cuidadores, y presentarles una alternativa para los hallazgos que se reportaron en cada uno de sus estudios, es la base para poder implementar una política de apoyo a las familias de las personas en esta situación. son esfuerzos de esta naturaleza, sistematizados, metodológicamente soportados y colectivamente construidos, los que la universidad pública está comprometida a mostrar como soporte de su razón de ser cuando se tiene un norte en el fortalecimiento de la investigación y el desarrollo académico. el programa está siendo replicado con enfermeras que lideran la investigación y cualificación de esta práctica en los diferentes países, y en ciudades que se han unido a estos esfuerzos para poder definir con los resultados de los mismos las necesidades sociales y de salud tendientes a mejorar la habilidad de cuidado de las personas cuidadoras de quienes viven en situación de enfermedad crónica. esto constituye un avance de la línea de investigación de cuidado crónico que permite la integración de la docencia y la asistencia en pro del desarrollo institucional y del recurso humano responsable por esta atención. de esta forma surge el actual problema de investigación que plantea el siguiente interrogante: ¿cuáles son las características y la efectividad que debe tener un programa de apoyo para el desarrollo de habilidades de cuidado en cuidadores familiares de personas con enfermedad crónica en américa latina? para resolverlo ha sido necesario contar con una red que debe fortalecerse. características del grupo el grupo de investigadores principales del �grupo de cuidado al paciente crónico� se conformó en el año 1994 alrededor del programa de maestría en enfermería de la universidad nacional de colombia. los tres miembros que presentan este proyecto han tenido desde entonces trabajo conjunto y complementario �una integrante tiene experticia en niños, otra en adultos y otra en ancianos�, aportando así al conocimiento del cuidado del paciente crónico desde su inicio, el grupo ha hecho aportes en programas de extensión, en investigación y en docencia dirigida a enfermería y a otros profesionales de la salud en niveles de pregrado y posgrado; también ha aportado escritos sobre la temática del cuidado, el cuidado al paciente crónico y su familia, los cuidadores, el cuidado en el hogar y la habilidad de cuidado. en el campo investigativo este grupo ha asesorado en estos años veinte tesis de maestría en el área de cuidado al paciente crónico y su familia, tres trabajos de especialización en enfermería cardiorrespiratoria que han abordado aspectos relacionados con el cuidado cróni...constituye un avance de la línea de investigación de cuidado crónico que permite la integración de la docencia y la asistencia en pro del desarrollo institucional y del recurso humano responsable por esta atención. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007204 co o con la calidad del cuidado, y 24 trabajos de grado del pregrado en el área. entre los años 2003-2005 las tres integrantes realizaron la investigación patrocinada por colciencias, �diseño y evaluación de un programa para el desarrollo de habilidades de cuidado en cuidadores familiares de personas con enfermedades crónicas� (8). los resultados encontrados en esta investigación sugieren la efectividad de un programa de apoyo de habilidades de cuidado, y surge como respuesta a las necesidades en esta área, situación que convoca a reconocer la eficiencia en otros escenarios permitiendo la validación y proyección como respuesta a la evidente necesidad de fortalecer a los cuidadores a través de una red. en mayo de 2006 el grupo se presentó a colciencias, órgano nacional que genera políticas investigativas y que estaba convocando a grupos de más de diez años de trayectoria con productos de investigación evaluables. este grupo, consolidado desde 1996, y reunido en varias ocasiones con el propósito de afianzar la asociación de enfermería en cuidado crónico en la región, cumplió con amplitud los requisitos y recibió la calificación a (calificación más destacada). a partir de ello inició una investigación colaborativa de comparación entre las habilidades de cuidado de cuidadores familiares de personas con enfermedad crónica en argentina, panamá, guatemala y colombia (bogotá, villavicencio, santa marta, cartagena, cúcuta). en este desarrollo se observa que la conformación de una red requiere de construcciones, esfuerzos permanentes y trayectorias que busquen la excelencia académica como justificación necesaria para la red. metodología la experiencia metodológica se ha basado en los procesos que incluyen: la comunicación, el acercamiento, la unión de esfuerzos y la generación de impacto. comunicación se establece que una forma de canalizar la red es a través de ponencias en eventos y publicaciones, estas últimas permiten socializar y dar visibilidad transmitiendo las experiencias, trayectoria, prácticas y descripción de contexto donde se encuentran las personas y familias con enfermedad crónica. se han incluido como formas comunicativas los artículos clasificados en diferentes categorías (9), tales como investigación, revisión, reflexión, ponencias, artículos cortos, reportes de caso y revisiones de tema. acercamiento teniendo en cuenta el rol docente de quienes constituyen inicialmente la red, se establece la connotación de lo referente a docencia, asistencia e investigación, lo que permite integrar estudiantes, profesionales y comunidad, representada ésta última en personas y cuidadores familiares con enfermedad crónica. desde esta perspectiva, se impulsan propuestas que logren objetivos académicos como: desarrollar competencias en los estudiantes de pre y posgrado para evaluar, planear y ejecutar modelos de cuidado de enfermería dirigidos a este grupo poblacional permitiendo satisfacer necesidades, solucionar problemas, promover su salud y afrontar la vivencia de la cronicidad fortaleciendo a los cuidadores familiares. a través de objetivos asistenciales logrados con programas que se desarrollan con estudiantes, como planes de egreso hospitalario que facilitan el regreso al hogar del paciente con enfermedad crónica que ha sido hospitalizado, con el programa de cuidado en casa que contribuye como apoyo para el paciente y su familia, y con talleres para fortalecer la habilidad de cuidado del cuidador familiar. la conformación de una red requiere de construcciones, esfuerzos permanentes y trayectorias que busquen la excelencia académica como justificación necesaria para la red. red de investigadores en: cuidado a cuidadores de pacientes crónicos 205 los objetivos investigativos están integrados a los anteriores, pues los programas desarrollados con estudiantes se basan en investigaciones que han respondido a la problemática identificando significados, vivencias, necesidades, situaciones de calidad de vida y habilidad de cuidado de cuidadores familiares. unión de esfuerzos se identificaron instituciones que apoyaron la investigación como colciencias, fundación nelly ramírez y la universidad nacional de colombia, entre otras. • colciencias, cuya acción se dirige a crear condiciones favorables para la generación de conocimiento científico y tecnológico en el ámbito nacional; a estimular la capacidad innovadora del sector productivo; a contar con las capacidades para usar, generar, apropiar y adquirir conocimiento; a fortalecer los servicios de apoyo a la investigación científica, al desarrollo tecnológico y a la innovación; a facilitar la apropiación pública del conocimiento; a consolidar el sistema nacional de ciencia y tecnología y de innovación y, en general, a incentivar la creatividad para el mejoramiento de la calidad de vida de los colombianos (10). • fundación nelly ramírez, que trabaja con personas de la tercera edad. • dirección de investigación sede bogotá (dib) de la universidad nacional de colombia, es la instancia encargada de la ejecución, en la sede de bogotá, de las políticas, los planes y programas de investigación de carácter nacional, como también de la dirección, administración presupuestal, planeación y coordinación de actividades investigativas que se realicen en la sede (11). en la conformación de la red se contó con la participación de profesionales de colombia en santa martha, ibagué, bogotá, girardot, cartagena, villavicencio, cúcuta, universidad de la sabana y universidad nacional de colombia. además, participan profesionales de otros países como guatemala, argentina y panamá. generación de impacto esto se logrará través de la página web www.gcronico.unal.edu.co que permitirá responder de manera interdisciplinaria e intersectorial a las necesidades de las personas, las familias y los cuidadores que vivan con situaciones de enfermedad crónica, por medio de consultas y servicios dispuestos en redes integradas por los pacientes, los cuidadores familiares, los profesionales, los estudiantes, los especialistas y demás personas interesadas en el cuidado de esta población. conclusiones con base en esta revisión y experiencia se puede concluir que la red latinoamericana para el cuidado del paciente crónico es un conjunto dinámico que interactúa con personas interesadas en la cualificación permanente del cuidado al paciente crónico y su familia en américa latina. una red para la disciplina de enfermería representa la oportunidad para potencializar recursos humanos y financieros, proporcionar intercambios, concentrar esfuerzos en áreas relevantes para el desarrollo de la disciplina en el área de conocimiento del cuidado al paciente crónico, y formular estudios y programas orientados a incentivar la investigación en este campo. en la experiencia narrada se han generado alcances que enlazan la oferta y la demanda, y permiten dinamizar y articular conocimientos, habilidades y servicios con investigadores en esta área de conocimiento, con la población de pacientes crónicos y familias, y con organizaciones e instituciones educativas y de servicio. se potencializa así un mecanismo para el desarrollo y la competitividad en el merlos programas desarrollados con estudiantes se basan en investigaciones que han respondido a la problemática identificando significados, vivencias, necesidades, situaciones de calidad de vida y habilidad de cuidado de cuidadores familiares. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007206 cado de proyectos que generan colaboración nacional e internacional, y se ha aumentado el conocimiento para atender problemáticas, y sustentar la toma de decisiones prioritarias para cuidar a las personas y a sus cuidadores familiares. referencias bibliográficas 1. coltell, o. servicio web como soporte de investigación de las redes de investigación en biomédica. la información de la salud: punto de encuentro disciplinas sanitarias. www.e0a.educared. net/index.php.2003. 2. eran, l. hacia un concepto de asociación de redes. centro internacional desarrollo humano (cinde). méxico: 1996. 3. gómez, h. treinta y siete modos de hacer ciencia en américa latina, colciencias. tm 1997. 4. arvantis, r. redes de investigación e innovación, un breve recorrido conceptual. revista latinoamericana de estudios del trabajo, año 2, n. 3. 1996. 5. sánchez, b. la experiencia de ser cuidadora de una persona en situación de enfermedad crónica. investigación y educación en enfermería. septiembre de 2001, xix (2): 36 � 51. 6. pinto, n. modelo de cuidado en el hogar para pacientes que viven enfermedad crónica. cuidado y práctica de enfermería. bogotá: unibiblos; 2000. 7. barrera, l. trabajo con padres de niños con fibrosis quística. trabajo presentado en el coloquio nacional de investigación en enfermería. bogotá, octubre de 2001. 8. código de la investigación en colciencias 1101-04-13122 9. http://www.enfermeria.unal.edu.co/revista/index2.htm 10. http://zulia.colciencias.gov.co:8098 portalcolindex.jsp?ct5= 88&ct1=121&ct=2&nctd=acerca%20 de%20la%20entidad &cargahome=3 11. http://www.unal.edu.co/dib/acercade/index.html 207 211 primeras paginas.indd 246 aquichan issn 1657-5997 vera regina waldow1 enseñanza de enfermería centrada en el cuidado 1 doctora en educación. escuela de enfermería de la universidad federal del río grande del sur. porto alegre/rs brasil. waldowvr@portoweb.com.br recibido: 4 de marzo de 2009 aceptado: 2 de septiembre de 2009 resumen el texto presenta una serie de reflexiones sobre el cuidado de enfermería desde dos puntos de vista: el tradicional y el fenomenológico. el tradicional centrado en la asistencia, la patología y los problemas de enfermería. el segundo en términos del enfoque de “cuidado humano”, y el proceso de cuidar con raíces fenomenológicas. adicionalmente se analizan los usos de elementos y la conceptualización del cuidado como referente filosófico disciplinar curricular, y las prácticas pedagógicas o de enseñanza-aprendizaje, que a su vez deben reflejarse en una educación que priorice el “cuidado humano” y sus procesos. palabras clave enseñanza, cuidado, enfermería, docente, alumno. (fuente: decs, bireme). the teaching of care-based nursing abstract the article offers a series of reflections on nursing care from two perspectives: traditional and phenomenological. the traditional perspective is centered on assistance, pathology and the problems in nursing. the other focuses on the “humane care” approach and the care process with phenomenological roots. there also is an analysis of the use of elements and the conceptualization of care as a curricular disciplinary philosophical reference, and the didactic or teaching-learning practices that must be reflected, in turn, in education that places a priority on “humane care” and its processes. key words teaching, care, nursing, teacher, student. (source: decs, bireme). año 9 vol. 9 nº 3 chía, colombia diciembre 2009 246 256 247 enseñanza de enfermería centrada en el cuidado vera regina waldow ensino de enfermagem centrada no cuidado resumo o texto apresenta uma série de reflexões sobre os cuidados de enfermagem a partir de duas perspectivas: o tradicional e o fenomenológico. o enfoque tradicional de assistência, a patologia e os problemas de enfermagem. em segundo lugar, em termos de abordagem de “cuidado humano” e o processo de cuidado com raízes fenomenológico. também discute a utilização de elementos e conceituação de cuidar como uma disciplina filosófica sobre currículo e práticas de ensino e de ensinoaprendizagem, que por sua vez, deve refletir-se em uma educação que dá prioridade ao atendimento “humano” e seus processos. palavras-chave educação, saúde, enfermagem, ensino, estudante. (fonte: decs, bireme). 248 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 introducción actualmente se puede observar una mayor receptividad y algún cambio de postura2 de los profesionales al incluir el referente “cuidado humano” (desde el punto de vista humanista, fenomenológico, holístico o ecológico) en las prácticas, tanto como modelo de asistencia de enfermería, como referente filosófico en los currículos de la disciplina. a pesar de esa tendencia, los estudios y relatos de experiencias sobre la utilización de tales referentes son escasos en la literatura de enfermería en américa latina, aún más las experiencias de cuidado en el área de educación en enfermería. actualmente, existen estudios en otras culturas que relatan las experiencias de la inclusión de un modelo de cuidado en la enseñanza, generalmente bajo el mismo enfoque del que trata el presente texto (1, 2, 3). mi propósito es reflexionar sobre el cuidado en las instancias que tienen que ver con la educación en enfermería, incluyendo las cuestiones curriculares, y las prácticas pedagógicas o de enseñanza-aprendizaje, de ahí su título, “enseñanza centrada en el cuidado”. es un abordaje orientado por una perspectiva humanista, y se fundamenta en el pensamiento filosófico, o sea, en la fenomenología heideggeriana (4). se han realizado algunos intentos que exponen una visión sobre el cuidado en la instancia de la enseñanza de enfermería, los cuales se pueden constatar en algunos trabajos (5, 6, 7, 8). el cuidado en la enseñanza para entender qué significa enseñanza centrada en cuidado, conviene aclarar aquello que no es. en primer lugar, al nombrar una educación / currículo / enseñanza centrada en el cuidado, es necesario aclarar que no se trata de proponer una ense ñanza del cuidado impartida bajo los parámetros tradicionales. esa advertencia se hace necesaria, pues, a menudo, los currículos de enfermería, al enfocar el cuidado, proponen programas o disciplinas que se preocupan por organizar quehaceres enseñanzaaprendizaje e incentivan prácticas pedagógicas que buscan habilitar alumnos para el cuidado. los enfoques más conservadores, que aún prevalecen en muchas instituciones, se caracterizan por componer una serie de listas o manuales de procedimientos que detallan, paso a paso, las maneras consideradas correctas de cuidar. el verbo “cuidar”, así como el sustantivo “cuidado”, no eran hasta hace poco tan populares como el verbo “asistir” y el sustantivo “asistencia”. varios trabajos describen, analizan y critican “los cuidados de enfermería” por privilegiar las tareas más que al ser humano a quien están destinados tales cuidados (9, 10). en el pasado, las escuelas de enfermería priorizaban una enseñanza técnica; más tarde, se añadió un énfasis en el conocimiento técnico-científico. en todas las disciplinas, 2 refiero “cierto” cambio, pues existen muchos simpatizantes y profesionales que reflexionan sobre el cuidado humano, pero de una forma muy teórica ya que en sus ambientes de trabajo conservan ciertas posturas originadas en paradigmas más tradicionales y, por tanto, totalmente desarticuladas de lo que se entiende por cuidado humano. actualmente se puede observar una mayor receptividad y algún cambio de postura de los profesionales al incluir el referente “cuidado humano” (desde el punto de vista humanista, fenomenológico, holístico o ecológico) en las prácticas, tanto como modelo de asistencia de enfermería, como referente filosófico en los currículos de la disciplina. 249 enseñanza de enfermería centrada en el cuidado vera regina waldow el conocimiento era basado en las ciencias biológicas, éstas constituían el denominado bloque teórico, y las acciones de enfermería comprendidas como cuidado se referían a las intervenciones terapéuticas. posteriormente, empieza a haber una mayor preocupación por el ser que presentaba una determinada patología, o señales y síntomas que exigían intervenciones tendientes a resolver otros problemas de los pacientes, denominados, sin embargo, “problemas de enfermería”. aún hoy, con los nuevos abordajes y cambios paradigmáticos que enfatizan la centralidad del ser (el paciente), el aspecto biológico todavía se hace presente. en general, los enfoques que se oponen al modelo biomédico son bastante teóricos y, a veces, poco viables en la práctica cotidiana del cuidado de la salud. varios son los obstáculos, entre éstos, presiones económicas, administrativas y políticas. se observa la predominancia de un discurso innovador, pero con prácticas fragmentadas y conservadoras. la invasión tecnológica frena la aproximación al ser-paciente. esos aspectos, sumados, promueven una serie de contradicciones e incoherencias. humanizar las relaciones, una meta política establecida por algunos países y que encuentra respaldo en el cuidar, en la práctica resulta un desafío. por tanto el cuidar, considerado hoy como la esencia de las acciones de enfermería, es un desafío. la relación pretendida entre cuidar y educar (11) se puede presentar como un equívoco, pues el acto de educar es cuidar y viceversa. hay autores que explican esa indisociabilidad. no obstante, aunque teorizado, hay una dificultad en visualizar el todo, considerando la integralidad del cuidado. ocurre lo mismo al decir que cuidar, gerenciar y educar componen acciones básicas, pero distintas, en el proceso de trabajo en enfermería. nuevamente, como en el caso anterior, el pensamiento evidencia fragmentación, reduccionismo, o sea, una incapacidad para percibir el cuidar en todas sus dimensiones, como un fenómeno que hace parte de todas las actividades y tiene una meta común: el crecimiento y el bienestar del ser, sea un paciente, un alumno, un vecino, un animal, una planta, la comunidad. cómo pensar la enseñanza enfocada en el cuidado para los seguidores del “cuidado humano”, teniendo en cuenta la orientación que acompaña esa denominación (humanista, fenomenológica), el cuidar es entendido como la esencia del ser. si el cuidar es lo que caracteriza las acciones de enfermería en sus diferentes dimensiones (asistenciales, educativas, administrativas), y es parte del ser cuidador (tanto la enfermera como la docente), todas sus acciones se deberían inscribir en el cuidado. ese cuidado significa realizar acciones acompañadas, siempre, de actitudes y comportamientos de cuidar (8). el cuidar es una característica que hace parte del ser, y es pensado y dirigido a todas las cosas, los objetos y los seres vivos, pues fundamentalmente esta acción se constituye en la relación con los otros (4), y en ayudarlos a crecer y a realizarse (12). por tanto, si el objetivo del cuidar es el ser —y considerando la visión heideggeriana de que el cuidado es parte del ser—, la enfermería tiene un compromiso que es el cuidado, y debería empeñarse en comhumanizar las relaciones, una meta política establecida por algunos países y que encuentra respaldo en el cuidar, en la práctica resulta un desafío. 250 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 prenderlo y ejercitarlo a fin de absorberlo en su quehacer diario3 (13). entonces, en una educación que priorice el cuidado humano, o mejor, al pensar las premisas relativas a la educación en enfermería, y sobre cómo enseñar el cuidar y cómo organizar un currículo orientado al cuidado, es necesario pensar y reflexionar primero acerca del cuidado en sí: ¿qué es cuidado? ¿qué significa cuidar? ¿qué referente adoptar? ¿cómo los docentes de una institución formadora piensan en términos de formar profesionales de cuidado? y, ¿qué significa exactamente ser un profesional del cuidado? algunas características en relación con el cuidado un aspecto para tener en mente, y que constituye otro desafío, es conciliar teorías y modelos fundamentados en los principios tradicionales de la ciencia, y la inclusión de un abordaje de cuidado que rechaza esos principios. por otro lado, algunas teorías de cuidado en enfermería son adoptadas con la inclusión del proceso de enfermería, lo que constituye una paradoja4. hoy día, al cuidar, aunque importe saber y conocer qué se hace, importa principalmente el cómo se hace y a quién va dirigido. antes que todo importa el ser a quien se destina cualquier acción y cómo vamos a portarnos con relación a ese ser. la enseñanza centrada en el cuidado no prioriza ni el quehacer ni el producto y sí el proceso; el interés del profesor es el alumno, y más que lo relacionado con su disciplina, importa saber quién es el alumno y cómo va a aprender a aprender. así sabrá que todo el aprendizaje tendrá como meta final el cuidado al paciente. el orientar cómo aprender es un factor importante en una enseñanza enfocada en el cuidado. el profesor que considera el cuidado como la práctica y el conocimiento que orienta la enfermería estará en ventaja y, probablemente, será sensible para profundizar e introducir este abordaje en su práctica pedagógica. en general, al considerar el cuidado como una forma de ser, el docente actúa más fácilmente como un ser de cuidado5. así, confía y permite que los alumnos encuentren sus propios medios para perseguir sus proyectos, ayudando siempre que sea necesario. esa ayuda se practica en el sentido de orientar, iluminar, motivar, sensibilizar, nutrir, dar coraje, incentivar la búsqueda, la imaginación, la creativi3 éste fue el término usado en la traducción del inglés “engrossment” para el portugués. el sentido de absorción indica un fuerte involucramiento que podría ser complementado, como menciono en algunos trabajos destacados en este texto, como compromiso y responsabilidad. es un total desprendimiento en el que el ser cuidador se entrega al cuidado, al ser que necesita cuidado y se dedica, se involucra. su misión es la de ayudar en lo que sea, dependiendo de la circunstancia, de la necesidad y del contexto. ese es otro desafío que se presenta al cuidar. 4 la sistematización o el proceso de enfermería que, para la mayoría de los profesionales de enfermería es motivo de orgullo (clásicamente denominado como “herramienta” de enfermería), contrasta fuertemente con los principios del “cuidado humano”. es considerado, por casi todas las estudiosas del cuidado, como un modelo anticuado, normativo, castrador de la creatividad, reduccionista, además de descaracterizar la experiencia del paciente y de recaer en su objectificación, entre otras colocaciones. 5 ser de cuidado se refiere a la traducción del inglés “caring being”. interpreto ser de cuidado el ser que exhibe comportamientos y actitudes de cuidado en sus acciones; se expresa en términos de cuidado consigo, con los demás, con las cosas, con el entorno, con el bienestar del planeta y sus habitantes. en general, esos comportamientos y actitudes incluyen respeto, consideración, generosidad, solidaridad, compasión, sensibilidad y responsabilidad. hay un sentido de conciencia del significado y de la experiencia que la vida y sus eventos tienen para los seres vivos, y de involucrarse a fin de contribuir con el bienestar de sus semejantes. hoy día, al cuidar, aunque importe saber y conocer qué se hace, importa principalmente el cómo se hace y a quién va dirigido. 251 enseñanza de enfermería centrada en el cuidado vera regina waldow dad, además de proponer nuevas pistas y direcciones. también ayuda a los alumnos proveyendo materiales y recursos de forma que sean expuestos a experiencias estimuladoras y significativas. el entorno el cuidar, como un proceso interactivo, implica confianza. la confianza debe partir del propio profesor en su habilidad para cuidar a otro ser, en este caso, el alumno. al ejercitar la habilidad como cuidador, el profesor se torna apto para proveer una atmósfera amigable y segura para el aprendizaje. un ambiente de cuidado es aquel en el que las personas exhiben comportamientos y actitudes de cuidado. las personas se sienten seguras y confiadas al compartir su “yo” de forma plena, espontánea (14). por otro lado, el docente desarrollará habilidades para reconocer lo que funciona mejor para sus alumnos. bevis (15) habla de cultura en la clase; el profesor es responsable por crear una cultura de cuidado en el aula, y ésta se puede extender a todo el medio académico a fin de lograr sensibilizar a otros docentes. es una cultura que se caracteriza por no poseer agendas dobles, según la autora, y, en ese sentido, el día a día se torna más agradable y todos se empeñan en ayudarse. compañerismo, búsqueda y cambio de experiencias e informaciones, incentivar los éxitos y ayudar a los menos privilegiados, solidaridad con los fracasos y las dificultades y, principalmente, ayudar al otro (colega) a crecer, son también características de una cultura de cuidado. si el entorno es hostil, caracterizado por agendas dobles, o las relaciones son tensas, cínicas, evidenciando celos, envidia y competitividad por el estatus, los alumnos lo captarán y acabarán absorbiendo, y muchos reproduciendo, esos comportamientos y actitudes más tarde en sus actividades profesionales. un entorno pobre, no saludable como el referido, dificulta el aprendizaje, desmotivando y haciendo perder la credibilidad en la enseñanza y en los profesionales. si los docentes sobreviven a cambios curriculares (en general relatados como difíciles) de manera saludable, se tornarán en un grupo fuerte. conflicto siempre habrá, sin embargo, con actitudes positivas, nuevos e iluminadores comienzos pueden surgir. el involucramiento con el cuidado el profesor que cree en el cuidado y se involucra con él, sabe que será capaz de ayudar al otro (el alumno) a crecer a su propio ritmo y estilo. el cuidar implica aprendizaje continuo acerca del otro y el profesor, como un ser de cuidado, sabe que siempre existe algo por aprender. en esa perspectiva, al ayudar al otro, el profesor también crece en el proceso de enseñanza-aprendizaje, siendo responsable por el crecimiento y desarrollo de los alumnos, agregando más experiencias y conocimiento (7, 8). es importante destacar que en la enseñanza centrada en el cuidado, así como en cualquier acción de cuidar, el ser que cuida no lo hace en el sentido de ayudar al otro a crecer para encontrar realización personal / profesional o llenar sus necesidades. al cuidar, en el verdadero sentido del término, el ser que cuida se realiza al sentir placer, satisfacción y gratificación por sus acciones, pero sin esperar nada a cambio. el cuidar, como un proceso interactivo, implica confianza. la confianza debe partir del propio profesor en su habilidad para cuidar a otro ser, en este caso, el alumno. 252 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 el cuidar significa responder a la necesidad de cuidado (de una persona, idea, objeto, etc.) aquí y ahora. el presente es alimentado por los significados e insights del pasado, y enriquecido por la anticipación del futuro, o sea, previendo lo que es significativo e importante para la realidad presente con miras al futuro, pero con la experiencia que brinda el pasado. el proceso representa la confección del producto, o sea, el producto en formación. el futuro es un presente que está por venir, y lo que interesa es el cuidado en el ahora. el crecimiento durante la acción. otra característica del cuidar es que involucra cambios en el sentido evolutivo. el ser que cuida debe estar atento a sus acciones, comportamientos y actitudes, buscando perfeccionarlas y eso, en consecuencia, la mayoría de las veces involucra cambios. por otro lado, el ser que es cuidado también se transforma en el sentido de crecimiento, evolucionando como ser (8). profesor y alumnos: enseñando y aprendiendo juntos no existen reglas, manuales o prodar, y eso se debe al hecho de que el cuidar no puede ser prescrito (7, 8, 14). cuidar consiste en maneras de ser, de portarse, de expresar comportamientos compatibles con lo que es considerado cuidado —ya hemos mencionado algunos anteriormente—, y lo que se puede hacer es sensibilizar, cultivar, motivar esos comportamientos. profesores y enfermeras del campo clínico sirven de modelo para los estudiantes, así que dos aspectos son de fundamental importancia: el rol del profesor y el desempeño de los profesionales de campo6. algunos trabajos apuntan hacia el primer aspecto (7, 15, 16, 17), e investigaciones realizadas con estudiantes de enfermería revelan elementos considerados importantes en el desempeño de los docentes (18, 19, 20). en cuanto al segundo aspecto, es recomendable proveer discusiones con los estudiantes en las que puedan analizar los comportamientos y las acciones de los profesionales de la salud, y de la enfermería en particular, especialmente con relación a cuestiones éticas y de juicio clínico, toma de decisión, entre otros (21, 22). las actitudes, el interés, la dedicación, el compromiso del docente con la enseñanza-aprendizaje, y la forma como se relaciona, además del conocimiento y las habilidades, son también elementos señalados. enseñar es abrir camino para el desarrollo del ser. es llegar a ser, es la búsqueda de la verdad en los términos de heidegger (4, 23), que significa no la búsqueda de lo que es cierto, sino de aquello que está encubierto. es el despertar para lo que está ahí, pero oculto, o sea, es el concienciarse (24). es también ir más allá, procurando alcanzar aquello que no está aún ahí (25). en una enseñanza centrada en el cuidado; así, tanto la clase, el laboratorio, como el campo clínico se tornan en lugares de encuentros. el ser de cada uno es va6 noddings hace hincapié en destacar que profesor, así como madre, no implican un rol y sí una relación. el cuidar es un emprendimiento, y si el encuentro entre los seres ocurre, se establece una relación de cuidado. en ese encuentro la cuidadora se involucra y se responsabiliza por el otro ser. antes de ser profesora se es, primeramente, cuidadora, enfatiza la autora. el ser que cuida debe estar atento a sus acciones, comportamientos y actitudes, buscando perfeccionarlas y eso, en consecuencia, la mayoría de las veces involucra cambios. gramas que prescriban formas de cui253 enseñanza de enfermería centrada en el cuidado vera regina waldow lorado; todos se portan de forma ética, o sea, entendiendo y respetendo el valor de la experiencia de cada uno y el valor de la vida humana. todos se sienten implicados, comprometidos, responsables de cuidar —a sí mismo, al otro, al medio—. los alumnos son copartícipes en las actividades de aprendizaje; sus opiniones y sugerencias son bienvenidas, así como las del equipo de enfermería del campo clínico. los alumnos reconocen y respetan el empeño del profesor, y se comprometen a buscar, a informarse y a crear experiencias que enriquezcan su conocimiento y habilidades. evidentemente, el profesor que está involucrado y comprometido, a su vez buscará, en la medida de lo posible, conocer el ser de cada uno, facilitando medios para que el aprendizaje se dé respetando sus características (7). el profesor es el orquestador de las actividades; debe ser sensible, perspicaz, disponible, un estratega y, claro, un cuidador. además de todo eso, el profesor es también un aprendiz, pues está siempre buscando y aprendiendo. como especialista que es, debe mantenerse actualizado y ampliar su conocimiento (7). las contribuciones de una enseñanza centrada en el cuidado entre las contribuciones de una enseñanza curricular centrada en el cuidado se pueden mencionar: 1. capacitar alumnos de enfermería para sensibilizarse con las necesidades societarias y, de forma más amplia, planetarias. 2. problematizar, de forma crítica, las cuestiones de salud. 3. proveer acciones de cuidado que humanicen el entorno de salud altamente tecnologizado. 4. favorecer medios que faciliten el discernimiento sobre temas morales y éticos. el ítem 1 abarca una visión amplia de los problemas que acometen las sociedades en el mundo globalizado de hoy, en especial los que tienen que ver con la realidad de américa latina. estar conscientes de que estamos atravesando un periodo de grandes cambios: políticos, económicos, de valores y de grandes impactos en el ecosistema que influencian la salud física, mental y social de las personas. por tanto, en necesario volver sobre la discusión de las políticas de salud y su viabilidad. los problemas característicos de países del tercer mundo, así como aquellos que caracterizan sociedades más avanzadas, se tornan globales. es necesario tomar conciencia de los problemas ecológicos y sus consecuencias para la vida de todos los seres en el planeta, así como de otros problemas que acometen al mundo moderno, como el problema poblacional —principalmente en los países menos desarrollados—, la urbanización descontrolada, el desempleo, el analfabetismo, el hambre, la pobreza, las cuestiones religiosas, raciales, entre tantas otras. así como se necesitan acciones primarias, se requieren acciones que evidencien competencia al lidiar con problemas de alta complejidad (26). el profesional de la salud es tan necesario en las actividades comunitarias (previniendo, orientando, educando y ayudando en la rehabilitación y recuperación de pacientes con alta temprana, y en atención domiciliaria para enfermedades de larga duración), como en las instituciones hospitalarias, cuidando y ayudando en la administración de terapéuticas curativas, de confort y medidas paliativas. la salud ha sido incluida en la agenda política mundial en función de sus implicaciones a nivel global. con relación al ítem 2, se convive hoy con problemas de gran diversidad demográfica; en los países en desarrollo, por ejemplo, persisten las altas tasas de mortalidad infantil y materna, desnutrición, enfermedades infecciosas, además del recrudecimiento de varias otras. así mismo, tanto en los países en desarrollo como en los más avanzados, estamos conviviendo con problemas cardiovasculares, sida, violencia de varios tipos, adicción a las drogas, accidentes de tránsito y de trabajo, estados depresivos y aumento creciente de la obesidad. las desigualdades son notorias y muchas de ellas se deben a diferencias en el acceso a un ingreso compatible con las necesidades, a los recursos sociales disponibles, trabajo, asistencia, servicios sanitarios, de seguridad y de educación, para nombrar solo algunos (26). son muchos los retos, los frentes y las competencias por tratar en las escuelas de enfermería. se hace imposible intentar organizar un programa de enseñanza que contemple todos los posibles problemas de salud enfrentados por las poblaciones. es necesario sensibilizar y concienciar a los alumnos de que el aprendizaje es un proceso sin fin; ellos deben ser capacitados para buscar medios a fin de mantenerse actualizados, perfeccionando su conocimiento. despertar el gusto por el conocimiento es una de las metas que se deben perseguir en la enseñanza; los alumnos pueden así mantener hábitos de lectura, investigación y de búsqueda continua de información. educación continuada, cursos de posgrado, son algunas alternativas, además de 254 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 la investigación y de la constante actualización a través de revistas científicas y demás publicaciones del área. el pensamiento crítico es un instrumento valioso; los profesores deben estar preparados para desarrollarlo con sus alumnos. conocer los problemas no garantiza estar capacitados para enfrentarlos, es necesario prepararse para analizar, interpretar, visualizar hipótesis y estrategias a fin de trabajar con varias alternativas para reducir, minimizar o resolver problemas según las circunstancias que se presentan. algunas autoras (21) usan el término juicio clínico, que no es muy diferente de pensamiento crítico. la diferencia es que el juicio clínico no prevé el tradicional modelo de resolución de problemas que está implícito en el proceso de enfermería o sistematización de la asistencia. en el ítem 3, las acciones humanizadoras incluyen el cuidado. aunque es una meta en el sistema de salud de varios países, para muchos profesionales la humanización no está relacionada con el cuidado. irónicamente, es el cuidado lo que caracteriza lo humano del ser; es a través de prácticas de cuidado que se dan las relaciones entre las personas, y es ahí donde los profesionales podrán concretar esta meta. sin embargo, no será por intermedio de cursos y “entrenamientos” que las personas se tornarán más humanas, y sí a través de la práctica y del ejercicio de comportamientos y actitudes demostradas en el día a día, y por medio de sensibilizaciones, además de material que tenga un vasto contenido que pueda ser absorbido, introyectado, compartido y no simplemente transmitido. es necesario vivir el cuidado, experimentarlo, sentirlo, tornarlo un hábito de vida (7, 8, 14). la educación estética preconizada por algunos autores (25) tiene que ver con una educación focalizada en el cuidado. la estética representa todas las cuestiones que tienen que ver con la relación entre los seres, e incluye sensibilidad y sentimientos. una educación de cuño estético es motivada por el deseo de explorar, de descubrir, de buscar. es un aprendizaje significativo, autoiniciado, marcado por el maravillarse, por la actitud de deslumbramiento frente a lo nuevo, por lo que podemos descubrir también en lo viejo, y por el placer que el conocer proporciona en su infinito desvelar, por las inquietudes y por la sensación de que existe siempre algo más allá que vale la pena descubrir. se deben crear situaciones de manera que las energías sean liberadas para que puedan provocar interés, y que muevan a las personas (alumnos) a ir más allá de ellas mismas (25). esto equivale a empoderar el ser para aprender, estando totalmente presente, en existencia y consciente. este tipo de educación, sea denominada de estética o de cuidado, no impide que los conflictos que afligen al mundo moderno ocurran, pero pueden cambiar al ser y la manera de ver las cosas, y ayudan a vislumbrar alternativas. ella impedirá el comodismo, la apatía y nutrirá al ser de coraje, de esperanza, de voluntad y deseo de innovar. la educación estética o de cuidado posibilita al ser, lejos de repeticiones y rutinas, crear, imaginar y transformar; ofrece experiencias y no conceptos, permitiendo ver al todo en sus detalles. conocer los problemas no garantiza estar capacitados para enfrentarlos, es necesario prepararse para analizar, interpretar, visualizar hipótesis y estrategias a fin de trabajar con varias alternativas. 255 enseñanza de enfermería centrada en el cuidado vera regina waldow el ítem 4 se refiere a las cuestiones morales y éticas que abundan en el escenario de la salud de hoy en día. se deben preparar alumnos para que, como profesionales, tengan voz y luchen por los derechos de los pacientes, y por lo que consideran justo, correcto y bueno. es importante trabajar valores durante el curso y discutir cuestiones que ocurren en el campo clínico, escuchando y observando las partes implicadas: pacientes, enfermeras, médicos, administración y demás miembros y elementos que componen el universo organizacional. es necesario posicionarse con relación al cuidado como un fin en sí mismo, que la misión de la enfermería sea cuidar, y que éste sea un proceso para la cura o para la muerte o invalidez. las relaciones entre colegas, profesores, equipo de enfermería, equipo de salud y familiares son aspectos importantes en la formación, y es de gran ayuda ejercitar la autoestima, incentivando la confianza, la asertividad y el liderazgo, este último basado en principios de cuidado (8). consideraciones finales en este texto se han presentado las ideas de la autora con relación a la inclusión de un abordaje de cuidado en la práctica de enseñanza de la enfermería. estas ideas, para un currículo centrado en el cuidado, parecen viables y compatibles con las proposiciones previstas en las diretrizes curriculares nacionais para o curso de graduação de enfermagem do brasil (dcenf) (27), y en algunos países de américa latina, principalmente considerando que adoptan como base los cuatro pilares de la educación (28): aprender a conocer (o aprender a aprender); aprender a buscar; aprender a convivir, y aprender a ser. sin embargo, según algunos autores (29): as escolas de enfermagem, apesar das novas diretrizes curriculares, não produziram mudanças significativas no ensino de enfermagem no país, uma vez que ainda são poucos os profissionais formados nesta proposta,talvez por isso são poucas as transformações ocorridas na prática profissional que têm contribuído para um cuidado pautado no atendimento integral ao ser humano. es imposible que en poco tiempo se puedan oír noticias y relatos de cambios. hago mías las palabras e intenciones de autores (30) que refieren que su trabajo pretende apenas sugerir la superación de abordajes tradicionales, buscando nuevos paradigmas y objetivando el coraje para enfrentar desafíos y proponer cambios, contribuyendo a un debate colectivo y crítico. al explicar cómo podría ser una enseñanza centrada en el cuidado, de forma muy sucinta, pienso que puedo sumar mi voz a la voluntad y al deseo de que las escuelas de enfermería y sus docentes se puedan sensibilizar, no para adoptar de manera íntegra los aspectos sugeridos, sino como un primer paso para una renovación, interiorizando los principios de cuidar en su vida cotidiana y, consecuentemente, en el hacer y pensar pedagógicos. referencias bibliográficas 1. boykin a. living a caring-based program. new york (ny): national league for nursing; 1994. 2. grams k, kosowski m, wilson c. creating a caring community in nursing education. nurse educator 1997; 22 (3): 10-15. 3. roch g, dallaire c, o´neill m, roy m, robinette l. the politics of caring: using a political tool to analyse and intervene in the implementation of a caring philosophy in a montreal hospital. international journal for human caring 2005; 9 (3): 9-14. 4. heidegger m. ser e tempo. parte 1 e 2. petrópolis (rj): vozes; 2001. 5. waldow vr. educação para o cuidado. rev. gaúcha de enferm 1993; 4 (2): 35-40. 6. waldow vr. cuidar como marco de referência para o ensino de enfermagem. anais do 50º cben. salvador: aben; 1999. pp. 197-204. 7. waldow vr. estratégias de ensino na enfermagem: enfoque no cuidado e no pensamento crítico. petrópolis (rj): vozes; 2005. 8. waldowvr. cuidar: expressão humanizadora da enfermagem. petrópolis (rj): vozes; 2006. 9. almeida mcp. o saber da enfermagem e sua dimensão prática. são paulo (sp): cortez; 1986. 10. meyer de. a formação da enfermeira na perspectiva do gênero: uma abordagem socio-histórica. in: waldow vr, lopes mj, meyer de. maneiras de cuidar, maneiras de ensinar: a enfermagem entre 256 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 a escola e a prática profissional. porto alegre (rs): artmed; 1995. pp. 63-78. 11. prado ml, reibnitz ks, gelbcke. aprendendo a cuidar: a sensibilidade como elemento plasmático para formação da profissional crítico-criativa em enfermagem. texto contexto enferm 2006; 15 (2): 296-302. 12. mayeroff m. on caring. new york (ny): harper; 1971. 13. noddings n. o cuidado: uma abordagem feminina à ética e à educação moral. são leopoldo (rs): unisinos; 2003. 14. waldow vr. o cuidado na saúde: as relações entre o eu, o outro e o cosmos. petrópolis (rj): vozes; 2004. 15. bevis eo, watson j. toward a caring curriculum: a new pedagogy for nursing. new york (ny): national league for nursing; 1991. 16. madeira mza, lima mgsb. a prática pedagógica das professoras de enfermagem e os saberes. rev bras enferm 2007; 60 (4): 400-4. 17. rodrigues mtp, sobrinho jacm. enfermeiro professor: um diálogo com a formação pedagógica. rev bras enferm 2006; 59 (3): 456-9. 18. macneil ms, evans m. the pedagogy of caring in nursing education. international journal for human caring 2005; 9 (4): 45-51. 19. hughes l. faculty-student interactions and the student perceived climate for caring. adv nurs sci 1992; 14 (3): 60-71. 20. sena rr, silva kl, gonçalves am, duarte ed, coelho s. o cuidado no trabalho em saúde: implicações para a formação de enfermeiros. interface –comunic saúde educ 2008; 12 (24): 23-34. 21. tanner c. re-thinking clinical judgment: implications for rn education. in: diekelmann nl, rather ml (eds.). transforming rn education: dialogue and debate. new york (ny): national league for nursing; 1993. pp. 15-41. 22. benner p. transforming rn education: clinical learning and clinical knowledge development. in: diekelmann nl, rather ml (eds.). transforming rn education: dialogue and debate. new york (ny): national league for nursing; 1993. pp. 3-14. 23. heidegger m. seminários de zollikon (ed. por medard boss). petrópolis (rs): vozes; 2001. 24. freire p. educação e mudança. rio de janeiro (rj): paz e terra; 1979. 25. greene m. variations on a blue guitar: the lincoln center institute lectures on aesthetic education. new york (ny): teachers college, columbia university; 2001. 26. malvárez s. el reto de cuidar en un mundo globalizado. texto contexto enferm 2007; 6 (3): 520-30. 27. ministério da educação. conselho nacional de educação. câmara de educação superior. resolução cne/ces n. 3, de 7 de novembro de 2001. institui as diretrizes curriculares nacionais do curso de graduação em enfermagem. diário oficial da república federativa do brasil. brasília (df), 9 nov. 2001. seção 1, p. 37. 28. delors j. (org.). a educação para o século xxi: quesotes e perspectivas. porto alegre (rs): artmed; 2005. 29. souza acc, filha mjmm, silva lf, monteiro arm, fialho avm. formação do enfermeiro para o cuidado: reflexões da prática profissional. rev bras enferm 2006; 59 (6): 1-5. 30. fernandes jd, xavier im, ceribelli mipf, bianco mhc, maeda d, rodrigues mvc. diretrizes curriculares e estratégias para implantação de uma nova proposta pedagógica. rev esc enferm usp 2005; 39 (4):1-7. >hospitalizations due to congenital syphilis in neonates: associated factors from the prenatal care process article hospitalizations due to congenital syphilis in neonates: associated factors from the prenatal care process hospitalizaciones por sífilis congénita en recién nacidos: factores asociados desde el proceso de la atención prenatal internações por sífilis congênita em neonatos: fatores associados a partir do processo da atenção pré-natal érica de brito pitilin 1 vanessa aparecida gasparin 2 debora tavares de resende e silva 3 jeane barros de souza 4 fabiana brum haag 5 1 0000-0003-3950-2633. universidade federal da fronteira sul, brazil. erica.pitilin@uffs.edu.br 2 0000-0002-4266-3668. universidade do estado de santa catarina, brazil. vanessa.gasparin@udesc.br 3 0000-0002-3813-7139. universidade federal da fronteira sul, brazil. debora.silva@uffs.edu.br 4 0000-0002-0512-9765. universidade federal da fronteira sul, brazil. jeane.souza@uffs.edu.br 5 0000-0002-1358-766x. universidade federal da fronteira sul, brazil. fabiana.haag@uffs.edu.br 10.5294/aqui.2020.20.4.8 received: 05/04/2020 sent to peers: 05/04/2020 approved by peers: 21/09/2020 accepted: 14/10/2020 theme: promotion and prevention. contribution to the discipline: this study provides subsidies to identify factors that can be improved in the context of maternal and child health through the indirect analysis of the hospitalizations of infected neonates and to help professionals, mainly from nursing, insert new conducts and routines in the care of women during the pregnancy-puerperal period. to reference this article / para citar este artículo / para citar este artigo: pitilin eb, gasparin va, de resende e silva dt, souza jb, haag fb. hospitalizations due to congenital syphilis in neonates: associated factors from the prenatal care process. aquichan. 2020;20(4):e2048. doi: https://doi.org/10.5294/aqui.2020.20.4.8 abstract objective: to identify the factors associated with hospitalizations due to congenital syphilis in neonates, based on the characteristics of prenatal care. materials and method: a quantitative case-control study, conducted by applying a questionnaire to 65 puerperal women with their babies hospitalized from july to november 2017. the data were analyzed using logistic regression, according to the plan proposed in the hierarchical approach. results: 20% of the hospitalizations were due to syphilis (cases) and 80% to other causes (control). the vulnerability risk (p = 0.036), previous history of sexually transmitted infection (p = 0,006), use of oral contraceptives (p = 0.011) and parity (p = 0.043) variables were statistically significant. the absence of the partner during the consultation (p = 0.028), failure to perform a rapid test for syphilis (p = 0.035) and educational activity for the partner (p = 0.033) were also associated with the occurrence of the outcome, in addition to the variables of the newborn: low birth weight(p = 0.025), not being on exclusive breastfeeding (p = 0.036) and not having had skin-to-skin contact(p = 0.043). conclusions: congenital syphilis has several risk factors for its occurrence. it was possible to observe that the assistance inequalities existing in care during the prenatal consultations directly reflect on the occurrence of this condition. keywords (source decs): syphilis; congenital syphilis; prenatal care; newborn infant; sexually transmitted diseases. resumen objetivo: identificar los factores asociados a las hospitalizaciones por sífilis congénita en recién nacidos desde las características de la asistencia prenatal. materiales y método: estudio cuantitativo tipo caso control, realizado por medio de la aplicación de encuesta a 65 puérperas con sus bebés hospitalizados de julio a noviembre del 2017. se analizaron los datos mediante regresión logística, de acuerdo con el plan propuesto en el enfoque jerárquico. resultados: el 20 % de las hospitalizaciones se dio por sífilis (casos) y el 80 % por otras causas (control). las variables riesgo de vulnerabilidad (p = 0,036), historia previa de infección sexualmente transmisible (p = 0,006), uso del contraceptivo oral(p = 0,011) y paridad(p = 0,043) fueron estadísticamente significativas. adicionalmente, se asociaron a la ocurrencia del desfecho la ausencia del compañero en la cita (p = 0,028), la no realización de la prueba rápida para detección de sífilis (p = 0,035) y la actividad educativa para el compañero (p = 0,033), además de las variables del neonato: bajo peso al nacer (p = 0,025), no encontrarse en lactancia exclusiva (p = 0,036) y no haber tenido contacto piel con piel (p = 0,043). conclusiones: la sífilis congénita presenta diversos factores de riesgo para su ocurrencia. fue posible observar que las iniquidades asistenciales en la atención durante las citas de prenatal refleten directamente en la ocurrencia de este agravo. palabras clave (fonte decs): sífilis; sífilis congénita; atención prenatal; recién nacido; enfermedades de transmisión sexual. resumo objetivo: identificar os fatores associados às internações por sífilis congênita em neonatos, a partir das características da assistência pré-natal. materiais e método: estudo quantitativo tipo caso controle, realizado por meio da aplicação de questionário a 65 puérperas com seus bebês internados de julho a novembro de 2017. os dados foram analisados mediante regressão logística, segundo o plano proposto na abordagem hierárquica. resultados: 20 % das internações foram por sífilis (casos) e 80 % por outras causas (controle). as variáveis risco de vulnerabilidade (p = 0,036), história prévia de infecção sexualmente transmissível(p = 0,006), uso do contraceptivo oral (p = 0,011) e paridade (p = 0,043) foram estatisticamente significativas. também foram associadas à ocorrência do desfecho a ausência do parceiro durante a consulta (p = 0,028), a não realização de teste rápido para a sífilis (p = 0,035) e a atividade educativa para o parceiro (p = 0,033), além das variáveis do neonato: baixo peso ao nascer (p = 0,025), não estar em aleitamento materno exclusivo (p = 0,036) e não ter tido contato pele a pele (p = 0,043). conclusões: a sífilis congênita apresenta diversos fatores de risco para a sua ocorrência. foi possível observar que as iniquidades assistenciais existentes no atendimento durante as consultas de pré-natal refletem diretamente na ocorrência desse agravo. palavras-chave (fonte decs): sífilis; sífilis congênita; cuidado pré-natal; recém-nascido; doenças sexualmente transmissíveis. introduction syphilis, although an infection that is easy to diagnose and treat, still represents a serious public health problem. characterized as a worldwide spreading disease, it affects nearly six million people annually, aged between 15 and 49 years old. its reservoir is the contaminated human being, and transmission occurs mainly through sexual intercourse, without using a condom, with an infected individual or through vertical transmission during pregnancy(1). of the several diseases that can be transmitted during the pregnancy-puerperal cycle, syphilis has the highest rates of congenital infection, with a 70 % to 100 % possibility of vertical transmission of this condition in the primary and secondary stages of maternal syphilis, decreasing to 30 % in the late and tertiary latent phases(2). congenital syphilis is the infection of the fetus predominantly by the transplacental route by treponema pallidum and it occurs in pregnant women who are not treated or treated inadequately, which can cause serious consequences such as spontaneous abortion, prematurity, stillbirth, death, in addition to psychological and social repercussions for the family and society(3). when observing the epidemiological panorama of congenital syphilis, an increase in the number of cases of this condition is evidenced. while the pan american health organization's recommendation for latin america and the caribbean estimates 0.5 cases per 1,000 live births, the brazilian rate is 6.5(4), considered 13 times higher. in this context, the number of research studies related to the topic also rose. the occurrence of congenital syphilis has already been associated, among other factors, with the younger age group and the woman's low schooling(5), as well as with late diagnosis of the pregnant woman and her partner (6). however, the search for factors related to congenital syphilis from the prenatal care process, with indirect assessment of the quality of care provided to pregnant women, is still incipient. even with the improvement of access and the proportion of coverage of prenatal care in the country, only a small percentage of women receive adequate assistance during pregnancy, which contributes to the occurrence of preventable injuries and unnecessary hospitalizations(7), as is the case of congenital syphilis. thus, this study assumes that a qualified and timely prenatal care for the pregnant woman and her partner would reduce the number of congenital syphilis cases and of hospitalizations of neonates/children for treatment. the findings can provide subsidies to identify factors that can be improved in the area and help the professionals who provide prenatal care to insert new conducts and routines in the care of women. thus, this study aims to identify the factors associated with hospitalizations due to congenital syphilis in neonates, based on the characteristics of prenatal care. materials and method a case-control study carried out with puerperal women over 18 years old, with their newborns admitted to a reference hospital in midand high-complexity care of southern brazil. for the selection of the participants, the following inclusion criteria were respected: puerperal women who had a single child in the current pregnancy diagnosed with congenital syphilis after birth, users of the unified health system (sistema único de saúde, sus), and seen at the obstetrics service of the hospital when the pregnancy was resolved. for the selection of the controls, puerperal women with characteristics homogeneous to those included in the case group, and with a newborn without a congenital syphilis diagnosis, were considered. only the main diagnosis recorded in the hospital admission authorization was considered. data collection by means of questionnaires with the mothers during the newborn's hospitalization occurred between july and november 2017. there was no refusal by the subjects to participate in the study. at the time of the interview, the medical records of the newborns and of the puerperal women were also obtained, in addition to the prenatal cards of the pregnant women. a pilot study was carried out for the adequacy and validation of the data collection instrument, built exclusively for this research. the instrument had socioeconomic, demographic and lifestyle habit variables, as well as related to reproductive history and assistance during prenatal care. the inpatient unit was visited from monday to friday. the sociodemographic and economic characteristics, lifestyle habits, the variables of reproductive history and the evaluation of the prenatal care process were defined as independent variables in relation to the outcome of the study. to obtain the gestational age at birth, the one recorded in the newborn's medical record was adopted. sample calculation was performed using the epilnfo 6.0 program, with the formula for case-control studies(8). from the number of cases that totaled 13 in the collection period and considering a maximum type i (alpha) error of 5 %, a minimum statistical power of 80 %, and a 5 % exposure between controls, 52 controls were necessary. according to the epidemiological assessment of congenital syphilis cases in other studies and in view of a discrepant observation between cases and controls, it was decided to use a 1:4 ratio. the cases group (n = 13) included the newborns diagnosed with congenital syphilis and was compared with the control group (n = 52), representative of the absence of the disease. the controls were matched to the cases by age and parity (number of children) to minimize or eliminate the confounding effect. the hierarchical approach strategy and conditional logistic regression(9) were used, whose regression coefficients represent the logarithms of the odds ratios, so as to try to explain the conceptual model of the occurrence of congenital syphilis. for the analysis, four hierarchical levels were considered, represented by the determinants of the distal, intermediate i and ii, and proximal levels (figure 1). the distal level consisted of the socioeconomic variables; the intermediate level was subdivided into i (demographic factors and lifestyle) and ii (reproductive history), and the proximal level comprised variables related to the prenatal care process. figure 1. conceptual model, hierarchical levels. brazil, 2017 source: own elaboration. the hierarchical approach and conditional logistic regression allow quantifying the contribution of each hierarchical level and minimizing the underestimation of the effects of risk determination. the set of the variables of one level was analyzed independently from those of other levels and integrated the adjustments of the variables of subsequent levels, when statistically significant (p < 0.05); the same order was adopted for the other levels. the variables were maintained in the final model when the adjustments were adequate. the modeling process was composed of the selected variables. a situation of risk and vulnerability was considered when an affirmative answer was given to any of these habits: smoking, alcohol, drugs, tattoos, piercing and more than two partners in the last year. for the periodic health control variable, gynecological or health professional monitoring before pregnancy was considered. in addition, the variables investigated regarding the prenatal care process were the following: a) number of prenatal consultations (obtained by counting the records of the dates of the consulfations and considered adequate according to the gestational age [ga]); b) ga in weeks; c) early beginning of prenatal care (up to the 13th week); d) minimum of six consultations carried out adjusted according to the ga, considering it appropriate to hold one in the first trimester, two in the second trimester (from the 14th to the 27th week) and three in the third trimester (from the 28th week); e) obstetric clinical conduct (the measurement of blood pressure, weight, the measurement of the height of the uterine fundus and the recording of cardiofetal beats in all consultations considered adequate); f) complete vaccination schedule (considered appropriate due to the presence of vaccine records against tetanus, hepatitis b and influenza); g) laboratory tests (basic tests considered complete: blood typing, toxoplasmosis, hiv/aids, vdrl, hepatitis b, blood count, partial urine, urine culture and fasting blood glucose). all these aspects were assessed in a dichotomous way (for example: yes or no, adequate or inadequate, complete or incomplete), judged according to the guidelines recommended by the brazilian ministry of health in assisting pregnant women(10). the data were entered with double entry and the statistical analysis was performed using the spss 20 software. the logistic regression analysis was conducted according to the plan proposed in the hierarchical approach. logistic regression was used for each of the blocks of variables. for all the inferential statistical tests, a significance level of p < 0.05 was used. the quality of fit was assessed by the hosmer-lemeshow test. the multicollinearity assumption test was performed by the vif (variance-inflation factor) and calculated by multiple linear regression, adopting a vif > 4 as the cutoff point for multicollinearity. the test showed no evidence of the presence of multicollinearity among the independent variables studied for multiple logistic regression. the study was conducted observing the ethical standards and approved by the committee of ethics in research with human beings of the federal university of fronteira sul, under opinion no. 2,157,128 and certificate of presentation for ethical appreciation no. 69347917.9.0000.5564. results among the hospitalizations of children under one year old, 20 % (n = 13) were due to congenital syphilis; while among the controls, 80 % (n = 52) were due to other causes (respiratory tract infection: 36.5 %, prematurity: 25 %, jaundice:17.3 %, other causes: 21.1 %). the mean age of the puerperal women was 24.1 years old (sd = 6.1) and the mean age of sexarche was 15.6 years old (sd = 1.3). in this study, the socioeconomic factors (distal hierarchical level) did not show an association with the occurrence of the outcome (table 1). the intermediate level i and ii variables — vulnerability risk, previous history of sexually transmitted infection (sti), use of oral contraceptives and parity — were significantly associated with the occurrence of hospitalizations (table 2). table 1. distribution of congenital syphilis cases according to the association between the variables of the distal hierarchical level, brazil, 2017 variables case n = 13 (%) control n = 52(%) total n = 65 (%) p-value maternal occupation 0.280 with an employment contract 3 (23.1) 13 (25) 16 (24.6)   without an employment contract 10 (76.9) 39 (75) 49 (75.4)   family monthly income 0.306 < 4 minimum wages 11 (16.9) 42 (64.6) 53 (81.5)   > 4 minimum wages 2* (3.1) 10 (15.4) 12 (18.5)   * chi-square test, with yates correction. source: own elaboration. table 2. distribution of congenital syphilis cases according to the association between the variables of the intermediate hierarchical levels i and ii, brazil, 2017 variables case n = 13 (%) control n = 52 (%) total n = 65 (%) p-value intermediate level i race/skin color 0.185 white 6 (9.2) 30 (46.2) 36 (55.4)   brown/black/asian 7 (10.8) 22 (33.8) 29 (44.6)   maternal schooling 0.193 up to 8 years 9 (13.8) 30 (46.2) 39 (60)   > 8 years 4* (6.2) 22 (33.8) 26 (40)   marital status 0.124 has a partner 12 (18.5) 43 (66.2) 55 (84.6)   no partner 1* (1.5) 10 (15.4) 10 (15.4)   vulnerability risk# 0.036 yes 9 (13.8) 20 (30.8) 29 (44.6)   no 4* (6.2) 32 (49.2) 36 (55.4)   previous history of sti 0.006 yes 7 (10.8) 8 (12.3) 15 (23.1)   no 6 (9.2) 44 (67.7) 50 (76.9)   periodic health control 0.201 yes 6 (9.2) 29 (44.6) 35 (53.8)   no 7 (10.8) 23 (35.4) 30 (46.2)   oral contraceptive 0.011 yes 11 (16.9) 24 (36.9) 35 (53.8)   no 2* (3.1) 28 (43.1) 30 (46.2)   intermediate level ii parity 0.043 primiparous 5 (7.7) 35 (53.8) 40 (61.5)   multiparous 8 (12.3) 17 (26.2) 25 (38.5)   previous c-section 0.127 yes 7 (10.8) 37 (56.9) 44 (67.7)   no 6 (9.2) 15 (23.1) 21 (32.3)   type of delivery 0.071 vaginal 6 (9.2) 12 (18.5) 18 (27.7)   cesarean 7 (10.8) 40 (61.5) 47 (72.3)   *chi-square test, with yates correction #considering smoking, alcohol, drugs, tattoos, piercing and number of partners in the last year greater than two. source: own elaboration. of the variables related to the prenatal care process: 84.6 % (n = 55) positively evaluated the care received in primary care and 75.4 % (n = 49) stated that they had an easy time making appointments for care. the absence of the partner during the consultations (53.8 %), associated with their non-participation in educational activities (40 %), was directly associated with the outcome (table 3). table 3. distribution of congenital syphilis cases according to the association between the variables of the proximal hierarchical level, brazil, 2017 variables case n = 13 (%) control n = 52 (%) total n = 65 (%) p-value perception of the care received       0.214 positive 10 (15.4) 45 (69.2) 55 (84.6)   negative 3* (4.6) 7 (10.8) 10 (15.4)   number of consultations       0.083 sufficient 5 (7.7) 32 (49.2) 37 (56.9)   insufficient 8(12.3) 20 (30.8) 28 (43.1)   early start of pn 0.185 yes 8(12.3) 38 (58.5) 46 (70.8)   no 5 (7.7) 14 (21.5) 19 (29.2)   presence of the partner in the consultation 0.028 yes 11 (16.9) 24 (36.8) 35 (67.3)   no 2* (3.1) 28 (43.1) 30 (53.8)   speed in performing the exams 0.099 yes 5 (7.7) 31 (47.7) 36 (55.4)   no 8(12.3) 21 (32.3) 29 (44.6)   quick access to the results 0.285 yes 10 (15.4) 40 (61.5) 50 (76.9)   no 3* (4.6) 12 (18.5) 15 (23.1)   easy scheduling of consultations 0.280 yes 10 (15.4) 39 (60) 49 (75.4)   no 3* (4.6) 13 (20) 16 (24.6)   vdrl* at 1st and 3rd trimester 0.053 performed 11 (16.9) 30 (46.2) 41 (63.1)   not performed 2* (3.1) 22 (33.8) 24 (36.9)   syphilis rapid test 0.035 performed 1* (1.5) 19 (29.2) 20 (30.8)   not performed 12 (18.5) 33 (50.8) 45 (69.2)   educational activity of the mother 0.162 yes 2* (3.1) 16 (24.6) 18 (27.7)   no 11 (16.9) 36 (55.4) 47 (72.3)   educational activity of the partner 0.033 yes 2* (3.1) 24 (36.9) 39 (60)   no 11 (16.9) 28 (43.1) 26 (40)   treatment of the partner   performed 5 (7.7) 0* (0) 5 (7.7)   not performed 8(12.3) 52 (80) 60 (92.3)   *chi-square test, with yates correction # vdrl — venereal disease research laboratory. source: own elaboration. it is noteworthy that all the patients diagnosed with syphilis (confirmed by the positive vdrl test) were referred to high-risk prenatal care and properly treated (84.6 % in the second trimester and 15.3% in the third trimester), according to the protocols in force in the country. however, only five of the partners were treated. table 4 shows the characteristics of the hospitalized neonates (cases and controls). the mean birth weight was 2,897 g (sd = 719 g). table 4. characteristics of the hospitalized neonates according to the association with the occurrence of congenital syphilis, brazil, 2017 variables case n = 13 (%) control n = 52 (%) total n = 65 (%) p-value low birth weight 0.025 yes 8 (12.3) 15 (23.1) 23 (35.4)   no 5 (7.7) 37 (56.9) 42 (64.6)   gestational age 0.078 preterm 5 (7.7) 9 (13.8) 14 (21.5)   term 8 (12.3) 43 (66.2) 51 (78.5)   exclusive breastfeeding 0.036 yes 9 (13.8) 4* (6.2) 29 (44.6)   no 20 (30.8) 32 (49.2) 36 (55.4)   skin-to-skin contact 0.043 yes 5 (7.7) 35 (53.8) 40 (61.5)   no 8 (12.3) 17 (26.2) 25 (38.5)   * chi-square test, with yates correction. source: own elaboration. discussion in this study, it was sought to identify the factors associated with the occurrence of congenital syphilis, in addition to proving that a qualified and timely prenatal care for the pregnant woman as well as for the partner would reduce the number of cases and of hospitalizations of neonates/children for the treatment. maternal occupation and family monthly income (socioeconomic variables) were not associated with the outcome, despite knowing that the health and disease process can be socially modified. the findings of this study refute what is shown in the literature(11), which can be explained by the social characteristics of women with better living conditions in the brazilian south region. in turn, the following were associated with the occurrence of congenital syphilis: vulnerability risk, previous history of sti, use of oral contraceptives and parity, in the light of other studies(12-14). vulnerability is understood as the possibility of exposing people to illness resulting not only from a set of individual aspects, but also from collective and contextual factors that make individuals more susceptible to the availability of resources to protect themselves(15). the use of drugs, understood as a situation of vulnerability in this study, increases the likelihood of involvement with multiple sexual partners, which, associated with the non-use of barrier contraceptive methods, can result in risk of sti contamination, in addition to unwanted pregnancies(15). on the one hand, being single can be related to the multiplicity of sexual partnerships and the risk of unprotected sexual activity. on the other hand, the trust conferred on the steady partner means that the woman does not use the condom or stops demanding its use. these combined facts underscore the low adherence to the sti preventive methods, which contributes to the uncontrolled spread of the disease(15). it is added that the use of oral contraceptives by itself does not have a clinical correlation with the occurrence of the outcome, but reinforces the practice of unsafe sex since, for these women, the choice of the contraceptive method can be based only on contraception. the number of children (parity) seems to have the same causal link, since multiparous women are at greater risk for the occurrence of congenital syphilis, as a result of the greater number of unprotected sexual relations. a research study carried out in pakistan corroborated with the findings that parity and the use of contraceptives are related to greater occurrence of syphilis (14). the absence of the partner in the consultation and his limited participation in the educational activities seem to be associated with the occurrence of congenital syphilis. it is necessary to intensify strategies that integrate and favor the partner's adherence to prenatal care during pregnancy. the partner's prenatal care is intended to promote the engagement of men in the actions of reproductive planning and in the monitoring of prenatal, childbirth and postpartum of their partners and in the care of the child's development, with the real possibility of improving the quality of life for all people involved and healthy affective bonds(16). although the timely treatment of the partner is not associated with the occurrence of the outcome in this study, other studies identified that the occurrence of syphilis resulted, among other factors, from untreated sexual partners and inadequate treatments, which demonstrates the potential for dissemination related to the therapeutic regimen (5, 17). another factor evidenced in the occurrence of the outcome was failure to perform the rapid test for syphilis, in the light of another study(4). the offer of the rapid test, whether for the detection of syphilis or any other sti covered by the test, must be performed at any opportunity to assist the woman and her sexual partners. it is a resource that is easy to implement, yet highly cost-effective, considered an important tool in the diagnosis and early treatment of pregnant women and their partners(17). some characteristics have already been related to a greater chance of not undergoing the rapid test, such as black-skinned women, with low family income and schooling, in addition to few prenatal consultations(4). another important factor evidenced by the study was the neonatal outcome. despite the high number of congenital syphilis, the newborns in this study had a low degree of asphyxia and a reduced proportion of congenital malformations. low birth weight was associated with the occurrence of congenital syphilis, in line with the findings described in the literature, which emphasize that, in addition to reduced weight, prematurity, stillbirth, neurological sequelae, and death can be seen in children with this condition(11). in addition, through the findings of this study, it was possible to show that the non-routine practice of skin-to-skin contact at birth, as well as the non-incentive to exclusive breastfeeding were associated with the presence of congenital syphilis. it is worth noting that breast milk does not transmit syphilis from the mother to the child and that, during breastfeeding, transmission can occur only if there is syphilitic breast injury, which is very rare(18). the same criterion applies to skin-to-skin contact, since treponema pallidum is acquired by crossing the placenta or through direct contact of the child with an infected lesion at birth(19). nevertheless, the type of delivery was not associated with the outcome. however, 72.3 % of the births were performed surgically, which may have explained the failure in the routine of skin-to-skin contact, as well as exclusive breastfeeding in high proportions. it should also be noted that, even in a relatively short collection period, the number of congenital syphilis cases diagnosed was considerable, in view of all the efforts directed at educational measures, which can and should be implemented and provided in prenatal care. conclusions through the objectives proposed for this study, it was possible to identify that congenital syphilis presents several risk factors for its occurrence, both those socially identified in the literature and those related to the specific characteristics of the pregnant women. it was also possible to observe that the assistance inequalities existing in care, during the prenatal consultations, directly reflect on the occurrence of this condition. in this sense, there is a need for nursing to be more active in prenatal care, with the execution of consultations, investigation of health problems and educational activities for the couple, as well as early performance of rapid tests to identify the condition, in a timely manner and for complete treatment. this study has some limitations: it is noteworthy that the hospitalizations analyzed were only those that occurred within the scope of the sus, which constitutes a partial view of reality, in addition to the small population of cases studied, which limits the generalization of the findings. it is suggested to carry out future studies that include hospitalizations from the private system, with a view to comparing the factors associated with the occurrence of congenital syphilis in different areas. conflicts of interest: none declared. references 1. de souza rl, dos santos madeira ldp, pereira mvs, da silva rm, de luna sales jb, azevedo vn et al. prevalence of syphilis in female sex workers in three countryside cities of the state of pará, brazilian amazon. bmc infect dis. 2020;20(1):129. doi: https://doi.org/10.1186/s12879-020-4850-1 2. costa cv, santos iab, silva jm, barcelos tf, guerra hs. congenital syphilis: repercussions and challenges. acm arq. catarin. med [internet]. 2017; 46(3):194-202. available from: http://www.acm.org.br/acm/seer/index.php/arquivos/article/view/94/191 3. hong fc, wu xb, yang f, lan ln, guan y, zhang cl et al. risk of congenital syphilis following treatment of maternal syphilis: results of a congenital syphilis control program in china. clin infect dis. 2017;65(4):588-94. doi: https://doi.org/10.1093/cid/cix371 4. cesar ja, camerini av, paulitsch rg, terlan rj. non-performance of serological tests for syphilis during prenatal care: prevalence and associated factors. rev bras epidemiol. 2020;23:e200012. doi: https://doi.org/10.1590/1980-549720200012 5. heringer als, kawa h, fonseca sc, brignol sms, zarpellon la, reis ac. desigualdades na tendência da sífilis congênita no município de niterói, brasil, 2007 a 2016. rev panam salud publica. 2020;44:e8. doi: https://doi.org/10.26633/rpsp.2020.8 6. de oliveira sim, de oliveira saraiva cop, de frança df, ferreira júnior ma, de melo lima lh, de souza nl. syphilis notifications and the triggering processes for vertical transmission: a cross-sectional study. int j environ res public health. 2020;17(3):984. doi: https://doi.org/10.3390/ijerph17030984 7. pitilin eb, pelloso sm. primary care sensitive admissions in pregnant women: associated factors based on the prenatal care process. texto contexto enferm. 2017;26(2):e06060015. doi: https://doi.org/10.1590/0104-07072017006060015 8. lwanga sk, lemeshow s. sample size determination in health studies: a practical manual. geneva: world health organization; 2001. 9. victora cg, huttly sr, fuchs sc, olinto mt. the role of conceptual frameworks in epidemiological analysis: a hierarchical approach. int j epidemiol. 1997;26(1):224-7. doi: https://doi.org/10.1093/ije/26.1.224 10. brasil. ministério da saúde. secretaria de atenção à saúde. departamento de atenção básica. atenção ao pré-natal de baixo risco. brasília: editora do ministério da saúde; 2013. 11. umapathi kk, thavamani a, chotikanatis k. incidence trends, risk factors, mortality and health care utilization in congenital syphilis-related hospitalizations in the united states: a nationwide population analysis. pediatr infect dis j. 2019;38(11):1126-30. doi: https://doi.org/10.1097/inf.0000000000002445 12. xiao y, li sl, lin hl, lin zf, zhu xz, fan jy et al. factors associated with syphilis infection: a comprehensive analysis based on a case-control study. epidemiol infect. 2016;144(6):1165-74. doi: https://doi.org/10.1017/s0950268815002344 13. sheffield js, wendel jr, gd. syphilis in pregnancy. clinical obstetrics and gynecology [internet].1999;42(1):97-106. available from: https://journals.lww.com/clinicalobgyn/citation/1999/03000/syphilis_in_pregnancy.15.aspx 14. qayum m, shaheen n, khan mqa, waheed n, ali w. frequency of syphilis among antenatal clinic attendee in combined military hospital abbottabad. pak armed forces med j [internet] 2015;65(5):664-8. available from: https://www.pafmj.org/index.php/pafmj/article/view/1094 15. meneses mo, vieira bdg, queiroz aba, alves vh, rodrigues dp, da silva jcs. o perfil do comportamento sexual de risco de mulheres soropositivas para sífilis. rev enferm ufpe on line. 2017;11(4):1584-94. disponível em: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/15226 16. brasil. ministério da saúde. secretaria de atenção à saúde. departamento de ações programáticas estratégicas. guia do pré-natal do parceiro para profissionais de saúde. rio de janeiro: ministério da saúde; 2016. 17. cardoso arp, araújo mal, cavalcante ms, frota ma, melo sp. analysis of cases of gestational and congenital syphilis between 2008 and 2010 in fortaleza, state of ceará, brazil. ciênc. saúde coletiva. 2018;23(2):563-74. doi: http://dx.doi.org/10.1590/1413-81232018232.01772016 18. brasil. ministério da saúde. secretaria de vigilância em saúde. programa nacional de dst/aids. diretrizes para controle da sífilis congênita: manual de bolso. 2. ed. brasília: ministério da saúde; 2006. 19. arriagada d, donoso a, cruces p, díaz f. sífilis congénita: presentación como shock séptico después del período neonatal. rev chilena infectol. 2012;29(5):558-63. doi: http://dx.doi.org/10.4067/s0716-10182012000600017 home mental health of postpartum women during the covid-19 pandemic: an integrative review article mental health of postpartum women during the covid-19 pandemic: an integrative review* salud mental de puérperas durante la pandemia de la covid-19: revisión integradora** saúde mental de puérperas durante a pandemia covid-19: revisão integrativa*** 10.5294/aqui.2022.22.2.7 naiane ribeiro prandini1 silvana regina rossi kissula souza2 ana clara antunes pereira resende3 efigênia aparecida maciel de freitas4 jhovana trejos serrato5 suellen vienscoski skupien6 1 0000-0001-9260-4132. universidade federal do paraná, brazil. naianeprandini@ufpr.br 2 0000-0002-1679-4007. universidade federal do paraná, brazil. skissula@ufpr.br 3 0000-0003-4617-2492. universidade federal do paraná, brazil. anaclara.antunes@ufpr.br 4 https://orcid.org/0000-0003-4434-7762. universidade federal de uberlândia, brazil. efigenia@ufu.br 5 0000-0002-4733-0686. universidade federal do paraná, brazil. jhovana.trejos@ufpr.br 6 0000-0002-9503-6334. universidade federal do paraná, brazil.suellen.skupien@ufpr.br * this article was funded by the coordenação de aperfeiçoamento de pessoal de nível superior (capes) through the covid-19 emergency action notice of the universidade federal do paraná, brazil, which is part of the emergency strategic program for prevention and response to outbreaks, endemics, epidemics, and pandemics. the article stems from the first stage of development of the dissertation entitled "the experiences of postpartum women during the covid-19 pandemic," under the project entitled "models, networks, protocols, and procedures to provide care for women undergoing labor and birth," submitted to the graduate program of the universidade federal do paraná, brazil. ** la coordenação de aperfeiçoamento de pessoal de nível superior (capes) financió el presente artículo por medio de la convocatoria de acción de emergencia covid-19 de la universidade federal do paraná, brasil, que hace parte del programa estratégico de emergencia de prevención y combate a brotes, endemias, epidemias y pandemias. el texto se deriva de la primera etapa de desarrollo de la tesis de doctorado titulada "experiencias de puérperas durante la pandemia de covid-19", que forma parte del proyecto "modelos, redes, protocolos y procesos para el cuidado a la mujer en proceso de parto y nacimiento", presentado al programa de posgrado de la universidade federal do paraná, brasil. *** este artigo foi financiado pelo coordenação de aperfeiçoamento de pessoal de nível superior (capes) por meio do edital de ação emergencial covid-19 da universidade federal do paraná que é integrante do programa estratégico emergencial de prevenção e combate a surtos, endemias, epidemias e pandemias. o artigo é oriundo da primeira etapa de desenvolvimento da tese de doutorado intitulada “experiência da mulher no puerpério durante pandemia”, que faz parte do projeto “modelos, redes, protocolos e processos para o cuidado à mulher no processo de parto e nascimento”. este artigo é derivado da tese de doutorado intitulada “experiências de puérperas durante a pandemia de covid-19”, apresentada ao programa de pós-graduação da universidade federal do paraná (ufpr). received: 18/03/2021 sent to peers: 03/09/2021 approved by peers: 22/02/2022 accepted: 23/02/2022 theme: promotion and prevention. contribution to the subject: the research demonstrates the mental health of postpartum women during the covid-19 pandemic, supporting professional practices through scientific evidence and encouraging research on the topic. para citar este artículo / to reference this article / para citar este artigo: prandini nr, souza srrk, resende acap, freitas eam, serrato jt, skupien sv. mental health of postpartum women during the covid-19 pandemic: an integrative review. aquichan. 2022;22(2):e2227. doi: https://doi.org/10.5294/aqui.2022.22.27 abstract objective: to identify and analyze the scientific evidence on the mental health of postpartum women during the covid-19 pandemic. method: this integrative review was carried out using the vhl, cinahl, pubcovid, scopus, and web of science databases, whose research question was "what is the scientific evidence on the mental health of postpartum women during the sars-cov-2 pandemic?" results: ten articles in english were included, identifying a higher frequency of cross-sectional research (n = 4), publications in november 2020 (n = 3), conducted in italy (n = 3), with level vi evidence (n = 6). the study found that postpartum women feel depressed, lonely, and afraid; attention is drawn to the worsening risk of postpartum depression with significant prevalence values. it points out factors that negatively influence the mental health of this population in the current pandemic and discloses care measures. conclusions: in addition to previous characteristics, socioeconomic conditions (e.g., living in highly infected areas, unemployment) and elements inherent to this pandemic (e.g., distance and fear of contagion) negatively influence the mental health of postpartum women. means of dealing with the conditions imposed by the covid-19 pandemic are available, such as relaxation techniques, physical exercise, and professional support. the relevance and need for research on this theme, mostly nationally, are highlighted. keywords (source decs): covid-19; mental health; pandemics; postpartum period; sars-cov-2; betacoronavirus. resumen objetivo: identificar y analizar las evidencias científicas sobre la salud mental de puérperas durante la pandemia de la covid-19. método: revisión integradora en las bases de datos bvs, cinahl, pubcovid, scopus y web of science, en la que se consideró la pregunta de investigación "¿cuáles son las evidencias científicas sobre la salud mental de las puérperas en la pandemia del sars-cov-2?" resultados: se incluyeron diez artículos, en inglés, y se identificó más frecuencia en investigaciones trasversales (n = 4), publicaciones en noviembre de 2020 (n = 3), realizadas en italia (n = 3), con nivel vi de evidencia (n = 6). se demostró que las puérperas se sienten deprimidas, solitarias y con miedo, lo cual agrava el riesgo de depresión posparto con valores importantes de prevalencia. se señalan factores que influyen de forma negativa en la salud mental de esta población y se evidencian acciones de cuidado. conclusiones: además de las características anteriores, algunas condiciones socio-económicas (como vivir en áreas de más infección, desempleo) y elementos inherentes a esta pandemia (como distanciamiento y miedo de contagiarse) influyen de forma negativa en la salud mental de puérperas. hay formas de manejar las condiciones impuestas por la pandemia de covid-19, como técnicas de relajación, práctica de ejercicio físico y soporte profesional. se destacan la importancia y la necesidad de investigaciones nacionales, principalmente, e internacionales en esta temática. palabras clave (fuente decs): covid-19; salud mental; pandemias; periodo posparto; sars-cov-2; betacoronavirus. resumo objetivo: identificar e analisar as evidências científicas sobre a saúde mental de puérperas durante a pandemia da covid-19. método: revisão integrativa nas bases de dados bvs, cinahl, pubcovid, scopus e web of science, na qual se considerou a pergunta de pesquisa "quais as evidências científicas sobre a saúde mental das puérperas na pandemia do sars-cov-2?" resultados: foram incluídos 10 artigos, em língua inglesa, e foi identificada maior frequência em pesquisas transversais (n = 4), publicações em novembro de 2020 (n = 3), realizadas na itália (n = 3), com nível vi de evidência (n = 6). demonstrou-se que as puérperas se sentem deprimidas, solitárias e com medo; atentam para a piora no risco de depressão pós-parto com valores importantes de prevalência. apontam fatores que influenciam negativamente a saúde mental dessa população na atual pandemia e revelam ações de cuidado. conclusões: além de características pregressas, há condições socioeconómicas — como residir em áreas de maior contaminação, desemprego — e elementos inerentes a essa pandemia — como distanciamento e medo da contaminação — que influenciam negativamente a saúde mental de puérperas. há meios de lidar com as condições impostas pela pandemia da covid-19, como técnicas de relaxamento, prática de exercício físico e apoio profissional. salientam-se a importância e a necessidade de pesquisas nacionais, principalmente, e internacionais nessa temática. palavras-chave (fonte decs): covid-19; saúde mental; pandemias; período pós-parto; sars-cov-2; betacoronavírus. introduction the respiratory disease caused by the novel coronavirus has been named "coronavirus disease 2019" (covid-19), causing concern mostly among risk groups, including pregnant and postpartum women until day 14. in brazil, the lethality rate stemming from the severe acute respiratory syndrome (sars-cov-2), caused by covid-19, has led to 544 deaths in 2020, with a mean weekly rate of 12.1. by may 2021, a total of 911 deaths had been reported, with a mean weekly rate of 47.9, indicating an alarming increase (1,2). in the americas, a total of 1,271 deaths among pregnant women who tested positive for sars-cov-2 had been reported between january 2020 and may 2021, with records in mexico (334), peru (114), the united states of america (99), colombia (69), and argentina (56). although lower than those reported in brazil, these numbers corroborate the impact of the virus in the pregnancy-postpartum cycle (3). in addition to the concern over the outcome of the disease in the maternal body, other factors include the family members' health (4,5), the baby's health, changes in maternal and child health services, the presence or absence of a companion during delivery and postpartum, and the scarcity of reliable information (4). postpartum women are at exceptionally high risk for mental health disorders during the pandemic (6); therefore, these maternal concerns may contribute to increased psychological distress (4,7-9), with evidence that women in the perinatal period face symptoms of stress, anxiety (60 %), and depression (12 %) (10), along with signs of likely increased depression (11), anxiety (1,12,13), and anhedonia (12), motivated by the perceived risk of covid-19 (12). social distancing due to covid-19 implies decreased intimate contact, generates uncertainty and anxiety regarding the pandemic context (14), and the perception that perinatal women are at greater risk due to covid-19 compared to non-pregnant women (15) increases their fear regarding childbirth (14,15). a possibility exists for increased depression and anxiety symptoms during the perinatal period during pandemic lockdown (16), which may have shortand long-term consequences, highlighting the caution required for the mental health of this population (7). furthermore, the current pandemic increases the likelihood of postpartum depression (ppd). according to a study, there was an incidence of 56.9 % of depression symptoms in chinese women where age, abortion history, and perceived stress were influential factors, and the demands related to parenting guidance (78 %), protection of the mother-child dyad (60.3 %), and feeding (45 %) were listed as care needs. in addition, this study found an increased need for psychological assistance for postpartum women who were depressed compared to those who were not depressed (12). against this backdrop, this study is substantiated by the urgent need to synthesize the theoretical and reflective framework on the mental health of postpartum women, understand the scope of this issue,vand, thus, contribute to quality care in line with demand-orientedvstrategies. postpartum is considered a period of unique and specific characteristics, both biologically, emotionally, and socially (17); it starts after childbirth and includes the restoration of the female organism, and, consequently, it has an imprecise time limit. the "unexpected conclusion" was selected for this review (18). considering the above, this article aims to identify and analyze the scientific evidence on the mental health of postpartum women during the covid-19 pandemic. materials and methods this integrative review, a method that widely synthesizes the results of national and international research, provides relevant, timely evidence that contributes to clinical practice, the production of critical knowledge, and future studies (19, 20) by pointing out research gaps (20), meeting the need for knowledge created by the pandemic. we followed six steps (19, 21). the first, "selection of the guiding question," was structured with the pico strategy, where p stands for population (postpartum women), i for interest (mental health), and co for context (covid-19 pandemic). it led to the question "what is the scientific evidence on the mental health of postpartum women during the sars-cov-2 pandemic?" the databases and search strategies were listed in the second step, "sampling." an author performed the digital search on november 24th, 2020, through the portal de periódicos da coordenação de aperfeiçoamento de pessoal de nível superior (capes), brazil, which provided access to the databases biblioteca virtual en salud (bvs), cumulative index to nursing and allied health literature (ci-nahl), and scopus. on the same date, the search in the pubcovid directory was performed. a digital search was conducted on january 20th, 2021, in the web of science (wos) database. the health sciences descriptors (decs) used in portuguese were "período pós-parto," "saúde mental"; alternative terms were used for the "covid-19" descriptor, considering the nomenclature changes since the emergence of covid-19 cases in december 2019. in spanish, the descriptors used were "período posparto," "salud mental," and "covid-19." in english, the medical subject headings (mesh terms) used were "postpartum period," "mental health," "covid-19", and "sars-cov-2." according to each database's suitability, the search strategies combined decs and mesh, using the boolean operators and and or, as presented in table 1. the bvs offers a specific strategy for the theme, and it was used for the search; the pubcovid database stores publications from pubmed and embase in folders organized by subtopics; in this case, the "gynecology, obstetrics, reproduction, and pregnancy" folder was intersected with the "mental health" folder. table 1. databases and search strategies used. curitiba, paraná, brazil, 2021 database strategy used bvs ("período pós-parto" or "postpartum period" or "periodo posparto" or "puerpério" or "period, postpartum" or "postpartum" or "postpartum women" or "puerperium" or "women, postpartum" or "periodo postparto" or "periodo de posparto" or "periodo de postparto" or "puérpera" or "puérperas" or "puerperal") and ("saúde mental" or "mental health" or "salud mental" or "área de saúde mental" or "higiene mental" or "mental hygiene") and (((("2019-2020" or 2019 or da:202*) ("new coronavirus" or "novel coronavirus" or "nuevo coronavirus" or "novo coronavirus" or "coronavirus disease" or "enfermedad por coronavirus" or "severe acute respiratory syndrome coronavirus 2")) or ((2019-ncov) or (ncov 2019) or 2019ncov or covid19 or (covid-19) or covid2019 or (covid-2019) or (covid 2019)) or ((srag-cov-2 or sars-cov-2 or sars2 or (sars 2) or (sars cov 2) or cov19 or cov2019 or coronavirus* or "severe acute respiratory infections" or "severe acute respiratory infection" or "coronavirus 2" or "acute respiratory disease" or mh:betacoronavirus or mh:"coronavirus infections" or mh:"sars virus") and (tw:2019 or da:202*) and not da:201*) or (wuhan market virus) or (virus mercado wuhan) or "wuhan coronavirus" or "coronavirus de wuhan") and not ti:dromedar*)) cinahl ("período pós-parto" or "postpartum period" or "periodo posparto" or "puerpério" or "period, postpartum" or "postpartum" or "postpartum women" or "puerperium" or "women, postpartum" or "periodo postparto" or "periodo de posparto" or "periodo de postparto" or "puérpera" or "puérperas" or "puerperal") and ("saúde mental" or "mental health" or "salud mental" or "área de saúde mental" or "higiene mental" or "mental hygiene") and ("wuhan coronavirus" or "covid19*" or "covid-19*" or "covid-2019*" or "coronavirus disease 2019" or "sars-cov-2" or "2019-ncov" or "2019 novel coronavirus" or "severe acute respiratory syndrome coronavirus 2" or "2019 novel coronavirus infection" or "coronavirus disease 2019" or "coronavirus disease-19" or "sars-cov-2019" or "sars-cov-19"). scopus ("período pós-parto" or "postpartum period" or "periodo posparto" or "puerpério" or "period, postpartum" or "postpartum" or "postpartum women" or "puerperium" or "women, postpartum" or "periodo postparto" or "periodo de posparto" or "periodo de postparto" or "puérpera" or "puérperas" or "puerperal") and ("saúde mental" or "mental health" or "salud mental" or "área de saúde mental" or "higiene mental" or "mental hygiene") and ("wuhan coronavirus" or "covid19*" or "covid-19*" or "covid-2019*" or "coronavirus disease 2019" or "sars-cov-2" or "2019-ncov" or "2019 novel coronavirus" or "severe acute respiratory syndrome coronavirus 2" or "2019 novel coronavirus infection" or "coronavirus disease 2019" or "coronavirus disease-19" or "sars-cov-2019" or "sars-cov-19") wos ("período pós-parto" or "postpartum period" or "periodo posparto" or "puerpério" or "period, postpartum" or "postpartum" or "postpartum women" or "puerperium" or "women, postpartum" or "periodo postparto" or "periodo de posparto" or "periodo de postparto" or "puérpera" or "puérperas" or "puerperal") and ("saúde mental" or "mental health" or "salud mental" or "área de saúde mental" or "higiene mental" or "mental hygiene") and ("wuhan coronavirus" or "covid19*" or "covid-19*" or "covid-2019*" or "coronavirus disease 2019" or "sars-cov-2" or "2019-ncov" or "2019 novel coronavirus" or "severe acute respiratory syndrome coronavirus 2" or "2019 novel coronavirus infection" or "coronavirus disease 2019" or "coronavirus disease-19" or "sars-cov-2019" or "sars-cov-19") pubcovid (("covid-19"[all fields] or "covid-2019"[all fields] or "severe acute respiratory syndrome coronavirus 2"[supplementary concept] or "severe acute respiratory syndrome coronavirus 2"[all fields] or "2019-ncov"[all fields] or "sars-cov-2"[all fields] or "2019ncov"[all fields] or (("wuhan"[all fields] and ("coronavirus"[mesh terms] or "coronavirus"[all fields])) and (2019/12[pdat] or 2020[pdat]))) or ("coronavirus"[mesh terms] or "coronavirus"[all fields]) or ("severe acute respiratory syndrome coronavirus 2"[supplementary concept] or "severe acute respiratory syndrome coronavirus 2"[all fields] or "sars cov 2"[all fields])). source: own elaboration based on the research data. the inclusion criteria set were publications between 2019 and 2020 (from the beginning of the covid-19 pandemic to the date of article collection) available in full-text in portuguese, english, and spanish that addressed the mental health of postpartum women solely during the covid-19 pandemic. the exclusion criteria were reflection papers, editorials, letters to the editor, experience reports, case reports, formative second opinion, videos, commentaries, research record protocols, and brief communication of results. for the "primary research characterization," which is the third step, duplicate publications were excluded using endnoteweb software, a free reference manager, and a practical, reliable, and transparent resource for the integrative review (20). in the sequence, titles and abstracts were read with a complete reading of the article when clarification was needed, tabulating information in an adapted instrument. meanwhile, the included and excluded publications were selected using the inclusion and exclusion criteria. pre-print publications were considered, which had already been published at the end of the review. two authors reviewed this process; when necessary, the third and fourth authors analyzed the articles. in the fourth step, "finding analysis," the included articles were read and reread thoroughly and critically, generating the content presented in the next section. in the second-to-last step, "result interpretation from convergent themes emerging from the review," the final product was discussed with the literature, describing achievements and implications. the sixth step, "review presentation," describes the steps for the review and the main findings of article analysis. since this literature review does not involve human beings, it was not submitted to the research ethics committee. results the search in the databases totaled 240 publications. upon checking for duplicates, the authors and reference manager excluded 53 publications, and 13 others were unavailable on the capes database. therefore, 174 publications were reviewed, excluding 164 and including ten as the corpus for the qualitative synthesis (figure 1) using the preferred reporting items for systematic reviews and meta-analyses (prisma) flowchart (22). figure 1. flowchart of the publications' search and selection. curitiba, paraná, brazil, 2021 source: own elaboration based on survey data and prisma adaptation (22). the results in table 2 present studies conducted in the united kingdom, the united states, china, iran, serbia, turkey, israel (n = 1 each), and italy (n = 3). the publishing journals were mostly correlated to mental health or women's health. all those included were published in 2020 during may (n = 2), september (n = 2), october (n = 1), november (n = 3), and december (n = 2). the study types consisted of qualitative descriptive (n = 1), review (n = 1), cohort (n = 2), case-control (n = 1), quantitative descriptive (n = 1), and cross-sectional descriptive studies (n = 4). overall, we noted that these studies aim to understand mood symptomatology, especially depressive symptoms in postpartum women during the covid-19 pandemic. table 2. articles included for review according to first author, country of research, journal, month and publication database, title, objective, method, results, and evidence level. curitiba, paraná, brazil, 2021 first author country/ journal/ publication month/ database title objective method results evidence level dib s (24) united kingdom international journal of gynecology & obstetrics september 2020 bvs "maternal mental health and coping during the covid-19 lockdown in the uk: data from the covid-19 new mum study" to evaluate how the mothers were feeling and dealing with the lockdown and potential ways to assist them descriptive analysis; online survey; participation of 1,329 women with infants under 12 months of age more than half (71 %) of these mothers reported feeling depressed, lonely, irritable, and worried since the start of the lockdown but able to cope with the situation. health care and contact with support groups were predictors of improved mental health while going out to work, lower family income, and the impact of the lockdown on their ability to buy food were predictors of worsening mental health. getting out for physical activity and relaxation techniques such as meditation and yoga were potential ways of coping with the lockdown. vi ostacoli l (25) italy bmc pregnancy and childbirth november 2020 bvs "psychosocial factors associated with postpartum psychological distress during the covid-19 pandemic: a cross-sectional study" to investigate the prevalence of depressive and post-traumatic stress symptoms in women who gave birth during the covid-19 pandemic and their associations with quarantine measures, obstetric factors, and relational attachment style cross-sectional; online survey; administration of epds, ies-r (impact of event scale-revised), and rq (relationship questionnaire); participation of 163 postpartum women a total of 44.2 % experienced depression symptoms, and 42.9 % experienced post-traumatic stress symptoms following childbirth. the relational attachment was avoidant-disdainful and avoidant with fear, related to the risk of depression and post-traumatic stress symptoms, respectively. the pain felt at delivery represented a risk factor for depression; the quietness at hospitalization due to the absence of visitors and the support from healthcare professionals represented a protective factor. vi silverman me (26) the united states scientific reports december 2020 wos "postpartum mood among universally screened high and low socioeconomic status patients during covid-19 social restrictions in new york city." to determine any changes in postpartum mood symptomatolog y among patients who gave birth before and during the covid-19 pandemic to explore whether any differences in reported postpartum mood symptomatolog y existed between those living at high and low socioeconomic levels during these same periods cohort; epds data collection in the medical record; participation of 516 women in the postpartum period a total of 12.4 % of the women scored above nine, suggesting depression. a statistically significant change in mood symptomatology was observed between the socioeconomic groups during the covid-19 restrictions: women with lower socioeconomic status showed a decrease in depressive symptomatology. iv oskovi-kaplan za (27) turkey psychiatric quarterly september 2020 scopus "the effect of covid-19 pandemic and social restrictions on depression rates and maternal attachment in immediate postpartum women: a preliminary study" to evaluate the rates of postpartum depression and maternal-infant attachment status among women in the immediate postpartum period whose last trimester overlapped with the lockdowns and who gave birth in a tertiary care center that had stringent hospital restrictions due to also providing care to covi d-19 patients in turkey's capital quantitative descriptive study; administration of epds and mai (maternal attachment inventory); participation of 223 women in the immediate postpartum period (48 hours) the mean epds score was 7 (7), and 33 (14.7 %) women were identified as at risk for ppd. the mean score on the mai was 100 (26); the mai scores of women with depression were significantly lower than those of women without depression, 73 (39) vs. 101 (18), respectively [p < 0,001]. it is suggested that the risk of ppd during the pandemic increased compared to pre-pandemic levels. the fact that postpartum women stay in isolated rooms and are not allowed to have any visitors may have influenced their higher epds scores. vi liang p (28) china bmc psychiatry november 2020 wos "prevalence and factors associated with postpartum depression during the covid-19 pandemic among women in guangzhou, china: a cross-sectional study" to investigate the prevalence of ppd and explore the ppd-related factors among women in guangzhou, china, during the covid-19 pandemic cross-sectional study; online survey; administration of the epds and structured questionnaire; participation of 845 women in the postpartum period between 6 and 12 weeks the ppd prevalence was 30 % in women within 6-12 weeks postpartum. the factors significantly related to the highest ppd scores were being an immigrant, having a sustained fever, insufficient social support, concerns regarding covid-19 infection, preventive measures such as avoiding sharing eating utensils, and the lowest ppd scores. vi spinola o(29) italy frontiers in psychiatry november 2020 wos "effects of covid-19 epidemic lockdown on postpartum depressive symptoms in a sample of italian mothers" to explore the impact of covid-19 on ppd symptoms in mothers with children under one year of age cross-sectional study; online survey; administration of the epds, the spss (scale of perceived social support), and the msss (maternity social support scale); participation of 243 women with children aged up to one year in 44.40 %, a prevalence of ppd symptoms occurred; in 51.90 %, a substantial perception of stress was noted; 87.20 % indicated deficient maternal support; 61 % indicated that covid-19 affected breastfeeding. time off work and receiving financial assistance from family members were significantly associated with depression symptoms. having been in contact with people infected with covid-19 and fear of the baby being infected with the disease were significantly related to increased epds scores; women who reported no fear that their close ones were infected with the disease had higher epds scores. prior abortion history and emotional issues significantly affected higher epds scores. women quarantined in northern italy had higher depression and perceived stress scores than those in central and southern italy. vi stonajov j (30) serbia international journal of psychiatry in medicine december 2020 wos "the risk for nonpsychotic postpartum mood and anxiety disorders during the covid-19 pandemic" to recognize the risk factors for nonpsychotic postpartum mood and anxiety disorders (npmads) in women during the pandemic and police lockdown in a state of emergency in serbia cross-sectional study; online survey; epds administration; participation of 108 postpartum women with children aged under 12 months. 14.8 % of postpartum women were at risk for nonpsychotic postpartum mood and anxiety disorders, while 85.2 % were not at risk. women over 35 years old, single, unemployed or who became unemployed due to the pandemic, or were dissatisfied with family income scored higher on the epds. quarantine, social isolation, lack of social support, and emotional issues were significantly associated with the risk of npmads. when comparing non-postpartum and postpartum women, postpartum women were more anxious, experienced helplessness and negative feelings, and were more worried for no real reason while in social isolation. postpartum women estimated no need for psychological support from a professional. vi zanardo v (31) italy international journal of gynecology & obstetrics may 2020 pubcovid "psychological impact of covid519 quarantine measures in northeastern italy on mothers in the immediate postpartum period" to explore whether quarantine measures and hospital containment policies among women giving birth in a covid-19 "hotspot" area in northeastern italy increased psycho-emotional distress in the immediate postpartum period retrospective case-control study; administration of the epds in the immediate postpartum period; participation of 91 women from the study group and 101 women from the control group the study group consisting of postpartum women during the covid-19 pandemic (n = 91) had significantly higher epds values compared to the pre-pandemic control group (n = 101) (8.5 ± 4.6 vs. 6.34 ± 4.1; p < 0.001). a total of 30 % of the study group presented with an increased risk of ppd (epds > 12) anhedonia, anxiety, and depression scored higher in the postpartum women study group during the covid-19 pandemic compared to the control group, with a significant difference for anhedonia. the quarantine and hospital containment measures strongly impacted postpartum women and, added to the fear of exposure to covid-19, may worsen depressive symptoms. iv pariente g (32) israel archives of women's mental health october 2020 scopus "risk for probable postpartum depression among women during the covid-19 pandemic" to evaluate the risk of postpartum depression among women who gave birth during the covid-19 pandemic compared to the risk among women who gave birth before the covid-19 pandemic cohort study on-site; epds administration in the immediate postpartum period; participation of 223 women. women who gave birth during the covid-19 pandemic were at a lower risk of scoring high (> 10) or very high (> 13) on the epds compared to women who gave birth before the covid-19 pandemic (16.7 % vs. 31.3 %, p = 0.002 and 6.8 % vs. 15.2 %, p = 0.014, for epds > 10 and epds > 13, respectively). maternal age, ethnicity, marital status, and adverse pregnancy outcomes were independently associated with a lower risk of depression (adjusted or 0.4, ci = 95 % 0.23-0.70, p = 0.001 and adjusted or 0.3, ci = 95 % 0.15-0.74, p = 0.007 for epds scores > 10 and > 13, respectively). iv sighaldeh ss (33) iran journal of maternal-fetal & neonatal medicine may 2020 wos "care of newborns born to mothers with covid-19 infection; a review of existing evidence" to discuss how to care for a newborn of a mother suspected or infected with covid-19 from the existing evidence systematic review study; articles and guidelines related to covid-19 in reproductive health, maternal, and newborn health it was found that maternal concern exists regarding fetal radiation exposure by computerized tomography. vertical transmission of covid-19 is inconclusive. early delivery of women with covid-19 is recommended when the mother is experiencing severe symptoms; however, testing positive for covid-19 is not the sole indicator for early delivery. late cord clamping is not indicative of an increased possibility of virus transmission, and its maintenance is recommended; early clamping is suggested if the mother presents with infection symptoms. divergence exists regarding skin-to-skin contact, and a shared decision with the parents is essential. covid-19 can have an insidious onset and be nonspecific in infants. the screening for covid-19 in newborns delivered by mothers with the disease involves collecting nasopharyngeal, oropharyngeal, and rectal swabs within 24 hours of birth and 24 hours after the first collection, ct scanning, and epidemiologic history. separation of the dyad if the mother tests positive for covid-19 and no direct breastfeeding may occur due to the risk of disease transmission following delivery; isolation of the baby, and care with the milking of breast milk may occur. separation of the mother-infant dyad and not breastfeeding may damage the mother-infant bond and increase maternal stress in the postpartum period. v* *referred to by the authors of the article as a systematic review. source: own elaboration based on the research results. data collection was performed digitally (n = 5), on-site (n = 3), and bibliographically (n = 2). in addition to other instruments associated with data collection, the edinburgh postnatal depression scale (epds) was used (n = 8). the evidence level was identified according to the articles' methodological characteristics and followed melnyk and fineout-overholt's proposal (23): •level i: systematic reviews or meta-analyses of randomized controlled studies or evidence-based practice guidelines based on randomized studies or meta-analyses • level ii: well-designed randomized clinical trials • level iii: well-delimited controlled trials without randomization • level iv: well-designed case-control and cohort studies • level v: systematic reviews of descriptive and qualitative studies • level vi: descriptive or qualitative studies • level vii: authority opinions or expert committee reports level i evidence considers that the recommendations contained in these publications are highly applicable in professional practice when compared to level vi. in this review, the levels identified were iv (n = 3), v (n = 1), and vi (n = 6). based on the articles read, two main contents emerged: "the effects of the covid-19 pandemic on the mental health of postpartum women" and "care measures for the mental health of postpartum women during the covid-19 pandemic". regarding "the effects of the covid-19 pandemic on the mental health of postpartum women", despite the particularities of each study, this pandemic caused postpartum women to feel depressed, lonely, in an irritable mood, and worried (24), with depression and post-traumatic stress symptoms (25). concerning the prevalence of ppd, 12.4 % presented with possible ppd (26), 14.7 % with risk for ppd (27), 30 % with a prevalence of ppd (28), 44.40 % with a prevalence of depressive symptoms, 51.90 % with perceived stress (29), and 14.8 % were at risk for nonpsychotic mood and anxiety disorders (30). comparing the postpartum period before and during this pandemic, postpartum women in the latter group were at 30 % higher risk for ppd (27), with higher scores also for anhedonia and anxiety (31). in the study that compared non-postpartum women to postpartum women in the pandemic, the latter presented with increased anxiety, negative feelings, and disability (30). in this pandemic context, economic issues such as lower family income, inability to buy food (29), unemployment (29,30), financial support from family members (29) and sociodemographic issues such as being an immigrant (28), living in an area with higher infection rates (29), being over 35 years old and single (30) were pointed out as factors related to the deterioration of the mental health of postpartum women. furthermore, low social support was associated with higher epds values (28,30). other factors such as the pain experienced at delivery (25), previous abortion history (29), and previous emotional issues (29,30) posed a risk for ppd. another study demonstrated that postpartum women were at lower risk of high epds scores during the pandemic (32) and that these women estimated no need for professional psychological support (30). themes related to worrying about exposure (31), getting covid-19 and having a sustained fever (28), contact with people infected with covid-19, and fear of the baby contracting the infection (29) were associated with worsening mental health. regarding preventive measures, separation from mother and baby postpartum (33), quarantine (30,31), isolation (30), hospital isolation (31), staying in an isolated room, and not receiving visits (27) were flagged as contributors to worsening depression symptoms. from another perspective, one article pointed out that women with a higher socioeconomic status showed no changes in mood following childbirth with social containment measures and decreased depression symptomatology (26). in "care measures for the mental health of postpartum women during the covid-19 pandemic", caring for oneself and contact with support groups (24), quietude in hospitalization, having received support from professionals (25), and avoiding sharing eating utensils (28) were protective measures for their mental health. going out for physical activity and relaxation techniques were means of coping with the imposed lockdown (24). discussion considering the global challenge of producing information on sars-cov-2 for public health, care, and research (33), it is noted that the articles included started being published in may 2020, peaking at the end of the second half (september, october, november, and december). the most significant number of publications in november indicates a possible gradation in the development of research and knowledge during the first year of the pandemic. italy ranks as the country with the highest number of publications, possibly due to being the first epicenter of the pandemic in europe, with numerous positive cases and deaths from covid-19, lockdown, and quarantine on a large scale (31). regarding the type of research, cross-sectional studies and those that used the epds for data collection stand out. this instrument inquires upon postpartum depression symptomatology and, given its sensitivity in the research, supports clinical practice in the health field (34, 35). the data collection strategy used the most was the virtual collection, possibly influenced by this pandemic's implications on field research, highlighting ventures conducted remotely that innovated research in this context (36,37). in this sense, it is vital to conduct research continuously, not limiting it to emergency contexts (38), as while periods of crisis reveal challenges for research, the mission of reducing uncertainty and assisting public health remains (39). relative to the evidence level, level vi contained the most significant number of studies, which indicates the development of research on this theme with other methodological designs. however, given the conditions imposed by the pandemic, it is necessary to develop alternative means of research other than face-to-face. the need for timely access to information has made it essential for the methodological research design to factor in the impositions resulting from the pandemic. identifying the level of evidence in a review enables critical observation of the information for use in clinical practice (23). despite the lack of symmetry in the publication of studies with well-defined methodological designs and a high level of scientific evidence that enables and subsidizes such evidence in professional nursing practice, the best evidence available is used instead of the best possible evidence. among the publications in brazil, systematic reviews without or with meta-analysis, protocol reviews, the synthesis of evidence studies, and the integrative review are the most adopted methodologies (40). the effects of the covid-19 pandemic on the mental health of postpartum women epidemic events produce adverse psychological effects, such as fear of getting sick, dying, loneliness, stress, depression, sadness, irritation, and feeling of loss (41, 42), leading to emotional suffering and affecting the health and well-being of individuals. it is possible to ponder the effects of the current pandemic on mental health considering the population's psychological response to previous epidemics (42, 43), which can be exteriorized in emotional responses, unhealthy behaviors, and disregard towards public health guidelines (42). the articles pointed out that depression symptoms in postpartum women may worsen in the current setting. maternal depression is considered one of the most common mental disorders during pregnancy or postpartum (44) and affects 13 % to 19 % of pregnant women (45). in brazil, a prevalence of 26.3 % (44) countrywide and 14 % (46) of ppd has been reported in the south of the country. significantly greater severity of ppd symptoms is reported at the onset than before the pandemic, associating this event with increased mental health issues in the postpartum period (47). sentiment analysis showed increased negativity (48) and a marked increase in the prevalence of self-reported significant depressive symptoms in the postpartum period compared with before the pandemic (16). factors that pose a risk for ppd exist. prenatal anxiety, postpartum blues, family income, women's occupation, and pregnancy complications are mentioned as significantly relevant. high levels of stress, low social support, current or previous history of abuse, history of prenatal depression, and marital dissatisfaction issues stand out as the most common, and history of prenatal depression and current abuse as the strongest (45). in brazil, risk factors significant for ppd were a brown-looking skin color, low economic status, alcohol consumption, history of mental disorder, unplanned pregnancy, being multiparous, improper care during birth or for the baby born (44). in the south of the country, personal or family history of depression, sadness experienced in the third gestational trimester, being multiparous and younger were associated with a higher risk for the disease (46). in the current pandemic, some risk factors may be increased, such as depression symptoms during pregnancy, a previous diagnosis of anxiety, perception of low social support during pregnancy, traumatic events before or during pregnancy, and harsh circumstances during pregnancy or postpartum, such as the death of a loved one, unemployment, and a high-stress load. there is a possibility of worsening symptoms due to common mental disorders (besides depression and anxiety) during pregnancy, perception of low support from the partner, marital dissatisfaction, and low socioeconomic level, added to the economic changes resulting from the pandemic (49). considering the known prevalence of ppd combined with changes in the postpartum period, the influence of the pandemic as a stress source (43, 47), and issues such as unemployment and economic adversity, profound interference with perinatal mental health can be indicated (43). furthermore, the measures globally adopted to decrease the transmission of sars-cov-2, such as quarantine, social distancing, and meeting cancellations, cause increased distress and the development of mental disorders (43) since reduced social support, social isolation, distance, and fear of being exposed or infected have consequences for maternal mental health (50). the concern that a close person is infected increases the fear of loss, and the possible contact with someone who tested positive for sars-cov-2 can raise the fear that the baby may be infected (29). these aspects can increase feelings of anxiety and fear in women in labor, further considering the changes in face-to-face care flows (8), whose suspension led women to feel anxious, neglected, sad, and frustrated (15). reports state that women in the perinatal period during the pandemic experienced high suffering due to the external environment of high risk, the despair by anticipation of mourning, the limitation of family and social support, the change in interpersonal relationships, and the guilt that altered the feeling of happiness for the pregnancy (48). in this review, anxiety and stress issues were found. a study pointed out that 12 % of participating women presented with high depression symptomatology, 60 % had moderate or severe anxiety, and 40 % felt lonely, mentioning the uncertainty regarding perinatal care, the risk of exposure of the dyad to infection, conflicting information, and the lack of a support network as key stress points (10). during the pandemic, fathers are not allowed to visit, and newborns are isolated when tested positive for sars-cov-2. this isolation can harm the healthy neurodevelopment of newborns, as the presence of fathers in the postpartum stimulates the affective bond (51, 52), in addition to the potential harm to the well-being and mental health of the mother (8). evidence indicates that the uncertainty or exclusion regarding the presence of a companion and inadequate support in breastfeeding influence negatively the quality of life during the postpartum period (15). care measures for the mental health of postpartum women during the covid-19 pandemic mental health care measures can mitigate the impact on obstetric patients (43, 50). initiatives such as teleconsultation, multidisciplinary psychological and social care support can be used (51, 53). receiving reliable information helps reduce the implication of fake news (54) and may contribute to the non-occurrence of adverse psychological effects (28, 53). in turn, watching negative news can lead to feelings of despair and helplessness (41), and lacking adequate information on the pandemic can influence the increase in fear (29, 54), uncertainty (54), anxiety, depression, and other symptoms (29). therefore, it is understood that access to reliable information is a strategy to cope with the adversities of the pandemic (41). limiting and monitoring access to news regarding the pandemic may be beneficial (9, 42, 50, 55). engaging in moderate-intensity physical exercise (9, 10, 41, 53) for at least 150 minutes a week reduces anxiety and depression compared to women who do not exercise (11). having family bonds, enjoying moments of reading, watching movies, and listening to music, professional assistance provided through technological resources, implementing policies to assist the vulnerable, providing essential elements for subsistence, hygiene, organization measures, meditation (9), and social support, an essential protective factor (6), are auxiliary in reducing the psychological effects of the pandemic (41). communication through digital media (9, 10, 53), self-care activities (9, 10), such as adequate sleep, healthy eating, emotional support from the partner staying at home, being outdoors, feelings of gratitude, and establishing routines were pointed out as sources of resilience (10). although the postpartum women estimate that they do not require psychological support from a professional (30), the importance of professional monitoring of mental health is emphasized (7) with guidelines on how to manage and cope with stress through the implementation and continuity of routines and social and mental health assistance (42). to identify higher-risk situations, nurses need to be aware of the relationship between the pandemic and mental health in the pregnancy-postpartum cycle (50). even though the covid-19 pandemic has altered workflow in health care units and caused a high professional workload (51), the population needs to be informed of which remote assistance mechanisms to seek for mental health support since the information from reliable sources decreases fear (54, 56). when it is recorded that postpartum women had a lower risk of scoring high on the epds during the pandemic, the influence of support and proximity of relatives is thought to be due to stringent quarantine, a consequence of the lower spread of the virus in the region, the fact that women were not required to leave home, and that they perceived their baby to be healthy (32). although they have not been highlighted as protective factors, these aspects should be monitored in the mental health care of this population. other measures that assist with protection in a withdrawal period, such as having clear and compelling government information, having adequate supplies, a set quarantine period, and emphasizing the altruistic choice of quarantine, are on record (57). in brazil, psychological prenatal care, initially proposed by bortoletti in 2007 (58), is a form of intervention intended as psychological care, which can be provided through teleconsultation (1), for pregnant women and their partners. it preventevely aims to support them emotionally, informatively, and instructionally (59). another resource consists of the prenatal and postpartum nursing consultation for the longitudinal follow-up, early identification of mental suffering, and the proposition of preventive, promotion, and treatment measures (60). conclusions this research has identified that postpartum women feel depressed, worried, anxious, negative, and afraid. it summarizes crucial risk and prevalence information for ppd in the covid-19 pandemic context. it has enabled the recognition of prior risk factors for postpartum mental illnesses that are not specific to the pandemic context, while factors that are unique and inherent to the pandemic, such as containment measures and risk of contracting the disease, elicit a negative effect on this population. the results also revealed that living in areas where the virus is more widespread, being an immigrant, unemployed, and lacking social support worsen mental health, particularly in vulnerable groups. furthermore, mental health care measures for postpartum women were identified, such as support groups, professional support, and relaxation activities that reduce mental distress. therefore, the importance and need for professional care for the mental health of postpartum women in all contexts are acknowledged. it becomes especially relevant in the current pandemic context, which has imposed specific conditions that can worsen mental health, considering that mood change symptoms can be harmful to the course of the entire postpartum period. in light of this, the identification of evidence on the mental health of postpartum women during the pandemic and protective measures suggest focusing on professional attention to this subject in future public health events. the importance of studies, including national research, whose subject matter is the mental health of postpartum women is emphasized, as the postpartum period is a unique event that, although related to pregnancy, is singular in itself. conflicts of interest. none to declare. acknowledgements. to librarian leonardo talone, from the reference sector of the health sciences library (botanical headquarters, universidade federal do paraná), for the substantial contribution to the decs and mesh listing, assembling the search strategy, and defining the databases. to capes for the financial support provided through the covid-19 emergency action scholarship and the social demand scholarship. references 1. brasil. ministério da saúde. nota informativa n.° 13/2020-se/gab/ se/ms: manual de recomendações para a assistência à gestante e puérpera frente à pandemia de covid-19. 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patients with an ostomy* 1 http://orcid.org/0000-0002-7536-3557. school of health, instituto politécnico de viana do castelo, portugal. clementinasousa@ess.ipvc.pt 2 http://orcid.org/0000-0001-9198-2668. escola superior de enfermagem do porto, portugal. celiasantos@esenf.pt * this article derives from a doctoral dissertation in the advanced nursing specialty: “criação e avaliação de um programa de intervenção em enfermagem de estomaterapia: contributos na adaptação à ostomia e qualidade de vida”, authored by clementina dos prazeres fernandes de sousa. universidade católica portuguesa, 2016. received: 08/11/2019 sent to peer review: 12/12/2019 accepted peer review: 02/02/2020 approved: 18/02/2020 doi: 10.5294/aqui.2020.20.1.4 para citar este artículo / to reference this article / para citar este artigo fernandes cp, brito cs. effect of a stoma nursing care program on the adjustment of patients with an ostomy. aquichan. 2020;20(1):e2014. doi: https://doi.org/10.5294/ aqui.2020.20.1.4 abstract objective: to evaluate the effect of a stoma nursing care program on the personal adjustment to an ostomy. materials and methods: a quasi-experimental study with a control group. the sample of 105 patients with stoma was divided into two groups (intervention group and control group), with assessments in the first and sixth month after hospital discharge. information was collected using the elimination ostomy adjustment scale. student’s t-tests analysis were performed. results: one month after hospital discharge, the adjustment to the stoma was satisfactory and similar (p > 0.05) in both groups, and in the sixth month, statistically more favorable in the intervention group (p < 0.001); a statistically significant difference between the two assessments (p < 0.001) is found in the intervention group only. conclusions: the intervention program has a positive influence on the adjustment to the stoma, and its contribution is significant six months after hospital discharge. systematic interventions of an ostomy care specialized nurse have shown positive effects on ostomy adjustment, which is recommended since the preoperative period. keywords (source: decs, mesh) surgical stoma; psychological adjustment; nursing care; preoperative period; postoperative period. año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2014 theme: chronic disease care. contribution to the discipline: this research has important implications in health planning, particularly nursing, since it means that the adjustment to an ostomy improves significantly if patients receive differentiated care during the preoperative, immediate, and follow-up periods. the present study has strengths such as the importance of the enterostomal therapist’s systematic intervention to promote a healthier adjustment. http://orcid.org/0000-0002-7536-3557 http://orcid.org/0000-0002-7536-3557 http://orcid.org/0000-0002-7536-3557 http://orcid.org/0000-0002-7536-3557 http://orcid.org/0000-0002-7536-3557 http://orcid.org/0000-0002-7536-3557 mailto:clementinasousa@ess.ipvc.pt mailto:clementinasousa@ess.ipvc.pt mailto:clementinasousa@ess.ipvc.pt mailto:clementinasousa@ess.ipvc.pt mailto:clementinasousa@ess.ipvc.pt mailto:clementinasousa@ess.ipvc.pt mailto:clementinasousa@ess.ipvc.pt http://orcid.org/0000-0001-9198-2668 http://orcid.org/0000-0001-9198-2668 http://orcid.org/0000-0001-9198-2668 http://orcid.org/0000-0001-9198-2668 http://orcid.org/0000-0001-9198-2668 http://orcid.org/0000-0001-9198-2668 mailto:celiasantos@esenf.pt mailto:celiasantos@esenf.pt mailto:celiasantos@esenf.pt mailto:celiasantos@esenf.pt mailto:celiasantos@esenf.pt https://doi.org/10.5294/aqui.2020.20.1.4 https://doi.org/10.5294/aqui.2020.20.1.4 https://doi.org/10.5294/aqui.2020.20.1.4 http://orcid.org/0000-0002-7536-3557 http://orcid.org/0000-0002-7536-3557 http://orcid.org/0000-0002-7536-3557 http://orcid.org/0000-0001-9198-2668 http://orcid.org/0000-0001-9198-2668 http://orcid.org/0000-0001-9198-2668 https://doi.org/10.5294/aqui.2020.20.1.4 https://doi.org/10.5294/aqui.2020.20.1.4 https://doi.org/10.5294/aqui.2020.20.1.4 https://doi.org/10.5294/aqui.2020.20.1.4 https://doi.org/10.5294/aqui.2020.20.1.4 https://doi.org/10.5294/aqui.2020.20.1.4 https://doi.org/10.5294/aqui.2020.20.1.4 https://doi.org/10.5294/aqui.2020.20.1.4 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2014 efecto de un programa de atención de enfermería en estomaterapia en la adaptación de la persona a la ostomía de eliminación* resumen objetivo: evaluar el efecto de un programa de atención de enfermería en estomaterapia en la adaptación de la persona a la ostomía de eliminación (oe). materiales y métodos: estudio cuasiexperimental con grupo control. la muestra de 105 personas con oe se dividió en dos grupos (grupo de intervención y grupo de control), con evaluación en el primer y sexto mes después del alta hospitalaria. la información se recopiló mediante la escala de adaptación a la ostomía de eliminación. se realizaron pruebas t de student para el análisis estadístico. resultados: en el primer mes después del alta hospitalaria, la adaptación a la oe fue satisfactoria y similar (p > 0,05) en los dos grupos y el sexto mes fue estadísticamente más favorable en el grupo de intervención (p < 0,001), con diferencias estadísticamente significativas en el grupo de intervención entre los dos momentos de evaluación (p < 0,001). conclusiones: el programa influenció positivamente la adaptación a la oe y su contribución se hizo visible al sexto mes después del alta hospitalaria. la intervención sistemática de la enfermería en estomaterapia reveló un efecto favorable en la adaptación a la oe, por lo que es recomendable que se inicie en el período preoperatorio. palabras clave (fuente: decs, mesh) estomas quirúrgicos; ajuste emocional; atención de enfermería; periodo preoperatorio; periodo posoperatorio. * este artículo se deriva de la tesis de doctorado: “criação e avaliação de um programa de intervenção em enfermagem de estomaterapia: contributos na adaptação à ostomia e qualidade de vida”, universidade católica portuguesa, 2016. 3 effect of a stoma nursing care program on the adjustment of patients with an ostomy l clementina prazeres fernandes sousa and other efeito de um programa de enfermagem em estomaterapia na adaptação da pessoa ao estoma de eliminação* resumo objetivo: avaliar o efeito de um programa de intervenção de enfermagem em estomaterapia na adaptação da pessoa à ostomia de eliminação (oe). material e métodos: estudo quasi-experimental com grupo de controlo. a amostra de 105 pessoas com oe repartiu-se por dois grupos (grupo de intervenção e grupo de controlo), com avaliação ao primeiro e sexto mês depois da alta hospitalar. a informação foi recolhida com a escala de adaptação à ostomia de eliminação. realizaram-se testes t-student para análise estatística. resultados: ao primeiro mês, a adaptação à oe era satisfatória e semelhante (p > 0,05) nos dois grupos, sendo ao sexto mês, estatisticamente mais favorável no grupo de intervenção (p < 0,001); com diferenças estatisticamente significativas entre os dois momentos de avaliação (p < 0,001), no grupo de intervenção. conclusões: o programa de intervenção influenciou positivamente o percurso de transição para a adaptação à oe, sendo visível o seu contributo, ao sexto mês depois da alta hospitalar. a intervenção sistematizada da enfermeira estomaterapeuta revelou um efeito favorável na adaptação à oe, sendo recomendável desde o período pré-operatório. palavras-chave (fonte: decs, mesh) estoma cirúrgico; ajustamento emocional; cuidados de enfermagem; período pré-operatório; período pós-operatório. año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2014 * este artigo é derivado da tese de doutorado “criação e avaliação de um programa de intervenção em enfermagem de estomaterapia: contributos na adaptação à ostomia e qualidade de vida”, universidade católica portuguesa, 2016. 4 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2014 aquichan issn 1657-5997 eissn 2027-5374 introduction an ostomy represents a potential threat to the dynamics of everyday life, which is expressed by emotional, physical, and social imbalance; therefore, individuals must learn a different modus vivendi and incorporate it into their daily life. adjusting to a changed body generates responses that reflect in various ways to deal with the new condition, which implies the acquisition of new skills to adjust and move forward (1-6). being colorectal cancer the most common disease and colostomy one of the surgical proposals, the ghost of recurrence, the progression to terminal disease and subsequent death, and the stoma can continuously torment the patient’s thinking, influencing his/her coping strategies and the adjustment process (1, 7, 8). however, the fact that an ostomy represents disease control and allows to continue living can ease acceptance as well as transition to psychosocial adjustment (7, 9). adjustment includes the individual’s intention and willingness to manage new situations and challenges (10). the adjustment to an ostomy means that the person will have to reorganize and redirect his/her life, face the changes, and accept new challenges knowing that they have a stoma (3-5, 11-13). if the stoma is permanent it will be with him/her for the rest of his/her lifetime, involving a smooth reformulation of his/her identity, body image, and new or renewed concept of life (2-5). given these assumptions, our research is based on meleis’ transitions theory, considering that ostomy surgery implies a health/illness transition. the conceptual basis of this theory supported the analysis and understanding of the nature of these phenomena and how people cope with changes in their bodies and self-care, as well as the factors associated with the adjustment to the transition to a life with an ostomy. it involves the awareness and commitment of the individual to accept the changes and the recognition of the personal potentials and the environmental resources that will enable them to overcome the transition period and adjust healthily to the new living conditions (14). in this context, the potential of nursing therapeutics emerges, improving the strengthening capacities directed to stoma care management and the appropriation of a new sense of life. this empowerment that is built step by step will have an impact on the healthy adjustment to the changes perceived by people who start living with an ostomy. thus, the incorporation of an ostomy and the reformulation of one’s identity happen, and the health outcomes flow smoothly (14). the identification of personal and environmental transition conditions (facilitators and inhibitors) will guide the educational action of nursing to allow the development of skills that help enjoy a more independent, more interactive, and healthier life (14). nurses, particularly the enterostomal therapist nurses (etn), face two major challenges. on the one hand, understanding the transition phase that patients are experiencing; on the other, providing them nursing therapeutics that promote, as far as possible, self-confidence, well-being, and autonomy (3, 11, 14). several studies emphasize the effect of psychosocial adjustment to the ostomy if stoma nurses take care of patients (3, 6, 11, 13, 15-20). if such intervention starts in the preoperative phase and continues after hospital discharge, it will strengthen their early involvement and management of self-care and the construction of more proactive attitudes toward the new life circumstances (1, 18, 19). the stoma self-care appropriation will be more effective if teaching strategies are structured and continued (6, 15). there are numerous studies that analyze changes in self-care after bowel or urinary stoma and its implications for adjustment, discovering positive associations between stoma care autonomy and the adjustment to an ostomy (12, 13). in this framework, this study was designed to assess the effect of a nursing program in enterostomal therapy (npet) on ostomy adjustment. considering the theoretical assumptions, scientific evidence, and purpose of our study, the following hypotheses were defined: • h1 patients benefiting from the npet have a better adjustment to the ostomy than those who have not received this intervention at the end of the first month after hospital discharge; • h2 patients who have received care through the npet have a better adjustment to the ostomy compared to those who received usual nursing care at the end of the sixth month after hospital discharge; • h3 between the first and sixth months after hospital discharge, the adjustment to the ostomy improves significantly https://dictionary.cambridge.org/es/diccionario/ingles-espanol/adaptation https://dictionary.cambridge.org/es/diccionario/ingles-espanol/the https://dictionary.cambridge.org/es/diccionario/ingles-espanol/individual_2 https://dictionary.cambridge.org/es/diccionario/ingles-espanol/intention https://dictionary.cambridge.org/es/diccionario/ingles-espanol/and https://dictionary.cambridge.org/es/diccionario/ingles-espanol/to https://dictionary.cambridge.org/es/diccionario/ingles-espanol/manage https://dictionary.cambridge.org/es/diccionario/ingles-espanol/new https://dictionary.cambridge.org/es/diccionario/ingles-espanol/and https://dictionary.cambridge.org/es/diccionario/ingles-espanol/adaptation 5 effect of a stoma nursing care program on the adjustment of patients with an ostomy l clementina prazeres fernandes sousa and other in those who were provided with the npet, compared to those without this interv ention. method an intervention nursing program (npet) was created in a previous study, using a mixed-method sequential design, supported by the guidelines of the medical research council for the development and evaluation of complex interventions. the study had two phases: • phase 1: construction of a npet pilot version based on theoretical nursing references, the international classification for nursing practice (10) and the nursing interventions classification (21), using the focus group technique, with a panel of seven expert nurses. • phase 2: pilot study of the implementation of the program. six focuses of the nursing practice (self-concept, self-care, acceptance, hope, sexual interaction, and social interaction) and nursing interventions that were considered relevant to the ostomized people care make up the npet consensus version to be applied to the present study. the intervention program was applied in the preoperative, transoperative, and follow-up phase of patients with ostomy this research is a quasi-experimental study with a control group (22) and involves an npet and data collection at two points in time: first and sixth-months after hospital discharge (table 1). table 1. study design g ro up p re op er at iv e ho sp it al iz at io n p os to pe ra ti ve ca re 1s t m on th af te r ho sp it al di sc ha rg e fo llo w -u p 6t h m on th af te r ho sp it al di sc ha rg e intervention (ig) x ie1 x ie2 a1 x ie3 n ≥ 5 a2 control (cg) a1 a2 legend: x ie1 1st nursing intervention with npet; x ie2 2nd nursing intervention with npet; x ie3 follow-up nursing interventions with npet. a1 1st moment of data collection; a2 2nd moment of data collection. source: own elaboration the sample size was obtained during 2015 and 2016, in nine hospital units in northern portugal. for the intervention group (ig) subjects from four hospitals with stomatherapy nursing consultation (snc) were selected and the participants allocated to the control group (cg) were from five hospitals without snc or etn. the criteria for inclusion in the sample include individuals hospitalized for ostomy elective surgery or even ostomy palliative surgery; with primary bowel or urinary stoma (temporary or permanent); aged 18 years or older, and study volunteers. after obtaining their written informed consent in the first assessment, 105 subjects, 72 for the ig and 33 for the cg, comprise the sample. in the second assessment, there were 93 participants, of whom 61 were in the ig and 32 in the cg, with a death rate between both assessments of 15.3 and 3 %, respectively (figure 1). figure 1. flow diagram of study participants as per consort (northern portugal) source: adapted from consort 2010 during hospitalization, two visits of the etn were planned in the intervention group to perform the npet: one preoperative and another postoperative. additionally, five follow-up consultations were programmed as a minimum for six months after discharge. more consultations could be planned according to the patient’s needs. in the same period, the general nurses provided routine care |to both groups, in all the hospitals involved. 6 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2014 aquichan issn 1657-5997 eissn 2027-5374 a demographic and clinical characteristics questionnaire and the elimination ostomy adjustment scale (eoas) (23, 24) were used as data collection instruments. the instruments were administered to the patients in two assessments: the first and sixth months after hospital discharge. the follow-up decision for this period was based on literature (19, 23), mentioning that around three to six months of ostomy experience are enough to develop new self-care skills, as well as a to improve adjustment gradually. open-ended questions about self-care autonomy before surgery, co-morbidities, and causal disease were assessed in the first moment. the eoas was developed for this study in two phases: • phase 1: development of the instrument. the initial version of the scale was analyzed by a committee of 25 experts for content validation and pre-tested on 20 ostomized patients. • phase 2: study of its psychometric properties. it employed a sample of 256 participants, with bowel or urinary stoma (temporary or permanent), aged 18 years or older. the eoas contains 35 items that measure six ostomy adjustment domains: self-concept, self-care, positive acceptance, negative acceptance, social/religious support, and sexual interaction, operationalized on a 7-point likert scale, ranging from 1 = strongly disagree to 7 = totally agree. fifteen items are reverse coded. in the original study, the cronbach’s alpha coefficients of the six domains were between 0.85-0.61, while the overall scale was 0.87. the results are organized in a way that generates a score for each domain and on a global scale. to identify the mean scores, we used a formula that transforms the averages obtained into scores from 0 to 100. a higher mean score corresponds to a more favorable ostomy adjustment. descriptive statistics were used with absolute frequency and percentage data of categorical variables to describe the sample profile. the calculation of position and dispersion measures (mean, standard deviation) was used for the continuous variables. to analyze the differences between the mean scores of two groups, independent sample t-test and paired sample t-test were used to analyze the effect size, with a margin of error of 5 % (p ≤ 0.05) and a confidence level of 95 % (25). all data were analyzed using spss software, version 22.0. the research was conducted according to decree-law no. 97/95 of the portuguese republic, which regulates health ethics commissions, and approved by the ethics committees of the hospitals involved. for the administration of the instruments, verbal and written consent was requested from the participants. anonymity and confidentiality of responses were ensured, and the informed consent form was provided. results in the first assessment (table 2), the cg on average was older than the ig, 63, 55 ± 10.13 years and 58, 38 ± 16.35 years, respectively. in the ig, men predominated (58.3 %) while in the cg, women did (60.6 %). most had completed the 1st cycle of basic education (ig, 77.8 % and cg, 90.9 %). most of them were retired, although 47.2 % of the ig participants and 27.3 % of cg still practiced a profession. the majority were married/cohabiting (58.3 % of the ig and 60.6 % of the cg). approximately 28 % of ig and 36 % of cg were a widow(er), separated, or divorced. no variables showed statistical differences. the members from the hospitals with snc (ig subjects) received preoperative information from both the nurse and the surgeon (100 and 97.2 %, respectively). in contrast, at hospitals without snc (cg subjects), only 12.1 % of them received information from the nurse and 66.7 % from the surgeon. regarding demographic variables, the groups were statistically equivalent (p > 0.05) in age, gender, marital status, education level, and occupation. significant differences were observed in the preoperative information. table 2. demographic characterization of the sample for the first assessment variables sample ig (n = 72) sample cg (n = 33) p-value n % n % age (years old) 0.097 18-39 11 15.3 1 3.0 40-69 39 54.1 22 66.7 ≥ 70 22 30.6 10 30.3 gender 0.071 female 30 41.7 20 60.6 male 42 58.3 13 39.4 7 effect of a stoma nursing care program on the adjustment of patients with an ostomy l clementina prazeres fernandes sousa and other variables sample ig (n = 72) sample cg (n = 33) p-value n % n % marital status 0.110 married/ cohabiting 42 58.3 20 60.6 single 10 13.9 1 3.0 separated/ divorced/ widow(er) 20 27.8 12 36.3 education 0.232 up to 4th grade 38 52.8 23 69.7 5th to 9th grade 18 25.0 7 21.2 10th to 12th grade 10 13.9 2 6.1 higher education 6 8.3 1 3.0 occupation 0.393 employee 27 37.5 6 18.2 unemployed 7 9.7 3 9.1 retired 38 52.8 24 72.7 preoperative information 0.000 nurse 72 100 4 12.1 surgeon 70 97.2 22 66.7 source: own elaboration in this data collection, concerning clinical variables (table 3), the colostomy predominated in cg (75.8 %) and in ig (50 %). most of ig subjects (62.5 %) had a permanent ostomy. in both groups, cancer was the most predominant as causal disease. the most frequent co-morbidities were hypertension, heart disease, and type 2 diabetes mellitus. before surgery, all participants were independent as to their personal hygiene, using the toilet and having meals. in the second assessment, 45.9 % of ig and a great part of the cg (68.7 %) were receiving a complementary treatment (chemotherapy or chemotherapy and radiotherapy). regarding the stoma site marking, 86.9 % of the ig subjects and 76.7 % of the cg confirmed the stoma was properly located. likewise, 65.6 % of the ig and 44 % of cg used a mirror to see the stoma. as to the complications in the ostomy and the peristomal skin area, 85 % of the ig did not mention any kind of problem, although 59.4 % of the cg did. the most referred complications by the participants of the two groups are redness/erythema (42.6 %) and stomal pain (16.2 %). table 3. clinical characterization of the sample variables sample ig (n = 72) sample cg (n = 33) p-value n % n % type of stoma 0.000 colostomy 36 50.0 25 75.8 ileostomy 22 30.6 1 3.1 urostomy 13 18.1 2 6.0 others 1 1.4 5 15.1 duration of ostomy 0.002 permanent 45 62.5 13 39.4 temporary 27 37.5 18 54.5 unknown 2 6.1 stoma site marking* 61 100 32 0.0 0.000 properly located 53 86.9 23 76.7 0.217 skin complications* 9 15.0 19 59.4 0.000 complementary treatment* 28 45.9 22 68.7 0.017 use of mirror* 40 65.6 14 43.8 0.079 * analyzed in the 2nd assessment (ig – n = 61; cg – n = 32) source: own elaboration concerning clinical variables, the groups were statistically equivalent (p > 0.05) for stoma site properly located and use of the mirror, while statistically different for duration and type of stoma, stomal and peristomal skin complication, complementary treatments, and stoma site marking. in the first assessment (first month after hospital discharge), statistically significant differences were not observed in the eoas global score; significant differences were noticed only in the social/religious support domain (t(97) = 3.121; p < 0.01), with the highest score in the control group (table 4). regarding the second assessment (the sixth month after hospital discharge), statistically significant differences were found between the two groups on the total scale (t(73) = -3.679; p = 0.000) and in four out of the six dimensions, (p < 0.01), except social/religious support and sexual interaction (table 4). 8 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2014 aquichan issn 1657-5997 eissn 2027-5374 table 4. eoas mean scores and sd by group (ig and cg) in the first and second assessments eoas domains and overall scale gr 1st assessment n = 105 ig n = 72 cg n = 33 2nd assessment n = 93 ig n = 61 cg n = 32 mean (sd) t df p-value mean (sd) t df p-value self-concept ig 45.15 (20.81) -0.146 83 0884 53.37 (13.47) 3.414 87 0.001 cg 45.84 (21.00) 43.17 (13.63) positive acceptance ig 56.89 (16.88) 0.789 102 0.432 64.37 (14.75) 3.114 91 0.002 cg 54.29 (12.54) 54.94 (11.92) negative acceptance ig 60.38 (18.64) -1.164 84 0.248 71.61 (15.50) 2.702 78 0.008 cg 65.50 (18.18) 61.92 (16.95) social/ religious support ig 70.40 (16.88) -3.121 97 0.002 67.66 (13.92) -1.220 90 0.226 cg 80.06 (11.56) 76.25 (14.40) sexual interaction ig 54.01 (14.95) -0.151 68 0.880 36.56 (13.54) -0.477 72 0.635 cg 54.60 (14.92) 38.11 (12.30) self-care ig 52.24 (16.65) 0.586 74 0.560 71.23 (19.99) 2.843 73 0.006 cg 50.00 (12.65) 53.26 (22.95) overall eoas score ig 57.70 (11.05) -0.258 67 0.797 67.07 (11.22) 3.679 73 0.000 cg 58.47 (12.12) 57.38 (10.42) source: own elaboration table 5. differences between eoas mean scores in the first and second assessments by group (ig and cg) eoas domains and overall scale ig p-value cg p-value t df t df self-concept -2.298 46 0.026 0.517 29 0.609 positive acceptance -3.166 59 0.002 -0.344 31 0.733 negative acceptance -3.852 48 0.000 0.630 23 0.535 social/religious support -2.410 54 0.019 2.022 31 0.052 sexual interaction 28.669 48 0.000 15.546 20 0.000 self-care -6.797 60 0.000 -3.328 31 0.002 overall eoas -5.076 38 0.000 0.599 19 0.556 source: own elaboration 9 effect of a stoma nursing care program on the adjustment of patients with an ostomy l clementina prazeres fernandes sousa and other between the first and second assessments (table 5), statistical differences were observed in the ig, both in the eoas (t(38) = -5.075; p < 0.001) and in its domains (negative acceptance, sexual interaction, and self-care, p < 0.001; self-concept, positive acceptance, and social/religious support, p < 0.05). it was found that sexual interaction domain deteriorated between the first and second assessments. contrariwise, the cg exhibited no significant differences between the two assessments, both in the overall scale score and in most of its domains. the stoma self-care domain was the exception; it showed statistically significant improvements between the first and the second assessments, while the sexual interaction domain, just as in the ig, worsened with significant differences in the second assessment. discussion in the first month after hospital discharge, despite the significant effects associated with the causative disease and the stoma, the psychosocial and functional adaptation to the new life circumstances was similarly perceived by and satisfactory to both groups. it is legitimate to admit that the nurses of the clinical contexts, where both ig and cg participants were hospitalized, were sensitized to the particular care for these patients, preparing them to return home. on the other hand, the belief in the self-control of the disease and the ostomy has been positively correlated with the development of autonomy in the first weeks, even without professional and specific help (16), which explains the results obtained in the cg. the expectation that the adjustment to an ostomy will be sensitive to etn care and, therefore, more favorable in the ig was not verified. the adjustment process is not easy or quick, which is a reasonable explanation for the absence of differences between both groups one month after hospital discharge. this illustrates that adjustment requires time and continued interdisciplinary care, integrating psychological aspects and support in coping with the stoma (4, 5, 14). comparing the groups six months after hospital discharge, both were different, being the adjustment to the ostomy significantly better in the ig. the differences were found both in the overall score of eoas and in its components (self-concept, positive acceptance, negative acceptance, and self-care). it is presumed, by our findings, that ig participants accepted their health condition better, had a higher self-concept, were more confident in managing their daily lives, and were more effective in the stoma self-care than the cg. searching for or provide social/religious support to solve daily life problems was similar in both groups, being the cg more active in the first month after hospital discharge. the demand for social support is widely described as one of the strongest coping strategies for facing change and challenges. it revealed to be a protection factor of the individual identity and a promoter of healthy transition, predicting a better psychosocial adjustment when people experience critical moments such as the creation of a stoma (13, 14). we cannot forget the etn intervention is a kind of social support that ig received, which is why it was attached importance by both groups. the assessment between the first and sixth month after hospital discharge showed significant improvements in the adjustment to the stoma in the intervention group. for this positive evolution, all eoas domains contributed significantly. like other studies showing the association of ostomy care autonomy with high levels of psychosocial adjustment, the adjustment is built in a complex relationship among ostomy acceptance, less discomfort and reluctance to social interaction, and more effective stoma self-care (12, 13). in the control group, the interpretation of the results did not indicate statistically significant changes in the global ostomy adjustment between the two assessments, indicating that their adaptive course was not modified from the first to the second assessments. however, the adoption of new behaviors in ostomy care management was ensured, which was significantly improving over time. sexual interaction stands out as one of the most fragile dimensions, progressively deteriorating in both groups. our results overlap previous studies, concluding that the ostomy effects on sexual life tend to persist over time. it causes great emotional suffering due to concerns for body image and deterioration or loss of the sexual function, thus influencing the way people express and live their sexuality (1, 2, 5, 8, 26-28). additionally, the impaired sexual function can derive from the surgical approach itself. in the ig, a significant percentage of patients remained with a permanent ostomy. it is known that this type of ostomy, generally associated with extensive surgeries, which can damage or remove fundamental organic structures, has transient or permanent collateral damage in sexual performance in both men and women (29). on the contrary, the temporary ostomy dominated 10 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2014 aquichan issn 1657-5997 eissn 2027-5374 the cg that, despite not having such a harmful potential on the physiological structures, suggests people opt for a break in their sexual activity until the stoma closure. moreover, the perspective of stoma closure in the near future causes individuals to over-value its reversibility and not to try to adapt. it may happen that the uncertainty about their permanence or closure can make them more vulnerable to fear, anxiety, and feelings of unhappiness, conditioning their daily lives and postponing personal projects (20, 30). another finding, six months after hospital discharge, is that there was still a considerable percentage of subjects from both the ig and the cg in the complementary treatment of chemotherapy and/or radiotherapy. the harmful effect of complementary therapy on sexuality is well known (27). the cited literature emphasizes the need for better nursing care regarding the sexuality of patients with an ostomy, not only during admission but also during continued care. it refers to a great lack of information, reinforcing the need for a better professional qualification both in the field of knowledge and in clinical competence (9, 26). cultural and age aspects are very important and should be explored (16, 30). being a very sensitive human dimension to the harmful effects of ostomy surgery, it requires an oriented and meticulous intervention by health professionals, particularly stoma nurses. it is important to note that the percentage of “no answer” in this area (16.4 % in the ig and 28.12 % cg) may have conditioned the current study findings. on the other hand, sexual function was not probed before the surgery. although the ileostomy is more frequent in the ig, peristomal skin complications prevailed in the cg. in both groups, erythema and stomal pain were the most reported, being these results confirmed by other studies (16, 31). the stomal and peristomal skin complications have a longer transition process, both because of its prevalence and severity, and may be deteriorating their comfort and well-being and consequently, their quality of life (31). based on the patients’ perceptions, the general interpretation of this study results revealed that those who received continuous and systematized stoma care since the preoperative period to the follow-up after leaving the hospital gradually showed higher levels of knowledge of and skills for stoma care, significantly improving their self-care management, social interactions, and self-concept. probably, the progressive integration of the ostomy into their daily lives improved their self-esteem and body image, positively influencing the psychosocial adjustment (14) between the first and sixth months after hospital discharge. the group that received conventional nursing care did not show evolution in their perception of ostomy adjustment. these results are similar to other studies that used a control group when observing the benefits of etn in increased stoma care proficiency and the reduction of peristomal skin complications (16, 31). by providing preoperative and follow-up information and individualized assistance, etn also increases patient’s self-confidence and autonomy, contributing to a more quickly psychosocial adjustment, compared to the group that received usual care (17, 30). it can be inferred from these results that the npet positively influenced the course of the transition for adjustment to the ostomy, being its contribution visible in the sixth month after hospital discharge. globally, healthier outcome indicators are present in ig, such as those perceived in ostomy acceptance, positive self-concept, and self-care proficiency, experiencing a comparatively more positive transition process than cg people. thus, systematized nursing therapeutics, as a complement, helped the ig to become autonomous in stoma care and better manage other life changes, promoting a healthier adjustment (14). the results of this study allowed us to better understand how some people with an ostomy interpret changes in their health and life, and how the structured and continuous nursing intervention received can influence their adjustment to the new condition. study limitations the study limitations to be considered are the small sample size and the difference in the number of subjects between the groups; no baseline since instruments were applied just after the surgery, before discharge; regarding the sexuality domain, the high rate of values not provided by the two groups, and the absence of pre-surgery data. recommendations to guarantee the reliability of the results and generalize after the study, an experimental study would be more robust. the 11 effect of a stoma nursing care program on the adjustment of patients with an ostomy l clementina prazeres fernandes sousa and other study suggests that ostomy adjustment improves significantly if patients have access to differentiated care from the preoperative period to continued care, particularly if the etn assistance is systematized in intervention protocols. outcome assessment using specific and reliable instruments is also essential. such a statement poses a challenge to the continuity of research with other designs that explore this problem from other views. conclusion it was confirmed that people who benefited from an organized and continuous etn intervention from preoperative to follow-up care experienced significant improvements in adjusting to the stoma between the first and the sixth month after hospital discharge. these improvements were significantly higher compared to those patients who did not have this intervention (cg), as they maintained improvement levels similar to those of the first assessment. as a final note, it is possible to assume that the changes and differences in the adjustment to an ostomy perceived by the intervention group compared to the control group between the first and sixth month after discharge were sensitive to the effects of the systematized etn intervention on research participants. conflict of interest: none. references 1. cesaretti iur, leite mg, fillipin mj, santos vlg. cuidando de pessoas nos períodos pré, trans e pós-operatórios de cirurgias geradoras de estomias. in: santos vlcg, cesaretti iur, editors. assistência em estomaterapia cuidando a pessoa com ostomia. 2nd ed. s. paulo: editora atheneu; 2015. isbn 978-85-388-0630-1 2. costa vf, eufrásio c, salomé gm, ferreira lm. assessing the body image and subjective wellbeing of ostomists living in brazil. gastrointestinal nursing. 2014;12(5). doi: 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an ostomy l clementina prazeres fernandes sousa and other 29. el-tawil am, nightingale p. living with stoma: long-term effects on patients’ quality of life. j clin cell immunol. 2013;4(145):1–5. doi: https://doi.org/10.4172/2155-9899.1000145 30. karabulut hk, dinç l, karadag a. effects of planned group interactions on the social adaptation of individuals with an intestinal stoma: a quantitative study. journal of clinical nursing. 2014;23(19-20):2800–13. doi: https://doi. org/10.1111/jocn.12541 31. pittman ja. ostomy complications and associated risk factors: development and testing of two instruments [dissertation]. indiana university; 2011 [cited 2019 nov 08]. available from: https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://doi.org/10.4172/2155-9899.1000145 https://doi.org/10.4172/2155-9899.1000145 https://doi.org/10.4172/2155-9899.1000145 https://doi.org/10.4172/2155-9899.1000145 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https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 https://pdfs.semanticscholar.org/2e6d/dfc3971afd3025c13b60f150a57811618564.pdf?_ga=2.19417656.1043655915.1573247262-717770295.1560791991 nursing care for people with chronic diseases and pulmonary infection by coronavirus: an integrative review article nursing care for people with chronic diseases and pulmonary infection by coronavirus: an integrative review* cuidados en enfermería a personas con enfermedades crónicas e infección pulmonar por coronavirus: revisión integrativa** cuidados de enfermagem para pessoas com doenças crônicas e infecção pulmonar por coronavírus: revisão integrativa*** 10.5294/aqui.2021.21.2.2 jina mariont velasco arias1 maria de fátima mantovani2 robson giovani paes3 vanessa bertoglio comassetto antunes de oliveira4 vanêssa piccinin paz5 adelmo fernandes do espírito santo neto6 1 0000-0001-8371-7581. universidade federal do paraná, brasil. jina.velasco@ufpr.br 2 0000-0001-7961-8273. universidade federal do paraná, brasil. mfatimamantovani@ufpr.br 3 0000-0001-6899-4054. universidade federal do paraná, brasil. robson.paes@ufpr.br 4 0000-0001-9140-2715. universidade federal do paraná, brasil. vanessacomassetto@ufpr.br 5 0000-0001-7157-4886. universidade federal do paraná, brasil. vanessa.piccinin@ufpr.br 6 0000-0001-5182-1843. universidade federal do paraná, brasil. adelmo.fernandes@ufpr.br * this article derives from the first elaboration stage of the master’s dissertation entitled “nursing intervention for patients with chronic pulmonary diseases infected with covid-19”, presented to the graduate nursing in program at universidade federal do paraná, and is part of a larger research project entitled “chronic disease and education in health: multiple approaches to nursing in self-management of care”. ** el artículo se deriva de la primera etapa de la tesis de maestría titulada “intervención de enfermería para pacientes con enfermedades crónicas pulmonares infectados con covid-19”, presentada al programa de posgrado en enfermería de la universidade federal do paraná, brasil, y es parte de un proyecto de investigación más amplio denominado “enfermedad crónica y educación en salud: múltiples enfoques para enfermería en la autogestión del cuidado”. *** este artigo é derivado da primeira etapa da construção da dissertação de mestrado intitulada “intervenção de enfermagem para pacientes com doenças crônicas pulmonares infectados com covid-19”, apresentada ao programa de pós-graduação em enfermagem da universidade federal do paraná, e faz parte de um projeto de pesquisa maior, denominado “doença crônica e educação em saúde: múltiplas abordagens para enfermagem na autogestão do cuidado”. received: 10/08/2020 sent to peers: 31/08/2020 approved by peers: 30/04/2021 accepted: 10/05/2021 theme: evidence-based practice. contribution to the subject: this integrative review contributes scientific evidence derived from research studies developed during other pandemics due to the virus of the coronaviridae family. this allows establishing nursing actions for the care of adults with chronic conditions and pulmonary infection related to coronavirus. the search for evidence is the path that will bring about advances for the nursing practice; thus, the care and guidelines proposed at the community, hospital and advanced care levels are fundamental for the prevention and control of pandemics, to contribute to the elaboration of protocols that optimize health management in contexts of the health crisis, ensuring effective and protective care to the population. to reference this article / para citar este artigo / para citar este artículo: arias jmv, mantovani mf, paes rg, oliveira vbca, paz vp, santos-neto afe. nursing care for people with chronic diseases and pulmonary infection by coronavirus: an integrative review. aquichan. 2021;21(2):e2122. doi: https://doi.org/10.5294/aqui.2021.21.2.2 abstract objective: to identify the implications, for nursing, of pulmonary infections by coronavirus in people with chronic non-communicable diseases and to propose actions for care. materials and method: a literature review, with a search for primary studies in the biblioteca regional virtual de saúde, cumulative index to nursing and allied health literature, national library of medicine and scopus databases, from march 15th to march 30th, 2020, in portuguese, english, and spanish, with a quantitative and qualitative approach, in adults with chronic non-communicable diseases with respiratory infection by viruses of the coronavirus family, from 2010 to 2020. results: a total of 11 articles were analyzed, which made it possible to identify guidelines for nursing actions at the community and hospital levels and in critical care; among the care actions proposed for people with chronic diseases are education in health, encouragement to control the disease, immunization and lifestyle change, monitoring of suspected and confirmed cases, and use of masks in public environments. conclusions: the study highlights the role of nursing at all health care levels and the possibilities for learning and improving care actions through the use of evidence obtained from previous experiences. keywords (source decs): nursing care; chronic disease; practice guideline; respiratory tract infections; coronavirus infections. resumen objetivo: identificar las implicaciones para la enfermería de las infecciones pulmonares por coronavirus en personas con enfermedades crónicas no transmisibles y plantear acciones para el cuidado. materiales y método: revisión de literatura desde la búsqueda de los estudios primarios en las bases de datos de la biblioteca regional virtual en salud, cumulative index to nursing and allied health literature, national library of medicine e scopus, del 15 al 30 de marzo del 2020, en portugués, inglés y español, con enfoque cuantitativo y cualitativo en adultos con enfermedades crónicas no transmisibles con infección respiratoria por virus de la familia del coronavírus, del 2010 al 2020. resultados: se analizaron 11 artículos que posibilitaron identificar directrices para las acciones de enfermería en los niveles comunitario y hospitalario, y en los cuidados críticos; entre los cuidados propuestos para las personas con enfermedades crónicas están la educación en salud, el fomento al control de la enfermedad, la inmunización y el cambio de estilo de vida, el monitoreo de casos sospechosos y confirmados, el uso de tapabocas en ambientes colectivos. conclusiones: se destaca el rol de la enfermería en todos los niveles de atención en salud y las posibilidades de aprendizaje y perfeccionamiento de las acciones de cuidado mediante la utilización de evidencias obtenidas en experiencia anterior. palabras clave (fuente decs): cuidado en enfermería; enfermedad crónica; guía de práctica clínica; infecciones respiratorias; infecciones por coronavirus. resumo objetivo: identificar as implicações para a enfermagem das infecções pulmonares por coronavírus nas pessoas com doenças crônicas não transmissíveis e propor ações para o cuidado. materiais e método: revisão de literatura, com busca dos estudos primários nas bases de dados da biblioteca regional virtual de saúde, cumulative index to nursing and allied health literature, national library of medicine e scopus, de 15 a 30 de março de 2020, em português, inglês e espanhol, com abordagem quantitativa e qualitativa em adultos com doenças crônicas não transmissíveis com infecção respiratória por vírus da família do coronavírus, de 2010 a 2020. resultados: analisaram-se 11 artigos que possibilitaram identificar diretrizes para as ações de enfermagem nos níveis comunitário e hospitalar, e nos cuidados críticos; entre os cuidados propostos para as pessoas com doenças crônicas, estão a educação em saúde, o incentivo ao controle da doença, a imunização e a mudança do estilo de vida, o monitoramento de casos suspeitos e confirmados, o uso de máscaras em ambientes coletivos. conclusões: destaca-se o papel da enfermagem em todos os níveis de atendimento da saúde e as possibilidades de aprendizagem e aperfeiçoamento das ações de cuidado mediante a utilização de evidências obtidas em experiência anterior. palavras-chave (fonte decs): cuidado de enfermagem; doença crônica; guia de prática clínica; infecções respiratórias; infecções por coronavírus. introduction the new infection by coronavirus, severe acute respiratory syndrome (sars-cov-2), was described for the first time in december 2019 in the city of wuhan, china (1, 2). the world health organization called this disease “covid-19”, which is highly contagious, mainly because it presents aerosols (coughing or sneezing) from symptomatic or asymptomatic infected people as a form of transmission (3). sars-cov-2 belongs to the coronaviridae family, composed of single-stranded rna viruses that cause respiratory infections, which can vary from mild catarrhal symptoms to severe pneumonia (4). in addition to sars-cov-2, six other types of coronavirus infect  human beings, four of which cause minor respiratory infections (229e, oc43, nl63 and hku1) and two causing epidemics (sars-cov and the middle east respiratory syndrome coronavirus: mers-cov) (5, 6). the symptoms of infections by coronavirus are non-specific, but they include fever, dry cough, myalgia, fatigue and dyspnea (2, 7), which can lead to severe hypoxemia requiring mechanical ventilation in up to 20 % of the cases (7), as the virus binds to the angiotensin-converting enzyme 2 (ace-2r) in human beings with greater affinity in the respiratory system (8); however, it can affect other organs, such as the stomach, small intestine, kidney, adrenal glands, skin, parathyroid glands, heart, brain, liver and pancreas. this is due to the presence of ace-2r in these organs, but with a lower density compared to the respiratory system (9). mortality in infections by coronavirus is associated with age (generally people over 60 years old) and with the presence of chronic non-communicable diseases (cncds), with emphasis on systemic arterial hypertension (sah), cardiovascular diseases, diabetes mellitus (dm) and chronic lung and kidney diseases; in addition, the presence of two or more comorbidities increases the mortality rates (10, 11). the sars-cov pandemic in 2002 spread to 29 countries, lasting seven months, with 8,000 cases and a mortality rate of 10 %; while mers-cov in 2012 was detected in 27 countries, with approximately 2,500 cases and a mortality rate of 37 % (12). in sars-cov-2 in china, the reported mortality rate was 2.3 %, with no deaths in children under nine years old and 21 % occurring in individuals over 70 years old, of whom 10.5 % had some cardiovascular disease, 7.3 % had dm, 6.3 % had some chronic respiratory disease, 6 % had sah and 5.6 % had cancer (13). until the date of this study, there is not enough evidence to determine the effectiveness of treatments for covid-19, although therapies used in previous pandemics with viruses from this same family are being tested, such as speculations on hydroxychloroquine, ritonavir, lopinavir, favipiravir, arbidol (umifenovir), oseltamivir, interferon and immunoglobulins, in the hope of finding an antigen against the disease (14). thus, the fundamental role of nursing in the care of people with cncds infected by coronavirus is unquestionable, which should be focused on the support of self-care, monitoring, follow-up and advanced care (15). considering the magnitude of the infections by coronavirus, the previous experiences with viruses from this family, the possibilities, the strengthening and the knowledge about the preparation to care for the health of people with cncds, this review aims at identifying the implications, for nursing, of pulmonary infections by coronavirus in people with cncds and to propose actions for care. materials and method review studies allow identifying the general perspective of a given subject matter, as well as the levels of evidence and the strength of the recommendations for applicability in the clinical practice (16). therefore, this study adapts to this type of review as it provides the basis for reflections and recommendations for the nursing practice. in this sense, this is an integrative review based on five stages. in the first stage, the guiding question was elaborated based on the pic acronym, where “p” is population (people with chronic diseases), “i” is intervention (nursing care) and “c” is context (pulmonary infections by coronavirus). thus, the following question was formulated: what are the implications for nursing care that can be obtained from the literature on pulmonary infections by coronavirus in people with cncds in the last 10 years? the search for studies took place between march 15th and march 30th, 2020, in biblioteca regional virtual de saúde (bvs), based on the following descriptors and boolean operators: “doença crônica” and “infecções respiratórias” and “coronavirus humano 229e ” or “coronavirus humano nl63 ” or “coronavirus humano oc43 ”, and with the following search strategy: “chronic disease” and “respiratory tract infections” and “coronavirus oc43, human” or “coronavirus nl63, human” or “coronavirus 229e, human” in the cumulative index to nursing and allied health literature (cinahl), national library of medicine (pubmed), scopus and web of science databases. a second search was conducted in the same databases and in the same period, with the following strategies: “doença crônica” and “infecções respiratórias” and “coronavírus humano 229e” or “coronavírus humano nl63” or “coronavírus humano oc43” and “cuidados de enfermagem” and “chronic disease” and “respiratory tract infections” and “coronavirus oc43, human” or “coronavirus nl63, human” or “coronavirus 229e, human” and “nursing care” (cart 1). the inclusion criteria for the articles were observational, cohort, cross-sectional, case-control, quantitative, and qualitative studies; adults with chronic non-communicable diseases with respiratory infection by viruses of the coronavirus family; published from 2010 to 2020, in portuguese, english and spanish, and available in full. systematic, integrative, narrative and scoping reviews or mini-studies were excluded, as well as consensus and letters to the editor. table 1: search strategies to select the studies portal/databases strategy number of articles bvs “doença crônica” and “infecções respiratórias” and “coronavírus humano 229e” or “coronavírus humano nl63” or “coronavírus humano oc43” 214 “doença crônica” and “infecções respiratórias” and “coronavírus humano 229e” or “coronavírus humano nl63” or “coronavírus humano oc43” and “cuidados de enfermagem” 0 cinahl, scopus and web of science “chronic disease” and “respiratory tract infections” and “coronavirus oc43, human” or “coronavirus nl63, human” or “coronavirus 229e, human” 703 “chronic disease” and “respiratory tract infections” and “coronavirus oc43, human” or “coronavirus nl63, human” or “coronavirus 229e, human” and “nursing care” 1,501 pubmed “chronic disease” [mesh] and “respiratory tract infections” [mesh] and “coronavirus oc43, human” [mesh] or “coronavirus nl63, human” [mesh] or “coronavirus 229e, human” [mesh] 166 “chronic disease” [mesh] and “respiratory tract infections” [mesh] and “coronavirus oc43, human” [mesh] or “coronavirus nl63, human” [mesh] or “coronavirus 229e, human” [mesh] 0 source: own elaboration based on research data. in the second stage, the duplicate articles were removed, the filters were applied, and a full reading of the titles and abstracts was performed, considering the eligibility criteria. a total of 26 articles remained for full-reading, of which 11 comprised the final sample, presented in the preferred reporting systematic reviews and meta-analyses of studies (prisma) flowchart (figure 1) (17). figure 1. flowchart corresponding to the identification, selection and inclusion of the studies, prepared based on the prisma recommendation. source: own elaboration based on research data. in the third stage, the data were collected and analyzed at two moments. at the first moment, the authors, year and place of the study, sample number, main results and level of evidence were verified according to the oxford center for evidence-based medicine (18); secondly, categories inferred from the main results were elaborated for nursing care directioning and actions. in the fourth stage, the actions were separated into three levels: community care, hospital care and advanced care; the ones classified at the community level are those likely to be carried out in primary care, related to human resources, care for registered users and preventive training in the community; the actions at the hospital level by the nursing team are the following: training, communication, diagnostic aid, and care according to the new guidelines and protocols for the treatment of infections by coronavirus; the third level is aimed at advanced care, such as training and using the best evidence in health care. in the fifth stage, the care proposals were discussed with the current parameters established by the competent authorities for the management of covid-19, in the search of possibilities for effective and safe nursing care at all assistance levels, as a contribution to the health and nursing practice. results the selected studies were retrospective, observational, prospective and case studies, with a quantitative approach; seven of them were from saudi arabia, three were from the united states and one was from south korea, all in english with levels of evidence 2b, 2c and 4; none mentioned nursing actions or care. regarding the prevalence of cncds, eight of the nine studies that addressed infection by the mers-cov strain reported sah and dm; the other studies reported prevalence of chronic respiratory and cardiac diseases with infections by oc43 and 229e strains. however, it is not possible to establish a causal relationship of dm and sah as risk factors, because they are also the two most prevalent comorbidities in the world (19). the most reported symptoms in mers-cov infections were fever, cough and dyspnea; while in the other strains, there was a predominance of nasal congestion and runny nose. it is to be noted that the male gender was predominant and, also, the age group between 30 and 70 years old, among the infected individuals. the mortality rates in the intensive care unit (icu) exceeded 70 % for mers-cov, affecting more men than women, aged between 50 and 70 years old. the non-survivors were longer-lived older adults, obtained higher scores in the acute physiology and chronic health disease classification system ii (apache ii) and in the sequential organ failure assessment score (sofa), and were prone to invasive mechanical ventilation interventions and vasopressor therapies at admission. chart 2 presents the results of the analysis of the articles and the care proposals, separated by the three proposed action levels: community care, hospital care and advanced care. table 2: results of the articles and of the proposals of nursing actions for the clinical practice level authors, years, place of publication and level of evidence directioning nursing actions means community care alraddadi et al., 2016, saudi arabia (20), level of evidence 2b kim et al., 2016, south korea (21), level of evidence 2b risk prevention and control diagnostic aid health promotion education in health and self-management life habits environment encouraging the prevention of vaccine-preventable diseases training for the primary care health professionals to identify suspected or confirmed cases of infection by coronavirus, based on the criteria and on the operational definitions for covid-19 in frequent updates by the competent bodies. to assess community factors for the transmission chain: life habits, schooling, stereotypes and hereditary diseases, among others. to encourage people with cncds to follow the preventive respiratory measures related to vaccine-preventable diseases: education in health, vaccination, lifestyle change and treatment adherence. to inform the community about infection prevention, such as the importance of social isolation. to prepare for situations of catastrophes with dimensioning of personnel, space, supplies and service flow with referral and counter-referral. to identify possible limitations or barriers in access to health, evaluating the existing family health management programs, mainly verifying the mapping of older adults, pregnant and puerperal women, to provide them with care by means of telemedicine and telenursing. to conduct training and qualification of health professionals and the community, to improve sanitary practices in public environments with 70 % alcohol supply, encouraging hand washing. continuing education for the professionals. teamwork. adequate human, material and physical resources. education in health for the community according to the needs resulting from the emergent diseases. hospital care walsh et al., 2013, united states (22), level of evidence 2b gorse et al., 2015, united states (23), level of evidence 2b kim et al., 2016, south korea (21), level of evidence 2b amer et al., 2018, saudi arabia (24), level of evidence 4 alqahtani et al., 2019, saudi arabia (10), level of evidence 2b al-abdely et al., 2019, saudi arabia (25), level of evidence 2c diagnostic aid treatment aid training for the health professionals access to the health service/ network, management in health and public health mental health to guide the support and welcoming team regarding the signs and symptoms of respiratory diseases, to indicate the use of masks from the main entrance of the hospital institution. to carry out screening, with initial anamnesis focused on prioritizing the main topics to identify the respiratory disease caused by the coronavirus, such as asking about travels to countries where there is local transmission, contact with suspected or confirmed cases, age (with relevance to greater risk of the severe form in older adults), people with immunological impairment, comorbidities (sah, types 1 and 2 dm, heart disease, kidney disease and lung disease). to identify and investigate, in people with cncds, signs and clinical complaints reported, time and duration, to seek information from previous appointments in the medical record to survey situations of uncontrolled diseases. to use the isolation protocol provided for in the screening room in the care for communicable respiratory diseases. to identify and prevent adverse events, with reorientation of flow, staff, supplies, space and time in the cases of respiratory disease caused by the coronavirus, from the initial approach to the outcome of the case in discharge for any type. to monitor signs and symptoms of respiratory complications, performing daily physical examinations or through clinical involution, aimed at recording the clinical signs, such as current and past temperature using a daily map, cardiac and respiratory rates together with the findings, systemic blood pressure, peripheral capillary perfusion, central and peripheral pulses, use of accessory muscles, presence of cyanosis, pulmonary auscultation and its findings. to guide the family members and other professionals about the care for infection prevention, restricting access or the number of visitors per bed; to provide the family members with access to the patient’s information through health status reports following the institution’s protocol. to use tools to assess the risk of complications through nursing diagnoses and interventions, aimed at the cases of respiratory diseases caused by coronaviruses, such as risk of shock, multiparametric monitoring and standard precautions, droplets and aerosols. to identify suspected or confirmed cases of infection by coronavirus and to appropriately isolate the cases through multidisciplinary screening, as well as evaluation of exams according to the existing clinical protocol. to encourage the proper use of personal protective equipment (ppe: gloves, masks, aprons, goggles and others) for professionals, patients and family members. to conduct training sessions for the health professionals, to improve hospital practices. to ensure the proper collection, handling and transportation of the diagnostic samples, defining the management of the responsibilities of each professional. environmental hygiene, enabling effective communication between the general service professionals and the nursing team about the accommodation and transport of patients with respiratory disease caused by the coronavirus. to prevent and identify psychological or emotional changes in the patient, to provide quality dialog between the professionals and the patient, promoting the effective participation of the psychology team. to prevent adverse events and complications. to pay attention to the humanization of care. evidence-based practices. use of guidelines, bundles and protocols specific to the institution and based on scientific evidence for the care of patients infected with coronavirus. continuing education for health professionals. adequate human, material and physical resources. to promote effective communication within the team. advanced care arabi et al., 2014, united states (26), level of evidence 4 lmekhlafi et al., 2016, saudi arabia (27), level of evidence 2b ko et al., 2016, saudi arabia (28), level of evidence 2b garout et al., 2018, saudi arabia (29), level of evidence 2b constant monitoring of the patient, the team, and the environment training in advanced care for the health professionals diagnostic aid treatment aid to provide advanced nursing care, according to the legislation in force. to prevent adverse events and complications. to articulate the team members in the provision of care. to use risk assessment tools for complications. to use techniques to improve the respiratory conditions, to meet the care needs in all systems and to prioritize humanization of care. to ensure adequate collection, handling and transportation of the diagnosis samples. to provide guidelines for waste management. to monitor the patient’s vital signs, level of consciousness and nutrition. advanced nursing practices based on scientific evidence (application and training). source: own elaboration based on research data. discussion the actions proposed for the community level by the study carried out in saudi arabia are related to the definition of the probable case as one that has an inconclusive laboratory result, and that of a confirmed case of infection by a conclusive laboratory test, regardless of symptoms. the possible actions and responsibilities of the nursing staff at the community level are the identification of suspected cases of infection by coronavirus, based on the operational definition criteria for infections by this virus, similar to those currently established by the ministry of health and by competent bodies for covid-19, defining as suspected cases those with fever, at least one respiratory symptom, and with a history of travel to areas with local transmission in the last 14 days or contact with a suspected or confirmed case of coronavirus in the same period (20, 30). the brazilian ministry of health, the national health surveillance agency (agência nacional de vigilância sanitária, anvisa) and the brazilian association of professionals in infection control and hospital epidemiology have established the following as possible nursing actions in the community: assessment of the life habits, underlying diseases and other factors that influence transmission; promotion of education and preventive measures in health, immunization, lifestyle changes and treatment adherence, especially for people with cncds; it is also noteworthy to identify the limitations in access to the health services, mainly in the aged population and pregnant and puerperal women, cases in which telemedicine and telenursing can be promoted (30-32). in this sense, we considered that, in addition to the above, nursing must include strengthening of education in health for the community, since the population is informed through the social networks, which, on many occasions, publish false data, which contributes to misinformation, causing anxiety and other psychiatric disorders associated with pandemics (33). in brazil, there has been an increase in the telenursing activities to assist the community with information related to the covid-19 pandemic (34); however, it becomes necessary to encourage universities and other educational institutions to lead the community to carry out practices based on current scientific evidence. it is also imperative to establish guidelines for home care after hospital discharge of the infected people: such care includes verification of the home environment, to ensure care and compliance with the preventive measures so that other people are not contaminated (hand hygiene, respiratory hygiene with the use of tissues or disposable paper and environmental cleaning); assessment of the possible environmental safety problems (places with risk of falls, presence of children in the house, airy and ventilated environments); and provision of health education support for the person and his/her caregivers (35). in a study on the lessons learned from covid-19, the authors indicated that the most important measures to slow down the spread of respiratory viruses in the community include closing mass meeting places (schools, libraries, shopping malls and cinemas), suspending all social events (sports, celebrations and meetings) and temperature screening at airports, bus stations and entrances to hospitals, banks or courts (36). in turn, concerning care at the hospital level, aged individuals and/or people with comorbidities infected by coronavirus must be prioritized, given the higher rate of complications and mortality in this population (10, 22, 23, 25). the main deficits that led to viral spread during previous coronavirus pandemics were reported, namely: late diagnosis, lack of isolation of suspected cases, lack of regulation of family visits, lack of facilities and equipment necessary for care, overcrowded emergency rooms with inadequate ventilation, problems with the screening systems, and lack of education on the infection control practices among the health professionals (21, 24). corroborating the reflections of this review regarding nursing care, other studies highlight the actions at the hospital level, such as guidelines for the team regarding the infection signs and symptoms; correct use of masks and other ppe (gloves and goggles) from the moment they enter the health service, screening of the suspected cases, especially older adults, people with comorbidities and/or immunocompromised patients; the protocol for the isolation of suspected cases at admission; identification and prevention of adverse events through risk management with adequate equipment, supplies, space and time to deal with the cases; constant monitoring of vital signs; and recording of the clinical evolution (37). the guidelines to family members and health professionals about the care and preventive measures for the infection are directed towards the restrictions on the number of visitors, correct hand washing and use of ppe. the professionals are encouraged to appropriately collect, handle and transport the samples for diagnostic confirmation, as well as to periodically ensure environmental hygiene with appropriate disinfectants, as the virus permanence time on surfaces can reach 72 hours; as well as to prevent and identify possible psychological and emotional crises in the people assisted or their family members, articulating the effective participation of the psychology team (30). for the control and treatment of covid-19, the ministry of health emphasizes the provision of masks, alcohol dispensers (in gel or solution) and other means for handwashing when entering the institution. the importance of keeping the environments ventilated and disinfecting surfaces and equipment used in care is also highlighted. in the case of transfers, the reference center must be notified in advance about the conditions and status of the suspected or confirmed case, to provide private environments with adequate ventilation and isolation (30). the anvisa recommends other preventive measures for viral transmission by coronavirus, which were not identified in the articles included in this review, namely: use of cloth masks for asymptomatic people and of surgical masks for symptomatic people and health professionals throughout their stay in the institution; and distance of at least one meter between individuals. emphasis is added to the implementation of diagnostic protocols, special care and isolation, which allow for the early identification and proper management of suspected covid-19 cases, as well as a contingency plan with actions that are necessary to face critical situations in the health services (32). pandemics require a nursing leadership that distributes roles and maintains effective communication with the multidisciplinary team. this is because education on infection control practices among health professionals is a fundamental aspect in the preparation for public health crises, in which it is urgent that everyone knows and enforces the national guidelines in a coordinated manner, adapted to the institutional conditions for adequate assistance (21). regarding care in the icu, it is highlighted that the complications due to infections by coronavirus are associated with multiple organ failure and occur mainly in men, older adults and with comorbidities; among the frequently reported are sah, dm and kidney failure (38, 39). in these cases, the recommendations were use of corticosteroids, strict monitoring of biochemical parameters for renal replacement therapy, individual isolation within the icu and adequate mechanical ventilation adjustments, monitoring using laboratory tests for diagnostic and prognostic parameters, maintaining strict hand hygiene measures, environmental disinfection, and continuous monitoring of the vital signs (26-29). it is considered that the possible nursing actions in the advanced care required in the icu are articulation and actions together with the members of the health team, correct management of contact isolation, prevention of adverse events with the use of tools to assess risks, continuous monitoring and vital signs records, guidance to the team members on the correct use of ppe, as well as the removal and disinfection of reusable equipment and the disposal of others (40). conserning the measures to be adopted in the hospital environments to prevent and/or reduce transmission of respiratory infections by coronavirus, isolation for at least 14 days is indicated among those infected, as well as scheduled discharge after two negative reverse transcription polymerase chain reaction (rt-pcr) tests, with an interval of at least 24 hours and/or resolution of fever and respiratory symptoms in the last 72 hours (31, 41). consequently, it becomes fundamental that the health professionals, mainly nurses, are trained and qualified to manage the challenges imposed by the disease. the training and qualification of nurses must follow the current technological evolution worldwide. this trend can provide opportunities for the use of advanced resources and improve knowledge and reasoning for the care practice (42), such as clinical simulation, which enables the representation of a real event to practice, learn and safely assess the care provided. among the advantages of this method is the reduction in the time needed to develop skills, considering that the training can be repeated as many times as necessary, in addition to stimulating clinical reasoning, leadership skills, teamwork and the development of skills for advanced nursing practices based on scientific evidence (43, 44). the need to implement evidence-based nursing practices is highlighted, which is a clinical decision-making process grounded on the best available evidence, based on research, clinical experience, preferences of the person assisted and available resources, to improve quality of care (45). the advanced nursing practices supported by evidence-based practices must be applied in the care of people infected by coronavirus in icus. the prone position has been a technique used since the 1970s, to increse arterial oxygenation, redistributing pleural pressures to make lung volumes more homogeneous, and improving alveolar recruitment in the collapsed dorsal areas. in the covid-19 pandemic scenario, this technique has been used in severe cases of acute respiratory infection by sars-cov-2 and as a prior protective measure (46, 47). nurses must minimize the risks of the prone position by managing and preventing problems, such as loss or obstruction of the tracheal tube, severe hypotension, bradycardia and desaturation associated with fluid movement and changes in the intrathoracic pressure, pressure ulcers, corneal ulcers, facial, eyelid or conjunctival edema, regurgitation or intolerance to enteral nutrition, muscle spasms and brachial plexus injury (46). in nursing care in the icu, attention to the basic hygiene needs and to the comfort of the people assisted must be considered, which should be established in a joint and orderly manner with the multidisciplinary team, within the person’s clinical conditions and, if possible, it represents the opportunity for nurses to identify systemic disorders, especially of the skin. during these procedures, there must be continuous monitoring to recognize any change in the vital signs and to prevent or minimize the adverse events (48). in addition to advanced care and prevention of complications, humanized care and psychological monitoring of the infected people and their family members must be considered. the professionals can facilitate communication through virtual technologies and phone calls, keeping current and accurate information on the clinical conditions, respecting the family values and beliefs, understanding people’s fears, anxieties and uncertainties in the context of the pandemic (49, 50). in this sense, it becomes important to provide care for people with no expectations of cure, such as the use of analgesics to relieve pain and discomfort, personal hygiene and minimizing adverse events. clarity, ethics and decision-making together with the family members are highlighted, respecting the acceptance time and providing them with emotional support (51). the limitations of this study include the dates proposed for searching the articles, the difficulty in finding guidelines for nursing care in the literature, the reduced number of articles that met the inclusion criteria and were selected for the final analysis, the scarce literature found on coronavirus strains other than those that cause mers-cov, and the research period of the articles used (from 2010 to 2020), considering that the reports of pandemics by coronavirus strains date back to the beginning of the present millennium. conclusions the results of this article highlight the need for evidence to guide health and nursing professionals in dealing with emergency public health situations. the previous sars-cov and mers-cov pandemics offered clues to control and optimize the care of people infected by these viruses, although this knowledge was not widespread in many countries. the absence of guidelines for care leads to inappropriate solutions, unsafe practices, and mass spread of the disease. undoubtedly, evidence-based attitudes and practices strengthen and encourage the health team in the fight against pandemics. for this reason, the continuous education of the health and nursing teams, the establishment of protocols, workflows and standardized instructions and prevention and control measures for the community with good levels of evidence are important to ensure life and environmental control with the reduction of transmissibility, complications and death caused by the disease, with the guarantee of ethical and quality care. conflict of interests: none declared. references 1. trujillo chs. consenso colombiano de atención, diagnóstico y manejo de la infección por sars-cov-2/covid-19 en establecimientos de atención de la salud: recomendaciones basadas en consenso de expertos e informadas en la evidencia. 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jackson d, bradbury-jones c, baptiste d, gelling l, morin k, neville s, smith gd. life in the pandemic: some reflections on nursing in the context of covid-19. journal of clinical nursing. 2020;29:2041-3. doi: https://doi.org/10.1111/jocn.15257 41. arcêncio l, rocha ds, aparecida c. covid 19: cuidados em pessoas com doenças respiratórias crônicas. laboratório de pesquisa em fisioterapia cardiovascular e respiratória da ufsc (lacor), hospital regional de araranguá, 2020. disponível em: https://noticias.paginas.ufsc.br/files/2020/04/covid-19_-cuidados-em-pessoas-com-doen%c3%a7as-respirat%c3%b3rias-cr%c3%b4nicas.pdf 42. klijn tp. enfermería y globalización. ciencia y enfermería. 2010;16(1):9-15. doi: http://dx.doi.org/10.4067/s0717-95532010000100002 43. rodriguez lj, agea jld, lapuente mlp, costa cl, rojo ar, pérez pe. la simulación clínica como herramienta pedagógica. percepción de los alumnos de grado en enfermería en la ucam (universidad católica san antonio de murcia). enfermería 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failure due to covid-19 (pron-covid): a prospective cohort study. the lancet respiratory medicine. 2020. doi: https://doi.org/10.1016/s2213-2600(20)30268-x 48. nieto pérez or, lópez eiz, gutiérrez mag, orozco rs, uribe aff, fermín jl et al. protocolo de manejo para la infección por covid-19. medicina critica. 2020;34(1): 43-52. doi: https://dx.doi.org/10.35366/93280 49. zwielewski g, oltramari g, santos ars, nicolazzi ems, moura ja, schlindwein-zanini r et al. protolocos para tratamento psicológico em pandemias: as demandas em saúde mental produzidas pela covid-19. revista debates in psychiatry-ahead of print, 2020. disponível em: http://www.hu.ufsc.br/setores/neuropsicologia/wp-content/uploads/sites/25/2015/02/protocolos-psic-em-pandemias-covid-final.pdf 50. ornell f, schuch jb, sordi ao, kessler fhp. pandemia de medo e covid-19: impacto na saúde mental e possíveis estratégicas. revista debates in psychiatry. 2020. disponível em: https://www.researchgate.net/publication/340442412 51. velarde-garcía jf, luengo-gonzález r, gonzález-hervías r, gonzález-cervantes s, álvarez-embarba b, palacios-ceña d. dificultades para ofrecer cuidados al final de la vida en las unidades de cuidados intensivos. la perspectiva de enfermería. gaceta sanitaria. 2017;31(4):299-304. doi: https://doi.org/10.1016/j.gaceta.2016.11.006 home influence of life habits and behaviors on the health of adolescents article influence of life habits and behaviors on the health of adolescents a influencia de los hábitos y comportamientos de vida en la salud de los adolescentes b influência de hábitos de vida e comportamentos na saúde de adolescentes c eloisa da fonseca rodrigues 1 giovana calcagno gomes 2 luciano garcia lourenção 3 aline campelo pintanel 4 simone quadros alvarez 5 adriane maria netto de oliveira 6 1 0000-0002-5052-4086. universidade federal do rio grande, brazil. eloisa.rodrigues@furg.br 2 0000-0002-2464-1537. universidade federal do rio grande, brazil. giovanacalcagno@furg.br 3 0000-0002-1240-4702. universidade federal do rio grande, brazil. lucianogarcia@furg.br 4 0000-0002-5076-8902. universidade federal do rio grande, brazil. acpintanel@furg.br 5 0000-0002-0501-7202. serviço nacional de aprendizagem comercial, brazil. simone.quadros@senacrs.com.br 6 0000-0001-9422-423x. universidade federal do rio grande, brazil. adrianemnoliveira@furg.br a article developed from the doctoral thesis titled "influencia del contexto socioambiental para el desarrollo de conductas de riesgo a la salud", from the postgraduate program in nursing of the universidade federal do rio grande, brazil. b artículo desarrollado desde la tesis de doctorado titulada "influencia del contexto socioambiental para el desarrollo de conductas de riesgo a la salud", adscrita al programa de posgrado en enfermería de la universidade federal do rio grande, brasil. c artigo desenvolvido a partir da tese de doutorado intitulada "influência do contexto socioambiental para o desenvolvimento de comportamentos de risco à saúde na adolescência", vinculada ao programa de pós-graduação em enfermagem da universidade federal do rio grande, rio grande do sul, brasil. 10.5294/aqui.2020.20.4.7 received: 08/05/2020 sent to peers: 29/06/2020 approved by peers: 02/07/2020 accepted: 28/07/2020 theme: promotion and prevention. contribution to the subject: the contribution to the new disciplinary knowledge of this research comes from the fact that, in the process of developing this work, we realized the importance of nursing performance in school spaces to promote and protect the adolescents' health, with actions that address from monitoring of vital signs, and growth and physical development, to health education for disease prevention. due to their scientific training and expertise, nurses can trigger health education actions in schools, taking specific knowledge from the health area, promoting, together with adolescents, reflections on the self-care process, health concepts, risk behaviors and healthy behaviors. to reference this article / para citar este artículo / para citar este artigo: rodrigues ef, gomes gc, lourenção lg, pintanel ac, alvarez sq, oliveira amn de. influence of life habits and behaviors on the health of adolescents. aquichan. 2020;20(4):e2047. doi: https://doi.org/10.5294/aqui.2020.20.4.7 abstract objective: to identify the influence of life habits and behaviors on the health of adolescents. materials and method: this is a quantitative research, with an exploratory and descriptive approach, developed with 124 adolescents, students from a pre-professional school in southernmost brazil. data was collected by means of a questionnaire. the analysis was performed using descriptive statistics by means of the spss software, version 20.0. results: the high consumption of ultra-processed food in intermediate meals and insufficient sleep hours per night cause risks to the health of adolescents. practicing physical activities has proved to be a health protection habit. conclusions: the adolescents need to reframe the importance of healthy eating and sleep in their routine. it was observed that there are modifiable factors for sleep improvement in quality and quantity, as well as the value and inclusion of in natura food in intermediate meals. we believe that the role of nurses in school spaces, giving rise to joint reflections on the process of self-care, health concepts, risky and healthy behaviors, is capable of promoting and protecting the health of adolescents and preventing morbidities in the future. keywords (source decs/mesh): health risk behaviors; health education; adolescent; environment; school nursing resumen objetivo: identificar la influencia de los hábitos de vida y comportamientos de los adolescentes en su salud. materiales y método: investigación cuantitativa, con un enfoque exploratorio y descriptivo, desarrollada con 124 adolescentes, estudiantes de una escuela preuniversitaria en el extremo sur de brasil. los datos se recolectaron mediante cuestionario. el análisis se realizó con la utilización de estadísticas descriptivas con el software spss, versión 20.0. resultados: el alto consumo de alimentos ultraprocesados en las comidas intermedias y la cantidad insuficiente de sueño por noche representan riesgos para la salud de los adolescentes. la realización de actividades físicas resultó ser un hábito de protección de la salud. conclusiones: los adolescentes deben resignificar la importancia de una alimentación saludable y del sueño en su rutina. se observó que existen factores modificables para que el sueño mejore en calidad y cantidad, igualmente el valor y la inclusión de alimentos in natura en las comidas intermedias. creemos que el papel del enfermero en los espacios escolares tiene que dar lugar a reflexiones conjuntas sobre el proceso de autocuidado, conceptos de salud, comportamientos de riesgo y saludables. igualmente, promover y proteger la salud de los adolescentes y prevenir las morbilidades en el futuro. palabras clave (fuente: decs/mesh): conductas de riesgo para la salud; educación en salud; adolescente; ambiente; servicios de enfermería escolar. resumo objetivo: identificar a influência de hábitos de vida e de comportamentos na saúde de adolescentes. materiais e método: trata-se de uma pesquisa de natureza quantitativa, com abordagem exploratória e descritiva, desenvolvida com 124 adolescentes, estudantes de uma escola pré-profissionalizante no extremo sul do brasil. foram coletados dados mediante questionário. a análise foi feita com a utilização da estatística descritiva por meio do software spss, versão 20.0. resultados: o alto consumo de alimentos ultraprocessados nas refeições intermediárias e a quantidade insuficiente de sono por noite causam riscos à saúde dos adolescentes. a realização de atividades físicas mostrou-se como hábito de proteção à saúde. conclusões: os adolescentes precisam ressignificar a importância da alimentação saudável e do sono em sua rotina. observou-se que existem fatores modificáveis para que o sono melhore em qualidade e quantidade, assim como o valor e inclusão dos alimentos in natura nas refeições intermediárias. acreditamos que a atuação do enfermeiro nos espaços escolares, suscitando reflexões conjuntas sobre o processo de autocuidado, conceitos de saúde, comportamentos de risco e saudáveis, é capaz de promover e proteger a saúde dos adolescentes e prevenir morbidades no futuro. palavras-chave (fonte decs/mesh): comportamentos de risco à saúde; educação em saúde; adolescente; meio ambiente; serviços de enfermagem escolar. introduction the adolescence period corresponds to the second decade of life of the individuals, that is, from 10 to 19 years old. it is considered a process of passage from childhood to adulthood, anchored by intense growth and development and great transformations in the biopsychosocial aspects, with physical changes and different social interactions. this phase is also marked by the search for autonomy over decisions, emotions, actions, and by the development of habits and behaviors that can influence the health of both this and future life stages(1). in the context of adolescence, the individuals suffer social, cultural and environmental influences with exposure to different situations of vulnerability to their health. risk behaviors such as inappropriate eating habits, physical inactivity and sleep disorders are associated with illness and with decreased life expectancy(1-4). during this period, some health problems can be acquired or aggravated by the adolescent's behavior, compromising their health in the future; therefore, it is considered that adolescence is a critical moment for health interventions(5). health risk behaviors, such as unhealthy habits and lifestyle, increase the likelihood of the emergence of noncommunicable diseases (ncds) usually manifested in adulthood, such as cardiovascular diseases, type 2 diabetes, stroke, and various types of cancer, which are the causes of increased morbidity and mortality in several countries around the world, including the young population(6, 7). a report issued by the world health organization devoted to the health of adolescents around the world estimated that mortality in this population group was 1.2 million individuals due to potentially avoidable causes. it stressed that the conditions and way of life have a serious impact on the health and development of adolescents and devastating effects in adulthood(8). adolescents' life habits are produced consciously or unconsciously by the interactions established with the environment, according to their time and to the prevailing and socially accepted culture. the individuals who live and interact with them — family, friends, teachers, colleagues — and the school constitute their exchange and learning environments. in them, shared experiences, either positive or negative, will have repercussions on their choices and inevitably on their health. in the search for diverse experiences in different contexts, the adolescent feels much more the need for immediate well-being than the concern with the consequences that their choices may have in the long term. habits, not always very healthy, result from a new way of thinking and acting in the adolescence phase, in the way of playing social roles and in the way of perceiving and being perceived, influenced by significant changes in interactions and in the relationships with their contexts(9). adolescents experience physical, biological, social and psychological changes typical of their growth and development process; in this journey, the conditions offered by the social and environmental contexts can influence them to develop behaviors harmful to their health. in this context, it was questioned about the influence of lifestyle habits and behaviors on the health of adolescents. from this perspective, the objective was to identify the influence of life habits and behaviors on the health of adolescents and how understanding this can help to improve health and development indicators in this age group, qualifying the work of nurses with this population segment in school, family and community spaces in general. materials and method a research study of a quantitative nature was conducted, with an exploratory and descriptive approach. it had as context a pre-professionalizing school, linked to a federal university in the south of brazil that serves adolescents in situations of social, economic and environmental vulnerability, especially those from poor communities. the 124 participating adolescents were between 14 and 17 years of age, a family income up to a 1.5 minimum wage, regularly enrolled and attending public schools in the municipality, regardless of the grade. adolescents were excluded when there was disagreement between parents and children to participate in the research or when they did not attend school on the days of data collection. data collection was carried out during the month of june 2019, on the school premises, in prior agreement with the direction and pedagogical coordination to define dates and times that do not interfere with the progress of school activities. the participants were asked questions that characterize the adolescent's profile and about their eating habits, sleep and physical activities. the data were typed and stored in a structured database in excel (microsoft) and later transferred to the statistical package for the social sciences (spss) software, version 20.0, analyzed by means of descriptive statistics, and presented in the form of tables. the study obtained a favorable opinion from the ethics committee on research with human beings of the federal university of rio grande, under number 130/2019. the ethical precepts for research with human beings were respected according to resolution 466/2012 of the brazilian national health council(10). the participants were informed about the free and informed consent term and about the free and informed assent term sent to their parents and guardians. the anonymity of the participants was guaranteed. results the research participants were 124 students aged from 14 to 17 years old (mean of 15.5 years old; sd: 1.1 years old). it was observed that 80 adolescents (64.5 %) were female. elementary school represented the schooling level of 62.9 % of the participants. as for religion, 41.9 % answered that they did not follow any and, of those who answered that they did, umbanda was the most mentioned with 23.4 %. the household is mostly shared (68.6 %) with three to five people and, when asked about family income, 70 % of the adolescents did not know how to inform it. food consumption for the analysis of food consumption data, the reference of the food guide for the brazilian population (guia alimentar para a população brasileira) was used, which presents the official food guidelines for our population. the adolescents were asked freely about the foods consumed in their meals, which were subsequently grouped according to the in natura, processed and ultra-processed categories. in the in natura category we find foods directly obtained from plants, such as leaves and fruits; or from animals, such as eggs, milk and meat, purchased for consumption without having undergone any changes after leaving nature. in another category, we grouped processed foods, canned vegetables and meats, fruit jams, cheeses and breads. among the ultra-processed foods, there are stuffed cookies, packaged snacks, soft drinks, artificial juices, instant noodles, and cold meats(11). food consumption was investigated based on the number of meals eaten per day and on preferences regarding food choices for breakfast, lunch and dinner, as well as snacks between main meals. regarding the number of meals per day, it stood out that 20.2 % do not have breakfast, 2.4 % do not have lunch and 9.7 % do not have dinner. in relation to snacks, 43.5 % eat the largest amount of ultra-processed foods. the data can be verified in table 1. table 1. meals and food consumption of the adolescents   n % meals/day one to three 59 47.6 four or five 49 39.5 more than five 16 12.9 breakfast does not have 25 20.2 in natura 61 49.2 processed 26 21.0 ultra-processed 12 9.7 lunch does not have 3 2.4 in natura 86 69.4 processed 27 21.8 ultra-processed 8 6.5 dinner does not have 12 9.7 in natura 73 58.9 processed 12 9.7 ultra-processed 27 21.8 snacks does not eat 32 25.8 in natura 25 20.2 processed 13 10.5 ultra-processed 54 43.5 total 124 100.0 source: own elaboration. the adolescents showed fairly similar eating habits. as they study in the opposite shift to the pre-professional course, they receive an afternoon meal at the regular school and lunch at the course school. both the school afternoon meals and lunches offered are nutritionally balanced. this can explain, for example, the fact that 1/4 of the adolescents do not have breakfast. among the reasons are the meal not being available at home, the habit of suppressing it or waiting for the afternoon meal in the regular school. we find in snacks the largest problem regarding food choices. almost half (43.5 %) currently eats ultra-processed foods. physical activity to investigate physical activity (pa), we used the "pa practice", "chosen location" and "frequency of practice" variables. the results showed that 58.9 % of them practice some physical activity. for 41.1 % of the adolescents, the school environment is the place for the practice of pas, while 58.9 % perform them outside the school, on the street or at the gym. regarding frequency, most of them practices physical activities two or more times a week. the data can be checked in table 2. table 2. physical activity of the adolescents, place and frequency   n % practices physical activity     yes 73 58.9 no 51 41.1 place     school 30 41.1 outside the school 43 58.9 frequency     1 time a week 18 24.6 2 to 3 times a week 27 37.1 more than 3 times a week 28 38.3 total 124 100 source: own elaboration. it was observed that most of the adolescents practice physical activities outside the school (58.9 %). some of them practice weight training and martial arts in gyms; the rest performs outdoor activities in public spaces. the practice of these activities is subject to unforeseen weather and safety conditions. the public administration of the municipality, interested in encouraging pa in the adolescent population, needs to be attentive to the creation and maintenance of public spaces with multi-sport courts that offer safety to the people who frequent them. the sample of the present study consisted of adolescents who attend regular school. however, only 41.1 % participate in physical education classes. this fact draws the attention, as we know that this is a curricular discipline in elementary and high school, whose objectives include health promotion and, consequently, the preparation of students to remain active. the fact that they are not practicing pa at school leaves a gap in the training of the students. the data can be verified in table 2. sleep quality although 59.7 % of the adolescents reported sleeping less than eight hours a day, 55.6 % believe that the quality of their sleep is good. among the factors that interfere with sleep, they predominantly cited the use of cell phones and computers, followed by insomnia and even studying at night, experiencing nightmares and anxiety, and having to share a room with other family members. the data can be verified in table 3. table 3. sleep quantity, quality and interference among adolescents   n % sleep hours does not know 1 0.8 less than 8 74 59.7 8 hours 39 31.5 more than 8 10 8.0 sleep quality good 69 55.6 bad 55 44.4 interference in sleep using cell phone or computer 50 40.3 insomnia 8 6.4 studying at night 6 4.8 nightmares and anxiety 4 3.2 sharing a room 4 3.2 waking up too early 2 1.6 total 124 100 source: own elaboration. discussion most of the adolescents demonstrated to eat adequate food at the main meals. they prefer in natura food over processed or ultra-processed foods. this fact corroborates with the findings of the cardiovascular risk study in adolescents, in which it was concluded that approximately half of the brazilian adolescents had healthy eating behaviors with regard to meals(12). it is important to note that adolescence is biologically the phase of the individual's highest growth rate, which implies a need for greater caloric and nutrient input(13). for this reason, it is considered a nutritionally critical life period, making adolescents vulnerable to the consumption of foods rich in energy and poor in nutrients. it is believed that, due to the influence of life contexts, eating habits can be modified and their choices can define the quality of food consumption and its repercussions on health, both in the present and the future. according to the food guide for the brazilian population, the consumption of ultra-processed foods should be avoided, since industrialization involves several processing techniques and the addition of ingredients such as salt, sugar, oils, fats and chemical substances. so as to make them long-lasting, ultra-processed foods are elaborated with fats that resist oxidation, but which tend to clog the arteries. they are low in fibers essential for the prevention of heart disease, diabetes and various types of cancer. they are foods that offer high energy content and low nutritional value, and the surplus calories ingested and not spent end up stored in the form of fat(11). ultra-processed foods are known for their inflammatory potential and their intake is a risk factor for adverse cardiovascular events. concerned about the adolescents' diet, spanish researchers analyzed the relationship between the inflammatory index of the diet and the anthropometric parameters of the body composition and blood pressure of 428 adolescents. it was concluded that there is a significant association between the inflammatory index of the diet and cardiovascular risk(14). several scientific instruments tested and approved nationally and internationally are used in scientific research studies to evaluate food consumption in adolescents. some examples are the 24-hour reminder, the three-day food record, and the food frequency questionnaire(15, 16). in this research, we grouped foods, coded and analyzed them by type and meal, which led us to understand the quality of the food, not the quantity consumed. most adolescents practice pas outdoors. however, unforeseen weather and safety conditions need to collaborate for them to be practiced. evidence suggests that pa is necessary for a healthy life, due to its interrelation with physical, mental and social well-being. physical inactivity is a modifiable risk factor for chronic non-communicable diseases. the world health organization recommends at least 150 minutes a week of moderate intensity pa, such as brisk walking and cycling, or 60 minutes spread over three times a week of moderate to vigorous physical activity, such as soccer and running, for the age group of 5 to 17 years old (17, 18). regarding the practice of pas, there are environmental, physical, socio-cultural, economic and political influences. a number of studies reveal that weather, for example, is an important aspect of the physical environment, where extreme temperatures make it less attractive. adolescents are most active during the hottest months of the year in the coldest countries. in the socio-cultural environment, represented by the home or school, when parents and colleagues exercise, they influence the practice of pa in the adolescents, because they are potentially susceptible to these people's orientations and stimuli. the safety aspect of the community also interferes with the performance of outdoor activities. in safer neighborhoods, the adolescents practice more activities and a greater variety of sports(19, 20). in brazil, physical education classes are guaranteed by law, but there are no specifications regarding the number or duration of classes. although there are differences according to the region and to the educational system, physical education classes are offered mainly twice a week, and the syllabuses must be based on the content of games, sports, gymnastics and on themes of movement, health, leisure and work(21). a number of studies prove the benefits of physical education classes on the students' health. participation in at least 200 minutes every 10 days increases the probability of the students meeting the health criteria for cardiopulmonary fitness, in addition to protecting from overweight and reducing cardiovascular risk, which contributes to the promotion of healthy habits(22). a research study conducted with adolescents from public schools in brazil showed that the students who were most active during classes were more likely to meet the health criteria for cardiopulmonary fitness and muscle strength. however, the classes did not protect the students against overweight, obesity or high blood pressure, as they lasted 50 minutes twice a week, which is less than necessary to meet the recommended goal for this age group(23). as for sleep, most scientists and physicians agree that its ideal duration for adolescents is 8.5 to 9.5 hours per night(24). fewer sleep hours result in mood and mental health disorders, drowsiness, behavioral problems, use and abuse of psychoactive substances, weight gain, and dysfunction of the immune system. the negative consequences related to school include inattention, absenteeism, school delay, learning and memory difficulties, and poor academic performance(25). american researchers examined the associations between sleep duration and risk behavior patterns in 41,690 adolescents from public schools. the results showed that those who slept the recommended eight to nine hours were less likely to have risky behaviors compared to those whose sleep duration was short(26). changes in sleep behavior can be attributed to two main factors: psychosocial environmental contexts and bioregulatory processes. impulsive behavior, irritability, negative thoughts and fatigue follow the deterioration of sleep patterns(27). insufficient sleep is associated with depressive symptoms, anguish and anxiety in individuals without a diagnosis of psychiatric disorders (28). in a literature review, with a sample of 15,364 adolescents who slept less than five hours a night, behaviors such as drunk driving, carrying weapons, attempted suicide, smoking, excessive alcohol consumption, marijuana use, sexual risk, and text messaging while driving were reported(29). several factors affect the sleep patterns in adolescents and contribute to insufficient sleep hours, including school start times, use of computers and smartphones at night, and social commitments(30, 31). in recent years, studies have found that the controversial use of smartphones is associated with health risks, ranging from psychosocial disorders such as anxiety, depression and sleep problems to potentially fatal injuries caused by traffic accidents(32). addiction or dependence on smartphones has become an emerging public health problem. chinese researchers associated adolescents' dependence on cell phones with poor sleep quality, obesity and hypertension. it was concluded that the use of the smartphone is associated with deprivation and poor quality of sleep, high blood pressure, and risk of cardiovascular diseases in adulthood(33, 34). an american study carried out with 193 adolescents between 14 and 17 years of age examined the correlation between sleep duration and quality of young people with family aspects. the results identified the potential influence that chaos and family disorganization have on sleep and mental health symptoms in adolescents. stressful and conflicting family environments impair the quantity and quality of sleep among adolescents(35). final considerations it was verified that the high consumption of ultra-processed foods in intermediate meals and insufficient sleep hours per night are risky habits and behaviors that can compromise the health of adolescents. it was also verified that practicing pas regularly is a health protection factor. for all the individuals, regardless of their age, sleep is fundamental for the full reestablishment of physical and mental functions between one day and another of study and work. the adolescents in this study have many activities in their daily lives; they go to regular school in one shift, in another they take a vocational course and need to study for both activities; they travel with public transportation, which increases the time away from their homes, making the daily journey more tiring. they need to reframe the importance of rest and sleep in their routine. it was observed that there are modifiable factors for improving sleep in terms of quality and quantity, such as the moderate use of cell phones or computers, and that the family can assume an important role in regulating the use of this equipment so that the adolescents can have a more repairing and healthy sleep. the importance of the nurse's performance in school spaces for the promotion and protection of the adolescents' health is highlighted, carrying out actions that range from monitoring vital signs and following-up growth and physical development to health education for the prevention of diseases. in view of their scientific training and capacity, nurses can trigger health education actions at school that lead adolescents to specific knowledge in the health area in order to promote reflections together with them on the process of self-care, concepts of health, risk behaviors, and healthy behaviors. references 1. organização pan-americana da saúde — opas/ministério da saúde. saúde e sexualidade de adolescentes. [internet]. construindo equidade no sus. brasília-df; 2017. 2. reis dc, alves hr, jordão naf, viegas am, carvalho sm. vulnerability and access in adolescent health in view of the parents. j. res.: fundam. care. online. 2014;6(2):594-606. doi: https://doi.org/10.9789/2175-5361.2014v6n2p594 3. brito lms, martins rk, cat mnl, boguszewski mcs. influência da educação em saúde da família no comportamento de risco em adolescentes. arq. ciênc. saúde. 2016;23(2):60-4. doi: https://doi.org/10.17696/2318-3691.23.2.2016.274 4. lopes sv, mielke gi, silva mc. comportamentos de risco relacionados à saúde em adolescentes escolares da zona rural. o mundo da saúde. 2015;39(3):269-78 doi: https://doi.org/10.15343/0104-7809.20153903269278 5. chimeli iv, nogueira mj, pimenta dn, schall vt. a abstração do risco e a concretude dos sujeitos: uma reflexão sobre os comportamentos de risco no contexto da adolescência. physis revista de saúde coletiva. 2016;26(2):399-415. doi: https://doi.org/10.1590/s0103-73312016000200004 6. mazzardo o, silva mp, guimarães rf, martins rv, watanabe pi, campos, w. comportamentos de risco à saúde entre adolescentes de acordo com gênero, idade e nível socioeconômico. medicina. 2016;49(4):321-30. doi: https://doi.org/10.11606/issn.2176-7262.v49i4p321-330 7. mello mvo, bernardelli junior, r, menossi brs, vieirafsf. comportamentos de risco para a saúde de estudantes da universidade estadual do norte do paraná (brasil) — uma proposta de intervenção online. ciência & saúde coletiva. 2014;19(1):159-64. doi: https://doi.org/10.1590/1413-81232014191.1976 8. organização mundial de saúde — oms. relatório mundial sobre a prevenção da violência: 2014. [internet]. genebra: organização mundial de saúde; 2014. 9. senna srcm, densen ma. reflexões sobre a saúde do adolescente brasileiro. psicologia, saúde & doenças. 2015;16(2):217-29. doi: https://doi.org/10.15309/15psd160208 10. brasil. conselho nacional de saúde. resolução n° 466, de 12 de dezembro de 2012. brasília-df; 2012. disponível em: http://www.conselho.saude.gov.br/web_comissoes/conep/index.html 11. brasil. ministério da saúde. secretaria de atenção à saúde. departamento de atenção básica. guia alimentar para a população brasileira. 2. ed., 1. reimpr. brasília: ministério da saúde; 2014. 12. barufaldi la, abreu ga, oliveira js, santos df, fugimori e, vasconcelos sml, vasconcelos fag et al. erica: prevalence of healthy eating habits among brazilian adolescents. rev public health. 2016; 50(suppl 1):6s. doi: https://doi.org/10.1590/s01518-8787.2016050006678 13. cunha db, costa thm, veiga gv, pereira ra, sichieri r. ultra-processed food consumption and adiposity trajectories in a brazilian cohort of adolescents: elana study. nutr diabetes. 2018;8(1):28. doi: https://doi.org/10.1038/s41387-018-0043-z 14. correa-rodríguez m, gonzález-jiménez e, rueda-medina b, tovar-gálvez mi, ramírez-vélez r, correa-bautista je, schmidt-riovalle j. dietary inflammatory index and cardiovascular risk factors in spanish children and adolescents. res nurs health. 2018;41(5):448-58. doi: https://doi.org/10.1002/nur.21904 15. george sm, horn lv, lawman hg, wilson dk. reliability of 24-hour dietary recalls as a measure of diet in african american youth. j acad nutr diet. 2016; 116(10):1551-9. doi: https://doi.org/10.1016/jjand.2016.05.011 16. godois am, leite, cfp, coelho-ravagnani cf. questionários de frequência alimentar: considerações para o esporte. revista brasileira de nutrição esportiva. 2017;11(66):777-87. disponível em: http://www.rbne.com.br/index.php/rbne/article/view/894 17. thapa k, bhandari pm, neupane d, bhochhibhoya s, thapa rj, ramjee pp. physical activity and its correlates among higher secondary school students in an urban district of nepal. bmc saúde pública. 2019; 19(1):886. doi: https://doi.org/10.1186/s12889-019-7230-2 18. world health organization. global recommendations on physical activity for health. [internet]. geneva; 2010. available from: https://apps.who.int/iris/bitstream/handle/10665/44399/9789241599979_eng.pdf;jsessionid=5060572b818fb5e5a318a56af303ce03?sequence=1 19. weinberg d, stevens gwjm, bucksch j, inchley j, looze m. do country-level environmental factors explain cross-national variation in adolescent physical activity? a multilevel study in 29 european countries. bmc saúde pública. 2019; 19(1):680. doi: https://doi.org/10.1186/s12889-019-6908-9 20. martins j, marques a, peralta m, palmeira a, costa fc. correlates of physical activity in young people: a narrative review of reviews. implications for physical education based on a socio-ecological approach. retos. 2017; 31:292-9. available from: https://research.unl.pt/ws/portalfiles/portal/3611106/martins_retos_2017_31_292.pdf 21. betti m, knijnik j, venâncio l, neto ls. in search of the autonomous and critical individual: a philosophical and pedagogical analysis of the physical education curriculum of são paulo (brazil). phys educ sport pedagog. 2014; 20(4):427-41. doi: https://doi.org/10.1080/17408989.2014.882891 22. erfle se, gamble a. effects of daily physical education on physical fitness and weight status in middle school adolescents. j sch health. 2015;85(1):27-35. doi: https://doi.org/10.1111/josh.12217 23. coledam dhc, ferraiol pf, greca jpa, teixeira m, oliveira ar. physical education classes and health outcomes in brazilian students. rev paul pediatr. 2018; 36(2):192-8. doi: http://dx.doi.org/10.1590/1984-0462/;2018;36;2;00011 24. short ma, weber n, reynolds c, coussens s, carskadon ma. estimating adolescent sleep need using dose-response modeling. sleep. 2018;41(4):1-14. doi: https://doi.org/10.1093/sleep/zsy011 25. crowley sj, wolfson ar, tarokh l, carskadon ma. an update on adolescent sleep: new evidence informing the perfect storm model. j adolesc. 2018; 67:55-65. doi: https://doi.org/10.1016/j.adolescence.2018.06.001 26. ordway mr, wang g, jeon s, owens j. role of sleep duration in the association between socioecological protective factors and health risk behaviors in adolescents. j dev behav pediatr. 2019; 41(2):117-27. doi: https://doi.org/10.1097/dbp.0000000000000721 27. carskadon ma, tarokh l. developmental changes in sleep biology and potential effects on adolescent behavior and caffeine use. nutr rev. 2014; 72(suppl 1):60-4. doi: https://doi.org/10.1111/nure.12147 28. tarokh l, saletin jm, carskadon, am. sleep in adolescence: physiology, cognition and mental health. neurosci biobehav rev. 2016; 70:182-8. doi: https://doi.org/10.1016/j.neubiorev.2016.08.008 29. wheaton ag, chapman dp, croft jb. school start times, sleep, behavioral, health, and academic outcomes: a review of the literature. j sch health. 2016; 86(5):363-81. doi: https://doi.org/10.1111/josh.12388 30. lebourgeois mk, hale l, chang am, akacem ld, montgomery-downs he, buxton om. digital media and sleep in childhood and adolescence. pediatrics. 2017;140(suppl 2):s92-6. doi: https://doi.org/10.1542/peds.2016-1758j 31. minges ke, redeker ns. delayed school start times and adolescent sleep: a systematic review of the experimental evidence. sleep medicine reviews. 2016; 28:86-95. doi: https://doi.org/10.1016/j.smrv.2015.06.002 32. zhang mwb, lim rbc, lee c, ho rcm. prevalence of internet addiction in medical students: a meta-analysis. acad psychiatry. 2018;42(1):88-93. doi: https://doi.org/10.1007/s40596-017-0794-1 33. ching sm, yee a, ramachandran v, lim sms, sulaiman waw, foo yl et al. validation of a malay version of the smartphone addiction scale among medical students in malaysia. plos one. 2015;10(10):e0139337. doi: https://doi.org/10.13 71/journal.pone.0139337 34. zou y, xia n, zou y, chen z, wen y. smartphone addiction may be associated with adolescent hypertension: a cross-sectional study among junior school students in china. bmc pediatr. 2019;19(1):310. doi: https://doi.org/10.1186/s12887-019-1699-9 35. peltz js, rogge rd, o'connor tg. adolescent sleep quality mediates family chaos and adolescent mental health: a daily diary-based study. journal of family psychology. 2019; 33(3):259-69. available from: https://www.apa.org/pubs/journals/features/fam-fam0000491.pdf home 1 editorial new knowledge required for nursing practice in a dynamic and changing society nuevos conocimientos que exige la práctica de enfermería en una sociedad dinámica y cambiante novos conhecimentos exigidos pela prática de enfermagem em uma sociedade dinâmica e mutável óscar rafael boude figueredo1 keywords (source: decs) nursing; science, technology and society; knowledge management; professional training; professional practice; professional training; information and communications technology; ict. palabras clave (fuente: decs) enfermería; ciencia, tecnología y sociedad; gestión del conocimiento; práctica profesional; ejercicio profesional; capacitación profesional; tecnologías de la información y de la comunicación; tic. palavras-chave (fonte: decs) enfermagem; ciência, tecnologia e sociedade; gestão do conhecimento; educação profissionalizante; capacitação profissional; prática profissional; novas tecnologias de informação e comunicação; ntic. 1 orcid.org/0000-0002-7414-2664. universidad de la sabana, colombia. oscar.boude@unisabana.edu.co doi: 10.5294/aqui.2019.19.1.1 to reference this article / para citar este artículo / para citar este artigo boude or. new knowledge required for nursing practice in a dynamic and changing society. aquichan; 19(1): e1911. doi: 10.5294/aqui.2019.19.1.1 mailto:http://orcid.org/0000-0002-7414-2664?subject= mailto:oscar.boude@unisabana.edu.co http://dx.doi.org/10.5294/aqui.2019.19.1.1 mailto:http://orcid.org/0000-0002-7414-2664?subject= http://dx.doi.org/10.5294/aqui.2019.19.1.1 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 1 chía, colombia febrero 2019 it is no secret to anyone that today’s society is undergoing a process of transformation in all its spheres. as many authors have pointed out, that transformation has changed the way citizens interact, relate, communicate, work and learn (1, 2). it is a process that requires citizens who have new skills and abilities that not only allow them to be an active part of society, but also to manipulate, transform and generate knowledge, to learn constantly, to select appropriate information, to encode and decode messages in different audiovisual languages, and to adapt to rapid social and cultural changes (3, 4). all of this has sparked a revolution in different areas of society, including education, which has not been immune to this phenomenon, as a number of authors have observed. such is the case that every day there are more parents, students and academics who agree in saying that education is in crisis. the reasons behind this assertion stem from the thinking expressed by jaques delors in his work education holds a treasure (5), which indicates that education has been one of the few sectors where no changes have occurred in the last one hundred years, and that this has generated a discrepancy between the expectations of students and parents as to what the educational process should be and what actually goes on in the classroom. however, the problem is even more complex when we take a look at higher education, since the research done by labor observatories worldwide tends to agree that there is a huge difference between the skills and abilities students develop during their professional training process and those they actually need in the workplace. this is because universities are focused more on developing disciplinary skills in students than on fostering soft skills such as teamwork, decision-making, digital competence or communication skills. in response to this situation, companies have begun to create their own universities the so-called corporate universities so as to enable their employees to develop the skills the organization needs, specifically those that make one company totally different from another, even though they offer the same products and services. and, although this phenomenon now occurs more often with companies in the service sector, banking and finance, it is rapidly being implemented in more economic sectors, including the field of health. when looking at the teaching-learning processes that are being used currently to train future nursing professionals, one sees they are facilitated increasingly by technology. however, we must be extremely careful in this regard since, in many cases, the desire to mediate these processes technologically results in tools being employed that are not the most appropriate for either the context or the educational practices in which they are implemented. this problem creates an additional difficulty that students must overcome. for that reason, before outfitting a learning environment with processes for technological mediation or facilitation, teachers must analyze the characteristics of the context in question, the technological abilities of their students, the skills to be developed, and the real benefits to be obtained by incorporating a particular technology. in the end, teachers must select the technology that is most relevant and appropriate, according to the objectives in question. as expressed in the technology, pedagogy and content knowledge (tpack) model, every nursing teacher now must have technological, pedagogical and disciplinary knowledge of the area he or she directs, so as to incorporate information and communication technology (ict) appropriately into the training process. however, research shows that most teachers lack the pedagogical and technological knowledge that allows them to incorporate ict into training processes, even when that technology includes only the use of mobile devices. although this is one of the few ict tools that both teachers and students know how to use, the skills each of them have developed in that respect are vastly different. while teachers use mobile devices to access email and to make use of instant messaging, students use them for almost anything (6). unlike what happens in other occupational areas, being a nursing professional implies not only a great willingness to serve, but also having the skills and ability needed to coach individuals, families and communities during their adaptation to chronic health conditions and with regard to the support they require to facilitate discharge processes, among others. all of this occurs in a dynamic and changing world permeated and transformed by ict, one where there are different notions about how this training process should be carried out, through technological mediation, between the nursing professional, the patient, caregivers and families. it also is important to bear in mind the expectations of clinics, hospitals and other health services concerning the use and utility of ict in patient care and follow-up. 3 for all these reasons, nursing professionals must be trained not only to acquire the essential disciplinary skills, but also to obtain the technological skills that will allow them to manage and systematize their processes, to communicate better with their patients, and to be up-to-date on search, selection, evaluation and classification processes for clinical cases. references 1. castells m. la era de la información: economía, sociedad y cultura. vol. 3. madrid: alianza; 2004. 2. mattelart a. historia de la sociedad de la información. barcelona: paidós; 2007. 3. tedesco j. educar en la sociedad del conocimiento. buenos aires: fondo de cultura económica de argentina: 2000. 4. hargreaves a. a decade of educational change and a defining moment of opportunity: an introduction. journal of educational change. 2009 april; 10(2-3):89-100. doi: 10.1007/s10833-009-9103-4 5. delors j. la educación encierra un tesoro. parís: santillana, unesco: 1996. 6. boude or, andrea j. el reto de formar a profesores universitarios para integrar el aprendizaje móvil. revista cubana de educación médica superior. 2017; 31(1):61-77. available from: http://scielo.sld.cu/scielo.php?script=sci_arttext&p id=s0864-21412017000100007 https://doi.org/10.1007/s10833-009-9103-4 http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=s0864-21412017000100007 http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=s0864-21412017000100007 1 gisele weissheimer1 julia mazul santana2 victória beatriz trevisan nóbrega martins ruthes3 verônica de azevedo mazza4 informações necessárias às famílias de crianças com transtorno do espectro autista: uma revisão integrativa* * este artigo foi financiado pelo conselho nacional de desenvolvimento científico e tecnológico, ministério da tecnologia, ciência e informação, com recursos obtidos pelo projeto universal, aprovado pela chamada mcti/cnpq 1/2016. também é derivado da primeira etapa de desenvolvimento da tese de doutorado intitulada “suporte informacional às famílias de crianças com autismo: validação de conteúdo”, defendida na universidade federal do paraná, brasil. 1 https://orcid.org/0000-0002-3054-3642. universidade federal do paraná, brasil. gisele.weissheimer@hc.ufpr.br 2 https://orcid.org/0000-0002-3419-8727. universidade federal do paraná, brasil. 3 https://orcid.org/0000-0003-1525-580x. universidade federal do paraná, brasil. 4 https://orcid.org/0000-0002-1264-7149. universidade federal do paraná, brasil. recebido: 23/03/2020 submetido a pares: 05/04/2020 aceito por pares: 20/05/2020 aprovado: 09/06/2020 doi: 10.5294/aqui.2020.20.2.8 para citar este artículo / to reference this article / para citar este artigo weissheimer g, santana jm, ruthes vbtnm, mazza va. necessary information for the families of children with autism spectrum disorder: an integrative review. aquichan. 2020;20(2):e2028. doi: https://doi.org/10.5294/aqui.2020.20.2.8 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2028 temática da revista: cuidado crônico. contribuição para a disciplina: esta pesquisa contribui para a área da enfermagem e da saúde por oferecer subsídio teórico sobre as informações necessárias às famílias de crianças com transtorno do espectro autista. a partir disso, os profissionais podem desenvolver ou melhorar programas de apoio formal de informações. resumo objetivo: identificar as evidências disponíveis sobre as informações necessárias às famílias de criança com transtorno do espectro autista (tea). método: revisão integrativa da literatura, realizada em seis bases de dados com descritores específicos para cada uma. elegeram-se estudos publicados sobre o tema entre janeiro de 2014 e fevereiro de 2020, e que estivessem disponíveis de forma integral e gratuita. para a síntese e análise dos dados, realizou-se categorização temática. incluíram-se 41 artigos. resultados: obtiveram-se duas categorias temáticas. na primeira, “necessidade de informação”, identificaram-se a carência de conhecimento das famílias sobre o tea (tratamento, como lidar com o comportamento da criança e perspectivas futuras), os direitos da criança com tea e os recursos para obter https://orcid.org/0000-0002-3054-3642 mailto:gisele.weissheimer@hc.ufpr.br https://orcid.org/0000-0002-3419-8727 https://orcid.org/0000-0003-1525-580x https://orcid.org/0000-0002-1264-7149 https://doi.org/10.5294/aqui.2020.20.2.8 https://orcid.org/0000-0002-3054-3642 https://orcid.org/0000-0002-3419-8727 https://orcid.org/0000-0003-1525-580x https://orcid.org/0000-0002-1264-7149 https://doi.org/10.5294/aqui.2020.20.2.8 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2028 informações. na segunda categoria, “fontes de suporte informacional acessadas pelas famílias”, perfizeram-se as fontes informais (familiares, amigos, vizinhos e pais de crianças com tea), formais (profissionais e instituições), a internet e outros recursos (livros, workshops, podcasts). constataram-se aspectos positivos e negativos no uso de tais fontes. conclusões: verificou-se um padrão de informações requeridas pelos familiares, bem como de fontes utilizadas para obtê-las. esses dados são relevantes para subsidiar a organização de fontes de apoio informacional às famílias e à comunidade. palavras-chave (fonte: decs) transtorno do espectro autista; acesso à informação; família; criança; apoio social. 3 informações necessárias às famílias de crianças com transtorno do espectro autista: uma revisão integrativa l gisele weissheimer e outros información necesaria para las familias de niños con desorden del espectro autista: una revisión integradora* resumen objetivo: identificar las evidencias disponibles acerca de las informaciones necesarias para las familias de niños con desorden del espectro autista (dea). método: revisión integradora de la literatura, desde seis bases de datos con descriptores específicos para cada una. se seleccionaron estudios publicados sobre el tema entre enero de 2014 y febrero de 2020, disponibles de forma integral y gratuita. para síntesis y análisis de los datos, se llevó a cabo una categorización temática. se incluyeron 41 artículos. resultados: se obtuvieron dos categorías temáticas. en la primera, “necesidad de información”, se identificaron la falta de conocimiento de las familias acerca del dea (tratamiento, cómo manejar la conducta de los niños en esta condición y perspectivas futuras), los derechos del niño con dea y los recursos para el acceso a las informaciones. en la segunda categoría, “fuentes de soporte informacional accedidas por las familias”, se encontraron las fuentes informales (familiares, amigos, vecinos y padres de niños con dea), formales (profesionales e instituciones), internet y otros recursos (libros, workshops, podcasts). se evidenciaron aspectos positivos y negativos en el empleo de tales fuentes. conclusiones: se encontró un patrón de informaciones requeridas por los familiares, así como de fuentes utilizadas para obtenerlas. los hallazgos son relevantes para subsidiar la organización de fuentes de soporte informacional a las familias y a la comunidad. palabras clave (fuente: decs) desorden del espectro autista; acceso a la información; familia; niño; apoyo social. año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2028 * el artículo fue auspiciado por el consejo nacional de desarrollo científico y tecnológico, ministerio de la tecnología, ciencia e información de brasil, con recursos del proyecto universal, aprobado por la convocatoria mcti/cnpq 1/2016. además, se deriva de la primera etapa de desarrollo de la tesis doctoral titulada “soporte informacional a las familias de niños con autismo: validación de contenido”, presentada en la universidade federal do paraná, brasil. 4 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2028 aquichan issn 1657-5997 eissn 2027-5374 necessary information for the families of children with autism spectrum disorder: an integrative review* abstract objective: to identify the available evidence on the necessary information for the families of children with autism spectrum disorder (asd). method: an integrative literature review carried out in six databases with specific descriptors for each one. studies published on the theme between january 2014 and february 2020 available in full and free of charge were selected. for synthesis and analysis of data, thematic categorization was performed. 41 articles were included. results: two thematic categories were obtained. in the first category (“need for information”), the families’ lack of knowledge about asd (treatment, how to deal with the child’s behavior, and future perspectives), rights of the child with asd, and resources to obtain information were identified. the second category (“information support sources accessed by the families”) comprised informal sources (family members, friends, neighbors, and parents of children with asd), formal sources (professionals and institutions), the internet, and other resources (books, workshops, podcasts). positive and negative aspects were found in the use of these sources. conclusions: a pattern of information requested by the family was verified, as well as sources used to obtain it. these data are relevant to support the organization of sources of informational support for the families and the community. keywords (source: decs) autism spectrum disorder; access to information; family; child; social support. * this article was funded by the national council for scientific and technological development, ministry of technology, science and information, with funds obtained by the universal project, approved by mcti/cnpq 1/2016. it is also derived from the first developmental stage of the doctoral thesis entitled “informational support for the families of children with autism: content validation”, defended at the federal university of paraná, brazil. 5 informações necessárias às famílias de crianças com transtorno do espectro autista: uma revisão integrativa l gisele weissheimer e outros introdução estimativas mostram que 1 a cada 59 crianças apresenta transtorno do espectro autista (tea). esses são dados da rede de monitoramento nos estados unidos entre 2000 e 2014 (1). no brasil, existem poucos estudos epidemiológicos sobre a prevalência do tea e discrepâncias entre alguns estudos (2-4). o tea é um distúrbio do neurodesenvolvimento humano caracterizado pelo prejuízo na interação social, na comunicação, verbal e não verbal, e nos padrões de comportamentos restritos e/ou repetitivos (5). as alterações do desenvolvimento são percebidas pelas famílias a partir de alguns sinais, como o atraso da fala ou da linguagem, os comportamentos estereotipados e a ausência de interação da criança com outras pessoas (6). as famílias se deparam com algo desconhecido e não esperado (7). muitas delas enfrentam vários percursos nos serviços de saúde para buscar o diagnóstico infantil (6) e muitos desafios, além de necessitarem diferentes formas de apoio para cuidar da criança. estudos mostram (8, 9) a necessidade de as famílias obterem informações sobre recursos (8) e profissionais disponíveis, e expressam dificuldades de acesso a informações e a recursos assistenciais (9). a oferta de informação faz parte da assistência à saúde e tem como objetivo melhorar o conhecimento e as habilidades da família, de modo a influenciar atitudes e comportamentos com vistas a manter ou melhorar a saúde dos seus membros (10). trata-se de um recurso importante para empoderá-la para o cuidado, como também para auxiliá-la na discussão com os profissionais sobre as condutas a serem tomadas com relação ao tratamento infantil e aos seus direitos, entre outros (11, 12). diante disso, reitera-se a importância do suporte de informações às famílias, bem como de orientações ao uso de recursos disponíveis em diferentes meios acessíveis à comunidade, os quais cada vez mais fazem parte do cotidiano de vida das pessoas. com o intuito de embasar o suporte informacional às famílias, torna-se relevante identificar quais são as evidências sobre as necessidades de informações das famílias para, a partir disso, elaborar estratégias a fim de auxiliá-las. destarte, tem-se como objetivo identificar quais as informações necessárias às famílias de crianças com tea. este estudo contribui para a disciplina de enfermagem porque oferta embasamento teórico para ajudar os profissionais da área a fornecerem o suporte de informações de forma adequada no processo de cuidar, com o gerenciamento das expectativas das famílias sobre a utilidade das informações disponíveis em diferentes fontes. método trata-se de uma revisão integrativa da literatura, cujo método possibilita a síntese, de modo sistemático e ordenado, de diversas pesquisas publicadas sobre uma temática, com a finalidade de gerar novos resultados, aprofundar no conhecimento e identificar possíveis lacunas a serem investigadas acerca desse tema (13). o estudo seguiu as seis etapas da metodologia de ganong (14), apresentadas a seguir. 1) definição da pergunta de pesquisa: quais são as evidências disponíveis sobre as informações necessárias às famílias de crianças com tea? para isso, utilizou-se de uma adaptação da estratégia pico (p — população; i — intervenção; c — comparador; o — resultados) para pic, em que p —população; i — fenômeno de interesse; c — contexto. assim, p — famílias de crianças com tea; i — necessidade de informações; c — contexto de vida diária da família. 2) estabelecimento dos critérios de inclusão/exclusão ou de seleção da amostra: estudos que abordassem familiares de crianças com tea; que especificassem as informações necessárias a esses familiares para subsidiá-los no cuidado diário à criança; publicados entre janeiro de 2014 e fevereiro de 2020; pesquisas com abordagem qualitativa e quantitativa, disponíveis na íntegra e gratuitamente, em espanhol, inglês e português, nas bases de dados scopus, pubmed (us national library of medicine national institutes database search of health), cinahl (cumulative index to nursing and allied health literature), web of science, eric (education resources information center) e psycinfo (american psychological association). o período de publicação dos artigos foi definido a fim de compreender publicações mais recentes, dos últimos seis anos. o quadro 1 ilustra as estratégias de busca realizadas nas bases de dados. a seleção das diferentes bases de dados foi realizada por abranger diferentes áreas do conhecimento, como educação, psicologia, enfermagem, e áreas multidisciplinares da saúde. 6 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2028 aquichan issn 1657-5997 eissn 2027-5374 quadro 1. estratégias de busca nas bases de dados scopus title-abs-key (autism and child and family and information) and (limit-to ( pubyear, 2020 feb) (limit-to ( pubyear, 2019) (limit-to (pubyear, 2018) or limit-to (pubyear, 2017) or limit-to (pubyear, 2016) or limit-to (pubyear, 2015) or limit-to (pubyear, 2014) ) and (limit-to (doctype, “ar”)) and (limit-to (language, “english”) or limit-to (language, “portuguese”) or limit-to (language, “spanish”)) and (exclude (exactkeyword, “adult”) or exclude (exactkeyword, “adolescent”) or exclude (exactkeyword, “young adult”) or exclude (exactkeyword, “middle aged”)) pubmed autism and family and child and information cinahl ab autism spectrum disorders and children and family and information web of science topic: (autism) and topic: (family) and topic: (children) and topic: (information) and document types: (article) and year published: (2014-2020) not topic: (adolescent) not topic:(adult) not topic: (old) eric autism and family not adolescent psycinfo any field: autism spectrum disorders or keywords: autism and any field: family experience or keywords: family and abstract: information and document type: journal article and population group: human and age group: childhood (birth-12 yrs) and apa full-text only and year: 2014 to 2020 fonte: dados da pesquisa. os critérios de exclusão foram publicações repetidas nas bases de dados, dissertações, teses, artigos de revisões, relatórios de conferências, congressos, capítulo de livros, livros, cartas, erratas, relatos de experiência e editoriais. os artigos de revisões foram excluídos porque se objetivou incluir pesquisas primárias/empíricas. as revisões caracterizam-se como pesquisas secundárias. após a identificação dos estudos nas bases de dados e considerando-se os critérios de elegibilidade, duas revisoras independentes realizaram a leitura dos títulos e dos resumos, de forma simultânea, a fim de selecionarem os estudos para a revisão. nos casos de falta de consenso a respeito da inclusão ou não do estudo, havia um terceiro revisor para ser consultado, o que não foi necessário; em seguida, os estudos pré-selecionados foram lidos na íntegra para definir a sua inclusão ou exclusão (figura 1). 3) coleta/extração dos dados: os estudos incluídos foram organizados por meio de um instrumento predefinido pelas pesquisadoras com informações de identificação, tais como a base de dados em que foi extraído, o título, os autores, o periódico, o ano de publicação, o idioma, o país do estudo, o objetivo deste e a abordagem metodológica. 4) análise: os dados extraídos foram classificados de acordo com a semelhança temática e organizados em categorias. nessa análise, utilizou-se da metodologia proposta por bardin (16) (2010), composta por organização da análise, leitura flutuante das publicações, codificação e categorização temática (16). a análise e categorização temática foram realizadas pelas pesquisadoras. realizaram-se a organização e preparação dos dados para a análise, a leitura dos dados e a codificação em segmentos de texto, agrupamentos do texto em categorias de acordo com a similaridade entre os dados encontrados. 7 informações necessárias às famílias de crianças com transtorno do espectro autista: uma revisão integrativa l gisele weissheimer e outros in c lu s ã o el eg ib il id a d e a v a li a ç ã o id en ti fi c a ç ã o artigos identificados por meio da pesquisando em base de dados (n=905) artigos removidos por duplicata (n=84) artigos pré selecionados (n=821) artigos selecionados para leitura integral (n=165) artigos incluídos (n=41) pubmed 193 psycinfo 221 web of science 223 scopus 165 eric 70 cinahl 33 artigos excluídos (n=656) 540 por não atenderem o objetivo do estudo 57 por serem de revisão 16 por estarem duplicados 1 por estar fora do idioma proposto 25 referiram-se a famílias de crianças com outros transtornos / agravos 17 trataram-se de familiares de adolescentes artigos completos excluídos (n=124) 88 por não atenderem o objetivo do estudo 11 por trataram-se de familiares de adolescentes / adultos / idosos. 11 por referirem-se à familiares de crianças com outras doenças / transtornos 6 artigos duplicados 4 por estarem fora do idioma proposto 1 por ser de revisão necessidade de informação tea a criança com tea direitos da criança com tea fontes de informação fontes de suporte informacional das famílias fontes formais fontes informais internet e outros recursos figura 1. fluxograma do processo de identificação, seleção e inclusão dos estudos, elaborado a partir da recomendação do prisma (15) fonte: dados da pesquisa. 5) interpretação e discussão dos resultados. 6) apresentação da revisão integrativa. resultado a amostra constituiu em 41 estudos, e a caracterização destes está apresentada no quadro 2. quanto ao ano de publicação dos artigos: 1 (2,4 %) em 2014; 11 (26,2 %) em 2015; 9 (21,95 %) em 2016; 4 (9,75 %) em 2017; 9 (21,95 %) em 2018; 6 (14,6 %) em 2019 e 1 (2,4 %) em 2020, conforme se apresenta na figura 2. todos foram realizados em países estrangeiros: 17 (41,5,2 %) representados pelos estados unidos; 5 (12,2 %) pela austrália; 3 (7,3 %) pelo canadá e pela suécia; 2 (4,9 %) pela china, pelo reino unido e pela irlanda; croácia, espanha, frança, grécia, itália, rússia e turquia representaram a publicação de 1 (2,4 %) artigo. com relação à metodologia, 23 (56,1 %) artigos apresentaram abordagem qualitativa, 11 (26,8 %) quantitativa e 7 (17,1 %) quanti-qualitativa. no que se refere ao idioma dos estudos, 40 (97,6 %) estão em inglês e 1 (2,4 %), em espanhol. figura 2. número de artigos selecionados por ano de publicação (2020) fonte: dados da pesquisa. a partir da análise temática dos dados, emergiram duas categorias e respectivas subcategorias: “necessidade de informação” e “fontes de suporte informacional das famílias”, conforme a figura 3. figura 3. categorias e subcategorias fonte: dados da pesquisa. necessidade de informação verificou-se que os pais necessitavam de informações que os auxiliassem no cuidado aos filhos. esta categoria foi dividida em quatro subcategorias que expressam o conteúdo das informações requeridas pelas famílias: tea; a criança com tea; direitos da criança com tea; fontes de informação. 8 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2028 aquichan issn 1657-5997 eissn 2027-5374 quadro 2. caracterização dos artigos selecionados (2020) identificação do estudo país do estudo/periódico/ base de dados objetivo blauth, 2017 (17) reino unido/health psychology report/web of science relatar a abordagem de aconselhamento a pais de crianças com tea, com o uso de feedback em vídeo das sessões de musicoterapia com as crianças. carlsson, miniscalco, kadesjö e laakso, 2016 (18) suécia/international journal of language & communication disorders/pubmed aumentar a compreensão da experiência vivida pelos pais no processo de diagnóstico neuropsiquiátrico, isto é, o período desde a triagem inicial aos 2,5 anos até o seguimento de 2 anos do diagnóstico de tea. chiu et al., 2014 (19) china/journal of the formosan medical association/web of science descrever a prática atual de aconselhamento sobre o diagnóstico do tea; avaliar a satisfação materna com o aconselhamento informado sobre o diagnóstico; identificar os fatores relacionados à satisfação materna; apresentar o aconselhamento ideal para o diagnóstico que as mães esperam. curtiss e ebata, 2019 (20) estados unidos/journal of autism and developmental disorders/eric explorar a natureza das refeições compartilhadas em família de crianças com tea. derguy, michel, m’bailara, roux e bouvard, 2015 (21) frança/journal of intellectual & developmental disability/scopus conhecer as necessidades de pais de crianças com tea. dinora, bogenschutz e lynch, 2017 (22) estados unidos/journal of social work in disability & rehabilitation/ web of science identificar quais fatores as famílias priorizam como importantes ao selecionar tratamentos para seus filhos com tea, quais pessoas e materiais influenciam suas decisões de tratamento e o grau de importância que os pais atribuem aos diferentes tipos de influências. dinora e bogenschutz, 2018 (23) estados unidos/journal of early intervention/scopus identificar quais experiências, crenças e valores de vida influenciaram tanto nas decisões dos pais para que seus filhos fossem avaliados para o diagnóstico de tea quanto nas suas decisões para o tratamento do tea e explorar como os fatores externos afetaram as decisões de avaliação e tratamento para o tea. edwards, brebner, mccormack e macdougall, 2018 (11) austrália/journal of autism and developmental disorders/scopus explorar como os pais de crianças com tea tomaram decisões sobre qual intervenção acessaram. frame e casey, 2019 (24) estados unidos/children and youth services review, elsevier/web of science identificar as razões e as potenciais influências que determinaram os pais a selecionarem o tratamento de seus filhos com tea. frye, 2016 (25) estados unidos/journal of pediatric health care/pubmed escrever a experiência dos pais de crianças com tea, com o uso de suas próprias palavras, e identificar quais os recursos necessários para ajudá-los a se envolverem ativamente em seu papel como pai de uma criança com tea. gibson, kaplan e vardell, 2017 (26) estados unidos/journal of autism and developmental disorders/ pubmed examinar as preferências da fonte de informação para os pais de indivíduos com tea na carolina do norte. grant, rodger e hoffmann, 2016 (27) austrália/child: care, health and development/pubmed explorar os processos de tomada de decisão e as preferências de informação dos pais após o diagnóstico de tea do filho. hays e butauski, 2018 (28) austrália/western journal of communication/scopus explorar com quem os pais compartilhavam detalhes particulares com relação ao tea dos seus filhos. hennel et al., 2016 (29) austrália/journal of paediatrics and child health/web of science comparar experiência e preferências dos pais sobre as informações ofertadas no diagnóstico da criança com tea pelo pediatra e identificar os tipos e utilidade dos recursos acessados por famílias pós-diagnóstico. hodgetts, zwaigenbaum e nicholas, 2015 (30) canadá/autism/cinahl explorar as necessidades gerais, os benefícios e as fragilidades dos serviços que atenderam as famílias de crianças com tea e identificar os preditores dessas necessidades. https://onlinelibrary.wiley.com/journal/14606984 https://onlinelibrary.wiley.com/journal/14606984 https://onlinelibrary.wiley.com/journal/14606984 https://onlinelibrary.wiley.com/journal/13652214 https://onlinelibrary.wiley.com/journal/13652214 9 informações necessárias às famílias de crianças com transtorno do espectro autista: uma revisão integrativa l gisele weissheimer e outros huus, olsson, andersson, granlund e augustine, 2017 (31) suécia/scandinavian journal of disability research/scopus investigar a percepção familiar sobre as necessidades de pais de crianças com deficiência intelectual leve diagnosticada, com autismo, asperger, epilepsia e paralisia cerebral; pesquisar a relação entre a percepção da autoeficácia dos pais em seu papel parental e a colaboração com os profissionais, bem como com suas necessidades de apoio. kocabiyik e fazlioğlu, 2018 (32) estados unidos/journal of education and training studies/eric determinar como as crianças diagnosticadas com tea moldaram a vida dos seus pais, com a especificação das histórias de vida deles. lajonchere et al., 2016 (33) estados unidos/journal of autism and developmental disorders/web of science desenvolver e testar em campo um produto educacional chamado “science briefs”, que foi projetado para melhorar o acesso dos pais à informação em pesquisas biomédicas publicadas sobre tea. li et al., 2016 (34) estados unidos/patient education and counseling/web of science examinar as necessidades de informação sobre o teste genético de tea entre pais de crianças afetadas. liu e fisher, 2017 (35) austrália/australian social work/ web of science explorar as experiências familiares de usar os serviços de apoio a crianças com deficiência para entender como a migração e suas expectativas culturais sobre deficiência e serviço afetaram o modo como usaram os serviços. lopez, magaña, xu e guzman, 2018 (36) estados unidos/journal of rehabilitation/scopus explorar e compreender a reação dos pais ao diagnóstico de tea para apoiá-los. mcintyre e brown, 2016 (12) estados unidos/journal of intellectual & developmental disability/scopus examinar a utilização e utilidade do apoio social a mães de crianças com tea. mereoiu, bland, dobbins e niemeyer, 2015 (37) estados unidos/early childhood research & practice/eric explorar as opiniões de pais de crianças pré-escolares com tea em programas de cuidados infantis. molteni e maggiolini, 2015 (38) itália/journal of child and family studies/scopus monitorar as necessidades das famílias de crianças com tea e identificar possíveis propostas operacionais para implementar a qualidade dos serviços territoriais. moro, jenaro e solano, 2015 (39) espanha/ediciones universidad de salamanca/scopus conhecer o processo de comunicação do diagnóstico e das informações recebidas; avaliar a percepção sobre a relação das famílias com os profissionais; compreender os apoios e obstáculos percebidos pelos pais com relação ao tea dos filhos. ntre et al., 2018 (40) grécia/international journal of caring sciences/cinahl investigar as preocupações gerais e as necessidades de apoio e informação de mães gregas de crianças com tea, seus problemas de saúde e os encargos financeiros da família. pearson, traficante, denny, malone e codd, 2019 (41) estados unidos/journal of autism and development disorders/scopus atender às necessidades das crianças com tea e de suas famílias, e oferecer aos pais oportunidades de aprender sobre os serviços de tea disponíveis em suas comunidades. pejovic-milovancevic, 2018 (42) sibéria/psychiatria danubina/scopus explorar o apoio, os desafios e as necessidades entre as famílias afetadas pelo tea na sérvia e definir a satisfação geral da família no apoio dos sistemas. pickard e ingersoll, 2015 (43) estados unidos/autism/pubmed examinar as necessidades de serviços percebidos pelos pais e as barreiras ao uso do serviço. pickard, rowless e ingersoll, 2019 (44) estados unidos/journal of autism and developmental disorders/eric avaliar o impacto das adaptações a uma intervenção mediada por pais e baseada em evidências. preece et al., 2016 (45) croácia/ european journal of special needs education/web of science identificar as atitudes e opiniões dos pais em relação ao recebimento de um treinamento para pais (tempo, duração das sessões, possíveis barreiras) e conteúdo do treinamento. prendeville e kinsella, 2019 (46) irlanda/journal of autism and development disorders/web of science explorar como os avós apoiam crianças com tea e seus pais, com o uso de uma perspectiva de sistemas familiares. https://www.sciencedirect.com/science/journal/07383991 https://www.sciencedirect.com/science/journal/07383991 https://www.tandfonline.com/toc/rasw20/current https://www.tandfonline.com/toc/cjid20/current https://www.tandfonline.com/toc/cjid20/current https://www.tandfonline.com/toc/cjid20/current https://link-springer-com.ez22.periodicos.capes.gov.br/journal/10803 https://link-springer-com.ez22.periodicos.capes.gov.br/journal/10803 https://link.springer.com/journal/10803 https://link.springer.com/journal/10803 10 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2028 aquichan issn 1657-5997 eissn 2027-5374 rivard, lépine, mercier e morin, 2015 (47) canadá/journal of child and family studies/scopus analisar como os pais de crianças com tea perceberam os determinantes da qualidade dos serviços prestados no contexto de uma rede pública de serviços. rivard, millau, magnan, mello e boulé, 2019 (48) canadá/journal of developmental and physical disabilities/web of science documentar obstáculos enfrentados pelas famílias imigrantes na obtenção de um diagnóstico de tea para a criança; documentar os fatores que facilitaram o acesso ao diagnóstico; identificar atitudes predominantes em relação ao tea na cultura de origem dos participantes; registrar os conselhos que os participantes dariam a outras famílias imigrantes em sua própria trajetória para obter um diagnóstico. roffeei, abdullah e basar, 2015 (49) reino unido/international journal of medical informatics/scopus explorar os pontos de vista dos pais e das partes interessadas (pediatria, psiquiatria, psicologia, serviços de saúde mental, pesquisa e instituições de caridade nacionais para o tea) em relação às suas necessidades de informação, modalidades de informação atuais e as barreiras percebidas e complexidades da informação. ryan e quinlan, 2018 (50) irlanda/journal of applied research in intellectual disabilities/web of science explorar as percepções dos pais sobre a comunicação e a colaboração com a equipe de saúde, e sobre a educação no contexto de uma reconfiguração de serviços de deficiências. tait, hu, sweller e wang, 2016 (51) china/journal of autism and developmental disorders/pubmed descrever a compreensão da família sobre a própria qualidade de vida e os serviços de diagnósticos utilizados por ela. tekinarslan, 2018 (52) turquia/journal of applied research in intellectual disabilities/eric explorar as experiências de mães turcas cujos filhos foram diagnosticados com tea quanto às emoções que sentiram e aos desafios que encontraram antes e depois do diagnóstico. wallace, 2016 (53) estados unidos/the qualitative report/scopus determinar o impacto da experiência do acampamento em famílias de crianças com tea. zajicek-farber, lotrecchiano, long e farber, 2015 (54) estados unidos/ maternal and child health journal/web of science explorar a percepção das famílias sobre a experiência relativa ao cuidado centrado na família de crianças com deficiências do desenvolvimento neurológico, recebido em serviços médicos. zakirova-engstrand, rollpettersson, westling-allodi e hirvikoski 2020 (55) suécia/journal of autism and developmental disorders/web of science relatar descobertas sobre as necessidades percebidas dos avós de crianças com tea no contexto cultural da suécia. fonte: dados da pesquisa. na subcategoria “tea”, observou-se, nos artigos 19, 21, 23, 27, 31, 36, 37, 43, 45, 47, 55 e 56, que os pais consideraram importante receber informações referentes ao tea, por exemplo, o que é o transtorno, a causa, os sinais e os sintomas (19, 43, 50, 57), sobre as dietas específicas (26), os testes e exames diagnósticos (27, 41), os testes genéticos e a probabilidade de ter um segundo filho com tea, sobre o significado do diagnóstico e do prognóstico (31), as opções de tratamentos (26, 43, 47), as terapias alternativas de assistência à criança (47) e a possibilidade de cura (35, 38). na subcategoria “a criança com tea”, identificaram-se necessidades de informações sobre como manejar e entender o comportamento do filho e o futuro da criança. segundo os estudos 22, 23, 26, 32, 38, 43 e 55, os pais necessitam de conhecimento para compreender os comportamentos da criança com tea e para lidar com eles, gerenciar comportamentos agressivos, autolesivos, birras e estereotipias. além disso, gostariam de saber sobre o desenvolvimento de habilidades sociais e sensoriais, como manejar as limitações da criança, como gerenciar a alimentação dela (22) e como auxiliar na sua integração social com a própria família e com outros indivíduos da sociedade. as famílias desejavam obter instruções que as ajudassem a se comunicar com a criança, criar rotinas diárias de repouso, sono, autocuidado, lazer (47), aconselhamentos que as orientassem como brincar com a criança, promover sua independência, como gerir a sexualidade e a chegada da adolescência (24, 47, 55). os artigos 32, 33, 41, 42 e 52 expuseram a necessidade de informações que abordassem cada etapa do desenvolvimento infantil e suas demandas. isso envolveu desde a capacidade da https://www.ncbi.nlm.nih.gov/pubmed/28401698 https://www.ncbi.nlm.nih.gov/pubmed/28401698 11 informações necessárias às famílias de crianças com transtorno do espectro autista: uma revisão integrativa l gisele weissheimer e outros criança falar, comunicar-se, socializar-se, adaptar-se na sociedade até a fase do crescimento e do desenvolvimento físico e sexual; além disso, abrangeu o desempenho no ambiente educacional, a possibilidade de estudar no ensino regular, de ingressar no mercado de trabalho, de obter independência e de ser feliz. em relação à subcategoria “direitos da criança com tea”, os familiares buscavam esclarecimentos sobre direitos, políticas, legislação (47), subsídios financeiros às pessoas com deficiências e recursos governamentais para a intervenção precoce (31). buscaram-se instruções para ajudá-los a explicar o transtorno para outras pessoas e aumentar a conscientização sobre o tea (47, 50, 55). os estudos 20, 21, 23, 25, 29, 31-33, 42, 43, 52, 53, 54 e 55 apontaram que as famílias necessitavam de informação sobre serviços disponíveis para atender seus filhos e profissionais de saúde qualificados para fazer o diagnóstico, oferecer tratamento/ terapia e aconselhamento familiar. do mesmo modo, percebeu-se a necessidade de informes sobre planos de saúde que atendessem as crianças com tea, bem como sobre onde buscar apoio, intervenção e recursos educacionais para estimular o desenvolvimento infantil. ademais, expressaram a necessidade de aprender a se comunicar melhor com professores e outros profissionais em relação à criança com tea e de obter aconselhamento familiar para pais e avós (57). a respeito da subcategoria “fontes de informação” (29, 31), as famílias gostariam de conselhos referentes a como buscar ou encontrar grupos de apoio e organizações para pais de crianças com tea. nos artigos 28, 29, 31 e 55, constatou-se a necessidade de indicações para a participação em seminários/encontros, eventos destinados ao tea, livros e sites para pais. fontes de suporte informacional acessadas pelas famílias nesta categoria, as fontes de informações utilizadas foram classificadas nas seguintes subcategorias: formais; informais; internet/outros recursos. na subcategoria das “fontes formais”, verificou-se que os pais obtiveram informações de diferentes profissionais; referiram o tipo de informação; apontaram aspectos positivos no recebimento de informes; identificaram limitações dos profissionais e de instituições sobre o suporte de informações, e pontuaram aspectos que dificultavam sua participação em eventos com caráter informacional. os pais buscavam informações com profissionais de várias categorias, com relação à área da saúde, como médicos generalistas (29, 30, 44), médicos da atenção primária (24, 44), especialistas em pediatria e neurologia (25), fonoaudiólogos, psicólogos e terapeutas ocupacionais. do mesmo modo, recebiam informações de profissionais da área da educação, como professores dos centros de educação infantil e escolas (25, 27). os aspectos positivos dos profissionais de saúde durante o recebimento de informação no período do diagnóstico foram: atitude positiva (21); tinham sensibilidade, eram realistas e cuidadosos na forma de se comunicar (41); o diagnóstico era claro (25, 41); ofereciam apoio emocional e encorajavam os pais a esclarecerem suas dúvidas (21, 31, 40); dispunham de tempo adequado para discutir sobre o diagnóstico (31); ouviam e tranquilizavam os pais (40); receberam informações sobre os direitos da criança/ família; tiveram oportunidade de checar a própria compreensão sobre as informações recebidas (55); foram informados sobre o tratamento (21, 25), centros especializados e programas como comunicação alternativa e aumentativa, picture exchange communication system/sistema de comunicação por troca de figuras, treatment and education of autistic and communication handicapped children/tratamento e educação de crianças autistas e com desvantagens na comunicação, terapia da fala, psicomotora e comportamental (38). pais foram treinados em um programa de capacitação que os ensinou a brincarem com a criança, a melhorarem a comunicação e a lidarem com o comportamento da criança (46). por sua vez, observaram-se aspectos negativos percebidos durante a informação do diagnóstico: falta de empatia (52); pouca sensibilidade (41); falta de atendimento às necessidades de aconselhamento (41); aconselhamento negativo; atitude pessimista (21, 41) e angustiante (31); pouco tempo para o aconselhamento e informações insuficientes (19, 25, 55). de acordo com as famílias, as orientações não eram claras; os médicos não tinham certeza do diagnóstico do tea infantil (40), e as famílias não entendiam o que era o transtorno (25, 38, 41, 53), a etiologia, o prognóstico, as manifestações clínicas do tea (16), o teste genético (12), os subsídios governamentais, a assistência médica e os recursos educacionais (21). as famílias não obtiveram informação referente às suas preocupações sobre: o futuro (53), o comportamento da criança (41, 53), o desenvolvimento e evolução do tea (41), onde buscar apoio 12 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2028 aquichan issn 1657-5997 eissn 2027-5374 (43), as necessidades sensoriais da criança (11), as intervenções e terapias personalizadas, o prognóstico e como explicar o diagnóstico para os profissionais da escola (31). além disso, não sabiam onde buscar instituições que as auxiliassem e orientassem (41). as famílias apontaram algumas limitações profissionais durante o processo de prestação de informação, a saber: diferentes graus de conhecimento sobre o tea (25, 50, 52); informações contraditórias entre os profissionais (53); os familiares não entendiam os encaminhamentos e compartilhamentos de informações entre a equipe multiprofissional (50, 52); os profissionais desconheciam serviços que prestavam atendimento especializado à criança com tea (50). além disso, as famílias não compreendiam por que os profissionais não valorizavam suas preocupações quanto às alterações que elas percebiam no desenvolvimento da criança (25). a respeito das limitações institucionais, constatou-se, em um estudo na espanha, a falta de profissionais especialistas (41); em uma pesquisa realizada nos estados unidos, a sobrecarga dos neurologistas que impediam o fornecimento de mais atenção às famílias após o diagnóstico (25). ademais, identificou-se, em uma investigação realizada na china, que os horários e dias de atendimento em locais que têm por função prestar informações para pais eram limitados, pois permaneciam abertos em horário de expediente do comércio em geral e fechados nos finais de semana e feriados, o que impossibilita o uso por familiares que também trabalham no horário de expediente. mencionou-se a falta de um centro de informações que oferecesse serviço on-line ou por telefone 24 horas/dia e que pudesse ser acessado pelas famílias (53). os familiares sentiam-se limitados na participação de treinamentos para pais devido ao fato de serem realizados em outras cidades e à coincidência com o horário de cuidados da criança ou horário de trabalho. além disso, havia falta de horários alternativos para os treinamentos, por exemplo, aos fins de semana ou à noite (47). ademais, muitas famílias referiam falta de tempo e motivação para participarem de treinamentos em razão do cansaço físico causado pela rotina de cuidados da criança (51). em relação à subcategoria das “fontes informais”, verificou-se que os pais obtinham informações de outros pais de crianças com tea e de amigos em condições semelhantes (11, 20, 22, 24, 31, 35, 55). famílias compartilhavam informações com o cônjuge e outros membros, tais como irmãos, tios, primos e os avós da criança (12, 30, 34, 38), outros membros da rede pessoal, como vizinhos, amigos (32, 33, 37, 38) e grupos de apoio ou associações (11, 28-30, 52). os avós têm um papel importante no compartilhamento de informações e no apoio aos pais de crianças com tea (48). na subcategoria “internet e outros recursos”, observaram-se o uso de tais recursos, as informações buscadas, as dificuldades e limitações para uso da internet e de livros. constatou-se a participação dos familiares em workshops, a leitura de livros e panfletos, a visualização de vídeos, os quais foram citados como meios para obter informações (24, 27, 28, 34, 36, 44, 54). utilizavam a internet (31) e blogs (26) para a obtenção de conhecimento sobre os direitos da criança (37), as possíveis causas do tea, os tratamentos diversos, os tratamentos com poucos estudos que comprovem eficácia (35) e o teste genético para a criança com tea (12). quanto ao uso das informações na internet, muitos dos pais mencionaram algumas dificuldades, como a quantidade massiva de informações (12, 24, 26, 51), informações confusas com muitos termos (tea, autista, transtorno global do desenvolvimento, asperger etc.) (53); dificuldades em discernir informações confiáveis dos mitos on-line (25); sites com intenção de venda de produtos (51); falta de informações confiáveis (31, 51). outras limitações para acessar a internet foram as desvantagens educacionais e/ou socioeconômicas que impossibilitam o acesso a um computador; não saber usá-lo ou não compreender a linguagem técnica com que as informações são disponibilizadas e a inabilidade para buscar informações confiáveis (35, 51). no que se refere ao uso dos livros, descreveram-se as seguintes limitações: sentimento de sobrecarga dos pais pela quantidade de informações fornecidas; linguagem técnica e fadiga dos pais para lerem devido à rotina de cuidados desenvolvidos (51). a identidade das pessoas com tea era definida de forma inadequada; dessa forma, os pais não se sentiam confortáveis em ler tais livros (51). outra preocupação levantada foi a vulnerabilidade das famílias diante das diferentes fontes de informações disponíveis, visto que, após o diagnóstico, é o período em que os pais mais necessitam de informações e, assim, são suscetíveis a informações inadequadas (51). discussão a busca de informações pelas famílias inicia-se com a percepção de que existe algo diferente no desenvolvimento da criança (20). após o diagnóstico ser confirmado, as famílias vivenciam a 13 informações necessárias às famílias de crianças com transtorno do espectro autista: uma revisão integrativa l gisele weissheimer e outros insegurança relacionada ao desconhecimento sobre o tea e aos tratamentos disponíveis; a dificuldade de lidar com o comportamento da criança; a necessidade de tomar decisões sobre tratamentos que desconhecem (24, 28, 29, 51, 56); em alguns casos, têm a dificuldade no acesso a recursos, apoio e informações (39). a família necessita de suporte dos familiares, dos profissionais e da comunidade. no entanto, constataram-se, nos estudos, relatos da falta de habilidade e acolhimento dos profissionais, mencionada pelas famílias que necessitam de tempo de aconselhamento, de mais informações, de serem ouvidas e saberem como/ onde buscar recursos (19, 20, 28, 41, 52, 53). a inadequação de informações pode gerar um efeito negativo nas famílias, seja pela inacessibilidade das informações, seja pelas limitações dos profissionais com relação ao conhecimento e manejo do tea, descritos em vários estudos pelas famílias (25, 52, 53). existem referências de limitações no atendimento aos familiares, como a sobrecarga dos profissionais — pela demanda de atendimentos diários — que acabam limitando o tempo do aconselhamento (25, 47). a consciência limitada sobre o tea pela comunidade e por parte dos profissionais ainda é um aspecto contemporâneo, que pode acarretar consequências importantes para as famílias (51). a falta de valorização das informações pelos profissionais relatada pelas famílias, entre outros aspectos, pode gerar o atraso do diagnóstico. isso significa a perda de oportunidade para as intervenções precoces que podem fazer a diferença no desenvolvimento da criança, principalmente relacionada à plasticidade cerebral no início da vida (57). a limitação de informações faz com que as famílias enfrentem estigmas da comunidade, principalmente quando as crianças com tea apresentam estereotipias, crises ou birras em público. as famílias são julgadas porque as pessoas desconhecem o transtorno e a forma como a pessoa com tea percebe o mundo e vive em sociedade. isso leva muitos pais a limitarem os passeios e as suas rotinas de vida a fim de reduzir os momentos desagradáveis em comunidade (58). apesar de diversos estudos mostrarem que as famílias tiveram dificuldades no acesso a informações, outras obtiveram conselhos positivos dos profissionais de saúde e da escola (12), os quais foram considerados fontes importantes de informações antes e depois do diagnóstico do tea (31, 44), com o suporte recebido (44) e as orientações para auxiliar nas decisões com relação aos tratamentos (25). o acesso a informações é imprescindível, visto que, por meio destas, os pais se sentem seguros e capacitados para tomarem decisões (29) referentes ao tratamento, às intervenções, aos serviços e ao futuro (55). muitos pais referem que os profissionais de saúde e as instituições formais proporcionam um sentimento de confiança e apoio aos familiares que desejam informações honestas (27) com relação à avaliação da criança para o tea e à indicação de tratamentos apropriados (25). além dos profissionais, muitas famílias utilizam outros meios para se informar sobre o transtorno e para auxiliá-las na tomada de decisão (39, 54), como outros pais de crianças com tea, membros da família, amigos e vizinhos. os pais valorizam os grupos de apoio como fonte de orientação, já que são pessoas que vivenciam a mesma situação e prestam apoio mútuo continuamente (11, 25, 30, 31, 52). a busca por pares na mesma situação refere-se ao fato de que tais famílias entendem melhor o que outras estão sentindo, diferentemente de outras pessoas, como da própria família, as quais não conseguem ou não têm conhecimento para auxiliá-las (54). portanto, pessoas que vivenciam a mesma condição e que já percorreram vários caminhos de busca de informações e serviços se tornam a esperança de obter capacidade para aprender a lidar e enfrentar tal situação (51, 55). as famílias buscam suporte informacional por meio das mídias sociais, conectam-se umas às outras por facebook, twitter, instagram, blogs, podcasts, entre outros. por meio dessa conexão, podem fornecer um sentimento de pertença, apoio mútuo e uma forma de entender o que está acontecendo (59). com o movimento da era digital e o uso cada vez mais frequente e de fácil acesso à internet, esta se tornou uma fonte de busca de informações sobre a saúde. as razões para o seu uso são a abundância de informações, o fácil acesso a esse recurso (28, 29) e a possibilidade de acessá-la conforme a disponibilidade de tempo da família (29). outros recursos, como a participação em workshops e seminários, são utilizados com o intuito de conhecer os serviços disponíveis para atender as crianças com tea (37), como forma de treinamento para pais (47) e obtenção de informações para orientar a tomada de decisão sobre intervenções necessárias. apesar da disponibilidade de informações às famílias, existe a preocupação com a confiabilidade destas. a vulnerabilidade emocional das famílias perante as fontes de informação é um aspecto 14 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2028 aquichan issn 1657-5997 eissn 2027-5374 importante a ser discutido na sociedade contemporânea em virtude do aumento das informações disponíveis de forma on-line (51). as famílias estão expostas a conteúdos on-line não confiáveis, além disso existe uma vulnerabilidade emocional em relação à busca da cura do tea. isso pode fazer com que os familiares confiem em conteúdos desqualificados que prometam tal cura, a qual, até o momento, não existe. a falta de evidências que comprovem a causa e a cura do transtorno pode justificar a razão pela qual os pais buscam tantas informações e modos alternativos de tratamentos. embora existam muitos graus variados de credibilidade científica, um aspecto essencial para alguns pais é compreender conteúdos confiáveis e não confiáveis (53). assim, o desafio para os profissionais é capacitar os pais para que possam buscar informações em bases de dados confiáveis. algumas famílias podem ser vulneráveis a retóricas persuasivas de informações não seguras, contudo nem todas as famílias são influenciadas. com o movimento da prática baseada em evidência, mostram-se estudos confiáveis comparados àqueles sem validação. no entanto, mesmo as práticas baseadas em evidências são vulneráveis a serem comercializadas (55). há algumas fontes de apoio destinadas às famílias, como a disponibilização de conteúdos on-line direcionados aos pais com linguagem para essa população e de conteúdos educativos, desenvolvidos e disponibilizados em sites de instituições reconhecidas cientificamente, como o autism speaks (estados unidos e parcerias com outros países), raising children network (austrália), sick kids (canadá), entre outros. com o uso das tecnologias, os conteúdos podem ser compartilhados durante um webinar, o qual pode ser apresentado e, posteriormente, arquivado, assim pode ser assistido por pessoas que não puderam participar ao vivo. um webinar pode ser usado para apresentar um programa educacional a um grupo geograficamente amplo. por exemplo, nas áreas rurais, pode ser difícil organizar um programa de educação familiar em que distância e tempo possam impedir famílias de participarem. no entanto, desde que estas tenham acesso à internet, podem participar do programa em suas casas e ter a oportunidade de interagir com o apresentador e com outros participantes (59). um estudo realizado no canadá mostrou que, em uma busca sobre saúde realizada no youtube, havia vários vídeos desenvolvidos por enfermeiros e outros profissionais de saúde com informações úteis e confiáveis para as famílias. os podcasts são outra forma de compartilhamento de conteúdo popular e útil. um podcast é um arquivo de áudio que pode ser baixado em um telefone celular e depois ouvido enquanto uma pessoa realiza as atividades da vida diária. os podcasts geralmente são curtos e uma pessoa pode se inscrever para receber novos podcasts diretamente, conforme o assunto que desejar. semelhantes a estes, há também os vodcasts (59). desse modo, percebe-se uma tendência no uso de informações de livre acesso pela comunidade. isso gera uma demanda aos profissionais e aos gestores para educar a comunidade quanto a como acessar informações confiáveis. além disso, leva à necessidade de repensar a prática e de desenvolver estratégias que visem minimizar possíveis riscos pelo acesso a informações inseguras que “desinstruam” as famílias e produzam danos à saúde da criança com tea. conclusões esta pesquisa evidenciou padrões de informações requeridas pelas famílias sobre o tea, o comportamento da criança, os seus direitos e a indicação de fontes de informações. com esses dados, os profissionais podem criar ou melhorar programas de apoio formal de informações. o apoio formal envolve programas e políticas que façam parte da assistência às famílias nas diferentes áreas de atendimento à saúde, social e educacional. os resultados fornecem embasamento aos gestores em estratégias para políticas públicas destinadas a essa população a fim de garantir os seus direitos. além disso, refletir sobre estratégias para capacitar as fontes formais de apoio a fim de que possam gerir as necessidades das famílias. diante das diversas fontes acessadas pelos familiares e da referência de uma quantidade grande de informações nessas fontes, verifica-se a necessidade de condensá-las em um formato utilizável sem que as famílias se sintam sobrecarregadas. poderiam ser condensadas em formato impresso ou on-line em um mesmo local de acesso pelas famílias. ademais, houve referências a informações com qualidade questionável. considerando-se a vulnerabilidade das famílias perante o acesso de informações não seguras, existem desafios para a área profissional no quesito de disponibilização e orientação de infor15 informações necessárias às famílias de crianças com transtorno do espectro autista: uma revisão integrativa l gisele weissheimer e outros mações seguras e modeladas para as famílias diante das tendências da era digital. nesse contexto, os profissionais são incitados a ensinar as famílias a fazerem julgamento crítico na seleção das fontes e do tipo de informações acessadas. as limitações deste estudo incluíram amostras de crianças com condições comórbidas ao tea, uma vez que as necessidades de informações podem ser diferentes nesse público. apesar de terem sido excluídos estudos que envolvessem adolescentes e adultos, muitos dos inclusos tinham em suas amostras adolescentes, assim surgiram alguns temas como a sexualidade. acredita-se que a demanda de informações pode ser diferente em cada fase de vida da criança com tea bem como de seus familiares. portanto, sugere-se, para estudos futuros, investigar quais seriam essas demandas e o impacto delas nos envolvidos. conflito de interesse: nenhum declarado. referências 1. eds jb. prevalence of autism spectrum disorder among children aged 8 years — autism 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https://doi.org/10.11114/jets.v6i12.3692 https://doi.org/10.11114/jets.v6i12.3692 https://nsuworks.nova.edu/cgi/viewcontent.cgi?referer=https://scholar.google.com.br/&httpsredir=1&article=2410&context=tqr/ https://nsuworks.nova.edu/cgi/viewcontent.cgi?referer=https://scholar.google.com.br/&httpsredir=1&article=2410&context=tqr/ https://doi.org/10.1007/s10995-015-1688-z https://doi.org/10.1007/s10995-015-1688-z https://doi.org/10.1007/s10803-019-03946-w https://doi.org/10.1590/2177-9465-ean-2018-0116 sociodemographic and clinical factors associated with postpartum hemorrhage in a maternity ward article sociodemographic and clinical factors associated with postpartum hemorrhage in a maternity ward* factores sociodemográficos y clínicos asociados a la hemorragia posparto en una maternidad** fatores sociodemográficos e clínicos associados à hemorragia pós-parto numa maternidade*** 10.5294/aqui.2021.21.2.7 daianne teixeira soares1 telmara menezes couto2 ridalva dias martins3 jules ramon brito teixeira4 jaqueline alves pires5 gleice de oliveira santos6 1 0000-0002-3025-9844. empresa brasileira de serviços hospitalares, universidade federal da bahia, brazil. daianne.soares@ebserh.gov.br 2 0000-0001-6836-8563. universidade federal da bahia, brazil. telmara.couto@ufba.br 3 0000-0003-0295-9998 . universidade federal da bahia, brazil. ridalvamartins@ufba.br 4 0000-0002-8443-7810 . universidade estadual de feira de santana, brazil. 5 https://orcid.org/0000-0002-5993-4567. universidade federal da bahia, brazil. jaquelineap@ufba.br 6 0000-0002-7582-8465. universidade federal da bahia, brazil. santos.gleice@ufba.br * this article is derived from the master’s thesis entitled “sociodemographic and clinical factors associated with postpartum hemorrhage in a maternity school”, presented to the graduate program in nursing of the universidade federal da bahia, brazil. ** el artículo se deriva de la tesis de maestría titulada “factores sociodemográficos y clínicos asociados a la hemorragia posparto en una maternidad escuela”, presentada al programa de posgrado en enfermería de la universidade federal da bahia, brasil. *** este artigo é derivado da dissertação de mestrado intitulada “fatores sociodemográficos e clínicos associados à hemorragia pós-parto em uma maternidade escola”, apresentada ao programa de pós-graduação em enfermagem da universidade federal da bahia, brasil. theme: evidence-based practice. contribution to the discipline: the study generated information capable of supporting strategies that can contribute to the reduction of postpartum hemorrhage and maternal mortality. received: 19/10/2020 sent to peers: 01/12/2020 approved by peers: 29/04/2021 accepted: 17/05/2021 para citar este artículo / to reference this article / para citar este artigo: soares dt, couto tm, martins rd, teixeira jrb, pires ja, santos go. sociodemographic and clinical factors associated with postpartum hemorrhage in a maternity ward. aquichan. 2021;21(2):e2127. doi: https://doi.org/10.5294/aqui.2021.21.2.7 abstract objective: checking the sociodemographic and clinical factors associated with the prevalence of postpartum hemorrhage (pph) in a maternity school. materials and methods: a quantitative cross-sectional study in a maternity hospital in salvador, bahia, brazil. in data collection, we used a standardized form that contained sociodemographic and clinical data from the medical records of 83 women for the period of 2018. stata version 14 software was used in the analyses. bivariate analysis was conducted using pearson’s or fisher’s exact tests. poisson regression was performed with robust variation in multivariate analysis. prevalence ratios (pr) and respective 95 % confidence intervals were estimated. the significance level of the tests was 5 %. results: the prevalence of pph was 38.6 % and 25.6 % for atony as the cause. in the bivariate analysis, there was an association between pph and non-breastfeeding in the first hour of life (p = 0.039). in the multivariate analysis, it was identified that multiparous women had an increase in the prevalence of pph by almost twice (pr = 1.97). not breastfeeding in the first hour of life increased this prevalence more than four times (pr = 4.16). conclusions: monitoring multiparous women during birth care and encouraging breastfeeding in the first hour of life may decrease the prevalence of pph. keywords (source decs): postpartum hemorrhage; maternal mortality; breast feeding; parity; nursing care. resumen objetivo: investigar los factores sociodemográficos y clínicos asociados a la prevalencia de hemorragia posparto (hpp) en una maternidad de enseñanza. materiales y métodos: estudio cuantitativo de corte transversal, en una maternidad de salvador, bahia, brasil. en la recolección de los datos, se empleó formulario estandarizado que contenía datos sociodemográficos y clínicos de los historiales de 83 mujeres referentes al período de 2018. en los análisis, se utilizó el software stata versión 14. se realizó análisis bivariado, por medio de las pruebas de pearson o exacto de fisher. además, regresión de poisson con variación robusta en el análisis multivariado. se estimaron razones de prevalencia (rp) y respectivos intervalos de confianza del 95 %. el nivel de significancia de las pruebas fue del 5 %. resultados: la prevalencia de hpp fue del 38,6 % y del 25,6 % para atonía como causa. en el análisis bivariado, se evidenció asociación entre hpp y no lactancia en la primera hora de vida (p = 0,039). en el análisis multivariado, se identificó que mujeres multíparas tuvieron incremento en la prevalencia de hpp en casi dos veces (rp = 1,97). no lactar en la primera hora de vida aumentó esta prevalencia en más de cuatro veces (rp = 4,16). conclusiones: monitorear multíparas durante la asistencia al parto e incentivar la lactancia materna en la primera hora de vida puede reducir la prevalencia de la hpp. palabras clave (fuente decs): hemorragia posparto; mortalidad materna; lactancia materna; paridad; atención de enfermería. resumo objetivo: investigar os fatores sociodemográficos e clínicos associados à prevalência de hemorragia pós-parto (hpp) em uma maternidade escola. materiais e métodos: estudo quantitativo de corte transversal, numa maternidade de salvador, bahia, brasil. na coleta de dados, utilizou-se formulário padronizado que continha dados sociodemográficos e clínicos dos prontuários de 83 mulheres referentes ao período de 2018. nas análises, utilizou-se o software stata versão 14. foi conduzida análise bivariada, por meio dos testes de pearson ou exato de fisher. realizou-se regressão de poisson com variação robusta na análise multivariada. foram estimadas razões de prevalência (rp) e respectivos intervalos de confiança de 95 %. o nível de significância dos testes foi de 5 %. resultados: a prevalência de hpp foi de 38,6 % e de 25,6 % para atonia como causa. na análise bivariada, evidenciou-se associação entre hpp e não amamentação na primeira hora de vida (p = 0,039). na análise multivariada, identificou-se que mulheres multíparas tiveram incremento na prevalência de hpp em quase duas vezes (rp = 1,97). não amamentar na primeira hora de vida aumentou essa prevalência em mais de quatro vezes (rp = 4,16). conclusões: monitorizar multíparas durante a assistência ao parto e incentivar o aleitamento materno na primeira hora de vida pode diminuir a prevalência de hpp. palavras-chave (fonte desc): hemorragia pós-parto; mortalidade materna; aleitamento materno; paridade; cuidados de enfermagem. introduction postpartum hemorrhage (pph) is a serious public health problem that is the obstetric complication with the highest maternal mortality rate in the world. it is traditionally defined as blood loss above 500 ml after vaginal birth or above 1000 ml after cesarean birth in the first 24 hours or any blood loss by the genital tract capable of causing hemodynamic instability. in brazil, it is configured as the second cause of maternal mortality, the first being pregnancy-specific hypertension, the third puerperal infection, and abortion as the fourth cause (1). besides being responsible for maternal deaths, pph can cause serious complications such as maternal shock, respiratory disease distress syndrome, coagulopathy, and secondary infertility, and most cases are preventable if there are conditions to put into practice current evidence on prevention and control of this morbidity (3). maternal death occurs in less than 1 % of pregnancies in most developed countries and between 25 % and 30 % occur due to pph. a worldwide loss of 150,000 lives per day is estimated because of pph; 88 % of them occur in the first four hours of postpartum. the maternal mortality ratio in developed regions such as the united states and canada in 2015 was 12 per 100,000 live births (lb), while in developing regions it was 239 per 100,000, much higher than the wealthier regions. in this sense, a study found that 99 % of maternal deaths were concentrated in developing countries and more than half of them occurred in contexts of crises, inadequate environments, and devoid of resources, which emphasizes social and economic inequalities between classes (1). estimates from the world health organization (who) indicate that in 2013 there were 287,000 maternal deaths worldwide, with a maternal death ratio (mdr) of 385 to 210 per 100,000 lb in a time frame from 1990 to 2013. in latin america and the caribbean, 8,800 maternal deaths were estimated, and the mdr reduced from 140 to 85 per 100,000 lb, which indicates a reduction in rates compared to 1990. in brazil, according to these estimates, the mdr decreased in the same period from 120 to 69 per 100,000 lb — a drop of 43 %. but to achieve the goal of the fifth-millennium goal, brazil should have presented an estimated mdr of 35 deaths per 100,000 lb (4). the mdr in brazil increased from 62 to 64 per 100,000 live births between 2015 and 2017, with an increasing difference between brazilian regions: south — 38.5; midwest — 56.9; southeast — 62.3; northeast — 73.2 and north — 88.9 per 100,000 lb. the northeast region had the highest number of cases of maternal mortality due to pph with 34.5 % (n = 719), while the south had the lowest with 16.5 % (n = 345). significant regional differences are observed in brazil, ranging from 95 per 100,000 lb in the northeast region, in salvador 60 per 100,000 lb, to 41 per 100,000 lb in the south region, which shows more than twice the ratio. variations in the mortality rate may be associated with the quality of care provided during the pregnancy and puerperal period and the information obtained through death surveillance (5, 6). brazil did not meet its commitment to arrive in 2015 with a maximum of 35 maternal deaths per 100,000 lb, agreed on by the millennium goals. between 2016 and 2030, as part of the sustainable development goals, the goal is to reduce the overall maternal mortality rate to less than 30 per 100,000 lb (1, 6). inequalities in access to health services contribute to many women experiencing these complications, during or after childbirth, as is the case of pph (1). the effectiveness of the prevention of pph and the decrease in maternal mortality is closely related to the social and economic situation present in developing countries. less favored areas, associated with socio-demographic issues, poverty, misery, and unfavorable financial conditions, expose women to more risks. in this sense, the frequency of injuries, such as pph and its repercussion on maternal mortality, becomes an indicator of inequity and disparity between men and women, as well as an important indicator of the population’s health condition, socioeconomic development, and the guarantee of women’s rights (3, 4). when death does not occur, the woman may have non-fatal complications such as hypotension and fatigue (impairing mother-child contact), important anemia, coagulopathy, need for blood transfusion and its possible complications, pituitary ischemia, and hypopituitarism (sheehan syndrome), reduction of lactation, myocardial ischemia, and complications of surgical treatment. more than 50 % of all maternal morbidity during pregnancy results from obstetric hemorrhage (1). inserted in this context, brazil is in a scenario of intense medicalization of the birth process, with 98 % of deliveries performed in hospitals and with good prenatal coverage, while persisting high rates of maternal morbidity and mortality with an index of 69 per 100,000 lb, which represents more than double the assumed goal (1). pph is a significant contributor to severe maternal morbidity and prolonged disability, so nursing professionals should be alert for pph symptoms and prepared to act and respond quickly and effectively. oxytocin after childbirth is the main action to prevent pph, a medication of first choice, and may reduce cases of pph by uterine atony by more than 50 %. early control of the bleeding site is the most effective measure in the treatment of pph (1, 2, 5). thus, the nursing professional and the health team play a crucial role in ensuring hemostasis in the postpartum period, to reduce blood loss and control pph (6,7). considering the magnitude of pph, which is an increasingly frequent problem in health systems and could be prevented in up to 90 % of cases, this theme becomes an important object of study capable of offering subsidies in the creation of strategies that can promote improvements in the quality of care provided by the nursing team to women’s health. for this, there must be early identification, adequate treatment, provision of information and educational actions in health, approach to harm reduction and contribution of scientific evidence. in this sense, it is necessary to better understand the phenomenon, which justifies the realization of this study, which aimed to investigate the sociodemographic and clinical factors associated with pph in a maternity school. materials and method this is a cross-sectional study with a retrospective collection. it was developed in a maternity school in salvador, bahia, brazil, from january to december 2018. the study population was represented by 83 women who attended the prepartum of this maternity. we included women who had a normal or cesarean birth, at the study site and during the data collection period. as an exclusion criterion, women who had abortions, fetal deaths, and stillborn. for data collection, a standardized form was used, based on information of interest for the study, which was available in the participants’ medical records. the explanatory variables analyzed were sociodemographic (age, race, education, marital status, occupation, religion, residence and maternity linkage) and clinics (current birth route, dystocia, pharmacological induction, risk classification, birth position, use of light technologies, birth care performed by a doctor or obstetric nursing professional, breastfeeding in the first hour of life). the outcome under study was pph. stata software, version 14, was used for data processing and data processing. for categorical variables, absolute and relative frequencies were estimated; for quantitative variables with normal distribution, minimum and maximum values, mean and standard deviation were estimated. prevalence was estimated and the pearson chi-square test or fisher’s exact test for the comparison of percentages with a significance level of 5 %. the measure of association used was the prevalence ratio (pr) and their respective confidence intervals of 95 % (ci = 95 %). the variables with p-value ≤ 0.20 in the bivariate model were inserted in the multivariate model. to determine the most parsimonious final model, the lowest value of akaike information criterion (aic) was considered. this study has the approval of the ethics committee in maternity research in which it was conducted, with opinion n.º 3,426,869. results we interviewed 83 women who attended in a maternity hospital in salvador, bahia. when analyzing the prevalence of pph according to sociodemographic characteristics, there was a predominance of age from 18 to 29 years old (51.8 %), black (94 %), high school/higher education (62.7 %), with a prevalence of high school (55.4 %), without a partner (83.1 %), with work outside the home (50.6 %), with religion (84.5 %) and residents in salvador or metropolitan region (71.1 %), predominantly salvador (60.2 %). it was found that 71 (85.5 %) of the participants had no connection with motherhood (table 1). table 1. prevalence of postpartum hemorrhage and prevalence ratio, according to sociodemographic characteristics. bahia, 2020 (n = 83) variables % n n p p-value* pr ci = 95 % age group <18 years old 10.8 3 9 33.3 0.867 1.00 from 18 to 29 years old 51.8 16 43 37.2   1.12 0.41-3.06 30 or over 37.3 13 31 41.9   1.26 0.45-3.48 race / color not black 6.0 4 5 80.0 0.070 1.00 black 94.0 28 78 35.9   0.45 0.26-0.76 schooling elementary school 37.3 9 31 29.0 0.169 0.66 0.34-1.24 high school/higher education 62.7 23 52 44.2   1.00 marital status no mate 83.1 30 69 43.5 0.068 1.00 with mate 16.9 2 14 14,3   0.32 0.09-1.23 occupation housewife 49.4 14 41 34.2 0.415 1.00 works away from home 50.6 18 42 42.9   1.26 0.72-2.18 religion yes 84.5 20 49 40.8 0.673 1.00 no 15.5 3 9 33.3   0.82 0.30-2.20 residence salvador/metropolitan area 71.1 20 59 33.9 0.172 1.00 countryside 28.9 12 24 50.0   1.48 0.86-2.53 link with maternity yes 14.5 2 12 16.7 0.117 1.00 no 85.5 30 71 42.3   2.54 0.69-9.32 % percentage concerning the total number of women, with data for each variable; n: number of women with pph; n: number of women in each category; p: prevalence; pr: prevalence ratio; ci = 95 %: 95 % confidence interval ; *p-value obtained by fisher chi-square or exact test. source: own elaboration. on the clinical characteristics of childbirth, the prevalence of pph was 38.6 %, with causes attributed to atony (25.6 %), followed by laceration (7.2 %), trauma (3.6 %) and coagulation disorder (1.2 %). in this maternity ward, the variable route of birth found a higher frequency of cesarean sections (59 %), lower dystocia (12 %) and pharmacological induction (39.8 %). there was homogeneous distribution in high-risk deliveries (56.6 %) and usual risk (43.4 %), with a predominance of horizontal position (73.5 %) together with medical care (84.3 %). to a lesser extent, light technologies were used (24.1 %) and breastfeeding in the first hour of life (18.1 %). in the bivariate analysis, there was an association between pph and non-breastfeeding in the first hour of life (p-value = 0.039) (table 2). table 2.  prevalence of postpartum hemorrhage and prevalence ratio, according to clinical characteristics of childbirth. bahia, 2020 (n = 83). variables % n n p p-valor* pr ci = 95 % type of birth route normal birth 41.0 14 34 41.2 0.683 1.00 cesarean 59.0 18 49 36.7   0.89 0.52-1.54 dystocia               no 88.0 28 73 38.4 1.000 1.00 yes 12.0 4 10 40.0   1.04 0.46-2.36 pharmacological induction no 60.2 20 50 40.0 0.739 1.00 yes 39.8 12 33 36.4   0.90 0.52-1.60 risk rating usual risk 43.4 14 36 38.9 0.956 1.00 high risk 56.6 18 47 38.3   0.98 0.57-1.71 birth position horizontal 73.5 25 61 41.0 0.449 1.00 vertical 26.5 7 22 31.8   0.78 0.39-1.54 use of lightweight technologies yes 24.1 8 20 40.0 0.879 1.00 no 75.9 24 63 38.1   0.95 0.51-1.78 childbirth care doctor 84.3 28 70 40.0 0.758 1.00 professional nursing obstetrician 15.7 4 13 30.8   0.77 0.32-1.83 breastfeeding in the first hour of life yes 18.1 2 15 13.3 0.039 1.00 no 81.9 30 68 44.1   3.30 0.88-12.46 source: own elaboration. it is important to highlight in the results that, in the normal birth group, the variable birth care allows us to analyze that the care provided by the physician predominates in this maternity ward (60 %), in relation to the obstetric nursing professional (40 %), and, compared to physicians, there was a higher proportion of use of light technologies in childbirth care by obstetric nursing professionals (p-value = 0.001) , with a statistically significant difference. in the multivariate analysis (table 3), adjusted for schooling, it was identified that multiparous women (with three or more previous pregnancies) had an increase in the prevalence of pph by almost twice (pr = 1.97). not breastfeeding in the first hour of life increased this prevalence more than four times (pr = 4.16). table 3. adjusted prevalence ratios and confidence intervals (95 %) factors associated with postpartum hemorrhage. bahia, 2019 variables pr adjusteda ci = 95 % previous pregnancies up to 2 1.00 3 or more 1.97 1.14-3.42 breastfeeding in the first hour of life yes 1.00 no 4.16 1.17-14.80 aic 1,5003 amodel adjusted by the variable schooling. source: own elaboration. discussion the diagnosis of pph presented a high prevalence in this study, and the investigation of associated sociodemographic and clinical factors inserted in this problem becomes important for the contribution of the prevention of this disease and reduction of maternal mortality. the present study presents statistical significance in the bivariate analysis, which evidences an association between pph and non-breastfeeding in the first hour of life. in the multivariate analysis, it was identified that multiparous women (with three or more previous pregnancies) had an increase in the prevalence of pph by almost twice (pr = 1.97). not breastfeeding in the first hour of life increased this prevalence more than four times (pr = 4.16). regarding the sociodemographic variables, it was noted that there was no statistical significance with pph. when investigating the prevalence of pph in women according to their age group, the predominance of age from 18 to 29 years old (51.8 %) and no studies that associate age range alone with pph are found, but a study was identified that analyzed the variable maternal age associated with greater complications in childbirth, causing more cesarean sections, which aggravates the risk, increases the frequency of pph and, consequently, maternal death. regarding the color variable, the black one predominated in this study without presenting a statistically significant association between the variable race and pph. however, it is important to highlight those women who had pph predominantly declared themselves black (94 %), due to the higher concentration of this breed in brazil and that black women end up being more susceptible to morbidities that result in maternal death. this is due not to this race being a risk factor, but to social inequalities and the difficulty of access of this population to health services, while it has the highest rate of public service users in brazil (8, 9). the level of education in this study presented predominant distribution in women who had access to high school (62.7 %), and a variable that is necessary to investigate when addressing women in the scope of health promotion, protection, and recovery behaviors. in this regard, research has proven that younger adults with low schooling are less regularly exposed to preventive tests, indicating the presence of inequalities in the use of services (8). regarding the variable marital status, there was a predominance of women without a partner (83 %). it is important to think about unofficially and/or open marital relationships since it is frequent to break the relationship between the baby’s father and mother, and/or make different decisions when discovering a pregnancy. these ruptures generate the woman’s lack of support and support from a network, if solo mothers, as well as widows and divorcees, have the propensity to make up an unprotected group. the arguments for this are justified due to the absence, for the most part, of affective, emotional, social, financial, and encouragement to self-care, both by the baby’s father and family. the presence of a partner during the gestational period is relevant, as it can provide emotional and financial support to the pregnant woman and prevent maternal complications (10). regarding the occupation of women, there was a homogeneous distribution among the variable data, being from the home (50.6 %) and workers outside the home (49.4 %). this allows an analysis that a significant portion of these women are not in the labor market, do not have a job relationship or paid employment outside the home. this finding is in line with the patriarchal model, in which the man (father, husband) is seen as a provider and caretaker of the family, responsible for the support of the house, leaving it to work, and in which the woman fulfills her role as wife, mother and housewife (11). regarding the variable marital status, there was a predominance of women without a partner (83 %). it is important to think about unofficially and/or open marital relationships, since it is frequent to break the relationship between the baby’s father and mother, and/or make different decisions when discovering a pregnancy. these ruptures generate the woman lack of support and support from a network, if solo mothers, as well as widows and divorcees, have the propensity to make up an unprotected group. the arguments for this are justified due to the absence, for the most part, of affective, emotional, social, financial and encouragement to self-care, both by the baby’s father and family. the presence of a partner during the gestational period is relevant, as it can provide emotional and financial support to the pregnant woman and prevent maternal complications (10). regarding the occupation of women, there was a homogeneous distribution among the variable data, being from the home (50.6 %) and workers outside the home (49.4 %). this allows an analysis that a significant portion of these women are not in the labor market, do not have a job relationship or paid employment outside the home. this finding is in line with the patriarchal model, in which the man (father, husband) is seen as a provider and caretaker of the family, responsible for the support of the house, leaving it to work, and in which the woman fulfills her role as wife, mother and housewife (11). regarding religion, there was a predominance of women with religion (84.5 %) and the finding of the absence of this information in 30.1 % of the medical records. this reveals the underreporting of religion by professionals who perform the admission of women and consequently generates a limitation in this study to better analyze the distribution of this variable. on the clinical variables, the prevalence results of pph found in this study (38.6 %) differ from national and international literature ranging from 5 % to 15 %, ranging from 2 % to 4 % in normal deliveries and 6 to 7 % in cesarean deliveries (1). the prevalence of pph in brazil may be even higher, since the disease is highly underreported, especially in the northeast region, which has the highest rate of underreporting of maternal mortality, parallel to characteristics such as high percentage of illiteracy, greater public vulnerability due to economic income, social deficiencies and problems found to access health services and make use of them (7). regarding the causes attributed to pph in this study, they are in accordance with current scientific evidence that is highlighted worldwide for uterine atony (80 %), followed by path lacerations, placental retention, and coagulation disorders (1). the results show that the predominant mode of birth was cesarean section (59 %), and the minority presented dystocia (12 %). the prevalence of cesarean section in this maternity ward is higher than that recommended by the who (15 %), a factor that corroborates negative outcomes, higher rate of complications, higher prevalence of pph and contributes to the increase in maternal mortality rates. in this sense, to ensure the safety of women and their children, normal birth should be encouraged because it is associated with fewer negative outcomes (12). the variable induction of birth can be observed in 39.8 %, and most of these inductions were performed without a clear indication, inferring that it is a non-standardized care routine. the drugs used in this case, such as oxytocin alone, the association with misoprostol and then misoprostol alone, presented homogeneously during the distribution of use; in studies, isolated misoprostol was the most indicated option, as it was more associated with the success of induction, resulting in more vaginal deliveries (13). the risk classification presented homogeneous distribution; although the maternity study had a high-risk prenatal outpatient clinic, women had a usual risk rating of 43.4 % and a high risk of 56 %. following these clinical characteristics of hospitalized women, it is important to consider that the obstetrician nursing professional is qualified and qualified to provide birth care for women classified as habitual risk (1). in the normal birth group, the variable birth care can be observed that the care provided by the physician (60 %), in relation to the obstetric nursing professional (40 %), predominates in this maternity ward. about this, a study pointed out that the obstetrician nursing professional is a strategic agent in stimulating normal birth aimed at evaluating the well-being of women, fetuses and the evolution of childbirth, following good practices and respect for scientific evidence. consequently, it strengthens women’s empowerment through the exercise of autonomy in the choices for preferences and respect for the expectations of this woman (14). the nursing team in the birth process with its closest care corroborates the early detection of possible alterations that indicate signs of pph and may also use some maneuvers to prevent maternal death, in the conduct of situations and management, including the diagnosis of those who are more prone to these risks. the nursing professional can act to bring to the patient the possibility of minor damage to their health, which is why he becomes an indispensable actor to the multidisciplinary team (14). it is worth mentioning that, in the variable birth position, in the normal birth group, 65 % experienced verticalization. throughout humanity, women have chosen to give birth in different positions. primitive women reached different upright positions, kneeling, crouching, seated, semis-seated, with the aid of sticks, nets, hanging with ropes, and in the vertical position, which became the most popular in history. however, from the technicalization and medicalization of childbirth, most women have horizontal birth because of fear of pain, the search for health safety, lack of freedom of choice, among other factors (15). light technologies are characterized as care actions, considered attributes of the human relationship, in which it is possible for professionals to develop quality care through touch, listening to preferences, claims and the use of non-pharmacological methods for pain relief, and the nursing professional obstetrician is the one who has the greatest connection with this practice (16). in this sense, it was possible to observe that the minority (25 %) women received care through light technologies. there was a higher proportion of use of light technologies in the group of normal birth in childbirth care by obstetric nursing professionals compared to physicians (p-value = 0.001), and a statistically significant difference. when analyzing the variable of breastfeeding in the first hour of life, it is noted in the results of this study that the higher frequency predominated (81.9 %) of women who did not breastfeed in this “golden hour”. there was an association in the bivariate analysis between pph and non-breastfeeding in the first hour of life (p-value = 0.039). breastfeeding plays an important role in several aspects and being early, reflects several advantages for women, such as decreased risk of hemorrhage, postpartum depression, increased bond with the child, improvement of postpartum libido, stress reduction and mood (17). in the multivariate analysis, factors associated with pph were identified in multiparous women (with three or more previous pregnancies) who had a prevalence of pph almost twice. this result corroborates a study that addresses the relationship between the number of pregnancies and maternal mortality, which has pph as its main cause in the world. soares, schor and tavares (18) analyzed 822 maternal deaths, in which a quarter, 206, were multiparous (five or more pregnancies were six times higher than for women with up to two pregnancies), and sociodemographic and reproductive profiles were more unfavorable for this group of multiparous women. low schooling, age equal to or above 30 years and prenatal care with less than four consultations were associated with the highest number of pregnancies. the proportion of deaths from indirect obstetric causes, hemorrhages and abortion was higher among multiparous women, and about 90 % of deaths in this group were considered preventable. when observing the variable of breastfeeding in this study, an important statistical association was found in which not breastfeeding in the first hour of life increased this prevalence by more than four times (table 3). during breastfeeding, the discharge of hormone that occurs reduces the size of the uterus, releases the placenta, decreases postpartum bleeding, causes a delay of menstruation and consequent prevention of anemia. this effect is mediated by the hormone oxytocin, which is released into the bloodstream during breastfeeding at high levels. the onset of oxytocin release begins at the time of birth for the promotion of uterine contraction. its action is continuous and enhanced in the act of breastfeeding by the stimulation that suction causes on the pituitary (17). oxytocin and prostaglandin hormones play a key role in the third phase of birth, as they are responsible for uterine contraction during this stage. receptors in uterine muscles are stimulated by exogenous or endogenous oxytocin, leading to uterine contractions. consequently, these can reduce bleeding during the third stage of labor (19). it is important to note that, since the mother expels the fetus and the placenta, an important process develops that consists of a powerful uterine contraction caused by natural oxytocin produced by sucking stimulus during breastfeeding, whose function is to close the blood vessels of the uterus, which allows bleeding to be minimal in the mother. when this process does not occur and there is a lack of this production of oxytocin due to the absence of breastfeeding, uterine atony or inertia originates and may have fatal consequences for the parturient, which characterizes one of the three main causes of maternal mortality in the world (20). conclusions when investigating pph in women attended in the maternity study, it was possible to identify, in relation to sociodemographic characteristics, the predominance of black women who end up being more susceptible to morbidities that result in maternal death from pph. regarding clinical characteristics, there was a high prevalence of pph (38.6 %) and atony (25.6 %), the main cause attributed during the period from january to december 2018. the bivariate analysis showed statistical significance with an association between pph and non-breastfeeding in the first hour of life (p = 0.039). when observing the factors associated with pph in the multivariate analysis, it was identified that multiparous women had an increase in the prevalence of pph by almost twice (pr = 1.97). not breastfeeding in the first hour of life increased this prevalence more than four times (pr = 4.16). this study suggests the construction of strategies for the reduction of pph, the reduction of cesarean sections, the expansion of women’s access to light care technologies and the implementation of obstetrician nursing professional care in a way that prioritizes respect for the physiology of women during their birth process. it is emphasized that the monitoring of multiparous women and the greater incentive to exclusive breastfeeding in the first hour of life are measures that can contribute to the reduction of the prevalence of pph and its complications in this maternity ward. the results found confirm the magnitude of the frequency of pph in this maternity ward; although the study had a sample considered small, the cross-sectional design allowed to find associated factors, but without establishing a causal relationship. considering these limitations, we emphasize the importance of conducting research and scientific evidence on this object and the need for further studies to investigate, in addition to statistical analyses, clinical significance to better understand the implications of pph for women’s health. conflict of interest: none declared. references 1. organização 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horizontal en mujeres que asisten al centro de salud de biblián 2018. pol. con. 2019;4(12):3-21. disponible en: https://polodelconocimiento.com/ojs/index.php/es/article/view/1188 16. ministério da saúde do brasil. departamento de gestão e incorporação de tecnologias em saúde. entendendo a incorporação de tecnologias em saúde no sus: como se envolver. brasília: ministério da saúde do brasil; 2016. 17. neovita study group. timing of initiation, patterns of breastfeeding, and infant survival: prospective analysis of pooled data from three randomised trials. lancet glob health. 2016;4(4):e266-e275. doi: https://doi.org/10.1016/s2214-109x(16)00040-1 18. soares vmn, schor n, tavares cm. vidas arriscadas: uma reflexão sobre a relação entre o número de gestações e mortalidade materna. rev. bras. crescimento desenvolv. hum. 2008;18(3):254-63. doi: https://doi.org/10.7322/jhgd.19888 19. abedi p, jahanfar s, namvar f, lee j. breastfeeding or nipple stimulation for reducing postpartum haemorrhage in the third stage of labour. cochrane database syst rev. 2016;(1):cd010845. doi: https://doi.org/10.1002/14651858.cd010845.pub2 20. checa vera jl, vizuete cevallos tj. atonía uterina asociada a expulsivo prolongado en mujeres de 15 a 35 años en hospital gustavo domínguez-santo domingo de los tsachilas, janeiro a junho de 2019 [proyecto de investigación para la obtención del título de obstetriz/obstetra]. babahoyo-los ríos: universidad técnica de babahoyo; 2019. disponível em: http://dspace.utb.edu.ec/bitstream/handle/49000/8079/p-utb-fcs-osbt-000157.pdf?sequence=1&isallowed=y home 1 luciana andressa feil weber1 maria alice dias da silva lima2 aline marques acosta3 qualidade da transição do cuidado e sua associação com a readmissão hospitalar* 1 https://orcid.org/0000-0002-9384-0521. escola de enfermagem, universidade federal do rio grande do sul, brasil. 2 https://orcid.org/0000-0002-3490-7335. escola de enfermagem, universidade federal do rio grande do sul, brasil. 3 https://orcid.org/0000-0002-4816-6056. escola de enfermagem, universidade federal do rio grande do sul, brasil. alacosta@hcpa.ufrgs.br * artigo extraído da dissertação de mestrado intitulada “avaliação da transição do cuidado de pacientes com doenças crônicas do hospital para o domicílio”, apresentada no programa de pós-graduação em enfermagem da universidade federal do rio grande do sul, brasil, em 2018. recebido: 03/09/2019 submetido: 30/10/2019 aceito por pares: 15/11/2019 aceito: 25/11/2019 doi: 10.5294/aqui.2019.19.4.5 para citar este artigo / para citar este artículo / to reference this article weber laf, lima mads, acosta am. quality of care transition and its association with hospital readmission. aquichan. 2019;19(4): e1945. doi: https://doi.org/10.5294/ aqui.2019.19.4.5 resumo objetivo: avaliar a qualidade da transição do cuidado de pacientes com doenças crônicas e verificar sua associação com a readmissão hospitalar em até 30 dias após a alta. método: estudo epidemiológico transversal com 210 pacientes com doenças crônicas que tiveram alta de um hospital no sul do brasil. utilizou-se o instrumento care transition measure-15, por meio de contato telefônico e, para identificar as readmissões em até 30 dias, consultou-se o sistema de gestão hospitalar. foram realizados testes t-student, análise de variância e correlação não paramétrica de pearson ou spearman. resultados: a pontuação do ctm-15 foi de 74,7 (± 17,1). não foi encontrada associação significativa entre a qualidade da transição do cuidado e a readmissão hospitalar. foram readmitidos 12,3 % pacientes, sendo 46,2 % das readmissões no serviço de emergência. conclusões: a qualidade da transição do cuidado de doentes crônicos de unidades de internação clínica para o domicílio apresentou um escore satisfatório. entretanto, não foi verificada associação entre a qualidade da transição do cuidado e a readmissão hospitalar em até 30 dias após a alta. palavras-chave (fonte: decs) continuidade da assistência ao paciente; alta do paciente; readmissão do paciente; doença crônica; enfermagem. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1945 temática: cuidado crônico. contribuição para a disciplina: a atuação qualificada dos enfermeiros é fundamental para a efetivação de transições do cuidado seguras na alta do hospital para o domicílio, proporcionando continuidade do cuidado e melhoria da qualidade da assistência de enfermagem. os resultados desta pesquisa estimulam novas reflexões sobre a qualidade das transições do cuidado e sua associação com a readmissão hospitalar, além de incentivar inovação no processo de trabalho, nas práticas assistenciais e nas políticas de saúde, o que contribuiria para a visibilidade e a valorização da enfermagem no desenvolvimento de transições do cuidado a pessoas com doenças crônicas não transmissíveis. https://orcid.org/0000-0002-9384-0521 https://orcid.org/0000-0002-3490-7335 https://orcid.org/0000-0002-4816-6056 https://doi.org/10.5294/aqui.2019.19.4.5 https://orcid.org/0000-0002-9384-0521 https://orcid.org/0000-0002-3490-7335 https://orcid.org/0000-0002-4816-6056 https://doi.org/10.5294/aqui.2019.19.4.5 https://doi.org/10.5294/aqui.2019.19.4.5 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1945 calidad de la transición del cuidado y su asociación con la readmisión hospitalaria* resumen objetivo: evaluar la calidad de la transición del cuidado de pacientes con enfermedades crónicas y averiguar su asociación con la readmisión hospitalaria en hasta 30 días luego del alta. método: estudio epidemiológico trasversal con 210 pacientes con enfermedades crónicas que tuvieron salida de un hospital ubicado en el sur de brasil. se empleó el instrumento care transition measure-15, por medio de contacto telefónico y, para identificar las readmisiones en hasta 30 días, se consultó el sistema de gestión hospitalaria. se realizaron pruebas t-student, análisis de variancia y correlación no paramétrica de pearson o spearman. resultados: el puntaje del ctm-15 fue de 74,7 (± 17,1). no se encontró asociación significativa entre la calidad de la transición del cuidado y la readmisión hospitalaria. se readmitió el 12,3 % pacientes, en que el 46,2 % de las readmisiones fue al servicio de urgencias. conclusiones: la calidad de la transición del cuidado de enfermos crónicos de unidades de hospitalización clínica hacia el domicilio presentó un indicador satisfactorio. sin embargo, no se encontró asociación entre la calidad de la transición del cuidado y la readmisión hospitalaria en hasta 30 días luego del alta. palabras clave (fuente: decs) continuidad de la atención al paciente; alta del paciente; readmisión del paciente; enfermedad crónica; enfermería. * artículo extraído de la tesis de maestría titulada “avaliação da transição do cuidado de pacientes com doenças crônicas do hospital para o domicílio”, presentada al programa de posgrados en enfermería de la universidade federal do rio grande do sul, brasil, en 2018. 3 qualidade da transição do cuidado e sua associação com a readmissão hospitalar l luciana andressa feil weber e outros quality of care transition and its association with hospital readmission* abstract objective: to evaluate the quality of care transition for patients with chronic diseases and to verify its association with hospital readmission within 30 days after discharge. method: cross-sectional epidemiological study of 210 patients with chronic diseases discharged from a hospital in southern brazil. the care transition measure-15 (ctm-15) instrument was used, through a telephone contact and, in order to identify readmissions within 30 days, the hospital management system was consulted. student’s t-tests analysis of variance and nonparametric pearson or spearman correlation tests were performed. results: ctm-15 score was 74.7 (± 17.1). no significant association was found between the quality of care transition and hospital readmission. 12.3 % of the patients were readmitted, and 46.2 % of these readmissions were to the emergency service. conclusions: the quality of the care transition for chronic patients from inpatient units to home, showed a satisfactory score. however, there was no association between the quality of care transition and hospital readmission within 30 days after discharge. keywords (source: decs) continuity of patient care; patient discharge; patient readmission; chronic disease; nursing. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1945 * article extracted from the master’s dissertation entitled “avaliação da transição do cuidado de pacientes com doenças crônicas do hospital para o domicílio”, presented in the nursing graduate program of the federal university of rio grande do sul, brazil, in 2018. 4 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1945 aquichan issn 1657-5997 eissn 2027-5374 introdução o período após a alta hospitalar é um momento de desafios para pacientes e familiares (1), pois encontram dificuldades na realização das atividades diárias e dúvidas quanto ao gerenciamento do autocuidado (2). tais problemas podem ocasionar baixa adesão ao tratamento, eventos adversos relacionados às medicações de uso contínuo (3) e exacerbação da doença de base (4), o que pode levar a readmissões. as readmissões hospitalares, além de trazerem prejuízos aos pacientes, acarretam maiores custos ao sistema de saúde, o que torna importante o desenvolvimento de medidas para evitá-las (5). altas taxas de readmissão nos hospitais podem estar relacionadas a fatores potencialmente evitáveis como planejamento de alta ineficiente, eventos adversos a medicamentos, falta de acompanhamento na atenção primária e insuficiente continuidade no cuidado após a alta (6). estima-se que, aproximadamente, um quarto das readmissões nos estados unidos seja potencialmente evitável (7). além disso, algumas doenças crônicas não transmissíveis (dcnt), como doenças cardiovasculares, respiratórias, neoplasias e diabetes, são associadas a altas taxas de readmissão (7), necessitando de maiores cuidados na preparação para a alta hospitalar. no contexto mundial, as dcnt têm causado elevado número de mortes prematuras, diminuição da qualidade de vida e são responsáveis por impactos econômicos para as famílias, as comunidades e a sociedade (8). portadores de doenças crônicas são mais vulneráveis à readmissão hospitalar, pois possuem maiores dificuldades para gerenciar os cuidados no ambiente domiciliar e necessitam de continuidade dos cuidados em longo prazo (9). no brasil, as dcnt são a principal causa de morbimortalidade e de grande parte das hospitalizações, o que constitui um grave problema de saúde pública (10). esses indivíduos são responsáveis por 12,7 % das reinternações nos estados unidos (2) e 27,4 % na itália (7). no brasil, estudo realizado no rio de janeiro identificou que 40,4 % dos pacientes com doenças crônicas foram readmitidos após a alta (11). a transição do cuidado é uma importante estratégia para evitar readmissões hospitalares, uma vez que contribui para a coordenação e a continuidade dos cuidados (12), minimizando os eventos adversos e as demais complicações pós-alta (13). ações realizadas incluem o planejamento de alta, a educação em saúde, a promoção do autogerenciamento dos cuidados, as orientações sobre as medicações e a articulação com a rede de saúde (14). essa estratégia é amplamente utilizada em diversos países com idosos, doentes crônicos, pacientes com diversos planos terapêuticos e complexas condições de saúde (15). nos últimos anos, é crescente o interesse de pesquisadores e gestores em saúde em estudar a temática da transição do cuidado. estudos internacionais verificaram a associação da qualidade da transição do cuidado com a readmissão hospitalar, identificando a redução das taxas de readmissão quando a qualidade da transição é elevada (1, 13). entretanto, no brasil, a literatura é escassa. existem pesquisas que avaliam aspectos pontuais da transição do cuidado, como ações de planejamento de alta, educação sobre autocuidado e medicamentos (4), acompanhamento domiciliar (16) e percepção dos enfermeiros sobre atividades realizadas durante as transições do cuidado (17), as quais demonstram fragilidades no sistema de saúde na garantia de transições seguras. identifica-se a inexistência de estudos que verifiquem a associação entre a qualidade da transição do cuidado e as readmissões hospitalares no cenário brasileiro, o que indica importante lacuna do conhecimento. reconhece-se que a atuação qualificada dos enfermeiros é fundamental para a efetivação de transições do cuidado seguras, bem como contribui para a visibilidade e valorização da assistência de enfermagem. porém, o desenvolvimento de intervenções inovadoras e baseadas em evidências é necessário. considera-se que avaliar a qualidade das transições do cuidado de portadores de doenças crônicas é importante para o aperfeiçoamento das práticas de transição do cuidado, bem como para a avaliação e o gerenciamento dos cuidados de doentes crônicos após a alta hospitalar. ademais, conhecer aspectos que podem acarretar readmissão hospitalar oferece subsídios para o aprimoramento de práticas assistenciais e de gestão para a melhoria da qualidade do cuidado em saúde. diante do exposto, o objetivo deste estudo é avaliar a qualidade da transição do cuidado de pacientes com doenças crônicas e verificar sua associação com a readmissão hospitalar em até 30 dias após a alta. este estudo está fundamentado nos princípios do programa care transitions program (ctp), desenvolvido para dar suporte a pacientes com necessidades complexas de cuidado e seus cuida5 qualidade da transição do cuidado e sua associação com a readmissão hospitalar l luciana andressa feil weber e outros dores, e promover transições do cuidado qualificadas e seguras, do hospital para o domicílio. o programa é sustentado por quatro pilares: registros centrados nos pacientes, autogerenciamento dos medicamentos, conhecimento dos sinais de alerta, acompanhamento na atenção primária e especializada (18). método trata-se de um estudo epidemiológico observacional e transversal, realizado em um hospital geral, público e universitário do sul do brasil. o hospital atende mais de 60 especialidades médicas, com 833 leitos; destes, 645 de internação. a população foi composta por pacientes com doenças crônicas que tiveram alta de unidades de internação clínica para o domicílio, identificados por meio de relatório do sistema informatizado de gestão hospitalar. para o cálculo amostral, foi utilizado um erro absoluto de 4 pontos, média 69 ± 27 de desvio-padrão e nível de confiança de 95 %, segundo estudo anterior que utilizou o mesmo instrumento para a coleta de dados (19), definindo-se uma amostra aleatória de 210 pacientes. foram estabelecidos como critérios de inclusão: ter idade igual ou superior a 18 anos, possuir doença crônica (neoplasias, doenças cardiovasculares, diabetes mellitus, doenças respiratórias, doenças neuropsiquiátricas e musculoesqueléticas) e ter recebido alta da unidade de internação clínica para o domicílio. além disso, o paciente deveria ter permanecido internado, no mínimo, por 72 horas no hospital e por 24 horas nas unidades de internação clínica. foram excluídos da amostra os pacientes que tiveram óbito ou que foram readmitidos no momento da coleta de dados. quando o paciente não tinha condições clínicas ou de comunicação para responder ao instrumento, o cuidador que acompanhou a internação e as orientações para a alta participou como respondente substituto. os instrumentos foram respondidos por 141 pacientes e 69 cuidadores. a coleta dos dados foi realizada em duas etapas. a primeira ocorreu no período de março a agosto de 2017 e utilizou a versão do instrumento ctm-15, adaptada e validada para o brasil, para avaliar a qualidade da transição do cuidado. a versão brasileira do instrumento tem equivalência semântica com o original, é confiável e apresenta validade de face e conteúdo. possui boa estabilidade no tempo e demonstra boa consistência interna (alfa de cronbach = 0,929) (19). o instrumento é composto por 15 itens, que são divididos em quatro fatores: “preparação para o autogerenciamento”, “entendimento sobre medicações”, “preferências asseguradas” e “plano de cuidado”. possui opções de respostas do tipo escala de likert de cinco pontos. a aplicação do instrumento ocorreu entre uma e quatro semanas após a data da alta hospitalar, por meio de contatos telefônicos (12). ademais, foi preenchida uma ficha de identificação com informações de caracterização dos pacientes a partir dos dados contidos no relatório do sistema informatizado. a segunda etapa da coleta de dados foi realizada em novembro de 2017. para identificar os participantes que foram readmitidos em até 30 dias após a data da alta na hospitalização index, obteve-se um novo relatório do sistema informatizado de gestão hospitalar, o qual continha informações referentes ao motivo e data da readmissão, à unidade em que foi readmitido e ao tempo de permanência na reinternação. as respostas a cada item do ctm-15 foram pontuadas do seguinte modo: 0 pontos — “não sei/não me lembro/não se aplica”; 1 ponto — “discordo muito”; 2 pontos — “discordo”; 3 pontos — “concordo”; 4 pontos — “concordo muito”. para identificar a média dos escores, utilizou-se uma fórmula que transforma as médias obtidas em escores de 0 a 100, sendo que, quanto maior o escore, melhor é a transição do cuidado (18). os autores do instrumento original indicam que escores iguais ou superiores a 70 podem ser considerados satisfatórios (12). os dados foram exportados para uma planilha no programa excel, com a realização de dupla checagem dos dados. a análise foi realizada por meio do programa statistical package for the social science (spss), versão 18. foi utilizada estatística descritiva com a apresentação de dados de frequência absoluta (n) e percentual (%) das variáveis categóricas para descrever o perfil da amostra e foi utilizado o cálculo de medidas de posição e dispersão (média, mediana, desvio-padrão, valores mínimo e máximo) para as variáveis contínuas. utilizaram-se os testes t-student, a análise de variância (anova), a correlação não paramétrica de pearson ou spearman, com margem de erro de 5 % (p ≤ 0,05) e nível de confiança de 95 %. o estudo foi conduzido com base nos princípios éticos de pesquisa que envolve seres humanos, segundo a resolução 466/2012 do conselho nacional de saúde (20), e foi aprovado pelo comitê de 6 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1945 aquichan issn 1657-5997 eissn 2027-5374 ética em pesquisa da instituição hospitalar (certificado de apresentação para apreciação ética número 63817417.5.0000.5327). foi obtido consentimento tácito para a participação na pesquisa, por meio de concordância verbal do participante no momento do contato telefônico, utilizando-se um roteiro com informações sobre o objetivo, a justificativa, a finalidade, o tempo destinado a responder ao instrumento, os riscos e benefícios da pesquisa, a garantia de voluntariedade e o anonimato. resultados houve prevalência de homens (52,4 %), média de idade de 60,9 anos (± 15) e ensino fundamental incompleto (50,5 %). as doenças mais frequentes foram as neoplásicas malignas (47,6 %) e cardíacas (45,7 %) (tabela 1). verificou-se que 25 % dos pacientes possuíam duas ou mais doenças (dado não mostrado em tabela). a média dos escores do ctm-15 foi de 74,7 (± 17,1). o fator 1 (preparação para o autogerenciamento) obteve escore médio de 78,1 (± 19,7), o fator 2 (entendimento sobre medicações) 69,0 (± 28,1), o fator 3 (preferências asseguradas) 69,7 (± 21,2) e o fator 4 (plano de cuidado) 78,8 (± 23,3). a tabela 2 apresenta as médias dos escores de cada item do instrumento. os itens 9 e 12 obtiveram as maiores médias. o item 9 é relacionado à compreensão do que é da responsabilidade do paciente para cuidar da saúde após a alta, e o item 12 é referente ao recebimento de uma lista de consultas ou exames para realizar depois da alta. os itens 2 e 15 obtiveram as menores médias. o item 15 refere-se a ter conhecimento dos efeitos colaterais das medicações de uso após a alta, e o item 2 considera as preferências dos pacientes para decidir as necessidades de saúde. identificou-se que 26 pacientes (12,3 %) foram readmitidos em até 30 dias após a alta, sendo 30,8 % pelo mesmo motivo da internação anterior e 61,5 % por doença inserida no mesmo grupo de classificação. verificou-se que 46,2 % foram readmitidos no serviço de emergência e 53,8 % em unidades de internação. foram obtidos maiores escores nas respostas no ctm-15 daqueles que foram readmitidos, embora as diferenças não tenham sido significativas. não houve correlação significativa entre o tempo da alta até a readmissão e os escores do ctm-15. contudo, pacientes que tiveram intervalo maior de tempo desde a alta até a readmissão foram mais propensos a terem escores maiores no fator 1 (tabela 3). tabela 1. caracterização da amostra. porto alegre, 2017 variáveis total amostra (n = 210) idade (anos)† 60,9 ± 15,0 sexo masculino* 110 (52,4) escolaridade (anos)* nenhum 9 (4,3) ensino fundamental incompleto 106 (50,5) ensino fundamental completo 25 (11,9) ensino médio incompleto 13 (6,2) ensino médio completo 27 (12,9) ensino superior incompleto 2 (1,0) ensino superior completo 18 (8,6) não registrado 10 (4,8) doenças crônicas*†† cardíacas 100 (47,6) neoplásicas malignas 96 (45,7) renais 19 (9,0) diabetes mellitus 18 (8,6) neurológicas 18 (8,6) respiratórias 16 (7,6) cirrose hepática 13 (6,2) musculoesqueléticas 5 (2,4) tempo de permanência (dias) na unidade‡ 4 (3-6) número de internações prévias‡ 4 (3-6) readmissão em 30 dias* sim 26 (12,3) não 184 (87,7) tempo (dias) decorrido da alta até reinternação* ≤ 7 dias 4 (15,4) 8 a 14 dias 5 (19,2) 15 a 21 dias 11 (42,3) acima de 21 dias 6 (23,1) fonte: elaborado pelas autoras, 2019. * variáveis categóricas expressas como n(%); †variáveis contínuas expressas como média ± desvio-padrão; ††mais de uma doença por paciente. ‡variáveis assimétricas apresentadas como mediana e intervalo interquartil. 7 qualidade da transição do cuidado e sua associação com a readmissão hospitalar l luciana andressa feil weber e outros tabela 2. itens por fatores, média e desvio-padrão dos escores dos itens do ctm-15 (n = 210). porto alegre, 2017 item fator média ± dp 1. concordou com a equipe de saúde sobre os objetivos para sua saúde e como eles seriam alcançados 3 70,7 ± 27,7 2. preferências consideradas para decidir as necessidades de saúde 3 65,4 ± 28,2 3. preferências consideradas para decidir onde as necessidades de saúde são atendidas 3 69,8 ± 30,8 4. teve informações que precisava para o autocuidado 1 75,7 ± 28,0 5. entende claramente como cuidar da saúde 1 78,4 ± 25,9 6. entende sinais de alerta e sintomas 1 72,2 ± 32,5 7. recebeu um plano escrito de cuidados 4 76,9 ± 28,1 8. compreende o que melhora ou piora sua condição de saúde 1 78,4 ± 28,8 9. compreende o que é de sua responsabilidade 1 84,1 ± 21,2 10. sente-se seguro de que sabe o que fazer 1 76,9 ± 26,9 11. sente-se seguro de que consegue fazer o que é necessário 1 74,5 ± 26,3 12. recebeu lista escrita das consultas ou exames 4 79,9 ± 27,0 13. entende o motivo de tomar os medicamentos 2 74,8 ± 32,2 14. entende como tomar os medicamentos 2 78,1 ± 29,8 15. entende os efeitos colaterais dos medicamentos 2 51,9 ± 38,2 fonte: elaborado pelas autoras, 2019. tabela 3. associação e correlação dos escores total e por fator do ctm 15-brasil com a readmissão em até 30 dias após a alta. porto alegre, 2017 variáveis total fator 1 fator 2 fator 3 fator 4 readmissão† sim* 79,2 ± 13,4 83,7 ± 13,6 74,4 ± 26,8 71,4 ± 19,4 82,7 ± 18,5 não* 72,9 ± 18,3 76,1 ± 21,5 67,4 ± 28,3 68,3 ± 22,6 77,8 ± 23,9 p 0,096 0,082 0,238 0,511 0,316 tempo da alta até a readmissão ‡ coeficiente de correlação 0,275 0,372 0,252 0,235 0,173 p 0,174 0,062 0,214 0,248 0,397 fonte: elaborado pelas autoras, 2019. * valores expressos como média ± desvio-padrão. †utilizado o teste t-student. ‡utilizado o teste de correlação de spearman. ao comparar os itens do instrumento com a readmissão, evidenciou-se que pacientes com readmissão obtiveram médias mais altas em quase todos os itens do que os que não foram readmitidos, sendo apenas o item 2 com menor média. diferença significativa foi encontrada no item 5 (tabela 4). tabela 4. média e desvio-padrão dos itens relacionados com pacientes que foram readmitidos e não readmitidos. porto alegre, 2017 item com readmissão sem readmissão p média ± dp média ± dp 1. concordou com a equipe de saúde sobre objetivos para sua saúde e como eles seriam alcançados 72,0 ± 20,8 70,5 ± 28,5 0,802 2. preferências consideradas para decidir as necessidades de saúde 65,3 ± 24,5 65,4 ± 28,8 0,993 3. preferências consideradas para decidir onde as necessidades de saúde são atendidas 74,4 ± 25,5 69,2 ± 31,5 0,425 4. teve informações que precisava para autocuidado 84,6 ± 19,4 74,5 ± 28,8 0,083 5. entende claramente como cuidar da saúde 88,5 ± 16,2 77,0 ± 26,7 0,004‡ 6. entende sinais de alerta e sintomas 82,1 ± 25,4 70,9 ± 33,2 0,100 7. recebeu um plano escrito de cuidados 81,9 ± 24,0 76,2 ± 28,6 0,347 8. compreende o que melhora ou piora sua condição de saúde 85,9 ± 19,3 77,3 ± 29,8 0,057 9. compreende o que é de sua responsabilidade 87,2 ± 19,0 83,6 ± 21,5 0,423 10. sente-se seguro de que sabe o que fazer 78,2 ± 23,0 76,7 ± 27,5 0,786 11. sente-se seguro de que consegue fazer o que é necessário 79,5 ± 25,1 73,8 ± 26,5 0,301 12. recebeu lista escrita das consultas ou exames 82,7 ± 19,5 79,5 ± 27,9 0,584 13. entende o motivo de tomar os medicamentos 82,1 ± 28,6 73,7 ± 32,6 0,218 14. entende como tomar os medicamentos 80,8 ± 28,6 77,7 ± 30,1 0,626 15. entende os efeitos colaterais dos medicamentos 60,3 ± 37,7 50,7 ± 38,2 0,234 fonte: elaborado pelas autoras, 2019. ‡ significância estatística (p ≤ 0,05). 8 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1945 aquichan issn 1657-5997 eissn 2027-5374 discussão este estudo avaliou a qualidade da transição do cuidado de pacientes com doenças crônicas, com a utilização do instrumento ctm, e testou sua associação com a readmissão hospitalar. embora o ctm seja o instrumento validado mais utilizado para avaliar a qualidade da transição do cuidado no mundo, é pontuado conforme as experiências vivenciadas pelos pacientes e cuidadores, o que pode gerar dados mais auspiciosos do que a realidade (21). considera-se que a transição do cuidado é complexa e envolve questões relacionadas à atuação dos profissionais, ao uso de protocolos clínicos, à organização da rede de atenção à saúde, entre outros. assim, a avaliação da qualidade da transição do cuidado é um desafio que necessita ser enfrentado a partir de múltiplos olhares e de diferentes instrumentos e indicadores (21). nesta pesquisa, foi verificado que a média do escore do ctm-15 foi de 74,7. estudos que utilizaram o ctm em unidades de internação encontraram resultados heterogêneos. foram identificados escores que variaram entre 66,6 e 82,4 nos estados unidos da américa (22, 23) e 76,4 no brasil (19). neste estudo, aspectos relacionados à preparação para o autogerenciamento e ao plano de cuidados obtiveram resultados positivos na perspectiva dos pacientes e de seus cuidadores. por outro lado, itens referentes ao entendimento sobre as medicações e à garantia das preferências dos pacientes e familiares obtiveram as piores médias nos escores do instrumento. outro estudo que utilizou o ctm-15 também encontrou achados semelhantes (22). o fator 4, que obteve maior pontuação nos escores por fator do ctm-15, é relacionado ao plano de alta e aos encaminhamentos após a alta hospitalar. a utilização de planos de alta e o estabelecimento de fluxos auxiliam o gerenciamento dos cuidados, bem como facilitam a transição do cuidado entre os diferentes níveis de assistência, o que proporciona a continuidade do cuidado (15). entretanto, identifica-se que ainda existem problemas de desarticulação entre os serviços na rede de atenção à saúde (24), principalmente quanto a encaminhamentos e/ou acompanhamento do problema de saúde quando se encontram na comunidade, o que gera a fragmentação dos cuidados após a alta (6). em estudo brasileiro, em um serviço de emergência, enfermeiros residentes realizaram contatos telefônicos para enfermeiros da atenção primária à saúde (aps), nos quais forneceram informações pertinentes sobre o quadro de saúde de pacientes com alta hospitalar e que necessitavam de cuidados após seu retorno para casa, o que fortaleceu a comunicação entre o hospital e a aps (25). o fator 1 é referente às informações recebidas durante a internação do paciente, principalmente sobre sinais e sintomas da exacerbação da doença crônica e informações para aprimorar o autocuidado no ambiente domiciliar. apesar de o fator 1 ter obtido média alta, o item 11, referente a sentir-se seguro de que consegue fazer o que é necessário para cuidar da saúde, foi identificado com média mais baixa entre os itens do fator, o que demonstra fragilidades nas informações prestadas aos pacientes. dado similar foi encontrado em estudo realizado nos estados unidos, no qual os pacientes e os cuidadores não se sentiam seguros para gerenciar os cuidados no retorno para o domicílio (22). a comunicação entre os profissionais de saúde e os pacientes é de suma importância e visa aprimorar os cuidados diários após a alta hospitalar. o enfermeiro, ao propiciar um ambiente passível para a exposição de problemas e dúvidas sobre o gerenciamento do autocuidado, pode facilitar a compreensão das orientações e, assim, proporcionar maior adesão aos cuidados e ao tratamento no domicílio (15). no entanto, sabe-se que informações referentes ao regime terapêutico e aos cuidados diários são fornecidas no momento da alta, em um período de tempo mais curto, o que pode indicar que os pacientes com necessidades complexas de cuidado sejam enviados para casa antes de serem totalmente informados, de forma clara, da sua condição de saúde (26), o que pode ocasionar complicações após a alta e reinternações desnecessárias nos serviços de emergência. o fator 3 é relacionado às preferências do paciente e familiares quanto aos cuidados com a doença crônica, no entanto tal fator obteve média baixa no escore do ctm-15. a inserção dos pacientes e familiares nas decisões do tratamento e dos cuidados tem recebido destaque durante os planejamentos de alta (26). introduzir paciente e família nas decisões sobre a gestão dos cuidados é crucial para promover o autogerenciamento dos cuidados após a alta, porém é necessário um papel mais ativo dos pacientes e da família para que isso ocorra (22). além disso, é relevante que haja mais conhecimento sobre a doença crônica para tomar decisões quanto às condutas a serem definidas, e o enfermeiro tem função importante ao promover a educação em saúde dos pacientes e da família. 9 qualidade da transição do cuidado e sua associação com a readmissão hospitalar l luciana andressa feil weber e outros já no fator 2, quanto ao entendimento sobre as medicações, aferiu-se a segunda pior média nos escores do instrumento. entretanto, salienta-se que os itens 13 e 14 foram identificados com bons escores, diferentemente do item 15, que foi o item com pior média do instrumento. resultado semelhante foi encontrado em estudo que utilizou o ctm-15, no qual o item 15 teve a média mais baixa entre os itens do instrumento (22), o que indica que as informações fornecidas sobre os efeitos colaterais foram limitadas. assim, muitos pacientes compreendem o motivo para administrar as medicações bem como sua dose diária, porém não sabem os possíveis efeitos adversos das medicações. as informações sobre o uso das medicações após a alta são de fundamental importância para evitar a ocorrência de eventos adversos no ambiente domiciliar (7). no entanto, as orientações sobre os efeitos colaterais das medicações ainda são incipientes. as informações sobre os medicamentos são fornecidas no momento da alta, e pacientes e famílias não são orientados sobre efeitos colaterais, recebendo apenas a receita médica, com dose, horário e via de administração (4), o que poderia gerar dúvidas após a alta e, por consequência, resultar em reinternações. neste estudo, 12,4 % dos participantes foram readmitidos em até 30 dias após a alta, valor inferior ao identificado em estudo brasileiro realizado com pacientes cardíacos (27). em investigações que utilizaram o ctm no âmbito internacional, encontram-se valores superiores (13) e valores inferiores de readmissão (1,22). sobre o motivo das readmissões, 30,8 % dos casos foram pelo mesmo motivo da internação anterior, e 61,5 % por doença inserida no mesmo grupo de classificação, o que está de acordo com investigações brasileiras realizadas com doentes crônicos e com comorbidades, as quais demonstraram porcentagens altas de readmissões pelo mesmo motivo (5, 27-28). estudo realizado em hospital público do estado de são paulo, brasil, identificou que as readmissões ocorreram pela mesma razão da internação anterior em 47,9 % dos pacientes (5). outro estudo com portadores de insuficiência cardíaca verificou que 96 % foram readmitidos em decorrência do que motivou a internação hospitalar prévia (28). há evidências que fragilidades na transição do cuidado ocasionam uso desnecessário de serviços de saúde, tanto em emergências como readmissões hospitalares (1). a literatura aponta que escores mais elevados do ctm diminuem as taxas de readmissão (1, 13). entretanto, neste estudo, não foram identificadas associações ou correlações entre os escores do ctm-15 com as readmissões. supõe-se que isso pode ocorrer devido ao fato de que a maioria dos pacientes pode estar muito debilitada, ser portadora de múltiplas comorbidades e/ou possuir necessidades de cuidado complexas, e as readmissões, nesses casos, não são evitáveis (29). ao associarmos os escores do ctm-15 com as readmissões, identificou-se que os escores foram maiores naqueles que readmitiram em até 30 dias após a alta, porém sem significância estatística. ainda, quando os itens do ctm-15 foram comparados com a readmissão hospitalar, encontrou-se diferença significativa no item 5, o que indica que pacientes que foram readmitidos entendiam mais de como cuidar da sua saúde em relação àqueles que não reinternaram. as doenças crônicas necessitam de cuidados contínuos ao longo do tempo, além de mudanças da vida diária e do autogerenciamento dos cuidados no ambiente domiciliar (10). no entanto, estudo brasileiro identificou que pacientes que são readmitidos pensam que seguir orientações médicas pode evitar readmissões, porém não relacionavam isso a outras ações de cuidado e acreditavam que suas readmissões ocorriam devido a condições de vida e a determinantes sociais (9). apesar de haver compreensão dos cuidados no ambiente domiciliar, os pacientes precisam saber qual a importância dos cuidados com a doença crônica, e mudanças nos hábitos diários são necessários para que a continuidade dos cuidados ocorra. a educação dos pacientes auxilia seu empoderamento, principalmente sobre aspectos relacionados ao processo saúde-doença, o que facilita entender o valor do autocuidado e propicia o manejo da doença crônica por maior tempo após a alta (9). tal evidência corrobora com o achado do estudo de que pacientes que levaram maior tempo para reinternar apresentaram escores maiores no fator 1, referente ao autogerenciamento dos cuidados após a alta hospitalar. os resultados deste estudo não encontraram associação entre a qualidade da transição do cuidado com as particularidades dos pacientes, com as características clínicas ou com as readmissões hospitalares, supondo que essas variáveis não interferem sobre a qualidade da transição do cuidado de doentes crônicos. no entanto, sugere-se que a transição do cuidado possui influência quanto às características dos serviços de saúde, podendo estar relacionada ao processo de trabalho, às práticas assistenciais e às políticas de saúde nacionais. 10 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1945 aquichan issn 1657-5997 eissn 2027-5374 conclusões a qualidade da transição do cuidado de doentes crônicos de unidades de internação clínica para o domicílio apresentou um escore satisfatório no ctm-15. os itens relacionados às orientações sobre o autogerenciamento dos cuidados, ao plano de alta e a encaminhamentos após a alta hospitalar mostraram-se como pontos favoráveis para qualificar a transição do cuidado durante as internações. no entanto, itens quanto às escolhas baseadas nas preferências dos pacientes e dos familiares para gerenciarem a doença crônica e informações sobre o uso das medicações no ambiente domiciliar necessitam de maior atenção e aprimoramento no ambiente hospitalar. não obstante esses resultados, não foi verificada associação entre o escore do ctm-15 e a readmissão hospitalar em até 30 dias após a alta. embora a readmissão seja um indicador importante para a avaliação da transição do cuidado durante o processo de alta hospitalar, entende-se que outros aspectos podem influenciar no retorno do paciente ao hospital, como gravidade e complexidade das condições de saúde, fatores institucionais e coordenação do cuidado na rede de atenção à saúde. tendo em vista os aspectos mencionados, a falta de formalização do processo de transição do cuidado é uma realidade brasileira, pois não há políticas nacionais de transição do cuidado. esse fato dificulta o compartilhamento das informações e das responsabilidades do cuidado, principalmente para pacientes com doenças crônicas e com complexas necessidades de cuidado que requerem cuidado contínuo ao longo do tempo. assim, novas investigações são necessárias a fim de avaliar e analisar, de forma mais abrangente e profunda, a qualidade da transição do cuidado e as readmissões hospitalares, observando diferentes percepções de pacientes, profissionais e gestores das instituições de saúde. também, faz-se importante avaliar os processos de trabalho nas instituições de saúde, bem como aprimorar as ações e cuidados com vistas a qualificar as transições do cuidado. como limitação, aponta-se que o estudo foi realizado com uma população de doentes crônicos e restrita a um único hospital. além disso, alguns cuidadores foram respondentes do instrumento, os quais podem ter percepções diferentes dos pacientes sobre a transição do cuidado. por fim, aponta-se a carência de estudos nacionais com a utilização do mesmo instrumento, já que se constatou o uso de diversos estudos internacionais, o que dificultou a comparação e discussão dos resultados no âmbito nacional. conflito de interesses: nenhum declarado. 11 qualidade da transição do cuidado e sua 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health care. j integr care. 2016;24(4):22532. doi: https://doi.org/10.1108/jica-06-2016-0022 26. buurman bm, verhaegh kj, smeulers m, vermeulen h, geerlings se, smorenburg s et al. improving handoff communication from hospital to home: the development, implementation and evaluation of a personalized patient discharge letter. int j qual health care. 2016;28(3):384-90. doi: https://doi.org/10.1093/intqhc/mzw046 27. rosa acm, lamari nm. caracterização de pacientes reinternados no setor de cardiologia. arq. ciênc. saúde. 2017;24(3):79-83. doi: https://doi.org/10.17696/2318-3691.24.3.2017.640 28. reis mb, dias mg, bibanco ms, lopes ct, gea gn. readmissão hospitalar por insuficiência cardíaca em um hospital de ensino do interior do estado de são paulo-sp. medicina [on-line]. 2015 [citado 28 nov. 2019];48(2):138-42. disponível em: http://www.revistas.usp.br/rmrp/article/view/99747/98168 29. arbaje ai, kansagara dl, salanitro ah, englander hl, kripalani s, jencks sf et al. regardless of age: incorporating principles from geriatric medicine to improve care transitions for patients with complex needs. j gen intern med. 2014;29(6):932-9. doi: https://doi.org/10.1007/s11606-013-2729-1 https://pesquisa.bvsalud.org/portal/resource/pt/biblio-999501 https://pesquisa.bvsalud.org/portal/resource/pt/biblio-999501 https://doi.org/10.1111/inr.12326 https://bvsms.saude.gov.br/bvs/saudelegis/cns/2013/res0466_12_12_2012.html https://doi.org/10.1161/jaha.114.001053 https://doi.org/10.1093/hsw/hlw009 https://doi.org/10.3402/meo.v20.26701 https://doi.org/10.3402/meo.v20.26701 https://doi.org/10.1590/0104-07072018004730016 https://doi.org/10.1590/0104-07072018004730016 https://doi.org/10.1108/jica-06-2016-0022 https://doi.org/10.1093/intqhc/mzw046 https://doi.org/10.17696/2318-3691.24.3.2017.640 http://www.revistas.usp.br/rmrp/article/view/99747/98168 https://doi.org/10.1007/s11606-013-2729-1 204 aquichan issn 1657-5997 diana carolina cárdenas-corredor1 brigitte melenge-díaz2 johanna pinilla3 gloria mabel carrillo-gonzález4 lorena chaparro-díaz5 soporte social con el uso de las tic para cuidadores de personas con enfermedad crónica: un estado del arte 1 enfermera, universidad nacional de colombia. dianacardenas60@hotmail.com 2 enfermera, universidad nacional de colombia. lunita1497@hotmail.com 3 enfermera, universidad nacional de colombia. jhopisar@gmail.com 4 enfermera, magíster en enfermería. profesora asistente, universidad nacional de colombia. gmcarrillog@unal.edu.co 5 enfermera; doctora en enfermería. profesora asistente, universidad nacional de colombia. olchaparrod@unal.edu.co recibido: 28 de julio de 2009 aceptado: 6 de septiembre de 2010 resumen el uso de tecnologías de información y comunicación (tic) en la nueva era es una necesidad para dar soporte social en salud. objetivo: caracterizar la producción académica y científica e identificar las estrategias y su evolución acerca del soporte social con el uso de tic para cuidadores familiares de personas con enfermedad crónica en américa en el periodo comprendido entre 1996-2009. materiales y métodos: revisión documental, descriptiva, con diseño trasversal, desarrollada mediante una búsqueda en bases de datos. se elaboró una matriz de análisis utilizando la metodología de elaboración de fichas de hoyos. resultados: para la elaboración de este estado del arte se seleccionaron 31 artículos publicados entre 1996 y 2009. la totalidad de la literatura existente en soporte social con uso de tic se ubicó en norteamérica, con una predominancia del idioma inglés, siendo su mayor producción en el 2004, de los cuales 14 eran cuantitativos y 13 cualitativos que evaluaron la calidad, satisfacción, accesibilidad, información proporcionada y estrategias de seguimiento. conclusiones: las tic en cuidadores familiares de personas con enfermedad crónica tienen un efecto protector y generan mejoría en la salud física y mental, y en el vínculo afectivo. las de mayor uso son la internet y el teléfono. se reconoce la importancia de incorporarlas en el contexto colombiano y en la práctica de enfermería a través de proyectos de investigación. palabras clave cuidadores, enfermedad crónica, apoyo social, tecnologías de la información, interacción social. (fuente: decs, bireme). social support through the use of ict for caregivers of the chronically ill: state of the art abstract the use of information and communication technology (ict) in this new era is necessary, especially to provide social support in health services. objective: characterize academic and scientific output and identify the strategies and trends in social support using ict with family caregivers of chronically ill persons in america during the period from 1996 to 2009. materials and methods: a descriptive review año 10 vol. 10 nº 3 chía, colombia diciembre 2010 l 204-213 205 soporte social con el uso de las tic para cuidadores de personas con enfermedad crónica: un estado del arte l diana carolina cárdenas-corredor, brigitte melenge díaz y otros. of documents with a cross-sectional design developed through a database search. the hoyos method for preparing record cards was used to design a matrix for the document analysis. results: thirty-one articles published between 1996 and 2009 were selected for this study on the state of the art. all existing literature on social support through the use of ict is found in north america. it is predominantly in english, and most of the articles were published in 2004: 14 quantitative and 13 qualitative studies that measure quality, satisfaction, access, information provided, and follow-up strategies. conclusions: the use of ict with family caregivers of the chronically ill has a protective effect that leads to improvement in their physical and mental health. the most widely used ict are internet and the telephone. the importance of incorporating ict in the colombian context and in nursing practice through research projects is recognized. key words caregivers, chronic disease, social support, information, technology, interpersonal relations. (source: decs, bireme). apoio social com tic para os cuidadores de pessoas com doenças crônicas: um estado da arte resumo o uso de tecnologias de informação e comunicação (tic) na nova era é necessário parao apoio social em saúde. objetivo: caracterizar a produção acadêmica e científica e identificar as estratégias e o desenvolvimento do suporte social, com o uso das tic, a cuidadores de pessoas com doença crônica en américa entre 1996 y 2009. materiais e métodos: revisão descritiva de documentos com desenho transversal, levada a cabo mediante pesquisa em bancos de dados. se construiu uma matriz de análise utilizando a metodologia de elaboração de fichas de hoyos. resultados: se seleccionaram 31 artigos publicados entre 1996 e 2009 para elaborar este estado da arte. a totalidade da literatura existente sobre apoio social das tic se localizou na américa do norte, com predominância do inglês. sua produção aumentou em 2004: 14 estudos foram quantitativos e 13 qualitativos, os quais avaliaram a qualidade, satisfação, acessibilidade, informação proporciionada e estratégias de acompanhamento. conclusões: nos cuidadores familiares de pessoas com doenças crônicas, as tic têm um efeito protector e melhoram a saúde física, assim como o apego. os mais utilizados são a internet e o telefone. se recohece a importância de incorporá-las no contexto colombiano e na prática de enfermagem através de projectos de investigação. palavras-chave cuidadores, doença crónica, apoio social, tecnologia da informação, relações interpessoais. (fonte: decs, bireme). 206 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 introducción el influjo de la globalización en el cuidado de la salud ha ido introduciendo en los últimos años herramientas como el teléfono, la internet, la radio y la televisión, que se han convertido en el medio que permite al profesional de enfermería fomentar el desarrollo de conocimientos y habilidades en las personas con enfermedades crónicas y sus cuidadores (1), así como formar redes sociales y de apoyo para facilitar un mejor proceso de adaptación frente a la enfermedad, a través de fuentes que le permiten recoger, sistematizar y difundir información con el fin de mejorar el nivel de conocimientos e inducir cambios hacia comportamientos y estilos de vida que favorecen la salud física y mental en el binomio cuidador-sujeto de cuidado (2). weiner y cols. (3) afirman que estas herramientas tecnológicas, utilizadas para proveer soporte social en salud, se han convertido en elementos altamente útiles en el abordaje del tratamiento, lo que permite proporcionar una atención oportuna y eficaz así como realizar un seguimiento oportuno, ya que eliminan barreras de accesibilidad y altos costos especialmente en comunidades vulnerables, como las que se enfrentan a enfermedades crónicas, entidades patológicas de especial interés en salud pública por su gran impacto epidemiológico. al respecto, la organización mundial de la salud (oms) (4) reporta que del total de las defunciones previstas para el 2005, el 60% correspondían a enfermedades crónicas, entre las cuales se destacan las cardiopatías, los accidentes cerebrovasculares, el cáncer, las enfermedades respiratorias crónicas y la diabetes. de acuerdo con lo anterior, es evidente la necesidad de generar intervenciones en salud que permitan el abordaje de la problemática de las enfermedades crónicas de una forma diferente, novedosa y acorde con las tendencias de la tecnología, fomentando la calidad de vida de la persona y su cuidador familiar, ya que como lo describe sánchez (5). el impacto de vivir o padecer una enfermedad crónica, o de cuidar a una persona en esa situación, genera cambios profundos y significativos en la vida de los implicados y puede modificar sus habilidades de cuidado, es así como dependiendo del afrontamiento ante el rol que cumpla tanto la persona enferma, como el nuevo cuidador, se expresará la adaptación o el desajuste frente a la condición de enfermedad crónica. asimismo, el cambio de rol, de relaciones sociales, la dificultad para alcanzar metas y realizar de forma satisfactoria el autocuidado, son algunos de los cambios a los cuales se ve enfrentado el cuidador familiar, lo cual repercute significativamente en sus esferas laboral, económica, familiar, social y psicológica, generando en muchas ocasiones la búsqueda de apoyo social. conscientes de la problemática, el grupo de investigación cuidado al paciente crónico y la familia, de la facultad de enfermería de la universidad nacional de colombia, con la vinculación de estudiantes de pregrado de enfermería, inició un proceso de documentación y revisión teórica de las estrategias de soporte social con el uso de tecnologías de la información y la comunicación (tic), para los cuidadores familiares de personas con enfermeel concepto de soporte social tomó fuerza hacia la mitad de los años setenta, y desde allí ha surgido gran interés por el estudio del mismo y su influencia sobre la salud y la enfermedad. 207 soporte social con el uso de las tic para cuidadores de personas con enfermedad crónica: un estado del arte l diana carolina cárdenas-corredor, brigitte melenge díaz y otros. dad crónica en américa en el periodo comprendido entre 1996-2009. se espera que dicha documentación y revisión teórica se constituya en un importante marco de referencia conceptual sobre la utilización de las tic, a fin de implementar estrategias exitosas, acordes con la realidad colombiana, para los cuidadores familiares de personas con enfermedad crónica. antecedentes el concepto de soporte social tomó fuerza hacia la mitad de los años setenta, y desde allí ha surgido gran interés por el estudio del mismo y su influencia sobre la salud y la enfermedad. smith y mackie (6) reportaron el gran impacto del apoyo social sobre la tasa de mortalidad de las personas con enfermedad crónica. asimismo, schwarzer y leppin (7), refieren que este tipo de apoyo social sobre la salud física, es más notable cuando es dado por la familia o los amigos que por personas lejanas al núcleo familiar. el soporte social es establecido por medio de redes sociales con objetivos comunes, como una herramienta de integración donde participan sectores académicos, científicos, tecnológicos y culturales como un sistema de comunicación para apoyar procesos, compartir experiencias, fortalecer conocimientos y unir esfuerzos en la construcción permanente que incluye el desarrollo individual y colectivo (2). se ha encontrado que el soporte social incluye cuatro componentes fundamentales: 1) la red social: se refiere a los individuos o grupos de individuos disponibles para brindar cualquier tipo de ayuda al sujeto; 2) la interacción social: es la frecuencia y calidad de las interacciones del sujeto con su red; 3) el soporte social percibido: es la apreciación subjetiva del sujeto, el grado de pertenencia a la red, la accesibilidad y disposición, el grado de intimidad, la confianza que mantiene con los individuos de la red, y 4) el soporte instrumental: son los servicios concretos y observables que la red social suministra al sujeto (2, 6, 7). en la actualidad, se considera que el uso de tic es una de las estrategias pertinentes y necesarias para aprovisionamiento del soporte social, con significativas ventajas y beneficios para el paciente y el cuidador. grant y cols. (8), en su investigación a cuidadores familiares de personas sobrevivientes de accidente cerebrovascular, refieren que aquellas personas que por medio de la intervención telefónica recibieron apoyo social, lograron significativos resultados ya que potencializaron la vitalidad, la salud mental, las habilidades de resolución de problemas y la preparación en el cuidado; asimismo, disminuyeron el negativismo, la impulsividad, la falta de autocuidado y la depresión relacionada con la carga del rol del cuidador. los estudios realizados por weiner y cols. (3) y badger (9) sostienen que las personas con enfermedad crónica incrementan el soporte social y la adquisición de destrezas de adaptación a la enfermedad. asi mismo, klemm y wheeler (10), afirman que los cuidadores de personas con cáncer encuentran esperanza y un buen apoyo al participar en grupos de apoyo en línea, ya que éstos contribuyen a la protección contra el desgaste del cuidador, facilitando su empoderamiento. shaw y cols. (11), en su estudio exploratorio de factores predictivos de particiel soporte social es establecido por medio de redes sociales con objetivos comunes, como una herramienta de integración donde participan sectores académicos, científicos, tecnológicos y culturales. 208 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 pación en un equipo de apoyo a un grupo de mujeres con cáncer de mama, encontraron que las mujeres que están más preocupadas por el cáncer escriben menos porque se sienten emocionalmente abrumadas por el diagnóstico, los tratamientos y los efectos secundarios, además hay temores relacionados con la muerte. matthew y robert (12) demuestran que aquellos que buscan activamente apoyo en línea realmente lo encuentran, que la internet es un medio social y puede ser utilizado para el intercambio de información de apoyo, y que los espacios en línea (correo electrónico, chat, mensajería instantánea, etcétera) les permiten buscar apoyo y comunicarse con las personas que no se encuentran tradicionalmente en el círculo de relaciones sociales, al tiempo que se disminuye la ansiedad que representa estar frente a frente (cara a cara). los hallazgos de los anteriores estudios denotan la importancia de introducir la tecnología en las intervenciones en apoyo social y de responder al llamado que la sociedad actual hace a la enfermería en demanda de mejor calidad y oportunidad en el cuidado, acorde con las tendencias de comunicación e información de la población sujeto de atención. materiales y métodos el estudio es de tipo descriptivo, con diseño transversal, a través de un estado del arte elaborado a partir de todos aquellos trabajos académicos y científicos que se han desarrollado en torno al soporte social con el uso de tic para cuidadores familiares de personas con enfermedad crónica en américa, en el periodo comprendido entre 1996-2009; se consultaron libros, tesis, revistas y artículos publicados ubicados en las bases de datos adscritas al catálogo aleph de la universidad nacional de colombia (ebsco, medline, pubmed, ovid, psycinfo, scielo, dynamed), bases de datos de la oms (lilacs, medline, scielo, biblioteca cochrane) y las bases de datos de la biblioteca de enfermería virginia henderson (science direct, pubmed, nursing center, biomed central, free medical journals). se utilizaron los descriptores: social support, internet support, support groups, online support, caregivers, care giving, caregiver burden, emotional support, telephone support, website, intervention, telehealth, home care, caregiver distress, computers, social burden, family care giving, computer based intervention, social network transformation, informal caregivers. para la recolección y sistematización de la información se utilizó la metodología de elaboración de fichas de hoyos (13), que describe cuatro tipos de fichas para análisis de documentos: la primera es una ficha de revisión bibliográfica identificada como “un instrumento que ofrece los datos fundamentales que identifican la unidad de análisis según los factores e indicadores propuestos”; la segunda es una ficha cuantitativa, donde “se condensan los datos mensurables de varias unidades de análisis agrupadas en núcleos temáticos”, la tercera ficha es la descriptiva, en la que “se condensa cómo se observa determinada unidad de análisis, mediante información cualitativa”, y por último la sinóptica, que contiene una “síntesis de lo investigado sobre el documento”. posteriormente, se elaboró una matriz de análisis con la información más relevante de dichas fichas para la obtención de los resultados, las conclusiones y las recomendaciones. klemm y wheeler, afirman que los cuidadores de personas con cáncer encuentran esperanza y un buen apoyo al participar en grupos de apoyo en línea, ya que éstos contribuyen a la protección contra el desgaste del cuidador, facilitando su empoderamiento. 209 soporte social con el uso de las tic para cuidadores de personas con enfermedad crónica: un estado del arte l diana carolina cárdenas-corredor, brigitte melenge díaz y otros. resultados se identificaron y seleccionaron 31 artículos que cumplían con los criterios de inclusión para la investigación, publicados entre 1996 y 2009. la mayor producción corresponde al 2004: 7 artículos reportados (22,6%), seguido por el 2005 con 6 artículos reportados (19,3%); en los años siguientes se identificó una disminución de artículos sobre este tema, de lo cual se infiere que puede relacionarse, en gran parte, a que la importancia de su impacto en la morbilidad no ha sido suficientemente reconocida, y a que la aplicabilidad de la tecnología en las intervenciones en salud también ha sido reciente y limitada por factores socioculturales y económicos. así, la totalidad de la literatura existente en soporte social con tic se ubicó en norteamérica, sin reporte alguno en centroamérica o américa del sur, con predominio del idioma inglés. se revisaron 14 artículos de metodología cuantitativa, publicados en estados unidos entre 2002 y 2009, los cuales se desarrollaron en su mayoría en unidades académicas (36%) con poblaciones de estudio de cuidadores familiares de personas con enfermedad crónica, predominantemente del grupo etario de 35-65 años (57%) y del género masculino (59%). estos estudios tenían como objetivo evaluar la calidad, satisfacción, accesibilidad y tic utilizados, la información proporcionada y los programas para brindar soporte social a los cuidadores familiares de personas con enfermedad crónica; así como realizar seguimiento a la intervención en soporte social para detectar falencias, corregirlas y mejorar su efectividad. entre los estudios cuantitativos (n=14) y los cualitativos (n=13) revisados se aprecia una tendencia a tener más mujeres en los abordajes cualitativos. esto quizás está asociado a la facilidad en la expresión de las experiencias con el lenguaje más que con las respuestas a encuestas. en cuanto a la edad, se mantiene la tendencia de la edad sándwich en la que por lo general se encuentran los cuidadores de 35-65 años (tabla 1). tabla 1. comparación en género y edad en los estudios cuantitativos y cualitativos categoría estudios cuantitativos estudios cualitativos (%) (%) género mujer 41 89 hombre 59 6 grupo de edad 18-35 años 14 8 35-65 años 57 38 mayor de 65 7 23 no reportaron 31 en cuanto a la tecnología utilizada se ratifica lo característico de los países desarrollados frente a la internet como la más usada. sin embargo, la tendencia a combinarla con otras permite que se alcancen niveles de soporte social asociados a la retroalimentación como el uso del teléfono, así como también el uso masivo de información a través de la televisión. respecto a la internet lo más común corresponde a cuestionarios en línea, el correo electrónico, el software, la capacitación en línea en informática, las comunidades en línea, las discusiones en línea y el chat, siendo el cuestionario en línea el más utilizado (tabla 2). fuente: datos del estado del arte. 210 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 tabla 2. comparación en tecnología utilizada en los estudios cuantitativos y cualitativos de manera particular, en los estudios cuantitativos se encontró la aplicación de 30 instrumentos o escalas de los cuales 4 median el concepto de soporte social, así: escala modificada de la red social de lubben (14), la encuesta modificada de los resultados médicos del estudio de soporte social (mos-sss) (14), la escala de wisconsin de apoyo social (15), y el instrumento de soporte social en línea (12). al encontrar en estos estudios muy poca instrumentación que mida el soporte social como una variable significativa, podría sugerirse que es un concepto complejo de medir y no hay consenso en este sentido para enfermería y para otras disciplinas. de igual forma, los resultados sobre las intervenciones en estos reportes demostraron una significativa mejoría en la salud física y mental de las personas con enfermedad crónica y sus cuidadores, lo cual se traduce en logros tales como: aprender a establecer objetivos (3); autorreconocer habilidades (3); utilizar nueva información (3); fortalecer y/o desarrollar la resolución de problemas (16); crear vínculos con otras personas (17); prepararse en el cuidado (16); mejorar relaciones con los médicos tratantes (11); potencializar la categoría estudios cuantitativos estudios cualitativos (n=14) (n=13) internet 9 6 teléfono 2 1 teléfono + internet 3 3 teléfono + internet + televisión 3 fuente: datos del estado del arte. autoestima (3), el empoderamiento (3), la autoeficacia (3, 18) y el autoaprendizaje para adquirir destrezas que le permitan manejar la enfermedad a largo plazo (3). la intervención logró disminuir el estrés, la impulsividad, la falta de cuidado, la depresión (18), la soledad y el aislamiento asociados en muchos casos al impacto que la enfermedad crónica genera en la persona enferma y su cuidador familiar (8, 19). el soporte social recibido mediante el uso de las tic es por lo general asociado a obtener información, recibir y dar apoyo (20). por otro lado, en los estudios cualitativos se encontró que los cuidadores de personas con enfermedad crónica hacen uso de las tic con el fin de obtener información clara y precisa principalmente sobre el diagnóstico y tratamiento de las diferentes patologías, como también para obtener apoyo social a través de los grupos establecidos para compartir emociones, sentimientos y experiencias de cuidado (21, 22). se evidenció que el apoyo social logrado a través del uso de tic genera efectos positivos tanto para el cuidador como para el sujeto de cuidado, fortalece el vínculo afectivo y mejora la unidad familiar pues brinda elementos para disminuir el estrés, la depresión, la soledad y el aislamiento que en la mayoría de los casos genera la enfermedad crónica (23, 24). además, se resalta que los cuidadores necesitan apoyo y servicios de educación, tienen buena disposición y son capaces de utilizar un apoyo en línea pero no tienen las habilidades o los recursos necesarios para aprovechar las intervenciones en casa ofrecidas por la web, aunque día a día aumenta el número de computadoras en el hogar y el acceso a internet (21, 25, 26). la asistencia en línea desde el hogar es una herramienta 211 soporte social con el uso de las tic para cuidadores de personas con enfermedad crónica: un estado del arte l diana carolina cárdenas-corredor, brigitte melenge díaz y otros. creativa, por lo que los profesionales del área de la salud deben utilizarla como tratamiento de soporte y fuente de seguimiento de los cuidados para cuidadores de personas con enfermedad crónica (23, 24, 27, 28). finalmente, en las tres revisiones de literatura encontradas se identificaron los siguientes niveles de evidencia (29)6: 1a (n=2), y 2b (n=1).. de dichas revisiones se destacan los siguientes hallazgos: mason y harrison (30) resaltan la importancia que tiene el soporte telefónico asociado a aspectos del cuidado humano ya que permite proveer apoyo emocional e información con sensibilidad cultural, se pueden mantener la conexión humana, la fe y la esperanza, y el teléfono conduce al establecimiento de relaciones que permiten la expresión de sentimientos positivos y negativos, de protección y de apoyo en aspectos de la salud física, emocional, espiritual y social. alexy e. (31), en su revisión de estudios basados en intervenciones por internet para ancianos y sus cuidadores, demostró que las redes sociales tienen ventajas para cuidadores informales como la disponibilidad las 24 horas del día, y el anonimato que puede conducir a una comunicación más desinhibida y franca. algunas barreras para proporcionar este tipo de intervenciones son el estigma, la falta de tiempo, el transporte cuando es necesario un encuentro presencial y la falta de conocimiento sobre el servicio. klemm y cols. (32) revisaron la literatura existente sobre grupos de apoyo en línea en cáncer y reportaron las siguientes limitaciones para la participación de los pacientes: no contar con un ordenador, módem, software de comunicación, el acceso a una cuenta de internet y tener dichos recursos en idioma inglés. estos autores proponen poner atención a aspectos sobre la calidad de la información sobre cáncer que se encuentra de manera libre, lo que es coherente con la tendencia actual de certificar los portales en internet a través de la organización mundial de la salud o sus asociados como por ejemplo honcode (www.hon.ch) y bases de datos científicas en salud reconocidas. conclusiones el apoyo social con tic es un método práctico y viable para promover el cuidado a cuidadores de personas que padecen enfermedad crónica, es una vía que facilita el acceso a la información sanitaria a aquellos que están emocional y geográficamente aislados permitiendo el empoderamiento de los sujetos a través de la educación continua y el mejoramiento de las estrategias de cuidado. la red social puede ayudar a los cuidadores de las personas con enfermedad crónica a expresar sus inquietudes, dificultades, experiencias y a darse apoyo emocional mutuo pues ofrece privacidad y la confianza de estar hablando con personas que están en su misma situación. la intervención en apoyo social con uso de tic es de alta aplicabilidad al contexto colombiano, es un método rentable y práctico de proveer cuidado si se tiene en cuenta que la tecnología hace las intervenciones más costo-efectivas porque disminuye la necesidad de despla6 niveles de evidencia: 1a obtenida desde meta-análisis o revisiones sistemáticas de ensayos controlados aleatorizados; 2b obtenidos desde al menos un estudio controlado bien diseñado sin aleatorización. alexy e., en su revisión de estudios basados en intervenciones por internet para ancianos y sus cuidadores, demostró que las redes sociales tienen ventajas para cuidadores informales como la disponibilidad las 24 horas del día, y el anonimato que puede conducir a una comunicación más desinhibida y franca. 212 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 zamiento de profesionales de la salud y cuidadores, mejora la capacidad de éstos para acceder a los programas y recursos existentes al tiempo que afianza el empoderamiento y la autoconfianza en el cuidado, no exige un contacto directo o cara a cara entre las personas que reciben el apoyo referências bibliográficas 1. struk c, moss j. focus on technology: ¿what can you do to move the vision forward?. cin: computers informatics nursing 2009; 27 (3): 192-194. 2. barrera l, pinto n, sánchez b. red de investigadores en: cuidado a cuidadores de pacientes crónicos. aquichan [on line]. octubre 2007; 7(2): 199206. disponible en: http://www.scielo.org.co/pdf/ aqui/v7n2/v7n2a08.pdf [consultado el 20 de septiembre de 2008]. 3. weiner c, cudney s, winters c. social support in cyberspace. the next generation. cin: computers informatics nursing 2005; 23 (1): 7-15. 4. world health organization. preventing chronic diseases: a vital investment. who global report [on line]. switzerland 2005. department of chronic diseases and health promotion. disponible en: http://www.who.int/chp/chronic_disease_report/ full_report.pdf. 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(fuente: decs, bireme). attitudes towards death in a group of adolescents and young adults in the city of bucaramanga abstract the objective of this transverse correlational study was to explore attitudes towards death and their association with several sociodemographic variables (gender, occupation and marital status). a non-probability sampling method was applied with a group of 150 adolescents and 150 young adults, all residents of the city of bucaramanga in colombia. those who were surveyed had experienced the death año 9 vol. 9 nº 2 chía, colombia agosto 2009 156-170 157 actitudes frente a la muerte en un grupo de adolescentes y adultos tempranos en la ciudad de bucaramanga leonardo yovany álvarez-ramírez or chronic or terminal illness of a loved one for a period of more than six months. pam-r was used to explore attitudes towards death (cronbach’s alpha = 0.893). the procedure included application of the instrument at public sites in the city, with prior informed consent. the data were processed with spss 15.0 software. the results showed attitudes of fear and acceptance of impending death in both groups. the two groups showed weak correlations between attitudes towards death and age (r<-0.132), socio-economic status (0.013< r< -0.0181) and level of schooling (0.084<r<0.119). gender differences were found among the young adults in their attitude of acceptance of impending death (t=3.607) with p<0.05 and in marital status, in avoidance of death (t=3.439) with p<0.05 and acceptance of escape (t=2.414) with p<0.05. the conclusion is that attitudes towards death are fear and acceptance, and this ambivalence is different in each stage of development. key words attitude towards death, adolescence, adult, nursing. (source: decs, bireme). atitudes frente à morte de um grupo de adolescentes e adultos jovens na cidade de bucaramanga resumo neste estudo correlacional-transversal pretende-se explorar as atitudes frente à morte e a sua associação com as variáveis sóciodemográficas de gênero, ocupação e estado civil. foi realizada uma amostragem não-probabilística em um grupo de 150 adolescentes e 150 adultos jovens, residentes na cidade de bucaramanga, colômbia. os entrevistados tinham experimentado a morte ou a doença crônica ou terminal de um ser querido em um período maior do que seis meses. para explorar lãs atitudes ante a morte empregou-se o pam-r (alpha de cronbach = 0,893). no procedimento, o instrumento se aplicou em sítios públicos da cidade, prévio consentimento informado. os dados foram processados no programa spss 15.0. os resultados revelaram atitudes de medo e aceitação de aproximação para a morte nos dos grupos. nestes acharam-se correlações débeis entre as atitudes frente à morte e à idade (r < –0,132), o nível socioeconômico (=.013 < r < –0,0181) e o nível educacional (=, 084 < r < –0,132). foram achadas diferenças de gênero nos adultos jovens na sua atitude de aceitação para a morte (t = 3,607), com p < 0,05, e no estado civil, na evitação da morte (t = 3,439), com p < 0,05, e aceitação de escape (t = 2,414), com p = 0,05. conclui-se que as atitudes frente à morte são de medo e de aceitação, e que esta ambivalência é diferente em cada fase evolutiva. palavras-chave atitude frente à morte, adolescência, adulto, enfermagem. (fonte: decs, bireme). 158 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 introducción el estudio de la muerte desde una perspectiva psicológica se ha centrado históricamente en la ansiedad que los individuos experimentan ante ésta, y se ha asociado principalmente a la edad y al género (1, 2, 3). estudios posteriores han abordado las actitudes frente a la muerte como nueva categoría psicológica, principalmente en operadores de la salud (trabajadores sociales, enfermeros, médicos) ancianos y enfermos terminales (4, 2, 5, 6). en general, éstos confirman que el miedo generado por la muerte es uniforme durante la edad adulta, en tanto que otros han encontrado una reducción con la edad, en ese tipo de angustia; cambio que sería explicado por la concepción de muerte en las diferentes etapas del ciclo vital, lo que generaría diferentes niveles de miedo y aceptación de ésta en cada una. en particular, se encuentra que el grupo de adultos mayores está más temeroso con respecto a la muerte, por la percepción de cercanía que tienen hacia ella (1), resultados que discrepan de otros estudios (7, 8) en los que se halla menos miedo a la muerte, pues, al parecer, los ancianos aceptarían la inevitabilidad de la propia muerte en razón a que éstos son sujetos perdedores de roles, de poder, de trabajo y, en segundo lugar, a que la sociedad occidental inculca que los sujetos que llegan a una determinada edad deben estar dispuestos para morir, no percibiéndose tal suceso como algo extraño sino más bien como un cumplimiento de las propias expectativas socioculturales. a la inversa, los adultos jóvenes percibirían la muerte como una interferencia en su profesión y tareas evolutivas por cumplir. con respecto al género, se confirman superiores niveles de miedo a la muerte en las mujeres en comparación con los hombres, lo cual es explicado en términos de mayor expresividad emocional en ellas (9). por su parte, neimeyer (10) halló que las mujeres puntúan más alto en la subescala de miedo al propio proceso de morir de la escala collettlester, pero no en miedo a la propia muerte, miedo a la muerte de los otros o miedo al proceso de morir de otros. en el contexto colombiano, uribe y valderrama (4), en un estudio comparativo en actitudes frente a la muerte hallaron que las mujeres presentan mayores niveles en miedo a la propia muerte y evitación de la muerte en comparación con los hombres, y lo contrario en aceptación de acercamiento, actitud en la cual se encuentran niveles más altos en los hombres que en las mujeres, lo que asocian con creencias religiosas según las cuales se tiene mayor confianza en una vida feliz después de la muerte. en relación con el estrato socioeconómico uribe y valderrama (4) encontraron diferencias significativas en las escalas de miedo a la muerte y aceptación de acercamiento. en función de la religión, solo hallaron diferencias significativas en la evitación de la muerte, que se relacionada con la actitud de rechazo ante el tema y toda situación, diálogo, lugar, que se asocie con el mismo. con respecto a la ocupación, los estudios realizados por echeverri y chacón (11) en población sanitaria muestran que parece haber mayor actitud de aceptación neutral en los médicos y las enfermeras, quienes aceptan la muerte como un suceso biológico en el cual se terminan las funciones vitales y con ellas finaliza la existencia. con respecto al género, se confirman superiores niveles de miedo a la muerte en las mujeres en comparación con los hombres, lo cual es explicado en términos de mayor expresividad emocional en ellas. 159 actitudes frente a la muerte en un grupo de adolescentes y adultos tempranos en la ciudad de bucaramanga leonardo yovany álvarez-ramírez en la escala de miedo a la muerte, los participantes manifiestan sentir principalmente inquietud o ansiedad frente al propio proceso de morir, es decir, aquel que implica la degeneración física o el dolor unido al proceso de morir; contradictoriamente, se observa que esta población manifiesta no sentir inquietud o ansiedad frente a su propia muerte, es decir, de acuerdo con los resultados, la población estudiada manifiesta mayor preocupación frente a cómo sería el propio proceso de morir, más no tanto como el hecho de la propia muerte en sí. de acuerdo con lo anterior, las actitudes han sido una categoría psicológica poco explorada con respecto a la muerte, siendo la emoción de ansiedad asociada con la misma la más abordada por los estudios. se plantea así la necesidad de acceder al constructo psicológico de las actitudes como factor que reviste importancia debido a que éstas mediarían los comportamientos y las posiciones afectivas que los individuos asumen ante la misma en un estado de enfermedad o en un estado de salud. por otra parte, la realización de estudios sobre ansiedad ante la muerte y actitudes hacia la misma se ha dirigido a agentes de la salud, ancianos y enfermos terminales, dejando de lado otros grupos poblacionales no necesariamente vinculados a experiencias de enfermedad o muerte cercana, como serían los mencionados, siendo importante abordarlos desde esta perspectiva de investigación psicológica en la medida en que en colombia las tasas por accidentes de tránsito (12) van en aumento, los homicidios —según el reporte de medicina legal en el 2005— (13) llegaron a 14.503 personas, las de muertes por cáncer ascendieron en 2005 a 27.785 personas. las enfermedades crónicas con pronóstico letal cobran cada vez más vidas en la población general en el país, y su curso y desenlace, así como su asunción por los familiares o pareja de los enfermos y fallecidos introduce el tema de las actitudes hacia la muerte en ellos, quienes sufren las secuelas psicológicas y sociales de la pérdida o del deterioro premórbido y del duelo, experiencias que se hallan mediatizadas por las actitudes hacia la muerte en los individuos. la edad se ha definido como una variable influyente en las actitudes hacia la muerte en la población, pero así mismo la resolución de las tareas evolutivas de cada ciclo del desarrollo humano que permiten un sentido de integración y tranquilidad con lo realizado en la vida. el género muestra en las actitudes frente a la muerte una diferencia entre hombres y mujeres, sin embargo, las diferencias posibles asociadas con el estrato socioeconómico y nivel educativo no han sido asumidas por estudios correlacionales en los diferentes grupos de edad en población general, tampoco las posibles diferencias asociadas con el estado civil del individuo. el presente estudio tiene como objetivo examinar los tipos de actitud frente a la muerte, sus posibles correlaciones con la edad, el nivel socioeconómico y educativo en cada grupo y entre ellos, y las posibles diferencias según género, estado civil y ocupación en un grupo de adolescentes y adultos tempranos en la ciudad de bucaramanga, colombia. método el presente estudio siguió un diseño no experimental, correlacional-transversal, y un diseño muestral no probabilístico. en la escala de miedo a la muerte, los participantes manifiestan sentir principalmente inquietud o ansiedad frente al propio proceso de morir, es decir, aquel que implica la degeneración física o el dolor unido al proceso de morir. 160 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 participantes participaron dos grupos que se dividieron en dos intervalos etáreos: adolescentes entre los 13 y 20 años de edad, y adultos entre los 21 y 40 años de edad residentes en la ciudad de bucaramanga. criterios de inclusión edad entre 13 a 20 años y 21 a 40 años. capacidad lecto-escritora básica. estratos socioeconómicos de 0 a 6. nivel educativo: primaria, secundaria, profesional. géneros: masculino y femenino. ocupación: sin restricción. estado civil: sin restricción. criterios de exclusión personas con experiencia inferior a seis meses de enfermedad terminal o muerte de un familiar o pareja. la muestra en el primer grupo examinado fue de adolescentes en el rango de edad de 13 a 20 años, se distribuyó así: 24 participantes de 13 años (16%), 17 participantes de 14 años (11,3%), 19 participantes de 15 años (12,7%), 14 participantes de 16 años (9,3%), 23 participantes de 17 años (15,3%), 32 participantes de 18 años (21,3%), 12 participantes de 19 años (8,0%) y 9 participantes de 20 años (6,0%). según el estado civil, los adolescentes contactados se distribuyeron así: 4 participantes casados (2,7%), 145 participantes solteros (96,7%), y un (1) participante en unión libre (0,7%). en la distribución de la ocupación se encuentran 131 participantes en la categoría de estudiantes (87,3%), 18 participantes en la categoría de labores no profesionales (12,0%), y no se encuentran participantes en la categoría de labores no profesionales por el rango de edad en el que se encuentran los adolescentes. para la muestra del segundo grupo de adultos tempranos, en el rango de edad (21 a 40 años), se encuentra una distribución así: 8 participantes de 21 años que representan el 5,3%, 13 participantes de 22 años (8,7%), 6 participantes de 23 años (4,0%), 14 participantes de 24 años (9,3%), 16 participantes de 25 años (10,7%), 14 participantes de 26 años (9,3%), 10 participantes de 27 años (6,7%), 10 participantes de 28 años (6,7%), 5 participantes de 29 años (3,3%), 10 participantes de 30 años (6,7%), 2 participantes de 31 años (1,3%), 3 participantes de 32 años (2,0%), 9 participantes de 33 años (6,0%), 3 participantes de 34 años (2,0%), 6 participantes de 35 años (4,0%), 5 participantes de 36 años (3,3%), 2 participantes de 37 años (1,3%), 4 participantes de 38 años (2,7%), 2 participantes de 39 años (1,3%), y 8 participantes de 40 años (5,3%). en la distribución del estado civil en la muestra de adultos tempranos se presentan 40 participantes casados (26,7%), 96 participantes solteros (64,0%), 11 participantes en unión libre (7,3%) y 3 participantes divorciados (2,3%). en la distribución de la ocupación se encuentran 27 participantes en la categoría de estudiantes (18,0%), 49 participantes en la categoría de labores profesionales (32,7%), 71 en la categoría de labores no profesionales (47,3%), y 3 desempleados (2,0%) de la muestra de adultos tempranos. 3 este es un instrumento validado que consta de 31 ítems y responde en un continuo de escala tipo likert el cual se administra de manera individual a los participantes. evalúa actitudes de acercamiento, escape, neutralidad, evitación y miedo a la muerte. instrumento para evaluar las actitudes hacia la muerte se utilizó la escala pam-r (14). esta escala contiene afirmaciones relacionadas con cinco tipos de actitudes y tiene un escalamiento tipo likert, con siete opciones de respuesta que van desde totalmente en desacuerdo (1) a totalmente de acuerdo (7). para cada tipo de actitud se puede calcular una puntuación media de la escala dividiendo la puntuación total por el número de ítems que la forman. este instrumento consta de cinco dimensiones evaluativas (actitudes), que junto a sus ítems se hallan ordenadas así: componente 1: aceptación reacercamiento (4, 8, 13, 15, 16, 22, 25, 27, 28,31) componente 2: miedo a la muerte (1, 2, 7, 18, 20, 21,32) componente 3: evitación de la muerte (3, 10, 12, 19,26) componente 4: aceptación de escape (5, 9, 11, 23,29) componente 5: aceptación neutral (6, 14, 17, 24,30) la escala pam-r3 (14) en sus subescalas tiene coeficientes de confiabilidad adecuados: miedo ( =0,86), evitación ( =0,88), neutral ( =0,65), acercamiento ( =0,97), escape ( =0,84). procedimiento se estableció contacto con la población (adolescentes y adultos tempranos 161 actitudes frente a la muerte en un grupo de adolescentes y adultos tempranos en la ciudad de bucaramanga leonardo yovany álvarez-ramírez de bucaramanga), seleccionados en algunos sitios de concurrencia en la cuidad (parques, centros comerciales, empresas), se seleccionaron según los criterios de inclusión y exclusión. a los participantes se les explicaron los objetivos del estudio y las instrucciones para diligenciar el instrumento; se acompañó a cada participante en el proceso de diligenciamiento del instrumento resolviendo dudas cuando fue necesario y verificando que éste se hiciera sobre la totalidad de los ítems del instrumento. con la información recolectada de la escala pam-r, se procedió a tabular los datos según los cinco tipos de actitudes y las variables sociodemográficas de la investigación. estos datos fueron organizados previamente en tablas y matrices de datos en el programa excel, luego se procesaron aplicando estadísticos descriptivos (medias y desviaciones típicas), y posteriormente aplicando correlaciones entre los puntajes obtenidos en cada actitud por los participantes y las variables de edad, nivel educativo y socioeconómico. se aplicó el estadístico t de student para las actitudes hacia la muerte en cada grupo según el género, estado civil y ocupación. todo esto con el paquete estadístico spss, versión 15.0. resultados la tabla 1 presenta los promedios de cada grupo examinado en cada tipo de actitud frente a la muerte, reflejando valores similares. en el caso de los adolescentes, la actitud hacia la muerte con mayor promedio fue la de aceptación de acercamiento (49,56), seguida por el miedo a la muerte (28,95), la aceptación neutral (27,02), la evitación de la muerte (21,77) y la aceptación de escape (20,94). en el caso de los adultos jóvenes, el mayor promedio lo obtuvo la actitud de aceptación de acercamiento (51,19), seguida por la aceptación neutral (28,17), por el miedo a la muerte (26,03), la evitación (21,25) y la aceptación de escape (20,45). las actitudes de miedo y aceptación de acercamiento hacia la muerte son las que predominan, coincidiendo en los adolescentes y adultos jóvenes evaluados. estas actitudes están caracterizadas por respuestas conscientes que tiene el ser humano ante la muerte, en donde las variables mediadoras se relacionan con el temor a la pérdida de sí mismo, a lo desconocido, al más allá de la muerte, al dolor y al sufrimiento, el bienestar de los miembros supervivientes de la familia, y con una percepción de la vida como una etapa feliz, y la transición a la muerte es vista de la misma manera por los individuos. está asociada con creencias como: “irse al cielo después de morir”, “la muerte es la entrada en un lugar de satisfacción definilas actitudes de miedo y aceptación de acercamiento hacia la muerte son las que predominan, coincidiendo en los adolescentes y adultos jóvenes evaluados. tabla 1. descripción de las actitudes hacia la muerte en las dos muestras muestra adolescentes muestra adultos tempranos tipo de actitud media tipo de actitud media miedo a la muerte 28,95 miedo a la muerte 26,03 evitación de la muerte 21,77 evitación de la muerte 21,25 aceptación de escape 20,94 aceptación de escape 20,45 aceptación de acercamiento 49,56 aceptación de acercamiento 51,19 aceptación neutral 27,02 aceptación neutral 28,17 162 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 tiva”, “el cielo será un lugar mucho mejor que este mundo”, “la muerte es la unión con dios y con la gloria eterna”. para determinar diferencias de medias significativas entre las actitudes frente a la muerte antes descritas se realizó la prueba t de student intragrupo (adolescentes y adultos jóvenes) (tablas 2 y 3), lo cual evidenció que la actitud de miedo a la muerte y de aceptación de acercamiento son las actitudes hacia la muerte que muestran diferencias más significativas (t=10,035 y t=26,365 con p<0,05) respectivamente, con respecto a las demás actitudes en adolescentes (tabla 2) y (t=6,053 y t=23,067 con p<0,05) en adultos jóvenes. en la tabla 4 se muestran las correlaciones entre las variables de edad, estrato socioeconómico y nivel educativo con los tipos de actitud frente a la muerte evaluados en los adolescentes. se encuentran correlaciones negativas y positivas débiles entre las actitudes hacia muerte y estas variables socio-demográficas destacándose las de mayor intensidad, así: diferencia de medias en las actitudes frente a la muerte en los adolescentes tipo de actitud t t no gl significativa significativa miedo a la muerte y evitación de la muerte 10.035 149 miedo a la muerte y aceptación de escape 9.311 149 miedo a la muerte y aceptación de acercamiento -21.161 149 miedo a la muerte y aceptación neutral 2.302 149 evitación de la muerte y aceptación de escape 0.960 149 evitación de la muerte y aceptación de acercamiento -28.778 149 evitación de la muerte y aceptación neutral -6.767 149 aceptación de escape y aceptación de acercamiento -32.757 149 aceptación de escape y aceptación neutral -8.386 149 aceptación de acercamiento y aceptación neutral 26.365 149 p ≤0,05 los resultados obtenidos con respecto a género, estado civil y ocupación, y las actitudes hacia la muerte en los adolescentes, no muestran diferencias significativas. tabla 2. resultados de la prueba t en las actitudes frente a la muerte en los adolescentes las correlaciones son: entre la actitud de miedo a la muerte y la edad (r=-0,054), entre ésta y el nivel educativo (r=-0,014), entre ésta y el estrato socioeconómico (r=-0,018). igualmente ocurre con las actitudes de evitación de la muerte y edad (r=-0,032), entre ésta y el nivel educativo (r=0,007) y el estrato socioeconómico (r=-0,004). con respecto a la actitud de aceptación de escape y edad la correlación es débil y negativa (r=-0,087), entre ésta y el nivel educativo (r=-0,055), entre ella y nivel socioeconómico (r=-0,072). en cuanto a las correlaciones entre actitud de aceptación de acercamiento y edad (r=-0,132), entre ésta y nivel educativo (r=-0,084) y el estrato socioeconómico (r=0,013). finalmente, con respecto a la correlación entre la actitud de aceptación neutral y la edad (r=-0,27), entre ésta y el nivel educativo (r=0,119) y el estrato socioeconómico (r=0,118). en la tabla 5 se muestran las correlaciones entre las actitudes frente a la muerte y las variables de edad, estrato socioeconómico y nivel educativo con los tipos de actitud hacia la muerte evaluados en los adultos tempranos. se hallaron correlacio163 actitudes frente a la muerte en un grupo de adolescentes y adultos tempranos en la ciudad de bucaramanga leonardo yovany álvarez-ramírez tabla 3. resultados de la prueba t en las actitudes frente a la muerte en los adolescentes diferencia de medias en las actitudes hacia la muerte en los adultos tempranos tipo de actitud t t no significativa significativa gl miedo a la muerte y evitación de la muerte 6.053 149 miedo a la muerte y aceptación de escape 5.306 149 miedo a la muerte y aceptación de acercamiento -20.465 149 miedo a la muerte y aceptación neutral -2.069 149 evitación de la muerte y aceptación de escape 0.845 149 evitación de la muerte y aceptación de acercamiento -27.021 149 evitación de la muerte y aceptación neutral -8.122 149 aceptación de escape y aceptación de acercamiento -32.155 149 aceptación de escape y aceptación neutral -9.678 149 aceptación de acercamiento y aceptación neutral 23.067 149 p≤0,05 tabla 4. resultados de las correlaciones entre las actitudes frente a la muerte y las variables edad, nivel educativo y nivel socioeconómico en los adolescentes. edad adoles. correlación de pearson -,054 -,032 -,087 -,132 -,027 sig. (bilateral) ,509 ,696 ,289 ,109 ,739 n 150 150 150 150 150 educación correlación de pearson -,014 ,007 -,055 -,084 ,119 adoles. sig. (bilateral) ,864 ,928 ,504 ,308 ,148 n 150 150 150 150 150 nivel sociocorrelación de pearson -,018 -,004 -,072 ,013 ,118 económico sig. (bilateral) ,824 ,962 ,383 ,875 ,149 adoles. n 150 150 150 150 150 m ie do a la m ue rt e a do le sc en te s ev it ac ió n de la m ue rt e ad ol es ce nt es a ce pt ac ió n ne ut ra l ad ol es ce nt es a ce pt ac ió n de a ce rc am ie nt o ad ol es ce nt es a ce pt ac ió n de e sc ap e ad ol es ce nt es nes negativas y positivas pero débiles entre las actitudes hacia la muerte y estas variables sociodemográficas, así: la correlación entre la actitud de miedo a la muerte y edad fue (r=0,186), con el nivel educativo (r=-0,193), con el estrato socioeconómico (r=-0,080). igualmente ocurre con las actitud de evitación de la muerte y edad, cuya correlación fue (r=0,234), entre ésta y el nivel educativo (r=-0,164), y entre ésta y el estrato sov ar ia bl es c or re la ci ón 164 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 cioeconómico (r=-0,024). con respecto a las correlaciones entre la actitud de aceptación de escape y edad (r=0,203), entre ésta y el nivel educativo (r=-0,319), y entre ella y nivel socioeconómico (r=-0,078). en cuanto a la correlación entre las actitudes de aceptación de acercamiento y edad (r=0,238), entre éstas y nivel educativo (r=-0,187), y entre éstas y el estrato socioeconómico (r=-0,026). finalmente, con respecto a las correlaciones entre actitud de aceptación neutral y la edad (r=-0,75), entre ésta y el nivel educativo (r=-0,006), y entre ésta y el estrato socioeconómico (r=0,082). los resultados obtenidos con respecto a género, estado civil y ocupación, y las actitudes frente a la muerte en los adolescentes, no muestran diferencias significativas. la tabla 6 muestra la comparación de medias de la variable género y cada uno de los tipos de actitudes frente a la muerte, m ie do a la m ue rt e a du lt ez . t ev it ac ió n de la m ue rt e ad ul te z. t a ce pt ac ió n ne ut ra l ad ul te z. t a ce pt ac ió n de a ce rc am ie nt o ad ul te z. t a ce pt ac ió n de e sc ap e ad ul te z. t edad adultez correlación de pearson ,186 ,234 ,203 ,238 -,075 temprana sig. (bilateral) ,023 ,004 ,013 ,003 ,360 n 150 150 150 150 150 educación correlación de pearson -,193 -,164 -,319 -,187 -,006 adultez temprana sig. (bilateral) ,018 ,045 ,000 ,022 ,943 n 150 150 150 150 150 nivel sociocorrelación de pearson -,080 -,024 -,078 -,026 ,082 económico sig. (bilateral) ,333 ,771 ,344 ,753 ,318 adultez temprana n 150 150 150 150 150 las cuales, con p≤ 0,05, fueron inferiores a las esperadas, así: en la actitud de miedo a la muerte , t=-0,047, con (gl)=146,9; en evitación de la muerte se obtuvo una t=0,316, con (gl)=145,3; en aceptación de escape una t=-0,240, (gl)=147,7; en aceptación de acercamiento una t=1,061, con (gl)=145,4; en aceptación neutral una t=1,097, con (gl)=147,9. la tabla 7 muestra la comparación de medias de la variable estado civil y las acmuestra adolescentes valores t según género actitud frente a la muerte t gl miedo a la muerte -0,047 146,9 evitación de la muerte 0,316 145,3 aceptación de escape -0,240 147,7 aceptación de acercamiento 1,061 145,4 aceptación neutral 1,097 147,9 p≤ 0,05 v ar ia bl es c or re la ci ón tabla 5. resultados de las correlaciones entre las actitudes frente a la muerte y las variables edad, nivel educativo y nivel socioeconómico en los adultos tempranos tabla 6. resultados de la prueba t de los tipos de actitudes frente a la muerte y la variable género en la muestra de adolescentes 165 actitudes frente a la muerte en un grupo de adolescentes y adultos tempranos en la ciudad de bucaramanga leonardo yovany álvarez-ramírez titudes frente a la muerte con p≤ 0,05 , las cuales fueron inferiores a la esperada, así: en la actitud de miedo a la muerte una t=0,786, con (gl)=3,202; en evitación de la muerte una t=1,684, con (gl)=3,188; en aceptación de escape una t=-0,643, con (gl)=3,35; en aceptación de acercamiento una t=0,866, con (gl)=3,175; en aceptación neutral una t=0,329, con (gl)=3,075. la tabla 8 presenta la comparación de medias de la variable ocupación y las actitudes frente a la muerte en el grupo de adolescentes evaluado. con p≤ 0,05, se hallaron diferencias no significativas, así: con la actitud de miedo a la muerte se obtuvo una t=-0,186, con (gl)=22,83; con la actitud de evitación de la muerte, una t=1,684, con (gl)=3,188; con la actitud de aceptación de escape una t=-0,643, con (gl)=3,35; con la actitud de aceptación de acercamiento una t=0,866, con muestra adolescentes valores t para estado civil casado y soltero actitud frente a la muerte t gl miedo a la muerte 0,786 3,202 evitación de la muerte 1,684 3,188 aceptación de escape 0,643 3,35 aceptación de acercamiento 0,866 3,175 aceptación neutral 0,329 3,075 p≤ 0,05 muestra adolescentes valores t para ocupación estudiantes y labores no profesionales actitud hacia la muerte t gl miedo a la muerte -0,186 22,83 evitación de la muerte -1,205 24,61 aceptación de escape -0,524 20,85 aceptación de acercamiento 0,236 19,16 aceptación neutral 1,079 18,79 p≤ 0,05 tabla 7. resultados de la prueba t de los tipos de actitudes frente a la muerte y el estado civil en la muestra de adolescentes tabla 8. resultados de la prueba t de los tipos de actitudes frente a la muerte y la ocupación de la muestra de adolescentes (gl)=3,175; con aceptación neutral una t=0,329, con (gl)=3,075. la tabla 9 muestra la comparación de medias entre los tipos de actitud frente a la muerte y el género en los adultos tempranos, las cuales con p≤ 0,05, fueron no significativas y por tanto inferiores a las esperadas, así: en aceptación neutral una t=-0,454, con (gl)=143,3; en miedo a la muerte una t=-0,837, con (gl)=147,5; en evitación de la muerte se obtuvo una t=0,907, con (gl)=147,9; en aceptación de escape una t=0,678, con (gl)=147,2. en el caso de la actitud de aceptación de acercamiento se obtuvo una t=3,607, con (gl)=138,4, la cual fue superior a la esperada (t=1,960), lo que indica una diferencia significativa entre este tipo de actitud hacia la muerte, siendo predominante en mujeres (en hombres la media=47,59 y en mujeres la media=57,80). 166 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 muestra adultos tempranos valores t para género actitud hacia la muerte t gl miedo a la muerte 0,837 147,5 evitación de la muerte 0,907 147,9 aceptación de escape 0,678 147,2 aceptación de acercamiento 3,607 138,4 aceptación neutral -0,454 143,3 p≤ 0,05 la tabla 10 presenta los valores t de las actitudes hacia la muerte según el estado civil en la muestra de adultos tempranos evaluados con p≤ 0,05. se hallaron diferencias para los casados en sus actitudes de miedo, evitación, aceptación de escape, con respecto a los solteros, y ninguna diferencia en las actitudes de aceptación de acercamiento y neutral entre casados y solteros. la tabla 10 muestra diferencias significativas a favor de los casados en la actitud de miedo a la muerte, con una t=1,974, con (gl)= 64,0; en evitación de la muerte con una t=3,439, con (gl)= 77,2; en aceptación de escape una t=2,414, con (gl)= 69,8. y ninguna diferencia entre casados y solteros en la actitud de aceptación de acercamiento con una t=1,437, con (gl)= 99,2, y en aceptación neutral con una t=0,560, con (gl)= 87,9. entre casados y en unión libre, las actitudes no presentaron diferencias por ser las t obtenidas inferiores a las esperadas, así: en miedo a la muerte una t=-0,541, con (gl)= 18,6; en evitación de la muerte una t=1,092, con (gl)= 13,5; en aceptación de escape una t=0,045, con (gl)= 14,7; en aceptación de acercamiento una t=-0,310, con (gl)= 17,2; en aceptación neutral una t=0,264, con (gl)= 12,5. entre solteros y en unión libre ocurrió lo mismo: en miedo a la muerte una t=1,941, con (gl) = 12,5; en evitación de la muerte una t=-0,516, con (gl)= 11,6; en aceptación de escape una t=-1,230, con (gl)= 11,7; en aceptación de acercamiento una t=-1,305, con (gl)= 15,7; en aceptación neutral una t=0,510, con (gl)= 11,5. de la misma manera ocurrió entre las actitudes hacia la muerte de casados y divorciados: en miedo a la muerte una t=-0,327, con (gl)= 2,3; en evitación de la muerte una t=0,634, con (gl)= 2,1; en aceptación de escape una t=-1,230, con (gl)= 11,7; en aceptación de acercamiento una t=-1,001, con (gl)= 2,4; en aceptación neutral una t=0,533, con (gl)= 2,1. también se hallaron diferencias no significativas en las actitudes frente a la muerte entre solteros y divorciados, así: en miedo a la muerte una t=-0,935, con (gl)= 2,0; en evitación de la muerte una t=-0,029, con (gl)= 2,0; en aceptación de escape una t=0,309, con (gl)= 2,1; en aceptación de acercamiento una t=-1,639, con (gl)= 2,3; en aceptación neutral una t=-0,385, con (gl)= 2,1. de la misma forma ocurrió entre las actitudes frente a la muerte entre quienes tabla 9. resultados de la prueba t de los tipos de actitudes frente a la muerte y la variable género en la muestra de adultos tempranos 167 actitudes frente a la muerte en un grupo de adolescentes y adultos tempranos en la ciudad de bucaramanga leonardo yovany álvarez-ramírez tabla 10. resultados de la prueba t de los tipos de actitudes frente a la muerte y la variable estado civil en la muestra de adultos tempranos muestra de adultos tempranos valores t para estado civil actitud frente a la muerte casado casado y soltero y casado y soltero y unión libre y soltero unión libre unión libre divorciado divorciado y divorciado t gl t gl t gl t gl t gl t gl miedo a la muerte 1,974 64,0 -0,541 18,6 -1,941 12,5 -0,327 2,3 -0,935 2,0 -0,059 2,7 evitación de la muerte 3,439 77,2 1,092 13,5 -0,516 11,6 0,634 2,1 -0,029 2,0 0,168 2,6 aceptación de escape 2,414 69,8 0,045 14,7 -1,230 11,7 1,132 2,3 0,309 2,1 0,964 3,9 aceptación de acercamiento 1,437 99,2 -0,310 17,2 -1,305 15,7 -1,001 2,4 -1,639 2,3 -0,729 3,5 aceptación neutral -0,560 87,9 0,264 12,5 0,510 11,5 -0,533 2,1 -0,385 2,1 -0,611 3,7 p≤ 0,05 tienen uniones libres y divorciados, así: en miedo a la muerte una t=-0,059, con (gl)= 2,7; en evitación de la muerte una t=-0,168, con (gl)= 2,6; en aceptación de escape una t=0,964, con (gl)= 3,9; en aceptación de acercamiento una t=0,729, con (gl)= 3,5; en aceptación neutral una t=-0,611, con (gl)= 3,7. la tabla 11 presenta las diferencias en actitudes frente a la muerte de acuerdo con la ocupación en adultos tempranos; con p≤ 0,05, no se hallaron diferencias significativas entre estudiantes y quienes se dedican a algún oficio como se aprecia en la t obtenida así: para aquellos dedicados a labores no profesionales y la actitud de miedo a la muerte se halló una t=-2,641, con (gl)= 74,5; en evitación de la muerte una t=-2,857, con (gl)= 54,9; en aceptación de escape una t=-2,615, con (gl)=48,0; en aceptación de acercamiento una t=2,211, con (gl)=63,3; en aceptación neutral una t=-0,140; con (gl)=63,3. entre estudiantes y labores profesionales ocurrió lo mismo, así: en miedo a la muerte una t=-1,325, con (gl)=66,6; en evitación de la muerte una t=-1,074, con (gl)=61,1; en aceptación de escape una t=-0,503, con (gl)=52,2; en aceptación de acercamiento una t=0,028, con (gl)= 61,2; en aceptación neutral una t=0,248, con (gl)=57,9. de la misma manera ocurre entre las labores profesionales y no profesionales, y las actitudes hacia la muerte, lo cual se ve representado así: en miedo a la muerte una t=-1,329, con (gl)=113,9; en evitación de la muerte una t=-1,863, con (gl)=103,7; en aceptación de escape una t=-2,586, con (gl)=107,0; en aceptación de acercamiento una t=-2,475, con (gl)=90,7; en aceptación neutral una t=0,431, con (gl)=114,9. discusión los tipos de actitud frente a la muerte característicos en el grupo de adolescentes fueron los de miedo y aceptación de acercamiento, lo cual coincide, en el caso de la primera, con la concepción de la muerte que se iniciaría en esta edad según la cual empezarían temores asociados con los procesos terminales, y el dolor y el sufrimiento concomitantes. por otra parte, se avendría a lo encontrado en esta población, relacionado con una creencia después de la vida, la cual soportaría la actitud de aceptación de acercamiento (15). 168 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 los hallazgos en los adolescentes son coincidentes en las actitudes de miedo y aceptación de acercamiento hacia la muerte de los adultos tempranos. al respecto, los motivos de miedo para estos adultos coincidirían con lo encontrado por feifel (7), acerca de que para ellos la muerte es percibida como algo catastrófico al imposibilitar las metas anheladas, relacionadas con la profesión y las relaciones afectivas características de esta etapa. estos resultados refuerzan la idea de que la muerte genera diversidad de actitudes y emociones, principalmente de naturaleza aversiva, ya que supone la mayor amenaza para la vida, y específicamente el miedo a la muerte coexiste con la aceptación y el significado de la vida que los adultos dan a la misma. con respecto a las correlaciones entre las actitudes hacia la muerte y los niveles educativo y socioeconómico, y la edad, los resultados débiles obtenidos, ya fueran positivos o negativos, señalarían para los dos grupos estudiados que estas variables no estarían asociadas con algún o algunos tipos de actitud hacia la muerte en particular. en el caso de la edad, estos resultados difieren de estudios similares, los cuales evidenciaron la edad como relacionada muestra adultos tempranos valores t para ocupación actitud frente a la muerte estudiantes y estudiantes y lab. no no labores labores profesionales y profesionales profesionales profesionales t gl t gl t gl miedo a la muerte -2,641 74,5 -1,325 66,6 -1,329 113,9 evitación de la muerte -2,857 54,9 -1,074 61,1 -1,863 103,7 aceptación de escape -2,615 48,0 -0,503 52,2 -2,586 107,0 aceptación de acercamiento -2,211 46,0 0,028 61,2 -2,475 90,7 aceptación neutral -0,140 63,3 0,248 57,9 -0,431 114,9 p≤ 0,05 con menor miedo a la muerte, aunque en adultos mayores, en los cuales las preocupaciones se relacionan con el proceso agónico, al temer quedarse indefensos y dependientes, y seguir vivos en un estado poco digno (1, 7, 6, 8). con todo, lo que sí parece claro es que el miedo a la muerte en los adultos tempranos estaría asociado con la interrupción de sus proyectos de vida profesional, personal y familiar, en tanto que los adolescentes mantendrían un miedo relacionado con la iniciación de su camino hacia la construcción de un espacio en el mundo adulto. referente al nivel socioeconómico, los resultados son contradictorios con otras investigaciones (4) donde se encontraron diferencias significativas entre el miedo a la muerte y la aceptación de acercamiento según el nivel socioeconómico, lo cual puede estar relacionado con las diferencias culturales dentro de cada uno de los estratos socioeconómicos, en los que los ritos, apegos, acceso a la extensión de vida, y la adaptación y preparación para las pérdidas pueden variar según el estrato. con relación al nivel educativo no se presentan antecedentes investigativos que expliquen la posible asociación de éste con las actitudes hacia la muerte; quizás parte los tipos de actitud frente a la muerte característicos en el grupo de adolescentes fueron los de miedo y aceptación de acercamiento. tabla 11. resultados de la prueba t de los tipos de actitudes frente a la muerte y la variable ocupación en la muestra de adultos tempranos 169 actitudes frente a la muerte en un grupo de adolescentes y adultos tempranos en la ciudad de bucaramanga leonardo yovany álvarez-ramírez de ello pueda estar relacionado con que en ningún sentido los currículos de formación para la vida se ocupan de la educación para el morir y para el afrontamiento emocional del propio deterioro de las funciones biológicas y psicosociales humanas, al menos dentro de la estructura educativa formal, quedando a merced de las representaciones que se tengan en la comunidad en la cual se vive acerca de la muerte. con respecto al género, los adolescentes examinados no reportaron diferencias significativas mientras que en los adultos tempranos se hallaron diferencias significativas en aceptación de acercamiento, siendo mayor en las mujeres, apoyando los hallazgos de wong y otros (14) y de keller, sherry y piotrowski (1). estos investigadores encontraron mayor creencia en una vida feliz luego de la muerte en las mujeres. con los otros tipos de actitudes hacia la muerte y la variable género no se presentaron diferencias significativas, lo cual es contrario a lo hallado por otros estudios (5, 14, 1, 2, 7) donde se encontraron niveles más altos de evitación de la muerte y miedo a la muerte en las mujeres en comparación con los hombres. en relación con el estado civil son pocos los estudios que lo relacionan con la variable muerte; sin embargo, en el presente estudio se encontraron diferencias significativas entre las personas casadas y solteras con los tipos de actitudes de evitación de la muerte y aceptación de escape en la muestra de adultos tempranos, presentándose niveles más altos de estas actitudes en las personas casadas. esto en parte resultaría atribuible a que los participantes casados, por una parte, habrían concretado una meta evolutiva importante de su vida y serían más aceptantes de la muerte que los solteros, y estos a su vez temerían la muerte por no haber concretado su meta de elección de pareja dentro de su proyecto personal. en los análisis con la variable ocupación no se encontraron diferencias significativas entre ésta y las actitudes hacia la muerte, siendo ésta una de las variables menos exploradas en los estudios precedentes. conclusión en las actitudes frente a la muerte en los adultos tempranos y adolescentes examinados éstas coincidieron en ser de miedo y aceptación, verificándose que esta ambivalencia resulta posible frente a la misma siendo los motivos diferentes en cada etapa evolutiva. la edad, el nivel educativo y socioeconómico no parecen estar relacionados con las actitudes frente a la muerte ni de manera positiva ni de manera negativa. en los adultos tempranos, las mujeres parecen tener mayor aceptación ante la muerte que los hombres, y en el grupo de los adolescentes no se encuentran diferencias. la ocupación no planteó diferencias de actitud entre los participantes estudiados en sus posiciones ante la muerte. los casados muestran en este estudio mayor aceptación frente a la muerte que los solteros. agradecimientos este trabajo contó con la colaboración de sylvia juliana rueda galvis y de laura milena suárez ortíz, estudiantes de décimo semestre de psicología, de la universidad autónoma de bucaramanga, colombia. la muerte genera diversidad de actitudes y emociones, principalmente de naturaleza aversiva, ya que supone la mayor amenaza para la vida, y específicamente el miedo a la muerte coexiste con la aceptación y el significado de la vida que los adultos dan a la misma. 170 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 referencias bibliográficas 1. keller jw, sherry d, piotrowski c. perspectives on death: a developmental study. journal of psychology 1984; 116: 137-142. 2. neimeyer ra. constructions of death and loss: evolution of a research program. personal construct theory & practice 2004; 1: 8-22. disponible en http:// www.pcp-net.org/journal/pctp04/neimeyer04.html. [consultado el 30 de agosto de 2007]. 3. martínez p, valera a, frances c. estudio comparativo de ansiedad ante la muerte en una muestra de ancianos y jóvenes. psiquis 2001; 22 (5): 176-182. 4. uribe a, valderrama l. actitud y miedo ante la muerte en adultos mayores. pensamiento psicológico 2007; 3 (8): 109-120. 5. kuperman sk, golden cj. personality correlates of attitude toward death. journal of clinical psychology 1978; 34: 661-663. 6. abengózar m, bueno b, vega j. intervention on attitudes toward death along the life span. educational gerontology 1999; 25: 435-447. 7. feifel h, branscomb ab. who’s afraid of death? journal of abnormal psychology 1973; 81: 282-288. 8. martin d, wrightsman ls. the relationship between religious behavior and concern about death. journal of social psychology 1965; 65: 317-323. 9. kvale j, berg ll, groff j, lange g. factors associated with residents’ attitudes toward dying patients. family medicine 1999; 31 (10): 691-6. 10. neimeyer ra. the threat hypothesis: a conceptual and empirical defense. death studies 1986; 10: 177-190. 11. echeverri l, chacón j. actitudes hacia la muerte asociadas al temor y miedo en los profesionales de medicina y enfermería del hospital universitario de santander 2006. trabajo de grado de la especialización en psicología de la salud. bucaramanga: universidad industrial de santander. 12. fondo de fonprevial.org.co/noticias. [consultado el 15 de octubre de 2007]. 13. instituto de medicina legal y ciencias forenses de colombia. división de referencia de información pericial. disponible en http: www.medicinalegal. gov.co [consultado el 30 de octubre de 2007]. 14. gala fj, lupiani m, raja r, guillen c, gonzález jm, villaverde m, sánchez a. actitudes psicológicas ante la muerte y el duelo. una revisión conceptual. cuadernos de medicina forense 2002; 30: 5-21. 15. wong p, reker g, gesser g. death attitude profilerevised: a multidimensional measure of attitude toward death. in r. a. neimeyer editors. death anxiety handbook: research, instrumentation, and application. washington dc: taylor and francis; 1994. pp. 121-148. professional care in home for children and teenagers with special health needs: an integrative review   article professional care in home for children and teenagers with special health needs: an integrative review atención profesional en atención domiciliaria para niños y adolescentes con necesidades especiales de salud: una revisión integradora assistência profissional no cuidado domiciliar de crianças e adolescentes com necessidades especiais de saúde: revisão integrativa 10.5294/aqui.2022.22.1.5 paloma mayara vieira de macena lima1 , leiliane teixeira bento fernandes2 mariana matias santos3 neusa collet4 beatriz rosana gonçalves de oliveira toso5 elenice maria cecchetti vaz6 1 0000-0002-0856-9993 universidade federal da paraíba, brazil. paloma.mayara@academico.ufpb.br 2 0000-0003-2643-5638 universidade federal da paraíba, brazil. leiliane.fernandes@academico.ufpb.br 3 0000-0002-4539-4707 universidade federal da paraíba, brazil. mariana.santos@unipe.edu.br 4 0000-0002-4795-0279 universidade federal da paraíba, brazil. neucollet@ccs.ufpb.br 5 0000-0001-7366-077x universidade estadual do oeste do paraná, brazil. beatriz.oliveira@unioeste.br 6 0000-0001-6149-1892 universidade federal da paraíba, brazil. emcv@academico.ufpb.br received: 14/04/2021 submitted to pairs: 29/07/2021 accepted in pairs: 12/11/2021 approved: 16/11/2021 thematic: evidence-based practice. contribution to the discipline: the results of the present study show that, worldwide, home services with relationships with necessities and special conditions improve their quality of life and that of their caregivers or family members by promoting support to health technologies and relief of symptoms resulting from health disorders, in addition to reducing caregiver or family burden. these actions are innovated, therefore, with technological advances, it is possible to perform a remote monitoring or use digital technologies that enable the approximation of the professional with the caregiver, as well as the recovery of the health of these children. this favors nursing and professionals who work at home in the performance of humanized and comprehensive care. para citar este artículo / to reference this article / para citar este artigo: lima pmvm, fernandes ltb, santos mm, collet n, toso, beatriz rgo, vaz emc. professional care in home for children and teenagers with special health needs: an integrative review. aquichan. 2022;22(1):e2215. doi: https://doi.org/10.5294/aqui.2022.22.1.5 abstract objective: analyzing the results of scientific publications on professional home care for children and teenagers with special health needs. materials and method: an integrative review with articles published between 2009 and 2020 conducted in the bdenf, lilacs, medline/ pubmed databases and in the scielo electronic library. the data were analyzed in four stages: data reduction; display of the data; comparison of data; drawing and verification of completion. results: there were identified 5,641 articles; after the application of the inclusion and exclusion criteria and disposal of duplicates, 637 articles were chosen for the reading of titles and abstracts, of which 61 were selected for full reading and of these, 28 composed the final sample. the offer of remote support actions and concern in training caregivers regarding the technical-scientific aspects of home care was identified, in addition to promoting the improvement of the quality of life of children/teenagers and their families. a gap was evidenced regarding the identification and management of pain by home service professionals. conclusions: the performance of home services to this specific population focuses on the demands of care with health technologies and on promoting symptom relief, reducing the workload of caregivers and assisting in dehospitalization. keywords (source decs):  homebound persons; home nursing; caregiver; child; teenager. resumen objetivo: analizar los resultados de publicaciones científicas acerca de la atención domiciliar profesional a niños y adolescentes con necesidades especiales de salud. materiales y método: una revisión integradora con artículos publicados entre 2009 y 2020 realizada en las bases de datos bdenf, lilacs, medline/pubmed y en la biblioteca electrónica scielo. se analizaron los datos en cuatro etapas: reducción de los datos; presentación de los datos; comparación de los datos; diseño y verificación de la conclusión. resultados: se identificaron 5 641 artículos; luego de la aplicación de los criterios de inclusión y exclusión y descarte de los duplicados, se seleccionaron 637 artículos para la lectura de títulos y resúmenes, de los que 61 se seleccionaron para la lectura integral y de estos 28 compusieron la muestra final. se identificaron la oferta de acciones de soporte remoto y la preocupación en capacitar los cuidadores en cuanto a los aspectos técnico-científicos del cuidado en el domicilio, además de la promoción de la mejoría de la calidad de vida de niños/ adolescentes y sus familiares. se evidenció la laguna en relación con la identificación y el manejo del dolor por los profesionales de los servicios domiciliares. conclusiones: la actuación de los servicios domiciliares a esta población específica enfoca en las demandas de cuidados con las tecnologías en salud y promoción de alivio de los síntomas, disminuyendo la carga de trabajo de los cuidadores y auxiliando en la deshospitalización. palabras clave (fuente decs): personas imposibilitadas; atención domiciliaria de salud; cuidador; niño; adolescente. resumo objetivo: analisar os resultados de publicações científicas acerca da assistência domiciliar profissional às crianças e adolescentes com necessidades especiais de saúde. materiais e método: revisão integrativa, com artigos publicados entre 2009 e 2020, realizada nas bases de dados bdenf, lilacs, medline/pubmed e na biblioteca eletrônica scielo. os dados foram analisados em quatro etapas: redução dos dados; exibição dos dados; comparação dos dados; desenho e verificação da conclusão. resultados: foram identificados 5641 artigos; após a aplicação dos critérios de inclusão e exclusão e descarte das duplicatas, foram eleitos 637 artigos para a leitura de títulos e resumos, dos quais 61 foram selecionados para a leitura na íntegra e destes, 28 compuseram a amostra final. identificaram-se oferta de ações de suporte remoto e preocupação em capacitar os cuidadores quanto aos aspectos técnico-científicos do cuidado no domicílio, além da promoção da melhora da qualidade de vida das crianças/adolescentes e seus familiares. evidenciou-se lacuna com relação à identificação e ao manejo da dor pelos profissionais dos serviços domiciliares. conclusões: a atuação dos serviços domiciliares a essa população específica tem foco nas demandas de cuidados com as tecnologias em saúde e na promoção de alívio dos sintomas, diminuindo a carga de trabalho dos cuidadores e auxiliando na desospitalização. palavras-chave (fonte decs): pacientes domiciliares; assistência domiciliar; cuidador; criança; adolescente. introduction child health care in brazil has undergone advances evidenced by the reduction in infant mortality, increased access to health services, high vaccination coverage and decreased malnutrition. this resulted in the stagnation of neonatal mortality rates and an increase in the survival of premature children with chronic diseases (1). in view of this change in the context of children's and youth health, there was the emergence of a group internationally entitled as "children with special health care needs". these are children who present changes in their health status related to chronic conditions, functional limitations, need for recurrent use of complex health services or considerable risk of developing physical, developmental, behavior and emotional alterations. in general, they present demands for comprehensive and sometimes continuous and intense care (2). in brazil, this group was named as "child with special health needs" (crianes) (3). because they also present specific care demands such as medication use, technological and development support, and habit modification, some cubs can be clinically fragile. thus, many families of these children and teenagers are socially vulnerable because they have low per capita income, aggravated by the restriction of the number of people who contribute financially to income due to the need for time of some of the family members to dedicate themselves to their care (4). depending on the special need for health, hospital admissions are recurrent and prolonged in this population group, resulting in an increase in the demand for care that, in the hospital, is performed by the members of the multidisciplinary team, but which, after clinical stability and hospital discharge, can be performed at home by the family (5). therefore, the family is fundamental for the continuity of care because it is directly involved in the actions of meeting the basic needs of life up to the handling of complex health devices (6). for home care, guidance on the management of devices and how to deal with their specificities is necessary. this training of the caregiver should be conducted from the moment of hospital admission. however, a study pointed out that these guidelines are provided in a segmented and sectorized way, in which professionals work with minimal integration, resulting in a multiprofessional gap and divergent information to families (7). in brazil, to meet the health demands of the crianes and guide their families, it is necessary professional follow-up, either through punctual care, or continuous, according to each case, by multidisciplinary teams. in the public health system, these teams are linked to home care (hc), defined as a modality of health care "characterized by a set of actions to prevent and treat diseases, rehabilitation, palliation and health promotion, provided at home, ensuring continuity of care" (8:1). the ad, in the country, is effected by primary care and/or the home care service and proposes the provision of multiprofessional support and technical-scientific knowledge for family caregivers to continue comprehensive and humanized care, which allows the keep of a stable health condition for people who have some disease or chronic disease (9). therefore, the ad is configured as an ideal strategy to ensure the integrality of health care and meet the needs of families and continuous and complex care of the crianes, because they go to the home equipped with technological devices such as: gastrostomy, tracheostomy, mechanical ventilation, oxygen therapy, nasoenteral tube, fully implanted catheter (10). therefore, to integrate the knowledge about this modality of health care promoted to the crianes as a subsidy to professionals working in the a, the aim of this study is to analyze the results of scientific publications on professional home care for children and teenagers with special health needs. materials and methods this is an integrative review of the literature, which was conducted in six phases: 1) identification of the problem, elaboration of the theme and the guiding question; 2) search of literature in electronic databases and libraries and selection of articles according to inclusion and exclusion criteria; 3) data collection and categorization of articles; 4) critical analysis of the included studies; 5) interpretation of the results; 6) presentation of the review (11). the preparation of the guiding question was based on the pico strategy, acronym for participants, interest and context (12), in which: p — children and teenagers with special health needs; i — home care; co — performance of professionals of home care services to the crianes. thus, the theme of this review is based on the following question: how has the performance of health professionals who compose home care services for children and teenagers with special health needs been? for classification purposes, the concept of home care services, present in the virtual health library, was considered as: "community health services and nursing services that provide multiple and coordinated services to patients in their homes" (13). these home care services provide the visit of nurses, health units, hospitals or organized community groups that use specialized professional staff in the health area. the literature search was conducted between december 2019 and february 2020, updated in march 2021, in the following databases: nursing database (bdenf/vhl), latin american and caribbean literature on health sciences (lilacs/vhl), medical literature analysis and retrieval system online (medline/pubmed) and electronic library scientific electronic library online (scielo). we chose to select these bases because they are the most used in nursing research. the descriptors in health sciences (decs), in portuguese and spanish: paciente domiciliares (personas imposibilitadas), assistência domiciliar (atención domiciliaria de salud), visita domiciliar (visita domiciliaria), criança (niño), adolescente (adolescente). in english, the decs/ medical subject headings (mesh): child, adolescent, homebound persons, home care services, house calls. the search strategy for obtaining the primary studies was performed through arrangements between descriptors and boolean operators (and and or) with parentheses and quotation marks. in scielo, lilacs and bdenf, the following search strategy was used: (teenager or child) and "home patients" or "home care" or "home visit" and its correspondents in spanish and english; at medline, mesh: (child or teenager) and "homebound persons"; (child or teenager) and "home care services"; (child or teenager) and "home care services" and "house calls". the inclusion criteria of the studies were publications between 2009 and 2020, available in full, in portuguese, english or spanish, which presented individuals aged between 0 and 18, and that portrayed the proposed theme. exclusion criteria were theses, dissertations and monographs, reviews, editorials, papers presented at scientific events, book chapters, obituary and letters to the editor. the titles and abstracts were read independently to ensure that the elected articles met the question and inclusion criteria established. in cases of divergences, there was discussion among the researchers to reach consensus. the process of selection and organization of articles occurred manually, based on the full reading and the use of a validated data extraction instrument for integrative review (14). this stage was performed independently by the two researchers, and the following steps were followed: data reduction, with the removal of the main results of the articles and coding for their better management; display of the data with the creation of a thematic framework, in which all articles and their respective codes are gathered; comparison of the data, in which patterns were identified in the codes, organizing them into groups with similar results, to which different colors were assigned for better definition of categories; and, in the final phase of drawing and verification of the conclusion, the synthesis of the resulting groups and their appointment into categories were carried out to enable the discussion (11). results a total of 5,641 articles were identified, which, after applying the filters according to the inclusion criteria, resulted in 828. after the disposal of the manuscripts in duplicate, 637 (11/scielo, 177/lilacs, 26/ bdenf and 423/medline) had their titles and abstracts read exhaustively, to verify whether they answered the study question. a good of 576 articles were excluded because they were not in portuguese, english or spanish (1 article); do not present individuals aged between 0 and 18 years (39 articles); not to be articles (9 works); not to respond to the research objective (527 articles). after this stage, 61 articles were selected for full reading and, of these, 28 composed the final sample (figure 1). of the 61 studies, 32 were excluded for not answering the research question (2/scielo; 3/lilacs; 27/medline) and one for not corresponding to the established age group (lilacs). figure 1. flowchart of the process of selecting articles in databases. source: own elaboration. of the articles, eight (28.5 %) were published in 2016; four (14.2 %) in 2019; (10.7 %) in 2015 and 2014; (7.1 %) in each of the following years 2013, 2017 and 2018; (3.5 %) in each of the years 2010, 2011, 2012 and 2020. in 2009, no studies addressing the theme were found. re­garding the research design, 24 (85.7 %) were quantitative studies, one (3.5 %) qualitative and three (10.7 %) addressed qualitative and quantitative methods (chart 1). table 1. characterization of articles and categories listed on professional care in home care to children and teenagers with special health needs. author/year of publication, database and country title and method category 1. child and teenager assistance with obvious symptoms and/or in use of health technologies category 2. factors that interfere with or promote health-related quality of life category 3. professional performance in home care with the family caregiver rossetto v, toso brgo, rodrigues rm, viera cs, neves et, 2019 (10) scielo brazil development care for children with special health needs in home care at paraná, brazil quantitative care with health devices related to oxygenation, urinary elimination and feeding; rehabilitation; drug dependence; use of diapers; fully implanted catheter; and other particular care.     prado af, salinas fp, 2013 (15) lilacs chile home non-invasive ventilatory care in children: initial impact of a national program in chile quantitative noninvasive mechanical ventilation assistance. reduction of hospitalization; quality of life; decreased of anxiety. provision of continuing education to parents regarding the management of the disease and equipment. ellis en, blaszak c, wright s, lierop av, 2012 (16) medline united states of america effectiveness of home visits to pediatric peritoneal dialysis patients quantitative decrease in peritonitis, related to care at the time peritoneal dialysis .   family guidance on the use, storage and administration of medicinal products and peritoneal dialysis and on care for the environment/machine. groh g, feddersen b, führer m, borasio gd, 2014 (17) medline germany specialized home palliative care for adults and children: differences and similarities quantitative care for children with neoplasia, metabolic diseases, nervous system, circulatory and congenital with improvement of the symptoms presented (pain, fatigue, cognitive impairment, dyspnea). increased probability of survival. improves caregiver quality of life by decreasing care overload, anxiety and depression. cantero mjp, rodríguez am, cardona alu, ortiz aj, 2014 (18) medline spain domiciliary parenteral antibiotic therapy: a prospective analysis of the last 12 years quantitative administration of antibiotic therapy. reduction of hospitalization and complication rates. guidance to family caregivers regarding the administration of medications. mariani fep, duarte ed, manzo bf, 2016 (19) lilacs brazil profile of children, adolescents and their caregivers assisted by a home care program quantitative care with health devices related to oxygenation, feeding, neurological disorders and drug administration.     groh g, borasio gd, nickolay c, bender hu, von lüttichau i, führer m, 2013 (20) medline germany specialized pediatric palliative home care: a prospective evaluation qualitative and quantitative general care for children with subsequent symptom control. improves the quality of life of caregivers/children. relief of the burden of care for caregivers, support for their activities of daily living, as well as psychological and psychosocial support. han yj, park jd, lee b, choi yh, suh di, lim bc, et al, 2015 (21) medline korea home mechanical ventilation in childhood-onset hereditary neuromuscular diseases: 13 years' experience at a single center in korea quantitative care with invasive and noninvasive mechanical ventilation, tracheostomy, nasogastric tube and gastrostomy. decrease in hypoxia episodes. reduction of hospitalization; the survival rate.   yeager a, lavigne aw, rajvanshi a, mahato b, mohan r, sharma r et al., 2016 (22) medline india can support: a model for home-based palliative care delivery in india qualitative and quantitative administration of medications, insertion of bladder and gastric catheters; pain relief and palliation.   guidance to family members regarding simple nursing tasks, such as wound treatment. lindley lc, mixer sj, mack jw, 2016 (23) medline united states of america home care for children with multiple complex chronic conditions at the end of life: the choice of hospice versus home health quantitative care for children with cardiovascular conditions, anomalies and decreased functional status.   training of family caregivers; ease of access to pediatric reference hospitals. chong la, khalid f, 2016 (24) medline malaysia pediatric palliative care at home: a single center's experience quantitative palliation and care with health devices related to oxygenation, urinary elimination and feeding. difficulty in pain management.     tiberg i, lindgren b, carlsson a, hallstróm i, 2016 (25) medline sweden cost-effectiveness and costutility analyses of hospital-based home care compared to hospital-based care for children diagnosed with type 1 diabetes; a randomized controlled trial; results after two years' follow-up quantitative     promoting parents' satisfaction with home care. from the presentation to the family of strategies for the management of diabetes that have an impact on daily life for a longer period. lindley lc, nageswaran s, 2017 (26) medline united states of america pediatric primary care involvement in end-of-life care for children quantitative   relationship between home care and approximation with primary care; beyond decreased predisposition to cardiovascular, psychological and functional problems.   chong ph, de castro molina ja, teo k, tan ws, 2018 (27) medline singapore pediatric palliative care improves patient outcomes and reduces health care costs: evaluation of a home-based program quantitative decreased pain during follow-up. reduction of hospital admissions; improve of emotions; quality of life related to health. reduction of caregiver care burden. carvalho ajl, ferreira hm, borges ef, borges junior lh, de paula alt, hattori wt et al., 2019 (28) medline brazil analyses of the effectiveness of a brazilian pediatric home care services: a preliminary study quantitative -------------- decreased infection rates, procedures (laboratory and imaging tests) and readmission.   lee yh, lu cw, huang ct, chang hh, yang kc, kuo cs et al., 2019 (29) medline china impact of a home health care program for disabled patients in taiwan: a nationwide population-based cohort study quantitative care of tubes or catheters and treatment of wounds. reduction of the risks of hospitalization and the use of emergency services.   naicker sn, richter l, stein a, campbell l, marston j, 2016 (30) medline south africa development and pilot evaluation of a home-based palliative care training and support package for young children in southern africa qualitative adequate pain management during home follow-up. greater permanence of the child in the home; favoring the approach of the child with the family members. promotion of support and preparation of the family for the experience of death, in addition to the mediation of learning for the performance of home care. tang mh, lin ck, lin wh, chen ch, tsai sw, chang yy, 2011 (31) medline china the effect of adding a home program to weekly institutional-based therapy for children with undefined developmental delay: a pilot randomized clinical trial quantitative   the home activity program resulted in average functional progress when compared to institutional therapy in terms of cognitive, language, motor activities and social domains. guidance and training on home management of children with developmental delay through rehabilitation activities. maynard r, christensen e, cady r, jacob a, ouellette y, podgorski h et al., 2019 (32) medline united states of américa home health care availability and discharge delays in children with medical complexity quantitative tracheostomy, gastrostomy, nasogastric tube, jejunostomy, nasal cannula, mechanical ventilation, among others. delayed initiation of home care reduces the quality of life of children and increases the risk of infection.   zuurmond m, o'banion d, gladstone m, carsamar s, kerac m, baltussen m, et al., 2018 (33) medline ghana evaluating the impact of a community-based parent training program for children with cerebral palsy in ghana quantitative   significant improvement in the physical and emotional health of the child and improvement in some aspec ts in infant feeding (some children were malnourished). the home support to the parents provided an increase in the number of patients and significant improvement in the knowledge and confidence of the family caregivers. ferre cl, brandão m, surana b, dew ap, moreau ng, gordon am, 2017 (34) medline united states of america caregiver-directed home-based intensive bimanual training in young children with unilateral spastic cerebral palsy: a randomized trial quantitative improved bimanual dexterity and occupational performance.   training for performing exercises at home to improve bimanual hand control, increasing parent-child interaction; remote professional follow-up (online). mankikar d, campbell c, greenberg r, 2016 (35) medline united states of america evaluation of a home-based environmental and educational intervention to improve health in vulnerable households: southeastern pennsylvania lead and healthy homes program quantitative -------------- reduction of hospital admissions and medical consultations. health education for the adaptation of the environment and asthma control. perera h, jeewandara kc, seneviratne s, guruge c, 2016 (36) medline sri lanka outcome of home-based early intervention for autism in sri lanka: follow-up of a cohort and comparison with a nonintervention group quantitative -------------- improvement of eye contact, response to name, social reciprocity, imitative behavior and pointing. guidance and training to stimulate, in a playful way, at home, the social interaction and communication of children. lorentzen j, greve lz, kliim-due m, rasmussen b, bilde pe, nielsen jb, 2015 (37) medline denmark twenty weeks of home-based interactive training of children with cerebral palsy improves functional abilities quantitative   improvement of activities of daily living resulting in greater school participation and leisure.   eskow kg, chasson gs, summers ja, 2015 (38) medline united states of america a cross-sectional cohort study of a large, statewide medicaid home and community-based services autism waiver program quantitative   improved skills in activities that could be performed independently. support for family members provided an improvement in the quality of life of the family. hoyt drazen c, abel r, lindsey t, king aa, 2014 (39) medline united states of america development and feasibility of a home-based education model for families of children with sickle cell disease qualitative and quantitative     conducting educational actions on the milestones of development, learning and skills appropriate for early childhood. potterton j, stewart a, cooper p, becker p, 2010 (40) medline south africa the effect of a basic home stimulation program on the development of young children infected with hiv quantitative   positive effect on the neurodevelopmental status of children with hiv. guidelines for performing activities that stimulate neurodevelopment. dangel t, kmiec t, januszaniec a, wazny b, 2020 (41) medline poland palliative care in 9 children with neurodegeneration with brain iron accumulation quantitative aid in the control of pain and other symptoms; brain stimulation; administration of medicines; oxygen-therapy.   family support for home care addressing emotional and spiritual aspects. source: own elaboration. the special health needs identified were related to diseases of respiratory (15), renal (16), neurological, cardiovascular, genetic, congenital, neoplastic and metabolic (17), infectious etiology (18). the professionals who performed home care were nurses, doctors, physiotherapists and occupational therapists (10). after in-depth reading of the articles, the results were organized into three categories: assistance to children and teenagers with evident symptoms and/or using health technologies; factors that interfere with or promote health-related quality of life; professional performance in home care with the family caregiver. in addition to the categories listed, it was evidenced that ad brings benefits to the health system, because it optimizes the occupation of hospital beds by reducing the frequency of hospitalization. this can lead to the minimization of trauma to the crianes by the lower exposure to stressors and the reduction of costs with hospital health expenses. discussion hc is recognized for effective actions of rehabilitation, palliation, health promotion, prevention and treatment of diseases. it aims to increase the autonomy of the user, family and caregiver, taking responsibility for the management and operationalization of care or home hospitalization. it requires qualified health professionals who offer home support to the user and their caregiver (8), according to the discussion of the following categories. child and teenager assistance with obvious symptoms and/or in use of health technologies the performance of health professionals in home services is focused on technological health support, especially the care of invasive and noninvasive mechanical ventilation, tracheostomy, gastrostomy, oxygen therapy, peritoneal ventricle bypass, nasoenteral/nasogastric tube, fully implanted catheter, urinary catheters, as well as assistance to symptoms presented by the child and teenager such as pain, fatigue, cognitive impairment, and dyspnea (10, 1524, 27, 29, 30, 32, 34). the conduction of these care stems from the fact that the crianes present a prominent subgroup: children and teenagers with complex chronic conditions (ccc). these are characterized as multisystemic diseases that permeate their birth, growth and development, often leading to technological dependence and prolonged stay in hospitals (41). the ccc was responsible for the prevalence of 84.2 % of pediatric hospitalizations, especially genetic and congenital anomalies (80.8 %), respiratory diseases (68 %), neuromuscular diseases (47.3 %) and gastrointestinal diseases (42.4 %). after hospital discharge, many required home health technologies, such as gastrostomy (29.6 %), oxygen therapy (7.4 %), special milk formulas (4.4 %) and noninvasive mechanical ventilation (2 %) (9 %). it is evident that children with ccc have multidimensional needs, depending on professional care plus family care (42). thus, referral to hc can be effected and bring benefits, such as the reduction of suffering caused by hospitalization and increased availability of beds for acute conditions (9). another potential of hc is related to the increase in the quality of care for health technologies, evidenced in research conducted with children on home peritoneal dialysis and their families (16). in this study, there was a decrease in the rates of peritonitis in children after professional interventions at home when compared with the incidence of this complication only with family care. another group of crianes that stood out was that of children and teenagers in palliative care in receiving home care, because, in addition to support with health technologies, they needed special attention to symptoms arising from their health conditions (17, 2224). a study in germany pointed out that, after the involvement of the pediatric palliative home care team, the companions perceived a significant improvement in the symptoms presented by children and teenagers (17). this was possible because, when they received treatment in the comfort of the household, they did not awaken a feeling of sadness as occurred in the hospital and needed less constant and difficult visits to the health service (43). on the other hand, a study states that there is difficulty in recognizing and managing pain, a symptom prevalent in patients receiving palliative care, and it is necessary to advance in the conduction of care plans, such as through scales or protocols that enable the measurement of this vital signal (24). the construction of the care plan conducted by the home service team should cover the needs of patients, starting from the evaluation of physical, psychological, emotional, basic diagnosis and understanding of the social relationships in which they are involved. thus, each professional will perform actions that fall into his or her category. the services that provide home care excel in the quality of care, using health technologies required by each child, who experiences home care. thus, they provide compliance with the demands arising from the condition of the crianes, maintaining the possible stability, which results in a better quality of life for the child and his/her family. factors that promote or interfere with health-related quality of life it is evident the increase in the quality of life related to the health of the crianes after the interventions of the professionals who provide home care, in the following aspects: reduction of hospital rehospitalizations and rates of complications such as infections; reduction in the constant performance of procedures such as laboratory tests and search for emergency services; improvement of emotions, anxiety, cognition, language and activities of daily living; survival rates (15, 17, 18, 20, 21, 2629, 31, 37). the increase in hospital stay, triggered by the delay in the beginning of home care, results in a decrease in the quality of life of the children and an increased risk of infections. a study points out that this delay is due to the lack of professionals with good financial incentive, adequate workload and migration in search of good working conditions (32). moreover, the multiple hospitalizations decrease their survival, further aggravated when ccc is present (45). these adversities are little present in timely home hospitalizations, as pointed out in a stud, in which the number of hospitalizations, procedures and number of infections decrease significantly in home services when compared to hospital services (28). therefore, the hc has the potential to reduce the hospital demand and the permanence of users in prolonged hospitalizations, complementing the care provided by primary care services. in this perspective, there is a reduction in the use of emergency services, sometimes required by the crianes after hospital discharge (29). consequently, the increase in home stay and the performance of these services in an environment in which the crianes feel safe, results in the improvement of the quality of life related to health. studies that evaluated home palliative services to children showed that, in the opinion of parents or caregivers, the quality of life of their children improved significantly after the involvement of these services (17, 20). in addition, the involvement of professionals in home care results in an improvement in emotional state, anxiety and levels of depression of both the child and the caregiver after home interventions (15, 17). these benefits are justified by actions such as that of a malaysian service, which provides 24-hour telephone access, providing physical and emotional support to its patients and caregivers (27). children with neurodevelopmental delay need special attention from home professionals. therefore, in the impossibility of an integral professional, the orientations and training of parents to perform home activities bring positive responses to the quality of life of these children (31). however, for family involvement to become effective, in ensuring adequate child neurodevelopment, a strategy used is to fit the routine activities of the family and child and teenager from stimulating activities, as pointed out research conducted with family members of children with hiv (40). another strategy in improving daily activities, which guarantee an excellent quality of life, such as leisure, school participation, attention of children with cognitive impairment, is the application of computer interventions in the online modality by parents, prescribed by professionals and with sporadic follow-up. in this modality, because it is possible to perform constant and intense interventions, without the limitations of weekly care only with the professional, the development of the crianes occurs considerably (37). but the continuous availability of support is still an essential component for the home caregiver, because, in addition to providing safety and help, it prepares them for the adversities that may arise at any stage of the disease, either in times of urgency or in the resolution of the doubts of the caregivers themselves. therefore, it favors continuous and comprehensive health care (27). in view of the above, the professionals of home care services, performing frequent care to the crianes, guarantee them a longer survival, if they have adequate working conditions (18, 20). the constant monitoring, in the physical, emotional and cognitive scope, using strategies beyond the presence of professionals such as the use of computers, internet and telephone, makes the improvement of the quality of life of this public be achieved, which brings benefits that radiate to family members, parents, caregivers who take care of these children daily. performance of health professionals in the home service with the family caregiver in families conformed by crianes, it is common to observe emotional stress, frustration and disappointment of mothers caused by the lack of knowledge of their pathology and resources that are necessary for care (46, 47). in addition, the exclusive dedication of mothers in the care of the crianes, due to the lack of support network that assists them, causes the abandonment of their jobs, a financial deficit and lack of self-care, affecting family well-being (48, 49). studies indicate that family members also be afraid in the handling of technological devices, such as tracheostomy (50) and gastrostomy (51), in the usual care such as bathing and feeding, in the administration of medication and its long-term effects, being evidenced by un-preparedness in situations of complication and infection (52). it is note that the importance that family members must acquire technical-scientific knowledge to promote adequate care to the crianes, being necessary notions of mathematics, disinfection, drug interaction, handling of health technologies, among others (5). the performance of home service professionals, portrayed in the literature investigated in this study, strongly highlights the offer of technical and scientific knowledge to family members. these actions are focused on guidance and training on the correct management of invasive devices, the use, storage and correct administration of medications and the daily care to crianes (15, 16, 20, 22, 23, 25). the recognition of families by health professionals enables their active participation in the care process, performing activities safely (6). this is highlighted in a home care unit in spain, where professionals train parents or caregivers to administer antimicrobial therapy intravenously long enough for them to feel safe to continue at home, in the absence of professionals (20). moreover, family involvement is more effective when therapeutic actions are also delegated to parents and inserted in the daily life of the family and in the playful activities performed with the crianes. this occurred in a home intervention program for autistic children, resulting in an improvement in social interaction, language and communication (36); in a home exercise program for bimanual hand control for children with cerebral palsy, resulting in greater father-child interaction (34). although this family involvement is advantageous, caution is necessary in conducting therapeutic activities at home, considering that these interventions tend to change the family routine and require the caregiver to have a psychosocial well-being to implement them. therefore, it is up to the professionals to outline with the caregiver the best time and daily time necessary for the activities to be performed with the children and teenagers so as not to overload them (34). preventive education is also part of the work of health professionals of the hc with family members, referring to the monitoring of child development and the reduction of environmental factors that interfere in the health status of the crianes. this was evidenced in studies in which preventive education modifies parental behavior for the adaptation of the home environment, making it safer and with the possibility of conducting activities appropriate to children and teenagers (39). these actions of prevention, guidance and training, and the involvement of home services professionals in the care of the crianes contributed significantly to the reduction of the work overload of the caregivers. in addition, there was a reduction in their psychological distress evidenced in the minimum prevalence of diseases such as anxiety and depression, implying an increase in the quality of life of family members (17, 20, 27). the receipt of home care provides families with more time for everyday life, not turning exclusively to the care of the crianes, partially returning to the common activities existing before the presence of this condition. moreover, it is emphasized the strengthening of relationships with relatives and friends, and the decrease in constant family displacement to the hospital, resulting in an increase in the physical and mental disposition for home care (43). the family members/caregivers of crianes are in the act of performing previously unusual activities. thus, the services that provide home care seek to meet the needs of technical and scientific knowledge of family members through prevention actions, guidance and training, both for care and in actions that improve the mental health and quality of life of the children and their families. conclusion the present study allowed the analysis of the performance of health professionals in home care services to the created at national and international level. however, in a continental country like brazil, not all municipalities have these services in place. as in other countries, although with different denominations for ad in brazil, it can be observed that these services act in the demands of care with health technologies, promote relief of the symptoms presented and reduce the workload of caregivers and family members. moreover, it was possible to identify the offer of remote support actions and concern to train caregivers regarding the technical-scientific aspects of the care of the crianes and the management of their health conditions. the provision of these services is not only limited to the presence of professionals at home but can also be performed using technologies such as internet, computers and telephone. this expands and strengthens the parent-professional relationship, resulting in feelings of safety and improvement of the quality of life related to the health of parents and crianes. professionals working in the home care service present difficulties in identifying and managing pain. this is a gap that could be minimized by the implementation of scales and protocols to measure this signal, generating greater comfort to the child and tranquility to the family. another gap in care was the delay in the beginning of home care, with a subsequent increase in the stay of crianes in the hospital. it should be noted that there was a limitation of the search in the databases due to the lack of a specific descriptor for crianes, since this term encompasses a diversity of groups of children and teenagers with special health needs. in addition, the present study was based on the brazilian model of home care, so that, as observed in the reading of the articles, there is a variety of organizations in this modality of care; thus, it cannot be generalized to all the realities of the world. therefore, it is suggested the development of research with the objective of longitudinally monitoring the performance of health professionals of home care in other countries of the world, according to their specificities, focusing on pain management and the time necessary for the organization of the team and the dehospitalization of crianes. this review brings as a benefit the unification of information on the services of hc for the crianes, enabling those interested in the area to understand them as an aid to dehospitalization. it also subsidizes professionals in the care of children at home, since it summarizes the main evidence of the methods used by health professionals in hc to this public. bringing to the fore how professional care has been taking place in the home care of crianes can give visibility to this population that, in fact, requires continuous and comprehensive care, and deserves to live with dignity. to this end, awareness and changes in the work process of those who care for them are necessary. conflict of interest: none declared. references 1. branquinho id, lanza fm. child health in primary care: evolution of brazilian policies and nurses' performance. recom 2018;8:e2753. doi: https://doi.org/10.19175/recom.v8i0.2753 2. mcpherson m, arango p, fox h, lauver c, mcmanus m, newacheck pw et al. a new definition of children with special health care needs. pediatrics. 1998;102(1):137-9. doi: 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lead and healthy homes program. int. j. environ. res. public. health. 2016;13(9):900. doi: https://doi.org/10.3390/ijerph13090900 36. perera h, jeewandara kc, seneviratne s, guruge c. outcome of home-based early intervention for autism in sri lanka: follow-up of a cohort and comparison with a nonintervention group. biomed res. int. 2016;2016:1-6. doi: https://doi.org/10.1155/2016/3284087 37. lorentzen j, greve lz, kliim-due m, rasmussen b, bilde pe, nielsen jb. twenty weeks of home-based interactive training of children with cerebral palsy improves functional abilities. bmc neurol. 2015;15:75. doi: https://doi.org/10.1186/s12883-015-0334-0 38. eskow kg, chasson gs, summers ja. a cross-sectional cohort study of a large, statewide medicaid home and community-based services autism waiver program. j. autism. dev. disord. 2015;45(3):626-35. doi: https://doi.org/10.1007/s10803-014-2217-4 39. hoyt drazen c, abel r, lindsey t, king aa. development and feasibility of a home-based education model for families of children with sickle cell disease. bmc public. health. 2014;14:116. doi: https://doi.org/10.1186/1471-2458-14-116 40. potterton j, stewart a, cooper p, becker p. the effect of a basic home stimulation program on the development of young children infected with hiv. dev. med. child. neurol. 2010;52(6):547-51. doi: https://doi.org/10.1111/j.1469-8749.2009.03534.x 41. dangel t , kmiec t , januszaniec a , wazny b. palliative care in 9 children with neurodegeneration with brain iron accumulation. neurol. sci 2020;41(3):653-60. doi: https://doi.org/10.1007/s10072-019-04099-5 42. moreira mcn, albernaz lv, sá mrcd, correia rf, tanabe rf. recommendations for a line of care for children and teenagers with complex chronic health conditions. cad. saúde pública. 2017;33(11):e00189516. doi: https://doi.org/10.1590/0102-311x00189516 43. martins pl, azevedo cs, afonso sbc. the role of family in treatment plans and pediatric inpatient care in complex chronic health conditions. saude soc. 2018; 7(4):1218-29. doi: https://doi.org/10.1590/s0104-12902018170402 44. castor c, landgren k, hallstrom ik. a possibility for strengthening family life and health: family members' lived experience when a sick child receives home care in sweden. health soc. care community. 2018;26:224-31. doi: https://doi.org/10.1111/hsc.12512 45. oliveira aj, ribeiro al, lima jsd, horta nc. performance of home care teams in palliative care. percurso acadêmico. 2019;9(18):39-58. doi: https://doi.org/10.5752/p.2236-0603.2019v9n18p71-90 46. kalzén h, larsson b, eksborg s, lindberg l, edberg ke, frostell c. survival after picu admission: the impact of multiple admissions and complex chronic conditions. plos one. 2018;13(4);1-14. doi: https://doi.org/10.1371/journal.pone.0193294 47. santos cct, miranda cssp, silva kdjm, pinto mfp, costa as, moraes-filho im. emotional stress in families of children with special needs-literature review. reicen. 2018;1(2):247-9. disponível em: https://revistasfacesa.senaaires.com.br/index.php/iniciacao-cientifica/article/view/89 48. reis kmn, alves gv, barbosa ta, lomba go, braga pp. a vivência da família no cuidado domiciliar à criança com necessidades especiais de saúde. cienc. enferm. 2017;23(1):45-55. doi: https://doi.org/10.4067/s0717-95532017000100045 49. leite fllm, gomes gc, minasi asa, nobre cmg, mota ms. facilidades e dificuldades vivenciadas pela família no cuidado à criança com necessidades especiais de saúde. res., soc. dev. 2020; 9(10):e5619108761. doi: https://doi.org/10.33448/rsdv9i10.8761 50. bossa pma, pacheco sta, araújo bbm, nunes mdr, silva lf, cardoso jmrm. desafios de familiares no cuidado domiciliar da criança em uso de cânula de traqueostomia. rev. enferm. uerj. 2019;27:e43335. doi: https://doi.org/10.12957/reuerj.2019.43335 51. nóbrega vm, araújo mgf, coutinho lrpc, oliveira ckn, dantas jc, collet n. vivências maternas no cuidado à criança gastrostomizada: subsídios para atuação da equipe de saúde. rev min enferm. 2019;23:e-1250. doi: https://doi.org/10.5935/1415-2762.20190098 52. barros abs. dúvidas dos familiares de crianças com necessidades especiais de saúde quanto aos cuidados domiciliares [trabalho de conclusão de curso]. niterói (rj): universidade federal fluminense; 2016. home 3 autocuidado.p65 autocuidado y adherencia en pacientes con falla cardiaca 139 año 7 vol. 7 nº 2 • chía, colombia octubre 2007 • 139-160 diana marcela achury saldaña1 resumen objetivo: determinar la adherencia al tratamiento de pacientes con falla cardiaca hospitalizados, al aplicar un plan educativo que fomenta el autocuidado. método: estudio cuasiexperimental (entrevistas enfermera-paciente) realizado entre diciembre de 2004 y mayo de 2006, con una muestra de 50 pacientes seleccionados por conveniencia. se diseñó un instrumento para evaluar los comportamientos de los pacientes, con base en algunos resultados de la adherencia y sus respectivos indicadores de la taxonomía noc (nursing out comes classification). la adherencia al tratamiento fue medida en dos momentos: el primero durante la hospitalización, seguido de la aplicación del plan educativo antes del alta, que proporcionaba información en el manejo de su enfermedad desde una dimensión física, psicológica y social que promueve el autocuidado; y el segundo un mes después del alta en su domicilio. resultados: diferencias estadísticamente significativas (p=0,0001) que demuestran cómo mediante la capacitación al paciente en el manejo de su tratamiento farmacológico y no farmacológico, el establecimiento de una sana relación entre el profesional de enfermería y el paciente, y la participación de la familia, se logra una total adherencia al tratamiento. conclusiones: para lograr una adherencia total del paciente con falla cardiaca al tratamiento es necesario un proceso educativo y un seguimiento continuo y personalizado que motive permanentemente al paciente y se le reconozca el papel protagónico en su cuidado y manejo de la enfermedad. palabras clave autocuidado, cuidados posteriores, enfermedad crónica. (fuente: decs, bireme). recibido: 23 de julio de 2007 aprobado: 30 de agosto de 2007 autocuidado y adherencia en pacientes con falla cardiaca autocuidado y adherencia en pacientes con falla cardiaca 1 facultad de enfermería. pontificia universidad javeriana. carrera 7 no. 40 62, bogotá, colombia. dianaachury@yahoo.es aquichan issn 1657-5997 aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007140 self-care and adherence among patients with heart tailure abstract objective: determine adherence to treatment among hospitalized patients with heart failure, following the implementation of an educational plan to promote self-care. method: a quasi-experimental study (nurse-patient interviews) was carried out between december 2004 and may 2006 with a convenience sample of 50 patients. an instrument was designed to assess the patients� behavior based on a set of adherence results and their respective noc indicators (nursing outcomes classification). adherence to treatment was measured at two points in time: the first during hospitalization, followed by application of the educational plan prior to release, which provided information on management of the patient�s illness from a physical, psychological and social perspective that promotes self-care; and the second, one month after release, in the patient�s home. results: statistically significant differences (p=0.0001) showing how total adherence to treatment can be achieved by training the patient to manage his/her pharmacological and non-pharmacological treatment, by establishing a healthy relationship between the nursing professional and the patient, and by involving the family. conclusions: an educational process, coupled with continuous, personalized follow-up that motivates the patient and makes him/her aware of their leading role in the care and management of their illness is necessary for total adherence to treatment by a patient with heart failure. key words self care, aftercare, chronic disease. auto-cuidado e aderência nos pacientes com parada cardíaca resumo objetivo: estabelecer a aderência ao tratamento de pacientes hospitalizados com parada cardíaca aplicando um plano educativo que promove o auto-cuidado. método: estudo quase-experimental (entrevistas enfermeira-paciente) realizado entre dezembro de 2004 e maio de 2006 com una amostra de 50 pacientes selecionados por conveniência. para avaliar os comportamentos dos pacientes, foi desenhado um instrumento baseado em resultados da aderência e os seus respectivos indicadores da taxonomia noc (nursing out comes classification). a aderência o tratamento foi medida em dois momentos: o primeiro durante a hospitalização, seguido da aplicação do plano educativo antes da alta, que proporcionou informação no manejo da doença desde una perspectiva física, psicológica e social que promove o auto-cuidado; o segundo, um mês depois da alta, em casa. resultados: diferencias estatisticamente significativas (p = 0.001) revelam que a capacitação do paciente no manejo do tratamento farmacológico e não farmacológico, o estabelecimento de uma boa relação entre o profissional da enfermagem e o paciente, e a participação da família favorecem a aderência total ao tratamento. conclusões: para o paciente lograr uma aderência total ao tratamento, é requerido um processo educativo e um acompanhamento continuo e pessoalizado que motive permanentemente ao paciente. também deve ser reconhecido o seu papel de protagonista no seu cuidado e no manejo da doença. palavras-chave auto-cuidado, assistência ao convalescente, doença crônica.  autocuidado y adherencia en pacientes con falla cardiaca 141 introducción a falla cardiaca se constituye en una entidad patológica con un gran impacto en la población general, se considera uno de los principales problemas de salud pública a nivel mundial, con repercusiones económicas y sociales de gran magnitud (1, 2). en colombia, según el sistema de información rips 2005 (ministerio de protección social), constituye aproximadamente el 6% de las hospitalizaciones en adultos, con un promedio de estancia hospitalaria de 5,8 días, un 7% de las consultas al servicio de urgencias, y aproximadamente un 2% de las causas de mortalidad global, teniendo en cuenta que estas estadísticas son independientes de otros diagnósticos de enfermedad cardiovascular altamente relacionados, como la enfermedad coronaria y el cor pulmonale, que ubican a la enfermedad cardiovascular como la primera causa de muerte hoy en día en nuestro país (3). la pirámide de población de colombia se encuentra en transición, con aumento del grupo de edad avanzada, y se enfrenta al fenómeno de polarización epidemiológica desencadenando que el envejecimiento, y por ende la enfermedad cardiovascular manifestada en muchas oportunidades como falla cardiaca, sea la primera causa de muerte para los años venideros (2, 4). según la organización mundial de la salud (oms), esta entidad con el paso de los años tomará características de �epidemia� en todos los países desarrollados y subdesarrollados, incrementando día a día no sólo la mortalidad, sino la pérdida de años productivos, el aislamiento psicosocial y el consiguiente aumento de los costos para los sistemas de salud. conociendo esta información, y la relevancia que tiene para el paciente, su familia y el gremio de la salud, no podemos quedarnos sólo en el conocimiento de estos datos sin buscar estrategias y realizar investigaciones que ayuden a reducir la morbi-mortalidad de esta importante población (4). teniendo en cuenta la importancia de una entidad tan prevalente, se han desarrollado algunas estrategias como son las clínicas de falla cardiaca constituidas por profesionales de la salud cuyos intereses son la prevención, el diagnóstico, el tratamiento y la paliación de las manifestaciones de la falla cardiaca que han demostrado ser exitosas en diferentes países. existen en colombia muy pocas clínicas de falla cardiaca en instituciones de salud capacitadas que cuentan con la infraestructura suficiente para desarrollar dichos programas, y aunque su esfuerzo es loable, la cobertura no es suficiente para las necesidades de la población. esto obliga a que todo profesional de la salud, y sobre todo la enfermera y el enfermero, conozca las estrategias para el fomento del autocuidado de estos pacientes. ante una enfermedad crónica e irreversible es necesario conocer el grado de adherencia que tienen los pacientes entendido como una expresión concreta del autocuidado que depende del compromiso, la participación activa y voluntaria del paciente en un curso de comportamiento aceptado de mutuo acuerdo con el fin de producir un resultado terapéutico deseado (5, 6). los estudios muestran que en los países desarrollados, la adherencia a los tratamientos a largo plazo en la población general es de alrededor de 50%, porcentaje determinado gracias a la utilización de herramientas tales como el test de moriski-green-levine, el cual evalúa la adherencia al tratamiento farmacológico en cualquier enfermedad crónica, y resulta mucho menor en los países en desarrollo (8-12). estos datos permiten buscar en el paciente un tratamiento y control óptimo de la enfermedad. la adherencia terapéutica deficiente es la razón principal de que no se logren los beneficios clínicos, por lo cual se desarrollan complicaciones físicas y psicosociales que afectan negativamente la calidad de vida de los pacientes y generan un alto costo en los recursos de atención de salud (13). por otro lado, la adherencia terapéutica es un fenómeno multidimensional puesto que está determinada por la acción recíproca de factores. la creencia común de que los pacientes se encargan exclusivamente de tomar su tratamiento es desorientadora y, a menudo, refleja una concepción errónea sobre cómo otros factores afectan el comportamiento de la gente y la capacidad de adherirse a su tratamiento (12, 14, 15). es por esto que es necesario reconocer una serie de factores aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007142 influyentes en la adherencia al tratamiento, tales como: las características demográficas (edad, sexo, raza, estudios, ocupación), así como el nivel cultural y la situación económica; éstos no son factores predictores del nivel de adherencia de un individuo (12, 16, 18), pero se ha observado que los pacientes de mayor edad presentan mejor adherencia al tratamiento, a excepción de los pacientes mayores de 75 años en los que la comorbilidad empeora el cumplimiento. el disponer de un lugar fijo para vivir y un soporte social con familia estructurada o amigos es un factor que facilita la adherencia. los factores psicológicos también influyen en el cumplimiento; la ansiedad y la depresión empeoran la adherencia. las actitudes y creencias de los pacientes respecto a la medicación, la enfermedad y el equipo de salud son factores indiscutibles a la hora de aceptar el tratamiento propuesto y realizarlo de forma correcta. la percepción de beneficio potencial es fundamental en enfermedades crónicas y de curso asintomático (19, 20). los problemas de cobertura y la poca calidad de algunas entidades prestadoras de salud han sido descritos como unos de los múltiples factores que llevan al abandono del tratamiento, por lo cual es muy importante el papel de los servicios en los siguientes aspectos: • organización de los servicios de salud. la falta de organización en los servicios de salud es señalada como factor generador de incumplimiento por las esperas prolongadas, los costos de las consultas, la dificultad para consecución de citas y demora en la atención. la flexibilidad en los horarios y el confort en el sitio de atención del paciente han demostrado mejorar la adherencia. • distancia al centro de salud. algunos estudios señalan la distancia de la residencia del paciente a los servicios de salud como un factor de riesgo para el abandono del tratamiento (21-24). por otro lado, la relación que se establece entre el equipo asistencial y el paciente es de suma importancia. la confianza, continuidad, accesibilidad, flexibilidad y confidencialidad son factores que influyen de manera favorable. probablemente, los factores más importantes son el suministro de una información detallada, auténtica, y la toma de decisiones conjuntas en un marco de confianza mutuo (24, 25). la motivación, la experiencia y los conocimientos son fundamentales para conseguir un nivel óptimo de calidad asistencial. en numerosos estudios se ha demostrado que la adherencia a un tratamiento disminuye cuando aumentan el número de medicamentos y la frecuencia de administración, con la aparición de efectos adversos, y cuando el tratamiento es prolongado en el tiempo (22, 25). si bien no se ha detectado sistemáticamente que el nivel socioeconómico sea un factor predictible independiente de la adherencia, en los países en desarrollo el nivel socioeconómico bajo puede poner a los pacientes en la posición de tener que elegir entre prioridades en competencia (26, 27). tales prioridades incluyen con frecuencia las exigencias para dirigir los limitados recursos disponibles a fin de satisfacer las necesidades de otros miembros de la familia, como los hijos y los padres que los cuidan. el apoyo social amortigua los efectos adversos de la enfermedad; hay numerosos datos que apoyan la idea de que las personas que cuentan con buenas redes sociales se adaptan fácilmente a su enfermedad mejorando la adherencia. el apoyo social protege contra el estrés generado por la enfermedad y capacita al paciente para reevaluar la situación y adaptarse mejor a ella, ayudándole a desarrollar respuestas de afrontamiento (28). la motivación hacia la salud como variable con potencial predictible en el mantenimiento de la salud, prevención de enfermedades y cumplimiento del tratamiento médico, ha recibido escasa atención científica, existiendo pocos estudios que evalúen la importancia de ésta en la adherencia al tratamiento en el paciente con falla cardiaca (24, 26). se asume que la motivación hacia la salud es multidimensional; las conductas dirigidas hacia el mantenimiento de un adecuado estado de salud deben ser llevadas a cabo el disponer de un lugar fijo para vivir y un soporte social con familia estructurada o amigos es un factor que facilita la adherencia. los factores psicológicos también influyen en el cumplimiento; la ansiedad y la depresión empeoran la adherencia. autocuidado y adherencia en pacientes con falla cardiaca 143 por personas que valoren altamente la salud y tengan grandes expectativas de que sus conductas servirán para mejorar su condición o para prevenir la enfermedad. igualmente, la salud debe ser considerada como una meta importante y deseada. la experiencia clínica, así como las investigaciones, muestran una serie de factores propios de los profesionales de la salud que influyen en la búsqueda y el mantenimiento de una adecuada adherencia en el paciente con falla cardiaca, como es la falta de conciencia y conocimiento acerca de la adherencia terapéutica, así como el déficit en el suministro de información durante la hospitalización, olvidándose el fomento del autocuidado, y afectando la historia natural de la enfermedad del paciente con algunas conductas y actitudes perjudiciales para su salud (21, 24, 27-29). lo anterior lleva a señalar que la adherencia al tratamiento en los pacientes con falla cardiaca es un desafío que involucra la competencia profesional, por eso es necesario desarrollar estrategias que promuevan la participación y el compromiso de las personas a través de la implementación de la educación como un componente esencial de cuidado de enfermería que permite formar, convencer, motivar y fortalecer a las personas para que participen activamente en su tratamiento, aprendan a acoplar las posibles limitaciones de su enfermedad con su actividad diaria, y se motiven para afrontarlas. es importante resaltar que para lograr el impacto que buscamos con la educación en la adherencia al tratamiento no basta con una sola instrucción, es necesario un proceso continuo, dinámico, participativo y, en medio de este proceso, promover y analizar el soporte social y emocional con que cuentan los pacientes. para lograr este propósito es necesario utilizar herramientas aplicadas de forma continua y permanente como la observación y la atención al paciente, escuchándolo de manera empática, promoviendo la aceptación de la enfermedad, contribuyendo al aumento de la autoestima, y proporcionando información útil y puntual sobre el manejo de la enfermedad. el presente estudio pretende dar a conocer a los enfermeros y enfermeras la influencia positiva que tienen los programas de autocuidado ofrecidos a los pacientes con enfermedades crónicas, que contribuyen a mejorar su estado de salud y a reducir costos. así mismo, quiere aportar un instrumento validado que permita medir el grado de adherencia al tratamiento farmacológico y no farmacológico, y una estrategia educativa que promueva el autocuidado y la adhesión al tratamiento para aplicarlos a los pacientes hospitalizados y ambulatorios con falla cardiaca como parte de la valoración de enfermería, de esta forma se contribuirá precozmente a identificar los niveles de adherencia y proporcionar un plan de cuidado propio para estos pacientes. objetivo general determinar el efecto de un plan educativo que fomente el autocuidado y la adherencia al tratamiento en un grupo de pacientes hospitalizados en una institución de tercer nivel con diagnóstico de falla cardiaca. objetivos específicos • determinar la adherencia al tratamiento que presentan los pacientes con falla cardiaca hospitalizados en una institución de tercer nivel, antes de la aplicación del plan educativo que fomenta el autocuidado. • determinar la adherencia al tratamiento de los pacientes con falla cardiaca en una institución de tercer nivel, posterior a la aplicación del plan educativo que fomenta el autocuidado. la experiencia clínica, así como las investigaciones, muestran una serie de factores propios de los profesionales de la salud que influyen en la búsqueda y el mantenimiento de una adecuada adherencia en el paciente con falla cardiaca. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007144 metodología se realizó un estudio cuasiexperimental aplicado a los pacientes adultos con diagnóstico de falla cardiaca hospitalizados en el servicio de medicina interna en una institución de cuarto nivel durante los meses de diciembre de 2004 a mayo de 2006, en el cual se evaluaron los efectos de un plan educativo estableciendo la capacidad de adherencia inicial y la posterior, transcurridos 30 días. la población estuvo constituida por 217 pacientes adultos con falla cardiaca hospitalizados en el servicio de medicina interna durante los meses de diciembre de 2004 a mayo de 2006. la muestra seleccionada corresponde a 50 pacientes adultos con falla cardiaca que cumplieron con los criterios de inclusión: pacientes hombres o mujeres mayores de 18 años, hospitalizados con diagnóstico de falla cardiaca clase funcional i, ii, iii, que no asistieran a clínicas de falla cardiaca, pacientes que aceptaran y estuvieran en capacidad de recibir y comprender la información del plan de autocuidado, y que tuvieran como sitio de residencia la ciudad de bogotá durante los siguientes cuatro meses del egreso. procedimiento el estudio se desarrolló en cuatro fases: fase a. construcción y validación facial y de contenido del instrumento al revisar la literatura no se encontraron instrumentos que midieran adherencia al tratamiento específicamente en el paciente con falla cardiaca, por lo cual para la elaboración de este instrumento se realizó una amplia revisión bibliográfica tomando como referencia los resultados de la adherencia y sus respectivos indicadores de la taxonomía noc. esta taxonomía es una agrupación estandarizada de resultados desarrollados para evaluar el efecto de las intervenciones de enfermería; dentro de estas agrupaciones existe un indicador denominado cumplimiento de los tratamientos cuya validez de contenido inicial fue avalada por el grupo de investigación de la universidad de iowa (31). la versión en español ya había tenido una validez facial por enfermeras docentes y con práctica en el área de atención al paciente cardiovascular, y ha sido utilizada en otras investigaciones como la de bastidas (32) titulada: asociación entre la capacidad de agencia de autocuidado y la adherencia al tratamiento farmacológico y no farmacológico de los pacientes con enfermedad cardiovascular. tomando como referencia estos indicadores se adicionaron otros que reflejaban los factores que se consideran influyentes en los comportamientos de adherencia del paciente con falla cardiaca; el resultado fueron 10 indicadores que evaluaban los siguientes aspectos: 1. confianza en el profesional de la salud 2. accesibilidad a los servicios de salud 3. conocimiento en el manejo del tratamiento farmacológico 4. aceptación de la enfermedad 5. reconocimiento de signos y síntomas de alarma 6. soporte social 7. mantenimiento del peso 8. conocimiento de la dieta adecuada 9. realización de actividad física 10. estado emocional estos indicadores se acompañaron de una guía más específica para evaluar cada comportamiento compuesto por 30 subindicadores. se acondicionó una escala de respuesta tipo likert (1: nunca, 2: pocas veces, 3: frecuentemente, 4: siempre) para calificar la valoración de cada indicador. una vez diseñado el instrumento se realizó su validación de contenido y facial. el análisis de la validez de contenido se hizo para determinar el grado en que el contenido del instrumento constituye una muestra representativa de los elementos al revisar la literatura no se encontraron instrumentos que midieran adherencia al tratamiento específicamente en el paciente con falla cardiaca, por lo cual para la elaboración de este instrumento se realizó una amplia revisión bibliográfica tomando como referencia los resultados de la adherencia y sus respectivos indicadores de la taxonomía noc. autocuidado y adherencia en pacientes con falla cardiaca 145 del constructo que pretende evaluar, en este caso la adherencia (33). el presente estudio permitió examinar si los subindicadores estaban claramente relacionados con el indicador que se deseaba medir. se establecieron los criterios de evaluación tales como: relevante, pertinente y adecuado para que los expertos calificaran el instrumento propuesto. una vez establecidos los criterios por evaluar, se seleccionó un grupo de expertos constituidos por 10 profesionales de enfermería con amplia experiencia en el manejo de los pacientes con falla cardiaca y en el área de investigación, a quienes se les entregó el formato que contenía los indicadores de comportamientos de adherencia, la guía de evaluación con los subindicadores y los criterios por evaluar. posteriormente, después de recibidos los conceptos de los expertos, se analizó el índice de validez de contenido (ivc) de la guía de evaluación con los subindicadores, y se procedió a modificar cada uno de ellos de acuerdo con las sugerencias recibidas y teniendo en cuenta unos criterios que permitían determinar el índice de validez de contenido, obteniéndose el instrumento final con un ivc de 1. la validez facial permitió evaluar la claridad y la comprensión del instrumento sin ambigüedad. en este estudio el análisis de validez facial se realizó teniendo en cuenta los siguientes criterios de evaluación: extensión y claridad, incluidos en un formato de evaluación que contenía los indicadores, subindicadores y los criterios de evaluación anteriores. se seleccionaron los mismos expertos que realizaron la validez de contenido. una vez recibidos los conceptos de los expertos se procedió a realizar la interpretación y el análisis de los resultados obteniéndose el instrumento final denominado �evaluación de los comportamientos de adherencia al tratamiento farmacológico y no farmacológico en el paciente con falla cardiaca�. este proceso de construcción y validación se desarrolló en un año. fase b. evaluación de la adherencia al tratamiento farmacológico y no farmacológico de los pacientes con falla cardiaca hospitalizados una vez obtenido el instrumento �comportamientos de adherencia� con validez de contenido y facial se procedió a evaluar la adherencia previa de los pacientes con falla cardiaca aplicando dicho instrumento. éste se aplicó a los pacientes seleccionados diariamente por el investigador y que cumplieran los criterios de inclusión establecidos. fase c. aplicación del plan educativo que fomenta el autocuidado y la adherencia en el paciente con falla cardiaca durante la hospitalización se elaboró una cartilla denominada cuida tu corazón. una guía de cómo hacerlo, que contenía un plan educativo con las recomendaciones de autocuidado y adherencia al tratamiento farmacológico y no farmacológico, el cual fue suministrado en forma verbal y escrita al paciente. para la elaboración de este contenido se establecieron las temáticas más relevantes que se consideraba que necesitaba el paciente con falla cardiaca para su autocuidado, las cuales fueron: • introducción • generalidades de la función del corazón • definición, causas, síntomas de falla cardiaca • medidas para un manejo adecuado (dieta, actividad física, tratamiento farmacológico, restricción hídrica, control de peso, sistemas de ayuda para la toma oportuna y adecuada de en este estudio el análisis de validez facial se realizó teniendo en cuenta los criterios de extensión y claridad, incluidos en un formato de evaluación. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007146 medicamentos, signos de alarma, apoyo emocional y social). los contenidos se desarrollaron utilizando un lenguaje claro, sencillo y apoyado en gráficos relacionados con cada temática, para facilitar el entendimiento y la motivación del paciente. una vez elaborada la cartilla se solicitó su revisión y evaluación por parte de dos enfermeras expertas en el área clínica, quienes evaluaron la estructura, el diseño y el contenido. para la selección de dichas expertas se tuvieron en cuenta los siguientes criterios: ser especialistas en el área cardiovascular, con experiencia en el cuidado de pacientes con falla cardiaca, en el área de promoción y prevención, y en la elaboración de contenidos educativos para pacientes. la información del plan educativo contenida en la cartilla fue suministrada por la investigadora y por una enfermera capacitada para tal fin, dos días antes del egreso del paciente en horas de la tarde principalmente, con un tiempo de duración en promedio de hora y media. la intervención educativa se iniciaba reconociendo a la persona enferma su función protagónica; los pacientes iniciaban la discusión sobre el tema, desde sus propias percepciones, sus ansiedades, sus necesidades reales, sentidas y sus vivencias. se les proporcionaba la información, se aclaraban dudas, se motivaba al paciente en la participación activa y continua en su tratamiento, y se estimulaba la comunicación con el personal de salud y su familia; esta última se integró en este proceso educativo como un apoyo importante para logar el desarrollo de comportamientos de adherencia y autocuidado del paciente con falla cardiaca. finalmente, se entregó la cartilla al paciente para afianzar sus conocimientos y para que la utilizara como medio de consulta permanente en su casa. fase d. evaluación de la adherencia al tratamiento farmacológico y no farmacológico de los pacientes con falla cardiaca posterior a la aplicación del plan educativo posteriormente el investigador hizo un seguimiento por medio de una visita en el domicilio a los pacientes al mes de su egreso, donde se aplicó de nuevo el instrumento para evaluar comportamientos de adherencia al tratamiento; éste fue diligenciado por el investigador en su totalidad. el tiempo empleado fue en promedio de una hora, e incluía no solamente el diligenciamiento sino también el aclarar dudas y reforzamiento de algunas recomendaciones necesarias para fomentar el autocuidado y la adherencia. durante esta etapa la familia se convirtió en un soporte social fundamental para que el paciente continuara desarrollando su capacidad de autocuidado. resultados esta investigación consideró la caracterización de los pacientes estudiados utilizando las variables edad, tiempo de diagnóstico, género, estrato, nivel de escolaridad, ocupación y clase funcional, las cuales fueron evaluadas utilizando estadísticas descriptivas como el promedio, y frecuencias absolutas y relativas (porcentajes). los indicadores del instrumento �comportamientos de adherencia al tratamiento� fueron evaluados antes y después de la intervención educativa utilizando estadísticas descriptivas, como promedio. la la intervención educativa se iniciaba reconociendo a la persona enferma su función protagónica; los pacientes iniciaban la discusión sobre el tema, desde sus propias percepciones, sus ansiedades, sus necesidades reales, sentidas y sus vivencias. autocuidado y adherencia en pacientes con falla cardiaca 147 hipótesis de comparación �antes y después� se probó utilizando la prueba estadística t-student, la cual fue evaluada con el 95% de confianza, considerándose diferentes estadísticamente cuando el valor de p fuera inferior a 0,05. este análisis se realizó para evaluar en forma global la adherencia y los indicadores de los pacientes con falla cardiaca. para el análisis de los indicadores de adherencia se utilizó la media interpretándola a través de unos rangos establecidos según el número de subindicadores que posee cada indicador, los cuales se multiplicaron por el valor de la escala de likert, obteniendo valores máximos y mínimos que se organizaron en rangos, y se les asignó una escala semántica para poder ubicar los resultados obtenidos y, de esta manera, identificar la adherencia o no en cada indicador o en la totalidad del instrumento (tabla 1). a continuación se muestra un ejemplo de la forma de interpretación de los resultados en cada indicador: tabla 1. interpretación del instrumento fuente: autora. indicadores total de rango según la escala de interpretación subindicadores escala de likert calificación 1.confía en el profesional 1. 2 3,5 nunca • no adherencia de la salud 2. 3,6 5,5 muy poco • poca adherencia 5,6 7 frecuente • frecuentemente adherido 7,1 8 siempre • adherido 2. conoce el tratamiento 1. 4 7 nunca • no adherencia farmacológico que le 2. 7,1 11 muy poco • poca adherencia han prescrito 3. 11,1 15 frecuente • frecuentemente adherido 4. 15,1 16 siempre • adherido 3. acceso a los 1. 3 5,5 nunca • no adherencia servicios de salud 2. 5,6 8 muy poco • poca adherencia 3. 8,1 11 frecuente • frecuentemente adherido 4. 11,1 12 siempre • adherido para el análisis global del instrumento se realizó la sumatoria del total de los indicadores de la guía de evaluación, teniendo en cuenta el valor máximo el cual correspondió a 120, y el valor mínimo que correspondió a 30, de acuerdo con la puntuación de la escala de likert propuesta (tabla 2). tabla 2. interpretación global del instrumento total de ítemes de la rango según escala de interpretación guía de evaluación puntaje obtenido calificación 30 30 55 nunca • no adherencia 56 80 muy poco • poca adherencia 81-105 frecuentemente • frecuentemente adherido 106 -120 siempre • adherido fuente: autora. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007148 análisis de resultados variables sociodemográficas y clínicas el análisis mostró que los pacientes evaluados presentaban edades que fluctuaron entre 45 y 89 años, con un promedio de 68 años y un tiempo de diagnóstico promedio de la enfermedad de 24 meses. estos resultados muestran la magnitud del problema, ya que la literatura expone que la falla cardiaca es una enfermedad crónica de mayor predisposición en personas mayores de 50 años. nuestra población, según la transición epidemiológica y pirámide poblacional tiende a envejecer, hecho que convertirá a la falla cardiaca en una entidad de mayor prevalencia e incidencia y, posiblemente, en la primera causa de mortalidad; de ahí la importancia de desarrollar estrategias centradas en la educación y motivación que permitan disminuir la aparición y las complicaciones de las enfermedades crónicas (1-4). en relación con el género, el 54% de los pacientes pertenecen al sexo masculino, lo que nos alerta ya que según la literatura que respalda el estudio framinghan, la mortalidad a cuatro años del diagnóstico es considerablemente mayor en el sexo masculino: 75%, frente a un 62% para mujeres (2). otro punto importante es la relación del género con la adherencia; estudios como el de haynes rb, concluyen que existe una menor adherencia en individuos de sexo masculino; esto se debe al rol que desempeñan y a la influencia psicosocial de su sexo que genera compromiso laboral y económico, disminuyendo el interés por su tratamiento (13). variable media edad 68 tiempo de dx 36,8 meses tabla 3. edad y tiempo de diagnóstico de la enfermedad género pacientes porcentaje femenino 23 46 masculino 27 54 total 50 100 tabla 4. género autocuidado y adherencia en pacientes con falla cardiaca 149 el estrato y la escolaridad muestran que el 32% de los pacientes están clasificados en estrato 2, y un 68% en estrato 3; el nivel de escolaridad es bajo en el grupo de pacientes incluidos, con un 76% que sólo tienen educación básica primaria, lo que limita la adherencia al tratamiento. pertenecer a un estrato socioeconómico bajo suele ser descrito como factor de riesgo para abandono del tratamiento, por un difícil acceso al sistema de salud, confirmando dicho resultado con la revisión de factores socioeconómicos y culturales realizada por la organización mundial de la salud (oms) en 2004, la cual expone que el bajo nivel socioeconómico y el analfabetismo son factores de riesgo importantes de adherencia deficiente. a menor nivel educativo mayores probabilidades de abandono; esto se explica principalmente porqué a menor nivel educativo se hace más difícil la comunicación tanto con el personal de salud como con la familia (12). la tabla 6 refleja que la población que se estudió se encontraba en su mayoría en clase funcional ii, con un 66%, y iii con un 28%. los pacientes en clase funcional ii presentan una leve limitación física con aparición temprana de disnea, mientras que en clase funcional iii presentan síntomas que limitan fuertemente al paciente en cada una de sus actividades, evidenciado en el estudio franmighan (1, 2). esto implica que la aparición e intensidad de los síntomas está estrechamente relacionada con el manejo inadecuado de la enfermedad, y por lo tanto, la adherencia al tratamiento, de ahí la importancia de trabajar con estas dos clases para contribuir a mejorar la funcionalidad. tabla 5. variables. estrato, escolaridad y ocupación variable porcentaje estrato 2 32 3 68 escolaridad primaria 76 secundaria 18 técnica 2 universitaria 2 ocupación ama de casa 46 cesante 8 ocupaciones técnicas 44 ocupación profesional 2 clase funcional porcentaje tabla 6. clase funcional i 6 ii 66 iii 28 aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007150 análisis global de evaluación de la adherencia al tratamiento farmacológico y no farmacológico en las etapas pre y posintervención educativa en pacientes con falla cardiaca figura 1. análisis global de comportamientos de adherencia al tratamiento. muestra (n=50) m e d i a rango según la interpretación del valor escala de likert promedio obtenido % ( m e d i a ) preintervención 73,0 30 55 • no adherencia 0,0001 56 80 • poca adherencia 81 105 • frecuentemente adherido posintervención 89,4 106-120 • adherido al encontrar un valor promedio en la etapa posterior a la intervención educativa, que es diferente y mayor que en la etapa inicial, se acepta la hipótesis h1 y se rechaza la h0. se encontraron diferencias estadísticamente significativas en el promedio del resultado total obtenido antes y después de la intervención (valor p=0,0001) (tabla 7). esto se atribuye a que la intervención permitió capacitar, fuente: autora. tabla 7. análisis global de la evaluación de la adherencia al tratamiento farmacológico y no farmacológico e interpretación del valor de la media según rangos establecidos. pre y posintervención motivar y hacer partícipe al paciente en el manejo adecuado de su tratamiento farmacológico y no farmacológico. sin embargo, uno de los ideales y propósitos en la adherencia al tratamiento del paciente con falla cardiaca es que se encuentre en un grado de adherencia total, para esto es necesario promover la participación activa del paciente en el manejo de su enfermedad identificando los factores que influyen en la 100 r e s u lt a d o t o ta l total a total d 90 80 70 60 autocuidado y adherencia en pacientes con falla cardiaca 151 adherencia, tales como el grado de confianza en el profesional, conocimientos en el tratamiento, accesibilidad a los servicios, y soporte social y emocional con que cuentan los pacientes. para lograr este propósito es necesario utilizar herramientas como la educación y el seguimiento aplicadas de una forma continua y permanente que permitan escuchar, observar, promover la aceptación de la enfermedad, contribuir al aumento de la autoestima, y proporcionar información útil y puntual sobre el manejo de la enfermedad. idealmente también se espera que los comportamientos de adherencia se mantengan en el tiempo, lo cual requiere que se evalúe la adherencia en plazos más extendidos en el tiempo (33-35). análisis comparativo de la evaluación de la adherencia a tratamiento farmacológico y no farmacológico según rangos establecidos para cada indicador y su interpretación del valor de la media en pacientes con falla cardiaca a continuación se presentan las figuras y tablas correspondientes a los valores obtenidos de la muestra para cada indicador de su evaluación antes y después de recibir el plan educativo. muestra (n=50) m e d i a rango según la escala de interpretación del valor % likert promedio (media) preintervención 5,78000 2 3,5 • no adherencia 0,0001 3,6 5,5 • poca adherencia 5,6 7 • frecuentemente adherido posintervención 6,70000 7,1 8 • adherido indicador 1. confía en el profesional de la salud fuente: autora. en cuanto a la confianza en el profesional de la salud, la media de la adherencia de los pacientes encuestados antes de la intervención se encuentra en frecuentemente adheridos. este resultado se respalda por las respuestas de los pacientes que destacaban la seguridad y la capacidad de escucha brindada por el profesional de la salud a lo largo de su enfermedad. posterior a la intervención educativa se ubican en un rango frecuentemente adherido, lo que sugiere que se sigue manteniendo la interacción con el paciente y una transmisión adecuada de las indicaciones de autocuidado. según la literatura, kilpatrick considera primordiales las características de la enfermedad en sí misma y la relación asertiva entre médico, enfermera y paciente que generen confianza, continuidad, accesibilidad, flexibilidad y confidencialidad, constituyéndose en factores que influyen favorablemente en la adherencia (5, 9, 12). probablemente, los factores más importantes en la mejoría de este comportamiento son el suministro de una información detallada, auténtica, y la toma de decisiones conjuntas en un marco de confianza mutuo. sin embargo, cabe reconocer que no se alcanzó a establecer una confianza plena; de ahí la necesidad de desarrollar una interacción permanente y continúa en el proceso de enseñanza y comunicación con el paciente, contribuyendo de esta manera a alcanzar un grado pleno de adherencia (36). aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007152 muestra (n=50) m e d i a rango según la de interpretación del valor % escala likert promedio (media) obtenido preintervención 9,18000 4 7 • no adherencia 0,0001 7,1 11 • poca adherencia 11,1 15 • frecuentemente adherido posintervención 11,50000 15,1 16 • adherido se observa que la media de las respuestas de los pacientes mostró un nivel de poca adherencia al tratamiento. una de las mayores falencias encontradas en las respuestas corresponde a que el paciente conocía muy poco sobre la dosis y el horario indicados por la enfermera y el médico, seguido por el déficit de conocimientos sobre los principales efectos secundarios de los medicamentos. posterior a la intervención se observó un rango que se interpretó como frecuentemente adherido, con una diferencia estadísticamente significativa (p= 0,001), mostrando un grado de conocimiento adecuado. según el estudio de gertlert y tim, el conocimiento adecuado del tratamiento farmacológico constituye una de las directrices en el tratamiento integral de la falla cardiaca y en una relación de la mejoría de la calidad de vida, una reducción en la limitación de la progresión de la enfermedad y disminución de la mortalidad; de ahí la importancia de seguir trabajando para alcanzar un grado de conocimiento ideal (6). en cuanto al tercer indicador, se evaluó la accesibilidad a los servicios de salud; se observó que la media de las respuestas de los pacientes se encontraba en frecuentemente adheridos, puesto que éstos contaban con facilidades para asistir a sus citas y la disposición oportuna a los medicamentos; este resultado no se correlaciona con lo que establecen algunos estudios como el de basterra (22) y zaldívar (23), donde muestran que una de las causas de deserción al tratamiento se presenta cuando el paciente enfrenta dificultades para acceder a los servicios de salud. otro punto que se debe tener en cuenta es el concepto negativo del paciente acerca de la calidad de la atención, en cuyo caso el riesgo de deserción se incrementa (24). en el análisis de la accesibilidad a los servicios de salud, posterior a la aplicación del plan educativo, no se encontraron difemuestra (n=50) m e d i a rango según la escala de interpretación del valor % likert promedio (media) preintervención 8,1o000 3 5,5 • no adherencia 0,593 5,6 8 • poca adherencia 8,1 11 • frecuentemente adherido posintervención 8,11000 11,1 12 • adherido indicador 2. conocimiento del tratamiento farmacológico fuente: autora. indicador 3. información sobre posibilidad de acceso a los servicios de salud fuente: autora. autocuidado y adherencia en pacientes con falla cardiaca 153 rencias estadísticamente significativas en el promedio del resultado total obtenido antes y después de la intervención (p=0,593). los pacientes se mantienen en un nivel frecuentemente adheridos ya que cuentan con facilidades para asistir a sus citas y disposición oportuna de medicamentos, esta facilidad contribuye en parte a mantener un grado de adherencia adecuado. el indicador 4 evaluó la aceptación del diagnóstico que da el profesional al paciente. se observa que la media se encuentra en un rango que se interpreta como poca adherencia. muy pocos pacientes reconocen las implicaciones de la enfermedad en su vida, y no muestran interés para realizar cambios que le permitan cuidar su salud; este resultado es alarmante, y en la literatura se confirma que si el paciente no tiene los suficientes conocimientos acerca de su enfermedad no va a entender la magnitud del problema dándole poca importancia al diagnóstico real y las implicaciones en su calidad de vida (9, 16). muestra (n=50) m e d i a rangos establecidos interpretación del valor % promedio (media) preintervención 11,0400 4 7 • no adherencia 0,0001 7,1 11 • poca adherencia 11,1 15 • frecuentemente adherido posintervención 12,9400 15,1 16 • adherido indicador 4. aceptación del diagnóstico dado por el profesional de la salud fuente: autora. en el análisis de la aceptación del diagnóstico por parte del paciente, posterior a la aplicación del plan educativo, se encontraron diferencias estadísticamente significativas en el promedio del resultado total obtenido antes y después de la intervención (p=0,0001). la media de las respuestas de los pacientes mostró que éstos frecuentemente reconocen las implicaciones de la enfermedad en su vida, este cambio de conducta según la literatura se debe al conocimiento que adquirió el paciente de su enfermedad, porque la percepción y el reconocimiento adecuados sobre las implicaciones de la enfermedad son directamente proporcionales al grado de adherencia al tratamiento (6, 7, 10, 12). indicador 5. reconocimiento de signos y síntomas muestra (n=50) m e d i a rango según la escala de interpretación del valor % likert promedio (media) obtenido preintervención 7,18000 3 5,5 • no adherencia 0,0001 5,6 8 • poca adherencia 8,1 11 • frecuentemente adherido posintervención 11,1 12 • adherido 9,32000 fuente: autora. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007154 este indicador evaluó el reconocimiento de los signos y síntomas; se observó que la media de las respuestas corresponde a un rango que se interpreta como poca adherencia, mostrando que muy pocas veces el paciente reconoce los signos que acompañan o demuestran empeoramiento de su enfermedad. una de las mayores falencias encontradas en las respuestas corresponde al poco conocimiento acerca de los signos de alarma y la poca capacidad de reconocer qué hacer en el momento de presentar un signo de alarma. se observó que estos resultados se generaron porque el paciente no conocía ampliamente su enfermedad, limitando el reconocimiento oportuno de estos signos, retardando las consultas, y empeorando su pronóstico. este resultado se correlaciona con lo demostrado en el estudio de helvi kyngas, quien afirma que cuando los síntomas no se reconocen oportunamente y no existe claridad en su presentación, se dificulta la adhesión al tratamiento, de ahí la necesidad de fortalecer el conocimiento de estos síntomas (16). posterior a la aplicación del plan educativo, se encontraron diferencias estadísticamente significativas en el promedio del resultado total obtenido antes y después de la intervención, mostrando un cambio significativo, puesto que el paciente a menudo conoce los signos de alarma y sabe qué hacer en el momento de presentarlos. este conocimiento contribuye a una mejoría en la adherencia al tratamiento; esta afirmación se respalda en el estudio de helvi kyngas, en el que muestra que los síntomas parecen jugar un papel muy importante en el cumplimiento efectivo de las prescripciones, puesto que cuando los síntomas tienen un inicio agudo, son reconocibles, molestos y se alivian con el tratamiento �como es el caso de la disnea y el edema�, la probabilidad de adhesión es mayor (16). este indicador evaluó si el paciente busca refuerzo externo para poder cumplir con los comportamientos de salud. llama la atención que existe un mayor déficit en la búsqueda de grupos de amigos, redes; este resultado nos alerta para trabajar arduamente en la motivación de este refuerzo dentro del plan educativo, puesto que existen diversos estudios como el de bayés (29) y gonzález y cols. (30) donde se confirma la relación entre un menor apoyo social y un aumento de la mortalidad global convirtiéndose en un pronóstico predictor de su recuperación. posterior a la aplicación del plan educativo no se encontraron diferencias significativas antes y después de la intervención (p=0,285). la media de las respuestas mostró una mejoría limítrofe a frecuentemente adheridos puesto que los pacientes tienden a contar un poco más con su familia y refieren buscar pocas veces grupos de apoyo. es importante destacar que la motivación y la necesidad de grupos de apoyo durante la instauración del plan educativo se manejó de forma verbal, pero en la cartilla que se entregó para reforzar la información brindada no se tuvo en cuenta, esto reitera que la información brindada, más un material que contemple cada aspecto enseñado, da mayor fortaleza al proceso de aprendizaje y reflexión en los pacientes (17). muestra (n=50) m e d i a rango según la escala de interpretación del valor % likert promedio (media) preintervención 5,34 2 3,5 • no adherencia 0,285 3,6 5,5 • poca adherencia 5,6 7 • frecuentemente adherido posintervención 5,5400 7,1 8 • adherido fuente: autora. indicador 6. busca refuerzo externo para poder cumplir con los comportamientos de salud autocuidado y adherencia en pacientes con falla cardiaca 155 este indicador mostró que los pacientes tienen escasa adherencia porque pocas veces mantienen un control adecuado de peso y de manejo de líquidos; se observó poco conocimiento en controlar diariamente el peso y conocer la cantidad de agua que deben consumir. en el análisis del indicador posterior al plan educativo se encontró que los pacientes mantienen en mayor medida su peso dentro del rango recomendado. se encontraron diferencias estadísticamente significativas en el promedio del resultado total obtenido antes y después de la intervención (p=0,0001). la media de las respuestas de los pacientes mostró que están controlando su peso semanalmente, registrándolo en una libreta y vigilando la cantidad de líquido que pueden consumir; relacionando este resultado con el contexto teórico de algunos estudios como los de atewart, rich y neily se llega a la conclusión de lo importante que es este comportamiento, puesto que se constituye en uno de los pilares básicos para lograr una adecuada adherencia al tratamiento ya que una de las principales causas de descompensación de la falla cardiaca y la necesidad de múltiples hospitalizaciones es la adherencia imperfecta de los pacientes al tratamiento no farmacológico, incluyéndose en éste la restricción hidrosalina y el control de peso, lo cual generalmente refleja un pobre entendimiento de su enfermedad. si se le da un mayor énfasis a este comportamiento dentro del plan educativo va a contribuir a una disminución en la estancia hospitalaria, a mejorar la satisfacción del paciente, y a una mayor adherencia al tratamiento prescrito (26, 18). indicador 7. mantiene su peso dentro del rango adecuado muestra (n=50) m e d i a rangos establecidos interpretación del valor % promedio obtenido (media) preintervención 7,3200 4 7 • no adherencia 0,0001 7,1 11 • poca adherencia 11,1 15 • frecuentemente adherido posintervención 10,6600 15,1 16 • adherido indicador 8. conoce la dieta recomendada muestra (n=50) m e d i a rango según la escala de interpretación del valor % likert promedio obtenido (media) preintervención 4,100 2 3,5 • no adherencia 0,001 3,6 5,5 • poca adherencia 5,6 7 • frecuentemente adherido posintervención 5,940 7,1 8 • adherido este indicador evaluó el conocimiento de la dieta recomendada; la interpretación del valor promedio mostró que los pacientes tenían poca adherencia. posterior a la aplicación del plan educativo se encontraron diferencias estadísticamente significativas en el promedio del resultado total obtenido antes y después de la intervención (p=0,001), la media de las respuestas según la interpretación correspondió a frecuentemente adheridos. este resultado refleja que gracias al plan educativo los fuente: autora. fuente: autora. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007156 pacientes tienen un nivel de conocimientos mejor. sin embargo, tal comportamiento debe reforzarse mucho más, puesto que el manejo de una dieta con restricción de sodio, rica en verduras, y baja en grasas y carbohidratos se constituye en otro pilar fundamental de una adecuada adherencia. estudios como los de gonzález y neily muestran que la falta de adherencia al tratamiento no farmacológico se basa en un este indicador evaluó la realización del ejercicio diario, de acuerdo con la interpretación del valor promedio que según su ubicación en el rango se interpreta como importante problema de ausencia de conocimiento acerca del régimen que deberían llevar ambulatoriamente con respecto a la restricción de sodio en la dieta. teniendo en cuenta este problema es necesario aplicar planes de educación que incluyan a la familia en la preparación de alimentos con el fin de mejorar significativamente la adherencia y, por tanto, la calidad de vida y la disminución en los reingresos hospitalarios (26, 33). poca adherencia, mostrando que pocas veces los pacientes realizaban ejercicio representado en el poco conocimiento que existía sobre los beneficios del mismo. indicador 9. realiza el ejercicio diario según lo recomendado por el profesional de la salud muestra (n=50) m e d i a rango según la escala de interpretación del valor % likert promedio (media) preintervención 7,12000 3 5,5 • no adherencia 0,0001 5,6 8 • poca adherencia 8,1 11 • frecuentemente adherido posintervención 9,20000 11,1 12 • adherido fuente: autora. indicador 10. estado de ánimo apropiado para su salud muestra (n=50) m e d i a rango según la escala de interpretación del valor % likert promedio obtenido (media) preintervención 8,06000 3 5,5 • no adherencia 0,0001 5,6 8 • poca adherencia 8,1 11 • frecuentemente adherido posintervención 9,24000 11,1 12 • adherido fuente: autora. posterior a la aplicación del plan educativo se encontraron diferencias estadísticamente significativas en el promedio del resultado total obtenido antes y después de la intervención (p=0,0001). la media de las respuestas se ubica dentro de un rango que se interpretó como frecuentemente adheridos, realizan actividad física y conocen los beneficios del ejercicio; este cambio es representativo ya que aumentaron la frecuencia e intensidad del ejercicio, y el conocimiento de los beneficios. sin embargo, es necesario reforzar mucho más este comportamiento ya que una práctica conautocuidado y adherencia en pacientes con falla cardiaca 157 tinua del ejercicio dirigido induce una participación en el cumplimiento del tratamiento así como la mejoría en la capacidad física y tolerancia al esfuerzo, de la clase funcional, reducción en la aparición continua de síntomas y en el incremento de la sobrevida (14, 15, 18). este indicador evaluó el estado emocional del paciente. se observó que la media de las respuestas antes de la aplicación del plan educativo se ubica dentro de un rango que se interpretó como de poca adherencia, mostrando que el estado de ánimo del paciente no es apropiado para su salud, manifestando poco interés por lo que lo rodea, a la vez refiere que el no poder descansar bien todas las noches por la ortopnea genera sentimientos de ira, ansiedad y depresión, así como la limitación para realizar ciertas actividades generadas por la fatiga y la disnea, lo que lleva a un aislamiento y a sentir poca motivación en cada una de sus actividades. esto se ve potencializado por el desconocimiento que tiene el paciente de su enfermedad ya que al no saber que es una entidad crónica, no podrá entender que en sus manos está la recuperación de su funcionalidad, su calidad de vida y el poder aprender a vivir con su enfermedad lo mejor posible, por medio de un manejo adecuado del tratamiento contribuyendo a mejorar sus síntomas y estimulando su motivación. posterior a la aplicación del plan educativo se encontraron diferencias estadísticamente significativas en el promedio del resultado total obtenido antes y después de la intervención (p=0,0001). la media de las respuestas de los pacientes se ubicó dentro de un rango que se interpretó como frecuentemente adherido ya que existió un cambio en el estado de ánimo con tendencia a sentirse bien, puesto que siendo conocedores de la enfermedad y de la importancia de un manejo adecuado en la dieta, el ejercicio y los medicamentos, han disminuido la intensidad y frecuencia de sus síntomas permitiendo descansar bien ya que no refieren sensación de ortopnea y disnea marcada, y muestran mayor interés por lo que los rodea. sin embargo, se observa cierta dificultad en continuar con sus relaciones interpersonales ya que con el tiempo transcurrido de su enfermedad se han alejado de sus amigos, y ante esto es muy difícil volver a recuperarlos; esto nos muestra que en el plan educativo es necesario fortalecer mucho más y generar estrategias que permitan estimular una mayor interacción entre el paciente y sus relaciones anteriores para desarrollar apoyos permanentes. existen pocos estudios que analicen a fondo los aspectos emocionales del paciente con falla cardiaca; sin embargo, algunos como el de bayés (29) han mostrado que si existe un manejo adecuado de la enfermedad se desarrollan en el paciente la motivación, la participación y el compromiso en su diario vivir, aumentando la autoestima y el interés, lo que le permite enfrentar y afrontar los cambios en su estilo de vida. conclusiones • la población en el estudio representa el tipo de individuos determinados como de alto riesgo, incluyendo predominantemente hombres de edad superior a los 65 años, de estratos socioeconómicos bajo y medio, y baja escolaridad, lo que lo hace comparable con la población incluida en la literatura mundial. • los resultados demuestran que los pacientes con falla cardiaca presentaban una baja adherencia al tratamiento antes de la intervención educativa representada según la interpretación del valor promedio obtenido a través de los rangos establecidos, puesto que existía un importante déficit de conocimientos acerca de la enfermedad. llama la atención que en el promedio de tiempo de evolución, correspondiente a 24 meses, no sabían con claridad qué significaba falla cardiaca, signos de alarma, manejo del tratamiento farmacológico y no farmacológico. todo esto es inquietante ya que, considerando a la falla cardiaca como una de las principales ...los pacientes con falla cardiaca presentaban una baja adherencia al tratamiento antes de la intervención educativa..., puesto que existía un importante déficit de conocimientos acerca de la enfermedad. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007158 enfermedades crónicas de alto impacto social, emocional y económico, la necesidad fundamental es que estos pacientes tengan un compromiso y una participación total en el manejo del tratamiento farmacológico y no farmacológico, con el fin de mejorar sus síntomas y, por ende, las complicaciones y las hospitalizaciones a repetición. • los comportamientos más deficientes identificados en el estudio antes de la aplicación del plan educativo que generaban una baja adherencia correspondían al conocimiento del tratamiento farmacológico, dieta, ejercicio, mantenimiento del peso y soporte social. este déficit de conocimientos incrementa una adherencia baja comprometiendo gravemente la efectividad del tratamiento. • es claro en el estudio que la intervención educativa integrada con la motivación brindada al paciente durante su hospitalización y el egreso mejoró la adherencia al tratamiento; sin embargo, es importante resaltar que para lograr el impacto que buscamos con la educación en la adherencia al tratamiento no basta con una sola instrucción, es necesario que sea un proceso continuo, dinámico, participativo y, en medio de este proceso, se debe promover y analizar el soporte social y emocional con que cuentan los pacientes. para lograr este propósito es necesario utilizar herramientas aplicadas de una forma continua y permanente, como lo es la observación y la atención al paciente, escuchándolo de manera empática, promoviendo la aceptación de la enfermedad, contribuyendo al aumento de la autoestima y proporcionando información útil y puntual sobre el manejo de la enfermedad. • es necesario realizar seguimientos domiciliarios o telefónicos a corto y mediano plazo que permitan dar más continuidad al proceso educativo, y reforzar más los comportamientos de tal manera que se haga más evidente el impacto del plan educativo, confirmando la permanencia en el tiempo de las conductas de adherencia esperadas. • a través del desarrollo continuo y temprano de planes educativos dirigidos a los pacientes con falla cardiaca se contribuyó a mejorar la adherencia al tratamiento, como se refleja en el estudio, representado en el nivel de frecuentemente adherido según la interpretación del valor promedio, fortaleciendo indicadores tales como conocimiento farmacológico, dietario, mantenimiento del peso, reconocimiento de signos y síntomas, ejercicio, aceptación de su enfermedad y confianza en el profesional de la salud. • el estudio mostró una media representativa centrada en la confianza y seguridad que tienen los pacientes en los profesionales de la salud; esto refleja lo importante que es este profesional, y cómo en un momento dado esta confianza se debe fortalecer por medio de una adecuada comunicación, seguimiento, y proporcionando un conocimiento claro de su enfermedad, de esta forma se motivará al paciente a mantener un grado de adherencia adecuado. • uno de los factores que influyen en la adherencia al tratamiento es el apoyo social. el estudio mostró que uno de los apoyos que buscan los pacientes es la familia, y en menor proporción programas de apoyo social. se evidenciaron algunas barreras de acercamiento a estos grupos tales como la no existencia de redes consolidadas y suficientes, así como la falta de motivación en el paciente. es necesario hacer mayor énfasis en este aspecto estimulando a la persona en la búsqueda de apoyo social, puesto que el apoyo externo genera en el paciente una mayor motivación sintiéndose importante y capaz en cada una de sus actividades, lo que aumenta la necesidad de comprometerse en un manejo adecuado del tratamiento. la intervención educativa integrada con la motivación brindada al paciente durante su hospitalización y el egreso mejoró la adherencia al tratamiento. autocuidado y adherencia en pacientes con falla cardiaca 159 • el enfoque de autocuidado en el plan educativo, como estrategia en la mejoría de la adherencia al tratamiento, permitió un cambio en los comportamientos de los pacientes, convirtiéndose en una directriz en el manejo adecuado de la enfermedad, guiando, orientando y apoyando al paciente en los cambios de su estilo de vida, y en el mejoramiento de la calidad de la misma. referencias bibliográficas 1. segundo consenso uruguayo de insuficiencia cardiaca. sociedad uruguaya de cardiología. en: rev noticias, sindicato médico del uruguay 2004; 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333: 1190. 22. basterra m. el cumplimiento terapéutico. pharmaceuticall care, 1999; 1: 97-106. 23. zaldívar d. adherencia terapéutica y modelos explicativos. salud para la vida 2003. disponible en: www.infomed.sld.cu 24. ni h, nauman d, burgess d, wise k, crispell k, heshberger e. factors influencing knowledge of and adherence to self-care among patients with heart failure. arch intern med 1999; 159: 1613-9. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007160 25. riegel b, carlson b, glaser d. development and testing of a clinical tool measuring self-management of heart failure. heart lung 2000; 26. neily jb, toto kh, gardner eb et al. potential contributing factors to non compliance with dietary sodium restriction in patients with heart failure. am heart j 2002; 143(1): 29-33. 27. fuentes a. autocuidado del paciente cardiovascular. archivos de cardiología de méxico 2001; 71 (supl. 1): s198-s200. 28. davidson p. issues in patient compliance. handbook of clinical health psychology 2000; 417-434. 29. bayés r. aspectos psicológicos de la adherencia terapéutica. revista de cardiología la mancha: ediciones de la universidad de castilla-la mancha; 2000; 95-103. 30. gonzález b, lupón j, parajón t, urrutia a, altimir s, coll r et al. nurse evaluation of patients in a new multidisciplinary heart failure unit. eur j cardiovasc nurs 2004; 3: 61-9. 31. aentde. etiqueta taxonómica nicnoc. segunda edición; 2004. 32. bastidas c. asociación entre la capacidad de agencia de autocuidado y la adherencia en los pacientes con enfermedad cardiovascular. tesis de maestría en enfermería con énfasis en salud cardiovascular. facultad de enfermería. universidad nacional de colombia. 2006; 78-81. 33. polit, d, hungler, b. investigación científica en ciencias de la salud. méxico: mcgraw-hill, 1997. 34. gonzález b, lupón j, parajón t, urrutia a, altimir s, coll r et al. patient�s education by nurse: what we really do achieve? eur j heart fail, suppl. 2003; 2: 72. 35. gonzález b, lupón j, parajón t, urrutia a, coll r, altimir s et al. educación de los pacientes con insuficiencia cardiaca por parte de enfermería. en: revista española de cardiología 2003; 56 (supl. 2): 74. 36. organización panamericana de la salud. la educación terapéutica. propuesta de un modelo teórico desde la experiencia del programa cubano de educación en diabetes. 17 edición, washington d.c.; 2007. 160 168 corriente epistemologica positivista.indd 160 aquichan issn 1657-5997 año 12 vol. 12 nº 2 chía, colombia agosto 2012 l 160-168 fredy andrés seguel-palma1 sandra valenzuela-suazo2 olivia sanhueza-alvarado3 corriente epistemológica positivista y su infl uencia en la generación del conocimiento en enfermería 1 estudiante del programa de doctorado en enfermería. docente, universidad austral de chile, chile. fredyseguel@uach.cl 2 doctora en enfermería. profesora asociada, universidad de concepción, chile. svalenzu@udec.cl 3 doctora en enfermería. profesora titular, universidad de concepción, chile. osanhue@udec.cl recibido: 5 de enero de 2011 aceptado: 11 de julio de 2012 resumen los paradigmas son múltiples movimientos de pensamientos filosóficos y formas de buscar la verdad que entran en conflicto de acuerdo con los postulados ideológicos vigentes. dentro de ellos, el positivismo y pospositivismo se orientan hacia un trabajo metodológico de investigación que ha prevalecido por sobre otras manifestaciones investigativas identificando la realidad en forma objetiva y empírica. el propósito de este trabajo es describir la evolución histórica en la época contemporánea del paradigma positivista como un sello importante en las estrategias metodológicas de investigación en enfermería, y relacionado con el paradigma de categorización que caracterizó las primeras etapas de evolución de la disciplina. palabras clave conocimiento, gestión del conocimiento para la investigación en salud, gestión del conocimiento, educación en enfermería. (fuente: decs, bireme). the positivist epistemological trend and its infl uence on the generation of knowledge in nursing abstract paradigms are multiple movements in philosophical thought and ways of searching for the truth that conflict with prevailing ideologies. among these paradigms, positivism and post positivism are oriented towards methodological research that has prevailed over other forms of investigation by identifying reality in an objective and empirical way. the purpose of this study is to describe the historical evolution of 161 corriente epistemológica positivista y su influencia en la generación del conocimiento en enfermería l fredy andrés seguel-palma, sandra valenzuela-suazo, olivia sanhueza-alvarado the contemporary positivist paradigm as an important hallmark in methodological strategies for research on nursing and as relates to the categorization paradigm that characterized the early stages of the evolution of the discipline. key words knowledge, knowledge management for health research, knowledge management, education, nursing. (source: decs, bireme). corrente epistemologia positivista e sua influência sobre a geração de conhecimento em enfermagem resumo os paradigmas são múltiplos movimentos de pensamentos filosóficos e formas de buscar a verdade que entram em conflito de acordo com os postulados ideológicos vigentes. dentro deles, o positivismo e o pós-positivismo se orientam a um trabalho metodológico de pesquisa que prevalece sobre outras manifestações investigativas que identificam a realidade em forma objetiva e empírica. o propósito deste trabalho é descrever a evolução histórica na época contemporânea do paradigma positivista como uma importante marca nas estratégias metodológicas de pesquisa em enfermagem, e relacionado com o paradigma de categorização que determinou as primeiras etapas de evolução da disciplina. palavras-chave conhecimento, gestão do conhecimento para a pesquisa em saúde, gestão do conhecimento, educação em enfermagem. (fonte: decs, bireme). 162 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 introducción la epistemología es una parte de la filosofía, su etimología proviene del griego epistéme que abarca los conceptos de inteligencia, conocimiento, saber, ciencia, destreza, pericia; y logía que significa “estudio de” (1). según el diccionario oxford el concepto se refiere a “la teoría del conocimiento, con respecto a sus métodos, validez y ámbito de aplicación” (2). la epistemología “es la investigación que distingue a la creencia justificada de la opinión” (2), está relacionada con las corrientes de desarrollo del conocimiento filosófico y de la forma en que se genera el conocimiento a lo largo de la historia. estas corrientes epistemológicas emergieron para responder a preguntas trascendentales como ¿qué son la verdad, la ciencia y el conocimiento? y ¿de qué manera las personas buscan la verdad produciendo así conocimiento respecto a esta? dependiendo de ella, los científicos elaboraron procedimientos y metodologías que permitieron trazar un camino científico, interpretar los resultados y determinar lo que comprenden por ciencia y conocimiento (3). la enfermería como ciencia ha ido incorporando las diversas formas de producir conocimientos a partir de las ideologías imperantes, y desde su creación como profesión el positivismo ha dominado la generación del saber; ya en 1968 dickoff y james describieron que en la formulación de una teoría el empirismo juega un papel importante que permite observar los fenómenos complejos (4). esta perspectiva particular-determinista ve el fenómeno aislado, donde sus características pueden medirse y el cuidado puede ser reducido a sus componentes más simples o categorizado de tal forma que se puedan obtener datos objetivos o estudiarlo en términos de los resultados obtenidos en una intervención terapéutica (5). en la época contemporánea (revolución francesa, 1789, a la actualidad) se genera una serie de cambios que incluye el desarrollo económico y tecnológico, lo que traspasa las fronteras geográficas; y en materia de salud se dan avances, gracias a la investigación científica avalada por los movimientos positivista y pospositivista cuantitativo imperantes representados por augusto comte (montpellier, francia, 1798-1857) y el círculo de viena (1925), respectivamente. el reconocimiento de este paradigma como preponderante en la construcción del conocimiento en enfermería motiva a rescatar de dónde emergen sus postulados. el positivismo es atribuido a la tradición científico-humanista proveniente del siglo xvii, a la revolución francesa, y a los problemas que debe enfrentar la sociedad. los cambios institucionales y las transformaciones, muchas veces violentas, mantienen atento al pensamiento europeo. se reconocen sus inicios en el siglo xix con el filósofo francés augusto comte (6, 7), quien recibe influencias importantes del movimiento empirista representado por bacon (1561-1626) y hume (1711-1776) respecto a la determinación de factores y sus relaciones, y de locke (1632-1704) y condillac (1715-1780) en relación con el conocimiento de los factores mediante la experiencia de los sentidos (8). esta filosofía se opone a las ideas imperantes que son más bien especulativas, metafísicas, que se alejan de los hechos que atañen a la persona, “solo estos pueden explicar cómo funciona el mundo y donde está la verdad”, y no conceptos intangibles que nadie puede ver o entender como el espíritu, por ejemplo. saint simon lo describe como “un pensamiento que debía enfrentar la crisis de la revolución francesa” (6, 7, 9). según comte, la misión de la filosofía es “determinar el desarrollo de cada ciencia y captar desde dentro de ella su línea directriz”, concepto enunciado en su ley de los tres estados. el primer estado hace referencia a lo teológico ficticio, el tratar de explicar lo inexplicable o desconocido, evitar lo perjudicial o atribuir a los fenómenos naturales causas sobrenaturales o mágicas, incluida la fe religiosa. en el segundo estado se reemplaza la fantasía por la razón reflexiva en donde el individuo, para explicarse los fenómenos, recurre a fuerzas ocultas como la motriz, química o física. por último, el tercer estado decisivo en los postulados de comte, que correspondería a la etapa más alta en la evolución humana, es el de derribar los mitos tanto teológicos como metafísicos para transformarlos en la experiencia humana como explicación de los hechos. toda generación de conocimiento, para que sea válida y auténtica, debe basarse en la experiencia, y toda ciencia que se precie de tal debe alejarse de la investigación de la esencia del fenómeno y apuntar estrictamente a este como tal (6, 7, 9). en este postulado la psicología y otras ciencias sociales no tienen cabida, pues no es posible ver un fenómeno interno, ya que la persona no puede dividirse en dos: en observador y observado. en cuanto a la sociología, llamada así debido a este autor, postuló 163 corriente epistemológica positivista y su influencia en la generación del conocimiento en enfermería l fredy andrés seguel-palma, sandra valenzuela-suazo, olivia sanhueza-alvarado una ciencia que describía los fenómenos sociales y que podía generalizar con análisis muy parecidos a los utilizados en mecánica, a esto le denominó “estática social”, por otro lado, la dinámica social es referida a las condiciones para llegar a una sociedad justa (6, 7, 9). otro movimiento que se gestó a partir de 1925 en viena fue el neopositivismo desde donde emerge el círculo de viena que asimila dos importantes líneas de pensamiento, la tradición empirista y la lógica formal; esta unión cuestiona y se contrapone sólidamente a la metafísica, la que a su criterio solo es capaz de formular discusiones estériles, por tanto, para que no existan dudas es necesario enfrentar la problemática con el máximo rigor lógicosintáctico, y si dicha estructura manifiesta insolubilidad inherente es necesario expulsarla de la ciencia y la filosofía como “carente de sentido”, en consecuencia, es pérdida de tiempo dejarse llevar por debates que no lleguen a ninguna solución (6, 7, 9). el positivismo, a lo largo de la historia, ha influido en los grandes descubrimientos que han permitido un desarrollo importante de la tecnología y la humanidad. en el siglo xx se formularon dos grandes principios: el de heisember, de incertidumbre, y el de einstein, de la relatividad, que cambiaron la forma de observar la relación sujeto/objeto (10). sin embargo, el paradigma de la simplicidad que involucra el empirismo y el idealismo se sitúa dentro de la racionalidad clásica que preconiza la idea de que la naturaleza posee esencias universales y que son uniformes en todas partes, y que “la razón del ser humano es capaz de entender a cabalidad la lógica de las interacciones en el mundo real” (11). en la actualidad, el paradigma positivista presenta ciertas características que es necesario precisar: su interés es explicar, controlar y predecir; la naturaleza de la realidad la describe como dada, singular, tangible, fragmentable y convergente; la relación sujeto objeto la manifiesta como independiente, neutral y libre de valores; su objetivo fundamental es la generalización mediante metodologías deductivas, cuantitativas, centradas sobre semejanzas; la explicación última está orientada a la causalidad, causas reales temporalmente precedentes y simultáneas; finalmente está libre de valores que pudieran contaminar los resultados. la realidad goza de existencia propia, su metodología hipotéticadeductiva logra la objetividad basada en la experiencia y es válida para todos los tiempos y lugares, postula que existe uniformidad y orden en la naturaleza (12). pero debido a que este modelo paradigmático no logra dar respuesta a la subjetividad de los acontecimientos es que surge el pospositivismo bajo la premisa: “la objetividad no es posible y la subjetividad no es suficiente”, que se inclina por la convivencia entre la tradición positivista y la fenomenológica. al mantener la tradición positivista genera postulados más flexibles: es posible aproximarse a la realidad —que se presenta como imperfecta— pero no obtenerla en su totalidad. pretende dilucidar de alguna manera los significados que los seres humanos en particular atribuyen a los hechos investigados, aproximándose a la metodología cualitativa (13). el pospositivismo evalúa las causas, las posibles relaciones que existen entre ellas y su influencia en los resultados, ocupando estrategias como la triangulación que en una de sus instancias promueve la combinación del método cuantitativo y cualitativo a fin de obtener la mirada completa del fenómeno en estudio y evidencia tangible para la práctica (14, 15). de acuerdo con los autores, para enfermería el positivismo ha contribuido a la validación de sus actividades al establecer evidencias a fin de mejorar la práctica y posesionarse en el mercado laboral donde es necesario mostrar datos concretos basados en fenómenos observados objetivamente de acuerdo con este paradigma, por tanto, es una forma de investigar que ha subsistido en la ciencia de enfermería validando su cuerpo de conocimiento y que no será erradicada o dejada de lado para producir investigación, sino que más bien, se están asumiendo otros abordajes que permitan la complementariedad de método empleando, por ejemplo, la triangulación con los abordajes cualitativos y utilizando nuevas estrategias positivistas como la enfermería basada en la evidencia. en este sentido, la corriente cualitativa surge debido a que teóricos analizaron que existían caminos filosóficos no explicados por el movimiento positivista en relación con la subjetividad del ser humano, por tanto, emergen corrientes de generación de conocimientos que contraponen la postura empírico-racionalista, el criticismo (emmanuel kant, prusia oriental, rusia, 1724-1804), el pragmatismo (william james, ee.uu., 1842-1910), el marxismo y el materialismo (carlos marx, alemania, 1818-1883), el historicismo (karl popper, alemania, 1902-1994), la fenomenología (edmund husserl, alemania, 1859-1938), el existencialismo (martin heidegger, alemania, 1889-1976), el posestructuralismo (michel foucault, francia, 1926-1984), el romanticismo (johann wolfgang von goethe, alemania, 1749-1832), y la teoría crítica del instituto para la investigación social (1923) de la universidad de frankfurt. estas filosofías rescatan la esencia de la persona como digna de 164 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 análisis y su visión particular de ver los fenómenos de la realidad, las impresiones, las ideas, la conducta reflexiva, la existencia humana auténtica y no auténtica, la estructura de los fenómenos de la naturaleza, del lenguaje, del mito, de la economía, el inconsciente de los individuos, la defensa del alma de los pueblos (antiguas tradiciones, costumbres propias y cultos) y critica la pasividad del modelo positivista por alcanzar las transformaciones necesarias para mejorar la sociedad (6, 7, 9). generación del conocimiento en enfermería: ¿qué paradigma ha prevalecido? enfermería, como señaló, por mucho tiempo basó su conocimiento en la tradición, la experiencia y la historia positivista; paralelamente, no se adhería a las teorías filosóficas existentes, y el método válido para la búsqueda del conocimiento fue el científico. sin embargo, con el desarrollo teórico de la enfermería y su desenvolvimiento en el campo de la humanidad, la antropología y la sociedad, se presentaron nuevos entendimientos de la realidad, surgieron las teorías prácticas, el conocimiento personal, el conocimiento experto y el conocimiento interpretativo. incluyó la observación en las investigaciones, las manifestaciones clínicas, los acercamientos histórico-científicos, la historia personal, y en el movimiento deductivo positivista se le dio importancia a los datos tratados en forma estadística con la formulación de una hipótesis y la generalización de los resultados a nivel poblacional a partir de una muestra (16). enfermería como profesión, disciplina y ciencia presenta en la actualidad sus propios paradigmas canalizados por las corrientes filosóficas del transcurso de la historia, que incluyen los conceptos metaparadigmáticos: persona, entorno, salud y cuidado. uno de ellos es el “paradigma de categorización” que se sitúa a fines del siglo xix y comienzos del xx, donde la búsqueda de la relación causal lineal era la base para su funcionamiento; así, los fenómenos poseen características definidas, fáciles de medir de acuerdo con una metodología deductiva y lógica. se distinguen dos orientaciones: la centrada en la salud pública, identificada por la necesidad de enfrentar las problemáticas infecciosas y de salubridad en la sociedad, y la orientada a la enfermedad, muy unida a la práctica médica, cuyos postulados sostienen que la persona es la suma de partes para formar un todo, el entorno se puede controlar, y la salud es la ausencia de enfermedad (17, 18), lo que concuerda con el paradigma positivista. de esta manera, los modelos y las teorías de enfermería transitan entre los conceptos positivistas y cualitativos, por tanto, muchas veces es difícil clasificarlos en alguno de estos. sin embargo, es posible identificar ciertas características que se relacionan con el paradigma de categorización (positivismo) evidenciando su contribución a la generación de teorías, ejemplificando aquí a florence nightingale (1820-1910), virginia henderson (1897-1996) y lydia hall (1906-1969). florence nightingale, con su formación estadística, recolectó datos y realizó análisis para describir la influencia del ambiente sobre las muertes por infecciones de los soldados en la guerra de crimea, su posición filosófica fue influenciada por escritos de pensadores del siglo xix como john stuart mill, agusto comte, henry thomas bucle y benjamin jowett. concuerda con los autores en cuanto al orden de las leyes naturales y que estas pueden proveer estabilidad en la existencia del ser humano debido a que todos los fenómenos ocurren bajo sus parámetros, lo cual describe ampliamente en sus obras suggestions for thought to searches after truth among the artizans of england y suggestions for thought to searchers after religious truths, donde muestra su amplia visión filosófica y sus acuerdos y desacuerdos con el paradigma positivista, describe que en la adquisición del conocimiento juega un papel fundamental la experiencia, y que la persona tiene la capacidad de llegar a alcanzar la felicidad por el aprendizaje, con ello demuestra la permanencia de la filosofía empirista dentro de sus relatos, por otro lado, su visión del cuidar y de la docencia estaba basada además en la teoría miasmático-bacteriológica (8). virginia henderson muestra la categorización de catorce necesidades básicas en las que se basa la atención de enfermería. establece que la persona es: “un ser integral con componentes biológicos, psicológicos, socioculturales y espirituales que interactúan entre sí, y tienden al máximo desarrollo de su potencial”, desde este punto de vista se dirige hacia la integración, sin embargo, al sugerir que la persona es dependiente por no satisfacer alguna de las necesidades, orienta los postulados a la enfermedad y afirma además que el diagnóstico médico es importante para la clasificación. esto demuestra que al igual que el pensamiento científico positivista, atañe a la enfermedad y se sitúa en el paradigma de la categorización en enfermería (19). de este modo, también parcela a la persona en componentes desconociendo la integridad, el holismo del ser. lydia hall postula tres factores importantes en las funciones de enfermería que están orientados por el área biomédica: la per165 corriente epistemológica positivista y su influencia en la generación del conocimiento en enfermería l fredy andrés seguel-palma, sandra valenzuela-suazo, olivia sanhueza-alvarado sona, “que incluye las ciencias sociales, la utilización terapéutica del propio yo; aspectos de enfermería: ‘la esencia’”. el cuerpo, que incluye las ciencias naturales y biológicas, cuidado corporal íntimo; aspectos de enfermería: “el cuidado”. la enfermedad, que incluye ciencias de la patología y la terapéutica, ver al paciente y a la familia a través del cuidado médico; aspecto de enfermería: “la curación”. se puede evidenciar su enfoque hacia lo biomédico, la enfermedad y el método científico para potenciar los cuidados de enfermería y las funciones que esta debe realizar (3). por otro lado, en los modelos y las teorías se han revisado las metodologías que se han utilizado dentro de la teoría misma y posteriormente por los investigadores para ponerla a prueba (precisión empírica), un ejemplo de la utilización del positivismo y de la estadística o metodología cuantitativa es la teoría del déficit de autocuidado de dorothea orem, ya que las entidades teóricas están bien definidas y se pueden elaborar instrumentos de medición. imogene king utilizó estudios empíricos descriptivos para desarrollar su teoría marco de sistemas de interacción y teoría de la consecución de objetivos; por otro lado, mediante sus ocho propuestas relacionales permite categorizar la interacción entre la enfermera y el paciente. jean orlando, en su teoría del proceso de enfermería utiliza en la demostración de sus postulados metodologías estadísticas complejas muchas veces difíciles de interpretar, las cuales describe en su obra the discipline and teaching of nursing process: an evaluative study. ramona mercer ha utilizado investigación cuantitativa para identificar los factores que intervienen en su teoría “adopción del rol maternal – convertirse en madre”, dentro de las variables estudiadas están la edad del primer nacimiento, la separación precoz del niño, las características de la personalidad, etc. pamela g. red, en su teoría de la auto-trascendencia desarrolla la escala de capacidades de resolución para las personas mayores, la cual consta de 36 ítems que permiten realizar trabajos empíricos para comprobar la teoría con procedimientos estadísticos. la teoría de depresión posparto, de cheryl tatamo beck, fue desarrollada incluyendo procedimientos estadísticos para la creación de un instrumento que permite medir la problemática evaluando las propiedades psicométricas de la escala (3). las teorías de mediano rango fueron desarrolladas para ser utilizadas como herramientas tangibles para la práctica, con niveles de abstracción y alcance menor, con características concretas, y para dar cabida a la prueba de hipótesis. su principal característica es: “relacionarse a través de codificaciones objetivas”, por tanto, son apropiadas para la prueba empírica y el desarrollo de indicadores derivados de sus premisas, su utilización permitiría el desarrollo de intervenciones, la formulación de guías y protocolos, y la definición de estándares de cuidado (20). en la estrategia habitual de formulación intervienen metodologías tanto inductivas como deductivas, integrando aspectos positivistas. en su aplicación y manteniendo la objetividad de evaluación de los fenómenos, característica tanto del positivismo como pospositivismo, se han desarrollado cuestionarios que permiten cuantificar la realidad, como es el caso de las teorías de mediano rango “incertidumbre en la enfermedad” (21) y “autotrascendencia” (22), lo que demuestra la importante contribución del positivismo. a pesar de que la evolución de los modelos y las teorías en enfermería ha transitado desde lo empírico-positivista a lo cualitativo, y que la profesión, disciplina y ciencia de enfermería tiene un carácter fundamentalmente humanista y social, esto no se ha reflejado a cabalidad en las investigaciones realizadas. el positivismo se desacreditó en los años sesenta pues presentaba muchos defectos en el análisis de los fenómenos, y porque la nueva visión de la realidad tiene que ver con la subjetividad de cada persona y su forma particular de ver los escenarios; a pesar de ello, resurge este movimiento en enfermería al alero del empirismo contemporáneo ya que sus investigadores insisten en utilizarla (23). el proceso de enfermería es el método científico empleado por los profesionales de esta disciplina, que presenta características positivistas en una valoración que muchas veces es realizada por sistemas, la formulación de un diagnóstico que permite una categorización, la planificación de acuerdo con el diagnóstico y la evaluación, todo bajo la observación de la persona que realizará los cuidados; por otro lado, se tiende a elaborar instrumentos a partir de conceptos abstractos que permitan medir la realidad de los individuos, por ende aparecen las escalas de satisfacción usuaria, los instrumentos de medición de calidad de vida, etc. (24). esto permite la transformación de las observaciones en datos que se analizan matemáticamente, se extrapolan y comparan con otros hallazgos para generalizar las conclusiones establecidas. desde este punto de vista, la ciencia en enfermería se ha enriquecido del levantamiento del conocimiento generado a partir de los datos mostrados por la técnica positivista traducido en modelos y teorías destinadas a describir, explicar, predecir o prescribir los fenómenos de interés, y a su vez, derivado de este conocimiento más abstracto, se han establecido teorías de mediano rango que crean instrumentos de evaluación que permiten valorar la práctica para mejorar la calidad de la atención, y elevar la calidad de 166 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 vida de los individuos. estos instrumentos han permitido medir y concebir nuevos datos y así generar mayor conocimiento enriqueciendo la toma de decisiones de la enfermera/o en situaciones asistenciales cotidianas. el positivismo y la modernidad han influenciado a la enfermería junto con otro factor importante que es la tecnología utilizada como instrumento para desarrollar ciencia. la tecnología en salud es definida como “el conjunto de saberes específicos, procedimientos técnicos, instrumentos y equipamiento utilizados en prácticas de salud”. esta afecta a la enfermería en dos aspectos: la forma de entregar los cuidados a los pacientes que los reciben; y los valores que implícitamente están integrados en este factor, pues la tecnología provoca cambios en el comportamiento de las enfermeras/os, pudiendo de alguna forma tecnificarse a tal punto que olvide el carácter integral del individuo y de paso mimetizarse con la relación que establece con el médico. este es un constructo social que implica saber cómo se da esta relación entre los cuidados humanos proporcionados y la tecnología que significa un medio. en sí misma, la tecnología no adquiere posición, “es neutra”, pero depende de la enfermera si se transforma en un medio o un fin en el logro del bienestar de acuerdo con el significado que le dé (25). en la práctica de enfermería diariamente es necesaria la evidencia científica para contrastar los resultados con otros para generalizar y mejorar la calidad de los cuidados otorgados a los usuarios. es en estos momentos, cuando los resultados de la investigación pueden ser verificables o reproducibles, y en ciertas condiciones adquieren veracidad, con lo que de acuerdo a ello se formulan leyes y generalidades científicas, es en esta instancia donde se plantea la contribución fundamental del positivismo. landeros (2009) describe el siguiente razonamiento: “la teoría de enfermería (como ciencia biológica) tiene el propósito de explicar o describir los fenómenos de cuidado de la salud mediante el apoyo teórico y el número de eventos favorables, es decir la evidencia se acumula, se contrasta y se verifica en diferentes escenarios” (24). en esto se evidencia claramente el pensamiento positivista de generalizar y comprobar los resultados obtenidos en diferentes ambientes con el fin de obtener la evidencia para respaldar la práctica en términos de modelos y teorías. el estudio realizado por cometto, piovan y gómez en 2008 muestra la tendencia de la investigación en enfermería presentada en los coloquios panamericanos. mediante una metodología descriptiva, cuantitativa documental se trabajaron las siguientes variables “a) temáticas de los coloquios, procedencia y cantidad de trabajos presentados, b) investigaciones: tema, tipo de investigación, población de estudio, unidad de análisis, técnica e instrumento, delimitación espacial del estudio, c) características de los investigadores: institución, ciudad, país, y d) propósito del estudio e institucionalización de la investigación”. la muestra correspondió a los resúmenes realizados en los años comprendidos desde el 2000 al 2006 con un total de 1376. la tendencia en cuanto a la cantidad de investigaciones fue de 221 en el 2000 (16,12%), 158 en el 2002 (11,58%), 387 en el 2004 (28,23%) y 605 en el 2006 (44,13%), los países con mayor cantidad de presentaciones fueron brasil, méxico, chile, argentina, perú y colombia; las temáticas abarcadas comprendieron salud pública, cuidado, educación y recursos humanos. respecto de la metodología, un 86% fueron cuantitativos y un 96% descriptivos, con un 82% de muestreo probabilístico. entre otras afirmaciones, las autoras concluyen que “la disciplina de enfermería en el periodo estudiado concentra sus mayores esfuerzos en las investigaciones empíricas cuantitativas y del tipo descriptivo, limitando el crecimiento de la producción de teorías explicativas y la transformación de la práctica profesional” (26). el positivismo se muestra claramente como una herramienta que permite contrastar fenómenos bajo condiciones específicas de ocurrencia (24), lo que posibilita fundamentar la práctica en evidencia comprobable y extensible a otras situaciones con factores intervinientes similares, lo que valoriza a enfermería como muy útil para el mejoramiento continuo de la calidad del cuidado en cuanto a la gestión y la atención directa. se plantea entonces como un medio para lograr una meta propuesta tanto en el área hospitalaria como en la comunidad, existiendo estudios (27, 28) que mediante instrumentos, generalmente cuestionarios, permiten objetivar la realidad para lograr diagnosticar o evaluar alguna situación de enfermería con el fin de mantener, mejorar o cambiar las actividades que hasta el momento se han realizado. por otro lado, aunque en menor medida, existen ejemplos de estudios pospositivistas que se han desarrollado en la actualidad donde la metodología mixta cualitativa-cuantitativa arroja evidencia científica para mejorar el cuidado del paciente. casey, en su estudio “issues in using methodological triangulation in research”, muestra estudios de enfermería donde se ha utilizado metodología de triangulación. ploeg, en la investigación “nursing best practice champions in diffusing practice guidelines: a mixed 167 corriente epistemológica positivista y su influencia en la generación del conocimiento en enfermería l fredy andrés seguel-palma, sandra valenzuela-suazo, olivia sanhueza-alvarado methods study”, utiliza metodología mixta (triangulación) para dilucidar el problema de estudio (29, 30). conclusiones la metodologías investigativas positivista y pospositivista son las más utilizadas por los profesionales de enfermería en concordancia con el paradigma existente, lo que permite evaluar la gestión de los cuidados para optimizar los recursos y mejorar la práctica basada en evidencia científica; desde este punto de vista, y a juicio de los autores de este artículo, su desarrollo ha sido y es necesario para la subsistencia de la enfermería como profesión y ciencia, ya que los datos y la evidencia generados, y la posibilidad de generalizar las conclusiones permite tomar decisiones acertadas y así mejorar la calidad de los cuidados impartidos a los usuarios del sistema de salud, herramienta importante para la autogestión de los establecimientos. sin embargo, los paradigmas de enfermería están preferentemente orientados a la integración y transformación, de acuerdo con lo cual se han formulado gran parte de sus modelos y teorías. esta disyuntiva plantea un ámbito de reflexión: por un lado, el modelo económico, político y social exige datos concretos y objetivos para identificar la realidad, optimizar recursos y plantear soluciones que abarquen la mayor población a un menor costo posible, y por otro, la verdad subjetiva de la percepción de cada individuo referente a las prestaciones en salud, en gran medida afecta su comportamiento en cuanto al sistema. estos son dos puntos de vista que pueden llegar a complementarse, por tanto, enfermería tiene la gran responsabilidad de lograr el equilibrio de las metodologías investigativas para satisfacer la necesidad del mercado y la relación de cuidado humanizado con el paciente, desde este punto de vista las teorías de rango medio y la metodología de triangulación entre técnicas cualitativas y cuantitativas son de gran importancia por su contribución. las primeras, al ser concretas y aplicables a la práctica diaria de enfermería, y las segundas, por la real integralidad de las percepciones del fenómeno en estudio. los paradigmas empírico positivista y pospositivista en estos momentos no se vislumbran como metodologías en decadencia o en vías de extinción en el mundo científico, pero sí existen otras metodologías que permiten medir aspectos de la realidad de acuerdo con la experiencia de los sujetos, por tanto, son complementarias; en consecuencia, los profesionales de enfermería deben capacitarse en las dos formas de enfrentar la problemática y desarrollar investigación que permita seguir validando su cuerpo de conocimientos, e innovar en la práctica para mejorar la calidad de los cuidados y que los pacientes reconozcan la labor específica que desarrollan. referencias bibliográficas 1. altisen cj. epistemología y metodología. 1 ed. ciudad de la plata; 2001. 2. oxford dictionaries. epistemology. electronic citation; 2010. disponible en: http://oxforddictionaries.com/definition/ english/epistemology [consultado el 10 de diciembre de 2010]. 3. marriner a, raile m. modelos y teorías en enfermería. 6 ed. barcelona; 2007. 4. dickoff j, james p. a theory of theoríes: a position paper. nursing research 1968; 17 (3): 197-203. 5. newman a, sime m, concoran s. the focus of de discipline of nursing. avances in nursing science 1991; 14 (1): 6. 6. geymonat l. historia de la filosofía y de la ciencia. 2 ed. barcelona; 2009. 7. giannini h. breve historia de la filosofía. 12 ed. santiago de chile; 2009. 8. almeida a, araújo e, ribeiro t. pesquisa em enfermagem e o positivismo. revista da escola de enfermagem da usp 1996; 30 (1): 25-32. 9. savater f. la aventura del pensamiento. 2 ed. buenos aires; 2010. 10. triviño z, sanhueza o. paradigmas de investigación en enfermería. ciencia y enfermería 2005; 11 (1): 17-24. 11. flores l. posiciones y orientaciones epistemológicas del paradigma de la complejidad. revista de epistemología de ciencias sociales 2010; (33): 195-203. 168 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 12. durán mm. marco epistemológico de la enfermería. aquichan 2002; oct; 2(2): 7-18. 13. guba e, lincoln y. paradigmas en competencia en la investigación cualitativa. in: denman cyjahc, editor. antología de métodos cualitativos en la investigación social. el colegio de sonora, hermosillo, sonora; 2002. p. 113-45. 14. ostlund u, kidd l, wengstrom y, rowa-dewar n. combining qualitative and quantitative research within mixed method research designs: a methodological review. international journal of nursing studies 2010; nov 15. 15. casey d, murphy k. issues in using methodological triangulation in research. nurse researcher 2009; 16 (4): 40-55. 16. meleis ai. theoretical nursing. 4 ed. phyladelphia; 2007. 17. kerouac s, pepin j, ducharme f, duquette a, major f. el pensamiento enfermero. 2 ed. barcelona; 2010. 18. sanabria l, otero m, urbina o. los paradigmas como base del pensamiento actual en la profesión de enfermería. revista cubana de educación médica superior 2002; 16 (4). 19. irigibel x. revisión crítica de una interpretación del pensamiento de virginia henderson. acercamiento epistemológico al libro de luis, fernández y navarro. index de enfermería 2007; 16 (57). 20. duran mm. teoría de enfermería ¿un camino de herradura? aquichan 2007; 7 (2): 161-73. 21. lin l, yeh ch, mishel mh. evaluation of a conceptual model based on mishel’s theories of uncertainty in illness in a sample of taiwanese parents of children with cancer: a cross-sectional questionnaire survey. international journal of nursing studies 2010 dec; 47 (12): 1510-24. 22. reed pg. demystifying self-transcendence for mental health nursing practice and research. archives of psychiatric nursing 2009 oct; 23 (5): 397-400. 23. monti e, tingen m. paradigmas múltiples de la ciencia de enfermería. advances in nursing science 1999; 21 (4): 60-80. 24. landeros e, salazar b, cruz e. la influencia del positivismo en la investigación práctica de enfermería. index de enfermería 2009; 18 (4). 25. palacios d. modernidad, positivismo y tecnología: influencia en la enfermería y en pacientes que necesitan equipamiento tecnológico. index de enfermería 2008; 17 (3). 26. cometto c, piovan m, gómez p. aportes de los coloquios panamericanos a la investigación en enfermería período 2000-2006. texto & contexto enfermería 2010; 17 (4): 720-6. 27. rogenski ke, togeiro fm, gaidzinski rr, brunet nm. tempo de assistência de enfermagem em instituição hospitalar de ensino. revista da escola de enfermagem da usp 2011; 45 (1): 223-9. 28. guerrero l, ramos r, alcolado a, lópez m, pons j, quesada m. programa de intervención multidisciplinaria para cuidadores de pacientes en atención domiciliaria. gaceta sanitaria 2008; 22 (5): 457-60. 29. ploeg j, skelly j, rowan m, edwards n, davies b, grinspun d et al. the role of nursing best practice champions in diffusing practice guidelines: a mixed methods study. worldviews on evidence based nursing 2010 dec; 7 (4): 238-51. 30. casey d, murphy k. issues in using methodological triangulation in research. nurse researcher 2009; 16 (4): 40-55. 2 la enfermera experta.p65 aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007130 año 7 vol. 7 nº 2 • chía, colombia octubre 2007 • 130-138 yariela gonzález ortega1 recibido: 28 de mayo de 2007 aprobado: 27 de junio de 2007 1 universidad de panamá, ciudad universitaria, panamá yarielag11@yahoo.es la enfermera experta y las relaciones interpersonales la enfermera experta y las relaciones interpersonales resumen la práctica de enfermería basada en el cuidado es un campo de experiencia, en donde los aspectos cognitivos de comportamiento y de integración de habilidades son aplicados al cuidado del individuo. este artículo tiene como finalidad desarrollar los elementos de conocimiento y de habilidad como puntos clave dentro de la experiencia de una enfermera, para favorecer la relación interpersonal. en la enfermera experimentada su maduración personal, su contexto laboral y su aprendizaje continuo, se evidencian en cuidados beneficiosos tanto para ella como para el paciente. en consecuencia, para poder cuidar es necesario poseer conocimientos que le permitan ser reconocida como una profesional experta en el cuidado de la salud, por lo que, se espera que el más alto resultado del conocimiento de enfermería se compruebe a través del contacto cálido y afectivo y, en situaciones prácticas, a través de la interacción enfermera-paciente. por otra parte, el cuidado que exige una relación interpersonal demanda habilidades que se adquieren con la experiencia de ser cuidador, al igual que con el tiempo de experiencia de la enfermera, para trascender y establecer la relación persona a persona. en conclusión, la experiencia genera en la enfermera una percepción personal de competencia donde surgen la destreza, la confianza en sí, la habilidad en la relación y en la comunicación, para despertar en el paciente su interés y atención, y producir un cambio en su comportamiento. palabras clave relaciones interpersonales, conocimiento, enfermera. (fuente: decs, bireme). la enfermera experta y las relaciones interpersonales 131 the expert nurse and inter-personal relations abstract care-based nursing practice is a field of experience where cognitive behavioral aspects and integrated skills are applied to individual care. the objective of this article is to the develop elements of knowledge and skill that are a crucial part of a nurse�s experience, specifically those that favor inter-personal relations. in an experienced nurse, her personal maturity, job context and continuous learning are demonstrated in care that is of benefit to the nurse herself and to the patient. therefore, if a nurse is to provide care, she must have the knowledge that allows her to be recognized as a health care professional. hopefully, the ultimate result of that knowledge will be demonstrated through kind and compassionate contact with the patient and, in practical situations, through nurse-patient interaction. care that demands an inter-personal relationship requires skills that are gained through experience as a care-giver over the course of time, so as to have an impact and to establish a person-to-person relationship. in short, experience gives the nurse a personal perception of competence that fosters the skill, self-confidence, ability in inter-personal relations and in communication to attract the patient�s attention and interest and to generate a change in his or her behavior. key words inter-personal relations, knowledge, nurse. a enfermeira experta e as relações inter-pessoais resumo a prática da enfermagem baseada no cuidado é um campo de experiência no que os aspectos cognitivos comportamentais e de integração de habilidades são aplicadas ao cuidado do individuo. neste artigo, os elementos de conhecimento e de habilidade são considerados pontos claves da experiência da enfermeira para melhorar a relação inter-pessoal. a enfermeira experta mostra a sua maduração pessoal, o seu contexto de trabalho e o seu aprendizagem contínuo nos cuidados benéficos dados para si mesma e ao paciente. para cuidar é necessário ela ser reconhecida como profissional experta no cuidado da saúde por seu conhecimento. portanto, é esperado o mais alto conhecimento da enfermagem através do contato cálido e afetivo e, em situações práticas, da interação enfermeirapaciente. o cuidado precisa de uma relação inter-pessoal que requere habilidades adquiridas com a experiência de cuidar e o tempo de experiência da enfermeira para transcender e fixar a relação pessoa-pessoa. em breve, a experiência gera à enfermeira um sentimento pessoal de competência na que surgem a destreza, a confiança em si, a habilidade para se comunicar e se relacionar para despertar o interesse e a atenção do paciente a fim de alterar o seu comportamento. palavras-chaves relação inter-pessoal, conhecimento, enfermeira. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007132 introducción a práctica de enfermería basada en el cuidado se concibe como un campo de experiencia (1), en donde los aspectos cognitivos, de comportamiento, de integración de habilidades, valores y creencias son aplicados al cuidado del individuo, la familia y la comunidad. de ahí que la experiencia, concebida como una situación única, individual e irreversible en la que se involucran sentimientos moldeados por la situación, adquiere una connotación que comprende un alto grado de compromiso y responsabilidad. dentro de este marco de referencia es importante considerar que la enfermera experimentada proporciona cuidado, producto de una interacción con su maduración personal, contexto laboral, y de aprendizaje continuo y progresivo que se evidencia en acciones favorables tanto para ella como para el paciente. estas acciones se reflejan a través del fomento de una relación interpersonal saludable con los pacientes, y se expresan a través de la honestidad, la sinceridad, el respeto, la comprensión, la sabiduría y la reciprocidad hacia el paciente, incorporando además los elementos que le permiten comunicarse y escuchar efectivamente. sin embargo, para llegar a esta relación es necesario que la enfermera involucre su propia experiencia para ayudarla a transformarse en una persona genuina dentro de la interacción, y pueda ser percibida por el paciente como una profesional totalmente involucrada. en enfermería, el campo de la experiencia se basa fundamentalmente en la acumulación de conocimientos y el desarrollo de las habilidades prácticas, elementos que hasta el momento han sido poco relacionados con la interacción enfermera-paciente, y los cuales tienen un significado importante en la capacitación de la enfermera para responder a cambios particulares en cada situación de cuidado, y aceptar su responsabilidad en las decisiones que toma durante la interacción con el paciente. elementos que desarrollan la experticia en la relación interpersonal conocimiento muchas veces se habla de experto cuando se trabaja profundamente en un conocimiento específico y se tienen destrezas pertinentes en un área (2), lo que da capacidad a una persona para desempeñarse en diferentes roles y afrontar situaciones accidentales con habilidad oportuna. enfermería no se escapa de esta situación, ya que para poder cuidar es necesario poseer un conocimiento, ya sea implícito o explícito, directo o indirecto, general o específico (3); un conocimiento adquirido a través de la práctica, el cual es apoyado por experiencias previas (4), y un conocimiento del yo. estos conocimientos se consideran habilidades iniciales que la enfermera debe tener (5) para hacer posible la conexión de cuidado entre ella y el paciente. el conocimiento específico que recibe la enfermera durante su preparación es un conocimiento integrado basado, entre otros, en las ciencias biológicas, sociales, psicológicas y antropológicas, que proporcionan algunas herramientas para desarrollar su capacidad de comunicación, interacción y socialización. sin embargo, la formación de las enfermeras en cuanto a la comunicación ha sido incompleta en las escuelas de enfermería (6), pues se la enfermera experta y las relaciones interpersonales 133 observa en muchas ocasiones que la enfermera no ha desarrollado esta capacidad de comunicación. por lo anterior se hace necesario introducir este proceso de comunicación de una manera compleja dentro de la formación de la enfermera, pues una adecuada comunicación con el paciente es una habilidad clínica fundamental que caracteriza a un profesional competente (6). cabe destacar que la adquisición de estos conocimientos, su integración, y las habilidades que va adquiriendo la enfermera, progresivamente le proveen un dominio para actuar en la complejidad de la práctica, con las diversas personalidades y métodos para comprender las necesidades de cada paciente. en este sentido, estos conocimientos le permiten a la enfermera ser reconocida como una profesional experta en el cuidado de la salud, por lo que se espera que el más alto resultado se evidencie a través del contacto cálido y afectivo, y en situaciones prácticas a través de la interacción enfermera-paciente. de igual manera, se espera que sea consejera experta que identifique con competencia el momento oportuno, la frecuencia y duración a fin de proporcionar este cuidado de interacción que requiere el paciente para mantener su bienestar. además del conocimiento adquirido a través de la educación formal e informal, la experiencia práctica forma dimensiones cognitivas (7) expresadas en el campo de la práctica de enfermería a través de los patrones de conocimiento (8, 9) y los trabajos realizados de desarrollo de expresión, transmisión y valoración de cada uno de ellos (10), los cuales son fundamentales para que la enfermera ponga en práctica las diferentes formas del conocimiento desde el punto de vista epistémico y ontológico. estos patrones son de gran relevancia para la práctica, ya que fomentan el cuidado basado en la relación e interacción con el paciente como un elemento significativo para intervenir en los actos de cuidado y poder trascender con el ser humano (11, 12), razón de ser de la enfermería. en este contexto es significativo subrayar el conocimiento personal como relevante en la interacción con el paciente, pues consideramos que capacita a la enfermera para responder al único llamado de cuidado personificado (13), descrito como una interacción personal de relación y transacción (7), que permite a la enfermera conocerse a sí misma, y reconocer sus fortalezas y debilidades como persona cuidadora para poder llegar a ser auténtica en la relación con los demás (14), y generar confianza y seguridad. esta autenticidad adquirida demanda madurez personal y profesional. desde lo personal, porque debe ser capaz de mantener un equilibrio personal, y desde lo profesional, porque debe poseer competencia clínica y habilidad en los dominios físico y psicológico para aplicarlos a la práctica de enfermería (15). todo esto apunta a que la enfermera que transmite una presencia auténtica requiere del conocimiento de la práctica y la confianza en las habilidades de la relación, de lo contrario consideramos difícil que su participación dé resultados favorables. por consiguiente, es importante que la enfermera desarrolle su imagen corporal, su crecimiento, su percepción y personalidad propia (16), como base para la preparación personal y el desarrollo permanente del yo, elementos que le permitirán conocerse a sí misma y sus reacciones ante las diversas experiencias de interacción, y de esta manera interpretar a los seres humanos y favorecer su interacción (17). de esta manera, la integración del conocimiento que muestra la enfermera experimentada, nutrida a través de la experiencia diaria de cuidar y el conocimiento interpersonal que se profundiza por medio de una intensa interacción con el otro durante la asistencia, hace que el nivel de estrés, tanto del paciente como de la enfermera, disminuya y se produzca un bienestar físico para los pacientes al proporcionarles cuidado (18). basados en esta perspectiva, se comprende que para ayudar a otro de manera eficaz es necesario desarrollar una sólida formación teórico-práctica, y haber trabajado sobre sí misma (19), siendo esta última una cualidad de la enfermera experta (18). sin embargo, la efectividad de estos conocimientos depende de la naturaleza y dimensión que cada enfermera lleva y adquiere en la práctica, convirtiéndose para ella en un desafío para perfeccionarlos, y cuya expectativa está orientada a mantener una relación enfermera-paciente con responsabilidad (16, 20), en donde se da un compromiso entre ambos, y en donde uno de ellos es responsable por el otro. habilidad práctica otro elemento que se debe tomar en cuenta dentro de la experiencia de la enfermera para mantener cuidados de relación la experiencia, concebida como una situación única, individual e irreversible en la que se involucran sentimientos moldeados por la situación, adquiere una connotación que comprende un alto grado de compromiso y responsabilidad. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007134 interpersonal, es la habilidad práctica que se aprende y se adquiere con la experiencia de ser cuidador, y con el tiempo de experiencia del rol (21-24, 6). este planteamiento lleva a pensar que la enfermera experimentada adquiere, gradualmente, habilidad y destreza que le permiten percibir de una manera oportuna las necesidades de interacción del paciente y sus familias, y de tal forma proporcionar un cuidado de relación en forma relajada, ya que al estar familiarizada con el contexto de la enfermería, disminuye su preocupación por los problemas asociados con seguridad y tecnología, y aumenta su interés por comprender al paciente y por disponer del tiempo necesario para interactuar con ellos. de aquí que, conforme la enfermera adquiere experiencia, se genera sabiduría clínica (24), la cual da pautas para que sea lo suficientemente madura, involucre sentimientos, actitudes y conductas, que le permiten comprender la situación del paciente, y desempeñarse dentro de las relaciones interpersonales con calidez humana. en este sentido, uno de los principales factores que influyen en la capacidad de la enfermera para manejar la interacción y solucionar sus problemas podría radicar en la experiencia, pues garantiza que ésta tenga confianza en sí misma, habilidad en la relación y habilidad en la comunicación (18), que son dominios que la enfermera debe tener y llevar a la práctica con el fin de mantener relación y comunicación (25-29) dentro de un contexto holístico. una enfermera con experiencia demuestra un lenguaje y medios manejados diestramente, lo que le permite conectarse en el campo de los significados del paciente, de tal manera que hace que éste exteriorice sus sentimientos y pensamientos. por consiguiente, la comunicación a través del diálogo constructivo y sin reserva, ya sea hablado o silencioso, demanda una habilidad para estar abierto y exigir a la otra persona (28). este diálogo, y los símbolos que progresivamente la enfermera adquiere a través de su experiencia, le permiten basar el cuidado de relación interpersonal en sentimientos dirigidos hacia la otra persona y convertirla en un puente de comunicación a través de un ambiente de mutualidad y reciprocidad con el paciente, la familia y el equipo de salud. cuando este diálogo ocurre de manera genuina, y en un ambiente de franqueza, disponibilidad, e intercambio, habilita a la enfermera para realizar conversaciones fluidas, coherentes y estructuradas (30, 26), cuyos contenidos hacen referencia a temas importantes y relevantes para las personas involucradas. de acuerdo con lo anterior, y considerando que los dominios son el resultado de un aprendizaje que se da en forma gradualmente ascendente de principiante a experto (31), se puede comprender que la relación y la comunicación son un punto importante que guarda estrecha relación con la experiencia ya que pone de manifiesto cómo las enfermeras, a medida que van adquiriendo experiencia clínica progresiva, integran sus conocimientos para tratar a los pacientes y ofrecer así una relación enfermera-paciente más comprometida. reafirmando lo anterior, los hallazgos de gjengedal (32) y hansen (33) han demostrado que las acciones de una enfermera con poca experiencia están enfocadas en el equipo técnico, en lugar de intentar desarrollar una relación de comunicación con el paciente. por consiguiente, resulta imprescindible resaltar que la práctica de una enfermera con experiencia redunda en una alta sensibilidad interpersonal y una recíproca intimidad enfermerapaciente (15), que le ayudan a interpretar los significados conscientes e inconscientes que se dan durante la comunicación con cada paciente. este punto se puede destacar más claramente a través de una situación sencilla que vive la enfermera diariamente, cuando los pacientes que son enviados a la sala de operaciones por lo general están inmersos en un mundo de ansiedades y temores, manifestados de una forma verbal o no verbal justo en el momento de su traslado. es entonces, en este momento oportuno, cuando la enfermera experimentada encuentra un espacio para establecer un cuidado de relación interpersonal con reciprocidad que le permite al paciente expresar los temores y las preocupaciones que lo agobian. un segundo ejemplo de este planteamiento se puede enfocar también en las unidades de cuidados intensivos, donde la tecnología de punta está a la orden del día; sin embargo, a pesar de ello, se puede hacer evidente la habilidad de la enfermera cuando pone entre sus prioridades la interacción con el paciente a través de una presencia auténtica. con estos ejemplos he querido resaltar que la enfermera, como ya es conocido por todos, está habitualmente en contacto con el paciente; sin embargo, paralela a esta condición, la experiencia le permite reconocer de otro elemento que se debe tomar en cuenta dentro de la experiencia de la enfermera para mantener cuidados de relación interpersonal, es la habilidad práctica que se aprende y se adquiere con la experiencia de ser cuidador, y con el tiempo de experiencia del rol. la enfermera experta y las relaciones interpersonales 135 una manera fluida la relación interpersonal y realizar las intervenciones de un modo confiable y oportuno. así, combinando estos dos elementos de habilidad y conocimiento dentro de una relación se obtiene una manera distinta de visualizar la relación enfermera-paciente, se adquiere un grado de madurez para dar respuesta a las necesidades individuales, habilidad en la comunicación, y conexión con el cuidado, lo que trae como resultado una expresión de satisfacción por parte del paciente de sentirse escuchado y comprendido, además de la satisfacción personal de la enfermera. relaciones interpersonales saludables como reflejo de la experiencia todo individuo sometido a una hospitalización confronta reacciones emocionales que demandan una estrecha relación con alguien en quien confiar sus problemas y preocupaciones. de aquí la importancia de la participación de una enfermera hábil en la interacción con el paciente, para que establezca relaciones interpersonales saludables llenas de afecto, confianza y seguridad con el fin de favorecer la adaptación del paciente a su situación. esta relación interpersonal saludable viene siendo el resultado de la utilización permanente y efectiva de los atributos de la interacción (34) tales como la confianza y la empatía (35-37), desarrollados por la enfermera experta en un ambiente de respeto por la dignidad del paciente como persona, demostrando la capacidad de sentir con éste, de ponerse en su lugar, y establecer tiempo y espacio para que se sienta comprendido y pueda lograr por sí mismo su bienestar. en este sentido, la poca experiencia muchas veces dificulta poner en práctica métodos eficaces en la relación con el paciente, quizá no sólo por las dificultades derivadas de la misma, sino por la inseguridad de lo que se hace, por el temor a lo desconocido, a la forma de trabajo, a la tecnología o al entorno laboral, lo que trae como consecuencia llevar el proceso de interacción a un último plano, tomándolo como una pérdida de tiempo o como una simple entrevista. por consiguiente, se espera que una enfermera principiante consolide su autenticidad con el apoyo y la guía de un mentor, y una enfermera experta use de manera hábil su presencia auténtica en ambientes favorables o no (38). así pues, la enfermera ofrecerá cuidado de relación de forma afable, que le permita percibir de manera anticipada las necesidades del paciente con habilidad y destreza y, al mismo tiempo, lograr que éste se sienta más cómodo. por ello, hoy día la enfermera debe enfrentarse al desafío de encaminar las acciones a cuidados de relación interpersonal, con compromiso, efectividad y una formación moral que incluya desarrollar el amor hacia los demás, pues éste refleja una apertura hacia el otro, una convivencia y una comunión con él (39). en el diario vivir de la enfermera, la experiencia obtenida representa un aprendizaje (40, 41) en el que también se adquiere habilidad y disponibilidad para proporcionar intervenciones fiables de acuerdo con el contexto y con cada experiencia de salud, para influir favorablemente en el cuidado de interacción, y lograr que el paciente y su familia se responsabilicen en el cuidado de la salud. esto implica que el cuidado que ofrece la enfermera experimentada conlleva conductas positivas relacionadas con la serenidad, la madurez y la neutralidad para mantener una interacción eficaz y afrontar situaciones, sin que pueda ser dañina para ella o para el paciente. en general, como se mencionó, el cuidado de interacción que proporciona una enfermera con experiencia se refleja en la seguridad al actuar, la empatía y la comprensión del otro; en actuar bajo su propio criterio, y buscar el momento oportuno para hacerlo. de esta manera, la experiencia produce una percepción personal de competencia para despertar en el paciente interés y atención, y generar un cambio en su comportamiento (29). el estudio realizado por conway (42) sobre la evolución de la enfermera experta y el conocimiento que posee en la práctica, presenta cuatro tipos de habilidades que son: tecnológica, tradicionalista, especialista y humanista, siendo esta última la que provee las condiciones para el crecimiento y desarrollo personal de la enfermera dentro de su práctica. la poca experiencia muchas veces dificulta poner en práctica métodos eficaces en la relación con el paciente, quizá no sólo por las dificultades derivadas de la misma, sino por la inseguridad de lo que se hace, por el temor a lo desconocido, a la forma de trabajo, a la tecnología o al entorno laboral. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007136 este despliegue de sentimiento humanista (43, 44) de las enfermeras sólo puede ser demostrado y practicado a través de las relaciones interpersonales (16), pues permite que el paciente exprese sus sentimientos (22, 45) y satisfaga sus necesidades biopsicosociales y espirituales, a través de una comprensión, dedicación e intimidad. todo esto indica que la práctica de la enfermera basada en el humanismo no es algo que acontece de manera espontánea sino que es fomentada, aprendida y practicada (46). por tal razón, la experiencia provee a la enfermera las condiciones para sensibilizarse hacia aspectos más humanos y comprender el significado que para el paciente conlleva su interacción con él. la relación entre la enfermera y el paciente es en sí un factor significativo para enfermería, por lo que diferentes autores presentan la conceptualización de la naturaleza de la enfermería como un proceso interpersonal (16, 29, 36, 47), donde se fomenta el cuidado basado en la relación. esta interacción basa la atención de la enfermera en la necesidad de relaciones humanas cuyo centro de interés son los procesos de interacción entre los conceptos metaparadigmáticos: enfermera y persona, es decir, entre una persona que tiene una necesidad y otra capaz de ayudarla. sin embargo, hoy día se habla de un deterioro de estas relaciones interpersonales el cual ha sido evidenciado a través de los años por diversas investigaciones (48-52), en las que paralelamente también han surgido reflexiones de diversos autores (53), lo que indica una gran preocupación de la comunidad científica de enfermería por buscar los factores que puedan influir en este fenómeno. este artículo pretende despertar el interés, desde la óptica de la experiencia de la enfermera, sobre el fenómeno de cuidado de relación interpersonal, pues la experiencia proporciona lecciones a través de situaciones que permiten a la enfermera reflexionar y perfeccionarse en cuanto a la forma de tratar al otro. por tanto considero que la enfermera experta, para ser reconocida como profesional que brinda cuidados de relación interpersonal, debe evidenciar un cuerpo de conocimientos y la capacidad creativa para intervenir con habilidad y tener un acercamiento más afectivo, dedicado y centrado en el conocimiento individual de cada paciente, a fin de hacerle frente a factores que de una u otra forma pueden condicionar la interacción como lo es la duración, continuidad y calidad de participación del paciente (27, 26, 54), para que de esta forma se favorezca la adaptación de su situación. por otra parte, la relación interpersonal debe ser incluida como parte del contenido del programa oficial de la carrera de enfermería para que la estudiante, en su formación, reciba las herramientas básicas del arte de la empatía y de la comunicación, y reflexione acerca del conocimiento de sí misma como enfermera y como persona. la futura enfermera podrá desarrollar progresivamente estos conocimientos a través del campo clínico con el fin de mejorar el cuidado de interacción que se ofrece en las distintas 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22: 72-78. 51. bengoechea i. estudio sobre la comunicación paciente-enfermera en cuidados intensivos. el estudio de las líneas de investigación predominantes y otras relevancias. enfermería clínica 2001; 11 (6): 34-42. 52. gutiérrez j, jiménez mc, pérez ml et al. ¿por qué reclaman los usuarios? rol de enfermería 1997; xx (230): 12-16. 53. watson j. commentary on shattell m. nurse-patient interaction: a review of the literature. journal of clinical nursing 2004; 13: 714-722. journal of clinical nursing 2005; 14 (4): 530-531. 54. morse j. negotiation commitment and involvement in the nurse-patient relationship. journal of advanced nursing 1991; 16: 455-468. 157 claudia patricia henao-lema1 julio ernesto pérez-parra2 lesiones medulares y discapacidad: revisión bibliográfica 1 fisioterapeuta. especialista en neurorrehabilitación. profesora asociada, universidad autónoma de manizales, manizales, colombia. cphenao@autonoma.edu.co 2 fisioterapeuta. especialista en neurorrehabilitación. profesor asociado, universidad autónoma de manizales, manizales, colombia. jeperez@autonoma.edu.co recibido: 26 de junio de 2009 aceptado: 1º de julio de 2010 resumen la lesión medular es una entidad neurológica causante de importantes procesos de discapacidad. su incidencia en el país puede estar cercana a los mayores estimativos mundiales debido a las condiciones actuales de violencia. el aumento de la expectativa de vida de esta población —gracias a los avances tecnológicos y científicos en prevención, atención y manejo de complicaciones— lleva a la necesidad de proveer servicios de rehabilitación integrales que trasciendan los aspectos funcionales y permitan la inclusión social. para este propósito es necesario un abordaje integral de la situación, que en el ámbito de la evaluación debe incluir no sólo la estimación de la condición de salud, sino todo lo relacionado con el funcionamiento de las personas en su vida diaria. la clasificación internacional del funcionamiento, la discapacidad y la salud, brinda un marco conceptual para abordar la discapacidad y el funcionamiento humano relacionado con la salud desde un enfoque biopsicosocial que articula las dimensiones corporal, individual y social de las personas y su relación con los factores del ambiente. este enfoque de abordaje, plasmado en el instrumento de evaluación denominado who-das ii, se considera un referente importante para evaluar la discapacidad asociada a la lesión medular. palabras clave médula espinal, evaluación de la discapacidad, traumatismos de la médula espinal, personas con discapacidad. (fuente: decs, bireme). spinal cord injuries and disabilities: a review abstract spinal cord injury is a neurological event that can result in major disability. its incidence in colombia is possibly among the highest in the world, given the current level of violence. the increased life expectancy for this group, thanks to technological and scientific progress with respect to prevention, care and treatment of complications, has created the need for comprehensive rehabilitation services that go beyond functional aspects and enable patients to rejoin society. this demands a holistic approach to the situation, including not only an año 10 vol. 10 nº 2 chía, colombia agosto 2010 l 157-172 158 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 assessment of health conditions but of everything related to how persons function in their daily lives. the international classification of functioning, disability and health provides a conceptual framework to address disability and human functioning related to health, through a biopsychosocial approach that articulates the person’s physical, individual and social dimensions and their relationship with factors in the environment. this approach, incorporated into an evaluation tool known as who-das ii, is considered an important benchmark for assessing disability associated with spinal medulla injury. key words spinal cord, disability evolution, spinal cord injuries, disabled persons. (source: decs, bireme). lesões medulares e discapacidade: uma revisão bibliográfica resumo lesão medular é uma entidade neurológica que causa processos graves de discapacidade. sua incidência no país pode aproximar-se às principais estimativas globais, devido às condições atuais de violência. o aumento da expectativa de vida da população, graças aos avanços tecnológicos e científicos na prevenção, cuidados e tratamento das complicações, exige a prestação de serviços de reabilitação integrais que vai além dos aspectos funcionais e permitem a inclusão social. para este efeito, é preciso uma amplio para a situação em matéria de avaliação deve incluir não apenas a estimativa do estado de saúde, mas tudo relacionado ao funcionamento das pessoas em suas vidas diárias. a classificação internacional de funcionalidade, discapacidade e saúde suministra um quadro conceptual para abordar a deficiência e a funcionalidade humanas relacionadas com a saúde usando uma abordagem biopsicossocial que integre o desenvolvimento físico, social e individual das pessoas e sua relação com os fatores do meio ambiente. esta abordagem, consagrada no instrumento de avaliação chamado oms das-ii, é considerada um marco importante para a avaliação da discapacidade associada com lesão medular. palavras-chave medula espinal, avaliação da deficiência, traumatismos da medula espinal, pessoas com deficiência. (fonte: decs, bireme). 159 lesiones medulares y discapacidad: revisión bibliográfica l claudia patricia henao-lema, julio ernesto pérez-parra introducción la lesión medular (lm) es un proceso patológico que produce alteraciones de la función motora, sensitiva o autónoma, con diversas consecuencias psicosociales para la persona y su familia, siendo así generadora de importantes procesos de discapacidad. la etiología de las lesiones medulares es muy variada e incluye causas de origen congénito, traumático, infeccioso, tumoral o secundario a enfermedades sistémicas (1-3). la mayoría de la literatura científica establece en primera instancia como causa de lm el trauma, se encuentra el asociado a accidentes de tránsito, heridas por arma de fuego, heridas por arma blanca, caídas de altura, inmersiones en aguas poco profundas, accidentes deportivos y accidentes laborales, entre otras (3-17). en segunda instancia se encuentran las lesiones no traumáticas asociadas a factores congénitos, secundarios a diferentes patologías o por intervenciones médicas o quirúrgicas (3). este tipo de lesiones ocurren con mayor frecuencia en población joven (8, 18, 19) con una distribución por sexo (hombre / mujer) de 4:1 (4, 19, 20). la incidencia de las lesiones medulares es variable entre países y entre regiones. wyndaele y wyndaele (21), en una revisión sistemática de publicaciones científicas entre 1977 y 2006 sobre incidencia, prevalencia y epidemiología de lesión medular a nivel mundial concluyen que la incidencia global oscila entre 10,4 y 83 por millón de habitantes por año, y la prevalencia entre 223 a 755 por millón de habitantes. mazaira et ál. estiman que en países desarrollados la incidencia de la lesión medular varía en un rango entre 9 y 53 por millón de habitantes (15). cada año suceden 12.000 nuevos casos en norteamérica (22), estimaciones actuales sugieren que la incidencia anual de lesiones medulares en los estados unidos es alrededor de 40 casos por millón (23). en colombia no se conocen estudios que reporten los datos epidemiológicos de lesión medular. el instituto de medicina legal y ciencias forenses estableció que en el año 2005 los accidentes de tránsito habían sido responsables de cerca de 1.036 traumas en las regiones del cuello y del área pélvica, representando el 2,99% de las personas que presentaron traumatismos en accidentes de tránsito en el país (24). jiménez (25) indica que la lesión medular es una condición que se presenta en 1 de 40 pacientes colombianos que ingresan a un hospital general consultando por trauma. garzón, en un estudio realizado en bogotá (6), reporta que la edad de las personas con lesión medular es en promedio de 35,8 años y en una relación de 4,1:1 (hombre:mujer). la lesión medular se ha reportado como uno de los motivos de consulta más frecuentes en los centros de atención de salud de todos los niveles de complejidad como consecuencia del estado de violencia que vive el país (26, 27). la expectativa de vida de las personas con lesión medular se ha venido incrementando en las últimas décadas gracias a los avances tecnológicos y científicos en aspectos de prevención, atención prehospitalaria y manejo de complicaciones en el trascurso de la enfermedad que exige proveer a esta población de procesos de atención y rehabilitación multidimensionales, interdisciplinares e intersectoriales que trasciendan los aspectos funcionales y permitan alcanzar verdaderos procesos de inclusión social. de esta forma, la valoración de la situación de discapacidad en esta población debe incluir no sólo aspectos relativos a la condición de salud, sino los relacionados con el funcionamiento de las personas en su vida diaria y la posibilidad de seguir participando activamente en su medio 160 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 social. este tipo de valoraciones implica un abordaje de la situación desde un enfoque biospicosocial que permita establecer las complejas relaciones entre los diferentes aspectos de la vida de las personas afectadas por la lesión medular. la organización mundial de la salud (oms) aprobó en el año 2001 la última versión de la clasificación internacional del funcionamiento, la discapacidad y la salud (cif), como un marco conceptual para abordar la discapacidad y el funcionamiento humano relacionado con la salud desde un enfoque biopsicosocial. este modelo permite establecer el perfil de funcionamiento y discapacidad de la persona articulando aspectos desde las dimensiones corporal, individual y social, y su relación con los factores del ambiente que pueden actuar como facilitadores o barreras de la situación de discapacidad (28). como medida de funcionamiento, el modelo de la cif es útil para establecer comparaciones a partir de su uso en el establecimiento de mediciones basales, a fin de determinar la eficacia y el resultado de las intervenciones, o como indicador de calidad de vida. asimismo, ya que es concebido bajo la óptica de un lenguaje común, permite describir el funcionamiento y la discapacidad de manera que pueda ser comparado a nivel internacional (29). bajo estas consideraciones, el abordaje de la problemática de la discapacidad asociada a la lesión medular debe involucrar la exploración de las diferentes dimensiones del individuo en cuanto a lo corporal, lo individual y lo social. lesiones de la médula espinal definición la lm puede definirse como todo proceso patológico (conmoción, contusión, laceración, compresión o sección), de cualquier etiología (traumática y no traumática), que afecta la médula espinal, y puede originar alteraciones de la función neurológica por debajo de la lesión: motoras, sensitivas y autonómicas (2). la complejidad del déficit neurológico, y por tanto del cuadro clínico resultante, depende del nivel y la completitud de la lesión, la extensión transversal o longitudinal del tejido lesionado, y la afectación de sustancia blanca o gris (2, 30). aspectos sociodemográficos diferentes estudios en el tema reportan una mayor incidencia de la lesión medular en hombres, la cual oscila entre 66 y 92% para los distintos países (5-13, 18, 19, 27, 31, 32), representando una relación promedio hombre / mujer de 4:1. se desconocen datos estadísticos para toda colombia, sin embargo, en la investigación de lugo et ál. realizada en pacientes con trauma raquimedular (trm) admitidos en el hospital san vicente paúl de medellín entre septiembre de 1999 y diciembre de 2001 (17), se encontró una proporción de 86% de hombres contra un 14% de mujeres. el sexo es una variable que ha sido importante en el momento de abordar la discapacidad asociada a la lesión medular. krause y broderick, en su estudio para identificar diferencias en cuanto a bienestar subjetivo, participación y salud general de acuerdo con el sexo (23), encontraron que no hay diferencias significativas entre hombres y mujeres respecto al nivel de la discapacidad evaluada a través del chart (craig handicap assessment and reporting technique), instrumento que mide la integración en la comunidad a través de variables de independencia física, movilidad, ocupación, integración social y autosuficiencia económica. sin embargo diferentes estudios en el tema reportan una mayor incidencia de la lesión medular en hombres, la cual oscila entre 66 y 92% para los distintos países. 161 lesiones medulares y discapacidad: revisión bibliográfica l claudia patricia henao-lema, julio ernesto pérez-parra sipski et ál., en el estudio sobre el efecto del sexo en la recuperación neurológica y funcional después de una lesión espinal (8), encontraron que las mujeres mostraron una mejor recuperación neurológica natural que los hombres (utilizando el índice motor asia), no obstante, en un nivel y grado de lesión neurológica determinado, los hombres tienden a ser funcionalmente mejores que las mujeres al momento de ser dados de alta del proceso de rehabilitación (utilizando la subescala motora del fim – functional impairment scale). en cuanto a la edad de ocurrencia, la lm se presenta principalmente en personas jóvenes entre los 16 y 35 años. la mayoría de estudios a nivel mundial reportan en sus muestras un promedio de edad entre 28 y 33 años (5, 8, 9, 17, 33, 34). lugo et ál. encontraron un promedio de edad de 32,6 años en su serie de casos colombianos (medellín) (17). garzón, en un estudio realizado en bogotá (6), reporta que la edad de las personas con lm es en promedio de 35,8 años. la edad ha sido establecida como factor predictor significativo de supervivencia en esta población (10); de igual manera, se ha reportado que algunos de los cambios funcionales a largo plazo se asocian de forma importante con esta variable (18), encontrando además que aquellos pacientes lesionados con mayor edad, tienen un mayor riesgo de mortalidad (10). etiología respecto a los factores etiológicos, los traumatismos constituyen aproximadamente el 60% de los casos de lesión medular en países desarrollados (3-15), y cerca del 80% en países en vía de desarrollo como colombia (17), los traumas son ocasionados con mayor frecuencia por heridas por armas blancas o de fuego, con un porcentaje entre el 20 y el 60% (11, 16, 17). los accidentes de tránsito tienen una incidencia global importante que oscila entre el 12 y 63% (7, 8, 11, 12, 16, 17). las caídas de altura, los accidentes deportivos y laborales, y las zambullidas en aguas poco profundas en general tienen una incidencia menor (11, 12, 16, 17). en colombia, lugo et ál. (17) encontraron como principal causa de lesión las heridas por arma de fuego con el 50% de los casos, seguida por accidentes automovilísticos con 15% y caídas con 14%. estas cifras coinciden con el estudio de krause y broderick (23) realizado en usa, que reporta como principal causa de lm en blancos, afroamericanos y amerindios los accidentes en vehículo con el 52, 50 y 82% respectivamente, en tanto en hispanos fue por hechos derivados de violencia con el 48%, seguido por accidentes de tránsito con el 35%. nivel y extensión de la lesión medular las lesiones medulares se denominan de acuerdo con el último nivel intacto, es decir, aquella metámera que preserva todas las funciones neurológicas: motoras, sensitivas y autonómicas. en este sentido, pueden clasificarse de acuerdo con la funcionalidad clínica del paciente como cervicales (c1 a c8), torácicas altas (t1 a t6), torácicas bajas (t7 a t12), lumbosacras (l1 a s1) y del cono medular (sacro coccígeas). entre más alta la lesión mayor será el compromiso funcional del paciente. de acuerdo con la extensión de la lesión, éstas pueden considerarse como transversales y longitudinales; en la mayoría de los pacientes existe una combinala edad ha sido establecida como factor predictor significativo de supervivencia en esta población; de igual manera, se ha reportado que algunos de los cambios funcionales a largo plazo se asocian de forma importante con esta variable. 162 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 ción de ambas. la primera hace referencia a la extensión transversal de la metámera, produciendo secciones completas o incompletas donde el compromiso de las distintas vías descendentes y ascendentes determina el cuadro clínico del paciente. la extensión longitudinal se refiere a la lesión en los planos verticales y se determina por el número de metámeras lesionadas por el proceso patológico; el cuadro clínico del paciente se manifiesta principalmente por el compromiso de sustancia blanca o gris. la escala más utilizada a nivel internacional para evaluar la extensión o completitud de la lesión medular es la ais (asia impairment scale) que sigue los estándares para clasificación neurológica de la asociación americana de lesiones medulares asia (american spinal injury association). esta escala clasifica la lm de acuerdo con cinco grados determinados por la ausencia o preservación de la función motora y sensitiva (2, 35), así: (ver tabla 1). la mayoría de las lesiones reportadas en las distintas investigaciones a nivel mundial se ubican en los niveles cervical, entre el 34 y 53% de los casos, y torácico, entre el 43 y 48%, en tanto las lesiones lumbosacras van del 10 a 14% (5, 7, 9, 1113, 34, 36). en la casuística del hospital universitario san vicente de paúl de medellín (colombia), se encontró 28,5% de lesiones cervicales, 41,5% torácicas altas y el 30% por debajo de t6 (17). de acuerdo con la extensión o completitud de la lesión, utilizando ais, se reporta en la literatura científica internacional un mayor predominio del grado a o lesión completa (48 a 58%), seguido de los grados b y c o lesiones incompletas (16 a 44%), y en menor proporción grados d y e (8, 12, 33, 36). según lugo et ál., en su muestra con pacientes colombianos, el 62% presentó lesión completa grado a, 10% b, 12% c, 14% d, y sólo el 2% presentó una condición normal o grado e (17). lesión completa a ausencia de función motora y sensitiva que se extiende hasta los segmentos sacros s4-s5. lesión incompleta b preservación de la función sensitiva por debajo del nivel neurológico de la lesión, que se extiende hasta los segmentos sacros s4-s5 y con ausencia de función motora. lesión incompleta c preservación de la función motora por debajo del nivel neurológico, y más de la mitad de los músculos llave por debajo del nivel neurológico tienen un balance muscular menor de 3. lesión incompleta d preservación de la función motora por debajo del nivel neurológico, y más de la mitad de los músculos llave por debajo del nivel neurológico tienen un balance muscular de 3 o más. normal e las funciones sensitiva y motora son normales. tabla 1. escala de clasificación de la lesión medular. 163 lesiones medulares y discapacidad: revisión bibliográfica l claudia patricia henao-lema, julio ernesto pérez-parra franceschini et ál., en un estudio longitudinal de personas con lesión medular (5), evaluaron la asociación entre el nivel, la completitud y la etiología de la lesión medular con variables asociadas a la calidad de vida encontrando una correlación significativa entre el nivel de la lesión con el grado de autonomía de las personas. complicaciones según mccoll et ál., existen por lo menos cinco tipos de cambios que las personas con lesión medular experimentan con el tiempo: 1) los efectos de vivir con la lesión por muchos años, tales como deterioro del hombro, infecciones urinarias crónicas o problemas posturales; 2) complicaciones secundarias a la lesión original, tales como siringomelia postraumática; 3) procesos patológicos no relacionados con la lesión medular, como enfermedad cardíaca u otras enfermedades crónicas; 4) cambios degenerativos asociados con el envejecimientos, tales como articulares, sensoriales y problemas de tejido conectivo; 5) factores medioambientales, como los sociales, comunitarios y aspectos culturales que pueden complicar la experiencia de envejecer con lesión de la médula espinal (36). las principales complicaciones reportadas por diferentes investigaciones con series de casos de pacientes con lm en el mundo son: espasticidad, contracturas musculares, hombro doloroso, dolor articular-artritis, osificación heterotópica, fracturas, esquinces y luxaciones, úlceras de presión, deterioro neurológico, dolor crónico, infecciones urinarias, problemas renales y vesicales, problemas intestinales, complicaciones cardíacas y respiratorias, presión sanguínea alta o baja, trombosis, edema, disreflexia autonómica, aumento de peso, depresión, estrés psicológico, adicción a drogas, entre otras (5, 7, 9, 12, 13, 17). en la muestra de lugo et ál. en el 2007, se encontraron principalmente las siguientes complicaciones: dolor en el 80% de los pacientes a los tres meses de ocurrencia de la lesión, espasticidad en el 64,9% de los casos al primer año, infecciones urinarias en el 38% a los tres meses, y úlceras de presión en el 25% al primer mes después de ocurrida la lesión (17). hitzig et ál., en su estudio con pacientes con lm con más de un año evolución, determinaron la asociación entre la incidencia autorreportada de complicaciones de salud secundarias a la lesión medular con las variables edad, tiempo de evolución de la lesión y deficiencia (13). en esta investigación se encontró que la relación de tasas (odds ratios) para complicaciones cardiacas, presión arterial alta y complicaciones respiratorias se incrementó con la edad, mientras la disreflexia autónomica, infecciones vesicales, osificación heterotópica, estrés psicológico y adicción a drogas decrecieron. la relación de tasas para úlceras de presión, disreflexia autonómica y osificación heterotópica se incrementó con el tiempo de evolución, mientras la presión arterial alta, problemas intestinales, estrés psicológico y depresión disminuyeron. las lesiones completas estuvieron asociadas con infecciones urinarias, úlceras de presión y disreflexia autonómica. la paraplejia estuvo asociada con presión arterial alta y la cuadriplejía con disreflexia autonómica. por su parte, charlifue et ál. en su estudio sobre el impacto de la edad, edad de inicio, años de evolución y severidad de la lesión, sobre los cambios en el tiempo de variables físicas y psicosociales de personas envejeciendo con lesión espinal e identificación de los mehitzig et ál., en su estudio con pacientes con lm con más de un año evolución, determinaron la asociación entre la incidencia autorreportada de complicaciones de salud secundarias a la lesión medular con las variables edad, tiempo de evolución de la lesión y deficiencia. 164 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 jores predictores de esas variables (19), encontraron que el mejor predictor de la aparición de una complicación, particularmente las úlceras de presión, es la incidencia previa de dicha complicación aún en sobrevivientes de larga data. desde esta perspectiva, los autores argumentan que el desafío para los clínicos es evitar la tendencia a dar por sentado que estas complicaciones son comunes, es de su incumbencia no dejar pasar la oportunidad para prevenirlas, y que tal esfuerzo debe ser renovado con cada intervención. discapacidad: referente conceptual y evaluación desde el who-das ii el proceso de evolución de la concepción de la discapacidad ha mezclado situaciones de rechazo y negación, actuaciones de beneficencia, caridad y asistencia, llegando finalmente a la promoción de la aceptación plena de la persona, a través de acciones que fomenten la autonomía personal y la inclusión social. este proceso no se ha dado de una forma lineal ni con unos límites de tiempo específicos; de igual manera, no ha trascendido todas las esferas de la sociedad. en la actualidad es posible hablar de la coexistencia de “distintas visiones sobre la misma situación que indica la propia y natural limitación del ser humano, con la dificultad que supone para él aceptar la evolución conceptual” (37). los modelos biologistas asumen la discapacidad desde el punto de vista anatomofuncional. desde este modelo se privilegia la intervención en el sector salud a través de acciones terapéuticas individualistas y de carácter compensador para que la persona vuelva a ser útil y apta para vivir en sociedad. a partir de los modelos sociales se asume que aunque la discapacidad siempre tiene un sustrato biológico que determina las condiciones de funcionalidad de la persona, lo realmente importante es el papel que juegan el entorno social y el entorno creado por el hombre, donde las barreras físicas y sociales, los estereotipos y las actitudes, se convierten en los factores responsables de las situaciones de desventaja que experimenta la persona y las que definen en sí mismas la “situación de discapacidad”. en este sentido, hanh expresa que “el problema radica en el fracaso de sociedad y del entorno creado por el ser humano para ajustarse a las necesidades y aspiraciones de las personas con discapacidad y no en la incapacidad de dichas personas para adaptarse a las demandas de la sociedad” (38). por tanto, las intervenciones desde este modelo son responsabilidad de la sociedad buscando realizar adecuaciones sobre el entorno que faciliten la plena participación de las personas en situación de discapacidad en todas las esferas de la vida social. el modelo sociopolítico, como extensión del social, se conoce también como el modelo de discapacidad de las minorías (39). este incorpora en su filosofía la lucha por los derechos de las personas con discapacidad, quienes se definen a sí mismas como miembros de un grupo minoritario que ha estado sistemáticamente discriminado y explotado por la sociedad, promulgándose como un “colectivo colonizado” por la cultura médica, que impone sus criterios y define las situaciones de discapacidad y sus necesidades, partiendo para ello de la premisa de que la persona con discapacidad es incapaz para autodefinirse y autorregularse (28). el proceso de evolución de la concepción de la discapacidad ha mezclado situaciones de rechazo y negación, actuaciones de beneficencia, caridad y asistencia, llegando finalmente a la promoción de la aceptación plena de la persona, a través de acciones que fomenten la autonomía personal y la inclusión social. 165 lesiones medulares y discapacidad: revisión bibliográfica l claudia patricia henao-lema, julio ernesto pérez-parra el modelo busca la reivindicación de los derechos de las personas en situación de discapacidad que exigen representarse y decidir por sí mismas, y eliminar la dependencia, lograr la autonomía personal y la participación en igualdad de condiciones en la sociedad (40), planteando un paradigma de intervención socio-política contrapuesto al trazado bajo el modelo rehabilitador, con el objetivo de empoderar a la persona y lograr que sea protagonista de su vida (39). desde el modelo biopsicosocial que soporta la clasificación internacional del funcionamiento, la discapacidad y la salud (cif) (28), la discapacidad se asume como un proceso continuo de ajuste entre las capacidades del individuo con una condición de salud específica y los factores externos que representan las circunstancias en las que vive esa persona, y las expectativas y exigencias de su entorno. en este contexto, la discapacidad deja de tener un carácter individual, ya que afecta directamente la familia y a la sociedad. clasificación internacional del funcionamiento, la discapacidad y la salud (cif) dentro de esta clasificación, la expresión funcionamiento humano se utiliza para designar todas las funciones y estructuras corporales, la capacidad de desarrollar actividades y la posibilidad de participación social del ser humano. la discapacidad, por el contrario, recoge las deficiencias en las funciones y estructuras corporales, las limitaciones en las actividades y las restricciones en la participación; en tanto el término salud se configura como el elemento clave que relaciona el funcionamiento humano con la discapacidad (28). bajo este enfoque, la oms abandona el enfoque de “consecuencias de la enfermedad” de la clasificación internacional de deficiencias, discapacidades y minusvalías (ciddm), para enfocar el objetivo hacia “la salud y los estados relacionados con la salud”. de esta forma, buscando una terminología más positiva, deja de emplear la palabra “enfermedad” para utilizar la expresión “estado o condición de salud”. la perspectiva biopsicosocial y ecológica de este enfoque se hace evidente con la inclusión de los factores contextuales, en tanto factores ambientales y personales que pueden influir tanto de forma negativa (barreras) como positiva (facilitadores) en la discapacidad y en la condición de salud. el esquema conceptual de la cif que se presenta en la figura 1 representa las múltiples interacciones entre las dimensiones y áreas que representan la discapacidad. de este esquema es posible deducir que (41): l los estados de salud tienen consecuencias en todos los componentes del funcionamiento (corporal, actividad y participación). a su vez, los componentes del funcionamiento tienen directa repercusión sobre los estados figura 1. modelo conceptual de discapacidad de la cif. tomada de: organización mundial de la salud (oms). clasificación internacional del funcionamiento, de la discapacidad y de la salud (cif). instituto de migraciones y servicios sociales, imserso, madrid; 2001. 166 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 de salud, en tanto que condicionan la posible aparición de nuevas alteraciones (trastornos o enfermedades). l los componentes del funcionamiento se relacionan, por pares, todos entre sí (cuerpo y actividad; cuerpo y participación; actividad y participación) y en ambos sentidos. los componentes del funcionamiento (todos y cada uno de ellos) se ven influidos por los factores contextuales, tanto ambientales como personales. al mismo tiempo, los factores contextuales pueden ser determinados por las circunstancias que acontezcan en los tres componentes del funcionamiento. la integralidad que sugiere este enfoque de abordaje abarca el planteamiento de procesos de intervención fundamentados en principios básicos de interdisciplinariedad e intersectorialidad, que exigen sobrepasar la mirada exclusiva desde el sector salud para involucrar de forma activa a la familia y los sectores educativo, laboral, de bienestar social y legislativo, entre otros, demandando además la participación activa de la sociedad y el estado. adicionalmente, es necesario que la persona en situación de discapacidad tenga un papel protagónico en la definición de sus necesidades y en la exposición de las expectativas que tiene frente al proceso. de esta forma, la persona se convierte en el eje de trabajo y, al mismo tiempo, es un miembro más del equipo. evaluación de la discapacidad bajo el enfoque de la cif desde su aprobación, la cif ha sido utilizada en diversos ámbitos de la rehabilitación especialmente en el área clínica. para garantizar y facilitar este proceso se han desarrollado diferentes propuestas de evaluación que hacen operativas las categorías originales mediante el desarrollo de instrumentos que permiten describir y evaluar el funcionamiento de las personas de acuerdo con diversas condiciones de salud o momentos específicos del proceso de rehabilitación. en la actualidad se cuenta con tres tipos de herramientas de evaluación compatibles conceptualmente con el modelo de discapacidad de la oms: la lista de comprobación breve de la cif (checklist), los conjuntos o las categorías básicas (core sets) y el who-das ii (world health organization disability assessment schedule ii) (42). la lista de chequeo es un instrumento sugerido para la aplicación en situaciones clínicas que a través de 125 ítems permite establecer de manera sencilla un perfil de funcionamiento y discapacidad de la persona en las áreas más relevantes. las categorías básicas de la cif son conjuntos o grupos de ítems de evaluación específicos para la valoración de personas con condiciones de salud de alta carga global por enfermedad. hasta el momento se han desarrollado core sets para doce condiciones de salud en las áreas musculoesquelética, cardiovascular, neurológica y oncológica (42). el who-das ii, por su parte, es un instrumento que evalúa de forma multidimensional el funcionamiento y la discapacidad con énfasis en las áreas de actividad y participación, y permite obtener una puntuación global del grado de discapacidad; su gran ventaja es que puede ser aplicado de manera universal a todas las “condiciones de salud” (43, 44). este instrumento posibilita la definición de un perfil de funcionamiento de la persona a través de seis dominios de actividades, como también un puntaje de la discapacidad en general, información que puede las categorías básicas de la clasificación internacional del funcionamiento son conjuntos o grupos de ítems de evaluación específicos para la valoración de personas con condiciones de salud de alta carga global por enfermedad. 167 lesiones medulares y discapacidad: revisión bibliográfica l claudia patricia henao-lema, julio ernesto pérez-parra ser utilizada para identificar necesidades, programar y controlar los procesos de intervención y medir los resultados y la efectividad de los tratamientos (45). los dominios incluidos en el instrumento son a) comprensión y comunicación, b) cuidado personal, c) capacidad de relacionarse con otras personas, d) actividades de la vida diaria y, e) participación en sociedad (39). el who-das ii puede ser aplicado a personas con antecedentes culturales y educacionales, y niveles cognoscitivos marcadamente diferentes. actualmente, hay disponible una versión en lengua española del who-das ii (44), desarrollada y validada por la unidad de investigación en psiquiatría de cantabria del hospital universitario “marqués de valdecilla”, españa, centro colaborador de la oms. el who-das ii ha sido ampliamente utilizado en la valoración de discapacidad asociada a diferentes tipos de condiciones clínicas (46-50). evaluación de la discapacidad asociada a la lesión medular tradicionalmente, la evaluación de las personas con lesión medular se ha realizado sobre la base de la determinación de las deficiencias corporales y, asociadas a ellas, aspectos relacionados con la funcionalidad del individuo en su vida diaria. la lesión medular no sólo afecta los aspectos físicos de la persona, en la mayoría de los casos tiene una importante repercusión en sus esferas psicológica y social. idealmente, estas situaciones deben ser condensadas en una sola evaluación que de manera integral permita establecer la condición global del individuo, fundamento esencial de un proceso de intervención ajustado a las necesidades reales de este grupo poblacional. desde los aspectos básicamente funcionales se han utilizado instrumentos como el asia impairment scale (ais) (4, 8, 10, 12, 17, 19, 20, 33, 36, 51, 52), el functional indepedence measures (fim) (8, 17, 18, 20, 51, 53), the spinal cord independence measure (scim) (54) y la escala de frankel (5, 55), entre otras. desde una perspectiva social, el instrumento más utilizado es el craig handicap assessment and reporting technique (chart) (8, 23, 52, 56). otros autores reportan el uso de instrumentos como el cuestionario de evaluación de hábitos de vida (life-h) y el cuestionario del impacto de la participación sobre la autonomía (ipaq) (56). para evaluar la calidad de vida en personas con lesión medular se han aplicado instrumentos como el medical outcomes study short-form 36 (sf-36) (20, 57) y medical outcomes study short-form 12 (sf-12) (57), el life situation questionnaire (lsq) (34), el quality of life scale (qols) (58), el módulo de calidad de vida relacionada con la salud o behavioral risk factor surveillance system (brfss), la escala quality of well-being (qwb), el instrumental activities of daily living (iadl) (23, 57), la satisfaction with life scale (swls) (19) y el índice de barthel (9), entre otros. no se conocen hasta el momento estudios que integren en una sola herramienta de medida la valoración de la discapacidad asociada a la lesión medular bajo un enfoque biopsicosocial. en la literatura se encuentra reportado un estudio realizado en venezuela donde se evaluó la lesión medular desde la clasificación internacional de deficiencia, discapacidad y minusvalía (ciddm) (31), vigente en la oms hasta los años noventa, el cual se fundamenta claramente en un enfoque médico-biológico de la discapacidad. por otra parte, recientemente se publicaron dos propuestas de categorías básicas de la lesión medular no sólo afecta los aspectos físicos de la persona, en la mayoría de los casos tiene una importante repercusión en sus esferas psicológica y social. 168 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 la cif (core sets) desarrolladas exclusivamente para personas con lesión medular (59, 60). estos core sets plantean aspectos del funcionamiento y la discapacidad que deben identificarse en las personas con lesión medular bajo la perspectiva de la cif (61). a partir de este análisis los investigadores proponen una serie de áreas y categorías que deben ser evaluadas en la fase subaguda (59) y crónica de la lesión (60). los investigadores, a través de un proceso que involucró entrevista y consenso de profesionales de la salud, estudios de campo y revisión sistemática de la literatura, definieron dos tipos de core sets para aplicación en los diferentes contextos de rehabilitación de la lesión medular, los denominados comprehensive icf core sets (59, 60, 61) para evaluaciones integrales de carácter multidisciplinar, y los brief icf core sets (59, 60, 61), útiles para que los profesionales de la salud puedan establecer un perfil general de los problemas en el funcionamiento de las personas con lesión medular. cabe aclarar que estos core sets no se consideran instrumentos de evaluación o medida en sí mismos, puesto que se constituyen únicamente en un listado de diferentes ítems de la cif, desde los niveles corporal, personal y social, que se sugiere sean medidos en las personas con lesión medular para determinar sus diferentes niveles de funcionamiento. de esta manera, los core sets proponen que debería medirse en una condición de salud y no como debe hacerse dicha medición. es claro que la evaluación de la lesión medular no puede limitarse a establecer las deficiencias corporales, asimismo es insuficiente la consideración exclusiva del impacto que la lesión tiene en la realización de las actividades básicas cotidianas del individuo sin la exploración de los roles individuales o de las expectativas que tiene la persona en cuanto a su vida futura y el papel que el entorno juega en la dinámica interna de la situación de discapacidad. debido al gran impacto que produce la lesión medular en el individuo, la utilización de herramientas de medida aisladas y desarticuladas no proporciona suficiente evidencia acerca del grado y la forma como es vivida la discapacidad en cada una de las personas. es necesario trascender a la aplicación de medidas que den información más integral, como puede ser la proporcionada por el who-das ii, instrumento compatible con un modelo biopsicosocial de abordaje de la discapacidad. relaciones entre aspectos asociados a la lesión medular y discapacidad en los últimos años un número importante de autores se han interesado por estudiar el curso de la lesión medular de acuerdo con las características sociodemográficas y clínicas de esta población, y su relación con la discapacidad y la recuperación funcional posterior (5, 8, 10, 13, 18, 19, 23, 33, 34, 36, 62). respecto a la relación entre sexo y discapacidad, sipski et ál. evaluaron las diferencias en variables neurológicas y funcionales en hombres y mujeres con lesión medular, encontrando que las mujeres mostraron una mejor recuperación neurológica natural que los hombres, sin embargo, en un nivel y grado de lesión neurológica determinado, los hombres tienden a tener mejor funcionalidad que las mujeres al final del proceso de rehabilitación (esto ya se dijo en la página 7) (8). por su parte, krause y broderick, en una muestra de 512 personas con lesión medular, de las cuales el 40% eran mudebido al gran impacto que produce la lesión medular en el individuo, la utilización de herramientas de medida aisladas y desarticuladas no proporciona suficiente evidencia acerca del grado y la forma como es vivida la discapacidad en cada una de las personas. 169 lesiones medulares y discapacidad: revisión bibliográfica l claudia patricia henao-lema, julio ernesto pérez-parra jeres, no encontraron diferencias entre personas de sexo masculino y femenino respecto a la puntuación obtenida en el chart (craig handicap assessment and reporting technique) (23). respecto a las relaciones entre edad, tiempo de evolución, nivel y severidad de la lesión con discapacidad, charlifue y gerhart construyeron un modelo de regresión para determinar el mejor predictor de los puntajes de cada una de las cinco dimensiones del chart y de su puntaje total en personas envejeciendo con lesión medular, a partir de variables demográficas y clínicas (edad, duración de la lesión y grupo neurológico) (62). encontraron que desde los resultados del chart, la edad es un factor que predice la integración social, el grupo de lesión (paraplejía o tetraplejía completa / incompleta) y la independencia física. un modelo que incluye tanto edad como grupo de lesión predice la movilidad, la ocupación y el puntaje del chart total como medida de integración a la comunidad. ninguna de las variables demográficas fue predictora del puntaje de la subescala de autosuficiencia económica. la duración de la lesión no fue predictora de ningún puntaje. por su parte, charlifue et ál. documentaron el impacto del estado civil, la edad de ocurrencia de la lesión, el tiempo de evolución, su severidad (completitud y nivel neurológico), el manejo de la vejiga y la existencia de complicaciones previas sobre variables físicas y psicosociales de personas envejeciendo con lesión medular. a partir de su análisis reportaron, entre otros hallazgos, que los únicos predictores significativos de las úlceras por presión fueron la presencia previa de úlceras y la mayor severidad de la lesión. el número de rehospitalizaciones fue predicho por la mayor severidad de la lesión, por la presencia de una sonda permanente, y por las hospitalizaciones previas. el análisis de grupos en función del tiempo de evolución de la lesión indicó que hubo una leve pero importante disminución de la autopercepción del estado de salud en quienes llevan más tiempo viviendo con la lesión (19). mccoll et ál. cuantificaron la relación entre tres grupos de factores: demográficos, relacionados con salud y discapacidad y calidad de vida, a través de un modelo estructural de relaciones lineales. este modelo muestra que la edad y la presencia de problemas de salud y relacionados con la discapacidad tiene efectos negativos, tanto directos como indirectos, sobre la calidad de vida. de la misma manera, la percepción negativa de envejecimiento prevaleció más entre los participantes más jóvenes y con menor duración de discapacidad que entre aquellos mayores (36). por su parte, franceschini et ál. encontraron que la autonomía en personas con lesión medular se asocia significativamente con el nivel de lesión, pero no con la completitud y la etiología (5). amsters et ál. encontraron que un número significativo de personas con lesión medular perciben que su nivel de funcionalidad se incrementa entre el alta de su proceso inicial de rehabilitación y los diez años poslesión y, subsecuentemente, disminuye entre este tiempo y los veinte o más años de duración de la lesión medular (18). en este mismo sentido, krause y coker, a través de la aplicación del life situation questionnaire (lsq), cuestionario que evalúa educación y empleo, actividades y participación, tratamientos recientes, autopercepción de ajuste y satisfacción con la vida en personas con lesión medular, hallaron que los principales cambios positivos ocurren en las primeras dos décadas después de la lesión medular, seguido de un periodo de estabilidad en algunas áreas de la vida, pero declinan con el envejecimiento en algunos aspectos relacionados con la participación y la salud (34). charlifue et ál. documentaron el impacto del estado civil, la edad de ocurrencia de la lesión, el tiempo de evolución, su severidad (completitud y nivel neurológico), el manejo de la vejiga y la existencia de complicaciones previas sobre variables físicas y psicosociales de personas envejeciendo con lesión medular. 170 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 conclusiones estos estudios demuestran que la edad de ocurrencia de la lesión, el sexo, la presencia de complicaciones, el tiempo de evolución y la severidad de la lesión, entre otros, son variables que condicionan la situación de discapacidad y el funcionamiento de las personas, por tanto, son aspectos que deben tenerse en cuenta al plantear tanto la evaluación como la intervención de esta población. un abordaje que involucre aspectos físicos, psicológicos y sociales asociados a esta condición de salud serviría de referencia para fijar políticas, programas y acciones, que trasciendan los enfoques tradicionales de carácter asistencial y terapéutico, a propuestas más integradoras enfocadas a intervenir el funcionamiento 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cieza a, kirchberger i, biering-sorensen f, baumberger m, charlifue s, post m. icf core sets for individuals with spinal cord injury in the long-term context. spinal cord advance online publication, 12 january; 2010. 61. biering-sorensen f, scheuringer m, baumberger m, charlifue sw, post mwm, montero f. developing core sets for persons with spinal cord injuries based on the international classification of functioning, disability and health as a way to specify functioning. spinal cord 2006; 44: 541-6. 62. charlifue s, gerhart k. community integration in spinal cord injury of long duration. neurorehabilitation 2004; 19: 91-101. 53 61 la adherencia al autocuidado.indd 53 madeleine cecilia olivella-fernández1 clara victoria bastidas-sánchez2 myriam angelica castiblanco-amaya 3 la adh erencia al autocuidado en personas con enfermedad cardiovascular: abordaje desde el modelo de orem 1 magister. universidad del tolima, colombia. mcolivel@ut.edu.co 2. magister. universidad del tolima, colombia. 3. magister. directora programa de enfermeria, universidad del tolima, colombia. recibido: 10 de marzo de 2011 aceptado: 20 de febrero de 2012 resumen objetivo: el presente artículo constituye una actualización del papel fundamental de los profesionales de enfermería en el cuidado de las personas con enfermedad crónica de origen cardiovascular. método: se abordan dos aspectos importantes: la adherencia y el autocuidado. esta revisión pretende trascender la visión biomédica con que se originó la concepción de adherencia terapéutica por una mirada integradora del autocuidado. resultados: se aclara el significado del autocuidado al presentar una desviación de la salud como un sistema integrador que permite al enfermo ser competente en su autocuidado —desde el diagnóstico y durante toda la trayectoria de la enfermedad—, permitiéndole aplicar el conocimiento relevante o significativo brindado por los prestadores de salud, y que es necesario para mantenerse estable. conclusiones: se presenta la complejidad del autocuidado desde el quehacer de enfermería, abordando el modelo de orem que constituye un aporte disciplinar importante y una opción de vida para la persona que padece enfermedad cardiovascular. palabras clave autocuidado, enfermería, enfermedad cardiovascular, teoría de enfermería (fuente: decs, bireme). adherence to self-care among persons with cardiovascular disease: an approach based on the orem model of nursing abstract objective: the following article constitutes an update on the fundamental role of nursing professionals in providing care to persons suffering from a chronic illness of cardiovascular origin. method: two important aspects are addressed: adherence and self-care. the año 12 vol. 12 nº 1 chía, colombia abril 2012 l 53-61 54 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 aim of this review is to go beyond the biomedical vision that gave rise to the concept of therapeutic adherence and to move towards a more comprehensive idea of self-care. results: the meaning of self-care is clarified by presenting health as an integrating system that affords the patient competence for his/her own care -beginning with diagnosis and continuing throughout the entire course of the illness by allowing the patient to apply relevant or significant knowledge that is supplied by health care providers and necessary to keep the patient stable. conclusions: the complexity of self-care is examined in light of the work of nursing, with a look at the orem model, which represents an important contribution to the discipline and a life-style option for the person with a cardiovascular disease. key words self-care, nursing, cardiovascular disease, nursing theory (source: decs, bireme). a aderência ao autocuidado em pessoas com doença cardiovascular: uma abordagem a partir do modelo de orem resumo objetivo: o presente artigo constitui uma atualização do papel fundamental dos profissionais de enfermagem no cuidado das pessoas com doença crônica de origem cardiovascular. método: abordam-se dois aspectos importantes: a aderência e o autocuidado. esta revisão pretende transcender a visão biomédica com a qual se originou a noção de aderência terapêutica por um olhar integrador do autocuidado. resultados: esclarece-se o significado do autocuidado ao apresentar um desvio da saúde como um sistema integrador que permite ao doente ser competente em seu autocuidado – desde o diagnóstico e durante toda a trajetória da doença – permitindo-lhe aplicar o conhecimento relevante ou significativo promovido pelos prestadores de saúde, e que é necessário para se manter estável. conclusões: apresenta-se a complexidade do autocuidado a partir da tarefa da enfermagem, abordando o modelo de orem que constitui uma contribuição disciplinar importante e uma opção de vida para a pessoa que padece doença cardiovascular. palavras-chave autocuidado, enfermagem, doença cardiovascular, teoria de enfermagem (fonte: decs, bireme). 55 la adherencia al autocuidado en personas con enfermedad cardiovascular: abordaje desde el modelo de orem l madeleine cecilia olivella-fernández, y otros. realidad del problema cada día aumentan los datos de morbilidad y mortalidad relacionados con el incremento de la enfermedad crónica. en colombia los indicadores reportados por el ministerio de protección social evidencian cómo las tasas de mortalidad por enfermedades crónicas de tipo cardiovascular superan otras causas de muerte incluyendo: la violencia, las enfermedades transmisibles, las lesiones neoplásicas y constituyen el 86.9% de la mortalidad general. el fenómeno de la enfermedad cardiovascular afecta por igual a las personas de los países industrializados y no industrializados. para el caso de norteamérica el panorama no es más alentador, esta enfermedad constituye una seria amenaza a la salud y a la esperanza de vida de las personas (3). "más de 5 millones de norteamericanos tienen insuficiencia cardiaca, y la incidencia sigue creciendo tanto en hombres como en mujeres, con más de 500.000 nuevos casos por año" (4). “los costos en el 2007 excedieron los 33 millones de dólares. además de la carga económica de la hospitalización, el número de hospitalizaciones por insuficiencia cardiaca se interpreta como un predictor de mortalidad” (4). la carga que genera la enfermedad cardiovascular se caracteriza por la gravedad de los síntomas, los tratamientos que requieren la toma de un gran número de medicamentos diarios, y la adopción de nuevas formas de vida que afectan la cotidianidad (5), la intimidad y las costumbres; todo esto hace que el enfermo sienta una gran demanda de la enfermedad, lo que vuelve más lejano el logro de un estado de salud estable, llegando así más rápidamente a una nueva hospitalización. asimismo, la enfermedad cardiovascular ocasiona otro tipo de problemas como son disminución de la capacidad funcional, aislamiento social y aumento en las hospitalizaciones, factores estos determinantes en el aumento de los costos de la salud. en el caso específico de las personas con enfermedad cardiovascular, muchas complicaciones podrían prevenirse o tratarse a tiempo con la inclusión de comportamientos de autocuidado que entren a modificar aquellas conductas detectadas como riesgo. entre estas conductas de autocuidado podrían citarse el control diario del peso, la disminución de la ingesta de sodio, el ejercicio cardiovascular mínimo tres veces a la semana, la toma de la medicación en las dosis y los horarios establecidos, entre otras, que son conductas cotidianas consideradas como “la piedra angular del tratamiento para los pacientes con enfermedades cardiovasculares” (2, 4, 5). sin embargo, en la rutina de los programas para la detección de las alteraciones del adulto mayor de 45 años que se llevan a cabo en nuestro país, los controles hacen énfasis en la valoración de la toma de medicamentos, cuando con el mismo esfuerzo se podría lograr que la persona se adhiera a todas las conductas necesarias para el mantenimiento de la salud, es decir, al autocuidado, como un comportamiento multidimensional determinado de una manera holística (6). el fomento del autocuidado se concreta en una serie de acciones que la persona (paciente) debe asumir sin la vigilancia, el apoyo y el seguimiento diario del prestador de salud. el control y seguimiento de estas recomendaciones se hará solamente en cada cita mensual, para saber cómo va la evolución. en la práctica se observa que las recomendaciones brindadas por el prestador de salud se quedan en la buena intención del enfermo. los pacientes se enfrentan a menudo con la terrible realidad de que muchos de estos cambios son difíciles, si no abrumadores de hacer. cambios en hábitos alimentarios y patrones de ejercicio son un reto para la mayoría. aprender a tomar múltiples medicamentos y el reconocimiento de los síntomas puede ser difícil, si no imposible, para algunos pacientes (por ejemplo, las personas de edad avanzada y las personas con baja alfabetización en salud) (7). fomentar la adherencia al autocuidado como elemento fundamental para afrontar las molestias que ocasiona este grupo de enfermedades permite mejorar la calidad y esperanza de vida del enfermo, reduciendo la morbilidad y la mortalidad (1, 4). es imperativo que los profesionales de enfermería reconozcan la magnitud del daño que la enfermedad cardiovascular ocasiona en la población, pero es mucho más importante que estén convencidos de lo que se puede lograr con acciones dirigidas a fomentar el autocuidado de las personas que viven con este flagelo. para esto, el fomento del autocuidado se debe adoptar como una estrategia para enfrentar los síntomas, prevenir las recaídas y aumentar la expectativa y la calidad de vida del enfermo. el fomento del autocuidado el fomento del autocuidado generalmente se queda en una simple lista de tareas y es a “menudo olvidado debido principalmente a que se centra en algo que el enfermo domina, en lugar 56 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 de algo que el personal del sistema de asistencia sanitaria o los proveedores de servicios de salud, pueden controlar y proveer, especialmente en las personas no hospitalizadas”. sin embargo, los investigadores han demostrado que el fomento del autocuidado que promueve la adherencia del paciente puede reducir la morbilidad y la mortalidad (2, 4, 7, 8) y, por tanto, puede optimizar los resultados clínicos (3). seguir adecuadamente el tratamiento hace parte del éxito en el mantenimiento de la salud en las enfermedades cardiovasculares (9, 10); no obstante, esta sola actividad no garantiza la no reaparición de síntomas. frente al aumento de las enfermedades de origen cardiovascular se han planteado soluciones ligadas al avance de las tecnologías biomédicas, los tratamientos quirúrgicos y farmacológicos que pretenden, si no proporcionar la curación, al menos proveer elementos rápidos de mejoría; la persona que vive esta situación de salud espera a menudo respuestas desde la medicina que mejoren su estado (11, 12). pero la realidad es otra, las enfermedades cardiovasculares ofrecen un panorama típico de la cronicidad caracterizado por el desequilibrio y la incertidumbre, en donde la persona es en gran medida responsable de su salud. el reto para estas personas “radica en la capacidad para cuidar de sí mismos, reconocer y manejar sus síntomas, adherirse a un régimen de tratamiento muy complejo, y adaptar los mecanismos existentes o establecer nuevos comportamientos de conducta para mejorar la salud o prevenir las exacerbaciones”. (5). el autocuidado se convierte así en una medida alentadora y eficaz para hacer frente a la enfermedad. infortunadamente, la literatura disponible sobre la eficacia de los programas que imparten los proveedores de asistencia sanitaria dirigida a los pacientes en relación con el autocuidado es limitada (3). la importancia de fomentar el autocuidado como función disciplinar radica en que “cuidar de sí mismo es una construcción especialmente importante debido a que capta la esencia de nuestra filosofía y una dimensión clave de nuestra práctica” (13, 14). desde la enfermería se puede alentar a las personas a direccionar su autocuidado y, sobre todo, a demostrar que este es posible; esto repercutirá en un mejor estado de salud para muchas personas. se requiere, entonces, implementar y probar acciones que lo muestren. las pocas intervenciones probadas son prometedoras, pero se necesita investigación adicional. en este sentido, es pertinente utilizar el modelo de orem con sus tres teorías: la del autocuidado, la teoría del déficit de autocuidado, y la teoría del sistema de enfermería como estrategia para abordar e intervenir a aquellas personas con enfermedad cardiovascular y fomentar el autocuidado como un todo, aportando elementos disciplinares para intervenir un problema real que afecta a la población mundial. la utilización del modelo de orem permite, además, generar un marco teórico que guíe la investigación, con el fin de limitar la conceptualización en un tema como el autocuidado que puede prestarse a confusión. “un elemento confuso de la literatura relacionada con el concepto de cuidar de sí mismo, es el uso de terminología variada e inconsistente: cuidados personales, autocuidado, automonitorización, autorregulación, la adhesión y el cumplimiento, todos estos se utilizan indistintamente, a menudo dentro de la misma fuente” (13). según este modelo, “el autocuidado es la práctica de actividades que los individuos inician y realizan para el mantenimiento de su propia vida, salud y bienestar” (13), algunas de ellas pueden ser prescritas por el médico y otras no (13). entre estas actividades estaría, como se mencionó, la toma del medicamento, el control de peso, la dieta baja en sal, el ejercicio, entre otras. entender el autocuidado en su esencia requiere reconocer las premisas sobre las que se basa la teoría: el autocuidado es una conducta, una actividad aprendida. las personas adultas tienen el derecho y la responsabilidad de cuidar de sí mismas para mantener la vida racional y la salud. al reconocer que el autocuidado es una conducta, se convierte en un hecho real, en una acción fruto del aprendizaje, en donde interactúan el profesional de enfermería y la persona o ser cuidado. en este sentido, se requiere de la participación de enfermería como servicio humano que satisface los requerimientos de la vida diaria de la persona con una alteración de la salud específica y, por parte de la persona cuidada, la comprensión de una serie de tareas que debe realizar a diario. para que estas actividades sean asimiladas debe mediar un proceso educativo en donde se orienten y supervisen las acciones antes de ser realizadas en forma autónoma por la persona en su casa. 57 la adherencia al autocuidado en personas con enfermedad cardiovascular: abordaje desde el modelo de orem l madeleine cecilia olivella-fernández, y otros. en la formación del profesional de enfermería se deben brindar los elementos del modelo de orem para poder interactuar de una manera natural al brindar educación a la persona cuidada. seguidamente se planteará una aproximación a la aplicación del modelo de orem a una persona con enfermedad cardiovascular. abordaje del autocuidado desde el modelo de orem en este abordaje se tomarán diferentes elementos de cada una de las teorías del modelo de orem. en la última revisión hecha por el nursing development conference group al modelo de orem se definen una serie de factores inherentes a la persona y a su entorno que condicionan de diversa manera las demandas de autocuidado terapéutico. estos factores son: edad, sexo, estado de desarrollo, estado de salud, orientación sociocultural, factores del sistema de cuidados de salud (diagnóstico y modalidades de tratamiento), factores del sistema familiar, patrón de vida —incluyendo actividades de la rutina diaria—, factores ambientales, y disponibilidad y adecuación de recursos. en la vivencia del paciente con enfermedad cardiovascular se deben valorar estos factores, que pueden ser internos o externos a la persona, pero que afectan directamente la capacidad para ocuparse del cuidado propio. es fundamental, además, que los profesionales de enfermería valoren cómo cada uno de estos factores influencia y determina la experiencia de la enfermedad y, a su vez, cómo pueden afectar positiva o negativamente el desarrollo y empoderamiento del autocuidado. para el desarrollo y la implementación de medidas diarias de autocuidado se requiere la valoración de esta capacidad en la persona, lo que orem define como la agencia de autocuidado, necesaria y acorde a las limitaciones propias de la capacidad funcional de las personas que padecen una enfermedad cardiovascular. es pertinente resaltar que, para abordar su autocuidado, las personas que viven en situación de cronicidad deben conocer además cuáles son los requisitos de autocuidado relacionados con la enfermedad que padecen, a partir de las medidas de cuidados prescritas o realizadas por los médicos (13), que pueden ser diagnósticas o relacionadas con el tratamiento. orem define seis categorías de requisitos de autocuidado (13): 1. buscar y asegurar la ayuda médica adecuada en el caso de exposición a agentes físicos o biológicos específicos, o a condiciones ambientales asociadas con acontecimientos y estados humanos patológicos, o condiciones psicológicas que se sabe que producen o están asociadas con patología humana. 2. tener conciencia y prestar atención a los efectos y resultados de estados patológicos, incluyendo los efectos sobre el desarrollo. 3. llevar a cabo las medidas diagnósticas, terapéuticas y de rehabilitación prescritas, dirigidas a prevenir tipos específicos de patología, a la propia patología o a la regulación del funcionamiento humano integrado, a la corrección de deformidades o anomalías, o a la compensación de incapacidades. 4. tener conciencia y prestar atención o regular los efectos de las medidas de cuidados prescritas por el médico que producen malestar o deterioro. 5. modificar el autoconcepto (y la autoimagen) para aceptarse uno mismo como ser humano con un estado de salud particular y necesitado de formas específicas de cuidados de la salud. 6. aprender a vivir con los efectos de las condiciones y los estados patológicos y los efectos de las medidas de diagnóstico y tratamiento médico, con un estilo de vida que fomente el desarrollo personal continuado. si el enfermo reconoce cuáles son los requisitos de autocuidado específicos que requiere en su situación de desviación de la salud, podrá hacerse competente para abordar su autocuidado y aplicar el conocimiento relevante que le es brindado por los prestadores de salud. en este sentido, la responsabilidad de enfermería radica en conocer y calcular cuál es la demanda de autocuidado terapéutico que tiene cada persona. el concepto de demanda de autocuidado terapéutico fue introducido en 1970 (13); antes de esto se usaban los términos demanda de acción y demanda de autocuidado para referirse a la cantidad y el tipo de cuidados que las personas deberían realizar o habían realizado para sí mismas dentro de un marco temporal. 58 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 la demanda de autocuidado terapéutico puede estar influenciada por los llamados factores básicos condicionantes (13). la demanda de autocuidado terapéutico varía de acuerdo con los requisitos del mismo, de allí la necesidad de conocer en primera estancia cuáles son los requerimientos de autocuidado para cada condición de desviación de la salud y en particular en cada persona. esto representa un amplio escenario para la investigación y producción de conocimiento enfermero, especialmente porque el autocuidado puede resultar gravoso y a veces abrumador para los individuos. un buen diseño de la demanda de autocuidado terapéutico puede disminuir el estrés de las actividades para satisfacerlo (13). a continuación se tratarán algunos elementos de interés enunciados en la teoría de orem para la persona con alteración cardiovascular: respecto a los factores básicos condicionantes es importante tener en cuenta cómo influyen directamente sobre la persona con enfermedad cardiovascular, entre ellos están la edad (mayores de 45 años), el sedentarismo (la falta de actividad física cardiovascular mínimo tres veces a la semana), las alteraciones relacionadas con la aparición de patologías crónicas para adultos mayores de 45 años (diabetes, hipertensión arterial, entre otras), factores del sistema de cuidado de salud específicamente en la modalidad de tratamiento (el gran número de medicamentos que tiene que tomar la persona para mantener controlada la enfermedad). la capacidad de la agencia de autocuidado definida por orem como la habilidad para ocuparse de sí mismo puede estar relacionada directamente con la capacidad funcional del enfermo y depende del tamaño de la lesión en el músculo cardiaco, lo que repercute en la realización de las actividades de la vida diaria. cualquier aumento en las demandas de actividad física va a recaer directamente sobre el deterioro de la capacidad funcional, limitando el poder hacer o no la actividad. este mismo deterioro influye en la capacidad de autocuidado del enfermo. en el cuadro 1 se tratarán los requisitos de autocuidado en la desviación de la salud para la persona con enfermedad cardiovascular. en este sentido, al esclarecer cuáles son las demandas específicas de autocuidado de la persona con enfermedad cardiovascular se requerirá de un cambio generalmente radical en el estilo de vida que incluye acciones diarias para el manejo de la enfermedad. los programas de manejo incluyen la educación sobre el autocuidado y el comportamiento de las acciones de vigilancia (14) (especialmente amplios mensajes acerca de tomar las medicinas como se ordena, hacer ejercicio con regularidad, una dieta baja en sodio, el seguimiento diario de valores de peso, la comunicación sobre empeoramiento de los síntomas a los proveedores de asistencia sanitaria); sin embargo, el nivel de intensidad y la atención a estos aspectos del autocuidado en una intervención multimodal son poco conocidos (3). las lagunas en el conocimiento enfermero abarcan todos los temas de autocuidado estudiados (toma de medicamentos, control de líquidos, cuidados con la dieta, ejercicio y la identificación temprana de síntomas) (15, 16). "la falta de resultados de investigación sobre estos temas dificulta a los profesionales de la salud el poder conocer cuál es la información definitiva, más importante que se debe suministrar y esto repercute para que las instituciones cada día reduzcan el tiempo asignado a la educación y a la adquisición de capacidades de estos comportamientos de autocuidado, se necesitan estudios controlados, aleatorizados, multicéntricos para ofrecer información más completa, así como pruebas de lo que significa el empoderarse realmente del autocuidado y de lo que el fomento del autocuidado integrador puede hacer como estrategia de ayuda a la persona para afrontar la cronicidad . el área de autocuidado a pacientes crónicos es aquella en la que las enfermeras podrían ser los principales investigadores" (5). agradecimientos las autoras expresan especial agradecimiento a la profesora maría mercedes durán de villalobos por su orientación en el desarrollo del presente artículo. 59 la adherencia al autocuidado en personas con enfermedad cardiovascular: abordaje desde el modelo de orem l madeleine cecilia olivella-fernández, y otros. requisito de autocuidado en desviación de la salud buscar y asegurar la ayuda médica adecuada en el caso de exposición a agentes físicos o biológicos específicos o a condiciones ambientales asociadas con acontecimientos y estados humanos patológicos, o condiciones psicológicas que se sabe que producen o están asociadas con patología humana. tener conciencia y prestar atención a los efectos y resultados de estados patológicos, incluyendo los efectos sobre el desarrollo. llevar a cabo efectivamente las medidas diagnósticas, terapéuticas y de rehabilitación prescritas, dirigidas a prevenir tipos específicos de patología, a la propia patología o a la regulación del funcionamiento humano integrado a la corrección de deformidades o anomalías o a la compensación de incapacidades. tener conciencia y prestar atención o regular los efectos de las medidas de cuidados prescritos por el médico que producen malestar o deterioro, incluyendo los efectos sobre el desarrollo. modificar el autoconcepto (y la autoimagen) para aceptarse uno mismo como ser humano con un estado de salud particular y necesitado de formas específicas de cuidados de la salud. aprender a vivir con los efectos de las condiciones y los estados patológicos, y los efectos de las medidas de diagnóstico y tratamiento médico, con un estilo de vida que fomente el desarrollo personal continuado. requisito de autocuidado de la persona con enfermedad cardiovascular buscar ayuda si presenta signos de alarma como: aumento de fatiga, ahogo, incremento de peso, palpitaciones, edemas de miembros inferiores (mmii) que no desaparecen. valorar conocimientos a cerca de los problemas propios de la patología: en caso de ser necesario reforzar los correctos, corregir los erróneos. es importante que la persona que padece la enfermedad cardiovascular reconozca los signos y síntomas que le indiquen que se está descompensando, lo que le va a permitir solicitar atención oportunamente. por ejemplo, en el aumento de peso y presencia de edema en mmii: distribuir o modificar el horario de diuréticos que no vayan a alterar su descanso y sueño. determinar el efecto de la mediación en el esquema de sueño. elevar cabecera de la cama para que disminuya la fatiga. conocer la composición de los alimentos y así disminuir la sal y redistribuir la cantidad y horas de comidas. importancia del autocuidado en: dieta baja en sal, actividad y ejercicio acorde a sus capacidades y a las limitaciones físicas del paciente. enseñarle la manera fácil de identificar intolerancia a la actividad o al ejercicio físico con: palpitaciones (arritmias), disnea, diaforesis, palidez, fr, de acuerdo con su capacidad funcional realizar la programación de actividad en el horario más adecuado, por ejemplo, en las mañanas, y no realizarlo después de haber hecho otra actividad como la ingesta de alimentos. ayudar al paciente a establecer los periodos de descanso acordes sus las capacidades y a la alarma de presencia de signos que le indiquen el grado de dificultad para realizarlo evitando ambientes y situaciones de alto riesgo. dentro de las medidas terapéuticas recomendadas por el médico se encuentran: dieta baja en sal, control de peso, realizar ejercicio, control de la presión arterial, triglicéridos, colesterol, glicemia, toma de medicamentos. estas recomendaciones pueden ser realizadas de forma eficaz, pero de igual manera pueden haber personas que no las realicen de la manera correcta. algunas de las formas del manejo ineficaz del régimen terapéutico pueden estar relacionadas con: complejidad del régimen terapéutico, déficit de conocimientos en cuanto a efectos secundarios, beneficios; la persona debe manifestar el grado de dificultad para poder realizar las recomendaciones. es importante que la persona evite conductas que puedan descompensarlo como son: la no ingesta de la medicación, dieta rica en sodio, ejercicio con alto grado de dificultad, aumento de peso los cuales agravan la patología y ocasionan recaídas que deterioran la calidad de vida. la persona con este tipo de patología debe identificar los resultados positivos cuando acoge el régimen terapéutico adecuado y cuando no, y así modificar la conducta desfavorable. la enfermedad cardiovascular como patología crónica requiere que la persona que padece la enfermedad acepte su condición, lo cual lleva inmersos unos cambios en su vida los cuales ella misma debe reconocer su benefici, entre ellos están: cambios en la nutrición, en la actividad física, en la ingesta de líquidos, en su aspecto físico (edema, disnea, ortopnea), recaídas que ocasionan hospitalizaciones repetidas, y la toma de gran cantidad de medicamentos. interiorizar esta cantidad de recomendaciones se puede observar en el grado de aceptación de padecer esta enfermedad y de su autocuidado. todos los cambios que tiene que realizar la persona que padece la enfermedad cardiovascular, no solamente en su estilo de vida sino en todos los aspectos que favorecen su condición de salud, se verán reflejados en su propio autocuidado. cambios que deben ser para siempre, no por el momento, y que de una u otra manera se modificarán de acuerdo al grado de complejidad de la patología. todos estos cambios le permiten a la persona aprender a vivir con sus limitaciones, pero de igual manera a optimizar otros aspectos que pueden ser útiles para su desarrollo personal. cuadro 1. requisitos de autocuidado en la desviación de la salud para la persona con enfermedad cardiovascular 60 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 referencias bibliográficas 1. sabate e. adherencia a los tratamientos a largo plazo: pruebas para la acción. oms; 2004. 2. swedberg k, cleland j, dargie h, et al. directrices para el diagnóstico y tratamiento de la insuficiencia cardiaca crónica: resumen ejecutivo (actualización 2005): el grupo de trabajo para el diagnóstico y tratamiento de la insuficiencia cardiaca crónica de la unión europea. eur heart j. 2005; 26 (11): 1115, 1140. 3. albert nm. promoting self-care in heart failure: state of clinical practice based on the perspectives of healthcare systems and providers. may/june 2008; 23 (3): 277-284. 4. granger b, sandelowski m, tahshjain hera, swedberg k, inger e. a qualitative descriptive study of the work of adherence to a chronic heart failure regimen patient and physician perspectives. journal of cardiovascular nursing 2009; 24 (4): 308 y 315. 5. rich m. management of heart failure in the elderly. heart fail rev 2002; 7: 89-97. 6. bonilla cp. adherencia y factores que influyen en la adherencia a tratamientos farmacológicos y no farmacológicos en personas que presentan factores de riesgo de enfermedad cardiovascular. bogotá: universidad nacional de colombia, editorial guadalupe; 2007. 7. evangelista ls, shinnick ma. what do we know about adherence and self-care? journal of cardiovascular nursing 2008; 23 (3): 250-257. 8. kutzleb j, reiner d. the impact of nurse-directed patient education on quality of life and functional capacity in people with heart failure. j am acad nurse pract 2006; 18: 116-123. 9. hunt sa, abraham wt, chin mh, et al. acc/aha. actualización de la orientación para el diagnóstico y manejo de insuficiencia cardiaca crónica en los adultos: un informe de la american college of cardiology / american heart asociación circulación 2005; 112 (12): e154 y 235. 10. tsuyuki rt, mckelvie rs, arnold jm, et al. acute precipitants of congestive heart failure exacerbations. arch intern med 2001; 161: 2337-2342. 11. schweitzer rd, head k, dwyer jw. psychological factors and treatment adherence behavior in patients with chronic heart failure. journal of cardiovascular nursing 2007; 22 (1): 76-83. 12. riegel b, vaughan v. a situation-specific theory of heart failure self-care. journal of cardiovascular nursing 2008; 23 (3): 190-196. 13. orem, de. modelo de orem. conceptos de enfermería en la práctica. barcelona: ediciones científicas y técnicas, savat; 1993. 14. moser mk, watkins jf. conceptualizing self-care in heart failure: a life course model of patient characteristics. j cardiovasc nurs 2008; 23: 205-218. 15. jovicic a, holroyd-leduc jm, straus s. effects of self-management intervention on health outcomes of patients with heart failure: a systematic review of randomized controlled trials. bmc cardiovasc dis 2006; 6: 43. 16. granger bb, swedberg k, ekman i, et al. adherence to candesartan and placebo and outcomes in chronic heart failure in the charm programme: double-blind, randomized, controlled clinical trial. lancet 2005; 366: 2005-2011. 61 la adherencia al autocuidado en personas con enfermedad cardiovascular: abordaje desde el modelo de orem l madeleine cecilia olivella-fernández, y otros. enlaces web de interés sobre autocuidado en enfermedades crónicas improving chronic illness care: www.improvingchroniccare.org institute for healthcare improvement: www.ihi.org health services management centre. university of birmingham: www.hsmc.bham.ac.uk international network of integrated care: www.integratedcarenetwork.org cdc preventing chronic disease journal: www.cdc.gov/pcd/index.htm stanford patient education research center: patienteducation.stanford.edu/ flinders human behaviour & health research unit: som.flinders.edu.au/fusa/cctu/home.html the oxford health alliance: www.oxha.org http://www.pacienteexperto.org/autocuidado.php. 1 brunno lessa saldanha xavier1 juliana faco amaral hermógenes2 yonara cristiane ribeiro3 ana carla silveira de sá4 fernanda maria vieira pereira ávila5 paula vanessa peclat flores6 sentidos e significados do tratamento conservador nas pessoas com doença renal crônica* 1 http://orcid.org/0000-0002-7431-9108. universidade federal fluminense, brasil. blessa@id.uff.br 2 https://orcid.org/0000-0002-6976-280x. universidade federal fluminense, brasil. 3 https://orcid.org/0000-0002-6868-1629. universidade federal fluminense, brasil. 4 https://orcid.org/0000-0003-4357-9369. universidade federal fluminense, brasil. 5 https://orcid.org/0000-0003-1060-6754. universidade federal fluminense, brasil. 6 https://orcid.org/0000-0002-9726-5229. universidade federal fluminense, brasil. * artigo extraído do trabalho de conclusão de curso intitulado: “as implicações do tratamento conservador no indivíduo com doença renal crônica”, da universidade federal fluminense, brasil, realizado em 2017. recebido: 10/03/2020 submetido a pares: 04/05/2020 aceito por pares: 20/05/2020 aprovado: 10/06/2020 doi: 10.5294/aqui.2020.20.3.5 to reference this article / para citar este artigo / para citar este artículo xavier bls, hermógenes jfa, ribeiro yc, sá acs, ávila fmvp, flores pvp. senses and meanings of conservative treatment in people with chronic kidney disease. aquichan. 2020;20(3):e2035. doi: https://doi.org/10.5294/aqui.2020.20.3.5 resumo objetivo: desvelar os sentidos e significados do tratamento conservador nas pessoas com doença renal crônica (drc). materiais e métodos: estudo descritivo, exploratório e com abordagem qualitativa. desenvolvido em 2017, com amostra de indivíduos com drc em tratamento conservador. utilizou-se de entrevista semiestruturada, e os dados foram analisados por meio de estatística descritiva simples e análise de conteúdo. resultados: participaram do estudo 25 indivíduos, dos quais 56 % são do sexo feminino; 52 % estão na faixa etária de 60 a 79 anos; 48 % são de etnia branca; 48 % não completaram o ensino fundamental, e apenas 12 % trabalham. a análise de conteúdo revelou duas categorias: restrição alimentar: angústias e impactos que repercutem no cotidiano dos pacientes com drc, e o imaginário social e o temor relacionados à terapia renal substitutiva. conclusões: os resultados revelaram que a dieta e o receio/temor acerca da terapia dialítica produzem incertezas, inquietude e insegurança, além de uma ampla e impactante modificação no viver das pessoas. palavras-chave (fonte: decs) insuficiência renal crônica; tratamento conservador; sentimentos; emoções; diálise renal; pesquisa qualitativa. año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2035 temática: cuidado crônico. contribuição para a disciplina: espera-se que esta pesquisa possa subsidiar estratégias de intervenção em saúde, a fim de identificar fatores que reverberam no viver do indivíduo com doença renal crônica, de modo a impulsionar a qualificação da assistência de enfermagem aos usuários. http://orcid.org/0000-0002-7431-9108 mailto:blessa@id.uff.br https://orcid.org/0000-0002-6976-280x https://orcid.org/0000-0002-6868-1629 https://orcid.org/0000-0003-4357-9369 https://orcid.org/0000-0003-1060-6754 https://orcid.org/0000-0002-9726-5229 https://doi.org/10.5294/aqui.2020.20.3.5 http://orcid.org/0000-0002-7431-9108 https://orcid.org/0000-0002-6976-280x https://orcid.org/0000-0002-6868-1629 https://orcid.org/0000-0003-4357-9369 https://orcid.org/0000-0003-1060-6754 https://orcid.org/0000-0002-9726-5229 https://doi.org/10.5294/aqui.2020.20.3.5 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2035 sentidos y significados del tratamiento conservador en personas con insuficiencia renal crónica* resumen objetivo: develar los sentidos y significados del tratamiento conservador en personas con insuficiencia renal crónica (erc). materiales y métodos: estudio descriptivo, exploratorio y con enfoque cualitativo. desarrollado en el 2017 con una muestra de individuos con erc en tratamiento conservador. se utilizó entrevista semiestructurada y los datos se analizaron mediante estadística descriptiva sencilla y análisis de contenido. resultados: participaron en el estudio 25 individuos, de los cuales 56 % son del sexo femenino; 52 % tienen entre 60 y 79 años; 48 % son de etnia blanca; 48 % no han terminado la educación básica y solo 12 % trabajan. el análisis de contenido evidenció dos categorías: restricción alimentaria, angustias e impactos que inciden en la cotidianidad de los pacientes con erc; y el imaginario social y el temor relacionados a la terapia renal sustitutiva. conclusiones: los resultados señalan que la dieta y el temor a la terapia dialítica generan incertezas, inquietud e inseguridad, además de un amplio e impactante cambio en el vivir de las personas. palabras clave (fuente: decs) insuficiencia renal crónica; tratamiento conservador; sentimientos; emociones; diálisis renal; investigación cualitativa. * artículo derivado de la monografía de grado titulada “as implicações do tratamento conservador no indivíduo com doença renal crônica”, en la universidade federal fluminense, brasil, realizado en el 2017. 3 sentidos e significados do tratamento conservador nas pessoas com doença renal crônica l brunno lessa saldanha xavier e outros senses and meanings of conservative treatment in people with chronic kidney disease* abstract objective: to unveil the senses and meanings of conservative treatment in people with chronic kidney disease (ckd). materials and methods: a descriptive and exploratory study with a qualitative approach. it was developed in 2017, with a sample of individuals with ckd undergoing conservative treatment. a semi-structured interview was used and the data were analyzed using simple descriptive statistics and content analysis. results: 25 individuals participated in the study, of which 56 % were female; 52 % belonged to the 60-79-year-old age group; 48 % were white-skinned; 48 % did not complete elementary school; and only 12 % worked. content analysis revealed two categories: food restriction: anguishes and impacts that affect the daily lives of patients with ckd and the social imaginary and fear related to renal replacement therapy. conclusions: the results revealed that diet and fear about dialysis therapy produce uncertainty, anxiety and insecurity, in addition to a wide and impacting change in people’s lives. keywords (source: decs) chronic renal insufficiency; conservative treatment; feelings; emotions; renal dialysis; qualitative research. año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2035 * article extracted from the course conclusion work entitled: “as implicações do tratamento conservador no indivíduo com doença renal crônica”, of the fluminense federal university, brazil, conducted in 2017. 4 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2035 aquichan issn 1657-5997 eissn 2027-5374 introdução o índice de pessoas com doença renal vem crescendo de maneira significativa, com mais de 750 milhões de indivíduos acometidos ao redor do mundo. a doença renal crônica (drc), estágio mais avançado desse importante problema de saúde pública, atinge, em média, 13 % da população adulta no mundo e, no brasil, estima-se que de 11 a 22 milhões de habitantes sejam acometidos. um inquérito realizado em 2016 mostrou uma estimativa de 122.825 clientes em tratamento dialítico no brasil (1, 2). a drc vem atingindo a população de homens e mulheres em idade cada vez mais baixa, fase em que o indivíduo é considerado ativo e produtivo. essa evidência alerta para o fato de que os distúrbios crônicos degenerativos, tal qual a drc, vêm se manifestando, em geral, de maneira cada vez mais precoce na população (3). por sua vez, há práticas de cuidado cujo objetivo é desacelerar ou até mesmo inibir a progressão da doença. após a confirmação do diagnóstico, o paciente passa a receber uma profusa carga de informações, sobretudo no tocante às possibilidades de tratamento, com vistas a referendar, em momento propício, uma melhor condição para se discutir e decidir acerca do caminho terapêutico mais adequado e conveniente para as fases mais avançadas da insuficiência renal (4). o tratamento conservador tem como propósito propiciar ao portador de drc um estado clínico bom e conciliável com a fase inicial de progresso da sua doença renal. nesse sentido, aponta-se para a importância da adoção de medicamentos e de uma dieta controlada e restritiva (5). não obstante, atenta-se para uma escassez de publicações nacionais referentes às percepções e concepções de pacientes renais, em tratamento conservador, sobre sua condição existencial e sobre como se relacionam e/ou convivem com todos os preceitos e nuances do plano terapêutico. a dimensão psicológica representa o componente humano mais prejudicado durante o tratamento conservador e que interfere significativamente na qualidade de vida (5). assim, é imprescindível que, além do tratamento para a melhora clínica do indivíduo, implemente-se um acompanhamento que atenda aos aspectos psicológicos. considerando a amplitude das repercussões de uma doença crônica (e seu tratamento), salienta-se a relevância de se desenvolver um estudo acerca das crenças e concepções pessoais de clientes renais crônicos em tratamento conservador, pelo potencial de representar uma singular contribuição para o aperfeiçoamento da assistência de enfermagem. nesse sentido, a análise das informações reveladas a partir do depoimento dos investigados poderá servir de balizamento para a elaboração de estratégias de orientação/cuidado em enfermagem, com vistas, principalmente, a fomentar o entendimento e a adesão dos pacientes ao plano terapêutico delineado pelos profissionais de saúde envolvidos. assim, este estudo tem como objetivo desvelar os sentidos e significados do tratamento conservador entre as pessoas com drc. materiais e métodos trata-se de uma pesquisa descritiva, exploratória, com abordagem qualitativa, desenvolvida em um ambulatório de nutrição renal, ligado a uma universidade federal, localizado em um município da região metropolitana do rio de janeiro (brasil). para a realização deste estudo, adotaram-se os critérios do consolidated criteria for reporting qualitative research (6). a coleta de dados foi realizada durante os meses de outubro e novembro de 2017. a amostra foi composta por 25 indivíduos com drc na fase de tratamento conservador. houve a saturação teórica dos dados quando nenhuma nova informação mudaria o curso da análise (7). foram critérios de inclusão: ter o diagnóstico de drc de qualquer etiologia; estar na fase de tratamento conservador. foram critérios de exclusão: idade inferior a 18 anos; tempo inferior a seis meses de tratamento; apresentar algum deficit cognitivo. realizaram-se entrevistas semiestruturadas, mediante a aplicação de dois questionários. um com questões sociodemográficas, com as variáveis: sexo, etnia autodeclarada, faixa etária, escolaridade, profissão/ocupação, estado civil e renda familiar. o segundo instrumento abordou as comorbidades, além de questões relacionadas ao convívio com a drc e ao conhecimento sobre o processo de adoecimento e tratamento, como, por exemplo: o que sabe sobre o tratamento conservador? qual é o tipo de alimentação recomendada? como o tratamento repercute na rotina diária? conhece outras modalidades de tratamento? as entrevistas foram realizadas em sala reservada, no cenário da pesquisa, com duração média de 20 minutos, com base no roteiro previamente delineado nos questionários. a partir do consen5 sentidos e significados do tratamento conservador nas pessoas com doença renal crônica l brunno lessa saldanha xavier e outros timento prévio dos participantes por meio da assinatura do termo de consentimento livre e esclarecido, e de breve explicação acerca da pesquisa, todos os sujeitos foram entrevistados de forma individual pelo pesquisador responsável, logo após o momento da consulta ambulatorial (pré-agendada) de acompanhamento da doença. ressalta-se que as entrevistas foram gravadas com o auxílio de recurso tecnológico, um aplicativo com função de gravador, com o devido consentimento prévio dos participantes e a garantia da confidencialidade e privacidade, conforme rege a resolução 466 de 2012 do conselho nacional de saúde do brasil. os dados foram transcritos com a utilização do programa microsoft word 2016. para a manutenção do anonimato, os entrevistados foram identificados com “ent.”, seguido de um número (ent. 1, ent. 2, ... ent. 25). a pesquisa foi aprovada pelo comitê de ética e pesquisa da universidade federal fluminense, com parecer 2.341.881 (certificado de apresentação de apreciação ética 73678717.6.0000.5243). todos os aspectos éticos foram devidamente contemplados, bem como o rigor metodológico, de modo a assegurar a confiabilidade dos dados desta investigação. os dados obtidos foram organizados, agrupados e tabulados. trabalhou-se com estatística descritiva simples, a partir de tabelas de contingência, com o cálculo da frequência absoluta e o percentual. utilizou-se da análise de conteúdo de laurence bardin, que propõe as seguintes fases para a sua condução: a) organização da análise; b) codificação; c) categorização; d) tratamento dos resultados, inferência e interpretação (8). diversos autores referem-se à análise de conteúdo como uma técnica de pesquisa que trabalha com a palavra, o que permite, de forma prática e objetiva, produzir inferências do conteúdo da comunicação de um texto replicáveis ao seu contexto social. nesse tipo de análise, o texto é um meio de expressão do sujeito, em que o analista busca categorizar as unidades de texto (palavras ou frases) que se repetem, inferindo uma expressão que as representem (9). resultados dos 25 participantes, 14 (56 %) eram do sexo feminino, 12 (48 %) referiram ser de etnia branca e não tinham concluído o ensino fundamental, 18 (72 %) estavam aposentados e 10 (40 %) informaram renda familiar de até um salário-mínimo. na faixa etária, a maior frequência foi entre 60 e 79 anos, totalizando 13 (52 %) indivíduos (tabela 1). tabela 1. distribuição dos clientes conforme as variáveis sociodemográficas. niterói-rj, brasil, 2017 variáveis n (%) faixa etária até 39 anos 1 (4) de 40 a 59 anos 10 (40) de 60 a 79 anos 13 (52) acima de 80 anos 1 (4) sexo feminino 14 (56) masculino 11 (44) cor/etnia preta 3 (12) branca 12 (48) amarela 1 (4) parda 8 (32) escolaridade analfabeto 3 (12) ensino fundamental incompleto 9 (36) ensino fundamental completo 6 (24) ensino médio incompleto 1 (4) ensino médio completo 2 (8) ensino superior incompleto 2 (8) ensino superior completo 2 (8) ocupação trabalha 3 (12) não trabalha 4 (16) aposentado 8 (72) estado civil solteiro 6 (24) casado 10 (40) divorciado 6 (24) viúvo 3 (12) renda familiar até 1 salário-mínimo 10 (40) de 1 a 3 salários-mínimos 11 (44) de 3 a 6 salários-mínimos 2 (8) de 6 a 9 salários-mínimos 1 (4) de 9 a 12 salários-mínimos 1 (4) fonte: elaboração própria a partir de dados da pesquisa, 2017. 6 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2035 aquichan issn 1657-5997 eissn 2027-5374 a hipertensão arterial foi autorreferida por 11 (44 %) indivíduos. em oito (32 %), a hipertensão arterial e o diabetes mellitus eram concomitantes. com relação à orientação, 20 (80 %) informaram que recebiam orientações de profissionais médicos e nutricionistas. no que se refere à dieta, 14 (56 %) dos entrevistados confidenciaram dificuldades para seguir a dieta recomendada. muitos que referiram não adaptação à dieta relataram, como justificativa, se sentirem fracos com ela. alguns afirmaram ainda não possuírem recursos financeiros para segui-la. sobre a terapia hemodialítica, 19 (76 %) afirmaram sentir receio desse tipo de tratamento. esse sentimento era, quase sempre, relacionado à morte de pessoas conhecidas que faziam a terapia e a obstáculos em sua rotina diária. a maioria alegou não ter conhecimento sobre outras modalidades de tratamento para a drc, além da hemodiálise (tabela 2). tabela 2. distribuição dos clientes conforme as variáveis relacionadas a comorbidade, orientação profissional, dieta e percepção sobre a terapia renal substitutiva. niterói-rj, brasil, 2017 variáveis n (%) comorbidades e/ou doenças de base não possui 3 (12) hipertensão 11 (44) diabetes mellitus 1 (4) hipertensão + diabetes mellitus 8 (32) outros 2 (8) orientação profissional médico 2 (8) nutricionista 1 (4) médico + nutricionista 20 (80) médico + nutricionista + psicólogo 1 (4) psicólogo + nutricionista 1 (4) dificuldade para seguir a dieta sim 14 (56) não 11 (44) sentimento de receio da hemodiálise sim 19 (76) não 6 (24) conhecimento de outras modalidades de tratamento sim 9 (36) não 16 (64) fonte: elaboração própria a partir de dados da pesquisa, 2017. no tratamento dos dados mediante a implementação da análise de conteúdo, foi possível inferir interpretações acerca das significações presentes nos discursos, a partir da tradução dos sentimentos/emoções presentes neles. assim, foi factível elaborar duas categorias: a) restrição alimentar: angústias e impactos que repercutem no cotidiano dos pacientes com drc; b) o imaginário social e o temor relacionados à terapia renal substitutiva. restrição alimentar: angústias e impactos que repercutem no cotidiano dos pacientes com drc evidenciou-se, mediante a aplicação do segundo questionário, que a maioria dos entrevistados relatou dificuldades para seguir a dieta. nesse sentido, quando questionados acerca do motivo de encontrarem dificuldades, sobressaíram apontamentos como: alimentação insuficiente, repetitiva e penosa, conforme demonstrado nas falas a seguir: porque é difícil beber e comer pouco, é muito difícil [...] um sacrifício danado! (ent. 2) algumas coisas a gente fura. às vezes, dá vontade e a gente acaba passando do ponto. eu evito, mas, se dá vontade, eu como um pouco mais [...] (ent. 8) às vezes, você quer comer coisas diferentes e também dá vontade de comer mais [...] você come e extrapola um pouco, porque essa lista que eles passam aqui é uma tristeza pra gente! (ent. 15) observa-se como a mudança do padrão alimentar implica o viver do indivíduo com drc. nota-se que as restrições preconizadas no tratamento se tornam complicador no âmbito do convívio com a doença, em razão da necessidade de alteração de hábitos alimentares, que, para muitos, representa uma inestimável supressão de costumes, sentimentos e prazeres rotineiramente compartilhados em família e/ou em grupos sociais. a adaptação às limitações na dieta é imprescindível para que o tratamento proporcione bem-estar e reduza os riscos de agravos nas pessoas com drc. não obstante, há casos em que as privações impostas funcionam como um “gatilho” para comportamentos perturbadores e recalcitrantes, com repercussões sociocomportamentais de difícil manejo, com potencial de gerar profundos e derradeiros abalos no tocante à adesão ao plano terapêutico. 7 sentidos e significados do tratamento conservador nas pessoas com doença renal crônica l brunno lessa saldanha xavier e outros o imaginário social e o temor relacionados à terapia renal substitutiva entre os sentimentos abarcados nesta categoria temática, sobrelevam-se, no discurso dos entrevistados, sensações de angústia, medo, negação/repulsa relacionadas à possibilidade de depender de uma terapia renal substitutiva para viver. ah...! eu tenho muito medo [...] eu fico muito nervosa em ver aquela máquina, aquele troço passando e tirando o sangue das pessoas. (ent. 3) [...] acho que uma cadeira de hemodiálise é pior do que ter um câncer e morrer. eu fico imaginando que deve ser muito triste. (ent. 5) aquilo é um absurdo! você fica toda furada e cheia de caroço e acaba que não tem qualidade de vida. eu não acho que vale a pena, é muito traumático. (ent. 7) só de você falar isso me dá vontade chorar aqui [...] eu sou um cara que amo a minha vida [...] agora na minha velhice que eu ia desfrutar, estou caminhando para a morte rapidamente. (ent. 14) muitos demonstraram sentimentos negativos sobre a hemodiálise, devido às experiências de pessoas conhecidas. outros associaram a hemodiálise diretamente à morte, como se não ajudasse na manutenção da vida, e sim, na piora do estado clínico, conforme comentado pelos entrevistados 5 e 14. em geral, a perspectiva delineada sob o prisma da inevitabilidade do tratamento é encarada com muita dificuldade e tensão, de modo a despertar um imaginário de perturbações, regado a sofrimento físico e psíquico, de acordo com a análise das entrevistas. destaca-se que muitos participantes evidenciaram pensamentos aflitivos, aprisionados à ideia de uma temida e inexorável mudança no seu dia a dia, ancorada nas severas e, de certa forma, já familiares limitações ditadas pelo implacável cotidiano da terapia dialítica, com o aditivo de uma permanente sensação de iminência da morte. discussão a presença predominante de mulheres em tratamento conservador, isto é, na fase pré-dialítica, pode ser explicada pelo fato de que elas dão mais atenção à saúde. ressalta-se que, nessa fase, o paciente não se encontra dependente de terapia dialítica, de modo que, em tese, pode dispor de mais tempo e tranquilidade para optar pelo tipo de tratamento que mais lhe for conveniente/ apropriado, conforme as orientações da equipe de saúde (10). evidenciou-se, ainda, a prevalência de idosos na amostra, a exemplo do que foi observado em uma pesquisa (11) em que 54,3 % dos participantes estavam na faixa etária de 60 a 70 anos, o que alerta para o aumento da drc em indivíduos com idade mais avançada. sobrelevam-se semelhanças nos dados sociodemográficos com os de uma pesquisa (12) feita no interior do estado de são paulo, na qual se detectou que a maioria em tratamento conservador era da etnia branca. em contraponto, há evidências de que os indivíduos de cor/ etnia preta têm um risco quatro vezes maior de desenvolver drc do que os caucasianos (13). no passado, pensava-se que essa diferença seria atribuída apenas ao status socioeconômico e ao acesso aos cuidados de saúde. no entanto, registros das últimas décadas evidenciaram o incremento de importantes conjunções de fatores ambientais, genéticos e clínicos ao risco do comprometimento da função renal. portanto, nesse cenário, o alerta para as evidências da associação de combinantes socioeconômicos com o risco para drc é relevante e aponta para os maiores índices da doença renal entre pessoas de classes sociais mais desfavorecidas (2, 13, 14). pesquisas (4-10) indicam que ter acesso à educação é uma necessidade de saúde, tendo em vista que a terapêutica implementada pela equipe de saúde pressupõe, muitas vezes, estratégias de treinamento e de educação em saúde na busca pelo êxito no âmbito do tratamento. além da escolaridade, o nível de compreensão, a responsabilidade e o compromisso do cliente são fatores essenciais para o sucesso do tratamento. alerta-se, nesse sentido, que indivíduos com um nível de escolaridade e social mais elevados tendem a conhecer e compreender mais acerca da enfermidade e do tratamento, o que demonstra mais (auto)cuidado. não obstante, dados de um estudo (15) da região nordeste do brasil revelam que o tempo médio de estudo dos pacientes com drc é de 6,5 anos, constatando que a baixa escolaridade é característica marcante nesse grupo. investigações (16, 17) que envolvem pessoas que apresentam declínio da função renal revelaram que a dificuldade e impos8 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2035 aquichan issn 1657-5997 eissn 2027-5374 sibilidade de realizar as atividades laborais, por consequência de complicações clínicas, incidem em desconforto e sofrimento para quem possui a doença, dado que se assemelha aos achados da presente pesquisa. o trabalho exerce um papel indispensável no viver dos cidadãos, em especial no período etário mais produtivo da vida. pacientes com drc relatam o trabalho como um referencial de tudo na vida, uma condição essencial para a preservação da saúde mental e da qualidade de vida, e, ainda, para a valorização pessoal, fazendo parte, inclusive, da consolidação da dignidade do indivíduo (16). o fato de os pacientes conviverem com familiares pode ser um fator positivo, pois a drc pode progredir com complicações físicas, sociais e emocionais, além de incapacidades, o que demanda um cuidado multirreferencial (12, 16). nessa perspectiva, o apoio familiar pode ser de extrema valia, contribuindo para a saúde desses pacientes, inclusive para a atenuação de sintomas depressivos (18). estudos relatam que pacientes hipertensos apresentam lesão renal mais séria e, devido a isso, sugerem que eles façam acompanhamento da evolução da insuficiência renal com mais rigor, a fim de postergar seu avanço e evitar maiores comorbidades (15, 19). assim, torna-se de extrema relevância que os profissionais de saúde tenham um olhar e cuidar mais criteriosos no que tange ao potencial danoso da hipertensão arterial sob a ótica da drc. os seres humanos, considerando sua vulnerabilidade, precisam de um cuidado que leve em consideração sua autenticidade e unicidade. portanto, é preciso identificar suas fragilidades, para logo ser provido o cuidado de acordo com a necessidade de cada ser (18). a ausência do enfermeiro no processo de cuidar foi uma informação alarmante. considera-se que o enfermeiro tem um papel essencial no cuidado aos indivíduos portadores de drc, principalmente no que se refere ao estímulo para o autocuidado em saúde, de modo a facilitar a cooperação e adesão do paciente ao tratamento, numa perspectiva de alcançar níveis satisfatórios de qualidade de vida e de bem-estar (20). há uma relação de muita proximidade entre a equipe de enfermagem e os clientes com drc que é construída a partir de uma frequente e assídua presença destes últimos nas consultas de acompanhamento da doença. ressalta-se, nesse contexto, uma valiosa oportunidade para se estabelecerem intervenções no âmbito da educação em saúde, com vistas a fomentar um comportamento de autocuidado e corresponsabilidade do usuário no tratamento (21). a alimentação encontra-se entre os assuntos mais sensíveis por parte dos clientes com drc. isso é preocupante, uma vez que a dieta é um fator primordial na prevenção, redução e controle da progressão da drc. a adoção de novos hábitos alimentares e de vida representa importantes sustentáculos do tratamento. no entanto, mudanças sem o devido e rigoroso acompanhamento podem repercutir na perda de qualidade de vida, muitas vezes relacionada à renúncia quanto ao consumo de alguns alimentos essenciais e à prática de certos hábitos considerados prazerosos (12, 22). no que tange à terapia dialítica, a maior parte dos participantes se mostrou apreensiva. isso se explica pelo fato de que a diálise, uma consequência quase irremediável da drc, ocasiona alterações na vida dos pacientes, devido ao tratamento ser doloroso e perdurável, fazendo com que, na maioria das vezes, a aceitação se torne mais difícil (22). além disso, foi possível observar que o conhecimento de outras modalidades de tratamento era escasso. essa informação é preocupante, pois o conhecimento é uma condição que promove a mudança de comportamento do paciente. no caso da drc, é primordial a adesão ao tratamento em seus estágios iniciais com vistas a impactar positivamente na sua progressão (23). da perspectiva dos pacientes, o tratamento conservador é comumente vinculado às restrições alimentares, de modo que, na maioria dos casos, eles mencionam inúmeras dificuldades para seguir a dieta (24). isso porque há um simbolismo relacionado à alimentação, a qual difere de um grupo populacional para outro, com variações nos padrões culturais, valores e crenças do indivíduo, e a restrição alimentar, fundamental para o sucesso do tratamento e para o bem-estar do paciente com drc, pode representar um fator de imensa insatisfação por impactar seu cotidiano (25). diante do exposto, percebe-se que são indispensáveis ações educativas com o cliente, para que ele seja capaz de criar novas formas de viver sem ultrapassar seus limites. nesse sentido, para 9 sentidos e significados do tratamento conservador nas pessoas com doença renal crônica l brunno lessa saldanha xavier e outros que o indivíduo assuma os cuidados e o controle do esquema terapêutico, é necessário que as intervenções educacionais sejam feitas de maneira horizontal, respeitando sua individualidade, crenças e valores (26). no imaginário de um indivíduo com drc em tratamento conservador, percorrem inúmeros significados para a terapia dialítica, que vão desde o reconhecimento da gravidade do estágio da doença e do tratamento até as suas consequências mais duradouras e penosas. na maior parte dos casos, a drc provoca pensamentos e sentimentos negativos, como frustrações, limitações, sensação de estar preso a uma máquina, principalmente quando o indivíduo se depara com a real necessidade do tratamento dialítico (22-24). a possível necessidade de uma terapia de substituição renal, como a hemodiálise, traz consigo sentimentos de dúvida e de conturbação nos clientes, porque, ao mesmo tempo que promove a manutenção da vida, torna a pessoa dependente de uma tecnologia. desse modo, existe um simbolismo atrelado ao tratamento dialítico, porque ele faz o elo entre o viver e o morrer, além de deixar marcas pelo corpo (27). conclusões os resultados evidenciaram que a drc vem atingindo homens e mulheres em percentuais bem próximos, em especial, os indivíduos com baixa escolaridade e pouca remuneração. sobreleva-se um perfil amostral majoritário de idosos na pesquisa, o que pode ser correlacionado ao aparecimento da hipertensão e do diabetes mellitus como as principais doenças preexistentes entre os entrevistados, sendo considerado um advento importante para o desenvolvimento e progressão da disfunção renal. percebeu-se o impacto emocional na forma de compreender a doença, experimentada pelos participantes do estudo. além de uma ampla modificação no viver das pessoas com drc em tratamento conservador, os resultados revelaram que a dieta e o receio/temor acerca da terapia dialítica produzem incertezas, inquietude e insegurança. isso reforça a importância de ações educativas que possam facilitar o entendimento e simbolismo das nuances do tratamento, de modo a contemplar as peculiaridades e necessidades de cada indivíduo. constatou-se um conhecimento deficitário acerca das estratégias/modalidades de tratamento da drc. esse fato pode ser consubstanciado, na fala dos participantes, pela ausência do enfermeiro como personagem atuante na equipe multidisciplinar. depreende-se, portanto, uma importante e preocupante lacuna nesse cenário, no qual a atuação do enfermeiro é de suma importância, visto que as terapias renais consistem em uma terapêutica de alto risco e com um elevado potencial de intercorrências. esse profissional tem a prerrogativa de atuar, a partir de uma abordagem holística, no pleno exercício do cuidar a partir de seu papel de educador/orientador em saúde, que implica auxiliar para um melhor enfrentamento do processo de adoecimento, a fim de repercutir positivamente na adesão do paciente ao tratamento. limitações do estudo a realização do estudo em apenas uma unidade de atendimento aos indivíduos com drc em tratamento conservador é considerada uma limitação do estudo, de modo que não se podem utilizar os resultados como uma expressão generalizada do referido grupo. conflito de interesses: nenhum declarado. 10 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2035 aquichan issn 1657-5997 eissn 2027-5374 referências 1. sesso rc, lopes aa, thomé fs, lugon jr, martins ct. brazilian chronic dialysis census 2014. j bras nefrol [internet]. 2016;38(1):54-61. doi: https://doi.org/10.5935/0101-2800.20160009 2. crews dc, bello ak, saadi g. 2019 world kidney day editorial — burden, access, and disparities in kidney disease. j bras nefrol [internet]. 2019;41(1):1-9. doi: 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(fuente: decs, bireme). caring for the caregiver: effects of an educational program abstract this study examines the results of a 12-month research project entitled effects of the ‘caring for caregivers’ ¨program on a group of family caregivers in the cities of girardot and flandes in association with the university of cundinamarca. objective: assess the effectiveness of the aforementioned program, which was conducted by the national university of colombia for family caregivers of chronically ill persons in the aforementioned cities in the departments of cundinamarca and tolima (colombia). method: the care ability inventory (cai) proposed by ngozi o. nkongho was applied as a pre and post-test. the study is quasiexperimental and involved 72 family caregivers distributed into two groups: a control group made up of 35 persons and an experimental group of 37 caregivers. año 9 vol. 9 nº 1 chía, colombia abril 2009 73 92 juan carlos díaz-álvarez1 maría victoria rojas-martínez2 74 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 results: the findings demonstrate the effectiveness of the program in helping the experimental group to develop know-how and patience. the value aspect remained unchanged in both the control group and the experimental group, which indicates the program was not effective in terms of increasing value as a dimension of care. key words care ability, family caregivers, chronic illness. (source: mesh, bireme). cuidar ao cuidador: efeitos de um programa educativo resumo neste estudo mostram-se os resultados da pesquisa efeitos do programa ‘cuidar ao cuidador’ em um grupo de cuidadores familiares nos municípios de girardot e flandes, vinculados à universidade de cundinamarca levada a cabo durante 12 meses. objetivo: avaliar a efetividade do programa desenvolvido pela universidade nacional de colômbia em cuidadores familiares de pessoas com doença crônica, nas ditas cidades do departamentos de cundinamarca e tolima, colômbia. método: foi utilizado o instrumento inventario de habilidade de cuidado (cai; care ability inventory), proposto por ngozi o. nkongho. foi aplicado como pré e pós-prova. o estudo, quase-experimental, foi realizado com 72 cuidadores familiares distribuídos em dois grupos: um de controle, constituído por 35 pessoas, e outro experimental, formado pelos 37 cuidadores restantes. resultados: os achados assinalam a efetividade do programa para desenvolver as dimensões de conhecimento e paciência no grupo experimental. a dimensão de valor permaneceu invariável no grupo de controle e no experimental. isso mostra que o programa não foi efetivo para aumentar o valor como dimensão de cuidado. palavras-chave habilidade de cuidado, cuidadores familiares, doença crônica. (fonte: decs, bireme). 75 cuidando al cuidador: efectos de un programa educativo juan carlos díaz-álvarez, maría victoria rojas-martínez introducción el presente artículo responde a un interés significativo para la disciplina de enfermería. incluye la realización del programa “cuidando al cuidador” propuesto por docentes de enfermería de la universidad nacional de colombia, donde se aborda una población vulnerable de cuidadores de personas con enfermedad crónica para validar un programa de cuidado formulado en el medio colombiano y latinoamericano. el programa “cuidando al cuidador” pretende fortalecer la habilidad de cuidado a través de la aplicación de un proceso educativo estructurado en nueve sesiones grupales para cada uno de los grupos: experimental y de control. según ngozi o. nkongho (1), el cuidado compromete la participación humana, y con ella el cuidador desarrolla habilidades en el cuidado de su familiar y de sí mismo. siempre ha existido la figura de cuidador como un imaginario en la dinámica familiar. este rol, generalmente atribuido a la mujer, le permite desarrollar habilidades para el cuidado de los miembros familiares; sin embargo, su labor tiene poco reconocimiento tanto en el contexto de su desarrollo como en el sector salud. ser cuidador familiar de una persona con enfermedad crónica lleva implicaciones, familiares, sociales, mentales, económicas y espirituales que merecen la atención y el reconocimiento centrado en el cuidado y autocuidado de la salud de las personas y colectivos. reconocer a los cuidadores familiares orienta al profesional de enfermería en la comprensión de cómo y qué debe reforzar para apoyar a este grupo. abordar la dimensión del conocimiento requiere explorar las debilidades y potencialidades humanas. la dimensión de paciencia es poco tangible e implica entrar en experiencias previamente aprendidas y esperar nuevas vivencias, sin saber con exactitud lo que se obtendrá. por su parte, la dimensión de valor tiende a compaginarse más con la dinámica familiar que el cuidador maneja, al igual que con los grupos de apoyo que presente; por tanto, esta dimensión se relaciona en gran parte con factores externos que apoyan al cuidador. todavía falta reconocer aspectos de la dinámica familiar de acuerdo con la cultura y la región, para individualizar el cuidado y llegar a desarrollar propuestas generales que partan de las necesidades sentidas en el cuidador y su familiar enfermo. el estudio consideró aspectos éticos referentes al consentimiento informado, la participación voluntaria y el manejo confidencial de la información. objetivo general: evaluar la efectividad del programa “cuidando al cuidador” para el desarrollo de habilidades de cuidado en cuidadores familiares de personas con enfermedad crónica en las ciudades de girardot (cundinamarca) y flandes (tolima). materiales y métodos: el estudio tiene un diseño cuasiexperimental, desarrollado en 72 cuidadores familiares de personas con enfermedad crónica, donde se pretendió evaluar el impacto del programa “cuidando al cuidador” sobre la habilidad de cuidado de 37 cuidadores, e incluyó un grupo de control compuesto por 35 cuidadores. el estudio se desarrolló durante un año, entre marzo de 2007 y marzo de 2008. los criterios de inclusión eran: ser cuidador familiar, mayor de 18 años, con experiencia en el cuidado superior a tres meses, ser cuidador familiar de una persona con enfermedad crónica lleva implicaciones, familiares, sociales, mentales, económicas y espirituales que merecen la atención y el reconocimiento centrado en el cuidado y autocuidado de la salud de las personas y colectivos. 76 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 con comunicación oral adecuada, con nivel de dependencia según escala de pulses, igual o mayor a 8 puntos. el principal instrumento fue el propuesto por la enfermera afroamericana ngozi o. nkongho (1), denominado inventario de habilidad de cuidado (cai, care ability inventory), el cual permite cuantificar la habilidad de cuidado que una persona tiene con otra cuando la cuida. el instrumento está formado por 37 ítems graduados en escala de licker de 7 puntos (donde 1 significa absoluto desacuerdo y 7 significa acuerdo absoluto), distribuidos en tres subescalas: 14 preguntas para la dimensión de conocimiento; 13 para la dimensión de valor y 10 para la dimensión de paciencia. el instrumento tiene confiabilidad de 0,84 y validez de 0,80, probada a través del coeficiente alfa de cronbach. otros instrumentos de apoyo para la recolección de información fueron: perfil pulses: es una escala de 4 puntos que permite medir la funcionalidad de la persona enferma en términos de: estabilidad de la patología, utilización de miembros superiores, capacidad de locomoción y traslado, capacidad sensorial, eliminación y actividad social, según lo esperado. cuando el enfermo es funcional, en la escala se señalan números pequeños, y cuando es dependiente, se marcan números altos, el resultado final se obtiene sumando los puntos señalados en el instrumento. instrumento de caracterización de los cuidadores familiares de personas con enfermedad crónica: ayuda determinando las características de los cuidadores familiares. fue elaborado por el grupo de cuidado al paciente crónico de la facultad de enfermería de la universidad nacional de colombia, bogotá, en 2002. de acuerdo con los fines de la investigación, la siguiente fue la definición operativa de conceptos: habilidad de cuidado del cuidador familiar: definido como el potencial de cuidado que tiene la persona adulta que asume el rol de cuidador principal de un familiar que padece de enfermedad crónica. la habilidad de cuidado incluye la dimensión cognoscitiva y la actitudinal, que son identificadas y medidas según los indicadores de conocimiento, valor y paciente propuestos por ngozi o. nkongho en 1999. la habilidad y sus dimensiones se miden con el instrumento denominado inventario de habilidad de cuidado (cai), mediante entrevista directa, y su percepción puede ser descrita. cuidador familiar: es la persona adulta con vínculo de parentesco familiar que asume responsabilidad en el cuidado de un ser querido que vive situación de enfermedad crónica, y que participa en la toma de decisiones y supervisa y colabora en las actividades de la vida diaria para compensar la disfunción existente o apoyar la persona cuidada. persona con enfermedad crónica: es quien experimenta algún trastorno orgánico y funcional que genera discapacidad y requiere largos períodos de cuidado, tratamiento paliativo o control, por lo cual debe modificar su estilo de vida. el enfermo crónico recibe soporte y ayuda del cuidador familiar los participantes fueron asignados a conveniencia a uno de los dos grupos de estudio, que para el grupo control correspondió a 35 cuidadores y para el grupo cuidador familiar es la persona adulta con vínculo de parentesco que asume responsabilidad en el cuidado de un ser querido que vive situación de enfermedad crónica. 77 cuidando al cuidador: efectos de un programa educativo juan carlos díaz-álvarez, maría victoria rojas-martínez experimental a 37. a todos los participantes se les evaluó la habilidad de cuidado con el cai, en dos momentos diferentes, correspondientes a la primera y última sesión de las nueve programadas, cumpliendo así con una preprueba y una postrueba como parte del desarrollo del programa “cuidando al cuidador”. a los participantes del grupo de control no se les expuso a intervención. la conformación de los grupos requirió de identificación de los cuidadores familiares en los municipios de girardot y flandes. entre las limitantes para el desarrollo investigativo estuvo la dificultad de los cuidadores para su desplazamiento, relacionadas con la condición del familiar enfermo y situaciones económicas propias, por lo cual se necesitó como estrategia, tras gran difusión del servicio por parte de la universidad de cundinamarca, formar pequeños grupos de trabajo, de entre seis y ocho participantes, los cuales fueron motivados permanentemente para su asistencia y puntualidad. una vez se terminaba el programa con un grupo, se conformaba otro, repitiéndose el proceso. la información obtenida mediante el cai fue procesada y organizada para describir las características generales de los participantes. los datos se clasificaron en una de dos categorías: “baja” y “alta” habilidad de cuidado. se consideraron las puntuaciones, tanto globales en el cai como las de cada una de las tres dimensiones (conocimiento, valor y paciencia); posteriormente, se procedió a hacer el análisis general de los datos de los dos grupos, tanto en la preprueba como en la posprueba, y a continuación se implementaron algunos procedimientos estadísticos para determinar la validez de las conclusiones formuladas del primer análisis y para precisar los alcances de hallazgos establecidos. resultados características generales de los participantes aunque la mayoría de los participantes son de género femenino, en la tabla 1 puede apreciarse que la proporción de cuidadores masculinos en el grupo de control duplica a la del grupo experimental (11% vs. 5%). respecto de sus edades, la información general muestra que el 57% de los participantes se encuentran en el rango de 36 a 59 años y que el 26% tiene 60 años o más. igualmente, respecto de sus edades no existen notables diferencias en la distribución en ambos grupos. respecto al grado de escolaridad, puede verse que hay mejores niveles educativos en el grupo experimental, si se considera que prácticamente la mitad de estos cuidadores cuenta con bachillerato (completo o incompleto), mientras que este porcentaje en el grupo de control es apenas del 29%, ya que más de la mitad de los cuidadores de este grupo cuentan con un menor nivel educativo (el solo 54% tiene primaria, completa o incompleta). también aparecen diferencias considerables en el estado civil de los cuidadores, según el grupo al que fueron asignados: en el grupo de control hay una mayor representatividad de los solteros (43%) y en el grupo experimental, de los casados (41%). esta situación contrasta, por su parte, con la condición de unión libre, en la que se semejan los dos grupos. de acuerdo con la ocupación de los participantes, puede apreciarse que en ambos grupos la mayoría se encuentra dedicada al hogar (el 71% del grupo de control y el 68% del grupo experimental). puede advertirse que mientras en el grupo control no hay empleados, el 11% del grupo exentre las limitantes para el desarrollo investigativo estuvo la dificultad de los cuidadores para su desplazamiento, relacionadas con la condición del familiar enfermo y situaciones económicas propias. 78 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 perimental lo está. adicionalmente, aunque en términos de frecuencias no es considerable, se detecta que la proporción de estudiantes en el grupo de control triplica la del grupo experimental (9% vs. 3%). por último, si se atiende al estrato de los cuidadores, se puede constatar que mientras la mayoría del grupo experimental pertenece al estrato 3 y 4 (51%), la mayoría del grupo de control pertenece al estrato 1 (34%) y al estrato 2 (40%). reconocer las diferencias reportadas en la asignación de los cuidadores a cada uno de los dos grupos de estudio es importante, por cuanto estas pueden tener una incidencia en los resultados obtenidos en su habilidad de cuidado. tabla 1 características sociodemográficas de los cuidadores familiares en los grupos de control y experimental. género del cuidador masculino 4 11 2 5 6 8 femenino 31 89 35 95 66 92 total 35 100 37 100 72 100 edad del cuidador 17 años o menos 1 3 0 0 1 1 entre 18 y 35 años 6 17 5 14 11 15 entre 36 y 59 años 19 54 22 59 41 57 60 años o más 9 26 10 27 19 26 total 35 100 37 100 72 100 escolaridad del cuidador primaria completa o incompleta 19 54 12 32 31 43 bachillerato completo o incompleto 10 29 18 49 28 39 técnica o más 6 17 7 19 13 18 total 35 100 37 100 72 100 estado civil soltero(a) 15 43 10 27 25 35 casado(a) 8 23 15 41 23 32 separado(a) 1 3 3 8 4 6 viudo(a) 5 14 3 8 8 11 unión libre 6 17 6 16 12 17 total 35 100 37 100 72 100 ocupación del cuidador hogar 25 71 25 68 50 69 empleado(a) 0 0 4 11 4 6 trabajo independiente 5 14 6 16 11 15 estudiante 3 9 1 3 4 6 otros 2 6 1 3 3 4 sin información 0 0 0 0 0 0 total 35 100 37 100 72 100 estrato del cuidador estrato 1 12 34 8 22 20 28 estrato 2 14 40 10 27 24 33 estrato 3 9 26 17 46 26 36 estrato 4 o más 0 0 2 5 2 3 total 35 100 37 100 72 100 fuente: resultados de la investigación: cálculos de los autores basados en la encuesta de caracterización del cuidador. características sociodemográficas control experimental general frec. % frec. % frec. % al comparar la edad del paciente respecto de la del cuidador, se aprecia que en cada grupo el mayor porcentaje está dado por los cuidadores de pacientes mayores que ellos mismos. 79 cuidando al cuidador: efectos de un programa educativo juan carlos díaz-álvarez, maría victoria rojas-martínez características del cuidado y la atención de los cuidadores al examinar la información expuesta en la tabla 2 sobre la relación de los cuidadores con la persona en situación de enfermedad crónica, se encontró que la mayoría de cada grupo cuida a la persona desde el diagnóstico (83%, en general). tampoco aparecen diferencias notables al atender la información acerca del tiempo que llevan como cuidadores: se aprecia que el 80% de los cuidadores del grupo de control y el 84% del grupo experimental tienen una experiencia superior a 37 meses como cuidadores. sin embargo, al mirar las horas diarias de cuidado, se puede sostener que los del grupo experimental perciben que dedican más tiempo diario a su labor: por una parte, se encuentra una diferencia de 7 puntos favorable a los del grupo experimental que se dedican las 24 horas al cuidado y, por otra, una diferencia de 10 puntos entre los que se dedican entre 13 y 23 horas. se estableció que el 69% de los participantes del grupo de control no cuenta con apoyo de otros familiares para ejecutar el cuidado, en tanto que el grupo experimental registra apenas el 30%. la diferencia entre los grupos equivale a 39 puntos; sin embargo, llama la atención que la relación se vuelve inversa, pues el 31% del grupo control, comparado contra el 70% del grupo experimental, reciben soporte familiar y no existe exclusividad para el cuidado. esta es, pues, una de las variables en las que se diferencian de manera destacable los dos grupos relacionados. de acuerdo con el parentesco que guarda el cuidador con la persona cuidada, reaparecen el tipo de diferencias que se vienen registrando. mientras que en el grupo de control los cuidadores que son madre o padre del paciente agrupan al 17%, en el grupo experimental este porcentaje asciende al 41%. en la misma tabla 2 puede reconocerse adicionalmente que en el grupo de control hay una cantidad relativamente importante de cuidadores que al parecer no tienen una relación familiar con el paciente, la cual alcanza a triplicar a la correspondiente del grupo experimental (34% vs. 11%). en general se pudo constatar lo reportado en la literatura, pues en ambos grupos se reconoce que el mayor porcentaje de los cuidadores son hijos(as) 32%, seguido por madre/padre 29%. finalmente, al comparar la edad del paciente respecto de la del cuidador, se aprecia que en cada grupo el mayor porcentaje está dado por los cuidadores de pacientes mayores que ellos mismos: el 46% del grupo de control y el 62% del grupo experimental, lo cual se explica porque la mayoría de los cuidadores son hijos de los enfermos crónicos. de todas maneras hay una diferencia importante entre los dos grupos, que alcanza los 16 puntos porcentuales, diferencia que está acompañada por la mayor proporción de cuidadores del grupo de control que tienen el mismo rango de edad que los pacientes a quienes cuidan y es cuatro veces mayor que la propia del grupo experimental (20% vs. 5%). resultados en la preprueba del grupo control y del grupo experimental (primera aplicación del cai) en la tabla 3 se exponen los resultados iniciales de la habilidad de cuidado de los participantes en la primera aplicación del cai, que sirvieron como preprueba. al se estableció que el 69% de los participantes del grupo de control no cuenta con apoyo de otros familiares para ejecutar el cuidado. 80 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 género del cuidador masculino 4 11 2 5 6 8 femenino 31 89 35 95 66 92 total 35 100 37 100 72 100 cuida a la persona desde el momento del diagnóstico sí 29 83 31 84 60 83 no 6 17 6 16 12 17 total 35 100 37 100 72 100 tiempo que se lleva como cuidador de 0 a 6 meses 1 3 3 8 4 6 de 7 a 18 meses 4 11 3 8 7 10 de 19 a 36 meses 2 6 0 0 2 3 37 o más meses 28 80 31 84 59 82 sin información 0 0 0 0 0 0 total 35 100 37 100 72 100 horas diarias dedicadas al cuidado 6 o menos horas 3 9 7 19 10 14 entre 7 y 12 horas 14 40 5 14 19 26 entre 13 y 23 horas 6 17 10 27 16 22 24 horas 12 34 15 41 27 38 total 35 100 37 100 72 100 se es el único cuidador sí 11 31 26 70 37 51 no 24 69 11 30 35 49 sin información 0 0 0 0 0 0 total 35 100 37 100 72 100 relación con la persona cuidada (rol) esposo(a) 3 9 3 8 6 8 madre/padre 6 17 15 41 21 29 hijo(a) 10 29 13 35 23 32 abuelo(a) 3 9 1 3 4 6 amigo(a) 1 3 1 3 2 3 otro 12 34 4 11 16 22 sin información 0 0 0 0 0 0 total 35 100 37 100 72 100 edad del paciente mayor que el rango de edad del cuidador 16 46 23 62 39 54 del mismo rango de edad del cuidador 7 20 2 5 9 13 menor que el rango de edad del cuidador 12 34 12 32 24 33 sin información 0 0 0 0 0 0 total 35 100 37 100 72 100 características del cuidado control experimental general frec. % frec. % frec. % tabla 2. características del cuidado y la atención de los cuidadores familiares según su distribución en grupos control y experimental. fuente: resultados de la investigación: cálculos de los autores basados en la encuesta de caracterización del cuidador. se pudo constatar lo reportado en la literatura, pues en ambos grupos se reconoce que el mayor porcentaje de los cuidadores son hijos(as), seguido por madre/padre. 81 cuidando al cuidador: efectos de un programa educativo juan carlos díaz-álvarez, maría victoria rojas-martínez respecto deben hacerse varias observaciones. se encuentra que en la línea de base ambos grupos presentan puntuaciones semejantes, lo cual constituye una característica favorable para hacer las debidas comparaciones y evaluar los cambios esperados. nótese que en el cai general 16 participantes del grupo de control y 15 del grupo experimental puntuaron con una baja habilidad general; en la dimensión del valor se presenta baja puntuación: 32 del grupo de control y 33 del grupo experimental. en la dimensión del conocimiento, todos los cuidadores del grupo de control tuvieron alta puntuación inicial y en el grupo experimental hubo solo cinco cuidadores con baja puntuación. por su parte, en la dimensión de la paciencia, como en la del conocimiento, los dos grupos obtuvieron alta puntuación en la primera medición. puede señalarse que, al juzgar los datos por dimensiones, se destaca la que atañe al valor de los cuidadores, puesto que 65 de los 72 participantes iniciaron con una baja puntuación en esta dimensión –situación que contrasta con lo obtenido en las dimensiones del conocimiento y la paciencia–. en otras palabras, los cuidadores, en general, antes de cualquier intervención cuentan con un conocimiento y una paciencia favorables y suficientes, mientras que el valor es la dimensión de la habilidad de cuidado menos adecuada. a partir de estos resultados la intervención del programa a los 33 cuidadores del grupo experimental deberán incrementar la puntuación en el desarrollo de las habilidades de cuidado para las dimensiones de conocimiento, valor y paciencia. tabla 3. habilidad de cuidado de los cuidadores familiares según su distribución en grupos control y experimental en la primera aplicación del cai o preprueba. fuente: resultados de la investigación. cálculos de los autores basados en cai. habilidad del cuidado control experimental preprueba baja habilidad de cuidado 16 15 alta habilidad de cuidado 19 22 bajo valor 32 33 alto valor 3 4 bajo conocimiento 0 5 alto conocimiento 35 32 baja paciencia 2 2 alta paciencia 33 35 total 35 37 cai general valor conocimiento paciencia según las observaciones precedentes, el diseño y los datos iniciales de la preprueba posibilitan someter a análisis las siguientes preguntas investigativas: 1. después del programa, ¿aumenta el número de participantes del grupo experimental con una alta habilidad de cuidado general en el cai? 2. después del programa, ¿aumenta el número de participantes del grupo experimental con una alta puntuación en la dimensión del valor del cai? 3. si mejora la habilidad de cuidado de los participantes del grupo experimental, ¿este resultado aparece por igual en las tres dimensiones o la intervenlos cuidadores, en general, antes de cualquier intervención cuentan con un conocimiento y una paciencia favorables y suficientes, mientras que el valor es la dimensión de la habilidad de cuidado menos adecuada. 82 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 ción revela un impacto diferencial en alguna de ellas? 4. en una segunda aplicación del cai, ¿se conserva la habilidad de cuidado de los participantes del grupo de control? 5. si no se conserva la habilidad de cuidado de los participantes del grupo de control, ¿su habilidad de cuidado aumenta o disminuye? si aumenta o disminuye, ¿lo hace de la misma forma en las tres dimensiones? 6. ¿los posibles cambios encontrados en la habilidad de cuidado de los participantes pueden atribuirse a la intervención recibida? resultados en la posprueba del grupo control y del grupo experimental (segunda aplicación del cai) y comparación con la preprueba la tabla 4 incorpora los datos sobre la habilidad de cuidado de los participantes en la segunda aplicación del cai, la cual corresponde, para los del grupo experimental, a la posprueba realizada una vez terminado el programa “cuidando al cuidador”. la inspección visual de los resultados obtenidos ofrece una primera aproximación. veamos: antes de cualquier comparación, considérense los tres primeros interrogantes que atañen a los resultados del grupo experimental. a juzgar por los datos del cai general, consolidados en la tabla 4, se muestra que, después de la intervención, nueve de los cuidadores aumentaron su puntuación en la habilidad de cuidado general. en efecto, en la primera aplicación o preprueba, 22 participantes tuvieron una alta habilidad de cuidado general, y en la segunda aplicación o posprueba, después de la intervención, aparecen 31 con alta habilidad de cuidado general. de esta manera, el primer interrogante debe responderse afirmativamente, señalando que después de la intervención 9 de los 15 (60%) cuidadores de este grupo mejoraron su habilidad de cuidado general. sin embargo, después de la intervención decreció en uno el número de participantes del grupo experimental que tenía una alta puntuación en la dimensión del valor; en efecto, como puede verse, después del programa “cuidando al cuidador” el número de participantes con puntuación alta en el valor pasó de cuatro a tres, y los cuidadores de los que se esperaba que mejoraran en la dimensión del conocimiento y de la paciencia mostraron una puntuación favorable después de la intervención. puede verse que los cinco cuidadores que en la preprueba tuvieron baja puntuación en la dimensión del conocimiento y los dos con baja puntuación en la dimensión de la paciencia lograron en la posprueba una alta calificación en la segunda medición. la descripción anterior responde no solo el segundo sino el tercer interrogante, que se pregunta por el posible impacto diferencial de la intervención en las tres dimensiones de la habilidad de cuidado de los cuidadores del grupo experimental. otra forma de describir la cuestión es considerar que en la dimensión del conocimiento se registró un cambio favorable absoluto: los cinco participantes que en la primera evaluación revelaron un bajo conocimiento cambiaron su puntuación después del programa y obtuvieron un resultado de alto conocimiento. algo semejante se encontró en la dimensión paciencia, puesto que los dos participantes que inicialmente obtuvieron una baja puntuación, posteriormente, en la segunda evaluación, obtuvieron una alta puntuación; es decir, se los cinco participantes que en la primera evaluación revelaron un bajo conocimiento cambiaron su puntuación después del programa y obtuvieron un resultado de alto conocimiento. 83 cuidando al cuidador: efectos de un programa educativo juan carlos díaz-álvarez, maría victoria rojas-martínez obtuvo un logro del 100%. en este sentido, puede afirmarse que la intervención tuvo un efecto positivo en las dimensiones del conocimiento y de la paciencia y que prácticamente no lo tuvo en la dimensión del valor. las preguntas investigativas 4 y 5, anteriormente expuestas, se ocupan de los resultados de los participantes del grupo de control. la primera indaga si hubo cambios o se mantuvo la distribución inicial de la habilidad de cuidado de los 35 participantes. al comparar la preprueba y la posprueba puede verse que en el cai general aumentaron dos participantes con alta habilidad general de cuidado en su segunda evaluación. en otras palabras, puede advertirse que tanto con la intervención como sin ella aumentó el número de cuidadores con una alta habilidad general de cuidado, cuando fueron evaluados nuevamente, el cual fue más significativo para el grupo experimental. en el grupo control hubo un cuidador que vio afectada negativamente su puntuación en la dimensión del valor. en la tabla 4 puede verse que, de los tres que tuvieron en la preprueba una alta puntuación, quedaron dos en la posprueba. por su parte, la dimensión del conocimiento quedó intacta y los 35 cuidadores de este grupo conservaron su alta puntuación en el conocimiento, y así también, en la dimensión de la paciencia, los cuidadores conservaron sus puntuaciones iniciales de la preprueba: 33 con alta paciencia y dos con baja paciencia. de lo anterior se concluye que en el grupo de control se observó en las dos mediciones una estabilidad en los resultados y un resultado desfavorable en la dimensión del valor para uno de los cuidadores. tabla 4. habilidad de cuidado de los cuidadores familiares según su distribución en grupos control y experimental en la segunda aplicación del cai o preprueba y comparación con la habilidad medida en la preprueba. fuente: resultados de la investigación. cálculos de los autores basados en cai. habilidad del cuidado control experimental preprueba posprueba preprueba posprueba cai general baja habilidad de cuidado 16 14 15 6 alta habilidad de cuidado 19 21 22 31 valor bajo valor 32 33 33 34 alto valor 3 2 4 3 conocimiento bajo conocimiento 0 0 5 0 alto conocimiento 35 35 32 37 paciencia baja paciencia 2 2 2 0 alta paciencia 33 33 35 37 total 35 35 37 37 la descripción anterior señala, entonces, que se encontró, como se esperaba, una relativa estabilidad en los resultados del grupo de control y cambios favorables relativamente importantes en los resultados del grupo experimental. se encontró una relativa estabilidad en los resultados del grupo de control y cambios favorables en los resultados del grupo experimental. 84 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 análisis estadístico de los efectos de la intervención de enfermería en el grupo experimental para el desarrollo de la habilidad de cuidado en cuidadores familiares en este apartado se presenta un análisis estadístico dedicado a los resultados de los dos grupos (control y experimental) en las dos aplicaciones del cai (preprueba y posprueba) considerando sus puntuaciones en el cai general, en de cada una de las tres dimensiones (el valor, el conocimiento y la paciencia de los cuidadores). el tratamiento estadístico se basó en las puntuaciones originales o “datos brutos” tanto del cai general como de las tres dimensiones. para explorar si el programa “cuidando al cuidador” tuvo efecto positivo en las habilidades de cuidado general de los participantes del grupo experimental, se graficaron los diagramas de caja (box plots) asociados para ambos grupos (control y experimental), los cuales se presentan en la figura 1, en la que se aprecia (de izquierda a derecha) la distribución del cai total del grupo control en la preprueba, y se observa en este grupo mayor variabilidad, en tanto que en la segunda evaluación este disminuyó su variabilidad inicial. al atender las barras horizontales que se encuentran cerca de los 190 puntos, se puede observar que la distribución de los puntajes de las dos mitades (vale decir, de cada 50%) de cuidadores fue el mismo en las dos mediciones de la habilidad de cuidado. no obstante, en esta misma figura se detecta que disminuyeron las puntuaciones máximas y no aumentaron las puntuaciones mínimas. nótese que el extremo del box plot de la preprueba es más alto que el de la posprueba, y los extremos inferiores de los box plots están a la misma altura. ahora bien, al ver la representación de los datos del grupo experimental, se alcanza a detectar un aumento en sus puntuaciones mínimas y, también, que el 50% de los cuidadores elevaron ligeramente sus puntuaciones (compárense los extremos de los dos box plots y la altura de cada barra horizontal, respectivamente). al comparar los dos box plots del grupo experimental con los del grupo de control, se destacan semejanzas para ambos grupos en la preprueba, y aunque el grupo experimental inició con puntuaciones ligeramente inferiores, se denota que en la posprueba aumentan las puntuaciones. figura 1. representación de la habilidad de cuidado general para los grupos de control y experimental en la preprueba y en la posprueba. en la figura 1 puede identificarse el aumento en las puntuaciones mínimas obtenidas por el grupo experimental en la posprueba frente a aquellas obtenidas por los cuidadores del grupo de control. es decir, parece existir una incidencia positiva del programa “cuidando al cuidador” en 85 cuidando al cuidador: efectos de un programa educativo juan carlos díaz-álvarez, maría victoria rojas-martínez las habilidades de cuidado de los cuidadores involucrados en este programa en la universidad de cundinamarca. para concluir que este aumento es significativo, se debe descartar que tal diferencia se deba a errores experimentales. para ello, se procedió a aplicar la prueba t para dos muestras con respecto a las diferencias entre los valores en el cai total de la posprueba y la preprueba. dado que un buen uso de la prueba t requiere que las distribuciones poblacionales de probabilidad –de las cuales fueron extraídos los dos grupos de cuidadores, a los que se les evalúo el cai total antes y después de la aplicación del programa al grupo experimental– sean normales, se aplicó el test de kolmogorov-smirnov para evaluar si la muestra de diferencias entre las puntuaciones de la posprueba y la preprueba en el cai total –tanto de los 37 cuidadores del grupo experimental como de los 35 del grupo de control– presenta un comportamiento normal. para este test estadístico se aceptaron valores p respectivos de 0,813 y 0,707. las diferencias entre la posprueba y la preprueba del grupo experimental y el grupo de control presentan un comportamiento normal. a continuación se procedió a evaluar la siguiente hipótesis estadística: la hipótesis nula afirma que el promedio de las diferencias entre las puntuaciones de la posprueba y la preprueba del grupo experimental es igual al promedio de las diferencias entre las posprueba y la preprueba del grupo de control. por su parte, la hipótesis alternativa nos afirma que tales promedios difieren significativamente. desde luego, la idea es aceptar la hipótesis alternativa, pues si ella no fuera aceptada se concluiría que el programa “cuidando al cuidador” no logra aumentar significativamente la habilidad de cuidado de los cuidadores de la universidad de cundinamarca. con una confianza del 95%, la estadística de prueba3 usada para probar la hipótesis estadística antes planteada fue: al evaluar la anterior hipótesis, con un valor asociado a la estadística de prueba t de 4,128 y un valor p menor de 0,001, se encontró evidencia estadística suficiente para ser aceptada la afirmación hecha en la hipótesis alternativa; es decir, en este estudio existe evidencia suficiente de que el promedio de las diferencias de las puntuaciones del cai total entre la posprueba y la preprueba del grupo experimental es diferente al promedio de las diferencias de estas puntuaciones, pero ello sucede entre la posprueba y la preprueba del grupo de control. ahora bien, dado que la media de las diferencias entre las pospruebas y prepruebas del grupo experimental es mayor (14,78) que la media de las diferencias del grupo control (-1,43), se concluye que el programa “cuidando al cuidador” aumentó significativamente la habilidad general de cuidado (cai total) de los cuidadores estudiados en la universidad de cundinamarca. el anterior análisis estadístico se implementó de manera semejante para los datos obtenidos en cada una de las tres dimensiones constitutivas del cai. 3 esta estadística de prueba también será la usada para evaluar las hipótesis asociadas a las diferencias en entre las puntuaciones de las post-prueba y las preprueba de las dimensiones valor, conocimiento y paciencia, las cuales se presentan enseguida. el programa “cuidando al cuidador” aumentó la habilidad general de cuidado de los cuidadores estudiados en la universidad de cundinamarca. 86 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 la figura 2 muestra los box plots que representan las puntuaciones en la dimensión del valor. el lector puede advertir que se encuentran puntuaciones relativamente bajas que oscilan entre el 12%, aproximadamente (véase el extremo inferior del box plot del grupo de control en la posprueba), y que no superan el 80%. más aún, puede apreciarse que más de la mitad de los cuidadores de los dos grupos en los dos momentos no superan los 60 puntos. igualmente, existe aumento en la posprueba de los cuidadores del grupo experimental; sin embargo, también se aprecia que hubo cuidadores de este grupo que disminuyeron sus puntuaciones mínimas, tal como lo revela la más baja altura del extremo inferior del box plot de la posprueba, al compararlo con el equivalente de la preprueba. por su parte, en el grupo de control decrecen claramente tanto las mínimas puntuaciones como las puntuaciones del 50% de los cuidadores con más baja puntuación. por su parte, la dimensión del valor presenta un comportamiento normal al aplicársele el test estadístico de kolmogorov-smirnov, y se aceptaron valores de perspectiva de 0,987 y 0,143, que los diferencia entre las puntuaciones de la posprueba y las de la preprueba. una vez aceptado el supuesto de normalidad requerido para ser usada la prueba t con dos muestras independientes, se procedió a evaluar, con una confianza del 95%, la siguiente hipótesis estadística. la hipótesis nula afirma que el promedio de las diferencias entre las puntuaciones de la posprueba y la preprueba en la dimensión de valor del grupo experimental es igual al promedio de las diferencias entre la posprueba y la prepruebas del grupo control. al evaluar la anterior hipótesis con un valor asociado a la estadística de prueba de 2,559 y un valor p de 0,013, se encontró evidencia estadística suficiente para ser aceptada la afirmación hecha en la hipótesis alternativa; es decir, en este estudio existe evidencia suficiente para concluir que el promedio de las diferencias de las figura 2. representación de la habilidad de cuidado en su dimensión de valor para los grupos control y experimental en la preprueba y en la posprueba. la dimensión del valor presenta un comportamiento normal al aplicársele el test estadístico de kolmogorov-smirnov. 87 cuidando al cuidador: efectos de un programa educativo juan carlos díaz-álvarez, maría victoria rojas-martínez puntuaciones de la dimensión valor entre la posprueba y la preprueba del grupo experimental es distinto del promedio de las diferencias de estas puntuaciones, pero ello sucede entre la posprueba y la preprueba del grupo de control. ahora bien, dado que la media de las diferencias entre la posprueba y la preprueba del grupo experimental es mayor (4,08) que la media de las diferencias del grupo control (-3,97), se concluye que el programa “cuidando al cuidador” aumentó significativamente el valor de los cuidadores asistentes al programa en la universidad de cundinamarca. ahora bien, en lo que concierne a la dimensión del conocimiento, la figura 3 representa gráficamente con los box plots el comportamiento de los cuidadores de los dos grupos en esta dimensión del cai. por una parte, se aprecia que en los dos momentos ambos grupos de cuidadores presentaron puntuaciones relativamente altas (salvo por un dato atípico, al que se aludirá más adelante). las mínimas puntuaciones iniciales mejoraron en los dos grupos, aunque es mayor el aumento de los cuidadores del grupo experimental (nótese, sin embargo, que en su preprueba sus puntuaciones mínimas fueron inferiores a las del grupo de control). también puede establecerse que las puntuaciones del 50% de los cuidadores, representados en la parte superior de la barra horizontal del grupo experimental, fueron especialmente sensibles al aumento, en contraste con las homólogas del grupo de control, que apenas exhiben un tenue aumento. en este grupo las puntuaciones aumentaron en mayor medida que para las del grupo de control. compárense para ello las alturas de las líneas negras horizontales de los cuatro box plots. al comparar los dos grupos, se puede identificar mayor homogeneidad del grupo de control en los dos momentos del tiempo y mayor sensibilidad del grupo experimental, expresada en cambios favorables en la dimensión del conocimiento, como los que se acaban de exponer. en la figura 3 se grafica un dato atípico4 obtenido de un cuidador del grupo experimental en la primera medición de la preprueba. como en las dimensiones anteriores, se empleó el test de kolmogorov-smirnov, aceptándose valores p respectivos de 0,997 y 0,451, de modo que las diferencias entre la posprueba y la preprueba de las puntuaciones, en la dimensión conocimiento del grupo experimental y del grupo control, presentan un comportamiento normal. 4 en estos box plots extraídos del paquete estadístico spss, un dato atípico se ilustra mediante elipses y los extremos mediante asteriscos. así mismo, un dato atípico es aquel que se aleja del comportamiento de las puntuaciones del grupo. por ejemplo, si se observa en la figura 1 el box plot de las puntuaciones en la preprueba del grupo control, se pueden detectar cuatro datos atípicos los cuales representan igual número de cuidadores; específicamente, estos cuatro cuidadores puntuaron en la preprueba por debajo de 100 puntos mientras que el resto de cuidadores del grupo control puntuaron en la preprueba valores iguales o superiores a 160. complementariamente, un dato extremo es aquel que se aleja exageradamente del comportamiento del grupo y el cual, en la mayoría de los casos, ameritaría ser revisado para ver si es efectivamente esa la puntación o, si por el contrario, se cometió algún tipo de problema en la obtención del mismo. figura 3. representación de la habilidad de cuidado en su dimensión de conocimiento para los grupos de control y experimental en la preprueba y en la posprueba. 88 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 una vez aceptado el supuesto de normalidad requerido para ser usada la prueba t para dos muestras independientes, se procedió a evaluar, con una confianza del 95%, la siguiente hipótesis estadística. la hipótesis nula afirma que el promedio de las diferencias entre la posprueba y la preprueba, en la dimensión conocimiento del grupo experimental, es igual al promedio de las diferencias entre la posprueba y la preprueba del grupo de control. al evaluar la anterior hipótesis, con un valor asociado a la estadística de prueba de 3,403 y un valor p de 0,001, se encontró evidencia estadística suficiente para ser aceptada la afirmación hecha en la hipótesis nula, es decir, que en este estudio existe evidencia suficiente para concluir que el promedio de las diferencias de las puntuaciones de la dimensión conocimiento entre la posprueba y la preprueba del grupo experimental es distinto al promedio de las diferencias de estas puntuaciones, pero entre la posprueba y la preprueba del grupo de control. ahora bien, dado que la media de las diferencias entre la posprueba y la preprueba del grupo experimental es mayor (5,97) que la media de las diferencias del grupo control (1,29), se concluye que el programa “cuidando al cuidador” aumentó el nivel de conocimiento de los cuidadores. figura 4 representación de la habilidad de cuidado en su dimensión de paciencia para los grupos de control y experimental en la preprueba y en la posprueba. respecto del comportamiento estadístico que exhiben los datos de los dos grupos de participantes en la dimensión de la paciencia, la figura 4 muestra los box plots de la preprueba y de la posprueba. de esta figura se pueden extraer varias observaciones. nótese que en ambos grupos y en los dos momentos se conservan puntuaciones que no superan los 70 puntos. sin embargo, para la segunda evaluación los dos grupos de cuidadores aumentan considerablemente las puntuaciones mínimas. si se acepta que las puntuaciones mínimas de los del grupo experimental fueron especialmente bajas, es destacable el aumento que mostraron en su segunda evaluación, después de la intervención. a diferencia del grupo de control, en el grupo experimental se presentó un aumento relativamente leve, en las el programa “cuidando al cuidador” aumentó el nivel de conocimiento de los cuidadores. 89 cuidando al cuidador: efectos de un programa educativo juan carlos díaz-álvarez, maría victoria rojas-martínez puntuaciones del 50% de los cuidadores, que se encuentra demarcado por la parte superior de la barra negra horizontal. en síntesis, se detectó una sensibilidad específica en el grupo experimental y, en varios aspectos, una relativa constancia en el grupo de control con respecto de lo obtenido en la dimensión de la paciencia. además, en la figura 4 aparecen tres datos atípicos en las puntuaciones del grupo control. puede verse que todos se encuentran por debajo de las puntuaciones generales del grupo y que uno surge en la preprueba y dos en la posprueba. al aplicar el test de kolmogorov-smirnov, se aceptaron valores respectivos de 0,852 y 0,342, y se vio que las diferencias entre la posprueba y la preprueba de las puntuaciones en la dimensión paciencia presentan un comportamiento normal. una vez aceptado el supuesto de normalidad requerido para ser usada la prueba t con dos muestras independientes, se procedió a evaluar, con una confianza del 95%, la siguiente hipótesis estadística. la hipótesis nula afirma que el promedio de las diferencias entre las puntuaciones de la posprueba y la preprueba en la dimensión paciencia del grupo experimental es igual al promedio de las diferencias del grupo control. al evaluar la anterior hipótesis con un valor asociado a la estadística de prueba de 3,065 y un valor p de 0,003, se encontró evidencia estadística suficiente para ser aceptada la afirmación hecha en la hipótesis nula; es decir, existe evidencia suficiente para concluir que el promedio de las diferencias de las puntuaciones de la dimensión paciencia entre la posprueba y la preprueba del grupo experimental es distinto del promedio de las diferencias de estas puntuaciones, pero entre la posprueba y la preprueba del grupo de control. ahora, dado que la media de las diferencias entre la posprueba y la preprueba del grupo experimental es mayor (4,73) que la media de las diferencias del grupo control (1,26), se concluye que el programa “cuidando al cuidador” aumentó significativamente el nivel de paciencia de los cuidadores. discusión de los resultados características generales y del cuidado de los participantes del estudio varios estudios (2-8) han señalado que la mayoría de cuidadores familiares son mujeres, debido a sus múltiples y tradicionales roles ejercidos en la familia y en la sociedad. aunque la tendencia en la participación por género es menor para los hombres, estos se están vinculando cada vez más al cuidado, lo cual se manifiesta en 8% para el presente estudio. a partir de los estilos de vida de las sociedades desarrolladas, es posible encontrar jóvenes entre 36 y 59 años que cuidan a personas mayores y están comprometidos por lazos afectivos y filiales. la presente investigación reportó que el 43% tiene estudios hasta primaria, el 39% hasta bachillerato, el 35% son solteros, el 32% son casados, el 69% se ocupa de labores en el hogar, el 61% pertenecen a los estratos 1 y 2, el 83% desarrolla su labor a partir del diagnóstico, la mayoría (82%) tiene experiencia superior a tres años, el 51% relacionan ser cuidadores únicos y el 38% cuida todas las 24 horas del día. varios estudios han señalado que la mayoría de cuidadores familiares son mujeres, debido a sus múltiples y tradicionales roles ejercidos en la familia y en la sociedad. aunque la tendencia en la participación por género es menor para los hombres, estos se están vinculando cada vez más al cuidado. 90 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 el cuidar a un familiar enfermo comporta pérdida de autoridad e identidad (4) y generalmente afecta la calidad de vida del cuidador e impacta su bienestar y su salud (9); el afrontar el cuidado puede estar motivado como respuesta de agradecimiento hacia el enfermo o como una obligación cultural. de alguna manera, los bajos niveles educativo y económico repercuten en el desarrollo cognitivo y en la suplencia de necesidades básicas familiares, y se presume que los recursos familiares destinados a las necesidades básicas y a los requerimientos del enfermo no son cubiertos en su totalidad. pinto y sánchez (10) informan que el cambio de rol y las finanzas pueden impactar la familia y, por tanto, se presentan situaciones no solo personales y emocionales sino también financieras que interfieren en la calidad del cuidado. los estilos de vida se modifican, los roles cambian. generalmente existe un cuidador principal que asume la función operativa e instrumental; a su lado aparecen otros cuidadores clasificados como de apoyo o disponibles, pretenciosos y eximidos, los cuales desarrollan un cuidado indirecto y algunas veces pueden entorpecer el cuidado ofrecido por el cuidador principal (10). en cuanto a la apreciación de las horas ofrecidas en el cuidado, su significado depende del compromiso adquirido, del tipo de enfermedad, de la capacidad de socialización, de la vigilancia ofrecida y de la sobrecarga percibida en la ejecución del cuidado. discusión de los resultados en la preprueba y posprueba de los grupos de control y experimental en la medición general de la habilidad de cuidado, el 57% de los cuidadores del estudio obtuvieron alta puntuación, influida por los registros de las puntuaciones altas para las dimensiones de conocimiento y paciencia, lo que significa que cuentan con un nivel óptimo para cuidar, pero solo en estas dos dimensiones, porque la dimensión de valor registró puntajes bajos. estudios como los de rojas (6), díaz (7) y barrera y cols. (11) señalan comportamientos similares en otros grupos de cuidadores donde el valor se ve afectado, lo que denota carencias para afrontar el cuidado; se puede presumir que, respecto al valor, a los cuidadores se les dificulta ejecutar tareas dirigidas a su familiar cuando este se encuentra deprimido, sienten intranquilidad permanente, les resulta difícil entender cómo se sienten otros cuando no experimentan situaciones de cuidado similar o se les dificulta pedir ayuda para no desviarse de su rutina diaria. aparentemente, el temor a dejar solo a quien se cuida lo acrecienta la incertidumbre ante lo desconocido, además los cuidadores se abstienen de generar compromisos futuros. algunos estudios, como los de galvis (12) y barrera et ál. (13), evidencian que una habilidad de cuidado deficiente es un problema que tiende a impactar la salud pública. respecto al valor, los resultados señalan que los cuidadores familiares carecen de un valor óptimo para la habilidad de cuidado, lo cual influye negativamente en el desarrollo de la fuerza necesaria para afrontar el cuidado. bayes (14) comenta que es posible que se presenten en el cuidador sentimientos de impotencia y desesperanza que podrían evitarse generando actividades que controlen factores estresantes (11-14). ahora bien, en la preprueba, ambos grupos obtuvieron puntajes similares tanto en el cai general como en cada una de el cuidar a un familiar enfermo comporta pérdida de autoridad e identidad y generalmente afecta la calidad de vida del cuidador e impacta su bienestar y su salud. 91 cuidando al cuidador: efectos de un programa educativo juan carlos díaz-álvarez, maría victoria rojas-martínez sus dimensiones, pero en la posprueba la variación fue más significativa para el grupo experimental, pues los resultados del cai general señalan un aumento favorable de 9 puntos para la alta habilidad de cuidado y un decremento de 9 puntos para la baja habilidad de cuidado, lo cual significa que una vez aplicada la intervención en el grupo experimental del programa “cuidando al cuidador”, nueve personas incrementaron su habilidad para cuidar. para la dimensión de conocimiento, las cinco personas que calificaron bajo en la preprueba, una vez hecha la intervención de enfermería, pasaron a reportar en la posprueba un alto conocimiento; situación similar ocurrida para la dimensión de paciencia, pues de dos personas reportadas con baja paciencia en la preprueba, en la posprueba incrementaron en tal habilidad, puntuando alto en tal dimensión. es muy importante señalar que ni en la preprueba ni en la posprueba del grupo experimental hubo variación significativa para la dimensión de valor, pues los mayores puntajes se ubicaron en un nivel bajo, lo que implica que el programa no surtió los efectos esperados para incrementar el valor en los participantes del grupo experimental, pero respecto al conocimiento y a la paciencia los resultados del programa sí fueron óptimos. en el grupo de control los resultados similares, en la preprueba como en la posprueba, indican que no es posible incrementar las habilidades de cuidado relacionadas con las dimensiones de conocimiento, valor y paciencia sin ejecutar una intervención dirigida a estos aspectos, a pesar de que en este grupo se estableció un programa para fortalecer aspectos operativos e instrumentales para el cuidado. conclusiones basándose en los hallazgos generales y en cada uno de los elementos que constituyen el estudio, se concluye lo siguiente: estadísticamente se pudieron comparar y evaluar los cambios esperados en los grupos experimental y control, a pesar de las diferencias encontradas en las distintas variables sociodemográficas relativas al cuidado; el grupo experimental mostró mayores ventajas respecto a su nivel educativo, estrato socioeconómico, parentesco con el enfermo crónico a quien se cuida y, muy especialmente, en relación con la condición de no ser únicos cuidadores; el 69% del grupo control y el 30% del grupo experimental son cuidadores únicos. igualmente, la intervención en el grupo experimental fue favorable en las dimensiones de conocimiento y paciencia, pues sus puntajes se incrementaron en niveles altos, pero en la dimensión de valor los puntajes no mostraron cambios significativos ni en la preprueba ni en la posprueba. en el presente estudio, los cuidadores, en general, antes de cualquier intervención, iniciaron con un conocimiento y paciencia favorables y suficientes, mientras que el valor fue la dimensión de habilidad de cuidado menos adecuada y la evaluada por ellos con menos suficiencia. consistentemente, los resultados revelaron que la dimensión del valor fue insensible tanto a la intervención (grupo experimental) como al efecto del tiempo (grupo de control), mientras que las dimensiones del conocimiento y la paciencia fueron sensibles en un 100% al programa “cuidando al cuidador”, según lo reveló la inspección de las frecuencias. así también, conforme con las expectativas del diseño investigageneralmente existe un cuidador principal que asume la función operativa e instrumental; a su lado aparecen otros cuidadores clasificados como de apoyo o disponibles. 92 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 tivo, se encontró estabilidad en el grupo de control considerando las dos mediciones. las observaciones precedentes, basadas en la inspección visual, tuvieron respaldo estadístico, puesto que el tratamiento matemático reveló que la información empleada constituyó evidencia suficiente para concluir que el programa “cuidando al cuidador” mejoró no solo la habilidad de cuidado general, sino también la habilidad en las dimensiones del valor, del conocimiento y de la paciencia de los participantes del grupo experimental. de todas maneras, la insensibilidad aparente de la dimensión del valor junto con la producción de datos atípicos (y extremos) sugieren la necesidad de atender posibles problemas metodológicos relacionados tanto con las condiciones mismas de aplicación como con las características o bien conceptuales o bien metodológicas (de confiabilidad y validez) del cai como instrumento para la medición de la habilidad de cuidado. la red de apoyo familiar y social debe ser analizada y trabajada en cada uno de los cuidadores, debido a que la mayoría no cuenta con un apoyo consistente; esto los hace susceptibles al buen afrontamiento de las situaciones que se presentan en el proceso de cronicidad. referencias 1. nkongho, nogozi. the caring inventory. strickland o, waltz c. measurement of nursing outcomes 1999; foru. 2. mateo inmaculada, garcía calvente maría del mar. reducir el estrés del cuidador mejora la calidad de su trabajo. escuela andaluza de salud pública; 1999. [sitio en internet]. disponible en: http:// www.diariomedico.com/entorno/ento70499.com. html. consultado: 10 de junio de 2007. 3. barrera lucy. el cuidado del cuidador que afronta enfermedades crónicas. en cuidado y práctica de enfermería. bogotá: unibiblos; 2000. p. 233-5. 4. merce josé. ancianos en casa. la labor de los cuidadores, poco valorada. consumer 2001 feb; 41. 5. galvis lópez clara rocío. comparación entre la habilidad de cuidado de cuidadores de personas en situación de enfermedad crónica en villavicencio, meta. avances en enfermería 2004 enero-junio; xxii(1): 8-12. 6. rojas martínez maría victoria. asociación entre la habilidad de cuidado del cuidador con el tiempo de cuidado y el grado de dependencia del adulto mayor que vive situación de enfermedad crónica, en la ciudad de girardot. avances en enfermería 2007; xxv(1): 33-45, 35. 7. díaz álvarez juan carlos. habilidades de cuidado de los cuidadores familiares de personas en situación de enfermedad crónica vinculados al hospital san rafael de girardot. avances en enfermería 2007; xxv(1): 69-82, 73. 8. barrera ortiz lucy, pinto afanador natividad, sánchez herrera beatriz. evaluación de un programa para fortalecer a los cuidadores familiares de enfermeros crónicos. salud pública 2006; 8(2): 141-52. 9. sánchez herrera beatriz. la cronicidad y el cuidado familiar, un problema de todas las edades: los cuidadores de ancianos. avances en enfermería 2004 enero-junio; xxii(1): 61-6. 10. pinto afanador natividad, sánchez herrera beatriz. el reto de los cuidadores familiares de personas en situaciones crónicas de enfermedad. en: grupo de cuidado, facultad de enfermería, universidad nacional de colombia. cuidado y práctica de enfermería. bogotá: unibiblos; 2000. p. 172-179, 178. 11. barrera ortiz lucy, blanco de camargo lidia, figueroa ingrid patricia, pinto afanador natividad, sánchez herrera beatriz. habilidad de cuidadores familiares de personas con enfermedad crónica. aquichan 2006; 6-6(1): 2233 12. galvis lópez clara rocío, pinzón rocha maría luisa, romero gonzález esperanza. comparación entre la habilidad de cuidado de cuidadores de personas en situación de enfermedad crónica en villavicencio, meta. avances en enfermería 2004 enero-junio; xxii(1): 8-12. 13. pinto afanador natividad, barrera ortiz lucy, sánchez herrera beatriz. reflexiones sobre el cuidado a partir del programa “cuidando a los cuidadores”. aquichan 2005 octubre; 5-5(1): 128-137. 14. bayes ramón. cuidando al cuidador, evaluación del cuidador y apoyo social, análisis de los recursos psicológicos y soporte emocional del cuidador. universidad autónoma de barcelona; 2002. p. 1. [sitio en internet]. disponible en: www.fehad.org/vahad/ pn022.htm. consultado: 4 de octubre de 2007. 13. educacišn en salud año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 46 l gran número de desplazados a las grandes ciudades, por la violencia, el incremento de la pobreza, el hacinamiento y el aumento de la morbimortalidad, ha llevado a los gobiernos, y a entidades como la unicef y la oms, entre otras, a crear estrategias de alto rendimiento en educación para la salud; para ello se formulan programas, hay designación de personas o contratación de entidades para impartirla, pero, ¿qué sucede con la población que es objeto de ella?, ¿por qué no mejoran sus condiciones de vida, si la intencionalidad es promover el desarrollo de las personas y las comunidades? para intentar dar una respuesta a los interrogantes anteriores, se debe revisar que el concepto de desarrollo está evolucionando y ha pasado de una concepción estrictamente economicista a una más humana, ecologista y sostenible en el futuro. el desarrollo lo define andrés yurjevic (7) como un proceso de transforresumen la violencia, el incremento de la pobreza, el hacinamiento y el aumento de la morbimortalidad han llevado a los gobiernos, y a las entidades nacionales e internacionales, a crear estrategias de alto rendimiento en educación para la salud, pero, ¿por qué no mejoran sus condiciones de vida, si la intencionalidad es promover el desarrollo de las personas y las comunidades? deben mirarse aspectos importantes, como el desarrollo, las condiciones de vida, la humanización y la educación en salud. a partir del planteamiento anterior, debe considerarse la visión de desarrollo ecológico y una concepción de educación por el desarrollo humano. el proceso educativo en salud se convierte en algo mucho más complejo, porque debe enrumbarse hacia el crecimiento de la persona y la humanización de la sociedad, al mismo tiempo que se amplían las opciones para lograr un nivel de vida aceptable en un medio ambiente sano, que debe ser la causa principal del proceso educativo en salud. palabras clave desarrollo, educación en salud, humanismo, medio ambiente, proceso educativo, educador en salud. abstract due to violence, increase of poverty, stacking, and the increase in morbi-mortality the governments, national and international entities have created strategies of high performance in health education, but: ¿why life conditions do not improve, if the intention is to promote the development of people and communities? important aspects should be considered, such as development, life conditions, humanization and health education. from that point of view, the vision of ecological development should be considered and a concept of education for human development. the educative process in health becomes something much more complex, because it should be oriented toward person’s growth and humanization of society, making wider options to reach an acceptable life level in a healthy environment, being the main cause of the process of health education. key words development, health education, humanism, environment, educative process, health educator. clara rozo de arévalo educación en salud 47 hombre integral, capaz de respetar y admirar toda forma de vida. para ello, debe armonizar la relación entre conciencia ecológica, experiencia estética y los pensamientos religiosos, éticos y filosóficos con el pensamiento científicotecnológico. lo anterior supone la necesidad de un cambio de mentalidad progresiva en los ámbitos individual, social y económico, un cambio en el que la educación tiene una función constructora, y es por ello que se plantea la necesidad de una educación por el desarrollo humano (5). el desarrollo humano contempla la ampliación de opciones de la gente, y el nivel de bienestar que logran esas opciones son: vivir una vida larga y saludable, adquirir conocimientos y tener acceso a los recursos necesarios para lograr un nivel de vida aceptable (2). es por esto que la educación en salud debe estar orientada hacia una formación humana que propenda por el desarrollo del ser humano, con metas y objetivos claros de superación y autorrealización, utilizando los conocimientos y habilidades de los integrantes de la comunidad, para fortalecer la capacidad innata de las personas en la resolución de los problemas que inciden en su salud. es así como el proceso educativo en salud a la comunidad resulta mucho más complejo, porque el objetivo se enrumba hacia el crecimiento de la persona y humanización de la sociedad, lo cual le da un carácter dialógico al estar en permanente contacto con la realidad cambiante y con seres humanos siempre en transformación. en última instancia, la educación debe atender a las necesidades, intereses y aspiraciones de la población, así como de su cultura, para que se cumpla de esta manera el carácter social y humano, el cual hará posible una participación enterada y consciente de la comunidad, una verdadera movilización social al detectarse el interés y el deseo de contribuir a mejorar la salud y la conservación del medio ambiente. de esta manera se propicia el desarrollo humano y ecológico de los usuarios, al brindarles educación para el manejo adecuado del medio ambiente (interno y externo), es decir, todas aquellas condiciones que existen dentro del organismo vivo, heredadas o adquiridas, y fuera del mismo, como los sistemas ecológicos, los cuales son el único camino para la estabilidad ambiental global y la preservación de la vida; esto los llevará a que conserven su equilibrio y no den origen a estados mórbidos, los cuales incidirán en la familia, el grupo y las condiciones laborales, y determinarán la calidad de vida y el desarrollo. la acción, en cuanto al modo de relacionarse con el entorno, es resultado y causa principal del proceso educativo. finalmente, el educador en salud debe tener como objeto a la persona, y poseer una actitud no definida por la dedicación profesional, sino por el emplazamiento frente a lo humano como preocupación central; esto lleva a replantear si verdaderamente se está dando educación en salud y si las personas que la brindan poseen las características requeridas, que propicien con el proceso educativo un cuidado ambiental, personal y familiar para alcanzar el desarrollo humano. mación que experimenta una sociedad en la búsqueda de márgenes crecientes de libertad, bienestar y participación para su población. según el autor, este concepto se ha ido construyendo con las contribuciones de vertientes teóricas diversas, que han aportado a la comprensión y relación entre pobreza y deterioro medioambiental, con estudios sobre temas específicos, evaluaciones empíricas, reflexiones y aportes conceptuales. ahora bien, si hacemos un análisis, en el hombre las necesidades absolutas provienen de la fisiología y la condición gregaria, son impulsos que deben ser guiados para que biológicamente el ser humano tenga una vida sana. además, este posee las aspiraciones que reflejan los intentos por ser mejores, empujan a la creación y se originan en las profundidades del espíritu, ligándolo al plan evolutivo, en busca de la creatividad, la sabiduría y la santidad (4). entonces, se puede plantear que la educación en salud, para propiciar el desarrollo, debería ser una disciplina que ponga orden a las diferentes aristas que tiene el hecho de que las acciones del hombre aumentan o disminuyen la salud individual y colectiva, que llevan o no al desarrollo. no podemos alejarnos de la concepción de que el hombre interactúa constantemente con el medio ambiente, y el resultado de esa interacción se manifiesta en el continuum salud-enfermedad, que a su vez acelera o retarda el desarrollo poblacional. de esta manera, se deduce que el tipo de desarrollo debe encaminarse hacia un humanismo que devuelva a hombres y mujeres su plenitud para proyectarse al mundo, que cultive al 1. bueno, gustavo. qué es la filosofía, ediciones oviedo, españa, 1995. 2. desarrollo a escala humana, cepaur, fundación dag hammarskjold, 1995. 3. durkeim, emile. educación y pedagogía, icfes, upn, colombia, 1990. 4. fernández, david, s. j. nuevos paradigmas para una educación humanista, iteso, cátedra paulo freire, méxico, 2000. 5. puleda, salvatore. interpretaciones del humanismo, roma, italia, 1999. 6. serrano, maría isabel. la educación para la salud del siglo xxi, editorial díaz de santos, españa, 1997. 7. yurjevic, andrés. marco conceptual para definir un desarrollo humano y ecológico, chile, 1999. bibliografía 1 carlos reyes-sánchez1 guillermo alonso castaño-pérez2 brenda ceballos-alatorre3 perla martínez-aguilera4 brenda guadalupe yañez-castillo5 influencia del ambiente en el desarrollo de la resiliencia en adolescentes de medellín, colombia* 1 https://orcid.org/0000-0001-7758-5906. universidad autónoma de tamaulipas, facultad de enfermería, méxico. crsanchez@docentes.uat.edu.mx 2 https://orcid.org/0000-0002-0291-3511. universidad ces, colombia. gacastano@ces.edu.co 3 https://orcid.org/0000-0001-7522-9617. universidad autónoma de tamaulipas, facultad de enfermería, méxico. bceballos@docentes.uat.edu.mx 4 https://orcid.org/0000-0003-1428-5142. universidad autónoma de tamaulipas, facultad de enfermería, méxico. pmaguilera@docentes.uat.edu.mx 5 https://orcid.org/0000-0002-3203-8156. universidad autónoma de tamaulipas, facultad de enfermería, méxico. bgyanez@docentes.uat.edu.mx * artículo derivado de la tesis doctoral titulada “modelo explicativo del consumo de drogas basado en el modelo de adaptación de roy, en un grupo de adolescentes de medellín, colombia.”, universidad de antioquia. recibido: 17/12/2019 enviado a pares: 23/01/2020 aceptado por pares: 29/03/2020 aprobado: 27/04/2020 doi: 10.5294/aqui.2020.20.2.4 para citar este artículo / to reference this article / para citar este artigo reyes-sánchez c, castaño-pérez ga, ceballos-alatorre b, martínez-aguilera p, yañez-castillo bg. environmental influence on adolescent resilience development in medellin colombia. aquichan. 2020;20(2):e2024. doi: https://doi.org/10.5294/aqui.2020.20.2.4 resumen objetivo: conocer la influencia del ambiente (funcionalidad familiar, apoyo social y ambiente barrial y escolar) en el desarrollo de la resiliencia de los adolescentes. métodos: diseño descriptivo, correlacional. participaron 184 adolescentes de seis colegios de la comuna aranjuez de medellín. muestreo probabilístico, bietápico. para recolectar los datos, se aplicaron cinco escalas: 1) la escala child and youth resilience measure; 2) el cuestionario de ambiente barrial; 3) la escala de evaluación de cohesión y adaptabilidad familiar; 4) la escala multidimensional de apoyo social percibido; y 5) el cuestionario de ambiente escolar. los datos se procesaron con el software spss 24v. resultados: se encontró una relación entre la resiliencia y el ambiente barrial (rs = .324, p = .000), funcionalidad familiar (rs = .380, p = .000), apoyo año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2024 temática: promoción y prevención. aporte a la disciplina: los resultados de esta investigación aportan información valiosa sobre la influencia del ambiente en el desarrollo de la conducta resiliente de los adolescentes. con este conocimiento, y en la medida en que los profesionales de enfermería puedan identificar las capacidades resilientes y los recursos que tienen los adolescentes para adaptarse a cada una de las etapas de su proceso, podrán ayudarlos a mantener estilos de vida saludables. esta es una de las metas de los programas de atención para los adolescentes. https://orcid.org/0000-0001-7758-5906 mailto:crsanchez@docentes.uat.edu.mx https://orcid.org/0000-0002-0291-3511 mailto:gacastano@ces.edu.co https://orcid.org/0000-0001-7522-9617 mailto:bceballos@docentes.uat.edu.mx https://orcid.org/0000-0003-1428-5142 mailto:pmaguilera@docentes.uat.edu.mx https://orcid.org/0000-0002-3203-8156 mailto:bgyanez@docentes.uat.edu.mx https://doi.org/10.5294/aqui.2020.20.2.4 https://orcid.org/0000-0001-7758-5906 https://orcid.org/0000-0002-0291-3511 https://orcid.org/0000-0001-7522-9617 https://orcid.org/0000-0003-1428-5142 https://orcid.org/0000-0002-3203-8156 https://doi.org/10.5294/aqui.2020.20.2.4 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2024 social (rs = .456, p = .000) y ambiente escolar (rs = .353, p = .000). además, la resiliencia fue explicada en un 35,8 % por el ambiente barrial (β =.20; p =.012), la funcionalidad familiar (β =.13; p =.090), el apoyo social (β =.30; p =.000) y el ambiente escolar (β =.15; p = .064). conclusión: la conducta resiliente de los adolescentes es influenciada por el apoyo social, la funcionalidad familiar y el ambiente escolar y barrial, factores externos que favorecen la autorregulación, como lo menciona roy en su modelo de enfermería. palabras clave (fuente: decs) resiliencia psicológica; adaptación psicológica; ambiente social; menores; modelo de adaptación de roy. 3 influencia del ambiente en el desarrollo de la resiliencia en adolescentes de medellín, colombia l carlos reyes-sánchez y otros environmental influence on adolescent resilience development in medellin colombia* abstract objective: to know the influence of the environment (family functionality, social support and neighbourhood and school environment) on the development of adolescent resilience. methods: descriptive, correlational design. a total of 184 adolescents from six schools in the aranjuez district of medellín participated. probabilistic, two-stage sampling. five scales were used to collect data: 1) the child and youth resilience measurement scale; 2) the neighbourhood environment questionnaire; 3) the family cohesion and adaptability assessment scale; 4) the multidimensional scale of perceived social support; and 5) the school environment questionnaire. data were analysed though spss 24v software. results: a relationship was found between resilience and neighbourhood environment (rs = .324, p = .000), family functionality (rs = .380, p = .000), social support (rs = .456, p = .000) and school environment (rs = .353, p = .000). in addition, resilience was explained in 35.8 % by the neighbourhood environment (β = .20; p = .012), family functionality (β = .13; p = .090), social support (β = .30; p = .000) and school environment (β = .15; p = .064). conclusion: adolescent resilient behaviour is influenced by social support, family functioning, and school and neighbourhood environment, all external factors fostering self-regulation, as mentioned by roy’s nursing model. keywords (source: decs) resilience; psychological; psychological adaptation; social environment; minors; roy’s adaptation model. año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2024 * article derived from the doctoral thesis entitled “modelo explicativo del consumo de drogas basado en el modelo de adaptación de roy, en un grupo de adolescentes de medellín, colombia.”, university of antioquia. 4 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2024 aquichan issn 1657-5997 eissn 2027-5374 influência do ambiente no desenvolvimento da resiliência em adolescentes de medellín, colômbia resumo objetivo: availar a influência do ambiente (funcionalidade familiar, apoio social e ambiente de bairro e escolar) no desenvolvimento da resiliência dos adolescentes. métodos: desenho descritivo, correlacional. participaram 184 adolescentes de seis colégios da comunidade aranjuez, medellín, colômbia. amostragem probabilística, bietápica. para coletar os dados, foram aplicados cinco instrumentos: 1) a escala child and youth resilience measure; 2) o questionário de ambiente de bairro; 3) a escala de avaliação de coesão e adaptabilidade familiar; 4) a escala multidimensional de apoio social percebido; 5) o questionário de ambiente escolar. os dados foram processados com o software spss 24v. resultados: verificou-se relação entre a resiliência e o ambiente de bairro (rs = .324, p = .000), funcionalidade familiar (rs = .380, p = .000), apoio social (rs = .456, p = .000) e ambiente escolar (rs = .353, p = .000). além disso, a resiliência foi explicada em 35,8 % pelo contexto de bairro (β =.20; p =.012), pela funcionalidade familiar (β =.13; p =.090), pelo apoio social (β =.30; p =.000) e pelo ambiente escolar (β =.15; p = .064). conclusões: o comportamento resiliente dos adolescentes é influenciado pelo apoio social, pela funcionalidade familiar e pelo ambiente escolar e de bairro, fatores externos que favorecem a autorregulação, como mencionado por roy no seu modelo de enfermagem. palavras-chave (fonte: decs) resiliência psicológica; adaptação psicológica; meio ambiente; meio social; menores de idade; modelo de adaptação de roy. * artigo derivado da tese de doutorado “modelo explicativo del consumo de drogas basado en el modelo de adaptación de roy, en un grupo de adolescentes de medellín, colombia.”, universidad de antioquia. 5 influencia del ambiente en el desarrollo de la resiliencia en adolescentes de medellín, colombia l carlos reyes-sánchez y otros introducción la adolescencia es un momento crítico por los múltiples cambios que se presentan en el individuo antes de alcanzar la madurez (1). durante esta etapa se define la personalidad, se construye la independencia y se fortalece la autoafirmación. además, se presentan importantes cambios físicos, sexuales, psicológicos y sociales (2). a menudo, el adolescente presenta comportamientos impulsivos o tiene una baja percepción del riesgo, lo cual lo coloca en una posición de vulnerabilidad y exposición a conductas de riesgo, como el uso y el abuso de drogas, iniciar una vida sexual a temprana edad, tener relaciones sexuales desprotegidas y manejar a exceso de velocidad (3, 4). por otro lado, influencias externas como los amigos, pares y familiares cercanos adquieren una gran importancia, dado el significado motivacional que tienen para los adolescentes. prueba de esto es la facilidad con la que siguen las indicaciones de sus amigos o compañeros, por encima de las de los padres. el deseo de ser aceptados por un grupo los lleva a efectuar prácticas de riesgo, en lugar de buscar su valoración por sus cualidades personales (5). en los adolescentes, el proceso de toma de decisiones, la adaptación a los cambios físicos, la resolución y el enfrentamiento a distintas situaciones en sus entornos social, familiar y escolar los hace susceptibles de caer en problemas que los alejan de una vida saludable, como las adicciones, la depresión y los trastornos alimenticios, lo cual les trae problemas con la autoridad (1). ante este fenómeno, el adolescente tendrá la capacidad de afrontar la adversidad, es decir, de ser resiliente (6). desde una perspectiva holística, la resiliencia se entiende como un proceso dinámico (7) y diacrónico que se desarrolla dentro de un marco ecológico y cultural (8). comúnmente conocida como la capacidad que tienen los seres humanos para afrontar exitosamente los diversos desafíos que la vida les presenta, en los adolescentes la resiliencia es aquella capacidad que desarrollan para sobreponerse a las condiciones difíciles del entorno, superarlas y salir transformados (9). en este sentido, tener una alta resiliencia se asocia con niveles más elevados de bienestar psicológico y salud mental, a la vez que con una alta capacidad para manejar el estrés y desarrollarse a pesar de experiencias desfavorables o adversas (10). en este orden de ideas, la resiliencia se considera la capacidad positiva que tienen los adolescentes de ver oportunidades y posibilidades donde otros no las ven y de encontrar soluciones para enfrentar situaciones críticas y adversas y convertirlas en oportunidades para triunfar en la vida (11). esta capacidad está sujeta a la existencia de ciertas cualidades, virtudes y recursos internos del adolescente que le permiten asumir cambios y afrontar situaciones críticas de una manera exitosa (12). la resiliencia también se desarrolla dependiendo de la personalidad desarrollada por el adolescente y de cada experiencia significativa que este viva. así, cada situación se convierte en una oportunidad para gestionar los diferentes recursos del ambiente para su beneficio propio o, al contrario, para deteriorar de su bienestar y su desarrollo personal (11). en este sentido, ungar define resiliencia como la capacidad individual y colectiva de navegar en dirección a los propios recursos psicológicos, sociales, culturales y físicos para lograr su bienestar y a la capacidad de poner a disposición tales recursos de una forma que tenga sentido en la cultura (13). es importante resaltar que la resiliencia no constituye un atributo absoluto; tampoco se practica a cada minuto; mucho menos se nace siendo resiliente. se trata de la capacidad de reflexionar acerca de las metas que desea alcanzar la persona en los distintos ámbitos de su vida, con el fin de mejorar las condiciones económicas propias y de su familia. es un proceso interactivo entre la persona y el entorno en una situación de riesgo (11). por otra parte, roy menciona que la persona tiene la capacidad de pensar y de sentir basada en la conciencia y en el significado, lo cual le permite adaptarse de manera eficaz o ineficaz a los cambios que se producen en el entorno, así como influir en este (14). es decir, el adolescente con alta resiliencia busca los recursos necesarios para alcanzar sus objetivos: aprovecha los servicios que su comunidad o su colegio le brindan para, así, solucionar las dificultades, capacitarse académica y laboralmente y hallar personas de confianza que le puedan brindar apoyo emocional o económico (11). el adolescente que cuenta con recursos externos positivos tiene la capacidad de responder de manera efectiva al ambiente por medio de una adaptación efectiva. por otro lado, roy señala que el cambio del ambiente estimula a la persona a responder de manera adaptativa (15). el adolescente, a lo largo de su vida, va 6 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2024 aquichan issn 1657-5997 eissn 2027-5374 adquiriendo la capacidad de tener una alta o una baja resiliencia (11). por ende, el ambiente barrial, la funcionalidad familiar, el apoyo social y el ambiente escolar pueden influir en el desarrollo de su resiliencia (16, 17). en este sentido, el fortalecimiento de estos recursos en los adolescentes les brinda la capacidad de responder efectivamente a las situaciones de riesgo presentes en el entorno (adaptación eficaz), es decir, de ser resilientes. dado el interés de este tema para los profesionales de enfermería, el objetivo de este trabajo fue conocer la influencia del ambiente (barrial, familiar, social y escolar) en el desarrollo de la resiliencia de los adolescentes. metodología la investigación fue de tipo descriptivo, correlacional (18). la población fue de 55.091 estudiantes de 10 a 18 años, distribuidos en 15 colegios públicos de la comuna de aranjuez de medellín. el cálculo del tamaño de la muestra se obtuvo por medio del programa estadístico epidat v4.1, con un nivel de confianza del 95 %, un error estimado máximo permitido del 3 % y un efecto de diseño del 1,5 %. por lo tanto, el tamaño de la muestra requerido fue de 184 adolescentes. el muestreo fue probabilístico y bietápico. en la primera fase, se aleatorizaron los colegios y se seleccionaron seis de ellos; en la segunda fase, se seleccionaron los estudiantes participantes (18). para la recolección, fue utilizada una ficha de datos personales que contenía cuatro preguntas (¿cuál es tu sexo?, ¿qué edad tienes?, ¿cuál es tu estructura familiar?, ¿cuál es tu estrato social?); la escala child and youth resilience measure (cyrm-28), la cual tuvo como objetivo identificar los recursos multidimensionales de la persona, teniendo en cuenta sus características individuales, su contexto y su relación con el entorno más próximo (19), compuesta por 28 preguntas, con respuesta tipo likert y un alpha de cronbach de 0,74; el cuestionario de ambiente barrial (cab), construido ad hoc mediante una búsqueda exhaustiva de la bibliografía existente, de 10 preguntas, con respuesta tipo likert (que va desde totalmente en desacuerdo hasta totalmente de acuerdo) y un alpha de cronbach de 0,69); la escala de evaluación de cohesión y adaptabilidad familiar (faces iii), la cual evaluó la cohesión y la adaptabilidad del funcionamiento familiar, de 20 preguntas, con una escala tipo likert de 1 a 5 (nunca, 1; casi nunca, 2; algunas veces, 3; casi siempre, 4; y siempre, 5) y un alpha de cronbach de 0,77 (20); la escala multidimensional de apoyo social percibido de zimet et al. (mspss), la cual evaluó la percepción de los adolescentes del apoyo social, conformada por 12 preguntas agrupadas en tres factores (la percepción de apoyo social de pares [preguntas 6, 7, 9 y 12], la percepción de apoyo social de la familia [preguntas 3, 4, 8 y 11] y la percepción de apoyo de la pareja u otras figuras significativas [preguntas 1, 2, 5 y 10]), una respuesta de tipo likert de siete puntos que va de 1 a 7 (1 = totalmente en desacuerdo; 2= bastante en desacuerdo; 3 = más bien en desacuerdo; 4 = ni de acuerdo ni en desacuerdo; 5 = más bien de acuerdo; 6 = bastante de acuerdo; 7 = totalmente de acuerdo) y un alpha de cronbach de 0,89 (21); y, finalmente, el cuestionario de ambiente escolar (cae), construido ad hoc mediante una búsqueda exhaustiva de la bibliográfica existente, de 20 preguntas, con una respuesta tipo likert que va desde totalmente en desacuerdo hasta totalmente de acuerdo y un alpha de cronbach de 0,76. los cuestionarios que se construyeron ad hoc mediante la búsqueda exhaustiva de la bibliográfica existente se sometieron a validez de contenido por tres expertos en la temática, a través de la técnica delphi. posteriormente, se realizó la validez de constructo por medio del análisis factorial exploratorio y confirmatorio, con rotación varimax con todos los ítems que conformaron cada cuestionario, además de aplicar la prueba clásica de alpha de cronbach. para la recolección de los datos, se contó con la autorización de los rectores de cada colegio participante, con el consentimiento de los padres de familia y con el asentimiento informado de los adolescentes que fueron elegidos al azar para participar en la presente investigación. posteriormente, se aplicaron los cuestionarios y la ficha de datos sociodemográficos a la muestra de adolescentes, en un lugar asignado por los directivos de la institución educativa. este contó con una iluminación adecuada y con el equipo necesario para aplicar los cuestionarios. por último, se agradeció la participación de los adolescentes, la disponibilidad del espacio y el tiempo del docente en el estudio. para el presente estudio, se siguieron los principios de la resolución 08430 de 1993 del ministerio nacional de salud de colombia y se contó con la aprobación del comité de ética de investigación de la facultad de enfermería de la universidad de antioquía, con número de acta cei-fe 2015-06 (22). por último, en el análisis de los datos se utilizó el programa estadístico para las ciencias sociales spss versión 24 (23). se cal7 influencia del ambiente en el desarrollo de la resiliencia en adolescentes de medellín, colombia l carlos reyes-sánchez y otros cularon los promedios de los instrumentos con valor de 0 a 100, por medio de la siguiente fórmula: ((sum (variable 1, variable 2,...) menos el valor mínimo) entre (valor máximo menos el valor mínimo)) multiplicado por 100. a partir del análisis descriptivo, se obtuvieron, para las variables cuantitativas (sexo, edad, estructura familiar, estrato socioeconómico), distribuciones de frecuencia absoluta y porcentual, y para las variables cuantitativas (resiliencia, ambiente barrial, apoyo social, funcionalidad familiar, ambiente escolar), medidas de tendencia central y variabilidad. se aplicaron la prueba coeficiente de correlación de spearman; la prueba de regresión lineal simple; la resiliencia (como variable dependiente); y el ambiente barrial, el apoyo social, la funcionalidad familiar y el ambiente escolar (como variables independientes). resultados la muestra estuvo compuesta por 184 adolescentes, de los cuales el 50,5 % estaba representado por el sexo femenino, el 81 % se encontraba en la adolescencia temprana, el 45,1 % pertenecía a una familia nuclear y el 47,3 % pertenecía al estrato 2 (tabla 1). tabla 1. datos sociodemográficos de los adolescentes variable f % sexo masculino femenino 91 93 49,5 50,5 edad adolescencia temprana adolescencia tardía 149 35 81,0 19,0 estructura familiar nuclear extendida monoparental ensamblada monoparental extendida 83 37 52 1 11 45,1 20,1 28,3 0,5 6,0 nivel socioeconómico 1 2 3 4 22 87 73 2 12,0 47,3 39,7 1,1 nota: cdp n = 184. fuente: elaboración propia. por otra parte, la media del índice de resiliencia en los adolescentes fue de 75,9 (de = 17,2); el ambiente barrial fue de 41,4 (de = 13,9); la funcionalidad familiar fue de 60,4 (de = 16,3); el apoyo social fue de 69,8 (de = 23,2); y el ambiente escolar fue de 65,6 (de = 13,8). es decir, se encontró que los adolescentes contaban con una buena resiliencia, una buena funcionalidad familiar y un buen apoyo social, por lo cual la percepción del ambiente escolar y del ambiente barrial fue positiva (tabla 2). tabla 2. recursos externos de los adolescentes variable x me de valor máximo valor mínino resiliencia 75,9 81,3 17,234 13 100 ambiente barrial 41,4 42,0 13,907 0 80 funcionalidad familiar 60,4 60,4 16,349 0 100 apoyo social 69,8 75,0 23,232 0 100 ambiente escolar 65,6 65,6 13,816 29 94 nota: x = media, me = mediana, de = desviación estándar. n = 184. fuente: elaboración propia. se encontró una relación positiva significativa entre la resiliencia y el ambiente barrial (rs = .324, p = .000), la funcionalidad familiar (rs = .380, p = .000), el apoyo social (rs = .456, p = .000) y el ambiente escolar (rs = .353, p = .000). es decir, entre mayor es la percepción positiva de estos factores, mayor será la conducta resiliente (tabla 3). tabla 3. coeficiente de correlación de spearman entre la resiliencia, el ambiente barrial, la funcionalidad familiar, el apoyo social y el ambiente escolar variable 1 2 3 4 5 1. resiliencia 1 2. ambiente barrial ,324 1 (,000) 3. funcionalidad familiar ,380 ,218 1 (,000) (,003) 4. apoyo social .456 ,307 ,504 1 (,000) (,000) (,000) 5. ambiente escolar ,353 ,275 ,301 ,377 1 (,000) (,000) (,000) (,000) nota: rs = coeficiente de correlación de spearman. n = 184 fuente: elaboración propia. 8 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2024 aquichan issn 1657-5997 eissn 2027-5374 al analizar la regresión lineal múltiple, se encontró que la resiliencia fue explicada en un 35,8 % por el ambiente barrial (β  = .20), la funcionalidad familiar (β = .13), el apoyo social (β = .30) y el ambiente escolar (β = .15) (tabla 4). tabla 4. influencia del ambiente en el desarrollo de la resiliencia en adolescentes coeficientes no estandarizados t valor de p β e. e (resiliencia) 29,471 5,563 5,298 ,000 ambiente barrial 0,20 0,081 2,531 ,012 funcionalidad familiar 0,13 ,074 1,704 ,090 apoyo social 0,30 ,054 5,416 ,000 ambiente escolar 0,15 ,083 1,866 ,064 modelo 1 f(5,179)=26,508, r²=35,8%, p=,000 nota: e.e = error estándar, t = t de student, f = distribución f n = 184 fuente: elaboración propia. discusión durante la adolescencia ocurren múltiples cambios fisiológicos y psicológicos que trastocan la estabilidad del adolescente y le crean una sensación de inseguridad e incertidumbre (24). todo ello lo conduce a luchar por adquirir una identidad y una independencia a partir de la formación que tuvo durante la infancia, tiempo en el cual se crean vínculos afectivos con la familia y se conforma un apoyo social, de seguridad personal y del entorno (ambiente barrial y escolar) (25). los resultados muestran que los adolescentes tienen, en general, un ambiente barrial seguro, una funcionalidad familiar, un apoyo social y un ambiente escolar positivos, además de que cuentan con una alta resiliencia. coinciden con lo reportado por rodríguez-fernández, ramos-díaz, ros, fernández-zabala y revuelta, quienes encontraron que los adolescentes tenían una alta resiliencia (media = 74,8, de = 9,23) y un alto apoyo social (media 33, de = 5,07) (17), situación que puede deberse a que aquellos, al pasar de la niñez a la adolescencia, y al enfrentarse a una fase académica diferente, requieren el apoyo de nuevos compañeros, amistades y profesores. además, la identificación de la capacidad del adolescente para aprovechar los recursos sociales y familiares dentro de sus sistemas integrados proporciona mecanismos para el desarrollo de la resiliencia (26). por otro lado, se encontró que un ambiente barrial, una funcionalidad familiar, un apoyo social y un ambiente escolar positivos aumentan la conducta resiliente en los adolescentes. los datos mencionados coinciden con la teoría de la funcionalidad familiar de liebschutz y cols. y de cárdenas (27, 16). estos autores evidenciaron que los adolescentes que cuentan con una familia funcional (r = .370; p = .001) presentan una alta resiliencia. cabe mencionar que los adolescentes que son altamente resilientes, aunque se encuentren consumiendo energía en sus procesos de adaptación al ambiente, autonomía y confianza, son capaces de enfrentar la adversidad. esta situación, por demás favorable para los ambientes barrial y escolar, demuestra que puede ser un desafío, al provocar desequilibrios en aquellos procesos cognitivos que mueven al adolescente hacia mayores grados de conciencia social, reflexión sobre su ambiente y sobre sí mismo y, desde luego, hacia la generación de aprendizajes significativos, al estar en constante interacción con el ambiente (1). en cuanto al apoyo social y al ambiente escolar, varios investigadores reportaron datos estadísticamente significativos: los adolescentes que reciben mayor apoyo social evidencian una conducta mayormente resiliente; así lo demostraron sabouripour y cols. (r = .530, p <. 001), además de cárdenas (r = .426; p = .001) (28, 16). por su parte, el ambiente escolar también influye de forma positiva en la conducta resiliente, como lo reportaron morales (z = 2.83; p = .005) y quiceno y vinaccia (r = .442; p <. 001) en el mismo año (29, 30). esto podría deberse a que los adolescentes que se sienten apoyados por los amigos, padres o personas significativas —como los profesores— tienden a buscar soluciones a los problemas por ellos mismos; además, su optimismo les permite superar con éxito las situaciones adversas (1). por otro lado, se encontró que a mayor ambiente barrial, mayor funcionalidad familiar, apoyo social y ambiente escolar, mayor será la conducta resiliente en los adolescentes. estos datos coinciden con los aportes de quiceno y vinaccia, quienes encontraron que un alto apoyo social (r = .467; p < .001) y un alto ambiente escolar (r = .442; p < .001) concuerdan con una alta resiliencia (29). estos resultados se deben a que, si bien los ambientes familiar, escolar y barrial, las nuevas interacciones sociales y los espacios de exploración e inserción brindan nuevas posibilidades de enriquecimiento al adolescente, pueden ayudarle a caer en conductas de riesgo (1). 9 influencia del ambiente en el desarrollo de la resiliencia en adolescentes de medellín, colombia l carlos reyes-sánchez y otros por otro lado, al realizarse el análisis de regresión lineal múltiple, se encontró que el ambiente barrial (β =.20), la funcionalidad familiar (β = .13), el apoyo social (β = .30) y el ambiente escolar (β =.15) explicaron la resiliencia en un 35,8 %. estos resultados coinciden con lo reportado por quiceno y vinaccia, para quienes el ambiente escolar ejerce un efecto sobre la resiliencia (β = .18; p < .001), y explican el 42 % de la varianza (29). por su parte, sabouripour y roslan hallaron que el apoyo social (β = .204, p < .001) es un predictor significativo de la resiliencia y que explica el 52,5 % de la varianza (28). esto se debe a que, aunque la influencia de la familia y de los amigos, entre otros, sea primordial, las redes de apoyo social que de aquí se deriven tienen efectos positivos en el desarrollo de la resiliencia (26). de acuerdo con los resultados descritos, morales menciona que el ambiente escolar y la resiliencia se manifiestan en conductas de compromiso con el trabajo escolar: la asistencia a las clases, la puntualidad, la atención a la clase y al profesor, la realización de tareas escolares, altos niveles de autoconfianza, autodisciplina, actitud positiva hacia el trabajo, locus de control interno y autoestima positiva; es decir, comportamientos y actitudes que suelen favorecer el aprendizaje. cabe mencionar que los adolescentes con rendimiento académico alto mostraron cualidades y habilidades adecuadas en las relaciones íntimas con la familia. esto se debe a que el sujeto se suele sentir respetado, tiene independencia y una concepción moral propia (30). en este sentido, el desarrollo de relaciones sociales significativas, así como el fomento de los procesos educativos como parte importante de la formación integral del adolescente, la comprensión de la solidaridad y el liderazgo social son valores transcendentales en el momento de desarrollar la resiliencia (12). cabe mencionar que estos resultados comprueban que contar con un ambiente barrial favorable, un buen apoyo social, un buen ambiente escolar y una familia funcional tiene efectos positivos en el desarrollo de la resiliencia. también demuestran la proposición del modelo de adaptación de roy, que menciona que los estímulos externos (sociales) sirven como entradas para el subsistema cognitivo, es decir, que constituyen una serie de factores que promueven la resiliencia. a la vez, apoyan el supuesto planteado en su modelo de adaptación (ram), el cual establece que contar con recursos externos (ambiente barrial, funcionalidad familiar, apoyo social y ambiente escolar) favorece la autorregulación del adolescente (15). en este orden de ideas, roy menciona que los sistemas humanos adaptativos son complejos y multifacéticos y reaccionan a estímulos del entorno donde se desenvuelven, mediante mecanismos de afrontamiento para adaptarse a las situaciones que se les presentan. esta capacidad de adaptación a los estímulos del entorno puede crear cambios en su ambiente para alcanzar su bienestar (31). según lo anterior, el contacto con los estímulos del ambiente activa la capacidad de afrontamiento (15). los estímulos focales se ven relacionados desde el momento en que cuentan con una baja funcionalidad familiar y bajo apoyo social; estos actúan de manera inmediata y directa en el adolescente, generándole experiencias adversas en la infancia, lo que puede conducir al desarrollo de comportamientos negativos para la salud (32). por su parte, los estímulos contextuales incluyen la propia adolescencia, el tipo de funcionalidad familiar, la presión del grupo o las relaciones con los pares, una cultura específica, el apoyo social disponible y el ambiente educativo. estos desempeñan un rol fundamental porque muestran la situación que viven los adolescentes (33). por esta razón, es importante el estudio de la resiliencia en los adolescentes. al llevarlos a utilizar sus propias capacidades y recursos para sobreponerse a las dificultades, se convierte en una herramienta de gran valor para disminuir posibles conductas de riesgo en una de las etapas más definitorias de la vida. el resiliente no solo supera la dificultad, sino que sale fortalecido y con la posibilidad de desarrollar un alto bienestar (1). el adolescente, como una persona que puede adaptarse a las situaciones, con capacidad de resiliencia, debe abordarse desde todas sus esferas. esto refleja la necesidad de integrar estrategias —con base en la evidencia científica existente en intervenciones específicas— para promover la acción, el empoderamiento y el liderazgo en el grupo de adolescentes, así como para gestar un mayor acercamiento entre pares y agentes de protección (12). conclusiones los resultados muestran que el ambiente barrial, el apoyo social, la funcionalidad familiar y el ambiente escolar influyen en la conducta resiliente de los adolescentes, pues son recursos externos que favorecen la autorregulación, tal como lo menciona roy en su modelo de enfermería. los resultados de esta investigación mostraron cómo los recursos externos influyen en el desarrollo de la resiliencia en los adolescentes, para que estos puedan adaptarse a los cambios propios de la etapa de vida en la que se encuentran y eviten las 10 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2024 aquichan issn 1657-5997 eissn 2027-5374 conductas de riesgo. además, contribuyeron en la generación de conocimiento, que se puede aplicar en la práctica clínica y que sirve como soporte para implementar estrategias de intervención de enfermería focalizadas en las necesidades de los adolescentes. por último, hay que anotar que aunque 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https://revenferneurolenlinea.org.mx/index.php/enfermeria/article/view/265/266 https://revenferneurolenlinea.org.mx/index.php/enfermeria/article/view/265/266 editorial 4-5.p65 aquichan issn 1657-5997 año 7 vol. 7 nº 1 • chía, colombia abril 2007116 año 7 vol. 7 nº 2 • chía, colombia 0ctubre 2007 ste último número de aquichan coincide con la apertura del nuevo programa de maestría en enfermería, que recibió el registro calificado por parte del ministerio de educación nacional, en el pasado mes de agosto. la facultad de enfermería, consecuente con los procesos de calidad y excelencia contemplados dentro del plan de desarrollo institucional, impulsa la investigación y la apertura de programas de formación avanzada. la maestría en enfermería es el resultado de la consolidación y madurez de los procesos académicos iniciados en 1991, con la apertura del programa de enfermería. a lo largo de estos años se han alcanzado, entre otros, la renovación de la acreditación de alta calidad del programa de pregrado, otorgada por el ministerio de educación nacional por siete años, el inicio y desarrollo de los programas de especialización en cuidado crítico pediátrico, gestión en rehabilitación y salud escolar. así mismo, la estructuración y el desarrollo del grupo de investigación sobre el modelo de adaptación de callista roy, clasificado por colciencias en categoría b, y sus resultados reflejados en publicaciones en revistas indexadas y productos editoriales, como el segundo libro del grupo titulado: la adaptación en el ser humano. una visión de enfermería, publicado por la universidad de la sabana en coedición con la editorial manual moderno en el 2007. igualmente, la asesoría a otros programas académicos e instituciones clínicas, la implementación de estrategias como la cátedra abierta para el desarrollo y estudio del modelo, la creación de la página web del grupo, junto con el reconocimiento académico otorgado a la profesora maría elisa moreno fergusson, coordinadora del grupo de investigación, por parte de la roy adaptation association como member fellow award, y la reciente creación del capítulo colombiano de esta asociación, evidencian los importantes logros alcanzados. el trabajo conjunto con pares nacionales e internacionales, y la presencia de profesores visitantes que han participado durante los seis seminarios internacionales, han contribuido al fortalecimiento de la internacionalización de la facultad. en la actualidad, se viene consolidando la estructuración del grupo de investigación en enfermería comunitaria, cuyos productos soportarán igualmente el componente investigativo de la maestría. de otro lado, el nivel académico y editorial alcanzado por la revista aquichan, y su reclasificación en el índice publindex, en categoría b, al igual que su inclusión en bases de datos como redalyc, lilacs, google académico, fuente académica, ebsco, dialnet, cuiden, entre otras, contribuyen de manera importante a impulsar la producción y publicación de trabajos científicos de investigadores y estudiantes de posgrado. editorialeditorial editorial 117 avance disciplinar nuevos retos en formación avanzada es de resaltar el incremento en el número de trabajos o artículos de investigación que recibimos de enfermeras(os) asistenciales y de servicio. en la práctica, y desde la práctica, surgen los problemas de investigación de la disciplina de enfermería. es por ello que la facultad, con sus programas académicos de posgrado, promueve el desarrollo de procesos investigativos y de formación avanzada. lo anterior se presenta como una base sólida para el inicio y desarrollo de este nuevo programa, con el cual se adquiere un gran reto y compromiso ante la comunidad académica de enfermería en el país y en el exterior, que esperan de este programa altos niveles de calidad y excelencia, respondiendo de manera pertinente a las necesidades sentidas en el campo asistencial. la revista aquichan, de acuerdo con lo contemplado en su misión, continuará con la promoción y el estímulo del desarrollo disciplinar, con la socialización y con la divulgación de los aportes del programa de maestría. maría clara quintero l. directora mariac.quintero@unisabana.edu.co primeras paginas.indd 4 aquichan issn 1657-5997 editorial la sociedad actual protagoniza una era de cambios y transformaciones; nuevos paradigmas hacen parte de estos procesos donde la multiculturalidad, la integración y, así mismo, las migraciones y los desplazamientos de poblaciones, entre muchos otros fenómenos, han trascendido las fronteras. esta situación demanda de las ciencias sociales y, muy particularmente, de enfermería, una profunda reflexión sobre su aporte y el de otras disciplinas a la solución de las problemáticas actuales. en este sentido, se hace necesario orientar los programas de formación de futuros profesionales, sus perfiles y áreas de desempeño, acordes con los actuales escenarios y contextos, enmarcados en un mundo globalizado y cambiante, reconociendo y valorando la cultura de los pueblos, sus raíces y su historia. estadísticas recientes de la organización panamericana de la salud (ops) reportan que en américa latina hay más de cien millones de personas sin ningún servicio de salud; es decir, en condiciones de pobreza extrema. entre ellos se cuentan menores de cinco años, mujeres, adultos mayores, grupos étnicos y raciales, para quienes la marginalidad con todos sus efectos adversos es el registro diario de su acontecer. la respuesta a este panorama, que se da desde diferentes ámbitos, constituye una experiencia intercultural de carácter global. una experiencia en la que las nuevas tecnologías resultan fundamentales y estratégicas para comprender e interactuar en este entorno y, por tanto, deben hacer parte de las competencias en la formación de nuevos profesionales. en enfermería, al igual que en otras disciplinas, resulta imprescindible la apropiación de nuevas tecnologías que den soporte a los procesos de formación, al igual que el énfasis que debe hacerse en una sólida formación científica y en el desarrollo de competencias que garanticen la calidad en el cuidado; estoes aspectos se deben enmarcar en los principios éticos y humanísticos propios de los paradigmas de la disciplina. por todo esto, la universidad debe apoyar y promover la generación y difusión de nuevos conocimientos, derivados de los procesos de investigación. para ello se requiere contar con alianzas estratégicas, redes de trabajo y cooperación que permitan compartir, año 8 vol. 8 nº 1 chía, colombia abril 2008 5 editorial ampliar y difundir este conocimiento, de manera que se beneficien amplios sectores de población, particularmente aquellos en situación de vulnerabilidad y de pobreza extrema. los resultados de investigación no pueden estar disociados del quehacer propio de enfermería, es decir, de la práctica. el diálogo entre la práctica y la investigación retroalimenta los procesos de desarrollo disciplinar de forma continua, favoreciendo la generación de nuevo conocimiento y el mejoramiento de la calidad en el cuidado de enfermería. en este sentido, las publicaciones científicas juegan un papel destacado, toda vez que éstas son, entre otros, un medio de comunicación propio de la ciencia y de los científicos. es el caso de la revista aquichan, en cuya misión se hace explícito este propósito: “orientar la promoción y el estímulo del desarrollo teórico de la disciplina de enfermería… aquichan será un órgano de divulgación de los aportes al desarrollo de la profesión…”. la reciente indexación de aquichan en el índice bibliográfico scielo, al igual que su inclusión en otras importantes bases de datos, hace visible el desarrollo disciplinar desde una perspectiva global. lo anterior ha sido posible gracias al esfuerzo conjunto de investigadores, autores, evaluadores, y de todo el equipo editorial, al igual que nuestros lectores, que retroalimentan y contribuyen a la consolidación de este proyecto. un proyecto en el que el acceso universal a la información es fundamental en la sociedad actual, caracterizada por la globalización y la transculturalidad. maría clara quintero l. directora mariac.quintero@unisabana.edu.co grandes retos y desafíos se presentan para enfermería en el siglo xxi 121 126 primeras paginas.indd 124 aquichan issn 1657-5997 editorial la historia de enfermería se ha caracterizado por múltiples dificultades, pero sobre todo por los retos y desafíos que han asumido quienes la ejercen para alcanzar un reconocimiento como disciplina profesional. en los servicios de salud, tanto el personal vinculado a éstos, como el público en general, reconocen que el personal de enfermería es la piedra angular de la atención que se presta a los pacientes. nadie se imaginaría un hospital o un centro de atención de salud sin personal de enfermería. y esto es real en la medida en que somos los responsables de garantizar un cuidado humano a todas las personas. los profesionales de enfermería, gracias a su formación fundamentada en las ciencias básicas, humanísticas y de enfermería, y al privilegio de permanecer al lado de los pacientes la mayor parte del tiempo, adquieren la información precisa sobre las necesidades particulares y únicas de cada una de las personas que atienden y de sus familias, para planear y brindar el cuidado que requieren en la prevención, el mantenimiento y la recuperación de la salud. el conocimiento de las personas y la calidad de los servicios que brindan, reflejan la filosofía humanística que promueven las instituciones de salud. al personal de enfermería se le reconoce por su responsabilidad, disciplina, dedicación, entrega y capacidad de gestión, entre otras cualidades. por ello las directivas de las entidades de salud han delegado en éste la ejecución de actividades administrativas relacionadas con los procesos de certificación y acreditación de la calidad. esta situación puede parecer una amenaza pero en realidad se constituye en un nuevo desafío para el ejercicio profesional. amenaza porque, sin desconocer la importancia de estos procesos, al asumir funciones diferentes al cuidado, el tiempo de contacto directo con el paciente se vuelve corto, lo cual desdibuja el rol de las enfermeras (os) profesionales en los servicios. las nuevas tareas administrativas han hecho que los cuidados propios de enfermería, considerados “una actividad sagrada e indelegable”, queden en manos del personal auxiliar y técnico, convirtiéndose en una limitante a la hora de valorar el estado de salud, planear el cuidado y fortalecer la relación enfermera-paciente (1). en algunas ocasiones se llega al extremo en que los pacientes y sus familiares no tienen la oportunidad de conocer a los “jefes de los servicios”, como se les denomina en colombia, porque el contacto directo con ellos es escaso y se limita a la ejecución de actividades médico-delegadas, como la administración de los medicamentos. año 9 vol. 9 nº 2 chía, colombia agosto 2009 124-126 para retomar el rumbo: menos procesos administrativos y más cuidado humano 125 editorial esta situación se opone al desarrollo del conocimiento en enfermería, marcado desde finales del siglo xix por florence nightingale, pionera de la enfermería moderna, quien demostró con datos estadísticos cómo el cuidado de enfermería centrado en optimizar las condiciones del ambiente es fundamental para la recuperación de la salud, como lo planteó en sus “notas de enfermería”, en las que señaló la esencia de la profesión y que hoy, más que nunca, constituye un legado que no podemos desconocer (2), a pesar de los importantes procesos de certificación que adelantan las instituciones de salud. este rumbo que nightingale trazó, se fue desdibujando en la primera mitad del siglo xx, con la institucionalización de los servicios de salud y el desarrollo de los grandes hospitales. las necesidades de la época favorecieron el desarrollo de los roles funcionales docente y administrativo, donde el hacer de enfermería, centrado en actividades médicodelegadas, y en la administración de los servicios, adquirieron una gran preponderancia y se dejó a un lado el interés por continuar el desarrollo del conocimiento propio de la disciplina. fue tan solo hasta mediados de los años cincuenta, y especialmente en las décadas de los sesenta y setenta, como resultado de la formación, en maestrías y los doctorados, que las enfermeras vuelven a preguntarse cuál es su razón de ser y cuál es su contribución al estado de salud de las personas. en esa época surgen los primeros modelos conceptuales y teorías de enfermería, con el propósito de ofrecer una mirada particular y única al conocimiento y a la práctica de enfermería en los diferentes ámbitos del ejercicio profesional (3). actualmente encontramos un gran desarrollo en el conocimiento disciplinar, los avances en investigación han demostrado la complejidad y la importancia del cuidado de enfermería. los eventos académicos y las publicaciones de enfermería dan cuenta de los innumerables campos de acción y de los interrogantes que se generan a partir de la práctica y la investigación. este conocimiento se hace visible gracias al desarrollo de las tecnologías de la información y la comunicación, pues hoy en día los profesionales de enfermería en todo el mundo tienen acceso a las publicaciones científicas de enfermería a través de internet y con ello a mantenerse al tanto de los avances del conocimiento disciplinar. publicaciones como aquichan dan cuenta del desarrollo del conocimiento no solo en diferentes regiones de colombia, sino en países como brasil y méxico, entre otros. getting back on course: fewer administrative processes and more human care para recuperar o rumo: menos processos administrativos e mais cuidado humano 126 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 referencias 1. fawcett j. guest editorial: on bed baths and conceptual models of nursing. journal of advanced nursing 2003; 44 (3): 229-30. 2. durán de villalobos mm. enfermería: desarrollo teórico e investigativo. bogotá: unibiblos; 1998. 3. parker m. nursing theories & nursing practice. 2 ed. philadelphia: f.a. davis; 2006. de tal manera que en este momento en que el hacer nos ocupa, desplazando la esencia de nuestra profesión, es hora de detenernos, reflexionar y repensar nuestro futuro. la sociedad reclama una atención humanizada en los servicios de salud, y las enfermeras sabemos que el cuidado es un aspecto central de la misma. en el mediano y largo plazo no vislumbramos una tecnología tan sofisticada que pueda reemplazar el cuidado humano, por esto el servicio de enfermería es la piedra angular de las instituciones de salud. la situación que se vive actualmente constituye una oportunidad. a diferencia de otros profesionales de la salud, el personal de enfermería desarrolla competencias administrativas y de cuidado durante su formación profesional para asumir el liderazgo en los servicios. por lo tanto, tenemos el conocimiento que respalda una práctica autónoma y que es necesario aprovechar para aceptar con decisión el desafío de una práctica profesional humana, compatible con las políticas y las demandas de los servicios de salud. maría elisa moreno-fergusson editora mariae.moreno@unisabana.edu.co 23 37 estar extrictamente enfermo.indd 23 óscar alberto beltrán-salazar1 la experiencia de estar hospitalizado en una unidad de cuidado intensivo 1 enfermero. especialista en enfermería cardiorrespiratoria. profesor, miembro del grupo de investigación en emergencias y desastres. universidad de antioquia. facultad de enfermería. medellín. colombia. calle 64 nº 53 09. oscar4242@tone.udea.edu.co recibido: 3 de diciembre de 2007 aceptado: 28 de febrero de 2009 resumen objetivo: describir el significado, para los pacientes gravemente enfermos, de estar hospitalizado en una unidad de cuidado intensivo (uci). metodología: trabajo de investigación, con enfoque fenomenológico, que incluyó a nueve personas adultas entre 24 y 80 años de edad que estuvieron críticamente enfermos y hospitalizados en una uci. la entrevista en profundidad fue la técnica de recolección de la información. el análisis de los datos se realizó según el esquema propuesto por cohen, kahan y steeves. el estudio se llevó a cabo en la ciudad de medellín, colombia, entre abril y octubre de 2006. resultados: este estudio permitió describir la “dureza” de la experiencia y las dificultades que se presentaron durante el episodio de la enfermedad, así como también con el sufrimiento físico y psicológico y algunas condiciones que contribuyeron para que el sufrimiento estuviera presente. discusión: la experiencia de padecer una enfermedad crítica y la hospitalización en uci es dura, debido al sufrimiento que ocasiona, tanto por los efectos de la enfermedad como por los elementos utilizados en el tratamiento y los procedimientos realizados para resolver la enfermedad. conclusión: en la enfermedad, sus manifestaciones en el organismo y en la persona, las intervenciones médicas y quirúrgicas, y los procedimientos enfermeros constituyen motivos de sufrimiento que contribuyen a la dureza de la experiencia de estar críticamente enfermo. palabras clave cuidados intensivos, dolor, cuidados básicos de enfermería, cuidado crítico. (fuente: decs, bireme). the experience of being hospitalized in an intensive care unit abstract objective: describe what hospitalization in an intensive care unit (icu) means to critically ill patients. method: this is a research project with a phenomenological approach. it includes nine adults between the ages of 24 and 80 who were critically ill and hospitalized in an intensive care unit. information was collected through in-depth interviews and analyzed pursuant to the scheme proposed by cohen, kahan and steeves. the study was conducted in medellín, colombia, between april and october 2006. año 9 vol. 9 nº 1 chía, colombia abril 2009 23 37 24 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 results: the study made it possible to describe the “harshness” of the experience and the difficulties that emerged during the illness, as well as the physical and psychological suffering and some of the conditions that contributed to suffering. discussion: the experience of having a critical illness and being hospitalized in an icu is harsh, given the suffering occasioned by the effects of the illness, the elements used in treatment, and the procedures conducted to resolve the illness. conclusion: the manifestations of an illness in the organism and in the person, medical and surgical interventions, and nursing procedures can cause suffering that contributes to the harshness of the experience of being critically ill. key words intensive care, pain, basic nursing care, critical care. (source: mesh, bireme). a experiência de estar internado em uma unidade de cuidados intensivos resumo objetivo: descrever o significado de estar hospitalizado em uma unidade de cuidados intensivos (uci) para os pacientes gravemente enfermos. metodologia: trabalho de pesquisa fenomenológica que incluiu nove pessoas adultas entre 24 e 80 anos de idade, que estiveram criticamente enfermos e hospitalizados em uma unidade de cuidados intensivos. para a recolhida da informação, foi aplicada a entrevista em profundo. a análise dos dados foi realizada com o esquema proposto por cohen, kahan e steeves. o estudo transcorreu em medellín, colômbia, entre abril e outubro de 2006. resultados: este estudo permitiu descobrir a “dureza” da experiência e as dificuldades experimentadas no curso da doença, assim como o sofrimento físico e psicológico, e certas condições que ajudaram à aparição do sofrimento. discussão: a experiência de padecer uma doença crônica e hospitalização na uci é crítica pelo sofrimento causado pelos efeitos da doença e os elementos usados no tratamento e os procedimentos empregados para atacar a doença. conclusão: na doença, nas suas manifestações no organismo e na pessoa, as intervenções médicas e cirúrgicas, e os procedimentos dos enfermeiros, são motivos de sofrimento que ajudam a sentir a dureza da experiência de estar gravemente enfermo. palavras-chave cuidados intensivos, dor, cuidados básicos de enfermagem, cuidado crítico. (fonte: decs, bireme). 25 la experiencia de estar hospitalizado en una unidad de cuidado intensivo óscar alberto beltrán-salazar introducción la insatisfacción de las necesidades físicas, sicológicas y sociales puede estar presente en todos los pacientes, pero cuando se presentan simultáneamente varias de ellas puede ponerse en peligro la vida, tal como ocurre en el paciente en estado crítico con enfermedad grave. por tanto, se hace necesario utilizar eficientemente una serie de elementos y equipos que permitan conocer el estado de salud del paciente, intervenir los signos, los síntomas y la causa de la enfermedad y también determinar los efectos que muchas de las intervenciones involucradas en los actos de cuidado puedan producir. peplau (1) plantea que “la profesión de enfermería tiene la responsabilidad legal de hacer un empleo eficaz de la enfermería y de sus consecuencias para los pacientes”, lo que significa que es tan importante el fin como los medios y que debe buscar siempre la alternativa de cuidado que sea más beneficiosa y mejor aceptada por los pacientes. el cuidado de enfermería en la uci implica la realización de una serie de procedimientos y la administración de medicamentos que, en asocio con la enfermedad, también pueden poner en peligro la vida de los pacientes e interferir en la satisfacción de sus necesidades. si bien es cierto que algunos de estos elementos terapéuticos permiten a los individuos mantener la vida mientras se remueve la causa de su trastorno y son capaces de satisfacer por sí mismos sus necesidades, también se han descrito algunos efectos indeseados en pacientes en quienes se utilizan, entre los cuales se presenta rechazo hacia ellos y es necesario recurrir a la inmovilización física para evitar el retiro accidental y traumático de catéteres y otros elementos y para evitar caídas y movimientos bruscos. en un estudio con pacientes que han estado hospitalizados en uci (2), estos relataron su experiencia como negativa debido a las alteraciones cognitivas, la incomodidad por presencia de elementos invasivos, la limitación del movimiento, la incapacidad para hablar, la sed, el ruido y el dolor. también reportaron dificultades para dormir, alteración de la imagen corporal y preocupación por la insatisfacción en las necesidades básicas; además expresaron que, aunque presentaban deterioro en la memoria, podían recordar en forma total o parcial las experiencias que habían vivido (2). en otro estudio (3) se encontró que los pacientes sometidos a la ventilación mecánica presentaron sentimientos de frustración por las alteraciones en la comunicación y afirmaron que les había generado negación, aprensión y temor, además de alivio y gratitud y también reportaron una mayor cercanía de la muerte. peralta y colaboradores (4), en un estudio con pacientes en uci, reportaron 46 extubaciones, el 41% de estas fueron autoextubaciones y el 20% debidas a maniobras inadecuadas del personal; de otro lado, en un estudio realizado por goñi y colaboradores (5), que involucraba a 74 pacientes con vía aérea artificial, se reportó una salida accidental del tubo orotraqueal y dos autorretiradas. todo lo anterior tiene relación con el dolor y el sufrimiento infligido por los enfermeros durante la realización de procedimientos y prácticas de cuidado. según encontró madjar (6) en un estudio, “este dolor infligido debe ser soportado y los pacientes deben cooperar y guardar compostura para no interferir en el trabajo del equipo de enfermería, para no desafiar la legitimidad de las acciones de cuidado y para cumplir con la parte del tratamiento que le[s] corresponde en su rol de paciente[s]”. en un estudio con pacientes que han estado hospitalizados en uci, estos relataron su experiencia como negativa debido a las alteraciones cognitivas, la incomodidad por presencia de elementos invasivos, la limitación del movimiento, la incapacidad para hablar, la sed, el ruido y el dolor. 26 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 el conocimiento por parte de los enfermeros de la experiencia que viven los pacientes durante una enfermedad grave permite la comprensión de las características que componen la experiencia y de los significados otorgados por los pacientes, y además dará bases para la toma de decisiones en relación con formas más humanizadas del cuidado que se brinda a los pacientes en estado crítico, cuando se encuentran hospitalizados en una uci. en un estudio fenomenológico realizado por g. balanza (7), en el que buscaba comprender el significado del cuidado de enfermería para los pacientes hospitalizados en un servicio médico, encontró que los pacientes reportaron el cuidado de enfermería en una dimensión de poder, lo que describieron en relación con la toma de decisiones por parte de enfermería sobre lo cotidiano en la atención, cuando los pacientes están limitados para hacerlo; además encontró que el cuidado de enfermería significaba ánimo, buen trato, amor y atención, que agradaba cuando se acompañaba de muestras de cariño y era mal aceptado cuando se percibía como maltrato; cabe entonces preguntarse si los pacientes perciben como “maltrato” la instalación de medios terapéuticos y de diagnóstico en su cuerpo, debido a que, además de ser necesarios, producen efectos no deseados, o si estar recluido en un ambiente con las características de la uci y sometido a las rutinas de cuidado propias de un servicio de hospitalización como la uci hacen parte de ese “maltrato”. al analizar la experiencia de las personas al padecer una enfermedad grave y estar hospitalizadas en uci, tomando como base el punto de vista de los enfermeros, puede encontrarse, como lo plantea madjar (6), “que los registros que los enfermeros elaboran contienen descripciones de la experiencia observada, no vivida, en las cuales se consignan los procedimientos realizados y las respuestas desde el punto de vista físico y en ocasiones sicológicas”. sin embargo, la experiencia descrita por los pacientes cuando la han vivido hace referencia, según plantea la misma autora, “al daño, al dolor que se siente por la enfermedad o que es infligido por otros, a la necesidad de ponerse de parte del paciente, de soportar lo que sucede, de restringir el llanto, la ira, la desesperación” (6). estas diferencias en la visión de una situación hacen necesario escuchar y conocer ambas posiciones, la de los enfermeros y la de los pacientes. la intención de este estudio es centrar la atención en el punto de vista de los pacientes. si se tiene en cuenta lo que plantea torralba (8) –acerca de que “en situaciones de dolor y desamparo, el ser humano siente con una especial intensidad la necesidad de dialogar, de expresar lo que siente, lo que vive en el seno de su interioridad. cuanto más próximo vive el ser humano de la vulnerabilidad radical, es decir, de la muerte, de la descomposición de su presencia exterior, más desnudo se presenta ante su prójimo”– es posible lograr que los pacientes transmitan su experiencia para ser descrita y analizada, que es lo que precisamente se busca con este estudio. con el fin de comprender el significado de la experiencia de padecer una enfermedad grave y estar hospitalizado en una uci se realizó un estudio fenomenológico, en el cual se incluyó a nueve personas adultas que estuvieron críticamente enfermas y hospitalizadas en una uci. los resultados obtenidos en este estudio permitieron describir los aspectos más significativos que los participantes reportaron en las entrevistas, tales como la dureza de la “en situaciones de dolor y desamparo, el ser humano siente con una especial intensidad la necesidad de dialogar, de expresar lo que siente”. 27 la experiencia de estar hospitalizado en una unidad de cuidado intensivo óscar alberto beltrán-salazar experiencia y las dificultades que se presentaron durante el episodio de la enfermedad, así como con el sufrimiento físico y psicológico y algunas condiciones que contribuyeron a que el sufrimiento estuviera presente. sobre el primer aspecto descrito de la experiencia trata este artículo. método estudio con enfoque fenomenológico que incluyó a nueve personas adultas, entre 24 y 80 años de edad, que hubieran estado críticamente enfermos y hospitalizados en una uci, con disposición y capacidad para relatar su experiencia y aceptaran la participación en el estudio. este número de participantes está acorde con los planteamientos de algunos autores (9, 10). la selección se hizo por muestreo teórico (11) y con “propósito”, esto es, “seleccionar el mejor informante para los requerimientos del estudio” (12). los participantes fueron un abogado, un odontólogo, un estudiante de enfermería, dos amas de casa, un agricultor, un jubilado, una secretaria y una magíster en ciencias sociales. se consideró la saturación de la información cuando en las entrevistas, “los datos aportados se repitieron sin producir elementos nuevos que contribuyeran a la comprensión del fenómeno” (9). seis de los participantes fueron mujeres y tres fueron hombres; todos fueron sometidos a ventilación mecánica por un lapso de tiempo de entre 4 y 20 días durante su hospitalización en la uci. el tiempo transcurrido entre el egreso de la hospitalización en la uci por una enfermedad crítica y el momento en que fueron entrevistados osciló entre 12 años y cero días en un paciente que aún estaba hospitalizado. la entrevista en profundidad fue la técnica utilizada para la recolección de la información (13). la duración de las entrevistas fue de cuarenta minutos a una hora; con cada paciente se realizó un encuentro que terminó cuando expresaron no tener nada más que decir acerca de la experiencia. en ninguno de los casos los participantes expresaron el deseo de suspender la entrevista antes de que esta llegara a su fin, por el contrario, su deseo de concederlas fue evidente. las entrevistas fueron grabadas en condiciones de privacidad en la unidad de los pacientes hospitalizados, en la casa o en la oficina, y a continuación se transcribieron fielmente por el investigador (14). además de la entrevista, la realización de seis horas de observación no participante en dos unidades diferentes sirvió para corroborar algunos datos reportados por los participantes, en especial los que hacían referencia al silencio y la falta de palabras dirigidas a los pacientes durante las intervenciones de enfermería. el análisis de la información fue realizado según el esquema propuesto por cohen, kahn y steeves (15), quienes plantean que se inicia durante la realización de la primera entrevista, seguido de una inmersión en los datos mediante la lectura de las transcripciones y del análisis línea por línea, con el fin de realizar una selección de temas y ejemplares; a continuación se separaron los temas que fueron significativos en las descripciones de los participantes, se redactaron memos y se realizaron diagramas sobre cada tema. el paso siguiente consistió en realizar una búsqueda bibliográfica y la narrativa de la experiencia. la comprensión de los significados de la experiencia se reflejó en los temas y en los “ejemplares”, y fueron descritos en memos analíticos que luego sirvieron de base para la narrativa final. en el último paso se escribió una narrativa para describir lo los resultados obtenidos en este estudio permitieron describir los aspectos más significativos que los participantes reportaron en las entrevistas, tales como la dureza de la experiencia y las dificultades que se presentaron durante el episodio de la enfermedad. 28 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 que reflejaban los temas en relación con la experiencia de los participantes (15). los temas fueron validados, permitiendo a dos de los participantes leer la descripción para determinar su correspondencia con lo que ellos querían decir (15). el estudio se llevó a cabo en medellín, colombia, entre abril y octubre de 2006. siete de los participantes vivieron su experiencia de enfermedad crítica en unidades de cuidado intensivo de esa ciudad, uno en un hospital de nueva york, ee.uu. y el otro en sincelejo, colombia. para asegurar el rigor metodológico, la recolección y la trascripción de la información fueron llevadas a cabo por el investigador; en las entrevistas y el análisis se tuvo en cuenta el punto de vista de los participantes, a quienes se les permitió “expresar su experiencia en su propio lenguaje para hacerla visible” (16). la trascripción de las entrevistas se hizo inmediatamente para conservar la mayor fidelidad en los datos, teniendo en cuenta lo que se dijo y cómo se dijo. en la interpretación se muestra el punto de vista del paciente y las conjeturas del investigador con la constante preocupación por que los hallazgos sean un reflejo de la realidad y la interpretación de los datos tenga concordancia con lo expresado por los participantes; esta concordancia fue determinada “volviendo a los sujetos para darles a conocer y permitirles validar los hallazgos de la interpretación” (9), para lo cual se invitó, como ya se dijo, a dos de los participantes, un ama de casa y un abogado, a que leyeran el texto que se había producido con base en el análisis. no se realizaron generalizaciones a partir de los datos y todas la entrevistas se consideraron de igual importancia por lo que los participantes expresaron, sin dar preponderancia a los datos por razones de poder social, riqueza, nivel educativo o importancia política de quien los expresaba (17); los casos negativos se tuvieron en cuenta para contrastar aquellos que concordaban en sus descripciones y para intentar obtener mayor información en el mismo sentido de dichos datos y dilucidar la presencia de nuevos patrones en la información (18). en forma periódica, los procedimientos para el procesamiento y análisis de los datos, los memos, diagramas y los frutos del análisis fueron revisados por la asesora del estudio, una investigadora experimentada, con título de doctorado, con una amplia trayectoria en estudios cualitativos, quien hacía recomendaciones, sugería correcciones y opinaba acerca de las categorías descriptivas derivadas del análisis. además, el texto escrito a partir del análisis de los datos fue revisado por una investigadora de la universidad nacional de colombia con título de magíster y por una investigadora fenomenóloga con título de doctora de la universidad del valle, quienes hicieron sugerencias para velar por la validez interna. una enfermera intensivista, con grado de especialista, que estuvo de turno durante los días que se llevó a cabo la observación, a manera de evaluación, expresó su concepto: “al leer el texto, a uno le parece que le estuvieran hablando de lo que sucede en un turno, o de lo que sucede con un paciente. es una experiencia real, y conocerla te permite entender muchas cosas. normalmente uno se preocupa por llenarse de cosas y no centra la atención en lo que el paciente tiene para decir”. también se realizaron cinco presentaciones en público sobre los resultados de este estudio para permitir que los pares enfermeros e investigadores hicieran críticas y sugerencias, que luego se tuvieron en cuenta para enriquecer el se realizaron cinco presentaciones en público sobre los resultados de este estudio para permitir que los pares enfermeros e investigadores hicieran críticas y sugerencias, que luego se tuvieron en cuenta para enriquecer el análisis. 29 la experiencia de estar hospitalizado en una unidad de cuidado intensivo óscar alberto beltrán-salazar análisis, lo que además ayudó a establecer la replicabilidad de la experiencia y la confiabilidad externa, así como también lo permitió la compatibilidad encontrada con otros estudios que se reportan en la discusión. en la presentación del texto sobre el análisis se agregan apartes de la entrevista como evidencia de los aspectos planteados en la interpretación por parte del investigador. por consideraciones éticas, se aseguró la privacidad y la confidencialidad de la información y de los participantes evitando el uso de nombres propios e identificando cada entrevista con un número; cada uno de ellos expresó su deseo de participar libremente; no se realizaron intervenciones o procesos relacionados con el estudio diferentes a las entrevistas. resultados los resultados hacen referencia a la forma como los pacientes describen la experiencia objeto de estudio y el significado que tuvo el sufrimiento, el cual fue un componente de la enfermedad que contribuyó en forma importante a la dureza de la situación. la experiencia vivida por los pacientes en estado crítico en una uci es muy compleja y llena de contrastes. uno de esos contrastes se muestra en la manera como los participantes consideran su experiencia, que va desde “normal” e “increíble” hasta “dura”, “difícil”, “triste” y “horrible” para las personas que la viven. es una experiencia normal e increíble cuando representa un paso que es necesario enfrentar para la solución a un problema o enfermedad, porque favorece la unión y el reencuentro con familiares y amigos y el acercamiento y la práctica de las creencias religiosas y porque además permite conocer a los enfermeros y a otros miembros del equipo de salud que demuestran apoyo y afecto en momentos difíciles. también lleva a lograr aprendizajes que son importantes para la vida presente y futura: para mí fue una situación que viví muy tranquila. suponía que me tenían que hacer una serie de cosas para ir evaluando el proceso que me habían realizado, pero yo no lo tomé con angustia. yo la tomé muy normal, en realidad que sí. uno allá metido en esa cama es difícil darse cuenta de todo lo que ocurre, pero mi experiencia personal fue increíble. pero fue una experiencia muy linda, maravillosa. tal vez tenía el privilegio de un médico tratante excelente, con muy buenas relaciones con el personal médico y de enfermería y la conciencia de que era algo que me estaba beneficiando a mí en mi salud (e. 8). es una experiencia difícil porque aleja del hogar, aísla de la familia, en un ambiente diferente de aquel en el que se desarrolla la vida cotidiana y que no siempre es agradable y porque es una situación acompañada de sufrimiento cuya aceptación no se da en forma simple: “que no me hubiera tocado, que no me hubiera ido a cuidados intensivos. eso fue un gran pellizco que me ha dado la vida” (e. 2). un factor que contribuyó enormemente a que la experiencia de una enfermedad crítica se considerara “dura y difícil” fue el sufrimiento, el cual es entendido por los participantes en este estudio de una forma que tiene estrecha relación con lo que plantea travelbee (19) sobre el sufrimiento, el cual define como “el dolor físico, mental, la aflicción, las pérdidas de todo tipo, el distress y la injuria”. sufrimiento la enfermedad crítica compromete las funciones corporales, se acompaña de sufrimiento físico con síntomas variados, entre los cuales son significativos el dolor, la incomodidad y la dificultad para respirar en el plano corporal, y de sufrimiento mental y espiritual; en el sufrimiento mental y espiritual son significativos la ansiedad, el temor, el desamparo y la desesperanza. yo sentía dificultad para respirar, un dolor en la espalda en el lado derecho y el dolor se fue agudizando y cada vez tenía más dolor para respirar. me pusieron oxígeno y me tomaron una placa y me dijeron que era el corazón […] me tuvieron que hacer una cirugía de pulmón, una lobectomía. mejor dicho, yo iba muy complicada, iba con de todo, yo iba con deficiencia respiratoria […] entonces, yo iba ya muerta. yo sentía muchos dolores y fuera del dolor físico esa parte moral que es muy dura […] estuve tanto tiempo que se me inflamó esta parte de acá del cóccix (e. 2). en este testimonio el sufrimiento espiritual es expresado por la participante en términos de dolor moral, y también expresa la cercanía a la muerte que acompaña al sufrimiento intenso. y porque el sufrimiento acerca a la muerte, les hace a los pacientes percibir su cercanía; su amenaza es constante. además, se dan cuenta de los problemas y de aquello que el equipo de salud hace para resolverlos, por tanto, en las entrevistas describieron los efectos de los tratamientos, sus limitaciones, sus propias respuestas, y diferenciaron el sufrimiento físico del psicológico. “todo bien hasta que empezaron fiebres muy altas y los dolores eran muy in30 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 tensos […] yo era desesperado por el dolor, le daba patadas a las barandas de la cama, porque llegó un momento [en] que la morfina no me quitaba el dolor” (e. 7). “yo a la gente la veía como amarilla, como renegrida. necesito que me diga, no, pues como […] alguna cosa me tuvieron que haber dado porque a toda la gente yo la veía así […] me pareció raro, me pusieron algo o me dieron algo” (e. 4). el contraste con el sufrimiento que acompaña a la enfermedad se presenta cuando la persona no ha tenido la necesidad de “sufrir” su enfermedad, debido, por ejemplo, a que la enfermedad no se había hecho manifiesta cuando se le practicó la intervención quirúrgica, cuyo período posoperatorio inmediato justificó la hospitalización en uci. por tanto, el sufrimiento fue dependiente del tratamiento y de las intervenciones terapéuticas, no tanto de la enfermedad. podría decirse que esto significó que se evitó, por decirlo de alguna manera, gran parte del sufrimiento, esa porción del sufrimiento dependiente de la enfermedad. en estas condiciones, asumir la situación con “tranquilidad” y “optimismo” no es difícil. no sentir la cercanía de la muerte hace que la situación sea menos “dura”, menos angustiante, tal como fue expresado por una participante durante su descripción de la experiencia. es que yo no tuve ninguna sintomatología. eso lo descubrieron accidentalmente […] lógicamente que con toda esa cosa que me hicieron ahí en la cabeza pues tenía que sentir, no sé, pero como que son molestias normales que le suceden en procedimientos de ese tipo, y entonces yo trataba de poner de mi parte lo más que podía para sobrellevar eso con tranquilidad, con optimismo y buscando que las cosas sí fueran mejorando cada día […] pues como dolores no estaba sintiendo, ningún tipo de dolor, ninguna situación angustiosa (e. 8). el sufrimiento que acompaña a la enfermedad tiene, de acuerdo con las descripciones de los participantes, varios componentes, tales como el tiempo de duración del mismo, la sensación de abandono y soledad, ansiedad, angustia, tristeza, llanto y temor, la alteración de la imagen corporal y la angustia ante la muerte. la duración del sufrimiento, en primer lugar, hace referencia al tiempo que se debe permanecer hospitalizado en la uci o en otro servicio de hospitalización, antes de regresar al hogar; significa el tiempo que el paciente fue dejado por padecer una enfermedad grave, en un lugar diferente al hogar, sin la compañía permanente de la familia, con lo cual la sensación de abandono también se hace presente. el tiempo de permanencia en el hospital se relaciona con la gravedad de la enfermedad: “no, pero es que esas cirugías son crueles, pues, tan largas” (e. 8). mientras mayor fue la gravedad de la enfermedad mayor era la duración de la permanencia en el hospital y más acentuada la dificultad para el acceso de la familia para estar al lado del enfermo, debido a que en determinados casos se restringía la visita familiar, y, por tanto, la sensación de abandono era más profunda. la permanencia en el hospital, en donde hay limitaciones en el número de personas que ingresan a visitar a los pacientes y en el horario para la visita familiar, plantea una situación paradójica, porque los participantes hacen referencia a estar solos, pero rodeados de gente; a sentirse solos cuando están en medio de muchas personas, como los miembros del equipo de el sufrimiento que acompaña a la enfermedad tiene, de acuerdo con las descripciones de los participantes, varios componentes, tales como el tiempo de duración del mismo, la sensación de abandono y soledad, ansiedad, angustia, tristeza, llanto y temor, la alteración de la imagen corporal y la angustia ante la muerte. 31 la experiencia de estar hospitalizado en una unidad de cuidado intensivo óscar alberto beltrán-salazar salud y otros pacientes, a sentirse solos cuando en realidad no lo están. por un lado, estar en la uci significa ser dejado solo y “abandonado”: “como abandonada en una sala tan fría […] en el momento en que yo abrí los ojos no había nadie en ese instante, entonces no yo me quería morir” (e. 1), abandonado en la uci, sitio en donde en realidad hay muchas personas alrededor del paciente, un sitio que cambia las rutinas familiares, la vida cotidiana, que cambia el rol social de las personas hasta tanto su recuperación les permita volver a asumir aquel que desempeñan en su vida diaria. la duración del sufrimiento se refiere, en segundo lugar, a la duración de la enfermedad y de las limitaciones derivadas de ella. en este caso se relaciona con el tiempo que transcurre desde el inicio de la enfermedad y el sufrimiento hasta la rehabilitación, el reintegro a las funciones y a las actividades habituales y el disfrute de la comodidad y el bienestar. también hace referencia a la duración de las limitaciones físicas, del reentrenamiento físico y psicológico, de la rehabilitación, de la terapia con medicamentos, hasta que es posible reasumir las actividades cotidianas. en términos del tiempo, la duración del sufrimiento no solo es importante para los pacientes. según los relatos de los participantes, la duración también la definen los miembros del equipo de salud en sus pronósticos respecto al tiempo durante el cual estará presente una determinada sintomatología o una limitación: “dictaminaron que caminaba aproximadamente en 2 meses y a los tres días estaba de pie. con la ayuda de alguien, pero estaba de pie” (e. 1). “la cabeza a mí se me desinflamó en cuatro semanas. los médicos dijeron que entre cuatro y seis meses. cuando yo volví, cuando se me desinflamó la cabeza yo pedí cita y el tipo estaba extrañado y me dijo `¿usted cómo hizo para que se le desinflamara la cabeza tan rápido?´” (e. 7). “el médico decía: ¡pues esto es lento, el crecimiento se puede demorar, pero causa dificultades, pero ya si se deja también! porque, según me comentaban, era un 20% nada más lo que habían podido extraer del tumor” (e. 8). también hacían mención de la duración los miembros del equipo de salud cuando dictaminaban el tiempo durante el cual estaría presente una terapia y el tiempo de permanencia de la persona en el hospital: “estuve veintidós días en uci, con ventilador veintiuno […] habían dicho que me tenían que dejar un mes en cuidados especiales […] que me iban a dejar mucho rato en la habitación” (e. 2). la utilización de elementos tecnológicos de diagnóstico e intervención, la administración de ciertos medicamentos, tales como sedantes y anestésicos, la realización de procedimientos y controles frecuentes de constantes vitales hacen parte de los cuidados que se brindan a los pacientes que presentan una enfermedad crítica y están hospitalizados en una uci. y todos ellos tienen una especial importancia en los significados que los pacientes otorgan a la experiencia de estar enfermo. según las descripciones de los participantes, los elementos tecnológicos reflejan la gravedad de la enfermedad que sufren, que son elementos necesarios pero también causan molestias. además, son elementos extraños al cuerpo que se instalan como parte del diagnóstico y trala duración del sufrimiento se refiere a la duración de la enfermedad y de las limitaciones derivadas de ella. 32 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 tamiento, conducen a deterioro en la autopercepción y autoconcepto y contribuyen al sufrimiento psicológico. por más medicamentos que me pusieron mi corazón no latía ni mis pulmones tampoco. tenía un balón de contrapulsación aórtica y tenía ventilación mecánica […] me veía cables y equipos por todos lados […] cada vez que me veía un aparato me decía ¡no, esta no soy yo! […] yo sabía que cuando a uno le ponen esos aparatos, no es porque uno esté muy bien que digamos, y yo no quería estar mal […] yo he sido una mujer muy dinámica y no podía concebir que a mí me hubiera sucedido algo como para estar con esos aparatos y todo (e. 1). el ventilador mecánico es una tecnología de uso frecuente en la uci. al tiempo que es una ayuda necesaria y proporciona alivio, estar conectado a él es una experiencia poco grata. sin embargo, también puede pasar desapercibido cuando la enfermedad y la administración de sedantes, analgésicos y anestésicos se acompaña de estados de inconsciencia y alteraciones en la percepción y de la memoria: “el ventilador mecánico era muy necesario al principio, porque la frecuencia respiratoria caía mucho, entonces le puede dar a uno un paro […] definitivamente yo creo que uno no se da cuenta qué es lo que hace, porque uno no lo siente”. e. 7 el ventilador mecánico aleja de la muerte. este es un aspecto que contribuye a los sentimientos paradójicos de los participantes. por un lado, lo aceptan como un elemento que hace lo que el paciente mismo no puede hacer, que ayuda a mantener la vida y a alejar la muerte. de otro lado, despierta rechazo, porque produce malestar, porque las personas perciben su dependencia de él, porque es un elemento extraño al cuerpo cuya presencia no es fácil de olvidar cuando se está consciente. “es muy duro, durísimo” (e. 2): yo me siento súper agradecida con ese equipo, porque sé que si no hubiera tenido la ayuda del ventilador mecánico yo no estuviera contando la historia […] la verdad, [da] alivio, porque vos sentís que sola no vas a ser capaz. es una relación un poco paradójica por el rechazo, pero al mismo tiempo reconocer el beneficio […] el rechazo, en el caso mío, por el hecho de que he sido muy independiente. yo en ese momento sentía que la máquina estaba haciendo el trabajo que yo no podía, de una manera, era mi orgullo […] yo veo eso y digo ¡ay, que nadie vuelva a usar eso!, conociendo los beneficios y lo necesarios que son […] después de eso a mí, cada vez que veo un ventilador, se me encrespan los pelitos (e. 1). para los participantes y sus familias la conexión a un ventilador mecánico es un indicador de mal estado de salud. depender de un ventilador significa tener una enfermedad grave. mientras más elementos de tratamiento y diagnóstico se requieran, más grave parece ser la situación y más cercana puede estar la muerte: “yo lo asocio con una fase muy grave del paciente […] yo decía ¡no, un monitor de signos vitales, un ventilador, esto está grave! […] yo me preguntaba, ¿si yo estoy bien, por qué todavía tengo este equipo?” (e. 1). por el contrario, el retiro progresivo de los elementos significa un avance hacia la mejoría, significa ir “saliendo”, recuperarse. por este motivo, el retiro de los equipos es deseado por los pacientes y para los participantes y sus familias la conexión a un ventilador mecánico es un indicador de mal estado de salud. depender de un ventilador significa tener una enfermedad grave. 33 la experiencia de estar hospitalizado en una unidad de cuidado intensivo óscar alberto beltrán-salazar aún por la familia. entre todos los equipos, en forma especial, el retiro del ventilador mecánico es esperado por los participantes y sus familiares, debido a que su presencia, si bien es tolerable cuando pasa desapercibido durante los períodos de inconsciencia y sedación, cuando se está consciente, el hecho de sentir su presencia y su actividad significa que es un factor que detiene el tiempo y que convierte la experiencia de usarlo en displacentera y angustiante: “cuando yo era consciente, yo quería que me quitaran todos esos aparatos rápido […] se me hizo eterno el tiempo de la conciencia, para cuando yo estaba consciente y tenía el ventilador […] me decían ¡mañana se lo quitamos! y uno era como con esa alegría y llegaba el otro día y no, ¡no, lo vamos a dejar un día más! y a mí eso me causaba angustia” (e. 1). el contraste en este aspecto se expresa cuando la conexión al ventilador mecánico no representó molestia alguna y en cambio su presencia se asumió en forma tranquila. sin embrago, como la conexión al ventilador mecánico se realiza mediante la instalación de una vía aérea artificial que impide o dificulta la comunicación verbal y causa otras molestias, como dolor e incomodidad, el uso de la ventilación mecánica no pasó desapercibido en forma completa: “no, yo no sentía ninguna […] nada que me causara […] me perturbaba en ese estar que estaba en ese momento, de verdad que me sentí muy tranquila […]. esa intubada (sic) sí me pareció cruel; lo más horrible que me parece de eso es quedarse uno mudo, ese deseo de expresarse uno, de decir un sonido siquiera, y ni un sonido puede producir […] es duro” (e. 8). la presencia de una vía aérea artificial, que en el caso de los participantes en este estudio era el tubo orotraqueal, si bien es cierto que era identificada como una ayuda, como un elemento indispensable para mantener la respiración y la vida, también era un elemento extraño al cuerpo, y tenerlo significaba una experiencia horrible y una molestia para el bienestar: “horrible, me molestaba mucho, no podía hablar, pero sí me doy cuenta de que me ayudó a respirar” (e. 3); “si bien tenía sus beneficios, porque me estaba ayudando a respirar, yo sentía que sola podía ser capaz y me molestaba mucho, me sentía ahogada, yo creo que me lastimó mucho en el cuello” (e. 1). por este motivo, los pacientes sienten rechazo y desean su pronto retiro: “yo quería que me lo quitaran lo antes posible, porque lo sentía como algo ajeno a mí. yo pienso que solo era por ser extraño y por eso me incomodaba” (e. 1). o intentan el retiro accidental voluntario, aún cuando también reconocieron su utilidad y sus beneficios: “el día que me quité el tubo o que se salió. dicen que yo me saqué el tubo” (e. 2). la permeabilidad de la vía aérea artificial requiere mantenerse y cuidarse mediante la aspiración de secreciones a través del tubo: yo tenía la idea de que estuvieran sacando así como los magos sacan una pañoleta que no acaba. así sentía yo, como si saliera y saliera algo que no terminaba. me daba nauseas saber que salía y salía y no se detenía, pero al mismo tiempo tenía alivio. era muy charro, porque yo no veía, pero sentía y lo asociaba como si fuera engrudo […] incluso tenía la idea de que el sabor era igual (e. 1). este procedimiento también significó una molestia que parecía no tener fin, de la misma forma que no tiene fin el pañuelo que el mago extrae de su sombrero. la inestar inmovilizado significó para los participantes estar incómodo, con limitación de la libertad. también significó tener dolor, tristeza, cansancio y sufrir las lesiones que se pueden presentar en el sitio de ubicación de las ligas, debidas a lucha con la inmovilización. 34 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 troducción de la sonda de succión estimula los reflejos nauseoso y tusígeno, la presencia de arritmias cardíacas y barre el oxígeno de la vía aérea con el consiguiente descenso en las cifras de la saturación de la hemoglobina con el oxígeno. por tanto, se observa dualidad de sentimientos del paciente frente a este procedimiento; por un lado, significa una molestia, por lo cual se siente rechazo hacia el procedimiento, y por otro lado, produce alivio y favorece la ventilación, y por esto es aceptado y considerado necesario. la inmovilización física mediante ligas, vendajes e inmovilizadores se utiliza en la uci para contener físicamente a los pacientes y evitar el retiro voluntario y traumático de los elementos. estar inmovilizado significó para los participantes estar incómodo, con limitación de la libertad. también significó tener dolor, tristeza, cansancio y sufrir las lesiones que se pueden presentar en el sitio de ubicación de las ligas, debidas a lucha con la inmovilización. además, significó estar amarrado, no moverse, no vivir, no ser libre, una experiencia innombrable, dolorosa y triste: “me intenté mover y me di cuenta de que estaba inmóvil; me mire y tenía las manos amarradas, los pies amarrados, la lengua amarrada” (e. 1). “mi esposo dice que no puede ser que yo me retirara el tubo, porque yo estaba muy conectada, que tenía demasiadas cosas como para sacarme el tubo […] uno sentirse así es tan triste. yo creo que eso es lo que más le duele a uno, es que no tengo palabras para decir eso” (e. 2). “parte de cuidados intensivos es también la comodidad del paciente, porque uno en una misma posición todo el día se cansa y se rinde y a ellas [las enfermeras] no les importa. el todo es que el monitor esté funcionando” (e. 6). la enfermedad involucra problemas y sufrimiento físico y psicológico. de la misma manera como los pacientes pueden darse cuenta de los problemas físicos que se presentan, también lo hacen con sus respuestas y alteraciones de índole psicológico y espiritual. la enfermedad crítica afecta la autoimagen corporal, no necesariamente en forma permanente, pero sí al menos durante el tiempo que está presente la enfermedad y sus limitaciones para la vida de los pacientes. como ya se dijo antes, este tipo de experiencia de enfermedad es “dura y difícil” y los pacientes sufren de angustia con todo lo que ocurre a su alrededor y con la cercanía de la muerte: “la situación no es fácil, pero es que uno no debe estar, no debe entrar como tan angustiado, no sé […] aburridor porque uno también está como en esa condición [de enfermo crítico] y entonces qué pereza, yo creo que eso debería ser agradable. sí, uno se angustia con lo que está pasando, debería ser más agradable” (e. 6). “cuando yo recibí la noticia de que tenía un tumor, lo primero que sentí fue desazón. en lo primero que pensé fue en mis hijos. porque cuando a uno le dicen que tiene un tumor en la cabeza uno se imagina lo peor, que sea maligno, que uno no pueda recuperarse y que quede con alguna secuela o que de pronto muera […] fueron unos días de mucha angustia, sobre todo después de que me dijeron que tenía la infección interna. la verdad es que yo en ese momento pensé que me moría […] no sé, me entró un tela enfermedad crítica afecta la autoimagen corporal, no necesariamente en forma permanente, pero sí al menos durante el tiempo que está presente la enfermedad. 35 la experiencia de estar hospitalizado en una unidad de cuidado intensivo óscar alberto beltrán-salazar mor bastante fuerte […] a la cirugía siguiente, cuando se me infectó la cabeza por dentro, entré digamos muy preocupado” (e. 7). otras respuestas de los pacientes ante la situación son la depresión, la tristeza y el llanto: me daba tristeza, mucha tristeza, de llorar todos los días de cuidados intensivos. había una hora de la tarde en la que yo sin saber qué hora era empezaba a llorar, desde que estaba en uci hasta que llegué a mi casa y por ahí dos meses más. no, me iba dando una angustia, un dolor, una cosa muy horrible, y yo empezaba a llorar […] empezaba a sentir una angustia, una cosa que yo no sabía lo que era, y yo lloraba y lloraba y lloraba y después me calmaba y seguía normal” (e. 2). llama la atención que la hora en la cual esta participante empezaba a llorar coincidía con el tiempo en el cual se terminaba la visita familiar, durante su hospitalización en la uci. la enfermedad grave también altera el autoconcepto, por lo cual los pacientes no se reconocen a sí mismos, no reconocen su propio cuerpo: “eso me deprimía […] a mí me dio una cosa muy horrible, yo creo que entré en shock, porque yo sentía que estaba en una pesadilla y que esa no era yo, que esa no era mi vida. como si hubiera soñado y hubiera despertado en un cuerpo que no era el mío” (e. 1). durante el período de la enfermedad los pacientes tienen emociones, sentimientos, reacciones y deseos relacionados con esta etapa de su vida, tales como ansiedad, angustia, tristeza, llanto y temor. una de las reacciones es denominada por travelbee (19) “reacción `por qué a mí´” (“why me reaction”), en la cual el paciente considera que la situación no debió ocurrir y siente rabia, culpa, depresión, angustia, indiferencia y la tendencia a responsabilizar a alguien más de la situación. como se ha visto, tanto la enfermedad como los componentes del cuidado tienen efectos sobre los pacientes que estos perciben y describen. además, la asignación de significados considera cada uno de estos aspectos; en relación con los elementos del cuidado, estos significados se expresan en forma paradójica, porque, por un lado, los pacientes reconocen su necesidad y utilidad y, por otro, perciben sus molestias y desean su retiro. la enfermedad tiene el significado de una condición que debe resolverse. otro aspecto que hace de la enfermedad crítica una experiencia difícil se relaciona con la falta de autonomía para decidir y de independencia para actuar. las descripciones de los participantes relacionadas con este aspecto de la experiencia se analizarán en otra publicación. discusión la experiencia de padecer una enfermedad crítica y la hospitalización en uci es dura debido al sufrimiento que ocasiona, tanto por los efectos de la enfermedad como por los elementos utilizados en el tratamiento y los procedimientos realizados para resolver la enfermedad. el sufrimiento es físico, psicológico y espiritual, es decir, que afecta al cuerpo, la mente y el espíritu, o sea, a la persona en su integridad; además del sufrimiento también contribuye a la dureza de la situación el hecho de tener que alejarse del hogar y de la familia durante la vivencia de la enfermedad. respecto al hecho de estar durante el período de la enfermedad los pacientes tienen emociones, sentimientos, reacciones y deseos relacionados con esta etapa de su vida, tales como ansiedad, angustia, tristeza, llanto y temor. 36 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 enfermo, travelbee (19) había planteado que es estar solo y temeroso es temer a lo conocido y a lo desconocido, al presente y al futuro; es experimentar el temor de no tener futuro; y continúa diciendo que estar enfermo y con dolor es creer que los que no lo tienen deben estar felices, es deprimirse fácilmente, es experimentar fatiga, malestar y debilidad en el cuerpo, en la mente y en el espíritu. el sufrimiento que vivieron los participantes estuvo caracterizado por la duración, la intensidad y el origen. estos hallazgos están de acuerdo con el planteamiento hecho por travelbee (19) respecto a que “el sufrimiento físico de la enfermedad tiene variados niveles de intensidad, duración y profundidad, de igual forma que el enojo y la desesperanza que lo acompañan”; además peplau (1) también afirma que “con frecuencia el sufrimiento puede llevar a que se consideren los síntomas como el problema principal debido a las molestias que plantean al usuario y no como una manifestación del problema principal”. la duración del sufrimiento, según los resultados de este estudio, hizo referencia al tiempo durante el cual fue necesaria la permanencia en la uci y en el hospital, al tiempo de duración de las manifestaciones de la enfermedad y las limitaciones físicas y sicológicas derivados de esta y al tiempo durante el cual fue necesario estar sometido a terapias y controles por parte de los profesionales de la salud. el ingreso a la uci por el inicio de la enfermedad y el reintegro a las actividades cotidianas marcaron dos momentos extremos en la duración del sufrimiento. en relación con la intensidad, se encontró que el sufrimiento fue tan intenso que hacía perder a los pacientes la noción de su propio cuerpo, alterar el autoconcepto y percibir la cercanía de la muerte. también el sufrimiento pudo ser aceptado sin dificultad debido a que representó una vía para resolver un problema de enfermedad, por ejemplo, cuando fue necesario recurrir a complejas cirugías, con su consiguiente hospitalización en uci, debido a la presencia de procesos tumorales. el origen del sufrimiento fue muy variado; dependió de las manifestaciones de la enfermedad y también fue infligido por los profesionales de la salud en la práctica del cuidado, durante la realización de procedimientos, cirugías, la utilización de elementos invasivos con propósitos de diagnóstico y terapia, la administración de ciertos medicamentos, tales como sedantes y anestésicos, la realización de controles frecuentes de las constantes vitales, que hacen parte de los cuidados que se brindan a los pacientes que presentan una enfermedad crítica y están hospitalizados en una uci, debido al mayor riesgo que tienen de morir, de presentar complicaciones y de sufrir secuelas. ciertos elementos tecnológicos y procedimientos utilizados en el cuidado contribuyeron a la dureza de la situación de padecer una enfermedad grave, no solo por los efectos no deseados que produjeron en los pacientes, sino también porque la relación con estos elementos fue vista como deshumanizada, cuando la atención del personal de salud y la importancia del cuidado se desplazaron para ubicar como aspectos primordiales el funcionamiento de estos equipos y no se tuvieron en cuenta las decisiones de los pacientes, a quienes no se ponía atención ni se escuchaban sus problemas o sus necesidades manifiestas. un ejemplo de los elementos tecnológicos utilizados en el cuidado lo constituyen los ventiladores mecánicos utilizados con pacientes que tenían alteraciones en la ventilación espontánea. según los participantes, ellos significaron una ayuda para alejarse de la muerte, pero además significaron algo externo al cuerpo y algo a lo que hubo necesidad de adaptarse; además, el ventilador mecánico es un indicador de la gravedad de la situación. conclusiones la experiencia de padecer una enfermedad crítica es “dura y difícil”, contribuye al sufrimiento en el cuerpo y en la persona. es una experiencia que se vive aun cuando para la mayoría de las personas es preferible no haberlo hecho. “es una experiencia cuyo contexto más íntimo son los cambios en el yo mismo debidos a la enfermedad y a las lesiones”, plantea madjar (6) y agrega que “la vivencia de la enfermedad y del sufrimiento contribuye a la pérdida del cuerpo, que es habitual y familiar para cada persona”. a que una experiencia como la descrita en este estudio sea dura contribuyen varios aspectos. en primer lugar, la enfermedad, con sus manifestaciones en el organismo y en la persona, es decir, el sufrimiento en el plano físico y psicológico. también las intervenciones médicas, quirúrgicas, los procedimientos enfermeros, la instalación de equipos, catéteres y elementos de monitoría y de asistencia a las funciones corporales, como la monitoria invasiva, la ventilación mecánica, la instalación de una vía aérea artificial y la inmovilización física constituyen motivos de sufrimiento o aumentan su dureza. a este último aspecto hace referencia madjar (6) en sus planteamientos sobre el dolor clínicamente infligido durante la realización de procedimientos sobre los pacientes, cuando 37 la experiencia de estar hospitalizado en una unidad de cuidado intensivo óscar alberto beltrán-salazar son tocados, manipulados e invadidos por agujas y otros instrumentos y cuando les son retirados tejidos para biopsias o por desbridamientos y amputaciones. sin embargo, como la mayoría de las situaciones que atraviesan los seres humanos a lo largo de sus vidas, este tipo de experiencia de enfermedad también constituye una forma de aprendizaje. es una experiencia que sirve de base para implementar cambios en la forma de ver o de enfrentar la vida y en las relaciones con las personas que están alrededor de quienes viven la experiencia y padecen la enfermedad. inclusive los miembros de la familia, a pesar de su sufrimiento, obtienen beneficios en el orden psicológico y social cuando acompañan a un paciente durante la estancia en uci por una enfermedad grave. referencias 1. peplau h. relaciones interpersonales en enfermería. barcelona: salvat; 1990. p. 6, 194. 2. del barrio m, lacunza m, armendáriz a. pacientes con transplante hepático: su experiencia en cuidado intensivo. estudio fenomenológico. enferm intensiva 2001; 12(3): 135, 136-41. 3. jablonski r. the experience of being mechanically ventilated. qualitative health research 1994; (2): 187-91,188. 4. peralta r, álvarez g, pérez y. desarrollo de un sistema de garantía de calidad en ventilación mecánica. enferm intensiva 2002; 13(4): 155-63. 5. goñi r, garcía m, vásquez m. evaluación de la calidad de los cuidados en la uci a través de un plan de atención de enfermería informatizado. enferm intensiva 2004; 15(2): 76-85. 6. madjar i. infligir y manejar el dolor. un desafío para enfermería. invest educ enferm 2000; 18(i): 45, 43, 43, 40, 39. 7. balanza g. el significado del cuidado de enfermería en la perspectiva del paciente adulto hospitalizado. revista iberoamericana de investigación 1997; (1): 65. 8. torralba f. el arte de cuidar. en: antropología del cuidar. españa: fundación mapfre medicina, instituto borja de bioética; 1998. p. 334. 9. nieswiadomy r. foundations of nursing research. 3 ed. stamford: appleton y lange; 1998. p. 158, 158, 158. 10. jablonski r. the experience of being mechanically ventilated. qualitative health research 1994 mayo; 4(2): 188. 11. strauss a, corbin j. bases de investigación cualitativa. técnicas y procedimientos para desarrollar teoría fundamentada. medellín: facultad de enfermería, universidad de antioquia; 2002. p. 219. 12. de la cuesta c. cuidado artesanal. la invención ante la adversidad. medellín: facultad de enfermería, universidad de antioquia; 2004. p. 38. 13. taylor s, bodgan r. introducción a los métodos cualitativos de investigación. barcelona: paidós; 1987. p. 55-6. 14. morse j. asuntos críticos en los métodos de investigación cualitativos. trad. zimermen eva. medellín: facultad de enfermería, universidad de antioquia; 2003. p. 145. 15. cohen m, kahn d, steeves r. hermeneutic phenomenological research. a practical guide for nurse research. londres: saac; 2000. p. 71-83, 81, 82. 16. foucault m. el nacimiento de la clínica. una arqueología de la mirada médica. argentina: siglo xxi; 2004. p. 167. 17. galeano. e. diseño de proyectos en la investigación cualitativa. 1 ed. medellín: eafit; 2004. p. 45. 18. donella e, rodríguez p. más allá del dilema de los métodos. la investigación en las ciencias sociales. 2 ed. bogotá: norma; 1997. p. 153. 19. travelbee j. interpersonal aspects of nursing. philadelphia: f.a. davis company; 1966. p. 70-72, 75, 86-87, 71. assessment of sexuality and frailty in older adults living in northeast brazil   article assessment of sexuality and frailty in older adults living in northeast brazil * evaluación de la sexualidad y la fragilidad en ancianos habitantes del noreste de brasil ** avaliação da sexualidade e da fragilidade em idosos residentes no nordeste do brasil *** 10.5294/aqui.2022.22.1.8 edison vitório de souza-júnior 1 gabriele da silva santos 2 suziane de aguiar brito 3 sterline therrier 4 lais reis siqueira 5 namie okino sawada 6 1 0000-0003-0457-0513 universidade de são paulo, brasil. edison.vitorio@usp.br 2 0000-0001-6969-0271 universidade federal da bahia, brasil. novaes.gabriiele@ufba.br 3 0000-0003-3004-5843 universidade de são paulo, brasil. suzianeaguiar6@usp.br 4 0000-0002-7713-3288 universidade federal de alfenas, brasil. ppgenf@unifal-mg.edu.br 5 0000-0002-6720-7642 universidade federal de alfenas, brasil. ppgenf@unifal-mg.edu.br 6 0000-0002-1874-3481 universidade federal de alfenas, brasil. namie.sawada@unifal-mg.edu.br * this study was carried out with the support of the coordination for the improvement of higher education personnel, brazil, funding code 001. ** el trabajo se realizó con el apoyo de la coordenação de aperfeiçoamento de pessoal de nível superior, brasil, código de financiación 001. *** o presente trabalho foi realizado com apoio da coordenação de aperfeiçoamento de pessoal de nível superior, brasil, código de financiamento 001. received: 10/25/2020 sent to reviewers: 12/01/2020 approved by reviewers: 07/22/2021 accepted: 09/27/2021 theme: promotion and prevention. contributions to the subject: this study contributes as an instigation for the possibility of identifying new non-pharmacological approaches for the promotion and protection of the health of older adults. in this case, the healthy experiences of sexuality can constitute one of these approaches and, in some way, contribute to the maintenance of health, as this study found positive and negative correlations between the experiences of sexuality and frailty in older adults. to cite this article / para citar este artículo / para citar este artigo: souza-junior ev, santos gs, brito sa, therrier s, siqueira lr, sawada no. assessment of sexuality and frailty in older adults living in northeast brazil. aquichan. 2022;22(1):e2218. doi: https://doi.org/10.5294/aqui.2022.22.1.8 abstract objective: to evaluate the experiences of sexuality and its correlation with frailty among older adults. materials and methods: cross-sectional study carried out with a total of 250 older adults living in the north-east of brazil. they answered three instruments to obtain biosocio-demographic, sexuality and frailty data. the analysis was performed using spearman correlation, mann-whitney and kruskal-wallis test with 95 % confidence interval. results: sexual intercourse was negatively correlated with reduced strength (p = -0.263; p < 0.001) and walking speed (p = -0.201; p = 0.001) and positively correlated with reported fatigue (p = 0.149; p = 0.018). affective relationships were negatively correlated with reduced strength (p = -0.254; p < 0.001) and walking speed (p = -0.207; p = 0.001) and positively correlated with reported fatigue (p = 0.207; p = 0.001). finally, physical and social adversities were positively correlated with reduced strength (p = 0.279; p < 0.001), reduced walking speed (p = 0.261; p < 0.001) and low physical activity (p = 0.140; p = 0.034), in addition to being negatively correlated with reported fatigue (p = -0.171; p = 0.009). conclusion: it was found that the sexuality of older adults is better experienced in affective relationships and weak positive and negative correlations between sexuality and frailty. keywords (source decs): public health; older adults health; sexuality; frailty; comprehensive health care. resumen objetivo: evaluar las vivencias de la sexualidad y su correlación con la fragilidad entre ancianos. materiales y métodos: estudio seccional realizado con 250 ancianos habitantes en el noreste de brasil. los ancianos contestaron tres instrumentos para obtener datos bio-sociodemográfico, la sexualidad y la fragilidad. se realizó el análisis con base en la correlación de spearman, prueba de mann-whitney y kruskal-wallis con intervalo de confianza del 95 %. resultados: el acto sexual se correlacionó negativamente con la reducción de la fuerza (p = -0,263; p < 0,001) y de la velocidad de marcha (p = -0,201; p = 0,001) y positivamente a la fadiga relatada (p = 0,149; p = 0,018). las relaciones afectivas se correlacionaron negativamente a la reducción de la fuerza (p = -0,254; p < 0,001) y de la velocidad de marcha (p = -0,207; p = 0,001) y positivamente a la fadiga relatada (p = 0,207; p = 0,001). por fin, las adversidades física y social se correlacionaron positivamente a la reducción de la fuerza (p = 0,279; p < 0,001), a la reducción de la velocidad de marcha (p = 0,261; p < 0,001) y a la baja actividad física (p = 0,140; p = 0,034), además de correlacionar negativamente con la fadiga relatada (p = -0,171; p = 0,009). conclusiones: se encontró que la sexualidad de los ancianos se vivencia de mejor manera en las relaciones afectivas y correlaciones positivas y negativas de magnitud débil entre la sexualidad y la fragilidad. palabras clave (fuente: decs): salud pública; salud del anciano; sexualidad; fragilidad; atención integral de salud. resumo objetivo: avaliar as vivências da sexualidade e sua correlação com a fragilidade entre idosos. materiais e métodos: estudo seccional realizado com 250 idosos residentes no nordeste do brasil. os idosos responderam a três instrumentos para a obtenção dos dados biossociodemográfico, da sexualidade e da fragilidade. a análise foi realizada com a correlação de spearman, teste de mann-whitney e kruskal-wallis com intervalo de confiança de 95 %. resultados: o ato sexual se correlacionou negativamente à redução da força (p = -0,263; p < 0,001) e da velocidade de caminhada (p = -0,201; p = 0,001) e positivamente à fadiga relatada (p = 0,149; p = 0,018). as relações afetivas se correlacionaram negativamente à redução da força (p = -0,254; p < 0,001) e da velocidade de caminhada (p = -0,207; p = 0,001) e positivamente à fadiga relatada (p = 0,207; p = 0,001). por fim, as adversidades física e social se correlacionaram positivamente à redução da força (p = 0,279; p < 0,001), à redução da velocidade de caminhada (p = 0,261; p < 0,001) e à baixa atividade física (p = 0,140; p = 0,034), além de se correlacionar negativamente com a fadiga relatada (p = -0,171; p = 0,009). conclusões: constatou-se que a sexualidade dos idosos é vivenciada de melhor forma nas relações afetivas e correlações positivas e negativas de fraca magnitude entre a sexualidade e a fragilidade. palavras-chave (fonte decs): saúde pública; saúde do idoso; sexualidade; fragilidade; assistência integral à saúde. introduction sexuality is an essential component of the individual's identity and influences both sexual expressions and the completeness of human functioning. it can be said that sexuality has two aspects: procreative, recreational or pleasurable. the procreative aspect is associated with the idea of reproduction and represents a very small part of sexuality, while the recreational or pleasurable aspect (pleasure and hedonism) is a more complex component and involves intimacy and the sexual act as a social connection (1). thus, the expression of sexuality includes thoughts, beliefs, values, attitudes, eroticism, fantasies, desires, practices, roles (1), partnership, functions, motivation (2), including sexual behaviors (1). it should be remembered that sexuality is present throughout the life cycle, regardless of age group, gender, sexual orientation or any other clinical and social stratification. it is a complex area that is strongly influenced by the cultural context in which the individual is inserted (3). it is estimated that around 8.5 % of the world's population is aged 65 or over, with the prospect of an increase to 16.7 % in 2050 (4). the aging process is often accompanied by chronic diseases and cognitive alterations that evolve with unsatisfactory outcomes over the years (5). in addition, it is estimated that around 10 to 25 % of the older adults population has certain clinical conditions that predispose them to a greater risk of frailty with consequent financial impacts on the government and family system (6). frailty can be defined as a biological syndrome that reduces reserve and resistance to stressors (5) and has a high prevalence in old age, characterized as being one of the factors responsible for the high rates of adverse health outcomes, such as morbidity and mortality, falls and institutionalization (7). from this perspective, frailty can be relevant for risk prediction and decision-making in health services (5). however, although the prevalence of frailty increases substantially with age, especially in people over 80 years old, it should be remembered that the accuracy of the prevalence rates depends on the definition adopted, as there are different approaches regarding specific aspects of frailty (8). thus, this study will adopt the frailty framework proposed by fried (7), who defined it as a clinical syndrome with the presence of at least three or more of the following criteria: unintentional weight loss, self-reported exhaustion, weakness, reduced walking speed and low physical activity (7). thus, the relevance of this study involves the possibility of identifying new non-pharmacological approaches for promoting and protecting the health of older adults. in this case, the healthy experiences of sexuality can constitute one of these approaches, and somehow contribute to the maintenance of health, which can be explored in future research, especially based on the salutogenesis model (9). this model was devised by israeli sociologist aaron antonovsky with the purpose of understanding the development of health, considering a continuous state of health and disease, going deep­er into its maintenance and use of available resources so that the entire process becomes effective. in this model, it is assumed that, if individuals became active beings in decision-making that culminate in health-promoting behaviors, the risks and suffering would be mitigated (9, 10). from this perspective, this study raises the hypothesis that sexuality is negatively correlated with frailty among older adults. it should be remembered that its expression continues to constitute an integral element of quality of life in old age and its valuation in the care context is essential for the provision of health care and the planning of institutional services. thus, an expanded and holistic understanding of sexuality among older adults can provide subsidies that increase the quality of research, education, policies and, especially, care for this population (2). nevertheless, it is noteworthy that most investigations that address sexuality in old age focus on the medical model of sexuality and on the physiological impact of aging on the sexual response of men and women (2), contributing with few reflections on the relationship between sexuality itself with health conditions in old age. thus, the objective was to evaluate the experiences of sexuality and its correlation with frailty among older adults. materials and methods this is a cross-sectional study with a descriptive and analytical approach, carried out with a total of 250 older adults living in the northeast of brazil. the older adults were recruited using the consecutive non-probabilistic technique through the dissemination of the survey on the facebook social network. the authors created a page exclusively for the development of the research, in which a personalized invitation was published with the indication of the link institution, the responsible researchers, the inclusion criteria of the participants and the contact number for the clarification of doubts and/or suggestions. in addition, along with the invitation, a hyperlink was published, prepared with the google forms tool, which gave direct access to the survey questionnaire. for the construction of the questionnaire, instruments validated and standardized for the brazilian population were used. the questionnaire was structured in three parts: biosociodemographic, sexuality and frailty. it is noteworthy that, before the older adults access the content of the questionnaire, it was mandatory to include their respective valid e-mails, in order to ensure the quality of the data through the identification of possible multiple responses by the same participant. in addition, the e-mail served as a strategy to send the second copy of the informed consent form and as a space for exchanging information about the relevance of the research to society. the biosociodemographic survey aimed to describe the profile of older adults through information such as age group (from 60 years old), biological sex (male and female), education, religious belief, ethnicity, marital status, time living with the partner, sexual orientation and if they had any orientation about sexuality by health professionals. the "sexuality" survey was assessed using the affective and sexual experiences of older adults scale (11). this is a psychometric scale composed of constructs that assess sexuality in its expanded understanding, considering the sexual aspects (dimension "sexual act"), affective (domain "affective relationships") and physical-social (domain "physical and social adversities"). it consists of 38 items with five possibilities for objective answers and organized in a likert-type scale, in which: 1 = never; 2 = rarely; 3 = sometimes; 4 = often and 5 = always. this instrument does not have a cutoff point, with the lowest/highest scores corresponding, respectively, to the worst/better experience of sexuality for the dimensions "sexual act" and "affective relationships". the dimension "physical and social adversity" has negative issues and, therefore, its interpretation is opposite to the other two dimensions, and the lower/higher the score, respectively, the better/worse is the older adult's coping with the adversities that hinder their experiences in sexuality (11). finally, the "frailty" survey was constructed with the self-reported frailty instrument (12). it is composed of six questions that assess the five components of the frailty phenotype proposed by fried (7): unintentional weight loss, reduced strength, reduced walking speed, low physical activity and reported fatigue. the "weight loss" component was scored in older adults who reported a loss of more than three kilograms in the last 12 months; the components "reduced strength", "walking speed" and "low physical activity" were scored in the positive responses in relation to the last 12 months in the dichotomous options (yes or no); finally, the component "reported fatigue" was scored in older adults who mentioned the option "sometimes" or "most of the time" in at least one of the questions in relation to the last week. the final classification was: non-frail (older adults who did not score any item), pre-frail (older adults who scored positively between one and two items) and frail (those who scored from three items) (12). to participate in the study, the older adults met the following inclusion criteria: having active facebook account and internet access; being 60 years old or older; living in the northeast region, of both sexes and who were married, in a stable union or with a steady partner. older adults living in long-term care facilities and hospitalized ones were excluded. due to the need for skills in handling electronic devices that provide access to the internet, in addition to active interaction in social networks, the instrument to assess the cognition of older adults was not applied. to delimit the study scenario, the authors used the geolocation tool available on the page created, which only allowed the inclusion of old­er adults living in the northeast of brazil. nevertheless, the authors resorted to the post boosting tool, which facebook extended the dissemination of questionnaires to as many people as possible until reaching the intended sample within the pre-established scenario. the sample size was defined a priori considering an infinite population, prevalence of frailty in older adults of 16.6 %, a = 0.05 (5 %) and confidence interval (ci) = 95 % (za/2 = 1.96), which resulted in a minimum sample of 213 older adults (13). however, more than 15 % was added to the calculation to compensate for possible losses due to duplication and/or incompleteness of responses, resulting in 250 participants in the final sample. data were stored and analyzed using the ibm spss® statistical software. initially, data distribution was verified using the kolmogorov-smirnov test, showing non-normal distributions (p < 0.05). thus, non-parametric statistics were used for the analyses, using the mann-whitney test for variables with up to two categories and kruskal-wallis for variables with three or more categories, with subsequent application of the bonferroni post-hoc test when needed. the analysis of the independent (sexuality) and the dependent (frailty) variable was performed using spearman's correlation (p). the correlation coefficients were interpreted as follows: weak magnitude (p < 0.4); moderate magnitude (from p > 0.4 to < 0.5) and strong magnitude (p > 0.5) (14). a 95 % ci (p < 0.05) was adopted for all statistical analyses. categorical variables were presented as absolute and relative frequencies. as for the quantitative variables, through the median (md), interquartile range (iq) and middle ranks (mr). this study fulfilled the ethical requirements for the development of research with human beings, according to resolution 466/2012 of the national health council. furthermore, it was approved by the research ethics committee of the university of sao paulo at ribeirao preto nursing school, under opinion 4 319 644 and certificate of presentation for ethical appreciation 32004820 0 0000 5393. results table 1 shows the distribution of the participants' responses in the sexuality scale and its three dimensions. table 1. absolute and relative frequencies of the affective and sexual experiences scale of older adults   never rarely sometimes frequently always n % n % n % n % n % 1. i have a favorable attitude towards sexuality in old age. 16 6.4 20 8.0 55 22.0 67 26.8 92 36.8 4. i desire my partner. 6 2.4 13 52 46 18.4 76 30.4 109 43.6 5. my partner and i have sex. 13 52 30 12.0 55 22.0 94 37.6 58 23.2 9. sexual experiences are good for my self-esteem. 3 1.2 11 4.4 23 9.2 30 12.0 183 73.2 10. enjoying my sexuality means being alive. 6 2.4 9 3.6 19 7.6 26 10.4 190 76.0 11. i feel desired by my partner. 12 4.8 21 8.4 59 23.6 58 23.2 100 40.0 14. i find that having sex improves our relationship. 10 4.0 8 3.2 43 17.2 49 19.6 140 56.0 20. sexual experiences make me feel more alive. 6 2.4 7 2.8 26 10.4 29 11.6 182 72.8 22. i see the existence of desire in our relationship. 14 5.6 24 9.6 45 18.0 53 21.2 114 45.6 24. i believe that, in old age, i remain a beautiful person. 8 3.2 15 6.0 65 26.0 52 20.8 110 44.0 26. i feel good when we have sex. 8 3.2 10 4.0 35 14.0 34 13.6 163 65.2 28. our sexual experiences are pleasurable. 12 4.8 20 8.0 47 18.8 49 19.6 122 48.8 29. i need the experiences of sexuality to live. 21 8.4 17 6.8 49 19.6 56 22.4 107 42.8 31. the practice of sexuality gives me well-being. 6 2.4 6 2.4 32 12.8 41 16.4 165 66.0 34. i express my sexuality without caring what others think of me. 26 10.4 20 8.0 43 17.2 43 17.2 118 47.2 35. my partner and i usually date. 15 6.0 25 10.0 73 29.2 75 30.0 62 24.8 36. with advancing age, i feel i have lost interest in sex. 110 44.0 46 18.4 76 30.4 8 3.2 10 4.0 38. kisses and cuddles are part of our relationship routine. 18 7.2 31 12.4 65 26.0 51 20.4 85 34.0 dimension ii — affective relationships 2. i enjoy being with my partner. 6 2.4 14 5.6 28 11.2 62 24.8 140 56.0 3. my partner enjoys privacy. 5 2.0 12 4.8 34 13.6 60 24.0 139 55.6 6. i feel that my partner likes me. 9 3.6 14 5.6 46 18.4 70 28.0 111 44.4 7. we are friends. 4 1.6 4 1.6 19 7.6 43 17.2 180 72.0 8. i love my partner. 4 1.6 6 2.4 23 9.2 27 10.8 190 76.0 12. our relationship is filled with a lot of affection. 13 52 23 9.2 58 23.2 57 22.8 99 39.6 13. i accept the changes caused by aging. 16 6.4 8 3.2 70 28.0 37 14.8 119 47.6 15. i'm not ashamed or afraid to express to my partner what i feel. 29 11.6 11 4.4 48 19.2 41 16.4 121 48.4 16. i think sexuality in old age is normal. 0.0 9 3.6 46 18.4 34 13.6 159 63.6 17. i feel my partner enjoys being with me. 8 3.2 18 7.2 38 15.2 44 17.6 142 56.8 18. our relationship is based on companionship. 5 2.0 10 4.0 28 11.2 52 20.8 155 62.0 19. i see the existence of love in our relationship. 11 4.4 11 4.4 32 12.8 47 18.8 149 59.6 21. i see complicity in our relationship. 12 4.8 17 6.8 36 14.4 44 17.6 141 56.4 23. i feel affection for my partner. 5 2.0 12 4.8 30 12.0 43 17.2 160 64.0 25. i feel loved by my partner. 8 3.2 15 6.0 40 16.0 46 18.4 141 56.4 27. i know i can count on my partner. 9 3.6 11 4.4 35 14.0 34 13.6 161 64.4 33. sexual experiences are important for the quality of life of older adults. 3 1.2 8 3.2 39 15.6 50 20.0 150 60.0 dimension iii — physical and social adversity 32. some health problems hinder my sexual experiences. 62 24.8 35 14.0 110 44.0 24 9.6 0.0 30. i feel uncomfortable with the changes in my sexuality brought by aging. 52 20.8 34 13.6 100 40.0 38 15.2 26 10.4 37. i'm afraid of being a victim of prejudice because of my attitudes towards sexuality. 151 60.4 26 10.4 58 23.2 6 2.4 9 3.6 source: self elaboration from vieira (11). table 2 shows the absolute and relative frequencies of the questions of the self-reported frailty instrument, according to its five components. table 2. details of the self-reported frailty instrument components questions n % weight loss in the past 12 months, have you lost weight without going on a diet?     no 179 71.6 yes, between 1kg and 3kg 36 14.4 yes, more than 3kg 35 14.0 weakness in the last 12 months (last year), do you feel weaker, do you think your strength has decreased?     no 122 48.8 yes 128 51.2 slowness do you think you are walking slower today than you walked 12 months ago (one year ago)?     no 132 52.8 yes 118 47.2 low physical activity do you think you do less physical activity than you did 12 months ago (one year ago)?     no 91 36.4 yes 159 63.6 exhaustion how often, in the last week, did you feel that you couldn't get on with your stuff (starting something but couldn't finish it)?     never or rarely (less than 1 day) 135 54.0 few times (1-2 days) 72 28.8 sometimes (3-4 days) 36 14.4 most of the time 7 2.8 how often, in the last week, did the performance of your routine activities require a great effort from you to happen?     never or rarely (less than 1 day) 108 43.2 few times (1-2 days) 94 37.6 sometimes (3-4 days) 39 15.6 most of the time 9 3.6 source: self-elaboration based on nunes et al. (12). it is observed in table 3 that non-frail and pre-frail older adults did not present a great discrepancy between their experiences of sexuality in the three dimensions. however, older adults classified as frail had the worst experiences in all dimensions of sexuality. the lowest medians observed among frail older adults in the sexual act and in affective relationships indicate that they experience these two dimensions with worse quality, when compared to non-frail and pre-frail older adults. the highest median in physical and social adversities indicates that frail people face adversities in a worse way in relation to their sexuality. table 3. sexuality of older adults according to frailty frailty dimensions of sexuality non-frail pre-frail frail general median (iq) median (iq) median (iq) median (iq) sexual act 76 (67.50-79) 76.50 (67.25-81) 73 (62-80) 74 (64-80) affective relationships 77 (69-81) 76.50 (68-81.75) 75 (63-81) 75 (67-81) physical and social adversity 6 (5-8.50) 6 (5-8) 7 (5-9) 7 (5-9) source: self-elaboration. furthermore, it is noteworthy that, in general, older adults experience their sexuality better in affective relationships when compared to the sexual act, although the observed scores are not so out of line. it is noteworthy that the iq indicates the values observed in the dispersion of data for each dimension evaluated. as shown in table 4, it is noted that, in the field of sexuality, the worst male gender faces physical and social adversity (mr = 121.99; p = 0.048). furthermore, there was a statistical association between marital status, which indicated that older adults with a steady partner experience the sexual act better (mr = 161.48; p < 0.001) and affective relationships (mr = 145.03; p = 0.003) with respect to married people. table 4. association between biosociodemographic data with sexuality and older adults frailty   sexuality frailty variables sexual act affective relationships physical and social adversity non-frail (n = 5) pre-frail (n = 84) frail (n = 161)   middle ranks absolute and relative frequencies gender male 121.52 120.91 121.99 5 (100 %) 57 (67.9 %) 104 (64.6 %) female 133.38 131.51 103.55 0 (0 %) 27 (32.1 %) 57 (35.4 %) p value 0.220 0.270 0.048* age group 60-64 years old 131.93 131.60 109.51 3 (60 %) 34 (40.5 %) 68 (42.2 %) 65-69 years old 125.24 122.09 119.45 1 (20 %) 37 (44.0 %) 61 (37.9 %) 70-74 years old 122.59 116.56 126.02 0 (0 %) 10 (11.9 %) 25 (15.5 %) 75-79 years old 83.05 113.50 118.06 1 (20 %) 3 (3.6 %) 6 (3.7 %) 80-84 years old 3.00 11.0 0 (0 %) 0 (0 %) 1 (0.6 %) p value 0.125 0.366 0.584 religion catholic 119.15 120.49 117.35 3 (60 %) 54 (64.3 %) 93 (57.8 %) protestant 146.45 133.29 115.30 1 (20 %) 9 (10.7 %) 18 (11.2 %) spiritualism 139.22 140.32 122.02 0 (0 %) 6 (7.1 %) 19 (11.8 %) african origins 200.75 187.32 114.75 0 (0 %) 1 (1.2 %) 3 (1.9 %) others 122.48 120.95 115.63 1 (20 %) 7 (8.3 %) 12 (7.5 %) no religion 116.07 114.54 102.19 0 (0 %) 7 (8.3 %) 16 (9.9 %) p value 0.102 0.335 0.948 ethnicity white 126.18 125.76 112.85 3 (60 %) 62 (73.8 %) 106 (65.8 %) yellow 108.00 92.80 171.70 0 (0 %) 1 (1.2 %) 4 (2.5 %) black 91.79 86.38 136.50 1 (20 %) 1 (1.2 %) 10 (6.2 %) brown 132.66 131.89 117.47 1 (20 %) 20 (23.8 %) 37 (23.0 %) indigenous 115.75 121.13 150.75 0 (0 %) 0 (0 %) 4 (2.5 %) p value 0.468 0.284 0.300 education primary 130.89 119.39 131.25 0 (0 %) 6 (7.1 %) 17 (10.6 %) elementary school i 140.68 127.75 120.75 1 (20 %) 6 (7.1 %) 13 (8.1 %) elementary school ii 110.03 110.60 105.15 4 (80 %) 4 (4.8 %) 11 (6.8 %) high school 124.84 121.16 116.34 0 (0 %) 28 (33.3 %) 50 (31.1 %) higher education 125.24 129.85 113.00 0 (0 %) 40 (47.6 %) 69 (42.9 %) no education 12.50 77.0 0 (0 %) 0 (0 %) 1 (0.6 %) p value 0.528 0.858 0.769 marital status married 112.00‡ 113.63‡ § 120.12 3 (60 %) 57 (67.9 %) 107 (66.5 %) stable union 142.73 147.33§ 119.56 1 (20 %) 12 (14.3 %) 26 (16.1 %) with a partner 161.48‡ 145.03‡ 98.93 1 (20 %) 15 (17.9 %) 28 (17.4 %) p value <0.001† 0.003† 0.164 time living with the partner ≤ 5 years 167.64‡ 152.92‡ 102.49 0 (0 %) 16 (19.0 %) 21 (13.0 %) between 6 and 10 years 159.48s 154.48 119.70 1 (20 %) 4 (4.8 %) 17 (10.6 %) between 11 and 15 years 118.46 107.54 116.15 0 (0 %) 3 (3.6 %) 10 (6.2 %) between 16 and 20 years 148.72 133.19 131.53 1 (20 %) 8 (9.5 %) 7 (4.3 %) > 20 years 109.53‡ s 114.57* 117.15 3 (60 %) 53 (63.1 %) 106 (65.8 %) p value <0.001† 0.009† 0.639 living with their children yes 122.61 116.43 119.77 1 (20 %) 14 (16.7 %) 46 (28.6 %) no 122.94 123.78 115.09 4 (80 %) 62 (73.8 %) 108 (67.1 %) do not have children 167.00 165.53 111.03 0 (0 %) 8 (9.5 %) 7 (4.3 %) p value 0.072 0.058 0.860 have you ever had guidance on sexuality by health professionals? yes 131.41 134.61 114.63 1 (20 %) 21 (25.0 %) 36 (22.4 %) no 123.71 121.48 116.42 4 (80 %) 63 (75.0 %) 125 (77.6 %) p value 0.477 0.225 0.862 sexual orientation heterosexual 127.97 127.83 112.73 5 (100 %) 77 (91.7 %) 137 (85.1 %) homosexual 153.67 142.67 86.83 0 (0 %) 1 (1.2 %) 2 (1.2 %) bisexual 120.00 94.75 114.63 0 (0 %) 0 (0 %) 4 (2.5 %) others 100.40 95.74 146.33 0 (0 %) 6 (7.1 %) 18 (11.2 %) p value 0.304 0.168 0.101 *statistical significance by mann-whitney test (p < 0.05). † statistical significance by the kruskal-wallis test (p < 0.05). ‡,§ statistically significant difference by bonferroni post-hoc. source: self-elaboration. another relevant finding concerns the statistical association identified in the time of living with a partner, in which older adults who have lived for five years or less experience the sexual act better (mr = 167.64; p < 0.001) and relationships affective (mr = 152.92; p = 0.009) compared to those who have lived together for more than 20 years. entering the field of frailty, there is a prevalence of 98 % (n = 245) of older adults in the frailty process, with 33.6 % (n = 84) being classified as pre-frail and 64.4 % (n = 161) classified as frail. among those in the frailty process, there was a higher prevalence of men (64.4 %; n = 161), aged between 60 and 64 years old (40.8 %, n = 102) and who lived with their partner for more than 20 years (63.6 %, n = 159). other information is described in table 4. it is observed in table 5 that the correlations found between sexuality and frailty were positive and weakly negative, but with a statistical association. it is noteworthy that the positive correlations indicate that the two variables have a directly proportional behavior, while the negative ones, inversely proportional. furthermore, cross-sectional studies do not allow the identification of causality. it is observed that all dimensions of sexuality were statistically correlated with reduced strength, reduced walking speed and reported fatigue. thus, it is noted that the greater the experience of the sexual act, the smaller the reduction in strength (p = -0.263; p < 0.001) and walking speed (p = -0.201; p = 0.001) will be and the greater will be the reported fatigue (p = 0.149; p = 0.018). furthermore, the greater the experience of affective relationships, the smaller the reduction in strength (p = -0.254; p < 0.001) and walking speed (p = -0.207; p = 0.001) and the greater the reported fatigue (p = 0.207; p = 0.001). finally, the more the older adults face physical and social adversities, the greater will be the reduction in strength (p = 0.279; p < 0.001), in walking speed (p = 0.261; p < 0.001), in low physical activity (p = 0.140; p = 0.034) and less fatigue will be reported (p = -0.171; p = 0.009). table 5. correlation between sexuality and frailty sexuality frailty spearman's p p value sexual act weight loss 0.072 0.259 weakness -0.263 <0.001* slowness -0.201 0.001* low physical activity -0.109 0.084 exhaustion 0.149 0.018* affective relationships weight loss 0.019 0.770 weakness -0.254 <0.001* slowness -0.207 0.001* low physical activity -0.087 0.172 exhaustion 0.207 0.001* physical and social adversity weight loss 0.023 0.733 weakness 0.279 <0.001* slowness 0.261 <0.001* low physical activity 0.140 0.034* exhaustion -0.171 0.009* *statistical significance (p < 0.05). source: self-elaboration. discussion in this study, a prevalence of 98 % (n = 245) of older adults in the frailty process was observed, a value higher than that found in similar studies that also used the same assessment instrument carried out in tocantins (66.7 %) (15), rio grande do sul (80.5 %) (16) and sao paulo (83.9 %) (17), in addition to being superior even to that found in a study that used different approaches to measurement (78.7 %) (6). it is worth mentioning that the information regarding the prevalence and incidence of frailty in older adults is insufficient, which may reflect the lack of consensus on the criteria capable of constituting screening parameters in different populations (6). among older adults in the frailty process, there was a higher prevalence of men (64.4 %; n = 161), diverging from other studies (1820), that found a higher prevalence in women. in fact, the female gender is considered a risk factor for frailty (21). of the reasons that justify this evidence, the fact that women have a lower rate of lean mass and muscle strength, are more vulnerable to sarcopenia, and have a higher survival rate are mentioned, which consequently exposes them for longer to chronic diseases (6), to central and peripheral degenerations, in addition to the increase in adipose tissue and the reduction in the intensity of daily activities (21). however, although in this study the highest prevalence of the frailty process was found in men, it does not eliminate the need for early interventions, especially in older adults classified as pre-frail, which corresponded to 67.9 % of men (n = 57) and 32.1 % of women (n = 27). such interventions must be carried out in order to prevent or delay as much as possible the onset of frailty and, consequently, functional incapacity (21). those classified as frail had the worst experiences in all dimensions of sexuality, in which the lowest medians indicated that they had the worst experience in the sexual act and in affective relationships and the highest median indicated worse coping with physical and social adversities, when compared with the non-frail and pre-frail older adults. the sexual act dimension refers, in fact, to the sexual practice between spouses and how older adults perceive and enjoy it. the "affective relationships" dimension involves aspects such as affection, love, complicity, companionship, affection, friendship, trust, pleasure, support and other qualitative feelings. finally, the dimension "physical and social adversity" refers to health problems that interfere in the experiences of sexuality, for fear of being victims of prejudice due to the attitudes taken to experience it and how older adults behave in the face of the changes that have occurred in sexuality due to the aging process (11). furthermore, it is noteworthy that, in general, older adults experience their sexuality better in affective relationships when compared to the sexual act, although the scores observed in this study were not so out of line. it is mentioned that these results are in accordance with a study (22) developed with a total of 213 english, brazilian and portuguese older adults, which identified some more prevalent expressions of sexuality among the participants, such as affection, attention, altruism, eroticism, positive communication and attractiveness, with the sexual component not being considered an immediate priority (22), although it is also one of the ways of expressing sexuality. another investigation (23) carried out with a total of 100 women older adults showed that, among the ways of expressing sexuality, the participants reported the involvement of autoeroticism, kisses and cuddles. it is noteworthy that sexuality goes beyond the limits of sexual practice and encompasses several other qualitative manifestations that provide pleasure and well-being (23). nevertheless, the fact is that, in old age, the sexual act seems to assume a secondary position, while other manifestations such as care, affection and emotions assume a prominent position in the sexuality of older adults (24). in this study, one of the dimensions of sexuality is the physical and social adversity, in which it was found that, for having a higher middle rank, the male gender is worse faced with the adversities that often reflect on the sense of masculinity and its social construction. currently, men who are unable to become sexually involved feel "less like a man", which demonstrates the power of sexual capacity for the social construction of masculinity (25). this sexual incapacity is strictly related to dysfunctions, especially those related to penile erection, as, physiologically, erectile dysfunctions are more frequent in older ages and affect not only the sexual act itself, but also the entire context of masculinity and well-being of these individuals (26). thus, men with erection problems frequently experience psychosexual stressors, loss of self-confidence and marital conflicts , which end up enhancing the aforementioned dysfunction (27). sexual ability is so strongly linked to a sense of masculinity that, since adolescence, men are encouraged to initiate and learn sexual practices whenever desired. on the other hand, women were always limited with regard to sexual freedom before marriage, and their virginity should be preserved until the day the marriage was signed (24). therefore, when men reach old age and perceive themselves without their sexual capacity, internal conflicts occur that can explain at least one issue corresponding to the dimension of adversity: the discomfort caused by changes in sexuality due to the aging process (erectile dysfunction). another important finding in this study concerns the statistical association between marital status, which indicates that older adults with a steady partner experience sexual intercourse better than married people. this is a curious finding, as it is inferred that older adults with a steady partner are those who, for some reason (divorce, widowhood, among others) have sought new partners to maintain not only sexual relationships, but loving ones. however, it was expected that this better experience in the sexual act would be observed in married people, as marriage is seen as a space for healthy exchange of affective and sexual expressions that contribute to strengthening the dynamics between spouses (28). somehow, this fact can represent some degree of self-indulgence that occurs among older adults within marriage, especially due to the routine and monotony that occur over the years of conjugality, which generate negative impacts on the conception and in the expression of sexuality (29). furthermore, this context may also explain why older adults who have lived with their partners for five years or less experience sexual intercourse and affective relationships better than those who have lived together for more than 20 years, as found in this study. it was observed that all dimensions of sexuality were statistically correlated with reduced strength, reduced walking speed and reported fatigue. only the dimension "physical and social adversity" correlated with an additional component of frailty — low physical activity. only data referring to male sexual dysfunction and its relationship with frailty were found in the literature. as an example, a european study carried out with a total of 1504 men older adults between 60 and 79 years old revealed that frailty was associated with an increase in the chances of erectile dysfunction. furthermore, frailty was associated with impaired general sexual functioning, suffering related to sexual function and erectile dysfunction (30). another chinese community-based study conducted with 341 men older adults aged 60 to 83 years old revealed a strong association between erectile dysfunction and frailty among the participants, evidencing the need to consider erectile dysfunction in multidimensional assessments of frailty (31). attention is drawn to the lack of studies that compare the influence of sexuality on frailty among older adults. the few existing research focus on male sexual dysfunction without considering sexuality as an integral component of the individual's identity. furthermore, it is worth mentioning that not even female sexual dysfunctions are addressed in the few studies found. thus, the discussion of results with the national and international literature was impaired, but the relevant point that deserves to be highlighted is that all this limitation makes our data unprecedented and pioneering in the subject. therefore, we encourage further research that aims to provide data capable of demonstrating the influence of sexuality on the frailty of older adults, especially longitudinal studies, to enable the causal relationship. conclusion this study revealed a high prevalence of older adults in the frailty process. thy experienced their sexuality better in affective rela­tionships and those classified as frail had the worst experiences in sexuality. furthermore, all dimensions of sexuality were statistically correlated with decreased strength, decreased walking speed and reported fatigue. only the dimension "physical and social adversity" was correlated with an additional component of frailty — low physical activity. it is noteworthy that the correlations found were positive and negative, both with weak magnitude. it is noteworthy that this study has some limitations. initially, the impossibility of generalizing the results is mentioned, due to both the non-probabilistic sampling and the sampling restriction of only older adults with internet access and an active account only on the facebook social network. this is a population specificity that does not represent the reality of most of them, as the participants in this study had a high level of education and, 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bio sci med sci.. 2013;68(7):837-44. doi: https://doi.org/10.1093/gerona/gls217 31. li c, sun j, zhao h, dai t. association between frailty and erectile dysfunction among chinese elderly men. biomed res int. 2020. doi: https://doi.org/10.1155/2020/9247237 home analysis of repeated violence against older adults in a brazilian stat article analysis of repeated violence against older adults in a brazilian state* análisis de la violencia de repetición hacia el adulto mayor en un estado brasileño** análise da violência de repetição contra a pessoa idosa em um estado brasileiro*** 10.5294/aqui.2021.21.1.8 gracielle pampolim1 franciele marabotti costa leite2 1 0000-0002-4157-3521 . escola superior de ciências da santa casa de misericórdia, universidade federal do espírito santo, brazil. gracielle.pampolim@emescam.br 2 0000-0002-6171-6972 . universidade federal do espírito santo, brazil. franciele.leite@ufes.br * this article derives from the ph.d. thesis entitled “overview of violence against older adults in espírito santo: an analysis of the cases notified between 2011 and 2018”, presented at the collective health ph.d. program of universidade federal de espírito santo, brazil. ** el artículo se deriva de la tesis de doctorado “panorama de la violencia al adulto mayor en espírito santo: análisis de los casos notificados entre el 2011 y el 2018”, presentada al programa de doctorado en salud colectiva de la universidade federal do espírito santo, brasil. *** este artigo é derivado da tese de doutorado intitulada “panorama da violência contra a pessoa idosa no espírito santo: uma análise dos casos notificados entre 2011 e 2018”, apresentada ao programa de doutorado em saúde coletiva da universidade federal do espírito santo, brasil. received: 17/06/2020 sent to peers: 13/07/2020 approved by peers: 02/11/2020 accepted: 20/01/2021 to reference this article / para citar este artigo / para citar este artículo: pampolim g, leite fmc. analysis of repeated violence against older adults in a brazilian state. aquichan. 2021;21(1):e2118. doi: https://doi.org/10.5294/aqui.2021.21.1.8 abstract objective: to identify notified cases of repeated violence against older adults and its association with the characteristics of the victims, of the aggressor, and the aggression. materials and methods: a cross-sectional study was conducted based on data recorded in the information system for notifiable health problems on interpersonal repeated violence perpetrated against older adults between 2011 and 2018 in espírito santo, brazil. the data were analyzed employing poisson multiple regression with robust variance. results: the frequency of repeated violence was 50.1 % (95 % ci: 47.7-52.6). being 80 years old or more, presenting disabilities or disorders, and having suffered violence by partners and/or children were associated with this condition in both genders. in aged men, violence was more frequently perpetrated by two or more aggressors and during the day, whereas aged women were more frequently assaulted in urban areas. conclusion: the high frequency of repeated violence and the associations with the characteristics studied reflect the need for care to older adults with disabilities or disorders and the possible signs of burden in family caregivers that may result in situations of violence. actions aimed at early detection and adequate assistance to the victims and to the aggressors are important to avoid the chronicity of the condition. keywords (source decs): violence; elder abuse; recidivism; mandatory reporting; epidemiological monitoring. resumen objetivo: identificar la frecuencia de violencia de repetición notificada hacia el adulto mayor y su asociación con características de la víctima, el agresor y la agresión. materiales y métodos: estudio transversal, desde dados registrados en el sistema de información de agravios y notificación acerca de la violencia interpersonal de repetición perpetrada hacia el adulto mayor en espírito santo, brasil, entre el 2011 y el 2018. se analizaron los datos por medio de la regresión múltiple de poisson con variancia robusta. resultados: la frecuencia de violencia de repetición fue de 50,1 % (ic 95 %: 47,7-52,6). tener 80 años o más, presentar discapacidades o trastornos y haber sido violentado por compañero(a) y/o hijo(a) estuvieron asociados con el agravo en ambos sexos. en hombres mayores, la violencia fue más frecuentemente perpetrada por dos o más agresores y durante el día, mientras que mujeres mayores fueron más agredidas en zonas urbanas. conclusiones: la alta frecuencia de la violencia de repetición y las asociaciones con las características estudiadas evidencian la necesidad de atención al adulto mayor con discapacidad o trastornos y las posibles señales de sobrecarga de cuidadores familiares que pueden resultar en situaciones de violencia. acciones que tienen el propósito de detectar de forma temprana y brindar adecuada asistencia a las víctimas y a los agresores son importantes para evitar la cronicidad del agravo. palabras clave (fuente decs): violencia; maltrato al anciano; reincidencia; notificación obligatoria; monitoreo epidemiológico. resumo objetivo: identificar a frequência de violência de repetição notificada contra a pessoa idosa e sua associação com características da vítima, do agressor e da agressão. materiais e métodos: estudo transversal, a partir de dados registrados no sistema de informação de agravos e notificação sobre a violência interpessoal de repetição perpetrada contra a pessoa idosa no espírito santo, brasil, entre 2011 e 2018. os dados foram analisados por meio da regressão múltipla de poisson com variância robusta. resultados: a frequência de violência de repetição foi de 50,1 % (ic 95 %: 47,7-52,6). ter 80 anos ou mais, apresentar deficiências ou transtornos e ter sido violentado por parceiro(a) e/ou filho(a) estiveram associados ao agravo em ambos os sexos. em homens idosos, a violência foi mais frequentemente perpetrada por dois ou mais agressores e durante o dia, enquanto mulheres idosas foram mais frequentemente agredidas em zonas urbanas. conclusões: a alta frequência da violência de repetição e as associações com as características estudadas refletem a necessidade de atenção à pessoa idosa com deficiências ou transtornos e aos possíveis sinais de sobrecarga de cuidadores familiares que podem resultar em situações de violência. ações que visem à detecção precoce e à adequada assistência às vítimas e aos agressores são importantes para evitar a cronicidade do agravo. palavras-chave (fonte decs): violência; maus-tratos ao idoso; reincidência; notificação de abuso; vigilância epidemiológica; monitoramento epidemiológico. introduction violence against older adults represents a serious public health problem (1, 2). it occurs in different ways and diverse situations, and it can be recognized as visible when caused by physical injuries, or as invisible when there are no wounds, but resulting in psychological distress and harm (3). the concept developed by the world health organization and adopted by the official documents in brazil defines violence against older adults as any individual or repeated act or the lack of proper action caused by a relationship in which there is expectation and/or trust, resulting in physical harms or psychological distress (1, 3, 4). this type of abuse results in harm to health in the individual and collective scopes causes physical and emotional trauma, compromises the quality of life of the older adult, the families, and the communities, in addition to attributing new demands and responsibilities to the health system (2). in the aged population, violence has been strongly associated with negative and devastating consequences not only to the older adult’s physical health but also to the onset of depressive conditions, which leads to higher use rates of the health services for longer periods, in addition to impacting on their social lives. violence against older adults has also been associated with the occurrence of early mortality in this population (5-7). systematic reviews published recently in different continents of the world, and taking into account the various countries, point out that the world prevalence of violence against older adults ranges from 14.3 % to 15.7 % (8, 9). similar results were found in studies carried out with older adults in several brazilian studies, which point out a range from 13 % to 14.4 % of violence against older adults in brazil (10, 12). it is important to highlight a severe problem that has been more and more associated with violence against older adults: the history of repeated abuse, which can result in the chronicity of this phenomenon. chronic violence tends to occur more frequently within the family, daily, and with a tendency to progressively increase the severity level (12). in this context, it is not uncommon to find reports of previous episodes of violence among cases of denunciation or notification of violence against older adults as observed by a multicentric study carried out in the metropolitan region of chicago, the united states, which showed that 52.3 % of the older adults’ victims of violence reported a repeated history (13). accordingly, the early identification of violence against older adults and qualified and effective care to the families are the main ways of preventing that this person is repeatedly assaulted (13). in this regard, the health sector plays an important role among the sectors able to act against violence since that, due to its proximity and access to older adults, families, and communities, the professional is capable of efficiently contributing to the identification and confrontation of this condition (14). an important public health strategy for this confrontation is the notification of the violence, as data generated from this system contributes not only to the sizing of the problem and the understanding of its associated factors, but it is also capable of subsidizing the public management in the definition of priorities care and in the implementation of public policies of surveillance and assistance to victims (2, 15). it is important to highlight that, even though it is not so frequent, revictimization is an aspect of violence against older adults still insufficiently analyzed in the literature, especially its associated factors (16). little is known about the characteristics of the victim or aggressor in cases of repeated violence (17). several studies suggest that these characteristics can differ from those related to first aggression, and understanding such factors can be essential to deal with this condition and reduce violence chronicity (16). given the above, the objective of this study was to identify the frequency of notified repeated violence against older adults and its association with the characteristics of the victim, the aggressor, and the aggression. materials and methods an analytical study of the cross-sectional type, conducted with all the cases of interpersonal violence in the aged population (age equal to or over 60 years old) notified between 2011 and 2018 in the state of espírito santo, brazilian southeast region. the database used, from the information system for notifiable health problems (sistema de informação de agravos de notificação, sinan), was provided by the epidemiological surveillance of the state health secretariat of espírito santo. the monitoring of cases of violence is supported through the use of forms for the notification/investigation of interpersonal, and self-provoked violence, which has information related to the profile of the victim and of the aggressor, the characteristics of the type of violence and the referrals performed. this form is filled out in the various notifying sources, including the health services, and is forwarded to the sector responsible for the municipal epidemiological surveillance office, and later transferred to the state and federal spheres to compose the national database (18). the initial cutoff point of the research period (january 2011) was selected since, from this date and the publication of ordinance 104, violence becomes an integral part of the list of mandatory reporting problems, generalizing its reporting to all the health services (2). between march and may 2019, an exploratory and descriptive analysis of the database was carried out to qualify the variables of interest and correct possible errors or inconsistencies, following the guidelines of the handbook for the notification of interpersonal and self-provoked violence. in this process, in addition to the corrections, five duplicate forms were excluded. the notification of violence against older adults was analyzed according to the outcome of interest: history of repeated violence (yes/no) stratified by gender (male/female). the independent variables were the following: characteristics of the victims – age (from 60 to 69 years old/from 70 to 79 years old/80 years old or more), race/skin color (white/black-brown), schooling (from 0 to 4 years/from 5 to 8 years/9 years or more), marital status (with a partner/no partner) and presence of disability/disorder (yes/no); characteristics of the aggressor – age (from 0 to 19 years old/from 20 to 58 years old/older than 60 years old), gender (male/female/both), relationship (daughter/son/partner/other relatives/unknown), suspicion of alcohol consumption (yes/no) and number of people involved (one/two or more); characteristics of the aggression – if it took place in the house (yes/no), period of the day (morning-afternoon/night-early morning), area (urban/rural), motivated by intolerance (yes/no) and referrals (yes/no). data was processed using the stata 13.0 statistical program and analyzed through descriptive statistics in gross and relative frequencies and 95% confidence intervals. the bivariate analyses were performed utilizing the chi-square (χ²) test, with a significance level of p < 0.05. the association between the variables was tested through poisson multiple regression with robust variance, expressed in gross and adjusted prevalence ratio (pr) values, and the respective 95% confidence intervals. for the adjusted analysis, the variables with a p-value<0.20 found in the bivariate analysis entered the model, and permanence was with p<0.05. the adjusted analysis occurred with entry into the model at two levels. at the first level, data of the victim was included and, at the second, all other variables analyzed were included. the study was approved by the research ethics committee of universidade federal do espírito santo under opinion no 2,819,597 and all rules and guidelines of resolution 499/2012 of the brazilian national health council were respected. results between 2011 and 2018, 1,635 notifications of interpersonal violence against older adults were recorded in the state of espírito santo. of these, 820 were cases of violence with a repeated history, which is equivalent to a frequency of 50.1 % (95 % ci: 47.7-52.6) (data not presented in the table). table 1 presents the general characterization of the cases of repeated violence notified. it is noticed that, among the older adults assaulted, most (72.2 %) are women, aged from 60 to 69 years old (46.6 %), black/brown-skinned (55. 9 %), with up to four years of studies (62.3 %), with a partner (59 %), and not presenting any disability/ disorder (69.7 %). regarding the profile of the aggressor, most (76.9 %) are adults, males (59.2 %), the victim’s children (56.1 %), and with no suspicion of alcohol abuse (53.7 %). the aggression was most commonly perpetrated by one person (66.5 %), in the house (91.8 %), during the day (67.4 %), in an urban area (89.2 %), and not motivated by intolerance (51.6 %). most of the cases (86.8 %) were referred to other sectors. table 1. characterization of the notified cases of repeated violence violence against older adults according to data of the victim, the aggressor, and the occurrence. espírito santo, 2011-2018 variables n % 95 % ci gender male 228 21.8 24.8-31.0 female 592 72.2 69-75.2 age of the older adult       60-69 years old 382 46.6 43.2-50 70-79 years old 230 28 25.1-31.2 80+ years old 208 35.4 22.5-28.5 race/skin color white 333 44.1 40.6-47.7 black/brown 422 55.9 52.3-59.4 schooling (years) 0-4 years 334 62.3 58.1-66.3 5-8 years 77 14.4 11.6-17.6 9+ years 125 23.3 19.9-27.1 marital status with a partner 430 59 55.4-62.5 no partner 299 41 37.5-44.6 disability/disorder yes 222 30.3 27-33.7 no 512 69.7 66.3-33.7 age of the aggressor 0-19 years old 15 2.7 1.6-4.3 20-59 years old 432 76.9 73.2-80.2 60+ years 115 20.4 17.3-24 gender of the aggressor male 469 59.2 55.7-62.6 female 193 24.4 21.5-27.5 both 130 16.4 14-19.1 relationship with the victim son/daughter 410 56.1 52.4-59.6 partner 172 23.5 20.6-26.7 other relatives 125 17.1 14.5-20 unknown 24 3.3 2.2-4.8 suspected use of alcohol yes 267 46.3 42.2-50.4 no 310 53.7 49.6-57.8 number of people involved one 538 66.5 63.2-69.7 two or more 271 33.5 30.3-36.8 took place in the house yes 729 91.8 89.7-93.5 no 65 8.2 6.4-10.3 period of the day morning/afternoon 331 67.4 63.1-71.4 night/early morning 160 32.6 28.6-36.9 area of occurrence urban 711 89.2 86.8-91.2 rural 86 10.8 8.8-13.1 motivated by intolerance yes 238 48.4 43.9-52.8 no 254 51.6 47.2-56.0 referrals yes 695 86.8 84.2-88.9 no 106 13.2 11-15.8 the absolute frequency totals differ due to missing data (blank or unknown in the notification forms) source: sinan, espírito santo, brazil, 2011-2018. in the bivariate analyses, described in table 2, it was observed that repeated violence, in both genders, was related to the age of the older adult, disability/disorder, gender of the aggressor, relationship with the victim, suspicion of alcohol consumption, locus, and period of the occurrence. repeated violence against male older adults was also related to the number of people involved while, against female older adults, it was also related to the age of the aggressor and to the area of occurrence. table 2. distribution of repeated violence against older adults, stratified by gender, according to the characteristics of the victim, the aggressor, and the occurrence. espírito santo, 2011-2018 variables male gender n=498 p-value female gender n=592 p-value n % 95 % ci n % 95 % ci age of the older adult 60-69 years old 99 35.1 29.7-40.9 < 0.001 283 64.2 59.6-68.5 < 0.001 70-79 years old 70 51.5 43.0-59.8 160 69.6 63.3-75.2 80+ years old 59 83.1 72.4-90.2 149 81.4 75.1-86.4 race/skin color white 80 43.9 36.9-51.3 0.237 253 67.8 62.9-72.4 0.421 black/brown 133 49.6 43.6-55.6 289 70.5 65.8-747 schooling (years) 0-4 years 103 45.6 39.1-52.1 0.835 231 71.1 65.9-75.8 0.382 5-8 years 21 42 29.1-56.1 56 63.6 53-73 9+ years 30 47.6 35.5-59.9 95 67.8 59.6-75.1 marital status with a partner 89 47.8 40.7-55.1 0.473 341 70.9 66.6-74.8 0.954 no partner 106 44.3 38.1-50.7 193 70.7 65-75.8 disability/disorder yes 65 81.2 71.1-88.4 < 0.001 157 87.2 81.5-91.4 < 0.001 no 138 39.1 34.1-44.3 374 64.1 60.2-67.9 age of the aggressor 0-19 years old 6 37.5 17.4-63.1 0.617 9 47.4 26.2-69.5 0.002 20-59 years old 126 49.6 43.4-55.8 306 71.8 67.3-75.9 60+ years old 15 51.7 33.7-69.3 100 82.6 74.8-88.4 gender of the aggressor male 97 33.5 28.2-39.1 < 0.001 372 70.3 66.3-74.1 0.006 female 70 69.3 59.6-77.6 123 66.1 59.0-72.6 both 44 86.3 73.7-93.4 86 83.5 75.0-89.5 relationship with the victim son/daughter 110 75.9 68.2-82.2 < 0.001 300 84.0 79.8-87.5 < 0.001 partner 25 56.8 41.8-70.7 147 79.9 73.4-85.1 other relatives 39 54.9 43.2-66.1 86 62.8 54.3-70.5 unknown 13 13.5 8-22 11 18.6 10.6-30.7 suspected use of alcohol yes 58 40.6 32.8-48.8 0.017 209 77.7 72.3-82.3 0.002 no 95 54 46.5-61.2 215 66.1 60.8-71.1 number of people involved one 127 42.3 36.8-48 0.003 411 68.4 64.5-71.9 0.051 two or more 92 56.8 49-64.2 179 75.2 69.3-80.3 took place in the house yes 182 58.7 53.1-64.1 < 0.001 547 74.7 71.4-77.8 < 0.001 no 31 22.6 16.3-30.4 34 36.9 27.7-47.3 period of the day morning/afternoon 94 53.1 45.7-60.4 < 0.001 237 69.5 64.4-74.2 0.009 night/early morning 42 25 19-32.1 118 58.4 51.5-65.0 area of occurrence urban 187 47.3 42.4-52.3 0.975 542 71.6 68.2-74.7 < 0.001 rural 33 47.1 35.7-58.9 53 54.1 44.1-63.7 motivated by intolerance yes 40 47.6 41.6-56.7 0.823 198 77 64.9-794 0.121 no 83 49.1 37.1-58.3 171 70.9 71.5-81.8 referrals yes 193 47.4 42.6-52.3 0.714 502 69.5 66.1-72.8 0.633 no 32 45.1 33.8-56.8 74 67.3 57.9-75.4 in table 3, we can see the adjusted analysis of repeated violence against male older adults, in which it is possible to notice that the age of the older adult, disability/disorder, relationship with the victim, the number of people involved, and period of day of the occurrence were associated with the problem. older adults aged 80 years old or more presented 2.10 times more prevalence of repeated violence (95 % ci: 1.72-2.57), which was also more prevalent among older adults with disability or disorders (pr: 1.93; 95 % ci: 1.63-2.28). among male older adults, this problem was almost five times more perpetrated by children (pr: 4.97; 95 % ci: 2.52-9.78) and/or female partners (pr: 4.57; 95 % ci: 2.18-9.58), involving two or more people (pr: 1.40; 95 % ci: 1.11-1.76) and occurring during the day (pr: 1.41; 95 % ci: 1.06-1.88). table 3. gross and adjusted analysis of the effects of the characteristics of the victim, the aggressor, and the occurrence on the repeated violence perpetrated against male older adults. espírito santo, 2011-2018 variables gross analysis adjusted analysis   pr 95 % ci p-value pr 95 % ci p-value age of the older adult 60-69 years old 1.0   < 0.001 1.0   < 0.001 70-79 years old 1.47 1.17-1.84 1.44 1.15-1.82 80+ years old 2.37 1.96-2.86 2.10 1.72-2.57 disability/disorder yes 2.08 1.76-2.46 < 0.001 1.93 1.63-2.28 < 0.001 no 1.0   1.0   gender of the aggressor male 1.0   < 0.001 1.0   0.930 female 2.07 1.68-2.55 1.0 0.68-1.47 both 2.58 2.12-3.14 1.08 0.69-1.68 relationship with the victim son/daughter 5.60 3.35-9.37 < 0.001 4.97 2.52-9.78 < 0.001 partner 4.20 2.38-7.41   4.57 2.18-9.58   other relatives 4.10 2.34-7.02   3.73 1.82-7.66   unknown 1.0     1.0     suspected use of alcohol yes 1.0   0.020 1.0   0.903 no 1.33 1.05-1.69 1.02 0.74-1.42 number of people involved one 1.0   0.002 1.0   0.004 two or more 1.34 1,11-,62 1.40 1.11-1.76 took place in the house yes 2.60 1.88-3.59 < 0.001 1.03 0.67-1.58 0.887 no 1.0   1.0   period of the day morning/afternoon 2.12 1.58-2.86 < 0.001 1.41 1.06-1.88 0.018 night/early morning 1.0   1.0   after adjustments for the confounding factors, the repeated violence perpetrated against female older adults remained associated with the age of the older adults, disability or disorder, relationship with the victim, and area of occurrence (table 4). this problem is 20 % more frequent among older adults aged 80 years old or more (pr: 1.20; 95 % ci: 1.09-1.33) and 33 % more frequent among those with some type of disability or disorder (pr: 1.33; 95 % ci: 1.221.44), was 3.67 times more perpetrated by children (95 % ci: 1.18-6.15) and 3.81 times more by the victims’ partners (95 % ci: 2.27-6.40); in addition to that, repeated violence practiced against female older adults was 34 % more prevalent in urban areas (pr: 1.34; 95 % ci: 1.11-1.63). table 4. gross and adjusted analysis of the effects of the characteristics of the victims, the aggressor, and the occurrence of the repeated violence perpetrated against female older adults. espírito santo, 2011-2018 variables gross analysis adjusted analysis pr 95 % ci p-value pr 95 % ci p-value age of the older adult 60-69 years old 1.0   < 0.001 1.0   < 0.001 70-79 years old 1.08 0.97-1.21   1.06 0.95-1.19   80+ years old 1.27 1.15-1.40   1.20 1.09-1.33   disability/disorder yes 1.36 1.25-1.48 < 0.001 1.33 1.22-1.44 < 0.001 no 1.0     1.0     age of the aggressor 0-19 years old 1.0   0.004 1.0   0.288 20-59 years old 1.52 0.94-2.45   1.24 0.58-2.63   60+ years old 1.75 1.08-2.82   1.39 0.66-2.94   gender of the aggressor male 1.0   0.001 1.0   0.272 female 0.94 0.84-1.06   1.15 0.94-1.40   both 1.19 1.07-1.32   1.14 0.92-1.41   relationship with the victim son/daughter 4.51 2.64-7.70 < 0.001 3.67 2.18-6.15 < 0.001 partner 4.29 2.50-7.34   3.81 2.27-6.40   other relative 3.37 1.95-5.83   2.82 1.66-4.79   unknown 1.0     1.0     suspected use of alcohol yes 1.18 1.06-1.30 0.002 1.09 0.96-1.25 0.202 no 1.0     1.0     number of people involved one 1.0 1.00-1.21 0.041 1.0   0.789 two or more 1.10     0.96 0.73-1.28   took place in the house yes 2.02 1.54-2.65 < 0.001 1.02 0.72-1.45 0.903 no 1.0     1.0     period of the day morning/afternoon 1.19 1.04-1.36 0.012 1.13 1.0-1.29 0.058 night/early morning 1.0     1.0     area of occurrence urban 1.32 1.10-1.60 0.003 1.34 1.11-1.63 0.003 rural 1.0     1.0     motivated by intolerance yes 1.09 0.98-1.21 0.124 0.98 0.83-1.17 0.835 no 1.0     1.0     discussion the objective of this study was to identify notified cases of repeated violence against older adults and its association with the characteristics of the victims, of the aggressor and of the aggression. it was observed that 50.1 % (95 % ci: 47.7-52.6) of the notified cases of violence against older adults between 2011 and 2018 in espírito santo, brazil, presented a repeated history. this finding is similar to that found in the international literature (13), which shows a 52.3 % prevalence of a history of repeated violence and in a study carried out with 3,593 notified cases of violence against older adults in more than 500 brazilian municipalities, in which a prevalence value of 53.6 % of revictimization was evidenced among the older adults studied (19). regarding the characteristics of the older adults associated with this problem, we found the repeated violence was frequent among people aged 80 years old or more. old age is usually marked by conditions that compromise the independence and autonomy of the older adults, which can increase the work demand of their caregivers and result in increasing burden. this situation results in concern since, according to the literature studied, overloaded caregivers tend to harm the older adult more, especially when this burden is associated with stress and with and their lack of preparation for care (1, 20). in addition to that, regarding the older adults’ health, it is noticed that repeated violence was more frequent among those who presented some disability or disorder. the literature shows that the presence of disabilities or disorders is a risk factor strongly associated with the occurrence of violence against older adults (1, 9). the presence of disabilities and/or disorders frequently leads the older adult to dependence and vulnerability conditions, which demands more and more attention and care, and gradually increases the caregiver’s workload. in this regard, and as showed in the literature, the caregivers’ burden can be a factor that contributes not only to the primary occurrence of violence, but also to the increase in its chronic repetition (1). another point widely discussed in the literature is the proximity of the relationship between victim and aggressor, in which the studies show that the main perpetrators of the aggressions against the older adults belong to their family circle (1, 9). corroborating this line of discussion, in this study higher frequencies of repeated violence were found among older adults who were assaulted by children and/or partners, and that the aggressions were generally committed by two or more people, similar to the results found in other studies (13, 16, 17) that also approached the revictimization of older adults and showed children and/or partners as the main aggressors. the family environment, which originally should be seen as a refuge and as safety for older adults, is also often pointed out as a space that can be stressful for the caregiver, with children and partners playing this role without proper preparation, and often taking the frustrations of day-to-day life on the older adult (16, 20). in this scenario, violence tends be chronic and constant, with a progressive increase in the frequency and severity of the aggressions, which can even come to cause physical injuries and result in hospitalization and death (12). consequently, it is perceived that the excess of tasks attributed to the family caregiver contributes in an excessive manner to their burden, especially when the older adult is not completely independent. also, in addition to caring for the older adults, it is noticed that the responsibility of managing the cleaning of the house and the family’s food often falls on the caregiver, among many other tasks common to the day-to-day organization of a house (21). in this regard, the association of repeated violence with the occurrence of abuse during the day is justified because such activities in this period tend to accumulate and can increase the levels of stress and burden in the caregiver. another characteristic observed in this study was the higher frequency of repeated violence against female older adults in urban areas. this finding corroborates with another study (22) that found that most of the cases of violence perpetrated against women occurs in urban areas, which, according to the author, can be a consequence of the higher agglomeration of people in these areas when compared to rural areas, in addition to the ease of access to the health and security services, which allegedly could make the notification of this problem easier in these regions. this scenario of discussion about repeated violence against older adults leads us to a reflection about institutional violence, in which the government fails in its constitutional duty of protection and assistance to older adults (23). this failure is present both in the difficulty of the professionals in identifying and welcoming the older adult victim of violence and in the criminalization of the family aggressor dissociated from a social approach capable of supporting and training this family member to take care of the older adult (23). in this sense, it is worth highlighting the important role of the health sector in preventing, identifying, confronting and combating violence against older adults, and especially in preventing the chronicity of this problem, which results from the increasing recurrence of abuse in this population. among all the segments capable to act in this problem, health professionals are strategically positioned close to the families and the community, presenting greater possibilities of creating bonds of trust with the older adult and their families, which can contribute to the discussion and dissemination of this theme in society (14). thus, these professionals must be trained for this function and understand violence in all its nuances, complexities and multi-causalities. it is also necessary that these professionals know the entire care and protection network offered to victims of violence and their families since, only in this way will it be possible to promote a real confrontation of this problem in our society (3). education and support programs for the aged population and support for family caregivers of these older adults are also worth to be mentioned, as they have effectively helped to reduce the recurrence of violence against older adults, in addition to having the potential to reduce even the primary occurrence of this problem (9, 13). finally, the results found in this study represent an important contribution for greater elucidation about repeated violence perpetrated against older adults and its associated factors, mainly for being a theme that still lacks further studies in the literature. however, some limitations must be considered, such as the secondary data analysis, the intrinsic under-notification of the information systems, and the cross-sectional nature of the study. however, it is important to highlight that measures were taken to mitigate such limitation: the database went through extensive qualification in order to reduce possible inconsistencies that could occur in secondary analysis of information systems databases, following the handbook created for notifications of this problem; despite the possibility of under-notification, the strong associations found only showed that they could be even more evident if the problem was properly notified and, despite their impossibility of establishing a casual relation, cross-sectional studies are essential in the scientific community for presenting a high descriptive potential and analytical simplicity, which enables greater understanding of the theme under study. conclusions the data presented showed a high frequency of repeated violence experienced by older adults and which characteristics of the victim, aggressor, and occurrence can make the older adult more vulnerable to experience repeated episodes of violence. these are findings that reflect the need for providing care to this long-lived population, as well as the importance of actions aimed at the early detection of violence and at adequate assistance to the victims and the family aggressors in order to avoid the perpetuation of aggressions in the older adults’ routine and, consequently, their chronicity, in addition to promoting the necessary support for the families to take care of the older adults. it is important to highlight that, despite the fact that studies related to violence against older adults are ever-increasing, especially in recent years, further deepening and diffusion of the analyses is still needed to aid in the understanding of the factors associated with the chronicity of this problem, so that it is possible to prevent and properly confront violence against older adults. conflicts of interest: none declared. references 1. orfila f, coma-solé m, 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http://dx.doi.org/10.9789/2175-5361.2019.v11i4.944-950 22. bernardino im, barbosa kgn, nóbrega lm, cavalcante gms, ferreira ef, d’ávila s. violência contra mulheres em diferentes estágios do ciclo de vida no brasil: um estudo exploratório. rev bras epidemiol. 2016;19(4):740-52. doi: https://doi.org/10.1590/1980-5497201600040005 23. rocha rc, cortes mcjw, dias ec, gontijo ed. violência velada e revelada contra idosos em minas gerais-brasil: análise de denúncias e notificações. saúde debate. 2018;42(4):81-94. doi: http://dx.doi.org/10.1590/0103-11042018s406 home 9 en puebla.p65 en puebla, méxico: estilos de aprendizaje de los estudiantes de enfermería 219 año 7 vol. 7 nº 2 • chía, colombia octubre 2007 • 219-226 francisco javier báez hernández 1 julia hernández álvarez 2 jorge eduardo pérez toriz 3 recibido: 9 de julio de 2007 aceptado: 26 de agosto de 2007 resumen objetivo: identificar el estilo de aprendizaje predominante en los estudiantes de segundo cuatrimestre de la licenciatura en enfermería de la facultad de enfermería de la benemérita universidad autónoma de puebla, méxico, y orientar la revisión curricular. materiales y método: estudio observacional, transversal, descriptivo; se estudiaron 101 estudiantes de enfermería de nivel licenciatura con el cuestionario honey-alonso de estilos de aprendizaje y cédula de datos generales elaborado por los investigadores. resultados: el 88,1% son mujeres, la media de edad es de 20,7, el rango fue de 18 a 41 años. el estilo de aprendizaje preferente fue el reflexivo, obtuvo una media de 13,69 (de = 2.962), seguido por el estilo pragmático con una media de 12,44 (de = 2.879). no se demostró diferencia significativa para los estilos de aprendizaje activo-teórico (p>,902). conclusiones: el estilo de aprendizaje reflexivo fue el resultado más alto entre los estudiantes de enfermería, se recomienda ampliar la muestra para toda la población, así como aplicar el mismo instrumento a los docentes para realizar un análisis de correlación. palabras clave estudiantes de enfermería, aprendizaje. (fuente: decs bireme). en puebla, méxico: estilos de aprendizaje de los estudiantes de enfermería en puebla, méxico: estilos de aprendizaje de los estudiantes de enfermería 1 benemérita universidad autónoma de puebla, 4 sur 104 col. centro cp 72000, puebla, méxico jav007@hotmail.com 2 benemérita universidad autónoma de puebla, 4 sur 104 col. centro cp 72000, puebla, méxico maestrajulia@unicup.edu.mx 3 benemérita universidad autónoma de puebla, 4 sur 104 col. centro cp 72000, puebla, méxico joe_corsola777@hotmail.com aquichan issn 1657-5997 aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007220 learning styles among nursing students in puebla, méxico abstract objective: identify the learning style that predominates among second four-month period undergraduate nursing students at the benemérita universidad autónoma nursing school in puebla (méxico) and guide curriculum change. materials and method: an observational, transverse, descriptive study of 101 undergraduate nursing students, using the honeyalonso learning style questionnaire and a document with general data prepared by the researchers. results: 88.1% are females and the average age is 20.7. the range was 18 to 41 years. the reflective learning style was the preferred one, with a mean of 13.69 (de = 2.962), followed by the pragmatic style, with a mean of 12.44 (de = 2.879). no significant difference was observed for the active-theoretical learning styles (p>.902). conclusions: the reflective learning style scored the highest among the nursing students. it is recommended the sample be expanded to include the entire population, and the instrument be applied to teachers for the purpose of a correlation analysis. key words students nursing, learning. em puebla, méxico: estilos de aprendizagem dos estudantes de enfermagem resumo objetivo: identificar o estilo de aprendizagem predominante nos estudantes do segundo período de quatro meses da licenciatura em enfermagem da faculdade de enfermagem da benemérita universidade autônoma de puebla, méxico, e orientar a revisão curricular. material e método: estudo observacional, transversal, descritivo. foram estudados 101 estudantes de enfermagem de nível de licenciatura com o questionário honey-alonso de estilos de aprendizagem e cédula de dados gerais, elaborados pelos pesquisadores. resultados: 88,1% são mulheres; a média de idade é 20,7 anos; o rango foi de 18 a 41 anos. o estilo de aprendizagem predominante foi o reflexivo com uma média de 13,69 (de = 2.962), seguido do estilo pragmático com uma média de 12,44 (de = 2.879). não houve diferencia significativa para os estilos cognitivos de aprendizagem ativo-teórico (p >,902). conclusões: o estilo de aprendizagem reflexivo obteve o resultado mais alto entre os estudantes de enfermagem. é recomendado ampliar a amostra a toda a população e aplicar e mesmo instrumento aos docentes para levar a cabo uma análise de co-relação. palavras-chaves estudantes de enfermagem, aprendizagem. en puebla, méxico: estilos de aprendizaje de los estudiantes de enfermería 221 introducción l estudiante universitario se desarrolla continuamente en un ciclo de enseñanza-aprendizaje, donde se pretende que éste adquiera habilidades que lo identifiquen dentro de un contexto social. se ha visto que dicho proceso de educación requiere de la elevación de la conciencia, haciéndose evidente la presencia de los procesos cognitivos (1). es por ello que las investigaciones que abordan el proceso de educación han considerado al alumno como el individuo cuyo proceso de aprendizaje muestra una diversidad de formas para recibir, procesar y aplicar la información percibida o concebida por su realidad circundante (2).  el aprendizaje es una contracción de la experiencia, un proceso cíclico que, de acuerdo con kolb, tiene cuatro etapas: experiencia concreta, observación reflexiva, conceptualización abstracta y experimentación activa. esto implica experimentar, reflexionar, elaborar hipótesis y verificarlas (3).  el estilo de aprendizaje indica una preferencia de la persona por enfocar sus mecanismos cognitivos hacia determinados tipos de selección, percepción y comprensión de la información (4). si consideramos a los estudiantes como actores principales, con características propias en cuanto a su proceso de enseñanza-aprendizaje, que se desenvuelven a través de etapas de desarrollo físico, cognitivo y de maduración psicosocial, se establecen diferencias significativas (5). por tal razón, las capacidades de aprendizaje no están directamente relacionadas con la edad cronológica del estudiante, sino más bien, con la etapa de desarrollo humano en la que se encuentre (6). examinar las fases o los cambios en los dominios cognitivo, afectivo, psíquico, físico y de la estructura socioeconómica donde el estudiante se ha desenvuelto es necesario para desarrollar las habilidades docentes.  según alonso, el estilo de aprendizaje de cada quien no guarda relación directa con sus aptitudes cognitivas generales, sino con su historia personal (7). es decir, que el acervo sociocultural, familiar y económico, es condicionante que torna a este proceso como un reflejo retrospectivo de los resultados actuales, lo que obliga a una exhaustiva búsqueda de las variables que intervienen en dicho proceso de formación. se considera pertinente que los docentes comprendan las variables que influyen en la capacidad de aprendizaje. esta comprensión involucra el estilo de aprendizaje preferente del estudiante universitario para el diseño de estrategias que atiendan las necesidades reales de aprendizaje y no las de los docentes; a mayor comprensión, mejores serán las estrategias educativas para lograr en el estudiante más aprendizaje por convicción con menos enseñanza por imposición.  se ha identificado que los individuos que acuden a la universidad suponen que han desarrollado en alguna medida una actitud dialogante y de respeto, un deseo de colaboración e implicación en las actividades, autodirección, una posición reflexiva y crítica ante la realidad que experimentan, y el deseo de emplear y mejorar el conocimiento otorgado (8). por lo anterior, la comprensión del propio estilo de aprendizaje se convierte en uno de los factores claves para comprender y desarrollar uno de los pilares de la educación: la capacidad de aprender a aprender en los estudiantes universitarios, convirtiéndolos en participantes activos en su proceso de enseñanza-aprendizaje (9).  finalmente, se ha considerado que el estilo de aprendizaje refleja la forma de enseñar en el futuro, el cual repercute en la enseñanza del cuidado-enfermero, dicho proceso se encuentra eminentemente ligado al aprendizaje de conductas generadoras de salud (10); lo anterior demuestra que esta variable es un factor importante, que condiciona el éxito o el fracaso en los procesos de aprendizaje en los profesionales de enfermería. así, consideraaquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007222 mos pertinente conocer a los estudiantes en sus primeros años de educación en enfermería de nivel licenciatura, la pregunta de investigación es: ¿cómo son los estilos de aprendizaje en los alumnos de segundo cuatrimestre de la facultad de enfermería de la universidad autónoma de puebla? figura 1. modelo de estilos de aprendizaje de honey y munford para el estudio se utilizó la teoría del aprendizaje de honey y mumford, que define cuatro estilos de aprendizaje, y describe las actitudes y conductas que determinan la manera de aprender preferida por un individuo. los autores postulan la existencia de cuatro dimensiones unipolares: el estilo activo, el estilo reflexivo, el estilo teórico y el estilo pragmático (7) (figura 1).  el estilo activo: tienen preferencia por implicarse en nuevas experiencias e involucrarse plenamente en el trabajo de equipo. suelen ser personas animadoras, improvisadoras, descubridoras, arriesgadas y espontáneas. el estilo reflexivo: observan la experiencia desde diferentes perspectivas. recogen datos y los analizan detenidamente, son ponderados, concienzudos, receptivos, analíticos y exhaustivos. el estilo teórico: adaptan e integran las observaciones dentro de las teorías lógicas y complejas. son profundos en su sistema de pensamiento, metódicos, lógicos, objetivos, críticos y estructurados. el estilo pragmático: prefieren la aplicación práctica de las ideas, son experimentadores, prácticos, directos, eficaces y realistas (7).  el propósito del estudio fue identificar el estilo de aprendizaje predominante en los alumnos de segundo cuatrimestre de nivel licenciatura de la facultad de enfermería de la universidad autónoma de puebla. los resultados aportan al rediseño del plan de estudios con un nuevo modelo educativo transcultural y humanista.  materiales la recolección de los datos se obtuvo a través de la cédula de datos generales elaborada por los investigadores, que contiene número de folio, género del estudiante, lugar de nacimiento, edad, y una pregunta que identifica si actualmente trabaja. para la identificación de los estilos de aprendizaje se utilizó el cuestionario de honeyalonso, que consta de 80 preguntas, 20 ítemes por cada uno de los cuatro estilos de aprendizaje, los cuales están distribuidos aleatoriamente, a las que se responde dicotómicamente manifestando si se está de acuerdo (signo +) o en desacuerdo (signo �). la puntuación es acumulativa para cada uno de los grupos, e indica el nivel de reflexión estilo reflexivo vivir la experiencia estilo activo elaborar hipótesis/inferir estilo teórico aplicación estilo pragmático en puebla, méxico: estilos de aprendizaje de los estudiantes de enfermería 223 la persona en cada uno de los estilos. el máximo que pueden alcanzar en cada estilo es de 20 (11). para llevar a cabo el procesamiento de los datos estadísticos se utilizó el statistical package for the social sciences versión 12.0.  el estudio se llevó a cabo en la facultad de enfermería de la universidad autónoma de puebla, durante los meses de enero a mayo de 2007.  metodología el diseño del estudio es observacional, transversal, descriptivo (12). se utilizó una muestra de 101 alumnos que están cursando el segundo cuatrimestre de licenciatura en enfermería, que representa el 65,1% de la población total. el muestreo que se utilizó es no probabilístico, por conveniencia (13); se aplicó la cédula de datos generales y el cuestionario de identificación de estilos de aprendizaje de manera anónima, en un plazo de 40 minutos, durante el proceso de reinscripción en las instalaciones de la facultad de enfermería. antes de iniciar la prueba se explicó en qué consistía el estudio, así como las instrucciones para el llenado de los instrumentos, haciendo hincapié en que se contestaran todos los ítemes.  se utilizó el baremo general de interpretación establecido por alonso, basándose en lo establecido previamente por honey y mumford, que categoriza los resultados en: muy alto, alto, moderado, bajo y muy bajo (14). para dar una mejor explicación de los resultados se empleó estadística descriptiva e inferencial, y se aplicó kolmogorov-smirnov para conocer la normalidad de las variables; sus resultados fundamentaron utilizar la t de student para muestras dependientes, ya que se trataba de individuos relacionados, y sólo se quería comparar por pares las medias de los estilos de aprendizaje.  resultados en cuanto al género de los estudiantes universitarios de enfermería se observa que el 88,1% son mujeres, característica muy común en una profesión con predominio femenino. el rango de edad osciló de los 18 a los 41 años, con una media de 20,78. sin embargo, el 94,1% de los estudiantes tienen una edad por debajo de los 23 años. en cuanto a los estudiantes que en este momento se encuentran trabajando, el 29,7% contestaron de manera afirmativa. tabla. diagrama de los estilos de aprendizaje de los estudiantes de enfermería de la universidad autónoma de puebla, méxico  p r e f e r e n c i a p r e f e r e n c i a p r e f e r e n c i a p r e f e r e n c i a p r e f e r e n c i a n � 101 muy baja b a j a m o d e r a d a a l t a muy alta 10 % 20% 40% 20% 10% estilo activo 0 8 9 10 11 13 14 15 16 20 media 11,73 estilo reflexivo 0 10 11 12 13 15 16 17 18 20 media 13,69 estilo teórico 0 8 9 10 11 13 14 16 17 20 media 11,78 estilo pragmático 0 9 10 11 12 14 15 16 17 20 media 12,44 fuente: cuestionario chaea aplicado a los estudiantes de segundo cuatrimestre de enfermería de la buap, 2007. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007224 en cuanto al lugar de origen el 14,9% de los estudiantes nacieron en otro estado de la república, el restante son originarios del estado; sin embargo, no todos nacieron en la ciudad de puebla, algunos son de zonas rurales. en cuanto a los resultados de los estilos de aprendizaje, el reflexivo fue el más alto entre los estudiantes de enfermería, con una media de 13,69 (de = 2.962), lo que muestra una preferencia hacia la observación frente a la acción, es decir, que les gusta observar experiencias desde diversas perspectivas y considerar todas las alternativas posibles. el estilo pragmático fue el segundo con una media de 12,44 (de = 2.879), que indica que los estudiantes se caracterizan por la búsqueda de la eficacia, el eclecticismo, la experimentación, la práctica y la solución de problemas. por otra parte, el estilo teórico obtuvo una media de 11,78 (de = 3.129) que indica que hay un menor número de estudiantes a los que les gusta adaptar e integrar las teorías en las situaciones de la práctica. finalmente, el estilo activo fue el menos elegido con una media de 11,73 (de = 2.881), que considera a los estudiantes como aquellos que se implican en nuevas experiencias y que se interesan por el trabajo en equipo (tabla). los rangos obtenidos en las puntuaciones en los estilos de aprendizaje van de un mínimo a un máximo de 4 a 18, 7 a 20, 5 a 19, 4 a 19 en los estilos activo, reflexivo, teórico y pragmático respectivamente. para comparar los estilos de aprendizaje con la variable de edad, se utilizó la t de student para muestras dependientes, dando como resultado una diferencia estadísticamente significativa para los cuatros estilos de aprendizaje (p<,000). figura 2. distribución de datos cualitativos de los estilos de aprendizaje de los estudiantes de enfermería de la universidad autónoma de puebla, méxico  i activo media 11,73 de 2,88 ii reflexivo iv pragmático iii teórico media 13,09 de 2,96 media 11,78 de 3,12 media 12,44 de 2,87 en puebla, méxico: estilos de aprendizaje de los estudiantes de enfermería 225 al realizar la comparación entre los estilos de aprendizaje, tomando en consideración que fue un solo grupo con individuos relacionados, se agruparon por pares las medias de los cuatro estilos obteniendo diferencias estadísticas entre: activoreflexivo (p<,000), activo-pragmático (p<0,032), reflexivo-teórico (p<,000), reflexivo-pragmático (p<,000). de dichas combinaciones, sólo las del estilo activoteórico, y teórico-pragmático, no presentan diferencias estadísticas significativas (p>,902), (p>,38).  por último, tomando el baremo realizado por alonso se elaboró una distribución de datos convirtiendo los resultados obtenidos de la muestra en datos cualitativos, clasificados en un nivel de preferencia que va de muy bajo, bajo, moderadamente alto y muy alto, de lo cual se obtuvo lo siguiente: 23,8% obtuvo una preferencia alta en el estilo de aprendizaje activo y teórico. el 18,8% fue de preferencia alta en el estilo de aprendizaje reflexivo. el 17,8% fue de preferencia alta en el estilo de aprendizaje pragmático, lo que indica que a pesar de que los estilos activo y teórico obtuvieron una menor preferencia por los estudiantes, fueron los mejores calificados en la distribución cualitativa (figura 2).  discusión los resultados obtenidos son de una muestra de individuos relacionados, contrario a lo estudiado por canalejas (15). sin embargo, los resultados coinciden en que los estudiantes de enfermería gustan por ser personas prudentes, que tienden a considerar todas las alternativas posibles antes de realizar un procedimiento, características de un estilo de aprendizaje reflexivo. las medias de los demás estilos de aprendizaje coinciden con lo reportado por ordóñez (16) al tener el siguiente orden: estilo pragmático, teórico y activo. así mismo, se coincide en el predominio del género femenino, lo que demuestra que la mujer es la principal cuidadora en los diferentes ámbitos del ejercicio profesional.  conclusiones los resultados indican que se debe trabajar de manera más consistente en el desarrollo de los cuatro estilos de aprendizaje, ya que guardan una estrecha relación con los perfiles ideales que se pretenden alcanzar dentro de la facultad. asimismo, se observó la utilidad de conocer los estilos de aprendizaje, ya que determinan las mejores estrategias de enseñanza-aprendizaje en el estudiante de enfermería de nivel licenciatura. por otra parte, se sugiere continuar con el estudio, convirtiéndolo en un estudio longitudinal, para poder observar los cambios que pueda tener el estudiante de enfermería durante su formación académica. también se propone ampliar la muestra para toda la población de estudiantes de la facultad de enfermería, con la finalidad de observar las posibles diferencias entre los estilos de aprendizaje de las diferentes generaciones de estudiantes. de otro lado, se sugiere la aplicación del mismo instrumento a los docentes de la facultad para realizar un análisis de correlación entre los estilos de aprendizaje de los alumnos a fin de descubrir la posible influencia entre el docente y el dicente.  se debe trabajar de manera más consistente en el desarrollo de los cuatro estilos de aprendizaje, ya que guardan una estrecha relación con los perfiles ideales que se pretenden alcanzar dentro de la facultad. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007226 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[recuperado en enero de 2007]. 52 aquichan issn 1657-5997 cielo noreña-quiceno1 lucía stella tamayo-acevedo2 cáncer de cuello uterino: análisis de la calidad de un programa 1 magíster en enfermería. magíster en educación y desarrollo humano. docente, facultad de enfermería, universidad de antioquia. canq@une.net.co 2 doctor en ciencias médicas. docente, escuela de microbiología, universidad de antioquia. ltamayo@catios.udea.edu.co este artículo es producto del proyecto de investigación "calidad del programa de prevención y detección precoz del cáncer de cuello uterino, en la upss luis carlos galán sarmiento, medellín, 2006-2007", presentado por el grupo de investigación citología ginecológica y prevención del cáncer de cuello uterino financiado por el comité de investigaciones de la universidad de antioquia en la convocatoria 2005. recibido: 12 de diciembre de 2008 reenviado: 27 de julio de 2009 aceptado: 15 de marzo de 2010 resumen objetivo: evaluar la calidad del programa de detección temprana y control del cáncer de cuello uterino en una unidad prestadora de servicios de salud, de la empresa social del estado metrosalud, medellín, colombia, 2006-2008. metodología: estudio descriptivo transversal. se siguió el método de evaluación de programas de salud en los componentes problema, estructura, procesos y resultados propuesto por avedis donabediam, a partir de diferentes técnicas de recolección de información. se hizo análisis estadístico descriptivo univariado y bivariado, y cualitativo de textos. resultados: aunque este cáncer se considera un problema de salud pública, se carece de un programa estructurado para la intervención. las actividades se centran en la detección y la prevención. para su ejecución se dispone, en general, de los recursos humanos, físicos, materiales y económicos requeridos; la auxiliar de enfermería desarrolla la mayor parte de las actividades; el médico ordena tratamientos y remite usuarias a otro nivel según la red de servicios. todas las usuarias reconocen la importancia del programa, la mayoría expresó satisfacción con la atención recibida. conclusiones: el programa de detección temprana y control de cáncer de cuello uterino debe fortalecer todos sus componentes con mayor eficiencia y eficacia para lograr mejor impacto en la salud de las mujeres, disminuyendo la morbilidad y mortalidad por este cáncer. retomar el concepto de integralidad, como programa de salud pública, debe ser una política de estado y, su desarrollo, un compromiso de todos los funcionarios que laboran en él. palabras clave cáncer de cuello uterino, salud pública, promoción, prevención (fuente: decs, bireme). cervical cancer: analysis of the quality of a program abstract objective: an evaluation of the quality of a cervical cancer early detection and control program being applied at a health care unit operated by empresa social del estado metrosalud, a public hospital network in medellín (colombia) during 2006-2008. methodology: a transversal descriptive study conducted pursuant to the health program evaluation method proposed by dr. avedis donabediam, speaño 10 vol. 10 nº 1 chía, colombia abril 2010 l 52-68 "el cáncer cervicouterino se puede prevenir y curar a un costo y riesgo bajos cuando el tamizaje para facilitar la detección oportuna de lesiones precursoras está disponible junto con el diagnóstico apropiado, el tratamiento y seguimiento". oms (2004) 53 cáncer de cuello uterino: análisis de la calidad de un programa l cielo noreña-quiceno, lucía stella tamayo-acevedo cifically the components related to problem, structure, processes and results, based on different information gathering techniques. a univariate and bivariate descriptive statistical analysis of texts was done, as was a qualitative analysis. results: although cervical cancer is considered a public health problem, there is no structured program for intervention. the activities center on detection and prevention. in general, the human, physical, material and economic resources required to develop them are available. most of the activities are carried out by the nurse’s aide, while the physician orders treatment and refers users to other levels within the service network. all users acknowledge the importance of the program and the majority expressed satisfaction with the care and attention they receive. conclusions: every component of the cervical cancer early detection and control program needs to be reinforced in the interest of greater efficiency and effectiveness, so as to have more of an impact on women’s health by reducing morbility and morbidity attributed to this type of cancer. it is important to rescue the concept of comprehensiveness, since a public health program must be state policy and its development must be a commitment assumed by all concerned. key words cervical cancer, public health, promotion, prevention (source: decs, bireme). câncer cervical: análise da qualidade de um programa resumo objetivo: avaliar a qualidade do programa de detecção precoce e controle do câncer cervical em uma unidade prestadora de serviços de saúde, da empresa social do estado metrosalud estado, medellín, colômbia, 2006-2008. metodologia: estudo transversal. empregouse o método de avaliação dos programas de saúde nos componentes: problema, estrutura, processos e resultados, proposto por avedis donabediam, utilizando diferentes técnicas de coleta de dados. aplicou-se a análise estatística univariada, bivariada e qualitativa de textos. resultados: embora esse tipo de câncer é um problema de saúde pública, falta um programa estruturado de intervenção. as atividades centrar-se na detecção e a prevenção. para a sua execução, existem os recursos humanos, físicos, materiais e financeiros necessários. de acordo com a rede de serviços, a auxiliar de enfermagem desenvolve a maioria das atividades e o médico ordena tratamentos e remete os usuários a outro nível. todas as usuárias reconhecem a importância do programa; a maioria manifestou-se satisfeita com o atendimento recebido. conclusões: o programa de detecção precoce e controle do câncer cervical deve reforçar seus componentes com maior eficiência e eficácia na obtenção de maior impacto sobre a saúde das mulheres, redução da morbidade e mortalidade por este câncer. recuperar o conceito de integralidade como programa de saúde pública deve ser uma política de estado; o seu desenvolvimento é um compromisso de todos os funcionários que nele trabalham. palavras-chave câncer cervical, saúde pública, promoção, prevenção (fonte: decs, bireme). 54 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 introducción el cáncer de cuello uterino es el segundo cáncer más frecuente entre las mujeres, antecedido sólo por el cáncer de mama. se calcula que cada año ocurren 500.000 casos nuevos y 274.000 muertes, de los cuales el 83% se presentan en países subdesarrollados (1). en los últimos 20 años, en colombia, la tendencia de la mortalidad por este tipo de cáncer presentó leves variaciones. según la encuesta nacional de demografía y salud de 2005 (2), en el período 1995-2000, las defunciones por cáncer de cuello uterino en mujeres de 40 a 69 años aumentaron de 58 a 62% (3). en el 2000, últimos datos consolidados por la agencia internacional de investigación del cáncer (iarc, por su sigla en inglés), las tasas de incidencia y mortalidad en colombia fueron 32,9 y 13,7 por cien mil mujeres, respectivamente; altas si se comparan con las tasas de incidencia 8,2 y de mortalidad 2,8 por cien mil mujeres en canadá (4). en el 2006, el departamento administrativo nacional de estadística (dane) de colombia reportó 2.005 muertes por cáncer de cuello uterino en mayores de 35 años y una tasa de mortalidad de 24,2 por cien mil mujeres (5), ligeramente inferior a la reportada en el 2002. en este mismo año, 2006, en antioquia y medellín, el cáncer de cuello uterino ocupó el primer lugar en la mortalidad por cáncer, con 203 y 56 muertes, respectivamente, y tasas de 6,8 y 4,7 por cien mil mujeres (6). el instituto nacional de cancerología colombiano, para esta fecha, registró 101 muertes por este cáncer, de las cuales un 23,8% se presentaron en el grupo de 15 a 44 años, el 23,8% en el de 45 a 54 años, el 18,8% en el de 55 a 64 años y el 33,7% en mayores de 65 años (7). por otro lado, el cáncer de cuello uterino es prevenible y curable si se dispone de modelos de atención en salud pertinentes para su intervención. los programas que poseen una red de servicios estructurada, acceso al tamizaje, diagnóstico, tratamiento y seguimiento; acciones de promoción de la salud y prevención de la enfermedad, impactan positivamente la morbilidad y mortalidad por este cáncer (4). en colombia, en la década de los noventa, el análisis de la tendencia de la mortalidad por cáncer de cuello uterino condujo a la definición de estrategias tendientes a intervenir positivamente la salud de las mujeres, una de ellas fue la reestructuración del programa “detección temprana y prevención del cáncer de cuello uterino”. por programa de salud se entiende, según alzate (8), “el conjunto de estrategias definidas mediante normas técnicas y administrativas que permiten enfrentar un problema o un evento, definiendo lo que se quiere hacer, los recursos necesarios y unificando los criterios y procedimientos de atención”. un programa es un proceso sistémico que consta de los siguientes elementos: 1) el problema, situaciones que se presentan y, dada su gravedad e importancia, ameritan de manera prioritaria organizar acciones y recursos dentro y fuera del sector salud. 2) la estructura, organización de recursos humanos, financieros técnicos y materiales necesarios para la solución del problema. 3) los procesos, procedimientos técnicos y administrativos que se emplean para utilizar eficaz y eficientemente los recursos asignados al programa. 4) los resultados que comprenden los logros administrativos (cobertura, producción, productividad) y el impacto en la salud de la población (cambios en los perfiles epidemiológicos). el control de los resultados facilita la redefinición y adaptación del programa a otros contextos sociales (8). según la encuesta nacional de demografía y salud de 2005, en el período 1995-2000, las defunciones por cáncer de cuello uterino en mujeres de 40 a 69 años aumentaron de 58 a 62%. 55 cáncer de cuello uterino: análisis de la calidad de un programa l cielo noreña-quiceno, lucía stella tamayo-acevedo en palabras de lewis (4): un programa eficaz de prevención y control del cáncer de cuello uterino debe abordar varios aspectos: la cobertura y la calidad de los servicios de tamizaje y detección temprana, la disponibilidad de diagnóstico, tratamiento y seguimiento rápidos, fiables y asequibles. contar con infraestructura de apoyo como servicios de orientación y sistemas de información para mejorar la calidad de la atención y facilitar la gestión eficaz de pacientes y programas. por otra parte, el ministerio de salud de colombia, en el marco de la reforma del sistema de seguridad social –ley 100 de 1993–, expidió en el 2002, la norma técnica para la detección temprana del cáncer de cuello uterino y guía de atención de lesiones preneoplásicas de cuello uterino que comprende actividades propias del tamizaje (9), en tal sentido, es el estándar de comparación para la evaluación del programa. en la oferta de los programas de salud, la calidad está relacionada con la efectividad, la eficiencia y la eficacia. la calidad es un concepto integral inmerso en las actividades y programas que se realizan para alcanzar un propósito, en este caso, evitar la enfermedad o muerte por cáncer de cuello uterino. donabedian, en 1990, definió la calidad como “el juicio sobre la atención en salud, a través del cual se determina el grado en que se utilizan los medios más deseables para lograr los mayores beneficios en salud" (10). en el sistema obligatorio de garantía de calidad de la atención de salud de colombia (decreto 1011 de 2006), la calidad es “la provisión de servicios de salud a los usuarios individuales y colectivos de manera accesible y equitativa, a través de un nivel profesional óptimo, teniendo en cuenta el balance entre beneficios, riesgos y costos, con el propósito de lograr la adhesión y satisfacción de dichos usuarios” (11). el objetivo general de esta investigación fue evaluar la calidad del programa de “detección temprana y control del cáncer de cuello uterino” en una unidad prestadora de servicios de salud (upss) de la empresa social del estado (ese) metrosalud, medellín, colombia, en el 2006-2008. los objetivos específicos fueron: 1) caracterizar la organización y disposición de los recursos humanos, financieros, técnicos y materiales del programa; 2) analizar los procedimientos técnicos y administrativos establecidos en la normatización del programa; 3) determinar cobertura, producción y productividad del programa; 4) describir el grado de satisfacción de las usuarias del programa, y 5) analizar las actividades de promoción de la salud y prevención de la enfermedad en el programa. materiales y métodos se realizó un estudio descriptivo transversal en una upss integrada por un hospital de primer nivel, cuatro centros y un puesto de salud que hacen parte de la red pública de servicios de la ese metrosalud. la upss se ubica en una de las comunas de mayor densidad poblacional de la ciudad de medellín. según el censo poblacional del 2005, habitan 191.387 personas, de las cuales el 37,9% poseen subsidio público de salud. en el 2006, la tasa de mortalidad por cáncer de cuello uterino fue 8,0 por cien mil mujeres, siendo la tercera más alta entre las 16 comunas del municipio (10). la unidad de análisis del estudio fue el programa de “detección temprana y control del cáncer de cuello uterino” o aclos programas que poseen una red de servicios estructurada, acceso al tamizaje, diagnóstico,tratamiento y seguimiento; acciones de promoción de la salud y prevención de la enfermedad, impactan positivamente la morbilidad y mortalidad por este cáncer. 56 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 tividades ofertadas sin interrupción en los dos últimos años. para la evaluación del programa se utilizó el método de evaluación de servicios de salud propuesto por donabedian, con los elementos que contemplan la estructura, los procesos y los resultados. la información se obtuvo a partir de encuestas, entrevistas, guía de observación y revisión de historias clínicas. la encuesta estructurada se aplicó a una muestra de 374 usuarias del programa, calculada bajo los parámetros estadísticos: nivel de confianza de 95%, error de muestreo 2%, probabilidad de encontrar el evento del 0,5. se hizo un muestreo estratificado por puesto, centros de salud y hospital. las preguntas se orientaron a la percepción de las mujeres en los diferentes momentos de la atención: toma de la citología (saludo, interrogatorio, procedimiento, educación y orientación), entrega de resultados y educación en salud. las preguntas cerradas se respondieron en la escala: excelente, bueno, regular y deficiente. se solicitó una explicación para la calificación dada. la encuesta semiestructurada se dirigió al personal de enfermería: ocho auxiliares quienes atendieron en su totalidad al llamado, y cuatro enfermeras, de las cuales sólo dos respondieron la encuesta. la entrevista, grabada en audio, se hizo a ocho médicos directores o coordinadores de las unidades de salud. tanto en la encuesta semiestructurada como en la entrevista se hicieron preguntas sobre condiciones técnicas y administrativas del programa, perfil laboral, participación y percepción del mismo. la guía de observación fue aplicada por las investigadoras en diferentes momentos de atención: solicitud y realización de la citología, entrega del resultado y actividad educativa. además, se revisaron 24 historias clínicas de pacientes con reporte de lesiones premalignas o cáncer de cuello uterino, en las cuales se analizó el manejo y seguimiento de la paciente. el consentimiento informado se solicitó por escrito a las usuarias del programa en el momento de aplicar la encuesta. el personal de enfermería y los médicos dieron el consentimiento verbal, en ambos casos con previa explicación de los objetivos y participación en la investigación. la información se sistematizó en dos bases de datos en excel versión 2003, una con la información de la encuesta de las usuarias y la otra con la información del personal de salud y la guía de observación. el análisis de los datos cuantitativos se hizo en spss versión 15. se calcularon medidas descriptivas según el nivel de medición de las variables (tendencia central, frecuencia absoluta y relativa) y se realizó el cruce de las variables sociodemográficas con variables de opinión, percepción y satisfacción de las usuarias con el programa, contrastadas a través del chi² y analizadas por puesto, centros de salud y hospital. la información obtenida con el personal de salud en la entrevista y la encuesta semiestructurada se transcribió textualmente. el análisis se realizó bajo categorías predeterminadas, relacionadas con el problema, la estructura, el proceso y los resultados (6). resultados la presentación de los resultados se inicia con las características sociodemográficas de las usuarias que participaron en la investigación. la edad mínima y máxima de quienes respondieron la encuesta fue de 15 y 74 años, respectivamente (promedio 38 años y desviación estándar, 12,7). el 57,9% estaban casadas o vivían en unión libre; 81,2% amas de casa; la presentación de los resultados se inicia con las características sociodemográficas de las usuarias que participaron en la investigación. 57 cáncer de cuello uterino: análisis de la calidad de un programa l cielo noreña-quiceno, lucía stella tamayo-acevedo 5,7% analfabetas, 41,3% tenían estudios de primaria, 19,6% alcanzaron educación secundaria completa, y sólo 2,2% el nivel técnico o universitario (cuadro 1). de las mujeres encuestadas, el 22,9% acudía por primera vez a la citología, el 60% se la había realizado entre los 12 y 24 meses anteriores, y el resto llevaba más de 24 meses sin realizarse el examen (cuadro 2). en colombia, la norma técnica del programa contempla el esquema 1:1:3, lo que equivale a realizarse la citología al año siguiente de la primera con resultado normal, y si ésta sigue siendo normal, se continúa cada tres años; sin embargo, es política de metrosalud promover la citología anual. el tamizaje citológico fue el eje alrededor del cual se analizaron los componentes del programa (problema, estructura, procesos y resultados), se indagó cómo es el proceso del tamizaje, qué se hace durante el mismo, qué actividades se ejecutan, quien las realiza, cómo se realizan, con qué se hacen, dónde y cuándo se hacen, la normatividad que lo rige, además de la percepción del personal de salud y de las usuarias sobre el programa. el problema. el personal de salud y las usuarias participantes en el estudio manifestaron que el cáncer de cuello uterino es un problema de salud que afecta de manera creciente a las mujeres, se detecta en fases tardías e impacta de manera negativa su vida personal, familiar, social y económica. uno de los médicos expresó: […]este problema de cáncer de cuello uterino es de una magnitud muy importante porque nuestra comunidad ha sido demasiado pobre e ignorante, la problemática no ha tenido todo el desarrollo y la vigilancia epidemiológica que se debería dar, porque a la mayoría de las personas se les detecta el cáncer en fases muy avanzadas (m01). la estructura. en el análisis de la estructura se incluyó la disponibilidad y organización de los recursos físicos, técnicos, materiales, humanos y financieros necesarios para el desarrollo de las actividades del programa. en los recursos físicos disponibles, se encontró que en todas las unidades de salud el consultorio donde se toma la citología se utiliza para desarrollar otras actividades como la toma de muestras de laboratorio, la asignación de citas, la respuesta a inquietudes de los usuarios de la unidad de salud, entre otras, en horarios previamente establecidos. los consultorios ofrecen privacidad a las usuarias; sin embargo, dos centros de salud no cumplen con el requisito establecido de unidad sanitaria dentro del consultorio. los espacios comunes de salas de espera están bien dotados de mobiliarios, pero en su totalidad no cumplían con el requisito de unidad sanitaria separada por sexo. en todas las unidades de salud los recursos materiales y técnicos eran suficientes y pertinentes, los funcionarios conocían la existencia de la norma técnica para realizar las actividades del programa. la disponibilidad de material educativo, visual o auditivo, era limitada o inexistente: en dos centros de salud contaban sólo con un afiche que incluía fotografías de las alteraciones del cuello uterino, siendo estas imágenes más adecuadas para la actualización del personal de salud que para la comunidad; en el hospital, dos centros y el puesto de salud no existía este material. en colombia, la norma técnica del programa contempla el esquema 1:1:3, lo que equivale a realizarse la citología al año siguiente de la primera con resultado normal, y si ésta sigue siendo normal, se continúa cada tres años. 58 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 cuadro 1. características sociodemográficas de las usuarias por unidad de salud en la unidad prestadora de servicios de salud. medellín, 2008. referente al recurso humano, la persona asignada al programa en todas las unidades de salud es la auxiliar de enfermería. en su conjunto, la upss dispone de cuatro enfermeras en consulta externa, una de ellas asignada para todos los programas de promoción de la salud y prevención de la enfermedad en el hospital, y las otras tres rotan por el puesto y los centros de salud, donde atienden la consulta y hacen el control de los usuarios de los programas, diferentes al de prevención de cáncer de cuello uterino. en cuanto a la experiencia y capacitación del personal, se encontró que el de mayor permanencia en el programa eran las auxiliares de enfermería, con un tiempo de antigüedad entre 6 meses y 15 años. siete auxiliares expresaron haber recibido inducción para desempeñarse en el programa, cuatro de ellas la calificaron de buena porque “nos enseñaron la técnica adecuada para tomar la muestra”; dos de regular, y una como muy deficiente, “no nos enseñaron la técnica de la citología”. la capacitación y actualización de las auxiliares de enfermería para desempeñarse en el programa no fue periódica, en cuatro de las ocho auxiliares se hizo con intervalos mayores a dos años, tres de estas expresaron que fue buena porque “actualizan y recuerdan conocimientos”, y consideraron que “debería ser cada año”. dos auxiliares no recibieron capacitación, a pesar de tener mayor tiempo en el programa, y las otras dos fueron las únicas en recibir capacitación al menos una vez en el año. las enfermeras y los médicos manifestaron no haber recibido capacitación formal para el desempeño en el programa, por tanto la actualización la hicieron por iniciativa propia. en cuanto al presupuesto, en ninguna de las unidades de salud se dispone de un rubro específico para el funcionamiento del programa. la solicitud de los materiales e insumos se hace según las necesidades del mismo, en cada unidad de salud, al nivel central de la red de servicios de metrosalud. en las unidades de salud la citología se oferta todos los días durante dos horas en la mañana, excepto en un centro de salud que se hace en la tarde. el 67,1% de las usuarias calificó el horario de adecuado y 13,1% muy adecuado, según ellas porque “es mejor en la mañana, uno está más tranquilo más relajado” (e290). para el 4,8% es inadecuado, algunas expresiones fueron: “dicen que a las 9 a.m. pero son las 11 y nada, debería de ser más temprano para que lo atiendan más rápido” (e44), “hay que esperar a que las del laboratorio acaben, entonces siempre empiezan a las 9:30 a.m.” (e122); y el 2,9% lo calificó como muy inapropiado porque “en la mañana uno está muy ocupado con los hijos, el esposos, y los bebés a esa hora necesitan atención” (e7). “uno por la ma59 cáncer de cuello uterino: análisis de la calidad de un programa l cielo noreña-quiceno, lucía stella tamayo-acevedo ñana tiene mucho que hacer, es una eternidad para que le facturen, debería ser después de las 12 m.” (e169). el 11,5% no respondió esta pregunta. la ocupación no se relacionó con la opinión de las usuarias sobre el horario (chi²: 4,58, p=0,205). la información sobre el programa. durante la observación se encontró que generalmente el horario de atención se publica en un lugar visible, lo cual está acorde con la normatividad. en dos unidades de salud, además, aparece descrito el trámite para solicitar el servicio. el proceso. en este elemento se revisaron los procedimientos técnicos y administrativos desarrollados para la utilización eficaz y eficiente de los recursos del programa. los procesos se analizaron teniendo en cuenta las actividades relacionadas con: 1) la toma de la citología que incluyó el procedimiento como tal, la aplicación de normas de bioseguridad, la información y educación brindada a la usuaria antes, durante, después del procedimiento y durante la entrega del resultado; 2) el sistema de referencia y contrarreferencia; 3) cuadro 2. frecuencia de la citología en las usuarias por unidad de salud de la unidad prestadora de servicios de salud, medellín, 2008. el sistema de información; 4) la relación enfermera-paciente; 5) la percepción de las usuarias referente al programa; 6) participación del personal de salud en el programa. 1. la toma de la citología. el procedimiento. las estrategias de captación de usuarias para la toma de la citología más usuales fueron: citar varias a la misma hora, por demanda espontánea y asignación de citas previas. el tiempo de espera observado desde la llegada de la usuaria a la institución hasta el inicio de la atención en el consultorio osciló entre 20 minutos y hora y media. el tiempo efectivo de atención en el consultorio fue 10 minutos aproximadamente, empleados en el interrogatorio, diligenciamiento de registros y toma de la citología. la fijación de la muestra citológica se hizo al medioambiente, sin alcohol isopropileico al 95%; luego se envolvían en papel higiénico o toallas de papel y se remitían al laboratorio de referencia el mismo día, excepto en un centro de salud que se enviaron uno o dos días después. el envío de las placas al laboratorio citológico de referencia se acompañó del registro clínico de la usuaria y la identificación de la unidad de salud. las normas de bioseguridad. la toma de la citología implica el manejo de secreciones fisiológicas, lo que amerita el uso de careta de bioseguridad o gafas, tapabocas, guantes, blusas y protector de camilla desechables por paciente (12), en este sentido se observó que durante el procedimiento estas normas no se cumplen a cabalidad, excepto el cambio de guantes que se hizo por usuaria. el lavado de manos antes y después del procedimiento es otro de los requeri60 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 mientos de bioseguridad, el cual se observó deficiente tanto en la frecuencia como en la calidad por parte de las auxiliares de enfermería durante la toma de la citología. en todas las unidades de salud el material contaminando (espéculos, citocepillos y bajalenguas) se depositó en bolsa roja, según la norma. este material es transportado con los demás deshechos hospitalarios por una ruta especial recolectora de este tipo de residuos. la educación en salud en el programa. en el componente de educación en salud que comprende actividades de orientación, información, consejería y asesoría, se encontró que la información que se brinda a las usuarias sobre el cáncer de cuello uterino (definición, prevención del cáncer y condiciones que debe cumplir la usuaria para el examen citológico) sólo en un centro de salud está visible en cartelera. se observó que las indicaciones a las usuarias se hicieron de manera verbal según sus dudas, siendo las más frecuentes el precio de la citología, las condiciones para el examen, el horario de atención y los documentos requeridos. en el momento de la toma de la muestra se observó que ninguna auxiliar de enfermería le explicó a las usuarias la técnica de la toma de la citología, antes o durante el procedimiento. las indicaciones se centraron en la posición ginecológica, la finalización del procedimiento y el requerimiento de consulta médica inmediata. cuando la auxiliar detectó algún signo de alteración en el cuello uterino, vagina y área perineal, se lo comunicó a la usuaria de inmediato, como se lee en los siguientes testimonios: “usted tiene que venir donde el médico, le dice que cuando le hicieron la citología le vieron la vejiga caída” (a3), “usted está muy quemada, debe cambiar la marca del protector, no echarse jabón, lavar los pantys solitos, si no mejora venga donde el médico” (a3). el procedimiento terminó con la información sobre la fecha para reclamar el resultado. no fue frecuente que se informara a las usuarias sobre la programación de las actividades educativas. por norma institucional, para la entrega del resultado se hace una actividad informativa grupal sobre el cáncer de cuello uterino y la importancia de la citología; este espacio también se utilizó para informar acerca del cáncer y autoexamen de mama. finalizada la actividad educativa se entregó el resultado de la citología a cada usuaria y se le indicó la conducta que debía seguir: consulta médica o próxima citología, según los hallazgos reportados. a ninguna usuaria se le dieron las indicaciones por escrito. el 87,5% (328 usuarias) calificó las indicaciones recibidas durante la toma de la citología como excelente y buena, predominando la excelente, 58,4%. el 69,6% (261 usuarias) calificó la orientación y educación entre excelente y buena, siendo mayor la valoración buena, 44,5%. se resalta el porcentaje de usuarias que calificaron este aspecto como deficiente 19,4% (56 usuarias) (cuadro 3). se encontró una diferencia estadística entre el mayor grado de escolaridad y la calificación buena y excelente dada por las usuarias (chi²: 29,72, p=0,013). el 42,4% de las usuarias manifestó haber recibido información sobre el procedimiento durante la toma de la citología, al 66,4% le explicaron la importancia de la citología, al 70,1% la relevancia de reclamar el resultado, al 17,6% las actividades educativas del programa, y al 70,7% la fecha para reclamar el resultado. el 87,5% consideró las indicaciones excelentes y se revisaron los procedimientos técnicos y administrativos desarrollados para la utilización eficaz y eficiente de los recursos del programa. 61 cáncer de cuello uterino: análisis de la calidad de un programa l cielo noreña-quiceno, lucía stella tamayo-acevedo buenas, valoradas en expresiones como: “lo animan a uno a hacerse la citología” (e35); “se toman la molestia de que uno esté tranquilo” (e64); el 9,6% las calificaron como regulares y deficientes, “no me dijeron nada”. la orientación y educación fue evaluada como excelente y buena por el 69,6% de las usuarias; “entendí lo que me dijeron” (e30); “con esta información uno está más prevenido y tiene más salud” (e99). en contraste con el 27,2% que la calificaron entre regular y deficiente, “no dijeron nada”, calificación que fue independiente del nivel educativo de la usuaria (chi²: 18,667, p=0,229). respecto a la educación en salud, el 48% de las usuarias desconocen las actividades educativas en el programa. el 27,5% no tiene conocimiento de la programación. el 24% asistó a alguna actividad educativa, y de éstas el 98,1% considera los temas adecuados y comprensibles. la entrega del resultado: el tiempo transcurrido entre la toma de la muestra y la entrega del resultado osciló entre 15 días y un mes. el 35,5% de las usuarias calificó este lapso como excelente y bueno, según ellas “tienen más tiempo para revisar bien el examen” (e38); el 31,2% regular y el 19,7% no apropiado porque “el resultado se demora mucho, uno se puede morir si la citología sale mala” (e125). la valoración hecha por las usuarias de este tiempo transcurrido fue independiente del nivel educativo (chi²: 14,10, p=0119). el registro del resultado de la citología es un componente de la historia clínica, el manejo que se le dio fue el siguiente: en un centro de salud se adjuntó el resultado y se hizo una nota de enfermería en la hoja de evolución. en tres unidades de salud el resultado se anexó a la historia clínica, y en las otras dos se esperó a que las usuarias reclamaran el resultado; en este último caso, según las auxiliares de enfermería, puede transcurrir un año o más hasta que las usuarias consulten por otro motivo o simplemente nunca lo reclaman. en todas las unidades de salud los resultados positivos para algún tipo de lesión intraepitelial escamosa o cáncer se consignan en la historia clínica y se llama de inmediato a la usuaria por teléfono, esta llamada muchas veces no tiene éxito y cuando esto ocurre se deja constancia en la historia clínica. 2. referencia y contrarreferencia. el tamizaje citológico es un procedimiento del primer nivel de atención, desde este nivel remite al superior cuando el resultado es positivo. al respecto, todos los médicos participantes manifestaron remitir las usuarias con reporte de lesiones intraepiteliales escamosas, cáncer cervicouterino o problemas ginecológicos a especialistas de la red oficial de servicios de salud; sin embargo, ninguno obtuvo la contrarreferencia para el seguimiento de la paciente. uno de ellos manifestó: “el especialista no manda ni una nota” (m 4). la escasa información que obtienen sobre el tratamiento realizado a las pacientes es a través de ellas mismas, cuando consultan nuevamente. 3. sistema de información. la información es fundamental para la toma de decisiones clínicas, epidemiológicas y administrativas en los servicios de salud. según el personal de salud participante, la información estadística, epidemiológica y de gestión del programa es limitada para la toma de decisiones, debido a que no se realizan informes completos de las activiel lavado de manos antes y después del procedimiento es otro de los requerimientos de bioseguridad, el cual se observó deficiente tanto en la frecuencia como en la calidad por parte de las auxiliares de enfermería durante la toma de la citología. 62 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 dades e indicadores de salud que permitan la evaluación y el seguimiento del programa. los informes mensuales generalmente contenían: el número de citologías realizadas, cumplimiento de actividades y procedimientos programados; no incluían el análisis de cobertura, concentración, rendimiento, utilización de los recursos en el programa y de los resultados citológicos para orientar las medidas de intervención. la evaluación del programa sólo se realizaba semestralmente en una unidad de salud, bajo la responsabilidad del médico. 4. relación enfermera paciente. en esta relación, dos médicos manifestaron la necesidad de sensibilizar a las auxiliares de enfermería en la atención a las usuarias, con el fin de evitar que ellas posterguen o nieguen la atención; también consideran que la empatía entre la usuaria y la auxiliar es un factor determinante para que las usuarias accedan o regresen a la toma de la citología. para los médicos, la sensibilidad de la auxiliar incluye capacidad de explicación, comprensión, respeto, prudencia y habilidad para realizar el procedimiento. 5. percepción de las usuarias de la relación con el personal de enfermería. en el cuadro 3 se presenta, por unidad de salud, la evaluación de cada uno de los aspectos calificados por las usuarias durante la atención de enfermería en la toma de la citología. el saludo fue evaluado como bueno por el 59,2% y excelente por el 31,5% de las usuarias, explicado en “decir buenos días”, “ser formal”, “respetuosa”, “tener carisma”, “ser educada y estudiada”; el 8,5% lo calificó de regular y deficiente, “la enfermera solo es amable cuando no hay casi gente”, “se ofusca, es muy repelente”. durante la atención de la usuaria se observó, en ocasiones, interrupciones por parte de la auxiliar de enfermería para responder a situaciones como: llamadas telefónicas, cumplimiento de otras actividades asignadas, mantenimiento del consultorio y atención de asuntos administrativos que interfirieron y retardaron la atención de la usuaria hasta 15 minutos. una de las auxiliares se justificó así “con tantas actividades no puedo prestarle atención a la historia personal o comentarios de todas las pacientes, no me alcanza el tiempo” (a1). el interrogatorio (anamnesis) fue valorado como bueno por el 59,5% y excelente por el 23,5%. las preguntas que hicieron las auxiliares de enfermería las consideraron útiles para orientar la toma de la muestra y el diagnóstico citológico; al respecto expresaron: “las preguntas son necesarias para un buen resultado de la citología” (e350); “para que el diagnóstico salga bueno y para saber si manda otro examen” (e181). el 9,3% consideró el interrogatorio regular y el 5,1% deficiente; la razón principal fue “no me hicieron preguntas” (e79). el procedimiento de la toma de la citología fue calificado como bueno por el 62,1% y excelente por el 26,9%, algunos testimonios de ello fueron: “tienen mucho cuidado con uno” (e120); “le preguntan si le dolió” (e5); “le dan apoyo” (e17); “es muy delicada para hacer el examen” (e211). el 10,1% lo calificó como regular y deficiente; expresado como: “pareció que me hubiesen metido el espéculo por donde no tenía hueco” (e23); “salí sangrando” (e49); “no me explicaron nada, sería bueno, porque en sí, no sabe uno lo que le hacen” (e153). 6. participación del personal de salud en el programa. siete de las ocho auxiliares de enfermería encuestadas consideraron el tiempo semanal dedicado al programa suficiente, el cual osciló entre 4 en tres unidades de salud el resultado se anexó a la historia clínica, y en las otras dos se esperó a que las usuarias reclamaran el resultado; en este último caso, según las auxiliares de enfermería, puede transcurrir un año o más hasta que las usuarias consulten por otro motivo o simplemente nunca lo reclaman. 63 cáncer de cuello uterino: análisis de la calidad de un programa l cielo noreña-quiceno, lucía stella tamayo-acevedo y 15 horas. los médicos expresaron que las auxiliares de enfermería eran idóneas para realizar las actividades contempladas en la norma técnica de la resolución 412 del ministerio de salud (9), y que las enfermeras eran más competentes en las actividades de educación en salud. los médicos y las auxiliares de enfermería reclamaron la presencia de la enfermera en el programa por su liderazgo y conocimientos en gestión y en educación en salud. la participación de los médicos en el programa consistió en atender a las usuarias en el tratamiento o la remisión a otro nivel de atención cuando fueron enviadas por las auxiliares. los resultados. en este elemento de la evaluación de un programa se incluyen los logros administrativos (cobertura, producción, productividad) y el impacto en la salud de la población (cambios en los perfiles epidemiológicos), sin embargo, ninguna unidad realizaba evaluación de impacto del programa, esencialmente porque carecen de la información para la construcción de los indicadores de impacto: prevalencia, tasas de mortalidad global y específica, años de vida saludables perdidos, costos económicos y sociales, cobertura de la citología. no se pudo determinar la cobertura del programa por no disponer de datos poblacionales y citología de primera vez en el año. según la encuesta aplicada a las usuarias, el 78,7% se sentían satisfechas con el programa, el 13,1% muy satisfechas, el 6,7% poco satisfechas y el 1,4%, insatisfechas. la satisfacción de las usuarias con el programa fue independiente de la edad (chi²: 9,795, p=0,832), la escolaridad (chi²: 14,100, p=0,119), la ocupación (chi²: 2,218, p=0,528) y el estado civil (chi²: 2,232, p=00,889). el 98,7% de las usuarias recomendarían el programa a otras mujeres, “es algo que necesitamos todas las mujeres para la salud” (e12), “es importante para prevenir” (e306), “porque es importante que cada mujer sepa cómo está su cuerpo” (e53). discusión para impactar en el problema del cáncer de cuello uterino, la organización panamericana de la salud (ops) (4) plantea la oferta de un programa de prevención y control del cáncer cervicouterino eficaz, que aborde aspectos relacionados con la cobertura y la calidad de los servicios de tamizaje y detección temprana, que integre la disponibilidad del diagnóstico, tratamiento y atención subsiguientes rápidos, fiables y asequibles; aunado a los demás elementos de infraestructura de apoyo: servicios de orientación y sistemas de información para mejorar la calidad de la atención y facilitar una gestión eficaz de pacientes y programas. siguiendo este lineamiento, la norma técnica para la detección temprana del cáncer de cuello uterino y guía de atención de lesiones preneoplásicas de cuello uterino descrita en la resolución 0412 del 2002 del ministerio de salud de colombia (9) tiene por objetivo identificar oportunamente lesiones preneoplásicas y neoplásicas del cuello uterino, orientar a las mujeres afectadas hacia los servicios de diagnóstico definitivo, y definir de manera adecuada y oportuna el tratamiento, tendiente a incrementar las posibilidades de curación y el tiempo de sobrevida. los planteamientos de la ops y de la norma técnica se encaminan hacia la oferta de un programa con acciones de prevención, tratamiento y rehabilitación, con poco énfasis en la promoción de salud, que se la información estadística, epidemiológica y de gestión del programa es limitada para la toma de decisiones, debido a que no se realizan informes completos de las actividades e indicadores de salud que permitan la evaluación y el seguimiento del programa. 64 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 cuadro 3. calificación de las usuarias de la atención recibida por unidad de salud, en la unidad prestadora de servicios de salud, medellín, 2008. plantea en la meta de detección temprana del cáncer de cuello uterino de la política nacional de salud sexual y reproductiva (13). en colombia, desde el 2007, el cáncer de cuello uterino hace parte de las prioridades de salud pública en el plan nacional de salud (14); sin embargo, el sistema de salud reconoce algunos problemas en el control de este cáncer, como son las bajas coberturas y las deficiencias en el sistemas de garantía de la calidad (2, 15, 16). los resultados de esta investigación mostraron que el programa que se ofrece en las unidades de salud valoradas se enfoca hacia el tamizaje de la citología cérvico-uterina con actividades como: captación de usuarias, toma de la muestra, entrega del resultado, información sobre el cáncer de cuello uterino y sobre el horario de atención, y remisión de la usuaria cuando se requiere. la captación de usuarias se hace por demanda espontánea y por la remisión desde la consulta médica, odontológica o desde otros programas que se ofrecen en las unidades; no se realizan actividades informativas o educativas por fuera de la unidad con participación de grupos o líderes comunitarios, estrategias que podrían aumentar la cobertura. el aumento en la demanda del programa sería más efectivo si se promueve y motiva su uso mediante una comunicación directa con la comunidad, en espacios diferentes a las instituciones de salud. en cuanto a la toma de la muestra citológica se encontró que esta actividad es efectuada únicamente por la auxiliar de enfermería, situación no concordante con lo planteado en la norma técnica antes citada, donde se especifica que “debe ser realizada por médico o enfermera debidamente capacitados” (9). si bien las auxiliares de enfermería de las unidades de salud estudiadas poseían habilidades técnicas para la toma de la muestra, es la enfermera, con su formación científicotécnica, quien debe asumir las funciones, como lo establece la norma. otro hallazgo de interés fue la deficiencia en la información, orientación y educación a la usuaria; en este sentido, en el 2006, azevedo et ál., reportaron la falta de información y educación en salud como una de las limitantes de las mujeres de fortaleza, brasil, para recuperar los resultados del examen citológico y continuar con el tratamiento (17). en colombia, wiesner et ál., hallaron que las barreras culturales, la desinformación y, particularmente, la mala calidad de los programas percibida por las usuarias son causales que determinan el acceso al tamizaje citológico (18). con relación a lo anterior, la entrega de los resultados citológicos acompañada de una actividad informativa es poco efectiva en el cambio de comportamientos de la población hacia hábitos saludables que 65 cáncer de cuello uterino: análisis de la calidad de un programa l cielo noreña-quiceno, lucía stella tamayo-acevedo repercutan en la disminución de las tasas de morbilidad y mortalidad causadas por el cáncer de cuello uterino, sin dejar de reconocer los otros factores que inciden en esta problemática. reyes et ál. (19) consideran que para lograr mayor impacto, la educación en salud, además de la información, debe comprender la comunicación, la asesoría directa e individual, y el compromiso de la población hacia su autocuidado y autorregulación. siguiendo con las actividades que se desarrollan, se encontró que el médico ordena el tratamiento para las infecciones vaginales cuando se detectan durante la citología, y remite a las usuarias con resultados patológicos a otro nivel de atención sin recibir la contrarreferencia, lo que afecta el seguimiento de las pacientes. aunque las usuarias con resultados de citología patológicos se remiten al nivel de atención correspondiente, generalmente encuentran obstáculos administrativos del sistema de salud que fragmenta la atención a través de la intermediación de las empresas promotoras de salud, siendo la condición más frecuente la falta de contratación con las instituciones de segundo nivel de atención. unido a esto, se presenta la ausencia de la contrarreferencia mencionada. de esta manera, la desarticulación entre las actividades detectada en esta investigación dificulta el impacto en la salud de las mujeres y afecta la calidad del programa. al respecto, la ops (20) manifestó que: la calidad de la salud debe ser una prioridad y una realidad para los gobiernos de todos los países de la región de américa latina, para ello se deben definir intervenciones que permitan mejores resultados para la salud, trabajar por el desarrollo de los recursos humanos, definir mecanismos de financiamiento social de los programas de salud, establecer modelos de cuidado basados en la promoción de la salud y la prevención de la enfermedad, aplicar las funciones esenciales de la salud pública, y extender la protección social en salud. como lo expresa la ops, el desarrollo de los recursos humanos es esencial para la calidad de los programas; “es indispensable que el personal se capacite en forma continua y esté totalmente comprometido con los objetivos del servicio” (20); contar con el personal suficiente, calificado y motivado para desarrollar las actividades le suma a la proyección del programa, situación que no fue detectada en esta investigación al identificarse limitaciones en cantidad y calidad del personal de salud asignado a las actividades del tamizaje citológico. por lo anterior, es necesario establecer planes de capacitación periódicos que permitan actualizar los conocimientos científicos y técnicos del personal de salud, y de esta manera mejorar la calidad de la prueba citológica y del programa. en este estudio no se evaluó la calidad del proceso, el análisis y la lectura de la citología debido a su concentración en un laboratorio de referencia de citopatología contratado por la red de metrosalud, sin embargo, se resalta la importancia de este componente en la evaluación de la calidad del programa de prevención del cáncer de cuello uterino (21, 22). aunque no hay asignación directa de recursos financieros para el programa, las actividades (toma de citología, remisión, charlas informativas) no se vieron afectadas por la falta de insumos, lo que no excluye que una organización diferente del ninguna unidad realizaba evaluación de impacto del programa, esencialmente porque carecen de información para la construcción de los indicadores de impacto. 66 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 programa, con asignación de presupuesto, pueda aportar mayor desarrollo y autonomía, destinando recursos para proyectos de intervención, investigación y evaluación de impacto en el ámbito comunitario, centrados en la promoción de la salud y prevención de factores de riesgo. en esta investigación la disponibilidad de recursos financieros en los servicios de diagnóstico y tratamiento del cáncer de cuello uterino, que puede ser una limitante unida a la prevención y control de este cáncer, no fue objeto de evaluación (20). otro de los hallazgos importantes fue la carencia de sistemas de información locales que apoyen la toma de decisiones en salud, la vigilancia y evaluación fiable y fidedigna, situación también descrita por la ops en los países de américa latina (20). en colombia, aún no se dispone de un registro poblacional unificado para el reporte de la morbilidad por cáncer de cuello uterino y lesiones intraepiteliales escamosas, solo se reporta la mortalidad consignada en los registros poblacionales de cáncer del país. el proceso de comunicación entre el personal de salud y las usuarias es unilateral, liderado por el personal de salud. la información unilateral en los diferentes momentos: indicaciones, orientación, actividad educativa, entrega de resultados, fue otra de las deficiencias detectadas en esta investigación, lo cual está influenciado por factores como estrategias de comunicación inadecuadas, escaso material educativo, falta de capacitación en educación en salud en el personal, y poca disponibilidad de tiempo; la consecuencia subsiguiente es la no participación de las mujeres en las decisiones que orientan las actividades del programa. en la encuesta aplicada por la oms en el 2001, en 35 países de las américas, con el fin de evaluar las capacidades específicas de cada país en la atención del cáncer de cuello uterino como un problema de salud pública, el 54,2% de los países dijeron tener un plan para el control de este cáncer, el 46% poseían sistemas de vigilancia o información sobre el cáncer cérvico-uterino, el 68,5% contaban con directrices o normas para la prevención y el tratamiento, y el 77% disponían de recurso humano y medios para la vigilancia de este tipo de cáncer al nivel de la atención primaria de salud (4). finalmente, la carta de otawa (23) expresa al respecto: la promoción de la salud consiste en proporcionar a los pueblos los medios necesarios para mejorar su salud y ejercer un mayor control sobre la misma; además, promueve la equidad, su acción se dirige a reducir las diferencias en el estado actual de la salud y a asegurar la igualdad de oportunidades y proporcionar los medios que permitan a toda la población desarrollar al máximo su salud potencial. lo anterior implica acceso a la información y capacidad para asumir el control de los factores determinantes de la salud con participación efectiva y concreta de la comunidad en la fijación de prioridades, la toma de decisiones, y la elaboración y puesta en marcha de estrategias de planificación para alcanzar un mejor nivel de salud; lo cual se ratifica en la v conferencia de la ops realizada en méxico (24). en esta investigación se enfatiza en la necesidad de trascender las normas técnicas y ofrecer programas a las mujeres con calidad (25) y con enfoque de equidad de género, en los cuales las voces de ellas en colombia, desde el 2007, el cáncer de cuello uterino hace parte de las prioridades de salud pública en el plan nacional de salud; sin embargo, el sistema de salud reconoce algunos problemas en el control de este cáncer, como son las bajas coberturas y las deficiencias en el sistemas de garantía de la calidad. 67 cáncer de cuello uterino: análisis de la calidad de un programa l cielo noreña-quiceno, lucía stella tamayo-acevedo cuenten en las decisiones y orientaciones de los programas para satisfacer sus necesidades de salud. conclusiones el programa de detección temprana y control de cáncer de cuello uterino debe fortalecer todos sus componentes con mayor eficiencia y eficacia para lograr mejor impacto en la salud de las mujeres, disminuyendo la morbilidad y mortalidad por este cáncer. retomar el concepto de integralidad como programa de salud pública debe ser una política de estado, y su desarrollo, un compromiso de todos los funcionarios que laboran en él. agradecimientos las autoras agradecen la colaboración del equipo de salud y la participación de las usuarias de la upss en estudio, a la empresa social del estado, metrosalud, y al comité de investigaciones de la universidad de antioquia, codi, por la cofinanciación. referencias bibliográficas 1. ferlay j, bray f, pisani p, parkin dm. globocan 2002 cancer incidence, mortality and prevalence worldwide iarc cancer base no. 5, version 2.0 iarc press, lyon; 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[fecha de acceso: 14 de febrero de 2010]. 14. república de colombia. ministerio de la protección social. decreto 3039 de 2007 por el cual se adopta 68 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 el plan nacional de salud pública. bogotá; 2007. disponible en: www.minproteccionsocial.gov.co/vbecontent/newsdetail.asp?id016491&dcompany=3. [fecha de acceso: 12 de julio de 2008]. 15. lucumí d, gómez l. accesibilidad a los servicios de salud en la práctica de la citología reciente de cuello uterino en una zona urbana de colombia. rev esp salud pública 2004; 78 (3): 367-77. 16. restrepo za, mejía ma, valencia am, tamayo al. accesibilidad a la citología cervical en medellín, colombia, en 2006. rev esp salud pública 2007; 81 (6): 657-666. 17. azevedo gs, antero smm, viera sn. motivos que levam mulheres a não retornarem para receber o resultado de exame papanicolaou. rev latino-am enfermagen 2006; 14 (4): 503-9. 18. wiesner cc, vejarano vm, caicedo mj, tovar ms, cendales dl. la citología de cuello uterino en soacha, colombia: representaciones sociales, barreras y motivaciones. revista salud pública 2006; 8 (3): 185-196. 19. reyes w, grau j, prendes m. ¿cómo hacer más efectiva la educación en salud en la atención primaria? en: rev cubana med gen integr 1999; 15 (2): 17683 disponible en: http://bvs.sld.cu/revistas/mgi/ vol15_2_99/mgi10299.pdf. [fecha de acceso: 10 de febrero de 2010]. 20. analysis of health sector reforms. region of the americas. washington, d.c., july 2004. d i s p o n i ble en: http://www.paho.org/spanish/dpm/shd/ hp/analisis_reforma_sector_salud-region_american.htm. [fecha de acceso: 16 de agosto de 2008]. 21. salmeron j, lazcano e, pérez r, río iliana del, torres i, hernández m. proposal to instituicionalize criteria and qualiyt standards for cervical cancer screening within a healt care system. cad sañude publica 1998; 14 (sup. 3): 67-75. 22. pineros m, cendales r, murillo r, wiesner c, tovar s. cobertura de la citología de cuello uterino y factores relacionados en colombia. rev salud pública 2005; 9 (3): 327-41. 23. carta de ottawa para la promoción de la salud. disponible en: http://www.cepis.ops-oms.org/bvsdeps/fulltext/conf1.pdf. [fecha de acceso: 14 de agosto de 2008]. 24. v conferencia mundial de promoción de la salud: hacia una mayor equidad. ciudad de méxico, 5-9 de junio de 2000. disponible en: http://www.who. int/hpr/nph/docs/mxconf_report_sp.pdf. [fecha de acceso: 14 de agosto de 2008]. 25. montero re. marco conceptual para la evaluación de programas de salud. población y salud en mesoamérica [publicación periódica en línea] 2004; 1(2). disponible en: http://ccp.ucr.ac.cr/revista/. publicado 12 de marzo, 2004. [fecha de acceso: 16 de septiembre de 2007]. 207 211 primeras paginas.indd 297 jacqueline fawcett1 using the roy adaptation model to guide research and/or practice: construction of conceptualtheoretical-empirical systems of knowledge 1 professor, college of nursing and health sciences. university of massachusetts. boston, usa. jacqueline.fawcett@umb.edu recibido: 26 de agosto de 2009 aceptado: 2 de noviembre de 2009 abstract this paper presents an explanation of a three-step process for the use of a conceptual model to guide nursing research and/or practice. step 1 involves learning the content of the conceptual model and its research and practice guidelines. step 2 requires a review of literature about the use of the model as a basis for research or practice. step 3 focuses on construction and communication of a conceptual-theoretical-empirical structure for diverse research topics and practice situations. emphasis is placed on application of the process to one conceptual model of nursing: the roy adaptation model. key words roy adaptation model, research, practice, nursing. (source: decs, bireme). año 9 vol. 9 nº 3 chía, colombia diciembre 2009 297 306 298 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 uso del modelo de adaptación de roy para guía de la investigación y/o la práctica: construcción de sistemas de conocimiento conceptuales-teóricos-empíricos resumen este artículo presenta una explicación para un proceso de tres pasos sobre el uso de un modelo conceptual para guía de la investigación y/o la práctica de la enfermería. el paso 1 implica el conocimiento del modelo conceptual y sus directrices para la investigación y la práctica. el paso 2 exige una revisión de la literatura sobre el uso del modelo como base para la investigación o la práctica. el paso 3 se enfoca en la construcción y la comunicación de una estructura conceptual – teórica – empírica sobre los diversos temas de investigación y las situaciones de práctica. el énfasis se hace sobre la aplicación del proceso a un modelo conceptual de enfermería: el modelo de adaptación de roy. palabras clave modelo de adaptación de roy, investigación, práctica, enfermería. (fuente: decs, bireme). aplicação do modelo de adaptação de roy na pesquisa o na prática: construção de sistemas de conhecimento conceptual e teórico-empírico resumo este artigo oferece uma explicação para um processo de três passos sobre o uso de um modelo conceitual para orientar a pesquisa ou a prática de enfermagem. o passo 1 implica um conhecimento do modelo conceptual e suas diretrizes para a pesquisa e a prática. o passo 2 requer uma revisão da literatura sobre a utilização do modelo como base para a investigação ou a prática. o passo 3 centra-se na construção e a comunicação de um quadro conceptual e teórico-empírico sobre temas de investigação e várias situações de prática. a ênfase está na aplicação do processo em um modelo conceitual de enfermagem: o modelo de adaptação de roy. palavras-chave modelo de adaptação de roy, investigação, práctica, enfermagem. (fonte: decs, bireme). 299 using the roy adaptation model to guide research and/or practice: ... jacqueline fawcett introduction the purpose of this paper is to present an explanation of three steps that need to be followed to use a conceptual model to guide nursing research and/or practice. the content of the paper reflects my belief that it is impossible to conduct nursing research or to practice nursing without guidance from a conceptual model. indeed, popper (1) pointed out that it is “absurd” (p. 46) to assume that development of any theory can occur without guidance from a conceptual model. the paper content also reflects my beliefs that the product of research always is a theory, and that nursing practice should be guided by nursing theories that are derived from nursing conceptual models. steps to follow to use a conceptual model to guide nursing research and/or practice the use of a conceptual model to guide research and/or practice involves a process made up of three steps (2). the three steps are listed here. 1. develop a comprehensive understanding of the content and the research and practice guidelines of the conceptual model. 2. review existing research and practice guided by the conceptual model. 3. construct and clearly communicate a conceptual-theoretical-empirical structure. step 1: conceptual model content and guidelines for research and practice the first step of the process of using a conceptual model to guide nursing research and/or practice is to understand the content of the conceptual model and to read carefully the guidelines for research and the guidelines for practice (2). a conceptual model is made up of abstract and general concepts and statements about those concepts (3). the content of the roy adaptation model, for example, is made up of such abstract concepts as environmental stimuli, coping processes, and modes of adaptation; the statements that broadly define each concept; and the statements that link the concepts (see figure 1). a narrative summary of the roy adaptation model is given in box 1. figure 1. the roy adaptation model the content of the roy adaptation model, for example, is made up of such abstract concepts as environmental stimuli, coping processes, and modes of adaptation. 300 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 box 1. narrative summary of the roy adaptation model within the context of the roy adaptation model, individuals and groups are regarded as adaptive systems whose behavior is a response to environmental stimuli (4). roy (4) identified three types of environmental stimuli--focal, contextual, and residual—that she regards as constantly changing forces that affect individuals and groups. the focal stimulus is the one most immediately confronting an individual or a group. the contextual stimuli are all other stimuli that contribute directly to the individual’s or the group’s responses. residual stimuli are unknown factors that may be affecting the individual or group. when a residual stimulus is identified, it usually becomes a contextual stimulus but may turn out to be the focal stimulus. environmental stimuli are directly related to coping processes (4) and both directly and indirectly related to the modes of adaptation (5). the indirect relation between environment stimuli and the modes of adaptation is mediated by the coping processes individuals use two coping processes to filter environmental stimuli, which are called the regulator and the cognator. the regulator coping process encompasses basic neural, chemical, and endocrine channels that process stimuli in an automatic, unconscious manner. the cognator coping process encompasses four cognitive-emotive channels for stimulus processing--perceptual/information processing, learning, judgment, and emotion. groups use two different coping processes to filter environmental stimuli, which are called the stabilizer and the innovator. the stabilizer coping process facilitates accomplishment of the purpose for which the group was formed, through use of the group’s structure, values, and usual activities. the innovator coping process focuses on the mechanisms by which the group changes and grows. roy (4) identified four modes of adaptation, which are the ways in which responses to environmental stimuli are expressed in people’s behavior. the physiological mode of adaptation incorporates individuals’ biological behaviors, such as vital signs and clinical laboratory values. the physical mode of adaptation focuses on needs of the group for the basic resources needed to function. the self-concept mode of adaptation incorporates individuals’ feelings about their bodies and their personal selves. the group identity mode of adaptation focuses on how the members of a group view themselves. the role function mode of adaptation draws attention to both individuals’ and groups’ performance of activities associated with the roles they enact in society. the interdependence mode of adaptation emphasizes interpersonal relationships and the giving and receiving of social support. roy adaptation model-based nursing interventions involve management of the environmental stimuli. roy (4) recommends focusing on managing the focal stimulus, taking the contextual stimuli into account. fawcett (3) identified guidelines for nursing research and guidelines for nursing practice based on the roy adaptation model. the guidelines for research are listed here (3, pp. 385-396). the purpose of roy adaptation modelguided research is to study the concepts and propositions of the model, which requires both basic nursing research and clinical nursing research. the purpose of roy adaptation modelguided research is to study the concepts and propositions of the model, which requires both basic nursing research and clinical nursing research. 301 using the roy adaptation model to guide research and/or practice: ... jacqueline fawcett the purpose of basic nursing research is to understand and explain people adapting within their life situations. the purpose of clinical research is to develop and test interventions and other strategies designed to enhance positive life processes and patterns. the phenomena of interest to roy adaptation model-guided research encompass the content that is depicted in figure 1. the problems to be studied include those stemming from the attempts made by individuals to meet their needs for physiological, psychological, spiritual, social, and relational integrity, as well as problems stemming from attempts made by groups to meet their collective needs for resource adequacy, identity and relational integrity, and role clarity. participants in roy adaptation modelguided research may be individuals or groups who are well or who have acute or chronic medical conditions. appropriate research methods include qualitative and quantitative descriptive, correlational, and experimental research design. data may be gathered in any health care setting in which human adaptive systems are found. research instruments should reflect the unique focus and intent of the roy adaptation model. data analysis techniques encompass qualitative content analysis and nonparametric and parametric statistical procedures, with an emphasis on statistical techniques that facilitate analysis of nonlinear and reciprocal relations. the guidelines for practice are listed here (3, p. 388). the broad purpose of roy adaptation model–based nursing practice is to promote the ability of human adaptive systems to adjust effectively to changes in the environment and also to create changes in the environment. practice problems of interest encompass adaptive and ineffective behavioral responses of human adaptive systems in the physiological/physical, self-concept/ group identity, role function, and interdependence adaptive modes. nursing may be practiced in any setting in which nurses encounter individuals and groups, ranging from virtually every type of health care institution to people’s homes and the community at large. legitimate participants in nursing practice are human adaptive systems, including individuals, families and other groups, communities, and society, that are considered sick or well. those adaptive systems may or may not manifest specific adaptation problems and ineffective behavioral responses. the nursing practice process is the roy adaptation model nursing process. the components of the process are assessment of behavior, assessment of stimuli, nursing diagnosis, goal setting, intervention, and evaluation. step 2: review of literature the second step in the process of using a conceptual model to guide research and/or practice is to search and critically review the literature about the research topic or practice situation (2). the concepts of the conceptual model can be used as the basis for search terms and to categorize the results of the literature search. the third step in the process of using a conceptual model to guide research and/ or practice requires the construction of a conceptualtheoretical-empirical (cte) structure and communication of that structure in a diagram and a narrative. 302 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 the cumulative index to nursing and allied health literature (cinahl) is an excellent electronic database for searches of literature about nursing conceptual models. for example, a cinahl search term is roy adaptation model. that search term can be combined with the search term, research, as well as with one or more search terms that reflect the specific research topic or practice situation. suppose, for example, you are interested in studying women’s responses to cesarean birth. combining the search terms, roy adaptation model, research, and cesarean, will yield relevant literature. or, suppose you are interested in the postpartum care of women who have had a cesarean delivery. literature that is relevant for this practice situation can be obtained by combining the search terms, roy adaptation model, practice, postpartum, and cesarean. the citations to literature that are obtained from the search of the database can be retrieved, reviewed for relevance, and then categorized using the concepts of the conceptual model. a worksheet that can be used to organize literature about the roy adaptation model is shown in table 1. an example of use of the worksheet is given in table 2. step 3: construct and communicate the conceptual-theoretical-empirical structure the third step in the process of using a conceptual model to guide research and/or practice requires the construction of a conceptual-theoretical-empirical (cte) structure and communication of that structure in a diagram and a narrative (2). the components of a cte are the conceptual model (c) that is the basis for the research topic or practice situation, the theory (t) that is to be generated or tested, and the empirical indicators (e) that provide a way to directly observe the theory. recall that the definition of a conceptual model—the c component—is a set of abstract and general concepts and statements about those concepts. the concepts and statements that make up a conceptual model are too broad to be used directly in research or practice. instead, theories— the t component are derived from the conceptual model and then are translated into empirical indicators—the e component. a theory is made up of relatively specific and concrete concepts and statements about the concepts (3). for example, a theory of adaptation to cesarean birth, which was derived from the roy adaptation model, is made up of three concepts—type of cesarean birth (planned or unplanned), perception of the birth experience, and responses to cesarean birth, as well as the definition of each concept and three statements linking the concepts. the type of cesarean birth is directly related to responses to childbirth, perception of the stimuli coping processes modes of adaptation intervention author, date author, date author, date author, date author, date author, date author, date author, date author, date author, date author, date author, date table 1: literature search worksheet for the roy adaptation model table 2: example of use of a literature search worksheet for the roy adaptation model stimuli coping processes modes of adaptation intervention bournaki, 1997 baron & roy, 1996 gagliardi et al., 2002 samarel et al. 1993, 1997 samarel et al., fawcett & knauth, tsai et al., 2003 mock et al., 1994 1993, 1997 1996 shin et al., 2006 shin et al. 2006 jirovec & templin, 2001 303 using the roy adaptation model to guide research and/or practice: ... jacqueline fawcett birth experience is related to responses to cesarean birth, and the indirect relation between the type of cesarean birth and responses to cesarean birth is mediated by perception of the birth experience (6). an empirical indicator is a very concrete and specific substitute for a theory concept that allows the concept to be measured for research purposes or observed in practice situations (3). for example, perception of the birth experience can be measured by the perception of birth experience scale (pobes), and responses to cesarean birth can be measured by the cesarean birth experience questionnaire (cbeq). many empirical indicators, including the pobes and the cbeq, can be used as research instruments and as practice tools (7). inductive reasoning: theory-generating research the cte structure for theory-generating research is constructed inductively, proceeding from the conceptual model to the empirical indicators to the theory. an example of a cte structure for a roy adaptation model-guided theory-generating study is shown in figure 2. deductive reasoning: theory-testing research and practice in contrast, the cte structure for theory-testing research and/or for practice is constructed deductively, proceeding from the conceptual model to the theory to the empirical indicators. an example of a cte structure for a roy adaptation modelguided theory-testing study or practice situation is shown in figure 3. inasmuch as theory-testing research and practice are essentially the same process, the cte structure is the same. this means that the research process and the nursing practice process are equivalent processes (7). for example, the statement of the problem in research is the same as the assessment phase of the nursing practice process, and conduct of the research is the same as the intervention phase of the nursing practice process. figure 2. example of theory-generating research figure 3. example of theory-testing research or practice 304 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 narrative description of the cte structure figures 2 and 3 are diagrams of cte structures. the narrative that accompanies the diagrams should clearly communicate what is illustrated in the diagram. clear communication can be accomplished by following the directions given here. for theory-generating research and for theory-testing research and/or practice, follow these directions: state the name of the conceptual model. provide a narrative summary of the content of the conceptual model. an example of the application of these directions is seen in box 1, which contains the name of a conceptual model – the roy adaptation model in this example – and a narrative summary of the content of that conceptual model. for theory-generating research, also follow these directions: state the linkage from the conceptual model to the empirical indicator-conceptual model concept a guided the construction of interview schedule z. state the linkages between the empirical indicators and the theory concept(s)--analysis of the data obtained from study participants who responded to interview schedule z revealed the theory of x, which is made up of the concept of a and its definition. an example of the application of these directions is seen in box 2, which provides the narrative for the cte structure illustrated in figure 2. for theory-testing research and/or practice, also follow these directions: state the linkages between the conceptual model concepts and the theory concepts--conceptual model concept a is represented by theory concepta. conceptual model concept b is represented by theory conceptb. …conceptual model conceptn is represented by theory conceptn. define each theory concept: -concepta is defined as …., conceptb is defined as …., conceptn is defined as …. state the linkages between the theory concepts and the empirical indicators—theory concepta will be measured by empirical indicatora, theory conceptb will be measured by empirical indicatorb, theory conceptn will be measured by empirical indicatorn. an example of the application of these directions is seen in box 3, which provides the narrative for the cte structure illustrated in figure 3. box 2. narrative for the conceptual-theoretical-empirical structure illustrated in figure 2. the roy adaptation model concept of modes of adaptation guided construction of the cesarean birth experience questionnaire (cbeq). content analysis of the data obtained from study participants, who provided answers to the open-ended questions on the cbeq, revealed the theory of responses to cesarean birth. the theory of responses to cesarean birth is made up of the concept of cesarean birth responses, which is defined as physical feelings, feelings about self, feelings about delivering by cesarean section, and feelings about the infant and other family members. 305 using the roy adaptation model to guide research and/or practice: ... jacqueline fawcett box 3. narrative for the conceptual-theoretical-empirical structure illustrated in figure 3. the roy adaptation model concept of environmental stimuli is represented by the theory concept of type of cesarean birth, which is defined as planned or unplanned cesarean delivery, as measured by an item on the background data sheet. the roy adaptation model concept of the cognator coping processes is represented by the theory concept of perception of the birth experience, defined as feelings about labor or preoperative procedures, delivery, and initial contact with the infant, as measured by the perception of birth experience scale. the roy adaptation model concept of modes of adaptation is represented by the theory concept of responses to cesarean birth, which is defined as women’s responses to the events surrounding cesarean childbirth, as measured by a numerical score based on answers to open-ended questions on the cesarean birth experience questionnaire. conclusion when conceptual model guided theory-testing research and/or practice are regarded as equivalent processes, the contributions made by both researchers and practicing nurses to theory development become obvious. however, the contributions will remain unrecognized if the work is not clearly communicated to others. the use of a conceptual model to guide nursing research and/or practice sometimes seems very complicated. however, following the three-step process (box 4) that is explained in this paper can simplify thinking about and communicating how you are using a conceptual model to guide your research and/or practice. box 4. the three-step process for using a conceptual model to guide nursing research and/or practice. develop a comprehensive understanding of the content and the research and practice guidelines of the conceptual model. review existing research and practice guided by the conceptual model. construct and clearly communicate a conceptual-theoretical-empirical structure. the roy adaptation model concept of the cognator coping processes is represented by the theory concept of perception of the birth experience, defined as feelings about labor or preoperative procedures, delivery, and initial contact with the infant, as measured by the perception of birth experience scale. 306 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 references 1. popper kr. conjectures and refutations. city (state): publisher, 1965. 2. fawcett j, e gigliotti. using conceptual models of nursing to guide nursing research: the case of the neuman systems model. nurs sci quarterly 2001; 14(4): 339-45. 3. fawcett j. contemporary nursing knowledge: analysis and evaluation of nursing models and theories. 2 ed. philadelphia (pa): fa davis company; 2005. 4. roy c. the roy adaptation model. 3 ed. upper saddle river (nj): pearson education; 2009. 5. fawcett j. the roy adaptation model. japanese j nurs res 2003; 36(2): 67-73. 6. fawcett j, s.t. myers, j.l. hall, and l. waters. women’s adaptation to cesarean birth: oklahoma site. in: fawcett j, garity, j. evaluating research for evidence-based nursing practice. philadelphia (pa): fa davis company, 2009; on book cd. 7. fawcett j, garity j. evaluating research for evidence-based nursing practice. philadelphia (pa): fa davis company; 2009. 08 22 bienestar espiritual.indd 8 aquichan issn 1657-5997 beatriz sánchez-herrera1 bienestar espiritual en personas con y sin discapacidad 1 master in science of nursing. vicerrectora general, universidad nacional de colombia. carrera 30 no. 45 03, edificio 101. bogotá, d.c. colombia. cbsanchezh@unal.edu.co recibido: 8 de enero de 2008 aceptado: 9 de marzo de 2009 resumen objetivo: describir y comparar el bienestar espiritual de personas con y sin discapacidad. método: abordaje cuantitativo, de tipo descriptivo, comparativo, midiendo el bienestar espiritual con la escala de bienestar espiritual de ellison®. la muestra incluye 86 personas, 43 vinculadas al proceso integral de rehabilitación (rht) de la clínica universitaria teletón y 43 con características sociodemográficas similares y sin alteraciones funcionales. resultados: el bienestar espiritual de las personas con discapacidad es alto, ligeramente mayor en la dimensión religiosa que en la existencial, al igual que el de las personas sin discapacidad. al comparar los índices de bienestar espiritual de las personas con y sin discapacidad, no se encontraron diferencias significativas. discusión: la literatura existente señala que la discapacidad puede modificar el bienestar espiritual de las personas en cuanto a la percepción de lo sagrado, la relación con dios, un ser o fuerza superior, la relación con el propio ser y la relación con las demás personas y el entorno. los resultados del estudio no permiten corroborar estos hallazgos. palabras clave espiritualidad, enfermedad crónica, bienestar, espiritual, discapacidad. (fuente: decs, bireme). the spiritual wellbeing of persons with and without a disability abstract objective: describe and compare the spiritual well being of persons who are disabled and those who are not. method: a quantitative, comparative study of a descriptive nature designed to measure spiritual well being according to the ellison well-being scale®. the sample includes 86 persons: 43 who are involved in an integrative rehabilitation process (rht) at the teletón university hospital and 43 who have similar socio-demographic characteristics but no functional alterations. results: the spiritual well-being of the disabled persons in the sample is high, slightly more in the religious aspect than in the existential dimension, as is the case with those who are not disabled. a comparison of the indicators of spiritual well being for persons with and without a disability showed no significant differences. discussion: existing literature indicates that disability can modify a person’s spiritual well being with respect to their perception of what is sacred, their relationship with god or a superior force or being, how they relate to themselves and their relationship with others and the environment. however, the results of the study do not make it possible to corroborate those findings. key words spirituality, chronic illness, spiritual, wellbeing, disability. (source: mesh, bireme). año 9 vol. 9 nº 1 chía, colombia abril 2009 8 22 9 bienestar espiritual en personas con y sin discapacidad beatriz sánchez-herrera bem-estar espiritual das pessoas que sofrem ou não sofrem discapacidade resumo objetivo: descrever e comparar o bem-estar espiritual das pessoas que sofrem ou não sofrem discapacidade método: abordagem quantitativa de tipo descritivo, comparativo, para medir o bem-estar espiritual com a escala de bem-estar espiritual de ellison®. a amostra abarca 86 pessoas: 43 do processo integral de reabilitação (rht) da clínica universitária teletón e 43 com características sócio-demográficas semelhantes e sim alterações funcionais. resultados: o bem-estar espiritual das pessoas com discapacidade é grande, um poço maior na dimensão religiosa do que a existencial. nas pessoas sim discapacidade, também é grande. comparados os índices de bem-estar espiritual das pessoas que sofrem discapacidade com os índices de quem não sofrem, não foram encontradas diferencias significativas. discussão: a literatura sobre este tema indica que a discapacidade pode alterar o bem-estar espiritual das pessoas pela percepção do sagrado, a sua relação com deus, um ser ou forca superior, a relação com seu próprio ser ou com as demais pessoas e o ambiente. os resultados do estudo não permitem corroborar estes achados. palavras-chave espiritualidade, doença crônica, bem-estar, espiritual, discapacidade. (fonte: decs, bireme). 10 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 introducción los seres humanos son espirituales y, muchos de ellos, religiosos. sus creencias les ayudan a afrontar las diferentes experiencias de la vida. la espiritualidad es parte de la totalidad del ser, tanto así que la integridad espiritual ha sido descrita como una necesidad básica humana (1). en la vida cotidiana, y a pesar de tener muchas manifestaciones de la espiritualidad, las personas no siempre son conscientes de ella. por el contrario, la espiritualidad resulta evidente cuando se siente la vida amenazada (2). quizá por ello se le ha dado atención al tema de la espiritualidad en personas que tienen afecciones crónicas de salud, en especial en aquellas condiciones que generan discapacidad y requieren de un proceso integral de rehabilitación rht (3-5). en algunos estudios adelantados con personas discapacitadas se ha encontrado que las necesidades espirituales no siempre son satisfechas (6). ignorar la dimensión espiritual en el cuidado de las personas con discapacidad es como ignorar el componente biológico, el social o el psicológico. la desatención de la espiritualidad deja un vacío cuando se busca velar por la persona integralmente (7-8). sin embargo, para que la dimensión espiritual pueda ser abordada de la mejor forma, es necesario perfilar la relación entre la espiritualidad y la salud (9). el presente estudio, basado en la teoría de la salud como conciencia expandida (10), busca apoyar este proceso de esclarecimiento al revisar y comparar los niveles de bienestar espiritual en personas con y sin discapacidad. estado del arte relación entre la enfermedad crónica y la discapacidad con la espiritualidad la literatura documenta las diferentes formas en que las personas experimentan la espiritualidad y la admite como una condición universal (11-12) la vivencia de la espiritualidad varía de una persona a otra y de un momento a otro de la vida y puede tener expresiones que fluctúan entre el silencio y la exultación. a su vez, la espiritualidad puede generar bienestar o malestar en las personas. ellison, uno de los más reconocidos estudiosos del tema de la espiritualidad, define el bienestar espiritual como un sentido de armonía interna, generado a partir de la relación de una persona consigo misma, con los otros, con el orden natural y con un ser o un poder superior. según ellison, el nivel de bienestar espiritual puede ser medido a partir de la percepción de cada persona, y esta percepción se compone de dos dimensiones que interactúan de manera estrecha: una dimensión transversal o existencial (hacia sí mismo y hacia los demás) y otra vertical o religiosa (hacia dios, un ser o una fuerza superior) (13). varios investigadores documentan la relación entre la espiritualidad y la salud y entre el desarrollo de rituales y prácticas religiosas y la calidad de vida (14-16). se encuentra descrito en la literatura cómo las creencias afectan el estilo de vida (17), la dieta, el tratamiento (18), las decisiones frente al cuidado de la salud (19-20) y la percepción de ellison define el bienestar espiritual como un sentido de armonía interna, generado a partir de la relación de una persona consigo misma, con los otros, con el orden natural y con un ser o un poder superior. 11 bienestar espiritual en personas con y sin discapacidad beatriz sánchez-herrera la situación de enfermedad (21). algunos estudiosos asocian la espiritualidad con comportamientos saludables (22). otros documentan las manifestaciones particulares de la espiritualidad en sus dimensiones religiosa o existencial en las personas con enfermedad crónica o cercanía de la muerte (23-24). dentro de los estudios de espiritualidad en situaciones crónicas de enfermedad con discapacidad, se destacan los que enfatizan la espiritualidad como una forma de manejar las dolencias (25), como un ancla en medio de la dificultad (26), como una esperanza en la cercanía de la muerte (27), como un componente fundamental para quienes tienen alteraciones genéticas (28) o endocrinas (29), problemas degenerativos (30) o limitaciones asociadas con la edad (31-33). se han desarrollado varias investigaciones en personas con dolor, cuya experiencia modifica la vida. los resultados han reflejado que la dolencia está asociada, de manera importante, con la espiritualidad y, en particular, con el comportamiento religioso (31, 34-37). de igual forma ha sucedido con aspectos que alteran la funcionalidad, como la modificación de la autoimagen (38) y la ansiedad (39-40). desde la perspectiva terapéutica, se ha estudiado el impacto de la espiritualidad en el comportamiento en situación de discapacidad y se encuentra documentación que muestra cómo los pacientes con enfermedad crónica discapacitante han podido mejorar los comportamientos o los resultados de algunos tratamientos (41), la forma como la espiritualidad influye en su adaptación (42), la asociación entre las creencias y los temores de quienes están hospitalizados (43-44), las estrategias de afrontamiento positivo (45-46),los patrones de este afrontamiento y su relación con el estrés (47-48), la asociación entre los valores y el afrontamiento (49) y el apoyo en el afrontamiento positivo del día a día (50). se ha encontrado, además, que en las situaciones de enfermedad crónica hay relación entre la espiritualidad y el soporte social (51-52). la religión se identifica como fuente de soporte social, de ayuda, de fortaleza y de esperanza en medio de situaciones de enfermedad y de discapacidad (45, 53-54). hay documentación abundante que señala que creer en dios y pedir su apoyo ayuda a muchos individuos a sobrellevar su limitación (55-58). de igual forma, se relaciona la oración con la sensación de control (57), y esta se tiene en cuenta como una forma de motivación interna (58). en este mismo sentido, varios autores han encontrado que las creencias y prácticas religiosas tienden a redimensionar el sufrimiento (59-60),disminuir el estrés (61), son fuente de autocuidado (62) y ayudan a evitar la depresión (63-65). si bien parece haber un consenso amplio entre diferentes autores al señalar que la espiritualidad puede tener utilidad para el cuidado de quienes tienen una condición de discapacidad asociada a enfermedad crónica, y que esta da elementos para permitirles afrontar mejor esa situación (66) y encontrar significado en la experiencia para aceptar, crecer o trascender (67-69), hay hallazgos ambivalentes de la utilidad de la espiritualidad en algunos trastornos mentales (70-72). también es evidente que, a pesar de haber buscado comprobar la existencia de modificaciones físicas objetivas y duraderas asociadas a las prácticas religiosas, estas no se han logrado demostrar (73-75). en resumen, la evidencia señala que cuando una persona, sea o no creyente, confronta la enfermedad o la discapacidentro de los estudios de espiritualidad en situaciones crónicas de enfermedad con discapacidad, se destacan los que enfatizan la espiritualidad como una forma de manejar las dolencias, como un ancla en medio de la dificultad. 12 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 dad, tiende a sentir vacío y falta de control sobre su vida. el uso de estrategias de afrontamiento espiritual y, en particular, religioso puede ayudarla. dimensión espiritual del cuidado en situaciones de discapacidad la enfermería como disciplina profesional ha aceptado desde su inicio que el componente espiritual hace parte de la mirada integral que se debe dar al ser humano (76-77), sin embargo, al revisar la documentación referente a este tema a lo largo de la historia, no hay verdadera claridad en cómo hacer operativo este concepto teórico (35, 78). en el campo del cuidado del enfermo crónico y en particular de quien tiene limitación o discapacidad, los profesionales del cuidado de la salud aceptan el valor terapéutico de la espiritualidad (79-81), pero varios de ellos continúan definiendo cómo, cuándo, dónde y qué hacer para fortalecerla (7), mientras otros estudiosos del tema hacen cuestionamientos éticos que surgen de la aplicación de estos avances (82). como se vio en el aparte anterior, puede afirmarse, con base en la evidencia, que al confrontar situaciones estresantes, como la discapacidad, el afrontamiento espiritual ayuda a que el individuo se empodere, y esto le permite encontrar significado y propósito y lo lleva a lograr un sentido de totalidad personal. es decir, las situaciones de enfermedad o discapacidad pueden llegar a ser una oportunidad de encuentro íntimo y una ocasión de crecimiento. no obstante, la naturaleza misma de estas situaciones y todo lo que ellas imponen a la persona no siempre generan un sentido de armonía interna (bienestar espiritual) que la ayude a sobrellevarlas mejor. el cuidado holístico debe, por tanto, reconocer los niveles de bienestar espiritual y, con base en ello, facilitar estrategias de afrontamiento religioso y/o existencial para salvaguardar la totalidad e integridad de las personas con discapacidad, como parte de su calidad de vida. la descripción del bienestar espiritual en individuos que viven con discapacidad es un elemento fundamental del cuidado de la salud que hace explícito el reconocimiento del significado de la trascendencia humana. no se conocen estudios de esta naturaleza en el país y son pocos los que la enfermería reporta de la literatura universal. ninguno de ellos se fundamenta en la teoría de la salud como conciencia expandida. esta experiencia, basada en la comprensión de la salud como una manera de expansión de la conciencia, lleva a algunas personas a dar una nueva mirada al ser y a la realidad y les suministra una forma más plena de estar en el mundo y mayor introspección, entendimiento, empatía y tolerancia con los otros (83). la descripción y comparación del bienestar espiritual de personas con y sin discapacidad aporta al trabajo de cuidado de enfermería en el país y, sin duda, fortalece la respuesta de cuidado holístico que día tras día es la búsqueda de quienes trabajan con personas discapacitadas y sus cuidadores familiares y profesionales. materiales y métodos el presente estudio tuvo un diseño cuantitativo de tipo descriptivo comparativo. su muestra fue intencional y la constituyeron 86 personas mayores de 18 años, divididas en dos grupos. uno de 43 pacientes con discapacidad, tratados en el servicio de rht de la clínica universitaria teletón de bogotá, que pudieran comunicarse con el entrevistador y estuvieran dispuestos a participar en el estudio. su entrevista tomó en promedio 40 minutos. el otro también estuvo conformado por 43 personas, vinculadas a la universidad sergio arboleda, con las mismas características sociodemográficas del anterior y la voluntad de participar. su entrevista tomó en promedio 35 minutos. las entrevistas fueron realizadas por la investigadora con el apoyo de dos auxiliares de investigación entrenados para tal fin. en todos los casos, se acompañó al participante en la investigación y se permitió que quienes quisieran y pudieran diligenciar su encuesta lo hicieran por sí mismos. el instrumento empleado para la recolección de la información fue la escala de bienestar espiritual de ellison®. esta tiene 20 ítems con graduación de tipo likert, con respuestas de 1 a 6, que van de total desacuerdo al total acuerdo. la encuesta se compone de dos subescalas: una que mide la dimensión existencial del bienestar espiritual y otra que mide su dimensión religiosa. en tal sentido, la investigación presenta tres resultados: bienestar espiritual total, dimensión religiosa y dimensión existencial del bienestar espiritual. la escala de bienestar espiritual de ellison® ha sido empleada por su autor en poblaciones de diferentes culturas y traducida y validada en diferentes idiomas, incluidas la comunidad latina y el idioma español. su coeficiente de confiabilidad es de 0,93 (bienestar espiritual), 0,96 (bienestar religioso) y 0,86 (bienestar existen13 bienestar espiritual en personas con y sin discapacidad beatriz sánchez-herrera cial). la consistencia interna se evaluó utilizando el coeficiente alfa, dando 0,89 (bienestar espiritual), 0,87 (bienestar religioso) y 0,78 (bienestar existencial) (13). los datos, una vez diligenciadas las encuestas, se incorporaron a una matriz creada en microsoft excel y se procesaron en el software estadístico minitab versión 14.0. el análisis de la información se hizo con base en las instrucciones de ellison para la administración del instrumento. a partir de ello, se generaron estadísticas descriptivas de las características demográficas de los grupos, utilizando frecuencias absolutas, y se conocieron los porcentajes, promedios, desviaciones estándar, valores mínimo y máximo del bienestar espiritual total y de cada una de sus dimensiones en los dos grupos. por último, se compararon los niveles de bienestar espiritual. las hipótesis planteadas sobre la diferencia en los niveles de bienestar espiritual entre los grupos estudiados, o la no diferencia entre ellos (hipótesis nula), fueron verificadas con un nivel de confianza del 95% (valor de p menor o igual a 0,5). las pruebas de comparación de grupos se realizaron a través de métodos estadísticos, con el empleo de la prueba t. los hallazgos se organizaron según las instrucciones de ellison en categorías alta, media o baja de bienestar espiritual. el estudio consideró los aspectos éticos referentes al costo-beneficio, el consentimiento informado, la participación voluntaria, el manejo confidencial de la información, la autorización de las instituciones y la del autor del instrumento, a quien se le pagaron los derechos por cada una de las encuestas aplicadas. en todos los casos, se ofreció información adicional sobre el cuidado de las personas con discapacidad, se remitió a la consulta de enfermería a quien así lo requería y se respondieron exhaustivamente las preguntas de los entrevistados o sus familias. la investigación es un producto académico de la línea de estudio de cuidado al paciente crónico y su familia, que desde 1996 tiene la facultad de enfermería, de la universidad nacional de colombia. el trabajo es parte de un grupo de seis estudios sobre el bienestar espiritual de personas en situación de enfermedad crónica, que iniciaron en 2003 y finalizaron en 2008. expertos han calificado el estudio con cero impacto ambiental, por cuanto no genera ningún tipo de contaminación. resultados a continuación se presentan los resultados, incluida la descripción de las características de los grupos de estudio y la del bienestar espiritual general y por componentes. así mismo, se presenta la comparación entre los niveles de bienestar espiritual de los grupos. todos los datos son analizados en el subtítulo “discusión”. características de las personas con y sin discapacidad personas con discapacidad el grupo de personas con discapacidad se componía de 41,86% de hombres y 58,14% de mujeres. en 51,16% de los casos, sus edades fluctuaron entre 18 y 35 años; en 44,19%, entre 36 y 65; y con más de 66 años el 4,65%. la edad promedio fue de 39,4 años. el nivel educativo fue: de universidad completa, el 30,23%; estudiantes universitarios, el 13,95%; técnicos, el 18,60%; con bachillerato comlas hipótesis planteadas sobre la diferencia en los niveles de bienestar espiritual entre los grupos estudiados, fueron verificadas con un nivel de confianza del 95%. 14 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 pleto, el 20,93% bachillerato incompleto, el 9,30%; primaria completa, el 4,65%; y primaria incompleta, el 2,33%. el tiempo de evolución de la situación de enfermedad fue de 18 meses o menos para el 60,46%, y de 19 a 36 meses para el 23,26%. el 16,28% no precisó su tiempo de evolución. sus diagnósticos médicos se asociaban a un trauma o lesión en el 83,72% y a una patología de carácter degenerativo en el 16,28%. personas sin discapacidad el grupo de personas sin discapacidad, por ser homólogo, presentó características idénticas al anterior en edad y sexo. el nivel educativo fue de universidad completa en el 18,60%; estudiantes universitarios, el 18,60%; técnicos, el 13,95%; con bachillerato completo, el 27,91%; bachillerato incompleto, el 6,98%; primaria completa, el 11,63%; y primaria incompleta, el 2,33%. niveles de bienestar espiritual en cuanto al nivel de bienestar espiritual general, los valores de la escala daban opciones en un rango de 20 a 120, siendo considerados niveles bajos los inferiores a 53,3; medios los de 53,4 a 86,6; y altos los de 86,7 a 120. los hallazgos de los dos grupos se presentan en la tabla 1. en la dimensión religiosa del bienestar espiritual, los valores posibles fluctuaban entre 10 y 60, siendo considerados bajos los valores inferiores a tabla 1. bienestar espiritual general en las personas con y sin discapacidad resultados personas personas con discapacidad sin discapacidad valores máximos 120 120 valores mínimos 58 76 media de bienestar espiritual general 101,98 100,84 mediana del bienestar espiritual general 108 99 desviación estándar bienestar espiritual general 15,76 12,31 número de la muestra 43 43 fuente: datos del estudio. 26,6; medios entre 26,7 y 43,3; y altos de 43,4 a 60. los hallazgos de los dos grupos valorados se presentan en la tabla 2. tabla 2. dimensión religiosa del bienestar espiritual en las personas con y sin discapacidad resultados personas personas con discapacidad sin discapacidad valores máximos 60 60 valores mínimos 24 30 media sumatoria de la dimensión religiosa 53,65 52,53 mediana del bienestar en la dimensión religiosa 58 56 desviación estándar de la dimensión religiosa 8,76 7,99 número de la muestra 43 43 fuente: datos del estudio. en cuanto al nivel de bienestar espiritual general, los valores de la escala daban opciones en un rango de 20 a 120, siendo considerados niveles bajos los inferiores a 53,3. 15 bienestar espiritual en personas con y sin discapacidad beatriz sánchez-herrera en la dimensión existencial del bienestar espiritual, los valores posibles fluctuaban entre 10 y 60, considerándose bajos los valores inferiores a 26,6; medios, entre 26,7 y 43,3; y altos, de 43,4 y 60. los hallazgos de los dos grupos valorados se presentan en la tabla 3. tabla 3. dimensión existencial del bienestar espiritual en las personas con y sin discapacidad resultados personas personas con discapacidad sin discapacidad valores máximos 60 60 valores mínimos 29 31 media de sumatoria de dimensión existencial 48,33 48,30 mediana del bienestar en la dimensión existencial 50 48 desviación estándar de la dimensión existencial 8,33 7,30 fuente: datos del estudio. la comparación basada en la prueba estadística t entre los niveles de bienestar espiritual general y por dimensiones de las personas con y sin discapacidad se presenta en la tabla 4. tabla 4. comparación entre los niveles de bienestar espiritual en personas con y sin discapacidad prueba analizada valor de la diferencia nivel de confianza valor de p de medias bienestar espiritual general 0,37 95% 0,710 dimensión religiosa 0,62 95% 0,539 dimensión existencial 0,01 95% 0,989 fuente: datos del estudio. análisis y discusión la falta de estudios que ilustren o contrasten los niveles de bienestar espiritual de personas con y sin discapacidad, en el contexto colombiano o latinoamericano, impide hacer un contraste de la presente investigación con otras similares. esa situación motivó el desarrollo del presente estudio de bienestar espiritual en personas con discapacidad con un grupo homólogo, de manera que se pudiera enriquecer la información obtenida a partir de una comparación. en cuanto a las características sociodemográficas, el estudio consideró el género, la edad y la escolaridad como aspectos fundamentales en la relación con el bienestar espiritual. en cuanto al género, el grupo estudiado tiene una composición con mayoría femenina, lo cual contrasta con las cifras de mujeres con discapacidad reportadas para colombia, en donde la proporción es menor con respecto a los hombres (84). de otra parte, resulta muy llamativa la edad de las personas, si se considera que el 95,35% de ellas tienen menos de 66 años. esto ratifica que las situaciones de discapacidad en el país dejan muchos años de vida productivos perdidos, lo que representa para colombia costos sociales y económicos incalculables. las situaciones de discapacidad en el país dejan muchos años de vida productivos perdidos, lo que representa para colombia costos sociales y económicos incalculables. 16 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 puede apreciarse que, a pesar de que fue imposible la homologación exacta de la muestra por nivel educativo, se buscó que ella fuera lo más cercana posible. mientras el grupo de personas con discapacidad que cuenta con educación superior o bachillerato completo es de 83,71%, el de personas de la comunidad universitaria es paradójicamente un poco más bajo, de 79,06%. los hallazgos señalan niveles de bienestar espiritual general en la categoría alta y de sus dimensiones religiosa y existencial en la misma categoría, para ambos grupos (tablas 1-3). por otro lado, se aprecia que los niveles de bienestar espiritual de tipo religioso son mayores que los de tipo existencial (tablas 2-3), lo que refleja un mayor sentido de trascendencia vertical (de las personas hacia dios, un ser superior o una fuerza superior) que horizontal (de ellas hacia sí mismas, hacia los demás y hacia el entorno). este estudio ratifica los hallazgos de la revisión teórica, que muestran que las personas entrevistadas identifican elementos de bienestar espiritual (79) y que los mismos son medibles a través de su percepción. además, es posible que muchas personas en medio de las dificultades o de la incertidumbre hayan hecho vínculos nuevos, redimensionado los anteriores, cambiado su forma de ser y apreciado algunos aspectos de la cotidianidad que antes no tenían en cuenta (8). sin embargo, sería necesario entrar a comprobar esta observación. en el marco de la teoría de la salud como conciencia expandida, la discapacidad y la crisis podrían ser vistas como elementos positivos. aunque los datos exactos señalan cifras mayores para el nivel de bienestar espiritual general y para el de cada uno de sus componentes en el grupo en situación de discapacidad, la diferencia estadística no es significativa (tabla 4). no es posible, por tanto, ratificar en los resultados que exista una diferencia real entre los grupos. puesto que la literatura señala que la discapacidad genera un impacto en la espiritualidad y que la espiritualidad a su vez tiene efectos en la vivencia de la enfermedad, sería de esperar que la diferencia encontrada entre los grupos fuera mayor. algunos de los argumentos que podrían explicar que el estudio apoye la hipótesis nula, que estableció que no hay diferencias entre los grupos, se enuncian a continuación. en primer lugar, pudo ocurrir que el grupo de personas sin discapacidad también se sintiera amenazado y con ello su nivel de bienestar espiritual se hubiera elevado. la conciencia de un tiempo de vida más corto que se presenta con la discapacidad y la enfermedad puede precipitar la búsqueda de significado y propósito (23). en el caso particular del grupo sin discapacidad, puede existir esta misma conciencia, ya que la sociedad colombiana ha vivido en los últimos tiempos situaciones amenazantes que pueden llevar a una mayor conciencia sobre el final de la vida. los hechos violentos sucedidos en la institución universitaria de la que se tomó el grupo de comparación para el estudio permitirían pensar que este puede ser un argumento importante. otra posible explicación de no haberse encontrado la diferencia esperada en el bienestar espiritual de los grupos puede estar en que la muestra para la comparación se tomó en un plantel universitario, lo cual puede provocar un sesgo en las personas, al contestar una encuesta la conciencia de un tiempo de vida más corto que se presenta con la discapacidad y la enfermedad puede precipitar la búsqueda de significado y propósito. 17 bienestar espiritual en personas con y sin discapacidad beatriz sánchez-herrera de este tipo, por sentir que están siendo evaluadas. de ser así, es posible que los participantes den respuestas más positivas de lo esperado. puede también ser una explicación el hecho de que la mayor parte de los pacientes estudiados tenga su discapacidad en un período inferior a 18 meses y requiera de un tiempo mayor para un cambio interno significativo, explicación un poco más difícil de aceptar a la luz de la literatura disponible (55). por último, podría pensarse, aunque la teoría no respalde este planteamiento, que las situaciones de discapacidad no movilizan recursos espirituales de manera tal que generan bienestar espiritual o que el bienestar espiritual no varía con la presencia de discapacidad. no se puede olvidar que cada individuo reacciona diferente en tiempos de crisis; por tanto, puede encontrarse a sí mismo como trascendente y buscar un poder superior como dios o relacionarse de manera diferente con la naturaleza, con otros y con él mismo, en un intento por afrontar efectivamente las situaciones de estrés, mientras que otro puede experimentar falta de armonía en su mente, cuerpo y espíritu por esta situación y alejarse de un proceso de crecimiento en esa vía. es decir, una persona puede encontrar significado y propósito en su experiencia de salud (con enfermedad o sin ella) que la lleve a la construcción de cambios en la vida y la reorganización de los valores personales, y otra puede no hacerlo. podría pensarse que, de ser cierto que tanto el grupo de personas con discapacidad como el de personas sin ella se ven afectados por una situación amenazante, la espiritualidad permitiría a la persona reconstruir su identidad, disminuir el estrés y tener sentido de confianza y control en medio de la incertidumbre (9). esta afirmación respaldaría los niveles altos de bienestar espiritual que se han encontrado. es importante recordar que quienes no han consolidado sus creencias religiosas lo pueden hacer en tiempos de crisis, ya que vuelven a la religión por ayuda, como una fuente de esperanza y fortaleza, permitiendo que la experiencia de vida sea un espacio para el encuentro espiritual (22, 60). el aspecto existencial requiere mayor exploración en ambos casos, en particular, al encontrarse en niveles ligeramente más bajos que el religioso (tablas 2 y 3). conclusiones y sugerencias este estudio reconoce la importancia del bienestar espiritual en el cuidado de las personas con y sin discapacidad. para quienes viven situaciones de crisis, el bienestar espiritual puede significar un factor de crecimiento personal, un hecho trascendente que los acerca a muchas respuestas necesarias para dar sentido a la vida, a la cotidianidad, al dolor y al sufrimiento humano. crear salud en la experiencia de discapacidad demanda un foco unitario que supere la dicotomía entre salud y enfermedad, puesto que acepta que estas son la expresión de una misma dimensión que solo tiene sentido dentro de la totalidad del ser humano. por ello, el modelo conceptual de margaret newman ha sido una guía útil para trabajar la dimensión espiritual del cuidado. a la vez, esta dimensión puede ser analizada de manera coherente a través de la escala de bienestar espiritual de ellison®. el nivel de bienestar espiritual encontrado en las personas con discapacidad cada individuo reacciona diferente en tiempos de crisis; por tanto, puede encontrarse a sí mismo como trascendente y buscar un poder superior como dios o relacionarse de manera diferente con la naturaleza, con otros y con él mismo, en un intento por afrontar efectivamente las situaciones de estrés. 18 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 que asistían al servicio de rht de la clínica universitaria teletón es alto, siendo mayor en la dimensión religiosa que en la existencial. por su parte, el encontrado en las personas sin discapacidad de la universidad sergio arboleda es alto, con un mayor resultado en la dimensión religiosa que en la existencial. con base en la evidencia lograda en la aplicación de la escala de bienestar espiritual de ellison® no se puede afirmar que exista diferencia entre el nivel de bienestar espiritual entre los grupos estudiados. los resultados del presente estudio aportan conocimiento en la construcción del cuidado de las personas con y sin discapacidad, y señalan que un bienestar espiritual alto, con un mayor nivel de bienestar religioso que existencial, se puede entender como un potencial para su cuidado. si las enfermeras van a promover la salud integral de sus usuarios, entonces sus esfuerzos deben estar enfocados a la vida total de las personas, a sus aspiraciones y patrones, más que a la discapacidad. la presencia auténtica de la enfermera en la relación de cuidado con los usuarios permite asegurar la totalidad e integridad que requieren. los hallazgos de esta investigación son un paso adelante en el camino de la aplicación de los conceptos de cuidado espiritual en la práctica. conocer el nivel de bienestar espiritual permite promover la salud holística de los usuarios. la valoración del bienestar espiritual deberá ser complementada con el desarrollo de estrategias de afrontamiento espiritual para quienes así lo requieran. es necesario seguir profundizando en el estudio de la dimensión espiritual del cuidado. si la espiritualidad tiene importancia terapéutica en pacientes que experimentan crisis vitales o en quienes viven en situaciones de discapacidad, esta temática debe considerarse en investigaciones posteriores, para ser debatida dentro de los currículos de enfermería y en la asistencia, con el fin de cualificar la práctica con integración de la dimensión espiritual del cuidado en ella. el cuidado de las personas en situación de discapacidad, que puede resultar frustrante para muchos cuidadores, puede enriquecerse al considerar aspectos espirituales donde se den espacios de reconciliación con dios, un ser o fuerza superior, compañía de los demás, consideración del entorno y reflexión de la propia vida como parte fundamental de la misma. este aspecto no debe limitarse a las personas con creencias religiosas específicas. una nueva mirada al significado de la espiritualidad para quienes interactúan en la relación de cuidado permitirá facilitar su desarrollo. puesto que la dimensión espiritual del cuidado es compleja y a la vez fundamental, se sugiere trabajar en colaboración con un equipo multidisciplinario, incluyendo capellanes u otros orientadores espirituales, para satisfacer así las necesidades de las personas que sean o no creyentes. en todos los casos, el conocimiento y la reflexión de la propia espiritualidad es un camino adecuado para interactuar en el 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[sitio en internet]. disponible en: http://www.dane.gov.co/files/investigaciones/discapacidad/inform_estad.pdf. consultado: 20 de junio de 2007. meaning of breast cancer in women’s discourse article meaning of breast cancer in women's discourse significado del cáncer de mama en el discurso de las mujeres significado do câncer de mama no discurso das mulheres 10.5294/aqui.2021.21.3.8 gabrielle maciel de souza1 luciana martins da rosa2 maría angélica arzuaga-salazar3 vera radünz4 maristela jeci dos santos5 yesica rangel-flores6 1 0000-0001-7620-1034. universidade federal de santa catarina, brazil. gabrielle.souza@ufsc.br 2 0000-0002-1884-5330. universidade federal de santa catarina, brazil. luciana.m.rosa@ufsc.br 3 0000-0002-1306-2556. universidad de antioquia, colombia. maria.arzuaga@udea.edu.co 4 0000-0002-9262-8457. universidade federal de santa catarina, brazil. vera.radunz@ufsc.br 5 0000-0003-1717-3410. centro de pesquisas oncológicas, brazil. maristela.santos@cepon.org.br 6 0000-0001-5673-6891. universidad autónoma de san luis potosí, mexico. yesica.rangel@uaslp.mx received: 18/01/2021 sent to peers: 13/05/2021 approved by peers: 05/08/2021 accepted: 05/08/2021 theme: chronic care. contribution to the subject: the results of this research portray the collective discourse of women who attribute meaning to the breast cancer diagnosis; therefore, it contributes to improving the nursing approach to women who survived this disease. to reference this article / para citar este artigo / para citar este artículo: de souza gm, rosa lm, arzuaga-salazar ma, radünz v, santos mj, rangel-flores yy. meaning of breast cancer in women's discourse. aquichan. 2021;21(3):e2138. doi: https://doi.org/10.5294/aqui.2021.21.3.8 abstract objective: to reveal the meaning of breast cancer. materials and method: a narrative research study that selected, using the snowball technique, 11 women (data saturation) diagnosed with breast cancer, on disease remission, and living in the region of florianópolis (brazil). semi-structured interviews were conducted between august and december 2018, and they were subjected to the collective subject discourse technique. four central ideas emerged from the analysis of the narratives; this article presents the central ideal called "meaning of the breast cancer diagnosis", which has eight sense categories. results: the central idea covers the following categories: "suffering when facing the diagnosis", "fear of the disease and of death", "professional inability for bad news", "initiatives to streamline treatment", "concern and affection with the family members as a driving force to face cancer", "difficulties with the family members", "support from the family members, from the professionals and/or from the support group", and "faith and spirituality". conclusions: the discourse reveals that the meaning of the disease diagnosis is linked to the need for treatment, to the support provided by faith, family members, the health team, and support groups, and to the difficulties faced with family members and professionals. these results should imply the provision of specific nursing care from the diagnostic phase until after cancer remission/survival. keywords (source deos): breast neoplasms; nursing; oncology nursing; speech; women's health. resumen objetivo: revelar el significado del diagnóstico de cáncer de mama. materiales y método: investigación narrativa, que seleccionó, desde la técnica bola de nieve, 11 mujeres (saturación de los datos), con diagnóstico de cáncer de mama, en remisión de la enfermedad, habitantes de florianópolis (brasil). se aplicó la entrevista semiestructurada, entre agosto y diciembre del 2018, sometida a la técnica del discurso do sujeto colectivo. del análisis de las narrativas, emergieron cuatro ideas centrales; en el artículo, se presenta la idea central "significado del diagnóstico del cáncer de mama", que cuenta con ocho categorías de sentido. resultados: la idea central abarca las categorías "el sufrimiento ante el diagnóstico", "miedo a la enfermedad y la muerte", "inhabilidad profesional para las malas noticias", "iniciativas para agilizar el tratamiento", "preocupación y afecto con los familiares como resorte impulsador para enfrentarse al cáncer", "dificultades con los familiares", "apoyo de los familiares, de los profesionales y/o del grupo de apoyo" e "fe y espiritualidad". conclusiones: el discurso evidencia que el significado del diagnóstico de la enfermedad se vincula a la necesidad del tratamiento, al apoyo de la fe, de familiares, del equipo de salud y de grupos de apoyo, a las dificultades enfrentadas con familiares y profesionales. estos resultados deben implicar la previsión de cuidados de enfermaría específicos desde la fase diagnóstica hasta después de la remisión/sobrevivencia del cáncer. palabras clave (fuente deos): neoplasias de la mama; enfermería; enfermería oncológica; habla; discurso; salud de la mujer. resumo objetivo: revelar o significado do diagnóstico de câncer de mama. materiais e método: pesquisa narrativa, que selecionou, pela técnica bola de neve, 11 mulheres (saturação dos dados), com diagnóstico de câncer de mama, em remissão da doença, residentes na região de florianópolis (brasil). aplicou-se entrevista semiestruturada, entre agosto e dezembro de 2018, submetida à técnica do discurso do sujeito coletivo. da análise das narrativas, emergiram quatro ideias centrais; neste artigo, apresenta-se a ideia central "significado do diagnóstico de câncer de mama", que conta com oito categorias de sentido. resultados: a ideia central abrange as categorias "o sofrimento diante do diagnóstico", "medo da doença e da morte", "inabilidade profissional para as más notícias", "iniciativas para agilizar o tratamento", "preocupação e afeto com os familiares como mola impulsionadora para o enfrentamento do câncer", "dificuldades com os familiares", "apoio dos familiares, dos profissionais e/ou do grupo de apoio" e "fé e espiritualidade". conclusões: o discurso revela que o significado do diagnóstico da doença vincula-se à necessidade do tratamento, ao apoio da fé, de familiares, da equipe de saúde e de grupos de apoio, às dificuldades enfrentadas com familiares e profissionais. esses resultados devem implicar a previsão de cuidados de enfermagem específicos desde a fase diagnóstica até após a remissão/sobrevivência do câncer. palavras-chave (fonte deos): neoplasias da mama; enfermagem; enfermagem oncológica; discurso; saúde das mulheres. introduction the incidence of breast cancer alone justifies the continuous need to conduct studies on this theme. in 2020, there were nearly two million new cases worldwide, approximately 684,000 deaths, and an estimate of almost eight million prevalent cases (1). in santa catarina (brazil), the locus of this study, 3,370 new cases of breast cancer are estimated for 2021 (2). despite such high incidence and mortality values, the survival rates, mainly in the shortand long-term, have been increasing, considering early diagnosis and new treatments. this increased survival requires greater attention from oncology nursing, as fear of the disease remains in patients who survived cancer, and the diagnosis period is still a challenge for the women (3), who describe it as conflicting, stressful, and characterized by a denial of the disease (4, 5). in addition to that, several studies reveal that the disease affects emotional well-being and that there is impaired family and personal coping, as well as sexual and gynecological changes. consequently, nursing professionals must be aware of the impact caused by breast cancer in the social and family life of these women. these professionals need to understand the disease to improve the provision of care (6-8). thus, considering the magnitude of breast cancer, the predicted significant increase in the incidence rates for the next decades, the changes in the sociodemographic conditions, and the advances in diagnosis and treatment, which may change the meaning of the disease, new studies can contribute to expanding understanding on the phenomenon and to providing excellent nursing care. the starting point is the assumption that the meaning of breast cancer is full of anxieties resulting from the diagnosis, fear of the disease and death, the impossibility of working, and need to change habits (9). in this sense, there is due reason to develop this study, which aims at revealing the meaning of the breast cancer diagnosis. this study is part of a macro-project jointly developed by three universities, from brazil, colombia, and mexico, and presents data linked to brazil. materials and methods a narrative research study, conducted in the metropolitan region of florianópolis (santa catarina, brazil), a city that has an institution that is a reference for oncology treatments. the participants were women aged over 18 years old, diagnosed with breast cancer, who underwent chemotherapy in the last ten years, were on disease remission (verified by absence of the disease as reported by the women), and who may be undergoing treatment with hormone therapy. women with a new cancer diagnosis or with some family members diagnosed with cancer were excluded. the exclusion criteria were defined with ethical concern, considering the psychological issues pertinent at the time, which could influence the meaning of the disease and/or trigger emotional harm or of other types. to select the women, it was defined that the snowball technique was to be developed where, for the choice of the first woman, it was decided to present the project to the members of the gama institute (support group for mastectomized women), which has 40 active participants. the choice of this initial setting was because this group has been active for nearly 20 years and for it being representative from the social point of view. it is noted that all women in the region where the study was conducted are assisted by the public health system and treated in the setting where the support group operates. in addition to that, this group frequently welcomes women treated in the private network who seek the public health system during the hormone therapy phase due to their financial conditions. it is also worth mentioning that the profile of the group is quite heterogeneous, including women from all age groups and socioeconomic levels, as well as those who were diagnosed with cancer at different stages of the disease. after the study was presented to the aforementioned support group and the women had expressed their interest in participating in the research, it was agreed that the group coordinator would provide a list of telephone numbers for contacting the eligible women, and that the women contacted could indicate other women. the number of people included in the study (11 women) was defined by data saturation (data repetition with no addition of new information [10]), identified in the analysis phase, which was conducted simultaneously with data collection. to select the women (via telephone contacts or through whatsapp), the sequence of names in the list forwarded by the group coordinator was followed. each woman who was interviewed was asked to indicate another. in case there was no indication, a new woman from the list provided was contacted. the list provided by the group coordinator had 20 names; five women were indicated without being in this list, of which two agreed to be included in the study; consequently, nine women from the support group's list were selected, when data saturation was reached. the interviews were conducted in a private environment, chosen by the participant (in her house, in a square, or in a room of the teaching institution that proposed this study); they were recorded and transcribed and involved the presence of the interviewed participant and the researcher. the first four interviews were conducted jointly by two researchers (researcher in charge and main researcher, both with no relationship with the study participants) to standardize the approach (the interviews were conducted alternately by the researchers). the researcher in charge of this study has worked for 30 years in oncology, with clinical, teaching and research experience in the context of breast cancer. the researcher in charge of the entire data collection process was a nursing student, a voluntary scholarship holder. the interviews investigated the age and year of the breast cancer diagnosis, meaning of breast cancer, current feelings, and what each participant would like to say to another woman who was been diagnosed with breast cancer. complementary questions (could you further explain this concept?) but, how did that happen? could you tell a little more about this meaning?) were included, whenever necessary, to explore the time dimension (past experiences that influence the current reality), the social dimension (personal, social and cultural experiences that impact on narratives), and the place dimension (the environment as an influencing factor of the meanings expressed in the narratives [11]). the interviews lasted a mean of 60 minutes. to preserve the participants' anonymity, pseudonyms were adopted, which were defined by the researchers. the study's ethical appreciation is recorded under opinion no. 2,565,680. for data analysis, the collective subject discourse (csd) was applied, conducted by two researchers. csd is a method that retrieves the social representation by reconstituting an empirical collective entity, in the form of a discourse produced in the first person singular, as if a collective group speaking through an individual. it consists of different key expressions from the individual speeches, grouped into collective sense categories (stage for coding the narratives) and which make up the central ideas. the key expressions are excerpts from the narratives which must be highlighted by the researcher and reveal the essence of the discourse content. the sense categories gather social-cognitive schemes that portray the socially shared ways of knowing or representing and interacting with the world and with everyday life, and which reveal possible awareness of these actors at a given historical moment. the central idea is the linguistic expression that reveals, describes and designates a homogeneous set of key expressions/sense categories. as collective statements, discourse translates how the social representations are perceived/ felt by a given society, a group or a culture (12, 13). the csds were elaborated using the dscsoft software (14, 15); and the presentation sequence of the key expressions and sense categories that comprise the csd was conducted by the researchers. the entire analysis process was performed by a researcher and subsequently reviewed by a second researcher. any divergences were discussed and agreed upon. four central ideas emerged from the analysis, namely: "meaning of the breast cancer diagnosis"; "finding out about breast cancer"; "current feelings"; and "advice to women with breast cancer"; 21 sense categories were related to the central ideas, which represented a significant information volume. given the above, this article was chosen to present the csd related to the central idea called "meaning of the breast cancer diagnosis". semi-structured interviews were conducted for data collection, between august and december 2018. the participants signed the free and informed consent form. after the analysis, all of the research findings were presented to the gamma institute, during a meeting of the group of women. results the 11 participants were aged between 43 and 72 years old; of this total, eight belonged to the age group between 40 and 59 years old. the time since the diagnoses ranged between two and 11 years; and most of the women (six) were diagnosed with breast cancer at least five years ago. the treatments indicated for disease control encompassed four therapeutic sequences: four women required surgery, chemotherapy, radiation therapy and hormone therapy; four required surgery, chemotherapy and hormone therapy; two required surgery, chemotherapy and hormone therapy; and one required surgery, chemotherapy and radiation therapy. the csd related to the central idea called "meaning of the breast cancer diagnosis" emerged from eight sense categories, according to what is presented below. central idea: meaning of breast cancer and collective subject discourse "suffering when facing the diagnosis" category it was horrible. (maria); in the diagnosis phase [...] i could not but cry. (lilian); when i went to the clinic to fetch the result, i opened the envelope and saw it, i went there alone, in my car... i didn't see the traffic lights, i didn't see anything. i was crying when i got home. (maria); when i read, i read carcinoma, carcinoma is cancer, how can i say i don't have anything? i didn't believe it. i thought that it wasn't happening to me. (nina); i felt helpless. (linda); my emotions were hidden behind the carpet. it was the worst experience in my entire life. a shock, the greatest i've ever had. because i didn't understand what cancer was. (eva); and there's also that distress of having to tell the family. i remember going out of "x" [treatment unit], sitting on the sidewalk, and calling my brother-in-law. the entire family already knew that i was going to the doctor i said: "it's confirmed. [...] tell mother and father." (ana); all that takes some time. i was sad, frustrated, it's quite complicated. (linda) "fear of the disease and of death" category real fear, i felt at the diagnosis. i was very afraid. (lilian); the breast cancer diagnosis, [...] that of cancer, is quite linked to death. (ana); in emotional terms, it was a surprise to me. i thought that i was going to die. (lena); i thought: "i'm going to die.'' (eli); you get scared. (lena); although i can't believe it yet. the first thing you think is: how much time do i have left? [...]. because, when you go there and the doctor tells you that you have cancer, you want to know at what stage it is. so, all the tests are made to map where it is. that's terrifying. it was the worst phase of my life. you can be the most well-structured person, the happiest person in the world, but it's a surprise, you think about death. because you have an incurable disease, which has no cure.(lilian) "professional inability for bad news" category i worked many years taking care of people. you notice when the doctor or the nurse are afraid, you perceive it in the air. (alice); then, what the doctor told me: "you have cancer.. like this, closer than we are now. she said: " you'll lose one or both breasts.. i mean, she was so straightforward that she ended up frightening me. [...] my head could not digest the first word, what to say about the second. [...] when she told me: " what you have is cancer, for me, it was as if she had said: "here's your death sentence.. i think that if she had spoken more calmly i wouldn't have been so afraid. (eva) "initiatives to streamline treatment" category i cried, i yelled, and i told her [the doctor]: "ok, explain everything to me. where should i go? what should i do?' i started to be practical, i went there right away. i had to see a mastologist, i saw him that same day. i had to do a biopsy and i went after it right away. then i shaved and donated my hair [...] i wanted a solution. let's be practical now. i cried, cried, cried, let's be practical now... (nina); i did everything alone. i paid some money to get the results in two days. [...] my head needed a solution. (selina) "concern and affection with the family members as a driving force to face cancer" category i have two children. [...] at that moment, i only thought of them. i said: "dear god, what will become of those two? who's going to take care of them if i die?' i started wondering. i'll have to leave them with my brother, because my mother is already dead, my father had come to live with me too, he didn't know about my situation, he also died shortly after that. i thought "i'll have to leave them with someone.. my family gave me a lot of strength. my brother, my neighbors too. (lena); my 10-year-old daughter... i told her: "darling, it's like this... if you want to cry you can cry." then she said: "i'm not going to cry mum.. and i said: "really? you don't feel like crying?' she said: "no. first, because i trust in god's strength and also because i trust in the doctors who will start treating you now. and i also trust in your strength.. then it was me who cried. (ana) "difficulties with the family members" category i went out [referring to the day when she fetched the biopsy report] and sat on the sidewalk. soon after that, a lady came out of the blue and said: is everything all right with you? and i said: "i've just been diagnosed with cancer and she said: "girl, this happened to me' [...] the first thing, be prepared, because your family will go crazy and will drive you crazy. at the beginning, the family gets sick together with you. [...] i cried when nobody could see me, my daughter cried when nobody could see her, my husband cried when nobody could see him. because i wanted to show strength at the beginning, and strong i was. so, physically strong, emotionally strong, but always terribly afraid. (ana); my husband kept on denying it. [...] my brother never came to visit me. i think he'd only come if i was dying. and my father came before the chemo, when i did the chemo, he said that he lacked the courage to come see me.[...] and i felt alone. (aline); people have this mania: "ah, i won't visit so-and-so because i lack the courage to see her. funny isn't it? then they have courage enough to attend her funeral. (linda) "support from the family members, from the professionals and/or from the support group" category i had support from my family. (lena); i think this was also one of the things that made me feel strong at all times. i tried to look at her [daughter] every day and say: "no, she's not going to be alone." so, after that, the entire process was pretty cool. (ana); it was my kids that went to the doctors. (maria); what gave me much support was our group [referring to the support group for women with breast cancer in which she participates]. you go to a group like this, where the coordinator of the support group for mastectomized women is wonderful, she's like a mother to us. (lena); i went to the group during the treatment. [...] it gives you a lot of strength. i went and didn't like it. but i kept going. because i thought that, if all those women were there and they liked it, it was me who was wrong. there was something wrong with me. but at that time of the disease i didn't have the ability and insight to see. [...] then i was able to understand that they had already gone through the treatment phase, but i got a sense of that only after i finished my treatment. and now i'm there and i'm happy too. [...] i participate in activities for mastectomized women there. [...] i even went to the health center, where i received more help [referring to the support received after the first appointments in the private network]. (linda); my oncologist said: "50 % of the treatment will be yours and 50 %, mine. i will guarantee my share. i'm going to prepare a special formula for you. you're going to be ok. as far as it depends on me, you're going to be fine. but the other 50 % is yours." (lilian) "faith and spirituality" category i think that i got better only thanks to my faith, because i never lost hope. (lilian); it's an exercise of determination, faith and hope all the time. (ana); i clung to god and said: "i'm going to be ok."(lena); when i found out [...] i went to [...] the spiritist center. (selina); it is this faith that we cling to, to these complementary treatments. (ana); i underwent the spiritual surgery [...] before the physical. [...] when i went to the physical surgery i was sure that everything was already ok. (selina); thanks to our lady i discovered the power of prayer. (lilian); i believe that, at this moment, it's important that you trust in the doctors, but you know that something between heaven and earth can help you too. (ana) discussion the most incidental age groups in this study with a qualitative approach are similar to those of the epidemiological studies. the international agency for research on cancer states that, in 2018, of all the women who were diagnosed with cancer, 46 % were aged between 40 and 59 years old (1). concerning the treatment modalities reported by the women, the indications were varied. all these modalities are widely indicated and knowingly related to several side effects and to other treatment consequences, such as physical and psychological changes, which can be permanent and/or transient. these changes exert a significant impact on self-esteem, confidence, and sexual and social life (16-18). due attention from professionals, friends and relatives contributes to reducing the negative impacts resulting from breast cancer, in addition to constituting a support network that gives women strength to face cancer. some family compositions were revealed as stressors or even as a source of concern, because women know that their premature death or their living with disabilities can also change family life. in this context, it was revealed that the meanings of breast cancer found in the csds and that portray the social representation of the breast cancer diagnosis are strongly influenced by experiences before the disease and by the environment where the women are inserted, with emphasis on the family environment and on the health care provided since the diagnostic phase. suffering due to the breast cancer diagnosis was reported by most of the women; therefore, it is inferred that, despite the scientific advances, the pain resulting from this diagnosis is still highlighted as a time of anguish and fear, insecurity about the immediate and future life, with the possibility of leading to depression in some cases. several studies point out that the main feelings arising from the cancer diagnosis involve fear, tension, depression, anger and denial; thus, this study corroborates these findings. conversely, other studies point to women's resilience in facing cancer and to the need for complementary studies on depression, considering the incipient scientific production (3, 19-22). however, in this context of distress, willingness to fight against the disease and to live emerges, and streamlining tests and health appointments is shown to be a support mechanism. consequently, women consider the moment when the diagnosis is revealed as one of the most difficult and traumatic periods of their lives. this aspect requires professional skill because how the diagnosis and/or prognosis is explained remains in women's memory, who continuously remember it. thus, effective communication during the diagnostic process collaborates with reducing the psychological harms (3, 19, 20). it is inferred that the meaning of death revealed is not only associated with breast cancer but also with all malignant neoplasms because, even today, late diagnoses are common, thus favoring premature deaths. in this context, the relevance of nursing consultations is reinforced, from the diagnostic phase, as an opportune moment to demystify the disease and its prognosis and to empower women in cancer survival, based on new experiences and overcomings. faith and spirituality were highlighted as strategies to face the disease diagnosis, mitigating and promoting resilience and coping with unexpected situations. from this perspective, the approach involving religiosity/spirituality becomes essential in oncology care (4). in addition to that, the need to encourage good family relationships and care with the family members is reinforced, to strengthen women with breast cancer (5). regarding the care provided by the health team and the support groups, their prominent role was evident in the csds. interaction with women who overcame cancer or are undergoing treatment and verbalizing their stories in the support groups favor the development of coping strategies (22, 24). about the professionals' inability revealed by the csd, it is argued that its origin is multifactorial, with emphasis on the complex care context, high care demand and insufficient training. in this scenario, there is a combination of humanization and dehumanization, with a close pain-suffering-pleasure interface in the workplace and in how people live and may exist in the life and workspheres (25). however, those requiring care have the need and the right to humanized care, despite any other adversity associated with the work world. regarding the time dimension (11), the csds highlight the value of small things, which start to exert an impact on the present time and on the desire of the future time to be lived. in the social dimension, the impacts caused by the breast cancer diagnosis in the different spheres (personal, family, social) and on health care itself stood out. it thus became evident that the cancer diagnosis exerts a negative impact on the relationships with the professionals, contributing as sources of social feelings due to the inability of most of them. in opposition, the welcoming relationship among women themselves and with support groups and specialized professionals, associated with faith/religiosity/spirituality, mitigates the impacts of the disease. in the place dimension, the moment/place where the diagnosis was discovered represents a dreadful environment characterized by helplessness, loneliness and sadness, which is compounded by the concerns about who will protect her children in case of premature death, where they will stay and who will take care of them. conclusions the results of this research reveal a discourse full of diversities in experiences, concerns and life priorities in facing the disease, with a significant impact on the lives of women with breast cancer. some women reveal negative feelings such as suffering, fear, difficulties with the family and/or professional inability, whereas others link the period with other feelings, such as faith and spirituality, support from the family members, the health team and the support groups, as well as initiatives to start the treatment. finally, the limitation of this study consists in the inclusion of women without considering cancer staging, which can change the social representation of the phenomenon. in turn, developing nursing care practices based on the meanings of the disease will contribute to reducing physical and psychological harms to which these women are exposed in breast cancer survival. consequently, it is recommended that these practices are investigated in future qualitative and/or quantitative research projects. the assumption presented in the introduction of this article is replicated in the csd found. this reasserts the results published by other authors, which assist in presenting the object of this research and in discussing the findings. in addition to that, at the end of this study, the initial assumption and the meaning are expanded, as there is the addition of the social representations related to the difficulties and concerns with the family members, treatment streamlining and the professionals' inability. conflict of interests: none declared. references 1. ferlay j, ervik m, lam f, colobet m, mery l, pineros m et al. glocal câncer observatory: cancer today. lyon/france; 2020. available from: https://gco.iarc.fr/today 2. instituto nacional de câncer josé alencar gomes da silva. estimativa 2020: incidência de câncer no brasil. rio de janeiro: inca; 2019. disponível em: https://www.inca.gov.br/ sites/ufu.sti.inca.local/files//media/document//estimativa-2020-incidencia-de-cancer-no-brasil.pdf 3. alvares rb, santos idl, lima nm, mattias sr, cestari mew, gomes ncrc et al. sentimentos despertados nas mulheres frente ao diagnóstico de câncer de mama. j nurs health. 2017;7(3):1-10. doi:https://doi.org/10.15210/jonah.v7i3.12639 4. machado mx, soares da, oliveira sb. meanings of breast cancer for women under going 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significado do câncer de mama na percepção da mulher: do sintoma ao tratamento. rev enferm uerj. 2012;20(4):445-50. 10. nascimento lcn, souza tv, oliveira ics, moraes jrmm, aguiar rcb, silva lf. theoretical saturation in qualitative research: an experience report in interview with school children. rev bras enferm. 2018;71(1):228-33. doi:https://doi.org/10.1590/0034-7167-2016-0616 11. clandinin dj. engaging in narrative inquiry. walnutcreek, ca: leftcoastpress, inc.; 2013. 12. figueiredo mz, chiari bm, de goulart bng. discurso do sujeito coletivo: uma breve introdução à ferramenta de pesquisa qualiquantitativa. disturb comun. 2013;25(1):129-36. 13. lefevre f, lefevre amc. discourse of the collective subject: social representations and communicate on interventions. texto & contexto enfermagem. 2014;23(2):502-7. doi: https://doi.org/10.1590/0104-07072014000000014 14. nicolau kw, escalda pmf, furlan pg. método do discurso do sujeito coletivo e usabilidade dos softwares qualiquanti-soft e dscsoft na pesquisa qualiquantitativa em saúde. fronteiras: journal of social, technological and environmental science. 2015;4(3):87-101. doi: https://doi.org/10.21664/2238-8869.2015v4i3.p87-101 15. tolteca informática. dscsoft [internet]. são paulo: tolteca informática; 2020. disponível em: http://www.tolteca.com.br/noticiadscsoft.aspx 16. cordeiro lam, nogueira da, gradim cvc. women with breast cancer in adjuvant chemotherapy: assessment of quality of life. rev enferm uerj. 2018;26:1-7. doi: https://doi.org/10.12957/reuerj.2018.17948 17. rodrigues ns, orsani mrca, tertuliano iw, bartholomeu d, machado aa, montiel jm. o impacto da mastectomia na sexualidade da mulher. educ.fis.deporte. 2018;23(242). disponível em: https://www.efdeportes.com/efdeportes/index.php/efdeportes/article/download/63/228?inline=1 18. sehati shafaee f, mirghafourvand m, harischi s, esfahani a, amirzehni j. self-confidence and quality of life in women undergoing treatment for breast cancer. asian pac j cancer prev. 2018;19(3):733-40. doi: https://doi.org/10.22034/apjcp.2018.19.3.733 19. otani map, barros nf, marin mjs, pinto aam. comunicação entre profissional de saúde e paciente: percepções de mulheres com câncer de mama. nursing (são paulo). 2018; 21(242):2272-6. disponível em: http://www.revistanursing.com.br/revistas/242-julho2018/comunicacao_entre_profissional_saude.pdf 20. ribeiro gs, campos cs, anjos acy. spirituality and religion as resources for confronting breast cancer. rev pesqui. 2019;11(4):849-56. doi: https://doi.org/10.9789/2175-5361.2019.v11i4.849-856 21. torre xa. factores asociados a depresión en pacientes con cáncer de mama. revfacmed hum (on-line). 2019;19(1):1-5. doi: https://doi.org/10.25176/rfmh.v19.n1.1795 22. pilevarzadeh m, amirshahi m, afsargharehbagh r, rafiemanesh h, hashemi sm, balouchi a. global prevalence of depression among breast cancer patients: a systematic review and meta-analysis. breast cancer research and treatment. 2019;176(3):519-33. doi: https://doi.org/10.1007/s10549-019-05271-3 23. santos ma, souza c. group interventions for women with breast cancer: challenges and possibilities. psicol teor pes-qui. 2019;35:1-14. doi: https://doi.org/10.1590/0102.3772e35410 24. dvaladze a, kizub da, cabanes a, nakigudde g, aguilar b, zujewski ja, duggan c, anderson bo, pritam singh rk, gralow jr. breast cancer patient advocacy: a qualitative study of the challenges and opportunities for civil society organizations in low-income and middle-income countries. cancer 2020;15(10):2439-47. doi: https://doi.org/10.1002/cncr.32852 25. santos, serafim barbosa. alienação no trabalho médico no enfoque da humanização-desumanização. cad saude publica. 2018;34(12):e00152118. doi: https://doi.org/10.1590/0102-311x00152118 home 01 07 primeras paginas.indd 4 aquichan issn 1657-5997 editorial algunos de los temas que más preocupan hoy en día a los profesionales de enfermería son la visibilidad y el reconocimiento social de la profesión, y esto, a mi modo de ver, se debe a la brecha que existe entre el desarrollo disciplinar y el ejercicio de la práctica profesional. desde el punto de vista disciplinar, el interés por la investigación y por demostrar la contribución de la enfermería en la recuperación de la salud de las personas se remonta a finales del siglo xviii, cuando florence nightingale, pionera de la enfermería moderna, evidenció con datos estadísticos los efectos del cuidado del ambiente en la recuperación de los soldados heridos en combate y escribió el primer libro, notas sobre enfermería, donde estableció su perspectiva de la disciplina como una actividad diferente de la medicina (1). aunque el interés por la investigación se mantuvo durante la primera mitad del siglo xx, con el estudio de casos para estandarizar la práctica, fue hasta la década de los cincuenta que surgió la necesidad de publicar los avances en investigación y la preocupación por definir la esencia de la enfermería. es así como en 1952 se publica la primera revista de investigación en enfermería, nursing research, y se plantean los primeros modelos conceptuales y teorías, en los cuales se identifica el cuidado como el fenómeno de interés de la disciplina (2). el desarrollo del conocimiento a partir de ese momento ha sido significativo, y esto se evidencia en el número y variedad de las publicaciones reconocidas e indexadas por su calidad científica, las cuales constituyen el medio de comunicación válido, que divulga los avances científicos de la disciplina (3). ahora bien, por ser la enfermería una disciplina profesional cuya razón de ser es la práctica, el desarrollo teórico e investigativo será representativo si es reconocido y tiene un impacto en el ejercicio profesional. la aplicación de los modelos y teorías es fundamental, porque dan al profesional una perspectiva particular y única de la práctica, tienen gran trascendencia en la manera como las enfermeras interactúan con los pacientes, y afectan la naturaleza de las intervenciones que realizan (4). según villalobos, la aplicación de la teoría favorece la comprensión de los fenómenos de la práctica y permite analizar procesos intangibles que influyen en los resultados del quehacer profesional (5). de tal manera que, en la medida que los profesionales de enfermería tengan mayor claridad sobre su contribución a la recuperación de la salud de las personas, tendrán mayor autonomía y reconocimiento social (6). los profesionales de enfermería son conscientes de la necesidad de fundamentar la práctica en el conocimiento propio. por ello se ha incrementado la producción y el consumo de literatura científica sobre aspectos esenciales del cuidado (7). para los editores de año 9 vol. 9 nº 1 chía, colombia abril 2009 4-5 5 editorial publicaciones científicas esta demanda constituye un reto, puesto que exigen un mayor rigor en los procesos de selección y evaluación de la calidad científica de los artículos, una publicación oportuna y pronta de los productos y generar las estrategias necesarias para facilitar el acceso a esta información. por nuestra parte, dadas las demandas de publicación y lectura que la revista aquichan muestra en la actualidad, a partir de este número circulará cuatrimestralmente, en abril, agosto y diciembre. de esta manera, la facultad de enfermería y rehabilitación de la universidad de la sabana ratifica su compromiso con el desarrollo teórico e investigativo de la disciplina. maría elisa moreno-fergusson editora divulgar el conocimiento de enfermería: una prioridad referencias 1. parker marylin e. nursing theories & nursing practice. 2 ed. philadelphia: f.a. davis; 2006. p. 39-57. 2. meleis afaf ibrahim. theoretical nursing, development & progress. 4 ed. philadelphia: lippincott williams & wilkins; 2007. p. 78-108 3. o’neill ann l, duffey margery a. communication of research and practice knowledge in nursing literature. nursing research 2000 july/aug; 49(4): 224-30. 4. fawcett jacqueline. contemporary nursing knowledge. analysis and evaluation of nursing models and theories. philadelphia: f.a. davis, 2005. 623 p. 5. durán de villalobos maría mercedes. enfermería. desarrollo teórico e investigativo. bogotá: unibiblos; 1998. p. 111-8. 6. fawcett jacqueline. guest editorial: on bed baths and conceptual models of nursing. adv nurs; 2003. 44(3): 229-30. 7. oermann marilyn h, et al. dissemination of research in clinical nursing journals, journal of clinical nursing, 17(2): 149-56. 8 aquichan issn 1657-5997 maría teresa quintero 1 margarita gómez 2 el cuidado de enfermería significa ayuda 1 especialista en rehabilitación en enfermería. magíster en educación y desarrollo humano. grupo de investigación de emergencias y desastres. docente, facultad de enfermería universidad de antioquia. mquintero@tone.udea.edu.co 2 magíster en salud colectiva, grupo de investigación gipecs. docente facultad de enfermería y de comunicación, universidad de antioquia. jotagebe@comunicaciones.udea.edu.co el presente artículo es producto de la investigación: el significado del cuidado de enfermería para el paciente con trauma, medellín 2006-2008 recibido: 8 de noviembre de 2008 reenviado: 26 de septiembre de 2009 aceptado: 29 de marzo de 2010 resumen objetivos: comprender el significado del cuidado de enfermería para los pacientes que han sufrido un trauma. método: metodología cualitativa, con enfoque en la etnografía particularista, aplicable a cualquier unidad social o grupo humano aislable. los datos se recogieron entre marzo de 2006 y diciembre de 2007, se entrevistaron 15 personas adultas que estuvieron hospitalizadas después de padecer un trauma. el estudio concluyó en noviembre de 2008. resultados: el cuidado de enfermería significó ayuda orientada hacia la satisfacción de las necesidades físicas y de tratamiento de los pacientes, además de compañía, esperanza, comprensión y seguridad. entendiéndose esta última como la garantía de calidad en el cuidado y la tranquilidad de ser atendidos directamente por el profesional de enfermería. conclusión: los participantes en este estudio reconocen y describen paso a paso el cuidado de enfermería como interacciones que se dan entre ellos y la profesional que les ayuda en la ejecución de las actividades que contribuyen al mantenimiento o recuperación de su salud, justifica mantener las metas de enfermería. dado que el cuidado por parte del profesional de enfermería da seguridad, se recomienda iniciar un trabajo activo con el fin de que éstos retomen el cuidado directo de los pacientes en las salas de hospitalización y se incentiven estudios que lleven a evidenciar el costo-beneficio al prestar un servicio con estas características. palabras clave cuidado de enfermería, ayuda, seguridad (fuente: decs, bireme). nursing care means help abstract objectives: to understand what nursing care means to trauma patients. method: qualitative, with a focus on particularistic ethnography, applicable to any social unit or human group that can be isolated. data collection was done between march 2006 and december 2007, and 15 adults who were hospitalized after suffering trauma were interviewed. the study was completed in november 2008. results: nursing care means help aimed at satisfying the physical and treatment needs of patients, as well as their need for companionship, hope, understanding and a sense of security. the latter is understood as a guarantee of quality care and the peace of mind that comes with being cared for directly by a nursing professional. conclusion: having found that the patients in the study acknowledge nursing care and describe it step-by-step as interaction between themselves and the professional who assists them in carrying out activities that help to preserve or restore their health, justifies maintaining the goals of nursing. inasmuch as the care provided by a professional nurse affords a sense of security, it is recommended that an active effort be made to have nurses resume caring for patients directly in hospital wards. it also is suggested that studies be encouraged to show the cost-benefit to be derived from service with these characteristics. key words nursing care, help, safety (source: decs, bireme). año 10 vol. 10 nº 1 chía, colombia abril 2010 l 8-18 9 el cuidado de enfermería significa ayuda l maría teresa quintero, margarita gómez o cuidado de enfermagem é ajuda resumo objetivos: compreender o significado do cuidado de enfermagem para pacientes que sofreram trauma. método: a metodologia qualitativa, com abordagem na etnografia particularista, aplicável a qualquer unidade social ou grupo isolável de pessoas. os dados foram coletados entre março de 2006 e dezembro de 2007; se entrevistaram 15 adultos hospitalizados depois de sofrer um trauma. o estudo concluiu em novembro de 2008. resultados: os cuidados de enfermagem implicaram ajuda orientada para a satisfação das necessidades físicas e tratamento dos pacientes, além de companhia, esperança, compreensão e segurança. esta última é entendida como a garantia de qualidade no cuidado e a tranqüilidade de receber atendimento diretamente da enfermeira. conclusão: os participantes neste estudo reconhecem e descrevem passo a passo os cuidados de enfermagem como as interações que ocorrem entre eles e os profissionais que os ajudam na realização de atividades que contribuem para a manutenção ou recuperação da sua saúde. estes achados são razões para manter metas de enfermagem. já que o cuidado da enfermeira dá segurança, é recomendável iniciar o trabalho ativo, a fim de eles retomar o atendimento direto de pacientes nas enfermarias do hospital e incentivar os estudos que demonstram o custo-benefício de prestar um serviço com estas características. palavras-chave cuidados de enfermagem, assistência, segurança (fonte: decs, bireme). 10 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 introducción en colombia, las elevadas cifras de morbilidad y mortalidad por traumatismos, que ocasionan anualmente hasta el 41% de los años de vida saludables perdidos por discapacidades (1), afectan en especial al grupo laboral y económicamente activo comprendido entre los 15 y 45 años de edad. según el informe de situación de salud en medellín (2) –indicadores básicos de 2004–, la mortalidad por accidentes de tránsito en la población de 15-44 años fue de 166 casos, para una tasa de 35,56%. en el 2006, el traumatismo fue la primera causa de consulta en los servicios de urgencias (3). el trauma se produce cuando el cuerpo recibe un impacto que altera las funciones propias de los órganos que resultan lesionados, y que a su vez desencadena respuestas orgánicas para proteger los sistemas vitales, respuestas que a veces no funcionan o son insuficientes, y donde el paciente sufre cambios desde leves hasta severos en su homeostasia. la persona politraumatizada sufre intranquilidad y confusión por las circunstancias, el medio desconocido y el temor hacia la muerte, la mutilación, inmovilización u otras alteraciones de su identidad e integridad corporales, que puedan sobrevenir como efectos del trauma (1). el paciente traumatizado experimenta un cambio inesperado en su vida que, además de afectar su capacidad funcional y de autocuidado, lo sitúa en un escenario donde encuentra personas desconocidas para él, como médicos, enfermeras y el personal de apoyo que labora en el hospital. cualquier alteración en la salud que limite o interrumpa las acciones de autocuidado hace visible la urgencia de satisfacer dichas acciones, y el retraso en la atención de alguna de estas, producto del cambio, puede adquirir significados insospechados (4). así pues, bajo estas circunstancias se hace indispensable el cuidado de enfermería, cuya función es ayudar al individuo sano o enfermo a la realización de aquellas actividades que contribuyan con su salud o su recuperación. el cuidado implica un compromiso por parte del personal de enfermería, que los pacientes perciben en fenómenos relacionados con la asistencia, el manejo de tecnología, la capacidad para prevenir complicaciones, las conductas de apoyo y las actitudes dirigidas a dignificar a otros en su condición humana y a proporcionar su crecimiento integral (4). el presente estudio, en el que participaron personas que sufrieron accidentes de tránsito, de trabajo o agresiones físicas con armas de fuego o corto punzantes —las principales causas de trauma en la ciudad de medellín—, evidenció el sentimiento de seguridad que les proporciona a los pacientes politraumatizados el cuidado directo brindado por el profesional de enfermería. en las revisiones bibliográficas realizadas no se encontraron trabajos llevados a cabo en colombia que hayan estudiado el significado del cuidado de enfermería para pacientes traumatizados, por esto, los hallazgos aquí presentados obligan a pensar que el cuidado directo sea brindado por los profesionales de enfermería. el cuidado implica un compromiso por parte del personal de enfermería, que los pacientes perciben en fenómenos relacionados con la asistencia, el manejo de tecnología, la capacidad para prevenir complicaciones, las conductas de apoyo y las actitudes dirigidas a dignificar a otros en su condición humana y a proporcionar su crecimiento integral. 11 el cuidado de enfermería significa ayuda l maría teresa quintero, margarita gómez metodología desde la perspectiva de la investigación cualitativa, se busca comprender el significado del cuidado en las personas que han sufrido un trauma, a partir de sus vivencias y experiencias. se trabajó con un enfoque etnográfico que permite describir y analizar los procesos culturales dentro de un contexto determinado; en este caso se tomaron elementos de la etnografía particularista, que aplica el enfoque etnográfico y holístico a cualquier unidad social o grupo humano aislable (5). se incluyeron 15 pacientes adultos, cuyo ingreso a la unidad hospitalaria fue causado por trauma, y que estuvieron hospitalizados por más de 24 horas. los pacientes eran amigos o familiares de integrantes de la comunidad de la facultad de enfermería de la universidad de antioquia (medellín, colombia), a quienes se informó acerca del estudio y, después de solicitarles su participación voluntaria, se tomaron sus datos personales para visitarlos posteriormente. no hubo una meta definida de pacientes para entrevistar, se llegó a este punto cuando las entrevistas no produjeron ninguna comprensión auténticamente nueva (6). la técnica de recolección de información fue la entrevista a profundidad, que permitió que el participante expresara con sus propias palabras todas las experiencias referentes al cuidado de enfermería recibido; en ningún caso la entrevista se excedió de una hora, y siempre se realizó considerando el estado de salud del paciente. las entrevistas se grabaron en audio y luego fueron transcritas con el fin de garantizar el contenido de toda la información expresada. a partir de la transcripción se determinaron los códigos y las categorías de análisis, y se tomaron los textos significativos. las primeras cinco entrevistas del total de participantes sirvieron para un análisis preliminar y el inicio de la codificación, para luego proceder con los ajustes necesarios de las siguientes entrevistas. una lectura inicial permitió conocer lo descrito en forma general, y luego su lectura en detalle reveló hechos, temas y eventos significativos para el área estudiada. el objetivo del estudio fue comprender el significado del cuidado de enfermería para los pacientes participantes a partir del análisis temático, el cual implica la reflexión sobre los temas esenciales que caracterizan al fenómeno, y las descripciones e interpretaciones del mismo. para ello fue necesario identificar temas y desarrollar conceptos a partir de lecturas repetidas que permitieran la comprensión. siempre se volvió sobre los datos, con el objeto de profundizar más y poder, entonces, proceder a la clasificación por temas o categorías, extraídas de los enunciados significativos; en este caso, se buscaron aquellas palabras o frases que emplearon los pacientes para describir lo que para ellos significó ser cuidados por el personal de enfermería. dado que categorizar es agrupar datos que componen significados similares y clasificar la información por categorías de acuerdo con criterios temáticos referidos a la búsqueda de significados (7), a los datos se les buscaron semejanzas o relaciones entre sí, y con ellos se elaboraron conceptos que ayudaron a interpretarlos. desde la perspectiva de la investigación cualitativa, se busca comprender el significado del cuidado en las personas que han sufrido un trauma, a partir de sus vivencias y experiencias. 12 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 como la investigación cualitativa pretende comprender los fenómenos desde la perspectiva de los participantes, la calidad de la investigación está dada por la posibilidad de captar con más fidelidad sus propias percepciones y conceptos. por tanto, como criterios de calidad para el presente estudio se consideraron los siguientes aspectos: la guía de entrevista se diseñó de tal forma que partiera de lo general a lo específico, dejando los temas que pudieran causar dificultades para cuando el entrevistado hubiera tenido confianza en el entrevistador. se evitó plantear preguntas con carga emocional o que convirtieran la entrevista en un interrogatorio. los datos se revisaron de manera sistemática, manteniendo el enfoque, monitoreando la interpretación y confirmándola constantemente (8). los hallazgos parciales se presentaron en tres oportunidades a los pares académicos del grupo de investigación de emergencias y desastres de la facultad de enfermería de la universidad de antioquia. más tarde, para verificar que los participantes se identificaran con lo encontrado, se presentó a algunos de ellos el resultado final. considerando el respeto como uno de los principios fundamentales de la ética, el presente estudio mantuvo el anonimato de las personas, por lo que se les notificó que toda la información sería manejada en forma confidencial y que sus nombres no aparecerían en ningún lugar; así, los datos se analizaron en forma global, y cuando alguna información mereció precisarse, se hizo de manera impersonal. igualmente, no se utilizó ningún tipo de presión directa o indirecta para lograr la participación de los pacientes, a cada uno de los cuales se les explicó con claridad el propósito del estudio y se les solicitó permiso para grabar las entrevistas, haciéndoles saber que su objetivo era evitar que se perdiera alguna información; además, se les informó que no había respuestas correctas o incorrectas. a todos se les leyó el consentimiento informado, aprobado por comité de ética de la facultad de enfermería de la universidad de antioquia, pero ninguno lo firmó, pues no lo consideraron necesario. resultados la experiencia de haber sufrido un trauma los participantes en este estudio señalaron que haber sufrido un trauma fue algo “inesperado, horrible y duro”, que los dejó sin explicación y siempre los llevó a preguntarse por qué les había sucedido a ellos, pues sufrirlo trajo consigo no poderse valer por ellos mismos, incapacidad, alejamiento del trabajo, gastos imprevistos e inestabilidad familiar. […] hubo momentos en los que yo decía: ¿por qué a mí?, ¿qué paso?, ¿yo qué hice? yo quiero estar con mis amigos, quiero estar en mi universidad, en mi gimnasio, quiero estar bailando; yo sentía esos viernes y sábados eternos (e12, p. 65). eso fue muy duro, pues, eso no se lo esperaba nadie de la familia mía (e11, p. 53). para beltrán (9), la enfermedad trae consigo el sufrimiento debido a que genera dolor, alteraciones físicas y psicológicas, la proximidad de la muerte y desesperanza. el sufrimiento varía en intensidad, duración y profundidad, así que cada persona lo vive a su manera, dependiendo de la valoración que se otorgue a la experiencia. haber sufrido un trauma fue descrito por los participantes como una experiencia dolorosa que se incrementaba con el transcurrir del tiempo, concomitante con el miedo a quedar inválido. sentí que no podía respirar y sentí un dolor inmenso y lo primero que dije fue: ‘me dañé la vida’, lo primero que pensé: “me quedé inválida…”, eso fue lo primero que se me vino a la mente (e12, p. 61). también, sufrir un trauma significó la experiencia de estar cerca de la muerte; pensar que se iban a morir ellos lo describen como algo “tremendo”; les dio tristeza saber que de pronto iban a faltar sin saber por qué, no creían ser merecedores de la muerte y pensaban que aún tenían algo por hacer. pues al verme así como estaba, pensaba era en mi familia, qué iba a ser de mi familia, si yo, o sea, si me pasaba algo grave (e13, p. 68). esta experiencia también significó una prueba divina que dios les puso para demostrar su amor y su camino, a fin de aprender nuevas cosas e incluso para remediar algo en lo que pudieron haber fallado. yo pensé: de pronto eso puede ser una lección que dios le quiere dar a uno, porque puede haber algo en lo que uno haya fallado o esté fallando y eso le puede servir de escarmiento para mejorar (e8, p. 41). 13 el cuidado de enfermería significa ayuda l maría teresa quintero, margarita gómez el cuidado de enfermería significó ayuda para wiedenbach (10), una necesidad es cualquier cosa que una persona requiera para mantener su bienestar o la plena capacidad en su situación. para travelbee (11), una necesidad de enfermera es cualquier requisito por parte de una persona enferma que aquella pueda cubrir. cuando una persona tiene una necesidad y no está en condiciones de satisfacerla por ella misma requiere la ayuda de otra persona, en este caso la enfermera, que cuenta con los recursos necesarios para lograr esa satisfacción. para henderson (12), la función única de una enfermera es ayudar al individuo sano o enfermo en la realización de aquellas actividades que contribuyen a su salud o a su recuperación, o a una muerte tranquila. este estudio reveló que para los pacientes que han padecido un trauma y que estuvieron hospitalizados, el cuidado de enfermería significó ayuda; recibir la ayuda que necesitaban en todo momento para realizar las actividades que ellos no podían hacer por su discapacidad: en el baño, en el cambio de la cama, en los cambios de posición, con la alimentación, cuando necesitaban que les hicieran la curación, con la administración de los medicamentos, aplicándoles los analgésicos, y tomándoles las muestras para los exámenes de laboratorio. […] muy pendientes de todo…, todo lo que uno necesitaba, de la droga, de los horarios, de cualquier dolor, pues, que uno tuviera cualquier necesidad, el baño… (e9, p. 46). la ayuda llegó en la mayoría de las ocasiones sin tener que pedirla porque el personal de enfermería estaba en todo momento pendiente de sus necesidades, se involucraban con ellos y su trato fue humano. […] yo creo que la enfermería no es de medicamentos, la enfermería es un acompañamiento, porque si no todo es “embutámosle las pastillas” y eso no es. es un acompañamiento que se hace a una persona que está enferma, es más difícil manejar la enfermedad del alma que la enfermedad física (e4, p. 17). para que el cuidado signifique ayuda los pacientes, además de la compensación física, debían recibir compañía, ánimo, esperanza, consuelo y seguridad del personal de enfermería en los momentos en que sintieran soledad, tristeza, incertidumbre, angustia, dolor. […] ellas al verme llorando a veces sacaban tiempo de su espacio y llegaban y se iban a hablar con uno y se iban a animarlo o sea, ahí me sentía cuidado, ahí me sentía que tenía una persona al lado (e5, p. 23). una que era muy querida me cogió la mano, me dijo: “tranquila que si le duele me aprieta” (e12, p. 64). esta forma de brindar cuidado genera familiaridad y confianza en el ámbito hospitalario, y ha sido reconocida por benner, según balansa (13), cuando afirma que la práctica de enfermería permite establecer una relación curativa con el paciente, donde se crea un clima que favorece y consolida su recuperación. “eso es lo que yo sentía con ella, sentía tranquilidad, hay personas que tienen eso… como ese carisma, como ese sentido de madre” (e7, p. 37). el cuidado es una interacción entre el cuidador y la persona que lo requiere; cuando una persona tiene una necesidad y no está en condiciones de satisfacerla por ella misma requiere la ayuda de otra persona, en este caso la enfermera, que cuenta con los recursos necesarios para lograr esa satisfacción. 14 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 algunos participantes expresaron que se hacían amigos del personal de enfermería como estrategia para obtener cuidado. “si vos tratás bien a una enfermera ella te va a querer y te va a correr más” (e3, p. 9). bermejo (14) se refiere a la relación de ayuda “como el modo de ayudar en el que, quien ayuda usa especialmente recursos relacionales para acompañar a otro a salir de una situación problemática, a vivirla lo más sanamente posible, sino tiene salida, o a recorrer un camino de crecimiento”. para los pacientes entrevistados el auxiliar de enfermería es quien brinda el cuidado directo, los asiste en el baño, les da los medicamentos, les cambia el suero, les hace los cambios de posición; en otras palabras, vela para que en todo momento estén cómodos. la profesional o jefe de enfermería es la principal, es quien tiene la responsabilidad del cuidado de todos los pacientes, de que todo el servicio funcione bien, recibe el turno y hace una ronda para ver cómo están los pacientes y conocer sus necesidades: les revisa las heridas, les pregunta por los medicamentos, planea el cuidado y los anima para seguir adelante; ella es la que designa las tareas al personal auxiliar, las supervisa, intercede por los pacientes cuando ellos lo necesitan, además a ella se le ponen las quejas de las faltas que cometen las auxiliares. la enfermera jefe es como la principal, pues la principal, la que se encarga de hacer todos los trámites de los enfermos, de pasar todos los datos, y es la que se mantiene siempre en la recepción, ella ordena tal cosa, así es la responsable, es como la cabeza de todas (e2, p. 3). cuando cambiaban de turno siempre eran: “¿cómo amaneciste?”, “¿cómo pasaste la noche?”, “¿cómo te sentís hoy?”, “¿estás de buen ánimo?” (e7, p. 38). algunos pacientes expresaron que durante la hospitalización, cuando necesitaron ayuda, se sintieron más seguros con el cuidado brindado por la enfermera jefe, porque ella les daba educación mientras llevaba a cabo los procedimientos; los escuchaba y animaba, generándoles confianza y esperanza para una pronta recuperación de su salud. a mí la jefe me hizo la curación y ahí es cuando más me sentía bien, porque ella sabía, como ella tenía conocimiento de todo y ella antes le explicaba a las auxiliares, entonces yo dije: estoy con la más dura acá, que me la haga ella (e3, p. 5). es importante referirse a las esperanzas que la enfermera transmite a los pacientes hospitalizados después de padecer un trauma porque, aunque su situación sea muy crítica, la persona tendrá la ilusión de salir para valerse por sí misma, rehacer su vida, reunirse con su familia, retomar el trabajo, es decir, lograr su independencia. smith-storne y lynn frost (15) dicen que la esperanza permite a los pacientes tener la energía para avanzar, por más limitado que sea su futuro; le permite actuar según sus deseos personales y restablecer o mejorar sus relaciones. entonces ella me decía que me tranquilizara, que no me desesperara, que pensara mucho en mi niño, porque ella sabía que yo tenía un niño y entonces eso me ayudó mucho, porque realmente eso me calmó mucho y a pesar pues, de que ese día sí estaba muy mal (e5, p. 25). para travelbee (16) la urgencia, el deseo que tiene la enfermera para aliviar la el cuidado es una interacción entre el cuidador y la persona que lo requiere; algunos participantes expresaron que se hacían amigos del personal de enfermería como estrategia para obtener cuidado. 15 el cuidado de enfermería significa ayuda l maría teresa quintero, margarita gómez angustia, el dolor del paciente son características de la simpatía; mientras que en el presente estudio este afán por dar el cuidado en forma oportuna, por aliviar el dolor, significó que para ser auxiliar o profesional de enfermería se tiene que tener vocación, entendiéndose ésta como la capacidad que tienen las enfermeras de hacer todas las cosas con amor, con gusto, en algunos casos con sacrificio. los participantes afirman que la enfermería es una labor social, porque ellas tienen una misión: “que el enfermo salga adelante”. […] uno siente como la calidad humana de la persona, uno siente como que ella se esmera de uno porque le nace, ahí es donde nace una vocación; eso es lo que sentí yo allá (e3, p. 8). mientras que otros participantes percibieron la relación con la enfermera jefe como muy lejana y poco significativa: “[…] había una muy seca, que era pues, no más venía, miraba… ta ta ta y chao, listo” (e6, p. 33). en el estudio también se encontró que los pacientes reconocieron que durante la hospitalización fueron ayudados por sus familiares, pues estuvieron pendientes de ellos en todo momento. mi mamá era la que me tenía que ayudar, entonces que va a dar del cuerpo, entonces y le traigo el pato, entonces era mi mamá la que me colaboraba (e7, p. 36). algunos participantes del estudio reconocieron que recibieron ayuda de otros pacientes, además del personal de enfermería y de la familia. […] entonces, yo con ganas de ir al baño, entonces la que estaba al lado mío, una muchacha de 25 años con una herida abierta abdominal, era la que me ayudaba a ir al baño (e4, p. 7). después del alta una vez superada la vulnerabilidad, los pacientes expresan que haber vivido esta situación les permitió comprender el valor que tiene el amor y la cercanía de los otros para la vida, la necesidad de cuidarse y cuidar de los demás en situaciones de riesgo, mientras que otros se siguen preguntado: ¿por qué a mí? las personas que han sufrido un trauma reconocieron que la experiencia fue una oportunidad para sentir el afecto y el acompañamiento de familiares, amigos o del personal de salud. después del alta, los pacientes en muchos casos buscaron establecer relaciones de amistad con el personal de enfermería cuando recibieron su apoyo. […] imagínate que en el momento en que salí las enfermeras me llamaban a la casa y todo y tuve una relación muy buena con ellas, y después pasaron cosas y nos volvimos pues amigos y yo voy y nos hablamos (e3, p. 8). de todas formas la vida es muy chévere y es bueno vivirla, pero saberla vivir de un modo bien bueno y saber que vos tenés mucha gente a tu lado que te quiere (e8, p. 44). para algunos participantes, haber sido vulnerados en su integridad de una forma sorpresiva les enseñó a cuidarse y aprendieron a alertarse ante situaciones riesgosas, lo que los hace cuidarse y cuidar a los demás. […] quedé como muy con el sustico, me voy en la buseta todos los días y soy… los participantes afirman que la enfermería es una labor social, porque ellas tienen una misión: “que el enfermo salga adelante”. 16 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 que no maneje muy rápido el señor, y quedé como con cierto miedito y por eso trato de cuidar mucho a mis amigos (e12, p. 64). cuando el trauma deja huellas, las personas suelen preguntarse por qué les pasó a ellas: […] yo llevo cuatro años y yo todavía me pregunto por qué, por qué me pasó eso a mí… pues no, no sé… yo me quedé con un problema para toda la vida, entonces me da muy duro (e12, p. 64). discusión los participantes percibieron que el compendio del cuidado se presenta en la satisfacción de sus necesidades físicas y de tratamiento, y de sus necesidades de compañía, esperanza, comprensión y seguridad, y que los pacientes referenciaron con la frase: “la enfermería es una labor social que tiene una misión de que el enfermo salga adelante”, confirmando que la meta fundamental de la enfermera es comprender la necesidad de cuidado que tiene una persona y brindarle ayuda. esta meta de la enfermería ha sido reconocida por gómez y jiménez (17) cuando afirman que la enfermera apoya al paciente por medio de actitudes y acciones que muestran interés por su bienestar y su aceptación como persona, no meramente como un ser mecánico, y por wiedenbach (18) cuando define que el objetivo de la enfermería clínica con sus actuaciones es lograr el bien del paciente. además, por beltrán (19) quien afirma que apoyo significa en enfermería dar ánimo, ayudar a los pacientes y estar pendientes de ellos; por balanza (13) que en su investigación: “el significado del cuidado de enfermería en la perspectiva del paciente adulto hospitalizado” define el cuidado de enfermería como ánimo, buen trato, amor y atención, y por mejía (20) cuando en su estudio: “percepción del cuidado de enfermería para el paciente en estado de cronicidad” describe que el cuidado se da con el buen trato y este a su vez se fortalece con la oportunidad que tienen los pacientes de expresar sus sentimientos tanto de ánimo y esperanza así como de desánimo y desesperanza. otra de las afirmaciones hechas por los pacientes en el presente estudio es el reconocimiento y la diferenciación que hacen del personal de enfermería cuando señalan que la auxiliar les brinda una atención permanente para satisfacer sus necesidades de autocuidado, y que la enfermera jefe es la encargada de garantizar la calidad en el cuidado. el cuidado del profesional de enfermería significa seguridad para los pacientes con trauma porque estos manifestaron sentir tranquilidad al ser atendidos directamente por él, pues sienten que el cuidado que reciben de ellos es garantía de calidad; además, calman la ansiedad y el temor que genera su nuevo estado de salud. rigol y ugalde (21) afirman que la seguridad tiene dos significados: el primero hace referencia al estado de armonía interna y externa, y que en enfermería se reconoce como una meta lograr la homeostasis de los pacientes, y el segundo es poseer la sensación de tranquilidad, ser capaz de disfrutar con los demás, mantener adecuada interacción con el entorno y buscar ser comprendido, apreciado, amado, lo que en el presente estudio se evidenció cuando los participantes afirmaron “me dio ánimo, me dio confianza. yo sentía que no estaba sola, que tenía a alguien allí. yo pienso que la tarea de una los participantes percibieron que el compendio del cuidado se presenta en la satisfacción de sus necesidades físicas y de tratamiento. 17 el cuidado de enfermería significa ayuda l maría teresa quintero, margarita gómez enfermera no es la inyección y canalizarle la vena sino que ellas se deben portar como la mamá” (e7, p. 37). el cuidado del profesional de enfermería, como seguridad para los pacientes, ha sido también reconocido por marcos y jiménez (22) en su proyecto de interrelación “cuidado al paciente nefrostomizado”. el cuidado del profesional significó el incremento de la satisfacción y aumento de la calidad asistencial percibida tanto por el paciente como por los profesionales, y la disminución en la estancia media hospitalaria, lo mismo que en el tiempo de reingreso al hospital. needleman y cols. (23) encontraron además que el cuidado del profesional redujo entre un 3 y un 12% la incidencia de eventos adversos como infección urinaria, neumonías, shock, hemorragias y otros, es por esto que se afirma la necesidad de realizar estudios en nuestro medio para conocer el costo-beneficio del cuidado directo brindado por el profesional de enfermería. conclusiones el reconocimiento que hacen los pacientes con trauma del cuidado como ayuda evidencia que, además de la compensación física, por parte del profesional de enfermería deben recibir compañía, ánimo, esperanza, consuelo y seguridad del personal de enfermería en los momentos de soledad, tristeza, incertidumbre, angustia, dolor, es decir, que deben recibir un cuidado humanizado. esto abre las puertas, por una parte, al inicio de un trabajo activo para que el cuidado en las salas de hospitalización sea brindado por profesionales de enfermería y, de otro lado, al incentivo de estudios que evidencien el costo-beneficio de prestar un servicio con estas características. referencias bibliográficas 1. gonzales l. cuidado de enfermería a pacientes politraumatizados en su etapa inicial. guía de enfermería basada en evidencia científica. bogotá: acofaen, 1998. p. 8. 2. alcaldía de medellín. secretaría de salud. situación de salud en medellín. indicadores 2005. 3. plan municipal de salud 2008-2011. disponible en http://www.asivamosensalud.org/descargas/plan_ municipal_salud_medellin_74_2.ppt.pdf [fecha de consulta: 23 de agosto de 2008]. 4. cuervo nr. relación entre la percepción de los comportamientos de cuidado de los pacientes y el personal de enfermería. actualización en enfermería 1999: 2 (3): 11, 16. 5. boyle j. estilos de etnografía. en: morse j. asuntos críticos en los métodos de investigación cualitativa. medellín: editorial universidad de antioquia; 2003. pp. 186187. 6. taylor js, bogman r. introducción a los métodos cualitativos de investigación. barcelona: paidos; 1992. p. 108. 7. galeano me. diseño de proyectos en investigación cualitativa. medellín: fondo editorial universidad eafit; 2003. p. 38. 8. morse jm, barrer m, mayan m, olso k, spiers j. verification strategies for establishing reliability and validity in qualitative research. international journal of cualitative methods; 2002. p. 242. 9. beltrán o. la práctica de enfermería en cuidado intensivo. aquichan 2008; 8 (1): 50-63. 10. wiedenbach e. clinical nursing: a helping art. new york: springer publishing; 1964. 11. travelbee j. interpersonal aspec of nursing. 2 edition. philadelphia: f. a. davis; 1971. 12. henderson v. the nature of nursing. 2 edition. philadelphia: f. a. davis; 1971. 13. balanza g. el significado del cuidado de enfermería en la perspectiva del paciente adulto hospitalizado. cienc enferm 1997; 3 (1): 55-68. 14. bermejo jc (ed.). salir de la noche por una enfermería humanizada. santander bilbao: salterrae; 1999. p. 69. 15. smith-stoner m, lynn frost a. cómo desarrollar la capacidad de transmitir esperanza. nursing 2000; 18 (4): 22-24. 16. travelbee j. interpersonal aspec of nursing. philadelphia: davis company; 1966. p. 145. 18 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 17. gómez g, jiménez a. cuidadores de enfermos. enfermería en anestesia, reanimación terapia de dolor. reportaje. disponible en http://www.aseedartd.org/pdfs/09-11.pdf [fecha de consulta: 26 de agosto de 2008]. 18. marriner a. modelos y teorías de la enfermería. 5 edición. barcelona: editorial trial edide; 2003. p. 86. 19. beltrán o. significado de la experiencia de estar críticamente enfermo en uci. udea cyvertesis 2007; 214: 81. 20. mejía me. significado del cuidado de enfermería para el paciente en estado de cronicidad (tesis maestría en enfermería). medellín: universidad de antioquia. facultad de enfermería; 2008. 21. rigol a, ugalde m. enfermería de salud mental y psiquiatría. 2 edición. madrid: editorial esevier masson; 2003. pp. 49-51. 22. marcos a, jiménez l. proyecto de interrelación “cuidado al paciente nefrostomizado. trabajo presentado en el congreso nacional de interrelación en enfermería en alicante, noviembre de 1998. disponible en http://www.a14.san.gua.es/hos/enfer/ inter/html. 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[fecha de consulta: 27 de septiembre de 2008]. 1 emilce salamanca-ramos1 zulma johana velasco páez2 nelson baquero álvarez3 health status of the elderly in life centers* 1 orcid.org/0000-0002-3549-7067. universidad de los llanos, colombia. esalamanca@unillanos.edu.co 2 orcid.org/0000-0003-1728-5631. universidad de universidad de los llanos. colombia. zvelasco@unillanos.edu.co 3 orcid.org/0000-0001-6434-9250. universidad de los llanos. colombia. nbaquero@unillanos.edu.co * the study is part of the research macro-project titled “social, demographic, and health characterization of the elderly from four municipalities from the piedmont zone of meta”, approved by universidad de los llanos, colombia. received: 21/01/2019 delivered to peers: 25/01/2019 accepted by peers: 07/02/2019 approved: 06/03/2019 doi: 10.5294/aqui.2019.19.2.3 para citar este artículo / to cite this article / para citar este artigo salamanca-ramos e, velasco zj, baquero b. health status of the elderly in life centers. aquichan 2019; 19(2): e1923. doi: 10.5294/aqui.2019.19.2.3 abstract objective: to identify the sociodemographic and health characteristics of the elderly in the life center programs in four municipalities of the department of meta, colombia. materials and methods: descriptive study with quantitative variables, non-probabilistic design with selection of units by discretionary sampling, in a sample of 819 older adults. a cognitive evaluation was carried out, along with depression scale, basic activities of daily living, evaluation of gait and balance, index for the instrumental activity of daily living, and comorbidity index. results: the multiple correspondence analysis indicates independent men with absence of non-depressive comorbidity and null risk of falls. in turn, women (profile: without studies, widowed) do have comorbidity, cognitive impairment, dependence, and greater fall risk. conclusions: it is fundamental to work on strengthening the formation of professionals, community agents, caregivers of older adults, as well as in the development of programs for health promotion that foster active aging. keywords (source: decs) elderly; risk factors; mental health; geriatric; aging; life centers. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1923 theme of the article: promotion and prevention. contribution to the discipline: the research results permitted enhancing nursing formation, by establishing lines for in-depth studies in the comprehensive care of the elderly in institutional and home environments. the objective is to promote care and selfcare according to individual, family, and social needs to strengthen active aging and implement policy. nursing professionals, from the primary health care consultation, and from geriatric nursing, identify elements of nursing action in caring for the elderly, starting from knowledge of the sociodemographic conditions and of the social and functional health of this population. the research will permit nursing professionals to design strategies and interventions according to the needs appertaining to this age group, which contribute to the wellbeing of social and health conditions, improving functionality levels, social and family integration, broadening support networks, coordinating routes of comprehensive health care and awareness and orientation to the authorities in charge of executing the country’s public policy on aging, in search of satisfactory and active longevity. this study highlights the permanent willingness of the elderly in wanting to participate in the investigation. research is recommended with greater coverage of the health conditions of the elderly in the region of meta, colombia. http://orcid.org/0000-0002-3549-7067 http://orcid.org/0000-0003-1728-5631 http://orcid.org/0000-0001-6434-9250 http://dx.doi.org/10.5294/aqui.2019.19.2.3 https://orcid.org/0000-0002-3549-7067 https://orcid.org/0000-0003-1728-5631 https://orcid.org/0000-0001-6434-9250 http://dx.doi.org/10.5294/aqui.2019.19.2.3 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1923 estado de salud de los adultos mayores de los centros vida* resumen objetivo: identificar las características sociodemográficas y de salud del adulto mayor en los programas de los centros vida de cuatro municipios del departamento del meta, colombia. materiales y métodos: estudio descriptivo con variables cuantitativas, diseño no probabilístico con selección de unidades por muestreo discrecional, en una muestra de 819 adultos mayores. se realizó valoración cognitiva, escala de depresión, actividades básicas de la vida diaria, valoración de la marcha y el equilibrio, índice para la actividad instrumental de la vida diaria e índice de comorbilidad. resultados: el análisis de correspondencia múltiple indica hombres con ausencia de comorbilidad no depresiva, independientes y con riesgo nulo de caídas. por su parte, las mujeres (perfil: sin estudios, viudas) sí presentan comorbilidad, deterioro cognitivo, dependencia y un mayor riesgo de caídas. conclusiones: es fundamental trabajar en el fortalecimiento de la formación de profesionales, agentes comunitarios y cuidadores de adultos mayores, así como en el desarrollo de programas de promoción de la salud que fomenten un envejecimiento activo. palabras clave (fuente: decs) adulto mayor; factores de riesgo; salud mental; geriatría; envejecimiento; centros vida. * el estudio hace parte del macroproyecto de investigación titulado “caracterización social, demográfica y de salud del adulto mayor de cuatro municipios del piedemonte del meta”, aprobado por la universidad de los llanos, colombia. 3 health status of the elderly in life centers l emilce salamanca-ramos and others estado de saúde dos idosos dos centros vida* resumo objetivo: identificar as características sociodemográficas e de saúde de idosos nos programas dos centros vida de quatro municípios do estado do meta, colômbia. materiais e método: estudo descritivo com variáveis quantitativas, desenho não probabilístico com seleção de unidades por amostragem arbitrária, com 819 idosos. foram realizados avaliação cognitiva, escala de depressão, atividades básicas da vida diária, avaliação da marcha e do equilíbrio, índice para a atividade instrumental da vida diária e índice de comorbilidade. resultados: a análise de correspondência múltipla indica homens com ausência de comorbilidade não depressiva, independentes e com risco nulo de queda. por sua vez, as mulheres (perfil: sem estudos, viúva) apresentam comorbilidade, deterioração cognitiva, dependência e maior risco de queda. conclusões: é fundamental trabalhar no fortalecimento da formação de profissionais, agentes comunitários e cuidadores de idosos, bem como no desenvolvimento de programas de promoção da saúde que proporcionem um envelhecimento ativo. palavras-chave (fonte: decs) idoso; fatores de risco; saúde mental; geriatria; envelhecimento; centros vida. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1923 * este estudo faz parte do macroprojeto de pesquisa intitulado “caracterização social, demográfica e de saúde do idoso de quatro municípios do sopé do meta”, aprovado pela universidad de los llanos, colômbia. 4 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1923 aquichan issn 1657-5997 eissn 2027-5374 introduction in latin america, aging generates much interest in society — and for public policy, particularly—, due to the high rate therein for this process compared with other regions of the world. according to estimates by the world health organization (who) (1), between 2015 and 2050, the proportion of the global population > 60 years of age will go from 12 % to 22 %, consequential of progress in medicine and in birth control, which has required important social changes in the regions. for latin america, according to the pan american health organization (2), “life expectancy at 60 years of age has been calculated at 21 years; 81 % of the people born in the region will live to 60 years of age, while 42 % of them will exceed 80 years of age”. in colombia, by 2050, life expectancy will be at 79 years of age, and individuals > 60 years of age will quintuple and exceed those < 15 years of age (3). the study adds that by 2020 it is expected that the percentage of people > 59 years of age will be around 12.64 %, until reaching 23.12 % in 2050 (3). the impact of aging lies on the morbidity burden, health service care, and reduced wellbeing. investigations suggest that the elderly have a positive self-perception of their health when they have no chronic diseases and need no help (4) for their mobility. that independence expression and economic self-sufficiency provide them a sense of wellbeing and fulfillment during their old age, while it is a health indicator of the functional state (5). nevertheless, mobility limitations in the elderly have high prevalence and incidence, and studies have shown an association among those limitations and nutritional, functional, and social factors (6). in latin america, especially in colombia, conditions for the elderly are not very promising. according to the paho (2), the prevalence of disability increases with age and, hence, the demand for long-term care in the region. this increase is due to unhealthy lifestyles, incapacitating disorders and fragility associated with aging (2). additionally, the prevalence of chronic diseases (7) and comorbidities is associated with lower functionality (8), which leads the elderly to not fulfilling their needs in autonomous and independent manner. furthermore, there is emphasis on the relationship between the decay of “physical function [and] increased age, generating a broad spectrum of negative effects, like difficulty with mobility, social isolation, diminished quality of life, and disability” (8). the impact of aging of the population in the colombian health system (9) is significant, and in many parts of the country, knowledge gaps exist on the theme. this reason justifies production of information that permits not only understanding the process of aging in each region, but also analyzing its conditions and, with such, prevent health situations that can alter the wellbeing of the population and promote active aging, considering the context. besides, establishing geriatric competences, both in nursing, as in other areas of knowledge (10), bearing in mind the needs of the receptors. the purpose of the study was to identify the health status of the elderly in programs at the life centers (lc)4 of four municipalities in the department of meta, colombia, and establish relationships in some social, demographic, and health aspects. materials and methods descriptive study with quantitative variables, using measures of central tendency and dispersion and multiple correspondence analysis. according to the study requirements, the universe of interest was stratified by the geographic variable of municipality. the selection established the following criteria: municipalities belonging to the piedmont of the department of meta with an lc in operation during 2017. the municipalities selected for the study were villavicencio, acacías, guamal, and el dorado. selection of the older adults was made through discretionary non-probabilistic sampling. the subjects were selected on a given day with the following inclusion criteria: > 60 years of age, actively registered in the life center program, having accepted voluntary participation in the study, and evaluation of their mental health by applying the mini cognitive exam (mce). in 2017, the municipality of villavicencio enabled 30 lc, with capacity for 40 elderly in each; guamal had on lc for 100 elderly; acacías had two lc for 150; and el dorado had one lc with 20 elderly. the sample corresponds to 819 elderly attending lc programs in the municipalities selected. 4 life centers (lc) are a strategy of the colombian policy on human aging and old age, which gathers a series of projects, procedures, protocols, and physical, technical, and administrative infrastructure to provide comprehensive care to the elderly during daytime hours (11). 5 health status of the elderly in life centers l emilce salamanca-ramos and others the instruments used to gather the information were basic activities of daily living (badl) by barthel and instrumental activities of daily living (iadl) from the scale by lawton and brody (12). the tinetti subscale assessed gait and balance; the mini-mental cognitive exam (spanish adaptation) was used for the cognitive evaluation (13); the affective assessment was done through the geriatric depression scale by yesavage (14); comorbidity was evaluated with charlson’s comorbidity index. the instruments are of free use and have been applied in the population of latin america, including colombia. a survey was elaborated for social characterization, contemplating social and demographic variables of the target population. researchers and four students from the faculty of health sciences in the last semesters, previously trained, collected data in the location assigned by the lc director. through a prior introduction, the elderly were instructed on the motive for the visit, information, and objectives of the study. the study applied the ethical considerations proposed in resolution 8430 of 1993 by the colombian ministry of health (15); informed consent was requested, emphasizing on the freedom of the participants to refuse to be part of the study and guaranteeing the confidentiality of the information collected. data collection took place from 01 october to 30 december 2017, with the same procedure in all the lc. the research adhered to the international research principles established in the 2013 helsinki declaration by the world medical association and it was approved by the bioethics committee at universidad de los llanos. results sociodemographic characteristics of the elderly 47.9 % are men (392 interviewed), and the remaining 52.1 % were women (427), with a mean age of 73 years (table 1). in this study, 17.6 % of the elderly are from the department of meta. in this regard, a migration phenomenon was observed, given that interviewees came mostly from municipalities different from those located in the piedemonte llanero (plains piedmont). with respect to marital status, 70.6 % are single, widowed, separated, or divorced and 19.4 % is in a marital relationship. however, reports indicate that 61.7 % live with some relative. in terms of education, 72.8 % has no academic studies or has incomplete primary education; only 27.2 % has secondary, technological, or university studies (table 1). table 1. sociodemographic characteristics of the elderly sociodemographic variables (n = 819*) no. % age 60-70 297 36.26 71-80 334 40.78 81-90 176 21.49 91-100 12 1.47 gender male 392 47.86 female 427 52.14 marital status single 130 15.9 married 153 18.7 widowed 277 33.8 separated 158 19.3 divorced 13 1.6 common law 88 10.7 educational level without studies 235 28.7 incomplete primary 361 44.1 complete primary 140 17.1 incomplete secondary 43 5.3 complete secondary 21 2.6 technical or technologist 12 1.5 university 7 0.8 with whom do they live family 505 61.7 alone, tenants, or acquaintances 314 38.3 source: own elaboration. self-perception of the health status of the elderly regarding mental health, 20 % suffers from probable depression, and 5.1 % has established depression; 53.1 % has some cognitive impairment and makes visible an important risk factor in the impaired capacity of the elderly in the region (table 2). according to the assessment of activities of daily living by barthel, 59 % of the elderly has evaluation as independent, bearing in mind that with greater age, there is less autonomy to perform the basic and essential activities of daily life. in function of the iadl evaluation by lawton and brody, 64.7 % of the elderly 6 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1923 aquichan issn 1657-5997 eissn 2027-5374 show evaluation as independent. the tinetti scale found that 57.6 % of the elderly is evaluated with lower risk of falling, while 42.4 % report an important risk. in this study, 85.1 % of the elderly has lack of comorbidity and 14.9 % has some level of comorbidity; however, 49.9 % of those interviewed perceive their health as regular, poor, and very poor, which leads researchers to think that the elderly, even when they do not report the presence of diseases, have an impaired perception of their health (table 2). table 2. health status evaluation of the elderly in life centers in the plains piedmont source: own elaboration. the multiple correspondence analysis shows three dimensions. the first factorial axis is defined by the presence or absence of disease and is reinforced with the self-perception of the health status; there is a marked difference shown by sick and healthy elderly. the right side of figure 1 illustrates elderly males and the following characteristics: they have technical studies, live with a relative, have absence of comorbidity, sense no depression, are independent, and have no fall risk. the left side of the figure has principally elderly females: widows, without academic studies and with some disease. other aspects are also observed, like the level of cognitive impairment, low and high comorbidity, with assessment of probable depression and established depression, a level of dependence and greater fall risk. the second factorial axis is determined by the presence of disease associated to weight, highlighting the difference between elderly with low weight and those enduring obesity with proximity to the health status, which suggests a relationship between weight and the presence of disease. other aspects are found, like low and high comorbidity, lower fall risk, and a level of independence (figure 1). the lower part has mainly men without academic studies, without disease, with normal weight or with low weight or malnutrition problems. other factors appear, like some level of cognitive impairment, presence of diseases, a level of dependence for daily living activities and high fall risk (figure 1). discussion women predominate with a mean age of 73 years. in colombia, life expectancy increased from 50.6 years by the middle of the last century to nearly 74 years. currently, the elderly population represents 10 % of the population total, with a projection toward 23 % by 2050 (16). ten percent of the population is from variables evaluation n % mini cognitive examination (mce) evaluation normality 384 46.9 slight deficit 230 28.1 slight cognitive impairment 110 13.4 moderate cognitive impairment 64 7.8 severe cognitive impairment 31 3.8 geriatric depression scale by yesavage normal 613 74.8 probable depression 164 20.0 established depression 42 5.1 barthel’s index of activities of daily living total 0 0.0 severe 15 1.8 moderate 148 18.1 slight 173 21.1 independent 483 59.0 tinetti scale evaluation high risk of falling 124 15.1 risk of falling 223 27.2 lower risk of falling 472 57.6 assessment of the instrumental activities of daily living by lawton and brody total 13 1.6 severe 26 3.2 moderate 63 7.7 light 187 22.8 independent 530 64.7 evaluation of charlson’s comorbidity index lack of comorbidity 697 85.1 low comorbidity 99 12.1 high comorbidity 23 2.8 variables evaluation n % self-perception of health very poor 8 1.0 poor 67 8.2 medium term 333 40.7 good 351 42.9 very good 60 7.3 7 health status of the elderly in life centers l emilce salamanca-ramos and others the plains region, information that points to important mobility, consequential of the armed violence during the last 50 years in colombia. some studies denote that the elderly represent 8.5 % of the displaced population, which places them as a highly vulnerable group, with different risks and affectations that make them different from younger people (17). the study reports an important number of elderly individuals who are separated, widowed, and single. this condition is a risk factor for functional dependence, given that upon being without a partner they are more fragile (18) against disease. the partnership is a protective factor for the elderly because it contributes to improving or maintaining good health conditions. in this study, 28.7 % of the elderly is illiterate, a figure close to the 23.4 % reported by some national studies with population > 60 years of age, located mostly in the rural area (17). the study report a higher presence of older adult women with particular social and health risk conditions. these results coincide with those from other studies (19), which show feminization of old age. said condition implies greater insecurity by this group of women, like being victims of diverse types of violence, in different regions, with relation to men (20), and the presence of comorbidities, like hip fractures and other osteoarticular lesions due to falls (21). however, the prevalence of women may have also been related with greater exposure to certain risk factors (22) with relation to the men, increased self-care actions, and man’s more direct participation in the armed conflict, particularly of the colombian population. the study indicates that 53.1 % has some cognitive impairment, a figure far from the results from other research in the colombian population that report 41.7 % of severe impairment (23) and 39 % of cognitive implication (24). the study reports a high degree of illiteracy and lack of actions, by institutions and families, which favor cognition. similar studies in the colombian population report that 16.1 % (25) and 14.2 % (26) of the population had depressive symptomatology. in this study, the figure was 25.1 %, with greater presence in women, a finding also observed in some similar international studies, which report some level of depression in the elderly, of 45 % (19) and 62 % (27). the multiple correspondence analysis reports elderly of male sex, without studies and separated, with depression. these results may be explained because, at the time of the study, the elderly from the lc were worried about the imminent closing of the places where they were welcomed during the daytime hours. the risk of depression among the elderly needs timely interventions that reduce comorbidity and tend for active aging and better quality of life. in the assessment of daily living activities (adla), 41 % of the elderly is dependent, a trait that appears more in women than in men. the multiple correspondence analysis shows elderly without studies, who live alone, and have a level of cognitive impairment associated with a level of slight and moderate dependence. some international studies report that 72.1 % (28) and 62.8 % (29) of the elderly have some degree of functional dependence. another study indicates a significant relationship between marital status and the degree of dependence of all the cognitive and functionality indicators (30). national studies reveal a good average of basic activities of daily living (21, 31) and highlight that “physical function decreases with age and produces a broad spectrum of negative effects, like difficulty in mobility, social isolation, diminished quality of life, disability, and need for internship in a specialized institution” (32). figure 1. factorial plane: multiple correspondence analysis source: own elaboration. 8 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1923 aquichan issn 1657-5997 eissn 2027-5374 although an important number of elderly subjects in the research has preserved functionality, what is important is to maintain and increase “physical activity” (28) to maintain functionality. of the study subjects, 35.3 % has a degree of functional dependence, according to the evaluation scale of iadl by lawton and brody. the multiple correspondence analysis suggests an association between cognitive impairment with elderly without studies, with high comorbidity, probable depression or established depression, and moderate and severe dependence. in a similar population group, it was found that 26.3 % had functional dependence in the performance of instrumental activities of daily living, which is why the need for help in their social setting prevails (33). likewise, the relationship among high educational levels leads to greater independence of the elderly (34). other studies signal that functional disability may be influenced by the elderly person’s lifestyle, infrastructure of the dwelling space, and cultural factors (35). as found, 42.3 % of the elderly report high fall risk, according to the tinetti scale, with equal presence of women and men. the multiple correspondence analysis shows a probable relationship between the absence of comorbidity with high fall risk, probable depression and very good or good self-perception of health, which indicates that there is no reality sensed by the elderly with relation to fall risk. some publications report that 18.5 % had fall risk, and 71.3 % had high fall risk (26, 36). in the same direction, another study shows that 18.8 % had medium risk and 73.1 % had high risk (27, 33, 37); significantly different results in relation to those from the study presented. other investigations with the same population show that the practice of neuromuscular training can provoke significant changes in their fall risk (22), which is not reflected in the population studied. this study showed that 14.9 % of the elderly indicates presence of comorbidity: the most-frequent diseases are high blood pressure, diabetes mellitus, and pulmonary disease. some studies with similar population reveal that the most-prevalent diseases are high blood pressure, with 56.7 % (19), 55.2 % (26), and 50 % (38); and diabetes mellitus, with 65 % (22), 16.8 % (23), and 23.6 % (33). the presence of chronic diseases in the population studied points to a higher possibility of having dependence and a correlation between the high fall risk and established depression, similar to a study that found a significant association among high blood pressure, depressive symptoms, and functional dependence (26). in this study, 49.9 % of the elderly have a regular or poor perception of their health status and 50.1 % have good or very good perception. the reports are quite similar to those presented by national studies in a sample of 88 elderly subjects, which suggest that 51 % of the elderly perceive themselves as ill (not healthy), while 49 % see themselves healthy (39). in addition, in a sample of 104 elderly subjects, 64 % perceives good health (21). the multiple correspondence analysis signals a relationship among enduring a disease, high fall risk, moderate dependence, established depression, and regular self-perception of health with progressive decay over time, which requires urgent measures that impede a progressive decay in their quality of life. the research denotes an approach to the health status of the elderly from four municipalities of the department of meta. however, health status is a very broad aspect, which is why it is recognized that it was important to have conducted a broader physical exploration, along with the analysis of the elderly individual’s family environment, to have a more complete study of the health conditions of the elderly. conclusions the elderly are considered a vulnerable group in the country. nursing care, from the perspective of health promotion and wellbeing, is fundamental and one of the main concerns of care to the elderly in the short, medium, and long term in caring by geriatric nursing. the research shows conditions of the elderly in the region not considered in the present; it indicates risk factors, like cognitive impairment associated to low educational level; a degree of dependence more marked in women than in men; and the presence of important depression symptoms in the population. the lack of programs in the lc that promote physical activity, recreation, social participation, and family integration can be a significant trigger that compromises functionality and, hence, the wellbeing of the elderly. the elderly have greater relevance in nursing care in the region due to the increase of the population in this age group and the scarce formation of health professionals on caring for their needs. caring implies establishing a relationship of help with the elderly and their families, which is why it becomes necessary to know their conditions, insufficiencies, and perceptions to carry out actions that meet the specific needs of the elderly. 9 health status of the elderly in life centers l emilce salamanca-ramos and others the results from this research will contribute with the bases to care for the elderly in the field of health promotion and in the nursing community diagnoses, as well as to generate a research process with greater coverage in the region and delve into problems, like the social and health conditions of the feminization of old age. limitations accessibility in some lcs in the municipalities due to the geographic and law and order conditions of a municipality. insecurity in some neighborhoods in the city where some lcs are located. acknowledgments the authors express their acknowledgments to the elderly, the secretary of social and community participation, and universidad de los llanos for the endorsement and economic support. gratitude is also expressed to the students from the faculty of health sciences and these research groups: gesi and sistemas dinámicos. conflicts of interest: none declared. references 1. organización mundial de la salud. envejecimiento y salud [internet]. 2018 [cited 2018 oct. 31]. available from: http:// www.who.int/es/news-room/fact-sheets/detail/envejecimiento-y-salud 2. organización panamericana de la salud. estado de salud en la población. salud en el adulto mayor [internet]. 2017 [cited 2018 oct. 31]. available from: 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https://doi.org/10.30552/ejihpe.v6i2.160 http://dx.doi.org/10.12804/revsalud12.03.2014.05 http://dx.doi.org/10.12804/revsalud12.03.2014.05 http://dx.doi.org/10.7705/biomedica.v37i1.3197 http://dx.doi.org/10.15359/mhs.14-2.2 http://dx.doi.org/10.1590/0034-7167-2017-0091 https://doi.org/10.12957/reuerj.2016.3785 http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s1134-928x2017000100002&lng=es http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s1134-928x2016000100002 http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s1134-928x2016000100002 http://dx.doi.org/10.12804/revsalud12.2.2014.01 http://dx.doi.org/10.12804/revsalud12.2.2014.01 http://rcientificas.uninorte.edu.co/index.php/salud/article/viewarticle/9673 http://rcientificas.uninorte.edu.co/index.php/salud/article/viewarticle/9673 effect of the organizational culture for patient safety in the hospital setting: a systematic review article effect of the organizational culture for patient safety in the hospital setting: a systematic review* efecto de la cultura organizativa para la seguridad del paciente en el entorno hospitalario: revisión sistemática** efeito da cultura organizacional para a segurança do paciente em ambiente hospitalar: revisão sistemática*** 10.5294/aqui.2021.21.2.3 leonor coelho da silva1 célia pereira caldas2 cintia silva fassarella3 patricia simas de souza4 1 https://orcid.org/0000-0001-5633-549x. brazilian navy, universidade do estado do rio de janeiro, brazil. leonor.silva@marinha.mil.br 2 https://orcid.org/0000-0001-6903-1778. universidade do estado do rio de janeiro, brazil. ccaldas@uerj.br 3 https://orcid.org/0000-0002-2946-7312. universidade do estado do rio de janeiro, universidade do grande rio, brazil. cintia.silva.fassarella@uerj.br 4 https://orcid.org/0000-0002-7700-6545. gaffrée guinle university hospital, brazil. patricia.simas@ebserh.gov.br * this article is derived from the doctoral thesis entitled “safety culture in the emergency department of a large size hospital in times of the covid-19 pandemic”, defended at the graduate program in nursing of the nursing school of universidade do estado de rio de janeiro, brazil. funded by the carlos chagas filho research support foundation of the state of rio de janeiro, process no. e-26-/010.002691/2019 and e-26-/010.100932/2018. ** este artículo se deriva de la tesis doctoral titulada “cultura de seguridad en la emergencia de un gran hospital en tiempos de pandemia covid-19”, presentada al programa de posgrado en enfermería de la facultad de enfermería de la universidade do estado do rio de janeiro, brasil. auspiciado por la fundação carlos chagas filho de amparo à pesquisa do estado do rio de janeiro, n.º proceso e-26-/010.002691/2019 y e-26-/010.100932/2018. *** este artigo é derivado da tese de doutorado intitulada “cultura de segurança na emergência de um grande hospital em tempos de pandemia covid-19”, defendida no programa de pós-graduação em enfermagem da faculdade de enfermagem da universidade do estado do rio de janeiro, brasil. financiado pela fundação carlos chagas filho de amparo à pesquisa do estado do rio de janeiro, n.º processo e-26-/010.002691/2019 e e-26-/010.100932/2018. received: 28/07/2020 sent to peers: 07/09/2020 approved by peers: 19/04/2021 accepted: 29/04/2021 theme: evidence-based practice. contribution to the subject: in this article, the importance of the organizational culture for patient safety is reinforced, showing that, when there is a positive safety environment, there is a possibility for improvement in the quality of health care. thus, this study may assist the health professionals in taking this interaction to the practice, achieving benefits for health care. to reference this article / para citar este artigo / para citar este artículo: silva lc, caldas cp, fassarella cs, souza ps. effect of the organizational culture for patient safety in the hospital setting: a systematic review. aquichan. 2021;21(2):e2123. doi: https://doi.org/10.5294/aqui.2021.21.2.3 abstract objective: to identify the effect of the organizational culture on patient safety in the hospital context. materials and methods: a systematic review, without meta-analysis, registered in prospero with number crd42020162981. cross-sectional and observational studies were selected that assessed the safety environment and safety culture published between 2014 and 2020 in journals indexed in the embase, latin american and caribbean literature in health sciences (literatura latinoamericana e do caribe em ciências da saúde, lilacs) via the virtual health library (biblioteca virtual em saúde, bvs), medline (international literature in health sciences) via pubmed, and cumulative index to nursing and allied health literature (cinahl). results: the findings show that a positive safety environment exerts a beneficial effect on the safety culture, favors the notification of events, and enables improvements in the quality of health care. conclusions: the effective interaction between safety culture and organizational culture is still scarce in the literature. most of the studies carried out investigate the situational diagnosis and little progress is made in terms of deepening the implications for the professional practice and the repercussions for the safety of hospitalized patients. keywords (source decs): organizational culture; health personnel; patient safety; hospitals; safety management. resumen objetivo: identificar el efecto de la cultura organizativa para la seguridad del paciente en el entorno hospitalario. materiales y métodos: revisión sistemática, sin metaanálisis, registrada en el prospero con el número crd42020162981. se seleccionaron estudios transversales y observacionales que evaluaron el clima de seguridad y la cultura de seguridad publicados en revistas indexadas en las bases embase, literatura latinoamericana y del caribe en ciencias de la salud (lilacs), por medio de la biblioteca virtual en salud (bvs), medline (literatura internacional en ciencias de la salud), vía pubmed y cumulative index to nursing and allied health literature (cinahl), entre 2014 y 2020. resultados: los hallazgos evidencian que el clima de seguridad positivo impacta de forma benéfica en la cultura de seguridad, favorece la notificación de eventos y posibilita la mejoría de la calidad del cuidado a la salud. conclusiones: la efectiva interacción entre cultura de seguridad y cultura organizativa aun es escasa en la literatura. gran parte de los estudios realizados investiga el diagnóstico situacional y poco se avanza en el sentido de profundizar las consecuencias para la práctica profesional y la repercusión para la seguridad del paciente hospitalizado. palabras clave (fonte decs): cultura organizacional; personal de salud; seguridad del paciente; hospitales; administración de la seguridad. resumo objetivo: identificar o efeito da cultura organizacional para a segurança do paciente no contexto hospitalar. materiais e métodos: revisão sistemática, sem metanálise, registrada no prospero sob o número crd42020162981. foram selecionados estudos transversais e observacionais que avaliaram o clima de segurança e a cultura de segurança publicados em periódicos indexados nas bases embase, literatura latino-americana e do caribe em ciências da saúde (lilacs), via biblioteca virtual em saúde (bvs), medline (literatura internacional em ciências da saúde), via pubmed e cumulative index to nursing and allied health literature (cinahl), entre 2014 e 2020. resultados: os achados demostraram que o clima de segurança positivo impacta de forma benéfica na cultura de segurança, favorece a notificação de eventos e possibilita a melhoria da qualidade do cuidado à saúde. conclusões: a efetiva interação entre cultura de segurança e cultura organizacional ainda é escassa na literatura. a maioria dos estudos realizados investiga o diagnóstico situacional e pouco se avança no sentido de aprofundar a implicação para a prática profissional e para a repercussão para a segurança do paciente hospitalizado. palavras-chave (fonte decs):  cultura organizacional; pessoal de saúde; segurança do paciente; hospitais; gestão da segurança. introduction patient safety involves several fields of professional performance and encompasses the care and managerial levels, with a view not only to ensuring adequate care but also to maintaining health and preventing health-related problems. in this sense, the consolidation of the patient safety culture is an important subsidy for the quality improvement proposals, since its constructs allow remodeling work processes, allowing for safe strategies to improve health care (1). it is understood that the safety culture is characterized as the result of values, attitudes, competencies, and patterns of individual and group behavior, which determine the commitment, style and proficiency of the management of a healthy and safe organization (2, 3). research studies on the assessment of the safety culture and the impact on health management were considered essential for the development of safe care, with an emphasis on learning, continuous improvement, and a non-punitive approach to errors (4). organizational culture is defined as the shared system of actions, values and beliefs that develops in an organization and guides the behavior of its members. the reason for an organization having a strong culture is that it has a long common history or because it has intense and important shared experiences (5). the patient safety environment can be defined as a measurable characteristic of the organizational culture, through the individuals’ perception and attitude, at a certain time (6). in this context, it awakens the need to know the organizational safety culture, intending to prevent, detect, and evaluate errors and adverse events, as well as for the formulation and implementation of improvement measures that will foster patient safety (7). studying the safety culture in the hospital makes it possible to understand the factors involved in the work process that impact patient safety. in this sense, the development of research studies on the theme can strengthen the effective communication of scientific evidence, experiences and recommendations aimed at ensuring patient safety in health care (1). given the need to disseminate and strengthen the patient safety culture, to reduce the risks to which they are exposed during health care, this study sought to answer the following question: “what is the effect of the organizational culture for patient safety in the hospital setting?” in addition to that, it aimed at identifying the effect of the organizational culture on patient safety in the hospital context. materials and methods this is a systematic literature review, without meta-analysis, conducted in the graduate program in nursing of the nursing school at universidade do estado do rio de janeiro, brazil. the report of this review complied with the recommendation of the preferred reporting items for systematic reviews and meta-analyses (prisma) checklist (8). the study protocol was registered under number crd42020162981 in the international prospective register of systematic reviews (prospero), an international database in which researchers register their systematic reviews, to avoid duplicated productions, another review being conducted and guaranteeing the reliability record (9). the following inclusion criteria were established: cross-sectional and observational studies, studies assessing the organizational safety environment and the safety culture, and studies with access to full-reading in portuguese, english, or spanish. duplicate studies were excluded, maintaining the article from a single database, as well as those that were related to a single professional category and assessed only a specific sector. after applying the eligibility criteria, the articles identified in the previous search were subjected to double-blind checking. in divergent cases, a third evaluator was consulted to determine whether or not the article would be selected. the selection details are shown in figure 1. figure 1. prisma — flowchart corresponding to the search in the literature and to the selection process. rio de janeiro, brazil, 2020 source: adapted from moher et al. (8). to elaborate the review, the pico strategy was used (10), where ‘p’ represents the participants (health professionals); ‘i’, the intervention/exposure (organizational culture); ‘c’, the comparator/control (none) (or ‘c’, context [hospital]); and ‘o’ for outcome (patient safety). searches were conducted from october 1st, 2014, to july 21st, 2020, in the following databases: embase, latin american and caribbean literature in health sciences (literatura latino-americana e do caribe em ciências da saúde, lilacs) via the virtual health library (biblioteca virtual em saúde, bvs), medline (international literature in health sciences) via pubmed, and cumulative index to nursing and allied health literature (cinahl). this time frame was established to find more recent contemporary evidence about the influence of the organizational culture on the safety of hospitalized patients. an initial search was conducted in november 2019 to verify the feasibility of the study. the terms and synonyms corresponding to each database were used. for the extraction of the descriptors, the controlled vocabularies of the health area were consulted in the descriptors in health sciences (descritores em ciências da saúde, decs), medical subject headings (mesh), and emtree (embase). the data from the literature search were collected in a standardized data collection record, which contains the following variables: author, year, country, population/sample, data collection, response rate, and the effect of the culture identified. the selected data were organized in a spreadsheet in microsoft excel® 2010 and subsequently analyzed according to pre-established variables, based on the study object. to assess the quality of the studies, the nhlbi quality assessment tool for cohort, observational and cross-sectional studies was used, with the articles that obtained a good evaluation being selected for the qualitative analysis of the data, based on the criteria of this tool (11). results a total of 22 articles (12-33) were selected for qualitative analyses that were conducted in 15 countries, with different levels of economic and socio-cultural development, published in english and between 2014 and 2020. all were read in full and their data were collected and presented in table 1. table 1. characteristics of the studies included (n = 22). rio de janeiro, brazil, 2020 reference, year, country population/ sample instrument used for data collection response rate results effect of the culture identified kolankiewicz acb, schmidt cr, carvalho refl, spies j, dal pai s, lorenzini e. (12), 2020, brazil sample: 698 participants: 630 safety attitude questionnaire (saq) 90.2 % positive scores were found in all the safety culture domains, except for the stress perception domain. schooling, gender, working time, and choice of the work unit exerted a positive influence on the safety environment. positive. it favors the participatory safety culture of the professionals. kumbi m, hussen a, lette a, nuriye s, morka g (13), 2020, ethiopia sample: 556 participants: 518 hospital survey on patient safety culture (hsopsc) 93.2 % the overall level of the patient safety culture was 44 % (ci = 95 %; 43.3-44.6). factor analysis indicated that hours worked per week, participation in a patient safety program, reporting of adverse events, communication openness, teamwork within the hospital, organizational learning, and exchange of feedback on the error were among the factors that were significantly associated with the patient safety culture. critical. need to strengthen the safety culture. yari sn, akbari mh, shahsavari s. (14), 2019, iran sample: 720 participants: 680 hospital survey on patient safety culture (hsopsc) 94 % the safety environment and safety culture scores were 3.61 and 3.30, respectively, which are appropriate values. there was positive significance in the relationships between safety environment and the safety culture, safety environment and any of its components, and safety culture and any of the components. positive. it favors the safety culture. magalhães fhl, pereira ica, luiz rb, barbosa mh, ferreira mbg (15), 2019, brazil sample: 206 participants: 198 safety attitude questionnaire (saq) 96 % professionals with a negative perception of the patient safety environment (69.5). the job satisfaction domain obtained the highest score (81.98) and the perception of the management domain (62.15), the lowest. negative. detrimental to the safety culture. jiang k, tian l, yan c, li y, fang h, peihang s et al. (16), 2019, china sample: 900 participants: 665 saq 74 % the participants rated job satisfaction as the best-rated domain, followed by teamwork environment, working conditions and stress recognition. there were significant differences between the domains of patient safety culture and those associated with other factors, such as gender, age, position and schooling. positive. contribution for improving the services. akologo a, abuosi aa, anaba ea (17), 2019, ghana sample: 406 participants: 384 hsopsc 94.50 % two dimensions with high scores: teamwork within the units (81.5 %) and organizational learning-continuous improvement (73.1 %). three dimensions with lower scores: professionals, non-punitive response to error, and frequency of events reported. the overall perception of patient safety was significantly correlated with all the dimensions, except staffing. positive. it favors the safety culture. alqattan h, cleland j, morrison, z (18), 2018, kuwait sample: 1,340 participants: 1,008 hsopsc 75.2 % the dimensions that needed improvements were: non-punitive response to error and communication openness. the positive dimensions were teamwork within the units and organizational learning-continuous improvement, as strong dimensions. the professional subcultures within the organizations must be considered when assessing the patient safety culture. critical. need to strengthen the safety culture. zhou p, bai f, tang h et al. (19), 2018, china sample: 4,753 participants: 4,176 patient safety climate in healthcare organizations (pscho) 87.86 % the dimensions with universally high scores in the different departments were fear of blame and punishment. the perceptions about the patient safety environment vary across departments and types of work. negative. detrimental to the safety culture. najjar s, baillien e, vanhaecht k et al. (20), 2018, belgium and palestine sample: 2,836 participants: 1,418 hsopsc belgium 51.9 % and palestine 53.6 % the overall patient safety level was predicted by organizational learning in palestine (β = 0.19, p < 0.001) and by personal learning in belgium (β = 0.19, p < 0.001). the number of reported events was predicted by staffing in palestine (β = −0.20, p < 0.001) and by feedback and communication in belgium. critical. need for investment in the dimensions to strengthen the safety organizational culture. li y, zhao y, hao y et al. (21), 2018, china sample: 1200 participants: 1,024 saq 85.33 % the working conditions domain (80.19) obtained the highest score, and the safety environment (70.48), the lowest. there were significant differences in the perceptions of the patient safety culture according to gender, age, years of experience, position, status and schooling level. different among the professionals. need to strengthen the safety culture. verbeek-van noord i, smits m, zwijnenberg n c, spreeuwenberg p, wagner c. (22) 2018 netherlands participants: 6,605 hsopsc 62.2 % the relative influence of the hospitals on the safety culture increased and became more favorable after the implementation of the patient safety program (psp). the perception of safety across hospitals and departments did not become more equivalent, except for the frequency of reported events. positive. favorable after the implementation of the psp, but in need of improvement in terms of the safety culture. huang ch, wu hh, chou cy, dai h, lee yc (23), 2018, taiwan sample: 800 participants: 405 saq 50.6 % the results highlighted that the safety environment was positive and significantly related to the teamwork climate and the perception of the hospital management, while recognition of stress was negatively related to burnout. positive. seeking to improve quality and to strengthen the safety culture. rajalatchumi a, ravikumar ts, muruganandham k, thulasingam m, selvaraj k, reddy mm et al. (24), 2018, india sample: 421 participants: 386 hsopsc 91.60 % the dimensions of teamwork within the units, organizational learning-continuous improvement, and supervisor/manager expectations and actions promoting patient safety showed the highest scores of positive answers. the safety culture was strengthened after the creation of a safety council, whose objective was to improve patient safety and the provision of health care. positive. strengthening of the safety culture after the creation of a quality council. burlison jd, quillivan rr, kath lm et al. (25), 2018, united states the data obtained from 223,412 individuals were analyzed. ahrq-hsopsc 51.3 % the dimensions return of information and communication regarding the error were the most exclusive predictive variation in the result of frequency of reported events. other dimensions significantly associated included organizational learning-continuous improvement, non-punitive response to error, and teamwork within the units (all with p < 0.001). positive. strengthening of the patient safety culture and event reporting. carvalho refl, arruda lp, nascimento nkp, sampaio rl, cavalcante mlsn, costa acp (26), 2017, brazil sample: 573; 106 (18.5 %) hospital a, 183 (31.9 %) hospital b and 284 (49,6%) hospital c saq 60.3 % the scores obtained by the three hospitals varied between 65 and 69. the job satisfaction domain showed the highest score and the opposite was observed in the perception of the management domain. higher-level professionals showed a better perception of the stressors when compared to mid-level professionals. positive related to job satisfaction, but the safety culture still shows opportunities for improvement. cheikh ab, bouafia n, mahjoub m, ezzi o, nouira a, njah m (27), 2016, tunisia participants: 116 physicians and 203 paramedics hsopsc 74.1 % physicians and 100 % paramedic team the scores of the dimensions vary between 32.7 % and 68.8 %. the highest (68.8 %) was the frequency of reported events and the lowest (32.7 %) was management support for patient safety, but all the dimensions need to be improved. critical. need for improvements in most of the safety culture dimensions. elsous a, sari aa, rashidian a, aljeesh y, radwan m, abuzaydeh h (28), 2016, palestine sample: 370 participants: 339 saq 91.6 % the mean score for the safety attitude in the six dimensions varied between 68.5 for job satisfaction and 48.5 for working conditions. workers with positive attitudes were more collaborative with their work colleagues than those without positive attitudes. positive. favorable for the safety culture based on cooperation among the professionals and improvement of the clinical results. zhou p, bundorf mk, gu j et al. (29), 2015, china sample: not informed participants: 1,272 pscho 75 % the fear of blame and punishment (79 %) and fear of shame  (41 %) dimensions presented higher percentages of problematic answers, which can be barriers to improvements in patient safety in chinese hospitals. negative. detrimental to the safety culture. kristensen s, badsberg jh, rischelv, anhøj j, mainz j, bartels p (30), 2015, denmark sample: 867 participants: 544 saq 63 % no differences were found in the percentage of positive perceptions between nurses and physicians (p > 0.05), but the difference between leaders and the front-line team was evident (p < 0.05). the perceptions varied more among individuals within the same unit than between the hospital units and between hospitals. it emerges as a multilevel construction, in need of strengthening the safety culture in some professional categories. barbosa mh, sousa em, felix mms, oliveira kf, barichello e (31), 2015, brazil sample: 107 participants: 66 saq 61.60 % the overall score of the instrument was 70.28. the best domain was job satisfaction (86.74) and the domains with the lowest scores were perception of the management (64.99) and stress recognition (61.74). there was no statistically significant difference between the genders, but there was between those who were undergraduate students or not. weak. requirement for permanent education. chakravarty a, sahu a, biswas m, chatterjee k, rath s (32), 2015, india sample and participants: 300 saq 100 % significant variations in the perception of the safety environment were observed across the different categories of health professionals in the domains of teamwork, perception of the management and stress recognition. inconsistent. need to strengthen the safety culture. al mandhari a, al-zakwani i, al-kindi m, tawilah j, dorvlo a, aladawi s (33), 2014, oman sample: not informed participants: 398 hsopsc 98 % the mean of positive answers was 58 %. the dimension with the highest score was the organizational learning-continuous improvement and the one with the lowest score was the non-punitive response to error. positive. it favors the safety culture. source: elaborated by the authors. ten articles (13, 14, 17, 18, 20, 22, 24, 25, 27, 33) used the hsopsc questionnaire as data collection instrument; another ten articles (12, 15, 16, 21, 23, 26, 28, 30-32) used saq, and two (19, 29) made use of pscho. regarding the population, the samples of studies 16, 19, 21 and 29 consisted of physicians and nurses, both managerial and assistants; of only physicians and nurses in studies 23 and 28, and of other health professionals in the remaining studies (12-15, 17, 18, 20, 22, 24-27, 30, 32-34). only nurses were included in all the research studies, and the physicians were not contemplated in the population of one of the studies (31). in general, the studies presented the overall response rate, without specifying by professional category; however, in the study that made this separation, nurses stood out with the highest response rate: 85 %-91.9 %; followed by physicians, with 81 %-91.8 % (28, 29). in one of the studies (27), the response rate was 74.1 % among the physicians, and 100 % among the other health professionals. in the others, the response rates were 50 %-59 % (20, 23, 25), 60 %-69 % (22, 26, 30, 31), 70 %-79 % (16, 18), 80 %-89 % (19, 21), 90 %-99 % (12-15, 17, 24,33) and 100 % (32). the objectives of the studies varied between investigating the interaction between the safety environment and the safety culture (14), analyzing the perception of the patient’s safety environment by health professionals (15, 29, 31, 32), investigating/evaluating the patient safety culture (12, 13, 16, 26-28, 33), assessing the perceptions about the patient safety culture among the health professionals (17-19, 21, 23, 24, 30), examining whether the safety culture has improved after the implementation of the patient safety program (22), assessing the associations between the dimensions of the patient safety culture and the perceived notification practices of safety events of varying severity (25), and investigating the relationships between dimensions of the patient safety culture in different cultures (20). in research studies on the safety culture, the dimensions that presented high values of positive answers were teamwork within the units (13, 17, 18, 24, 33), organizational learning-continuous improvement (17, 18, 24, 33), supervisor/manager expectations and actions promoting patient safety (24), and frequency of event reporting (22, 27). the dimensions that recorded lower values of positive answers were non-punitive responses to error (13, 17, 18, 22, 25, 33) and frequency of event reporting (17, 24), communication openness (18, 22), the general perception of patient safety (22), and management support for patient safety (13, 27). in the studies that investigated the safety environment, the safety domains that obtained the highest scores were job satisfaction (12, 15, 16, 26, 28, 31, 32), teamwork climate (16, 23, 28, 30) and working conditions (21). in study 12, all the domains had a positive answer, except for the stress perception dimension. the safety domains that obtained the lowest score were perception of the unit/hospital management (12, 15, 26, 30, 31), stress perception (12, 16, 23, 31, 32), fear of blame and punishment (19, 29), fear of shame (29), safety environment (19) and working conditions (28). the findings show that a positive safety environment exerts a positive impact on the safety culture (14), favors the notification of events (25, 27), and enables improvements in quality (16, 23, 27, 32). in the opposite direction, a negative safety environment weakens the safety culture (13, 15, 19, 29), is related to the decrease in the reporting of events for strengthening punitive responses to errors (13, 17) and to the fear of blame and of shame (19, 29). a weak safety environment requires permanent education (31) and improvement of the patient safety program (22). the safety environment emerged as a multilevel construction (30), which suffers variations among professionals from different categories (15, 16, 19, 21, 24, 32), with differences in schooling (12, 15, 16, 21, 26, 31), within the same unit (22, 30) or across units (22, 30, 32). it was identified that the schooling/training level exerts a positive impact on the safety culture and on the safety environment (14, 15, 16) and that there is a difference in the patient’s perception of safety among professional categories at the same institution (12, 15, 6, 18, 21, 31, 32). discussion the quality of the health services has been related to the patient safety culture; in this sense, the hsopsc and saq questionnaires have been widely used by various countries to gather data on the patient safety culture and on the safety environment (34, 35). the pscho tool is also used to obtain data on the safety environment, although it adds the fear of blame and fear of shame dimensions, as well three additional items that ask the interviewees if they witnessed or were involved in the provision of unsafe care (35, 36). the response rate of all the studies was over 50 %, which is one of the criteria for assessing the quality of the tool used in this study (11). in 85 % of the studies selected for this review (14-19, 21, 22, 24, 26-33), the rate was over 60 %. the literature suggests rates over 60 % as representative (37). the dimension of teamwork within the units was identified as a strong dimension (38, 39); however, it also appears as a dimension with potential for improvement (40, 41), which, when strengthened, will enable commitment among the professionals and strengthening of the security environment. there are divergences in the perception of the participation of managers and leaders. this divergence can be related to the real commitment of managers in strengthening the safety actions and improving the organizational environment (38, 41) or to the workers’ reticence in expressing negative opinions about managers and institutions (38). the low scores identified in terms of communication openness can be associated with the rigid relationship between workers and managers, which leads to passive behavior regarding event reporting (42), as there is no room to discuss errors (34). this attitude is reflected in organizational silence, which weakens individual initiatives; in addition to discouraging the issuance of opinions, thoughts and suggestions that could contribute to the improvement of processes and services (43). the frequency of event reporting can be negatively associated with non-punitive responses to errors, since the professionals fear that their errors will be used to punish them (1, 44) instead of considering them as an opportunity for improvement (44). the studies that presented this dimension with positive results associated them with the implementation of the patient safety program (22) and with the positive safety environment (27). several studies point out that job satisfaction and the organizational environment exert a positive influence on the safety culture (45, 46), playing a significant role in guaranteeing the quality of the health services (46) and, consequently, in patient safety. on the other hand, stress perception addresses how much each professional can perceive that the stress load favors risk situations for patient safety (34), since the difficulty in perceiving and dealing with stressors can result in errors, reduced productivity, feelings of discomfort, illness or poor team performance (4). identifying weaknesses in the patient safety culture is considered as an opportunity to improve quality (47). in this context, identifying and monitoring the dimensions or domains with the lowest scores can become a subsidy for the establishment of strategies to develop them, as well as for the strengthening of the most solid dimensions and domains. the interaction between the safety environment and the safety culture deserves attention from researchers, managers and health workers. the impact of the organizational influence affects the entire care system, the maturity of a safety culture that permeates all actions of care practice being a challenge for patient safety (34). the safety environment and the safety culture had a positive impact on each other, which suggests that the safety culture accompanies the improvement of the safety environment, and vice versa (14). there is a complex relationship between safety culture and safety environment, which can indicate that organizations with a certain type of culture can more or less develop a positive safety environment (48). the evidence points out that the insufficiency in the reports of events is related to trust in a culture of blame, instead of a safety culture, risk management and improvement system (49), precluding a fair, participatory and open culture between professionals and managers (39). however, occasionally blaming the professional for frequent errors, caused by neglect or non-adherence to the safety standards, may be appropriate (50). therefore, the institutions must encourage the patient safety culture among all the professionals with a view to improve quality (51). permanent education is presented as a tool for the insertion of patient safety in the daily lives of health professionals (52). interdisciplinary team training emerges as a strategy to strengthen the relationship between the teams and solve misunderstandings that can have an impact on patient care (53). due to the existence of local microcultures within the organizations (34), knowledge of the organizational culture will allow managers to identify the differences across the services of the same hospital, which promotes their improvement (54). in this context, the safety culture may be perceived differently among the professional categories (41), which highlights the need to know this difference to enable the planning and implementation of actions aimed at standardizing and strengthening the perception of the safety culture. patient safety is considered as one of the cornerstones of health care quality (41), a requirement for ensuring care quality (55). the implementation of the patient safety center denotes an advance towards encouraging the patient safety culture and the quality of health care, as it reveals the concern and support of managers for the actions to improve the structure and processes, whose objective is to improve care (56). the concern with the quality of care provided by the health services, with a focus on harm-free assistance, has been an objective sought by institutions worldwide. a positive safety culture will promote individual and organizational learning, enabling the achievement of quality care (53). this is because the organizational culture can directly influence the patient safety culture concerning risks, expectations, and actions (57). studying the effect of the organizational culture on the patient safety culture can be an effective tool for reducing the harms resulting from health care, since a positive organizational culture provides a more effective safety environment. in this sense, we hope that this study can contribute to the professional practice, as knowing the strengths and weaknesses in the organizational culture will enable the identification of multiple factors that put patient safety at risk, as well as to research, as the understanding of what determines safe assistance can guide more effective educational processes and enable the establishment of evidence that points to the needs for improving health care. conclusions the objective proposed for this review was attained, as it was possible to identify the effect of the organizational culture on the safety culture for hospitalized patients. the effect is positive when the organizational culture is strong, geared towards improving processes and quality, resulting in strengthening the patient safety culture and achieving positive results related to health care; whereas a fragile and punitive organizational culture is related to a culture of deficient safety in which adverse events with or without harms may be more present. there is still a long way to go in the search for safe care, but it is undisputed that strengthening the patient safety culture is the path to follow. the evidence points towards the need to establish a fair, non-punitive culture, geared towards the development of interpersonal, professional and institutional capacity. much has been studied about the safety culture and the organizational culture; however, the effective interaction between them is still little reported in the literature, which possibly makes the topic relevant for future studies, since most of the research studies investigated the situational diagnosis and little progress has been made in investigating the implication for the professional practice and the repercussion for the safety of hospitalized patients. a limitation of this study is the choice of only four databases, which was considered adequate for the selection of studies according to the proposed theme and objective, but which may have allowed eligible studies not to be found, as well as the restriction to studies published in english, portuguese and spanish, in addition to the non-performance of a meta-analysis. conflicts of interest: none declared. references 1. silva-batalha ems da, melleiro mm. cultura de segurança do paciente em um hospital de ensino: diferenças de percepção existentes nos diferentes cenários dessa instituição. texto e context enferm. 2015;24(2):432-41. doi: https://doi.org/10.1590/0104-07072015000192014 2. fan cj, pawlik tm, daniels t, vernon n, banks k, westby p et al. association of safety culture with surgical site infection outcomes. j am coll surg. 2016;222(2):122-8. doi: https://doi.org/10.1016/j.jamcollsurg.2015.11.008 3. national patient 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[internet]. 2015;17(4). doi: http://dx.doi.org/10.5216/ree.v17i4.34614 32. chakravarty a, sahu a, biswas m, chatterjee k, rath s. a study of assessment of patient safety climate in tertiary care hospitals. medical journal armed forces india. 2015;71(2):152-7. doi: https://doi.org/10.1016/j.mjafi.2015.01.007 33. al mandharia, al-zakwani i, al-kindi m, tawilah j, dorvlo a, aladawi s. patient safety culture assessment in oman. oman medical journal. 2014;29(4):264-70. doi: https://doi.org/10.5001/omj.2014.70 34. santiago th, turrini rn. cultura e clima organizacional para segurança do paciente em unidades de terapia intensiva. rev. esc. enferm. usp. 2015;49(spe):123-30. doi: http://dx.doi.org/10.1590/s0080-623420150000700018 35. cunha mr, guirardello eb. patient safety climate in healthcare organizations: tradução e adaptação para a cultura brasileira. rev. gaúcha enferm. [internet]. 2018;39:e20180010. doi: https://doi.org/10.1590/1983-1447.2018.20180010 36. singer s, meterko m, baker l, gaba d, falwell a, rosen a. workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey. health services research. 2007;42(5):1999-2021. doi: https://doi.org/10.1111/j.1475-6773.2007.00706.x 37. hamdan m. measuring safety culture in palestinian neonatal intensive care units using the safety attitudes questionnaire. j critcare. 2013;28(5):886.e7-e14. doi: https://doi.org/10.1016/j.jcrc.2013.06.002 38. tereanu c, sampietro g, sarnataro f, siscanu d, palaria r, savin v, cliscovscaia t, pislaru v, oglinda v, capmare l, ghelase m, turcanu t. survey on patient safety culture in the republic of moldova: a baseline study in three healthcare settings. medicine and pharmacy reports [internet]. 2018;91(1):65-4. doi: https://doi.org/10.15386/cjmed-869 39. fassarella cs, silva ld, camerini fg, barbieri-figueiredo m. indicador organizacional da cultura de segurança em um hospital universitário [organizational indicator of safety culture in a university hospital] [indicador organizacional de la cultura de seguridad en un hospital universitario]. revista enfermagem uerj. 2019;27:e34073. doi: https://doi.org/10.12957/reuerj.2019.34073 40. fassarella cs, camerini fg, henrique dm, almeida lf, figueiredo mcb. evaluation of patient safety culture: comparative study in university hospitals. rev esc enferm usp. 2018;52:e03379. doi: http://dx.doi.org/10.1590/s1980-220x2017033803379 41. notaro mk, corrêa ar, tomazoni a, rocha pk, manzo bf. cultura de segurança da equipe multiprofissional em unidades de terapia intensiva neonatal de hospitais públicos. rev. latino-am. enfermagem [internet]. 2019;27:e3167. doi: https://doi.org/10.1590/1518-8345.2849.3167 42. boughaba a, aberkane s, youcef-oussama f, djebabra m. study of safety culture in healthcare institutions: case of an algerian hospital. int j health care qual assur. 2019; 32(7):1081-97. doi: https://doi.org/10.1108 / ijhcqa-09-2018-0229 43. harmanci ak, topcu i̇, bacaksiz fe, baydin, nu, ekici et, yildirim, a. organisational silence among nurses and physicians in public hospitals. j clin nurs. 2018;27:1440-51. doi: https://doi.org/10.1111/jocn.14294 44. minuzzi ap, salum nc, locks mo. avaliação da cultura de segurança do paciente em terapia intensiva na perspectiva da equipe de saúde. texto contexto enferm. [internet]. 2016;25(2):e1610015. doi: https://doi.org/10.1590/0104-07072016001610015 45. merino-plaza mj, carrera-hueso fj, roca-castelló mr, morro-martín md, martínez-asensi a, fikri-benbrahim n. relación entre la satisfacción laboral y la cultura de seguridad del paciente. gac sanit [internet]. 2018;32(4):352-61. doi: http://dx.doi.org/10.1016/j.gaceta.2017.02.009 46. gonzález ib, melo na, limón ml. (2014). el clima organizacional y su relación con la calidad de los servicios públicos de salud: diseño de un modelo teórico. estudios gerenciales. 2015;31:8-19. doi: http://dx.doi.org/10.1016/j.estger.2014.08.003 47. andrade le, lopes jm, filho mc, júnior rf, farias lp, santos cc et al. cultura de segurança do paciente em três hospitais brasileiros com diferentes tipos de gestão. ciênc. saúde coletiva [internet]. 2018;23(1):161-72. doi: https://doi.org/10.1590/1413-81232018231.24392015 48. petitta l, probst tm, barbaranelli c, ghezzi v. disentangling the roles of safety climate and safety culture: multi-level effects on the relationship between supervisor enforcement and safety compliance. accident analysis & prevention. 2017;99:77-89. doi: https://doi.org/10.1016/j.aap.2016.11.012 49. shaw cd. quality and safety of health care in the republic of moldova. who regional office for europe. republic of moldova; 2015. (health policy paper series no. 19). available from: https://www.euro.who.int/__data/assets/pdf_file/0007/281869/quality-safety-of-health-care-in-mda.pdf 50. reis ct, paiva sg, sousa p. the patient safety culture: a systematic review by characteristics of hospital survey on patient safety culture dimensions, international journal for quality in health care. 2018;30(9):660-77. doi: https://doi.org/10.1093/intqhc/mzy080 51. siddharth v, koushal vk, goyal v. patient safety is the need of the hour: a study in nursing department of a tertiary care teaching hospital. international journal of research foundation of hospital & healthcare administration. 2017;5(2):55-9. doi: https://doi.org/10.5005/jp-journals-10035-1076 52. wegner w, silva sc, kantorski kj, predebon cm, sanches mo, pedro en. educação para cultura da segurança do paciente: implicações para a formação profissional. esc. anna nery [internet]. 2016;20(3):e20160068. doi: http://dx.doi.org/10.5935/1414-8145.20160068 53. elmontsri m, almashrafi a, banarsee r et al. status of patient safety culture in arab countries: a systematic review. bmj open. 2017;7:e013487. doi: https://doi.org/10.1136/bmjopen-2016013487 54. fassarella cs, silva ld, camerini fg, figueiredo mc. nurse safety culture in the services of a university hospital. rev bras enferm. 2019;72(3):767-73. doi: https://doi.org/10.1590/0034-7167-2018-0376 55. santos fj, nascimento hm, santos jm, cunha jo, santos jc, pena ja. patient safety culture in a low-risk maternity hospital. abcs health sci. [internet]. 2019;44(1). doi: https://doi.org/10.7322/abcshs.v44i1.1066 56. santos rp, soppa fb, ruths jc, rizzoto ml. evaluation of the implantation of a patient safety nucleus. rev. enferm. ufpe on line. 2019;13(2):532-7. doi: https://doi.org/10.5205/1981-8963-v13i02a238189p532-537-2018 57. bishop ac, boyle ta. the role of safety culture in influencing provider perceptions of patient safety. j patient saf. 2016;12(4):204‐9. doi: https://doi.org/10.1097/pts.0000000000000092 1 francielle garcia da silva1 marlene teda pelzer2 bruna ruoso da silva neutzling3 atitudes das idosas quanto à expressão da sua sexualidade 1 orcid.org/0000-0002-9496-119x. escola de enfermagem, universidade federal do rio grande, brasil. franciellesilva@furg.br 2 orcid.org/0000-0002-9844-5459. escola de enfermagem, universidade federal do rio grande, brasil. 3 orcid.org/0000-0002-1964-264x. escola de enfermagem, universidade federal do rio grande, brasil. recibiddo: 21/12/2018 enviado a pares: 15/01/2019 aceptado por pares: 26/03/2019 aprobado: 13/05/2019 doi: 10.5294/aqui.2019.19.3.4 para citar este artigo / para citar este artículo / to reference this article da silva fg, pelzer mt, neutzling brs. attitudes of elderly women regarding the expression of their sexuality. aquichan 2019; 19(3): e1934. doi: https://doi.org/10.5294/ aqui.2019.19.3.4 resumo objetivo: identificar as atitudes que as idosas têm a respeito da sua sexualidade. material e método: estudo exploratório, descritivo, de abordagem qualitativa, realizado no segundo semestre de 2018. participaram 19 idosas, entre 60 e 69 anos de idade, integrantes de dois grupos para idosos situados na cidade de rio grande-rs, brasil. a coleta de dados ocorreu por meio da entrevista individual, semiestruturada e gravada em áudio. em seguida, os dados foram submetidos à análise temática de bardin. resultados: ao analisar os dados, emergiram quatro categorias: mudança na expressão da sexualidade após os 60 anos; sentimentos auferidos ao falar acerca da sexualidade; com quem conversa sobre sexualidade; importância do relacionamento afetivo para o idoso. as idosas demonstraram atitudes favoráveis quanto à sua sexualidade e não notaram mudanças significativas na expressão da sexualidade após completarem 60 anos. entretanto, elas tinham vergonha de falar sobre esse assunto, pois haviam recebido uma educação repressora. além disso, elas procuravam os amigos para sanar quaisquer questionamentos. conclusão: o relacionamento afetivo, amoroso e sexual é extremamente importante, pois promove o bem-estar físico e mental, gera sentimentos de alegria e felicidade, o que proporciona mais vitalidade e prazer em viver às idosas. palavras-chave (fonte: decs) idoso; sexualidade; enfermagem; gênero; gênero e saúde; infecções sexualmente transmissíveis. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1934 tema: promoção e prevenção. contribuição para a disciplina: os resultados deste estudo evidenciam a importância da atuação da enfermagem ante a promoção da educação em saúde, da qualidade de vida e da criação de uma nova imagem da pessoa idosa na sociedade, na qual ela possa expressar os sentimentos e vivenciar a sexualidade livre de preconceitos, mitos e tabus. http://orcid.org/0000-0002-9496-119x http://orcid.org/0000-0002-9844-5459 http://orcid.org/0000-0002-1964-264x https://doi.org/10.5294/aqui.2019.19.3.4 https://orcid.org/0000-0002-9496-119x https://orcid.org/0000-0002-9844-5459 https://doi.org/10.5294/aqui.2019.19.3.4 https://doi.org/10.5294/aqui.2019.19.3.4 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1934 actitudes de las ancianas en relación con la expresión de su sexualidad resumen objetivo: identificar las actitudes que tienen las ancianas en relación con su sexualidad. material y método: estudio exploratorio, descriptivo, de enfoque cualitativo, llevado a cabo en el segundo semestre del 2018. participaron 19 ancianas entre 60 y 69 años de edad, integrantes de dos grupos para adultos mayores en la ciudad de río grande del sur, brasil. la recolección de datos se hizo por medio de entrevistas individuales, semiestructuradas y grabadas en audio. tras ese proceso, los datos se sometieron al análisis temático de bardin. resultados: al analizar los datos emergieron cuatro categorías: cambio en la expresión de la sexualidad luego de los 60 años; sentimientos surgidos al hablar sobre sexualidad; con quién conversa sobre sexualidad; e importancia de la relación afectiva para el adulto mayor. las ancianas demuestran actitudes favorables respecto a su sexualidad y no se notan cambios significativos en la expresión de la sexualidad después de los 60 años. sin embargo, según los testimonio, en algunos casos sienten vergüenza de hablar acerca del tema, pues tuvieron una crianza represora. además, buscan a amigos, en primera instancia, para aclarar sus inquietudes sobre sexualidad. conclusiones: la relación afectiva, amorosa y sexual es extremadamente importante, pues fomenta el bienestar físico y mental y genera sentimientos de alegría y felicidad, lo que les proporciona a las ancianas más vitalidad y placer en vivir. palabras clave (fuente: decs) anciano; sexualidad; enfermería; género; género y salud; enfermedades de transmisión sexual. 3 atitudes das idosas quanto à expressão da sua sexualidade l francielle garcia da silva e outros attitudes of elderly women regarding the expression of their sexuality abstract objective: to identify the attitudes elderly women have with respect to their sexuality. material and method: exploratory, descriptive study of qualitative approach conducted during the second semester of 2018, with the participation of 19 elderly women, between 60 and 69 years of age, members of two groups for the elderly located in the city of rio grande-rs, brazil. data was collected through individual, semistructured interview and audio recorded. thereafter, the data were subjected to the bardin thematic analysis. results: upon analyzing the data, four categories emerged: change in the expression of sexuality after 60 years of age; feelings derived from talking about sexuality; with whom do they talk about sexuality; importance of affective relationships for the elderly. the elderly women show favorable attitudes regarding their sexuality and noted no significant changes in the expression of sexuality after turning 60 years of age. however, they were embarrassed to talk about this matter because they had received a repressive education. in addition, they sought friends to address any questions. conclusion: affective, loving, and sexual relation are extremely important, given that it promotes physical and mental wellbeing, generates feelings of joy and happiness, which provides more vitality and pleasure in living to the elderly women. keywords (source: decs): aged; sexuality; nursing; gender; gender and health; sexually transmitted diseases. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1934 4 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1934 aquichan issn 1657-5997 eissn 2027-5374 introdução o envelhecimento populacional vem crescendo de uma forma acelerada tanto em nosso país quanto em todo o mundo, e isso pode se dar devido ao declínio das taxas de mortalidade, à diminuição das taxas de natalidade, às melhores condições socioambientais e aos avanços tecnológicos na área da medicina (1). esse processo, que ocorre de forma natural, irreversível e mundial, define a mudança na estrutura etária da população. dentro dessa estrutura, os denominados “mais idosos”, “muito idosos”, “idosos em velhice avançada” ou “octogenários” (acima de 80 anos) também vêm aumentando de maneira proporcional e mais lépida, constituindo o segmento populacional que mais cresce nos últimos tempos (2). no entanto, em decorrência do aumento populacional, nota-se, atualmente, uma atenção maior de estudos sobre o envelhecimento humano e a saúde (3). porém, quando se trata da sexualidade na idade da pessoa idosa, o tema continua sendo visto como um tabu e de forma preconceituosa pelos profissionais da saúde, pelos familiares, pela comunidade e, até mesmo, pelos próprios idosos. a partir disso, precisa-se compreender que não há um limite de idade para os idosos se relacionarem com outras pessoas. nesse sentido, os sentimentos, a demonstração de carinho, afeto e a capacidade de amar não terminam durante o envelhecer (4). é imprescindível que se desvincule a imagem negativa do idoso que remete apenas a doenças e se promova a ideia de que, nessa fase, há liberdade, acúmulo de experiência, amadurecimento e sabedoria, direito a expressar o amor, a sexualidade e o desejo (5). com esse propósito, estudos realizados nos estados unidos, com idosos na faixa etária entre 65 e 80 anos, puderam comprovar que eles mantêm sim o interesse nas atividades sexuais (6, 7). dentre os participantes da pesquisa, 76 % afirmaram que o sexo é uma parte importante do relacionamento amoroso em qualquer idade; 54 % estão em um relacionamento e são sexualmente ativos (5). ainda, nesse mesmo estudo, para 54 % dos participantes, o sexo é importante para manter a qualidade de vida, a qual engloba o domínio da percepção individual sobre a sexualidade, que é uma variável complexa pelo seu caráter multidimensional (6, 8). a sexualidade pode ser expressa a partir da interação com o outro e manifestada nas relações sociais através da corporeidade. assim, a sexualidade pode ser distinguida do sexo, o qual retrata apenas uma das formas de expressão do amor humano (9, 10). as pessoas querem e precisam ser amadas e amar aos outros, logo a sexualidade faz parte desse amor, desse relacionamento íntimo. de acordo com a organização mundial da saúde, a sexualidade é a energia que motiva a encontrar o amor; ela engloba o toque, a intimidade, o sentimento (11). é uma necessidade básica do ser humano e está interligada aos outros aspectos da vida, indo além do ato sexual em si. ela influencia pensamentos e, por isso, também influencia a saúde física e mental do indivíduo. as possíveis causas da escassez de estudos sobre a sexualidade dos idosos e suas atitudes se devem à omissão da sexualidade dos idosos pela sociedade e, até mesmo, pelos profissionais da saúde, além do preconceito ainda existente em um século avançado tecnologicamente. desse modo, essa área de pesquisa permanece muito negligenciada. por isso, compreender as atitudes dos idosos acerca da sexualidade é fundamental para que se possam articular novas propostas de intervenção junto a esse grupo populacional (12). diante disso, o enfermeiro possui um papel fundamental de educador e promotor da saúde e do bem-estar dos idosos em todas as áreas, incluindo a sexualidade. no que se refere à educação em saúde, ela pode ser uma estratégia elaborada com o intuito de construir uma nova imagem do idoso perante a sociedade, na qual ele possa expressar os seus sentimentos e vivenciar a sexualidade livre de preconceitos, mitos ou tabus. tais ações podem ser colocadas em prática nos diversos cenários disponíveis, por exemplo, nas consultas de enfermagem ou nos grupos de idosos. nesse contexto, destaca-se novamente a enfermagem, que promove a educação em saúde nos diferentes espaços de atuação profissional e nas diferentes temáticas, incluindo a educação sexual (12). de acordo com a temática exposta e com a necessidade de conhecer mais as atitudes da população idosa ante a sexualidade, esta pesquisa tem como objetivo identificar as atitudes que as idosas têm a respeito da sua sexualidade. 5 atitudes das idosas quanto à expressão da sua sexualidade l francielle garcia da silva e outros metodologia trata-se de um estudo exploratório e descritivo, de abordagem qualitativa, acerca das atitudes que as idosas têm a respeito da sua sexualidade. a pesquisa qualitativa permite analisar as experiências de indivíduos ou grupos que podem estar relacionadas a histórias biográficas ou a práticas educativas, além de permitir analisar o conhecimento, os relatos e as histórias do dia a dia da população em estudo (13). ainda, por meio dela, é possível compreender o universo das relações humanas estabelecidas no contexto da pesquisa, da observação e da interação do pesquisador com o participante do estudo (14). dessa forma, participaram do estudo 19 idosas integrantes de dois grupos de convivência para pessoas idosas situados na cidade de rio grande, rio grande do sul, brasil. os grupos de idosos, um de cunho privado e outro público, têm o foco em promover o bem-estar social, o envelhecimento ativo e a qualidade de vida dos seus integrantes com faixa etária a partir dos 60 anos. os grupos foram selecionados por apresentarem os maiores números de participantes, bem como pela maior oferta de atividades à comunidade idosa. assim, estima-se que 150 idosos participem das ações promovidas por esses grupos. as participantes foram selecionadas conforme os seguintes critérios de inclusão: idosas com 60 anos ou mais de idade; participação em um dos grupos há, pelo menos, três meses; autorização da publicação dos resultados em trabalhos científicos. os critérios de exclusão foram: não participar de forma assídua das atividades do grupo, ou seja, se as atividades do grupo acontecessem duas vezes por semana, não era considerada assídua a idosa que comparecesse uma vez a cada duas semanas. a coleta de dados, realizada pela mestranda em enfermagem, autora da pesquisa, teve início no mês de outubro de 2018, após a aprovação do projeto no comitê de ética e pesquisa da área de saúde da universidade federal do rio grande, sob o número 218/2018, e após a autorização dos grupos. a coleta dos dados ocorreu na sede dos grupos por meio da entrevista individual, semiestruturada e gravada em áudio. antes de serem realizadas as entrevistas, foi efetuado um primeiro contato, de forma presencial, com as participantes para explicar a temática da pesquisa, seus benefícios às pessoas idosas e questionar se elas gostariam de participar. para manter o anonimato das participantes e seguir os preceitos éticos previstos pela resolução 466/2012 do conselho nacional de saúde/ministério da saúde (cns/ms), cada idosa entrevistada foi representada pela letra i, seguida do número correspondente à sequência das entrevistas (exemplo: i1, i2, …, i19). as entrevistas foram realizadas individualmente em salas reservadas, com o intuito de garantir a privacidade das participantes, e duraram entre 15 e 20 minutos, em média. antes de iniciar a entrevista, foram esclarecidos os objetivos do estudo, a relevância da temática, a garantia do sigilo das informações, a possibilidade de cancelar a participação em qualquer momento sem prejuízo pessoal. todas as participantes assinaram o termo de consentimento livre e esclarecido. para a coleta dos dados, foi utilizado um instrumento semiestruturado, dividido em duas partes: a primeira parte foi referente aos dados de caracterização das participantes, e a segunda parte abordou as questões a respeito das atitudes sobre a sexualidade, que englobavam as mudanças observadas depois dos 60 anos de idade, os sentimentos auferidos ao falar sobre a temática, com quem conversa a respeito e a importância do relacionamento afetivo para o idoso. após a realização das entrevistas, os dados foram transcritos, organizados e tabulados de forma a facilitar o processo de análise. a técnica utilizada foi a análise temática segundo bardin (15), pois a coleta de dados torna-se mais concentrada e produtiva, sendo possível formular algumas questões mais específicas, o que auxilia na sistematização dos dados coletados (15). para bardin, fazer uma análise temática consiste em descobrir os “núcleos de sentido” que compõem as categorias temáticas. para compor esses núcleos, é necessário analisar se os elementos evidenciados na comunicação, a presença de significados marcantes ou a frequência de aparição destes podem significar algo para o objetivo analítico escolhido. assim, as etapas de pré-análise, de exploração do material, do tratamento dos resultados, da inferência e da interpretação são fundamentais (15). analisar os dados qualitativos significa “trabalhar” todo o material obtido durante a pesquisa. a tarefa de análise implicou, em um primeiro momento, transcrever os áudios registrados, organizar todo o material, dividi-lo em partes, relacioná-las e identificar as tendências e os padrões relevantes. em um segundo momento, essas tendências e padrões foram reavaliados a fim de buscar as relações e as inferências em um nível de abstração mais elevado. do trabalho de codificação, resultou um conjunto inicial de cate6 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1934 aquichan issn 1657-5997 eissn 2027-5374 gorias que foram reexaminadas e modificadas em um momento subsequente. a classificação e a organização dos dados foram preparadas para uma fase mais complexa da análise, que ocorreu à medida que a pesquisadora reportou os seus achados (16). na pré-análise, após a transcrição dos dados, foi desenvolvida uma leitura flutuante das entrevistas com vistas a visualizar as particularidades que contribuíssem para a elaboração das ideias iniciais sobre os traços de caracterização dos participantes. dessa forma, a partir da tabulação dos dados coletados, foram feitas várias leituras do conteúdo das entrevistas em uma tentativa de visualizar as particularidades de cada uma. realizou-se, ainda, uma nova leitura detalhada das 19 entrevistas obtidas, com o objetivo de identificar os núcleos de sentido quanto aos objetivos da pesquisa, as quais foram transcritas no programa pages e tabuladas no programa numbers para que se tivesse uma melhor visualização e organização dos dados. já na fase de exploração do material, foram executadas operações de codificação das entrevistas com números e letras, de forma que os recortes mais importantes da pesquisa fossem agrupados em “núcleos de sentido” semelhantes ou afins que deram origem aos “temas” ou às “categorias” (15). na fase de tratamento dos resultados, foram realizadas a análise e a discussão das respostas, baseadas no referencial já exposto e na sensibilidade e experiência adquirida na trajetória da pesquisa. após terminar a análise das categorias, as informações foram entregues aos participantes a fim de que validassem os resultados obtidos. resultados a população da pesquisa foi composta por 19 idosas; a faixa etária foi compreendida entre 60 e 85 anos; destas 8 tinham entre 60 e 69 anos; 15 se autodeclararam brancas. quanto ao estado civil, 8 eram casadas e 8 viúvas; 10 das entrevistadas declararam-se católicas; 7 tinham como renda mensal um salário-mínimo e 7 recebiam dois salários-mínimos. em relação à escolaridade, 6 disseram ter o ensino fundamental incompleto. no tocante às patologias, 7 idosas afirmaram ter hipertensão arterial sistêmica (has), no entanto 6 realizam o tratamento medicamentoso para o controle da doença. por meio da análise de dados, foi possível elaborar três categorias e as suas respectivas subcategorias, descritas a seguir. mudança na expressão da sexualidade após os 60 anos nesta categoria, as participantes relataram que houve mudanças decorrentes da idade e do condicionamento físico, mas nada que pudesse impedir de seguir ativamente com a expressão da sexualidade. mudou um pouco, já não sou mais jovem, não tenho o mesmo fôlego, mas não é por isso que deixo de ser ativa sexualmente. (i2) claro, a gente vai adquirindo algumas limitações com a idade, mas nada que impeça de se relacionar sexualmente até porque a chama não apaga, a vontade não desaparece com o tempo [risos]. (i3) já outras idosas relataram que a mudança acerca da sua sexualidade ocorreu devido a não ter um parceiro fixo ou por não haver mais o interesse em se relacionar sexualmente. a gente não dá muita importância ao sexo, mas quando tem carinho, resolve tudo. mas mudou também porque não tenho um parceiro fixo. (i5) e também vai depender da pessoa que está com a gente, da companhia... porque, se tiver um companheiro que seja carinhoso, de repente acontece. (i6) ainda, algumas idosas relataram que a expressão da sexualidade mudou antes de completarem os 60 anos de idade devido às alterações decorrentes da menopausa, que interfere diretamente no desejo de se relacionar sexualmente. além disso, outro fator que foi citado como motivo da mudança foi a viuvez. ah, mudou. não sou a mesma. o doutor me disse que meus ovários estão murchos, é normal, mas tem gente que não acontece. acho que isso também tira a vontade da pessoa. (i7) muda muito, depois dos 60 anos muda para qualquer pessoa. depois que a pessoa para de menstruar, que os hormônios diminuem, muda para qualquer um. (i8) para mim mudou antes, quando fiquei viúva, porque não tive mais relações. mas não foi algo ruim, foi decisão minha mesmo. (i13) bah, para mim mudou antes do 60, quando o meu marido faleceu e não tive mais ninguém desde os 37 anos. (i14) 7 atitudes das idosas quanto à expressão da sua sexualidade l francielle garcia da silva e outros por fim, algumas participantes afirmaram que não notaram mudanças decorrentes da idade que afetassem a sua sexualidade. não, eu acredito que não. continuo igual, para mim sempre foi uma coisa satisfatória, quando eu era casada com o meu marido, ele era uma pessoa muito carinhosa. e atualmente, o meu ficante é muito bom de cama, e é mais jovem do que eu. (i9) não, eu acho que continua a mesma coisa. me considero como uma guria de 15 anos, só que mais madura, sei aproveitar melhor, e eu não tenho mais aquela fragilidade, medo, é tudo normal. (i19) os sentimentos auferidos ao falar acerca da sexualidade esta categoria descreve os relatos acerca dos sentimentos que as idosas demonstraram ao serem questionadas quanto à sexualidade. a maioria das entrevistadas afirmou que trata o assunto com normalidade, visto que é algo inerente ao ser humano. eu falo normal, não tenho sentimos de vergonha, de nada. é tudo normal para mim. (i19) nada, para mim é normal, faz parte da vida. tem idosos que não gostam de falar, ficam constrangidos, mas eu não. (i2) já outras participantes referiram que não sentem nenhum tipo de constrangimento ou outros sentimentos, porém não gostam de falar sobre o assunto. ah, não sinto nada, mas às vezes eu não quero nem falar (risos). para não relembrar, entende? deixa quietinho… (i10) não, eu não tenho vergonha para falar. mas não que eu ache que é bom falar [...]. (i11) falaram ainda que não sentem vergonha ou que dispunham de outros sentimentos, mas que essa neutralidade ou ausência de sentimentos vai depender do ambiente em que estão inseridas e das pessoas com quem conversam. ah, dependendo com quem você fala, quando se fala certas coisas. mas eu não sentiria vergonha. (i1) eu não tenho vergonha para falar, mas vai depender do ambiente e com quem vou falar. [...] filhos a gente fica constrangido, ainda mais que só tenho homem, a nora também não tenho muito acesso. (i6) ainda, surgiu, nesta categoria, o sentimento de vergonha devido à temática não ter sido abordada com naturalidade pela família, quando jovem, culminando em um sentimento que se perdurou ao longo da vida. também foi citado que haveria constrangimento se tivesse que conversar sobre sexualidade com alguém do sexo oposto. vergonha de falar, até mesmo pela criação mais reservada que se teve na minha época, de tudo ser proibido, velado. (i3) a gente, mulher falando, eu não tenho constrangimento, mas se fosse um rapaz, teria sim. (i5) com quem conversa sobre sexualidade esta categoria emergiu dos relatos das idosas quando questionadas sobre quem elas procurariam caso tivessem algum questionamento sobre a sexualidade. a maioria expôs que iria buscar, primeiramente, apoio com os amigos. eu tenho uma amiga minha, muito coisa eu aprendi com ela. (i1) com as amigas. (i3) eu falo com a minha amiga, ela gosta dessas coisas. [risos] (i7) quanto à busca por profissionais para o esclarecimento de dúvidas, algumas disseram que buscariam auxílio dos profissionais da saúde, seja de enfermeiros, seja de médicos. falaria com a minha chefe, enfermeira. a gente é muito amiga mesmo, aí se eu preciso, falo com ela. (i5) olha, eu no momento procuraria a ginecologista, principalmente porque ela é muito minha amiga, a gente conversa muito, [...] tenho liberdade com ela. (i6) com médico ou enfermeira também. (i17) no entanto, por outro lado, algumas entrevistadas afirmaram que nunca conversaram sobre suas dúvidas com alguém. olha, na realidade, eu nunca conversei sobre isso com alguém, é a primeira vez. a minha mãe era muito rígida, naquela época não se podia falar. eu aprendi tudo sozinha mesmo. (i15) com ninguém, depois da minha cirurgia mioma, nunca mais procurei alguém. (i12) talvez uma amiga, mas eu nunca falei disso aí. (i4) 8 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1934 aquichan issn 1657-5997 eissn 2027-5374 a importância do relacionamento afetivo para o idoso as idosas relataram, nesta categoria, a importância de ter alguém para se relacionar tanto sexual quanto afetivamente. tem sim, ainda mais se tiver um parceiro amoroso, carinhoso. é bom para se sentir amada, cuidada, viva, sentir prazer. (i12) claro que deve, faz bem para o corpo, para a mente. (i2) só se não quiser, mas pode e deve porque é bom e faz bem para a pele. (i5) deve-se relacionar sim até para envelhecer mais devagar. (i3) por outro lado, algumas expressaram que a importância de ter um relacionamento afetivo vai depender das necessidades de cada indivíduo, da sua saúde, se ele quer ou não seguir se relacionando com alguém. vai depender da vontade e necessidade da pessoa. (i13) acho que deve sim, vai da cabeça da pessoa, da vontade, da vida, da saúde porque tem pessoas que querem, mas não conseguem fazer. (i17) já outras disseram que talvez se relacionassem novamente, porém a família, principalmente os filhos e os ex-maridos, tornam-se um grande obstáculo e não aceitam que voltem a se relacionar por vários motivos, entre eles, o ciúme e a não aceitação de um companheiro. faz um ano que briguei com o meu companheiro e bastou, não fiz mais nada. mas era muito bom. era meu namorado e eu sinto falta, mas não tem como voltar, a minha família também deu contra, então eu também não quero mais, foi bom enquanto durou. (i10) se aparecer alguém, a minha filha me mata. ela já me disse: se tu me aparecer com velho aqui, tu vai ver, eu pego as minhas coisas e vou me embora [...] (i7) estou sozinha, mas sinto falta de sexo porque eu sou sadia, então de noite eu fico pensando nessas coisas e tudo, mas não posso ter ninguém porque meu ex-marido é muito ciumento e na cabeça dele nós ainda estamos juntos, e ele não aceita. (i17) discussão a velhice pode apresentar desafios para permanecer com a sexualidade ativa e saudável (17). porém, este estudo demonstrou que a maioria das idosas não apresentou mudanças significativas que interferissem de forma negativa na expressão da sexualidade após os 60 anos de idade. em algumas falas, foi possível identificar que a sexualidade se tornou melhor e mais prazerosa com o passar dos anos, superando até mesmo as experiências de quando eram jovens. algumas participantes afirmaram que notaram mudanças no condicionamento físico, mas que, nem por isso, deixavam de expressar a sua sexualidade ou de serem ativas sexualmente. um estudo evidencia que os idosos continuam ativos sexualmente nos seus 70 e 80 anos, e que as mudanças físicas associadas ao envelhecimento não reduzem, necessariamente, a capacidade sexual (18). no entanto, as idosas relataram que houve mudanças na sua sexualidade devido à ausência de parceiro fixo, e que isso foi uma mudança negativa na vida delas. já outras relataram que a vontade de expressar a sua sexualidade mudou porque não existia mais o interesse em se relacionar com alguém novamente. para muitas pessoas idosas, a sexualidade pode não ter um papel importante em suas vidas, seja por não ter um parceiro, seja por ter alguma barreira física ou por não ter interesse em mantê-la (19). se o idoso tiver essa decisão, os profissionais da saúde, amigos e familiares devem respeitá-la. as demais afirmaram que as mudanças ocorreram muito antes dos 60 anos, ao passarem pelo período da menopausa e por todas as alterações hormonais desencadeadas por ela. durante o envelhecimento humano, podem surgir intercorrências em relação ao processo saúde e doença que trazem repercussões significativas e marcantes na vida dos indivíduos, impactando diretamente na qualidade de vida, nos relacionamentos e no que diz respeito à sexualidade humana. dentre elas, estão a menopausa, a diminuição da libido sexual, a incontinência urinária, alguns tipos de cânceres, a utilização de medicamentos, entre outras (20). além da atividade sexual, cabe salientar que a manifestação da sexualidade pode ser expressa pelo desejo, pela possibilidade de estar conectado a alguma pessoa ou objetos, a ideias e a ideais (21). 9 atitudes das idosas quanto à expressão da sua sexualidade l francielle garcia da silva e outros em qualquer idade, é sempre tempo de viver, de expressar os seus sentimentos e a individualidade que constitui o ser humano. o amor, o afeto e a intimidade são elementos fundamentais para promover o bem-estar e a qualidade de vida do indivíduo (22). quanto aos sentimentos auferidos ao falar sobre sexualidade, a maioria das idosas declarou que se sente normal e que não há constrangimentos, visto que essa temática é algo inerente ao ser humano. de acordo com essa declaração, em um outro estudo realizado, 66 % dos idosos entrevistados se mostraram à vontade em falar sobre tal assunto. eles também acreditavam que a sexualidade é algo normal da vida do ser humano e que não é diferente por serem idosos (23). porém, despontou-se o sentimento de vergonha ao falar sobre esse assunto, e tal sentimento seria potencializado se a entrevista fosse realizada por alguém do sexo oposto. a sexualidade é um assunto tão privado ao ponto de o idoso não conseguir discutir abertamente com outras pessoas, nem mesmo com os profissionais da saúde. o desconforto gerado acaba inibindo-os de falar sobre a sua vida sexual, suas dúvidas ou dificuldades (24). tal ação é muito perigosa, pois, dessa forma, o indivíduo acaba não tendo acesso a informações e orientações, expondo, assim, a sua saúde a riscos e agravos que poderiam ser evitados com uma simples ação de prevenção. mas, nesta pesquisa, a maioria das idosas falou que, em caso de dúvidas relacionadas à sexualidade, primeiramente, elas procuravam a sua rede de amigos para conversar. depois, outras verbalizaram que procuravam a enfermeira da atenção primária mais próxima da sua casa ou então consultavam o médico ginecologista. esse achado vai de encontro com o estudo no qual os autores expõem que, em caso de dúvidas, 62 % dos idosos procuravam primeiramente os profissionais da saúde para conversar; em seguida, 36 % o parceiro; 17 % ninguém e 10 % a família, os amigos ou outros. portanto, na maioria dos entrevistados, os profissionais da saúde foram citados como a primeira fonte de apoio que os idosos procuravam para sanar as suas dúvidas. diferentemente desta pesquisa, em que os idosos citaram como primeira fonte de apoio os amigos. além disso, outro dado que emergiu foi que, se as idosas tivessem algum tipo de dúvida, elas não procuravam alguém para conversar, pois acreditam que, por ter mais idade, já não possuem mais dúvidas ou que não precisam esclarecê-las, seja porque já não têm mais companheiro, seja porque não têm interesse em buscar novos conhecimentos. de acordo com essa afirmação, um estudo demonstrou que 53,3 % dos idosos também não conversavam sobre os assuntos relacionados à sexualidade e, em caso de dúvidas, não houve o interesse nem a preocupação em saná-las (25). com isso, infere-se que esse assunto ainda é um tabu na sociedade, para os próprios idosos e, até mesmo, para os profissionais da saúde. no entanto, existem alguns profissionais que reconhecem a importância da sexualidade na saúde dos idosos, mas que não se consideram totalmente qualificados para discutir especificamente sobre isso (26). considerando que os enfermeiros têm papel importante no que se refere à promoção de uma sexualidade saudável durante a velhice, é fundamental formá-los com conhecimentos específicos na área, sensibilizá-los e conscientizá-los acerca da problemática, o que lhes permitiria prestar cuidados de excelência aos idosos (27). há evidências de que, quando os enfermeiros são mais capacitados para lidar com a sexualidade da pessoa idosa, eles acabam dispondo de clareza e honestidade para falar sobre os assuntos que norteiam essa temática de forma mais aberta, sem preconceitos. e, com isso, eliminam os tabus socioculturais, o que leva à manutenção da qualidade de vida dos idosos (28, 29). por fim, na última categoria abordada nos resultados, questionou-se acerca da importância do relacionamento afetivo para o idoso. algumas participantes mencionaram que é muito importante ter alguém ao lado, em virtude dos benefícios voltados à saúde, ao corpo, à mente, entre outros. a importância de se relacionar com alguém também foi citada em outro estudo, em que 40 % dos entrevistados afirmaram ser muito importante ter um companheiro, principalmente no que se refere à continuidade das relações sexuais. esses resultados apresentam uma superação do estereótipo, o qual foi criado e mantido pela sociedade ao longo dos anos, de que o idoso não tem mais o interesse pelo sexo ou por outras formas de expressão da sua sexualidade (25). todavia, alguns participantes disseram que, para ter um novo relacionamento afetivo, vai depender da necessidade e da vontade de ter alguém ao lado. cada pessoa tem a sua forma de vivenciar a sexualidade e, para compreendê-la, é preciso levar em conta e respeitar a cultura, a religião e a educação, pois esses valores influenciam direta e intensamente no desenvolvimento da sexualidade (30, 31). 10 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1934 aquichan issn 1657-5997 eissn 2027-5374 de outro ponto de vista, as idosas declararam que talvez tivessem um novo relacionamento amoroso, mas a família e, até mesmo, os ex-cônjuges se mostram contra essa vontade e proíbem um novo relacionamento, sendo um dos motivos o ciúme. com isso, privam a pessoa idosa de tomar as suas próprias decisões da sua vida. o desejo de ter um novo relacionamento continua sendo negligenciado pela sociedade, pela família ou pelos profissionais da saúde, os quais mantêm a ideia de que o idoso é assexuado (31). a repressão da sexualidade por parte da família é uma das barreiras mais difíceis que os idosos enfrentam, pois, muitas vezes, eles são proibidos de vivenciar os seus prazeres, tendo que aceitar a vontade imposta pelos familiares, principalmente quando moram no mesmo teto dos filhos, por exemplo (32). quanto a essa opressão familiar e social, ela desencadeia a inversão de papéis em que o idoso perde o comando da sua vida e precisa se adaptar e se submeter à nova realidade. além disso, os filhos veem a sexualidade dos pais como algo inapropriado e depreciativo (33). um outro estudo evidencia também que, em 53 % dos casos, a família interfere diretamente no desejo do idoso de se relacionar sexualmente e limita-o (25). isso demonstra que não se considera que algumas pessoas idosas permanecem sexualmente ativas na velhice, e que o desejo de expressão e realização sexual não desaparece (34). além disso, não se leva em conta que a sexualidade é um componente importante da identidade humana e construído ao longo do ciclo da vida e que não pode ser suprimido à força da vida da pessoa idosa. limitações do estudo: poucos idosos aceitaram participar da pesquisa, o que reforça a ideia de que a sexualidade durante a velhice ainda é permeada por tabus e preconceitos. contudo, é importante destacar que, mesmo com um número reduzido, os objetivos da pesquisa foram alcançados. considerações finais a partir do exposto, pode-se concluir que as idosas demonstraram ter atitudes favoráveis quanto à sua sexualidade. os achados principais desta pesquisa evidenciam que os participantes, em sua maioria, não notaram mudanças significativas na expressão da sua sexualidade após completarem 60 anos de idade. percebe-se que a capacidade de se manifestar sexualmente não é perdida ao longo do processo de envelhecimento, ela apenas se transforma, visto que a grande parte dos idosos continua mantendo a sexualidade ativa. para a maioria das idosas entrevistadas, o relacionamento afetivo, amoroso e sexual é extremamente importante, devido à capacidade de promoção do bem-estar físico e mental na vida do ser humano, além de proporcionar sentimentos de alegria e felicidade, fazendo com que elas tenham mais vitalidade e mais prazer em viver. por fim, cabe ressaltar a importância do profissional da área da enfermagem na promoção da educação em saúde, da qualidade de vida e da criação de uma nova imagem do idoso diante da sociedade, na qual ele possa expressar os seus sentimentos e vivenciar a sexualidade livre de preconceitos, mitos ou tabus. tais ações podem ser colocadas em prática nos diversos cenários de atuação desses profissionais, como nas consultas de enfermagem ou nos grupos de idosos. conflito de interesse: nenhum declarado. 11 atitudes das idosas quanto à expressão da sua sexualidade l francielle garcia da silva e outros referências 1. instituto brasileiro de geografia e estatística. número de idosos cresce 18 % em 5 anos e ultrapassa 30 milhões em 2017 [internet]. brasília, df: ibge; 2017 [acesso em 20 jul. 2018]. disponível em: 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paul enferm. 2012; 25(esp. 1):115-2. doi: http://dx.doi.org/10.1590/s0103-21002012000800018 33. neto fad, santana mas, lucena ecl, soares mcs, lima kmm. sexualidade na terceira idade: compreensão e percepção do idoso, família e sociedade. rev univ vale rio verde. 2014; 12(1):317-6. disponível em: http://periodicos.unincor.br/ index.php/revistaunincor/article/view/1385/pdf_115. doi: http://dx.doi.org/10.5892/ruvrd.v12i1.1385 34. mahieu l, gastmans c. sexuality in institutionalized elderly persons: a systematic review of argument-based ethics literature. international psychogeriatrics. 2012; 24(3):346-57. doi: http://dx.doi.org/10.1017/s1041610211001542 http://dx.doi.org/10.1111/jan.12398 http://dx.doi.org/10.1111/jan.12398 http://www.seer.ufsj.edu.br/index.php/recom/article/view/913/930 https://webcache.googleusercontent.com/search?q=cache:ojmst4wox2oj:https://revistas.pucsp.br/kairos/article/download/12636/12676+&cd=2&hl=es&ct=clnk&gl=co 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http://dx.doi.org/10.1590/s0104-12902015132060 http://dx.doi.org/10.1590/s0103-21002012000800018 http://periodicos.unincor.br/index.php/revistaunincor/article/view/1385/pdf_115 http://periodicos.unincor.br/index.php/revistaunincor/article/view/1385/pdf_115 http://dx.doi.org/10.5892/ruvrd.v12i1.1385 http://dx.doi.org/10.1017/s1041610211001542 6-7 correo del lector.p65 revista aquichan issn 1657-5997 año 7 vol. 7 nº 1 • chía, colombia abril 2007118 año 7 vol. 7 nº 2 • chía, colombia octubre 2007118 las transiciones y la salud de la mujer el artículo sobre las transiciones y la salud de la mujer en el embarazo y en el posparto, publicado en el vol. 7, nº 1 de 2007, se convierte en una orientación que surge de la investigación y su comparación con una teoría de rango medio, como la de las transiciones de meleis, messias y shumacher, lo cual es de gran utilidad para la comprensión holística de eventos que ocurren en las mujeres durante la gestación y el posparto. en ese sentido, el artículo ofrece una clara descripción de las transiciones durante el embarazo y el posparto, vividas por las mujeres del estudio y comparadas a la luz de la teoría de las transiciones, y ofrece una ruta para brindar un cuidado de enfermería apropiado, de acuerdo con las condiciones, las características, los patrones e indicadores de las transiciones presentadas. sobresalen de manera importante los momentos críticos y los recursos con que cuentan las madres para el paso saludable de la transición. al respecto vale la pena señalar como momentos críticos la noticia del embarazo, y el inicio y sostenimiento de la lactancia durante el posparto, pero si se cuenta con recursos como el apoyo social, proveniente de las redes sociales informales como esposo, familia y amigos, los resultados para este grupo de mujeres se representan en su empoderamiento, autonomía y toma de decisiones. es conocido y aceptado que durante la gestación y el posparto se presentan diversos cambios que afectan la estabilidad de la mujer y su familia, y que estos cambios trascienden la esfera biológica, hacia lo comportamental, lo social y lo cultural, con efectos que pueden alterar la salud de la mujer y de su hijo por nacer, pero con afrontamientos que las mujeres realizan para hacer una mejor adaptación. estos procesos, generalmente, son desconocidos por los prestadores de servicios de salud, y son las enfermeras, quienes en la búsqueda para ofrecer cuidado de enfermería, vislumbran conocimientos y acciones que pueden contribuir a esclarecer estas situaciones. tal es el caso del aporte que hace este tipo de investigaciones y de la teoría de las transiciones, que por su carácter de rango medio es de fácil aplicación a la práctica de los cuidados de enfermería. por lo anterior, este trabajo de canaval, jaramillo, rosero y valencia, aporta significativamente al rescatar en las personas dimensiones olvidadas, para ofrecerles un mejor cuidado, tales como: el tener seguridad social, poseer vivienda, sus creencias, su espiritualidad, el apoyo social, sus momentos críticos, y los recursos con que cuentan para realizar transiciones saludables. el artículo, además, es un recurso para el aprendizaje de este tipo de estudios cualitativos y su análisis a la luz de una teoría de rango medio, para su posterior aplicación a la práctica. ofrece además variedad de recurso bibliográfico que posibilita la ampliación de estos temas a los interesados. lucy muñoz de rodríguez enfermera, magíster en enfermería con énfasis en salud familiar; facultad de enfermería, universidad nacional de colombia bogotá, colombia. correo del lector 119 el subsistema cognitivo en la etapa preescolar el artículo �el subsistema cognitivo en la etapa preescolar� me parece muy interesante, ya que su aplicación es pertinente no sólo para la estudiante de pregrado sino dentro de la especialización de enfermería porque hace un abordaje completo desde el modelo de calixta roy en lo que se refiere a la adaptación y el afrontamiento del niño en la etapa preescolar, teniendo en cuenta además los conceptos de muchos autores a la hora de definir esta etapa y los cambios presentes en el niño típico de esta edad. si bien la valoración de enfermería que se hace al niño preescolar es difícil por su transición de lo imaginario a un mundo más real, el artículo orienta al lector sobre lo que se debe tener en cuenta para hacerla de manera adecuada y dinámica; los cambios en cada una de las áreas como lenguaje, juego, pensamiento, religión, etc., y la forma como se describen aquí facilitan este proceso. cuando se hace una lectura acerca de un tema determinado se espera ver su utilidad y aplicabilidad durante las intervenciones que realiza la enfermera en el día a día, me parece que en este caso se da porque su contenido cumple con las expectativas del lector, pues es claro y completo. amanda guacaneme enfermera fundación cardio infantil cuidado crítico pediátrico bogotá, colombia. adquiriendo la habilidad en el cuidado tuve la oportunidad de leer el artículo �adquiriendo la habilidad en el cuidado: de la incertidumbre al nuevo compromiso�, presentado por alejandra maría alvarado garcía en la reciente edición del 2007. la autora da cuenta de las experiencias de los cuidadores en el tiempo, y de cómo se van produciendo los cambios antes, durante y después de su participación en el programa cuidando a los cuidadores. la indagación y el entendimiento del complejo mundo de las experiencias vividas por los cuidadores se recorre solo en el terreno de la investigación cualitativa, fuente de evidencia y tipo de estudio que se adecua muy bien al ser y quehacer de enfermería. en palabras de swanson y chenitz citada por c. de la cuesta, �la enfermería tiene una posición privilegiada para explicar a otros el mundo del enfermo, su familia y los procesos que acontecen en el interior; enfermería conoce esos mundos como no lo hace otra disciplina�. en la actualidad, un grupo de docentes de la facultad ciencias de la salud de la universidad francisco de paula santander adelantan el estudio liderado por la universidad nacional de colombia sobre implementación y evaluación en red del programa cuidando a los cuidadores; la calidad del estudio lo convierte en fuente obligada de consulta en el análisis de los resultados obtenidos del proyecto en ejecución. en visita de maría clara quintero l. a nuestra institución nos enteramos de la reindexación a la categoría b de la revista aquichan, mi reconocimiento a la directora y al consejo editorial por el logro alcanzado. éxitos. olga marina vega angarita directora grupo de investigación cuidado de enfermería, universidad francisco de paula santander. cúcuta, colombia. maternal perception of the child’s weight, lifestyle problems and self-efficacy to deal with them article maternal perception of the child’s weight, lifestyle problems and self-efficacy to deal with them percepción materna del peso del hijo, problemas del estilo de vida y autoeficacia para manejarlos percepção materna do peso do filho, problemas do estilo de vida e autoeficácia para lidar com eles 10.5294/aqui.2021.21.2.8 yolanda flores-peña1 hermelinda ávila-alpirez2 1 https://orcid.org/0000-0001-6200-6553. universidad autónoma de nuevo león, mexico. yolanda.florespe@uanl.edu.mx 2 https://orcid.org/0000-0001-5286-5944. universidad autónoma de tamaulipas, mexico. havila@docentes.uat.edu.mx received: 26/08/2020 sent to peers: 22/10/2020 approved by peers: 29/04/2021 accepted: 07/05/2021 topic: promotion and prevention. contribution to the subject: nursing can participate in the promotion of adequate maternal perception of the child’s weight and enhance self-efficacy in mothers of children with overweight-obesity, who perceive more lifestyle behavior problems and less self-efficacy to deal with them. to reference this article / para citar este artículo / para citar este artigo: flores-peña y, ávila-alpirez h. maternal perception of the child’s weight, lifestyle problems and self-efficacy to deal with them. aquichan. 2021;21(2):e2128. doi: https://doi.org/10.5294/aqui.2021.21.2.8 abstract objectives: to associate the maternal perception of the child’s weight (mpcw) and the child’s nutritional status. to describe child’s lifestyle behavior problems (clbps) and maternal self-efficacy (se) to deal with them, as well as to verify differences according to children with and without overweight-obesity (ow-ob) and mpcw. material and methods: there was participation of 274 dyads (mother-preschool child). mpcw was assessed through words and images. the mothers answered the lifestyle behaviour checklist. the child’s weight and height were measured. results: 18.8 % (n = 13) of the mothers of children with ow-ob and 78.8 % (n = 160) of the mothers of children without ow-ob obtained adequate mpcw values through words (x2 = 77.759; dof = 1; p < .001). it was identified that the mothers of children with ow-ob reported more clbps and less se. when the child’s ow-ob is perceived through words, there are more clbps (f = 17.041; p = .001) and less se (u = 1,118; p = .015). conclusions: inadequate mpcw was predominant in mothers of children with ow-ob. when ow-ob is perceived, there are more clbps and fewer se. it is recommended to promote adequate mpcw, particularly in mothers of children with ow-ob. images assist in the identification of the child’s ow-ob more than to classify it into a category. keywords (source decs): weight perception; self-efficacy; problem behavior; obesity; preschool child. resumen objetivos: asociar la percepción materna del peso del hijo (pmph) y estado nutricional del hijo. describir problemas conductuales del estilo de vida del hijo (pcev) y autoeficacia materna (ae) para manejarlos, verificar diferencias conforme a con y sin sobrepeso-obesidad (sp-ob) del hijo y pmph. material y métodos: participaron 274 diadas (madre-hijo preescolar). la pmph se evaluó por palabras e imágenes. las madres contestaron la lista de verificación de conductas del estilo de vida. se midió peso y talla del hijo. resultados: 18.8 % (n = 13) madres de hijos con sp-ob y 78.8 % (n = 160) madres de hijos sin sp-ob tuvieron pmph adecuada por palabras (x2 = 77.759, gl = 1, p < .001). las madres de hijos con sp-ob tuvieron que manejar más baja ae y más pcev. cuando las madres perciben el sp-ob del hijo por palabras, tienen menor ae (u = 1118, p = .015) y más pcev (f = 17.041, p = .001). conclusiones: predominó pmph no adecuada en madres de hijos con sp-ob. cuando se percibe el sp-ob, más pcev y menor ae. se recomienda promover pmph adecuada particularmente en madres de hijos con sp-ob. las imágenes ayudan a reconocer el sp-ob del hijo más que a clasificarlo en una categoría. palabras clave (fuente decs): percepción del peso; autoeficacia; problema de conducta; obesidad; preescolar. resumo objetivos: associar a percepção materna do peso do filho (pmpf) e o estado nutricional dele. descrever problemas comportamentais do estilo de vida do filho (pcev) e autoeficácia materna (ae) para lidar com eles, verificar diferenças entre com e sem excesso de peso-obesidade (ep-ob) do filho e pmpf. materiais e métodos: participaram 274 díades (mãe-filho em idade pré-escolar). a pmpf foi avaliada por meio de palavras e imagens. as mães responderam à lista de verificação de comportamentos do estilo de vida. peso e altura do filho foram medidos. resultados: 18,8 % (n = 13) mães de filos com ep-ob e 78,8 % (n = 160) mães de filhos sem ep-ob tiveram pmpf adequada por palavras (x 2 = 77.759; gl = 1; p < ,001). foi identificado que as mães de filhos com ep-ob referiram mais pcev e menos ae. as mães de filhos com ep-ob tiveram que lidar com mais baixa ae e mais pcev. quando as mães percebem o ep-ob do filho por palavras, têm menos ae (u = 1118, p = ,015) e mais pcev (f = 17,041, p = ,001). conclusões: pmpf não adequada predominou em mães de filhos com ep-ob. quando o ep-ob é percebido, mais pcev e menos ae. promover pmpf adequada particularmente em mães de filhos com ep-ob é recomendado. as imagens ajudam a reconhecer o ep-ob do filho mais do que a classificá-lo numa categoria. palavras-chave (fonte: decs): percepção de peso; autoeficácia; comportamento problema; obesidade; pré-escolar. introduction childhood obesity is one of the most severe public health problems of the 21st century. its prevalence has been increasing at an alarming pace. in 2016, more than 41 million children aged less than 5 years old worldwide were overweight or obese (1). multiple factors contribute to excess weight during childhood, such as high consumption of fat and sugar and reduced physical activity (2), as well as false traditional beliefs regarding health and nutrition (3). excess weight during childhood has repercussions on health, such as hyperlipidemia, hypertension, and abnormal tolerance to glucose. in addition, it has been documented that an overweight 5-year-old child has 4 times more chances of presenting obesity at the age of 9 when compared to a child with normal weight at the same age (4). during childhood, and according to the traditional gender role, the mother is the main caregiver (5), the reason why she is in a unique position to exert an influence on her child’s lifestyle behaviors. however, the literature has documented that the mothers of overweight-obese children have an inadequate perception of the child’s weight: they underestimate it (6-10). therefore, they could be less willing to motivate them to participate in healthy behaviors and less likely to resort to health services (6). likewise, it has been documented that the mothers of children aged between 2 and 6 years old present more chances of underestimating overweight and obesity in their children (9). assessing how the mother perceives her child’s body weight is a previous step to involving her in programs to prevent and treat excess weight in childhood. the maternal perception of the child’s weight (mpcw) is the mother’s opinion regarding the child’s body weight, formulated based on the recognition of body size, standards related to body weight, health and beliefs associated with upbringing (11). in addition, it has been documented that mothers of children with overweight-obesity need to deal with the children’s lifestyle behavior problems (clbps) linked to childhood obesity, such as: demanding extra helpings at meals or watching too much television; and they report less self-efficacy (se) to deal with these problems when compared to the mothers of children with normal weight (12-14). self-efficacy allows the caregiver, in this case, the mother, to perceive her own ability and competence to exert a positive influence on the children’s behaviors, upbringing and development. the concept of self-efficacy was proposed by bandura in 1977 as a core cognitive element to explain the acquisition, maintenance and changes of human behavior, along with other variables of the social cognitive theory (15). as already pointed out, most of the mothers of children with overweight-obesity present inadequate mpcw; in addition, they have fewer chances of participating in programs to lose weight (6), as well as less motivation to help the children reduce their body weight and foster healthy behaviors (16). on the other hand, several studies conducted with adolescents and adults have found that an adequate perception of overweight-obesity is associated with depression and with unhealthy behaviors that could favor weight gain (17). however, up to date, it has not been explored if the clbps and se to deal with them differ according to an adequate maternal perception of overweight-obesity in preschool children. given the above, this research study was conducted with the following objectives: 1) to associate mpcw with the child’s nutritional status, 2) to describe the clbps and verify if they differ according to children with and without overweight-obesity, 3) to describe se and verify if it differs according to children with and without overweight-obesity; and 4) to evaluate if the clbps and se differ according to mpcw. given that nursing is the first contact of the user with the health services, it is considered that the knowledge that is generated could ground nursing actions targeted at preventing and treating childhood overweight-obesity, promoting adequate mpcw, and implementing actions targeted at reducing the clbps that are identified, as well as offering strategies to strengthen se to deal with them. material and methods design a correlational and cross-sectional study. inclusion criteria women who identified themselves as mothers of preschool children enrolled in the selected educational institutions. women who were able to read and write to answer the questionnaires. exclusion criteria questionnaires in which the mothers reported that the preschool children had some diseases affecting their development, such as endocrine disease and asthma. participants and sample the participants were preschool children and their mothers, the latter being recruited for having their children enrolled in 4 public educational institutions attended by 524 preschoolers. recruitment was conducted in 2016 and the institutions belonged to school zone no. 1 of the metropolitan area of monterrey, nuevo león, mexico. the zone was randomly selected from the list provided by the public education secretariat. to calculate the sample, the nquery advisor package, version 4.0, was used for means comparison of se according to mpcw with and without ow-ob, a bilateral significance level of .05 and power of 95, which resulted in 270 participants. subsequently, using cluster-stratified sampling, where the schools were the strata and the groups were the clusters, the groups were randomly selected, and 300 mothers were invited to participate. a total of 274 dyads (mother-preschool child) were considered for the analysis; the questionnaires in which the mothers reported that the children had some disease (n = 8) were excluded, as well as incomplete questionnaires (n = 12) or those with duplicate answers (n = 6). study variables and measurements mpcw was the mother’s perception regarding her preschool child’s weight, which was assessed through two methods. in the first, called perception through words, the mothers answered the following question: “i believe that my child is”, with the following answer options: a) “underweight”, b) “slightly underweight”, c) “around normal weight”, d) “slightly overweight”, and e) “overweight”. this corresponds to the physical appearance and health perceptions questionnaire (18); it was considered adequate when the mother’s report was in agreement with the nutritional status assessed in the child (19). it is worth noting that, in the mothers of children with overweight-obesity, when inadequate mpcw is present it corresponds to underestimation; regarding the mothers of children with low or normal weight, it can present underestimation or overestimation. in addition, mpcw was assessed through images with a panel containing 7 images according to the child’s gender and age (18). it was considered adequate when a) the mothers of children with low weight selected images 1 and 2 to the right, b) the mothers of children with normal weight selected images 3, 4, or 5 in the center, and c) the mothers of children with overweight-obesity selected images 6 or 7 to the left. the mothers also answered the lifestyle behaviour checklist questionnaire (12), which presents 25 different child’s lifestyle behaviors related to childhood obesity. they are asked to indicate to what extent each of these behaviors represents a problem, for example: demands extra helpings at meals, with likert-type answers, namely: 1) not at all, 2) and 3) a little, 4) somewhat, 5) and 6) very much, and 7) a lot, with a minimum score of 25 and a maximum score of 175, where higher scores indicate that the behavior is perceived as a problem. subsequently, they are asked to select from 1 to 10 to indicate how confident they feel to deal with each of the behaviors, where 1 represents no confidence and 10 means feeling confident. in case the behavior is not occurring, they are asked to indicate how confident they feel that they could deal with it if it did occur; the minimum score is 25 and the maximum score is 250, where higher scores represent greater self-efficacy. this questionnaire has reported cronbach’s alpha values of 0.97 for the bp subscale and 0.92 for the se scale. preschooler nutritional status was the preschool child’s body mass index classified in percentiles according to what is set forth by the who (19), namely: malnutrition (< percentile 3), low weight (≥ 3 and < 15), normal weight (≥ 15 and < 85), overweight (≥ 85 but < 97) and obesity (≥ 97). weight was measured in kilograms with a 0.1 kg precision seca 804 scale and was divided by the square of the height expressed in meters, which was measured with a seca 214 stadiometer. in addition, sociodemographic information such as maternal age, schooling and occupation was asked, as well as the child’s age and gender by requiring the presentation of a sociodemographic information card. data analysis the data were captured and analyzed in the statistical package for the social sciences (spss) for windows statistical program, version 21.0. the reliability of the lifestyle behaviour checklist questionnaire (12) was assessed using cronbach’s alpha coefficient and the descriptive statistics of the sociodemographic information were obtained. for objective 1 (to associate mpcw with the child’s nutritional status), a 2x2 contingency table was prepared with adequate and inadequate mpcw and the child’s nutritional status according to children with and without overweight-obesity, and the chi-square test was applied. for objective 2 (to describe the clbps and verify if they differ according to children with and without overweight-obesity), objective 3 (to describe se and verify if it differs according to children with and without overweight-obesity) and objective 4 (to evaluate if the clbps and se differ according to mpcw), the distribution of the clbps and se variables was verified using the kolmogorov-smirnov test with lilliefors correction and, according to this, parametric and non-parametric statistics were applied. the single-factor anova test was applied for objective 2. according to objective 3, the mann-whitney u test was applied and, according to objective 4, the sum of clbps and se was considered; in addition, the single-factor anova test and the mann-whitney u test were applied, respectively. ethical considerations this research was reviewed and approved by an ethics committee, registered with no. 12cei19039007 at the federal commission for the protection against health risks, and observed the ethical standards outlined in the 1973 declaration of helsinki. the participating mothers were explained the research objectives and the procedures to be performed, as well as the risks and benefits inherent to participation in the study. they were guaranteed freedom to withdraw their consent at any time of the study, without this representing negative consequences for them or their children. anonymity and confidentiality of the information were ensured, in addition to guaranteeing that the data would only be analyzed and handled jointly; subsequently, the mothers signed the informed consent. assent was also obtained from the preschool children to perform the anthropometric measurements, which were in charge of qualified and standardized health staff that preserved the preschool children’s integrity and privacy. data collection was conducted in educational institutions. results the internal consistency of the two subscales of the lifestyle behaviour checklist (12) was assessed using cronbach’s alpha coefficient; both subscales presented acceptable reliability: clbps, α = 0.78 and se, α = 0.94. there was participation of 274 dyads (mother-child), with a mean maternal age of 30.79 years old (sd = 5.9) and a mean schooling of 11.19 years of study (sd = 3.01); 82.5 % (n = 226) lived with their partner; and 62.4 % (n = 171) were housewives. regarding the children, their mean age was 4.38 years old (sd = 0.69), 54.4 % (n = 149) were female, mean weight of 18.90 kg (sd = 3.66), mean height of 108.83 cm (sd = 6.80), and 25.2 % (n = 69) with overweight-obesity; the information is presented in table 1. table 1. descriptive statistics of the sociodemographic and anthropometric characteristics of the participating dyads maternal characteristics (n = 274) mean age (standard deviation) 30.79 (5.9) mean schooling in years (standard deviation) 11.19 (3.01) mean family income in mxn (standard deviation) 9,726.10 (7,343.75) marital status (n, %) married or lives with her partner 226 (82.5 %) occupation (n, %) housewife 171 (62.4) child’s characteristics (n = 274) mean age (standard deviation) 4.38 (.69) gender   female (n, %) 149 (54.4) male (n, %) 125 (45.6) anthropometric measures   mean weight (standard deviation) 18.9 (3.66) mean height (standard deviation) 108.83 (6.80) nutritional status   with overweight-obesity (n, %) 69 (25.18) without overweight-obesity (n, %) 205 (74.82) source: own elaboration statistics to verify the study objectives according to objective 1, adequate mpcw through words was found in 18.8 % (n = 13) of the mothers of children with overweight-obesity and in 78.8 % (n = 160) of the mothers of children without overweight-obesity (x2 = 77.759; dof = 1; p < .001). through images, adequate mpcw was found in 2.9 % (n = 2) of the mothers of children with overweight-obesity and in 44.4 % (n = 91) of the mothers of children without overweight-obesity (x2 = 39.638; dof = 1; p < .001); the information is presented in table 2. table 2. mpcw through words and through images according to the child’s nutritional status child’s nutritional status mpcw through words with overweight-obesity without overweight-obesity adequate 13 (18.8 %) 160 (78.0 %) inadequate 56 (81.2 %) 45 (22.0 %)   x2 = 77.759; dof = 1; p < .001 mpcw through images with overweight-obesity without overweight-obesity adequate 2 (2.9 %) 91 (44.4 %) inadequate 67 (97.1 %) 114 (55.6 %)   x2 = 39.638; dof = 1; p < .001 source: own elaboration it was found that 10 behavior problems are more frequent in preschool children with overweight-obesity; the information is presented in table 3. table 3. single-factor anova test for the child’s lifestyle behavior problems according to children with and without overweight-obesity behavior problem with ow-ob without ow-ob p mean sd mean sd 1.  eats too quickly 2.94 1.34 2.60 1.21 .050 2.  eats too much 3.26 1.37 2.99 1.27 .137 3.  eats unhealthy snacks 3.30 1.34 3.16 1.28 .413 4.  whinges or whines about food 2.39 1.46 2.32 1.50 .721 5.  yells about food 1.97 1.43 1.66 1.20 .077 6.  throws a tantrum about food 2.33 1.56 2.00 1.33 .084 7.  refuses to eat certain foods 3.22 1.93 3.01 1.71 .411 8.  argues about food 2.39 1.62 1.66 1.15 .001 9.  demands extra helpings at meals 2.67 1.51 2.22 1.24 .017 10.  requests food continuously between meals 3.29 1.33 3.24 1.47 .800 11.  demands food when shopping or on outings 3.32 1.65 3.09 1.62 .321 12.  sneaks food when they know they are not supposed to 1.90 1.43 1.29 .78 .001 13.  hides food 1.55 1.32 1.08 .02 .001 14.  steals food from other children 1.28 1.13 1.14 .80 .680 15.  eats food to comfort themselves when feeling let down or depressed 1.74 1.55 1.24 .90 .001 16.  watches too much television 3.70 1.87 3.17 1.46 .018 17.  spends too much time playing video or computer games 3.12 1.77 2.36 1.46 .001 18.  complains about doing physical activity 1.94 1.27 1.65 1.13 .78 19.  refuses to do physical activity 1.71 1.17 1.48 1.50 .183 20.  complains about being unfit 1.26 .67 1.20 .65 .473 21.  complains about being overweight 1.14 .55 1.04 .24 .039 22.  complains about being teased 1.41 1.07 1.26 .90 .281 23.  complains about not having enough friends 1.67 1.29 1.36 .83 .022 24.  complains about being unattractive 1.10 .54 1.04 .22 .221 25.  complains about not fitting into clothes 1.46 1.23 1.24 .75 .074 *note: ow-ob = overweight-obesity; sd = standard deviation; f = variance; p = significance source: own elaboration according to objective 3, it was found that the mothers of children with overweight-obesity presented less self-efficacy when compared to the mothers of children without overweight-obesity to deal with 15 of the 25 behavior problems; the information is presented in table 4. table 4. mann-whitney u test for self-efficacy to deal with the child’s lifestyle behavior problems according to children with and without overweight-obesity behavior problem self-efficacy p with ow-ob without ow-ob mr sr mr sr 1.  eats too quickly 107 7,449 147 30,226 .001 2.  eats too much 113 7,862 145 29,813 .004 3.  eats unhealthy snacks 109 7,586 146 30,089 .001 4.  whinges or whines about food 122 8,473 142 29,202 .065 5.  yells about food 122 8,470 142 29,205 .058 6.  throws a tantrum about food 116 8,059 144 29,615 .009 7.  refuses to eat certain foods 112 7,793 145 20,882 .002 8.  argues about food 107 7,385 147 30,289 .001 9.  demands extra helpings at meals 103 7,163 148 30,511 .001 10.  requests food continuously between meals 110 7,654 146 30,020 .001 11.  demands food when shopping or on outings 107 7,431 147 30,244 .001 12.  sneaks food when they know they are not supposed to 113 7,827 145 30,244 .001 13.  hides food 113 7,797 145 29,878 .001 14.  steals food from other children 123 8,555 142 29,120 .050 15.  eats food to comfort themselves when feeling let down or depressed 113 7,844 145 29,831 .001 16.  watches too much television 109 7,557 146 30,118 .001 17.  spends too much time playing video or computer games 106 7,355 147 30,319 .001 18.  complains about doing physical activity 117 8,090 144 29,585 .008 19.  refuses to do physical activity 127 8,801 140 28,874 .182 20.  complains about being unfit 130 8,993 139 28,682 .322 21.  complains about being overweight 134 9,246 138 28,428 .611 22.  complains about being teased 134 9,312 138 28,363 .719 23.  complains about not having enough friends 125 8,650 141 29,025 .091 24.  complains about being unattractive 136 9,395 137 28,180 .844 25.  complains about not fitting into clothes 130 8,997 139 28,678 .308 *note: ow-ob = overweight-obesity; mr = mean range; sr = sum of ranges; u = mann-whitney; p = significance source: own elaboration. finally, regarding objective 4, table 5 shows that, when mpcw through words is adequate, the mean of clbps is higher (x= 63.14; sd = 18.14). when compared to the mean of inadequate mpcw (x = 49.67; sd = 11.49.14), the difference was significant. no significant difference was found in mpcw through images. table 5. single-factor anova test for the child’s lifestyle behavior problems according to mpcw behavior problem n x sd f p mpcw through words adequate 14 63.14 18.14 17,041 .001 inadequate 260 49.67 11.49 mpcw through images adequate 2 58.50 03.530 .891 .346 inadequate 272 50.30 12,261 * note: x = mean; sd = standard deviation; f = variance; p = significance source: own elaboration. regarding se, it was found that, when mpcw is adequate, the mothers’ se is lower (mr = 87.36) when compared to the mothers with inadequate mpcw (mr = 140.20), and the difference was significant (u = 1,118; p = .015). no significant difference was found in mpcw through images; the information is presented in table 6. table 6. mann-whitney u test for self-efficacy according to mpcw through words and images regarding overweight-obesity in the child self-efficacy n mr sr u p mpcw through words adequate 14 87.36 1,223 1,118 .015 inadequate 260 140.20 36,452 mpcw through images adequate 2 128.75 257 254 .875 inadequate 272 137.56 34,417 *note: u = mann-whitney; p = significance source: own elaboration. discussion this study assessed mpcw, as well as the clbps and se to deal with them, and it was verified if they differ according to mpcw. it was found that most of the mothers of children with overweight-obesity present inadequate mpcw, perceive more clbps and have less se. when the perception of the child’s overweight-obesity is adequate, higher clbp scores and lower se values are presented. as already mentioned, inadequate mpcw was present in most of the mothers of children with overweight-obesity, which indicates that they underestimate their children’s weight. this finding is consistent with what is reported in other studies and systematic reviews of studies conducted in countries such as australia, germany, italy, united states, brazil, united kingdom and singapore, among others (7-10). therefore, the results of this study confirm the existing evidence. the clbp and se variables were assessed using the lifestyle behaviour checklist questionnaire (12), which presented acceptable internal consistency, similarly to what is published in the literature regarding the population living in australia (13), the netherlands (14) and mexico (20). it is worth pointing out that, to the present day regarding research, this questionnaire is the only one that assesses se to deal with clbps; likewise, the authors have indicated that assessing self-efficacy for a specific behavior is the best se indicator, which would allow working to reinforce it (15). it was found that the mothers of children with overweight-obesity reported more clbps and less se when compared to the mothers of children without overweight-obesity, which is similar to a study conducted with mothers of children aged from 4 to 11 years old living in australia (21). however, a study conducted in the netherlands with mothers and fathers of children aged from 3 to 13 years old (14) and another study conducted in sweden with mothers and fathers of preschool and school children (22) found that the mothers of children with overweight-obesity obtained the highest scores in the clbps subscale, whereas in the se scale, no significant difference was identified according to the groups with and without overweight-obesity regarding the individual analysis by items, the mothers of children with overweight-obesity presented higher scores in 10 of the 25 clbps. it is worth noting that the study conducted in sweden (22) identified a significant difference in 20 out of 25 clbps, and that the survey conducted in australia (21) did so in 24 out of 28 clbps. lower scores were identified in 15 of the 25 se items in mothers of children with overweight-obesity. the study conducted with mothers in sweden (22) identified a significant difference in 7 out of 25 items and, in australia (21), there was a significant difference in 26 out of 28 items. among the mexican mothers of children with overweight-obesity, the clbp that obtained the highest score was that of watches too much television, followed by eats too quickly. for the australian (21) and swedish mothers, the highest scores were in eats too much and watches too much television (22). regarding se, in the mexican mothers the lowest score was in the demands extra helpings at meals item and, for the australian (21) and swedish mothers, it was eats too much (22). these findings have important implications, since one of the main factors related to excess weight is the increased consumption of calories, a factor that was not pointed out by the mexican mothers, who, in addition, present less se when their children demand extra helpings at meals. likewise, it was found that, when the perception of the child’s overweight-obesity is adequate, higher clbps scores and lower se values are presented; the aforementioned when mpcw is evaluated through words. a possible explanation as to why no difference was found between the clbps and se variables and mpcw through images is that the latter was assessed with a panel consisting in 7 images, which do not represent categories defined by body weight. in addition, the mothers of children with overweight-obesity could select 2 possible options for mpcw to be adequate (18). other authors point out that, up to date, the best method to assess mpcw has not yet been established, and add that images are useful to help sensitize the parents regarding excess weight in childhood (23). however, as these images are not shown to the parents along with weight categories, they do not allow them to recognize the child’s weight in a category, as is the case with mpcw through words. this finding is significant and further exploration is recommended, since the studies conducted in adolescents and adults have found that, when there is an adequate perception of overweight-obesity, depression and lower quality of life can emerge (17). likewise, although the recommendation is to promote adequate mpcw in mothers of children with overweight-obesity, it is necessary to explore if, when more child’s clbps and less se to deal with them are perceived, depression and stress could emerge, variables related to unhealthy upbringing practices and to childhood obesity (24). in addition, the literature indicates that the mothers who feel sufficiently confident to achieve the expected outcomes might not initiate actions or get involved in programs targeted at preventing and treating excess weight in their children (25). a negative and significant relationship has also been documented between se, restrictive eating practices, and pressure to eat (26), which could result in children gaining weight. among the strengths of this study, we can point out that the children’s nutritional status was obtained from the body mass index measured and that the lifestyle behaviour checklist questionnaire (12) showed acceptable internal consistency. one of the limitations is that only mothers participated; therefore, seeking the fathers’ contribution is an opportunity area (27). in addition, this study did not identify determining factors of adequate mpcw in the mothers of children with overweight-obesity, as well as it did not analyze if some maternal-child sociodemographic characteristics were related to the clbps and to se to deal with them. conclusions and recommendations it is concluded that the mothers of children with overweight-obesity present inadequate mpcw, underestimate their children’s weight, report more clbps in the children and less se to deal with them. likewise, when overweight-obesity in the child is perceived, more clbps are presented, as well as less se to deal with them. it is recommended to replicate this study in other populations with children belonging to a broader age group, as well as to explore the relationship between the perception of the child’s overweight-obesity and variables such as depression, stress, eating habits, and physical activity. it is also suggested to study the relationship between self-efficacy and the promotion of healthy habits in the family, a situation that was not assessed in this research. finally, it 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doi: https://doi.org/10.3109/17477160902811199 22. ek a, sorjonen k, nyman j, marcus c, nowicka p. child behaviors associated with childhood obesity and parents’ self-efficacy to handle them: confirmatory factor analysis of the lifestyle behavior checklist. int j behav nutr phys act. 2015; 12(1):36. doi: https://doi.org/10.1186/s12966-015-0194-4 23. garcia ml, crespo nc, behar ai, talavera ga, campbell n, shadron lm, elder jp. examining mexican-heritage mothers’ perceptions of their children’s weight: comparison of silhouette and categorical survey methods. child obes. 2020; 16(1):44-52. doi: https://doi.org/10.1089/chi.2019.0015 24. jang m, owen b, lauver dr. different types of parental stress and childhood obesity: a systematic review of observational studies. obes rev. 2019; 20(12):1740-1758. doi: https://doi.org/10.1111/obr.12930 25. chen j-l, guo j, esquivel jh, chesla ca. like mother, like child: the influences of maternal attitudes and behaviors on weight-related health behaviors in their children. j transcult nurs. 2018; 29(6):523-31. doi: https://doi.org/10.1177/1043659617736883 26. camfferman r, van der veek smc, rippe rca, mesman j. maternal feeding practices, health cognitions, and children’s eating styles and weight status. j dev behav pediatr. 2019; 40(2):122-30. doi: https://doi.org/10.1097/dbp.0000000000000640 27. penilla c, tschann jm, deardorff j, flores e, pasch la, butte nf, et al. fathers’ feeding practices and children’s weight status in mexican american families. appetite. 2017; 117:109-16. doi: https://doi.org/10.1016/j.appet.2017.06.016 home editorial.pdf año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 4 n este número de aquichan, dedicado al desarrollo teórico de nuestra profesión, se hace imperioso mencionar la importancia que tiene, para el progreso de la enfermería, promover en los estudiantes un aprendizaje, a través del cual se aborden los temas y los problemas de manera global, para dar cabida a los conocimientos locales y parciales, pero con una visión totalizadora de los procesos, de tal manera que los objetos, los sujetos y las situaciones sean vistos y analizados dentro de sus contextos y sus complejidades. el manejo fragmentado de una disciplina, proceso tan frecuente en nuestro tiempo, impide a menudo establecer una relación entre las partes y el todo, y el desarrollo de una visión totalizadora, en donde se estudien las influencias y dependencias mutuas que permitan explicar los procesos como resultado de un sinnúmero de factores y ubicarlos dentro de un contexto propio. estas premisas son perfectamente aplicables a la enseñanza de la enfermería, pero no del todo suficientes, pues para lograr el aprendizaje de un cuidado integral es necesario tener en cuenta la naturaleza del ser humano, quien es a la vez un ser biológico, psíquico, físico, social, cultural e histórico. es esta unidad compleja la que con tanta facilidad se desintegra en la educación, a través del manejo de currículos totalmente fraccionados, que no permiten abordar la totalidad del hombre, sino, por el contrario, lo presentan y lo tratan como si funcionaran por separado sus componentes constitutivos, es decir, como un todo solamente físico o psíquico, suprimiéndole a ese conocimiento la complejidad que el hombre tiene, inherente a su condición de ser humano. federico mayor, representante de la unesco, en la presentación del libro de edgar morán, refiriéndose a la educación, decía que “uno de los desafíos más difíciles será modificar nuestro pensamiento, de manera que enfrente la complejidad creciente, la rapidez de los cambios y lo imprevisible, que caracteriza a nuestro mundo. ”la educación es la fuerza del futuro, porque ella constituye uno de los instrumentos más poderosos para realizar el cambio”. para avanzar y lograr el cambio, de manera efectiva, debemos derribar barreras tradicionales y paradigmas; reformular los currículos, pero con una mirada futurista, previendo lo que acontecerá a los jóvenes y niños de hoy, en una sociedad que cambia cada día con mayor rapidez y que afrontará problemas totalmente inesperados. la enfermería como disciplina ha logrado avanzar notoriamente en la búsqueda de esta meta. hace algunos años no se contaba con una fundamentación científica de los cuidados, y, sin embargo, en la actualidad, con la divulgación y el desarrollo de las teorías y modelos de enfermería, se ha podido justificar las acciones y construir los propios planteamientos, con el apoyo de otras disciplinas, que de una u otra manera enriquecen la esencia de la profesión. la selección y utilización del modelo de adaptación en el plan de estudios de la carrera de enfermería, cuya autora, callista roy, engalana hoy nuestra portada, no fue una casualidad ni una decisión afectiva, sino el producto de un minucioso análisis, que dio como resultado una total congruencia entre sus planteamientos y su visión holística del ser humano, con los principios promulgados por la universidad de la sabana y con la visión de futuro que el programa deseaba tener. con su implementación, la facultad podrá garantizar una enseñanza del cuidado integral de la salud, a través de la cual el estudiante aprende que el ser humano, en cualquiera de las etapas de su vida y bajo cualquier circunstancia, debe ser tratado como un todo, como una unidad, en la cual lo físico, lo biológico, lo psíquico, lo social, lo cultural y lo histórico se unen para determinar sus comportamientos y sus reacciones particulares, y que estos ameritan una atención individualizada, en la cual se evidencie el respeto por su singularidad y por los derechos que como ser humano y trascendente tiene. el futuro de la educación en general, pero muy especialmente el de la enfermería, cuyo sujeto de atención es el hombre, exige un mayor y continuo esfuerzo en el avance de los procesos científicos de su propio campo de acción, de tal suerte que el cuidado se pueda fundamentar con experiencias investigativas que demuestren la conveniencia o inconveniencia de ciertas y determinadas acciones y procesos. qué gran satisfacción se podrá tener cuando se identifique a una alumna totalmente segura de que sus acciones están sustentadas en una sólida fundamentación teórica y en procesos de experimentación que le dan validez a la práctica, y que su profesión se hace realidad cuando ella cuida y enseña a cuidarse. ¡nuestro reto es el futuro! propongámonos, al igual que la doctora callista roy, autora del modelo, avanzar en la producción de conocimientos propios de nuestra área, y para ello creemos espacios para compartir nuestras experiencias, y establezcamos procesos de comunicación que nos permitan validarlas, seguras de que esto redundará en beneficio de nuestros estudiantes, quienes serán los encargados de dar a la sociedad una nueva imagen de la profesión, y a los pacientes, un verdadero cuidado integral e individualizado. editorial 5 1 renata francielle melo dos reis fonseca1 silvia matumoto2 joab jefferson da silva xavier3 jossiane wilke faller4 comportamiento de riesgo para caídas en adultos mayores: experiencias de los agentes comunitarios en salud* 1 https://orcid.org/0000-0002-5878-0826. universidade de são paulo, brasil. renatafrmelo@alumni.usp.br 2 https://orcid.org/0000-0002-8590-5276. escola de enfermagem de ribeirão preto, universidade de são paulo, brasil. smatumoto@eerp.usp.br 3 http://orcid.org/0000-0001-5748-1018. universidade de são paulo, brasil. yoav@alumni.usp.br 4 https://orcid.org/0000-0002-1216-8180. universidade estadual do oeste do paraná, brasil. jossiana.faller@unioeste.br * este artículo es derivado de la tesis de maestría “prevenção de quedas nos idosos: adesão na atenção primária”, presentada a la escuela de enfermería de ribeirão preto, universidade de são paulo, disponible en: https://teses.usp.br/teses/disponiveis/22/22134/ tde-30052018-105526/pt-br.php recibido: 06/06/2019 enviado a pares: 31/07/2019 aceptado por pares: 04/02/2020 aprobado: 20/02/2020 doi: 10.5294/aqui.2020.20.2.3 para citar este artículo / to reference this article / para citar este artigo fonseca rfmr, matumoto s, xavier jjs, faller wf. risk behavior for falls in the elderly: experiences of community health workers. aquichan. 2020;20(1):e202x. doi: https://doi.org/10.5294/aqui.2020.20.2.3 resumen objetivo: identificar los comportamientos de riesgo de los adultos mayores en el domicilio descritos por las agentes comunitarias de salud y sus factores relacionados. material y método: investigación cualitativa, en la perspectiva dialéctica, realizada por medio de un grupo focal con agentes comunitarios de salud de una unidad de estrategia de salud de la familia de un municipio en el estado de são paulo, brasil. para el análisis, se utilizó el análisis de contenido temático. resultados: los comportamientos de riesgo revelados están relacionados con factores extrínsecos (arquitectura, mobiliario y equipamiento), factores socioeconómicos (escolaridad e ingresos bajos, déficit de apoyo social y familiar) y factores psicológicos (sensación de vulnerabilidad, dependencia y no reconocerse en una condición peligrosa). conclusiones: las caídas son el resultado de una compleja interacción entre los factores y los comportamientos estudiados, por lo que una adecuada identificación de estos puede subvencionar acciones de intervención individual y colectiva, así como procesos de gestión y planificación de cuidados dirigidos a la salud de la persona mayor. palabras clave (fuente: decs/mesh) adulto mayor; anciano; accidentes por caídas; factores de riesgo; atención primaria de salud; promoción de la salud. año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2023 temática: promoción y prevención. contribución a la disciplina: discutir y describir los factores que constituyen los comportamientos de riesgo para las caídas, con el fin de proporcionar conocimientos que contribuyan a planear intervenciones de cuidado por parte del equipo de salud, desarrollar y mejorar la atención y promover la salud en los adultos mayores. https://orcid.org/0000-0002-5878-0826 mailto:renatafrmelo@alumni.usp.br https://orcid.org/0000-0002-8590-5276 mailto:smatumoto@eerp.usp.br http://orcid.org/0000-0001-5748-1018 mailto:yoav@alumni.usp.br https://orcid.org/0000-0002-1216-8180 mailto:jossiana.faller@unioeste.br https://teses.usp.br/teses/disponiveis/22/22134/tde-30052018-105526/pt-br.php https://teses.usp.br/teses/disponiveis/22/22134/tde-30052018-105526/pt-br.php https://doi.org/10.5294/aqui.2020.20.2.3 https://orcid.org/0000-0002-5878-0826 https://orcid.org/0000-0002-8590-5276 http://orcid.org/0000-0001-5748-1018 https://orcid.org/0000-0002-1216-8180 https://doi.org/10.5294/aqui.2020.20.2.3 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2023 risk behavior for falls in the elderly: experiences of community health workers* abstract objective: to identify the risk behaviors of the elderly at home, described by community health workers, and related factors. materials and methods: qualitative research, in the dialectical perspective, carried out through a focus group with community health workers from a family health strategy unit in a municipality of the state of são paulo, brazil. thematic content analysis was used for the study. results: the revealed risk behaviors are related to extrinsic factors (architecture, furniture, and equipment), socioeconomic factors (low income, level of education, deficit of social and a family support), and psychological factors (feeling of vulnerability, dependence and not self-acknowledging in a dangerous condition). conclusions: falls are the result of a complex interaction between the factors and, the behaviors studied so that adequate identification of these can subsidize individual and collective intervention actions, as well as care management and planning processes aimed at the health of the elderly person. keywords (source: decs/mesh) aged; elderly; accidental falls; risk factors; primary health care; health promotion. * this article is derived from the master’s thesis entitled “prevenção de quedas nos idosos: adesão na atenção primária”, presented to the school of nursing of ribeirão preto, universidade de são paulo, available in: https://teses.usp.br/teses/disponiveis/22/22134/tde-30052018-105526/pt-br.php https://teses.usp.br/teses/disponiveis/22/22134/tde-30052018-105526/pt-br.php 3 comportamiento de riesgo para caídas en adultos mayores: experiencias de los agentes comunitarios en salud l renata francielle melo dos reis fonseca y otros comportamento de risco e fatores para quedas em idosos: experiências de agentes comunitários em saúde* resumo objetivo: identificar os comportamentos de risco dos idosos em domicílio e descrever fatores relacionados. material e método: pesquisa de abordagem qualitativa, realizada por meio de grupo focal com agentes comunitárias de saúde de uma unidade de estratégia de saúde da família de um município no interior do estado de são paulo, brasil. para análise, utilizou-se análise temática de conteúdo. resultados: revelaram comportamentos de risco relacionados a fatores extrínsecos (arquitetônicos, mobiliários e equipamentos), fatores socioeconômicos (baixa renda e escolaridade, déficit suporte social e familiar) e fatores psicológicos (sentir-se vulnerável, dependente e não reconhecer-se em condição de risco). conclusão: as quedas são resultado da complexa interação entre os fatores e comportamentos estudados, portanto uma adequada identificação destes podem subsidiar ações de intervenção individual e coletiva, assim como processos de planejamento de cuidado e gestão voltadas à saúde do idoso. palavras-chave (fonte: decs/mesh) idoso; pessoa idosa; acidentes por quedas; fatores de risco; atenção primária à saúde; promoção da saúde. año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2023 * este artigo é derivado da tese de mestrado “prevenção de quedas nos idosos: adesão na atenção primária”, apresentado ao escuela de enfermería de ribeirão preto, universidade de são paulo, disponível em: https://teses.usp.br/teses/disponiveis/22/22134/ tde-30052018-105526/pt-br.php 4 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2023 aquichan issn 1657-5997 eissn 2027-5374 introducción las caídas tienen un alto impacto sobre la calidad de vida de las personas mayores (y, consecuentemente, sobre diversos sectores de la salud), debido a la obligada reducción de sus funciones diarias, hospitalización o institucionalización, y a sus altos costos. los significativos índices de morbimortalidad que presentan demuestran la necesidad de crear políticas públicas y programas de prevención y rehabilitación (1). por lo tanto, las caídas representan una gran importancia con respecto a la atención integral de las personas de edad avanzada y requieren la intervención de la enfermería como proveedor de educación en salud y participante fundamental del equipo de atención primaria y de la gestión de los cuidados ofrecidos (2, 3). las caídas son multifactoriales, pero, como lo constatan los estudios anteriores, las investigaciones poco retratan la influencia del comportamiento y de las actitudes de riesgo del mayor sobre las caídas (4, 5). el comportamiento de riesgo abarca actitudes, tareas o actividades y hábitos que los adultos mayores adoptan y ejecutan, incluso ante posibles perjuicios, como la caída. los factores de riesgo comportamentales se relacionan con acciones humanas, emociones o elecciones diarias que pueden modificarse (6). en las personas mayores, se establece un juicio sobre los comportamientos de riesgo, como su tendencia a continuar con sus actividades cotidianas, a pesar del peligro que ello implica. esto, dada la dificultad de adaptarse a su nueva condición, acompañada por los cambios propios de la edad y un déficit del desempeño sensorial y motor (7). los comportamientos de riesgo incluyen actividades inadecuadas, como bajar escaleras con una carga pesada; movimientos motores inseguros; movimientos rápidos (como caminar, levantarse o cambiar de postura a un ritmo acelerado) o bruscos (como girar la cabeza o el tronco bruscamente hacia atrás); sedentarismo; exposición y actividades en superficies resbaladizas o desniveladas, y a lugares poco iluminados; bañarse sin barras de apoyo; uso de zapatos inadecuados (con suelas deslizantes, tacones altos, sandalias abiertas sin fijación [como velcro o hebilla] y suelas muy gruesas); uso inadecuado de artefactos auxiliares de movilidad, como el caminador; uso de muebles para alcanzar objetos fuera del alcance, como banquitos; caminar en áreas de tráfico pesado; no pedir ayuda; uso de alcohol y tabaco, polifarmacia o automedicación (4, 5). en la esfera de la atención primaria, los agentes comunitarios de salud (acs) están cotidianamente en contacto con adultos mayores de la comunidad. aquellos realizan acciones de promoción de la salud y prevención de agravios (individuales y colectivos). la implementación de los subsidios que apoyan las prácticas de los acs para potenciar sus acciones junto a la población se encuentra en la literatura (8). por lo tanto, la búsqueda abordó el comportamiento de riesgo en personas mayores para subvencionar acciones de prevención de caídas. así, el objetivo del artículo fue identificar los comportamientos de riesgo para caídas de los adultos mayores descritos por los acs y sus factores relacionados. material y método se realizó una investigación cualitativa, que se define por su naturaleza de revelar características humanas que serían arduas con metodologías cuantitativas. esencialmente, permite, de manera interactiva, investigar, explicar, analizar y dilucidar lo humano y sus relaciones, constituidas por estructuras reales de inmaterialidad y abstracción, como la fe, creencias, valores, hábitos, actitudes y costumbres (9). las diferentes corrientes paradigmáticas organizan los fundamentos teóricos según la visión del mundo, los principios, las convicciones metodológicas y las aplicaciones conceptuales, para explicar los procedimientos en la construcción de la investigación y orientar el proceso de interpretación, con el fin de aclarar la investigación cualitativa con rigor y fiabilidad (10). para privilegiar las observaciones, explicaciones y percepciones desde el punto de vista de los sujetos del universo en el que se producen, se utilizó el método dialéctico. con este, se propone comprender la relación constitutiva entre el fenómeno y el conjunto, a partir de la experiencia concreta. la objetividad, que mediante el uso meticuloso del método permite una mayor aproximación al objeto de estudio, ayuda a comprender la interacción sujeto-objeto en un contexto sociohistórico. la comprensión puede profundizarse a través de la discusión guiada por un ojo crítico, la comparación con el conocimiento científico y la exposición de subjetividades, como las relaciones entre los sujetos y la cultura, la historia personal y la material (es decir, la residencia, el mobiliario y todos aquellos objetos que hacen parte de la historia de la persona mayor). de esta manera, la objetivación describe el 5 comportamiento de riesgo para caídas en adultos mayores: experiencias de los agentes comunitarios en salud l renata francielle melo dos reis fonseca y otros problema antes de sus determinaciones y transformaciones por parte del actor social (11). a veces, la esencia que constituyen los comportamientos de riesgo y las caídas no es evaluada ni identificada por el equipo de salud. al valorar los elementos que los determinan, buscamos comprender, a través de los sujetos implicados en su contexto, las contradicciones, lo subjetivo y lo objetivo del método dialéctico. los acs, como actores sociales, participan en el fenómeno a través de la interacción diaria, la inserción en los lugares donde se producen las dinámicas sociales (como los espacios domésticos y comunitarios), el vínculo y la confianza establecida con las personas mayores y la familia (12). dicho esto, la investigación con los trabajadores en el escenario de los adultos mayores, que experimentan el evento de la caída desde el punto de vista de la salud, se hace indispensable y justificada. la investigación se realizó en un municipio del estado de são paulo. la unidad de salud elegida para el estudio está ubicada en un barrio tradicional y es reconocida por atender una gran parte de la población de edad avanzada. esta trabaja desde la perspectiva de la estrategia de salud de la familia y tiene un equipo multiprofesional para acompañar a las familias. se utilizó la técnica del grupo focal (gf) para recolectar los datos. este método de captación de la interacción entre los participantes se ha destacado por la accesibilidad de ejecución que brinda y por la libre expresión de las experiencias de unos pocos participantes, a través de conversaciones sin interferencias ni prejuicios por parte del investigador (13). la propuesta de participación de los acs fue del gerente de la unidad de salud, al observar el criterio de inclusión de tener más de tres años de experiencia en el monitoreo de adultos mayores en la estrategia de salud familiar. la invitación fue hecha personalmente por el investigador principal, quien subrayó la total libertad para decidir participar en el estudio. no hubo rechazos. en octubre de 2017, se realizó un encuentro del grupo focal de 90 minutos con 5 participantes, en la sala de reuniones de la unidad de salud, espacio que ofreció privacidad e interacción en mesa redonda. fue coordinado por un investigador con doctorado y con dominio de la técnica y del campo de conocimiento en el cuidado de la salud de los adultos mayores, apoyado por una de las autoras previamente entrenadas. se utilizó un guion con preguntas orientadoras, como: “¿hay muchos adultos mayores que sufren caídas en su área?; ¿cómo identifica los riesgos para caer?; ¿cuáles son sus acciones en la prevención de caídas en los mayores?; reporte los riesgos de caídas percibidos y cómo manejó la situación”. el guion semiestructurado permitió discutir las preguntas genéricas en profundidad, mientras se abordaba el tema. el ambiente de discusión se favoreció por la interacción previa entre los acs y la libertad de expresión entre ellos. el coordinador del gf era una persona muy conocida de los acs porque ya se habían desarrollado investigaciones y actividades de promoción de la salud en esa unidad. el grupo de discusión se cerró cuando los acs consideraron que no había más aspectos por añadir. el registro se hizo a través de un diario de campo. el coordinador y auxiliar grabó el proceso con una grabadora digital, y la auxiliar anotó impresiones, conversaciones informales, detalles sobre la comunicación no verbal y otros aspectos del entorno en un cuaderno. ambos transcribieron el material por medio del software microsoft office word®. los discursos de los participantes se identificaron por la secuencia a1, y así sucesivamente. el análisis temático del contenido del grupo focal se dividió en tres etapas: pre-análisis, exploración del material e interpretación de los resultados. el pre-análisis comprendió una lectura superficial de los datos, a fin de familiarizarse con ellos. en la etapa de exploración del material, se extrajeron las unidades de significancia, sintetizadas por frases y diferenciadas según sus elementos esenciales. en la interpretación de los resultados, se agregaron las unidades según su similitud y pertinencia, clasificadas en categorías temáticas. estas se compararon y basaron en estudios actuales, bajo las referencias “caídas de mayores”, “factores relacionados” y “ejemplos de comportamientos de riesgo percibidos” (14). la triangulación múltiple permitió validar los datos. las comprobaciones externas, mediante evaluaciones independientes por diferentes personas idóneas en el área, como doctores (phd) en enfermería, y en el ámbito de la investigación y el conocimiento del método cualitativo, redujeron la posibilidad de sesgo debido a interpretaciones erróneas. además, la triangulación de los datos se refiere a los mismos elementos encontrados y descritos 6 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2023 aquichan issn 1657-5997 eissn 2027-5374 por las investigaciones internacionales y nacionales en diferentes contextos y condiciones de las poblaciones de edad, lo que permitió generalizar los resultados (15). el estudio fue aprobado por el comité de ética en investigación de la escola de enfermagem de ribeirão preto da universidade de são paulo, caae: 68815317.3.0000.5393 y observó las normas establecidas en la resolución 466/2012 del conselho nacional de saúde (brasil). para dar fiabilidad y rigor a la investigación, este estudio se basó en las directrices para la evaluación crítica de la investigación cualitativa (coreq). la investigación y los resultados se realizaron tras la firma del término de consentimiento libre e informado de cada uno de los entrevistados. resultado y discusión los participantes proporcionaron información básica que permitió caracterizar mejor a los sujetos (tabla 1). tabla 1. caracterización de los participantes del grupo focal característica descriptor porcentaje/ variación sexo femenino 100 % edad años 38-56 años ocupación en la unidad agente comunitario 100 % tiempo de actuación en el cargo años 5-17 años educación enseñanza media superior incompleto 80 % 20 % formación en geriatría formación/capacidad 100 % fuente: tabla extraída de la tesis de maestría base de este artículo, fonseca (16). en cuanto a la formación en el área de geriatría, todos los acs refirieron haber participado de la capacitación brindada por la propia unidad. los cursos fueron sobre sexualidad, caídas, vulnerabilidad y violencia, entre otros temas. el análisis de contenido permitió relacionar el discurso de los participantes, que se agruparon por categorías de comprensión, con la aproximación a los factores relacionados con las caídas descritos en la literatura científica. según esto, entonces, los factores de riesgo son extrínsecos, socioeconómicos y psicológicos. factores extrínsecos los acs relataron situaciones diversas que caracterizan los comportamientos de los adultos mayores, como en el ejemplo siguiente: “ella tiene 68 años, [...] cayó feo tropezando sobre la mesita de noche, en la noche, yendo al baño en la oscuridad [...]. ahora tiene miedo de caminar en la calle, [...] se siente prisionera dentro de casa”. (a3) en el registro anterior, se muestra el comportamiento de riesgo (ir al baño en la oscuridad), el factor de riesgo extrínseco (mesita de noche en el camino) y la consecuencia de la caída (miedo a la caída y aislamiento social). los factores de riesgo extrínsecos descritos en la literatura son ambientes con mala iluminación; alfombras sueltas o con pliegues; bordes de alfombras, principalmente dobladas; pisos resbaladizos —como los encerados— o mal conservados; ambientes desorganizados; muebles bajos u objetos dejados en el suelo, como zapatos, ropa, hilos, juguetes, basuras y escombros, entre otros; muebles inestables o deslizantes; escalones altos o irregulares; escaleras con un piso muy diseñado, que dificulta la visualización de cada escalón; escalones sin señalización de terminación; presencia de animales, barras de apoyo, sillas, camas y asientos de altura inadecuada; sillas sin brazos; uso de zapatillas, zapatos desatados, o mal ajustados, o con solado resbaladizo; escaleras con iluminación frontal (17-19). estos factores están especialmente relacionados con la residencia; son predisponentes y son los más prevalentes. están presentes en el 30-50 % del acontecimiento de la caída. otro estudio muestra que el 65 % de las caídas ocurren en el domicilio y en un ambiente inadecuado (5, 17, 20). la investigación realizada en ribeirão preto, são paulo, cita que, acerca de los lugares de ocurrencia de caídas, el 65 % ocurrieron en un ambiente domiciliar y el 15 %, en vías públicas (21). de esta manera, se puede afirmar que la mayoría de las caídas ocurre en casa o en las áreas externas al domicilio, durante actividades rutinarias del día a día. 7 comportamiento de riesgo para caídas en adultos mayores: experiencias de los agentes comunitarios en salud l renata francielle melo dos reis fonseca y otros los acs presentan comportamientos de riesgo en personas mayores, como el uso de muebles para realizar actividades y el uso de calzados inadecuados: “subió sobre el banquillo y fue a recoger unos papeles. mientras subía, se fue a coger del armario, y el maletero se le vino y le cayó por encima”. (a2) “…esa chancla no es buena para la señora. porque varias veces voy allí y ella tiene la misma chancla”. (a3) muchas caídas ocurren en el intento de evitar los obstáculos o en lugares donde el ambiente exige cierta habilidad física (22). también se destaca que hay una dinámica entre las condiciones ambientales y el comportamiento individual. una caída es fruto de la interacción compleja entre el conjunto de factores de riesgo intrínsecos y extrínsecos involucrados, pero no es posible determinar la influencia precisa de cada factor. solo se puede afirmar que el riesgo de caídas aumenta linealmente con el número de factores de riesgo asociados. aunque aquellos de naturaleza intrínseca, a menudo, se refieren al proceso de envejecimiento, la intervención sobre los factores que pueden estar relacionados con las caídas, como los extrínsecos, pueden obtener resultados efectivos en la reducción de la incidencia o minimizar la gravedad de las caídas (23). factores socioeconómicos en esta categoría, se agruparon las declaraciones de los acs relacionadas con los factores socioeconómicos: baja escolaridad, bajos ingresos, déficit en el acceso a servicios sociales y de salud, falta de interacción social y comunicación, vivienda inadecuada o en áreas rurales, vivir solo (24, 25). los siguientes registros presentan una dificultad financiera como elemento desencadenante del comportamiento de riesgo y la falta de condiciones ambientales adecuadas: “no deja la luz encendida porque cree que gasta mucho”. (a1) “muchos conseguimos que coloquen la barra de apoyo para ayudar a darse la vuelta. unos no consiguen o no tienen condición financiera... la cuestión es muy financiera, a veces de la familia”. (a3) muy evidente en el panorama general señalado por los acs fue la falta de apoyo social o familiar enfrentado por los mayores en la comunidad. “como la mayoría de los agentes, en el área encontramos bastantes adultos mayores. he encontrado bastantes adultos mayores que viven solos, y algunos que no tienen ningún apoyo de la familia”. (a3) “hay adultos mayores que piden mucha ayuda, pero no la obtienen de ningún lugar”. (a1) para el adulto mayor, la calidad de las relaciones interpersonales y las dificultades emocionales y psicológicas (como la depresión o la soledad) son tan significativas como las condiciones físicas de salud. la literatura apunta a la correlación entre el respaldo social y el estado general de salud de los adultos mayores, y a la capacidad de promover o mantener emocional y funcionalmente el estado mental y físico de aquellos (26). el apoyo social, principalmente familiar, es capaz de proveer apoyo instrumental para auxiliar las actividades diarias; soporte de evaluación o ayuda en las decisiones o resolución de problemas; asesoramiento y soporte emocional, como cariño, afecto, comprensión y reconocimiento (25). el apoyo social también incentiva a los adultos mayores a adoptar actitudes protectoras (27, 28). cuando se analiza la naturaleza del comportamiento de riesgo, muchas veces se observa que el adulto mayor asume tal comportamiento porque no tiene alternativas. sin ayuda disponible, desempeña la tarea, independientemente de los riesgos. “tuvo que ir por algo que estaba al otro lado de la calle. al cruzar, tropezó con la acera y se cayó”. (a1) el equipo de salud debe evaluar las actividades que el adulto mayor desempeña. la jardinería, por ejemplo, puede considerarse esencial para el adulto mayor, mientras que para los profesionales de la salud puede ser opcional (29). factores psicológicos aquí están incluidas las razones o justificaciones del adulto mayor para asumir un riesgo. los acs relacionan dichas razones con la dificultad de aquel para aceptar su vulnerabilidad. “creo que el adulto mayor no quiere ser visto como incapaz. incluso, sabe de sus limitaciones, pero no quiere mostrar... que él... no puede. ‘no quiero que nadie haga nada por mí, aún quiero hacerlo’”. (a5) 8 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2023 aquichan issn 1657-5997 eissn 2027-5374 el comportamiento de riesgo refleja que los adultos mayores no ven la caída como relevante para no sentirse vulnerables. por esto, al hacer tareas o actividades, no toman las debidas medidas de precaución por temor a ser tachados de viejos o frágiles. un ejemplo claro es su preocupación por lo que piensen de su apariencia en público, y esto, en consecuencia, hace que quieran caminar sin usar los aditamentos requeridos, aunque esto represente un riesgo. cualquier restricción de las actividades cotidianas trae sentimientos de frustración y de pérdida y disminución de la independencia. muchas personas mayores, por estos motivos, se vuelven ansiosos y renuentes cuando hay conversaciones o discusiones sobre las caídas. es común entre los adultos mayores el deseo de probar sus propios límites físicos; se resisten a reconocer las limitaciones y a entender los cambios de su cuerpo. muchos adultos mayores no reconocen los propios niveles de riesgo de caída (24, 28, 30). “entonces, se preocupan mucho por el qué dirán, por lo que van a pensar los otros...”. (a1) “pero ella no se tranquilizó [...], fue sola a recoger la cama base para llevarla al cuarto [...]. la cama cayó encima de ella. ella fue hospitalizada unos días a causa de eso”. (a5) hay muchas precauciones que los adultos mayores pueden tomar para evitar caídas, sin requerir ajustes muy grandes en su comportamiento o en el ambiente doméstico. las actividades diarias requieren, a menudo, ponderar entre el riesgo de caer y la capacidad de evitar la caída. de esta forma, debe haber un equilibrio entre el comportamiento de riesgo y la prevención, que es difícil para muchos adultos mayores (22, 31). otra situación comúnmente escuchada en el día a día de los profesionales de la salud es la dificultad de los adultos mayores para solicitar ayuda a otros, por la sensación de dependencia o de incomodidad que ello implica. “y una cosa que escucho decir a los adultos mayores: ‘yo no quiero dar trabajo [o molestar] a nadie’ [para que lo cuiden]”. (a1) “es como que ellas... la hija viene todos los días, y ella se siente como si fuera una carga para la hija. y ahí, ella llora”. (a4) el sentimiento de ser una carga para la familia proviene de los cambios en las composiciones y atributos tradicionales de las relaciones y los deberes familiares, los cuales influyen en los cuidados ofrecidos a los adultos mayores y en la disposición de estos a comprometerse con su autocuidado (25). muchos adultos mayores no son conscientes de las consecuencias ni del peligro que sus comportamientos de riesgo involucran (24, 32). “el cuerpo ya no es lo mismo... ellos creen que todavía da… que no tiene limitaciones. ahí, ellos se levantan de una vez y tienen mareos”. (a4) “y en una visita de esas, conversaron e iniciaron a hablar sobre el riesgo de las alfombras. [...] de ahí en adelante, en las otras visitas, yo observaba que no tenía más”. (a4) a veces, el comportamiento de riesgo forma parte del proceso de rehabilitación y adaptación al estado de independencia o aclaración al adulto mayor de sus reales limitaciones (29). los discursos descritos y analizados muestran que los riesgos conductuales de los adultos mayores pueden caracterizarse como una deficiencia de su autocuidado, desconocimiento de los riesgos ambientales y de sus limitaciones, o falta de apoyo e interacción social. también muestran cómo las caídas afectan el sentido de identidad de quienes las sufren, a lo cual se suma el prejuicio despectivo sobre la edad avanzada. así, la aceptación del riesgo pasa por el miedo a la vulnerabilidad, a la pérdida de la independencia y a la finitud de la vida (31, 33). los factores presentados permiten entender que son prevenibles, como el comportamiento de riesgo. la orientación del modelo de atención y de recursos debería centrarse en las intervenciones de rehabilitación intersectorial temprana, en la reducción de los daños causados por las comorbilidades, en el estilo y la calidad de vida de las personas mayores y en su capacidad funcional. además, desde la perspectiva de los acs, los elementos que cruzan los aspectos psicosociales, que se encuentran en la vida cotidiana, adquieren una gran proporción en la génesis de las caídas. en otras palabras, para los acs, los factores descritos que forman los comportamientos de riesgo son puntos clave para la prevención de caídas porque forman parte de la experiencia diaria de los mayores (3, 34). utilizando su principal instrumento de trabajo —las visitas domiciliarias—, los acs pueden ampliar su observación, propor9 comportamiento de riesgo para caídas en adultos mayores: experiencias de los agentes comunitarios en salud l renata francielle melo dos reis fonseca y otros cionar información, interpretar y reflexionar sobre las vulnerabilidades, las ausencias y las dinámicas familiares y sociales que no sería posible verificar de manera superficial mediante consultas biomédicas (12). este es el núcleo del papel de los acs, en el que contribuyen a la promoción de la salud mediante la identificación de los determinantes que actúan sobre la incidencia de las caídas, el proceso salud-enfermedad, la reestructuración de la atención y la reorientación del trabajo multiprofesional (35). con respecto a las caídas, la tarea de los acs es fortalecer la comprensión de las personas mayores y de sus familias sobre los factores extrínsecos de las residencias y el entorno, el cuidado de la movilidad urbana, la necesidad de acompañamiento regular por parte de profesionales de la salud la importancia del ejercicio físico y las actividades de recreación para mantenerse activos. también cabe señalar las actividades de vigilancia, el registro de las caídas de los adultos mayores más vulnerables y la presentación de informes al equipo de salud (36). para que esto sea posible, los acs cuentan con el apoyo y la supervisión del enfermero como gestor del cuidado. cabe resaltar que una atención integral a los adultos mayores es factible solo cuando hay un acercamiento a la realidad diaria de cada individuo, sus hábitos y sus problemas (12). de esta manera, el enfermero debe tener conocimientos en el área gerontológica para actualizarse, así como para entrenar al equipo de salud y educar a sus pacientes. en lo que respecta a los acs, el enfermero es responsable de su formación, calificación con conocimientos técnicos y perfeccionamiento de aquellos (37). es muy importante que el enfermero reconozca a los acs como mediadores entre el servicio de salud y la comunidad. se recomienda que estos participen activamente en la educación en salud, sea en visitas domiciliarias o con el equipo en actividades como conferencias, talleres o rondas de conversaciones. de esta manera, la atención primaria desarrolla una educación permanente que permite escuchar y compartir información para consolidar el vínculo entre el equipo, la adecuación del lenguaje y el uso de métodos de enseñanzas creativas, eficaces y transformadoras (38). por consiguiente, la atención primaria proporciona al adulto mayor un carácter activo, propio de un individuo que elige adoptar comportamientos protectores y reflexiona sobre los elementos multidimensionales que pueden causarle una caída o posibles enfermedades (37). consideraciones finales el estudio posibilitó analizar, junto a los acs, los comportamientos de riesgo de las personas mayores y los factores asociados a dichos comportamientos. los acs identificaron factores extrínsecos, socioeconómicos y psicológicos, cuya interacción produce comportamientos de riesgo y consecuentes caídas. los factores identificados constituyen conocimiento que puede subvencionar procesos de educación en salud para la prevención de caídas en adultos mayores, elementos por considerar en la planificación de acciones colectivas de cuidado y de gestión en salud, así como una concientización de los profesionales de atención primaria en salud para prevenir las caídas de forma eficaz. limitaciones la principal limitación del este estudio fue trabajar con la percepción y las vivencias de los acs de apenas una unidad de salud de la familia respectiva a un municipio, pues esto presenta un sesgo en la investigación y, por ende, unos resultados parciales. con base en la devolución del estudio a los participantes, se sugiere para futuras investigaciones evaluar programas para prevenir caídas en los adultos mayores que contemplen los comportamientos de riesgo y programas de educación para la salud que aborden los factores extrínsecos, fortalezcan la red de apoyo social y trabajen en los aspectos psicológicos de los mayores en relación con el envejecimiento (sentimientos, creencias, hábitos, entre otros). agradecimientos los autores expresan sus agradecimientos al responsable de la unidad de salud investigada, al coordinador para el grupo focal y a los acs participantes de la investigación, por su apoyo y colaboración. 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narrativa de idosos. ciênc. saúde coletiva. 2016 nov. 21(11):3565-3574. disponible en: http://dx.doi.org/10.1590/1413-812320152111.06782016 31. pohl p, sandlund m, ahlgren c, bergvall-karenborn b, lundin-olsson l, wikman am. fall risk awareness and safety precautions taken by older community-dwelling women and men: a qualitative study using focus group discussions. plos one. 2015 mzo.; 10(3):e0119630. disponible en: https://doi.org/10.1371/journal.pone.0119630 32. hill am, francis-coad j, haines tp, waldron n, etherton-beer c, flicker l, et al. “my independent streak may get in the way”: how older adults respond to falls prevention education in hospital. bmj open. 2016;6(7):e012363. disponible en: http://dx.doi.org/10.1136/bmjopen-2016-012363 33. gardiner s, glogowska m, stoddart c, dphil sp, lasserson d, jackson d. older people’s experiences of falling and perceived risk of falls in the community: a narrative synthesis of qualitative research. international journal of older people 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http://dx.doi.org/10.1590/1413-812320152111.06782016 https://doi.org/10.1371/journal.pone.0119630 http://dx.doi.org/10.1136/bmjopen-2016-012363 http://dx.doi.org/ 10.1111/opn.12151 https://doi.org/10.5205/1981-8963-v11i12a23068p5066-5073-2017 https://doi.org/10.25110/arqsaude.v22i3.2018.6559 https://revistaenfermagematual.com.br/index.php/revista/article/download/560/531 https://revistaenfermagematual.com.br/index.php/revista/article/download/560/531 http://dx.doi.org/10.1590/0034-7167-2017-0702 https://pesquisa.bvsalud.org/portal/resource/pt/biblio-1024531 primeras paginas.indd aquichan issn 1657-5997 6 año 8 vol. 8 nº 1 chía, colombia abril 2008 correo del lector enfermería para el siglo xxi con profundo agrado me permito dirigir a usted algunas premisas respecto de la revista que usted dirige. primero, se trata de un destacado escenario que promueve y difunde el desarrollo de la investigación en enfermería en américa latina. se ha constituido en una plataforma que incentiva la ciencia, interpretada como el descubrimiento de la verdad, y que concibe a la metodología de la investigación con rigor, consistencia y validez. es a su vez un espacio que permite transformar la práctica de enfermería, aportando la mejor evidencia, para realizar intervenciones de cuidado. esta práctica necesita de la actividad intelectual y de una masa crítica de investigadores e ideólogos que orienten sus acciones. segundo, la investigación científica en enfermería es una necesidad, una manera de analizar la realidad, una forma de actuación humana orientada al conocimiento de la realidad observable y del mundo que nos rodea. es, al mismo tiempo, un componente formativo esencial en la construcción de la formación profesional de enfermeras/os, guiado por escuelas de pensamiento y enfocado principalmente al desarrollo científico de la disciplina. en esta línea, hace algunos años la 0ms especificaba que enfermería debía investigar para contribuir a que la población alcance estilos de vida saludables y una atención adecuada. un requisito indispensable en este contexto es el dominio del método científico con sus componentes, etapas y procesos. método conceptualizado como procedimiento sistemático de obtención del conocimiento, cuyo fin último es la difusión y el uso de resultados para la toma de decisiones en materia de políticas públicas en el cuidado de la salud. por tanto, método y pregunta de investigación plantean interrogantes de creatividad, situación que debemos profundizar apoyados en la interdisciplinariedad, la intersectorialidad y complementariedad, el trabajo sobre la base de procesos, la conciencia en las determinaciones ético-políticas, la profundización en las ciencias sociales y, fundamentalmente, en la migración del paradigma biologicista asistencial hacia el ecológico preventivo. de esta forma se produce un desarrollo acorde a las exigencias de los nuevos tiempos, con amplia difusión hacia la comunidad científica y población en general, situación que sin duda aquichan considera en sus publicaciones. tercero, debido a la naturaleza de su misión y a las características de la composición de su fuerza de trabajo, enfermería tiene un lugar de privilegio para abordar problemas emergentes y cuestiones éticas. tiene incuestionablemente un peso estratégico en salud, y deberá velar por la producción del conocimiento. finalmente, cabe preguntarse: ¿qué rol jugará la investigación en enfermería en el nuevo siglo? el camino señala que se debe recoger la historia y desde allí construir futuro. 7 correo del lector en colombia, la comunidad académica de enfermería se ha comprometido con la divulgación del desarrollo teórico e investigativo de la profesión, muestra de ello ha sido el número cada vez mayor de publicaciones en las cuales se hace visible el desarrollo del quehacer de enfermería y los avances investigativos que han permitido validar la teoría. los artículos publicados en la revista aquichan evidencian la producción nacional e internacional de enfermería en los diferentes escenarios. en cada una de sus ediciones se presenta un espacio que resalta la importancia de las teorías y los modelos de enfermería y su aplicabilidad en la clínica, en la docencia y en la administración. en el segundo número de 2007 se publica el artículo de la enfermera maría mercedes durán de villalobos, teoría de enfermería ¿un camino de herradura?, el cual describe aspectos fundamentales del desarrollo teórico de la enfermería y sus transiciones, e invita a la reflexión acerca de los retos que en el actual contexto de globalización, avances tecnológicos e innovación en las tradicionales formas de ofrecer cuidado, se le presentan a la disciplina de enfermería. enmarcado en la historia, presenta un recorrido a partir de la dependencia del modelo biomédico, hasta el reconocimiento social ¿estará el futuro de enfermería en el nuevo paradigma, expresado por cuidados de calidad y desarrollo humano? frente a la interrogante planteada no puedo de dejar de mencionar la siguiente cita: “la manera de ser de la existencia humana en el mundo, no consiste en estar puesta en él, sino en estar comprometida, decisiva y significativamente con él” (heidegger). edith rivas riveros magíster en salud pública profesora asociada, universidad de la frontera, chile. de la producción de enfermería precisando, entre otros, la gama de modelos teóricos de la enfermería contemporánea y los enfoques investigativos. finalmente, enfatiza y expone cómo las teorías de mediano rango orientarán la práctica disciplinar y, al ser validadas en ella por su sencillez y facilidad de articulación con indicadores empíricos, ofrecen un abanico de posibilidades para el enriquecimiento teórico. en este artículo la autora evidencia la necesidad de la búsqueda de un cuerpo de conocimientos propios que respalden la identidad de la disciplina y la profesión, a la vez que invita a mantener una identidad con la misma, a seguir caminando en lo esencial para enfermería que es “la experiencia del cuidado de la salud de las personas” como fenómeno universal, pero también a propiciar la discusión disciplinar desde el ser y el quehacer de enfermería, a seguir avanzando. amparo montalvo-prieto decana facultad de enfermería universidad de cartagena, colombia. inna flórez-torres docente facultad de enfermería universidad de cartagena, colombia. teoría de enfermería ¿un camino de herradura? psychosocial determinants of the intention to take oral antihypertensive drugs: a cross-sectional study article psychosocial determinants of the intention to take oral antihypertensive drugs: a cross-sectional study a determinantes psicosociales de la intención de tomar antihipertensivos orales: estudio transversal b determinantes psicossociais da intenção de tomar anti-hipertensivos orais: estudo transversal c taciana da costa farias almeida 1 mailson marques de sousa 2 bernadete de lourdes andré gouveia 3 ricardo alves de olinda 4 josé luiz tatagiba lamas 5 simone helena dos santos oliveira 6 1 0000-0002-9390-9656. universidade federal de campina grande, brazil. taciana.costa@professor.ufcg.edu.br 2 0000-0002-8099-4310. hospital municipal santa isabel, joão pessoa, brazil. 3 0000-0001-8133-6048. universidade federal de campina grande, brazil. bernadete.lourdes@professor.ufcg.edu.br 4 0000-0002-0509-8428. universidade estadual da paraíba, brazil. prof_ricardo@servidor.uepb.edu.br 5 0000-0003-4266-6209. universidade estadual de campinas, brazil. zelamas@unicamp.br 6 0000-0002-9556-1403. universidade federal da paraíba, brazil. simone.helena@academico.ufpb.br a this article is the result of the doctoral thesis entitled "psychosocial determinants of the use of oral antihypertensive drugs: measurement instrument and motivational technologies", within the scope of the graduate program in nursing of the federal university of paraíba. https://sig-arq.ufpb.br/arquivos/20190770885c54181015136a6f29d9b01/tese_-_taciana_da_costa_farias_almeida.pdf b el artículo es resultado de la tesis de doctorado "determinantes psicossociais do uso de anti-hipertensivos orais: instrumento de medida e tecnologias motivacionais" ("determinantes psicosociales del uso de antihipertensivos orales: instrumento de medida y tecnologías motivacionales"), en el marco del programa de posgrado en enfermería de la universidade federal da paraíba. https://sig-arq.ufpb.br/arquivos/20190770885c54181015136a6f29d9b01/tese_-_taciana_da_costa_farias_almeida.pdf c este artigo é resultado da tese de doutorado intitulada "determinantes psicossociais do uso de anti-hipertensivos orais: instrumento de medida e tecnologias motivacionais", no âmbito do programa de pós-graduação em enfermagem da universidade federal da paraíba. https://sig-arq.ufpb.br/arquivos/20190770885c54181015136a6f29d9b01/tese_-_taciana_da_costa_farias_almeida.pdf 10.5294/aqui.2020.20.4.6 received: 05/04/2020 sent to peers: 16/04/2020 approved by peers: 20/08/2020 accepted: 24/08/2020 theme: chronic care. contribution to the subject: the results of this study can support the development of behavioral approaches conducted by nurses and by an inter-professional team to improve medication adherence in individuals with systemic arterial hypertension. the findings signal the importance of nurses to pay attention to the predictors of the behavior and beliefs of patients about their medication, their ability to self-administer (forgetfulness) and have access to medications, taking into account socioeconomic and cultural factors in medication adherence. it is recognized that the intervening factors in the behavioral intention to take antihypertensive pills are restricted to a specific population and with their regional values, which can limit the generalization of the findings. additional research studies are needed to understand the behavioral beliefs, the subjective norm, and the perceived behavioral control in taking antihypertensive drugs in other regions. para citar este artículo / to reference this article / para citar este artigo: almeida tcf, sousa mm, gouveia bla, olinda ra, lamas jlt, oliveira shs. psychosocial determinants of the intention to take oral antihypertensive drugs: a crosssectional study. aquichan. 2020;20(4):e2046. doi: https://doi.org/10.5294/aqui.2020.20.4.6 abstract objective: to identify the psychosocial predictors that influence the behavioral intention to take oral antihypertensive drugs. materials and methods: a cross-sectional study, based on the theory of planned behavior. a questionnaire constructed and validated was applied to 220 individuals with systemic arterial hypertension in outpatient follow-up at a public hospital. the chi-square and fisher's exact tests, spearman's correlation and multiple logistic regression were used for data analysis. results: the participants presented a high intention of taking antihypertensive drugs. the behavioral beliefs (ß = 0.0432; p = 0.0364), subjective norm (ß = -1.5708; p < 0.01) and perceived behavioral control (ß = 2.2809; p = 0.0028) explained the behavioral intention in 33 %. conclusions: the behavioral beliefs, the subjective norm, and the perceived behavioral control are significant psychosocial predictors of taking antihypertensive drugs and must be valued, individually and jointly, in the health actions targeted at this population. keywords (source decs): hypertension; antihypertensive agents; treatment adherence and compliance; social theory; nursing. resumen objetivo: identificar los predictores psicosociales que influyen la intención comportamental de tomar los antihipertensivos orales. materiales y métodos: estudio transversal, fundamentado en la teoría de la conducta planeada. se aplicó un cuestionario construido y validado a 220 individuos con hipertensión arterial sistémica en seguimiento ambulatorio en un hospital público. se emplearon las pruebas de cui-cuadrado y exacto de fisher, correlación de spearman y regresión logística múltiple para analizar los datos. resultados: los participantes presentaron alta intención de tomar los antihipertensivos. las creencias comportamentales (ß = 0,0432; p = 0,0364), la norma subjetiva (ß = -1,5708; p < 0,01) y el control comportamental percibido (ß = 2,2809; p = 0,0028) explicaron la intención comportamental en el 33 %. conclusiones: creencias comportamentales, norma subjetiva y control comportamental percibido son predictores psicosociales significativos de la tomada de los antihipertensivos y deben valorarse, de forma individual y conjunta, en las acciones de salud hacia esta población. palabras clave (fonte decs): hipertensión; antihipertensivos; cumplimiento y adherencia al tratamiento; intención; teoría social; enfermería. resumo objetivo: identificar os preditores psicossociais que influenciam a intenção comportamental de tomar os anti-hipertensivos orais. materiais e métodos: estudo transversal, fundamentado na teoria do comportamento planejado. aplicou-se um questionário construído e validado a 220 indivíduos com hipertensão arterial sistêmica em acompanhamento ambulatorial em um hospital público. utilizaram-se os testes qui-quadrado e exato de fisher, correlação de spearman e regressão logística múltipla para as análises dos dados. resultados: os participantes apresentaram alta intenção de tomar os anti-hipertensivos. as crenças comportamentais (ß = 0,0432; p = 0,0364), a norma subjetiva (ß = -1,5708; p < 0,01) e o controle comportamental percebido (ß = 2,2809; p = 0,0028) explicaram a intenção comportamental em 33 %. conclusões: crenças comportamentais, norma subjetiva e controle comportamental percebido são preditores psicossociais significativos da tomada dos anti-hipertensivos e devem ser valorizados, de forma individual e conjunta, nas ações de saúde direcionadas a essa população. palavras-chave (fonte decs): hipertensão; anti-hipertensivos; cooperação e adesão ao tratamento; intenção; teoria social; enfermagem. introduction adherence to medication and the behavior related to taking prescription drugs are a challenge for the treatment of systemic arterial hypertension (sah)(1-2). adherence to treatment is a complex area of health behavior and little is known about what actually influences its performance, since sociodemographic factors, beliefs and experiences can intervene in this behavior(3-4). the theory of planned behavior (tpb) states that intention (motivation) is a precursor of behavior and, since people have a sufficient degree of real control over behavior, they are expected to fulfill their intentions when the opportunity arises. intention is composed of three determinants: attitude, consisting of the behavioral beliefs combined with the probable or expected outcomes in relation to the performance of the behavior; subjective norm, formed by the normative beliefs that are based on the evaluation of the opinion of social referents regarding the performance or not of the behavior and the consideration in agreeing or not with it; perceived behavioral control, formed by the control beliefs, which correspond to the individual's perception of the perceived practicalities or difficulties in carrying out the behavior(5). in addition to the theoretical components of the tpb, variables can be included to understand health-related behaviors. past behavior is an aspect that guides future responses when considering well-practiced behaviors in constant and recurring contexts, such as taking antihypertensive pills daily. in general, people tend to form conscious and favorable intentions about acts that they have frequently performed in the past, redundancy is worth here; thus, when associated with the frequency of performance and combined with the other determinants of the tpb, past behavior tends to be a good predictor of behavior, being able to mediate well-practiced or repeated behavioral intentions, since previous experiences can also interfere with behavioral intention(5-6). the behavioral intention that involves the act of taking the prescribed pill can be influenced by factors that may be beyond the control of the individual, such as the ability to access the medications, their psychosocial and health characteristics(7), beliefs regarding the treatment, health knowledge, recognition of the need for medication(8-9), understanding of the practicalities and difficulties in managing the disease and stable marital status(1). other factors such as ignorance of the benefits and adverse effects of the medication and ineffective communication with the team that prescribes care are described as causes of low adherence to drug therapy(1, 7-9). there are international studies(10-12) based on the tpb that have identified the determinants of the behavioral intention of individuals with sah to take antihypertensive pills. it is observed that none of the aforementioned studies addressed past behavior as an additional variable for the adherence to taking antihypertensives. in the brazilian context, there is no knowledge of studies that have used the tpb to understand the determinants of the behavior of taking antihypertensive drugs. thus, in order to understand the behavioral intention of taking antihypertensive pills, it is relevant to study it based on theoretical assumptions of the tpb, considering the cultural valuation, beliefs and experiences of the individual, in order to improve medication adherence and health outcomes. in this sense, the present study aimed to identify the psychosocial factors that influence the behavioral intention to take oral antihypertensives. materials and methods study type and locus a descriptive, cross-sectional and quantitative study, carried out in a cardiology outpatient clinic of a public hospital linked to the unified health system of the state of paraíba, brazil, in march and april 2019. the institution is a reference for teaching, research and assistance with mediumand high-complexity procedures. population and sample sample calculation was performed considering the 32.5 % prevalence of sah(13) and the mean number of monthly visits made at the cardiology outpatient clinic of the study site (514 consultations performed by cardiologists). a 95 % confidence index and a 5 % sampling error were adopted, which resulted in a sample of 205 individuals with systemic arterial hypertension. the sample was selected for convenience, during the data collection period stipulated for the research. the individuals eligible to participate in the study were those diagnosed with sah, aged 18 years old or older and on continuous and self-administered use of antihypertensive pills for at least six months (14). those with some cognitive impairment confirmed in medical records were excluded. data collection the individuals who waited for a medical consultation at the cardiology outpatient clinic during the data collection period and who met the aforementioned inclusion criteria were invited by the researchers to participate in the study. a questionnaire built by the researchers was applied according to a survey of beliefs about the "taking antihypertensive pills" behavior. the items of direct and indirect measures were formulated according to the recommendations of the theoretical model of the tpb(5). the direct measures (past behavior, attitude, subjective norm, perceived behavioral control and intention) are global statements about the behavior under study. the indirect measures (behavioral, normative and control beliefs) are questions formulated based on a previous study that analyzed the beliefs expressed by individuals with arterial hypertension related to the drug treatment for sah. the measurement instrument developed focuses on the behavior of interest: taking the prescribed pills to control blood pressure in the following 30 days. it consists of 36 questions with a choice of answers in the form of a five-point likert scale and bipolar adjectives of semantic differential, and was divided into two parts: the first included behavioral variables; and the second, questions for the sociodemographic and clinical characterization of the participants. regarding its content, it was validated by specialists with experience in the theoretical model (one psychologist and five nurses), obtaining a content validity index of 0.90 for clarity and of 0.93 for the relevance of the items. semantic validation was carried out with 30 individuals with sah to assess the comprehension capacity and the clarity of the items. the instrument's internal consistency obtained a cronbach's alpha of 0.82(15). examples of direct and indirect measures are presented below. past behavior assessed with a direct measure item: "in the past 30 days, i took all the pills to control high blood pressure, as prescribed by the doctor". answer option: from "totally disagree" — 1 to "totally agree" — 5. attitudewas measured with a direct measure item: "for me, taking all the pills prescribed to control high blood pressure in the next 30 days is...". four bipolar adjectives were used on the answer scale: from "very unpleasant" to "very pleasant"; from "very harmful" to "very beneficial"; from "very useless" to "very useful"; and from "very difficult" to "very easy". behavioral beliefs (14 indirect measure items), which were measured by the product of each of the seven items of behavioral beliefs by the item corresponding to the evaluation of the results. as an example: "taking all the high blood pressure pills as prescribed for the next 30 days will keep my pressure under control". the five-item scale answer options ranged from "very unlikely" — 1 to "very likely" — 5, with the result multiplied by the answer of its corresponding variable: "keeping my blood pressure under control is...", with answers: from "very bad" — 1 to "very good" — 5 on the scale. subjective norm, measured directly by the following item: "most people who are important to me think that i should take all the pills prescribed to control blood pressure in the next 30 days", with answers ranging from "strongly disagree" — 1 to "strongly agree" — 5. normative beliefs (eight indirect measure items), in which the products of four items were combined with four of motivation to fulfill the prescription of the corresponding referent. for example: "my children think i should take all the pills prescribed to control blood pressure in the next 30 days", with answer options ranging from "very unlikely" — 1 to "very likely" — 5, having as motivation measure to fulfill the corresponding item: "when it comes to taking all the pills prescribed to control my blood pressure, i do what my children think i should do", whose answers varied from "totally disagree" — 1 to "totally agree" — 5. perceived behavioral control, assessed by two direct measures: "i am confident that i can take all my prescribed pills to control blood pressure in the next 30 days", with a scale that ranged from "strongly disagree" —1 to "strongly agree" — 5; "taking all the pills as prescribed to control blood pressure in the next 30 days depends on me", with answer variability similar to the item previously mentioned. control beliefs (eight indirect measure items), which were evaluated based on the product of four control belief items multiplied by four corresponding control perception items. as an example, we can mention the following: "i will receive all the pills prescribed to control my blood pressure for free in the next 30 days", with answers that ranged from" very unlikely" — 1 to" very likely" — 5, related to the "free receipt of all the pills prescribed to control blood pressure will allow me to do the right treatment in the next 30 days" control perception item, with answers ranging from "totally disagree" — 1 to" totally agree" — 5. finally, the behavioral intention variable, measured by a direct measure item: "i intend to take all my pills prescribed to control high blood pressure in the next 30 days", with answer adjectives ranging from "very unlikely" — 1 to "very likely" — 5. the second part of the instrument contains ten items related to sociodemographic and clinical data: age; gender; race/skin color; marital status; family arrangement; work situation; family income; schooling; class of antihypertensive medications in use; and blood pressure values measured in the office. the scores of the instrument's constructs are calculated and evaluated separately. for the direct measures (past behavior, attitude, subjective norm, perceived behavioral control, and behavioral intention), the scores were obtained by the mean of the items; for the indirect measures, the product of the beliefs was calculated as follows: the higher the scores, the greater the motivation to carry out the behavior. thus, the scores of the behavioral beliefs range from 55 to 175 (strength of behavioral belief x assessment of consequences); of the normative beliefs, from 8 to 100 (strength of normative belief x motivation to agree with the referent); and, of the control beliefs, from 28 to 76 (strength of control belief x control power). the instrument integration time was approximately 15 minutes. in addition to answering the questionnaire, two measurements of the participants' blood pressure were taken with validated equipment of the omron® brand, model hem 7200(16). the first measurement was taken at the beginning of the interview, and the second, at the end of the application of the data collection instrument. the mean of these measures was used to classify the pressure levels of the participants, according to brazilian guidelines(13). data treatment and analysis the data collected were tabulated and inserted into a microsoft excel® spreadsheet, with subsequent submission to descriptive and inferential statistical analysis using the r software, and presented in table format. to analyze data normality data, the anderson-darling test was used. after applying the test, it was observed that the data did not follow normality (p < 0.05). the sociodemographic and clinical data are presented using absolute and relative frequencies. the direct measures are presented by the median of the items; the indirect ones, by the product of the beliefs, according to the theoretical assumptions of the tpb. as part of the analysis, the higher the scores, the greater the intention to take oral antihypertensive drugs. the correlations between the independent variables (attitude, behavioral beliefs, subjective norm, normative beliefs, perceived behavioral control, control beliefs, and past behavior) and the dependent variable (behavioral intention) were described by spearman's correlation coefficients, since the data did not follow normality. the following correlation values are considered for this analysis: <0.4, weak; from ≥ 0.4 to < 0.5, moderate; ≥ 0.5, strong magnitude (17). to analyze the variables that predict the behavioral intention to take antihypertensives, the multiple logistic regression model was used(17). to make the application of this statistical model feasible, the dependent variable assumed only two values, or rather, it is contained in a finite range of values, between 0 (has no intention) and 1 (has intention). considering that, in this study, the assessment of behavioral intention was based on a likert-type scale, with scores ranging from 1 to 5, for the value of 0 was adopted for "i have no intention" (≤ 3); and, for that of "i have intention" (≥ 4), the value of 1. thus, the outcome under study, the behavioral intention to take the prescribed pills, started to present binary values: "i intend to take the antihypertensive pills" — 1 and "i have no intention of taking the antihypertensive pills" — 0. the wald test is obtained by comparing the maximum likelihood estimate of the parameter (ß) and the estimate of its standard error, being used to test whether the coefficient is not really significant when this test does not reject the null hypothesis. it was used to assess the significance of each variable for the model. the backward procedure was applied to initially incorporate all the variables; subsequently, in stages (stepwise), each one could or could not be deleted. in the final model, it was decided to maintain the variables that presented p < 0.20. the chi-square test was applied to separately assess each independent variable in relation to the outcome variable. nagelkerke's r2, in a logistic regression, demonstrates the model's accuracy in predicting the observed value, and is the most suitable to measure the model presented, with values between 0 and 1. the closer to 1 (100%), the greater the explanatory power of the model, in relation to the set of variables and the outcome variable. p-values below 0.05 were adopted as statistically significant. ethical aspects all the procedures were approved by the local research ethics committee (no. 2,446,615/2017) and are in accordance with the national and international regulations for research involving human beings. the individuals who agreed to participate in the study signed the free and informed consent form. results a sample of 220 individuals with sah participated in the study. table 1 presents their sociodemographic and clinical characteristics. table 1.sociodemographic and clinical variables of individuals with systemic arterial hypertension. campina grande, paraíba, brazil, 2019 (n = 220) variables n (%) sbp n (%) dbp n (%) age < 60 years old >= 60 years old 133 (60.45)     87 (39.55)     gender male female 32 (14.55)     188 (85.45)     race/skin color white 69 (31.36)     non-white 151 (68.64)     marital status single married widower/widow divorced 39 (17.73)     116 (52.73)     30 (13.64)     35 (15.90)     family arrangement lives alone lives with relatives 20 (9.09)     200 (90.91)     work situation active inactive 80 (36.36)     140 (63.64)     family income* none < 1 minimum wage 1 minimum wage 1 to 3 minimum wages > 3 minimum wages 05 (2.30)     29 (13.20)     85 (38.60)     80 (36.40)     21 (9.50)     schooling =< 8 years of study > 8 years of study 114 (57.82)     106 (48.18)     class of medications in use angiotensin ii receptor antagonists 151 (68.60)     diuretic 130 (59.09)     beta-blocker 53 (24.09)     acei ii 40 (18.18)     calcium channel blockers 38(17.27)     vasodilators 07 (3.20)     adrenergic inhibitors 05 (2.30)     classification of the blood pressure values** normal   55 (25.0) 104 (47.3)   pre-sah   96 (43.6) 60 (27.3)   stage 1 sah   48 (21.8) 43 (19.5)   stage 2 sah   17 (7.7) 13 (5.9)   stage 3 sah   04 (1.8)   source: own elaboration. *brazilian minimum wage in 2019: r$ 998.00. acei: angiotensin-converting enzyme inhibitors; sbp: systolic blood pressure; dbp: diastolic blood pressure. * when sbp and dbp are in different categories, the greater value must be used for bp classification. isolated systolic hypertension is considered if sbp ≥ 140 mmhg and dbp ≤ 90 mmhg, with classification in stages 1, 2 or 3. table 2 shows the scores obtained from the investigated behavioral variables. the predominance of medians of 4.00 in the direct measure variables stands out. this indicates a high behavioral intention to carry out the behavior, measured by items of broader approaches. high intention was also identified in indirect measures (based on beliefs), which approached the maximum expected score for high intention, as well as the highest median score for past behavior. table 2. statistical description of the scores of the direct and indirect variables of the theory of planned behavior. campina grande, paraíba, brazil, 2019 (n = 220) variable (abbreviation) possible variation median interquartile range attitude (at) 1-5 4.00 3.75-4.5 behavioral beliefs (bb_pb) 55-127 114.00 103.5-124 subjective norm (sn) 1-5 4.00 4-5 normative beliefs (n_b) 8-100 64.00 48-75 perceived behavioral control (pbc) 1-5 4.00 4-5 control beliefs (c_b) 28-76 54.50 47.75-64 behavioral intention (bi) 1-5 4.00 4-5 past behavior (p_b) 1-5 4.50 4-5 source: own elaboration. in the analysis of the correlation between the scores of the independent variables (p_b, at, b_pb, ns, n_b, pbc, c_b) and the dependent one (bi), all showed a positive and significant correlation (p < 0.01) with the measure of intention behavioral having weak magnitude: r < 0.4 (p_b, at, b_pb, c_b), moderate magnitude: ≥ 0.4, r < 0.5 (sn, n_b), and strong magnitude: r ≥ 0.5 (pbc) variability. that is, the higher the scores of the psychosocial determinants, the greater the individual's intention to take the antihypertensives (table 3). table 3. spearman's correlation coefficients between the scores of the theory of planned behavior. campina grande, paraíba, brazil, 2019 (n = 220) variables p_b at b_pb sn n_b pbc c_b bi p_b 1.00 0.24** 0.03 0.07 0.19 0.24** 0.10 0.29** at   1.00 0.45** 0.34** 0.34** 0.43** 0.17* 0.30** b_pb     1.00 0.39** 0.36** 0.53** 0.23** 0.38** sn       1.00 0.49** 0.47** 0.28** 0.48** n_b         1.00 0.45** 0.33** 0.44** pbc           1.00 0.31** 0.57** c_b             1.00 0.31** source: own elaboration. key: p-values: *p < 0.05 **p < 0.01. multiple logistic regression was performed to relate the probability of individuals with sah having the intention to take antihypertensives, conditioned to the probabilities of the determinants of the intention in their direct (past behavior, attitude, subjective norm, and perceived behavioral control) and indirect (behavioral beliefs, normative beliefs, and control beliefs) measures to influence it. according to the values of ß, it was observed that the subjective norm variable ( ß = -1.5708 and p < 0.001) presented a protective action regarding the behavioral intention of taking antihypertensive pills in this sample, that is, the "negative beta" indicated that, as the behavioral intention increased, the valuation of the opinion of the social referents decreased, which contributes to autonomy and self-confidence in the intention to carry out the behavior. the behavioral beliefs (ß = 0.0432 and p = 0.0364) and perceived behavioral control (ß = 2.2809 and p = 0.0028) variables positively influenced this intention, since the valuesof ß approached 1, and the p-valuesshowed statistical significance (table 4). table 4. multiple logistic regression to define the predictors of the behavioral intention to take the prescribed pills in order to control high blood pressure. campina grande, paraíba, brazil, 2019 (n = 220) variables ß p-value exp (ß) 95 % ci for exp (ß) lower upper wald's test 0.7860 0.3752 past behavior 0.5142 0.0767 1.6724 0.64 4.41 attitude 1.3441 0.0686 0.2608 0.02 3.04 behavioral beliefs 0.0432 0.0364 1.3041 1.05 1.92 subjective norm 1.5708 < 0.001 0.2079 0.04 0.97 normative beliefs 0.0406 0.0500 1.0414 0.97 1.12 perceived behavioral control 2.2809 0.0028 9.7857 1.79 121.58 control beliefs 0.0256 0.1318 0.9619 0.88 1.05 chi-square test 0.9763 nagelkerke's r2 0.33         source: own elaboration. legends: ß = estimates of the equation parameters; p-value < 0.05 (significant); exp (ß) : or; ci: 95 % confidence interval for or; chi-square test < 0.05 (significant). nagelkerke's r2 presented a value of 0.33, which demonstrates that 33% of the behavioral intention to take the pills prescribed to control arterial hypertension in this sample can be explained by the model chosen for the analysis. discussion the present study verified a predominance of a high score of the behavioral intention of female individuals with sah to take the pills prescribed to control the disease, a finding that is significantly and positively influenced by the behavioral beliefs and perceived behavioral control, having the subjective norm as a protective action factor. as for the assessment of the behavioral intention to take the prescribed pills to control arterial hypertension, there was a high intention evidenced by the predominance of high medians in all constructs and closed interquartile ranges. in analogy to the indirect variables, greater variability of answers was observed, which is consistent with the participants' beliefs and opinions, which are supported by their values and experiences, despite being inserted in the same context. these findings reinforce the importance of strategies aimed at valuing aspects related to the subjective and individual beliefs of each user with systemic arterial hypertension(7). regarding the interrelationship between the scores of behavioral intention and its determinants (independent variables), a significant and positive correlation was observed between them, ranging from weak (p_b, at, b_pb and c_b), moderate (sn and n_b) to strong (pbc) correlation magnitude. these findings differ from studies carried out internationally(10-12). one of the possible reasons is the use of only direct measures by the studies cited, and that, in this survey, indirect measures were included, which were built based on the beliefs of the individuals with sah inserted in the study context(18). the comparisons in relation to the international studies are based on the incipience of national studies on the studied behavior, which hinders comparisons in similar contexts. since the direct measure of the pbc is specifically associated with the individual control power, safeguarding the individual's autonomy in carrying out the studied behavior ("i am confident that i can take the pills", "taking the pills depends on me"), a strong correlation and prediction were verified analyzed by the logistic regression model (spearman's rô = 0.57, ß = 2.2809, p = 0.0028), with the intention of carrying out the treatment, since confidence and security in carrying out the treatment directly interfere in the intention of its realization and, consequently, in the execution of the action. although these findings corroborate previous studies(10-12), it should be noted that cultural differences can negatively influence the patients' beliefs about medication and their perceptions of the treatment. the difference in generation, family composition and religion can also create variability in the beliefs and behaviors (7). thus, understanding the mechanisms that affect taking antihypertensives or not, depending on the regionalization of the study and on the sociopsychocultural aspects that involve behavior, is of great importance in the effective management of systemic arterial hypertension, making it important to point out that interventions directed to the attitude, subjective norm and perceived behavioral control should result in more adherence to the medications prescribed(11). in addition, considering that most of the participants present a sociodemographic profile of being married, female and living with someone, added to the high intention of carrying out the studied behavior, the valuation of the opinions of social referents did not interfere in the behavioral intention since, the greater it was, the lower was the relevance attributed by the participants to the opinions of social referents (subjective norm — ß = -1.5708, p < 0.001). this finding is significant and relevant, as it shows an aspect of conscious self-care essentially related to the female gender, added to the independence and autonomy of their individual care actions, even in view of the cultural context in which they live, differing from a study that showed the value of subjective norm with the aim of improving adherence to the sah treatment(19). considering that the research sample was predominantly constituted by women, studies are needed that evaluate both the intention and its determinants in the male population, for purposes of knowledge and comparisons, as well as the interference of this variable in adherence to the treatment since, in this study, only the intention to carry out the behavior was analyzed, without applying adherence scales. in this study, past behavior, added to the constructs of the tpb, was a factor that significantly contributed to the intention to take the medications, presenting a positive correlation with attitude, behavioral beliefs and perceived behavioral control, even if weak. that is, processes of self-perception and cognitive consistency can produce influences on the psychosocial determinants, which are consistent with the frequency of past performance. more frequent past behaviors are likely to produce more favorable attitudes, positive perceptions of regulatory pressure and greater control, and these factors can then contribute to favorable intentions(6). thus, it becomes relevant to understand the past behavior of the individuals who use antihypertensive pills, considering the other constructs of the tpb, in order to value them and intervene in these aspects, evaluating those who can positively contribute in conducting the treatment. it was observed that the b_pb, sn and pbc predictive variables explained the bi in 33 % (nagelkerke's r2 = 0.33 %), a result that partially differs from studies in which at and pbc explained the bi in 47.8 %(10); at, sn and pbc explained the bi in 43 %(12); and at, sn and pbc explained the bi in 61.9 %(11). these results show how much the components of the tpb can behave in different manners, when considering the context, beliefs and regional sociodemographic differences, associated with the items used in the questionnaires (direct or indirect measures), which can differ for each location(5). the importance of the behavioral beliefs (advantages and disadvantages), subjective norm (positive and negative social referents) and perceived behavioral control (practicalities and difficulties) psychosocial determinants in the analysis of the behavioral intention of individuals with sah to take antihypertensives becomes relevant, since these constructs proportionally, directly and inversely influence the behavioral intention to carry out this behavior, either individually or when analyzed together. this result corroborates other studies that analyzed intention in different contexts(10-12). perceived behavioral control, a construct of the tpb that showed better association with hf in isolation (spearman's rô = 0.57, p < 0.001) or jointly (ß = 2.2809, p = 0.0028), is the predictor variable of the bi that assesses how much control the individual has over a certain behavior, as well as the perception of the practicalities and difficulties found to perform it(5). when elaborating the indirect hf measures for this construct, the beliefs (18) highlighted the ease of acquiring the pills free of charge, the act of taking the pills with water, and the low cost of the drugs; pondering the difficulties, forgetfulness of the time to take them and when there is the need to buy them stood out. purchasing pills for free and forgetting the times to take them were also important findings when surveying the beliefs of individuals with diabetes mellitus and cardiovascular diseases(7). the interpretation of a person with sah about perceived control in relation to drug treatment can affect their decision to take the medications and adhere to the prescription. this suggests that the control power and the beliefs in the practicalities and difficulties in taking antihypertensives can specifically influence the therapeutic regime(3). therefore, health professionals must schedule interventions based on this control power, as well as on the negative beliefs related to the difficulties encountered in taking the prescribed pills and stimulating aspects associated with the practicalities, in order to improve adherence to the proposed treatment and, in turn, quality of life. when considering that the pbc explains the bi of taking antihypertensives and that, among the difficulties encountered by the hypertensive individuals to take them, there is forgetful-ness(7, 18-19), the professionals involved with these patients must encourage them to set alarms to remember to take the pills, ask relatives to remember them, so that, in that way, the behavior of taking the drugs as prescribed is improved(3, 10). the cost of the medications and the fact of having to buy them promote non-adherent decisions(3). in this study, inactive individuals in their work activities predominated, with incomes of a minimum wage and uncontrolled blood pressure levels (p < 0.001), since most of the values were at pre-hypertension (sbp = 121139 mmhg ) and normal (dbp < 80 mmhg) levels, classifying them as isolated hypertension(13). governmental actions must be promoted in order to improve access to these medications free of charge, so that they are accessible to the population, so as to keep the disease under control and reduce the number of health problems, which incurs in a greater number of specialized consultations, urgency/emergency assistance, hospitalizations, disabilities and health costs. non-adherence to drug treatment for chronic diseases is a remaining, complex and multifaceted problem, influenced by different sociodemographic and economic characteristics, behavioral and cognitive problems, medication complexity, and social support systems(7). on the other hand, intentional non-adherence in chronic diseases, which includes non-adherence due to lack of access to medication, seems reversible and subject to interventions that address treatment-related barriers(2). thus, patient-centered approaches must be implemented in the daily clinical practice, since the patients' health beliefs, experiences and behaviors influence medication taking. motivational interviewing, patient-centered prescription and emotional support can improve medication adherence, making it possible to manage the emotional state, motivation and confidence among individuals with sah and health professionals(1, 3). in this sense, during the daily clinical practice, health professionals must explore these determinants of behavioral intention, focusing on beliefs, experiences involved with past behavior, and the preferences of their patients, emphasizing the overcoming of barriers, in order to motivate them adhere to the prescribed treatment. it is also necessary to encourage and value the positive behavioral beliefs (ß = 0.0432, p = 0.0364), and to propose strategies to reverse the negative ones; stimulate the subjective norm as a positive factor for a high behavioral intention (ß = -1.5708, p < 0.001), since the latter variable presented an inverse relationship with the intention, which explains that, although the person presents important social references, their self-confidence in the treatment is greater than the opinion of third parties; in addition, encouraging perceived behavioral control (ß = 2.2809, p = 0.0028), since the interference of these constructs in the behavioral intention listed for the study was significant in its determination and explanation. although past behavior has not shown statistical significance in this regression model, it addresses the actions that people have frequently performed in the past, so redundancy is worth in this case(6). this construct, added to the other tpb variables, was one of the predictors that presented a significant correlation to the intention of taking antihypertensives, and the frequency with which the past behavior was carried out can explain the judgments of perceived control, in such a way that acts performed with high frequency are judged under the individual's domain(5). bearing in mind that taking antihypertensive pills is a volitional behavior carried out with high frequency (daily) in everyday life and, as the patient recognizes the practicalities and difficulties of doing it, these two predictors form conscious intentions and must be considered in the construction of health-related actions in order to achieve the prescribed objective. in this context, the nurse can make a significant difference to improve medication adherence among the patients(1, 7). it is necessary to bear in mind that the intervening aspects in taking antihypertensives found in this study — motivational interview/consultation (1, 3, 7); technologies that aim to send text messages with reminders of taking the medications and educational texts sent by smartphones(9, 21-23); the remedy at home program(24); and telephone contacts with home visits(25-26) — are strategies that can be implemented to improve and motivate adherence to the behavior under study. the results obtained are relevant when providing the nurse with the psychosocial variables that influence the decision of taking of oral antihypertensives. as a proposal for future research,an experimental intervention study is suggested in order to ascertain the effect of persuasive messages in modulating behavioral intention to strengthen and self-manage the use of antihypertensive, which would reveal the potential theoretical-practical implications for the nursing science. as a limitation of the study, the use of a convenience sample is pointed out, as well as the fact that the data reflects a single institution in northeast brazil. therefore, it is recommended that additional multicenter research studies be developed, especially in the brazilian context, in order to refute or corroborate the results achieved. conclusions the results obtained allow us to conclude that the psychosocial determinants of behavioral intention described by the tpb, together with past behavior, are significantly related to behavioral intention, acting as influencers in the behavior of taking oral antihypertensives by individuals with sah. the influence of the behavioral beliefs, the subjective norm and perceived behavioral control on the explanatory variability of this behavioral intention was highlighted. these psychosocial determinants must be assessed, individually and jointly, by the health team, in order to understand the determinants that can influence low adherence to treatment. these assessments allow for interventions based on contextual factors, with the purpose of improving the behavior of taking oral 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program. epidemiol serv saude. 2016;25(3):647-54. doi: https://doi.org/10.5123/s1679-49742016000300021 25. raimundo acn, pierin amg. adherence to anti-hypertensive treatment within a chronic disease management program: a longitudinal, retrospective study. rev esc enferm usp. 2014; 48(5):811-9. doi: https://doi.org/10.1590/s0080-6234201400005000006 26. gaziano ta, bertam m, tollman sm, holfman kj. hypertension education and adherence in south africa: a cost-effectiveness analysis of community health workers. bmc public health. 2014;14(240):1-9. doi: https://doi.org/10.1186/1471-2458-14-240 home 01 la practica de la higiene en las manos.indd 8 aquichan issn 1657-5997 ángela maría salazar-maya1 gladys elena guarín-berrío2 marta lucía arroyave-cadavid3 jesús ernesto ochoa-acosta4 marta galeano-ochoa5 la higiene de las manos en una unidad de cuidado intensivo 1 enfermera. magíster en educación y desarrollo humano. grupo la práctica de enfermería en el contexto social. profesora asistente. universidad de antioquia. medellín, colombia. amsalazar@tone.udea.edu.co 2 enfermera. grupo la práctica de enfermería en el contexto social. universidad de antioquia. medellín, colombia. glamau@tone.udea.edu.co 3 enfermera. magíster en salud pública. universidad de antioquia. medellín, colombia. inge@epm.net.co 4 médico. magíster en epidemiología. grupo de epidemiología. universidad de antioquia. medellín, colombia. jochoa@guajiros.udea.edu.co 5 enfermera. especialista en educación y orientación sexual. universidad san buenaventura. medellín, colombia. diabetologia@elhospital.org.co recibido: 28 de noviembre de 2007 aceptado: 14 de enero de 2008 resumen objetivo: comprender cómo el equipo de salud valora, jerarquiza y prioriza la higiene de las manos en la unidad de cuidado intensivo de un hospital universitario. materiales y métodos: metodología cualitativa con enfoque etnográfico. los datos se construyeron por medio de la observación participante y entrevistas a médicos, enfermeras y auxiliares de enfermería participantes en el estudio, en la unidad de cuidado intensivo de un hospital universitario. resultados: la higiene de las manos es una práctica contextualizada a condiciones tales como el paciente, el procedimiento y el mundo material, y lleva a los participantes a valorarla, ponderarla y priorizarla. al profesional de enfermería se le ha delegado la tarea de supervisar el cumplimiento de dicha práctica, lo que le genera conflictos con los otros estamentos. conclusiones: la higiene de las manos es considerada una práctica episódica, temporal, contextualizada, con restricciones e imperativa. los participantes la ponderan y jerarquizan según el tipo de paciente, el tipo de procedimiento y el espacio físico donde se encuentre. palabras clave lavado de manos, infecciones nosocomiales, paciente, vigilancia epidemiológica. año 8 vol. 8 nº 1 chía, colombia abril 2008 8-18 9 la higiene de las manos en una unidad de cuidado intensivo hand hygiene in an intensive care unit abstract aim: to understand the importance and priority assigned to hand hygiene by the health team of an intensive care unit at a university hospital. materials and methods: a qualitative methodology, with an ethnographic approach, was used. the figures were constructed through participatory observation and interviews with the doctors, nurses and auxiliary nurses who took part in the study, which was conducted inside an intensive care unit at a university hospital. results: hand hygiene is a contextualized practice that hinges on the patent, the procedure and the surrounding environment. those elements determine its value and priority for the hospital staff. nursing professionals have been given responsibility for ensuring compliance with hand hygiene practices. however, this has sparked conflict with other professionals in the work place. conclusions: hand hygiene is an episodic, temporary and contextualized practice with restrictions and demands. the weight and importance assigned to it by the participants depends on the type of patient, the procedure and physical setting. key words hand-washing, nosocomial infections, patient, epidemiological surveillance a higiene das manos em uma unidade de cuidado intensivo resumo objetivo: compreender como valora, hierarquiza e prioriza a equipe de saúde a higiene das mãos na unidade de cuidado intensivo de um hospital universitário. materiais e métodos: metodologia qualitativa com enfoque etnográfico. os dados foram coletados por observação participante e entrevistas a médicos, enfermeiras e auxiliares de enfermagem participantes no estudo em uma unidade de cuidados intensivos de um hospital universitário. resultados: a higiene das mãos é uma prática contextualizada a condições como o paciente, o procedimento e o mundo material, que levam a valorá-la, ponderá-la e priorizá-la. o profissional de enfermagem tem que supervisar o cumprimento desta prática, o que lhes origina conflitos. conclusões: a higiene de mão se considera uma prática episódica, transitória, contextualizada, com restrições e imperativos. os participantes no estudo ponderam-na e hierarquizam dependendo do tipo de paciente, de procedimentos e de espaço físico onde se encontre. palavras-chave lavagem de mãos, infecção hospitalar, paciente, vigilância epidemiológica 10 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 introducción las infecciones nosocomiales acarrean graves repercusiones y sufrimiento para el enfermo, y a los sistemas de salud les generan costos adicionales, por la prolongación de la estancia hospitalaria, los exámenes de laboratorio, los insumos especiales y los antibióticos. la piel de los pacientes y del personal puede albergar microorganismos y ser el vehículo para transferirlos a personas susceptibles y a las superficies hospitalarias. uno de los pilares para limitar la diseminación de la infección nosocomial son las prácticas adecuadas de higiene hospitalaria, y la higiene de las manos sustenta en buena parte dichas prácticas. pero a pesar de las múltiples evidencias sobre las bondades de este procedimiento, la adherencia de los trabajadores de la salud a esta práctica continúa siendo baja en muchas partes del mundo (1, 2). la mayoría de los estudios disponibles se ha propuesto investigar la relación entre la frecuencia de la infección nosocomial y la adherencia al procedimiento de higiene de las manos. también se han ocupado en describir la flora de las manos (3) y la utilidad de los diferentes antisépticos (4); pero no se encuentran investigaciones donde se explique por qué el personal de salud no se adhiere a dicha práctica. ante esta carencia, el presente estudio busca comprender, desde los médicos, las enfermeras y las auxiliares de enfermería participantes, la valoración, jerarquización y priorización que le dan. así pues, se planteó la siguiente pregunta: ¿cómo valora y jerarquiza el equipo de salud la higiene de las manos en la unidad de cuidado intensivo de un hospital universitario? antecedentes la fiebre puerperal fue la entidad mórbida que permitió acercarse a la comprensión de la transmisión cruzada de infecciones en los hospitales, y a la importancia de la higiene de las manos para prevenir dicho fenómeno. entre los primeros estudios que se ocuparon del tema hacia finales del siglo xviii y principios del xix está el realizado por charles white quien promovió la higiene de las salas de parto como medida para controlar la mortalidad materna (5). alexander gordon, por su parte, hizo público el tratado de la fiebre epidémica puerperal de aberdeen. en el señala que “después de asistir a las pacientes atacadas de fiebre puerperal, procurasen lavarse con esmero e hicieran fumigar debidamente sus instrumentos” (5). oliver wendell holmes (5) consideró como fuentes de infección a las salas de disección, y ordenaba a los médicos que se lavaran sus manos después de asistir a las parturientas. l. j. boër (6), siguiendo las orientaciones de charles white, promovió, en las clínicas de maternidad de viena, normas orientadas a la disminución de la frecuencia de muertes atribuibles a la fiebre puerperal, redujo mediante procedimientos mínimos de higiene la mortalidad hasta el 0,9% (no se dispone de cifras previas). sin embargo, su reemplazo en el cargo, el profesor klein, no las aceptó, y la mortalidad llegó a ser del 7,8%, y más tarde del 29,3%. ignaz philipp semmelweis comenzó a trabajar como ayudante del doctor klein y sospechó que el “material cadavérico infeccioso”, proveniente de las manos de los estudiantes que realizaban autopsias, era el principal factor causal de la mortalidad de las puér11 la higiene de las manos en una unidad de cuidado intensivo peras (5, 6). ordenó en consecuencia que los estudiantes se lavaran y cepillaran sus manos con hipoclorito de calcio después de las autopsias y antes de examinar a las parturientas. estas elementales medidas tuvieron como consecuencia la disminución de la mortalidad materna a cifras cercanas al 3% (5, 6). la mortalidad y sus determinantes eran, en ese entonces, el centro del pensamiento epidemiológico. en 1856, florence nightingale y william farr (6) se interesaron en la mortalidad de los pacientes de los hospitales ingleses y definieron la metodología para la elaboración de las tasas de mortalidad, utilizando como denominador el total de admisiones o de egresos hospitalarios, lo que permitió establecer la comparación con otros hospitales. el trabajo conjunto de nightingale y farr, consignado en notas sobre hospitales, fue probablemente la primera referencia a la vigilancia epidemiológica en los hospitales por parte de las enfermeras. los aportes de william farr, ignaz philipp semmelweis, florence nightingale y j. simpson fortalecieron el concepto de la medición de la frecuencia de la infección en los hospitales y la reflexión sobre sus causas. el desarrollo de la higiene hospitalaria y de la antisepsia, y el fomento de las medidas preventivas, fueron el comienzo de la aplicación del método epidemiológico dentro del ambiente hospitalario. algunos de los estudios revisados se han orientado por un lado en cuantificar el efecto de la higiene de las manos sobre la frecuencia de la infección nosocomial (7); el impacto del programa de la higiene de las manos en las diferentes unidades hospitalarias (8); la persistencia en la carga de bacterias gram negativas en las manos (9-10); la cuantificación de la disminución del número de unidades formadoras de colonias del s. aureos o especies de candida cuando se realiza una correcta desinfección de las manos (11); la relación causal entre la higiene de las manos y la reducción del riesgo de transmisión de gérmenes nosocomiales (12); la comparación en el uso de diferentes productos para la higiene de las manos y sus resultados (9, 13). otros estudios, en cambio, han medido y definido la adherencia del personal de salud a la práctica de la higiene de las manos (14). con una mirada diferente, elaine larson y edna k. kretzer (15) revisaron la teoría del comportamiento para aumentar las prácticas de la higiene de manos. sostienen que dicha teoría es insuficiente para lograr un cambio sostenido. las intervenciones para mejorar la adherencia a la práctica que nos ocupa deben incluir los niveles de interacción, el comportamiento, la interdependencia de factores individuales, restricciones ambientales y el clima institucional. en el mismo sentido otros autores, como carol o’boyle, susan j. henly, elaine larson (7-16), han estimado la adherencia a la higiene de manos, y han descrito la relación entre los factores motivacionales, la adherencia y la identidad de las actividades de enfermería, probando un modelo explicatorio para la adherencia a las guías de higiene basados en la teoría del comportamiento planeado. sin embargo, concluyen que todos estos aspectos motivacionales o de comportamiento, relacionados con la adherencia del personal, aun hoy continúan siendo un enigma. según afirman, las razones para esta baja adherencia son desconocidas: “posiblemente la higiene de las manos es concebida como una medida muy simple, sin ningún efecto” (13). el desarrollo de la higiene hospitalaria y de la antisepsia, y el fomento de las medidas preventivas, fueron el comienzo de la aplicación del método epidemiológico dentro del ambiente hospitalario. 12 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 participantes en su vida cotidiana laboral, observando lo que hacen, escuchando lo que dicen, preguntando y recogiendo todo tipo de datos accesibles, para posteriormente transcribirlos y elaborar el diario de campo, los memos analíticos y las anotaciones reflexivas. antes de iniciar la recolección de la información nos presentamos al personal del servicio de la unidad de cuidado intensivo con el objetivo de dar a conocer el proyecto de investigación. también se recurrió a entrevistas semiestructuradas, en total veinte, así: dos a médicos intensivistas de la unidad, cinco a médicos interconsultantes, cinco a enfermeras que trabajan o han realizado turnos en la unidad de cuidado intensivo, y seis a auxiliares de enfermería de dicha unidad. su duración osciló entre treinta minutos y una hora. antes de cada entrevista se obtuvo oralmente el consentimiento informado, de acuerdo con la legislación colombiana vigente (parágrafo primero, artículo 16, de la resolución 004830/1993 del ministerio de salud): “en el caso de investigaciones con riesgo mínimo, el comité de ética en investigación de la institución investigadora, por razones justificadas, podrá autorizar que el consentimiento informado se obtenga sin formularse por escrito, y tratándose de investigaciones sin riesgo, podrá dispensar al investigador de la obtención del mismo” (19). cada una de las entrevistas fue grabada y se le asignó un código y un seudónimo para dar cumplimiento a la confidencialidad de la información. muestra: se definió durante la evolución del estudio a medida que se recogía la información aportada por los participantes, entre ellos médicos, enfermeras y auxiliares de enfermería, dada su mayor permanencia y frecuencia en las visitas, y atención directa a los pacientes de dicha unidad. se excluyó otro tipo de personal de salud, como nutricionistas, terapistas respiratorios, fisioterapeutas, por ser más esporádica su permanencia en la atención directa. se llegó a la finalización de la recolección de los datos cuando las observaciones y las entrevistas con los participantes no produjeron ninguna comprensión nueva, lográndose así la saturación de la información (20). análisis de la información: se inició con la transcripción exacta de la información, tal como fue expresada por los participantes, y de las observaciones realizadas en la unidad. se continuó con la lectura cuidadosa de la información, hasta familiarizarnos con ella. en esta fase se extrajeron segmentos significativos, aspectos destacados de la información que permitieron construir cada una de las categorías que dieron respuesta a la pregunta del estudio, y se procedió a desarrollarlas y saturarlas. simultáneamente se procedió a relacionar estos aspectos entre sí y con los conocimientos previos, haciendo contrastes o reafirmando lo ya conocido, y fueron confrontadas con la literatura; esto permitió hacer comprensibles los datos aportados por los participantes y por los diarios de campo (21). paralelamente se elaboraron memos analíticos en donde se registraron las impresiones, comprensiones, sentimientos, inferencias y conclusiones parciales de cada uno de los investigadores (22), y así se finalizó con la descripción densa de cada una de las categorías emergentes. para el manejo de la información se organizaron diferentes archivos, como el de los participantes, la guía de la entrevista, la guía de la observación, codificación de cada una de las entrevistas, y archivos materiales y métodos el estudio se desarrolló con metodología cualitativa y enfoque etnográfico que permitió estudiar, desde una perspectiva emic, la realidad del participante, comprender y describir de manera exacta las situaciones, los comportamientos, y “las experiencias desde el punto de vista de las personas que la viven” (17), y, desde la perspectiva etic (18), permitió interpretar las abstracciones de los investigadores o las explicaciones científicas de la realidad a medida que se realizó la inmersión en el trabajo de campo. se buscó algo más que limitarse a describir el comportamiento, pues se trató de comprender por qué ocurrió y bajo qué circunstancias los participantes se involucraron con los otros, o el contexto (18) de interés, es decir, en las situaciones implicadas en la práctica de la higiene de las manos. acceso: el acceso a la unidad de cuidado intensivo del hospital donde se realizó el estudio se dio por medio del grupo epidemiología, previa presentación y aceptación del proyecto por el comité de investigación y de ética del hospital y del comité para el desarrollo de la investigación, de la universidad de antioquia (codi). el grupo de epidemiología fue siempre el enlace entre el personal de la unidad de cuidado intensivo y los investigadores. recolección de la información el trabajo de campo se desarrolló desde octubre de 2003 hasta enero de 2005 –aproximadamente unas 100 horas de observación participante–, con el propósito de obtener datos sobre la conducta humana mediante contactos directos con los 13 la higiene de las manos en una unidad de cuidado intensivo metodológicos en los que están consignados la bibliografía consultada, memos analíticos, diagramas y notas personales. para garantizar el rigor del estudio (su auditabilidad y credibilidad), se siguieron los principios de la investigación cualitativa, se procedió minuciosamente en la recolección de la información (23), e inmediatamente se transcribieron las entrevistas y observaciones, se chequearon los datos sistemáticamente, manteniendo el enfoque, monitoreando la interpretación y confirmándola constantemente (24). el análisis se fundamentó en los datos. en él los participantes podrán ver reflejada su experiencia. además, se realizó una triangulación de los datos obtenidos en las entrevistas y las observaciones. resultados los participantes del estudio nos enseñan que la higiene de las manos es una práctica ponderada y contextualizada a situaciones como el paciente, los procedimientos y el espacio físico donde este se encuentre. el paciente (…) el paciente que atiende el hospital es propio de este hospital. este tiene una clientela cautiva que no va a ir a ninguna otra parte sino aquí (…) tenemos todo tipo de pacientes… son pacientes de la calle con unas características como la adicción a la marihuana y al sacol; sin familia. ramiro, md. las condiciones generales del paciente a su llegada permiten catalogarlo, y así diseñar un plan de acción acerca de cómo protegerse o no, y hasta dónde. al realizar el cálculo de riesgo, el personal tiene en cuenta factores como la condición del paciente en cuanto a nutrición, sus hábitos, y la enfermedad de base que marca su pronóstico, ya que su futuro o evolución están dados por su propia condición, es decir, por los factores endógenos: …obvio: estado nutricional, todo un montón de cosas, hábitos, en fin, todo eso, pues yo creo que es lo que verdaderamente marca en él el pronóstico y, además, la enfermedad que tiene de base… cómo no se va a infectar en este hospital un paciente que nosotros con frecuencia evaluamos en el servicio de urgencias?… son una cantidad de hipoalbumineicos, desnutridos… son de estratos uno, dos y cero, no se alimentan, no tienen defensas, esas son cosas que también hay que tener en cuenta cierto?… camilo, md interconsultante así nos enseñan los parámetros o indicadores que tienen en cuenta para calcular el riesgo de infección de los pacientes. en cambio, las auxiliares perciben a los pacientes como un riesgo puesto que desconocen todo de ellos: … a todos los pacientes, como yo le había dicho ahorita, es que a todos hay que tratarlos como posibles portadores, porque uno no sabe qué traen, y hay que cuidarse… no, todos no, hay pacientes como que le inspiran más confianza a uno para tocarlos, o para acomodarles digamos un pie, subirles el pie o bajarles la cabecera, no necesariamente necesito guantes. de acuerdo con los parámetros utilizados por los participantes los pacientes son catalogados como: los participantes del estudio nos enseñan que la higiene de las manos es una práctica ponderada y contextualizada a situaciones como el paciente, los procedimientos y el espacio físico donde este se encuentre. 14 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 el paciente que no se debe infectar: la primera categoría la constituye el paciente electivo que, por su buen estado de salud, no se debe infectar: … en la unidad hay tantas infecciones! esta unidad, por la cantidad de pacientes que maneja, tiene tanta infección!,… uno no puede comparar pacientes posquirúrgicos de otras instituciones, de otros servicios, por ejemplo, una paciente de cardio no se debe infectar, un paciente de cardiovascular electivo no se debe infectar. mario, md. el paciente de alto riesgo o en peligro … son pacientes que llegan muy complicados, porque casi siempre vienen de un posquirúrgico… casi siempre nos los pasan de aquí de cirugía, que con la craneotomía, que es el paciente con el piecito, la osteosíntesis, el vascular también lo traen mucho acá, son pacientes muy delicados y muy inmunosuprimidos, porque después del trauma pasan por un quirófano, después llegan aquí, son pacientes muy delicados, pero a medida que pasan los días se van recuperando. ana maría, auxiliar. el paciente “peligroso”: a este paciente se le dará una ubicación física determinada, por ejemplo, el paciente infectado se aislará en un cubículo: …yo digo que en las infecciones intrahospitalarias el médico puede obrar por omisión, en el sentido de que si uno no pide que se aísle un paciente que es potencialmente peligroso tanto para él como para los otros pacientes, él puede estar contribuyendo a diseminar la enfermedad intrahospitalaria. joaquín, md. la vigilancia epidemiológica da pautas de manejo para este tipo de pacientes: …unas medidas que se practican con estos pacientes quienes son un riesgo para ellos mismos o para el médico, y por eso se utilizan las medidas de protección o barreras, y además hay restricciones para la entrada a ese lugar en cuanto al número de personas, estudiantes, uso de antibiótico. ramiro, md. dichas medidas buscan visualizar al paciente infectado, y por tanto el riesgo que presenta y que los lleva a tomar, entre muchas precauciones, la del aislamiento y el manejo adecuado de los desechos. los procedimientos en sus labores de cuidado con el paciente (independientemente de que sea médico, enfermera, auxiliar o familiar), se hace ineludible la higiene de las manos con los diferentes jabones según el procedimiento que se vaya a realizar, y éste en ocasiones demanda incluso el uso de indumentaria como lo expresa nohra, enfermera: …parte de la parafernalia está en el uso del gorro, mascarilla y gafas para determinados procedimientos, como cuando se le va a colocar una línea central al paciente. [y lo confirma joaquín, md.] …hay unos casos muy claros, por ejemplo, una punción lumbar, una punción abdominal, ahí es casi obligatorio, o una puesta de catéter… el médico tiene que lavarse las manos, cien por ciento, ahí no es una o muchas veces, o pocas veces, es siempre, y yo creo que son las actividades donde más asepsia se guarda, en la invasión del paciente. este es un procedimiento invasivo, por tanto, el paciente corre el riesgo de adquirir una infección porque se penetra la piel directo al torrente sanguíneo, en comparación con otro tipo de procedimientos, como la palpación de la piel, en donde no se considera fundamental la higiene de las manos como lo expresan: “ciertos pacientes que no los tocas mucho, solamente les tomas el pulso, yo creo que tampoco tiene sentido que tu, por tomarle el pulso a un paciente, te tengas que lavar las manos” joaquín, md. hay otras situaciones que influyen en el ejercicio de las prácticas: …la carga es muy alta, muchas veces usted esas cosas, estas cositas, los pequeños detalles los va dejando a un lado… yo creo que la carga para los médicos y las enfermeras ha empeorado… es muy alta, eso influye indudablemente, o sea, si usted tiene premura para atender el paciente va dejando a un lado esas cosas, esas cositas, los pequeños detalles…, y hay situaciones de situaciones… si estoy ante un paciente para reanimación primero está la reanimación. josé, md. el mundo material el significado que atribuyamos al mundo material, o sea a los objetos, a los espacios físicos, condicionará nuestras prácticas de asepsia o la higiene de manos. victoria, una de las enfermeras, considera la planta física de la unidad como privilegiada, de fácil acceso, e invita a la higiene de las manos, pero a pesar de esto, y de la norma establecida (higiene de manos con el yodóforo al llegar al servicio), afirma que a veces no se cumple, y compara con el quirófano, donde es lo primero que hace el personal al ingresar al servicio. en este sentido, parece que el área física condiciona e influye en la adherencia o no a las prácticas de asepsia o la higiene de las manos. es decir, a cada 15 la higiene de las manos en una unidad de cuidado intensivo espacio físico del hospital los participantes le atribuyen un valor, y “cirugía” no es ajeno a esto, pues allí se realizan cierto tipo de procedimientos que involucran y ponen en juego el self del cirujano, como sujeto responsable del procedimiento y del paciente, quien pasa a ser objeto o posesión del médico; entonces la higiene de las manos allí es altamente valorada no solo al ingreso al servicio sino al realizar el procedimiento, así lo comenta: …es más, en cirugía yo me les paro a los residentes al pie, a ver cómo se lavan y les cuento el tiempo, y en el quirófano me doy cuenta cómo lavan mi paciente, de qué manera y cuánto tiempo le dedican al lavado, cómo ponen la sonda vesical, porque todo eso redunda en los resultados finales en una operación a la cual yo voy a someter a un paciente cuya responsabilidad es mía. camilo, md. allí hay una adherencia extrema a la higiene de manos, por el tipo de procedimientos que se realizan. aunque parezca contradictorio, la higiene de las manos en los servicios de hospitalización se realiza cuando hay una sensación de contaminación: “…pero en las áreas de hospitalización no lo hacemos con tanto rigor… sólo se lava uno porque se contaminó” ramiro, md. los significados que le atribuyen los participantes a las situaciones ya expuestas hacen que cada uno las interprete y elija adherirse o no a la práctica de higiene de manos, y no necesariamente aceptan los significados y los símbolos que les vienen impuestos desde afuera (25). en todas las situaciones los seres humanos actuamos como agentes racionales, calculando riesgos (26). el individuo no es neutro, ni está libre de su condición cultural. la cognición de los peligros y la elección que hace ante determinados riesgos tienen que ver más con las ideas sociales de moral y justicia, que con ideas de probabilidad de costos y beneficios (27). lo que en realidad hace cada participante es sopesar los riesgos a los cuales se está enfrentando en cada una de las situaciones que vive. las discusiones en el equipo de salud los participantes, de una u otra manera, hacen referencia a dos formas de tratar de lograr la adherencia al lavado de las manos; la primera la constituirían los mecanismos de control y penalización, y la segunda sería una conducta racional producto de la enseñanza, de los acuerdos y de la relevancia de la evidencia: hay dos maneras de resolver esto, amenazando o enseñando... el hospital debe tener conductas claras y debe tener explicaciones… pero hay normas coercitivas: usted no se lava las manos, entonces está suspendida un día; el sindicato no deja, pero eso es parte del reglamento; si el reglamento es claro y concreto y con racionalidad, cada cosa de esas tiene que tener una justificación que sea que indique por qué y para qué se necesita. camilo, md. la enfermera se ha convertido en la recordadora o vigilante de la norma, y este papel le genera conflictos: “…pues yo estoy convencida, nosotros aquí lo hacemos porque es política de la institución, es una norma y tratamos de cumplirla, pero es difícil”. victoria, enfermera. el malestar de enfermería viene principalmente porque el médico no se adhiere a la práctica. las enfermeras consideran esta tarea de vigilancia una responsabilidad delegada por las directivas del hospiel concepto de riesgo en salud obedece al paradigma positivista vigente, pero los participantes perciben el riesgo desde preceptos culturales y morales, y desde las normas sociales y éticas. por tanto, es importante comprender que el riesgo es también una construcción social y cultural, y no una entidad objetiva que se mide de manera independiente del contexto. 16 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 tal, pero sin autoridad, ya que el médico puede realizar o no el lavado de las manos y contestar lo que quiera: “…no, jefecita, es que el agua para las matas, y siguen, entonces ya uno les dice: doctor, es que es en serio, es que yo le estoy hablando en serio jefe. y él responde: no me las voy a lavar. y no se las lava”. esta responsabilidad es un legado que pone a las enfermeras en una situación difícil, y deteriora el self y el clima laboral, teniendo en cuenta que la estrategia propuesta por las directivas, según relatan las enfermeras participantes, es que se reporte al personal que no cumpla la norma. pero las enfermeras sienten que no deben hacerlo porque son las personas con las que trabajan y eso generaría indisposición entre los compañeros. discusión este es un estudio preliminar. aporta datos valiosos que permiten evidenciar la forma como los participantes del estudio aprecian y practican la higiene de las manos, la cual responde más a factores motivacionales o comportamentales que a reales probabilidades de riesgos comprobadas por las ciencias positivistas. la práctica está relacionada con diferentes situaciones, como el espacio físico, el procedimiento y el paciente. todas estas situaciones les permiten a los participantes del estudio valorar, ponderar y adherirse o no a dicha práctica. es importante tener en cuenta que en las actividades cotidianas se tiende a minimizar la probabilidad de obtener malos resultados, o prácticamente a ignorarla, y se tiende también a restar importancia a las posibilidades de riesgo más infrecuentes y de poca trascendencia aparente. la familiaridad parece generar confianza. por eso, el individuo tiende a evitar los riesgos altamente probables, de manera que su mundo inmediato parece más seguro de lo que es en realidad (26). el concepto de riesgo en salud obedece al paradigma positivista vigente, pero los participantes perciben el riesgo desde preceptos culturales y morales, y desde las normas sociales y éticas. por tanto, es importante comprender que el riesgo es también una construcción social y cultural, y no una entidad objetiva que se mide de manera independiente del contexto (28). no obstante, se hace necesario situar la seguridad del paciente como centro de la práctica clínica; por eso se requieren consensos sobre dicha práctica y sobre condiciones del ambiente de trabajo que favorezcan la calidad del cuidado del paciente hospitalizado, y no se debe propiciar un clima desfavorable producto de las discusiones entre los profesionales. el estudio evidencia cómo, en algunas situaciones, los participantes obvian la higiene de manos; por tanto, lo ideal sería que esta práctica tuviese un sentido moral, y que cada uno actuara correctamente, considerando al otro de manera responsable, de acuerdo con una convicción íntima, y no por normas impuestas. este estudio nos invita a continuar investigando sobre el tema en los escenarios hospitalarios de manera que sea posible clarificar cómo se valora, pondera y prioriza la higiene de las manos en estos espacios, y en el personal de salud. además, se puede constituir en un insumo para la elaboración de un instrumento que permita validar los hallazgos encontrados. conclusión la literatura evidencia cómo los estudios sobre la higiene de las manos se han enfocado en estudiar la frecuencia de la infección nosocomial, la descripción de la flora, la adherencia al procedimiento, y la utilización y eficacia de los diferentes productos o antisépticos. la motivación de este estudio la constituyeron factores de motivación y comportamiento del personal de salud respecto a la práctica de la higiene de manos que poco se han visibilizado en los estudios referidos al tema. este estudio reporta que esta práctica se caracteriza por ser episódica, temporal, contextualizada, con restricciones e imperativos. los participantes la ponderan y jerarquizan según el tipo de paciente, el tipo de procedimiento y el mundo material. la institución delega en las enfermeras del grupo participante la labor de vigilancia de dicha práctica, lo que genera discusiones entre los estamentos. limitaciones del estudio los resultados de este estudio participan de su naturaleza pequeña, su ámbito local y la no generalización de los hallazgos. agradecimientos a los participantes del estudio, y a la asesora de investigación carmen de la cuesta benjumea, ph. d., por su apoyo y orientación durante el desarrollo del estudio. 17 la higiene de las manos en una unidad de cuidado intensivo referencias 1. pittet d. improving compliance with hand hygiene in hospitals. infect control hosp epidemiol 2000; 21(6): 381-386. 2. henderson e. hand hygiene and the transmisión of bacilli in a neonatal intensive care unit. clin infect dis 2004; 38 (15): 1688-1689. 3. waters v, larson e, wu f, san gabriel p, haas j, cimiotti j et al. molecular epidemiology of gramnegative bacilli from infected neonatos and health care workers hands in neonatal intensive care units. clin infect dis 2004; 38 (15): 1682-1687. 4. ng pc, wong hl, lyon dj, so kw, liu f, lam rky et al. combined use of 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thousand oaks ca: sage; 1994. p.118. 18. boyle js. estilos de etnografia. en: morse jm, editora. asuntos críticos en los métodos de investigación cualitativa. medellín: universidad de antioquia; 2003. p.186-187,193, 199-200. 19. duque zjh. el consentimiento informado en la práctica médica. medellín: hospital universitario san vicente de paúl; 2000. p.108. 20. taylor sj, bogdan r. introducción a los métodos cualitativos de investigación. madrid: paidós; 1992. p. 31-46. 21. hammersley m, atkinson p. etnografía métodos de investigación. buenos aires: paidós; 2001. p. 15, 20-21, 39, 191-192, 297. 22. sandoval c. programa de especialización en teoría y métodos de la investigación social. bogotá: instituto colombiano para el fomento de la educación superior icfes; 1996. p. 51-85. 23. burns n, grove sk. investigación en enfermería. 3a ed. barcelona: elsevier; 2004. p. 425. 24. morse jm, barrer m, mayan m, olson k, spiers j. verification strategies for establishing reliability and validity in qualitative research. international journal of qualitative methods 2002; 1(2): 10. 25. ritzer g. teoría sociológica contemporánea. madrid: mcgrawhill; 1993. p. 242. 18 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 26. picasso f. percepción, elección y riesgo. the social science paper publisher 2002; 5 (1): 26. 27. douglas m. la aceptabilidad del riesgo según las ciencias sociales. buenos aires: paidós; 1996. p. 13-14, 27, 58-59. 28. díaz mp. el riesgo en salud: entre la visión del lego y el experto. bogotá: universidad nacional; 2002. pp. 46. 1 mauricio arias-rojas1 sonia carreño-moreno2 jennifer rojas-reyes3 incertidumbre ante la enfermedad de cuidadores familiares de pacientes en cuidados paliativos: scoping review* 1 https://orcid.org/0000-0003-2096-1792. universidad de antioquia, facultad de enfermería, colombia. emauricio.arias@udea.edu.co 2 https://orcid.org/0000-0002-4386-6053. universidad nacional de colombia, facultad de enfermería, colombia. spcarrenom@unal.edu.co 3 https://orcid.org/0000-0001-8962-5135. universidad de antioquia, facultad de enfermería. jennifer.rojasr@udea.edu.co * artículo derivado de la tesis doctoral titulada: “’cuidadores paliactivos’ intervención para el manejo de la incertidumbre y la calidad de vida: eca fase ii.” recibido: 17/12/2019 enviado a pares: 23/01/2020 aceptado por pares: 29/03/2020 aprobado: 27/04/2020 doi: 10.5294/aqui.2020.20.3.4 para citar este artículo / to reference this article / para citar este artigo arias-rojas m, carreño-moreno s, rojas-reyes j. uncertainty towards the disease of family caregivers of patients in palliative care: a scoping review. aquichan. 2020;20(3):e2034. doi: https://doi.org/10.5294/aqui.2020.20.3.4 resumen objetivo: conocer el desarrollo de la evidencia científica sobre la incertidumbre ante la enfermedad de cuidadores familiares de pacientes en cuidados paliativos. materiales y métodos: revisión descriptiva tipo scoping review. se realizó una búsqueda en las bases de datos embase, sciencedirect, medline, academic search complete y scopus, en el periodo 2000-2019. se usaron los términos mesh uncertainty, paliative care, end of life, nursing y caregiver. luego del proceso de crítica, se seleccionaron cincuenta artículos. resultados: emergieron cinco núcleos temáticos: caracterización de la incertidumbre en el cuidador, factores influyentes en la incertidumbre, recursos para el manejo de la incertidumbre, evaluación de la incertidumbre y terapéuticas e intervenciones para abordar la incertidumbre. la año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2034 temática: cuidado crónico. aporte a la disciplina: cuidar a un cuidador de una persona en cuidados paliativos es una función propia de los profesionales de enfermería. la incertidumbre ante la enfermedad del cuidador familiar es un fenómeno que marca la experiencia de cuidar a una persona en cuidados paliativos. por esta razón, conocer y organizar la evidencia disponible sobre este fenómeno permitirá optimizar la toma de decisiones en y para la práctica del cuidado orientado a cuidadores familiares, así como desarrollar futuras investigaciones en el área. esta revisión aporta al desarrollo disciplinar sobre el uso y aplicación de la teoría de la incertidumbre ante la enfermedad, en el contexto del cuidado de las personas en cuidado paliativo. https://orcid.org/0000-0003-2096-1792 mailto:emauricio.arias@udea.edu.co https://orcid.org/0000-0002-4386-6053 mailto:spcarrenom@unal.edu.co https://orcid.org/0000-0001-8962-5135 mailto:jennifer.rojasr@udea.edu.co https://doi.org/10.5294/aqui.2020.20.3.4 https://orcid.org/0000-0003-2096-1792 https://orcid.org/0000-0002-4386-6053 https://orcid.org/0000-0001-8962-5135 https://doi.org/10.5294/aqui.2020.20.3.4 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2034 mayor escala de evidencia se encuentra en la caracterización de la incertidumbre en el cuidador, y los vacíos orientan el desarrollo de intervenciones de enfermería sobre la incertidumbre de los cuidadores de personas en cuidado paliativo. conclusiones: si bien existe una amplia exploración de los factores que influyen en la incertidumbre ante la enfermedad del cuidador, la evidencia sobre las intervenciones que ayuden a disminuir la incertidumbre ante la enfermedad es aún escasa. palabras clave (fuente: decs) incertidumbre; enfermería; cuidadores; cuidados paliativos; cuidados paliativos al final de la vida. 3 incertidumbre ante la enfermedad de cuidadores familiares de pacientes en cuidados paliativos: scoping review l mauricio arias-rojas y otros uncertainty towards the disease of family caregivers of patients in palliative care: a scoping review* abstract objective: to know the development of the scientific evidence on the uncertainty towards the disease of family caregivers of patients in palliative care. materials and methods: a descriptive scoping review. a search was conducted in the embase, sciencedirect, medline, academic search complete, scopus databases, during the 2000-2019 period. the following mesh terms were used: uncertainty, palliative care, end of life, nursing and caregiver. fifty articles were selected after the criticism process. results: five thematic nuclei emerged: characterization of uncertainty in the caregiver, factors influencing uncertainty, resources to manage uncertainty, uncertainty assessment, and therapies and interventions to approach uncertainty. the higher scale of evidence is found in the characterization of uncertainty in the caregiver, and the voids direct the development of nursing interventions on the uncertainty of the caregivers of individuals in palliative care. conclusions: although the factors influencing uncertainty towards the disease of the caregiver are widely explored, the evidence on the interventions that may help to reduce uncertainty towards the disease is still limited. keywords (source: decs) uncertainty; nursing; caregivers; palliative care; palliative care at the end of life. año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2034 * article derived from the phd thesis entitled “’cuidadores paliactivos’ intervención para el manejo de la incertidumbre y la calidad de vida: eca fase ii.” 4 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2034 aquichan issn 1657-5997 eissn 2027-5374 incerteza dos familiares e cuidadores perante a doença de pacientes em cuidados paliativos: scoping review* resumo objetivo: conhecer o desenvolvimento de evidências científicas sobre a incerteza de cuidadores familiares em relação à doença de pacientes em cuidados paliativos. materiais e métodos: revisão descritiva tipo scoping review. foi realizada pesquisa nas bases de dados embase, sciencedirect, medline, academic search complete e scopus, no período 2000-2019. foram utilizados os termos mesh uncertainty, palliative care, end of life, nursing e caregiver. após análise crítica, foram selecionados cinquenta artigos. resultados: caracterização da incerteza no cuidador, fatores influentes na incerteza, recursos para lidar com a incerteza, avaliação da incerteza e terapêutica e intervenções para lidar com a incerteza. a maior escala de evidência é encontrada na caracterização da incerteza do cuidador, e as lacunas orientam o desenvolvimento de intervenções de enfermagem sobre a incerteza do cuidador de pessoas em cuidados paliativos. conclusões: embora exista uma ampla exploração dos fatores que influenciam a incerteza do cuidador, ainda são escassas as evidências sobre intervenções que contribuam para reduzir a incerteza em relação à doença. palavras-chave (fonte: decs) incerteza; enfermagem; cuidadores; cuidados paliativos; cuidados paliativos na terminalidade da vida. * artigo derivado da tese de doutorado intitulada: “’cuidadores paliactivos’ intervención para el manejo de la incertidumbre y la calidad de vida: eca fase ii.” 5 incertidumbre ante la enfermedad de cuidadores familiares de pacientes en cuidados paliativos: scoping review l mauricio arias-rojas y otros introducción a pesar de los avances de la tecnología y el surgimiento de nuevos tratamientos, el cáncer y otras enfermedades crónicas han aumentado en el mundo, independientemente de los ingresos de los países. por ejemplo, en el contexto de los países con ingresos bajos y medios, las enfermedades crónicas ocupan la primera causa de mortalidad (1). muchas de estas avanzan y requieren cuidados paliativos por motivos como el diagnóstico tardío, la agresividad de la enfermedad o fallos en el tratamiento (2). sumado a lo anterior, la experiencia de la persona con una enfermedad avanzada en cuidados paliativos es compleja, con grandes necesidades físicas y espirituales, y el cuidador familiar acompaña esta situación (3). en muchas ocasiones, este cuidador debe asumir su rol sin una adecuada preparación, sin el acompañamiento continuo de profesionales de la salud y sin redes de apoyo apropiadas, lo que desencadena en aquel sentimientos de incertidumbre ante la enfermedad del paciente (4). además, convertirse en cuidador implica factores estresantes, cambios en las relaciones y expectativas sobre la labor de cuidado, que producen descontrol (5), inestabilidad emocional y sentimientos negativos ante esta nueva realidad (6, 7). los cuidadores familiares de pacientes en cuidados paliativos experimentan, con mayor intensidad, sensaciones y sentimientos como los descritos, por lo cual presentan mayores episodios de ansiedad y depresión que los cuidadores de otro tipo de pacientes (8-9). según un estudio que respalda dicha afirmación, el 80 % de los cuidadores presenta rasgos de ansiedad y el 82 %, de depresión, mientras que el 69 % advirtió una sobrecarga en su labor. a esto se suman las características del contexto, en el cual están constantemente cercanos a la muerte de la persona que cuidan, factor que aumenta la incertidumbre ante la enfermedad (10). dicha incertidumbre ante la enfermedad es un estado cognitivo que inhabilita a la persona para determinar el significado de los eventos relacionados con la enfermedad. esto genera incapacidad para asignar valores definitivos a objetivos y a eventos y para predecir consecuencias con exactitud (11). la evidencia demuestra que otros aspectos que están relacionados con la incertidumbre ante la enfermedad del cuidador son la falta de conocimientos sobre la situación del paciente, sus cuidados en casa y el manejo de la medicación, además de la falta de seguimiento y respaldo social (6-7). así, descrita la importancia de abordar la incertidumbre ante la enfermedad para los cuidadores de personas en cuidado paliativo, este artículo tiene por objetivo conocer el desarrollo de la evidencia científica sobre la incertidumbre ante la enfermedad de cuidadores familiares de pacientes en cuidados paliativos. materiales y métodos revisión descriptiva tipo scoping review (12) que pretende responder a las siguientes preguntas: ¿cuál es el estado actual de conocimiento científico del fenómeno de la incertidumbre ante la enfermedad en cuidadores de pacientes en cuidado paliativo? ¿qué tipo de evidencia se encuentra sobre el tema y cuáles son los vacíos de la investigación? la búsqueda se realizó en las bases de datos embase, sciencedirect, medline, academic search complete y scopus, en inglés, español y portugués, y estuvo limitada al periodo 2000-2019. se utilizaron los términos mesh y los operadores booleanos de la siguiente manera: uncertainty and paliative care or end of life and nursing and caregiver. se consideraron criterios de inclusión para esta revisión artículos originales o derivados de investigación que incluyeran sujetos como cuidadores de personas con cáncer u otras enfermedades crónicas en estadios avanzados, al final de la vida o en cuidado paliativo. se excluyeron libros y tesis, por su extensión, y artículos de reflexión y de revisión narrativa, por no poder catalogarlos dentro de los niveles de evidencia dados por la joanna briggs institute (jbi) (13). la clasificación que se utilizó de la evidencia fue por nivel de efectividad y significado que aplica para estudios de tipo cuantitativo y cualitativo, respectivamente. el mayor nivel de evidencia se clasificó con el número uno, y el menor se clasificó con el cinco. se seleccionó este tipo de clasificación por ser una de las más amplias en la inclusión de diversos abordajes metodológicos. la estrategia de búsqueda y selección de artículos se detalla en la figura 1. la búsqueda bibliográfica permitió seleccionar 145 artículos originales, de los cuales se excluyeron 65 por fallas en su validez interna. luego de aplicar el instrumento caspe, se seleccionaron para el análisis 50 artículos originales o resultados de investigación. 6 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2034 aquichan issn 1657-5997 eissn 2027-5374 figura 1. diagrama de flujo de la estrategia de búsqueda y selección de artículos. bogotá, 2020. ción clara de los objetivos del estudio, congruencia de la metodología empleada y una selección adecuada de participantes, entre otros aspectos (14). la información se organizó por características comunes y se asignó un nombre a cada grupo de artículos, teniendo en cuenta los criterios de afinidad temática o metodológica. este proceso generó cinco grupos en total: 1) caracterización de la incertidumbre en el cuidador, 2) factores influyentes en la incertidumbre, 3) recursos para el manejo de la incertidumbre, 4) evaluación de la incertidumbre y 5) terapéuticas e intervenciones para abordar la incertidumbre. sobre las consideraciones éticas del estudio, los investigadores tuvieron en cuenta los principios de derechos de autor en la utilización y referenciación de todo el material analizado. resultados la distribución temática de la información permitió integrar los conceptos más abordados en los artículos. se encontró que el concepto más abordado fue factores influyentes en la incertidumbre, con el 36 % del total de la frecuencia de los temas. por abordaje metodológico, predominó investigación cualitativa, con el 38 % del total analizado, y desarrollo de intervenciones para cuidadores, con el 8 %. en la tabla 1 se presenta la información. además de los aportes encontrados en cada uno de los artículos revisados, se presentan en la tabla 2 el nivel de evidencia predominante de acuerdo con la jbi (13) y los vacíos en la investigación según cada categoría temática. discusión a continuación, se presentan los hallazgos de la literatura por cada categoría temática. caracterización de la incertidumbre en el cuidador de manera descriptiva, la literatura reporta que los cuidadores de pacientes en cuidados paliativos tienen niveles de incertidumbre más altos que otro tipo de cuidadores de personas en situaciones agudas o crónicas. por ejemplo, un estudio (15) fuente: elaboración propia. se desarrollaron los pasos que propone la metodología de revisión seleccionada (12), la cual incluye pregunta, objetivo, criterios de inclusión, participantes, concepto principal, contexto, búsqueda y selección de artículos, extracción y clasificación de resultados y discusión (12). para el análisis de la información, se recopilaron los artículos en el programa microsoft excel, con el cual se creó una matriz en la que se definieron como variables por considerar el abordaje investigativo, el diseño del estudio, la forma de recolección de los datos, el análisis empleado, sus principales resultados y conclusiones. luego, se criticó la calidad del artículo por medio de los instrumentos caspe, que son una serie de listas de verificación para evaluar los contenidos de los estudios cuantitativos y cualitativos. las listas contienen preguntas para identificar en el artículo de investigación si existe una definirevisión de la literatura = 2705 embase, science direct, pubmed, medline, academic search complete y scopus periodo: 2000-2019 artículos seleccionados por título y por ser full text n = 800 artículos seleccionados para primera lectura completa n = 145 artículos seleccionados para crítica con casp-e n = 80 total de artículos seleccionados para análisis n = 50 se excluyeron artículos de reflexión o de revisión n = 1905 artículos excluidos luego de la lectura del resumen n = 655 artículos excluidos luego de la primera lectura n = 65 artículos excluidos luego de la crítica n = 30 cualitativos: 18 cuantitativos: 12 n full text n n n n n n n n casp-e 7 incertidumbre ante la enfermedad de cuidadores familiares de pacientes en cuidados paliativos: scoping review l mauricio arias-rojas y otros tabla 1. distribución de los artículos revisados según la metodología y el tema. medellín, colombia, 2020 temáticas abordaje metodológico total n (%)cualitativos n (%) cuantitativos revisiones sistemáticas n (%) no experimentales n (%) experimentales n (%) caracterización de la incertidumbre en el cuidador 1 (2) 5 (10) 4 (8) 10 (20) factores influyentes en la incertidumbre 10 (20) 7 (14) 1 (2) 18 (36) recursos para el manejo de la incertidumbre 6 (12) 3 (6) 3 (6) 12 (24) evaluación de la incertidumbre 2 (4) 2 (4) 2 (4) 6 (12) terapéuticas e intervenciones para abordar la incertidumbre 4 (8) 4 (8) total 19 (38) 17 (34) 7 (14) 7 (14) 50 (100) fuente: datos de la revisión, 2009-2019. tabla 2. niveles de evidencia y vacíos explícitos encontrados por tema. medellín, colombia, 2020 temáticas nivel de evidencia jbi* vacíos explícitos caracterización de la incertidumbre en el cuidador niveles 1b, 2b y 4b en efectividad se debe orientar al desarrollo de estudios que establezcan comparativamente niveles de incertidumbre en cuidadores de personas que estén al final de la vida, como consecuencia de enfermedades diferentes al cáncer. es necesario caracterizar la incertidumbre del cuidador y su relación con la salud mental y los procesos de afrontamiento por los que atraviesa. factores influyentes en la incertidumbre niveles 3 en signficado y 4b en efectividad hay que realizar estudios que comprueben la influencia de diversos factores sobre los niveles de incertidumbre ante la enfermedad de los cuidadores. recursos para el manejo de la incertidumbre nivel 2 en signficado y 4b en efectividad los profesionales de la salud son uno de los recursos que más puede ayudar a controlar la incertidumbre de los cuidadores; sin embargo, lo descrito en la literatura muestra la falta de preparación en cuidado paliativo y en habilidades comunicativas para abordar a estos cuidadores. es importante entonces conocer la percepción y la experiencia de estos profesionales ante el final de la vida, así como desarrollar intervenciones que favorezcan estas competencias para el cuidado paliativo. evaluación de la incertidumbre niveles 4a y 4b en efectividad se debe orientar la investigación hacia el desarrollo de instrumentos válidos y fiables que sean sensibles para evaluar la incertidumbre del cuidador en diferentes contextos de enfermedades avanzadas y al final de la vida. con esto, se esperaría poder determinar el nivel educativo del cuidador, el respaldo social con el que cuenta, su percepción de los profesionales de la salud y las estrategias de afrontamiento que lleven a una evaluación positiva o negativa de la incertidumbre ante la enfermedad. terapéuticas e intervenciones para abordar la incertidumbre niveles 1c y 2c en efectividad este tema es el que presenta menos estudios. son pocas las intervenciones existentes para abordar la incertidumbre en cuidadores de personas en cuidado paliativo. por ello, surgió la necesidad de desarrollar diferentes estrategias de intervención sobre la incertidumbre ante la enfermedad y sus factores influyentes, y para esto se requiere evualar su aceptación por parte de los cuidadores, su impacto y su efecto. fuente: datos de la revisión, 2009-2019. midió el nivel de incertidumbre en cuidadores de pacientes con cáncer de próstata y encontró una media de incertidumbre de 60 sobre 140 puntos; sin embargo, dichos valores son menores a los encontrados en otro estudio (16), que halló un nivel medio de incertidumbre de 92 puntos sobre 155 en cuidadores de pacientes en cuidado paliativo. los estudios sugieren que estos niveles se dan por aspectos como las características específicas del contexto de los cuidados paliativos, la falta de apoyo adecuado a los cuidadores, la discontinuidad de la atención y la falta de habilidades profesionales para identificar las necesidades del cuidador, además de una escasa planeación y evaluación de los objetivos del cuidado del paciente (17-18). 8 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2034 aquichan issn 1657-5997 eissn 2027-5374 como se observa, existen unas características únicas asociadas al cuidado de una persona en cuidados paliativos, y estas se relacionan con la aparición de incertidumbre ante la enfermedad. el cuidador reporta una prevalencia alta de necesidades de cuidado no atendidas que desencadenan resultados negativos en la ejecución de su rol. dichas necesidades incluyen acceso a información veraz —sobre temas como el cuidado físico del paciente—, apoyo psicológico, acceso a apoyos financieros y bienestar espiritual. los estudios (19) muestran que existe una prevalencia de necesidades no atendidas del 26 al 100 % en aspectos como recibir información relacionada con el cuidado del paciente, la enfermedad, su tratamiento, manejo de síntomas, nutrición y medicación. las necesidades no atendidas de tipo físico son del 42 % y están relacionadas con la calidad del cuidado; las psicológicas van del 17 al 78 % y se refieren al manejo de los sentimientos de tristeza y soledad, entre otros aspectos; las financieras van del 17 al 67 %, y tienen relación con encontrar apoyo financiero y beneficios gubernamentales para el cuidador y el paciente; las espirituales van del 3,8 al 100 %, e implican resignificar la experiencia; finalmente, las sociales van del 42 al 71 % y están conectadas con la falta de respaldo social para ayudar en el cuidado. estas necesidades reportadas son distintas a las de otras poblaciones de cuidadores, puesto que la condición de salud y las demandas de cuidado de la persona en cuidados paliativos aumentan con el paso del tiempo. además, no solo se requiere la asistencia en actividades básicas de la vida diaria, sino que, con el avance de la enfermedad, se hace necesario el manejo de dispositivos complejos, como sistemas de drenaje o bombas de infusión, y de medicamentos, como opioides y ansiolíticos (20). por último, el enfrentarse al final de la vida, a la muerte y a la inminente pérdida de un ser querido (21), hace la experiencia de cuidar a una persona en cuidados paliativos única y compleja, por luchar diariamente ante un duelo anticipado, ante la expectativa del empeoramiento o la aparición de nuevos síntomas del paciente, y a esto se suma la incertidumbre sobre el futuro (22). en muchas ocasiones, la incertidumbre ante la enfermedad experimentada por el cuidador genera en él resultados negativos. por ejemplo, se han reportado problemas de salud mental debido a que los mismos cuidadores refieren una carga del cuidado que termina afectando su bienestar psicológico. otros resultados negativos están relacionados con la diminución de la calidad de vida, la aparición de fatiga, depresión, ansiedad, aislamiento, soledad, tristeza y frustración (23-24). de esta manera, la incertidumbre ante la enfermedad se caracteriza por traer consigo problemas en todas las dimensiones de la calidad de vida del cuidador familiar. factores que influyen en la incertidumbre en este apartado se describe lo que reporta la literatura sobre los factores que se asocian a la incertidumbre en el cuidador familiar de la persona en cuidados paliativos; estos se circunscriben a la falta de conocimientos, la invisibilización del rol de cuidador, la ausencia de respaldo social y la calidad de vida. sobre la falta de conocimientos de la enfermedad, varios estudios han encontrado que esta carencia aumenta la incertidumbre ante aquella. se ha reportado también que, aunque existe una falta de conocimientos por parte del cuidador, se experimenta una dualidad entre lo que el cuidador quiere saber y lo que sabe. una investigación describió que los cuidadores se llevan grandes sorpresas al descubrir que la enfermedad del paciente es incurable o que se encuentra en una fase terminal (25), noción que pocas veces es clara para los cuidadores y mínimamente abordada por los profesionales de la salud (26). lo anterior trae como consecuencia un fenómeno llamado pérdida ambigua (27), el cual se caracteriza por la incapacidad que tiene el cuidador de trabajar en los sentimientos de pérdida de su ser querido, dado que no hay claridad sobre el pronóstico de la enfermedad ni su desenlace (28). por otra parte, los cuidadores refieren tener pocos conocimientos relacionados con el cuidado físico del paciente, en aspectos como el manejo de la medicación, el control del dolor y el apoyo para las actividades de la vida diaria. un estudio reportó que de veinte cuidadores entrevistados, solo seis reconocieron el término opioide (29). también se encontró que los cuidadores tienen falsas creencias relacionadas con la adicción a los medicamentos para el dolor y que se sienten abrumados por la complejidad de la administración de la analgesia, el uso de la vía subcutánea, la valoración del dolor y la ansiedad por la aparición de episodios de dolor no controlado. esta situación se deriva de la falta de reconocimiento del rol del cuidador y de su labor en el manejo del dolor por parte de los profesionales de salud (30). en cuanto a las necesidades educativas orientadas a las actividades de la vida diaria, los cuidadores no reciben un entrenamiento para la movilización, el levantamiento, cambios de posición en la cama, traslados al baño, aseo en la cama, cuidado de la piel del paciente o dieta prescrita (25, 30). por tal razón, 9 incertidumbre ante la enfermedad de cuidadores familiares de pacientes en cuidados paliativos: scoping review l mauricio arias-rojas y otros deben aprenderlas a través del método de ensayo y error, lo cual expone al paciente y a su cuidador a un alto riesgo de lesiones físicas (31) y a sentimientos de frustración por parte del cuidador, por la poca retroalimentación que recibe sobre el éxito o el fracaso de su esfuerzo. sobre la invisibilización del rol del cuidador, la literatura reporta que su falta de inclusión por parte de los profesionales de la salud en los procesos de cuidado de los pacientes le genera ansiedad y miedo en relación con las responsabilidades que debe asumir en el hogar, para las cuales no se sienten preparado (3233). un ejemplo de ello se presenta cuando los cuidadores refieren que los profesionales de la salud no los escuchan, no tienen tiempo para hablar y discutir asuntos del cuidado y no los incluyen en la toma de decisiones, haciéndolos más vulnerables al estrés y a la incertidumbre (33). del mismo modo, la falta de inclusión y de reconocimiento de los cuidadores deriva en una dinámica en la que no quieren molestar o poner dificultades a los profesionales de la salud, por percibirse a sí mismos como barreras para la atención (34); sin embargo, ellos esperan que los profesionales de la salud entablen una comunicación asertiva, honesta, sencilla y empática sobre el estado del paciente, la toma de decisiones sobre la retirada de tratamientos fútiles y las expectativas que pueden tener sobre su cuidado y el final de la vida (35). estos comportamientos aumentan la autoconfianza de los cuidadores y disminuyen su sentimiento de estar navegando sin rumbo (36). respecto al apoyo social, el cuidador de la persona en cuidados paliativos percibe una disminución de este a medida que avanza la enfermedad. algunos estudios demuestran que la disponibilidad y calidad de aquel se reduce después de un año del diagnóstico, lo que implica un gran desafío para los cuidadores de pacientes con patologías como el cáncer avanzado, que necesitan sistemas de apoyo más fuertes a medida que la enfermedad se desarrolla (37-38). lo anterior genera consecuencias en el cuidador como la pérdida del empleo o la reducción en el número de horas de trabajo, el agotamiento físico y emocional, la falta de un afrontamiento efectivo y el escaso tiempo para sí mismo (39). finalmente, diversas investigaciones lograron concluir que la incertidumbre ante la enfermedad es un factor que influye en la calidad de vida de los cuidadores. un estudio (40) encontró que la incertidumbre ante la enfermedad del paciente fue un predictor negativo débil en el reporte de la calidad de vida relacionada con la salud del cuidador [r = -0,29, p = 0,002]. de igual modo, otro estudio (41) identificó que en cuidadores familiares de adolescentes con tumores cerebrales la incertidumbre se relacionó con una disminución de la dimensión psicológica de la calidad de vida. otro estudio (42) demostró que cuando se tienen menos temores y dudas sobre la enfermedad, la incertidumbre es baja, mejora la calidad de vida del cuidador y hay un mejor afrontamiento por parte de este. dichos aspectos ratifican la importancia del apoyo que los profesionales de la salud deben dar a los cuidadores familiares. recursos para el manejo de la incertidumbre lo recursos que están disponibles para el cuidador desempeñan un papel importante en la disminución de la incertidumbre ante la enfermedad y están relacionados con la educación para el cuidador, el apoyo social y el acompañamiento por parte de los profesionales de la salud. hay varios estudios que respaldan la importancia de la educación en la reducción de la incertidumbre, como el de henson et al. (43), que descubrió que el proceso de toma de decisiones del cuidador sobre la asistencia al servicio de urgencias con el paciente derivó de la educación recibida por parte de los profesionales de la salud. en adición, teno et al. (44) determinaron que la falta de educación llevó a los cuidadores a sentirse excluidos en las decisiones sobre el tratamiento del paciente. asimismo, hallaron que algunos cuidadores no desean escuchar opiniones sobre la trayectoria de la enfermedad (45) ni recibir información en exceso; más bien, rechazan el tema (46). los estudios expuestos coindicen en encontrar la educación como un predictor de la sobrecarga del cuidador (b.17, p = 0,017) (47). es decir, el cuidador familiar de una persona en cuidado paliativo que se ha informado sobre la enfermedad, los tratamientos, los síntomas y el probable desenlace comprende la situación a la que se enfrenta y, con el uso de sus mecanismos de afrontamiento, modera la aparición de la carga del cuidado y, consecuentemente, la incertidumbre ante la enfermedad (48). por otra parte, algunos estudios muestran que el respaldo social modula la incertidumbre del cuidador. por ejemplo, aquellos cuidadores que pudieron compartir su experiencia, expresar sus dudas y sus temores con personas que pasan por la misma si10 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2034 aquichan issn 1657-5997 eissn 2027-5374 tuación, se perciben más preparados para el cuidado (p = 0,014) (49). por su parte, aquellos que tienen cerca amigos o familiares profesionales de la salud, que les explican mejor los términos médicos, aprenden a modificar su perspectiva de la vida y a sentirse validados en su labor (50). por otro lado, se ha demostrado que niveles altos de incertidumbre están asociados con una percepción baja de respaldo social (r = -0,36 p < 0,05) (51) y con mayores niveles de ansiedad y de síntomas depresivos (52). finalmente, sobre el acompañamiento que deben brindar los profesionales de la salud a los cuidadores familiares de personas en cuidado paliativo, se observó que los cuidadores experimentan incertidumbre ante la enfermedad cuando van en busca de respuestas con los profesionales de la salud y no las encuentran; esto les genera frustración (53). de allí que los profesionales de la salud, como autoridades con credibilidad, deban estar dispuestos a escuchar al cuidador y orientarlo en sus inquietudes. al respecto, otra investigación (54) concluyó que cuando el cuidador tiene la oportunidad de discutir con los profesionales de la salud temas relacionados con la enfermedad del paciente, se siente reconocido, empoderado y apoyado, y esto reduce su incertidumbre ante la enfermedad. evaluación de la incertidumbre el contexto en el que se cuida a una persona con una enfermedad avanzada y en cuidados paliativos difiere de las condiciones que se presentan cuando se cuida a alguien con otra enfermedad crónica o crítica, pues la complejidad de la situación de cuidado aumenta conforme el paciente se acerca al final de la vida. la evaluación que hacen los cuidadores sobre la incertidumbre que experimentan suele ser negativa, es decir, la evalúan como un caos constante en el que no se siente una relación entre los eventos que se vivencian (55). por ejemplo, se ha encontrado que la incertidumbre se evalúa de forma negativa cuando existe una fluctuación diaria de los síntomas, como el dolor en el paciente (56). ante el panorama descrito, es fundamental que el cuidador se familiarice con la situación, la enfermedad, su evolución y sus cuidados, lo cual se logra con el pasar del tiempo y a través de la experiencia. aquellos cuidadores que no reciben información sobre el pronóstico de su paciente reportan altos niveles de incertidumbre, como resultado de enfrentar la realidad de una manera distinta a sus expectativas (57), pues no esperaban un deterioro tan marcado y un acercamiento al final de la vida tan repentino. experiencias como ver que el paciente estuviera bien en la mañana y entrara en situación de agonía en la tarde son frecuentes (58). en contraste, algunos estudios han encontrado una evaluación positiva de la incertidumbre en contextos de enfermedades menos adversas, con cuidadores de pacientes que reciben tratamientos prolongados (59). en estos casos, con el paso del tiempo, la incertidumbre se ve como una oportunidad para el crecimiento personal y el fortalecimiento de la relación con el ser querido en cuidados paliativos. a esto se suman el restablecimiento de la esperanza hacia nuevas metas, la resignificación de la experiencia y un mejor proceso de afrontamiento de la muerte y de su duelo posterior (60-61). terapéuticas e intervenciones para abordar la incertidumbre en la literatura incluida en esta revisión, son escasos los estudios que intervienen la incertidumbre ante la enfermedad en el cuidador familiar. además, las pocas investigaciones reportadas no han sido efectivas para abordar este fenómeno. el estudio (62) más representativo aplicó una intervención a pacientes con cáncer de estadios tempranos y avanzados y a sus cuidadores familiares. por medio de tres visitas familiares de noventa minutos y dos sesiones telefónicas de treinta minutos cada una, encontró que los cuidadores del grupo experimental mejoraron la evaluación negativa del cuidado después de la intervención, pero no se presentaron cambios en el nivel de incertidumbre ante la enfermedad ni en el afrontamiento en ninguno de los grupos. la autora describe que estos resultados se dieron porque la intervención no se enfocó de forma exclusiva en pacientes en cuidados paliativos —quienes tienen unas necesidades especiales, dado el contexto de la enfermedad avanzada—, sino también en pacientes con estadios iniciales de cáncer. los aportes de esta investigación al desarrollo del conocimiento en enfermería se dan principalmente al describir el nivel de evidencia en torno a los cinco temas extraídos de la revisión de los artículos. sobre la caracterización de la incertidumbre en el cuidador y los factores influyentes, los hallazgos permiten a los profesionales de enfermería conocer los niveles de incertidumbre en cuidados paliativos e identificar algunos de los factores desencadenantes de dichos niveles. en este mismo sentido, se describe la posibilidad de seguir investigando los niveles de incertidumbre de manera comparativa con otras poblaciones. en relación 11 incertidumbre ante la enfermedad de cuidadores familiares de pacientes en cuidados paliativos: scoping review l mauricio arias-rojas y otros con los recursos para el manejo de la incertidumbre, la evidencia muestra que es necesaria la capacitación continua de los cuidadores sobre el cuidado paliativo, ya que es un recurso básico para su manejo. respecto a la evaluación de la incertidumbre, la revisión muestra la necesidad de hacer evaluaciones sistemáticas del nivel de incertidumbre en el cuidador y, con esta información, plantear terapéuticas para abordarla, ya que, de acuerdo con los resultados, son pocas las terapéuticas e intervenciones que se han planteado para manejar este fenómeno en los cuidadores. conclusiones la incertidumbre ante la enfermedad del cuidador familiar del paciente con cáncer en cuidados paliativos obedece a causas multifactoriales, como los conocimientos sobre la enfermedad, la comunicación, el reconocimiento de su rol en cuidados paliativos, la satisfacción de necesidades y el respaldo social. cuando el cuidador experimenta incertidumbre ante la enfermedad, tiene una incapacidad para determinar el significado de todos los eventos relacionados con esta —es decir, de asignar valores definitivos a objetos y a eventos—, así como para predecir consecuencias con exactitud relacionadas con la enfermedad, debido a la escasez de información y conocimiento para hacerlo. la literatura revisada de veinte años solo reporta una intervención formal para el manejo de la incertidumbre ante la enfermedad. de este hallazgo, se interpreta la necesidad de desarrollar intervenciones de enfermería que puedan dar un acompañamiento al cuidador que experimenta incertidumbre ante la enfermedad del paciente en cuidados paliativos y, de la misma manera, impactar en otras variables, como su calidad de vida. intervenciones como estas son necesarias en contextos como el colombiano, donde la atención a pacientes en cuidados paliativos y el acompañamiento de sus cuidadores familiares es precaria. financiación: la presente investigación no ha recibido ayudas específicas provenientes de agencias del sector público, del sector comercial o de entidades sin ánimo de lucro. conflicto de intereses: ninguno declarado. referencias 1. world health organization. noncommunicable diseases country profiles, 2018. ginebra: world health organization; 2018. 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https://pubmed.ncbi.nlm.nih.gov/27521394-ultimate-journey-of-the-terminally-ill-ways-and-pathways-of-hope/ https://pubmed.ncbi.nlm.nih.gov/27521394-ultimate-journey-of-the-terminally-ill-ways-and-pathways-of-hope/ https://doi.org/10.1016/j.ejon.2016.08.007 https://doi.org/10.1002/pon.871 https://doi.org/10.1002/pon.871 1 sofia almeida1 ana nascimento2 pedro bernardes lucas3 élvio jesus4 beatriz araújo5 rn4cast study in portugal: validation of the portuguese version of the practice environment scale of the nursing work index 1 https://orcid.org/0000-0002-1874-0432. universidade católica do porto, center for interdisciplinary health research (ciis), portugal. spalmeida@porto.ucp.pt 2 https://orcid.org/0000-0001-6179-034x. universidade católica do porto, center for interdisciplinary health research (ciis), portugal. ananascimento@porto.ucp.pt 3 https://orcid.org/0000-0002-2560-7306. school of nursing of lisbon, nursing research and development unit, portugal. prlucas@esel.pt 4 https://orcid.org/0000-0002-8407-9240. universidade católica do porto, center for interdisciplinary health research (ciis), portugal. ejesus@porto.ucp.pt 5 https://orcid.org/0000-0003-0266-2449. universidade católica do porto, center for interdisciplinary health research (ciis), portugal. baraujo@porto.ucp.pt received: 10/01/2020 sent to peers: 28/02/2020 approved by peers: 06/03/2020 approved: 14/07/2020 doi: 10.5294/aqui.2020.20.3.8 para citar este artículo / to reference this article / para citar este artigo almeida s, nascimento a, lucas pb, jesus e, araújo b. rn4cast study in portugal: validation of the portuguese version of the practice environment scale of the nursing work index. aquichan. 2020;20(3):e2038. doi: https://doi.org/10.5294/aqui.2020.20.3.8 abstract objective: this study aims to validate the portuguese version of the practice environment scale of the nursing work index (pes-nwi) and assess construct validity through exploratory and confirmatory factor analyses. materials and methods: this cross-sectional study validates the psychometric properties of the pes-nwi in portugal. exploratory factorial analysis is used to analyze the psychometric properties of the pes-nwi in a sample of 5,075 portuguese nurses; the data sample covers all geographic regions in the country. confirmatory año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2038 theme: evidence-based practice contribution to the discipline: this paper presents a shorter version of the practice environment scale of the nursing work index (pes-nwi) for portuguese nurses, with five dimensions, which constitutes a new solution for the portuguese context. the validated version of the scale for portuguese nurses can be used in several contexts (hospital centers, primary care); it is an essential tool for supporting decision-making and improving working conditions. https://orcid.org/0000-0002-1874-0432 mailto:spalmeida@porto.ucp.pt https://orcid.org/0000-0001-6179-034x mailto:ananascimento@porto.ucp.pt https://orcid.org/0000-0002-2560-7306 mailto:prlucas@esel.pt https://orcid.org/0000-0002-8407-9240 mailto:ejesus@porto.ucp.pt https://orcid.org/0000-0003-0266-2449 mailto:baraujo@porto.ucp.pt https://doi.org/10.5294/aqui.2020.20.3.8 https://orcid.org/0000-0002-1874-0432 https://orcid.org/0000-0001-6179-034x https://orcid.org/0000-0002-2560-7306 https://orcid.org/0000-0002-8407-9240 https://orcid.org/0000-0003-0266-2449 https://doi.org/10.5294/aqui.2020.20.3.8 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2038 factor analysis is performed to confirm the model’s data adequacy. results: factorial analysis explained 54.6 % of the variance and a five-dimension structure. the five factors identified were nurse participation in hospital affairs, nurse manager ability, leadership and support of nurses, nursing foundations for quality of care, staffing and resource adequacy, and nurse-physician relations. the confirmatory analysis showed that the five-factor model fit well with the data in the portuguese context. conclusion: in a portuguese health context, the pes-nwi is a valid scale to access the nursing environment and improve working conditions. keywords (source: decs) nursing; pes-nwi; psychometric properties; validation; working environment; surveys; questionnaires. 3 rn4cast study in portugal... l sofia almeida and others estudio rn4cast en portugal: validación de la versión portuguesa de la escala del entorno de práctica del índice de trabajo de enfermería resumen objetivo: este estudio tiene como objetivo validar la versión portuguesa de la escala del entorno de práctica del índice de trabajo de enfermería (pes-nwi, por sus siglas en inglés) y evaluar la validez de los constructos mediante análisis factorial exploratorio y confirmatorio. materiales y métodos: el presente estudio transversal valida las propiedades psicométricas de la pes-nwi en portugal. el análisis factorial exploratorio se utilizó para analizar las propiedades psicométricas de la pes-nwi en una muestra de 5 075 enfermeras portuguesas; la muestra de datos abarcaba todas las regiones geográficas del país. se realizó un análisis factorial confirmatorio para corroborar la adecuación de los datos del modelo. resultados: un análisis factorial explicó el 54.6 % de la varianza y una estructura de cinco dimensiones. los cinco factores identificados fueron la participación de la enfermera en los asuntos hospitalarios; la capacidad del gerente de enfermería, el liderazgo y el apoyo de las enfermeras; los fundamentos de la enfermería para la calidad de la atención; la adecuación del personal y de los recursos y las relaciones entre la enfermera y el médico. el análisis confirmatorio mostró que el modelo de cinco factores se ajustaba bien a los datos en el contexto portugués. conclusión: en el contexto de salud portugués, la pes-nwi es una escala válida para acceder al entorno de enfermería y mejorar las condiciones de trabajo. palabras clave (fuente: decs) enfermería; pes-nwi; propiedades psicométricas; validación; ambiente de trabajo; encuestas; cuestionarios. año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2038 4 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2038 aquichan issn 1657-5997 eissn 2027-5374 estudo rn4cast em portugal: validação da versão portuguesa da escala do ambiente de prática do índice de trabalho de enfermagem resumo objetivo: o objetivo deste estudo é validar a versão portuguesa da escala do ambiente de prática do índice de trabalho de enfermagem (pes-nwi, por sua sigla em inglês) e avaliar a validade dos constructos mediante análise fatorial exploratória e confirmatória. materiais e métodos: este estudo transversal valida as propriedades psicométricas da pes-nwi em portugal. a análise fatorial exploratória foi utilizada para analisar as propriedades psicométricas da pes-nwi em uma amostra de 5 075 enfermeiras portuguesas; a amostra de dados abrangia todas as regiões geográficas do país. foi realizada uma análise fatorial confirmatória para corroborar a adequação dos dados do modelo. resultados: uma análise fatorial explicou 54,6 % da variância e uma estrutura de cinco dimensões. os cinco fatores identificados foram a participação da enfermeira nos assuntos hospitalares; a capacidade do gerente de enfermagem, a liderança e o apoio das enfermeiras; os fundamentos da enfermagem para a qualidade da atenção; a adequação do pessoal e dos recursos e das relações entre a enfermeira e o médico. a análise confirmatória mostrou que o modelo de cinco fatores se ajustava bem aos dados no contexto português. conclusões: no contexto de saúde português, a pes-nwi é uma escala válida para acessar o ambiente de enfermagem e melhorar as condições de trabalho. palavras-chave (fonte: decs) enfermagem; escala pes-nwi; propriedades psicométricas; validação; ambiente de trabalho; questionários. 5 rn4cast study in portugal... l sofia almeida and others introduction the practice environment scale of the nursing work index (pes-nwi) is an instrument that measures the nursing practice environment and is the most used worldwide. it was developed by lake (1), who defines the nursing practice environment as “the organizational characteristics of a work setting that facilitate or constrain professional nursing practice” (1). the pes-nwi has been translated and validated for several contexts worldwide and is applied to identify the organizational characteristics of the environments that are attractive to nurses. it was built through factor analysis of data from magnet hospitals (2) and is composed of subscales representing distinct domains of the nursing practice environment: nurse participation in hospital affairs (npha); nursing foundations for quality of care (nfqc); nurse manager ability, leadership and support of nurses (nmalsn); staffing and resource adequacy (sra); and collegial nurse-physician relations (cnpr) (1, 2). from the perspective of lake (1), favorable nursing practice environments are characterized by the adequacy of human and material resources, the active participation of nurses in organizations’ internal governance, the existence of nursing fundamentals for the quality of care, and the good relations among different professional groups, particularly doctors and nurses (3). in light of the scientific evidence in the last decades, such environments have significant impacts on the levels of quality and safety of user care, health workers’ well-being, and the quality, productivity, and effectiveness of health services, organizations, and systems. thus, developing instruments to determine the quality of indicators that measure those work environments is necessary. in portugal, few studies have evaluated the practice environment and its implications. nursing in the portuguese context is associated with elevated stress, insufficient staff in the workplace, and poor recognition of professional nurses’ skills and experience (3). amaral, ferreira, and lake (4) translated and validated the portuguese pes-nwi, which retained the 31 items from the original version. however, the model revealed some limitations concerning its convergent, discriminant, and factorial validity, justifying the need for studies that adapt the pes-nwi to the portuguese healthcare context. more studies could provide a different factor structure to obtain an adequate pes-nwi model to apply to the portuguese nursing context. this study aims to validate the portuguese version of the pes-nwi in the framework of the rn4cast portugal 2018 study and assess construct validity through exploratory and confirmatory factor analyses in a national sample of portuguese nurses. materials and methods the study is methodological with a cross-sectional design to evaluate the psychometric properties of the pes-nwi in the portuguese rn4cast 2018 survey, which is a replication of the initial protocol. it involved 5,075 nurses. the data sample covered 48 acute care hospitals (under the same administrative council), including three public-private partnerships and two private hospitals (primary health care centers and hospitals). the hospitals are located across the portuguese continental territory and its autonomous regions, madeira and the azores. the sample was obtained through an online survey that was part of a broader research study (rn4cast portugal 2018). the participation of nurses was voluntary and anonymous. nurses were included in the study regardless of their contractual relationship with the hospital (contractors or in-house staff). nurses that were not practicing at the time of data collection were not considered. data collection occurred between november 2017 and may 2018. the data was obtained from an online questionnaire with the following variables: demographic data (gender, age, educational background, marital status), and professional experience data (years of nursing practice experience and workplace. the pes-nwi developed by lake (1) was translated into portuguese by amaral, ferreira, and lake (4). it is composed of five subscales and 31 items that describe characteristics of practice nursing environments (1), which are rated on a likert scale ranging from 1 (‘strongly agree’) to 4 (‘strongly disagree’). the original version comprises five domains that characterize practice environments: (a) npha, with nine items; (b) nfqc, with ten items; (c) nmalsn, with five items; (d) sra, with four items; and (e) cnpr, with three items (1). in the portuguese version, amaral, ferreira, and lake (4) keep the 31 items but has seven domains as a result of npha subdivision into participation in hospitals affairs (pha) with six items and opportunities for professional development (opd) with three items; and nfqc into philosophy of quality (pq) with seven 6 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2038 aquichan issn 1657-5997 eissn 2027-5374 items and continuity of care (cc) with three items. the other dimensions of the scale had no changes (4). lake (1) proposed the use of a mean score (set as 2.5) for each subscale and a composite measure as the average of the five subscale scores for data comparison among studies. statistical analyses continuous variables were described by mean and standard deviation, while categorical variables by absolute frequency and relative frequency. statistical package for the social sciences software (ibm® spss®, version 22.0) was used for descriptive analyses. in the first stage, we performed an exploratory factorial analysis (efa) with varimax rotation to analyze the psychometric properties of the pes-nwi and identify its dimensions in a portuguese national sample. the kaiser-meyer-olkin (kmo) measure of sampling adequacy was 0.909, while bartlett’s test of sphericity had a p-value < 0.001, indicating that the data were appropriate for factor analysis. for factor interpretation, items with a factor loading above 0.4 were retained. the cronbach’s alpha was used to test internal consistency, considering values above 0.7 as acceptable. in the second stage, using a subsample, we performed a confirmatory factorial analysis (cfa) to assess the instrument’s structure. we employed the ibm® amos software (25.0 version) to assess the model adjustment quality obtained from the efa. the cfa was performed using the maximum likelihood method, which implies independence of observations, multivariate normality, and nonexistence of outliers. the normal distribution of the variables was analyzed using the skewness (sk) and kurtosis (ku) coefficients. outliers were assessed using the squared mahalanobis distance (d²) (5). the goodness-of-fit index (gfi) was used to assess the global goodness-of-fit of the model. the comparative fit index (cfi), which scored above 0.90, revealed reasonable adjustment, and the root mean square error of approximation (rmsea), with scores between 0.05 and 0.1, was acceptable. the model with the lowest modified expected cross-validation index (mecvi) shows proper adjustment; for this purpose, the modification indices predicted by amos and theoretical considerations were taken into account (5). convergent validity was assessed through the average variance extracted (ave) with a minimum of 0.5 for each factor. discriminant validity was considered good if the ave of each factor was equal to or higher than the square of the correlations among the same factors (5). reliability and convergent validity of the adjusted model internal consistency was analyzed using cronbach’s alpha (α). construct validity was calculated using three sub-components. convergent validity was calculated using the ave for each factor and considering 0.50 as the minimum value for convergent validity. discriminant validity was established when the ave for both factors was equal to or greater than their squared correlation. results characteristics of hospitals and participants five thousand fifty-five nurses who work in mainland portugal participated in this study. most participants were female (72.6 %), and 21.7 % were male (table 1). the nurses’ age varied between 22 and 66 years (m = 39.0; sd = 9.1); the mean worked as a nurse for 16.1 years. most professionals (99.3 %) had a degree in nursing, and 45.7 % were specialists. most nurses work in a hospital context (72.6 %) and primary care (20.9 %). the efa of the pes-nwi identified five components that explain 54.6 % of the total variance. items 14, 15, 18, and 19 did not respect the factor loading criteria and, for that reason, were excluded. the four excluded items were part of nfqc in the original version (1), and pq in the portuguese version (4). the final solution is composed of 27 items and five components (table 2). the five components identified are npha with 11 items, nmalsn with five items, sra with four items, nfqc with four items, and npr with three items. in the internal consistency analysis, the total scale had cronbach’s alpha of 0.912, and, in the subscales, alpha was greater than 0.8, revealing excellent internal consistency. the cfa was performed on the pes-nwi five-factor structure found in our sample. the pes-nwi items presented good factorial weights (> 0.3). initially, the afc model showed poor adjustment of the model (χ2/df = 8,523; cfi = 0.851; rmsea = 0.072). 7 rn4cast study in portugal... l sofia almeida and others as the changes were not significant, we analyzed the model modification indices. the highest modification indices occurred in the correlations of errors: items 10 and 20, items 5 and 17, and items 23 and 27. the final model showed significantly better goodness-of-fit (figure 1) with the sample under analysis and lower mecvi (1.06 vs. 1.70) than the original model. adequate internal consistency and reproducibility of the total scale (α = 0.912) and subscales (table 3) were observed. as an indicator of convergent validity, the ave proved to be adequate for the nfqc and npr factors (> 0.5), close to acceptable for the nmalsn and sra factors, and low for the remaining factors. the analysis of the model’s factorial invariance in both independent subsets (test and validation) showed adequate goodness-of-fit indices in the final factor solution (χ2/df = 2,758.4; cfi = 0.91; gfi = 0.91; rmsea = 0.056; mecvi = 1.15). figure 1. five-factor model of the portuguese pes-nwi table 1. descriptive analysis of demographic variables of the study sample n % mean sd gender female 3,974 78.3 male 1,101 21.7 age group 22–35 2,150 42.4 36–49 2,188 43.2 > 50 707 13.9 workplace hospital context 3,686 72.6 primary care 1,059 20.9 integrated continuous care 143 2.8 residential structure for the elderly 82 1.6 other 105 2.1 degree in nursing yes 5,041 99.3 specialty in nursing yes 2,318 45.7 age (years) 39.0 9.1 years as a nurse 16.1 9.1 sd: standard deviation source: own elaboration. additionally, the mahalanobis distances indicated the presence of several multivariate outliers. thus, we decided to remove some multivariate outliers from the model and analyze the modification indices. the pes-nwi model, without the five most severe outliers, also exhibited adjustment quality statistics that classify the model as suffering (χ2/df = 8,552; cfi = 0.851; rmsea = 0.072). source: own elaboration. item 4 item 5 item 6 item 11 item 17 item 21 item 22 item 23 item 25 item 27 item 28 item 1 item 8 item 9 item 12 item 3 item 7 item 10 item 13 item 20 item 26 item 29 item 30 item 31 item 2 item 16 item 24 e4 e5 e6 e11 e17 e21 e22 e23 e25 e27 e28 e1 e8 e9 e12 e3 e7 e10 e13 e20 e26 e29 e30 e31 e2 e16 e24 npha sra nmalsn nfqc npr ,44 ,35 ,56 ,39 ,45 ,37 ,37 ,51 ,30 ,31 ,23 ,28 ,50 ,21 ,28 ,79 ,78 ,49 ,53 ,34 ,51 ,30 ,29 ,51 ,34 ,54 ,50 ,62 ,66 ,29 ,54 ,58 ,67 ,61 ,61 ,71 ,55 ,56 ,48 ,52 ,71 ,88 ,89 ,53 ,46 ,55 ,71 ,73 ,70 ,59 ,73 ,58 ,71 ,54 ,82 ,79 ,71 ,48 ,43 ,93 ,52 ,34 ,22 ,51 ,47 ,39 ,26 8 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2038 aquichan issn 1657-5997 eissn 2027-5374 table 2. components of the portuguese pes-nwi npha sra nmalsn nfqc cnpr 4. active staff development or continuing education programs for nurses 0.562 5. career development/clinical ladder opportunity 0.622 6. opportunity for staff nurses to participate in policy decisions 0.606 11. a chief nursing officer who is highly visible and accessible to staff 0.469 17. opportunities for advancement 0.614 21. management that listens and responds to employee concerns 0.593 22. an active quality assurance program 0.568 23. staff nurses that are involved in the internal governance of the hospital 0.667 27. opportunity for staff nurses to serve in hospital and nursing committees 0.612 28. nursing managers that consult with staff on daily problems and procedures 0.537 25. a program with a mentor for newly hired nurses 0.418 1. adequate support services to allow spending time with patients 0.555 8. enough time and opportunity to discuss patient care problems with other nurses 0.590 9. enough registered nurses to provide quality patient care 0.863 12. enough staff to get the work done 0.859 3. a team of supervisors who support nurses 0.511 7. mistakes used by supervisors as learning opportunities rather than criticism 0.500 10. a nurse manager who is a good manager and leader 0.820 13. appreciation and recognition for the good accomplishment of a task 0.443 20. a nurse manager who backs up the nursing staff in decision-making, even in a conflict with a physician 0.792 26. nursing care based on a nursing, not a medical model 0.540 29. written, current nursing care plans for all patients 0.768 30. patient care assignments that foster continuity of care, i.e., the same nurse takes care of the patient from one day to the next 0.646 31. use of nursing diagnoses 0.808 2. good working relationships between physicians and nurses 0.793 16. much teamwork between nurses and physicians 0.830 24. collaboration (joint practice) between nurses and physicians 0.812 variance (%) 31.1 7.1 6.3 5.6 4.5 alpha 0.862 0.779 0.816 0.730 0.813 source: own elaboration. 9 rn4cast study in portugal... l sofia almeida and others discussion the purpose of this study was to validate the portuguese version of the pes-nwi in a national sample of portuguese nurses, in the context of the rn4cast portugal 2018 study. it is the first study in the country to use a sample of portuguese nurses who work in different health contexts to validate the pes-nwi. our results indicated a final 27-item structure and a five dimensions model, resulting in a different solution from that of the previous version validated in the portuguese context (4). our final study results for the pes-nwi matched three domains in the original version, sra, nmalsn, and cnpr. the items excluded in our factorial analysis belong to the nfqc domain in the original version (1) and the pq subscale in the portuguese version (4). in this study, we found a factorial structure with five components, which agrees with the one suggested by the author of the original scale (1). the cfa supported the five-factor model. the results are similar to other international studies (6–10). the results from the efa presented a five-dimension solution, which is like the original scale presented by lake (1), but the items within the factors are different. in previous studies, similar variations in item structure have been observed (6–9). these can be due to differences in culture, health care systems, and management among countries, which may influence nurses’ responses. efa is a technique sensitive to sample size. it is important to note that the present study had a nationwide sample that was larger compared to the original version (n = 2299) (1), and more significant than the one used in the portuguese context (n = 236) (4). this difference in sample sizes may contribute to different responses and the exclusion of most items within the nfqc domain. the cfa model showed that the five-factor model fits well with the study sample in the portuguese health context. the coefficients of the model’s goodness-of-fit indices were satisfactory. nevertheless, the five-factor model showed good convergence, discriminant validity, and global internal consistency (α = 0.91) that was higher than the seven-factor model of amaral, ferreira, and lake (4) (α = 0.83). the final model showed excellent reliability and construct validity, which supports the decision to exclude the items that are not essential to the construct being measured. therefore, this shorter version of the pes-nwi can be used for future studies. the invariance analysis of the five-factor model confirmed its stability. in our study, the internal consistency observed in the final five-factor model is higher than that obtained by lake (1) (α = 0.82), amaral, ferreira, and lake (4) (α = 0.89), and fuentelsaz-gallego, moreno-casbas, and gonzález-maría (8) (α = 0.90). the total scale and sub-scales of the five-factor model showed adequate reliability and internal consistency. our results agree with those of other studies about the psychometric properties of the pes-nwi in different contexts (1, 4, 6, 10–15). this methodological study has limitations. first, it administered a self-report questionnaire that cannot distinguish the influence of response biases. second, it employed a non-random sampling technique that cannot distinguish between nurses working in private and public hospitals, which have critical organizational differences that could impact nurses’ perceptions of the work environment. this shorter version of the pes-nwi should be used in new studies and different work contexts to evaluate the nursing environment. conclusion for the success of healthcare systems, the nursing work environment is critical; so, its measurement should be a regular practice available for both professionals and citizens to consult. this study contributed to the validation and psychometric property assessment of the portuguese version of pes-nwi in a large sample at the national level. it also showed the adequate five-factor structure of the pes-nwi. the five-dimension model shows better specificity and stability in the analysis than the original version. upon confirming this structure was reliable, all the factors showed adequate loading in their component and a semantic relationship among the items. this new model should be used in new studies to evaluate the work environment and improve healthcare conditions. table 3. construct validity analysis of the pes-nwi factors (5) ave nurse participation in hospital affairs 0.37 nursing foundations for the quality of care 0.51 nurse manager ability, leadership and support of nurses 0.46 staffing and resource adequacy 0.41 collegial nurse-physician relations 0.60 source: own elaboration. 10 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2038 aquichan issn 1657-5997 eissn 2027-5374 the validation of the portuguese version of the pes-nwi in this study is a substantial contribution to the healthcare context; it is an essential tool in supporting decision-making, accessing the nursing environment, and improving working conditions. ethics approval and consent to participate: all participants were fully informed about the study, participated voluntarily, and had the right to withdraw at any time. anonymity was maintained in all stages of the study. the catholic university committee of ethics reviewed and approved the study’s protocol, which included the above ethical considerations (process no. 3/2018). conflict of interests: none declared. references 1. lake et. development of the practice environment scale of the nursing work index. res nurs health. 2002;25(3):176– 188. doi: https://doi.org/10.1002/nur.10032 2. lake et. the nursing practice environment: measurement and evidence. med care res rev. 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analizó cada una de las 66 características y las 200 variables, y emitió juicios basados en documentos de análisis y soporte y en encuestas de opinión aplicadas a estudiantes, profesores, directivos y egresados, acerca de la realidad académica y administrativa, lo cual permitió determinar las fortalezas y debilidades y proponer planes de mejoramiento en el fortalecimiento del programa. palabras clave autoevaluación, acreditación, autorregulación, heteroevaluación, diagnóstico, cna, pei, pep. abstract self evaluation and self regulation determines the functioning and achievements of the program, which revert in the capacity for feedback and obtain excellence, to demonstrate that the program for accreditation has quality, verified by external pairs to the institution or program. the nursing program of la sabana university, since its beginning, has done self-evaluations to improve its process and give feedback to its action in the education of students and professors. keeping in mind law, the process of accreditation was inscribed, following the rules given by the direction of accreditation and curriculum, with self evaluation of the program of ten factors proposed by the cna; analyzed each one of the 66 characteristics and 200 variables, and giving judgements based on documents of analysis and support and in opinions, questionnaires to students, professors, directors and graduates, about the academic and administrative reality, to determine the strengths and failures and propose plans to improve the program. key words self-evaluation, accreditation, self-regulation, hetaerae evaluation, diagnosis cna, pei, pep. la autoevaluación dentro del proceso de acreditación del programa de enfermería de la universidad de la sabana 31 a acreditación responde al marco normativo expedido en la ley 30 de 1992, la cual plantea la necesidad de que los programas académicos de las instituciones de educación superior demuestren, a través de un proceso de autoevaluación y autorregulación, que tienen calidad; en otras palabras, la acreditación es un proceso de evaluación, que tiene como objetivo fundamental asegurar que el programa o la institución dispone de los medios apropiados para la tarea que debe realizar, y que su organización y enfoque permiten lograr la excelencia. un programa académico tiene calidad en la medida en que se aproxima al prototipo de los estándares establecidos para tal efecto; según el sistema nacional de acreditación, los programas serán evaluados teniendo en cuenta las características y variables definidas para cada uno de los factores, los cuales deben responder a los siguientes criterios: universalidad, integridad, equidad, idoneidad, responsabilidad, coherencia, transparencia, pertinencia, eficacia y eficiencia. la autoevaluación: proceso por medio del cual el funcionamiento y los logros del programa o la institución son estudiados por sus actores, a la luz de su misión, principios, objetivos y funciones de docencia, investigación y proyección social, con el fin de proponer juicios de valor acerca de sus fortalezas y debilidades, que conduzcan a plantear programas de perfeccionamiento y transformación. la autorregulación: es la capacidad que tiene el programa para retroalimentar su funcionamiento y procurar la excelencia, por medio de la introducción de correctivos traducidos en planes de desarrollo, de manera que haya coherencia y consistencia en su quehacer. la evaluación externa o heteroevaluación, realizada por los pares académicos de la misma disciplina, cuyo propósito es comprobar la objetividad y veracidad de la autoevaluación que el programa ha hecho, y emitir con ello un informe sobre la calidad del programa. una vez cumplidos los tres pasos anteriores, se concede o no la acreditación; esta es otorgada por el ministerio de educación nacional, previa recomendación del consejo nacional de acreditación, ente que la promueve y ejecuta, designando a los pares académicos que realizan las evaluaciones de los programas. dicho proceso es voluntario y temporal, lo cual significa que el programa o la institución decide libremente cuándo y en qué momento se someterá a él; igualmente, el reconocimiento de la calidad del programa no es indefinido, pues se otorga por un período de tiempo que puede oscilar entre tres y diez años. para llevar a cabo el proceso de acreditación se han determinado los siguientes pasos: • evaluación de las condiciones iniciales para ingresar al sistema nacional de acreditación: su objetivo es garantizar que las instituciones educativas cumplan con las condiciones básicas que determinan la posibilidad de éxito en la obtención de la acreditación. • autoevaluación del programa o la institución: la evaluación se realizará siguiendo los lineamientos o factores establecidos por el consejo nacional de acreditación (cna), que son siete, los cuales permiten apreciar las condiciones de desarrollo de las funciones de docencia, investigación y proyección social del programa. • evaluación realizada por pares académicos, un grupo de expertos de la misma disciplina, designados previamente por el consejo nacional de acreditación: ellos identifican las condiciones internas del programa, revisan los resultados de la autoevaluación y elaboran un informe sobre la calidad del mismo. • evaluación final: el consejo nacional de acreditación, con base en el informe de autoevaluación de los pares académicos, elabora el informe y recomienda o no la acreditación, según si el programa cumple o no con los estándares de calidad. • decisión para conceder la acreditación: este procedimiento es de competencia del ministerio de educación nacional, quien toma la decisión y la comunica al respectivo programa o institución. etapas que debe seguir el proceso año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 32 la autoevaluación en el programa de enfermería de la universidad de la sabana la universidad coordina los procesos de autoevaluación a través del centro de acreditación, proporcionando así la base para implementar planes de desarrollo. en el año 1994 se inicia el proceso de autoevaluación y acreditación en la universidad; no obstante, es preciso no desconocer los procedimientos anteriores en materia de autoevaluación institucional, entre los años 1980 y 1994, dirigidos por el departamento de planeación de la universidad, cuyos resultados sirvieron de base para la elaboración de los planes quinquenales y cuatrienales de desarrollo. entre 1994 y 1998, la universidad coordina los procesos de autoevaluación de los programas a través del centro de acreditación, quien en coordinación con todas las dependencias de la universidad y las diferentes unidades académicas conceptualizaron las funciones de docencia, investigación, proyección social y el bienestar universitario, que dieron las bases para la elaboración definitiva del proyecto educativo institucional. este centro se convierte más tarde, en 1998, en la dirección de acreditación y currículo, dependencia que orienta, asesora y da las directrices para que cada unidad académica realice el proceso. la facultad de enfermería inició desde 1991, y continuó durante sus diez años de funcionamiento, sus autoevaluaciones con estudiantes, profesores, directivos y egresados, que han servido de base para las implementaciones de sus planes de desarrollo. igualmente, participó con un delegado en la comisión de autoevaluación permanente de delegados de unidades académicas y administrativas, durante los años 1995 a 1998; su finalidad era servir de puente de comunicación entre el centro y las diferentes unidades, para socializar lo referente a la acreditación y comenzar la elaboración del proyecto educativo del programa. en el año 1999 se elabora el proyecto educativo del programa, el cual se cimentó en las bases del proyecto educativo institucional, orientando su misión a la formación científica, técnica, profesional y humanística del enfermero egresado del programa. en la elaboración del mismo se tuvieron en cuenta el estudio de factibilidad en relación con el recurso humano de enfermería y las políticas que en el ámbito nacional e internacional orientaban las condiciones de salud de la población colombiana; recoge además los perfiles de ingreso, ocupacional y de formación que el egresado debía desempeñar y las competencias que a nivel del saber, del hacer y del saber tener debían desarrollar los estudiantes; contempla también las bases de investigación y de proyección social que desarrolla el programa e igualmente la visión y el rumbo que espera tener en los futuros años. en 1999 se crea en el programa la “subcomisión de autoevaluación”, que será la encargada de organizar, diseñar y elaborar las estrategias y mecanismos que se llevarán a cabo en el proceso de autoevaluación y en el planteamiento de los planes de mejoramiento, así como de divulgar sus avances y resultados, y sensibilizar a la comunidad académica. esta subcomisión la integran: el director del programa, quien es el responsable de llevar a feliz término el proceso; el director de estudiantes, el secretario académico, el secretario administrativo, dos representantes de los profesores y un egresado, que se reúnen periódicamente y orientan y dirigen el proceso de autoevaluación y autorregulación del programa, con participación de profesores y algunos estudiantes. el programa ha tenido en cuenta las directrices sobre autoevaluación emanadas de la dirección de acreditación y currículo y de la comisión coordinadora del proceso de autoevaluación de la universidad, quien definió el modelo de autoevaluación que se debía seguir, el cual fue aprobado por el consejo superior de la universidad; además, dividió los factores en diez y asignó un grado de importancia a cada uno, de acuerdo con su relevancia en la misión de la universidad; su orden de clasificación fue: el proyecto educativo institucional ocupó el primer lugar, con un 19% de importancia; profesores, el segundo, con un 15%; la investigación, el tercero, con un 13%; el cuarto correspondió a los estudiantes, con un 12%; el currículo, el quinto, con 10%; en el sexto, la gestión y el gobierno, con 7%; el bienestar universitario ocupó el séptimo lugar, con 7%; el octavo correspondió a los egresados e impacto sobre el medio, con 6%; en el noveno lugar se ubicó el factor organización y administración, con 6%, y por último los recursos físicos y financieros, con un 5%; esta ponderación será igual para todos los programas y se traduce en el orden de las intenciones, preocupaciones e importancia que la institución atribuye a sus distintos componentes. antecedentes la autoevaluación dentro del proceso de acreditación del programa de enfermería de la universidad de la sabana 33 • diagnóstico de las condiciones básicas del programa para ingresar a la acreditación: con base en las evaluaciones realizadas en los últimos cinco años, donde participaron profesores, estudiantes y algunos egresados, se identificaron las fortalezas y debilidades del programa, que concluyó con el informe síntesis de autoevaluaciones realizadas en los últimos cinco años; en él se aprecian los aspectos fuertes que tenía el programa para entrar en el proceso de acreditación y los puntos débiles que requerían mejorarse. en dicho informe se identificaron como fortalezas: la proyección social que realiza el programa en los municipios aledaños a la universidad; el enfoque de atención primaria y la implementación del modelo de adaptación en el área profesional de enfermería, que lo constituye en el único programa que utiliza un modelo en colombia; la formación humanística y ética que se imparte a los estudiantes y a los profesores; el complemento de un programa de proficiencia en inglés para lograr las habilidades comunicativas en una segunda lengua; la experiencia y formación de los profesores que sirven al programa; los estímulos académicos para profesores y estudiantes; la organización del programa en áreas académicas que contribuyen al desarrollo del conocimiento; los servicios de bienestar, traducidos en becas, servicios de cafetería, médicos, espirituales, y las actividades culturales, extracurriculares, complementarias y recreativas a que tienen acceso estudiantes y profesores. como debilidades se destacan: la poca flexibilidad curricular, que limita a los estudiantes para escoger materias optativas y cursar asignaturas en otras instituciones; la investigación limitada de los profesores, por su carga académica; el reconocimiento de los egresados, debido al poco tiempo de haber egresado del programa, y el no tener un estudio de impacto del programa en el contexto donde actúa. una vez que el consejo de facultad determinó que el programa de enfermería sí entraría en el proceso, se hizo un autoanálisis de la guía de condiciones básicas que debían tener los programas objeto de acreditación, la cual incluía: los antecedentes históricos del programa; la especificidad e identidad, reflejada en sus objetivos; el perfil que lo distingue de otros programas; el enfoque teórico-práctico y epistemológico de la profesión; el enfoque pedagógico de cómo se espera formar integralmente al alumno; el plan de estudios y las modificaciones efectuadas; las competencias y dominios que el alumno debe alcanzar; los recursos humanos (profesores, estudiantes y egresados); los recursos físicos y locativos; los recursos de apoyo con que cuenta el programa, de beneficio común para toda la universidad (bienestar universitario, biblioteca, centro de informática y espacios deportivos de recreación y esparcimiento); los laboratorios y convenios existentes, donde se realizan las prácticas de los estudiantes. además, la relación con el impacto externo, a través del reconocimiento que han tenido los egresados; la formación investigativa que tienen los estudiantes, así como las líneas de investigación y la producción intelectual de los profesores; la proyección social que adelanta el programa en el medio externo, con sus relaciones interinstitucionales; la estructura organizativa y funcional de la facultad de enfermería, y los servicios que ofrece el bienestar universitario para beneficio de los miembros de la comunidad. todo lo anterior sirvió para complementar la elaboración del proyecto educativo del programa. el informe de las condiciones básicas del programa fue enviado al cna, quien designa a dos de sus miembros; estos visitaron la universidad, para verificar sus condiciones, y permitieron a la institución y a los programas iniciar el proceso de acreditación. • ponderación de características y variables: siguiendo el procedimiento realizado por el consejo superior de la universidad para la ponderación de factores, la subcomisión de autoevaluación del programa asignó, después de un riguroso estudio por parte de cada uno de sus miembros, un valor a cada una de las 66 características propuestas por el cna y a las 200 variables que las evalúan. lo anterior sirvió de base para llevar a cabo la calificación cuantitativa de cada característica correspondiente a cada factor y al factor mismo, y ello dio como resultado la apreciación cuantitativa del programa. esta cuantificación permite determinar el grado de cumplimiento en los siguientes parámetros: cumplimiento pleno, en alto grado, aceptable, insatisfactorio y no cumplimiento. • fase de recolección de información: en esta se determinó el tipo de información que se requería levantar y la actividades seguidas en el programa una vez analizadas las características de cada factor, se califica cualitativa y cuantitativamente el factor correspondiente, para determinar sus fortalezas y debilidades. año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 34 fuente que debía proporcionarla; se tomaron de base las matrices funcionales elaboradas por la dirección de acreditación y currículo y ajustadas por el programa; en ellas se vuelca la información correspondiente a los indicadores establecidos por el cna. esta fue extraída de los archivos de la facultad, de las actas del consejo, de la comisión y de la subcomisión del currículo, de los informes institucionales y del programa, de las normas y resoluciones que rigen la universidad y de cada una de las dependencias administrativas, académicas y de apoyo que tiene la institución para el servicio de la academia. igualmente, se recurrió a una encuesta de opinión, aplicada a los estudiantes, profesores, directivos, administrativos y una muestra de egresados, a fin de conocer su apreciación sobre diferentes aspectos del programa, en relación con la docencia, la investigación, la proyección social, el bienestar, los reglamentos y los recursos. además, se tuvieron en cuenta varios estudios realizados por algunas dependencias de la universidad, como: satisfacción del cliente, contexto y pertinencia, y egresados y su efecto de acción en el medio. todo lo anterior permitió clasificar los documentos en análisis y soporte, que sirvieron de base para la emisión de los juicios en cada característica. • análisis de la información y formulación de planes de mejoramiento: recopilada la información, se procedió a emitir el juicio correspondiente a cada una de las características agrupadas según el factor, y se destacaron los aspectos positivos y las debilidades encontradas; para realizar lo anterior se tuvieron en cuenta las categorías de análisis, las cualidades sensibles y los ideales realistas propuestos por acreditación y currículo, que son los referentes cualitativos y cuantitativos que permiten comparar los aspectos de cada factor frente a lo que el programa espera cumplir. se procede luego a calificar cuantitativamente cada característica, teniendo como referencia la ponderación realizada de sus variables, para formular, según los resultados obtenidos, las oportunidades de mejoramiento que retroalimentarán el programa. una vez analizadas cada una de las características de cada factor, se procede a calificar cualitativa y cuantitativamente el factor correspondiente, para determinar sus fortalezas y debilidades; al final se bibliografía 1. consejo nacional de acreditación. lineamientos para la acreditación, 3ª ed., república de colombia, ministerio de educación nacional, santafé de bogotá, d.c., febrero de 1998. 2. consejo nacional de acreditación. autoevaluación con fines de acreditación de programas de pregrado, 2ª ed., república de colombia, ministerio de educación nacional, santafé de bogotá, d.c., diciembre de 1998. 3. informe del taller sobre procesos de aprobación y acreditación para la educación de enfermería. serie 24. desarrollo de recursos humanos. división de desarrollo de sistemas y servicios de salud. ops/oms. mayo del 2000. 4. kells, herbert r. organización de la autorregulación, asociación colombiana de universidades (ascun), agosto de 1995. 5. universidad de la sabana. el modelo de autoevaluación institucional en la universidad de la sabana con miras a su acreditación, cartilla, 3ª ed., puente del común, chía, enero de 2001. 6. universidad de la sabana, facultad de enfermería. informe final de autoevaluación del programa de enfermería, chía, 2001. 7. universidad de la sabana, facultad de enfermería. resumen ejecutivo del proceso de autoevaluación con miras a la acreditación, puente del común, chía, abril de 2001. hace una apreciación cuantitativa y cualitativa de todo el programa. realizado el análisis y los juicios de cada factor, se puede resaltar que el programa ha sido coherente con los principios y postulados definidos en el pei y en el plan de desarrollo de la institución; sus resultados son el esfuerzo permanente de profesores y directivos, quienes siempre han encontrado la motivación y el apoyo de la universidad, lo cual hace que los propósitos y objetivos se cumplan satisfactoriamente. los resultados obtenidos en el análisis de los juicios se presentaron al consejo de facultad y a la comisión permanente del consejo superior, quienes aprobaron el informe para ser enviado al cna, el cual determinará los pares externos que visitarán el programa. se anota que durante el año 2000 se realizó una evaluación del programa por parte de pares externos invitados por la universidad, con propósitos formativos y colaborativos. esta visita de simulación se constituyó en un ejercicio que permitió preparar la organización, evaluar la autoevaluación, confrontar el contenido del informe y emitir apreciaciones sobre las condiciones del programa y recomendaciones acerca del informe final, las cuales sirvieron para la reelaboración del informe definitivo. factors related to depressive symptoms in university students article factors related to depressive symptoms in university students factores relacionados con los síntomas depresivos en estudiantes universitarios fatores relacionados à sintomatologia depressiva em universitários 10.5294/aqui.2021.21.3.5 allana allitsa da costa bento1 monnik helles pereira correia higino2 andréia guedes oliva fernandes3 talita de cássia raminelli da silva4 1 0000-0003-0908-7379. centro universitário euro-americano, brazil. allana35649@unieuro.com.br 2 0000-0002-6016-9647. centro universitário euro-americano, brazil. monnik36732@unieuro.com.br 3 0000-0001-5584-5658. centro universitário euro-americano, brazil. andreia003470@unieuro.com.br 4 0000-0002-9181-8478. centro universitário euro-americano, brazil. talita003788@unieuro.com.br received: 12/08/2020 sent to peers: 07/09/2020 approved by peers: 17/04/2021 accepted: 02/08/2021 theme: promotion and prevention. contribution to the subject: this study contributes to the nursing and health areas by enabling a reflection about depressive symptoms and their associated factors in university students. consequently, it provides more grounds for nursing care assistance regarding the development of strategies for health promotion and prevention. to reference this article / para citar este artigo / para citar este artículo: bento aac, higino mhpc, fernandes ago, raminelli da silva tc. factors related to depressive symptoms in university students. aquichan. 2021;21(3):e2135. doi: https://doi.org/10.5294/aqui.2021.21.3.5 abstract objective: to identify and discuss the frequency of depressive symptoms and their associated factors in university students. materials and method: this is a cross-sectional and descriptive study with a quantitative approach, conducted in a higher education institution. the study was developed with a convenience sample consisting of 571 undergraduate students from different areas. a questionnaire was used to collect sociodemographic/academic data, as well as depressive symptoms and their associations, life habits, emotional aspects, and possible eating disorders. for data analysis, descriptive statistics and pearson's chi-square test were used for associations, with a significance level of 5 % (p-value ≤ 0.05). results: the university students presented depressive symptoms such as sleep disorders (61.1 %) and reduced self-confidence (50.9 %). there was an association of depressive symptoms with the course, satisfaction with academic performance, obesity, consumption of sugars and sweets, and practice and frequency of physical activity. conclusions: it is expected that the results of this research contribute to the population's critical and reflective thinking to expand visibility and scientific studies referring to the theme, as well as to increase resources for the management of mental health and reduce the stigmas generated. keywords (source decs): depression; students; higher education; signs and symptoms; health behavior. resumen objetivo: identificar y discutir la frecuencia de los síntomas depresivos y sus factores asociados en estudiantes universitarios. materiales y método: se trata de un estudio transversal, descriptivo con enfoque cuantitativo, realizado en una institución de educación superior. el estudio se desarrolló a partir de un muestreo de conveniencia con 571 estudiantes de diferentes facultades. se utilizó cuestionario para recolectar los datos sociodemográficos/académicos, de la sintomatologia depresiva y sus asociaciones, los hábitos de vida, los aspectos emocionales y los posibles disturbios alimenticios. para el análisis de los datos, se emplearon la estadística descriptiva y la prueba de qui-cuadrado de pearson para asociaciones, con nivel de significancia del 5 % (valor p ≤ 0,05). resultados: los universitarios presentaron sintomatologia depresiva como sueño perturbado (61,1 %) y autoconfianza reducida (50,9 %). hubo asociación de la sintomatologia depresiva con el grado, con la satisfacción del desempeño académico, con el sobrepeso, con el consumo de azúcares y dulces, con la práctica y la frecuencia de actividad física. conclusiones: se espera que los resultados de la investigación puedan aportar al pensamiento crítico y reflexivo de la población, con el intuito de expandir la visibilidad y los estudios científicos sobre la temática, así como aumentar los recursos para la gestión de la salud mental y disminuir los estigmas generados. palabra clave (fuente deos): depresión; estudiantes; educación superior; signos y síntomas; conductas relacionadas con la salud. resumo objetivo: identificar e discutir a frequência da sintomatologia depressiva e seus fatores associados em estudantes universitários. materiais e método: trata-se de um estudo transversal, descritivo com abordagem quantitativa, realizado em uma instituição de ensino superior. o estudo foi desenvolvido por amostra de conveniência com 571 estudantes de graduação de diferentes áreas. utilizou-se um questionário para a coleta de dados sociodemográficos/acadêmicos, da sintomatologia depressiva e suas associações, dos hábitos de vida, dos aspectos emocionais e dos possíveis distúrbios alimentares. para a análise dos dados, utilizaram-se a estatística descritiva e o teste de qui-quadrado de pearson para associações, com o nível de significância de 5 % (valor p < 0,05). resultados: os universitários apresentaram sintomatologia depressiva como sono perturbado (61,1 %) e autoconfiança reduzida (50,9 %). houve associação da sintomatologia depressiva com o curso, com a satisfação do rendimento acadêmico, com a obesidade, com o consumo de açúcares e doces, com a prática e a frequência de atividade física. conclusões: espera-se que os resultados desta pesquisa possam contribuir para o pensamento crítico e reflexivo da população, a fim de expandir a visibilidade e os estudos científicos referentes à temática, bem como de aumentar os recursos para o manejo da saúde mental e diminuir os estigmas gerados. palavras-chave (fonte deos): depressão; estudantes; educação superior; sinais e sintomas; comportamentos relacionados com a saúde. introduction depression is a public health problem and one of the causes of disabilities in social life (1), where it affects approximately 322 million people worldwide (2). in brazil, this figure is over 11.5 million individuals, and diverse evidence points out an increase in the prevalence of this pathological process in university students (3, 4). depression is understood as a multi-factorial pathological process, which encompasses biopsychosocial and spiritual aspects. this disease is characterized by losses in mood balance, a complete absence of interest, sleep alterations, anxiety, decreased concentration, excessive guilt, feelings of worthlessness and periodic thoughts of death and suicide, among other signs, and symptoms, which result in negative consequences in the process of professional training during undergraduate (1, 3, 5). as a result of the significant academic overload and the increasingly competitive environment, these signs and symptoms are common in the university environment, which predisposes students to various stressors that can configure triggering factors for depression (6). after entering academic life, the following are emphasized as stressful elements that predispose this population: significant emotional instability, heavy study load, academic requirements, fears about future instability and change in the individual's daily routine, bad habits and unruly lifestyle, as well as carelessness in performing basic care with their own health (7-11). considering that depression is a public health problem on the rise, whose high prevalence in university students results in harm during undergraduate and life, such as social withdrawal, disinterest in curricular activities, and even dropping out of the course, it is relevant to explore the factors associated with this mental disorder in this population to expand scientific knowledge on the theme and to reflect on the importance of thinking about strategies to promote the students' mental health in the academic environment (1, 3, 12, 13). given the above, this study has the following guiding question: "which factors are related to depressive symptoms in university students of a higher education institution (hei) in the federal district?". in addition to that, the objective is to identify and discuss the frequency of depressive symptoms and their associated factors in university students. materials and method study type or design this is a descriptive and cross-sectional study with a quantitative approach. locus and period the study was conducted in three units of an hei in brasília, brazil. data collection took place between april and may 2019. population undergraduate students. during the data collection period, the hei had 5,507 university students enrolled in different undergraduate courses: administration, architecture and urbanism, accounting sciences, law, physical education, nursing, civil engineering, pharmacy, physiotherapy, environmental management, medicine, nutrition, dentistry, gastronomy, language and linguistics, information system, public management technology, human resource management technology, pedagogy, financial management technology, logistics technology, environmental management technology, marketing technology, management process technology, data processing, and psychology. selection criteria as participants, students with a regular enrollment in the hei and aged between 18 and 60 years old were included. university students diagnosed with depression and/or using an antidepressant, anxiolytic and psychotropic medications, in general, were excluded since the objective of the study was to identify the depressive symptoms and not the established disease, in which these medications could alter the signs and symptoms presented by the students, which could lead to biases in the study. participants the participants were 571 undergraduate students from administration, architecture and urbanism, accounting sciences, law, physical education, nursing, civil engineering, pharmacy, physiotherapy, environmental management, medicine, nutrition, dentistry, and psychology. it is emphasized that the sample was for convenience. study variables gender, occupation, affective relationship, course, semester, individual and family income, life habits, emotional factors and possible eating disorders were the variables studied to verify the association between them and depressive symptoms in the students. instruments used to collect the information a questionnaire was used consisting of 22 questions corresponding to sociodemographic characteristics (age, gender, emotional relationship, occupation, individual and family income); life habits (eating habits, practice of physical activity, use of illicit and licit substances, water intake); emotional factors (level of satisfaction with affective relationships); possible eating disorders (bulimia, obesity, anorexia, underweight); academic factors (school, course, semester, level of satisfaction with academic performance) and depressive symptoms, as well as their associations (depressed mood, reduced concentration/attention, feeling of guilt, suicidal ideation, ideation of self-mutilation, loss of interest, feeling of worthlessness, reduced self-esteem, reduced self-confidence, pessimistic view of the future, sleep disorders, fatigue, and decreased appetite), according to the diagnostic and statistical manual of mental disorders (1). it is noteworthy that this questionnaire was developed by the researchers based on the diagnostic and statistical manual of mental disorders (1) and on the patient health questionnaire-9 (phq9), an instrument validated and adapted in brazil (14-16) and used in one of the stages of the larger research project to which the current study belongs. data collection the questionnaires were applied by duly trained undergraduate female students, from the research team, linked to a scientific initiation project of the hei. data collection took place at the institution's premises, in places with the greatest circulation of students, such as food court, library, corridors, parking lot and classrooms, through an active search and in agreement with the professor, when performed in a classroom. the questionnaire was self-administered, and the meantime for its completion was 20 minutes. data treatment and analysis the descriptive data analysis was performed in the statistical package for the social sciences (spss) software, version 21.0, to identify the frequency, median and interquartile range, as well as the valid percentage of the variables. to associate the sociode-mographic, emotional, academic and life habits variables with the presence of depressive symptoms, the pearson's chi-square test was used, with a statistical significance level of p < 0.05. ethical aspects data collection took place upon approval by the research ethics committee, under certificate of presentation for ethical appreciation protocol number 08598819.4.0000.505, following with the ethical precepts stipulated in resolution 466/2012 (17) and the necessary institutional authorizations. the free and informed consent form (ficf) was handed into all the study participants for them to read: such document informed them about the study topic, objective and justification, the responsible researchers, the benefits of the project (contributing to knowledge about depressive symptoms and their associated factors in the population of students and thus stimulate awareness-raising in society about the prevention, promotion and restoration of mental health in this population), as well as the risks of this research (feeling of possible discomfort, embarrassment or fatigue in the participant when answering the questionnaire), as well as how such risks could be minimized. the participants could answer the questionnaire in their own time, sitting comfortably and, if they presented any discomfort, they could stop participating, and the researchers would be available to talk to and, if necessary, guide the participants to seek professional help, according to their possibilities. this document was elaborated in two copies: one to be kept by the researcher in charge and the other, by the research volunteer. the ficf requested permission to use the data provided by the participant and ensured confidentiality of the information, in addition to the freedom to refuse to answer any question in the questionnaire and/or instrument that would cause them embarrassment or to withdraw at any time during the study. data collection was initiated immediately after signature by the participants, when accepting to participate in the study. results a total of 571 students participated in the research, with predominance of the female gender, 66.5 % (n = 356; p* = 0.38), and a median age of 21 years old (from 18 to 58 years old). the university students were mostly single, 49.3 % (n = 267; p* = 0.19); students, 70.7 % (n = 384; p* = 0.14); had no individual monthly income, 47.7 % (n = 255; p* = 0.31); and 36.8 % (n = 196; p* = 0.55) indicated a monthly family income of one to three minimum wages. regarding the course, 27.7 % (n = 157) of the students were enrolled in nursing; 20.5 % (n = 116), in law; 12.3 % (n = 70), in dentistry; 9.2 % (n = 52), in physical therapy; 8.3 % (n = 47), in physical education; 4.8 % (n = 27), in pharmacy; 4.1 % (n = 23), in architecture and urbanism; 3.9 % (n = 22), in civil engineering; 3.4 % (n = 19), in psychology; and 3.2 % (n = 18), in nutrition. the undergraduate courses in administration, accounting sciences and medicine presented a percentage of 0.9 % (n = 5 each) and the value for environmental management was 0.2 % (n = 1). as for the semester, 23.5 % (n = 125) of the university students reported being in the third undergraduation semester; 18.9 % (n = 101), in the first semester; 14.1 % (n = 75), in the seventh semester; 12.9 % (n = 69), in the ninth semester; 8.4 % (n = 45), in the fifth semester; 7.9 % (n = 42), in the eighth semester; 5.1 % (n = 27), in the sixth semester; 3.4 % (n = 18), in the second; 3.2 % (n = 17), in the tenth; and 2.6 % (n = 14), in the fourth semester. in relation to the life habits, it was observed that most of the students, 59 % (n = 319; p* = 0.23), stated following a partially healthy diet, but 43.7 % (n = 237) reported frequent consumption of sugars and sweets. it was evidenced that 89.8 % (n = 434) of the participants denied obesity, that 64.9 % (n = 326; p* = 0.30) reported no eating disorders during their lifetime, and that 53.5 % (n = 272; p* = 0.58) of the participants denied using chemical substances. regarding practice of physical activity, 50.7 % (n = 274) of the participants stated adherence, although with low frequency, with 35.8 % (n = 191). concerning satisfaction in interpersonal relationships, 51.2 % (n = 274; p* = 0.79) of the students indicated satisfaction with their friends; 41.8 % (n = 225; p* = 0.36), with their family members, and 38.1 % (n = 199; p* = 0.64), with their affective relationships. in relation to the academic setting, 47 % (n = 255) reported little satisfaction. of the university students who stated having some professional/employment contract, 33.9 % (n = 133; p* = 0.97) reported satisfaction with the work environment. table 1 presents the frequency of depressive symptoms among university students. table 1. frequency of depressive symptoms among university students. brasília, distrito federal, brazil, 2020 depressive symptoms n (%) depressed mood yes 217 (40 %) no 325 (60 %) loss of interest   yes 211 (38,9 %) no 331 (61,1 %) fatigue   yes 263 (48,5 %) no 279 (51,5 %) reduced concentration/attention   yes 195 (36 %) no 347 (64 %) reduced self-esteem   yes 226 (41,7 %) no 316 (58,3 %) reduced self-confidence   yes 276 (50,9 %) no 266 (49,1 %) feeling of guilt   yes 268 (49,4 %) no 274 (50,6 %) feeling of worthlessness   yes 229 (42,3 %) no 313 (57,7 %) depressive symptoms n (%) pessimistic view about the future yes 196 (36,2 %) no 346 (63,8 %) suicidal ideation yes 33 (6,1 %) no 509 (93,9 %) sleep disorders yes 331 (61,1 %) no 211 (38,9 %) reduced appetite yes 85 (15,7 %) no 457 (84,3 %) ideation of self-mutilation yes 09 (1,7 %) no 533 (98,3 %) source: own elaboration. regarding the depressive symptoms, 59.7 % (n = 323; p* = 0.41) and 55.0 % (n = 295) of the university students stated the influence of the semester and the course, respectively, on the negative feelings. with the analysis of pearson's chi-square test, it was possible to notice an association between depressive symptoms and some of the variables under study, which are presented in table 2. table 2. association between the academic and health variables and depressive symptoms in university students. brasília,distrito federal, brazil, 2020 variable p* course 0.01 obesity 0.02 consumption of sugars and sweets 0.02 frequency of physical activity 0.02 physical activity 0.05 satisfaction with academic performance 0.05 p* = pearson's chi-square test source: own elaboration. as for the interest in participating in activities aimed at mental health, 84.3 % (n = 451; p* = 0.67) of the students showed interest if such activities were offered by the institution and 81.4 % (n = 438; p* = 0.91) of the participants agreed that promoting mental health in the university environment would be beneficial for their quality of life. discussion in agreement with the results presented in the current study about the predominance of females in terms of depressive symptoms, flesch et al. (18) carried out a cross-sectional study with 1,825 students, aiming to assess the prevalence of major depressive episodes in students, and reported that 55.1 % (n = 1005) of the participants were women. other studies also point out such similarity (3, 5, 19, 20). in the brazilian context, the insertion of women in the academic setting, concerning men, is a recent episode in history and, in the 2000s, a reversal was evidenced as to the number of students, in which 60 % of the university graduates were women (21, 22). such situation can elucidate the frequency of the female gender in the study. although this study does not show any significance between the gender variable and depressive symptoms, it is noted that, generally, the number of women affected by the depressive process is higher than in men. such phenomenon can be explained due to women's vulnerability, by their own physiologicals issue (mood swings due to hormonal interference) and by their role in countless social roles (maternal, professional, marital), which can often be stressful and contributing factors to the depressive process (12, 23). about depressive symptoms, sleep disorders and reduced self-confidence were the symptoms most frequently mentioned by the participants, resulting in complications in their lives. such result is similar to other scientific evidence (3, 5, 24, 25). a cross-sectional study carried out in an hei from ceará with 649 students attending health courses and to evaluate the prevalence and factors associated with depression and anxiety identified, among the results, the participants' dissatisfaction with sleep quality and a high tendency for the onset of the depressive process among them (5). galvão et al. (26) indicate that sleep disorders can result in impaired concentration and attention, fatigue and other pathologies. as for reduced self-confidence, understood as an individual's limited perception of their ability to believe in the success of their actions (27), there are similarities with results presented by other studies (28, 29). a descriptive study carried out in an hei from the federal district with a sample of 91 nursing students related to fear of dealing with patients with the practical teaching-learning process experienced by the university students, as well as situations of insecurity in their professional activity (29). in addition, the quantitative study by nogueira (28), carried out in an hei from belo horizonte with 70 university students attending courses in the areas of humanities and social sciences, associated the students' feelings of vulnerability and insecurity with the uncertainties about the professional market and with social ascension. according to menezes et al. (30), the development of critical and reflective thinking in the academic environment allows influencing the improvement of the transition from theoretical to practical knowledge, to ensure self-confidence in the professional performance. it is understood that a way to minimize these feelings of vulnerability and insecurity in the university students would be the use of active methodologies in undergraduate courses, as proposed in the national curriculum guidelines for the nursing course (31). the active methodology allows the students to act as protagonists in the development of their training since, by getting involved in the teaching-learning process, instead of being mere receivers of knowledge, they acquire cognitive, procedural and attitudinal skills for the development of critical and reflective thinking (32, 33). this study indicated the course as a significant factor for the development of depressive symptoms in university students. in a quantitative and analytical study carried out in a public institution from brasília with 203 nursing students and to measure the levels of depressive symptoms among the students, in addition to evaluating their association with academic life factors, facioli et al. (34) evidenced certain depressive predisposition with the course, due to the significant dedication to the workload by the students, in addition to being associated with a limitation of the time available to perform physical and leisure activities. another descriptive study by victoria et al. (35), conducted in a public university from rio de janeiro with a sample of 637 students and referring to courses in the areas of biomedical sciences, social sciences, education and humanities, technologies and science, identified depressive rates in the students attending the courses in the aforementioned areas, with high levels in students from the language and linguistics course. diverse scientific evidence also point to depressive predisposition associated with the course, with an emphasis on academic overload, mainly in the health area courses; for example, during the internships, when the students are faced with the health-disease process and address the life and death duality (20, 24, 35). regarding satisfaction with academic performance, this study presents significant values similar to the study by flesch et al. (18), which evidenced an association between academic performance (p* = < 0.001) and depressive symptoms. according to victoria (35), academic performance can be impaired due to the demands, along with the strong emotional strain and the intense academic routines. the results of the study by bresolin et al. (20) corroborate those of the present study, regarding the association between academic performance and the prevalence of depressive symptoms, which can compromise daily and personal issues. in addition to that, these researchers indicate that the possibility of developing a pessimistic and negative outlook in university students can cause them distress and contribute to the onset of depression. the practice and frequency of physical activity were also factors that presented significance concerning depression, according to what is pointed out in diverse scientific evidence (5, 20, 36). a quantitative and observational study, carried out through an online questionnaire and applied in a social network with students from the physical education course, with a sample of 155 participants, revealed an association of depressive symptoms with low frequency of physical activity and showed that students who exercise for more than 150 minutes per week were less likely to develop depressive symptoms (37). it is revealed that the practice of physical activity has a direct effect on the individuals' life cycle because, due to the production of endorphin and serotonin, neurotransmitters responsible for the feeling of pleasure and well-being, it interferes with sleep quality, promotes physical and psychological well-being, guarantees an increase in self-esteem, and helps maintain homeostasis and prevent complications. in addition to that, the practice of physical activity is understood as an opportunity for social mingling and works as a therapeutic agent against depression (5). in relation to the consumption of sugars and sweets by university students, diverse scientific evidence has pointed, as in this study, to an association between depression and high-energy foods, classified as emotional eating, as they are probably eaten compulsively during the manifestation of depressive symptoms. an observational cohort study (nutri-net-santé), carried out in france and which monitored 30,240 participants, revealed a strong relationship between emotional eating and depressive symptoms in women, for foods such as cakes, cookies, sweets and artificially sweetened chocolates, among others (38). it is noteworthy that excessive consumption of these foods judged as comforting can lead to serious health problems, such as the development of chronic diseases like systemic arterial hypertension, diabetes mellitus and obesity (1, 39, 40). this study revealed an association between obesity and depressive symptoms, following others found in the literature. in a cross-sectional research study carried out in the netherlands with 2,809 participants to examine the association between depressive disorders, anxiety, obesity, physical activity and social activity, wit et al. (41) highlighted bilaterality between obesity and depression, that is, obesity contributes to the development of the depressive process and vice versa. santos et al. (42) suggest that body weight and compulsive eating in unfavorable situations can be associated, in addition to generating negative feelings. obesity leads to complications in brain structures such as the hypothalamus, responsible for satiety, the hippocampus, related to memory and learning, and the prefrontal cortex, associated with the reward system. such disorders in these structures can favor the emergence of cognitive and mental problems, such as depression (43). it is understood that health promotion strategies are fundamental to prevent cognitive and mental problems such as depression (19). in this study, for example, the university students stated their interest in participating in activities aimed at mental health, offered by the school, in addition to asserting the importance of health promotion in the university environment. such results disclosed in this study can contribute for students and other members of the academic population to reflect on the importance of the existence of health promotion and prevention actions in the academic environment, as well as to encourage them to participate in existing programs and/or even create health strategies within the educational institutions to which they are linked. the literature emphasized that the use of strategies for health promotion and prevention in the university setting exerts a positive influence on the students' mental health. after applying these strategies, improvements are noticed in social relationships, balance in the daily activities, and reduction in the risk behavior among the students (44, 45). in synthesis, it is observed that this study attained the objective proposed. as described, the results can contribute to advances in scientific knowledge in the health and nursing areas, considering that data generation and their interpretation by researchers is the basis for the creation of strategies for the promotion, prevention, treatment and recovery of the population's health. although there are references in the literature about depressive symptoms, such as reduced self-confidence and the association found between the consumption of sugars and sweets and depression, they are outdated. consequently, it is recommended to intensify studies on the theme addressed. it is emphasized that the limitations of this research were as follows: the non-probabilistic sampling field, by convenience, and the difficulty accessing university students attending the last semester who were in the internship periods of their courses and, therefore, were not in the places where data collection was conducted. conclusions characterized as a multi-factorial pathological process, it is considered that depression can trigger negative interferences in the academic training process. according to what has been described, the university students presented a high frequency of depressive symptoms, such as sleep disorders (61.1 %) and reduced self-confidence (50.9 %). it was verified that the depressive symptoms presented by the students are associated with academic factors due to academic overload and to the tensions experienced at the university, as well as to the life habits regarding binge/emotional eating and the reduction of the time available for physical activities. variables such as the course, satisfaction with academic performance, obesity, consumption of sugars and sweets, and the practice and frequency of physical activity influenced the emergence and exacerbation of depressive symptoms in students in the current study. it is expected that the results of this research may contribute to the critical and reflective thinking of the population in general, specifically, the studied population (health professionals and researchers), to increase visibility and promote scientific research studies about this disease, as well as to increase resources for the management of mental health and reduce the stigma generated. conflict of interests: none declared. references 1. american psychiatric association diagnostic and statistical manual of mental disorders: dsm-ivtr. 4a ed. washington, dc: american psychiatric association; 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[internet]. 2017. available from: http://editora.universidadedevassouras.edu.br/index.php/rpu/article/view/896 home 207 211 primeras paginas.indd 222 aquichan issn 1657-5997 fred manrique-abril1 alba fernández2 anita velandia3 análisis factorial de la escala valoración de agencia de autocuidado (asa) en colombia 1 doctor en salud pública. universidad nacional de colombia. bogotá. fgmanriquea@unal.edu.co 2 candidata a doctora en enfermería. universidad nacional de colombia. bogotá. arfernandez@unal.edu.co 3 magíster en enfermería salud cardiovascular. universidad nacional de colombia. bogotá. anita_velandia@hotmail.com recibido: 28 de enero de 2009 aceptado: 11 de agosto de 2009 resumen objetivo. validar la confiabilidad y el contenido por análisis factorial de la escala valoración de agencia de autocuidado (asa) en una institución hospitalaria. métodos. estudio metodológico con datos secundarios en una muestra de 201 pacientes adultos, del programa de crónicos del hospital de tunjuelito, de bogotá, colombia. la consistencia interna (alfa de cronbach) y la estructura factorial fueron procesadas en spss11.5®. resultados. el análisis de los componentes principales indica una estructura conformada por nueve factores que explican el 65,87% de la varianza total. el instrumento mostró un alfa de cronbach de 0,68 y 0,74 corregido. conclusión. la versión en español del asa evaluada demuestra que tiene las propiedades psicométricas válidas y adecuadas para su aplicación en los diferentes ámbitos de la práctica de enfermería en colombia. palabras clave estudios de validación, análisis factorial, investigación en enfermería, colombia, autocuidado (fuente: decs, bireme). factor analysis of the appraisal of self-care agency scale (asa) in colombia abstract purpose. validate, through factor analysis, the reliability and contents of the appraisal of self-care agency scale (asa) in a hospital institution. methods. this is a methodological study with secondary data for a sample of 201 adult patients listed in the database on chronically ill patients at tunjuelito hospital in bogotá, colombia. internal consistency (cronbach alpha) and the factor structure were processed in spss11.5®. results. the analysis of the principal components indicates a structure comprised of nine factors that explain 65.87% of the total variance. the instrument showed a cronbach alpha of 0.68 and 0.74 corrected. conclusion. the assessed spanish version of the asa was found to have psychometric properties that are valid and adequate for application in the different fields of nursing practice in colombia key words validation studies, factor analysis, nursing research, colombia, self-care (source: decs, bireme). año 9 vol. 9 nº 3 chía, colombia diciembre 2009 222 235 223 análisis factorial de la escala valoración de agencia de autocuidado (asa) en colombia fred manrique-abril, alba fernández, anita velandia análise fatorial da escala de avaliação de agência de autocuidado (asa), na colômbia resumo objetivo. validar a fiabilidade e o conteúdo por meio de análise fatorial da escala de avaliação de agência de autocuidado (asa) em um hospital. métodos. estudo metodológico com dados secundários de uma amostra de 201 pacientes adultos, do programa de crônicos do hospital de tunjuelito, em bogotá, colômbia. a consistência interna (alfa de cronbach) e a estrutura funcional foram processados em spss11.5®. resultados. a análise dos componentes principais indica uma estrutura composta por nove fatores que explicam 65,87% da variância total. o instrumento apresentou um alfa de cronbach de 0,68 e 0,74 corrigido. conclusão. a versão em espanhol do asa mostra que tem as propriedades psicométricas válidas e adequadas para aplicação em diferentes áreas da prática da enfermagem na colômbia. palavras-chave estudos de validação, análise fatorial, pesquisa em enfermagem, autocuidado. (fonte: decs, bireme). 224 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 introducción la escala valoración de agencia de autocuidado (appraisal of self-care agency scale, asa), fue desarrollada por evers (1) para valorar la agencia de autocuidado reportada por el paciente (asa-a) (2), y la agencia de autocuidado estimada por la enfermera (asa-b) (3), con el fin de valorar si una persona puede conocer las necesidades generales actuales de agencia de autocuidado. la escala asa fue desarrollada para medir el concepto central de la teoría de enfermería de déficit de autocuidado de orem, agencia de autocuidado, entendido este concepto como la capacidad o el poder de la persona para realizar operaciones de autocuidado (4). la estructura de la agencia de autocuidado está constituida por las capacidades para realizar operaciones de autocuidado estimativas, transicionales y productivas. las operaciones estimativas comprenden la investigación de las condiciones y los factores internos y externos significativos para el autocuidado; las transicionales determinan el tipo de acción o curso que debería tomarse con respecto al autocuidado, mientras que las productivas ejecutan las acciones de autocuidado. estas capacidades fueron formuladas como los diez componentes de poder de la agencia de autocuidado, que incluyen el desarrollo de un conjunto de habilidades, el uso controlado de energía y la adquisición de conocimiento (3, 5, 6, 7). aunque los diseñadores de la escala asa establecieron que los ítems de la misma reflejan la estructura de la agencia de autocuidado, no reportan las dimensiones de la escala (8). la escala asa se compone de 24 ítems con un formato de respuesta de cinco alternativas tipo likert, donde el 1 (totalmente en desacuerdo) significa el valor más bajo de capacidad de autocuidado y el 5 (totalmente de acuerdo) el más alto. cada individuo puede obtener un puntaje que va de 24 a 120 puntos (7). estudios transculturales han revelado propiedades psicométricas aceptables de la escala asa en poblaciones de holanda (3, 9), noruega (5), suiza (6), méxico (7), hong kong (8). las pruebas psicométricas del asa original mostraron una confiabilidad de 0,72-0,82 para el coeficiente alfa, y un índice de validez de contenido ivc de 0,88 en hong kong (8); una validez de constructo por análisis de componentes principales con rotación varimax de 8 factores que explicaban el 67,9% de la varianza (9); un análisis factorial de segundo orden de 4 factores que explicaban el 50% de la varianza (6); el análisis factorial con rotación quartimax mostró 7 factores que explicaban el 68% de la varianza (8); la correlación de la escala asa con la escala de la habilidad de los adultos mayores (self-care ability scale for the elderly) para el autocuidado fue de 0,69 (6). la traducción de la escala asa al español, originalmente desarrollada en el idioma inglés, fue hecha por estudiantes de doctorado en enfermería y traductores profesionales en méxico. el cuestionario fue revisado por un experto en lengua española a fin de corregir la estructura gramatical y la semántica, los ítems 4, 6, 13 y 16 fueron reescritos en forma más simple, directa y gramaticalmente correcta. la versión al español de la escala asa es equivalente a la original en el idioma inglés, por lo que se considera que está lista la estructura de la agencia de autocuidado está constituida por las capacidades para realizar operaciones de autocuidado estimativas, transicionales y productivas. 225 análisis factorial de la escala valoración de agencia de autocuidado (asa) en colombia fred manrique-abril, alba fernández, anita velandia para su uso en la población mexicana, con una confiabilidad por alfa de cronbach de 0,77 (7). en colombia, la profesora edilma de reales, de la facultad de enfermería de la universidad nacional de colombia, elaboró una segunda versión en español de la escala asa, modificando la redacción de los ítems, de tal manera que fueran más claros y comprensibles para la población colombiana, sin cambiar el sentido de cada uno de ellos; también modificó la escala likert a solo 4 apreciaciones (nunca 1, casi nunca 2, casi siempre 3 y siempre 4), las posibles puntuaciones de la escala tienen un rango entre 24 y 96 puntos, hay que considerar que los ítems 6, 11 y 20 son negativos (10). en colombia se ha usado la escala asa en tesis de maestría (10) y en estudios que referencian varios artículos (11-15); igualmente, se ha determinado su confiabilidad, reportando un alfa de cronbach de 0,744 (16), pero aparentemente no hay estudios que reporten su análisis factorial, y que permitan conocer no solo la estructura factorial sino de qué manera los ítems representan los distintos factores o dominios, así como retirar ítems que no aportan variabilidad a la medición del síndrome (17), dando confianza a los investigadores para su uso (1). el objetivo del artículo es presentar la confiabilidad y la validez factorial de la versión en español de asa adaptada por la profesora edilma de reales de la universidad nacional de colombia, con permiso escrito de la autora para el presente estudio. materiales y método en una investigación con enfoque descriptivo, correlacional y de abordaje cuantitativo (10) se aplicó la escala asa a 210 pacientes inscritos en la base de datos de pacientes crónicos de consulta externa del hospital tunjuelito, bogotá; del total de la muestra se perdieron 9 personas: 3 por defunción y las restantes por cambio de dirección que hizo imposible su ubicación, quedando finalmente una muestra de 201. los datos sociodemográficos de cada uno de los pacientes se recogieron en un formato diseñado para tal fin, reportando género, edad, estrato socioeconómico, escolaridad, entre otros. se consideró adecuado incluir 201 pacientes para la confiabilidad y el análisis factorial, dada la recomendación para el cálculo del tamaño de la muestra para estudios factoriales: incluir 100 pacientes o 5 sujetos, como mínimo, por cada ítem que compone la escala (18, 19). la escala asa fue aplicada por una enfermera profesional, previo consentimiento informado a los participantes. el proyecto inicial tuvo la aprobación del comité de ética de la facultad de enfermería, universidad nacional de colombia. la base de datos se elaboró y analizó en spss 11.5 ®; el análisis de consistencia interna se llevó a cabo mediante los coeficientes alfa de cronbach para establecer qué ítems tenían una medida de homogeneidad entre 0,7 y 0,9 (17). para la conveniencia del análisis factorial se tuvieron en cuenta tres aproximaciones: inicialmente, se hizo una inspección visual de la matriz de correlación de pearson y se consideró como buen indicador la detección de un número sustancial de coeficientes de correlación superiores a 0,25. posteriormente, se aplicó la prueba de la medida de adecuación de la muestra de kaiser-meyer-olkin (kmo), la cual indica que las variables miden factores comunes cuando el índice es superior a 0,7 y, finalmente, se practicó la prueba de esse consideró adecuado incluir 201 pacientes para la confiabilidad y el análisis factorial, dada la recomendación para el cálculo del tamaño de la muestra para estudios factoriales: incluir 100 pacientes o 5 sujetos, como mínimo, por cada ítem que compone la escala. 226 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 fericidad de bartlett que permite definir estadísticamente si la matriz de intercorrelación es una matriz de identidad (20). para el análisis factorial se seleccionó el método de análisis de componentes principales (acp), teniendo en cuenta que el propósito fundamental era determinar la estructura de los dominios de autocuidado buscando la presencia de variables latentes no observadas (21). para definir el número de factores que se debían incluir, se tuvo en cuenta el método de kaiser (valores propios mayores de 1). la estructura factorial se evaluó también mediante el método de cargas factoriales por rotaciones ortogonal (promax) y oblicua (varimax), a fin de determinar si ofrecían las mismas condiciones de interpretación que el método de componentes principales. resultados estadísticos descriptivos. de los 201 sujetos encuestados, 157 (78%) correspondieron al género femenino y 44 (22%) al género masculino. la edad promedio de los participantes fue de 65,6, con una edad mínima de 36 años y una máxima de 89 años (ds 11,3). el estrato socioeconómico corresponde a bajo en un 35%, medio bajo en un 62%, y medio en un 3%; la mayoría de los pacientes no cumple los grados de primaria básica. la tabla 1 presenta la estadística descriptiva de los 24 ítems de la escala, este análisis revela que todos los ítems poseen suficiente varianza para incluirlos en un análisis factorial. las puntuaciones totales de la escala tuvieron un rango entre 60 y 95 puntos, una media de 78,87 (de=7,3), una mediana de 78 y una moda de 71. consistencia interna. en la tabla 2 se muestran los resultados del análisis de consistencia interna efectuados con los coeficientes alfa de cronbach. al observar los valores de la correlación entre cada ítem y el puntaje de la escala, y entre cada ítem y el resto de los mismos, se identifica que los ítems 4, 6, 11, 12 y 20 mostraron un pobre ajuste al instrumento, además se observa que la puntuación negativa de los ítems 6, 11 y 20 se refleja en una correlación negativa. se observó también que al retirar los ítems 6, 11, 12 y 20 de la escala el valor alfa se incrementaba de 0,68 a 0,71. el alfa global para la escala asa con 24 ítems es de 0,6891 y estandarizada de 0,7440. análisis factorial. antes de realizar el análisis factorial se consideró conveniente tomar en cuenta algunos criterios para valorar la viabilidad del mismo: el examen de la estructura de la matriz de correlación de pearson reveló múltiples valores superiores a 0,25 (18%). además, la evaluación de la adecuación de la muestra mediante la prueba de kaiser-meyer-olkin indicó que las variables medían factores comunes al obtenerse un índice de 0,70. finalmente, el resultado de la prueba de esfericidad de bartlett fue estadísticamente significativo (p<0,001; 276 gl; chi 1174,6), lo cual está a favor de adelantar el análisis para determinar los factores subyacentes en la matriz de correlación. se probó un análisis simple; con rotaciones ortogonal y oblicua los factores mostraron los mismos niveles de interpretación que el factorial con rotación varimax. el estudio factorial mediante el método de componentes principales con rotación varimax sugirió el análisis con nueve ejes factoriales, que correspondió al número de valores propios (eigenvalue) mayores de 1, que explicaron el 65,87% de la varianza total, tomando como criterio asignar un ítem al factor que presentara una carga factorial mayor de 0,55. para el análisis factorial se seleccionó el método de análisis de componentes principales (acp), teniendo en cuenta que el propósito fundamental era determinar la estructura de los dominios de autocuidado buscando la presencia de variables latentes no observadas. 227 análisis factorial de la escala valoración de agencia de autocuidado (asa) en colombia fred manrique-abril, alba fernández, anita velandia no. ítem media desviación típica 1 a medida que cambian las circunstancias yo voy haciendo ajustes para mantener mi salud. 3,55 0,58 2 reviso si las formas que practico habitualmente para mantenerme con salud son buenas. 3,52 0,61 3 si tengo problemas para moverme o desplazarme me las arreglo para conseguir ayuda. 3,19 0,98 4 yo puedo hacer lo necesario para mantener limpio el ambiente donde vivo. 3,52 0,86 5 hago en primer lugar lo que sea necesario para mantenerme con salud. 3,77 0,48 6 me faltan las fuerzas necesarias para cuidarme como debo. 2,55 1,10 7 yo puedo buscar mejores formas para cuidar mi salud que las que tengo ahora. 3,36 0,76 8 cambio la frecuencia con que me baño para mantenerme limpio. 3,61 0,73 9 para mantener el peso que me corresponde hago cambios en mis hábitos alimenticios. 3,10 0,78 10 cuando hay situaciones que me afectan yo las manejo de manera que pueda mantener mi forma de ser. 3,30 0,66 11 pienso en hacer ejercicio y descansar un poco durante el día pero no llego hacerlo. 2,58 0,92 12 cuando necesito ayuda puedo recurrir a mis amigos de siempre. 2,71 1,10 13 puedo dormir lo suficiente como para sentirme descansado. 3,31 0,79 14 cuando obtengo información sobre mi salud pido explicaciones sobre lo que no entiendo. 3,64 0,67 15 yo examino mi cuerpo para ver si hay algún cambio. 3,07 1,01 16 he sido capaz de cambiar hábitos que tenía muy arraigados con tal de mejorar mi salud. 3,46 0,66 17 cuando tengo que tomar una nueva medicina cuento con una persona que me brinda información sobre los efectos secundarios. 3,51 0,81 18 soy capaz de tomar medidas para garantizar que mi familia y yo no corramos peligro. 3,41 0,78 19 soy capaz de evaluar qué tanto me sirve lo que hago para mantenerme con salud. 3,54 0,67 20 debido a mis ocupaciones diarias me resulta difícil sacar tiempo para cuidarme. 2,50 1,04 21 si mi salud se ve afectada yo puedo conseguir la información necesaria sobre qué hacer. 3,69 0,49 22 si yo no puedo cuidarme puedo buscar ayuda. 3,48 0,76 23 puedo sacar tiempo para mí. 3,42 0,77 24 a pesar de mis limitaciones para movilizarme soy capaz de cuidarme como a mí me gusta. 3,35 0,65 tabla 1. estadísticos descriptivos del asa (n=201) 228 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 tabla 2. valores de confiabilidad alfa de cronbach para la escala asa ítem media si se varianza si se correlación correlación alfa si se elimina ítem elimina ítem ítem-total múltiple elimina ítem 1 75,59 41,39 0,41 0,34 0,67 2 75,62 40,53 0,50 0,49 0,66 3 75,95 41,35 0,20 0,37 0,69 4 75,62 43,39 0,06 0,35 0,70 5 75,37 42,44 0,34 0,33 0,68 6 76,59 44,89 (0,09) 0,28 0,72 7 75,78 42,09 0,22 0,34 0,68 8 75,53 42,48 0,18 0,32 0,68 9 76,04 40,22 0,40 0,32 0,67 10 75,84 42,21 0,25 0,27 0,68 11 76,56 44,61 (0,06) 0,22 0,71 12 76,43 42,49 0,07 0,28 0,70 13 75,83 43,09 0,10 0,32 0,69 14 75,50 41,01 0,39 0,38 0,67 15 76,06 38,07 0,46 0,48 0,66 16 75,68 40,27 0,48 0,47 0,66 17 75,63 39,72 0,43 0,41 0,66 18 75,73 41,57 0,26 0,33 0,68 19 75,60 40,52 0,45 0,45 0,66 20 76,64 44,20 (0,04) 0,24 0,71 21 75,45 42,16 0,38 0,37 0,67 22 75,66 40,73 0,36 0,32 0,67 23 75,72 39,26 0,51 0,51 0,66 24 75,79 41,69 0,32 0,42 0,67 al observar los valores de la correlación entre cada ítem y el puntaje de la escala, y entre cada ítem y el resto de los mismos, se identifica que los ítems 4, 6, 11, 12 y 20 mostraron un pobre ajuste al instrumento. 229 análisis factorial de la escala valoración de agencia de autocuidado (asa) en colombia fred manrique-abril, alba fernández, anita velandia la estructura de los nueve ejes factoriales (tabla 3) fue la siguiente: factor 1 (f1): incorporó el 9,23% de la varianza total, e incluyó los siguientes ítems: 19, 21, 22 y 23. el hecho de que un determinado factor sea el que más varianza explique significa que es el elemento que más dispersión mide, es decir, que explica mejor las diferencias entre los distintos individuos de la muestra, pues los factores son meros instrumentos de medida de la dispersión. factor 2 (f2): incorporó el 8,79% de la varianza total, e incluyó los ítems: 2, 5, 9 y 10. factor 3 (f3): incorporó el 8,01% de la varianza total, e incluyó los ítems: 4, 18 y 24. factor 4 (f4): incorporó el 7,44% de la varianza total, e incluyó los ítems: 15 y 16. factor 5 (f5): incorporó el 7,26% de la varianza total, e incluyó los ítems: 3 y 17. factor 6 (f6): incorporó el 7,11% de la varianza total, e incluyó los ítems: 1 y 14. factor 7 (f7): incorporó el 6,19% de la varianza total, e incluyó los ítems: 7 y 8. factor 8 (f8): incorporó el 5,93% de la varianza total, e incluyó los ítems: 6, 11 y 20. que corresponden a los ítems con puntuación negativa o invertida en la escala likert. factor 9 (f9): incorporó el 5,92% de la varianza total, e incluyó los ítems: 12 y 13. en un segundo paso se realizó un análisis factorial exploratorio ajustando a dos el número de factores por extraer para contrastar con qué grado de ajuste los datos obtenidos reproducían la distribución original de los ítems, y para poder comparar los resultados de sousa y colaboradores (22). el procedimiento seguido fue también el de componentes principales con rotación varimax, este resultado aparece reflejado en la tabla 4. los dos factores explicaron de manera conjunta el 27,84% de la varianza total. al examinar la matriz de comunalidades se observa que la mayoría son superiores a 0,25, excepto las de los ítems 7, 8, 10, 11, 12 y 20. estos ítems fueron eliminados y se elaboró un nuevo análisis factorial presentado en la tabla 5, que conduce a una escala de 18 ítems, ajustada y adecuada, visible en el gráfico de sedimentación (figura 1) que indica claramente que solo los dos factores sistemáticamente intervienen los ítems propuestos. discusión el alfa determinado de la escala asa, versión en español, es fuerte, aunque solo llega al rango inferior sugerido por sánchez y echeverri (17) para validación de escalas de medición en salud, pero es consistente con estudios que determinaron el mismo coeficiente para el asa (1, 3-10, 22, 23, 24, 25-26) que oscila entre 0,65 y 0,86. en colombia, la escala asa —tanto en inglés como en español— no se había validado, a pesar de que se está utilizando en los escenarios académicos y clínicos. el análisis de la estructura de dominios de la escala en la muestra estudiada produjo en colombia, la escala asa —tanto en inglés como en español— no se había validado, a pesar de que se está utilizando en los escenarios académicos y clínicos. 230 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 tabla 3. matriz de cargas factoriales para la solución de factores con eigenvalue superior a 1 utilizando componentes principales y rotación varimax (n=201) ítem f1 f2 f3 f4 f5 f6 f7 f8 f9 1 0,18 0,20 0,16 -0,03 0,06 0,64 0,26 -0,02 0,10 2 0,44 0,62 0,04 -0,01 0,05 0,28 0,05 -0,05 0,09 3 -0,01 0,11 -0,10 0,12 0,83 0,09 -0,06 -0,04 0,01 4 -0,05 -0,08 0,75 0,00 -0,14 0,10 0,17 -0,14 -0,13 5 0,13 0,60 0,10 0,25 0,06 0,04 -0,04 0,05 -0,23 6 -0,17 0,12 -0,25 -0,24 0,29 0,22 -0,14 0,56 -0,16 7 0,10 0,08 0,22 0,00 0,17 0,02 0,77 -0,09 -0,19 8 0,05 0,16 -0,12 0,16 -0,32 0,21 0,71 0,03 0,04 9 0,10 0,68 0,15 0,14 0,01 0,12 0,13 0,05 -0,07 10 0,04 0,62 -0,19 0,09 0,16 -0,12 0,15 -0,23 0,28 11 0,13 -0,02 -0,09 -0,07 -0,06 -0,17 -0,03 0,78 -0,01 12 0,15 -0,16 -0,03 -0,02 0,09 0,06 -0,02 0,02 0,85 13 -0,15 0,28 0,34 0,00 -0,10 -0,05 -0,25 -0,04 0,59 14 0,18 0,02 0,03 0,23 0,18 0,72 -0,01 -0,01 -0,06 15 0,14 0,19 0,14 0,76 0,06 0,24 -0,09 -0,09 -0,04 16 0,15 0,21 0,01 0,75 0,19 0,02 0,26 -0,01 0,00 17 0,24 0,05 0,00 0,19 0,58 0,40 0,07 -0,04 0,07 18 0,03 0,13 0,68 0,05 -0,12 0,23 -0,08 -0,04 0,18 19 0,61 0,17 -0,07 0,24 0,01 0,24 0,11 -0,14 0,03 20 -0,23 -0,20 0,02 0,33 -0,31 0,15 0,09 0,57 0,24 21 0,69 0,21 -0,05 0,07 -0,18 0,28 -0,02 -0,09 0,00 22 0,68 -0,02 0,09 -0,01 0,30 0,04 0,20 0,18 0,03 23 0,59 0,26 0,28 0,38 0,18 -0,16 -0,12 0,12 0,05 24 0,16 0,16 0,65 0,19 0,30 -0,28 0,07 -0,03 0,10 eig 2,22 2,11 1,92 1,79 1,74 1,70 1,49 1,42 1,42 %ve 9,23 8,79 8,01 7,44 7,26 7,11 6,19 5,93 5,92 f= factor; eig= eigenvalue; %ve= porcentaje de varianza explicada; valores ≥ 0,55 en negrita. 231 análisis factorial de la escala valoración de agencia de autocuidado (asa) en colombia fred manrique-abril, alba fernández, anita velandia tabla 4. matriz de cargas factoriales para la estructura de dos factores utilizando componentes principales y rotación varimax (n=201) f1 = factor 1; f2 = factor 2; h2 = comunalidades. no. ítem componente h2 f1 f2 1 a medida que cambian las circunstancias yo voy haciendo ajustes para mantener mi salud. 0,50 0,12 0,26 2 reviso si las formas que practico habitualmente para mantenerme con salud son buenas. 0,67 0,11 0,46 3 si tengo problemas para moverme o desplazarme me las arreglo para conseguir ayuda. 0,42 (0,30) 0,26 4 yo puedo hacer lo necesario para mantener limpio el ambiente donde vivo. (0,05) 0,66 0,43 5 hago en primer lugar lo que sea necesario para mantenerme con salud. 0,49 0,12 0,25 6 me faltan las fuerzas necesarias para cuidarme como debo. 0,01 (0,55) 0,31 7 yo puedo buscar mejores formas para cuidar mi salud que las que tengo ahora. 0,32 0,16 0,13 8 cambio la frecuencia con que me baño para mantenerme limpio. 0,27 0,07 0,08 9 para mantener el peso que me corresponde hago cambios en mis hábitos alimenticios. 0,51 0,21 0,30 10 cuando hay situaciones que me afectan yo las manejo de manera que pueda mantener mi forma de ser. 0,40 0,06 0,16 11 pienso en hacer ejercicio y descansar un poco durante el día pero no llego hacerlo. (0,08) (0,28) 0,08 12 cuando necesito ayuda puedo recurrir a mis amigos de siempre. 0,03 0,12 0,02 13 puedo dormir lo suficiente como para sentirme descansado. (0,07) 0,51 0,27 14 cuando obtengo información sobre mi salud pido explicaciones sobre lo que no entiendo. 0,53 (0,07) 0,28 15 yo examino mi cuerpo para ver si hay algún cambio. 0,55 0,26 0,38 16 he sido capaz de cambiar hábitos que tenía muy arraigados con tal de mejorar mi salud. 0,60 0,15 0,38 17 cuando tengo que tomaron una nueva medicina cuento con una persona que me brinda información sobre los efectos secundarios. 0,60 (0,14) 0,38 18 soy capaz de tomar medidas para garantizar que mi familia y yo no corramos peligro. 0,12 0,66 0,44 19 soy capaz de evaluar qué tanto me sirve lo que hago para mantenerme con salud. 0,63 0,03 0,40 20 debido a mis ocupaciones diarias me resulta difícil sacar tiempo para cuidarme. (0,17) 0,05 0,03 21 si mi salud se ve afectada yo puedo conseguir la información necesaria sobre qué hacer. 0,56 0,04 0,31 22 si yo no puedo cuidarme puedo buscar ayuda. 0,53 (0,07) 0,28 23 puedo sacar tiempo para mí. 0,58 0,27 0,41 24 a pesar de mis limitaciones para movilizarme soy capaz de cuidarme como a mí me gusta. 0,25 0,57 0,38 232 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 tabla 5. matriz de cargas factoriales para la estructura de dos factores utilizando componentes principales y rotación varimax, y extrayendo ítems con comunalidades <0,25 (n=201) f1= factor 1; f2= factor 2; h2= comunalidades no. ítem componente h2 f1 f2 1 a medida que cambian las circunstancias yo voy haciendo ajustes para mantener mi salud. 0,50 0,06 0,26 2 reviso si las formas que practico habitualmente para mantenerme con salud son buenas. 0,67 0,10 0,45 3 si tengo problemas para moverme o desplazarme me las arreglo para conseguir ayuda. 0,42 (0,33) 0,28 4 yo puedo hacer lo necesario para mantener limpio el ambiente donde vivo. (0,02) 0,66 0,44 5 hago en primer lugar lo que sea necesario para mantenerme con salud. 0,49 0,14 0,25 6 me faltan las fuerzas necesarias para cuidarme como debo. 0,00 (0,52) 0,27 9 para mantener el peso que me corresponde hago cambios en mis hábitos alimenticios. 0,50 0,22 0,30 13 puedo dormir lo suficiente como para sentirme descansado. (0,04) 0,51 0,26 14 cuando obtengo información sobre mi salud pido explicaciones sobre lo que no entiendo. 0,55 (0,12) 0,31 15 yo examino mi cuerpo para ver si hay algún cambio. 0,59 0,24 0,40 16 he sido capaz de cambiar hábitos que tenía muy arraigados con tal de mejorar mi salud. 0,59 0,13 0,37 17 cuando tengo que tomar una nueva medicina cuento con una persona que me brinda información sobre los efectos secundarios. 0,61 (0,19) 0,41 18 soy capaz de tomar medidas para garantizar que mi familia y yo no corramos peligro. 0,17 0,64 0,44 19 soy capaz de evaluar qué tanto me sirve lo que hago para mantenerme con salud. 0,62 0,01 0,39 21 si mi salud se ve afectada yo puedo conseguir la información necesaria sobre qué hacer. 0,56 0,02 0,32 22 si yo no puedo cuidarme puedo buscar ayuda. 0,54 (0,09) 0,29 23 puedo sacar tiempo para mí. 0,62 0,29 0,46 24 a pesar de mis limitaciones para movilizarme soy capaz de cuidarme como a mí me gusta. 0,28 0,58 0,41 233 análisis factorial de la escala valoración de agencia de autocuidado (asa) en colombia fred manrique-abril, alba fernández, anita velandia resultados que son consistentes con la estructura factorial definida en estudios previos (6, 8, 22, 23). este análisis factorial indicó la presencia de nueve factores, mayor a lo encontrado por soderhamn (6), fok (8) y evers (9). sin embargo, esta estructura factorial tiene una obvia posibilidad de interpretación desde el punto de vista clínico y cultural, por el nivel educativo y las patologías de los pacientes, como también por el estrato socioeconómico y el sistema de salud de atención que posibilitan el manejo de la agencia de autocuidado en colombia. aunque las rotaciones demostraron igual número de factores, no se pudieron determinar con certeza las dimensiones del instrumento ya que, desde el constructo, en su origen es unidimensional. es posible que en el análisis simple el agrupamiento de los ítems al primer factor determine inclinación por los conceptos de la teoría de mediano rango del autocuidado, dejando con menos peso matricial el déficit de autocuidado y el sistema de apoyo educativo propuestos por orem (24). el análisis en dos factores permite proponer un instrumento con 18 ítems, que debería ser sometido al mismo proceso de validación en futuros estudios, tal como lo sugiere sousa (22) para pacientes diabéticos con 20 ítems. los resultados de este estudio han documentado, por medio de un proceso sistemático, satisfactorias cualidades psicométricas de la escala asa en español, versión de edilma de reales, lo cual sustenta el uso en colombia de esta versión del instrumento en adultos crónicos. agradecimientos los autores agradecen a los pacientes del hospital tunjuelito; a la universidad nacional de colombia, sede bogotá; a la universidad de los andes, mérida, venezuela, y al grupo de investigación en salud pública de la universidad pedagógica y tecnológica de colombia por la financiación de esta investigación. figura 1. gráfico de sedimentación para 18 ítems del asa 234 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 referencias bibliográficas 1. evers gcm. appraisal of self-care agency: asa-scale: van corcum; 1989. 2. fawcett j. analysis and evaluation of conceptual models of nursing. third edition. philadelphia: f. a. davis company; 1995. 3. van achterberg t, lorensen m, isenberg ma, evers gc, levin e, philipsen h. the norwegian, danish and dutch version of the appraisal of self-care agency scale; comparing reliability aspects. scand j caring sci 1991; 5 (2): 101-108. 4. evers gc, isenberg ma, philipsen h, senten m, brouns g. validity testing of the dutch translation of the appraisal of the self-care agency asa-scale. int j nurs stud 1993; 30 (4): 331-42. 5. lorensen m, holter im, evers gcm, isenberg ma, van achterberg t. cross-cultural testing of the appraisal of self-care agency: asa scale’ in norway. international journal of nursing studies 1993; 30 (1): 15-23. 6. soderhamn o, evers g, hamrin e. a swedish version of the appraisal of self-care agency (asa) scale. scand j caring. sci. 1996; 10 (1): 3-9. 7. gallegos ce. validez y confiabilidades de la versión en español de la escala: valoración de las capacidades de autocuidado. desarrollo científ. enferm. 1998; 6 (9): 260-266. 8. fok msm, alexander mf, wong tks, mcfadyen ak. contextualising the appraisal of self-care agency scale in hong kong. contemporary nurse 2002; 12 (2): 124-134. 9. evers gc, isenberg ma, philipsen h, brouns g, halfens r, smeets h. the appraisal of self-care agency’s asa-scale: research program to test reliability and validity. in: proceedings of the international nursing research conference “new frontiers in nursing research.” edmond: university of alberta, canada; 1986. 10. velandia a. relación entre la capacidad de agencia de autocuidado y la adherencia al tratamiento farmacológico y no farmacológico en personas con factores de riesgo cardiovascular que asisten a consulta externa en el hospital tunjuelito. [tesis de maestria]. bogotá: universidad nacional de colombia; 2007. 11. bastidas sánchez cv. asociación entre la capacidad de la agencia de autocuidado y la adherencia a tratamientos farmacológicos y no farmacológicos en personas con alguna condición de enfermedad coronaria. av. enferm 2007; 25 (2): 65-75. 12. peñaloza garcía m. capacidad de agencia de autocuidado en personas con hipertensión arterial de la fundación médico preventiva, san josé de cúcuta, 2004. av. enferm 2006; 24 (2): 63-79. 13. rivera álvarez ln. capacidad de agencia de autocuidado en personas con hipertensión arterial hospitalizadas en una clínica de bogotá, colombia. rev. salud pública 2006; 8 (3): 235-247. 14. rivera álvarez ln. autocuidado y capacidad de agencia de autocuidado: [revisión]. av. enferm 2006; 24 (2): 91-98. 15. bastidas sánchez cv. asociación entre la capacidad de la agencia de autocuidado y la adherencia a tratamientos farmacológicos y no farmacológicos en personas con alguna condición de enfermedad coronaria. av. enferm 2007; 25 (2): 65-75. 16. velandia arias a, rivera álvarez ln. confiabilidad de la escala “apreciación de la agencia de autocuidado” (asa), segunda versión en español, adaptada para población colombiana. av. enferm 2009; 27 (1): 38-47. 17. sánchez r, echeverri j. validación de escalas de medición en salud. revista salud pública 2004; 6 (3): 302-318. 18. streiner dl. figuring out factors: the use and misuse of factor analysis. canadian journal of psychiatry 1994; 39 (3): 135-140. 19. tabachnick bg, fidell ls. using multivariate statistics boston. ma: allyn and bacon 2007. 20. pett ma, lackey nr, sullivan jj. making sense of factor analysis: the use of factor analysis for instrument development in health care research: sage; 2003. 21. hamilton lc. regression with graphics: a second course in applied statistics: duxbury press belmont, calif; 1992. 22. sousa vd, zauszniewski ja, musil cm, lea pjp, davis sa. relationships among self-care agency, 235 análisis factorial de la escala valoración de agencia de autocuidado (asa) en colombia fred manrique-abril, alba fernández, anita velandia self-efficacy, self-care, and glycemic control. research and theory for nursing practice 2005; 19 (3): 217-230. 23. muñoz mendoza c, cabrero garcía j, richart martínez m, orts cortés mi, cabañero martínez mj. la medición de los autocuidados: una revisión bibliográfica. enfermería clínica 2005; 15 (2): 76-87. 24. orem de. nursing: concepts of practice. st. louis: mosby; 1991. 25. geden e, taylor s. construct and empirical validity of the self-as-carer inventory. nursing research 1991; 40 (1): 47. 26. kearney by, fleischer bj. development of an instrument to measure exercise of self-care agency. res. nurs. health 1979; 2 (1): 25-34. nota del autor: el concepto de validez de contenido obtenido a través de análisis factorial está respaldado por los autores en la referencia 17 del artículo y adicionalmente por argimón pallás et ál. (1) “una forma empírica de evaluar la validez de contenido es aplicar un análisis factorial”. linares et ál. (2) sugieren que “… el análisis de los componentes principales se realiza con el propósito de analizar la estructura subyacente de los datos, dando validez de contenido”. lugo et ál. (3) manifiestan: “…tradicionalmente la literatura recurre al análisis factorial clásico como recurso para evaluar la validez de contenido, también llamada validez ‘de constructo’. no obstante, a los fines de verificar la naturaleza de la estructura de correlaciones y la existencia de dimensiones subyacentes (que son los propósitos de este estudio) el análisis factorial clásico y el análisis de componentes principales pueden utilizarse indistintamente. el factorial clásico es claramente referible cuando se desea reconstruir la estructura de correlaciones a través de la definición de los nuevos factores”. 1 ronny anderson de oliveira cruz1 glenda agra2 jacira dos santos oliveira3 maria auxiliadora pereira4 maria emília limeira lopes5 marta miriam lopes costa6 cuidados de enfermagem para avaliar, prevenir e tratar a xerose cutânea em pessoas idosas* 1 https://orcid.org/0000-0001-6443-7779. universidade federal da paraíba, brasil. ronny.cruz@unipe.edu.br 2 https://orcid.org/0000-0002-7628-9029. unidade acadêmica de enfermagem, universidade federal de campina grande, brasil. 3 https://orcid.org/0000-0002-3863-3917. universidade federal da paraíba, brasil. 4 https://orcid.org/0000-0002-0614-4051. universidade federal da paraíba, brasil. 5 https://orcid.org/0000-0003-2391-6399. universidade federal da paraíba, brasil. 6 https://orcid.org/0000-0002-2119-3935. universidade federal da paraíba, brasil. * extraído da dissertação “cuidados de enfermagem para avaliação, prevenção e tratamento da xerose cutânea em pessoas idosas”, no âmbito do programa de pós-graduação em enfermagem da universidade federal da paraíba, em 2019. recebido: 18/03/2019 submetido: 11/04/2019 aceito por pares: 29/07/2019 aceito: 02/08/2019 doi: 10.5294/aqui.2019.19.4.3 para citar este artigo / para citar este artículo / to reference this article cruz rao, agra g, oliveira js, pereira ma, lopes mel, costa mml. nursing care to evaluate, prevent, and treat cutaneous xerosis in the elderly. aquichan 2019; 19(4): e1943. doi: https://doi.org/10.5294/aqui.2019.19.4.3 resumo objetivo: identificar os cuidados de enfermagem realizados por enfermeiros para avaliar, prevenir e tratar a xerose cutânea em pessoas idosas. materiais e métodos: estudo descritivo com abordagem quantitativa, realizado com 101 enfermeiros assistenciais que exercem atividades na clínica médica e na unidade de terapia intensiva de quatro hospitais da paraíba, brasil. a coleta dos dados ocorreu entre julho e setembro de 2018 por meio de um instrumento composto por variáveis sociodemográficas e por itens relacionados aos cuidados de enfermagem. a análise estatística realizou-se por cálculos de distribuição e frequência, medidas de tendência central, desvio-padrão e teste qui-quadrado para variáveis categóricas. resultados: a maioria afirmou sempre considerar a faixa etária (84,2 %), avaliar a coloração da pele (83,2 %), avaliar o turgor e a elasticidade da pele (64,4 %), buscar a existência de rachaduras (53,5 %), observar a existência de lesões na pele (90,1 %). dos profissionais participantes, 83,2 % disseram nunca ter usado equipamento importado para avaliar a hidratação da pele. conclusões: o estudo demonstrou que os enfermeiros enfatizaram a importância em considerar a faixa etária, avaliar a coloração da pele, estar atento a áreas com hiperemia e observar a existência de lesões, bem como a necessidade da educação continuada para melhorar a qualidade do cuidado. palavras-chave (fonte: decs) enfermagem; cuidados de enfermagem; envelhecimento da pele; terapêutica; saúde do idoso. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1943 temática: cuidado crônico. contribuição científica para a disciplina: espera-se que este estudo possa contribuir para o direcionamento das intervenções de enfermagem assim como para a realização de pesquisas futuras e para a criação de protocolos sobre a temática. apresentou como base teórico-conceitual a teoria das necessidades humanas básicas de horta, com a possibilidade de agregar os cuidados aqui apresentados ao considerar a hidratação inerente ao conjunto de necessidades psicobiológicas. https://orcid.org/0000-0001-6443-7779 https://orcid.org/0000-0002-7628-9029 https://orcid.org/0000-0002-3863-3917 https://orcid.org/0000-0002-0614-4051 https://orcid.org/0000-0003-2391-6399 https://orcid.org/0000-0002-2119-3935 https://doi.org/10.5294/aqui.2019.19.4.3 https://orcid.org/0000-0001-6443-7779 https://orcid.org/0000-0002-7628-9029 https://orcid.org/0000-0002-3863-3917 https://orcid.org/0000-0002-0614-4051 https://orcid.org/0000-0003-2391-6399 https://orcid.org/0000-0002-2119-3935 https://doi.org/10.5294/aqui.2019.19.4.3 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1943 cuidados de enfermería para evaluar, prevenir y tratar la xerosis cutánea en personas ancianas* resumen objetivo: identificar los cuidados de enfermería realizados por enfermeros para evaluar, prevenir y tratar la xerosis cutánea en personas ancianas. materiales y métodos: estudio descriptivo, con enfoque cuantitativo, realizado con 101 enfermeros asistenciales que ejercen actividades en la clínica médica y la unidad de terapia intensiva de cuatro hospitales de paraíba, brasil. la recolección de los datos ocurrió entre julio y septiembre del 2018 por medio de un instrumento compuesto por variables sociodemográficas y por ítems relacionados con los cuidados de enfermería. el análisis estadístico se realizó por cálculos de distribución y frecuencia, medidas de tendencia central, desviación estándar y prueba chi-cuadrado para variables categóricas. resultados: la mayoría afirmó siempre considerar el rango de edad (84,2 %), evaluar la coloración de la piel (83,2 %), evaluar la hinchazón y la elasticidad de la piel (64,4 %), buscar la existencia de hendiduras (53, 5 %), observar la existencia de lesiones en la piel (90,1 %). de los profesionales participantes, el 83,2 % dijo nunca haber usado equipo importado para evaluar la hidratación de la piel. conclusiones: el estudio encontró que los enfermeros enfatizaron la importancia de considerar el grupo de edad, evaluar la coloración de la piel, estar atento a áreas con hiperemia y observar la existencia de lesiones, así como la necesidad de la educación continuada para mejorar la calidad del cuidado. palabras clave (fuente: decs) enfermería; cuidados de enfermería; envejecimiento de la piel; terapia; salud del anciano. * extraído de la diseración “cuidados de enfermagem para avaliação, prevenção e tratamento da xerose cutânea em pessoas idosas”, del programa de posgrados en enfermería de la universidade federal da paraíba, 2019. 3 cuidados de enfermagem para avaliar, prevenir e tratar a xerose cutânea em pessoas idosas l ronny anderson de oliveira cruz e outros nursing care to evaluate, prevent, and treat cutaneous xerosis in the elderly* abstract objective: identify nursing care performed by nurses to evaluate, prevent, and treat cutaneous xerosis in the elderly. materials and methods: descriptive study with quantitative approach, conducted with 101 care nurses working in the medical clinic and in the intensive care units of four hospitals in paraíba, brazil. the data collection took place between july and september 2018 through an instrument composed of sociodemographic variables and by items related with nursing care. the statistical analysis was performed by distribution and frequency calculations, central tendency measures, standard deviation, and chi-squared test for categorical variables. results: the majority stated always considering the age range (84.2 %), assessing skin color (83.2 %), evaluating skin turgor and elasticity (64.4 %), looking for the existence of skin fissures (53.5 %), and noticing the existence of lesions on the skin (90.1 %). of the participating professionals, 83.2 % reported never having used imported equipment to evaluate skin hydration. conclusions: the study showed that nurses emphasized the importance of considering age range, assessing skin color, being aware of areas with hyperemia, and noticing the existence of lesions, as well as the need for continuing education to improve the quality of care. keywords (source: decs) nursing; nursing care; aging skin; therapy; health of the elderly. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1943 * extracted from the dissertation: “nursing care for the evaluation, prevention, and treatment of cutaneous xerosis in the elderly”, in the graduate nursing program at universidade federal da paraíba, in 2019. 4 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1943 aquichan issn 1657-5997 eissn 2027-5374 introdução a estrutura etária da população tem sido marcada nos últimos anos por mudanças, sobretudo, no tocante à longevidade. porém, não basta ampliar a quantidade de anos vividos, mas sim realizar melhorias das condições de vida da pessoa idosa para que possa usufruir de uma velhice ativa, saudável e com qualidade de vida (1). o processo de envelhecimento traz consigo inúmeras alterações — fisiológicas, morfológicas, bioquímicas e funcionais — em todo o organismo, deixando-o mais susceptível às agressões intrínsecas e extrínsecas. nesse contexto, a pele seca ou a xerose cutânea apresenta elevada frequência e contribui para a ocorrência de desconforto e para as alterações do aspecto visual e sensorial da pele. dentre as características da xerose cutânea, podem-se observar: descamação, fissuras, tensão, hiperemia e, ocasionalmente, sangramentos (2). a xerose cutânea tem prejudicado a qualidade de vida de muitos idosos e afetado entre 15 % e 20 % da população mundial; quando grave, pode interferir na produtividade do trabalho e nas atividades da vida diária, especialmente, quando as mãos são afetadas. a base do tratamento é a reidratação e a reparação da pele, muito importantes para recuperar a função de barreira epidérmica (3). para que a pele apresente um estado adequado de funcionamento, dois processos básicos agem em conjunto: a limpeza e a hidratação cutâneas. a limpeza contribui para a remoção de debris externos, secreções cutâneas naturais bem como micro-organismos. já a hidratação tem o papel primordial de manter o conteúdo de água na epiderme e manter a barreira epidérmica dentro dos parâmetros de normalidade (4). prevenir, avaliar e tratar uma lesão são responsabilidades importantes inerentes à equipe de saúde, sobretudo, no que tange à enfermagem. nesse sentido, são necessários conhecimentos sobre fatores de risco, fisiologia, anatomia, processo de cicatrização e produtos para prevenir e tratar. esse conhecimento passa a ser fundamental para realizar um diagnóstico preciso e indicar tecnologias adequadas. tanto a prevenção como o tratamento são dinâmicos e devem acompanhar as evoluções científicas, e esse aspecto tem sido potencializado por meio da oferta de cursos e da fundamentação do cuidado a partir do processo de enfermagem (pe) (5). com a finalidade de orientar, direcionar e organizar o cuidado profissional de enfermagem, os enfermeiros encontram, no pe, seu método de trabalho, para o qual se necessita um suporte teórico que subsidie o percurso da assistência. no brasil, o modelo teórico mais utilizado tem sido a teoria das necessidades humanas básicas (tnhb) de horta, que orienta o cuidado de enfermagem nas dimensões psicobiológica, psicossocial e psicoespiritual (6). assim, no contexto da construção de um campo de conhecimentos próprios, os sistemas de linguagem padronizada (slp) organizam informações e estão relacionados ao desenvolvimento do conhecimento da disciplina de enfermagem, já que permitem a construção de bancos de dados em relação aos diagnósticos, às intervenções ou aos resultados de enfermagem, além de dar visibilidade para a contribuição da enfermagem à saúde das pessoas (7). existem diversos slp para nomear os fenômenos de enfermagem, tais como a classificação dos diagnósticos de enfermagem da nanda-i (8), a classificação das intervenções de enfermagem (9) e a classificação de resultados de enfermagem (10). é fato que há uma fragilidade no que se refere a estudos que tratam especificamente de produtos e tecnologias utilizadas pelos profissionais de enfermagem para o tratamento da xerose cutânea; além disso, observa-se que tanto a prevenção quanto o tratamento de lesões já instalados demandam grande atenção por parte da equipe, apresentam custo elevado e necessitam dos enfermeiros uma prática de capacitação e educação permanente com vistas à qualificação para atuar com eficiência e eficácia (11). assim, este estudo tem como objetivo identificar os cuidados de enfermagem realizados por enfermeiros para avaliar, prevenir e tratar a xerose cutânea em pessoas idosas. materiais e métodos trata-se de um estudo descritivo, com abordagem quantitativa. foi realizado em quatro hospitais da região metropolitana de joão pessoa, no estado da paraíba, brasil. a escolha pelas instituições se deu pelo fato de receberem rotineiramente um número elevado de pessoas idosas, além de servir como instituições de ensino e formação para discentes de graduação e residência multiprofissional em saúde hospitalar em atenção à saúde do idoso e ao paciente crítico. a população foi composta por 120 enfermeiros que atuavam nos setores de clínica médica e de unidade de terapia intensiva 5 cuidados de enfermagem para avaliar, prevenir e tratar a xerose cutânea em pessoas idosas l ronny anderson de oliveira cruz e outros (uti) nos três turnos de trabalho. a amostra não probabilística e por conveniência foi constituída por 101 participantes que atenderam aos critérios de inclusão e concordaram em participar da pesquisa. considerando um erro amostral de 5 % e nível de confiança de 95 %, a amostra mínima considerada suficiente era de 92 sujeitos. foram considerados critérios de inclusão: enfermeiros que atuassem nas unidades como assistenciais, estar no serviço há pelo menos seis meses, utilizar o processo de enfermagem como método para a assistência, além de estar em atividade durante o período de coleta de dados, que ocorreu entre julho e setembro de 2018. foram excluídos da pesquisa enfermeiros que atuassem apenas em funções administrativas, estivessem afastados por licença ou de férias no período de coleta. para a coleta de dados, foi utilizado um instrumento composto por duas partes: a primeira com dados sociodemográficos de identificação dos participantes e a segunda com questões objetivas agrupadas em três domínios e classificadas a partir de uma escala likert de cinco pontos, de 1 (nunca), 2 (quase nunca), 3 (às vezes), 4 (quase sempre) até 5 (sempre). os domínios foram: 1. avaliação da pele do idoso; 2. produtos utilizados para prevenir e tratar a xerose cutânea; 3. cuidados de enfermagem prescritos na presença do diagnóstico de enfermagem “integridade da pele prejudicada relacionada à xerose cutânea”. o instrumento construído passou pelo processo de validação de conteúdo por cinco juízes, o que permitiu verificar as propriedades para medir o fenômeno pesquisado. a validação de conteúdo é indispensável ao desenvolvimento de ferramentas de medição, já que envolve o processo de elaboração e julgamento por especialistas na definição do universo teórico e das diferentes dimensões do conceito a ser observado e medido (12); neste estudo, foi realizada com a finalidade de identificar itens que porventura não estivessem adequados aos objetivos propostos. após a coleta, os dados foram tabulados e armazenados no programa excel para windows e posteriormente transportados para o software statistical package for the social sciences (spss), versão 25.0. para os dados, foram realizadas análises estatísticas descritivas de distribuição e frequência e calculadas medidas de tendência central e desvio-padrão; para as variáveis categóricas, foi realizado o teste qui-quadrado. a pesquisa foi realizada de acordo com o que preconiza a resolução 466/2012, do conselho nacional de saúde, que dispõe sobre a ética relacionada a pesquisas que envolvem seres humanos, direta ou indiretamente, certificando, entre outros pontos, a garantia ao direito à privacidade dos participantes (13). foi aprovada pelo comitê de ética em pesquisa do centro de ciências da saúde da universidade federal da paraíba, sob o número do certificado de apresentação para apreciação ética (caae): 89318318.3.0000.5188 e parecer 2.731.985. resultados a amostra foi constituída por 101 enfermeiros e houve um predomínio do sexo feminino (84,2 %), com idade média de 36,51 (dp = 7,67; mínimo = 24, máximo = 62). o tempo de exercício laboral dos participantes apresentou uma média de 9,33 anos (dp = 7,99; mínimo = 6 meses, máximo = 35 anos), e foi observado que a maioria tinha o título de especialista (59,4 %). foi constatado que 65 enfermeiros (64,4 %) não tinham nenhum curso na área de prevenção e/ou tratamento de lesões de pele. quanto ao número de vínculos de trabalho, a maioria dos sujeitos relatou atuar em mais de um emprego (60,4 %) e, destes, 52 (85,2 %) referiram atuar com dois vínculos empregatícios. a jornada semanal variou entre 20 e 74 horas por semana com média de 42,63 horas (dp = 12,8) conforme os dados apresentados na tabela 1. na tabela 2, encontram-se a distribuição das frequências de resposta para os itens do instrumento. destaca-se que a maioria afirmou sempre considerar a faixa etária (84,2 %), avaliar a coloração da pele (83,2 %), avaliar o turgor e a elasticidade da pele (64,4 %), observar a temperatura do paciente (54,7 %), considerar o excesso de umidade (63,4 %), buscar a existência de rachaduras (53,5 %), observar a existência de lesões na pele (90,1 %), a presença de descamação (61,4 %) e de prurido (63,4 %), ficar atento(a) para a exposição ao frio (52,5 %) e considerar a avaliação da pele para escolher o tipo de hidratante (53,5 %). a maioria dos enfermeiros (83,2 %) disse nunca ter usado equipamento importado para avaliar a hidratação da pele. dos 34 itens do instrumento, apenas oito não obtiveram escores com valores acima de 50 % para cuidados sempre ou quase sempre prescritos, o que pode estar relacionado ao tempo de exercício profissional bem como a uma boa qualidade na formação universitária. 6 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1943 aquichan issn 1657-5997 eissn 2027-5374 tabela 1. distribuição das variáveis sociodemográficas dos enfermeiros participantes (n = 101) na cidade de joão pessoa, paraíba, brasil, 2018 variável n % média (desvio-padrão; mínimo-máximo) idade 101 100 % 36,51 (dp = 7,67; 24-62) sexo masculino 16 15,8 % feminino 85 84,2 % tempo de exercício profissional 101 100 % 9,33 (dp = 7,99; 0,6-35) titulação graduado 33 32,7 % especialista 60 59,4 % mestre 6 5,9 % doutor 2 2 % anos de atuação com processo de enfermagem 101 100 % 7,48 (dp = 6,25; 0,6-35) possui cursos na área de prevenção e tratamento de lesões de pele sim 36 35,6 % não 65 64,4 % atua em mais de um emprego sim 61 60,4 % não 40 39,6 % se sim, quantos? 2 empregos 52 85,2 % 3 empregos 9 14,8 % jornada de trabalho semanal, considerando todos os empregos 101 100 % 42,63 (dp = 12,8; 20-74) fonte: elaboração própria. 7 cuidados de enfermagem para avaliar, prevenir e tratar a xerose cutânea em pessoas idosas l ronny anderson de oliveira cruz e outros tabela 2. distribuição da frequência de respostas ao instrumento na cidade de joão pessoa, paraíba, brasil, 2018 nunca quase nunca às vezes quase sempre sempre domínio item n % n % n % n % n % d i av al ia çã o da p el e do id os o 1. considero a faixa etária. 2 2 % 1 1 % 13 12,9 % 85 84,2 % 2. avalio a coloração da pele. 2 2 % 15 14,9 % 84 83,2 % 3. avalio o turgor e a elasticidade da pele. 8 7,9 % 28 27,7 % 65 64,4 % 4. observo a temperatura do paciente. 2 2 % 16 15,8 % 25 24,8 % 58 57,4 % 5. não considero o excesso de umidade. 64 63,4 % 6 5,9 % 9 8,9 % 7 6,9 % 15 14,9 % 6. busco a existência de rachaduras. 4 4 % 2 2 % 12 11,9 % 29 28,7 % 54 53,5 % 7. observo a existência de lesões na pele. 4 4 % 6 5,9 % 91 90,1 % 8. observo a presença de descamação. 5 5 % 34 33,7 % 62 61,4 % 9. observo a presença de prurido. 4 4 % 10 9,9 % 23 22,8 % 64 63,4 % 10. fico atento(a) para a exposição ao frio. 3 3 % 2 2 % 16 15,8 % 27 26,7 % 53 52,5 % 11. utilizo equipamento importado que avalia a hidratação da pele. 84 83,2 % 8 7,9 % 6 5,9 % 3 3 % d ii pr od ut os u til iz ad os p ar a pr ev en ir e tr at ar a x er os e cu tâ ne a 12. para escolher o tipo de hidratante, não considero a avaliação da pele. 54 53,5 % 15 14,9 % 11 10,9 % 3 3 % 18 17,8 % 13. uso produtos à base de ácidos graxos essenciais. 9 8,9 % 9 8,9 % 30 29,7 % 28 27,7 % 25 24,8 % 14. utilizo cremes à base de ureia a 10 % ou 20 %. 32 31,7 % 19 18,8 % 19 18,8 % 20 19,8 % 11 10,9 % 15. faço uso de creme de barreira. 10 9,9 % 11 10,9 % 30 29,7 % 21 20,8 % 29 28,7 % 16. emprego qualquer hidratante que estiver disponível. 16 15,8 % 12 11,9 % 24 23,8 % 18 17,8 % 31 30,7 % 17. aplico formulações à base de aloe vera. 20 19,8 % 24 23,8 % 40 39,6 % 9 8,9 % 8 7,9 % 18. utilizo formulações à base de triglicérides de cadeia média. 27 26,7 % 29 28,7 % 26 25,7 % 17 16,8 % 2 2 % 19. aplico óleo mineral. 30 29,7 % 21 20,8 % 21 20,8 % 10 9,9 % 19 18,8 % d ii i cu id ad os d e en fe rm ag em p re sc ri to s na p re se nç a do d ia gn ós tic o de e nf er m ag em “ in te gr id ad e da p el e pr ej ud ic ad a re la ci on ad a à xe ro se c ut ân ea ” 20. inspeciono as condições da pele diariamente. 2 2 % 8 7,9 % 5 5 % 16 15,8 % 70 69,3 % 21. registro os achados acerca da pele do paciente. 1 1 % 2 2 % 6 5,9 % 12 11,9 % 80 79,2 % 22. identifico pacientes em risco de lesões de pele devido ao ressecamento. 1 1 % 5 5 % 8 7,9 % 11 10,9 % 76 75,2 % 23. realizo a hidratação da pele com os produtos adequados. 2 2 % 10 9,9 % 20 % 12 11,9 % 57 56,4 % 24. estou atento a áreas de maceração. 1 1 % 4 4 % 3 3 % 27 26,7 % 66 65,3 % 25. estou atento a áreas de hiperemia. 2 2 % 3 3 % 10 9,9 % 86 85,1 % 26. avalio com atenção os membros inferiores, principalmente os espaços interdigitais. 10 9,9 % 25 24,8 % 26 25,7 % 40 39,6 % 27. proporciono higiene corporal sempre que necessário. 8 7,9 % 15 14,9 % 78 77,2 % 28. proporciono higiene íntima sempre que necessário. 3 3 % 2 2 % 16 15,8 % 80 79,2 % 29. retiro os resíduos aderidos à pele proveniente de fixadores. 6 5,9 % 4 4 % 6 5,9 % 23 22,8 % 62 61,4 % 30. discuto com a equipe de enfermagem a necessidade de aumentar a hidratação oral ou parenteral. 3 3 % 6 5,9 % 15 14,9 % 26 25,7 % 51 50,5 % 31. oriento os familiares sobre os sinais de ressecamento da pele do paciente. 6 5,9 % 10 9,9 % 26 25,7 % 59 58,4 % 32. oriento a equipe de enfermagem em relação à temperatura da água. 8 7,9 % 11 10,9 % 28 27,7 % 54 53,5 % 33. oriento a equipe de enfermagem em relação ao uso do sabonete adequado. 11 10,9 % 8 7,9 % 19 18,8 % 26 25,7 % 37 36,6 % 34. oriento para o autocuidado. 3 3 % 8 7,9 % 18 17,8 % 72 71,3 % fonte: elaboração própria. 8 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1943 aquichan issn 1657-5997 eissn 2027-5374 com a finalidade de avaliar a associação entre a escolha dos itens e ter ou não cursos na área de prevenção e tratamento de lesões de pele, foi realizado o teste qui-quadrado e analisados os respectivos valores de p conforme a tabela 3. após a realização do teste, verificou-se que existem relações estatisticamente significativas nos itens 19, 20, 25, 28, 30, 32, 33 e 34, cujos p-valores foram respectivamente 0,014, 0,050, 0,024, 0,043, 0,001, 0,007, 0,017 e 0,007. os resultados revelam que, a um nível de 95 % de significância, a escolha por esses itens independe do fato de ter ou não curso na área de prevenção e tratamento de lesões de pele. discussão as alterações que ocorrem em decorrência da redução da quantidade de água no estrato córneo (ec) comprometem a função da barreira transepidérmica e trazem como complicações a descamação e o ressecamento. o ec tem em sua composição corneócitos com seus fatores naturais de hidratação e uma bicamada lipídica intracelular, que, quando estão funcionando em harmonia, são capazes de garantir a integridade cutânea e a hidratação (14). por ser a hidratação uma condição essencial à vida e necessária à homeostase, relaciona-se intrinsecamente com a tnhb de wanda aguiar horta, que tem como princípios a hemostasia, o holismo e a adaptação. representa um modelo teórico metodológico que fundamenta a sistematização da assistência de enfermagem (sae), auxilia no reconhecimento da realidade e na definição de papéis que promovem a qualificação e a melhora do desempenho profissional (15). identificar como os enfermeiros têm realizado o cuidado de enfermagem para avaliar, prevenir e tratar a xerose cutânea em pessoas idosas apresenta grande relevância, sobretudo pela incidência e pela prevalência desse agravo nessa população, bem como pelo processo de transição demográfica que tem sido apresentado não só nos países desenvolvidos, mas também naqueles em desenvolvimento. tabela 3. análise da significância entre ter cursos na área de prevenção e tratamento de lesões da pele na cidade de joão pessoa, paraíba, brasil, 2018 ter cursos na área de prevenção e tratamento de lesões de pele nunca quase nunca às vezes quase sempre sempre total x 2 p-valor 19. aplico óleo mineral. sim 17 5 8 4 2 36 12,425 0,014não 13 16 13 6 17 65 total 30 21 21 10 19 101 20. inspeciono as condições da pele diariamente. sim 1 0 4 7 24 36 9,414 0,050não 1 8 1 9 46 65 total 2 8 5 16 70 101 25. estou atento a áreas de hiperemia. sim 0 0 3 1 32 36 9,483 0,024não 0 2 0 9 54 65 total 0 2 3 10 86 101 9 cuidados de enfermagem para avaliar, prevenir e tratar a xerose cutânea em pessoas idosas l ronny anderson de oliveira cruz e outros neste estudo, houve uma prevalência de enfermeiros com aproximadamente uma década de atuação na assistência de enfermagem e com título de especialistas. nos últimos, anos têm-se observado um incremento na procura por especializações nos diversos campos do saber em enfermagem, em que se reitera que, para manter a qualidade na prática assistencial, é necessário que os profissionais tenham cada vez mais domínio dos conhecimentos nas áreas de trabalho em que atuam, o que possibilita o atendimento das demandas sociais e de saúde da população (16). em contrapartida, 65 enfermeiros (64,4 %) relataram não ter nenhum curso referente à prevenção ou ao tratamento de lesões de pele, dado relevante, já que os enfermeiros assumem papel importante no gerenciamento de ações voltadas para o cuidado de pessoas durante a avaliação, a prevenção e o tratamento destas lesões. assim, ao se observar a importância em ter ou não curso específicos para cuidados com a pele, é possível inferir a necessidade de educação continuada e permanente como pontos fundamentais para melhorar a qualidade dos cuidados. ter cursos na área de prevenção e tratamento de lesões de pele nunca quase nunca às vezes quase sempre sempre total x 2 p-valor 28. proporciono higiene íntima sempre que necessário. sim 3 0 1 8 24 36 8,145 0,043não 0 0 1 8 56 65 total 3 0 2 16 80 101 30. discuto com a equipe de enfermagem a necessidade de aumentar a hidratação oral ou parenteral. sim 3 2 11 8 12 36 18,252 0,001não 0 4 4 18 39 65 total 3 6 15 26 51 101 32. oriento a equipe de enfermagem em relação à temperatura da água. sim 6 0 6 12 12 36 11,991 0,007não 2 0 5 16 42 65 total 8 0 11 28 54 101 33. oriento a equipe de enfermagem em relação ao uso do sabonete adequado. sim 7 4 10 4 11 36 12,083 0,017não 4 4 9 22 26 65 total 11 8 19 26 37 101 34. oriento para o autocuidado. sim 0 0 6 2 28 36 12,117 0,007não 0 3 2 16 44 65 total 0 3 8 18 72 101 fonte: elaboração própria. 10 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1943 aquichan issn 1657-5997 eissn 2027-5374 nessa perspectiva, há que se considerar que apenas oito dos 34 itens listados independem do enfermeiro ter ou não curso na área de prevenção e tratamento de lesões de pele, o que reforça que avanços científicos na enfermagem e na saúde exigem conhecimentos específicos e habilidades, bem como ressalta a importância que os enfermeiros devem ter em se manter atentos e presentes em programas de aperfeiçoamento/qualificação para que o cuidado prestado seja efetivo e eficaz (17). dos participantes, 85 (84,2 %) afirmaram sempre considerar a faixa etária da pessoa idosa, e esse resultado corrobora com a afirmação de vários autores sobre a relação entre a idade avançada e o surgimento de lesões de pele. estudo realizado no hospital de clínicas do triângulo mineiro, brasil, revelou que 44 % dos idosos internados nas unidades de clínica médica ou cirúrgica apresentavam algum tipo de lesão cutânea (18). sobre isso, neste estudo, 70 enfermeiros (69,3 %) afirmaram sempre realizar a inspeção diária das condições da pele dos idosos. esse cuidado permite a prevenção de lesões, já que uma avaliação criteriosa direciona para a implementação de medidas eficazes (19). a avaliação da coloração da pele foi apontada como um cuidado realizado por 84 (83,2 %) enfermeiros, bem como sempre estar atento às áreas com hiperemia, apontado por 86 (85,1 %) participantes. com o avançar da idade, ocorre a redução do número de melanócitos e, consequentemente, o surgimento de manchas hipocrômicas, bem como a formação de sardas que surgem no rosto e no corpo, sobretudo naqueles com pele muito clara. com frequência, há a presença de melanose, hiperemia, palidez, cianose, icterícia e dermatografismo. em situações mais graves e na presença de complicações sistêmicas, a coloração pode sinalizar estados necróticos (2). um quantitativo de 65 (64,4 %) dos enfermeiros consideraram sempre avaliar o turgor e a elasticidade da pele da pessoa idosa. estudo propôs construir uma escala que avaliasse o turgor da pele de idosos em são paulo utilizada pelos profissionais de saúde com finalidade de avaliar a hidratação cutânea. a água que hidrata a pele provém da epiderme e da derme e evapora-se a partir de um fenômeno denominado “perda de água transepidérmica”. já o manto hidrolipídico permite a manutenção da hidratação e previne o ressecamento. uma pele hidratada tem um turgor normal, representado por maciez, elasticidade e suavidade, que estão relacionadas ao teor de umidade no estrato córneo (20). no que se refere ao excesso de umidade, 64 (63,4 %) enfermeiros disseram que este é um cuidado que nunca deixam de considerar em relação à assistência ao idoso com xerose cutânea, bem como 66 (65,3 %) afirmaram sempre estar atentos às áreas de maceração. essa condição é corroborada com os resultados de um estudo de validação de conteúdo do diagnóstico de enfermagem “risco de úlcera por pressão”, em que 24 especialistas em cuidados com a pele apontaram a umidade como um fator de risco muito importante, principalmente quando relacionada à urina e às fezes, às forças de abrasão, à fricção e ao cisalhamento, que aumentam a maceração e predispõem à ulceração (21). a termorregulação ocorre, principalmente, através de centros regulatórios da temperatura localizados no hipotálamo e pela circulação cutânea, que contribui como isolante de calor variável. quanto mais próxima da pele, maior a troca de calor, o que caracteriza um benefício em ambiente quente e uma perda no frio. na pessoa idosa, com a diminuição da espessura da camada da pele associada ao ressecamento, observa-se que a regulação se torna menos eficiente (22). assim, 58 (57,4 %) enfermeiros disseram sempre observar a temperatura e 53 (52,5 %), estar atentos à exposição ao frio. estudo realizado, em berlim, alemanha, com 280 idosos residentes em instituições de longa permanência concluiu que, de um total de 60 doenças dermatológicas, a xerose cutânea foi a mais frequente, o que perfaz um total de 99,1 % destas (23). a xerose cutânea tem como características morfológicas: pele pruriginosa, seca, com presença de fissuras e descamação, o que reitera a importância dada por 54 (53,5 %) enfermeiros no que concerne a sempre buscar a existência de rachaduras, a 62 (61,4 %) que observam a presença de descamação e a 64 (63,4 %) que sempre observam a presença de prurido. neste estudo, 76 (75,2 %) participantes disseram que sempre identificam o risco de lesões associadas ao ressecamento da pele, e 91 (90,1 %) observam a existência de lesões. estudo realizado em curitiba, brasil, com 19 enfermeiros assistenciais sobre o exame físico de pessoas idosas hospitalizadas, revelou que a avaliação da integridade da pele foi o item mais referido pelos enfermeiros e, nesta, são consideradas características como umidade, textura, 11 cuidados de enfermagem para avaliar, prevenir e tratar a xerose cutânea em pessoas idosas l ronny anderson de oliveira cruz e outros espessura, temperatura, elasticidade, sensibilidade e presença de lesões nas diversas regiões do corpo. o estado da pele demonstra os sinais de envelhecimento a partir da perda do tecido de sustentação, da gordura subcutânea, da diminuição de pelos, das glândulas sudoríparas e sebáceas, deixando-as mais propensas a lesões e a processos infecciosos (24). dos entrevistados, 84 (83,2 %) afirmaram que nunca utilizaram equipamento importado para avaliar a hidratação da pele de pessoas idosas. estudo realizado por farmacêuticas do estado de são paulo, brasil, apontou quatro instrumentos disponíveis do mercado: o corneometer cm 825, que se baseia no princípio da capacitância, o skincon 200 ex e o dermalab, que se baseiam no princípio da condutância, e, por fim, o nova derm phase meter dpm 9003, que utiliza o método da impedância. o corneometer cm 825 tem se mostrado como o mais eficaz para avaliar a pele seca (25), no entanto, mesmo na ausência de equipamentos específicos, 70 (69,3 %) enfermeiros afirmaram que realizam a inspeção diária das condições da pele. já 80 (79,2 %) enfermeiros disseram sempre registrar os achados em relação às condições da pele da pessoa idosa. o registro de enfermagem é um dos meios de comprovar a prestação dos cuidados e um indicador de qualidade da assistência. assim, o preenchimento incorreto e, sobretudo, a falta de periodicidade são fatores que impossibilitam, de forma irreversível, processos avaliativos, de certificação e até mesmo sindicâncias periciais que possam, inclusive, amparar juridicamente o profissional e a instituição (14). para 54 (53,5 %) enfermeiros, é importante sempre considerar as alterações observadas durante a avaliação para escolher o tipo de hidratante, o que pode ter justificado a variabilidade de respostas no tocante aos produtos utilizados. estudo realizado com 50 pacientes com idade entre 61 e 70 anos verificou que 39,3 % utilizavam ácidos graxos essenciais para prevenir ou tratar lesões cutâneas (26). neste estudo, houve destaque para produtos à base de aloe vera, citados por 40 (39,6 %) entrevistados. no tocante às orientações para a realização do autocuidado, 78 (77,2 %) enfermeiros enfatizaram as questões de higiene corporal e 80 (79,2 %) a higiene íntima, bem como 54 (53,4 %) consideraram orientar a equipe de enfermagem acerca da temperatura da água. o banho com água quente deve ser evitado, uma vez que reduz a oleosidade natural e piora a condição do ressecamento; além disso, atentaram para o uso do sabonete com ph ácido, que é o mais recomendando, já que apresenta menor efeito deletério na microbiota cutânea (27). em berlim, estudo realizado em hospitais e instituições de longa permanência (ilps) com 835 sujeitos observou que 48,8 % das pessoas idosas apresentavam pele seca, com uma prevalência maior nas ilps e destaque para as áreas dos pés e pernas, o que ressalta a importância de realizar intervenções voltadas para o autocuidado (28). conclusões o estudo possibilitou analisar como enfermeiros atuantes em clínica médica e uti têm realizado o cuidado de enfermagem para avaliar, prevenir e tratar a xerose cutânea em pessoas idosas. dentre os cuidados, destacam-se a importância em considerar a faixa etária, avaliar a coloração da pele, estar atento às áreas com hiperemia e observar a existência de lesões. a valorização do olhar voltado à existência de lesões de pele reforça o modelo curativista e faz um contraponto com os cuidados preventivos, reforçado pela ausência de equipamentos que podem colaborar com a avaliação do grau de hidratação e o estabelecimento de condutas. com uma média de formação profissional aproximada de 10 anos e com a maioria dos participantes sem cursos de prevenção ou tratamento de lesões de pele, infere-se que a vivência e a construção de conhecimentos durante o exercício profissional podem ter contribuído para melhores escores relacionados a alguns itens do instrumento, bem como para o desenvolvimento das tecnologias digitais. no entanto, ao se observar a relevância em ter ou não cursos específicos para cuidados com a pele, conclui-se que há a necessidade de educação permanente com a finalidade de melhorar a qualidade dos cuidados. outro aspecto importante encontra-se na carência de instrumentos ou protocolos validados para o processo de cuidar em enfermagem voltados às condições de ressecamento da pele em pessoas idosas. assim, espera-se que este estudo possa contribuir para o direcionamento das intervenções, bem como para a realização de novas pesquisas e para a criação de protocolos. 12 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1943 aquichan issn 1657-5997 eissn 2027-5374 limitações do estudo uma limitação do estudo a ser considerada foi a amostragem que, apesar de ser significativa, sinaliza para a necessidade de uma amostra com a finalidade de transpor barreiras geográficas e possibilitar um diagnóstico real e ampliado. cabe ainda salientar que, em se tratando dos cuidados para as pessoas idosas com xerose cutânea, há uma tímida produção científica sobre a temática nos países da américa latina, onde é possível inferir que estudos realizados em escalas amostrais maiores poderão dirimir resultados influenciados por questões culturais, de formação acadêmica e econômicas inerentes a cada região. conflito de interesse: nenhum declarado. referências 1. pagliuca lmf, lima bs, silva jm, cavalcante lm, martins mc, araújo tl. access of the elderly to primary health care units. reme rev min enferm. 2017;16(21):e-1021. doi: https://doi.org/10.5935/1415-2762.20170031 2. fortes tml, suffredini ib. skin evaluation in elderly: literature review. j. health sci. inst. 2014 [cited 2019 jan 12];32(1):94-101. available from: http://www.unip.br/comunicacao/publicacoes/ics/edicoes/2014/01_jan-mar/v32_ n1_2014_p94a101.pdf 3. onselen jv. dry skin condition: an evidenced-based focus on natural oatmeal emollients. prim. health care. 2011;21(2):31-8. doi: https://doi.org/10.7748/phc2011.03.21.2.31.c8363 4. costa a, pires mc, fabrício lhz, torloni lbo, langen s, botero eb. multicenter clinical study to evaluate safety and clinical efficacy of a body moisturizer based on ceramides, omegas, glycerin, 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de 2012. dispõe sobre diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. brasília (df): ministério da saúde; 2012 [citado 17 set. 2018]. disponível em: http://conselho.saude.gov.br/resolucoes/2012/reso466.pdf 14. melo ma, campos pmbgm. técnicas para avaliar a hidratação e a oleosidade da pele. cosmet. toiletries. 2016 [citado 29 nov. 2018];28(2):30-4. disponível em: http://www.cosmeticsonline.com.br/ct/painel/class/artigos/uploads/0b33c-282_ edmar_abr-2016.pdf https://doi.org/10.5935/1415-2762.20170031 http://www.unip.br/comunicacao/publicacoes/ics/edicoes/2014/01_jan-mar/v32_n1_2014_p94a101.pdf http://www.unip.br/comunicacao/publicacoes/ics/edicoes/2014/01_jan-mar/v32_n1_2014_p94a101.pdf https://doi.org/10.7748/phc2011.03.21.2.31.c8363 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ge, severob pc, richterc sa, santos ep, santos vcf, duartef êrm. gerenciamento do cuidado de enfermagem com lesões de pele no contexto rural: percepções de enfermeiros. rev. atenção saúde 2018;16(55):5-13. doi: https:// doi.org/10.13037/ras.vol16n55.4832 18. chavaglia srr, ohl rib, ferreira la, santiago vr, abdanur af, soares as. characterization of patients with cutaneous lesion in hospitalization medical surgical units. rev enferm ufpe online. 2015;9(1):183-92. available from: https:// periodicos.ufpe.br/revistas/revistaenfermagem/article/view/10324 19. vieira cpb, sá ms, madeira mza, luz mhba. caracterização e fatores de risco para úlceras por pressão na pessoa idosa hospitalizada. rev rene. 2014;15(4):650-8. doi: https://doi.org/10.15253/2175-6783.2014000400012 20. giaretta vma, silva ams, renó acm, aguiar daf, arantes cms, posso mbs. proposta de escala para avaliar o turgor da pele em idosos. rev ciên saúde. 2016 [citado 30 nov. 2018];1(1):1-7. disponível em: http://revistaeletronicafunvic.org/ index.php/c14ffd10/article/view/7 21. santos ct, almeida ma, lucena, af. the nursing diagnosis of risk for pressure ulcer: content validation. rev. latinoam. enferm. 2016;24:e2693. doi: https://doi.org/10.1590/1518-8345.0782.2693 22. blatteis cm. age-dependent changes in temperature regulation — a mini review. gerontology. 2012;58:289-95. doi: https://doi.org/10.1159/000333148 23. hahnel e, blume-peytavi u, trojahn c, dobos g, jahnke i, kanti v et al. prevalence and associated factors of skin diseases in aged nursing home residents: a multicentre prevalence study. bmj open. 2017;7(9):e018283. doi: https://doi. org/10.1136/bmjopen-2017-018283 24. majczak já, hohl m. the physical nursing examination of the hospitalized older adult. cogitare enferm. 2015;20(2):31624. doi: https://doi.org/10.5380/ce.v20i2.39888 25. gardona rgb, ferracioli mm, salomé gm, pereira mtj. assessing the quality of records in the dressing charts, performed by nursing. rev. bras. cir. plást. 2013 [cited 2018 nov 27];28(4):686-92. available from: http://www.rbcp.org.br/ details/1460/avaliacao-da-qualidade-dos-registros-dos-curativos-em-prontuarios-realizados-pela-enfermagem 26. chibante clp, santo fhe, santos td. perfil de clientes hospitalizados com lesões cutâneas. rev. cuba. enferm. 2015 [citado 27 nov. 2018];31(4):1-13. disponível em: http://www.revenfermeria.sld.cu/index.php/enf/article/view/895 27. garbaccio jl, ferreira ad, pereira algg. self-skincare knowledge and practice described by elderly persons in the mid-west of minas gerais. rev. bras. geriatri. gerontol. 2016;19(1):45-56. doi: https://doi.org/10.1590/18099823.2016.14237 28. lichterfeld a, lahmann n, blume-peytavi u, kottner j. dry skin in nursing care receivers: a multi-centre cross-sectional prevalence study in hospitals and nursing homes. int j nurs stud. 2016;56(1):37-44. doi: https://doi.org/10.1016/j. ijnurstu.2016.01.003 https://doi.org/10.1590/1983-1447.2016.esp.68435 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http://portal.revistas.bvs.br/transf.php?xsl=xsl/titles.xsl&xml=http://catserver.bireme.br/cgi-bin/wxis1660.exe/?isisscript=../cgi-bin/catrevistas/catrevistas.xis|database_name=titles|list_type=title|cat_name=all|from=1|count=50&lang=pt&comefrom=home&home=false&task=show_magazines&request_made_adv_search=false&lang=pt&show_adv_search=false&help_file=/help_pt.htm&connector=et&search_exp=can fam physician http://portal.revistas.bvs.br/transf.php?xsl=xsl/titles.xsl&xml=http://catserver.bireme.br/cgi-bin/wxis1660.exe/?isisscript=../cgi-bin/catrevistas/catrevistas.xis|database_name=titles|list_type=title|cat_name=all|from=1|count=50&lang=pt&comefrom=home&home=false&task=show_magazines&request_made_adv_search=false&lang=pt&show_adv_search=false&help_file=/help_pt.htm&connector=et&search_exp=can fam physician https://doi.org/10.1590/1518-8345.0782.2693 https://doi.org/10.1159/000333148 https://doi.org/10.1136/bmjopen-2017-018283 https://doi.org/10.1136/bmjopen-2017-018283 https://doi.org/10.5380/ce.v20i2.39888 http://www.rbcp.org.br/details/1460/avaliacao-da-qualidade-dos-registros-dos-curativos-em-prontuarios-realizados-pela-enfermagem http://www.rbcp.org.br/details/1460/avaliacao-da-qualidade-dos-registros-dos-curativos-em-prontuarios-realizados-pela-enfermagem http://www.revenfermeria.sld.cu/index.php/enf/article/view/895 https://doi.org/10.1590/1809-9823.2016.14237 https://doi.org/10.1590/1809-9823.2016.14237 https://doi.org/10.1016/j.ijnurstu.2016.01.003 https://doi.org/10.1016/j.ijnurstu.2016.01.003 1 alicia elizabeth hermosilla-ávila1 olivia inés sanhueza-alvarado2 intervención de acompañamiento humanizado de enfermería y calidad de vida en personas con cáncer avanzado 1 orcid.org/0000-0002-5532-1755. departamento de enfermería, universidad del bío bío, chile. ahermosilla@ubiobio.cl 2 orcid.org/0000-0002-0184-8957. facultad de enfermería, universidad de concepción, chile. osanhue@udec.cl recibido: 15/02/2019 enviado a pares: 19/03/2019 aceptado por pares: 28/05/2019 aprobado: 12/06/2019 doi: 10.5294/aqui.2019.19.3.3 para citar este artigo / para citar este artículo / to reference this article hermisilla-ávila ae, sanhueza-alvarado oi. intervention of humanized nursing accompaniment and quality of life in people with advanced cancer. aquichan 2019; 19(3): e1933. doi: https://doi.org/10.5294/aqui.2019.19.3.3 resumen objetivo: evaluar el efecto de una intervención de acompañamiento humanizado de enfermería en domicilio, en la calidad de vida de las personas con cáncer avanzado y su cuidador familiar. método: estudio pre-experimental con medición pre y post intervención. la intervención incluyó visitas domiciliarias, plataforma de internet y contacto telefónico por tres meses. la muestra fue de diecisiete diadas paciente-cuidador. el análisis de los datos fue descriptivo y correlacional. resultados: se obtuvo una magnitud grande del efecto de la intervención en la salud global de la persona con cáncer, con diferencias altamente significativas entre la pre y la post intervención, además de la diminución de síntomas como la fatiga y la disnea. en los cuidadores, hubo una magnitud moderada del efecto de la intervención año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1933 tema: cuidado crónico. aporte a la disciplina: en la atención de pacientes con patologías crónicas, los profesionales de enfermería amplían y utilizan las redes asistenciales para generar sinergias y una mejoría de los procesos de atención, con lo cual fortalecen el contacto permanente con la familia y la persona. en este proceso, el compromiso ético con la humanización es continuo; se valora a la persona en su totalidad: en su entorno familiar, social, económico y laboral, lo que permite guiar los cuidados con eficiencia para mejorar la calidad vida de las personas con cáncer avanzado y su familia. se aúna la atención de calidad con la incorporación de elementos tecnológicos, que, lejos de deshumanizar, contribuyen a la relación transpersonal paciente-familia-profesional de enfermería. el acompañamiento permanente humanizado favorece la gestión del cuidado centrado en las personas, con énfasis en los cuidados paliativos, en intervenciones orientadas al bienestar particular de la persona y su familia, basadas en fundamentos teóricohumanistas, mediante la aplicación de un proceso de enfermería con valoración y diagnóstico individualizado, lo que contribuye a los objetivos sanitarios internacionales, destinados a mejorar la calidad de vida de la persona con cáncer y del cuidador familiar, a pesar del avance inevitable de la enfermedad. https://orcid.org/0000-0002-5532-1755 mailto:ahermosilla@ubiobio.cl https://orcid.org/0000-0002-0184-8957 mailto:osanhue@udec.cl https://doi.org/10.5294/aqui.2019.19.3.3 https://orcid.org/0000-0002-5532-1755 https://orcid.org/0000-0002-0184-8957 https://doi.org/10.5294/aqui.2019.19.3.3 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1933 en la calidad de vida, en los ámbitos de relaciones sociales y ambiente, con diferencias altamente significativas entre la pre y la post intervención. conclusión: una intervención de cuidado humanizado de enfermería, que refuerza y reafirma las áreas sociales, afectivas, espirituales y comunicacionales en la diada paciente-cuidador familiar, aumenta la calidad de vida de las personas con cáncer avanzado y la de sus cuidadores. palabras clave (fuente: decs) neoplasia; calidad de vida; cuidado de enfermería; cuidado de hospicio; intervención. intervention of humanized nursing accompaniment and quality of life in people with advanced cancer abstract objective: to assess the effect of an intervention of humanized nursing accompaniment, at home, on the quality of life of people with advanced cancer and of their family caregivers. method: pre-experimental study with preand post-intervention measurements. the intervention included home visits, internet platform, and telephone contact for three months. the sample was comprised of 17 patientcaregiver dyads. the data analysis was descriptive and correlational. results: the study obtained a large magnitude of the effect of the intervention, in the global health of the person with cancer, with highly significant differences between the preand post-intervention, besides the decrease of symptoms, like fatigue and dyspnea. in the caregivers, there was moderate magnitude of the effect of the intervention on quality of life, in the settings of social relationships and environment, with highly significant differences between the preand post-intervention. conclusion: a humanized nursing care intervention, which reinforces and reaffirms the social, affective, spiritual, and communication areas in the patient-family caregiver dyad, increases the quality of life of people with advanced cancer and that of their caregivers. keywords (source: decs): neoplasia; quality of life; nursing care; hospice care; intervention. 3 intervención de acompañamiento humanizado de enfermería y calidad de vida en personas con cáncer avanzado l alicia elizabeth hermosilla-ávila y otro intervenção de acompanhamento humanizado de enfermagem e calidad de vida em pessoas con cáncer avançado resumo objetivo: avaliar o efeito de uma intervenção de acompanhamento humanizado de enfermagem em domicílio, na qualidade de vida das pessoas com câncer avançado e cuidador familiar. metodo: estudo pré-experimental com medição pré e pós intervenção. a entrevista inclui visitas domiciliares, plataforma de internet e telefone por 3 meses. la muestra fue de 17 diadas paciente-cuidador. a análise dos dados foi descritiva e correlacional. resultados: uma grande magnitude do efeito da intervenção global de saúde da pessoa com câncer foi obtida, com diferenças altamente significativas entre o pré e o pós-intervenção, além da diminuição de sintomas como fadiga e dispneia. nos cuidadores, houve moderada magnitude do efeito da intervenção na qualidade de vida, nas áreas de relações sociais e meio ambiente, com diferenças altamente significativas entre o pré e pós-intervenção. conclusão: uma intervenção humanizada de cuidados de enfermagem, que reforça e reafirma as áreas social, afetiva, espiritual e de comunicação na família cuidador-paciente, aumenta a qualidade de vida das pessoas com câncer avançado e de seus cuidadores. palavras-chave (fonte: decs) neoplasia, consciência de vida, cuidado de enfermagem, cuidado no hospício, intervenção. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1933 4 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1933 aquichan issn 1657-5997 eissn 2027-5374 introducción los actuales cambios demográficos, epidemiológicos y de estilos de vida en chile han traído como consecuencia un aumento creciente del número de personas con diagnóstico de cáncer. los factores económicos, sociales y culturales influyen en la incidencia y en la supervivencia del cáncer (1), así como un aumento del promedio de los costos relacionados con su cuidado (2, 3). es tal el impacto provocado por esta patología a escalas nacional y mundial, que ha aumentado la preocupación por mejorar las condiciones y la calidad de vida de las personas aquejadas por esta enfermedad, lo que ha validado al área de la salud como un eslabón potenciador de la calidad de vida de las personas. la organización mundial de la salud (oms) estima que al menos treinta millones de personas en el mundo sufren innecesariamente dolor severo y otros síntomas a causa del cáncer, lo cual obliga a los países a crear programas integrales para controlar la enfermedad (4). en 1980, la oms incorporó los cuidados paliativos como parte del control del cáncer, bajo el argumento de que mejoran la calidad de vida de los pacientes y las familias que se enfrentan a problemas asociados con enfermedades amenazantes para la vida, a través de la prevención y el alivio del sufrimiento, por medio de la identificación temprana y la evaluación y tratamiento del dolor y otros problemas físicos, psicosociales y espirituales. a pesar de que muchos países los han incorporado en sus sistemas de salud, en latinoamérica su cobertura es aún del 10 al 12 %, en zonas urbanas, y del 0 % en zonas rurales, a excepción de países como chile, donde la cobertura es casi del 99 % (5, 6). al respecto, el consejo internacional de enfermería ha establecido que la función de la enfermería es fundamental para brindar cuidados paliativos destinados a reducir el sufrimiento y a mejorar la calidad de vida de las personas durante sus últimos días de vida, así como la de sus familias. dichos cuidados deben incluir una valoración precoz, identificación y gestión del dolor y de las necesidades físicas, sociales, psicológicas, espirituales y culturales (7), equivalente a preocuparse por la experiencia del sujeto (8), abordada desde una perspectiva multidimensional (9). el cáncer, por su gravedad, por constituir una enfermedad estigmatizada y temida por la población, debido al sufrimiento que causa al que la padece y a sus seres queridos, trae como consecuencia numerosas alteraciones en toda la estructura familiar (10), y esto hace necesarios numerosos y complejos cuidados, así como la participación del conjunto del equipo sanitario. el cuidador experimenta una sobrecarga intensa, con repercusiones severas. al tener que entregarse al cuidado, en promedio, por trece o más horas diarias, su bienestar psicológico se ve considerablemente afectado; así, presenta depresión, ansiedad e insatisfacción en áreas fundamentales de su vida personal y familiar (11, 12). desde la enfermería domiciliaria, se hace necesario buscar y evaluar nuevas formas de apoyar el cuidado de las personas con cáncer avanzado, así como de sus familias; formas que promuevan el trato humanizado, con compromiso moral y de protección a la dignidad humana, en condiciones de crisis o vulnerabilidad. por lo anterior, la siguiente investigación tuvo como objetivo evaluar el efecto de una intervención de acompañamiento humanizado de enfermería en domicilio en la calidad de vida de las personas con cáncer avanzado y de su cuidador familiar. cabe agregar que todos los alcances de esta intervención se planificaron con base en el marco teórico que sustenta la investigación, específicamente en su conexión con los factores de cuidado humanizado desarrollados por watson, según se especifica en la tabla 1 (13, 14): método este estudio utilizó un diseño preexperimental de pre y post intervención en un grupo intacto, conformado previamente por los usuarios inscritos en un servicio de salud de atención primaria de cuidados paliativos con diagnóstico de cáncer avanzado, sometidos a una medición pre-intervención, que proporcionó puntuaciones basales y de control de la misma. al final, se realizó una medición post-intervención, con los mismos instrumentos utilizados en la medición basal, y con el análisis de las puntuaciones obtenidas pre y post intervención. la muestra estuvo conformada por un muestreo incidental de todos los usuarios inscritos, mayores de 18 años, en el servicio de cuidados paliativos, en conjunto con sus cuidadores principales. la captación de la muestra y la autorización de la investigación fueron aprobadas por el comité ético-científico del servicio de salud regional, garantizaron la protección de los derechos del paciente y consideraron los aspectos éticos referidos por exequiel emanuel (16). se excluyó a quienes, por sus circunstancias físicas o cognitivas, no estuvieron en condiciones para comprender o responder al instrumento de recolección; a quienes tenían cuidadores 5 intervención de acompañamiento humanizado de enfermería y calidad de vida en personas con cáncer avanzado l alicia elizabeth hermosilla-ávila y otro factores del cuidado consideraciones de la intervención realizada 1. formación de un sistema de valores humanísticos y altruistas. entrega de un cuidado amable y ecuánime. visitas domiciliarias frecuentes con base en un plan de cuidados que respetó la multidimensionalidad de la persona y su familia. entrega de cuidados de calidad. cuidado de enfermería no taxativo, con una planificación personalizada, con tiempos y acciones individualizadas. 2. instilación de fe y esperanza. en cada visita domiciliaria, se otorgó cuidado, promoviendo fe y esperanza. promoción de conductas orientadas al bienestar y a una mejor calidad de vida. se motivó la adherencia a la intervención en el seguimiento de las recomendaciones. 3. cultivo de la sensibilidad hacia uno mismo y hacia los demás. identificación de sentimientos de la persona y de su familia. promoción de la aceptación de la enfermedad por parte de la persona y de su familia. desarrollo de cuidados holísticos, ante el imperativo de cubrir las necesidades reales de la persona. 4. desarrollo de una relación de cuidados humanos de ayuda y de confianza. mejoramiento de la confianza familia-enfermera con visitas domiciliarias frecuentes. relación de cuidados transpersonales. comunicación efectiva y continua mediante una plataforma web y vía telefónica. 5. promoción y aceptación de la expresión de sentimientos positivos y negativos. actividades orientadas al reconocimiento de las manifestaciones emocionales. comprensión intelectual y emocional de la situación de salud. trato y plan de cuidado según las particularidades de cada persona y familia. 6. uso sistemático del método científico para la resolución de problemas y toma de decisiones. manejo de cada visita domiciliaria con planificación de enfermería. uso de procesos creativos e individualizados. 7. promoción de la enseñanza y el aprendizaje transpersonal. promoción de actividades educativas especialmente diseñadas para la persona y su familia. plataforma web con contenidos educativos adecuados a las situaciones más frecuentes de cuidado de la persona con cáncer avanzado. 8. creación de un entorno de apoyo o conexión mental, física, sociocultural y espiritual. evaluación continua del bienestar de la persona y de su familia a través de visitas domiciliarias y consultas telefónicas. educación para la creación conjunta de un entorno correcto. 9. ayuda a la satisfacción de las necesidades humanas. valoración de necesidades con ficha guía. planificación del cuidado de enfermería en domicilio según estándares nanda-i. 10. aceptación de fuerzas existenciales y fenomenológicas. estimulación de la mejor comprensión y afrontamiento de la situación de salud actual, de las posibles complicaciones, la muerte y el duelo. tabla 1. factores de cuidado y sustentos de la intervención fuente: elaboración propia con base en los factores del cuidado de j. watson (15). no familiares o fueran remunerados; y a aquellos que se negaron a participar. obtenido el consentimiento informado, diecisiete diadas paciente-cuidador completaron y concluyeron su participación en el estudio, con una permanencia de tres meses en la intervención de acompañamiento humanizado de enfermería. los encuentros entre la investigadora, las familias y sus pacientes se dieron en el contexto del hogar, donde se recolectaron las mediciones basales o de control del estudio. a las diecisiete diadas participantes, se les aplicó un cuestionario sociodemográfico y de salud, y cuestionarios de calidad de vida relacionada con la salud, validados anteriormente a escala nacional: la european organization for research and treatment of cancer (eortc qlq30) (17), aplicado a las personas con diagnóstico de cáncer, y el world health organization of the abbreviated quality of life (whoqol-bref) (18), aplicado a los cuidadores familiares. estos cuestionarios se aplicaron con una medición inicial —al ingresar al estudio— y una medición final —a los tres meses de la intervención de enfermería de acompañamiento humanizado, intervención que se describe más adelante—. asimismo, nuevamente se determinó la confiabilidad de los cuestionarios para la corroboración de los mismos en el contexto del estudio, por medio del alfa de cronbach, estimando una alta confiabilidad para valores cercanos a 1, y una baja para aquellos menores de 0,5 (19). en el análisis de los datos, con el objeto de una mejor descripción y discusión de los resultados de calidad de vida, cada dimensión y puntaje global fue estandarizado a una escala de 0 a 6 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1933 aquichan issn 1657-5997 eissn 2027-5374 100, donde el resultado fluctúa entre peor calidad de vida, para puntajes cercanos a 0, y mejor calidad de vida, para aquellos valores cercanos a 100. para probar las hipótesis del estudio, se analizó la información mediante comparación de medias para t-student, para una muestra relacionada en aquellas variables con distribución normal, y comparación de tendencias de distribución con prueba de wilcoxon, en las variables no paramétricas, especialmente para medir diferencias entre la pre y la post intervención, lo cual determinó diferencias significativas para valores p menores de 0,05, y altamente significativas para valores menores de 0,01. finalmente, para conocer la magnitud del efecto de la intervención en la calidad de vida en la diada, se procedió a probar estadísticamente la cuantificación de la relevancia del efecto obtenido (pequeño, moderado o grande) en esta variable, a través de la d de cohen, que representa el número de desviaciones típicas que separan las mediciones pre y post intervención, en cada dimensión evaluada por los cuestionarios de calidad de vida, tanto en los aplicados en la persona con diagnóstico de cáncer, como en las efectuadas al cuidador familiar, donde el tamaño del efecto pequeño considera una d de cohen de 0,2; del efecto mediano, de 0,5; y del efecto grande, de 0,8 (19). intervención de acompañamiento humanizado el objetivo general de la intervención fue otorgar acompañamiento humanizado de cuidado de enfermería en el domicilio. se hizo énfasis en cubrir las necesidades multidimensionales y particulares de la persona con cáncer y su familia, a través de visitas domiciliarias; capacitar al cuidador familiar en la procuración de los cuidados paliativos del ámbito de la enfermería que requiriera la persona con cáncer avanzado; enseñar los cuidados según las necesidades de la persona con cáncer avanzado, a través de material audiovisual disponible en la plataforma en internet; y brindar acompañamiento humanizado de modo constante, promoviendo una comunicación efectiva, de manera presencial y vía telefónica, una vez por semana, con la persona con cáncer o su familia. la intervención de acompañamiento reúne estrategias didácticas de enseñanza-aprendizaje que complementan la atención habitual de los programas de gobierno que recibían las personas con cáncer avanzado y su familia en el programa de alivio del dolor y cuidados paliativos. en la figura 1, se observa el protocolo implementado, con las temáticas de cuidados abordadas por mes, además de su conexión con el programa al que pertenecían. cada sesión de consejería se realizó a través de la entrevista personal, como método para la comunicación de la información, contenidos, actitudes y conductas al paciente con cáncer y al cuidador familiar principal —así como de enseñanza-práctica—, fomentando la participación, adaptación de los contenidos a las preferencias o necesidades familiares, con interacción continua, basada en la relación transpersonal enfermera-paciente-cuidador de jean watson (15). además, la intervención contó con el apoyo de contenidos audiovisuales, por medio de una plataforma en internet adaptable a formato web, tablet y celular, con el fin de proporcionar información general y aspectos concretos solicitados por los pacientes y sus cuidadores respecto a cuidados específicos de enfermería, en la persona con cáncer avanzado, y de autocuidado, para el cuidador familiar. se incorporó la telefonía móvil, para resolver consultas imprevistas, y un libro de notas, como registro para perfeccionar los planes individualizados de enfermería. con el fin de fortalecer el acompañamiento humanizado de enfermería, se utilizaron tres metodologías principales: consejería de enfermería en domicilio, para reducir el impacto emocional en las personas y su familia frente a situaciones de crisis asociadas al diagnóstico de cáncer avanzado; crear espacios de comunicación en el interior de la familia; fomentar la adherencia al tratamiento; ayudar al control y abordaje de problemas y necesidades específicas en la persona con cáncer avanzado, así como al cuidado brindado por la familia y abordado desde la perspectiva de enfermería. consejería en línea con plataforma educativa, destinada a ser una herramienta audiovisual de apoyo en los cuidados durante el proceso final de la vida. es un material en el que se visualizan los cuidados generales de enfermería más frecuentes para el acompañamiento de personas con cáncer avanzado. contacto telefónico, destinado a fortalecer la comunicación interpersonal, afianzar la relación transpersonal persona con cáncer-cuidador-profesional de enfermería y brindar acompañamiento a distancia. 7 intervención de acompañamiento humanizado de enfermería y calidad de vida en personas con cáncer avanzado l alicia elizabeth hermosilla-ávila y otro figura 1. protocolo de intervención fuente: elaboración propia. la consejería de enfermería se realizó por medio de tres visitas domiciliarias al mes por familia, para abordar temáticas según lo valorado en cada una, durante un periodo de tres meses. la planificación de actividades fue específica y acotada a la realidad familiar; muchas actividades se enfocaban solo en algunos de los aspectos de los cuidados paliativos, lo cual estableció una consejería dinámica y cambiante en cada visita, e incluso en cada momento dentro de la misma. en cada visita, se realizó una valoración inicial, según el contexto global de la persona y de su familia, a través de diagnósticos de enfermería detectados en las personas con cáncer avanzado, como dolor, sufrimiento espiritual, riesgo de caídas, riesgo de úlceras por presión, inmovilidad, alteración de la nutrición, deshidratación, entre otros, con objetivos a corto plazo. se ejecutaron y se delegaron los cuidados al familiar encargado, según las prioridades, con evaluación posterior directa, y, finalmente, evaluando cada cuidado en el proceso y resultado (20-22). 8 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1933 aquichan issn 1657-5997 eissn 2027-5374 resultados la tabla 2 describe el total de las intervenciones y las consejerías efectuadas, según los requerimientos de las personas con cáncer y su cuidador, luego de realizada la valoración y el diagnóstico de enfermería. tabla 2. características operativas de intervención de acompañamiento humanizado hacia las personas con diagnóstico de cáncer avanzado y el cuidador familiar de enfermería. en su mayoría, consumían medicamentos para el dolor y no requerían fármacos o algún suplemento natural para conciliar el sueño. en relación con los cuidadores familiares, estos, en su mayoría, eran mujeres adultas mayores de 65 años, pensionadas, con pareja, de escolaridad media, de religión católica y completamente autónomas en los cuidados diarios de la persona con cáncer avanzado. no mostraron presencia de dolor, y, a pesar de que prácticamente la mitad padecía enfermedades crónicas, solo una fracción de presentaba adherencia al medicamento indicado para su enfermedad. resultados pre-intervención de manera previa a la intervención, la calidad de vida relacionada con la salud de las personas con diagnóstico de cáncer avanzado, en la subescala de salud global, se mostró en el puntaje medio, sin inclinación a una baja o a una alta valoración, mientras que las dimensiones con más baja calidad de vida se relacionaron con el rol emocional, evidenciado por la percepción de sentirse preocupado, nervioso, irritado o deprimido, junto a la función cognitiva, en los niveles de concentración y memoria. los síntomas con alto puntaje, referidos a mala calidad de vida y relacionados con la patología, fueron la fatiga y la disnea. en esta medición, el cuestionario presentó alta confiabilidad (alpha de cronbach: 0,892). en los cuidadores familiares, la medición se acercó, en su mayoría, a valoraciones de muy buena calidad de vida global y muy satisfactoria salud global. la dimensión de salud física presentó el mejor perfil de calidad, y las relaciones sociales, la peor valoración. en esta medición, el cuestionario presentó alta confiabilidad (alpha de cronbach: 0,936). resultados post intervención durante tres meses, la intervención de acompañamiento humanizado de enfermería contempló las tres modalidades de consejerías (visitas domiciliarias, visitas al contenido en línea y llamadas telefónicas) para contactarse con el paciente y con el familiar encargado, con el objetivo de satisfacer las necesidades básicas y espirituales de las personas con diagnóstico de cáncer avanzado. aun cuando se realizaron numerosas intervenciones de apoyo al cuidado otorgado por el cuidador en domicilio, las visitas a los recursos en línea fueron mayoritariamente de consulta a los contenidos de cuidados de la persona con cáncer. tipos de consejerías total visitas domiciliarias 82 visitas a los contenidos en línea 66 llamadas 23 consejerías en domicilio total de consejerías efectuadas necesidades básicas 96 afrontamiento 26 espirituales 78 al cuidador 60 final de la vida 17 duelo 6 consejerías vía internet total de enlaces visualizados hacia la persona con cáncer 85 hacia el cuidador familiar 6 fuente: elaboración propia. perfil de los participantes de las diecisiete personas con diagnóstico de cáncer participantes en la investigación, la mayoría eran adultos mayores de 65 años, de sexo femenino, pensionados, sin pareja, de religión católica, y compartían su hogar como familia nuclear. la mayoría conocía su diagnóstico de cáncer —avanzado o terminal— y no presentaba enfermedades crónicas —ni antes ni después de ingresar al programa—. respecto a su nivel educativo, se distribuían homogéneamente en básica, media, técnica y universitaria. en cuanto al estado general de las personas con cáncer avanzado, la escala de performance status reveló que un tercio de los usuarios tenía síntomas leves de la enfermedad y eran autovalentes, mientras que la mayoría ya presentaba signos de postración: reposaban al menos la mitad del día, y necesitaban cuidados ocasionales, parciales o totales por parte de la familia y 9 intervención de acompañamiento humanizado de enfermería y calidad de vida en personas con cáncer avanzado l alicia elizabeth hermosilla-ávila y otro al final de la intervención, la medición de la calidad de vida relacionada con la salud de las personas con diagnóstico de cáncer avanzado resultó orientada hacia la mejor calidad de vida en la escala de salud global, pues algunos síntomas relacionados con la patología disminuyeron: fatiga, disnea y dolor, sin molestias gastrointestinales. la función social también obtuvo una alta calidad de vida. existieron dos dimensiones con baja calidad de vida, específicamente el rol emocional y la función cognitiva. al comparar los resultados pre y post intervención de la calidad de vida y la evolución del efecto de la intervención de acompañamiento humanizado de enfermería de las personas con cáncer avanzado (tabla 3), desde el mes inicial hasta el mes final, hubo una mejoría altamente significativa en la subescala de salud global, valoración que mide la percepción hacia la salud y la calidad de vida, y un efecto de magnitud grande. del mismo modo, existió una mejora en relación con el síntoma de estreñimiento, con una diferencia significativa y un efecto de magnitud grande. también, la percepción de todos los síntomas relacionados con el cáncer por la persona disminuyeron con diferencias significativas para la fatiga, la disnea y la falta de apetito. la comparación pre y post intervención de los cuidadores familiares permitió evaluar el efecto de la intervención de acompañamiento humanizado de enfermería en su calidad de vida, y demostró mejoría de la calidad de vida global, al igual que de la salud global, aunque la diferencia no fue estadísticamente significativa. la salud psicológica mostró una mejoría, con un aumento moderado, una diferencia significativa y el mejor perfil de calidad: se observaron deseos de disfrutar y de dar sentido a la vida, así como una disminución de los sentimientos negativos. respecto a las dimensiones de relaciones sociales y del ambiente —referidas a la valoración del ocio, a la información disponible, a las condiciones de vivienda, al servicio de salud y de transporte— también se observó una mejoría; el aumento en la calidad de vida fue estadísticamente significativo. tabla 3. comparación de la calidad de vida relacionada con la salud de las personas con diagnóstico de cáncer avanzado – eortc qlq – c30 media valor p magnitud del efecto pre (mes 0) post (mes 3) pre v/s post d de cohen escala de salud global 49,5 60,8 <0,001a 0,841* función física 53,7 40,8 0,003 b 0,429 actividades cotidianas 53,9 40,2 0,006 a 0,489 función social 57,8 44,1 0,008 b 0,007 b 0,473 rol emocional 30 14,2 0,084 a 1,001* función cognitiva 26,4 17,6 0,553 fatiga 52,3 39,2 0,012 b 0,473 dolor 39,2 36,3 0,469 a 0,134 náuseas/vómitos 16,7 8,8 0,252 a 0,443 estreñimiento 21,6 5,9 0,023 a 0,856* disnea 54,9 41,2 0,020 a 0,388 anorexia 37,2 17,6 0,033 a 0,672 imp. económico 45,1 35,3 0,025 a 0,414 a 0,312 diarrea 11,8 7,8 0,739 a 0,169 insomnio 33,3 35,3 0,068 fuente: elaboración propia. a con prueba de rangos con signo de wilcoxon. b con prueba de t-student de muestras relacionadas. * tamaño grande de la magnitud del efecto. 10 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1933 aquichan issn 1657-5997 eissn 2027-5374 discusión los resultados del estudio confirman que las unidades de salud de cuidados paliativos tienen un rol fundamental, tanto en los elementos técnicos como en sus elementos humanos (23), que deben proporcionar a la diada paciente-cuidador familiar. se observó que requieren perentoriamente de lo que watson denomina “factores del cuidado” (15). en el proceso llevado a cabo, el compromiso ético con la humanización fue permanente, basado en el factor 4 del cuidado, que habla de desarrollar una relación de cuidados humanos de ayuda y de confianza, que valora a la persona en su totalidad, en su entorno familiar, social, económico y laboral, permitiendo guiar los cuidados con eficiencia para mejorar la calidad de vida de las personas con cáncer avanzado y de su familia. los elementos tecnológicos incorporados contribuyeron a la relación transpersonal paciente-familia-profesional de enfermería, gracias a una comunicación permanente. el acompañamiento humanizado se basó también en el factor 2 del cuidado de watson (15), que llama a infundir fe y esperanza durante el cuidado, lo que en todo momento fue proporcionado. el factor 6, relacionado con el uso sistemático del método científico para la resolución de problemas y la toma de decisiones, fue establecido, aplicando el proceso de enfermería con valoración y diagnóstico individualizado, lo que favorece la gestión del cuidado centrado en las personas, con énfasis en los cuidados paliativos y en intervenciones orientadas al bienestar particular de la persona y de su familia, basadas en fundamentos teórico-humanistas. los factores de cuidado 7, 8 y 9 (15) se aplicaron a través de la promoción, en todo el proceso, de la enseñanza y el aprendizaje transpersonal, creando un entorno de apoyo o conexión mental, física, sociocultural y espiritual, para ayudar a la satisfacción de las necesidades humanas. los objetivos principales de los cuidados paliativos, a escalas nacional e internacional, están dirigidos a mejorar la calidad de vida de los pacientes y sus familias (4, 5, 7, 24), instando a los profesionales a satisfacer las necesidades que surgen durante el cáncer avanzado, así como a hacerse cargo del carácter multidimensional del cuidado. este estudio intentó relevar estas características en la intervención realizada, proporcionando cuidados de enfermería dinámicos y flexibles, desde un enfoque individualizado de la vivencia (4), lo cual mejoró la salud global y disminuyó la percepción de todos los síntomas relacionados con el cáncer por la persona con cáncer, con diferencias significativas para la fatiga, la disnea, la falta de apetito y el estreñimiento. a diferencia de otros estudios, la investigación muestra que las personas con cáncer siguen manteniendo una valoración media de la calidad de vida en la dimensión de función social. el diagnóstico de cáncer avanzado, y la subsiguiente incorporación a cuidados paliativos, es probablemente el inicio de un proceso de sufrimiento personal y familiar, marcado por la proximidad de los últimos días de vida de una persona. en la comprensión de este proceso, se consideró el factor 10 de cuidado (15), relativo a la aceptación de fuerzas existenciales y fenomenológicas: se estimuló una mejor comprensión y afrontamiento de la situación de salud actual, de las posibles complicaciones, la muerte y el duelo, en combinación con la percepción de tener un espacio de tiempo único y trascendente para el paciente y la familia. esto podría generar una experiencia de acompañamiento muy valiosa, siempre y cuando el paciente reciba la implementación oportuna de cuidados, pues se encuentra en una situación de sufrimiento y dolor —en todas las dimensiones que definen al ser humano— que marca profundamente a su familia y seres cercanos. en la dimensión global, la calidad de vida de los cuidadores familiares se mostró muy buena, y en la mayoría de las dimensiones, con una calificación media a buena. la cifra menor se presentó en la dimensión de relaciones sociales, calificación similar a la que ha estimado otro estudio (25), aunque con una menor valoración a la calidad de vida general. ese mismo estudio evidencia, en el caso específico de cuidadores familiares de pacientes dependientes, una calidad de vida mala o muy mala en mayores porcentajes, desde la valoración subjetiva de la misma. dichos valores se relacionan significativamente con las esferas de la energía, el sueño, las relaciones sociales y la emocionalidad. respecto a la baja valoración obtenida en la dimensión social, otro estudio destaca la falta de apoyo en el cuidado, la angustia asociada a su rol de cuidador y los obstáculos que presenta el cuidado para sus relaciones personales y las del hogar. respecto a esta última, se menciona una mayor carga económica (26). aun cuando los familiares manifiestan abiertamente disfrutar de actividades que les permiten desconectarse de las consideraciones del diagnóstico y el pronóstico, reconocen la importancia del apoyo ofrecido por otras personas, pero igualmente no solicitando ayuda para cuidar (27). otra dimensión de importancia, revelada por medio de la vivencia del cuidador, es la psicológica, que denota la importancia 11 intervención de acompañamiento humanizado de enfermería y calidad de vida en personas con cáncer avanzado l alicia elizabeth hermosilla-ávila y otro de su consideración al momento de brindar un cuidado humanizado, establecido primeramente por la apertura ante las expectativas personales y ante la necesidad manifiesta de fortalecer el vínculo, la comunicación, la empatía y el acompañamiento con el profesional de enfermería. asimismo lo refiere otro estudio, según el cual la gestión del bienestar psicológico está dada por las estrategias de afrontamiento del propio paciente y su familia, incluyendo una relación realista, indulgente, de apoyo y de aprendizaje colectivo por parte del profesional (28). en general, son escasas las intervenciones de humanización identificadas en la literatura, dirigidas a las personas con cáncer avanzado, a pesar de que muchas de las orientaciones sanitarias, nacionales e internacionales, buscan cumplir objetivos relacionados con mejorar la calidad de vida del paciente y de su cuidador familiar. por su parte, los profesionales de enfermería son los responsables, en el equipo de salud, de los cuidados paliativos, que han de ser innovadores, basados en la evidencia y en la teoría del cuidado humano (15), en pro de la calidad de vida familiar, y destinados a la ayuda al buen morir y a enfrentar los desafíos de esta etapa. son pocos los países que han establecido programas especializados para proporcionar alivio del dolor y cuidados paliativos (5), aun con la evidencia de que los programas específicos o especializados en cuidados paliativos procuran reducir el sufrimiento y elevar la calidad de vida del paciente y de su familia desde la multidimensionalidad de sus necesidades (6, 7, 9, 29). los beneficios de los cuidados paliativos tempranos demuestran que favorecen la calidad de vida y la disminución de la intensidad de los síntomas, en comparación a las personas con cáncer avanzado que reciben un tratamiento estándar. de la misma manera que este estudio, estos cuidados tempranos muestran un tamaño del efecto pequeño y coinciden con la conclusión de que, en el contexto de la enfermedad avanzada y su pronóstico limitado, este aumento es clínicamente relevante (30). conclusiones en la persona con diagnóstico de cáncer avanzado, luego de la intervención de acompañamiento humanizado de enfermería, que incluía cuidados específicos de enfermería, consejería entregada según sus necesidades básicas, apoyo en el afrontamiento, fortalecimiento espiritual y apoyo recibido a través de los recursos web y telefónico, hubo una mejora significativa y un gran tamaño del efecto en la calidad de vida y en la dimensión particular de salud global, que se observan en la disminución de la percepción de todos los síntomas relacionados con el cáncer (fatiga, disnea, falta de apetito y estreñimiento). los cuidadores familiares, luego de la intervención con consejería complementaria a la del paciente, más las orientadas a los cuidados al final de la vida y al duelo, mejoraron la calidad de vida en las dimensiones de las relaciones sociales y el ambiente, con una magnitud moderada del efecto. a pesar del progreso de la enfermedad hacia estados de deterioro y dependencia, se evidenció que el acompañamiento humanizado de enfermería a las personas con cáncer avanzado y a sus cuidadores logró aumentar, en forma significativa, la calidad de vida de todos los involucrados en la relación de cuidado, al reforzar y reafirmar las áreas sociales, afectivas, espirituales y comunicacionales en la diada paciente-cuidador familiar. conflicto de intereses: ninguno declarado. 12 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1933 aquichan issn 1657-5997 eissn 2027-5374 referencias 1. world health organization. cancer. descried note nº297. who [internet]. 2018. 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http://www.redcronicas.cl/index.php?option=com_docman&task=cat_view&gid=38&itemid=234 https://www.medigraphic.com/pdfs/conamed/con-2017/con174i.pdf 1 chardsongeicyca maria correia da silva melo1 antonio jorge ferreira delgado filho2 emanuela rozeno de oliveira3 andreza amanda de araújo4 heloíza gabrielly de oliveira cavalcanti5 chardsonclesia maria correia da silva melo6 magaly bushatsky7 luiz miguel picelli sanches8 mariana boulitreau siqueira campos barros9 desenvolvimento e avaliação de um aplicativo para os cuidados primários aos usuários com diabetes mellitus 1 https://orcid.org/0000-0001-5878-7641. universidade federal de pernambuco, centro acadêmico de vitória, brasil. chardsongeicyca.melo@ufpe.br 2 https://orcid.org/0000-0002-6935-4857. universidade federal de pernambuco, centro de informática, brasil. 3 https://orcid.org/0000-0002-7341-9983. prefeitura da cidade do recife (secretaria de saúde), brasil. 4 https://orcid.org/0000-0003-4590-9229. universidade federal de pernambuco, centro acadêmico de vitória, brasil. 5 https://orcid.org/0000-0002-9674-4017. universidade de pernambuco, departamento de enfermagem, brasil. 6 https://orcid.org/0000-0002-5245-1554. universidade federal de pernambuco, departamento de ciências médicas, brasil. 7 https://orcid.org/0000-0002-0792-6469. universidade de pernambuco, faculdade de enfermagem nossa senhora das graças, brasil. 8 https://orcid.org/0000-0001-8660-5606. universidade federal de pernambuco, centro acadêmico de vitória, brasil. 9 https://orcid.org/0000-0002-3576-2369. departamento de enfermagem, universidade federal de pernambuco, brasil. recebido: 31/01/2020 submetido: 28/02/2020 aceito por pares: 15/04/2020 aceito: 27/04/2020 doi: 10.5294/aqui.2020.20.2.6 para citar este artículo / to reference this article / para citar este artigo melo cmcs, delgado filho ajf, oliveira er, aráujo aa, cavalcanti hgo, melo cmcs, bushatsky m, sanches lmp, barros mbsc. development and assessment of an application for primary care for users with diabetes mellitus. aquichan. 2020;20(2):e2026. doi: https://doi.org/10.5294/aqui.2020.20.2.6 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2026 temática: promoção e prevenção. contribuição para a disciplina: em paralelo ao progresso do conhecimento em saúde, ressalta-se o caráter inédito deste estudo como inovador na introdução da tecnologia móvel a partir de uma tecnologia leve-dura que contribui para consolidar e fortalecer a enfermagem na atenção primária à saúde, constituindo-se como instrumento de mudanças, sobretudo, na integralidade do cuidado. mesmo diante da abrangência do protocolo no âmbito estadual, caso de pernambuco, brasil, os resultados do estudo propulsam para uma capilarização a outras regiões do brasil, por fomentar a sistematização da assistência de enfermagem e consolidar as práticas de cuidados primários da enfermagem. ademais, a produção tecnológica aumentará o escopo para o embasamento de teorias na área da enfermagem e da tecnologia da informação. https://orcid.org/0000-0001-5878-7641 mailto:chardsongeicyca.melo@ufpe.br https://orcid.org/0000-0002-6935-4857 https://orcid.org/0000-0002-7341-9983 https://orcid.org/0000-0003-4590-9229 https://orcid.org/0000-0002-9674-4017 https://orcid.org/0000-0002-5245-1554 https://orcid.org/0000-0002-0792-6469 https://orcid.org/0000-0001-8660-5606 https://orcid.org/0000-0002-3576-2369 https://orcid.org/0000-0001-5878-7641 https://orcid.org/0000-0002-6935-4857 https://orcid.org/0000-0002-7341-9983 https://orcid.org/0000-0003-4590-9229 https://orcid.org/0000-0002-9674-4017 https://orcid.org/0000-0002-5245-1554 https://orcid.org/0000-0002-0792-6469 https://orcid.org/0000-0001-8660-5606 https://orcid.org/0000-0002-3576-2369 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2026 resumo objetivo: desenvolver um aplicativo sobre cuidados primários de enfermagem aos usuários com diabetes mellitus e avaliar sua usabilidade à luz da teoria unificada de aceitação e uso de tecnologia. materiais e métodos: trata-se de um estudo metodológico, que utilizou uma abordagem quantitativa e de delineamento transversal, a partir do método design instrucional sistemático. o produto foi validado quanto à usabilidade por 11 enfermeiros especialistas, por meio do questionário system usability scale, fundamentado pela teoria unificada de aceitação e uso de tecnologia 2 de venkatesh, thong e xu. resultados: o aplicativo foi desenvolvido por meio de frameworks abertos e sem custo, baseado no conteúdo atualizado do protocolo de enfermagem na atenção primária sobre diabetes mellitus, acrescido da classificação internacional das práticas de enfermagem na saúde coletiva. na avaliação da usabilidade, o aplicativo alcançou um score de 90 pontos, sendo classificado numa escala de melhor alcançável, com dimensões que alicerçam os constructos teóricos. conclusões: a tecnologia denominada “diabetes em foco” apresenta-se promissora para melhorar e avançar o conhecimento teórico-prático, além do acesso rápido e facilitado ao protocolo, do apoio oportuno à tomada de decisões e do fortalecimento da sistematização da assistência de enfermagem na atenção primária à saúde. palavras-chave (fonte: decs) tecnologia da informação; aplicativos móveis; atenção primária à saúde; cuidados de enfermagem; diabetes mellitus. 3 desenvolvimento e avaliação de um aplicativo para os cuidados primários aos usuários com diabetes mellitus l chardsongeicyca maria correia da silva melo e outros desarrollo y evaluación de una aplicación de atención primaria para usuarios con diabetes mellitus resumen objetivo: desarrollar una aplicación de atención primaria de enfermería para usuarios con diabetes mellitus y evaluar la usabilidad a la luz de la teoría unificada de aceptación y uso de la tecnología. materiales y métodos: estudio metodológico, que utilizó un enfoque cuantitativo y transversal, basado en el método de diseño instruccional sistemático. el producto fue validado para la usabilidad por 11 enfermeros especializadas, mediante el cuestionario de escala de usabilidad del sistema, basado en la teoría unificada de aceptación y uso de la tecnología 2, de venkatesh, thong y xu. resultados: la aplicación se desarrolló por medio de frameworks abiertos y gratuitos, basados en el contenido actualizado del protocolo de enfermería en atención primaria sobre diabetes mellitus, más la clasificación internacional de prácticas de enfermería en salud pública. al evaluar la usabilidad, la aplicación alcanzó un puntaje de 90 puntos, clasificándose en una escala de la mejor calidad posible, con dimensiones que sustentan las construcciones teóricas. conclusiones: la tecnología llamada “diabetes em foco” es prometedora para mejorar y avanzar en el conocimiento teórico y práctico, además del acceso rápido y fácil al protocolo, el apoyo oportuno para la toma de decisiones y el fortalecimiento de la sistematización de la atención de enfermería en atención primaria a la salud. palabras clave (fuente: decs) tecnología de la información; aplicaciones móviles; atención primaria a la salud; cuidados de enfermería; diabetes mellitus. año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2026 4 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2026 aquichan issn 1657-5997 eissn 2027-5374 development and assessment of an application for primary care for users with diabetes mellitus abstract objective: to develop an application on primary nursing care for users with diabetes mellitus and to assess its usability in the light of the unified theory of acceptance and use of technology. materials and methods: a methodological study, which used a quantitative and cross-sectional approach, based on the systematic design of instruction method. the product was validated for usability by 11 specialist nurses, using the system usability scale questionnaire, based on the unified theory of acceptance and use of technology 2 by venkatesh, thong and xu. results: the application was developed through open and free frameworks, based on the updated content of the nursing protocol in primary care on diabetes mellitus, plus the international classification of nursing practices in public health. in assessing usability, the application reached a score of 90 points, being classified on a scale of best achievable, with dimensions that ground the theoretical constructs. conclusions: the technology named diabetes em foco (diabetes in focus in english) is promising to improve and advance theoretical and practical knowledge, in addition to quick and easy access to the protocol, timely support for decision-making and strengthening the systematization of nursing care in primary health care. keywords (source: decs) information technology; mobile applications; primary health care; nursing care; diabetes mellitus. 5 desenvolvimento e avaliação de um aplicativo para os cuidados primários aos usuários com diabetes mellitus l chardsongeicyca maria correia da silva melo e outros introdução o diabetes mellitus (dm) trata-se de uma afecção crônica, epidemiologicamente expressiva, caracterizado como um importante problema de saúde pública de alta prevalência e incidência no âmbito global (1, 2). atualmente, segundo a federação internacional de diabetes (3), 1 de 11 adultos (463 milhões de pessoas) apresenta a doença; 1 entre 6 nascidos vivo é acometido pela diabetes gestacional e, a cada seis segundos, uma pessoa com essa afecção evolui a óbito. para 2045, a expectativa é de 642 milhões de novos casos, sendo os países em desenvolvimento os mais atingidos. no brasil, estimam-se que 14,3 milhões de pessoas possuam a doença, entretanto 7,15 milhões não apresentam diagnóstico prévio (3). esses dados mostram a relevância e o acréscimo desse agravo na morbidade da população, o que indica imprescindibilidade de reorganização e qualificação do cuidado aos usuários, posto que um tratamento incorreto em decorrência de uma assistência que não considera as especificidades de sua cronicidade pode ocasionar inúmeras complicações que, além de gerar grandes impactos econômicos e sociais aos serviços de saúde, estão entre as principais causas de mortalidade, incapacidade, internações hospitalares e redução da qualidade de vida (4). a inserção e expansão do conhecimento e a compreensão dos profissionais de saúde, especificamente enfermeiros da atenção primária à saúde (aps), acerca dessa doença é de extrema importância, visto que esse nível de atenção é caracterizado pelo ministério da saúde do brasil como a principal porta de entrada aos serviços, além de ter alta resolutividade e coordenar ações de promoção, prevenção, proteção, tratamento e reabilitação em saúde. nesse sentido, a enfermagem, cuja responsabilidade é monitorar diretamente os usuários da aps, protagoniza os cuidados primários à saúde em um cenário oportuno e essencial para o rastreamento e monitoramento dos principais agravos, como o dm e o estímulo ao autocuidado (5). uma assistência adequada, que considera as especificidades da doença, oportuniza uma redução dos índices de internações e melhora a qualidade de vida da população, bem como os impactos socioeconômicos dos serviços de saúde (6). as tecnologias de informação e comunicação (tics) em saúde podem contribuir para o cuidado, a disseminação de informações e o aceleramento da comunicação (7-10). com o seu advento, os dispositivos móveis, em especial, os aplicativos, ganharam espaços nos últimos anos, principalmente com a crescente utilização de smartphones, que, além da quebra de limitação de mobilidade, ficam ao alcance dos usuários 24 horas por dia, além de lhes possibilitarem agilidade e precisão de informações em seus trabalhos (11). assim, neste estudo, optou-se por um aplicativo, o qual pode ser um forte aliado para a sistematização do cuidado em enfermagem. na área da saúde, essas tecnologias não substituem o saberfazer profissional, mas constituem um dispositivo adicional, que facilita a melhora na tomada de decisões clínicas e o acesso à informação, assim como contribui para a implementação de condutas qualificadas (9,12). inúmeros modelos teóricos são estudados para compreender a aceitação e a utilização de tecnologias, entre estes, a teoria unificada de aceitação e uso de tecnologia (tuaut), que emerge com o objetivo de procurar entender os constructos que envolvem a aceitação e o uso de uma ferramenta tecnológica (13-15). proposta por venkatesh et al. (16), a tuaut apresenta quatro constructos: expectativa de desempenho, expectativa de esforço, influência social e condições facilitadoras, por quatro moderadores: idade, gênero, experiência e intencionalidade para analisar a influência dos constructos no desenvolvimento da intenção comportamental para a adesão de uma tecnologia. em seguida, venkatesh et al. (17) propuseram e testaram a tuaut2, que incorporou novos fatores-chave como: motivação hedônica, valor de preço e hábito (14, 15). o uso e aceitação de tecnologias de apoio pela enfermagem, a sistematização dos cuidados primários, tal como a consolidação de uma rede assistencial, podem oportunizar aos enfermeiros da aps uma forma efetiva de atuar no rastreamento, acompanhamento e prevenção de complicações da dm durante suas práticas diárias, além de impedir a exposição de usuários a consultas e/ ou procedimentos desnecessários. diante do exposto, a presente pesquisa visa desenvolver um aplicativo sobre cuidados primários de enfermagem aos usuários com dm e avaliar sua usabilidade à luz da tuaut2. 6 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2026 aquichan issn 1657-5997 eissn 2027-5374 materiais e métodos trata-se de um estudo metodológico que, para a avaliação da usabilidade, apresenta-se em uma abordagem quantitativa e de delineamento transversal, realizado no período de janeiro de 2017 a outubro de 2018, no estado de pernambuco, brasil. para alcançar os objetivos referidos, o processo de desenvolvimento do aplicativo emergiu em um dos métodos mais difundidos (18): o design instrucional sistemático (dis), de walter dick e lou m. carey (19), a partir das etapas: (i) análise e levantamento dos requisitos para a elaboração do aplicativo; (ii) design e desenvolvimento da prototipação de telas; (iii) implementação; (iv) avaliação e usabilidade (20). análise e levantamento dos requisitos para a elaboração do aplicativo nesta etapa, estabeleceram-se o modo como as informações seriam exibidas, os conteúdos a serem disponibilizados e as ferramentas utilizadas. este momento contou com a participação de um grupo de pesquisa composto de 1 desenvolvedor de sistemas e 8 profissionais de enfermagem, autores do estudo e especialistas na temática, para uma melhor projeção das informações, a fim de que todos os requisitos para melhor atender os profissionais de saúde fossem dispostos de maneira simples e objetiva. para isso, foram empregados os métodos previstos no human centered design (hcd) toolkit, que lista formas e ferramentas com o intuito de ser um guia para os processos de inovação e design na construção de projetos (20). o aplicativo, nomeado pelos autores como “diabetes em foco”, apresenta uma linguagem uniforme e está fundamentado no protocolo de enfermagem na aps do conselho regional de enfermagem do estado de pernambuco (coren-pe)10, principalmente no capítulo sobre dm, desenvolvido a partir da seleção de conteúdos atualizados contidos em diretrizes, cadernos, protocolos e manuais sobre estratégias para os cuidados primários de enfermagem, na tentativa de oportunizar uma padronização do cuidado e possibilitar, por meio da classificação internacional das práticas de enfermagem em saúde coletiva (cipesc) e da 10 esse documento foi elaborado por um grupo de 15 enfermeiros especialistas e trabalhadores da aps do estado de pernambuco, selecionados em 2016 pelo órgão competente. dispõe de 15 capítulos em forma de fluxograma. para mais informações, consultar o site do coren-pe: http://www.coren-pe.gov.br/novo/protocolo-de-enfermagem-na-atencao-basico classificação internacional da atenção primária (ciap), um sistema de delineamento do cuidado. a cipesc, como uma prática inovadora em saúde coletiva, possibilita aos enfermeiros, por meio de suas potencialidades, formular diagnósticos, intensificar suas intervenções e realizar ações de promoção, prevenção, proteção e reabilitação em saúde. portanto, é um instrumento de grande importância para a pesquisa e o ensino, visto que orienta a sistematização da assistência de enfermagem na atenção básica (21). a ciap, no contexto de cuidado, toma como foco as características biopsicossociais do indivíduo, ao dispor de nomenclaturas que não substituem os diagnósticos de enfermagem, mas engloba os problemas mais frequentes da aps (22). sinteticamente, com o intuito de auxiliar as demandas dos profissionais na sua prática clínica, o aplicativo dispõe de uma breve explicação sobre o diabetes mellitus e seus tipos; os processos de rastreamento, acompanhamento e prevenção de complicações (pé diabético); acolhimento; exames; prescrição; valores glicêmicos; insulinoterapia; reeducação alimentar; ciap e cipesc. a princípio, por intermédio do planejamento para a execução do aplicativo, foi desenvolvido gratuitamente o seu logotipo (figura 1), como forma de expor, graficamente, seu principal objetivo. figura 1. logotipo do aplicativo “diabetes em foco” fonte: https://editor.freelogodesign.org/?lang=pt portanto, com o intuito de incluir o maior número de usuários e facilitar o acesso de informações sem restrição de tempo e espaço, bem como atingir popularidade, optou-se pela construção de um aplicativo disponível de forma off-line e com disponibilidade para o sistema operacional android. http://www.coren-pe.gov.br/novo/protocolo-de-enfermagem-na-atencao-basico 7 desenvolvimento e avaliação de um aplicativo para os cuidados primários aos usuários com diabetes mellitus l chardsongeicyca maria correia da silva melo e outros design e desenvolvimento da prototipação de telas nesta fase, a fim de proporcionar uma modelagem inicial, que poderia sofrer modificações durante o desenvolvimento do aplicativo, foram projetados manualmente as telas e os fluxos do aplicativo (figura 2). em seguida, foi escolhido o template adminlte11, pois abrangia todas as necessidades do protótipo planejado pela equipe. figura 2. protótipo de telas do aplicativo “diabetes em foco” fonte: elaboração própria. como forma de oportunizar aos usuários satisfação mediante a utilização da ferramenta, o extreme programming (xp) foi a engenharia de software selecionada para o desenvolvimento do aplicativo. o xp é uma metodologia ágil e de rápida execução, criado nos estados unidos com a finalidade de produzir sistemas de boa qualidade em menor tempo, com um incessante feedback de produção de softwares em curtas séries de lançamentos, o que permite que erros ou falhas no sistema sejam corrigidos antes de transcorrer para um novo passo (23). 11 template adminlte: https://almsaeedstudio.com para o desenvolvimento do aplicativo, utilizou-se dos frameworks apache cordova na versão 7.0.1 e angular na versão 4.0; além de serem ferramentas sem custos, permitem ao desenvolvedor utilizar linguagens de programação javascript, html5 (hypertext markup language) e css3 (cascading style sheets) abertas e com extenso suporte on-line disponíveis para a definição de aparência, estrutura e comportamento da aplicação (24). implementação com o software finalizado, o aplicativo foi publicado e disponibilizado de forma gratuita na play store12, para que seu acesso, por parte dos enfermeiros especialistas que elaboraram o protocolo da aps do coren-pe, fosse facilitado. a amostragem foi selecionada de forma não aleatória por critério da intencionalidade, visto que a escolha de trabalhar com uma amostra intencional não probabilística é baseada na proposta de participação livre e espontânea, constituída por 11 enfermeiros especialistas na temática do estudo, consoante a norma brasileira abnt iso/iec 25062:2011, regulamentadora da avaliação da qualidade de softwares, que recomenda uma amostra de, no mínimo, oito voluntários na pesquisa (6). o estudo também adotou os critérios propostos por jasper (25) quanto às características de, pelo menos, dois critérios entre titulação, habilidades clínicas, experiência na temática em discussão, conhecimento especializado, aprovação em um teste específico, entre outros (24). a seleção de juízes foi realizada por meio da consulta ao currículo da plataforma lattes (conselho nacional de desenvolvimento científico e tecnológico — cnpq), na busca por indivíduos que apresentassem os critérios supracitados nas áreas da saúde da família, da saúde pública ou coletiva, de tecnologias em saúde e de diabetes, além de serem autores do protocolo de enfermagem na aps do coren-pe. a cada juiz selecionado foi encaminhada uma carta convite, por e-mail, juntamente com o link gerado pelo formulário do google docs para o acesso à versão da escala de usabilidade. os endereços eletrônicos dos juízes foram acessados pela plataforma lattes (cnpq), acesso livre e público. 12 loja virtual do google em que se encontram disponíveis aplicativos gratuitos para o sistema android. aplicativo “diabetes em foco”: https://play.google.com/store/apps/ details?id=br.com.diabetesemfoco https://play.google.com/store/apps/details?id=br.com.diabetesemfoco https://play.google.com/store/apps/details?id=br.com.diabetesemfoco 8 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2026 aquichan issn 1657-5997 eissn 2027-5374 a participação destes deu-se a partir da aceitação livre e espontânea, de forma voluntária, pela assinatura do termo de consentimento livre e esclarecido, pelo preenchimento de todos os requisitos presentes no questionário de usabilidade, bem como na sessão de caracterização dos profissionais. avaliação e usabilidade como instrumento de avaliação da usabilidade, foi utilizado o system usability scale (sus), questionário validado, simples, confiável, de fácil administração, disponível em português do brasil e desenvolvido por john brooke (1986) a partir de dez afirmativas com opções de resposta numa escala tipo likert, que varia de um a cinco: 1 — discordo totalmente; 2 — discordo parcialmente; 3 — neutro; 4 — concordo parcialmente e 5 — concordo totalmente (26-29).para o cálculo da pontuação sus, das questões ímpares (1, 3, 5, 7 e 9), redigidas positivamente quanto aos aspectos do aplicativo, subtrai-se um ponto da escala marcada pelo usuário, entretanto, para as questões pares (2, 4, 6, 8 e 10), redigidas negativamente, a pontuação é de cinco menos a posição da escala marcada pelo usuário. em seguida, somam-se as pontuações individualmente das dez afirmativas de cada participante e multiplica-se o resultado por 2,5 para obter o total da escala de usabilidade do sistema (sus score), ou seja, o índice de satisfação que varia de 0 a 100 pontos (26, 27). os sistemas com sus score entre 0 e 25 pontos é classificado como pior alcançável; de 26 a 39, ruim; de 40 a 52, aceitável; de 53 a 74, bom; de 75 a 85, excelente; de 86 a 100 considera-se como o melhor alcançável (30). de acordo com tenório et al. (31), por meio da utilização do sus, também é possível analisar as cinco principais características para a usabilidade indicadas por nielsen j. (32): avaliar a facilidade de conhecimento do sistema — o qual está contido nos quesitos 3, 4, 7 e 10 do sus; verificar a eficiência do sistema — por meio das questões 5, 6 e 8; identificar inconsistências — com base na questão 6; avaliar a facilidade de memorização — avaliada por meio da questão 2; verificar a satisfação do usuário — pontuada pelas questões 1, 4 e 9 do sus. o teste de usabilidade é uma etapa primordial para o processamento de pontos essenciais na indicação de qualidade de softwares, visto que a singularização da satisfação do usuário também se torna imprescindível para um bom resultado do produto. portanto, para pontuar as características de usabilidade individuais, as respostas obtidas foram multiplicadas por 25, no intuito de congregar o intervalo de valores possíveis de 0 a 100. por meio de uma análise descritiva, estudaram-se as médias dos escores das questões de cada participante, e os resultados foram dispostos em tabelas no microsoft office excel 2016 para uma melhor compreensão das informações contidas na pesquisa. a análise do sus foi embasada pela tuaut2, uma teoria de médio alcance e preditiva, que contextualiza as mudanças de um fenômeno, como eles acontecem e vão além da explicação e previsão de conceitos (33). a avaliação da usabilidade pela tuaut2 nas intervenções de enfermagem revela-se promissora para a crescente produção tecnológica nesta ciência; um aporte para que as futuras pesquisas possam explicar o impacto da utilização real de uma tecnologia nos âmbitos educacionais, assistenciais e gerenciais, além de identificar o nível de satisfação dos enfermeiros quanto a atitudes, emoções e sentimentos engendrados por essas mudanças nas suas atividades diárias (7). o projeto foi encaminhado ao comitê de ética em pesquisa do centro de ciências da saúde da universidade federal de pernambuco e aprovado com o certificado de apresentação para apreciação ética (caae) 80662617.4.0000.5208, conforme os preceitos éticos da resolução 466 de 12 de dezembro de 2012, do conselho nacional de saúde do brasil, em relação à pesquisa com seres humanos (34). resultados e discussão o aplicativo “diabetes em foco” ocupa 53 megabytes de armazenamento, foi elaborado a partir da prototipação manual de aproximadamente 60 telas (figura 2), fornece aos enfermeiros uma ferramenta de auxílio para os processos de rastreamento, acompanhamento e prevenção de complicações (pé diabético) em usuários com dm no âmbito da atenção básica. atualmente, verifica-se uma difusão de tecnologias e aplicativos que cooperam na organização e sistematização da assistência à saúde, porém, em sua maioria, poucos se relacionam com a prática clínica. o aplicativo “diabetes em foco”, assim como o aplicativo “cuidar tech” (exames dos pés) (6), auxilia o enfermeiro, 9 desenvolvimento e avaliação de um aplicativo para os cuidados primários aos usuários com diabetes mellitus l chardsongeicyca maria correia da silva melo e outros por meio da coleta de dados, na avaliação e classificação do risco de pé diabético nos serviços de atenção à saúde em geral. além disso, inclui informações que são oportunas para a otimização do cuidado e um processo contínuo de capacitação-atualização para identificar achados clínicos e propostas de intervenções necessárias imediatas para o enfrentamento da problemática. além de apresentar uma tela principal, na qual é possível acessar os principais temas abordados no protocolo, o aplicativo “diabetes em foco” apresenta um menu lateral que facilita a navegação do usuário enquanto utiliza a aplicação, pois ele pode alterar de temática facilmente. também dispõe de recursos extras, como vídeos, imagens, ícones de informações, contato e uma calculadora com a qual é possível, a partir da combinação dos valores do índice de massa corporal e da circunferência abdominal, avaliar o risco de dm tipo 2 e já propor condutas assistenciais específicas a fim de prevenir suas complicações (figura 3). ademais, sua interface gráfica foi projetada de forma que as opções de acesso às informações fossem claras e objetivas. figura 3. telas do aplicativo “diabetes em foco” fonte: https://play.google.com/store/apps/details?id=br.com.diabetesemfoco na pesquisa, a amostra para a avaliação da usabilidade foi constituída por 11 enfermeiros, com uma média de idade de 36,3 anos (dp ± 6,9) e amplitude de 28 a 54 anos. referente ao tempo de atuação na aps, a média foi de 9,1 anos (dp ± 6,5). cabe destacar que apenas 27,2 %, ou seja, três desses participantes, já desenvolveram ou trabalharam com projetos voltados para diabetes, bem como na área de tecnologias em saúde. proporcionar medidas de qualificação em prol das atribuições do enfermeiro implica reconhecer seu perfil e atuação na atenção primária à saúde no brasil, e assim desenvolver mudanças voltadas para a integralidade do cuidado, implementações de intervenções ante os fatores de riscos, prevenção de agravos, promoção da saúde e da qualidade de vida (35). as variáveis “idade” e “experiência no uso das tecnologias” são aspectos a serem considerados a partir da tuaut2, pois podem interferir na atitude em relação ao comportamento esperado, assim como explicar a aceitação da tecnologia como precondição para seu uso (16, 17). embora, neste estudo, o número de profissionais que já desenvolveram ou trabalharam com projetos voltados para a área de tecnologias em saúde seja reduzido, as tics (36) aparecem como potenciais na educação permanente, no acesso às informações para a dinamização do cuidado, na inovação e na implementação de ações para a qualificação das atividades de profissionais que têm contato direto com pessoas com dm (37). com o objetivo de certificar-se da usabilidade do aplicativo, além da qualidade e do índice de satisfação dos usuários finais, pela análise estatística das respostas obtidas mediante a aplicação do questionário sus, observou-se que o valor total referente à média de todos os scores foi de 90, moda e mediana de 92,5 e um desvio-padrão de ± 10,1, com amplitude de 65 a 100. assim, como forma de categorizar o valor médio de usabilidade resultante da distribuição entre os participantes, 1 dos respondentes (9,09 %) classificou como “bom”; 2 (18,2 %), “excelente” e 8 dos participantes (72,7 %), como “melhor alcançável” (tabela 1). portanto, o aplicativo “diabetes em foco”, dentro dos parâmetros estabelecidos, alcançou o grau máximo em termos de usabilidade, visto que os maiores percentuais se encontram entre 86 e 100 da escala de categorização. https://play.google.com/store/apps/details?id=br.com.diabetesemfoco 10 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2026 aquichan issn 1657-5997 eissn 2027-5374 tabela 1. escala de categorização e classificação da usabilidade do aplicativo “diabetes em foco”, por enfermeiros da aps que colaboraram na construção do protocolo de enfermagem do coren-pe. pernambuco, brasil, 2018 escala de categorização frequência classificação da usabilidaden % 0-25 pior alcançável 26-39 ruim 40-52 aceitável 53-74 1 9,09 bom 75-85 2 18,2 excelente 86-100 8 72,7 melhor alcançável fonte: elaboração própria. esse resultado condiz com os achados na avaliação do aplicativo “oncoaudit”, elaborado como consulta de medicamentos quimioterápicos para o auxílio na auditoria em enfermagem de contas hospitalares. esse aplicativo, por meio da utilização do sus, obteve um valor médio de score de 90 (dp ± 5), classificado dentro da escala de usabilidade como “melhor alcançável”. portanto, é considerado, pelos enfermeiros, um dispositivo de fácil utilização, útil, completo e possuidor de informações bastante importantes para a prática (29). para a avaliação da usabilidade de um website sobre exercícios respiratórios no pós-operatório (38), o valor médio de score foi de 85,5 (dp ± 6,6). portanto, assim como o aplicativo “diabetes em foco”, apresenta um grau de usabilidade numa escala “melhor alcançável”. diante desses achados, verifica-se que os benefícios da implementação do sus, embora seja utilizado em pequenos tamanhos de amostras e para a avaliação de diferentes tipos de ferramentas tecnológicas, tornam-no um instrumento confiável, pois, além de ser simples, gratuito e de fácil administração, dispõe de resultados compreensíveis, bem como apresenta um número reduzido de questões, o que pode aumentar a aderência dos participantes na pesquisa (27, 28). a usabilidade é entendida como um conjunto de qualidade de medida de como uma ferramenta tecnológica pode ser usada por usuários específicos, para o alcance de objetivos que facilitem a aprendizagem, para sua eficiência, identificação de inconsistências, facilidade de memorização e satisfação do usuário (32). ressalta-se que, além da relevância de desenvolver recursos tecnológicos para diversos contextos, avaliar sua usabilidade, no que se refere a ter ferramentas com boa aceitação e utilidade, antes de disponibilizá-los para os usuários finais, também é uma etapa fundamental para o alcance de bons resultados (39). diante do valor médio de usabilidade pontuado pela conversão dos intervalos de valores possíveis de 0 a 100, como forma de quantificar e ratificar os componentes de qualidade indicados por nielsen j. (32), os achados do estudo revelam uma amplitude de 87,75 a 90,75 (tabela 2). o aplicativo apresentou-se como um recurso tecnológico de elevada facilidade de aprendizagem e gerou satisfação. no entanto, embora a rapidez na execução das tarefas, a facilidade de memorização e as inconsistências tenham apresentado valor abaixo da média geral de usabilidade, o aplicativo alcançou uma classificação de melhor alcançável. tabela 2. característica de usabilidade do aplicativo “diabetes em foco” avaliado pelo sus. pernambuco, brasil, 2018 característica da usabilidade média significado facilidade de aprendizagem 90,75 sistema de fácil utilização quando utilizado pela primeira vez. eficiência 87,75 rapidez na execução das tarefas estabelecidas. inconsistências 88,50 ausência de erros. facilidade de memorização 88,50 sistema de fácil execução mesmo após um longo período sem utilizá-lo. satisfação 90,75 design agradável. fonte: elaboração própria. 11 desenvolvimento e avaliação de um aplicativo para os cuidados primários aos usuários com diabetes mellitus l chardsongeicyca maria correia da silva melo e outros um ambiente virtual de aprendizagem (27), que corroborou em parte com os achados da presente pesquisa, foi criado com o objetivo de avaliar a qualidade do sistema fornecido pela empresa ouro moderno, com a média do sus score de 70, 76,05 de aprendizagem, 76,45 de eficiência, 76,13 correspondentes à memorização, 74,68 referente à inconsistência e 77,85 à satisfação. no entanto, os participantes relataram dificuldades na utilização desse sistema e falhas técnicas relacionadas a configurações de hardware e de rede. diante dessa avaliação desfavorável, realizaram atualizações e criaram um manual de ajuda sobre a utilização da plataforma, para sanar dúvidas e auxiliar na redução da necessidade de suporte técnico on-line (27). a análise das dimensões do sus fundamenta o comportamento, aceitação e utilização de tecnologias conforme a tuaut2. a partir da expectativa de desempenho, que demonstra como a aplicabilidade de uma tecnologia proporcionará benefícios na realização de determinadas atividades, observa-se a excelente avaliação desse constructo teórico a partir das características de usabilidade “eficiência” (87,75) e “inconsistências” (88,5). a expectativa de esforço, definida como a facilidade da usabilidade das tecnologias, pôde ser representada pela “facilidade de aprendizagem” (90,75) e pela “facilidade de memorização” (88,5). as condições facilitadoras, os recursos e apoio disponíveis para determinar o uso da tecnologia e a motivação hedônica, que enfatizam a utilidade, o prazer que o uso de uma tecnologia pode proporcionar, foram representadas pela característica de usabilidade “satisfação” (90,75). vale salientar que a utilização do questionário sus não possibilitou a fundamentação pelos constructos da influência social, preço/custo de consumo e hábito (16, 17). referente ao somatório de cada afirmativa que varia de 36 a 42 pontos (tabela 3), o aplicativo “diabetes em foco” alcançou melhores resultados, em que os maiores percentuais se encontram nas questões ímpares, o que resulta outro ponto positivo. entre as afirmativas redigidas positivamente, que indicam aspectos relevantes no software desenvolvido, estão: “1 — eu acho que gostaria de utilizar este sistema frequentemente”, “3 — eu achei o sistema fácil para usar”, “5 — eu achei que as diversas funções neste sistema foram bem integradas”, “7 — eu imagino que a maioria das pessoas aprenderão a usar esse sistema rapidamente” e “9 — eu me senti muito confiante usando esse sistema”. tabela 3. resultados referentes à usabilidade do aplicativo “diabetes em foco” conforme as questões do sus. pernambuco, brasil, 2018 questões somatório sus 1 41 2 39 3 40 4 39 5 41 6 39 7 42 8 36 9 40 10 39 fonte: elaboração própria. usuários de aplicativos para smartphones com fins de gerenciamento de diabetes tipo 1 demonstraram insatisfação geral com a tecnologia atualmente disponível, apesar do interesse pelo uso de ferramentas para diabetes na perspectiva do paciente. para que seja totalmente aproveitada, a tecnologia existente deve ser adaptada para melhor atender às necessidades dessa população de pacientes, assim como inovar no compartilhamento de dados, entre os usuários e os profissionais da saúde (40, 41). além das atribuições de valores, foi disponibilizado aos avaliadores um questionário para proporem sugestões e comentários a respeito da aplicação. então, quando indagados sobre o que acharam do aplicativo, se gostariam de sugerir, acrescentar ou retirar algo, referiram que o aplicativo “diabetes em foco” é uma ferramenta excelente, de fácil manuseio, didático, perfeito, prático, com conteúdo muito bem embasado e atualizado, objetivo, ágil, resolutivo, funcional, informativo, de extrema importância na aplicabilidade, bem como um recurso que facilitará e apoiará as condutas de enfermagem no âmbito da atenção básica. 12 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2026 aquichan issn 1657-5997 eissn 2027-5374 entretanto, os enfermeiros também propuseram pontos de melhorias, como: atualização de alguns parâmetros de rastreio e acréscimo de informações sobre diabetes gestacional; como projetos futuros, disponibilização do aplicativo para o sistema operacional ios. esses pontos, exceto o último, foram revistos e atualizados em novas versões do aplicativo, o que contribuiu para uma melhor usabilidade e aperfeiçoamento da ferramenta. todos esses feedbacks são de grande valia, pois, além de satisfazer os pesquisadores, permitem a organização, complementação, atualização das informações, bem como ajudam a identificar fragilidades e oportunidades de melhorias a fim de tornar o aplicativo apto para o uso. conclusões o aplicativo “diabetes em foco”, sobre os cuidados primários de enfermagem aos usuários com dm baseado no protocolo de enfermagem na aps do coren-pe, foi avaliado com grau máximo de usabilidade numa escala de melhor alcançável, com melhores percentuais nos componentes de facilidade de aprendizagem e satisfação, e pontos de melhorias diante da eficiência, facilidade de memorização e inconsistências. diante da crescente utilização das tics em diversas áreas como a saúde, os resultados deste estudo contribuíram para ampliar os conhecimentos sobre a importância do desenvolvimento, avaliação e embasamento teórico de ferramentas tecnológicas que alinhem o conhecimento teórico-prático, além de minimizarem as dificuldades e carências dos enfermeiros em relação à prática clínica e lhes facilitarem o acesso ao protocolo de enfermagem. como limitação no estudo, pode-se destacar a resistência de alguns profissionais na utilização das tics no seu processo de trabalho, assim como a disponibilidade do aplicativo apenas para o sistema operacional android. pretende-se, neste cenário, promover uma interoperabilidade do aplicativo, adaptando essa ferramenta para operar com outros sistemas, a fim de oportunizar a troca de informações e a tomada de decisões com maior embasamento científico. projeta-se, também, a sensibilização dos enfermeiros para o uso do aplicativo na assistência, com o intuito de uma maior qualificação na sistematização da assistência de enfermagem para os cuidados primários à saúde das pessoas com dm. a análise crítica pela tuaut2 oportunizou perspectivas de ampliação em sua utilização no âmbito da enfermagem, por assim proporcionar contribuições para a prática, a pesquisa, a educação e a gestão nos diferentes níveis de atuação do enfermeiro, além do desenvolvimento de novos conhecimentos e reflexões sobre o uso e aceitação das tecnologias de saúde. conflito de interesses: nenhum declarado. referências 1. diretrizes da sociedade brasileira de diabetes. rio de janeiro: sociedade brasileira de diabetes; 2017-2018. 2. organização mundial de saúde. doenças transmissíveis e não transmissíveis. geneva: oms-opas; 2017. 3. federação internacional de diabetes. atlas de diabetes da idf. 9. ed. bruxelas, bélgica; 2019. disponível em: http://www.diabetesatlas.org 4. santos al, teston ef, latorre mrdo, mathias taf, marcon ss. tendência de hospitalizações por diabetes mellitus: implicações para o cuidado em saúde. acta paul enferm, 2015;28(5):401-7. doi: http://dx.doi.org/10.1590/19820194201500068 5. departamento de atenção básica. estratégias para o cuidado da pessoa com doença crônica: diabetes mellitus. caderno de atenção básica n. 36. brasília-df: ministério da saúde; 2013. disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/estrategias_cuidado_pessoa_diabetes_mellitus_cab36.pdf http://www.diabetesatlas.org http://dx.doi.org/10.1590/1982-0194201500068 http://dx.doi.org/10.1590/1982-0194201500068 https://bvsms.saude.gov.br/bvs/publicacoes/estrategias_cuidado_pessoa_diabetes_mellitus_cab36.pdf https://bvsms.saude.gov.br/bvs/publicacoes/estrategias_cuidado_pessoa_diabetes_mellitus_cab36.pdf 13 desenvolvimento e avaliação de um aplicativo para os cuidados primários aos usuários com diabetes mellitus l chardsongeicyca maria correia da silva melo e outros 6. vêscovi sdjb, primo cc, anna hcs, bringuete medo, rohr rv, prado tn et al. aplicativo móvel para avaliação dos pés de pessoas com diabetes mellitus. acta paul. enferm, 2017;30(6):607-13. doi: http://dx.doi.org/10.1590/19820194201700087 7. maillet e, mathieu l, sicotte c. modeling factors explaining the acceptance, actual use and satisfaction of nurses using an electronic patient record in acute care settings: an extension of the utaut. inter j medical informatics. 2015;84(1):3647. doi: http://dx.doi.org/10.1016/j.ijmedinf.2014.09.004 8. torres aal, bezerra jaa, abbad gs. uso de tecnologias de informação e comunicação no ensino na saúde: revisão sistemática 2010-2015. rev eletrônica gestão & saúde. 2015;6(2):1883-9. doi: http://doi.org/10.18673/gs.v6i2.22507 9. lopes je, heimann c. uso das tecnologias da informação e comunicação nas ações médicas à distância: um caminho promissor a ser 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http://dx.doi.org/10.18803/capsi.v17.305-320 http://www.venkatesh.com/wp-content/uploads/2015/11/2003(3)_misq_venkatesh_etal.pdf http://www.venkatesh.com/wp-content/uploads/2015/11/2003(3)_misq_venkatesh_etal.pdf https://doi.org/10.2307/41410412 https://doi.org/10.1590/0104-07072017002260017 https://doi.org/10.1590/0104-07072017002260017 http://dx.doi.org/10.1590/s0080-62342012000300032 http://www.scielo.br/pdf/csc/v17n11/v17n11a18.pdf http://atenas.cpd.ufv.br/dpi/xp/artigo06.pdf http://atenas.cpd.ufv.br/dpi/xp/artigo06.pdf 14 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2026 aquichan issn 1657-5997 eissn 2027-5374 24. camden rk. apache cordova in action. shelter island, editor. estados unidos. manning publications company; 2015. 25. jasper ma. expert: a discussion of the implications of the concept as used in nursing. j. adv nurs. 1994;20(4):769-79. 26. brooke j. sus — a quick and dirty usability scale. redhatch consulting ltd. 1986 [acesso em 22 de agosto de 2018];1-7. disponível em: https://hell.meiert.org/core/pdf/sus.pdf 27. boucinha rm, tarouco lmr. avaliação de ambiente virtual de aprendizagem com o uso do sus — system usability scale. renote — novas tecnologias na educação. 2013;11(3):1-10. doi: https://doi.org/10.22456/1679-1916.44479 28. nascimento md. manual — system usability scale (sus). fortaleza; 2013. disponível em: https://pt.slideshare.net/ devaner/manual-usability 29. grossi lm, pisa it, marin hf. oncoaudit: desenvolvimento e avaliação de aplicativo para enfermeiros auditores. acta paul. enfermagem. 2014;27(2):179-85. doi: http://dx.doi.org/10.1590/1982-0194201400031 30. bangor a, kortum p, miller j. determining what individual sus scores mean: adding an adjective rating scale. journal usab. stud. 2009;4(3):114-23. disponível em: https://pdfs.semanticscholar.org/3399/f83ff6149dc65b52600f52ed372be5a6aa86.pdf?_ga=2.7942068.744099555.1577414554-73469440.1567020681 31. tenório jm, sdepanian vl, pisa it, marin hf. desenvolvimento e avaliação de um protocolo eletrônico para atendimento e monitoramento do paciente com doença celíaca. revista de informática teórica e aplicada, 2011;17(2):210-20. disponível em: https://seer.ufrgs.br/rita/article/download/rita_v17_n2_p210/11210 32. nielsen j. usability 101: introduction to usability; 2003. disponível em: http://www.ingenieriasimple.com/usabilidad/ introtousability.pdf 33. mcewcn m, evell’n mw. bases teóricas de enfermagem. 4. ed. porto alegre: artmed; 2016. 34. resolução 466/2012. diretrizes e normas regulamentadora de pesquisas envolvendo seres humanos. brasília, df: conselho nacional de saúde; 2012. 35. ferreira srs, périco lad, dias vrfg. the complexity of the work of nurses in primary health care. revista brasileira de enfermagem, 2018;71(1):704-9. doi: http://dx.doi.org/10.1590/0034-7167-2017-0471 36. mota dn, torres ram, guimarães jmx, marinho mnasb, araújo af. tecnologia da informação e comunicação: influência no trabalho da estratégia saúde da família. journal of health informatics, 2018;10(2):44-9. disponível em: http://www. jhi-sbis.saude.ws/ojs-jhi/index.php/jhi-sbis/article/view/563 37. duffy s, svenson j, chavez a, kelly m, wise p. empowering community health with mobile technology to treat diabetes. ann fam med. 2019;17(2):176. doi: https://doi.org/10.1370/afm.2361 38. santos fdrp, nunes sfl, pascoal lm, neto pml, viana rp. avaliação de um website sobre exercícios respiratórios no pós-operatório. congresso brasileiro de informática em saúde; 2016; goiânia, brasil: sociedade brasileira de informática em saúde; 2016. pp. 139-45. disponível em: https://www.sbis.org.br/biblioteca_virtual/cbis/anais_cbis_2016_artigos_completos.pdf 39. martins ai, queirós a, rocha np, santos bs. avaliação de usabilidade: uma revisão sistemática da literatura. revista ibérica de sistemas e tecnologias de informação, 2013;31-43. disponível em: http://www.scielo.mec.pt/scielo. php?script=sci_abstract&pid=s1646-98952013000100004 40. lithgow k, edwards a, rabi d. uso de aplicativo para smartphone para gerenciamento de diabetes: avaliando as perspectivas do paciente. jmir diabetes. 2017;2(1). doi: https://doi.org/10.2196/diabetes.6643 41. bonn se, alexandrou c, hjörleifsdottir sk et al. tecnologia de aplicativos para aumentar a atividade física entre pacientes com diabetes tipo 2 — o estudo diacert, um estudo controlado randomizado. bmc public health. 2018;18:119. doi: https://doi.org/10.1186/s12889-018-5026-4 https://hell.meiert.org/core/pdf/sus.pdf https://doi.org/10.22456/1679-1916.44479 https://pt.slideshare.net/devaner/manual-usability https://pt.slideshare.net/devaner/manual-usability http://dx.doi.org/10.1590/1982-0194201400031 https://pdfs.semanticscholar.org/3399/f83ff6149dc65b52600f52ed372be5a6aa86.pdf?_ga=2.7942068.744099555.1577414554-73469440.1567020681 https://pdfs.semanticscholar.org/3399/f83ff6149dc65b52600f52ed372be5a6aa86.pdf?_ga=2.7942068.744099555.1577414554-73469440.1567020681 https://seer.ufrgs.br/rita/article/download/rita_v17_n2_p210/11210 http://www.ingenieriasimple.com/usabilidad/introtousability.pdf http://www.ingenieriasimple.com/usabilidad/introtousability.pdf http://dx.doi.org/10.1590/0034-7167-2017-0471 http://www.jhi-sbis.saude.ws/ojs-jhi/index.php/jhi-sbis/article/view/563 http://www.jhi-sbis.saude.ws/ojs-jhi/index.php/jhi-sbis/article/view/563 https://doi.org/10.1370/afm.2361 https://www.sbis.org.br/biblioteca_virtual/cbis/anais_cbis_2016_artigos_completos.pdf https://www.sbis.org.br/biblioteca_virtual/cbis/anais_cbis_2016_artigos_completos.pdf http://www.scielo.mec.pt/scielo.php?script=sci_abstract&pid=s1646-98952013000100004 http://www.scielo.mec.pt/scielo.php?script=sci_abstract&pid=s1646-98952013000100004 https://doi.org/10.2196/diabetes.6643 https://doi.org/10.1186/s12889-018-5026-4 04 la practica de la enfermeria en cuidado intensivo.indd 50 aquichan issn 1657-5997 óscar alberto beltrán-salazar1 la práctica de enfermería en cuidado intensivo recibido: 26 de noviembre de 2007 aceptado: 27 de febrero de 2008 1 enfermero. magíster en enfermería. profesor facultad de enfermería, universidad de antioquia. medellín, colombia. oscar4242@tone.udea.edu.co resumen los supuestos teóricos de los autores de enfermería han sido realizados con base en la realidad percibida, y en la práctica en muchos casos; es por esto que en la práctica cotidiana del cuidado puede verse que múltiples conceptos de la disciplina de enfermería son aplicados por algunos profesionales sin tener conciencia de quién los ha propuesto. el presente artículo tiene como objetivo analizar aspectos relacionados con el cuidado de enfermería integral a los pacientes en estado crítico, sometidos a ventilación mecánica, a la luz de los conceptos disciplinares propuestos en el modelo de relación de persona a persona de joyce travelbee. se realizó observación participante en uci de 80 horas de duración, durante la cual se analizó el desarrollo de la práctica diaria del cuidado de las enfermeras que estaban de turno. los datos de la observación fueron confrontados con los propuestos teóricos de travelbee y otros autores, lo que permitió ver que aun cuando los enfermeros no tengan conocimiento acerca de las teorías de enfermería, su práctica de cuidado puede estar en consonancia con ellas, no en vano las teorías son formuladas, en muchos casos, con base en eventos prácticos. palabras clave apoyo social, atención al paciente, enfermería, relaciones enfermero-paciente, sufrimiento físico, ventilación mecánica. año 8 vol. 8 nº 1 chía, colombia abril 2008 50-63 51 la práctica de enfermería en cuidado intensivo nursing practice in intensive care units abstract oftentimes, the theoretical assumptions of nursing authors are based on perceived reality and practice. as a result, many professionals apply a variety of nursing concepts in their every day work, without knowing exactly where they come from. this article is intended to analyze several aspects associated with comprehensive nursing care for critical patients subject to mechanical ventilation, based on the nursing concepts proposed in joyce travelbee’s human-to-human relationship model. eighty (80) hours of active observation in an intensive care unit made it possible to analyse normal, every day care provided by nurses on duty. observation data were compared to travelbee’s theoretical proposals and to those of other authors. it was concluded that, even if nurses lack sufficient knowledge about nursing theories, their care-giving might be consistent with those theories, which often are formulated on the basis of practical experience. key words social support, patient care, nursing, patient-nurse relationship, physical suffering, medical ventilation. a prática de enfermagem no cuidado intensivo resumo os autores de enfermagem têm proposto os seus supostos teóricos baseados na realidade percebida, e na prática, em muitos casos. portanto, alguns profissionais aplicam na sua labor cotidiana do cuidado vários conceitos da disciplina sem terem consciência do quem os propõe. este artigo analisa aspectos relacionados ao cuidado integral de enfermagem brindado aos pacientes em estado crítico, submetidos a ventilação mecânica, à luz dos conceitos disciplinares propostos por joyce travelbee no seu modelo de relação pessoa-pesssoa. foi realizada observação participante em uma unidade de cuidados intensivos durante 80 horas, na que foi analisado o desenvolvimento da prática diária do cuidado das enfermeiras de turno. os dados se confrontaram com os postulados de travelbee e outros autores. isto permitiu concluir que mesmo se os enfermeiros não conheçam as teorias sobre o cuidado, a sua prática neste assunto pode concordar com elas. não em vão as teorias se formulam com base em eventos práticos em muitos casos. palavras-chave apoio social, atenção ao paciente, enfermagem, relações enfermeiro-paciente, sofrimento físico, ventilação mecânica. 52 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 introducción en este trabajo se analizan los conceptos propuestos por joyce travelbee (1) en relación con dos de los componentes del metaparadigma de enfermería: la enfermera y el paciente; se tomarán en cuenta sus planteamientos debido a sus referencias específicas sobre las personas enfermas, y al papel de enfermería frente a la enfermedad, que es uno de los tópicos de interés en este escrito, en el cual el componente paciente hace referencia al paciente en estado crítico sometido a la ventilación mecánica; además, se incluye el análisis de algunos aspectos que tienen que ver con la relación enfermero-paciente que se lleva a cabo en la unidad de cuidado intensivo. en relación con cada uno de los componentes, inicialmente se presentarán los planteamientos hechos por la teórica de enfermería a quien se hace referencia; a continuación se analizan, a luz de dichos contenidos, las actividades desarrolladas durante la práctica del cuidado por parte de los enfermeros. las fuentes de información para este artículo consisten en una revisión bibliográfica sobre el modelo teórico involucrado y la ventilación mecánica, observaciones realizadas en la unidad de cuidado intensivo, y entrevistas a los enfermeros que participan en el cuidado del paciente en estado crítico. la observación participante fue el método de recolección de la información respecto a la forma de proceder de los enfermeros y los aspectos que ponían en práctica en los actos de cuidado. no se pretendía evaluar conceptos teóricos sino averiguar los lineamientos o postulados llevados a la práctica. se trató de observación participante porque se dio en términos de interacción entre el observador y los participantes en el medio en el cual se realizaban las intervenciones propias de una práctica de enfermería, que en este caso era la uci. se seleccionaron dos uci. el observador participó a manera de auxiliar en las intervenciones de cuidado, teniendo especial cuidado de no liderar dichas intervenciones porque la finalidad de la observación era tomar notas respecto a la práctica del cuidado del los participantes y no del observador. para facilitar el acceso a las unidades se enviaron cartas y se realizaron contactos personales con los miembros de la administración general, específicamente con directores de enfermería de las instituciones. tanto coordinadores como enfermeros de asistencia estuvieron enterados de los motivos y la metodología de la observación antes de iniciarla. la observación estaba centrada en aspectos del cuidado ofrecido por los enfermeros a los pacientes en estado crítico de salud. el observador fue un enfermero más, colaboraba en intervenciones a la vez que tomaba notas. este tipo de contacto con los enfermeros permitió observar, preguntar sobre determinadas acciones o comportamientos prácticos, y tomar nota en forma simultánea con la expresa colaboración de los participantes. las notas de campo eran consignadas a la vista de los participantes, y el interés de ellos por participar fue permanente. tomar notas y hacer registros en una uci no es infrecuente, por el contrario, los registros acompañan a cada intervención por lo que los enfermeros no veían con extrañeza la insistencia del observador por registrar lo que se observaba, y nunca hubo manifestaciones de incomodidad u otras emociones al respecto. se registraban los comportamientos, los procedimientos, las ideas compartidas, las respuestas a las pre53 la práctica de enfermería en cuidado intensivo guntas para buscar ideas, las concepciones, las posturas teóricas y las prácticas. se realizaban preguntas antes, durante y después de las intervenciones, y las respuestas eran consignadas en los diarios de campo. las preguntas eran abiertas sobre aspectos del cuidado, enfocadas a lo que cada uno de los enfermeros pensaba o aceptaba como válido. no se tomaron como base los planteamientos de travelbee para hacer las preguntas, pero sí se tomaron en cuenta para analizar y comparar los contenidos de las respuestas y de los datos sobre las observaciones. también se realizaron algunas preguntas a los pacientes. las preguntas surgían de los acontecimientos, y en ocasiones buscaban explorar la posición de los enfermeros sobre aspectos como la definición de paciente, de cuidado de enfermería, y el rol de los enfermeros en el cuidado. el establecimiento del rapport 2 fue fácil debido a que el observador participaba en las prácticas de cuidado, lo que también contribuyó para acceder fácilmente a cada una de las instancias físicas de la uci, y ver de primera mano lo que ocurría entre pacientes y enfermeros. no se registraron los nombres propios de los participantes, los cuales fueron cambiados por nombres ficticios. en el análisis de los datos producidos durante el registro de las observaciones se trató de establecer la concordancia entre lo que plantea joyce travelbee en el libro interpersonal aspects of nursing, con los planeamientos realizados por los enfermeros participantes, especialmente en lo que hace referencia a los conceptos de paciente, enfermera, enfermería e interacción entre enfermeros y pacientes. la enfermería travelbee define la enfermería como “un proceso interpersonal, en el cual el enfermero asiste a un individuo o familia a prevenir y enfrentar la enfermedad y el sufrimiento y a encontrar significados de esa experiencia” (1). el proceso interpersonal involucra una serie de contactos que los enfermeros llevan a cabo con los pacientes, que van desde contactos verbales hasta la interpretación de gestos y movimientos que son utilizados para informar y comunicar cuando no es posible hacerlo mediante el lenguaje hablado. otra característica de la interacción enfermero-paciente consiste en que genera cambios en ambos participantes; el enfermero influye sobre el paciente, lo mismo que éste lo hace sobre el enfermero; este hecho permite al enfermero apoyar a los pacientes y contribuir para el bienestar por la vía de prevenir la enfermedad, la inhabilidad y el sufrimiento, y contribuir al mantenimiento de la salud, o a una muerte con tranquilidad y dignidad. “un enfermero siempre asiste a otros” (1), es otro postulado de travelbee; pero se debe tener en cuenta que en la asistencia a los pacientes en estado crítico se presentan condiciones específicas que demandan del enfermero un abordaje especial, con características propias y que ofrece mayores dificultades en muchas ocasiones. en este tipo de pacientes la enfermedad está presente hasta el grado de poner en peligro la vida; el cuidado de enfermería debe estar dirigido a preservar la vida y a la resolución de los problemas 2 la palabra rapport es conocida en la investigación cualitativa. travelbee utiliza la palabra (que entre otras cosas no la traducen) para hacer referencia a la fase en la cual se establece una verdadera relación enfermera-paciente, se logra confianza y conocimiento mutuo; comparten pensamientos, sentimientos y actitudes. ambos se ven como seres humanos. hay aceptación mutua. otra característica de la interacción enfermero-paciente consiste en que genera cambios en ambos participantes; el enfermero influye sobre el paciente, lo mismo que éste lo hace sobre el enfermero. 54 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 más apremiantes; a enfrentar la enfermedad y el sufrimiento; en otras palabras, a devolver la salud o a lograr el más óptimo nivel de salud posible (1). la preocupación de la enfermería estará relacionada con asistir a los pacientes y sus familias para enfrentar la enfermedad, el sufrimiento y el estrés que estas situaciones generan; a prevenir complicaciones; a reconocer tempranamente los signos de enfermedad; a participar en un tratamiento oportuno, y a recuperar la salud. los enfermeros apoyan, animan y brindan confianza respecto a la recuperación, pero cuando se está frente a aquellos pacientes que no recuperan la salud completamente, se hace necesario enseñar a vivir con enfermedades crónicas, a controlar los síntomas de la enfermedad, a realizar técnicas y procedimientos para el mantenimiento de la salud; además de “promover la adherencia a los tratamientos, ayudar a enfrentar los sentimientos de desesperanza y a explorar las percepciones y contribuir al entendimiento de la enfermedad” (1). para enfrentar las necesidades de cuidado de los pacientes, los enfermeros deben tener un método lógico para enfocar los problemas; conocimiento sobre conceptos y principios de física, biología, psicología, y de ciencias médicas y de enfermería; pero también “es fundamental poseer la habilidad para usar sus conocimientos en el cuidado de los pacientes y la capacidad para convertir el pensamiento en acciones inteligentes orientadas a resolver los problemas del paciente”, como plantea a su vez watson (2). los enfermeros deben percibir la interacción enfermero-paciente como una interacción entre dos seres humanos; los pacientes no representan una tarea por cumplir, un número de cama o una enfermedad, ni se debe asumir, automáticamente y sin mayor análisis, que todos son dependientes de enfermería; cuando los pacientes se asumen de esta manera, las energías de enfermería se enfocan en cumplir las expectativas institucionales y no en los requerimientos de los pacientes; aceptar la individualidad humana es el primer paso para iniciar el camino hacia la humanización del cuidado. en la unidad de cuidado intensivo, los enfermeros tienen especial habilidad para establecer las relaciones con los pacientes, a pesar de las dificultades que se presentan debido al estado de salud y a las limitaciones a las que están sometidos, a causa de las manifestaciones del cuadro clínico, de las complicaciones clínicas y de las medidas terapéuticas tales como inserción de tubos, catéteres, administración de medicamentos e incluso la inmovilización física a la que se recurre para evitar retiros accidentales. la relación enfermero-paciente involucra variados contactos físicos en la realización de procedimientos, la interpretación de gestos, movimientos y posiciones con las cuales los pacientes, sometidos a ventilación mecánica, comunican sus emociones, sentimientos y percepciones, debido a que no pueden expresarlos por medio del lenguaje hablado. así mismo, los enfermeros tienen la habilidad para buscar opciones comunicativas cuando el lenguaje hablado no es posible; negocian movimientos y gestos del lenguaje simbólico, a los cuales atribuyen significados en la comunicación; además, recurren a papeles y elementos para escribir lo que no es posible decir oralmente. la preocupación de la enfermería estará relacionada con asistir a los pacientes y sus familias para enfrentar la enfermedad, el sufrimiento y el estrés que estas situaciones generan. 55 la práctica de enfermería en cuidado intensivo los contactos con los pacientes en estado crítico son más frecuentes, y el tiempo de permanencia de los enfermeros al lado de la cama es más prolongado; los pacientes requieren frecuentes procedimientos que hacen que los enfermeros permanezcan más tiempo con ellos. pero también, “las intervenciones que generan dolor y sufrimiento” (3) son frecuentes y los pacientes ponen en manos de los enfermeros su propia seguridad, su confort y comodidad, aun cuando ellos en la práctica del cuidado también contribuyen al sufrimiento, tal como plantea madjar (4) al referirse al dolor infligido por los miembros del equipo de salud durante la realización de los procedimientos e intervenciones propias del cuidado. de esta interacción, el beneficio para el paciente se expresa en recuperar la salud, presentar menos complicaciones o morir tranquilamente; pero también, aprender a vivir con sus limitaciones, secuelas y con sus tratamientos en forma permanente. los enfermeros, por su lado, reciben la satisfacción de cumplir con su deber, de haber contribuido a la resolución de los problemas de otros seres humanos, y por este camino avanzar hacia la experticia como profesionales. la contribución de los enfermeros a la superación de los problemas de los pacientes parte de la identificación e interpretación de múltiples signos clínicos aportados por monitores, ventiladores mecánicos, reportes de laboratorio y examen físico con los cuales los enfermeros construyen el “perfil clínico” de los pacientes, que luego servirá de base para la toma de decisiones; las fuentes de información son múltiples, incluso se puede llegar a pensar que el paciente es quien menos información aporta; lo que no debe olvidarse es que es el paciente, en coordinación con los aparatos e instrumentos, quien en realidad genera la información y expresa sus necesidades. el reto en la interacción lo ofrecen los pacientes con alteraciones de la conciencia como efecto de traumas, lesiones o de medicamentos sedantes, relajantes y anestésicos; estos pacientes no buscan la comunicación, no hablan, y sus expresiones y mensajes en la mayoría de los casos se limitan a gestos o a permanecer en silencio; la aparente incomunicación no los convierte en simples receptores del cuidado, y los enfermeros y las familias deben estar pendientes de mantener con ellos el contacto físico y la comunicación, y de ofrecerles la información necesaria para favorecer la ubicación en la realidad y evitar que la sensación de soledad y desamparo que presentan generen efectos físicos y sociológicos; pero es posible encontrar cierto grado inhibición en determinadas personas para sostener diálogos con aquellos que no están en capacidad de responder. maría3, una enfermera que trabaja en cuidado intensivo, expresa a este respecto que “antes creía que no era posible hablar con este tipo de pacientes, me aterraba ver a otras personas hablándoles, pero ahora me parece muy importante hablar con ellos”. juan respondió que “lo que entendemos como comunicación verbal y gestual no son posible, ellos no se comunican, no se mueven; los pacientes despiertos hacen gestos, hablan, tocan, pero los sedados no”. se debe reconocer que durante la práctica no se observó una contribución directa por parte de los enfermeros hacia la comprensión de los significados otorgados por los pacientes a la experiencia 3 los nombres han sido cambiados para preservar la privacidad de los participantes. el reto en la interacción lo ofrecen los pacientes con alteraciones de la conciencia como efecto de traumas, lesiones o de medicamentos sedantes, relajantes y anestésicos. 56 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 vivida durante una enfermedad severa que requirió la asistencia ventilatoria con elementos tecnológicos. en muchos casos, los pacientes son trasladados a otros servicios antes de recuperar plenamente sus funciones mentales y cognitivas, por lo que el diálogo a profundidad no es posible; queda entonces, como tarea pendiente, que los enfermeros de los servicios generales retomen las casos para favorecer el aprendizaje de los pacientes. en relación con el método lógico para enfrentar, los enfermeros demostraron un alto grado de interés en la capacitación permanente, en la asistencia a conferencias, en la participación en la ronda del equipo de salud y en la realización de discusiones para la toma de decisiones respecto a las conductas que se deben seguir en cada caso. aunque, como expresa maría, “el cuidado está basado en protocolos, pero es muy frecuente que se requieran variaciones, por eso siempre nos preocupa ir más allá de lo que está definido para dar lo que se necesita”. juan corrobora lo dicho,” la preparación académica y la experiencia muestran que hay que ir más allá de la norma; no consiste solo en voltear a un paciente, hay que acomodarlo, hay que mirar muchas otras cosas”. para la satisfacción de sus necesidades, los pacientes en estado crítico requieren de un cuidado de enfermería riguroso, permanente, ético y empático, brindado por enfermeros comprensivos, tolerantes y bien entrenados en el uso de sus conocimientos. a este respecto, lucía expresa que “un paciente en estado crítico es aquel que exige un cuidado de enfermería continuo, monitoreo y valoración permanentes, y el uso de mayor tecnología”. además del conocimiento empírico, los enfermeros demostraron habilidades en las esferas de conocimiento estético, personal y ético (5); ellos iban más allá de la labor asignada, ponían sus valores internos al servicio de los demás, y se preocupaban por establecer los límites de lo que es razonable y humano, para defender a los pacientes y evitarles el sufrimiento innecesario; además, favorecían el conocimiento en los pacientes de la misma forma que el propio, y ponían en práctica lo que travelbee (1) denomina “el uso terapéutico del yo”. se observó que siempre que fue necesario los enfermeros demostraron una clara disposición para actuar como intérpretes de los médicos clarificando las informaciones solicitadas (1). el paciente travelbee (1) plantea que “la percepción que los enfermeros tienen de los pacientes afecta profundamente su comportamiento, realza sus acciones y determina la calidad del cuidado que se ofrece”. así mismo, plantea que el ser humano es un organismo biológico, afectado, influenciado y transformado por factores hereditarios, culturales y por experiencias previas; es una criatura de contradicciones y confrontaciones constantes, que debe enfrentar conflictos y opciones para tomar decisiones; es un organismo pensante, con la habilidad de tener pensamientos lógicos y racionales, pero también puede tornarse emocional e ilógico (1). el ser humano tiene la habilidad para conocer a otros, para comunicarse con ellos; tiene la capacidad de transmitir su individualidad, aun cuando en ocasiones esto sea incomunicable e incomprensible para los demás; es capaz de relacionarse con quienes le rodean, de conocer, querer y responder al aprecio de ellos de la misma manera como puede disgustarse, desconfiar y odiar (1). para la satisfacción de sus necesidades, los pacientes en estado crítico requieren de un cuidado de enfermería riguroso, permanente, ético y empático, brindado por enfermeros comprensivos, tolerantes y bien entrenados en el uso de sus conocimientos. 57 la práctica de enfermería en cuidado intensivo las capacidades del ser humano están en constante cambio; por ejemplo, la capacidad para recordar –que es a la vez una bendición y un problema, cuando se recuerda lo que no se desea– puede sufrir distorsiones, lo que no permite recordar los significados y los conocimientos generados por determinadas experiencias de forma que sean útiles para el aprendizaje. una causa de distorsión de las habilidades es la enfermedad que convierte a las personas en pacientes; el concepto “paciente” es definido por travelbee como un “individuo enfermo”, aun cuando también plantea que en realidad no existen los pacientes, sino seres humanos con necesidades para satisfacer. además, advierte sobre el peligro de que este concepto sea usado para una generalización, olvidando por consiguiente las diferencias individuales entre los pacientes. de igual forma que el concepto de ser humano tiene influencia en el comportamiento de los enfermeros y en la calidad del cuidado, el concepto de paciente también la tiene; si bien es cierto que todos los pacientes tienen en común los problema y las debilidades de la condición humana, no se debe olvidar que cada uno de ellos es un ser individual, con requerimientos de cuidado diferentes, y con percepciones de la enfermedad y del sufrimiento que son particulares (1). pero la enfermedad y sus repercusiones no afectan solamente a las personas que la padecen, sino también a los demás miembros de la familia y a sus amistades, influye en sus relaciones, y tiene efectos económicos, sociales y psicológicos (1). las percepciones personales y familiares de la enfermedad dependen de la cultura, del conocimiento previo sobre la enfermedad y los síntomas, del tipo de lesión, del área corporal comprometida, de la forma de afrontar los problemas, de los contactos previos con el personal de salud, y del apoyo y relaciones familiares (1). la enfermedad trae consigo el sufrimiento debido a que genera dolor, alteraciones físicas y psicológicas, la proximidad de la muerte y la desesperanza; el sufrimiento no es común a todas las personas, sino que varía en intensidad, duración y profundidad; cada persona lo vive a su manera, dependiendo de la significancia que se otorga a la experiencia. el sufrimiento genera una serie de respuestas y patrones de conducta en los pacientes; aquéllos con respuestas de rechazo al sufrimiento muestran comportamientos como rabia, depresión, angustia, apatía, rebeldía, temor y culpa dirigida hacia sí mismo o hacia los demás; la respuesta de aceptación se presenta en individuos que entienden el sufrimiento como un cambio o una experiencia a la que son vulnerables y de la cual pueden obtener aprendizajes significativos. en el estudio fenomenológico realizado por del barrio y lacunza (6) con pacientes con transplante hepático se encontró que los pacientes relataron su vivencia en la uci como una experiencia negativa debido a las alteraciones cognitivas, la incomodidad por presencia de vías invasivas, la limitación del movimiento, la incapacidad para hablar, la sed, el ruido y el dolor. existen algunos factores que contribuyen a la aceptación del sufrimiento, entre los cuales están las creencias religiosas, el apoyo familiar, el cuidado de enfermería y una filosofía de vida que considera la vulnerabilidad humana. a este respecto torralba (3) afirma que desde un punto de vista interpersonal, la percepción de el sufrimiento genera una serie de respuestas y patrones de conducta en los pacientes; aquéllos con respuestas de rechazo al sufrimiento muestran comportamientos como rabia, depresión, angustia, apatía, rebeldía, temor y culpa dirigida hacia sí mismo o hacia los demás. 58 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 la enfermedad es mucho más alentadora cuando la persona enferma se siente acompañada y cuidada desde el respeto, desde el cariño y la proximidad; en un estudio fenomenológico realizado por del barrio y cols. (6) se observó que los pacientes críticos encontraban apoyo en sus familias debido a las alegrías que proporcionaban con sus visitas, y porque transmitían consuelo, tranquilidad y optimismo; además, también se apoyaron en sus creencias religiosas y en el cuidado de enfermería el cual percibían como científico y humanístico pues se sintieron bien cuidados, percibían simpatía y buen trato, porque los enfermeros transmitían confianza, seguridad y tranquilidad, y porque demostraban dominio de su labor. las respuestas y los comportamientos que genera la enfermedad deben ser conocidos e identificados por los enfermeros para enfrentar la enfermedad y el sufrimiento de una forma eficaz; se debe ir más allá de comprender los signos y los síntomas, la etiología, los tratamientos y los pronósticos de las enfermedades, y llegar a comprender que el sufrimiento es una experiencia vivida por un ser humano individual, con una historia, costumbres, cultura y apoyos que son diferentes de los demás. para travalbee (1), estar enfermo es estar solo y temeroso. es temer a lo conocido y a lo desconocido, al presente y al futuro; es experimentar el temor de no tener futuro; estar enfermo y con dolor es creer que los que no lo tienen deben estar felices, es deprimirse fácilmente, es experimentar fatiga, malestar y debilidad en el cuerpo, en la mente y en el espíritu. también plantea que las personas se dan cuenta que están enfermas cuando contrastan su presente condición con la situación previa, cuando no tenían la enfermedad, cuando se percatan de la pérdida de habilidad para ver, hablar, tocar, oler, escribir, escuchar, alcanzar y levantar objetos, vestirse y para el cuidado personal. para ofrecer un cuidado de enfermería humanizado los enfermeros deben comprender la enfermedad, el sufrimiento y la muerte como experiencias vividas por seres humanos, asistir a los individuos y las familias a enfrentar la experiencia de la enfermedad y el sufrimiento, y ayudarles a encontrar significado a esas experiencias (1). los pacientes en estado crítico presentan la insatisfacción simultánea de varias necesidades, llegando incluso a poner en peligro la vida. la insatisfacción de necesidades puede depender del compromiso que la enfermedad de base y las complicaciones presentes generan en los órganos y sistemas corporales; como consecuencia, se presenta la pérdida de la independencia en el logro de los requerimientos básicos para recuperar la salud y favorecer el bienestar. además de las limitaciones impuestas por la enfermedad, para el tratamiento se requiere la utilización de sondas, catéteres, instrumentos de monitoreo y de asistencia de funciones corporales, que también suponen restricciones y limitaciones en la realización de actividades y en la comunicación, y generan malestar, sufrimiento y dolor. otro factor que contribuye a la insatisfacción de necesidades es el efecto de algunos medicamentos requeridos como parte de la terapia, comúnmente usados en la uci; entre los efectos causados por los medicamentos están las alteraciones de la conciencia, el mareo y el malespara ofrecer un cuidado de enfermería humanizado los enfermeros deben comprender la enfermedad, el sufrimiento y la muerte como experiencias vividas por seres humanos. 59 la práctica de enfermería en cuidado intensivo tar, la depresión respiratoria, debilidad e inmovilidad, cambios en la nutrición y eliminación urinaria. en determinados casos se utilizan sedantes y relajantes, como ocurre en los pacientes sometidos a ventilación mecánica para disminuir las molestias del procedimiento, favorecer la tolerancia a la vía aérea artificial, facilitar el acople del paciente con el ventilador y asegurar la ventilación. en este tipo de pacientes, para evitar el retiro accidental de los elementos y reducir el riesgo de lesiones por caídas, se recurre a la utilización de inmovilizadores; los miembros superiores, y en muchas ocasiones, también los inferiores, son atados con ligaduras a los bordes de la cama, lo que por supuesto también contribuye a la inmovilidad y genera otros riesgos como lesiones localizadas en el sitio de la ligadura y favorece la aparición de úlceras por presión. los factores descritos y muchos otros afectan la satisfacción de necesidades en el paciente en estado crítico con ventilación mecánica; pero no están solamente comprometidas las necesidades físicas, sino también las psicológicas y sociales. en estas condiciones los pacientes no pueden comunicarse, ni interactuar con otros de la forma como están acostumbrados, no se percatan de recibir el afecto, y no pueden demostrar el suyo a los demás; además, se tornan dependientes de otras personas, en especial de los enfermeros, quienes se encargan de suplir sus necesidades manifiestas. maría expresa que “los pacientes bajo sedación se limitan a proporcionar datos, signos y algunas respuestas de las que enfermería tiene que sacar conclusiones; reciben mucho pero expresan poco; mientras que los pacientes despiertos hablan, dicen con claridad lo que les pasa”. la dependencia de otras personas no se limita al plano físico, también involucra la toma de decisiones. la selección entre opciones y la toma de decisiones que, según travelbee, caracterizan al ser humano, deben ser asumidas por miembros de la familia o del equipo de salud. de otro lado, el sufrimiento en los pacientes sometidos a ventilación mecánica es evidente, y a menudo se observan diverso tipos de respuesta y de comportamiento; las respuestas van desde la aceptación hasta el rechazo, y los comportamientos incluyen la quietud, el llanto, la desesperación y repetidos intentos por retirar los elementos terapéuticos que más frecuentemente generan malestar como el tubo endotraqueal, las sondas nasogástrica y vesical, y los catéteres venosos periféricos. en un estudio realizado por peralta, álvarez y pérez (7), se reportaron 46 extubaciones accidentales, el 41% de éstas fueron autoextubaciones, y el 20% debidas a maniobras inadecuadas del personal; de otro lado, en un estudio realizado por goñi, garcía y vázquez (8), que involucraba a 74 pacientes con vía aérea artificial se reportó una salida accidental del tubo endotraqueal y dos autorretiradas. jablonski (9) encontró que los pacientes describían la intubación como una experiencia extremadamente dolorosa, opresiva, como un proyectil descargado suavemente sobre su vía aérea. en este orden de ideas, especial atención merecen los pacientes sometidos a la ventilación mecánica que están en proceso de retiro, quienes se caracterizan por la mejoría en el patrón y los indicadores respiratorios, y porque sus procesos patológicos van en resolución; se les han retirado los sedantes y los analgésicos que causan compromiso respiratorio; en otras palabras, están alerta, pero aún tiela dependencia de otras personas no se limita al plano físico, también involucra la toma de decisiones. 60 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 nen instalados los elementos terapéuticos y las ligaduras para inmovilizar. ellos solicitan con frecuencia la presencia de los enfermeros, se muestran ansiosos e impacientes para esperar el momento en el cual sean desconectados del ventilador y la vía aérea artificial sea retirada. estos pacientes reciben instrucciones muy claras respecto a la forma de respirar, y son motivados vigorosamente por el personal de enfermería para hacerlo y permanecer despiertos con el fin de que el destete sea exitoso y evitar la reconexión. la comunicación con los pacientes en ventilación mecánica no es fácil; ellos tiene claras limitaciones para expresarse, y para los enfermeros es difícil entender lo que los pacientes quieren; la capacidad para entender los mensajes se logra con la práctica, con los repetidos intentos por hacerse entender, con el desarrollo de códigos y señales mediante el movimiento de los dedos, de las manos, de los ojos, de la cara, de los labios y de la cabeza; incluso en algunas ocasiones los pacientes pueden escribir lo que quieren decir. estas formas de comunicación, en cierta forma precaria, ocasionan con frecuencia que algunos familiares y miembros del equipo de salud se sientan inhibidos para tratar de comunicarse con los pacientes, para expresarles el afecto y ofrecerles las explicaciones que sean necesarias. la situación generada por la enfermedad, el tratamiento, la presencia de elementos terapéuticos y las dificultades en la comunicación provocan variaciones en la interacción con el paciente y afectan, no solo al paciente, sino también a su familia y al equipo de enfermería. esto conduce a los enfermeros a establecer relaciones “simpáticas” (1) motivados por un verdadero interés para ayudar a las personas y por contribuir a la resolución exitosa de su experiencia con una enfermedad grave. juan expresa a este respecto que “un paciente crítico necesita todo nuestro apoyo para continuar siendo quien era y a mí me gusta ayudarle”. la participación de los enfermeros en el cuidado de este tipo de pacientes es de vital importancia pero depende, como plantea travelbee, de la percepción que se tenga de ellos. la comunicación la comunicación es la vía por la cual se lleva a cabo el propósito de la enfermería, que consiste en asistir a un individuo o familia a prevenir y enfrentar la enfermedad y el sufrimiento, y a encontrar los significados de esa experiencia (1). la comunicación tiene lugar en cada interacción enfermero-paciente, se da en la conversación y en el silencio, en lo verbal y en lo no verbal; por el lenguaje simbólico mediante la apariencia, el comportamiento, la postura, la expresión facial y los gestos que comunican ideas, pensamientos y sentimientos, y se otorgan significados tal como se hace con el lenguaje hablado; los enfermeros deben entender el significado de la comunicación con los pacientes y usar esa información en la planeación de las intervenciones (1). en la comunicación los pacientes transmiten sus requerimientos de cuidado y ejercen influencias sobre los enfermeros; los enfermeros, por su lado, ofrecen motivación, instrucción y conocimiento para contribuir a la recuperación del bienestar en los pacientes. las habilidades comunicativas como leer, observar, escuchar, interpretar, hala comunicación tiene lugar en cada interacción enfermeropaciente, se da en la conversación y en el silencio, en lo verbal y en lo no verbal; por el lenguaje simbólico mediante la apariencia, el comportamiento, la postura, la expresión facial y los gestos que comunican ideas, pensamientos y sentimientos, y se otorgan significados tal como se hace con el lenguaje hablado. 61 la práctica de enfermería en cuidado intensivo blar y expresar son requisitos ineludibles para la práctica de la enfermería, debido a que en muchos casos la comunicación enfermero-paciente se lleva a cabo bajo circunstancias que ofrecen barreras y distorsiones; pero estas mismas circunstancias llevan a que la comunicación no verbal –mediante el silencio, los gestos, las expresiones faciales, los movimientos, el llanto o por el contacto o el olor– adquiera un lugar preponderante. mediante la comunicación y la observación el enfermero conoce a los pacientes y obtiene de ellos la información necesaria acerca de sus necesidades, respuestas y sentimientos para tomar decisiones respecto a las estrategias de comunicación o de la terapéutica requerida. la comunicación permite ir más allá del signo o del síntoma, para determinar sus verdaderas implicaciones en el ser humano y la forma como los vive, y establecer su significancia. identificar las necesidades es el primer paso en el proceso de atención del paciente. la relación enfermero-paciente atraviesa por varias etapas que es necesario recorrer; la fase inicial es la del conocimiento y reconocimiento mutuo, en la cual el enfermero valora e identifica las necesidades del paciente, y este último identifica a la persona en la cual depositará su confianza; a continuación de da la fase de empatía que se manifiesta por la comprensión mutua; la tercera fase, o de simpatía, se caracteriza por el deseo de ayudar o de dejarse ayudar, y se establece un lazo de sensibilidad según el cual las emociones y experiencias de uno de los participantes en la interacción afectan al otro (1). otro aspecto que deben tener en cuenta los enfermeros está relacionado con las fallas en la comunicación, de las cuales existe una gran variedad; la primera falla se presenta cuando el interlocutor no es entendido como un ser humano, individual y diferente de los demás, con criterios, experiencias y sentimientos propios; otra falla se presenta cuando los pacientes son incluidos en estereotipos sin un detallado análisis previo, y se les tilda de demandantes, agresivos o poco colaboradores. no captar el real sentido del mensaje expresado es otro tipo de falla de la comunicación; en este caso se le resta importancia o se da por obvio lo que la persona expresa; los síntomas de la enfermedad, la sensación de soledad y de desamparo, el temor, la incertidumbre frente al futuro, la proximidad de la muerte y el sufrimiento persistente, pueden generar en los pacientes la emisión de mensajes que no siempre son claramente entendidos por los enfermeros (1). las dificultades para escuchar también generan fallas en la comunicación y conducen a informaciones difusas e incompletas, a falsas inferencias e incluso, a decisiones erróneas, y pueden ser percibidas por los pacientes y familiares como una falta de interés. otra falla en la comunicación, que es bien frecuente, se presenta cuando se recurre a expresiones tales como “no se preocupe”, “todo estará bien”, “eso no vale la pena”, “hay otros en peor situación que usted” (1); este tipo de expresiones restan importancia a lo que el paciente expresa y siente, representan una manera de evadir la comunicación, son un impedimento para conocer la real situación, por lo cual se restan posibilidades de que las necesidades del paciente sean enfrentadas de forma eficaz. en los pacientes en estado crítico sometidos a ventilación mecánica, las bamediante la comunicación y la observación el enfermero conoce a los pacientes y obtiene de ellos la información necesaria acerca de sus necesidades, respuestas y sentimientos para tomar decisiones respecto a las estrategias de comunicación o de la terapéutica requerida. 62 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 rreras en la comunicación son múltiples; la comunicación verbal de sentimientos y pensamientos no es posible; los gestos, los movimientos, la posición corporal, el llanto y el silencio son los medios más comunes a los cuales recurren los pacientes para comunicarse; los enfermeros desarrollan la habilidad para captar el real significado de los mensajes, debido a que estos son la base para la detección y para la toma de decisiones. sin embargo, existen otros medios a los cuales recurren los enfermeros para obtener la información que los pacientes brindan. otras formas de comunicación que incluyen los equipos de monitoreo cardiaco, de presión arterial, de respiración, oximetría y capnografía, los ventiladores mecánicos y los reportes de laboratorio. esto elementos, unidos a la comunicación gestual, no verbal, son los medios de los que se valen los pacientes para comunicarse con el equipo de enfermería; por tanto los enfermeros tienen como requisito indispensable, para desempeñar su práctica profesional en la uci, desarrollar la capacidad para captar los significados exactos de este tipo de mensajes, debido a que las lecturas e interpretaciones inexactas conducen a decisiones erróneas. acostumbrarse a este tipo de comunicación es difícil, en especial para la familia de los pacientes, pero ellos obtienen mensajes importantes aun cuando no es frecuente que algunos de éstos sepan interpretar la información que ofrece, por ejemplo, un ventilador mecánico; la presencia de este elemento en funcionamiento, al lado de la cama y conectado al paciente, es interpretada como un signo de gravedad en la condición clínica, mientras que su retiro es entendido como un signo de mejoría. esto mismo ocurre con muchos de los elementos terapéuticos que se utilizan en la uci, que generan preocupación entre los familiares porque son asociados con estados de gravedad, mientras que su retiro infunde optimismo al asociarlo con la mejoría. infortunadamente, estas dificultades en la comunicación generan fallas en ella, tal como lo plantea travelbee; con frecuencia se observa que los mensajes emitidos por los pacientes no son comprendidos, lo que hace que expresiones como “todo va a estar bien” y “el paciente es poco colaborador”, sean comunes. conclusiones el cuidado de los pacientes en estado crítico pone a prueba las habilidades, los conocimientos y la experiencia clínica de los enfermeros, no solo por el estado de salud de los pacientes con múltiples necesidades interferidas, sino también por las barreras y distorsiones que se presentan para que la interacción y comunicación con los pacientes ofrezca los resultados que se esperan en términos de contribuir a la recuperación de la salud o a la muerte tranquila. como pudo verse, algunos de los planteamientos de una teórica de enfermería eran puestos en práctica por los enfermeros al llevar a cabo el cuidado con pacientes críticos, aun cuando ellos no tuvieran la pretensión, ni la conciencia de hacerlo. esta situación puede encontrarse en muchos escenarios de cuidado; sin embargo, es de esperarse que se logren mejores resultados en la práctica del cuidado si se lleva a cabo bajo directrices teóricas claramente definidas que dirijan las acciones. en los pacientes en estado crítico sometidos a ventilación mecánica, las barreras en la comunicación son múltiples; la comunicación verbal de sentimientos y pensamientos no es posible; los gestos, los movimientos, la posición corporal, el llanto y el silencio son los medios más comunes a los cuales recurren los pacientes para comunicarse. 63 la práctica de enfermería en cuidado intensivo referencias 1. travelbee j. interpersonal aspects of nursing. philadelphia: davis company; 1966. 2. watson j. nursing: human science and human care. a theory of nursing. boston: jones and bartlett; 1999. 3. torralba f. antropología del cuidar. españa: fundación mapfre medicina; 1998. 4. madjar i. infligir y manejar dolor: un desafío para enfermería. revista investigación y educación en enfermería 2000; xviii (1): 37-47. 5. carper b. fundamental patterns of knowing in nursing. en duran m. enfermería: desarrollo teórico e investigativo. bogotá: facultad de enfermería, universida nacional; 2001. 6. del barrio m, lacunza m, armendáriz a. pacientes con transplante hepático: su experiencia en cuidado intensivo. estudio fenomenológico. enfermería intensiva 2001; 12 (3): 135, 135-139, 141-142. 7. peralta r, álvarez g, pérez y. desarrollo de un sistema de garantía de calidad en ventilación mecánica. enfermería intensiva 2002; 13 (4): 155-163. 8. goñi r, garcía m, vásquez m. evaluación de la calidad de los cuidados en la uci a través de un plan de atención de enfermería informatizado. enfermería intensiva 2004; 15 (2): 76-85. 9. jablonski r. the experience of being mechanically ventilated. qualitative health esearch 1994; 4 (2): 190. 159 169 nutricion.indd 159 mirtha idalia celestino-soto1 bertha cecilia salazar-gonzález2 hilda irene novelo-huerta3 nutrición y desempeño cognitivo del adulto mayor 1 magíster en ciencias de enfermeria. auxiliar de investigación y docente. universidad autónoma de nuevo león. facultad de enfermería. gonzalitos 1500 nte. col. mitras centro monterrey. n.l. méxico. mirtha_idalia@hotmail.com.mx mirtha_idalia@yahoo.com.mx 2 doctor of philosophy (phd). docente y secretaria de investigación. universidad autónoma de nuevo león. facultad de enfermería. gonzalitos 1500 nte. col. mitras centro monterrey. n.l. méxico. bsalazar@fe.uanl.mx 3 magíster en salud púlica. subdirectora de enseñanza y proyectos estratégicos e investigadora del área de nutrición clínica y salud pública. universidad autónoma de nuevo león. facultad de salud pública y nutrición. gonzalitos 1500 nte. col. mitras centro monterrey. n.l. méxico. hnovelo@faspyn.uanl.mx recibido: 14 de marzo de 2008 aceptado: 20 de septiembre de 2008 resumen el objetivo del estudio fue conocer el estado nutricional, la ingesta dietética y su relación con el desempeño cognitivo en 85 adultos mayores que acudían a comedores públicos del área metropolitana de monterrey, méxico, mediante un estudio descriptivo. se utilizó la valoración breve nutricional y la ingesta dietética (observada y complementada mediante un registro de alimentos por tres días seriados); el desempeño cognitivo se evaluó con mini-mental y prueba de trazos. el 58,8% de los participantes obtuvo buen estado de nutrición, 40% riesgo de malnutrición, y 1,2% malnutrición. el 72,1% obtuvo desempeño cognitivo aceptable, el 23,6% desempeño cognitivo inadecuado, y el 3,5% desempeño cognitivo pobre. los resultados mostraron relaciones significativas entre: a) mejor estado de nutrición y mayor consumo de energía, proteínas, carbohidratos, calcio, tiamina, niacina y folatos; b) mejor desempeño cognitivo y mayor ingesta de energía, carbohidratos, proteínas, niacina y cobalamina; en contraparte, c) a mayor edad peor desempeño cognitivo. la relación encontrada entre la valoración breve nutricional, y lo observado y medido mediante el registro de alimentos sugiere que la primera constituye una herramienta útil para enfermería a fin de guiar la preservación del estado nutricional y, por ende, el funcionamiento cognitivo de este grupo poblacional. palabras clave adulto mayor, estado nutricional, memoria inmediata, test de kolmogorov-smirnov. (fuente: decs) elderly adult nutrition and cognitive performance abstract this is a descriptive study designed to detect the nutritional status, dietetic intake and cognitive performance of 85 elderly adults who take their meals at community kitchens in the metropolitan area of monterrey, mexico. a brief nutrition analysis was done, dietetic intake was measured (observed and supplemented with a record of food intake for three-day series), and cognitive performance was evaluated through mini-mental state examinations and trace tests. the nutritional state of 58.8% of the sample group was good, 40% were at risk of malnutrition and 1.2% of the group was malnourished. the cognitive performance of 72.1% was acceptable, while 23.6% displayed inadequate cognitive performance and 3.5% showed poor cognitive performance. año 8 vol. 8 nº 2 chía, colombia octubre 2008 159-169 160 año 8 vol. 8 nº 2 chía, colombia octubre 2008 159-169 aquichan issn 1657-5997 the findings denote a significant association between: a) a better nutritional state and more consumption of energy, proteins, carbohydrates, calcium, thiamine, niacin and folates; b) better cognitive performance and better intake of energy, carbohydrates, proteins, niacin and cobalamine; and c) age and cognitive performance. with respect to the latter, the greater the age, the worse the cognitive performance. the relationship found between the brief nutrition analysis and actual nutrition and that measured by the food record suggests the first is a useful nursing tool to guide the preservation of nutritional state and, therefore, the cognitive performance of people in this age group. key words elderly adult, nutritional state, immediate memory, kolmogorov-smirnov test. nutrição e desempenho cognitivo do adulto maior resumo o objetivo deste estudo descritivo foi conhecer o estado nutricional, a ingestão dietética e sua relação com o desempenho cognitivo de 85 adultos maiores que iam aos comedores públicos da área metropolitana de monterrey, méxico. foi usada a valoração breve nutricional, a ingestão dietética (observada e suplementada com um registro de alimentos por três dias seriais). o desempenho cognitivo foi avaliado com mini mental e proba de trazas. o 58.5% dos participantes logrou bom estado nutricional, 40% risco de mal nutrição e 1.2% mal nutrição. o 72.1% logrou desempenho cognitivo aceitável, 23.6% desempenho cognitivo inadequado e 3.5% desempenho cognitivo deficiente. os achados amostraram relações significativas entre: a) melhor estado nutricional e maior consumo de energia, proteínas, carbohidratos, cálcio, tiamina, niacina e folatos; b) melhor desempenho cognitivo e maior ingestão de energia, carbohidratos, proteínas, niacina e cobalominas; em compensação, c) quanto maior idade pior desempenho cognitivo. a relação achada entre a valoração breve nutricional e o observado e medido com o registro de alimentos revela que a primeira é uma ferramenta útil para enfermagem a fim de orientar a conservação do estado nutricional e, em conseqüência, o funcionamento cognitivo deste grupo de população. palavras-chave adulto maior, estado nutricional, memória imediata, test de kolmogorov-smirnov. 161 nutrición y desempeño cognitivo del adulto mayor mirtha idalia celestino-soto, bertha cecilia salazar-gonzález, hilda irene novelo-huerta introducción en casi todos los países del mundo el grupo poblacional que más rápido crece es el de las personas de edad avanzada. méxico ocupa el séptimo lugar entre los países de envejecimiento acelerado. lo anterior se debe a factores como el descenso de la natalidad, la emigración de la población joven a otros países, la disminución de la mortalidad, el aumento de la esperanza de vida y los avances tecnológicos y médicos (1). para vivir más años en óptimas condiciones se sugiere llevar una alimentación sana y, en consecuencia, poseer un buen estado de nutrición. éste constituye un factor vital para que los adultos continúen con una vida saludable y activa dentro de la familia y la comunidad conforme avanzan en edad. por tanto, la nutrición es considerada un determinante importante para el envejecimiento exitoso, y constituye un estilo de vida modificable (2) (modificación en la que enfermería puede contribuir). las condiciones nutricionales intervienen directamente en la conservación del estado de salud, en el que los procesos cognitivos son de especial relevancia (3). sin embargo, la edad avanzada se considera factor de alto riesgo para los estados de déficit nutricional (4). según la literatura revisada (5, 6), la deficiencia vitamínica puede afectar la memoria y se asocia también a otras deficiencias cognitivas. un deterioro de la función cognitiva en un adulto mayor causa problemas serios en la vida familiar; implica costos adicionales, dependencia de otros miembros de la familia o profesionales de la salud, disminución de la interacción social del adulto, entre otros. dado que el nivel de incidencia de dicho deterioro, y de demencia aumentan fuertemente con la edad, el deterioro cognitivo se convierte en un problema social importante, y puede ser causado o empeorado por deficiencia nutricional. el adulto mayor tiende a consumir una menor cantidad de alimentos por múltiples razones: disminución de la fuerza de contracción de los músculos de masticación, reducción progresiva de piezas dentales, alteración de los umbrales del gusto y el olfato, cambios en la función motora del estómago que disminuyen los procesos de síntesis y secreción de diferentes sustancias, relajación de las paredes gástricas que provoca sensación de saciedad más temprana, y disminución de los mecanismos de absorción (4). un constante y adecuado suministro de nutrientes conduce a un funcionamiento eficaz del sistema nervioso central (snc), en el que las vitaminas del grupo b, incluyendo folatos, juegan un papel importante. si hay alguna deficiencia de estos nutrientes aumentan los niveles de homocisteína en plasma que inhiben los neurotransmisores; como consecuencia se deteriora la función cognitiva del adulto (4). la hipótesis de la hipometilación propone que los folatos y las vitaminas b12 y b6 tienen efecto directo en el funcionamiento del cerebro mediante su rol en el ciclo del uno-carbono, esencial para muchas reacciones de transmetilación con el snc (7, 8). los niveles bajos de folatos llevan a una hipometilación, inhibiendo la síntesis de metionina y de s-adenosilmetionina, que a su vez inhibe muchas reacciones de metilación del snc que involucran proteínas, membranas de fosfolípidos, ácido desoxirribonucleico (adn), y el metabolismo de los neurotransmisores tales como los monoaminos (dopamina, norepinefrina, serotonina), y las melatoninas que son cruun deterioro de la función cognitiva en un adulto mayor causa problemas serios en la vida familiar; implica costos adicionales, dependencia de otros miembros de la familia o profesionales de la salud, disminución de la interacción social del adulto, entre otros. 162 año 8 vol. 8 nº 2 chía, colombia octubre 2008 159-169 aquichan issn 1657-5997 ciales para un buen estado neurológico y psicológico (7, 9, 10, 11). el desempeño cognitivo comprende funciones receptivas, de memoria y aprendizaje, pensamiento y funciones expresivas. el deterioro de las funciones cognitivas específicas se puede manifestar primero entre los 50 y 60 años de edad, con un declive más pronunciado después de los 70 años (12). dentro de la evaluación del desempeño cognitivo, las valoraciones rápidas informan acerca del estado mental; comprenden áreas de orientación, memoria inmediata, atención y cálculo, recuerdo diferido, lenguaje y construcción. el estado nutricional es uno de los diagnósticos de enfermería más utilizados en la práctica clínica para atender las respuestas humanas que se presentan en las personas con alteraciones en el mismo. por ello es necesario explorar el estado nutricional y la ingesta dietética en el adulto mayor. particularmente, es importante conocer la asociación de estas variables con el desempeño cognitivo, que orienten futuros estudios de intervención dirigidos a mantener un buen estado nutricional y evitar en lo posible el deterioro del funcionamiento cognitivo. se planteó la siguiente pregunta de investigación: ¿cuál es la relación entre el estado nutricional, la ingesta dietética y el desempeño cognitivo del adulto mayor? materiales y métodos la población de interés fueron adultos mayores de 60 años que asistían a comedores (uno gubernamental y otro de asistencia social), donde se les proporcionaba la comida (mediodía); la mayoría de las personas que acudían a dicho lugar pertenecían a un estrato socioeconómico bajo. las instituciones a cargo de los comedores regularmente proporcionan la comida de lunes a viernes intentando incluir todos los grupos de alimentos y darles variedad, lo que permite que por lo menos consuman una comida equilibrada al día. el muestreo fue por conveniencia, con una n = 85 participantes. para este estudio se requirió que los adultos mayores supieran leer y escribir, y escucharan sin necesidad de que el entrevistador elevara la voz por encima de su tono acostumbrado. en caso de que el participante obtuviera en el mini-mental de folstein (versión en español) un puntaje < 23 pero > 18 puntos, debía contar con un familiar que también supiera leer y escribir, y aceptara observar y registrar los alimentos que consumía el adulto mayor. se solicitó la autorización correspondiente a las dos instituciones encargadas de los comedores donde se realizó el estudio, y se seleccionaron los participantes potenciales. posteriormente se verificó que los posibles sujetos de estudio cumplieran los criterios de inclusión ya señalados. al participante potencial se le explicó el propósito del estudio, enfatizándole que se le visitaría en su hogar (en tres ocasiones), ya que era necesario que una parte de un formato fuera llenado en el hogar por el/ella o por un familiar. una vez aceptado se iniciaba con el llenado de la cédula de identificación que comprendía las características sociodemográficas, posteriormente se realizaban las mediciones antropométricas. para la función cognitiva se aplicaron el mini mental state examination versión en español (mmse), dentro de la evaluación del desempeño cognitivo, las valoraciones rápidas informan acerca del estado mental. 163 nutrición y desempeño cognitivo del adulto mayor mirtha idalia celestino-soto, bertha cecilia salazar-gonzález, hilda irene novelo-huerta y la prueba de trazos a y b. se cuidó que el ambiente fuera tranquilo y sin presencia de ruido. enseguida, se aplicó el mininutritional assessment (mna), bajo las mismas condiciones, y se concluyó con el registro diario de alimentos. el mmse valora el estado mental y comprende áreas tales como: orientación, memoria inmediata, recuerdo diferido, cálculo, lenguaje y construcción. dicho instrumento tiene un puntaje total de 30 puntos; a mayor puntaje mejor desempeño cognitivo de la persona. un puntaje mayor a 24 se considera desempeño cognitivo normal, menor a 24 pero mayor a 19 se considera desempeño cognitivo inadecuado, y menor o igual a 19 se considera desempeño cognitivo pobre. la prueba de trazos (13) mide la capacidad de dirigir la atención siguiendo una secuencia visual y motora, y consta de dos partes, a y b. la parte a se compone de 25 círculos numerados del uno al 25; se le pide al participante que tome un lápiz y una los números en orden progresivo mediante una línea. con un cronómetro se toma el tiempo que tarda en realizarlo. a menor tiempo en terminar de unir los números mayor capacidad de atención. posteriormente, en la parte b, que consta de 25 círculos (unos con números del uno al trece y otros con letras de la a a la l) se le explica al participante que esta vez unirá los círculos alternando número y letra en orden progresivo, es decir 1-a, 2-b y así sucesivamente. de igual manera, se toma el tiempo que tarde en realizarlo, y también a menor tiempo en terminar de unir los círculos mayor capacidad de atención. el investigador estuvo atento durante la realización de la prueba, y cuando el participante cometía un error, se le daba a conocer deteniéndole la mano y regresándolo al número o letra previo a la equivocación (señalando con una cruz el error cometido), el participante debía corregir y proseguir con la secuencia correcta, mientras el tiempo continuaba su curso. es importante señalar que antes de iniciar ambas pruebas se realizaban ejercicios de ensayo similares, pero que contenían sólo ocho círculos. se verificaba que se hubiera entendido, y se indicaba que tomara el lápiz con su mano separada de la punta a fin de que ésta no tapara el resto de los círculos, y que no despegara el lápiz de la hoja para no perder la secuencia, y corrigiera. la prueba se iniciaba cuando el participante había practicado satisfactoriamente los ejercicios de ensayo. a fin de que estas pruebas reflejaran el sentido positivo con respecto a la prueba del mmse, se obtuvo el inverso del tiempo empleado en cada una, y el cociente se multiplicó por 1000 para eliminar las decimales. es decir, un mayor puntaje reflejaba mejor desempeño. el mna es un instrumento que implica realizar mediciones antropométricas simples y contiene 18 preguntas que abarcan: evaluación antropométrica, evaluación general, evaluación dietética y evaluación propia (percepción de sí mismo en relación con su salud y nutrición). para la evaluación antropométrica se pesa y se mide al entrevistado para obtener el índice de masa corporal (imc), y se mide la circunferencia braquial y de pantorrilla. para obtener la talla del participante se realizó la medición de la altura de la rodilla debido a que algunos adultos mayores con osteoporosis suelen presentar curvatura de la columna vertebral y desgaste óseo, por lo que la talla medida con un estadímetro no es exacta. una vez obtenida la medición de rodilla se aplicó la fórmula para este estudio se requirió que los adultos mayores supieran leer y escribir, y escucharan sin necesidad de que el entrevistador elevara la voz por encima de su tono acostumbrado. 164 año 8 vol. 8 nº 2 chía, colombia octubre 2008 159-169 aquichan issn 1657-5997 de chumlea et ál. para hombres: talla en cm = [2,02 x altura rodilla (cm)] [0,04 x edad] + 64,19, y para mujeres: talla en cm = [1,83 x altura rodilla (cm)] [0,24 x edad] + 84,88) (14). la evaluación general comprende seis preguntas acerca de estilos de vida, movilidad y medicación. en la evaluación dietética se realizan ocho preguntas sobre el tipo de dieta y líquidos ingeridos, número de comidas y autonomía de la alimentación. en la evaluación propia se cuestiona acerca de la percepción personal de salud y nutrición. el instrumento posee un puntaje máximo de 30, significa que a mayor puntaje mejor estado de nutrición, un puntaje de 17 a 23,5 puntos indica que hay riesgo de malnutrición, y menor de 17 puntos se considera malnutrición (15). el registro diario de alimentos fue llenado por el participante o por un familiar, y complementado por el investigador. como se señaló, se realizó una parte en el hogar, y otra en el comedor por tres días. durante los tres días el participante o su familiar se encargó de reportar por escrito los alimentos que consumía fuera del comedor (desayuno y cena), además de las cantidades y los modos de preparación. en el transcurso de los días del registro el entrevistador visitó al participante y lo cuestionó acerca del reporte realizado el día previo con el objetivo de reafirmar datos y añadir en caso de existiera algún dato no reportado en el formato. adicionalmente a la observación de la comida (en los comedores) el entrevistador cuestionó a las personas que preparaban los alimentos, auxiliándose de la lista de los ingredientes utilizados, acerca de las condiciones bajo las que se cocinaban, y el tamaño de las porciones servidas a cada persona. con el fin de tener un mejor control en la observación y el registro de los alimentos, el plato de cada participante se rotuló con su nombre, y al final se recogieron sus platos y se registró la ingesta de alimentos consumidos y sin consumir. análisis de los resultados se aplicó estadística descriptiva para conocer las características sociodemográficas de los participantes y de los instrumentos aplicados, se obtuvieron frecuencias y medidas de tendencia central. para conocer la distribución de las variables se utilizó la prueba de kolmogorov-smirnov; para analizar el objetivo se utilizó el coeficiente de correlación de spearman porque las variables no prestaron distribución normal. se realizó análisis de varianza no paramétrica (kruskal wallis), y se aplicaron diferencias de medianas de acuerdo con la ingesta (según la categoría) mediante pruebas de u de mann whitney. para conocer la ingesta dietética y las cantidades consumidas de nutrientes se recurrió al nutris versión 1.0 (16). resultados los resultados corresponden a 85 adultos mayores. el promedio de edad fue de 70,82 + 7,14 años, el 83,5% (71) correspondió al sexo femenino. el 57,6% (49) señaló no tener pareja. el promedio de años de educación formal fue de 4,75 + 2,84 años. el desempeño cognitivo medido por el mmse, y según los criterios establecidos originalmente por el autor, mostró al 72,1% (62) dentro del rango aceptable (24-30 puntos), el 23,6% (20) con un desel mmse valora el estado mental y comprende áreas tales como: orientación, memoria inmediata, recuerdo diferido, cálculo, lenguaje y construcción. 165 nutrición y desempeño cognitivo del adulto mayor mirtha idalia celestino-soto, bertha cecilia salazar-gonzález, hilda irene novelo-huerta empeño cognitivo inadecuado (< 24, > 19 puntos) y el 3,5% (3) con un desempeño cognitivo pobre (< 19 puntos). en relación con el riesgo de malnutrición medido por el mna se obtuvieron los siguientes resultados: el 58,8% (50) se ubicó dentro de un buen estado de nutrición (< 23,5 puntos), el 40% (34) presentó riesgo de malnutrición (< 17 pero > 23,5 puntos), y el 1,2% (1) se encontró en la categoría de malnutrición. los participantes con menor edad reportaron tener mayor grado de escolaridad (p = ,011). los coeficientes de correlación mostraron que a mayor edad menor desempeño cognitivo medido por el mmse (p < ,001) y por las dos pruebas de trazos (p < ,01). a más años de educación mejor desempeño cognitivo (mmse y trazos a y b) y buen estado de nutrición (todas p < ,01). congruente con ello se encontró relación negativa entre los años de educación y los errores obtenidos en la prueba de trazos a y b, es decir, a más años de educación menor cantidad de errores (tabla 1). los coeficientes de correlación mostraron que a mayor ingesta de energía, carbohidratos, proteínas, niacina y cobalamina, mejor fue el desempeño cognitivo medido por el mmse. así mismo, a mayor ingesta de energía, carbohidratos, proteínas, tiamina y niacina, mejor desempeño en la prueba de trazos a y b; y a mayor consumo de calcio se observó mejor desempeño en trazos a. por último, se observó que a mayor consumo de energía, proteínas, carbohidratos, calcio, tiamina, niacina y folatos mejor estado nutricional reportado por los adultos mayores (p < , 05) (tabla 2). finalmente, se exploraron las diferencias de medianas de los nutrientes según su categorización con el desempeño cognitivo y el estado nutricional, se aplicaron series de análisis de varianza no paramétrica (kruskal wallis). a todos los nutrientes que mostraron diferencias significativas se les aplicaron las pruebas de u de mann whitney a fin de explorar las diferencias de acuerdo con todas las categorías de los mismos. para evitar el error tipo 1, por las múltiples comparaciones, se ajustó el valor de p =,004. el desempeño cognitivo mostró diferencia de medianas en la ingesta de energía y piridoxina (p < ,003). los participantes con ingesta aceptable mostraron mejor desempeño cognitivo en comparación con aquellos con ingesta deficiente. el estado nutricional obtuvo diferencia de medianas en la niacina, los participantes con ingesta en exceso tuvieron mejor estado nutricional que aquellos con una ingesta deficiente (p < ,001). se concluye que el desempeño cognitivo se asocia con la edad y la escolaridad. a mayor ingesta de nutrientes mejor desempeño cognitivo y estado nutricional (tabla 3). tabla 1. correlación entre variables demográficas y del estudio los coeficientes de correlación mostraron que a mayor ingesta de energía, carbohidratos, proteínas, niacina y cobalamina, mejor fue el desempeño cognitivo medido por el mmse. 1 2 3 4 5 1. edad - 2. años de educación 0-,274 * - 3. mmse 0-,377** 0,563** - 4. trazos a y b 0-,481** 0,562** 0,697** - 5. errores de trazos a y b 00,089 -,368** -,555** -,602** -6. mna 00,116 0,264* 0,263** 0,260* -,310** *p < ,05; **p <,01 fuente: cédula de datos, mmse, trazos a y b, mna. 166 año 8 vol. 8 nº 2 chía, colombia octubre 2008 159-169 aquichan issn 1657-5997 tabla 2. correlación entre nutrientes, desempeño cognitivo y estado nutricional *p < ,05; ** p < ,01 fuente: registro diario de alimentos, mmse, trazos a y b, mna. tabla 3. diferencia de ingesta de nutrientes con variables de estudio fuente: registro diario de alimentos, mmse, trazos a y b, mna. mmse trazos a trazos b mna energía ,246*+ ,362** ,306** ,275*+ carbohidratos ,238*+ ,276*+ ,223*+ ,281** proteínas ,227*+ ,344** ,285** ,384** fibra ,092** ,198** ,098** ,278** calcio ,076++ ,222*+ ,162++ ,442** fósforo ,117** ,201** ,146** ,228** hierro ,142** ,249** ,181** ,297** magnesio ,171** ,354** ,270** ,392** sodio ,074** ,256** ,250** ,267* potasio ,202** ,356** ,256** ,399** zinc ,130** ,313** ,240** ,335** acido ascórbico ,043** ,203** ,369** ,257** tiamina ,210++ ,369** ,307** ,294** riboflavina ,268** ,197** ,305** ,326** niacina ,251*+ ,353** ,321** ,314** piridoxina ,290** ,370** ,290** ,275*+ cobalamina ,214*+ ,173++ ,164++ ,104++ folatos ,046++ ,080++ -,036++ ,214*+ mmse categoría de nutrientes mediana u de valor mann-whitney de p energía deficiente 24a 204 ,003 aceptable 27b piridoxina deficiente 2,73a 213 ,002 aceptable 4,63b mna niacina deficiente 23,50a 240 ,001 exceso 25,50b discusión el desempeño cognitivo medido por el mmse y por la prueba de trazos a y b, se relacionó negativamente con la edad, similar a lo reportado en estudios realizados en corea, españa y estados unidos (5, 17, 18). de acuerdo con lee et ál. (5), la mayoría de las personas mayores sufren una declinación en la función cognitiva que puede deberse a factores de riesgo relacionados con la edad, tales como la demencia y las enfermedades cardiovasculares, así como con el envejecimiento propio. de igual manera, el desempeño obtenido en las pruebas de trazos a y b se relacionó positivamente con los años de educación formal, lo cual coincide con lo encontrado por jansen y keller (18). se reportaron datos semejantes respecto a la relación positiva encontrada entre el desempeño cognitivo obtenido en el mmse y la prueba de trazos a y b con algunas de las vitaminas del complejo b. una explicación es que la ingesta de vitaminas del complejo b puede tener efecto directo o indirecto en el metabolismo de los neurotransmisores, que su vez preservan la integridad cerebro-vascular (12). en relación con la ingesta de piridoxina se obtuvo relación positiva con el desempeño cognitivo, lo cual coincide con la investigación realizada por bryan y calvaresi (19). respecto a la ingesta de niacina se obtuvo relación en la misma dirección que la piridoxina, dato similar a lo encontrado en un estudio realizado en corea por lee et al. para la ingesta de cobalamina este estudio encontró también una relación positiva, lo cual se asemeja con las investigaciones realizadas por bryan y calvaresi (19), lee et ál. (5), y morris et ál. (20). 167 nutrición y desempeño cognitivo del adulto mayor mirtha idalia celestino-soto, bertha cecilia salazar-gonzález, hilda irene novelo-huerta sin embargo, la ingesta de folatos en esta muestra no mostró asociación con el desempeño cognitivo, lo cual difiere con lo reportado en otros estudios que señalan relación positiva (17, 19). otra investigación consultada reportó relación negativa, los autores atribuyeron dicho resultado a que la alta ingesta de folatos enmascara una deficiencia de vitamina b12 (20). es importante señalar que de acuerdo con la literatura, una deficiencia de folatos aumenta los niveles de homocisteína, lo cual provoca la inhibición de los neurotransmisores, y como consecuencia se deteriora la función cognitiva. es probable que la falta de relación en este estudio se deba a la amplia desviación respecto a la media observada. la ingesta recomendada para este nutriente de acuerdo con el nutris es de 400 microgramos; en la presente investigación se encontró que el 75,3% (n = 64) tuvo un consumo por debajo de dicha recomendación. respecto a la ingesta de vitamina c (ácido ascórbico) se encontró que a mayor ingesta mejor desempeño cognitivo de acuerdo con la prueba de trazos b, lo cual coincide con una de las investigaciones realizadas en españa, donde reportaron que la ingesta de vitamina c fue mayor en adultos mayores de 75 años con un desempeño cognitivo satisfactorio. la vitamina c constituye uno de los antioxidantes más importantes, y está implicada en la producción de los neurotransmisores que son cruciales para la memoria y la función mental (17). la ingesta de macronutrientes mostró relación positiva con el desempeño cognitivo, particularmente de la energía, carbohidratos, proteínas, lo cual coincide con los datos reportados por estudios realizados en corea, finlandia, italia y países bajos (5, 21, 22). de acuerdo con estos resultados se concluye que la nutrición tiene un papel importante en la capacidad cognitiva. si la dieta del adulto mayor es variada y suficiente, conduce al correcto funcionamiento del cerebro (17). conclusiones las valoraciones realizadas para medir el desempeño cognitivo se relacionan negativamente con la edad y positivamente con los años de educación formal. la ingesta adecuada de nutrientes se relaciona positivamente con el desempeño cognitivo y el estado nutricional. los participantes con una ingesta adecuada tuvieron mejor desempeño cognitivo y estado nutricional en comparación con aquellos con una ingesta deficiente. las correlaciones entre la ingesta de nutrientes y el estado nutricional (mna) reflejan que este último constituye una buena valoración en el adulto mayor. es importante destacar la participación del gobierno en la entrega de alimentos que brinda a los adultos mayores de escasos recursos a través de los comedores gratuitos, ya que coadyuvan a preservar su integridad cognitiva permitiéndoles tener una mejor calidad de vida. aunque no fue el objetivo del estudio, se observa que esto favorece una mayor socialización y, a la vez, mantenerse alerta y activo. la aplicación del mna refleja el estado nutricional del adulto mayor, lo cual permite en el caso especial de enfermería conocer el estado en que se encuentra. una deficiencia de folatos aumenta los niveles de homocisteína, lo cual provoca la inhibición de los neurotransmisores, y como consecuencia se deteriora la función cognitiva. 168 año 8 vol. 8 nº 2 chía, colombia octubre 2008 159-169 aquichan issn 1657-5997 recomendaciones profundizar sobre la ingesta dietética a través de mediciones biológicas, con el fin de conocer de manera precisa los niveles de micro y macronutrientes de los participantes. contemplar igual número de participantes femenino y masculino bajo características sociodemográficas semejantes para conocer las diferencias en el desempeño cognitivo. realizar un estudio en población abierta incluyendo diversos estratos socioeconómicos para conocer las diferencias nutricionales y cognitivas. realizar estudios de seguimiento para valorar los cambios cognitivos que ocurren conforme aumenta la edad y se modifican los hábitos dietéticos. referencias 1. rico r, martínez p, romero c, vargas e, gómez b, tezoquipa i. información científica para el cuidado de enfermería: promoción de la salud del adulto en plenitud. instituto nacional de salud pública 2004; 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52: 826-831. 22. correa l, nicolosi a, cristina s, hauser w, nappi g. nutrition and cognitive deficit in the elderly: a population study. european journal of clinical nutrition 2001; 55: 1053-1058. 8 la ansiedad.p65 la ansiedad en niños hospitalizados 207 año 7 vol. 7 nº 2 • chía, colombia octubre 2007 • 207-218 paulina aguilera pérez1 martha v. whetsell 2 resumen este estudio investigó la relación del nivel de ansiedad y el evento de hospitalización en una población mexicana de niños de 7 a 11 años de edad. el estudio se basó en el modelo de adaptación de roy. el diseño fue descriptivo y correlacional, el muestreo fue probabilístico, sistemático con inicio aleatorio. la muestra (n=155) con un nivel de significancia de 0,05, para una diferencia de media de 1,6 y un efecto de potencia de 80. el instrumento utilizado fue el cuestionario �¿cómo me siento?� (c-1 del state-trait anxiety inventory for children, staic) de spielberger. presentó una alpha de cronbach de ,94. se utilizó la prueba anova para mediciones repetidas que resultó significativa (f (2, 308) = 1327,09, p < 0,001). la edad osciló entre 7 y 11 años de edad. la muestra (54%) corresponde al sexo masculino, el 49,3% señaló haber tenido admisión previa hospitalaria. la prueba de kolmogorov smirnov no mostró distribución normal. el coeficiente de correlación de spearman mostró correlación negativa significativa en el momento tres. para cada momento se ajustó un modelo de regresión lineal múltiple donde las variables independientes fueron sexo, edad y admisiones previas sobre el índice de ansiedad, el modelo significativo ocurrió en el tercer momento en cuanto a la edad, es decir, a mayor edad menor nivel de ansiedad. palabras clave ansiedad, hospitalización. (fuente: decs, bireme). recibido: 29 de junio 2007 aceptado: 20 de agosto de 2007 1 universidad de tamaulipas, matamoros 8 y 9 col. centro c.p. 87000 cd. victoria tamaulipas, méxico. lyngeo@prodigy.net.mx 2 lehman collegg of nursing, 431 gillet hall, 250 bedford park blvd. west bronx, n.y. 10468 estados unidos marwhet@hotmail.com aquichan issn 1657-5997 la ansiedad en niños hospitalizados la ansiedad en niños hospitalizados aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007208 anxiety in hospitalized children abstract objectives: to determine the level of anxiety among children ages 7 to 11 during and after hospitalization, the effect of which varies in intensity and fluctuates with time; to explore the relationship between that level and ages; and to detect the level of anxiety with respect to gender, prior admissions and the moment of hospitalization. materials and methods: a descriptive and correlational study was done using a systematic probabilistic sample initiated at random. sample size: 155 children. procedure: measurements taken at three points in time during and after hospitalization. point one: 12 hours after admission; point two: 12 hours prior to release; and point three: 10 days after release. a multiple linear regression model was adjusted for each point in time; the independent variables were sex, age and prior admissions compared to the anxiety index. place: a second tier institution in tampico, tamaulipas. instrument: �how do i feel?� questionnaire (c-1 of spielberger�s state-trait anxiety inventory for children, staic). reliability ratio: cronbach�s alpha =.94. results: the average rates of anxiety at the three points in time are not equal, as demonstrated by the anova test for repeated measurements, which proved to be significant (f (2, 308) = 1327.09, p < 0.001). the kolmogorov smirnov test did not show normal distribution. spearman�s correlation coefficient showed a significant negative correlation at point three, with respect to age. in other words, the older the child, the lower the level of anxiety. given the high reliability of the inventory, it is recommended the measurement be repeated at 30 days after release from the hospital. key words anxiety, hospitalization. a ansiedade nas crianças hospitalizadas resumo objetivos: determinar o nível de ansiedade nas crianças de 7 a 11 anos durante e depois da hospitalização, cujo efeito é variável na intensidade e flutua no tempo; explorar a relação entre este nível e a idade, e conhecer o nível de ansiedade com respeito ao sexo, as admissões previas e ao momento da hospitalização. material e métodos: foi realizado um estudo descritivo e co-relacional com uma amostra probabilística sistemática com começo aleatório. tamanho da amostra: 155 crianças. procedimento: medições em três momentos durante e depois da hospitalização. momento 1: 12 horas posteriores ao ingresso. momento 2: 12 horas antes da saída. momento 3: 10 dias depois da saída. em cada momento se ajustou um modelo de regressão lineal múltiplo no que as variáveis independentes foram sexo, idade e admissões previas sobre o índice de ansiedade. lugar: instituição de segundo nível de tampico, tamaulipas, méxico. instrumento: questionário como me sinto? (c-1 do state-trait anxiety inventory for children, staic) de spielberger. coeficiente de confiabilidade: 94 mediante o alpha de cronbach. resultados: os índices média de ansiedade dos três momentos não são iguais, como foi mostrado por a prova anova par medições repetidas, que resultou significativa (f(2, 308) = 1327,09, p < 0,001). a prova de kolmogorov-smirnoff não mostrou distribuição normal. o coeficiente de co-relação de spearman revelou co-relação negativa no momento 3; quanto a idade, a maior idade menor nível de ansiedade. dada a alta confiabilidade do levantamento, é recomendado repetir a medição aos 30 dias da saída do hospital. palavras-chaves ansiedade, hospitalização. la ansiedad en niños hospitalizados 209 introducción a hospitalización, por su naturaleza, representa un evento que causa ansiedad (1-3), y se reconoce como el evento que produce mayor ansiedad en los niños (4-6). la percepción de éstos en la experiencia de hospitalización excede sus capacidades para poder resolverla y afrontarla, lo que los lleva a presentar estados de ansiedad (7, 8). los efectos de la ansiedad en los niños durante y después de la hospitalización pueden persistir por semanas o meses después del egreso (9), y en algunos casos hasta la edad adulta (10, 11). las reacciones en el niño que experimenta ansiedad son diversas e incluyen conductas de agresión física y verbal (12, 13), así como cambios afectivos y de actitud (12). de acuerdo con la opinión de expertos se han identificado respuestas emocionales negativas en algunos niños en el periodo poshospitalario. estas respuestas incluyen problemas alimentarios, alteraciones en sueño, ansiedad incrementada ante la separación, temores, preocupaciones por su cuerpo, regresión a un nivel de conducta previo, y síntomas somáticos tales como tics y enuresis (14). se calcula que entre un 15 y 20% de la población mundial padece, o padecerá a lo largo de su vida, problemas de salud relacionados con la ansiedad, con importancia suficiente como para requerir tratamiento (15). está documentado en las estadísticas de méxico que el 10% de la población infantil se hospitaliza por diversas razones en algún momento de la infancia; en tamaulipas, el 16% de los ingresos de hospitalización ocurren en el área de pediatría (16). diversos autores han sugerido el estudio de las respuestas de ansiedad en los niños hospitalizados con variables como la edad, el sexo, la duración de la hospitalización y admisiones previas (17-21). es así como astin (1), barton (2) y farquhar (3) afirman que los niños hospitalizados presentan mayor nivel de ansiedad que los niños que no han sido hospitalizados. la relación positiva entre el nivel de ansiedad y la duración de la hospitalización es evidenciada por diferentes investigadores (2, 9, 22-26). las admisiones previas de hospitalización y mayor nivel de ansiedad en el niño, que presenta diversas manifestaciones como enojo, agresión y vulnerabilidad, muestran una relación directa según lo reportan diferentes estudios (27, 28). la edad sugerida como variable de estudio en relación con el nivel de ansiedad muestra relación negativa; según lo reportado en algunos estudios, el mayor nivel de ansiedad se presentó en niños más pequeños (29-33). algunos autores han encontrado resultados discrepantes en cuanto a la asociación del género y el nivel de ansiedad (12); así, tsigounis (28) reportó en su estudio que los varones presentaron los mayores niveles de ansiedad, mientras que edwards (34) reportó un mayor nivel de ansiedad en las niñas. las investigaciones realizadas en pediatría hasta inicios de la década de los noventa habían enfocado su atención en el análisis de las respuestas de ansiedad del niño durante la poshospitalización, desde la percepción de los padres como observadores de las conductas de sus hijos y no desde la perspectiva de los niños (35-38). kain, mayes, o�connor y cicchetti (39) estudiaron el estado de ansiedad preoperatoria en niños y encontraron relación significativa positiva entre la edad, el sexo y las admisiones previas de los niños y el nivel de ansiedad. es importante señalar que en méxico no se aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007210 localizaron estudios relacionados sobre respuestas de ansiedad desde la percepción del niño hospitalizado, por lo que se pretende explorar este fenómeno para contribuir a su conocimiento. la ansiedad en niños hospitalizados se abordó desde la perspectiva teórica de lazarus y folkman (40), y se define como la relación particular entre el individuo y el entorno que es evaluado por éste como amenazante o desbordante de sus recursos, y que pone en peligro su bienestar. posteriormente se abordan los conceptos de ansiedad de spielberger (41), basados en lazarus y folkman (40), en el preoperatorio. la ansiedad presente en el ser humano oscila desde una respuesta adaptativa hasta un trastorno incapacitante. es decir, que bajo condiciones normales, mejoran el rendimiento y la adaptación al medio social y académico. el estado de ansiedad puede movilizar a la persona frente a situaciones amenazantes o preocupantes, de forma que hace lo necesario para evitar el riesgo, neutralizarlo, asumirlo o afrontarlo adecuadamente. sin embargo, cuando sobrepasa determinados límites, la ansiedad se convierte en un problema de salud, impide el bienestar, e interfiere notablemente en las actividades sociales e intelectuales. cada persona, según su predisposición biológica o psicológica, se muestra más vulnerable o susceptible a unos u otros síntomas. algunos de estos síntomas se manifiestan de manera significativa en alteraciones o trastornos de la ansiedad como fobias y temores. diversos autores (42, 43) han tratado de establecer una función que exprese el paso de la activación saludable, favorecedora del rendimiento y la adaptación, a la patógena, generadora de inadecuación y enfermedades. lazarus (44), tratando de superar las definiciones de ansiedad en términos de estímulo o respuesta predominantes hasta esa fecha, la define como una relación particular entre el individuo y el entorno, que es evaluada por éste como amenazante o desbordante de sus recursos, y que pone en peligro su bienestar. el proceso a través del cual la persona maneja las demandas de la relación individuoambiente que evalúa como estresante, y las emociones que ello genera, se denomina afrontamiento. la ansiedad tiene que ver con el hecho de sentirse en riesgo, spielberger (41) define el estado de ansiedad como las sensaciones subjetivas, conscientemente percibidas de manera transitoria, es decir, que la aprehensión, tensión y preocupación varían en intensidad y fluctúan en un cierto plazo de tiempo. la ansiedad es característica de la sociedad actual, y existen importantes indicios de que cuando es elevada es un problema para muchos niños y adolescentes, repercutiendo en su desarrollo psicológico y social. las categorías utilizadas para el estudio de las respuestas de ansiedad en el adulto no resultan adecuadas cuando se aplican a los niños, dado que ellos experimentan eventos vitales propios de su desarrollo y crecimiento, donde la presencia de ansiedad puede ser normal a cierta edad y llegar a ser incapacitante pocos años después, transformándose en trastornos de ansiedad como fobias (45). algunos estudios han reportado las respuestas de ansiedad en niños que han sido hospitalizados. tiedeman (46) ubica a la hospitalización como una situación estresante que representa una variedad de amenazas reales o imaginarias, tanto para los niños como para sus familias. el niño que es hospitalizado debe obtener especial atención en lo que se refiere a comunicación, ya que debido a su edad y al estado de su desarrollo cognitivo sus preguntas no reflejan sus dudas ni tampoco evidencian la ansiedad que tienen acerca de los cuidados que se les impartirán (47). bossert (48) estudió el nivel de ansiedad en 82 niños de 8 a 11 años hospitalizados a través de la escala de ansiedad estado-rasgo de spielberger (41) (beta-,259, índice de confiabilidad de ,05); había 20 niños de 8 años de edad, 16 de 9 años, 19 de 10 años, y 27 niños de 11 años, siendo el promedio de edad 9,6 años (de = 1,2). la distribución por género fue del 50%. veintiún niños fueron admitidos a hospitalización por padecimientos de tipo agudo (fracturas, infección respiratoria y apendicetomía), y 61 por padecimientos de tipo crónico (leucemia, rabdomiosarcoma y artritis juvenil reumatoide). se obtuvo un índice promedio global de 24 de 53 puntos de la escala total de 20 a 60 puntos para hombres y mujeres, los varones obtuvieron un índice de 38,1 (de = 6,6). los niños mostraron mayor nivel de ansiedad que las niñas. kain, mayes, o�connor y cicchetti (39) efectuaron un estudio de tipo prospectivo longitudinal en 163 niños de 2 a 10 años de edad a partir de las mediciones repetidas del nivel de ansiedad en el preoperatorio de cirugía ortopédica (dos semanas, 6 meses y un año). se aplicó una regresión múltiple (r2 = 0,42, f 3 = 8,2, p =,001), los niños mantuvieron una relación significativa del nivel de ansiedad a través del tiempo; 54% de los niños presentaron alteraciones de conducta asociadas a ansiedad a la ansiedad presente en el ser humano oscila desde una respuesta adaptativa hasta un trastorno incapacitante. es decir, que bajo condiciones normales, mejoran el rendimiento y la adaptación al medio social y académico. la ansiedad en niños hospitalizados 211 las dos semanas, el 20% mantuvo efectos de ansiedad a los 6 meses, y el 7,3% al año aún presentaba efectos de ansiedad. lamontagne, hepworth y salisbury (26), examinaron las respuestas de ansiedad en 74 niños de 8 a 17 años (m = 13,5, de = 2,1 años) a través del tiempo en la admisión para tratamiento médico-quirúrgico y en el posoperatorio, y encontraron un incremento en el nivel de ansiedad en los niños del momento preoperatorio al posoperatorio. teichman, ben y lerman (49), estudiaron las respuestas de ansiedad en los niños hospitalizados reportando un elevado nivel de ansiedad como efecto de la hospitalización con duración variable después del egreso. pottinger y ehikhametalor (50), en su estudio en niños de 3 a 13 años con historia de admisiones previas, reportaron elevados niveles de ansiedad como efecto de la hospitalización. tiedeman y clatworthy (8), al examinar las respuestas de ansiedad desde la perspectiva de los niños de 5 a 11 años (n = 52) durante y después de la hospitalización reportaron que éstos mostraron una disminución en la ansiedad de la admisión al momento del alta, mientras que la ansiedad se mantuvo más o menos constante del alta a la poshospitalización. los niños de 5 a 7 años, varones y que nunca habían sido hospitalizados, presentaron más ansiedad y no mostraron disminución a través del tiempo. thompson (51) estudió las respuestas de ansiedad en 43 niños de 8 a 12 años durante y después de la hospitalización por intervención quirúrgica electiva para lo que se utilizó el staic en relación con la edad, el sexo, las admisiones previas, el tiempo de hospitalización y la información previa recibida. el índice global de ansiedad obtenido por el staic fue de 26 de 55 puntos de la escala total de 20 a 60 puntos, para los varones se obtuvo una media de 36,91 (de = 6,34). el coeficiente de correlación de pearson aplicado a las variables demográficas no reportó relación significativa con el nivel de ansiedad del niño hospitalizado. en síntesis, la revisión de la literatura permitió concluir que la edad, el género, el tiempo y las admisiones previas son factores que influyen en la presencia de ansiedad en el niño que es admitido a servicios de hospitalización pediátrica por padecimientos agudos o crónicos que requieren tanto tratamiento médico como quirúrgico. marco teórico esta investigación se guió por el modelo de adaptación de callista roy (ram) (52), y está enfocada particularmente a estudiar si existe una correlación entre los niveles de ansiedad y la hospitalización de niños. el ram provee las bases para conceptualizar relaciones mediante la identificación de conceptos cognitivos y emocionales positivos que puedan ayudar al proceso de enfrentamiento a los cambios que se producen durante la experiencia de hospitalización en los niños. el evento de hospitalización actúa como estímulo focal que confronta el niño en su modalidad adaptativa de autoestima. los estímulos contextuales como los factores demográficos de edad, género y admisiones previas tienen una influencia en el efecto del estímulo focal. hipótesis 1. los niveles de ansiedad cambian a través del tiempo de hospitalización de los niños. 2. existe relación entre la edad y los niveles de ansiedad. 3. existe diferencia en los niveles de ansiedad por sexo, tiempo de hospitalización y admisiones previas. material y métodos diseño descriptivo correlacional (53), la población la conformaron niños de 7 a 11 años que fueron admitidos en unidad hospitalaria representativa del sector público. los niños fueron hospitalizados por problemas de salud agudos o crónicos, y para recibir tratamiento médico o quirúrgico. se realizó un muestreo probabilístico sistemático con un inicio aleatorio de uno de cada tres; se obtuvo a través del paquete n query advisor 2.0 (54) estimada para un 95% de nivel de confianza, para una diferencia de medias de 1,6, un tamaño de efecto de ,32 con una desviación estándar de 5 y una potencia de 80%. se obtuvo un tamaño de muestra de 155 niños. la selección de participantes fue de inicio aleatorio, uno de cada tres de los niños hospitalizados ubicados en tiempo, espacio y persona para responder las preguntas (valorado a través de las preguntas: ¿cuál es tu nombre?, ¿dónde estás?, ¿qué día es hoy?). se excluyeron los niños con diagnóstico de retardo en el desarrollo para su edad de acuerdo con la valoración de denver. la edad, el género, el tiempo y las admisiones previas son factores que influyen en la presencia de ansiedad en el niño que es admitido a servicios de hospitalización pediátrica por padecimientos agudos o crónicos que requieren tanto tratamiento médico como quirúrgico. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007212 la medición se realizó con el cuestionario �¿cómo me siento?� (c-1 del state-trait anxiety inventory for children, staic) de spielberger (41). para el uso y la reproducción de este cuestionario se adquirió la licencia en la agencia autorizada por el autor; además de una cédula de datos personales. el cuestionario es una escala con 20 ítemes para la subclase estado (state c-1); fue diseñado para medir las sensaciones transitorias percibidas de manera consciente en niños de 5 a 15 años ante eventos productores de ansiedad que varían en intensidad y fluctúan en el tiempo. el cuestionario y la cédula fueron aplicados por una de las investigadoras, el tiempo recomendado por los autores es de 8 a 12 minutos para niños de la edad elegida. se obtuvo el consentimiento informado por escrito de los padres de los niños seleccionados, y el consentimiento verbal de los participantes de acuerdo con los criterios de inclusión. la aplicación del cuestionario se efectuó a las 12 horas después del ingreso hospitalario del participante, se realizó en su unidad pediátrica y representó el momento uno (m1). la segunda medición se realizó 12 horas antes del egreso hospitalario del participante en su unidad pediátrica, y representó el momento dos (m2). la tercera medición se efectuó entre los siete y diez días posteriores al egreso hospitalario del participante en el área de consulta externa al acudir a cita de control, lo que representó el tercer momento (m3). en el análisis de los resultados se aplicó estadística descriptiva e inferencial; para el procesamiento de la información se utilizó el paquete estadístico spss v10.0 (statistical package for the social sciences). se obtuvo la estadística descriptiva e inferencial. para la estadística descriptiva se obtuvieron frecuencias, proporciones, medidas de tendencia central y de variabilidad. se aplicó la prueba de normalidad de kolmogorov-smirnov para variables continuas. la estadística inferencial utilizada fueron pruebas no paramétricas. para la hipótesis uno se calculó anova para mediciones repetidas, incluyendo la prueba de esfericidad de mauchly a las varianzas de ansiedad, pruebas de efectos de ansiedad entre sujetos en mediciones repetidas, prueba de contrastes dentro de sujetos, así como comparaciones por pares de momentos de hospitalización. para la hipótesis dos se utilizó la correlación de spearman, y para la hipótesis tres se aplicó el modelo de regresión lineal múltiple. cada ítem tiene tres opciones de respuesta con valor total por ítem de 3 puntos, cada respuesta tiene un valor asignado de 1, 2 y 3 respectivamente. el puntaje total es de 60 puntos como máximo y 20 puntos como mínimo; en cuanto mayor sea el puntaje indicará presencia de ansiedad. resultados de la población estudiada la mayor proporción (54%) de los niños participantes en el estudio fueron de sexo masculino. en relación con la edad, su distribución porcentual fue de 20% cada año hasta los 11 años. el 50% de los participantes tuvieron admisiones previas. dado que todos los valores de p son < 0,05 de la prueba de normalidad de kolmogorov-smirnov aplicada a índice de la escala del staic, se utilizaron pruebas no paramétricas para sustentar las hipótesis. para las hipótesis los niveles de ansiedad cambian durante y después de la hospitalización de los niños: después del ingreso, antes de egresar y después de egresar. esta hipótesis se verificó mediante un anova (análisis de varianza) de mediciones repetidas con un factor dentro de sujetos. en este análisis el momento de aplicación del instrumento staic fue el factor �dentro de sujetos� con tres niveles (12 horas después del ingreso, 12 antes del egreso y 10 días después del egreso). la prueba de anova resultó significativa (f (2, 308) = 1327,09, p < 0,001), por tanto, se sustenta la hipótesis 1; es decir, los índices promedio de ansiedad de los tres momentos no son iguales. en la figura 1 se muestran gráficamente estos índices, donde se puede observar que el nivel más alto de ansiedad se presenta en el momento 1 (12 horas después del ingreso), le sigue el momento 2 (12 horas antes del egreso), y finalmente el momento 3 (10 días después del egreso). por tanto, durante la hospitalización se tienen niveles más altos de ansiedad que después de ésta. figura 1. índice de ansiedad staic y momento de hospitalización in d ic e s t a ic 50 40 30 20 10 0 12 hrs después de ingreso 12 hrs antes de ingreso 10 días después de egreso momento de hospitalización la ansiedad en niños hospitalizados 213 en la figura 2, mediante diagramas de caja, se muestra la relación de edad con el índice de ansiedad staic en el tercer momento (10 días después del egreso) en forma separada para cada género. estos diagramas de caja muestran la distribución de los índices de ansiedad en el tercer momento. el ancho de las cajas representa la variación de los datos, mientras que la línea dentro de la caja es la media de los datos. en la tabla 1 se presentan los promedios de estos índices, así como sus errores estándar e intervalos de confianza del 95%. dado que ninguno de los intervalos de confianza se traslapa con otro, estadísticamente los tres niveles de ansiedad son diferentes. puede observarse que las diferencias de medias resultaron significativas. así, la media del momento 1 es estadísticamente superior a la del momento 2, y ésta, a su vez, es superior a la del momento 3. para confirmar estos hallazgos se obtuvieron la prueba de mauchly a las varianzas de ansiedad, pruebas de efectos de ansiedad en sujetos en mediciones repetidas, y pruebas de contraste en de m o m e n t o m e d i a error estándar intervalo de confianza del 95% límite inferior límite superior 1 49,21 ,277 48.659 49.754 2 45,29 ,494 44.315 46.265 3 29,98 ,300 29.388 30.573 sujetos, así como comparaciones por pares de momentos de la hospitalización. para la hipótesis: existe relación entre la edad y los niveles de ansiedad. en general la edad es una variable continua, pero en este caso, dado el rango, se consideró esencialmente como una variable ordinal. además, como se ve en la tabla 2, debido a que los índices staic no siguen la distribución normal, se utilizó la correlación de spearman. la correlación en el tercer momento resultó negativa por lo que la relación entre edad e índice de ansiedad es inversa, a mayor edad menor valor del índice de ansiedad. tabla 1. índice staic de ansiedad para cada momento de hospitalización fuente: staic. n = 155 tabla 2. correlaciones de spearman de la variable edad con los índices del staic en los tres momentos de hospitalización * correlación significativa al 0,05. ** correlación significativa al 0,01 n=155. fuente: staic. m o m e n t o escala total subescala presencia subescala ausencia de ansiedad de ansiedad de ansiedad correlación valor de p correlación valor de p correlación valor de p 12 horas 0,096 0,231 0,049 0,537 -0,035 0,665 después del ingreso 12 horas antes -0,100 0,212 -0,059 0,464 -0,139 0,083 del egreso 10 días -0,220** 0,006 -0,215** 0,007 -0,098 0,222 después del egreso aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007214 figura 2. diagramas de caja de los índices de ansiedad staic con edad para cada género después de 10 días del egreso de la hospitalización. se observa que mientras en los hombres hay una clara relación inversa entre la edad y el índice de ansiedad, en las mujeres no existe algún tipo de relación. también se aprecia que en las mujeres hay una mayor variación en el índice de ansiedad que en los hombres. para la hipótesis: existe diferencia en los niveles de ansiedad por sexo, tiempo de hospitalización y admisiones previas. para cada momento se ajustó un modelo de regresión lineal múltiple donde las variables independientes fueron sexo, edad y admisiones previas sobre el índice de ansiedad. los factores sexo y admisiones previas se incluyeron en el modelo como variables de engaño. en la variable sexo, el valor 1 indica masculino y 0 femenino; en la variable admisiones previas, 1 indica que el participante tenía por lo menos 1 ingreso hospitalario previo a la entrevista y 0 cuando no había ningún registro previo de ingreso hospitalario. las tablas 3, 4 y 5 presentan los resultados de este análisis. tabla 3. regresión lineal múltiple de edad, sexo y admisiones previas sobre el índice de ansiedad de staic después de 12 horas del ingreso m o d e l o grados suma de cuadrado de libertad cuadrados m e d i o f valor de p regresión 3 37,299 12,433 1,045 ,374 residual 151 1796,094 11,895 r2 0,2% fuente: staic. n = 155 edad en años sexo femenino sexo masculino 38 36 34 32 30 28 26 24 22 n = 12 7 18 8 12 9 14 10 16 11 ín di ce d e an si ed ad s ta ic 38 36 34 32 30 28 26 24 22 n = 19 7 13 8 20 9 17 10 14 11 edad en años ín di ce d e an si ed ad s ta ic la ansiedad en niños hospitalizados 215 el único modelo significativo ocurrió en el tercer momento. el modelo de regresión explica el 24,4% de la variabilidad total del nivel de ansiedad del niño hospitalizado. sin embargo, como se puede apreciar en la tabla 6, el análisis del efecto individual de cada uno de los factores o variables del modelo de regresión reveló que sólo edad tiene un efecto significativo, y como el signo del coeficiente es negativo, entonces a mayor edad menor índice de ansiedad. tabla 5. regresión lineal múltiple de edad, sexo y admisiones previas sobre el índice de ansiedad de staic después de 10 días del egreso m o d e l o grados suma de cuadrado de libertad cuadrados m e d i o f valor de p regresión 3 173,679 57,893 1,549 ,204 residual 151 5642,257 37,366 r2 24,4% fuente: staic. n = 155 es decir, los niños de mayor edad reducen más rápidamente los niveles de ansiedad después de salir de la hospitalización, sin importar el sexo ni los antecedentes previos de hospitalización (véanse figuras 3 y 4). de esta manera, los resultados no apoyan completamente la hipótesis. tabla 4. regresión lineal múltiple de edad, sexo y admisiones previas sobre el índice de ansiedad de staic antes de 12 horas del egreso m o d e l o grados suma de cuadrado de libertad cuadrados m e d i o f valor de p regresión 3 173,679 57,893 1,549 ,204 residual 151 5642,257 37,366 r2 0,3% fuente: staic. n = 155 tabla 6. efecto de la edad, sexo y admisiones previas sobre el índice staic después de 10 días del egreso fa c t o r b error estándar b e t a t valor de p edad -,624 ,210 -,235 -2,975 ,003 sexo -,322 ,590 -,043 -,546 ,586 admisiones previas ,537 ,589 ,072 ,911 ,364 constante 35,492 1,951 18,193 ,000 fuente: staic. n = 155 aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007216 discusión el estudio permitió verificar empíricamente el concepto de ansiedad (39) en niños hospitalizados de 7 a 11 años de edad. con relación a la hipótesis uno se observaron diferencias en la ansiedad a través del tiempo siendo más alto durante la hospitalización y más bajo después de egresar del hospital. esto coincide con lo reportado por kain y cols. (39), tiedeman (46), thompson (51), tiedeman y clatworthy (8) en el sentido de que la ansiedad es más alta al ingreso del niño a la hospitalización, probablemente debido a lo desconocido. además, la disminución de la ansiedad después del egreso posiblemente se debió a que el niño está más seguro y tiene control de su medioambiente. los resultados con relación a la hipótesis dos, donde se encontró correlación negativa entre la edad y los niveles de ansiedad de los niños después de la hospitalización, probablemente se deben a que los niños de mayor edad poseen mejores recursos para afrontar y superar las situaciones que producen ansiedad. respecto a la hipótesis tres, el único modelo significativo ocurrió en el tercer momento observándose que sólo la edad tiene efecto significativo en la variabilidad mostrada del nivel de ansiedad con o sin admisión previa. sin embargo, estos resultados no coinciden con lo reportado por thompson (51) que demostró que los niños hospitalizados con admisiones previas presentan mayor efecto de ansiedad. la posible explicación de los resultados encontrados podría ser que los niños con admisiones previas no consideran la hospitalización como un evento desconocido, lo que representa un valioso recurso para un afrontamiento efectivo de la situación e incide en su nivel de ansiedad. cabe señalar que existe evidencia que sugiere la presencia de ansiedad en los niños como respuesta emocional al evento de hospitalización. por tanto, es necesario intervenir para prevenir, identificar y tratar la ansiedad en el niño en las diferentes etapas de crecimiento y desarrollo, a través de programas de educación para la salud durante y después de la hospitalización. referencias bibliográficas 1. astin ew. self-reported fears hospitalized and non hospitalized children aged ten to twelve. maternal child nursing 1977; 6: 17-24. 2. barton ph. the relationship between fantasy and over stress reactions of children to hospitalization. dissertation abstracts 1968; 29: 809a. 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23 (2): 87-97. 52. roy c, andrews h. the roy adaptation model. ed. stanford, ct: appleton & lange; 1999. 53. burns ny, grove sk. the practice of nursing research. conduct, critique & utilization. 4 ed. usa: saunders; 2001. 54. elashoff dj, dixon jw, crede mk, fothenringham n. n query advisorr copyright; 1997. 127 134 el significado del cuidado.indd 127 francisco javier báez-hernández1 vianet nava-navarro2 leticia ramos-cedeño3 ofelia m. medina-lópez4 el signifi cado de cuidado en la práctica profesional de enfermería 1 maestro en ciencias de enfermería. benemérita universidad autónoma de puebla, puebla, méxico. jav007@hotmail.com 2 maestra en ciencias de enfermería. benemérita universidad autónoma de puebla. puebla, méxico. vianetnn28@hotmail.com 3 maestra en ciencias de enfermería. puebla, méxico. ciately_tapia@hotmail.com 4 maestra en ciencias de enfermería. benemérita universidad autónoma de puebla. puebla, méxico. ofeliamedina77@hotmail.com recibido: 1 de septiembre de 2008 aceptado: 17 de junio de 2009 resumen cuidar es una actividad humana que se define como una relación y un proceso cuyo objetivo va más allá de la enfermedad. este artículo presenta los resultados de un estudio cualitativo de tipo descriptivo interpretativo, realizado con el propósito de comprender cómo representan los profesionales de enfermería su quehacer profesional. método: se realizó, un muestreo teórico. los participantes del estudio fueron profesionales de enfermería, un hombre y seis mujeres, con un promedio de edad de 30 años. los datos se recolectaron a través de diario de campo y siete entrevistas semiestructuradas aplicadas de manera individual y a profundidad, las cuales fueron grabadas y transcritas en su totalidad; se realizaron tablas y esquemas de codificación abierta y axial que sirvieron para el análisis de los datos, mediante el marco interpretativo de las representaciones sociales de moscovicci, que contempla cuatro dimensiones: información, imagen, actitud y opinión. resultados: se encontraron seis categorías periféricas que forman el significado de cuidado: factores, implicaciones, contribuciones, aplicaciones, creencias y actitudes. conclusiones: el cuidado de enfermería envuelve y comparte la experiencia humana a través de una relación transpersonal y de respeto. palabras clave cuidado, enfermería, análisis cualitativo. (fuente: decs, bireme). the signifi cance of care in professional nursing practice abstract care is a human activity defined as a relationship and a process with an objective that goes beyond illness. this article presents the results of a descriptive-interpretive qualitative study conducted to understand how nurses portray their professional practice. method: a theoretical sampling was done. the participants in the study were nurses (one man and six women). their average age was 30. the data were collected through a field diary and seven semi-structured interviews were conducted individually and in depth. the interviews were taped and transcribed in their entirety. tables were developed, along with open axial codification schemes that were used to analyze the data. this was done with the interpretive framework of moscovicci social representations, which considers four dimensions: information, image, attitude and opinion. results: the study reveals six peripheral categories that form the significance of care: factors, implications, contributions, applications, beliefs and attitudes. conclusions: nursing care is enveloped by and shares the human experience through a transpersonal relationship marked by respect. key words care, nursing, qualitative analysis. (source: decs, bireme). año 9 vol. 9 nº 2 chía, colombia agosto 2009 127-134 128 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 o signifi cado do cuidar na prática profi ssional de enfermagem resumo o cuidar é uma atividade humana que é, ao mesmo tempo, uma relação e um processo cujo objetivo está mais para lá da doença. neste artigo apresentam-se os resultados de um estudo qualitativo do tipo descritivo-interpretativo, levado a cabo a fim de compreender como representam os profissionais de enfermagem a sua tarefa profissional. método: aplicou-se uma amostragem teórica. no estudo participaram seis homens e uma mulher, profissionais de enfermagem, com idade média de 30 anos. para recolher os dados, utilizaramse diário de campo e sete entrevistas semi-estruturadas aplicadas individualmente e em profundidade, gravadas e transcritas na sua totalidade. foram elaboradas tabelas e diagramas de codificação aberta e axial, que serviram na análise dos dados, aplicando o marco interpretativo das representações sociais de moscovicci, que consta de quatro dimensões: informação, imagem, atitude e opinião. resultados: foram achadas seis categorias periféricas que conformam o significado do cuidar: fatores, implicações, contribuições, aplicações, crenças e atitudes. conclusões: o cuidar de enfermagem implica e comparte a experiência humana através de uma relação trans-pessoal e de respeito. palavras-chave cuidar, enfermagem, análise qualitativo. (fonte: decs, bireme). 129 el significado de cuidado en la práctica profesional de enfermería francisco javier báez-hernández, vianet nava-navarro, leticia ramos-cedeño, ofelia m. medina-lópez introducción cuidar es una actividad humana que se define como una relación y un proceso cuyo objetivo va más allá de la enfermedad (1). en enfermería, el cuidado se considera como la esencia de la disciplina que implica no solamente al receptor, sino también a la enfermera como transmisora de él (2). según watson, el cuidado se manifiesta en la práctica interpersonal, que tiene como finalidad promover la salud y el crecimiento de la persona (3). swanson, a través de la teoría de los cuidados, propone cinco procesos básicos secuenciales (conocimiento, estar con, hacer por, posibilitar y mantener las creencias), en los que se hace evidente el cuidado de enfermería, que se caracteriza por la actitud filosófica de la enfermera, la comprensión, los mensajes verbales y no verbales, las acciones terapéuticas y las consecuencias de los cuidados (4). dichos conceptos permiten reflexionar acerca de la cosmovisión del cuidado enfermero, donde convergen las dimensiones históricas, antropológicas y filosóficas de la ciencia de enfermería (5). actualmente, en la práctica de enfermería se observa que el cuidado es identificado en el hacer monótono, lineal y sin sentido, dentro de la racionalidad técnica y el enfoque biomédico (6), entendido como una ayuda o un complemento en las ciencias de la salud, situación que propicia la negación de la enfermería como ciencia y como arte. estudios recientes acerca del significado de cuidado por parte del profesional de enfermería se refieren a la sinonimia de atención oportuna, rápida, continua y permanente, orientada a resolver problemas particulares que afectan la dimensión personal de los individuos que demandan un servicio institucionalizado (7). por otra parte, el cuidado se ha definido como el conjunto de categorías que involucran la comunicación verbal y no verbal, la minimización del dolor físico, la empatía para atender el todo, y el envolvimiento, que se refiere a la aproximación entre el cuidador y el ser cuidado como finalidad terapéutica (8). si se entiende que el significado que se tenga de un fenómeno condiciona la forma en que va a ser representada la realidad en los sujetos, y que, de acuerdo con levinas, las palabras introducen la franqueza de la revelación en la cual el mundo se orienta y adquiere un significado entre los individuos (9), entonces, la relación enfermera(o)-paciente, como seres dialógicos, implica un encuentro humanizador, que tiene como propósito despertar la conciencia del otro (10) a través de la reflexión de los cuidados, que incluye las creencias y los valores que impregnan la atmósfera en la que tienen lugar los hechos y las circunstancias del quehacer de enfermería (11). por lo antes mencionado, es necesario comprender cómo representa la enfermera(o) su hacer profesional a través de formaciones subjetivas como: opiniones, actitudes, creencias, informaciones y conocimientos (2); tal comprensión servirá para mejorar el cuidado de su práctica, que actualmente adolece de significado y, por tanto, de un reconocimiento propio. la teoría de las representaciones sociales de serge moscovici permite comprender de manera flexible la posición intermedia entre el concepto que se obtiene del sentido real, y la imagen que el personal de enfermería reelabora del cuidado. cuidar es una actividad humana que se define como una relación y un proceso cuyo objetivo va más allá de la enfermedad. en enfermería, el cuidado se considera como la esencia de la disciplina que implica no solamente al receptor, sino también a la enfermera como transmisora de él. 130 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 las representaciones se estructuran alrededor de tres componentes fundamentales: la actitud hacia el objeto, la información sobre ese objeto, y un campo de representación donde se organizan jerárquicamente una serie de contenidos (12). si se considera que la enfermería tiene la responsabilidad de articular y difundir definiciones claras de las funciones que desempeña en su práctica (13), y que el cuidado es la parte ontológica y epistémica que guía los aspectos axiológicos de su hacer profesional, se hace necesario comprender el significado de cuidado a través de la investigación cualitativa, el cual produce evidencias relevantes para la práctica profesional (14). por esta razón, se decidió abordar el presente estudio mediante una metodología cualitativa, con el propósito de comprender cómo el profesional de enfermería construye el significado de cuidado en su práctica. materiales y método para el desarrollo de esta investigación se utilizó el método cualitativo, que permite una mejor comprensión y aproximación sistemática y subjetiva de cómo la enfermera(o) construye el significado de cuidado en su práctica profesional. la recolección de los datos se hizo a través de un muestreo teórico que se refiere a la selección suficiente de casos, hasta llegar a la saturación de categorías y el análisis de ellas (15). el estudio se llevó a cabo en un hospital de segundo nivel de atención de la ciudad de puebla. los datos se recolectaron mediante un diario de campo y siete entrevistas semiestructuradas, aplicadas de manera individual y a profundidad, las cuales fueron grabadas y transcritas en su totalidad en el programa de microsoft word, donde se realizaron tablas y esquemas de codificación abierta y axial que sirvieron para el análisis de contenido a partir de las dimensiones de la teoría de las representaciones sociales de serge moscovici (1979). se consideró lo dispuesto en la ley general de salud del 2000, así como el código de ética para enfermeras y enfermeros de méxico. se obtuvo el consentimiento informado de manera verbal y por escrito de todos los informantes, garantizándoles su anonimato. resultados el profesional de enfermería estuvo representado por seis mujeres y un hombre, con un promedio de edad de 30 años, y un rango de uno a 20 años de ejercicio profesional. todos con alguna especialidad postécnica: dos en cuidados intensivos, dos en médico-quirúrgica, uno en administración en los servicios de enfermería, otro en enfermería pediátrica y una en inhalo-terapia. en relación con el nivel académico, solo una de ellas mencionó tener la licenciatura en enfermería. en el análisis de contenido se encontraron seis categorías periféricas que forman el significado de cuidado, que se define como el conjunto de factores, implicaciones, contribuciones, aplicaciones, creencias y actitudes que realiza el profesional de enfermería con la persona hospitalizada. la categoría de factores se encuentra en la dimensión de información, y se relaciona con los motivos que tuvo la enfermera(o) para elegir esta profesión, en la que se observan dos tipos (extrínseco e intrínseco), el primero tiene su origen en el orden social, y se refiere a todas las circunstancias que son ajenas a la enfermera(o), pero que de estudios recientes acerca del significado de cuidado por parte del profesional de enfermería se refieren a la sinonimia de atención oportuna, rápida, continua y permanente, orientada a resolver problemas particulares que afectan la dimensión personal de los individuos que demandan un servicio institucionalizado. 131 el significado de cuidado en la práctica profesional de enfermería francisco javier báez-hernández, vianet nava-navarro, leticia ramos-cedeño, ofelia m. medina-lópez manera directa o indirecta influyen en la toma de sus decisiones: “primero, afectó mucho mi situación económica… para ser enfermera” (e1, e4, e6). el factor intrínseco hace referencia a un llamado interno del yo, e involucra decisiones que influyen directa e indirectamente en su contexto social, a través de actitudes de ayuda que generan un reconocimiento de la enfermería como una carrera humanitaria: “soñaba de chiquita que quería ser enfermera y curar enfermos, fue mi sueño” (e2, e3, e4). en la información, la implicación se describe como las acciones que realiza la enfermera(o) hacia la persona, y los insumos que se consideran para llevar a cabo su quehacer profesional a partir de la aplicación de sus conocimientos: “tomar signos vitales y recibir el material que me corresponda” (e1, e5, e7). la contribución representa las actitudes que tiene el personal de enfermería para mejorar su práctica profesional, en ellas se encuentran acciones dirigidas hacia la aplicación y actualización de los saberes propios: “llenarme más de conocimientos, tener más cursos” (e3, e5, e7). así mismo, se observa que existen otras acciones que se encuentran dirigidas hacia la persona hospitalizada: “decirle su procedimiento cada vez que le estoy haciendo algo, qué implica si deja de tomar sus medicamentos y si se deja de cuidar, ayudarle a prevenir algo que pueda suceder peor” (e2, e6, e7). la aplicación del cuidado se localiza en las tres dimensiones (información, actitud y representación), hace referencia a la experiencia del profesional de enfermería definida como un hecho del presente, pasado y futuro, en el que se observa un conjunto de acciones y actitudes que describen los procesos del cuidado; el primero es hermenéutico, consiste en un ir y venir de interpretaciones empírico-científicas, originadas por la observación que realiza de manera interna la enfermera(o), motivándola(o) a sentir una necesidad de ayudar a la persona: “como enfermera… a pesar de los conocimientos médicos… sientes la necesidad del paciente” (e1, e3, e4). el segundo es dialógico, y se refiere a un proceso intercomunicativo entre dos seres que se reconocen uno al otro, lo que genera un diálogo activo de palabras entre la enfermera (o) y la persona. tiene como propósito interpretar y conocer al otro: “lo trataba de escuchar cada vez de sus problemas… le decía échele ganas, ánimo, ya va bien su pie” (e2, e4, e6). el tercero es dialéctico, formado por la praxis, lo que significa un hacer reflexionado, que no se limita a la integración de un conocimiento, sino a la aplicación a priori de los conocimientos empíricos y científicos de la enfermería, que además del cuidado físico, abordan también el cuidado espiritual dando como resultado el reconocimiento de la enfermería: “me quedé como su familiar, lo cambié y demás, y antes de poder irme a la casa, hable con él… y platicamos… de dios” (e3, e4, e6). las creencias se encuentran en la dimensión de opinión, y son el conjunto de pensamientos que tiene la enfermera(o) antes de realizar sus actividades; se relacionan con representaciones místico-religiosas, que le dan mayor seguridad durante su trabajo: “yo la verdad rezo antes de entrar a mi servicio” (e2, e4, e7). el factor intrínseco hace referencia a un llamado interno del yo, e involucra decisiones que influyen directa e indirectamente en su contexto social, a través de actitudes de ayuda que generan un reconocimiento de la enfermería como una carrera humanitaria. 132 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 la actitud se refiere a la postura que toma la enfermera(o) frente a la persona hospitalizada, en la que se observan acciones positivas o negativas: “mi actitud es de empatía, que él es mi familia, que puede ser mi padre, puede ser mi hermana, puede ser mi hijo” (e1, e3, e6). o, “venimos con un carácter… serio… que no le inspira confianza a la paciente y tampoco siente que va saliendo adelante” (e2, e5, e7). la actitud es la manifestación física y emocional observable en la cual se generara la transmisión del cuidado, llamada “respuesta ante la acción percibida”: “por ejemplo una sonrisa, el tono amable de tu voz, suena un tono estresado y eso el familiar o el paciente lo toma como que grosera, ¿no?” (e2, e4, e6, e7). discusión en el presente estudio la acción de cuidado rompe las barreras de materia, tiempo y espacio, ya que los informantes reviven emociones en las narraciones de sus experiencias, por lo que el cuidado se vuelve trascendente en el presente, en el aquí y ahora, lo que hace que se coincida con benner en que el cuidado es entrar al mundo vivencial de cada individuo para compartir sus momentos más especiales (16). esta situación implica un conocimiento propio de cada enfermo, un darse cuenta de sus actitudes, intereses y motivaciones; además, requiere su manifestación como persona única, auténtica, capaz de generar confianza, serenidad y apoyo efectivo (3). se concuerda con el grupo de cuidado de colombia que ve al paciente como ser humano con comportamientos relacionados con las actitudes, lo que implica un acercamiento personal (2). debido a lo anterior, el profesional de enfermería requiere de sensibilidad, intelecto, disciplina y conocimientos sistematizados para identificar y atender las necesidades y posibilidades humanas, mediante un contacto personal cercano con el paciente (17). se coincide con gaut en identificar tres condicionantes para el cuidado: 1) la conciencia y el conocimiento de que alguien necesita cuidado, 2) la intención de actuar y acciones basadas en el conocimiento, y 3) un cambio positivo como resultado del cuidado. situaciones que watson completa con: el compromiso moral y la voluntad para el cuidado (18). así mismo, se concuerda con el metaanálisis realizado por swanson, en el que el cuidado se desarrolla bajo un conocimiento que se dirige a la persona, que involucra emociones, las cuales conllevan un pensamiento de un hacer para el otro, en el que se mantienen las creencias de un futuro con mayores esperanzas (4). en relación con la aplicación del cuidado y la actitud de los participantes, se coincide con queiroz al mencionar que las situaciones de cuidado se transforman en un ayudar a vivir. de modo que la empatía debe fundamentarse para que los cuidados de enfermería sean realmente eficaces y, por ende, reconocidos por el otro (19); esta situación apoya lo escrito por de figueiredo al mencionar que el cuidado transpersonal exige al profesional de enfermera la capacidad de unirse, experimentar e imaginar el sentimiento del paciente (20). en cuanto al significado de cuidado que refieren los sujetos del presente estudio, éstos coinciden con lo referido por leonardo boff al considerar que el cuidado implica una capacidad de sentir como el otro, lo que impulsar a generar la actitud se refiere a la postura que toma la enfermera(o) frente a la persona hospitalizada, en la que se observan acciones positivas o negativas. 133 el significado de cuidado en la práctica profesional de enfermería francisco javier báez-hernández, vianet nava-navarro, leticia ramos-cedeño, ofelia m. medina-lópez una ciencia con conciencia, dirigida hacia la vida, situación por la cual los significados que da el profesional de enfermería logran trascender entre otros (21). este fenómeno se desarrolla a través de la solidaridad de estar con la persona, lo que permite tener una conciencia en que es posible la praxis auténtica en la cual la enfermera y el paciente dejan de ser objetos del proceso salud-enfermedad, para convertirse en verdaderos sujetos de acción, con identidad propia, con capacidad para transformar su mundo (22). también se coincide con maturana al afirmar que el escuchar se encuentra determinado por los propios valores y preferencias, en los que el lenguaje se convierte en una manera de convivir, en un devenir de coordinación y coordinaciones conductuales con la persona, donde se van construyendo realidades que son compartidas por la enfermera(o) y el paciente (23). por otra parte, se coincide con el análisis de investigaciones brasileñas enfocadas en el cuidado de enfermería, al identificar un cuidado dialógico y estético, que consiste en un pensar abierto, creativo y ético entre los sujetos involucrados, hecho que posibilita el sentir y las formas de vivir. (24). del mismo modo se concuerda con moscovicci, en que la representación social del cuidado se encuentra formada a partir de un cuerpo organizado de conocimientos y de actividades psíquicas, a las cuales el profesional de enfermería hace inteligible la realidad física y social del cuidado, integrándose en una relación cotidiana de intercambios entre la persona y la enfermera(o). conclusiones el significado de cuidado en el profesional de enfermería se construye a través de factores, implicaciones, contribuciones, aplicaciones, creencias y actitudes que realiza con la persona, por lo que se hace necesario que enfermería comprenda que cuidar envuelve y comparte la experiencia humana a través de una relación transpersonal y de respeto. estos conocimientos servirán a la enfermería para mejorar los procesos de cuidado en cualquier situación de salud que tenga la persona. el cuidado de enfermería se cristaliza en una esencia trascendente, convertida en una acción holísticamente humana, que hace del diálogo un proceso interno que sobrepasa la interpretación de la persona convirtiéndolo en un proceso dialéctico de comprensión, y no de aprensión, de los conocimientos y las emociones generados por la acción de un cuidado no profesional, diferencia sustancial entre el cuidado genérico y el de enfermería (25). dicha situación es manifestada en respuestas físicas y emocionales que se reflejan en agradecimientos recíprocos por parte de la persona y la enfermera(o), que concluyen en reconocer al cuidado profesional de enfermería como una pieza importante en la recuperación de la salud. agradecimientos agradecemos a las autoridades del hospital regional número 36 del instituto mexicano del seguro social, del estado de puebla, por su apoyo en la realización de la presente investigación. 134 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 referencias bibliográficas 1. de la cuesta bc. el cuidado del otro: desafíos y posibilidades. investigación y educación en enfermería 2007; 25 (1): 106-112. 2. grupo de cuidado. facultad de enfermería. universidad nacional de colombia. capítulo i: cuidado y práctica de enfermería: nuevos avances conceptuales del grupo de cuidado. bogotá: unibiblos; 2002. pp.4-13. 3. watson j. nursing: the philosophy and science of caring. boston: little brown and company; 1979. p. 320. 4. swanson km. nursing as informed caring for the well being of others. the journal of nursing scholarship 1993; 24 (4): 352-357. 5. ortega c. el cuidado de enfermería. revista mexicana de enfermería cardiológica 2002; 10 (3): 88-89. 6. medina j. la pedagogía del cuidado: saberes y prácticas en la formación universitaria en enfermería. madrid: leartes; 1999. pp. 29-87. 7. daza c, medina l. significado del cuidado de enfermería desde la perspectiva de los profesionales de una institución hospitalaria de tercer nivel en santafé de bogotá, colombia. revista: cultura de los cuidados 2006; 19 (10): 55-62. 8. baggio ma. o significado de cuidado para profissionais da equipe de enfermagem. revista electrónica de enfermería 2006; 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2006: 20-35. 16. benner p. la supremacía del cuidado (disertación). méxico. viii coloquio panamericano de investigación en enfermería; 2002. 17. aguilar hr. relación enfermera paciente, un enfoque de calidad. desarrollo científico de enfermería 2005; 13 (8): 234-239. 18. watson j. nursing: human science and human care, a theory of nursing. new york: national league for nursing; 1988. p. 158. 19. queiróz aa. empatia e respeito. 2 ed. coimbra: editora ariane; 2004. 20. de figueiredo cz, núñez ha, mulet ff, núñez am, andrade ml. el significado de cuidado para los enfermos que cuidan de personas con lesión medular. cultura de los cuidados 2008; 12 (24): 117-113. 21. boff l. el cuidado esencial. ética de lo humano. traducción de juan valverde. madrid: trotta; 2002. 22. freire p. pedagogía del oprimido. méxico: editorial siglo xxi; 2005. pp. 25-123. 23. maturana hr. del ser al hacer. los orígenes de la biología del conocer. buenos aires: granica; 2008. p. 232. 24. lorenzini ea, luzia lj, costa mi, auxiliadora tm, carvalho dc. análisis de investigaciones brasileñas enfocadas en el cuidado de enfermería años 20012003. ciencia y enfermería 2005; 11 (2): 35-46. 25. marriner t, raile a. modelos y teorías en enfermería. teoría transcultural de los cuidados. 5 edición. madrid: harcourt brace; 2005. 69 ruth vanessa rosero-martínez1 paola vernaza-pinzón2 perfil postural en estudiantes de fisioterapia 1 estudiante de fisioterapia. programa de fisioterapia facultad ciencias de la salud, universidad del cauca, popayán, colombia. ruthvanessa5@hotmail.com 2 especialista en epidemiología general. docente asociada, departamento de fisioterapia. universidad del cauca, popayán, colombia. pvernaza@gmail.com recibido: 21 de julio de 2009 aceptado: 16 de febrero de 2010 resumen objetivo: caracterizar el perfil postural de los estudiantes del programa de fisioterapia de la universidad del cauca, colombia. métodos: se realizó un estudio descriptivo a 44 estudiantes matriculados en el programa de fisioterapia de la universidad del cauca. las características sociodemográficas y antropométricas de la población se consignaron en una ficha diseñada para tal fin, y el análisis postural se realizó por medio del software apic v2.0. resultados: el estudio arrojó que el 100% de los estudiantes analizados presentaron disbalances anatómicos en las diferentes imagenes evaluadas, siendo los más frecuentes las desalineaciones en hombros y pelvis. conclusiones: es preocupante que los futuros fisioterapeutas presenten disbalances anatómicos antes de iniciar activamente su ejercicio profesional, puesto que si esta situación no es corregida a tiempo los años de vida profesionales potencialmente saludables se verán reducidos probablemente por la presencia de lesiones músculo-esqueléticas; por ello es importante recomendar un programa de control postural sobre esta población relativamente sana. palabras clave fisioterapia, estudiantes, postura, colombia (fuente: decs, bireme). postural profile among physical therapy students abstract objective: characterize the postural profile of students who are majoring in physical therapy at the universidad del cauca, colombia. methods: a descriptive study was done of 44 students who are enrolled in the physical therapy program at the universidad del cauca (colombia). the socio-demographic and anthropometric features of the population in question were recorded on a card designed for that purpose, and a postural analysis was done with apic version 2.0. results: the study showed 100% of the students analyzed had anatomic imbalances in the different images evaluated; the most frequent were shoulder and pelvis misalignments. conclusions: it is worrisome año 10 vol. 10 nº 1 chía, colombia abril 2010 l 69-79 70 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 that future physical therapists have anatomic imbalances even before they enter professional practice. if this situation is not remedied in time, their potentially healthy years of professional life will be reduced, most likely by the presence of muscular-skeletal lesions. therefore, it is important to recommend a posture control program for this relatively healthy population. key words physical therapy, students, posture, colombia (source: decs, bireme). perfil postural em estudantes de fisioterapia resumo objetivo: caracterizar a postura dos alunos do programa de fisioterapia da universidade do cauca (colômbia). métodos: estudo descritivo de 44 alunos matriculados no programa de fisioterapia na universidad do cauca (colômbia). as características sociodemográficas e antropométricas da população se registraram em um cartão destinado a esse efeito; utilizou-se software apic v2.0 para analisar a postura. resultados: o estudo mostrou que 100% dos alunos testados tinham desequilíbrios anatômicos em diferentes vistas avaliadas. as distorções mais freqüentes ocorrem em ombros e pélvis. conclusões: é preocupante que os fisioterapeutas do futuro tenham desequilíbrios anatômicos antes de começar o seu exercício profissional, porque se esta situação não for corrigida a tempo, os anos de vida profissional, potencialmente saudáveis, serão reduzidos provavelmente devido à presença de lesões músculo-esqueléticas. portanto, é importante recomendar um programa de controle postural na população relativamente saudável. palavras-chave fisioterapia, estudantes, postura, colômbia (fonte: decs, bireme). 71 perfil postural en estudiantes de fisioterapia l ruth vanessa rosero-martínez, paola vernaza-pinzón introducción mantener una postura adecuada establece las bases para una buena calidad de vida, puesto que la postura humana está directamente relacionada con los estados de salud (1). ésta ha sido ampliamente estudiada durante las últimas décadas, y es por ello que encontramos varias definiciones: “la postura es la posición que nuestro cuerpo adopta habitualmente cuando estamos sentados, de pie o corriendo” (2). kendall la define como “la composición de las posiciones de todas las articulaciones del cuerpo humano en todo momento”; así, la postura correcta representa una alineación con un máximo de eficiencia fisiológica y biomecánica, lo cual lleva a un mínimo de esfuerzo y tensión (3). la postura también ha sido descrita como “cada una de las posiciones asumidas por el cuerpo en relación espacial entre las diferentes partes o segmentos que lo conforman” (4). por su parte, palos conceptualiza la postura como “la disposición relativa de las partes del cuerpo en un estado de equilibrio en todo momento dado, e influenciado por factores como la gravedad, las estructuras anatómicas, así como también por la cultura, la religión, las emociones y el medioambiente en el que se desarrollan las personas” (5). esta última definición, a nuestro modo de ver, es la que debe integrarse al conocimiento e interiorización de las buenas prácticas de hábitos saludables posturales tanto en los estudiantes del área de la salud en formación, como en aquellos pacientes –clientes-usuarios– en los cuales debe intervenirse. dada la definición anterior, hay que tener en cuenta que la postura debe ser pensada dentro de un proceso de movimiento dinámico, facilitada por la infinidad de posiciones que existen para conseguir una armonía funcional dentro del esquema de movimiento humano, libre de restricciones o limitaciones (6). de esta manera, la postura puede ser identificada con el concepto general de balance en el sentido de optimizar la relación entre el individuo y su entorno. las definiciones anteriores permiten integrar el concepto de “postura eficiente”, siendo ésta la que requiere el mínimo gasto energético y que surge de una correcta alineación articular de cada una de las cadenas biocinemáticas dejando ausente la fatiga muscular, el dolor y la sensación de incomodidad corporal; por tanto, la postura será mala cuando es ineficaz, es decir, cuando no consigue cumplir la finalidad para la cual está destinada, produciendo un gasto energético innecesario para mantener el equilibrio (7). es entonces a partir de la adopción continua y sostenida de esquemas corporales inadecuados cuando aparecen los problemas de alineación segmentaria que derivan en desajustes posturales que, al no ser corregidos a tiempo, pueden desencadenar deficiencias en los diferentes sistemas corporales, haciendo al cuerpo humano más propenso a presentar molestias osteomusculares (8). la postura debe analizarse tanto de forma estática como dinámica (9, 10), y para ello existen actualmente múltiples métodos de evaluación. la ergonomía ha permitido avanzar en este tema favoreciendo la interacción hombre-máquina-ocupación, lo que ha hecho posible implantar programas de vigilancia epidemiológica para la prevención de cualquier forma de lesión osteomuscular y dolencias, que en muchas ocasiones son el la postura debe ser pensada dentro de un proceso de movimiento dinámico, facilitada por la infinidad de posiciones que existen para conseguir una armonía funcional dentro del esquema de movimiento humano, libre de restricciones o limitaciones. 72 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 producto de malas posturas sumadas a movimientos repetitivos. la evaluación postural estática bipodal es una herramienta que permite el diagnóstico de asimetrías estructurales, la posición pélvica y los músculos contraídos y debilitados (11). el software de postura es un método de análisis basado en la demarcación previa de puntos anatómicos en el cuerpo de una persona, para luego tomar fotografías que sirvan de base para su análisis mediante un sistema de captura de coordenadas cartesianas. el hecho de emplear un software para análisis postural es muy significativo pues permite tener un alto grado de precisión, contrario a la evaluación postural tradicional con plomada la cual es menos objetiva y requiere de un evaluador mucho más experimentado en la observación; además, vale la pena tener en cuenta que ninguna visión individual es suficiente para obtener una información completa del individuo. entre los programas informáticos para evaluación postural encontrados en la literatura está el programa apic v 2.0 utilizado en el presente estudio y aplicado en el estudio de molano (12), el software de evaluación postural computarizada “posturograma v 2.8” (13), el software spinal analysis (14), y el método de avaliação quantitativa da postura deitada baseado em fotografía (15). la fisioterapia, como profesión de la salud, estudia el movimiento corporal humano, y como una de sus tantas acciones —si no la principal— busca la correcta alineación de los diferentes segmentos osteoatromusculares puesto que la deficiente alineación de éstos puede llegar a interferir en el adecuado desempeño de las actividades de la vida diaria afectando la relación del individuo con su entorno. caracterizar el perfil postural en los estudiantes de fisioterapia, y retroalimentar por medio de la entrega de sus resultados a cada sujeto investigado les permitirá interiorizar la importancia del análisis postural y los beneficios que trae la buena alineación biomecánica a partir del adecuado movimiento osteo-artro-cinemático. metodología se realizó un estudio descriptivo de corte transversal a los estudiantes matriculados en el ii periodo académico de 2008 en el programa de fisioterapia de la universidad del cauca. se solicitó a la secretaría académica del programa el listado de los estudiantes de los cinco últimos semestres dado el proceso de aprendizaje a este nivel. el universo estuvo constituido por 142 estudiantes. el total de estudiantes que aceptaron participar en el estudio fue de 44, correspondientes al 30,98% del universo, y a un nivel de confianza del 90%. por sexo, el 79,5% fueron mujeres y 20,5% hombres. la media de edad de los sujetos estudiados fue de 23 años, con una desviación estándar de ± 2,17. el 57,3% de los estudiantes que participaron en el estudio se encontraban matriculados en noveno semestre. un 63,6% de la población estaba vinculada al sistema general de seguridad social, mientras que un 36,4% no contaba con ningún tipo de vinculación. las características antropométricas evaluadas en el estudio fueron: peso, talla e índice de masa corporal. el promedio de peso fue de 59,9 kg, con una moda de 47,0 kg, un peso mínimo de 43,0 kg, un máximo de 81,0 kg, y una desviación estándar de ± 10,49. con respecto a la talla, el promedio se encontró en 1,59 m, con un valor mínimo de 1,49 m y un máximo de 1,75 m, la el software de postura es un método de análisis basado en la demarcación previa de puntos anatómicos en el cuerpo de una persona, para luego tomar fotografías que sirvan de base para su análisis mediante un sistema de captura de coordenadas cartesianas. 73 perfil postural en estudiantes de fisioterapia l ruth vanessa rosero-martínez, paola vernaza-pinzón desviación estándar fue ± 0,69. el 66,7% de la población presentó un índice de masa corporal dentro del rango de normalidad, seguido en un 29,5 % por estudiantes % c o n b a j o peso. una vez realizada la encuesta se procedió a hacer el registro fotográfico digital en vista anterior, lateral y posterior, marcando los puntos de referencia anatómicos especificados en el software apic v. 2.0 de análisis postural. para el registro fotográfico se solicitó a los estudiantes el uso mínimo de ropa (en mujeres, ropa interior o vestido de baño de dos piezas; en hombres, pantaloneta ajustada al cuerpo). el lugar donde se tomó el registro fotográfico cumplió con las siguientes especificaciones: fondo blanco, en el piso se ubicó un tapete el cual tenía en el centro una cuadrícula donde se puso una base de madera de seis centímetros de alto por quince centímetros de ancho y quince de largo, siendo una plataforma de referencia para mantener la posición erecta. posteriormente se utilizaron bolas de icopor de distintos tamaños marcando su centro con color negro, éstas se ubicaron en los siguientes referentes óseos: maléolo interno y externo en tobillo, crestas iliacas antero-superiores, trocánter mayor (bilateral), articulación acromionclavicular (bilateral), séptima vértebra cervical, décima vértebra torácica, primera vértebra sacra. después se colocaron adhesivos circulares de color blanco en: mentón, fosa yugular, tuberosidad tibial, bordes superior, lateral, medial e inferior de la rótula. las fotografías fueron tomadas en febrero de 2009, y los estudiantes del programa de fisioterapia dieron su consentimiento para registrarlas; se utilizó una cámara digital de 7.2 megapíxeles ubicada sobre un trípode el cual era ajustado previamente en cada registro fotográfico, teniendo en cuenta que la distancia entre el piso y la base de la cámara fuera paralela a la distancia entre el piso y el ombligo de la persona evaluada. las fotografías se ingresaron al software apic v. 2.0, el cual arrojó gráficas y tablas de resultados para cada uno de los 44 estudiantes evaluados (figuras 1 y 2). para la toma de talla la persona era medida descalza, de espalda contra la pared, con los brazos en aducción total y las palmas de la mano en la cara lateral del muslo, una vez se alineaba posturalmente la persona, se marcaba con escuadra sobre la cabeza un punto fijo y se delineaba con marcador borrable; cuando el sujeto se retiraba una de las investigadoras realizaba la toma de la talla con una cinta métrica desde el punto referente del piso al punto marcado en la pared. se realizaron dos mediciones y se calculó una media aritmética entre ellas. el peso fue medido figura 1. puntos de referencia, vista anterior y posterior. figura 2. puntos de referencia, vista lateral derecha e izquierda. en una balanza mecánica marca detecto con precisión de 100 gramos, una vez la persona se quitaba los zapatos y se liberaba de carga procedía a subir a la balanza. se realizaron dos mediciones del peso, si la segunda medición era igual a la primera se consignaba el valor, si era distinta, se realizaba una nueva medición reportándose este último valor (16). con los datos de talla y peso se obtuvo el índice de masa corporal (imc) o índice de quételet, medida indirecta de la cantidad de grasa corporal, la cual se calcula por el peso en kilogramos dividido por el cuadrado de la talla en metros (17). para el procesamiento y análisis estadístico de la información se construyó una base de datos en el programa spss versión 11.5. las variables continuas se expresaron con la media ± desviación estándar, y las variables discretas se expresaron en frecuencias y proporciones. el presente estudio hizo parte del proceso de investigación formativa contemplado en el plan de estudios del programa de con sobrepeso, y un 3,8 74 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 fisioterapia de la universidad del cauca, proyecto aprobado por expertos en cada una de sus cuatro fases: formulación, preensayo, trabajo de campo y resultados; contó además con el acompañamiento permanente del docente-director, por lo que todos los procedimientos siguieron las consideraciones éticas de la nueva declaración de helsinki (18), en la que todos los participantes mayores de edad leyeron el consentimiento informado y asintieron con su firma a participar en el estudio, permitiendo el registro fotográfico con el mínimo de ropas. una vez analizados y verificados los datos en el software apic 2,0 se realizaron las gráficas de líneas producto del análisis, con el fin de entregar a los sujetos participantes del estudio sus registros fotográficos con el informe respectivo de evaluación. las copias de dichas tomas fotográficas, una vez eran entregadas por una de las investigadoras y recibidas personalmente por los investigados, se iban destruyendo con el fin de respetar y salvaguardar la intimidad personal; solamente uno de los sujetos evaluados solicitó al equipo investigador utilizar sus registros fotográficos con fines académicos. resultados en las 44 personas evaluadas se observaron diferentes alteraciones en los segmentos corporales. en la gráfica 1 se pueden apreciar los resultados arrojados por el software de postura en cada una de las vistas evaluadas. entre tanto, en la tabla 1 se indican las características posturales en vista anterior, en la tabla 2 las características posturales en vista posterior, y en la tabla 3 las características posturales en vista lateral derecha e izquierda. a partir de los resultados obtenidos se creó el perfil para cada sexo con las características más sobresalientes en cada vista. para el sexo masculino, en vista anterior de proximal a distal, se observó: cabeza centrada, hombro derecho e izquierdo elevado, tronco centrado, cadera izquierda elevada, rodilla derecha en valgo, rodilla izquierda en varo, rótula derecha en rotación externa, rótula izquierda en rotación externa, tibia derecha centrada, tibia izquierda en rotación externa, torsión femoral derecha en rotación externa, torsión femoral izquierda en rotación externa, ángulo q derecho incrementado, ángulo q izquierdo normal. en vista posterior se encontró: cabeza centrada, hombro derecho elevado, tronco centrado, cadera derecha elevada, tobillo derecho en varo, tobillo izquierdo en varo, séptima vértebra cervical con desviación izquierda, décima vértebra lumbar con desviación izquierda. en vista lateral derecha se observó: tronco en extensión, rodilla alineada, lordosis cervical aumentada, cifosis normal, lordosis normal; con respecto al centro de gravedad, meato auditivo externo en retroversión, hombro en retroversión, trocánter mayor en retroversión. vista lateral izquierda: tronco flexión, rodilla alineada, lordosis gráfica 1. resultado del análisis de la evaluación postural en estudiantes del programa de fisioterapia del sistema apic 2.0 en las diferentes dimensiones 75 perfil postural en estudiantes de fisioterapia l ruth vanessa rosero-martínez, paola vernaza-pinzón tabla 1. perfil postural según sexo de los estudiantes del programa de fisioterapia, vista anterior cervical aplanada, cifosis normal, lordosis lumbar normal; con respecto al centro de gravedad meato auditivo externo en anteversión, hombro en retroversión, trocánter mayor en retroversión. en el sexo femenino se encontró, en vista anterior: cabeza centrada, hombro izquierdo alto, tronco centrado, cadera izquierda elevada, rodilla derecha valgo, rodilla izquierda varo, rótula derecha en rotación interna, rótula izquierda en rotación interna, tibia derecha centrada, tibia izquierda en rotación externa, torsión femoral derecha en rotación externa, torsión femoral izquierda en rotación izquierda, ángulo q derecho incrementado, ángulo q izquierdo incrementado. en vista posterior se observó: cabeza centrada, hombro izquierdo alto, tronco cen trado, cadera izquierda elevada, tobillo derecho varo, tobillo izquierdo varo, séptima vértebra cervical desviación izquierda, décima vértebra lumbar desviación izquierda. para vista lateral derecha: tronco en extensión, lordosis cervical aplanada, cifosis normal, lordosis lumbar normal, rodilla recurvatum; con respecto a la línea de gravedad, meato auditivo externo en retroversión, hombro en retroversión, trocánter mayor en retroversión. en vista lateral izquierda se encontró: tronco en extensión, lordosis cervical aplanada, cifosis normal, lordosis lumbar normal, rodilla recurvatum; con respecto a la línea de gravedad, meato auditivo externo en retroversión, hombro en retroversión, trocánter mayor en retroversión. discusión en el ambiente universitario, cada día de práctica los estudiantes del programa de fisioterapia intervienen para promover la salud, prevenir la discapacidad o restablecer la funcionalidad de pacientes. pero como grupo profesional también están expuestos a riesgos ergonómicos que en muchas ocasiones se traducen en lesiones músculo-esqueléticas derivadas de mala higiene postural, estrés, y presiones laborales y sociales (19). con el transcurrir de los años el cuerpo se adapta progresivamente a cualquier postura, y se dice que la mejor postura que debe adoptar un individuo es aquella que le posibilite mantener una posición erecta con mínimo de esfuerzo muscular permitiendo la realización de movimientos en contra de la gravedad. la postura y el equilibrio de la estructura corporal como un todo dependen de la armonía entre la cintura escapular, los miembros superiores, la columna vertebral, la cintura pélvica y los miembros inferiores; si existen problemas para mantener la armonía de estas estructuras ocurre el desorden postural. las alteraciones posturales están 76 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 tabla 2. perfil postural según sexo de los estudiantes del programa de fisioterapia, vista posterior siendo consideradas un problema serio de salud pública, con gran incidencia sobre la población, incapacitando temporal o definitivamente a las personas para realizar las actividades cotidianas (20). en general, entre los efectos de una mala postura están los desórdenes en los diferentes segmentos corporales iniciando en el complejo osteoartomuscular con incidencia en el cardiopulmonar, y con alteraciones en el neurológico (21). muñoz-tamarit evidenció que “la deformidad no se localiza sólo en un segmento, sino que repercute desfavorablemente sobre el resto de la anatomía” (22), aspecto que se percibe en el presente estudio, observando disbalances anatómicos en las diferentes vistas evaluadas. respecto a la cabeza, nuestro estudio encontró cabeza alineada en gran porcentaje, con lo que se infiere que el segmento está en una posición simétrica. de igual manera, en su estudio del sol y hunter (23) encontraron que la posición de la cabeza se halla en equilibrio en el 83,9% de los casos, de manera que aparentemente durante la evaluación postural estática la posición de ésta no incide en la alineación de los segmentos corporales. con respecto al tronco, al analizar la relación entre el vector del tronco con la línea horizontal se encontró que todos los hombres, y gran parte de las mujeres, tienen un tronco alineado, sin alteración, lo cual disminuye la probabilidad de que se presenten desviaciones a nivel del raquis; aunque la desviación lateral es una forma de déficit postural, hay más probabilidades de que ésta se encuentre directamente relacionada con los síntomas del paciente referidos a dolor lumbar (24). a pesar de observar una mayor alineación en el tronco podríamos revisar varios aspectos: 1) la dominancia del sujeto evaluado, 2) un desbalance muscular en tronco (músculos elongados o hipertrofiados), 3) la probabilidad de encontrar algún grado de escoliosis de convexidad izquierda dada la compensación postural (25). teniendo en cuenta las diferencias observadas respecto a la alineación de los hombros y la pelvis nuestro estudio encontró mayor frecuencia de elevación tanto en el hombro izquierdo como en la pelvis izquierda. según kendall, la posición de la pelvis representa la clave del correcto alineamiento postural. en la presente investigación se encontró desalineación de la pelvis, observándose mayor elevación de la cadera izquierda. ramón (26) menciona que la horizontalidad de la pelvis depende en gran medida de la simetría en los miembros inferiores; por su parte, gerstner (27) señala que la diferencia de altura entre las dos espinas iliacas anterosuperiores puede provenir de una angulación en varo o en valgo del pie, o de una angulación anterior o lateral de las rodillas o, simplemente, de una diferencia de longitud de los miembros inferiores similar a lo encontrado en el presente estudio. al observar los resultados obtenidos en la alineación de las rodillas un alto porcentaje de la población del estudio presenta alteraciones en este nivel. tanto en hombres como en mujeres existe desviación del eje normal de las rodillas, donde la alineación difiere entre la rodilla derecha y la izquierda. en ambos sexos, la característica más frecuente es el genu valgo derecho y el genu varo izquierdo; lo que para la primera resulta en sobrecarga del compartimiento externo, para 77 perfil postural en estudiantes de fisioterapia l ruth vanessa rosero-martínez, paola vernaza-pinzón la segunda se traduce en sobrecarga del compartimiento interno de la articulación, existiendo desigualdad en la descarga de peso, la cual se genera en diferentes ejes y planos. en condiciones normales, al realizar el análisis biomecánico sobre un plano cartesiano, los vectores de la tuberosidad anterior de la tibia y del centro geométrico de la patela deben ser iguales; tanto la patela como la tuberosidad anterior de la tibia deben estar alineadas en el centro de la rodilla. si la patela está centrada pero la tuberosidad anterior de la tibia es desviada hacia adentro o hacia fuera, se describe esta anormalidad como una rotación tibial interna o externa, respectivamente. nordin menciona que si la tuberosidad anterior de la tibia está centrada y la patela está desviada hacia dentro o hacia fuera, el fémur estará rotado interna o externamente (28), esto se evidencia en el 99% de la población estudiada que presentó torsión femoral en rotación externa bilateral. la desalineación presentada en miembros inferiores en ambos sexos se considera como un problema de desajuste postural en los estudiantes, aunque se espera que esta situación pueda ser corregida en los sujetos evaluados por las posibles consecuencias que se pueden presentar en el futuro, tal como lo citado por converso y korell (29), quienes consideran las alteraciones posturales como factor predisponente para el desarrollo de enfermedades osteoarticulares en miembros inferiores y columna vertebral. respecto a lo observado en vista posterior, las variables estuvieron encaminadas a identificar simetría y anormalidades en la alineación de los segmentos que conforman la cabeza, el tronco y los tobillos, y la diferencia de alturas de caderas y hombros. en la evaluación de la vista posterior se evidencia en ambos sexos cabeza y tronco centrados, encontrándose alteración postural en el nivel de hombros y caderas, presentando en el sexo masculino hombro derecho alto y cadera derecha elevada; en el caso de las mujeres hombro izquierdo alto y cadera izquierda elevada. al correlacionar los resultados obtenidos en el género masculino en hombros y caderas con la desviación observada hacia el lado izquierdo de la séptima vértebra cervical y la desviación de la décima vértebra torácica –por lo cual la elevación de cadera hacia el lado derecho genera desviación de la columna vertebral con la finalidad de compensar estructuras–, esto probablemente puede generar a corto plazo alteraciones estructurales como escoliosis, y comprometer la unidad funcional de la columna vertebral. en el plano sagital se tomaron dos referencias: derecha e izquierda. las variables definidas en este plano estuvieron encaminadas a determinar la angulación de tronco (lordosis cervical, cifosis dorsal, lordosis lumbar) y rodilla, y las distancias de los segmentos corporales a la línea de gravedad. de otro lado, se apreció mayor tendencia en el sexo femenino a colocar el tronco en extensión, lo cual hace que el cuerpo tienda a desplazar su centro de gravedad hacia atrás; la tendencia hacia la extensión lleva a que la carga sobre la rodilla se invierta, tensionando el ligamento cruzado posterior produciendo un recurvatum, y recargando el músculo psoas ilíaco para evitar la tendencia de rotación de la rodilla. finalmente, se correlacionó la alineación de tres puntos (meato auditivo externo, acromion, trocánter mayor) con el centro de gravedad. un factor importante en la determinación de la simetría del cuerpo es el establecimiento de la línea de la gravedad perpendicular al piso. el programa apic v 2.0 calcula el centro de tabla 3. perfil postural según sexo de los estudiantes del programa de fisioterapia, vista lateral 78 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 gravedad del sujeto utilizando parámetros biomecánicos determinados por la comunidad internacional de manera que una vez obtenidas las coordenadas del centro de gravedad del sujeto, se establecen las comparaciones. según norkin y levangie (30), el meato auditivo externo, el hombro, la cadera y la rodilla deberían estar en paralelo con la línea de gravedad, suceso que no se cumple en el presente estudio puesto que respecto al meato auditivo externo se encontró retropulsión en ambos sexos; tanto en los hombres como en las mujeres el acromion estuvo ubicado por detrás de la línea de gravedad, y la distancia del trocánter mayor a la línea de gravedad en la población estudiada estuvo por detrás de la misma, es decir, la cadera se encontraba en anteversión. en el estudio se pudo apreciar, entonces, cómo la alteración en una estructura genera cambios tanto en la biomecánica de otras, como en sus componentes muscular y ligamentoso. a modo de conclusión, encontrar desbalances anatómicos en los futuros fisioterapeutas es preocupante si se tiene en cuenta que aún no se ha iniciado activamente el ejercicio profesional propiamente dicho, si esta situación no es corregida a tiempo los años de vida profesionales potencialmente saludables se verán reducidos por la presencia de lesiones músculoesqueléticas derivadas de los desajustes posturales; por ello es importante recomendar un programa de control postural sobre esta población. una recomendación para nuevos estudios es analizar la estructura del pie, puesto que esta estructura influye de manera significativa en la alineación de los diferentes segmentos. como recomendación adicional se sugiere la toma de fotografías en los diferentes planos al mismo tiempo para evitar las acomodaciones del evaluado, lo que puede generar resultados diferentes entre las posiciones observadas, no necesariamente de desbalances sino de ajustes posturales. agradecimientos: a los estudiantes del programa de fisioterapia que participaron en el estudio, a la docente nancy janeth molano, y a las profesoras maría claudia astaiza y sandra jácome por sus valiosos aportes como expertas en la última fase del proceso investigativo. referencias bibliográficas 1. pérez m, maestre u, pons a. experiencia de un programa para la rehabilitación física del paciente escoliótico. efdeportes revista digital, vol. 64; 2003 [fecha de acceso: 20 de abril de 2009]. disponible en: http://www.efdeportes.com/efd64/escol.htm 2. castro f. educación postural. teoría y práctica. efdeportes revista digital, vol. 117; 2008. [fecha de acceso: 13 de marzo de 2009]. disponible en: http://www.efdeportes.com/efd117/educacionpostural.htm 3. kendall’s fp, kendall e, geise p. músculos: pruebas, funciones y dolor postural, 4 ed. madrid: marbán; 2000. pp. 70-118. 4. vélez m. posturología clínica en evaluación de riesgos individuales. vii congreso internacional de ergonomía, monterrey-méxico, 2005. [fecha de acceso: 20 de noviembre de 2008]. disponible en http://www.wikilearning.com/monografia/posturologia_clinica_en_deteccion_de_riesgo_individual-posturologia_clinica_en_deteccion_de_riesgo_individual/13479-1 5. palos. alineación normal y sus alteraciones, 2000. [fecha de acceso: 12 de diciembre de 2008]. disponible en: http://www.efdeportes.com/efd70/postura.htm. 6. pérez m, pons a. la educación física terapéutica en la educación como factor de calidad de vida comunitaria. efdeportes revista digital, vol. 48. 2002. 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[fecha de acceso: 4 de noviembre de 2009]. disponible en: http://viref.udea. edu.co/contenido/pdf/121-caracterizacion.pdf 27. gerstner j. manual de semiología del aparato locomotor, 7 ed. cali: aspromédica; 1993. 422 p. 28. nordin m, frankel v. biomecánica básica del sistema músculo-esquelético, 3 ed. aravaca: mcgrawhill; 2004. 512 p. 29. converso, korell. estándar de tamizaje para trastornos posturales en infantes. memorias congreso argentino de ortopedia y traumatología, diciembre, 1999. [fecha de acceso: 20 de abril de 2009]. disponible en: http://www.efdeportes.com/efd70/postura.htm 30. norkin c, levangie pk. join structure and function: a comprehensive analysis. philadelphia: davis company; 1992. [fecha de acceso: 20 de abril de 2009], pp. 426-445. disponible en: http://viref.udea.edu. co/contenido/pdf/121-caracterizacion.pdf 1 mateus carneiro vicente1 cleane rosa ribeiro da silva2 cláudia jeane lopes pimenta3 thaíse alves bezerra4 hannah karolyne vieira de lucena5 stella costa valdevino6 kátia neyla de freitas macedo costa7 capacidade funcional e autocuidado em idosos com diabetes mellitus 1 https://orcid.org/0000-0001-5454-6808. universidade federal de pernambuco, brasil. 2 https://orcid.org/0000-0002-0475-2950. universidade federal da paraíba, brasil. 3 https://orcid.org/0000-0002-1458-8226. universidade federal da paraíba, brasil. claudiapimenta@ufpb.com.br 4 https://orcid.org//0000-0003-3242-4468. universidade federal da paraíba, brasil. 5 https://orcid.org/0000-0003-3982-0260. universidade federal de pernambuco, brasil. 6 https://orcid.org/0000-0003-3099-9495. universidade federal da paraíba, brasil. 7 https://orcid.org/0000-0003-2054-6943. universidade federal da paraíba, brasil. recebido: 17/12/2019 submetido a pares: 23/01/2020 aceito por pares: 29/03/2020 aceito: 27/04/2020 doi: 10.5294/aqui.2020.20.3.2 para citar este artigo / para citar este artículo / to reference this article vicente mc, silva crr, pimenta cjl, bezerra ta, lucena hkv, valdevino sc, costa knfm. functional capacity and self-care in older adults with diabetes mellitus. aquichan. 2020;20(3):e2032. doi: https://doi.org/10.5294/aqui.2020.20.3.2 resumo objetivo: correlacionar a capacidade funcional e o autocuidado em pessoas idosas com diabetes. método: estudo transversal e quantitativo, realizado com 189 idosos com diabetes mellitus atendidos em um ambulatório de endocrinologia. utilizou-se do instrumento estruturado para a obtenção dos dados sociodemográficos e clínicos, do índice de barthel e do questionário de atividades de autocuidado com o diabetes. os dados foram analisados por estatística descritiva e inferencial. resultados: a maioria dos idosos era independente e apresentava médias elevadas de aderência ao autocuidado. observou-se correlação positiva com significância estatística entre a capacidade funcional e os domínios das atividades de autocuidado relacionados à atividade física e ao cuidado com os pés. conclusões: a capacidade funcional apresentou uma relação positiva com os itens referentes à prática de atividade física e ao cuidado com os pés. a independência funcional na pessoa idosa pode influenciar na adesão às práticas de autocuidado ante o diabetes mellitus. palavras-chave (fonte: decs) atividades cotidianas; autocuidado; diabetes mellitus; idoso; enfermagem. año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2032 temática: promoção e prevenção. contribuição para a disciplina: os achados deste estudo reforçam a necessidade de os enfermeiros investigarem a presença de limitações funcionais e os seus impactos nas práticas de autocuidado com o diabetes em população idosa. nesse sentido, durante a consulta de enfermagem, o profissional deve realizar uma avaliação multidimensional do idoso e identificar as atividades de autocuidado que apresentam maior e menor adesão, a fim de orientar e incentivar acerca da importância dessas ações para tratar a doença e prevenir complicações. https://doi.org/10.5294/aqui.2020.20.3.2 https://doi.org/10.5294/aqui.2020.20.3.2 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2032 capacidad funcional y autocuidado en ancianos con diabetes mellitus resumen objetivo: correlacionar la capacidad funcional y el autocuidado en adultos mayores con diabetes. método: estudio transversal y cuantitativo, llevado a cabo con 189 ancianos con diabetes mellitus atendidos en un ambulatorio de endocrinología. se utilizó del instrumento estructurado para obtener los datos sociodemográficos y clínicos, el índice de barthel y el cuestionario de actividades de autocuidado con la diabetes. se analizaron los datos por medio de estadística descriptiva e inferencial. resultados: la gran parte de los ancianos era independiente y presentaba promedios elevados de adherencia al autocuidado. se observó correlación positiva con significancia estadística entre la capacidad funcional y los dominios de las actividades de autocuidado relacionados a la actividad física y el cuidado con los pies. conclusiones: la capacidad funcional presentó una relación positiva con los ítems referentes a la práctica de actividad física y el cuidado con los pies. la independencia funcional en el adulto mayor puede influenciar en la adherencia a las prácticas de autocuidado hacia la diabetes mellitus. palabras clave (fuente: decs) actividades cotidianas; autocuidado; diabetes mellitus; anciano; enfermería. 3 capacidade funcional e autocuidado em idosos com diabetes mellitus l mateus carneiro vicente e outros functional capacity and self-care in older adults with diabetes mellitus abstract objective: to correlate functional capacity and self-care in older adults with diabetes. method: a cross-sectional and quantitative study, carried out with 189 older adults with diabetes mellitus treated at an endocrinology outpatient clinic. the structured instrument to obtain sociodemographic and clinical data, the barthel index, and the diabetes self-care activities questionnaire were used. data was analyzed with descriptive and inferential statistics. results: most of the older adults were independent and had high mean values of adherence to self-care. there was a positive correlation with statistical significance between functional capacity and the domains of selfcare activities related to physical activity and care with the feet. conclusions: functional capacity showed a positive relationship with items related to physical activity and care with the feet. functional independence in the older adult can influence adherence to self-care practices facing diabetes mellitus. keywords (source: decs) activities of daily living; self care; diabetes mellitus; aged; nursing. año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2032 4 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2032 aquichan issn 1657-5997 eissn 2027-5374 introdução a população de idosos tem aumentado em todo o mundo devido, principalmente, à queda da fecundidade e ao aumento da expectativa de vida. no entanto, é preocupante a forma como esse grupo está envelhecendo, sendo observada uma transição no perfil epidemiológico, em que há o predomínio das doenças crônicas, com destaque para o diabetes mellitus (1). a prevalência de diabetes é elevada em todos os países, afetando atualmente mais de 425 milhões de pessoas e ocasionando cerca de quatro milhões de mortes que resultam diretamente da doença ou de suas complicações. nas pessoas idosas, esse cenário também representa um sério problema de saúde pública, haja vista que, em 2017, aproximadamente 122,8 milhões de pessoas com idade entre 65 e 99 anos apresentavam diabetes, com projeções de 253,4 milhões para 2045 (2). o diabetes é definido como um quadro de instabilidade glicêmica, que tem como efeito a alteração no metabolismo dos lipídios, proteínas e carboidratos, e que ocasiona disfunções na secreção de insulina. o aumento da prevalência associado ao crescente número de pessoas obesas e ao envelhecimento populacional caracteriza o diabetes como uma doença epidêmica da atualidade (2, 3). os indivíduos com diabetes sofrem diversas modificações em seu cotidiano, não apenas pelos efeitos da doença, mas também pelas mudanças requeridas em seu padrão de vida, o que causa prejuízos para a sua funcionalidade. a incapacidade funcional é caracterizada como um processo dinâmico e progressivo que está associada a limitações físicas e mentais que podem comprometer a autonomia e a independência para a realização de atividades rotineiras (4). estudo realizado com idosos hospitalizados por complicações do diabetes em joão pessoa, brasil, identificou que mais de 85 % dos pacientes apresentavam algum grau de dependência na realização das atividades de vida diária, o que poderia ser resultado das próprias características da doença, do maior risco de acometimento por outras morbidades e dos prejuízos causados pelas complicações (5). nas pessoas idosas, as alterações decorrentes do diabetes se agravam devido às limitações inerentes ao processo de envelhecimento e à presença frequente de incapacidades funcionais, o que pode impactar negativamente a prática do autocuidado (6). este, por sua vez, é caracterizado como a realização de atividades executadas pelo indivíduo em seu próprio benefício, com o objetivo de evitar, tratar e promover o convívio com as doenças crônicas (7). além disso, essa prática favorece a melhoria da qualidade de vida, a manutenção da saúde e do bem-estar, assim como a execução das atividades diárias (8). o controle glicêmico é um dos desafios mais complexos na rotina da pessoa idosa com diabetes, haja vista que requer esforços diários para a adesão a um estilo de vida saudável e para a adoção de práticas de autocuidado, já que é necessário que o indivíduo apresente um nível satisfatório de capacidade funcional para realizar essas atividades (7, 9). nesse sentido, o enfermeiro deve utilizar ferramentas de rastreamento das condições de saúde da pessoa idosa. destaca-se a avaliação multidimensional por identificar precocemente um déficit funcional nas atividades de vida diária e nas práticas de autocuidado, além de prevenir os agravos decorrentes do diabetes, como alterações dermatológicas, musculoesqueléticas, vasculares e neurológicas (10). associado a isso, o cuidado desse profissional deve ser embasado em alguma teoria que possa explicar, fundamentar e subsidiar a implementação das etapas do processo de enfermagem (11). entre os referenciais teóricos utilizados no cuidado à pessoa com diabetes mellitus, a teoria do autocuidado de orem é uma das mais frequentes (11), haja vista que valoriza a responsabilidade do próprio indivíduo com a sua saúde ao reconhecer o papel do enfermeiro na prevenção de complicações na educação em saúde. estudo realizado em unidades básicas de saúde com pessoas com diabetes tipo 2 no paraná, brasil, evidenciou que o uso dos pressupostos do autocuidado apoiado pelo enfermeiro representou uma estratégia eficaz na identificação das principais barreiras para o controle glicêmico (12). embora o diabetes seja um problema que apresenta grande investigação na literatura científica, ainda são escassos os estudos que avaliam a capacidade funcional e a adesão às práticas de autocuidado na pessoa idosa. nesse sentido, a questão que orientou este estudo foi: existe correlação entre a capacidade funcional e o autocuidado em pessoas idosas com diabetes? diante dos prejuízos causados pela doença para os diversos aspectos 5 capacidade funcional e autocuidado em idosos com diabetes mellitus l mateus carneiro vicente e outros da vida e da saúde, emerge a necessidade de investigar se há essa correlação — o que se tornou o objetivo deste estudo —, visto que isso poderá contribuir para a implementação de intervenções referentes às competências mais comprometidas e para a identificação das atitudes desses indivíduos em determinadas circunstâncias, o que permitirá efetivar estratégias mais específicas para o tratamento do diabetes (9, 13). método trata-se de um estudo transversal, com abordagem quantitativa, realizado em um serviço ambulatorial de endocrinologia de um hospital-escola, localizado na cidade de joão pessoa, paraíba, brasil, de maio a agosto de 2018, com a utilização do instrumento strobe para fundamentar a metodologia (14). esse ambulatório foi escolhido por ser um dos serviços de referência para a atenção especializada de endocrinologia no estado da paraíba, por receber pacientes encaminhados das unidades básicas de saúde com o propósito de acompanhamento ambulatorial das doenças endócrinas e uma média de 90 atendimentos mensais de pessoas idosas com diabetes mellitus. a população do estudo foi composta por pessoas idosas com diagnóstico de diabetes atendidas no serviço ambulatorial de endocrinologia. a amostra foi calculada considerando-se o atendimento de 371 pessoas idosas com diabetes mellitus, de julho a dezembro de 2017, período que antecedeu à coleta de dados, os quais foram fornecidos pelo serviço de regulação da referida instituição. o tamanho da amostra foi definido com a utilização do cálculo para populações finitas com proporção conhecida e intervalo de confiança de 95 %, prevalência estimada de 50 % e margem de erro de 5 %, o que levou a um total de 189 idosos. não houve perdas ou recusas na amostra. para a seleção dos participantes do estudo, foi solicitada, à coordenação do serviço, uma listagem dos pacientes com diabetes mellitus agendados para o atendimento em cada dia da coleta de dados, com a posterior realização de um sorteio aleatório de três participantes por dia. os critérios de inclusão estabelecidos nesta pesquisa foram: ter idade igual ou superior a 60 anos, ser acompanhado no ambulatório de endocrinologia durante o período da coleta e apresentar diagnóstico médico de diabetes mellitus, confirmado pela listagem cedida pelo serviço. os critérios de exclusão foram: idosos que apresentaram déficit cognitivo segundo o miniexame do estado mental, o qual é composto por questões relacionadas à orientação, à memória imediata e de evocação, ao cálculo, à linguagem, à concentração e ao domínio espacial (15). os dados foram coletados por pesquisadores previamente treinados, em um processo que envolveu a apresentação, a explicação e a aplicação da escala entre os entrevistadores para padronizar a coleta de dados. os sujeitos que se enquadravam nos critérios de inclusão foram convidados a participar do estudo, sendo a entrevista realizada antes da consulta de acompanhamento, em uma sala do ambulatório cedida pelo serviço. utilizou-se do instrumento estruturado para a obtenção de dados referentes ao perfil sociodemográfico e clínico dos participantes: sexo, idade, conjugalidade, escolaridade, situação previdenciária, renda familiar e arranjo familiar, tipo de diabetes, situação de saúde autorreferida, prática de atividade física, tabagismo, alcoolismo, presença de comorbidades associadas e número de medicamentos utilizados por dia. para avaliar a capacidade funcional, foi utilizado o índice de barthel, validado para o contexto brasileiro. esse instrumento compreende dez itens que avaliam higiene pessoal, independência no banheiro, alimentação, transferência da cadeira, marcha, capacidade de se vestir, de se banhar e de subir escadas, e controle dos esfíncteres vesical e intestinal. cada item apresenta uma pontuação específica, que, quando somada, é possível chegar a um valor total de 0 a 100 pontos, que correspondem à total dependência ou à total independência, respectivamente (16). a partir da pontuação, foi utilizada a seguinte classificação: independente (100 pontos), dependência leve (91 a 99 pontos), dependência moderada (61 a 90 pontos), dependência severa (21 a 60 pontos) e dependência total (0 a 20 pontos) (4). para avaliar o autocuidado com o diabetes, foi utilizado o questionário de atividades de autocuidado com o diabetes, traduzido para o brasil com 18 itens, distribuídos em sete eixos temáticos: alimentação geral, alimentação específica, atividade física, monitorização da glicemia, cuidados com os pés, uso da medicação e tabagismo. para a análise da adesão, os itens do questionário foram caracterizados em sete dias da semana anteriores à coleta, atribuindo o escore de cada item de 0 a 7, em que 0 é a situação menos desejável e 7, a mais favorável, com exceção para a dimensão alimentação específica que aborda o consumo de alimentos ricos em gordura e doces, cujos valores foram invertidos (17). 6 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2032 aquichan issn 1657-5997 eissn 2027-5374 os dados coletados foram compilados e armazenados no programa microsoft office excel e, posteriormente, importados para o programa statistical package for the social sciences (spss) versão 22.0, sendo analisados por meio de estatística descritiva e inferencial. consideraram-se, como variável dependente, o autocuidado e, como independente, a capacidade funcional. para a verificação da normalidade dos dados numéricos, utilizou-se do teste de kolmogorov-smirnov. por apresentarem distribuição não normal, a correlação entre as variáveis dependente e independente foi realizada por meio do coeficiente de correlação de spearman. o nível de significância utilizado para as análises estatísticas foi de 5 % (p ≤ 0,05). o estudo foi desenvolvido de acordo com o preconizado pela resolução 466/2012 do conselho nacional de saúde do brasil, com a aprovação do comitê de ética em pesquisa que envolve seres humanos do local em que esta foi realizada, sob caae (certificado de apresentação para apreciação ética) 90238718.3.0000.5183 e aprovação 2.714.334. os participantes assinaram o termo de consentimento livre e esclarecido após terem sido devidamente aclarados sobre a justificativa da pesquisa, sua finalidade, os riscos e os benefícios, além dos procedimentos a serem realizados e da garantia de sigilo e confidencialidade das informações prestadas. resultados dos 189 idosos participantes, 130 (68,8 %) eram do sexo feminino; 114 (60,3 %) tinham idade entre 60 e 69 anos; 103 (54,5 %) casados ou com companheiro; 150 (79,4 %) apresentavam baixa escolaridade; 134 (70,9 %) eram aposentados; 161 (85,2 %) tinham renda familiar entre um e dois salários-mínimos e 96 (50,8 %) residiam com uma ou duas pessoas. no que se refere às condições de saúde, 185 (97,9 %) tinham diabetes tipo 2; 102 (54,0 %) avaliaram a sua situação de saúde como nem boa, nem ruim; 148 (78,3 %) não praticavam atividade física; 179 (94,7 %) não fumavam; 181 (95,8 %) não consumiam bebidas alcoólicas; 148 (78,3 %) apresentavam hipertensão arterial e 103 (56,6 %) referiram utilizar cinco ou mais medicamentos diariamente. em relação à análise da capacidade funcional dos idosos, observou-se que 129 (68,3 %) eram independentes para a realização das atividades diárias (tabela 1). tabela 1. capacidade funcional de idosos com diabetes mellitus capacidade funcional n % independente 129 68,3 dependente leve 17 9,0 dependente moderado 38 20,1 dependente severo 4 2,1 dependente total 1 0,5 total 189 100 fonte: dados da pesquisa, 2018. as atividades de autocuidado com o diabetes que apresentaram as maiores médias por dia da semana, durante os sete dias, foram: tomar os medicamentos do diabetes (6,97); tomar o número indicado de comprimidos do diabetes (6,97) e tomar as injeções de insulina (6,90). as atividades que obtiveram os menores índices de adesão pelos idosos foram: avaliar a glicemia (1,83); realizar atividade física por menos de 30 minutos (1,07) e realizar exercício específico, como caminhar, nadar etc. (1,06). embora as atividades de ingerir alimentos ricos em gordura (0,71) e ingerir doces (0,62) apresentem baixos valores, isso indica que os idosos obtiveram uma elevada adesão ao autocuidado, uma vez que consumiram esses alimentos poucas vezes durante a semana (tabela 2). as atividades de autocuidado com o diabetes referentes ao tabagismo evidenciaram que 178 (94,2 %) idosos não fumaram nos últimos sete dias. quando questionados sobre a data do último cigarro fumado, 111 (58,7 %) idosos referiram que nunca fumaram e 62 (32,8 %) citaram que isso ocorreu há mais de dois anos. tabela 2. atividades de autocuidado com o diabetes em pessoas idosas autocuidado média de aderência (desvio-padrão) alimentação geral seguir uma dieta saudável 5,63 (± 2,078) seguir a orientação alimentar 5,20 (± 2,486) alimentação específica ingerir cinco ou mais porções de frutas ou de verduras 5,71 (± 1,874) ingerir alimentos ricos em gordura 0,71 (± 1,585) ingerir doces 0,62 (± 1,408) 7 capacidade funcional e autocuidado em idosos com diabetes mellitus l mateus carneiro vicente e outros autocuidado média de aderência (desvio-padrão) atividade física realizar atividade física por, pelo menos, 30 minutos 1,07 (± 2,203) realizar exercício específico (caminhar, nadar etc.) 1,06 (± 2,198) monitorização da glicemia avaliar a glicemia 1,83 (± 2,621) avaliar a glicemia o número de vezes recomendado 1,85 (± 2,689) cuidado com os pés examinar os pés 5,87 (± 1,853) examinar dentro dos sapatos antes de calçá-los 5,84 (± 1,882) secar os espaços entre os dedos dos pés após lavá-los 5,88 (± 1,868) medicação tomar os medicamentos do diabetes 6,97 (± 0,242) tomar as injeções de insulina 6,90 (± 0,693) tomar o número indicado de comprimidos do diabetes 6,97 (± 0,251) fonte: dados da pesquisa, 2018. ao correlacionar a capacidade funcional com as atividades de autocuidado, observou-se uma correlação positiva, com significância estatística (p ≤ 0,050), entre os domínios “atividade física” (p = 0,007) e “cuidado com os pés” (p = 0,021). esse achado demonstra que o aumento da capacidade funcional dos idosos está correlacionado com a prática dessas atividades (tabela 3). tabela 3. correlação entre as atividades de autocuidado com o diabetes e a capacidade funcional domínios das atividades de autocuidado capacidade funcional r p* alimentação geral 0,135 0,063 alimentação específica 0,130 0,076 atividade física 0,195 0,007 monitorização da glicemia -0,004 0,956 cuidados com os pés 0,168 0,021 uso de medicação -0,094 0,569 *teste de correlação de spearman. fonte: dados da pesquisa, 2018. discussão na avaliação da capacidade funcional, observou-se maior frequência de pessoas idosas independentes, o que poderia estar relacionado ao fato de serem indivíduos que estavam sendo acompanhados em nível secundário de atenção e com ausência de complicações do diabetes que pudessem causar prejuízos para a realização das atividades de vida diária. a preservação da funcionalidade pode ter influência sobre a qualidade de vida dos idosos, uma vez que permite maior autonomia e independência, favorece o desenvolvimento das tarefas cotidianas e facilita os cuidados com o diabetes (18). a capacidade funcional representa um importante indicador da condição de saúde do indivíduo com diabetes mellitus, sobretudo na pessoa idosa, haja vista que a doença pode gerar cansaço físico, fadiga, enfraquecimento muscular e diminuição da sensibilidade plantar, o que, associados às alterações naturais do envelhecimento, provoca limitações na amplitude dos movimentos e na habilidade para a realização de diversas ações (5, 19). a consulta de enfermagem à pessoa idosa com diabetes não deve ser restrita à investigação dos aspectos inerentes à doença; portanto, é necessário realizar uma avaliação multidimensional que aborde, dentre outros aspectos, a capacidade funcional como um dos pilares para a promoção da saúde e do autocuidado desses indivíduos (12, 18, 20). embora o tratamento do diabetes envolva mudanças na rotina, com destaque para a adoção de hábitos alimentares saudáveis, para a prática regular de atividade física, para o uso de medicamentos e para o cuidado com os pés, a presença de limitações na funcionalidade pode interferir diretamente na sua adesão (8). diante disso, percebe-se que o autocuidado no diabetes pode ser influenciado por fatores intrínsecos e extrínsecos à pessoa idosa (11), com o estabelecimento de uma relação de confiança entre enfermeiro e paciente, a fim de auxiliar este último no gerenciamento da sua condição de saúde, o que permitiria a identificação dos elementos que prejudicam e favorecem a realização das práticas de autocuidado. no que diz respeito ao autocuidado no manejo do diabetes, a produção científica nacional e internacional evidencia que a adesão de atividades realizadas pelo indivíduo para a conservação da sua vida, da saúde e do bem-estar, potencializa o sucesso te8 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2032 aquichan issn 1657-5997 eissn 2027-5374 rapêutico (6, 8, 10, 12). no presente estudo, os itens do autocuidado com o diabetes relacionados à terapêutica medicamentosa apresentaram maiores médias, o que pode ser justificado porque é mais fácil ter acesso aos medicamentos do que mudar comportamentos no estilo de vida, já que isto implica aspectos culturais e socioeconômicos (13, 21). o idoso que adere ao uso de medicamentos para o diabetes e o considera eficaz para o controle glicêmico apresenta 18 vezes mais chances de controlar a doença quando comparado ao idoso que não adere (22). contudo, no que se refere à prática regular de insulinoterapia, existe a necessidade de intervenção do enfermeiro no ensino do autocuidado no manejo desse método terapêutico, devido a suas especificidades e riscos, com alusão aos erros na autoadministração da insulina como a não lavagem das mãos, a aspiração de ar na seringa, o déficit nos rodízios de aplicação e o descarte inadequado dos perfurocortantes (23, 24). de acordo com orem (11), a realização das ações de autocuidado é resultado direto da decisão pessoal do indivíduo. assim, a habilidade de se comprometer a colocar em prática o autocuidado está sujeita a alguns elementos condicionantes, tais como a idade, as experiências de vida, os valores, a cultura e o nível educacional da pessoa idosa, haja vista que são particularidades inerentes a cada indivíduo e podem influenciar de modo positivo ou negativo na qualidade e adesão ao autocuidado (21). os participantes do estudo demonstraram não realizar regularmente a monitorização da glicemia, com baixa adesão nos itens referentes a essa prática. tal achado pode ser justificado por dificuldades econômicas para a aquisição dos materiais, falha na oferta pelo serviço público de saúde, receio/medo da técnica, pouca instrução para o manuseio do procedimento, prejuízos na capacidade funcional ou por conhecimento reduzido sobre a importância dessa atividade para o autocuidado (20, 25). a monitorização da glicemia é indicada para todos os indivíduos em insulinoterapia ou tratamento medicamentoso, uma vez que a observação dos níveis glicêmicos possibilita a intervenção diante de adversidades, como a hipo ou a hiperglicemia (21). todavia, embora essa atividade apresente uma grande relevância, a baixa escolaridade apresentada pelos participantes do presente estudo pode ter sido um fator que influenciou negativamente a sua adesão, por dificultar a busca ou a assimilação de informações relacionadas ao diabetes e aos cuidados para prevenir as suas complicações. quanto à realização de atividade física, observou-se que a maioria dos idosos não exerce rotineiramente essa prática, o que também foi constatado por outros estudos (21, 26). a baixa adesão à atividade física torna as pessoas com diabetes mais vulneráveis a desenvolverem complicações, visto que tal prática é eficaz por reduzir a necessidade do tratamento farmacológico, melhorar o controle metabólico por meio do aumento da sensibilidade à ação da insulina e captação da glicose, diminuir o peso e o risco de doenças cardiovasculares (2, 22). a prática de exercícios físicos, sobretudo na população idosa, proporciona benefícios para a qualidade de vida e para a autonomia desses indivíduos, uma vez que melhora a capacidade funcional e promove um envelhecimento mais ativo, com a preservação da saúde física e mental (27). no entanto, existem dificuldades que limitam essa prática, com destaque para os aspectos relacionados à senescência e à senilidade, à falta de apoio/suporte familiar e à inexistência ou à deficiência de serviços públicos e de profissionais habilitados para promoverem a prática de exercícios físicos a essa população (22). a participação efetiva da família é um dos fatores condicionantes do autocuidado (11), representando um fator primordial para o controle do diabetes (6). nesse sentido, o enfermeiro deve orientar o idoso e seus familiares acerca da importância da prática de autocuidado para a efetivação do tratamento, a fim de que essas pessoas compreendam os principais aspectos relacionados à doença, a partir da adoção de um estilo de vida saudável, com ênfase em uma dieta equilibrada e na prática regular de atividade física (12). a maioria dos idosos referiu não fumar, o que representa um dado positivo para o tratamento do diabetes, haja vista que o consumo de cigarros está associado a uma piora no controle glicêmico e ao aumento do risco cardiovascular e da taxa de mortalidade (28). nesse sentido, o abandono do hábito de fumar corresponde a uma importante medida de autocuidado no diabetes, sobretudo entre os idosos; contudo, é importante o apoio dos familiares e dos profissionais de saúde para a efetiva cessação do tabagismo (29). ao correlacionar a capacidade funcional com os domínios relativos ao autocuidado, verificou-se que a independência pode ter promovido uma maior adesão à prática de atividade física. em estudo que avaliou a funcionalidade de idosos por meio de um teste de caminhada, observou-se que os praticantes de exercícios físicos apresentaram uma capacidade funcional satisfatória, uma vez 9 capacidade funcional e autocuidado em idosos com diabetes mellitus l mateus carneiro vicente e outros que essa atividade proporciona o aumento da força muscular e do gasto de energia, melhora o equilíbrio, promove a diminuição da gordura corporal e auxilia na melhoria do ritmo cardiorrespiratório, o que serve de subsídio para a independência funcional (30). foi identificada correlação significativa entre a funcionalidade dos idosos com as atividades de autocuidado com os pés. esses cuidados representam a principal forma preventiva do pé diabético, o qual é uma das complicações prevalentes que advêm da doença, além de serem motivo constante para hospitalizações e amputações, o que pode interferir na capacidade funcional da pessoa idosa e torná-la dependente de terceiros (6, 31). dessa forma, faz-se imprescindível que a avaliação da capacidade funcional se torne uma prática de rotina na atenção à saúde da pessoa idosa, a fim de identificar as necessidades e as prioridades para o cuidado, promover maior autonomia e independência desses indivíduos e atuar no estímulo para maior adesão às práticas de autocuidado com o diabetes (3, 7). associado a isso, o enfermeiro pode utilizar teorias de enfermagem que subsidiem a sua prática clínica e a sistematização da assistência aos idosos com diabetes, o que favorece a qualidade, segurança e integralidade do cuidado prestado (32). conclusões constatou-se que a maioria dos idosos era independente para as atividades cotidianas e aderia às práticas de autocuidado com o diabetes, embora ainda precisem ser orientados no que diz respeito, principalmente, à realização de atividade física e ao monitoramento da glicemia capilar, os quais são elementos essenciais para o controle e manejo do diabetes. na correlação entre as variáveis, percebeu-se que a capacidade funcional apresentou uma relação positiva significativa com os itens referentes à prática de atividade física e ao cuidado com os pés. assim, observa-se que a independência funcional na pessoa idosa pode influenciar na adesão às práticas de autocuidado ante o diabetes, o que reforça a necessidade de se planejarem programas de intervenção com enfoque na manutenção e reabilitação da capacidade funcional das pessoas idosas acometidas por essa morbidade. os resultados deste estudo demonstraram a importância da funcionalidade da pessoa idosa para a adesão às práticas de autocuidado com o diabetes. nesse sentido, a capacidade funcional desses indivíduos, além de atuar como um importante preditor de independência e qualidade de vida, representa uma ferramenta relevante para a aderência ao autocuidado, sobretudo na presença do diabetes, em que as mudanças impostas pela doença requerem mais autonomia do indivíduo para a realização de adaptações em sua rotina de atividades diárias. como limitação do estudo, destaca-se o delineamento da pesquisa, pois o método transversal não traz 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https://doi.org/10.1111/scs.12670 https://doi.org/10.1590/1413-81232018233.03722016 https://doi.org/10.1590/1413-81232018233.03722016 https://doi.org/10.1371/journal.pone.0187119 https://doi.org/10.1155/2018/3190849 https://doi.org/10.1590/0034-7167-2017-0089 https://doi.org/10.1590/0034-7167-2017-0089 https://doi.org/10.4322/2526-8910.ctoao0899 https://doi.org/10.4322/2526-8910.ctoao0899 https://doi.org/10.2337/dc16-1728 https://doi.org/10.2337/dc16-1728 https://doi.org/10.1007/s00125-016-4003-7 https://doi.org/10.1161/circulationaha.115.017926 https://doi.org/10.1161/circulationaha.115.017926 https://doi.org/10.9789/2175-5361.2015.v7i1.2042-2050 https://doi.org/10.9789/2175-5361.2015.v7i1.2042-2050 https://doi.org/10.12957/demetra.2015.13990 https://doi.org/10.1111/scs.12670 self-inflicted injuries among adolescents: prevalence and associated factors, espírito santo, brazil article self-inflicted injuries among adolescents: prevalence and associated factors, espírito santo, brazil* lesión autoprovocada entre adolescentes: prevalência y factores asociados, espírito santo, brasil** lesão autoprovocada entre adolescentes: prevalência e fatores associados, espírito santo, brasil*** 10.5294/aqui.2021.21.3.3 mayara alves luis1 nataly adriana jiménez monroy2 luciana graziela de godoi3 franciéle marabotti costa leite4 1 0000-0002-5162-8899. universidade federal do espírito santo, brazil. mayara.luis@edu.ufes.br 2 0000-0003-4593-9479. universidade federal do espírito santo, brazil. nataly.monroy@ufes.br 3 0000-0002-1681-0281. universidade federal do espírito santo, brazil. luciana.godoi@ufes.br 4 0000-0002-6171-6972. universidade federal do espírito santo, brazil. franciele.leite@ufes.br * this article derives from the dissertation entitled “self-inflicted violence among adolescents in espírito santo: an analysis of notified cases from 2011 to 2018”, presented to the graduate program in collective health of the faculty, universidade federal do espírito santo, brazil. this research was funded by the espírito santo research support foundation (fapes/cnpq/decit-sctie-ms/sesa call no. 3/2018-ppsus). ** este artículo deriva de la tesis "violencia autoprovocada entre adolescentes en espírito santo: análisis de los casos notificados de 2011 a 2018", presentada al programa de postgrado en salud colectiva del cuerpo docente, universidade federal do espírito santo, brasil. la investigación fue patrocinada por la fundación de apoyo a la investigación de espírito santo (convocatoria fapes/ cnpq/decit-sctie-ms/sesa n.° 3/2018-ppsus). *** este artigo é derivado da dissertação intitulada "violência autoprovocada entre adolescentes no espírito santo: uma análise dos casos notificados de 2011 a 2018", apresentada ao programa de pós-graduação em saúde coletiva do corpo docente, da universidade federal do espírito santo, brasil. esta pesquisa foi financiada pela fundação de amparo à pesquisa do espírito santo (edital fapes/cnpq/decit-sctie-ms/sesa n.o 3/2018-ppsus). received: 11/10/2020 sent to peers: 16/12/2020 approved by peers: 21/05/2021 accepted: 16/07/2021 theme: promotion and prevention. contribution to the discipline: given self-inflicted injuries in adolescence, this research presents a relevant contribution to nursing and public health in general, since this problem has serious implications for the health of individuals and is a predictor of suicide. the results evidence the high frequency of the problem, report data about the factors associated with the notification of this phenomenon, and contribute to its identification, confrontation, and prevention. in addition, the study evidences the importance of mandatory notification. to reference this article / para citar este artículo / para citar este artigo : luis ma, monroy naj, godoi lg, leite fmc. self-inflicted injuries among adolescents: prevalence and associated factors, espírito santo, brazil. aquichan. 2021;21(3):e2133: doi: https://doi.org/10.5294/aqui.2021.21.3.3 abstract objective: to identify the prevalence of notified self-inflicted injuries among adolescents in espírito santo and to analyze the associated factors. materials and methods: a cross-sectional and analytical study, with the notified data of self-inflicted violence among adolescents in espírito santo registered in the notifiable diseases information system from 2011 to 2018. the bivariate analyses considered the chi-square (x2) and fisher's exact tests. the multivariate analysis considered the log-binomial model, and the adjustment results were presented as prevalence ratio. results: the prevalence of notified self-inflicted injuries was 33 % and, of this total, 79.8 % occurred among female adolescents. prevalence was higher among adolescents aged from 13 to 17 years old (female gender) and from 18 to 19 years old (male gender), as well as among those with some disability or disorder. higher prevalence values were found in the residence and in collective housing, as well as among those who did not consume alcohol at the event in question. in the female gender, there was also an association with the urban area (p < 0.05). conclusions: hhigh prevalence of notified self-inflicted injuries is perceived among adolescents in espírito santo, as well as of the factors associated to this phenomenon. the importance of adopting promotion, prevention and recovery measures for the problem is verified. keywords (source  deos): adolescent; attempted suicide; self-injurious behavior; epidemiology; health information systems. resumen objetivo: identificar la prevalencia de lesiones autoprovocadas notificadas entre adolescentes en espírito santo, brasil, y analizar los factores asociados. materiales y métodos: estudio analítico de tipo transversal, a partir de datos notificados de violencia autoprovocada entre adolescentes en espírito santo registrados en el sistema de información de problemas de salud y notificación entre 2011 y 2018. en los análisis bivariados se consideraron las pruebas de chi-cuadrado (x2) y exacta de fisher. el análisis multivariado adoptó el modelo log-binomial, y los resultados del ajuste se presentaron a partir de la razón de prevalencia. resultados: la prevalencia de lesiones auto-provocadas notificadas fue del 33 % y, de este total, el 79,8 % ocurrió entre adolescentes del género femenino. la prevalencia fue mayor en adolescentes de 13 a 17 años (sexo femenino) y de 18 y 19 años (sexo masculino), y entre aquellos con alguna discapacidad o trastorno. se encontraron valores de prevalencia más elevados en la vivienda y en alojamiento compartido, y entre aquellos que no consumieron alcohol en el evento en cuestión. en el sexo femenino, también se registró una asociación con el área urbana (p < 0,05). conclusiones: se percibe la elevada prevalencia de lesiones autoprovocadas notificadas entre los adolescentes en espírito santo y los factores asociados a este fenómeno. se evidencia la importancia de adoptar medidas de promoción, prevención y recuperación del problema. palabras clave (fuente deos): adolescente; intento de suicidio; conducta autodestructiva; epidemiología; sistemas de información en salud. resumo objetivo: identificar a prevalência de lesão autoprovocada notificada entre adolescentes no espírito santo e analisar os fatores associados. materiais e métodos: estudo analítico do tipo transversal, com os dados notificados de violência autoprovocada entre adolescentes no espírito santo registrados no sistema de informação de agravos e notificação de 2011 a 2018. análises bivariadas consideraram o teste qui-quadrado (x2) e o exato de fisher. a análise multivariada considerou o modelo log-binomial, e os resultados do ajuste foram apresentados em razão de prevalência. resultados: a prevalência de lesão autoprovocada notificada foi 33 % e, desse total, 79,8 % ocorreram entre adolescentes do sexo feminino. houve maior prevalência em adolescentes com idade de 13 a 17 anos (sexo feminino) e de 18 a 19 anos (sexo masculino), e entre aqueles com deficiência ou transtorno. maiores prevalências foram encontradas na residência e na habitação coletiva, e entre aqueles que não consumiram álcool no evento. no sexo feminino, também houve associação com a zona urbana (p < 0,05). conclusões: percebe-se a alta prevalência de lesão autoprovocada notificada entre os adolescentes no espírito santo e os fatores associados a esse fenômeno. constata-se a importância da adoção de medidas de promoção, prevenção e recuperação contra o agravo. palavras-chaves (fonte deos): adolescente; tentativa de suicídio; lesão autoinfligida não suicida; epidemiologia; sistema de informação em saúde. introduction adolescence can be considered as a stressful event for the individual due to the multiple and intense physiological and physical changes that occur during this period (1). in this phase, where the person is vulnerable, there may be reactions with suicidal attitudes in response to conflicts, either internal or external (2). in this context, self-inflicted injuries among adolescents became a public health problem and drew attention due to the severity of their impacts (3, 4). there can be self-inflicted injuries with or without suicidal ideation. self-inflicted injuries with suicidal ideation are called "attempted suicide" and occur when the individuals try to put an end to their own life, although without consummation (5). in turn, self-inflicted injuries are defined as the direct and deliberate destruction of one's own body tissue in the absence of lethal intent and for reasons not socially established (6). although they are commonly classified as similar acts — since, generally, non-suicidal injuries are treated as attempted suicide (7, 8) — the literature (7) points out relevant differences between them, such as: the intention to die present only in attempted suicide while, in non-suicidal injuries, the intention is to achieve relief of unwanted feelings (7, 9); the difference between the most commonly used means of aggression since, in suicide attempts, they are more aggressive (6); the psychological consequences, which are generally of relief after the act of self-inflicted injury without suicidal intention and of failure after attempted suicide (7); and the number of times the individuals attack themselves, with the frequency of self-inflicted injuries without the suicidal intention being higher (7). although these differences exist, these practices are related to each other and, according to some studies, adolescents involved in non-suicidal injury practices are more likely to attempt suicide at some point in their lives (10, 11). according to some studies (12, 13), the incidence of self-inflicted injuries in adolescents can be conceptualized from a three-level iceberg model. at the first level is a suicide, which is the fatal and less common outcome; at the second level are injuries, which result in health care services; and, finally, self-inflicted injuries, which occur in the community, being the most common, but hidden for the most part. in a meta-analysis conducted with studies produced in 41 countries, the prevalence of self-inflicted injuries throughout life was 16.5 % (14). a systematic review that aimed at estimating the prevalence of suicidal behavior, deliberate self-injury and non-suicidal self-injury in children, and adolescents worldwide, indicated that the lifetime prevalence of attempted suicide was 6 %, while injury without suicidal intent presented a prevalence of 22.1 % (15). between 2011 and 2014, in espírito santo, the notification rate of self-inflicted injuries was 22.8 cases among female adolescents in the age group from 15 to 19 years old for every 100,000 adolescents (16). in the literature, many factors have been associated with the practice of self-inflicted injuries in adolescence, such as: gender; age; the presence of mental disorders; having feelings of guilt, rejection and loneliness; family and peer conflicts; being a victim of bullying; having been a victim of domestic violence, and consumption of alcoholic beverages (17-21). in brazil, ministry of health ordinance 1,271 of 2014 incorporated self-inflicted violence to the national list of immediate and mandatory notification health problems, to ensure intervention in cases through the health sector (22). therefore, a mandatory notification is an institutional duty, and it is up to the health professionals to report the cases in full compliance with the current legislation (23). given the above, the objective of this study is to analyze the factors associated with the occurrence of self-inflicted injuries and the characteristics of both the victims and the aggressions among adolescents in espírito santo. materials and method this is an epidemiological, analytical and cross-sectional study, carried out with the notified data of self-inflicted and interpersonal violence against adolescents, aged between 10 and 19 years old, produced by the epidemiological surveillance system and registered in the notifiable diseases information system (sistema de informação de agravos de notificação, sinan). the sinan is one of the health information systems fed by the notification and investigation of cases of mandatory notification diseases and health problems, such as interpersonal and self-inflicted violence. its objective is to collect, transmit and disseminate data generated by the epidemiological surveillance system to support the investigation process and provide subsidies for the analysis of the epidemiological surveillance information regarding the mandatory notification problems (24). for this research, the data used were those from the notifications of self-inflicted injuries among adolescents from 2011 to 2018 produced by the state health secretariat of espírito santo. espírito santo is a state located in the brazilian southeast region, with a territorial extension of 46,074.444 km2. according to the last demographic census conducted in 2010 by the brazilian institute of geography and statistics, it had nearly 3.5 million inhabitants, with an estimated population of 603,835 adolescents at the time, a demographic density of 76.25 inhabitants/km2, and a human development index of 0.740 (25). initially, a descriptive exploratory analysis was performed to qualify the variables of interest and correct the inconsistencies in the database, following the guidelines of the tutorial for the notification of interpersonal and self-inflicted violence. immediately after that, the duplicate cases were verified and later excluded. it is worth noting that duplicates were analyzed by organizing the records by notification date, comparing occurrence date, name of the victim, and of the mother, and date of birth. the dependent variable of the study was "self-inflicted injuries". according to the tutorial for filling out the interpersonal/ self-inflicted violence notification forms, self-inflicted injuries are considered as those cases in which the individuals assisted/victims provoked aggression against themselves or attempted suicide; as well as attempted suicide and the act trying to put an end to one's life, although without consummation (23). the following were chosen as independent variables for this study: age (from 10 to 12 years old, from 13 to 17 years old, from 18 to 19 years old), race/skin color (white/non-white), disability/ disorder (no/yes), area of residence (urban/rural, peri-urban), place of occurrence (residence/school/collective housing/others), other occurrences (no/yes), means of aggression (poisoning, intoxication/sharps/others), and suspected alcohol consumption (no/yes). as the objective is to adjust a regression model, the database used in all analyses of this study considered only those forms that had all the independent variables filled in according to the categorization of the variable considered. from 2011 to 2018, a total of 3,410 forms with this characteristic were obtained, of which 1,131 corresponded to the notifications of self-inflicted violence. the data were analyzed through descriptive statistics in absolute and relative frequencies, with 95 % confidence intervals. the bivariate analyses were performed using the chi-square (x2) and fisher's exact tests according to the assumption, with a 95 % significance level. the association between the independent variables and the outcome under study was assessed based on the non-adjusted and adjusted prevalence ratios. to obtain the adjusted measures, the log-binomial regression model was considered, as the response variable is dichotomous and there is interest in knowing if the prevalence ratios are obtained. in the initial analysis of the model, all the dependent variables proposed in this study were considered. however, it was verified that the "means of aggression" variable in the modeling is acting as a confounding variable due to its almost perfect association with the response variable. for example: for the female adolescents, the polychoric correlation between the outcome and the "means of aggression" variable is 0.97. in addition to that, 93.44 % of the cases of self-inflicted injuries among adolescents were with sharps or by poisoning/intoxication. these means were used by only 7 % of the aggressors against the female adolescents who suffered types of violence other than self-inflicted. such phenomenon also occurs among male adolescents. if this variable is retained in the model fit, negative impacts on the results range from non-significance of notably relevant variables, such as age group, to drastic underestimation of the prevalence ratios. another negative impact concerns the modeling technique, in which, with the presence of the "means of aggression" variable, only the poisson regression model with robust variance can be considered, a method that is often used as an approximation of the log-binomial model. a permanence of the variables in the model was considered for p < 0.05. the bivariate analyses were performed in the stata 13.0 program, and the log-binomial modeling was conducted by using the logbin package from the r software, version 4.0.0. the study was approved by the research ethics committee of universidade federal do espírito santo, under opinion no 2,819,597, and all rules and guidelines outlined in resolution 499/2012 were respected. results between 2011 and 2018, the prevalence of self-inflicted injuries among the notified cases of violence was 33.2 % (n = 1,131; 95 % ci = 31.60-34.76) among adolescents in espírito santo, of the total violence notification forms filled out in this period. among the cases of self-inflicted violence, 79.8 % of the adolescents were female, 69.9 % were aged between 13 and 17 years old, 68.7 % were of non-white race/skin color, nearly 25.3 % presented some disability/disorder, and 90.7 % lived in the urban area. as for the characteristics of the self-aggressions, most of them occurred in the residence (88.4 %), were recurrent (52.8 %), the most prevalent means of self-inflicted aggression was poisoning/intoxication (65.1 %) and, in 9.1 % of the cases, there was suspicion of alcoholic beverage consumption at the event in question. table 1. characteristics of the notified cases of self-inflicted violence among adolescents aged from 10 to 19 years old.espírito santo, 2011-2018 (n = 1,131) variables n (%) ci (95 %) gender male 228 20.2 17.91-22.60 female 903 79.8 77.39-82.08 age 10-12 years old 100 8.9 7.31-10.64 13-17 years old 791 69.9 67.19-72.54 18-19 years old 240 21.2 18.93-23.70 race/skin color white 354 31.3 28.65-34.06 non-white 777 68.7 65.93-71.34 disability/disorder no 845 74.7 72.09-77.16 yes 286 25.3 22.83-27.90 area of residence urban 1,026 90.7 88.87-92.27 rural/peri-urban 105 9.3 7.72-11.12 place of occurrence residence 1,000 88.4 86.41-90.15 school 68 6.0 4.76-7.55 collective housing 14 1.3 0.73-2.08 others 49 4.3 3.28-5.68 other occurrences no 534 47.2 44.31-50.13 yes 597 52.8 49.86-55.68 means of aggression poisoning/intoxication 737 65.1 62.33-67.89 sharps 280 24.8 22.32-27.36 others 114 10.1 8.45-11.97 suspected use of alcohol no 1,028 90.9 89.06-92.43 yes 103 9.1 7.56-10.93 source: elaborated by the authors. in the bivariate analyses described in table 2, it is verified that self-inflicted injuries in both genders were related to age, race/skin color, disability/disorder, place of occurrence, means of aggression, and suspected alcohol consumption (p < 0.05). in the female gender, the "area of residence" variable was also associated, as well as "other occurrences" p < 0.05). table 2. distribution of the characteristics of the notifications of self-inflicted violence among adolescents, by gender. espírito santo, 2011-2018 variables female (n = 903) male (n = 228) n (%) ci (95 %) p-value n (%) ci (95 %) p-value age group 10-12 years old 84 21.9 18.06-26.36 0.000 16 10.2 6.32-16.01 0.000 13-17 years old 654 41.2 38.85-43.70   137 25.6 22.03-29.43   18-19 years old 165 29.1 25.50-32.98   75 41.2 34.26-48.52   race/skin color white 276 39.6 36.02-43.28 0.010 78 30.9 25.53-36.94 0.036 non-white 627 34.1 31.97-36.31   150 24.1 20.87-27.59   disability/ disorder no 678 30.5 28.65-32.49 0.000 167 22.5 19.66-25.69 0.000 yes 225 71.4 66.18-76.15   61 45.5 37.25-54.04   area of residence urban 826 36.4 32.35-34.85 0.014 200 26.4 23.39-29.68 0.536 rural/peri-urban 77 28.8 21.41-28.66   28 23.7 16.88-32.27   place of occurrence residence 804 43.0 40.76-45.25   196 41.7 37.31-46.22   school 57 41.0 33.11-49.39 0.000 11 16.2 9.14-27.01 0.000 collective housing 6 35.3 16.35-60.34   8 47.1 24.95-70.37   others 36 7.1 5.14-9.65   13 4.1 2.36-6.87   other occurrences no 405 32.6 30.05-35.26 0.002 129 23.9 20.47-27.67 0.064 yes 498 38.5 35.89-41.20   99 29.5 24.89-34.67   means of aggression poisoning/ intoxication 608 96.2 94.39-97.44   129 97.0 92.22-98.87   sharps 226 73.1 67.90-77.79 0.000 54 50.0 40.62-59.37 0.000 others 69 4.33 3.43-5.44   45 7.1 5.33-9.38   suspected use of alcohol no 832 42.9 40.69-45.10 0.000 196 29.2 25.88-32.77 0.000 yes 71 11.9 9.59-14.79   32 15.7 11.29-21.36   source: elaborated by the authors. the non-adjusted and adjusted analyses of the cases of self-inflicted violence in the male gender are presented in table 3. it is observed that the prevalence of self-inflicted injuries among boys is 4.03 times higher in those aged 18 and 19 years old when compared to the younger group (10-12 years old) and 1.47 times more prevalent among those who presented some type of disability or disorder. as for the characteristics of the self-aggressions, it is noted that, among boys, this type of violence is more frequent in the residence and in collective housing when compared to other possible locations (pr = 10.22; 95 % ci = 5.96-17.54; pr = 10.20; 95 % ci = 5.06-20.59). regarding suspected alcohol consumption, a higher prevalence of self-inflicted injuries was observed among adolescents who were not suspected of having consumed alcohol (pr = 1.82; 95 % ci = 1.34-2.48) (p < 0.05). table 3. non-adjusted and adjusted analyses of the effects of the characteristics of the self-inflicted violence cases among male adolescents (n = 228). espírito santo, 2011-2018 variables non-adjusted analysis adjusted analysis   pr ci (95 %) p-value pr ci (95 %) p-value age 10-12 years old 1.0 -0.000 1.0 -0.000 13-17 years old 2.50 1.54-4.07   2.75 1.73-4.37   18-19 years old 4.04 2.46-6.64   4.03 2.53-6.41   race/skin color white 1.28 1.02-1.62 0.033 1.09 0.95-1.25 0.216 non-white 1.0 -  1.0 -  disability/disorder yes 2.01 1.60-2.53   1.47 1.25-1.73   no 1.0 -0.000 1.0 -0.000 area of residence urban 1.11 0.78-1.57 0.541 1.09 0.83-1.42   rural/peri-urban 1.0 -  1.0 -0.533 place of occurrence residence 10.26 5.96-17.67   10.22 5.96-17.54   school 3.98 1.86-8.51   4.27 2.00-9.11   collective housing 11.58 5.56-24.12   10.20 5.06-20.59   others 1.0 -0.000* 1.0 -0.000 other occurrences yes 1.23 0.98-1.54   0.94 0.81-1.09   no 1.0 -0.062 1.0 -0.397 suspected use of alcohol no 1.86 1.32-2.61   1.82 1.34-2.48   yes 1.0 -0.000 1.0 -0.000 * obtained by means of fisher's exact test. source: elaborated by the authors. table 4 presents the adjusted analyses of the self-inflicted injuries in the female gender. the prevalence of self-inflicted injuries was 73 % higher in girls aged from 13 to 17 years old and among the female adolescents who had some type of disability or disorder. a 19 % increase in the prevalence of the problem is observed among the adolescents who lived in the urban area. in addition, in the female group there was a higher occurrence of the problem in the residence (pr = 5.17; 95 % ci = 3.78-7.09), being 2.96 times higher among those who did not consume alcohol (p < 0.05). table 4. non-adjusted and adjusted analyses of the effects of the characteristics of the self-inflicted violence cases among female adolescents (n = 903). espírito santo, 2011-2018 variables non-adjusted analysis adjusted analysis   pr ci (95 %) p-value pr ci (95 %) p-value age 10-12 years old 1.0 -0.000 1.0 -0.000 13-17 years old 1.88 1.54-2.29   1.73 1.44-2.08   18-19 years old 1.32 1.05-1.66   1.46 1.19-1.80   race/skin color white 1.16 1.03-1.29   1.04 0.95-1.13 0.407 non-white 1.0 -0.009 1.0 -  disability/disorder yes 2.33 2.12-2.56   1.73 1.59-1.87   no 1.0 -0.000 1.0 -0.000 area of residence urban 1.26 1.03-1.53   1.19 1.01-1.39   rural/peri-urban 1.0 -0.020 1.0 -0.036 place of occurrence residence 6.07 4.41-8.36   5.17 3.78-7.09   school 5.79 3.99-8.41   4.48 3.11-6.47   collective housing 4.99 2.43-10.21   3.65 1.91-6.97   others 1.0 -0.000 1.0 -0.000 other occurrences yes 1.18 1.06-1.31   0.946 0.87-1.03   no 1.0 -0.002 1.0 -0.196 suspected use of alcohol             no 3.59 2.87-4.49 0.000 2.96 2.38-3.68 0.000 yes 1.0 -  1.0 -  source: elaborated by the authors. discussion from 2011 to 2018, a 33.2 % prevalence of notifications of self-inflicted violence among adolescents was identified in espírito santo. the surveillance of violence and accidents in urgency and emergency sentinel services survey (viva survey) indicated that, in 2017, brazil presented a 28.8 % prevalence of self-inflicted violence among adolescents (26); whereas a study conducted in an emergency hospital from alagoas evidenced 26 % occurrence of self-inflicted injuries among the adolescents (27). it is important to note the higher proportion in the notifications of self-inflicted violence among female victims (79.8 %). such findings align with the results presented by other studies (16, 28-31). these findings are similar because they evidence the self-inflicted injuries that were mostly recorded in girls (18). in england, the prevalence of self-inflicted injuries was also higher in the girls when compared to the boys (12). added to this fact, a research study conducted in mexico highlights higher chances of attempted suicide in female adolescents, when compared to their male counterparts (28). the difference between the genders can be justified as a consequence of the countries' social and cultural context where the girls' status in each society is defined. in societies dominated by men, it is observed that girls can attempt suicide more frequently, taking into account the problems faced regarding the female gender (29). in addition, women present more internalizing disorders, such as depression and anxiety, which reflects in higher frequency values of suicidal ideation and attempted suicide (32). regarding the associated factors, in this study, it is verified that male adolescents aged between 18 and 19 years old, as well as female adolescents between the ages of 13 and 17, presented a higher prevalence of self-inflicted injuries. the prevalence values found in this study corroborate the findings from a survey (33), in which suicidal behavior in female adolescents was found to occur with higher prevalence in mid-adolescence. in turn, in the male adolescents, the highest prevalence values were found at the end of the adolescence period, at the ages of 18 and 19 years old. this finding suggests that younger girls may be more likely to seek help to express their emotional problems and, therefore, suicidal behavior is interrupted earlier among them than among male adolescents (34). self-inflicted violence among adolescents with some type of disability or disorder was more prevalent when compared to those without these problems, which is in line with another study conducted with data from the sinan (16). mental disorders are at least 10 times more prevalent among individuals who already attempted or consummated suicide than in the general population (35). adolescents with bipolar disorder, eating disorders, melancholic depression or anxiety present higher prevalence values of self-inflicted injuries (19). corroborating these findings, a research study conducted in the united states shows that the depressive, or bipolar disorders increase the chances of suicidal behavior among adolescents (20). many suicide attempts can occur impulsively in crisis moments due to a collapse in the ability to deal with life's acute or chronic stress (3). in addition to that, mental disorders such as depression can cause major distress and interfere in the individuals' quality of life (36). regarding the area of residence, the outcome prevalence was higher among female adolescents who lived in the urban area. this finding is in line with a study conducted in the united states, where the highest prevalence of non-fatal self-inflicted injuries was found in the urban area (37). in a study conducted in australia, adolescents living in rural areas felt less lonely when compared to those from urban areas, suggesting greater social support, which is an important protective factor for suicidal behavior (38). it is frequently postulated that cities exert an adverse effect on people's health, since some problems such as mental disorders, exposure to risk behaviors and psychological stressors, may be more present in this area (39). concerning the place of occurrence, it is noted that, for girls, the prevalence of self-inflicted injuries was higher in the residence; and, for boys, in addition to the high the prevalence in the residence, prevalence was also significant in collective housing spaces. a study conducted with institutionalized adolescents showed a higher prevalence of suicidal behavior in this group when compared to those who were not institutionalized (40). thiscan be related to the occurrence of adversities before and during the time of institutionalization, which can lead to depressive symptoms, mainly due to the disruption of bonds (41, 42). regarding self-inflicted injuries that occurred in residences, other studies corroborate this research (21, 43). such occurrence can be higher in these places because of the isolated environment and the feeling of loneliness, which can lead them to self-aggression without being interrupted by others (21). regarding the main means of self-aggression used by the adolescents, the highest number of cases of poisoning and/or intoxication and sharps (cutting) is observed, corroborating a research study that used national data from the sinan (16). data from a research study conducted by beckman et al. (10) are in line with these findings as they evidence higher prevalence values of self-intoxication and cutting. self-intoxication was also the most prevalent method in a study conducted in ireland (44). data from a research study conducted in england also corroborate this study by evidencing that self-inflicted injuries among adolescents through self-intoxication were the main causes of hospital care after the occurrences. in the same research, self-aggressions with sharps were the most prevalent in the general population (12). the means of aggression pointed out deserve attention, as they can be associated with repeated violence and with consummated suicides. according to studies conducted in ireland (44, 45), adolescents who injured themselves with sharps present higher risks of repeated self-aggressions when compared to those who used other methods. the highest prevalence of self-inflicted injuries was among adolescents who were not suspected of having used alcohol before the self-aggressions. this association can suggest more premeditation and planning in the aggression attempts since they occur without resorting to alcoholic beverages. however, the occurrence of self-aggression has been associated in the literature with acute alcohol intoxication, as suggested by the data from a meta-analysis article in which acute alcohol consumption increased by up to 37 times the chances of suicide attempts (46). as of ordinance 1,271 of the brazilian ministry of health, dated june 6th, 2014, notification of self-inflicted injuries in the health services became of compulsory registration within 24 hours of knowledge of its occurrence (22). in this context, notification is one of the care line dimensions, where it is up to the health team to incorporate the adolescents into a comprehensive protection network for the sake of their own health. therefore, in addition to the notification, it is important to continue monitoring these young individuals by referring them to appointments with multi-disciplinary teams capable of recognizing and resolutely intervening in suicidal behavior (47). the study has some limitations, such as selection bias, since it is probable that only the most severe cases that depend on care in health services are notified, which excludes the cases that occur in the community in general; therefore, it is not possible to make inferences regarding the prevalence of the problem in the state. another limitation refers to the notification instrument, which does not discriminate if the violent event was an attempted suicide or a self-inflicted injury without suicidal ideation. taking this instrument into consideration, it is also noted as a limitation the fact that it was not possible to analyze other factors associated with the occurrence of self-inflicted injuries among adolescents described in the literature. conclusions this study presents the prevalence of the notified cases of self-inflicted violence in adolescents, a fact until then not explored in espírito santo. in addition to that, it also evidences factors such as characteristics of the victim and of the occurrence, associated with the higher prevalence in the notification of this problem. identifying the associated factors is crucial for prevention measures to be implemented assertively. it is worth pointing out the need to address and work on this issue to welcome the adolescents and dialog with them, as well as to provide opportuni­ties for their needs to be addressed in the health services; thus, training the professionals is an important strategy to prevent self-inflicted violence behaviors from continuing into adulthood and to avoid negative outcomes of this practice. it is also to be noted the importance of mandatory notification by the health professionals within 24 hours, to ensure timely intervention. although registration of self-inflicted injuries is a challenge for collective health due to its underreporting, this instrument is fundamental for feeding and strengthening the sinan as an important tool for epidemiological surveillance and as a signpost for necessary changes by the government, as it allows managers to know the situation of the problem as well as to provide subsidies for decision-making and for the implementation of public policies focused on the theme, which aim at strengthening health care for these individuals within the brazilian unified health system. finally, it is suggested that research studies with this population be carried out in the community in general to evidence the reasons, distribution, and impacts of this problem, as well as for promotion, prevention, and recovery measures to be adopted. conflict of interests: none declared. funding: this research was funded by the espírito santo research support foundation (fapes/cnpq/decit-sctie-ms/sesa call no. 3/2018-ppsus). references 1. claumann gs, pinto a de a, silva das, pelegrini a. prevalência de pensamentos e comportamentos suicidas e associação com a insatisfação corporal em adolescentes. j bras psiquiatr 2018;67:3-9. doi: https://doi.org/10.1590/0047-2085000000177 2. cicogna jir, hillesheim d, hallal al de lc. mortalidade por suicídio de adolescentes no brasil: tendência temporal de crescimento entre 2000 e 2015. j bras psiquiatr 2019;68:1-7. doi: https://doi.org/10.1590/0047-2085000000218 3. saxena s, krug eg, chestnov o. world health organization. preventing suicide: a global imperative. geneva: world health organization; 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2010. disponível em: https://bvsms.saude.gov.br/bvs/publicacoes/linha_cuidado_crian-cas_familias_violencias.pdf home 99 claudia ariza-olarte1 definición de los conceptos evento clínico y situación que requieren cuidado de enfermería 1 doctora en enfermería. docente asociada, pontificia universidad javeriana, bogotá d.c., colombia. claariza@javeriana.edu.co recibido: 22 de septiembre de 2009 aceptado: 16 de julio de 2010 resumen la definición y el análisis de conceptos han llegado a constituir un proceso importante para la producción de conocimiento en la disciplina de enfermería; esta afirmación se ve apoyada en la literatura publicada en las últimas décadas, la cual muestra artículos en los que se desarrollan conceptos que han contribuido al crecimiento del conocimiento de dicha disciplina. sin embargo es claro que, a pesar de ello, en el área clínica hace falta clarificar conceptos que aporten al conocimiento y que unifiquen el lenguaje usado por enfermería en dicha área; con ello se podría demostrar que enfermería no son solo acciones de cuidado en su naturaleza, sino que también maneja conceptos (palabras y frases) que indican atención en la práctica clínica, los cuales deben resultar del estudio riguroso. este artículo presenta la definición de la síntesis de los conceptos evento clínico que requiere cuidado de enfermería (ecrce) y situación que requiere cuidado de enfermería (srce), a partir de los cambios fisiológicos, sentimientos, emociones y preocupaciones, que presenta el paciente que se encuentra en posoperatorio temprano (48 a 96 horas) de una revascularización miocárdica (rvm), los cuales conformaron el marco conceptual de la tesis doctoral titulada “cuidado de enfermería al paciente en postoperatorio temprano de una revascularización miocárdica”. dicha definición se realizó mediante el método de síntesis de conceptos planteado por walker y avant, como estrategia para la construcción de teoría que contribuya al enriquecimiento del conocimiento de enfermería. estas autoras consideran que la síntesis de conceptos está basada en la observación o en la evidencia empírica. en esta metodología, los datos se pueden obtener desde la observación directa hasta la evidencia cuantitativa, la literatura, o con una combinación de los tres. este proceso de síntesis de conceptos es considerado como uno de los más excitantes caminos para comenzar a construir teoría, además permite a las teóricas el uso de la experiencia clínica como un lugar para comenzar. palabras clave formación de concepto, cuidado de enfermería, revascularización miocárdica, posoperatorio. (fuente: decs, bireme). año 10 vol. 10 nº 2 chía, colombia agosto 2010 l 99-114 100 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 definition of concepts clinical event and situation that require nursing care abstract concept definition and analysis has become an important process for producing knowledge in the field of nursing. this assertion is supported by the literature published in recent decades, which contains articles on concepts that have contributed to the growth of knowledge with respect to nursing. yet, the concepts that contribute to knowledge in the clinical area and favor unification of the language used by nurses in that area clearly need to be clarified. doing so could demonstrate that nursing is more than action focused on care; it also deals with concepts (words and phrases) that indicate attention in clinical practice, concepts which must be the result of rigorous study. this article offers a definition of the synthesized concepts of a clinical event that requires nursing care (cernc) and a situation that requires nursing care (srnc), based on the patient’s physiological changes, feelings, emotions and concerns during the early postoperative phase (48-96 hours) of myocardial revascularization (mrv). these concepts provided the conceptual framework for a doctoral dissertation entitled “nursing care for patients in the early postoperative phase of myocardial revascularization.” the definition was developed using walker and avant’s concept synthesis method as a strategy for constructing theory that helps to enrich knowledge in the field of nursing. in their opinion, concept synthesis is based on observation or empirical evidence. with this method, data can be obtained from direct observation, quantitative evidence, literature or a combination of all three. the concept synthesis process is regarded as one of the most exciting ways to begin to construct theory. it also allows theory to use clinical experience as a starting point. key words concept formation, nursing care, myocardial revascularization, postoperative. (source: decs, bireme). definição de conceitos evento clínico e situação que requerem cuidados de enfermagem resumo a definição e a análise de conceitos são um importante processo para a produção de conhecimento na disciplina de enfermagem. nas últimas décadas, esta conclusão é corroborada pela literatura, que mostra artigos que desenvolvem conceitos ter contribuído para o crescimento do conhecimento da disciplina. no entanto, é evidente que na área clínica é necessário clarificar conceitos que contribuam 101 definición de los conceptos evento clínico y situación que requieren cuidado de enfermería l claudia ariza-olarte para o conhecimento e promovam a unificação da linguagem utilizada pelos enfermeiros nesta área. assim, poderia mostrar-se que a enfermagem não é apenas ações de cuidado na sua base, mas também utiliza conceitos (palavras e frases) que indicam atenção na prática clínica. estes conceitos devem provir de um rigoroso estudo. este artigo apresenta a definição da síntese de duos conceitos: evento clínico que requere cuidados de enfermagem (ecrce) e situação que requerem cuidados de enfermagem (srce), com base nas alterações fisiológicas, sentimentos, emoções e preocupações apresentadas pelo paciente no pós-operatório imediato (48-96 horas) de cirurgia de revascularização do miocárdio (rvm). essas definições formaram a estrutura conceitual da tese de doutorado intitulada o cuidado de enfermagem a pacientes em pós-operatório imediato de revascularização do miocárdio. essa definição foi feita pelo método de síntese dos conceitos expostos por walker e avant, como estratégia para elaborar teorias que contribuem para o enriquecimento do conhecimento de enfermagem. nós pensamos que a síntese de conceitos é baseada na observação ou evidência empírica. nesta metodologia, os dados se coletam a partir da observação direta, da evidencia quantitativa ou da literatura, ou de uma combinação dos três campos. este processo de síntese de conceitos é uma das formas mais interessantes para começar a construir a teoria e permite a utilização da experiência clínica como lugar de início. palavras-chave síntese de conceito, cuidados de enfermagem, revascularização miocárdica, pos-operatorio. (fonte: decs, bireme). 102 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 introducción debido a la elevada prevalencia de la enfermedad coronaria (ec) a nivel mundial, la revascularización miocárdica (rvm) se ha convertido en un procedimiento frecuente, y ha presentado un desarrollo tecnológico progresivo en las últimas tres décadas, convirtiéndose en uno de los avances más importantes de la medicina, que se dieron durante el siglo xx, y en los que la enfermería ha venido participando de manera activa; dicha participación exige juicio clínico, capacidad de toma de decisiones y valoración reflexiva y crítica del paciente; asimismo, exige conocimiento y compromiso. este conocimiento debe partir de la evidencia científica recopilada de investigaciones que permitan complementar, mejorar o modificar la práctica desarrollada actualmente con el paciente, y al mismo tiempo permitan definir conceptos propios de la disciplina que aporten y enriquezcan el conocimiento. a pesar de los beneficios que proporciona la rvm al paciente con ec, del perfeccionamiento continuo de las técnicas quirúrgicas, y del uso de nueva tecnología que ha facilitado que individuos complejos sean sometidos a este procedimiento, es característico que durante el posoperatorio temprano (48 a 96 horas) este paciente presente cambios fisiológicos asociados a la rvm, a nivel de los sistemas neurológico, cardiovascular, respiratorio, gastrointestinal, de eliminación y en la piel. dichos cambios conducen a la presencia de alteraciones que requieren, no solo de la intervención médica, sino también del cuidado de enfermería; en ocasiones son denominados con conceptos diversos, encontrándose la necesidad de unificarlos, para de esta manera complementar, mejorar o modificar la intervención de enfermería a los mismos. de otro lado, el proceso que el paciente debe enfrentar cuando se le realiza este tipo de procedimiento implica permanecer hospitalizado durante mínimo cuatro días (siempre y cuando no se presenten complicaciones), y vivir la experiencia de estar en servicios especializados tales como la unidad de cuidado intensivo y el servicio de hospitalización; esto implica estar separado de la familia, de su ambiente habitual y tener una ruptura con la rutina de vida diaria, lo cual a la vez genera alteraciones en su esfera psicosocial, manifestadas por sentimientos, emociones y preocupaciones con respecto al procedimiento mismo y sus resultados, al futuro y a su vida personal y laboral. estas alteraciones también requieren cuidado de enfermería, si se tiene en cuenta que éste debe ser holístico, es decir, debe ver al paciente como la persona cuya dignidad está ubicada en las esferas de ser, libertad y respeto hacia sí mismo y hacia los demás, a quien por presentar ec severa y refractaria a tratamiento médico se le practica una rvm con el fin de restablecer la perfusión del músculo miocárdico. estos sentimientos, emociones y preocupaciones, igual que los cambios fisiológicos mencionados, son denominados de diversas formas, razón por la que es necesario definirlos para de esta manera, complementar mejorar o modificar el cuidado de enfermería requerido con base en los problemas que se identifiquen a través del análisis e interpretación de los mismos. metodología una vez revisada la literatura de enfermería se determinó que los conceptos evento clínico que requiere cuidado de enfermería (ecrce) y situación que requiere cuidado de 103 definición de los conceptos evento clínico y situación que requieren cuidado de enfermería l claudia ariza-olarte enfermería (srce), no han sido definidos de manera precisa, razón por la cual se recurrió, para definirlos, a la estrategia de síntesis de conceptos planteada por walker y avant. estas autoras consideran que la síntesis de conceptos está basada en la observación o en la evidencia empírica. los datos necesarios para establecer una definición clara y precisa se pueden obtener desde la observación directa hasta la evidencia cuantitativa, la literatura, o con una combinación de los tres. este proceso de síntesis de conceptos es considerado como uno de los más excitantes caminos para comenzar a construir teoría, además permite a las teóricas el uso de la experiencia clínica como un lugar para comenzar (1). en este caso se utilizó la combinación de la observación directa, la evidencia cuantitativa y la revisión de la literatura de otras disciplinas respecto a la forma como éstas definen estos conceptos, tales como la psicología. al realizar esta combinación se desarrollaron algunos de los pasos recomendados por walker y avant respecto a la metodología de síntesis de conceptos. estos pasos son los siguientes: l ser experto en el área. l revisar la literatura que proporcione datos útiles sobre el concepto que se va a sintetizar. l clasificar los datos de acuerdo con lo que se quiere alcanzar. l buscar el mayor número de cúmulo de fenómenos que se relacionen entre sí, examinarlos y luego tratar de buscar semejanzas con el fin de reducir varios cúmulos en uno solo. l una vez haya sido nominado el concepto, se debe verificar el nuevo concepto empíricamente, y cambiarlo si es necesario. l para realizar la verificación se recomienda regresar a la literatura y los estudios de campo, y a otros profesionales, para descubrir si el concepto es empíricamente soportado. l por último, se debe describir el concepto incluyendo los atributos establecidos para su definición (1). para la realización de estos pasos se partió de la preparación formal y experiencia clínica con la que cuenta la investigadora en el área cardiovascular. luego se indagó a 15 profesionales de la salud (médicos y enfermeras) sobre la forma como definían los conceptos evento clínico y situación. esta información se organizó y se clasificó de acuerdo con las definiciones que se encontraron al revisarla de manera rigurosa, con el propósito de ir determinando el mayor cúmulo de fenómenos que se relacionaban entre sí, y de esta forma poder ir reduciéndolos a uno solo de acuerdo con las semejanzas encontradas. una vez fue denominado cada uno de los conceptos, se realizó una revisión minuciosa de la literatura en enfermería, psicología, diccionario de la lengua española, diccionario de filosofía, y de trabajos de investigación realizados desde otras disciplinas en las que se han utilizado estos conceptos, sobre la definición que se emplea al hablar de ellos y el uso que se les ha dado. por último, se revisó nuevamente la literatura de enfermería relacionada con la definición de cuidado, y con base en esta revisión se decidió adoptar los atributos de cuidado planteados por zane robinson wolf y patricia larson, de manera independiente para los conceptos de evento clínico que requiere cuidado de enfermería y situación que requiere cuidado de enfermería, teniendo en cuenta que el primero los datos necesarios para establecer una definición clara y precisa se pueden obtener desde la observación directa hasta la evidencia cuantitativa, la literatura, o con una combinación de los tres. 104 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 está relacionado con la esfera biológica, y el segundo con la esfera psicosocial del paciente. de esta manera se pudo llegar a la síntesis de los mismos. procedimiento: síntesis de los conceptos el paciente con ec que requiere de tratamiento quirúrgico de revascularización miocárdica ha sido estudiado por enfermería en diferentes momentos, desde la etapa previa al procedimiento, el posoperatorio inmediato en la unidad de cuidado intensivo, al mes de posoperatorio, hasta cinco años después de habérsele realizado el procedimiento de rvm. sin embargo, al revisar estos estudios se encontró un vacío importante en el periodo comprendido entre las 48 y 96 horas del pop, es decir, desde el momento en que es dado de alta de la unidad de cuidado intensivo y es trasladado al servicio de hospitalización, hasta el momento inmediatamente anterior a irse para su casa, periodo que se denominó posoperatorio temprano (popt); asi mismo se pudo identificar un vacío con respecto a la unificación de conceptos utilizados por enfermería para brindar cuidado a este tipo de paciente. se consideró importante observar e indagar al paciente respecto a los cambios fisiológicos secundarios al procedimiento, sentimientos, emociones y preocupaciones con relación al mismo, al futuro y a su vida personal y laboral, los cuales encierran las manifestaciones hechas por el paciente al ser indagado mediante entrevista semiestructurada a profundidad, con el propósito de poder identificar, con base en ellos, los problemas propios del paciente durante este periodo, y sobre ellos realizar una propuesta de cuidado de enfermería, lo cual conduciría a complementar o modificar el que se da en la actualidad, teniendo en cuenta que el cuidado brindado debe contemplar a quien lo recibe como el ser integral que es, es decir, centrarse no solo en aspectos fisiológicos y tecnológicos, sino también en la esfera psicosocial. el paso siguiente en este proceso fue determinar los conceptos que conformarían el marco conceptual del estudio titulado “cuidado de enfermería al paciente en postoperatorio temprano de una rvm”, resultando como tales evento clínico que requiere cuidado de enfermería, que incluiría los cambios fisiológicos que presenta el paciente, secundarios a la realización de una rvm, a nivel de los sistemas neurológico, cardiovascular, respiratorio, gastrointestinal, de eliminación y piel. y situación que requiere cuidado de enfermería, que incluiría sentimientos, emociones y preocupaciones con respecto al procedimiento en sí, al futuro y a su vida personal y laboral. evento clínico que requiere cuidado de enfermería como se ha indicado para el estudio, un evento clínico corresponde a un cambio fisiológico característico del paciente en proceso de recuperación de una rvm, durante el posoperatorio temprano (48 a 96 horas). estos cambios fisiológicos se originan en los sistemas neurológico, cardiovascular, respiratorio, gastrointestinal, de eliminación y de la piel, como consecuencia del procedimiento en sí, de la bomba de circulación extracorpórea y del monitoreo invasivo que éste requiere para el seguimiento minucioso de su evolución (2). se caracterizan por ser objetivos, observables, medibles, y por estar relacionados con signos y síntomas en los sistemas ya mencionados. estos cambios fisiológicos un evento clínico corresponde a un cambio fisiológico característico del paciente en proceso de recuperación de una revascularización miocárdica. 105 definición de los conceptos evento clínico y situación que requieren cuidado de enfermería l claudia ariza-olarte y sus características resultaron de la opinión de los expertos en el área, y de la experiencia clínica de la investigadora en cardiovascular. una vez fueron determinados los cambios fisiológicos mencionados, se acogió la metodología de síntesis de conceptos como estrategia para generar conocimiento en la disciplina de enfermería, y de esta forma contribuir a complementar, mejorar o modificar el cuidado de enfermería brindado, en este caso, al paciente en periodo de posoperatorio temprano (48 a 96 horas) de una rvm. se indagó a 15 profesionales del área de salud (médicos y enfermeras) en el campo asistencial acerca del significado de “evento clínico”. la segunda fuente fue el diccionario de la lengua española; y la tercera fue una revisión de la literatura sobre estos conceptos desde enfermería y psicología. para los profesionales de la salud, evento clínico es algo que sucede y que puede ocasionar cambios; es un cambio del estado fisiológico de un paciente que amerita evaluación y cambio en la terapéutica; es un suceso relacionado con una modificación en las funciones de un paciente que requiere de la intervención del equipo de salud; es una manifestación de algo objetivo que se presenta en la evolución de la situación de salud de un paciente; es un hecho clínico que ocurre en un momento en el tiempo y que hay que resolver; es un acontecimiento de características fisiológicas; es algo que sucede en relación con una enfermedad, que se define en un tiempo y en un espacio; es un suceso que puede presentarse o no; son manifestaciones clínicas, datos objetivos de alguien que tiene alterado su estado de salud; y por último algo que se presenta de manera súbita o no, y que no se puede controlar. según el diccionario de la lengua española, la palabra “evento” viene del latín eventus que significa acontecimiento. “es algo que puede ocurrir, una posibilidad, suceso, acontecimiento” (3). “es un hecho imprevisto o previsto. suceso importante que puede suceder o no” (4). en general, esta palabra designa un suceso imprevisto; también significa acontecimiento que no es contingente, opuesto a lo necesario, no es en sí sino en otro (4). y lo clínico viene del latín kliniqué que significa morboso o enfermedad; y del griego klinein que significa inclinarse, apoyarse, reclinarse; en el comienzo de la humanidad, este término fue utilizado para denominar el bautizo recibido en cama. desde la psicología (5), el concepto “evento clínico” ha sido abordado como evento psicológico, definido como una adaptación. se considera que en gran medida los eventos psicológicos son la continuación compleja de las adaptaciones bioecológicas al medio simple o complejo. los contactos con el medio, junto con otros criterios, se denominan como normales o anormales. los intercomportamientos adecuados pueden no desarrollarse, deteriorarse o no existir. el evento psicológico incluye la interacción de estos eventos interdependientes y es independiente de cualquiera de ellos. en consecuencia, se reconoce al cerebro como un órgano coordinador necesario, de esta manera, la particular organización biológica de la especie aparece dentro del campo para establecer los límites, o proveer las posibilidades de lo que el organismo es capaz de hacer (5, 6). se considera que en gran medida los eventos psicológicos son la continuación compleja de las adaptaciones bioecológicas al medio simple o complejo. los contactos con el medio, junto con otros criterios, se denominan como normales o anormales. 106 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 al revisar la literatura se encuentra que existen investigaciones en las que, a pesar de que en su título aparece el concepto evento, o que éste es mencionado en el desarrollo de la investigación, su interés no ha estado centrado en su estudio. sin embargo, para la definición del concepto evento clínico en el presente estudio es pertinente tener en cuenta el uso que dan a este concepto autores como: juan josé calva-mercado, en su artículo “estudios clínicos experimentales”, en el que define evento clínico como: un desenlace que se refiere a toda una diversidad de resultados, como mediciones bioquímicas, fisiológicas o microbiológicas; eventos clínicos, como intensidad del dolor, aparición de infecciones oportunistas, desarrollo de un infarto del miocardio, recaída de una leucemia; escalas de actividad de una enfermedad como la del lupus eritematoso generalizado; mediciones de bienestar o funcionalidad como escalas de calidad de vida; o el tiempo de supervivencia (7). en el documento de la sociedad iberoamericana de información científica el concepto “evento clínico” aparece definido como cualquier acontecimiento médico desfavorable que se presenta en un paciente o sujeto de estudio clínico al que se administra un producto farmacéutico, y el cual no tiene necesariamente una relación causal con ese tratamiento. un evento adverso puede ser, por tanto, cualquier signo desfavorable e inesperado (incluyendo un hallazgo de laboratorio anormal), síntoma o enfermedad temporal asociada con el uso de un producto medicinal (en investigación), esté o no relacionado con este producto (8). de acuerdo con paglayan, del brutto, solís y franklin, el concepto “evento clínico” es utilizado para designar estados patológicos resultantes de la presencia de una serie de factores de riesgo a los que se encuentra expuesta una persona, tales como el infarto del miocardio, denominado evento cardiovascular. es utilizado, además, para designar otras patologías, como aquellas de origen aterotrombótico, como es el caso de las enfermedades cerebrovasculares. y también como el proceso infeccioso desarrollado por citomegalovirus considerado como un evento común con escaso impacto clínico en las condiciones de salud de los pacientes o la población en general (9, 10, 11). después de haber revisado y analizado las fuentes mencionadas, se sintetiza que el concepto “evento clínico” ha sido utilizado para determinar la patología que presenta el paciente estudiado; en otros casos, como las manifestaciones fisiológicas y físicas de patologías tales como la hipertensión arterial, el infarto agudo del miocardio, y la enfermedad cerebrovascular. para otros, es el desenlace que se observa en el paciente luego de habérsele administrado un tratamiento bien sea farmacológico o quirúrgico, con lo cual se pretende evaluar la efectividad del mismo. este último concepto fue el adoptado para el estudio “cuidado de enfermería al paciente en postoperatorio temprano de una revascularización miocárdica”. al aplicarlo al paciente en popt de una rvm, es necesario enfatizar que este desenlace requiere cuidado de enfermería, cuyo concepto ha sido planteado por diversos autores del área, dentro de los cuales se adoptaron los conceptos de larson y ferketich, y las dimensiones de cuidado planteadas por wolf. estos autores contemplan el cuidado de enfermería como un proceso interactivo y entre sujetos, que ocurre durante en el documento de la sociedad iberoamericana de información científica el concepto “evento clínico” aparece como evento adverso definido como cualquier acontecimiento médico desfavorable que se presenta en un paciente o sujeto de estudio clínico... 107 definición de los conceptos evento clínico y situación que requieren cuidado de enfermería l claudia ariza-olarte momentos de vulnerabilidad compartida entre la enfermera y el paciente, y se caracteriza porque está dirigido tanto al ser (enfermera) como al otro (paciente). además está dirigido hacia el bienestar del paciente y se lleva a cabo cuando la enfermera responde a este en una situación de cuidado. para estos autores, el cuidado cuenta con dimensiones tales como deferencia y respeto hacia el otro, la seguridad de que la persona encargada del cuidado estará presente siempre, la interacción positiva, la preparación y habilidad en la profesión y la consideración de la experiencia del otro (12). el cuidado es considerado como las acciones intencionales realizadas por la enfermera, que conllevan cuidado físico y preocupación emocional, y promueven protección y seguridad en otro (13). luego de contar con la información descrita, se aplicaron los pasos de la metodología de síntesis de conceptos como estrategia para generar conocimiento, y se definió que evento clínico que requiere cuidado de enfermería es: el desenlace de la revascularización miocárdica manifestado en el paciente en posoperatorio temprano, por cambios fisiológicos objetivos, observables, medibles, y relacionados con signos y síntomas, en los sistemas neurológico, cardiovascular, respiratorio, gastrointestinal, de eliminación y en la piel; ocurren durante momentos de vulnerabilidad compartida entre la enfermera y el paciente y requieren cuidado de enfermería, el cual se caracteriza porque está dirigido tanto al ser (enfermera) como al otro (paciente); está encaminado hacia el bienestar del paciente y se lleva a cabo cuando la enfermera responde mediante la realización de acciones intencionales que conlleven la recuperación de las funciones fisiológicas del paciente, caracterizadas por conocimiento científico, seguridad, interacción positiva, preparación y habilidad, compromiso, ética, competencia y experiencia. situaciones que requieren cuidado de enfermería además de los cambios fisiológicos, durante el posoperatorio temprano (popt) de una rvm (48 a 96 horas), como consecuencia de este procedimiento, el paciente presenta sentimientos, emociones y preocupaciones en cuanto al procedimiento en sí, al futuro y a su vida personal y laboral, tales como el miedo, la depresión, la confusión, la culpa y la conmoción, lo cual coincide con las conclusiones de la investigación de clare screeche-powell y suzanne owen, quienes desarrollaron un estudio sobre las experiencias tempranas que presentan los pacientes que están en una lista de espera para que se les realice una rvm (14). estos sentimientos, emociones y preocupaciones que presenta el paciente en popt de una rvm, son evidenciados por las expresiones que hace frente a las consecuencias del procedimiento relacionadas con los resultados de éste, su capacidad para reincorporarse a la vida familiar y laboral, y a las actividades de la vida diaria. la expresión de estos sentimientos, emociones y preocupaciones —los cuales son subjetivos, temporales, transitorios, individuales e irrepetibles— están directamente relacionados con las características personales del paciente. hay pacientes en posoperatorio temprano de una rvm, cuyos rasgos de personalidad le facilitan la expresión de los mismos. el cuidado es considerado como las acciones intencionales realizadas por la enfermera, que conllevan cuidado físico y preocupación emocional, y promueven un sentido de protección y seguridad en otro. 108 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 es importante mencionar que a la presencia de sentimientos, emociones y preocupaciones contribuyen, además del procedimiento de rvm, la hospitalización para la realización del mismo, la separación de la familia y del medio habitual en el que el paciente vive y se desempeña, la preocupación por los resultados del procedimiento, por la familia, y por el empleo, en caso de que aún se encuentre en etapa productiva. el concepto situación que requiere cuidado de enfermería, igual que el concepto evento clínico que requiere cuidado de enfermería, no ha sido definido de manera específica; por esta razón se recurre a la estrategia planteada por walker y avant sobre síntesis de conceptos (1), tal como ya fue comentada para la definición de evento clínico que requiere cuidado de enfermería. se exploraron tres fuentes. la primera de ellas fue la consulta a 15 profesionales del área de la salud (médicos y enfermeras) acerca del significado que tienen sobre el concepto “situación”; la segunda fuente fue el diccionario de la lengua española y diccionarios de filosofía; y la tercera fue una revisión de la literatura sobre este concepto desde la psicología, la enfermería e investigaciones realizadas por diferentes disciplinas. para los profesionales de la salud “situación” es: una circunstancia que vive una persona la cual puede ser imprevista, creada, programada, y que afecta la parte sensible y afectiva de la persona; son las características de un medio que alteran la actividad o la actitud de una persona que se encuentre expuesta a ellas; es una condición particular dada en un momento y en un lugar determinado; son circunstancias subjetivas que repercuten en la percepción de la persona; es un momento particular en la vida de alguien; es un evento en un tiempo y en un espacio determinado que implica unos seres humanos haciendo historia como actores sociales; es algo que se presenta, que alguien tiene que vivir y afrontar; es algo subjetivo desde el punto de vista de que es única para cada ser, es lo que una persona expresa; es algo que no se repite. según el diccionario de la lengua española, el concepto “situación” es el estado o la constitución de las cosas o las personas. “es el conjunto de factores o circunstancias que afectan a alguien o a algo en un momento determinado” (15). “es el conjunto de circunstancias que afectan a una persona; es una gama amplia de experiencias que pueden o no ser nocivas para la persona” (16). desde el punto de vista filosófico, de acuerdo con renato lazzarini (status e situazione) el concepto moderno de situación tiene un antecedente en el concepto medieval del estatus. éste se entiende o como un status viae o como un status termini. el status viae designa la situación de cada cual y a la vez la de todos los hombres, caracterizada por la forma del pasaje, de la transición, del estatus o posición entre dos mundos. status termini designa la situación final, punto a donde ha ido a concentrarse todo movimiento positivo o de acercamiento a la fuente del ser (17). continuando con el enfoque filosófico, según ferrater (17), el concepto actual de situación denota una realidad afín a la connotada por el concepto moderno. este concepto se ha abordado por diversas tendencias filosóficas especialmente por aquellas que han intentado considerar lo real como algo distinto de una el concepto situación que requiere cuidado de enfermería, igual que el concepto evento clínico que requiere cuidado de enfermería, no ha sido definido de manera específica; por esta razón se recurre a la estrategia planteada por walker y avant sobre síntesis de conceptos. 109 definición de los conceptos evento clínico y situación que requieren cuidado de enfermería l claudia ariza-olarte objetividad que no se decide a incluir el sujeto mismo como elemento suyo o como ámbito dentro del cual se da la realidad objetiva. el concepto situación parece fundamental para una filosofía que considera necesario retroceder a la realidad radical de la vida, más acá de toda interpretación de ella y del mundo en el cual la vida está alojada por una de sus dimensiones fundamentales (17). karl jaspers habla de situación como la imagen de la posición de las cosas dentro de una ordenación espacial-topográfica, pero que no puede identificarse con ella. para este autor el pensamiento de la situación de la existencia surge más bien como el de una realidad para un sujeto interesado en ella en tanto que existencia, y por eso la situación espacial o temporal del sujeto existencial es solo un modo de la radical situación en que la existencia se halla y aun que la existencia misma es. la existencia será siempre un ser en situación, que no puede salir de una sin entrar en otra (17). de acuerdo con nicol, mientras el cambio de lugar no afecta a las cosas en sí mismas, al hombre le afecta de manera fundamental. dice que el carácter único de cada situación para el hombre está ligado al hecho de que el hombre está en la situación de un ser que vive una vida única (18). estar en situación, lo característico de la existencia humana, no es solamente ocupar un sitio, sino vivir desde una situación que puede ser a la vez única o aislada, dada por el contorno o auténticamente forjada. según zubiri, la situación no es algo añadido al hombre o a las cosas, sino que es una condición radical a fin de que pueda haber cosas para el hombre, y para que ellas descubran a éste sus potencias. para marías y cencillo, citados por ferrater, situación se refiere a una realidad más restringida y precisa que una circunstancia, ya que la situación no es circunstancial, pertenece al ser en sí mismo y puede llamarse la presencia que lo constituye, y que lo hace primero estar en una situación y luego salir de ella para pasar a otra. situación es el estar del hombre en la realidad (17). para john dewey, citado por ferrater (17), el concepto situación no designa un solo objeto o acontecimiento, ya que nunca se experimenta o se forman juicios sobre objetos o acontecimientos aislados, sino solo dentro de un contexto, y este contexto es lo que se denomina situación. la situación es un todo en virtud de una cualidad inmediata que lo penetra por entero. la cualidad une todos los elementos constitutivos en un todo, y además da a este su carácter único formando una situación individual, indivisible e induplicable. desde la psicología el concepto “situación” ha sido contemplado a partir de varios puntos de vista. situación como aquellas circunstancias que no requieren de un resultado particular como consecuencia de la interacción del organismo y los objetos. situación en que se requiere de un resultado particular, producto de la interacción de organismo y objetos, consecuencia de una nueva función de respuesta. y situación en que se requiere de un resultado particular producto de la interacción organismo-objetos, consecuencia de una función de respuesta ya disponible. la diferencia entre las tres situaciones no radica en la operación de distintos procesos psicológicos, sino en la estructuración de dichos procesos en relación con la obtención o no de resultados específicos, dependientes de funciones de respuestas karl jaspers habla de situación como la imagen de la posición de las cosas dentro de una ordenación espacial-topográfica, pero que no puede identificarse con ella. para este autor el pensamiento de la situación de la existencia surge más bien como el de una realidad para un sujeto interesado en ella... 110 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 nuevas o ya disponibles históricamente (5). también desde la psicología, el concepto “situación” está relacionado con la conducta del ser humano considerada ya no como una cualidad que emerge de un algo interior y que se despliega en un afuera, sino como algo que hay que buscar adentro de acuerdo con lo que se manifiesta afuera. desde este punto de vista, situación es el conjunto de elementos, hechos, relaciones y condiciones, que cubre siempre una fase o un cierto periodo (19). en enfermería el concepto “situación” es abordado como respuestas humanas ante problemas de salud, por lo cual el diagnóstico de enfermería es considerado como una síntesis de la manera como el sujeto responde frente a las situaciones que afectan su salud. estas respuestas son la manifestación del cambio físico, expresión de sentimientos y o comportamientos en torno a una determinada situación de salud, y descripción del modo de relacionarse el hombre con su entorno; de esta forma, el diagnóstico de enfermería responde a la consideración de la persona como un ser holístico, ya que sobre la situación identificada, la enfermera inicia acciones que van desde la promoción y la prevención hasta la recuperación (20, 21). planas et ál. utilizan el concepto “situación” para expresar la ansiedad que caracteriza al paciente oncológico, y explican cómo ella genera inseguridad y una diversidad de dificultades para establecer una comunicación efectiva; por esta razón recomiendan que para manejarla es conveniente conocer bien las variaciones del estado de ánimo del paciente y las diferentes etapas psíquicas por las que atraviesa hasta el momento de la muerte (22). consideran que la apertura de los canales de comunicación afectiva o emocional entre la familia y el paciente es la clave para conseguir el manejo adecuado de la situación de ansiedad a la que se enfrentan; la buena comunicación de los sentimientos facilita el bienestar mental y emocional del paciente y la familia; una buena comunicación afectiva ayuda a prevenir situaciones de depresión, aislamiento o abandono. consideran que en ocasiones la familia tiende a evitar situaciones emocionalmente molestas mediante el fingimiento de una falsa euforia ante el enfermo (22). castañeda considera el concepto “situación” como el conjunto de circunstancias que rodean al paciente que se encuentra críticamente enfermo; hace énfasis en cómo el objetivo de las unidades críticas es promover, mantener y restablecer niveles óptimos de funcionamiento orgánico, psicológico y social. plantea que es ahora cuando existe la posibilidad de no solo quedarse en aspectos biomédicos, sino de reevaluar la situación a la que se enfrenta el paciente y atender los problemas que ella genera (25). considera que el paciente que se encuentra hospitalizado en una unidad de cuidado crítico vive una situación caracterizada por conflictos emocionales y afectivos que debe afrontar, los cuales no solo afectan su salud psíquica sino que también influyen en su recuperación física. propone que la percepción de la situación está condicionada por la personalidad de cada individuo, la salud psicológica en ese momento, la comprensión de la realidad que se está viviendo, las expectativas, la tolerancia frente a la incertidumbre y la forma de enfrentar las situaciones. la percepción inicial suele afectarse profundamente por la experiencia previa de situaciones similares, sean negativas o positivas, y por el grado de familiaridad con el ambiente médico hospitalario (23). en enfermería el concepto “situación” es abordado como respuestas humanas ante problemas de salud, por lo cual el diagnóstico de enfermería es considerado como una síntesis de la manera como el sujeto responde frente a las situaciones que afectan su salud. 111 definición de los conceptos evento clínico y situación que requieren cuidado de enfermería l claudia ariza-olarte albístur et ál., contemplan el concepto “situación” como la perspectiva humana y el conocimiento del ambiente socio-cultural al cual pertenece la persona enferma. la mayoría de veces la situación se plantea con familias legalmente constituidas, nucleares, y pacientes jefes de familia. la familia sufre un fuerte estrés emocional ante la incertidumbre; desconoce lo que sucede con su familiar dentro de la uci y está a la expectativa de la evolución que éste presente (24). después de haber revisado y analizado las fuentes mencionadas, se sintetiza que el concepto “situación” es utilizado tanto para determinar un lugar, como para describir un estado caracterizado por una amplia gama de experiencias, en ocasiones nocivas o no para la persona. el concepto “situación” puede definirse desde diferentes puntos de vista o enfoques. situación como un lugar, como el estado de una persona, o una cosa, como una tensión emocional, situación como un conjunto de factores de tensión psíquica del individuo, como una pérdida cuando el sujeto se enfrenta a la muerte de un ser querido, o situación como una urgencia cuando se presenta una emergencia sobre la que hay que tomar medidas de intervención inmediata. igual que con la síntesis del concepto de evento clínico que requiere cuidado de enfermería, para la síntesis del concepto situación que requiere cuidado de enfermería se adoptaron los atributos propuestos en las definiciones de cuidado de enfermería planteadas por larson y ferketich, y por wolf, en las que se considera el cuidado como acciones intencionales que conllevan cuidado físico y preocupación emocional, y promueven un sentido de protección y seguridad en el otro (25). el cuidado es un proceso interactivo y entre sujetos, que ocurre durante momentos de vulnerabilidad compartida entre la enfermera y el paciente, y se caracteriza porque está dirigido tanto al ser (enfermera) como al otro (paciente). además, está dirigido hacia el bienestar de la persona enferma, y se lleva a cabo cuando la enfermera responde a los pacientes en una situación de cuidado. el cuidado tiene dimensiones tales como deferencia y respeto hacia el otro, seguridad de que la persona encargada estará presente siempre, interacción positiva, preparación y habilidad en la profesión y consideración de la experiencia del otro (12). teniendo en cuenta la estrategia de síntesis de conceptos planteada por walker y avant ya mencionada (1), y de acuerdo con los datos obtenidos, la situación que requiere cuidado de enfermería se define como: expresiones del paciente en posoperatorio temprano de una revascularización miocárdica, que hacen parte de su esfera psicosocial, acerca de sus sentimientos, emociones y preocupaciones frente al procedimiento, a la familia y al futuro, ante las cuales la enfermera intervendrá mediante la realización de acciones intencionales que conlleven la satisfacción de las necesidades psicológicas y sociales, caracterizadas por deferencia y respeto hacia el otro, la seguridad de que la persona encargada del cuidado estará presente siempre, la interacción positiva, la preparación y habilidad en la profesión, la consideración de la experiencia del otro, el afecto, la paciencia y la confianza. las expresiones del paciente son subjetivas, temporales, transitorias, individuales e irrepetibles. una vez concluida la definición de los conceptos evento clínico que requiere cuipara la síntesis del concepto situación que requiere cuidado de enfermería se adoptaron los atributos propuestos en las definiciones de cuidado de enfermería planteadas por larson y ferketich, y por wolf, en las que se considera el cuidado como acciones intencionales que conllevan cuidado físico y preocupación emocional. 112 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 dado de enfermería y situación que requiere cuidado de enfermería, se determina que éstos permiten establecer un lenguaje común para las enfermeras que participan en el cuidado del paciente en popt de una rvm. en resumen, el concepto evento clínico que requiere cuidado de enfermería hace referencia a los cambios fisiológicos que presenta este paciente, de manera secundaria al procedimiento, a la bomba de circulación extracorpórea y al monitoreo invasivo necesario para el control de su evolución, en los casos en que ésta es utilizada. dichos cambios se manifiestan a nivel del sistema neurológico, cardiovascular, respiratorio, gastrointestinal, de eliminación y de la piel. en el servicio de hospitalización el paciente en popt de una rvm se encuentra alerta, orientado en las tres esferas (persona, espacio y tiempo), en estado hemodinámico estable dado por una frecuencia cardíaca dentro de parámetros normales (60 a 100 pulsaciones por minuto), en ritmo sinusal, pa entre 120/80 y 140/90 mmhg, sin necesidad de soporte farmacológico con medicamentos vasoactivos y normotérmicos. el paciente puede tener periodos prolongados de sueño y descanso, y al mismo tiempo puede recuperar dichos parámetros, ya que éstos se han alterado como consecuencia de la administración de anestesia durante el transoperatorio, por la presencia de dolor, y por la alta frecuencia con que se realizan los controles mientras permanece en la uci. por otra parte, la presencia de dolor puede afectar no solo su estado fisiológico, sino también su esfera psicosocial, razón por la cual durante este periodo de recuperación la participación de la enfermera debe centrarse en acciones de cuidado no farmacológicas que contribuyan a la disminución o desaparición del dolor, y también es importante la administración de analgesia y la evaluación de la respuesta a la misma (25). se espera que el paciente tolere y acepte la vía oral. si no hay presencia de náuseas o vómito, se reinicia la vía oral con dieta líquida durante el posoperatorio mediato; si ésta es tolerada se pasa a dieta blanda, y si esta también se tolera, se administra la dieta con las restricciones médicas pertinentes, las cuales pueden ser rechazadas por el paciente en algunos casos. debido al reposo en cama, y a la suspensión de la vía oral durante el posoperatorio inmediato, el paciente presenta alteración del hábito intestinal, cuando se normalizan la dieta y la actividad física, éste se normaliza (25). el paciente, además, debe estar respirando espontáneamente; no debe observarse dificultad al respecto, así como tampoco aumento del trabajo de los músculos respiratorios. al auscultar los campos pulmonares éstos deben estar bien ventilados; en algunas ocasiones presenta hipoventilación basal y respiración superficial debido a la ansiedad que le produce al paciente la presencia de la herida quirúrgica de esternotomía, por el temor a que ésta pueda abrirse, y en otros casos, por la presencia de dolor. en otras ocasiones la herida quirúrgica y el dolor favorecen la presencia de atelectasias pequeñas debido al patrón respiratorio adoptado por el paciente, cuya presencia favorece la alteración de la frecuencia respiratoria (fr) y la expansión torácica (et) (25). se observan también cambios en la piel. hay pérdida de su continuidad debido a la presencia de la herida quirúrgica de esternotomía y, con frecuencia, de safenectemomía. estas heridas han estado cubiertas durante las primeras 48 horas; el concepto evento clínico que requiere cuidado de enfermería hace referencia a los cambios fisiológicos que presenta el paciente, de manera secundaria al procedimiento, a la bomba de circulación extracorpórea y al monitoreo invasivo necesario para el control de su evolución. 113 definición de los conceptos evento clínico y situación que requieren cuidado de enfermería l claudia ariza-olarte ya en el servicio de hospitalización son descubiertas y deben observarse limpias y secas, sin signos de infección, en proceso normal de cicatrización. asimismo, el paciente pierde la continuidad de su piel por la presencia de múltiples punciones para canalizar venas periféricas (25, 26). el paciente elimina espontáneamente, puede hacerlo en el pato, o desplazarse al baño; la orina debe ser de características normales, y la frecuencia de eliminación debe haber sido recuperada (26). respecto a la actividad y el ejercicio del paciente, los cuales están muy relacionados con los cambios fisiológicos del sistema cardiovascular, deben encontrarse recuperados casi en su totalidad; se espera que el paciente deambule por la habitación o por el pasillo del servicio, pase a la ducha y al baño; mediante el programa de rehabilitación cardiaca logrará recuperar por completo la actividad física, de manera paulatina; dicho programa es iniciado, en la mayoría de los casos, antes del egreso hospitalario del paciente. para este momento los exámenes de diagnóstico tales como glicemia, cuadro hemático, electrolitos, pruebas de coagulación, gases arteriales, rx de tórax y electrocardiograma, han recuperado sus parámetros normales, excepto en aquellos casos en los que además de la ec, el paciente presente otro tipo de enfermedad crónica (diabetes mellitus). de otro lado, como se mencionó, el concepto situación que requiere cuidado de enfermería hace referencia a la esfera psicosocial del paciente, en la que se encuentran sentimientos, emociones y preocupaciones con respecto al procedimiento en sí, al futuro y a su vida personal y laboral. como consecuencia del procedimiento que se le ha realizado, de la hospitalización, y de la separación de la familia y de su medioambiente habitual, el paciente presenta sentimientos, emociones y preocupaciones tales como miedo, depresión, confusión, culpa y conmoción, lo cual coincide con las conclusiones de la investigación de clare screeche-powell y suzanne owen, quienes desarrollaron un estudio sobre las experiencias tempranas que presentan los pacientes que están en una lista de espera para que se les realice una rvm (16), y el realizado por schneider et ál. sobre el acogimiento del paciente y su familia en la unidad coronaria (27). estas srce son evidenciadas por las preguntas que hace el paciente frente a las consecuencias del procedimiento tales como los resultados de éste, la capacidad de realizar las actividades de la vida diaria y de reincorporarse a la vida familiar y laboral. es común que este tipo de pacientes presente periodos de silencio y de depresión ocasionados, en algunos casos, probablemente por efectos de la anestesia, en otros por sus características individuales. además, puede expresar otras srce, como la impotencia que siente ante las circunstancias de su salud, la sensación de haber perdido el control del manejo de su vida, el miedo a su nuevo estilo de vida; depresión por las circunstancias de salud y, en algunos casos, como efecto secundario de la anestesia; incertidumbre generada por el futuro incierto; sufrimiento generado por características particulares de su estado de salud, de la familia, del empleo; fe y esperanza en que dios lo sacará triunfante adelante, y otros (2). el concepto situación que requiere cuidado de enfermería hace referencia a la esfera psicosocial del paciente, en la que se encuentran sentimientos, emociones y preocupaciones con respecto al procedimiento en sí. 114 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 por último, se concluye que con la definición de los conceptos evento clínico que requiere cuidado de enfermería y situación que requiere cuidado de enfermería, se hace un aporte importante al conocimiento de la disciplina en cuanto al cuidado que debe brindarse al paciente en popt de una rvm, teniendo en cuenta que la participación de la enfermera está presente durante todo el proceso de recuperación; esta exige juicio clínico, capacidad de toma de decisiones y valoración reflexiva y crítica del paciente; asimismo, exige conocimiento y compromiso. por tanto, se considera que definir ecrce y srce, permite a la enfermera complementar, mejorar o modificar el cuidado de enfermería que actualmente se da a este tipo de pacientes, y también le permite identificar de manera objetiva los problemas característicos de este periodo del posoperatorio, no solo desde lo biológico, sino también desde la esfera psicosocial. dichos problemas deben constituir la base para planear el cuidado, de tal forma que éste se adapte a las circunstancias reales del paciente, y contemple su esfera biológica, psicosocial y espiritual, lo cual constituye un aporte al conocimiento de enfermería, a la práctica disciplinar y a la problemática social representada por la ec. referencias bibliográficas 1. walker lo, avant kc. strategies for theory construction in nursing. 4 ed. pearson education; 2005. p. 39-83. 2. vitello-cicciu j, fitzgerald c, whalen d. en el horizonte: cirugía cardiaca como mínimo invasora. the journal of cardiovascular nursing 1998; 12 (iss. 3): 1, 16. 3. gómez g. diccionario etimológico de la lengua española. 2 ed. méxico: fondo de cultura económica; 2003. 4. martínez l. diccionario de filosofía. bogotá: panamericana; 1997. 5. ribes e. psicología general. méxico: trillas; 1990. 6. noel w, smith rj. kantor’s interbehavioral psychology: beyond mechanism and mentalism. richmond: cherion society, earlham college; 1966. p. 27-30. 7. calva-mercado jj. estudios clínicos experimentales. salud pública de méxico 2000; 42 (4). 8. sociedad iberoamericana de información científica. declaración de helsinki. guía para la buena práctica clínica; 1996. 9. paglayan mv. infarto agudo del miocardio. monografía; 1997. 10. del brutto o. enfermedad cerebrovascular. sociedad ecuatoriana de neurología; 2004. 11. solís s. vasculitis cutánea asociada a lesión aguda por citomegalovirus en un lactante clínicamente inmunocompetente. médica sur 2000; 7 (2). 12. wolf, zr, giardino, hr. relación entre el cuidado de enfermería y la satisfacción del paciente. clinical nursing 1998: 86-93. 13. malin n, teasdale k. caring versus empowerment: considerations for nursing practice. journal advanced nursing 1991: 657. 14. screeche-powell c, owen s. early experiences of patients waiting to be accepted for cabg. british journal of nursing 2003; 12 (iss. 10): 612. 15. real academia española. diccionario de la lengua española. 20 ed. madrid: espasa-calpe; 2001. 16. diccionario terminológico de cuidado médico. 12 ed. salvat; 1984. 17. mora j, ferrater. diccionario de filosofía. barcelona: ariel; 1994. 18. nicol e. psicología de las situaciones vitales. 2 ed. montenvideo, uruguay: editorial; 1963. p. 125. 19. bleger j. psicología de la conducta. méxico: paidos; 1989. 20. benavent a. fundamentos de enfermería. españa: dae; 2003. 21. potter p, perry a. fundamentals of nursing. 5 ed. harcourt/ocean; 2004. 22. roca j, viladin p. cuidados paliativos en oncología. comunicación entre el paciente y la familia. barcelona; jims; 1996. 23. castañeda am, chang. el duelo en pacientes y familias en situaciones de urgencia y cuidados críticos. la familia del paciente internado en la unidad de cuidados intensivos 2000; 16 (3): 243. 24. de albístur mc, bacigalupo jc, gerez j. la familia del paciente internado en la unidad de cuidados intensivos. montevideo: hospital policial; 1999. 25. deaton c, namasivayam s. nursing outcomes in coronary heart disease. the journal of cardiovascular nursing 2004; 308. 26. mennen a, garner k. recent advances in the management of cardiothoracic patients. australian nursing journal 2003;11 (iss. 3): 19. 27. schneider d, manschein mm et ál. acolhimento ao pacinte e familia na unidade coronariana. texto contexto enfermagem 2008; 17 (1): 81-89. 10. enseœanza de la etica la enseñanza de la ética en enfermería 35 l fin último de la educación, como de toda actividad humana éticamente válida, es la búsqueda de la realización del ser humano (galdona, 2000). si se asume el hecho de que la educación no es el mero aprendizaje de contenidos teóricos y de ciertas habilidades manuales, sino que abarca el desarrollo de toda la persona, se debe entender que el objetivo esencial del proceso educativo es la conformación de una “personalidad ética”. de este modo, la persona asume como tarea esencial de la propia vida el desarrollarse plenamente como ser humano. por esta razón, la tarea educativa se debe orientar a ayudar a cada estudiante a descubrir y asumir el propio sentido de la vida y a desarrollar al máximo todas sus potencialidades de crecimiento en forma armónica y ponderada. para conseguir el desarrollo de una personalidad ética integral es importante abordar específicamente contenidos proresumen el fin de la educación es la búsqueda de la realización del ser humano, pues la tarea educativa consiste en orientar al estudiante para que asuma el propio sentido de la vida. para conseguir una personalidad ética es necesario abordar contenidos propios, que permitan el desarrollo de una conciencia moral y autónoma. la ética profesional se ocupa de las obligaciones que surgen del ejercicio de cualquier profesión. la ética da criterios generales, pero además contempla dilemas propios, específicos, que requieren una formación particular. la enseñanza de la ética en enfermería se ha hecho más práctica y mejor orientada, para corresponder a los grandes cambios que se han generado en la atención de salud. varios estudios han revelado la necesidad de enseñar contenidos específicos de la ética en enfermería, que se diferencien de los contenidos de la ética en otras profesiones. palabras clave educación, ética, enfermería. abstract the purpose of teaching is the realization of the human being, because the objective of education is to guide the student to assume its own meaning of life. to reach an ethical personality it is necessary to obtain proper contents, for the development of a moral and autonomous conscience. the professional ethic studies the obligations of any profession. ethic gives general criteria considering proper and specific dilemmas, which needs a particular formation. teaching ethics in nursing has been much more practical and better oriented to correspond to the great changes generated by health care. several studies have revealed the need to teach specific contents of ethics in nursing, different from the contents of other professions. key words education, ethics, nursery. lucía restrepo arzayús pios, apoyados en el desarrollo de una conciencia moral autónoma. en la construcción de una personalidad ética sólida se deben abarcar tres niveles diferenciados que, al interactuar de modo permanente, conducen a la formación real de la persona. estos tres niveles se orientan a: 1. el desarrollo de un fuerte “sentido de vida”, lo que implica la capacidad de dar una respuesta autónoma a la pregunta fundamental de la vida. año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 36 2. el desarrollo de un “proyecto de vida” concreto y realizable. esto implica un intento consciente y deliberado de alcanzar coherencia personal entre los propios ideales y la escala de valores. 3. el desarrollo de una “estructura ética personal” capaz de realizar y sostener los contenidos éticos de la propia vida. para contribuir a estructurar una personalidad ética se requieren estrategias pedagógicas para compartir con la persona en formación sus expectativas y valores con aquellos que el desempeño de su futuro trabajo espera de ella. la ética profesional o deontológica se ocupa de las obligaciones que surgen del ejercicio de cualquier profesión, al brindar enfoques teóricos que orientan la toma de decisiones éticas. cualquier trabajo profesional se debe regir por una serie de criterios generales comunes a diferentes actividades, pero, además, cada profesión se plantea dilemas propios, específicos, que deben ser resueltos adecuadamente y para lo cual se necesita una formación particular. las profesiones relacionadas con la salud de los seres humanos demandan una excelente competencia científica y técnica, pero a la vez una formación ética profunda con criterios seguros que permitan actuar con excelencia moral. en la actualidad, la práctica de enfermería necesita orientaciones más claras, a medida que las enfermeras amplían su campo de acción. el objetivo de la enseñanza de la ética en enfermería es formar una enfermera moralmente responsable, dotada de capacidad para tomar decisiones éticas en el desempeño de su trabajo. según sara fry, para lograr este objetivo, los estudiantes deben aprender a integrar sus valores y convicciones personales con el conocimiento de conceptos éticos, enfoques tradicionales y contemporáneos. a partir de los años setenta, la enseñanza de la ética en enfermería se hizo más urgente, más práctica y con una mejor orientación. en décadas anteriores, era impartida por sacerdotes o religiosos, u otras personas ajenas a la profesión, quienes exponían algunas generalidades sobre moral, más orientadas a actuar por obediencia que a formar profesionales capaces de tomar decisiones responsables e independientes. citando de nuevo a fry, los grandes cambios que se han generado en la atención de salud, las nuevas tecnologías y el creciente papel de la enfermera han planteado la pregunta de “qué tan bien preparadas están hoy día las enfermeras para tomar decisiones éticas en sus nuevos roles, en la atención de salud”. varios estudios han revelado la necesidad de “enseñar contenidos específicos de la ética de enfermería”, y la dificultad de dedicar el tiempo necesario a la enseñanza de la ética, debido al recargo de los planes de estudios, aunque todos reconocen la importancia de incluir tales contenidos en la formación de la enfermera. a raíz de estos estudios surgieron varios textos, que definen los elementos teóricos básicos en la formación de la enfermera. aunque no todos están bien orientados, cumplen con la función de guiar a los docentes responsables de las asignaturas propias de la disciplina, en materia de decisiones éticas. a medida que la enfermería evoluciona como profesión, con un conjunto de conocimientos que le son propios y diferentes a los de otras disciplinas, su práctica se independiza cada vez más del tradicional modelo médico. esto se deriva también de que los fundamentos filosóficos de la enfermería hoy día difieren de los de la medicina, si se tiene en cuenta que las teorías, especialmente las más recientes, expresan claramente que la enfermería se relaciona con las personas, con la dignidad del ser humano en forma integral, para lo cual es fundamental el concepto de “holismo” tanto en la salud como en las prácticas y en el cuidado. la enfermería está orientada hacia la persona y no hacia la enfermedad, respeta la autonomía y la individualidad del sujeto de cuidado y se aleja de cualquier noción de paternalismo, porque la relación entre la enfermera y el paciente se lleva a cabo entre personas del mismo nivel, relación en que se motiva a este para que participe activamente en el proceso de cuidado, no siendo únicamente receptor de las acciones de enfermería, sino coautor del plan de cuidado. la facultad de enfermería de la universidad de la sabana ha tomado la ética como uno de los ejes curriculares que dan soporte a su plan de estudios, con el fin de dar respuesta a los principios que orientan el pei de la universidad, cuya misión es formar integralmente a sus estudiantes como ciudadanos con una orientación ética que garantice un futuro de colombia más humano. bibliografía fry, sara t. teaching ethics in nursing curricula: traditional and contemporary models, nursing clinics of north america, june, 1989. fry, sara t. la ética en la práctica de enfermería, cie, ginebra, suiza, 1994. garzón alarcón, nelly. ciencia y humanismo en enfermería. hacia una medicina más humana, panamericana, bogotá, 1997. garzón alarcón, nelly. “ética en el cuidado de la vida”, en enfermería misión y valores de una profesión, universidad panamericana, méxico, 1998. rayon valpuesta, esperanza. “la dimensión ética de la persona humana”, en enfermería misión y valores de una profesión, universidad panamericana, méxico, 1998. rumbold, graham. ética en enfermería, mcgraw-hill, méxico, 2000. 1 maría josé aguilar-cordero1 raquel rodríguez-blanque2 antonio sánchez-lópez3 ximena alejandra león-ríos4 manuela expósito-ruiz5 norma mur-villar6 valoración de la técnica de amamantamiento en bebés con síndrome de down* 1 https://orcid.org/0000-0002-6268-0975. complejo hospitalario universidad de granada, españa. mariajoseaguilar@ugr.es 2 https://orcid.org/0000-0003-2086-1222. complejo hospitalario universidad de granada, españa. rarobla@ugr.es 3 https://orcid.org/0000-0001-5482-226x. universidad de sevilla, españa. asanchez47@us.es 4 https://orcid.org/0000-0002-3494-331x. universidad de granada, españa. ximenalr@correo.ugr.es 5 https://orcid.org/0000-0003-2789-9442. instituto de investigación biosanitaria y fundación para la investigación biosanitaria de andalucía oriental (fibao), españa. mexposito@fibao.es 6 https://orcid.org/0000-0002-0205-7460. facultad de ciencias médicas, universidad de ciencias médicas de cienfuegos, cuba. normamur@jagua.cfg.sld.cu * producto de investigación realizado por el grupo de investigación cts-367, “grupo de humanización de los cuidados. diagnósticos de enfermería, niños con problemas de salud, nutrición, dolor.” de la universidad de granada. recibido: 06/05/2019 enviado a pares: 10/07/2019 aceptado por pares: 19/11/2019 aprobado: 19/11/2019 doi: 10.5294/aqui.2019.19.4.6 para citar este artículo / to reference this article / para citar este artigo aguilar-cordero mj, rodriguez-blanque r, sánchez-lópez am, leon-rios xa, exposito-ruiz m, mur-villar n. assessment of the technique of breastfeeding in babies with down syndrome. aquichan. 2019;19(4):e1946. doi: https://doi.org/10.5294/aqui.2019.19.4.6 resumen objetivo: evaluar la técnica y la duración de la lactancia materna (lm) en niños sanos y en niños con síndrome de down (sd), a través del formulario de observación del amamantamiento. materiales y métodos: se realizó un estudio observacional de cohorte prospectivo en el hospital clínico de granada, a finales de 2015. el grupo de estudio estuvo constituido por cuarenta pacientes con sd, y el grupo control se conformó por niños recién nacidos con dicha alteración y, en la misma cantidad, por niños sanos, con las mismas características de peso y edad gestacional. los recién nacidos evaluados estuvieron en una habitación conjunta con la madre, donde el personal sanitario valoró la técnica durante los primeros cinco días posparto. se realizó un análisis bivariante para comparar los grupos, utilizando el test t de student para las variables numéricas, y el chi-cuadrado, para las categóricas. resultados: la lactogénesis se produjo primero en el grupo sin sd (92,5 % en las primeras 24 horas vs 20 %; p<0,001). se observó que el 60 % de los niños sanos mantuvieron la lm por más de tres meses, mientras que el grupo de bebés con sd logró en este tiempo el 47,5%. conclusiones: la lm presentó, al inicio, más dificultades en las madres de niños con sd. los errores técnicos influyen en el inicio y en el mantenimiento de la lm en las madres de estos niños. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1946 temática: práctica basada en la evidencia. aporte a la disciplina: la investigación destaca la importancia de la lactancia materna para mejorar la fuerza muscular en la boca de los niños con síndrome de down. al ayudar a compensar el bajo tono muscular, alienta a las madres a aprender a amamantar con mayor eficacia. actualmente, tras una etapa de abandono masivo, es necesario desarrollar políticas que promuevan la lactancia materna frente a la lactancia artificial, sobre todo en niños que padecen alteraciones de desarrollo. las valoraciones realizadas a partir de los resultados obtenidos nos permiten sostener que una correcta orientación en los primeros días de vida puede fomentar una lactancia adecuada y duradera en estos pacientes. https://orcid.org/0000-0002-6268-0975 file:///f:/temporal/ https://orcid.org/0000-0003-2086-1222 file:///f:/temporal/ https://orcid.org/0000-0001-5482-226x file:///f:/temporal/ https://orcid.org/0000-0002-3494-331x file:///f:/temporal/ https://orcid.org/0000-0003-2789-9442 file:///f:/temporal/ https://orcid.org/0000-0002-0205-7460 file:///f:/temporal/ https://doi.org/10.5294/aqui.2019.19.4.6 https://orcid.org/0000-0002-6268-0975 https://orcid.org/0000-0003-2086-1222 https://orcid.org/0000-0001-5482-226x https://orcid.org/0000-0002-3494-331x https://orcid.org/0000-0003-2789-9442 https://orcid.org/0000-0002-0205-7460 https://doi.org/10.5294/aqui.2019.19.4.6 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1946 palabras clave (fuente: decs) lactancia materna; síndrome de down; niño; enfermería en salud comunitaria; cuidado del lactante. assessment of the technique of breastfeeding in babies with down syndrome* abstract objective: to evaluate the technique and duration of breastfeeding in healthy children and children with down syndrome (ds) using the breastfeeding observation form. materials and methods: an observational study of a prospective cohort was carried out at the clinical hospital of granada during 2015. the study group consisted of 40 children with ds and the control group was formed by each newborn with ds and a healthy new-born with the same characteristics of weight and gestational age was selected. the new-borns evaluated shared housing with the mother where the technique was valued during the first 5 days postpartum by a health professional. a bivariable analysis was performed to compare the groups using student’s “t” test for numerical variables and chi-square for categorical variables. results: lactogenesis onset was earlier in the ds group (92.5 % in the first 24 hours vs 20 %; p <0.001). it was observed that 60 % of the healthy children were breastfed for more than three months while in the group of babies with ds this time period was 47.5 %. conclusions: the results of this study reveal that the breastfeeding technique presented at the beginning more difficulties in mothers of children with ds and it has been shown that technical errors influence the onset and duration of breastfeeding in mothers of these children. keywords (source: decs) breastfeeding; down syndrome; child; community health nursing; infant care. * study performed by the research group cts-367. “humanization of the health care. nursing diagnoses, children with health conditions, nutrition, pain.” universidad de granada. 3 valoración de la técnica de amamantamiento en bebés con síndrome de down l maría josé aguilar-cordero y otros avaliação da técnica de amamentação em bebês com síndrome de down* resumo objetivo: avaliar a técnica e a duração do aleitamento materno em crianças saudáveis e crianças com síndrome de down (sd), com a utilização do formulário de observação do aleitamento materno. materiais e métodos: estudo de coorte prospectivo observacional, realizado no hospital clínico de granada, em 2015. o grupo de estudo foi composto por 40 pacientes com sd e o grupo controle formado por recém-nascidos com essa alteração e com crianças saudáveis, considerando as mesmas características de peso e idade gestacional. os recém-nascidos avaliados estavam em um quarto conjunto com a mãe, onde a técnica foi avaliada durante os primeiros cinco dias pósparto pela equipe médica. uma análise bivariada foi realizada para comparar os grupos, utilizando o teste t de student para as variáveis numéricas e o qui-quadrado para as variáveis categóricas. resultados: a lactogênese ocorreu primeiramente no grupo sem sd (92,5 % nas primeiras 24 horas vs 20 %; p <0,001). tornou-se evidente que 60 % das crianças saudáveis mantiveram a amamentação por mais de três meses, enquanto no grupo de bebês com sd, esse tempo foi de 47,5 %. conclusões: os resultados deste estudo revelam que a técnica de amamentação apresentou no início mais dificuldades em mães de crianças com sd e demonstrou que erros técnicos influenciam o início e a manutenção do aleitamento materno em mães dessas crianças. palavras-chave (fonte: decs) aleitamento materno; síndrome de down; criança; enfermagem em saúde comunitária; cuidado do lactent. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1946 * produto de pesquisa realizado pelo grupo de pesquisa cts-367, “grupo de humanização dos cuidados. diagnósticos de enfermagem, crianças com problemas de saúde, nutrição, dor” da universidad de granada. 4 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1946 aquichan issn 1657-5997 eissn 2027-5374 introducción la lactancia materna (lm) es la única fuente alimenticia que suministra todos los nutrientes necesarios para el desarrollo óptimo del niño en los primeros meses de vida. la investigación epidemiológica ha demostrado que proporciona una serie de beneficios para la salud, el crecimiento y el desarrollo, al tiempo que disminuye significativamente el riesgo de padecer un gran número de enfermedades agudas y crónicas, como la obesidad (1, 2). además de ser la mejor opción de alimentación del ser humano en los seis primeros meses de vida (otros autores lo recomiendan hasta los dos primeros años de vida), la lm tiene también ventajas para la madre. se le reconoce como un método eficaz para prevenir el cáncer de mama y la hipertensión a mediano y a largo plazo (2, 3). la leche humana aporta una gran cantidad de poliaminas, que ayudan en el proceso de maduración intestinal (3). es un fluido que varía durante las etapas de la lactancia y a lo largo de las 24 horas del día (4). en la etapa inicial o de secreción del calostro, la cantidad de nitrógenos es total, y las proteínas aumentan en la muestra nocturna con respecto a las horas diurnas. con este estudio, queda patente la variabilidad circadiana de la leche humana (3, 4). para analizar los aspectos vinculados al descenso significativo de la lm, es necesario destacar los aspectos técnicos y, dentro de estos, el mecanismo de la succión. tomar de un pecho es diferente de tomar de un biberón: la leche pasa de la madre al niño mediante la combinación de una expulsión pasiva (reflejo de eyección o subida de la leche) y una extracción activa por parte del bebé (succión). la literatura técnica expone que la hormona oxitócica se ocupa de conducir la leche secretada por los conductos galactóforos para llegar finalmente al pezón. la producción de oxitocina se estimula por la succión, pues se trata siempre de un mecanismo reflejo (4, 5). otro aspecto reportado en la literatura es la posición en la que la madre se coloca el niño al pecho. varios autores consideran que cuando esa postura es incorrecta, la boca del niño no abarca todo el pezón y no extrae adecuadamente la leche; por ello, se ve obligado a aspirar en el vacío. la detección temprana de problemas en la aplicación de la técnica de succión evita inconvenientes como este, así como grietas, mastitis e hipogalactia, principales causas del abandono de la lm (6, 7). resulta oportuno destacar que un buen comienzo es importante para una buena relación entre la madre y su hijo. así, establecer una buena técnica de succión desde el inicio resulta fundamental para evitar problemas. los errores repetidos en las primeras horas en que la madre comienza la lactancia condicionan el fracaso, lo que ha sido reiteradamente demostrado en la literatura especializada en este tema (7, 8). en los últimos años, la lm ha disminuido de manera considerable. este hecho ha tenido graves efectos para la salud de los niños, especialmente en los países en vías de desarrollo y en los niños con síndrome de down (sd). existe la creencia de que la hipotonía y la disminución de algunos reflejos impiden la lm a los niños con sd, pero es solo un mito (8, 9). es cierto que algunas de las características propias del recién nacido con sd, como la hipotonía y las dificultades de succión y deglución, hacen un poco más difícil esta forma de alimentación, lo que puede acarrear el abandono de la misma antes del tiempo deseado (9-11). sin embargo, muchos de los problemas encontrados se derivan de la inseguridad y del desconocimiento de las técnicas de lm, así como de la separación del niño de la madre durante los primeros días de vida. algunos estudios han comprobado las ventajas de esta forma de alimentación para los bebés, y especialmente para los que padecen sd, por lo cual el abandono precoz de la lm en los niños con sd se debe evitar. junto con la familia, hay que lograr disminuir las barreras potenciales y las dificultades que encontrarán las madres durante el amamantamiento, como la succión más débil, la propia hipotonía, la deglución más lenta y la posición (12, 13). las necesidades biopsicosociales de las madres y de los bebés con sd se deben atender desde el momento del nacimiento, facilitando, en el propio paritorio, el contacto piel con piel y la lactancia materna (14, 15). objetivo evaluar la técnica y la duración de la lactancia materna en niños sanos y en niños con sd, utilizando el formulario de observación del amamantamiento. 5 valoración de la técnica de amamantamiento en bebés con síndrome de down l maría josé aguilar-cordero y otros material y método se realizó un estudio observacional de cohorte prospectivo, en un grupo de recién nacidos con sd y en otro sin sd, en el hospital clínico universitario san cecilio de granada, a finales de 2015. el grupo 1 de estudio estuvo constituido por niños con sd n=40, y el grupo 2 control se conformó por recién nacidos con sd y por recién nacidos sanos (por cada recién nacido con sd, un niño sano), con las mismas características de peso y edad gestacional. los niños que participaron en el estudio fueron seleccionados mediante la técnica de muestreo por conveniencia. mediante esta, se escogió una muestra de la población accesible, debido a que se encontraba hospitalizada y en una habitación conjunta con la madre. todas las madres participantes firmaron el consentimiento informado para formar parte del estudio. el proyecto dispone de la aprobación del comité de ética del hospital clínico universitario san cecilio de granada, con el número pi0397/08. los criterios de inclusión fueron bebés con sd y bebés sanos, ingresados sin patología grave, cuyos padres dieran por escrito el consentimiento informado. las matronas, debidamente entrenadas por el equipo investigador, valoraron la técnica durante los primeros cinco días posparto. el seguimiento de la lactancia después del alta se realizó en los controles del programa niño sano, en los centros de salud correspondientes. para la valoración de la toma, se utilizó el formulario de observación del amamantamiento (16). este cuestionario evalúa los siguientes ítems: la posición del cuerpo, la respuesta observada del niño, el vínculo afectivo manifestado, la anatomía de las mamas, el tipo de succión y la duración de la lactancia. si se reconocía un signo, se colocaba una marca en la casilla que está al lado del signo. se sumaron las marcas, y el resultado se clasificó en buena, regular o mala, al igual que la calidad de la toma. la asociación española de pediatría acepta este formulario como instrumento para evaluar el amamantamiento de los niños sanos y de aquellos con alteraciones del desarrollo. está validado por la organización mundial de la salud y por el fondo de las naciones unidas para la infancia, desde 1998, mediante su publicación consejería en lactancia materna: curso de capacitación. el cuestionario evalúa el amamantamiento, sea correcto, sea difícil. siguiendo las recomendaciones de la comisión europea, dirección pública de salud y control de riesgos, diversos hospitales utilizan este cuestionario (17, 18). otros datos fueron el perfil académico de las madres, su lugar de procedencia, la etnia, el peso del niño al nacer, el tipo de parto (eutócico o distócico) y los días de estancia hospitalaria. análisis estadístico se efectuó un análisis descriptivo de las variables del estudio. para las de tipo numérico, se calculó la media y la desviación estándar; para las cualitativas, las frecuencias absoluta y relativa. posteriormente, se completó, mediante un análisis bivariante, con el estudio de las diferencias entre los grupos. para las variables cualitativas, se utilizó el test chi-cuadrado de pearson o fisher, en aquellos los casos en los que no se cumplieran los criterios de aplicabilidad. para las de carácter cuantitativo, se trabajó con el test t de student. se calculó la razón de probabilidades (odds ratio) y su intervalo de confianza, al 95 %. el nivel de significación considerado para los análisis fue de 0,05. los datos se analizaron con el software estadístico ibm spss statistics 19. resultados se incluyeron en el estudio 80 recién nacidos: 40 con sd y 40 sin sd. la edad de las madres fue superior en el grupo de niños con sd: 31,85+/-4,58 vs 25,83+/-4,39, de forma estadísticamente significativa (p<0.001). no se encontraron diferencias respecto al perfil académico ni al lugar de procedencia, y la mayoría eran de origen caucásico (80 y 90 %, respectivamente). en cuanto al tabaco, la proporción de mujeres fumadoras fue superior en el grupo de los niños con sd: 40 % frente a 12,5 %, en el grupo de los niños sin sd (p=0,005). las semanas de gestación fueron muy similares en ambos grupos: por encima de las 37 semanas, en el 72,5 % de las madres del grupo de niños sin sd, y en el 77,5 % de aquellas del grupo con sd. no se encontraron diferencias significativas en el tipo de parto: el 60 % en el grupo sin sd, y el 50 % en el grupo con sd fueron eutócicos. en cuanto al peso al nacer de los niños, también fue muy similar en ambos grupos: el 72,5 % de los niños sin sd, y el 77,5 % de aquellos del grupo con sd pesaron por encima de los 2500 gr (tabla 1). en las variables resultado, se encuentran diferencias estadísticamente significativas respecto a la subida de la leche; esta surge de manera más temprana (en las primeras 24 horas) en el grupo de las madres con niños sin sd (92,5 % de los casos) que en el de aquellas con niños con sd (20 %) (p<0,001). la subida de la leche en las madres de estos últimos vino clínicamente acom6 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1946 aquichan issn 1657-5997 eissn 2027-5374 pañada por síntomas de ingurgitación mamaria, que se manifestaba con llenado y pesadez de los pechos, dolor de las mamas y aumento de la temperatura. respecto a la valoración de la toma, fue buena en el 45 % de las madres con niños sin sd, frente al 25 % de las madres del grupo con sd (p=0,005). la calidad de la puesta al pecho fue buena en el 65 % de las madres del grupo sin sd frente al 40 % de las madres del grupo con sd (p=0,025). este fue el peor resultado obtenido para la valoración de la toma. se encontraron dificultades en la postura de la madre: la cabeza del recién nacido no estaba alineada con el cuerpo de la madre, y el bebé se soltó del pecho en el 60 % de los niños con sd. los principales problemas encontrados en la técnica fueron dificultades en la postura de la madre y un agarre deficiente. en la duración de la lactancia, no se encontraron diferencias estadísticamente significativas entre los grupos: en el 60 % de las madres del grupo sin sd, y en el 47,5 de las madres del grupo con sd fue superior a los 3 meses (p=0,262) (tabla 2). al calcular la razón de probabilidades y su intervalo de confianza para la valoración y la calidad de la toma, se observó que los niños con sd tienen mayor riesgo de una mala o regular valoración 2,40 [0,76-7,51] y de una lactancia de peor calidad 3,30 [1,07-10,17], independientemente de la edad de la madre (tabla 3). tabla 1. características basales de los dos grupos niños sin sd 40 (50%) niños con sd 40 (50%) p edad de la madre 25,83+/–4,39 31,85+/–4,58 <0,001 nivel de estudios técnico y primario universitario 28(70) 12(30) 23(27,5) 17(42,5) 0,245 lugar de procedencia caucásico otros 32(80) 8(20) 36(90) 4(10) 0,210 fumadora 5(12,5) 16(40) 0,005 sg >37 29(72,5) 31(77,5) 0,606 tipo de parto eutócico distócico 24(60) 16(40) 20(50) 20(50) 0,369 peso al nacer <2500 gr >2500 gr 11(27,5) 29(72,5) 9(22,5) 31(77,5) 0,606 fuente: elaboración propia. tabla 2. comparación de las variables resultado entre los grupos niños sin sd 40(50 %) niños con sd 40(50 %) p subida de la leche < inferior a 24 horas > superior a 24 horas 37(92,5) 3(7,5) 8(20) 32(80) <0,001 valoración toma buena regular mala 18(45) 17(42,5) 5(12,5) 10(25) 12(30) 18(45) 0,005 calidad puesta al pecho buena regular/mal 26(65) 14(35) 16(40) 24(60) 0,025 duración de la lactancia materna < 3 meses > 3 meses 16(40) 24(60) 21(52,5) 19(47,5) 0,262 fuente: elaboración propia. tabla 3. razón de probabilidades cruda y ajustada para valoración y calidad de la lactancia or crudas or ajustadas por edad y tabaco or ic 95% p or ic 95% p valoración mala/ regular de la toma 2,45 0,95-6,34 0,064 2,74 0,83-8,97 0,097 calidad regular/ mal puesta al pecho 2,79 1,1256,90 0,027 3,86 1,19-12,53 0,024 notas: grupo sd vs no sd. or: sigla en inglés de razón de probabilidades. fuente: elaboración propia. discusión en los niños sanos, la toma se considera buena en el 65 % de los casos. sin embargo, los recién nacidos con sd recibieron la misma calificación solo en el 25 % de los casos. estos resultados corresponden con los reportes de varios autores que aseveran que los bebés con sd tienen menos probabilidades de ser amamantados, y que señalan que una de las razones es el ingreso hospitalario a causa de las alteraciones. también refieren que la separación madre-hijo interfiere en la lactancia, así como una función motora de la boca débil, hipotonía muscular generalizada y la edad de la madre (19). 7 valoración de la técnica de amamantamiento en bebés con síndrome de down l maría josé aguilar-cordero y otros pisacane et al. consideran que estos bebés ingresados, con una buena asesoría a los padres, pueden mejorar el índice de lactancia, sobre todo si se evita la separación madre-hijo. también señalan que la depresión y la baja autoconfianza de las madres después del nacimiento de un bebé con sd están relacionadas con el abandono precoz. la formación de los profesionales de la salud y al apoyo a las madres durante las primeras semanas del nacimiento se asocia con la prevalencia de la lactancia (19-21). esta forma de alimentación proporciona beneficios relevantes para la salud de los niños con sd. por ello, se sugiere que la política de ingreso en el hospital debe ser cuidadosamente revisada. si la hospitalización de la madre es necesaria, la lactancia materna deberá ser un punto relevante de apoyo, como lo reconocen la mayoría de las participantes en el estudio cualitativo para comprender los factores culturales que afectan la decisión de una madre de amamantar o alimentar con fórmula (21, 22). un estudio retrospectivo manifiesta que amamantar a los bebés con sd representa un verdadero desafío. muchas de los participantes expresaron un alto nivel de dificultad y decepción porque no eran capaces de amamantar como les hubiese gustado. un estudio identificó que el 84,6 % de los niños con sd experimentaba algún impedimento para la succión. este estudio se realizó mediante una encuesta, años después del nacimiento, y algunas madres no recordaban como había sido la lactancia. según este autor, en la actualidad no existe consenso con los profesionales sanitarios respecto a la capacidad de los niños con sd para ser amamantados (23, 24). la mayoría de las madres de niños con sd pueden lactar a sus hijos, y esta práctica es muy importante. sin embargo, en algunos bebés hay profundos obstáculos para lograr que la lactancia materna sea un éxito. los profesionales deben estar preparados para detectar estos casos y aconsejar a las madres sobre los pasos por seguir. en las declaraciones de las madres, se observa la importancia de formar a los profesionales para atender el sufrimiento y la frustración que rodea el nacimiento de un niño con discapacidad. también es importante la capacidad y la habilidad de los profesionales para actuar de forma adecuada en la información, orientación y en el apoyo a la lactancia materna (25). se observa que la lactogénesis o subida de la leche en las madres de niños sanos fue < 24 horas en el 92,5 %, y en las madres de niños con sd, > 24 horas para el 80 %, manifestado por llenado y pesadez de los pechos, dolor de las mamas y aumento de la temperatura. este hecho dificulta también la propia lactancia, por lo que madres requieren mayor asesoramiento por parte del personal sanitario. los estudios revelan que un retraso en la subida de la leche tiene implicaciones en la nutrición del niño porque afecta los comportamientos de la lactancia materna. las mujeres con niveles de cortisol elevados en el alumbramiento y en el postparto son un factor de riesgo para el retraso de la subida de la leche. las concentraciones de cortisol aumentan en las primeras horas posparto, y pasadas las 17 horas del parto se produce un descenso. en las mujeres con niveles de estrés elevado, el descenso de cortisol no se produce. este estudio tiene una importante implicación en la salud pública porque las mujeres que sufren estrés, tanto psicosocial como de origen biológico, relacionado con el parto y el nacimiento, tienen probabilidades de experimentar un retraso en la subida de la leche (26). ante cualquier situación estresante, los sistemas neuroendocrinos y hormonales están activados. el hipotálamo es el centro de control de estos sistemas. cuando la persona sufre de estrés, hay una liberación de hormonas, vasopresinas y corticotropina (crh), y todas tienen efectos estimulantes en el cerebro. se desplazan desde la glándula pituitaria, donde se produce la liberación de la hormona adrenocorticotropina (acth). esta estimula las glándulas suprarrenales, que producen el cortisol, el cual moviliza la energía para responder ante el estrés (24, 27). las madres que dan pecho tienen menos estrés percibido que las que dan biberón, y esto lo corrobora el hecho de que al dar de mamar aumenta el estado de ánimo (los resultados lo confirman). parece ser atribuible a los efectos fisiológicos de la lactancia y no a las diferencias individuales entre madres lactantes y no lactantes (28). el estrés producido durante el parto y la glucosa alta en el cordón umbilical son factores de riesgo para el retraso de la lactogénesis. se midieron hormonas de estrés y se recogieron datos detallados durante el comportamiento de la alimentación temprana. se valoraron cuatro marcadores de la lactogénesis, de los cuales dos (la aparición de la caseína y la concentración de lactosa) eran marcadores bioquímicos. el tercero medía el volumen de leche del quinto día después del parto, y el cuarto era una valoración subjetiva por parte de la madre (pechos llenos) (28). en nuestro estudio, todas las madres de los bebés con sd presentaron un retraso en la lactogénesis. 8 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1946 aquichan issn 1657-5997 eissn 2027-5374 en relación con la duración de la lm, en nuestro estudio se observa que el 60 % de los niños sanos mantuvieron la lm por más de tres meses, mientras que en el grupo de bebés con sd solo logró este tiempo el 47,5 %. estos datos indican que las orientaciones que se dieron en los primeros días posparto fueron eficaces para incrementar los meses de lactancia en los bebés afectados por sd. en un estudio realizado en jerusalén durante diez años, se observó que a pesar de las complicaciones perinatales comunes, como insuficiencia respiratoria o necesidad de suplementos de oxígeno (presentadas en el 32 % de los participantes) en los niños con sd, alrededor del 84 % fueron alimentados con leche humana. de ellos, dos tercios se alimentaron exclusivamente con leche materna, y un tercio se suplementó con fórmula infantil (29). asimismo, la revisión de la literatura especializada reporta que, en estados unidos, la tasa real de iniciación de la lactancia es del 73,4 %. la duración de la lactancia materna hasta los seis meses es del 56 %, y más de seis meses es del 42 %. estos datos confirman que, a pesar de cualquier desafío, como es el sd, la lactancia materna es la forma de alimentación más adecuada para la familia (30). otro estudio demuestra que la lactancia materna en los niños con sd fue más corta, sobre todo si después del nacimiento debía ingresar al hospital o si era primogénito. según los autores, dar el pecho depende más de su madre y de la estructura social, que de padecer sd. en este estudio, más del 70 % de las participantes sostuvo que, al ser diagnosticado su bebé con sd, no cambió su intención de amamantar a su hijo. en un porcentaje muy elevado, las madres consideraban que dar pecho era una ventaja importante para sus hijos y para ellas. los bebés con sd que han sido amamantados tienen una menor incidencia de dermatitis atópica, otitis media, asma infantil, gastroenteritis, obesidad, diabetes tipo 1 y leucemia infantil (31-33). se observa que los hábitos tóxicos están relacionados con los recién nacidos prematuros, tanto en niños con sd como en niños sanos. esta información permite corroborar los efectos negativos en la salud materno-infantil. estudios realizados en canadá demuestran que el riesgo de tener un bebé pretérmino, si la madre es fumadora, es cuatro veces superior al que se expone una madre que no consume tabaco. este estudio fue muy significativo cuando la madre fumaba más de diez cigarrillos al día, en comparación con las no fumadoras. el consumo de alcohol fue valorado en el 13,3 % de las fumadoras, y el 18,3 % consumía otra sustancia durante el embarazo. más del 75 % de los nacimientos pretérminos correspondían a mujeres menores de 30 años. las mujeres entre 35 y 39 años fueron las que tuvieron una tasa de tabaquismo menor (33). el efecto adverso del tabaco sobre la lactancia implica un efecto fisiológico de la nicotina sobre el sistema hormonal de la madre y también sobre la leche directamente. se ha comprobado que los bebés amamantados de madres fumadoras muestran un comportamiento más irritable. el mecanismo consiste en que la nicotina hace bajar la prolactina, sobre todo a corto plazo. también se relaciona con la reducción del flujo sanguíneo de la mama por el efecto de la nicotina, dando lugar a una reducción de la oxitocina y a una disminución de la eyección de la leche (33, 34). como se ha observado en este estudio, la mayoría de los niños con sd, según la etnia de la madre, son caucásicos. es importante destacar que no se reportaron recién nacidos con sd en madres de etnias gitanas. un estudio realizado en 2009, en estados unidos, presenta la prevalencia del sd en relación con la etnia y demostró que el nacimiento fue más alto entre blancos no hispanos, a diferencia de las personas de raza negra, que resultó menor. en relación con el sexo, fue significativamente mayor el nacimiento en varones (35). los resultados de la distribución del sd según la edad de la madre permiten constatar que en la medida que aumenta la edad de la madre, se incrementan los nacimientos de niños que padecen sd. en estados unidos, los estudios revelan que el nacimiento de los niños con sd ha aumentado en los últimos años. igualmente, aumentó la prevalencia de nacimientos de estos bebés en madres de edad más avanzada y han disminuido los nacimientos de estos niños en madres más jóvenes (35, 36). conclusiones los resultados de este estudio revelan que la técnica de la lactancia materna presentó, al inicio, más dificultades en las madres de niños con síndrome de down y se ha observado que los errores técnicos influyen en el inicio y en el mantenimiento de la lactancia materna (lm). 9 valoración de la técnica de amamantamiento en bebés con síndrome de down l maría josé aguilar-cordero y otros el análisis de la bibliografía manifiesta la importancia de la información relacionada con los aspectos técnicos del amamantamiento para lograr que se prolongue en el tiempo. las valoraciones realizadas a partir de los resultados de este estudio permiten plantear que una adecuada orientación a las madres, en los primeros días de la vida de su hijo, sobre las ventajas de la lm y su técnica promovería su práctica. asimismo, la hospitalización de un niño es más tolerable cuanto más cerca esté de la madre. además, si esta está correctamente informada, se podría fomentar una correcta técnica de lactancia materna, utilizando como medio verificador la ficha de observación de amamantamiento. se ha comprobado que se necesitan formas de promoción que incluyan los aspectos técnicos, el apoyo a las madres y el vínculo permanente madre e hijo. asimismo, que es importante, especialmente en estos bebés y sus padres, fomentar el contacto piel con piel lo máximo posible, para fortalecer el vínculo y la sensación de autoconfianza de 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https://doi.org/10.1186/s13052-015-0192-9 https://doi.org/10.1002/ajmg.a.11 file:///f:/temporal/ file:///f:/temporal/ file:///f:/temporal/ file:///f:/temporal/ https://doi.org/10.1177/0890334419838225 https://doi.org/10.1177/0890334419838225 https://doi.org/10.1080/24694193.2018.1496493 https://doi.org/10.1080/24694193.2018.1496493 https://doi.org/10.1186/s12955-014-0144-x https://doi.org/10.4067/s0370-41062018000100032 https://doi.org/10.4067/s0370-41062018000100032 11 valoración de la técnica de amamantamiento en bebés con síndrome de down l maría josé aguilar-cordero y otros 29. ergaz-shaltiel z, engel o, erlichman i, naveh y, schimmel ms, tenenbaum a neonatal characteristics and perinatal complications in neonates with down síndrome. am j med genet a [internet]. 2017 my. 173(5):1279-1286. doi: https:// doi.org/10.1002/ajmg.a.38165 30. chen cl, gilbert tj, daling jr. maternal smoking and down syndrome: the confounding effect of maternal age. am j epidemiol [internet]. 1999 mzo. 1;149(5):442-6. doi: https://doi.org/10.1093/oxfordjournals.aje.a009831 31. schieve la, boulet, sl, boyle c, rasmussen sa, schendel d. health of children 3 to 17 years of age with down syndrome in the 1997-2005 national health interview survey. pediatrics [internet]. 2009, 123(2), e253-e260. doi: https://doi. org/10.1542/peds.2008-1440 32. walters dd, phan lth, mathisen r. the cost of not breastfeeding: global results from a new tool. health policy plan [internet]. 2019 jul. 1;34(6):407-417. doi: https://doi.org/10.1093/heapol/czz050 33. emma j. glasson e, jacques a, wong k, bourke j, leonard h. improved survival in down syndrome over the last 60 years and the impact of perinatal factors in recent decades. j pediatr [internet]. 2016; 169:214-20. doi: https://doi. org/10.1016/j.jpeds.2015.10.083 34. timur taşhan s, hotun sahin n, omaç sönmez m. maternal smoking and newborn sex, birth weight and breastfeeding: a population-based study. j matern fetal neonatal med [internet]. 2017 nov. 30(21):2545-2550. doi: https://doi.org/1 0.1080/14767058.2016.1256986 35. de graaf g., buckley f., skotko b. g. estimation of the number of people with down syndrome in the united states. genetics in medicine [internet]. 2017 (19): 439-447. doi: https://doi.org/10.1038/gim.2016.127 36. organización mundial de la salud. metas mundiales de nutrición 2025: documento normativo sobre lactancia materna [global nutrition targets 2025: breastfeeding policy brief ]. ginebra: organización mundial de la salud; 2017. https://doi.org/10.1002/ajmg.a.38165 https://doi.org/10.1002/ajmg.a.38165 https://doi.org/10.1093/oxfordjournals.aje.a009831 https://doi.org/10.1542/peds.2008-1440 https://doi.org/10.1542/peds.2008-1440 https://doi.org/10.1093/heapol/czz050 https://doi.org/10.1016/j.jpeds.2015.10.083 https://doi.org/10.1016/j.jpeds.2015.10.083 https://doi.org/10.1080/14767058.2016.1256986 https://doi.org/10.1080/14767058.2016.1256986 https://doi.org/10.1038/gim.2016.127 12 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1946 aquichan issn 1657-5997 eissn 2027-5374 formulario de observación del amamantamiento fuente: organización mundial de la salud 214 aquichan issn 1657-5997 óscar alberto beltrán-salazar1 hay que poner de su parte para afrontar una enfermedad grave 1 especialista en enfermería cardiorrespiratoria. profesor, miembro del grupo de investigación en emergencias y desastres, universidad de antioquia. medellín, colombia. oscar4242@tone.udea.edu.co recibido: 5 de agosto de 2009 aceptado: 25 de septiembre de 2010 resumen objetivo: describir el significado de la experiencia de estar gravemente enfermo y hospitalizado en una unidad de cuidado intensivo. metodología: investigación cualitativa basada en la teoría fundada, realizada en medellín, colombia, de abril a octubre de 2006; incluyó a nueve personas adultas entre 24 y 80 años que estuvieron críticamente enfermas y hospitalizadas en uci. la entrevista en profundidad se utilizó para la recolección de información. los datos se analizaron según el esquema propuesto por cohen, kahan y steeves. resultados: poner de su parte es necesario para afrontar una enfermedad y hace referencia a los medios personales y externos que los participantes utilizaron para aceptar y adaptarse a la enfermedad y atenuar su condición amenazante. discusión: vivir la experiencia de padecer una enfermedad grave significó que los participantes se valieran de recursos personales internos disponibles y de algunas formas de apoyo social como la familia, la religión, los enfermeros, los amigos y conocidos e incluso de personas desconocidas. conclusión: los recursos personales y sociales ayudan a los pacientes a afrontar las emociones que despierta una situación que no pueden resolver por sí mismos como es el padecimiento de una enfermedad grave. palabras clave atención de enfermería, apoyo social, relaciones enfermero-paciente, enfermedad crítica. (fuente: decs, bireme). coping with a serious illness abstract objective: describe what it means to be seriously ill and hospitalized in an icu. methodology: this is a qualitative study based on grounded theory and conducted in medellín, colombia from april to october, 2006 with nine adults between the ages of 24 and 80 who were critically ill and hospitalized in an icu. in-depth interviews were used to gather information, which was analyzed pursuant to the scheme proposed by cohen, kahan and steeves. results: patients must do their part in order to cope with an illness. the study describes the personal and external means employed by the participants to accept and adapt to an illness and to lessen its threatening conditions. discussion: patients who experience a serious illness take advantage of internal personal resources and certain kinds of social support año 10 vol. 10 nº 3 chía, colombia diciembre 2010 l 00-00 215 hay que poner de su parte para afrontar una enfermedad grave l óscar alberto beltrán-salazar such as that provided by family, religion, nurses, friends, acquaintances, and even people they do not know. conclusion: personal and social resources help patients to cope with the emotions sparked by a situation they cannot resolve on their own, such as suffering from a serious illness. key words nursing care, social support, nurse-patient relations, critical illness. (source: decs, bireme). o afrontamento pessoal para superar uma doença grave resumo objetivo: descrever o significado da experiência de estar gravemente doente e internado em uma unidade de terapia intensiva. metodologia: estudo qualitativo com base na teoria fundamentada, levada a cabo em medellín, colômbia, de abril a outubro de 2006. incluiu nove adultos entre 24 e 80 anos, gravemente doentes e internadas na uti. para coletar informação se utilizou a entrevista em profundidade. os dados se analisaram de acordo com o esquema proposto por cohen, kahan e steeves. resultados: para lidar com uma doença é necessário fazer a sua parte, ou seja, os recursos pessoais e externos que os participantes utilizaram para aceitar e se adaptar à doença, e diminuir sua condição ameaçadora. discussão: na experiência da doença grave os participantes recorreram aos recursos pessoais disponíveis e a formas de apoio social, como família, religião, enfermeiros, amigos e conhecidos e até desconhecidos. conclusão: os recursos pessoais e sociais ajudam os pacientes a lidar com as emoções despertadas por uma situação que não podem resolver por si mesmos; por exemplo, uma doença grave. palavras-chave cuidados de enfermagem, apoio social, relações enfermeiro-paciente, estado terminal. (fonte: decs, bireme). 216 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 introducción el propósito de la participación de enfermería en el cuidado, según travelbee (1), consiste en “asistir a los individuos y las familias a prevenir y enfrentar la experiencia de la enfermedad y del sufrimiento y a encontrar significados en esa experiencia mediante la relación enfermero-paciente”. según lo anterior, la valoración de enfermería también debe estar orientada a determinar y conocer los significados otorgados por los pacientes a las experiencias de la enfermedad y no solo limitarse a una descripción de los signos y los síntomas. las percepciones y los significados de la experiencia de padecer una enfermedad crítica varían de persona a persona, debido a diferencias en la personalidad, los conocimientos y las experiencias previas; la significancia del sufrimiento es personal y diferente en cada individuo, y depende de la habilidad para el afrontamiento (2) que ayuda a enfrentar la enfermedad y la muerte mediante “una serie de comportamientos, respuestas y apoyos para manejar y controlar la ansiedad, para atenuar los efectos de la enfermedad y para adaptarse a ella” (3), lo que también es necesario durante el periodo de rehabilitación y convalecencia. la significancia del sufrimiento y de la enfermedad también “dependen de la capacidad para percibir la realidad y para aceptar las limitaciones de la condición humana y la naturaleza transitoria de la vida” (4). lazarous (2) plantea que la religión y la búsqueda de apoyo social, ya sea familiar, de las amistades o apoyo de enfermería ayudan a afrontar el peligro que altera la seguridad personal. torralba (5) afirma que “desde un punto de vista interpersonal, la percepción de la enfermedad es mucho más alentadora cuando la persona enferma se siente acompañada y cuidada desde el respeto, el cariño y la proximidad”. otras formas de enfrentar las situaciones que amenazan están representadas por los mecanismos de defensa planteados por freud, tales como la supresión, la represión, la negación y la fantasía (6, 7). los enfermeros para “ofrecer un cuidado de enfermería humanizado deben comprender los efectos de la enfermedad, el sufrimiento y la muerte como experiencias vividas por seres humanos” (1). un paso para lograr este propósito puede consistir en tratar de comprender las repercusiones personales que la enfermedad y todos los elementos usados por los enfermeros pueden producir en las personas en quienes se utilizan. con el fin de comprender el significado de la experiencia de padecer una enfermedad grave y estar hospitalizado en una uci se realizó un estudio cualitativo, en el cual se incluyó a nueve personas adultas que cumplieran con requerimientos tales como haber estado críticamente enfermos y hospitalizados en una uci. los resultados obtenidos permitieron describir los aspectos más significativos que los participantes reportaron en las entrevistas respecto a los recursos internos y externos que utilizaron para afrontar la experiencia de la enfermedad y adaptarse a ella. ofrecer un cuidado de enfermería humanizado deben comprender los efectos de la enfermedad, el sufrimiento y la muerte como experiencias vividas por seres humanos. 217 hay que poner de su parte para afrontar una enfermedad grave l óscar alberto beltrán-salazar metodología estudio cualitativo realizado con instrumentos de organización y análisis de datos de la teoría fundada para develar los “significados sobre una situación dada mediante sistemas de intereses biográfica y situacionalmente determinados y experimentados subjetivamente en el pensamiento de la vida cotidiana como motivos para actuar y elegir sobre proyectos y objetivos” (8). incluyó a nueve personas adultas, entre 24 y 80 años de edad, que hubieran estado críticamente enfermas y hospitalizadas en una uci, con disposición y capacidad para relatar su experiencia y que aceptaran la participación en el estudio. este número de participantes está acorde con los planteamientos de algunos autores (9, 10), y la selección se hizo por muestreo “teórico” (11) con “propósito”, esto es, “seleccionar el mejor informante para los requerimientos del estudio (12). los participantes fueron un abogado, una odontóloga, una estudiante de enfermería, dos amas de casa, un agricultor, un jubilado, una secretaria y una magíster en ciencias sociales, es decir, seis mujeres y tres hombres. uno de ellos estaba hospitalizado en la uci, dos en el servicio quirúrgico después del traslado de la uci, y en los demás el tiempo transcurrido entre el egreso de la hospitalización y el momento de la entrevista osciló entre uno y doce años. se consideró la saturación de la información cuando “los datos aportados se repitieron sin producir elementos nuevos que contribuyeran a la comprensión del fenómeno” (9). todos los participantes fueron sometidos a ventilación mecánica por un lapso entre 4 y 20 días durante su hospitalización en la uci. la entrevista en profundidad fue la técnica utilizada para la recolección de la información (13). la duración de las entrevistas fue de cuarenta minutos a una hora; con cada paciente se realizó un encuentro que terminó cuando expresaron no tener nada más que decir acerca de la experiencia. las entrevistas fueron grabadas en condiciones de privacidad en la unidad de los pacientes hospitalizados, en la casa o en la oficina de los demás, y a continuación se transcribieron fielmente por el investigador (14), quien también realizó todas las entrevistas. el análisis de la información fue realizado según el esquema propuesto por cohen, kahn y steeves (15), quienes plantean que se inicia durante la realización de la primera entrevista, seguido de una inmersión en los datos mediante la lectura de las transcripciones y del análisis línea por línea con el fin de realizar una selección de temas y ejemplares; a continuación se separaron los temas que fueron significativos en las descripciones de los participantes, se redactaron memos y se realizaron diagramas sobre cada tema. el paso siguiente consistió en realizar una búsqueda bibliográfica y la narrativa de la experiencia. la comprensión de los significados de la experiencia se reflejó en los temas y en los “ejemplares”, y fueron descritos en memos analíticos que luego sirvieron de base para la narrativa final. en el último paso se escribió una narrativa para describir lo que reflejaban los temas en relación con la experiencia de los participantes (15). los temas fueron validados, permitiendo a dos de los participantes leer la descripción para determinar su correspondencia con lo que ellos querían decir (15). todos los participantes fueron sometidos a ventilación mecánica por un lapso entre 4 y 20 días durante su hospitalización en la uci. la entrevista en profundidad fue la técnica utilizada para la recolección de la información. 218 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 el estudio se llevó a cabo en la ciudad de medellín, colombia, entre abril y octubre de 2006. siete de los participantes vivieron su experiencia de enfermedad crítica en unidades de cuidado intensivo de esa ciudad, uno en un hospital de nueva york, estados unidos, y el otro en sincelejo, colombia; cinco de ellos en hospitales privados y cuatro en hospitales oficiales. el primer contacto con los pacientes hospitalizados para la participación en el estudio lo realizó una enfermera del servicio quien informó de la aceptación al investigador. para asegurar el rigor metodológico, la recolección y la transcripción de la información fueron llevadas a cabo por el investigador; la transcripción de las entrevistas se hizo inmediatamente después de realizarlas para conservar la mayor fidelidad de los datos; en las entrevistas y el análisis se tuvo en cuenta el punto de vista de los participantes a quienes se les permitió “expresar su experiencia en su propio lenguaje para hacerla visible” (9-16). en la interpretación se mostró el punto de vista del paciente y las conjeturas del investigador con la constante preocupación porque los hallazgos fueran un reflejo de la realidad y tuvieran concordancia con lo expresado por los participantes; esta concordancia fue determinada “volviendo a los sujetos para darles a conocer y permitirles validar los hallazgos de la interpretación” (9), para lo cual se invitó a dos de los participantes —una ama de casa y un abogado— para leyeran el texto que se había producido con base en el análisis. no se realizaron generalizaciones a partir de los datos, y todas la entrevistas se consideraron de igual importancia por lo que los participantes expresaron, sin dar preponderancia a los datos por razones de poder social, riqueza, nivel educativo o importancia política de quien los expresaba (17); los casos negativos se tuvieron en cuenta para contrastar con aquellos que concordaban en sus descripciones y dilucidar la presencia de nuevos patrones en la información (18). en forma periódica, los procedimientos para el procesamiento y análisis de los datos, memos, diagramas y los frutos del estudio fueron revisados por la asesora, una investigadora experimentada, con título de doctorado, con una amplia trayectoria en estudios cualitativos. además, el texto escrito a partir del análisis de los datos fue revisado por una investigadora de la universidad nacional de colombia con título de magíster, y por una investigadora fenomenóloga con título de doctora de la universidad del valle, quienes hicieron sugerencias para velar por la validez interna. una enfermera intensivista, con grado de especialista, que estuvo de turno durante los días en que se llevó a cabo la observación, también leyó el texto y a manera de evaluación expresó que: al leer el texto, a uno le parece que le estuvieran hablando de lo que sucede en un turno, o de lo que sucede con un paciente. es una experiencia real y conocerla te permite entender muchas cosas. normalmente uno se preocupa por llenarse de cosas y no centra la atención en lo que el paciente tiene para decir. también se realizaron cinco presentaciones en público sobre los resultados de este estudio para permitir que los pares enfermeros e investigadores hicieran críticas y sugerencias que luego se tuvieron en cuenta para enriquecer el análisis, lo que además ayudó a establecer la replicabilidad de la experiencia y la confiabilidad externa, así como también lo permitió la compatibilidad encontrada con otros estuen las entrevistas y el análisis se tuvo en cuenta el punto de vista de los participantes a quienes se les permitió “expresar su experiencia en su propio lenguaje para hacerla visible”. 219 hay que poner de su parte para afrontar una enfermedad grave l óscar alberto beltrán-salazar dios que se reportan en la discusión. en la presentación del texto, sobre el análisis se presenta una descripción y apego de los procedimientos propuestos para la toma, organización y análisis de la información (19), y se agregan apartes de la entrevista como evidencia de los aspectos planteados en la interpretación por parte del investigador. por consideraciones éticas se protegió la privacidad y la confidencialidad de la información y de los participantes evitando el uso de nombres propios e identificando cada entrevista con un número; cada uno de ellos expresó su deseo de participar libremente; no se realizaron intervenciones o procesos, relacionados con el estudio, diferentes a las entrevistas. resultados “poner de su parte” hace referencia a los medios personales y externos que los participantes utilizaron para aceptar la enfermedad, adaptarse a ella y atenuar su condición amenazante. el afrontamiento personal, la creencia religiosa y el apoyo de familiares, amigos, personas desconocidas y del equipo de enfermería fueron descritos como elementos de ayuda para el afrontamiento de la experiencia de una enfermedad crítica y la hospitalización en una uci: “pero yo creo que uno tiene que poner de su parte también uno mucho. considero que es parte del éxito del tratamiento que le están realizando”, e. 8. la forma de afrontar la realidad y las situaciones difíciles involucra un aprendizaje personal. en otras palabras, se puede decir que las personas afrontan cada situación de la manera como lo hayan hecho en el pasado, como les haya funcionado para resolver las crisis anteriores (20): “de pronto mi forma de ser y de afrontar las situaciones me ha ayudado mucho”, e. 8. cuando la situación que rodea a la enfermedad crítica sobrepasa las capacidades de los pacientes para hacerle frente, el afrontamiento dirigido al problema no es posible, porque el paciente no está en capacidad de modificar la enfermedad ni todo aquello que trae consigo para que deje de ser una experiencia amenazante. es por esto que sus esfuerzos se canalizan hacia la forma de afrontamiento dirigido a la emoción que la situación despierta (21): “hasta ahí me acuerdo. hay épocas de mi vida que quedaron totalmente borradas”, e. 1. la forma de afrontamiento dirigida hacia la emoción es útil en situaciones muy difíciles o irreversibles y no busca modificar la situación sino evitarla mediante el alejamiento ilusorio y mental, y se logra con algunos mecanismos psicológicos de defensa (4).uno de ellos es el “olvido inconsciente o represión” (2, 6), que es útil para aislar partes de una experiencia de la conciencia; ser sometido a algunas conductas terapéuticas como el uso de sedantes, anestésicos y analgésicos, además del compromiso de la enfermedad, favorecen el olvido. afrontar una enfermedad crítica significa olvidar: “se me borró el casete”, e. 2. la represión también despierta ansiedad y angustia por lo que se olvida y los pacientes responden a esto con sentimiento de pérdida. el olvido produce confusión e influye en los significados que los pacientes otorgan a una experiencia: “a mí me angustiaba que yo olvidé muchas cosas, nombres”, e. 2. el olvido voluntario o supresión (6) es otro mecanismo de afrontamiento dirigido “poner de su parte” hace referencia a los medios personales y externos que los participantes utilizaron para aceptar la enfermedad, adaptarse a ella y atenuar su condición amenazante. 220 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 a la emoción que despierta la experiencia, que los participantes utilizaron en la vivencia de la enfermedad crítica: “yo pienso que más que una droga fui yo misma la que olvidó muchas cosas, como si hubiera limpiado el disco duro y saqué infinidad de basura”, e. 1. tanto en la forma de represión como de supresión el olvido no abarca completamente una determinada situación o experiencia y los pacientes tuvieron recuerdos selectivos, de partes de la experiencia, no solo relacionados con aspectos agradables de la misma, sino también con partes consideradas como no agradables. fue posible recordar la cercanía de la muerte: “eso me parece a mí curioso, que haya olvidado muchas cosas de la vida real. sí, hubo un momento como un poquito lúgubre y fue un momento en que yo sentí que me despegaba de acá”, e. 1. aparte del olvido, los participantes también recurrieron a la disociación y a la inatención selectiva para separar partes de la situación de la realidad y de los sentimientos y las emociones asociados con ellas o al menos para no darse cuenta de ellas: “es que no me daba cuenta de donde estaba, no me di cuenta de nada”, e. 2. estos mecanismos de defensa permiten no poner atención en forma selectiva a aspectos de una experiencia que amenaza la seguridad (1, 6). ahora bien, aparte de los mecanismos de defensa, las alteraciones cognitivas y perceptuales debidas a la enfermedad también contribuyeron a que los pacientes no se dieran cuenta de partes de la experiencia o que se olvidaran de ella. enfermedades que se acompañan de alteraciones ácido básicas, déficit de perfusión y oxigenación del sistema nervioso central, cambios metabólicos y problemas infecciosos producen estados de confusión, amnesia y déficit en la atención, percepción y memoria reciente e incluso en la memoria remota. la ilusión y la fantasía (6) son otras formas de afrontamiento dirigidas hacia la emoción de la experiencia utilizadas por los pacientes y expresadas en el hecho de recurrir a pensamientos agradables para ayudarse durante el tiempo que vivieron la experiencia: “pensaba mucho en mi familia, en mi hijo”, e. 3. estas formas de afrontamiento son aprendidas por las personas en el diario vivir y las ponen en práctica cuando una situación difícil lo requiere: “¿cómo me ayudé? pensando que iba a salir en el futuro, pensando en el futuro. tengo muchas cosas que hacer y no pensaba que me iba a morir”, e. 6. de otro lado, conocer la situación en la cual la persona se encuentra significó estar tranquilo debido a que permitió establecer la importancia del evento vivido y otorgarle significados. el conocimiento favorece la movilización de los recursos personales para adaptarse a la situación y el afrontamiento dirigido hacia el problema. por tanto, otra forma de afrontamiento consistió en solicitar información respecto a la situación, a lo que ocurría y podría ocurrir o acerca de las cosas que producían inquietud: “lo primero que yo le pregunté al médico fue, ¿bueno, sus manos que tal son? y él me dijo que no había problemas y entré a cirugía tranquilo y desprevenido”, e. 7. entre las formas personales de afrontamiento los participantes utilizaron determinados comportamientos para evadirse la ilusión y la fantasía son otras formas de afrontamiento dirigidas hacia la emoción de la experiencia utilizadas por los pacientes y expresadas en el hecho de recurrir a pensamientos agradables para ayudarse durante el tiempo que vivieron la experiencia. 221 hay que poner de su parte para afrontar una enfermedad grave l óscar alberto beltrán-salazar de una situación difícil. ignorar la situación permitía el descanso, servía para no tener que escuchar frases estereotipadas de falsa seguridad como “todo está bien”, y no requerir actividades adicionales de valoración o intervención. es como decir que si no hay queja no hay intervención. según expresa berwick (22), “la visita de la enfermera aumenta el estrés en los pacientes”: “¿como me ayudaba? pensando allá, haciéndome la dormida para que no me jodieran. yo no estaba dormida totalmente, me hacía la dormida para que no me jodieran”, e. 6. la familia ayuda para el afrontamiento la presencia de la familia al lado de la cama en la uci fue identificada por los pacientes como parte de la terapia y una contribución para salir de la situación y recuperarse debido al apoyo emocional, físico y espiritual que proporciona: “el apoyo de la gente que está cercana a uno es también fundamental para recuperarse; sin eso yo creo que a los médicos se les haría más difícil o más demorado el proceso de recuperación de los pacientes”, e. 7. la compañía de la familia también significó tranquilidad, ayuda y ánimo en la angustia y en el estrés causados por el aislamiento, por la enfermedad e incluso por los efectos de la terapia: “ellos me ayudaron a aliviarme, porque me visitaban, me daban ánimos”, e. 3. en el esquema hospitalario actual las familias no ayudan a cuidar la parte física de los pacientes en la uci, debido a que no se les permite la realización de procedimientos de comodidad y aseo, que sí pueden realizar en otras áreas del hospital, a causa de la gravedad de la enfermedad y la presencia de múltiples tubos, catéteres y otros dispositivos; pero la familia sí participa activamente en el cuidado psicológico y espiritual: “la misma forma de acercamiento familiar me daba una paz, una tranquilidad”, e. 8. la familia significa una motivación importante para estimular en el paciente el deseo de participar en el tratamiento; la familia no solo ayuda en la recuperación sino que también se constituye en un motivo para recuperarse: “yo pensaba que me iba a recuperar por mi hijo”, e. 4. la enfermedad de uno de los miembros de la familia afecta la dinámica familiar, tanto en la familia nuclear como la extensa, especialmente cuando la duración de la enfermedad es prolongada (1). un evento de este tipo significa un motivo para que la unión familiar se afiance o se restablezca cuando se había perdido. hay cambios en las rutinas familiares para adaptarse a las necesidades del enfermo e incluso los miembros de la familia extensa, poco cercanos afectivamente a los pacientes, se involucran en el apoyo. también, las familias viven un proceso de organización para ofrecer el apoyo que incluye establecer cadenas de oración en las cuales a las oraciones se les atribuyen poderes curativos y se realizan como muestras de solidaridad y afecto: “todo el mundo iba a visitarme. fue una unidad, pues hicieron cadenas de oración y apoyaron mucho a mi familia”, e. 2. la participación del apoyo familiar como ayuda para el afrontamiento de una enfermedad ha sido descrita por diversos autores tales como del barrio (23) y casado (21), con base en estudios realizados previamente. pero a pesar de que existen la compañía de la familia también significó tranquilidad, ayuda y ánimo en la angustia y en el estrés causados por el aislamiento, por la enfermedad e incluso por los efectos de la terapia. 222 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 planteamientos teóricos acerca de la contribución de la familia al lado del paciente, existe en el medio hospitalario la tendencia a restringir su entrada a la uci. la presencia de la familia también significó estar emocionado. una participante relata el efecto de la presencia familiar durante una enfermedad: “mi esposo cuando llegaba a donde yo estaba, sin él tocarme, yo empezaba a mirar para arriba y para abajo y a los médicos les daba susto; yo me emocionaba de sentirlo”, e. 2. algunas restricciones en la compañía familiar son impuestas en la uci tomando como pretexto los efectos de esta emoción sentida por los pacientes sobre algunos sistemas corporales; se presenta inquietud acompañada de alteraciones de la frecuencia y el ritmo cardiaco y de la presión arterial sistólica durante los periodos de visita familiar, debido a la descarga adrenérgica que se presenta en los pacientes por el contacto o la cercanía de las personas que aman, que les despiertan emociones y han sido establecidos como motivos para justificar los “esquemas restrictivos”. de hecho, la compañía familiar estaba, en las instituciones en donde los participantes estuvieron hospitalizados, sometida a un esquema restrictivo, en el que algunas medidas de control al ingreso de personas son impuestas por la administración hospitalaria o por el equipo de salud presente en las uci: “la visita era permitida una vez al día, solamente dos personas, y generalmente entraba mi esposo o mis hermanas pero entraban todos desesperanzados, como asustados”, e. 6. sin embargo, la compañía familiar también significó angustia y contrariedad debido a las preguntas insistentes, relatos sobre los problemas que afectan a otros miembros de la familia y actitudes que reflejan angustia y lástima. los efectos no deseados de la visita familiar son planteados por travelbee (1) al expresar que “estar enfermo es esperar la visita familiar y cuando llegan, esperar que se vayan para poder descansar”: “había algo que me incomodaba muchísimo y era el hecho de que mucha gente entrara a visitarme; puede sonar paradójico pero a pesar de que yo quería sentir la presencia de mi familia me incomodaba mucha gente, y toda la gente preguntaba lo mismo”, e. 1. otras personas ayudan para el afrontamiento el apoyo de la familia en el afrontamiento del paciente es complementado por amigos, especialmente cuando han tenido experiencias semejantes, y algunas personas desconocidas, el cual significó recibir ánimo y compartir experiencias: “otra cosa que me ayudó mucho es que mis amigos me daban ánimo”, e. 7. los desconocidos son personas con experiencias similares de enfermedad o con inclinación religiosa que se organizan para ofrecer ayuda, consuelo y motivación mediante la práctica y creencia religiosa: “mucha gente allá hacían por uno y era gente que había estado en problemas graves de salud pasaban por las camas dando aliento a las personas; los grupos de oración, están por las habitaciones hablando con los pacientes y lo llaman a uno, inclusive por teléfono. es una labor bonita, con eso ayudan, por que uno se motiva”, e. 7. los enfermeros ayudan para el afrontamiento el cuidado de los enfermeros aportó en forma significativa para que los pacienel apoyo de la familia en el afrontamiento del paciente es complementado por amigos, especialmente cuando han tenido experiencias semejantes. 223 hay que poner de su parte para afrontar una enfermedad grave l óscar alberto beltrán-salazar tes pudieran salir de la crisis de la enfermedad y de la uci; dicho cuidado significó un acercamiento profundo y “un trato muy especial”, como expresó un participante, que se ofrece en condiciones de igualdad para todos los pacientes, aun cuando también es reconocido como una labor desarrollada bajo condiciones difíciles; también significó ánimo, ayuda, apoyo irreemplazables y estar pendiente de los pacientes: “las enfermeras divinas, yo pienso que ellas fueron un apoyo muy grande porque me dieron ánimo”, e. 1. el apoyo de enfermería también significó recibir un cuidado de personas queridas, atentas, cuidadosas: “las enfermeras, un personal increíble, muy atento, muy cuidadoso, muy pendiente del paciente”, e. 8. “las enfermeras fueron muy especiales conmigo”, e. 3. en contraste, la participación de enfermería también es vista desde la óptica que le atribuye la característica de la práctica de “no cuidado” como lo plantea watson (24), que no contribuye al bienestar de los pacientes. el cuidado involucra la realización de prácticas y procedimientos que son dolorosos y molestos para los pacientes, pero que cuando son realizados en medio de las mejores condiciones de diálogo, explicación y afecto son mejor tolerados y aceptados por los pacientes: “a las de enfermería no les importa que uno esté incómodo, les importa que uno esté bien monitoreado y ya; ellas entran sonrientes y le preguntan a uno ¿cómo se siente?, pero no esperan la respuesta e inmediatamente le dicen a uno que todo va a salir bien; lo más traumático para mí, la hora del baño porque ser tratada como un pollo, quedabas empapado e indispuesto”, e 6. la religión como apoyo para el afrontamiento el apoyo religioso es una forma de apoyo social que los pacientes utilizaron durante la vivencia de la enfermedad para afrontarla, superarla o adaptarse a ella. la creencia religiosa significó ayuda, compañía: “el que tiene fe y cree en un señor superior o en una fuerza superior tiene más posibilidades de recuperarse más rápido, en esa época me volví más apegado a dios”, e. 7. la intervención del ser supremo aceptado por cada una de las personas en la práctica religiosa es una explicación suficiente para curarse de una enfermedad o para que una enfermedad sea aceptada: “¡está muy bien, supremamente bien, esto es un milagro! ellos decían”, e. 2. al respecto, travelbee (1) afirma que “las creencias religiosas favorecen la aceptación de la enfermedad como parte de la vida e incluso ayudan a ver el sufrimiento como un mérito”. los pacientes utilizaron formas de práctica religiosa organizada que ofrecen diversos medios de sanación y que incluso tienen mediadores que ponen sus habilidades a disposición de otros para la curación mediante la creencia religiosa: “tenía una hermana religiosa que me visitaba todos los días. el capellán del hospital también pasaba a saludar; una señora que tiene algunos poderes de sanación y yo hacíamos oración”, e. 7. la creencia y la práctica religiosa son formas muy difundidas de afrontamiento, independientemente de la religión que se practique, que fueron reportadas por del barrio y cols. (23, 24) y planteadas por lazarous (2). sin embargo, travelbee (1) el cuidado involucra la realización de prácticas y procedimientos que son dolorosos y molestos para los pacientes, pero que cuando son realizados en medio de las mejores condiciones de diálogo, explicación y afecto son mejor tolerados y aceptados por los pacientes. 224 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 plantea que un individuo que no esté acostumbrado a practicar una determinada religión difícilmente logra la creencia religiosa suficientemente fuerte para afrontar la enfermedad y con frecuencia el interés religioso disminuye con la recuperación. discusión vivir la experiencia de padecer una enfermedad grave significó para los participantes “poner de su parte” para adaptarse a la situación y para superarla; “adaptarse a una nueva vida”, afirma bellido (25), para lo cual toman algunos recursos personales internos y de algunas formas de apoyo social disponibles entre los cuales se mencionó el apoyo de la familia, de los enfermeros, de amigos, de personas conocidas e incluso desconocidas, y la creencia religiosa. recurrir al apoyo de la familia y el cuidado brindado por parte de personal de enfermería es un hallazgo reportado en un estudio fenomenológico realizado por del barrio y cols. (23), quienes informaron que los pacientes críticos encontraban apoyo en sus familias, creencias religiosas y en el cuidado enfermero debido a la alegría que proporcionaban con sus visitas y porque transmitían consuelo, tranquilidad y optimismo. los pacientes no se dieron cuenta o no recordaron partes de la experiencia porque utilizaron mecanismos de defensa como la supresión o la represión, o debido a las alteraciones cognitivas, preceptuales y de memoria causadas por la enfermedad y la administración de sedantes, analgésicos y anestésicos. estos hallazgos coinciden con lo reportado por granja y colaboradores (26) al estudiar el efecto de la experiencia de estar en cuidado intensivo sobre la calidad de vida; estos autores encontraron que la mayoría de los pacientes no eran conscientes de su condición hasta varios días después de estar en la uci y aún después de salir de ella; el 45% de los pacientes reportaron amnesia de la admisión y el 38% amnesia de toda la hospitalización. en otros estudios anteriores se reportó, a parte de la negación, “la minimización, el escape y la evitación de la situación, la resignación y la autojustificación” (23, 25, 27, 28, 29, 30). además, tener suficiente información también contribuyó a la tranquilidad y al bienestar de los pacientes; sin embargo, en contraste, algunos estudios reportan que “la información recibida es escasa y poco comprensible” (31, 32), y en estas condiciones, el desconocimiento de la situación “aumenta el estrés y la preocupación, lo cual influye negativamente en la forma de afrontar la enfermedad” (30). uno de los pacientes dijo que para evitar el estrés e intervenciones adicionales de los diferentes miembros del equipo de enfermería se mostró indiferente o aparentó estar dormida y no escuchar. la contribución de la familia en la recuperación del paciente fue exaltada por algunos de ellos; preocupados por el cuidado al enfermo, los familiares sufren alteraciones en su proceso de funcionamiento diario como familia y se constituyen en una red de apoyo que involucra a otras personas tanto conocidas como desconocidas que también ofrecen su participación espiritual mediante oraciones y súplicas en búsqueda de la mejoría del ser querido (33). cambios en las constantes vitales y estados de inquietud son efectos que se han observado en los pacientes a causa de la presencia de la familia en la cabecera de la cama. este tipo de cambios los pacientes no se dieron cuenta o no recordaron partes de la experiencia porque utilizaron mecanismos de defensa como la supresión o la represión, o debido a las alteraciones cognitivas, preceptuales y de memoria causadas por la enfermedad y la administración de sedantes, analgésicos y anestésicos. 225 hay que poner de su parte para afrontar una enfermedad grave l óscar alberto beltrán-salazar fueron explicados por uno de los participantes como causados por la emoción que despiertan en ellos sus familiares y allegados, lo cual no debería ser motivo para restringir la visita familiar. respecto a la restricción de la visita berwick (22) expresa que “no es cuidado, no demuestra compasión y no es necesaria”, y que el esquema restrictivo de visitas fue impuesto en los hospitales desde hace varios años basado en la pretensión de reducir en el paciente el estrés fisiológico atribuido a la presencia de la familia al lado de la cama, para controlar las interferencias en el cuidado reportadas especialmente por el personal de enfermería, y para prevenir el cansancio físico y mental en el paciente y la familia. sin embargo, en contra de estos argumentos, el mismo autor afirma, y fue corroborado en este estudio, que la visita familiar calma la angustia del paciente, de los familiares y amigos; además, contribuye a aliviarlo, apoya en la estimulación sensorial, lo ayuda a familiarizarse con el ambiente en la uci, y se reportan datos para la historia clínica cuando el paciente no puede hacerlo. diversos estudios han mostrado que las familias rechazan las restricciones a la visita por la incertidumbre que genera la falta de información a cerca de la situación y el alejamiento de su ser querido (25, 27, 31, 32, 34, 35, 36). los enfermeros también fueron identificados como una ayuda irreemplazable para resolver la situación porque daban apoyo, estaban pendientes de lo que se necesitaba y participaron en la resolución de los problemas. estos hallazgos están de acuerdo con lo expresado por benner (37), quien afirma que “la práctica de enfermería permite que el profesional entable una relación curativa con el paciente, en la cual se dé la creación de un clima que favorezca y consolide su recuperación”. la realización de prácticas y procedimientos que son dolorosos y molestos está a menudo involucrada en el cuidado de enfermería, especialmente cuando se padece una enfermedad grave (38); si son llevados a cabo en medio de las mejores condiciones de diálogo, explicación y afecto se puede lograr una mejor tolerancia física y psicológica y la aceptación por parte de los pacientes. el cuidado enfermero fue identificado como una contribución importante para la recuperación, hallazgos que coinciden con lo encontrado en otros estudios en los cuales los paciente “resaltan la delicadeza, la amabilidad y la humanidad mostrada por las enfermeras” (23, 35, 39). la creencia religiosa también fue útil para aceptar y explicar los hechos relacionados con la experiencia de la enfermedad. como pudo verse en los resultados, la intervención de un ser supremo aceptado por cada una de las personas en la práctica religiosa es una explicación suficiente para salir de la situación y curarse de la enfermedad, o para que la enfermedad sea aceptada. algunos estudios reportan que “la creencia religiosa proporciona confort y una ayuda para transitar este proceso” (23, 29, 30, 34, 36). pero “más allá de un sentimiento religioso”, se reportó “un componente espiritual, común a todos los seres humanos” (34). conclusión los medios internos y externos que los participantes utilizaron para afrontar la experiencia de la enfermedad y adaptarse a ella estuvieron relacionados con las habilidades de afrontamiento personal, la ayuda de familiares y amigos, del equipo de enfermería y la creencia religiosa. tener especial consideración sobre el temor, la ansiedad y la sensación de soledad y desamparo a los cuales pueden estar expuestos los pacientes se convierte en un mandato y por lo tanto también el ofrecer apoyo y compañía. 226 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 para contribuir a que los recursos personales apunten a favorecer la adaptación y el afrontamiento de la experiencia los enfermeros deben ayudar a los pacientes en el logro del contacto con la realidad, ofrecer explicaciones e informaciones claras y oportunas, y brindar un cuidado de enfermería enmarcado en claras disposiciones de la disciplina. tener especial consideración sobre el temor, la ansiedad y la sensación de soledad y desamparo a los cuales pueden estar expuestos los pacientes se convierte en un mandato y por lo tanto también el ofrecer apoyo y compañía. en ese mismo sentido se plantea la necesidad de revisar los esquemas restrictivos de visita vigentes, que al contrario de permitir la compañía y el apoyo familiar lo restringen favoreciendo la soledad y el aislamiento. debido a dichas restricciones de la visita familiar a los pacientes críticos impuestas por la administración hospitalaria en nuestro medio, y considerando los efectos de dicha visita reportados por los pacientes, se sugiere realizar cambios al respecto para que sea más amable y no un obstáculo para la contribución de la familia a evitar los sentimientos de soledad que junto con la tristeza y otras emociones que despierta la experiencia de estar enfermo y que contribuyen al sufrimiento psicológico. para favorecer la ubicación de los pacientes en la realidad son imprescindibles el diálogo, la explicación y la compañía familiar. referencias bibliográficas 1. travelbee j. interpersonal aspects of nursing. philadelphia: fa davis company; 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cuya fase de recolección se realizó entre enero y julio de 2009; preliminarmente se presentan resultados relativos al estilo de vida. se aplicó una cédula de datos personales y se realizaron mediciones antropométricas. para el análisis estadístico se utilizaron medidas de tendencia central y se construyeron modelos de regresión lineal múltiple. resultados: las mayores proporciones tanto del grupo de hombres como del de mujeres, señalaron no fumar, ni realizar algún deporte o ejercicio. en el caso del consumo de alcohol, la mayor proporción del grupo de hombres dijo consumirlo. los modelos de regresión mostraron que en el total del grupo, así como en el grupo de mujeres, las variables tabaco y ejercicio influyeron en el imc de los participantes, ya que tuvieron efecto en el modelo de regresión. dichas variables se correlacionaron significativa e inversamente con el imc, lo que particularmente llamó la atención en el caso del tabaco. discusión: el estudio muestra que el estilo de vida influye de manera importante en el imc de esta población de adultos. palabras clave estilo de vida, índice de masa corporal, obesidad. (fuente: decs, bireme). lifestyle and body mass index of an adult population in southern tamaulipas, mexico abstract obesity is a multifactor disease involving genetic and environmental aspects. objective: assess the influence of lifestyle on the body mass index (bmi) of an adult population. method: this descriptive study is derived from a project entitled the eating habits and body composition of overweight and obese adults. the data collection phase was from january to july 2009, and the preliminary results are año 10 vol. 10 nº 3 chía, colombia diciembre 2010 l 244-252 245 estilo de vida e índice de masa corporal de una población de adultos del sur de tamaulipas, méxico l eunice reséndiz, paulina aguilera, martha elia rocher related to lifestyle. a format for collecting personal data was applied and anthropometric measurements were taken. for the statistical analysis, central tendency measurements were used and multiple linear regression models were constructed. results: the largest proportions of both groups men and women indicated they neither smoke, nor practice sports or exercise. in the case of alcohol consumption, the largest proportion of the male group indicated alcohol consumption. the regression models showed that, in the group of participants as a whole and in the female group, the tobacco and exercise variables influenced the bmi, inasmuch as they had an effect on the regression model. these variables were significant and inversely correlated with the bmi, particularly in the case of tobacco. discussion: the study shows that lifestyle plays an important role in the bmi of the adult population. key words lifestyle, body mass index (bmi), obesity. (source: decs, bireme). estilo de vida e índice de massa corporal de uma população adulta no sul de tamaulipas, méxico resumo a obesidade é uma doença multifatorial que envolve aspectos genéticos e ambientais. objetivo: avaliar a influência do estilo de vida sobre o índice de massa corporal de uma população adulta. método: estudo descritivo transversal derivado do projeto "hábitos alimentares e composição corporal de adultos com sobrepeso e obesidade", cuja fase de coleta foi realizada entre janeiro e julho de 2009. os resultados preliminares estão relacionados ao estilo de vida. se registraram os dados pessoais e as medidas antropométricas. a análise estatística utilizou medidas de tendência central e construiu vários modelos de regressão linear. resultados: a maioria de ambos os grupos de homens e mulheres disse não fumar nem praticar esportes ou exercícios. a maior proporção de homens consume álcool. os modelos de regressão mostraram que, na totalidade do grupo e no grupo de mulheres as variáveis cigarro e exercício influenciaram o imc dos participantes, posto que tiveram efeito sobre o modelo de regressão. essas variáveis se correlacionaram significativamente e inversamente com o imc, o que chamou a atenção em especial no caso do cigarro. discussão: o estudo mostra que o estilo de vida desempenha um papel importante no imc desta população adulta. palavras-chave estilo de vida, índice de massa corporal, obesidade. (fonte: decs, bireme). 246 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 introducción la obesidad es una enfermedad de etiología multifactorial de curso crónico en la cual se consideran aspectos genéticos y ambientales que conducen a un trastorno metabólico. esta enfermedad constituye el principal factor de riesgo para el desarrollo de diabetes tipo 2, enfermedades cardiovasculares, hipertensión arterial, dislipidemias, padecimientos cerebro-vasculares, osteoarticulares y algunos tipos de cáncer (1). se reconoce que aunque en los determinantes de la obesidad actúan factores genéticos, ésta es producida fundamentalmente por factores ambientales como el desequilibrio entre el ingreso y el gasto de energía. el 95% de los casos de obesidad tienen en su desarrollo un claro componente ambiental vinculado al sedentarismo y a malos hábitos alimentarios (2). existe literatura que reporta asociación positiva del índice de masa corporal (imc) con el sedentarismo, o bien, asociaciones inversas con la práctica de ejercicio (3, 4, 5). así como también se observa un aumento lineal del imc y la prevalencia de sobrepeso, con el consumo de alcohol (5, 6). en méxico, datos recientes publicados en la encuesta nacional de salud y nutrición 2006 (ensanut) (7), reportaron una prevalencia de obesidad en las mujeres del 34,5% y del 24,2% en los hombres; mientras que en relación al sobrepeso, éste se presentó en el 42,5% de los hombres y 37,4% de las mujeres. es así que el 71,9% de las mujeres y 66,7% de los hombres tuvieron prevalencias combinadas de sobrepeso-obesidad. en el caso del estado mexicano de tamaulipas, la ensanut 2006 (8), informó que el 73% de los adultos presenta una prevalencia combinada de sobrepeso-obesidad (72,6% para mujeres y 73,6% para hombres), lo que implica que dichas prevalencias se ubican discretamente por arriba del promedio nacional. solamente el 25,1% de los adultos tuvo un peso adecuado. en lo concerniente al estilo de vida, la ensanut 2006 (7) dio a conocer que en méxico la cantidad de hombres que fuman es tres veces mayor a la de las mujeres, independientemente de la edad. además, se observó un incremento en la proporción de mujeres que fuman al comparar la población por grupo de edad entre la encuesta nacional de salud 2000 (ensa) (9) y la ensanut-2006 (7). así por ejemplo, en las mujeres del grupo de 20 a 29 años, la proporción aumentó de 8,4 a 10,7%; en el de 50 a 59 años, de 9,4 a 10,1%, y en el de 70 a 79 años, de 5 a 6,3%. por otra parte, el consumo de alcohol entre los hombres también resultó mayor casi tres veces al consumo por parte de las mujeres. se observó que en el grupo de 20 a 29 años, 60% de los hombres consumían bebidas alcohólicas al menos una vez al mes, cinco o más copas; mientras que poco más de 20% de las mujeres refirieron el mismo consumo. en ambos sexos, el porcentaje de personas que consume alcohol fue disminuyendo conforme el grupo de edad era mayor. sin embargo, no se exploró relación entre estas variables del estilo de vida con el imc o con las prevalencias de sobrepeso y obesidad. al hacer una búsqueda de literatura en el país sobre la relación de variables de estilo de vida con índice de masa corporal, o de su influencia sobre éste, se encontró que existe limitada información al respecto. dado que el sobrepeso y la obesidad constituyen un prola obesidad es una enfermedad de etiología multifactorial de curso crónico en la cual se consideran aspectos genéticos y ambientales que conducen a un trastorno metabólico. 247 estilo de vida e índice de masa corporal de una población de adultos del sur de tamaulipas, méxico l eunice reséndiz, paulina aguilera, martha elia rocher blema de salud pública para la población adulta, el presente estudio buscó valorar la influencia del estilo de vida (considerando el consumo de alcohol, tabaco y ejercicio) en el índice de masa corporal de los participantes. lo anterior contribuirá de manera importante en la disciplina de enfermería al evaluar las conductas del estilo de vida que influyen en el imc, conocimiento que permitirá orientar los contenidos de futuras intervenciones con énfasis en la prevención del sobrepeso y la obesidad. objetivo. valorar la influencia del estilo de vida en el índice de masa corporal de una población de adultos. materiales y métodos diseño. el diseño fue de tipo descriptivo transversal. población. la población estuvo integrada por adultos que vivían en tampico, tamaulipas, méxico, en un área geoestadística básica (ageb) de la zona de influencia de una institución de salud de primer nivel de atención. la ageb seleccionada contaba con 701 casas habitadas. muestreo y muestra. el presente trabajo se deriva del proyecto uatexb-200: hábitos alimentarios y composición corporal de adultos con sobrepeso y obesidad, en el cual se utilizó un muestreo por conglomerados unietápico; en dicho proyecto la muestra se calculó utilizando el programa nquery advisor 4.0, se estimó para un 95% de nivel de confianza, potencia del 80% y para un análisis de correlación un coeficiente de ,25. el tamaño muestral fue de 196 conglomerados. la recolección de datos se llevó a cabo de enero a julio del 2009. criterios de elegibilidad. se incluyeron participantes de ambos sexos, con una edad de entre 20 a 59 años. se excluyeron personas con diagnóstico médico previo de diabetes mellitus, hipotiroidismo, hipertiroidismo, síndrome de cushing, mujeres embarazadas y personas con alguna discapacidad física que les impidiera mantenerse en pie o subirse al instrumento de medición utilizado. mediciones. se utilizó una cédula de datos personales para obtener información sociodemográfica y de estilo de vida de los participantes, como: sexo, edad, estado civil, escolaridad, tabaquismo (frecuencia y cantidad), práctica de deporte o ejercicio (tipo, frecuencia y cantidad) y consumo de bebidas alcohólicas (frecuencia). además, se realizaron mediciones antropométricas (peso, estatura) y se calculó imc (peso en kilogramos entre la estatura en metros al cuadrado). la estatura se midió con el estadímetro portátil marca seca, modelo 225, el cual cuenta con un rango de medición de 6 a 230 cm y una precisión de 1 mm. la circunferencia de cintura fue medida con una cinta métrica de fibra de vidrio, con enrollado automático marca seca, modelo 201, con un alcance de medición de 15 a 205 cm y precisión de 1 mm. finalmente, para el peso se utilizó una báscula tanita, modelo bc-554. para clasificar el imc de los participantes se utilizaron los criterios establecidos por la organización mundial de la salud (oms) (10). análisis. los datos fueron analizados con estadística descriptiva (medidas de tendencia central), y se construyeron modelos de regresión lineal múltiple tanto para el total de la muestra, como para el grupo de hombres y el de mujeres; las variables independientes incluidas en los modelos de regresión fueron: consumo de alcohol, tabaquismo y ejercicio. en méxico, datos recientes publicados en la encuesta nacional de salud y nutrición 2006 (ensanut), reportaron una prevalencia de obesidad en las mujeres del 34,5% y del 24,2% en los hombres; mientras que en relación al sobrepeso, éste se presentó en el 42,5% de los hombres y 37,4% de las mujeres. 248 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 resultados dado que seis conglomerados no reunieron criterios de inclusión, se presentan resultados provenientes de 190 conglomerados; el número de participantes fue de 207. del total de la muestra, como fue reportado por reséndiz et ál. (11), el 86% fueron de sexo femenino y el 60% refirieron estar casados. la edad promedio de los participantes fue de 38 años (sd = 10,6; 20-59) y una escolaridad de 12 años de estudio (sd = 4,55; 0-25). con respecto al índice de masa corporal, en el total del grupo se observó una prevalencia combinada de sobrepeso-obesidad de 71,5%. al ser divididos por sexo, los hombres tuvieron un imc promedio de 28,9 kg/m2 y las mujeres de 28,8 kg/m2. en la gráfica 1 se describen las prevalencias de sobrepeso y obesidad en hombres y mujeres. las categorías de obesidad grado i, grado ii y grado ii, fueron reagrupadas en una sola, a la cual se le denominó “obesidad”. gráfica 1. prevalencias de sobrepeso y obesidad, por sexo en cuanto a las variables de estilo de vida, en el grupo de hombres (n = 29) el 59% dijo no practicar ningún deporte o ejercicio; quienes sí refirieron practicarlo, señalaron con mayor frecuencia el fútbol; el promedio de duración del deporte en el grupo fue de 100 minutos por semana (sd = 154,9; 0-630). el 55% de los hombres refirió sí consumir bebidas alcohólicas, el promedio de frecuencia en el consumo fue de 25 veces al año (sd = 41,4; 0-156); por último, en cuanto al consumo de tabaco, se estimó un consumo promedio de 7 cigarrillos por semana (sd = 16,4; 0-70); sin embargo, la mayor proporción de hombres (76%) refirió no fumar. por su parte, en el grupo de mujeres (n = 178), el 73% dijo no practicar ningún deporte o ejercicio; entre quieres sí lo hacían, señalaron con mayor frecuencia hacer caminata o aerobicos. el promedio de duración del deporte en el grupo de mujeres fue de 61 minutos por semana (sd = 128,9; 0-900). además, el 35% señaló consumir bebidas alcohólicas. en el grupo, el promedio de frecuencia en el consumo fue de 7 veces al año (sd = 19,6; 0-156); finalmente, con respecto al tabaquismo, se estimó un consumo promedio de 4 cigarrillos a la semana (sd = 17,4; 0-140). sin embargo, la mayor proporción de mujeres (82%) señalaron no fumar. para valorar si el estilo de vida (consumo de alcohol, tabaco y ejercicio) tenía efecto en el índice de masa corporal de los participantes, se construyeron modelos de regresión lineal múltiple, tanto en el grupo de hombres como en el de mujeres. específicamente en el grupo de hombres el modelo total no fue significativo, y ninguna de las variables introducidas mostró tener efecto o influencia sobre el imc. esta situación se presentó de manera diferente en el grupo de mujeres, los resultados se muestran en las tablas 1 y 2. e da d 249 estilo de vida e índice de masa corporal de una población de adultos del sur de tamaulipas, méxico l eunice reséndiz, paulina aguilera, martha elia rocher en el grupo de mujeres se observó que el modelo total fue significativo, con una varianza explicada del 7,4%. al valorarse el peso que tuvo cada una de las variables en el modelo total, se determinó que aquellas que tuvieron efecto en imc fueron el tabaco y el ejercicio. paralelamente, se revisaron las correlaciones de las variables de estilo de vida con el imc; se observó que todas se asociaban inversa y significativamente, lo cual se describe a continuación: consumo de alcohol e imc (r = -,153, p = ,020), tabaco e imc (r = -,163, p = ,015), deporte e imc (r = -,170, p = ,012). posteriormente, se construyó otro modelo de regresión introduciendo las mismas variables, pero se hizo considerando el total de la muestra; se observó que el modelo era significativo (f [3, 203] = 4.644, p = ,004) con una varianza explicada del 6,4%, y de igual manera las variables que tuvieron efecto en el imc fueron el tabaco y el ejercicio. también se presentaron asociaciones inversas y significativas entre el imc y el tabaco (r = -,154, p = ,013) y el imc y el ejercicio (r = -,187, p = ,003). discusión el estudio mostró una alta prevalencia de sobrepeso y obesidad en esta población de adultos, información que fue consistente con lo reportado a nivel nacional y estatal por la ensanut-2006 (7, 8). a diferencia de lo reportado en esas encuestas, en este grupo de adultos nadie clasificó en el rango de bajo peso; sin embargo, este dato fue consistente con los resultados de luján-méndez (12) en una población de trabajadores del área de la salud. otro dato que llamó la atención fue que se presentó tabla 1. modelo de regresión lineal múltiple para las variables consumo de alcohol, tabaco y ejercicio, del grupo de mujeres variable dependiente: índice de masa corporal n = 178 fuente: cédula de datos personales. modelo sc gl cuadrado f valor de la media p regresión 396.406 3 132.135 4.638 ,004 residual 4956.975 174 28.488 total 5353.381 177 r 2 = ,074 n = 178 variable dependiente: índice de masa corporal fuente: cédula de datos personales. tabla 2. efecto del consumo de alcohol, tabaco y ejercicio sobre el imc, del grupo de mujeres modelo ee ß t valor de p alcohol ,021 -,128 -1,749 ,082 tabaco ,023 -,163 -2,225 ,027 ejercicio ,003 -,164 -2,228 ,027 se presentó una prevalencia más alta de sobrepeso en el grupo de mujeres que en el de hombres, lo cual difirió a lo encontrado en otras investigaciones en donde los hombres han sido los que presentan las prevalencias más altas de sobrepeso. 250 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 una prevalencia más alta de sobrepeso en el grupo de mujeres que en el de hombres, lo cual difirió a lo encontrado en otras investigaciones en donde los hombres han sido los que presentan las prevalencias más altas de sobrepeso (7, 9, 13, 14). es notorio que tanto hombres como mujeres, se encuentran con un riesgo aumentado para desarrollar complicaciones metabólicas y cardiovasculares (1). en cuanto al estilo de vida proporciones muy altas, tanto de hombres como de mujeres, refirieron no practicar ningún deporte o ejercicio; además, los hombres refirieron con mayor frecuencia consumir bebidas alcohólicas; estos aspectos del estilo de vida, aunados al sobrepeso y la obesidad, son factores de riesgo para el desarrollo de enfermedades crónicas como la diabetes mellitus, enfermedad que infortunadamente en méxico se encuentra entre los primeros lugares como causa de mortalidad general entre la población (15, 16). para valorar la influencia del estilo de vida en el imc se construyeron modelos de regresión múltiple, los cuales en el grupo de las mujeres y en el grupo del total de la muestra dejaron ver que las variables que tuvieron efecto sobre el imc fueron el tabaquismo y el ejercicio. cabe señalar que no hay un consenso claro sobre la relación entre el consumo de tabaco y alcohol con la obesidad, o con el imc (5). en el presente estudio el tabaco tuvo efecto sobre el imc, presentándose una relación inversa entre las variables, lo cual difirió a lo reportado por rodríguezmartín et ál. (5), en donde no se observó asociación entre el imc y el ser fumador o no serlo; sin embargo, la relación encontrada en el presente estudio puede ser consistente con lo reportado en una población de la india (17), en donde el consumo de diferentes formas de tabaco se relacionó con los niveles más bajos del imc; pero debe considerarse que en este país las prevalencias de niveles bajos de imc son altas. en cuanto al efecto que se observó del ejercicio sobre el imc, este mostró una asociación inversa entre las variables; estos datos son consistentes con lo reportado en otras investigaciones (4, 5), y tiene congruencia en el sentido de que también se han reportado relaciones positivas entre el imc y el sedentarismo (3). finalmente, a pesar de que en este estudio la frecuencia en el consumo de alcohol no tuvo efecto sobre el imc, hubo consistencia con otros estudios (5, 7) en el sentido de que el grupo de hombres presentó una mayor proporción de participantes que refirieron sí consumir bebidas alcohólicas en comparación con las mujeres. es indudable que el estilo de vida tiene un impacto importante en la salud de los adultos; infortunadamente, en la actualidad se observa la tendencia a la adopción de estilos de vida no saludables, situación a la cual no escapa la población adulta mexicana, y es probable que como consecuencia de esto estén aumentando las prevalencias de enfermedades crónicas. como se señaló, los resultados de este estudio mostraron prevalencias muy altas de sobrepeso-obesidad y sedentarismo entre la población, lo cual denota un estilo de vida no saludable, dato que se observa de manera similar en resultados de otras investigaciones (12, 18, 19, 20). se considera importante que en méxico se continúe explorando la influencia y las relaciones del estilo de vida sobre el índice de masa corporal. agradecimientos las autoras agradecen al programa del mejoramiento del profesorado (promep) de la secretaría de educación pública de méxico, por el financiamiento otorgado al proyecto uat exb-200, del cual se deriva el presente trabajo. 251 estilo de vida e índice de masa corporal de una población de adultos del sur de tamaulipas, méxico l eunice reséndiz, paulina aguilera, martha elia rocher referencias bibliográficas 1. barquera-f s, barquera s, garcía e, gonzález-villalpando c, hernández-a m, lonngi g et ál. obesidad en el adulto (e66*). práctica médica efectiva 2003; 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30 (10): 2690-2694. 7. olaiz-fernández g, rivera-dommarco j, shamahlevy t, rojas r, villalpando-hernández s, hernández-ávila m et ál., editores. encuesta nacional de salud y nutrición 2006. cuernavaca, méxico: instituto nacional de salud pública; 2006. 8. instituto nacional de salud pública. encuesta nacional de salud y nutrición 2006. resultados por entidad federativa, tamaulipas. cuernavaca, méxico: instituto nacional de salud pública-secretaría de salud; 2007. 9. olaiz g, rojas r, barquera s, shamah t, aguilar c, cravioto p et ál., editores. encuesta nacional de salud 2000. tomo 2. la salud de los adultos. cuernavaca, morelos, méxico: instituto nacional de salud pública; 2003. 10. organización mundial de la salud. obesity: preventing and managing the global epidemic. report of a who consultation. geneva, switzerland: world health organization; 2000 (who technical report series, no. 894). 11. reséndiz e, aguilera p, del angel e, rocher me, flores f, compeán lg et ál. prevalencia de sobrepesoobesidad en una población de adultos de tampico, tamaulipas: resultados preliminares proyecto uat-exb-200. foro internacional de investigación en enfermería; 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2 (1): 18-20. 1 sandra patricia moreno reyes1 freiser eceomo cruz mosquera2 paola andrea calvo bolaños3 ángela mayerly cubides munevar4 maría cristina tenorio5 diana patricia jiménez durán6 prevalencia y posibles factores asociados al consumo tabáquico en adolescentes escolarizados* 1 https://orcid.org/0000-0001-6790-8644. universidad santiago de cali, colombia. sandra.moreno04@usc.edu.co 2 https://orcid.org/0000-0001-7584-4636. universidad santiago de cali, colombia. freiser.cruz00@usc.edu.co 3 https://orcid.org/0000-0003-1342-9554. universidad santiago de cali, colombia. paola.calvo00@usc.edu.co 4 https://orcid.org/0000-0002-3590-8954. universidad san martin, colombia. angela.cubides00@usc.edu.co 5 https://orcid.org/0000-0002-0144-8144. universidad santiago de cali, colombia. mtenorio00@usc.edu.co 6 https://orcid.org/0000-0001-8738-1552. universidad santiago de cali, colombia. diana.jimenez01@usc.edu.co * artículo producto de un proyecto financiado por la universidad santiago de cali, colombia; proyecto número 450-62118-215. recibido: 29/08/2019 enviado a pares: 06/11/2020 aceptado por pares: 16/01/2020 aprobado: 29/01/2020 doi: 10.5294/aqui.2020.20.1.3 para citar este artículo / to reference this article / para citar este artigo moreno sp, cruz fe, calvo pa, cubides am, tenorio mc, jiménez dp. prevalencia y posibles factores asociados al consumo tabáquico en adolescentes escolarizados. aquichan. 2020;20(1):e2013. doi: https://doi.org/10.5294/aqui.2020.20.1.3 resumen objetivo: estimar la prevalencia del consumo de tabaco y los factores asociados a esta práctica en adolecentes de instituciones educativas oficiales del municipio de palmira. métodos: estudio transversal con un componente analítico, que incluyó 205 estudiantes de bachillerato de seis colegios oficiales. el análisis se realizó con el programa estadístico spss versión 24. las variables cualitativas se expresaron como proporciones, con sus respectivos intervalos de confianza (ic) al 95 %; y las variables cuantitativas como medidas de tendencia central y dispersión, según la distribución de la variable. para los factores asociados, se calcularon odds ratio con su ic al 95 %, y el ajuste de variables se realizó a través de regresión logística binaria. resultados: la prevalencia global del consumo tabáquico fue del 38.5 %, ic 95 % (31.6-45.4 %); cigarrillo electrónico, del 20 %, ic 95 % (14.2-25.7 %); cigarrillo, del 18.5 %, ic 95 % (12.9-24.1 %); y año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2013 temática: promoción y prevención. contribución a la disciplina: los hallazgos encontrados en la presente investigación son de suma importancia en materia de salud pública, dado que demuestran la frecuencia y la distribución de un evento de interés en dicha área, como el tabaquismo en adolescentes. resultados como el uso habitual de productos tabáquicos nuevos en el mercado colombiano (cigarrillo electrónico) y una mayor frecuencia de su uso por parte de las mujeres reflejan claros cambios en el patrón de consumo descrito hasta hace pocos años y exigen reforzar las estrategias de prevención y la regulación del expendio de dispositivos como el cigarrillo electrónico. https://orcid.org/0000-0001-6790-8644 mailto:sandra.moreno04%40usc.edu.co?subject= https://orcid.org/0000-0001-7584-4636 mailto:freiser.cruz00%40usc.edu.co?subject= https://orcid.org/0000-0003-1342-9554 mailto:paola.calvo00%40usc.edu.co?subject= https://orcid.org/0000-0002-3590-8954 mailto:angela.cubides00%40usc.edu.co?subject= https://orcid.org/0000-0002-0144-8144 mailto:mtenorio00%40usc.edu.co?subject= https://orcid.org/0000-0001-8738-1552 mailto:diana.jimenez01%40usc.edu.co?subject= https://doi.org/10.5294/aqui.2020.20.1.3 https://orcid.org/0000-0001-6790-8644 https://orcid.org/0000-0001-7584-4636 https://orcid.org/0000-0003-1342-9554 https://orcid.org/0000-0002-3590-8954 https://orcid.org/0000-0002-0144-8144 https://orcid.org/0000-0001-8738-1552 https://doi.org/10.5294/aqui.2020.20.1.3 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2013 narguile, del 17.9 %, ic 95 % (12.1-23 %), con más frecuencia en mujeres que en hombres. los factores asociados fueron la edad (or 3.17, ic 95 % [1.48-6.79]), tener novio que consuma tabaco (or 2.51, ic 95 % (1.36-4.63 %), estar rodeado de amigos que fumen (or 7.0, ic 95 % [3.4 -14.5]) y comprar cigarrillos sueltos (or 2.60, ic 95 % (1.26-5.3). conclusión: la prevalencia global del hábito tabáquico es superior a la reportada en adolescentes, mayor en el sexo femenino, con mayor frecuencia de consumo de cigarrillos electrónicos. los factores asociados fueron la edad, tener novio o amigos que consuman tabaco y la posibilidad de comprar cigarrillos sueltos. palabras clave (fuente: decs) tabaquismo; adolescentes; factores de riesgo; tabaco; sistemas electronicos de liberación de nicotina; epidemiología. 3 prevalencia y posibles factores asociados al consumo tabáquico en adolescentes escolarizados l sandra patricia moreno reyes y otros prevalence and potential factors associated with tobacco consumption in schooled adolescents* abstract objective: this study estimates the prevalence in tobacco consumption and the associated factors in adolescents at official educational institutions in the municipality of palmira. methods: this was a crosss-sectional analysis with an analytical component, including 205 high school students from six official schools. the analysis was performed through the spss statistics software version 24. qualitative variables were expressed as ratios with their corrsponding 95% confidence intervals (ci). quantitative variables were expressed as central tendency and dispersion measures, depending on the distribution of the variable. finally, an odds ratio was calculated for the associated factors with a 95% ci and the binary logistic regression model statistical model was used to adjust the variables. results: the tobacco consumption’s overall prevalence was 38.5%, ci 95% (31.6–45.4%); e-cigarette, 20%, 95% ci (14.2–25.7%); cigarette, 18.5%, 95% ci (12.9–24.1%) and hookah, 17.9%, 95% ci (12.1–23 %), with a greater incidence in women than men. the resulting associated factors were age (or 3.17, ci 95% [1.48–6.79]), a partner who smokes (or 2.51, 95% ci (1.36–4.63%), friends who smoke (or 7.0, 95% ci [3.4–14.5]), and the possibility of buying individual cigarettes instead of a pack (or 2.60, 95% ci (1.26–5.3). conclusions: smoking habit’s overall prevalence is higher than the one reported in adolescents. female subjects reported greater and more frequent consumption of e-cigarettes. keywords (source: decs) smoking; adolescents; risk factors; tobacco; electronic nicotine release systems; epidemiology. año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2013 * article resulting from a project funded by the universidad santiago de cali, colombia; project number 450-62118-215. 4 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2013 aquichan issn 1657-5997 eissn 2027-5374 prevalência e possíveis fatores associados ao consumo de tabaco em adolescentes escolarizados* resumo objetivo: estimar a prevalência do consumo de tabaco e os fatores associados a esse hábito em adolescentes de instituições educativas oficiais do município de palmira, colômbia. métodos: estudo transversal com um componente analítico, que incluiu 205 estudantes do ensino médio de seis colégios oficiais. a análise foi realizada com o programa estadístico spss versão 24. as variáveis qualitativas foram expressas como proporções, com seus respectivos intervalos de confiança (ic) a 95 %; as variáveis quantitativas como medidas de tendência central e dispersão, segundo a distribuição da variável. para os fatores associados, foram calculados odds ratio com seu ic a 95 %, e o ajuste de variáveis foi realizado por meio de regressão logística binária. resultados: a prevalência global do consumo de tabaco foi de 38,5 %, ic 95 % (31,6-45,4 %); cigarro eletrônico, de 20 %, ic 95 % (14,2-25,7 %); cigarro, de 18,5 %, ic 95 % (12,9-24,1 %); narguilé, de 17,9 %, ic 95 % (12,1-23 %), com mais frequência em mulheres do que em homens. os fatores associados foram a idade (or 3,17, ic 95 % [1,48-6,79]), ter parceiro(a) que consuma tabaco (or 2,51, ic 95 % (1,36-4,63 %), estar rodeado(a) de amigos que fumam (or 7,0, ic 95 % [3,4 -14,5]) e comprar cigarro solto (or 2,60, ic 95 % (1.26-5.3). conclusões: a prevalência global do hábito tabágico é superior à relatada em adolescentes, maior no sexo feminino, com mais frequência de consumo de cigarros eletrônicos. os fatores associados foram a idade, ter parceiro(a) ou amigos que consumam tabaco e a possibilidade de comprar cigarros soltos. palavras-chave (fonte: decs) tabagismo; adolescentes; fatores de risco; tabaco; sistemas eletrônicos de liberação de nicotina; epidemiologia. * artigo produto de um projeto financiado pela universidad santiago de cali, colômbia, sob o número 450-62118-215. 5 prevalencia y posibles factores asociados al consumo tabáquico en adolescentes escolarizados l sandra patricia moreno reyes y otros introducción el consumo de tabaco es un problema de orden mundial, según reportes de la organización mundial de la salud (oms). la mortalidad asociada al uso de este producto es de siete millones de personas al año, de las cuales el 86 % son consumidores directos, y alrededor del 13 % son fumadores pasivos. si bien hasta hace algunos años el uso habitual del tabaco era exclusivo de adultos, en la actualidad la gran mayoría de los consumidores empiezan a fumar durante la adolescencia. hoy, más de 150 millones de adolescentes en el mundo consumen tabaco, y lo más alarmante es que esta cifra, en algunos países, parece ir en ascenso, a pesar de las innumerables intervenciones en salud pública (1). distintos autores han expuesto este fenómeno, que no tiene distinción entre países desarrollados y no desarrollados (2-3). sinha et al. (4), a través de un estudio realizado en un grupo de personas de la región de asia sudoriental, reportó que la prevalencia del consumo de tabaco en estudiantes de 13 a 15 años osciló entre el 5.9 y el 56.5 %. es importante resaltar que la prevalencia notificada fue mayor en hombres que en mujeres, y los productos tabáquicos distintos al cigarrillo eran más consumidos en comparación con este. en estados unidos, la prevalencia del consumo de productos tabáquicos en adolecentes oscila entre el 9 y el 25 %., según distintos reportes, los productos usados con mayor frecuencia son el cigarrillo electrónico (13.4 %), el narguile (9.4 %) y los cigarros (9.2 %). el 40 % usa más de un producto (5-6). en colombia, en un estudio realizado por pardo et al., con el objetivo de estimar la prevalencia del tabaquismo en adolescentes en cinco capitales del país (bogotá, bucaramanga, cali, manizales y valledupar), se estimó que la frecuencia del consumo de cigarrillo osciló entre el 7.4 y el 34.1 %; el riesgo de inicio de no fumadores fue entre el 12.3 y el 32 %, y las ciudades con mayor frecuencia de tabaquismo fueron manizales (68.8 %) bogotá (57.1 %) y cali (55 %) (7). actualmente, según datos del ministerio de salud y protección social de colombia, la prevalencia del tabaquismo es del 26.8 % (8). con relación a la edad de inicio de consumo y a los factores asociados, diversos estudios muestran que los adolescentes empiezan a experimentar con el cigarrillo y con otros productos tabáquicos entre los 10 y los 14 años. los factores de riesgo habituales son ser mayor de 13 años, el nivel académico de los padres, tener padres fumadores y estar expuestos a publicidad relacionada con estos productos en distintos escenarios (9-13). las nuevas dinámicas sociales, el ingreso de nuevos productos tabáquicos al mercado colombiano y considerar el tabaquismo en adolescentes un evento de interés en salud pública, además de los elementos de contexto considerados, hicieron necesario realizar la presente investigación, que tuvo como objetivo estimar la prevalencia del tabaquismo y los posibles factores asociados en adolecentes escolarizados de la ciudad de palmira, durante el 2018. métodos diseño y participantes se realizó un estudio de corte transversal, con un componente analítico, en el que se incluyeron adolecentes entre los 11 y los 19 años de edad, pertenecientes a seis colegios de la ciudad de palmira, colombia. la población total de estudiantes en el rango de edad en mención, en los seis colegios, fue de 3566, entre los grados sexto y undécimo. para calcular el tamaño de la muestra, se tuvo en cuenta la representatividad de los resultados y se usó la fórmula para estimar proporciones con factor de corrección, con los siguientes supuestos: nivel de confianza del 95 %, error estándar admisible del 5 % y proporción esperada del 17 %, con un n: 205 estudiantes. para la selección de los participantes, se realizó un muestreo probabilístico estratificado. para recolectar la información, cuatro personas entrenadas asistieron a las instituciones educativas durante un mes, en el primer semestre del 2018. allí, aplicaron el instrumento encuesta mundial sobre tabaquismo en jóvenes (emtajoven), cuyas preguntas, en su versión original, fueron redactadas bajo la iniciativa “libre de tabaco” de la oms y unicef, revisada y adaptada en colombia en el 2001 por el instituto nacional de cancerología (14). antes de implementar la encuesta, el proyecto fue socializado y se indagó acerca de la voluntad de participación de cada estudiante, la cual fue manifestada por cada uno y por su tutor. en el estudio, se contemplaron variables sociodemográficas, como edad, género, grado académico, religiosidad, estrato 6 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2013 aquichan issn 1657-5997 eissn 2027-5374 socioeconómico y nivel académico de los padres. variables relacionadas con el consumo de tabaco (cigarrillo, narguile, cigarrillo electrónico), como edad de inicio del consumo, cantidad de cigarrillos fumados, lugar de obtención de los productos y lugar habitual de consumo. factores sociales, como contar con pareja en la actualidad, posibilidad de acceder al producto tabáquico y tener padres o amigos con hábito tabáquico. medidas preventivas y de percepción del riesgo de consumo, como la opinión de los padres sobre el consumo de tabaco, la percepción sobre la dificultad para abandonar el hábito, creer que fumar aumenta el círculo de amigos, la exposición a la publicidad sobre tabaco y la percepción de su influencia en la decisión de fumar. análisis estadístico el análisis de los datos se realizó con el paquete estadístico spss versión 24. inicialmente, se hizo un estudio exploratorio de las variables para identificar valores omitidos y extremos. para establecer la normalidad de las variables y determinar el uso de pruebas paramétricas o no paramétricas, se utilizó el test de kolmogorov smirnov, con corrección de lilliefors. las variables cuantitativas se expresaron a través de medidas de tendencia central, con su respectiva medida de dispersión. adicionalmente, las variables cualitativas se describieron en frecuencia o porcentajes. para establecer la asociación cruda entre las variables independientes y el consumo de tabaco, se estimaron los odd ratios con sus respectivos intervalos de confianza del 95 %. finalmente, se realizó una regresión logística binaria con el método “wald hacia atrás”, utilizando las variables que en el análisis bivariado presentaron una significancia estadística < 0.20. aspectos éticos la investigación siguió los lineamientos éticos de la resolución 8430 del ministerio de salud de colombia y de la declaración del helsinki. el protocolo contó con el aval ético de la universidad santiago de cali, la autorización por parte de la secretaría de educación de la ciudad de palmira y la aprobación de las instituciones involucradas. todos los participantes diligenciaron el consentimiento o asentimiento informado, y sus datos fueron tratados de forma confidencial. resultados se estudiaron 205 adolecentes escolarizados, de los cuales el 58 % eran de sexo femenino, con una edad promedio de 15 años (de: +/-1.8). la mayoría (60 %), en el momento del estudio, estaban entre noveno y undécimo grado y eran de estrato o nivel socioeconómico 2 (48 %). desde la perspectiva espiritual, el 34 % practicaba una religión; en cuanto al nivel educativo de los padres, el más frecuente fue primaria (el 46 % de las madres y el 32 % de los padres) (tabla 1). tabla 1. características sociodemográficas de los adolescentes escolarizados de la ciudad de palmira, año 2018 no % sexo masculino 118 58 femenino 87 42 estrato socioeconómico 1 54 26 2 99 48 3 49 24 4 3 2 religioso sí 70 34 no 135 66 grado escolar sexto 33 16 séptimo 28 14 octavo 22 10 noveno 34 17 décimo 45 22 undécimo 43 21 nivel académico de la madre no tiene 1 1 no sabe 23 11 primaria 95 46 secundaria 53 26 educación técnica 15 7 pregrado 17 8 posgrado 1 1 7 prevalencia y posibles factores asociados al consumo tabáquico en adolescentes escolarizados l sandra patricia moreno reyes y otros no % nivel académico del padre no tiene 24 12 no sabe 50 24 primaria 40 20 secundaria 65 32 educación técnica 11 5 pregrado 15 7 posgrado 0 0 fuente: elaboración propia. la prevalencia total de tabaquismo fue del 38.5 %. el producto más usado fue el cigarrillo electrónico (20 %), seguido del cigarrillo convencional (18.5 %) y el narguile (17.1 %) (figura 1). tras analizar el consumo de tabaco por sexo, se observó que este es mayor en mujeres que en hombres (47 vs 32 %, respectivamente). figura 1. prevalencia del consumo de productos tabáquicos en adolecentes escolarizados de la ciudad de palmira, año 2018 tras estimar la odd ratio cruda de las variables sociodemográficas, familiares y sociales, se encontró que aquellas asociadas al consumo tabáquico fueron ser de sexo femenino (0r = 1.88 ic 95 %: 1.06 3.32 p = 0.03), ser de estrato socioeconómico bajo (0r = 2.72 ic 95 %: 1.32 5.6 p = 0.008), tener una relación sentimental con una persona que consume tabaco (0r = 2.51 ic 95 %: 1.36 4.63 p = 0.003), tener la posibilidad de comprar cigarrillos sueltos (0r = 2.86 ic 95 %: 1.58 5.1 p = 0.000), tener amigos que fuman (0r = 6.96 ic 95 %: 3.69 -13.12 p = 0.00) y creer que es difícil dejar de fumar una vez se empieza (0r = 2.36 ic 95 %: 1.30 4.28 p = 0.006). por otro lado, los factores protectores identificados fueron ser hombre, pertenecer a un estrato socioeconómico alto y creer que la publicidad relacionada con el tabaco puede tener injerencia en su decisión de fumar (tabla 2). finalmente, se presenta el modelo de regresión logística que más se ajustó x2: 58.57 p = 0.000. las variables que se asociaron de forma independiente al consumo tabáquico fueron la edad (entre 11-15 años. or: 3.17 ic 95 %: 1.48 6.79 p = 0.003), tener un novio fumador (or: 3.09 ic 95 %: 1.48 6.4 p = 0.003), la posibilidad de comprar cigarrillos sueltos (or: 2.60 ic 95 %: 1.26 5.3 p = 0.01) y estar rodeado de amigos que fuman (or: 7.0 ic 95 %: 3.4 14.5 p = 0.000) (tabla 3). tabla 2. tabaquismo y variables sociodemográficas, familiares y de percepción del riesgo en adolescentes escolarizados de la ciudad de palmira, año 2018 or ic 95 % p lci lcs género femenino 1.88 1.06 3.32 0.03 edad 1115 años 1.18 0.60 2.05 0.06 grado escolar 9-11 1.19 0.67 2.11 0.66 religioso no 1.75 0.95 3.2 0.07 estrato socioeconómico 1-2 2.72 1.32 5.6 0.008 17.1 % 18.5 % 20 % 38.5 % fuente: elaboración propia. al considerar las características de consumo de cada uno de los productos tabáquicos, se observó que la media de edad para empezar a consumir el cigarrillo fue de 13 años (de: +/5.5). gran parte de los adolescentes (55 %) que tienen el hábito de fumar fuman un promedio de nueve cigarrillos (de:+/6), en mayor medida, de 1 a 3 días al mes. con relación al cigarrillo electrónico, las mujeres lo consumen con mayor frecuencia (80 %), y la moda de inicio de consumo es de 15 años, similar a lo que sucede con el narguile. generalmente, el uso de productos tabáquicos en este grupo etario se presenta en lugares públicos o de reunión con su círculo más íntimo de amigos (37 y 23 %, respectivamente). 8 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2013 aquichan issn 1657-5997 eissn 2027-5374 or ic 95 % p lci lcs escolaridad madre 1.62 0.73 3.60 0.23 padre 0.54 0.21 1.36 0.19 factores sociales, familiares y percepción del riesgo novio(a) fuma 2.51 1.36 4.63 0.003 posibilidad de comprar cigarrillos sueltos 2.86 1.58 5.1 0.007 amigos fumadores 6.96 3.69 13.12 0.000 amigos que ofrecen cigarrillo 7.1 2.27 22.4 0.000 percepción de la familia sobre consumir tabaco 0.44 0.19 1.01 0.08 creer que es difícil dejar de fumar una vez se empieza 2.36 1.30 4.28 0.006 creer que las mujeres que fuman tienen más amigos 0.23 0.10 0.53 0.001 creer que los hombres que fuman tienen más amigos 1.02 0.57 1.83 0.95 cree que la publicidad del tabaco puede influir en su decisión de consumirlo. 0.52 0.29 0.93 0.02 lcs: límite de confianza superior; lci: límite de confianza inferior. fuente: elaboración propia. tabla 3. modelo de regresión de las variables asociadas con el consumo de tabaco en adolescentes escolarizados instituciones oficiales en palmira. valle, 2018 p or ic 95 % lci lcs edad 0.003 3.1 1.48 6.79 novio(a) fuma 0.003 3.0 1.48 6.46 posibilidad de comprar cigarrillos sueltos 0.010 2.6 1.26 5.39 amigos fuman 0.000 7.0 3.44 14.55 fuente: elaboración propia. discusión el consumo de productos tabáquicos continúa siendo un problema de salud pública, del cual no están exentos los adolescentes. en el presente estudio, se halló una prevalencia global del consumo de tabaco del 38.5 % ic 95 % (31.6 45.4 %); los productos más usados son el cigarrillo electrónico (20 % ic 95 %; 14.225.7 %) y el cigarrillo convencional (18.5 % ic 95 % (14.2 25.7 %). lo anterior llama la atención si se tiene en cuenta que el uso habitual de estos productos se asocia con la aparición de enfermedades crónicas y constituye una de las principales causas de muerte prematura (15). el comportamiento encontrado tiene una estrecha relación con lo reportado en el estudio de mohammed et al., en el que en un grupo de 695 adolescentes saudíes de 11 a 16 años reportó una prevalencia del 39.6 %, pero dista de la frecuencia del consumo de productos tabáquicos observado en países y ciudades de américa latina, como méxico, que identificó en adolescentes una prevalencia del 24 %; brasil (20.9 %); argentina (22 %), paraguay (12.9 %); y venezuela (9.4 %) (3, 16-18). en colombia, según cifras del ministerio de salud y protección social obtenidas a partir de una medición en las ciudades principales, la frecuencia de consumo de tabaco es del 28.6 %, con una prevalencia mayor en hombres (28.8 %) que en mujeres (24.6 %), y una frecuencia más alta en estudiantes de instituciones educativas públicas que privadas (27.8 vs 20.4 %, respectivamente). al realizar el análisis por ciudad, aquella que mostró una prevalencia más baja fue barranquilla (20.8 %), mientras que medellín registró la más alta (28.3 %). ambas distan de la cifra reportada en la presente investigación (8). la frecuencia del consumo de cigarrillo electrónico reportada en este estudio demuestra una tendencia al incremento en el uso de dichos dispositivos. este comportamiento se da porque el producto se ha presentado como una alternativa menos lesiva que el cigarrillo convencional y, en algunos casos, inocua (19-20). en concordancia con lo anterior, un estudio realizado en canadá con 1188 sujetos entre 16 y 30 años demostró que el 16.1 % había probado el cigarrillo electrónico (21). por otro lado, en países como estados unidos, en las tres últimas décadas el consumo del cigarrillo electrónico se ha incrementado del 2 %, en 2011, al 11 %, en 2015, incluso con mayor frecuencia que el cigarrillo convencional en adolescentes (22). 9 prevalencia y posibles factores asociados al consumo tabáquico en adolescentes escolarizados l sandra patricia moreno reyes y otros el cigarrillo electrónico es el más común de los dispositivos de sistemas electrónicos de administración de nicotina; produce aerosoles y su uso se llama “vapear”. el vapor expelido no es inocuo para la salud: funciona con altas cantidades de propilenglicol o glicerol, calienta una solución a 250 grados centígrados en cartuchos recargables y contiene concentraciones variables de nicotina entre 0 y 24 miligramos. además, los contenidos reales de nicotina de los cartuchos no suelen coincidir con los presentados en los envases (23). los niveles de nicotina que estos cigarillos liberan llegan a ser más elevados que la nicotina terapéutica, por lo que pueden generar adicción y síntomas de abstinencia al reducir su uso, además de niveles séricos de cotinina (metabolito de la nicotina) similares al cigarrillo fumado (60,6 + o 34,3 versus 61,3 + o 36,6 mg/ ml) (24). adicionalmente, estos dispositivos presentan diversos saborizantes para atraer a la población general: los sabores dulces contienen diacetilo (saborizante autorizado para la ingesta, no para la inhalación), sustancia que al ser inhalada se convierte en un factor de riesgo para contraer bronquitis obliterante (25). el cigarrillo electrónico se propone como un producto menos dañino que el cigarrillo convencional, lo que contribuye a dilatar la decisión de fumar (26); sin embargo, el aerosol que produce se acompaña de componentes potencialmente nocivos, que contienen tóxicos, compuestos cancerígenos y metales pesados como el cromo, el plomo y el níquel (este último, más alto que en los cigarrillos convencionales) (27). dentro de los efectos en la salud vinculados al cigarrilo electrónico, se destacan: explosión y quemaduras, principalmente de manos y rostro; un aumento del 18 % de la resistencia de las vías aéreas y una disminución significativa de la fracción espirada de óxido nítrico, que se observa en enfermedades como la inflamación de las vías aéreas, neumonía infecciosa y lipoidea, irritación de la faringe y de la boca, tos seca, desorientación e insuficiencia cardiaca. el vapeo tiene la potencialidad de modificar la expresión genética de las celulas del epitelio bronquial, lo que representa un riesgo de transformación maligna (28-31). con relación a la edad de inicio del consumo de cigarrillo, los datos demuestran que esta es cada vez menor. en la presente investigación, se encontró un promedio de 13 años, lo cual coincide con la media reportada para colombia por el ministerio de salud y protección social, a través del informe panorama de la salud escolar en colombia (8), y es similar a lo hallado por cisneros et al. (32), quienes reportaron una edad de inicio de 14 años en adolescentes mexicanos. respecto al sexo, las mujeres presentaron una mayor frecuencia que los hombres, hallazgo que difiere de los expuestos en otros estudios, pues el hábito se ha asociado tradicionalmente con los hombres (33-34). los cambios en las dinámicas sociales pueden explicar este resultado, pues las mujeres han tenido la oportunidad de adoptar comportamientos y prácticas que antes eran exclusivas de los hombres. el consumo de tabaco está asociado a diversos factores familiares y sociales, y este estudio destaca factores independientes, como tener una pareja con hábito tabáquico, la posibilidad de comprar cigarrillos sueltos y estar rodeado de amigos fumadores. los factores aquí descritos han sido reportados por estudios como el de morello et al., quienes comprobaron que consumir tabaco se asocia a tener amigos que consumen de forma habitual estos productos (or 12,6 ic 95 % 7,8-20,5) (35). por otro lado, una investigación realizada en cuba demostró que entre las motivaciones más usuales para consumir tabaco se encuentran tener familiares consumidores (72 %), profesores que fuman (44 %) y tener pareja (38 %) (36). de los factores relacionados de forma independiente con el consumo de tabaco en esta investigación, es menester resaltar la capacidad de comprar cigarrillos sueltos, aspecto que, combinado con el sitio usual de consumo manifestado (lugares públicos), llama la atención por los múltiples esfuerzos realizados por las entidades gubernamentales colombianas para restringir la venta de estos productos a personas menores de edad y desestimular su consumo. claro ejemplo de ello son las normas que prohíben abiertamente la venta a menores de edad, la prohibición del consumo de tabaco en lugares públicos, el alza de los precios de estos productos y la regulación del expendio por unidad (37). se identificaron como factores protectores ser de un estrato socioeconómico alto y la percepción de que la publicidad relacionada con el tabaco puede tener influencia en sus decisiones de consumirlo. con relación a las limitaciones del estudio, es importante mencionar que en la investigación solo se incluyeron adolecentes institucionalizados en colegios oficiales, lo cual puede limitar la capacidad de extrapolación de los datos a sus pares con características distintas. los hallazgos de esta investigación son de suma importancia, dado que reportan un incremento en la frecuencia del hábito tabá10 año 20 vol. 20 nº 1 chía, colombia enero-marzo 2020 l e2013 aquichan issn 1657-5997 eissn 2027-5374 quico en adolescentes y el nuevo aporte del cigarrillo electrónico al consumo habitual. adicionalmente, reflejan claros cambios en el patrón de consumo descrito hasta hace muy poco —como una mayor frecuencia de consumo en las mujeres—, los cuales exigen reforzar las estrategias de prevención y la regulación en materia de expendio de dispositivos como el cigarrillo electrónico. los datos encontrados no solo invitan a las instituciones educativas y gubernamentales a fortalecer las estrategias orientadas a disminuir el consumo de tabaco en los adolescentes, sino también a los padres a informar a sus hijos sobre los efectos derivados del consumo de tabaco, pues este es un evento de trasmisión social. conclusiones el consumo de tabaco sigue siendo un problema latente en los adolecentes escolarizados. la prevalencia global encontrada es superior a la reportada previamente, y el producto usado con mayor frecuencia es el cigarrillo electrónico. se observó que las mujeres tienen una mayor prevalencia de consumo, dato que muestra que los patrones de uso de estos productos han cambiado junto con el rol social de aquellas. los factores que se asocian de forma independiente al uso de productos tabáquicos son la edad, tener pareja o amigos que fuman y contar con la posibilidad de conseguir cigarrillos sueltos. financiamiento: el proyecto fue financiado por la dirección general de investigaciones de la universidad santiago de cali. conflictos de interés: ninguno declarado. agradecimientos: se agradece de forma especial a la dirección general de investigación de la universidad santiago de cali, a las instituciones educativas involucradas en el estudio y a las terapeutas respiratorias jennifer aristizábal orellano, hellen marcela ramírez trujillo, lizeth quiñones balanta y katherine amu amu. referencias 1. organización mundial de la salud. tabaco. informe de la oms sobre la epidemia mundial del tabaquismo, 2019 [internet]. organización mundial de la salud. washington. organización mundial de la salud; 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16(2):127-134. disponible en: https:// www.researchgate.net/publication/318199729_descripcion_del_consumo_de_tabaco_y_alcohol_en_adolescentes_de_ complementos_urbanos_del_estado_de_nuevo_leon_mexico 33. rodriguez l, castillo b, castillo m, castillo m, garcía n, rodriguez n. consumo de alcohol y tabaco en adolescentes. eletrônica saúde mental álcool drog.2016;12(4):200-6. doi: https://doi.org/10.11606/issn.1806-6976.v12i4p200-206 34. gonzález e, zavala l, rivera l, leyva a, natera g, reynales l. factores sociales asociados con el consumo de tabaco y alcohol en adolescentes mexicanos de poblaciones menores a 100 000 habitantes. salud publica mex. 2019;61:764-774. doi: https://doi.org/10.21149/10563 35. morelloa p, pereza a, peñaa l, brauna s, cattanob c, thrasherb j, et al. factores de riesgo asociados al consumo de tabaco, alcohol y otras drogas en adolescentes escolarizados de tres ciudades de argentina. arch argent pediatr 2017;115(2):155-168. doi: https://doi.org/10.5546/aap.2017.155 36. medina a, márquez j, torres c, ramos l, hernández y. presencia de consumo de tabaco en un grupo de adolescentes. gac méd espirit 2015; 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[tesis para optar al título de maestría en administración]. medellín: universidad eafit; 2013. disponible en: https://repository.eafit.edu.co/bitstream/handle/10784/2920/federico_gonzalezposada_2013. pdf?sequence=3&isallowed=y https://doi.org/10.3109/08958378.2012.758197 https://doi.org/10.3109/08958378.2012.758197 https://doi.org/10.1016/j.ijheh.2013.11.003 https://doi.org/10.1039/c4em00415a https://doi.org/10.1378/chest.11-1334 https://doi.org/10.5487/tr.2014.30.1.013 https://doi.org/10.1158/1078-0432.14aacriaslc-b16 https://doi.org/10.1158/1078-0432.14aacriaslc-b16 https://doi.org/10.1186/1471-2458-11-786 https://www.researchgate.net/publication/318199729_descripcion_del_consumo_de_tabaco_y_alcohol_en_adolescentes_de_complementos_urbanos_del_estado_de_nuevo_leon_mexico https://www.researchgate.net/publication/318199729_descripcion_del_consumo_de_tabaco_y_alcohol_en_adolescentes_de_complementos_urbanos_del_estado_de_nuevo_leon_mexico https://www.researchgate.net/publication/318199729_descripcion_del_consumo_de_tabaco_y_alcohol_en_adolescentes_de_complementos_urbanos_del_estado_de_nuevo_leon_mexico https://doi.org/10.11606/issn.1806-6976.v12i4p200-206 https://doi.org/10.21149/10563 https://doi.org/10.5546/aap.2017.155 http://scielo.sld.cu/pdf/gme/v17n1/gme04115.pdf https://repository.eafit.edu.co/bitstream/handle/10784/2920/federico_gonzalezposada_2013.pdf?sequence=3&isallowed=y https://repository.eafit.edu.co/bitstream/handle/10784/2920/federico_gonzalezposada_2013.pdf?sequence=3&isallowed=y 8 21 validacion de dos escalas.indd 8 aquichan issn 1657-5997 margarita del carmen poblete-troncoso1 sandra verónica valenzuela-suazo2 josé manuel merino3 validación de dos escalas utilizadas en la medición del cuidado humano transpersonal basadas en la teoría de jean watson 1 doctor en enfermería. universidad católica del maule, chile. mpoblete@ucm.cl 2 doctor en enfermería. universidad de concepción, chile. svalenzu@udec.cl 3 doctor en sociología. universidad de concepción, chile. jmerino@udec.cl recibido: 8 de junio de 2011 aceptado: 9 de marzo de 2012 resumen objetivo: validar caring efficacy scale y nyberg´s caring assessment, elementos basados en la teoría transpersonal del cuidado humano que se fundamenta en los aspectos humanos y éticos del cuidado. método: los instrumentos fueron validados en una muestra de 360 enfermeras chilenas. los coeficientes de alfa de cronbach fueron de 0,76 para caring efficacy scale, y de 0,82 para el nyberg´s caring assessment. en cuanto a la validez de constructo ambos instrumentos se correlacionan positiva y significativamente. resultados: se pondera divergencia como estrategia de esta validez en ambos instrumentos y se utiliza una subescala que evalúa la falta de empatía con el sufrimiento del otro. conclusión: la validación de estas escalas es un aporte al cuidado humano transpersonal, para conocer el significado que las enfermeras le otorgan, y cuán eficaces se sienten, así cómo remediar aspectos deficitarios en la enseñanza y práctica del cuidado. palabras clave estudios de validación, teoría, cuidado de enfermería. (fuente: decs, bireme). validation of two scales used to measure transpersonal human caring, based on jean watson’s theory abstract objective: validate the caring efficacy scale and nyberg’s caring assessment. both these elements are based on the theory of transpersonal human caring, which is founded on the humanistic and ethical aspects of care. method: these scales were validated in a sample año 12 vol. 12 nº 1 chía, colombia abril 2012 z 8-21 9 validación de dos escalas utilizadas en la medición del cuidado humano... z margarita del carmen poblete-troncoso, sandra verónica valenzuela-suazo, josé manuel merino comprised of 360 chilean nurses. cronbach’s alpha was 0.76 for the caring efficacy scale and 0.82 for nyberg’s caring assessment. in terms of construct validity, both instruments are correlated positively and significantly. results: divergence is weighted as a strategy or approach to this validity in both instruments, and a subscale was used to evaluate lack of empathy with the suffering of others. conclusion: the validation of these scales is a contribution to transpersonal human caring in terms of knowing the significance nurses give to it and how effective they feel, as well as to remedy shortcomings in the teaching and practice of human care. key words validation studies, theory, and nursing care (source: decs, bireme). validação de duas escalas utilizadas na medição do cuidado humano transpessoal baseadas na teoria de jean watson resumo objetivo: validar caring efficacy scale e nyberg´s caring assessment, elementos baseados na teoria transpessoal do cuidado humano que se fundamenta nos aspectos humanos e éticos do cuidado. método: os instrumentos foram validados em uma amostra de 360 enfermeiras chilenas. os coeficientes de alfa de cronbach foram de 0,76 para caring efficacy scale, e de 0,82 para o nyberg´s caring assessment. quanto à validade de construto, ambos os instrumentos se correlacionam positiva e significativamente. resultados: considera-se divergência como estratégia desta validade em ambos os instrumentos e se utiliza uma subescala que avalia a falta de empatia com o sofrimento do outro. conclusão: a validação dessas escalas é uma contribuição para o cuidado humano transpessoal, para conhecer o significado que as enfermeiras lhe outorgam, e quão eficazes se sentem, assim como remediar aspectos deficientes no ensino e prática do cuidado. palavras-chave estudos de validação, teoria, cuidado de enfermagem (fonte: decs, bireme). 10 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 introducción los instrumentos son importantes para el investigador, ya sea para la obtención de datos o para acercarse al fenómeno y extraer de ellos información. en enfermería, el cuidado se ha convertido en el centro de la praxis, y evaluar que estos cuidados sean humanizados beneficia a los profesionales de enfermería y a los usuarios, mejorando la calidad de estos en los servicios de salud. en chile, como en latinoamérica, existen escasos instrumentos para evaluar el constructo de “cuidado”, de ahí la importancia de este trabajo al identificar instrumentos confiables y validados en el espacio latinoamericano. el presente estudio aborda la experiencia de validar instrumentos, en particular escalas del cuidado humano basadas en una teoría de enfermería con énfasis en los aspectos filosóficos y éticos involucrados en el acto de cuidar, como es la teoría transpersonal del cuidado humano de watson (1, 2, 3). se destaca que estos instrumentos fueron validados por los autores como parte de una investigación cuyo objetivo era evaluar la influencia institucional en la percepción de autoeficacia para otorgar un cuidado transpersonal en grupos de enfermeras académicas y asistenciales chilenas. los instrumentos validados fueron el caring efficacy scale (ces) (4) y el nyberg´s caring assessment (nca) (5), seleccionados por ser aplicables en diversos ámbitos del quehacer en el que se desarrolla la profesión de enfermería. el caring efficacy scale fue desarrollado por carolie coates (4) para la medición y evaluación de programas de formación de enfermeras en la universidad de colorado, estados unidos, en 1992. el objetivo era evaluar la percepción de autoeficacia que tiene la enfermera/o para otorgar cuidados y relacionarse con sus pacientes como resultado de la aplicación del programa curricular basado en la teoría de autoeficacia de bandura y en la teoría transpersonal del cuidado humano de watson (4, 6, 7); se obtuvo un coeficiente de alfa de cronbach de 0,88 (4). la autoeficacia percibida se define como los juicios de cada individuo sobre sus capacidades, con base en los cuales organizará y ejecutará sus actos de modo que le permitan alcanzar el rendimiento deseado (7). para bandura la autoeficacia, además de ser un mecanismo predictivo de la conducta futura, influye sobre la misma, es decir, hace a la persona productora de su propio comportamiento. la importancia de relacionar ambas teorías en el instrumento permite determinar la capacidad percibida por enfermeras/os de expresar cuidados humanos con base en la teoría de watson en ámbitos de práctica y enseñanza del cuidado (7). la versión original del instrumento, realizada en el año 1980, se adaptó para ser aplicada en 1992, quedando constituida por 30 ítems de formato likert con intensidades -3 a +3, balanceados en ítems positivos y negativos (4). el otro instrumento por validar en este estudio fue el nyberg´s caring assessment (nca), desarrollado en el año 1990 por jan nyberg durante su estudio doctoral en la universidad de colorado. en este se miden esencialmente los atributos del cuidado —basándose también en la filosofía de la teoría transpersonal del cuidado humano—, e intenta captar aspectos subjetivos del mismo enfatizando en la actitud de profundo respeto hacia las necesidades del otro, como la sensibilidad por sus necesidades espirituales, de comunicación y esperanza (5, 6). el nca tiene 20 ítems, y sus respuestas también están diseñadas en formato likert con puntuación de 1 a 5. en los estudios realizados en estados unidos por la autora se encontraron alfas de cronbach de 0,85-0,98 (5,6). para validación por divergencia se utilizó una subescala del instrumento interpersonal reactivity index (iri) —que evalúa “la medida de la empatía”—, creado por mark davis en l980 (8), y posteriormente traducido y validado al español por vicente mestre, maría dolores frías y paula samper en méxico (9); este instrumento evalúa la empatía que se establece con el otro. en sus subescalas presenta una divergente, denominada “malestar personal” (pd), centrada en el “yo”, que valora los sentimientos de ansiedad y malestar que un sujeto manifiesta al observar las experiencias negativas o el sufrimiento de los demás; se optó por ella dada la oposición con el constructo de las escalas del cuidado humano, ya que cuidado implica preocupación por el otro. como se mencionó, el caring efficacy scale y el nyberg´s caring assessment, desarrollados originalmente en lengua inglesa, están basados en la filosofía transpersonal del cuidado humano de watson y en los diez factores relacionados con el cuidado — caratives— que incorpora la teoría. 11 validación de dos escalas utilizadas en la medición del cuidado humano... z margarita del carmen poblete-troncoso, sandra verónica valenzuela-suazo, josé manuel merino de acuerdo con esta teoría, el “cuidado” es para la enfermería su razón moral, no es un procedimiento o una acción, el cuidar es un proceso interconectado, intersubjetivo, de emociones compartidas entre el profesional de enfermería el y paciente (1). la autora de la teoría transpersonal del cuidado humano le otorga al cuidado una dimensión espiritual y una abierta evocación de amor a esta acción. para esta, el acto de cuidar debe ser amplio, sanador del espíritu y el cuerpo. el profesional de la enfermería, en su interrelación con el paciente, debe ayudarlo a adoptar conductas de búsqueda de la salud, determinando para ello diez factores del cuidado (1). en sus últimos estudios (2,10) watson expande su trabajo original como ciencia del cuidado humano, dentro de un contexto ético-moral y científico apoyado en las filosofías éticas de emmanuel lévinas —ética del cara a cara— y knud logstrup —el sostener el alma del otro en nuestras manos—. en este último trabajo teórico presenta los conceptos “clinical caritas o caritas processe” como extensión de los diez factores que evocan el amor y el cuidado como soporte teóricofilosófico del cuidado humano transpersonal que emergen desde un paradigma expandido, para conectar con las dimensiones existencial-espiritual y las experiencias del proceso de la vida humana. a continuación se exponen brevemente los diez factores del cuidado (1). 1. formación de un sistema de valores humanistas y altruistas para que los cuidados se conviertan en una práctica amable y ecuánime, dándole sentido al acto de cuidar. estos valores se aprenden desde muy temprano en la vida, pero en la juventud son importantes los modelos, es por ello que las docentes de enfermería y las enfermeras asistenciales juegan un rol destacado en la formación de estos valores en las y los jóvenes estudiantes de enfermería. 2. instilación de fe y esperanza, en donde los cuidados se transforman en una presencia auténtica que permite y sostiene el sistema profundo de creencias, tanto del que cuida, como del ser que es cuidado. es necesario volver la mirada hacia los aspectos ancestrales del cuidado, en donde adquieren importancia la fe y la esperanza en las creencias que el ser humano sustenta tanto para su salud como para su curación. 3. cultivar la sensibilidad hacia uno mismo y los demás, y las propias prácticas espirituales y transpersonales. la psicología humanista y transpersonal (7, 11) considera que la relación que se establece con el paciente es clave para lograr resultados en salud incluso más que los métodos tradicionales. la comunicación entre la enfermera/o y la persona cuidada debe ser auténtica, un encuentro persona a persona. 4. desarrollar una relación de cuidados humanos de ayuda y de confianza. para que los cuidados sean auténticos es necesario que esta relación se desarrolle y se sostenga en una confianza mutua. la enfermera debe ver al paciente como ser humano que necesita ser comprendido, no como “objeto” de sus cuidados, objeto al que se puede manipular y tratar. 5. promocionar y aceptar la expresión de sentimientos positivos y negativos. este punto se deriva del tercero: cultivar la sensibilidad de uno mismo y de los demás. el auto-conocimiento y la aceptación permiten compartir sentimientos con el otro. la autora de esta teoría reconoce que es una experiencia que implica riesgos, tanto para las enfermeras como para los pacientes; la enfermera debe estar preparada para los sentimientos positivos y negativos, comprender emocional e intelectualmente una situación, y ser capaz de establecer la diferencia. 6. uso sistemático del método científico para la resolución de problemas y toma de decisiones. esta es una actitud creativa para resolver problemas, es una forma de conocer las partes del proceso del cuidado incorporando el arte en la práctica de cuidar-sanando. el cuidado de enfermería adquiere el carácter científico basándose en un método organizado y sistemático. el uso del método de resolución de problemas como herramienta ha permitido a las enfermeras una práctica científica del cuidado. 7. promocionar la enseñanza y el aprendizaje transpersonal. es una experiencia genuina de enlazar la enseñanza y aprendizaje como una unidad de “ser” y con “significado”. los profesionales de la salud, en general, tienen el deber de prepararse para educar y entregar información a la persona cuidada, de este modo, la van a ayudar a adaptarse y a disminuir el estrés; a la vez, las enfermeras/os también deben aprender a recibir del otro. 8. crear un entorno de apoyo o conexión mental, física, sociocultural y espiritual, proporcionando un ambiente sanador en todos los niveles, dando fuerza y energía al “ambiente no físico”, reforzando la belleza, la integridad, la comodidad, la dig12 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 nidad y la paz. el bienestar se debe evaluar desde el paciente y no por rutinas establecidas en los servicios hospitalarios. aspectos como una cama confortable, una posición correcta y la realización de ejercicios, son tan importantes como explicar al paciente los procedimientos que se van a realizar, y la satisfacción de sus necesidades espirituales. 9. ayudar a la satisfacción de las necesidades humanas. satisfacer las necesidades básicas dándole sentido al cuidado, suministrando la esencia del cuidado humano, reforzando la integridad cuerpo, mente y espíritu, como un ser único en todos los aspectos del cuidar, incorporando el desarrollo espiritual profundo. 10. aceptación de fuerzas existenciales-fenomenológicas. se deben atender y abrir los misterios espirituales y existenciales de la vida y la muerte cuidando el alma de uno mismo y del ser que se cuida. estos factores del cuidado son evaluados en los instrumentos validados, que se tornan importantes hoy en los sistemas de salud, en donde el usuario solicita ser respetado y valorado como ser humano. es por ello que en el marco del nuevo paradigma de enfermería como gestora de cuidados en chile, se deben enfatizar los aspectos éticos que involucra el cuidar. en chile, como en el resto de latinoamérica, diversos estudios evidencian la importancia que tiene para el paciente un cuidado humanizado y ético (12, 13, 14, 15). en colombia (15) se realizó un estudio del comportamiento del cuidado entre pacientes y profesionales de enfermería utilizando el caring behaviors inventory, instrumento que también se basa en la teoría transpersonal del cuidado humano (16), destacando como un valor importante del cuidado la comunicación que la enfermera establece con el enfermo. por tanto, ilustra la importancia de evaluar el cuidado de enfermería a través de herramientas cuyo soporte teórico incorpora una visión humanista y ética. método el presente estudio cuantitativo y transversal fue realizado en chile, entre marzo y diciembre de 2007. a continuación se describe la metodología aplicada en la validación de los instrumentos utilizados. desde el punto de vista metodológico se observaron pasos sugeridos por diversos autores (17, 18) respecto a este proceso, y que se deben tener en cuenta durante la validación. 1. pruebas para ajuste: adaptación cultural. 2. pruebas de validez. prueba de ajuste de adaptación cultural como ambos instrumentos originalmente están en idioma inglés, se consideró importante la fase de adaptación cultural. a continuación se describe este procedimiento de validación. para este estudio se llevaron a cabo los siguientes pasos (17, 18): selección de las escalas: la teórica jean watson, en entrevista directa, sugirió la escala caring efficacy scale (ces), que mide los supuestos del cuidado humano transpersonal. para validar la escala por convergencia se decidió utilizar la nyberg´s caring assessment (nca), escala que también está basada en el trabajo filosófico de esta teórica (5, 6). traducción de instrumentos ces y nca: fue necesaria la traducción directa e inversa de ambos instrumentos por académicos bilingües. la traducción directa es aquella que se realiza del idioma original al idioma de aplicación. este paso fue ejecutado por tres profesionales, investigadores de enfermería, con amplia trayectoria académica y en investigación. la traducción inversa es aquella que se realiza en sentido contrario o retraducción, y en este caso fue realizada por dos investigadores de la salud y un sociólogo. pruebas preliminares para realizar ajustes de ítems y su utilidad. para ello se realizó una prueba piloto donde se analizaron aspectos relacionados con particularidades de los ítems como su comprensión, tiempo de aplicación requerido y claridad en las instrucciones para las respuestas. se tomó una muestra de enfermeras académicas y asistenciales de la región del maule, chile, quedando constituida por un total de treinta personas. se observó que la comprensión de los ítems era adecuada. todas estas pruebas forman parte de la adaptación cultural de los instrumentos, cuyo idioma original es el inglés. pruebas de validez la validez aparente o parcial se obtuvo con base en el criterio de dos grupos: las enfermeras que participaron en la prueba 13 validación de dos escalas utilizadas en la medición del cuidado humano... z margarita del carmen poblete-troncoso, sandra verónica valenzuela-suazo, josé manuel merino piloto y los expertos. la validez aparente no supone conceptos estadísticos, sino solo juicios de pertinencia de los ítems entregados por expertos (17, 18). la validez de contenido evalúa si los diferentes ítems son representativos del dominio o universo de contenido que se busca medir, aspecto que fue verificado mediante juicio de expertos, quienes coincidieron en que los ítems del instrumento se basan en y evalúan la teoría del cuidado humano transpersonal. la validez del constructo está compuesta por los conceptos de validez convergente y divergente o discriminante. en el primer caso, el instrumento debe concordar o converger en el sentido de sus puntuaciones con otros instrumentos que miden dimensiones teóricas similares. en el caso de la validación divergente o discriminante, se debe demostrar que el instrumento diverge de otro similar que se ha usado para medir una dimensión teórica de sentido contrario al del instrumento original. ambas dimensiones de la validez constructiva en el terreno operativo suponen correlacionar los instrumentos positivamente en la convergencia y negativamente en la divergencia. en este estudio la validez constructiva de las escalas ces y nca fue implementada mediante la demostración de convergencia entre ambas escalas nombradas (4, 5) y, en forma simultánea, mediante su validación divergente con una subescala de “malestar personal” (8, 9). prueba de confiabilidad. se realizó medición del coeficiente alfa de cronbach en ambos instrumentos, obteniéndose valores altos de confiabilidad: caring efficacy scale (0,76) y nyberg´s caring assessment (0,82). determinación de su utilidad. se observó que ambas escalas permitían la evaluación de la percepción del cuidado transpersonal de watson. aspectos éticos para utilizar ambos instrumentos se solicitó autorización por escrito a las autoras. las autorizaciones fueron obtenidas en el año 2005. además, se solicitó consentimiento libre e informado a cada una de las enfermeras que participaron en el estudio. población la población del estudio estuvo constituida por las enfermeras profesionales clínicas y académicas que trabajan en el sistema universitario chileno. el universo de estudio fue de 2.615 enfermeras clínicas y académicas. se decide aplicar los instrumentos en las siguientes regiones: antofagasta, coquimbo, valparaíso, bernardo o´higgins, maule, bío bío, araucanía, los lagos y metropolitana. la muestra definitiva estuvo conformada por un total de 360 enfermeras, clínicas y académicas, de nueve regiones de chile, excluyendo solo las regiones extremas del país, a las que se excluyó debido al excesivo costo agregado por incluirlas en el estudio, respecto al muy reducido beneficio de representatividad adicional. la muestra final obtenida incluye a todas las profesionales que aceptaron participar en las instituciones universitarias, que fueron un total de trece universidades pertenecientes a la asociación chilena en educación en enfermería (achieen). las unidades académicas socias a la achieen son 18, por tanto, esta muestra corresponde al 72% (19). en chile existe un total de 200 hospitales públicos, este estudio se realizó en veintiuno de ellos, por tanto, esta muestra incorporó a profesionales de enfermería chilenas de un 11% de los servicios públicos hospitalarios del país (20). todas las participantes firmaron el respectivo formulario de consentimiento informado. la investigadora principal visitó las nueve regiones del país incluidas en la muestra para aplicar personalmente la mayoría de los instrumentos. en algunas instituciones de salud, por el tipo de trabajo de los servicios, los cuestionarios debieron ser autoaplicados siguiendo las instrucciones pertinentes diseñadas para esos efectos. se logró obtener un total de 360 cuestionarios respondidos: 99 de académicas de diversas universidades (27,5%) y 261 de enfermeras asistenciales, (72,5%). criterios de inclusión y exclusión de la muestra como esta investigación se proponía, además de validar estos instrumentos, evaluar la percepción de autoeficacia en la entrega del cuidado transpersonal de enfermeras académicas y asistenciales, estos criterios fueron amplios. criterios de inclusión 1. enfermeras asistenciales que trabajan en instituciones hospitalarias que participan en el proceso de enseñanza y aprendizaje de los estudiantes de enfermería. 2. enfermeras docentes universitarias que participan en el proceso de enseñanza y aprendizaje de los estudiantes de enfermería. 14 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 3. enfermeras académicas y asistenciales que trabajen su jornada completa, ya sea, en instituciones universitarias u hospitalarias (para observar la influencia de los sistemas institucionales). 4. enfermeras académicas y asistenciales hospitalarias que tengan una experiencia laboral mayor o igual a tres años en la misma institución (se estima que la antigüedad en una institución va determinar la adaptación a las normas dentro de los subsistemas sociales). 5. profesionales académicos y asistenciales hospitalarios de sexo femenino. enfermería es una profesión feminizada y para el diseño de obtención de la muestra mediante la técnica de los puntajes de propensión se necesita de un gran número de sujetos para obtener una muestra y hacer que los grupos sean comparables. 6. enfermeras académicas y asistenciales que aceptaron participar en el estudio criterios de exclusión 1. enfermeras académicas y asistenciales que tengan menos de tres años de permanencia en las instituciones. 2. enfermeras asistenciales y académicas que no participen en la docencia de enfermería. resultados prueba piloto se efectuó una prueba piloto en una muestra de treinta enfermeras académicas y asistenciales de la región del maule. en la tabla 1 se observa la validación por convergencia entre el ces y nca, y divergencia con la subescala malestar personal (pd) que correspondía a una subescala del instrumento iri. en la validez convergente se destaca la correlación positiva entre el caring efficacy scale y el nyberg caring assessment significativa al 9 por diez mil, lo que significa que ambos instrumentos miden el mismo constructo; la correlación negativa y significativa con la subescala malestar personal al 1,6 por mil, como prueba de validez divergente indica que está validando a ambos fuente: poblete (21). tabla 1. validez constructiva de las escalas caring efficacy scale y nyberg´s caring assessment en prueba piloto (n = 30) malestar personal (pd (subescala del iri) caring efficacy 1,00000 0,57569 0,0009 -0,55029 scale (ces) 0,0016 nyberg caring 0,57569 1,00000 -0,15092 assessment 0,0009 0,4260 (nca) malestar personal (pd) 0,55029 -0,15092 1,00000 (subescala 0,0016 0,4260 del iri) instrumentos en su constructo correlacionándose negativamente con ellos, ya que mide lo contrario: la falta de empatía con el otro. una vez obtenidos los resultados de la prueba piloto en que se observó la calidad y confiabilidad de los instrumentos, se repitió este análisis de calidad de los datos en una muestra de 360 enfermeras, esto se muestra en la tabla 2 donde se observa la validez de constructo. los resultados son similares a los de la prueba piloto, observándose convergencia entre ambos instrumentos que miden cuidados, con una correlación positiva y significativa. la validez discriminante utilizando la subescala malestar personal del instrumento iri obtuvo una correlación negativa y significativa en ambas escalas, según se expresa en esta tabla. una vez realizada la validez de constructo al caring efficacy scale y nyberg´s caring assessment, se llevó a cabo el análisis factorial para identificar otros posibles factores no observados en población norteamericana (tabla 3). mediante la aplicación de esta técnica se obtuvieron tres factores; el primero, formado por los 15 ítems positivos, reúne el 45% de la varianza y da sentido a la eficacia de cuidar; los otros dos factores, con un 30 y un 25% de la varianza, respectivamente, caring efficacy nyberg caring scale assessment 15 validación de dos escalas utilizadas en la medición del cuidado humano... z margarita del carmen poblete-troncoso, sandra verónica valenzuela-suazo, josé manuel merino no constituyen dimensiones distintas sino solo capturan los ítems invertidos en el instrumento, por lo que se ratifica la unidimensionalidad en su estructura, es decir, la escala solo mide la percepción de autoeficacia respecto al cuidado humanizado, basada en la teoría transpersonal del cuidado humano de watson. en la tabla 4 se observa la consistencia interna de cada ítem del instrumento expresada en el alto puntaje promedio de cada reactivo, lo que permite concluir que el ces valida ampliamente la teoría del cuidado transpersonal. en la tabla 4 se observa que todos los ítems presentan una correlación positiva y significativa entre ellos, validando cada uno de los factores del cuidado transpersonal. la mayoría de los ítems están sobre 5 puntos siendo el mínimo 1 y el máximo 6, lo que demuestra que las enfermeras perciben estos factores como importantes al momento de brindar cuidado. los ítems 8, 13 y 27 presentan promedios bajo 5 puntos, estos se relacionan con dejar de lado las creencias y los prejuicios al escuchar al otro, tener una conversación más personal con él y agobiarnos con sus vivencias. a continuación se muestran los resultados por ítem del instrumento nyberg caring assessment. en los resultados del instrumento de nyberg caring assessment los ítems presentan promedios altos y correlación tabla 2. convergencia y divergencia entre instrumentos aplicados. pearson correlation coefficients en estudio definitivo (n = 360) tabla 3. resultado de análisis factorial en el instrumento caring efficacy scale (ces) (n=360) fuente: poblete (21). malestar personal (pd) (subescala del iri caring efficacy scale 1,00000 0,57542 0,0009 -0,36261 <0,001 nyberg´s caring 0,57542 -0,22760 assessment <,0001 1,00000 <,0001 malestar personal -0,36261 -0,22760 (pd) <,0001 <,0001 1,00000 (subescala del iri) fuente: poblete (21). varianza total factor 1 factor 2 factor 3 porcentaje explicada acumulado % de varianza 3,5841738 2,3919442 2,0176841 7,993802 explicada (45%) (30%) (25%) (100%) matriz de componentes rotados factor 3 0,27057 0,30724 0,05482 0,08268 0,18380 0,08453 0,16125 0,33603 0,44526 0,23210 0,12739 0,22661 0,13165 0,22190 co1 co2 co3 co4 co5 co6 co7 co8 co9 co10 co11 co12 co13 co14 factor 1 0,12587 0,15058 0,43382 0,65421 0,44378 0,46310 0,57899 0,15873 0,45200 0,51323 0,44351 0,24424 0,13952 0,50846 factor 2 -0,08828 0,04025 0,10288 0,02716 -0,10268 0,16937 0,07421 0,07070 -0,05314 0,03919 0,07935 0,16807 0,25433 -0,11082 co15 co16 co17 co18 co19 co20 co21 co22 co23 co24 co25 co26 co27 co28 co29 co30 0,03011 -0,02155 0,03484 0,61586 0,63886 0,00670 0,04129 0,23761 0,00414 -0,08922 0,36922 0,05069 -0,06342 0,28853 0,22755 0,14642 0,09413 0,15086 0,08901 0,21786 0,21607 0,24884 0,54696 0,38163 0,55833 0,46349 0,35855 0,45314 0,51272 0,25432 0,41549 0,45228 0,48397 0,60052 0,50823 -0,21854 -0,08602 0,43000 0,09772 0,00640 -0,13821 0,22438 -0,14613 0,10583 0,06808 0,20110 0,04758 0,148 caring e nyberg´s caring efficacy scal assessment 16 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 tabla 4. resultados por ítem del instrumento caring efficacy scale (n = 360) desviación correlación estándar ítem -escala 1. no siento confianza en mis habilidades para expresar un sentido de cuidado a mis clientes/pacientes. 5,75 0,93 0,196 0,0002 2. si no me estoy relacionando bien con un cliente/paciente trato de analizar qué puedo hacer para llegar a él/ella. 5,60 0,85 0,279 < 0,0001 3. me siento cómoda al “tocar” a mis clientes/pacientes cuando proporciono cuidado. 5,64 0,80 0,358 < 0,0001 4. transmito un sentido de fortaleza personal a mis clientes/pacientes. 5,65 0,60 0,458 < 0,0001 5. mis clientes/pacientes pueden hablarme de casi cualquier cosa y yo no me sentiré choqueada. 5,53 0,90 0,307 < 0,0001 6. tengo habilidades para introducir un sentido de normalidad en condiciones estresantes. 5,40 0,67 0,40 < 0,0001 7. es fácil para mí considerar las múltiples facetas del cuidado de un cliente/paciente, al mismo tiempo que lo escucho. 5,39 0,71 0,44 < 0,0001 8. tengo dificultades para dejar de lado mis creencias y prejuicios para escuchar y aceptar el cliente/paciente 4,58 1,87 0,38 como persona. < 0,0001 9. puedo caminar en una habitación con aspecto de serenidad y energía que haga sentir mejor a los clientes/pacientes. 5,59 0,79 0,42 < 0,0001 10. soy capaz de sintonizar con un cliente/paciente en particular y olvidar mis preocupaciones personales. 5,59 0,68 0,41 < 0,0001 11. usualmente puedo establecer alguna forma de relacionarme con la mayoría de los pacientes/clientes. 5,68 0,66 0,35 < 0,0001 12. carezco de confianza en mi habilidad para hablar con pacientes/clientes cuyos orígenes son diferentes al mío. 5,55 1,14 0,37 < 0,0001 13. siento que si tengo una conversación muy personal con mis pacientes/clientes las cosas pueden perder el control. 4,97 1,58 0,35 < 0,0001 14. uso lo que aprendo de mis conversaciones con clientes/pacientes para suministrar un cuidado más individualizado. 5,53 0,71 0,34 < 0,0001 15. no me siento con la fortaleza suficiente para escuchar los temores y las preocupaciones de mis clientes/pacientes. 5,59 1,05 0,31 < 0,0001 16. aun cuando siento confianza en mí misma respecto a la mayor parte de las cosas, todavía soy incapaz de 5,72 o,90 0,31 relacionarme con clientes/pacientes. < 0,0001 17. creo tener problemas para relacionarme con mis clientes/pacientes. 5,83 0,86 0,28 < 0,0001 items media 17 validación de dos escalas utilizadas en la medición del cuidado humano... z margarita del carmen poblete-troncoso, sandra verónica valenzuela-suazo, josé manuel merino fuente: poblete (21). tabla 4. resultados por ítem del instrumento caring efficacy scale (n = 360) 18. usualmente puedo establecer una relación estrecha con mis clientes/pacientes. 5,34 1,03 0,41 < 0,0001 19. usualmente logro agradarles a mis clientes/pacientes. 5,44 0,89 0,48 < 0,0001 20. a menudo encuentro difícil transmitir mi punto de vista a los pacientes/clientes cuando lo necesito. 5,12 1,38 0,37 < 0,0001 21. cuando trato de resolver un conflicto con clientes/pacientes, habitualmente lo hago peor. 5,70 0,89 0,37 < 0,0001 22. si pienso que un cliente/paciente está incómodo o puede necesitar ayuda, me acerco a esa persona. 5,57 1 0,38 < 0,0001 23. si encuentro difícil el relacionarme con un cliente/paciente, dejo de trabajar con esa persona. 5,20 1,35 0,29 < 0,0001 24. a menudo encuentro difícil relacionarme con clientes/pacientes de culturas diferentes a la mía. 5,49 1,13 0,34 < 0,0001 25. he ayudado a muchos clientes/pacientes a través de mi habilidad para desarrollar relaciones cercanas 5,16 1,07 0,38 y significativas. < 0,0001 26. a menudo encuentro difícil expresar empatía con clientes/pacientes. 5,57 1,07 0,36 < 0,0001 27. a menudo me siento agobiada por la naturaleza de los problemas que los clientes/pacientes están viviendo. 4,89 1,49 0,33 < 0,0001 28. cuando un paciente/cliente está teniendo dificultades para comunicarse conmigo, soy capaz de adaptarme 5,28 1,12 0,41 a su nivel. < 0,0001 29. aún cuando realmente trato, no puedo terminar los cuidados con clientes/pacientes difíciles. 5,23 1,36 0,43 < 0,0001 30. no uso formas creativas o poco usuales para expresar cuidados a mis clientes. 5 1,45 0,44 < 0,0001 total escala coates 162,7 11,42 n: 360 coeficiente alfa de cronbach: 0,76 media: 5,42 desviación estándar: 0,38. desviación correlación estándar ítem -escala items media 18 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 fuente: poblete (21). tabla 5. resultados por ítem del instrumento nyberg caring assessment (n = 360) desviación correlación estándar ítem -escala 1. tiene un profundo respeto por las necesidades del otro. 4,88 0.31 0,34 < 0,0001 2. no desiste de transmitir esperanza a otros. 4,49 1,00 0,34 < 0,0001 3. permanece sensitivo a las necesidades de otros. 4,65 0,57 0,45 < 0,0001 4. comunica a otros una actitud de ayuda y confianza. 4,71 0,47 0,47 < 0,0001 5. expresa sentimientos positivos y negativos. 4,10 0,99 0,43 < 0,0001 6. soluciona problemas creativamente. 4,17 0,78 0,54 < 0,0001 7. comprende que las fuerzas espirituales contribuyen al cuidado humano. 4,70 0,64 0,34 < 0,0001 8. considera las relaciones ante que los reglamentos. 3,97 0,99 0,41 < 0,0001 9. basa las relaciones en lo que es mejor para las personas involucradas. 4,47 0,69 0,51 < 0,0001 10. comprende plenamente lo que las situaciones significan para las personas. 4,40 0,64 0,58 < 0,0001 11. va más allá de lo superficial para conocer bien a la gente. 4,34 0,68 0,60 < 0,0001 12. implementa bien habilidades y técnicas. 4,51 0,64 0,48 < 0,0001 13. elige tácticas que lograrán las metas. 4,39 0,60 0,48 < 0,0001 14. concede plena consideración a los factores situacionales. 4,30 0,75 0,55 < 0,0001 15. se centra en ayudar a crecer a otros. 4,28 0,69 0,64 < 0,0001 16. deja tiempo para necesidades personales y crecimiento. 3,92 0,95 0,34 < 0,0001 17. se permite tiempo para las oportunidades de cuidado. 4,14 0,85 0,55 < 0,0001 18. permanece comprometido con una relación continua. 4,41 0,74 0,58 < 0,0001 19. escucha cuidadosamente y está abierta a la retroalimentación. 4,59 0,58 0,62 0< 0,0001 20. cree que otros tienen un potencial que puede lograrse. 4,62 0,64 0,52 < 0,0001 total nyberg 88,12 7,01 n: 360 coeficiente alfa de cronbach: 0,82 media: 4,40 desviación estándar: 0,35 items media 19 validación de dos escalas utilizadas en la medición del cuidado humano... z margarita del carmen poblete-troncoso, sandra verónica valenzuela-suazo, josé manuel merino significativa entre ellos. el puntaje máximo es 5 y el mínimo 1, la mayoría de los ítems tiene promedios sobre 4. dos de ellos presentan promedios bajo 4 (los ítems 8 y 16). el 8 se relaciona con los reglamentos establecidos en los servicios, y el ítem 16 se refiere al autocuidado de estas profesionales en la salud (tabla 5). en el análisis factorial realizado al nca (tabla 6) se observa que al aplicar la técnica de análisis factorial en el instrumento nca se forman seis factores: el primero acumula una varianza de un 45%, esta reúne los ítems que expresan la importancia que conceden las enfermeras a satisfacer las necesidades del otro (1, 2, 3); el segundo factor tiene un 14% de la varianza acumulada y congrega los ítems referidos a habilidades técnicas de la enfermera; el tercer factor (12%) expresa la relación enfermera-paciente; el cuarto factor (10%), conformado por ítems en relación con el autocuidado de la profesional, el quinto factor (10%) reúne a los ítems que están en concordancia con aspectos espirituales del cuidado del enfermo y, finalmente, el sexto factor (9%) está compuesto por un solo ítem que tiene relación con aspectos éticos del cuidado. el instrumento representa el cuidado humano en todos sus ámbitos. discusión en general, los ítems del instrumento ces presentan promedios sobre 5 puntos siendo el máximo 6, lo que revela que las enfermeras se perciben con autoeficacia para realizar un cuidado humanizado, resultados comparables a los obtenidos por coates en 1992 (4). solo dos ítems muestran puntajes bajos, estos se refieren esencialmente a la dificultad que presentan las enfermeras para dejar de lado sus creencias; el ítem 8, tener una conversación más cercana con el usuario; el ítem 13 muestra el agobio que experimentan las profesionales frente a la naturaleza de los problemas que viven los usuarios, aspecto que hoy día adquiere importancia en los esfuerzos que se realizan para otorgar un cuidado más cercano al otro y centrado en la persona, no en los procedimientos y técnicas estructurados por las instituciones de salud que terminan invisibilizando el cuidado de los profesionales de enfermería (22, 23). en los resultados del nca en su mayoría los ítems presentan promedios sobre 4 puntos confirmando que para las enfermeras adquiere importancia realizar un cuidado humanizado, es decir, centrado en la persona; estos resultados tienen un puntaje levetabla 6. resultado del análisis factorial en el instrumento nyberg caring assessment (n = 360) varianza total factor factor factor factor factor factor porcentaje explicada 1 2 3 4 5 6 acumulado % de varianza 5,19 1,6 1,4 1,2 1,2 1,02 11,6 explicada 45% 14% 12% 10% 10% 9% 100% matriz de componentes rotados fuente: poblete (21). factor 1 factor 2 factor 3 factor 4 factor 5 factor 6 ny1 0,38924 0,06987 0,0141 0,08545 0,10142 0,67299 ny2 0,47702 -0,10963 -0,05036 -0,1186 0,53476 -0,35780 ny3 0,72838 0,12745 0,0961 -0,06505 -0,01412 -0,00061 ny4 0,49931 0,31931 0,0229 -0,01556 0,16549 0,22036 ny5 0,03202 0,04624 0,0826 0,09805 0,79621 0,08321 ny6 0,09356 0,44767 0,0792 0,14564 0,55652 0,16183 ny7 -0,03403 -0,02385 0,5981 -0,04938 0,19375 0,42113 ny8 0,09523 -0,02036 0,7507 0,05772 -0,02175 -0,26756 ny9 0,22628 0,14788 0,6859 0,02891 -0,05814 0,15869 ny10 0,25491 0,46727 0,3703 0,05419 0,17069 0,14420 ny11 0,42569 0,20228 0,4845 0,06871 0,16734 -0,03314 ny12 0,17976 0,77570 0,0293 0,09997 -0,01557 -0,04137 ny13 0,07225 0,79578 0,0541 0,10099 0,07626 0,02683 ny14 0,06966 0,30841 0,3885 0,35251 0,24515 -0,34295 ny15 0,45666 0,25301 0,3161 0,22900 0,21178 0,03346 ny16 -0,05088 -0,02999 -0,0757 0,82363 0,11787 0,09228 ny17 0,15368 0,19497 0,0880 0,81376 0,01518 0,00427 ny18 0,30398 0,36210 0,1886 0,45760 -0,00264 -0,13007 ny19 0,61380 0,16220 0,1592 0,39529 0,02856 0,10137 ny20 0,54400 0,01493 0,2559 0,22383 0,03847 0,24199 20 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 mente mayor a lo obtenido por nyberg en 1990, en que se presentan promedios cercanos al 3,9 (5). en este instrumento los ítems que presentan promedios más bajos muestran que las enfermeras reconocen que tienen dificultad para superar las normas institucionales y establecer relaciones interpersonales, aspectos observados por otros investigadores (14, 15) en los que las enfermeras muestran priorizar más los elementos técnicos y normativos que la relación con el usuario. por último, reconocen las dificultades para autocuidarse, siendo el cuidado de uno mismo considerado un prerrequisito para el cuidado de los demás (1). conclusiones los resultados demuestran que es posible evaluar la percepción de diversos aspectos del cuidado a partir de una filosofía humanista y ética, lográndose visualizar y medir la teoría transpersonal del cuidado humano en la práctica a través de ambas escalas. el esfuerzo por objetivar el cuidado humano transpersonal hace necesaria la validación de estos instrumentos que son un recurso del que se valen los investigadores para acercarse al fenómeno del cuidar desde la filosofía de watson. se reconoce toda la labor previa de investigación de coates y nyberg (4, 5), que permitieron la utilización de sus instrumentos en el presente trabajo de validación y adaptación cultural en población chilena. los resultados de estos instrumentos muestran promedios altos en todos sus ítems, incluso el nca, con puntajes superiores a los obtenidos por la autora en estados unidos (5), lo que puede deberse a que esta lo aplicó solo en enfermeras clínicas de servicios hospitalarios. las correlaciones significativas en los ítems y los coeficientes de alfa de cronbach en ambos instrumentos revelan una consistencia interna adecuada. en cuanto a la validación constructiva el ces y nca son significativamente convergentes y validan la teoría transpersonal del cuidado humano de jean watson y, por tanto, son útiles a la comunidad de enfermería en chile para futuras investigaciones que busquen profundizar el estudio del cuidado humano. la validación de estas escalas permite continuar con investigaciones futuras del cuidado, conocer el significado que las enfermeras le otorgan y cuán eficaces se sienten respecto a cómo lo realizan, aspectos congruentes e incongruentes del cuidado en diferentes grupos de profesionales que necesario conocer, analizar y buscar puntos de encuentro para remediar aquellos puntos débiles desde la práctica y la enseñanza, con la finalidad última de mejorar la calidad en las prácticas de enfermería. por último, como desafío, enfermería debe conservar y lograr avances en el cuidado humano a través de la práctica de los ideales del cuidado en la asistencia, la academia y la investigación, superando los criterios economicistas y administrativos de los servicios de salud que terminan por ocultar y absorber el trabajo de enfermería (23, 24, 25). referencias bibliográficas 1. watson j. nursing: the philosophy and science of caring. 2 ed. colorado: published by the university press of colorado; 1985. 2. watson j. watson’s theory of human caring and subjective living experiences: caritative factors/caritas processes as a disciplinary guide to the professional nursing practice. texto contexto enferm [online] 2007; 16 (1): 129-135. doi: 10.1590/s0104-07072007000100016. 3. rivera l, triana a. cuidado humanizado de enfermería: visibilizando la teoría y la investigación en la práctica, en la clínica del country. actual enferm 2007; 10 (4): 15-21. 4. coates c. the caring efficacy scale: nurses´self-reports of caring in practice settings. adv practice nurs quarterly/ summer 1997; 3 (1): 53-9. 5. nyberg j. the effects of care and economics on nursing practice. jona. 1990 may; 20 (5): 13-18. 6. watson j. assessing and measuring caring in nursing and health science. new york: springer publishing company; 2002. 21 validación de dos escalas utilizadas en la medición del cuidado humano... z margarita del carmen poblete-troncoso, sandra verónica valenzuela-suazo, josé manuel merino 7. bandura a. comments on the crusade against the causal efficacy of human thought. journal of behavior therapy and experimental psychiatry 1995; 26 (3): 179-190. 8. davis mh. a multidimensional approach to individual differences in empathy. jsas catolog of selected documents in psychology 1980; 10: 85. 9. mestre v, frías md, samper p. la medida de la empatía: análisis del interpersonal reactivity index. psicothema 2004; 16 (2): 255-260. 10. watson j. caring science as sacred science. philadelphia: fa davis company; 2005. 11. rogers c, stevens b. persona a persona. el problema del ser humano. una nueva tendencia en psicología. buenos aires: amorrortu; 2003. 12. balanza n. el cuidado de enfermería en la perspectiva del paciente adulto hospitalizado. revista ciencia y enfermería 1997; 3 (1): 59-68. 13. da silva l, coelho m, de lima c, silva de souza p. cuidado de enfermería: su sentido para enfermeras y pacientes. revista de enfermería, colegio de enfermeras chile 2002; 37 (120): 22-27. 14. montecilli m, elsen i. el hospital como una realidad clínica: una comprensión a partir del encuentro entre las trabajadoras de enfermería y familias de un servicio de alojamiento conjunto. rev horizonte de enfermería 2004; 15: 37-52. 15. cardona l, silva l. relación entre la percepción de los comportamientos de cuidado de los pacientes y la del personal de enfermería de la unidad de cuidado intensivo del hospital santa clara. en: grupo de cuidado, facultad de enfermería, universidad nacional de colombia. el arte y la ciencia del cuidado. bogotá; unibiblos; 2002. 16. wolf z. the caring concept and nurse identified caring behaviors. top cli nurse 1986; 8 (2): 84-93. 17. sánchez r, echeverry j. validación de escalas de medición en salud. rev salud pública 2004; 6 (3): 302-318. 18. lucero i, meza s. validación de instrumentos para medir conocimientos. [monografía en internet]. [citado el 31 de julio 2009]. disponible en: http://www1.unne.edu.ar/cyt/2002/09-educacion/d-027.pdf 19. asociación chilena de educación en enfermería. escuelas socias. disponible en www.achieen.cl/achieen/escuelassocias. 20. ministerio de salud. gobierno de chile. departamento de estadística e información en salud. establecimientos de salud. disponible en www.minsal.cl/ 21. poblete m. cuidado humanizado: percepción de la autoeficacia en enfermeras académicas y asistenciales. tesis doctoral. concepción, chile: universidad de concepcion; 2009. 145 p. 22. coelho s, schwartz e, buss m. a humanização do trabalho para os profissionais de enfermagem. acta paul enferm 2006; 19 (4): 444-9. 23. murillo de la vega s. la invisibilización del cuidado en la familia y en los sistemas sanitarios. política y sociedad. salamanca: universidad de salamanca 2000; 35: 73-80. 24. merhy emerson e. saúde a cartografía do trabalho vivo. sao paulo: hucites; 2002. 25. poblete m, valenzuela s. cuidado humanizado: un desafío para las enfermeras en los servicios hospitalarios. acta paulista 2007; 20 (4), 499-503. 243 256 condiciones laborales.indd 243 giomar herrera-amaya1 fred gustavo manrique-abril2 condiciones laborales y grado de satisfacción de profesionales de enfermería 1 enfermera. investigadora grupo de salud pública. universidad pedagógica y tecnológica de colombia. escuela de enfermería. avenida central del norte. tunja. boyacá. colombia. giomymar@latinmail.com 2 enfermero. doctor en salud pública. magíster en salud pública. profesor asociado. universidad nacional de colombia y universidad pedagógica y tecnológica de colombia. grupo de investigación en salud pública. avenida central del norte. tunja. boyacá. colombia. gisp@uptc.edu.co fgma75@gmail.com recibido: 11 de diciembre de 2007 aceptado: 26 de septiembre de 2008 resumen objetivo: evaluar la satisfacción laboral con la modalidad de contratación y el tipo de vinculación en profesionales de enfermería de un hospital de tercer nivel de tunja, boyacá, colombia, entre junio y diciembre de 2005. método: estudio de corte transversal con 39 profesionales del hospital utilizando el ntp 394 (overal job satisfaction, autorizado por pérez-bilbao). se analizó la información en epiinfo 2002, se buscaron diferencias entre medias a través de kruskall wallis con ic 95% p<0,05. resultados: se encontraron medias para la satisfacción general de 77,10 (de 12,36) con un rango de la escala de 15-105; para satisfacción intrínseca 35,46 (de 6,67) rango: 7-49; y para satisfacción extrínseca 41,69 (de 6,50) rango: 8-56. las diferencias encontradas con el estudio fueron las relacionadas con la satisfacción extrínseca y el tipo de vinculación ( p<0,05). conclusiones: la remuneración guarda relación con la insatisfacción, la estabilidad laboral mejora la sensación de satisfacción intrínseca. la mayoría de las investigaciones indican que el aumento de la edad y los años de ejercicio profesional incrementan la satisfacción laboral, situación contraria en nuestro estudio. palabras clave satisfacción en el trabajo, hospital, trabajo, enfermeras, enfermeros. (fuente: decs) working conditions and job satisfaction among nursing professionals abstract objective: to evaluate satisfaction with the type of work contract and labor relationship in a group of nursing professionals at a third tier hospital in tunja, boyacá (colombia) between june and december 2005. method: this is a transverse study with 39 professionals from the hospital. the ntp 394 (overall job satisfaction, authorized by perez-bilbao) was used and the data were analyzed in epi-info 2002. the search for differences among measurements was done via kruskall wallis, with ic 95% p<0.05. año 8 vol. 8 nº 2 chía, colombia octubre 2008 243-256 244 año 8 vol. 8 nº 2 chía, colombia octubre 2008 243-256 aquichan issn 1657-5997 results: the measurement of general job satisfaction was 77.10 (de 12.36) with a range of 15-105; intrinsic satisfaction, 35.46 (de 6.67) with a range of 7-49; and extrinsic satisfaction, 41.69 (de 6.50) with a range of 8-56. the differences found with this study were related to extrinsic satisfaction and the type of labor relationship (p<0.05). conclusions: wage compensation has a bearing on lack of satisfaction. job stability improves the sensation of intrinsic satisfaction. most studies show an increase in job satisfaction with age and years of professional experience, which is contrary to what this study revealed. key words job satisfaction, hospital, work, female nurses, male nurses. condições de trabalho e grau de satisfação de profi ssionais de enfermagem resumo objetivo: avaliar a satisfação de trabalho com a modalidade de contratação e a classe de vinculação de profissionais de enfermagem em um hospital do terceiro nível em tunja, boyacá, colômbia, entre junho e dezembro de 2005. método: estudo transversal com 39 profissionais do hospital usando o ntp 394 (overall job satisfaction, autorizado por pérez-bilbao). a informação foi analisada em epiinfo 2002; as diferencias entre médias foram buscadas usando kruskall wallis com ic 95% p< 0.05. resultados: as médias para satisfação geral foram 77.10 (de 12.36) com um rango da escala de 15 a 105; para satisfação intrínseca, 35.46 (de 6.67), com um rango de 7 a 49; e para satisfação extrínseca, 41.69 (de.650), com um rango de 8 a 56. o estudo achou diferencias na satisfação extrínseca e na classe de vinculação (p< 0.05). conclusões: a remuneração tem relação com a insatisfação. a estabilidade no trabalho incrementa a sensação de satisfação intrínseca. a maior parte dos estudos sinalam que com o aumento da idade e dos anos de exercício profissional aumentam a insatisfação no trabalho, contrário ao revelado no nosso estudo. palavras-chave satisfação no trabalho, hospital, trabalho, enfermeiras, enfermeiros. 245 condiciones laborales y grado de satisfacción de profesionales de enfermería giomar herrera-amaya, fred gustavo manrique-abril introducción la ley 100 de 1993 permitió a los hospitales públicos convertirse en empresas sociales del estado (ese) y funcionar con autonomía financiera, administrativa y fiscal (1), teniendo que ajustar sus plantas de personal para su supervivencia en el mercadeo de servicios de salud. ante esta situación, se afirma que la reestructuración (2) tiene que darse porque los costos laborales y administrativos son excesivos, lo que implica redireccionar a fondo todas las áreas de los hospitales, bajando costos y subiendo la eficiencia de dichos centros asistenciales (3). los ajustes en las plantas de personal, la ampliación de la carga y los horarios de trabajo, la flexibilización y los sistemas de turnos sin incentivos laborales de horas nocturnas y festivas, con contratos de salario integral, donde ni la seguridad social ni los estímulos ni mucho menos las bonificaciones hacen parte de la relación laboral, permiten una diferenciación entre los trabajadores de planta y vinculados con contrato a término indefinido que venían en los sistemas tradicionales y el de ahora, con las nuevas figuras de la intermediación a través de asociaciones de trabajo y cooperativas convirtiéndose en un proceso mercantilista de explotación de la plusvalía, situación que afecta las relaciones laborales, oportunidades de empleo, apreciación del trabajo y la percepción profesional de aquellos que desean iniciar sus estudios en esta área. hoppock (4) publicó en 1935 sus investigaciones donde pone en evidencia que la satisfacción laboral (sl) tiene una estrecha relación con factores como fatiga, monotonía, condiciones de trabajo y supervisión; posteriormente, herzberg sugirió que la real satisfacción del hombre con su trabajo provenía del hecho de enriquecer el puesto de trabajo para que de esta manera pudiera desarrollar una mayor responsabilidad y experimentar a su vez un crecimiento mental y psicológico (5, 6), condiciones requeridas en el trabajo de enfermería en la actividad del cuidado permanente. maslow (7) afirma que la satisfacción de las necesidades da como resultado una actitud positiva de los trabajadores, por tanto se establece que éste es uno de los factores prevalentes relacionados con su motivación, indispensable en la calidad del servicio ofertado por enfermería. a partir de lo anterior, la satisfacción laboral (sl) se entiende como factor determinante de la calidad de la atención (8), y un estado emocional positivo o placentero de la percepción subjetiva de las experiencias laborales del sujeto (9), en el que inciden las circunstancias y características de la labor que se desempeña, y las individuales de cada trabajador condicionando la respuesta afectiva de éste hacia diferentes aspectos del trabajo (10). la teoría bifactorial (9) postula que existen dos grupos o clases de aspectos laborales: un grupo de factores extrínsecos o “factores higiénicos”, y otro de factores intrínsecos o motivadores. los primeros, que no pueden ser controlados o modificados directamente por el trabajador, están relacionados con la higiene, las políticas de organización, la supervisión, la disponibilidad de recursos, el salario y la seguridad. estos factores sólo pueden prevenir la insatisfacción laboral o evitarla cuando ésta exista, de lo contrario hoppock publicó en 1935 sus investigaciones donde pone en evidencia que la satisfacción laboral (sl) tiene una estrecha relación con factores como fatiga, monotonía, condiciones de trabajo y supervisión. 246 año 8 vol. 8 nº 2 chía, colombia octubre 2008 243-256 aquichan issn 1657-5997 pueden conducir a una conducta agresiva, manifestada por sabotaje, maledicencia o agresión directa. los motivadores más eficaces son los intrínsecos al trabajo mismo; desde luego que los extrínsecos, como el salario, son un incentivo importante utilizado fundamentalmente en la industria, aunque también se demostró que con frecuencia no tiene las características de motivación que se le atribuyen (11). la insatisfacción laboral (il) es un riesgo profesional muy extendido entre el personal que presta sus servicios en las instituciones públicas de salud, dicha insatisfacción guardaría una intensa relación con las condiciones de trabajo (12, 13). las características personales determinan los umbrales de satisfacción e insatisfacción. valorar el impacto que tienen la modalidad de contratación (indeterminado y fijo) (14) y el tipo de vinculación (por contrato con intermediario o de planta y carrera) con los niveles de satisfacción tanto del sujeto como de sus compañeros, por las condiciones físicas del trabajo, permitirá una mejor planificación del recurso humano en el sector salud, y mejores condiciones de vida para los profesionales de enfermería. el objetivo del trabajo fue evaluar la satisfacción laboral con la modalidad de contratación, y el tipo de vinculación presente en los profesionales de enfermería de una institución de tercer nivel de tunja a través del instrumento ntp 394. materiales y métodos tipo de estudio: estudio descriptivo evaluativo de corte transversal, mediante la aplicación de los instrumentos: ntp 394 de jesús pérez-bilbao (escala general de satisfacción laboral), y una encuesta de caracterización demográfica. población y muestra: 42 profesionales de enfermería que laboran actualmente en la ese hospital san rafael de tunja. instrumentos: previa autorización del autor, se utilizó el instrumento adaptado al castellano por pérez-bilbao (9) denominado escala general de satisfacción ntp 394 (overal job satisfaction desarrollado por warr, cook y wall en 1979) (15). el instrumento fue validado previamente con un grupo piloto de 30 trabajadores, eliminando las preguntas que no cumplieron con los criterios de validez y confiabilidad en las dimensiones exploradas. se calculó el poder discriminativo con la t de student, y el método de mitades por la r de pearson. la confiabilidad fue de 0,78, que corregida con la prueba de spearman-brown fue de 0,89. la escala operacionaliza el constructo de satisfacción laboral, reflejando la experiencia de los trabajadores de un empleo remunerado, y recoge la respuesta afectiva al contenido del trabajo. la escala está conformada por quince ítems, divididos en dos subescalas que se responden en una escala likert desde muy insatisfecho a muy satisfecho, que oscila entre 1 y 7. la satisfacción general resulta de la puntuación total de la escala que oscila entre 15 y 105, de manera que una mayor puntuación refleja una mayor satisfacción general. la subescala de factores intrínsecos está formada por siete ítems que corresponden a los pares, y su puntuación oscila entre 7 y 49, y la subescala de factores extrínsecos la constituyen ocho ítems impares y la puntuación oscila entre valorar el impacto que tienen la modalidad de contratación y el tipo de vinculación con los niveles de satisfacción tanto del sujeto como de sus compañeros, por las condiciones físicas del trabajo, permitirá una mejor planificación del recurso humano en el sector salud. 247 condiciones laborales y grado de satisfacción de profesionales de enfermería giomar herrera-amaya, fred gustavo manrique-abril 8 y 56. la encuesta se complementó con variables demográficas y laborales para establecer las relaciones propuestas. análisis estadístico: para el análisis de la información se elaboró una base de datos en excel y se analizó con epinfo 2002. se describieron frecuencias y porcentaje para todas las variables sociodemograficas, se estimaron medidas de tenencia central y dispersión para las variables continuas y discretas, se realizó prueba de kruskall wallis para diferencias entre medias, se aceptaron diferencias p<0,05. resultados de 42 profesionales de enfermería del hospital se logró recoger la información de 39 de ellos, las censuras y pérdidas se relacionaron con dos profesionales en periodo de vacaciones, y un profesional rehusó a participar en el estudio. tabla 1. descripción de la población variable rango frecuencia/porcentaje ic 95% sexo masculino 2 (5,1%) 0,6-17,3 femenino 37 (94,9%) 82,7-99,4 edad <32 6 (15,4%) 5,9-30,5 32-40 11 (28,2%) 15-44,9 40-48 15 (38,5%) 23,4-55,4 >48 7 (17,9%) 7,5-33,5 tipo de vinculación hospital, planta 31 (79,5%) 63,5-90,7 intermediación 8 (20,5%) 9,3-36,5 modalidad de contratación indefinido 25 (64,1%) 47,2-78,8 definido 14 (35,9%) 21,2-52,8 salario 500-999 2 (5,1%) 0,6-17,3 1’000-1’499 8 (20,5%) 9,3-36,5 1’500-1’999 25 (64,1%) 47,2-77,8 2’000-más 4 (10,3%) 2,9-24,2 antigüedad < de 10 años 12 (30,8%) 17-47,6 10-20 años 19 (48,7%) 32,4-65,2 > de 20 años 8 (20,5%) 9,3-36,5 categoría profesional universidad 18 (46,2%) 30,1-62,8 posgrado 13 (33,3%) 19,1-50,2 cursos 8 (20,5%) 9,3-36,5 estado civil casado 20 (51,3%) 34,8-67,6 divorciado 3 (7,7%) 1,6-20,9 unión libre 4 (10,3%) 2,9-24,2 soltera 12 (30,8%) 17-47,6 servicio de trabajo ambulatorio 3 (7,7%) 2-21,9 hospitalización 24 (61,5%) 44,6-76,1 u. especiales 12 (30,8%) 17,5-47,7 intensidad horaria semanal 36 horas 6 (15,38%) 5,9-30,5 48 horas 27 (69,24%) 52,4-83 >48 horas 6 (15,38%) 5,9-30,5 ic 95% = intervalo de confianza. la insatisfacción laboral (il) es un riesgo profesional muy extendido entre el personal que presta sus servicios en las instituciones públicas de salud, dicha insatisfacción guardaría una intensa relación con las condiciones de trabajo. 248 año 8 vol. 8 nº 2 chía, colombia octubre 2008 243-256 aquichan issn 1657-5997 las características de los sujetos de estudio se observan en la tabla 1, mostrando que sociodemográficamente la mayor parte de profesionales son mujeres –concepción cultural y razón histórica de la enfermería en colombia–; de edad adulta, entre 32 y 48 años; etapa productiva laboral; la mayoría con una intensidad horaria de 48 horas laborales a la semana y un salario que oscila entre 1.500.000-1.999.000 pesos. en su gran mayoría están contratadas de planta y con contrato indefinido según para la categoría profesional, la especialización y otras variedades de posgrado no representan la mayoría, notándose la despreocupación por la realización de estudios después del pregrado. código sustantivo del trabajo (14). para la categoría profesional, la especialización y otras variedades de posgrado no representan la mayoría, notándose la despreocupación por la realización de estudios después del pregrado. se encontró que la antigüedad de 1020 años predomina, sin llegar a ser mayoría. en cuanto a la situación civil, el 51,3% son casadas, el 30,8% solteras, el 10,3% en unión libre, y el 7,7% divorciadas. en cuanto a las variables mostradas en la tabla 2, se encuentra diferencia significativa (p<0,05) para edad, salario y antigüedad, frente al tipo de vinculación y la modalidad de contratación. en relación con la intensidad horaria se presenta la ausencia de dicha diferencia observándose que la carga laboral es similar en ambos campos. al analizar los 15 índices influyentes en la satisfacción laboral y el tipo de vinculación encontramos que su asociación es débil; sin embargo, las diferencias encontradas en la libertad para elegir el propio método de trabajo (p=0,03) con una mejor satisfacción para los vinculados de planta (media 5,64; de 1,37) que para los vinculados por cooperativa (media 5; de 0,75), en la posibilidad de utilizar tus capacidades (p=0,04) donde la vinculación por intermediación se encuentran menos satisfechos (media 4,5; de 1,77) que los vinculados directamente por el hospital (media 5,64; de 1,22), y las encontradas en la asociación con la estabilidad en el empleo con un mayor promedio de satisfacción en la población vinculada directamente por el hospital (media 5,67; de 1,19) que los vinculados por intermediación (media 4,37; de 1,18) son estadísticamente significativas (tabla 3). al observar las medias de los ítems restantes, aunque la brecha no es signifi edad * salario* antigüedad* intensidad horaria media de media de media de media de tipo de planta 44,9 5,1 1717,7 239,2 16,6 5,2 46,8 4,4 vinculación intermediación 29,6 4,3 1250,0 267,2 1,1 0,6 46,1 4,5 modalidad definido 36,8 10,0 1464,2 323,1 6,5 8,4 45,6 5,2 de contratación indefinido 44,5 4,8 1710,0 266,9 16,9 5,3 46,6 4,0 total 41,7 7,9 1621,7 308,1 13,2 8,2 46,3 4,4 tabla 2. medias y desviación de variables cuantitativas por vinculación y contratación * p< 0,01. de desviación estándar. 249 condiciones laborales y grado de satisfacción de profesionales de enfermería giomar herrera-amaya, fred gustavo manrique-abril cativa, en el reconocimiento que obtienes por el trabajo bien hecho y el salario en los profesionales de enfermería vinculados por intermediación, de igual manera en el reconocimiento que obtienes por el trabajo bien hecho, las posibilidades de promoción, modo en que la empresa está gestionada y la atención que prestan a las sugerencias que hacen para los profesionales vinculados directamente por el hospital, hay que optimizar la satisfacción sin dejar de lado el constante proceso de fortalecimiento de los ítems restantes en los dos tipos de vinculación para no tener brecha alguna. al analizar la asociación entre los índices influyentes de la satisfacción y la modalidad de contratación se observa que en el salario hay significancia estadística (p= 0,00) con un mayor promedio de satisfacción extrínseca en la población contratada por tiempo definido (media 3,66; de 1,63) que los contratados por tiempo indefinido (media 5,09; de 1,42). en la estabilidad en el empleo hay diferencia estadísticamente significativa (p= 0,04) con un menor promedio de satisfacción en la población contratada por tiempo definido (media 5,5; de 0,83) que los contratados por tiempo indefinido (media 5,67; de 1,19). aunque las medias restantes no son estadísticamente significativas, se presentan brechas en el reconocimiento que obtienes por el trabajo bien hecho, la posibilidad de promoción, el modo en que la empresa está gestionada y la atención que prestan a las sugerencias que hacen para la modalidad de contratación indefinida siendo necesario el proceso de fortalecimiento en éstos. tipo de vinculación grado de satisfacción planta cooperativa p media de media de 1. condiciones físicas del trabajo 5,32 1,13 5,25 0,46 0,58 2. libertad para elegir tu propio método de trabajo 5,64 1,37 5 0,75 0,03** 3. tus compañeros de trabajo 5,61 1,08 5,37 1,06 0,49 4. reconocimiento que obtienes por el trabajo bien hecho 4,35 1,88 4,62 1,06 0,90 5. tu superior inmediato 5,45 1,28 5,62 1,18 0,76 6. responsabilidad que se te ha asignado 5,8 0,90 5 1,69 0,12 7. tu salario 5,09 1,42 4 1,85 0,09 8. la posibilidad de utilizar tus capacidades 5,64 1,22 4,5 1,77 0,04** 9. relación entre dirección y trabajadores en tu empresa 5,06 1,61 5,37 1,50 0,49 10. tus posibilidades de promoción 4,22 1,87 4,75 1,38 0,54 11. el modo en que tu empresa está gestionada 4,61 1,87 4,75 1,03 0,94 12. la atención que prestan a las sugerencias que haces 4,54 1,47 4,75 1,16 0,83 13. tu horario de trabajo 5,45 1,20 5,12 1,126 0,32 14. la variedad de tareas que realizas en tu trabajo 5,67 0,83 5,12 1,72 0,56 15. tu estabilidad en el empleo 5,67 1,19 4,37 1,18 0,00 * *p<0,01. **p<0,05 (test de kruskal-wallis para dos grupos). de desviación estándar. tabla 3. análisis de los índices de satisfacción por tipo de vinculación en la estabilidad en el empleo hay diferencia estadísticamente significativa (p= 0,04) con un menor promedio de satisfacción en la población contratada por tiempo definido (media 5,5; de 0,83) que los contratados por tiempo indefinido (media 5,67; de 1,19). 250 año 8 vol. 8 nº 2 chía, colombia octubre 2008 243-256 aquichan issn 1657-5997 (de 12,8), levemente mayor que los vinculados por intermediación con una media de 73,6 (de 10,5). frente a la modalidad de contratación se puede afirmar que hay un mayor promedio de satisfacción general en la población contratada por tiempo indefinido con una media de 78,4 (de 12,4) que los contratados por tiempo definido con una media de 74,4 (de 12,2). en la satisfacción general la media encontrada es de 77,1 (de=12,36) en la población total, y su asociación con las variables determinantes es débil, sin diferencia estadísticamente significativa para las medias frente a la modalidad de contratación y al tipo de vinculación; sin embargo, en la población vinculada directamente por el hospital la media fue 77,9 frente a la modalidad de contratación se puede afirmar que hay un mayor promedio de satisfacción general en la población contratada por tiempo indefinido con una media de 78,4 (de 12,4) que los contratados por tiempo definido con una media de 74,4 (de 12,2). 1. condiciones físicas del trabajo 5,16 1,47 5,32 1,13 0,34 2. libertad para elegir tu propio método de trabajo 6 0,89 5,64 1,37 0,29 3. tus compañeros de trabajo 5,16 1,32 5,61 1,08 0,19 4. reconocimiento que obtiene por el trabajo bien hecho 4,16 2,31 4,35 1,88 0,92 5. tu superior inmediato 5,33 1,03 5,45 1,28 0,82 6. responsabilidad que se te ha asignado 5,83 1,16 5,8 0,90 0,36 7. tu salario 3,66 1,63 5,09 1,42 0,00* 8. la posibilidad de utilizar tus capacidades 6 0,63 5,64 1,22 0,33 9. relación entre dirección y trabajadores en tu empresa 4,66 1,75 5,06 1,61 0,92 10. tus posibilidades de promoción 4 2,09 4,22 1,87 0,84 11. el modo en que tu empresa está gestionada 4,5 1,51 4,61 1,87 0,75 12. la atención que prestan a las sugerencias que haces 4,83 1,72 4,54 1,47 0,58 13. tu horario de trabajo 5,33 1,63 5,45 1,20 0,43 14. la variedad de tareas que realizas en tu trabajo 5,33 1,21 5,67 0,83 0,30 15. tu estabilidad en el empleo 5,5 0,83 5,67 1,19 *0,01 modalidad de contratación índices de satisfacción contrato definido contrato indefinido p media de media de tabla 4. análisis de los índices de satisfacción por modalidad de contratación *p<0,01. **p<0,05 (test de kruskal-wallis para dos grupos) de desviación estándar. 251 condiciones laborales y grado de satisfacción de profesionales de enfermería giomar herrera-amaya, fred gustavo manrique-abril en la asociación realizada para la satisfacción intrínseca (media 35,46; de 6,6) con la satisfacción extrínseca (media 41,64; de 6,5) se encuentra diferencia estadística (p= 0,00), sin diferencia para el tipo de vinculación y la modalidad de contratación. las diferencias estadísticas encontradas en la satisfacción extrínseca fueron las relacionadas con categoría profesional (p=0,05) y el estado civil (p=0,03); para la satisfacción intrínseca no se encontró ninguna diferencia significativa. dentro de las variables poblacionales asociadas con la satisfacción intrínseca y extrínseca encontramos los niveles más variable rango satisfacción general n media de p total 15-105 39 77,1 12,36 sexo masculino 2 71 4,2 0,23 femenino 37 77,3 12,6 edad <32 6 71,5 8,6 0,30 32-40 11 82,7 9,5 40-48 15 76,5 13,9 >48 7 73,8 14,1 tipo de vinculación hospital, planta 31 77,9 12,8 0,40 intermediación 8 73,6 10,5 modalidad de contratación indefinido 25 78,4 12,4 0,31 definido 14 74,4 12,2 salario 500-999 2 75 1,4 0,41 1’000-1’499 8 69,2 15,1 1’500-1’999 25 79 10,6 2’000-más 4 80,7 16,8 antigüedad < de 10 años 12 76,7 11,8 0,97 10-20 años 19 77,1 14,4 > de 20 años 8 77,2 8,6 categoría profesional universidad 18 72,3 12,8 0,10 posgrado 13 83,1 11,7 cursos 8 77,5 8,4 estado civil casado 20 79,5 10,7 0,18 divorciado 3 88 11,5 unión libre 4 78,5 5,7 soltero 12 69,9 13,9 intensidad horaria semanal 36 horas 6 75 12,44 0,60 48 horas 27 77,5 12,7 >48 horas 6 76,6 12,5 tabla 5. asociación de las variables determinantes con el grado de satisfacción general n = número de individuos, de = desviación estándar. p = (test de kruskal-wallis para dos grupos) dentro de las variables poblacionales asociadas con la satisfacción intrínseca y extrínseca encontramos los niveles más altos en los rangos de sexo femenino, que están vinculados directamente por el hospital, los contratados por tiempo indefinido, con una intensidad horaria laboral no mayor a 48 horas. 252 año 8 vol. 8 nº 2 chía, colombia octubre 2008 243-256 aquichan issn 1657-5997 altos en los rangos de sexo femenino, con edades entre 32 y 40 años, que están vinculados directamente por el hospital, los contratados por tiempo indefinido, las/os profesionales con posgrado, las/os divorciadas/os y las/os enfermeras/os con una intensidad horaria laboral no mayor a 48 horas. para la variable antigüedad hay una percepción opuesta frente a la satisfacción ya que intrínsecamente hay mayor satisfacción en los que tienen más de 20 años de antigüedad (media 36,2; de 5,3), y extrínsecamente es mayor la satisfacción en el personal con menos de 10 años de antigüedad (media 42,2; de 5,7). con para locke, las remuneraciones guardan relación con el valor asignado al trabajo, lo que permite aproximarnos a definir políticas de equidad salarial frente al trabajo, en mejora de condiciones de vida. satisfacción intrínseca satisfacción extrínseca media de p media de p total 35,46 6,6 41,64 6,5 **0,00 sexo masculino 34,5 3,5 0,79 36,5 0,7 0,13 femenino 35,5 6,8 41,9 6,6 edad <32 32,8 6,8 0,56 38,6 2,8 0,10 32-40 37,9 5,4 44,8 4,7 40-48 34,8 7,3 41,7 7,3 >48 35,2 7,0 39 8,2 tipo de vinculación hospital, planta 35,9 6,7 0,55 42 6,9 0,17 intermediación 33,7 6,6 39,8 4,7 modalidad de contratación indefinido 35,8 6,7 0,58 42,7 6,4 0,09 definido 34,7 6,8 39,6 6,4 salario 500-999 33,5 2,1 0,43 41,5 3,5 0,32 1’000-1’499 31,2 8,2 38 7,4 1’500-1’999 36,4 5,7 42,7 5,9 2’000-más 38,7 8,0 42 8,9 antigüedad < de 10 años 34,5 7,1 0,90 42,2 5,7 0,89 10-20 años 35,7 7,1 41,3 7,9 > de 20 años 36,2 5,3 41,3 4,4 categoría profesional universidad 33,4 7,1 0,22 38,9 63,5 **0,05 posgrados 38 6,8 45,1 6,1 cursos 35,8 3,6 42 4,8 estado civil casado 36,6 6,2 0,44 43,2 5,1 **0,03 divorciado 40,3 7,6 47,6 4,04 unión libre 36 1,1 42,5 6,1 soltero 32,6 7,7 37,2 7,2 intensidad horaria semanal 36 horas 33,6 7,2 0,50 41,3 6,1 0,91 48 horas 35,9 6,3 41,7 7,0 >48 horas 35,1 8,5 41,5 5,2 tabla 6. asociación de las variables determinantes con el grado de satisfacción intrínseca y extrínseca n =número de individuos, de = desviación estándar. *p<0,01; **p<0,05 (test de kruskal-wallis para dos grupos) 253 condiciones laborales y grado de satisfacción de profesionales de enfermería giomar herrera-amaya, fred gustavo manrique-abril respecto al salario, aunque los mayores grados de satisfacción no se encuentran en el mismo rango, la tendencia no corresponde a mayor salario mayor satisfacción, reflejándose las transiciones salariales actuales. discusión en relación con el perfil biosociodemográfico de las/os enfermeras/os participantes en el estudio, se puede decir que son jóvenes, sus edades varían entre 22 y 48 años; con respecto al tipo de vinculación el 79,5% está de planta y el 20,5% restante por intermediación; frente a la modalidad de contratación el 64,1% están contratadas a término indefinido y el 35,9% a término definido; para la variable ejercicio profesional, el 71,7% tiene menos de 10 años de trabajo. el tiempo de trabajo no mostró significancia estadística al relacionarlo con la satisfacción general observando similar satisfacción; así mismo, con la edad no existió diferencia, aunque hubo un marcado aumento en el grupo de 32 a 40 años de edad, lo que no guarda relación con estudios que indican que la satisfacción laboral aumenta con la edad y los años de trabajo (16, 17, 18, 19). en cuanto al estado civil, el 52,3% son casadas y el 30,8% solteras. aunque no hay diferencias respecto a las satisfacción general, sí se evidencian cambios significativos (p<0,05) en la satisfacción extrínseca que indaga sobre la satisfacción del trabajador con aspectos relativos a la organización del trabajo, resultado relevante muy contrario al metaanálisis de brush (16) y colaboradores, que no demostró esta diferencia. se observa mayor satisfacción en las divorciadas, lo que no coincide estrictamente con la situación civil, pero sí refleja una tendencia que se viene dando en la última década donde el control social ya no es tan intenso y la mujer ha tenido una participación más activa reivindicando sus derechos y libertades, entre ellos el divorcio. la satisfacción en general es muy buena en las dimensiones extrínsecas, muy similar a lo encontrado por crose (20). la remuneración se encontró diferente por tipo de contratación, hay mayor satisfacción en el grupo de enfermeras contratadas indefinidamente, la estabilidad dada por el tipo de contrato favorece la satisfacción. para locke (10), las remuneraciones guardan relación con el valor asignado al trabajo, lo que permite aproximarnos a definir políticas de equidad salarial frente al trabajo, en mejora de condiciones de vida. los efectos de plantas de personal globales llevan a insatisfacción laboral por no permitir asensos laborales, algunas de las actividades de dirección dentro de la institución son delegadas y normalmente se prefiere al personal de planta, por lo tanto la discriminación en el ascenso por el tipo de vinculación favorece la insatisfacción. en la mayoría de las investigaciones se concluye que las promociones son escasas o que las políticas de promoción no son las adecuadas, y las remuneraciones son consideradas como menos de lo que merecen, entre otras cosas (21, 22, 23). estos mismos hallazgos fueron encontrados en otros estudios, que concluyeron que las promociones son uno de los aspectos del trabajo que más insatisfacción produce entre las/os enfermeras/os (22, 24, 25). una estrategia que mejoraría la satisfacción serían modalidades de contrato mercantil como el outsourcing, fien la mayoría de las investigaciones se concluye que las promociones son escasas o que las políticas de promoción no son las adecuadas, y las remuneraciones son consideradas como menos de lo que merecen, entre otras cosas. 254 año 8 vol. 8 nº 2 chía, colombia octubre 2008 243-256 aquichan issn 1657-5997 ducia, el consorcio, la unión temporal, la agencia comercial y la preposición. respecto a la variable remuneraciones, resultó diferente con estadística significativa cuando se analiza según tipo de contratación (p<0,001); en los nuevos sistemas un alto número de enfermeras/ os perciben que sus remuneraciones son menos de lo que merecen, están mal pagadas/os, no les proporcionan lujos ni cumplen con sus expectativas; también creen que no son adecuadas a sus gastos normales y que son malas. además, sienten que su alta capacitación y la complejidad del trabajo que realizan no es reconocida. en la variable interacción con los compañeros de trabajo es mayor la satisfacción para el de planta y el de contrato indefinido. esto se corrobora con estudios realizados más recientemente en los que se encontró que la interacción satisfactoria con los pares generaba satisfacción laboral (24, 26, 27, 28). la satisfacción laboral se ha relacionado también con la familia, es así como los empleados que experimentan altos niveles de conflicto familiar tienden a demostrar bajos niveles de satisfacción laboral (29). otras investigaciones revelan que la familia es vista como un soporte importante para la consecución de la satisfacción laboral (30). la autonomía de las eps como intermediarias para contratar los servicios entre las ips se convierte en una dificultad para aquellos profesionales que no se encontraban asociados u organizados previamente, que son la mayoría, y casi siempre son las nuevas promociones; ante esta situación son las empresas intermediadoras las que definen unilateralmente las tarifas por los servicios profesionales, tarifas que no representan los costos reales de la prestación del servicio, obligando a las enfermeras y, en general, al personal de salud, a mejorar la calidad lo cual no es negativo para la profesión; sin embargo, lo que está en discusión es el mercadeo de sus servicios, donde es necesario plantear si la reforma se seguirá inclinando hacia la reducción de los costos donde lo que corre mayor riesgo es la recompensa, es decir, los salarios y las políticas de acenso que deben ser percibidos como justos por parte de los empleados para sentirse satisfechos con el mismo, ya que la problemática salarial hace que el trabajador se sienta poco valorizado en compensación con su trabajo. las acciones de mejora que se podrían plantear pueden ser del tipo de desarrollo organizacional, así la dirección debe promover una estrategia para conseguir un cambio planificado y una mejora en la organización. en la literatura de desarrollo organizacional se pueden encontrar numerosos ejemplos en que la promoción de determinados climas ha producido efectos positivos en la mejora de la organización. básicamente, la intervención sobre el clima incluye programas de entrenamiento y perfeccionamiento promovidos por la dirección y basados en dinámicas grupales. no obstante, dado su carácter descriptivo, los resultados de esta investigación deben ser tomados con cautela, ya que nuestro trabajo no está exento de limitaciones, una de ellas es el carácter subjetivo del instrumento utilizado; pese a ello, consideramos que los resultados de este estudio pueden ser útiles para plantear intervenciones concretas que tengan como objetivo la mejora del nivel de satisfacción laboral. la satisfacción laboral se ha relacionado también con la familia, es así como los empleados que experimentan altos niveles de conflicto familiar tienden a demostrar bajos niveles de satisfacción laboral. 255 condiciones laborales y grado de satisfacción de profesionales de enfermería giomar herrera-amaya, fred gustavo manrique-abril finalmente, es necesario reaccionar ante las dificultades de contratación actual, y dar una profunda negativa a la intermediación laboral (confundida con el principio de cooperativismo), donde primero conozcamos nuestros derechos como enfermeras y luego luchemos por nuestro bienestar laboral, exigiendo se valore la esencia del quehacer de enfermería como uno de los mejores brindados a la sociedad; debemos también buscar, ante la modernización de los hospitales, nuevas formas de contrato que beneficien al colectivo de enfermería como el outsourcing, fiducia, el consorcio, la unión temporal, la agencia comercial y la preposición (forma de mandato que tiene por 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article experience of post-icu syndrome in critical disease survivors experiencia del síndrome post-uci en  supervivientes de enfermedades críticas experiência da síndrome pós-uti em sobreviventes de doenças críticas 10.5294/aqui.2022.22.1.6 ángela maría henao-castaño 1 nathaly rivera-romero 2 heidi paola ospina garzón 3 1 https://orcid.org/0000-0003-4203-0016. universidad nacional de colombia, colombia. angmhenaocas@unal.edu.co 2 https://orcid.org/0000-0002-3758-8798. universidad nacional de colombia, colombia. nrive rar@unal.edu.co 3 https://orcid.org/0000-0002-9802-7628. hospital federico lleras acosta, colombia. hpospina@ucundinamarca.edu.co received: 17/03/2021 sent to peers: 02/09/2021 approved by peers: 07/10/2021 accepted: 04/11/2021 theme: evidence-based practice. contribution to the discipline: post icu syndrome is characterized by physical, cognitive, and emotional problems in the medium and long term after discharge. considering the prevalence of these alterations, and their impact on people and even their families, understanding the experience of critical illness survivors after icu discharge will make it possible to propose interventions that mitigate these symptoms, include this phenomenon in the training of personnel working in these units, and provide research tools to justify early symptom detection, mitigation, and rehabilitation programs that allow the patient to recover altered functions or minimize their impact. to reference this article / para citar este artículo / para citar este artigo: henao-castaño am, rivera-romero n, ospina hp. experience of post-icu syndrome in critical disease survivors. aquichan. 2022;22(1):e2216. doi: https://doi.org/10.5294/aqui.2022.22.1.6 abstract introduction: surviving intensive care unit (icu) brings positive and negative feelings, depending on each person's experience. likewise, some patients may present with negative mental and physical consequences after discharge, causing a very complex stay at home. aim: to understand the experience of critical illness survivors after three months of icu discharge. methods: hermeneutical phenomenological study using in-depth interviews with 15 adult participants after three months of icu discharge. data analysis was made considering cohen, kahn, and steeves' procedures. results: phenomenological analysis revealed three existential themes: changes in memory and mood, changes in day-to-day life, and my body after icu. conclusion: surviving icu brings with it positive aspects such as winning a battle against death. however, psychological, emotional, and physical consequences after discharge turn it into an exhausting experience. keywords (source decs): critical illness; critical care; qualitative research; patient; survivors. resumen introducción: sobrevivir a la unidad de cuidados intensivos (uci) trae sentimientos positivos y negativos, dependiendo de la experiencia de cada persona. asimismo, algunos pacientes pueden presentar consecuencias físicas y mentales negativas tras el alta, lo que ocasiona una estadía en casa muy compleja. objetivo: comprender la experiencia de los sobrevivientes de enfermedades críticas después de tres meses del alta de la uci. métodos: estudio fenomeno-lógico hermenêutico mediante entrevistas a profundidad a 15 participantes adultos después de tres meses del alta de la uci. el análisis de datos se realizó con base en los procedimientos de cohen, kahn y steeves. resultados: el análisis fenomenológico reveló tres temas existenciales: cambios en la memoria y el estado de ánimo, cambios en la vida cotidiana y mi cuerpo después de la uci. conclusión: sobrevivir en la uci trae consigo aspectos positivos como ganarle una batalla a la muerte; sin embargo, las consecuencias psicológicas, emocionales y físicas tras el alta convierten todo esto en una experiencia agotadora. palabras clave (fuente decs): enfermedad crítica; cuidados críticos; investigación cualitativa; paciente; sobrevivientes. resumo introdução: sobreviver à unidade de tratamento intensivo (uti) traz sentimentos positivos e negativos, dependendo da experiência de cada um. além disso, alguns pacientes podem apresentar consequências físicas e mentais negativas após a alta, o que ocasiona um período complexo de repouso domiciliar. objetivo: compreender a experiência dos sobreviventes de doenças críticas depois de três meses da alta da uti. materiais e métodos: estudo fenomenológico hermenêutico mediante entrevistas a profundidade com 15 participantes adultos depois de três meses de receberem alta da uti. a análise de dados foi realizada com base nos procedimentos de cohen, kahn e steeves. resultados: a análise fenomenológica revelou três temas existenciais: "mudanças na memória e no humor", "mudanças na vida cotidiana" e "meu corpo depois da uti". conclusões: sobreviver à uti traz consigo aspectos positivos como o sentimento de ter ganhado uma batalha contra a morte; contudo, as consequências psicológicas, emocionais e físicas após receber a alta tornam tudo isso uma experiência exaustiva. palavras-chave (fonte decs): estado terminal; cuidados críticos; pesquisa qualitativa; paciente; sobreviventes. introduction despite technology and medical and care advances, a typical experience in the intensive care unit (icu) involves many patients leaving it. consequently, discharge from the intensive care unit becomes a long road for many former patients. during hospitalization in the icu, they are faced with isolation from their families, immobilization, sedation, painful procedures, and physical deconditioning that may persist one to five years after hospital discharge, resulting in motor problems and risk of falling and adversely affecting the quality of life (1). other patients develop delirium, a consciousness alteration shown in disorganized cognition and perception; it varies from hours to days and prevents the information from being properly processed, stored, and remembered (2). it is also associated with poor prognosis for the patient (3), such as more extended hospital stay (4), high mortality rates (5, 6), readmission to icu (7), cognitive decline (8), and long-term functional impairment (9); anxiety, depression (10) , and other psychiatric symptoms in 17-47% of the cases (11). the american association for critical care defines post intensive care syndrome (pics) as a set of new impairments that worsen physical and cognitive or mental health beyond icu hospitaliza-tion (12). pics considers the impact that the intensive care unit can have on the patients' lives after discharge and the manifestations experienced. the first manifestation reported in the literature is generalized muscle weakness and poor mobility and signs and symptoms of myopathy due to critical illness; the triggers considered are malnutrition and sensory disorders (13). alteration in sleep patterns is reported in a study in which some patients did not remember their stay in the icu, for which amnesia is often cited as a consequence of sedating a mechanically ventilated patient (14). in one study, patients reported confused or disoriented memories and negative memories (20-45%) related to pain, anguish, sleeping difficulties, noise, fear, and feeling of abandonment; 20 reported positive memories. at three months, the experience in the icu was characterized by anxiety and post-traumatic stress disorder (15). in qualitative studies, participants describe sleeping difficulties, expressing the need for a night of normal sleep and how nightmares torment them after hospital discharge (16). thus, this research aims to understand the experience of critical illness survivors three months after icu discharge. this study will allow the nursing staff to understand patients' sequelae after discharge and thus develop strategies that reduce problems with timely integration into daily life. materials and methods this qualitative research is of a hermeneutical phenomenological type. qualitative research helps to understand social phenomena, emphasizing participants' experiences and points of view (17). the phenomenological approach is the deep understanding of a phenomenon from the experience until it reaches its essence (18). the study was conducted in a twelve-bed icu of a tertiary referral hospital in a city in colombia. the inclusion criteria were as follows: adults with physical and mental conditions, after icu hospitalization, willing to be interviewed and participate in the study. records were available to locate each participant. after explaining the aim and method to each participant, they gave their verbal consent. no financial or other remuneration was offered, with no coercion by the researcher, who announced that the interview would end when they said so. interviews were conducted by a single interviewer from the nursing staff affiliated with the icu from which participants were discharged. the interviews were carried out without complications, protecting privacy and confidentiality by avoiding proper names and giving a number to each interview. the sampling included fifteen volunteers who met the selection criteria. the participants' contact details were provided by the discharge registry of the last three months of the icu in which the study was conducted. in-depth interviews were conducted to collect the information, asking a central question about their experience. questions: how was your experience three months after icu discharge? what changes have you experienced in your daily life? the interviews lasted 40 to 60 minutes, were recorded in magnetic medium, and conducted between october and november 2019. the participants were interviewed individually at their homes. in eight interviews, they were with a family member who did not participate in the interview. the participant's autonomy to end the interview at the time indicated was respected. we analyzed data manually as recommended by cohen, kahn, and steeves (16). first, the interview was transcribed to the end, without omitting any phrase or expression, then compared to the recording and finally saved on a computer. then, each sentence was read line by line. the initial interpretation gave the general aspects, followed by coding, analysis, and transformation into significant data. topics in another record were labeled with the interview number, page, and consecutive number to locate each interview. their interpretation showed the participants' point of view and depth the researcher gave to each finding; it reflected reality but respected their individual expression. then, the second interview was conducted, following the same process and order described above, until obtaining the theoretical saturation of the data, achieved with 15 participants. the data analysis followed the three phases proposed by van manen. phase i describes the experience three months after icu discharge. in phase ii, the experience was interpreted by generating units of meaning and themes supported by the interviews and field notes; the themes were identified by two of the researchers. in phase iii, description and interpretation were combined, reflected in themes and their similarities, allowing an understanding of the phenomenon and the preparation of the text (19). two preliminary interviews were conducted to assess communication and interaction with the participant. questions were also evaluated to identify those that produced enriching answers for later analysis. experts reviewed all results and helped to estimate their relationship with the aim. the study has the institutional endorsement under the declaration of helsinki guidelines (20) and includes all ethical aspects to protect participants. signing the written informed consent was requested to participate in the study and record the interviews, where the study objectives and methods were explicit. the interviewer had training for referring and counseling the interviewee in case of identifying alterations in their physical and mental health that require immediate attention. results fifteen people, including five women and ten men, participated in the study, with educational levels ranging from primary to secondary education. the youngest was 25 years old and the oldest 86, and for thirteen of the participants, it was their first icu hospitalization. admission to the icu was elective for one participant with a post-operative diagnosis of orthopedic surgery; the other 14 participants were admitted unplanned due to pneumonia (4), acute myocardial infarction (3), renal failure (4), and stroke (3). the average length of icu stay was nine days, with mechanical ventilation. all interviews were held at home. the icu where the participants were hospitalized is a unit for different critical illness diagnoses. it is the most important referral center in the city. it has 12 independent patient cubicles and the care of an interdisciplinary group changes in memory and mood for the participants, hospitalization in the icu meant dramatic changes. their stories revealed alterations in their mental functions, mainly in memory, mood, sleep cycle, and cognition. regarding memory, they had from occasional gaps that improved over time to significant alterations in working memory that needed the company of a family member for some activities: " the first few days at home, i hardly remembered things. now, thank god, i have recovered most of my memory because it was like losing it." e2 "i have noticed that my memory has decreased; in any case, having been there has been a complication because i feel that i would have been someone if i had not gone through that event." e4 "i have become forgetful; i forget to take my medication." e10 most of the participants reported significant changes in their mood after the icu. they had no desire to do anything, avoided contact with other people, and felt discouraged; symptoms such as anhedonia, sadness, and even anxiety were identified in the speech. some of them experienced these effects just after discharge, but others continued with these symptoms even until the interview. "depressed, tired; there are days when i am very disheartened. i went out alone. i did not want to contact anyone; everyone annoyed me. i was very depressed, exhausted. i did not want to do anything with anyone. i did not want to go out. it seemed awkward to me." e15 "i feel discouraged. i do not feel like talking to anyone or listening to people, much less having long conversations. i used to talk a lot, and i liked learning about many things. now, i am not interested in anything." e8 "depression. i just want to cry and run away. that's how i feel, and i don't know why." e13 few participants reported disturbances in the sleep cycle, such as conciliation insomnia, waking up several times at night, and sleeping but no resting. this aspect is striking, given that sleep is essential to have physiological and emotional balance, especially after being hospitalized in the icu. "some nights i don't sleep well; i can't fall asleep." el "i am sleepless, and i feel tired, like exhausted from not sleeping. the tranquility of sleeping goes away. i cannot sleep at night." e3 changes in day-to-day life during the interviews, patients described before and after icu scenarios in their daily lives. they talked about physical alterations that made it difficult or impossible for them to perform some daily activities, including decreased independence, especially in activities outside the home. this topic highlighted the importance of physical therapy as a treatment for critical patients to mitigate short-term sequelae and keep their independence. "i do all my shores by myself. now i get tired after a long walk, but things at home are fine. if i go to a place with big crowds, i get tired. i do not do that kind of activity alone anymore." e17 "i was a little bit worried when i started feeling exhausted, but after a while, everything came back to normal." e7 accompaniment became emotional support due to the participants' muscle fatigue when doing outdoor activities involving cognition such as money management. the impact on the degree of the person's independence went beyond muscular disorders, turning into emotional sequelae that affected social integration after admission to the icu. "i carry out daily life activities at home normally, although i feel exhausted. however, i have limited activities outside the house; now, my family always go with me." e3 "i require assistance to go shopping, and with money, however, i can do activities such as bathing or brushing my hair by myself." e11 "now i am afraid of going out alone; i feel nervous and worried about that. i always look for someone to go out with me." e15 my body after the icu some patients reported changes in their bodies after their stay in the icu. voice changes were identified with some other physical alterations that made communication difficult. they also talked about changes in their weight and appearance caused by the orotracheal tube associated with mechanical ventilation and the routine laryngoscopy procedures performed in the icu. "my voice has changed; it is very deep now. it was not like that, and now people hardly understand me." e4 "there are days in which i have many mouth sores. my mouth is covered in sores." eg "the truth is i have felt so bad these days; it is not the same as before i entered the icu." e11 "tragically, i am in my bones; even my hair fell out." e6 likewise, they identified pain as a symptom that persisted after discharge. they emphasized the discomfort that it causes. prolonged times in bed with a critical illness left a mark on the participants' skin of such a magnitude that muscle discomfort and pain were present even three months after icu discharge. "when i sit and then get up, my legs hurt, at the level of the hip." e4 "my back sores; i feel excruciating pain." e7 "sometimes, i'm in pain." e12 discussion the results identified the meaning given to the experience of being an icu survivor. however, despite recovering from a critical illness, they still present with psychological, cognitive, and physical disorders. these results are consistent with those provided by other studies in which survivors expressed psychological disorders (particularly depression), respiratory problems (abnormal spirometry), and moderate to severe dyspnea during daily life activities. significant deterioration in the quality of life and functional capacity were also noted (21, 22). these aspects were recognized by the participants, remarking by their dependence on other family members to carry out life activities, such as managing money. studies one year after discharge report improvements in physical function, vitality, and social skills. however, these domains are also the least likely to recover in the common population, as they were more deeply affected by critical illnesses (23). the study participants were contacted three months after admission to the icu; hence, the reported experiences should continue to be investigated much longer. alterations such as anxiety and depression in icu survivors were higher than in the general population. almost one-third of icu survivors with delirium dealt with depression, anxiety, and posttraumatic stress and needed psychiatric help even one year after discharge (24). another study reported poor quality of life after icu discharge, showing a significant association with post-traumatic syndromes, anxiety, and depression (25). sleep disturbances are present in patients with the post-icu syndrome. a study in icu survivors showed that prolonged mechanical ventilation was related to fragmented sleep after discharge (26, 27). in some cases, sleep cycle distortions associated with mechanical ventilation finally improved six months after discharge. dependence on others for specific activities has been reported in studies with elderly icu survivors. in these studies, the baseline functional state did not recover after one year, with a moderate to severe level of dependence (28). in another study, functional dependence initially increased but decreased one to three months after discharge. it affected the quality of life regarding mobility, personal care, habitual activities, pain, and anxiety/depression three months after icu discharge (29). dependence occurs because icu survivors do not feel safe. prior­ities during their return home are focused on feeling comfortable, improving mobility, self-control, and self-care. other essential goals are affirming personality, connecting with people, ensuring family well-being, restoring psychological and physical health, resuming previous roles and routines, and looking for new experiences (30). in this way, it is vital to incorporate improvement strategies related to early detection of pain and delirium, favoring early mobility and conscious sedation management while preventing patients from reaching their maximum level of suffering. after discharge, the consequences of admission to the icu were evaluated. therefore, strategies with educational aids such as videos, simulation, and training in detection instruments must be developed for the interdisciplinary group that works in the icu. conclusions surviving the intensive care unit has many advantages such as winning a battle against death. however, discharge's psychological, emotional, and physical consequences make this experience exhausting for patients and caregivers. knowing these experiences provides a research approach to propose interventions that mitigate these symptoms after icu discharge. it makes it possible to demonstrate the need to include this phenomenon in the training of personnel working in these units and strengthen interdisciplinary work aimed 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2020;33(2):116-22. doi: https://doi.org/10.1016/j.aucc.2019.04.002 30. scheunemann lp, white js, prinjha s, hamm me, girard td, skidmore er, et al. post-intensive care unit care: a qualitative analysis of patient priorities and implications for redesign. ann am thorac soc. 2020;17(2):221-8. doi: https://doi.org/10.1513/annalsats.201904-332oc home 38 49 auditoria de enfermagem.indd 38 aquichan issn 1657-5997 auditoria de enfermagem: o impacto das anotações de enfermagem no contexto das glosas hospitalares 1 acadêmica do 9º período da graduação em enfermagem –unipli 2 professores do departamento de fundamentos de enfermagem e administração – mfe da escola de enfermagem aurora de afonso costa –eeaac/uff, membros do necigen –núcleo de estudos sobre cidadania, educação e gerência em enfermagem. recibido: 14 de octubre de 2008 aceptado: 24 de febrero de 2009 resumo este estudo tratou da nossa observação frente ao impacto das anotações de enfermagem no contexto das glosas hospitalares. nesta perspectiva, a pesquisa se norteia pela seguinte questão: como o profissional de enfermagem pode contribuir através dos registros para não ocorrência da glosa? temos como objetivo identificar o impacto causado pelo não registro de enfermagem contrapondo às eventuais glosas, evidenciando os principais tipos decorrentes destes registros. metodologicamente a pesquisa utilizada foi descritiva e exploratória, onde utilizamos uma abordagem qualitativa e quantitativa. o estudo se materializou por meio documental e foi realizado no serviço de urologia de um hospital privado do município de niterói/rj. após a coleta de dados realizamos uma leitura exploratória, seletiva, analítica e interpretativa. a análise foi à temática e estatística das quais emergiram tabelas e gráficos, sendo: glosas de medicamentos (53%); glosas de taxas e aluguéis (24%); glosas de materiais (23%). desta forma, procuramos expor a importância da contribuição do registro de enfermagem no processo de diminuição de glosas hospitalares, mostrando como o profissional de enfermagem é a ferramenta fundamental neste contexto. sendo assim, pretendemos conscientizar e conduzir a prática dos profissionais da equipe de enfermagem, da responsabilidade e do comprometimento da elaboração completa e adequada do prontuário médico hospitalar. palavras-chave auditoria de enfermagem; gerência; administração em saúde. (fonte: decs, bireme). auditoría de enfermería: el impacto de las notas de enfermería en el contexto de glosas hospitalarias resumen este estudio se basó en nuestra observación del efecto que producen los registros de enfermería en el contexto de las glosas hospitalarias. por consiguiente, la investigación se orienta a la pregunta: ¿cómo puede contribuir con los registros el profesional de enfermería para evitar la glosa? el objetivo es identificar el efecto de no haber registro de enfermería que evite las eventuales glosas y evidencie los año 9 vol. 9 nº 1 chía, colombia abril 2009 38 49 tânia s. ferreira1 andré luiz de souza-braga2 geilsa soraia cavalcanti-valente2 deise ferreira de souza2 enilda moreira carvalho-alves2 39 auditoria de enfermagem: o impacto das anotações de enfermagem no contexto das glosas hospitalares tânia s. ferreira, andré luiz de souza-braga, et al. principales tipos resultantes de estos registros. la investigación fue descriptiva y exploratoria, de tipo cualitativo-cuantitativo. el estudio se materializó en un documental realizado en el servicio de urología de un hospital privado del municipio de niteroi, rio de janeiro. después de recolectar los datos, se hizo una lectura exploratoria, selectiva, analítica e interpretativa. el análisis temático permitió elaborar tablas y gráficas de glosas de medicamentos (53%), de impuestos y arriendos (24%), de materiales (23%). de este modo se muestra la importancia del registro de enfermería para lograr la disminución de glosas hospitalarias, destacando que el profesional de enfermería es el elemento clave en este contexto. en consecuencia, tratamos que los profesionales del equipo de enfermería se concienticen de la responsabilidad y el compromiso que significa llevar completa y apropiadamente el registro médico hospitalario. palabras clave auditoria de enfermería, gerencia, administración en salud. (fuente: decs, bireme). nursing audit: the impact of nursing annotation in the context of hospital gloss abstract this study is based on our observation of the effect nursing records can have on hospital audits. the question motivating the research is: how can the professional nurse’s records help to avoid audits? the objective is twofold: to identify the effect of not having nursing records that can avoid eventual audits, and to show the primary results of having nursing records. this is a descriptive, exploratory study of a qualitative-quantitative nature. it was developed in documentary form at the urology unit of a private hospital in the town of niteroi in rio de janeiro. the data was collected and examined from an exploratory, selective, analytical and interpretive standpoint. a thematic analysis made it possible to construct tables and graphs of audits involving medication (53%), taxes and rentals (24%), and materials (23%). the study demonstrates the value of nursing records in reducing hospital audits. for that reason, the nursing team must be made aware of the responsibility and commitment involved in keeping complete and appropriate hospital medical records. key words nursing audit, management, health administration. (source: mesh, bireme). 40 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 introdução a anotação de enfermagem é o registro do cliente nas 24 horas no ambiente hospitalar. contem dados sobre sua saúde geral e dados administrativos. sendo assim, promove então a informação da assistência prestada ao cliente e a equipe multidisciplinar, servindo de instrumento para auditoria, evitando as glosas hospitalares. este tipo de anotação, independentemente da filosofia e das teorias de enfermagem adotadas para fundamentar o processo de enfermagem na instituição, deve ser valorizada, uma vez que é um dos meios para se avaliar os cuidados prestados ao cliente a partir da adoção de indicadores de qualidade, para mensurar tanto o processo como os resultados da assistência de enfermagem (1). na sociedade atual as instituições de saúde estão evoluindo rapidamente e associando qualidade na hospitalização aos serviços prestados, com baixos custos hospitalares. deste modo, os instrumentos para o monitoramento dos cuidados vêm sendo utilizados com a inserção de profissionais altamente qualificados, que tenha a visão financeira e holística do cliente. para podermos entender este processo de custos hospitalares, fizemos um breve relato sobre auditoria e glosas hospitalares (2). a auditoria em enfermagem refere–se à avaliação sistemática da qualidade da assistência prestada ao cliente, verificada através das anotações de enfermagem no prontuário ou das próprias condições deste. existe a auditoria de cuidados, que mensura a qualidade da assistência em enfermagem, verificada através dos registros no prontuário do cliente e das próprias condições deste, e a auditoria de custos, que confere e controla o faturamento enviado para os planos de saúde, quanto aos procedimentos realizados, visitas de rotina, cruzando as informações recebidas com as que constam no prontuário. portanto, através destas auditorias, podemos indicar alternativas preventivas e corretivas. este é um processo educativo, pois não procura os responsáveis, mas questiona o porquê dos resultados adversos (1). a auditoria em enfermagem visa o controle de custos, a qualidade do atendimento ao cliente, pagamento justo da conta hospitalar e a transparência da negociação, embasada na conduta ética (1). um dos elementos imprescindíveis deste processo é o prontuário médico, importante ferramenta legal na avaliação da qualidade da assistência prestada ao cliente que fornece informação vital para possíveis processos judiciais e convênios de saúde, pois este é o conjunto de documentos padronizados e ordenados, destinados ao registro dos cuidados profissionais prestados pelos serviços de saúde públicos e privados. desta forma, sua informação é analisada e, portanto, havendo dúvidas quanto aos procedimentos realizados ou a falta de anotações de enfermagem, pode incidir em glosas das contas hospitalares (3). a glosa é o cancelamento parcial ou total do orçamento, por serem considerados ilegais ou indevidos, ou seja, referem-se aos itens que o auditor do plano de saúde não considera cabível o pagamento. as glosas são aplicadas quando qualquer situação gera dúvidas em relação à regra e prática adotada pela instituição de saúde (4). os instrumentos para o monitoramento dos cuidados vêm sendo utilizados com a inserção de profissionais altamente qualificados, que tenha a visão financeira e holística do cliente. 41 auditoria de enfermagem: o impacto das anotações de enfermagem no contexto das glosas hospitalares tânia s. ferreira, andré luiz de souza-braga, et al. temos as glosas administrativas, decorrentes de falhas operacionais no momento da cobrança, falta de interação entre o plano de saúde e o prestador de serviço, que estão vinculadas às cláusulas contratuais; e as glosas técnicas, decorrentes da equipe de enfermagem ou médica, onde estão vinculadas a falta de justificativas ou embasamento que se apliquem à indicação de determinado procedimento, e a falta de anotação de enfermagem durante a assistência prestada ao cliente (4). quando as instituições de saúde têm suas contas hospitalares glosadas pelas operadoras de planos de saúde, elas podem utilizar os recursos de glosas a fim de recuperar suas perdas econômicas. entende–se por recurso de glosa a maneira de recuperar descontos indevidos e corrigir ou detectar erros de faturamento (5). em conseqüência, acreditamos na suma importância da responsabilidade e compromisso da equipe de enfermagem no que diz respeito a registros, tendo como conseqüência às glosas hospitalares, mostrando que é necessário o aperfeiçoamento continuo da equipe multidisciplinar e todos os profissionais envolvidos no processo do cuidado, com ênfase na enfermagem, para uma permanente e melhor qualidade de assistência (6). sendo assim, o objeto do nosso estudo é o impacto causado pelo registro de enfermagem na diminuição das glosas, que são decorrentes dos registros da equipe médica e de enfermagem. um prontuário com a evolução de enfermagem, as checagens de medicações e as anotações de procedimentos e materiais utilizados relatados corretamente estará isento de glosa. é importante destacar que as anotações não abrangem toda a prática assistencial da enfermagem, mas por meio das informações registradas as ações cuidativas são evidenciadas, possibilitando a avaliação dos procedimentos assistenciais por meio da auditoria. tendo como questão norteadora: como o profissional de enfermagem pode contribuir através dos registros para não ocorrência da glosa, cabe ressaltar que atualmente os enfermeiros estão cada vez mais se especializando como auditores, pois as instituições estão à procura de profissionais altamente qualificados (7). o presente estudo tem como objetivo identificar o impacto causado pelo não registro de enfermagem contrapondo às eventuais glosas, evidenciando os principais tipos decorrentes destes registros. diante do crescente número de contas glosadas neste serviço de urologia e escassas bibliografias sobre o assunto, buscamos definir como o enfermeiro pode atuar através dos registros para a diminuição das glosas através de pesquisa realizada neste hospital. este estudo contribui na trajetória de disseminação como exercício fundamental e aumento do conhecimento diante deste importante contexto, e para a linha de pesquisa do ensino permanente e da qualidade na assistência. a auditoria teve sua origem na área contábil, cujos fatos e registros datam dos 2.600 anos a.c. porém, é a partir do século xii d.c. que esta técnica passa a receber o nome de auditoria, constatando-se na inglaterra o seu maior desenvolvimento com a revolução industrial. deste modo, a prática da auditoria recebeu novas diretrizes na busca de atender as necessidades das grandes empresas. na área de saúde aparece pela primeira vez no trabalho realizado pelo médico george gray ward, nos estados unidos, em 1918. neste trabalho este estudo contribui na trajetória de disseminação como exercício fundamental e aumento do conhecimento diante deste importante contexto, e para a linha de pesquisa do ensino permanente e da qualidade na assistência. 42 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 era verificada a qualidade da assistência prestada ao cliente, através dos registros no prontuário médico (8). kurcgant (2006) afirma ser indiscutível a necessidade e a importância de um sistema de informação que propicie a todos os elementos da equipe de enfermagem, informações necessárias ao desenvolvimento da assistência. assim sendo, o sistema de informação em enfermagem viabiliza o processo de comunicação entre os integrantes da equipe de saúde e o cliente (9). destaca–se, em 1955, o primeiro trabalho de auditoria na área da enfermagem, desenvolvido no hospital progress nos estados unidos (8). antes de 1976, as atividades de auditoria com base no então instituto nacional da previdência social (inps) eram realizadas pelos supervisores, por meio de apuração em prontuários de clientes e contas hospitalares, porque nesta época não havia auditoria direta em hospitais. neste mesmo ano, as contas hospitalares transformam-se em guia de internação hospitalar, ficando as atividades de auditoria estabelecidas como controle formal e técnico. logo, em 1978, foi criada a coordenadoria de controle e avaliação, nas capitais, e o serviço de medicina social, nos municípios (8). em 1983 se reconhece o cargo de médico auditor, e a auditoria passa a ser feita nos próprios hospitais. no brasil, no hospital de ipanema, no rio de janeiro (8), foram iniciadas experiências isoladas com auditoria médica, com vista ao fornecimento de informação para decisões administrativas e para o corpo clínico.. quanto à auditoria na área da enfermagem, surgiu no hospital universitário de são paulo como um processo implantando desde 1983, com padrões estabelecidos para sustentar a sistematização da assistência de enfermagem (sae). com este mesmo objetivo, outros hospitais universitários implantaram método avaliativo na década de 80 (1). em 1985 a demanda por serviços de saúde de qualidade, mobilizou tanto profissionais quanto instituições. um exemplo foi o documento da organização mundial de saúde (oms), quando foi estabelecido como meta a ser atingida: saúde para todos. embora não concretizada, houve a proposta de estabelecer métodos de monitorazação sistemática dos cuidados ministrados, visualizou-se a avaliação e o controle como componentes permanentes das atividades profissionais e institucionais (1). em 1990, a lei 8080 estabelece a necessidade de criação do sistema nacional de auditoria (sna) como instrumento fiscalizador, atribuindo-lhe uma coordenação da avaliação técnica e financeira do sistema único de saúde (sus) em todo o território nacional. o decreto 1651 de 28 de setembro de 1995 regulamenta o sna e define suas competências nos três níveis de gestão: federal, estadual e municipal. a lei 9649 de 27 de maio de 1991 define ainda as áreas de competência, como função legal à coordenação, fiscalização do sus (8). a portaria 169 do ministério da saúde (ms), do gabinete do ministro, de 19 de agosto de 1999, estabelece uma nova organização de atividades do sna: as de controle e avaliação ficam com a secretaria de assistência a saúde (sas), as de auditoria, com o departamento nacional de auditoria do sus (denasus), representada em todos os estados da federação no distrito federal (8). kurcgant afirma ser indiscutível a necessidade e a importância de um sistema de informação que propicie a todos os elementos da equipe de enfermagem, informações necessárias ao desenvolvimento da assistência. 43 auditoria de enfermagem: o impacto das anotações de enfermagem no contexto das glosas hospitalares tânia s. ferreira, andré luiz de souza-braga, et al. em dezembro de 1999, foi criada a sociedade brasileira em enfermeiros auditores em saúde (sobeas), tendo como finalidade agregar profissionais de todo país, fossem enfermeiros envolvidos ou interessados em auditoria (8) (10). em 2000 (decreto 3.496), compete ao denasus determinar as responsabilidades dos órgãos de auditoria, controlar e avaliar a correção de irregularidades praticadas no sus, e ainda da assistência direta e imediata ao gabinete do ministro (8) (10). existe atualmente uma série de organizações que praticam a avaliação global da qualidade da saúde em instituições, por exemplo, organização internacional para padronização (iso) e a organização nacional de acreditação (ona), além de comissões internas que possibilitam a execução da avaliação. a comissão da auditoria em enfermagem é responsável de atuar em vários hospitais (8) (11). desta forma, percebemos que no brasil a auditoria vem tomando impulso nos últimos cinqüenta anos, mesmo se necessita ainda alguns arranjos que melhor se adaptem ao processo da nossa realidade (1). método nossa pesquisa foi descritiva, por estar interessada em descrever e conhecer o fenômeno, procurando interpretá-lo e descrevê-lo; exploratória, pois têm por objetivo facilitar a compreensão do assunto, de modo a construir hipóteses, contribuindo para posteriores estudos científicos, e proporcionar uma visão mais ampla do problema a ser estudado para orientar, explicar e explorar o contexto da importância das anotações de enfermagem (12). a abordagem metodológica utilizada foi a qualiquantitativa, pois a pesquisa qualitativa se preocupa com a compreensão dos processos e fenômenos e a quantitativa faz o estudo de caso, quantifica os valores e procura correlações estatísticas (13). antes, foi realizada pesquisa documental de materiais que não receberam tratamento analítico, como documentos conservados em órgãos públicos e instituições privadas, e os documentos que de alguma forma já foram analisados: relatórios de pesquisa, relatórios de empresas, tabelas estatísticas e outros. e assim, utilizamos documentos não convencionais, porém usuais no ambiente hospitalar, vinculandose a relatórios de glosas do convênio de saúde e contas hospitalares já auditadas internamente neste hospital (14). elaboramos como instrumento de coleta de dados uma planilha no microsoft excel, que possua os elementos da pesquisa, onde mencionaremos as glosas ocorridas em um serviço de urologia de um hospital privado de médio porte da cidade de niterói, rj, no setor de faturamento, no período de fevereiro de 2008, tendo como referência os meses de outubro e novembro de 2007. foram obtidos 215 internações e 926 atendimentos ambulatórias; destes, ocorreram 125 atendimentos glosados. em total, foram 4.380 itens glosados, que dão uma grande importância na elaboração da pesquisa científica. após a coleta de dados, realizamos a leitura exploratória para evidenciar se o texto tem sentido em relação à pesquisa. posteriormente, fizemos uma leitura seletiva, elegendo e avaliando a contribuição de cada texto e seus principais tópicos; e uma leitura analítica para apresentar os pontos relevantes e avaliar a contribuição de cada pesquisa (15) (16). finalizamos existe atualmente uma série de organizações que praticam a avaliação global da qualidade da saúde em instituições, por exemplo, organização internacional para padronização e a organização nacional de acreditação, além de comissões internas que possibilitam a execução da avaliação. 44 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 com a leitura interpretativa para estabelecer relações, confrontar idéias e confirmar opiniões (15). em seguida, a análise foi feita de forma temática e estatística, onde verificamos o que o texto diz, focalizando a capacidade do pesquisador para avaliar a adequação das teorizações disponíveis aos fenômenos por ele observados (15). análise e discussão dos dados com vistas a identificar o impacto causado pelo não registro de enfermagem contrapondo às eventuais glosas, evidenciando os principais tipos decorrentes destes registros, realizamos a pesquisa no serviço de urologia de um hospital privado de médio porte no município de niterói, no estado do rio de janeiro, setor de faturamento. recolhemos dados elaborados em planilha no programa microsoft excel, em fevereiro de 2008, tendo como referencia os meses de outubro e novembro de 2007. com um total de 215 internações e 926 consultas ambulatórias, pudemos observar que destes 125 atendimentos e 4.380 itens foram glosados. desta forma, elaboramos quadros para descrever as glosas ocorridas e seus respectivos motivos, considerando os componentes medicamentos, taxas e aluguéis, e materiais. não nos estendemos nas glosas de exames, as glosas médicas e as glosas administrativas, pois o foco da pesquisa é o registro de enfermagem, e assim organizamos breves comentários. itens glosados quantidade motivo da glosa valores (r$) % maxcef 2g 21 falta registro de enfermagem. 2.505,00 47,12 levaquim frasco 09 falta registro de enfermagem. 1.680,89 31,61 fortaz 1g 30 falta registro de enfermagem. 1.264,75 23,79 oxacilina 500mg 28 falta registro de enfermagem. 952,35 17,91 dersani loção 20 falta registro de enfermagem. 649,06 12,20 óleo mineral frasco 12 falta registro de enfermagem. 573,12 10,78 rocefin 1g 15 falta registro de enfermagem. 340,80 6,41 diprivan ampola 25 falta registro de enfermagem. 215,60 4,05 cepacol solução 18 falta registro de enfermagem. 119,52 2,24 dormonid 5 mg 26 falta registro de enfermagem. 118,72 2,23 tilatil frasco 30 falta registro de enfermagem. 66,90 1,25 xylocaina gel 17 falta registro de enfermagem. 64,36 1,21 quadro 1: relação de glosas de medicamentos no período de outubro a novembro de 2007, com suas respectivas perdas em real. fonte: arquivo do setor de faturamento do serviço de urologia privado da cidade de niterói, rj. a análise foi feita de forma temática e estatística, onde verificamos o que o texto diz, focalizando a capacidade do pesquisador para avaliar a adequação das teorizações disponíveis aos fenômenos por ele observados. 45 auditoria de enfermagem: o impacto das anotações de enfermagem no contexto das glosas hospitalares tânia s. ferreira, andré luiz de souza-braga, et al. o item medicamento recebeu o maior número de glosas, sendo seu valor em real de r$ 8.551,07 (53,16%), seguido de taxas e aluguéis r$ 3.919,41 (24,36%) e materiais r$ 3.614,80 (22,47%), como demonstra o gráfico 1. gráfico 1. relação de glosas e suas respectivas perdas em porcentagem. dado que é alto o número de itens mencionados dentre os múltiplos elementos, optamos por selecionar somente os três mais representativos de cada um deles. no quadro 1, em medicamento observamos os itens que tiveram maior representatividade: maxcef r$ 2.505,00 (47,12%), levaquim r$ 1.680,89 (31,61%) e fortaz r$ 1.264,75 (23,79%). as glosas ocorridas foram por falta de anotação/ checagem de enfermagem e de justificativa. estes desacertos vêm ocorrendo porque na maioria das vezes a enfermagem atua com certa desatenção nas anotações. ao escrever as evoluções de enfermagem de forma ilegível e incompleta, não dão a informação necessária e geram dúvidas sobre o tratamento aplicado. segundo brunner (17), o registro de cuidados de saúde do cliente foi e ainda é executado com a intenção de promover um meio de comunicação entre os membros do grupo de saúde para facilitar a coordenação e a continuidade do planejamento. o registro de enfermagem tem outras funções: atua como registro legal e comercial da organização hospitalar e dos grupos de profissionais responsáveis pelo tratamento do cliente, serve de base para avaliação e eficiência da qualidade das práticas em saúde, promovendo um dado útil de pesquisa, educação e planejamento a curto e longo prazos. segundo o código de ética de medicina, é de responsabilidade médica, a elaboração da prescrição e receita de medicamento, pois é atribuição exclusiva do médico o diagnóstico de qualquer patologia e o seu tratamento específico, ou seja, ao médico cabe a prescrição do medicamento e a enfermagem cabe a anotação e checagem (3). as anotações que demonstram a realização adequada da terapêutica medicamentosa com resultados de intervenções de enfermagem, orientações, cuidados prestados de forma sistematizada e coerente, são evidências objetivas da qualidade da assistência prestada ao cliente (1). o profissional enfermeiro, que é um educador na sua essência, deve sensibilizar os membros dessa equipe quanto à importância da anotação e do envolvimento no processo de trabalho por ser responsáo código de ética de medicina, é de responsabilidade médica, a elaboração da prescrição e receita de medicamento, pois é atribuição exclusiva do médico o diagnóstico de qualquer patologia e o seu tratamento específico, ou seja, ao médico cabe a prescrição do medicamento e a enfermagem cabe a anotação e checagem. 46 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 vel dos resultados obtidos por sua equipe. podem--se utilizar ferramentas educativas para tal, sempre enfatizando que dita anotação servirá como respaldo legal sobre a qualidade da assistência prestada ao cliente e quanto aos valores que a instituição receberá ou não dependendo desse registro (1). quadro 2: relação de glosas de taxas e aluguéis no período de outubro a novembro de 2007, com suas respectivas perdas em real. fonte: arquivo do setor de faturamento do serviço de urologia privado da cidade de niterói/rj. itens glosados quantidade motivo de glosa valores(r$) % taxa de oxigênio 242 falta registro de enfermagem. 1.936,96 79,51 taxa de curativo 222 falta registro de enfermagem. 1.008,52 41,40 taxa de nebulização 166 falta registro de enfermagem. 644,08 26,44 aluguel de bomba inf. 15 falta registro de enfermagem. 329,85 13,54 de acordo com o quadro 2, de taxas e aluguéis o item mais representativo foi o oxigênio com o valor de r$ 1.936,96 (79,51%), seguido do curativo r$ 1.008,52 (41,40%) e nebulização r$ 644,08 (26,44%). a carência de carimbos, relato de hora de início e término, falta de assinatura ou a falta de relato na evolução de enfermagem incidem em glosa. no item oxigênio, uma das maiores perdas da instituição, há falha na evolução ou a mesma pode estar incompleta, sem nenhuma justificativa para o cliente estar utilizando o mesmo, acarretando também em glosa. quadro 3: relação de glosas de materiais no período de outubro a novembro de 2007, com suas respectivas perdas em real. fonte: arquivo do setor de faturamento do serviço de urologia privado da cidade de niterói, rj. itens glosados quantidade motivo da glosa valores(r$) % compressa cirúrgica 1401 falta de justificativa 1.001,12 44,55 para quantidade utilizada. luva procedimento 1600 falta de justificativa 869,62 38,70 para quantidade utilizada. cateter jelco 31 falta de justificativa 656,76 29,22 para quantidade utilizada. equipo micro gotas 51 falta de justificativa 517,40 23,02 para quantidade utilizada. marcodine scrub 112 falta de justificativa para 186,92 8,31 quantidade utilizada. equipo padrão 45 falta de registro de enfermagem 104,07 4,63 mostrando a necessidade deste. micropore 17 falta de registro de enfermagem 75,77 3,37 mostrando a necessidade deste. algodão bola 23 falta de relato de enfermagem. 72,60 3,23 máscara descartável 68 falta de justificativa 46,80 2,08 para quantidade utilizada. gorro descartável 69 falta de justificativa 42,20 1,87 para quantidade utilizada. sapatilha descartável 67 falta de justificativa 41,54 1,84 para quantidade utilizada. as instituições, tentando recuperar seus prejuízos, elaboram recursos de glosas baseados em justificativas dos profissionais envolvidos nos procedimentos. ponderando as justificativas dos recursos, percebe-se que a maioria estava relacionada à equipe de enfermagem. 47 auditoria de enfermagem: o impacto das anotações de enfermagem no contexto das glosas hospitalares tânia s. ferreira, andré luiz de souza-braga, et al. posteriormente, apresentamos o quadro 3 de materiais. os itens compressa de gaze r$ 1.001,12 (44,55%), luva de procedimento r$ 869,62 (38,70%) e jelco r$ 656,76 (29,22%) denotam mais a carência do registro de enfermagem sobre procedimento realizado, pois a falta de justificativa pela quantidade utilizada pode advir à glosa. as falhas ocorridas na maioria das vezes por falta de anotação, prescrição e checagem da equipe de enfermagem elevam as glosas e acarretam de forma expressiva as despesas da instituição. segundo figueiredo (18), são de responsabilidade da equipe de enfermagem as anotações no gráfico de sinais vitais, na folha de relatório, que contem informação sobre dieta, eliminações, movimentações, procedimentos realizados, intercorrências e outros dados relacionados ao cliente. as instituições, tentando recuperar seus prejuízos, elaboram recursos de glosas baseados em justificativas dos profissionais envolvidos nos procedimentos. ponderando as justificativas dos recursos, percebe-se que a maioria estava relacionada à equipe de enfermagem. os resultados apontam que as anotações de enfermagem contribuem de forma substancial para um elevado percentual de recuperação dos itens glosados, foco da pesquisa. os recursos de glosa aplicados de medicamentos, taxas e aluguéis, materiais, exames, glosa médica e glosa administrava, totalizam aproximadamente o valor de r$ 26.789,26, e acham-se relacionadas aos medicamentos (r$ 8.551,07), aos materiais (r$ 3.614,80) e as taxas e aluguéis (r$ 3.919,41). porém, os itens medicamentos, materiais e taxas são recuperados mediante a anotação de enfermagem, visto que a recuperação das glosas de exames, as glosas médicas e as administrativas será mais complexas. observou-se que a não anotação de enfermagem representou um custo para instituição no valor de r$ 16.085,28, mostrando sua importância, pois a maioria das justificativas encontrava-se suportada apenas em registros de enfermagem. vimos também que o quantitativo de recursos humanos pode acabar por ocasionar estas falhas, pois a equipe de enfermagem estará prestando os cuidados aos clientes, acabando por faltar tempo necessário para realização dos registros. então devemos atentar para o aspecto da identificação da carga média de trabalho diária na assistência, consistindo na quantidade de clientes assistidos. pois os trabalhadores não são produtivos, igualmente, em todo o tempo do turno de trabalho, por realizarem uma série de atividades não diretamente relacionadas às suas tarefas profissionais. porém isto não justifica, pois devemos nos organizar, fazendo planejamento das atividades para estruturar os recursos humanos de acordo com a quantidade de clientes (9). a questão de custos na área de saúde tem exigido profissionais qualificados que cooperem no resultado econômico da instituição. dado que as perdas de materiais e medicamentos –as principais fontes lucrativas do hospital– são pouco controladas, a auditoria em enfermagem pode desempenhar um trabalho proativo em semelhança a este aspecto (1) (18). considerações finais a informação atinente às ações e observações cumpridas pela equipe de enfermagem são registradas para gerenressalta-se que a anotação de enfermagem não deve ser encarada como um simples cumprimento de norma burocrática, passível de esquecimento; é preciso que se tenha a noção de sua real importância e das implicações decorrentes do não preenchimento correto deste documento. 48 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 ciar a assistência e avaliar a qualidade do atendimento ao cliente (19). isso deve ser feito com base nas auditorias externas provenientes dos convênios de saúde ou nas internas da própria instituição, que visam apurar a desatenção na assistência, e assim reavaliar contas detectadas freqüentemente pela ausência de dados fundamentais para o esclarecimento de ações realizadas, bem como pela falta de registros (19) (20). ressalta-se que a anotação de enfermagem não deve ser encarada como um simples cumprimento de norma burocrática, passível de esquecimento; é preciso que se tenha a noção de sua real importância e das implicações decorrentes do não preenchimento correto deste documento. ressalta-se que a anotação de enfermagem não deve ser encarada como um simples cumprimento de norma burocrática, passível de esquecimento; é preciso que se tenha a noção de sua real importância e das implicações decorrentes do não preenchimento correto deste documento. deve ser do interesse de toda equipe multidisciplinar que o prontuário esteja preenchido adequadamente, no intuito de gerar informações precisas, pois diante de procedimentos não comprovados ou anotados de forma deficiente, repercutirá em glosas e a instituição será penalizada em seus resultados financeiros (4). o quantitativo de profissionais não é suficiente muitas vezes para executar completamente as ações pertinentes à equipe de enfermagem. cabe à empresa atentar se mais vale à pena ter poucos profissionais e assim acarretar em futuras glosas ou se contratar mais profissionais seria a solução (15). acreditamos na necessidade de que os enfermeiros avaliem como estão sendo realizados os registros, tendo uma visão crítica e propositora de sua atuação, pois devemos desempenhar as atividades focando sempre na qualidade da assistência prestada aos clientes, e atuar administrativamente gerenciando sua equipe. neste estudo destaca-se que os enfermeiros passem a avaliar como estão os registros de sua equipe, fazendo um planejamento das atividades, visando à educação continuada, realizando treinamento sistematizado, capacitando sua equipe para a valorização das anotações. estas ações são um indicador de qualidade dos cuidados prestados ao cliente e de uma gestão eficaz. é indispensável neste processo o pleno conhecimento da equipe, a padronização do processo de trabalho com protocolos, a capacitação contínua e sistematizada, a reflexão sobre o conteúdo da informação e dos impressos para anotação (1). cabe também salientar a importância do compromisso, da responsabilidade, da competência técnico-cientifica e o resgate do trabalho da enfermagem expresso nas anotações acerca da assistência prestada. diante do exposto, desejamos que este estudo contribua a proporcionar uma maior reflexão dos profissionais de enfermagem quanto à importância de seus registros e à trajetória de disseminação como exercício fundamental e aumento do conhecimento diante deste importante contexto, e assim colaborar para a linha de pesquisa do ensino permanente e da qualidade na assistência. cabe também salientar a importância do compromisso, da responsabilidade, da competência técnico-cientifica e o resgate do trabalho da enfermagem expresso nas anotações acerca da assistência prestada. 49 auditoria de enfermagem: o impacto das anotações de enfermagem no contexto das glosas hospitalares tânia s. ferreira, andré luiz de souza-braga, et al. referencias 1. d`innocenzo m et al. indicadores, auditorias, certificações: ferramentas de qualidade para gestão em saúde. são paulo: martinar; 2006. 2. oliveira af. avaliação do impacto das intervenções nos pontos críticos detectados na pré-análise de auditoria em enfermagem. [tese de doutorado]. são paulo: (usp; 2003. 3. conselho federal de medicina. código de ética dos profissionais de medicina [online]. resolução 1331/89. disponível em: www.portalmedico.org.br acesso em nov 2007. 4. francisco mtr. auditoria em enfermagem: padrões, critérios de avaliação e instrumentos. 3ª ed. são paulo: cedas; 1993. 5. torres l. auditoria em enfermagem. [tese de doutorado]. são paulo: usp; 1977. 6. bauer l, feldman. como alcançar qualidades nas instituições de saúde: critério de avaliações, procedimentos de controle, gerenciamento de riscos hospitalares até a certificação. são paulo: martinar; 2004. 7. oswaldo l. princípios elementares de custos hospitalares. 2ª ed. são paulo: 1975. 8. ministério da saúde: história da auditoria em saúde. 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administração. são paulo: epu; 1976. distal symmetric polyneuropathy pain in diabetes mellitus article distal symmetric polyneuropathy pain in diabetes mellitus* dolor por polineuropatía simétrica distal en la diabetes mellitus** dor devido à polineuropatia simétrica distal em diabetes mellitus*** 10.5294/aqui.2021.21.3.7 daniella silva oggiam1 juliana vallim jorgetto2 guilherme luiz chinini3 denise miyuki kusahara4 mônica antar gamba5 1 0000-0001-9814-8924. universidade federal de são paulo, brazil. prof.daniella.oggiam@unipinhal.edu.br 2 0000-0003-3758-5201. universidade federal de são paulo, brazil. juliana.vallim@unifesp.br 3 0000-0001-8548-0696. unipinhal, brazil. prof.guilherme.chinini@unipinhal.edu.br 4 0000-0002-9498-0868. universidade federal de são paulo, brazil. dkusahara@unifesp.br 5 0000-0003-1470-4474. universidade federal de são paulo, brazil. antar.gamba@unifesp.br * this article is part of the doctoral dissertation "effects of monochromatic infrared light intervention on neuropathic pain levels in people with diabetes mellitus: a randomized controlled clinical trial," nursing graduate program, universidade federal de são paulo, brazil. it was financed by the fundação de amparo à pesquisa do estado de são paulo (fapesp), grant number 2017/26282-3. ** el presente artículo hace parte de la tesis doctoral "efectos de la intervención con luz infrarroja monocromática en los niveles de dolor neuropático de personas con diabetes mellitus: ensayo clínico controlado aleatorizado", programa de posgrado en enfermería, universidade federal de são paulo, brasil. el proyecto contó con la financiación de la fundação de amparo à pesquisa do estado de são paulo (fapesp), subvención número 2017/26282-3. *** el presente artículo hace parte de la tesis doctoral "efectos de la intervención con luz infrarroja monocromática en los niveles de dolor neuropático de personas con diabetes mellitus: ensayo clínico controlado aleatorizado", programa de posgrado en enfermería, universidade federal de são paulo, brasil. el proyecto contó con la financiación de la fundação de amparo à pesquisa do estado de são paulo (fapesp), subvención número 2017/26282-3. received: 26/10/2020 sent to peers: 01/12/2020 approved by peers: 10/06/2021 accepted: 16/07/2021 to reference this article / para citar este artículo / para citar este artigo: oggiam ds, jorgetto jv, chinini gl, kusahara dm, gamba ma. distal symmetric polyneuropathy pain in diabetes mellitus. aquichan. 2021;21(3):e213x. doi: https://doi.org/10.5294/aqui.2021.21.3.7 theme: chronic care and health promotion contribution to the discipline: neuropathic pain is one of the most disabling complications in patients with diabetes mellitus. systematically screening neuropathic pain through instruments validated for this purpose and recognizing factors associated with it enable primary health care nurses to establish early interventions for pain prevention and management. abstract objective: to evaluate neuropathic pain (np), its intensity, and complications in people with type 2 diabetes mellitus (t2dm) in a city of eastern são paulo. method: cross-sectional study conducted with 96 individuals with t2dm served by primary health units in são joão da boa vista-sp. the following instruments were used to screen np: michigan neuropathy screening instrument, leeds assessment of neuropathic symptoms and signs, douleur neuropathique 4, and brief pain inventory. the data were analyzed using descriptive and inferential statistics, with a 5 % significance level. results: of the 96 people with t2dm for longer than five years, 22.9 % had pain. np was related to high levels of fasting blood glucose (mean = 214 ± 65.58 mg/dl; p = 0.0002), glycated hemoglobin (mean = 8.8 ± 0.11 %; p < 0.001), absence of a balanced diet (p = 0.0066), obesity (p = 0.023), and high blood pressure (p < 0.001). conclusion: higher values of glycated hemoglobin rates increased three times the chance of np. the screening and management of painful diabetic neuropathy is a challenge but adopting a screening protocol supports the secondary prevention of this manifestation. keywords (fonte decs): diabetic neuropathy; chronic pain; diabetes mellitus; complications; physiotherapy; physical therapy specialty; nursing. resumen objetivo: evaluar el dolor neuropático (dn), su intensidad y sus complicaciones en personas con diabetes mellitus tipo 2 (dm2) en una ciudad del este de são paulo. método: estudio transversal realizado con 96 individuos con dm2 atendidos en unidades básicas de salud en são joão da boa vista-sp. se utilizaron los siguientes instrumentos para rastrear el dn: el instrumento para la detección de la neuropatía de michigan, la evaluación de signos y síntomas neuropáticos de leeds, el cuestionario douleur neuropathique 4 y el inventario breve del dolor. los datos se analizaron mediante estadística descriptiva e inferencial, con un nivel de significancia del 5 %. resultados: de las 96 personas con dm2 durante más de cinco años, el 22,9 % tenía dolor. el dn se relacionó con niveles altos de glucosa en sangre en ayunas (media = 214 ± 65,58 mg/dl; p = 0,0002), la hemoglobina glucosilada (media = 8,8 ± 0,11 %; p < 0,001), la ausencia de una dieta (p = 0,0066), la obesidad (p = 0,023) y la hipertensión arterial (p < 0,001). conclusión: los altos valores en las tasas de hemoglobina glucosilada aumentaron tres veces la probabilidad de dn. la detección y el tratamiento de la neuropatía diabética dolorosa es un desafío, pero la adopción de un protocolo de detección contribuye a la prevención secundaria de esta manifestación. palabras clave (fuente decs): neuropatías diabéticas; dolor crónico; diabetes mellitus; complicaciones; fisioterapia; enfermería. resumo objetivo: avaliar a dor neuropática (dn), sua intensidade e suas complicações em pessoas com diabetes mellitus tipo 2 (dm2) numa cidade do leste de são paulo, brasil. materiais e método: estudo transversal realizado com 96 indivíduos com dm2 atendidos em unidades básicas de saúde em são joão da boa vista, são paulo. foram utilizados os seguintes instrumentos para rastrear a dn: o instrumento para detectar a neuropatia de michigan, a avaliação de sinais e sintomas neuropáticos de leeds, o questionário de douleur neuropathique 4 e a escala breve da dor. os dados foram analisados por meio de estatística descritiva e inferencial, com um nível de significância de 5 % resultados: das 96 pessoas com dm2 durante mais de cinco anos, 22,9 % sentiam dor. a dn esteve relacionada com níveis altos de glicose em sangue em jejum (média = 214 ± 65,58 mg/dl; p = 0,0002), hemoglobina glicosilada (média = 8,8 ± 0,11 %; p < 0,001), ausência de dieta (p = 0,0066), obesidade (p = 0,023) e hipertensão arterial (p < 0,001). conclusões: os altos valores nas taxas de hemoglobina glicosilada aumentaram três vezes a probabilidade de dn. a detecção e o tratamento da neuropatia diabética dolorosa são um desafio, mas a adoção de um protocolo de detecção contribui para a prevenção secundária dessa manifestação. palavras-chave (fonte decs): neuropatias diabéticas; dor crônica; diabetes mellitus; complicações; fisioterapia; enfermagem. introduction diabetic peripheral neuropathy (dpn) is prevalent in about 50 % of diabetes mellitus (dm) cases. it is characterized by chronic clinical or subclinical manifestations resulting from injuries to the somatic peripheral nervous system involving nerve fibers. progressively, dpn becomes a risk factor for developing a series of clinical complications such as degeneration of the nerves in the distal region of the lower limbs, ulcers, amputations, and neuropathic pain (np) (1-3). among dpn cases, 75 % had distal symmetric polyneuropathy (dsp) of multifactorial pathogenesis, caused by a metabolic dysfunction. it results in oxidative stress and inflammation of peripheral nerves, in addition to variations in voltage-dependent sodium channels that worsen dsp and np (4,5). np, the most incapacitating clinical complication of dsp among dpns, is caused by extensive lesions in fine aβ-, aδ-, and c-type nerve fibers that adversely affect the sensory and motor nerve components. it has different clinical manifestations, pathophysiological mechanisms, development, and evolution. np appears as spontaneous chronic pain, without any stimulus, or painful hypersensitivity triggered by sensitive neuronal injury (6-10). pathophysiological studies report loss of nerve fibers, axonal degeneration, and demyelination associated with oxidative stress. the latter is induced by chronic hyperglycemia that causes mitochondrial damage and thus neural apoptosis (11, 12). the prevalence of np is around 20 % and increases according to dm duration, advancing age, and a lack of glycemic control. the prevalence is likely to rise as the global population ages. therefore, screening np is vital for implementing public policies aimed at early intervention and improving the quality of life of those affected. there is a growing need for adequate pdn and np screening to make diagnosis and clinical treatment easy and effective (2). validated assessment instruments in the portuguese language, which are easy to use and fairly accurate, can assist in screening the signs and symptoms of np with high predictive values for diabetic neuropathy and np. these instruments include michigan neuropathy screening instrument (mnsi) (13, 14), leeds assessment of neuropathic symptoms and signs (lanss) (15), douleur neuropathique 4 (dn4) (16), and brief pain inventory (bpi) (17), which provide better clinical accuracy in dm (3, 18). the mnsi is widely used in clinical trials worldwide, facilitating the screening of diabetic neuropathy with clinical history and physical examination (13, 14, 19). it comprises 13 items for clinical history: numbness, burning, sensitivity to touch, cramps, tingling, pain, temperature sensitivity, weakness of muscles, night-time worsening of symptoms, and tactile sensitivity. these are associated with 10 items for physical examination of the feet: appearance (deformities, dry skin, calluses, infections, fissures), ulcerations, deep ankle reflex, hallux vibration perception test with 128 hz tuning fork, and 10 g monofilament test (19,20). for screening dm np, the lanss and dn4 instruments are extensively used due to their high predictive value. the first differentiates np from nociceptive pain; it consists of seven items with specific pain characteristics associated with physical assessment, allodynia, and pain threshold at needle examination. its score ranges from 0 to 24 points; less than 12 points characterize nociceptive pain and more than 12 points np (15,21,22). the dn4 questionnaire has 10 questions, three of which are for the physical examination of signs such as burning, tingling, numbness, changes in temperature sensitivity, and tactile stimulus. the score ranges from 0 to 10; equal to or greater than four indicates np (23). bpi is a numerical instrument that assists in assessing pain intensity and location, pain interference in daily life activities, social activities, mood, sleep, and walking. it allows quantifying pain self-perception through a score ranging from 0 to 10 for each item evaluated; above four points indicate significant pain (15,24). the multidisciplinary team working in primary health care, including nursing and physiotherapy, is essential in the care and guidance of people with dm, as it screens, monitors, and treats complications arising from dm and the lack of adequate glycemic control. these professionals are skilled in using these assessment tools for effective monitoring, patient self-care, and treatment guidance. given the need and importance of screening diabetic neuropathy complications with instruments that calculate their prevalence, this study aims to analyze np through validated instruments, measure its intensity, and identify related complications in a group of individuals with type 2 diabetes mellitus (t2dm) covered by the primary health care network in a city in the state of são paulo. method this cross-sectional study on np, its intensity, and complications involved people with t2dm using primary health care in são joão da boa vista (sp) in 2018. data collection and np screening were carried out from november 2018 to april 2019 using four validated instruments to measure np and dpn after approval by the research ethics committee (no. 2.303.253). this research guarantees subjects' confidentiality and privacy regarding their personal data and autonomy. participants were selected by stratified random sampling from a population of 2,542 individuals diagnosed with t2dm (international classification of diseases (icd) code e10 and e11), registered in the extinct hiperdia program, in 13 primary health units in the different regions of the municipality. the study included individuals residing, domiciled, and registered in the municipal public network of são joão da boa vista, having cognitive conditions to participate in the study (alertness, mental soundness to meet the study requirements voluntarily), aged over 30 years, and with a diagnosis of t2dm for five years or more. additionally, the following exclusion criteria were adopted: alcoholism, decompensated hypothyroidism, signs of spinal cord compression, stenosis or radiculopathy, chronic pain of another nature such as vascular pain and nociceptive pain, severe peripheral artery disease, ischemic or hemorrhagic stroke associated with t2dm, uncontrolled high blood pressure, pregnancy, lactation, malignant disease in the lower limbs, active systemic can­cer, posterior knee and spine surgery, score greater than 12 on the hamilton depression rating scale (hdrs) (25), no glycemic monitoring, and no glycated hemoglobin in the last six months. the hdrs is used in the assessment and exclusion processes, as depression may interfere with the pain level we investigated variables related to sociodemographic characteristics, laboratory, clinical aspects, and complications related to t2dm, lifestyle habits, comorbidities, treatments, hospitalization for the disease, treatment satisfaction in primary health units, and assessment of np and its intensity. the data of each patient with t2dm were obtained at the health units during an appointment scheduled by telephone by the responsible researcher and from information recorded in the medical records. participants signed the informed consent and filled out a form on sociodemographic characteristics, lifestyle, and clinical history. for screening diabetic neuropathy and np and measuring pain intensity and complications, we used four validated instruments, namely, the mnsi (13,14) to assess the characteristic symptoms of diabetic neuropathy; the lanss (15) to differentiate the type of neuropathic or nociceptive pain; the dn4 (16) to identify specific symptoms of np, and the bpi (17) for the numerical quantification of pain. based on instrument results, np was determined when lanss scores were greater than or equal to 12, dn4 scores were greater than or equal to 4, and bpi scores were greater than 4. the mnsi classified individuals with dpn in scores above 6 (26) through data computed in a software called fuzzy, which classifies the evaluated neuropathic symptoms. the hdrs considered a score greater than or equal to 9 points for depression symptoms (25). predictive values for the instruments that assessed np (lanns, dn4, and bpi) were calculated from the probabilistic expression of an individual with t2dm having a score sufficient to determine np. the complications related to the dm studied were assessed by temperature sensitivity test with a test tube and water at different temperatures, light touch test with cotton on the feet for allodynia, and simple yes or no questions on painful symptoms. sleep quality was evaluated by asking the individual with t2dm whether they had had a peaceful night of sleep without pain or a night disturbed by pain in their feet. the sample was calculated assuming about 20 % of people with np of the total number of individuals with t2dm in the municipality. then, 194 people with t2dm were recruited, approximately 15 individuals per primary health unit. we employed the simple random sampling calculation to determine the proportion according to equation (1): where n: sample size; n: population size; z: abscissa of the normal distribution (1.65 to 90 % confidence level); d: maximum permissible error (decimal); p: the proportion of one of the events (p= 0.5 is allowed when the previous proportion of pilot samples is not known) (27). the prevalence of np was calculated as a static measure through specific assessments to identify the number of individuals with t2dm and np from the total sample. we used equation (2): the specificity of the instruments used for np (lanns, dn4, and bpi) was calculated using the likelihood ratio (lr) to obtain their predictive values. the data were analyzed using descriptive and inferential statistics. quantitative variables were presented as mean, median, and standard deviation, while categorical variables were represented by absolute and relative frequency. after parametric and non-parametric calculations, the variables associated with np were quantified, building a roc curve, and defining the odds ratio value. moreover, the hosmer-lemeshow test was employed to identify the model's fit to the data obtained. the odds ratio was calculated as a measure of the intensity of association based on a multivariate logistic model to quantify the chances of events enabling the onset of np in the studied population. results a total of 194 medical records of people with t2dm were analyzed. according to the eligibility criteria, 96 people were included in the study, three died before any assessment, and 95 people were excluded. thirty-four (33.32 %) had less than five years of t2dm, 26 (25.48 %) had spinal disorders with medullary compression, stenosis, or herniated disc; 17 (17.46 %) refused to answer the questionnaire or have their feet examined; 12 (11.76 %) had ischemic stroke, and 6 (11.98 %) severe artery disease, hypothyroidism, decompensated dm, or poliomyelitis. the general age range of individuals who participated in the study was between 30 and 87 years. most were female (53; 57.6 %), caucasian (53; 55.2 %), married (65; 68.2 %), residing in the rural area (69; 72 %), with elementary education (21; 21.9 %), income from agriculture (69; 72.0 %), and classified according to per capita income as class c (46; 47.8 %). their mean time since t2dm diagnosis was 12 ± 6.5 years, average fasting glucose was 184 ± 12 mg/ dl, and average glycated hemoglobin was 7.8 % ± 0.01. diabetic neuropathy and np were identified in 22 (22.9 %) individuals (95 %; ci: 0.2032-0.3867). table 1 shows data on sociodemo-graphic characterization and lifestyle habits considered risk factors for comorbidities, with and without diabetic neuropathy and np. table 1. qualitative variables: sociodemographic characteristics, risk factors, and comorbidities of individuals with t2dm, according to np variables diabetic neuropathy with no pain n = 74 n (%) diabetic neuropathy with pain n = 22 n (%) p-value 95 °% ci age range > 60 years 53 (71.6) 16 (72.7) 0.494 [0.1323; 0.3315] female 45 (60.8) 16 (63.6) 0.7771 [0.1519; 0.3727] caucasian 43 (58.1) 11 (50.0) 0.4614 [0.0963; 0.3111] smoking and alcoholism 28 (37.8) 12 (54.5) < 0.001 [-3.0967; 1.9655] physical activity 22 (29.7) 01 (4.5) 0.2502 [-1.6242; 0.3756] balanced diet 29 (39.1) 03 (13.6) 0.0066 [-3.2911; -0.6223] high blood pressure 64 (86.4) 21 (95.4) < 0.001 [0.1554; 0.3387] obesity (bmi > 30) 31 (41.9) 15 (68.2) 0.023 [-0.1707; 2.0456] dyslipidemia 1 (41.8) 15 (68.1) 0.4719 [0.1906; 0.4615] note. bmi = body mass index. source: own elaboration we identified a statistically significant association between alcoholism and smoking, not having a balanced diet, and comor-bidities such as obesity, high blood pressure, and the peripheral neuropathy with pain. table 2 presents the results regarding t2dm control in individuals with and without np. table 2. variables related to clinical history in the control of t2dm, according to np variables diabetic neuropathy with no pain n= 74 n(%) diabetic neuropathy with pain n= 22 n(%) p-value 95 %% ci t2dm time years (mean ± sd ) 8 ± 6.55 12 ± 6.57 0.0039 [0.0382; 0.1866] fasting blood glucose mg/dl (mean ± sd ) 172 ± 55.4 214 ± 65.58 0.0002 [0.0074; 0.0235] glycated hemoglobin % (mean ± sd) 7 ± 0.12 8.8 ± 0.11 < 0.001 [59.1416; 63.2348] monitoring frequency of capillary blood glucose n (%) daily weekly monthly 18 (24.3) 30 (40.5) 25 (33.7) 4 (18.2) 7 (31.8) 11 (50.0) 0.4093 0.4195 0.356 [0.657; 0.979] [0.685; 0.937] [0.544; 0.845] form of glycemic control n (%) oral medication insulin both 34 (45.9) 14 (18.9) 25 (33.7) 2 (9.0) 7 (31.8) 9 (40.9) 0.119 0.234 0.356 [0.869; 1.019] [0.465; 0.868] [0.587; 0.884] note. sd=standard deviation. source: own elaboration we identified a statistically significant association between alcoholism and smoking, not having a balanced diet, and comorbidities such as obesity, high blood pressure, and the peripheral neuropathy with pain. table 2 presents the results regarding t2dm control in individuals with and without np. there was a statistically significant difference between individuals with and without np and disease duration, fasting blood glucose, and glycated hemoglobin. patients with peripheral neuropathy and pain had longer t2dm duration and higher levels of glycemia and glycated hemoglobin (table 2). table 3 shows the mean and standard deviation of the scores obtained through the tools for assessing diabetic neuropathy and screening np. it was possible to identify higher scores in people with diabetic neuropathy and np in relation to the mean scores of each administered instrument. table 3. scores of the instruments for screening painful neuropathy in t2dm, according to np variables diabetic neuropathy with no pain (mean ± sd ) diabetic neuropathy with pain (mean ± sd ) p-value mnsi 3.70 (3.36) 13.54 (2.75) < 0.001 lanns 3.34 (3.80) 16.10 (2.55) < 0.001 dn4 1.40 (1.54) 7.78 (1.89) < 0.001 bpi 1.49 (2.09) 7.67 (1.58) < 0.001 note. lanss: leeds assessment of neuropathic symptoms and signs; bpi: brief pain inventory; dn4: douleur neuropathique 4; mnsi: michigan neuropathy screening instrument. source: own elaboration bpi measures pain intensity as mild (up to 2 points), moderate (3 to 7 points), and severe (8 to 10 points). the average score of individuals with t2dm who had np was 7.67 points, considered as moderate to severe pain intensity. additional analysis of the positive predictive value of specific instruments for assessing np (lanns and dn4) demonstrated a specificity of 84.85 % and 98.4 %, respectively. meanwhile, the bpi numerical pain scale, nonspecific to np, showed a specificity of 81.2 % for this type of pain. table 4 shows the most apparent manifestations and complications associated with t2dm and diabetic neuropathy with pain compared to people with diabetic neuropathy without pain. table 4. complications associated with t2dm, according to np variables diabetic neuropathy with no pain n (%) diabetic neuropathy with pain n(%) p-value 95 %% ci temperature sensitivity changes 33 (44.5) 6(27.2) 0.0021 [0.0406; 0.2671] allodynia 1 (1.3) 14 (63.6) < 0.001 [0.80709; 1] night-time worsening of symptoms 12 (16.2) 19 (86.3) < 0.001 [0.4414; 0.7844] poor sleep patterns 40 (54.0) 15 (68.2) 0.0054 [0.1550; 0.3904] depression symptoms 10 (13.5) 8 (36.3) 0.0022 [0.21488; 0.674] amputation 1 (1.4) 3 (13.6) 0.0176 [0.3256; 1] ulcers 7 (9.46) 4(18.2) 0.0137 [0.0794; 0.6479] source: own elaboration hospitalization in the last 12 months was not significant for any of the groups, generally around 2.08 %, and there was no difference between them. regarding the prevalence of individuals who used specific medications for np, only one (4.54 %) individual with diabetic neuropathy and pain took pregabalin. the individuals assessed reported 67 % satisfaction with the treatment of the unified health system. table 5 shows the multivariate analysis of the association between demographic variables, risk factors, t2dm-related factors, and the complications of t2dm with diabetic neuropathy and np. table 5. association between demographic variables, risk factors, and complications of t2dm with peripheral neuropathy and np variables estimation sd 95 %% ci p-value intercept -19.2796 8.7772 [-42.4236; -5.2077] 0.0281 fasting blood glucose -0.0167 0.0138 [-0.0481; 0.0086] 0.2276 hb1ac 204.8823 93.8609 [42.7929; 428.4307] 0.0290 dm time 0.0344 0.0888 [-0.1493; 0.2322] 0.6986 male -1.6534 1.9437 [-6.8181; 1.5126] 0.3950 diet for dm -4.0907 2.2755 [-9.8344; -0.3553] 0.0722 previous use of tobacco and alcohol -0.2400 1.8659 [-3.9079; 3.9309] 0.8977 smoking and alcoholism -1.5543 3.3681 [-8.8636; 5.1881] 0.6445 obesity 0.7386 1.2261 [-1.7612; 3.3311] 0.5469 decreased vibratory sensitivity -1.0485 1.4033 [-4.3624; 1.5688] 0.4550 absent vibratory sensitivity 0.2160 2.0288 [-3.9072; 4.5434] 0.9152 decreased temperature sensitivity 3.3169 2.0229 [0.0725; 8.8623] 0.1011 temperature sensitivity -1.9473 2.3561 [-6.7377; 3.2267] 0.4085 physical activity 4.0447 2.1055 [0.6459; 9.3609] 0.0547 night-time worsening of symptoms 0.7194 1.8985 [-3.2168; 4.6288] 0.7048 good sleep quality -0.9796 1.3649 [-4.2455; 1.5637] 0.4730 amputation 1.1531 1.9445 [-2.5738; 5.4062] 0.5532 allodynia indicator 0.9914 1.5877 [-2.1986; 4.3773] 0.5324 ulcer indicator -0.4523 1.8685 [-4.4390; 3.3579] 0.8087 age group indicator 2.2560 3.9863 [-5.9017; 10.2529] 0.5714 race indicator -1.7476 2.0689 [-6.1938; 2.2572] 0.3983 source: own elaboration estimates of the logistic model with multivariate analysis allowed isolating the influence of hb1ac on diabetic neuropathy with np (p = 0.0290). for every 1 % of increased hb1ac, there was an increase of 2.8954 times the chance of developing this complication. when calculating the area for the roc curve, we obtained a value of 0.8225, indicating the model's good discrimination (or 2.8954; -95 %: 2.7519; 3.0465; p < 0.001). discussion diabetic neuropathy manifested by np is one of the most devastating and disabling complications of t2dm. despite its medical and social relevance, there are few studies on its main clinical and epidemiological characteristics, making it even more difficult to screen, assess, and diagnose and impairing adequate therapeutic management. this research identified diabetic neuropathy and np in 22.9 % of the individuals. patients with peripheral neuropathy and pain had t2dm for longer and higher levels of glycemia and glycated hemoglobin. for every 1 % of increased hb1ac, there was a 2.8fold increase in the chance of developing this complication. a statistically significant association was identified between the use of alcohol and cigarettes, failure to have a balanced diet, and co-morbidities such as obesity, high blood pressure, and peripheral neuropathy with pain. in addition, people with np experienced complications such as changes in temperature sensitivity, allodynia, amputations, ulcers, worsening sleep quality, and depression symptoms significantly more frequently than those without pain. np assessment and diagnosis in people with t2dm is little targeted and specific concerning their symptomatology. thus, it is necessary to exclude other causes not to be confused with pains related to diabetes itself, such as symptoms of spinal lesions, which is a widespread disorder (28). about a quarter of the individuals included in this research had np, which spotlights the magnitude of this complication and the importance of making health professionals aware of the clinical screening of dpn and np using specific scales for identifying their signs and symptoms (29,30). we noted a high prevalence coefficient of painful diabetic neuropathy among the sample studied compared to data from other brazilian regions that have a lower prevalence of np, such as santa catarina with 16.7 % (31). this may result from the association between prolonged illness time and inadequate management of people with diabetes in the region, where there is no standard monitoring and strict treatment in health units. a lack of a multi-disciplinary team responsible for the comprehensive monitoring of these patients leads to inadequate glycemic control and, thus a high frequency of complications inherent to the disease (32,33). the association between dm and pain with the sex, race, and age group variables was described by (32). in our study, these variables were not associated with np. however, we identified that other variables such as disease duration and glycemic variability could increase complications associated with pain, such as changes in temperature sensitivity, allodynia, amputations, ulcers, poor sleep quality, depression symptoms, changes in biomechanics, and worsening of quality of life, as revealed by other researchers (32-35). research aimed at identifying risk factors for developing np has shown that its prevalence can increase dramatically when dm duration is longer than 20 years and is associated with smoking, high levels of fasting blood glucose and hb1ac, low educational level, and underemployment (36). our research revealed similar results, as many individuals in the sample were low-income rural workers with inadequate glycemic control. it should be noted that the development of diseases caused by agricultural activity blurs np screening, as it shares symptoms with several diseases of different etiologies. degenerative changes in the spine and discopathies, which are very prevalent in the population, show symptoms such as pain, tingling, and sensitivity alterations like np caused by dm, demonstrating the importance of np-specific (35,37). studies carried out recently in portugal point out to the prevalence of np in t2dm (18-23 %) and its associations with the risk factors highlighted by dn4 pain screening. as in our study, increased prevalence of pain was related to high levels of hb1ac, age group, and dm duration. there are no reports associating sex and ethnicity with pain (29,34). in 2019, a danish center conducted a cohort survey of 5,514 people with diabetes, identifying an average of 4.6 years of disease duration and 10 % prevalence of pain through the mnsi and dn4 instruments. it reports significant associations between the appearance of np and females, an increase in the age group, duration of the disease, bmi greater than 30, and smoking. the study also relates pain to allodynia, changes in temperature sensitivity, depression symptoms, and changes in the quality of sleep of individuals with an average dm duration of 12 years (32). according to the 2019 consensus on diabetic neuropathy, about 26 % of patients with t2dm developed chronic diabetic neuropathy, maintaining symptoms for more than three months. in fact, in our research, the main complications associated with np in t2dm were the most referred to, i.e., allodynia, poor sleep quality, and night-time worsening of symptoms. these complications were present in more than 50 % of the people examined. such manifestations are due to injury of the thin nerve fibers and a lack of glycemic control, producing changes in sensitivity, worsening burning and tingling symptoms, mainly at night, and influencing the quality of sleep of patients with painful diabetic neuropathy (37-39). pai et al. (40) investigated the risk factors for the onset of np in taiwan through an observational study with 2,837 people with t2dm screened using the mnsi and dn4 questionnaires. they found an np prevalence of 21.2 %, related to advanced age, treatment with insulin, high blood pressure, high cholesterol, and hb1ac. these data are like those in the present study, in which the 1 % increase in hb1ac elevated three times the chance of developing np (41). high blood pressure, dyslipidemia, obesity, and smoking associated with painful diabetic neuropathy cause a higher prevalence of complications in individuals with more than ten years of disease, especially in more than half of people with np. current data show that this association occurs when 95.4 % of the studied individuals with pain have high blood pressure, 68.1 % dyslipidemia, 68.2 % obesity, and 54.5 % smoking, physically and emotionally impacting their quality of life (3, 38, 42). the lanns and dn4 instruments in patients with dn showed high scores for np caused by nervous impairment of fine fibers aõ and c, with symptoms such as hyperalgesia or allodynia. the bpi reported an average of seven points for pain intensity. these data corroborate an epidemiological study on the prevalence of painful diabetic neuropathy in the states of são paulo, ceará, and bahia, brazil, by applying the dn4 and bpi instruments, with scores above seven points (43). in conclusion, hyperalgesia and allodynia are related to high scores on the numerical pain scale, and this reflects in daily-life and professional activities, items assessed by the bpi (9). our results, associated with previously published studies, demonstrate that np screening in diabetes mellitus can be performed using existing instruments validated in portuguese. it is possible to design a systematic, integrative study to select instruments with more significant predictive value, sensitivity, and specificity and develop a more specific evidence-based protocol to screen and treat np in t2dm. the sensitivity and specificity values of the instruments used in the screening were above 80 %, indicating good accuracy. higher scores on the instruments were related to a longer duration of the disease, high levels of hb1ac, and insulin glycemic control (15,16,34). it is possible to outline the profile of individuals with t2dm treated in primary health care and their complications related to diabetic neuropathy and pain. for this, control measures, stricter risk factor assessments, and targeted programs are necessary to raise awareness of painful diabetic neuropathy in order to decrease or even prevent the resulting biomechanical and psychic changes. because diabetes is a disease with multisystem complications and pain is a multifactorial event, nursing and a multidisciplinary team are necessary to care for the patient holistically. implementing a standardized protocol and monitoring the nursing and physiotherapy team for people with t2dm in the municipalities' primary health units is essential to maintain adequate glycemic control and, consequently, reduce the rates of np complications and prevalence. the present study had some limitations because the assessment of np in people with diabetes mellitus relied on records made available by health units. therefore, data from private institutions was not computed to obtain the actual prevalence of np in the municipality. conclusion np screening allowed identifying pain in about 20 % of individuals surveyed, with moderate to severe intensity. np was significantly associated with the use of alcohol and cigarettes, failure to have a balanced diet, and comorbidities such as obesity and high blood pressure. the probability of np was three times greater upon a percentage increase in glycated hemoglobin. complications such as changes in temperature sensitivity, allodynia, night-time worsening of symptoms, poor sleep patterns, depression symptoms, amputations, and ulcers were more frequent in patients 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https://care.diabetesjournals.org/content/diacare/suppl/2016/12/15/40.supplement_1.dc1/dc_40_s1_final.pdf 38. rolim lc, koga da silva em, de sá jr, dib sa. a systematic review of treatment of painful diabetic neuropathy by pain phenotype versus treatment based on medical comorbidities. front neurol. 2017. doi: https://doi.org/10.3389/fneur.2017.00285 39. pop-busui r, boulton ajm, feldman el, bril v, freeman r, malik ra, et al. diabetic neuropathy: a position statement by the american diabetes association. diabetes care. 2017;40(1):136-54. doi: https://doi.org/10.2337/dc16-2042 40. pai yw, lin ch, lee it, chang mh. prevalence and biochemical risk factors of diabetic peripheral neuropathy with or without neuropathic pain in taiwanese adults with type 2 diabetes mellitus. diabetes metab syndr. 2018;12(2):111-116. doi: https://doi.org/10.1016/j.dsx.2017.09.013 41. ponirakis g, elhadd t, chinnaiyan s, dabbous z, siddiqui m, al-muhannadi h, et al. prevalence and management of diabetic neuropathy in secondary care in qatar. diabetes metab res rev. 2020;8. doi: https://doi.org/10.1002/dmrr.3286 42. pedrosa hc, vilar l, boulton ajm et al. neuropatias e pés diabéticos. acf. 2013. 43. udall m, kudel i, cappelleri jc, sadosky a, king-concialdi k, parsons b, et al. epidemiology of physician-diagnosed neuropathic pain in brazil. j pain res. 2019;7(12):243-253. doi: https://doi.org/10.2147/jpr.s160504 home 207 211 primeras paginas.indd 257 ma. del refugio zavala-rodríguez1 maría del carmen ríos-guerra2 guillermina garcía-madrid3 claudia patricia rodríguez-hernández4 funcionalidad familiar y ansiedad en pacientes adultos con enfermedad crónica 1 doctora en educación. universidad autónoma de tamaulipas. méxico. mzavala07@hotmail.com 2 enfermera. hospital general dr. norberto treviño zapata, boulevard fidel velázquez no. 645 cd. victoria tamaulipas, méxico. carmenrios_2010@hotmail.com 3 enfermera. benemérita universidad autónoma de puebla, méxico. guillergm25@hotmail.com 4 enfermera pediatra. hospital general de nuevo laredo tamaulipas, méxico. claurdzhdz@hotmail.com recibido: 23 de junio de 2009 aceptado: 29 de octubre de 2009 resumen objetivo. describir el grado de relación entre la funcionalidad familiar y el nivel de ansiedad en pacientes adultos con enfermedad crónica de una institución de salud de segundo nivel. metodología. el diseño del estudio fue descriptivo, transversal, correlacional, se efectuó en una muestra de 97 pacientes y una misma cantidad de familiares; los primeros se seleccionaron mediante un análisis de potencia, cubriendo los siguientes criterios de inclusión: pacientes adultos, orientados, de los servicios de hospitalización y consulta externa de una institución de segundo nivel de atención. se utilizó una cédula sociodemográfica, la escala de efectividad en el funcionamiento familiar de friedemann (e-eff), y la escala de ansiedad-rasgo de spielberger, estos últimos con una consistencia interna de ,83 y ,75 respectivamente, determinada por el alpha de cronbach. los datos se analizaron a través de estadística descriptiva e inferencial. resultados. el grupo de edad que predominó en los familiares fue de 33 a 47 años, con una media de 45,73, y en los pacientes predominó el grupo de 60 a 70 años, con una media de 65,05; en ambos grupos se destacó el género femenino. el 56% de los pacientes presenta diabetes mellitus tipo 2. en cuanto a los índices, la ansiedad-rasgo obtuvo una media de 51 (de 10,7), en la e-eff fue de 84 (de 11,5). por tanto, se detectó nivel moderado de ansiedad en el 92% de los pacientes, y el 91% integra una familia funcional. la correlación de spearman no arrojó una asociación significativa entre las dos variables del estudio (rho= -,094, p= ,362). conclusión. las cuatro subescalas de la e-eff obtuvieron una media significativa, con valores que fluctúan entre 77,0 a 92,0. este último valor equivale a la subescala de coherencia que, de acuerdo con friedemann, guía a la unidad y pertenencia familiar, y permite vínculos emocionales positivos. palabras clave funcionalidad familiar, ansiedad, enfermedad crónica. (fuente: decs, bireme). año 9 vol. 9 nº 3 chía, colombia diciembre 2009 257 270 258 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 family functionality and anxiety in adult patients with chronic disease abstract objective. describe the degree of relationship between family functioning and the level of anxiety in adult patients with chronic disease in a health institution at the second level. methodology. the study design was descriptive, cross correlation, was performed on a sample of 97 patients and an equal number of families, the first ones were selected with a potential analysis, covering the following inclusion criteria: adultoriented patients about the services and outpatient consultation of an institution at second level of care. we used a sociodemographic card, the scale of effective family functioning of friedemann (e-eff) and the scale of spielberger trait-anxiety, the latter with an internal consistency of .83 and .75, respectively, as determined by alpha cronbach. data were analyzed using descriptive and inferential statistics. results. the age group that prevailed in the family was from 33 to 47 years, a mean of 45.73, and in the patients, was the group of 60 to 70 years, an mean of 65.05; in both groups stressed the female gender. 56% of patients had diabetes mellitus type 2. as for the indices, trait-anxiety had a mean of 51 (10.7) in the eff-e was 84 (11.5). therefore, there was moderate level of anxiety in 92% of the patients and 91% integrating a functional family. the spearman correlation showed no significant association between the two variables of the study (rho = -. 094, p = .362). conclusion. the four subscales of the e-half eff obtained significant values ranging from 77.0 to 92.0. the latter value is equivalent to the subscale of consistency, according to friedemann, guide to family unity and membership also allows positive emotional bonds. key words family functioning, anxiety, chronic illness. (source: decs bireme). funcionalidade familiar e ansiedade em pacientes adultos com doença crônica resumo objetivo. descrever o grau de relação entre a funcionalidade familiar e o nível de ansiedade em pacientes adultos com doença crônica de uma instituição de saúde segundo nível. metodologia. o estudo foi descritivo, transversal, de correlação. foi realizado em uma amostra de 97 pacientes e um número similar de parentes; os primeiros foram selecionados através de uma análise de energia, com os seguintes critérios de inclusão: pacientes adultos, orientados, dos serviços hospitalares e de consulta externa de uma instituição de segundo nível. nós usamos um cartão sócio-demográfico, a escala de efetividade no funcionamento familial, de friedemann (e-eff), e a escala de ansiedadetraço de spielberger; estes últimos com uma consistência interna de ,83 e ,75, respectivamente, determinada pelo alfa de cronbach. os dados foram analisados através de estatística descritiva e inferencial. resultados. a faixa etária predominante nos familiares foi de 33 a 47 anos, com uma média de 45,73; nos os pacientes predominou o grupo de 60 a 70 anos, com uma média de 65,05. em ambos os grupos sobressaiu o sexo feminino. o 56% dos pacientes têm diabetes mellitus tipo 2. para índices, a ansiedade-traço marcou uma média de 51 (de 10,7); na e-eff foi 84 (dp 11,5). o 92% dos pacientes apresentou nível moderado de ansiedade; o 91% conforma uma família funcional. a correlação de spearman não mostrou associação significativa entre as duas variáveis do estudo (rho = -, 094, p =, 362). conclusão. as quatro subescalas da e-eff apresentam uma media significativa, com valores oscilando de 77,0 a 2,0. este valor equivale à subescala de coerência que, de acordo com friedemann, orienta a unidade familiar e a pertencia familiar, e permite vínculos emocionais positivos. palavras-chave funcionalidade familiar, ansiedade, doença crônica (fonte: decs, bireme). 259 funcionalidad familiar y ansiedad en pacientes adultos con enfermedad crónica ma. del refugio zavala-rodríguez, maría del carmen ríos-guerra, y otros. introducción en méxico, como en muchos otros países, la familia representa una unidad básica de la sociedad, comparte entre sus miembros la vida en común, sus fortalezas, debilidades, y el conocimiento y significado que tienen de sí mismos y de su realidad (1). sin embargo, los cambios sociales, como la aparición de nuevos roles tanto para el hombre como para la mujer, y la transición demográfica, entre otros, son factores generadores de modificaciones en la estructura y dinámica familiar. de acuerdo con friedemann (2), la familia es una unidad con estructura y organización que interactúa con su medioambiente, es un sistema social, con subsistemas interpersonales definidos por uniones emocionales y responsabilidades comunes, sujeta a cambios que pueden afectar su estabilidad. el consejo nacional de población (conapo, cit. por moreno, 2008) (3), reporta que en méxico, de los 103,3 millones de habitantes, 8,2 millones de personas tienen 60 años y más; las proyecciones indican que para el 2030 serán 22,2 millones y para la mitad del siglo alcanzarán 36,2 millones. este proceso de envejecimiento poblacional tiene múltiples repercusiones en el país, en los ámbitos económico y social, en el sector salud y, de manera particular, en el contexto familiar, pues culturalmente el cuidado de este grupo de población recae principalmente en la familia, en los miembros del género femenino, en general en las esposas e hijas. además de los cambios y las limitaciones propios de la edad, el adulto mayor es susceptible a desarrollar padecimientos crónicos, en consecuencia, se pueden incrementar los niveles de discapacidad y dependencia física con repercusiones en la funcionalidad familiar. aguilar f. (citado en garcía tafolla, 2005) (4), señala que las enfermedades crónicas repercuten en la autopercepción del individuo, por tanto, se puede decir que actúan como un estímulo estresor que puede afectar física y emocionalmente a las personas. cada persona tiene una manera particular de responder a las alteraciones emocionales, la respuesta adaptativa requiere tiempo y esfuerzo. la ansiedad es la más común y universal de las emociones, se define como una respuesta subjetiva al estrés, como una sensación de aprensión, incertidumbre o temor, a consecuencia de una amenaza real o percibida cuyo origen real se desconoce o no es reconocido (5). la ansiedad también afecta las capacidades de enfrentarse al estrés, de aprender y de centrarse en un campo perceptivo (5). el concepto de ansiedad-rasgo se refiere a las diferencias individuales, en la manera como las personas responden a situaciones como amenazantes (6). de acuerdo con gordon (7), la ansiedad es un vago sentimiento de incomodidad cuyo origen es a menudo inespecífico o desconocido para el individuo; este autor la categoriza en tres niveles: leve, moderado y severo, según el aumento del grado de alerta asociado con la expectativa de una amenaza que puede ser hacia el estado de salud, la posición socioeconómica, el desempeño del rol, el autoconcepto, los patrones de interacción o el entorno. además de los cambios y las limitaciones propios de la edad, el adulto mayor es susceptible a desarrollar padecimientos crónicos, en consecuencia, se pueden incrementar los niveles de discapacidad y dependencia física con repercusiones en la funcionalidad familiar. 260 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 la variable funcionalidad familiar ha sido estudiada con modelos y teorías de otras disciplinas (medicina, psicología); con el sustento del marco teórico de organización sistémica de friedemann, ha sido estudiada principalmente en adolescentes (8). en méxico no se hallaron estudios que relacionen la funcionalidad familiar y el nivel de ansiedad en pacientes adultos con enfermedad crónica, por tanto se plantea la siguiente pregunta de investigación: ¿cuál es el nivel de correlación entre funcionalidad familiar y ansiedad-rasgo en pacientes adultos con enfermedad crónica de una institución de segundo nivel de atención? el objetivo del estudio fue determinar los niveles de funcionalidad familiar y de ansiedad, y describir si existe correlación entre ambas variables en pacientes adultos con enfermedad crónica de una institución de segundo nivel de atención de ciudad victoria, tamaulipas. la hipótesis del estudio fue: a mayor nivel de funcionalidad familiar en pacientes adultos con enfermedad crónica menor nivel de ansiedad. marco teórico esta investigación está sustentada en el marco teórico de organización sistémica, una aproximación al sistema familiar y personal de friedemann (2), quien define a la familia como un sistema de miembros los cuales han decidido residir juntos o interrelacionarse afectivamente con el objetivo primario de apoyarse unos con otros. la teoría comprende cuatro dimensiones desarrolladas a nivel interpersonal, intrapersonal y familiar, que se definen de la siguiente manera: coherencia. se refiere a relaciones armónicas entre los miembros familiares que proveen de un sentido de unidad y pertenencia familiar a través de la internalización de respeto, amor e interés de unos por otros; incluye valores y creencias, elementos que les permiten vínculos emocionales necesarios para la sobrevivencia del sistema. individuación. es una estructura de identidad personal que se desarrolla mediante la comunicación con otros sistemas, este proceso interactivo implica el desempeño de roles y responsabilidades, se fortalecen los talentos, las iniciativas y los conocimientos que proveen de apertura al entendimiento, el aprender de sí mismo y de otros. mantenimiento del sistema. abarca la mayoría de las estrategias de la vida familiar y personal que proveen de un sentido de seguridad y autonomía; implica roles, patrones de comunicación, rituales, normas, valores, toma de decisiones, manejo financiero, patrones de cuidado y planeación del futuro, entre otros elementos. cambio del sistema. comprende la incorporación de nuevos conocimientos para asumir diferentes conductas frente a presiones internas personales, familiares y del ambiente; requiere de apertura para la nueva información que modifica la estructura de valores ante prioridades vitales presentes y futuras, fortalece el control y crecimiento familiar y personal apoyado por un sentido de seguridad y autonomía. esta teoría, a su vez, contempla cuatro grandes metas, las cuales se pretenden lograr a través de la congruencia y el equilibrio de las dimensiones antes mencionadas. a continuación se describen brevemente. la ansiedad es la más común y universal de las emociones, se define como una respuesta subjetiva al estrés, como una sensación de aprensión, incertidumbre o temor, a consecuencia de una amenaza real o percibida cuyo origen real se desconoce o no es reconocido. 261 funcionalidad familiar y ansiedad en pacientes adultos con enfermedad crónica ma. del refugio zavala-rodríguez, maría del carmen ríos-guerra, y otros. estabilidad familiar: atiende a la estructura, organización y comunicación tradicional familiar lo que implica valores y patrones que se transmiten de generación en generación. espiritualidad: implica armonía de los patrones de la persona unificada, lo cual ofrece una seguridad interior que le permite un desarrollo interactivo con otros sistemas abiertos mediante lo que aprende de sí mismo y de otros, con nuevos propósitos en la vida. crecimiento: la meta del crecimiento demanda una reorganización sustancial de los valores y las prioridades básicos, una amenaza a las creencias básicas de una persona requiere una redefinición de identidad y propósito, el individuo intenta alcanzar un nuevo nivel de estabilidad basado en un conjunto revisado de valores y prioridades en la vida. control: constituye la reducción colectiva de las amenazas que surgen del ambiente; la energía que se produce de dichas amenazas es cuidadosamente canalizada para restablecer la congruencia familiar de tal forma que se fortalece el sistema y se logra la autoconfianza de sus miembros; un sentido de autonomía colectiva se adquiere al neutralizar la ansiedad derivada de incertidumbre, vulnerabilidad y desconfianza. todo lo anterior es un proceso complejo, en constante cambio, que se difunde mediante un equilibrio dinámico que permite preservar un sentido de identidad familiar / personal, y a la vez mantener la flexibilidad necesaria para lograr un balance funcional que tienda a la sobrevivencia del sistema. en el siguiente esquema se integran los conceptos clave de esta teoría (2). figura 1. procesos de vida del sistema humano (2). estudios relacionados este apartado se inicia con los resultados de estudios que miden la funcionalidad familiar con relación a la autoestima y capacidad física de los sujetos de estudio, y continúa con investigaciones que la vinculan con estados de ansiedad y depresión. posteriormente, se describen resultados de estudios que reportan la variable de ansiedad en relación con calidad de vida, fortaleza relacionada con la salud, bienestar espiritual y enfermedades crónicas. zavala y cols. (9), realizaron un estudio descriptivo, relacional, para conocer, entre otros aspectos, la autoestima del 262 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 adulto mayor y su percepción del funcionamiento familiar. evaluando esta variable a través de la escala de apgar, encontraron que el 51% de los adultos presenta autoestima alta y el 84,5% tiene una percepción de funcionamiento familiar alto. ortega y cols. (10), realizaron un estudio descriptivo con 57 familias cuyo objetivo fue valorar la percepción que tiene cada grupo generacional (hijos, nietos) sobre el funcionamiento de sus respectivas familias, así como los signos de alarma (migraña, depresión, ansiedad, fatiga crónica) presentes en ella. los resultados indicaron que de los 155 encuestados distribuidos en el total de familias, el 65,2% consideró que sus familias son disfuncionales. los adultos mayores opinaron lo contrario, para ellos, sus familias son funcionales (71,4%). el signo de alarma que se presenta con mayor frecuencia es la ansiedad. lópez (11) llevó a cabo un estudio descriptivo en 75 familias con el propósito de identificar la percepción de la funcionalidad familiar en adultos mayores con diabetes mellitus tipo 2, aplicó la escala de eff de friedemann. el 75,7% percibe a su familia con disfuncionalidad familiar; se encontró una relación significativa del proceso de coherencia con respecto al sexo (p=,01), y una asociación negativa de la edad con el proceso de mantenimiento del sistema (x2= _213). se concluyó que la funcionalidad familiar se sustenta en estas dos dimensiones de funcionamiento, y que la diabetes mellitus altera el funcionamiento de la familia (39%). garcía y cols. (8), desarrollaron un estudio exploratorio, correlacional con 100 familias de una comunidad rural, con el objetivo de explorar la influencia de la funcionalidad sobre la capacidad física de los adultos mayores integrantes de la familia. utilizaron la escala de eff de friedemann para medir la primera variable, y el índice de barthel para la segunda. identificaron familias funcionales en un 69%, y de ellas el 88% de adultos mayores presentaron independencia física total. el mantenimiento del sistema familiar se correlacionó positivamente con la capacidad física de movimiento (r= ,276, p= ,005) y eliminación (r= ,284, p= ,004). los autores reportaron que los procesos de vida del sistema familiar: mantenimiento del sistema, cambio del sistema, e individuación, soportan la funcionalidad familiar. entre los estudios que se han desarrollado sobre la variable ansiedad se localizó el de vettore y cols. (12), quienes analizaron la relación de estrés y ansiedad en pacientes con periodontitis crónica; distribuyeron 79 pacientes, según la severidad de la enfermedad, en tres grupos: un grupo control y dos grupos de prueba. en cuanto a la ansiedad, medida por el inventario de spielberger (stai), en el grupo de prueba 1 y en el grupo control detectaron promedios similares de ansiedad-rasgo, con promedios bajos en el grupo 2 de prueba. detectaron correlación positiva entre la ansiedad-rasgo y las frecuencias de los parámetros clínicos para dicha enfermedad, concluyendo que este tipo de ansiedad puede ser un predictor importante para la enfermedad periodontal. de los ríos y cols. (13), efectuaron un estudio ex post facto con el propósito de indagar la frecuencia de alteración emocional en una muestra poblacional integrada por 100 pacientes con insuficiencia renal crónica por neuropatía diabética. utilizaron el instrumento ghk-28 (general health questionnaire) de goldberg. documentaron que el 86% presentó algún grado de alteración emocional (ansiedad), garcía y cols. desarrollaron un estudio exploratorio, correlacional con 100 familias de una comunidad rural, con el objetivo de explorar la influencia de la funcionalidad sobre la capacidad física de los adultos mayores integrantes de la familia. 263 funcionalidad familiar y ansiedad en pacientes adultos con enfermedad crónica ma. del refugio zavala-rodríguez, maría del carmen ríos-guerra, y otros. tuvieron más riesgo de padecerla los pacientes con diez y más años de evolución de su enfermedad. young y cols. (14), llevaron a cabo un estudio descriptivo, longitudinal, en 32 pacientes; uno de sus objetivos fue explorar la ansiedad en pacientes adultos que experimentaban el trasplante de médula ósea, los datos fueron recogidos en tres momentos, distribuidos en un lapso de tiempo de uno a 100 días. utilizaron el inventario de ansiedad de state/trait (stai) y la escala gráfica de la ansiedad (gas). se encontró una correlación positiva significativa entre el stai y las cuentas del gas. la cuenta de la ansiedad-estado fue moderada en dos de las tres etapas en que se recabaron los datos. lawrence y cols. (15), desarrollaron un estudio transversal de observación en un centro de medicina familiar, con el propósito de analizar las asociaciones estadísticas entre síntomas, diagnósticos y severidad de la enfermedad como indicadores de ansiedad y depresión. utilizaron el cuestionario denominado duque anxiety-depression scale (duke-ad). en todas las regresiones logísticas, el sexo femenino, la percepción de salud baja, más dolor y mayor inhabilidad por días en cama, persistieron como predictores positivos y significativos de síntomas más severos de ansiedad y depresión. entre los diagnósticos de mayor prevalencia detectados se encontraban la diabetes mellitus y la osteoartritis. de los ríos y cols. (16), realizaron un estudio ex post facto, transversal, contemplando 100 pacientes con diabetes mellitus tipo 2; como instrumento de medición aplicaron la escala de calidad de vida relacionada con la salud (escaviris). en el 43% de los pacientes encontraron algún grado de deterioro en su calidad de vida; una de las áreas que predominó fue la psicosocial, en donde se evaluaron aspectos emocionales como la ansiedad, la depresión y algunos elementos de interacción social, el 60% de los pacientes no manifestó deterioro en esta área, y en un 15% fue severo (p<0,003). la mayoría de los pacientes mostró gran ansiedad y estrés ante el avance de la enfermedad, manifestado por molestias físicas y pérdida de peso. zavala y cols. (17), mediante un estudio descriptivo, correlacional, analizaron la relación entre el bienestar espiritual y el grado de ansiedad en 190 pacientes con diabetes mellitus tipo 2, el género femenino representó el 55%, predominando un nivel moderado de ansiedad en ambos géneros. estadísticamente, a través de correlación de spearman, se encontró asociación significativa negativa entre las dos variables objeto de estudio (-,276, p= ,000). zavala y col. (18), desarrollaron un estudio con el propósito de determinar el grado de correlación entre los niveles de fortaleza relacionada con la salud y de ansiedad-rasgo en una muestra de 200 pacientes con enfermedad crónica. se utilizó la escala de autoevaluación de ansiedad-rasgo de spielberger. cerca del 90% de la muestra estudiada padece de diabetes mellitus. el coeficiente de correlación de spearman fue significativo (,570, p= ,000). en la mayoría de los pacientes se encontró nivel moderado, tanto de fortaleza (83%) como de ansiedad (73%). el análisis de regresión múltiple determinó que la relación significativa entre las dos variables no es afectada por la edad, el género o los años de evolución de la enfermedad crónica. zavala y col. desarrollaron un estudio con el propósito de determinar el grado de correlación entre los niveles de fortaleza relacionada con la salud y de ansiedad-rasgo en una muestra de 200 pacientes con enfermedad crónica. 264 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 metodología el presente estudio tuvo un diseño cuantitativo, de tipo descriptivo, transversal y correlacional. el tamaño de la muestra se calculó a través del paquete estadístico nquery advisor 4.0, se consideró un nivel de significancia de 0,5, una potencia de ,80 y una r2 = ,28, quedando conformada por 97 pacientes adultos, orientados (en tiempo, persona y espacio), diagnosticados con enfermedad crónica, del área de consulta externa y del servicio de hospitalización de la especialidad de medicina interna de una institución de segundo nivel de salud de ciudad victoria, tamaulipas, méxico. para realizar la entrevista de los pacientes se estableció como requisito que estuvieran acompañados por un familiar, por consiguiente, se integró un grupo de 97 personas, quienes contestaron las preguntas siguientes: rol dentro de la familia, edad, género, ocupación, tipo de familia, número de integrantes y estado civil del jefe de la familia. se entrevistó un familiar por cada paciente con la finalidad de identificar si eran acompañados por un pariente directo, hecho que contribuye en las interrelaciones familiares y en el aspecto emocional ante situaciones de salud. uno de los instrumentos de medición utilizado fue la escala modificada de efectividad en el funcionamiento familiar (eeff) de friedemann, la cual fue rediseñada y readaptada por garcía y cols. (8), con los lineamientos que al respecto dicta la norma oficial mexicana para la prestación de servicios de asistencia social para menores y adultos mayores (nom-167-ssa11997) (8); de 17 reactivos originales, se añadieron 7 preguntas, por lo que su estructura quedó integrada por 24 reactivos en total, con la misma escala original de respuestas tipo likert con tres opciones: 1= nunca, 2= a veces, y 3= siempre; los autores reportan una consistencia interna de ,73 determinada a través del coeficiente de alpha de cronbach. la escala de eff contempla cuatro subescalas: la de mantenimiento del sistema con 10 reactivos, la subescala cambio del sistema con 6, la de individuación con 5 reactivos, y la subescala de coherencia con 3 reactivos. dicha escala tiene un nivel de medición ordinal, con un valor mínimo de 24 puntos y un valor máximo de 72. en función de estos valores se consideraron familias funcionales o sin problemas, las que obtuvieran un puntaje de 56 a 72 puntos, familias con funcionalidad moderada de 40 a 55 puntos, y familias disfuncionales o con problemas de 24 a 39 puntos. para la medición de la variable ansiedad se utilizó la escala de autoevaluación (idare) de spielberger y díaz guerrero (1975) (5), en su versión al español, la cual consta de 20 reactivos con una escala de respuesta de cuatro puntos: 1= casi nunca, 2= algunas veces, 3= frecuentemente, y 4= casi siempre. la puntuación mínima es de 20 y la máxima de 80. a través de la categorización de su valor máximo se determinaron tres niveles de ansiedad: bajo, de 20 a 40 puntos; moderado, de 41 a 60, y alto, de 61 a 80 puntos. también se utilizó una cédula de datos sociodemográficos de los participantes, dividida en dos apartados: siete reactivos que fueron contestados por el familiar de los pacientes y 12 preguntas contestadas por el paciente en donde se registró: edad, género, rol dentro de la familia, familiares con los que vive, ingreso económico mensual, nivel socioeconómico, tipo de vivienda y religión. también se preguntó la escolaridad del paciente, el servicio hospitalario, el diagnóstico médico y los años de evolución. durante el procedimiento de recolección de los datos a cada participante se le explicó la finalidad del estudio y se recabó la firma del formato de consentimiento informado. 265 funcionalidad familiar y ansiedad en pacientes adultos con enfermedad crónica ma. del refugio zavala-rodríguez, maría del carmen ríos-guerra, y otros. durante el procedimiento de recolección de los datos a cada participante se le explicó la finalidad del estudio y se recabó la firma del formato de consentimiento informado. se inició con la cédula sociodemográfica, se les leyeron las preguntas y se registró la respuesta emitida en primer término por el familiar y posteriormente por el paciente; se continuó con la cédula de ansiedad-rasgo y, finalmente, se aplicó la cédula de efectividad en la funcionalidad familiar. este proceso se realizó en un lapso de 30 a 40 minutos por paciente encuestado, en los turnos matutino y vespertino, durante los meses de enero a marzo de 2008. la presente investigación se apegó a lo establecido por el reglamento de la ley general de salud en materia de investigación para la salud de la secretaría de salubridad y asistencia, respecto a cuestiones éticas, como el anonimato de los sujetos, la confidencialidad de los datos, y el derecho a la información con respecto al estudio y a retirarse en el momento que lo desearan. la información recabada se procesó a través del paquete estadístico spss (versión 13), se analizó mediante estadísticas descriptivas (valor mínimo, máximo, media, desviación estándar y mediana); para la parte inferencial se realizó análisis de correlación de spearman en consonancia con los resultados emitidos por la prueba de kolmogorov smirnov en relación con la normalidad en la distribución de los datos. también se determinó la consistencia interna de los instrumentos de medición a través del coeficiente alpha de cronbach, cuyos valores fueron: para la escala idare ,75 y para la escala eff el valor de ,83. resultados respecto a los datos sociodemográficos de los 97 familiares entrevistados, en el rol que desempeñan dentro de la familia predominó el de hijo (a) (48,5%); en cuanto a su género se destacó el femenino (77,3%); en un alto porcentaje son casados (67%); con relación a la edad se detectó un rango de 18 a 65 años, resaltando el grupo de 30 a 41 años (36%); en su mayoría señalaron integrar una familia nuclear (72,2%), la diferencia en porcentaje pertenece a una familia extensa (27,8%). en más del 50%, la familia está integrada por uno a tres miembros. en función de la ocupación del familiar, el 55% expresó que no trabaja, el resto contestó afirmativamente. en relación con los datos sociodemográficos de los pacientes, el 91% indicó que cuenta con vivienda propia. en la tabla 1 se distribuye la muestra poblacional por género y edad, este dato fluctuó entre 40 a 80 años, con media de 65,05, de de 10,35; referente a los grupos de edad, sobresalieron los comprendidos entre los 60 y 80 años (70%); predominó el género femenino. tabla 1. distribución de pacientes por grupos de edad y género grupo de edad femenino masculino total f % 40 49 11 1 12 12,4 50 59 9 2 11 11,3 60 69 20 16 36 37,1 70 80 24 14 32 33,0 total 64 33 97 100 fuente: datos del estudio. 266 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 en la tabla 2 se muestra el resto de los datos demográficos de los pacientes; se observa que más del 85% desempeña el rol de padres, arriba del 50% vive con su esposo (a). cerca del 70% manifestó un ingreso mensual menor a $1000,00, en consecuencia, el 78% consideró tener un nivel socioeconómico bajo. la mayoría pertenece a la religión católica, y más del 50% cuenta con estudios básicos de primaria. el 51,5% de los pacientes se entrevistó en el servicio de hospitalización (medicina interna), el resto (48,5%) en el servicio de consulta externa. tabla 2. datos sociodemográficos de los pacientes participantes fuente: datos del estudio. variable f % rol familiar padres 85 87,6 abuelos 6 6,2 otro 6 6,2 familiar con que vive esposo (a) 55 56,7 hijos nietos 29 29,9 otros 13 13,4 ingreso mensual de $1000 67 69,0 $1000 3000 25 25,5 + de $3000 5 5,5 religión católica 75 77,3 otra 22 22,7 escolaridad analfabeto 25 25,8 primaria 50 51,5 secundaria 10 10,3 profesional 6 6,2 otro 6 6,2 respecto al diagnóstico médico de los pacientes se tomó como base el de ingreso, o bien el que fue motivo de consulta médica; se identificaron como diagnósticos de mayor incidencia la diabetes mellitus tipo 2 con y sin complicaciones (53%), y los padecimientos cardiovasculares (hipertensión arterial, angina de pecho) (37%). en cuanto a los años de evolución de la enfermedad crónica, el 36% de los pacientes tiene de uno a 5 años, el 12% de 6 a 10 años y el 48% más de 10 años de evolución. en la tabla 3 se muestran los índices por variables de interés y los resultados de la prueba de kolmogorov smirnov, los cuales reportaron que ambas escalas de medición no se ajustaron a una distribución normal. en relación con la variable ansiedad-rasgo se obtuvo una media de 51, de de 10,7. con base en la escala general de funcionalidad familiar se detectó una media de 84, de de 11,5, así mismo, se encontraron valores de media favorables por cada una de las cuatro dimensiones en que se subdivide la escala eff; identificando en las dimensiones de individuación y coherencia los mayores valores (88 y 92 respectivamente). en la tabla 4 se presentan los niveles de las variables objeto de estudio, derivados de la categorización de las puntuaciones respectivas por cédula. referente a la variable ansiedad-rasgo se encontró nivel moderado en el 92% de los pacientes; en cuanto a la funcionalidad familiar, el 91% pertenece a una familia funcional (rango de puntuación de 56 a 72). con el propósito de determinar si existe asociación estadísticamente significativa entre las variables ansiedad y funcionamiento familiar, se efectuó la prueba de correlación de spearman, se encontró 267 funcionalidad familiar y ansiedad en pacientes adultos con enfermedad crónica ma. del refugio zavala-rodríguez, maría del carmen ríos-guerra, y otros. tabla 3. estadísticas descriptivas de ansiedad, funcionalidad familiar por dimensión y prueba kolmogorov smirnov tabla 4. distribución de pacientes por niveles de ansiedad y funcionalidad familiar variable min. max x de md d p ansiedad 30,0 98,3 50,8 10,7 48,3 1,562 0,15 funcionamiento familiar 50,0 100 83,7 11,5 85,4 1,44 ,032 f.f. mantenimiento del sistema 50,0 100 83,1 12,3 85,0 1,402 ,039 f.f. cambio del sistema 25,0 100 76,8 16,5 75,0 1,44 ,031 f.f. individuación 40,0 100 88,1 15,7 90,0 2,65 ,000 f.f. coherencia 33,0 100 92,0 14,25 100 4,05 ,000 fuente: datos del estudio. fuente: datos del estudio. ansiedad f % funcionalidad familiar f % bajo 1 1,0 funcional 88 90,7 moderado 89 91,8 funcional medio 9 9,3 alto 7 7,2 disfuncional total 97 100 97 100 correlación positiva significativa entre las cuatro dimensiones y la escala general de funcionamiento familiar, cuyos valores son: mantenimiento del sistema ,861, cambio del sistema ,786, individuación ,676 y coherencia del sistema ,461, con valor p= ,000 a un nivel de significancia de 0,01. sin embargo, no se encontró correlación significativa entre las dos variables centrales del estudio (r= -,094, p= ,362). discusión en el presente estudio predominó el género femenino tanto en el grupo de familiares (77%) como en los pacientes participantes (66%), situación que se relaciona con la literatura que señala a la mujer como cuidador principal de los familiares enfermos, así como también en el sentido de que son las mujeres las que presentan mayor deterioro de salud a consecuencia de las enfermedades degenerativas asociadas a la edad avanzada. no obstante que la muestra poblacional contempla pacientes entre 40 a 80 años, sobresalieron los adultos mayores (60 a 80 años) (70,1%), esto es reflejo de la transición demográfica en méxico, representada por el crecimiento de la cúspide de la pirámide poblacional integrada por las personas mayores. también se puede relacionar con las características propias de la muestra, pacientes con enfermedades crónicas, teniendo en cuenta que la enfermedad crónica es más frecuente en los adultos. la gran mayoría de los pacientes son miembros de una familia nuclear (72%), en donde desempeñan el rol de padres (88%), viven con su esposo (a) (57%) y profesan la religión católica (77%). estas variables podrían estar apoyando las dimensiones del sistema familiar denominadas mantenimiento del sistema, individuación y coherencia, como lo señala friedemann. con relación a las dos primeras dimensiones se puede inferir que coinciden con lo reportado por garcía y cols. (8), y con lo registrado por lópez (11) respecto a la dimensión de coherencia y mantenimiento del sistema. con base en el nivel de funcionalidad familiar, el 91% de los pacientes manifestó que integran una familia funcional; resultados similares reportaron zavala y cols. (9) en torno a la opinión positiva de los adultos mayores encuestados, y garcía y cols. (8) en familias rurales. parcialmente coinciden con lo reportado por ortega y cols. (10), en cuanto a la percepción positiva de los adultos mayores estudiados, difiriendo con lo expresado por 268 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 sus familiares, ya que el 65% se calificó como familias disfuncionales. también se encontró divergencia con el reporte de lópez (10), quien halló mayor porcentaje de familias disfuncionales (75%). en relación con el grado de ansiedad detectado en los pacientes, el 92% presentó nivel moderado, encontrando similitud con los resultados reportados por young (14), zavala y cols. (17, 18), vettore y cols. (12). a diferencia de lo documentado por ríos y cols. (13), el 86% de los pacientes estudiados presentaban alteraciones emocionales; también difiere con lo señalado por lawrence y cols. (15), ya que asocian la diabetes mellitus con síntomas severos de ansiedad y, no obstante ser este padecimiento el que predominó en más del 50% de la población participante, se manifestó con moderado grado de ansiedad. el coeficiente de correlación de spearman arrojó una asociación positiva entre las cuatro dimensiones y la escala general de funcionalidad familiar, sin embargo, no se encontró correlación significativa entre las variables de estudio —funcionalidad familiar y ansiedad—. esta diferencia de asociación entre las variables centrales puede ser debida a que se encontró funcionalidad familiar adecuada, es decir, obtuvieron el rango de puntuación (56-72 puntos) que identifica, según friedemann, a familias funcionales; en cuanto a la ansiedad presentaron nivel moderado, estado emocional que puede estar asociado con las repercusiones propias de la enfermedad crónica que presentan los pacientes. en relación con lo anterior, se encontraron marcadas diferencias con el estudio de ortega (10), ya que la mayoría de los grupos familiares se perciben disfuncionales, e identifican la ansiedad como signo de alarma y predictor de este tipo de familias. no obstante los niveles favorables detectados por variable, más del 50% de los pacientes padecen de diabetes mellitus tipo 2, en su mayoría con complicaciones, esto pudiera presentar un riesgo en la conservación de la estabilidad y el control de la dinámica familiar, aspectos establecidos por friedemann como metas en la sobrevivencia del proceso sistémico de la familia. en cuanto al diagnóstico médico predominante, coincide con lo reportado por de los ríos y cols. (13), zavala y col. (18), y lópez (11), difiriendo con lo documentado por este último autor, el cual establece que la diabetes mellitus altera el funcionamiento familiar. conclusiones cerca del 100% de los pacientes participantes en el estudio integran familias funcionales; sin embargo, su condición de salud ante problemas metabólicos y cardiovasculares pone de manifiesto que se requiere indagar su conocimiento de autocuidado, factor que contribuye a su calidad de vida y, por consiguiente, al equilibrio funcional de la familia en sus diferentes roles. las cuatro dimensiones que integran la escala de funcionalidad familiar alcanzaron una media significativa, valor que osciló entre 77,0 a 92,0, correspondiendo este último valor a la subescala de coherencia la cual, con base en friedemann, guía a la unidad y pertenencia familiar, además permite vínculos emocionales positivos. por ello, se concluye que los resultados del cerca del 100% de los pacientes participantes en el estudio integran familias funcionales; sin embargo, su condición de salud ante problemas metabólicos y cardiovasculares pone de manifiesto que se requiere indagar su conocimiento de autocuidado. 269 funcionalidad familiar y ansiedad en pacientes adultos con enfermedad crónica ma. del refugio zavala-rodríguez, maría del carmen ríos-guerra, y otros. estudio otorgan sustento al marco conceptual teórico de dicho autor. así mismo, se deduce que la familia sigue siendo la principal fuente de apoyo para los miembros adultos lo que contribuye al bienestar emocional de los mismos. de acuerdo con los resultados estadísticos derivados de la correlación no se encontró asociación significativa entre las variables de interés; sin embargo, por el resultado (funcionalidad familiar alta, nivel moderado de ansiedad) en cuanto al manejo como variables categóricas (niveles), se puede plantear la premisa de que a mayor funcionalidad familiar menor grado de ansiedad en los pacientes adultos estudiados, situación que apoya la hipótesis establecida. sugerencias los resultados derivados del estudio tienen implicaciones para los profesionales de enfermería, tanto en el aspecto educativo como clínico, por lo que se sugiere enfatizar en las nuevas generaciones los conocimientos básicos en valores y cuestiones socioculturales de las familias, para que respondan con eficiencia y efectividad a las nuevas necesidades de salud que la sociedad demanda. respecto al personal de salud, en especial el de enfermería del primero y segundo nivel de atención, se sugiere capacitarse, a través de diversas estrategias, en la atención holística de los pacientes adultos y cuidadores principales, considerando a los familiares como red de apoyo en el cuidado, que contribuyen en el mantenimiento y la estabilidad de la unidad familiar. referencias bibliográficas 1. medina om, castillo mm, rugerio ma, mtz mc. la familia: situación de vida y salud. revista desarrollo científico de enfermería 2008; 16 (3): 119-122. 2. friedemann ml. the framework of systemic organization: a conceptual approach to families and nursing. thousand oask: sage publications; 1995. 3. moreno mg. inclusión social del adulto mayor: un reto para la política pública. revista desarrollo científico de enfermería (sección docencia) 2008; 16 (3): 127-131. 4. garcía g, díaz r. diabetes mellitus tipo 2: autoconcepto, evolución y complicaciones. revista desarrollo científico de enfermería 2005; 13 (7): 207-210. 5. isaacs a. enfermería de salud mental y psiquiátrica. 2ª ed. madrid: mcgraw-hill/interamericana de españa, sau; 2000. 6. spielberger ch, díaz-guerrero r. inventario de ansiedad: rasgo-estado (idare). méxico d.f: el manual moderno; 1975. 7. gordon m. manual de diagnósticos enfermeros. 10 ed. españa: mosby; 2003. 8. garcía g, landeros e, arrioja g, pérez am. funcionalidad familiar y capacidades de los adultos mayores en una comunidad rural. revista de enfermería del instituto mexicano del seguro social 2007; 15 (1): 21-26. 9. zavala g, vidal g, castro s, quiroga p, klassen p. funcionamiento social del adulto mayor. revista ciencia y enfermería 2003; xii (2): 53-62. 10. ortega a, fernández v, osorio p. funcionamiento familiar. su percepción por diferentes grupos generacionales y signos de alarma. revista cubana medicina general integral 2003; 19 (4): 1-6. 11. lópez m. percepción de la funcionalidad familiar en el paciente con diabetes mellitus tipo 2. [tesis de maestría no publicada]. facultad de enfermería de la universidad autónoma de nuevo león, méxico; 2005. pp. 37-41. 12. vettore mv, lea at, montero am, quintanilla rs., lamarca ga. relationship of stress and anxiety with chronic periodontitis. blackwell munsgaard, 2003; 30:394-402. 13. de los ríos jl, barrios p, ávila t. alteraciones emocionales en pacientes diabéticos con nefropatía. revista médica imss 2004; 42 (5): 379-385 [en línea]. disponible en: http://www.imss.gob. mx/nr/rdonlyres/5185e4ab-507a-4159-8dbac2df5a576dfb/0/2004rm4205alt_emocionales. pdf [fecha de consulta 14 de octubre de 2005]. 14. young l, todd k., simuncak s. validation of the diagnosis of anxiety in adults wtih marrow grafo. [en línea]. disponible en: http://www.findarticles.com/p/ articles/mi_qa4065/is_200207/ai_n9110748 [fecha de consulta 10 de octubre de 2005]. 270 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 15. lawrence r, parkerson g, doraiswamy m. opinion, pain and incapacity of health as correlations of anxiety symptoms and the depression in patients of the primary care. [en línea]. disponible en: http:// www..medscape.com/viewartticle/434349_2 [fecha de consulta 10 de septiembre de 2005]. 16. de los ríos jl, sánchez jj, barrios p, guerrero v. calidad de vida en pacientes con diabetes mellitus tipo 2. revista médica, imss 2003: 42 (2): 109-116 [en línea]. disponible en: http://buscador.imss. gob.mx:8080/search engine/jsp/search adv search. jsp?query text= espiritualidad &result start= 1&result count=20&serverspec=11.254.14.41%3a99 20&last query=%28ansiedad%29&sportspec. [fecha de consulta 14 de octubre de 2005]. 17. zavala mr, vázquez o, whetsell m. bienestar espiritual y ansiedad en pacientes con diabetes mellitus tipo 2. revista aquichan 2006; 6 (1): 8-21. 18. zavala mr, whetsell m. la fortaleza de los pacientes con enfermedad crónica. revista aquichan 2007; 7 (2): 174-188. psychometric properties of the sexual self-concept inventory for early adolescent girls. article psychometric properties of the sexual self-concept inventory for early adolescent girls. propiedades psicométricas: inventario de autoconcepto sexual en mujeres adolescentes en etapa temprana** propriedades psicométricas do inventário de autoconceito sexual em mulheres na adolescência precoce*** 10.5294/aqui.2022.22.2.4 magda liliana villamizar-osorio 1 elveny laguado-jaimes2 1 0000-0003-4774-8545. universidad cooperativa de colombia, sede bucaramanga, colombia. magda.villamizar@campusucc.edu.co 2 0000-0001-7169-6912. universidad cooperativa de colombia, sede bucaramanga, colombia. elveny.laguado@campusucc.edu.co * this project was funded by the universidad cooperativa de colombia and approved by the conadi internal notification: psychometric validation of the sexual self-concept inventory (ssci) for early adolescent girls. code: inv2477 ** financiación: proyecto financiado por la universidad cooperativa de colombia y aprobado por convocatoria interna conadi: validación psicométrica del instrumento inventario del autoconcepto sexual (ssci) en adolescentes en etapa temprana. código: inv2477 *** projeto financiado pela universidad cooperativa de colombia, aprovado pela chamada interna conadi: "validação psicométrica do instrumento inventário do autoconceito sexual (ssci) na adolescência precoce". código: inv2477. received: 16/07/2021 sent to peers: 24/11/2021 approved by peers: 03/03/2022 accepted: 15/03/2022 topic: promotion and prevention. contribution to the discipline: nursing, responsible for the programs on the prevention and promotion of sexual and reproductive health, regards adolescence as a stage entailing specific changes, including the moment when sexual maturity is reached and as a period of vulnerability when they experience various emotions. therefore, determining the sexual self-concept using the sexual self-concept inventory for early adolescent girls in spanish allows us to understand teenage girls' expectations, behaviors, and expressions, thereby protecting them from potential risks, such as sexuality-related behaviors or feelings, through timely preventive actions. to reference this article / para citar este artículo / para citar este artigo: villamizar-osorio ml, laguado-jaimes e. psychometric properties of the sexual self-concept inventory for early adolescent girls. aquichan. 2022;22(2):e2224. doi: https://doi.org/10.5294/aqui.2022.22.2.4 abstract objective: to establish the validity and dependability of the sexual self-concept inventory (ssci) for early adolescent girls in spanish among the colombian population of santander. materials and methods: methodological study with samples used for the theoretical construct validity of the study's dimensions and internal consistency. the sample consisted of 308 adolescent girls aged between 10 and 14 from two schools in girón, santander, colombia. results: inventory of 34 items with three dimensions; exploratory factor analysis confirmed the three factors with a total variance of 43.261 %. the instrument reported internal consistency of α = 0.89 for the following dimensions: sexual arousability (0.908), sexual agency (0.812), and negative sexual affect (0.572). conclusions: the ssci in spanish is dependable enough to evaluate a person's sexual behaviors or feelings and comprehend the sexual behavior of adolescent girls. keywords (source decs): adolescent; women; psychometrics; sexual health; reproducibility of results; validity and reliability; schools. resumen objetivo: establecer la validez y la confiabilidad del instrumento autoconcepto sexual en mujeres adolescentes en etapa temprana (ssci) —versión en español— en población colombiana, más exactamente en santander. material y métodos: estudio metodológico. se emplearon pruebas para la validez del constructo teórico de sus dimensiones y consistencia interna con una muestra de 308 mujeres adolescentes, de 10 a 14 años, de dos instituciones educativas de girón, santander, colombia. resultados: inventario de 34 ítems con tres dimensiones; mediante un análisis factorial exploratorio, se confirmaron los tres factores con una varianza total de 43,261 %. el instrumento reportó una consistencia interna de α = 0,89 para las dimensiones de excitabilidad sexual (0,908), agencia sexual (0,812) y efecto negativo sexual (0,572). conclusiones: el inventario de auto-concepto sexual (ssci) en mujeres adolescentes escolarizadas en etapa temprana—versión en español— es confiable para evaluar los comportamientos, sentimientos sexuales sobre sí mismo y comprender la conducta sexual de las adolescentes. palabras clave (fuente decs): adolescentes; mujeres; psicometría; salud sexual; reproducibilidad de los resultados; confiabilidad y validez; instituciones académicas. resumo objetivos: estabelecer a validade e confiabilidade do instrumento "autoconceito sexual em mulheres na adolescência precoce" (sexual self-concept inventory, ssci), versão em espanhol, em população colombiana de santander. material e métodos: estudo metodológico em que foram utilizados testes para validar o construto teórico de suas dimensões e consistência interna com uma amostra de 308 mulheres adolescentes de 10 a 14 anos de duas instituições educacionais de girón, santander, colômbia. resultados: inventário de 34 itens com três dimensões; a partir da análise fatorial exploratória, confirmam-se os três fatores com uma variância total de 43,261 %; o instrumento relatou uma consistência interna de α = 0,89 para as dimensões de excitabilidade sexual (0,908), agência sexual (0,812) e efeito negativo sexual (0,572). conclusões: o inventário de autoconceito sexual (ssci), versão em espanhol, em mulheres na adolescência precoce escolarizadas é confiável para avaliar os comportamentos e sentimentos sexuais sobre si, e compreender o comportamento sexual das adolescentes. palavras-chave (fonte: decs/mesh): adolescente; mulheres; psicometria; saúde sexual; reprodutibilidade dos testes; confiabilidade e validade; instituições acadêmicas. introduction issues of sexual and reproductive health are complex, particularly during adolescence. they represent a global cause for concern, especially in developing countries (1). research has focused on sexual relations and their results, namely sexually transmitted diseases, unintended pregnancies, and hiv (2). in low and average-income countries, the pregnancy rate among girls younger than 15 is roughly one million (3), hence the need for new approaches to preventing pregnancy before the middle or late adolescence, focused on early adolescent women aged between 10 and 14. girls in this age range face the biggest obstacles to achieving their full potential and development and display a lower ability to make good life decisions related to their sexual and reproductive health (4). this population of early adolescent girls is generally considered sexually inactive but is indeed the opposite (5). a study in taiwan revealed that this population displayed a high level of sexual activity regarding kisses, caresses, and contemplating the possibility of sexual relations (6). these results showed that adolescent girls were conscious of their erotic feelings and sexual desire (6). according to the social cognitive theory, a person's self-efficacy and belief in their ability to adopt a particular behavior in a specific situation are related to their skills and knowledge of their actual conduct (7). therefore, adolescents' favorable opinions of themselves as sexual beings improve their ability to identify sexual risks and take actions to ensure the safety of their sexual health and well-being (8). this way, the consolidation and development of the sexual self-concept during early adolescence become essential. the sexual self-concept comprises sexual behaviors, attitudes, feelings, self-esteem, and self-confidence (9). moreover, it is a multidimensional construct that includes negative or positive perceptions and feelings about oneself as a sexual being (8). during adolescence, a person's sexual self-concept evolves along with their development and growth and becomes established in future sexual conduct (10). presently, scales have been devised to analyze the sexual self-concept among women. nonetheless, despite it being necessary, few studies have focused on measuring the sexual self-concept as a predictor of sexual activity among early adolescent girls (10, 11). in healthcare, measurements carried out in the biophysical dimension have been predominant, but the biophysical approach does not consider the subjective attributes of the different phenomena (12). consequently, there arises the need for instruments that evaluate the subjective properties of constructs and dimensions, which are necessary to direct actions for treating, preventing, or promoting health. scales allow for analyzing the unmeasurable physical, social, and psychological dimensions through observation. the information must be obtained validly and reliably (13). in our search for instruments, particularly those related to the sexual and reproductive health of early adolescent girls, we performed the transcultural adaptation of the sexual self-concept inventory (ssci) in english (14) to analyze how prepared the girls were in terms of sexual maturity. this instrument helps predict sexual health and well-being, including positive affect and the assessment of sexual desire (15, 16). previous studies showed that sexual arousability and agency were linked to sexual self-esteem and future orientation toward positive sexuality, with a low desire to engage in sexual relations (5). sexual arousability is the feeling or right to engage in sexual activities. when adolescent women have a people-oriented perspective on sexuality, pregnancy and early-first-sexual-relation rates diminish. the sexual agency represents the positive assessments of sexuality through thoughts, feelings, behaviors, and body perceptions within the sexual context. generally, adolescents with higher sexual self-esteem feel safer in sexuality-related situations (5, 10). sexual anxiety refers to tensions, nuisances, and negative assessments of sexuality. it manifests through abstinence, low possibility of engaging in sexual relations soon, not having a partner, or taking very little part in erotic expressions. as mentioned earlier, this ssci is valid for analyzing the opinions of early adolescent girls on their sexuality and sexual behavior and could be helpful in healthcare studies and risk-related decision-making (5, 10, 17). this study aims to establish the validity and reliability of the ssci in spanish among the colombian population of santander. materials and methods in this methodological study, we used psychometric samples to determine the reliability and dependability of the ssci in spanish. reliability refers to the accuracy with which the instrument evaluates the attributes for which it was built. those attributes show a correlation between the items that make up the construct, which need to be homogenous (18). dependability is the ability of an instrument to consistently measure an element reflected by cronbach's alpha coefficient, which reveals how far the items go in measuring the construct. this property is related to the validity of the instrument (19). participants participants in this study comprised adolescent girls aged between 10 and 14. a nonprobability convenience sample was used, with a sample parameter of between 5 and 10 persons per instrument item (20). the sample included 308 early adolescent schoolgirls from two institutions in the urban area of girón municipality in santander, colombia. the girls had to fulfill the following criteria: be early adolescents aged between 10 and 14 and take part in the study voluntarily with informed consent from their parents. we did not consider adolescent girls with cognitive disorders or sensory alterations. instrument we applied the spanish version of the ssci obtained through a methodological process of transcultural adaptation (14) of the ssci for early adolescent girls (5). this inventory comprises three dimensions: sexual arousability (17 items), sexual agency (ten items), and negative sexual affect (seven items). we used a likert-scale questionnaire with six possible answers to measure the 34 items: the higher the score, the better the sexual self-concept. procedure once we obtained the parents' informed consent and the adolescents' assent, we administered the ssci for early adolescent girls in classrooms during periods agreed upon with the two public schools in girón, santander, thereby ensuring the reliability of the participants' data. data analysis we carried out a descriptive analysis of the sociodemographic variables using percentage distribution. we then determined the results of the items and the median, maximum/minimum score, and standard deviation by descriptive statistics. we calculated the reliability of the ssci for early adolescent girls in spanish using cronbach's alpha coefficient, which reflected an excellent internal consistency, ranging between 0.7 and 0.9 (21). as part of the process of adapting the instrument, we employed the correlation matrix to confirm the proper use of factorial analysis (fa), which integrates the variability of the items and correlations. when there are various item pairs with correlations above 0.3, we can perform the fa. however, we employ statistical techniques such as the reverse correlation, bartlett's test, or the kaiser meyer olkin (kmo) test when it is not easy to notice. the latter provides enough information to decide whether we could use fa as a statistical strategy in scale validation (22). ethical considerations the research protocol was approved by the bioethics committee at universidad cooperativa de colombia and authorized by the schools in girón, following the international guidelines for bioethical research on human beings and the wma declaration of helsinki (23). moreover, according to law 911 of 2004 (24) and resolution 8430 of 1993 (25), colombia's health department deemed this research risk-free as it did not involve any medical treatments or manipulation of the participants' behavior. initially, we requested institutional permission at a management level. then, we contacted parents to inform them about our objectives and procedures, emphasizing that participation was voluntary and that data would remain confidential. we also informed them that they could withdraw their children from the study at any time without any legal or social consequences and allow the children to take part in the study only by signed informed consent. at the end of this process, we called the participants to obtain their informed consent, providing them with the same information above, i.e., reliability of the information, the anonymity of the answers, and the possibility to withdraw from the study voluntarily at any time. in addition, we assured them that their data would not appear in any reports, presentations, or academic publications related to the study. as for the psychometric process related to the spanish version of the instrument, we obtained permission from the instrument's rightful creator. results we administered the spanish version of the ssci to 308 adolescent girls from two schools. the girls were between 10 and 14 years old and had an education level that ranged between sixth (31 °%), seventh (32 °%), eighth (22 °%), ninth (10 °%), and tenth grade (4 °%). we analyzed the baseline cronbach's alpha to establish the internal consistency of the instrument. for the full scale, it was 0.89, whereas, for factors one, two, and three, it was 0.908, 0.812, and 0.572, respectively. we noticed that factors one and two displayed an acceptable coefficient, while factor three displayed a lower score, which can be explained by the fact that it had fewer items than the other factors (table 1). table 1. statistics of total scores, inventory, and dimensions scale/dimensions descriptive statistics cronbach's alpha   n min. max. m dt value no elements ssci 308 1.11 5.47 3.17 0.80 0.89 34 sexual arousability 308 1 5.64 2.52 0.97 0.91 17 sexual agency 308 1 6 3.75 1.12 0.81 10 negative sexual affect 308 1 6 3.90 0.97 0.57 7 source: own elaboration the kolmogorov-smirnov test for assessing normality was significant for the ssci (p = .001). the median score on the ssci among the participant population was 3.17, while the sexual arousability factor was 2.52, the sexual agency factor was 3.8, and the negative sexual affect factor was 3.9 (figure 1). figure 1. median showing the scores of the ssci and its factors source: own elaboration we used the sample adequacy tests from the kmo data matrix (sample adequacy measure) and bartlett's test of sphericity to analyze the data. in our case, the kmo indicated that the variables measured common factors with a value of 0.85 and a bartlett test with p = 0.000. thus, the data was suitable for the analysis. using factor analysis with the extraction of the principal components and varimax rotation of the three factors, we considered the items with a value higher than 0.4. when revising the communality of the 34 items, we discovered that not all of them corresponded with the initial factor (table 2). table 2. results of the exploratory factor analysis with three factors   items f1 f2 f3 es1 i sometimes think i'd like to try doing the sexual things that my friends are doing with their boyfriends 0.627 0.001 -0.155 es2 when i kiss a boy, i get hot 0.664 0.142 0.092 es3 i would really like to touch a boyfriend if we were left alone together 0.721 0.109 -0.069 es4 i sometimes want to know how different types of sex feel 0.663 0.142 -0.092 es5 if i'm going to see a guy i like, i like to dress sexy 0.427 0.427 -0.063 es6 if a guy kisses me, i also want him to touch my body 0.624 0.098 -0.017 es7 when i flirt with a guy, i like to feel him up 0.378 0.457 -0.028 es8 sometimes i dress sexy to get attention from guys 0.370 0.324 -0.023 es9 if i were to kiss a guy, i'd get really turned on 0.557 0.171 0.106 es10 there are things about sex i want to try 0.811 0.45 -0.158 es11 if a boy kisses me, my body feels good 0.571 0.385 -0.126 es12 i enjoy talking about sex or talking sexy with boys i know really well 0.724 0.190 -0.087 es13 if i were kissing and touching a guy, i would get hyped, real excited 0.772 0.187 0.008 es14 i enjoy talking about sex with my girl friends 0.727 0.112 0.062 es15 it's okay to feel up on a guy 0.328 0.664 -0.196 es16 i like it when a guy tells me i look good 0.114 0.653 -0.138 es17 i think i'm ready to have sex 0.693 -0.043 -0.117 as1 girls always wonder what sex is going to be like the first time 0.499 0.473 -0.003 as2 i sometimes think about who i would want to have sex with 0.680 0.307 -0.012 as3 when i decide to have sex with a guy, it will be because i wanted to have sex and not because he really wanted me to have sex with him 0.067 0.585 -0.116 as4 girls sometimes have sex because they're curious and want to see what it's like 0.359 0.498 0.082 as5 sex is best with a guy you love 0.090 0.679 0.142 as6 i like to let a guy know when i like him 0.258 0.461 -0.062 as7 if i have sex, my friends will want to know all about it 0.396 0.379 0.330 as8 if i had sex with a guy, i would be running the risk of being played (taken advantage of) 0.013 0.590 0.047 as9 flirting is fun, and i am good at it 0.440 0.323 -0.042 as10 if i have sex with a guy, i would worry that i could get my feelings really hurt 0.092 0.681 0.252 esn1 if i kiss a guy i don't really know, i'm afraid of what people will think about me -0.045 0.414 0.257 esn2 sex is nasty -0.018 -0.116 0.640 esn3 sex isn't fun for girls my age -0.111 -0.039 0.534 esn4 i would be scared to be really alone with a boyfriend -0.111 -0.135 0.490 esn5 some girls have sex just to be accepted or popular -0.036 0.398 0.534 esn6 i think i am too young to have sex -0.397 0.264 0.416 esn7 if i have sex, my friends will want to know all about it 0.329 0.262 0.496 note: f1 = sexual arousability, f2 = sexual agency, f3 = negative sexual affect. source: own elaboration the total explained variance for the factor variables stands at 43.261 % for the 34 items that make up the ssci, as seen below in table 3. table 3. total explained variance for the factor variables component initial self-values rotation sums of squared loadings total variance % accumulated % total variance % accumulated % 1 9.605 28.249 28.249 7.762 22.828 22.828 2 3.335 9.808 38.057 4.835 14.222 37.050 3 1.769 5.204 43.261 2.112 6.211 43.261 extraction method: principal component analysis. source: results from the statistical package spss v. considering that for the sexual arousability factor, which included items between 1 and 17 in the original version, three items, namely, 7, 11, and 15, are now excluded and subsequently assigned to factor two. in addition, items as1, as2, as7, and as9 are moved from factor two (sexual agency) to factor one, leaving factor one with 18 items. therefore, factor two keeps six original items, plus items 7, 11, and 15 from factor one, and items esn1 and esn5 from factor three (negative sexual affect), totaling eleven items. lastly, factor three keeps five items from the original scale and item es5, which has a similar value within two factors left there according to the original scale. table 4 shows the scale with the rearranged items. table 4. order of the items according to their values and the corresponding factor sexual arousability dimension sexual agency dimension negative sexual affect dimension no. items no. items no. items es1 i sometimes think i'd like to try doing the sexual things that my friends are doing with their boyfriends as3 when i decide to have sex with a guy, it will be because i wanted to have sex and not because he really wanted me to have sex with him esn2 sex is nasty es2 when i kiss a boy, i get hot as4 girls sometimes have sex because they're curious and want to see what it's like esn3 sex isn't fun for girls my age es3 i would really like to touch a boyfriend if we were left alone together as5 sex is best with a guy you love esn4 i would be scared to be really alone with a boyfriend es4 i sometimes want to know how different types of sex feel as6 i like to let a guy know when i like him esn6 i think i am too young to have sex es5 if i'm going to see a guy i like, i like to dress sexy as8 if i had sex with a guy, i would be running the risk of being played (taken advantage of) esn7 if i have sex, my friends will want to know all about it es6 if a guy kisses me, i also want him to touch my body as10 if i have sex with a guy, i would worry that i could get my feelings really hurt   es8 sometimes i dress sexy to get attention from guys es7* when i flirt with a guy, i like to feel him up   es9 if i were to kiss a guy, i'd get really turned on es11* if a boy kisses me, my body feels good   es10 there are things about sex i want to try es15 it's okay to feel up on a guy     i enjoy talking about sex or   if i kiss a guy i don't really know,   es12 talking sexy with boys i know really well esn1* i'm afraid of what people will think about me   es13 if i were kissing and touching a guy, i would get hyped, real excited esn5* some girls have sex just to be accepted or popular   es14 i enjoy talking about sex with my girl friends       es16 i like it when a guy tells me i look good       es17 i think i'm ready to have sex       as1 * girls always wonder what sex is going to be like the first time       as2 * i sometimes think about who i would want to have sex with       as7 * if i have sex, my friends will want to know all about it       as9 * flirting is fun, and i am good at it       subtotal: 18 items subtotal: 11 items subtotal: 5 items *items from the original scale, rearranged source: own elaboration discussion the thorough methodological process developed throughout this psychometrics-based study allows us to evaluate the ssci in spanish, for which we frequently used cronbach's alpha coefficient. this enabled us to identify the level of accuracy of the adaptation process, after which we would be able to interpret the scores obtained appropriately to generate more accurate, unquestionable knowledge (26, 27). the sexual self-concept has been considered a predictor of the sexuality of early adolescent girls(6), departing from the definition of the sexual self-concept as a person's perception of their sexual self (8). in present times, sexual self-concept scales in the adoles­cent population have been developed (5), which require validation within the various contexts that involve early adolescents. that is why our study in colombia, whose sample of 308 participants from a school environment was lower than the one in taiwan (590) and higher than the one in new york (180), highlighted the fact that the instrument obtained similar reliability (5) overall, although lower when it came to the negative sexual affect dimension (28). the explained variance in our study (43.261 °%) is different from the one in the new york version, reflecting a higher development of the scale. in addition, we did not include data on puberty-, familyor religious-related development. the ssci for early adolescent girls adapted in this study represents a tool to analyze dimensions like sexual arousability, which has been studied and referred to as a trait and component of sexual response, aiding the development of a positive assessment of sexual ability. knowledge of its response tendency will allow us to evaluate interactions with others and the pleasant experience of sexuality with improvements in sexual self-esteem (29). the sexual self-concept significantly influences knowledge related to sexual health, as it represents a mediatory factor for the protection and treatment of adolescents' sexual behaviors (28). a different study (30) has analyzed the direct correlation between the positive/negative sexual self-concept and safe intercourse, enabling people to adopt healthy sexual behaviors. according to other authors, self-concept and self-efficacy contribute to developing self-care conduct, motivating people to adopt behaviors beneficial to their health (31). the results showcase good reliability of the factors, with the exploratory factor analysis reproducing the structure in the original version of the scale, which indicated that it was suitable for use among the colombian population. the results are promising; thus, further research on other validity evidence could make the colombian version of the scale more solid, following the established psychometric standards. conclusions the ssci, designed as a sexual predictor among early adolescent girls, displays an excellent psychometric quality in our study. further studies on its predictive capacity, with evidence of validity based on the link with other variables, can contribute to this instrument becoming useful for predicting sexual conduct in diverse cultural contexts. our adapted instrument helps develop research and comparison with other similar instruments, including the participation of parents and teachers in interventions related to sexual and reproductive health. in the results obtained through exploratory factor analysis, the items were rearranged based on the observed interrelations and higher affinity with the respective factor. this modified the original scale, which means that further studies should be conducted using the adjusted scale and comparing the results to verify the scale's internal structure. acknowledgments we would like to thank institución educativa juan cristóbal martínez and colegio nieves cortes picón in girón, santander, for their collaboration and the information provided. conflicts of interest: none declared. references 1. lauglo m. la salud sexual y reproductiva del joven y del adolescente: oportunidades, enfoques y opciones. washington, d. c.: organización panamericana de la salud [internet]. 2008 [citado 2020 nov. 09]. disponible en https://www.paho.org/hq/dmdocuments/salud_sexual_final.pdf 2. mason-jones aj, sinclair d, mathews c, kagee a, hillman a, lombard c. school-based interventions for preventing hiv, sexually transmitted infections, and pregnancy in adolescents. cochrane database syst rev [internet]. 2016 nov. 08;2016(11): 1-73. doi: https://doi.org/10.1002/14651858.cd006417.pub3 3. organización mundial de salud. el embarazo en la adolescencia [internet]. 2020 en. 31. disponible en 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[citado 2020 oct. 24]; 32(3). disponible en http://scielo.sld.cu/scielo.php?script=s-ci_arttext&pid=s0864-03192016000300001&lng=es 29. sierra jc, lópez herrera f, álvarez muelas a, arcos-romero ai, calvillo c. la autoestima sexual: su relación con la excitación sexual. suma psicol [internet]. 2018;25(2):102-112. doi: https://doi.org/10.14349/sumapsi.2018.v25.n2.6 30. mohammadi nik m, modarres m, ziaei t. the relation between sexual self-concepts and attachment styles in married women: a cross-sectional study. npt [internet]. 2018;5(1):235-242. 31. orcasita lt, mosquera gil ja, carrillo gonzález t. autoconcepto, autoeficacia y conductas sexuales de riesgo en adolescentes. inf. psicológicos[internet]. 2018;18(2):141-168. doi: https://doi.org/10.18566/infpsic home qualitative evaluation of an educational intervention about healthcare improvement for nursing students article qualitative evaluation of an educational intervention about healthcare improvement for nursing students evaluación cualitativa de una intervención educativa en mejoras en salud en estudiantes de enfermería avaliação qualitativa de uma intervenção educativa em melhorias em saúde em estudantes de enfermagem 10.5294/aqui.2021.21.1.2 maría cristina sierras-davó1 manuel lillo-crespo2 patricia verdú-rodríguez3 1 0000-0002-9940-0455. universidad de alicante, faculty of health sciences, spain. mcsd1@alu.ua.es 2 0000-0003-2053-2808. universidad de alicante, faculty of health sciences, spain. manuel.lillo@ua.es 3 0000-0003-0542-2379. university of alicante polytechnic school, spain. pvr8@alu.ua.es received: 10/06/2020 sent to peers: 13/07/2020 approved by peers: 28/07/2020 accepted: 28/10/2020 to reference this article / para citar este artículo  / para citar este artigo: sierras-davo mc, lillo-crespo m, verdu p. qualitative evaluation of an educational intervention about healthcare improvement for nursing students. aquichan. 2021;21(1):e2112. doi: https://doi.org/10.5294/aqui.2021.21.1.2 abstract objective: to explore the meaning of the experience and knowledge acquired by nursing students trained in healthcare improvement. material and methods: a phenomenological approach based on the giorgi method was made through a group discussion of 21 european students from four countries in july 2019. the data was triangulated with the testimonies of key informants and with the use of an evaluation tool specific to this topic. the analysis was also triangulated with three experienced researchers who reduced the data by consensus to eight units of meaning. results: nursing empowerment and horizontal health organizations were two of the most recurrent units of meaning along with professional values such as teamwork and humanization of care. conclusions: the knowledge, attitudes and values acquired are evidence of the shortcomings in the training of future nursing professionals in europe. the theoretical and practical approach of the sessions, as well as the mixture of cultures, were strengths for the students. it is necessary to follow up on more cases that show the return on the training investment in substantial improvements in real contexts and its impact on the quality of care. keywords (source decs): quality of health care; nursing education; qualitative research; quality improvement. resumen objetivo: explorar el significado de la experiencia y los conocimientos adquiridos por estudiantes de enfermería formados en mejora de cuidados de salud. material y métodos: se realizó una aproximación fenomenológica basada en el método giorgi mediante una discusión grupal de 21 estudiantes europeos de cuatro países en julio 2019. los datos fueron triangulados con los testimonios de informantes clave y con el uso de una herramienta de evaluación específica para este tema. el análisis también se trianguló con tres investigadores experimentados que redujeron los datos por consenso a ocho unidades de significado. resultados: el empoderamiento de enfermería y las organizaciones sanitarias horizontales fueron dos de las unidades de significado más recurrentes junto a los valores profesionales como el trabajo en equipo y la humanización en los cuidados. conclusiones: los conocimientos, las actitudes y los valores adquiridos evidencian las carencias de la formación de los futuros profesionales de enfermería en europa. el enfoque teórico-práctico de las sesiones, así como la mezcla de culturas supusieron fortalezas para el alumnado. es necesario el seguimiento de más casos que evidencien el retorno de la inversión formativa en mejoras sustanciales en contextos reales y su impacto sobre la calidad asistencial. palabras clave (fuente decs): calidad de la atención de salud; educación en enfermería; investigación cualitativa; mejoramiento de la calidad, estudiantes de enfermería. resumo objetivo: explorar o significado da experiência e dos conhecimentos adquiridos por estudantes de enfermagem formados em melhoria de cuidados de saúde. materiais e métodos: foi realizada uma aproximação fenomenológica baseada no método giorgi, mediante uma discussão em grupo com 21 estudantes europeus de quatro países, em julho de 2019. os dados foram triangulados com os depoimentos de informantes-chave e com o uso de uma ferramenta de avaliação específica para o tema. a análise também foi triangulada com três pesquisadores experientes que reduziram os dados por consenso a oito unidades de significado. resultados: o empoderamento da enfermagem e das organizações sanitárias horizontais foram duas das unidades de significado mais recorrentes junto com os valores profissionais, como o trabalho em equipe e a humanização dos cuidados. conclusões: os conhecimentos, as atitudes e os valores adquiridos evidenciam as carências na formação dos futuros profissionais de enfermagem na europa. a abordagem teórico-prática das sessões, bem como a fusão de culturas supuseram fortalezas para os estudantes. é necessário seguir mais casos que evidenciem o retorno do investimento em formação em melhorias substanciais em contextos reais e seu impacto sobre a qualidade assistencial. palavras-chaves (fonte: decs): qualidade da assistência à saúde; educação em enfermagem; pesquisa qualitativa; melhoria de qualidade. introduction healthcare improvement science emerged in the 1980s at the us institute for healthcare improvement (ihi) as a working culture aimed at improving patient care by building bridges between theory and practice (1). this working methodology is designed to improve the health care provided and prevent adverse events arising from it (2), however, this is not a content present in the training of future nursing professionals in most european or latin american countries. in the report a brief synopsis on patient safety, published in 2010 by the world health organisation (3), as well as in its latest online update in 2019, it is still estimated that one in ten patients admitted to hospitals is unintentionally harmed and around 50 % of these cases could have been avoided if lessons had been learned from previous mistakes (4-5). the urgent need to improve patient care is not a one-country phenomenon. in a 2018 study by linda aiken conducted in the usa as a result of the european registered nurse forecast (rn4cast) project, it is shown that a combination of educational level and nursing staff skills is associated with significantly lower mortality, higher patient satisfaction with care and fewer associated adverse events (6-7). healthcare improvement science (his) is an anglo-saxon concept that focuses on “making it easy to do the right thing” for the patient, promoting strategies that provide safe, effective and person-centred care (8). in general, in europe, the contribution of his has been more focused on clinical practice, where initiatives have been developed more widely in recent years. there are examples of specific projects in spain, sweden, the united kingdom or ireland, among others (10-11). however, as became clear after the european project improvement science training for european healthcare workers (istew) from 2013 to 2015, at the educational level, his in europe continues to be an emerging science since specific education in improvements does not exist in all countries and, if it does, it is not standardised (12). one of the main results of this project was the creation of four specific university modules on his, accredited by higher education institutions (heis) (8). after the completion of the istew project in 2015, the efforts of the spanish research team were directed towards the adaptation and implementation of the educational modules created.  as a consequence, the summer courses in healthcare improvement science at the university of alicante, called immersion to his, were created. these courses began in 2016 and continue today with a total participation of 76 european students. the modules created at istew were adapted and implemented, incorporating faculties from different academic and professional backgrounds. in addition, it was given an international focus as the students came from different universities in different countries (scotland, ireland, finland, greece and spain). the main objective was to foster a critical and analytical mindset in the students, encouraging the continuous search for improvement of their contexts through his interventions and self-assessment (13). throughout these courses, the healthcare improvement science evaluation framework (hisef), a specific his evaluation framework created by the spanish team as part of the istew project, was used as an evaluation tool (13). this has the capacity to effectively identify the strengths, weaknesses and gaps in the education provided on his, as well as the return on investment in the systems themselves. after each course, the research team meets and analyses the results. in the course of 2018, a gap was identified in the information collected, there was a set of data on the students’ previous experience and the key concepts learned about which more qualitative information could be gathered. therefore, in the following year of 2019, the qualitative assessment described in this article was included with the aim of exploring the previous learning experience in healthcare improvement science and the new knowledge acquired by nursing students from different european countries. methodology type of study a qualitative evaluation study was carried out with a phenomenological approach using the giorgi method as a reference framework. phenomenological description and reduction was sought through the most relevant basic units of meaning (14). after the consensus on the notes taken, a second group reading was made analysing the students’ experience and identifying the basic units of meaning. the different uses of language were discussed, synthesising the comments into concrete ideas and then assigning the concepts. two of the authors were part of the research team of the istew project and after its completion, they adapted and implemented the educational modules created during the project to real contexts and using the english language as a vehicular language (15). scenario the whole course was carried out by researchers belonging to the european project istew and was held in the facilities of the university of alicante and in different clinical and provincial hospitals in alicante, spain. since 2016 it has had a total population of 76 participants. for the research described in this article and carried out in 2019, a sample of 21 students participated between 1st and 5th july with a total of 50 teaching hours distributed between 41 hours of theory and 9 hours of practice. visits were made to public and private hospitals, ideas for improvement were developed by groups and evaluated by means of indicators, finally presentations were made to the rest of the peers.  users were studying nursing at the university of western scotland (uk), laurea university of applied sciences (finland), the university of alicante (spain) and the university of the peloponnese (greece). instruments for collecting information and ethical aspects although the evaluation of the course as a whole has been carried out through the healthcare improvement science evaluation framework (hisef) (13), the interest of the researchers in capturing reality through the experiences of the participants was the main reason for adding a new section during the course of 2019. after the explanation and prior collection of the informed consent, a qualitative evaluation was carried out through a group discussion between the 21 participating students and the teachers. the informed consent and the data collection were done according to the law of data protection and guarantee of digital rights (lopdgdd) (organic law 3/2018 of 5 december); furthermore, as an extension of the european project istew, it has the approval of the irb/iacuc of the university of jesenice with code 10/01/002/2014-sht. the demographic characteristics of the students, the main actors of the intervention, can be seen in table 1. the users expressed their experiences and opinions about what they had learned, the ideas and concepts acquired, the values in care and the previous experience about his. the intervention was guided through four open questions, presented below: table 1. answers grouped by units of meaning units of meaning percentage nursing empowerment 21,43 % flat health organisations 16,67 % motivation of health personnel 14,29 % nursing research 14,29 % professional recognition 11,90 % values in care 11,90 % teamwork 7,14 % professional development 2,38 % source: own elaboration 1.   what new ideas and concepts have you learned? 2.   what would you improve in this context (spain) and in your own? 3.   what caring values have you learned? 4.   have you ever had contact with his? please briefly summarize the basic highlights of your experience. data collection, processing and analysis the data collected through field notes was triangulated with the testimonies of key informants from each group of students and teachers, as well as with the use of data collected through the hisef. subsequently, the triangulation of the analysis was carried out by three experienced researchers one of them from outside the context extracting and analysing the key concepts that reduced the data by consensus to eight units of meaning (table 2). during this process, the notes taken were re-read and exchanged, detecting the units of meaning, and then, after reduction, arriving at categorisation in a circular process that was feedbacked many times. finally, once the eight units of meaning had been obtained, their division according to the person responsible for the action can be seen in table 3: internal (the individual is responsible) or external (the person responsible is an external person/institution). the answers to the first three questions have also been classified in order of repetition, with the first ones in the tables having the highest number of answers associated. finally, the results of the fourth question were grouped by country, since the analysis of the data showed that the content of the students’ answers was consistent with their place of origin. the ultimate interest of the whole analysis carried out as a result of the four questions and the evaluation framework has been the search for units of meaning of the phenomenon studied. table 2. responsible for the action intern (responsible-> own person) external (responsible -> outsider) empowerment flat health organisations motivation teamwork recognition (own) recognition (from others) values (own) values (of the system) research professional development source: own elaboration table 3. units of meaning, definition and examples units of significance definition student responses nursing empowerment empowerment is the process by which people strengthen their capacities, confidence, vision and leadership to drive positive change in the situations they live in (15). “better understanding of empowerment in nursing”. (c1) “we don’t have many male nurses there, we feel more able now to inspire others. (c2) “we need more empowerment. we are absorbed in the welfare work but we don’t think about doing something else”. (c3) teamwork when two or more people who interact interdependently have a common purpose, working towards measurable objectives (16). “teamwork. in finland they sometimes don’t even talk to each other”. (c4) “collaboration between different professionals”.(c5) “collaboration between other health professionals is impossible. i see this here”. (c6) motivation of health personnel motivation is the degree to which the individual is willing to exercise and maintain an effort towards the objectives of the organisation (17). “i have gained in motivation, inspiration and improvement. we have a lot of motivation now. the course has inspired us. (c7) “we have seen a lot of motivation among nurses in spain. (c2) “the spanish nurses are very positive and nice. (c8) flat health organisations a flat system is one in which most of the middle managers and their functions have been eliminated, so that senior management is in direct contact with the workers (18). “i like the concept of the flat system but i don’t see it in reality”. (c9) “we don’t have key people in key positions. (c3) “in finland our system is more rigid”. (c10) professional recognition professional recognition has the capacity to renew a nurse’s commitment to her profession, to give greater pride to her work and to deepen her loyalty to both the nursing team and the health organisation (19). “nurses in spain are highly respected.” (c11) “we nurses should feel more proud, not say more: i am just a nurse”. (c12) “there must be more recognition if you continue to study, it must translate into more pay”. (c13) nursing research research seeks to understand and improve the way societies organise themselves to achieve collective health goals (20). “now we feel the need to do research. (c1) “we understand that further research is needed. (c14) “this course opened my mind about research. (c15) professional development professional development is the lifelong process of managing learning, work, leisure and transitions in order to move towards a personally determined preferred future (21). “in greece, the number of nurses doing research is increasing. (c6) “more training and updating is needed”. (c7) “the visible effort in increasing wages needs to be recognized”. (c16) values in care values are principles that allow us to provide ethical and humanised care in the maintenance of human health (22). “positivism about life and work”. (c8) “family involvement”. (c17) “more respect and humanization of care”. (c14) source: own elaboration rigour the intervention described in this article belongs to an annual educational intervention, which, following deming’s methodology, has been evaluated year after year through short pdca cycles, improving content and structure. both the course itself to which this intervention belongs, and the evaluation framework, have not been static, and continuous improvements have been made in accordance with all study participants. in addition, considering the feedback from students, clearly different versions of the framework were created; the latest version (the fourth) was created in 2019. as for the students’ experiences, all researchers made their own notes and the conclusions emerged from their consensus. the course has a clear content and structure and could easily be replicated in any other institution, as has been done year after year at the university of alicante. results the demographic characteristics of the participants in the research and their previous experience in healthcare improvement science can be seen in figure 1. it can be seen that 100 % of the participants had no previous training in his, 88.9 % of the total were women and most of the students (59.4 %) were in the 21-30 age range. figure 1. demographic characteristics and previous his experience source: own elaboration as a result of the answers to questions one and two (what new ideas and concepts have you learned? and what would you improve in this context (spain) and in your own? ), eight basic units of meaning have been extracted, according to the giorgi method, as shown in table 1 (14). after having grouped the basic units, they have in turn been classified into two categories: internal and external according to the owner of the action. in table 2 this division can be seen and in table 3 we find the definition of the units of meaning together with extracts of the participants’ answers associated with them. these eight units of meaning allow an approach to the impact and the lived experience of the students in the course. the units of meaning with the highest number of associated responses were “empowerment in nursing” with 21 % of the total responses, followed by “flat health organisations” (16.67 %) and “motivation in health personnel” (14.29 %). focusing on question three (what values have you learned in relation to care?), the professional values chosen by the students have been ordered by relevance according to the number of associated answers. as can be seen in table 4, the most recurrent were teamwork, respect and passion, among others.  table 4. most repeated professional values relevance values 1 teamwork 2 respect 3 passion 4 humanisation in care 5 communication source: own elaboration finally, in table 5, you will find the results for the fourth question (have you ever had contact with his? please briefly summarize the basic highlights of your experience). also, and after consensus among the participants themselves, they have been grouped by country. table 5. his experience by country country answer greece “previously we have had courses on hospital management, but they have been related to systems, not improvements or his. the nurse in greece feels more empowered in the community. training in general is improving and more and more research topics are being studied, however, the most important thing for us is that our leaders belong to the nursing field. usually, the teachers are doctors and they don’t even recognize our discipline. we have no specific laws to protect and promote us. (c17) finland “we have university subjects in management, but not anything like this. there are some courses in health improvement, but they are not always in all universities or accessible to everyone. in finland, a lot depends on the universities. in laurea we have a subject that includes his, but we don’t know if it exists in other universities in the country”. (c18) scotland “in scotland there are specific programmes in his at universities and hospitals. however, the promotion of research as carried out in this course is not as strong”. (c19) spain “here the nurse works on many initiatives to improve specific aspects of health care, but his is not recognized as a concept or discipline. except for this course we are not aware of any further specific training”. (c20) source: own elaboration. discussion the results show the importance of healthcare improvement science in all professional and educational stages of nursing (12-13, 23), as well as the lack of training in this area since 100 % of students had no contact with the subject before. the implementation of the istew project modules contributes to the main objective of the project: the dissemination and implementation of his culture throughout europe (8). the annual evaluation has allowed integrating the comments received taking into account the needs and experiences of the students through the participatory action research methodology. however, and at the researchers’ discretion, the information received through the healthcare improvement science evaluation framework (hisef) had to be complemented with a qualitative intervention in which the main experiences and knowledge acquired by the students as a result of their participation in the course were examined in depth. the group discussion, held last year, was very useful in order to highlight the concepts acquired by the students. their answers about what they learned in the course revealed gaps in the previous training they had received. all the students participating were in the last years of their degree and yet 100 % had no previous training in healthcare improvement science. the theoretical and practical focus of the sessions, as well as the mix of cultures, became strengths for the students. it is also interesting to highlight the main ideas learned: empowerment in nursing, the incorporation of values in daily practice such as compassion or humanisation of care, professional recognition or health research. there is evidence to suggest that support for healthcare personnel in the early stages of training is the key step to driving systems towards sustainable change and values such as the humanisation of care, always promoting patient-centred care (24). it is therefore clear that this type of educational intervention is needed and has an impact on students, helping to understand how the development of a culture in healthcare improvement science, through education, gives them the confidence to make changes in their future working environments, providing safe, effective, person-centred, efficient, equitable and timely care (2). as a limitation, there is mainly temporality. it is an activity carried out within an annual programme of one week duration, so the results obtained are in a short term. it is necessary to follow up cases that show the return of the training investment in improvements of real contexts and in an impact on the quality of care and the critical mentality of the professionals. on the other hand, the methodology itself has a potential risk: the perspective of the researchers when analysing the data and drawing conclusions. to avoid this possible bias, three different researchers, one of them from outside the research, participated in the analysis of the results and the reduction of the basic units of meaning agreed upon prior completion. finally, the relationship of trust between the participants and the educators was taken into account as a possible limitation and a safe and open atmosphere was promoted in order to promote participation and the exchange of ideas. conclusions following the results of the qualitative research carried out in 2019, the gap in improvement training and between theory and practice for nursing students is evident. the health and education systems must collaborate in a strategic and standardized way to create bridges that help students in this transition to generate a professional culture based on improved health outcomes for populations, as well as improved care (25). the implementation of training with an international focus based on healthcare improvement science could be one of the possible solutions to the gaps in current education, also creating the perfect context for the development of future changes and improvements in work contexts. due to the temporality of the intervention, there is a lack of long term results, however, as a result of the current data, students are observed to develop a mentality on critical thinking and an increase in their resources to improve patient safety and their future working environments. education in his is at an early stage of development in europe and elsewhere in latin america. its promotion remains a real need. developing a his-based professional and educational culture and investing in a healthcare workforce trained in health improvements could also increase the quality and satisfaction of patient care by reducing unwanted events. conflict of interest: none declared. references 1. institute for healthcare improvement.timeline. [internet] [citado 2020 abr 25]. disponible en: http://www.ihi.org/about/documents/ihi_timeline_2018.pdf 2. skela-savič b, macrae r, lillo-crespo m, rooney k d. the development of a consensus definition for healthcare improvement science (his) in seven european countries: a consensus methods approach. sjph. 2017;56(2): 82-90. doi: https://doi.org/10.1515/sjph-2017-0011 3. world health organization. a brief synopsis on patient safety [internet]. copenhagen: world health organization; 2010 [citado 2020 en 21]. disponible en: http://www.euro.who.int/__data/assets/pdf_file/0015/111507/e93833.pdf?ua=1 4. world health organization. patient safety [internet]. world health organization;  2019 [citado 2020 ene 21]. disponible en: https://www.who.int/news-room/fact-sheets/detail/patient-safety 5. organización para la cooperación y el desarrollo económico​ (oecd). the economics of patient safety in primary and ambulatory care [internet]. organización para la cooperación y el desarrollo económico; 2018. 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[internet]. career development association of alberta; 2018 [citado 2020 ene 21]. disponible en: https://www.careerdevelopment.ab.ca/whatiscd 22. bernal-martínez em, martín-estévez l, acosta-gaibor mp, roca m,  narcisa, b. florence nightingale y la formación de valores en la enfermería.  dcepv. 2019; 6. disponible en: https://www.dilemascontemporaneoseducacionpoliticayvalores.com/index.php/dilemas/article/view/1403/1739 23. lillo-crespo m, sierras-davó mc. quality improvement with compassion: developing healthcare improvement science in the european health professions’ education. in gibbs p, jameson j, elwick a., editors. values of the university in a time of uncertainty.   switzerland: springer, cham; 2019. p. 231-240. doi: https://doi.org/10.3390/ijerph16224480 24. coffey a, saab mm, landers m, cornally n, hegarty j, drennan j, et al. the impact of compassionate care education on nurses: a mixed‐method systematic review. jan. 2019; 75(11): 2340-2351. doi: https://doi.org/10.1111/jan.14088 25. meleis, ai. facilitating and managing transitions: an imperative for quality care. investg. enferm. imagen desarollo. 2019; 21(1). doi: https://doi.org/10.11144/javeriana.ie21-1.famt 26. marques da silva mc, popim rc, melleiro mm, rizatto dm, molina sa, casquel cm. the reasons of the nursing staff to notify adverse events. rev. latino-am. enfermagem  [internet]. 2014 oct [citado 2020 may  9];  22(5): 747-754. doi: https://doi.org/10.1590/0104-1169.3556.2476 27. meleis af. facilitar y administrar las transiciones: un imperativo para el cuidado de calidad. investg. enferm. imagen desarollo [internet]; 2019 [citado 2020 en 21]; 21(1). disponible en: https://revistas.javeriana.edu.co/index.php/imagenydesarrollo/article/view/24436 home 93 105 experiencias de adolecentes.indd 93 hilda evelia prías-vanegas1 clarybel miranda-mellado2 experiencias de adolescentes embarazadas en control prenatal 1 enfermera. especialista en enfermería en salud mental. docente, universidad de sucre. carrera 14 no. 15c-132, sincelejo, sucre, colombia. hilda_prias@hotmail.com 2 enfermera. especialista en epidemiología. docente, jefe programa de enfermería, universidad de sucre. carrera 14 no. 15c-132, sincelejo, sucre, colombia. clarybel.miranda@unisucre.edu.co recibido: 26 de septiembre de 2008 aceptado: 23 de febrero de 2009 resumen objetivo: describir e interpretar las experiencias relacionadas con los sentimientos e ideas experimentados por las adolescentes al conocer su estado de embarazo. método: se trabajó con un grupo de 22 adolescentes de instituciones públicas de i nivel de salud de sincelejo, colombia. el estudio, realizado en 2005, se abordó desde un enfoque cualitativo, con información recogida en entrevistas personales, grabadas con consentimiento de las jóvenes. resultados: el embarazo genera en la adolescente sentimientos de displacer relacionados con miedo, tristeza, dolor, sufrimiento, culpa, vergüenza y decepción, acompañados de ideas de negación, evasión, duda, arrepentimiento y deseos de abortar, los cuales no aparecen cuando la adolescente cuenta con el apoyo de su compañero sentimental o el de sus padres. conclusión: las adolescentes necesitan apoyo, comprensión y ayuda, dado que están más sensibles, lábiles, inseguras y con baja autoestima, situación que requiere que el equipo de salud desarrolle y muestre competencias en el área humanística, acercamiento personal, empatía y trato humanizado e individualizado en la atención de la población de adolescentes embarazadas. palabras clave embarazo, adolescentes, experiencias, sentimientos, ideas. (fuente: decs, bireme). experiences of pregnant teenagers in prenatal care abstract objective: describe and interpret the experiences related to the thoughts and feelings teenagers go through upon learning they are pregnant. method: the study involved a group of 22 teenagers at level i public institutions in the city of sincelejo, colombia. it was conducted in 2005 and featured a qualitative approach. the information was collected through personal interviews taped with the consent of the teenagers in question. results: teenage pregnancy causes feelings of unhappiness and discontent due to fear, sadness, pain, suffering, a sense of wrongdoing, embarrassment and deception, accompanied by thoughts associated with denial, evasion, doubt, remorse and the desire to abort, which do not appear when the teenager has the support of her boyfriend or her parents. año 9 vol. 9 nº 1 chía, colombia abril 2009 93 105 94 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 conclusion: teenagers need support, understanding and help, since they are more sensitive, susceptible, insecure, and have low self-esteem. this situation demands the health team develop and demonstrate skill and ability with respect to humanistic aspects, personal approach, empathy, and humane and individualized treatment in attending to pregnant teenagers. key words pregnancy, teenagers, experiences, feelings, thoughts. (source: mesh, bireme). experiências de adolescentes grávidas em controle pré-natal resumo objetivo: descrever e interpretar as experiências relativas aos sentimentos e idéias experimentadas pelas adolescentes ao conhecer o seu estado de gravidez método: trabalhou-se com um grupo de 22 adolescentes de instituições públicas de primeiro nível de saúde de sincelejo, colômbia. o estudo, com abordagem qualitativa, realizou-se em 2005 com informação recolhida em entrevistas pessoais gravadas com o consentimento das jovens. resultados: a gravidez causa sentimentos de desagrado na adolescente, relacionados com temor, tristeza, dor, sofrimento culpa, vergonha e decepção, acompanhados de idéias de negação, evasão, duda, arrependimento e desejos de abortar, que não aparecem quando a adolescente conta com o suporte do seu companheiro sentimental ou dos seus pais. conclusão: as adolescentes necessitam apóio, compreensão e ajuda, já que estão sensíveis, lábeis, inseguras e com baixa autoestima. esta situação demanda que a equipe de saúde desenvolva e mostre competências na área humanista, aproximação pessoal, empatia e trato humano e pessoalizado na atenção da população de adolescentes grávidas. palavras-chave gravidez, adolescente, sentimentos, experiências, idéias. (fonte: decs, bireme). 95 experiencias de adolescentes embarazadas en control prenatal hilda evelia prías-vanegas, clarybel miranda-mellado introducción para el estudio, el término experiencia involucra dos elementos fundamentales: los sentimientos que experimenta la adolescente y las ideas que se desarrollan en ella para afrontar y adaptarse a una nueva situación a la que le da mucho significado, como es el embarazo. el embarazo a temprana edad genera y moviliza una gran variedad de sentimientos e ideas en la adolescente y su familia, que en algunas ocasiones se convierte en eventos críticos que en el ámbito familiar no se resuelven en forma adecuada y ponen en riesgo la salud física y sicológica de la adolescente. este tipo de situaciones se observa de manera regular en los servicios de atención prenatal de las diferentes instituciones de salud, donde el equipo de salud enfatiza la parte física y deja de lado lo psicosocial, que para la etapa de su ciclo evolutivo es bien importante y trascendental. el embarazo en adolescentes es de gran trascendencia, dado que aproximadamente 15 millones de adolescentes entre 15 y 19 años dan a luz cada año en el mundo, cifra que equivale al 10% de todos los partos, y en países menos desarrollados alcanza el 17% (1). se han estudiado ampliamente los factores biopsicosociales del embarazo en adolescentes, los cuales reportan que este ocurre por falta de conocimiento, ligado a razones culturales, religiosas, sociales, económicas y de salud, o a temores a los efectos secundarios de dichos métodos (2). también influye el desarrollo socioeconómico del contexto en que vive la adolescente, los conflictos familiares y las relaciones sexuales a temprana edad. en cuanto a consecuencias del embarazo, se reporta que la principal causa de muerte de jóvenes de 15 a 19 años son las complicaciones asociadas al embarazo. en lo social, las madres adolescentes alcanzan menor escolaridad, tienen menor preparación para competir en el mundo laboral y limitadas posibilidades económicas para sostenerse ellas y sus hijos (3). entre otras consecuencias estudiadas por gutiérrez (4), espino (5), araujo (6) y patrón (7), se citan las hemorragias, amenaza de aborto y parto prematuro, mal genio y aislamiento, insomnio y depresión. en colombia, la encuesta nacional de demografía y salud de 2005 (ends) (8) reveló que el embarazo en adolescentes sigue en aumento, al pasar del 19% al 21% entre el 2000 y el 2005, con una tasa de 90 nacimientos por mil mujeres; se reporta que una de cada cinco mujeres de 15 a 19 años ha estado alguna vez embarazada. de estas, el 16% ya son madres y 4% está esperando su primer hijo. para el 2000 (9), estos indicadores fueron similares: 15% y 4% respectivamente. en cuanto a la mortalidad, se reportan 25 defunciones por cada mil nacimientos (8). para el departamento de sucre se encontró que 13,7% de las adolescentes ya eran madres, y el 19,1% alguna vez estuvo embarazada (8); así mismo, en las prácticas clínicas y comunitarias de los estudiantes de enfermería de la universidad de sucre se observa a diario la ocurrencia de estos embarazos, y es así que hasta el 30 de noviembre de 2004 se había atendido en los cuatro centros de salud más grandes de sincelejo a 160 embarazadas menores de 19 años; para el 2007, del total de nacidos vivos, el 21,30% fueron de madres adolescentes (10). estos estudios muestran ampliamente el fenómeno desde el embarazo en adolescentes es de gran trascendencia, dado que aproximadamente 15 millones de adolescentes entre 15 y 19 años dan a luz cada año en el mundo, cifra que equivale al 10% de todos los partos, y en países menos desarrollados alcanza el 17%. 96 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 la perspectiva cuantitativa; sin embargo, existen pocos estudios que abordan este problema desde lo cualitativo, que permitan profundizar en las experiencias y vivencias por las que atraviesa la joven al enfrentarse a una situación de embarazo. según un estudio de florián (11) realizado en medellín, se encontró que la decisión de continuar el embarazo origina en la adolescente una serie de cambios internos y en su modo de vida, para hacer una transición rápida hacia el rol de adulta, con temor a ser rechazada por su familia y su novio y a perder actividades que realizaba, como el estudio. la incertidumbre estuvo ligada a la crítica de los demás, a enfrentar un futuro difícil y a la elección de una alternativa de aborto, que llega a desechar ante sus principios morales, religiosos y al temor a la pérdida de la vida. para llegar a la decisión de continuar con el embarazo tuvo que superar la percepción de desamparo, desesperación y rechazo, lo cual logra a través de estrategias de apoyo, que consigue con tácticas de informar de su estado a través de intermediarios, negociar el futuro o buscar apoyo por fuera del hogar. otra investigación, realizada en manizales por lugo (12), reportó que la experiencia central que viven las jóvenes durante el embarazo es el sufrimiento, profundamente ligado a su identidad; la descripción de ese sufrimiento se evidenció en desconsuelo y desilusión. una investigación hecha en cali por canaval (13) encontró que para unas mujeres el embarazo fue una noticia inoportuna, que generó sentimientos negativos, por los efectos en sus planes futuros, la situación económica y la estabilidad conyugal. otro estudio, realizado en la misma ciudad por vanegas (14), reportó que la mayoría de ellas tenía la autoestima baja, siendo el grupo de menor edad el de autoestima más baja. de la cuesta (15) halló que el embarazo en adolescentes ocurre en el contexto de una relación amorosa que ellas denominan “noviazgo en serio”. en un estudio realizado en sincelejo por herrera y otros (16), al preguntarles a las adolescentes acerca de sus sentimientos durante el embarazo, el 50% manifestaron sentir alegría, el 25% sintieron miedo y un 8,3%, tristeza; por otro lado, reportaron cambios en sus relaciones con los padres (50%), con los amigos (40%) y con la pareja (60%). las estadísticas y estudios anteriores evidencian, por un lado, una amplia exploración de los factores y consecuencias biopsicosociales relacionados con el embarazo a temprana edad, y por otro, vacíos en la profundización de lo que la joven siente, experimenta y piensa durante su embarazo. todo ello estimuló al grupo de trabajo a investigar acerca de las experiencias de las adolescentes, especialmente en la primera etapa, donde se enfrenta y asume el embarazo, para saber qué siente, qué piensa y qué experimenta la joven ante esa situación, nueva para ella. por tanto, este estudio fue orientado a comprender las experiencias manifestadas por un grupo de adolescentes que asistían al control prenatal de ocho instituciones de salud (ips) oficiales de primer nivel de sincelejo. la utilidad del proyecto radica en que ofrece una información contextualizada de las adolescentes embarazadas que permita una reflexión al grupo de salud y lo motive a tener una mayor interacción y seguimiento a la joven en su embarazo, propiciando la prevención y detección oportuna de riesgos psicosociales. la utilidad del proyecto radica en que ofrece una información contextualizada de las adolescentes embarazadas que permita una reflexión al grupo de salud y lo motive a tener una mayor interacción y seguimiento a la joven en su embarazo, propiciando la prevención y detección oportuna de riesgos psicosociales. 97 experiencias de adolescentes embarazadas en control prenatal hilda evelia prías-vanegas, clarybel miranda-mellado materiales y métodos el estudio realizado fue de tipo descriptivo con abordaje cualitativo. se trabajaron dos categorías: sentimientos e ideas, como parte de la comprensión de las experiencias vividas por la joven al enfrentar su embarazo. la población de referencia correspondió a 160 adolescentes inscritas en el programa de control prenatal de ocho ips públicas de primer nivel del municipio de sincelejo, en donde se seleccionó intencionalmente una muestra de 22 participantes en la que cada ips estuviera representada al menos por una adolescente, cumpliendo además con los siguientes criterios: gestantes menores de 19 años, que asistieran regularmente al control, que residieran en la ciudad de sincelejo y que voluntariamente quisieran participar en el estudio. se hizo contacto con las embarazadas en una de las citas de control, se les dio a conocer los propósitos del estudio y la forma de recolectar la información. se solicitó su participación voluntaria, y las que aceptaron firmaron el consentimiento informado para garantizar la intimidad, anonimato y confidencialidad de los datos. cada una de las 22 adolescentes participantes de la muestra expresó sus sentimientos y pensamientos en las entrevistas personalizadas, para así constituirse como fuente primaria en la obtención de la información. antes de recoger la información se hicieron cuatro entrevistas exploratorias con adolescentes que no formaron parte del estudio, con el fin de ensayar el manejo de la entrevista y la utilidad de las preguntas de la guía. la información fue recolectada por medio de entrevistas en un espacio privado, para crear un ambiente de confianza que facilitara a la joven expresar abiertamente toda su vivencia acerca de su embarazo. para su realización se diseñó una guía con preguntas generales que permitieron orientar la entrevista. esta tuvo una duración entre 40 y 70 minutos. las entrevistas fueron grabadas y sistematizadas; después de impresas se hizo una lectura que se comparó con la grabación. el análisis de los datos se hizo simultáneamente, a medida que se iban realizando las entrevistas. el ejercicio consistió en leer, subrayar textos y volver a leer para encontrar el significado de las frases e ir más allá de la mera lectura literal y así poder interpretar la intencionalidad y sentimiento expresado por la joven. a partir de la información ya organizada y revisada, surgieron dos grandes categorías relacionadas con sentimientos y pensamientos o ideas; a cada una se le asignó un color para tener control y diferenciación entre ellas en el texto de la entrevista; posteriormente, se volvió a leer y analizar cada categoría para encontrar en ellas la diversidad de frases que se iban identificando en términos de similitudes y diferencias en lo relativo a sentimientos e ideas que las jóvenes iban expresando. finalmente, después de organizada la información, se llamó a cada una de las adolescentes para darles a conocer la interpretación de la información ofrecida por ellas, dándose así la oportunidad de confrontar, verificar, corregir y validar dicha interpretación. resultados la experiencia del embarazo en una adolescente llega a ser tan impactante que genera desequilibrio en su personalidad, debido a que es algo que llega de improviso a truncar el desarrollo normal de su vida cotidiana; se convierte así en un evento traumático que moviliza una la experiencia del embarazo en una adolescente llega a ser tan impactante que genera desequilibrio en su personalidad; se convierte así en un evento traumático. 98 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 serie de sentimientos displacenteros y abrumadores. a continuación se presentan los principales hallazgos orientados a describir los sentimientos y las ideas o pensamientos encontrados en el grupo de jóvenes gestantes. sentimientos en el momento en que la adolescente se dio cuenta de su estado de embarazo emergieron en ella sentimientos diversos, tales como: miedo, tristeza, dolor, sufrimiento, culpa, vergüenza, decepción, frustración y baja autoestima. estos hallazgos confirman lo manifestado por ulibarrie (17), quien refiere que la maternidad no programada frecuentemente genera tensión, dado que la capacidad biológica y psicológica de la joven se ve fuertemente exigida, agudizándose más si ha sido rechazada por su familia y abandonada por su compañero sentimental. la respuesta a esta tensión puede producir desesperación, miedo, dolor, culpa, rabia, pena, angustia y podría incluso llegar a estados depresivos. las jóvenes experimentaron miedo al enfrentar una realidad difícil de aceptar y al no saber cómo darla a conocer a sus padres y demás personas importantes para ella; algunas tienen percepciones subjetivas de que sus padres las pueden rechazar o agredir al enterarse del embarazo, lo cual se ilustra con los siguientes comentarios: “cuando el resultado me salió positivo a mí me dio un shock, que duré tres a cuatro días que no podía hablar; sentía que me tragaba la tierra, imagínate, mi mamá llorando en la casa, mejor dicho, la única hija menor y tan jovencita; entonces yo me sentía mal, quería que no fuera real, sino que fuera un sueño”. “yo tenía mucho susto, tenía miedo de contarle a mi mamá, porque pensé que me iba a echar de la casa; yo aparentaba estar bien para que mi mamá no se diera cuenta”. “me sentí asustada porque no sabía cómo decírselo a mi mamá, pero no se lo dije a ella, sino a mi papá”. “pensaba mucho en la reacción de mis padres, no sabía cómo decirles esto, yo no les comenté nada porque sentí miedo, pensaba que no me iban a apoyar, que me iban a echar de la casa, pero no fue así”. “lo primero que yo pensé fue en irme de la casa sin contarle nada a mis papás, para no darles otra carga”. estos miedos surgen cuando la joven es consciente de las implicaciones que su estado le puede acarrear en el ámbito familiar; siente que ha sido descubierta y que todos se van a dar cuenta de su situación, producto de su comportamiento, de las cosas que hizo a escondidas y que ya no puede ocultar, miedo a defraudar a sus padres, a causarles dolor y, lo más importante, miedo a perder el amor y apoyo de ellos. los sentimientos de tristeza surgen cuando perciben el embarazo como un obstáculo para cumplir con sus expectativas y las de sus padres, unidos a la percepción de soledad y abandono, que les produce inseguridad para enfrentar una situación que es nueva para ellas, al sentir que han decepcionado a sus padres y han perdido la confianza que ellos les habían depositado. ejemplos de esta percepción: “me puse a llorar porque traicioné a mi mamá, tantos consejos que ella me dio y nada”. “cuando mi papá se lo contó a mi mamá, ella me regañó, me dijo que había violado la confianza que había depositado en mí”. “duró dos semanas brava conmigo, que no me hablaba”. “yo [me la] la maternidad no programada frecuentemente genera tensión, dado que la capacidad biológica y psicológica de la joven se ve fuertemente exigida, agudizándose más si ha sido rechazada por su familia y abandonada por su compañero sentimental. 99 experiencias de adolescentes embarazadas en control prenatal hilda evelia prías-vanegas, clarybel miranda-mellado pasaba llorando cada rato pensando en mi mamá, pensando en mi familia”. “me puse muy triste, porque se me acabaron todas las oportunidades que tenía, porque el sueño mío era terminar mi bachillerato e iniciar una carrera”. también puede vivenciarse cuando la joven enfrenta varias pérdidas, como la de su niñez, de su inocencia, de sus antiguos amigos, de las actividades que realizaba como adolescente: “cuando supe que estaba embarazada yo lloré y me dio tristeza, me sentía sola”. “me hablan solo tres compañeras del salón y dos compañeros, los demás me cogieron rabia, en el colegio hago grupo solo con ellos y a veces me toca trabajar solita”. “ellos no gustan de mí porque salí así”. “yo me he acercado al grupo con quien andaba, pero ellos me rechazan, se quitan de mi lado, nada más se queda una sola compañera, que es mi mejor amiga, las otras se pusieron hasta bravas con ella, porque no querían que ninguno de mis compañeros me hablara”. “para unas fue [algo que estuvo] mal, porque como nosotras siempre habíamos andado juntas desde sexto ellas como que pensaron que yo ya no podía andar para arriba y para abajo con ellas, pero hubo otras que sí me apoyaron y me dieron buenos consejos, no como las otras, que me decían que lo botara, que no lo tuviera, que me iba era a amarrar”. las jóvenes también experimentaron momentos de dolor y sufrimiento ante el rechazo de personas que tenían mucho significado afectivo para ellas, como sus padres. lo perciben como un gran vacío, como el derrumbe de su estabilidad y seguridad. igualmente, pueden vivenciar su vida como un caos, sin vislumbrar alternativas que logren restablecer la armonía personal y familiar: “me sentí muy mal porque me estaban rechazando”. “a mí me dolió, porque es mi papá y lo único que recibí de él fue groserías”. “yo no dormía, [me la] pasaba era nerviosa, no me provocaba nada, yo no comía, me asustaba cuando mi mamá y mi papá se acercaban a preguntarme algo”. el embarazo también generó culpa y vergüenza en algunas adolescentes, sentimientos que muestran el estado emocional con el cual la joven evidencia su indefensión y soledad, ante la incomprensión y señalamiento de las personas que ama y que han estado afectivamente cerca de ella; personas que han sido el apoyo y estímulo en su vida y que ahora la juzgan y critican, por lo que puede llegar a sentirse aislada; todo ello moviliza en la joven una gran cantidad de emociones difíciles de manejar y que la hacen más vulnerable a la experiencia de su embarazo: “me sentí con pena, me sentí extraña, porque todo el mundo me miraba, como si todo el mundo me estuviera señalando, y por eso decidí retirarme del colegio”. “cuando le conté al papá del niño, él primero me dijo que sí, que ese peladito era de él; después pasaron los días, me mandó a buscar y me dijo que él había hecho cuentas y que ese hijo no era de él y que por eso no me iba a ayudar”. ante rechazos tan evidentes como el de su compañero sentimental, siente que ella es la única culpable de su situación, que estaba en sus manos haberlo evitado y no lo hizo, y se castiga y juzga a sí misma antes que los demás lo hagan; es una forma de recriminación personal y de liberar de responsabilidad a su compañero; tal vez como un medio de proteger el amor de la persona que espera que la apoye y le responda; lo hace para no sufrir la gran el embarazo también generó culpa y vergüenza en algunas adolescentes, sentimientos que muestran el estado emocional con el cual la joven evidencia su indefensión y soledad. 100 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 decepción que le produce ser rechazada por el hombre que le hizo tantas promesas de amor: “me sentí culpable, obviamente lo soy, porque el embarazo se dio más por mi culpa, por dejarme de cuidar”. las anteriores experiencias llevan a su vez a sentimientos de decepción y frustración; estos se presentan en la joven al sentirse diferente de las compañeras de grupo; percibe que ya no puede disfrutar como antes las actividades con su grupo de iguales, se siente lanzada abruptamente al mundo de los adultos, con responsabilidades para las cuales no está preparada, unido a la falta de compromiso y responsabilidad por parte del compañero sentimental: “cuando salía veía que no tenía vida, que todas disfrutaban las fiestas, y yo en mi casa; era como un castigo que me estaba ocurriendo”. “antes de salir embarazada él me ayudaba para el colegio, la matrícula, el bolso, los cuadernos, y me decía que me iba a sacar a vivir, pero apenas salí embarazada me dejó; por eso me siento engañada y decepcionada de haberme metido con él”. toda esta turbulencia de sentimientos y percepciones negativas y subjetivas dan como resultado baja autoestima y desvalorización de sí misma; la alegría con que antes vivía ahora se cambia por dolor, preocupación y ansiedad; se siente inadecuada al interactuar con sus amigos y juzgada por los adultos y compañeros de estudio. no sabe a qué lugar pertenece, se ve sola asumiendo un rol de adulto, llena de responsabilidades, cuando es una niña, cuando todavía está preparándose para asumirlas: “me hacían sentir como menos, y a veces me ponía a llorar, me daba pena sentarme con los amigos míos, porque yo sentía que me miraban de una manera rara”. “me hacían sentir como menos, nada más por el hecho de que estaba embarazada, y a veces me ponía a llorar”. “a veces decía, si dios me lo dio, así voy a seguir”; me daba tristeza los primeros meses, me daba como pena sentarme con los amigos míos y las amigas mías, porque yo sentía que me miraban diferente, entonces yo me iba para adentro y mejor me ponía a llora”. “yo me sentía mal, porque tantos años estudiando juntas y nunca había sentido un desprecio; estaba muy recaída (sic), no tenía ánimos de nada, ni de jugar”. esta última experiencia es similar a la reportada en el estudio de vanegas (14), donde se encontró que la mayoría de las jóvenes tenían baja la autoestima. los anteriores comentarios reflejan el cambio que la joven experimenta en su mundo personal, familiar y social al salir en embarazo. su mundo de sueños y de ilusiones se estrella ante una realidad a la cual siente que debe enfrentar sola; situación muy difícil de llevar para una joven que está en un momento de gran vulnerabilidad emocional y en proceso de cambio biopsicosocial. por otro lado, no todas las adolescentes experimentaron sentimientos displacenteros como los anteriores; algunas, en número muy reducido, mostraron sentimientos de felicidad y alegría relacionados con el apoyo y estabilidad de la relación con su compañero y del respaldo recibido por su familia, lo cual hace que la joven se sienta feliz, con deseos y expectativas de tener a su hijo, con ilusiones y sueños relacionados con el bebé: “cuando yo me enteré, me puse obviamente feliz, porque eso era lo que yo quería, yo deseaba tener un hijo”. “sentí algunas adolescentes mostraron sentimientos de felicidad y alegría, relacionados con el apoyo de su compañero y de su familia. 101 experiencias de adolescentes embarazadas en control prenatal hilda evelia prías-vanegas, clarybel miranda-mellado una alegría muy grande, quería tener el bebé, porque yo estaba más o menos preparada para aceptar la noticia, y eso era lo que más deseaba”. “me siento bien feliz, encantada, porque es una nueva etapa que estoy viviendo y que ya tengo que aprender a madurar más, por lo que ya voy a ser mamá; la verdad es que estoy contenta y pienso que es un regalo que me ha dado dios, y que tengo que aprovechar esta oportunidad que no se la da a todas las mujeres del mundo”. “él [compañero] se puso muy feliz, me está ayudando, me colabora con lo que yo necesite”. “mi papá está muy feliz y mis hermanos, que lo iban a querer bastante, como querían a sus otros nietos”. “yo le comenté y él se puso contento porque él quería tener un bebé y me dijo que me fuera a vivir con él, pero mis padres no me dejaron ir, entonces él se fue a vivir conmigo a mi casa y estamos viviendo los dos con mis papás”. herrera (16), quien exploró los sentimientos de las adolescentes durante el embarazo, encontró que el 50% manifestaron sentir alegría, porcentaje muy superior a lo hallado en el presente estudio. ideas o pensamientos las ideas que surgieron en la adolescente al enterarse de su estado de embarazo fueron de negación, evasión, incertidumbre, duda, arrepentimiento junto con deseos de abortar. estas también dependieron de la estabilidad y apoyo que le brindó el compañero sentimental y la familia. las ideas de negación y evasión se presentan como un mecanismo de protección que la adolescente toma ante una realidad traumática y de no aceptación de su embarazo, que no fue planeado ni deseado y que llega de improviso a alterar toda su vida familiar, escolar y grupo de amigos; fenómeno que se convierte en una crisis, para la cual es limitada la habilidad para utilizar sus recursos internos y externos con los cuales afrontarla y superarla: “yo no quería pensar que estaba embarazada, me hacía la loca”; “pensé irme de la casa sin contarle nada a mis papás, para no darles otra carga”; “cuando yo llegaba del colegio, yo casi no hablaba con mi mamá, trataba de evadirla; me ponía a ver televisión, pasaba acostada”. las ideas de incertidumbre y duda generalmente surgen cuando la joven no sabe qué hacer, cómo actuar, cómo informarles a los padres de un suceso que podría generar en ellos dolor, decepción, tristeza y rabia; duda por la reacción y decisiones que los padres puedan asumir; incertidumbre para enfrentar el futuro. es un estado lleno de dudas, incógnitas no resueltas, sufrimiento e impotencia frente a una realidad que para ella es difícil de aceptar y afrontar, pues piensa que todavía necesita la protección de sus padres y depende de ellos, y que, al ser madre, se verá forzada a tomar las riendas de su vida como persona independiente: “lo único que se me venía a la mente era, `qué va a pasar con mi vida de ahora en adelante´”. “pensaba cómo hacer para decírselo a mis padres; creí que me iban a echar de la casa”. “yo no pasaba [el tiempo] en mi casa, yo me iba para donde mis compañeras, me ponía a pensar `se los digo o no se los digo´”. “yo no se lo conté a mi mamá, porque pensé que ella me iba a rechazar y me iba a echar de la casa”. “cuando me acostaba pensaba cómo hacer para decírselo a ellos; y que de todas maneras se me vería la barriga más adelante”. el estudio realizado por florián (11) coincide con la percepción de estas jóvenes, ya que la incertidumbre también estuvo ligada a la situación de enfrentar un futuro difícil. las ideas de negación y evasión se presentan como un mecanismo de protección que la adolescente toma ante una realidad traumática y de no aceptación de su embarazo. 102 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 así mismo se evidenciaron ideas de arrepentimiento, que se relacionan con el no acatamiento de las orientaciones y consejos de los padres, lo que despierta en la joven culpa y frustración por no haberlos tenido en cuenta. la manifestación del arrepentimiento es un buen signo, pues indica que aún existen opciones futuras de construcción de un nuevo proyecto de vida; el arrepentimiento podría ayudar a que la adolescente tome decisiones para evitar embarazos futuros y la experiencia que enfrenta la puede tomar como un aprendizaje y un aporte positivo a su vida personal y familiar. una de las adolescentes refirió, por ejemplo: “tantos consejos que mi mamá me dio y yo no le hice caso, me arrepiento de haberme entregado a él”. también surgieron ideas de abortar, pensamientos comprensibles en el estado de miedo ante una situación nueva y amenazante, al no saber cómo salir del problema. para la adolescente la solución más rápida es deshacerse del niño, aparentar que no ha sucedido nada y continuar con su vida cotidiana. por su estado de confusión y angustia, se centra en una solución egoísta y facilista, y solamente avizora su bienestar personal, mas no las consecuencias éticas, morales, legales, físicas y sicológicas que implicaría llevar a cabo un aborto y acabar con la vida de su propio hijo: “hubo un momento en que le pedí a dios que este niñito se me saliera, y muchas veces intenté botarlo”. “yo pensaba que si abortaba mis amigas otra vez iban a estar conmigo, se iban a unir a mí, o sea, yo decía que por un simple bebé no iba a perder mis amistades; por momentos pensaba perderlo para terminar mis estudios”. “yo no sabía qué hacer; yo hablé con mi amiga y mi pensar era no tenerlo; me sentía inconforme, mal, porque no lo quería tener”. “por momentos pensaba perderlo para terminar mis estudios y luego sí tener una familia”. un estudio similar realizado en méxico (4) encontró que la decisión de continuar el embarazo origina en la adolescente una serie de cambios internos y en su modo de vida, que le permiten hacer una transición rápida hacia el rol de adulta. contrario a las anteriores ideas negativas, también surgieron ideas de protección al bebé y de rechazo al pensamiento de abortar. se vislumbra que, a pesar del caos que están experimentando, algunas adolescentes no aceptan la idea de eliminar a su hijo, sienten que no es lo correcto y que, de hacerlo, tendrían un gran “cargo de conciencia” para el resto de su vida. por ello se despierta el instinto maternal, con ideas de protección y de asumir la responsabilidad de sus actos: “sentí una cosa horrible, pensé que no podía hacer eso, o sea, botar el bebé, porque me iba a quedar un remordimiento todo el tiempo”. “una solita vez se me vino la idea de abortar, después me arrepentí y pensé que yo me lo busqué y que él no tiene la culpa”. la aceptación fue otra de las ideas que surgieron en el grupo investigado y que están relacionadas con una actitud de aceptar el embarazo como un acontecimiento natural y normal, que puede ocurrir a cualquier mujer, posiblemente tomado del referente social en el cual cada vez se presentan más embarazos en adolescentes: “me gustaría que mi papá entendiera, que se dé cuenta de que voy a tener un hijo, que no puedo abortar, que no soy ni la primera ni la última que se ve en esta situación”. “tampoco me gustaría un estudio similar realizado en méxico encontró que la decisión de continuar el embarazo origina en la adolescente una serie de cambios internos y en su modo de vida, que le permiten hacer una transición rápida hacia el rol de adulta. 103 experiencias de adolescentes embarazadas en control prenatal hilda evelia prías-vanegas, clarybel miranda-mellado botarlo, para qué sale uno embarazada si lo va a botar”. “tenía el apoyo de él y tampoco yo desconocía tanto allá, yo ya había criado a mis sobrinitos”. “mi mamá me dijo que lo tuviera, que eso era malo quitarle la vida a un niño. y recibí su apoyo, y el de mis hermanas y de mi suegra. me decidí a tenerlo”. discusión la adolescencia es una etapa de cambios de tipo físico, biológico, emocional y social (18), que genera un estado de desequilibrio temporal y de adaptación en que la joven debe movilizar una gran cantidad de recursos internos y externos para ajustarse a ciertos cambios. el estado emocional de las adolescentes es variable e inestable, dado que están en proceso de cambio y de transición para pasar de ser niñas a ser adultas; de depender de sus padres a exigir y tener más control y dominio de sí mismas; es una etapa de grandes sueños, temores y expectativas para el futuro. si a esta etapa de turbulencia emocional se agrega una situación nueva y amenazante, como es el embarazo, para el cual no estaban preparadas, que las lanza de un momento a otro al rol de adultas, sin tener tiempo para adaptarse, las jóvenes se tornan vulnerables y altamente sensibles a los estímulos externos. los hallazgos de la investigación muestran que la joven experimenta sentimientos altamente negativos que emergen especialmente cuando no cuenta con un ambiente familiar que le brinde seguridad y confianza, en el que se pueda hablar abiertamente de sus fracasos, errores, logros y aciertos. igualmente, los sentimientos de displacer surgen cuando la joven no tiene estabilidad emocional con su pareja y no se siente segura del afecto y apoyo que le pueda brindar, lo que la lleva a sentirse sola, angustiada y frustrada, sin saber qué hacer y qué rumbo tomar. por el contrario, si la adolescente cuenta con el apoyo manifiesto de su compañero sentimental, en ella no se manifiestan sentimientos displacenteros, no le importan las opiniones de sus padres y amigos, más bien se siente plena y feliz al lado de su compañero y con sentimientos de bienvenida para su hijo. la adolescencia es una etapa de grandes sueños, de pensamientos positivos. las adolescentes creen que lo pueden lograr todo, están llenas de energía para emprender cosas nuevas y no ven obstáculos para alcanzar sus metas. sin embargo, al enfrentar un embarazo, también surgen en la joven ideas o pensamientos negativos, como la negación, evasión, incertidumbre e ideas agresivas para el bebé que espera, ideas muy consistentes con los sentimientos de displacer experimentados. en esta investigación las ideas giraban en torno a las formas inmediatas de hacer visible su embarazo, a las posibles reacciones que iban a tener sus padres, su compañero sentimental o las demás personas cercanas afectivamente a ellas. igualmente, surgieron ideas de abortar, de cómo salir del problema, a quién recurrir y a qué persona contarle en busca de comprensión, apoyo y seguridad. estos pensamientos son una respuesta esperada ante una situación de indefensión, de dependencia afectiva y económica y de incertidumbre hacia el futuro; es una especie de derrumbe del castillo de sueños y esperanzas que la adolescente ha construido. los hallazgos de la investigación muestran que la joven experimenta sentimientos altamente negativos que emergen especialmente cuando no cuenta con un ambiente familiar que le brinde seguridad y confianza. 104 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 conclusiones se concluye que las adolescentes experimentan su embarazo como un acontecimiento traumático, con sentimientos de displacer relacionados con la angustia, temor, miedo y tristeza que, a su vez, llevan a estados de incertidumbre, soledad, inestabilidad y frustración, con ideas negativas relacionadas con las formas de dar a conocer su embarazo, a las reacciones de las personas con significado afectivo para ellas y también a la idea de abortar. en la adolescente, estas se atenúan en la medida en que va encontrando a las personas y los espacios para compartir lo que le está ocurriendo. las adolescentes que se embarazan necesitan el apoyo, comprensión y ayuda, dado que están más sensibles, lábiles, inseguras y con baja autoestima; esta situación requiere que el equipo de salud desarrolle y muestre competencias en el área humanística, acercamiento personal, comunicación empática y trato humanizado e individualizado, en los momentos en que las adolescentes demandan de los servicios de salud. lo anterior amerita que los trabajadores de la salud hagan una profunda reflexión sobre sus actitudes al ofrecer sus servicios a este grupo vulnerable, de tal forma que sean agentes facilitadores en la adaptación de la joven embarazada a su nueva condición de vida, convirtiéndose en una importante red de apoyo social para que las jóvenes cuenten con una consejería y orientación oportuna ante los múltiples problemas y dificultades que se le presentan en esta etapa trascendental de su ciclo de vida personal. referencias 1. population reference bureau. la juventud del mundo 2000. washington; 2000. p. 7. 2. family care international. embarazo no planeado y aborto inseguro: evadir o enfrentar el problema. dialoguemos sobre salud sexual y reproductiva 1998 abril; 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2001. p. 91-2 y 96. 17. ulibarrie m. maternidad adolescente. internet 2004. en línea (25-5-04): www.monografias.com/trabajos10/adant/adant2.shtml 18. negrete y. factores de riesgo biopsicosociales y familiares que alteran la salud de la adolescente embarazada. revista de enfermería: humanismo, ciencia y tecnología 2003; (11): 53-54. analysis of the "diagnostic reasoning" concept in nursing article analysis of the "diagnostic reasoning" concept in nursing análisis del concepto "razonamiento diagnóstico" en enfermería análise do conceito "raciocínio diagnóstico" em enfermagem 10.5294/aqui.2022.22.2.2 bárbara coeli oliveira da silva1 millena freire delgado2 rafaela cavalcanti de albuquerque nascimento3 ana luisa brandão de carvalho lira4 alexsandra rodrigues feijão5 bertha cruz enders6 1 0000-0002-2933-0930  secretaria de estado da saúde pública do rio grande do norte e secretaria municipal  de saúde de parnamirim, brazil barbaracoeli@outlook.com 2 0000-0003-3769-5427  universidade federal do rio grande do norte, brazil millenadelgado@gmail.com 3 0000-0003-0609-4813 universidade federal do rio grande do norte, brazil rafaela.cavalcanti.065@ufrn.edu.br 4 0000-0002-7255-960x universidade federal do rio grande do norte, brazil ana.luisa.brandao@ufrn.br 5 0000-0002-8686-9502 universidade federal do rio grande do norte, brazil alexsandra.feijao@ufrn.br 6 0000-0001-5258-4579 universidade federal do rio grande do norte, brazil bertha@ufrnet.br received: 16/11/2020 sent to peers: 03/06/2021 approved by peers: 02/03/2022 accepted: 15/03/2022 theme: epistemology. contribution to the discipline: understanding the diagnostic reasoning phenomenon based on precedents, critical attributes, and consequences. para citar este artículo / to reference this article / para citar este artigo: silva bco, delgado mf, nascimento rca, lira albc, feijão ar, enders bc. analysis of the "diagnostic reasoning" concept in nursing. aquichan. 2022;22(2):e2222. doi: https://doi.org/10.5294/aqui.2022.22.2.2 abstract objective: to develop an operational definition of the "diagnostic reasoning" concept in nursing. materials and methods: this concept analysis is based on walker and avant's model. all the referential steps were followed: concept selection, determining the objectives and proposals for concept analysis, identifying the possible uses of the concept, determining the defining attributes, identifying a model case, identifying the contrary case, and identifying the precedents and consequences of the concept. results: a sample of 20 studies was selected, identifying the following attributes: specialized thinking, cognitive skills, existing knowledge, intellectual competence; hypothesis-oriented reasoning; precedents: clinical assessment, practical experience, data interpretations, intuition, diagnostic judgment, information processing, clinical reasoning; consequences: improvement of nursing care, communication, planning interventions, addressing the identified problem, achieving effective results, autonomous actions, and quality of patient records. conclusions: the study contributes to understanding the operational definition of the diagnostic reasoning concept in nursing by identifying the core attributes, precedents, and consequences. keywords (source decs): clinical decision-making; nursing diagnosis; nursing; concept formation. resumen objetivo: desarrollar una definición operacional del concepto "razonamiento diagnóstico" en enfermería. materiales y métodos: se trata de un análisis de concepto según el modelo de walker y avant. se siguieron todos los pasos de la referencia: selección del concepto; determinación de los objetivos y las propuestas para el análisis conceptual; identificación de los posibles usos del concepto; determinación de los atributos definidores; identificación de un caso modelo; identificación del caso contrario; identificación de los antecedentes y de las consecuencias del concepto. resultados: se seleccionó una muestra de 20 estudios, en los que se identificaron los atributos: pensamiento especializado, habilidades cognitivas, conocimiento existente, competencia intelectual; razonamiento orientado a la hipótesis; antecedentes: evaluación clínica, experiencia práctica, interpretaciones de los datos, intuición, juicio diagnóstico, procesamiento de informaciones, razonamiento clínico; consecuencias: avance de los cuidados de enfermería, comunicación, planeación de intervenciones, actuación sobre el problema identificado, alcance de los resultados eficaces, acciones autónomas, calidad de la documentación del paciente. conclusiones: el estudio aporta a la comprensión de la definición operacional del concepto "razonamiento diagnóstico" en enfermería por medio de la identificación de los atributos esenciales, de los antecedentes y de las consecuencias. palabras clave (fuente decs): toma de decisiones clínicas; diagnóstico de enfermería; enfermería; formación de concepto. resumo objetivo: desenvolver uma definição operacional do conceito "raciocínio diagnóstico" em enfermagem. materiais e métodos: trata-se de uma análise de conceito segundo o modelo de walker e avant. foram seguidos todos os passos do referencial: seleção do conceito; determinação dos objetivos e das propostas para a análise conceitual; identificação dos possíveis usos do conceito; determinação dos atributos definidores; identificação de um caso modelo; identificação do caso contrários; identificação dos antecedentes e dos consequentes do conceito. resultados: selecionou-se uma amostra de 20 estudos, nos quais foram identificados os atributos: pensamento especializado, habilidades cognitivas, conhecimento existente, competência intelectual; raciocínio orientado para a hipótese; antecedentes: avaliação clínica, experiência prática, interpretações dos dados, intuição, julgamento diagnóstico, processamento de informações, raciocínio clínico; consequentes: avanço dos cuidados de enfermagem, comunicação, planejamento de intervenções, agir sobre o problema identificado, alcance de resultados eficazes, ações autônomas, qualidade da documentação do paciente. conclusões: o estudo contribui com a compreensão da definição operacional do conceito de raciocínio diagnóstico em enfermagem por meio da identificação dos atributos essenciais, dos antecedentes e dos consequentes. palavras-chave (fonte decs): tomada de decisão clínica; diagnóstico de enfermagem; enfermagem; formação de conceito. introduction the diagnostic reasoning process in nursing has been under investigation due to its magnitude and complexity, as it involves the interpretation of responses regarding the patient's health status, which, if conducted in a non-structured way, is more prone to risks and misjudgments (1). the diagnostic decision becomes a major assignment for the nursing staff, as they directly contact patients and experience the most varied clinical situations. thus, to propose measures to qualify clinical reasoning and critical thinking, educational institutions and service providers have been demanding more trained and updated professionals who can meet the workplace needs (2). due to these requirements, the resolution of the federal council of nursing (cofen) states that nurses have their actions supported by the systematization of nursing care (snc) and the nursing process (np). cofen's resolution 358/2009 states that the snc organizes professional work in terms of method, personnel, and instruments, making it feasible to implement the np, which consists of a methodological instrument that must be used in public and private health institutions to guide the care provided by nursing staff and the documentation of professional practice (3). however, despite studies demonstrating its advantages for care practice (4-6), education, and research in nursing, several professionals and institutions are reluctant and hesitant to use the np (7) due to a series of obstacles that must be overcome: a lack of acknowledgment by the nursing team, the number of nurses in institutions, the involvement with the process, the recognition by the institution's management, and the care result indicators. it is emphasized that the care process involves far more than technical knowledge, and professionals should measure their actions with scientific knowledge and ethical commitment (8). one of the most critical steps of the np is the nursing diagnosis, as it is through this step that the other ones can be performed. the nurse identifies the individual, group, or community responses to a health problem when establishing a diagnosis. however, for this purpose, nurses must develop specific skills and competencies to guide the diagnostic reasoning that will enable planning interventions and predicting nursing outcomes (9). in medical science, the logic of the diagnostic process lies in the use of scientific methods in clinical reasoning intellectually and operationally to address a given clinical problem. for this, steps such as data collection, clinical history, physical examination, laboratory tests, data analysis, critical evaluation of the data collected, a listing of findings in order of importance, the selection of core findings, and a listing of diseases in which these core findings are found need to be taken to reach the final diagnosis and select the disease that best explains the alterations manifested by the patient (10). in nursing, diagnoses are based on analyzing and measuring human responses obtained through clinical judgment. therefore, the correct diagnosis will depend on nurses' diagnostic ability and theoretical references; thus, a correct diagnosis requires intellectual, interpersonal, and technical competencies, along with mental and cognitive skills (11, 12), which characterize diagnostic reasoning, as well as its use and interpretation. hence, diagnostic reasoning is a process that enables observing and assigning meaning to phenomena in clinical situations, from the integration of critical thinking and observation, which leads to hypotheses that solve patients' problems (13). in this way, it is a theme of considerable relevance to improving care practice and skills that, added to clinical experience, are considered core to the critical thinking and deductive reasoning, such as interpreting, analyzing, evaluating, interfering, and clarifying (13). diagnostic reasoning is closely related to the choice of expected outcomes consistent with the diagnosis of appropriate patient interventions. in this sense, it becomes vital to analyze the "diagnostic reasoning" concept in nursing, as the development of the ability to think and reason for decision-making should be a key component for implementing np. on the other hand, there are few studies on the analysis of the diagnostic reasoning concept, as shown by a search in the cumulative index to nursing and allied health literature (cinahl), lilacs, and medline databases using the descriptors "nursing diagnosis," "reasoning diagnosis," and "nursing," combined with the boolean operator and. therefore, this theme requires further discussion and fostering within academia. with the progress of research on clinical validation of nursing diagnosis, typical nursing phenomena have been used to create analytical rules for the inclusion or exclusion of diagnoses. the north american nursing diagnosis association taxonomy is a reference for identifying patterns, symptoms, signs, and behaviors defined in a nursing diagnosis, enabling diagnostic intervention with a high level of accuracy (14). given this scenario, and considering that concept analysis is a method that allows for its thorough study, this research was designed to clarify the meaning of diagnostic reasoning in nursing and identify its attributes, precedents, and consequences. thus, this study aims to develop an operational definition of the "diagnostic reasoning" concept in nursing to support clinical reasoning in diagnostic decision-making and interpretation. the importance of furthering knowledge of this concept is noted, as the use of diagnostic reasoning can be found both in the clinical context, where nurses apply the np (15), and in the teaching context so that students can develop skills relevant to the implementation and execution of the np (16, 17). materials and methods this concept analysis study was developed according to walker and avant's (18) theoretical framework. the analysis was operationalized by an integrative review using the whittemore and knafl (19) method, following these five steps: 1) problem identification, 2) literature search, 3) data evaluation, 4) data analysis, and 5) presentation. it should be noted that the concept analysis proposed by walker and avant (13) is strongly related to nursing and its classification systems, which are relevant to the improvement of language and understanding in the contexts that encompass clinical practice. for the study, the concept analysis model steps were considered: concept selection; determining the objectives and proposals for concept analysis; identifying the possible uses of the concept; determining the defining attributes; identifying a model case; identifying the contrary case; identifying the precedents and the consequences of the concept (18). however, the decision was not to develop the empirical references since the measurement of the terms found was not evident in the literature. the integrative review was guided by the following questions: what attributes of the "diagnostic reasoning" concept in nursing? what are the precedents and consequences of the "diagnostic reasoning" concept in nursing? we searched the cinahl, scopus, pubmed, web of science, and nursing database (bdenf) databases in january 2018 to address the questions via the federated academic community of the journal website, coordination for the improvement of graduate personnel. for the search above, we used a combination of the descriptors indexed in the health sciences descriptors (decs) of the virtual health library ("nursing diagnosis," "clinical competence"), the medical subject headings (mesh) of the national library of medicine ("professional practice" and "nursing"), and the keywords "reasoning diagnosis," "clinical reasoning," and "critical reasoning." five crossings were performed: nursing diagnosis and clinical competence and nursing; nursing diagnosis and professional practice and nursing; nursing diagnosis and reasoning diagnosis and nursing; nursing diagnosis and clinical reasoning and nursing; nursing diagnosis and critical reasoning and nursing. the inclusion criteria for the publications in the study were the following: full-text articles available in the selected databases in english, portuguese, or spanish, addressing the theme "diagnostic reasoning in nursing" and he guiding questions of this study. we decided not to restrict the publishing period, aiming to cover as many studies on the subject as possible, regardless of the year of publication. editorials, letters to the editor, abstracts, specialist opinions, and integrative review articles were excluded. the exclusion of these publications is justified by their level of evidence. the search was performed in pairs simultaneously to ensure quality. initially, after reading the titles and abstracts, we selected 179 articles. after the initial selection, the researchers performed a second reading of the titles and abstracts; if they met the research objectives, the articles would be read in full. in cases of disagreement between the researchers, the article was read in full. if it met the objectives, it was included in the sample. following this careful process, 86 articles were selected, as presented in figure 1. of the 86 articles, 39 were duplicates, totaling a partial sample of 47 articles read in full by the two researchers to confirm the inclusion and exclusion criteria. of the 47, 20 articles were part of the final sample, read thoroughly to extract the mental constructs that represent categories of information to name diagnostic reasoning, precedents (events that occur before diagnostic reasoning) and consequences (events that occur as a result of diagnostic reasoning). figure 1 demonstrates the search process performed (20). figure 1. database search layout key: cr01 (crossing 01): nursing diagnosis and clinical competence and nursing; cr02 (crossing 02): nursing diagnosis and professional practice and nursing; cr03 (crossing 03): nursing diagnosis and reasoning diagnosis and nursing; cr04 (crossing 04): nursing diagnosis and clinical reasoning and nursing; cr05 (crossing 05): nursing diagnosis and critical reasoning and nursing. *after reading the eligible studies in full, some were excluded for being duplicates and not meeting the eligibility criteria, resulting in a total of 20 selected studies. source: own elaboration. when reading the references in full, the researchers tried to extract the events related to the "diagnostic reasoning" concept,: what the literature covers on the theme, that is, how it is described and understood in the literature; everything that comes before (precedents) and after (consequences) the occurrence of the concept. these data were recorded on sheets. a characterization sheet was prepared for each reference with its title, year of publication, language, method, attributes, consequences, precedents, and references. results the results are centered on publications between 1986 and 2015, predominantly 2011 (n = 4), followed by 2009 (n = 3) and 2015 (n = 2). it is also noteworthy that most studies stemmed from brazil (n = 8), the united states (n = 6), and england (n = 3). furthermore, the methods used in most studies were descriptive (n = 5), quasi-experimental (n = 5), methodological (n = 2), case study (n = 2), and experimental (n = 2) (table 1). table 1. sample characterization reference title year country method (21) activating clinical inferences: a component of diagnostic reasoning in nursing 1986 the united states exploratory study (22) metacognitive skills in diagnostic reasoning: making the implicit explicit 1992 the united states descriptive study (23) a longitudinal framework for fostering critical thinking and diagnostic reasoning 1997 england descriptive study (24) the influence of nursing diagnosis on information processing by undergraduate students 1998 brazil quasi-experimental study (25) diagnostic reasoning processes using patient simulation in different learning environments 2002 england case study (26) an analysis of expert nurse practitioners' diagnostic reasoning 2003 the united states descriptive study (27) differential diagnosis in advanced nursing practice 2006 england case study (28) the impact of tutorial strategies on student nurses' accuracy in diagnostic reasoning in different educational settings: a double pragmatic trial in italy 2008 italy experimental study (29) o processo ensino-aprendizagem do diagnóstico de enfermagem, na ótica de estudos acadêmicos 2009 brazil reflective study (30) improving critical thinking and clinical reasoning with a continuing education course 2009 brazil quasi-experimental study (31) model of critical diagnostic reasoning: achieving expert clinician performance 2009 the united states descriptive study (32) virtual patients for assessment of clinical reasoning in nursing: a pilot study 2011 taiwan quasi-experimental study (33) diagnóstico de enfermagem: estratégia educativa fundamentada na aprendizagem baseada em problemas 2011 brazil experimental study (34) avaliação do objeto virtual de aprendizagem "raciocínio diagnóstico em enfermagem aplicado ao prematuro" 2011 brazil descriptive study (9) avaliação de objeto virtual de aprendizagem sobre raciocínio diagnóstico: estudo descritivo 2011 brazil methodological study (35) do knowledge, knowledge sources and reasoning skills affect the accuracy of nursing diagnoses? a randomized study 2012 the netherlands randomized factorial design study (36) effect of continuing nursing education on nurses' attitude toward and accuracy of nursing diagnosis 2013 the united states quasi-experimental study (37) teaching dual-process diagnostic reasoning to doctor of nursing practice students: problem-based learning and the illness script 2014 the united states quasi-experimental study (1) análise do conteúdo de uma tecnologia para raciocínio diagnóstico de enfermagem 2015 brazil methodological study (38) objeto virtual de aprendizagem sobre o raciocínio diagnóstico em enfermagem aplicada ao sistema tegumentar 2015 brazil methodological study source: own elaboration use of the "diagnostic reasoning" concept in nursing the "diagnostic reasoning" concept in nursing was not explicit in the selected studies; however, it was possible to extract its attributes, precedents, and consequences, which are crucial to the development of the concept. determining the attributes and formulating the concept definition regarding the analysis of the "diagnostic reasoning" concept, the critical attributes for the occurrence of the concept were identified. the researchers extracted the terms involved in diagnostic reasoning to identify the attributes. after selecting terms, those that appeared in all studies were singled out: specialized thinking, cognitive skills, existing knowledge, intellectual competence, and hypothesis-driven reasoning. specialized thinking (25, 27, 28, 30, 31) is the type of thinking framed in the decision-making process and used to identify a problem and its solution. accurate recognition of the patient's problems precedes formulating a solution and implementing it. cognitive skills (9, 22, 23, 25-28, 30, 33-35, 37, 38) include critical thinking skills such as information seeking, discernment, and analysis. mental habits refer to the affective aspects of critical thinking or traits such as perseverance, flexibility, contextual perspective, and confidence. for the authors, it is important to develop cognitive skills and mental habits when interpreting human responses. existing knowledge (1, 20, 22, 23, 29, 35, 36, 38), in turn, is related to the nurses' ability to diagnose: the greater the knowledge, the better the diagnostic reasoning. the authors discuss the perspective that diagnostic ability in nursing evolves from experience and clinical knowledge. knowledge is a prerequisite for the development of diagnostic reasoning. the intellectual competence attribute (1, 23, 29-31, 36, 37) is addressed along with knowledge; the greater the knowledge, the better the nurse's judgment skills are when exercising diagnostic reasoning. hypothesis-driven reasoning (23, 26-28, 31, 32) refers to processing information through critical analysis and pattern recognition, leading the nursing professional to generate a diagnostic hypothesis. the analysis of these attributes resulted in the formulation of a conceptual definition for the "diagnostic reasoning" concept: cognitive abilities that involve prior knowledge, intellectual competence, and specialized thinking and culminate into reasoning driven towards the diagnostic hypothesis. developing a model case maria lucia is a 37-year-old assistant nurse who has been working at the university hospital of rio grande do norte, brazil, for seven years. since her graduation, the nurse has used the nursing process following all the proposed steps. when collecting data from the hospitalized patient, the nurse analyzes all the reports, searches her memory for knowledge acquired during her academic training and professional experience to identify the relevant problems for nursing, and thus be able to design interventions that improve the patient's clinical condition. this professional can reason critically and analyze based on her cognitive abilities and intellectual competencies, developing diagnostic hypotheses and outlining a care plan for the patient. this model case is fictional and highlights the attributes identified in the literature for the "diagnostic reasoning" concept. developing the contrary case maria lucia is a 37-year-old assistant nurse who has been working at the university hospital of rio grande do norte, brazil, for seven years. the nurse has never used the nursing process in her work environment and does not believe that it would bring benefits to the patient since the medical diagnoses have already been listed. when collecting the inpatient's data, she notes the nursing evolution in the chart without prescribing any assessment or diagnostic hypotheses. the patient's care plan is followed by medical recommendations. in this example of a contrary case, the "diagnostic reasoning" concept has not occurred. the nurse mistakes medical diagnosis for nursing diagnosis and demonstrates a lack of ability, interest, and willingness to promote patient care through the nursing process. identifying the concept's precedents and consequences according to the literature, seven precedents and seven consequences concerning the concept have been identified in table 2. table 2. the concept's precedents and consequences precedents consequences clinical evaluation (1, 21-29, 31, 33, 34, 35-37-39) advances in nursing care (27, 29, 31, 36) practical experience (23, 24, 26, 27, 29, 31, 35-37) communication (24, 29, 36) data interpretation (30, 31, 33) intervention planning (1, 22, 24, 27, 29-31, 33-35) intuition (24, 26, 29, 37) acting upon the identified problem (23, 27, 28, 31, 33) diagnostic judgment (21, 24, 28 ,31) achieving effective results (28, 29, 34) information processing (21-22, 24, 26, 33) autonomous actions (1, 24, 26, 28, 29, 33, 34, 38) clinical reasoning (22, 26, 27, 29-34, 36) quality of patient documentation (36) source: own elaboration. regarding the precedents for diagnostic reasoning, it is expected that nurses can identify health problems and know the best ways to solve them. to identify these health problems, nurses use diagnostic reasoning. it is necessary to identify the problems to develop the skills for this type of reasoning, which will occur by recognizing the signs and symptoms and what the patient manifests at a given moment. this information will be extracted in data collection, which nurses will interpret based on their experiences acquired in academia, their professional practice, and their intuition. processing this information supports clinical reasoning and data interpretation; with this, nurses can formulate a diagnostic judgment. regarding the consequences, diagnostic reasoning enables the planning of care through interventions directed towards the health problem and its evaluation; this way, it is possible to achieve effective results and ensure the quality of care. it is also added that taking action on the identified problems, guided by care planning, guarantees autonomy for nurses, quality in the documentation and safety for the evaluation of such care. the research results are presented in figure 2, which displays the consolidated analysis of the diagnostic reasoning concept. figure 2. structural consolidation of the analysis of the "diagnostic reasoning" concept according to walker and avant's theoretical framework source: own elaboration. discussion initially, it is understood that nursing needs to be well-conceptualized regarding diagnostic reasoning. teaching strategies such as case reports, case studies, and simulations using a virtual patient should be present in the nurses' learning process. they substantially contribute to developing the expected clinical reasoning and, consequently, the cognitive process of making nursing diagnoses, which is commonly referred to as "diagnostic reasoning" (9). the attributes identified in this study that encompass diagnostic reasoning were specialized thinking, cognitive skills, existing knowledge, intellectual competence, and hypothesis-driven reasoning. specialized thinking is vital to achieving diagnostic reasoning, as it guides thoughts in an organized manner and represents the actions and events of a person with greater knowledge in specific domains (39). regarding critical reasoning, cognitive skills are essential to maintain the accuracy of the individual's health situation and support the decision-making process-. through this essential act for clinical practice, the professional establishes the correct diagnosis and proposes appropriate conduct in the face of the clinical problem encountered (4). existing knowledge is essential to reach the diagnosis, which is an attribute that involves the need for step interpretation, so that diagnostic reasoning is supported by the existing knowledge and the data obtained. thus, obtaining a general idea of the patient's condition favors the direction of clinical attention, and indirect evaluation of the patient increases the effectiveness of information and its processing (1). the identification of evidence, the confrontation of scientific evidence, the mental construction of probable nursing diagnoses, and the validation of those diagnoses through patient discussion are part of a complex process of intellectual competence, which consists of the whole process of diagnostic reasoning (40). some strategies can be implemented as data collection enablers, namely: the use of care and shift models that favor the flow of information, enabling effective communication; the use of external sources such as care records, clinical discussion meetings, and conversations with family and significant others; consultation of clinical records, laboratory and imaging tests, data on lifestyle, ethnic group, occupation, socioeconomic conditions, and others, and effective communication between teams (1). hypothesis-driven reasoning is essential to reach the outcome of the nursing diagnostic process. for this, the nurse must have a questioning approach during data collection directly with the patient and indirectly by using previously collected data, laboratory tests, and shift reports to interpret, evaluate, and organize them for judging the patient's health problems and subsequently making a decision (40). in short, for the diagnostic reasoning process, the collected data must be analyzed, summarized, and categorized, considering the best concept in one of the classification systems (41). the subsequent steps of diagnostic reasoning are the following: the planning process (expected results), implementation of nursing interventions, and evaluation of nursing care. the importance of a diagnosis choice and how it directly implies selecting the care plan (outcomes and interventions) is emphasized (42). based on the assumption that nursing diagnosis and results are complementary phenomena, it is understood that adequate diagnostic reasoning promotes good quality decisions by involving risks, benefits, identification of care, and assistance priorities. these are crucial elements to precede and rationalize outcomes and nursing interventions (43). subsequently, during planning, the objectives, goals, and deadlines should be established to reach the expected results, which will be achieved by selecting appropriate interventions. the intervention should clearly define what is planned, formulate precisely the problems to be addressed, identify the cause of the problem, analyze operations to address the problem, analyze the plan's viability, and implement the intervention (44). it is noted that decision-making based on identifying a diagnosis is a complex step in the nursing process, which can have consequences for the patient. the adequate application of diagnostic reasoning will allow nurses to act based on the patient's actual conditions, reaching greater commitment and results for the patient. if effective, it will result in a positive evaluation of the patient's clinical condition (29). conclusions the present study identified specialized thinking, cognitive skills, existing knowledge, intellectual competence, and hypothesis-driven reasoning as essential attributes for the concept to occur. regarding the precedents and the consequences, seven items were identified for each. knowing these points is a valuable tool for the nurses' decision-making process, formulated according to the principles of health problem identification and intervention planning focused on the patient's needs. critical thinking skills for diagnostic intervention in nursing are necessary for strengthening the profession as a science, highlighting the need to address these issues in academia. the study's limitations involve using controlled descriptors for the search and including available full-text articles only. conflict of interest: none declared. references 1. cleire bb, brandão ma, dias bf, primo cc. análise do conteúdo de uma tecnologia para raciocínio diagnóstico de enfermagem. revista bras. enferm. 2015;68(2):261-8. doi: http://dx.doi.org/10.1590/0034-7167.201568o211i 2. riegel f, oliveira júnior nj. processo de enfermagem: implicações para a segurança do paciente em centro cirúrgico. cogitare enferm. 2017;22(1):1-5. doi: http://dx.doi.org/10.5380/ce.v22i1.4557 3. conselho federal de enfermagem. resolução n. 358 de 15 de outubro de 2009. dispõe sobre a sistematização da assistência de enfermagem e a implementação do processo de enfermagem em ambientes, públicos ou privados, em que ocorre o cuidado profissional de enfermagem, e dá outras providências. brasília: conselho federal de enfermagem; 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department of medical-surgical nursing, universidade de são paulo, brazil. vilanice@usp.br 4 0000-0002-8828-2190. department of nursing, universidad andrés bello, chile. denisse.cartagena@unab.cl received: 21/09/2021 sent to peers: 29/09/2021 approved by peers: 30/09/2021 accepted: 15/10/2021 * the authors declare that this product was partially funded by the scientific research support policy, department of nursing and midwifery, universidad de los andes (chile), under identification number 2021-01. ** los autores declaran que esta producción fue financiada de manera parcial por la política de apoyo a la investigación científica de la facultad de enfermería y obstetricia de la universidad de los andes (chile) bajo el número de identificación 2021-01. *** os autores declaram que esta produção foi financiada de maneira parcial pela política de apoio à pesquisa científica da faculdade de enfermagem e obstetrícia da universidad de los andes (chile) sob o número de identificação 2021-01. theme: evidence-based practice. contribution to the discipline: this article provides relevant information on the approach to joanna briggs institute's (jbi) reviews, training programs, and inputs to evidence-based nursing practice. additionally, it provides critical information about the cochrane living systematic reviews and systematic reviews of measurement instruments. to reference this article / para citar este artículo / para citar este artigo: fuentealba-torres m, lagos sánchez z, püschel vaa, cartagena-ramos d. revisiones sistemáticas para el fortalecimiento de la práctica de enfermería basada en evidencias. aquichan. 2021;21(4):e2145. doi: https://doi.org/10.5294/aqui.2021.21.4.5 abstract systematic reviews are essential to developing evidence-based nursing practice. the jbi, formerly known as the joanna briggs institute, has contributed significantly to research through technical training on reviews. cochrane living systematic reviews and systematic reviews of measurement instruments have been approaches recently used by the scientific community. the purpose of living systematic reviews is to continuously update priority issues, while systematic reviews of measurement instruments condense evidence on the validity of measurement instruments. this arti­cle overviews the jbi systematic review approaches and provides critical information about cochrane living systematic reviews and systematic reviews of measurement instruments. the use of these new approaches is necessary to maintain the evidence-based nursing practice and advance nursing knowledge. keywords (source decs): evidence-based practice; evidence-based nursing; systematic review; psychometry; nursing. resumen las revisiones sistemáticas son esenciales para el desarrollo de la práctica de enfermería basada en la evidencia. el jbi, conocido anteriormente como joanna briggs institute, ha contribuido significativamente al desarrollo de la investigación mediante el entrenamiento técnico sobre revisiones. las revisiones sistemáticas vivas cochrane y las revisiones sistemáticas de instrumentos de medición han sido enfoques recientemente utilizados por la comunidad científica. las revisiones sistemáticas vivas tienen como propósito generar actualizaciones continuas de temas prioritarios y las revisiones sistemáticas de instrumentos de medición aportan síntesis de evidencias relacionadas con la validez de los instrumentos de medida. este artículo es una overview, que tiene como objetivo proporcionar una visión general sobre los abordajes de revisiones sistemáticas del jbi y brindar informaciones claves acerca de las revisiones sistemáticas vivas cochrane y las revisiones sistemáticas de instrumentos de medición. la utilización de estos nuevos abordajes es necesaria para mantener la práctica de enfermería basada en la evidencia y aportar al desarrollo del conocimiento enfermero. palabras clave (fuente decs): práctica clínica basada en la evidencia; enfermería basada en la evidencia; revisión sistemática; psicometría; enfermería. resumo as revisões sistemáticas são essenciais para o desenvolvimento da prática de enfermagem baseada em evidências. o jbi, conhecido anteriormente como jhoanna briggs institute, contribuiu significativamente para o desenvolvimento da pesquisa mediante o treinamento técnico sobre revisões. as revisões sistemáticas vivas cochrane e as revisões sistemáticas de instrumentos de medição vêm sendo abordagens recentemente utilizadas pela comunidade científica. as revisões sistemáticas vivas têm como objetivo gerar atualizações contínuas de temas prioritários e as revisões sistemáticas de instrumentos de medição contribuem com sínteses de evidências relacionadas com a validade dos instrumentos de medida. este artigo é um overview, que tem como objetivo proporcionar uma visão geral sobre as abordagens de revisões sistemáticas do jbi e oferecer informações-chave sobre as revisões sistemáticas vivas cochrane e as revisões sistemáticas de instrumentos de medição. a utilização dessas novas abordagens é necessária para manter a prática de enfermagem baseada em evidências e contribuir para o desenvolvimento do conhecimento em enfermagem. palavras-chave (fonte decs): prática clínica baseada em evidências; enfermagem baseada em evidências; revisão sistemática; psicometria; enfermagem. introduction systematic reviews (sr) originated between 1970 and 1980 (1) and have considerably influenced the formulation of health policies and clinical decision-making (2). these reviews intend to condense multiple studies rigorously and transparently (3). srs regularly use the prisma guidelines, available on equator-network (https://www.equator-network.org/reporting-guidelines/prisma/), to ensure quality and transparency in reporting these summaries. srs synthesize and assess the quality of primary studies and provide reliable and updated information on the evidence available in the scientific literature (4). among their objectives, srs aim to comprehensively identify global evidence, confirm current practice, address any variations, identify niches for future research, investigate contradictory results, and produce statements to guide decision-making (2, 3). therefore, the world health organization's (who) international recommendations rely on the critical analysis of the evidence provided by srs, including quality assessment, the degree of data certainty, and evidence synthesis (5). according to the international council of nurses (icn), evidence-based nursing practice minimizes the gap between theory and practice (6). thus, srs are mainstays to transfer the evidence-based nursing (ebn) approach (7), which integrates the best available evidence for health decision-making and considers clinical experience and the values and preferences of individuals, families, and communities (6, 8). according to the society of nursing sigma theta tau international, the ebn approach directly impacts clinical outcomes because it reduces waiting times, minimizes adverse events, diminishes hospitalization days, and decreases mortality with the consequent cut in health spending (7). in august 2021, more than 35,500 indexed articles with the term "evidence-based nursing" and more than 17,000 indexed articles with the combination "systematic review" and "nursing" were recorded in the pubmed database. likewise, more than 2 million indexed titles with the combination "systematic review" and "nursing" were registered in google scholar. this level of scientific production demonstrates the relevance of srs for nursing practice and their contributions to evidence-based practice (ebp). currently, both the cochrane collaboration—through the cochrane nursing group (https://nursing.cochrane.org/homepage)— and the jbi promote decision-making based on reliable evidence provided by srs. the uk cochrane collaboration created the cochrane nursing in 1993 to make, maintain, and disseminate timely, up-to-date, and rigorous srs in order to minimize bias, ensure quality, prevent duplication of srs, and promote global involvement of different actors, including scientific communities and citizen participation, such as the cochrane iberoamérica initiative (https://es.cochrane.org/es/revisiones-cochrane). in 2009, the cochrane collaboration partnered with the jbi through the cochrane nursing care area (9) to strengthen ebp and enhance jbi indexed databases (https://crai.ub.edu/es/tags/joanna-briggs-institute-jbi) and the cochrane library (https://www.cochranelibrary.com/). the jbi contributes significantly to srs by providing methodological support and constant training to clinical nurses, researchers, scholars, and students (10). recent sr approaches, such as the cochrane living systematic reviews—designed to insert an ongoing updating model in priority srs— and the systematic reviews of measurement instruments—designed to summarize health instruments' measurement properties—are underutilized resources in nursing. this article aims to overview the jbi systematic review approaches and provide critical information about the cochrane living systematic reviews and the systematic reviews of measurement instruments. materials and methods this article provides an overview of a specific topic from an expert point of view, supported by informational sources (11). official documents and websites of the jbi and the cochrane collaboration andrelevant articles published mainly in the last five years were used. the critical review was provided by a cochrane author (mft), a leading representative from jbi brazil (pva), and researchers with training in psychometrics (zls, dcr). the results were presented based on clarke and braun's (11) thematic analysis and the following phases: i) familiarization with the data, ii) coding, iii) thematic search, iv) thematic review, v) definition and designation of cat­egories, and vi) orderly and coherent writing of relevant findings. the results were grouped into three categories: i) overview of jbi reviews, ii) living systematic reviews, and iii) systematic reviews of measurement instruments. joanna briggs institute reviews overview the jbi is an international organization based at the university of adelaide (australia); it comprises a network of health scientists, professionals, researchers, and students committed to health practices based on reliable scientific evidence (12, 13). this organization aims to improve health outcomes through scientific production, training, and dissemination (14). the jbi developed the evidence-based medical care model to bring this approach closer to clinical practice, a proposal applicable to all health workers that considers evidence synthesis as an essential component for ebp (15, 16). the jbi network brings together about 80 centers of excellence and affiliated groups of more than 70 universities and hospitals worldwide, which continually develop methods and tools for rigorous srs (13, 14). the jbi srs are designed to answer questions that meet clinical needs and the requirements of healthcare service providers and health policy-makers (17). the jbi has made methodological recommendations to conduct eleven types of reviews: effectiveness, qualitative studies, economic/cost assessment, prevalence or incidence, diagnostic test accuracy, etiology and risk, textual synthesis, mixed methods, umbrella reviews, psychometric reviews, and scoping reviews (12). for all types of srs, there is an open access manual to guide them (14). regardless of their classification, these reviews are characterized by the systematization of the literature selection process according to the objectives, research question, and inclusion/exclusion criteria stipulated a priori in a protocol. these criteria determine the eligibility of studies and provide the guidelines for conducting an exhaustive search of the literature in different databases and informational sources. subsequently, a screening process is carried out to select the studies to be included, that is, those undergoing quality assessment and data analysis to create an objective synthesis of the results, evaluating the certainty of the evidence and the implications for practice through a transparent and detailed report on the methods used for the review (14). an sr requires a methodological and technical approach; therefore, the jbi has devised a comprehensive systematic review training program (csrtp) (18) to train researchers, health workers, scholars, and people interested in making srs using jbi methods. these methods include training in the systematic review software system for the unified management of the assessment and review of information (jbi-sumari) (10). the csrt program has a workload of 40 hours distributed in three modules: module 1: introduction to evidence-based healthcare and systematic review of the evidence; module 2: making srs of quantitative evidence; module 3: sr of evidence generated by qualitative, narrative, and textual research. course certification is awarded by the jbi (18). in latin america, the jbi brazilian center for evidence-based medical attention has continuously trained health professionals interested in using the csrt program since 2009. this center has trained and certified more than 500 health workers, primarily nurses, in the south american region. in addition, it has launched an evidence implementation training program (eitp) aimed at health personnel to transform health service providers' care practices (19). jbi initiatives have improved the training of researchers, systematic and scoping reviewers, consumers, and implementers to strengthen ebn. currently, the jbi focuses its efforts on creating new affiliated groups in latin america; the expansion of these groups will undoubtedly improve the results of health practices in this region (17). cochrane living systematic review cochrane living systematic reviews (lsrs) are a relatively new proposal, released in 2017 by the cochrane collaboration in a provisional guide for lsr pilots, which was subsequently validated and published in 2019 (20). lsrs constitute an approach specially designed to cater to the need for continuous sr updating and publication (21). this approach aims to answer a priority question when the level of evidence is uncertain due to scarce primary studies or a high probability that new evidence will modify current knowledge (21, 22). lsrs usually predominate in medicine (23), and their application in nursing represents a challenge because this type of approach involves a continuous update that, according to cochrane, must be monthly (20). keeping srs up-to-date bridges knowledge and time gaps in the dissemination of knowledge, especially when the level of certainty is low and the evidence is inaccurate (23). an lsr proposal can originate from a research question or a pre-existing systematic review. this review will identify the uncertainties of knowledge in priority areas for nursing. the cochrane collaboration has a guide that describes complementary processes to the cochrane manual (24) designed to make and publish an lsr (20). in general terms, the cochrane lsr guide describes each stage of the lsr process and recommends tools called 'enabling,' which offer resources to supporting the work team in searching and screening primary studies, summarizing, and writing until publication (25). these tools have been designed to offer potential gains in saving time and resources allocated to keep the sr permanently updated (26). researchers and health workers can find a list of cochrane enabling tools in the systematic review toolbox, available at http://systematicreviewtools.com/. for example, the task exchange (28) and cochrane crowd (37) tools are platforms that support the working group because they help organize and distribute tasks in large teams involving researchers and citizen science collaborators (27), which implies active participation of citizens (29). moreover, machine learning tools such as rct classifier help collaboratively assess and select the available evidence (30), while text mining tools classify information according to importance, considering the most recent updates in the scientific literature (31, 32). text mining automates information search and retrieval by identifying patterns or correlations between the terms used in databases (33) through tools such as mesh on demand (34), designed to generate automatic searches by identifying mesh (medical subject heading) descriptors in the bibliography published on pubmed. other similar tools such as polyglot search (35) and medline transpose (36) can be used for the same purpose. for the eligibility and screening stage, machine learning algorithm tools such as clasificador de ensayos clínicos aleatorizados (24) and cochrane crowd (37) help identify randomized clinical trials (20). additionally, full-text report retrieval can be automated and accelerated using tools such as crossref (38) and sra-helper (39). another helpful tool for lses is rayyan qcri (40), designed to speed up the initial selection of abstracts and titles through a semi-automation process, reducing the time used to filter and preselect search results by 40 % (40). for data extraction, tools such as robotreviewer (41), the content-mine (42), and machine-learning (20) allow extracting structured data according to the components of a pico (population, intervention, comparison, outcome) question and integrating the risk of bias (20). the facilitating tools for evidence synthesis and automatic text generation include revman replicant (43) and revman hal (44), designed to automatically generate a text for the meta-analysis results section (20). finally, to publish an lsr, the reviewers and the editorial team carry out an exhaustive review of the full text when it is the first version. reviewers check modified sections for subsequent update versions to identify changes and optimize time (20, 45). in this case, three possible situations may occur: i) no new studies are found to include in the review and, in this case, the lsrs will not require a new peer review and may only be submitted for editorial review; ii) there is new evidence, but it is not possible to incorporate it into the review for reasons described in the protocol, or the new evidence will probably not change the results and conclusions of the previous version of the lsr, in which case the update will go through editorial review, while peer review will be optional; iii) new evidence was incorporated, and the update will require a peer review and a new editorial review (46). systematic reviews of measurement instruments self-reports are instruments to assess behaviors, attitudes, and values in individuals (47). health sciences tend to use them more frequently for patient assessment; however, these instruments must be valid and reliable to measure a subjective construct. an sr of measurement instruments aims to evaluate the psychometric properties and validity evidence of instrument validation studies. these reviews facilitate selecting the most appropriate instruments to be employed in academic, clinical, and research contexts based on a given instrument's validity, reliability, and sensitivity evidence. having validated and reliable measurement instruments allows progress in disciplinary knowledge and its appropriate application to nursing practice. between 2015 and 2021, more than 2,900 nursing articles related to the validation of instruments derived from con­struction, translation, and cross-cultural adaptation have been published,  showing a constant increase in this type of publication and highlighting the need for methods that systematize and optimize the obtaining of results of an sr of measurement instruments. an sr in psychometrics seeks to characterize the articles published on a phenomenon of interest and identify the results on the different measurement instruments used to compare their reliability, validity, and other relevant statistics. a tool can be used in this type of sr to evaluate article quality: the cosmin (consensus-based standards for the selection of health status measurement instruments) checklist assesses the methodological quality of studies on psychometric properties and measurement instruments (48). this tool includes the assessment of three domains: validity, reliability, and sensitivity. validity considers three measurement properties: content, construct (internal structure), and sensitivity. in turn, reliability includes three other measurement properties: internal consistency, reliability (based on interand intra-observer test-retests), and measurement error. finally, sensitivity considers the ability of an instrument to correctly classify a sick individual based on a positive result (48). specificity is the probability of classifying an individual as healthy through a negative result. this checklist has been used to critically evaluate measurement instruments, strengthen ebp, and encourage the use of measurement instruments, with the consequent standardization of patient assessment for the health and nursing professionals in multiple contexts. nonetheless, the critical evaluation of an instrument entails techniques and procedures that ensure their accuracy according to international recommendations. for this, analyzing the validity of the content, internal structure, response processes, measure testing, relationship with other variables, reliability, and invariance has been suggested (49). for content validity, study reports should incorporate standards for cross-cultural adaptation. in health, a quasi-experimental study proposed five stages for the cultural adaptation of instruments (50); besides, an integrative review showed that 49 °% of the studies had used these five stages for the cultural adaptation of instruments in nursing (51). content validity should include the initial translation, the synthesis of translations, a back translation, the committee of specialists' assessment, and the pretest (51). content assessment can be qualitative (52) or quantitative (53), and authors should use it to adjust the content of the original instrument to the adapted version. authors must analyze items' semantic, idiomatic, experiential/cultural, and conceptual equivalences in the qualitative assessment, as it shows the significance of dimensions, the relevance of items, and the meaning equivalence of those items. the quantitative assessments advise implementing a content analysis through the content validity ratio (cvr) because it is one of the most rigorous indexes for content evaluation (53). concerning the construct validity analysis, currently called 'internal structure' validity, authors should report data inspection techniques, analysis method, structure, extraction, factor retention, and factor loading cut-off points (54, 55). for data inspection, the application of two techniques is suggested, kaiser-meyer-olkin (kmo) and the sphericity test, since both tools determine the adequacy of data for factor analysis (56). for selecting a factor analysis method, authors should have conducted an exploratory factor analysis (efa) to determine the dimensionality of the instrument. furthermore, authors should report necessary analysis parameters such as factor loadings of all items, total variance explained, and communalities (49). it is also advisable that the study reports present the confirmatory factor analysis (cfa) since it is a valuable method to confirm the theoretical model that underlies a measurement instrument. the factorial model should be evaluated using at least three adjustment coefficients (57). another relevant aspect is the report of the factorial extraction method, and for this, the optimal implementation of parallel analysis (pa) is recommended, as it is the most accurate method of factor retention (58). one study suggested resorting to more than one factor retention method since oblique rotation has been applied to psychosocial variables (59). the report of factor loading cut-off points is relevant since it allows evaluating the factor loadings and total variance explained of a theoretical model using factor loadings > 0.40, with a total variance explained > 60 °% and communalities > 0.40 (49). study reports must describe the coefficient used to estimate reliability. although cronbach's alpha (α) (60) is frequently adopted, several studies have shown limitations and assumptions of uncorrelated errors, tau equivalence (λ), and normality (61). other recommended analyses to measure reliability are test-retest, equivalent forms, split halves, inter-rater, and kr-20 (kuder-richardson 20, for instruments with dichotomous variables); similarly, other authors have suggested other techniques such as greatest lower bound (glb) or mcdonald's omega (ω) (62). when the total scores of the tests are normally distributed, the coefficient w should be the first option since it prevents the overestimation problems of glb (62). however, when there is a low or moderate test skew, glb should be used (63). the evaluation of invariance is becoming increasingly relevant. therefore, studies should report its use through δcfi, δrmsea, or other valuable indices to determine the difference between tested models so that authors can guarantee the invariance of the instrument for a given culture (64). final comments srs are essential for health and nursing professionals because they allow the implementation of evidence-based nursing practices through rigorous knowledge synthesis methods. acknowledgments: we thank the jbi for collaborating in the preparation of this manuscript. conflicts of interest: following the journal's editorial policy, all authors completed a conflict-of-interest statement. the authors stated that they are associated with the jbi or are cochrane authors. despite this, the authors affirm that they have no relationships or activities that could influence this publication. ethical considerations: as it was a discussion study, approval by the scientific ethics committee (cec) was unnecessary. references 1. bastian h, glasziou p, chalmers i. seventy-five trials and eleven systematic reviews a day: how will we ever keep up? plos med. 2010;7(9):e1000326. doi: https://doi.org/10.1371/journal.pmed.1000326 2. munn z, stern c, aromataris e, lockwood c, jordan z. what kind of systematic review should i conduct? a proposed typology and guidance for systematic reviewers in the medical and health sciences. bmc med res methodol. 2018;18(1):1-9. doi: https://doi.org/10.1186/s12874-017-0468-4 3. aromataris e, pearson a. the systematic review: an overview. am j nurs. 2014;114(3):53-58. doi: https://doi.org/10.1097/01.naj.0000444496.24228.2c 4. farrah k, young k, tunis mc, zhao l. risk of bias tools in systematic reviews of health interventions: an analysis of prospero-registered protocols. bmc syst rev. 2019;8(1):e280(1-9). doi: https://doi.org/10.1186/s13643-019-1172-8 5. organización mundial de la salud [oms]. manual para la elaboración de directrices, 2 a.ed. ginebra: oms; 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19(2): e1925. doi: 10.5294/aqui.2019.19.2.5 abstract objective: this work sought to describe the meanings constructed by patients with coronary disease (pcd) the communication process used by nurses during the transition from the hospital (coronary care unit) to the home for therapeutic adherence. method: the article corresponds to a qualitative study, which used an approach through grounded theory. the participants were 12 informants from the city of medellin, colombia. data reliability was guaranteed. results: construction of a theoretical postulate: “reconstructing the significance of treatment: from the indifference to reviving with a dialogic bond that relieves”. the process faced by pcd, derived from the communication process, goes from “living in ignorance”, “experiencing rupture with the treatment” to “reconstructing: finding sense” and, finally, “finding a state of harmony: new learnings”. this last achievement is obtained when creating awareness in the “dialogic bond that relieves”. conclusions: the meaning granted by pcd to the communication process for therapeutic adherence is established when reaching transformation and expanding the conscience (creating awareness) in a “dialogic bond that relieves”; likewise, when this process is full of apathy and indifference, the sense of the treatment is lost. keywords (source: decs) communication; bonding; adhesion; treatment adherence and compliance; nursing; coronary disease. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1925 theme: chronic care. contribution to the discipline: the dialogic bond is a contribution, from the theoretical, to the communicative interaction of nurse-patient care in the transition from hospital to the home and to the multidimensional phenomenon of therapeutic adherence. it reflects the aesthetic pattern of care and demonstrates how care during the transition of patients with coronary disease goes beyond nurse-patient communication. it permits contributing elements to the aesthetic pattern of care that lead to explaining how a patient manages to conduct mental processing that allow transforming the negative and transcend to a state of equilibrium. http://orcid.org/0000-0001-9015-430x http://orcid.org/0000-0002-8641-1833 http://dx.doi.org/10.5294/aqui.2019.19.2.5 http://orcid.org/0000-0001-9015-430x http://orcid.org/0000-0002-8641-1833 http://dx.doi.org/10.5294/aqui.2019.19.2.5 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1925 el vínculo dialógico que alivia: encuentro para transcender la adherencia terapéutica* resumen objetivo: describir los significados que construye el paciente con enfermedad coronaria del proceso comunicativo utilizado por la enfermera en la transición del hospital (unidad de cuidados coronarios) al hogar, para la adherencia terapéutica. método: el artículo corresponde a un estudio cualitativo, en el que se usó un abordaje a través de la teoría fundamentada. los participantes fueron doce informantes de la ciudad de medellín, colombia. se garantizó la confiabilidad de los datos. resultados: la construcción de un postulado teórico: “reconstruyendo el significado del tratamiento: de la indiferencia a renacer con un vínculo dialógico que alivia”. el proceso que enfrentan los pacientes con enfermedad coronaria, derivado del proceso comunicativo, va desde “viviendo en el desconocimiento”, “experimentando ruptura con el tratamiento” hasta “reconstruyendo: encontrando sentido” y, finalmente, “encontrando un estado de armonía: nuevos aprendizajes”. este último logro lo obtienen al crear conciencia en el “vínculo dialógico que alivia”. conclusiones: el significado que le otorgan los pacientes con enfermedad coronaria al proceso comunicativo para la adherencia terapéutica se establece al alcanzar transformación y expandir la conciencia (crear conciencia) en un “vínculo dialógico que alivia”; asimismo, cuando este proceso se encuentra colmado de apatía e indiferencia, se pierde el sentido del tratamiento. palabras clave (fuente: decs) comunicación; vínculo; adherencia; cumplimiento y adherencia al tratamiento; enfermería; enfermedad coronaria. * artículo derivado de la investigación: significados del proceso comunicativo enfermera-paciente con enfermedad coronaria para la adherencia terapéutica. 3 the dialogic bond that relieves: encounter to transcend therapeutic adherence l maría cristina arango restrepo y otros o vínculo dialógico que alivia: encontro para transcender a adesão terapêutica* resumo objetivo: descrever os significados que o paciente com doença coronária constrói do processo comunicativo utilizado pela enfermeira na transição do hospital (unidade de cuidados coronários) ao lar para a adesão terapêutica. método: este artigo corresponde a um estudo qualitativo, no qual foi utilizada uma abordagem por meio da teoria fundamentada. participaram 12 informantes da cidade de medellín, colômbia. garantiu-se a confiabilidade dos dados. resultados: a construção de uma premissa teórica “reconstruindo o significado do tratamento: da indiferença a renascer com um vínculo dialógico que alivia”. o processo que os pacientes com doença coronária enfrentam, derivado do processo comunicativo, vai desde “vivendo no desconhecimento”, “experimentando ruptura com o tratamento”, até “reconstruindo: encontrando sentido” e, finalmente, “encontrando um estado de harmonia: novas aprendizagens”. este último é atingido ao criar consciência sobre o “vínculo dialógico que alivia”. conclusões: o significado que os pacientes com doença coronária outorgam ao processo comunicativo para a adesão terapêutica é estabelecido ao alcançar transformação da consciência e sua expansão (conscientizar) em um “vínculo dialógico que alivia”; além disso, quando esse processo se encontra permeado de apatia e indiferença, perde-se o sentido do tratamento. palavras-chave (fonte: decs) comunicaçao; vínculo; aderência; cooperação e adesão ao tratemento; enfermagem; doença das coronárias. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1925 * artigo derivado da pesquisa: significados do processo comunicativo enfermeira-paciente com doença coronária para a adesão terapêutica. 4 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1925 aquichan issn 1657-5997 eissn 2027-5374 introduction currently, cardiovascular disease represents one of the principal causes of morbidity and mortality in colombia. the 2014 report by the world health organization (who) determined how this disease produces the highest number of deaths globally (1). it has been determined that non-adherence to pharmacological or non-pharmacological treatment is associated to non-control of the disease, which implies increased complications and, likewise, according to iuga and mcguire (2), costs of hospital care. conthe et al., (3) determined that 50 % of patients with chronic diseases present lack of therapeutic adherence. additionally, literature has reported that variables, like quality in communication, trust, and empathy with the patient are factors that permit improving adherence and are highly correlated with therapeutic adhesion (4, 5); communication is one of the fundamental pillars to achieve this, given that authors, like linn et al., (6) and zullig et al., (7) have determined that communication is an important resource to support adherence to medications in patients with cardiovascular disease. likewise, the meta-analysis by zolnierek and dimatteo (8) with 127 studies revealed the existence of a relationship between the way of communicating with patients and adherence, and indicated that the probabilities of adhesion by patients are 2.16 times higher if effective communication exists. the studies cited refer to the relationship between the manner of communicating with the patient and therapeutic adherence, but it is necessary to explore the meanings the patient grants to the communication process as fundamental factor in nursing care. according to shannon and weaver (9), all communication produces behaviors, besides producing meanings. for this reason, the present research sought to describe the meaning granted by patients with coronary disease (pcd) to the communication process used by nurses during the transition from the hospital to the home for therapeutic adherence. methodology this study had a qualitative approach and used as method the grounded theory (gt), guided through the corbin and strauss guidelines (10), which permits explaining social processes and meanings from the point of view of those constructing them. it uses a systematic and dynamic non-sequential design to generate categories, which permits data to come and go, to prove that the interpretation made is congruent with the expressions of the participants, through constant comparison (11). development of this methodology focuses on symbolic interactionism, about which blumer proposes how patients act from the meanings things have for them (communication), and do not merely respond to stimuli (12). to gather the information, a founding aspect of gt was considered: the quality and depth of the data collected (11). upon this, the study opted for the in-depth interview, a method that permits obtaining a wealth of information, of holistic nature and contextualized, through the words of the interviewee (the pcds). that method favored the transmission of non-superficial information and permitted analyzing the meanings (13). it is worth nothing that each interview was transcribed and coded before continuing with the second interview to comply with the criteria established by the gt: data collection must be followed immediately by the analysis so that it becomes a guide for the next data collection (11). the study had 12 participants considered pcd, who were in the transition process (discharge) from the coronary care unit (ccu) to the home, in an institution of medellin, and the number of participants was determined by the theoretical sampling, a point where properties, dimensions, or new relationships no longer emerge during the analysis process (11). of these, five were women and seven were men, ranging in age between 58 and 78 years; time of the disease ranges between five months and 12 years, which is equivalent to the same time required of treatment of chronic use, both pharmacological and non-pharmacological. to maintain method rigor, the study kept in mind the criteria by chiovitti and piran (14) for qualitative research, with the gt approach: credibility (the participants’ own language was used in all coding levels and the data were validated with the participants), auditability (data were examined among different levels of codes existing in the literature to, from them, consolidate conclusions equal or similar to those of the original researcher), and transferability (the work described the relationship of the categories emerging with respect to the literature). each criterion was key to maintain the work’s internal coherence. it is emphasized that to conduct the research, it was endorsed by the ethics committee at universidad nacional de colombia 5 the dialogic bond that relieves: encounter to transcend therapeutic adherence l maría cristina arango restrepo y otros and approved by the health institution where the interviews took place. the ethical principles of beneficence and non-maleficence, truthfulness and fidelity were considered, as well as the right to confidentiality and privacy, the right to self-determination and to being informed about the nature of the research, the potential benefits, and inconveniences the study can have to the participants. to comply with the aforementioned, an informed consent was elaborated, detailing the fundamental aspects, like potential benefits, the right to resign, management of data, and the promise of reliability and relevance of the study in nursing care. this permitted participants to freely decide whether to participate in the study, as well as to resign at any moment, if they so desired. the data analysis used open coding (to analyze line by line), axial coding (to relate codes), and selective coding (to integrate concepts around the central category), bearing in mind – as base – two fundamental elements: the constant comparison and the “theoretical sensitivity” (15); this process permitted describing in detail three constructs: one related with the difficulties experienced with communication on discharge (passage from the ccu to the home) “perceiving difficulties in the trajectory of the treatment from communication for care”, and two related with satisfactory communication: “establishing dialogic bonds that heal” and “originating resonant: transform communication”. finally, from a higher level of abstraction, an analytic integration was performed through diagrams and an abstract representation of the data was obtained (10), which permitted proposing and describing the medullar category denominated “reconstructing the meaning of treatment: from the indifference to reviving with a dialogic bond that relieves”. from this postulate, “the dialogic bond that relieves” is highlighted, a medullar structure upon which the whole process revolves to transcend to the construction of creating awareness regarding the therapeutic adherence, and as a way of finding a state of wellbeing. thus, the categories described ahead are constructed from their properties and dimensions. difficulties of the treatment from communication for care during the transition process (discharge), patients can experience communicative encounters with the nurse, considered asynchronous: they feel indifferent, ignored and with lack of information for self-care, which produces an alteration in the process of therapeutic adherence that leads them to lose sense of the treatment. …during discharge, they treat you coldly, indolently, what we came to do … and i believe that sometimes not even like that, they don’t even look at you [pcd: 12.12.19]. …they give you papers for you to claim, and nobody explains anything [pcd: 01.01.31]. given the importance of the communication process during the transition from the hospital to the home, a moment when information is transmitted and the patient is educated for self-care and management of the treatment of chronic use, when this process becomes negative for the patient, it generates a “dealing with communication barriers for care”, and patients report feeling “indifferent to the other” (nurse) or “immersed in ignorance and losing credibility in the treatment”. …you are there waiting, you are not explained anything, but no, they (nurses) don’t even look at you… that feels bad because you go home the same way as you arrived [pcd: 07.07.17]. the use of technical language associated to apathy is another limitation in a communication process that affects learning for self-care, given that it generates feelings of anger and lack of motivation. …you are hard pressed to understand what they tell you […] you see they talk that way so that you cannot understand them, i didn’t ask them anymore, and sure, what are you going to ask them if they are so grim as they are rude, that gives you so many things, like anger, and it discourages [pcd: 12.12.38]. messages transmitted in confusing or incomprehensible manner are omitted and forgotten, and do not generate any importance; due to this, patients also resort to other learning strategies that do not cover their needs and can lead them to making mistakes. with all these experiences, fear is consolidated and this emotion becomes an impediment to establishing and mobilizing strategies of self-care. in those encounters, the word no tends to be reactive and taxing, and generates conflicts in the communicative interaction of care. this word impedes entering into harmony with the other 6 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1925 aquichan issn 1657-5997 eissn 2027-5374 (patient), which is why patients report having had feelings of frustration and lack of support: … the answers one receives is everything “no”…, for everything, you ask them and them … and that also fill you up with anger, and you start to fight with them (nurses) and you don’t reach any understanding or find support, and learn something, much less [pcd: 02.02.28]. lacking information to give continuity to the treatment of chronic use at home makes patients more vulnerable and does not let them take on positive actions; on the contrary, patients experience a variety of critical conditions and adverse feelings, like uncertainty, suffering, and frustration with the treatment. …imagine that my husband died because, of all the hospitals where we went, nobody explained to us how we had to take care of him, what medications to give him [pcd: 01.01.45]. losing the sense of the treatment is founded in that, at cognitive and psycho-emotional levels, they experience fear and disbelief, consequential of the absence of fruitful communicative encounters, where mutual understanding can take place and they can live shared experiences that generate awareness. …for several reasons, i did not go back to the controls, i never took anything again; one of them, and of which i just realize, is that none of the people who treated me, not the physician or the nurse, created in me the conscience to take the medications [pcd: 04.04.22]. lack of self-care and adherence are associated with the questions that arise during the very self-care, which are not solved, given that patients have not been accompanied. in the search for alternatives due to the limitations they experience, patients and their relatives are subjected to obtaining information that, quite often, influences or leads them to remain in a state of confusion, which impacts upon the patient’s emotional and physical dimensions. ...i get very concerned about my mom [daughter of the pcd], i want to know it all, and more so when they don’t tell her so many things that are important to take care of her and for them [pcd] to heed. so, since you have information more easily at hand because in the computer you find everything, but since you don’t understand, you start to read and get all influenced [pcd: 01.01.18]. establishing dialogic bonds that relieve communicative encounters mediated by healing words and cozy contexts permit the formation of affective bonds represented in rapport and communicative harmony between the patient and nurse. the dimensions that characterize the dialogic bond depend on: 1) the coupling or the way to synchronize the communication process for it to respond to the needs; 2) the quality of the messages or the clarity in the language used to transmit messages that meet the expectations of each patient; 3) the duration versus the quality of the encounter, given that patients do not demand prolonged times in the discharge and, on the contrary, seek spaces and settings to establish a communication process ladened with human quality and learnings; and 4) the human quality, represented in the words issued, in the non-verbal communication (treatment and tone of voice), and in the messages that transmit peacefulness to the patients and make communicative encounters soothing. in a friendly communication process, empathy emerges as an integrating mechanism for the maintenance of the whole process; it is constructed as of the warmth with which the encounter begins and is nourished in how messages are transmitted: clarity, fondness and humanity. it is a crucial factor to have encounters that permit overcoming those negative feelings and difficulties derived from lack of knowledge. …if empathy exists along with that humanity and warmth to teach you how to handle yourself, how to go out and how to care for yourself; that make you fond of the treatment, […] i learned to endure it, i calmed so many fears, it is that she [the nurse] like that with me, we understood each other well, and i achieved many things for my care, both with my treatment as with everything [pcd: 04.04.14]. in these settings, they discover each other again and new meanings of the treatment are found, like: …an inseparable life companion [pcd: 06.06.07], a way of finding quality of life. […] [pcd: 03.03.18] and understanding how … the information was necessary for me to now be well and not quit the treatment [pcd: 04.04.25]. patients argue that communication is supported on reciprocity and on the transmission of comprehensible messages; they 7 the dialogic bond that relieves: encounter to transcend therapeutic adherence l maría cristina arango restrepo y otros find in it a sense for life during the trajectory of the treatment; it also becomes a therapy to achieve relief, tranquility, and credibility, given the power and force these messages have. …communication kind of reaches this sick heart and heals you; it is funny, but that’s the way it is [pcd: 06.06.11]. with communication that relieves, one learns to endure the treatment through awareness, which permits maintaining a balance in the health status. originating resonant communication: transforms resonant communication is described as a therapeutic element that permits “transforming and creating awareness (transcending)”; it emerges due to interconnections, like the “dialogic bond that relieves”, when patients maintain active a reflexive function as reasoning strategy and retrospective and prospective comparison of the past, present and future regarding the treatment, throughout their lives. for some of the participants, the information transmitted “stays working in your head and creates awareness of doing everything better to find wellbeing” [pcd: 08.08.18]. these reasoning permits them to scale in the process until finding a satisfactory trajectory of the treatment. for pcd, words of resonant communication cause in them an experience of “feeling cared”, given the affective component immerse in them. this way, they form positive bonds with the treatment and manage to see it “with love or… as a small magnet that cannot be detached” [pcd: 09.09.24]. resonant communication has a regulating component that permits awakening positive feelings to construct motivations that stimulates in them the desire to struggle and find states of wellbeing. figure 1 illustrates the process of resonant communication. figure 1. resonant communication source: recovered from arango mc (16), 122. 8 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1925 aquichan issn 1657-5997 eissn 2027-5374 in this process, when the relationship is human and affective, alliances are created of mutual learnings: …the way they reach out to you, how they explain it, it is for you to find a true meaning to take so much drugs to heal and not quit, how can one find sense in something that one does not know, does not understand, well i don’t know [pcd: 03.03.20]. in this new communication process, patients recognize the importance of learning to carry out the treatment to avoid relapse, not as an imposition established by another, but to reach stability, give that “one [a pcd] becomes aware of doing everything better for one’s wellbeing, not because of scolding or fear, but to be well” [pcd: 08.08.18]. theoretical approach reconstructing the meaning of the treatment: from the indifference to reviving with a dialogic bond that relieves an extensive analysis of the data permitted understanding how the therapeutic adherence acquires meaning within the context of the communicative encounter; the central category is the result of the reduction of the information collected during the interviews, through an inductive process and of constant comparison of the data (11). it describes how the process starts when pcd confront a disorder, a product of communication barriers for care during the transition (discharge), upon perceiving indifference. said indifference immerses them into a state of lack of knowledge, which makes them lose sense of the treatment and get sick again. patients in condition of continuous vulnerability, impotence, and confusion must assume a therapeutic process that requires clear and motivating education. if the communication process is characterized by empathy, mutual growth, harmony (understanding) and words that care, the denominated “dialogic bond that relieves” is formed, which emerges from the need to acquire significant learning for one’s own care. these words permit enhancing the care interaction, as well as sharing ideas and experiences in a mutual process. this form of communication for care is resonant in the patient, that is, it transforms meanings and negative emotions and modifies the course of the treatment, given it overcomes the need for information and the uncertainty, product of the lack of knowledge. in the “dialogic bond that relieves”, ties and creative and empathic interconnections of care are formed that offer satisfaction and permit the rebirth and the emotional regulation that provide security to the patient to continue. in this encounter, patients are perceived as active agents of their care, which is why their vision of the treatment changes and are transformed into protectors to maintain an equilibrium with the disease. discussion this study arrives at the concept of the “dialogic bond that relieves”, which permits representing and nourishing the aesthetic pattern of care, besides feeding back the elements of care within the context of the transition and the therapeutic adherence, recognizing that it is about a multidimensional phenomenon and with high influence as of the communication process. from the etymological roots of latin, the word communication comes from comunicare, which means ‘to share something, put in common’, or the means that permits a union and bond, and from vinculum, which means ‘union or tie of one person or thing with another’ (17). thus, when joining both concepts, it can be appreciated how communication (verbal and non-verbal) is a key process through which two people are linked to put in common thoughts, needs, knowledge, and to establish a relationship of nurse-patient help. upon analyzing the theories of bonds, it was found that these have been studied from different areas of knowledge, and that it is a process that is part of the evolution (survival), development (finding care, learning, and emotional health), and relationship of the human being (finding meaning to experiences). from the theory of attachment, bowlby (18) has determined how the bond maintains its conservation from the proximity with another individual trained to help face the world; it is through the bond that human beings find relief, consolation, and care. this concept is related with that described in the “dialogic bond that relieves”, by being associated with the rapport and communicative harmony that characterize it, to help relieve the anguish product of not knowing, and to experiencing a climate of affection and trust, to transcend to creating awareness regarding the treatment. the classic concept of bond by pichon-rivière gets closer to the phenomenon of the “dialogic bond that relieves”, a complex 9 the dialogic bond that relieves: encounter to transcend therapeutic adherence l maría cristina arango restrepo y otros spiral structure involving the transmitter, receptor, coding and decoding; in each turn there is interaction to gain feedback and solve contradictions between the parts (19). likewise, the “dialogic bond that relieves” is a dyadic process, readjusted and coupled to the needs of patients, where knowledge is mutually fed-back through words that relieve and care, and a communicative synchrony is created that permits constructing motivations that vanish the anguish and reach a rebirth connected to the treatment. communicative synchrony (patient-nurse) is an evident element in the bond, which permits patients and nurses to develop a relationship of “sensing tacit subjective meanings” from experiences and situations that expand conscience and to construct meanings (20). one way to validate the expansion of conscience (creating awareness) in the dialogic bond against the condition of coronary disease is through the health theory as expansion of conscience (21), which affirms how the expansion of conscience is an innate trend of human beings. although some experiences and processes precipitate it, in this case, the “dialogic bond that relieves” leads to faster transformations, and the mutual nurse-patient association permits reflecting on the evolutionary pattern (therapeutic adherence). each knowledge they acquire in the process leads to awakening and to transforming the conscience at a higher level. each process lived in the “dialogic bond that relieves” is a representation of the dialogue experienced, which is why it became the medullar unit, the fundamental pillar of care, being the search form for common understanding. it is the environment that permits knowing each other reciprocally and offer unique care; in it, one speaks to and listens to the other to understand the fear and uncertainty they face due to lack of knowledge (22). acosta and garcés (23) have defined how the knowledge dialogue permits creating encounters to weave bonds, as well as to recognize the other (patient). resonance was another component within the communication that relieves. it showed the new mental processing patients manage to carry out when understanding exists in the interaction of care. according to meleis (20), resonance describes the direction of change from the lowest wave patterns to the highest. in the dialogic bond that relieves, it was possible to scale from an indifference (lowest level) to a revival accompanied by the treatment (highest level). ramírez et al., (24) state that the bond is a phenomenon that facilitates improving the attitude regarding the treatment and achieving its loyal adherence, given that participative processes are established that permit patients to carry out a positive co-construction of the meaning of the treatment. for this reason, the pcd, when constructing a “dialogic bond that relieves” with the nurse, manages to feel projected and finds a meaning to the experience. furthermore, the study by flórez and hernández (25) reported that for 32.6 % of patients, treatment was complex to understand, due to confusing explanations, while 36.8 % ignored how to treat the disease. the result is congruent with that reported in the study in which patients manifest confusing explanations, or the lack of these, and ignore how to continue the trajectory of the treatment, which leads them to feeling indifferent for the other (nurse) and to giving up the treatment. according to the systemic cognitive theory of communication (26), the way information enters the system (brain) is fundamenta. given that, according to this, it is conserved (memory), recovered and used (knowledge) to produce new changes (creating awareness); thus, human beings take only the information that is susceptible to being grouped in the conscience, to generate a mental representation. this agrees with the results and explains why when for patients the messages were confusing and incomprehensible, these were forgotten and had no important meaning for self-care, while when they found sense, their conscience expanded, and that generated in them a sense of wellbeing, which permits achieving therapeutic adherence. from the perspective of interpersonal relationships in nursing, peplau (27) states that clarity in messages ensures a useful communication process, an evident element in the “dialogic bond that relieves”, for patients to reach significant learning. the concept of transactions described by king (28) was also related with the “dialogic bond that relieves”, given that two individuals identify with each other significantly and mutually (nursepatient), and interact to reach agreements and establish shared therapeutic goals (mutual objectives), understood, applied, and adapted to daily life. multiple studies, like those by deley et al., (29), arnow and steidtmann (30), vélez (31), durig, rous and rousset (32), have 10 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1925 aquichan issn 1657-5997 eissn 2027-5374 demonstrated how making shared decisions, the bonds, association models during care, and the positive therapeutic alliances permit forming contexts where patients manage to feel secure to achieve therapeutic success and shape their disease through the medication. this statement explains why when patients find a dialogic bond that relieves, they construct a mutual association that lets them learn to endure the disease, because they perceive treatment with love and as a way of maintaining the quality of life. according to the systematic review by cófreces et al., (33), high levels of adherence are associated with communication models where negotiation processes, agreements, and comprehension are constructed. these elements, implicit in the dialogic bond that relieves, led to scaling higher stages, like the therapeutic adherence. the growth reached in the “dialogic bond that relieves” is also fruit of the feedback, a process that makes the other a participant (patient) of the communicative interaction and guarantees comprehension of the messages. for weinstein (34), feedback is a way of giving structure to a relationship and of finding support; this element permits pcd to give sense and meaning to the treatment. to end, the systematic review by zill et al., (35) shows the existence of multiple psychometric instruments that measure communication during health care, but not with respect to the communication for nurse-patient care during the transition from the hospital to the home for therapeutic adherence. this study is the description of a theoretical first level of the phenomenon, which generates some elements that can be retaken during its construction. upon studying the bonds described in other areas of knowledge, it may be stated that the bond defined in this study results authentic or genuine because its construction occurs through words and dialogues that inspire and transfer care, and inspire the search for a meaning of the treatment of chronic use to adapt it and maintain it in daily life. conclusions the detailed analysis and the interrelation between each of the categories permitted to conclude that, according to the communicative experience faced by patients during the transition from the hospital to the home for therapeutic adherence, is defined a path loaded with failure or success with the treatment. thus, communication barriers in care lead to losing sense of the treatment and make patients invisible during the transition. experiencing a satisfactory communicative interaction modifies the patients’ vision with respect to their treatment, it permits their regulating their negative emotions, as well as finding a reason to continue and reassign new meanings to the treatment. due to this, it acquires the meaning of “reviving with a dialogic bond that relieves”. the process that describes the actions/interactions of “reviving with a dialogic bond that relieves” is discovering that “words care (transform)”. it is characterized by being individual and dynamic, and it permits scaling until finding a new sense to the treatment. however, not all patients manage to reach the ideal, some remain “trapped” in the webs of communication barriers, which keeps them from granting sense to the treatment and projecting it as a life companion. the meaning constructed by pcd from the qualitative permits understanding that the communicative processes they experience are determinant and constitute the central axis to construct motivational schemes and give a positive meaning to the treatment. conflict of interest: none declared. 11 the dialogic bond that relieves: encounter to transcend therapeutic adherence l maría cristina arango restrepo y otros references 1. organización mundial de la salud. informe sobre la situación mundial de las enfermedades no transmisibles [internet]. 2014. available in: https://apps.who.int/iris/bitstream/handle/10665/149296/who_nmh_nvi_15.1_spa.pdf;jsessioni d=d9f6d2e5b400bc65290adcbb955d2be3?sequence=1 2. iuga ao, mcguire mj. adherence and health care costs. risk manag health policy. 2014 feb. 20; 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http://www.revistagpu.cl/gpu-dic-2018.pdf#page=101 https://encolombia.com/medicina/revistas-medicas/enfermeria/ve173/valoracion-cardiopatia-isquemica/ https://encolombia.com/medicina/revistas-medicas/enfermeria/ve173/valoracion-cardiopatia-isquemica/ http://dx.doi.org/10.2147/ppa.s80158 https://doi.org/10.1002/wps.20147 http://dx.doi.org/10.1111/hex.12230 http://doi.org/10.1371/journal.pone.0112637 the impact of covid-19 on the physical well-being of nursing and medical personnel: an integrative review article the impact of covid-19 on the physical well-being of nursing and medical personnel: an integrative review impacto de la covid-19 en el bienestar físico de profesionales de enfermería y médicos: revisión integradora impacto da covid-19 no bem-estar físico de profissionais de enfermagem e médicos: revisão integrativa 10.5294/aqui.2022.22.2.5 carolina renz pretto 1 karen cristiane pereira de morais 2 valentine cogo mendes 3 adilaeti lopes paiva 4 rosângela marion da silva 5 carmem lúcia colomé beck 6 1 0000-0002-6925-7969 universidade federal de santa maria, brazil carol.renzpretto@gmail.com 2 0000-0003-4538-715x universidade federal de santa maria, brazil k.cristy.p@hotmail.com 3 0000-0001-9679-958x universidade federal de santa maria, brazil valentinemendes@hotmail.com 4 0000-0002-6019-6290 universidade federal de santa maria, brazil adilaetilopes@gmail.com 5 0000-0003-3978-9654 universidade federal de santa maria, brazil cucasma@terra.com 6 0000-0001-9060-1923 universidade federal de santa maria, brazil carmembeck@gmail.com received: 14/05/2021 sent to peers: 18/01/2022 approved by peers: 25/03/2022 accepted: 28/03/2022 subject: evidence-based practice. contributions to the subject: the present manuscript contributes to the nursing field and other healthcare-related subjects as it highlights the damage to physical well-being, health, productivity, and care quality caused to nursing and medical personnel by responding to covid-19. furthermore, it indicates and stimulates actions to improve the work environment, the management of healthcare services, self-care, and thus the health and well-being of all personnel facing the current pandemic, particularly regarding the risk of coronavirus infections, sleep quality, and the damage caused by protective measures. the results also favor the development of knowledge on the subject by reducing the existing gap and strengthening the need to conduct studies with different methodological approaches to increase available evidence. para citar este artículo / to reference this article / para citar este artigo: pretto cr, morais kcp, mendes vc, paiva al, silva rm, beck clc. the impact of covid-19 on the physical well-being of nursing and medical personnel: an integrative review. aquichan. 2022;22(2):e2225. doi: https://doi.org/10.5294/aqui.2022.22.2.5 abstract objective: to highlight the impact of responding to covid-19 on the physical well-being of nursing and medical personnel. method: this integrative literature review includes spanish, english, and portuguese articles. from july 10 to 16, 2020, the search was carried out in the cumulative index to nursing and allied health literature, latin american and caribbean health sciences literature, web of science, sciverse scopus, and national library of medicine databases. twenty-five studies were analyzed, and the results are presented descriptively and in tables. results: of the total number of articles, 52 % addressed coronavirus infection and related factors as an impact on nursing and medical personnel's physical well-being resulting from responding to covid-19, 28 % addressed sleep quality and predictors, and 20 % addressed damage stemming from the use of personal protective equipment or other preventive measures. conclusions: responding to covid-19 has been conducive to coronavirus infection among personnel due to the work process and prevention measures, poor sleep quality due to mental disorders and lack of social support, and physical harm, such as headaches and skin injuries, due to the use of protective equipment and hand disinfection. keywords (source decs): coronavirus infections; occupational health; health personnel; occupational risks; disease prevention. resumen objetivo: evidenciar el impacto del afrontamiento de la covid-19 en el bienestar físico de profesionales de enfermería y médicos. método: revisión integradora de la literatura con artículos en español, inglés y portugués. la búsqueda se dio entre y el 10 y el 16 de julio de 2020 en las bases de datos cummulative index to nursing and allied health literature, literatura latinoamericana y del caribe en ciencias de la salud, web of science, sciverse scopus y national library of medicine. se analizaron 25 estudios, cuyos resultados se presentan de forma descriptiva y mediante tablas. resultados: del total de artículos, el 52 % abordó la infección por coronavirus y factores relacionados como impacto en el bienestar físico de profesionales de enfermería y médicos por efecto del afrontamiento de la covid-19; el 28 °%, la calidad del sueño y factores predictores y el 20 °%, los daños provenientes del uso de equipos de protección personal u otras medidas de prevención. conclusiones: el afrontamiento de la covid-19 ha propiciado la infección por coronavirus entre los profesionales, debido al proceso laboral y las medidas de prevención, la mala calidad del sueño relacionada con los desórdenes mentales y la falta de soporte social y daños físicos, como cefalea y heridas cutáneas, por el uso de equipos de protección personal y de la desinfección de las manos. palabras clave (fuente decs): infecciones por coronavirus; salud laboral; personal de salud; riesgos laborales; prevención de enfermedades. resumo objetivo: evidenciar o impacto do enfrentamento da covid-19 nobem-estar físico de profissionais de enfermagem e médicos. método: revisão integrativa da literatura com artigos em espanhol, inglês e português. a busca ocorreu de 10 a 16 de julho de 2020 nas bases de dados cummulative index to nursing and allied health literature, literatura latino-americana e do caribe em ciências da saúde, web of science, sciverse scopus e national library of medicine. foram analisados 25 estudos, cujos resultados estão apresentados de forma descritiva e por meio de quadros. resultados: do total de artigos, 52 °% abordaram a infecção por coronavírus e fatores relacionados como impacto no bem-estar físico decorrente do enfrentamento da covid-19 de profissionais de enfermagem e médicos; 28 °%, a qualidade do sono e fatores preditores e 20 °%, os danos provenientes do uso de equipamentos de proteção individual ou de outras medidas de prevenção. conclusões: o enfrentamento da covid-19 tem propiciado a infecção por coronavírus entre os profissionais, devido ao processo de trabalho e às medidas de prevenção; a má qualidade do sono, relacionada às desordens mentais e à falta de apoio social, e danos físicos, como cefaleia e lesões cutâneas, causados pelo uso de equipamentos de proteção e pela desinfecção de mãos. palavras-chave (fonte decs):  infecções por coronavírus; saúde do trabalhador; pessoal de saúde; riscos ocupacionais; prevenção de doenças. introduction in december 2019, the world health organization was alerted of several cases of pneumonia in wuhan city, in the hubei province of the people's republic of china, which was a novel strain (type) of coronavirus that had not been previously identified in humans. in january 2020, the chinese authorities confirmed that they had identified a novel coronavirus strain (1). in brazil, the first case of the disease caused by the novel coronavirus (covid-19) was reported on february 26, 2020. the increasing number of cases caused by this disease has led to changes in work organization, particularly that of healthcare personnel providing care to patients suspected or confirmed to have the disease. nursing and medical personnel have been subjected to long working hours, overtime, and a rushed pace, increasing social, psychological, and physical risks, including coronavirus infection (2). thus, this disease can be considered the first new work-related disease (3). covid-19 high transmissibility and potential for aggravation, the limited availability of personal protective equipment (ppe), the lack of adequate training to respond to outbreaks of highly infectious diseases (4), and the inefficient use of ppe promote better working conditions and the implementation of biosafety measures for healthcare personnel a priority. brazil is already considered the world leader in nursing personnel deaths due to covid-19; according to data from the international council of nursing, the country represents 38 % of the recorded deaths of nursing personnel in the world (5). along with the high risk of infection, covid-19 has been associated with other health hazards for healthcare personnel. damage to health is defined as all forms of losses or injuries caused by work-related demands and experiences, designated as physical, psychological, and social (6). it is noteworthy that the increased frequency and time of ppe use and the application of other infection prevention measures, such as hand washing, have determined the occurrence of damage to the physical well-being of personnel, such as skin injuries, pressure spots, headaches (7), dermatitis, eczema (8), among others. in addition, the uncertainties surrounding the disease, along with the stress and concern experienced in the work environment when responding to covid-19, have affected the sleep quality of healthcare personnel (9), manifested as insomnia, daytime sleepiness, and nightmares, among others (10), which can compromise their well-being and productivity. the literature has extensively evidenced the damage to the mental and psychological health of personnel who are responders to covid-19 (11-13). however, there are knowledge gaps regarding these people's physical well-being. in this context, it is crucial to broaden the knowledge on the subject to develop measures that improve the work environment, implement biosafety measures, and provide occupational health. thus, this study aims to highlight the impact of responding to covid-19 on the physical well-being of nursing and medical personnel. method this integrative literature review is structured from the following steps: the development of the research question; search and selection of primary studies; data extraction of the selected studies; critical evaluation of the studies included in the integrative review; synthesis of the results and review presentation (14). the research question was developed according to the pico strategy, where p stands for population; i for interest; and co for context. the study population consisted of nursing and medical personnel; the interest was related to physical well-being; the context was related to responding to covid-19. thus, the research question established was: what is the scientific evidence on the impact of responding to covid-19 on the physical well-being of nursing and medical personnel? regarding the search and selection of studies, we included primary studies that addressed the impact of responding to covid-19 on the physical well-being of nursing and medical personnel and were available online in portuguese, english, and spanish. letters, editorials, experience reports, reports, and publications already selected in the search in another database that failed to answer the research question were excluded. the search was conducted from july 10 to 16t, 2020, via the capes journal website, through the comunidade acadêmica federada. the databases accessed were the cumulative index to nursing and allied health literature (cinahl), latin american and caribbean health sciences literature (lilacs), web of science (clarivate analytics), sciverse scopus (scopus), and the national library of medicine (pubmed). for the search, the following strategy was developed: ("covid-19" or "2019-ncov" or "2019 novel coronavirus disease" or "covid19" or "sars-cov-2 infection" or "coronavirus disease 2019") and ("health personnel" or "health care providers" or "healthcare providers" or "healthcare workers" or "medical and nursing staff" or "medical staff" or "nursing staff"). this strategy was adjusted to each base considering their specifications. in lilacs, the strategy was also used with the variations of terms for the portuguese language. all documents found in the databases were imported into mendeley reference management software. it is noteworthy that two independent researchers searched and selected materials simultaneously, and, in case of disagreement, another researcher participated in reaching a consensus. the recommendations of the preferred reporting items for systematic reviews and meta-analyses (prisma) were adapted for this review. on the mendeley software, after excluding duplicates, the documents were pre-selected by reading the titles and abstracts. from the total of 3,200 articles found, 668 duplicates and 2494 studies were excluded for failing to answer the research question and fitting the exclusion criteria. in total, 25 reports were included in the review. the information from the articles included in the review was extracted using an instrument developed by the authors with the following items: title, authors, objective, method, results, evidence level, and observation. initially, members of the research team in which the authors participated applied the instrument to selected articles on the topic to prepare the researchers for data extraction. the critical analysis of the studies consisted of a detailed reading and comparison of findings and checking whether the methodology used accomplished the study objective. at this stage, the evidence level was also categorized. for diagnostic, treatment, and intervention studies, the following classification was followed: level 1 — systematic review or meta-analysis; level 2 — randomized controlled trials; level 3 — non-randomized controlled trials; level 4 — case-control or cohort studies; level 5 — systematic reviews of qualitative or descriptive studies; level 6 — qualitative or descriptive studies, and level 7 — opinions or consensus. research related to etiology and prognosis was classified as follows: level 1 — synthesis of cohort or case-control studies; level 2 — case-control or cohort studies; level 3 — synthesis of descriptive studies; level 4 — qualitative or descriptive studies; and level 5 — opinions or consensus (15). the results were presented descriptively and in tables for better visibility for readers. subsequently, there was a synthesis of the main findings, interpretation, analysis, and comparison between studies, inferences, and literature discussion. regarding the ethical aspects, the definitions and concepts followed by the authors of the analyzed works were respected and, as this is an integrative literature review, this research was not submitted to the ethics committee. results based on the articles search and selection process, 25 were included in the review, as shown in figure 1. of these, 52 % (n = 13) addressed coronavirus infection and related factors as an impact on the physical well-being of nursing and medical personnel, 28 % (n = 7) covered the sleep quality and predictors, and 20 % (n = 5) contemplated the damage resulting from ppe use or other infection prevention measures. figure 1. flowchart of the selection and inclusion process of primary studies in the review adapted from prisma source: own elaboration based on research data. the evidence on coronavirus infection suffered by nursing and medical personnel and related factors was produced predominantly from cross-sectional and cohort studies, half of them (53.8 %) with level 4 evidence, in countries such as china (46.2 %) and italy (23.1 %), as shown in table 1. table 1. evidence synthesis on coronavirus infection suffered by nursing and medical personnel and related factors. santa maria, rio grande do sul, brazil, 2020 authors research location (service, country) study type evidence level main results zheng l, wang x, zhou c, liu q, li s, sun q, et al. several hospitals in wuhan, china cross-sectional 4 more than half of the infected individuals were nurses working in a general hospital chu j, yang n, wei y, yue h, zhan f, zhao j, et al. tongji hospital, china cohort 2 more than half of the positive cases were men working in clinical sectors lai x, wang m, quin c, tan l, ran l, chen d, et al. tongji hospital, china cross-sectional 4 there is an infection rate of 1.1 % among staff; more than half were women garzaro g, clari m, ciacan c, grillo e, mansour i, godono a, et al. university hospital, italy series of cases 4 providing care to patients did not increase the risk of infection, but sharing the work environment did dabholkar yg, sagane ba, dabholkar ty, divity s tertiary referral hospital for covid-19, india cross-sectional 4 forty healthcare personnel were infected in two months since the first case in the hospital. almost half of the staff felt they had been infected at work, and 15 % reported unprotected exposure to a covid-19 positive patient fusco fm, pisaturo m, iodice v, bellopede r, tambaro o, parrella g, et al. the emergency room of two clinics, italy cohort 2 there is a general prevalence of 3.4 % of coronavirus infections chen cc, chi cy nanjing drum tower hospital, china cohort 4 there is a seroprevalence of 17.1 % of personnel (initial outbreak in china). there is a higher prevalence in those with exposure time > 30 min within one meter of contaminated patients. the use of masks was associated with a reduced risk of seroconversion felice c, di tanna gl, zanus g, grossi u research carried out via social media, italy cross-sectional 4 twenty-five percent of the staff presented with covid-19 symptoms. of the 25 % tested, one-third had symptoms; 18 % tested positive. only 22 % considered the ppe adequate in quality and quantity. kluytmans-van den bergh mfq, buiting agm, pas sd, bentvelsen rg, van den bijllaardt w, van oudheusden ajg, et al. two teaching hospitals, the netherlands cross-sectional 6 covid-19 prevalence in 6 % of staff; 3 % with a travel history to china and italy, and 3 % had contact with a covid-19 positive patient barrett es, horton db, roy j, gennaro ml, brooks a, tischfield j, et al. two university hospitals in new jersey, united states cohort 2 higher infection rates among personnel who spent more time in patient rooms, having increased contact with suspected or confirmed covid-19 patients ran l, chen x, wang y, wu w, zhang l, tan x covid-19 referral hospital, wuhan, china cohort 2 the risk of infection increases when personnel contact covid-19 positive family members, fail to perform hand hygiene properly, use inappropriate ppe, and work for more than 15 hours in high infection risk areas el-boghdadly k, wong djn, owen r, neuman md, pocock s, carlisle jb, et al. multicenter prospective cohort study carried out in 17 countries cohort 2 ten point seven percent of the providers who assisted in intubating patients suspected or confirmed covid-19 had symptoms. women were at a significantly higher risk of developing the disease wang s, xie l, xu y, yu s, yao b, xiang d zhongnan hospital in wuhan, china cross-sectional 4 social network density was higher in infected staff. touching the cheek, nose, and mouth during work considerably raised the rate of coronavirus infection, while wearing ppe in the adequate size and timing was a protective factor. source: own elaboration based on research data still, regarding the infection among healthcare personnel, the studies identified that sharing the environment is considered a risk factor for infection and the time of exposure and participation in the intubation of patients with covid-19. the use of ppe, especially masks, is a protective factor. table 2 explains the properties of evidence and the main results regarding sleep quality and predictors in nursing and medical personnel who respond to covid-19. it can be noted that almost all were conducted in china using cross-sectional designs, with level 4 evidence. table 2. evidence synthesis on sleep quality and predicting factors in nursing and medical personnel who respond to covid-19. santa maria, rio grande do sul, brazil, 2020 authors research location (service, country) study type evidence level main results wu k, wei x a referral hospital for covid-19 and one that is not, china non-randomized clinical trial 3 frontline medical personnel have worse sleep quality compared to those who are not huang y, zhao n the chinese population, china cross-sectional 4 compared to other occupational group, healthcare personnel had a higher rate of poor sleep quality zhuo k, gao c, wang x, zhang c, wang z the children's hospital, wuhan central hospital, and other covid-19 referral hospitals, china cross-sectional 4 medical and nursing personnel with insomnia showed clear signs of comorbid sleep apnea attributable to stress wang y, wu y, cheng z, tan x, yang z, zeng x, et al. children's health center in wuhan, china cross-sectional 4 thirty-eight percent of the participants had sleep disturbances, regardless of whether being an only child, exposure to covid-19 patients, and depression zhang c, yang l, liu s, ma s, wang y, cai z, et al. chinese hospitals, china cross-sectional 4 more than one-third of the medical team suffered insomnia during the covid-19 outbreak. mid-level personnel, medical personnel, personnel working in isolation units, and those concerned about being infected or controlling the covid-19 outbreak were at higher risk of experiencing insomnia xiao h, zhang y, kong d, li s, yang n provinces responding to covid-19, china cross-sectional 4 these professionals' sleep quality was poor. the levels of social support affected sleep quality. stress was negatively associated with sleep quality jahrami h, bahammam as, algahtani h, ebrahim a, faris m, aleid k, et al. facilities belonging to the ministry of health, bahrain cross-sectional 4 seventy-five percent of the professionals have poor sleep quality; 85 % had moderate-severe stress. the female sex and professional background (not being a physician) were predictors of poor sleep quality and stress source: own elaboration based on research data the studies presented in table 2 suggest that, in responding to covid-19, these professionals had worse sleep quality than others, primarily due to their concerns regarding the disease, stress, other mental disorders, and being female. table 3 presents the synthesis of the articles that contemplated the damage stemming from the use of ppe or other measures to prevent coronavirus infections. it is noted that the studies were conducted in different countries, including one that included professionals from 90 countries. all used the cross-sectional study methodology with level 4 evidence. table 3. evidence synthesis contemplates the damage stemming from ppe or other measures to prevent coronavirus infections. santa maria, rio grande do sul, brazil, 2020 author research location (service, country) study type evidence level main results ong jjy, bharatendu c, goh y, tang jzy, sooi kwx, tan yl, et al. national university hospital, singapore cross-sectional 4 eighty-one percent of the personnel had headaches due to ppe use (n95 face mask and goggles), which were associated with a preexisting diagnosis of headache and ppe use > 4h per day guertler a, moellhoff n, schenck tl, hagen cs, kendziora b, giunta re, et al. surgical center and intensive care unit for covid-19 at the ludwig maximilian university hospital of munich, germany cross-sectional 4 there is a prevalence of symptoms associated with acute hand dermatitis in 90.4 % of personnel. the pandemic caused a significant increase in hand washing, disinfection, and hand creams tabah a, ramanan m, laupland kb, buetti n, cortegiani a, mellinghoff j, et al. an international study carried out with healthcare providers working in 90 different countries cross-sectional 4 for 52 % of the providers, at least some standard ppe was unavailable, and 30 % reported reusing single-use ppe. damage stemming from ppe use: heat, thirst, pressure spots, headaches, inability to use the bathroom, and extreme exhaustion jiang q, song s, zhou j, liu y, chen a, bai y, et al. one hundred sixty-one hospitals, china cross-sectional 4 the general prevalence of skin injuries is 42.8 %. two or more skin injuries and injuries with multiple locations affected 27. 4 % and 76.8 % of the providers, respectively. only 45 % of the injuries were treated jiang q, liu y, wei w, zhu d, chen a, liu h, et al. one hundred sixty-one hospitals, china cross-sectional 4 there is a high prevalence of ppe-related pressure injuries among the medical team. the risk factors for injury were sweating, being male, using level 3 ppe (n95/kn95 respirators with goggles or face masks and protective gowns, latex gloves, and shoes), and extended time of use source: own elaboration based on research data. the results in table 3 demonstrate that, albeit having their respective functionality, the use of ppe and other protective measures against coronavirus infection can also cause damage to the well-being of personnel, most notably headaches, skin injuries, and exhaustion. discussion the available evidence on the impact of responding to covid-19 on the physical well-being of nursing and medical personnel refers particularly to coronavirus infection, quality of sleep, and the consequences of using ppe or other infection prevention measures. these were mainly found to be cross-sectional type studies, with level 4 evidence carried out in china. the low evidence level is justified by the fact that covid-19 is a novel disease that requires the development of quick and low-cost research, which could direct healthcare and generate new hypotheses for further studies. therefore, the cross-sectional study methodology, which combines these characteristics (16), was the most used. the high number of studies of chinese origin can be explained by the fact that the coronavirus outbreak started in that country with an imminent need for evidence to support clinical practice. coronavirus infection among nursing and medical personnel and related factors the covid-19 pandemic has been affecting the general population. however, frontline healthcare providers are more susceptible to infection (17). during the initial coronavirus outbreak in china, the healthcare services were unaware of how the virus was transmitted and the necessary precautions. soon, an increasing number of infected healthcare providers was identified, with a prevalence ranging from 1.1 % (18) to 17.1 % (19). in this context, research in that country found that 40 healthcare providers were infected within two months since the first case in the hospital; half of them became infected at work, and 15 % through unprotected exposure to patients with covid-19 (20). even after learning about what was being experienced in china, infections among healthcare providers were still significant in other countries. in italy, a study in two medical clinics found an overall prevalence of 3.4 % (21), but in a nationwide study, 18 % of all healthcare providers had the disease (22). in the netherlands, a study found that 6 % of providers had covid-19 with a travel history to china and italy or contact with a covid-19 patient (23). regarding infections by contact with patients, studies have found that the infection rates were higher among personnel who worked for more than 15 hours in high-risk areas for infection (24) and who had increased contact with suspected or diagnosed covid-19 cases (25). a study indicated a higher prevalence of the disease among personnel exposed for more than 30 minutes within a meter of patients and among those in close contact with patients with a higher viral load (26). this evidence may justify the results of a study that identified that 52.06 % of infected personnel were nurses, and 33.62 % were physicians (27). sharing the work environment and social network density (28, 29) have also been associated with increased risk for coronavirus contamination, as demonstrated in a study conducted in italy, where sharing a work environment represented an additional 2.63-fold risk of infection. the same study showed that non-medical services had an increased risk of infection (or = 4.23), as did administrative staff (or = 5.77) (28). among the personnel who are a source of infection, those involved in managerial activities with increased human contact were the greatest covid-19 disseminators (28). in this same line, another italian study found that coronavirus infections occurred in personnel who constantly worked the same shifts (21). this data emphasizes the need for infected personnel to be granted leave from their work environment to prevent the infection of their co-workers and patients (30). in brazil and other countries, thousands of healthcare providers have been relieved from their professional activities because they have become infected (31). standard infection prevention measures that were disregarded also elevated the risk of infection. research has shown that inadequate hand washing before and after contact with patients (24) and touching the cheek, nose, and mouth during work (29) were associated with infection among healthcare personnel. these issues emphasize the need for permanently training nursing and medical personnel regarding infection prevention, including orientation on hand-washing and self-care. in the context of medical procedures, research has indicated that performing or assisting with intubation is a cause of covid-19 among medical personnel. although most providers were wearing ppe (caps, n95 masks, gloves, goggles), 10.7 % experienced the disease symptoms up to 32 days after an intubation procedure. women were at a higher risk of developing the disease (32). it is noteworthy that this procedure produces aerosol and requires the adequate use of ppe. the high risk faced by women of being infected with covid-19 supports further research into the influence of sex on infection with this disease. the use of ppe in the adequate size and timing was considered a protective factor against infection (24, 29), especially masks (19). however, an italian study showed that only 22 % of the personnel considered the ppe adequate in quality and quantity (22). another study indicated a higher number of infected people originated from clinical settings, where surgical masks were more common than that n95, which was prioritized for professionals working in fever clinics (33). the difficulties in accessing and using adequate ppe are a global problem contributing to professionals' exposure to the coronavi­rus and the contamination of patients, other professionals, family members, and communities (34). the guarantee of safe conditions for professional practice requires management strategies regarding resource optimization and allocation. given the above, it is inferred that the response to covid-19 by nursing and medical personnel increased the risk of coronavirus infection in this population, primarily due to the time in contact with infected patients, sharing the work environment, social and work contact, disregard for infection prevention measures, participation in intubations, and inadequate use or lack of ppe. the active search and mass testing of professionals for disease diagnosis promote occupational safety and standardize the protection of these professionals when performing procedures (34). furthermore, the results also indicate the need for further research on the virus and the disease; the management of health services to promote measures to reduce the exposure of professionals; training related to care for the prevention of infections, and the provision of ppe. sleep quality of nursing and medical personnel responding to covid-19 sleep is a physiological process considered essential for maintaining physical and mental health. when exposed to stressful situations, individuals can manifest sleep suppression and increased wakefulness, which favors the occurrence of insomnia (difficulty falling asleep, maintaining sleep, and waking up early), drowsiness and daytime dysfunction, and nightmares, among others (10). in this context, the covid-19 outbreak has triggered a more significant negative impact on the sleep quality of healthcare providers compared to other occupational groups (35). the prevalence of poor sleep quality among nursing and medical personnel ranged among the studies reviewed from 36.1 % (36) to 100 % (37). a chinese national study identified that almost one in four healthcare providers had sleep disorders and a high risk for developing psychological disorders and mental illnesses (35). other studies highlight that psychological/mental factors interfere with sleep quality. a study found an independent association between sleep disturbance, depression, and exposure to patients with covid-19 (36). similarly, a study found that anxiety levels were associated with stress, negatively impacting self-efficacy and sleep quality (38). a study corroborates these findings by showing that somatization, depression, terror, and mental state affect sleep time and efficiency (37). stress in healthcare providers has also been correlated to insomnia with comorbid sleep apnea. professionals with moderate to severe sleep apnea-hypopnea syndrome had higher insomnia severity and worse mental states (39). additionally, a study has shown that the female sex and professional background (not being a physician) were predictors of poor sleep quality and stress combined (40). both poor sleep quality and stress in healthcare providers may impair their cognitive abilities and decision-making skills (41), requiring managers' awareness to implement measures to promote their well-being. furthermore, among the factors related to sleep quality, it was identified that low educational level (middle or lower), concern regarding coronavirus infection, extreme uncertainty about effective covid-19 control, working in an isolated environment (42), and perceived lack of psychological support are risk factors for insomnia (38, 42). being a physician was found to be a protective factor (42). thus, it is inferred that health education activities that provide increased knowledge of covid-19 and the establishment of safety measures and support for professionals can improve their sleep quality and well-being. in general, poor sleep quality is common among nursing and medical personnel who work responding to covid-19, associated with exposure to patients suspected or confirmed of having the disease, psychological or mental disorders, somatization of diseases, and lack of social support. the need to expand mental health services for staff in hospital institutions, health education, and psychological support is noted (36, 37) to improve their sleep quality. damage stemming from ppe or other preventive measures ppe and hand washing are essential measures to prevent infection in healthcare, protecting the staff and users (43). the coronavirus pandemic has demanded more frequent ppe and hand washing, including damage to professionals' health. in this regard, a study with physicians, nurses, and assistants from more than 90 countries, found reports of surgical masks for routine care by 15 % of professionals and, in intubations, by 2 % of them. the results also showed that ppe was used for a median of four hours and that, although they promoted protection to personnel, they triggered adverse effects, particularly associated with longer shifts, such as heat, thirst, pressure spots, headaches, inability to use the bathroom, and exhaustion (7). regarding headaches related to ppe use, a study showed that n95 protective masks was associated with this event, with pain related to the ppe pressure points and straps. the pain caused a slight decrease in work performance for 82.8 % of the professionals. a preexisting diagnosis of primary headache and the combined use of ppe for more than four hours a day were independently associated with this type of headache (44). as to pressure spots, a study has found the prevalence of skin injuries in 42.8 % of physicians and nurses, and of these, 30 % were device-related pressure injuries, 10.7 % were skin damage associated with humidity, and 2 % were skin cracks (45). another article reported the prevalence of device-related pressure injuries most­ly in stages 1 and 2 (98.8 %), located primarily on the nasal bridge, cheeks, ears, and forehead (98.8 %). the risk factors also included sweating, being male, using grade 3 ppe (n95/kn95 masks with goggles or face masks, protective aprons, latex gloves, and shoes), and extended time of use (46, 47). it is highlighted that the discomforts in the work environment can affect the professionals' ability to work, which is understood as the ability to meet the physical and mental demands resulting from their activity (48). in this sense, occupational protection involves measures for promoting well-being and the development of technologies that protect professionals during their activities without causing adverse effects or damage (49). the skin on the hands of nursing and medical personnel also requires attention, as the recurrent use of gloves can lead to injury. a study found a significant increase in hand washing, disinfection, and hand cream use in all healthcare providers, regardless of whether they had been in direct contact with covid-19 patients or not during the pandemic (50). there was a prevalence of symptoms associated with acute hand dermatitis in 90.4 % and under-reported eczema in 14.9 %. the most frequent symptoms were dryness (83.2 %), erythema (38.6 %), itching (28.9 %), burning (21.1 %), scaling (18.4 %), cracks (9.6 %), and pain (4.4 %). the authors inferred that the onset of eczema on the hands was probably associated with their intensified hygiene measures (8). considering the above, it can be inferred that the use of ppe and other protective measures, such as hand washing, was intensified with the pandemic; however, additional care should be planned to reduce the associated damage to professionals' health. conclusions the scientific evidence enabled the identification of the impact resulting from responding to covid-19 on the physical well-being of nursing and medical personnel: the prevalence of coronavirus infection related to the environment, the work process, and the prevention measures; the poor sleep quality due to the uncertainties related to the pandemic, mental disorders, and the lack of psychological support; as well as the damage resulting from the frequency of exposure to ppe and hand washing, such as headaches and skin injuries. the results also make clear the need for measures that can prevent damage to physical well-being and promote the health of professionals. the small number of publications on physical damage stemming from exposure to ppe and other infection prevention measures requires further research. furthermore, the insufficient evidence on the research topic highlights the need for studies with a different methodological approach. conflicts of interest: none declared. references 1. organização pan-americana da saúde. folha informativa covid-19 — escritório da opas e da oms no brasil [internet]. escritório regional para as américas da organização mundial da saúde: opas. disponível em: https://www.paho.org/pt/covid19 2. xiang yt, yang y, li w, zhang l, zhang q, cheung t, et al. timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. the lancet psychiatry. 2020;7(3):228-9. doi: https://doi.org/10.1016/s2215-0366(20)30046-8 3. 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https://doi.org/10.1590/1413-81232020259.19562020 home nursing care for people with chronic diseases and pulmonary infection by coronavirus: an integrative review article consequences of using artificial nipples in exclusive breastfeeding: an integrative review consecuencias del uso de pezones artificiales para la lactancia exclusiva: una revisión integradora consequências do uso de bicos artificiais para a amamentação exclusiva: uma revisão integrativa 10.5294/aqui.2021.21.3.2 vitória de oliveira cavalcante1 maria lucilândia de sousa2 camila da silva pereira3 nadilânia oliveira da silva4 rodrigues de albuquerque5 rachel de sá barreto luna callou cruz6 1 0000-0002-6140-3677. universidade regional do cariri, brazil. vitoria.cavalcante@urca.br 2 0000-0002-8223-7161. universidade regional do cariri, brazil. lucilandia.sousa@urca.br 3 0000-0002-5888-5150. universidade regional do cariri, brazil. camila.pereira@urca.br 4 0000-0002-4800-0937. universidade regional do cariri, brazil. nadilania.oliveira@urca.br 5 0000-0002-6374-3843. universidade regional do cariri, brazil. thais.alb@urca.br 6 0000-0002-4596-313x. universidade regional do cariri, brazil. rachel.barreto@urca.br received: 25/01/2021 sent to peers: 24/05/2021 approved by peers: 06/08/2021 accepted: 11/08/2021 theme: promotion and prevention. contributions to the field: this review provides a better understanding of the mechanisms by which the offer of artificial nipples to newborns interferes with the initiation or maintenance of exclusive breastfeeding. this may favor planning by multidisciplinary primary medical care teams focused on promoting, protecting, and supporting breastfeeding. to reference this article / para citar este artículo / para citar este artigo: cavalcante vo, sousa ml. pereira cs, silva no, albuquerque tr, cruz rsblc. consequences of using artificial nipples in exclusive breastfeeding: an integrative review. aquichan. 2021;21(3):e2132. doi: https://doi.org/10.5294/aqui.2021.21.3.2 abstract objective: to describe the consequences of using artificial nipples to exclusive breastfeeding. materials and method: an integrative review carried out in the medline®, cinahl, lilacs, web of science, and scopus databases to answer the following question: what are the consequences of using artificial nipples to exclusive breastfeeding? results: 38 articles were analyzed; the analysis gave rise to two categories: neonatal factors and maternal factors influencing exclusive breastfeeding. breastfeeding interruption was the neonatal factor most associated with the use of artificial nipples, while the level of maternal education stood out as an intervening factor in exclusive breastfeeding. pacifiers were the dummy type more commonly mentioned, followed by feeding bottles and nipple shields. conclusions: the consequences of offering artificial nipples to breastfed infants are mostly negative and associated with the newborn, such as early weaning, refusal to breastfeed, impaired suction technique, incorrect latch-on, interference with orofacial development, and interruption of exclusive breastfeeding. mothers who offered artificial nipples to their infants are more likely to experience pain, nipple fissures, frustration, and reduced interaction with their infants. keywords (source deos): breastfeeding; nursing bottles; bottle feeding; maternal and child health; artificial nipples. resumen objetivo: describir las consecuencias del uso de pezones artificiales para la lactancia exclusiva. materiales y método: revisión integradora realizada en las bases de datos medline®, cinahl, lilacs, web of science e scopus para contestar a la siguiente cuestión: ¿cuál es la influencia que ejerce en la lactancia la oferta de pezones artificiales a los recién nacidos? resultados: se analizaron 38 artículos; el análisis originó dos categorías: factores neonatales y factores maternos de influencia en la lactancia exclusiva. la interrupción de la lactancia materna fue el factor neonatal más asociado al uso de pezones artificiales, mientras el nivel de escolaridad materno se destacó como factor interviniente en la lactancia exclusiva. el chupo fue el pezón artificial más encontrado citado, seguido del biberón y del protector mamilar. conclusiones: las consecuencias de la oferta de pezones artificiales a los bebés em la lactancia son, en su mayoría, negativas y relacionadas con el neonato, como el desmame temprano y el rechazo al seno, la succión perjudicada, el agarre inadecuado, la interferencia en el desarrollo orofacial y la interrupción de la lactancia materna exclusiva. las madres que ofrecieron pezones artificiales a sus hijos están más propensas a sentir dolor, tener fisura mamilar, frustración y reducción de la interacción con su hijo. palabras clave (fuente deos): lactancia materna; biberones; alimentación artificial; salud materno-infantil; pezoneras. resumo objetivo: descrever as consequências do uso de bicos artificiais para a amamentação exclusiva. materiais e método: revisão integrativa realizada nas bases de dados medline®, cinahl, lilacs, web of science e scopus para responder à seguinte questão: qual a influência que a oferta de bicos artificiais aos recém-nascidos exerce na amamentação? resultados: foram analisados 38 artigos; a análise deu origem a duas categorias: fatores neonatais e fatores maternos de influência na amamentação exclusiva. a interrupção do aleitamento materno foi o fator neonatal mais relacionado ao uso de bicos artificiais, enquanto o nível de escolaridade materno destacou-se como fator interveniente na amamentação exclusiva. a chupeta foi o bico artificial mais encontrado citado, seguido da mamadeira e do protetor mamilar. conclusões: as consequências da oferta de bicos artificiais às crianças em amamentação são, em sua maioria, negativas e relacionadas ao neonato, como o desmame precoce, a recusa do peito, a sucção prejudicada, a pega incorreta, a interferência no desenvolvimento orofacial e a interrupção do aleitamento materno exclusivo. as mães que ofereceram bicos artificiais aos seus filhos estão mais propensas a ter dor, fissura mamilar, frustração e redução da interação com seu filho. palavras-chave (fonte deos):  aleitamento materno; mamadeiras; alimentação artificial; saúde materno-infantil. introduction exclusive breastfeeding is considered the gold standard in infant feeding and, when maintained for up to six months of age, provides proven benefits to the mother-infant binomial, the family, and the society (1). however, breastfeeding is strongly influenced by external factors that can lead to the interruption of exclusive breastfeeding (ebf), such as the use of dummies — pacifiers and feeding bottles, for example —, which are affordable and geographically disseminated (2). according to the world health organization (who), ebf is the ideal form of infant nutrition up to six months of age, when solid foods are introduced as complementary feeding. the who has drafted the "ten steps to successful breastfeeding" and does not recommend the use of feeding bottles and other dummies because they can potentially interfere with optimal breastfeeding practices (3). however, women in lowand middle-income countries show poor adherence to ebf, with only 37 % of infants under six months of age being exclusively breastfed (4). in brazil, breastfeeding (bf) is initiated but more than half of brazilian mothers interrupt it after the first month (5). bf indicators have been stable in brazil since 2006: 36.6 % of ebf in infants under six months of age and 52.1 % of bf in infants under two years of age (6). it is known that the use of artificial nipples can lead to early weaning and/or reduced bf duration. however, the aspects and mechanisms by which this interference occurs must be clarified and discussed (7-9). thus, this article aimed at describing the consequences of using artificial nipples to exclusive breastfeeding. materials and methods type of study integrative literature review carried out in six steps: identifying the research question; setting inclusion and exclusion criteria; categorizing (extracting, organizing, and summarizing information); reviewing the studies; interpreting the results; and presenting the review (10). identifying the research question the population, variables, and outcomes strategy (table 1) was used, which also allows for the identification of the most ap propriate descriptors for the search intended in the review. table 1. formulating the research question and identifying descriptors, with population, variables, and results from elements. crato, ceará, brasil, 2020 strategy items components subject descriptors population newborns infant, newborn variables mamilos educational technology outcomes consequences to breastfeeding health promotion source: prepared by the authors based on research data. so, the question is: what are the consequences of using artificial nipples to exclusive breastfeeding? setting the inclusion and exclusion criteria original studies that answered the research question and were published between 2006 and 2019 were defined as inclusion criteria. this time frame is justified by the year when law 11.265/2006 became effective, which regulates the marketing and appropriate use of food and dummies for infants and children. duplicate references and studies unavailable for download were excluded. methodology a paired search was carried out by two authors in march 2020, in the medical literature analysis and retrieval system online (medline®), cumulative index to nursing and allied health literature (cinahl), latin american and caribbean health sciences literature (lilacs), web of science, and scopus databases. the following controlled descriptors of the medical subject heading (mesh) were used: "breastfeeding", "pacifiers", "breastfeeding", "bottles". two crossings were implemented using the boolean operator "and". a total of 1,239 references were identified in the databases, with the respective crossings (table 2). table 2. references found with the respective crossings (n = 1,239), 2020 crossings cinahl lilacs medline® scopus web of science total "breastfeeding and pacifiers" 52 98 346 193 138 827 "breastfeeding and bottles" 11 62 137 119 83 412 total 63 160 483 312 221 1,239 source: prepared by the authors based on research data. this process resulted in 427 studies, but after excluding 37 duplicates, 390 studies were read in full. after careful reading, 247 studies were excluded for not addressing the desired population (infants aged 0 to 6 months) and 105 were excluded for not being available for download. thirty-eight articles were included in the final sample. the flowchart of the preferred reporting items for systematic review and meta-analysis (prism) was used to illustrate the process of study identification, screening, eligibility, and inclusion, as shown in figure 1. figure 1. flowchart for identifying, screening, selecting, and including studies. crato, ceará, brasil, 2020 source: prisma flowchart for systematic reviews. data were collected with the aid of a previously defined table, which included: author, year, journal/database, location, methodological design, level of evidence, and types of artificial nipples. subsequently, the factors influencing the use of artificial nipples on breastfeeding were summarized, found in primary studies, giving rise to two categories: neonatal factors and maternal factors. therefore, the articles found were numbered and the levels of evidence of the studies were categorized. level 1: evidence resulting from a meta-analysis of multiple randomized controlled clinical trials; level 2: evidence obtained in individual studies with experimental design; level 3: evidence from quasi-experimental studies; level 4: evidence from descriptive (non-experimental) studies or with a qualitative approach; level 5: evidence from a case or experience reports; level 6: evidence-based on expert opinions. results thirty-eight articles were analyzed, initially characterized by authors, year, journal, database, location, methodological design, level of evidence, and types of dummies (according to table 3). table 3. characterization of the primary studies included in the review, regarding authorship, year, journal, database, location, design, type of dummy found, and level of evidence. crato, ceará, brasil, 2020 authors and year journal and database location methodological design dummy level of evidence rocha, verga, sipsma, larson, phillipi, kair, 2020 (2) breastfeed med scopus the united states. qualitative, 23 women, interview pacifier 4 zarshenas, zhao, scott, binns, 2020 (11) int j environ res public health. medline iran prospective cohort, 700 women, interview pacifier 4 bezerra, magalhães, pereira, gomes, netto, rocha, 2019 (7) rev. bras. saúde mater. infant scopus brazil cross-sectional study, 354 infants, interview feeding bottle and pacifier 4 maastrup, walloee, kronborg, 2019 (12) plos one. medline denmark prospective cohort, 1,488 newborns and 1,221 mothers, questionnaire, telephone interview nipple shield 4 salcan, topal, ates, 2019 (13) eurasian j med. scopus turkey cross-sectional, 2,166 babies, interview pacifier and feeding bottle 4 silva, caminha, silva, serva, azevedo, filho, 2019 (14) jpediatr (rio j). lilacs brazil analytical cross-sectional study, 310 infants, database pacifier 4 wu, gao, sha, zeng, liu, li et al., 2019 (15) int j environ res public health. medline switzerland cohort, 951 binomials, questionnaire, phone call feeding bottle 4 batista, ribeiro, nascimento, rodrigues, 2018 (9) j pediatr (rio j). web of science brazil cross-sectional, observational study 427 binomials, questionnaire pacifier and feeding bottle 4 buccini, pérez-escamilla, benicio, giugliani, venancio, 2018 (16) plos one. medline england secondary study, 42,395 infants, national bf prevalence research data pacifier 4 cruz, reducino, probst, guerra, ambrosiano, cortellazzi et al., 2018 (17) cad. saúde coletiva. web of science brazil cross-sectional, epidemiological study, 301 binomials, data from medical records pacifier 4 júnior, mohr, pereira, 2018 (18) arq. catarinense med. lilacs brazil randomized clinical trial, 132 mothers, interview, questionnaire, telephone call pacifier 2 manhire, williams, tipene-leach, baddock, abel, tangiora et al., 2018 (19) bmc pediatr. cinahl new zealand randomized controlled trial, 197 mother-infant binomials, questionnaires pacifier 2 silva, cirino, santos, oliveira, sousa, lima, 2018 (20) saúde e pesquisa. lilacs brazil quantitative, cross-sectional, descriptive-exploratory study, 546 newborns, form pacifier and feeding bottle 4 bomfim, novaes, bonanato, navarro, tedesco, imparato et al., 2017 (21) pesq bras odontopediatria clin integr. scopus brazil cross-sectional, qualitative study, 156 binomials, interview feeding bottle 4 carvalho, fonsêca, nobre, silva, pessoa, ribeiro et al., 2017 (22) ciên saúde colet. web of science brazil cohort, 247 infants, semi-structured interview with mothers pacifier 4 dadalto, rosa, 2017 (23) rev paul pediatr. scopus brazil cross-sectional, descriptive study, 114 binomials, interview feeding bottle and pacifier 4 silva, pellegrinelli, pereira, passos, santos, 2017 (24) ciên saúde colet medline brazil retrospective study, 12,283 mothers, secondary form data feeding bottle and pacifier 4 praborini, purnamasari, munandar, wulandari, 2016 (25) clinical lactation. web of science the united states. quantitative, cross-sectional study, 58 mothers and infants, observation, and questionnaire feeding bottle, nipple shield 4 figueiredo, bueno, ribeiro, lima, silva, 2015 (26) j. hum. growth dev. scopus brazil cross-sectional study, 25 mothers, structured questionnaire pacifier and feeding bottle 4 lindau, mastroeni, gaddini, lallo, nastro, patanè et al., 2015 (27) eur j pediatr. cinahl italy longitudinal study, 605 women, questionnaire pacifier 4 pellegrinel, pereira, ribeiro, santos, 2015 (28) revnutr. lilacs brazil cross-sectional, retrospective study, 9,474 mothers, secondary form data pacifier and feeding bottle 4 carrascoza, possobon, ambrosano, júnior, moraes, 2014 (29) rev. cefac. web of science brazil descriptive, exploratory, longitudinal, quantitative study, 120 binomials, questionnaire pacifier and feeding bottle 4 demitto, bercini, rossi, 2013 (30) esc. anna nery. lilacs brazil descriptive, exploratory, quantitative study, 378 mothers and 383 infants, structured interview pacifier 4 ducci, vannuchi, tacla, souza, reis, 2013 (31) rev min enferm. lilacs brazil quantitative cross-sectional study, 285 infants, interview with a questionnaire pacifier and feeding bottle 4 rocha, garbin, garbin, saliba, moimaz, 2013 (32) pesqui bras odontopediatria clin integr. lilacs brazil longitudinal, prospective study, 87 binomials, interview with a questionnaire pacifier 4 kaufmann, albernaz, silveira, silva, mascarenhas, 2012 (33) ver. paul pediatr. web of science brazil prospective cohort, 951 binomials, interview with a questionnaire pacifier 4 queluz, pereira, santos, leite, ricco, 2012 (34) rev esc enferm usp. web of science brazil quantitative, cross-sectional study, 275 infants, questionnaire pacifier 4 salustiano, diniz, abdallah, pinto, 2012 (35) rev bras ginecol e obstet. lilacs brazil cross-sectional, analytical study, 667 infants, semi-structured interview pacifier 4 carrascoza, possobon, ambrosano, costa, moraes, 2011 (36) cien saude colet. web of science brazil longitudinal study, 111 binomials, questionnaire pacifier 4 sanches, buccini, gimeno, rosa, bonamigo, 2011 (37) cad saúde pública. lilacs brazil cross-sectional, 170 binomials, 2 forms pacifier 4 roig, martínez, garcía, hoyos, navidad, álvarez et al., 2010 (38) rev lat am enfermagem. scopus brazil cross-sectional, quantitative, descriptive study248 mother-infant binomials, interview pacifier and feeding bottle 4 vieira, martins, vieira, oliveira, silva, 2010 (39) j pediatr (rio j). web of science brazil cohort, 1,309 binomials, interview pacifier 4 araújo, silva, coutinho, 2009 (40) revcefac. lilacs brazil observational, cross-sectional study, 74 infants, infant assessment, filming, and recording pacifier 4 kishi, caccia-bava, martinez, 2009 (41) rev aps. lilacs brazil quantitative, cross-sectional study, 53 mothers, interview with a questionnaire pacifier 4 marques, cotta, araújo, 2009 (42) rev bras enferm. web of science brazil qualitative study, 19 mothers, semi-structured interview pacifier 4 parizoto, parada, venâncio, carvalhaes, 2009 (43) j pediatr (rio j). web of science brazil comparison of three cross-sectional surveys, with 496, 674, and 509 infants, interview pacifier 4 frança, giugliani, oliveira, weigert, santo, kohler et al., 2008 (44) rev saúde pública. web of science brazil cross-sectional in a cohort, 211 binomials, interview and observation feeding bottle and pacifier 4 source: prepared by the authors based on research data. pacifiers were the type of dummy more commonly found in th studies, followed by feeding bottles and nipple shields. the summary of the consequences of the use of artificial nipples to exclusive breastfeeding is shown in table 4. the consequences have been divided into two categories: neonatal consequences and maternal consequences. table 4. consequences of the use of artificial nipples to exclusive breastfeeding consequences evidence extracted from studies neonatal refusal to breastfeed (2, 26) reduced crying — newborn soothing (26, 30, 43) impaired suction technique (2, 9, 46, 12, 21, 26, 29, 36, 41, 44, 45) incorrect latch-on (7, 9, 44, 45) interference with orofacial development (2, 9, 46) interruption of ebf (2, 12, 25, 26, 29-33, 35, 36, 39, 14, 40-46, 15, 17, 19-23) early weaning (2, 17, 19-21, 23, 27, 31, 33, 34, 36, 39-41, 43) maternal nipple fissure/pain (9, 21, 30, 40, 45, 46) frustration (23, 30, 37, 38, 45) decreased interaction with the newborn (9, 13, 46) source: prepared by the authors based on research data. in the first category, the consequences that stood out were the interruption of ebf and early weaning. regarding maternal consequences, the most prevalent were nipple fissure/pain, frustration, and reduced interaction with the newborn. discussion regarding the consequences of the use of artificial nipples to breastfeeding that are associated with the newborn, this review pointed out aspects that ranged from incorrect latch-on to longterm anatomical changes. one of the relevant effects of the use of artificial nipples on newborns related to exclusive breastfeeding may be changes to the latch and suction pattern. disagreement on the mechanisms by which this relationship occurs has been found in the literature, with nipple confusion being one of the aspects mentioned. nipple confusion is a situation in which the suction pattern of the infant is modified due to the properties of the dummy (rigidity and shape of the dummy and base). consequently, the infant may lose interest in sucking the breast because it is harder to express milk compared to artificial nipples. the nipple confusion phenomenon is not fully elucidated, as research studies indicate that suction processing in the brainstem allows healthy term infants to adapt suction in response to the specific properties of each dummy being used (1). thus, nipple confusion is a risk newborns are exposed to when using pacifiers, feeding bottles, or nipple shields. another result of this study was newborns refusing to breastfeed due to the use of a pacifier or feeding bottle. another hypothesis to explain the negative influence of pacifiers on the biomechanics of breastfeeding includes reduced demand for breast milk by the newborn, since pacifier non-nutritive sucking causes fatigue and reduced nursing sessions or breastfeeding suspension (45). nevertheless, the pacifier is useful in conditioning and to help preterm infants transition from enteral or gavage nutrition to oral feeding during hospitalization in intensive care units. they also benefit from the weight gain that occurs by regulating gastric motility. pacifiers with sensory technologies are being developed to quantify the pressure of the sucking pattern and thus gain a better understanding of neurological and motor development in childhood, and explore the potential diagnostic information contained in sucking patterns under various clinical conditions (46, 47). a positive outcome of the use of artificial nipples was reduced crying and the soothing effect for infants. this effect is also reported in the literature as a causal factor for using a pacifier (48). a study with a spanish cohort showed that co-sleeping for more than six months seems to be associated with less anxiety, less negative sucking habits (with a pacifier or feeding bottle), and a lower incidence of malocclusions (49), which indicates that other strategies can be used to reduce infant's stress, such as bouncing and breastfeeding. as for feeding bottles, these similarly interfere with breastfeeding because of the great difference between the flow of milk that is extracted from the breast and that from the feeding bottle, making infants prefer the latter. furthermore, breastfeeding is a complex task that requires the integration and organization of several different skills, demanding greater effort from newborns (9, 50). regarding growth performance, partially breastfed and formula-fed newborns lag slightly behind exclusively breastfed infants in the first six months of life (51), confirming the benefits of maintaining exclusive breastfeeding. as a result of the use of artificial nipples, this study significantly revealed the negative influence on ebf, leading to interruption and early weaning. however, even though the use of a pacifier/feeding bottle is an indicator of breastfeeding problems, a woman's desire and intention to breastfeed must be taken into account. given its decisive character for the success of exclusive breastfeeding, this is perhaps the most important indicator of breastfeeding duration. it should be mentioned that the success of breastfeeding depends on several factors, including sociodemographic, biophysical, and psychosocial factors (52, 53). this study also found factors associated with mothers as a result of the use of artificial nipples, such as the incidence of pain, nipple fissures, frustration, and reduced interaction with their infants. nipple pain is related to breast trauma and infections, such as nipple fissures and candidiasis. therefore, it has been shown that the use of pacifiers and feeding bottles is associated with a higher rate of nipple injury because it can potentially change the sucking pattern and interfere with a proper breastfeeding latch (54). in an iranian study, pacifier use was a significant risk factor for acute mastitis in the first four weeks and between weeks 5 and 12 postpartum, being associated with duct obstruction, as the infant does not fully empty the breast, in addition to oral contamination with the transmission of pathogens to the breast (55). an experimental study concluded that pacifiers can potentially interfere with a mother's or infant's ability to read emotional expressions. that is, the harmful effects of the use of pacifiers in newborns imply the perception of less pleasant and less stimulating emotions (56). this finding corroborates a study with binomials in australia, where mothers with depression were evaluated. when asked to interact with their infants, they inserted a pacifier into their mouths several times, which showed difficulty in interacting (48). breastfeeding is not only a result of knowing the benefits and correct techniques or prior decision, but also of a woman's relationships with her social network. that said, women must get support from members of their primary network (relationship with family members, friends, or neighbors), who can help them with household chores and childcare. taking the relationships established between breastfeeding women and the members of their social networks into account helps professionals address other aspects in addition to the biological aspects of breastfeeding (57), reaching dimensions that can lead to increased ebf duration. as a limitation, we emphasize the inclusion of studies with a low level of evidence. the descriptors also do not restrict knowledge that is associated with the nursing field. however, the findings allow nursing professionals to broaden their knowledge regarding the risk factors for interrupting ebf due to the use of pacifiers, feeding bottles, and nipple shields. conclusions the consequences of offering artificial nipples to breastfed infants are mostly negative and associated with the newborn, such as early weaning, refusal to breastfeed, impaired suction technique, incorrect latch-on, interference with orofacial development, and interruption of ebf. reduced crying and newborn soothing are positive outcomes of the use of artificial nipples during breastfeeding. repercussions associated with the mother as a result of offering artificial nipples to infants include nipple fissures and pain, frustration, and reduced interaction with her infant. it can be emphasized that offering artificial nipples to infants of any age without the risk of discontinuing ebf is not guaranteed. the discussion about whether or not to use artificial nipples does not end here, considering that their use has been normalized by the population. nevertheless, this review made it possible to understand the mechanisms by which artificial nipples interfere with ebf, and this can support planning by multidisciplinary primary medical care teams focused on promoting, protecting, and support breastfeeding. conflicts of interest: none declared. references 1. zimmerman e. chupeta e mamadeira: os alvos para os desfechos desfavoráveis da amamentação. j pediatr (rio j). 2018;94(6):571-3. doi: 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randomized clinical trial type article effectiveness of ginger in the treatment of type 2 diabetes mellitus: a pilot study of the randomized clinical trial type* efectividad del jengibre en el tratamiento de la diabetes mellitus tipo 2: estudio piloto del tipo ensayo clínico aleatorizado** efetividade do gengibre no tratamento do diabetes mellitus tipo 2: estudo-piloto do tipo ensaio clínico randomizado*** 10.5294/aqui.2021.21.1.5 gerdane celene nunes carvalho1 josé claudio garcia lira neto2 lívio césar cunha nunes3 ana maria parente garcia alencar4 regina lúcia lino marques5 marta maria coelho damasceno6 1 0000-0001-9625-7617. universidade estadual do piauí, brazil. gerdanecelene@pcs.uespi.br 2 0000-0003-2777-1406. universidade federal do piauí, brazil. jclira@ufpi.edu.br 3 0000-0002-1178-7940. universidade federal do piauí, brazil. liviocesar@ufpi.edu.br 4 0000-0003-0459-4291. universidade regional do cariri, brazil. ana.parente@urca.br 5 0000-0003-0242-2488. centro de pesquisas em diabetes e doenças endócrino metabólicas, brazil. regina.lino@hemoce.ce.gov.br 6 0000-0003-4461-0145. universidade federal do ceará, brazil. marta.damasceno@pq.cnpq.br received: 07/27/2020 sent to peers: 8/30/2020 approved by peers: 11/9/2020 accepted: 12/15/2020 * this article derives from the doctoral thesis entitled “efeito do gengibre (zingiber officinale) no controle glicêmico e lipêmico de pessoas com diabetes tipo 2: ensaio clínico randomizado duplo-cego controlado por placebo”, presented to the graduate program in nursing at the universidade federal do ceará and funded by the conselho nacional de desenvolvimento científico e tecnológico, grant: 310496/2017–9. available in: http://www.repositorio.ufc.br/handle/riufc/36485. ** el artículo es resultado de la tesis doctoral “efeito do gengibre (zingiber officinale) no controle glicêmico e lipêmico de pessoas com diabetes tipo 2: ensaio clínico randomizado duplo-cego controlado por placebo” (“efecto del jengibre (zingiber officinale) en el control glicémico y lipémico de personas con diabetes tipo 2: ensayo clínico aleatorizado doble ciego controlado por placebo”), presentada al programa de posgrado en enfermería de la universidade federal do ceará y financiada por el consejo nacional de desarrollo científico y tecnológico, grant: 310496/2017– 9. disponible en: http://www.repositorio.ufc.br/handle/riufc/36485. *** este artigo é derivado da tese de doutorado intitulada “efeito do gengibre (zingiber officinale) no controle glicêmico e lipêmico de pessoas com diabetes tipo 2: ensaio clínico randomizado duplo-cego controlado por placebo”, apresentada ao programa de pós-graduação em enfermagem da universidade federal do ceará e financiada pelo conselho nacional de desenvolvimento científico e tecnológico, grant: 310496/2017– 9. disponível em: http://www.repositorio.ufc.br/handle/riufc/36485. to reference this article / para citar este artigo / para citar este artículo: carvalho gnc, lira-neto jcg, nunes lcc, alencar ampg, marques rll, damasceno mmc. effectiveness of ginger in the treatment of type 2 diabetes mellitus: a pilot study of the randomized clinical trial type. aquichan. 2021;21(1):e2115. doi: https://doi.org/10.5294/aqui.2021.21.1.5 abstract objective: to analyze the effectiveness of ginger in the reduction of the glycemic, lipid and anthropometric levels in people with type 2 diabetes mellitus. materials and method: a double-blind pilot study of the randomized clinical trial type, conducted between october 2017 and january 2018. the inclusion criteria were as follows: individuals with type 2 diabetes, aged from 18 to 80 years old, using oral antidiabetic drugs, and with glycated hemoglobin values between 7 % and 10 %. the participants were randomized and allocated in two different groups. in the experimental group, the participants used 1.2 g of ginger and, in the control group, 1.2 g of placebo. the primary outcome was the reduction in blood glucose. the reduction in the lipid and anthropometric levels was the secondary outcome. the intervention lasted four weeks. results: a total of 21 participants were included in the study. the use of 1.2 g of ginger resulted in noticeable reductions in the anthropometric and lipid levels in 30 days of follow-up, but it did not reduce the glycemic levels. conclusions: in this study, it was shown that ginger capsules, in doses of 1.2 g a day, can help to reduce anthropometric measures and lipid levels in the population under study; however, it had no effect on the glycemic levels. keywords (source decs): type 2 diabetes mellitus; ginger; clinical trial; primary health care; complementary therapies. resumen objetivo: analizar la efectividad del jengibre en la reducción de los niveles glicémicos, lipídicos y antropométricos de personas con diabetes mellitus tipo 2. materiales y método: estudio piloto, del tipo ensayo clínico aleatorizado, doble ciego, llevado a cabo entre octubre de 2017 y enero de 2018. los criterios de inclusión fueron los siguientes: personas con diabetes tipo 2, de 18 a 80 años de edad, en uso de antidiabéticos orales y con valores de hemoglobina glicada entre 7 % y 10 %. los participantes fueron aleatorizados y asignados en dos grupos distintos. en el grupo experimental, los participantes usaron 1,2 g de jengibre y, en el de control, 1,2 g de placebo. el resultado primario fue la reducción de la glicemia. la reducción de los niveles lipídicos y antropométricos fue el resultado secundario. la intervención duró cuatro semanas. resultados: 21 participantes formaron parte del estudio. el uso de 1,2 g de jengibre evidenció perceptibles reducciones de los niveles antropométricos y lipídicos en 30 días de seguimiento, pero no se mostró suficiente para reducir los niveles glicémicos. conclusiones: en el estudio se demostró que cápsulas de jengibre, en dosis de 1,2 g por día, pueden ayudar a reducir medidas antropométricas y niveles lipídicos en la población del estudio, sin embargo, sin efecto en los niveles glicémicos. palabras clave (fuente decs): diabetes mellitus tipo 2; jengibre; ensayo clínico; atención primaria de salud; terapias complementarias. resumo objetivo: analisar a efetividade do gengibre na redução dos níveis glicêmicos, lipídicos e antropométricos de pessoas com diabetes mellitus tipo 2. materiais e método: estudo-piloto, do tipo ensaio clínico randomizado, duplo-cego, realizado entre outubro de 2017 e janeiro de 2018. os critérios de inclusão foram: pessoas com diabetes tipo 2, de 18 a 80 anos, em uso de antidiabéticos orais e com valores de hemoglobina glicada entre 7 % e 10 %. os participantes foram randomizados e alocados em dois grupos distintos. no grupo experimental, os participantes usaram 1,2 g de gengibre e, no grupo controle, 1,2 g de placebo. o desfecho primário foi a redução da glicemia. a redução dos níveis lipídicos e antropométricos foi o desfecho secundário. a intervenção durou quatro semanas. resultados: 21 participantes fizeram parte do estudo. o uso de 1,2 g de gengibre trouxe perceptíveis reduções dos níveis antropométricos e lipídicos em 30 dias de acompanhamento, mas não se mostrou suficiente para a redução dos níveis glicêmicos. conclusões: neste estudo, mostrou-se que cápsulas de gengibre, em doses de 1,2 g por dia, podem ajudar a reduzir medidas antropométricas e níveis lipídicos na população estudada, no entanto sem efeito nos níveis glicêmicos. palavras-chave (fonte decs): diabetes mellitus tipo 2; gengibre; ensaio clínico; atenção primária à saúde; terapias complementares. introduction even after years of research, type 2 diabetes mellitus (t2dm) is still characterized as one of the main chronic diseases in the world (1). when diagnosed with this disease, the patient generally presents metabolic dysregulations that require continuous and expensive care. currently, the clinical treatment is mainly focused on pharmacological interventions. however, oral antidiabetic medications are commonly associated with unwanted adverse effects that lead to discontinuation of therapy or clinical inertia, influencing the chronicity degree of the disease (2). with this in mind, a number of research studies have been developed in an attempt to incorporate strategies that can minimize the lack of medication adherence and improve glycemic control. given the above, experts have highlighted the antidiabetic properties of food supplements traditionally used in different cultures around the planet. among them, ginger (zingiber officinale) stands out, which has been used both as a spice, especially in cooking, for its spicy acid flavor and unique aroma, and as herbal medicine in the treatment of arthritis, non-alcoholic fatty liver disease, primary dysmenorrhea, seasickness and oncological therapies (3). in addition to that, evidence has shown that ginger has the potential to reduce glycemic levels in people with t2dm, as well as its complications, as it interacts with different molecular pathways involved in the genesis of the disease, such as the inhibition of several transcriptional pathways, lipid peroxidation, reduction of carbohydrate metabolizing enzymes, and activation of the capacity of the antioxidant enzymes and low-density lipoprotein receptors. this cascade of events is reflected in the increase in insulin synthesis, in the reduction of insulin resistance, and in the accumulation of fat, in addition to the protective effects against complications arising from diabetes (4-9). a meta-analysis showed that ginger can be considered an effective and promising adjuvant in the treatment of t2dm, since it does not present important adverse events and has been beneficial in attenuating the glycemic, lipid or even anthropometric levels of people with the disease. despite this, researchers continue to recommend new studies to explore the therapeutic capacity of this product (3). in brazil, studies on this topic are scarce and, for this reason, the objective of this research was to analyze the effectiveness of ginger in reducing glycemic, lipid and anthropometric levels in people with t2dm. methods type of study this is a double-blind and placebo-controlled pilot study of the randomized clinical trial type, conducted between october 2017 and january 2018 according to the consort recommendations in a basic health unit (bhu) in the city of picos, piauí, brazil. population the population consisted of 50 individuals with t2dm, registered and monitored in a bhu located in the urban area of the municipality, selected for convenience. selection criteria the inclusion criteria were as follows: individuals aged between 18 and 80 years old; using oral antidiabetic medications; with glycated hemoglobin (hba1c) between 7 % and 10 %; and with preserved cognitive functions. the age group was determined for the following reasons: 1) individuals over 18 years of age have a better understanding of the disease and could be aware of the relationship of the study; 2) individuals over 80 years old begin to show a decline in their cognitive functions and, in order not to record any bias in this regard, we decided to limit such condition. the participants’ cognitive function was assessed by means of the mini-mental state exam. the exclusion criteria were as follows: being allergic to ginger, being pregnant or lactating, being an alcohol or tobacco user, making use of insulin, having severe complications associated with t2dm (chronic kidney, ischemic, autoimmune, liver, severe cardiovascular, gastrointestinal and inflammatory diseases), and the use of ginger supplementation. in addition to that, discontinuity criteria were adopted, namely: hospitalization, having started insulin therapy and/or presenting an allergic reaction. definition of the sample as this is a pilot study in which the researchers involved sought to evaluate the effectiveness and feasibility of the intervention proposal, in addition to estimating the sample size for a future study, the sample of this research was selected for convenience. of the 50 patients recruited, only 41 were interested in participating and, of these, 17 were excluded for the following reasons: one used daily ginger supplementation; one had ascites; one was on insulin therapy; three reported having severe heart problems, and 11 had hba1c results < 7 %. thus, 24 participants were randomized. the patients were randomly allocated in parallel groups (1:1), one being the experimental (ginger) and the other the control (placebo), each one with 12 people. randomization was performed based on the hba1c levels, by a researcher external to the study, using the r software, version 3.1.1. each number of the randomization sequence was placed inside an envelope, sealed and given to the lead researcher only at the time of vial delivery. in this study, the participants and the lead researcher were kept blind. data collection before recruitment was started, the researcher responsible for the study met with the team of the bhu chosen and clarified the research to the professionals. the potential participants were recruited over the course of 15 days, through printed invitations made by the researcher and delivered by community health agents. day and time were scheduled so that patients could attend the bhu. in addition to the bhu nurse, the responsible researcher was present to clarify the intention of the research and to invite the patients to participate. for those who showed interest, the free and informed consent form (ficf) was presented, signatures were collected, and the hba1c test was collected at the site. after this stage, with the results in hand, the patients were instructed on the possibility of participating in the study. data collection was conducted at the same moment for those who were able and wanted to participate. for data collection, the questionnaire used included socioeconomic variables (gender, skin color, schooling, occupation, etc.), anthropometric variables (waist circumference, hip circumference, neck circumference, waist-hip ratio, body adiposity index, body mass index, thigh circumference, waist-to-height ratio), clinical variables (blood pressure, time since t2dm diagnosis, episodes of hypo/hyperglycemia in the 30 days prior to collection) and laboratory variables (capillary blood glucose — cbg, fasting blood glucose — fbg, low density lipoprotein — ldl, high density lipoprotein — hdl, total cholesterol — tc, and triglycerides — tg). first, in order to guarantee data uniformity, the responsible researcher trained the other nursing students and professionals involved in data collection. as for the anthropometric variables, body weight was measured on an empty stomach, with the participants wearing light clothes and without shoes. height was also measured with the participants barefooted, using a stadiometer attached to the scale. the body mass index (bmi) was calculated using the weight-to-height ratio (kg/m2), where < 18.5 kg/m2 indicated low weight; between 18.5 kg/m2 and 24.9 kg/m2, normal weight; between 25 kg/m2 and 29.9 kg/m2, overweight; and ≥ 30 kg/m2, obesity. aged patients were classified as underweight when bmi ≤ 22 kg/m2, as with appropriate weight when bmi was between > 22 kg/m2 and < 27 kg/m2, and as overweight with bmi ≥ 27 kg/m2 (10). to measure neck circumference (nc), the participants were in a full standing position, with the head positioned in the frankfurt horizontal plane. an inelastic tape was placed at the midpoint of the neck. in men, the measurement was taken just below the laryngeal prominence. nc was considered high when men presented values ≥ 39 cm, and ≥ 35 cm for women (11). waist circumference (wc) was measured with an inelastic measuring tape placed against the skin, at the midpoint between the iliac crest and the last rib at the end of the exhalation movement. the wc measure was considered according to gender, with cutoff points ≤ 90 cm for men and ≤ 80 cm for women (11). the hip circumference (hc) cutoff value was ≤ 100 cm for both genders (11). the waist-to-height ratio (whtr) showed a cutoff value of 0.5 for both genders. with regard to the waist-to-hip ratio (whr), the cutoff points were 0.8 for women and 1.0 for men (11). regarding the body adiposity index (bai), the values considered were 25 % for men and 35 % for women (12). thigh circumference (thc) was measured with an inelastic measuring tape, at the midpoint between the inguinal crease and the proximal edge of the patella, and the cutoff values were ≥ 44 cm for men and ≥ 43.70 cm for women (12). to be considered hypertensive, the participants should have blood pressure values over 139/89 mmhg, according to the vii brazilian guideline on arterial hypertension. below this value, they were classified as normotensive (13). the laboratory data corresponded to the values established by the brazilian diabetes society (14) and by the vi brazilian guideline on the prevention of dyslipidemias and atherosclerosis (15), with fbg (≤ 100 mg/dl), hba1c (< 7 %), tc (≤ 90 mg/dl), tg (≤ 150 mg/dl), ldl (≤ 100 mg/dl) and hdl (≥ 40 mg/dl). 10 ml blood samples were collected after 12 to 14 hours of fasting. the samples were centrifuged at room temperature, at 3000 rpm for 10 minutes, to separate the serum from the blood cells. fbg, tg, tc, ldl, hdl, and hba1c were determined by the enzymatic colorimetric method with commercially available kits (pars azmun co., tehran, iran) in an automated analyzer (abbott, alcyon 300 model, abbott park, il, usa). in this study, the participants in the experimental group received 60 capsules of 600 mg/each, with ginger (zingiber officinale). the cg participants received 60 capsules of 600 mg/each, with microcrystalline cellulose (placebo). all the participants were instructed to take two capsules a day, one 30 minutes before breakfast and another 30 minutes before dinner, daily, for 30 days. both the ginger and the placebo were encapsulated and packaged in identical, opaque white plastic vials, properly sealed. each vial was numbered, and the dosage and the participant’s name were printed on its label. the experiment participants were carefully instructed to avoid changes in their physical activity routines or eating patterns during the study period. all the participants were instructed to return after the 30 days of intervention. in addition to that, guidelines were given on the continuity of ingestion of medications for t2dm, prescribed by the physicians, and on the usual care for managing the disease. although foreign studies prove a safety ginger dose of up to 6 g/day, in brazil, the maximum dosages allowed in compounding pharmacies for daily consumption are 2 g for fresh ginger and 1.2 g for 0.1 % ginger dry extract. thus, ginger dry extract was selected, in which the daily dose was distributed in two 600 mg capsules instead of fresh ginger, which would have its daily dose divided into four capsules. for production of the ginger capsules, the rhizome was used, processed in the form of powder, and the final product was 0.1 % ginger dry extract. in addition to that, an extraction was performed with water as solvent and starch as excipient. drying was done by spray dryer. as for the physical aspects, the concentration of the extract in water was 33.51 %, and alcohol, 0.89 %. dosage was 0.36 % for total gingerols (6-gingerol, 10-gingerol, 6-shogaol). in addition to the physical-chemical test carried out by the manufacturer, a microbiological test was performed, with values within normality for the amount of bacteria, fungi and yeasts, and the purity test measured heavy metals such as lead, copper, and antimony. the use of ginger is authorized in brazil and does not require permission to be used in research studies. therefore, the concept of “access to the genetic heritage” available in provisional measure 2,186-16/2001 does not apply. it is worth remembering that this spice, despite being originally from the island of java, indonesia, is widely used in the tropical regions of the world. after the purchase of 0.1 % ginger dry powdered extract by gemini indústria de insumos farmacêuticos ltda, the weighing, encapsulation, and repetition of the quality control tests, such as the physical-chemical test, were carried out in a compounding pharmacy that has the green seal of quality, the seal of excellence in franchising, and the sinamm diploma. weighing was computed using an analytical balance. the ginger and placebo capsules were prepared by a private laboratory, certified by the national health surveillance agency, in compliance with the international standards for handling products and medications. after preparation, the capsules were analyzed by pharmacists associated with the federal university of piauí, through biochemical and toxicological tests. the primary outcome was the reduction in the levels of fbg and cbg. the reduction in the lipid and anthropometric levels was established as the secondary outcome. data analysis and treatment the data were analyzed by intention to treat, by repeating the values of the last evaluation, according to the consort recommendations. the confounding variables were minimized through randomization in parallel groups (1:1). for the scalar variables, data was presented as mean and standard deviation or as median, minimum, and maximum. in the categorical variables, data was presented in the form of frequency and prevalence rate, in order to investigate associations between risk factors and disease. the mann-whitney’s u test was used to analyze the characteristics of the groups. to verify the behavior of the numerical variables, at both moments, the wilcoxon test was used. a significance level of 5 % was adopted. pearson’s chi-square test or fisher’s exact test for categorical variables were used to investigate the association between the variables. the statistical analyses were performed with the statistical package for the social sciences software, version 22.0 (united states) and the r program, version 3.3.1. ethical aspects the study was approved by a research ethics committee under opinion no. 2017 (caae: 71423617.3.0000.5209), registered in the brazilian network of clinical trials (rbr-2rt2wy / trial: u111-1202-1650), and followed all the ethical recommendations of the brazilian national health council, according to resolutions 466/2012 and 580/2018. all the participants were informed about the benefits and risks of the study and were free to abandon it, at any time and for any reason. results a total of 24 participants received guidelines on the study, signed the ficf and were randomized, with 12 being allocated to the eg and the cg each. subsequently, three eg participants were discontinued for the following reasons: two for travel reasons and one for reporting tachycardia. thus, 21 individuals concluded the study (figure 1). figure 1. flowchart of the participants involved in the study. picos, piauí, brazil, 2017 source: own elaboration. most of the patients were female (66.7 %), brown-skinned (66.7 %), and with a mean age of 57.9 years old (sd ± 9.22). the overall mean schooling of the participants was 6.95 years (sd ± 5.1) and 85.7 % lived with a partner or family members. one third of the participants stated being unemployed, received unemployment benefits or had the income of another family member, where 85.8 % had a monthly income of one to three minimum wages (value of the monthly minimum wage effective in 2017 in brazil), and 85.7 % were married or in a stable union. when asked about hyperglycemia or hypoglycemia episodes in the 30 days prior to the intervention, 66.7 % of the participants reported episodes of hyperglycemia and none of hypoglycemia. almost half of the individuals (47.6 %) reported going to nursing and medical appointments every six months, and a large proportion (76.23 ± 4.27) only measures glycemic and lipid levels twice a year. in this study, arterial hypertension was the disease most associated with t2dm (61.9 %). of the research participants, only one reported heartburn as an adverse effect. in table 1, it can be seen that, after the intervention with ginger, the researchers did not identify significant differences in the percentage values of the variables analyzed. table 1. distribution of the data of the patients with t2dm according to clinical, anthropometric and laboratory variables, before and after the intervention. picos, piauí, brazil, 2017 variables pre-intervention p* post-intervention p* total ginger placebo total ginger placebo blood pressure       0.661       0.397 normal 12 (57.1 %) 06 (66.7 %) 06 (50 %)   14 (66.7 %) 05 (55.5 %) 09 (75 %)   hypertension 09 (42.8 %) 03 (33.3 %) 06 (50 %)   07 (33.3 %) 04 (44.5 %) 03 (25 %)   bmi†       0.659       1 eutrophic 06 (28.6 %) 02 (22.2 %) 04 (33.3 %)   05 (23.8 %) 02 (22.2 %) 03 (25 %)   overweight/obesity 15 (71.4 %) 07 (77.8 %) 08 (66.7 %)   16 (76.2 %) 07 (77.8 %) 09 (75 %)   wc       1       0.603 normal 03 (14.3 %) 01 (11.1 %) 02 (16.7 %)   04 (19 %) 01 (11.1 %) 03 (25 %)   altered 18 (85.7 %) 08 (88.9 %) 10 (83.3 %)   17 (81 %) 08 (88.9 %) 09 (75 %)   nc       0.331       0.397 normal 06 (28.6 %) 04 (44.4 %) 02 (16.7 %)   07 (33.3 %) 04 (44.4 %) 03 (25 %)   altered 15 (71.4 %) 05 (55.6 %) 10 (83.3 %)   14 (66.7 %) 05 (55.6 %) 09 (75 %)   hc       1       1 normal 07 (33.3 %) 04 (33.3 %) 03 (33.3 %)   08 (38.1 %) 05 (41.7 %) 03 (33.3 %)   altered 14 (66.7 %) 08 (66.7 %) 06 (66.7 %)   13 (61.9 %) 07 (58.3 %) 06 (66.7 %)   thc       1       1 normal 02 (09.5 %) 01 (11.1 %) 01 (8.3 %)   02 (09.5 %) 01 (11.1 %) 01 (08.3 %)   altered 19 (90.5 %) 08 (88.9 %) 11 (91.7 %)   19 (90.5 %) 08 (88.9 %) 11 (91.7 %)   whr       1       1 normal 06 (28.6 %) 03 (33.3 %) 03 (25 %)   07 (33.3 %) 03 (33.3 %) 04 (33.3 %)   altered 15 (71.4 %) 06 (66.7 %) 09 (75 %)   14 (66.7 %) 06 (66.7 %) 08 (66.7%)   bai‡       0.367       0.642 normal 08 (38.1 %) 02 (22.2 %) 06 (50 %)   07 (33.3 %) 02 (22.2 %) 05 (41.7 %)   altered 13 (61.9 %) 07 (77.8 %) 06 (50 %)   14 (66.7 %) 07 (77.8 %) 07 (58.3%)   ntr       1       0.486 normal 01 (4.8 %) 01 (8.3 %)   02 (9.5 %) 02 (16.7 %)   altered 20 (95.2 %) 11 (91.7 %) 09 (100 %)   19 (90.5 %) 10 (83.3 %) 09 (100 %)   capillary blood glucose       1       0.229 normal   03 (14.3 %) 03 (25 %)   altered 21 (100 %) 09 (100 %) 12 (100 %)   18 (85.7 %) 09 (100 %) 09 (75 %)   fasting blood glucose       1       0.229 normal   03 (14.3 %) 03 (25 %)   altered 21 (100 %) 09 (100 %) 12 (100 %)   18 (85.7 %) 09 (100 %) 09 (75 %)   total cholesterol       0.396       1 normal 09 (42.9 %) 05 (55.6 %) 04 (33.3 %)   05 (23.8 %) 02 (22.2 %) 03 (25 %)   altered 12 (57.1 %) 04 (44.4 %) 08 (66.7 %)   16 (76.2 %) 07 (77.8 %) 09 (75 %)   hdl       0.087       1 normal 12 (57.1 %) 03 (33.3 %) 09 (75 %)   15 (71.4 %) 06 (66.7 %) 09 (75 %)   altered (low) 09 (42.9 %) 06 (66.7 %) 03 (25 %)   06 (28.6 %) 03 (33.3 %) 03 (25 %)   ldl       1       0.673 normal 06 (28.6 %) 03 (33.3 %) 03 (25 %)   08 (38.1 %) 04 (44.4 %) 04 (33.3 %)   altered 15 (71.4 %) 06 (66.7 %) 09 (75 %)   13 (61.9 %) 05 (55.6 %) 08 (66.7 %)   triglycerides       1       0.553 normal 04 (19 %) 02 (22.2 %) 02 (16.7 %)   03 (14.3 %) 02 (22.2 %) 01 (08.3 %)   altered 17 (81 %) 07 (77.8 %) 10 (83.3 %)   18 (85.7 %) 07 (77.8 %) 11 (91.7 %)   * fisher’s exact test; †body mass index; ‡body adiposity index. source: own elaboration. as for the mean values of the anthropometric and laboratory variables, the participants who used ginger had reductions in weight (75.1-74.4/p = 0.021), bmi (29.5-29.3/p = 0.031), wc (100.8-99.7/p = 0.050), nc (36.7-36.1/p = 0.293), hc (105.0-104.4/p = 0.066), thc (47.1-46.7/p = 0.483), bai (33.41-32.92/p = 0.066), hdl (37.78-45.08/p = 0.086), and ldl (113.99-108.50/p = 0.038) (as well as a 95 % confidence interval) (table 2). table 2. distribution of the mean values of the patients with t2dm, according to clinical, anthropometric and laboratory variables, before and after the intervention. picos, piauí, brazil, 2017 variables placebo ginger pre-intervention post-intervention p* pre-intervention post-intervention p* systolic pressure 122.5 (100 165) 120 (105 160) 0.514 125 (99 175) 125 (104 140) 0.362 diastolic pressure 75 (70 100) 76 (66 110) 0.959 80 (70 100) 80 (70 91) 0.205 weight 70.5 (59.2 95.7) 69.8 (57.8 97.1) 0.108 75.1 (46 90.3) 74.4 (46.3 89.5) 0.021 bmi† 27 (22.8 34.2) 27 (22.3 34.3) 0.283 29.5 (20.4 34.8) 29.3 (20.6 34.5) 0.031 wc‡ 99 (81 109.9) 97.1 (78.7 114.5) 0.050 100.8 (79 106) 99.7 (78.7 105.5) 0.050 nc§ 37.6 (33.9 41.9) 37.7 (33.7 43.5) 0.220 36.7 (32.6 44.9) 36.1 (32.6 45.5) 0.293 hc|| 103.3 (94 114.8) 103.6 (93 115.1) 0.306 105 (88.2 120) 104.5 (88.4 120.6) 0.066 thc¶ 47.5 (38.9 50.9) 47.1 (40.7 52) 0.388 47.1 (37.3 60) 46.7 (37.7 58.7) 0.483 whr** 0.9 (0.7 1.0) 0.9 (0.7 1) 0.106 0.9 (0.8 1) 0.9 (0.8 1) 0.236 bai†† 32.3 (24.9 49.8) 31.5 (24.2 50) 0.306 33.4 (29.9 47) 32.9 (29.8 46.4) 0.066 whtr‡‡ 0.6 (0.5 0.7) 0.5 (0.48 0.69) 0.093 0.6 (0.52 0.71) 0.6 (0.5 0.71) 0.577 capillary blood glucose 243 (144 360) 216 (142.2 345.6) 0.754 203.4 (131.4 306) 207 (111.6 253.8) 0.953 fasting blood glucose 223.2 (135 -369) 226.8 (136.8 363.6) 0.844 198 (117 -318.6) 223.2 (111.6 261) 0.859 total cholesterol 235.8 (139.2 309.3) 204.9 (139.2 278.4) 0.480 185.6 (123.7 282.2) 197.2 (135.3 239.7) 0.953 hdl 46.4 (19.3 65.7) 50.2 (30.9 65.7) 0.239 34.8 (23.2 69.6) 42.5 (30.9 61.8) 0.086 ldl 135.3 (65.7 587.7) 112.1 (69.6 -165.8) 0.071 112.1 (69.6 -185.6) 108.2 (42.5 -131.4) 0.038 triglycerides 186 (79.7 -345.4) 203.7 (106 -354.2) 0.347 194.3 (115.1-504.8) 248 (124 -575.7) 0.260 *  wilcoxon test; †body mass index; ‡waist circumference; §neck circumference; ||hip circumference; ¶thigh circumference; **waist-to-hip ratio; ††body adiposity index; ‡‡waist-to-height ratio. source: own elaboration. discussion the results of this study showed that the daily intake of 1.2 g of ginger reduced weight, bmi, wc and ldl in 30 days of follow-up. studies that used ginger in people with t2dm, with a focus on reducing blood sugar levels, also found positive results in reducing the anthropometric levels (weight, bmi and wc) (16-19). although directly linked to the diagnosis of t2dm, changes in the anthropometric levels — caused by the accumulation of fat — are still poorly investigated in studies that address the use of ginger. in this research, although ginger has improved the lipid profile ranges, such as ldl (112.14-108.27 mg/dl, p = 0.038) and hdl (34.08-42.53 mg/dl, p = 0.086), there was no unanimity in the consistency of the individual results. a similar study, involving 80 people with t2dm, with 41 using 3 g/day of ginger, for eight weeks, concluded that the product reduces ldl levels and increases hdl levels (17). iranian researchers conducted a clinical trial with 64 patients for two months, in which the participants used 2 g/day of ginger and achieved a reduction in the mean ldl values (77.33-65.73 mg/dl, p = 0.04). however, when analyzing the impact on hdl, the results were negative, as the levels of this cholesterol decreased (42.53-38.66 mg/dl, p = 0.28) (16). amounts of ginger smaller than these have not been shown to be effective in reducing the lipid levels (20). results like these are important, since it is already firmly established in the literature that insulin resistance in the peripheral tissues is intimately associated to the high amount of circulating lipids and to the accumulation of tissue lipids, which indicates a high need for control, essential to minimize secondary complications of t2dm and of associated diseases (21). ginger has enzymes that inhibit the metabolism of carbohydrates, preventing hyperglycemia or the perpetuation of insulin resistance, and appears to modulate the action of insulin while regulating blood glucose homeostasis (21). although the results did not show that fasting blood glucose or capillary blood glucose were reduced after the intervention, different studies highlight the hypoglycemic effect of ginger in non-insulin-dependent t2dm patients (17-18, 22-27). the outcomes of this study and others with a similar objective can be supported by differences in the patients’ responses, the duration of the disease, the dose, the intervention time or because of the type of therapeutic regimen. in general, all this evidence shows that the consumption of a moderate dose of ginger can modify the glycemic and lipid status, and reduce the anthropometric parameters of people with diabetes, pointing out the value of the product in the management of the disease. thus, it is possible to say that ginger can even be used as an adjunct, but not exclusive, therapy for the control of t2dm. in addition to that, it is important to note that ginger is a low-cost product, easily found and with great potential to be introduced into the daily lives of people with t2dm and comorbidities associated with lipid alteration. undoubtedly, the results of research studies like this support the health team in the use of products like ginger in the clinical practice, increasing the management power of people with t2dm, especially in primary care. likewise, it is also necessary to take into account that the current scenario requires greater autonomy, preparation and leadership from these professionals in the creation of policies that disseminate effective and innovative practices, as highlighted by the nursing now campaign (28-30). based on our observations and on data from other research studies, it is possible that ginger is considered a promising supplement for t2dm therapy when hypertriglyceridemia and hyperlipidemia cannot be satisfactorily controlled by means of other strategies, such as exercise, diet and prescription medications. a research study on the cost-effectiveness of the product is also important, since the use of ginger can be part of the economic and health strategies used by the brazilian government to control t2dm. study limitations as a limitation of this pilot study we point out the intervention time, of only 30 days, which seems to be short to show metabolic changes in patients with diabetes, as well as the sample size, precluding data generalization. another limitation of the research was the therapeutic dose of only 1.2 g per day — the maximum dose allowed by the brazilian government. in addition to that, the need to monitor and record the dietary pattern and the practice of physical exercises by the participants is emphasized, since they can influence the outcomes found. conclusions this study identified that ginger, in doses of 1.2 g/day, for 30 days, can help to reduce some anthropometric and lipid levels in people with t2dm, but it does not have enough hypoglycemic power to reduce the investigated glycemic levels. in addition to that, inconsistencies found in the literature, with positive and negative results in studies of this nature, raise the need for further research studies. therefore, caution is required when using the results. nurses must lead research studies like this, as they are at the forefront of care for people with t2dm, especially in primary care. in addition, policy makers are expected to expand the list of recommendations for this product and to provide opportunities for developing new studies that take into account the limiting aspects of this research, especially the size of the daily therapeutic dose.  conflict of interests: none declared. references 1. chatterjee s, khunti k, davies mj. type 2 diabetes. lancet diabetes endocrinol [internet]. 2017; 389:2239-51. doi: http://dx.doi.org/10.1016/s0140-6736(17)30058-2 2. khunti k, nikolajsen a, thorsted bl, andersen m, davies mj, paul sk. clinical inertia in intensifying therapy among people with type 2 diabetes treated with basal insulin. diabetes obes metab [internet]. 2016; 8:401-9. doi: https://doi.org/10.1111/dom.12626 3. zhu j, chen h, song z, wang x, sun z. effects of ginger (zingiber officinale roscoe) on diabetes mellitus type 2 and components of the metabolic syndrome: a systematic review and meta-analysis of randomized controlled trials. evid based complement alternat med [internet]. 2018; 2018:5692962. doi: https://doi.org/10.1155/2018/5692962 4. huang f-y, deng t, meng l-x, ma x-l. dietary ginger as a traditional therapy for blood sugar control in patients with type 2 diabetes mellitus: a systematic review and meta-analysis. medicine (baltimore) [internet]. 2019; 98(13):e15054. doi: https://doi.org/10.1097/md.0000000000015054 5. wang j, ke w, bao r, hu x, chen f. beneficial effects of ginger zingiber officinale roscoe on obesity and metabolic syndrome: a review. ann n y acad sci [internet]. 2017; 1398(1):83-98. doi: https://doi.org/10.1111/nyas.13375 6. honarvar nm, zarezadeh m, khorshidi m, arzati mm, yekaninejad ms, abdollahi m et al. the effect of an oral ginger supplementation on nf-kb concentration in peripheral blood 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2010; 42(4):224-30. available from: http://www.inaactamedica.org/archives/2010/21063044.pdf 14. malachias mvb, souza wksb, plavnik fl, rodrigues cis, brandão aa, neves mft et al. vii brazilian guidelines for hypertension. arq bras cardiol [internet]. 2016; 107(3):1-83. available from: http://publicacoes.cardiol.br/2014/diretrizes/2016/05_hipertensao_arterial.pdf 15. brazilian diabetes society. guidelines from the brazilian diabetes society: 2017-2018 [internet]. 2017. available from: https://www.diabetes.org.br/profissionais/images/2017/diretrizes/diretrizes-sbd-2017-2018.pdf 16. faludi aa, izar mco, saraiva jfk, chacra apm, bianco ht, afiune neto a et al. atualização da diretriz brasileira de dislipidemias e prevenção da aterosclerose — 2017. arq bras cardiol [internet]. 2017; 109(2 suppl 1):1-76. disponível em: http://publicacoes.cardiol.br/2014/diretrizes/2017/02_diretriz_de_dislipidemias.pdf 17. mahluji s, attari ve, mobasseri m, payahoo l, ostadrahimi a, golzari se. effects of 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[internet]. 2014; 22(1):9-16. doi: http://doi.org/10.1016/j.ctim.2013.12.017 20. shidfar f, rajab a, rahideh t, khandouzi n, hosseini s, shidfar s. the effect of ginger (zingiber officinale) on glycaemic markers in patients with type 2 diabetes. j complement integr med [internet]. 2015; 12(2):165-70. doi: http://doi.org/10.1515/jcim-2014-0021 21. atashak s, peeri m, azarbayjani ma, stannard sr, haghighi mm. obesity-related cardiovascular risk factors after long-term resistance training and ginger supplementation. j sports sci med [internet]. 2011; 10(4):685-91. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3761505/pdf/jssm-10-685.pdf 22. li y, tran vh, duke cc, roufogalis bd. preventive and protective properties of zingiber officinale (ginger) in diabetes mellitus, diabetic complications, and associated lipid and other metabolic disorders: a brief review. evid based complement alternat med. [internet]. 2012; 2012:516870. doi: http://doi.org./10.1155/2012/516870 23. al-amin zm, thomson m, al-qattan kk, peltonen-shalaby r, ali m. anti-diabetic and hypolipidaemic properties of ginger (zingiber officinale) in streptozotocin-induced diabetic rats. br j nutr [internet]. 2006; 96(4):660-6. doi: http://doi.org/10.1079/bjn20061849 24. ozougwu jc, eyo je. evaluation of the activity of zingiber officinale (ginger) aqueous extracts on alloxan-induced diabetic rats. pharmacologyonline [internet]. 2011; 1:258-69. available from: https://pharmacologyonline.silae.it/files/archives/2011/vol1/026.ozougwu.pdf 25. kazeem mi, akanji ma, yakubu mt, ashafa aot. protective effect of free and bound polyphenol extracts from ginger (zingiber officinale roscoe) on the hepatic antioxidant and some carbohydrate metabolizing enzymes of streptozotocin-induced diabetic rats. evid based complement alternat med [internet]. 2013; 2013:935486. doi: http://doi.org/10.1155/2013/935486 26. oludoyin ap, adegoke sr. efficacy of ginger (zingiber officinale roscoe) extracts in lowering blood glucose in normal and high fat diet-induced diabetic rats. am j food nutr [internet]. 2014;2(4):55-8. available from: http://pubs.sciepub.com/ajfn/2/4/1/index.html 27. arablou t, aryaeian n, valizadeh m, sharifi f, hosseini af, djalali m. the effect of ginger consumption on glycemic status, lipid profile and some inflammatory markers in patients with type 2 diabetes mellitus. int j food sci nutr [internet]. 2014; 65(4):515-20. doi: http://doi.org/10.3109/09637486.2014.880671 28. arzati mm, honarvar nm, saedisomeolia a, anvari s, effatpanah m, arzati rm et al. the effects of ginger on fasting blood sugar, hemoglobin a1c, and lipid profiles in patients with type 2 diabetes. int j endocrinol metab [internet]. 2017; 15(4):e57972. doi: http://doi.org/10.5812/ijem.57927 29. miranda neto mv, rewa t, leonello vm, oliveira mac. advanced practice nursing: a possibility for primary health care?. rev bras enferm [internet]. 2018; 71(supl 1):716-21. [issue edition: contributions and challenges of practices in collective health nursing]. doi: http://dx.doi.org/10.1590/0034-7167-2017-0672 30. cassiani shb, lira neto jcg. nursing perspectives and the “nursing now” campaign. rev bras enferm [internet]. 2018; 71(5):2351-2. doi: http://dx.doi.org/10.1590/0034-7167.2018710501 home cognitive impairment and quality of life of patients subjected to hematopoietic stem cell transplantation article cognitive impairment and quality of life of patients subjected to hematopoietic stem cell transplantation* disfunción cognitiva y calidad de vida de pacientes sometidos al trasplante de células madre hematopoyéticas** comprometimento cognitivo e qualidade de vida de pacientes submetidos ao transplante de células-tronco hematopoéticas*** 10.5294/aqui.2021.21.2.6 celina angélica mattos machado1 angela da costa barcellos marques2 luana aparecida alves da silva3 francisco jose koller4 paulo ricardo bittencourt guimarães5 luciana puchalski kalinke6 1 0000-0002-7241-7169. universidade federal do paraná, brasil. celina.machado@ufpr.br 2 0000-0003-1442-0308 . universidade federal do paraná, brasil. angelamarques@ufpr.br 3 0000-0003-0210-2791 . universidade federal do paraná, brasil. luana.alves@ufpr.br 4 0000-0002-2911-7670 . universidade federal do paraná, brasil. fjkoller@ufpr.br 5 0000-0002-9852-6777 . universidade federal do paraná, brasil. prbg@est.ufpr.br 6 0000-0003-4868-8193 . universidade federal do paraná, brasil. lucianakalinke@ufpr.br * this study is part of the theme project entitled “quality of life of the patients with hematologic neoplasm subjected to hematopoietic stem cell transplantation”, which was supported by the brazilian coordination for the improvement of higher level personnel, under no. 88881.311846/2018-01, and by the araucária foundation and universidade federal do paraná in edict 15/2017. ** el estudio es parte del proyecto temático “calidad de vida de los pacientes con neoplasia hematológica sometidos al trasplante de células madre hematopoyéticas”, que contó con el apoyo de la coordinación de perfeccionamiento de personal de nivel superior de brasil, bajo el n.º 88881.311846/2018-01, y de la fundación araucária y universidade federal do paraná, convocatoria 15/2017. *** este estudo faz parte do projeto temático “qualidade de vida dos pacientes com neoplasia hematológica submetidos ao transplante de células-tronco hematopoéticas”, que teve apoio da coordenação de aperfeiçoamento de pessoal de nível superior do brasil, sob o n.º 88881.311846/2018-01, e da fundação araucária e universidade federal do paraná no edital 15/2017. received: 31/08/2020 sent to peers: 06/10/2020 approved by peers: 20/04/2021 accepted: 29/04/2021 theme: chronic care, promotion and prevention. contribution to the discipline: the findings of this research evidence the importance of assessing the quality of life in patients with cancer with a focus on the multidimensionality of the construct, considering not only the physical aspects but also all the other domains that comprise it (cognitive, social, emotional, and functional). in this study, the cognitive function was assessed, and it was found that it changes during treatment and that it presents a positive correlation with the quality of life, which suggests that the greater the impairment of the cognitive function, the worse the overall quality of life. to reference this article / para citar este artigo / para citar este artículo: machado cam, marques acb, da silva laa, koller fj, guimarães prb, kalinke lp. cognitive impairment and quality of life of patients subjected to hematopoietic stem cell transplantation. aquichan. 2021;21(2):e2126. doi: https://doi.org/10.5294/aqui.2021.21.2.6 abstract objective: to assess and correlate overall quality of life and the cognitive function of adult patients with hematologic cancer subjected to autologous and allogeneic hematopoietic stem cell transplantations up to three years after treatment. materials and method: a longitudinal, observational, and analytical study was conducted with 55 patients in a reference hospital in latin america, from september 2013 to february 2019, with the quality of life questionnaire-core 30, analyzed with the spearman’s correlation coefficient and generalized linear mixed model tests. results: overall quality of life in autologous and allogeneic transplantations presented a decline in the pancytopenia phase (59.3 and 55.3, respectively). there was impairment of the cognitive function in the autologous group in post-transplantation after two years (61.90) and, in the allogeneic group (74), in pancytopenia. in the autologous group, a positive (0.76) and significant (p < 0.04) correlation is observed between the cognitive domain and quality of life in post-transplantation after two years. in the allogeneic group, there was a positive (0.55) and significant (p < 0.00) correlation from 180 days after transplantation. conclusions: quality of life and the cognitive function present impairment and there is a correlation after the hematopoietic stem cell transplantation for both groups: autologous and allogeneic. keywords (source decs):  quality of life; cognitive dysfunction; hematopoietic stem cell transplantation; neoplasms, bone marrow transplant. resumen objetivo: evaluar y correlacionar la calidad de vida general y la función cognitiva de pacientes adultos con cáncer hematológico sometidos al trasplante de células madre hematopoyéticas autólogo y alogénico hasta tres años luego del tratamiento. materiales y método: estudio longitudinal, observacional y analítico con 55 pacientes, en un hospital de referencia en latinoamérica, de septiembre del 2013 a febrero del 2019, con el instrumento quality of life questionnarie-core 30, analizado con las pruebas coeficiente de correlación de spearman y el generalized linear mixed model. resultados: la calidad de vida general en el trasplante autólogo y alogénico presentaron descenso en la fase de pancitopenia (59,3 y 55,3, respectivamente). hubo disfunción cognitiva en el grupo autólogo posteriormente al trasplante dos años (61,90) y el grupo alogénico (74), en la pancitopenia. en el grupo autólogo, se observa correlación positiva (0,76) y significativa (p < 0,04) entre el dominio cognitivo y la calidad de vida en el post-trasplante dos años. en el alogénico, hubo correlación positiva (0,55) y significativa (p < 0,00) desde el post-trasplante 180 días. conclusiones: la calidad de vida y la función cognitiva presentan compromiso y hay correlación luego del trasplante de células madre hematopoyéticas para ambos grupos, autólogo y alogénico. palabras clave (fuente decs): calidad de vida; disfunción cognitiva; trasplante de células madre hematopoyéticas; neoplasias; transplante de médula ósea. resumo objetivo: avaliar e correlacionar a qualidade de vida geral e a função cognitiva de pacientes adultos com câncer hematológico submetidos ao transplante de células-tronco hematopoéticas autólogo e alogênico até três anos após o tratamento. materiais e método: estudo longitudinal, observacional e analítico com 55 pacientes, num hospital de referência na américa latina, de setembro de 2013 a fevereiro de 2019, com o instrumento quality of life questionnarie-core 30, analisado com os testes coeficiente de correlação de spearman e o generalized linear mixed model. resultados: a qualidade de vida geral no transplante autólogo e alogênico apresentaram declínio na fase de pancitopenia (59,3 e 55,3, respectivamente). houve comprometimento da função cognitiva no grupo autólogo no pós-transplante dois anos (61,90) e no grupo alogênico (74), na pancitopenia. observa-se, no grupo autólogo, correlação positiva (0,76) e significativa (p < 0,04) entre o domínio cognitivo e a qualidade de vida no pós-transplante dois anos. no grupo alogênico, houve correlação positiva (0,55) e significativa (p < 0,00) a partir do pós-transplante 180 dias. conclusões: a qualidade de vida e a função cognitiva apresentam comprometimento e há correlação após o transplante de células-tronco hematopoéticas para ambos os grupos, autólogo e alogênico. palavras-chave (fonte decs): qualidade de vida; disfunção cognitiva; transplante de células-tronco hematopoéticas; neoplasias; transplante de medula óssea. introduction the advancement of cancer treatment technologies has considerably improved the chances of patient survival. however, it causes adverse effects in different systems of the organism and generates a negative impact on quality of life (qol), which can last after the disease is cured (1, 2). for hematologic cancers, hematopoietic stem cell transplantation (hsct) represents a chance of increasing survival or even cure; however, it is at the same time a challenging treatment, with impacts on qol domains and the patients’ life experience (1). hsct puts the patient at risk of cognitive impairment due to the use of chemotherapy at high doses, total body irradiation, and prophylaxis of chronic graft-versus-host disease. adherence to treatment and the patient’s qol can be affected (3). cognitive impairment is a recurrent and little understood adverse effect of the chemotherapy and radiotherapy treatments, as well as of the disease itself. it is important to highlight that it can have late-onset and, in some patients, be progressive even years after ceasing therapy against cancer (2-4), particularly involving memory, concentration/attention, information processing speed, and executive functioning (5). cancer-related cognitive changes are a clinically relevant problem among adult patients, particularly after systemic treatment with chemotherapy. the potential consequences for the qol of cancer survivors are significant and include issues related to overall, and emotional well-being, return to work and self-care ability (5, 6). despite the increasing number of research studies on this topic, the mechanism by which cancer and its treatment impact on the cognitive function have not been elucidated yet. several researchers point out that cancer treatment can change the normal path of cognitive aging or even accelerate this mechanism through inflammatory processes, oxidative stress, and damage to the deoxyribonucleic acid (dna) (6, 7). the loss of neural progenitor cells of the hippocampus is also considered a key mechanism for the cognitive impairment induced by cancer therapy. it is believed that the structural effects are mediated by the direct toxicity of the cell treatment, inflammation and oxidative stress (2, 8). however, cancer-related cognitive impairment can have a multifactorial cause; in this context, different aspects must be considered, the type of treatment and the patients themselves among them (9). its relationship with chemotherapy is little recognized and insufficiently treated (9). the increase in the number of cancer survivors and survival enhances the relevance of the concern about cognitive impairment and quality of life in these individuals. therefore, the objective of this study was to assess overall quality of life (oqol) and cognitive function impairment in adult patients with hematologic cancer subjected to hsct up to three years after the treatment and to verify if there is a relationship between oqol and the cognitive function in the monitoring stages and in the autologous and allogeneic transplantation modalities. materials and method this is an observational, longitudinal, and analytical study, structured according to the recommendations of the strengthening the reporting of observational studies in epidemiology initiative (better known as strobe) (10), carried out in a hematopoietic stem cell transplantation service of a teaching hospital in the brazilian south region, a reference in latin america. the non-probabilistic sample included 55 patients, considering the number of transplantations in the service from 2010 to 2012, with an addition of 50 % due to the the characteristic of the therapy with a high death rate evidenced by a number of authors (11). the inclusion criteria were patients aged 18 years old or more, with a diagnosis of hematologic cancer and subjected to hsct. patients who did not present physical aptitude to fill in the questionnaires would be excluded; however, there were no such cases. the patients who withdrew their consent (n = 0), who evolved to death (n = 28), who did not attend the post-hsct follow-up (n = 5), and who were subjected to a new hsct (n = 0) during the study were discontinued. data collection took place from september 2013 to february 2019 in the hospitalization sector and the outpatient clinic of the hematopoietic stem cell transplantation service, in eight stages: pre-hsct (to establish a baseline), pancytopenia period (between the seventh and tenth day after hsct), pre-hospital discharge (between the twentieth and fortieth day after confirming medullary attachment), 100 days post-hsct, 180 days post-hsct, 360 days post-hsct, two years post-hsct, and three years post-hsct. to such an end, a sociodemographic and clinical questionnaire was used in the baseline stage to characterize the participants and, from 180 days onwards, another one to update the registration data and detect possible complications. in all the data collection stages, the quality of life questionnaire-core 30 (qlq-c30), version 2.0 was used, prepared by the european organization for research and treatment of cancer (eortc), translated/validated for brazil (12, 13), and authorized/availed via download directly to the researchers upon registration of the research project. qlq-c30 consists of 30 items divided into functional scales (physical, emotional, cognitive, social functioning, and personal performance), a scale of symptoms/simple items, and oqol, with scores expressed from 0 to 100. for the functional scale and oqol, higher scores represent better qol assessments (14). for this research, the values of the cognitive functioning scale and of oqol were used. the data obtained were tabulated in a microsoft® excel 2010 spreadsheet and analyzed and calculated according to the eortc scoring manual (14) and using the statistica 7.0 software. descriptive analysis was performed with its results expressed as absolute and relative frequency values. for the analysis of the oqol scores and of the cognitive function of qlq-c30, spearman’s correlation coefficient was obtained. to assess associations between groups (autologous versus allogeneic), stages and possible group-stages interaction, the generalized linear mixed model (glmm) was applied, using the spss 20 software. in this research, glmm was used for it enables the use of all the observations carried out since the beginning of the study. the measures do not need to be equally spaced and balanced, and the analyses can be conducted with data of individuals who were lost to follow-up or who presented a lack of information at some point in the study (15). the patients were considered as a random effect and as first-order autoregressive covariance matrix (ar1), with fit defined by the akaike information criterion (aic). the assumption of normality of residuals was verified by the qq plot graph and the analysis of multiple paired comparisons was performed through the sidak test. this study has been approved by the research ethics committee of the health sciences sector of universidade federal do paraná, brazil, under opinion no. 411,548. after clarification of the research objectives, the individuals who agreed to participate in the study signed the free and informed consent form. to ensure the participants’ anonymity, a sequential number (like 1, 2, 3...) was attributed to each of them as they were included in the study. results regarding the sociodemographic and clinical description, 55 patients were included in the study; of these, 33 (60 %) were discontinued during the first three years after hsct (five [9 %] due to follow-up loss and 28 [51 %] due to death). there was a discrete prevalence of males, with 29 (52 %) subjects; 30 (55 %) stated being married or in stable unions and 27 (49 %) reported a family income of one to three minimum wages. in the sample, leukemia was the diagnosis with the highest occurrence, 36 (65 %), and 39 (71 %) were subjected to allogeneic hsct. the mean rates of hr-qol in autologous and allogeneic hscts presented a decline in the pancytopenia phase (59.3 and 55.3, respectively), with relapse in the autologous group (63.1) two years after hsct (table 1). table 1. overall quality of life and cognitive function scores of the quality of life questionnaire – core 30 of the patients subjected to autologous and allogeneic transplantation and of the total group obtained in the eight research stages quality of life questionnaire — core 30 (qlq — c30) scores pre-hsct n = 55 pancytopenia n = 50 pre-discharge n = 49 post-hsct 100 days n = 41 post-hsct 180 days n = 38 post-hsct 360 days n = 32 post-hsct 2 years n = 25 post-hsct 3 years n = 22 means sd means sd means sd means sd means sd means sd means sd means sd aut. n=16 allo. n=39 aut. n=16 allo. n=34 aut. n=16 allo. n=33 aut. n=13 allo. n=28 aut. n=12 allo. n=26 aut. n=11 allo. n=21 aut. n=7 allo. n=18 aut. n=4 allo. n=18 oqol 70.8 16.3 79.2 17.8 59.3 19.2 55.3 20.9 73.9 15.1 66.7 20.6 80.7 13.3 71.4 23.7 75.6 21.4 77.5 20.1 72.7 16.7 70.6 22.7 63.1 28.8 77.7 16.4 75.0 21.5 82.8 13.8 cognitive function 81.2 18.3 84.1 21.9 85.4 19.1 74 16.6 91.6 18.2 83.3 24.6 91 12.9 82.1 29 91.6 11.2 80.7 21.9 83.3 23.57 80.9 28 61.9 36.9 84.2 25.8 70.8 25 82.4 23.2 spearman aut./allo. 0.44 0.28 -0.24 0.24 0.11 0.27 0.46 0.03 0.33 0.55 0.55 0.58 0.76 0.61 0.73 0.88 p-value 0.08 0.08 0.37 0.16 0.67 0.11 0.11 0.86 0.29 0.00* 0.07 0.00* 0.04* 0.00* 0.26 0.00* spearman total 0.33 0.12 0.27 0.14 0.49 0.55 0.74 0.82 p-value 0.01* 0.37 0.05 0.38 0.00* 0.00* 0.00* 0.00* p-value: statistical significance; hsct: hematopeic stem cell transplantation; sd: standard deviation; aut.: autologous; allo.: allogeneic; oqol: overall quality of life; *: p < 0.05. source: own elaboration. regarding the means of the qlq-c30 cognitive function domain, higher impairment was observed in the autologous group two years post-hsct (61.9) and, in the allogeneic group (74), in the pancytopenia period. when the spearman’s correlation coefficient between the cognitive function domain and oqol was obtained, the results show that, in the autologous group, there was a positive (0.76) and significant (p < 0.04) correlation two years post-hsct, which suggests that the lower the scores of the cognitive function domain, the worse the assessment of oqol, that is, in this stage, there is impairment of the cognitive function, as well as of oqol. in the allogeneic group, there was a positive and significant (p < 0.00) correlation starting from 180 days post-hsct. figure 1 shows the evolution of the mean scores of oqol and the cognitive function domain throughout time in the autologous group, with the worst mean value 2 years post-hsct. figure 1. quality of life and cognitive function of the quality of life questionnaire — core 30 of the patients subjected to autologous and allogeneic transplantation in the eight research stages qol: quality of life; cf: cognitive function; panc: pancytopenia. source: own elaboration. figure 2 shows the evolution of the scores throughout the stages. in the allogeneic group, the worst mean of oqol and of the cognitive function is observed in the pancytopenia stage, with the recovery of the baseline values from pre-discharge. figure 2. quality of life and cognitive function of the quality of life questionnaire — core 30 of the patients subjected to allogeneic and allogeneic transplantation in the eight research stages qol: quality of life; cf: cognitive function; panc: pancytopenia. source: own elaboration. in the analysis of the evolution over time of the oqol and cognitive function domain scores, glmm was used and adjusted considering the patients as random effect. the best fit was defined by the aic criterion = 2,678.89. the multiple paired comparisons performed by means of the sidak test proved that the cognitive function score does not change over time, since oqol presents a significant change across the stages. table 2 shows the results of the glmm analysis for the group, stage, and group-stage interaction factors. a significant difference is observed across the stages for oqol, with a change in the scores after the pancytopenia stage for both modalities. table 2. mixed generalized linear model analysis of overall quality of life and cognitive function between groups (autologous and allogeneic), stages (eight stages), and group-stage interaction type iii test of the fixed effects factors oqol** cognitive function f p f p intercept 1.362.54 0.00 895.88 0.00 groups 0.25 0.61 0.04 0.84 stages 6.18 0.00* 1.63 0.12 groups-stage 1.65 0.12 1.92 0.06 oqol overall quality of life; f: snedecor statistics; p: statistical significance; *: p < 0.05. source: own elaboration. discussion the diagnosis of severe disease and the indication of treatment with potential for cure, although with high mortality risk, impair the patients’ qol and the various domains that comprise it: physical, emotional, social, functional, spiritual, and cognitive. the health care team must be aware of the impairments that can occur due to the therapy chosen and, based on this information, promote the possible preventive and coping strategies to improve qol and its domains. according to the worldwide network for blood and marrow transplantation, over a million of hscts were performed worldwide, and approximately fifty thousand hsct procedures are performed every year (16). these survivors run the risk of late effects that can adversely affect their qol and increase morbidity and mortality. in this research, a high death rate is observed (51 %), characteristic of this treatment modality. a similar outcome (45.8 %) was found in a study that included 114,491 patients subjected to hsct, which aimed to analyze the causes of death after hsct over time (11). in brazil, survival after autologous hsct is 86 % in the first year and 77 % in the third year. for related allogeneic hsct, 63 % and 53 %, and for unrelated hsct, 58 % and 50 % in the first and third year, respectively (17). in relation to the sociodemographic and clinical characteristics, a slight predominance of the male gender was observed (51 %). regardless of gender, men and women share expectations and afflictions during the entire therapeutic path due to physical changes, social isolation and changes in the activities of daily living. discomfort before the weaknesses perceived impairs qol. the mean age evidenced in this research was 36 years old. the age group of people who are on the rise in productive, family, social, and professional life stands out. the diagnosis of aggressive disease and the treatment with potential to develop severe and risky complications result in concerns. there are feelings of fear and insecurity, mainly when the family member affected is the home provider, and their health condition interrupts their activities, even if partially, with the consequent reduction in income. regarding the data related to oqol assessed with qlq-c30, it was possible to observe that there are changes in both hsct modalities. during the course from cancer diagnosis to survival, changes in qol and in the cognitive function can occur; therefore, their identification is necessary as they represent complications with a high improvement rate when treated (18). a review study that aimed to determine the association between hsct, anxiety, depression, and psychological quality found that the anxiety and depression rates were higher in hsct survivors when compared to values of the general population. the presence of multiple complications and the patients’ chronic conditions were important risk factors for deterioration in mental health (19). regarding the self-assessment of the cognitive function, it is observed that the scores are stable with satisfactory assessments, except for the autologous group two years post-hsct, in which there is a decline in the mean value, with a positive and significant correlation. for the allogeneic group, a significant correlation was observed from 180 days onwards, which suggests that the higher the qol impairment, the worse the cognitive function. neurocognitive impairment, including symptoms such as memory dysfunction, impaired concentration, and difficulty in performing several tasks simultaneously, was recognized as a common complication in patients that are subjected to hsct (20). the cognitive function is complex and multi-determined. it is important to exhaust all risks and opportunities for improvement reflected in existing multimodal intervention approaches (21). pre-, during, and post-hsct neurocognitive assessments must be indicated to detect early possible deteriorations that may compromise oqol. a mean of 15 % to 50 % of the patients with malignant tumors showed persistent cognitive impairment after chemotherapy (22). the mechanisms that lead to this are unknown; however, a number of studies point out that cognitive dysfunction before hsct can result from the disease itself or from previous treatments. after hsct, impairment can be associated with physical, emotional, and social decline, which can impact on adherence to the treatment and, consequently, on an increase in the risk of morbimortality (20). in this research, there was a correlation between qol and cognitive function in some stages, for both modalities, namely: autologous and allogeneic. in the analysis overtime carried out by means of the glmm test, it was observed that there was a significant change in oqol across the stages. in the cognitive function domain, there was not any significant change across stages, and groups, and even less in the group-stage interaction. the results for the cognitive changes in all types of cancer, except for those of the central nervous system, and the modalities of multiple treatments (chemotherapy, radiation, hormone therapy) point to multifactorial etiologies in addition to only the neurotoxicity of the chemotherapeutic agents. stressful experiences have been postulated as a contributing factor for these cognitive changes (23). a variety of problems hampers the ability to characterize and understand neurocognitive dysfunction after hsct. in the first place, it is not clear if self-assessments of neurocognitive dysfunction are correlated with the results of objective neurocognitive tests, and most of the studies do not include an analysis of the patients’ perspectives. a study of correlations between the patients’ perspective and the test results presented variations in relation to the return to work after transplantation, mentioning cognitive and health problems as the reason for the negative change in the functional domain, which included the ability to perform activities of daily living. the same study showed significant associations between the reports of cognitive impairment and younger age (p = 0.02), depressive mood (p = 0.02), anxiety (p = 0.002), and health-related qol (p = 0.008) (24). cognitive decline and neurological changes associated with cancer diagnosis and treatment have been increasingly identified in a subgroup of patients (23). new research studies on the assessment of cognitive function and its impact on the course of the hematologic disease are necessary, not only during treatment but also in the survival period. early detection strategies and coping interventions must be developed to control cognitive declines and, consequently, improve qol during the treatment of hematologic cancer and in the survival period. this research can contribute to the health professionals’ practice regarding the reflection about the various domains that compose the qol construct, as well as it evidences the need for the early assessment of the possible impairments, to promote actions that may prevent or reduce harms in qol. this is the first longitudinal evidence in which this change was shown; therefore, new research studies are suggested, with a focus on specific groups and populations, defining risk and protection factors, objective and subjective measures in which analyses of the patients’ perceptions on the cognitive function are included. as a limitation, the research presents its sample size and the fact that it was conducted in only one transplantation center, which precludes generalization of the results. conclusions it is concluded that the adult patients with hematologic cancer subjected to hsct present oqol impairment with the worst assessment in the pancytopenia period, in both modalities, namely: autologous and allogeneic. regarding the cognitive domain, the worst assessment was observed two years post-hsct for the autologous group and in the pancytopenia for the allogeneic group. in this research, a correlation was observed between oqol and the cognitive function for both hsct modalities, which suggests that the higher the cognitive function impairment, the worse the oqol of the patients subjected to hsct. however, when the analysis of the relationship across groups (autologous versus allogeneic), stages and group-stage interaction, a significant relation was observed between the stages and oqol. regardless of that, knowledge about the changes that occur during the different post-hsct stages can assist health professionals in improving the care provided, with a view to the multidimensionality of the qol construct. conflict of interests: none declared. references 1. machado cam, proença sf, marques acb, mantovani mf, guimarães prb, kalinke lp. calidad de vida de los pacientes sometidos al trasplante de células madre autólogo y alogénico en la hospitalización. enferm. glob. 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however, this research identified that, as a global strategy to prevent covid-19 infection, social distancing causes profound loneliness but allows caregivers to feel safe and free from risks to themselves and the people cared for when carrying out their activities, being a predictive variable for satisfactory adoption of the role. to reference this article / para citar este artículo / para citar este artigo:carrillo-cervantes al, medina-fernández ia, carreño-moreno s, chaparro-díaz l, cortéz-gonzález lc, medina-fernández ja. loneliness, anxiety, depression, and adoption of the role of caregiver of older adults with chronic diseases during covid-19. aquichan. 2022;22(3):e2234. doi: https://doi.org/10.5294/aqui.2022.22.3.4 abstract objective: to determine the effect of loneliness, anxiety, and depression on adopting the role of caregiver of older adults with chronic conditions in a sample of mexican caregivers during the covid-19 pandemic. materials and method: predictive and correlational design. the study was conducted with 157 caregivers through the dyad characterization scale, the hads scale, the ucla scale, and the caregiver role adoption scale. the analysis used descriptive and inferential statistics. results: most participants were female, with a mean care time of seven months. mostly, the caregivers have anxiety as a clinical problem (27 %), doubtful depression (14.9 %), profound loneliness (66.2 %), and satisfactory adoption of the role (71.2 %). we found that the more significant the role of adoption, the lower the anxiety, depression, and loneliness levels (p < .05). the psychosocial factors, the age of the person cared for, the age of the informal caregiver, and the care time explained 36 % of the variance in role adoption (f = 13.12; p < .01), with loneliness as a predictive variable. conclusion: the covid-19 pandemic has impacted the caregivers' mental health and caused profound loneliness, the latter being a predictor for adopting the role. keywords (source: decs): anxiety; depression; loneliness; caregivers; coronavirus infections. resumen objetivo: determinar el efecto de la soledad, la ansiedad y la depresión sobre la adopción del rol cuidador de adultos mayores con enfermedad crónica en una muestra de cuidadores mexicanos durante la pandemia de la covid-19. materiales y método: diseño correlacional predictivo. se realizó el estudio en 157 cuidadores mediante la encuesta de caracterización de la diada, escala hads, escala ucla y escala adopción del cuidador. el análisis fue con estadística descriptiva e inferencial. resultados: la mayoría de los participantes fueron mujeres, con un tiempo medio de cuidados de siete meses. los cuidadores en su mayoría tienen ansiedad como problema clínico en un 27 %, depresión dudosa con un 14,9 %, soledad severa con un 66,2 % y adopción satisfactoria del rol en el 71,2 %. se encontró que a mayor adopción del rol, menor ansiedad, depresión y soledad (p < 0,05). los factores psicosociales, la edad de la persona receptora de cuidado, la edad del cuidador informal y el tiempo de cuidado explicaron un 36 % de la varianza de la adopción del rol (f = 13,12; p < 0,01), siendo variable predictora la soledad. conclusión: la pandemia de la covid-19 ha ocasionado un impacto en la salud mental y la soledad severa de los cuidadores, siendo esta última un predictor de la adopción del cuidador. palabras clave (fuente: decs): ansiedad; depresión; soledad; cuidadores; infecciones por coronavirus. resumo objetivo: determinar o efeito da solidão, ansiedade e depressão na adoção do papel de cuidador de idosos com doença crônica em uma amostra de cuidadores mexicanos durante a pandemia de covid-19. material e método: desenho correlacional preditivo. o estudo foi realizado com 157 cuidadores utilizando a pesquisa de caracterização da díade, a escala hads, a escala ucla e a escala de adoção do papel de cuidador. a análise realizou-se com estatística descritiva e inferencial. resultados: a maioria dos participantes era do sexo feminino, sendo o tempo médio de atendimento de sete meses. a maioria dos cuidadores apresentou ansiedade como problema clínico (27 %>), depressão duvidosa (14,9 °%), solidão severa (66,2 °%) e adoção satisfatória do papel (71,2 %). constatou-se que quanto maior a adoção do papel, menor o índice de ansiedade, depressão e solidão (p < 0,05). os fatores psicossociais, a idade da pessoa que recebe os cuidados, a idade do cuidador informal e o tempo de cuidado explicaram 36 %% da variância na adoção do papel (f = 13,12; p < 0,01), sendo a solidão variável preditora. conclusão: a pandemia da covid-19 tem impactado a saúde mental e a solidão severa dos cuidadores, sendo esta última uma variável preditora da adoção do papel de cuidador. palavras-chave (fonte decs): ansiedade; depressão; solidão; cuidadores; infecções por coronavirus. introduction the world faces the challenge imposed by the increased demand for family care. in the case of mexico, having a non-communicable disease and aging are the leading causes of dependence and, consequently, the ones that condition the need for care. in 2018, nearly 7.8 % of the total mexican population was over 60 years old (1), which has implied a rapid growth of the aged population amid economic hardships and continuous dependence on families; furthermore, it is expected that the proportion will triple and reach 23 % by 2050. in turn, although mainly affecting the aged population, non-communicable diseases represent a general problem that, by 2017, had caused approximately 80 % of the overall mortality in mexico. such being the case, aging and 9.4 % overall prevalence of type ii diabetes mellitus (2), as a result of the fact that 71.3 % of the population is overweight and obese, pose a challenge for the health system, especially the high demand of care to be provided by informal caregivers (3). currently, the covid-19 pandemic is added as a new challenge in increasing caregivers' demand. in mexico, the reported cases are 2.46 million people and 231,000 deaths, whereas 71,454 infected individuals and 6,344 deaths are reported in coahuila (4). this increase in cases generates a series of psychological and social responses in people, as they are generally subjected to chronic stress due to social isolation, uncertainty, concern about the risk of death, and complications due to the disease in the people cared for. in most cases, this situation exerts considerable effects on physical and mental health (5, 6). consequently, social isolation resulted in the non-activity of the therapeutic teams, as the care services were suspended during the quarantine, which had repercussions on the caregivers' tasks and limited their free time. it doubles the stress related to caring for people with chronic diseases in a context marked by fear of infection, generating in some caregivers more anxiety and less tolerance towards the people cared for (7). according to recent studies, family caregivers of people with chronic conditions requiring long-term care are mainly women aged 40 to 60, with a higher proportion of daughters and wives (8-10). frequently, family caregivers are members of the family group who take on the role suddenly due to the dependence condition of the person cared for. they are responsible for providing direct care related to feeding, bathing, getting dressed, mobilization, medication administration, and handling of devices, among other activities, in addition to providing emotional and spiritual support to the person cared for and, of course, making decisions and solving care-related problems (11, 12). therefore, becoming the family caregiver of a dependent person is assuming a new role, a transition that implies new functions and, very probably, with a need for support that leads care-givers to search for training and knowledge to adopt the role with dexterity (13). consequently, satisfactory adoption of the role implies learning to perform the tasks inherent to it; in other words, provision of direct care and care management actions, such as organizing the environments, agendas, resources, and support networks to ease the performance of the role. these conditions favor suitable responses to the role, matching the caregivers' burden and quality of life (14). regarding the responses to the caregiver role, the literature reports several ones that can be classified as positive or negative, among which loneliness, anxiety, and depression are the most known. a study conducted in sweden and italy (15) reported a high prevalence of anxiety and depression in caregivers of older adults with dementia, with the following factors related to their higher prevalence: female gender, lacking family support or care takeover, not having any additional occupation other than that of caregiver, and inadequate behaviors of the subject cared for. in addition, the study pointed out that more hours of daily care and being aged between 40 and 54 years old were predictive variables for anxiety and depression symptoms. anxiety and depression are such prevalent and complex problems in the caregivers that even studies conducted with caregivers of cancer patients have revealed higher scores in these variables compared to the patients themselves; they even triple the anxiety and depression levels compared to the people cared for (16). however, anxiety and depression are not independent variables, as the literature shows a correlation between them; anxiety is a predictor of depression. in combination, both are variables associated with a more significant burden and lower quality of life in the caregiver (17, 18). regarding loneliness, it is a prevalent phenomenon not only in the dependent aged population but also in their family caregivers, who often state that they perform their roles marked by loneliness and social isolation (19). a study conducted in spain (20) with caregivers of people with dementia revealed prevalence values between 25 % and 30 % for loneliness and that family dysfunction, lower social support, and fewer leisure activities were related to its higher prevalence. in addition, maladaptive thoughts and behaviors associated with the cultural environment, such as the belief that care issued must be solved inside the house and that a good caregiver does not ask for help, negatively influence the perception of loneliness. furthermore, the evidence supports the theory that loneliness might play a mediating role between that of the caregiver and depression symptoms, which urges us to continue studying these variables together and to determine their relationship dynamics aiming to propose interventions that mitigate their effects on family caregivers of dependent people (21). the objective of this study was to determine the effect of loneliness, anxiety, and depression on the adoption of the role of caregivers of older adults with chronic conditions in a sample of mexican caregivers during the covid-19 pandemic. materials and methods design according to burns and grove's proposal, this study is classified as descriptive, correlational, predictive, and cross-sectional (22). it was conducted during the first half of 2021 in saltillo, coahuila, mexico. sample with the aid of the g power program (23), a sample size of 112 family caregivers was calculated, considering a 0.5 probability of type 1 error, 90 % power (1-β = 0.9), and size effect of 0.3. the latter was considered due to findings reported in previous studies about the correlation between loneliness, anxiety, and depression (21). the sample collected consisted of 157 family caregivers, a sufficient number according to prior calculation. for study viability purposes, purposeful sampling was conducted, including family caregivers aged at least 18 in the research and those who had performed such roles for a minimum of three months and self-declared as primary family caregivers. in addition, pfeiffer's test (24) was used to confirm that the participants had their mental state preserved. data collection data collection was conducted from january to june 2021, considering that, in mexico, aged people and their caregivers were then in confinement, and, given the limitations associated with the covid-19 pandemic, the data were collected through google surveys. the variables to be measured, their instruments, and the psychometric properties are presented below. characterization of the dyad it was carried out based on the dyad characterization survey proposed by chaparro and cols (25). this survey includes 42 items investigating the sociodemographic profile and the care time in hours and months, in addition to the self-perception about the impact on the care provided. the survey is validated in spanish for the colombian context, with good content validity tests and cvr values above 0.7 reported for all the items. the research team performed a review and semantic adjustment of the items for this study. no difficulties associated with non-understanding items were detected during the administration of this survey to the study sample. anxiety and depression they were assessed using the hads scale for anxiety and depression (26). such instrument has seven items that assess anxiety and another seven for depression, measuring the variables using a likert-type scale from 0 to 3 with 21 points as its maximum possible score. in terms of reliability, the instrument's cronbach alpha is 0.83. the scale can be selfor hetero-applied, considering that the higher the score, the higher the anxiety and depression levels. in addition, it has cutoff points to classify the variables into levels: normal, from 0 to 7 points; doubtful, from 8 to 10 points; and an indication of a clinical problem with scores above 10 points. loneliness it was measured with the university of california in los angeles (ucla) scale (27). this questionnaire can be selfor hetero-applied and consists of ten questions. in terms of reliability, the internal consistency of the questionnaire has a cronbach alpha of 0.94. in order to interpret the score, it should be considered that the higher it is, the lower the loneliness level; therefore, there is evidence of profound loneliness if the person reports 19 or fewer points, of moderate loneliness if 20-30 points are reported, and of no anxiety, if the patient reports at least 31 points. adoption of the caregiver role it was assessed with the caregiver role adoption scale (14). this instrument assesses the role transition and has diverse construct validity evidence for three factors or dimensions: responses, organization, and role tasks. regarding reliability, the instrument's internal consistency has a cronbach alpha of 0.8 or higher in the full scale and the subscales. the instrument can be selfor hetero-applied and includes the following strata: insufficient adoption of the role, 22-60 points; basic adoption of the role, 61-77 points; and satisfactory adoption of the role, 78-110 points. ethical considerations participation in this study was voluntary, and acceptance to participate was validated through an informed consent filled out electronically using a google form in which the data were collected. this form did not allow progressing with the questions if such confirmation was not previously made, concluding data collection if no consent to participation was provided. the study was endorsed by the ethics and research committee of the nursing school belonging to universidad autónoma de coahuila. data analysis it was performed with the spss statistical package, version 24. the qualitative variables, including nominal and ordinal ones, were analyzed through the distribution of absolute and relative (proportions) frequencies. statistical data such as mean, standard deviation, minimum and maximum were used, building 95 % confidence intervals (95 % cis) to analyze the continuous quantitative variables. in addition, an analysis was performed with pear­son's correlation coefficient to explore the correlations, with prior adherence to the requirements regarding fit to the standard model or evidence of a size effect below 0.20 (28). finally, a multiple linear regression model was prepared to adopt the caregiver role. results a total of 157 family caregivers with a mean age of 45 years old (sd = 13.75) were included, primarily female (75.2 %, f = 118), married, and homemakers (48.4 %, f = 76), with pre-university schooling level (42.7 %), and seven months as mean care time. regarding the characteristics of the people cared for, their mean age is 62 years old, and they are mostly the caregivers' mothers (51.6 %), with elementary school as the most prevalent schooling level (42 %, f = 63), no partner (49.68 %, f = 78), and needing help to perform activities requiring mobility (60.5 %, f = 95) and activities associated with eliminations (28.7 %, f = 64). in most cases, the person cared for has only one caregiver (56.76 %, f = 89). the sociodemographic characteristics and profiles of the caregivers are presented in table 1. table 1. sociodemographic variables of the informal caregivers and the older adults cared for characteristics of the informal caregivers fr % characteristics of the people cared for fr % gender female male 118 39 75.2 24.8 gender female male 86 71 54.8 45.2 marital status single married separated widowed consensual union 33 76 15 5 28 21 48.4 9.6 3.2 17.8 marital status single married separated widowed consensual union 49 59 10 30 9 31.2 37.6 6.4 19.2 5.7 occupation household chores employee self-employed student other 76 38 21 8 14 48.4 24.2 13.4 5.1 8.9 occupation household chores employee self-employed student unemployed retiree 71 18 20 8 26 24 45.2 11.5 12.7 5.1 16.6 14 schooling elementary school high school pre-university level higher education 33 19 67 38 21 12 42.7 24.2 schooling elementary school high school pre-university level higher education 63 23 44 18 42 14.6 28.1 11.5 person cared for mother/father spouse friend grandfather/grandmother neighbor son/daughter 81 30 11 8 7 20 51.6 19.1 7 5.1 4.5 12.7 perception of burden very high high moderate low 23 41 27 36 14.6 26.1 36.3 22.9 n = 157; % = percentage source: own elaboration table 2 shows the values obtained in the variables of interest, noting that the ics mostly perceive normal anxiety and depression levels, profound loneliness, and satisfactory adoption of the role during confinement due to covid-19. table 2. descriptive statistics of the variables of interest variables percentage mean sd 95 % ci lower limit higher limit hads 22.70 4.12 22.03 23.38 anxiety   7.35 4.44 6.63 4.56 normal 55.4 doubtful 17.6 clinical problem 27 depression   4 3.50 3.43 4.56 normal 80.4 doubtful 14.9 clinical problem 4.7 loneliness   32.56 7.93 31.27 33.85 no loneliness 8.8 moderate loneliness 25 profound loneliness 66.2 role   82.85 11.56 80.96 84.74 insufficient adoption of the role 4.1 basic adoption of the role 24.7 satisfactory adoption of the role 71.2 sd = standard deviation; ci = confidence interval. source: own elaboration table 3 shows the values obtained in the correlations test. it was found that the higher the age of the people cared for, the lower the depression and anxiety levels in the ics; also, the longer the care time, the higher the anxiety and depression levels. table 3.correlation of the variables   1 2 3 4 5 6 7 8 9 10 1. age of the older adult 1   -0.195**               2. care time   1 0.163*               3. hads     1     -0.239**     -0.232**   4. anxiety       1   -0.393** -0.302** -0.194* -0.349** -0.182* 5. depression         1 -0.339** -0.339** -0.307** -0.286** -0.248** 6. ucla           1 0.573** 0.338** 0.645** 0.365** 7. role             1       8. tasks               1     9. responses                 1   10. organization                   1 note: ** = p < .001; * = p < .05. hads = hospital anxiety and depression scale; ucla = loneliness scale. source: own elaboration. the overall score for depression and anxiety was negatively correlated with the loneliness scale and the "responses" dimension of the role scale, i.e., the higher the anxiety and depression levels, the higher the perception of loneliness and the lower the recognition enjoyed by the ics for their activities. likewise, the higher the anxiety, depression, and loneliness levels, the greater the role adoption; in other words, the greater the task performance, response, and care organization. finally, the lower the loneliness level, the more satisfactory the role adoption and its three dimensions. the psychosocial factors, the age of the person cared for, the age of the informal caregiver, and the care time explained 36 % of the variance in adopting the role (f = 13.12; p < .01), with the perception of loneliness (β = -0.147) as a predictive factor. table 4. multiple linear regression model to measure the predictors for adopting the role of caregiver variable b sd b t p-value 95 % ci for exp (p) lower higher anxiety -0.015 0.230 -0.006 -0.067 0.947 -0.471 0.440 depression -0.015 0.230 -0.006 -0.067 0.093 -0.471 0.440 ucla -0.487 0.288 -0.147 -1.693 0.000 -1.056 0.082 age of the person cared for 0.754 0.109 0.520 6.946 0.453 0.540 0.969 age of the caregiver 0.034 0.045 0.051 0.752 0.411 -0.055 0.123 time as a caregiver (months) -0.047 0.058 -0.056 -0.824 0.311 -0.161 0.066 note: dof = degrees of freedom, f calc. = snedecor's f-distribution, p = significance level, b= beta, sd = standard deviation, t = student's t-test. source: own elaboration discussion the current study allowed determining the effect of loneliness, anxiety, and depression on the adoption of the role of caregiver in a sample of mexican caregivers during the covid-19 pandemic. in such a sense, providing care during the pandemic is an action inherent to life, the result of a construction specific to each promotion and protection situation, and a consequence of external factors that can affect family care and health (29). feminization of care was found, with 75.2 %, a lower frequency than that reported in medellin, colombia, where 92.6 % frequency was found, or argentina, where 70 % frequency of female gender was verified (30, 31). as already noted, women have been related to care, being something naturalized and deemed a moral obligation. the main consequences of such naturalization are the following: non-appreciation of care work, the persistence of marked gender stereotypes, and persistence of representing a caregiver's form of love and abnegation (32, 33). on the other hand, we found that the mean care time was seven months, with the shortest period reported in two studies from colombia, with mean values of 37 and 137 months, respectively (34, 35). the scarcity of health professionals and the reducted response to recurrent population consultations in health centers and hospitals during the pandemic made several people assume a new role: family care. the mean of months indicates the need to be a family caregiver during the covid-19 pandemic; however, the time required for this transition is variable and depends on the nature and magnitude of the change. therefore, it is frequent for family caregivers to take on the role in a short period, which does not allow them to reflect or question what they know, what they do not know, the burden it will represent for their lives, or even if they want to assume this role, as often there is no alternative in the face of this reality (13). likewise, in this study, the anxiety level found had a mean of 7.35 (sd = 4.44), while depression obtained a mean of 4 (sd = 3.50). the anxiety level reported in caregivers from mexico city is lower, with a mean of 7.83 (sd = 4.53), whereas depression has a higher value: 5.85 (sd = 5.27) (36). similarly, they were lower than the levels reported in italy, as anxiety obtained a mean of 8.8 (sd = 4.2) and depression reached a value of 7.1 (sd = 4.4) (37). anxiety and depression can result from the burden caused by care itself and the social isolation conditions imposed by covid-19. during data collection, mexico was under strict isolation, where the people cared for were only allowed to go out of their homes for emergencies. along with this, there were restrictive measures for the general population, as access to public places was only allowed to one person per family, and there was a constant concern about the health status of relatives and higher mortality risk due to covid-19 (38, 39). profound loneliness was found in 66.2 % of the caregivers participating in this study, a percentage higher than the one reported in brazil, where 23.8 % of loneliness was found (40). this finding can be due to the data obtained in the current study, as they were collected during the confinement period. in addition, care cannot fall solely on one individual; it must be shared with the entire family because the burden and costs it generates are very high and can only be managed with the egalitarian and fair organization of family work (41). however, this organization was hindered by the global epidemiological situation, as one of the strategies for self-care and family care in the face of covid-19 was reducing interaction with other relatives. another impact on the caregivers was the adoption of the role, which was satisfactory in 71.2 % of the cases. given the need to provide care during the pandemic, informal caregivers assume the role, unaware of the burden it will represent in their lives (42). coupled with the above, during the pandemic, caregivers might feel comfortable when providing care despite having to perform an increasing number of tasks, such as specific care measures and risk control for covid-19 prevention. we also found that the caregivers who acted as such for extended periods had higher anxiety and depression levels, which the caregiver role can explain. they undertake a large number of tasks that can place them in a situation of high vulnerability, such as negative affect states, which increase the risk of feeling emotionally trapped, even with feelings of guilt that can cause capitulation or inability to continue meeting their sick family member's needs (43). however, when the anxiety and depression levels are high, there is a deeper perception of loneliness. this extended time devoted to caring for a family member constitutes a propitious reality for the caregivers to develop physical and mental health disorders, resulting from this responsibility and the high demand to care for another person without due training or the necessary support to do so (42). it was identified that the higher the anxiety and depression levels, the greater the role adoption; it may be due to reflection by the caregivers, which emerges as time passes, as the caring role demands gradually come to light. they usually develop care skills and adequately take on new functions and roles despite their frequent concern regarding care and their activities (42). it is important to note that role adoption increases as loneliness decreases because the family caregivers organize their role, knowing the support the care recipient needs and how they need it. however, although other actors such as the family and close people are involved, it is the family caregivers who decide to seek support, organize, and enliven the relationships with the people supporting them, seeking to maintain such aid active, in force, and motivated to carry out activities most appropriately (13). in such a sense, loneliness, anxiety, depression, and care characteristics, such as the age of the person cared for, age of the caregiver, and care time, exert 36 % influence on the adoption of the role. that said, disease situations have a progression and are associated with the role of adoption and refinement of the care task phases, which, due to their mutual nature, allow growth of the individuals and the dyad. these relationships are modulated by time, family, social networks, and the context, which made most caregivers take on roles or accelerate their adoption due to the covid-19 pandemic (44). far from being a simple redistribution of time and tasks, this new role exerts a significant effect on their livelihoods, considering that they not only had to face the mental health changes caused by this health emergency, and that they needed to do so in isolation and far from their loved ones, but that they also have undergone changes in their roles (32). conclusion family care during confinement due to covid-19 was mainly the responsibility of married women and homemakers who mainly cared for their parents. normal anxiety and depression levels were prevalent, and the participants presented with moderate loneliness and satisfactory adoption of the caregiver role. similarly, anxiety, depression, loneliness, age, and care time influence the adoption of the role by 36 %, with loneliness as a predictive factor. nursing professionals' intervention is necessary to improve the negative affect states, provide more outstanding social support from a comprehensive perspective, and always consider the characteristics of family care. conflicts of interest: the authors declare no conflicts of interest. references 1. montero lópez m, luna-bazaldúa d, shneidman la. loneliness in the elderly in mexico, challenges to the public policies. j chinese sociol. 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[internet]. 2016 my. 12;366:139-45. doi: https://doi.org/10.1016/j.jns.2016.05.016 38. medina i, carreño s, chaparro l, gallegos-torres r, medina j, hernández k. temor, estrés y conocimientos ante el covid-19 en estudiantes y recién egresados de enfermería en méxico. invest. educ. enferm. [internet]. 2021;39(1):1-12. doi: https://doi.org/10.17533/udea.iee.v39n1e05 39. garcía-guillamón g. factores asociados a la ansiedad de los cuidadores de pacientes con enfermedad pulmonar obstructiva crónica (epoc) durante su hospitalización. rev. psicopatol. psicol. clin. [internet]. 2017 sep. 17;22(2):117-125. doi: https://doi.org/10.5944/rppc.vol.22.num.2.2017.17784 40. dos santos-orlandi aa, brigola ag, ottavianni ac, moretti b, nestor é, gomez f, et al. elderly caregivers of the elderly: frailty, loneliness and depressive symptoms. rev. bras. enferm. [internet]. 2019 nov.;72(suppl. 2):88-96. doi: https://doi.org/10.1590/0034-7167-2018-0137 41. flores e, rivas e, seguel f. nivel de sobrecarga en el desempeño del rol del cuidador familiar de adulto mayor con dependencia severa. cienc. enferm. [internet]. 2012 abr.; 18(1):29-41. doi: https://doi.org/10.4067/s0717-95532012000100004 42.eterovic ca, mendoza se, sáez kl. habilidad de cuidado y nivel de sobrecarga en cuidadoras/es informales de personas dependientes. enfermería glob. [internet]. 2015 abr. 02; 14(2):235-248. doi: https://doi.org/10.6018/eglobal.14.2.198121 43.hernández-cantú ei, reyes-silva aks, villegas-garcía ve, pérez-camacho j. ansiedad, depresión y sobrecarga en cuidadores primarios de pacientes internados en un hospital general de zona en nuevo león, méxico. rev. enferm. inst. mex. seguro soc. [internet]. 2017; 25(3):213-220. disponible en http://www.medigraphic.com/pdfs/enfermeriaimss/eim-2017/eim173h.pdf 44. chaparro l. cómo se constituye el "vínculo especial" de cuidado entre la persona con enfermedad crónica y el cuidador familiar. aquichan [internet]. 2011; 11(1)7-22. doi: https://doi.org/10.5294/aqui.2011.11.1.1 home 171 184 atencion domiciliaria.indd 171 gilberto a. gamboa-bernal1 atención domiciliaria de la persona anciana: una perspectiva bioética 1. máster en bioética. facultad de medicina, universidad de la sabana, chía, colombia. gilberto.gamboa@unisabana.edu.co recibido: 25 de noviembre de 2008 aceptado: 12 de junio de 2009 resumen una práctica cada vez más frecuente es la atención domiciliaria de las personas ancianas, la cual genera ciertos problemas que dependen directamente de la longevidad misma, de la patología que pueden padecer y de la actitud que asumen sus familiares o quienes los atienden. el artículo presenta una reflexión sobre esta realidad desde la perspectiva bioética, con el ánimo de proponer cambios en las actitudes que se adoptan frente al anciano que es atendido en la casa. palabras clave anciano, servicios de salud para ancianos, servicios de atención de salud a domicilio, bioética, calidad de vida, instituciones de salud. (fuente: decs, bireme). home care for the elderly: a bioethical view abstract home care for the elderly is becoming increasingly common. this creates certain problems that are directly dependent on the patient’s longevity, pathology and the attitude assumed by the patient’s family members or caregivers. the article examines the facts of this situation from the standpoint of bioethics, in an effort to propose changes in the attitudes adopted towards the elderly who are cared for at home. key words elderly, health service for the elderly, homecare, bioethics, quality of life, health-care institutions. (source: decs, bireme). año 9 vol. 9 nº 2 chía, colombia agosto 2009 171-184 172 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 atenção domiciliária da pessoa idosa: uma perspectiva bioética resumo la atenção domiciliária das pessoas idosas é uma prática cada vez mais freqüente. esta origina alguns problemas que dependem diretamente da longevidade do paciente, da patologia que pode sofrer e da atitude que assumam os seus familiares ou quem os cuidam. neste artigo apresenta-se uma reflexão sobre esta realidade desde a perspectiva bioética, a fim de introduzir mudanças nas atitudes adotadas frente aos idosos cuidados é tratado em casa. palavras-chave idoso, serviços de saúde para idosos, serviços de saúde domiciliária, bioética, qualidade de vida, instituições de saúde. (fonte: decs, bireme). 173 atención domiciliaria de la persona anciana: una perspectiva bioética gilberto a. gamboa-bernal un hecho que los marcadores demográficos no hacen más que constatar (1), es el envejecimiento progresivo de la población (2), que en los países europeos se está constituyendo en un verdadero problema de manejo y sobre el cual los gobiernos han venido tomando medidas conducentes a conjurarlo (3); una de esas alternativas es la atención domiciliaria. las largas listas de espera, la creciente demanda de consulta para la atención de pacientes que cursan patologías crónicas o de entidades propias del envejecimiento y la precaria distribución de profesionales para atenderla, han fomentado la búsqueda de alternativas para la adecuada atención de estos grupos etarios de población. el incremento de personas ancianas es consecuencia —en buena medida— del progreso de la misma ciencia médica: la expectativa de vida ha ido incrementándose al ritmo del desarrollo tecnológico y asistencial. la sofisticación de los recursos diagnósticos ha permitido detectar e intervenir con mayor precocidad patologías que antes se descubrían cuando ya era demasiado tarde. pero a la par con este desarrollo, la asistencia a grupos específicos de la población se ha visto comprometida, y un ejemplo de ello es el caso del paciente anciano (4). el incremento de la demanda no ha permitido la conveniente adecuación de los servicios destinados a la atención de esos grupos; la organización social no se encuentra preparada para manejar con propiedad este tipo de situaciones (5), y esto hace que otras alternativas de prestación de servicios de salud, como la atención domiciliaria, cobre cierta relevancia. a este fenómeno se suma otro que tal vez sea más preocupante, pero no más importante: muchos de esos grupos poblacionales específicos —casi siempre minoritarios (pacientes, negros, mujeres, homosexuales)— se han puesto en la tarea de reivindicar una serie de “derechos” que las más de las veces no pasan de ser sólo meras pretensiones o aspiraciones más o menos legítimas (6). y puede ser más preocupante por la fuerza de presión que saben ejercer sobre la opinión pública en general y sobre la misma comunidad científica. esta presión se puede traducir no sólo en públicas manifestaciones sino en algo que es mucho más delicado: el apoyo de grupos económicos que enarbolan esas nuevas banderas, sin casi ocultar su avidez pecuniaria. poco a poco se han venido creando unos “nuevos derechos humanos” (7), han venido apareciendo nuevas generaciones de ellos. los derechos civiles y políticos hacen parte de una primera generación; los derechos económicos, sociales y culturales de una segunda. hoy se habla de una tercera generación de derechos: derecho al desarrollo, a la paz, a gozar de un medioambiente sano, a la propiedad del patrimonio cultural de la humanidad, a la protección de los datos personales almacenados en sistemas informáticos o los derechos de las generaciones futuras. estos derechos originan no pocos problemas al momento de intentar concretar quién es el titular de ellos, quién es el obligado a cumplirlos, cuál es el objeto y cuál el fundamento de esos derechos. actualmente se propone una cuarta generación de derechos humanos. en esta categoría se han querido introducir pretensiones —más que derechos— de ciertos sectores o grupos sociales: “derechos reproductivos” (entre ellos el derecho al aborto libre el incremento de personas ancianas es consecuencia —en buena medida— del progreso de la misma ciencia médica: la expectativa de vida ha ido incrementándose al ritmo del desarrollo tecnológico y asistencial. 174 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 y subsidiado por el estado)2, derechos de los homosexuales, etc. aunque parezca contradictorio, también se pretende el reconocimiento, dentro de los derechos humanos, del derecho de los animales (8) y de la naturaleza (9). los estudiosos están, en general, en contra de esta cuarta generación de “derechos humanos” (10), sin embargo, existen fuertes movimientos e intereses que buscan su reconocimiento. “no fue otra cosa distinta la que se vio en las últimas dos conferencias mundiales de la onu sobre la población (el cairo, 1994) y sobre la mujer (pekín, 1995)” (11). en el contexto latinoamericano estos problemas apenas se insinúan y no son ajenos al tema que nos ocupa, puesto que las personas ancianas, por su misma condición, pueden ser fácilmente manipulables (12). no es utópico pensar que sea posible hacer de ellas una nueva fuerza contestataria —no tanto por su número como por su condición de indefensión y muchas veces de marginalidad— que en lugar de proponer soluciones para reclamar la atención que en justicia merecen, pueda dificultar la intervención pública y privada en relación con los problemas para los que demandan soluciones. es patente que en la práctica clínica cada vez se está atendiendo a un número creciente de personas ancianas (13): en los hospitales el índice de ingresos de este tipo de pacientes es lentamente creciente. este hecho hace que se empiecen a generar problemas, pues la institución hospitalaria es una estructura física y humana especializada en resolver problemas puntuales de salud, que sin embargo se muestra muy inadecuada como vivienda; entre otras cosas, por el incremento de la rotación de pacientes y la disminución de los días de hospitalización, pero principalmente y como consecuencia directa de lo anterior, porque no ha sido posible —al menos en nuestro medio— evitar la pérdida del sentido de hogar, tan necesario para cualquier ser humano. así, la atención en casa se muestra como un recurso real para brindar al paciente anciano una mejor atención (14). el hogar es el lugar donde transcurre la vida de una persona, y está íntimamente unido a ella. es el lugar donde se guarda a sí misma, donde se mantiene en contacto con sus posesiones, no sólo las materiales. el hogar hace parte de la intimidad de una persona, de cada ser humano, es parte de él mismo. el arraigo hacia el lugar donde se habita es una inclinación natural. el hombre tiende a identificarse con el paraje donde vive, sobre todo cuando ha permanecido un cierto tiempo en ese lugar, que es su hábitat. el hogar es también el ámbito de la intimidad familiar. en su propia casa la persona se siente a gusto porque no hay miradas extrañas, todo le es familiar, no hay que disimular. son numerosas las obras de la literatura y el cine donde se dibujan dramas humanos vivos relacionados con el hogar o su pérdida: la odisea de homero, los hermanos karamazov de dostoyevski, el doctor zhivago de pasternak, lo que el viento se llevó de margaret mitchell, magistralmente llevada al cine, y la pequeña obra maestra de roberto benigni la vida es bella, son sólo algunos ejemplos. 2. la corte constitucional colombiana, mediante sentencia c-355 de 2006, despenalizó el aborto en colombia en tres situaciones y recomendó su reglamentación. el arraigo hacia el lugar donde se habita es una inclinación natural. el hombre tiende a identificarse con el paraje donde vive, sobre todo cuando ha permanecido un cierto tiempo en ese lugar, que es su hábitat. 175 atención domiciliaria de la persona anciana: una perspectiva bioética gilberto a. gamboa-bernal una de las tareas propias del hogar, que nuestra sociedad occidental ha ido perdiendo o abandonando, es el guardar, cuidar y amar a la persona anciana (15). y si en la vida actual se ha ido perdiendo esta natural inclinación, en un centro hospitalario es sumamente difícil de lograr, si no se toma conciencia de ella y no se ponen en práctica pequeñas y sencillas estrategias encaminadas a lograr que la permanencia de un anciano (y en general de cualquier paciente, también los niños) no se constituya en una nueva agresión. los profesionales de la salud no podemos perder de vista que toda hospitalización es una ruptura de nuestro paciente con su ambiente; un cambio brutal que además, en el caso de los ancianos, se produce en un periodo de la vida en el cual las posibilidades de adaptación están muy disminuidas (16). un recurso que puede servir para la aproximación a este sistema de la atención en casa del paciente anciano puede ser la reflexión bioética. y parecería un buen camino utilizar el contexto que estuvo en el origen de esta nueva ciencia. la bioética (17)3 resurgió en el ambiente biomédico norteamericano, allí adquirió su primera configuración y recibió su primer impulso con el apoyo de instituciones serias4 que, desde años atrás, tenían como uno de sus principales cometidos el permear la práctica profesional con los elementos rectores de la ética. sin embargo, las siguientes reflexiones tendrán un enfoque que parte de la persona, pues parece preferible al modelo principialista, propuesto por beauchamps y childress, en su conocido libro principios de ética biomédica, uno de los pioneros en bioética y precursor de la encyclopedia of bioethics. este paradigma –el principialista–, que tiene amplia difusión en la bioética norteamericana, se resume en la formulación de los principios de autonomía, de beneficencia, de no maleficencia y de justicia (18). y aunque es indudable que estos principios contienen elementos válidos, su mutua articulación no guarda la coherencia antropológica que es necesaria cuando de personas se habla, y no aclaran qué se debe entender, por ejemplo, por el bien de la persona y por la autonomía del individuo (18). además, tales principios son interpretados a la luz de dos teorías que poco pueden tener de coincidentes: el utilitarismo y la deontología. el principialismo carece de una antropología fundante; los principios sostenidos por él están indeterminados y esto lleva necesariamente al relativismo ético (19); no hay una jerarquía entre los cuatro principios. el empuje de la bioética en la segunda mitad del siglo xx no pudo ser ajeno al utilitarismo, pues una de las raíces del contexto norteamericano está en el pragmatismo que desde finales del siglo xix quiso servir de base a la reflexión filosófica. una de las derivaciones del pragmatismo originario de c. s. pearce es el pragmatismo utilitarista que pretendió establecer el significado de las cosas por sus consecuencias, privilegiar la acción (pragma en griego) sobre la reflexión, hacer depender la verdad, el ser de las cosas –y el bien– del éxito de las acciones, de su utilidad. por el contrario, otro enfoque de la bioética se apoya en la realidad del ser una de las tareas propias del hogar, que nuestra sociedad occidental ha ido perdiendo o abandonando, es el guardar, cuidar y amar a la persona anciana. 3. el término bioética se utilizó por primera vez en el editorial de la revista kosmos de 1927; allí aparece un escrito de fritz jahr titulado “bio-ética. una perspectiva sobre la relación ética del hombre con los animales y plantas”. 4. el hastings center y el kennedy institute of ethics. 176 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 personal, en su dignidad propia e inalienable, en el estatuto objetivo y existencial (ontológico) de la persona, en su unitotalidad de cuerpo y espíritu (20). este modelo está muy lejos de poderse confundir con el individualismo subjetivista (21) —al que podría parecerse— que subraya, casi como constitutivo único de la persona, la capacidad de autodecisión y de elección. un modelo de bioética que parte de la persona habla también de principios, pero los toma en su genuina acepción5 y los considera, no exentos, sino íntimamente ligados a la realidad del ser personal y a su correspondiente dignidad (22). estos principios muestran su alcance en la reflexión sobre los diversos casos de la biomedicina, y en el estudio de los principales momentos éticos vinculados con la práctica biomédica. pasaremos, por tanto, a reflexionar sobre la realidad de la persona anciana que recibe atención en casa, a la luz de los principios ofrecidos por este modelo de bioética, aunque en líneas anteriores ya se hayan comentado algunos elementos. principio de defensa de la vida física la vida física de la persona es una realidad abordable sólo de manera sistémica (23). “quien pretenda entender la vida humana desde un punto de vista analítico, más si es meramente empírico o biologista, está abocado al fracaso, porque la vida no se ve; no tiene ni forma ni figura. lo que se ve es el vivo, pero no la vida del vivo. se ven las manifestaciones del vivo, pero no la vida que permite tales acciones” (24). la vida humana es un movimiento que no es físico, es inmaterial; es interno, no transitivo; es el acto primero que anima todas las restantes operaciones vitales que se denominan actos segundos (nutrición, sensaciones, desarrollo, etc.) (25); vivir es el acto primero, o si se prefiere, siguiendo a aristóteles, vivir para los seres vivos es ser (26). la vida de cada ser vivo es principio que controla los movimientos propios (27). los seres vivos –y a la cabeza de ellos la persona humana–, son más que sustancias, son naturalezas, principios intrínsecos de operaciones. es por esto que las operaciones son secundarias respecto de la vida, y hacen parte del proceso de humanización (27). la vida humana es un valor fundamental, no absoluto (28); es el primer valor del cual dependen todos los restantes. se dice valor fundamental porque se debe entender que: la vida corporal no agota toda la riqueza de la persona, la cual es también, y ante todo, espíritu, y por esto trasciende como tal al cuerpo mismo y a la temporalidad. sin embargo, respecto de la persona el cuerpo es coesencial, el fundamento único en el cual y por medio del cual la persona se realiza y entra en el tiempo y en el espacio, se expresa y se manifiesta, construye y expresa los otros valores (…) (19). por todo esto, y mucho más, la vida del paciente anciano es valiosa y, como tal, hay que tratarla. no es posible soslayar que detrás de la fragilidad, de la disminución de la autonomía física o social, de las limitaciones propias del paso de los años, etc., siempre está en la base de la 5. se entiende por principio la fuente de donde deriva o procede algo real. existen diversos tipos de principios: los físicos, que son las cuatro causas (material, formal, eficiente y final); los metafísicos, que son los primeros principios reales; los cognoscitivos y apetitivos, que son las facultades o potencias, etc. vida de una persona anciana un valor intrínseco que parte de la experiencia que aportan los años vividos —y muchas veces sufridos— y que se puede revelar en distintos contextos, si se lo permitimos. pero en nuestro medio, en la cultura occidental, aunque se sostenga esto en la teoría, la práctica revela una verdad algo distinta: la retórica habitual consiste en ensalzar la vejez, pero en la práctica es ésta una etapa de soledad, abandono y pérdida. precisamente en aquellos aspectos en los que suele invocarse la solidaridad social suele percibirse un discurso ambiguo, cuando no equívoco. la mayor demanda de servicios asistenciales en la edad provecta suele aparecer como un lastre para los rendimientos societarios (29). el reflejo de esta realidad en el paciente anciano que se cuida en casa se traduce más en actitudes que en acciones. y aunque en el ambiente familiar pueda pensarse que las atenciones estarían mejor invertidas en los niños y las personas jóvenes, esta postura solo refleja una base conceptual utilitarista. la defensa a ultranza del bienestar de muchos lleva a descuidar necesariamente la atención de los más débiles, de los más indefensos, como los discapacitados, los ancianos, los enfermos incurables y también los no nacidos. cuando se habla del principio de defensa de la vida física hay también necesidad de concretar qué es calidad de vida, pues bajo este concepto no se incluyen generalmente las mismas realidades, dado que éste es un término equívoco (30). para el utilitarista la calidad de vida es el componente de una ecuación: posibilidad de éxito + calidad de vida + duración de vida costos = intensidad del deber de beneficencia 177 atención domiciliaria de la persona anciana: una perspectiva bioética gilberto a. gamboa-bernal según esta ecuación son los costos, en último término, los que determinarán cuál ha de ser la calidad de vida: a mayores costos, menor calidad de vida, a menores costos más calidad de vida. pero una sana y correcta apreciación ética no puede aceptar tal ecuación. “la llamada calidad de vida se interpreta principal o exclusivamente como eficiencia económica, consumismo desordenado, belleza y goce de la vida física, olvidando las dimensiones más profundas –relacionales, espirituales y religiosas– de la existencia” (31) . en el contexto utilitarista se usa el término calidad de vida para procurar conjurar el sufrimiento humano. pero una aproximación a la realidad del sufrimiento permitirá desligarlo de una calidad de vida sanamente comprendida. el sufrimiento es algo todavía más amplio que la enfermedad, más complejo y más profundamente enraizado en la humanidad misma; el sufrimiento físico se da cuando de cualquier manera duele el cuerpo, mientras que el sufrimiento moral es dolor del alma. se trata, en efecto, del dolor de tipo espiritual, y no solo de la dimensión psíquica del dolor que acompaña tanto al sufrimiento moral como al físico (32). el sufrimiento surge cuando el hombre interioriza tanto el dolor físico como aquello que se opone a su bien o a su felicidad. en un anciano este proceso es más vivido y esto es importante tenerlo en cuenta. las líneas que siguen versarán preferentemente sobre el sufrimiento humano, dejando de lado la realidad fisiológica del dolor, pero retomando sus consecuencias para el ser personal del hombre, y así tratar de encontrar el sentido antropológico del sufrimiento. la primera pregunta que surge en torno al sufrimiento es su “por qué”. como se ha dicho, el sufrimiento es una realidad que la experiencia manifiesta a diario; sería necio negar el sufrimiento humano; es una realidad que el hombre enfrenta, pero la causa de su existencia está envuelta en el misterio, principalmente cuando se ve esa realidad encarnada en una persona inocente, indefensa o anciana (33). solo con el tiempo se puede llegar a tratar de desentrañar su causa aunque en ocasiones muchas personas nunca lleguen a ello. la respuesta al porqué del sufrimiento es sencilla pero por lo mismo difícil de asimilar: el hombre sufre porque además de ser viviente, sabe que lo es; pero no sólo esto, el hombre sufre principalmente porque tiene corazón (34). el sentido del sufrimiento es un poco más intrincado que su causa. y si se decía que algunas personas no llegan a entender el porqué del sufrimiento, muchas más no pueden encontrar respuesta al para qué. ¿qué sentido puede tener el sufrimiento humano? el ambiente actual no ve ningún sentido, significado o valor al sufrimiento del hombre; como se afirmaba antes, el enrarecido concepto de “calidad de vida”6 lo excluye de plano como un verdadero mal, que hay que evitar a toda costa o eliminar cuando se presenta (35). es un hecho que el hombre reacciona al sufrimiento con la natural tendencia a rechazarlo, pero no porque necesaria6. la calidad de vida, correctamente entendida, lejos de desestimar el sufrimiento lo considera como una realidad que es casi siempre susceptible de contribuir al crecimiento integral de la persona. al sufrir, la persona no ve mermada su calidad de vida, antes por el contrario, le puede encontrar sentido. el sufrimiento surge cuando el hombre interioriza tanto el dolor físico como aquello que se opone a su bien o a su felicidad. en un anciano este proceso es más vivido y esto es importante tenerlo en cuenta. 178 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 mente lo considere un mal en sí mismo, sino porque el sufrimiento contradice la vocación radical del hombre a la felicidad. esto tampoco quiere decir que el sufrimiento sea antihumano, o inhumano, y mucho menos antinatural. simplemente es una manifestación más de que el hombre está llamado a realizar su propia naturaleza y reacciona cuando esto se le dificulta o se le impide. es en este sentido, en el plano ético, como el sufrimiento puede ser valorado como bueno, el criterio de bondad o maldad depende de la relación a la perfección de la naturaleza y al cumplimiento de los fines. una buena y positiva manera de ver el sufrimiento referido a la persona humana es la de considerarlo como una oportunidad de cambio: tendrá sentido si permite un cambio personal (36); la decisión de “aprovechar” esa posibilidad está en el interior (37) y depende directamente del grado de comprensión que la persona tenga de su potencialidad de perfección. también influye, aunque menos, el grado de equilibrio psicoafectivo que la persona posea y su capacidad de manifestarlo. ante el sufrimiento el hombre puede decidir encerrarse en sí mismo o darse con generosidad; puede contraerse sobre su instinto, o abrirse al mejor conocimiento de sus limitaciones existenciales y de sus recursos espirituales; puede revelarse ante su destino o reorientarlo y conducirse a su verdadero y trascendente fin; puede hacerse la criatura más desdichada o alcanzar la felicidad por un camino sólo en apariencia heterodoxo. los ancianos no sólo sufren sino que también mueren, y muchas veces padeciendo un síndrome de enfermedad terminal. es por ello que es obligatorio pensar en la muerte para poder asumir frente al anciano moribundo las actitudes convenientes. la muerte forma parte de la vida de cada uno y constituye un momento personal y único. vivir y morir forman parte de lo mismo: morir es uno de los parámetros del vivir. cada vida humana que se apaga en el silencio es un misterio que apenas pueden intuir los que están a su lado. nadie puede sustituir al anciano moribundo, ni tan siquiera comprenderle, pues por mucho que alguien intente ponerse en su lugar, siempre se estará muy lejos y distante de quien agoniza. el que se muere lo hace a solas consigo mismo; nadie puede hacerlo por él. la muerte constituye una situación límite íntimamente relacionada con la personal trayectoria biográfica y las actitudes ante la vida que se hayan tenido. estas actitudes marcarán sus vivencias y orientarán el comportamiento que se manifiesta en la fase terminal, cuando la hay, pues no siempre así acontece. la atención al anciano enfermo en esta fase terminal constituye una de las funciones más importantes e ineludibles del médico, para la que casi no recibe en la actualidad ningún tipo de información. pero también es cierto que a nadie se le enseña a morir, ni en la casa, ni en el colegio, ni en la universidad. la pedagogía de la muerte debería empezar desde el principio de la educación. los padres no suelen hablar de la muerte a sus hijos, como tampoco los maestros a sus alumnos. una de las manifestaciones más graves de aquella omisión es que los médicos evitan hablar de la muerte a los enfermos. y es que en occidente se prefiere ignorar la muerte, aunque en nuestro medio es un hecho que el hombre reacciona al sufrimiento con la natural tendencia a rechazarlo, pero no porque necesariamente lo considere un mal en sí mismo, sino porque el sufrimiento contradice la vocación radical del hombre a la felicidad. 179 atención domiciliaria de la persona anciana: una perspectiva bioética gilberto a. gamboa-bernal vivamos inmersos en una verdadera cultura de la muerte (38). tanto es así que el anciano moribundo suele inhibir y ocultar sus sentimientos al respecto. su comportamiento acaso esté justificado por resultarle extraordinariamente difícil disfrutar de la presencia y el apoyo de una persona en quien poder confiar, de manera que sea posible comentar con ella lo que piensa e imagina acerca de la muerte. para esto es necesario tener su confianza; que el enfermo esté persuadido de que si hace ciertas preguntas no se le contestará con mentiras o evasivas. en la comunicación con el anciano, y con cualquier enfermo terminal, no hay lugar para las mentiras piadosas. aunque algunos autores afirmen lo contrario, no puede ser posible escamotear la verdad a una persona que libremente la desea acerca de un hecho fundamental para su existencia. y si, como se decía atrás, al médico no se le forma para tratar al paciente terminal, mucho menos para saber cómo hablar con él y cómo prestarle la información que se le debería facilitar en relación con su propia muerte. en la actualidad, en el entorno de un enfermo terminal se da un cambio de actitudes y comportamientos. lo ordinario es que al paciente se le aísle, creándose alrededor de él un extraño clima de sobreprotección y distanciamiento, entreverado en ocasiones de engaño, que ha sido calificado justamente con el término “conspiración del silencio” (39). esta situación se pretende justificar aludiendo a la necesidad de evitar al paciente el “trauma” que, seguramente, podría causarle conocer la gravedad del estado en que se encuentra. los familiares más próximos quieren convencerse de que el enfermo es mucho menos consciente de su situación de lo que suele ser. quienes así piensan se olvidan de que en ocasiones el propio enfermo es moralmente más fuerte que los que le cuidan. en estos casos es lógico pensar que la “conspiración del silencio” a quien realmente protege no es al anciano enfermo, sino a sus familiares y cuidadores. de ahí que sean éstos quienes —acaso por sus temores y la angustiosa resonancia que en ellos produce la vivencia de la muerte— traten de sustraer al paciente y a sí mismos de enfrentarse con la situación y tomar las decisiones oportunas. se engaña a los moribundos porque a los vivos les cuesta decir la verdad. el criterio por el que no se comunica la verdad, en la mayor parte de los casos, no es por caridad con el que se va a morir sino por el miedo del que sigue vivo. en la mayoría de las pseudos-razones y los argumentos a los que se apela para tratar de hacer racional lo que en absoluto es, late incontenible una gran falsedad. es falso que la persona que está muy grave ignore la más de las veces su estado; que si se le informa puede empeorar a causa de la noticia suministrada; que tal vez se le haga sufrir con esa información más de lo necesario, etc. la comunicación profunda con el enfermo terminal exige, previamente, haber tomado conciencia de la decadencia personal y de la propia muerte, y haber superado la angustia que esto conlleva. de lo contrario, el profesional de la salud sólo verá en el paciente el reflejo de su propia y mal asumida muerte, por lo que difícilmente le podrá ayudar. el engaño, el distanciamiento y la innecesaria aplicación de técnicas agresivas durante esta en occidente se prefiere ignorar la muerte, aunque en nuestro medio vivamos inmersos en una verdadera cultura de la muerte. tanto es así que el anciano moribundo suele inhibir y ocultar sus sentimientos al respecto. 180 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 etapa son manifestaciones que expresan bien la intención de huir de la confiada y profunda relación con la persona que se está muriendo. también expresan la convicción –más o menos consciente– que pueda tener el médico, o su equipo de trabajo, de que la muerte es un enemigo contra el que se ha de luchar irrestrictamente, sin admitir nunca la posibilidad de fracaso. y es que el médico ha sido formado para combatir la muerte y salir victorioso. la actitud del médico frente a la muerte ha de ser diametralmente opuesta (40): no es un enemigo al que imperiosamente hay que vencer, la muerte es una amiga que se debe conocer, que se debe respetar, que se debe aprender a tratar; más aún, en realidad el médico no está ni frente a ella, ni en contra de ella, sino frente a una persona que la experimenta y a la que hay que ayudar. el médico es también responsable de que al paciente no se le deje solo con su sufrimiento, en estas circunstancias. el médico ha de intervenir personalmente siempre que, en su equipo o en la familia del enfermo, no haya nadie más capacitado que pueda y quiera hacerlo. a pesar de que haya otra persona que reúna estas características, el médico debe aportar siempre su ayuda, bien de forma indirecta o bien colaborando directamente con las personas que más estrechamente cuidan al paciente. esta relación entre el médico y el paciente forma parte –y parte importante e irrenunciable– del tratamiento que el paciente ha de recibir. a través de esa relación, el médico puede aliviar o aumentar las expectativas del paciente, aun cuando persistan o sean muy intensas sus molestias, más allá del tratamiento antálgico que de forma adecuada esté recibiendo. para el médico, ayudar a morir con dignidad significa asistir durante el proceso de la muerte al enfermo y a sus familiares, con honestidad y compasión. además de administrar los cuidados físicos y psicológicos necesarios, ha de esmerarse en evitar el sufrimiento y la inseguridad, que con mayor frecuencia son producidos por la soledad y la indiferencia; y también ha de facilitar el apoyo y la asistencia espiritual que necesita su paciente (41). larga ha salido la reflexión sobre el primer principio de defensa de la vida física. sin embargo, es necesario tener presentes todas y cada una de las anteriores líneas para estar en capacidad de brindar al anciano que se atiende en casa parte del cuidado que su estado personal demanda. de manera necesariamente sucinta terminaremos mencionando, sin comentar en extenso, otros tópicos que ayudan al personal de salud a manejar lo más integralmente posible al anciano. y esto lo haremos siguiendo los otros principios derivados del modelo bioético que parte de la realidad ontológica de la persona, teniendo en cuenta que siempre se han de reflexionar a la luz del primer principio: la defensa de la vida física. principio de libertad y responsabilidad este principio ha de aplicarse siempre antecedido de la salvaguardia de la vida física, pues para actuar con libertad es necesario estar vivo (42); pero a este principio han de atenerse tanto el personal del equipo sanitario –cuando de una hospitalización se trata–, como la misma familia cuando atiende a un anciano en su casa, como el paciente, de tal manera que ni el pacienpara el médico, ayudar a morir con dignidad significa asistir durante el proceso de la muerte al enfermo y a sus familiares, con honestidad y compasión. 181 atención domiciliaria de la persona anciana: una perspectiva bioética gilberto a. gamboa-bernal te puede forzar la conciencia de quien le atiende, ni el personal de salud ni la familia puede imponer su criterio sin contar con el parecer del paciente. en el caso del paciente anciano es importante tener presente este principio pues, por su misma condición (43), en ocasiones se puede tender a desestimar su opinión y su consentimiento. “ni la conciencia del paciente puede ser violentada por el médico, ni la del médico puede ser forzada por el paciente: ambos son responsables de la vida y de la salud tanto como bien personal cuanto como bien social” (19). algunos detalles, que pueden parecer pequeños, se derivan de guardar este principio: la intimidad del anciano (44) ha de ser tenida en cuenta y valorada en casos tan simples como el uso del pato, del baño, las visitas, etc. a la par con la intimidad hay que cuidar el pudor del anciano: exámenes físicos, procedimientos especiales, traslados, administración de terapias y tratamientos, higiene, etc. no es posible olvidar que en general los pacientes ancianos no tienen comprometida su capacidad de consentir y no pierden tampoco su competencia legal; por tanto, es necesario tenerlo en cuenta en el momento de adelantar acciones que a ellos los involucren: hay que contar con su permiso, con su consentimiento, se les debe informar siempre, se ha de conocer qué piensan, qué quieren. estas actitudes frente al anciano se han de dar también cuando su independencia física, económica o social esté empezando a declinar, o incluso cuando su libertad física esté altamente comprometida, siempre y cuando su dimensión cognitiva lo permita. principio de totalidad o principio terapéutico este principio de basa en el hecho de que la corporeidad humana es un todo unitario resultante de distintas partes, que están unificadas entre sí de una manera orgánica y jerárquica por la existencia personal y única (45). dentro de este principio está vinculada la norma de la “proporcionalidad de las terapias” (46): cuando se decide practicar cualquier terapia, ésta ha de evaluarse en el contexto de la totalidad de la persona, de modo que se tengan en cuenta y exista cierta proporción entre los riesgos y daños que tal terapia pueda ocasionar, y los beneficios derivados de ella. siguiendo este principio se han de cuidar, entre otras muchas cosas, las siguientes: la manera como se viste al anciano (una simple bata con abertura posterior no es generalmente suficiente para que el anciano se encuentre a gusto), pero también la manera como viste el personal que le trata son importantes; la forma como se maneja al paciente cuando padece de alguna deformidad o simplemente está conectado a diversos artefactos; el respeto que se les demuestra al llamarlos por su nombre o utilizando un tratamiento más formal; el respeto por sus silencios, etc. el paciente anciano necesita que le sea proporcionada una seguridad mínima, que normalmente encuentra en casa, pero que es conveniente no dar por supuesta, pues en algunas ocasiones no puede realizar por sí mismo muchas cosas simples, por su estado de dependencia y desvalimiento, de incompetencia y discapacidad. hay que procurar hacerles sentir que hay siempre alguien a su lado y que son queridos (47): no son detalles irrelevantes el ni la conciencia del paciente puede ser violentada por el médico, ni la del médico puede ser forzada por el paciente: ambos son responsables de la vida y de la salud tanto como bien personal cuanto como bien social. 182 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 tomarles de la mano, tocarles la cabeza con respeto, dar una suave palmada en la espalda, etc., pero teniendo en cuenta, por supuesto, que no todos los ancianos agradecen esos detalles de cariño, y que incluso pueden llegar a reaccionar con cierta agresividad. también hay que tener en cuenta que la alimentación y los patrones de sueño del anciano son diferentes, y hay que prever y estar atentos ante la posibilidad de caídas, accidentes, etc. todas estas medidas materiales son importantes, pero más que cuidado y seguridad físicas, lo que el anciano generalmente necesita es compañía, amor, comprensión y paciencia. la experiencia con la utilización de los cuidados paliativos en casa en el caso de los pacientes con enfermedades terminales muestra con claridad cómo sí es posible tener en cuenta los elementos derivados de este principio. principio de sociabilidad y subsidiariedad sgreccia habla de este principio en los siguientes términos: el principio de sociabilidad compromete a todas y cada una de las personas en su propia realización al participar en la realización del bien de sus semejantes. en el caso de la promoción de la vida y de la salud, implica que todo ciudadano se ha de comprometer a considerar su propia vida y la de los demás como un bien, no sólo personal, sino también social, y compromete a la comunidad a promover la vida y la salud de todos y cada uno, a fomentar el bien común promoviendo el bien de todos y cada uno (19). este principio se aplica con gran propiedad en el caso de la atención domiciliaria de pacientes. cuando el estado y las instituciones de salud no alcanzan a dar un cubrimiento apropiado, la iniciativa particular o privada cobra especial relevancia (48). no es posible desconocer que tampoco este mecanismo está exento de dificultades, pero la buena organización —y formación adecuada de los empleados— de las empresas que se constituyen para brindar este cuidado domiciliario, un óptimo sistema de contratación con el estado y las instituciones prestadoras de salud, y la convicción de que los ancianos (y muchos más pacientes) pueden recibir una mejor atención en sus casas, harán de este sistema una muy buena opción. solo tres aspectos mencionaré para concluir el comentario de este principio. el primero es la aceptación que demanda el anciano por parte de quienes le cuidan, le tratan o acompañan. a este respecto hay que tener en cuenta que la mayoría de estos pacientes tienen la tendencia a permanecer callados, tal vez recordando su pasado; que anhelan no ser olvidados por los suyos; que aprecian la compañía de sus seres queridos, y en especial de sus nietos. otro aspecto que también hay que tener en cuenta es el ayudar al anciano a manejar el miedo que generalmente le acompaña. muchas veces el miedo se encubre en una actitud de resignación, de inconformidad o de abierta crítica y exigencia, esto hay que saber comprenderlo para poder darle un manejo adecuado. sencillas estrategias facilitan esta tarea: el trabajo de explicarles todo; que el anciano perciba cómo los miembros del equipo de salud, que se desplazan hasta el domicilio para prestarle las necesarias ayudas que demanda un entrenamiento específico, hablan con sus familiares, y que esa relación es cordial y productiva; el solo hecho de la alimentación y los patrones de sueño del anciano son diferentes, y hay que prever y estar atentos ante la posibilidad de caídas, accidentes, etc. todas estas medidas materiales son importantes, pero más que cuidado y seguridad físicas, lo que el anciano generalmente necesita es compañía, amor, comprensión y paciencia. 183 atención domiciliaria de la persona anciana: una perspectiva bioética gilberto a. gamboa-bernal acompañar y estar dispuestos a escuchar ayuda a que el anciano pueda conjurar sus miedos (49). cuando sea necesario, no se debe olvidar el recurso a la interconsulta con grupos de apoyo especializado. finalmente, es necesario decir una palabra sobre un fenómeno que aparentemente no debería revestir mayor problema pero que es necesario tener en cuenta para dar un buen manejo a los ancianos que reciben atención domiciliaria: el saber cuándo y cómo trasladarlo al centro de atención sanitaria. hay que entrenar a los familiares o cuidadores para que sepan moverse entre dos extremos: no precipitar traslados a la clínica, al hospital o al centro de salud cuando se experimenta la primera complicación, o posponerlos tanto que cuando se hacen efectivos ya es tarde para brindar una ayuda real al anciano enfermo. todo lo anterior no puede quedarse solo en palabras o en buenas intenciones, con aquéllas y con éstas el anciano atendido a domicilio no se sentirá mejor tratado. las acciones de las personas que conforman los equipos de salud han de tener siempre ese apoyo proporcionado por una ética que se lleva a la vida diaria, que no se contenta con mínimos, que tiene siempre por fundamento el ser personal de cada paciente, de cada colega, de cada ser humano. referencias bibliográficas 1. populations. eu population compared with other world regions. europe in figures. eurostat yearbook 2006-07. disponible en http://epp.eurostat. ec.europa.eu/cache/ity_offpub/ks-cd-06-001-01/ en/ks-cd-06-001-01-en.pdf. 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obstructive pulmonary disease in colombia article effects of pulmonary rehabilitation in men compared to women with chronic obstructive pulmonary disease in colombia efectos de la rehabilitación pulmonar en hombres vs. mujeres con enfermedad pulmonar obstructiva crónica en colombia efeitos da reabilitação pulmonar em homens vs. mulheres com doença pulmonar obstrutiva crônica na colômbia 10.5294/aqui.2021.21.1.6 jhonatan betancourt-peña1 juan carlos ávila-valencia2 arley facundo-duarte3 1 0000-0002-7292-7628. institución universitaria escuela nacional del deporte, colombia. jhonatan.betancourt@endeporte.edu.co 2 0000-0003-3642-6428. institución universitaria escuela nacional del deporte. colombia. juanc.avila@endeporte.edu.co 3 0000-0003-4403-7780. institución universitaria escuela nacional del deporte, colombia. arley.facundo@endeporte.edu.co received: 19/06/2020 sent to peers: 13/07/2020 approved by peers: 01/12/2020 accepted: 28/01/2021 to reference this article / para citar este artículo / para citar este artigo: betancourt-peña j, ávila-valencia jc, facundo-duarte a. effects of pulmonary rehabilitation in men compared to women with chronic obstructive pulmonary disease in colombia. aquichan. 2021;21(1):e2116. doi: https://doi.org/10.5294/aqui.2021.21.1.6 abstract objective: to determine the effects of pulmonary rehabilitation in men and women with a copd diagnosis in a colombian clinic. method: a longitudinal and descriptive study was conducted with 75 copd patients who entered a pulmonary rehabilitation program during 2018 and 2019. the population was divided into groups according to gender and some sociodemographic characteristics were assessed, such as spirometry expressed in percentage of the predicted value, body mass index, mmrc dyspnea, and capacity for physical exercise, as well as some physiological variables with the six-minute walk test, anxiety-depression (hads) and quality of life (sgrq). a p-value<0.05 was considered statistically significant. results: the cigarette packs smoked per year index was higher in men, 34±29.11 (p<0.001), whereas the exposure to firewood smoke was five times higher in women (p=0.037). all the variables related to the capacity for physical exercise improved significantly (p<0.021), with distance covered standing out: 63.26±60.03 vs. 51.53±61.02 in favor of women. mmrc dyspnea was initially higher in women when compared to men, 0.709±0.287, and presented a greater change in women with 1.294±0.415 when compared to men, 0.736±0.880, at the end of pulmonary rehabilitation. conclusion: pulmonary rehabilitation in women shows an increase of 63.26 meters in the distance covered and a 1.294-point reduction in dyspnea; while, for men, these figures were 51.53 meters and 0.736 points, respectively, as well as an improvement in quality of life in men by 11.47 sgrq points when compared to women: 0.600. keywords (source decs): rehabilitation; lung diseases; sex; dyspnea; quality of life; exercise. resumen objetivo: determinar los efectos de la rehabilitación pulmonar en hombres y mujeres con diagnóstico de epoc en una clínica de colombia. método: estudio descriptivo longitudinal en 75 pacientes con epoc que ingresaron a un programa de rehabilitación pulmonar durante el año 2018 y 2019. la población se dividió en grupos según el sexo y se evaluaron algunas características sociodemográficas, la espirometría en porcentaje del predicho, el índice de masa corporal, la disnea mmrc, la capacidad de ejercicio y algunas variables fisiológicas con el test de la caminata de los seis minutos, la ansiedad-depresión (hads) y la calidad de vida (sgrq). se tuvo un valor p<0,05 como estadísticamente significativo. resultados: el índice paquetes fumados por año fue mayor en hombres 34±29.11 (p<0,001), mientras que la exposición al humo de leña fue cinco veces mayor en las mujeres (p=0,037). todas las variables de capacidad de ejercicio mejoraron significativamente (p<0,021), sobresaliendo la distancia recorrida 63,26±60,03 versus. 51,53±61,02 a favor de las mujeres. la disnea mmrc fue inicialmente mayor en las mujeres comparado con hombres 0,709±0,287 y evidenció un mayor cambio en las mujeres 1,294±0,415 versus hombres 0,736±0,880 al final de la rehabilitación pulmonar. conclusión: la rehabilitación pulmonar en mujeres muestra un incremento en la distancia recorrida de 63,26 metros, disminución de 1,294 puntos en la disnea, para hombres 51,53 metros y 0,736 puntos respectivamente, y una mejoría en la calidad de vida en hombres de 11,47  puntos sgrq con respecto con mujeres de 0,600. palabras clave (fuente decs): rehabilitación; enfermedades pulmonares; sexo; disnea; calidad de vida; ejercicio físico. resumo objetivo: determinar os efeitos da reabilitação pulmonar em homens e mulheres com diagnóstico de dpoc em uma clínica na colômbia. método: estudo descritivo longitudinal em 75 pacientes com dpoc que ingressaram em programa de reabilitação pulmonar durante os anos de 2018 e 2019. a população foi dividida em grupos de acordo com o sexo e foram avaliadas algumas características sociodemográficas, espirometria em porcentagem do previsto, índice de massa corporal, mmrc dispneia, capacidade de exercício e algumas variáveis  fisiológicas com o teste de caminhada de seis minutos, ansiedade-depressão (hads) e qualidade de vida (sgrq). considerou-se o valor de p <0,05 como estatisticamente significativo. resultados: a taxa de fumaça de maços por ano foi maior nos homens 34 ± 29,11 (p <0,001), enquanto a exposição à fumaça de lenha foi cinco vezes maior nas mulheres (p = 0,037). todas as variáveis da capacidade de exercício melhoraram significativamente (p <0,021), destacando-se a distância percorrida 63,26 ± 60,03 versus 51,53 ± 61,02 a favor das mulheres. o mmrc dispneia foi inicialmente maior nas mulheres em relação aos homens 0,709 ± 0,287 e evidenciou maior alteração nas mulheres 1,294 ± 0,415 versus homens 0,736 ± 0,880 ao final da reabilitação pulmonar. conclusão: a reabilitação pulmonar em mulheres mostra um aumento na distância percorrida de 63,26 metros e uma diminuição de 1.294 pontos na dispneia, enquanto para os homens os valores obtidos foram 51,53 metros e 0,736 pontos, respectivamente, e uma melhoria na qualidade de vida nos homens de 11,47 pontos do sgrq em relação às mulheres, onde foi de 0,600 pontos. palavras-chave (fonte: decs): reabilitação; pneumopatias; sexo; dispneia; qualidade de vida; exercício físico. introduction chronic obstructive pulmonary disease (copd) has historically had a connotation of male predominance, mainly associated with the smoking habit (1). on the other hand, it has been described that the prevalence of copd is higher in men than in women in any age group (2); furthermore, in countries like china, its prevalence is two-fold in men (3). however, in other countries, the smoking habit can even be stronger in women, and higher prevalence is evidenced in this population (2,4). it is important to consider that, in patients with copd, two types of interventions are recommended: pharmacological and non-pharmacological, this latter being of great relevance as it includes pulmonary rehabilitation; however, it has been evidenced that the medical personnel can better diagnose copd in men than in women, which affects treatment, allowing men greater access to the health services (4,5,6). several authors suggest that copd has different physiological and psychological impacts in men than in women (5,7). the evidence indicates that men and women can be phenotypically different in their response to the smoke from tobacco, and even to other risk factors of the disease, reason why their intervention needs could vary according to the clinical and functional condition (8). although the benefits of the interventions are equally manifested both in men and for women, it is important to consider that the effects of pulmonary rehabilitation can bring about different outcomes according to gender, which renders it necessary that, in some conditions, individualization of the interventions be indispensable to denote benefits in similar proportions (8). on the other hand, in latin america, the studies investigating copd considering the patients’ gender are scarce; and it is even rarer to find studies in which there is evidence of the changes in the aerobic capacity, anxiety or depression, and quality of life, the latter being related to the health of male and female patients who undergo pulmonary rehabilitation (pr). for this reason, the objective of this study was to determine the effects of pulmonary rehabilitation in men and women with a copd diagnosis in a clinic in the city of cali, colombia. methods this is a longitudinal and descriptive study. it was conducted from july 2018 to july 2019 and two groups of patients with copd were linked according to gender (men and women), which was corroborated by the patients’ medical record. participants a total of 75 male and female patients with a medical diagnosis of copd (chronic bronchitis and pulmonary emphysema types) were included in the study. they underwent pulmonary rehabilitation (pr) in the city of cali, colombia. the study was approved by the ethics committee of the clinic and adopted the norms outlined in resolution 8,430 of the ministry of health and social protection and the declaration of helsinki. the following were adopted as inclusion criteria: a) patients who signed the informed consent; b) diagnosis by post-bronchodilator spirometry, according to the american thoracic society guidelines (9); and c) first-time participation in a pr program. whereas the exclusion criteria were as follows: a) cognitive change which limited assessment; and b) uncontrolled heart or metabolic diseases. instruments and materials the following variables were taken into account in this study: age, gender, socioeconomic status, marital status, a smoking habit with its respective index of packs smoked per year (p/y), exposure to firewood smoke, use of home oxygen, fev1, fvc, fev1/fvc in post-bronchodilator spirometry expressed in percentage of the predicted value, body mass index (bmi), and modified medical research council (mmrc) dyspnea in the activities of daily living (10). in turn, the six-minute walk test (6mwt) was performed at the beginning and the end of pr following all the ats (11) recommendations and recording the following data: distance covered, estimated oxygen consumption (vo2), mets, respiratory frequency, borg’s dyspnea and fatigue in the lower limbs according to borg’s modified scale, spo2 at the beginning and at the end, and degree of desaturation at the end of the stop test during the 6mwt. once the 6mwt was finished, the patients answered the anxiety and depression questionnaire, assessed with the hospital anxiety and depression scale (hads), which has 14 items and 2 subscales with 7 items each; one for anxiety and the other for depression. in this way, scores over 11 points are indicative of clinical problems; scores between 8 and 10 points are considered probable, and results below 8 points are considered normal (12). subsequently, the saint george´s respiratory questionnaire (sgrq) (13) for health-related quality of life (hrqol) was administered, which consists of 50 questions grouped into three domains: symptoms (8 items), activity (16 items), and impact (26 items). the results are expressed as percentages and the final score varies from zero (best performance) to one hundred (worst performance) (12). pulmonary rehabilitation program all the patients are assessed by a pulmonologist before entering the program. this professional determines the inclusion criteria for the pr program; once the patients are referred to the program, they are assessed by a physiotherapist specialized in cardiac and pulmonary rehabilitation that defines the intervention objectives for each of them. the pr program was conducted during 24 sessions distributed in 3 sessions per week for a total of 8 weeks. physical exercise activities were performed in each pr session. they presented the following routine: general warming and muscle strengthening exercises (4 series of 12 repetitions) in the first weeks with 50 % of maximum resistance (mr) for upper and lower limbs, and mr was increased to 60 % after 4 weeks. the estimation of mr was carried out based on the number of times that the patients managed to make each movement assessed using the correct technique (14); subsequently, the continuous exercise was executed on a treadmill for 30 minutes, beginning at 60 % of the estimated vo2 reached in the aerobic capacity test (6mwt). the estimation of vo2 was calculated with the following formula: vo2 = 3.5 ml/kg/min + (speed m/min × 0.1) and, in turn, the calculation of the mets was performed by mets = vo2/3.5 (15), which allowed prescribing physical exercises in a precise manner for each of the participants. the progression in the intensity of the continuous exercise on the treadmill was guided considering borg’s modified scale; for this, speed and angle were changed, maintaining a score between 3 (moderate) and 5 (severe) (16) for each of the sessions. the educational component was also implemented, which consisted of individual and group sessions on topics such as knowledge of the disease, importance of quitting smoking, inhalators and their adequate use technique, recognition of the alert signs, home oxygen, adequate nutrition, measures against panic and anxiety, and home breathing exercises (14,17). the individual sessions were conducted during the pr sessions; and the group sessions, once a week, were attended by patients and family members. data analysis a descriptive analysis of all the variables was performed. the qualitative variables are presented as frequency and percentage, whereas the behavior of each quantitative variable was assessed using normality tests using kolmogorov-smirnov’s test, which presents results in mean values and standard deviations. the difference between the data found according to gender at the beginning and the end of the program was determined from the student’s t-test for independent samples; on the other hand, to determine the changes presented by the men and women after pr, the student’s t-test for paired samples was applied. a p-value below 0.05 was considered statistically significant for the variables analyzed at the beginning and the end of the study. results table 1 shows the patients’ sociodemographic characteristics. the total population consisted of 75 patients, mainly men (55). in the men, the mean age was 70.78 ± (8.636) and, in the women, 70.85 ± (10.36). more than 90 % of the participants live in the city of cali and less than half of the men (43.6 %) and the women (45 %) presented excess weight. the marital status of most of the men was stable union (70.9 %), in opposition to the women, who were mostly in unstable relationships (p=0.01). concerning the smoking habit, most of the men (90.9 %) and women (65 %) were smokers (p=0.019). also, it was found that more than half of the men (54.4 %) and the women (65 %) belonged to the middle and high socioeconomic strata, which identifies the access capacity to the rehabilitation services of the population with more resources. they belonged to the contributive health regime (81.8 % vs. 85 %), did not use home oxygen (52.7 % vs. 50 %), had been admitted to urgency departments (69.1 % vs. 70 %), and hospitalized (58.2 % vs. 50 %) in the last year, respectively. in addition, although exposure to firewood smoke was relatively low in the total population, it was observed that 40 % of the women were exposed, against 16.4 % of the men. table 1. characteristics of the men and women variables men n=55 women n=20 p-value age 70.78 ± (8.636) 70.85 ± (10.36) 0.977 grouped marital status stable union 39 (70.9 %) 7 (35.0 %) 0.010 no stable union 16 (29.1 %) 13 (65.0 %)   grouped place of residence cali 50 (90.0 %) 19 (95.0 %) 0.923 outside cali 5 (9.1 %) 1 (5.0 %)   stratum low 25 (45.5 %) 7 (35.0 %) 0.585 middle/high 30 (54.5 %) 13 (65.0 %)   hpe subsidized 10 (18.2 %) 3 (15.0 %) 0.982 contributive 45 (81.8 %) 17 (85.0 %)   home oxygen yes 26 (47.3 %) 10 (50.0 %) 0.958 no 29 (52.7 %) 10 (50.0 %)   urgency departments yes 38 (69.1 %) 14 (70.0 %) 0.836 no 17 (30.9 %) 6 (30.0 %)   hospitalization yes 32 (58.2 %) 10 (50.0 %) 0.712 no 23 (41.8 %) 10 (50.0 %)   bmi classification thin 6 (10.9 %) 1 (5.0 %) 0.742 normal 25 (45.5 %) 10 (50.0 %)   excess weight/obesity 24 (43.6 %) 9 (45.0 %)   smoked yes 50 (90.9 %) 13 (65.0 %) 0.019 no 5 (9.1 %) 7 (35.0 %)   exposure to firewood smoke yes 9 (16.4 %) 8 (40.0 %) 0.064 no 46 (83.6 %) 12 (60.0 %)   meanwhile, table 2 shows a comparison of the clinical factors between men and women. the mean of the pack/year index was significantly higher in men than in women (34.07 ± 29.11 vs. 9.7 ± 12.01, with an se of means difference of 24.37 ± 4.758 and a p-value<0.001. the mean time of exposure to firewood smoke in years was also lower in men (1.36 ± 3.941 vs. 6.15 ± 9.315) with an se of means difference of -4.786 ± 1.524 and a p-value<0.037. both the visits to urgency departments (2.70 ± 4.835 vs. 0.98 ± 0.991) and the hospitalizations (1.10 ± 1.832 vs. 0.78 ± 0.994) in the last year presented a higher mean value in the women, whereas the number of hospitalization days was higher in the men (8.62 ± 11.62 vs. 6.40 ± 8.016). fev1 (44.23 ± 14.89 vs. 43.54 ± 12.92), fvc (69.80 ± 18.78 vs. 67.32 ± 17.82), and fev1/fvc (61.24 ± 10.34 vs. 63.25 ± 6.144) were similar to those of the women. table 2. clinical comparison between men and women with copd variables men n=55 women n=20 se of means difference p-value visits to urgency departments in the last year 0.98 ± (0.991) 2.70 ± (4.835) -1.718 ± (3.994) 0.131 hospitalizations in the last year 0.78 ± (0.994) 1.10 ± (1.832) -0.318 ± (1.210) 0.468 days hospitalized 8.62 ± (11.62) 6.40 ± (8.016) 2.218 ± (3.405) 0.434 fev1 44.23 ± (14.89) 43.54 ± (12.92) 0.696 ± (6.801) 0.854 fvc 69.80 ± (18.78) 67.32 ± (17.82) 2.473 ± (7.176) 0.611 fev1/fvc 61.24 ± (10.34) 63.25 ± (6.144) -2.003 ± (5.924) 0.311 p/y index 34.07 ± (29.11) 9.700 ± (12.01) 24.37 ± (4.758) <0.001 time of exposure to firewood smoke in years 1.36 ± (3.941) 6.15 ± (9.315) -4.786 ± (1.524) 0.037 in relation to the changes presented in table 3 after pulmonary rehabilitation, a clinical improvement with statistical significance (p<0.05) was found in men and women in distance covered (51.53 ± 113.7 meters vs. 63.26 ± 60.03 meters), speed (7.320 ± 13.73 meters/minute vs. 8.144 ± 14.5 meters/minute), estimated vo2 (1.4 ± 2.229 ml/kg/min vs. 0 806 ±1.452 ml/kg/min), mets (0.399 ± 0.633 mets vs. 0.234 ± 0.415 mets) and mmrc dyspnea (0.736 ± 0.88 vs. 1.294 ± 0.415). initial mmrc dyspnea was significantly higher in women (3.6 ± 1.273 vs. 2.89 ± 1.031, p<0.001). table 3. changes in men and women with copd after pulmonary rehabilitation variable men n=55   pre-pr men n=55   post-pr se of means difference p-value women n=20 pre-pr women n=20  post-pr se of means difference p-value bmi (kg/m2) 24.14 ± (4.473) 23.77 ± (5.511) 0.467 ± (3.272) 0.303 26.33 ± (6.192) 25.63 ± (5.750) 0.703 ± (2.715) 0.261 distance covered (meters) 316.2 ± (113.7) 369.4 ± (107.4) -51.53 ± (61.02) <0.001 226.1 ± (120.6) 289.4 ± (124.7) -63.26 ± (60.03) <0.001 speed (m/min) 52.71 ± (18.95) 60.43 ± (19.61) -7.320 ± (13.73) <0.001 37.68 ± (20.10) 45.82 ± (22.93) -8.144 ± (14.50) 0.021 hr at rest (bpm) 82.05 ± (13.33) 83.42 ± (11.85) -1.264 ± (14.60) 0.531 82.00 ± (11.50) 81.06 ± (11.35) 0.833 ± (11.22) 0.757 hr at the end of 6mwt (bpm) 107.2 ± (15.69) 110.2 ± (15.53) -3.113 ± (12.30) 0.071 104.4 ± (14.64) 102.3 ± (20.65) 2.222 ± (14.00) 0.510 sao2 at rest (%) 93.38 ± (3.188) 94.25 ± (3.088) -0.887 ± (2.486) 0.012 94.50 ± (2.306) 94.94 ± (2.100) -0.278 ± (1.127) 0.311 sao2 at the end of 6mwt (%) 86.85 ± (6.246) 87.06 ± (6.954) -0.094 ± (4.198) 0.871 89.65 ± (4.475) 88.39 ± (5.992) 1.333 ± (2.473) 0.035 desaturation (%) 6.53 ± (5.228) 6.95 ± (5.880) -0.418 ± (4.528) 0.496 4.85 ± (3.843) 5.85 ± (5.412) -1.000 ± (3.261) 0.186 rf at rest (brpm) 19.87 ± (4.342) 21.42 ± (10.60) -1.585 ± (10.12) 0.260 19.85 ± (3.435) 19.89 ± (3.197) 0.444 ± (5.090) 0.716 rf at the end of 6mwt (brpm) 26.13 ± (4.982) 26.00 ± (5.446) 0.358 ± (4.884) 0.595 26.30 ± (3.672) 28.56 ± (4.985) -1.667 ± (5.941) 0.250 borg at rest 0.47 ± (0.790) 0.30 ± (0.723) 0.189 ± (0.982) 0.168 0.60 ± (0.940) 0.29 ± (0.772) 0.412 ± (0.870) 0.069 borg at the end of 6mwt 2.04 ± (1.774) 1.72 ± (1.524) 0.321 ± (1.978) 0.243 2.25 ± (1.482) 2.00 ± (1.904) 0.412 ± (2.265) 0.464 fatigue in lls at rest 0.40 ± (0.735) 0.32 ± (0.754) 0.094 ± (0.741) 0.358 0.90 ± (1.210) 0.71 ± (1.404) 0.353 ± (0.996) 0.163 fatigue in lls at the end 1.51 ± (1.585) 1.72 ± (1.714) -0.245 ± (1.505) 0.241 2.30 ± (2.250) 1.94 ± (1.819) 0.353 ± (1.693) 0.403 stops in 6mwt 0.25 ± (0.552) 0.12 ± (0.323) 0.135 ± (0.397) 0.018 0.70 ± (1.129) 0.70 ± (0.831) 0.000 ± (1.118) 1.000 estimated vo2 (ml/kg/min) 8.045 ± (2.490) 9.445 ± (2.109) -1.400 ± (2.229) <0.001 7.275 ± (2.012) 8.082 ± (2.304) -0.806 ± (1.452) 0.022 mets 2.297 ± (0.706) 2.697 ± (0.601) -0.399 ± (0.633) <0.001 2.081 ± (0.578) 2.315 ± (0.656) -0.234 ± (0.415) 0.021 mmrc 2.89 ± (1.031) 2.11 ± (1.155) 0.736 ± (0.880) <0.001 3.60 ± (1.273) 2.41 ± (1.004) 1.294 ± (0.920) <0.001 had: anxiety 5.75 ± (4.186) 4.62 ± (4.030) 1.212 ± (4.021) 0.034 7.85 ± (5.594) 6.65 ± (4.974) 1.294 ± (3.158) 0.110 had: depression 4.76 ± (3.882) 4.15 ± (3.280) 0.769 ± (3.376) 0.107 4.95 ± (3.486) 4.06 ± (3.631) 0.824 ± (2.430) 0.181 sgrq symptoms 49.22 ± (20.06) 37.09 ± (19.89) 12.30 ± (21.59) <0.001 47.45 ± (22.38) 35.00 ± (24.66) 13.20 ± (24.11) 0.117 sgrq activities 61.07 ± (22.51) 49.60 ± (22.97) 10.37 ± (23.25) 0.002 61.00 ± (24.78) 53.00 ± (24.87) 6.800 ± (15.49) 0.198 sgrq impact 41.04 ± (17.98) 29.28 ± (17.55) 11.18 ± (15.54) <0.001 32.82 ± (15.14) 33.60 ± (17.18) -0.300 ± (8.097) 0.909 sgrq total 50.65 ± (16.30) 38.60 ± (17.30) 11.47 ± (14.31) <0.001 45.18 ± (15.41) 44.50 ± (17.08) 0.600 ± (12.07) 0.879 there were also clinically positive results in both groups for had anxiety (1.212 ± 4.021 vs. 1.294 ± 3.158) and hrqol (sgrq total [11.47 ± 14.31 vs. 0.6 ± 12.07], sgrq symptoms [12.30 ± 21.59 vs. 13.2 ± 24.11], sgrq activities [10.37 ± 23.25 vs. 6.8 ± 15.49]), although statistically significant (p<0.05) only in men. the sgrq total showed statistical significance (p=0.000) with an important clinical improvement only in men, whereas it remained almost unchanged in women (11.47 ± 14.31 vs. 0.6 ± 12.07). the sgrq presented similar results in men and women in the symptoms (49.22 ± 20.06 vs. 47.45 ± 22.38) and activities (61.07 ± 22.51 vs. 61 ± 24.78) items, but worse in men in the impact (41.04 ± 17.98 vs. 32 82 ± 15.4) and total (50.65 ± 16.3 vs. 45,18 ± 15,41) items, with statistical significance only the group of men, possibly associated to the sample of women being smaller. arterial o2 saturation at rest presented statistical significance in men (p=0.012), although it did not vary in a significant manner between the two groups (-0.887 ± 2.486 vs. -0.278 ± 1.127). arterial o2 saturation at the end of the 6mwt in women presented a slight increase with statistical significance (p=0.035), whereas the clinical impact was limited in men (1,333 ± 2.473 vs. -0.094 ± 4.198). although not reaching statistical significance, the desaturation percentage during the 6mwt at the beginning and  the end of pulmonary rehabilitation did present clinical importance in men (6.53 ± 5.228 vs. 6.95 ± 5.880) and in women (4.85 ± 3.843 vs. 5.85 ± 5.412), although the means differences only showed a slight increase of desaturation in women (-1.0 ± 3.261). in the number of stops during the 6mwt, the means difference was statistically significant in the men (0.135 ± 0.397) and did not vary in the women (0.0 ± 1.118). variables such as respiratory frequency, heart rate, and fatigue did not show important clinical or statistically significant changes in any group. when comparing the preand postvariables between men and women, table 4 shows that both distance covered (90.18 ± 30.17 vs. 80.03 ± 29,98) and speed (15.03 ± 5.03 vs. 14.61 ± 5.377) presented important and statistically significant clinical differences (p<0.05) between men and women, respectively; similarly, estimated vo2 (0.769 ± 0.62 vs. 1.363 ± 0.564) and mets (0.216 ± 0.176 vs. 0.381 ± 0.160) presented increases, although the latter with statistical significance only at the end of the program. although the number of stops reached statistical significance at the end of the program, it did not present clinical relevance. sgrq impact (8.218 ± 5.804 vs. -4.317 ± 6.033) and sgrq total (5.473 ± 5.341 vs. -5.896 ± 5.955) presented a slight clinical advantage in the se of means difference in favor of the men at the beginning of the program, and an advantage in favor of the women at the end. the rest of the variables do not show clinical or statistically significant changes. table 4. comparisons between men and women at the beginning and the end of the pulmonary rehabilitation program   comparison of pre-pr variables between men and women comparison of post-pr variables between men and women variable se of means difference p-value se of means difference p-value bmi (kg/m2) -2.193 ± (1.299) 0.096 -1.860 ± (1.463) 0.208 distance covered (meters) 90.18 ± (30.17) 0.004 80.03 ± (29.98) 0.009 speed (m/min) 15.03 ± (5.030) 0.004 14.61 ± (5.377) 0.008 hr at rest (bpm) 0.055 ± (3.365) 0.987 2.360 ± (3.201) 0.464 hr at the end of 6mwt (bpm) 2.618 ± (4.028) 0.518 7.894 ± (4.623) 0.092 sao2 at rest (%) -1.118 ± (0.779) 0.156 -0.699 ± (0.785) 0.376 sao2 at the end of 6mwt (%) -2.795 ± (1.524) 0.071 -1.332 ± (1.836) 0.471 desaturation percentage (%) 1.677 ± (1.281) 0.194 1.095 ± (1.504) 0.469 rf at rest (brpm) 0.023 ± (1.078) 0.983 1.526 ± (2.548) 0.551 rf at the end of 6mwt (brpm) -0.173 ± (1.221) 0.888 -2.556 ± (1.456) 0.084 borg at rest 0.127 ± (0.217) 0.560 0.008 ± (0.205) 0.970 borg at the end of 6mwt -0.214 ± (0.445) 0.632 -0.283 ± (0.452) 0.533 fatigue in uls at rest -0.500 ± (0.288) 0.095 -0.385 ± (0.356) 0.293 fatigue in uls at end of 6mwt 0.791 ± (0.547) 0.160 -0.224 ± (0.485) 0.645 number of stops during 6mwt -0.445 ± (0.263) 0.104 -0.649 ± (0.207) 0.006 estimated vo2 (ml/kg/min) 0.769 ± (0.620) 0.219 1.363 ± (0.564) 0.018 mets 0.216 ± (0.176) 0.224 0.381 ± (0.160) 0.020 mmrc -0.709 ± (0.287) 0.016 -0.299 ± (0.312) 0.343 had: anxiety -2.105 ± (1.200) 0.084 -2.032 ± (1.194) 0.094 had: depression -0.186 ± (0.988) 0.851 0.095 ± (0.941) 0.920 sgrq symptoms 1.764 ± (6.752) 0.795 2.094 ± (7.125) 0.770 sgrq activities 0.073 ± (7.557) 0.992 -3.396 ± (8.022) 0.674 sgrq impact 8.218 ± (5.804) 0.162 -4.317 ± (6.033) 0.477 sgrq total 5.473 ± (5.341) 0.309 -5.896 ± (5.955) 0.326 discussion this study allowed determining that, in the population under study, men participate more in pulmonary rehabilitation programs when compared to women; and that, despite the growing prevalence in the latter group, copd affects both genders almost equally (18). this situation can be related to the delay in seeking medical assistance by the women (19) and to the fact that the medical personnel diagnoses the disease to more men because it is related to the smoking habit, which probably leads to more referrals to the pr programs (5,7).  it is noted that, in colombia, there is growth in the prevalence of women with copd, whereas the results of the prepocol (20) and puma (21) studies reported higher prevalence in men. a more recent study showed that the prevalence between 2010 and 2015 was higher in women (22); nevertheless, this is based on the diagnoses obtained from the medical consultations of the colombian population and could present underestimations given the difficulty in contrasting with diagnostic tests such as spirometry. the study entitled proyecto latinoamericano de investigación en obstrucción pulmonar (platino) (23), conducted in five latin american countries (brazil, chile, mexico, uruguay, and venezuela), also showed that the prevalence of copd was higher in men; however, in countries such as sweden and canada, higher prevalence is reported in women (2, 24). this increase in the prevalence of copd in women is possibly because smoking habit index in high-income countries is similar between men and women, which is in opposition to middleand low-income countries (1) since the prevalence of copd is directly related to that of the smoking habit. added to this, air pollution in closed places due to the burning of wood and other biomass fuels, such as organic sources for energy production, generate gases and harmful particles, thus becoming another important occupational factor of copd in some countries (18), this type of exposure being more common in women (25). regarding the sociodemographic conditions, most of the participants of this study lived in the city of cali, which aligns with the description by some authors who state that, in our context, the patients with copd mainly attend pulmonary rehabilitation programs located in the big cities, thus reflecting access to the pr programs (26). it has also been evidenced that the smoking habit is not an exclusive risk factor associated with copd, as set out by the who, and, therefore, there are clear differences in risk factors between men and women (25, 27). in this study, the time of exposure to firewood smoke was 5 times higher in women, which is similar to the national data, where 39 % of the population over 40 years old, living in the five main cities, had cooked with firewood for more than 10 years. consequently, the risk is higher in women due to their more frequent devotion to the art of cooking (28). this same situation has been reported in a study conducted in china, where exposure to firewood smoke is higher in women and, consequently, it is a more relevant risk factor than the smoking habit (7). half of the study population used home oxygen, a condition that could have been related to the severity of the airflow limitation in the total population according to the 2021 gold guide (gold 3: severe, fev1 mean<45 %) (18). this is supported by the conclusions of perincek and avci (29), who found that bmi, fev1, and smoking habit, among others, affect the severity of copd. the women presented more admissions to urgency departments and hospitalizations, although the men had longer stays, data that are in agreement with those reported by other authors (19). in addition, lisspers et al. (30) reported a higher risk (12 %) for early exacerbation in men and a higher number of visits to urgency departments, hospitalizations and hospital stays when considering the incidents related to copd (23). all the variables related to the capacity for physical exercise showed clinically and statistically significant improvements. the distance covered in the 6mwt test and the preand post-pr speeds were higher in the men, but it was the women that presented the most significant change at the end of the program in both variables, evidencing increases of 63.26 meters in distance covered and of 8.144 m/min in speed in the post-pr 6mwt test. in both cases, the clinically significant minimum difference of 35 meters was exceeded (31). spielmanns et al. (32) also found a lower pre-pr distance in women and a greater difference in the distance covered in women post-pr, because the initial walk distance is related to the response probability, since a longer initial walk distance is in line with a reduced response probability, as was the case with the men in our study. vo2 and the mets also improved significantly in both groups, although in these two variables the gain was greater in the men since robles et al. (33) reported similar results: the women presented worse pre-pr results than the men and the capacity for physical exercise improved similarly in both genders. nevertheless, in one of the studies reviewed, it was reported that the average improvement did not reach clinical relevance for any of the groups (even when taking 54 m as a clinically significant distance). pulmonary function was homogeneous and the mmrc data presented statistical significance in both groups (p<0.001), with higher dyspnea numbers both at the beginning and at the end of pr. nevertheless, a more relevant clinical difference was found pre-pr. according to these data, a systematic review sets outs that, for a similar degree of airflow limitation, women present more dyspnea than men. likewise, a clinical improvement was found in both groups, as well as greater impact in the women at the end of pr (33). however, reports were also found with similar baseline dyspnea values in both genders, such as the study by jia g. et al. (7) with mmrcm<2. on the other hand, the initial anxiety level was higher in the women, with a similar clinical improvement post-pr. these results are similar to those reported by other authors (34), who state that women are more concerned about caring for their disease; however, it has been reported that, in pr programs, both genders showed similar anxiety levels and health statuses with similar improvements, although reduced post-pr (33). the pre-pr depression level and the post-pr improvements presented similar behaviors in both groups. sgrq also presented an important positive change in both groups concerning symptoms and activities, whereas the impact and total items only improved in men. the systematic review by robles et al. (33) suggests that women present more probabilities of being benefited in terms of dyspnea, health, and psychological state; with respect to hrqol, the studies did not find gender differences, reason why it is assumed that pr equally benefits men and women in relation to the quality of life (35). as limitations of this study, it is evidenced that, in the population linkage, there could have been biases in the selection because no randomized sampling selection was performed, which was evidenced in a predominance of linked men in the study. in its turn, the instruments used do not guarantee initial homogeneity between the genders, the reason why their sensitivity to change due to this condition should be a study motivation for future research. the use of mixed-methods studies might help to better understand the results of the interventions based on physical exercise, given that, although both groups experienced significant improvements, these results may be perceived differently according to gender. conclusions in this study, it was evidenced that, when compared to the men, the women presented more dyspnea and lower aerobic capacity before the pulmonary rehabilitation. however, after pr, the women presented improvements of 1.294 points in mmrc dyspnea and 63.26 meters in distance covered related to the aerobic capacity, p-value=<0.001; on the other hand, the men presented reductions of 1.212 points in anxiety, p-value=0.034, and of 11.47 points in quality of life in the total sgrq domain, p-value=<0.001. given the above, a different impact is evidenced in pulmonary rehabilitation between men and women; and, for this reason, studies are suggested with interventions targeted at responding to the particular needs of the patients with copd who require pulmonary rehabilitation. acknowledgments: to the population of participants, to clínica de occidente s.a. and to institución universitaria escuela nacional del deporte. conflict of interests: none declared. 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available from: https://revistas.uis.edu.co/index.php/revistamedicasuis/article/view/9230/9051 home 1 astrid nathalia páez esteban1 claudia consuelo torres contreras2 maría stella campos de aldana3 sonia solano aguilar4 nubia quintero lozano5 olivia lorena chaparro díaz6 costos directos e indirectos derivados del cuidado familiar del paciente con enfermedad crónica no transmisible 1 https://orcid.org/0000-0003-0010-7564. facultad de ciencias de la salud, universidad de santander, colombia. ast.paez@mail.udes.edu.co 2 https://orcid.org/0000-0001-7064-9380. facultad de ciencias de la salud, universidad de santander, colombia. clau.torres@mail.udes.edu.co 3 https://orcid.org/0000-0002-6190-181x. facultad de ciencias de la salud, universidad de santander, colombia. al.campos@mail.udes.edu.co 4 https://orcid.org/0000-0003-3250-0942. facultad de ciencias de la salud, universidad de santander, colombia. convenios@udes.edu.co 5 https://orcid.org/0000-0002-5746-3896. hospital san juan de dios de floridablanca, colombia. 6 https://orcid.org/0000-0001-8241-8694. red latinoamericana de cuidado al paciente crónico y la familia, universidad nacional de colombia, colombia. olchaparrod@unal.edu.co recibido: 29/07/2019 enviado a pares: 19/08/2019 aceptado por pares: 17/03/2020 aprobado: 01/04/2020 doi: 10.5294/aqui.2020.20.2.2 para citar este artículo / to reference this article / para citar este artigo páez na, torres cc, campos de aldana ms, solano s, quintero n, chaparro ol. direct and indirect costs of caring for patients with chronic non-communicable diseases. aquichan. 2020;20(2):e2022. doi: https://doi.org/10.5294/aqui.2020.20.2.2 resumen objetivo: determinar los costos directos no aplicables a los servicios de salud e indirectos derivados del cuidado familiar del paciente con enfermedad crónica no transmisible (ecnt) de tres instituciones de salud del área metropolitana de bucaramanga, colombia. metodología: estudio transversal descriptivo en 77 personas con ecnt y sus cuidadores familiares, seleccionados mediante muestreo sistemático entre 2018 y 2019. resultados: la mayoría de las personas con ecnt son mujeres (55 %), con una edad media de 70 años. cuatro de cada cinco cuidadores son mujeres, con una edad media de 40 años, y ofrecen cuidados 14 horas por día, en promedio. el costo año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2022 temática: cuidado crónico. aporte a la disciplina: conocer los costos relacionados con el cuidado familiar de la persona con enfermedad crónica permite visibilizar el cambio de la dinámica familiar no solo en el aspecto físico, psicológico y funcional, sino también financiero, debido al aumento de los costos y a la disminución de los ingresos del paciente y del cuidador. estos aspectos se deben tener en cuenta en el momento de definir una política y una estrategia para cualificar estos cuidados y mantener el bienestar personal y familiar. https://orcid.org/0000-0003-0010-7564 mailto:ast.paez@mail.udes.edu.co https://orcid.org/0000-0001-7064-9380 mailto:clau.torres@mail.udes.edu.co https://orcid.org/0000-0002-6190-181x mailto:al.campos@mail.udes.edu.co https://orcid.org/0000-0003-3250-0942 mailto:convenios@udes.edu.co https://orcid.org/0000-0002-5746-3896 https://orcid.org/0000-0001-8241-8694 mailto:olchaparrod@unal.edu.co https://doi.org/10.5294/aqui.2020.20.2.2 https://orcid.org/0000-0003-0010-7564 https://orcid.org/0000-0001-7064-9380 https://orcid.org/0000-0002-6190-181x https://orcid.org/0000-0003-3250-0942 https://orcid.org/0000-0002-5746-3896 https://orcid.org/0000-0001-8241-8694 https://doi.org/10.5294/aqui.2020.20.2.2 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2022 total mensual atribuido al cuidado familiar del paciente fue de 324.207 pesos colombianos, en promedio. los costos más representativos son en salud, alimentación, vivienda, transporte y comunicaciones. el 60,5 % de los pacientes con ecnt asumían las finanzas del hogar antes de enfermar y, de estos, aproximadamente la mitad dejó de trabajar y la otra mitad presentó una reducción del 33 % en sus ingresos mensuales después de enfermar. conclusión: los costos relacionados con el cuidado familiar aumentan y los ingresos de los pacientes con ecnt y de sus cuidadores disminuyen, debido a que se requieren tratamientos, cuidados e intervenciones complementarias e integrales, entre otras. palabras clave (fuente: decs) costo de enfermedad; gastos en salud; enfermedades no transmisibles; cuidadores; enfermedades cardiovasculares. 3 costos directos e indirectos derivados del cuidado familiar del paciente con enfermedad crónica no transmisible l astrid nathalia páez esteban y otros direct and indirect costs of caring for patients with chronic non-communicable diseases abstract objective: to determine direct and indirect non-medical costs derived from caring for patients with chronic non-communicable diseases (ncds) in three health institutions located in the metropolitan area of bucaramanga, colombia. methods: a descriptive crosssectional study was conducted with 77 patients with ncds and their family caregivers, who were selected through systematic sampling between 2018 and 2019. results: most people with ncds are women (55 %) at an average age of 70. four out of five caregivers are women, at an average age of 40, who deliver care for an average of 14 hours a day. the total monthly cost for patient care was on average 324,207 cop. the most significant costs are related to health, food, housing, transport, and communication. 60.5 % of ncds patients were responsible for household finances before becoming ill. about half of them stopped working and the other half experienced a reduction of 33 % in their monthly income after becoming ill. conclusion: due to the need for complementary and comprehensive treatment, care, and interventions, costs related to care of ncds patients increase despite the income of ncds patients and their caregivers do not. keywords (source: decs/mesh) cost of illness; health expenditures; noncommunicable diseases; caregivers; cardiovascular diseases. año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2022 4 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2022 aquichan issn 1657-5997 eissn 2027-5374 custos diretos e indiretos derivados do cuidado familiar do paciente com doença crônica não transmissível resumo objetivo: determinar os custos diretos não aplicáveis aos serviços de saúde e indiretos derivados do cuidado familiar do paciente com doença crônica não transmissível (dcnt) de três instituições de saúde da área metropolitana de bucaramanga, colômbia. metodologia: estudo transversal descritivo com 77 pessoas com dcnt e com seus cuidadores familiares, selecionados mediante amostra sistemática entre 2018 e 2019. resultados: a maioria das pessoas com dcnt são mulheres (55 %), com idade média de 70 anos. quatro de cada cinco cuidadores são mulheres, com idade média de 40 anos, e oferecem cuidados 14 horas por dia, em média. o custo total mensal destinado ao cuidado familiar do paciente foi de 324.207 pesos colombianos, em média. os custos mais representativos são em saúde, alimentação, moradia, transporte e comunicações. dos pacientes com dcnt, 60,5 % assumiam as finanças do lar antes de ficarem doentes e, destes, aproximadamente a metade deixou de trabalhar, e a outra metade apresentou redução de 33 % em seus ingressos mensais depois da doença. conclusões: os custos relacionados com o cuidado familiar aumentam, e o ingresso dos pacientes com dcnt e o de seus cuidadores diminuem, devido a que são exigidos tratamentos, cuidados e intervenções complementares e integrais, entre outros. palavras-chave (fonte: decs) efeitos psicossociais da doença; gastos em saúde; doenças não transmissíveis; cuidadores; doenças cardiovasculares. 5 costos directos e indirectos derivados del cuidado familiar del paciente con enfermedad crónica no transmisible l astrid nathalia páez esteban y otros introducción según la organización panamericana de la salud (ops), en los últimos años han venido aumentando los costos de las enfermedades crónicas no transmisibles (ecnt), tanto para el sistema de salud como para las empresas y las personas. los gobiernos, las comunidades y las industrias privadas también se ven afectados por los costos de los tratamientos y de la prestación de cuidados para quienes tienen ecnt, así como por la muerte prematura y la discapacidad (1). lo anterior configura un riesgo importante de pérdidas económicas para los sistemas de salud, así como una disminución en la expectativa y la calidad de vida de las personas (2). por otro lado, es alta la carga económica que representan las cuatro enfermedades crónicas no transmisibles más importantes: las enfermedades cardiovasculares, el cáncer, la diabetes y las enfermedades respiratorias crónicas. en un reporte de la ops, se estimó en 13.540 millones de dólares la pérdida acumulativa del pib en el periodo 2006-2015, a causa de las cardiopatías, los accidentes cerebrovasculares y la diabetes en méxico, argentina, brasil y colombia (1). en colombia, las ecnt representan altos costos por su dificultad en el diagnóstico y en los tratamientos, los cuales son prolongados y complejos; esto afecta, en especial, a la población económicamente activa (3). por tratarse de enfermedades de larga duración, ocasionan una demanda de costos directos e indirectos. según el observatorio de la calidad en atención en salud, los costos directos de los servicios de salud comprenden medicamentos, pruebas diagnósticas, infraestructuras sanitarias, personal sanitario y equipos médicos. los costos directos no aplicables a los servicios de salud involucran gastos fuera del sistema de salud, como el transporte de los pacientes, el costo por cuidados informales u otros gastos a cargo del paciente (4). los costos indirectos se generan a partir del concepto de capital humano, y su cálculo incluye la estimación de la pérdida en productividad y en ingresos, debida a la mortalidad y a la discapacidad generada por la enfermedad (3, 4). las ecnt afectan directamente a la persona que las sufre y a su familia, debido al impacto económico por la disminución del ingreso per cápita, dependiendo de la duración y la severidad de la enfermedad que conlleva la incapacidad (o la disminución de la capacidad temporal o permanente para trabajar), los costos del tratamiento, el transporte, entre otros (5). generalmente, las investigaciones abordan los costos directos relacionados con la atención en salud y los gastos de bolsillo o gastos que asume directamente el paciente, pues ni el seguro público ni el privado cubren el costo total del bien o servicio de salud. la capacidad de los países para estimar el gasto privado en atención a largo plazo varía ampliamente. el gasto de consumo final de los hogares cubre todas las compras realizadas por los hogares para satisfacer sus necesidades cotidianas, como alimentos, ropa, alquiler de vivienda o servicios de salud (6). así, este estudio ofrece un estimado completo del costo de las ecnt en el contexto familiar, al tener por objetivo determinar los costos directos no relacionados con la salud y los costos indirectos del cuidado familiar de la persona con ecnt. materiales y métodos estudio de abordaje cuantitativo, transversal y descriptivo. la muestra estuvo conformada por adultos con enfermedades crónicas y sus cuidadores familiares de tres hospitales del área metropolitana de bucaramanga, colombia, seleccionados a través de muestreo sistemático. el tamaño de la muestra se calculó considerando un nivel de confianza del 95 %, un error del 5 % y una varianza de 500; además, se adicionó un 10 % por posible pérdida o suministro de información incompleta. de esta forma, el tamaño de la muestra total fue de 77 díadas paciente-cuidador. los criterios de selección fueron adultos con ecnt de, por lo menos, seis meses de antigüedad, y con cuidador familiar durante ese mínimo de tiempo, provenientes de los servicios de hospitalización y ambulatorios de dos hospitales de segundo nivel de las ciudades de bucaramanga y floridablanca, y de un hospital de tercer nivel de bucaramanga, colombia. los criterios de exclusión fueron personas con alguna discapacidad neurológica o cognitiva que impidiera el suministro de información confiable. la información se recolectó entre febrero de 2018 y mayo de 2019. inicialmente, se identificaron los pacientes que cumplían con los criterios de selección, se realizó el proceso de consentimiento informado y la aplicación del instrumento de recolección de la información. este último estuvo conformado por dos encuestas: 1) caracterización de la díada persona con enfermedad crónica y cuidador familiar, desarrollada por el grupo de cuidado al paciente crónico y su familia de la facultad de enfermería de la universidad nacional de colombia (7), y 2) costo financiero del cuidado de la enfermedad crónica, que indaga sobre el consumo real efectivo 6 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2022 aquichan issn 1657-5997 eissn 2027-5374 atribuible mensual y el impacto familiar del cuidado a una persona con ecnt, desarrollado por montoya y colaboradores (8). las variables evaluadas se agruparon en tres secciones, de la siguiente forma: 1. características sociodemográficas del paciente y del cuidador sexo, edad, zona, grupo familiar, escolaridad, ocupación, estado civil, religión, escala de valoración funcional pulses (la escala valora: p = estabilidad de la patología o condición física, u = utilización de miembros superiores, l = locomoción o función de los miembros inferiores, s = función sensorial, e = eliminación o control de esfínteres, s = capacidad de socializar) (9), valoración del estado cognitivo, a través del cuestionario de pfeiffer’s short portable mental status questionnaire (spmsq) (10), percepción de carga para la familia de zarit (11), diagnóstico clínico, tiempo con la enfermedad, único cuidador, número de horas de cuidado, nivel de apoyo psicológico, familiar, religioso, económico, social y de tecnologías de la información y las comunicaciones (tic). 2. costos directos consumo real efectivo atribuible al cuidado de las personas con ecnt: • alimentación. • vivienda: arriendo, energía o electricidad, gas, agua, servicio doméstico y atención de visitas. • salud: eps, medicina prepagada, medicamentos incluidos en el plan de beneficios (pbs), medicamentos no incluidos en el pbs, servicio de enfermería y apoyos similares, servicios complementarios, medicina alternativa, seguros, elementos de aseo, productos de consumo, sillas de ruedas, camas especiales, entre otros. • transporte: público y particular. • comunicaciones: teléfono fijo, teléfono móvil, internet, televisión y otros medios de comunicación. • bienes y servicios diversos: gastos financieros, intereses, papelería y fotocopias y trámites administrativos. 3. costos indirectos pérdida de productividad laboral mediante la cuantificación del tiempo remunerado y los ingresos del paciente y del cuidador familiar antes y después de enfermar. se realizó doble digitación y validación de la información en epidata 3.1 (12); luego, se hizo el análisis en stata 14.0 (13). inicialmente, se calcularon proporciones para las variables cualitativas y se evaluó la distribución de las variables cuantitativas a través de la prueba de shapiro wilk. se calcularon medidas de tendencia central según su distribución normal, mediante promedio y desviación estándar para las variables de carga financiera familiar atribuible al cuidado de una persona con ecnt. en relación con los aspectos éticos, se consideraron las pautas para la investigación biomédica adoptadas por el consejo de organizaciones internacionales de las ciencias médicas (cioms) (14) y las normas establecidas por el ministerio de salud de colombia en la resolución 8430 del 4 de octubre de 1993 (15). se solicitó consentimiento escrito a los pacientes y a los cuidadores. la investigación fue aprobada por los comités de ética de la universidad (acta cbu-006) y de las instituciones de los participantes. la protección de datos personales se realizó conforme al decreto 1377 de 2013 (16), que reglamentó la ley 1581 de 2012 de colombia. resultados en la tabla 1, se describen las características sociodemográficas del paciente y del cuidador familiar. en cuanto a la caracterización de los pacientes, más de las mitad eran mujeres (55 %), con edades promedio de 70 años, provenientes de la zona urbana (94 %), estrato socioeconómico dos7 (52 %), grupo familiar conformado en promedio por cuatro personas, con nivel de escolaridad primaria (84 %), dedicados principalmente al hogar (51 %), casados (34 %), de religión católica (82 %), con un puntaje pulses 7 nota del editor: brindamos este contexto para enriquecer la lectura del artículo: en colombia se reconocen seis estratos socioeconómicos divididos de esta forma: estrato 1, bajobajo; estrato 2, bajo; estrato 3, medio-bajo; estrato 4, medio; estrato 5, medio-alto; estrato 6, alto. según el departamento administrativo nacional de estadística (dane) de colombia, “la clasificación en cualquiera de los seis estratos es una aproximación a la diferencia socioeconómica jerarquizada, léase pobreza a riqueza o viceversa” y “los estratos 1, 2 y 3 corresponden a estratos bajos que albergan a los usuarios con menores recursos, los cuales son beneficiarios de subsidios en los servicios públicos domiciliarios”. más información: https://www.dane.gov.co/files/geoestadistica/preguntas_frecuentes_estratificacion.pdf https://www.dane.gov.co/files/geoestadistica/preguntas_frecuentes_estratificacion.pdf 7 costos directos e indirectos derivados del cuidado familiar del paciente con enfermedad crónica no transmisible l astrid nathalia páez esteban y otros entre 12 y 24 (51 %) —es decir, con alta disfuncionalidad o dependencia—, y en el test spmsq, de 3-4, es decir, con alteración intelectual mínima (30 %). el grupo diagnóstico predominante de los pacientes fue cardiovascular (45 %), con una duración promedio de la enfermedad de 118 meses (9,8 años); además, poseen baja autopercepción de carga para la familia (36 %), único cuidador (56 %) y requieren en promedio 13,8 horas de cuidado por día. respecto a la percepción del apoyo, la mayoría manifiesta que no tiene apoyo psicológico (32 %), máximo apoyo familiar (42 %) y religioso (35 %), moderado apoyo económico y social y, por último, bajo apoyo en las tic para su cuidado (83 %). por otro lado, en la caracterización de los cuidadores, aproximadamente cuatro de cada cinco son mujeres (78 %), con edades promedio de 42,8 años, provenientes de la zona urbana (94 %), estrato socioeconómico dos (44 %), grupo familiar conformado por 4 personas, con nivel de escolaridad secundaria (47 %), dedicados principalmente al hogar (44 %), solteros (35 %), de religión católica (78 %), con un puntaje pulses entre 6 y 8 (49 %) —baja dependencia—, y un puntaje en el test spmsq entre 0 y 2 (75 %) —función intelectual intacta—. uno de cada cinco cuidadores tenía alguna enfermedad crónica, con una duración promedio de 55,9 meses (4,6 años). respecto al cuidado de la persona con ecnt, perciben que este es de alta carga para la familia (42 %), la mayoría solo tiene un único cuidador (56 %) y ofrece en promedio 13,4 horas de cuidado por día. en cuanto a la percepción del nivel de apoyo, la mayoría manifiesta que no tiene apoyo psicológico (36 %), máximo apoyo familiar (35 %), moderado apoyo religioso (38 %), económico (40 %) y social (38 %), y cuenta con apoyo en las tic para el cuidado (49 %). tabla 1. caracterización de las personas con enfermedad crónica no transmisible y sus cuidadores familiares variable paciente cuidador n (%) n (%) género femenino 42 (55) 60 (78) masculino 32 (41) 14 (18) nr 3 (4) 3 (4) variable paciente cuidador n (%) n (%) edad promedio (de) 70,1 (15,6) 42,8 (13,2) zona urbana 72 (94) 72 (94) rural 5 (6) 5 (6) estrato socioeconómico 1 16 (21) 12 (16) 2 40 (52) 34 (44) 3 11 (14) 20 (26) 4 6 (8) 8 (10) 6 1 (1) nr 3 (4) 3 (4) personas en el grupo familiar promedio (de) 4,0 (1,5) 4,0 (1,5) escolaridad analfabeta 1 (1) 1 (1) primaria 61 (84) 18 (23) secundaria 8 (11) 36 (47) universitario 3 (4) 6 (8) técnico 12 (16) posgrado 1 (1) nr 3 (4) ocupación ninguna 4 (6) hogar 35 (51) 34 (44) empleado 2 (3) 18 (23) independiente 6 (9) 13 (17) estudiante 4 (5) otro 21 (31) 5 (6) nr 3 (4) 8 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2022 aquichan issn 1657-5997 eissn 2027-5374 variable paciente cuidador n (%) n (%) estado civil soltero 14 (18) 27 (35) casado 26 (34) 22 (29) separado 8 (10) 4 (5) viudo 20 (26) 3 (4) unión libre 6 (8) 18 (23) nr 3 (4) 3 (4) religión católica 63 (82) 60 (78) evangélica 11 (14) 12 (16) otra 2 (3) nr 3 (4) 3 (4) pulses (funcionalidad) baja 6-8 21 (27) 38 (49) mediana 9-11 14 (18) 5 (6) alta 12-24 39 (51) 30 (39) nr 3 (4) 4 (5) test spmsq intacta (0-2) 17 (22) 58 (75) mínima (3-4) 23 (30) moderada (5-7) 17 (22) 1 (1) severa (8-10) 17 (22) 13 (17) nr 3 (4) 5 (6) percepción de carga para la familia baja 28 (36) 30 (39) moderada 18 (23) 11 (14) alta 19 (25) 32 (42) muy alta 6 (8) nr 6 (8) 4 (5) variable paciente cuidador n (%) n (%) diagnóstico ninguno 61 (79) cardiaco 35 (45) cerebrovascular 5 (6) metabólico 6 (8) 1 (1) respiratorio 8 (10) 1 (1) sistema nervioso 6 (8) otros 14 (18) 8 (10) nr 3 (4) 6 (8) tiempo con la enfermedad/cuidado promedio (de) 117,8 (111,4) 55,9 (64,1) único cuidador no 31 (40) 31 (40) sí 43 (56) 43 (56) nr 3 (4) 3 (4) número de horas de cuidado diarias promedio (de) 13,8 (7,8) 13,4 (8,1) apoyo psicológico 0 25 (32) 28 (36) 1 2 (3) 8 (10) 2 18 (23) 2 (3) 3 8 (10) 24 (31) 4 21 (27) 12 (16) nr 3 (4) 3 (4) apoyo familiar 1 2 (3) 9 (12) 2 14 (18) 12 (16) 3 26 (34) 26 (34) 4 32 (42) 27 (35) nr 3 (4) 3 (4) 9 costos directos e indirectos derivados del cuidado familiar del paciente con enfermedad crónica no transmisible l astrid nathalia páez esteban y otros variable paciente cuidador n (%) n (%) apoyo religioso 0 8 (10) 9 (12) 1 4 (5) 12 (16) 2 12 (16) 5 (6) 3 23 (30) 29 (38) 4 27 (35) 19 (25) nr 3 (4) 3 (4) apoyo económico 0 4 (5) 6 (8) 1 4 (5) 7 (9) 2 26 (34) 9 (12) 3 19 (25) 31 (40) 4 21 (27) 21 (27) nr 3 (4) 3 (4) apoyo social 0 20 (26) 13 (17) 1 4 (5) 9 (12) 2 20 (26) 5 (6) 3 13 (17) 29 (38) 4 17 (22) 18 (23) nr 3 (4) 3 (4) apoyo en las tic para el cuidado no 60 (85) 40 (56) si 11 (15) 32 (44) apoyo percibido en las tic ninguno 2 (3) bajo 59 (83) 35 (49) medio 8 (11) 24 (33) alto 2 (3) 13 (18) variable paciente cuidador n (%) n (%) género femenino 42 (55) 60 (78) masculino 32 (41) 14 (18) nr 3 (4) 3 (4) edad promedio (de) 70,1 (15,6) 42,8 (13,2) zona urbana 72 (94) 72 (94) rural 5 (6) 5 (6) estrato socioeconómico 1 16 (21) 12 (16) 2 40 (52) 34 (44) 3 11 (14) 20 (26) 4 6 (8) 8 (10) 6 1 (1) nr 3 (4) 3 (4) personas en el grupo familiar promedio (de) 4,0 (1,5) 4,0 (1,5) escolaridad analfabeta 1 (1) 1 (1) primaria 61 (84) 18 (23) secundaria 8 (11) 36 (47) universitario 3 (4) 6 (8) técnico 12 (16) posgrado 1 (1) nr 3 (4) ocupación ninguna 4 (6) hogar 35 (51) 34 (44) empleado 2 (3) 18 (23) independiente 6 (9) 13 (17) 10 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2022 aquichan issn 1657-5997 eissn 2027-5374 variable paciente cuidador n (%) n (%) estudiante 4 (5) otro 21 (31) 5 (6) nr 3 (4) estado civil soltero 14 (18) 27 (35) casado 26 (34) 22 (29) separado 8 (10) 4 (5) viudo 20 (26) 3 (4) unión libre 6 (8) 18 (23) nr 3 (4) 3 (4) religión católica 63 (82) 60 (78) evangélica 11 (14) 12 (16) otra 2 (3) nr 3 (4) 3 (4) pulses (funcionalidad) baja 6-8 21 (27) 38 (49) mediana 9-11 14 (18) 5 (6) alta 12-24 39 (51) 30 (39) nr 3 (4) 4 (5) test spmsq intacta (0-2) 17 (22) 58 (75) mínima (3-4) 23 (30) moderada (5-7) 17 (22) 1 (1) severa (8-10) 17 (22) 13 (17) nr 3 (4) 5 (6) percepción de carga para la familia baja 28 (36) 30 (39) moderada 18 (23) 11 (14) alta 19 (25) 32 (42) muy alta 6 (8) nr 6 (8) 4 (5) variable paciente cuidador n (%) n (%) diagnóstico ninguno 61 (79) cardiaco 35 (45) cerebrovascular 5 (6) metabólico 6 (8) 1 (1) respiratorio 8 (10) 1 (1) sistema nervioso 6 (8) otros 14 (18) 8 (10) nr 3 (4) 6 (8) tiempo con la enfermedad/cuidado promedio (de) 117,8 (111,4) 55.9 (64,1) único cuidador no 31 (40) 31 (40) sí 43 (56) 43 (56) nr 3 (4) 3 (4) número de horas de cuidado diarias promedio (de) 13,8 (7,8) 13.4 (8,1) apoyo psicológico 0 25 (32) 28 (36) 1 2 (3) 8 (10) 2 18 (23) 2 (3) 3 8 (10) 24 (31) 4 21 (27) 12 (16) nr 3 (4) 3 (4) apoyo familiar 1 2 (3) 9 (12) 2 14 (18) 12 (16) 3 26 (34) 26 (34) 4 32 (42) 27 (35) nr 3 (4) 3 (4) 11 costos directos e indirectos derivados del cuidado familiar del paciente con enfermedad crónica no transmisible l astrid nathalia páez esteban y otros variable paciente cuidador n (%) n (%) apoyo religioso 0 8 (10) 9 (12) 1 4 (5) 12 (16) 2 12 (16) 5 (6) 3 23 (30) 29 (38) 4 27 (35) 19 (25) nr 3 (4) 3 (4) apoyo económico 0 4 (5) 6 (8) 1 4 (5) 7 (9) 2 26 (34) 9 (12) 3 19 (25) 31 (40) 4 21 (27) 21 (27) nr 3 (4) 3 (4) apoyo social 0 20 (26) 13 (17) 1 4 (5) 9 (12) 2 20 (26) 5 (6) 3 13 (17) 29 (38) 4 17 (22) 18 (23) nr 3 (4) 3 (4) apoyo en las tic para el cuidado no 60 (85) 40 (56) si 11 (15) 32 (44) apoyo percibido en las tic ninguno 2 (3) bajo 59 (83) 35 (49) medio 8 (11) 24 (33) alto 2 (3) 13 (18) de: desviación estándar. nr: no responde. fuente: elaboración propia. en relación con los costos directos no relacionados con los servicios de salud o los costos reales atribuibles al cuidado del paciente con enfermedad crónica, en la tabla 2 se presenta el costo en pesos colombianos (tanto el costo total de la familia como por paciente), discriminado por rubros relacionados con vivienda, salud, transporte, comunicaciones, bienes y servicios y deudas. se puede observar que el mayor gasto para las familias es en alimentación (461.623 pesos), servicios públicos (167.418), artículos de aseo (147.610) y transporte (106.546). un 40 % de las familias paga en promedio 445.645 pesos de arriendo. los rubros más representativos con gastos diferenciales son: alimentación, en el 64 % de las familias, con un valor de 169.796 pesos; transporte público, en el 68 %, con 39.942; productos de aseo e higiene personal, en el 42 %, con 35.531; trámites administrativos, en el 86 %, con 24.318; y atención a visitas, en el 67 %, con 20.313. en cuanto a los gastos relacionados con salud asumidos por la familia o gastos de bolsillo al mes, el 17 % de las familias paga aportes para afiliación a salud del paciente (97.254 pesos); el 30 % gasta en medicamentos del pbs (28.600); el 16 %, en medicamentos no incluidos en el pbs (42.408); el 10 %, en servicios de enfermería (157.375); el 19 %, en servicios complementarios (66.200); el 4 %, en medicina alternativa (96.667); y el 6 %, en aditamentos terapéuticos (103.000). además, el 22 % de las familias paga eps al cuidador, por un valor de 95.647 pesos. por otro lado, el 31 % de las familias adquirió una deuda en promedio de 2.166.667 pesos, debido a la enfermedad del paciente y paga 90.417 en intereses mensuales. en la tabla 3, se presenta el promedio de los gastos agrupados por rubros discriminados para la familia y el paciente. del total del valor de alimentación, vivienda, transporte y comunicaciones de la familia, el 23, 10, 29 y 9 %, respectivamente, se deben al cuidado del paciente. el costo total mensual atribuido al cuidado del paciente fue de 324.207 pesos en promedio por familia. adicionalmente, al transformar esta variable por cuartiles, se observa que la distribución de los rangos fue entre 10.000 y 150.000, 150.001 y 225.000, 225.001 y 382.900, y 382.901 y 2.030.002. adicionalmente, en el 44 % de las familias existe algún nivel de preocupación por el desgaste financiero debido al cuidado de la persona con enfermedad crónica, y el 19 % manifiesta que se ha presentado un conflicto relacionado con las finanzas del cuidado de la persona enferma. dentro de estos últimos, el principal motivo es el dinero insuficiente en el 67 % de los casos. la persona enferma asumía las finanzas en el 43 % de los hogares. 12 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2022 aquichan issn 1657-5997 eissn 2027-5374 el 6 % manifestó que ha tenido que vender algún bien o propiedad (joyas, moto, casas) para asumir el costo del cuidado. en la mitad de los casos, los hijos son quienes asumen los costos del cuidado familiar. tabla 2. costos directos del cuidado familiar de personas con enfermedad crónica no transmisible y sus familias desagregados por rubros variable familia gasto diferencial paciente vivienda n (%) promedio de n (%) promedio de alimentación 77 (100) 461.623 250.965 49 (64) 169.796 109.573 arriendo 31 (40) 445.645 151.552 energía eléctrica 77 (100) 74.545 65.242 14 (18) 45.071 37.674 gas 77 (100) 29.379 31.421 23 (30) 10.739 5.910 agua 77 (100) 63.494 43.846 18 (23) 25.333 21.698 servicio doméstico 4 (5) 280.000 116.619 3 (75) 266.667 152.753 atención a visitas 48 (62) 24.833 23.153 32 (67) 20.313 11.939 salud eps 17 (22)* 95.647* 52.461 13 97.254 38.044 medicina prepagada medicamentos pos 7 (9)* 96.428* 17.796 23 28.600 65.492 medicamentos no pos 1 (1)* 50.000* 12 42.408 36.825 servicio de enfermería y apoyos similares 8 157.375 110.703 servicios complementarios 15 66.200 48.144 medicina alternativa 3 96.667 25.166 seguros aseo 77 (100) 147.610 133.055 32 (42) 35.531 19.566 elementos terapéuticos 5 103.000 58.694 transporte público 77 (100) 106.546 161.472 52 (68) 39.942 36.984 particular 24 (31) 71.250 63.198 13 (54) 59.615 38.862 comunicaciones fijo 50( 65) 40.940 37.781 6 (12) 13.333 6.055 móvil 72 (94) 52.222 74.623 24 (33) 29.583 38.608 internet 18 (23) 42.556 21.064 televisión 63 (82) 38.476 32.032 1 (2) 10.000 bienes y servicios papelería 73 (95) 17.438 10.815 trámites administrativos 66 (86) 24.318 16.122 deuda valor deuda 24 (31) 2´166.667 3´832.517 intereses 24 (31) 90.417 119.445 *cuidador. de: desviación estándar. fuente: elaboración propia. 13 costos directos e indirectos derivados del cuidado familiar del paciente con enfermedad crónica no transmisible l astrid nathalia páez esteban y otros ron trabajando, sus horas laborares e ingresos disminuyeron a 4 horas (50 %) y a 500.000 pesos (33 %), respectivamente. en cuanto a los cuidadores, 29 realizaban alguna actividad económica remunerada; estos trabajaban, en promedio, 10 horas al día y devengaban 1.007.924 al mes. cuando asumieron el cuidado de su familiar, dichas horas laborales disminuyeron a 8, y su ingreso a 950.690 pesos (6 %). por otra parte, los costos indirectos fueron evaluados en 38 díadas (reclutados en 2019), como se muestra en la tabla 4. respecto a los pacientes, 15 (38,5 %) no realizaban ninguna actividad económica remunerada, y los 23 (60,5 %) restantes trabajaban, en promedio, 8 horas al día, devengando 747.826 pesos al mes (poco menos de un salario mínimo legal vigente [smlv]) antes de enfermar. de estos últimos, después de enfermar, 12 (52 %) pacientes dejaron de trabajar, y para los 11 (48 %) que continuatabla 3. costos directos derivados del cuidado familiar de la persona con enfermedad crónica variable familia paciente promedio de promedio de alimentación 461.623 250.965 108.052 119.759 vivienda 367.769 268.164 36.156 62.933 transporte 128.753 179.962 37.039 48.578 comunicaciones 116.844 96.562 10.390 25.942 salud 22.643 48.298 64.779 122.602 bienes 37.376 24.324 total 324.207 313.440 de: desviación estándar. fuente: elaboración propia. tabla 4. costos indirectos del cuidado familiar de la persona con enfermedad crónica variable paciente cuidador n promedio ic del 95% n promedio ic del 95% horas antes 23 8 6 a 9 29 10 9 a 12 después 11 4 2 a 6 29 8 7 a 10 ingresos antes 23 747.826 638.258 a 857.394 29 1.007.924 811.655 a 1.204.192 después 11 500.000 324.814 a 675.186 29 950.690 733.169 a 1.168.210 ic: intervalo de confianza. fuente: elaboración propia. 14 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2022 aquichan issn 1657-5997 eissn 2027-5374 discusión costos directos no relacionados con servicios de salud las ecnt son un problema de salud pública porque influyen en el cambio social, cultural, político y económico, y alteran las condiciones de vida de la gran mayoría de la población (17, 18). cabe resaltar en estos hallazgos que más de la mitad de las personas con ecnt son mujeres, con un promedio de edad de 70 años, provenientes de estrato socioeconómico dos, con nivel de escolaridad de primaria, amas de casa y con alto nivel de disfuncionalidad o dependencia. también se observó que cuatro de cada cinco cuidadores son mujeres, aproximadamente la mitad tienen formación secundaria, se dedican al hogar y manifiestan algún grado de preocupación por el costo financiero del cuidado del familiar con ecnt. en cuanto a los costos directos no atribuibles a la salud, entre el 9 y el 29 % se debe al cuidado del paciente, siendo los rubros más representativos, en su orden, salud, alimentación, vivienda, transporte y comunicaciones. el promedio del costo total del cuidado del paciente fue de 324.207 pesos al mes. con respecto a la perspectiva del costo y del cuidado, en el estudio de costos derivados de la atención a pacientes con ecnt llevado a cabo por campos y colaboradores, uno de los principales factores que aumenta el costo es el declive del autocuidado de la persona hospitalizada, además del cambio que existe entre el ingreso y el alta hospitalaria. los costos durante la recuperación aumentan por la necesidad de un cuidador y de terapias adicionales, además del tiempo que tarda el paciente en volver a la vida cotidiana (5). en un estudio similar, realizado por sánchez y colaboradores con 92 familias de la región andina en colombia, encontraron una alta carga financiera manifestada por dinero adicional que se debe emplear, según su orden, para gastos en servicios de salud, transporte, vivienda, alimentación, comunicaciones, entre otros (19). estos hallazgos son consistentes con los reportados en 30 díadas de la ciudad de guatemala, así como en el presente estudio, pues el mayor costo fue en salud. los otros costos fueron relevantes, pero difieren levemente en el orden (20). además, las familias de la región andina gastan un promedio mensual de 349.617 pesos en alimentación, de los cuales el 28 % está destinado al cuidado del paciente. estos valores son inferiores a los presentados en este estudio, que son de 461.623 pesos y del 37 %, respectivamente. sánchez concluye que es necesario acudir a políticas de salud pública y establecer estrategias que permitan a las familias y a los pacientes reorganizar su estilo de vida (19). gastos de bolsillo en salud la protección financiera, a través del seguro de salud público o privado, reduce la cantidad que las personas pagan directamente por la atención médica; sin embargo, en algunos países, la carga de los gastos de bolsillo todavía puede crear barreras para el acceso y uso de la atención en salud. dentro de los costos directos no aplicables a los servicios de salud, se incluyen los gastos producidos por un tratamiento fuera del sistema de salud, como los gastos de bolsillo, y gastos que corren por cuenta del paciente, cuando su aseguradora en salud —ni pública ni privada— cubre el costo total del servicio. los hogares que enfrentan dificultades para pagar las facturas médicas pueden demorar o incluso renunciar a la atención necesaria. en promedio, en los países de la organización de cooperación y desarrollo económicos (ocde), el 19 % del gasto en salud lo pagan directamente los pacientes (6). los gastos de bolsillo dependen de la capacidad de pago de las personas. si la financiación de la atención médica se vuelve más dependiente de los gastos de bolsillo, la carga se desplaza hacia quienes más utilizan los servicios y, posiblemente, hacia los hogares con bajos ingresos, en los cuales las necesidades de atención médica son mayores. muchos países han adoptado políticas para proteger ciertos grupos poblacionales de pagos excesivos, como exenciones parciales o totales de asistencia social, beneficiarios adultos mayores o personas con enfermedades crónicas o discapacidades (6). en los países de la ocde, en 2013, estos gastos fueron desde menos del 1,5 % del consumo total de los hogares en turquía, países bajos, francia, estados unidos y reino unido, a más del 4 % en corea, suiza y grecia. en promedio, en estos países el 2,8 % de los gastos del hogar se destinó a bienes y servicios de salud (6). existe una relación directamente proporcional entre la utilización de los servicios de salud y los gastos de bolsillo en hogares con personas con ecnt. los gastos de bolsillo son aproximada15 costos directos e indirectos derivados del cuidado familiar del paciente con enfermedad crónica no transmisible l astrid nathalia páez esteban y otros mente el 40 % de los gastos totales en salud de américa latina, y para las ecnt son los más relevantes. en colombia, los gastos de bolsillo en hogares con una persona con ecnt son el doble que en un hogar sin esta condición (21). en el presente estudio, los costos en salud representan del 16 al 20 % del costo total del cuidado del paciente, y el 8 % del gasto de consumo total de la familia. sin embargo, en los últimos años, el estado ha implementado diferentes estrategias para disminuir esta situación, como la ampliación de la cobertura en salud, la igualación de los planes de salud, las prestaciones entre el régimen contributivo y el subsidiado, y exenciones a personas con ecnt (21). por otro lado, los hallazgos del presente estudio son consistentes con lo reportado por gallardo y colaboradores: los gastos de bolsillo en salud abarcan, principalmente, transporte, la cuota modera dora, los medicamentos y las fotocopias (3). en cuanto a los gastos de bolsillo en pacientes con patologías respiratorias, más del 90 % de estos se vieron afectados por el pago de bonos o cuotas de atención y traslados. adicionalmente, el 56 % de los usuarios señaló que el mayor valor monetario se debe al pago en servicios públicos por el uso de oxígeno (22). costos indirectos las familias o el sistema de salud asumen altos costos por la atención en salud de las ecnt, que afectan principalmente a la población pobre y vulnerable. las enfermedades cardiovasculares son, quizá, la mayor amenaza para el desarrollo económico a largo plazo, dada su frecuencia, sus efectos directos, la atención en la salud y los costos indirectos (21). en un estudio que evaluó los costos indirectos en pacientes colombianos con patologías respiratorias como el asma, se concluyó que los costos indirectos constituyen una carga importante para el paciente y su familia. el número de consultas a urgencias en el último año, la duración de la hospitalización, los días de incapacidad generados y los días de trabajo con limitación son similares a los reportados en estudios realizados en otros países (22). respecto a los costos indirectos en el presente estudio, el 61 % de los pacientes trabajaba antes de enfermar y ganaba, en promedio, un smlv. después de enfermar, este porcentaje disminuyó al 29 %, y entre quienes continuaron trabajando hubo una reducción del 50 % en las horas laborales al día y del 33 % en los ingresos. en lo concerniente a los cuidadores, el 76 % realizaba alguna actividad económica remunerada; sin embargo, al asumir el cuidado, el número de horas laborales diarias se redujo de 10 a 8, y sus ingresos el 6 %. además, independientemente de que el cuidador ejerza una actividad económica remunerada o no, la carga del cuidador se considera el esfuerzo adicional que realiza para satisfacer las necesidades de las personas enfermas, y en las mayoría de las veces es desconocido y no cuantificado (23). además de la reducción de las horas laborales y, por ende, de los ingresos, tanto de los pacientes como de los cuidadores (quienes generalmente son los hijos), la mayoría de estrato socioeconómico bajo y con ingresos alrededor de un smlv, se observa que se ven afectados, principalmente, la capacidad y el potencial de desarrollo humano en grupos vulnerables. este hallazgo es coherente con lo reportado por la ops en el análisis de desarrollo humano y crecimiento económico relacionado con las ecnt, en el cual, con la reducción del tiempo de trabajo y de las aptitudes del capital humano, disminuyen los ingresos y se puede retardar el cambio tecnológico, aspecto fundamental para el crecimiento económico de un país. además, el tiempo de trabajo y los ingresos disponibles deben destinarse a la atención de las personas con ecnt, por lo que el ahorro disminuye. esto favorece el retraso en el desarrollo humano y la persistencia de la pobreza en un contexto intergeneracional de crecimiento económico (21). por otra parte, el estudio de la diabetes en colombia reveló que el costo total anual de la atención de esta enfermedad, controlada, es de 1015 millones de dólares (435 millones correspondieron a costos directos; 580 millones, a costos indirectos). asimismo, los costos directos anuales por pacientes con enfermedad cardiaca representan el 24 %, y los costos indirectos, el 55 %. por su parte, los costos indirectos (5 %) de la retinopatía diabética duplican los costos directos (2 %) (24). la carga de salud de las ecnt representa altos costos económicos y sociales que pueden afectar la calidad de vida y las finanzas de las personas que las padecen y de sus familias. asimismo, puede aumentar las brechas de inequidad entre las personas con menos y más ingresos, perpetuando patrones de pobreza y vulnerabilidad (18). además, son las mujeres quienes generalmente asumen la función del cuidado de sus familiares con enfermedad crónica, con discapacidad y ancianos, sin ningún tipo de remuneración ni afiliación al sistema de seguridad social. a pesar del gran valor social de la función de cuidadora, esta dificulta su inserción y su permanencia en la economía formal de la mujer. por 16 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2022 aquichan issn 1657-5997 eissn 2027-5374 lo tanto, cuando envejecen y se enferman, deben afrontan un déficit de recursos económicos, servicios sociales y salud (1). por consiguiente, una de las metas contempladas en el tercer objetivo de desarrollo sostenible es reducir en un tercio la mortalidad por ecnt para el 2030 (25), a través de la formulación, financiamiento y desarrollo de políticas multisectoriales integrales respaldadas por evidencia (18). para esto, la organización mundial de la salud (oms), a través de diferentes alianzas, desde 2011 ha venido trabajando en intervenciones que sean eficaces en función de los costos y estén basadas en evidencia (26). posteriormente, la oms desarrolló el plan de acción mundial para la prevención y control de las ecnt 2013-2020, en el cual se destacan quince intervenciones como las de mayor costo-efectividad y factibilidad (27). por otra parte, en chile, en el marco del sistema de protección social del ministerio de desarrollo social, se ha desarrollado e implementado, de forma progresiva, el sistema nacional de apoyos y cuidados (snac), con la finalidad de acompañar, promover y respaldar a las personas dependientes y a su red de apoyo, a través de acciones en el hogar y la comunidad (28). de forma similar, en uruguay, en 2015, se aprobó la ley de cuidados (ley 19.353), que estructuró el sistema nacional de cuidados, el cual desea mejorar la vida de la infancia, de las personas mayores, con discapacidad y en condición de dependencia, a través de diferentes acciones como la prestación de cuidados integrales y la capacitación para los cuidadores, tanto remunerados como no remunerados. todo esto, gracias a la articulación de los ministerios de desarrollo social, educación y cultura, trabajo y seguridad social, salud pública, y economía y finanzas (29). conclusión en este artículo, se estimó el costo relacionado con el cuidado de la persona con enfermedad crónica en 324.207 pesos colombianos por familia. los rubros más representativos de estos costos fueron salud, alimentación, vivienda y transporte. esto afecta la dinámica familiar, no solo porque se enfrenta a un aumento de los costos, sino también a una disminución de los ingresos. la razón es que, en la mitad de los casos, la persona objeto de cuidado asumía las finanzas del hogar: el 60 % trabajaba antes de enfermar, y, después de enfermar, la mitad dejó de trabajar y la otra mitad presentó una reducción del 33 % en sus ingresos. en el caso del cuidador familiar, por su parte, esta reducción fue del 6 %. de esta forma, se pueden perpetuar patrones de pobreza intergeneracional e inequidad en salud. por lo tanto, es relevante continuar generando evidencia en los ámbitos regional y nacional sobre el efecto de las ecnt en el desarrollo social y económico, así como evaluar los costos y los beneficios de aplicar medidas de prevención y control en contextos específicos, en función del país y la frecuencia de las ecnt en las desigualdades socioeconómicas (18). especialmente, es fundamental analizar aquellas informaciones difíciles de obtener, como los gastos para acceder a los servicios de salud, derivados de cuidadores informales e ingresos potenciales, tanto de los pacientes como de los cuidadores no remunerados (26). conflicto de intereses: ninguno declarado. agradecimiento: a las personas con ecnt y sus cuidadores familiares. 17 costos directos e indirectos derivados del cuidado familiar del paciente con enfermedad crónica no transmisible l astrid nathalia páez esteban y otros referencias 1. organización mundial de la salud. la carga económica de las enfermedades no transmisibles en la región de las américas. informe temático sobre enfermedades no transmisibles. ops; 2011. 2. world economic forum. the global risks report 2016. geneva: the global competitiveness and risks team; 2016. 3. gallardo k, 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enfermeiras administradoras na colômbia*** 10.5294/aqui.2022.22.2.3 lucero lópez-díaz 1 blanca piratoba-hernández2 vilma velásquez gutiérrez3 villerland rodríguez gómez4 irena papadopoulos5 1 0000-0002-2157-763x. universidad nacional de colombia, colombia. allopezdi@unal.edu.co 2 0000-0001-6278-9877. universidad nacional de colombia, colombia. bnpiratobah@unal.edu.co 3 0000-0002-5232-9073. universidad nacional de colombia, colombia. vvelasquez@unal.edu.co 4 0000-0002-1960-482x. universidad antonio nariño, colombia. virodriguez77@uan.edu.co 5 0000-0001-6291-4332. middlesex university, london, uk. r.papadopoulos@mdx.ac.uk * funded by the universidad nacional de colombia. code: 24899. ** financiado por la universidad nacional de colombia. código: 24899. *** financiado pela universidad nacional de colombia. código: 24899. received: 15/10/2021 sent to peers: 25/01/2022 approved by peers: 07/03/2022 accepted: 31/03/2022 theme: evidence-based practice. contribution to the subject: emerging cross-cultural nursing and compassion theories are configured in a setting of behavioral ideals, professional standards, and healthcare values. para citar este artículo / to reference this article / para citar este artigo: lópez-díaz l, piratoba-hernández b, velásquez v, rodríguez v, papadopoulos i. compassionate practices for nurse managers in colombia. aquichan. 2022;22(2):e2223. doi: https://doi.org/10.5294/aqui.2022.22.2.3 abstract objective: to recognize compassionate practices and the obstacles to their use by nurse managers in colombia. method: this is a mixed cross-sectional, descriptive, exploratory, international study with an online survey administered in 17 countries. data were extracted from colombia with a sample of 69 nurse managers. quantitative data were analyzed with descriptive statistics, and qualitative data were processed using the nvivo software and thematic analysis. results: 90 % women, mainly from a hospital setting (40 %). compassionate practices in administrative nursing involve four categories: listening; supporting and recognizing staff individuality; defining compassion practices, needs, and benefits; receiving compassion and complementary views of compassion and administration where the influence of cultural and organizational patterns become obstacles to compassion. conclusion: for nursing, compassion demonstrates the intentional ability to recognize the singularity of someone else's suffering, understand their needs, offer support, and find solutions based on an understanding of what being human means. these aspects require significant changes at the organizational and health legislation levels to mitigate the obstacles to compassion. keywords (source decs/mesh): compassion; empathy; cultural competency; nurse managers; leadership. resumen objetivo: reconocer las prácticas de compasión y sus obstáculos por parte de enfermeras administrativas en colombia. método: estudio mixto de tipo transversal, descriptivo, exploratorio e internacional con una encuesta en línea aplicada en 17 países. fueron extraídos los datos de colombia con una muestra de 69 enfermeras administrativas. se analizaron los datos cuantitativos con estadística descriptiva y los datos cualitativos se procesaron con el programa nvivo y con un análisis temático. resultados: 90 % mujeres, principalmente del ámbito hospitalario (40 %). la práctica de la compasión en enfermeras administrativas involucra cuatro categorías: escuchar; defender y reconocer la individualidad del personal; definir la práctica de la compasión, las necesidades y las ventajas; recibir compasión y opiniones complementarias de compasión y administración en las cuales la influencia de patrones culturales y organizacionales se presentan como obstáculos a la compasión. conclusión: la compasión para enfermería demuestra la capacidad intencional de reconocer la singularidad del sufrimiento del otro, comprender sus necesidades, ofrecer soporte y encontrar soluciones desde la comprensión del sentido de lo humano. estos aspectos requieren cambios significativos a nivel organizacional y de legislación en salud para mitigar los obstáculos con el fin de ofrecer compasión. palabras clave (fuente decs/mesh): compasión; empatía; competencia cultural; enfermeras administrativas; liderazgo. resumo objetivo: reconhecer as práticas de compaixão e seus obstáculos por parte de enfermeiras administradoras na colômbia. método: estudo misto de tipo transversal, descritivo, exploratório e internacional, com um questionário on-line aplicado em 17 países. foram extraídos os dados da colômbia com uma amostra de 69 enfermeiras administradoras. foram analisados os dados quantitativos com estatística descritiva e os dados qualitativos foram processados com o programa nvivo e com uma análise temática. resultados: 90 °/o mulheres, principalmente do ambiente hospitalar (40 °%). a prática da compaixão em enfermeiras administradoras envolve quatro categorias: escutar, defender e reconhecer a individualidade do pessoal; definir a prática da compaixão, as necessidades e as vantagens; receber compaixão e opiniões complementares de compaixão e administração em que a influência de padrões culturais e organizacionais são apresentados como obstáculos para a compaixão. conclusões: a compaixão para a enfermagem demonstra a capacidade intencional de reconhecer a singularidade do sofrimento do outro, compreender suas necessidades, oferecer suporte e encontrar soluções a partir da compreensão do sentido do humano.  esses aspectos requerem mudanças significativas no âmbito organizacional e legislativo em saúde para amenizar os obstáculos a fim de oferecer compaixão. palavras-chave (fonte decs/mesh): compaixão; empatia; competência cultural; enfermeiras administradoras; liderança. introduction compassion has been understood as people's intrinsic and extrinsic experiences harmonized with understanding and comprehension. it includes the desire and empathic response that arises from other people's suffering to relieve it (1) until reaching a degree of synchrony with patients and the commitment to help them (2,3). however, this study is based on the ideas of other authors, who have defined compassion as a construct that implies a deep awareness of one's and others' suffering and the willingness to relieve it (4, 5). from this perspective, it is necessary to improve professional excellence and safeguard ethical virtues such as respect, sincerity, compassion, and selflessness (6). these practices focus on equitable treatment, closeness, and individualization of care plans as indicators of institutional quality (7) and aspects investigated in educational and health settings (8-10). moral distress has been found in nursing professionals in general due to low self-compassion and compassion on their end and the healthcare organization processes, as they frequently face dilemmas such as meeting patients' needs, following work rules, and having conflicts with other hierarchical members of the healthcare organization (11, 12). recent studies with nurses from different parts of the world show the perceptions of compassion, the actions in which they materialize it, and its effects (13-17). in addition, reflections have been drawn on leadership strengthened by compassion, which can lead to job satisfaction, improve organizational sustainability, mitigate harm, reduce costs, and allow progress in comprehensive health quality processes (15, 18, 19). the need to delve into the compassion phenomenon in nurse managers stems from a preliminary study carried out in fifteen countries, including colombia, which revealed, among other issues, the lack of compassion of managers (15, 16, 20). likewise, other studies have shown that an organizational climate with a high division in objectives, concrete tasks, and a scarce treatment in empathy and compassion leads to moral distress, affecting one's well-being, that of the group in their charge, and the environment (21, 22). this study reports the compassion practices and the obstacles nurse managers in colombia face regarding compassion. method design and participants a mixed, cross-sectional, descriptive, exploratory study was carried out with an online survey. it was conducted within the framework of the international study led by professor irena papadopoulos of middlesex university, uk, and coordinated by dr. magdeline aagard, walden university, usa; seventeen countries participated in the study (23). the research was conducted from 2018 to may 2020. the colombian sample consisted of 69 nurses out of 89, with 20 participants excluded because they failed to complete the online questionnaire. the participants were invited through social networks in the nursing area, and a direct invitation was made to managers from different cities nationwide. the inclusion criteria were as follows: having a nursing degree and managerial responsibilities, hospital unit supervision, area supervision, sub-direction or nursing direction, responsibility for care centers, and responsibility for nursing teaching units, schools, or faculties when answering the questionnaire. nursing students or nurses who had previous managerial or administrative experience and were not performing this activity at the study time were excluded. instruments the questions of the online questionnaire were previously tested among the international team members to detect possible issues with the translation and improve question clarity and the survey flow. the collaborating research teams from spain and chile carried out the translation and cultural adaptation processes of the questionnaire into spanish, following the methodology proposed by the world health organization (24). the colombian team contributed to the cultural adjustment process by omitting the term midwife, as it does not exist as a profession in colombia. the questionnaire consisted of twenty-six items, with nine sociodemographic, eight dichotomous or multiple choice, and nine open-ended questions, which enabled collecting nurse managers' perspectives on compassion and ideas regarding barriers, enablers, advantages, and practical manifestations of a compassionate administrator. data analysis the online data were collected using the qualtrics survey software by the middlesex university team from england, who sent the data from the participants in colombia. the quantitative data were processed with descriptive statistics, and the open-ended questions were processed qualitatively and initially categorized in the nvivo program. then, the thematic analysis was carried out considering braun and clarke's proposal (25), identifying inductive, central themes in the texts and constructing categories based on the content found. the categories were discussed and extracted by consensus with the colombian research team in different discussion sessions, in addition to revalidating categories and defining dimensions for the main themes. in addition, the criteria in qualitative research were considered, such as auditability, as the study has complete digital documentation that enables the route followed in the research to be known and the information obtained for contrasting. to achieve greater credibility, the researchers held several meetings to discuss the data collected, considering the textual transcriptions of the information collected in the open-ended questions. the transferability is given by the complete description of the participants' characteristics and the presentation of the participants' typical responses and data representativeness. ethical aspects the study contemplated the international normative ethical criteria of the declaration of helsinki and the national criteria outlined in resolution 8430 of 1993. the study received the approval of middlesex university, england, and the ethics committee of the nursing college of the universidad nacional de colombia (fe-un), which endorsed the english committee's decision. participants were asked for their approval to participate in the study before filling out the form and were informed that they could stop filling out the questionnaire at any time. results this section initially presents the participants' sociodemographic description, followed by a description of the categories that emerged, containing the descriptive data. sociodemographic description the study participants were 90 % female, 79 % held some postgraduate education, and 42 % had more than eleven years of experience. the work settings were mostly hospital (40 %), home care (29 %), and higher education for nursing education (31 %). the number of nurse managers with more than 51 employees was 29 %, one to five 25 %, 21 to 50 22 %, six to ten 15 %, and 11 to 20 10 %. listening to staff, advocating for them, and recognizing individual characteristics a total of 58 % of nurse managers reported not having time to listen to their staff; however, 88 % reported advocating for and defending them. how they defend and advocate for their reports are described in three components: 1. defending entails the actions of advocating for the workers' rights and compliance regarding the exact and diligent fulfillment of what is established in order, prescription, or regulation. 2. claiming entails the actions of promoting appropriate and fair working conditions, as well as listening to workers. my office is an open office, where i am always available to listen and provide solutions to the different problems the personnel face in my institution. (co004, q8) 3. recognition acknowledges the value of work and workers as integral human beings and their abilities. in their role as managers, 84 % of them consider the individual and cultural characteristics of the employees in their charge, framed in two components: 1. putting oneself in someone else's place implies understanding and adapting administrative processes to respond to individuality, such as rotation tables and services, and understanding and negotiating regional manifestations, i.e., staff beliefs, languages, and behaviors in the work environment. i try to ask my colleagues how they feel and how they are doing in their activities and try to solve problems together. (co006, q15) other actions are related to defending and advocating against the stigmatization of any staff member's cultural diversity. 2. personalizing/individualizing is related to being aware of their personnel's human and cultural diversity without discriminating. individual, gender, age, and cultural characteristics must be known; health problems, abilities, skills, socioeconomic and family contexts, and needs must be recognized. if i oversee a staff member who belongs, for example, to a native ethnic group, i consider and respect their way of dressing, life values, management of health situations, rituals, and care. (co001, q2) time is made available during working hours to talk about doubts, fears, or failures in executing tasks, and their capabilities are highlighted as a group. (co008, q20) defining the practice of compassion, its necessity, and benefits the nurse managers' perspectives on compassion evidenced a higher-order theme defined as conscious and intentional in nature and five components that describe it: 1. individualizing entails recognizing the singularity of suffering, self-compassion, health problems, individual gender, cultural, and socioeconomic characteristics, as well as understanding the needs of others. for me, compassion is an individual's ability to make oneself available to help another get better and is based on the willingness to relate to others. (co005, q10) 2. investing time refers to offering support, listening, educating, and developing a therapeutic relationship. 3. being present denotes accompanying, recognizing the importance of the moment and the expression of affection. 4. going beyond means selflessness, sharing a sense of what is human, putting oneself in someone else's place, and involvement beyond one's duty and roles. compassion is an innate or learnable skill that drives people to care about situations that may distress others. (co001, q8) 5. defense and advocacy denote promoting equality and challenging injustice and stereotypes. attending to needs that are different from our own, defending others. (co006, q42) eighty-eight percent of the nurse managers state that they advocate for their staff and defend their rights in practice. they describe this in three components: 1.   advocating for workers' rights and compliance with regulations. 2.   claiming by promoting appropriate and fair working conditions and actively listening to workers. 3.   recognizing and valuing workers as integral human beings, including their skills as workers. these findings show the intentional capability to recognize the singularity of someone else's suffering, the understanding of their needs, and the importance of offering support and finding solutions based on understanding what it means to be human. these findings have been reported in a previous study with colombian nurses (16). the nurse managers' compassionate actions and behaviors are described in four components: 1. respect for others: interpersonal relationships of consideration and interest are consolidated and centered on listening to employees, which strengthens assertive communication, balances successes and failures, and demonstrates more empathy than compassion. listening to the problematic situations that prevent them from performing at their best. (co004, q13) 2. creating a supportive environment means identifying the needs and strengths and individualizing the administrative aspects to favor the staff. time is granted to get to know the personnel, listen to them, and support them in the solutions with resource management, orientation, training, or advocacy for workers. time is offered when employees need it and request leaves of absence or breaks. when there is flexibility in dealing with personal situations and when absences are authorized without disciplinary processes. (co009, q33) regarding this component, the risk of leniency and irresponsibility towards requests for time is identified as a liability: trying to take advantage of such compassion most of the time to impede their work, lying, and neglecting their responsibilities. (co002, q28) 3. harmony in the workplace: a greater willingness is perceived, favoring teamwork, communication, frequent meetings, and the perception of tranquility at work. 4. knowing how to listen: keeping communication channels open, offering a relationship of trust and support, and identifying personal and work-related needs and problems with a joint search for possible solutions. the benefits of providing compassion to staff are represented in three components: 1. achieving better results in the work environment with a supportive/collaborative work team and appropriate communication and interpersonal relationships. it promotes physical and mental occupational health and personal and job satisfaction and recognition. staff who work with pleasure, with a harmonic working relationship, is essential for the group to do their best, providing quality and efficient care. (co003, q32) 2. to favor humanization by recognizing workers as human beings who suffer and face problems and promoting the identification of workers' and users' particularities. promoting respect for human rights benefits the interconnection with others, and the administrator becomes a compassionate role model. if they are treated with compassion, they will treat their assistants and patients with compassion. (co001, q16) 3. to create a collective construct that recognizes and accepts cultural diversity and particularity. it generates empowerment and promotes conflict resolution and proposals for improvement. in addition, there is solidarity toward co-workers' suffering, perceiving the administrator's support, trust, and solidarity. receiving compassion a total of 78 % of nurse managers reports receiving compassion in their workplace from people in other senior positions such as chiefs of staff, managers, supervisors, colleagues, work team, subordinates, students, other professionals, patients, or family members. from my colleagues, co-workers, and bosses. (co005, q16) the importance of compassion lies in three components: 1. having a better work environment: given that it contributes to solving difficulties or problems, organizing support for the work, expressing positive feelings and actions, and favoring humanized attention. 2. particularizing: reducing boundaries', putting oneself in someone else's place, and supporting others. it is to become familiar with and understand the problems or needs of others. (co002, q48) 3. retributing and transforming the environment: whether at work, personally, or as a way of providing care. because i feel that i am not alone, but i have a team that, as i support them when they need it, they retribute that to me when i need it. it allows me to realize that they treat users with the same compassion. (co002, q6) complementary views when discussing compassion and administration the nurse managers emphasized two core components when talking about compassion and administration: 1. compassion, necessity, and opportunity: these aspects involve experience and time, development of human qualities, growth to foster capabilities and reciprocity, improvement of relationships and communication, the creation of a culture of change focused on the search for peace, justice, and a pleasant and constantly supportive life. this component also involves the transformation of an organizational climate in which teamwork, focused on the multiple benefits to the health system and impacting the user, requires stimulating challenges and productivity. nursing interventions are limited by institutional schedules and the different administrative tasks, nursing notes, and requests. (co003, q18) the challenge involves breaking hegemonic management paradigms and a new way of managing human resources detached from the fear of losing leadership and authority or being a compassionate administrator. others may think that a preferential stance is being taken towards certain members of the work team or the person in question. they may think that they have the freedom to take on responsibilities that are not theirs, or to undermine their work, crossing the sphere from trust to disrespect. (co002, q6) 2. barriers to compassion: these are visible from extrinsic factors, such as the non-existence of compassion in the colombian system. the subject is not discussed, and there are no institutional stimuli; some regulations do not favor compassion. additionally, it is not taught as a subject in the undergraduate program. the mechanization of health systems in colombia and the high restriction on nurses' work. (co005, q21) intrinsic factors highlight the lack of skills and an instrumental view of the role associated with —"they see me as a machine"—. dilemmas are at play that glimpse whether being compassionate is positive or not, as it coexists with the fear of abuse and deception. in addition, stereotypes exist around the idea that administration is incompatible with compassion, and there are different perspectives of what administration is and what compassion is. likewise, the non-existence of compassion among colleagues is raised. the vast number of activities prevent closer attention to details regarding people's feelings. (co005, q37) furthermore, three components that prevent nurses from providing compassion were identified: 1. the health system is a source of factors related to over-productivity and minimal resources. it implies authoritarianism and the mechanization of human beings, privileging technology that results in depersonalizing, lack of time for interaction with the team and patients, work overload due to personnel shortage, and undervaluation of nursing work. 2. lack of time for quality interactions when staff requires urgent support, they are addressed personally, and the situation is resolved, but there is no room for feedback or follow-up, given the time constraints. (co001, q11) 3. the administrator's authoritarian leadership culture begins with selecting someone with a strong personality. from the academy, authoritarian leadership roles are molded; beliefs regarding leadership as a superior power, demands, and vertical re­lationships are fostered, creating a hierarchy of rivalry where human beings are rendered invisible. a compassionate leader is perceived as fragile, insecure, or as someone afraid and lacking training or experience in the decision-making process. the invisibilization of human beings, the health system, and the selfish pursuit of one's goals. (co004, q22) in the organizational culture, work demands and compliance with standards take precedence over people. managers are faced with demands and dilemmas in their professional practice, which places the practice of compassion in the background. i believe that in the historical moment we have been living, the manifestation of compassion has not been approved, but there is room to talk about it and express it. (co004, q22) discussion this study provides a glimpse of compassion in the practice of nurse managers as a conscious action that includes individualizing the suffering of others and devoting time to being present with actions that promote equality and equity in the face of human needs. these findings are like those of previous studies with colombian nurses in the framework of international studies (16 ,23), which indicates that nurses in the care and administrative roles share similar notions on the compassion construct. in addition, they are close to the theoretical ideas addressed by other authors (1-5) in that they coincide with a conscious and intentional behavioral approach that recognizes suffering and the need to contribute to alleviating it. the compassion displayed by nurse managers is materialized in the appropriation of their employees' particular needs and empathy according to cultural characteristics, and the recognition of diversity can be perceived. this idea reaffirms the relevance of a culturally compassionate competence reported in the literature (23,26,27), representing an understanding of other people's suffering and the desire to alleviate it, considering the conditions and cultural background. human behaviors are described as the nurse managers' intention, among which respect for their co-workers stands out. it is strengthened through communication that prioritizes active listening and leads to a work environment of constant support and harmony, advocating to solve situations of their reports regarding the needs that may arise. these indicators have been theorized and studied in the cycles of positive interaction between supervisors and subordinates (22), resulting in higher work performance and increased positive emotions, loyalty, and organizational commitment (23). the benefits of providing compassion to the staff are evidenced by favoring humanization, achieving common goals, and establishing a constant climate of collective construction that welcomes employees' suffering and needs. in other studies on compassionate practice in nursing (23, 26-28), these benefits have been considered strategies that reduce burnout, nurses' loyalty within hospital organizations, and improve their quality of life and mental health. for nurse managers, it is vital to receive compassion both from the work team, their superiors, and users. this finding has been documented in other reports that indicate the need for a comprehensive institutional care design that promotes bidirectional compassion and counteracts current practices focused on instrumentalization and production (29). in the constraints to compassion, intrinsic factors were identified that reflect a duality between assuming a compassionate approach and the fear or distrust of being deceived. there are fears regarding social imaginaries about the administrative role, as they may be incompatible with compassionate practices. these factors have been reported in other studies (11, 12, 17, 18). they are potentially influential in reducing compassion levels and leading to moral distress, given that, as reported in the international study with nurse managers (17), compassionate practice is considered highly demanding and causes more stress. for this purpose, other studies have recommended implementing strategies that improve well-being and relational leadership (23, 30). the inexistence of compassion from extrinsic factors reflects a lack of organizational stimuli and a colombian health system that fails to contemplate compassionate practices. it is an entirely invisible issue, as institutions fail to consider stimuli or regulations that favor compassion; to these aspects, undergraduate training is also added, disregarding this competence. these findings have been made visible in other studies, both in latin america and worldwide (17, 23, 31). these studies reiterate the relevance of a renewal in healthcare that needs to be claimed with integral humanization from compassionate practices, including a change in the triad: the health system, the organizational level, and personnel transformation. conclusions the study shows that colombian nurse managers perceive compassion as that intentional ability to recognize the particularity of someone else's suffering, understand their needs, offer support, and find solutions based on understanding what being human means. the practice of compassion favors the recognition of the rights of others as workers and their defense as human beings who suffer, face problems, and need support; therefore, with this practice, changes in the human resource management paradigms are proposed when the fear or belief of losing leadership and authority for being compassionate exists. for nurse managers and their work teams, it is crucial to establish the connection between offering and receiving compassion; 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[internet]. 2020 mzo. 24;45(1):74-79. doi: https://doi.org/10.11565/arsmed.v45i1.1581 home 4 aquichan issn 1657-5997 año 11 vol. 11 nº 1 chía, colombia abril 2011 l 4-6 editorial en el desarrollo disciplinar de enfermería, la calidad de la producción científica —en términos de relevancia de las investigaciones, novedad de las mismas, utilidad y aportes de verdadera trascendencia— confirma la jerarquía de la disciplina y justifica su particular manera de entender los conceptos de salud y cuidado y de atender a las personas enfermas. aunque la importancia de enfermería en la sociedad científica quedó registrada a mediados del siglo xviii, cuando florence nightingale desarrolló la primera teoría conceptual, la proyección de la disciplina ha sido ratificada no solo por la idoneidad del trabajo de miles de enfermeras, sino por la calidad de las publicaciones científicas, que cumplen con ese conjunto de condiciones relacionadas con escritura, evaluación y edición de textos. porque es en la edición científica donde se considera el mérito de las investigaciones, se anticipa y visualiza su impacto. es en el proceso editorial donde se inicia el diálogo ético-científico entre autores, editores, comités editoriales y evaluadores (peer review), actores de quienes la sociedad espera cualificación; eso que el diccionario de la lengua española define como “preparación para ejercer determinada actividad o profesión”. entre los actores de primer orden están los evaluadores, que bien puede llamárseles “certificadores de conocimiento”. elegidos por comités editoriales, los pares hacen posible la definición de contenidos en las revistas y, en consecuencia, marcan el perfil de las mismas. por estas razones, la selección de los árbitros es una tarea rigurosa que exige “ojo clínico” y grandes dosis de ética. sí, porque la experiencia de editar una revista científica va más allá de la transformación de manuscritos en buenos textos impresos o electrónicos. exige ética. eso que no es ciencia dura, pero sí garantiza la calidad de la literatura científica. en enfermería, como en las demás disciplinas, de los evaluadores se espera integridad a la hora de identificar conflictos de intereses, confidencialidad, compromiso y respeto por los derechos de autor, precisión, validez y aplicabilidad de sus conceptos; además, certeza de su actividad como investigadores (1, 2). la importancia de la evaluación científica en enfermería 5 editorial sus consideraciones sobre los manuscritos van más allá de los consabidos aprobado, rechazado o aprobado con modificaciones. los artículos que evalúan enriquecen el conocimiento de sus respectivas disciplinas, dan información y argumentos a los diseñadores de políticas públicas, aportan a esa población que no es científica, y promueven su desarrollo. es aquí donde se evidencia el altruismo de los científicos, que supera los afanes académicos y personalistas (3). salvar, o mejor, resolver estos dilemas es la tarea del editor que, mediante argumentos académicos, apoyados en el diálogo respetuoso y constructivo con autores y evaluadores, lo conducen a presentar nuevos conocimientos a la sociedad para su utilización. a dinamizar al mundo científico con resultados de investigaciones avaladas por examinadores, cuyo juicio legítimo y autorizado son su soporte como editor. respaldado en el dictamen de un experto grupo de evaluadores, el equipo editorial de aquichan presenta en esta edición los artículos “calidad de vida en pacientes esquizofrénicos”, del equipo de investigadores chilenos integrado por magali rodríguez vidal, manuel castro salas, valentina sanhueza escobar, andrea del valle utreras y josé martínez arriagada; también del país austral es el manuscrito “aplicación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado”, escrito por sara barrios casas y tatiana paravic klijn. de colombia se publican “cómo se constituye el ‘vínculo especial’ de cuidado entre las persona con enfermedad crónica y el cuidador familiar”, de lorena chaparro; “afrontamiento y adaptación en pacientes egresados de unidades de cuidado intensivo”, firmado por inna elida flórez torres, eliana herrera alarcón, estefany carpio jiménez, maría a. veccino amador, diana zambrano barrios, yoleidis reyes narváez y sandra torres contreras; y “producción científica latinoamericana de fisioterapia / kinesiología”, de los investigadores paola vernaza pinzón y gabriel álvarez bravo. de un equipo de enfermeras brasileñas integrado por fernanda maria do carmo da silveira, neves de oliveira, emiliane cunha ferreira, neide angelica rufino y maria da soledade simeão dos santos es el artículo educação permanente e qualidade da assistência the importance of scientific evaluation in nursing a importância da avaliação científica na enfermagem 6 aquichan issn 1657-5997 año 11 vol. 11 nº 1 chía, colombia abril 2011 à saúde: aprendizagem significativa no trabalho da enfermagem, y de un grupo interdisciplinario de méxico, conformado maría guadalupe moreno monsiváis, maría guadalupe interial guzmán, paz francisco sauceda flores, leticia vázquez arreola y julia teresa lópez españa, es el manuscrito “satisfacción de las madres con la atención a sus hijos hospitalizados”. elsa cristina robayo-cruz comunicadora social y periodista jefe editorial de revistas científicas universidad de la sabana elsa.robayo@unisabana.edu.co 1 ministerio de ciencia e innovación, consejo superior de investigaciones científicas. código de buenas prácticas científicas del csic; 2010. disponible en http://www.csic.es/web/guest/etica-en-la-investigacion [consultado el 2 de marzo de 2011] 2 sogi s, perales a, anderson a, zavala s. calidad de la producción científica de los investigadores de la facultad de medicina, unmsm. an fac med 2003; 64 (2). disponible en http://www.scielo.org.pe [consultado el 2 de marzo de 2011] 3 carrizales g. la ética de la ciencia. disponible en 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enfermería realiza múltiples acciones de cuidado dirigidas a la persona, la familia y la comunidad, todas ellas de gran complejidad, ya que requieren del dominio de conocimientos que las sustenten, con el fin de ofrecer una atención óptima y de calidad. este texto representa un aporte de conocimientos a los profesionales de enfermería relacionados con la nutrición y el metabolismo, aspectos fundamentales al dar cuidado directo relacionado con necesidades básicas del ser humano, como el alimentarse para lograr un equilibrio corporal que permita mantener la salud y el bienestar físico y mental. esta edición muestra al lector de forma secuencial todo el proceso de nutrición desde sus bases biológicas, bioquímicas, líquidos y electrolitos, degradación y metabolismo de proteínas, grasas y carbohidratos, la forma como se adquieren y absorben en el organismo, y los órganos anatómicos donde se almacenan y se degradan. también hace referencia a los parámetros de valoración metabólica y nutricional al paciente hospitalizado y en diferente condición clínica, como por ejemplo durante la preparación para un procedimiento quirúrgico, y los cuidados especiales durante el posoperatorio. se aborda la nutrición de manera amplia, desde el estado natural del ser humano hasta las situaciones más críticas como el shock, la pancreatitis, el trasplante de órganos, la sepsis, falla hepática, el paciente con cáncer y el diabético, entre otras. muestra el soporte nutricional que se puede ofrecer a una mujer durante la gestación, o el tratamiento que se ofrece actualmente para la obesidad. una de las acciones más frecuentes del profesional de enfermería en el rol asistencial es el apoyo que se ofrece al individuo a través de la nutrición parenteral, en esta obra se pueden encontrar los conceptos básicos, las vías de acceso, los componentes fisicoquímicos en la preparación, y diferentes fórmulas para el manejo nutricional del paciente que, por sus condiciones de salud, tiene incapacidad de ingerir los alimentos por la vía oral. este texto puede ser consultado por estudiantes de ciencias de la salud del pregrado que estén abordando la temática de nutrición tanto a nivel ambulatorio como a nivel hospitalario, en servicios de pacientes quirúrgicos, quemados, ginecoobstetricia o servicios de medicina interna; de la misma manera, es de interés para profesionales tanto de enfermería como otras profesiones relacionadas con salud. blanca cecilia venegas bustos profesora asistente facultad de enfermería universidad de la sabana josé félix patiño restrepo 4 edición, editorial médica panamericana, 2006. metabolismo, nutrición y shock 02 gaining insight.indd 19 gaining insight into student nurses’ clinical decision-making process eleanor t. campbell2 gaining insight into student nurses’ clinical decisionmaking process1 recibido: 7 de diciembre de 2007 aceptado: 8 de febrero de 2008 1 acknowledgements: funding for research supported by the george n. shuster fellowship award 2 assistant professor of nursing herbert lehman college of the city. university of new york 250 bedford park blvd.west bronx, ny 10468. ecampolo541@al.com abstract the purpose of this study was to gain a clearer understanding of the clinical decision-making process of generic baccalaureate student nurses during patient care. a descriptive qualitative design, using semi-structured open-ended questions, was employed to obtain information about the choices culturally diverse student nurses made in the care of adult patients in a variety of clinical settings. connectedness, knowing, heroism, anxiety and frustration were the emerging themes. the findings indicate that students used mutual goal setting throughout the decision-making process. the author applied imogene king’s theory of goal attainment to interpret the findings of the study and to link theory to practice. clinical decision-making is an important topic in nursing education and practice. faculty understanding of thought processes precedes the design of specific strategies to enhance clinical reasoning. helping students to advance from reliance on memorization of textbook information to the application of concepts from the liberal arts and from biological and nursing science is part of that process. this is a special challenge for nursing faculty and staff educators who teach nursing students and new graduates from diverse experiential and educational backgrounds. numerous clinical decision-making studies offer conflicting and inconclusive findings concerning predictive outcomes and related factors. this investigator chose to study the decision-making phenomenon from a holistic point of view, using a qualitative methodology. as opposed to focusing solely on the outcome of clinical choices, the aim of the study was to gain a clearer understanding of the ways in which student nurses make clinical decisions. key words nursing, clinical decision-making, patient care, qualitative methodology issn 1657-5997 año 8 vol. 8 nº 1 chía, colombia abril 2008 19-32 20 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 ¿cómo ganar perspicacia en el proceso de toma de decisiones clínicas por parte de los estudiantes de enfermería? resumen: el propósito de este estudio fue obtener una más clara comprensión del proceso de toma de decisiones en estudiantes de enfermería que van a recibir su licenciatura, durante el cuidado de los pacientes. se empleó un diseño descriptivo cualitativo, basado en preguntas abiertas semi-estructuradas, con el fin de recolectar información acerca de las decisiones, culturalmente diversas, tomadas por las estudiantes de enfermería durante el cuidado de pacientes adultos, en una variedad de situaciones clínicas. los temas que surgieron incluyen capacidad de comunicación, conocimiento, heroísmo, ansiedad y frustración. los descubrimientos hallados indican que los estudiantes se propusieron metas en forma recíproca a todo lo largo del proceso de toma de decisiones. el autor empleó la teoría de la consecución de metas, de imogene king, para interpretar los descubrimientos de este estudio y relacionar la teoría con la práctica. la toma de decisiones clínicas es un punto importante dentro de la educación y práctica de la enfermería. la facultad, entendiendo qué son los procesos de pensamiento, se anticipa con un diseño de estrategias específicas que refuerzan el razonamiento en la práctica clínica. una parte de este proceso es ayudar a los estudiantes a salir de la dependencia que generan cuando quieren memorizar la información contenida en los textos, y hacerlos avanzar hacia la aplicación de los conceptos provenientes, tanto de las artes liberales, como de las ciencias biológicas y de enfermería. se trata de un especial desafío para las facultades y personal docente de enfermería encargado de impartir educación a los estudiantes de la carrera, así como para el recién egresados de otras áreas de formación y de experiencia. los resultados de estudios anteriores sobre toma de decisiones clínicas presentan conclusiones conflictivas e inconclusas, concernientes a determinadas consecuencias predecibles y otros factores relacionados. el investigador de este caso decidió estudiar el fenómeno de la toma de decisiones desde un punto de vista holístico, haciendo uso de la metodología cualitativa. el propósito del estudio, como se dijo al comienzo, fue obtener una más clara comprensión de la manera como los estudiantes de enfermería toman decisiones en clínica, más que limitar la investigación a las consecuencias de las elecciones clínicas. palabras clave: enfermería, toma de decisiones clínicas, cuidado de pacientes, método cualitativo. 21 gaining insight into student nurses’ clinical decision-making process como podem ser mais perspicazes os estudantes de enfermagem quando devem tomar uma decisão resumo o propósito deste estudo foi obter, durante o cuidado dos pacientes, uma compreensão mais clara do processo da tomada de decisão de estudantes de enfermagem que vão receber a sua licenciatura. foi utilizado um desenho descritivo qualitativo, baseado em perguntas abertas semi-estruturadas para coletar informação sobre as decisões culturalmente diversas, tomadas por estudantes de enfermagem durante o cuidado de pacientes adultos em varias situações clínicas. entre os temas surgidos estão capacidade de comunicação, conhecimento, heroísmo, ansiedade e frustração. os resultados revelam que os estudantes se propuseram metas entre si durante o processo da tomada de decisões. para interpretar as descobertas deste estudo e relacionar teoria e prática, o autor recorreu à teoria de consecução de metas de imogene king. a tomada de decisões é um aspecto importante no ensino e a prática da enfermagem. a faculdade, a entender os processos de pensamento, antecipa-se com um desenho de estratégias particulares reforçarem o razoamento na prática clínica. em parte, este processo procura apoiar aos estudantes deixarem a sua dependência gerada quando desejam memorizar a informação contida nos textos, e dirigirlos para a aplicação dos conceitos provenientes das artes liberais, das ciências biológicas e da enfermagem. este é um desafio especial para a faculdade de enfermagem, para os professores encarregados de dar aulas aos estudantes da carreira, e para os recém-graduados de outras áreas de formação e de experiência. os resultados de outros estudos sobre a toma de decisões em clínica trazem conclusões divergentes e parciais, concernentes a conseqüências que podem se predizer, e outros fatores relacionados. neste caso, o pesquisador decidiu estudar o fenômeno desde uma perspectiva holística, utilizando a metodologia qualitativa. o propósito do estudo no foi restringir a pesquisa as conseqüências das eleições clínicas, senão compreender melhor como tomam decisões em clínica os estudantes de enfermagem. palavras-chave enfermagem, tomada de decisões clínicas, cuidado de pacientes, método qualitativo. 22 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 literature review prior studies on clinical decision-making have examined accepted beliefs about parts of the phenomena such as critical thinking and problem solving. in many cases, these terms have been used interchangeably in nursing research studies (8, 9) critical thinking has varying definitions both in and outside the discipline of nursing, making a comparison of study findings difficult. definitions include logical reasoning, open-mindedness, reflective thinking, and intuitive understanding (8, 10, 11, 12). problem solving has been studied in terms of data gathering and information processing, including individual perceptions, and data and task analysis (9, 13, 14). the nursing process is a scientific approach to problem solving in with respect to patient-related health care issues. the majority of early research utilized quantitative measures to examine clinical decision-making (7, 5, 15, 16). their findings are problematic due to the wide variety of instruments designed to measure this skill (4, 6, 18, 19, 20). the watson glaser critical thinking appraisal, the california critical thinking skills test, and the cornell critical thinking test are three of the most frequently cited measurement instruments for critical thinking used in nursing research. clinical decision-making has been measured using a variety of investigatordesigned tests that, although similar in format to the nclex-rn exam ,do not have the sophistication of algorithmic design for implementation and evaluation of outcome, nor the statistical validity and reliability of nclex-rn tests. definitions of critical thinking are numerous and varied among nursing and other disciplines, causing reliability of data to be diluted and a comparison of findings elusive (5, 21). bowles, in her study examining the relationship of critical thinking and clinical judgment of baccalaureate nursing students, used the california critical thinking skills test to measure critical thinking and a researcherdesigned instrument to measure judgment. this leaves the practitioner confused when it comes to drawing comparisons to other instruments claiming to measure both constructs, although validity and reliability data are included (5). quantitative measurement instruments do not measure the feelings, emotions, and intuitive knowledge that go into making a clinical decision in nursing. quantitative research attempts to formulate a hypothesis statement about the expected results of relationships between two phenomena using experimental or controlled conditions. making hypotheses can be premature when not enough is known or understood about a particular phenomenon (22). conversely, qualitative studies are designed to gather data about phenomena in real time when there is limited knowledge of the concept or it is poorly understood. since the study of clinical decision-making in nursing and particularly among student nurses is in its infancy and research findings have been ambiguous, taking a qualitative view of this phenomenon is most appropriate to gather more information about the various aspects of this very complex concept. clinical decision-making there are no specific theories on clinical decision-making in nursing. however, the two distinct perspectives that have emerged on this topic include the humanistic approach 23 gaining insight into student nurses’ clinical decision-making process of benner et al., and the logical positivistic approach of information processing (23). in order to better understand how nurses make decisions, researchers have begun to inquire about this process using qualitative methodologies (8, 24, 25). benner has continued to expand her research with expert nurses in critical care settings where fast, accurate decision-making is required (26). conceptual framework imogene king’s theory of goal attainment was used to guide the research question and to interpret the data in this study. king’s theory was selected because of her conceptual framework on dynamic interacting systems, which views the social aspect of human relationships and the nurse-patient relationship as an interpersonal system. she explains human beings as “dynamic systems interacting” with society, groups and individuals (figure 1). king’s theory has eight propositions related to interactions and transactions between the nurse and the patient. the theory emphasizes the mutuality of goal setting between the nurse and the patient to achieve goal attainment. nurse and patient are equal partners in this social interaction. the role of the nurse is to help the patient to attain mutual goals through use of the nursing process and to maintain the nurse’s functional role in society (figure 2), (27). the main objective of this study was to gain a clearer understanding of the ways in which student nurses make clinical decisions. the study included gaining insight into how students use cognitive and emotive thinking processes to make judgments and choices about nursing care given to patients in a clinical setting. the significance of this study was to add to the sparse body of existing knowledge on how student nurses make accurate clinical decisions. methods sample the investigator used a convenience sample of 12 generic baccalaureate student nurses enrolled in a large urban public university. the sample included six juniors and six seniors; there were three males and nine females. the subjects’ ages ranged from 20-28 years. students represented five ethnic groups, including two minority groups. based on research data suggesting that knowledge impacts positively on clinical decision-making accuracy (8, 28) the students were required to have a grade point average of b+ (3.5) or higher to participate in the study. this additional selection criterion was implemented to obtain internal consistency among the sample. human rights protection confidentiality and procedures for the protection of the rights of human subjects were maintained through a special coding system. irb approval was received from the college where the study was conducted. a monetary incentive was offered to all participants who volunteered for the study. the investigator conducted private interviews at her campus office; this involved two sessions of approximately two hours each. the meetings were one week apart for each student interviewed. all interviews were taperecorded and the data were stored in a locked file. in this study students passed through a series of three major steps in their decisionmaking process. these included connectedness, knowing, and heroism. these themes were the pillars of clinical decision-making that formed the basis for understanding student’s thinking and feelings throughout this process. 24 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 procedure a grounded theory approach was used to gather data through in-depth personal interviews. a series of eight open-ended questions was asked of all student participants regarding direct patient care experiences with adult clients and the student’s choices made concerning that care. the interview questions were developed using the results of clinical decision-making research from benner and king’s model of dynamic interaction between nurse and patient. see table 1. interviews were conducted at the college campus where the investigator was on faculty. a dialogical style between participant and investigator was used. participants were given free range to share personal accounts of their decision-making situations. the investigator prompted students for clarity of information about the described situations. students were questioned about their ways of thinking, their feelings during and after making their decisions, and the context of the situation described. the reflective process used including “thinking in action” and “thinking on action”. schon discussed the reflective technique as a teaching strategy among various disciplines to move the learner from apprentice to master levels of performance (29). his technique has been cited frequently in nursing literature and employed to teach student nurses how to analyze their reasoning processes during and after patient care, using reflection. students shared their thoughts and emotions about their decision-making experiences at a deeply personal level. it was evident to the investigator that both the patients and the experiences were extremely meaningful to the students. every minute detail was described in their reflections about the situations, as if they were revisiting the scenarios. this information helped the investigator to fully comprehend what the student experienced in this process. interviews were conducted until saturation was achieved; that is, until no new information was shared. analysis data were analyzed through content analysis. taped interviews were transcribed verbatim. the investigator listened to the audiotapes and read the written transcripts several times to gain an understanding of each student’s responses and the context of the situations described. the researcher verified transcribed information with participants during the second meeting. after that, statements significant to the clinical decision-making process were extracted. categories and sub-categories were identified and comparisons made to determine connections between categories, including conditions that initiated or supported the categories. meanings were formulated from coded statements and organized by themes. a detailed description of the themes was drawn up to explain the participant’s experiences. a synthesis of themes to develop a relational hypothesis was the final step in the analytical process. the investigator developed the analysis manually so as to keep a close relationship with the data. throughout the analysis, the investigator consulted with two expert nurse researchers, both with prior research experience in descriptive qualitative methodology, regarding interpretation of the meaning of the data and the investigator’s prior knowledge and potential biases regarding clinical decisionmaking. this process added to the validity and reliability of the findings. this investigator chose to study the phenomenon of decision-making from a holistic viewpoint using qualitative methodology. the aim of the study was to gain a more clear understanding of the ways in which student nurses made clinical decisions rather than limit the investigation to the outcomes of clinical choices. 25 gaining insight into student nurses’ clinical decision-making process results and discussion five themes were identified by means of the study: connectedness, knowing, heroism, frustration and anxiety. see figure 3. connectedness connectedness with their patients was the first theme to emerge from the interviews. this concept was used as the transaction and was the first step in the decision-making process. this transaction marked the beginning of establishing mutual goals. king describes transaction as “mutuality” or a “harmonious reciprocal” sharing in the student nurse-patient relationship (30). if students were connected to their patients, they then moved smoothly on to the next step; that is, towards interpreting the patient’s behavior and “knowing” or accurately identifying the patient’s problems or needs. all students felt a closeness or intimate professional relationship with the patients selected for the cases shared. the fact that students remembered these patients, and that the patient had an impact on their learning and professional development, was significant to the decision-making process. students were asked to share a clinical experience where they made a decision about the nursing care they were giving to a patient. they had no hesitation recalling these situations and shared information in great detail. intimate communication between the student and patient was evident in their narratives. the communication between student nurse and patient was both verbal and non-verbal. one student described her semi-comatose patient turning toward her during personal care as if to send the student a non-verbal message. the student was sensitive to this subtle form of communication and responded appropriately, noting that the patient was able to relax and become more at ease. “she would turn her head towards me even though it was difficult.” “you could feel by some minor detail that she would feel more comfortable.” imogene king, in her theory, describes this form of communication as a transaction or harmonious reciprocal sharing. harmonious reciprocal sharing or mutuality was key to the connectedness that students and their patients developed. this was the first step in the decision-making process. it led to the next step in the decision-making process; namely, that of knowing or accurately interpreting the patient’s behavior and identifying needs. knowing the correctness or accuracy of the student’s perceptions was captured in their “knowing”. they used words like “i knew right away” for immediacy of accurately interpreting patient behavior for a nursing diagnosis. “i knew the patient had pain” “i knew, even though the patient had no symptoms.” at other times, the knowledge occurred during the care of the patient throughout the day, indicating a developing understanding of the problem or need “i came to know”. students used both cognitive and emotive aspects of thinking in this “knowing.” “knowing” was supported by their research on the patient’s diagnosis and a review of patient records. discussions with peers, professional nursing staff members, and clinical instructors were very helpful to their developmental understanding; however, quantitative measurement instruments do not measure the feelings, emotions, and intuitive knowledge that go into making a clinical decision in nursing. quantitative research attempts to formulate a hypothesis statement about expected results of relationships between two phenomena using experimental or controlled conditions. 26 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 student nursepatient interactions and patient’s behavioral cues dominated their exemplars. frequently, students “knew” independent of input from anyone other than the patients themselves “a lot of time, i get feedback from the patients themselves.” this finding supports the advancement in decision-making skills from theoretical knowledge to practical understanding (8). the emotive aspect of “knowing” was gained through studentpatient transaction or intimate communication between the dyad. in this way, students understood patient’s needs, expressed both verbally or non-verbally, as well as through disease research and chart review. this way of knowing was the essence of the decision-making process; that is, accuracy of perception in order to make an appropriate nursing diagnosis. connectedness between student nurses and patients was essential to the students’ knowing or the perceptual accuracy of identifying and prioritizing the patient’s needs. all behavioral cues were important to this process, both verbal and non-verbal. heroism patients were described as needing the student. also, the students needed the patients in the sense that they provided a valuable learning experience for the students. patients were seen as vulnerable and described as being in a weaker state requiring the intervention of the student nurse. “she was moaning.” “…[a] very weak and frail old lady.” students were there to rescue the patients from their problems. “nurses are very busy and need to be reminded about the patients’ needs.” students always expressed “feeling good” during those times when they were present for their patients. during those times of “feeling good,” students were able to achieve the mutual goals set by themselves and the patients. they evaluated the outcome of these goals as positive. the students wanted very much to help or rescue their vulnerable patients and to achieve the mutual goals. as long as patient’s behavioral cues signaled a need for the student nurse, the student’s decision was to continue to advocate for the patient. by helping the patient, student were empowered, rather than feeling helpless or frustrated. “ …the patient verbalized she is happy that i am there.” being a hero was a part of the emotional encouragement student nurses needed to initiate and continue to be connected with their patients. this served as a powerful feedback mechanism for students. it was part of the continued harmonious reciprocal relationship between the student nurse and the patient, as described by king. frustration feelings of frustration were cited when students met obstacles from others including the patient that impeded the accomplishment of mutually-agreed-upon patient goals. one student had an issue with a patient regarding the goal of pain relief. “relaxation… the patient was never getting any rest. the phone was ringing off the hook. he kept screaming on the phone, (to a business colleague) ……. as if nobody could make a decision without him. i tried telling him that he shouldn’t do that but, in my opinion, it was very difficult to do. he had his own way and it’s like if i am in pain the medication should work. he was so agitated. it was hard to make him understand and to do it (relax)”. the theory emphasizes the mutuality of goal setting between the nurse and the patient to achieve goal attainment. nurse and patient are equal partners in this social interaction. the role of the nurse is to assist the patient to attain mutual goals through use of the nursing process and to maintain their functional role in society. 27 gaining insight into student nurses’ clinical decision-making process in this case, the student nurse and patient had mutual goals and were connected in part. however, the plan of care that the student had for the patient could not be carried out in full, due to miscommunication between the two. although the relationship was harmonious, it was not totally reciprocal in nature, as described by king. the patient did not understand how to completely relax and let the pain medication take effect, and the student nurse was not in control of the stressful distractions in the patient’s immediate environment. once the student enlisted the aid of the patient’s girlfriend to minimize and eliminate distractions, the goal of pain relief was accomplished completely and quickly. “because he was so agitated, i decided to take a different approach and i decided to approach his girlfriend.” although students were frustrated, they continued to attempt to meet the goals that had been established mutually between themselves and their patients. in her theory, king explains that, in the nurse-patient relationship, each member of the dyad perceives the other, makes judgments and takes action. perceptual awareness includes thinking and feeling. the emotive and cognitive aspects of experiencing a situation are key components of goal attainment. together, this exchange is known as a “reaction”. the “reaction” is the interaction within the dyad. “transaction” then occurs, if perceptual accuracy is present, and goals will be attained. goal attainment leads to effective nursing care. as a result of goal attainment, each member of the dyad will experience satisfaction, growth and development. for the student nurse, perceptual accuracy was critical to mutual goal attainment and to accurate decision-making. in this case, the student was able to perceive that, although pain medication was administered, the patient was not relaxed enough for the drug to work effectively. here, the blocker was lack of reciprocity between the student and the patient. the student enlisted the aid of the patient’s girlfriend, after establishing a harmonious reciprocal relationship with the patient’s significant other to attain the mutual goal of pain relief. however, if either the nurse or the patient experiences role conflict based upon perceptual differences, then stress in the relationship will occur (30). in another narrative, a different student described a mentally ill patient who was manipulative in his behavior. yet, the student connected with this patient as a human being in need of help, while the patient was placing barriers to their relationship. that barrier left the student with a sense of frustration, because there was no “reciprocal connection.” “my goal was to establish trust.” “at first, he sounded very true, because i was taking everything at face value, …after i read his chart, i started questioning him on some things, like homelessness …he couldn’t give me a straight answer. he just lived in a big house. he was very vague. ...… i was just trying to work with him. i hope he will trust someone and not be so grandiose and vague.” in this case, due to the lack of connectedness, the student’s frustration was never alleviated. the relationship did not grow or develop further. the student’s decision was to have hope for the patient in his new discharged setting (a men’s shelter). it was evident to the investigator that both the patients and the experiences were extremely meaningful to the students. every minute detail was described in their reflections about the situations as if they were revisiting the scenarios. this information helped the investigator to fully comprehend what the student experienced in this process. 28 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 feelings of frustration and helplessness added extra layers to the decision-making process and delayed or prevented goal achievement. anxiety students experienced remorse or indicated “feeling bad” when they were unable to meet the patient care goals established with their patients. a student describes her personal anxiety when attempting to maintain a sterile technique during her first tracheotomy suctioning experience on a ventilator dependent patient, “i was so scared. i was afraid of introducing more infection.” after input from the clinical instructor, the student was able to implement the procedure correctly and stated, “i made myself concentrate on her (patient) feelings and not my skills. and i did it…. the instructor told [me] that i did it right, that i didn’t panic. that was a good lesson for me.” fear and anxiety caused students to step back and reflect on the situation and to re-assess the events. the student’s fears got in the way of her understanding of the patient’s feelings and a reciprocal relationship did not develop initially. once she relaxed and let herself feel and understand what the patient was experiencing, the student was able to carry out the procedure skillfully. the student was then able to accurately perceive the patient’s needs and to carry out the procedure. conclusions the researcher initially set out to understand the decision-making process used by student nurses in direct patientcare situations. a descriptive qualitative approach to research design was utilized in order to gain a clearer understanding of the perspective of decision-making among this population in various healthcare settings. student narrative exemplars about their thoughts and feelings during decision-making were analyzed to better understand this process. in this study, students passed through a series of three major steps in their decision-making process. these included connectedness, knowing, and heroism. these themes were the pillars of clinical decision-making that formed the basis for understanding the student’s thinking and feelings throughout this process. the sample group of twelve novice nurses used mutual goal setting as the key to their clinical decision-making accuracy by establishing and continuing a transactional relationship with patients. patient behavioral cues were the most significant data that students collected and learned to interpret in the decision-making process. continuous patient reassessment for goal achievement was paramount. this finding reinforces the importance of therapeutic communication and holistic behavioral and physical assessment skills within the clinical context for beginning-level student nurses who tend to seek greater information and comfort from a review of patient records and textbooks during clinical practice. the questionnaire used and the themes found in this study can serve as a blueprint for clinical nurse faculty understanding of how to help student nurses to blend theoretical knowledge with practical application. the faculty can reinforce positive thinking and decision-making skills by refocusing clinical conferences on patient findings through both emotive and theorethe harmonious reciprocal sharing or mutuality was key to the connectedness that student-patient developed. this was the first step in the decision-making process. this led to the next step in the decision-making process that of knowing or accurately interpreting the patient’s behaviors and identifying needs. 29 gaining insight into student nurses’ clinical decision-making process tical ways of knowing. reinforcing the establishment of “connectedness” between the student and the patient to more accurately interpret the meaning of patient behavior and correlation with theoretical knowledge to “know” or correctly identify patient care needs are key components of the decision-making process. the clinical faculty must help students to distinguish between the two levels of “knowing”; that is, theoretical and practical. reflecting on and sharing thoughts and feelings through journaling and pre and post conference discussions continues to be important to the development of student’s clinical decision-making skills and confidence in their nursing actions. it is equally important that student nurses learn to identify mutual and accurate goals when caring for patients and to be in touch with their own thinking and feelings. students can be taught to establish simple and more complex goals with patients, as they advance in their nursing program and as practicing registered nurses. meaningful engagement with patients and sharing thoughts and feelings about references 1. joint commission on accreditation of healthcare organizations. accreditation overview. chicago: joint commission resources, inc., 2005. 2. national league for nursing accrediting commission. national league for nursing accreditation manual with interpretive guidelines by program type for post-secondary and higher degree programs in nursing. new york: national league for nursing accrediting commission, inc., 2005 edition. 3. american association of colleges of nursing. standards for accreditation of baccalaureate and graduate nursing programs. washington dc: aacn, 2005. 4. bauwens, e. and g. gerhard. “the use of the watson-glaser critical thinking appraisal to predict success in a baccalaureate nursing program.” journal of nursing education 26 (1987): 278-281. 5. bowles, k. “the relationship of critical thinking skills and clinical judgment skills of baccalaureate nursing students.” journal of nursing education. 2000; 39 (8) 373-376. 6. brooks, e.m. “the perception and judgment of senior baccalaureate student nurses in clinical decision-making.” advances in nursing science 1997; 19 (3) 50-69. 7. brooks, r. and j. shepherd. “the relationship between clinical decision-making skills in nursing and general critical thinking abilities of senior nursing students in four types of nursing programs.” journal of nursing education 1990; 29 391-399. clinical findings with the clinical faculty and professional colleagues who are skilled in accurate clinical decision-making can provide needed feedback on student judgment abilities. future studies of this type require duplication with larger samples of student nurses from various types of nursing programs and at various geographic locations to continue to expand the body of knowledge on student nurse clinical decision-making processes. 8. benner, patricia. novice to expert: excellence and power in clinical nursing practice. menlo park: addison-wesley, 1984. 9. yura h. and m. walsh (1988). the nursing process: assessing, planning, implementing, evaluating. new york: appleton-lange. 10. dewey, j. (1933). how we think: a restatement of the relation of reflective thinking to the education process. boston: heath. 11. fancione n. and p. fancione (1996). “externalizing critical thinking in knowledge development and clinical judgment.” nursing outlook 4: 129-136. 12. brookfield, s. (1987). developing critical thinkers: challenging adults to explore alternative ways of thinking and acting. san francisco: jossey-bass. 13. argyris, c. (1971). management and organization: the path from xa to yb. new york: mcgraw-hill. 14. newell a. and h. simon (1971). human problem solving. englewood cliffs: prentice-hall, inc. 15. dincher, j. and s. stidger. “evaluation of a written simulation format for clinical nursing judgment: a pilot study.” nursing research 1976; 25 280-285. 16. tschikota, s. (1993). “the clinical decision-making process of student nurses.” journal of nursing education. 32 (9): 389-98 17. pardue, s. “decision making skills and critical thinking ability among associate degree, diploma, baccalaureate and master’s prepared nurses.” journal of nursing education 1987; 26 (9) 354-360. 30 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 figure 1 king`s dynamic interacting systems (king, 1980, p. 20) 18. twibell, r., m. ryan and m. hermiz. “faculty perceptions of critical thinking in student clinical experiences.” journal of nursing education 2005; 44 (2) 71-9. 19. daly, n. “the development of an alternative method of critical thinking as an outcome of nursing education.” journal of advanced nursing 2001; 36 (1) 120-30. 20. campbell, e.t. (1998). clinical judgment and critical thinking abilities among senior nursing students: a comparative study. ny: teachers collegecolumbia university. thesis. 21. dickerson, s. “guidelines for evaluating tools for clinical decision making.” nurse educator 2001; 26 (5) 215-220. 22. polit, denise f. and cheryl t. beck. nursing research principles and methods. 7th ed. philadelphia: lippencott, 2003. 23. garrett, b. “student nurses’ perceptions of clinical decision-making in the final year of adult nursing studies.” nurse education in practice 2005; 5 (1) 30-9. 24. benner, p., c. tanner and p. chesla. expertise in nursing practice, caring, clinical judgment and ethics. new york: springer publishing company, 1996. 25. bakalis, n.a. “nurse’s decision-making in clinical practice”. nursing standard. 2005; 19 (23) 33-9. 26. benner, p., p. hooper-kyriakidis and d. stannard, d. clinical wisdom and interventions in critical care: a thinking-in-action approach. philadelphia: w.b. saunders company, 1999. 27. king, imogene. toward a theory for nursing: general concepts of human behavior. new york: j. wiley, 1971. 28. tanner, c., p. benner, c. chesla and d. gordon. “the phenomenology of knowing the patient.” image: journal of nursing scholarship 1993; 25 (4) 273-280. 29. schon, d. educating the reflective practitioner. san francisco: jossey-bass, 1987. 30. king, imogene. a theory for nursing: systems, concepts, process. new york: wiley, 1981. 31 gaining insight into student nurses’ clinical decision-making process figure 2 king`s interaction-transaction process (king, 1980, p. 26) 8. gaining insights into cdm manuscript.doc steps in the clinical decision-making process student nurse 32 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 connectedness between the sn and the patient leads to a transaction. this connectedness leads to knowing or accurately understanding the patient’s problems and needs, and to mutual goal setting. the good feeling students have when they connect with patients is that of a hero who attempts to save a vulnerable human being and to meet that person’s needs. this feeling establishes the student as a patient advocate, and helps to prioritize patient needs and goals that lead to actions or decisions that directly or indirectly assist in satisfying the patient’s needs. lack of connectedness between the sn and the patient or others delays mutual goal setting and leads to feelings of frustration and helplessness. students feel remorse for not having lived up to their role as a hero or patient advocate. errors in decision-making lead the student to feel fear. nursing delirium screening scale, a tool for early detection of delirium: integrative review article nursing delirium screening scale, a tool for early detection of delirium: integrative review nursing delirium screening scale, una herramienta para la detección temprana del delírium: revisión integrativa nursing delirium screening scale, uma ferramenta para detectar precocemente o delírio: revisão integrativa angela maría henao-castaño 1 laura elizabeth pachón cetina 2 juan david monroy rodríguez 3 1 0000-0003-4203-0016. universidad nacional de colombia, colombia. angmhenaocas@unal.edu.co 2 0000-0003-2708-8391. universidad nacional de colombia, colombia. laepachonce@unal.edu.co 3 0000-0002-6534-9102. universidad nacional de colombia, colombia. jdmonroyr@unal.edu.co 10.5294/aqui.2020.20.4.5 received: 09/03/2020 sent to peers: 19/03/2020 approved by peers: 23/07/2020 accepted: 14/08/2020 theme: evidence-based practice contribution to the discipline: knowing the different contexts in which the nursing delirium screening scale can be applicable provides nurses with an easy-to-use tool for the diagnosis of delirium and, thus, enables them to implement non-pharmacological interventions that contribute to its prevention and treatment. this instrument will allow nursing to be at the forefront of the management of this cognitive impairment. para citar este artículo / to reference this article / para citar este artigo: henao-castaño am, pachón le, monroy jd. nursing delirium screening scale, a tool for early detection of delirium: integrative review. aquichan. 2020;20(4):e2045. doi: https://doi.org/10.5294/aqui.2020.20.4.5 abstract objective: to analyze the context and use of the nursing delirium screening scale (nu-desc) for early detection of delirium in adult patients, compiling the available evidence. method: searching for relevant articles on databases such as cinahl, medline, ovid, scopus, and web of science. inclusion criteria: articles written in english, spanish, and portuguese, published between january 2013 and october 2019. search terms: "nursing delirium screen," "inpatient delirium screening," and "nursing assessment." we identified 23 articles in which the nu-desc was used. two reviewers independently assessed the articles using the caspe (critical appraisal skills program in spanish) tool. results: the nu-desc is employed in different contexts such as the adult intensive care unit (icu), post-anesthetic care unit (pacu), palliative care unit, and hospitalization unit. it is more frequently used in the pacu with a more sensitive threshold (≥ 1); the test showed greater sensitivity of 54.5 % (95 % ci: 32.2-75.6) and specificity of 97.1 % (95 % ci: 95.3-98.4). conclusion: the nu-desc facilitates the recognition of delirium episodes by the nursing team, makes care quicker and individualized for each patient, avoiding immediate pharmacological interventions, and coordinate interdisciplinary actions for diagnosis, especially in post-anesthetic care units. keywords (source: decs): delirium; nu-desc; screening; nursing; assessment; critical care; hospitalization; perioperative period. resumen objetivo: compilar la evidencia disponible con el fin de analizar el contexto y uso de la escala de detección del delírium para enfermería (nu-desc, por sus siglas en inglés) en la detección temprana del delírium en pacientes adultos. método: búsqueda de artículos relevantes en bases de datos como cinahl, medline, ovid, scopus, web of science. criterios de inclusión: artículos escritos en idioma inglés, español y portugués; publicaciones entre enero del 2013 y octubre del 2019. los términos de búsqueda fueron: "nursing delirium screen", "inpatient delirium screening" y "nursing assessment". se identificaron 23 artículos en los que se utilizó el instrumento nu-desc en diferentes contextos. dos revisores de manera independiente realizaron la evaluación de los artículos utilizando la herramienta caspe. resultados: el uso de la nu-desc se presentó en diferentes contextos, tales como la unidad de cuidado intensivo adulto, la unidad de cuidado posanestésica, la unidad de cuidado paliativo y la unidad de hospitalización. en la unidad de cuidado posanestésico su uso es frecuente con un umbral más sensible en ≥ 1; la prueba mostró una mayor sensibilidad del 54,5 %> (ic del 95 %>: 32,2-75,6) y una especificidad del 97,1 %o (ic del 95 %: 95,3-98,4). conclusión: la nu-desc les permite a los enfermeros entrenados realizar el reconocimiento del evento de manera rápida y oportuna, individualizar el cuidado, lo que evita realizar intervenciones farmacológicas de manera inmediata, y coordinar acciones interdisciplinarias para el diagnóstico, en especial en unidades de cuidado postanestésico. palabras clave (fuente decs): delírium; nu-desc; cribado; enfermería; evaluación; cuidado intensivo; hospitalización; periodo perioperatorio. resumo objetivo: compilar a evidência disponível a fim de analisar o contexto e o uso da escala de detecção do delírio para enfermagem (nu-desc, por sua sigla em inglês) na detecção precoce do delírio em pacientes idosos. método: busca de artigos relevantes em bases de dados como cinahl, medline, ovid, scopus, web of science. critérios de inclusão: artigos em inglês, espanhol e português; publicações realizadas entre janeiro de 2013 e outubro de 2019. os termos de busca foram: "nursing delirium screen", "inpatient delirium screening" e "nursing assessment". foram identificados 23 artigos, nos quais foi utilizado o instrumento nu-desc em diferentes contextos. dois revisores, de maneira independente, realizaram a avaliação dos artigos com o emprego da ferramenta caspe. resultados: a nu-desc foi utilizada em diferentes contextos, como a unidade de terapia intensiva de adultos, a unidade de recuperação pós-anestésica, a unidade de cuidado paliativo e a unidade de internação. na de recuperação pós-anestésica, seu uso é frequente com uma faixa mais sensível em ≥ 1; o teste mostrou maior sensibilidade de 54,5 % (ic de 95 %: 32,2-75,6) e especificidade de 97,1 % (ic de 95 %: 95,3-98,4). conclusões: a nu-desc permite aos enfermeiros capacitados realizar o reconhecimento do evento de maneira rápida e oportuna, individualizar o cuidado, o que evita intervenções farmacológicas imediatas, e coordenar ações interdisciplinares para o diagnóstico, em especial em unidades de recuperação pós-anestésica. palavras-chave (fonte decs): delirium; delírio; nu-desc; peneiramento; enfermagem; avaliação. introduction delirium is a disruption of consciousness characterized by inattention and cognitive/perception alterations developed in a short period (hours or days) and fluctuating over time(1). within the perceptual-cognitive sphere, it is vital to recognize delirium in time, avoiding shortand long-term side effects. therefore, monitoring is essential for its prompt identification and treatment(2). approximately 60-80% of all patients in intensive care units (icu) develop this disorder. they may suffer other complications due to a lack of recognition, assessment, and treatment, hence the essential role nurses play in its identification and assessment for being by the patient's bedside. early delirium detection facilitates treatment, minimizing its duration and possible side effects. in many hospitals, delirium detection is a standard procedure, but 72% of cases are not detected or are misdiagnosed. some possible reasons for this are little time, knowledge of this condition, and unavailability of feasible and reliable instruments for diagnosis. the nursing delirium screening scale (nu-desc) was developed and validated in a palliative care unit(3) for early detection of delirium; it consists of five items or categories. its administration takes about two minutes and is accessible for clinical practice. it has been validated in different languages such as danish(4), turkish(5), czech(6), and korean(7), and used in different clinical practice scenarios: palliative care patients(8, 9), cardiac surgery(10,11), liver transplantation(12), orthopedic surgery(13), urological surgery(14, 15), scheduled post-operative patients(16-19), post-anesthesia with medications such as ketamine(20), hospitalization(21), geriatrics hospitalization(22), oncologic hospitalization(23), and icus(24-26). the results of these studies report an average sensitivity of 96% and specificity of 81% using this scale. the nurse must be able to carry out a complete and exhaustive evaluation to achieve an adequate clinical judgment; from the evidence-based practice, the nurse must help in the assessment using validated tools to measure and compare the patient's clinical evolution per shift. delirium assessment tools include the confusion assessment method for the icu (cam-icu), the intensive care delirium screening checklist (icdsc), and the nu-desc, the latter being the most used by nurses. this article presents an analysis of the use of nu-desc, particularly in the icu and postoperative care unit, to provide elements for the timely assessment of delirium by nurses. method we conducted an integrative review applying the stages proposed by ganong(27): identifying the topic and selecting the hypothesis or research question, establishing criteria for inclusion and exclusion of studies, sampling or searching in the literature, categorization of studies, interpreting and synthesizing the results. for this, the pico (problem, intervention, comparison, and outcomes) strategy was used(14). the question that guided the intervention was, "what is the context of the application of the nu-desc for delirium detection?" we searched for articles on online databases such as cinahl, medline, ovid, scopus, and web of science. the inclusion criteria were articles in english, spanish, portuguese, french, german, and korean published between january 2013 and october 2019. the search terms were "nursing and delirium screen," "inpatient and delirium screening," and "hospitalized patients" (figure 1). figure 1. diagram of the process of searching for and selecting articles source: own elaboration based on(56). two independent researchers first assessed all articles based on the title and abstract. if more information was needed, per the inclusion criteria, they read the whole article. to categorize the articles, two reviewers evaluated the studies included in the integrative review with the critical appraisal skills program templates in spanish (caspe) and then interpreted the results. finally, the articles that met the inclusion and exclusion criteria (shown in figure 2) were selected. the caspe instrument was used for analysis and critical reading of the articles, which is fully available on the caspe website (http://redcaspe.org). figure 2. steps of the search methods and outcomes source: own elaboration. we developed an instrument to collect data from the articles with information such as year of publication, authors, aim, country, database, type of research, sampling details, intervention, results, and recommendations/conclusions. then, they were categorized by topic, according to the interpretation of the outcomes and contributions to this review (table 1). table 1. summary of selected articles ref objective analysis of results 29 to compare the validity of the nu-desc and short-cam in general medical units and explore the impact of delirium education on the successful implementation of delirium screening tools the nu-desc proved to be an easy-to-use tool for hospitalization services. 30 to compare phenotypes of diurnal fluctuation among different delirium subtypes using a prospective design the nu-desc was used for diagnosing delirium in a liaison consultation service by mental health nurses. 31 to validate the nu-desc under certain circumstances in hospitalized patients the nu-desc exhibits good sensitivity and specificity in hospitalized patients. 32 to validate the nu-desc in a german emergency department (ed) the nu-desc showed good specificity but moderate sensitivity when performed by nurses during their daily work in a german hospital. 33 to translate the nu-desc and evaluate its performance in italian settings the nu-desc can be used in research and clinical practice in italian settings because of its outstanding performance, similar to previous validation studies. 34 to validate the portuguese version of the nu-desc for use in critical care settings the nu-desc showed in its portuguese version good sensitivity and specificity for clinical use. 35 to validate the swedish version of the nu-desc as a screening tool the nu-desc was quickly incorporated into clinical care and showed high sensitivity in detecting hyperactive symptoms of delirium. 36 to evaluate the frequency, determining factors, and outcome of inadequate delirium emergence after elective surgery in the pacu the nu-desc was used to diagnose post-operative delirium. 37 to determine the incidence of emerging delirium in adult patients who had anesthesia with sevoflurane as the volatile agent and the potential risk factors associated with its occurrence the nu-desc was employed in the diagnosis of delirium in patients under sevoflurane in the pacu. 38 to evaluate the performance of the 4at in the pacu in a tertiary german medical center the nu-desc was used with the 4at to diagnose delirium after anesthesia. 39 to evaluate the quality of recovery in elderly patients with post-operative delirium (pod) the nu-desc was used for diagnosing delirium in the elderly after anesthesia. 40 to evaluate delirium screening tools in post-operative settings while highly specific, neither the cam-icu nor the nu-desc (threshold > 2) is adequately sensitive to identify delirium post-operatively; the nu-desc (threshold > 1) increases sensitivity but reduces specificity. 41 to assess the agreement between the cam-icu and the nursing delirium screening scale (ndss) in the post-operative period of cardiac surgery there was an agreement between the cam-icu and ndss in the post-operative period of cardiac surgery. 42 to compare three tools in assessing patients upon admission to the recovery room in order to detect early signs of postoperative brain dysfunction the nu-desc detected delirium in the first seven postoperative days. 43 to test psychometrically the finnish versions of the neecham confusion scale (neecham) and the nu-desc in surgical nursing care the nu-desc was used to diagnose delirium in a surgical unit. 44 to evaluate patients' pupils and the glasgow coma scale (gcs) the nu-desc was used to detect neurological complications in post-operative craniectomy. 45 to detect the presence of delirium using the nu-desc the nu-desc was used in the pacu by nursing personnel with a low incidence. 46 to evaluate the relationship between alcohol abuse and the development of pod the portuguese nu-desc in post-operative patients with previous alcohol consumption test showed > 2 in any of the observations. 47 to analyze pod in clinical practice after cardiac surgery, how it is detected and documented, and whether the use of a screening scale improves the detection rate the recognition of delirium improved when nu-desc was used for systematic screening after cardiac surgery. 48 to determine the frequency and severity of symptom distress and delirium the nu-desc is not a reliable tool for screening delirium when a caregiver conducts the scoring. 49 to explore nurse perceptions of the feasibility of integrating the nu-desc into practice within the inpatient palliative care setting the nu-desc is feasible for use in a palliative care inpatient setting but requires research on its psychometric properties before routine use in this patient population. 50 to test the feasibility and acceptability of the delirium measurement methodology the nu-desc and physician application of dsm-5 proved to be feasible and acceptable in palliative care. source: own elaboration. results the nu-desc is an observational detection instrument composed of five items (orientation, behavior, communication, illusions/hallucinations, and psychomotor retardation). it has a sensitivity of 32-96% and specificity of 69-92%(28). after the integrative review, the categories obtained are utility of the nu-desc in the hospitalization unit, pacu, icu, and palliative care unit. nu-desc and its use in hospitalization nu-desc validation studies in multipurpose hospitalization units, where the incidence of delirium varies between 14.9-18.2 % and the mixed and hyperactive type prevails, demonstrate a moderate detection capacity with a sensitivity of 42-77.1 %> and specificity between 76-98 %> when the threshold is > 2, compared to short-cam whose sensitivity is 8.6-11.1 %> and specificity is 100 %>. also, it has optimal operational feasibility as it can be completed in approximately 2 minutes, which promotes the adherence of nursing professionals (approximately 90 %>) to its use in the healthcare practice(29). this measurement tool also responds to the characteristics of this pathology, such as fluctuation or severity of symptoms per type of presentation. this result is consistent with dsm-v criteria, as kim et al. point out(30), identifying significant variations of symptoms in 244 hospitalized psychiatric patients when nu-desc scores showed that severe symptoms increased during the afternoon or at night. patients with hyperactive and mixed type of delirium had higher scores in the disorientation, inappropriate behavior, and inappropriate communication items than patients with unspecified or hypoactive delirium. the difference between these types is a higher average score in psychomotor retardation and more significant fluctuations during the afternoon, while at night, the symptoms of hyperactive type intensified. patients who had the hypoactive type had the highest average score in the psychomotor retardation item that differs from the unspecified type, whose fluctuations occur mostly during the day(30). concerning low diagnostic sensitivity, associated with the limited capacity to detect hypoactive delirium, a study was conducted in three hospitalization units with a sample of 405 patients (103 participants were admitted to neurology, 84 to general medicine, 82 to general surgery or orthopedics, and 136 to neurosurgery), 185 of which had delirium (11 % hypoactive type). it showed no statistical differences between the groups regarding age, sex, hospitalization unit, language, and post-operative state. this result indicates increased sensitivity ranging from 42 %> to 67 %> when the threshold is > 1; however, specificity decreased from 98 % to 93 %(31). another exploratory analysis was conducted within a study of 315 patients admitted to an emergency unit for at least 12 hours, where the incidence of delirium was 14.9 %, with a predominance of the hypoactive type (46.8 %). it showed that the evaluation of item 1 (disorientation) combined with two elements of the mini-mental state examination (mmse) indicates that asking the patient the day of the week and name of the unit where he or she is located increases sensitivity from 66 %> to 77.8 %>. this finding contrasts with the results obtained in the same study, where the disorientation item was not identified in 14 of 16 false positives cases(32). although questions arise about the ability of nu-desc to detect all forms of delirium, it is necessary to add the capacity to discriminate between delirium and differential diagnosis; spendale et al. demonstrated it in a study of 101 patients hospitalized in different units where 79 %> of positive cases had a history of cognitive impairment(33). nu-desc and its use in the uci studies conducted in post-operative patients admitted to the icu, where hypoactive type delirium predominates, show that nu-desc is a practical tool for delirium detection and has a sensitivity of 65.5-100 % and specificity of 81.3-86 %. when considering the type of surgical intervention, a trend towards overestimating the incidence of post-operative delirium (pod) in patients undergoing non-cardiac or intracranial interventions was identified because of the number of false positives (n = 9) and positive predictive value (57 %>). abelha et al.(34) reported this in a study of 78 patients admitted to the icu, where nu-desc performance was compared with the icdsc as a gold standard. when applying the nu-desc on days 1 to 4 of the post-operative period in patients undergoing scheduled cardiac surgery, the detection capacity decreases considerably from 65.6 %> (day 1) to 46.9 %o (day 4) when the threshold is > 2. these results are associated with underestimation of hypoactive delirium that, due to its signs, unlike the hyperactive type, does not demand attention. however, it requires more monitoring for identification, accounting for the difference in diagnostic sensitivity between days 1 and 4 because on day one, the scale was applied in the icu where the nurse-patient relationship was closer than in the general room, where it was applied on day 4. although changing care units implies diminution in suggestive sign detection (because of the fluctuating characteristics of delirium and the nurse/patient ratio), a change in the cognitive performance of patients is observed as the number of cases of delirium decreases on day 4 (n= 49), mostly with the hypoactive type (n = 28); the nu-desc detected just 50 % (n =14) of those cases. therefore, the evidence does not support that nu-desc detects the symptoms of hypoactive delirium optimally since there is a tendency to recognize the hyperactive type(35) mostly. nu-desc and its use in the pacu in adding all the articles reviewed in this area, approximately 1,500 patients were assessed for pod at different times: before surgery (where the nu-desc and mmse were used to assess the pre-operative cognitive function(36)), ten minutes after extubation to verify ongoing delirium(37), upon admission to the pacu, upon discharge from the unit(36, 38), or up to 14 days after surgery(39). previously, it was necessary to train the nursing staff in topics like delirium and application of the nu-desc(36). during the assessments, it was demonstrated that the execution time of the nu-desc does not take more than two minutes(40). when making a detailed comparison with the cam-icu, it was found that its discriminatory characteristics are not better than this standard diagnostic criterion; therefore, it should not be replaced, despite low staff adherence due to difficulties in its application. however, the nu-desc showed a moderate agreement, according to the kappa coefficient (0.514)(41). at the same time, the results obtained by the nu-desc were compared or complemented with other scales such as the richmond agitation and sedation scale (rass), the post-anesthetic recovery score (pars), the neelon and champagne confusion scale (neecham), the canadian neurological scale (cns), the bispectral index (bis), the glasgow coma scale, (gcs) and the ramsey scale, showing high reliability in the nu-desc to detect pod(42-44). pod was evaluated by the nu-desc in patients between 16(45) and over 80 years old, finding that the most affected patients were older adults (> 65), especially those over 80(39) who had asa 3 or 4 in the pre-surgical period, while younger patients (with asa 1 or 2) developed delirium in a smaller amount. age influenced the incidence of delirium, which was between 4.3 % (45) and 12.3 %>(39) in post-operative patients, who also had a more extended stay in the pacu (24 % vs. 10 %) and hospitalization unit (7 vs. 4 days) compared to those who did not develop pod(46). studies also showed that the nu-desc is highly effective in detecting hyperactive and mixed types, and moderately effective in the hypoactive type(47), with higher scores for disorientation and psychomotor retardation(43). regarding discriminatory capacities, a sensitivity between 69 96 % and specificity between 82-100 % were reported (40). neufeld et al.(40) and saller et al.(38) found that the > 1 threshold is more sensitive for the nu-desc (69 % (vs. 32 %) and 54.5 % (vs. 27 %), respectively). however, significant changes that affect specificity by decreasing it from 92 %> to 80 %> are also described(40). one of the recommendations given by smulter et al.(47) is to have better reports in clinical records about clinical findings in the pacu because, of all the patients who develop delirium in this unit, only 23 % are diagnosed and 1 % correctly identified and registered. the nu-desc also showed improvement in the recognition rate and allowed clinical staff to better record the findings(46). nu-desc and its use in the palliative care unit despite the incidence and prevalence of delirium, particularly the hypoactive type, it is poorly recognized in patients who require palliative care or specialized care due to malignant tumor diagnosis. clinical condition factors and patient's comorbidities, such as fatigue or depression, may make it challenging to recognize cognitive changes associated with delirium(48). while multiple detection methods have been developed and validated, such as the cognitive rating scale (crs), memorial delirium assessment scale (mdas), confusion assessment method (cam), and delirium rating scale-revised-98 (drs-r-98), these instruments are very complex to be applied or do not have adequate discriminatory power compared with the nu-desc. although recent studies reported a lower discriminatory power when the threshold is > 2 (63 %)(48), the original study indicates that the nu-desc has greater sensitivity (85.7 %>) when the threshold is > 1. this result corroborates what was mentioned in the categories above and should be considered in subsequent studies(3). regarding the ability to detect hypoactive delirium (which is also related to our findings and the most underdiagnosed type), questions are raised about measuring the psychomotor delay, which can be linked or not as a symptom of delirium detected by health care personnel or caregivers. many patients receive pharmacological treatment for symptom management, casting doubts about its application time, changing the outcome of the nu-desc(49), and increasing the number of false positives or false negatives as reported by gaudreau et al.(3) (who associated severe analgesia as a factor that makes it difficult to establish a correct diagnosis). besides, the findings of hosie et al.(50) indicate an overestimation of the incidence of delirium by the nu-desc since only 19 % of the evaluations were carried out on patients in the "stable" or "deteriorating" palliative care phases and terminal phase, following the dsm-v criteria. discussion the use of nu-desc in different contexts such as the hospitalization unit, pacu, icu, and palliative care unit facilitated the early diagnosis of delirium due to its easy application, considering that many of the studies were descriptive or comparative with other diagnostic scales. the nu-desc, cam-icu, and dsm tools were the most used by nurses for detecting delirium in critical care units, post-operative units, especially older adults(51, 52). however, because of the lack of education in delirium recognition, nurses are not prepared to identify delirium in the unit. from their speeches, a strong relationship was observed with the lack of training, updating, and recycling on the subject to substantiate this conduct(53). the role that nursing plays in the timely diagnosis of delirium through validated scales becomes increasingly valuable, knowing that delirium is a predictor of death in the patient, and the use of these tools allows for its timely recognition(54). the nu-desc is recognized for its easy application; it can be administered several times during the shift since the high workload and complexity of other scales are barriers to the timely diagnosis of delirium by nursing staff(55). conclusions this review provides nurses with information and tools to assess delirium, especially in the icu and pacu, at the time of discharge from the unit. compared with other scales and individually, the nu-desc showed high sensitivity and specificity and is the most usable option for pod assessment, especially in the hyperactive and mixed subtypes. however, it does not replace cam-icu as a gold standard in delirium diagnosis. in hospitalization units where education about delirium was given, we note that nu-desc is better at evaluating and helping to recognize and diagnose delirium than other scales, as contrasted with cam-icu, showing greater sensitivity and negative predictive value but lower specificity. we found no distinction of age or gender for a greater tendency to develop delirium. nevertheless, a clinical history of a neurological or psychiatric disease does increase the prevalence of delirium. the most recurrent subtype of delirium in hospitalized patients was the hyperactive one, backed by the identification of a high percentage of these cases by the nu-desc. nevertheless, it is not very sensitive or specific to identify the development of the hypoactive subtype. it is not possible to conclude that there is some relationship between taking one or more medications with the development of delirium during hospitalization. we found that when the hyperactive or mixed subtypes were present, higher nu-desc scores were obtained. we recommend evaluating the first item of the scale (disorientation) by asking the patient the current day of the week and the name of the unit where he/she is as it increases the sensitivity. the implementation of the nu-desc in care, research, education, cancer prevention, and palliative care units demonstrates that it is a delirium detection tool with moderate discriminatory power and optimal operational feasibility (two minutes) compared to mdas or cam that are highly efficient in diagnosing. nonetheless, it is more complex and presents difficulties when applied in patients with a fluctuating intensity of associated symptoms such as pain, fatigue, and nausea, among others, or impaired and terminal patients. therefore, nu-desc allows the trained nurse to recognize the event and individualize care, avoiding immediate pharmacological interventions, and coordinate interdisciplinary actions for delirium diagnosis and management involving family as the principal active caregiver. limitations articles in languages different from spanish, english, or portuguese were not included, neither the category of delirium in oncology patients. implications for practice the literature reports the importance of early and routine detection of delirium in clinical practice. so, nurses need to know easy-to-use tools like the nu-desc scale, which is applicable in different hospital areas, to create a culture of prevention, detection, and management of delirium. conflict of interest: none declared. references 1. american psychiatric association. diagnostic and statistical manual of mental disorders (dsm-iv-tr). 4th ed., text revision (dsm-iv-tr); 2000. 2. slooter ajc, van de leur rr, zaal ij. delirium in critically ill patients. in handbook of clinical neurology. 1st ed. vol. 141. elsevier b.v.; 2017. p. 449-466. doi: http://dx.doi.org/10.1016/b978-0-444-63599-0.00025-9 3. gaudreau jd, gagnon p, harel f, tremblay a, roy ma. fast, 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2016;35(2):100-10. doi: https://doi.org/10.18566/medupb.v35n2.a04 56. moher d, liberati a, tetzlaff j, altman dg; prisma group. preferred reporting items for systematic reviews and meta-analyses: the prisma statement. plos med. 2009 jul 21;6(7):e1000097. doi: https://doi.org/10.1371/journal.pmed.1000097 home 19 natalia tobo-medina1 gladys eugenia canaval-erazo2 las emociones y el estrés en personas con enfermedad coronaria 1 doctora en psicología. profesora titular, escuela de enfermería, facultad de salud, universidad del valle, santiago de cali, colombia. nataliatobo@yahoo.es 2 doctora en enfermería. profesora titular, escuela de enfermería, facultad de salud, universidad del valle, santiago de cali, colombia. glacanav@univalle.edu.co recibido: 20 de febrero de 2009 reenviado: 12 de febrero de 2010 aprobado: 24 de marzo de 2010 resumen estudios han identificado que comportamientos, emociones y estrés están asociados con la enfermedad de arterias coronarias (eac). existe soporte a la hipótesis de que una zona de la corteza cerebral, ligada con las emociones, se activa ante condiciones estresantes y genera respuestas como hipertensión e infarto. los aspectos que preceden o generan estrés y comportamientos de riesgo para eac no son abordados en la atención en salud, y su estudio se ha centrado en la ansiedad o la depresión. la pregunta fue: ¿cuáles son los estados afectivos y emociones más frecuentes y predominantes que subyacen a la experiencia del estrés en las personas con eac, y su diferencia según algunas características socio-demográficas? métodos: estudio transversal correlacional, participaron 65 personas con eac. se empleó un cuestionario sobre 38 estados afectivos y emocionales para identificar las emociones características según frecuencia, predominio y fuerza de aparición. resultados: se identificaron 12 características predominantes, de las cuales 10 los define afectivamente: hipersensibilidad, impaciencia, infalibilidad, miedo, excesiva preocupación por otros, autorrepresión emocional, rigidez moral, deseo de ser ejemplo para otros, sobreprotección, soledad y aislamiento. estas se correlacionaron significativamente con la culpa, el sentimiento de infelicidad, la desolación, la angustia extrema y la desesperanza. discusión: la excesiva importancia a la razón, al reconocimiento por otros, en detrimento de expresión de emociones y necesidades afectivas, señala conflictos internos persistentes, deficiente autocuidado y estrés emocional. se sugiere investigar aspectos emocionales para prevención temprana y rehabilitación. palabras clave enfermedad coronaria, emociones, sentimientos, estrés, riesgo, promoción de la salud, prevención (fuente: decs, bireme). emotions and stress in persons with coronary disease abstract a number of studies have determined that behavior, emotions and stress are associated with coronary artery disease (cad). there is evidence to support the hypothesis that the zone of the cerebral cortex linked to emotions is activated under stressful conditions and generates responses such as hypertension and cardiac arrest. nevertheless, emotions that precede or generate stress and behavior that poses a risk of cad are not addressed in health care, and their study has centered on anxiety or depression. the question is: what are the feelings and emotional states most often and predominantly associated with stress experienced by persons with cad, and whether or not they differ according to certain socio-demographic characteristics? methods: a correlational cross-sectional study of 65 women año 10 vol. 10 nº 1 chía, colombia abril 2010 l 19-33 20 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 and men with cad. a questionnaire on 38 feelings and emotional states was used to identify the characteristic emotions, according to frequency, predominance and force of appearance. results: twelve predominant characteristics were identified, 10 of which were identified and defined emotionally as hypersensitivity, impatience, infallibility, fear, excessive concern for others, emotional self-restraint, moral rigidity, the desire to be an example for others, over-protection, loneliness and isolation. these correlated significantly with feelings of blame, unhappiness, grief, extreme anxiety and desperation. discussion: excessive importance to reason and recognition from others, to the detriment of expressing ones feelings and emotional needs, appear to be indicative of persistent internal conflicts, a lack of self-care and emotional stress. it is suggested that emotional aspects be researched further in the interest of early prevention and rehabilitation. key words coronary disease, emotions, feelings, stress, risk, health promotion, prevention (source: decs, bireme). as emoções e o stress em pessoas com doença cardíaca coronária resumo alguns estudos descobriram que o comportamento, as emoções e o estresse estão associados com doença arterial coronária (dac). existe suporte para a hipótese de que uma área do córtex cerebral, associada às emoções, é ativada por condições de estresse e produz respostas como hipertensão e infarto. os fatores afetivos e as emoções que antecedem ao estresse e aos comportamentos de risco para dac, ou geram-nos, não são abordados nos cuidados de saúde, e a pesquisa está orientada à ansiedade ou à depressão. a pergunta proposta foi: quais são os estados afetivos e emocionais predominantes mais freqüentes, subjacentes à experiência do estresse em pessoas com dac, assim como suas diferenças de acordo com algumas características sócio-demográficas? métodos: um estudo correlacional de corte transversal, em que participaram 65 pessoas com dac. aplicou-se um questionário acerca de 38 estados afetivos e emocionais para identificar as emoções características seguindo a freqüência, a prevalência e a intensidade de aparecimento. resultados: se identificaram 12 elementos característicos, dos quais 10 os identificam e definem afetivamente: hipersensibilidade, impaciência, infalibilidade, medo, preocupação excessiva para outros, auto-repressão emocional, rigidez moral, desejo de ser um exemplo para os outros, sobreproteção, solidão e isolamento. estes foram significativamente correlacionados com a culpa, o sentimento de infelicidade, a desolação, a angústia extrema e a desesperança. discussão: ênfase excessiva na razão e ao reconhecimento pelos outros em prejuízo da expressão de emoções e necessidades afetivas; indica conflitos internos constantes, autocuidado deficiente e estresse emocional. sugere-se investigar os aspectos emocionais para prevenção precoce e reabilitação. palavras-chave doença coronária, emoções, sentimentos, estresse, risco, promoção da saúde, prevenção (fonte: decs, bireme). 21 las emociones y el estrés en personas con enfermedad coronaria l natalia tobo-medina, gladys eugenia canaval-erazo introducción la enfermedad de arterias coronarias (eac) es uno de los principales problemas de salud pública a escala mundial (1, 2, 3), ha llegado a cifras que la pueden clasificar como epidemia, lo que merece especial atención según reporte de la organización mundial de la salud (oms) (1). en el ámbito mundial representa la principal causa de morbilidad y mortalidad en la mayoría de los países en desarrollo, siendo el infarto la principal causa de muerte en occidente y en los países industrializados (3). en colombia, es la segunda causa de mortalidad. la situación expuesta ha llevado a progresos importantes en el tratamiento de la eac con el consiguiente aumento de la sobrevida de las personas afectadas por la misma. pero el incremento en su incidencia permite concluir que aún requiere de la identificación, prevención y control de factores de riesgo antes que la eac se manifieste clínicamente. los primeros trabajos epidemiológicos que confirmaron el valor del patrón de conducta tipo a como factor de riesgo coronario fueron realizados en los años setenta, uno es el de framingham referido por haynes (4). en las últimas décadas, diversos estudios (5, 6, 7, 8, 9) han identificado que el estrés, y aspectos comportamentales y emocionales, tienen aproximadamente la misma potencia de asociación con la eac que la hipercolesterolemia, la hipertensión y el tabaquismo, y que son factores de riesgo significativos y tan importantes como los tradicionales. investigaciones muestran que las personas con mayor reactividad cardiovascular al estrés mental agudo presentan mayores incrementos en niveles circulantes de il-6 y tnf tras, el factor estresor, que luego pueden estimular una cascada inflamatoria que desempeña un papel crucial en la aterogénesis (10). de las expresiones de estrés, han sido estudiadas la hostilidad, la ansiedad y la depresión (11, 12, 13), y se ha encontrado una relación positiva con el inicio o evolución clínica de la eac (14, 15). actualmente, se reconoce que el estrés puede aumentar la presión arterial, pero hasta hace poco no se conocía la forma como la emoción podía aumentar el riesgo de infarto. en los últimos años, científicos han aportado datos que apoyan la hipótesis de que la corteza del cíngulo anterior, ubicada en el lóbulo frontal, una zona ligada con las emociones, se activa ante condiciones psicológicas estresantes y genera en el resto del cuerpo respuestas fisiológicas negativas como la hipertensión, y graves problemas cardíacos como el infarto (16). con respecto al cuidado, en enfermería es relevante el ser humano en sus diferentes dimensiones, no solo en la física o biológica. el impacto psicológico de la percepción de los eventos estresantes en las personas con eac, y de estos con su enfermedad, ha sido escasamente tratado; pero en las personas en general la relación entre la psiquis y el cuerpo se ha puesto de relieve al evidenciarse las implicaciones físicas de los estados de estrés. en la teoría de enfermería de cuidado humano de la doctora jean watson, la persona es vista como mayor que y diferente a la suma de las partes, se plantea así una visión del ser humano como un yo funcional e integrado, en el que sus condiciones psicológicas y espirituales, y la transacción entre las personas y su ambiente afectan la salud y la sanación (17). en esa dirección, enfermería ha elegido como opción profesional el cuidado del indivien las últimas décadas, diversos estudios han identificado que el estrés, y aspectos comportamentales y emocionales, tienen aproximadamente la misma potencia de asociación con la eac que la hipercolesterolemia, la hipertensión y el tabaquismo, y que son factores de riesgo significativos y tan importantes como los tradicionales. 22 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 duo desde una perspectiva holística, cuyo objetivo primordial es la búsqueda de su bienestar. a partir de esa premisa, tal como lo propone leininger en su teoría de enfermería, interesa conocer la respuesta del ser humano ante distintas situaciones a lo largo de la vida, también ante la salud y la enfermedad, y adaptar los cuidados de enfermería a las formas de vida y las necesidades generales del individuo (18). todo ello con el propósito de promover el bienestar y una mejor solución a sus necesidades. a pesar de lo anterior, las variables afectivas y emocionales no han sido ampliamente estudiadas. con frecuencia la atención en salud se ha centrado en los factores biológicos, en tanto que lo psicológico se aborda de manera secundaria y desde las manifestaciones físicas y bioquímicas del estrés, sin abordar los aspectos afectivos internos que preceden o generan estas manifestaciones de estrés y comportamientos de riesgo. algunos estudios citados por eugene braunwald (8) no han podido demostrar la validez de la hipótesis de comportamiento tipo a en relación con la mortalidad y morbilidad por causa del infarto, y otros han mostrado que la reincidencia del infarto agudo es más frecuente en la personalidad tipo b; así que como lo señala lazarus “parece ser que no es la expresión externa o propia de la personalidad lo que más cuenta, sino la manera como el individuo experimenta internamente sus emociones” (19). cada persona reacciona a las perturbaciones o eventos de manera más o menos intensa de acuerdo con un código psicoafectivo propio, por lo que un determinado estímulo que resulta estresante para una persona puede no serlo para otra (20). lazarus y folkman (21) afirman, con base en sus investigaciones, que es el significado asignado a la situación, que se refleja en la expresión emocional, lo que realmente cuenta en la experiencia de estrés y el afrontamiento de los eventos. tales afirmaciones sugieren que las condiciones afectivas o emocionales pueden producir: 1) alteración en el equilibrio biopsicosocial generando conflicto interno y estrés; 2) conductas desadaptativas a determinados estímulos como las señaladas en la “personalidad tipo a”, convirtiéndose en generadores de estrés y de riesgo. por lo anterior, es necesario explorar y profundizar en el reconocimiento de la vida afectiva, de sentimientos y emociones de las personas que desarrollan eac, en busca de información concreta que ayude en la prevención de factores relacionados con la enfermedad coronaria, en el cuidado a la persona enferma y su rehabilitación, con miras a favorecer su recuperación y prevenir complicaciones. con base en lo anterior, se planteó el siguiente problema de investigación: ¿cuáles son los estados afectivos y las emociones más frecuentes y predominantes que subyacen a la experiencia del estrés en las personas con eac, y su diferencia según algunas características sociodemográficas? objetivos específicos 1. identificar las características afectivas, los sentimientos y las emociones que aparecen con mayor frecuencia en la vida de las personas con eac que asisten a consulta especializada, y cuáles de esas características son predominantes por su frecuencia e intensidad o fuerza de aparición. 2. determinar si existen correlaciones significativas entre las diferentes caractecon frecuencia la atención en salud se ha centrado en los factores biológicos, en tanto que lo psicológico se aborda de manera secundaria y desde las manifestaciones físicas y bioquímicas del estrés. 23 las emociones y el estrés en personas con enfermedad coronaria l natalia tobo-medina, gladys eugenia canaval-erazo rísticas emocionales, y entre éstas con las variables socio-demográficas de edad, sexo, estado civil y ocupación. materiales y métodos estudio correlacional de corte transversal, en una muestra de personas con diagnóstico de eac, que asistían a consulta externa especializada en dos instituciones de salud de tercer nivel de atención de la ciudad de cali, colombia, cuyos criterios de inclusión fueron: personas adultas, con diagnóstico médico de eac reportado en historia clínica institucional como resultado de estudios clínicos, inscritos en el programa de control cardiovascular, que no presentaran otro tipo de patología primaria y sin cirugía cardiaca. la muestra fue calculada mediante análisis de poder con base en un delta de 0,5, un poder del 95%, un nivel de significancia del 5% y una prueba de una cola (22). de acuerdo con la tabla maestra, la muestra mínima correspondía a 37 personas. adicionalmente, se calculó un período de tres meses definido para la recolección de la muestra, en el que se consideró que asistirían a control en consulta externa todos los pacientes inscritos al programa. del tota de las personas que asistieron, 65 reunieron los criterios de inclusión y fueron los que constituyeron la muestra. se diseñó un cuestionario con preguntas sobre características socio-demográficas y una escala tipo likert de 114 enunciados con puntajes de 0, 1 y 2, para que la persona señalara la frecuencia con que se presentaban emociones, sentimientos y estados afectivos subyacentes a diversas situaciones de la vida cotidiana, y no con las respuestas emocionales generadas por la situación actual de la enfermedad. la escala se denominó “emoción, afecto y entorno”, y se aplicó por medio de entrevista personal. la escala se construyó con base en la revisión de teorías relacionadas con las emociones, entre ellas la teoría cognitiva-motivacional-relacional (tcmr) (19), y se tomaron como referencia los supuestos teóricos formulados por bach (23, 24, 25). los enunciados se redactaron de tal forma que hicieran reflexionar sobre las experiencias de la vida diaria, en tres fases: a) vividas en el pasado, b) en su relación con el entorno en situaciones cotidianas, c) que han perdurado o acompañado a lo largo de la vida. cada fase incluye 38 enunciados, uno para cada condición afectiva y emoción definida por bach (23, 24, 25, 26, 27). los 114 enunciados abordan de manera diferente en cada una de las tres fases las 38 expresiones afectivas y emocionales que de acuerdo con la teoría de bach se dividen en siete grupos. cada una de las tres fases se puede evaluar independientemente. la confiabilidad del instrumento estudiada con la consistencia interna, y como medida estadística el coeficiente de correlación y la fórmula de cálculo de spearman-brawnm mostraron un r1 = 0,80 (significativa para p ≤ 0,05 con 12 grados de libertad). la congruencia se evalúo con el grado de correlación entre las tres fases denominadas a, b y c; todas fueron estadísticamente significativa para p ≤ 0,01 y 12 grados libertad: fase a con b: r1= 0,93; fase a con c: r1 = 0,70; fase b con c: r1 = 0,80. la confiabilidad del instrumento estudiada con la consistencia interna también fue medida con el coeficiente alfa de cronbach, el cual fue de 0,93 para el la validez de contenido del instrumento fue evaluada por expertos, quienes revisaron la congruencia de éste con los objetivos del estudio, así como la claridad de los enunciados. 24 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 instrumento con los 114 enunciados, y de 0,85, 0,85, y 0,87 para las fases a, b y c, respectivamente. la validez de contenido del instrumento fue evaluada por tres expertos, quienes revisaron la congruencia de éste con los objetivos del estudio y el marco conceptual de la investigación, así como la claridad de los enunciados. hubo acuerdo en el 97% de los enunciados, concepto favorable por ser congruentes, claros y no tendenciosos. la validez de construcción, que se refiere a la extensión en la cual un instrumento mide el concepto que se desea medir, y para el cual fue creado de acuerdo con las expectativas teóricas, se da a partir de la revisión bibliográfica del tema y del marco de referencia de lo expuesto por bach (28, 29, 30); el instrumento se construyó con base en los siete grupos propuestos por este autor. la validez de construcción se evaluó mediante análisis factorial confirmatorio de componentes principales con base en los enunciados que cubren las características afectivas y emocionales que, como se anotó, se reúnen en siete subgrupos. el análisis factorial extrajo siete factores con valores propios (eigenvalue) por encima de 1,7 y cargas para cada uno en términos de porcentaje de la varianza así: factor 1: 17,5; factor 2: 8,5; factor 3: 6,4; factor 4: 6,0; factor 5: 5,5; factor 6: 5,0; factor 7: 4,5; los cuales explican el 53,4% del total la varianza. el cuestionario fue probado con 14 personas entre 30 y 68 años de edad, con diferente nivel educativo, que emplearon un promedio de 46 minutos para desarrollar la encuesta. el 100% catalogó el instrumento como claro. el 78,5% consideró que era fácil de responder. el 77% lo encontró extenso; para el 78,5% el grado de cansancio fue de 1 y 2 en una escala de 1-10, siendo 1 lo más bajo. el estudio contó con la aprobación del comité de ética institucional y se cumplieron con todos los requisitos exigidos y reglamentarios de acuerdo con la normatividad vigente. análisis de los datos los datos se manejaron siguiendo los parámetros de análisis temático. se utilizó estadística descriptiva e inferencial. el chi2 y la correlación de sperman y de pearson se emplearon para confirmar la significancia estadística y la fuerza y dirección de las correlaciones. de cada característica emocional se estudió: 1. la frecuencia: número de veces en el que la persona percibía que el estado emocional o afectivo se repetía o persistía en ella en cada una de las tres fases, según las opciones: siempre, algunas veces, nunca. una característica afectiva o emocional se consideró predominante para el grupo si más del 70% respondía a esta con puntajes de 2 ó 1 (estaba presente siempre o algunas veces) en al menos dos de las tres fases. 2. la fuerza: sumatoria de los puntajes correspondientes a la frecuencia señalada en las tres fases para cada uno de los enunciados; el valor osciló entre 0 y 6 puntos; se clasificó en categoría débil (0-2 puntos), fuerte (34 puntos) y muy fuerte (56 puntos). el cuestionario fue probado con 14 personas entre 30 y 68 años de edad, con diferente nivel educativo, que emplearon un promedio de 46 minutos para desarrollar la encuesta. 25 las emociones y el estrés en personas con enfermedad coronaria l natalia tobo-medina, gladys eugenia canaval-erazo 3. si define e identifica afectiva y emocionalmente al grupo, es decir, cuando por su frecuencia de aparición clasificaba como predominante y poseía una intensidad o fuerza igual o mayor a 3 (es decir, fuerte o muy fuerte). resultados la muestra fue de 65 personas entre 44 y 74 años, con un promedio de edad de eac. el 66,7% era de sexo masculino. el 68,3% tenían pareja permanente. el 51,3% trabajaba en un nivel operativo, seguido por las amas de casa (22,4%); el 6,89% tenía un cargo administrativo de tipo directivo. en el tiempo libre el 49,27% desarrollaban actividades sedentarias como tejer, leer, ver televisión, entre otras. el 37,68% caminaba o hacia deporte, el 13% realizaba actividades de tipo laboral. aspectos afectivos o emocionales predominantes que identifican y definen en el grupo se manifestaron 12 características predominantes, de las 38 afectivas o emocionales estudiadas, por tener frecuencia de aparición de siempre o algunas veces (puntaje 2 y 1 respectivamente), en al menos dos de las tres fases, y en más del 70% de la muestra. la tabla 1 presenta en orden descendente las medidas de tendencia central de los puntajes obtenidos por estas características. diez de estas manifestaciones por presentarse adicionalmente con una intensidad de fuerte o muy fuerte (intensidad mayor de 3 puntos), fueron definidas como las características que identificaban y definían afectivamente esta muestra. de las características que definen afectivamente la muestra se destacan las tres primeras de la tabla por haber sido señaladas en las tres fases y haber sido reconocidas en algunas de las fases con una frecuencia de siempre por más del 90% de las personas, estas son: l la autorrepresión en la expresión de emociones y afectos, la rigidez moral y el deseo de ser ejemplo para otros. estas personas sienten que quienes sigan sus ideas y conducta podrán ser mejores. fue sobresaliente el mantenerse siempre fiel a sus principios y normas, y guiar y construir toda su vida en torno a ellas, con una marcada autodisciplina que les llevó a relegar a un plano secundario la expresión afectiva o emocional, su salud o bienestar físico y emocional, y las actividades recreativas, sociales y de ocio. porcentaje características cdi me mo p75 con grupo puntaje > 3 **º infalible, dominante. x 5 5 6 85,7 preocupación por el poder y bienestar ajeno ** miedo a desgracia de otros. x 4 4 5 88,9 preocupación por el poder y bienestar ajeno **º autorrepresión, rigidez moral. x 4 4 5 90,5 preocupación por el poder y bienestar ajeno +º forzamiento obstinado al deber. x 4 4 5 82,5 desaliento y desesperación + impaciencia, irritabilidad. x 4 4 5 80,9 soledad sentimiento de vergüenza, necesidad extrema de limpieza y orden. x 4 3 5 73,0 desaliento y desesperación + introversión, autosuficiencia. x 3 4 4 77,8 soledad deseo de convertir a otros a sus convicciones. x 3 3 4 74,6 preocupación por el poder y bienestar ajeno nostalgia, absorbida en el pasado. 3 4 5 66,1 falta de interés por el presente + inhibición, enmascara afecto. x 3 4 4 74,6 susceptibilidad a influencias e ideas ajenas. posesividad, manipulación afectiva. 3 4 4 66,7 preocupación por el poder y bienestar ajeno sometimiento, sumisión exagerada. x 3 4 4 66,7 susceptibilidad a influencias e ideas ajenas tabla 1. características predominantes que identifican y definen (cdi), medidas de tendencia central de la fuerza de manifestación y porcentaje de personas ** están en más del 70% de la muestra en las tres fases. en una de las fases en más del 90%. + está en más del 90% en una de las tres fases. º se presentó con una frecuencia de siempre en más del 70% del grupo. de 62,7 +/8,77, con diagnóstico médico la muestra 26 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 l la sensación de infalibilidad y el deseo de que los demás hagan las cosas en la forma que ellos esperan, ya que generalmente sienten que están en lo correcto. por lo anterior, cuando toman una decisión “no les gusta perder tiempo escuchando a los otros”, haciendo manifiesta su actitud de dominio. l miedo e inquietud excesivos por lo que pueda suceder a otros, con tendencia a anticipación a la desgracia de los demás, expresión del temor y pesimismo en la vida. le sigue en importancia la disposición al forzamiento al deber de manera obstinada, dado que aparece en más del 90% de las personas en alguna de las tres fases y con una frecuencia de siempre en más del 70% de ellas. tal disposición les induce a luchar pese al desaliento y las dificultades, y pese a que otros crean que es imposible lograrlo, llegando incluso al autosacrificio a costa de su salud y descanso. otras características predominantes que sobresalen porque estuvieron presentes en alguna fase en más del 90% de la muestra, son: l la inhibición para expresar sentimientos como la angustia, el tormento o el malestar, y el enmascararlos con alegría o bienestar y cortesía para evitar conflictos y mantener la paz y armonía a su alrededor, o evitar que otros conozcan su verdadero estado. esta condición que los llevó en algunas circunstancias a comportamientos sumisos o de temor para defender sus derechos. l la autosuficiencia mental, acompañada por una fuerte necesidad de independencia, que les dificulta expresar simpatía hacia las demás personas o acudir en su ayuda cuando tienen problemas, conduciéndolos a abstraerse del medio y a resguardarse en su propio mundo. l la impaciencia e irritabilidad ante la lentitud de otras personas. esta disposición les lleva a preferir hacer sus cosas solos, a sobrecargarse de trabajo y a permanecer solos. esas doce características permitieron identificar la propensión de estas personas al autodominio y a una alta exigencia consigo mismas y con el mundo que les rodeaba, generada por: 1) el ánimo de ser ejemplo para los demás, para lo cual seguían un comportamiento rígido, normativo, con autorrepresión de sus sentimientos, emociones y necesidades; 2) la sensación o idea de ser infalibles, que les conducía a la disposición impositiva y dominante; 3) la propensión a niveles extremos de responsabilidad, rigidez y normatividad, que hacía que todo su ánimo se centrara en el deber y en la lucha obstinada por obtener objetivos que podían ir más allá de sus posibilidades o capacidades; 4) la inclinación a valorar el ritmo y la capacidad de las demás personas y de sí mismas como inapropiado, lento e inoportuno, ante lo que responden con sensación de irritabilidad, impaciencia, crítica, desesperación y la preferencia por hacer las cosas solos; 5) la vergüenza y necesidad, muchas veces inconsciente, por liberarse de suciedad e infecciones. características emocionales correlacionadas con los aspectos afectivos que definen la muestra las características que se correlacionaron de manera significativa y en forma directa con las que definen afectivamente la muestra fueron la culpa y el autorrela autorrepresión en la expresión de emociones y afectos, la rigidez moral y el deseo de ser ejemplo para otros, hace que estas personas sientan que quienes siguen sus ideas y conducta pueden ser mejores. 27 las emociones y el estrés en personas con enfermedad coronaria l natalia tobo-medina, gladys eugenia canaval-erazo proche, el sentimiento de inferioridad y extrema modestia (tabla 2). fue notable la carencia de alegría y de felicidad en su vida, manifiesta por la presencia de situaciones de desolación y angustia extrema, la desesperanza, la infelicidad por pérdidas afectivas o materiales o de causa desconocida, y sentir la vida como un duro trabajo carente de placer. se puede identificar que detrás de un aparente gran sentido de responsabilidad, seguridad y dominio se encuentra una persona con temores, con sentimientos de inferioridad y de autorreproche, y la vivencia de altos niveles de ansiedad e infelicidad. la intensidad con que experimentaron el diario vivir carente de placer, presentó correlación estadística positiva (p≤0,01) con características que permiten identificar dificultades en la autoestima, como la falta de confianza en su propio juicio, vergüenza y sensación de impureza, y otras no incluidas en la tabla 2 como el sentimiento de inferioridad, desaliento por duda de sí mismos. a su vez, estas cuatro características se correlacionaron directamente con el grado de depresión profunda (p≤0,05) expresada por los participantes. correlaciones entre las características socio-demográficas y la intensidad de las características emocionales la significancia estadística de la distribución de las frecuencias obtenidas al cruzar la intensidad de las características emocionales con las variables personales de sexo, edad, estado civil y ocupación laboral, se analizaron con el chi cuadrado (x2), y la magnitud y dirección de la correlación entre ellas con la correlación de sperman (rs). ocho manifestaciones afectivas se correlacionaron estadísticamente con alguna de las características sociodemográficas (tabla 3). la inseguridad en su propia capacidad con temor al fracaso, y la introversión con marcada necesidad de independencia, presentaron una correlación estadísticamente significativa con la edad. ambas características mostraron proporciones mayores con intensidad fuerte y muy fuerte en el grupo entre 56 y 67 años, y débil en el grupo de 44 a 55 años. la intensidad del sentimiento de ira, desconfianza y susceptibilidad a los desaires, mostró una correlación inversa con la edad, siendo significativa para una p ≤0,05. con el estado civil solamente la inhibición para expresar los sentimientos con tendencia a enmascararlos mostró una diferencia significativa. esta característica presentó, para el grupo de solteros, porcentajes más altos en la intensidad (muy fuerte), los que fueron disminuyendo paulatinamente entre las personas casadas, las viudas y, finalmente, los separados. la intensidad de la necesidad de comunicación y de hacerse valer difiere según el género, ésta presenta intensidad fuerte y muy fuerte en las mujeres; mientras que el miedo a perder el control y la irreflexión tienen una mayor proporción con intensidad fuerte en los hombres. entre los distintos tipos de ocupación se encuentran diferencias significativas con las características emocionales de inhibición para expresar los sentimientos, dificultad para definir qué ocupación seguir, y con la desolación, la angustia extrema y la depresión por duda de sí mismo. estas se presentaron con intensidad débil en cargos administrativo-directivo, mientras que la inseguridad en su propia capacidad con temor al fracaso, y la introversión con marcada necesidad de independencia, presentaron una correlación estadísticamente significativa con la edad. 28 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 en amas de casa y operativos se presentan con intensidad fuerte o muy fuerte. discusión se manifestó un patrón afectivo y emocional en el grupo estudiado con 12 características predominantes y 10 características que definen afectivamente la muestra. el patrón permitió identificar la propensión tabla 2. características afectivas y emocionales correlacionadas con más del 50% de las características que las definen e identifican sensación de miedo a la auto-represión impaciencia, forzamiento vergüenza, deseo introversión y inhibición sometimiento correlaciones ser infalible, desgracia de y rigidez prefiere hacer obstinado necesidad convertir a autosuficiencia para y sumisión significativas dominante lo demás moral todo solo al deber de limpieza sus expresar exagerada convicciones sentimientos autorreproche, sentimiento de culpa (31) .27* .33** .39** .38** .37** .25* .32* .36** 8 sentimiento de inferioridad y extrema modestia .40** .28* .26* .34** .40** .39** .42** 7 desolación y angustia extrema .26* .49** .29* .29* .45** .33** .40** 7 nostalgia, absorbido en el pasado .32* .51** .43** .32* .26* .38** .39** 7 +posesividad y manipulación afectiva .37** .25* .33** .33** .47** .39** 6 soñadores, vivir más en el futuro .29* .40** .44** .39** .27* .32** 6 depresión profunda de causa desconocida .26* .41** .27* .25* .53** .38** 6 desesperanza y falta de fe .35** .30* .26* .26* .32* .40** 6 infelicidad, secuelas debidas a duelo .25* .28* .33** .39** .58** 5 sentimiento de no tener fuerzas carente de placer .31* .35** .36** .30* .57** 5 autorrepresión y rigidez moral .32* .44** .31* .45** .33** 5 número de correlaciones significativas 6 9 7 7 9 8 3 5 7 7 otras características correlacionadas características que definen e identifican o inclinación de estas personas a un alto dominio y exigencia consigo mismas y con el mundo que les rodeaba; entre otros, por el ánimo de ser ejemplo para los demás, la sensación de infalibilidad y la propensión a extrema rigidez y responsabilidad, impaciencia e irritabilidad. como consecuencia de lo anterior, les acompañan la dificultad e inhibición para manifestar el afecto, sus deseos y emociones, situación que estuvo condicionada por alta susceptibilidad a la opinión de otros, la sumisión y el miedo, y preocupación por otros y por su soledad. la muestra tenía, acorde con el inventario de hostilidad de buss-duikee (bdhi), manifestaciones de hostilidad como la impaciencia e irritabilidad, y crítica exagerada o intolerancia. el complejo ira-hostilidad engloba un componente cognitivo que ** p ≤ 0,01 * p ≤ 0,05 29 las emociones y el estrés en personas con enfermedad coronaria l natalia tobo-medina, gladys eugenia canaval-erazo consiste en las creencias negativas sobre la naturaleza humana y que las conductas desagradables se dirigen de manera intencionada hacia uno (2). se cita además que una de sus manifestaciones es la ausencia de reconocimiento o el no tener en cuenta al otro objeto de su acción (8, 27). se podría decir que en la muestra existen manifestaciones hostiles consigo mismos y con el entorno, por la autorrepresión de sus necesidades, y por el comportamiento normativo y obstinado por el deber hasta llegar a estados de agotamiento extremo. con respecto al entorno, se observa una inclinación a evaluar la conducta de otros como inapropiada, una actitud impositiva e irritable, así el móvil sea el deseo de cuidar de otros o la preocupación por el bienestar de los demás. el resentimiento manifestado por algunos es una forma de agresividad más ideativa (28, 29). serrano y moreno (27) ven –a partir de la exigencia de una sociedad competitiva– la agresividad dirigida hacia uno mismo y hacia el entorno, entre otros motivos, como una causa del aislamiento y el incremento de situaciones frustrantes. aunque en este estudio no se midió en forma directa la frustración, ésta se pudo identificar a través de la evaluación de la nostalgia y el autorreproche porque no se sentían realizados en la vida, especialmente en el orden económico, de capacitación y laboral. la confrontación con esa realidad se manifestó como motivo de frustración, conflicto interno y estrés. en ese sentido, y desde la inhibición para expresar sus sentimientos y emociones, y el sometimiento a normas sociales o deseo de otros, es comprensible la dificultad para autorrealizarse. la autoexpresión de los derechos es una de las dimensiones de asertividad más frecuentemente reportadas. las personas con baja asertividad se preocupan más por lo que otros piensan de ellas o el insulto de otros; por ese motivo rechazan el desafío, lo que les impide ser dueñas de sus emociones, les dificulta recibir y aceptar la simpatía de quienes les rodean, y ser amables si así lo desean (14). el predominio de la “sobreprotección y excesiva preocupación por el bien de los otros” demuestra la necesidad de convertirse en modelo de los demás e influir en ellos para inducirles su estilo y visión de la vida idealizada. para lograrlo, se ira, desconfianza, inseguridad, introversión, inhibición, necesidad de miedo a perder dificultad soñadores, susceptibilidad temor al fracaso necesidad de enmascara comunicación el control, para definir vivir más a desaires independencia sentimientos y hacerse valer irreflexión ocupación en el futuro a seguir edad rs=-.25* x2=14.3** x2=9.2* gl. 4 gl. 4 estado civil x2=12.8* gl. 6 sexo rs=.31** rs=.25* ocupación x2=15.8* x2=15.9* x2=16.2* gl. 8 gl. 8 gl. 8 características emocionales características sociodemográficas tabla 3. correlaciones significativas entre las características emocionales y socio-demográficas, x2 y rs someten a una forzada autodisciplina, y quitan la flexibilidad frente a su realidad y la realidad que les rodea, reprimen sus sentimientos y desconocen el límite de sus capacidades. según blome (26), las personas con autorrepresión y rigidez intentan dominar la realidad con un estricto blanco y negro, puesto que sus sentimientos las debilitan y las ponen en conflicto con su necesidad de unas condiciones de vida claras y reguladas. es común que la autorrepresión suceda bajo la influencia de padres que estimulan de modo unilateral la voluntad de rendimiento y la responsabilidad de su hijo, quien se convierte en obsesionado por el éxito, insensible a sus propios límites. se encuentran así ante un adulto bajo estrés ininterrumpido causado por ellos mismos, que es tanto peor por cuanto que no brindan ninguna posibilidad al cuerpo de regenerarse. el ansia por cumplir con ideales, y la dificultad para reconocer la diversidad del mundo exterior, los lleva a encerrarse en su propio mundo, como lo demostró la correlación directa (p≤0,05) entre el forzamiento obstinado al deber y la introversión con fuerte necesidad de inde** p< 0,01 *p< 0,05 30 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 pendencia. la preferencia por hacer las cosas sólo debido a la impaciencia, se correlacionó en forma directa (p≤0,05) con la sensación de ser infalible y dominante. la existencia de tales condiciones simultáneamente, propicia así el aislamiento y la soledad. gilbert y allen (14) indican que la sumisión generalmente involucra el incremento de la tensión por miedo a la confrontación, relacionada con “no quererse a sí mismo o rechazarse”; e inhibición en situaciones de desafío o conflicto de intereses, en donde escogen ceder o inhibir su proyección. en esa misma dirección, bach (25) observó que las personas que se inhibían para expresar sus sentimientos y emociones se convertían en excelentes actoras para ocultar sus debilidades, se tornaban hipersensibles o expresaban autosuficiencia y podían percibir lo desagradable como extremadamente doloroso, lo cual las llevaba a huir de las situaciones, y las conducía a mayor estrés. un pobre autoconcepto, tal como parecer o creerse “incapaz, incompetente, indigno, inseguro”, o el ser susceptible de avergonzarse, como se encontró en la actual muestra, señala una reducida posibilidad para participar en las relaciones sociales con tendencia a actuar de forma sumisa o inhibida socialmente. la inhibición crece en la medida que se tenga temor a producir esos efectos (30, 31), o a que su autoestima sea lastimada con pérdida de estatus y vergüenza. la inhibición o aparentar otra emoción se ha correlacionado con depresión, miedo, agresividad, sentimientos de soledad u otras emociones (26), y con altos niveles de estrés (28). ello concuerda con la correlación directa significativa (p≤0,01) entre la intensidad de la inhibición, y los sentimientos de culpa, vergüenza e inferioridad encontrados en el estudio (tabla 2), y correlaciones altamente significativas con sentimientos de inferioridad y extrema modestia. el no trabajar para lograr sus propios objetivos, y el no expresar sus reales sentimientos, se vio también correlacionado estadísticamente con resentimiento, enfado, autorreproche, temor, angustia extrema e infelicidad, sugiriendo la vivencia de altos niveles de estrés. estos resultados indican que el código psicoafectivo hace que los estímulos de la vida sean estresantes para estas personas, al activar emociones negativas y conductas de alta demanda personal, y que, como señalan lazarus y folkman (21), las emociones como los estados afectivos y sentimientos tienen un papel relevante en el estrés y en el afrontamiento de las situaciones. respecto a la manifestación simultánea de sumisión e inhibición, junto con alta exigencia con otros, intolerancia e infalibilidad, blome (26) refiere que los niños con educadores egocéntricos y caprichosos apenas si se atreven a expresar sus deseos; para sobrevivir deben aprender a ceder siempre a las exigencias de otros. al no poder desarrollar su personalidad, llegan a la edad adulta con una doble naturaleza: dominantes con las personas de menor rango y sumisos con la autoridad. al respecto, erikson refiere que durante el proceso de desarrollo de la voluntad, el demasiado control o la imposición de los adultos puede llevarlo a inhibición y pérdida de la autoestima. en esa dirección, experiencias clínicas (24) encuentran que detrás de una personalidad dominante, que da la sensación de ser infalible, se encuentra una persona insegura y temerosa; mientras que las personas con rigidez moral y autorrepresión, esconden una persona culposa y con autorreproche. un pobre autoconcepto, tal como parecer o creerse “incapaz, incompetente, indigno, inseguro”, o el ser susceptible de avergonzarse, como se encontró en la actual muestra, señala una reducida posibilidad para participar en las relaciones sociales con tendencia a actuar de forma sumisa o inhibida socialmente. 31 las emociones y el estrés en personas con enfermedad coronaria l natalia tobo-medina, gladys eugenia canaval-erazo conclusión en el actual estudio, estas dos características –dominante-infalible y autorrepresión-rigidez moral– se correlacionaron significativamente en forma directa con el sentimiento de culpa. la autorrepresión se correlacionó con sentimientos de inferioridad, miedo a perder el control, temor a la vida, timidez y sentimientos de incapacidad ocasional, haciéndose manifiesto un conflicto entre lo que les dicta su yo interno y lo que manifiesta externamente la persona. los resultados de este estudio conducen a pensar que las personas valoradas vivían una situación similar a la descrita por bach; es decir, que su falta de autoafirmación y la inhibición para expresar sus sentimientos reales enmascaraban un dolor y sufrimiento interno a través de manifestaciones afectivas o emocionales como las que identifican afectivamente la muestra en el actual estudio. se encontró un grupo de personas que proyectan una necesidad de reconocimiento externo, muy seguramente para llenar su vacío afectivo, en quienes su estado anímico está dirigido hacia el exterior —incluso, la búsqueda de cariño y amor de las personas que les rodean—, con falta de autoafirmación y expresión de sus necesidades reales, las que desplazan y ocultan utilizando mecanismos protectores psíquicos como la norma, el rito, la rigidez, la autorrepresión y el autodominio. ello refleja un desequilibrio profundo originado en antecedentes de conflictividad, la pérdida del equilibrio entre su propio cuidado y crecimiento interior, con el cuidado o interés por y hacia el entorno y la razón. siendo esto último, como se mencionó, lo que más pesa en ellos y en su experiencia de estrés continuo. resultados importantes apoyan la presunción de que condiciones psicológicas estresantes activan la corteza del lóbulo frontal y generan respuestas fisiológicas negativas y serios problemas cardíacos como el infarto (16); adicionalmente, esta zona tiene sus límites, y un control excesivo o autocontrol de las emociones o represión de las mismas, conduce a falta de motivación, apatía y depresión (30), lo que podría repercutir en el autocuidado del enfermo. en consecuencia, las anteriores condiciones pueden relacionarse con la salud cardiovascular y el curso de la enfermedad coronaria de estas personas, haciendo necesario e importante contemplar el abordaje de las mismas en los programas de prevención y rehabilitación cardiaca. limitaciones del estudio. es de notar que los resultados descritos se obtuvieron con un instrumento que se encuentra en fase de desarrollo; este es un primer estudio que aporta elementos de las personas desde las dimensiones emocional y afectiva, con un hallazgo consistente en la muestra de un grupo de características comunes que permite definir e identificar afectiva y emocionalmente a estas personas con eac. es necesario continuar su validación con otros grupos de pacientes de diferentes diagnósticos y o características socio-demográficas comunes. recomendación. para lazarus y lazarus (31) cuando las emociones son el resultado de valoraciones y procesos de afrontamiento inadecuados, se convierten en disfuncionales y por ello deben ser corregidas. para cambiar las emociones y el afrontamiento de estas situaciones se necesita conocer más acerca de sus creencias sobre la vida, el mundo, sobre sí mismo, y de los principios que rigen sus conductas y sus emociones frente a los hechos. en consecuencia, con base en los resultados actuales y en otras investigaciones, se recomienda en los programas de promoción de la salud, de prevención de la enfermedad y de rehabilitación cardiaca, reconocer e identificar las condiciones afectivas en las personas desde etapas tempranas de la vida, así como los aspectos asociados a ellas. el cuidado de enfermería cobra relevancia desde la valoración de las personas en sus diferentes dimensiones para orientar los planes de cuidado en la promoción de la salud, la prevención y la rehabilitación. 32 año 10 vol. 10 nº 1 chía, colombia abril 2010 aquichan issn 1657-5997 referencias bibliográficas 1. organización mundial de la salud (oms). prevención de las enfermedades crónicas: una inversión vital; 2005 [acceso 7 de octubre de 2005]. disponible en: http://www.who.int/chp/chronic_disease_report/overview_sp.pdf. 2. barefoot jc. developments in the measurement of 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[acceso: diciembre de 2008]. disponible en: http://home.psych.utoronto.ca/assets/ news/inzlicht.pdf 31. lazarus r, lazarus b. pasión y razón. la comprensión de nuestras emociones. barcelona: paidós; 2000. cardiac complications in patients with covid-19: an integrative literature review article cardiac complications in patients with covid-19: an integrative literature review complicaciones cardíacas en pacientes con covid-19: revisión integrativa de la literatura complicações cardíacas em pacientes com covid-19: revisão integrativa da literatura suellen rodrigues de oliveira maier 1 joão paulo ferreira rodrigues 2 mayara rocha siqueira sudré 3 carina aparecida marosti dessotte 4 1 0000-0002-4677-1674. escola de enfermagem de ribeirão preto, universidade de são paulo, brazil. suellenromaier@usp.br 2 0000-0002-4986-1130. escola de enfermagem de ribeirão preto, universidade de são paulo, brazil. joao.ferreira.rodrigues@usp.br 3 0000-0002-9515-5907. escola de enfermagem de ribeirão preto, universidade de são paulo, brazil. maysrocha@usp.br 4 0000-0002-5521-8416. escola de enfermagem de ribeirão preto, universidade de são paulo, brazil. camarosti@usp.br 10.5294/aqui.2020.20.4.3 received: 18/08/2020 sent to peers: 30/08/2020 approved by peers: 21/09/2020 accepted: 25/09/2020 theme: evidence-based practice. contribution to the subject: the results of this review are relevant, as it is a synthesis of the findings related to the main cardiac complications in patients with covid-19. the knowledge about the main clinical, laboratory and imaging findings can favor the early recognition of cardiac complications and assist in decision-making and in the establishment of appropriate therapeutic approaches, in order to avoid unfavorable outcomes during treatment. in short, the cardiac complications evidenced can contribute to the implementation of assistance for this disease, which is so emerging and still unknown in the scientific literature. to reference this article / para citar este artigo / para citar este artículo: maier sro, rodrigues jpf, sudré mrs, dessotte cam. cardiac complications in patients with covid-19: an integrative literature review. aquichan. 2020;20(4):e2043. doi: https://doi.org/10.5294/aqui.2020.20.4.3 abstract objective: to verify, based on the literature, what the main cardiac complications are in patients with covid-19, during treatment in a hospital unit. materials and methods: an integrative review, carried out by searching for studies in eight national and international databases. the final sample consisted of 16 studies published between january and may 2020, which were subjected to structural evaluation by the following instruments: case report guidelines, for case reports; and strengthening the reporting of observational studies in epidemiology, for observational studies. results: the main cardiac complications were predominantly obstructive events, herein understood as acute myocardial infarction, followed by severe arrhythmic conditions and heart failure, all due to the hyperinflammation condition resulting from viral infection. conclusions: the knowledge about cardiac complications during covid-19 treatment has become important, since it can collaborate for the adoption of more effective treatment protocols and guide the assistance offered by health professionals, in order to identify such complications and intervene early. keywords (source decs): coronavirus infections; hospital care; cardiology; critical care; nursing care. resumen objetivo: verificar a partir de la literatura cuáles son las principales complicaciones cardíacas en pacientes con covid-19, durante el tratamiento en una unidad hospitalaria. materiales y método: revisión integradora, realizada mediante la búsqueda de estudios en ocho bases de datos nacionales e internacionales. la muestra final estuvo conformada por 16 estudios publicados entre enero y mayo de 2020, que fueron sometidos a evaluación estructural, utilizando las case report guidelines, para los reportes de caso, y el strengthening the reporting of observational studies in epidemiology, para los estudios observacionales. resultados: las principales complicaciones cardíacas fueron principalmente eventos obstructivos, entendidos aquí por infarto agudo de miocardio, seguidos de arritmias severas e insuficiencia cardíaca, todo debido a la condición de hiperinflamación por infección viral. conclusiones: el conocimiento sobre las complicaciones cardíacas durante el tratamiento de la covid-19 ha cobrado importancia, ya que puede colaborar para la adopción de protocolos de tratamiento más efectivos y orientar la asistencia brindada por los profesionales de la salud, con el fin de identificar dichas complicaciones e intervenir tempranamente. palabras clave (fuente decs): infecciones por coronavirus; atención hospitalaria; cardiología; cuidados críticos; atención de enfermería. resumo objetivo: verificar, a partir da literatura, quais as principais complicações cardíacas em pacientes com covid-19, durante o tratamento em unidade hospitalar. materiais e método: revisão integrativa, realizada mediante busca de estudos em oito bases de dados nacionais e internacionais. a amostra final foi constituída por 16 estudos publicados entre janeiro e maio de 2020, os quais foram submetidos à avaliação estrutural pelos instrumentos case report guidelines, para os relatos de caso, e strengthening the reporting of observational studies in epidemiology, para os estudos observacionais. resultados: as principais complicações cardíacas foram predominantemente os eventos obstrutivos, entendidos aqui com infarto agudo do miocárdio, seguido dos quadros arrítmicos graves e da insuficiência cardíaca, todos devido ao quadro de hiperinflamação em decorrência da infecção viral. conclusões: o conhecimento sobre as complicações cardíacas durante o tratamento da covid-19 tornou-se importante, visto que pode colaborar para a adoção de protocolos de tratamento mais eficazes e orientar a assistência ofertada pelos profissionais de saúde, a fim de identificar tais complicações e intervir precocemente. palavras-chave (fonte decs): infecções por coronavírus; assistência hospitalar; cardiologia; cuidados críticos; cuidados de enfermagem. introduction in 2019, more precisely in december, the first cases of the disease caused by the severe acute respiratory syndrome coro-navirus 2 (sars-cov-2), a new category of coronavirus(1), were disclosed. the first cases occurred in the city of wuhan, hubei province, china, and, in less than 30 days, cases were reported in other countries and even on other continents(2). some authors described that it was a zoonosis, coming from wild animals, more precisely bats, with high pathogenicity in humans, affecting the airways first, causing severe acute respiratory syndrome and, subsequently, affecting other systems(3). the viral disease, called "covid-19", has an important potential for transmissibility via air and contact. it is a viral pneumonia, which affects the upper and lower airways, causing severe respiratory failure, with the need, in cases of too much effort by the individual, to offer oxygen by positive pressure, through mechanical invasive ventilation, that is, the patient will need uninterrupted care in an intensive care unit. in some cases, the disease causes progressive and rapid deterioration, leading to death(2). in late january 2020, the world health organization declared that sars-cov-2, or covid-19, became a public health emergency, that is, a pandemic(4, 5). currently, covid-19 has already affected the population of several countries in different continents, with contamination records higher than those of other diseases transmitted by air, such as, for example, influenza, and high mortality in older adults and in individuals with pre-existing chronic diseases(6-8). due to the emergency, several therapeutic approaches have been adopted and successful ones have been disseminated in several countries. studies were carried out that sought to approve the efficacy of drugs such as hydroxychloroquine®, alpha-inter-feron® and lopinavir®; however, they were non-randomized and unblinded studies, which negatively interfered with the level of evidence of the publications. there were also some adverse cardiovascular effects, such as, for example, prolongation of the qt interval, arrhythmias and an increased risk of sudden death(9-11), based on the drug interaction between some drugs of different pharmacological groups. respiratory repercussions —fever, cough, pharyngitis, fatigue and complications related to pneumonia and respiratory syndrome— are the first symptoms in individuals considered symptomatic. however, a number of studies have revealed the involvement of other systems, such as the cardiac one, from the onset of tachyarrhythmias and signs of cardiac failure(12, 13). in other chinese studies, in addition to the complications described above, ischemic cardiac events, characteristic of acute myocardial infarction in patients with covid-19(14-16), were identified. obstructive conditions in individuals with previous coronary artery disease (cad) and other conduction or mechanical disorders have contributed to the worsening of patients who require intensive care. some authors highlight the presence of comorbidities, such as systemic arterial hypertension (sah) and/or diabetes mellitus(dm), as risk factors for the development of cardiac complications during care for individuals with covid-19. the treatment of these chronic diseases with angiotensin-converting enzyme inhibitors and angiotensin-2 receptor blockers increases the bioavailability of the angiotensin-converting enzyme 2, which is the target molecule of sars-cov-2, found in the epithelial pulmonary, intestinal, and renal tissues, as well as in blood vessels(17, 18). as it is an emerging disease with a varied pathogenic profile that triggers important systemic repercussions in order to favor the involvement of the heart, it was sought to identify, based on the literature, what the main cardiac complications are in patients with covid-19 during hospital treatment. materials and methods this is an integrative review, based on articles published from january to may 2020. the phases related to the study method were distributed sequentially: a) identification of the research question; b) establishment of criteria for the inclusion and exclusion of studies found in the literature; c) definition of the information to be extracted from the selected studies in line with the guiding question; d) evaluation of the studies included in the review; e) interpretation of the results found; and f) synthesis of knowledge(19-21). the selection phase of the studies took place in the first half of june 2020, by means of an electronic search paired with original articles and case reports, given the pandemic nature of the disease, which answered the research question, by using the pico(22) (acronym for patient, intervention, control or comparison and outcomes) strategy, according to table 1, to construct the following question: is there scientific evidence in the literature about the main cardiac complications in patients with covid-19 during hospital treatment? table 1. description of the research question with the use of the pico strategy. ribeirão preto, são paulo, brazil, 2020 acronym definition description practical question component p patient patients with covid-19. patients in treatment for covid-19. i intervention treatment of patients with covid-19 in hospital units. treatment in non-critical unit or in critical unit (intensive care unit) c comparison does not apply. does not apply. o outcome cardiac repercussions during the treatment for covid-19. main cardiac complications during the treatment for covid-19. source: elaborated by the authors based on research data. the final sample consisted of articles published in full, from primary studies or case reports in which the main cardiac complications were evident; published in 2020, in portuguese, english or spanish. articles that did not describe the main cardiac complications during the hospitalization period of patients with covid-19 were excluded. the electronic databases accessed were medical literature analysis and retrieval system online (medline), via pubmed; scopus, via elsevier; cumulative index to nursing and allied health literature (cinahl), via ebsco; latin american and caribbean literature on health sciences (literatura latino-americana e do caribe em ciências da saúde, lilacs); spanish bibliographic index on health sciences (índice bibliográfico español en ciencias de la salud, ibecs), nursing database (base de dados de enfermagem, bdenf), via the virtual health library; web of science; and embase. the choice of these databases was justified by the emerging characteristic of the investigated disease, which allowed for the use of controlled and uncontrolled descriptors (keywords) in a combined manner, using the boolean operators and and or, as described in table 2. table 2. combinations searched in the databases: medline, scopus, cinahl, lilacs, ibecs, bdenf, web of science and embase. ribeirão preto, são paulo, brazil, 2020 databases combinations in the aforementioned databases medline/pubmed mesh ("coronavirus") and ("cardiovascular disease") scopus keyword ("covid-19") and ("complications") and ("cardiac") cinahl cinahl titles ("coronavirus infection") and ("cardiacpatients") or ("coronavirus infection") and ("cardiac output, decreased') lilacs decs descriptors ("coronavirus infection") and ("cardiovascular disease") web of science keyword ("covid-19") and ("complications") and ("cardiac") embase emtree ("coronavirus infection") and ("cardiovascular disease") ibecs decs descriptors ("infecciones por coronavírus") and ("enfermedades cardiovasculares") or ("infecções por coronavírus ") and ("doenças cardiovasculares ) bdenf decs descriptors ("infecções por coronavírus ") and ("doenças cardiovasculares ") source: elaborated by the authors based on research data. the option to use controlled descriptors, in the medline/ pubmed, cinahl, lilacs, embase, ibecs and bdenf databases, and uncontrolled descriptors, in scopus and web of science, occurred because the search was supported in eight databases, with the objective of integrating information about the theme under study. the combinations and data analysis were carried out independently by the researchers, respecting the inclusion and exclusion criteria described above. then, the reading of the titles was conducted and those that described the cardiac complications were selected. after this process, the articles were inserted in the mendeley(20) reference manager to separate duplicate studies. after the analysis of the titles, careful readings of the abstracts were carried out and those that approached the central subject matter, proposed by the guiding question, were selected for full-reading. for consolidation, reading and evaluation were performed, and 16 articles were included in the final sample, which showed cardiac complications through the clinical evolution of the investigated patients, results of laboratory tests, and imaging that showed worsening of the clinical condition. from the selection of articles, the structural consistency was evaluated, using the following instruments: case report guidelines (care), for case reports, and strengthening the reporting of observational studies in epidemiology (strobe), for observational studies. such instruments represent international guidelines for the construction of research reports(23-25). care consists of 13 topics: title, keywords, abstract, introduction, information about the patient, clinical aspects, history, diagnosis, treatment/interventions, outcome, discussion, perspective, and patient consent(24). on the other hand, strobe consists of 22 items: title and abstract; introduction, which includes the justification and objectives; method, which shows the type of study, location, participants, variables, quantitative variables, bias, data collection, data analysis and statistical analysis; results, which bring the number of participants, characterization of the participants, main results, outcome, and other analyses; discussions, which contemplate the key results, limitations, interpretation and generalization; finally, other information with emphasis on the funding of the study, if any(24). due to the fact that the review proposal is related to an emerging disease and little described in the literature until then, it was sought to highlight the structural consistency of each study from the analysis, using the care and strobe instruments. all the selected studies covered the description of all items concerning each type of study. the methodological quality assessment of the selected studies was performed by the authors based on the critical appraisal checklist for systematic review and research synthesis tool of the joanna briggs institute(25-27). the extraction of information related to the main cardiac complications occurred after the consolidation of the final sample of articles included in the present review, with information extracted for the characterization of the manuscript (name of the authors, database, year, title and journal) and the presentation itself of the methodological design, the study population, and the main cardiac complications found. results for the description of the search process, the preferred reporting items for systematic review and meta-analyses (prisma) flow diagram was used in order to guide the selection of studies(26), as shown in figure 1. figure 1. flow diagram adapted for selection of studies. ribeirão preto, são paulo, brazil, 2020 source: elaborated by the authors based on research data. a total of 49 articles were selected for reading their titles; of these, 14 were excluded because they were not primary studies or case reports, leaving 35 articles for reading their abstracts, with the exclusion of 19 articles for not describing cardiac complications in patients with covid-19 during hospital treatment. after a careful selection, 16 studies made up the final sample of articles, seven of which were published in journals indexed in scopus, one in web of science, one in embase and seven in medline, all published in 2020 and in english. the other databases searched did not have studies selected to compose this review. the selected studies were published in electronic and publicly accessible journals, with seven being published in journals in the cardiovascular area and the others in journals in other areas. as for the type of study, 14 were observational studies (cohort or cross-sectional) and three were case reports. the sample consisted of 14 studies developed in china, two in italy, and one in england. regarding the objectives, four were related to cardiac complications of patients with covid-19, seven to cardiovascular complications, naming cardiac complications, and the others referred to complications in general, with emphasis on adverse cardiac events during treatment. table 3 shows the data related to the selected studies, according to the authors, database, title, journal, study location, objectives, methodological design, and complications. table 3. studies selected to compose the review, according to authors, database, title, journal, methodological design, and cardiac complications. ribeirão preto, são paulo, brazil authors and database title and journal methodological design population complications huang et al. (12) scopus clinical features of patients infected with 2019 novel coronavirus in wuhan, china. the lancet observational and prospective study. 41 patients in a chinese hospital. acute cardiac injury. guo et al. (2) scopus cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (covid-19). jama cardiology cross-sectional and retrospective study. 187 patients in a chinese hospital. arrhythmia and myocardial injury. zhou et al. (14) scopus clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. the lancet multicentric and retrospective cohort. 191 patients in two chinese hospitals. coronary heart disease. zeng et al. (16) scopus first case of covid-19 complicated with fulminant myocarditis: a case report and insights. infection case report. a 63-year-old patient in a chinese hospital. obstructive coronary disease. lei et al. (1) scopus clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection. e clinical medicine cross-sectional and retrospective study. 34 chinese patients submitted to surgery. arrhythmia and acute cardiac injury. inciardi et al. (13) scopus cardiac involvement in a patient with coronavirus disease 2019 (covid-19). jama cardiology case report. a 53-year-old patient in a italian hospital. obstructive coronary disease. shi et al. (17) scopus association of cardiac injury with mortality in hospitalized patients with covid-19 in wuhan, china. jama cardiology retrospective cohort. 416 patients in a chinese hospital. acute cardiac injury. chen et al. (8) web of science clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. the bmj retrospective cohort study. 161 patients in a chinese hospital. acute cardiac injury. inciardi et al. (28) embase characteristics and outcomes of patients hospitalized for covid-19 and cardiac disease in northern italy. european heart journal cross-sectional and retrospective study. 99 patients in an italian hospital. heart failure, atrial fibrillation and coronary disease. wang et al. (15) medline coronavirus disease 2019 in elderly patients: characteristics and prognostic factors based on 4-week follow-up. journal of infection cross-sectional and retrospective study. 339 patients in a chinese hospital. acute myocardial infarction, arrhythmias and heart failure. li et al. (29) medline cardiovascular disease potentially contributes to the progression and poor prognosis of covid-19. nutrition, metabolism & cardiovascular diseases cross-sectional and retrospective study. 83 patients in a chinese hospital. myocardial injury. xiong et al. (30) medline clinical characteristics of and medical interventions for covid-19 in hemodialysis patients in wuhan, china. journal of the american society of nephrology cross-sectional, retrospective and multicentric study. 131 patients admitted to chinese hospitals. acute myocardial infarction. zhang et al. (31) medline do underlying cardiovascular diseases have any impact on hospitalised patients with covid-19? heart cross-sectional and retrospective study. 541 patients in a chinese hospital. acute myocardial infarction and arrhythmias. zhen et al. (32) medline epidemiological characteristics and clinical features of 32 critical and 67 noncritical cases of covid-19 in chengdu. journal of clinical virology cross-sectional and retrospective study. 99 patients in a chinese hospital. myocardial injury. wan et al. (33) medline clinical features and treatment of covid-19 patients in northeast chongqing. jorunal of medical virology a cross-sectional study. 135 patients in a chinese hospital. acute coronary disease. rothstein et al. (34) medline management of a patient presenting with anterior stemi with concomitant covid-19 infection early in the course of the u.s. pandemic. catheterization & cardiovascular interventions case report. a 79-year-old patient admitted to a hospital in england. obstructive cardiac injury. source: elaborated by the authors based on research data. based on the cardiac complications evidenced by the authors of the selected studies, the discussion was structured with an emphasis on highlighting cardiac impairment during the treatment of inpatients. discussions the limitations of this study can be related to the possibility of some study which did not necessarily have the objective of describing cardiac complications, but found them from the characterization of the investigated patients. another possible limitation is associated with the number of studies available in the literature, according to the search strategy used, since it is a new and emerging disease, with a pathogenic potential to be known and therapeutics still being implemented in several countries. despite the limitations described, the present study advances from the summary of the results regarding care for patients with covid-19 during hospitalization. according to table 3, the cardiac complications described by the authors of the selected articles were arrhythmias(1, 2, 15, 28, 31, 32), changes in the conduction of the electrical impulse generated by the physiological pacemaker of the heart; acute heart injury(1, 7, 8, 12, 17, 32), myocardial injury(2), coronary heart disease(14, 31-34), obstructive coronary disease(15, 16, 28, 30, 31) and heart failure(15, 28, 32). seeking to conceptually understand the complications highlighted by the authors of the selected studies, it was verified that the expressions "acute cardiac injury", "myocardial injury", "coronary heart disease" and "obstructive coronary disease" are synonymous, as they were acute diseases centered on the obstruction of the coronary arteries, identified from the laboratory findings (elevation of troponin i, myoglobin creatinophosphokinase [ckmb] and creatine kinase [ck]) and the description of signs and symptoms presented by the participants of the studies that composed this review. within the sample of selected articles, those that showed the main cardiac complications in hospitalized patients with covid-19 were included, even considering studies with participants with pre-existing diseases, such as cardiovascular diseases (cvds), as they tend to increase the risk of developing more severe conditions in patients with covid-19, mainly due to the onset of obstructive events and the presence of a systemic inflammatory response(35, 36). all the selected studies(1, 2, 8, 13-17, 28-34) for the final sample of this review brought coronary obstructive events as the main cardiac complication evidenced during hospitalization of patients with covid-19. the obstructive events predominantly represented by acute myocardial infarction are possibly the result of an increased myocardial workload during infections, which cause myocardial injuries(37, 38-40). in addition, sars-cov-2 has been shown to trigger an exaggerated systemic inflammatory response, which, in addition to acute lung injury and acute respiratory distress syndrome, can lead to multiple cardiovascular complications(32, 34), unstable angina, tachycardia, heart failure, stroke, cardiogenic shock and even cardiopulmonary arrest(37, 39). patients hospitalized with covid-19 tend to have high serum levels of ck and lactate dehydrogenase. evidence of myocardial injury, such as increased levels of high cardiac troponin i (ctni) (> 28 pg/ml), can contribute to the emergence of obstructive events throughout treatment(41). elevation of biomarkers (troponin i and ckmb), as well as electrocardiographic and echocardiographic changes were observed, revealing a condition of coronary obstruction during hospitalization(38, 39). obstructive injury is caused by the rupture of the plaque or thrombus in the vessel walls, by the proliferation of cytokines, by the reduction of oxygen in the heart muscle, by coronary spasm, by microthrombi or by direct endothelial or vascular injury(7, 8, 12, 17, 32, 33, 34, 38, 42, 43). such situations described lead to an obstructive condition, reflected by changes in the cardiac biomarkers and electrocardiographic changes, especially the elevation of the st segment. most of the studies revealed the relationship between laboratory and imaging findings by electrocardiographic examination in patients with comorbidities(38, 44, 45). the increase in troponin i and ckmb, combined with depression of the st segment and/or inverted t wave at electrocardiographic examination, increased the risk of death, when combined with systemic arterial hypertension in patients with dm(17, 29). the progressive increase in the biomarkers, in addition to indicating coronary obstructive events, can signal the development of systemic complications, such as disseminated intravascular coagulation(45, 46). this finding considerably raises the mortality rates due to covid-19(8, 12), especially in patients with a previous history of sah, dm, dyslipidemia and/or cad(16, 33, 34, 38). from this perspective, it can be said that cvds are considered important risk factors for the occurrence of cardiac complications during hospitalization, increasing the potential for severity and deaths, especially in aged patients(15, 29, 30, 31, 32, 33, 38). in this perspective, the importance of monitoring cardiac biomarkers throughout hospitalization was perceived in order to anticipate cardiac complications, especially in patients with covid-19 who have previous comorbidities. arrhythmias were highlighted in six(1, 2, 15, 28, 31, 32) of the 16 articles included in the final sample of this review; however, only one(15) of them highlighted heart rate. atrial fibrillation was highlighted as the most common cardiac complication, due to changes in the electrocardiographic tracing, in addition to increased serum levels of hypersensitive ctni, in patients with covid-19 admitted to intensive care units(15). in the other articles(1, 2, 28, 31, 32), the electrocardiographic changes which occurred during hospitalizations of patients with covid-19 were not described; however, the authors pointed out that arrhythmic conditions can increase the severity of the covid-19 patients' clinical conditions, due to the presentation of severe cardiac rhythms that evolve to cardiopulmonary arrest, especially in patients with cardiovascular comorbidities identified on admission to the hospital unit. the centers for disease control and prevention conducted a survey with 72 patients admitted to a north american medical center, of whom 43 had cvds, six presented cardiac complications, such as supraventricular tachycardia, atrial fibrillation, atrial flutter or complete atrial ventricular block(35). thus, it was perceived that the arrhythmic conditions need to be identified early so that therapeutic approaches can be taken, with the aim of restoring sinus rhythm. heart failure was evidenced in three of the 16 studies included in the final sample of this review. all the articles were developed with adult and aged patients diagnosed with covid-19, with pre-existing cvds; however, the development of heart failure was predominantly related to the advanced age profile of the patients under study(15, 28, 32). it was also verified that the left ventricular ejection fraction of less than 40%, at echocardiographic examination in cases of heart failure, combined with elevated serum troponin i and elevated st segment at electrocardiographic examination, favor the worsening of covid-19 patients' prognoses(36, 38-40). infection with sars-cov-2 is a mild disease in most people, although a small portion of patients affected by the virus has developed severe respiratory failure characterized by a hyperinflammatory syndrome. dysfunction of the vascular endothelial cell promoted by viral infection, combined with myocardial depression associated with inflammation, stress cardiomyopathy and/or the host's response can cause or worsen heart failure, demand-related ischemia and arrhythmias(32). many discussions have occurred about cardiac complications, diagnosed based on the existence of the arrhythmic conditions identified through electrocardiographic tracings and obstructive events in coronary arteries, verified by electrocardiographic and echocardiographic changes, and by the measurement of cardiac biomarkers(47-49). from the synthesis of the findings in the texts, it was perceived that cardiac complications can occur at different periods of hospitalization(40-52) and that the presence of comorbidities(38, 49) can promote worsening of the clinical condition of patients with covid-19. in summary, the studies that comprised this review allowed highlighting the importance of the cardiac monitoring of patients undergoing covid-19 treatment, with the aim of intervening early in the reversal of arrhythmic conditions and verifying electrocardiographic findings corresponding to obstructive myocardial injury and heart failure. some studies highlighted the importance of monitoring cardiac biomarkers in order to make increasingly anticipate the therapeutic approaches. the study limitation was the number of articles on the subject matter that accurately revealed cardiac complications in patients with covid-19 during hospitalization, through primary studies and with methodological consistency. until june 2020, there are many studies underway that will allow greater knowledge about the disease and its complications. conclusions the cardiac complications that most emerged were coronary obstructive events, arrhythmic conditions, and heart failure. it was perceived that such complications can be related to the previous existence of cvds, verified on admission to the hospital unit, predominantly in patients over the age of 60, who have contracted covid-19. knowledge about cardiac complications during the treatment of patients with covid-19 has begun to emerge, since it can contribute to the adoption of more efficient care protocols in order to prevent such complications, which leads to favorable outcomes, mainly related to patients with cvds. conflict of interest: none declared. references 1. lei s, jiang f, sua w, chend c, chene j, meif w et al. clinical characteristics and outcomes of patients undergoing surgeries during the incubation period of covid-19 infection. e clinical medicine. 2020;21:e100331. available from: https://doi.org/10.1016/j.eclinm.2020.100331 2. guo t, fan y, chen m, wu x, zhang l, he t et al. cardiovascular implications of fatal outcomes of patients with coronavirus disease 2019 (covid-19). jama cardiol. 2020;27:e201017. available from: https://doi.org/10.1001/jamacardio.2020.1017 3. cui j, li f, shi z-l. origin and evolution of pathogenic coronaviruses. nat rev microbiol. 2019; 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35:401-9. doi: https://doi.org/10.1007/s10654-020-00646-z 52. abajo fj, rodriguez-martin s, lerma v, mejía-abril g, aguilar m, garcía-luque a et al. use of renin-angiotensin-al-dosterone system inhibitors and risk of covid-19 requiring admission to hospital: a case-population study. lancet. 2020;395(1):1705-14. available from: https://www.thelancet.com/journals/lancet/article/piis0140-6736(20)31030-8/ fulltext home 5 la fortaleza.p65 aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007174 aquichan issn 1657-5997 • año 7 vol. 7 nº 2 • chía, colombia octubre 2007 • 174-188 maría del refugio zavala rodríguez1 martha v. whetsell2 resumen el propósito del estudio fue determinar el grado de correlación entre los niveles de fortaleza para la salud y de ansiedad-rasgo, en una muestra de 200 pacientes integrada por medio de muestreo no probabilístico; los criterios de inclusión fueron: adultos de ambos géneros diagnosticados con enfermedad crónica, con estudios de enseñanza básica y orientada. el marco teórico que guió la investigación es el modelo de adaptación de roy. el diseño fue descriptivo, transversal, correlacional. se utilizó el cuestionario de fortaleza de s. pollock y la escala de autoevaluación de ansiedad-rasgo de spielberger; los instrumentos presentaron una consistencia interna aceptable con un alpha de cronbach de ,852 y ,813 respectivamente. la información se recabó de cuatro instituciones de salud ubicadas en los municipios de tampico-cd. madero tamaulipas, méxico. el análisis de los datos se efectuó mediante estadística descriptiva e inferencial, se utilizó el paquete estadístico spss versión 13. el rango de edad que predominó fue de 45 a 64 años (54%); el 55% fue del sexo femenino, el 48% cuenta con estudios de primaria, cerca del 90% padece de una enfermedad metabólica. el coeficiente de correlación de spearman entre la fortaleza para la salud y la ansiedad-rasgo fue significativo (�,570, valor �p,000). en la mayoría de la población participante se encontró un nivel moderado tanto de fortaleza (83%) como de ansiedad (73%). el análisis de regresión múltiple indicó que la relación significativa entre estas dos variables no es afectada por la edad, el género o los años de evolución de la enfermedad crónica. los datos de este estudio muestran evidencia de que en los pacientes con enfermedades crónicas a mayor nivel de fortaleza menor nivel de ansiedad-rasgo. esta situación invita a desarrollar más estudios de estos fenómenos, en la disciplina de enfermería, que sirvan como sustento teórico-práctico para el diseño o la mejora de protocolos de atención en esta dimensión humana. palabras clave ansiedad, autopercepción, enfermedad crónica, estrés psicológico. (fuente: decs, bireme). la fortaleza de los pacientes con enfermedad crónica la fortaleza de los pacientes con enfermedad crónica recibido: 14 de junio de 2007 aceptado: 8 de agosto de 2007 1 facultad de enfermería, campus tampico, universidad autónoma de tamaulipas, matamoros 8 y 9 col. centro c.p. 87000 cd. victoria tamaulipas, méxico mzavala07@hotmail.com 2 lehman collage of nursing, 431 gillet hall, 250 bedford park blvd. west bronx, n.y. 10468 estados unidos marwhet@hotmail.com la fortaleza de los pacientes con enfermedad crónica 175 the strengvhs of chronically ill patients abstract the study was intended to determine the degree of correlation between levels of strength for health and state-trait anxiety in a sample of 200 patients created through non-probabilistic sampling. the following were the inclusion criteria: adults of both genders who have been diagnosed with a chronic illness and have a basic and occupationally-oriented education. the roy adaptation model was used as the theoretical framework for the study. the design was descriptive, transverse and correlational. s. pollock�s strength questionnaire was used, along with spielberger�s self-assessment scale for state-trait anxiety. the instruments showed an acceptable internal consistency with a cronbach alpha of .852 and.813 respectively. the data were collected from four health-care institutions in the towns of tampico and ciudad madero, tamaulipas, mexico, and analyzed by means of a descriptive and inferential statistical study. spss, version 13, was the statistical package used. the predominant age range was 45 to 64 years (54%); 55% of the sample is female, 48% has a primary education, and nearly 90% has a metabolic illness. the spearman correlation coefficient between strength for health and state-trait anxiety was significant (�.570, value �p .000). most of the participating population showed a moderate level of strength (83%) and anxiety (73%). according to the multiple regression analysis, the significant relationship between these two variables is not affected by age, gender or evolution of the chronic illness in terms of years. according to the data from the study, the greater the strength level among patients with chronic illnesses, the less the state-trait anxiety level. this suggests the need for further studies on these phenomena in the field of nursing, so as to provide theoretical-practical support for the design or improvement of care protocols focused on this aspect of human life. key words anxiety, self concept, chronic disease, stress psychological.  a fortaleza dos pacientes com doença crônica resumo o estudo determina o grau de correlação entre os níveis de fortaleza para a saúde e de ansiedade-rasgo numa amostra nãoprobabilística de 200 pacientes. os critérios de inclusão foram adultos de ambos gêneros diagnosticados com doença crônica, com estudos de ensino primário e orientado. o modelo de adaptação de roy foi o marco teórico da pesquisa. o desenho foi descritivo, transversal, corelacional. foram utilizados o questionário de fortaleza de s. pollock e a escala de auto-avaliação de ansiedade-rasgo de spielberger. a coerência interna dos instrumentos foi aceitável, com um alpha de cronbach de.852 y.813, respectivamente. a recolha de informação foi levada a cabo em quatro instituições de saúde situadas nos municípios de tampico-ciudad madero, tamaulipas, méxico. foi aplicada estatística descritiva e de inferência utilizando o paquete estatístico spss, versão 13. o rango de idade predominante foi de 45 a 64 anos (54%); o 55% foi de sexo feminino; o 48% tem estudos primários; cerca de 90% sofre uma doença metabólica. o coeficiente de co-relação de spearman entre a fortaleza para a saúde e a ansiedade-rasgo foi significativo (�.570, valor �p.000). a maior parte da população participante apresenta um nível moderado de fortaleza (83%) e de ansiedade (73%). a análise de regressão múltipla revelou que a relação significativa entre estas duas variáveis não é afetada por a idade, o genro ou os anos de evolução da doença crônica. os dados deste estudo indicam que os pacientes com doenças crônicas têm menor nível de ansiedade-rasgo quando apresentam maior nível de fortaleza. esta situação demanda mais estudos de estes fenômenos na disciplina da enfermagem, que sirvam como apoio teórico-prático no desenho e melhoramento de protocolos de atenção nesta dimensão humana. palavras-chaves ansiedade, auto-imagem, doença crônica, estresse psicológico.  aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007176 introducción omo en muchas otras partes del mundo, en méxico el cambio epidemiológico y demográfico se ha producido con tal velocidad, que conlleva mayores probabilidades de que las personas que vivan más presenten enfermedades crónicas. un indicador acerca del tipo de problemas de salud más frecuentes en una población lo constituye la mortalidad; en este sentido, en 2003, en méxico, entre las 10 primeras causas de mortalidad en mujeres, ocuparon los tres primeros lugares la diabetes mellitus con una tasa de 61,6 (por 100 000 habitantes), las enfermedades isquémicas del corazón con 43,5, y las enfermedades cerebrovasculares con tasa de 27,2. en cuanto al género masculino, en ese mismo año ocuparon el primer lugar como causa de defunción las enfermedades del corazón con una tasa de 54,0, seguidas de la diabetes mellitus con 51,6, y en tercer lugar la cirrosis y otras enfermedades crónicas del hígado con una tasa de 39,5 (1). en 2003, el porcentaje de defunciones generales de 30 a 64 años tuvo como principales causas: los tumores malignos con 16,0%, la diabetes mellitus con 15,5%, y las enfermedades del corazón con 12,5% (2). respecto a la mortalidad por enfermedades crónicas, en el estado de tamaulipas, en el año 2002, en las mujeres fueron las mismas causas que a nivel nacional con una tasa de 88,1, 70,3 y 36,9 respectivamente. respecto a los hombres, en primer lugar fueron las enfermedades del corazón con una tasa de 110,6, en segundo lugar la diabetes mellitus con 90,9, y las enfermedades cerebrovasculares ocuparon el tercer lugar con una tasa de 41,9 (3). los padecimientos crónicos se relacionan con síntomas de incapacidad que conducen a diversos grados de dependencia y requieren de terapéutica a largo plazo, en donde se incluye aprender a vivir con las limitaciones y continuar con los regímenes diseñados para controlar las manifestaciones clínicas, así como para prevenir las complicaciones (4). asociado a lo anterior, pinto (citado por medina lópez) (5) señala que �los individuos en situación de cronicidad están devaluados, carecen de roles sociales y son de preferencia invisibles para el resto de la sociedad�. aunado a esto, aguilar figueroa (citado por garcía tafolla) (6), manifiesta que las enfermedades crónicas repercuten en la autopercepción del paciente, afectando el autoconcepto, por tanto, se puede decir, actúan como un estímulo estresor que afecta física y emocionalmente a las personas; siendo la ansiedad la alteración de mayor incidencia, se conceptúa como la respuesta fisiológica, psicológica y de comportamiento de un sujeto que busca adaptarse y reajustarse a presiones tanto internas como externas (7). spielberger (8) menciona dos dimensiones distintas de la ansiedad: la ansiedad-estado como una fase emocional momentánea del organismo humano, y la ansiedad-rasgo en función de las diferencias individuales para responder a situaciones percibidas como amenazantes. cada persona tiene una manera particular de responder frente a un estresor e, independientemente del resultado, la respuesta adaptativa requiere tiempo y esfuerzo. entre los recursos que utilizan los individuos para afrontar los estados de estrés-ansiedad que les genera el vivir con una enfermedad crónica está el grado de fortaleza que poseen, concepto definido por pollock (citado por martín y cols.) (9) como un conjunto de características de la personalidad que funcionan para amortiguar los efectos negativos de los factores estresantes asociados con la experiencia de la enfermedad crónica. en varios estudios reportados por este autor señala los resultados positivos encontrados en cuanto al uso y la asociación de la escala hrhs con niveles de salud percibidos y con aspectos de adaptación (10, 24). la fortaleza de los pacientes con enfermedad crónica 177 las personas con enfermedades crónicas han sido estudiadas en diversos aspectos; sin embargo, en méxico son escasas las investigaciones en las que se asocian con la fortaleza como una característica de la personalidad y con el grado de ansiedad que pudiera generar, situación por la cual se realizó el presente estudio, formulando la siguiente pregunta de investigación: ¿cuál es la relación entre el nivel de fortaleza para la salud y el nivel de ansiedad-rasgo en los pacientes adultos con enfermedad crónica? la hipótesis fue: a mayor fortaleza para la salud menor nivel de ansiedad en los pacientes con enfermedades crónico-degenerativas. el propósito del estudio fue identificar si existe correlación significativa, desde el punto de vista estadístico, entre fortaleza y ansiedad, e identificar en qué proporción las variables demográficas seleccionadas pueden afectar esta asociación en personas adultas y usuarios de los servicios clínicos de cuatro instituciones de salud en los municipios de tampico-cd, madero tamaulipas. el marco teórico que sustentó el trabajo de investigación fue el modelo de adaptación de callista roy, en donde la ansiedad y la enfermedad crónica se identificaron como el estímulo focal, generador de estímulos contextuales que afectan los cuatro modos adaptativos de la persona generando una respuesta positiva o desfavorable en la calidad de vida de los individuos. revisión de literatura el concepto del estrés no es nuevo, pero fue sólo hasta principios del siglo xx cuando las ciencias biológicas y sociales iniciaron la investigación de sus consecuencias en la salud física y mental de las personas. lazarus (citado por lewis) (11) definió el estrés psicológico, como una relación particular entre la persona y el medioambiente, esta interacción es evaluada cognitivamente por el sujeto, quien puede apreciar diferentes resultados al hacer frente a los estresares, lo cual depende tanto de factores condicionantes como de la forma en que son percibidos y del significado personal atribuido a la demanda. un componente integral de este modelo transaccional, de acuerdo con lazarus (11), son las emociones, tales como la ira, el miedo, la tristeza y la ansiedad. se considera que una persona está en una situación estresante o bajo un estresor cuando se enfrenta a situaciones que implican demandas conductuales que le son difíciles de poner en práctica o satisfacer. es decir, depende tanto de las demandas del medio como de sus propios recursos para enfrentarse a él (lazarus y folkman, 1984, citado por alonso gaeta) (7). lewis (11) define los recursos de afrontamiento como las características o acciones encaminadas a controlar el estrés, éstas incluyen factores de la persona (salud, valores, creencias, capacidades individuales) o del medioambiente (redes sociales, recursos económicos e institucionales). por consiguiente, se puede decir que afrontar es un proceso independiente del resultado, el cual consistirá en una respuesta que puede ser positiva o negativa (lazarus y folkman, citados por quelopana del valle) (12). por su parte selye (citado por isaacs) (13), en su teoría denominada síndrome de adaptación general, afirma que cuando hay estrés, el sujeto pasa por una serie de respuestas predecibles (reacción de alarma) independientemente de cuáles sean los factores estresantes. la ansiedad también afecta la capacidad de enfrentarse al estrés, la de aprender y la de centrarse sobre un campo perceptivo (13). sin embargo, al incrementar el estado de alerta y la capacitación, la ansiedad aporta energía que puede ser constructiva. se conceptúa como una respuesta subjetiva al estrés; es una sensación de aprensión, incertidumbre o temor como consecuencia de una amenaza real o percibida cuyo origen real se desconoce o no es reconocido (13). el término ansiedad proviene del latín anxietas, que significa congoja o aflicción; consiste en un estado de malestar psicofísico (14). se puede clasificar en varios grados; gordon (15) la clasifica en ansiedad leve, moderada y severa, se considera que una persona está en una situación estresante o bajo un estresor cuando se enfrenta a situaciones que implican demandas conductuales que le son difíciles de poner en práctica o satisfacer. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007178 y se diferencian por el aumento del nivel de alerta asociado con la expectativa de una amenaza hacia la persona o el entorno. para la resolución de este problema emocional mccloskey y bulechek (16) proponen, entre otras intervenciones, aumentar el afrontamiento, técnicas de relajación, distracción, enseñanza individual, facilitar las visitas y grupos de apoyo. respecto al concepto de fortaleza, en 1979 kobasa (citado por wang) (17) y lo definió como un constructo personal que incluye actitudes, creencias y conductas. lo describió como un aspecto de la personalidad que almacena los efectos del estrés en la salud. también lo identificó como un constructo compuesto por tres subconceptos relacionados: control, compromiso y reto (18) (citado por low). pollock (citado por kenneally) (19) extendió el constructo de fortaleza para estudiar la adaptación en enfermedad crónica, es decir, propuso asociar la fortaleza al contexto de salud y enfermedad. la escala de fortaleza (hrhs, siglas en inglés) la refinó en tres subescalas que miden compromiso, control y reto. la primera dimensión se refiere a la motivación y a la habilidad para hacer frente a estresores de la salud, la segunda dimensión fue definida como la habilidad en la valoración e interpretación de los estresores de la salud. el reto, como tercera dimensión, se enfoca en la valoración del estresor como un potencial que produce crecimiento (pollock, citado por kenneally) (19). pollock (10) afirma que el constructo de fortaleza relacionada con la salud, difiere del concepto genérico de fortaleza de kobasa en dos sentidos: por el uso de definiciones específicas de salud para la medición de las tres dimensiones, y por la medición de la presencia, en vez de ausencia, de esos tres conceptos para determinar la fortaleza. adicionalmente, introdujo el concepto de estresor para facilitar la investigación relacionada con la salud. en otros enfoques de personalidad relacionados con fortaleza, por ejemplo, constantini y cols. (citados por low) (18) discuten como características de una personalidad fuerte, la flexibilidad cognitiva y de comportamiento, la motivación para el manejo exitoso de planes, y la resistencia bajo estrés. en tanto que lee (citado por low) (18) señala que el individuo sano muestra cuatro rasgos de personalidad: a) resistencia, como la firmeza psicológica o fisiológica para continuar; b) fortaleza, como la habilidad para resistir el estrés, la dificultad; c) la audacia, equivalente a valentía, atrevimiento, y d) el control, definido como la habilidad de ejercer autoridad o influir. marco teórico esta investigación se respaldó en el modelo de adaptación de callista roy. la ansiedad-rasgo, definida como las diferencias entre las personas en la disposición para responder a situaciones de tensión (8), se identificó como el estímulo focal que afecta al individuo en su totalidad, manifestándolo por diversas alteraciones; en términos generales, una enfermedad crónica, también calificada como estímulo agresor, en el modo fisiológico del paciente puede desencadenar limitaciones físicas y deformidades que dificultan el desarrollo de las actividades de la vida diaria; se enfrenta a restricciones en los hábitos alimenticios; esto repercute en su apreciación como persona, generando sentimientos de minusvalía e inseguridad en su autoestima y autoconcepto, lo que redunda en forma negativa en el desarrollo de sus roles en el ámbito familiar, laboral y social. por consiguiente, su modo de interdependencia se acentúa hacia un mayor grado de dependencia, con la consiguiente debilidad en la toma de decisiones y en su autonomía. esta situación de salud genera estímulos contextuales, en donde el sujeto interactúa según sus características personales (perfil demográfico) y, en este caso particular, en el nivel de fortaleza que posee. constructo que se define como un conjunto de rasgos de la personalidad que funcionan como amortiguador de los efectos estresantes negativos asociarespecto al concepto de fortaleza, en 1979 kobasa lo definió como un constructo personal que incluye actitudes, creencias y conductas. lo describió como un aspecto de la personalidad que almacena los efectos del estrés en la salud. la fortaleza de los pacientes con enfermedad crónica 179 dos a la experiencia de cronicidad (9). al hacer frente a estos estímulos internos y externos, el individuo podría mediar la severidad del deterioro fisiológico y psicológico de la enfermedad crónica lo cual le permitiría alcanzar un grado de adaptación en su situación de salud-enfermedad, dándole un sentido a su vida y regulando respuestas adaptativas en el sistema. estudios relacionados boytell (citado por pollock) (10), realizó una investigación en adultos hispanos con hepatitis crónica tipo c. la variable fortaleza fue significativamente relacionada con el nivel de salud percibida y con ciertos aspectos de adaptación psicosocial. no se encontró relación significativa con las variables demográficas de edad, sexo, educación o estatus marital. resultado similar detectó harris (citado por pollock) (10) en pacientes angloamericanos y afroamericanos que recibían quimioterapia; no se reportaron diferencias significativas en la hrhs con relación a las variables de etnicidad, enfermedad o tratamiento. ross (citado por pollock) (10), halló correlación significativa entre fortaleza y aceptación al tratamiento de diabetes mellitus; encontró también que la hrhs explicó el 36% de la varianza en los puntajes de conformidad. huckestein (citado por pollock) (10), en un estudio con sobrevivientes de trauma, de diversas nacionalidades, encontró que altos niveles de fortaleza relativa a la salud estaban relacionados con altos niveles de adaptación, esta variable fue medida por ajuste psicosocial, adaptación psicológica y orientación del cuidado de salud. el empleo, fue la única variable demográfica significativamente relacionada con la hrhs. nicholas y webster (citadas por pollock) (10), desarrollaron un estudio con adultos mayores en donde la fortaleza, las prácticas de autocuidado, el índice de enfermedad y dos variables demográficas (mayor ingreso, vivir con otras personas) determinaron el 56% de la varianza en el estatus de salud percibida. otro estudio sobre esta variable fue el de chiang (citado por pollock) (10), quien lo relacionó con la percepción del estrés, y la fortaleza en una muestra taiwanesa de cuidadores de pacientes que habían presentado paro cardiaco. los resultados reportaron que a mayor nivel de fortaleza, menor el estrés y mayor el estatus de salud percibidos en los integrantes de la muestra. los niveles de fortaleza, el estrés y el nivel educativo representaron el 60% del total de varianza al predecir el estatus de salud de los cuidadores. pollock (20) utilizó la escala hrhs en un estudio de factores que promovían la adaptación en 60 adultos con enfermedad crónica, distribuidos en tres grupos de igual tamaño con diagnóstico médico de diabetes mellitus, hipertensión arterial y artritis reumatoide, respectivamente. la correlación de pearson para la fortaleza en los adultos diabéticos reveló relación significativa con la adaptación psicológica (r=,43, p<,05) y adaptación psicosocial /r=,62, p<,01), además se encontró una relación significativa entre estos dos tipos de adaptación en los sujetos con diabetes, mientras que para los otros dos grupos de pacientes esas adaptaciones se reportaron como dominios independientes. el autor considera que actividades psicosociales específicas pueden ser factibles por la presencia de fortaleza, apoyando así los efectos indirectos de la fortaleza en la adaptación. en otro estudio, pollock (20) investigó la adaptación psicológica en relación con los patrones de afrontamiento, fortaleza y características sociodemográficas, en una muestra de 110 adultos con diabetes mellitus tipo 1; el 56% de la varianza fue dada por cinco variables (valoración de la diabetes como daño y beneficio, combinación de patrones desde el afrontamiento, fortaleza, participación en programas de educación y el tiempo transcurrido de diagnóstico). se concluyó que la percepción individual del estresor y las estrategias de afrontamiento usadas se relacionaron significativamente con la presencia de fortaleza lo cual predijo la adaptación a la enfermedad crónica. huckestein en un estudio con sobrevivientes de trauma, de diversas nacionalidades, encontró que altos niveles de fortaleza relativa a la salud estaban relacionados con altos niveles de adaptación. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007180 pollock (20) también aplicó la escala hrhs en una muestra conformada por 244 adultos quienes se describían como sanos, no obstante, el 43% presentaba una enfermedad crónica. se encontró correlación significativa entre la fortaleza y altos niveles de salud percibidos (r =,28, p<,05), entre fortaleza y participación en actividades de promoción de la salud (r =,23, p<,05) y en el uso de recursos (apoyo social) y la presencia de fortaleza (r=,45, p<,05). estos resultados apoyaron los efectos indirectos de la fortaleza en el proceso de adaptación. medina (5) llevó a cabo un estudio de corte cualitativo con el propósito de observar y comprender la vivencia de una enfermedad crónica; participaron ocho personas con edades entre 56 y 69 años que asistían a consulta externa en un hospital universitario de puebla, méxico, y siete informantes generales: familiares y amigos. cada informante clave se entrevistó seis veces en un lapso de cuatro meses. todos los pacientes coincidieron en expresar que viven una experiencia única, un cambio en todos los aspectos de su vida; se sienten devaluados, tienen miedo de las complicaciones y de la muerte. solamente dos personas perciben esa experiencia como positiva, les ha ayudado a valorar la vida, han crecido en la comprensión de su existencia, y les ha permitido modificar actitudes, valores y refugiarse en la espiritualidad. los familiares expresaron desconocimiento de lo que a los pacientes les pasa en cuanto a su estado emocional. otro estudio en este aspecto, fue el de tenahua quitl y cols. (21), en donde participaron 10 adultos mayores que viven en una fundación para ese tipo de personas en puebla, méxico; el objetivo fue comprender, desde el punto de vista de los participantes, el significado de la experiencia de vivir con hipertensión arterial, utilizaron la teoría de las representaciones sociales de moscovici (1989). la representación se considera como un proceso que incluye los conceptos o las ideas de sentido común, las creencias y las emociones que se generan de vivir (mora, citado por tenahua) (21). con base en los datos obtenidos, las representaciones de la experiencia de los participantes se interpretaron como una expresión de sentimientos tanto positivos como negativos, actitudes de enfrentamiento y rechazo, además se encontró falta de conocimientos sobre el padecimiento. garcía tafolla y cols. (6) efectuaron un estudio exploratorio en 30 pacientes hospitalizados, con el propósito de identificar la relación entre el tiempo de evolución y las complicaciones tardías con el modo de autoconcepto en personas con diabetes mellitus tipo 2. utilizaron el inventario de tennessee. siete perfiles de un total de nueve que evaluaban el autoconcepto, se identificaron por debajo de los rangos normales a excepción de autosatisfacción y autocrítica. no se encontró relación significativa entre las variables del estudio. magnani (citado por whetsell) (22), utilizó la escala hrhs, una valoración de salud dada por cada uno de los participantes, y una escala sobre actividad en una muestra de 115 adultos mayores con actividades independientes que vivían en el área de nueva york. detectó que los adultos con niveles más altos de actividad tenían niveles más altos de fortaleza. los resultados también revelaron que aquellos con una cifra alta en los dos instrumentos, tenían un nivel de actividad más alto, que aquellos con una cifra alta en un solo instrumento. en cuanto al concepto de ansiedad, en 1973, basado en el trabajo de hildegard peplau (citado por young) (23), la ansiedad fue identificada como diagnóstico en el ejercicio de enfermería. lawrence y cols. (24) efectuaron un estudio transversal de observación en un centro de medicina familiar con el fin de analizar las relaciones entre síntomas, diagnósticos y la severidad de la enfermedad como indicadores de ansiedad y depresión. mediante el análisis por regresiones logísticas, el género femenino, la percepción de la salud más baja, más dolor y la mayor inhabilidad por días en cama, se mantuvieron como estadísticos predictores positivos y significatila depresión vino a igualarse a la ansiedad como desorden, a la cual las mujeres eran considerablemente más vulnerables que los hombres. la fortaleza de los pacientes con enfermedad crónica 181 vos de síntomas más severos de ansiedad y depresión. otro estudio que reveló mayor tendencia en las mujeres de presentar estados de ansiedad, fue el de murphy y cols. (25), en donde examinaron las tendencias históricas con respecto a la ansiedad en términos de su predominio, de su distribución por edad y género y de su asociación con la depresión. concluyeron que las relaciones entre ansiedad y depresión seguían siendo en un cierto grado similares, con la excepción del hecho de que la depresión vino a igualarse a la ansiedad como desorden, a la cual las mujeres eran considerablemente más vulnerables que los hombres. de los ríos y cols. (26), efectuaron un estudio ex post facto con el propósito de examinar la frecuencia de alteración emocional en una muestra de 100 de pacientes con nefropatía diabética. utilizaron el instrumento ghk-28 (general health questionnaire) de goldberg. en el 86% de los pacientes identificaron algún grado de alteración emocional; tuvieron más riesgo de padecerla aquellos pacientes con 10 y más años de evolución de su enfermedad. vettore y cols. (27) efectuaron un estudio en donde analizaron la relación de estrés y ansiedad en pacientes con periodontitis crónica. distribuyeron 79 pacientes, según la severidad de la enfermedad, en tres grupos: un grupo control y dos grupos de prueba. en cuanto a la ansiedad, medida por el inventario de spielberger (stai), en el grupo de prueba 1 y en el grupo control detectaron promedios similares en el tipo de ansiedad-rasgo, con promedios bajos en el grupo 2 de prueba. detectaron correlaciones positivas entre la ansiedad-rasgo y las frecuencias de los parámetros clínicos para dicha enfermedad, concluyendo que este tipo de ansiedad puede ser un predictor importante para la enfermedad periodontal. material y método se realizó un estudio descriptivo, transversal y correlacional; la muestra se integró con 200 pacientes mediante el método de muestreo no probabilístico, por disponibilidad, en función de los siguientes criterios de inclusión: pacientes adultos de 28 años en adelante, ambos géneros, con estudios básicos, con diagnóstico médico de enfermedad crónico-degenerativa; de los servicios de consulta externa y de hospitalización de cuatro instituciones de salud (una del primer nivel de atención y tres del segundo nivel) localizadas en los municipios de tampico y madero tamaulipas, méxico. se excluyeron los sujetos con trastornos de conducta. los participantes procedían de los estados de veracruz, san luis potosí y tamaulipas. se diseñó una cédula sociodemográfica con la que se recabaron los datos de género, edad, escolaridad, estado civil, tipo de trabajo y religión; también se preguntó el diagnóstico médico y los años de evolución de la enfermedad. para la medición de la fortaleza relacionada con la salud se utilizó la cédula estandarizada de susan pollock, estructurada con 34 reactivos relacionados con la forma en que las personas perciben asuntos importantes acerca de la salud; contiene una escala tipo likert con seis opciones de respuesta: 1= completamente en desacuerdo, 2= moderadamente en desacuerdo, 3= ligeramente en desacuerdo, 4= ligeramente de acuerdo, 5= moderadamente de acuerdo, 6= completamente de acuerdo. del total de reactivos, 19 están redactados en forma negativa con el fin de evitar respuestas cruzadas. el puntaje mínimo del instrumento es 34 y el máximo es de 204. con relación a la medición de la variable ansiedad, se aplicó el inventario de ansiedad rasgo-estado (idare) de spielberger y díazguerrero (1973) en su versión al español, denominado inventario de autoevaluación. en el presente estudio se utilizó únicamente la escala de ansiedad-rasgo que mide las diferencias individuales, es decir, las diferencias entre las personas en la tendencia a responder a situaciones percibidas como amenazantes. la cédula contempla 20 reactivos con una escala de respuesta de en el presente estudio se utilizó únicamente la escala de ansiedad-rasgo que mide las diferencias individuales, es decir, las diferencias entre las personas en la tendencia a responder a situaciones percibidas como amenazantes. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007182 cuatro puntos: 1= casi nunca, 2= algunas veces, 3= frecuentemente y 4= casi siempre. contempla siete reactivos invertidos, esto es, el valor numérico de la calificación para las respuestas marcadas 1, 2, 3 ó 4 viene a ser de 4, 3, 2 y 1 respectivamente. la puntuación mínima es de 20 y la máxima de 80. todos los análisis se realizaron usando el software spss (versión 13). las variables de interés son tanto discretas como continuas, por lo que los métodos estadísticos incluyen cálculo de porcentajes y estadísticas descriptivas (mínimo, máximo, media, mediana y desviación estándar). además, para la parte inferencial se realizaron análisis de correlación bivariada, análisis de regresión lineal múltiple y pruebas ji-cuadrada para el cruzamiento de variables categóricas. también se determinó la consistencia interna de los instrumentos de medición a través del coeficiente alpha de cronbach, y se efectuó la prueba de kolmogorov-smirnov, revelando que los índices de las escalas de fortaleza y ansiedad no tienen normalidad en la distribución de datos (valores z, 1.751 y 1.803, y valores �p,003 y ,004 respectivamente). al realizar el estudio se consideraron los aspectos éticos señalados en el reglamento de la ley general de salud en materia de investigación, donde se incluye el anonimato de los sujetos, confidencialidad de la información brindada por los mismos, derecho a información con respecto al estudio y a retirarse en el momento que lo deseen. a los pacientes se les explicó la finalidad del estudio y cuál sería su participación, en ese momento se obtuvo el consentimiento informado por escrito. se les leyó cada uno de los ítemes y sus respuestas fueron registradas en los formatos correspondientes. la encuesta se efectuó en un lapso de tres meses, participaron alumnos de enfermería del 8º periodo. resultados con respecto a las características sociodemográficas de los 200 pacientes participantes, en la tabla 1 se observa que predominó el género femenino, así como los estudios de primaria y la religión católica; en cuanto al estado civil, cerca del 50% estaban casados. el 60% de los sujetos no trabajan y de los que sí laboran, en su mayoría su trabajo es temporal. tabla 1. características sociodemográficas de los pacientes variable f % género masculino 89 45 femenino 111 55 escolaridad primaria 95 48 secundaria 45 22 otros 60 30 estado civil casado 95 48 viudo 42 21 otro 63 31 r e l i g i ó n católica 166 83 otra 25 12 ninguna 9 5 fuente: cédula sociodemográfica. n=200 la fortaleza de los pacientes con enfermedad crónica 183 tabla 2. distribución de pacientes por grupos de edad y género edad en m a s c u l i n o f e m e n i n o t o t a l años f % f % f % 28 a 47 20 10 37 18 57 28 48 a 67 51 26 56 28 107 54 68 a 87 18 9 18 9 36 18 total 89 45 111 55 200 100 fuente: cédula sociodemográfica. n= 200 en la tabla 2 se identifica el rango de edad, el cual varió desde los 28 hasta los 85 años, la media fue de 54,9 con desviación estándar de 12,7, y la mediana de 55 años. se destacó el grupo de edad de 48 a 67 años, con representación similar de ambos géneros. en la tabla 3 se muestra que aproximadamente el 90% de los participantes padece de una enfermedad metabólica, en donde se incluyó la diabetes mellitus, nefropatía diabética y pie diabético; en lo que se refiere a los años de evolución de la enfermedad crónica, en más del 50% de los pacientes es entre uno a diez años. para medir la confiabilidad de los instrumentos de medición se efectuó la prueba de coeficiente de alfa de cronbach, la cédula de fortaleza obtuvo un valor de ,852 y la cédula de ansiedad un valor de ,813, por ello, puede considerarse que demuestran consistencia interna favorable. tabla 3. distribución de pacientes por grupos de años de evolución y diagnóstico fuente: cédula sociodemográfica. n=200 e v o l u c i ó n m e t a b ó l i c o s o n c o l ó g i c o s otros en años f % f % f % 1 5 64 32 11 6 8 4 6 -10 58 29 2 1 3 2 11 -15 22 11 1 ,5 1 .5 16 20 17 9 21 25 9 4 26 30 3 1,5 31 36 1 ,5 total 174 87 14 7 12 6 de la tabla 4 se puede derivar que el grado de fortaleza de los 200 pacientes fue moderado, pues de la puntuación total de la cédula (204) obtuvieron un promedio de 130, esto es, presentaron un 57% (índice) de fortaleza. respecto al grado de ansiedad, también se puede considerar que presentaron, en promedio, regular nivel, ya que de los 80 puntos en total del cuestionario obtuvieron una media de 47, o sea un 44% de ansiedad. el máximo valor encontrado de ansiedad fue de 92%, mientras que el mínimo fue de tan sólo 3%. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007184 en la tabla 5 se puede apreciar que en general no existen diferencias importantes de género en relación con los índices de las dos variables centrales del estudio. con la finalidad de determinar si existe una asociación estadísticamente significativa entre las variables fortaleza y ansiedad, a través de sus índices, se efectuó un análisis de correlación de spearman, arrojando un coeficiente de r = �,570, valor p=,000 (correlación al nivel del ,01). la relación lineal entre dichas variables resultó significativa. dado que la relación entre estas dos variables objeto de estudio puede ser afectada por otros factores, se realizó un análisis de regresión múltiple, considerando como variables independientes la edad, el sexo y los años de evolución del padecimiento, encontrando que dichas variables no afectan la relación significativa entre ansiedad y fortaleza. p u n t a j e n m í n i m o m á x i m o m e d i a e stándar fortaleza 200 75 189 130,30 19,95 ansiedad 200 22 75 46,68 9,09 desv. índice n mínimo máximo media estándar fortaleza 200 24,12 91,18 56,64 11,74 ansiedad 200 3,33 91,67 44,47 15,15 tabla 4. estadísticas básicas de los puntajes e índices de fortaleza y ansiedad fuente: cédulas de fortaleza y de ansiedad. n= 200 fuente: cédulas de fortaleza y de ansiedad. n=200 tabla 5. estadísticas básicas de los índices de fortaleza y ansiedad por género desv. f o r t a l e z a n m í n i m o m á x i m o m e d i a estándar hombres 89 38,82 91,18 57,34 12,90 mujeres 111 24,12 88,82 56,09 10,74 desv. ansiedad n mínimo máximo media estándar hombres 89 3,33 76,67 44,23 14,81 mujeres 111 3,33 91,67 44,67 15,49 tomando en cuenta que los valores de las variables fortaleza y ansiedad se pueden categorizar formando niveles y, posteriormente, realizar una prueba ji-cuadrado entre ellas con el objeto de determinar si existe una asociación estadísticamente significativa, se procedió a la especificación de tres niveles de acuerdo con los puntajes de los cuestionarios, quedando de la siguiente manera: para la fortaleza, nivel la fortaleza de los pacientes con enfermedad crónica 185 bajo: de 34-104 puntos, nivel moderado: de 105-154 y para el nivel alto: de 155-204. en lo que se refiere a la variable ansiedad, los valores fueron para estos mismos niveles: 20-40, 41-60 y 61-80, respectivamente. en las tablas 6 y 7 se presentan las distribuciones de frecuencias de estos niveles respecto al género de los pacientes. no se encontraron diferencias significativas en los niveles de fortaleza entre hombres y mujeres (valor� p= 0,34); ni tampoco en los niveles de ansiedad entre géneros (valor� p=,89). la tabla 8 muestra la distribución de frecuencias entre el cruce de nivel fortaleza y nivel de ansiedad, así como los resultados de la prueba ji-cuadrado. se encontró que el valor-p fue menor a los niveles usuales de significancia (,05 y ,01); por consiguiente, se establece que existe asociación estadísticamente significativa entre el nivel de fortaleza y el nivel de ansiedad. tabla 6. distribución de participantes por niveles de fortaleza y género nivel de m a s c u l i n o f e m e n i n o a n s i e d a d * f % f % bajo 4 4 5 4 moderado 70 79 95 86 alto 15 17 11 10 total 89 100 111 100 *resultados de la prueba de ji-cuadrado: valor de estadística = 2,160; valor p = ,339 tabla 7. distribución de participantes por niveles de ansiedad y género nivel de m a s c u l i n o f e m e n i n o a n s i e d a d * f % f % bajo 21 24 25 22 moderado 64 72 82 74 alto 4 4 4 4 total 89 100 111 100 *resaltados de la prueba de ji-cuadrado: valor de estadística= ,236; valor p = ,894 tabla 8. distribución de pacientes por niveles de fortaleza y ansiedad niveles de ansiedad niveles de f o r t a l e z a b a j o moderado a l t o t o t a l f % f % f % f % bajo 0 0 7 3 2 1 9 4 moderado 29 14 131 66 5 3 165 83 alto 17 9 8 4 1 0 29 13 total 46 23 146 73 8 4 200 100 * resultados de la prueba de ji-cuadrada: valor de estadística= 32.2; valor p < .001. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007186 discusión la literatura analizada y los estudios consultados expresan las bondades de la fortaleza en la adaptación a enfermedades crónicas en poblaciones con diversas características sociodemográficas. sin embargo, en un estudio con hispanos no se encontró que la educación afectara la relación entre fortaleza y nivel de salud percibido (10); en este sentido, no obstante que los pacientes encuestados fueron en su mayoría de estrato socioeconómico bajo, los resultados reportaron que cuentan con un nivel moderado de fortaleza, esto hace creer que se apoyan en sus creencias y valores para tratar de lograr un grado de adaptación a su cronicidad, sin estar, tal vez, profundamente conscientes de sus capacidades personales. varios estudios (10, 20) asocian la fortaleza con aspectos psicológicos y psicosociales equivalentes a los niveles de adaptación, por tanto, la ansiedad como estado emocional está presente en la vida diaria de toda persona. en la muestra estudiada se detectó regular nivel de ansiedad-rasgo en ambos géneros. en este aspecto difiere con otros estudios que registran mayor riesgo en la mujer (24, 25). con relación al nivel predominante en las dos variables centrales del estudio, se puede deducir que la población estudiada posee adaptación a su enfermedad crónica encontrando similitud con estudios documentados por pollock (10, 20), en función de cuestiones culturales y religiosas y, posiblemente, de la percepción que tengan los sujetos de su enfermedad. la relación significativa entre fortaleza y ansiedad encontrada en el estudio, no fue afectada por la edad, el sexo y los años de evolución de la enfermedad; las dos primeras variables coinciden con lo reportado por boytel (citado por pollock) (10) y tafolla (6). en cuanto al tercer factor difieren con lo reportado por pollock (20) ya que sí influyó en el porcentaje de varianza en su estudio sobre adaptación y patrones de afrontamiento en personas diabéticas. no obstante los resultados, los años de evolución de la enfermedad podrían representar un factor de riesgo en la medida en que se acentúen las discapacidades en el individuo con enfermedad crónica, como también lo manifiesta de los ríos (26). la ansiedad-rasgo, como concepto psicológico, tiene las características del tipo de locuciones que atkinson denomina �motivos�, definidos como disposiciones que permanecen latentes hasta que las señales de una situación los activan (8); por tanto, existe la posibilidad de establecer como premisa que este tipo de ansiedad puede actuar como predictor de un nivel de adaptación favorable en sujetos en estado de cronicidad, supuesto también expresado por vettore (27). los resultados del estudio otorgan sustento a los elementos conceptuales del modelo de adaptación de roy, pues las enfermedades crónicas involucran numerosos factores internos y externos que influyen en la respuesta de la persona en función de las alteraciones en sus modos adaptativos. de éstos, y de acuerdo con la doctora roy (citada por garcía tafolla) (6), el autoconcepto es la totalidad de actitudes que incluyen los pensamientos y sentimientos que el individuo tiene sobre sí mismo. por lo anterior se puede decir que la adaptación depende de los recursos físicos, psicológicos y sociales propios de cada persona. dentro de la experiencia de vivir en situaciones de enfermedad, además de las dificultades, existen espacios de crecimiento a través de redimensionar la vida, por lo que se necesita mejorar las intervenciones de promoción de la salud a través de un trabajo interdisciplinario. bajo esta perspectiva, pollock (20) establece que el uso de recursos de tipo social (instituciones de salud, grupos de apoyo) contribuye a los efectos indirectos de la fortaleza en el proceso de adaptación. en este orden de ideas están también dirigidos algunos resultados y conclusiones de varios estudios (5, 20, 21). la literatura analizada y los estudios consultados expresan las bondades de la fortaleza en la adaptación a enfermedades crónicas en poblaciones con diversas características sociodemográficas. la fortaleza de los pacientes con enfermedad crónica 187 referencias bibliográficas 1. principales causas de mortalidad en méxico. 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[en línea]. disponible en: http:/ /www.medscape.com/viewartticle/434349_2 [con acceso en 10/09/2005]. 25. murphy, horton, laird, monson, sobol, leighton. anxiety and depression: a 40-year perspective on relationships regarding, prevalence, distribution and co morbidity. acta psychiatr scand 2004; 109:355-375 [en línea]. disponible en: http:// www.blackwell-synergy.com [con acceso en 17/08/2005]. 26. de los ríos, barrios, ávila. alteraciones emocionales en pacientes diabéticos con nefropatía. revista médica imss 2004; 42(5): 379-385 [en línea]. disponible en: http://www.imss.gob.mx/ nr/rdonlyres/5185e4ab-507a-4159-8dba-c2df5a576dfb/0/ 2004rm4205alt_emocionales.pdf [con acceso en 14/10/2005]. 27. vettore, lea, montero, quintanilla, lamarca. relationship of stress and anxiety with chronic periodontitis. blackwell munsgaard 2003; 30: 394-402. 1 editorial tiempos de crisis, tiempos de oportunidades times of crisis, times of opportunity tempos de crise, tempos de oportunidade manuel moreno preciado1 1 https://orcid.org/0000-0002-3325-8468. universidad camilo josé cela, españa. mmoreno@ucjc.edu doi: 10.5294/aqui.2020.20.2.1 para citar este editorial / to reference this editorial / para citar este editorial moreno m. times of crisis, times of opportunity. aquichan. 2020;20(2): e2021. doi: https://doi.org/10.5294/aqui.2020.20.2.1 palabras clave (fuente: decs) diversidad; diversidad cultural; migración; migración humana; prejuicio; cuidados; salud. keywords (source: decs) diversity; cultural diversity; migration; human migration; prejudice; care; health. palavras-chave (fonte: decs) diversidade; diversidade cultural; migração; migração humana; preconceito; cuidado; saúde. año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2021 https://orcid.org/0000-0002-3325-8468 mailto:mmoreno@ucjc.edu https://orcid.org/0000-0002-3325-8468 https://doi.org/10.5294/aqui.2020.20.2.1 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 2 chía, colombia abril-junio 2020 l e2021 son numerosos los desafíos y las amenazas a los que la humanidad tendrá que hacer frente a lo largo de este siglo: sostenibilidad, desequilibrios demográficos, riesgos de la biotecnología y pobreza, por mencionar algunos. entre aquellos, destaca la necesidad de aprender a vivir en la diferencia, lo que implica superar el pensamiento moderno, basado en la creencia de que hay una jerarquía de las culturas y de que la occidental está en la cima. confinado en mi casa, como tantos millones de personas en el mundo, quiero dedicar este espacio para reflexionar sobre el quehacer de las enfermeras (y de los enfermeros) en estos tiempos de gran incertidumbre. tiempos de modernidad y globalización, que han traído nuevos estilos de vida y nuevos problemas de salud: un aumento de la cronicidad y la dependencia, estrés, depresión, soledad, trastornos alimentarios y todo tipo de adicciones, pues a las tradicionales se han añadido otras nuevas basadas no en substancias, sino en conductas compulsivas. los estudios sobre percepción de salud (1) muestran que hoy los principales problemas de la población tienen una etiología sociocultural. por ejemplo, un macroestudio publicado en the lancet (2) señala que la pobreza acorta la vida de las personas más que otros cuadros mórbidos, como la obesidad, el alcoholismo y la hipertensión. de forma general, podemos decir que en las sociedades abiertas se han producido profundos cambios socioculturales y tecnológicos: cambios en la gestión del tiempo y en la ocupación del espacio; cambios en los patrones demográficos, reproductivos y familiares; cambios en la relación con el “otro”. por otra parte, los procesos demográficos y de movilidad de las personas han impulsado un aumento de la diversidad cultural y un cambio en las relaciones sociales. las sociedades abiertas son más competitivas y más conflictivas que las sociedades tradicionales. esto explica un aumento del recelo y del miedo al “otro”, visto como una amenaza (3). según datos de las naciones unidas (4), el número de migrantes internacionales a escala global ascendió a 272 millones, un registro que indica un incremento de 51 millones de personas desde el año 2010, lo que representa un 3,5 % de la población global. en españa, esa cifra asciende al 10,67 %. aunque, a veces, el discurso mediático transmite ideas alarmistas sobre la salud de los migrantes, asociándolas a sus países de origen, todos los estudios epidemiológicos demuestran que los principales problemas de salud tienen relación, principalmente, con sus condiciones de vida. contraen las “patologías del destino”: problemas de salud mental, como consecuencia del duelo migratorio; accidentes, tanto laborales como domésticos, por la precariedad sociolaboral; problemas derivados del área materno-infantil, por tratarse de población joven; trastornos alimentarios, por la adaptación al nuevo entorno y la escasez económica, entre otros. las principales barreras que obstaculizan la relación enfermera-paciente inmigrado, a mi entender, son dos: los prejuicios y nuestro modelo sanitario (5). la biomedicina prioriza el orden biológico, relegando a rangos secundarios cualquier otra perspectiva, como los factores socioculturales del cuidado. la fuerza de los prejuicios permite la reproducción de los estereotipos sociales en la atención sanitaria a los inmigrados, bajo lo que podríamos llamar discurso culturalista: “¿quiénes son?” en lugar de “¿qué les pasa?”. este escenario sitúa a las enfermeras ante nuevos desafíos y oportunidades: ¿está la enfermería preparada para dar respuesta a problemas de salud de etiología sociocultural? mi propuesta sería: “ante los cambios, ¡cambiar!”. 1. aprender a vivir en la diversidad y a neutralizar nuestros prejuicios. nuestras sociedades están plagadas de prejuicios hacia todo aquello que, por ser diferente, pueda percibirse peligroso. es necesario evitar que el prejuicio se convierta en perjuicio. 2. sentar las bases de una nueva alianza con el paciente. no solo la sociedad ha cambiado, también el paciente: el paciente se ha vuelto impaciente. este nuevo perfil de paciente ya no se conforma con el rol pasivo que tenía asignado, es más exigente y pide mayor participación, lo cual choca a veces con las culturas profesionales de marcado carácter paternalista: “todo por el paciente, pero sin el paciente”. 3. profundizar en la ética del cuidado. esto significa aprender a decir: “perdón, lo siento, me equivoqué”. los errores son humanos, todo el mundo los comete, pero ocultarlos forma parte de una mala praxis. se trata de ejercer con humildad y de desmarcarnos de la arrogancia que caracteriza al científico que mira por encima del hombro a los demás. la coincidencia del año de la enfermería y de la campaña del nursing now con la crisis del coronavirus me permite proponer que apartemos los debates de carácter identitario y corporativo y nos involucremos en los grandes desafíos sociales. para finalizar, les dejo una frase del prestigioso filósofo y pensador edgar morin, que resume bien la pedagogía que necesitamos para estos tiempos: “es necesario aprender a navegar en un océano de incertidumbres a través de archipiélagos de certeza”. 3 tiempos de crisis, tiempos de oportunidades l manuel moreno preciado referencias 4. instituto nacional de estadística. encuesta europea de salud en españa. 2014 [pdf]. madrid: instituto nacional de estadística. 2015 oct. 21. disponible en: https://www.ine.es/prensa/np937.pdf 5. salas j. la pobreza acorta la vida más que la obesidad, el alcohol y la hipertensión [artículo en el país] el país; 2017 feb. 2. disponible en: https://elpais.com/elpais/2017/01/31/ciencia/1485861765_197759.html 6. moreno-preciado m. el cuidado del “otro”. barcelona: bellaterra; 2008. 7. naciones unidas. naciones unidas. paz, dignidad e igualdad en un planeta sano. [internet]. nueva york: naciones unidas [fecha de publicación desconocida, actualizado 2020 abr. 14; citado 2020 abr. 14]. disponible en: https://www. un.org/es/sections/issues-depth/migration/index.html 8. moreno-preciado m. enfermería cultural. una mirada antropológica del cuidado. madrid: garceta; 2018. https://www.ine.es/prensa/np937.pdf https://elpais.com/elpais/2017/01/31/ciencia/1485861765_197759.html https://www.un.org/es/sections/issues-depth/migration/index.html https://www.un.org/es/sections/issues-depth/migration/index.html palliative care and nursing: a look inside editorial palliative care and nursing: a look inside cuidados paliativos y enfermería: una mirada hacia dentro cuidados paliativos e enfermagem: um olhar para dentro 10.5294/aqui.2022.22.2.1 maria yaquelin expósito concepción 1 1 0000-0002-8933-8221. nursing department. universidad del norte, colombia. mexposito@uninorte.edu.co keywords (source decs): palliative care; nursing; hospice and palliative care nursing; nursing education palabras clave (fuente decs): cuidados paliativos; enfermería; enfermería de cuidados paliativos al final de la vida; educación en enfermería palavras-chave (fonte decs): cuidados paliativos; enfermagen; enfermagem de cuidados pálitivos na terminalida de da vida; educação em enfermagem. para citar este editorial / to reference this editorial / para citar este editorial: expósito my. palliative care and nursing: a look inside. aquichan. 2022;22(2):e2221. doi: https://doi.org/10.5294/aqui.2022.22.2.1 according to the world health organization (who)(1) [...] palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. in 2018, the international association for hospice and palliative care put forward a consensus-based definition of palliative care (pc) "palliative care is the active, holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially of those near the end of life. its aims to improve the quality of life of patients, their families, and their caregivers" (2). when it comes to pc, it is necessary to go back to the hospice movement in the 1970s, led by cicely saunders, a british professional who established the basic principles of what we know today as pc. thanks to her vision as a nurse and training as a doctor and social worker, she was able to promote this movement (3). from its origins, saunders (4) emphasized the importance of eliminating terminal agitation and the fear of suffering from it by combining sound science and personal attention to detail. for her, the unit to be treated is the whole family—patient and caregiver-family—. she recommends sharing as much truth about the situation as possible, recognizes the importance of teamwork, and discloses her own experiences of loss and change. the pc approach is multi-professional and interdisciplinary in caring for people diagnosed with an advanced, incurable, progressive disease or in the end-of-life stage. the main characteristic of pc is the comprehensive care provided, considering the physical, emotional, social, and spiritual aspects; that is, holistic, personalized, and continuous care. on the one hand, the patient's autonomy and dignity are guiding factors in making therapeutic decisions in an environment of respect, comfort, support, and adequate communication. on the other hand, the family is considered the primary support nucleus for the patient, fundamentally during home care and assistance, for which they require guidance, help, and learning (5). the pc nurse bases her care on compassion, concern, affection, commitment, sensitive response, active listening, therapeutic communication, the helping relationship, and the humanization of care. this care "is not directly observable and often not even perceived by the patient or family," according to collière (6) and alberdi (7), and neither by the rest of the team's professionals. this invisible dimension of care shapes the essence of pc assistance (8). pc is becoming increasingly important in health systems. therefore, there are international references and recommendations from the who/paho, strategies, a documented and argued knowledge field, and trained professionals. however, the public and professional debate have reached a consensus on the need to increase the training of professionals and extend the creation of specialized units, support teams, home care programs, and, above all, regional and local programs that favor uniform and coordinated development and eliminate existing territorial inequalities. so, what is necessary to respond to this demand? what is our role as nurses? the current scenario in which pc takes place encounters a misalignment in specific nursing training, and a lack of curricula and graduate training is evident. although the bill "whereby palliative care education is consolidated" is in the approval process, a significant achievement, rigid and aligned work is required (9). training is needed that covers the wide range of knowledge and skills necessary for nurses to deal with the care situations of these patients. knowing and conducting advance care planning (acp) from individuality, continuity, flexibility, accessibility, polyvalence, and a multidisciplinary approach becomes a mainstay of this care (8,10). professional practice in pc must be considered in the framework of a conceptual model, the application of the scientific method, and the development of care plans under critical thinking, clinical judgment, decision-making, and problem-solving. at the same time, it is necessary to advance in reflective practices based on the best available scientific evidence that enables nurses to provide the best possible care to patients and their families. therefore, upon graduation, the challenge first is that professionals must have the training to carry out their care activity with patients with chronic, degenerative, advanced, or end-of-life diseases and their families. study plans must integrate basic pc knowledge, skills, and abilities. secondly, continuous training must be guaranteed at those care levels in which these patients and their families are treated, which caters to professionals' need to refresh their knowledge of specific topics. finally, the next level should be specific pc training for professionals who tend to reach an advanced graduate level. currently, the offer of multidisciplinary and specific pc programs that nurses can access in the country is still insufficient. thus, efforts must continue to encourage advanced training, recognition in the labor field, and the commitment of universities and health institutions to supporting this purpose. the professional role within the care team should be clarified. nursing skills in pc must be defined to provide advanced quality practice that ensures excellence in the care provided to patients and their families and defines the scope of action. identifying skills will directly affect care and show the need for training, management, and research. in conclusion, there is awareness of the care gap that can occur when the patient needs pc, particularly when they reach an advanced or end-of-life stage. patients in this situation only have one chance to die with dignity and for their families to be with them. it is an obligation, a responsibility, and a continuous challenge to assure patients that the best professionals will treat them. this is a great task; fortunately, more individuals are interested in broadening their pc knowledge, and more initiatives are being undertaken to contribute to this end. references 1. organización mundial de la salud. cuidados paliativos. [internet]. 2020 ag. 20. disponible en: https://www.who.int/es/ news-room/fact-sheets/detail/palliative-care 2. radbruch l, de lima l, knaul f, wenk r, ali z, bhatnaghar s, blanchard c, bruera e, buitrago r, burla c, callaway m, munyoro ec, centeno c, cleary j, connor s, davaasuren o, downing j, foley k, goh c, gomez-garcia w, harding r, khan qt, larkin p, leng m, luyirika e, marston j, moine s, osman h, pettus k, puchalski c, rajagopal mr, spence d, spruijt o, venkateswaran c, wee b, woodruff r, yong j, pastrana t. redefining palliative care-a new consensus-based definition [redefinición de los cuidados paliativos: una nueva definición basada en el consenso]. j pain symptom manage [internet]. 2020 oct;60(4):754-764. doi: https://doi.org/10.1016/j.jpainsymman.2020.04.027 3. sociedad española de cuidados paliativos (sepcal). historia de los cuidados paliativos y movimiento hospice. madrid; 2017. disponible en: http://www.cuidarypaliar.es/wp-content/uploads/20i7/0i/movhospice.-secpal.pdf 4. saunders c. "velad conmigo", inspiración para una vida en cuidados paliativos. houston, tx, usa: iahpc press; 2011. 87 p. 5. expósito y. intervención de cuidados paliativos para mejorar la calidad de vida de cuidadores primarios de mujeres con cáncer de mama avanzado [tesis doctoral]. [la habana, cuba]: universidad de ciencias médicas de la habana; 2012. 6. colliere mf. invisible care and invisible women as health careproviders. int j nurs stud [internet]. 1986;23(2):95-112. doi: https://doi.org/10.1016/0020-7489(86)90001-5 7. alberdi castell rm, cuxart ainaud n. cuidados, enfermeras y desarrollo profesional: una reflexión sobre las bases del ejercicio profesional. presencia [internet]. 2005 jul.-dic.;1 (2): [2 pantallas]. disponible en: http://www.index-f.com/presencia/n2/r23articulo.php 8. codorniu n, bleda m, alburquerque e, guanter l, adell j, garcía f., barquero, a. cuidados enfermeros en cuidados paliativos: análisis, consensos y retos. index enferm [internet]. 2011 en.-jun; 20(1-2): 71-75. doi: https://doi.org/10.4321/s1132-12962011000100015 9. república de colombia. proyecto de ley 002 de 2020 senado "por el cual se fortalece la educación en cuidados paliativos" disponible en: https://ascun.org.co/wp-content/uploads/2021/10/informe-de-ponencia-primer-debate-senado.pdf 10. escobar escobar mb, angulo albán kj, calderón orozco v, gallego marín ma, ramírez morales am. problemas a los que se enfrenta el personal de enfermería en el cuidado paliativo. rhe [internet]. 2020 dic. [citado 2022 mzo 22];31(3)325-39. disponible en: http://ojs.uc.cl/index.php/rhe/article/view/horiz_enferm.31.3.325-339 home 4 teoria de nefermeria.p65 teoría de enfermería ¿un camino de herradura? 161 año 7 vol. 7 nº 2 • chía, colombia octubre 2007 • 161-173 maría mercedes durán de villalobos1 resumen esta revisión pretende reflexionar sobre las dificultades que tenemos las enfermeras para la selección, utilización y desarrollo de la teoría de enfermería que respalde la práctica autónoma. se revisa la historia de la evolución de la teoría a partir del nacimiento del pensamiento teórico disciplinar hasta la generación de la teoría de rango mefio. posteriormente, se acnaran elementos fundamentanes para diferenciar la teoría de enfermería prestada a la teoría propia, y se"analizan a partir de la literatura de enfermería los aspectos que, a juicio dg la autora, han sido obstáculos para el desarrollo teórico: la diferencia semántica y estructural del modelo conceptual y la teoría de enfermería, la utilización de la teoría propia y la teoría prestada, y el surgimiento de la teoría de rango medio y su trascendencia para la práctica disciplinar. palabras clave epistemología, enfermería, teoría de enfermería. (fuente: decs, bireme). teoría de enfermería ¿un camino de herradura? teoría de enfermería ¿un camino de herradura? recibido: 12 de junio de 2007 aceptado: 2 de agosto de 20071 universidad nacional de colombia, ciudad universitaria, bogotá, colombia. mmvillalobos@gmail.com aquichan issn 1657-5997 aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007162 nursing theory: a bridle path? abstract the purpose of this review is to reflect on the difficulties we nurses face in the selection, use and development of nursing theory that supports independent practice. the history of theoretical development is reviewed, beginning with the birth of disciplinary theoretical thought and extending to the generation of middle-range theory. fundamental elgments for differentiating"between borrowed theory in nursing and nursing�s own theory are clarified, and the aspects the author regards as obstacles to theoretical development are analyzed on the basis of nursing literature. they incnude the semantic and structural difference between the conceptual model and nursing theory, the use of nursing�s own theory and borrowed theory, and emergence of the middle-range theory and its importance in nursing practice. key words knowledge, nursing, nursing theory. teoria de enfermagem, um caminho de ferradura? resumo esta revisão trata de reflexionar acerca das dificuldades das enfermeiras para selecionar, utilizar e desenvolver a teoria da enfermagem respaldando a prática autônoma. é revisada a historia da evolução da teoria desde o nascimento do pensamento teórico disciplinar até a geração da teoria de rango médio. são clarificados elementos fundamentais para diferenciar a teoria emprestada á teoria própria e analisados, partindo da literatura de enfermagem, aspetos que, segundo a autora, tem sido obstáculos para desenvolvimento teórico: a diferencia semântica y estrutural do modelo conceitual e a teoria de enfermagem, a utilização da teoria própria e a teoria emprestada, e a emergência da teoria de rango médio e a sua transcendência para a pratica disciplinar. palavras-chaves conhecimento, enfermagen, teoria de enfermagen. teoría de enfermería ¿un camino de herradura? 163 introducción por qué ha existido y existe todavía entre las enfermeras controversia sobre la teoría de enfermería y su aplicación en la práctica y la investigación? o, ¿finalmente, llegaremos a un acuerdo entre nosotras antes de perder la oportunidad de desarrollar plenamente el liderazgo que deberíamos tener dentro del grupo de las disciplinas orientadas a la práctica del cuidado y promoción de la salud? a pesar de las sugerencias de florence nightingale (1) relacionadas con la dirección que debía tomar el desarrollo del conocimiento de enfermería, la evolución de éste nos ha llevado, en ocasiones, a alejarnos de la responsabilidad que demanda la disciplina, y solamente a partir de la década de los sesenta comenzamos a descubrir nuevamente el tipo de conocimientos que nos permitirán establecernos como una ciencia enfocada al cuidado y a la promoción del bienestar de los seres humanos en la salud y la enfermedad. nightingale, en notas de enfermería (1), señaló: está claro, como lo apunta newman (2), que aunque los lineamientos para el desarrollo del conocimiento fueron claros, la enfermería del siglo xx basó su conocimiento en el conocimiento médico. las enfermeras �instruidas� por los médicos aprendieron lo necesario para llevar a cabo el régimen médico. pero como veremos, el conocimiento de enfermería florece y es necesario conocerlo para apreciar su riqueza y utilidad. algo de historia margaret newman (2) y afaf i. meleis (3) hacen un recuento claro sobre el desarrollo teórico y epistemológico de enfermería, respectivamente, y coinciden en sus apreciaciones referentes a cuál ha sido el sendero de la teoría de enfermería. sendero porque, como se verá, el camino ha sido largo, de más de cuarenta años, tortuoso, ascendente o descendente y, en términos coloquiales, se podría sugerir que ha sido un �camino de herradura�2 . las autoras coinciden en apreciar que durante las primeras décadas del siglo pasado, el conocimiento disciplinar de enfermería se basó en gran parte en el conocimiento médico y que, aún teniendo educación universitaria autónoma, ésta giró alrededor de las necesidades de llenar el régimen de prescripción médica para el paciente; y podríamos sugerir, con cautela, que la modalidad organizativa curricular y los contenidos programáticos de las asignaturas profesionales por áreas de especialización, son comunes hoy en día. paralelamente, y por algún tiempo (años treinta, cuarenta y cincuenta) otro enfoque que contribuyó al desarrollo del conocimiento de enfermería fue el de manejo administrativo y educativo. este periodo cambió la pregunta sobre cómo atender al paciente y asegurar el régimen médico, hacia cuál currículo plantear para educar mejor a las enfermeras, y cómo enseñarlo. igualmente, se relacionó con los roles funcionales para los cuales debía estar preparada la enfermera. por tanto, mucho del interés y énfasis curricular y de preparación de los docentes de enfermería tuvo que ver con contenidos administrativos, pedagógicos, didácticos, disciplinas que manejan conocimientos útiles para enfermería, pero que no son conocimiento de enfermería, y nuevamente la propuesta de nightingale quedó relegada a un segundo o tercer plano. 2 camino de polvo o adoquín hecho para que transitaran bestias de carga y que aún existe en ciertas zonas muy montañosas de nuestro país. es un camino trazado sin las consideraciones tecnológicas modernas, pero que fue fundamental para el desarrollo de los países y las regiones, antes de la aparición y utilización de los automóviles, camiones� aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007164 la etapa de educación y administración fue importante para el posterior desarrollo teórico, ya que generó preguntas tales como: ¿qué es enfermería?, ¿cuál es la diferencia del cuidado que brinda una enfermera con el que brinda una auxiliar de enfermería?, ¿cuál es la diferencia entre enfermería y medicina?, y otras tantas que urgieron a las enfermeras a articular el núcleo teórico de enfermería (4). de acuerdo con meleis (3), esta etapa aligeró el camino para el desarrollo teórico posterior, a pesar de no haber tenido en cuenta, por sí misma, el conocimiento disciplinar. este proceso dio paso a la investigación. pero a una investigación que inicialmente tuvo un enfoque de roles, centrada en las enfermeras más que en enfermería. la etapa de investigación fue básica para el desarrollo teórico ya que, durante este periodo, las enfermeras sentaron los cimientos y las instrumentaciones para el desarrollo científico, la crítica y el avance académico. aunque los marcos de referencia y los hechos fundamentales del núcleo de la disciplina faltaban por desarrollar, durante este periodo se formuló la sintaxis disciplinar (5, 6). finalmente, los primeros años de la década de los sesenta dieron apertura a lo que se puede considerar el desarrollo teórico de enfermería. muchos esfuerzos se dieron en esta década a partir de los académicos, el soporte y la financiación de la investigación, y el reconocimiento de las publicaciones científicas, hechos que fueron fundamentales para el giro que dio la disciplina de enfermería, pero sobre todo para la mejor comprensión de la necesidad de la utilización de la teoría, generación y validación de la misma para garantizar la autonomía de la práctica disciplinar. el tipo de teoría para enfermería para entender el tipo de teoría que requiere enfermería debemos atender a dos preguntas: ¿qué es la teoría? y ¿por qué para enfermería? la teoría es un elemento esencial para el desarrollo de las disciplinas, y es componente primario del conocimiento disciplinar. son numerosas las autoras que han clarificado el concepto, y éste depende básicamente de la utilización que se pretenda para la teoría como se puede apreciar en ellis, mckey, hardy, jacox, fawcett, meleis, stevens, citadas por de villalobos (7) y chinn y kramer (8). burns y grove (9), así mismo, explican gráficamente cómo para validar los hechos del mundo empírico de enfermería se requiere el desarrollo teórico que, junto con el desarrollo de la ciencia de enfermería, generarán el conocimiento disciplinar necesario para garantizar la autonomía de la práctica clínica. villalobos (7) aclara que este proceso generador de conocimiento debe producirse a partir del pensamiento abstracto porque las respuestas a las preguntas del conocimiento se generan a partir de la abstracción. la abstracción es clave en el mundo de enfermería, dada la complejidad de la naturaleza de los conceptos metaparadigmáticos de la disciplina (10, 11). además, porque sin abstracción enfermería queda atrapada en el mundo del empirismo en el cual dicho mundo puede ser sentido y experimentado, pero nunca entendido. la abstracción permite la generación y la prueba teórica (lo único que puede explicar el mundo de enfermería), y de esta manera avanzar en la conformación de un cuerpo propio de conocimientos disciplinares. el conocimiento abstracto es el que permite que los hallazgos científicos derivados de investigación se desarrollen en teorías que, guiadas por un soporte filosófico, puedan sustentar la práctica. en síntesis, podemos asegurar que la teoría es uno de los componentes de la estructura del conocimiento que nos permite dar sentido al mundo empírico y, por tanto, entender de una manera más coherente y controlada nuestra práctica. para responder acerca del porqué, es importante concordar que enfermería requiere teoría para la práctica e investigación, y es preciso no perder de vista que la teoría es la herramienta fundamental para la práctica, y que tanto la teoría como la investigación son requerimiento esencial para aquélla; esta afirmación no es motivo de discusión en los medios académicos, a pesar de las afirmaciones de levine (12) sobre las dificultades y los malos entendidos iniciales sobre la necesidad del desarrollo teórico, y la confusión semántica que aclararemos posteriormente en esta revisión. donalson y crowly (13) aclaran con amplitud el significado de ser una disciplina profesional, como lo es enfermería, y de las necesidades teóricas que den respuesta a la relación de la disciplina con la práctica; en este sentido explican la urgencia de tener una amplia gama de teorías que expliquen, predigan y prescriban o controlen los fenómenos de la misma. continúan expresando que la disciplina requiere teoría descriptiva y explicativa, para entender los fenómenos básicos del dominio de enfermería, pero agregan, al igual que stevens (14), que para generar práctica confiable y autónoma se requiere teoría de prescripción o de control. pero cualquiera sea el tipo de teoría con el cual nos encontremos para comprender la práctica, debe ser significativa, relevante y, sobre todo, comprensible. dickoff y james (15, 16), y dickoff, james y weidenbach (17, 18) en 1968 propusieron formas aclaratorias sobre la teoría de enfermería e hicieron énfasis en la necesidad de tener una teoría orientada hacia la acción que apuntara a moldear la realidad de la práctica, no de una manera fútil, sino a través de una conceptualización clara, de fines y medios de la misma, la cual se basara en su conocimiento adecuado con relación a la estructura, el desarrollo y el potencial futuros. dadas estas condiciones, está claro que para la disciplina no es suficiente el desarrollo teórico prescriptivo exteoría de enfermería ¿un camino de herradura? 165 clusivamente, se requiere también una estructura conceptual inventada o extraída de la práctica, que sirva como prerrequisito o propósito para ajustar en ésta la teoría o teorías de más concreto alcance o mayor operatividad. en palabras comunes, la teoría prescriptiva es la adecuada para guiar las acciones que conducen a dar forma a nuestra realidad. ¿y cómo podría enfermería, una disciplina nueva, producir este tipo de teoría sofisticada? los autores proponen que la respuesta radica en el eventual y privilegiado intercambio con el mundo empírico de la práctica disciplinar. este rico recurso de conocimiento preconceptual es la raíz para la comprensión de fenómenos complejos y patrones de comportamiento que, al articularse en conceptos y proposiciones, conducen al desarrollo teórico pero teniendo en cuenta que este desarrollo no debe seguir los procedimientos ortodoxos de otras disciplinas académicas, sino aquellos que conduzcan a un proceso de utilidad para las peculiaridades de enfermería. a manera de conclusión se puede afirmar que la teoría es el componente que da forma e identificación a la disciplina, y que las teorías que ésta utiliza deben estar impregnadas por las clarificaciones de los supuestos básicos y los valores compartidos por las enfermeras que, en última instancia, definen los resultados y el propósito de la práctica (19, 20). dicho de otra manera, clarifica la complejidad intelectual y la interacción de los elementos del dominio de enfermería, lo que permite plantear investigación relevante y aplicable a la práctica, situación que hace la diferencia entre una práctica de cuidado experta y coordinada y la mera ejecución de tareas sin conexión o delegadas de la práctica médica, por más sofisticadas que éstas sean (21, 8). otras de las ganancias que aportan las teorías al conocimiento de enfermería fueron mencionadas por fawcett (10), y vale la pena hacerlas notar en esta revisión: 1. permiten identificar estándares para la práctica, ya que la teoría razona sobre las mejores opciones y estrategias que se deben tener en cuenta al determinar las intervenciones de cuidado. 2. identifican ambientes en donde la práctica de enfermería debe ocurrir, y las características de los recipientes del cuidado de enfermería, ya que la teoría no es universal, más bien apunta a comprender fenómenos o situaciones determinados facilitando su comprensión y resolución, en un momento dado. 3. identifican los diversos procesos de enfermería y las tecnologías que deben utilizarse para la práctica, incluyendo instrumentos de valoración, etiquetas sobre los problemas de los pacientes o usuarios del cuidado, estrategias de intervención y criterios para la evaluación de los resultados del cuidado. 4. dirigen las formas de prestación de servicios de enfermería porque, junto con los elementos filosóficos, proveen marcos de referencia para el cuidado y las diversas formas de atención que puede brindar enfermería. 5. sirven de base para los sistemas de información que requiere enfermería para la toma de decisiones fundamentales para el cuidado. 6. dan forma a los programas de aseguramiento de la calidad de los servicios de enfermería que son consecuencia o resultado del desarrollo de los puntos anteriores. como se puede deducir, sin hacer aclaraciones adicionales, la teoría junto con la investigación pueden ser los agentes de cambio que permitan a enfermería no sólo sustentar la práctica, sino proponer cambios para revaluar los modelos de prestación de servicios que realmente se ajusten a las necesidades de los usuarios de las empresas que gestionan las necesidades de salud de la gente, es decir, modificar con evidencias las decisiones sobre políticas de salud. terminología de la teoría de enfermería la terminología de la teoría de enfermería ha sido algo problemática, como puede derivarse de la literatura respectiva. los conceptos utilizados se han manejado de forma indiscriminada (modelo conceptual, modelo teórico, marco de referencia, teoría), y tal vez sea ésta una de las razones para que se haya generado dificultad para su comprensión y utilización, hasta llegar a extremos de descartarla totalmente en el trabajo científico, en algunos sectores de enfermería. la teoría puede explicarse desde tres puntos de vista que se notan claramente, tanto en la literatura como en el lenguaje cotidiano de las enfermeras: a) la diferencia semántica y estructural de los modelos conceptuales y las teorías, que así mismo tiene que ver con la jerarquía de abstracción, como lo propone fawcett (22); b) la utilización de teoría propia y de teoría prestada, y c) el surgimiento de la teoría de rango medio y la teoría práctica. los primeros años de la década de los sesenta dieron apertura a lo que se puede considerar el desarrollo teórico de enfermería. muchos esfuerzos se dieron en esta década a partir de los académicos, el soporte y la financiación de la investigación, y el reconocimiento de las publicaciones científicas. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007166 pero antes de comenzar a discutir los tres aspectos mencionados en el párrafo anterior es importante proponer una conceptualización de teoría y de teoría de enfermería. de acuerdo con meleis (3), la teoría es: una articulación organizada, coherente y sistemática, de una serie de definiciones que se relacionan de forma coherente con los cuestionamientos de una disciplina y que se articulan en un todo significativo. es una descripción simbólica de aspectos de la realidad que se descubren o inventan para describir, explicar, predecir o prescribir eventos, situaciones, respuestas, condiciones o relaciones. las teorías manejan conceptos relacionados con los fenómenos de la disciplina. estos conceptos se relacionan entre sí dando forma a las proposiciones teóricas. la teoría de enfermería la define la misma autora, como: la conceptualización de algún aspecto de la realidad de enfermería que se propone con el fin de describir y explicar los fenómenos, y de mostrar las relaciones entre fenómenos, predecir consecuencias o prescribir el cuidado de enfermería. las teorías de enfermería son los depósitos en donde se almacenan o guardan los hallazgos sobre los conceptos que maneja enfermería tales como, comodidad, sanación, recuperación, movilidad, descanso, cuidado, fatiga, cuidado familiar, ayudar a ser capaz de, transiciones, tristeza, dolor, insomnio� también son los depósitos en donde se acumulan las respuestas para los fenómenos significativos de la práctica, tales como niveles de cognición posaccidente cerebrovascular, procesos de recuperación, rechazo a un régimen de rehabilitación posinfarto del miocardio, admisiones concurrentes, para mencionar algunos ejemplos. estas definiciones o conceptualizaciones de teoría nos proponen una serie de requisitos que se deben contemplar al hablar de ésta: primero, la teoría debe estar enmarcada dentro de los límites de la disciplina, es decir, debe referirse a fenómenos que encajen dentro de las fronteras del dominio disciplinar, o dentro de las fronteras del metaparadigma disciplinar, y deben tener un propósito determinado; segundo, deben caracterizar el fenómeno, situación, problema� bien de manera total, como sería el caso de los síntomas desagradables (23), o de una forma parcial como sería el caso de los modos adaptativos que forman parte del modelo de adaptación de callista roy (24); tercero, las relaciones entre las proposiciones teóricas deben estar determinadas con toda claridad, es decir, debe reflejarse una estructura o modus operandi de la teoría, y cuarto, puede derivarse de la observación de hechos empíricos, de la evidencia resultante de procesos investigativos o de una combinación de éstos. lo enunciado concuerda con los pensamientos de dickoff y james (15) referentes a que la teoría no es un fin en sí del desarrollo del conocimiento, sino un medio (instrumento) para su comprensión y sistematización, y además que todas las propuestas teóricas apuntan a conceptualizaciones e interpretaciones de la realidad que para enfermería, idealmente, deben estar ligadas a la clarificación de la práctica disciplinar. con las aclaraciones anteriores podemos ocuparnos de los tres puntos sobre la terminología de la teoría. a. diferencia semántica y estructural de los modelos conceptuales y las teorías la diferencia semántica está íntimamente relacionada con los niveles de abstracción del conocimiento y la estructura de las teorías, lo que llama fawcett (22) la jerarquía u �holarchy�3 estructural del conocimiento. la propuesta señala que existe una diferencia, dado el nivel de abstracción, entre los modelos conceptuales y las teorías, y que éstas a su vez pueden clasificarse por su mismo nivel de abstracción y posibilidad de operacionalización de sus conceptos integrantes. en este orden de ideas se podría decir que el modelo conceptual de enfermería es la expresión de la entidad teórica de mayor abstracción dentro de la jerarquía del conocimiento de enfermería. la función del modelo es expresar, a través de conceptos y proposiciones, de una manera amplia, un fenómeno de interés para enfermería (25); en este sentido, se puede afirmar que el modelo representa un paradigma de enfermería, un enfoque4 , una guía que da perspectiva a la práctica, un horizonte, incluyendo formas instrumentales e indicadores empíricos derivados de la meta del modelo; por ejemplo, y por nombrar algunos, los modelos de roy (24), rogers (26, 27), orem (28), neuman (29) proponen la generación de una práctica con perspectiva o enfoque adaptativo, de promoción y �unitariedad� de las personas, de autocuidado y de prevención respectivamente; estas propuestas hoy en día dan forma a ciertos paradigmas de enfermería: rogeriano, de roy, de autocuidado, entre otros. el modelo conceptual es descriptivo en su esencia y es imposible generar investigación a menos que se fragmente en partes lógicas y se hagan operativos sus conceptos; sin embargo, siempre conceptualizan, bajo su propia caracterización los conceptos mayores de la disciplina identificados en el metaparadigma. no existe el mejor modelo, ni tampoco éstos explican en su totalidad los fenómenos de enfermería. cada uno, de acuerdo con los intereses 3 concepto acuñado por la doctora j. fawcett que pretende dar un significado integral y no jerárquico a la estructura del conocimiento. es decir, lo muestra con un sentido de integración y totalidad, y no estructurado de acuerdo con cierta categorización abstracta. de esta forma sugiere que todos los elementos, ya sean abstractos o concretos, son de igual importancia para el desarrollo del conocimiento; son de igual importancia tanto los conceptos metaparadigmáticos y las filosofías, como los indicadores empíricos. en este sentido es importante aclarar que en esta �holarchy � los elementos de mayor abstracción que los modelos conceptuales se consideran filosofías. (este concepto no tiene todavía traducción al castellano, por tanto se continuará utilizando el término �jerarquía�.) 4 es importante no confundir el término �paradigma� que apunta a describir una forma de pensamiento, una forma de utilización de herramientas científicas y de la práctica, con el término �metaparadigma� que describe los cuatro conceptos (persona, ambiente, salud y cuidado de enfermería) que delimitan las áreas de conocimiento o dominio de la disciplina de enfermería. teoría de enfermería ¿un camino de herradura? 167 de la teórica, trata de mostrar la relevancia de ciertos aspectos de un fenómeno y deja de lado otros que no le son de interés particular. pero de todas formas se utilizan de manera efectiva para dar estructura y significado a las actividades generales de la práctica, la educación y la administración, y como referentes mayores en la investigación. de otro lado, aparece el concepto de teoría que es la segunda entidad teórica, en nivel de abstracción, según fawcett (22), y la que se suele confundir con modelo conceptual. las mismas teorías se diferencian en grandes teorías, teorías y teorías de rango medio. la teoría de mayor amplitud es la gran teoría, la de menor amplitud es la microteoría, y la ubicaremos dentro del concepto de teoría de rango medio. dejaremos las teorías de rango medio para posterior discusión. la gran teoría se compone de conceptos y proposiciones abstractos, pero un poco menos generales que los de los modelos conceptuales. la mayoría de los modelos conceptuales se consideran grandes teorías, aunque algunas autoras como fawcett (22) discrepan de esta clasificación. la autora sugiere que la gran teoría es más restrictiva al interpretar los fenómenos o las situaciones; como ejemplos se pueden citar las teorías de: expansión de la conciencia de newman (30), la de ser y llegar a ser humano de parse (31) y la de cuidado humano de watson (32). las teorías, al igual que los modelos, son descriptivas y explicativas, pero pueden llegar a ser predictivas y, al igual que los modelos, requieren operacionalizaciones para aplicarlas en la práctica y la investigación. es decir, es necesaria su instrumentación específica, y además requieren indicadores empíricos concretos para la medición. como se puede observar, es difícil hacer una delimitación inequívoca entre modelo conceptual, gran teoría y teoría: un modelo debe modelar o moldear otra entidad, o un fenómeno, y presenta un grupo de conceptos discretos que no siempre proponen relaciones claras, mientras que la teoría no necesariamente modela el fenómeno, más bien clarifica propiedades, relaciones, estructuras y funciones. siendo así, es necesario sugerir que la discusión semántica parece estar totalmente fuera de lugar, y que como propone meleis (3), el concepto �teoría� es suficiente para describir las conceptualizaciones teóricas que ha propuesto y propondrá enfermería para satisfacer las necesidades de la disciplina, y que se requieren tanto modelos conceptuales como teorías de diversa amplitud para dar interpretación a nuestros fenómenos. continuando con el nivel de abstracción y la teoría nos encontramos finalmente con la teoría de rango medio (trm) o teoría de mediano rango que es la más concreta que maneja enfermería. su nacimiento puede ubicarse en los primeros años de la década de 1990, aunque fawcett (22) sugiere que teorías como la de relaciones interpersonales de peplau (33) y la de promoción de salud de pender (34), se ubican en esta categoría. meleis (3) considera que el surgimiento de la teoría de rango medio fue un avance significativo para el desarrollo disciplinar y ésta ha evolucionado hasta la fecha, de manera significativa, como se verá. las tmr, originarias de la sociología (23), se ocupan de fenómenos específicos de enfermería, y surgen y reflejan tanto la práctica como los procesos clínicos. son sustantivamente específicas, se limitan a fenómenos del mundo real, manejan un número limitado de conceptos concretos que están definidos operativamente y de proposiciones que dejan apreciar con claridad sus relaciones, lo que permite, con relativa sencillez, la prueba empírica (23, 25, 35-37), y de acuerdo con nuestra experiencia práctica utilizan un lenguaje coloquial que se ajusta perfectamente a la comprensión y las necesidades de enfermería. concretamente, la trm es verificable a través de la prueba hipotética, y permite generalizar propuestas para el trabajo con ciertos fenómenos de enfermería (8, 38, 39). dentro de esta categoría se pueden incluir las llamadas teorías clínicas, las teorías prácticas y las microteorías, que aunque algunos autores las caracterizan de manera independiente, en verdad no presentan características tan diferenciadas que ameriten un análisis particular. b. teoría propia y teoría prestada el otro aspecto que llama la atención sobre el desarrollo teórico es el falso dilema sobre si enfermería trabaja con teoría propia o con teoría prestada, y el significado de esta diferencia para el desarrollo de la disciplina. estos planteamientos se relacionan con dos aspectos, primero si consideramos que enfermería es una ciencia, y segundo si la teoría es de enfermería o para enfermería, hecho que está íntimamente ligado con el anterior. la terminología de la teoría de enfermería ha sido algo problemática, como puede derivarse de la literatura respectiva. los conceptos utilizados se han manejado de forma indiscriminada, y tal vez sea ésta una de las razones para que se haya generado dificultad para su comprensión y utilización, hasta llegar a extremos de descartarla totalmente en el trabajo científico. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007168 comenzaremos afirmando que, sin duda, enfermería es una disciplina (2, 3, 8, 9, 11, 13, 22, 24, 26, 27, 40), y que consecuentemente ésta abarca el conocimiento delimitado por el metaparadigma disciplinar. ese conocimiento está conformado, en esencia, por la teoría, materia de nuestra discusión, y por la ciencia de enfermería derivada de los hallazgos sistemáticos de la indagación científica. teoría propia o teoría prestada: esta discusión ha perdurado en nuestro medio, hasta el presente, en el sentido de si enfermería debe utilizar solamente teoría propia o debe usar a su vez teoría de otras disciplinas. johnson (41) explica que este dilema se puede enfocar desde dos puntos de vista, el tipo de conocimiento que requiere la práctica disciplinar, la disponibilidad de conocimiento que tiene enfermería para suplir esta necesidad, y la producción o el enfoque de los fenómenos de los productos de la indagación científica. es decir, que siendo enfermería una disciplina que lidia con la complejidad de los seres humanos, es difícil pensar en que, dada su juventud teórica, podremos satisfacernos con la teoría planteada por enfermería, con exclusividad. lo referente a los productos de indagación radica en el tipo de preguntas que queremos respondernos con la investigación y, en este sentido, la determinación de los fenómenos permitirá mirar el conocimiento con frescura, originalidad y creatividad, para así llegar a aumentar los planteamientos teóricos requeridos. en fin, es difícil imaginar el conocimiento y la teoría de enfermería totalmente apartados de los conocimientos de las ciencias biológicas, sociales y humanas, pero también es difícil imaginar que sin teoría propuesta por enfermería se puedan responder las inquietudes de la práctica, con lo cual el conocimiento estaría incompleto y nunca llegaríamos a generar una práctica disciplinar autónoma que esté respaldada por una teoría que clarifique los cuestionamientos surgidos de ésta. siguiendo este orden de ideas, no sería apresurado pensar que el conocimiento generado a partir de teorías prestadas ha evolucionado porque finalmente éste se utilizó en el contexto propio de la disciplina de enfermería y por ello lo prestado, eventualmente se cambia y reajusta a la necesidad disciplinar porque se utiliza de manera única y específica para sus requerimientos existentes (42). en última instancia tenemos que recordar que el conocimiento es universal, y que si bien existen barreras artificiales que delimitan espacios y definen los ámbitos de las disciplinas, cada vez la interdisciplinariedad y la naturaleza de los problemas que debemos resolver nos invitan a mirar al conocimiento como un bien compartido ya que la verdadera diferencia entre disciplinas radica no tanto en los problemas que indagamos, sino en cómo los interpretamos, los resolvemos, y en los instrumentos y métodos que utilizamos para alcanzar las respuestas. con referencia a si la teoría es de enfermería o para enfermería barrett (43) comenta sobre este hecho y sugiere que el asunto está relacionado con la manera como comprendamos la posición de enfermería en cuanto a si es una ciencia básica o una ciencia aplicada. �de � significa que el conocimiento, o desarrollo teórico es original de la disciplina y describe la singularidad del fenómeno de enfermería. así mismo, implica el surgimiento de nuevo conocimiento derivado de enfermería. �para � significa que el desarrollo teórico es una síntesis de conocimiento de varias disciplinas y se aplica en la práctica de enfermería. es decir, que el conocimiento ya estaba desarrollado con anterioridad y ahora lo utiliza enfermería. pero el elemento crítico se centra en si enfermería se percibe como una ciencia básica cuyo núcleo está exclusivamente definido para enfermería, o por el contrario es una ciencia aplicada que utiliza el conocimiento, sea éste cual fuere, para sustentar la práctica. las teóricas del paradigma de la simultaneidad, entre ellas rogers (26, 27), parse (31, 44), newman (30) y watson (46), representan la teoría del �de �. definen enfermería como una ciencia básica asentada en el conocimiento de los seres humanos unitarios, irreducibles, en total compenetración con su ambiente (un todo único e inseparable) y, como señala rogers (45), la teoría del �de � es un conocimiento totalmente emergente, un nuevo producto, lo cual genera a su vez, otro lenguaje, diferente al de las ciencias biomédicas, y esto es importante porque como sugiere watson (46), sin un lenguaje propio somos invisibles como disciplina y enfermería seguirá percibida como una práctica derivada de las ciencias médicas y sociales con un perfil totalmente indiferenciado. dos teóricas del paradigma de la totalidad, roy y orem, están de acuerdo con la teoría �de � aunque su terminología difiere un tanto de las mencionadas anteriormente (43). esto demuestra que el hecho �de-para � no es exclusivamente paradigmático; más bien, que la idea es transversal y se maneja en los dos paradigmas. aún así hay teóricas del paradigma de la totalidad que mantienen la idea de la teoría �para �, esta posición nació a partir de la el modelo conceptual de enfermería es la expresión de la entidad teórica de mayor abstracción dentro de la jerarquía del conocimiento de enfermería. la función del modelo es expresar, a través de conceptos y proposiciones, de una manera amplia, un fenómeno de interés para enfermería. teoría de enfermería ¿un camino de herradura? 169 propuesta de que la teoría prestada, una vez utilizada y reformulada para solucionar los problemas de enfermería, conduciría a nuevos conceptos y teorías de enfermería (41, 47). a pesar de las diferencias de epistemología y ontología de las dos visiones, está claro que las teóricas del �de y para� están identificadas con la importancia de la ciencia y el conocimiento de enfermería, y con la necesidad de que la disciplina tenga su diferenciación propia y particular; aunque como se puede esperar, las diferencias persisten, no sólo para la práctica, sino para la indagación. nuestro deber es contribuir al logro de esta meta aunque es imposible y poco deseable unificar el pensamiento general de enfermería. c. surgimiento de la teoría de rango medio (trm) y la teoría práctica el tercer elemento de esta revisión tiene que ver con la teoría de rango medio (trm) y la práctica, que ya fueron comentadas parcialmente. pero, ¿por qué dedicar un espacio a la trm? sin duda alguna los modelos conceptuales y las teorías fueron piedra angular para el futuro de la teoría; jugaron y continúan jugando un papel definitivo en el proceso de pensamiento y desarrollo teórico de enfermería ya que generaron y reforzaron la identidad profesional de la disciplina. así mismo, se consideran como los elementos disciplinares que dieron nacimiento a la teoría. y existen numerosas teorías de menor amplitud que se han derivado de los modelos conceptuales y las grandes teorías, pero en gran parte del medio de enfermería ha existido cierta resistencia para su utilización. la primera razón, que es poco válida y que es imposible referir por ausencia de literatura pertinente, toca con expresiones como las siguientes: �los modelos conceptuales y las teorías no se pueden aplicar en la práctica porque son muy confusos�, o �utilizan lenguaje sofisticado que no es comprensible�, o �son muy abstractos y no es posible operacionalizarlos con facilidad�� y en nuestro medio, en especial, porque se asegura que �con tanto paciente es imposible aplicar un modelo o teoría�. estas razones son totalmente inválidas, pero hasta cierto punto no se pueden ignorar porque tal vez han sido una oportunidad para la generación y el éxito de las trm, como veremos a continuación. la trm tuvo su origen en la sociología, y fue el trabajo de robert merton (1968) el que facilitó su desarrollo al hacer una diferenciación entre la gran teoría y la trm en términos de bajo nivel de abstracción, alcance relativo, y utilización y caracterización concretas, y probabilidad de prueba hipotética. es decir, que la trm sobrepasa las posibilidades de la descripción y explicación pudiendo llegar a proponer teorías productoras de situaciones, o sea teorías prescriptivas. pero la esencia de la trm radica en la posibilidad de sus fundamentos empíricos de relacionarse a través de codificaciones objetivas (21, 46-48). consistentemente con lo planteado, enfermería ha determinado las características de la trm como sigue: 1. limitada amplitud, ya que aunque suficientemente general dado que los fenómenos de interés se pueden utilizar en múltiples situaciones, ofrece acceso a la solución de problemas clínicos de forma deliberativa y fácil de comprender (49). 2. relacionadas con fenómenos concretos y específicos, pero que atraviesan de manera transversal numerosos fenómenos de enfermería. esta característica se relaciona con la anterior, y los ejemplos facilitan apreciar su significado. la teoría de síntomas desagradables de lenz y cols. (23, 50) tiene que ver con síntomas como el dolor, la disnea, la fatiga y la náusea. estos síntomas pueden aparecer en numerosas situaciones, con pacientes de cualquier edad. es decir, la teoría es útil para solucionar numerosos problemas de la práctica y como referente para la investigación. la teoría de la incertidumbre (51, 52) de mishel, la cual se presentó inicialmente como �incertidumbre ante la enfermedad crónica�, y posteriormente se planteó para situaciones agudas. esta nueva posibilidad permitió utilizar la teoría en múltiples circunstancias, que, como se señala en esta segunda característica, puede trabajarse transversalmente. 3. compuestas por pocos conceptos y proposiciones. esta característica va de la mano con la sencillez de la teoría. el número de conceptos facilita la comprensión y operacionalización de éstos, y genera proposiciones que son susceptibles de llevarse a la prueba empírica. esta característica es muy importante porque a partir de ella se puede generar la teoría productora de situaciones o teoría prescriptiva ya que el limitado número de proposiciones conduce a una capacidad de control muy superior que con las descripciones complejas que se suceden cuando existen numerosos conceptos imposibles de delimitar con indicadores empíricos y, por tanto, muy difíciles de observar empíricamente. así mismo, esta característica hace que la estructura de la teoría sea mucho más fácil de comprender y se comporte con agilidad. el otro aspecto que llama la atención sobre el desarrollo teórico es el falso dilema sobre si enfermería trabaja con teoría propia o con teoría prestada, y el significado de esta diferencia para el desarrollo de la disciplina. aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007170 4. apropiadas para la prueba empírica, sin ser meras consideraciones empíricas. 5. aplicables directamente en la práctica e investigación. estas dos características se derivan de tres anteriores descripciones, porque gracias a la facilidad de manejo de la trm es utilizable en la práctica dando forma a varias expresiones de ésta como son intervenciones a partir de diagnósticos, elaboración de guías y protocolos clínicos, definición de estándares de cuidado y otros indicadores empíricos que expresan las características de la práctica. de la misma forma, en la investigación son útiles como marcos teóricos y de referencia, por la facilidad de articulación con indicadores empíricos, bien sean éstos derivados de esquemas cualitativos o cuantitativos. 6. manejan lenguaje genérico utilizado en la práctica. ejemplo de esto son los títulos de algunas teorías: síntomas desagradables, incertidumbre, afrontamiento, transiciones, tristeza crónica, dolor agudo y efectos colaterales. como se puede ver, ésta es la terminología del diario vivir de la práctica, es la que utilizamos cuando cuidamos, es comprensible para todas las enfermeras. estos atributos son atractivos para las enfermeras investiga doras y clínicas, quienes ven en las tmr una herramienta útil y sencilla que responde a sus necesidades disciplinares. al contrario de los modelos conceptuales que, como se dijo, son descripciones amplias que dan una perspectiva a enfermería, las teorías de mediano rango tienen fuentes un tanto más concretas, y sin duda se puede asegurar que provienen, en su mayoría, de la combinación de la práctica y la investigación (53, 54). ¿cómo se generan las tmr? lenz (1996), citada por liher y smith (49) identificó, en un análisis del estado del arte de las 22 tmr existentes a la fecha, seis estrategias disciplinares que describen los métodos que se utilizan en la generación de tmr. las estrategias no son mutuamente excluyentes porque en numerosas ocasiones las teóricas usan más de un método para desarrollar sus planteamientos. la primera estrategia es inductiva y se soporta en resultados de investigación. la segunda es deductiva y deriva la teoría de guías de la práctica clínica. estos dos recursos, investigación y práctica, son los más comunes para el desarrollo de la tmr. los resultados de la investigación de teoría fundamentada y de otros métodos cualitativos interpretativos son recursos para la generación de la teoría. ejemplo de ello son: la teoría de cuidado de la mujer (55), promoción del autocuidado (56), depresión posparto (57). las teóricas reportan la combinación de resultados de investigación y revisión de literatura; el análisis y la síntesis de conceptos y otras técnicas para el desarrollo teórico, tal como lo llevaron a cabo en 2000 con la teoría de transiciones (58). lenz y cols., 1995 y 1997 (23, 52), utilizaron observaciones de la práctica, en primera instancia, para el desarrollo de la teoría de síntomas desagradables y posteriormente utilizaron resultados de investigación. igual estrategia utilizó good (59) al proponer la teoría del manejo del dolor agudo. la tercera estrategia es la derivación de un modelo conceptual o una gran teoría. dada la dificultad que existe de trabajar el modelo conceptual o la gran teoría como un todo, en la prueba empírica e investigación se ha sugerido el desarrollo de tmr derivadas de ellos. la forma como opera esta estrategia es la siguiente: se mantienen los supuestos del modelo o gran teoría que son pertinentes a la tmr propuesta, se seleccionan conceptos y proposiciones manteniendo coherencia a partir del análisis y la síntesis de conceptos para la teoría en desarrollo, y se crea una estructura diferente. ejemplos son la teoría de expresión de empatía (60) que se deriva del modelo de orlando, la de autocuidado para indigentes (61) derivada del modelo de orem, y la prevención como intervención (62) basada en el modelo de neuman, entre otras. otros modelos que han gestado tmr son el de rogers, newman, roy (57-63). la cuarta estrategia es una combinación de teorías de enfermería y de otras disciplinas. esta tmr se desarrolla combinando conceptos o elementos de múltiples teorías. (64) utilizó elementos de rogers complementados con conceptos de la psicología del desarrollo de piaget y fagin, para la teoría de autotrascendencia. otro ejemplo es la teoría de dunn (65) de adaptación al dolor crónico. utilizó conceptos de lazarus y folkman, benson y wilson, y del modelo conceptual de adaptación de roy. la estrategia número cinco es derivar la teoría de teorías de otras disciplinas. las disciplinas que más ha utilizado enfermería para tal efecto son las ciencias del comportamiento (psicología, sociología y antropología). ejemplo de la estrategia lo presentan la teoría de comodidad de (66), ya que la autora reporta utilización de conceptos derivados de revisiones de literatura de medicina, psiquiatría, ergonomía y psicología, además de enfermería; la incertidumbre de (67), quien reporta inclusión de aspectos de la siendo enfermería una disciplina que lidia con la complejidad de los seres humanos, es difícil pensar en que, dada su juventud teórica, podremos satisfacernos con la teoría planteada por enfermería, con exclusividad. teoría de enfermería ¿un camino de herradura? 171 teoría de caos, y mercer quien utilizó la teoría de roles para plantear la tmr5 de rol maternal (68). finalmente, la sexta estrategia propone sintetizar la teoría de resultados de investigación, pero aparentemente esta categoría se puede agrupar con las números uno y dos, ya que es casi imposible pensar en tmr de enfermería que no esté ligada a la práctica de alguna forma ya sea ésta presentada como hechos y situaciones particulares, o como estándares, guías, protocolos de cuidado, entre otros. como se puede apreciar, la tmr es la herramienta adecuada para sustentar las intervenciones de cuidado de enfermería ya que genera explicaciones sobre el porqué de los fenómenos íntimamente ligados al quehacer cotidiano de enfermería (69), e igualmente da respuesta al planeamiento del mismo cuando se trabaja con una perspectiva profesional basada en un modelo conceptual o una gran teoría. se debe aclarar que cuando se da este enlace entre utilización de modelo o gran teoría con la tmr es indispensable tener la certeza de que tanto la una como la otra se ubican en la misma visión de enfermería. de otra forma se rompería con una estructura mental organizada que da sentido a la práctica. este manejo debe sustentarse de forma analítica, y es posible de llevar a cabo ya que las presentaciones de las tmr permiten, con facilidad, a través de los supuestos que las respaldan y de un análisis evaluativo, hacer la ubicación pertinente. por ejemplo, el modelo de adaptación de roy (24) que se ubica en la visión del mundo de enfermería de la reciprocidad o interactiva-integrativa es compatible con la tmr de incertidumbre de mishel (53, 54), o el modelo de los seres humanos unitarios de rogers (26, 27), que ese ubica en la visión de simultaneidad o unitaria transformativa, es compatible con la teoría de autotrascendencia de reed. la teoría práctica, como se dijo anteriormente, se puede considerar una trm. sin embargo, es una teoría mucho más concreta, que interpreta la realidad de una forma rígida y limitada, por ello su amplitud y abstracción giran dentro de límites predeterminados. no se puede utilizar transversalmente como la trm porque está ligada a poblaciones muy especiales o a determinado campo de la práctica. la estructura es lineal y sencilla. los conceptos se operacionalizan fácilmente y las proposiciones permiten ver con claridad las relaciones lo que conduce a una prueba empírica relativamente sencilla. las fuentes que dan origen a la teoría práctica son las grandes teorías o las trm y la práctica, naturalmente. se podría sugerir que la teoría práctica tiende a convertirse en una microteoría, que es el nivel de teoría de más baja abstracción, y muchos académicos la definen como un grupo de proposiciones o hipótesis (70). la simplicidad de estas teorías no nos debe confundir ya que son instrumentos muy valiosos para respondernos ciertas cuestiones. permiten, por ejemplo, probar relaciones de proposiciones de trm, identificar situaciones concretas como el cuidado de un determinado catéter o una úlcera por decúbito, y juzgar a priori o de forma proactiva circunstancias previsibles para el cuidado de cualquier tipo de paciente o persona que requiera cuidado de enfermería. sería imposible mencionar en esta revisión todas las posibilidades y combinaciones de que disponemos en la actualidad para transformar nuestra práctica en una práctica diferenciada, creativa y autónoma que resuelva los problemas del cuidado de los pacientes. esta es una invitación a reflexionar sobre lo que podemos crear para nuestro futuro y sobre la riqueza con que contamos en la actualidad y que podemos generar en el mediano plazo para garantizar el cuidado de calidad. si respondemos que sí a la invitación nos estaríamos contestando la pregunta introductoria de esta revisión, es decir, que en el mediano plazo, utilizando nuestro conocimiento teórico, podríamos dar respuestas más asertivas a las inquietudes sobre el liderazgo que debe mantener enfermería relacionado con el cuidado y la promoción de la salud de la gente que cuidamos. las trm se deben utilizar con amabilidad y amigablemente. si pensamos que podemos avanzar en la idea de la práctica descrita en el párrafo anterior, debemos dejar de lado las discusiones retóricas y centrarnos en la idea de generar conocimiento que resuelva los vacíos de la práctica disciplinar a partir de condiciones que para nosotras están dadas, ya que nuestra enfermería está en capacidad de aportar a esta meta porque su desarrollo académico es suficiente para lograrlo. para reforzar esta posición citaré el comentario de fawcett (71), cuando cita a jean watson (1997) al referirse a la práctica de enfermería: si no deseamos continuar con una práctica de enfermería qua6 médica sino con práctica qua enfermería, nuestra práctica debe basarse en conocimiento desarrollado por sus integrantes y no en conocimiento desarrollado por una maza disciplinar ajena e indiscriminada respecto al interés propio. este conocimiento propio se evidencia con los modelos conceptuales, con más de 50 trm derivadas de sólo siete de esos modelos conceptuales, y muchas otras más teorías de rango medio que han sido desarrolladas por enfermeras. el conocimiento de enfermería abarca patrones de conocimiento que nos explican a través de teorías de rango medio empíricas, éticas, estéticas, sociopolíticas y personales cómo es nuestro mundo y cuáles son nuestros fenómenos de interés. podemos preguntarnos ¿cómo sería el mundo de la salud si enfermería dejara de desarrollar actividades de enfermería qua medicina y se dedicara a lo propio de la práctica disciplinar del cuidado desarrollando una práctica de enfermería qua enfermería? la respuesta la tenemos todas nosotras y en nuestras manos está lograr la utopía. 5 teoría de rango medio 6 característica de, capacidad de, cómo. aquichan issn 1657-5997 año 7 vol. 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56: 97-99. aspects of palliative care nursing in the time of covid-19 editorial aspects of palliative care nursing in the time of covid-19 aspectos de la enfermería en cuidados paliativos en los tiempos de la covid-19 aspectos da enfermagem em cuidados paliativos no contexto da covid-19 10.5294/aqui.2021.21.1.1 clare butt1 1 0000-0002-0214-0379 . sisters of the holy family of nazareth, united states of america. cmbutt@holyfamily.edu keywords (source decs): coronavirus infections; pandemic; stress; physiological stress; hospice and palliative care nursing; quality of life. palabras clave (fuente decs): infecciones por coronavirus; pandemias; estrés; estrés fisiológico; enfermería de cuidados paliativos al final de la vida; calidad de vida. palavras-chave (fonte decs): infecções por coronavirus; pandemias; estresse; estresse fisiológico; enfermagem de cuidados paliativos na terminalidade da vida; qualidade de vida. para citar este editorial / to reference this editorial / para citar este editorial : butt c. aspects of palliative care nursing in the time of covid-19. aquichan, 2021;21(1):e2111. doi: https://doi.org/10.5294/aqui.2021.21.1.1 in this time of a global pandemic, the care of seriously ill patients falls heavily on nurses. joined with their colleagues in the interdisciplinary team, nurses have the difficult task of providing care in an altered environment. the provision of holistic care is a challenge due to limited time and resources; families may not be able to visit their loved ones, and quality of life suffers for both the patient and the family. perhaps as never before, the provision of palliative care is highlighted as essential. additionally, despite enormous stress, nurses can continue caring for others only when they take the time to care for themselves. care for patients with covid-19 during this global pandemic, the care of seriously ill patients and loved ones who cannot be present falls more heavily on nurses than on other healthcare workers. the increased volume and acuity of patients in hospitals and other healthcare settings have been unprecedented during the coronavirus pandemic. even for seasoned nurses, caring for ventilated patients suffering from blood clots and other complications is challenging. in addition, patients require multiple medications, which change as the science advances quickly, and families may not be permitted to visit their loved ones. as a consequence, nurses may be overcome with grief due to the loss of patients, family members, and even fellow nurses. according to the world health organization, around 14% of covid-19 cases reported to who are among healthcare workers (1). how do nurse educators and administrators prepare nurses to not only survive but also to remain compassionate in this environment? palliative care skills may be the key. palliative care according to the world health organization (2), “palliative care is an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life-threatening illness. it prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual.” palliative care skills can be taught to nurses in order to address the pressing needs of patients and families precipitated by the coronavirus pandemic. rosa et al. state, “palliative care—now more than ever—should be integrated into mainstream health care delivery and further upstream in the illness process to ensure all frontline providers have a degree of comfort managing symptoms, communicating empathically, and guiding important care discussions in a time of high stress and uncertainty” (3 p 262). palliative care is holistic     “since palliative care is holistic in nature, it is provided by a team of physicians, advanced practice registered nurses, physician assistants, nurses, social workers, and chaplains” (4, p1685). because nurses have the difficult task of providing care in the altered environment of the pandemic, the palliative care skills of addressing physical, psychosocial, and spiritual needs are essential. palliative care skills include addressing physical symptoms, such as pain and nausea; psychosocial symptoms, such as anxiety and delirium; spiritual symptoms, such as moral distress and communication difficulties; and end-of-life symptoms, such as dyspnea and terminal secretions. while the provision of holistic care is a challenge due to limited time and resources, palliative care skills can assist nurses in addressing patient and family needs more effectively and efficiently. palliative care focuses on the patient and the family at a time when families may not be able to visit their loved ones, palliative care skills offer ways to address the needs of both the patient and the family (4). besides focusing on assessing and managing pain and other patient symptoms, palliative care skills help nurses assess and support families and coordinate communication, even remotely during these times. nurses can work closely with other team members to ensure a continuous dialogue with family members, including timely updates about the patient’s condition and assessing how the family is coping with separation and grief. this can help build trust, improve communication, and minimize family distress. palliative care improves quality of life during the pandemic, quality of life is compromised for both the patient and the family. through early integration into the care of the seriously ill patient, nurses can use palliative care skills to improve the quality of life for both the patient and the family by preventing and relieving suffering. with a comprehensive assessment, the nurse can develop and implement a care plan that respects patient and family values, goals, and beliefs, assuring the best quality of life for patients and their families. when the time comes for end-of-life patient care, palliative care nursing skills are especially needed. according to dobratz, “psychological adaptation in death and dying is using spiritual and social resources, and managing physical symptoms to maintain self-integration” (5), p373). the author names three theoretical assumptions for psychological adaptation at the end-of-life. psychological adaptation in death and dying is 1) influenced by pain and physical function; 2) promoted by connecting to supportive others, and 3) influenced by spirituality. therefore, the palliative care skills of nurses are valuable in supporting quality of life when death is near. nurses need to care for themselves during the covid-19 crisis there are consequences to the stress and trauma experienced by nurses when caring for patients and families during the coronavirus pandemic. in addition to acute care settings, palliative care may be delivered in patient homes and other community settings (4). the world health organization reports that “the pandemic has placed extraordinary levels of psychological stress on health workers exposed to high-demand settings for long hours, living in constant fear of disease exposure while separated from family and facing social stigmatization” (1). educators and administrators need to be proactive in providing support to nurses and other healthcare workers because their well-being directly affects the well-being of patients and families. rosa et al. (3) offer some suggestions for nurses during the covid-19 pandemic, focusing on improved education, communication, teamwork, and mental health support. particularly for new or student nurses, they advise training related to the ability to lead goals of care and ethical discussions; knowledge of institutional resources to educate patients/families on various levels of care for the patient, and keeping informed about research related to likely outcomes for patients who test positive for covid-19. may the tireless efforts of all, including educators, administrators, and researchers, work together to support nurses during these unusual times. references 1. world health organization. keep health workers safe to keep patients safe: who. (september 17, 2020) https://www.who.int/news-room/detail/17-09-2020-keep-health-workers-safe-to-keep-patients-safe-who 2. world health organization. palliative care fact sheet. (august 5, 2020). https://www.who.int/news-room/fact-sheets/detail/palliative-care 3. rosa we, gray tf, chow k, davidson pm, dionne-odom jn, karanja v, et al. recommendations to leverage the palliative nursing role during covid-19 and future public health crises. j hosp palliat nurs. 2020;22(4),260-9. doi: https://doi.org/10.1097/njh.0000000000000665 4. ferrel br, twaddle ml, melnick a, meier de. national consensus project clinical practice guidelines for quality palliative care guidelines, 4th edition. j pall med. 2018;21(12);1684-9. doi: https://doi.org/10.1089/jpm.2018.0431 5. dobratz, m. toward development of a middle-range theory of psychological adaptation in death and dying. nurs sci q. 2011;24(4):370-6. doi: https://doi.org/10.1177/0894318411419212 home 08 significado del cuidado.indd 97 significado del cuidado de si y de su hijo por nacer en gestantes desplazadas maría carmen bernal-roldán1 lucy muñoz de rodríguez2 carmen helena ruiz de cárdenas3 signifi cado del cuidado de si y de su hijo por nacer en gestantes desplazadas recibido: 15 de agosto de 2007 aceptado: 14 de enero de 2008 1 investigadora principal. magíster en docencia. profesora asociada. facultad de enfermería. universidad nacional de colombia. mcbernalr@unal.edu.co 2 coinvestigadora. magíster en enfermería. profesora asociada. facultad de enfermería. universidad nacional de colombia. lucymdero@yahoo.com 3 coinvestigadora. magíster en enfermería. profesora asociada. facultad de enfermería. universidad nacional de colombia. ccruizd@unal.edu.co, maestria_febog@unal.edu.co resumen este estudio forma parte de la línea de investigación cuidado materno perinatal desde la enfermería transcultural, de la facultad de enfermería de la universidad nacional de colombia. tuvo como objetivo general explorar el significado del cuidado de sí y de su hijo por nacer para un grupo de gestantes desplazadas residenciadas en bogotá, a partir de sus propias creencias y prácticas. fue realizado en la capital de la república, en las localidades de suba y cuidad bolívar, en el 2006. es una investigación de tipo cualitativo; el método utilizado fue la etnoenfermería; para el manejo de los datos se aplicó el análisis etnográfico de spradley. la población estuvo compuesta por 12 gestantes, los datos se recolectaron mediante la entrevista individual y grupal, y por observación. se encontró el tema “significado del cuidado de si y de su hijo por nacer en gestantes desplazadas”. dentro de los aprendizajes de este estudio se puede ver cómo estas personas desarrollan gran capacidad de adaptación y realizan prácticas de cuidado para proteger al hijo/a por nacer. palabras clave desplazamiento, embarazo, nutrición prenatal. issn 1657-5997 año 8 vol. 8 nº 1 chía, colombia abril 2008 97-115 98 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 signifi cance of self-care and prenatal care among displaced pregnant women abstract this study is part of maternal and perinatal care based on transcultural nursing, a research project being developed by the nursing faculty at the national university of colombia. broadly speaking, its aim is to explore the significance of self-care and prenatal care for a group of displaced pregnant women living at bogotá, based on their own beliefs and practices. the study was conducted during 2006 in suba and ciudad bolivar, which are two of the largest districts in the nation’s capital. the research is qualitative and uses the ethnonursing method. spradley’s ethnographic analysis was applied for data management. the target group was comprised of 12 pregnant women; data collection was based on personal and group interviews, as well as observation. the focus was on “the significance of self-care and prenatal care among displaced pregnant women”. one of the lessons derived from the study concerns how these women manage to adapt and to find ways to protect and care for their unborn children. key words displacement, pregnancy, prenatal nutrition. signifi cado do cuidado pessoal e do fi lho a nascer nas gestantes deslocadas resumo este estudo faz parte da linha de pesquisa cuidado materno perinatal desde a enfermagem transcultural, da faculdade de enfermagem da universidad nacional de colombia. o seu objetivo geral explora o significado do cuidado pessoal e do filho a nascer em um grupo de gestantes deslocadas viverem na cidade de bogotá, partindo das suas próprias práticas e crenças. esta pesquisa qualitativa foi realizada nas localidades de suba e ciudad bolívar em 2006. o método aplicado foi a etnoenfermagem; no manejo dos dados se utilizou a análise etnográfica de spradley. a população foram 12 gestantes; os dados foram coletados mediante entrevista individual e grupal, e por observação. foi encontrado o tema significado do cuidado pessoal e do filho a nascer nas gestantes deslocadas. entre as aprendizagens deste estudo, pode se ver que estas pessoas desenvolvem grande capacidade de adaptação, de conformismo, e realizam práticas de cuidado para proteger o filho a nascer. palavras-chave deslocamento, gravidez, nutrição prenatal. 99 significado del cuidado de si y de su hijo por nacer en gestantes desplazadas introducción el desplazamiento de personas es un fenómeno alarmante, que tiende a extenderse en todo el territorio nacional. después de sudán y angola, colombia ocupa el tercer lugar como país del mundo con más desplazamientos, siendo los campesinos, los indígenas y los afrodescendientes los más afectados (1). la población en desplazamiento forzado se ha incrementado en nuestro país de manera considerable en la última década, y las consecuencias de esto son la ruptura de las relaciones sociales debido a la destrucción de bienes materiales, la pérdida de vida, la amenaza sobre los individuos y sus familias (2). bogotá tiene las cifras más altas de desplazados del país, quienes pasan muchas dificultades para satisfacer sus necesidades básicas: “seguridad, comida, agua, salud, educación y medio de sustento” (3). se considera gestante desplazada a la mujer víctima de desplazamiento forzado por la situación de conflicto que vive el país y que se encuentra en estado de gestación. en el año 2003 se desplazaron 34.784 familias con 170.434 personas, y un tamaño promedio de familia desplazada de 5,09 (4). el cuidado de enfermería involucra la diversidad, la universalidad y la individualidad, aspectos que se deben tener en cuenta al ofrecer el cuidado a las gestantes desplazadas, quienes en este momento en nuestro país son un grupo poblacional vulnerable desde la salud materno-perinatal. la teoría del cuidado transcultural de leininger concibe al ser humano como un ser social e histórico. por tanto, el hombre se encuentra envuelto en una red de relaciones sociales y situado en un determinado contexto; su comportamiento depende del aprendizaje que él tenga en dicho contexto, es decir, de la cultura en la cual crece y vive. según marriner y raile (5), leininger plantea en su teoría de los cuidados culturales que “la enfermería debe ir más allá de un mero estado de reconocimiento o de apreciación de las diferentes culturas”. se trata de lograr que los conocimientos y la práctica de la enfermería profesional tengan una base cultural, una conceptualización y una planificación basadas en la cultura. la cultura es para ella el conjunto de valores, creencias, normas y estilos de vida característicos de un grupo humano, y que son aprendidos, compartidos, transmitidos de generación en generación, y que guían el pensamiento, las decisiones y las acciones. leininger (6) se refiere al cuidado cultural como: “los valores, creencias y expresiones estructuradas conocidas de una forma cognitiva y que ayudan, apoyan o capacitan a las personas o grupos a mantener su bienestar, mejorar su situación o modo de vida o enfrentarse a la muerte o a sus discapacidades”. según leininger (7), es importante el conocimiento obtenido desde lo émic (punto de vista del nativo o del participante), para identificar los contrastes en relación con la visión étic (punto de vista del profesional). el cuidado de enfermería transcultural se debe ofrecer teniendo en cuenta las diferencias y similitudes culturales de las personas con el objetivo de: 1) preservar aquellos valores, creencias y prácticas que promuevan el bienestar y eviten las enfermedades; 2) acomodar o negociar aquellos valores y prácticas que podrían eventualmente ser mejorados, y 3) reestructurar los valores, las creencias, y 100 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 las prácticas que definitivamente pueden ser perjudiciales para la salud. el cuidado de enfermería, por tanto, debe ser congruente con la cultura de la persona que lo recibe (7). en la literatura se encuentran estudios desde la enfermería transcultural, mas no sobre las gestantes desplazadas; por ejemplo, hao guan liu y jayne f. moore (8), compararon el cuidado perinatal entre mujeres de estados unidos y china, encontrando que las gestantes chinas tienen menos acceso a los servicios de salud calificados y su educación perinatal es limitada. acosta y molano (9), en su investigación realizada a gestantes adolescentes, encontraron que las principales prácticas de autocuidado de ellas para obtener su bienestar y el del hijo por nacer incluyen la alimentación, el bienestar emocional y la asistencia al control prenatal; la mayoría evita levantar objetos pesados y el uso de medicamentos. hernández (10) realizó un estudio cualitativo, con el enfoque de la etnoenfermería de leininger, con gestantes cuyas edades oscilaron entre los 18 y 30 años. de allí surgió el tema “la gestación, proceso de preparación de la mujer para el nacimiento de su hijo/a”, con dos dominios culturales: alistarse para el nacimiento y realizar prácticas alimentarias adecuadas. otros temas necesarios para abordar el manejo de los datos obtenidos en el presente estudio son: el apoyo social –muñoz (11) y pérez (12)– como elemento básico para que la mujer realice el ajuste psicosocial y comportamental durante su gravidez; igualmente lo es la nutrición –universidad de harvard (13) y ortiz (14)–, los cuidados generales que tienen las mujeres durante la gestación: alcázar (15) habla acerca del cuidado de la piel, argueta (16), rodríguez (17) y carranza (18) investigaron sobre prácticas de cuidado de las gestantes con ellas y con sus hijos por nacer, y acerca de la infección urinaria (19). en nuestro medio no se han estudiado las prácticas de cuidado que realizan las gestantes desplazadas con ellas y con sus hijos por nacer durante la gestación, aspecto fundamental para que los profesionales de enfermería ofrezcan un cuidado acorde con la diversidad cultural, por lo cual se hace necesario obtener este conocimiento. objetivo la investigación se realizó con el fin explorar el significado del cuidado de sí y de su hijo por nacer de un grupo de gestantes desplazadas, residenciadas en bogotá, a partir de sus propias creencias y prácticas. método el método usado fue el de la etnoenfermería de leininger (7). el análisis de datos tuvo como base lo expuesto por spradley (20), organizando los dominios (son sólo una categoría de significado), y haciendo uso de las relaciones semánticas; luego se realizó la construcción de las taxonomías, es decir, juntar las categorías (categorías de significado que incluyen otras categorías menores), organizadas sobre la base de una sola relación semántica; el siguiente paso fue el desarrollo del análisis de componentes, haciendo explícitos los atributos o componentes de significado asociados con símbolos culturales; el último paso fue la elaboración de los temas, los cuales implican la síntesis de pensamiento que permite la configuración, el análisis y la interpretación de los hallazgos. en nuestro medio no se han estudiado las prácticas de cuidado que realizan las gestantes desplazadas con ellas y con sus hijos por nacer durante la gestación, aspecto fundamental para que los profesionales de enfermería ofrezcan un cuidado acorde con la diversidad cultural. 101 significado del cuidado de si y de su hijo por nacer en gestantes desplazadas el presente estudio se realizó con la metodología de la etnoenfermería (21), a fin de explorar la perspectiva émica de las participantes, de acuerdo con lo propuesto por leininger (7). los criterios de selección de las participantes fueron: mujeres desplazadas por causa del conflicto armado que vive nuestro país, y que estuvieran en gestación. en total se entrevistaron doce mujeres desplazadas provenientes de los departamentos de atlántico, córdoba, tolima, cundinamarca, caquetá, bolívar, cauca, arauca y guainía. en cuanto al momento de la ocurrencia de la gestación, con relación al desplazamiento, la mitad de ellas, es decir seis, estaban en gestación cuando ocurrió el desplazamiento, y las restantes seis quedaron en gestación luego de que éste sucedió. la muestra fue teórica y se obtuvo por saturación de los datos. como leininger (22) indica, la saturación se alcanza cuando hay una redundancia en la información obtenida. …el muestreo teórico se relaciona con el punto de saturación teórica: un momento donde las observaciones adicionales no conducen a comprensiones adicionales. los datos comienzan a ser repetitivos y no se logran aprehensiones nuevas importantes (23). …cuando el análisis de la información que se desarrolla paralelamente con la recolección de información, no adiciona aspectos o hallazgos y su confrontación con la teoría existente no aporta evidencias adicionales, se dice que se ha llegado a la saturación teórica de la muestra… la muestra la constituye la información que dan los sujetos al investigador… cuando se llega a este punto, se puede decir que hay una saturación de información y que no es necesario buscar más sujetos o ahondar en la información que ya se ha obtenido (24). es importante destacar que, al ser el presente estudio una etnografía focalizada, no se considera que sus resultados puedan ser construcciones universales extrapolables a otros escenarios culturales, sino que deben ser entendidos dentro de los límites temporo-espaciales en que se desarrolló la investigación, y como generadores de hipótesis para otros estudios. la parte ética estuvo enmarcada en la resolución 008430 de 1993 del ministerio de salud, se contó con el aval del comité de ética de la facultad de enfermería de la universidad nacional de colombia, se protegió la privacidad de las informantes escribiendo letras y números para su identificación. esta investigación se consideró sin riesgo, sin intervenciones de tipo biológico, fisiológico, psicológico ni social. para la recolección de la información, previa firma del consentimiento informado, se realizó una entrevista no estructurada a profundidad, la cual fue grabada en casete de audio; se tomaron notas de campo, y se realizó la trascripción de la información. las entrevistas a las mujeres se desarrollaron en su medio natural, es decir, en el barrio donde vivían. inicialmente, y como una forma de acercamiento, se hicieron preguntas generales relacionadas con la edad, la ocupación, la escolaridad, el tiempo de residencia en el barrio y el lugar de origen. hubo dos formas de abordaje para la recolección de los datos: una primera fue la entrevista individual (cuatro participantes) a cada gestante desplazada –en sus respectivos sitios de vivienda, en la localidad de suba–, y la segunda fue el grupo focal (reunión de ocho personas, en un comelos criterios de selección de las participantes fueron: mujeres desplazadas por causa del conflicto armado que vive nuestro país, y que estuvieran en gestación. 102 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 dor comunitario no gubernamental de la localidad de ciudad bolívar). esta última se aplicó debido a la dificultad de ubicar gestantes desplazadas por la gran movilidad de su sitio de vivienda. análisis de los datos y resultados el análisis de los datos se hizo desde el inicio de la recolección de la información. los datos se presentaron a las informantes en las diferentes fases, con el fin de asegurar que lo escrito e interpretado correspondía a la visión que ellas tenían del fenómeno en estudio. tema: el surgimiento de la esperanza en medio de la dificultad del desplazamiento de la gestante: el camino por seguir. explorar el significado de cuidado en estas mujeres fue difícil por cuanto surgió en ellas la necesidad de expresar sus vivencias alrededor del desplazamiento o de la situación que experimentaron entorno del mismo. sin embargo, se encuentra que estas mujeres sienten la necesidad de proteger a ese hijo por nacer y se empeñan en hacerlo con coraje, de tal manera que viven la gestación con deseos de que el hijo nazca bien, y sienten satisfacción de estar en gestación, con la esperanza de que todo salga bien y de que algún día se van a mejorar las cosas. el camino por seguir una vez sucedido el hecho que generó el desplazamiento, y conscientes de que no pueden volver a su sitio de procedencia, porque corre peligro la vida de ellas y de sus seres queridos, las gestantes comienzan un proceso de transición hacia una nueva vida que no saben cuál será. pero el hecho es sobrevivir adaptándose a lo que el día a día les traiga “por la misericordia de dios”, buscando compañero o un embarazo, la limosna, o lo que cualquier persona les pueda ofrecer, o “aprender algo, lo que sea”. a pesar de que el desplazamiento es devastador, llama la tención que aparecen testimonios sobre cómo afrontar esta situación. las gestantes desplazadas comienzan un proceso de adaptación a la ciudad, reportado en algunas de ellas con el “tener amigos, salir, aceptar toda ayuda, agradecer a dios porque no les falta el pan”, aspectos estos que les permiten afrontar el desplazamiento de manera positiva ante esta nueva y difícil circunstancia de la vida. por otra parte, el vivir en bogotá les genera un cambio de costumbres en cuanto a las comidas, a estar más limpias, a sentir que tienen tranquilidad, y que todo es más bonito y limpio. las participantes tienen diversas formas de obtener recursos, entre otros, el contar con el apoyo de personas de su mismo pueblo y de familiares quienes les proveen algo de alimentación y vestido, realizar trabajos informales y coser a mano la ropa del bebé. además, buscan la ayuda de las organizaciones que atienden desplazados, donde obtienen beneficios por un periodo de tres meses en cuanto a mercado, elementos de cocina y de habitación. expresan lo que consideran forma parte de una adecuada alimentación como desayunar bien, comer huevos, granos, verduras, carnes y disminuir el consumo del arroz, lo cual tratan de suplir de acuerdo con los recursos que hayan obtenido. otro aspecto que se debe resaltar en el camino de este grupo de gestantes es estas mujeres sienten la necesidad de proteger a ese hijo por nacer y se empeñan en hacerlo con coraje, de tal manera que viven la gestación con deseos de que el hijo nazca bien, y sienten satisfacción de estar en gestación. 103 significado del cuidado de si y de su hijo por nacer en gestantes desplazadas el acceso oportuno al control prenatal, para lo cual deben contar con una carta que certifique su estado de desplazadas, condición que algunas no cumplen por la falta del documento de identidad. cuando obtienen la atención de salud, las mujeres resaltan la importancia de lo obtenido en cuanto a educación alrededor del cuidado del embarazo como hablar al bebé, la lactancia, la realización de exámenes de laboratorio, la toma de la ecografía y el acceso a consulta odontológica. destacan la importancia de la información sobre el estado de salud del hijo por nacer con expresiones como “que el líquido amniótico esté bien, que el ritmo cardiaco esté bien”. durante la gestación, las desplazadas aprenden que el no comer y el bajar de peso son característicos de un cuidado deficiente con ellas mismas; a la vez realizan cuidados para proteger a su hijo de situaciones tales como que “se enferme de frío o se congele”; se cuidan de no realizar trabajos que impliquen “levantar cosas pesadas o tener caídas, usar ropa cómoda”; para protegerse de infecciones vaginales consideran importante que el esposo “las respete, usar óvulos vaginales”; no les gusta el agua de bogotá, procuran mantenerse asedas, buscan formas de sentirse queridas, procuran evitar las estrías, algunas han dejado los estudios porque “se van las luces”, comen cuando sienten “gastritis”, realizan actividades para comunicarse con el bebé como por ejemplo “cogerse la barriga, hablarle al bebé, ponerle música, darle besitos a la barriga”, y se tratan de cuidar en la alimentación para que “el bebé nazca grande, gordo y sano”. como vemos, el desplazamiento forzado exige el despliegue de capacidades y potencialidades disponibles en quienes lo sufren. esa actitud dirigida a la sobrevivencia generalmente conlleva diferentes manifestaciones de proyección en la vida de las personas, desde donde surgen alternativas de vida y posibilidades de reestabilización definitivas, con perspectivas de mejorar las condiciones de vida… (25) ahora bien, en el sitio de su nuevo asentamiento, al iniciar el proceso de reconstrucción de la vida cotidiana en el sitio de desplazamiento, las mujeres desplazadas muestran gran flexibilidad al asumir labores de rebusque, son recursivas y pueden apoyarse en su larga experiencia de trabajo doméstico, ahora un recurso vendible. tejen con habilidad y menos prevención, un nuevo entorno social de reciprocidad y solidaridad al nivel de las relaciones cercanas. en todos estos sentidos y pese a la miseria extrema, pese a la doble jornada, la nostalgia y ese sentirse desplazada, los pequeños avances en la reconstrucción de su vida cotidiana pueden significar otros tantos en la construcción de mayor autonomía que hará más sostenible el cambio de su rol como consecuencia del desplazamiento (26). contar con apoyos. según khan (citado por muñoz) (11), parte del apoyo social es la entrega de ayuda material o simbólica a otra persona, éste se configura en las participantes como la “aceptación por parte de la mamá, la colaboración de los hermanos y de la mamá”. además, consideran importante la colaboración familiar en cuanto a “comprar ropa de maternidad y ropa para el bebé, que el hermano le lleve frutas, la hermana le lleva papas y bombombun”. otra forma de apoyo es “pedir ayuda a dios para que no vaya a tener nada malo, que le ayude mucho, que no le pase nada al bebé, que le ayude en el nacimiento de la niña, que no le toque tan duro”. durante la gestación, las desplazadas aprenden que el no comer y el bajar de peso son característicos de un cuidado deficiente con ellas mismas. 104 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 dominio general. el camino por seguir dominios generales adaptación al desplazamiento obtención de recursos adecuada alimentación acceso oportuno a control prenatal la gestación y su cuidado relación semántica es una manera de afrontar la gestación en el desplazamiento dominio 1. adaptación al desplazamiento las gestantes expresan varias maneras de adaptarse al desplazamiento en la ciudad de bogotá, tales como salir, sentir la ayuda de vecinos, agradecer a dios porque no les falta el pan, y expresan como características del vivir en bogotá el que la ciudad es bonita, ellas están más limpias y sienten gran tranquilidad. es por ello que: las mujeres desplazadas se han constituido en el ejemplo digno, que reconcilia la vida con la subsistencia… es la mujer quien tiene que de inmediato resolver el problema de la seguridad alimentaria, puesto que abastecer a los hijos es para ella cuestión de dignidad. y aquí es donde se desarrolla aún más la capacidad de resiliencia de la mujer para vencer los obstáculos y diversificarse en múltiples papeles, ya sea como aseadora por horas, vendedora en la plaza del barrio, entre otros. o sea que se lanza en el desempeño de oficios que ya no son enteramente de su control, ni con respecto a la tierra ni con respecto a su casa… (27) dominio 1. taxonomía 1: adaptación al desplazamiento (relación semántica: x es la manera de y) parte del desplazamiento forzado implica en estas mujeres cambios sociales como una manera de afrontar de manera positiva su condición; entre ellos está salir, tener amigos, adaptarse a la ciudad, tener personas que les brindan una voz de aliento y ayudas reales, según lo testimonian algunas de ellas: …allá es… por lo menos yo allá no salía, yo no hablaba con nadie, con nadie, en cambio acá como que, por lo menos ya tengo amigos, ya salgo, ya algún lado voy en cambio allá yo… como que uno se adapta es a allá, en cambio acá uno vive es adaptado a la ciudad, a ver más cosas. c2e3 …que me ha llevado a alivianar es la gente de bogotá porque de pronto es una mano amiga, de pronto le hablan, le dicen una palabra de aliento, le dicen a uno que lo que va ha hacer es salir adelante; eso es muy bonito. gfp2 dominio 1. taxonomía 2: adaptación al desplazamiento (relación semántica: x es la razón de y) las características del vivir en bogotá, percibidas por este grupo de gestantes desplazadas como ventajosas son: pues allá, o sea, la niña mía nació en la casa; entonces yo pues a la niña mía tampoco nunca me tocó comprarle nada, ni para mí, en cambio acá… en cambio en el hospital va a haber más, harta gente… c2e2 pues de pronto allá se ve más la leche, los huevitos, así cosas… en cambio acá a veces no se ve eso… c2e2 es la mujer quien tiene que de inmediato resolver el problema de la seguridad alimentaria, puesto que abastecer a los hijos es para ella cuestión de dignidad. 105 significado del cuidado de si y de su hijo por nacer en gestantes desplazadas como el cambio de clima y todo aquí todo es como más limpiecito, más bonito… la tranquilidad sí porque aquí no tengo nada que hacer. c3e1 tranquilidad. mas confiado. c3e2 dominio 2. obtención de recursos las gestantes desplazadas son grandes luchadoras, aprenden a defenderse solas; se las ingenian para buscar medios de supervivencia al llegar a la gran ciudad, y buscan la manera de enfrentar la falta de dinero para sostener a sus hijos recurriendo a trabajos informales como vendedoras de dulces, recicladoras y en servicios domésticos por horas a cambio comida y techo. también recurren a la colaboración de los vecinos y al apoyo de entidades que trabajan en pro de los desplazados. no obstante lo anterior, el empleo informal o subempleo, o la llamada …viveza criolla, ocasiona más daño al tejido social que la desocupación… la generalización de la misma práctica es una verdadera ofensa a la dignidad humana… el ser humano no podrá gozar de un merecido retiro como jubilado. ni que hablar de salario familiar ni de ayuda escolar, mucho menos el tener la cobertura de una obra social, que cubra las necesidades que en materia de salud requiere una familia. se le restringe la posibilidad de acceder al crédito. es un excluido social. pero lo más grave de esta situación lo constituye el compromiso para con las generaciones futuras: deterioro constante de la salud, caída alarmante de los índices de alfabetización, elevada tasa de delincuencia, consumo de drogas y la prostitución, para rematar, con el angustiante estado de inseguridad (28) dominio 2. taxonomía 1. obtención de recursos (relación semántica: x la manera de y) la obtención de alojamiento y comida por medio de compañeros de su pueblo es una manera de sentir apoyo y es expresada así: … ellos me dan aloje acá… a veces que me colaboran con la comida… c4 e1 ...y por eso sé que viene ese mercado, porque ella, cuando le viene así en el mercado, ella siempre viene y me trae algo del mercado que a ella le dan. c4e2. dominio 2. taxonomía 2. obtención de recursos el apoyo familiar en lo concerniente al vestido, al alimento y a la aceptación de la gestación es verbalizado como: …digamos que en la ropita para maternidad, pues mi hermana ya me compró tres camisas grandecitas, mi mamá me compró unas chanclas pues para no usar zapatos altos… mi hermano por las noches que llega de trabajar me trae furtivas: naranja, manzana… mi hermana… me lleva papa, bombombun…mi mamá está pendiente en el día de que coma bien. c1e1 el día que me mandé hacer la prueba de sangre (para embarazo y fue positiva), yo ese mismo día le conté a mi mamá… me dijo que ya lo que había pasado, había pasado… que si quería abortar, que no… porque desde el momento en que el espermatozoide le entra al óvulo, ya eso es vida… que ella me iba a colaborar muchísimo en lo que pudiera, tanto, mis hermanos también… c1e1 las gestantes desplazadas son grandes luchadoras, aprenden a defenderse solas; se las ingenian para buscar medios de supervivencia al llegar a la gran ciudad, y buscan la manera de enfrentar la falta de dinero para sostener a sus hijos recurriendo a trabajos informales. 106 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 dominio 2. taxonomía 3. obtención de recursos (relación semántica: x es la manera de y) diversas manifestaciones revelan las maneras de obtener recursos del trabajo informal, y esperan aprender un oficio para un futuro: …para diciembre una señora me dijo, la señora que vive en el primer piso, me dijo que le ayudara a hacer para regalo y para que le ayudara a vender bolsas de regalo y yo le dije que sí. c1e1 como estar por ejemplo aprendiendo algo para de aquí a mañana cuando uno sale de su embarazo de pronto ya haya aprendido una cosita más y uno se puede desenredar en algo, de pronto trabajar o alguna cosa... aprender a manejar las máquinas, o sea me gusta mucho aprender a manejar las máquinas planas, me fascina la confección todo eso lo que es por ejemplo. aprender la peluquería... algo para un futuro. gfp1 dominio 2. taxonomía 4. obtención de recursos. (relación semántica: x es la forma de y) hacen uso de habilidades como el coser a mano la ropa del bebé: a mí me dice él y ella [compañero y la suegra]… que pues para comprarle bayetillita para hacerle camisitas. pero ayer estuvimos también averiguando el metro de la bayetilla, nos vale $4.000. pero averigüé haber cuánto me cobran por hacerlas y por cada camisa me cobran dos mil, por la hecha de cada camisita me cobran dos mil; entonces me dijo: pues si no, nos va a tocar comprarlas y nosotras mismas, yo le ayudo y nosotras mismas las cosemos (a mano)… e2, c2 dominio 2. taxonomía 5. obtención de recursos (relación semántica: x es la razón de y) hacer oficios domésticos le genera alojamiento y comida: …ellos me dan aloje acá, yo le hago el oficio, bueno lo que yo puedo hacerle; bueno, y ellos a veces que me colaboran con la comida… dominio 2. taxonomía 6. obtención de recursos (relación semántica: x es la manera de y) la importancia de las organizaciones que atienden desplazados se visualiza en: … los mercaditos que nos están dando; ahoritica ya hace un mes que me dieron de la red de emergencia y nos dieron lo de tres meses de arriendo. c2 e3 por parte de opción vida me dieron los tres meses de arriendo y me dan un mercadito y un kit de cocina. ahorita el lunes tengo que ir también y no sé cuándo tengo la segunda entrega que es otro mercadito y un kit de habitación, dan colchonetas… c2 e porque solo son tres que ellos hacen ósea, solo son tres mercados que ellos dan… y ya de pronto a conseguir un trabajito, pues vamos a ver. c3e2 dominio 3. alimentación adecuada las gestantes desplazadas consideran como un pilar fundamental la alimentación adecuada con manifestaciones como el alimentarse bien, y la alimentación después de su desplazamiento; esta última con énfasis en la falta de proteínas. las gestantes desplazadas consideran como un pilar fundamental la alimentación adecuada con manifestaciones como el alimentarse bien, y la alimentación después de su desplazamiento; esta última con énfasis en la falta de proteínas. 107 significado del cuidado de si y de su hijo por nacer en gestantes desplazadas la adecuada alimentación diaria según la pirámide de vida saludable del departamento de salud pública y nutrición de la universidad de harvard incluye el consumo de agua entre 5 a 8 vasos, y en el mismo nivel de la pirámide están los cereales, aceites vegetales de canela, oliva o girasol; en el segundo nivel aparecen los vegetales y las frutas con 3 a 4 porciones; luego las leguminosas con 2 porciones; le siguen el pescado, el huevo y la carne de aves con 1-2 porciones; lácteos bajos en grasas y ricos en calcio con 2-3 porciones, y finalmente en la cúspide de la pirámide, es decir, con la menor proporción, aparecen las carnes rojas, el arroz, la papa, el pan blanco, la pasta y la mantequilla. la alimentación en los desplazados tiene un alto componente de carbohidratos y es baja en proteína animal: cereales, papa/yuca, azúcar y panela (azúcar sin procesar) corresponden a 35% de los gastos alimentarios. la dependencia de carbohidratos como fuente principal de alimento es compensada con el restante 21% de gastos alimentarios, destinados a elementos con contenido proteínico: carne y pescado, huevos, leguminosas (fríjoles y lentejas), leche y queso. no obstante, la alta dependencia de cereales y tubérculos como principales alimentos comprados, indica que la diversidad de alimentos es baja (29). dominio 3. taxonomía 1. adecuada alimentación (relación semántica: x es la característica de y) las participantes expresan como características de alimentarse bien: …alimentarse bien es cocinar y comer las comiditas del día... c3e2 …hay veces desayuno bien, un desayuno nutritivo… por ejemplo a mí mandaron comer una dieta en el cami, que tiene que comer esto, que tiene que comer frutas… yo por ejemplo que tengo una moneda…voy a comprar yo, fruta o algo… c4e1 [buena comida] fríjoles, lentejas, más que todo los granos. c3e2 …dejar de comer arroz… c1e2 dominio 3. taxonomía 2. adecuada alimentación (relación semántica: x es la característica de y) la alimentación luego del desplazamiento presenta características que destacan las gestantes participantes del presente estudio como: no, aquí pues acá, por lo menos ahorita yo hago, yo me levanto a veces, muchas veces aquí no hacemos …, sino agua de panela y pan, y al almuercito se hace arroz, un guisito de papas, así cualquier cosa, y a la comida que caldo, cafecito, así. c2e3 dominio 4. acceso oportuno al control prenatal para estas gestantes, acceder al control del embarazo en el hospital tiene importancia como parte de su cuidado durante esta etapa. sin embargo, éste no llena sus expectativas para sentirse realmente cuidadas. el tener carta de desplazadas es una razón para ser atendidas en el cami; en el mismo sentido, el no tener documento o cédula es la razón para no recibir atención acceder al control del embarazo en el hospital tiene importancia como parte de su cuidado durante esta etapa. sin embargo, éste no llena sus expectativas para sentirse realmente cuidadas. 108 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 de salud; quienes han asistido al control prenatal expresan que el hecho de que les hablen de “lactancia, alimentación, cómo darle pecho al bebé, cómo tomar medicamentos, cómo dormir, prevención del sida”, es una manera de recibir enseñanza de cuidados durante el embarazo. que les realicen pruebas diagnósticas es el resultado de estar inscritas en el cami, y que les informen sobre el resultado de los mismos es una manera de saber que el bebé está bien. dentro de la percepción de las necesidades mínimas para contar con un adecuado cuidado de sí mismas y de sus hijos por nacer las gestantes desplazadas expresan que la atención de salud es un aspecto básico, necesario y prioritario para su salud y la de sus hijos. en el hospital uno va y si no lo ven muriéndose no lo atienden. uno llega a una hora y lo atienden a las dos horas. uno se desmaya; uno es una mujer embarazada, ni lo atienden; que se espere. gf3 la verdad es que le toca a uno hacer mucha fila y a veces no lo atienden. es fila para todo, piden muchas fotocopias. gf3 yo tenía problemas porque me da mucha sed, el doctor dice que es normal, me mandó frutas y verduras, pero si tengo para una cosa, no tengo para la otra. gf1 de otro lado, …el estigma de ser desplazados o desplazadas… frente a los servicios del estado la expresión más material de esa situación es la falta de documento de identidad, el cual se perdió durante el desplazamiento o a cuya posesión nunca se ha accedido [el caso de muchas mujeres campesinas]… (26). según la comisión para el refugio de mujeres y niños: el estatus de la salud reproductiva de las mujeres marginadas en colombia, incluyendo las desplazadas, es más bajo que el del promedio nacional. el 56% de las mujeres desplazadas no recibe atención prenatal, en contraste con 47% de las pertenecientes a grupos marginados: menos atención prenatal durante el embarazo que otras mujeres colombianas en general. (30) dominio 4. taxonomía 1. acceso oportuno al control prenatal (relación semántica: x es la razón de y). una razón para ser atendida en el cami es contar con la carta que las acredita como desplazadas: “…bueno, que me estoy haciendo los controles allá [en el cami], con la carta que me dieron…”. c4e1 dominio 4. taxonomía 2. acceso oportuno al control prenatal (relación semántica: x es la razón de y). a la vez, una razón para no acceder al control prenatal es la falta de documento de identidad: yo no tenía papeles de donde salí; mejor dicho me tocó volver a sacar papeles… me tocó ir hasta allá y sacarlos… hasta …caldas; allá me entregaron los papeles y ay sí poder pasar al médico y me dieron un papel del estrato económico para que yo pueda ir al médico. gfp3 …ahorita estoy sin controles… por parte de la red de suba… me dieron para que fuera a profamilia y ahí me hicieron un control y no me han visto más; y ahorita no tengo papeles porque no he sacala percepción de las necesidades mínimas para contar con un adecuado cuidado de sí mismas y de sus hijos por nacer las gestantes desplazadas expresan que la atención de salud es un aspecto básico, necesario y prioritario para su salud y la de sus hijos. 109 significado del cuidado de si y de su hijo por nacer en gestantes desplazadas do mi cédula, porque no he tenido posibilidades… y no me han querido dar droga y no me han querido atender en el cami; por la cédula (por no tenerla). c2e1 dominio 4. taxonomía 3. acceso oportuno al control prenatal (relación semántica: x es la manera de y). parte del cuidado ofrecido en los controles prenatales es la educación acerca de ciertas situaciones como: el primer control, ahí nos dieron una charla (enfermera)… nos habló de la lactancia, de la alimentación, de cómo uno se debe alimentar, o sea todo así… sus medicinas, cómo darle pecho al bebé, cómo uno debe dormir cuando está en gestación, así en embarazo; qué más, pues ella nos habló sobre el sida, todo eso nos habló ella. c4e1 dominio 4. taxonomía 4. acceso oportuno al control prenatal (relación semántica: x es la manera de y) cuando las gestantes están inscritas en el cami se les realizan exámenes diagnósticos como: “…el cami cubre todo: exámenes, examen, examen, ecografías, examen de seno, odontología; por ahorita visión, todo eso, pero sí me está atendiendo…” c3e1 domino 5. la gestación y su cuidado en general, este grupo de gestantes desplazadas adopta unos cuidados generales para ella y su hijo por nacer; sin embargo, “bajar de peso y dejar de comer” es una forma de no cuidarse durante su gestación. ahora bien, dentro de la diversidad de cuidados que ellas asumen se encuentran el “evitar que les dé frío”, por las consecuencias sobre ella y el bebé: “que se congele y quede como un pedazo de hielo”, para lo cual tienen formas de evitar esto como “bañarse con agua caliente”, “colocarse chaqueta cuando duerme”, “cubrirse bien cuando sale a la calle”; otra manera de cuidarse es “no levantar objetos pesados”, “usar zapatos bajitos”, “evitar caerse al trapear”, “tener alimentos”, “no usar ropa apretada”, “cuidarse de la rabia”, “contar con apoyo espiritual” y “de alguien que la apoye”. se cuidan de tener infecciones vaginales al tener el baño con candado”, “echar agua caliente al inodoro”, “que el esposo la respete” y “usar óvulos vaginales”; tienen razones para no tomar agua en bogotá que “es muy fría y sabe raro”; procuran “bañarse y mantener todo aseado” para que las consideren “limpias a pesar de ser desplazadas”. una forma de sentirse queridas es “quedar en embarazo”; aducen razones para no trabajar porque “no tiene seguro y se puede partir un pie”; suspender el estudio debido a los mareos y recomendación de la mamá y del compañero. una razón para cuidarse es que les den mensajes positivos acerca de su gestación. los cuidados de la piel específicamente para evitar las estrías son “no rascarse” y “aplicar crema en la piel”. usan “zapatos bajitos” debido a que consideran que los “zapatos altos son dañinos”; para evitar el ardor en el estómago consumen “leche y galletas de soda”; las razones para olvidarse de su sobrepeso son que “el bebé va creciendo” y “sentir hambre”. las consecuencias del sobrepeso de las gestantes son que el “bebé nace alterado, con mayor peso del normal y la una forma de sentirse queridas es “quedar en embarazo”; aducen razones para no trabajar porque “no tiene seguro y se puede partir un pie”; suspender el estudio debido a los mareos y recomendación de la mamá y del compañero. una razón para cuidarse es que les den mensajes positivos acerca de su gestación. 110 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 tensión arterial alta en la mamá”. las razones para evitar las relaciones sexuales son “por recomendación médica, para no maltratar y que no sufra el bebé”; que el “bebé se mueva” es una forma de pedir comida a la mamá; que las gestantes se “levanten, desayunen” son formas de hacer que éste se mueva; es común que las gestantes le “hablen al bebé” cuando él se mueve; “cogerse la barriga, poner luz y música” al bebé a través de la pared abdominal son formas de comunicarse con el hijo/a por nacer; “sobarse el estómago y decir al bebé que lo quieren” es una manera de consentir al hijo/a no nacido. que las gestantes tengan buena alimentación, se sientan mejor de ánimo y sin preocupaciones son las razones para que el bebé nazca bien; que el bebé no tenga deformidades en el cuerpo y que sea grandote son características de un bebé sano y fuerte. de acuerdo con los reportes de estudios investigativos en mujeres gestantes de latinoamérica se encontró: • el hecho de usar zapatos bajitos es considerado como una práctica saludable, así lo informa carranza (18) en su estudio sobre prácticas de cuidado de las gestantes, donde 98,3% de ellas usan zapatos de tacón bajo debido a que así se puede evitar la hinchazón de los pies, el dolor de cintura. según argueta (16), 99,2% usan zapatos de tacón bajo. • en cuanto al uso de ropa cómoda, 99,2% la usa así (18). el 97% usa ropa confortable por comodidad, bien del niño, evitar várices y no maltratarse ellas, argueta (16). el 85,4% utiliza ropa que le permite la libertad de movimiento (17). • las gestantes estimulan a los hijos por nacer a través del tacto, de la música y tocando el vientre; el 98,3% no estimula los bebés con la luz; el 50,8% no estimula al bebé por medio del habla (18). el 64% de las gestantes le habla a sus hijos por nacer, y el 47% les coloca música por amor maternal, para que se esté quieto, y para comunicarse con el bebé; ninguna realiza estimulación visual (16). • el 23% de las gestantes levanta objetos pesados por la necesidad de cargar agua y leña; las mujeres que no lo hacen es porque tienen miedo de abortar y lo consideran malo para el embarazo (18). el 75,6% estimula de forma táctil al bebé acariciándolo a través del abdomen, el 43,9% lo estimula con música, y el 55% no hace estímulo visual a sus hijos (17). • el 70,8% de las gestantes se cuida de no tener relaciones sexuales o no tenerlas frecuentemente para no hacer daño al bebé (18). el 86,9% tiene relaciones sexuales con menor frecuencia por temor a ocasionar daños al bebé (16). • el 65,8% pide a dios por su bienestar, el 91% necesita sentirse respetada y el 90% sentirse amada para poderse cuidar (18). el 79,2% necesita sentirse amada, y el 82,3% respetada para cuidarse (16). • el 91% de las gestantes que realiza el baño diario lo hace por costumbre, bienestar de ellas y de sus hijos (16). • las gestantes realizan su baño con agua tibia para evitar que el niño salga frío (10). puede observarse que los datos de estas investigaciones, y los resultados obtenidos en el presente estudio, son muy similares en cuanto al uso de zapalas gestantes estimulan a los hijos por nacer a través del tacto, de la música y tocando el vientre. 111 significado del cuidado de si y de su hijo por nacer en gestantes desplazadas tos bajitos, de ropa cómoda y lo referente a la estimulación de los hijos por nacer, excepto en la parte de estimulación visual que sí es realizada por las gestantes desplazadas; igualmente, todas las gestantes desplazadas y no desplazadas tienen cuidados en las relaciones sexuales; el apoyo social que sienten para cuidarse está presente en las gestantes desplazadas y no desplazadas; la razón del baño diario es diferente en las gestantes desplazadas quienes lo realizan para que los demás las consideren limpias, no por costumbre o bienestar de ellas; el uso de agua tibia durante el baño para evitar el enfriamiento del bebé también está presente en las gestantes desplazadas y no desplazadas. otro cuidado que tienen las gestantes es con su piel, específicamente para “evitar las estrías, las cuales aparecen en 90% de las embarazadas, con predominio en el abdomen” (15). para prevenir las infecciones, especialmente la urinaria, se debería aumentar el consumo de líquidos a fin de realizar el efecto de arrastre (19) de los gérmenes patógenos; sin embargo, las gestantes desplazadas no tienen ese hábito. dominio 5. taxonomía 1. la gestación y su cuidado (relación semántica: x es la manera de y) a pesar de que en general las gestantes tratan de cuidarse durante el embarazo, expresan características de la deficiencia del mismo: …yo sí me estoy cuidando muy mal porque en mis controles en lugar de subir… estoy bajando de peso… he bajado como cinco libras en cuatro días; pasé por urgencias el 25 del mes de septiembre y el control lo tenía el 29; y del 25 al 29 yo había bajado cinco libras, eso es mucho, demasiado… me mandan muchas frutas y verduras pero si uno tiene para una cosa no tiene para la otra… gfp1 dominio 5. taxonomía 2. la gestación y su cuidado las gestantes consideran que las consecuencias de que a ellas les dé frío son: se congela allá dentro y pobrecita… por ejemplo que me levante así sin chaqueta y así descubierta, tengo que mantener con la chaqueta, una chaqueta que tenemos por ahí, que es bastante calientita porque por la mañana aquí hace mucho frío; me cubro bien cuando voy a salir… porque este frío de pronto le hace daño a ella ¿cierto?... que se congela allá dentro y queda como un pedazo de hielo… se enferma o me enfermo yo. nos enfermamos las dos; me da resfriadito; yo creo que eso es el frío, el frío que nos hace daño. c3e2 dominio 5. taxonomía 3. la gestación y su cuidado (relación semántica: ¿??) las gestantes que participaron en el estudio encuentran maneras para evitar que el bebé sienta frío: …me bañé con agua caliente y el agua fría él le da frío y tengo que acostarme con chaquetas y cosas… tengo que mantener con la chaqueta, una chaqueta que tenemos por ahí que es bastante calientita; porque por la mañana aquí hace mucho frío, me cubro bien cuando voy a salir; me pongo… porque este frío de pronto le hace daño a ella ¿cierto? c3e2 el uso de agua tibia durante el baño para evitar el enfriamiento del bebé también está presente en las gestantes desplazadas y no desplazadas. 112 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 reflexiones de la experiencia con gestantes desplazadas como investigadoras hemos tenido la experiencia de conocer una parte del mundo de las gestantes desplazadas por la violencia, que reciben apoyo sin importar de qué tipo, pero como lo expresan ellas: “cualquier cosa es bien recibida”; además, se observa cómo estas personas desarrollan gran capacidad de adaptación y de conformismo, y mantienen una búsqueda permanente de afecto. otro aprendizaje obtenido es que los modelos de prestación de servicios en salud se alejan de responder a las necesidades reales de este tipo de población, que no cuenta con la facilidad para vivir en ambientes sanos, para alimentarse con lo mínimo requerido para la gestación, para tener el abrigo necesario, y tiene dificultad muchas veces para tener acceso de emergencia al servicio de salud y, aún más, a un cuidado prenatal y de posparto y recién nacido. que el cuidado creado solamente desde nuestra perspectiva etnocéntrica se aleja de responder a las concepciones de estas personas y a sus necesidades reales. hemos llegado a este grupo con la necesidad de aprender desde su cultura, sus significados de cuidado a partir de sus valores, prácticas y creencias culturales, pero hemos notado que la preservación de su cultura se rompe por la inminencia de satisfacer sus necesidades básicas de abrigo, alimentación y afecto, y de encontrar un futuro para sus hijos. a pesar de esto, ellas traen unos saberes, prácticas y creencias, y tenemos el reto de aprender de éstos, descubrir lo poco que es lo propio de ellas y a pesar de esto hay un choque cultural. (¿) proponemos el reto nuestro como investigadoras es aprender del acervo cultural de estas mujeres. como docentes hemos aprendido que la enseñanza del cuidado de enfermería no debe ser homogénea, sino que debe tener en cuenta las situaciones particulares de la población a la cual está dirigida. el desplazamiento forzado es una realidad social de nuestro país que afecta a un gran número de familias y de regiones, y que por tanto nuestro currículo debe tener cambios y no estar ajeno a esta realidad. estos cambios en el currículo de enfermería deben estar apoyados en las enseñanzas de leininger para aplicar la enfermería transcultural y de esta manera poder ofrecer cuidado congruente con estos grupos culturales, pero soportados en la sensibilidad, el conocimiento y la experiencia del cuidado cultural por parte de los docentes. conclusiones a pesar de la fuerte y devastadora experiencia del desplazamiento forzado, las gestantes que viven esta situación potencian la manera de afrontar su nueva vida tratando de adaptarse a lo que la ciudad les ofrece en cuanto al alimento, el techo, el vestido, entre otros, y tratan de buscar el apoyo desde las instituciones de salud para beneficio de ellas mismas y de su hijo por nacer y, sobre todo, para tener un lugar donde se pueda dar el próximo nacimiento del bebé. los cuidados de las gestantes desplazadas consigo mismas consisten en no levantar cosas pesadas, tratar de seguir las recomendaciones que les dan en la institución de salud, aunque muchas vese observa cómo estas personas desarrollan gran capacidad de adaptación y de conformismo, y mantienen una búsqueda permanente de afecto. 113 significado del cuidado de si y de su hijo por nacer en gestantes desplazadas ces por falta de dinero no lo pueden hacer (comprar los alimentos o las medicinas); se cuidan de no apretar su abdomen con la ropa, usan zapatos bajitos, y tratan de no hacer oficios que impliquen riesgos, como por ejemplo caídas; sienten confianza en dios y están agradecidas por las ayudas que reciben de las organizaciones que apoyan a los desplazados y de los vecinos. no toman agua de bogotá porque es helada y les sabe raro; procuran estar asedas para que las consideren limpias a pesar de ser desplazadas, es decir, en su imaginario está la creencia de que las personas las consideren sucias debido a su condición. se olvidan del sobrepeso y de que las harinas engordan, a pesar de conocer las consecuencias de esto: tensión alta, hijo/ a muy grande lo que les traería dificultades en el momento del nacimiento, porque el bebé va creciendo y les pide de comer; se cuidan en las relaciones sexuales para evitar lastimar al bebé; estimulan en sus bebés los sentidos del oído, tacto, visión; esperan que el bebé nazca completo y que sea grandote, lo que les significa que es sano. el profesional de enfermería debe enfrentar no sólo los aspectos físicos de la salud, sino el entorno que tiene actualmente la gestante desplazada, valorar sus apoyos sociales y formas de cuidado cultural, ofrecer información acerca de instituciones o grupos de ayuda a fin de favorecer la salud de la gestante y su hijo por nacer, y de manera contundente ocuparse de la parte alimentaria. de otro lado, debe fortalecer desde la educación básica la forma de solucionar los conflictos de manera pacífica. la propuesta para guiar las intervenciones toma como marco de referencia las tres modalidades que leininger (1991) utiliza, basándose en la evaluación del conocimiento genérico –los beneficios o riesgos de creencias y prácticas culturales–, y en el conocimiento profesional: preservar (prácticas que se deben mantener): evitar hacer grandes esfuerzos. usar calzado de tacón bajito. evitar el uso de ropa apretada. mantener los cuidados con la higiene personal. estimular al hijo/a por nacer. negociar o reacomodar (prácticas que se deben reacomodar): la ingesta de alimentos con alto contenido calórico (difícil porque muchas veces no depende de ellas sino de su situación de desplazamiento). periodos de ayuno prolongado por los efectos negativos para su hijo/a por nacer). ingesta de agua. corregir (prácticas que se deben corregir): asistencia a control prenatal a pesar de las dificultades para acceder a las citas. el profesional de enfermería debe enfrentar no sólo los aspectos físicos de la salud, sino el entorno que tiene actualmente la gestante desplazada, valorar sus apoyos sociales y formas de cuidado cultural, ofrecer información acerca de instituciones o grupos de ayuda a fin de favorecer la salud de la gestante y su hijo por nacer. 114 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 referencias 1 guevara r. mujeres desplazadas por el conflicto armado. situaciones de género en cali y popayán. colombia. 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[consultado en mayo de 2007]. disponible en: http://www.rhrc.org/pdf/spanishwcrhassesmtcolombia.pdf 190 aquichan issn 1657-5997 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 l 190-191 editorial para el mundo de la comunicación científica, las revistas indexadas en los más conocidos servicios de indexación y resumen —sires— son el primero y más importante medio de información. tal como lo afirman mendoza y paravic (1), las revistas científicas son “el canal directo y formal del mensaje científico”, el cual comienza con la producción de los autores y luego es legitimado y depurado por evaluadores y editores. para las bases de datos internacionales de alto prestigio, como isi y scopus, indexar una nueva revista exige que la misma demuestre repercusión científica no solo en su entorno nacional sino, también, en ambientes internacionales, con lo cual se da respuesta, de un lado, a los intereses de los investigadores, que exigen información actualizada sobre su especialidad y, de otro, se cumple con los propósitos documentales y de recuperación bibliográfica (2). según jim testa, director de desarrollo editorial de thomson reuters, “las revistas especializadas que se están cubriendo actualmente se controlan para asegurar que mantengan altos estándares y una importancia clara para los productos sobre los que informan” (3). y estos mandatos o exigencias cada vez más son entendidos y acogidos por investigadores y editores de enfermería que, como en las demás disciplinas, saben que es un imperativo visibilizar el nuevo conocimiento, a través de revistas que garanticen el cumplimiento de los criterios de calidad en los contenidos; que reflejen investigaciones cuyo rigor metodológico se traduzca en aportes originales a la disciplina y en conceptos novedosos, tal como lo manifiestan delgado et ál.(4). en este sentido, la visibilidad de aquichan se ha convertido en un propósito de la comunidad científica, principalmente de la latinoamericana —por ser la que más autores registra en sus páginas—. desde su primera edición, como una revista conmemorativa de los diez años de la facultad de enfermería y rehabilitación de la universidad de la sabana, aquichan ha cumplido con los criterios de calidad científica y editorial exigidos por los más prestigiosos sires, hasta llegar a isi ya scopus, donde ya fue aceptada y será visible en los próximos meses, y a la categoría a1 del índice publindex, en colombia. este es un logro importante para la enfermería latinoamericana, porque el contenido de la revista refleja la calidad y cantidad de la producción científica de la disciplina en la visibilidad del conocimiento de enfermería 191 editorial región, debido al desarrollo de la investigación y al incremento en los programas de formación, de maestrías y doctorados (5). en la medida en que este ascenso se va dando, se aumenta la visibilidad internacional de los productos publicados y por ello se debe ser más exigente. incrementar la visibilidad de aquichan tiene sentido siempre y cuando los artículos sean leídos y citados por la comunidad científica mundial en los diferentes escenarios del ámbito profesional, bien sea como fuente de nuevas preguntas y proyectos de investigación, o para mejorar la calidad del cuidado que se presta a las personas. maría elisa moreno-fergusson editora mariae.moreno@unisabana.edu.co visibility of nursing knowledge visibilidade do conhecimento em enfermagem 1. mendoza s, paravic t. origen, clasificación y desafíos de las revistas científicas. investigación y postgrado 2006; 12 (1): 51-55. 2. ruiz-pérez r, lópez cózar, jiménez-contreras e. criterios del institute for scientific information para la selección de revistas científicas. su aplicación a las revistas españolas: metodología e indicadores. international journal of clinical and health psychology 2006; 6 (2): 415-422 3. testa j. proceso de selección de revistas especializadas de thomson reuters. disponible en: http://wokinfo.com/media/pdf/selection_essay-spanish.pdf [consultado el 11 de noviembre de 2010]. 4. delgado lópez-cózar e, torres-salinas d, jiménez-contreras e, ruiz-pérez r. análisis bibliométrico y de redes sociales aplicado a las tesis bibliométricas defendidas en españa (1976-2002): temas, escuelas científicas y redes académicas. revista española de documentación científica [revista electrónica]. 2006; 29(4), no. 4 (2006). disponible en: http://redc.revistas.csic.es/index. php/redc/article/viewarticle/306 [consultado el 3 de noviembre de 2010]. 5. mendoza-parra s, paravic-klijn t, muñoz-muñoz am, barriga oa, jiménez-contreras e. visibility of latin american nursing research (1959-2005). journal of nursing scholarship 2009; 41(1): 54-63. 135 146 cuidadores de cartagena.indd 135 amparo montalvo-prieto1 inna elida flórez-torres2 cuidadores de cartagena y su contexto de cuidado: estudio comparativo 1 magíster en enfermería. decana facultad de enfermería, universidad de cartagena. cartagena, colombia. denfermeria@unicartagena.edu.co 2 magíster en enfermería. docente, universidad de cartagena. cartagena, colombia. iflorezt@unicartagena.edu.co recibido: 17 de noviembre de 2008 aceptado: 29 de junio de 2009 resumen objetivo: comparar las características sociodemográficas y de relación de cuidado de cuidadores de niños y adultos con enfermedades crónicas discapacitantes de cartagena, colombia. método: estudio descriptivo, cuantitativo, de corte transversal. se realizó un muestreo no probabilístico, por conveniencia, entre el 2006 y el 2007. participaron 300 cuidadores: 98 de niños y 202 de adultos con enfermedades crónicas. se utilizó la encuesta de caracterización de los cuidadores. para describir las asociaciones entre las variables seleccionadas se empleó el análisis factorial de correspondencias múltiples. resultados: ser cuidador de niños se asoció con ser padre o madre, ejercer el rol durante 37 meses o más, dedicarse a actividades del hogar y estar en unión libre. ser cuidador de adultos se asoció con pacientes mayores, llevar 36 meses o menos como cuidador, ser hijo del paciente y estar casado. conclusiones: las variables que mejor diferenciaron los dos grupos de cuidadores fueron nivel socioeconómico, estado civil y tiempo de dedicación al cuidado. el grupo de cuidadores de adultos presentó mayor variabilidad en las distintas categorías estudiadas. palabras clave cuidadores, enfermedad crónica, enfermería. (fuente: decs, bireme). caregivers in cartagena and the context for providing care: a comparative study abstract objective: to compare the socio-demographic characteristics and the relationship established by caregivers in cartagena (colombia) who work with children and adults with chronic, disabling illnesses. method: a transversal quantitative-descriptive study. for convenience, a non-probability sampling method was applied between 2006 and 2007. three hundred (300) caregivers took part: 98 working with chronically ill children and 202 working with chronically ill adults. the caregiver characterization survey was used. a multiple correspondence factor analysis was employed to describe the associations between the selected variables. results: being a caregiver for children is associated with being a parent, performing the role of caregiver during 37 months or more, dedication to domestic activities, and being año 9 vol. 9 nº 2 chía, colombia agosto 2009 135-146 136 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 part of a common law marriage. being a caregiver for adults is associated with older patients, having spent 36 months or more as a caregiver, being the patient’s offspring, and being married. conclusions: socio-economic level, marital status and time dedicated to providing care were the variables that most differentiate the two groups of caregivers. the group of caregivers working with adults showed the most variability in the different categories studied. key words caregivers, chronic illness, nursing. (source: decs, bireme). cuidadores de cartagena e o seu contexto de cuidado: estudo comparativo resumo objetivo: comparar as características sócio-demográficas e de relação de cuidado de cuidadores de meninos e adultos com doenças crônicas e discapacitantes de cartagena, colômbia. método: estudo descritivo, quantitativo, de tipo transversal. entre 2006 e 2007 realizou-se uma amostragem não-probabilística por conveniência. nesta participaram 300 cuidadores: 98 de meninos e 202 de adultos com doenças crônicas. aplicou-se a pesquisa de caracterização dos cuidadores. empregou-se a análise fatorial de correspondências múltiples para descrever as associações entre as variáveis selecionadas. resultado: o ser cuidador de meninos foi associado ao ser pai ou mãe, exercer o role durante 37 meses ou mais, dedicar-se as atividades do lar e estar em união livre. o ser cuidador de adultos foi associado a pacientes maiores, ter 36 meses ou mais como cuidador, ser filho do paciente e estar unidos por casamento. conclusões: as variáveis que diferençaram melhor os dois grupos de cuidadores foram nível socioeconômico, estado civil e tempo de dedicação ao cuidado. o grupo de cuidadores de adultos teve maior variabilidade nas diversas categorias estudadas. palavras-chave cuidadores, doença crônica, enfermagem. (fonte: decs, bireme). 137 cuidadores de cartagena y su contexto de cuidado: estudio comparativo amparo montalvo-prieto, inna elida flórez-torres introducción las enfermedades crónicas no transmisibles (ecnt) son actualmente la principal causa de muerte en todo el mundo, y ocasionan el doble de las defunciones causadas por las enfermedades infecciosas, las complicaciones del parto y la desnutrición combinadas. ocho de cada diez defunciones producidas por las enfermedades crónicas ocurren en países de ingresos bajos y medios, y en todos ellos la gente pobre soporta la mayor carga de estas dolencias (1). la organización panamericana de la salud (ops) señala que las ecnt son la principal causa de muerte y discapacidad prematuras en la gran mayoría de los países de américa latina y el caribe. tienen efectos devastadores para las personas, las familias y las comunidades, especialmente las poblaciones pobres, lo que se constituye en un obstáculo cada vez mayor para el desarrollo económico. los costos sociales asociados con las enfermedades crónicas son abrumadores (2). la cronicidad que aparece durante cualquier etapa de la vida se mantiene hasta la vejez, pero el proceso de envejecimiento, las consecuencias de estilos de vida poco saludables, y la suma de diferentes lesiones y desgastes que hacen más vulnerables a las personas de este grupo de edad a padecer enfermedades crónicas discapacitantes (3). la tecnología y los avances en la medicina permiten a las personas sobrevivir a enfermedades fatales y con ello a la incidencia de enfermedades crónicas que constituyen la principal causa de discapacidad (4). en colombia, las enfermedades crónicas discapacitantes son una causa importante de morbilidad y mortalidad, y su tendencia es al aumento. del total de muertes registradas entre 1990 y 2005, la mortalidad por enfermedades crónicas se incrementó del 59 al 62,6% (5). según el departamento administrativo nacional de estadísticas (2005), la situación de la discapacidad guarda correspondencia con la situación mundial, aproximadamente 2.640.000 personas presentan alguna limitación permanente, lo cual equivale al 6,4% del total de la población colombiana (6). las personas con discapacidad constituyen el 10% de la población general, y se considera que tiene repercusión sobre el 25% de la población total. sólo el 2 al 3% de la población discapacitada tiene acceso a los servicios de rehabilitación y programas de atención para este sector. un 2-3% de los recién nacidos presentan graves deficiencias, y del 6 al 8% de los menores de 6 años presentan problemas significativos del desarrollo (7). mientras que en el adulto las causas más frecuentes de enfermedad crónica discapacitante se relacionan con la reducción de la mortalidad de las enfermedades crónicas no transmisibles, en el niño los factores genéticos inciden con mayor frecuencia en su producción (8). algunos autores documentan que en los países desarrollados, entre un 5 y un 10% de niños que no han cumplido los 18 años tienen situaciones de este tipo, y muchos pueden llegar a tener una expectativa de vida más elevada si tienen al alcance la tecnología mola organización panamericana de la salud (ops) señala que las ecnt son la principal causa de muerte y discapacidad prematuras en la gran mayoría de los países de américa latina y el caribe. 138 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 derna, lo que implica nuevos retos en sus vidas y en la de sus cuidadores, bien sean éstos familiares o profesionales (9). en el departamento de bolívar, y en la ciudad de cartagena, colombia, no se encontraron estadísticas que permitan conocer el número de personas en situación de discapacidad. se presenta subregistro en lo referente a los pacientes crónicos, lo que impide conocer la dimensión del problema. al no conocer el número y tipo de afección que presentan estas personas, se hace menos visible la situación de sus cuidadores y la experiencia de cuidado (10). al hablar de cuidadores familiares se hace referencia a las personas adultas con vínculo de parentesco o cercanía, que asumen las responsabilidades del cuidado de un ser querido que vive en situación de enfermedad crónica discapacitante, y participan con él en la toma de decisiones (5). la experiencia de cuidar a personas en situación de enfermedad crónica discapacitante es particular; aun cuando se compartan similitudes en las demandas de cuidado, en ella influyen factores específicos como las características personales del binomio cuidador-sujeto de cuidado, la severidad de la enfermedad, los ajustes que debe hacer el cuidador en su estilo de vida y en el rol familiar, entre otras. diversos autores han estudiado la situación de los cuidadores y las implicaciones del rol sobre su calidad de vida (11, 12, 13, 14, 15); otros han documentado la habilidad y la carga de cuidado desde la perspectiva de género y, en general, otras relaciones de cuidado. no obstante, la situación de los cuidadores y su entorno no ha sido lo suficientemente abordada, desde la perspectiva de la experiencia del cuidador de niños y de adultos, en sus diferencias o similitudes en la ejecución y las consecuencias del rol, orientadas a dar respuestas desde la disciplina de enfermería a las necesidades específicas y a redefinir intervenciones de apoyo a quienes asumen una labor no reconocida por el sistema y las políticas de salud. en la presente investigación se comparan las características sociodemográficas y de relación de cuidado de cuidadores de niños y de adultos con enfermedades crónicas discapacitantes. método estudio descriptivo, comparativo con abordaje cuantitativo y de corte transversal. la muestra estuvo conformada por 300 cuidadores, de los cuales 98 correspondieron a cuidadores de niños, y 202 a cuidadores de adultos con enfermedades crónicas, caracterizados en investigaciones realizadas por el grupo de cuidado de la facultad de enfermería de la universidad de cartagena, durante los años 2006 y 2007. se realizó un muestreo no probabilístico, por conveniencia, a través de la selección de las direcciones tomadas de las historias clínicas de la consulta externa en tres de las cuatro instituciones hospitalarias, y de la selección de los cuidadores que acudían a los programas desarrollados por una fundación en cartagena. se tuvieron en cuenta como criterios de inclusión los cuidadores de niños y adultos con enfermedades crónicas, con un tiempo de dedicación mayor de tres meses que desearan voluntariamente hacer parte del estudio. la investigación respetó los parámetros éticos para estudios con seres humaal hablar de cuidadores familiares se hace referencia a las personas adultas con vínculo de parentesco o cercanía, que asumen las responsabilidades del cuidado de un ser querido que vive en situación de enfermedad crónica discapacitante. 139 cuidadores de cartagena y su contexto de cuidado: estudio comparativo amparo montalvo-prieto, inna elida flórez-torres nos contenidos en la resolución 008430 de 1993 del ministerio de salud de colombia y del código de ética de enfermería. esta investigación fue aprobada por el comité de ética de la universidad de cartagena, y se solicitó la autorización para el uso de los instrumentos (16). se utilizó la encuesta de caracterización de los cuidadores, diseñada por el grupo de cuidado al paciente crónico, la cual consta de trece preguntas cerradas y proporciona información sociodemográfica y de relación con las características de dedicación al cuidado (17). la patente de este instrumento está en curso y ha permitido caracterizar a cuidadores del contexto nacional e internacional. para el análisis y la interpretación de los resultados inicialmente se utilizó la estadística descriptiva a partir de distribuciones de frecuencias absolutas y relativas. para comparar los dos grupos de cuidadores se realizó un modelo de correspondencias múltiples, método factorial que permite establecer tipologías de individuos y describir asociaciones entre las variables seleccionadas, las cuales incluyeron: sociodemográficas (sexo, edad del cuidador, rango de edad del receptor de cuidado, escolaridad, estado civil, ocupación y nivel socioeconómico medido por el estrato de la vivienda), y de relación de cuidado (inicio del cuidado, tiempo y horas de dedicación, único cuidador, relación con la persona cuidada). esta técnica permitió, a partir de un único gráfico conocido como primer plano factorial, observar las asociaciones más representativas existentes entre las distintas opciones de respuesta que definieron a cada una de las variables. resultados características sociodemográficas de los dos grupos de cuidadores con respecto al total de los cuidadores participantes, el 87% son de sexo femenino, y el 13% masculino. al comparar la distribución de los dos grupos, la proporción de hombres cuidadores en el grupo de pacientes adultos, duplica la correspondiente en el grupo de cuidadores de niños (15% frente a 8%, respectivamente). en relación con la edad del cuidador, el 44% tienen entre 19 y 35 años, y el 43%, entre 36 y 59 años. la menor proporción estuvo representada en los cuidadores menores de 18 años y mayores de 60. entre los dos grupos se observan diferencias al respecto, mientras un 10% de cuidadores de pacientes adultos tienen 60 años o más, este porcentaje en el grupo de cuidadores de niños es del 1%. los dos grupos revelaron diferencias en relación con el rango de edad del receptor del cuidado. es así como, el 69% de los cuidadores de adultos cuidan pacientes mayores que ellos. la mayoría de los cuidadores de niños tienen un vínculo de parentesco de madrepadre que representa un 83%, mientras que este porcentaje en el caso de cuidadores de adultos representa un 18%. en este grupo el 36% de los cuidadores cuidan a alguno de sus padres, y un 26% no tienen un parentesco familiar. con respecto a la escolaridad de los participantes, un 26% cuenta con bachillerato completo y un 22% incompleto. el 28% la mayoría de los cuidadores de niños tienen un vínculo de parentesco de madre-padre que representa un 83%, mientras que este porcentaje en el caso de cuidadores de adultos representa un 18%. 140 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 de los cuidadores cursó estudios de primaria (completa o incompleta). en los cuidadores de adultos es mayor la proporción de aquellos con formación técnica o universitaria, 28%. en el grupo de cuidadores de niños, el 60% cursó bachillerato completo o incompleto. el 34% del total de cuidadores son casados, el 28% solteros, y un 25% se encuentra en unión libre. al comparar los dos grupos, el 39% de cuidadores de niños se encuentra en unión libre, mientras que en el grupo de adultos, se encontró un 18%. los cuidadores casados en este grupo se encontraron en un 40%, y en el grupo de los cuidadores de niños en un 22%. en cuanto a la ocupación, el 56% de los cuidadores se dedica al hogar, y un 18% son empleados y trabajadores independientes. los cuidadores dedicados al hogar en el grupo que cuida a niños representan un 74%, y en el grupo de adultos, un 47%. en este grupo, la proporción de empleados triplica a la de los cuidadores de niños (24% frente a 7%); de igual forma, la proporción de cuidadores que trabajan como independientes es casi el doble (21% frente a 11%). los participantes se encuentran en un nivel socioeconómico bajo en un 63%. sin embargo, los dos grupos de cuidadores difieren respecto a esta variable. mientras que entre los cuidadores de adultos con enfermedades crónicas se encontró el 22% en nivel medio o medio alto, en el grupo de cuidadores de niños se reportó sólo un 3% en estos niveles. el 88% de los cuidadores desempeña este rol desde el momento del diagnóstico. en el grupo de cuidadores de niños un 94% de ellos asumieron el rol desde el inicio del diagnóstico. este resultado es consistente con el tiempo de dedicación al cuidado, puesto que los cuidadores de niños llevan más tiempo realizando esta función que los del grupo de adultos; el 76% de los cuidadores de niños llevan más de 36 meses, mientras que sólo el 38% de los cuidadores de adultos han cumplido el mismo tiempo ejerciendo el rol de cuidadores (figura 1). con respecto a las horas de dedicación al cuidado, el 51% del total de los cuidadores se dedican a esta labor las 24 horas del día. al discriminar este dato, se encontró que es mayor esta dedicación en los figura 1. tiempo que lleva como cuidador. figura 2. horas diarias dedicadas al cuidado. 141 cuidadores de cartagena y su contexto de cuidado: estudio comparativo amparo montalvo-prieto, inna elida flórez-torres ser cuidador de adultos se asocia principalmente con pacientes mayores que el rango de edad del cuidador, estar casados, llevar 36 meses o menos como cuidador, y ser hijo del paciente. figura 3. distribución de los cuidadores según único cuidador. varianza explicada 23%. figura 4. primer plano factorial con todas las variables estudiadas. cuidadores de niños que entre los cuidadores de adultos (62% frente a 46%). de igual forma, el tiempo de dedicación al cuidado de 13 a 23 horas, es mayor en los cuidadores de niños que en el grupo de adultos (23% frente a 11%) (figura 2). del total de los cuidadores participantes, el 57% es único cuidador, condición que predomina en el grupo de los cuidadores de niños (61%), mientras que en el grupo de cuidadores de adultos reportó un 54% (figura 3). 142 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 varianza explicada 34%. asociaciones entre las características de los dos grupos las figuras 4 y 5 presentan algunas características asociadas con cada uno de los dos grupos de cuidadores que participaron en el estudio. en la primera se presenta la totalidad de variables. el ser cuidador de niños se asocia altamente con ser padre o madre, estar en unión libre, con pacientes menores que el rango de edad del cuidador y llevar 37 meses o más como cuidadores. ser cuidador de adultos se asocia principalmente con pacientes mayores que el rango de edad del cuidador, estar casados, llevar 36 meses o menos como cuidador, y ser hijo del paciente. estas figuras presentan, además, dos grupos de asociaciones entre las variables investigadas. no obstante estos grupos, si bien tienden a acercarse más al de cuidaser cuidador de niños se asocia altamente con ser padre o madre, tener una edad mayor que la del paciente, llevar 37 meses o más como cuidador y dedicarse a actividades del hogar. dores de adultos, su cercanía aún no es lo suficientemente próxima para aseverar que se asocian altamente. específicamente se detecta una alta asociación entre cuidadores con nivel socioeconómico medio bajo, que tienen una edad de 35 años o menos, únicos cuidadores y, muy levemente, que llevan 37 meses o más como cuidadores. así mismo, se detecta una alta asociación entre cuidadores con 36 años o más, no ser el único cuidador, tener un bajo nivel socioeconómico, no cuidar al paciente desde el comienzo y, muy levemente, dedicarse a las actividades del hogar. la figura 5 ilustra las asociaciones más representativas en los dos grupos. en primer lugar, la elipse de la parte izquierda muestra cómo el ser cuidador de niños se asocia altamente con ser padre o madre, tener una edad mayor que la del paciente, llevar 37 meses o más como cuifigura 5. primer plano factorial con las asociaciones más representativas. 143 cuidadores de cartagena y su contexto de cuidado: estudio comparativo amparo montalvo-prieto, inna elida flórez-torres dador, dedicarse a actividades del hogar y, muy levemente, estar en unión libre. así mismo, se ratifica que el ser cuidador de adultos (elipse derecha) se asocia de forma importante con pacientes mayores que sus cuidadores, llevar 36 meses o menos dedicado al cuidado, ser hijo del paciente y, muy levemente, estar casado. discusión la comparación de los dos grupos de cuidadores reveló diferencias en la composición de ambos grupos, asociadas con sus características sociodemográficas y de la relación de cuidado. los dos grupos de cuidadores presentan una distribución de género con predominio femenino; sin embargo, la proporción de hombres cuidadores es mayor en el grupo de cuidadores de adultos. estos hallazgos han sido descritos en diferentes estudios del contexto nacional e internacional, que evidencian que el rol de cuidador es más frecuente en mujeres que en hombres (18, 19, 20). en el entorno colombiano es frecuente que los familiares, en especial las mujeres, asuman el papel de cuidadoras de los enfermos crónicos, mucho más si éste es un niño (21, 22). con respecto a la edad, en ambos grupos de cuidadores se observaron proporciones similares en las edades comprendidas entre los 18 y 35 años, y 36 y 59 años. similares resultados reportaron barrera et al., en un estudio comparativo de la habilidad de cuidado de los cuidadores familiares de personas con enfermedad crónica, donde los cuidadores jóvenes y de edad intermedia presentaron un porcentaje significativo (20). este hallazgo concuerda con lo referido en la literatura como las dificultades de una generación intermedia o “sandwich” sobre la cual recae, además de la crianza de los hijos, el cuidado de las personas dependientes y mayores (18, 19, 20, 23). en el grupo de cuidadores de niños predominaron las madres cuidadoras, mientras que en el grupo de cuidadores de adultos la mayoría de los cuidadores son hijos de los pacientes o sin ningún tipo de relación familiar con los sujetos de cuidado. castillo et al., informan características sociodemográficas similares en cuidadores de niños y adultos con cáncer; en el caso de los adultos estos cuidadores eran hijos(as) y esposas, y en los niños eran sobre todo madres y abuelas (23). estas últimas características coinciden con los hallazgos de blanco, en un grupo de cuidadores de niños (21). se identificaron diferencias leves con respecto a la escolaridad; se encontró no sólo mayor heterogeneidad, sino mejores niveles educativos en el grupo de cuidadores de pacientes adultos, quienes cuentan con estudios técnicos y universitarios. contrario a estos resultados, díaz reportó escolaridad baja en cuidadores de adultos y planteó la relación del bajo nivel educativo en el ejercicio del cuidado, especialmente en lo que respecta al desarrollo cognoscitivo (24). así mismo, en otros contextos se han reportado altos porcentajes de estudios primarios en cuidadores de adultos dependientes (25). en el entorno colombiano es frecuente que los familiares, en especial las mujeres, asuman el papel de cuidadoras de los enfermos crónicos, mucho más si éste es un niño. 144 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 aunque el estrato socioeconómico de los cuidadores fue bajo en general, esta condición predominó en el grupo de los cuidadores de niños. estos hallazgos son consistentes con los reportados por castillo et al., donde los cuidadores familiares de niños en un 67,6%, refirieron haber dejado de trabajar o estudiar para dedicarse al cuidado de su hijo. la mayoría pertenecían a los estratos 1 y 2 (23). igual situación encontraron garcía et al., quienes informan el predominio de las mujeres como cuidadoras informales, sin empleo, y de clases sociales menos privilegiadas, las que componen el gran colectivo de cuidadoras (26). con respecto al tiempo, los cuidadores de niños le han dedicado más horas como únicos cuidadores, comparados con los cuidadores de pacientes adultos. barrera señala —acerca de los cuidadores familiares de niños— que las madres y, en algunos casos, los padres tienen dedicación exclusiva al cuidado de sus hijos, se olvidan de sí mismos, renuncian a sus objetivos personales, centran sus intereses en ellos, y siempre están sobrecargados con sus responsabilidades (27). conclusiones en general, los cuidadores de niños pertenecen a un nivel socioeconómico bajo, la unión libre es la que con mayor frecuencia se presenta, y es mayor el tiempo de dedicación al cuidado. ser cuidador de adultos se asocia de forma importante con pacientes mayores que sus cuidadores, llevar 36 meses o menos dedicado al cuidado, ser hijo del paciente y, muy levemente, el estar casado. el análisis de correspondencias mostró que las variables que diferenciaron los dos grupos de cuidadores fueron nivel socioeconómico, estado civil y tiempo de dedicación al cuidado. los resultados de este estudio constituyen una oportunidad para visibilizar y reconocer a los cuidadores de cartagena en su contexto de cuidado. conducen a plantear la necesidad de profundizar en la situación de los cuidadores. permiten, a su vez, la articulación con el conocimiento generado por diferentes estudios a nivel nacional, que fortalecen la disciplina de enfermería. 145 cuidadores de cartagena y su contexto de cuidado: estudio comparativo amparo montalvo-prieto, inna elida flórez-torres referencias bibliográficas 1. organización panamericana de la salud 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[consultado: 6 de agosto de 2008]. 2. organización panamericana de la salud (ops). resumen: estrategia regional y plan de acción para un enfoque integrado sobre la prevención y el control de las enfermedades crónicas. 2007; 52. en http:// www.paho.org/spanish/ad/dpc/nc/reg-strat-cncds.pdf [consultado: 6 de agosto de 2008]. 3. sánchez b. la cronicidad y el cuidado familiar, un problema de todas las edades: los cuidadores de ancianos. av. enferm 2004; 22 (1): 61-67. 4. vega om, gonzález ds. apoyo social: elemento clave en el afrontamiento de la enfermedad crónica social, núm. 16, junio de 2009. en www.um.es/eglobal [consultado: 6 de agosto de 2008]. 5. lucumi d, gutiérrez a, moreno j. et al. planeación local para enfrentar el desafío de las enfermedades crónicas en pasto, colombia. rev salud pública 2008; 10 (2): 343-351. 6. discapacidad colombia. censo 2005. resultado sobre limitaciones permanentes. informe oficial. en http://discapacidadcolombia.com/modules.php?n ame=news&file=article&sid=1268. [consultado: 10 de agosto de 2008]. 7. fondo nacional de discapacidad. fonadis. ministerio de planificación. santiago de chile. en http://www. fonadis.cl/index.php?seccion=15&articulo=%20 1001 [consultado: 10 de agosto de 2008]. 8. organización mundial de la salud. clasificación internacional de deficiencias, discapacidades y minusvalías (ciddm). 1980. en www.fonadis.cl/tools/ resources.php?id=171. 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[consultado: 13 de abril de 2008]. 27. barrera l. la cronicidad y el cuidado familiar, un problema durante la niñez. ac. enferm. 2004; 22(1):47-53. 1 dora isabel giraldo montoya1 francy edith lópez herrera2 alexandra marcela quirós jaramillo3 andrea agudelo gómez4 sara maría sierra cano5 daniela agudelo restrepo6 causas de abandono de la lactancia materna y factores de éxito para la relactación* 1 https://orcid.org/0000-0003-0324-3975. universidad pontificia bolivariana, facultad de enfermería, colombia. dora.giraldo@upb.edu.co 2 https://orcid.org/0000-0002-5774-863x. universidad pontificia bolivariana, facultad de enfermería, colombia. francy.lopez@upb.edu.co 3 https://orcid.org/0000-0002-5925-1627. clínica universitaria bolivariana, colombia. alexandra.quiros@upb.edu.co 4 https://orcid.org/0000-0003-2253-601x. universidad pontificia bolivariana, facultad de enfermería, colombia. andrea.agudelog@upb.edu.co 5 https://orcid.org/0000-0003-4130-9568. universidad pontificia bolivariana, facultad de enfermería, colombia. sara.sierrac@upb.edu.co 6 https://orcid.org/0000-0001-8741-190x. universidad pontificia bolivariana, facultad de enfermería, colombia. daniela.agudelor@upb.edu.co * artículo derivado de un proyecto de investigación formativa, financiado por el centro de investigación para el desarrollo y la investigación (cidi) y clínica universitaria bolivariana (cub). recibido: 21/11/2019 enviado a pares: 02/12/2019 aceptado por pares: 20/04/2020 aprobado: 07/05/2020 resumen objetivo: identificar las causas de abandono de la lactancia materna y los factores de éxito para la relactación en madres con hijos atendidos en una institución de salud. metodología: descriptivo, transversal. muestreo no probabilístico a conveniencia, con una muestra de cien madres y sus hijos. se utilizó una encuesta estructurada y se analizaron las medidas de tendencia central y las frecuencias. el estudio fue aprobado por el comité de ética de la escuela de ciencias de la salud de la universidad pontificia bolivariana. resultados: las participantes tenían una media de edad de 26,8 años; el 73 % era de estrato socioeconómico bajo; el 59 % se encontraba en unión libre; el 46 % eran amas de casa; el 32 % contaba con bachillerato completo; el 57 % eran primigestantes; el 74 % tenía un alto riesgo obstétrico; y el 59 % tuvieron a su hijo por cesárea. causas de abandono de la lactancia: hospitalización de los neonatos (79 %) y bajo peso al nacer año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2036 temática: promoción y prevención. aporte a la disciplina: los resultados sirvieron de soporte para gestionar un protocolo de cuidado en la unidad materno infantil de una clínica privada, orientado al fortalecimiento de la lactancia materna a través de la relactación. se tuvieron en cuenta las causas de abandono y los factores de éxito en este proceso para contribuir, desde la enfermería, al restablecimiento de la salud de los menores, a su sano crecimiento y desarrollo y al fomento del vínculo materno infantil. doi: 10.5294/aqui.2020.20.3.6 para citar este artículo / to reference this article / para citar este artigo giraldo di, lópez fe, quirós am, gómez aa, sierra sm, agudelo d. breastfeeding abandonment causes and success factors in relactation. aquichan. 2020;20(3):e2036. doi: https://doi.org/10.5294/aqui.2020.20.3.6 https://orcid.org/0000-0003-0324-3975 mailto:dora.giraldo@upb.edu.co https://orcid.org/0000-0002-5774-863x mailto:francy.lopez@upb.edu.co https://orcid.org/0000-0002-5925-1627 mailto:alexandra.quiros@upb.edu.co https://orcid.org/0000-0003-2253-601x mailto:andrea.agudelog@upb.edu.co https://orcid.org/0000-0003-4130-9568 mailto:sara.sierrac@upb.edu.co https://orcid.org/0000-0001-8741-190x mailto:daniela.agudelor@upb.edu.co https://doi.org/10.5294/aqui.2020.20.3.6 https://orcid.org/0000-0003-0324-3975 https://orcid.org/0000-0002-5774-863x https://orcid.org/0000-0002-5925-1627 https://orcid.org/0000-0003-2253-601x https://orcid.org/0000-0003-4130-9568 https://orcid.org/0000-0001-8741-190x https://doi.org/10.5294/aqui.2020.20.3.6 2 aquichan issn 1657-5997 eissn 2027-5374 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2036 (52 %). el personal de salud sugirió sucedáneos por hipogalactia en el 18 % de las madres. postura incorrecta de la madre: 66,1 y 61 %, sin experiencias previas. factores de éxito para relactar: edad cronológica menor de un mes (48 %); el bebé succionó al ponerlo al pecho (89 %); buen agarre (71 %). durante el periodo de no lactancia, el 72 % recibió leche mixta, el 82 % no lactó entre 8 y 30 días, el 98 % de las madres estuvieron dispuestas a relactar, el 91 % consideró bueno el apoyo de sus familias y del personal de salud. conclusión: la hospitalización del hijo fue la principal causa de abandono de la lactancia, y los principales factores de éxito para la relactación fueron la succión efectiva, la disposición de las madres y el apoyo. palabras clave (fuente: decs) lactancia materna; trastornos de la lactancia; nutrición del lactante; métodos de alimentación; cuidado del niño. 3 causas de abandono de la lactancia materna y factores de éxito para la relactación l dora isabel giraldo montoya y otros breastfeeding abandonment causes and success factors in relactation* abstract objective: to identify the causes of breastfeeding abandonment and the success factors associated with relactation in mothers with children attended in a specialised health institution. methodology: descriptive transversal design through non-probabilistic convenience sampling, with 100 mothers and their children. a structured survey was used and central tendency measurements and frequencies were analysed. the study was approved by the ethics committee of the school of health sciences at the university pontificia bolivariana. results: the average age was 26.8 years; 73 % had a low socioeconomic level; 59 % were cohabitating; 46 % were housewives; 32 % had a high school degree; 57 % were first-time mothers; 74 % had a high obstetric risk; and 59 % had children by caesarean section. causes of breastfeeding abandonment were newborn hospitalization (79 %) and low birth weight (52 %). health professionals suggested substitutes for hypogalactia in 18 % of the mothers. incorrect maternal posture: 66.1 and 61 % with no previous experience. relactation success factors were: chronological age under one month (48 %); effective newborn breast sucking (89 %); good newborn breast grasping (71 %). during the non-breastfeeding period, 72 % received mixed milk, 82 % did not breastfeed between 8 and 30 days, 98 % of the mothers were willing to relactate, 91 % considered the support of their families and health professionals as good. conclusion: children hospitalization was the main cause of breastfeeding abandonment and the main success factors for relactation were effective breast sucking, mothers’ readiness and support. keywords (source: decs) breastfeeding; breastfeeding disorders; infant nutrition; feeding methods; child care. año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2036 * manuscript produced in relation with an educational research project, funded by centro de investigación para el desarrollo y la investigación (cidi) and clínica universitaria bolivariana (cub). 4 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2036 aquichan issn 1657-5997 eissn 2027-5374 causas de abandono do aleitamento materno e fatores de sucesso para a relactação* resumo objetivo: identificar as causas de abandono do aleitamento materno e os fatores de sucesso para a relactação em mães de filhos atendidos em uma unidade de saúde. metodologia: descritiva e transversal. amostragem não probabilística por conveniência, com 100 mães e seus filhos. um questionário estruturado foi utilizado e as medidas de tendência central e as frequências foram analisadas. o estudo foi aprovado pelo comitê de ética da escola de ciências da saúde da universidad pontificia bolivariana, colômbia. resultados: as participantes tinham em média 26,8 anos de idade; 73 % eram de classe social baixa; 59 % estavam em união estável; 46 % eram donas de casa; 32 % contavam com ensino médio completo; 57 % eram primigestas; 74 % tinham alto risco obstétrico, e 59 % tiveram seu filho por cesariana. causas de abandono do aleitamento: hospitalização dos recém-nascidos (79 %) e baixo peso ao nascer (52 %). a equipe de saúde sugeriu a hipogalactia como causa da substituição do leite materno em 18 % das mães; postura incorreta da mãe em 66,1 % e 61 % devido à falta de experiência. fatores de sucesso para relactar: idade cronológica menor de um mês (48 %); sucção do peito por parte bebê (89 %); pega correta (71 %). durante o período de não aleitamento materno, 72 % receberam aleitamento misto; 82 % não lactaram entre 8 e 30 dias; 98 % das mães estiveram dispostas a relactar; 91 % consideraram o apoio de suas famílias e da equipe de saúde como bom. conclusões: o internamento do filho foi a principal causa do abandono do aleitamento materno, e os principais fatores de relactação foram a sucção efetiva, a disposição das mães e o apoio. palavras-chave (fonte: decs) aleitamento materno; transtornos da lactação; nutrição do lactente; métodos de alimentação; cuidado da criança. * artigo derivado de um projeto de pesquisa financiado pelo centro de investigación para el desarrollo y la investigación e pela clínica universitaria bolivariana. 5 causas de abandono de la lactancia materna y factores de éxito para la relactación l dora isabel giraldo montoya y otros introducción la lactancia materna es una de las recomendaciones de la organización mundial de la salud (oms), que plantea, aumentarla de forma exclusiva en un 50 % para 2025 (1). también se considera la mejor opción para alimentar a bebés prematuros de cualquier edad gestacional y está asociada con una menor incidencia de infecciones, con un aumento de peso adecuado y con la prevención de enfermedades como la obesidad (2, 3) si la lactancia ha sido descontinuada o si la producción de leche ha disminuido, esta puede ser restablecida empleando la técnica llamada relactación, la cual se define como el restablecimiento de la producción de leche materna por parte de una mujer que ha interrumpido el amamantamiento, o también como el reinicio o incremento de la producción de leche cuando esta ha disminuido o cesado completamente. una mujer que ha interrumpido la lactancia de su hijo, recientemente o en el pasado, puede volver a producir leche para su propio hijo o para uno adoptado, incluso sin un embarazo adicional (4, 5). entre sus beneficios, el estudio de hormann et al. refiere que la relactación es de gran utilidad cuando la lactancia materna se retrasa por hospitalización de los bebés o de las madres, o cuando los bebés fueron prematuros o estuvieron demasiado enfermos para tolerar la ingesta oral (4). por su parte, el estudio de mehta et al. (6) mostró que la relactación es efectiva para aquellas madres que alimentaron a su bebé con leche artificial, que tuvieron problemas en los senos o para los bebés que estuvieron hospitalizados sin vía oral por largo tiempo; los autores concluyeron que, con un buen apoyo a las madres, este proceso puede ser muy exitoso. dehkhoda (2) afirma que se debe intentar restablecer la lactancia en cada oportunidad y en cualquier situación, dado el impacto positivo en el peso diario de los lactantes de su estudio. asimismo, tomar (7) argumenta que la relactación fue una intervención efectiva para promover la lactancia materna exclusiva. la relactación también ha mostrado que tiene beneficios como optimizar la nutrición en los niños y fortalecer el vínculo materno infantil. según el estudio de dehkhoda et al. (2), hubo un impacto positivo en el peso diario de los lactantes —con una tendencia creciente— y en el aumento del vínculo entre la madre y el lactante. igualmente, el estudio de lommen, brown y hollist (8) mostró que el vínculo entre madre e hijo se fortaleció cuando se forjó el contacto con los ojos a través del proceso de relactación, y la investigación de cazorla et al. (9) expuso que en el proceso de la lactancia materna inducida aumentó la cercanía entre la madre y el niño. la técnica de la relactación se establece cuando la producción de leche ha disminuido o se ha abolido por falta de estímulo o en ausencia de embarazo y se reactiva mediante la estimulación del pezón y terapia psicoafectiva, hasta producir la cantidad de leche suficiente para el bebé (2, 7, 10, 11). una de las técnicas de relactación consiste en conectar el extremo inferior de una sonda orogástrica a un vaso con alimento lácteo, y el otro extremo, a la boca del niño junto al pezón, con la finalidad de proporcionar un flujo continuo de alimento mientras esté amamantándose, estimulando así el pecho y el pezón (4). la motivación de la madre y el apoyo de la familia y del personal de salud son los principales factores de éxito para conseguir la relactación, como lo argumentaron el estudio de dehkhoda et al. (2) y otras investigaciones (2, 6, 12). en nuestra región, se desconocen la relactación y sus ventajas. así lo demostró el estudio de calderón et al (13), quienes encontraron que el 60,5 % del personal de enfermería desconocía el significado de la relactación. también, el estudio de cazorla et al. (9) refiere que los profesionales de la salud hacen poco para promover la relactación porque no están familiarizados con este proceso. dado este problema, surgió un interés por indagar sobre las causas de abandono de la lactancia materna y los factores de éxito para la relactación en madres con hijos atendidos en una institución de salud de alto nivel de complejidad, donde se presentan a menudo problemas que interfieren con la lactancia materna. la idea es motivar y ayudar a las madres a reiniciar la lactancia y, con ello, contribuir a la disminución de muertes infantiles por desnutrición en los contextos local, regional y nacional. desde esta perspectiva, el presente estudio tuvo como objetivo identificar las causas de abandono de la lactancia materna y los factores de éxito para la relactación en madres con hijos atendidos en una institución de salud de alto nivel de complejidad de la ciudad de medellín, en 2018. metodología estudio; descriptivo, transversal. población: madres con hijos atendidos en una institución de salud. criterios de inclusión: madres con hijos menores de seis meses de edad, pertenecientes 6 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2036 aquichan issn 1657-5997 eissn 2027-5374 al programa familia canguro, hospitalizados en cuidado básico y pediatría y con suspensión de la lactancia materna por más de siete días. criterios de exclusión: madres con trastornos mentales y con vih positivo. muestreo no probabilístico a conveniencia, para un total de cien madres con sus recién nacidos. las investigadoras pasaban diariamente por los servicios seleccionados para verificar que las madres, con sus hijos, cumplieran con los criterios de inclusión. se empleó una encuesta estructurada diseñada por las investigadoras, quienes tienen más de diez años de experiencia en el área materno infantil. se tuvieron en cuenta las variables de mayor relevancia (conocimientos y apoyo de las madres, causas de abandono y factores de éxito), analizadas en estudios científicos sobre relactación (6, 7, 14, 15), y se tomó información del manuscrito de elizabeth hormann y felicity savage —revisado por el grupo de trabajo técnico sobre lactancia materna de la oms—, titulado “relactación: revisión de la experiencia y recomendaciones para la práctica” (4). este sirvió de referente para indagar las variables más significativas y dar respuesta al objetivo del estudio, dado que sustenta las causas de abandono de la lactancia y de éxito para la relactación, con base en la experiencia y evidencia científica de más de diez años. las variables se agruparon en cuatro apartados: 1) características sociodemográficas, obstétricas y del recién nacido; 2) conocimientos, experiencia y apoyo de la madre en la lactancia materna y la relactación; 3) información sobre las causas de abandono de la lactancia materna; y 4) información sobre los factores de éxito para la relactación. para obtener los datos de la técnica de lactancia, se observó a la madre cuando se le pidió pegar a su hijo al pecho, a través de una lista de chequeo, sin que ella recibiera previamente alguna capacitación por parte de las investigadoras; sin embargo, cuando se notaron errores en la técnica, se le dieron instrucciones al respecto. a las variables cuantitativas, se les estimó la media y su desviación estándar y la mediana con rangos intercuartílicos. a las variables cualitativas, se les calcularon las frecuencias absolutas y relativas, y para el análisis estadístico se utilizó el programa epi-info versión 3.5.4. el estudio tuvo el aval del comité de ética de la escuela de ciencias de la salud de la universidad pontificia bolivariana y de la dirección científica de la institución de salud. los investigadores salvaguardaron los principios bioéticos de la investigación en humanos: justicia, respeto, beneficencia y no maleficencia. teniendo en cuenta lo estipulado por la resolución 8430 de 1993, por medio de la cual se establecen las normas científicas, técnicas y administrativas para la investigación en salud, este proyecto se definió como una investigación con riesgo mínimo. se solicitó el consentimiento informado a todas las madres participantes; a las menores de edad, el consentimiento de su representante legal. se garantizó la confidencialidad de la información y se mantuvo el anonimato. resultados características sociodemográficas la edad de las madres tuvo una distribución normal con una p = 0,09, una media de 26,8 años y una desviación estándar de 6,3 años. según el estrato socioeconómico, el 73 % pertenecía a estratos socioeconómicos bajos. sobre el estado civil, el 59 % se encontraba en unión libre. respecto a su escolaridad, el 32 % había cursado el bachillero completo, mientras que el 25 % tenía una carrera técnica. la tabla 1 presenta las características obstétricas y del recién nacido. tabla 1. características obstétricas y del recién nacido variable frecuencia porcentaje paridad ninguna uno > 2 57 11 32 57,0 11,0 32,0 clasificación obstétrica alto riesgo 74 74,0 bajo riesgo 26 26,0 tipo de parto espontáneo 41 41,0 cesárea 59 59,0 edad cronológica del recién nacido <1 mes 48 48,0 1 mes 28 28,0 >2 meses 24 24,0 peso del bebé en gramos al nacer, según la clasificación de la oms 4000 g o más 1 1,0 2500 3999 g 22 22,0 1500 2499 g 52 52,0 1000 1499 g 24 24,0 500 999 g 1 1,0 hospitalización del recién nacido sí no 79 21 79,0 21,0 intervalo de no lactancia 8 30 días 31 90 días >91 días 82 17 1 82,0 17,0 1,0 fuente: elaboración propia. 7 causas de abandono de la lactancia materna y factores de éxito para la relactación l dora isabel giraldo montoya y otros causas de abandono de la lactancia materna el 79 % de los niños estaba hospitalizado, el 52 % presentó bajo peso al nacer y el 24 % presentó muy bajo peso al nacer. el 14 % de las madres estuvo hospitalizado después del parto. en el 18 % de los casos, el personal de salud sugirió complementar la alimentación del bebé con sucedáneos de la leche por hipogalactia. se observó la técnica de amamantamiento como posible causa de abandono y se encontró que muy pocas madres elevaron los pies (5 %), el 35 % apoyó los pies, y el 49 % tuvo la espalda recta. en total, el 66,1 % de las madres presentó una postura incorrecta. el 61 % de las madres no tuvo experiencias previas en lactancia, y el 57 % eran primerizas. factores de éxito para la relactación el 98 % de las madres tenía disposición para relactar. el tiempo mínimo de suspensión de la lactancia fue de ocho días, y el máximo fue de tres meses. el 89 % de los recién nacidos succionó cuando se le puso el pecho. el tipo de alimentación del lactante durante el tiempo transcurrido sin amamantar directamente del pecho fue mixta, en el 72 % (leche materna y leche artificial), y solo artificial, en el 28 %. el 91 y el 85 % de las madres respondieron que el apoyo de sus familias y del personal de salud fue bueno, respectivamente. se observó que la mayoría de los bebés presentaron un buen agarre al pecho (el mentón del lactante estaba tocando o casi tocando el pecho [69 %], el labio inferior estaba evertido [75 %], la boca estaba muy abierta [69 %], se observaba más areola por encima del labio superior [71 %]). la postura del bebé, en la mayoría de los casos, estuvo correcta (la madre sostuvo todo el cuerpo del lactante con su brazo [62 %], el cuerpo del lactante estuvo pegado al cuerpo de la madre [57 %], la cabeza y el cuerpo del bebé estuvieron bien alineados [70 %]). la experiencia de la madre en lactancia materna se consideró un factor de éxito, dado que el 90 % no tuvo dificultades para pegar al bebé al pecho. discusión nuestro estudio encontró que los bebés hospitalizados, con bajo y muy bajo peso al nacer, las madres hospitalizadas y la hipogalactia favorecieron el abandono de la lactancia materna de modo precoz. contrario a este hallazgo, el estudio de lópez et al. (14) mostró que el estado de salud del hijo y de la madre no fue una razón importante para suspender la lactancia de manera precoz, con un porcentaje del 11,63 %. oribe et al. (15) refieren que la razón hallada con más frecuencia fue la laboral (31,1 %), seguida de la hipogalactia (19,4 %). el estudio de vila candel et al. (16) reportó que la hipogalactia (21,8 %) y un aumento de peso del recién nacido inferior al recomendado (14,9 %) fueron los factores más frecuentes que motivaron el abandono precoz. es importante tener en cuenta que estos tres estudios captaron la población en el ámbito ambulatorio, situación que es diferente al contexto donde se realizó la presente investigación. en el ámbito hospitalario, lau (17) refiere que la hospitalización prolongada en el entorno austero de una unidad de cuidado intensivo neonatal se vio interrumpida al inicio temprano de la lactancia materna, así como en el caso de aquellos bebés con afecciones crónicas, como displasia broncopulmonar y anomalías cardíacas o congénitas. mehta et al. (6) estudiaron a madres hospitalizadas con sus bebés y mostraron que el 31,24 % de estas suspendieron la lactancia por bajo flujo de leche, debido al estado de salud de los recién nacidos. la investigación de gianni et al. (18) mostró que el 71 % de los neonatos presentó al menos una comorbilidad durante su estancia en el hospital; el 23 % tuvo dificultades respiratorias; el 18 %, hipoglucemia; y el 35 %, ictericia. esto significó una barrera para la lactancia materna. en nuestro estudio, otra de las razones de abandono fue que el personal de salud sugirió alimentar al recién nacido con sucedáneos de la leche por hipogalactia y por recibir medicamentos incompatibles con la lactancia materna. igualmente, el estudio de oribe et al. (15) refiere que el profesional sanitario fue la fuente principal para suspender la lactancia, pero el motivo aludido fue la escasa ganancia de peso (70,8 %). otros estudios encontraron que la causa más importante de abandono fue la percepción, por parte de la madre, de leche insuficiente o hipogalactia. así, consideramos que es importante intervenir, de manera inmediata, a aquellas madres que manifiestan expresiones del tipo “se me secó o no me baja la leche” y analizar si es una percepción errónea sobre la hipogalactia, para evitar el abandono temprano de la lactancia. tomar (7) mostró que la causa más común (con el 53,1 %) fue la leche insuficiente. como lo expresa vila et al. (16), es importante considerar que la mayor parte de los motivos de hipogalactia expresados por las madres se basan en percepciones subjetivas, que pueden estar afectadas por una gran variedad de factores externos, incluidos los consejos profesionales. 8 año 20 vol. 20 nº 3 chía, colombia julio-septiembre 2020 l e2036 aquichan issn 1657-5997 eissn 2027-5374 en el presente estudio, se mostró que la posición para lactar en la mayoría de las madres no fue la correcta, y consideramos este aspecto una barrera para la lactancia. los estudios presentados por borre ortiz et al. (19) y por mehta et al. (6) presentaron resultados similares, pues ninguna madre conocía la posición correcta. por su parte, gallardo et al. (20) mostró que las enfermeras, al evaluar la técnica de amamantamiento, descubrieron que la mitad de los casos fue regular (50 %). también encontramos que la mayoría de las madres no tenía experiencia previa en lactancia materna, posiblemente porque eran primíparas, jóvenes y tuvieron el parto por cesárea. el estudio de crippa et al. (21) identificó que la cesárea tuvo un efecto negativo en el inicio temprano de la lactancia, y que factores como la edad, el origen étnico, la educación, experiencias desfavorables con la lactancia, tener gemelos y la sensación de reducción de la producción de leche fueron factores de riesgo para su interrupción temprana. los estudios de oribe et al. (15), tomar (7) y mehta et al. (6) expresan que la experiencia previa de lactancia en una mujer puede tener un efecto sobre su capacidad para relactar, puesto que esta probabilidad es mayor en aquellas mujeres que han amamantado previamente. el estudio de zingler et al. (22) refiere que la relactación es posible en aquellas madres que alquilan vientres, pero que la inducción de la lactancia en este grupo tuvo como objetivo ofrecer a la madre y al niño la posibilidad de experimentar los beneficios emocionales y afectivos de la lactancia materna, consolidar el vínculo madre-hijo y permitir la transferencia de anticuerpos protectores de la madre, más que la producción de leche suficiente como tal. el estudio comparativo de crippa et al. (21) encontró que el 57 % de las madres extranjeras que habían tenido experiencias positivas de lactancia materna tenían una mayor probabilidad de amamantar a demanda frente al 45,5 % de mujeres italianas con la misma situación. también encontramos que las madres de la institución de salud donde se desarrolló el presente estudio cumplen con condiciones para que la relactación sea exitosa, como el apoyo de la familia y del personal de salud. la mayoría respondió que el apoyo por parte de los funcionarios de los servicios de neonatos y del programa canguro, así como de la familia, fue bueno. igualmente, hormann y savage (4) expresan que los factores relacionados con el éxito de la relactación son el apoyo de su familia y del personal de salud. el estudio de mehta et al. (6) reportó que la relactación fue posible en el 100 % de las madres cuando recibieron el apoyo continuo y positivo de los miembros de la familia y de los trabajadores de salud capacitados. los estudios de azabache y caravedo (5) y gianni et al. (18) refieren la influencia de la educación y de la motivación materna en el éxito de la lactancia y en la relactación. esto resulta imprescindible, pues la madre participará de un proceso difícil que demandará de ella mucha dedicación, paciencia y perseverancia. otro factor de éxito encontrado fue que la mayoría de las madres estaban dispuestas para reiniciar la lactancia materna. una situación similar se observó en el estudio de azabache y caravedo (5), que refiere que el 93,7 % de las madres tuvo el deseo de dar pecho a su bebé, de forma exclusiva, antes del parto. el estudio de lommen, brown y hollist (8) reportó algunas de las razones que motivaron a las madres para reiniciar la lactancia: el deseo de brindar una mejor nutrición a su bebé y de desarrollar un vínculo más cercano con su hijo y un “instinto” que las motivaba a reiniciarla. en el presente estudio, se mostró que el intervalo de no lactancia más frecuente fue de 8 a 30 días, resultado que consideramos positivo, dado que el documento revisado por un grupo de expertos de la oms (4) argumenta que el éxito de la relactación está relacionado con el intervalo de la no lactancia. asimismo lo reportó el estudio de tomar (7), quien encontró que mientras el intervalo de no lactancia fue de 15 a 30 días, el éxito de la relactación fue del 95 %, pero cuando el intervalo fue mayor de 60 días, el éxito fue del 52,6 %. estos resultados mostraron que la incidencia de falla se incrementó con el aumento de la brecha en el tiempo de lactancia. la mayoría de las mujeres pueden relactar en cualquier momento (incluso años) después del nacimiento de su último hijo, pero resulta más sencillo para las mujeres que han suspendido la lactancia recientemente o si el lactante succiona de forma ocasional (4). en nuestro estudio, encontramos que cuando se le pidió a la madre poner al bebé al pecho para observar la técnica de lactancia, gran parte de los recién nacidos succionaron y tuvieron un buen agarre, aspecto que consideramos positivo para la relactación. el estudio de gianni et al. (18) afirma que los factores relacionados con el bebé, como la inmadurez del desarrollo, generalmente acarrean problemas como dificultad para prenderse, letargia y succión ineficaz, que pudieron predisponerlos a malos resultados en la iniciación de la lactancia materna. sin embargo, agrega que se ha demostrado que los bebés muy prematuros desarrollan una succión nutritiva competente en edades gesta9 causas de abandono de la lactancia materna y factores de éxito para la relactación l dora isabel giraldo montoya y otros cionales bajas (18). sobre el agarre correcto, crippa et al. (21) estudiaron los problemas de la lactancia en los neonatos prematuros tardíos y mostraron que el 29,5 % de este grupo de bebés tuvo un mal agarre antes del alta y menos probabilidades de ser amamantados exclusivamente después del alta además de que requirieron más tiempo para adquirir habilidades de lactancia materna. en nuestro estudio, la mayoría de los lactantes tenía una edad cronológica menor de un mes, resultado que es favorable en la medida que hay mayor posibilidad de éxito para la relactación, como también lo afirman hormann y savage (4). el estudio de mehta et al. (6) encontró una asociación entre una relactación exitosa y una edad del lactante menor de seis semanas, resultado que es estadísticamente significativo con p <0,001. de otro lado, el estudio de tomar (7) refiere que la relactación fue exitosa en el 95,5 % de los casos, cuando los bebés eran menores de dos meses, mientras que solo fue exitosa en el 64,5 % de los casos, cuando los bebés tenían más de cuatro meses de edad. en cuanto al tipo de alimentación recibida durante el tiempo transcurrido sin amamantar directamente al pecho, fue en su mayoría mixta (leche materna y leche artificial). este fue un dato favorable para el reinicio exitoso de la lactancia porque se mantuvo el estímulo del pecho. el estudio de tomar (7) mostró que el 88 % de los bebés fueron alimentados con biberón y el 37,2 % tomaba leche animal. a partir de ahí, refirió que los bebés alimentados con biberón tardaron más tiempo en iniciar la relactación debido a la confusión del pezón. este estudio concluye que la principal causa de abandono de la lactancia fue la hospitalización del hijo, seguida del bajo peso al nacer, madres primerizas sin experiencias previas en lactancia y la posición incorrecta de la madre para lactar. los factores de éxito fueron el apoyo de la familia y del personal de salud, la motivación de las madres, un intervalo menor de no lactancia, la succión efectiva del bebé y una edad cronológica menor de un mes de vida. con los resultados, se implementó un protocolo de cuidado sobre relactación en la institución donde se desarrolló el presente estudio, que se adaptó a las características y condiciones de salud de la población materno infantil de alta complejidad, con el fin de contribuir al restablecimiento de la salud de los menores, a su sano crecimiento y desarrollo y al fomento del vínculo materno infantil. dicho protocolo de cuidado en relactación se diseñó para las madres del programa familia canguro, e incluye las siguientes fases: 1) indagar por la motivación de la madre para relactar; 2) escuchar a la madre y reforzar su confianza; 3) valorar, desde enfermería, a la madre y al recién nacido; 4) estimular la glándula mamaria si hay producción de leche; y 5), utilizar un relactador si no hay producción de leche. esta iniciativa da prioridad a la lactancia materna para que sea restablecida cuando se haya interrumpido y promueve un apoyo permanente a la madre en este proceso por parte del profesional de enfermería. conflicto de interés: ninguno declarado. referencias 1. organización mundial de la salud. plan de aplicación integral de nutrición materna, del lactante y del niño pequeño [internet]. washington: oms; 2014 [citada 2019 nov. 13]. disponible en: https://apps.who.int/iris/bitstream/handle/10665/130456/who_nmh_nhd_14.1_spa.pdf;jsessionid=616123d0b32fa93a4170424035b34480?sequence=1 2. dehkhoda n, valizadeh s, jodeiry b, hosseini mb. the effects of an educational and supportive relactation program on weight gain of preterm infants. j caring 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30(2):115-127. doi: https://doi.org/10.7764/horiz_enferm.30.2.115-127 14. lópez be, martínez lj, zapata nj. motivos del abandono temprano de la lactancia materna exclusiva: un problema de salud pública no resuelto en la ciudad de medellín. rev fac nac salud pública. 2013 [citada 2019 jul. 13]; 31(1):117-126. disponible en: http://www.scielo.org.co/scielo.php?pid=s0120-386x2013000100014&script=sci_abstract&tlng=es 15. oribe m, lertxundi a, basterrechea m, begiristain h, santa marina l, villar m et al. prevalencia y factores asociados con la duración de la lactancia materna exclusiva durante los 6 primeros meses en la cohorte inma de guipúzcoa. gac sanit. 2015;29(1):4-9. doi: https://doi.org/10.1016/j.gaceta.2014.08.002 16. vila r, soriano fj, murillo m, pérez m, castro e. mantenimiento de la lactancia materna exclusiva a los 3 meses posparto: experiencia en un departamento de salud de la comunidad valenciana. aten primaria. 2019;51(2):91-98. doi: https:// doi.org/10.1016/j.aprim.2017.09.002 17. lau c. breastfeeding challenges and the preterm mother-infant dyad: a conceptual model. breastfeed med. 2018;13(1):817. doi: https://doi.org/10.1089/bfm.2016.0206 18. giannì ml, bezze e, sannino p, stori e, plevani l, roggero p, et al. facilitators and barriers of breastfeeding late preterm infants according to mothers’ experiences. bmc pediatr. 2016;16(1):179. doi: https://doi.org/10.1186/s12887-0160722-7 19. borre ym, cortina c, gonzález g. lactancia materna exclusiva: ¿la conocen las madres realmente? rev cuid. 2014;5(2):723-730. doi: https://doi.org/10.15649/cuidarte.v5i2.84 20. gallardo j, garcía c, lujano j, pifano v, alejos m. enfermería en las prácticas de lactancia materna exclusiva y de las técnicas de amamantamiento. salud, arte y cuidado. 2017 [citada 2019 jul. 13];10(1):33-44. disponible en: https:// revistas.ucla.edu.ve/index.php/sac/article/view/566/ 21. crippa bl, colombo l, morniroli d, consonni d, bettinelli me, spreafico i et al. ¿do a few weeks matter? late preterm infants and breastfeeding issues. nutrients. 2019;11(2):1-9. doi: https://doi.org/10.3390/nu11020312 22. zingler e, amorim a, zanatta a, brito m, da silva m, mariani c, et al. lactation induction in a commissioned mother by surrogacy: effects on prolactin levels, milk secretion and mother satisfaction. rev bras ginecol obstet 2017;39(02): 086-089. doi: https://doi.org/10.1055/s-0037-1598641 http://doi.org/10.20453/rmh.v3i1.362 https://doi.org/10.24911/sjp.2018.1.6 https://doi.org/10.18203/2349-3291.ijcp20161054 https://doi.org/10.1177/0890334415581646 https://doi.org/10.1177/0890334419852939 https://doi.org/10.1177/0890334419852939 https://doi.org/10.1177/0890334416682007 https://doi.org/10.15253/2175-6783.2014000200009 https://doi.org/10.1089/bfm.2014.0049 https://doi.org/10.7764/horiz_enferm.30.2.115-127 http://www.scielo.org.co/scielo.php?pid=s0120-386x2013000100014&script=sci_abstract&tlng=es https://doi.org/10.1016/j.gaceta.2014.08.002 https://doi.org/10.1016/j.aprim.2017.09.002 https://doi.org/10.1016/j.aprim.2017.09.002 https://doi.org/10.1089/bfm.2016.0206 https://doi.org/10.1186/s12887-016-0722-7 https://doi.org/10.1186/s12887-016-0722-7 https://doi.org/10.15649/cuidarte.v5i2.84 https://revistas.ucla.edu.ve/index.php/sac/article/view/566/ https://revistas.ucla.edu.ve/index.php/sac/article/view/566/ https://doi.org/10.3390/nu11020312 https://doi.org/10.1055/s-0037-1598641 1 vanessa almeida maia damasceno1 marisa silvana zazzetta2 fabiana de souza orlandi3 adaptação da escala para medir a habilidade de cuidado de cuidadores familiares de pessoas com doença crônica no brasil* 1 https://orcid.org/0000-0002-3367-7996. universidade federal de são carlos, brasil. 2 https://orcid.org/0000-0001-6544-767x. universidade federal de são carlos, brasil. marisam@ufscar.br 3 https://orcid.org/0000-0002-5714-6890. universidade federal de são carlos, brasil. forlandi@ufscar.br * este trabalho teve apoio financeiro da coordenação de aperfeiçoamento de pessoal de nível superior (capes) em forma de bolsa de estudos, concedido à primeira autora, e do conselho nacional de desenvolvimento científico e tecnológico (cnpq), brasil. recebido: 17/02/2019 submetido: 12/03/2019 aceito por pares: 13/08/2019 aceito: 01/09/2019 doi: 10.5294/aqui.2019.19.4.8 para citar este artigo / para citar este artículo / to reference this article damasceno vam, zazzetta ms, orlandi fs. adapting the scale to measure the care ability of family caregivers of people with chronic diseases in brazil. aquichan 2019; 19(4): e1948. doi: https://doi.org/10.5294/aqui.2019.19.4.8 resumo objetivo: traduzir e adaptar culturalmente a escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica para o contexto brasileiro. materiais e método: trata-se de um estudo metodológico que seguiu as etapas preconizadas por dorcas beaton para tradução e adaptação cultural da referida escala no brasil. todos os preceitos éticos foram respeitados. resultados: a tradução inicial do instrumento para o português brasileiro realizou-se por dois tradutores; em seguida, estabeleceu-se a versão consensual, a qual se retrotraduziu para o espanhol por outro tradutor independente. o comitê de especialistas contou com sete profissionais da área da saúde, obtendo-se índice de validade de conteúdo (ivc) = 1,00 em 41 itens, ivc = 0,86 em três itens e ivc = 0,71 em quatro itens. após a adequação dos sete itens, aplicou-se o pré-teste com 14 cuidadores familiares de pessoas com doenaño 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1948 temática: cuidado crônico. contribuição para a disciplina: o cuidador é o ponto central no processo de tratamento e está diretamente ligado ao paciente. nesse contexto, este estudo contrubui para verificar sua habilidade e/ou competência para o cuidado, uma vez que tal variável interfere diretamente no tratamento e na qualidade de vida do paciente. no âmbito da saúde, desenvolver o ciclo de cuidado do paciente crônico pautado em instrumento adaptado e validado para o contexto dele é relevante, pois favorecerá a análise de aspectos do cuidador que implicam diretamente a qualidade do cuidado ofertado. quanto ao ensino, a disponibilização de instrumentos de avaliação contribui para formar os profissionais, implantar pesquisas em saúde e nas áreas assistenciais, e é fundamental para compilar ações preventivas e de tratamento aos cuidadores familiares. https://orcid.org/0000-0002-3367-7996 https://orcid.org/0000-0001-6544-767x https://orcid.org/0000-0002-5714-6890 https://doi.org/10.5294/aqui.2019.19.4.8 https://orcid.org/0000-0002-3367-7996 https://orcid.org/0000-0001-6544-767x https://orcid.org/0000-0002-5714-6890 https://doi.org/10.5294/aqui.2019.19.4.8 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1948 ça renal crônica; a partir disso, foi possível verificar as dificuldades dos participantes e, assim, rever os itens. conclusões: finalizado o processo de tradução e adaptação, obtém-se a versão brasileira do instrumento intitulada de “escala para medir a habilidade de cuidado de cuidadores familiares de pessoas com doença crônica”. palavras-chave (fonte: decs) tradução; estudo transcultural; enfermagem transcultural; avaliação de necessidades; determinação de necessidades de cuidados de saúde; habilidade; aptidão; cuidadores; brasil. adaptación de la escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica en brasil* resumen objetivo: traducir y adaptar culturalmente la escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica para el contexto brasileño. materiales y método: se trata de un estudio metodológico que siguió las etapas preconizadas por dorcas beaton para traducción y adaptación cultural de la referida escala en brasil. todos los principios éticos se respetaron. resultados: la traducción inicial del instrumento para el portugués se realizó por dos traductores; luego, se estableció la versión consensual, la que se retrotradujo al español por otro traductor independiente. el comité de expertos contó con siete profesionales del área de la salud, obteniéndose índice de validez de contenido (ivc) = 1,00 en 41 ítems, ivc = 0,86 en tres ítems y ivc = 0,71 en cuatro ítems. tras la adecuación de los siete ítems, se aplicó la preprueba con 14 cuidadores familiares de personas con enfermedad crónica; de ahí, se logró encontrar las dificultades de los participantes y, así, revisar los ítems. conclusiones: terminado el proceso de traducción y adaptación, se obtuvo la versión brasileña del instrumento titulada “escala para medir a habilidade de cuidado de cuidadores familiares de pessoas com doença crônica”. palabras clave (fuente: decs) traducción; estudio transcultural; enfermería transcultural; evaluación de necesidades; determinación de necesidades de cuidados de salud; habilidad; aptitud; cuidadores; brasil. * este artículo tuvo apoyo financiero de la coordenação de aperfeiçoamento de pessoal de nível superior (capes), por medio de una beca concedida a la primera autora, y del conselho nacional de desenvolvimento científico e tecnológico (cnpq), brasil. 3 adaptação da escala para medir a habilidade de cuidado de cuidadores familiares de pessoas com doença crônica no brasil l vanessa almeida maia damasceno e outros adapting the scale to measure care ability of family caregivers of people with chronic diseases in brazil* abstract objective: to translate and culturally adapt the scale to measure the care ability of family caregivers of people with chronic diseases to the brazilian context. materials and methods: this is a methodological study that followed the steps recommended by dorcas beaton for translating and culturally adapting this scale in brazil. all ethical precepts have been respected. results: the first translation of the instrument into brazilian portuguese was done by two translators; the consensual version was then established, which was back-translated into spanish by another independent translator. the committee of specialists comprised seven health professionals, obtaining a content validity index (cvi) = 1.00 in 41 items, cvi = 0.86 in three items and cvi = 0.71 in four items. after adjusting the seven items, a pretest was applied to 14 family caregivers of people with chronic kidney disease. based on this, the participants’ difficulties were observed, and then the items were reviewed. conclusions: after the translation and adaptation process was completed, the brazilian version of the instrument entitled “scale to measure the care ability of family caregivers of people with chronic diseases” was obtained. keywords (source: decs) translation; cross-cultural study; cross-cultural nursing; needs assessment; assessment of health care needs; ability; aptitude; caregivers; brazil. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1948 * this study was funded by the coordenação de aperfeiçoamento de pessoal de nível superior (capes). the first author was awarded a grant from this agency. this study was also funded by the conselho nacional de desenvolvimento científico e tecnológico (cnpq), brazil. 4 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1948 aquichan issn 1657-5997 eissn 2027-5374 introdução a doença crônica não transmissível (dcnt) pode ser definida como permanente ou de longa duração. devido às alterações fisiopatológicas, é considerada quase ou totalmente incapacitante (1), portanto pode levar à perda da renda, à dependência física, à necessidade de cuidadores, entre outros (2). o paciente, nessa condição, sente as modificações causadas pela doença que, por sua vez, geram um processo de adaptação dele e dos familiares, principalmente o familiar responsável pelo cuidado (3). embora o paciente tenha a assistência do serviço de saúde, necessita de um cuidador. na maioria das vezes, trata-se de um cuidador familiar, mulher, sem remuneração e sem conhecimento específico sobre a doença (4). é importante salientar que esse cuidador tem a sua vida diária modificada para que possa se dedicar ao cuidado do seu ente querido (5). a família que cuida realiza tarefas de natureza diversificada, relacionadas com as atividades da vida diária, as quais abrangem desde cuidados com higiene, alimentação, tarefas domésticas, atenção, conforto, tratamento, socialização, administração de medicação, acompanhamento em consultas médicas, até outras atividades, como gerir aspectos econômicos (5). o ato de cuidar causa estresse, esgotamento mental e físico, sobrecarga, podendo, inclusive, gerar dificuldades no desempenho da função de cuidar, o que compromete os cuidados prestados e a sua vida como um todo. além disso, há a falta de pessoas para dar um suporte físico, emocional, financeiro e até mesmo dar instruções técnicas do tratamento (6). pensando nas competências e nas habilidades para o cuidado, podemos definir competência como o desempenho de cada indivíduo para determinado trabalho e/ou tarefa. relaciona-se com o aspecto do conhecimento e com as habilidades desenvolvidas para tal função, porém a competência não se reduz simplesmente ao aspecto do conhecimento, ela envolve também a capacidade que a pessoa tem de iniciar o que lhe foi solicitado, assumi-lo e se responsabilizar por isso (7). a competência para o cuidado envolve vários aspectos, como a capacidade de coordenar o tratamento, a anteposição a problemas e o fortalecimento do vínculo afetivo da família. à medida que o cuidador familiar adquire mais conhecimentos e habilidades para lidar com os momentos de cuidado, o seu enfrentamento melhora, o que eleva a qualidade do cuidado (8). a habilidade de cuidado do cuidador é a capacidade que ele possui e sua experiência em cuidar de pessoas com doença crônica (dc). para os referidos autores, essa habilidade que o cuidador precisa ter para cuidar adequadamente envolve três dimensões: relação, compreensão e modificação da vida (9). além disso, o cuidador familiar é a pessoa com maior responsabilidade por prestar assistência básica ao familiar cuidado, dando apoio tanto nas atividades de vida diária como na participação e até mesmo na tomada de decisões sobre a pessoa cuidada (9). na universidade nacional da colômbia, o grupo de cuidado de enfermería al paciente crónico vem investigando a habilidade de cuidado do cuidador desde 2004. em 2008, barrera (10) elaborou e validou a escala habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica, a qual continha 55 itens. entretanto, em 2014, após diversas pesquisas (11-14) das propriedades psicométricas do referido instrumento, disponibilizou outra versão com 48 itens, que incluiu relação (23 itens), compreensão (17 itens) e mudança na rotina (8 itens), e foi denominada como “escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica”. a dimensão “relação” refere-se ao vínculo entre a pessoa cuidada e o cuidador, para ajudar aquela com orientações e atitudes, busca de apoio nas situações de sobrecarga, restrição e dependência; a dimensão “compreensão” indica a capacidade que o cuidador tem em entender a situação, organiza o que lhe é exigido e considera a agilidade em aprender com a situação vivenciada pelo doente, bem como seus comportamentos e habilidades para o cuidado, a fim de reconhecer e aceitar o processo da doença e do tratamento. a “mudança na rotina” abrange a capacidade de aceitar as mudanças ocasionadas em sua vida por ser um cuidador familiar e a recompensa pessoal por tal ato (14). no brasil, existem instrumentos que avaliam aspectos físicos e emocionais de cuidadores, porém são escassos os estudos com dados normativos para o contexto brasileiro que avaliem a habilidade de cuidado do cuidador familiar de pessoas com dc (15). assim, é importante ressaltar que a tradução e a adaptação cultural de instrumentos de avaliação em diversas culturas facilitam a comparação de dados em diferentes países (16). 5 adaptação da escala para medir a habilidade de cuidado de cuidadores familiares de pessoas com doença crônica no brasil l vanessa almeida maia damasceno e outros portanto, é de suma importância disponibilizar um instrumento traduzido e adaptado para o contexto brasileiro que investigue a habilidade de cuidado especificamente do cuidador familiar de pessoas com dc, uma vez que essas habilidades interferem diretamente no tratamento, bem como na vida de seus cuidadores. diante do exposto, esta pesquisa teve como objetivo traduzir e adaptar culturalmente a “escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica” para o contexto brasileiro. materiais e método trata-se de uma pesquisa metodológica que visa à tradução e à adaptação cultural da escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica, do espanhol para o português do brasil. esse tipo de estudo demanda planejamento prévio de todas as etapas, uma vez que o processo de tradução e adaptação cultural é realizado para ter equivalência entre o idioma de origem e o de destino (16). o estudo seguiu as cinco etapas preconizadas por beaton et al. (17), conforme se verifica na figura 1. após ser concedida formalmente a autorização da autora do instrumento original para o desenvolvimento das etapas da versão brasileira da escala, que atendeu ao rigor ético e científico, a pesquisa foi aprovada pelo comitê de ética em pesquisa em seres humanos da universidade federal de são carlos, sob o parecer n.o 1.435.698, e respeitou plenamente as recomendações da resolução 466/2012 do conselho nacional de saúde do ministério de saúde. a tradução e a adaptação cultural contaram com as seguintes etapas: tradução inicial; síntese das traduções e consenso; retrotradução (back-translation); revisão por um comitê de especialistas; e pré-teste. a primeira etapa foi realizada com a tradução inicial do espanhol (versão original) para o português brasileiro. essa etapa foi realizada por dois tradutores independentes e qualificados. ambos atendiam aos critérios necessários para a tradução: possuir proficiência em língua espanhola e domínio do português brasileiro. ambos possuíam expertise na área de tradução relacionada à saúde, conhecimento de termos específicos e conhecimento do objetivo da pesquisa. foram enviadas aos tradutores a versão original e uma carta explicativa; dessa etapa, originaram-se a versão traduzida 1 (vt1) e a versão traduzida 2 (vt2). a segunda etapa da pesquisa contou com a síntese das traduções (vt1 e vt2) e a formação da versão consensual (vc), realizada entre tradutores e pesquisadoras. na terceira fase, ocorreu a retrotradução (back-translation) por um terceiro tradutor, que possuía expertise na área e no idioma espanhol. o sigilo quanto ao objetivo da pesquisa foi mantido, a fim de não ter interferências. posteriormente, a versão retrotraduzida (vrt) do instrumento foi encaminhada para a autora, a qual deu a aprovação. na quarta etapa, foi realizada a adaptação cultural, que contou com a avaliação de conteúdo e com a análise de equivalência figura 1. esquema do modelo metodológico e das fases adotadas no processo de tradução e adaptação cultural da escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica vt1* (versão traduzida 1), vt2** (versão traduzida 2), vc*** (versão consensual), vrt**** (versão retrotraduzida) e vpf***** (versão pré-final) fonte: elaboração própria que seguiu as diretrizes para o processo de adaptação transcultural de medidas de autorrelato (17). autorização para a tradução e a adaptação cultural tradução do idioma de origem (espanhol) para o idioma a ser adaptado (português brasileiro) vt1* vt2** síntese das traduções vc*** vrt**** revisão pelo comitê de especialistas vpf***** pré-teste versão final et ap a 5 et ap a 4 et ap a 3 et ap a 2 et ap a 1 m od el o m et od ol óg ic o be at on e t a l. (1 7) 6 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1948 aquichan issn 1657-5997 eissn 2027-5374 cultural. nessa fase, foi formado um comitê de especialistas, com sete integrantes, todas professoras doutoras, com atuação em pesquisa e/ou com experiência assistencial ao cuidador e com domínio do idioma espanhol. após aceitarem fazer parte do comitê, foi encaminhada uma carta explicativa a fim de sanar as dúvidas sobre o instrumento e as análises solicitadas. logo, o instrumento foi analisado como um todo e foi estabelecida a versão pré-final (vpf) do instrumento em português brasileiro. na quinta etapa, a vpf do instrumento foi pré-testada com cuidadores familiares de pessoas com dc; participaram do pré-teste 14 cuidadores familiares de pessoas com doença renal crônica (drc) em hemodiálise. o local do estudo foi em uma unidade de terapia renal substitutiva (utrs) do interior do estado de são paulo. a coleta de dados foi realizada entre março e abril de 2017. os critérios de inclusão foram: ser familiar de uma pessoa com drc em hemodiálise da referida utrs, ter idade igual ou superior a 18 anos, ser cuidador principal do familiar e saber ler e escrever. todos os participantes foram entrevistados individualmente, em uma sala privativa da própria utrs, após a assinatura do termo de consentimento livre e esclarecido. inicialmente, foram abordados os cuidadores acompanhantes dos pacientes que se encontravam na utrs e foram indagados quanto ao grau de parentesco com o paciente; além disso, verificou-se se os cuidadores cumpriam com o critério de inclusão. em seguida, foram apresentados os objetivos da pesquisa. a entrevista contou com a aplicação de três instrumentos. o primeiro deles foi um questionário de caracterização do cuidador (informações sociodemográficas). o segundo foi a versão pré-final do instrumento de habilidade de cuidado de cuidadores familiares de pessoas com dc, o qual estava acrescido de duas colunas, a fim de se verificar a clareza dos termos e obter sugestões. o terceiro foi um questionário geral de avaliação da clareza do instrumento, adaptado do disabkids (18). os dados coletados foram planilhados no programa excel for windows e processados no software statistical package for social science (spss), versão 20.0, no qual foram realizadas as análises descritivas referentes às características sociodemográficas dos participantes do pré-teste. também foi calculado o índice de validade de conteúdo (ivc) dos 48 itens da escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermidad crónica. para tanto, os juízes avaliaram todos os itens do instrumento em uma escala likert de resposta, que variou de um a quatro pontos. para a análise do ivc, foi utilizado o critério proposto por lynn em 1986 (18), em que é preconizado que, para seis ou mais juízes, o valor esperado seja acima de 0,78 (18). resultados no processo de tradução do original, que levou às versões 1 e 2, o tradutor 1 — apenas esse tradutor expôs dificuldade no processo de tradução — relatou que, em algumas questões da escala original, utilizava-se o termo “familiar” e, em outras, a expressão “familiar doente”, sem padronização. as demais diferenças entre as traduções se referiram a léxico, regência e tempos verbais, e não comprometeu o conteúdo. em seguida, as pesquisadoras, juntamente com os tradutores, estabeleceram a versão consensual da escala, a qual passou por um processo de retrotradução, realizado por outro tradutor. dando sequência ao processo, a versão retrotraduzida da escala foi encaminhada à autora, para que ela pudesse verificar a fidelidade ao instrumento original, o qual obteve a sua aprovação sem objeções. a autora do instrumento não fez objeções e concordou com a versão adaptada ao contexto brasileiro. o comitê de especialistas analisou item por item do instrumento, com base em uma escala likert. quando necessário, sugeriram alterações. posteriormente, foi verificado o ivc. dos 48 itens avaliados, 41 itens obtiveram ivc = 1,00, três itens apresentaram ivc = 0,86 e quatro itens alcançaram ivc = 0,71. a fim de disponibilizar o instrumento de forma clara e de fácil compreensão, os itens que obtiveram valor inferior a 1,00 foram revistos (tabela 1), apesar de ser preconizada, na literatura, a obrigatoriedade de revisão somente dos itens com ivc igual ou inferior a 0,78. após a revisão do instrumento pelos especialistas, pelas pesquisadoras e pelos tradutores, foi estabelecida a versão préfinal da escala, que foi submetida ao pré-teste. no pré-teste, a amostra foi composta por 14 cuidadores familiares de pessoas com drc, com idade entre 27 e 66 anos, com média de 49,92 (dp = 11,11) anos; em sua maioria, mulheres (78,58 %), com estado civil casado (78,58 %) e ensino fundamental incompleto (78,58 %) (tabela 2). 7 adaptação da escala para medir a habilidade de cuidado de cuidadores familiares de pessoas com doença crônica no brasil l vanessa almeida maia damasceno e outros com relação ao tempo em que o cuidador cuida do familiar, variou de 3 a 96 meses, com uma média de 29,42 meses (dp = 25,16). já com relação ao tempo de dedicação do dia para as atividades de cuidado, observou-se que os cuidadores apresentaram o tempo médio de 16,28 (dp = 8,34) horas por dia, com variação de 5 a 24 horas por dia (tabela 2). na aplicação da versão pré-final da escala, todos os participantes avaliaram os 48 itens do instrumento como claros e, em consequência, não sugeriram alterações. quanto à avaliação da importância da temática, assim como da clareza da versão pré-final do instrumento, por meio do questionário geral de clareza adaptado do disabkids (19), os participantes consideraram o instrumento muito bom (n = 7; 50 %) ou bom (n = 7; 50 %). com relação ao grau de dificuldade das questões, 11 participantes (78,57 %) indicaram que todos os itens foram fáceis, enquanto três (21,43 %) pessoas responderam que alguns itens estavam difíceis, porém não relataram as dificuldades, assim como não houve sugestões de mudança. por fim, foi perguntado se os itens eram importantes para avaliar as percepções e experiências dos cuidadores, e a maioria dos respondentes considerou como “muito importante” (n = 13; 92,86 %), enquanto apenas um entrevistado respondeu que “às vezes, é importante”. muito embora todos os participantes não tenham sugerido mudanças nos itens, no momento da aplicação do pré-teste do instrumento, verificou-se, por parte da entrevistadora, dificuldade de alguns cuidadores avaliados no entendimento do tempo verbal adotado nos itens. assim, novamente os itens da escala foram analisados, uniformizando-se o tempo verbal dos itens com a adoção predominante do presente do indicativo. item questão traduzida ivc questão revisada 4 preocupa-me não poder responder como o espera meu familiar doente. 0,71 eu me preocupo em não poder atender as expectativas do meu familiar. 13 senti que não posso responder pelo cuidado do meu familiar doente. 0,71 eu sinto que não posso assumir o cuidado do meu familiar. 33 tenho clareza do que farei com a minha vida quando penso na morte do meu familiar doente. 0,86 eu tenho clareza do que eu farei com a minha vida quando penso na morte do meu familiar. 36 valorizo que a vida é importante devido à experiência que tenho adquirido com o cuidado do meu familiar doente. 0,86 eu valorizo a importância da vida devido à experiência adquirida com o cuidado do meu familiar. 41 sinto-me tranquilo por saber cumprir com o dever de cuidar do meu familiar doente. 0,86 eu me sinto tranquilo quando penso que cumpro com o dever de cuidar do meu familiar. 44 as tarefas das pessoas próximas mudaram por terem que cuidar de meu familiar doente. 0,71 as tarefas das pessoas próximas do meu familiar mudaram por terem que cuidar dele. 47 tenho aplicado com meu familiar doente aquilo que aprendi sobre cuidados. 0,71 eu aplico o que aprendi sobre o cuidado do meu familiar. tabela 1. ivc dos itens da escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica adequada pelo comitê de especialistas fonte: elaboração própria. 8 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1948 aquichan issn 1657-5997 eissn 2027-5374 discussão os processos de tradução e adaptação transcultural de instrumentos de medida se encontram delimitados nos estudos metodológicos e, em geral, são complexos por exigirem, além da tradução literal das palavras, sua adaptação cultural (19). esse processo abrange, ainda, a realização de equivalências semântica, idiomática, experimental e conceitual (20). com base nos estudos realizados por beaton et al. (17), na presente pesquisa, foram desenvolvidas as etapas metodológicas preconizadas para a adaptação cultural de instrumentos de medida, visto que são eficazes para o desenvolvimento do processo de tradução, adaptação e validação de escalas de medida (17). no estudo brasileiro de rosanelli, da silva e gutiérrez (15), foram desenvolvidas a tradução, a adaptação e a validação do caring ability inventory (cai) para a língua portuguesa; nesse estudo, as autoras adotaram a mesma metodologia proposta por beaton et al. por ser um processo consolidado e muito usual para esse tipo de pesquisa (21). a fim de buscar padrões elevados de qualidade, preconiza-se que a tradução seja realizada por dois tradutores independentes e que tenham qualificação para tal atividade e, de preferência, que ambos sejam do país de origem do instrumento a ser trabalhado, pois, dessa forma, espera-se que o profissional domine o idioma, conheça a cultura e tenha os conceitos mais esclarecidos. a versão consensual da escala é realizada para sanar possíveis divergências ou ambiguidades (22). a retrotradução é a parte do processo que visa aperfeiçoar a versão final e identificar falhas da tradução. a tradução reversa tem a finalidade de lapidar o instrumento, e o tradutor dessa etapa deve ser fluente em ambos os idiomas, ou seja, fluente no idioma de origem do instrumento e no qual será adaptado (22). tabela 2. caracterização sociodemográfica e de cuidado dos cuidadores familiares de pessoas com drc participantes do pré-teste. são joão da boa vista, são paulo, 2017 característica categoria frequência % sexo feminino masculino 11 3 78,58 21,42 estado civil casado solteiro 11 3 78,58 21,42 escolaridade ensino fundamental incompleto ensino médio incompleto ensino superior completo 11 1 2 78,58 7,14 14,28 reside com o familiar cuidado sim não 7 7 50,00 50,00 grau de parentesco entre o cuidador e o familiar cuidado filho cônjuge mãe irmão 8 3 2 1 57,14 21,42 14,30 7,14 recebe ajuda no cuidado sim não 11 3 78,58 21,42 o familiar recebe ajuda financeira de terceiros sim não 5 9 35,71 64,28 fonte: elaboração própria. 9 adaptação da escala para medir a habilidade de cuidado de cuidadores familiares de pessoas com doença crônica no brasil l vanessa almeida maia damasceno e outros dessa forma, fica evidente que as etapas desenvolvidas no presente estudo (tradução, síntese das traduções e retrotradução da escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica) foram desenvolvidas de maneira apropriada. para a alcançar a versão pré-final do instrumento, foi indispensável a formação do comitê de especialistas, com o intuito de revisar e comparar as traduções, bem como sua versão consensual, modificando e adaptando-a até que se obtenha uma réplica do instrumento no brasil. os especialistas devem dominar o idioma de origem do instrumento e ter expertise na área da saúde com experiência na temática estudada (23). portanto, na presente pesquisa, o comitê de especialistas contou com sete integrantes que atenderam as atribuições citadas no método. compete aos especialistas avaliar o instrumento de forma geral e individual, verificando item a item, o que assegura que a versão pré-final esteja clara e compreensível para a cultura. cabe também aos juízes sugerir e orientar alterações no contexto do instrumento (23, 24). o ivc verifica a quantidade de juízes que concordam que os itens analisados no instrumento estão claros/equivalentes/representativos. o cálculo é realizado a partir das respostas likert, em que os itens que obtiverem resposta 1 e/ou 2 devem ser revisados ou excluídos, e os itens com pontuação 3 e/ou 4 devem passar por um cálculo que é feito a partir do somatório das respostas de cada juiz em cada item e dividido pelo número total de respostas, sendo o valor de concordância recomendado maior ou igual a 0,78 (23). o instrumento da presente pesquisa é composto de 48 itens; destes, sete obtiveram ivc < 1, os quais foram revistos apesar de apenas quatro itens terem alcançados ivc < 0,78 (18). um estudo realizado por blanco-sánchez et al. (14), na colômbia, visou verificar a validade de conteúdo da escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica e contou com a participação de 10 especialistas; estes foram selecionados considerando a formação acadêmica e a experiência. nove eram enfermeiros, dois deles com doutorado em enfermagem, três mestres com vasta experiência, um com mestrado e experiência na construção e validação de instrumentos de medida, três doutorandos em enfermagem, que se aprofundaram nessa temática, e um psicólogo com mestrado em educação e ensino, com experiência em psicologia clínica, medição psicométrica de avaliação psicológica. durante a análise da validade de conteúdo, foi verificado o valor global de kappa de fleiss, que foi de 0,78, o que demonstra uma boa concordância entre os especialistas e retrata que a escala de barrera tem validade de conteúdo, ou seja, os especialistas relatam que a maioria dos itens é clara e mede o que são propostos (14). após a revisão dos itens da escala em processo de adaptação, considerando-se as avaliações dos especialistas, constituiuse a versão final do instrumento para o pré-teste. este conta com a aplicação do instrumento em uma determinada amostra da população e visa detectar erros, bem como confirmar a clareza e a compreensão dos itens pela população (22). a população-alvo do instrumento refere-se a cuidadores de familiares com dc, que, no caso desta pesquisa, referiu-se a pessoas com drc em hemodiálise. nesse contexto, a fase de pré-testar o instrumento foi desenvolvida com 14 cuidadores familiares de pessoas em hemodiálise, o que possibilitou o aperfeiçoamento do instrumento de medida. o perfil sociodemográfico e os aspectos relacionados ao cuidado dos cuidadores participantes do pré-teste foram compostos de mulheres, em sua maioria, estado civil casado, com ensino fundamental incompleto, com média de idade de 49,92 anos. além disso, verificou-se que 57,14 % dos cuidadores cuidavam dos pais (25). vale ressaltar que, com relação à ajuda de terceiro para o cuidador, 78,58 % relataram receber ajuda de mais alguém no cuidado; quanto à questão financeira do paciente, 64,28 % disseram que o familiar não recebe ajuda financeira no cuidado. pesquisadores descreveram a experiência de cuidadores de pacientes em diálise peritoneal que participaram de um programa com enfoque na habilidade de cuidado. a pesquisa contou com uma amostra de 277 cuidadores familiares, em que a maioria era do gênero feminino, casada e com média de idade semelhante ao presente estudo. os resultados evidenciaram sete aspectos que o programa ajudou a fortalecer: novos conhecimentos, interação com outros cuidadores, apoio, descanso, bem-estar, oportunidade de melhoria na prestação de cuidado e, por fim, nova perspectiva dos cuidadores. os autores concluíram que o programa ampliou as experiências dos cuidadores (25). em outro estudo realizado com oito cuidadores familiares de pacientes com drc em tratamento hemodialítico, com o objetivo de investigar a percepção dos familiares ante o cuidado prestado, 10 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1948 aquichan issn 1657-5997 eissn 2027-5374 verificou que a maioria dos cuidadores era mulher (62,50 %), com média de idade de 47 anos (26). no estudo, os cuidadores evidenciaram que possuem certo domínio sobre as intercorrências ocorridas após a sessão de tratamento, que recebem constantemente orientações do médico responsável assim como da enfermeira; além disso, os cuidadores percebem o quanto é importante se comunicarem sobre o quadro clínico do familiar e relatam que sentem o peso da responsabilidade que acaba gerando sobrecarga. os autores concluíram que os cuidadores se adaptam facilmente a essa nova condição de vida, vencendo todas as limitações e aumentando seus conhecimentos específicos. estudiosos compararam a habilidade de cuidado e a sobrecarga de cuidadores de pacientes com drc em diálise peritoneal ou em hemodiálise, os quais eram atendidos na institución especializada de la ciudad de cúcuta (colômbia), durante 2015 e 2016. o estudo contou com a participação de 25 cuidadores de pessoas em diálise peritoneal e 43 cuidadores de pessoas em hemodiálise. observou-se, dentre os resultados, que a maioria dos participantes era mulher, com baixa escolaridade e casada. os resultados evidenciaram que as habilidades de cuidado foram similares nos grupos, no entanto as dimensões “relação” e “mudança na rotina” foram melhores no grupo de hemodiálise, já o compromisso do cuidador foi semelhante nos grupos, com piores níveis de sobrecarga. além disso, os cuidadores dos familiares em hemodiálise apresentaram maior habilidade de cuidado e menor sobrecarga que os cuidadores de pessoas em diálise peritoneal (27). nesse contexto, verifica-se que, de forma geral, o perfil sociodemográfico e os aspectos relacionados ao cuidado dos participantes do pré-teste do presente estudo se assemelharam às pesquisas supracitadas, também desenvolvidas com cuidadores de familiares com drc. o principal intuito da realização do pré-teste do instrumento foi identificar problemas de entendimento e compreensão dos termos utilizados nas questões por parte dos participantes. para tanto, na avaliação dos itens do instrumento, os participantes foram indagados sobre a clareza de cada item e, caso a resposta fosse negativa, o respondente sugeria alterações para melhorar a compreensão. essa fase tem o propósito de averiguar a presença de dificuldades de compreensão de forma, como foram expressos as questões, o conteúdo e as opções de resposta (28). também se verificou a clareza/compreensão/relevância das afirmações, através do questionário geral de clareza adaptado de disabkids (19) para a pesquisa, o que possibilitou que os 14 participantes pudessem avaliar a relevância da escala para medir a habilidade de cuidado do cuidador familiar de pessoas com doença crônica, no caso com drc em hemodiálise. dessa forma, ocorreu a validação semântica do instrumento; cada uma das questões foi avaliada de acordo com seu significado, relevância e compreensão. um grupo de pesquisadores realizou a tradução e a adaptação do questionário disabkids — cystic fibroses module, versão brasileira —, e a fase de pré-teste contou com a participação de 12 pessoas, que também responderam ao questionário supracitado para a validação semântica do questionário. os autores concluíram que tal instrumento de clareza foi importante devido à avaliação que os participantes fizeram do referido questionário e, assim como no presente estudo, não houve alterações sugeridas (29). os pacientes da presente investigação avaliaram a escala como clara e compreensível, além de ser relevante para avaliar as vivências dos cuidadores familiares de pessoa com drc em tratamento de hemodiálise, corroborando com achados de outros pesquisadores que relataram que a etapa de pré-teste é uma técnica de prova, porque torna possível averiguar o entendimento sobre o instrumento pela população, pois citam que ela é uma técnica de prova, que torna possível averiguar o entendimento do instrumento pela amostra da população (22). vale reiterar que houve ainda uma reanálise do conteúdo dos itens em relação ao tempo verbal, muito embora os cuidadores não tivessem sugerido alterações, mas, no transcorrer do pré-teste, a entrevistadora percebeu que a uniformização do tempo verbal para o presente do indicativo facilitaria a compreensão dos participantes; em função disso, optou-se por essa última adequação, chegando, então, à versão adaptada final da escala. situações como esta (reanálise de itens) são previstas no transcorrer do processo de tradução e adaptação cultural de instrumentos de medida, como pode ser verificado na investigação de roediger et al. (29), que adaptaram o método de triagem nutricional (determine your nutritional health®) para o português com idosos em domicílio e preconizaram a utilização de um único tempo verbal, pois cada pergunta se referia a acontecimentos distintos, e não em um único momento (30). como limitações do estudo, pode-se citar o tamanho amostral do pré-teste. outro aspecto limitante refere-se aos respon11 adaptação da escala para medir a habilidade de cuidado de cuidadores familiares de pessoas com doença crônica no brasil l vanessa almeida maia damasceno e outros dentes serem vinculados a uma única utrs, o que impede de ampliar o conhecimento sobre o cuidado em culturas e regiões diferentes do brasil. por fim, a escassez de artigos sobre a temática na população com drc. conclusões com base no objetivo proposto e nos resultados obtidos, pode-se concluir que a escala para medir a habilidade de cuidado de cuidadores familiares de pessoas com doença crônica encontra-se devidamente traduzida e adaptada culturalmente para o brasil. após a finalização da etapa de análise das propriedades psicométricas da versão brasileira do instrumento, almeja-se disponibilizá-lo para o uso assistencial e investigativo acerca da habilidade de cuidado de cuidadores de familiares com dc por equipes multidisciplinares, o que possibilitaria a melhoria da assistência e evidências científicas sobre o assunto. com o uso da referida escala, os profissionais estarão instrumentalizados para propor medidas preventivas e de educação, a fim de proporcionar ao paciente com dc um cuidado de qualidade e que favoreça a adesão ao tratamento. conflito de interesses: nenhum declarado. referências 1. ribeiro f, marques b, botelho mr, marcon ss, lenzi js. coping strategies used by family members of individuals receiving hemodialysis. 2014;23(4):915-24. doi: http://dx.doi.org/10.1590/0104-07072014002220011 2. gonzalez me, maria m, c, gelehrter r, lopes c. convivendo com a doença renal: entre ditos e não ditos. 2018 [acesso 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na área da saúde. cien saude colet [internet]. 2015;20(3):925-36. doi: http://dx.doi.org/10.1590/1413-81232015203.04332013 24. nora crd, zoboli e, vieira mm. validation by experts: importance in translation and adaptation of instruments. 2017;38(3):1-9. doi: http://dx.doi.org/10.1590/1983-1447.2017.03.64851 25. león dl, calderón lr, moreno sc, cuenca i, lorena chaparro díaz. cuidadores de pacientes en diálisis peritoneal: experiencia de participar en un programa de habilidad de cuidado. enferm nefrol. 2015;18 (3):189-95. doi: http://dx.doi. org/10.4321/s2254-28842015000300007 26. rodrigues de lima l, flôres cosentino s, marinês dos santos a, strapazzon m, cembranel lorenzoni am. family perceptions of care with patients in renal dialysis. j nurs ufpe on line/rev enferm ufpe on line. 2017;11(7):2704-10. available from: https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/23443/ 27. pérez clp. habilidad de cuidado y sobrecarga en cuidadores de personas en terapia de hemodialisis y diálisis peritoneal [tesis]. bucaramanga: universidad nacional de colombia; 2017. disponible en: http://bdigital.unal.edu.co/63639/1/ http://www.bdigital.unal.edu.co/3806/ http://www.bdigital.unal.edu.co/3925/ http://www.bdigital.unal.edu.co/4122/ http://www.bdigital.unal.edu.co/4122/ http://www.bdigital.unal.edu.co/43068/ http://dx.doi.org/10.1590/1982-0194201600048 https://repositorio.ufscar.br/handle/ufscar/7637 https://doi.org/10.1097/00007632-200012150-00014 http://dx.doi.org/10.1097/00006199-198611000-00017 http://dx.doi.org/10.1097/00006199-198611000-00017 http://dx.doi.org/10.1590/s0080-62342011000200021 http://dx.doi.org/10.1590/0104-1169.3232.2402 http://dx.doi.org/10.1590/0104-1169.3232.2402 http://repositorio.unifesp.br/handle/11600/47983 https://doi.org/10.1016/0895-4356(93)90142-n http://dx.doi.org/10.1590/1413-81232015203.04332013 http://dx.doi.org/10.1590/1983-1447.2017.03.64851 http://dx.doi.org/10.4321/s2254-28842015000300007 http://dx.doi.org/10.4321/s2254-28842015000300007 https://periodicos.ufpe.br/revistas/revistaenfermagem/article/view/23443/ http://bdigital.unal.edu.co/63639/1/habilidad%20de%20cuidado%20y%20sobrecarga%20en%20cuidadores%20de%20personas%20en%20terapia%20de%20hemodialisis%20y%20di%c3%81lisis%20peritoneal.pdf 13 adaptação da escala para medir a habilidade de cuidado de cuidadores familiares de pessoas com doença crônica no brasil l vanessa almeida maia damasceno e outros habilidad%20de%20cuidado%20y%20sobrecarga%20en%20cuidadores%20de%20personas%20en%20terapia%20de%20hemodialisis%20y%20di%c3%81lisis%20peritoneal.pdf 28. tagliaferro m, gonçalves a, bergmann m, sobral o, graça m. share request full-text assessment of metal exposure (uranium and copper) by the response of a set of integrated biomarkers in a stream shredder. ecol indic. 2018;95(parte 2):991-1000. doi: https://doi.org/10.1016/j.ecolind.2017.10.065 29. santos dmss, deon kc, fegadolli c, reis ra, torres lagmm, bullinger m et al. cultural adaptation and initial psychometric properties of the disabkidstm — cystic fibrosis module — brazilian version. rev da esc enferm. 2013;47(6):1311-7. doi: http://dx.doi.org/10.1590/s0080-623420130000600009 30. roediger m de a, marucci m de fn, latorre m do rd de o, hearst n, oliveira c de, duarte ya de o et al. adaptação transcultural para o idioma português do método de triagem nutricional determine your nutritional health® para idosos domiciliados. cien saude colet [internet]. 2017;22(2):509-18. doi: http://dx.doi.org/10.1590/1413-81232017222.00542016 http://bdigital.unal.edu.co/63639/1/habilidad%20de%20cuidado%20y%20sobrecarga%20en%20cuidadores%20de%20personas%20en%20terapia%20de%20hemodialisis%20y%20di%c3%81lisis%20peritoneal.pdf http://bdigital.unal.edu.co/63639/1/habilidad%20de%20cuidado%20y%20sobrecarga%20en%20cuidadores%20de%20personas%20en%20terapia%20de%20hemodialisis%20y%20di%c3%81lisis%20peritoneal.pdf https://doi.org/10.1016/j.ecolind.2017.10.065 http://dx.doi.org/10.1590/s0080-623420130000600009 http://dx.doi.org/10.1590/1413-81232017222.00542016 10 reseñas.p65 reseñas 227 año 7 vol. 7 nº 2 • chía, colombia octubre 2007 nursing care is a practice that is guided by knowledge and by love when i think what the essence of nursing practice is, i realize that our delivery of care is based on love for humanity and knowledge that is guided by theory and research. to elaborate a little as an educator, i know that nurses learn theory as some sort of a road map to guide their research and practice, which facilitates the acquisition of their mission: to insure patients� well-being. adaptacion y cuidado en el ser humano. una vision de enfermeria is a wonderful tool for teaching under-graduate and graduate nurses how to build delicate structures of logic, in order to comprehend the pivotal role that theory plays in our practice. in this book, the roy adaptation model is an excellent example in how to integrate nursing theory into our practice. the purpose of this book is to help nurses comprehend that, through the use of theory, our visions broaden. its readers see many things differently and envision many different ways to impart bedside care. they will also learn to critically create nursing interventions whose existence they were unaware of and to evaluate many relationships that we could not have possibly done without the use of theory. the group of la sabana school of nursing began this project with the conviction that the roy adaptation model (ram) has the breadth, scope, and adaptability to be used with south american populations. furthermore, this group believes that nursing practice, based on the model, has created a higher level of knowledge that it is particularly efficient for nursing practice, and also aids in establishing guidelines for critical analyses and processes to evaluate the relationships of its practice to the model. the book is divided in nine chapters. chapter one deals with historical and philosophical bases, and visions for the 21st century written by dr. callista roy. chapter 2 describes the roy adaptation model and processes of adaptation and cognition taking sociological and psychological nursing references to conclude that the cognitive process can determine the parameters that can guide the nursing process. chapter 3 addresses pre-natal and post-partum care while chapter 4 covers newborn care. chapter 5 presents the infant care. the next chapter discusses the adaptation of the adolescent. chapter 7 focuses on the young adult care while chapter 8 elaborates the adaptation of the older healthy adult. the final chapter talks about experiences and application of the model to research, education, and practice. i believe that the dream and the vision in writing this book has been to make theory more relevant for the practice of nursing in south america and also to stimulate further use of the model maría del carmen gutiérrez, coordinadora editorial universidad de la sabana, manual moderno, 2007 aquichan issn 1657-5997 año 7 vol. 7 nº 2 • chía, colombia octubre 2007228 by leading the way to the development of better nursing practice and establishment of evidence-based practice. this book is unique in that it is comprehensive and moves beyond the description of the model, and it gives direction for its utilization in practice settings. nurses in academia and in practice will benefit from the many examples of the use of the model that are provided. the members of the college of nursing of la sabana university are indebted to sr. callista roy, and to all who have encouraged and assisted in the development of this project. martha v. whetsell, phd, rn, arnp doctora en enfermería profesora lehmon college of nursing new york, ee.uu. reflexiones y perspectivas de la educación superior en américa latina el proyecto tuning-américa latina, en el que se comprometieron 19 países del área, ofrece un marco referencial de trabajo conjunto y construcción de lenguajes comunes que permiten la comprensión de los sistemas de enseñanza superior en varias disciplinas, en lo relacionado con competencias (genéricas y específicas de las áreas temáticas seleccionadas); enfoque de enseñanza, aprendizaje y evaluación de estas competencias, créditos académicos y calidad de los programas. este texto hace relación a un proceso de reflexión y debate colectivo llevado a cabo por más de 200 académicos de 190 universidades que en latinoamérica, en las áreas temáticas específicas de administración, arquitectura, derecho, educación, enfermería, física, geología, historia, ingeniería civil, matemáticas, medicina y química, adelantaron en sus respectivos países abordando la metodología propuesta por el proyecto, y que se encuentra anexada a la obra, en donde se consultaron a los académicos (docentes universitarios), graduados, estudiantes y empleadores cuyos aportes en cada institución sirvieron de base para construir las competencias genéricas y específicas en el campo de estudio. sus resultados fueron analizados y comparados, y su priorización permitió determinar las conclusiones y proyecciones pertinentes en cada una de las disciplinas consultadas, aspectos que se podrán apreciar detalladamente en este libro. son de interés general para todos los académicos las reflexiones sobre las unidades de medida de trabajo del estudiante, cuyas conclusiones preliminares ofrecen una herramienta que enmarca en un futuro los estudios de movilidad, homologación y convalidación para estudiantes y profesionales de los diferentes países, los que están complementados por las fichas descriptivas de las características educativas que se tienen en cada lugar de los participantes del proyecto, y que se encuentran en el anexo ii. esta obra recoge una importante experiencia y significativos aportes que los participantes en el proyecto tuning-américa latina hicieron desde su visión de la educación superior, y se convierte en un medio de consulta para quienes deseen ahondar en los sistemas educativos que se siguen en latinoamérica. maría del carmen gutiérrez agudelo profesora asociada facultad de enfermería universidad de la sabana informe final. proyecto tuning-américa latina 2004-2007 cuidado de la salud mental de las enfermeras: prioridad en la pandemia por la covid-19 editorial cuidado de la salud mental de las enfermeras: prioridad en la pandemia por la covid-19 nurses' mental health care: priority in the covid-19 pandemic cuidado da saúde mental das enfermeiras: prioridade na pandemia pela covid-19 10.5294/aqui.2021.21.3.1 liliana villarraga de ramírez1 1 0000-0003-3710-990x. universidad nacional de colombia, facultad de enfermería, bogotá (colombia). lvillarraga@unal.edu.co palabras clave (fuente decs): enfermeras y enfermeros; salud mental; cuidado de enfermería; infecciones por coronavirus; enfermería. keywords (source: decs): nurses; mental health; nursing care; coronavirus infections; nursing. palavras-chave (fonte: decs): enfermeiras e enfermeiros; saúde mental; cuidados de enfermagem; infecções por coronavirus; enfermagem. para citar este editorial / to reference this editorial / para citar este editorial: villarraga-ramírez l. cuidado de la salud mental de las enfermeras: prioridad en la pandemia por la covid-19. aquichan. 2021;21(3):e2131. doi: https://doi.org/10.5294/ aqui.2021.21.3.1 en tiempos de pandemia, la salud física y las consecuencias clínicas de la infección viral son la preocupación esencial; no obstante, también se debe tener en cuenta el impacto sobre la salud mental. de acuerdo con frawley et al. (2020): "específicamente la relacionada con la angustia moral" derivada de la presión psicológica que experimentan las enfermeras, lo cual constituye el motivo especial de este escrito (1). tanto la ley 1616 del 2013 del ministerio de salud de colombia (2), como la organización mundial de la salud (oms), definen la salud mental como un saber autónomo de bien-estar. es indispensable que las personas conozcan sus propias capacidades para afrontar la vida, siendo conscientes de sí mismos y de ser productivos para la comunidad. actualmente, la salud mental es imperativa frente a la pandemia por la covid-19. "el campo de la salud mental es complejo y transdisciplinario, admite la comprensión de la subjetividad, la singularidad y la diferencia entre lo individual y lo colectivo; incluye el conflicto en el devenir cotidiano de las instituciones y de la sociedad, abre la mirada hacia la vida social y advierte sus interrelaciones saludables y perjudiciales." (3) con estos conceptos las enfermeras de la salud mental abordamos el afrontamiento de la pandemia por la covid 19. es inevitable que al despertar, en cada amanecer, nos encontremos con una novedad relacionada con la pandemia a la cual aún no nos acostumbramos, ¿cómo es que llegamos a una pandemia? ¿a un confinamiento por meses y años?, ¿cómo llegó a ser mundial esta infección?, ¿cuántas mutaciones de un virus se han generado?, ¿cuántas variedades nos sorprenderán? róhr s. et al., (2020) en su artículo psychosocial impact of quarantine measures during serious coronavirus outbreaks: a rapid review, establece la importancia de: "recopilar evidencias sobre las consecuencias psicosociales de las medidas de cuarentena en relación con brotes anteriores de coronavirus relevantes. dos coronavirus graves y brotes asociados ya se han producido en el siglo xxi. el primer brote grave fue el síndrome respiratorio agudo severo sras en 2002 y 2003 en el sur de china y treinta países más. en 2012, se identificó el síndrome respiratorio agudo severo coronavirus de oriente medio mers-cov, la primera aparición se ubicó en arabia saudita."(4) en el mes de diciembre del año 2019 el coronavirus ya se encontraba inundando a la humanidad e infectando a miles de personas. se insistía en que "el virus no viaja" (5) y que son los viajeros quienes lo transportan por todo el mundo: a colombia llega en el mes de marzo del 2020. a todos nos tomó por sorpresa, sin preparación y la pandemia puso en evidencia la precariedad de los sistemas de salud. en el momento en que llegó el virus no se contaba con adecuaciones, equipos, materiales y recurso humano del área de la salud para desplegar una óptima atención e incluso aún se presentan algunas dificultades en la atención. todos hemos aprendido "mientras caminamos" (5), porque "nadie tiene la verdad" (5). en este sentido, la enfermería en salud mental es un grupo clave dentro de una respuesta integrada ante la covid-19 porque cuenta con mayor información, la cual se basa en sus experiencias cotidianas (1) y que se podrían ver reflejadas en escritos sobre las vivencias de las enfermeras y los enfermeros colombianos durante la pandemia. en las instituciones de salud el personal de enfermería es insuficiente y muchas(os) han adquirido la infección por el virus; paralelamente se registra un incremento en la sobrecarga laboral y psicológica. el personal de enfermería es el primero en abordar a las personas infectadas quienes se encuentran en riesgo de muerte, atienden a las familias en situaciones críticas e intervienen en el duelo de las personas por los continuos fallecimientos en las instituciones. la dinámica del duelo que deben abordar las enfermeras pone en evidencia el desconcierto y la incredulidad ante la noticia de "positivo para covid-19" de una persona o varios integrantes de una familia, quienes requieren información para reasegurarse de "la verdad". en ese preciso momento, súbitamente se interrumpe la estabilidad personal por la negación e indignación que expresan las personas para evitar la pérdida del propio control; en efecto, al no contar con defensas para el momento de la noticia inesperada, se dificultará afrontar la pérdida y mantener la cordura. frecuentemente, este descontrol lo reciben las enfermeras, quienes simultáneamente atienden a la familia que necesita ayuda; para este acompañamiento se requiere tiempo y disposición para la escucha y comprensión de las emociones de las personas en sufrimiento. ante esta situación, el objetivo de la salud mental es restablecer el equilibrio anterior que tenía la persona y la familia, mediante la comprensión del duelo, el apoyo en el conocimiento de la pérdida por muerte inesperada y la prevención de sentimientos de culpa (5). lo anterior constituye la fuente principal de ansiedad para las enfermeras quienes, a través de sus testimonios, expresan: "necesitamos asesoría para la intervención en duelo", ... en el hospital covid donde yo trabajo, diariamente mueren más de tres personas; en mi turno, la intervención la hacía en la calle, donde podía ser agredido, hasta que me dieron un galpón donde ahora yo atiendo a las familias . frecuentemente se me vienen las lágrimas". "necesitamos apoyo psicosocial, varios compañeros están incapacitados por depresión, pido a dios no colapsar", . "me siento desesperado y quisiera no volver al hospital". "lloro todos los días a gritos antes de llegar y poder ver a mi familia. me diagnosticaron estrés postraumático; ahora voy a tratamiento psiquiátrico como prevención para mi salud mental" (6). "al respecto las enfermeras irlandesas hablan de "daño moral o angustia por los resultados de las acciones o la falta de ellas" que violen la responsabilidad moral o ética (añade greenberg citado por ellas); ese estrés es un riesgo particular del personal sanitario, podría contribuir al desarrollo de dificultades para la salud mental" (1). ¿cómo no preocuparnos por la salud mental de las enfermeras? presentan exceso laboral, sobrecarga emocional y diversas hostilidades como el estigma de personas y familias. "la crisis emocional no la hemos dimensionado aún", enfatiza el psiquiatra psicosocial a. rodríguez (2020) (5). los riesgos para la salud mental se exacerban para toda la población mundial haciéndola vulnerable a síntomas y trastornos físicos, psicosomáticos y mentales. así, "[...] la pandemia de covid-19 no tiene precedentes y el alcance de los efectos psicosociales actualmente no está claro, la oms lo evalúa como grave" (4). de acuerdo con a. rodríguez (2020) (5), la cuarta ola de la actual pandemia estará relacionada con los trastornos mentales: temor, ansiedad, alimentación, sueño, sentimientos de culpa, cansancio, soledad, estrés y estrés postraumático, angustia, pánico, iniciación y/o aumento del consumo de psicoactivos, alcohol y tranquilizantes, ideación suicida, suicidio y maltrato familiar. ello sin tener en cuenta secuelas aún no estudiadas, como la aparición de trastornos de memoria, sentimientos paranoides, reactivación de duelos y cambios en las dinámicas familiares. con la presente pandemia por la covid-19 se requiere una formación urgente para las enfermeras(os) en temas relacionados con la intervención en crisis de niños, adolescentes, jóvenes, parejas y familias. así mismo, sobre el apropiado acompañamiento en el duelo a personas, parejas y familias en los momentos de contagio de la enfermedad y la muerte; y también en los temas de acompañamiento físico, emocional y espiritual al moribundo, y en la promoción de la solidaridad social y comunitaria. respecto de la acción psicosocial, las instituciones deben contar con grupos de apoyo para abordar la salud física y psicológica del personal de enfermería: "las experiencias en italia, por ejemplo, apuntan a que el personal sufre síntomas somáticos relacionados con el trabajo, la carga psicológica y el estrés emocional" (1). los grupos de apoyo son importantes para la liberación de las propias crisis, los duelos y el estrés traumático y postraumático. esta intervención permitiría la comprensión intelectual del fenómeno y el fortalecimiento de intervenciones de autocuidado y cuidado. surge entonces la pregunta: ¿cómo constituirnos en grupo de apoyo y acogimiento para enfermeras en crisis, afrontando el sufrimiento por el contagio y la muerte de sus propios familiares y compañeros? este momento crucial nos permite ver con claridad las brechas en salud, las inequidades frente a los profesionales y la necesidad de liderar el cambio, así como la necesidad de desarrollar consciencia gremial y elaborar recomendaciones laborales con apoyo jurídico desde una perspectiva de derechos humanos. es el momento de decir, sentir y pensar "somos un nosotros" (5). con apoyo de la fundación formarte, la comisión de salud mental de la asociación colombiana de facultades y escuelas de enfermería -acofaeny la asociación nacional de enfermeras de colombia -anec-, se articularon las artes con la enfermería en salud mental, y tomando como referente la teoría de mishel (2011) (7), en el año 2020 se llevaron a cabo dos encuentros de nueve horas cada uno con enfermeras docentes, de urgencias y de cuidados intensivos, para abordar la incertidumbre que nos rodea y así, promover y prevenir los efectos nocivos para la salud mental. en el presente año (2021) apoyamos a 40 enfermeras docentes y de servicio en la prevención y promoción de su salud mental; además, se profundizó sobre "la escucha", herramienta esencial para el establecimiento de la empatía. recomendamos prepararnos, de manera anticipatoria, para evitar el estigma que se comienza a construir alrededor de la covid-19, así como surgió el estigma sobre el trastorno mental y, hace unos años, sobre el vih/sida, entre otros. referencias 1. frawley t, van gelderen f, somanadhan s, coveney k, phelan a, lynam-loane p, et al. the impact of covid-19 on health systems, mental health and the potential for nursing. ir j psychol med. 2020;38(3):220-226. doi: https://doi.org/10.1017/ipm.2020.105 2. república de colombia. ley 1616 del 21 de enero de 2013. "por medio de la cual se expide la ley de salud mental y se dictan otras disposiciones". [internet]. [citado agosto 4 de 2021]. disponible en: http://www.secretariasenado.gov.co/senado/basedoc/ley_1616_2013.html 3. rodríguez jj (editor) & organización panamericana de la salud [ops]. salud mental en la comunidad [internet]. 2a. ed. washington: ops. disponible en: https://iris.paho.org/handle/10665.2/51463 4. róhr s, müller f, jung f, apfelbacher c, seidler a, riedel-heller sg. psychosocial impact of quarantine measures during serious coronavirus outbreaks: a rapid review. psychiatr prax. 2020;47(4):179-189. doi: https://doi.org/10.1055/a-1159-5562 5. rodríguez a. (asociación colombiana de facultades y escuelas de enfermería -acofaen-). conversación con: liliana villarraga de ramírez (universidad nacional de colombia, facultad de enfermería) en "encuentro sobre promoción y prevención en salud mental en momentos de incertidumbre". bogotá, 2020, julio 22. 6. rodríguez a. (asociación colombiana de facultades y escuelas de enfermería -acofaen-). conversación con: liliana villarraga de ramírez (universidad nacional de colombia, facultad de enfermería) en "enfermeros en atención a personas infectadas por covid 19". bogotá, 2020, julio 29. 7. mishel m. uncertainity in illness. j nurs scholarsh 1988;20(4):225-231 doi: https://doi.org/10.1111/j.1547-5069.1988.tb00082.x home 305 315 nivel de importancia de las competencias.indd 305 cecilia latrach-ammar1 naldy febré2 ingrid demandes3 julieta araneda4 irene gonzález5 importancia de las competencias en la formación de enfermería 1 enfermera, magíster en educación universitaria. profesor titular. universidad mayor, chile. cecilia.latrach@umayor.cl 2 magíster en enfermedades infecciosas. profesora, universidad mayor, chile 3 docente, universidad mayor, chile 4 especialista en salud preventiva. docente, universidad mayor, chile 5 docente, universidad mayor, chile. irene.gonzalez@umayor.cl recibido: 10 de diciembre de 2010 aceptado: 22 de septiembre de 2011 resumen objetivo: conocer la opinión de los profesionales e internos de enfermería sobre la importancia de las competencias de egreso en la formación de estudiantes para la práctica profesional en la escuela de enfermería de la universidad mayor de chile, en el 2008. método: estudio descriptivo de tipo transversal; la recolección de datos se efectuó mediante una encuesta autoadministrada en dos grupos: internos y profesionales de enfermería. para el análisis de datos se utilizó estadística descriptiva. en los resultados se observa que los grupos encuestados aprecian que las competencias asistencial, general, educativa y de sello son “muy importantes para el desarrollo profesional”; sin embargo, el grado de importancia varía dependiendo de la función que ejercen los encuestados. conclusión: la presente investigación permite validar, por parte de los egresados y profesionales, las competencias adquiridas por los estudiantes durante su formación universitaria, las cuales responden a las exigencias laborales y permiten la integración de los profesionales a la gestión académica. palabras clave competencias, evaluación, enfermeros, educación (fuente: decs, bireme). the importance of expert knowledge in nursing education abstract objective: the study was designed to find out how nursing professionals and interns at the universidad mayor de chile nursing school in 2008 felt about the importance of professional competences in training students for professional practice. method: the authors performed a cross-sectional descriptive study. data collection was done through a self-administered survey among two groups: interns and nurses. descriptive statistics were used for data analysis. the results show the groups surveyed appreciate the fact that care-giving, general, educational and hallmark competences are "very important for professional development”. however, the degree of importance año 11 vol. 11 nº 3 chía, colombia diciembre 2011 l 305-315 306 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 varies depending on the function performed by the respondents. conclusion: the study enabled graduates and professionals to validate the skills students acquire as part of their university education, which respond to the demands of the job and provide an opportunity for professionals to become involved in academic management. key words professional competence, assessment, nurses, education (source: decs, bireme). importância das competências na formação da enfermagem resumo objetivo: conhecer a opinião dos profissionais e internos de enfermagem sobre a importância das competências de graduação na formação de estudos para a prática profissional na escola de enfermagem da universidade maior, do chile, no ano de 2008. método: estudo descritivo de tipo transversal. a coleta de dados foi efetuada mediante uma enquete autoadministrada em dois grupos: internas e profissionais de enfermagem. para a análise de dados foi utilizada uma estatística descritiva. resultados: os grupos entrevistados apreciam que as competências assistencial, geral e educativa são “muito importantes para o desenvolvimento profissional”; alem disso, o grau de importância varia dependendo da função que exercem os pesquisados. conclusão: a presente pesquisa permite validar, os recém-graduados e profissionais, as competências feitas aos estudantes durante sua formação universitária, as quais respondem às exigências laborais e permitem a integração dos profissionais à gestão acadêmica. palavras-chave competências, avaliação, enfermeiros, educação (fonte: decs, bireme). 307 importancia de las competencias en la formación de enfermería l cecilia latrach-ammar introducción la enfermería como ciencia, disciplina y profesión contempla exigencias de una formación amplia y sistematizada que se lleva a cabo en los contextos laboral y disciplinar. los procesos formativos en el área de la salud tienen como ejes centrales el desarrollo de habilidades procedimentales y la adquisición de diversas competencias a través de la experiencia clínica, siendo la práctica reflexiva un elemento clave en este proceso (1, 2). gran parte de la práctica de enfermería se relaciona con los conocimientos técnicos, es decir, con el aprendizaje de los motivos y los métodos para realizar las técnicas necesarias. sin embargo, los conocimientos científicos, la fundamentación teórica y especialmente la formación humanística y ética son aspectos esenciales para el desempeño de una profesión que se desarrolla a través de las relaciones humanas (3). la evaluación de las competencias profesionales constituye el elemento central en el desarrollo de las profesiones, siendo la clave para garantizar la calidad de los servicios sanitarios. la competencia profesional y la buena práctica en los estudiantes no se vinculan solo a la memorización, sino sobre todo al razonamiento clínico, a la toma de decisiones, a la resolución de problemas y a las habilidades en las relaciones interpersonales (4). la formación por competencias en enfermería responde a un cambio continuo y global del mundo profesional. la evaluación de las competencias profesionales se encuentra presente en los procesos formativos del pregrado, posgrado y actividad profesional (5, 6). se reconocen actualmente dos objetivos para evaluar la competencia profesional: el primero, con fines certificativos, ya sea de carácter académico o para autorización legal de ejercer como profesional. el segundo, con fines diagnósticos, para evaluar la calidad del aprendizaje, la eficiencia del sistema formativo o para identificar necesidades de aprendizaje (7). en la competencia se destaca la relación entre dos elementos claves: la persona y sus atributos, y la situación o el contexto profesional en la que se desempeña (7, 8, 9). el desarrollo del currículum por competencias desde hace unos años se encuentra presente en varias profesiones, entre ellas la enfermería (6). las competencias del alumno determinan aquello que deben aprender los estudiantes y aquello que debe ser evaluado, además de constituir el eje de todo el proceso de enseñanza-aprendizaje (10). la definición de las competencias es una tarea fundamental, tanto para los agentes implicados en la formación del futuro profesional como para las instituciones sanitarias y la sociedad general (11). es por este motivo que la escuela de enfermería de la universidad mayor, como parte de los procesos de autoevaluación del currículum por competencias, definió aquellas que dan respuestas al perfil de egreso de los futuros profesionales de esta casa de estudio, clasificándolas en dos tipos: 1) profesionales, en las que se encuentran las asistenciales, de gestión, investigación y educación; 2) genéricas, en las cuales se encuentran las de sello institucional y las generales. cada una de estas, a su vez, tiene categorías que permiten su evaluación. las escalas o los cuestionarios de opinión han sido utilizados para evaluar satisfactoriamente el logro de competencias, estas técnicas tienen sentido si el evaluador ha observado los conocimientos científicos, la fundamentación teórica, y especialmente la formación humanística y ética, son aspectos esenciales para el desempeño de una profesión que se desarrolla a través de las relaciones humanas. 308 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 o posee evidencias de la actuación del profesional evaluado en situaciones reales, y especialmente si se plantea con carácter formativo. en este caso, y entendiendo que las percepciones son subjetivas y sujetas a múltiples condicionantes, uno de los procedimientos más habituales en este tipo de evaluación es el contraste de información mediante la triangulación (1). la gestión universitaria por parte de las escuelas de enfermería debiera encontrarse orientada a facilitar la inserción laboral de sus egresados mediante la evaluación de la eficiencia del sistema formativo, determinando si las competencias finales del estudiante de enfermería instituyen el nivel exigible en la práctica laboral, permitiendo identificar las necesidades reales de aprendizaje. objetivo conocer la opinión de los profesionales e internos de enfermería sobre el nivel de importancia de las competencias de egreso en la formación de estudiantes para la práctica profesional en la escuela de enfermería de la universidad mayor. materiales y método para responder al objetivo propuesto se realizó un estudio descriptivo de tipo transversal en santiago de chile, en el año 2008. en el estudio fueron seleccionadas dos muestras por conveniencia, siendo la primera constituida por 111 profesionales de enfermería (enfermeros clínicos y enfermeros supervisores que realizan su actividad laboral en instituciones de salud públicas y privadas de chile), la segunda muestra estuvo constituida por 43 internos de enfermería (estudiantes de la carrera en su última etapa de formación, esto es, estudiantes de quinto año a punto de egresar). los datos fueron recolectados mediante aplicación de encuesta autoadministrada, documento que contiene aspectos biosociales básicos y evaluación de las competencias profesionales de egreso definidas en el currículum, donde se encuentran las seis competencias con sus respectivas categorías para evaluar (asistencial, de gestión, educativa, de investigación, general y de sello). para la evaluación de la importancia de cada categoría se definió una escala arbitraria según el logro de desempeño como: “muy importante” cuando la competencia evaluada es indispensable para el desarrollo profesional, “medianamente importante” cuando la competencia evaluada es requerida y es medianamente indispensable para el desempeño profesional, y “poco importante” cuando la competencia evaluada no se debería tomar en cuenta ya que no es requerida para el desempeño profesional. concluida una primera versión del instrumento, se sometió a la evaluación de seis expertos todos profesionales de enfermería con grado de magíster en educación universitaria; posteriormente, para evaluar la validez interna se aplicó el instrumento en una muestra constituida por enfermeras docentes, obteniendo como resultado un alfa de cronbach igual a 0,90. para la tabulación de los resultados se utilizó el programa spss, el análisis de datos fue realizado con estadística descriptiva. el proyecto fue evaluado y aprobado por el comité de ética en investigación de la facultad de medicina de la universidad mayor, y se cumplió con la aceptación del consentimiento informado de los participantes. 309 importancia de las competencias en la formación de enfermería l cecilia latrach-ammar resultados la tasa de respuesta obtenida en la presente investigación fue similar en ambos colectivos: 95,34% (41/43 internos de enfermería) y 94,87% (111/117 profesionales de enfermería). entre la muestra de las estudiantes el 100% pertenece al género femenino, con un promedio de edad de 23 años. para la muestra de profesionales de enfermería el promedio de edad es igual a 36 años (rangos 24 a 60 años), predominando el género femenino (94,6%), con un promedio de 16 años de experiencia laboral (rangos 1 a 37 años). el 54,5% trabaja en instituciones públicas, mientras el 45,5% realiza su actividad laboral en instituciones de salud privada. de los 111 profesionales evaluados, el 65,8% se desempeñan como enfermeros asistenciales, y el 34,2% como enfermeros con cargos administrativos de jefaturas. en la tabla 1 se observa la distribución según nivel de importancia para la actividad profesional del grupo de competencias profesionales; al calcular las medias correspondientes a la asignación de respuestas como “muy importantes” declaradas por las 73 enfermeras clínicas que participaron de este estudio observamos que estas atribuyeron a las asistenciales un (90,16%) de las respuestas, seguidas por competencia educativa (87,7%), de gestión (86,5%) y de investigación (84,22%). por su parte, las 38 enfermeras con cargos de jefatura perciben como muy importantes a las competencias de gestión (93,85%), de investigación (90,02%), asistencial (92,7%) y educativa (84,76%). los resultados obtenidos de la evaluación de las competencias genéricas o blandas (generales y de sello) se encuentran en la tabla 2. de las siete categorías evaluadas en la competencia general, la media calculada de la frecuencia de respuesta en el ítem de “muy importante” por parte de las enfermeras clínicas y supervisoras es igual a 87,9 y 88,35% respectivamente. destacamos que las enfermeras clínicas evaluaron con un 5,8% la categoría “comprende lo propio del país y su interdependencia del mundo globalizado” en el ítem “poco importante”. para la evaluación de las cinco categorías de la competencia de sello encontramos que las enfermeras clínicas definieron según media de frecuencia de respuesta a los ítems de “muy importante” (84,62%), “medianamente importante” (11,16%) y “poco importante (0,76%). por su parte, las enfermeras supervisoras clasificaron estos ítems en porcentajes iguales a 92,1, 5,8% y 0,0% respectivamente. ambos grupos evaluaron según frecuencia de respuestas; así, en primer lugar está la categoría “demuestra capacidad de crítica y autocrítica en la ejecución del rol de enfermero” como “muy importante”, en 96,2 y 97,4% para las enfermeras clínicas y enfermeras supervisoras respectivamente (tabla 2). en el gráfico 1 se observa que para la competencia de investigación la percepción de “muy importante” para el grupo de internas de enfermería alcanza un 73,8%, en contrapartida, los enfermeros clínicos y enfermeros supervisores asignaron 84,2 y 90% respectivamente a esta competencia. destacamos que la competencia asistencial, competencia general y competencias educativas presentaron una menor variación en la frecuencia de respuesta por los tres grupos evaluados, con diferencias entre la media máxima y mínima igual a 2,9; 2,8 y 2,3 puntos respectivamente. destacamos que las enfermeras clínicas evaluaron con un 5,8% la categoría “comprende lo propio del país y su interdependencia del mundo globalizado” en el ítem “poco importante”. 310 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 discusión a la luz de los datos encontrados podemos definir que los profesionales de enfermería y estudiantes en su última etapa de formación perciben las competencias evaluadas como indispensables para el desarrollo profesional en diferentes niveles. destacamos la tasa de respuesta sobre el 94% obtenida en el presente estudio, lo que ha permitido el logro del objetivo planteado, a diferencia de lo encontrado por otros autores quienes evaluaron el logro de competencias en estudiantes de diferentes carreras de la salud, obteniendo tasas de respuesta iguales a 26 y 47% (1, 12). los estudios encontrados hacen referencia a la evaluación, ya sea por competencias según nivel, evaluación de una determinada competencia, o bien, definen niveles de desempeño global sin analizar el conjunto de competencias de egreso exigibles a los internos de enfermería, motivo por el cual no es posible la contrastación global de los resultados del presente estudio (1, 4, 10, 12, 13). al evaluar las respuestas relacionadas con la percepción de la importancia de las cuatro competencias profesionales definidas en la presente investigación (gestión, asistencial, educativa e investigación), ambos grupos de enfermeros encuestados responden que estas son indispensable para el desarrollo profesional, con porcentaje asignado sobre 84%. los datos obtenidos muestran diferencias en las frecuencias de respuestas sobre la percepción de las competencias por parte de las enfermeras asistenciales y aquellas con cargos de jefaturas, en especial al realizar una jerarquización de dicha frecuencia, destacándose que las enfermeras supervisoras percibieron las de gestión, asistencial y sello como aquellas evaluadas con mayores porcentajes; a su vez, las enfermeras clínicas perciben las competencias relacionadas con la atención del paciente en los tres primeros lugares de frecuencia. en un estudio que evaluó competencias en el nivel de bachiller de una escuela de enfermería, las autoras destacan que para la actividad “realiza registros”, el nivel de desempeño no es adecuado y requiere mejoramiento (13), resultados que concuerdan con la presente investigación, donde destacamos que, en la competencia asistencial la categoría “documenta la información” fue considerada medianamente indispensable para el desempeño profesional por parte de las enfermeras clínicas y supervisoras con 23,0 y 10,5% respectivamente, aspecto que debe ser enfrentado con preocupación partiendo de la base de que una correcta documentación de la información en los registros de atención es uno de los pilares de la seguridad de paciente, meta reconocida por la organización mundial de la salud (oms) para el próximo milenio (14). la competencia educativa fue percibida en un 84% como indispensable para el desarrollo profesional en ambos grupos de profesionales, observándose que esta competencia se encuentra integrada en todo el trabajo realizado por enfermería en su práctica diaria, tanto a nivel asistencial como gerencial. esta competencia ha sido investigada desde el paradigma cualitativo, un ejemplo de esto es la investigación realizada con el propósito de construir un perfil de competencias para la acción educativa de la enfermería a partir de la perspectiva de los sujetos participantes, utilizando como referente teórico-metodológico el materialismo histórico y dialéctico, en el que se observó la construcción de diez competencias para la competencia de investigación fue evaluada como indispensable para el desarrollo profesional por las enfermeras con grado de jefatura en el 90,2% de los casos, y para las enfermeras clínicas en el 84%. 311 importancia de las competencias en la formación de enfermería l cecilia latrach-ammar la acción educativa de las enfermeras orientadas a la necesidad de dar un nuevo significado a la acción educativa en el cuidado de la salud (4), investigación que complementa los resultados encontrados en este estudio, demostrando la necesidad de investigar esta competencia desde el paradigma cualitativo. la competencia de investigación fue evaluada como indispensable para el desarrollo profesional por las enfermeras con grado de jefatura en el 90,2% de los casos, y para las enfermeras clínicas en el 84%, difiriendo con lo encontrado en el año 2005, en un estudio latinoamericano que evaluó la importancia de la investigación en los diferentes niveles de formación de la enfermera, en donde el 73% de las competencias para el nivel de licenciatura sugieren que las encuestadas percibieron estas aptitudes como apropiadas pero no esenciales (12), publicación que difiere con los datos de la presente investigación, por la diferencia en objetivos y metodologías. en la competencia de investigación evaluada se destaca la categoría “realiza investigación respetando las etapas del método científico”, que fue considerada medianamente indispensable para el desempeño profesional por parte de las enfermeras clínicas y supervisoras con 30,8 y 28,9% respectivamente, las cuales privilegian las categorías orientadas a la aplicación de la práctica basada en la evidencia. datos que concuerdan con investigación realizada en el año 2004 en barcelona, donde médicos tutores de estudiantes de la especialidad de medicina familiar y comunitaria en el campo clínico muestran que un 25% de los estudiantes evaluados son considerados no aptos para la competencia de investigación; según los tutores, las debilidades en investigación están directamente relacionadas con la falta de tiempo durante la residencia para consolidar estas competencias, considerando que tiene un papel secundario para el profesional (1). en la competencia general los resultados evaluados en ambos colectivos de profesionales de enfermería la perciben como indispensable para el desarrollo profesional sobre el 84%. en la competencia general se destaca la categoría “comprende lo propio del país y su interdependencia del mundo globalizado” con porcentajes entre 63 y 67% para enfermeras clínicas y supervisoras respectivamente, situación que debe ser evaluada con cuidado e intervenida adecuadamente ya que la enfermería se encuentra inserta en un mundo globalizado y su actividad diaria depende de políticas de salud locales, nacionales y mundiales. en la competencia de sello se resalta la categoría “diseño y gestión de proyecto” considerada medianamente indispensable para el desempeño profesional por parte de las enfermeras clínicas y supervisoras con 38,5 y 21,1% respectivamente, lo que indica la necesidad de desarrollar estudios complementarios que permitan la evaluación de la permanencia de la categoría en esta competencia para este nivel de estudiantes. al analizar y contrastar las percepciones de los profesionales y estudiantes de enfermería sobre la importancia atribuida a las competencias finales se destaca una aparente diferencia en esta percepción, observándose que los estudiantes evaluaron las competencias de gestión, investigación y sello como indispensables para el desarrollo profesional en menos del 80% del total de la muestra seleccionada; en contrapartida, los profesionales perciben estas competencias como indispensables en porcentajes de frecuencia que alcanzan en la competencia de sello se resalta la categoría “diseño y gestión de proyecto” considerada medianamente indispensable para el desempeño profesional por parte de las enfermeras clínicas y supervisoras con 38,5 y 21,1% respectivamente. 312 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 rangos de 84 a 93%, datos que concuerdan con los obtenidos en investigación en la carrera de medicina, donde sobresale en las conclusiones que la percepción del residente puede estar condicionada por la inseguridad propia del profesional novel, sumado a que durante la etapa en formación es necesario fijar conocimientos en los diferentes niveles del aprendizaje del estudiante (1). se destaca la necesidad de continuar esta línea de investigación con el paradigma cualitativo el cual nos permitiría probablemente entender y comprender por qué los estudiantes perciben el logro de las competencias en forma diferente a aquellas definidas por los profesionales como deseables e importantes para el desarrollo laboral del enfermero. en conclusión, a la luz de los datos, las competencias profesionales y genéricas fueron evaluadas como “muy importante” por el 80%, en especial en el grupo de enfermeras supervisoras, esto permite validar a nivel local las competencias definidas en el currículum por competencias. la presente investigación muestra la utilidad para las escuelas de enfermería de orientar su modelo educativo al desarrollo de un currículum basado en competencias, elaborado y compartido con los participantes del proceso educativo, lo que permite: 1) realizar una gestión universitaria de calidad; 2) fortalecer el nexo docente-asistencial; 3) permitir a las escuelas de enfermería evaluar las competencias de egreso de sus estudiantes en el marco de los procesos de autoevaluación frente a un modelo de acreditación; 4) ofrecer las herramientas necesarias a los futuros profesionales de enfermería para la adquisición de competencias que permitan promover el desarrollo de atributos y valores de acuerdo con las necesidades de la sociedad donde se encuentran inmersos. referencias 1. ros me. las competencias profesionales adquiridas en medicina familiar y comunitaria. una mirada desde tutores y residentes. educ méd 2004; 7 (4): 125-131. 2. durán de villalobos mm. marco epistemológico de la enfermería. aquichan 2002; 2 (2): 7-18. 3. hernández as. algunas consideraciones acerca de los valores humanos y el profesional de enfermería. aquichan 2001 (1): 18-22. 4. leonello vm, campos ma. competencias para la acción educativa de la enfermera. rev latino-am enfermagem 2008; 16 (2): 177-183. 5. calhoun jg, davidson pl, sinioris me, vincet et, griffith jrm. toward an understanding of competency identification and assessment. in: health care management. quality management in healt care 2002; 17 (1): 14-28. 6. falcó pa. la nueva formación de profesionales: sobre la competencia professional y la competencia del estudiante de enfermería. educ méd 2004; 7 (1): 42-45. 7. ruthes rm, kowal coc. entendendo as competências para aplicação na enfermagem. rev bras enferm 2008; 61 (1): 109-12. 8. hager p, gonczi a. what is competence? medical teacher 1996;18:15-18. 9. mirable rj. everything you wanted to know about competency modeling. in: nilson c. training and development yearbook. new jersey: prentice hall; 1998. pp. 55-59. 10. pérez c, alameda a, albeniz c. la formación práctica en enfermería de la comunidad de madrid. opinión de los alumnos y de los profesionales asistenciales. un estudio cualitativo con grupos de discusión. rev esp salud pública 2002; 76: 517530. 11. nolla m, palés j, gual a. desarrollo de las competencias profesionales educ méd 2002; 5 (2): 76-81. 12. harrison l, ray ha, cianelli r, rivera ms, urrutia m. competencias en investigación para diferentes niveles de formación de enfermeras: una perspectiva latinoamericana. cienc enferm 2005; 11 (1): 59-71. 13. muñoz cj, latrach ca, gonzález iv, araya mn. evaluación de competencias del nivel de bachiller: aseguramiento de la calidad en la formación de estudiantes de enfermería. cienc enferm 2010; 16 (1): 77-84. 14. ques aam, montoro ch, gonzález mg. fortalezas y amenazas en torno a la seguridad del paciente según la opinión de los profesionales de enfermería. rev latino-am enfermagem 2010; 18 (3): 339-345. 15. ruthes rm, kowal olm, cunha ic. entendendo as competências para aplicação na enfermagem. rev brás enferm 2008; 61 (1): 109-12. 313 importancia de las competencias en la formación de enfermería l cecilia latrach-ammar tabla 1. distribución porcentual de la frecuencia de respuestas de los profesionales de enfermería frente a la evaluación de las categorías de cada competencia profesional evaluadas (n = 111 enfermeras) *= (a = muy importante; b = medianamente importante; c = poco importante) 314 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 tabla 2. distribución porcentual de la frecuencia de respuestas de los profesionales de enfermería frente a la evaluación de las categorías de cada competencia genérica evaluadas (n = 111 enfermeras) *= (a = muy importante; b = medianamente importante; c = poco importante) enfermeros clínicos enfermeros supervisores categorías evaluadas según competencia a* b c a b c % % % % % % competencias generales demuestra habilidades para liderar grupos humanos 94,2 5,8 0,0 92,1 7,9 0,0 demuestra flexibilidad para adaptarse a diferentes contextos y situaciones 92,3 7,7 0,0 100,0 0,0 0,0 capacidad de comunicarse de manera efectiva 94,2 5,8 0,0 94,7 5,3 0,0 demuestra pensamiento crítico, reflexivo y habilidad de resolución de problemas 92,3 7,7 0,0 97,4 2,6 0,0 respeta diversidad de costumbres, creencias, ideas en su desempeño profesional 94,2 5,8 0,0 97,4 2,6 0,0 comprende lo propio del país y su interdependencia del mundo globalizado 67,3 26,9 5,8 63,3 36,8 0,0 demuestra capacidad para integrarse a la comunidad y participación responsable 80,8 19,2 0,0 73,7 26,3 0,0 competencia de sello demuestra espíritu de emprendimiento, creativo e innovador para enfrentar y resolver problemas pertinentes a su quehacer profesional 90,4 9,6 0,0 94,7 5,3 0,0 demuestra capacidad de crítica y autocrítica en la ejecución del rol de enfermero 96,2 3,8 0,0 97,4 2,6 0,0 gestiona autoaprendizaje y desarrollo personal 92,3 3,8 3,8 97,4 2,6 0,0 demuestra habilidades básicas de investigación 82,7 17,3 0,0 92,1 7,9 0,0 diseña y gestiona proyectos 61,5 38,5 0,0 78,9 21,1 0,0 315 importancia de las competencias en la formación de enfermería l cecilia latrach-ammar gráfico 1. comparación de la percepción de “muy importante” atribuida a las diferentes competencias profesionales y genéricas por parte de enfermeras clínicas, enfermeras supervisoras e internas de enfermería effects of a healthy habit promotion strategy on colombian schoolchildren article effects of a healthy habit promotion strategy on colombian schoolchildren* efectos de una estrategia de promoción de hábitos de vida saludable en niños colombianos en edad escolar** efeitos de uma estratégia de promoção de hábitos de vida saudável em crianças colombianas em idade escolar*** 10.5294/aqui.2021.21.4.7 angélica maría ospina romero1 gloria carvajal carrascal2 tania catalina chinchilla salcedo3 césar a. niño hernández4 paola sarmiento gonzález5 humberto mayorga álvarez6 1 0000-0001-7845-1889 facultad de enfermería y rehabilitación, universidad de la sabana. colombia. angelica.ospina@unisabana.edu.co 2 0000-0001-8244-2731 facultad de enfermería y rehabilitación, universidad de la sabana. colombia. gloria.carvajal@unisabana.edu.co 3 0000-0002-6534-6673 facultad de enfermería y rehabilitación, universidad de la sabana. colombia. tania.chinchilla@unisabana.edu.co 4 0000-0001-7510-024x facultad de enfermería y rehabilitación, universidad de la sabana. colombia. cesar.nino@unisabana.edu.co 5 0000-0001-9164-970x facultad de enfermería y rehabilitación, universidad de la sabana. colombia. paola.sarmiento1@unisabana.edu.co 6 0000-0001-8040-0378 facultad de enfermería y rehabilitación, universidad de la sabana. colombia. jhmayorgaa@unal.edu.co received: 30/09/2021 sent to peers: 04/10/2021 approved by peers: 11/10/2021 accepted: 15/10/2021 * this study was sponsored by the universidad de la sabana and nestlé, colombia. after this first stage the study changed its name from "united for healthy kids" to "nestlé for healthy kids". project enf-35-2019 design and validation of a reinforcement intervention within the health promotion strategy "united by healthy children" in schools of the sabana centro region, 2019. ** este estudio fue patrocinado por la universidad de la sabana y nestlé colombia. después de esta primera etapa, el estudio cambió su nombre de "united for healthy kids" a "nestlé for healthy kids". proyecto enf-35-2019 design and validation of a reinforcement intervention within the health promotion strategy "united by healthy children" in schools of the sabana centro region, 2019. *** este estudo foi patrocinado pela universidad de la sabana e pela nestlé colômbia. após esta primeira etapa, o estudo mudou seu nome de "united for healthy kids" a "nestlé for healthy kids". projeto enf-35-2019 — design and validation of a reinforcement intervention within the health promotion strategy "united by healthy children" in schools of the sabana centro region, 2019. theme: promotion and prevention. contribution to the discipline: the positive effect of the "united for healthier kids" (u4hk) strategy on colombian schoolchildren strengthens health care in schools and responds to one of the most critical health problems worldwide. the u4hk promotes healthy nutrition and physical activity habits in schoolchildren, is consistent with the best available evidence, and could be replicated in similar populations, especially in latin america. to reference this article / para citar este artículo / para citar este artigo:ospina am, carvajal g, chinchilla tc, niño ca, sarmiento p, mayorga h. effects of a healthy habit promotion strategy on colombian schoolchildren. aquichan. 2021;21(4):e2147. doi: https://doi.org/10.5294/aqui.2021.21.4.7 abstract chronic non-communicable diseases (cncd) show an increasing tendency, especially in lowand medium-income countries. it is necessary to develop and evaluate strategies to strengthen healthy habits at an early age in these countries. objective: to determine the effect of the health promotion strategy "united for healthier kids" (u4hk) on health lifestyle habits of a group of colombian schoolchildren for the 2018-2020 period. materials and methods: this quasi-experimental study features treatment and control groups and pre and post-intervention measurements. the study involved 1,011 schoolchildren between six and twelve years old from seven rural and urban schools of the sabana centro region of colombia. we used the healthy habits measurement tool, previously validated in colombia. results: when comparing within and between groups, the uhk strategy showed statistically significant differences in healthy habits (p < 0.05) related to nutrition and physical activity in schoolchildren. conclusions: the u4hk strategy had a positive effect and impact on the schoolchildren' healthy habits, especially in the 'chooses to drink water' and 'moves more' components. there were statistically significant differences (p < 0.05) between groups in four out of the five categories: drinks more water, chooses nutritios and varied options, eats and cooks as a family, and moves more. the u4hk strategy responds to current and future health problems in schoolchildren and helps prevent chronic diseases. it could be replicated in similar populations. keywords (source decs): school nursing; public health; health policy; health promotion; nutrition; exercise. resumen las enfermedades crónicas no transmisibles (ecnt) muestran una tendencia creciente, en especial en los países de ingresos bajos y medios. es necesario desarrollar y evaluar estrategias para fortalecer hábitos de vida saludable en edades tempranas en estos países. objetivo: determinar el efecto de la estrategia de promoción de la salud "unidos por niños más sanos" (u4hk, por sus siglas en inglés) en un grupo de estudiantes colombianos para el período 2018-2020. materiales y métodos: este estudio cuasiexperimental cuenta con grupos de tratamiento y control y con mediciones previas y posteriores a la intervención. en el estudio participaron 1011 estudiantes de entre seis y doce años de siete instituciones educativas de colombia. se utilizó la herramienta de medición de hábitos de vida saludable, previamente validada en colombia. resultados: al comparar dentro de los grupos y entre ellos, la estrategia u4hk mostró diferencias estadísticamente significativas en los hábitos saludables relacionados con la nutrición y la actividad física en niños en edad escolar. conclusiones: la estrategia u4hk tuvo un efecto y un impacto positivo en los hábitos saludables de los estudiantes, en particular en los componentes "beber más agua" y "moverse más". hubo diferencias estadísticamente significativas (p < 0.05) entre los grupos en cuatro de las cinco categorías: beber más agua, variedad y nutrición, comer y cocinar en familia y moverse más. la estrategia u4hk responde a los problemas de salud actuales y futuros de los estudiantes y ayuda a prevenir enfermedades crónicas. además, podría replicarse en poblaciones similares. palabras clave (fuente decs): servicios de enfermería escolar; salud pública; política de salud; promoción de la salud; nutrición; ejercicio físico. resumo as doenças crônicas não transmissíveis mostram uma tendência crescente, em especial nos países de rendas baixa e média. é necessário desenvolver e avaliar estratégias para fortalecer hábitos de vida saudável de forma precoce nesses países. objetivo: determinar o efeito da estratégia de promoção de saúde "unidos por crianças mais saudáveis" (u4hk, por sua sigla em inglês) num grupo de estudantes colombianos para o período 2018-2020. materiais e métodos: este estudo quase experimental conta com grupos de tratamento e controle, e com avaliações prévias e posteriores à intervenção. do estudo, participaram 1011 estudantes de entre 6 e 12 anos de sete instituições educacionais da colômbia. foi utilizada a ferramenta de avaliação de hábitos de vida saudável, previamente validada na colômbia. resultados: ao comparar dentro dos grupos e entre eles, a estratégia u4hk mostrou diferenças estatisticamente significativas nos hábitos saudáveis relacionados com a nutrição e a atividade física em crianças em idade escolar. conclusões: a estratégia u4hk teve efeito e impacto positivos nos hábitos saudáveis dos estudantes, em particular nos componentes "beber mais água" e "se movimentar mais". houve diferenças estatisticamente significativas (p < 0,05) entre os grupos em quatro das cinco categorias: beber mais água, variedade e nutrição, comer e cozinhar em família, e se movimentar mais. a estratégia u4hk responde aos problemas de saúde atuais e futuros dos estudantes e ajuda a prevenir doenças crônicas. além disso, poderia ser reproduzida em populações semelhantes. palavras-chave (fonte decs): serviços de enfermagem escolar; saúde pública; política de saúde; promoção da saúde; nutrição; exercício físico. introduction the global increase in non-transmissible chronic illness (ntci) outweighs the capacity of health systems and demands intervention to reduce that load (1). the world health organization (who) has pointed out the need to reduce risk factors and improve healthy lifestyles (2). one proposed alternative to take on this challenge is the 'health promotion schools' (3). the pan american health organization (paho) defines a 'health promotion school' as one that helps children and adolescents to make better decisions regarding their health and the health of the community (4). some studies conducted with schoolchildren of higher-income countries have pointed out to a positive response to health promotion strategies (5). in mid and low-income countries such as colombia, sedentarism (6), overweight (7, 8), and cardiovascular risk have continued to increase, with a higher prevalence in schoolchildren from urban areas (9). in the same way, there are dysfunctional family dynamics that increase health risks for schoolchildren (10). parents' age, educational level, and dietary patterns are associated with the high consumption of sugary drinks (11), while food handling at schools shows unhealthy practices (12). these factors increase the sense of urgency for interventions relating to this matter. the "united for healthier kids" (u4hk) strategy comprises five areas: 1) more water, 2) more managed portions, 3) more fruits and vegetables, 4) more eating and cooking as a family, and 5) more movement. although this strategy follows the best available evidence and focuses on schoolchildren with their teachers, parents, and school context (13), its effect on colombian schoolchildren has not been assessed yet. this document shows evidence of the uhk's effect on a group of colombian schoolchildren. materials and methods this quasi-experimental quantitative study encompasses pre and post-intervention measurements for treatment and control groups. this research is part of the prosalud us 2018-2020 project. participants. this study included 1,011 children aged 6 to 12 from seven schools in the sabana centro region of colombia; 682 in the treatment group and 329 in the control group and their parents, teachers, and food service personnel. there were four schools in the treatment group and three in the control group chosen for convenience. all children in the grades we chose participated in the experiment; however, we excluded the measurements of those who had a physical or mental condition that prevented them from answering the questions correctly. instruments. we used the healthy lifestyle measurements in schoolchildren tool (hm-hvs-esc in spanish), validated in colombia. the tool has 20 items that assess expertise, attitude, and behavior about nutrition  and physical activity in schoolchildren (14). this tool has versions for schoolchildren, parents, teachers, and food service personnel. procedure. this study took place during a whole school year. we began by requesting informed consent from participating adults, the parent's or tutor's authorization for their child's participation, and the child's approval. the treatment group received the u4hk intervention. as noted above this strategy includes five aspects of health promotion related to nutrition and physical activity. the control group received a community-guided intervention and included topics such as interpersonal relations, environmental care, and life planning. both interventions had the same duration and employed similar dynamics. different groups handled the experiment and measurements, but both followed previously established guidelines. activities in the u4hk intervention included workshops with schoolchildren, learning activities during recess, support for teachers to incorporate these topics into their classes, the promotion of a school garden, and workshops directed towards parents, teachers, shop keepers, and school cafeteria personnel. treatment and control activities also included workshops with students, learning activities during recess, and voluntary participation by teachers, parents, and school staff. analysis. we compared groups between and within them, preand post-intervention, using spss version 22, by establishing frequency tables and response percentages before and after the intervention. we also analyzed the group through ratio comparison and determined whether the u4hk had a positive, negative, or neutral effect on keeping healthy habits. we then created and calculated an impact index composed of the strategy's ratio of positive change to negative change in knowledge, attitude, and behavior. this means it shows the ratio of positive to negative change when the group is compared before and after the intervention, which is an essential methodological tool to compare results in different time frames. we made a chi-squared test to compare treatment and control groups with a confidence interval of 95 % to reject the null hypothesis that a student is equally likely to achieve a determined level of healthy habits regardless of the u4hk intervention. ethical aspects. this study follows national and international ethical guidelines for health research in human beings. it was reviewed and approved by the institutional ethics committee (minutes no. 0030518). researchers were given complete freedom to handle procedures and results with no interference from the sponsoring company. results table 1 summarizes the effects and impact of the assessment in schoolchildren who participated in the u4hk and indicates each component compared within the group (see table 1). table 1. effect and impact of the u4hk strategy on colombian schoolchildren, 2018 – 2020 dimension strategy component item effect (%) + effect (%) impact nutrition chooses to drink water selection of a healthy beverage 76.4 23.6 2.79 attitude towards water intake 80.3 19.7 0.98 amount of water to be consumed daily 68.9 31.1 2.63 importance of water consumption 87.0 13.0 1.15 benefits of drinking water 66.5 33.5 1.21 component average 75.8 24.2 1.75 chooses nutritious and varied options daily food intake 22.5 77.5 0.4 benefits of food 42.9 57.1 0.7 component average 32.7 77.3 0.5 manages portions adequate size of portions 47.1 52.9 0.60 number of meals per day 34.8 65.2 0.69 healthy arrangement of the plate 41.5 58.5 0.56 component average 41.1 58.9 0.61 enjoys meals together attitude towards eating with the family 83.6 16.4 1.06 benefits of preparing foods and eating with the family 74.3 25.7 1.13 practice of hand washing 65.6 34.4 0.63 order of hand washing 62.6 37.4 0.94 component average 71.53 28.48 0.94 physical activity moves more regular practice of physical activity, exercise, or sports 95.4 4.6 1.3 weekly physical activity 43.5 56.5 1.1 hours per day of physical activity 59.1 40.9 1.2 benefits of physical activity, exercise, or sports 53.8 46.2 0.9 awareness of the time of physical activity, 24.8 75.2 0.3 exercise, or sports required/day attitude towards physical activity, exercise, or sports 89.2 10.8 1.1 weekly distribution of activity time 49.2 50.8 0.9 desired weekly distribution of the time of day 49.1 50.9 0.9 component average 58.0 42.0 1.00 source: research data, 2018 2020. when comparing groups, we found statistically significant differences (p < 0.05) in four of the five proposed u4hk categories (see table 2). table 2. p-values of the chi-squared test for difference in knowledge, attitude, and behavior between the treatment and control groups, 2018-2020 dimension inter-group compared question p-value chooses to drink water recognizes water consumption as the healthiest beverage 0.014 water consumption per day 0.000 chooses nutritious and varied options recognizes the principal benefit of dairy products 0.007 moves more frequent practice of physical activity, exercise, or sports 0.004 relates physical activity, exercise, or sports to learning capacity 0.004 relates physical activity, exercise, or sports to the possibility of making friends 0.002 diminished time devoted to playing on the tablet, computer, mobile, or videogames 0.000 diminished time meeting with friends with sedentary activity 0.009 applies knowledge of the distribution of time for sedentary activities 0.004 applies knowledge of the distribution of time for sports 0.003 enjoys meals together recognizes that cooking and eating with the family helps to organize family life 0.000 recognizes that cooking and eating with the family helps to eat better 0.000 recognizes that they consume more fruits and vegetables when cooking and eating with the family 0.001 recognizes that cooking and eating with the family makes them feeling good by helping at home 0.000 washes hands adequately before eating 0.000 source: research data, 2018 2020. discussion this study shows that the u4hk strategy implemented in schoolchildren aged six through twelve had a positive impact and effect on the 'drinks more water,' 'moves more,' 'chooses nutritious and varied options,' and 'eats and cooks as a family' components. its findings are similar to those of the maestra natura study that included italian children aged six through 13 (15). in both cases, we have tried to assess a strategy meant for a specific population, and we suggest a continuation of this strategy to achieve a sustainable effect. the u4hk strategy showed improvements in schoolchildren's physical activity beyond what amornsriwatanakul et al. reported with the strategy they implemented in schoolchildren aged six through 17 in thailand (16). similarly, this study highlights the need to sponsor physical activity through public policy; this would make it possible to promote it outside of school settings. some authors report the necessity to include the afterschool period in these health promotion activities. for instance, rieder et al. carried out a longitudinal three-year study with 76 predominantly latino schoolchildren in the united states, with pre and post-intervention measurements (17). their strategy reinforced healthy eating habits, good physical activity, and rest in the afterschool period. nonetheless, their results vary from those achieved by the u4hk strategy in that they only show non-significant improvements in behavior towards food (17). when jung et al. evaluated the effectiveness of a program that promotes awareness and healthy food-related behavior in the united states through a quasi-experimental study with 337 primary school-children supported by their teachers, they found statistically significant differences with the treatment group's better performance (p < 0.05) (18). this study applied a similar nutrition and physical activity guiding frame and achieved similar positive results. however, aside from involving children and their teachers, the u4hk strategy also involved parents and school cafeteria staff in reinforcing healthy lifestyles, which respond to unfavorable associations between families, contexts, and healthy habits in schoolchildren (10-12). in spain, gallardo et al. conducted a study with 368 primary school teachers to identify organizational factors influencing schoolchildren's sports practice (19). the authors found that if a wider variety of activities are more oriented towards play, better schoolchildren participation is achieved. girls value the play component more than boys, and in both cases, teachers' attitude and experience are critical factors for participation in sports (19). it could be a valuable complement for this study to make differentiations by gender and consider different inclusion criteria for teachers to improve the u4hk strategy. pablos et al. undertook a quasi-experimental study during eight months to evaluate the impact of a healthy lifestyle school program with 158 children aged 10 through 12 (20). their evaluation included physiological and anthropometric variables, behavior, quality, and frequency of diets, physical activity, rest, and perceived health. their results showed significant improvements (p < 0.05) in triglycerides, glycemia, and oxygen saturation; higher prevalence of normal cholesterol levels, blood pressure, and body mass; better habits and better quality of diet (20). their findings match those presented by polo-ateiza et al., who conducted an intervention for over 20,000 mexican children in five schools consisting in children participation in supervised medium-effort physical activity for 30 minutes daily, five days a week for a year and achieved a 31.9 %  reduction in overweight and obesity indexes, better levels of glycemia and lipidic profile (21). these two studies show a positive effect that agree with our findings. it is vital to continue this line of research with colombian schoolchildren, incorporating objective measures to evaluate physiological effects of adequate exercise, hydration, and nutrition. taejin et al. examined the effectiveness of the healthy highway school program, which promotes awareness and proper behavior regarding healthy nutrition in primary schoolchildren (18). their results reflect that the strategy was helpful to improve comprehension of the value of adequate nutrition as a factor for good health and improved behavior towards diets that included healthy items by verifying food labels. the u4hk strategy differs from this study because it helped children select variety and nutrition, eat and cook as a family, and hydrate well, without considering whether foods are good or bad, but their adequate use and distribution. it is paramount to continue strengthening the role of schoolchildren as leading actors in their health and that of the community, as suggested by the paho and demonstrated by blunt et al. in indian schoolchildren. these authors built a young champion community of kids between six and twelve years of age dedicated to promoting healthy practices that modify this growing tendency in ntci (4, 22). in any case, these initiatives will require reinforcement and motivation in time, as noted by nettlefold et al. (23). their study with students and teachers to promote physical activity and cardiorespiratory capacity found that behavior can improve in the initial phase of these interventions. as emphasized by ankur et al., positive reinforcement will be a crucial factor for the impact of these strategies to be long-lasting and reduce chronic illness (24). in short, this research responds to the call to coordinate education and health in school habits, as proposed by jourdan et al. and merlo et al. (25, 26). the u4hk evaluation ratifies the findings of mcmullen et al. concerning partnerships between disciplines and sectors of the community being valuable and necessary for health promotion rooted in schools (27). we consider the schoolyear timeframe a limitation to the study since these health promotion strategies should have continuity over time. we suggest trying longitudinal survey designs that would make it possible to assess the impact and effectiveness of these strategies on the lives of schoolchildren more thoroughly. it is necessary to create more specific variables to determine the effect in different population subgroups. as love et al. point out, based on their systematic review of 7,963 records of evidence on the effects of physical activity promotion strategies on children aged six through 18, gender, body mass index, socioeconomic variables, ethnic origin, place of residence, and religion can have varying effects (28). assessing these strategies by adding health indexes and variables may be needed, discriminating characteristics by gender or urban versus rural homes to see if these results vary. it would also be helpful to review whether better habits are related to better academic performance, as demonstrated in other studies (29). conclusions ntcis have a growth rate, especially in lowand mid-income countries such as colombia. it is necessary to create and evaluate strategies to favor the creation of healthy habits from a young age in these countries. this study showed that the u4hk strategy, which comprised 1,011 colombian schoolchildren aged six through twelve from the sabana centro region, had a positive effect. we supported our measurements on the healthy habits in schoolchildren measuring tool. we rejected the null hypothesis since we found statistically significant differences between the treatment and control groups (p < 0.05) in four of the five examined categories: 'drinks more water,' 'chooses nutritious and varied options,' 'eats and cooks as a family,' and 'moves more.' the u4hk strategy responds to current and future problems of the schoolchildren population and helps prevent chronic illnesses. it could also be replicated in similar populations. acknowledgements the authors would like to thank the school community for their decisive participation in this study. conflicts of interest: none declared. references 1. forouzanfar mh, afshin a, alexander lt, anderson hr, bhutta za, biryukov s, et al. global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the global burden of disease study 2015. lancet [internet]. 2016 oct;388(10053):1659-724. available from: https://linkinghub.elsevier.com/retrieve/pii/s0140673616316798 2. world health organization. tackling ncds: "best buys" and other recommended interventions for the prevention and control of non-communicable diseases [internet]. geneva; 2017. available from: https://apps.who.int/iris/handle/10665/259232 3. world health organization. an effective approach to early action on non-communicable disease risk factors [internet]. geneva; 2017. available from: https://apps.who.int/iris/handle/10665/255625 4. world health organization. promover la salud en la escuela. ¿cómo construir una escuela promotora de salud? 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[internet]. 2015 nov 6;85(11):740 -58. doi: https://doi.org/10.1111/josh.12309 27. mcmullen jm, george m, ingman bc, pulling kuhn a, graham dj, carson rl. a systematic review of community engagement outcomes research in school-based health interventions. j sch health [internet]. 2020 dec 12;90(12):985-94. doi: https://doi.org/10.1111/josh.12962 28. love re, adams j, van sluijs emf. equity effects of children's physical activity interventions: a systematic scoping review. int j behav nutr phys act [internet]. 2017 dec 2;14(1):134. doi: https://doi.org/10.1186/s12966-017-0586-8 29. valois rf, lewallen tc, slade s, tasco an. the ascd healthy school communities project: formative evaluation results. health educ [internet]. 2015 jun 1;115(3/4):269-84. doi: https://doi.org/10.1108/he-04-2014-0050 home investigación en el grupo de cuidado de enfermería – unisabana y aquichan: trayectoria y retos. editorial research in the nursing care group unisabana and aquichan: track record and challenges investigación en el grupo de cuidado de enfermería unisabana y aquichan: trayectoria y retos pesquisa no grupo de cuidado de enfermagem — unisabana e aquichan: trajetória e desafios 10.5294/aqui.2021.21.4.1 gloria carvajal-carrascal 0000-0001-a244-2731. decana facultad de enfermería y rehabilitación, uni­versidad de la sabana, colombia. gloria.carvajal@unisabana.edu.co keywords (source decs): nursing; health; nursing research; evidence-based nursing; scientific and technical publications. palabras clave (fuente decs): enfermería; salud; investigación en enfermería; enfermería basada en la evidencia; publicaciones científicas y técnicas. palavras-chave (fonte decs): enfermagem; saúde; pesquisa em enfermagem; enfermagem baseada em evidências; publicações científicas e técnicas. to reference this editorial / para citar este editorial / para citar este editorial: carvajal-carrascal g. research in the nursing care group unisabana and aquichan: track record and challenges. aquichan. 2021;21(4):e2141. doi: https://doi.org/10.5294/aqui.2021.21.4.1 nursing is a professional discipline that, building on scientific knowledge, seeks to take care of people and improve professional practice in different areas based on understanding its phenomena and using the best available evidence (1). its core or subject matter is the care of human health experience (2, 3), although recent conceptualizations indicate that the discipline is oriented towards humanization, meaning, choice, quality of life, and healing in living and dying processes (4). therefore, theoretical development, research, and practice should focus on comprehending these constructs and devising transferable care strategies that promote health, improve well-being, and ensure a comprehensive approach to human beings' health (5, 6). based on the different professional practice roles, nursing is bound to rise to the demographic, cultural, social, and global health challenges, pointed out by various international organizations and institutions, and fufill the commitments established in the global agenda of the sustainable development goals (sdgs). it must address challenges related to maternal and infant mortality, improved nutrition, mental health, progress in the prevention and control of infectious diseases, the management of chronic non-communicable diseases (cncd), the strengthening of response to emergencies and disasters, the provision of person-centered care, the assurance of access to universal health coverage, among others (7-12). to continue its disciplinary development, nursing needs to reinforce research understood as a creative, systematic, and rigorous process to produce and use knowledge to impact the health experience of individuals, families, and community groups positively. nursing research is essential to improve health care, understand the problems of practice, identify the most effective strategies or interventions, and guide institutional and public policies aimed at more affordable and equitable health and social services (10, 13, 14). based on knowledge and practical experience, nursing professionals can theorize, formulate hypotheses, and collect evidence to improve patient care and outcomes (15). in this regard, the available literature shows current trends in nursing research, namely: i) demographic changes; ii) diversity and globalization; iii) technological innovation; iv) individualized care and population health; v) health policies, and vi) changes in the nursing workforce. some guidelines are related to the cost/effectiveness of care analysis; reducing the gaps between nursing research and practice —by identifying barriers and enablers in the development of highly innovative evidence-based approaches for advanced practice—; using data science to facilitate research and improve health care services; training the future generation of researchers from a range of high-quality, flexible, and accessible programs and the necessary interdisciplinarity to address the population's health problems (16). consistent with these global social and health challenges, and with the universidad de la sabana's educational project postulates and the mission of the department of nursing and rehabilitation, the nursing care research group unisabana has promoted the development of disciplinary, interdisciplinary, and intersectoral research for 24 years to improve practice from knowledge transfer. the benefits of this work are noticeable in the improved health and well-being conditions of people regionally, nationally, and internationally. the group has also resolved to understand the health experience of care recipients, developing simple and complex interventions to meet the resulting needs, influencing health outcomes, validating the results for the benefit of people, and consolidating disciplinary knowledge (17). for more than two decades of work, the group has concentrated on investigating those nursing phenomena that promote health and well-being in communities, schools, workplaces, and hospi­tals, to better the experience of caring for the patient's health, respond to problems of social inequity, promote healthy lifestyles, and strive for greater autonomy and participation in health with the leadership and commitment of individuals and communities. it has also inquired about phenomena related to the theory and quality of nursing care, emphasizing the development of nursing interventions and the measurement of empirical indicators that make the cost/effectiveness of care variable visible to ensure autonomy and dignify the human condition (17). a significant initiative, derived from the track record of this research group, has been the creation of the master's in nursing (campus-based and virtual) and, more recently, the doctorate in nursing that, based on researcher training, seeks to align advanced nursing training with the practice needs and the care priorities of the health sector. according to the literature, these programs are responsible for consolidating high-quality lines of research that further the understanding of phenomena related to health care and the development of nursing interventions that contribute to building practice on scientific evidence, in addition to guiding institutional policies related to people's health care and influencing public health policies to transform health services (17-19). efforts to consolidate and make visible the research development of the discipline are also materialized in revista aquichan. in its 20 years of existence as a scientific publication, it has been faithful to the meaning of its name, "caring." as such, it aims to make the theoretical development of nursing visible and become a means of disseminating advances in nursing science in favor of disciplinary practice and the well-being of patients. this commemorative issue brings together outstanding national and international scholars and icons in nursing who present their conceptualizations, reflections, and prospects regarding the disciplinary development required for the coming years. topics such as pragmatic and empirical adequacy in medium-range theories, the conceptual and theoretical origins of empirical indicators, and the development of medium-range theories to strengthen nursing in colombia are addressed from conceptual advances. from the methodological perspective, the contribution of systematic reviews and meta-analyses is examined. we also introduce a change in the graphic line of the journal that gives a modern and versatile look to the issue without affecting its mission, scope, and themes. for the coming years, the nursing care group unisabana sees an excellent opportunity to continue impacting people's health and quality of life significantly by generating knowledge that can be transferred to practice, responding to the actual needs of the population. revista aquichan will continue to lead high-quality editorial processes that ensure the visibility of nursing knowledge worldwide. references 1. donaldson sk, crowley dm. the discipline of nursing. nurs outlook. 1978;26(2):113-120. pmid: 245616. disponible en: https://pubmed.ncbi.nlm.nih.gov/245616/ 2. newman ma, sime am, corcoran-perry sa. the focus of the discipline of nursing. ans adv nurs sci. 1991;14(1):1-6. doi: https://doi.org/10.1097/00012272-199109000-00002 3. newman ma, smith mc, pharris md, jones d. the focus of the discipline revisited. ans adv nurs sci. 200831(1): e16-e27. doi: https://doi.org/10.1097/01.ans.0000311533.65941.f1 4. willis dg, grace pj, roy c. a central unifying focus for the discipline: facilitating humanization, meaning, choice, quality of life, and healing in living and dying. ans adv nurs sci. 2008;31(1):e28-e40. doi: https://doi.org/10.1097/01.ans.0000311534.04059.d9 5. national institute of nursing research. bringing science to life: ninr strategic plan 2011. disponible en: https://www.ninr.nih.gov/sites/files/docs/ninr-strategic-plan-2011.pdf 6. meleis ai. theoretical nursing. development and progress. 6th edition. philadelphia: wolters kluwer health lippincott williams & wilkins; 2017. disponible en: https://shop.lww.com/theoreti cal-nursing/p/9780060000424 7. world health organization [who]. world health statistics 2016. monitoring health fot the sdgs. disponible en: https://www.who.int/docs/default-source/gho-documents/world-health-statistic-reports/world-heatlth-statistics-2016.pdf 8. organización de las naciones unidas [onu]. programa de las naciones unidas para el desarrollo [pnud]. objetivos de desarrollo sostenible objetivo 3: salud y bienestar. disponible en: http://www.undp.org/content/undp/es/home/sustainable-development-goals/goal-3-good-health-and-well-being.html 9. the lancet. editorial: 2020: unleashing the full potential of nursing. lancet. 2019;394(10212):1879. doi: https://doi.org/10.1016/s0140-6736(19)32794-1 10. osigada chp, porta cm. nursing and sustainable development goals (sdgs) in a covid-19 world: the state of the science and a call for nursing to lead. public health nurs. 202037(5)799-805. doi: https://doi.org/10.1111/phn.12776 11. organización panamericana de la salud [ops] organización mundial de la salud [oms] nursing now. situación de la enfermería en el mundo 2020. resumen de orientación: invertir en educación, empleo y liderazgo [internet]. washington: ops-oms; 2020. disponible en: https://apps.who.int/iris/bitstream/handle/10665/331675/9789240003392-spa.pdf . all-party parliamentary group on global health [appg]. triple impact: how developing nursing will improve health, promote gender equality and support economic growth [internet]. london: appg; 2016. disponible en: https://www.who.int/hrh/com-heeg/digital-appg_triple-impact.pdf 13. yanbing s, hua l, chao l, fenglan w, zhiguang d. the state of nursing research from 2000 to 2019: a global análisis. j adv nurs. 2021;77:162-175. doi: https://doi.org/10.1111/jan.14564 14. catton h. international council of nurses: putting nurses at the centre of the world's policymaking has benefits for us all. int nurs rev. 2019;66(3): 299-301. doi: https://doi.org/10.1111/inr.12546 15. castañeda-hidalgo h, visovsky c, hernández de, gonzález-quirarte nh, compeán-ortiz l, campiño sm. nursing's contributions to sustainable development goals in latin america through education, leadership, and partnerships. int j nurs stud. 2021;121:104004. doi: https://doi.org/10.1016/j.ijnurstu.2021.104004 16. im eo, sakashita r, lin cc, lee th, tsai hm, inouye j. current trends in nursing research across five locations: the united states, south korea, taiwan, japan, and hong kong. j nurs scholarsh. 2020;52(6):671-679. doi: https://doi.org/10.1111/jnu.12592 17. universidad de la sabana. facultad de enfermería y rehabilitación. documento maestro para la creación del programa de doctorado en enfermería. chía (cundinamarca): unisabana; 2019. 18. bednash g, breslin et, kirschling jm, rosseter rj. phd or dnp: planning for doctoral nursing education. nurs sci q. 2014;27(4):296-301. doi: https://doi.org/10.1177/0894318414546415 19. bueno robles ls, díaz heredia lp, mejía rojas me, lópez l. panorama de la formación doctoral en enfermería. av. enferm. 2010;(28) 2: 134-144. disponible en: https://revistas.unal.edu.co/index.php/avenferm/article/view/21388 home 126 139 herramienta para el calculo de personal.indd 126 aquichan issn 1657-5997 juan guillermo rojas1 natalia andrea henao-murillo2 alexandra quirós-jaramillo3 herramienta para el cálculo de personal de cuidado intensivo neonatal 1 magíster en enfermería; profesor de la facultad de enfermería, universidad de antioquia, medellín, colombia. rojitas620@tone.udea.edu.co 2 especialista en cuidado al niño en estado crítico de salud; coordinadora enfermería uci, valle de san nicolás, rionegro, antioquia, colombia. enfermeriaserviucis@une.net.co; nathyh75@hotmail.com. 3 especialista en cuidado al niño en estado crítico de salud, ucin, clínica universitaria bolivariana, medellín, colombia. amq@geo.net.co, alexamqj@gmail.com recibido: 04 de febrero de 2010 aceptado: 03 de junio de 2011 resumen la gestión del cuidado de enfermería supone la utilización de métodos y herramientas que de manera práctica permitan una aproximación a las necesidades de cuidado de los pacientes y ayuden a planear los requerimientos humanos y técnicos para tal fin. objetivo: identificar la utilidad del neonatal therapeutic intervention scoring system (ntiss) en el cálculo de personal de enfermería en la unidad de cuidado intensivo (ucin) e intermedio neonatal (ucen) de la clínica universitaria bolivariana (cub) en medellín, colombia. método: estudio descriptivo, transversal, realizado durante el mes de abril de 2007. la población estuvo conformada por los neonatos ingresados y hospitalizados en la ucin y ucen, para lo que fue necesario aplicar el instrumento al final de cada turno. se calculó una muestra de 384 instrumentos (proporción desconocida y un intervalo de confianza de 0,5). la consistencia interna del instrumento se determinó con el alfa de cronbach (0,8). resultados: se recolectaron 425 instrumentos diligenciados de 22 neonatos. las patologías más frecuentes fueron las de tipo respiratorio. el puntaje total de los ntiss analizados fue de 5.200 puntos, con un promedio de 12,3, equivalentes a 123 minutos de trabajo de enfermería por turno de 6 horas. del total de intervenciones el 62% están asignadas a las enfermeras, el 22% a las auxiliares de enfermería y el 16% a terapia respiratoria. se calculó el requerimiento de 4 enfermeras por turno en la ucin y ucen. conclusiones: el ntiss es útil para la asignación y el cálculo del personal de enfermería y contribuye a mejorar los procesos de gestión del cuidado. palabras clave atención de enfermería, personal de enfermería, enfermería neonatal, cuidados intensivos. año 11 vol. 11 nº 2 chía, colombia agosto 2011 l 126-139 127 herramienta para el cálculo de personal de cuidado intensivo neonatal l juan guillermo rojas, natalia andrea henao-murillo, alexandra quirós-jaramillo a tool for calculating the nursing staff at neonatal intensive care units abstract nursing care management implies the use of methods and tools that make it possible, in a practical way, to estimate the patient’s needs and to help plan the respective human and technical resources and requirements. objective: to identify the usefulness of the ntiss (neonatal therapeutic intervention scoring system) in calculating the nursing staff for the neonatal intensive care unit and the neonatal intermediate care unit at the clinica universitaria bolivariana (bolivarian university clinic) in medellín, colombia. methodo: this is a cross-sectional, descriptive study conducted in april 2007. the sample was comprised of the neonates admitted to and hospitalized in both facilities. the instrument was applied at the end of every shift. a sample with 384 instruments was calculated (unknown ratio and a reliability interval of 0.5). cronbach’s alpha was used to measure the internal consistency of the instrument (0.8). results: a total of 425 instruments were completed and collected for 22 neonates. respiratory illnesses were the most frequent pathology. the total score of the ntiss analyzed for the study was 5200, with an average of 12.3, which is equivalent to 123 minutes of nursing work per six-hour shift. as for the total number of interventions, 62% are assigned to nurses, 22% to auxiliary nurses and 16% to respiratory therapists. it was estimated that four nurses are required for every six-hour shift in the neonatal intensive care unit and the neonatal intermediate care unit. conclusions: ntiss is a useful tool to estimate the nursing staff and to help improve processes for nursing care management. key words nursing care, nursing staff, neonatal nursing, critical care. ferramenta para o cálculo do pessoal de cuidado intensivo neonatal resumo a gestão dos cuidados de enfermagem envolve o uso de métodos e ferramentas que permitam uma abordagem prática para as necessidades de cuidados dos doentes e ajudem a planejar os recursos humanos e técnicos necessários para este fim. objetivo: identificar a utilidade do therapeutic intervention scoring system neonatal (ntiss) no cálculo dos enfermeiros/as nas unidades de cuidados intensivos (uci) e intermédios neonatais (ucin) da clínica universitaria bolivariana (cub) em medellín, colômbia. método: estudo descritivo transversal, realizado em abril de 2007. a população foi composta de bebês ingressados e hospitalizados na uci e na ucin. aplicou-se o instrumento ao final de cada turno. calculamos uma amostra de 384 instrumentos (proporção desconhecida e intervalo de confiança de 0,5). a consistência interna do instrumento foi avaliada pelo alfa de cronbach (0,8). resultados: foram coletados 425 instrumentos 128 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 preenchidos de 22 recém-nascidos. as patologias mais freqüentes foram de tipo respiratório. a pontuação total dos ntiss analisados alcançou 5.200 pontos, média de 12,3, o equivalente a 123 minutos de trabalho de enfermagem por turno de 6 horas. de todas as intervenções, 62% são atribuídos a enfermeiros/as, 22% para auxiliares de enfermagem e 16% para fisioterapia respiratória. calculou-se que são necessárias 4 enfermeiros/as por turno na uci e na ucin. conclusões: o ntiss é útil para o cálculo e a atribuição de pessoal de enfermagem, e contribui para melhorar os processos de gestão de cuidados. palavras-chave atendimento de enfermagem, enfermagem neonatal, enfermeiros/as, cuidados intensivos. 129 herramienta para el cálculo de personal de cuidado intensivo neonatal l juan guillermo rojas, natalia andrea henao-murillo, alexandra quirós-jaramillo introducción el cuidado de enfermería en la unidad de cuidado intensivo neonatal (ucin), comprende la realización de actividades en las dimensiones biológica y psicológica, orientadas al mantenimiento de la vida, el crecimiento y el desarrollo de los neonatos, cuidado de la familia, gestión del cuidado y gestión de los servicios de enfermería. las particularidades del cuidado al recién nacido están determinadas por su vulnerabilidad en relación con los procesos mórbidos coexistentes, sus necesidades de cuidado, la forma de comunicación, la dependencia de la tecnología y las implicaciones que tiene para los padres la hospitalización de un hijo recién nacido en tales circunstancias. en este orden de ideas, es preciso considerar los propósitos de los cuidados en la ucin enfocados hacia la resolución de las alteraciones fisiopatológicas, la culminación de los procesos de madurez física en un entorno favorable, el cuidado a la familia del neonato y el fomento del vínculo filial que promueva la transición exitosa del hospital al domicilio (1), para lo cual la gestión del cuidado en este tipo de unidades aporta los elementos teóricos y prácticos necesarios. al definir la gestión del cuidado, kérouac (2) se refiere al proceso heurístico encaminado a movilizar los recursos humanos y del entorno con la intención de mantener y favorecer el cuidado de las personas que experimentan dificultades en su salud en un contexto dado, lo que supone la realización de una práctica profesional fortalecida en los patrones de conocimiento empírico, estético, personal y ético, es decir, con perspectiva disciplinar de enfermería y comprometida con el aseguramiento de la calidad y la seguridad en el cuidado. la gestión del cuidado en la ucin hace referencia a la realización de actividades con y mediante las personas y los recursos disponibles necesarios para el logro de los objetivos en el cuidado de enfermería (3), a través de procesos como la planeación, el cálculo de personal, la asignación de pacientes y la medición de las cargas de trabajo. la planeación del cuidado de enfermería al neonato con alteraciones de salud conlleva la realización de acciones que demandan la valoración constante de los resultados alcanzados, el establecimiento de metas y de las competencias científicas, técnicas y humanas que deben reunir las personas que se desempeñan en el área. por tanto, la valoración de las cargas de trabajo, el cálculo de personal y la asignación de los pacientes mediante la escala neonatal therapeutic interventions score (ntiss) (índice de intervenciones terapéuticas neonatales), constituye una herramienta útil para la gestión en los servicios de enfermería como estrategia que permite tener una aproximación objetiva a la realidad y al rendimiento esperado en relación con las necesidades de los pacientes, la gravedad de los procesos mórbidos que cursan, y los recursos humanos y las tecnológicos de los que se dispone para su cuidado (4). en neonatología se han utilizado medidas convencionales para clasificar y medir de manera indirecta el riesgo de morbilidad y mortalidad de los recién nacidos, entre ellas, 130 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 variables como el peso, la edad gestacional y el test de apgar al nacer, las cuales han sido utilizadas con fines estadísticos sin tener en cuenta su relevancia como herramientas pronósticas con las que es posible caracterizar la severidad de las complicaciones en los primeros minutos de vida, la ocurrencia de otros problemas de salud a lo largo del periodo neonatal, y la planeación de los recursos para brindar los cuidados específicos. el índice ntiss resultó de una adaptación hecha por gray en 1992 (5), a partir del sistema de puntuación de intervenciones terapéuticas tiss (therapeutic intervention scoring system) empleado para estratificar la gravedad en los pacientes en estado crítico. esta herramienta evalúa indirectamente la severidad de la enfermedad en relación con la intensidad de las actuaciones terapéuticas realizadas a los pacientes tomando como referencia las 70 intervenciones que con frecuencia se llevan a cabo en una ucin. la severidad de los problemas y la intensidad de las terapias recibidas por los pacientes analizados con la escala provee una información más amplia sobre el neonato, dando una aproximación al riesgo de mortalidad, el tiempo de estancia hospitalaria, los costos de la atención, la planeación del trabajo, la medición de la carga laboral, el consumo de recursos y la evaluación de los estilos de trabajo (4). las actividades contempladas en el ntiss se agrupan en: acciones para el soporte respiratorio, soporte cardiovascular, terapias con medicamentos, monitoría, soporte metabólico y nutricional, terapia transfusional, procedimientos y accesos vasculares. la utilidad del ntiss ha sido reportada por autores como mendes (6), quien concluyó y sugirió la utilización periódica del índice para detectar las variaciones de las prácticas asistenciales que podrían influir sobre los resultados clínicos, y los costos y las contingencias operacionales en cada unidad examinada, con el propósito de optimizar los recursos y tratamientos para los recién nacidos de alto riesgo. se encontraron pocas referencias y trabajos sobre la utilización del ntiss en la práctica, tanto en el contexto latinoamericano como el colombiano; no obstante, se documentó la utilización de registros basados en variables convencionales como el test de apgar, el peso al nacer, las semanas de gestación, el diagnóstico al ingreso, las complicaciones asociadas a la prematurez y las intervenciones realizadas, información que, aunque valiosa, solo ha servido para caracterizar el perfil epidemiológico y poco ha aportado a la gestión del cuidado de enfermería a los neonatos. en 2003, la sociedad colombiana de neonatología (7) revisó los criterios de admisión a una ucin bajo los supuestos de la intensidad de cuidado requerido, y los principios de ética, equidad, justicia y calidad, estableciendo como parámetros el estado clínico del recién nacido, las patologías y la necesidad de cuidado estimada con el uso de índices de morbilidad y mortalidad. dichos criterios han permitido organizar las unidades neonatales con base en la complejidad de los servicios ofrecidos (cuidados intensivos, cuidados intermedios y básicos), y las formas de establecer contrataciones con las entidades promotoras de salud dentro del plan obligatorio de salud (pos) en los regímenes subsidiado y contributivo. por otra parte, la legislación actual sobre el cumplimiento de los requisitos la legislación actual sobre el cumplimiento de los requisitos esenciales para la prestación de los servicios de salud se refiere al requerimiento de un profesional de enfermería con especialidad en el área durante las 24 horas del día. 131 herramienta para el cálculo de personal de cuidado intensivo neonatal l juan guillermo rojas, natalia andrea henao-murillo, alexandra quirós-jaramillo esenciales para la prestación de los servicios de salud se refiere al requerimiento de un profesional de enfermería con especialidad en el área durante las 24 horas del día, sin tener en cuenta la relación numérica enfermera-paciente, y la complejidad del cuidado y de las intervenciones requeridas para tal fin (8). con base en estas premisas cobra vigencia la necesidad de utilizar escalas pronósticas o índices que correlacionen las intervenciones requeridas por los pacientes, y de manera objetiva consoliden el proceso de gestión del cuidado, tales como el índice ntiss. la clínica universitaria bolivariana (cub) es una institución privada prestadora de servicios de salud de mediana y alta complejidad, orientada a la formación universitaria tomando como punto de partida la integralidad de la atención, la calidad científica, humana y ética, y la aplicación de los valores del humanismo cristiano, principalmente la solidaridad y el respeto por la vida. la unidad neonatal de dicha institución tiene un modelo de atención basado en la mínima intervención de los recién nacidos, para lo que cuenta con 25 camas distribuidas así: 8 para cuidados básicos, 9 para cuidados intermedios y 8 para cuidados intensivos. en esta unidad, el cuidado de enfermería es brindado en cada turno por 2 enfermeras, una para labores asistenciales y otra para labores administrativas, 6 auxiliares de enfermería y el apoyo de una terapeuta respiratoria; este personal ha sido calculado de acuerdo con la normativa vigente y las posibilidades de dotación de recurso humano. a partir de los supuestos teóricos, la experiencia del equipo de investigadores y el interés en el área, se planteó la pregunta sobre la utilidad del ntiss en la determinación de la carga de trabajo y el cálculo de personal de enfermería en la unidad neonatal, concretamente en la ucin y la ucen. en tal sentido, se plantearon como objetivos la caracterización de los neonatos ingresados, el cálculo de los índices de cada uno de ellos y, con base en estos datos, la estimación del número de enfermeras requerido, con el propósito de contribuir a la realización de una práctica de cuidado ajustada a las condiciones y necesidades reales de los recién nacidos mediante la utilización de herramientas objetivas para la gestión del cuidado, visibilizando el aporte de la enfermería al cuidado de la vida, y fortaleciendo el cuerpo de conocimientos propios. en síntesis, promoviendo la utilización de las competencias especializadas y del conocimiento de enfermería a fin de responder a las necesidades y expectativas de los pacientes y de la sociedad (9). método se realizó un estudio descriptivo de corte transversal en la unidad neonatal de la clínica universitaria bolivariana de medellín, en el mes de abril de 2007. la población estudiada fueron los 22 neonatos admitidos durante el periodo a la ucin y ucen; se tomaron como unidades de análisis los ntiss diligenciados, es decir, que a cada neonato se le aplicó el índice varias veces durante su estancia. con el programa epidat se calculó una muestra de 384 instrumentos tomando una proporción desconocida y un intervalo de confianza de 0,5, finalmente se recolectaron 425 instrumentos que se utilizaron en su totalidad para el proceso analítico. las variables estudiadas fueron: aspectos sociodemográficos del neonato, puntaje del índice ntiss, tiempo requerido para el diligenciamiento y actitud del equipo de enfermería frente a la escala. se 132 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 realizaron varias sesiones educativas con el equipo de enfermería para familiarizarlo con el índice ntiss y su diligenciamiento. se llevó a cabo una prueba piloto con enfermeras expertas en cuidado intensivo neonatal, la confiabilidad del instrumento se estimó con el alfa de cronbach de 0,8, indicando buena consistencia interna (10). para la recolección de la información se diligenció el índice ntiss a cada neonato al finalizar cada turno de 12 horas. una vez completada la etapa de recolección, se aplicó una escala likert al grupo de enfermeras para conocer su actitud frente a la aplicación del índice. la información depurada fue procesada en una base de datos en excel, y posteriormente en el programa spss versión 14, para el análisis de tipo descriptivo con la estimación de proporciones, frecuencias y medidas como la media, la desviación estándar y la suma. la investigación contó con la aprobación del comité de ética de la institución. en el desarrollo del proceso se salvaguardaron los principios éticos de beneficencia, justicia y respeto en razón de que se emplearon fuentes documentales y no se llevaron a cabo intervenciones en los participantes (11). se cumplió con los compromisos establecidos en la institución en cuanto a la devolución de la información a los integrantes del equipo de enfermería y el manejo confidencial de los datos con fines estrictamente académicos. resultados el número de neonatos admitidos a la ucin durante el tiempo de recolección de la información fue de 22, de los cuales el 59% era de sexo masculino. los recién nacidos provenían de la unidad materno infantil de la cub (68%), remitidos de instituciones del área metropolitana de medellín (23%) y de otras instituciones del departamento (9%). la tabla 1 muestra la distribución de frecuencias del peso de los neonatos, y el gráfico 1 indica la distribución de las semanas de gestación de los mismos. los diagnósticos maternos más frecuentes fueron el síndrome hipertensivo asociado al embarazo (shae) (36%), madre sana (26%) y otros cuadros patológicos, como síndrome nefrítico, lupus eritematoso sistémico, amnionitis, oligoamnios y sífilis (26%); a su vez, los diagnósticos de ingreso de los neonatos se agruparon en afecciones de tipo respiratorio (45%), riesgos asociados a la prematurez (27%), enfermedades cardiovasculares (14%) y problemas quirúrgicos (14%). la naturaleza compleja de los diagnósticos de ingreso, tanto de la madre como del recién nacido, se debe al hecho de que la cub es una institución de tercer nivel que atiende a mujeres embarazadas con alto riesgo obstétrico, situación asociada a los problemas de la prematurez y sus complicaciones en los recién nacidos. escala del ntiss la muestra calculada fue de 384 índices, finalmente se diligenciaron 425 instrumentos que fueron empleados en su totalidad; el promedio de índices por cada neonato fue de 19 (mínimo 2; máximo 54). el puntaje total de todos los ntiss fue de 5.200 puntos (de: 70.10), con un promedio de 12,3 puntos por cada instrumento que equivalen a 123 minutos de intervenciones de enfermería durante una jornada de 6 horas. las intervenciones que obtuvieron más puntaje fueron las de monitoría con 1.782 puntos (34%), intervenciones 133 herramienta para el cálculo de personal de cuidado intensivo neonatal l juan guillermo rojas, natalia andrea henao-murillo, alexandra quirós-jaramillo con los accesos vasculares (19%), acciones para la nutrición y el metabolismo (16%) y la administración de medicamentos (15%); las menos frecuentes fueron las acciones cardiovasculares (4%), las transfusiones y los procedimientos (1% cada una). la tabla 2 muestra la distribución de los puntajes de los ntiss en la población estudiada. de acuerdo con el puntaje promedio obtenido, los neonatos que más tiempo demandan para la realización de las intervenciones contempladas en el índice son los que presentan problemas quirúrgicos (tabla 3). el análisis de los puntajes del ntiss en relación con los días de hospitalización muestra un comportamiento variable determinado por valores altos al ingreso, y posteriormente una disminución y estabilización de los puntajes en directa relación con la mejoría de los recién nacidos y la necesidad de menos intervenciones. carga de trabajo y cálculo de personal al revisar el manual de funciones de la unidad neonatal se comprobó que la mayor proporción de actividades son realizadas por las enfermeras seguidas de las auxiliares de enfermería, quienes se encargan de labores de higiene, alimentación y comodidad de los neonatos. el análisis de los puntajes calculados con el ntiss permitió corroborar esta situación, dado que el 62% de las intervenciones eran realizadas por enfermeras, el 22% por las auxiliares y un 16% por el personal de terapia respiratoria. con base en lo anterior se calculó el requerimiento de 246 minutos más de trabajo de enfermera por cada neonato en una jornada de 12 horas, para ser distribuidos así: 40 minutos para la administración de medicamentos, 46,6 para los accesos venosos, y 25 para las intervenciones de terapia respiratoria que son compartidas con las auxiliares de enfermería y el personal de esta área; además, para la realización de otras actividades de monitorización (parámetros hemodinámicos, muestras de laboratorio, etc.), soporte metabólico, administración de insulina y concentrados de electrolitos y transfusiones. es preciso aclarar que el ntiss no contempla intervenciones como la educación, el acompañamiento a la familia, la gestión del cuidado, y los ingresos y egresos que son competencia de las enfermeras. por unidades se determinó la necesidad de 320 minutos de enfermería para cuidar a cada neonato en la ucin y 219 minutos en la ucen por cada jornada. de manera general, el requerimiento en la unidad de neonatos era de 49 horas de trabajo de enfermería distribuidas en 26,5 horas para cuidar a los recién nacidos ingresados en la ucin, y 22,5 horas para los hospitalizados en cuidados intermedios por cada turno de 12 horas. con base en lo anterior, se estimó la necesidad de tener 4 enfermeras por cada turno para asumir el cuidado de los neonatos en ucin, ucen y cuidados básicos. al contrastar los datos calculados con la situación de la sala se estableció que solo se cubría el 48% del tiempo requerido de enfermería, lo que motivó el análisis y la discusión a nivel directivo para mejorar la relación enfermera-paciente aumentando de 2 a 4 enfermeras por turno, y estableciendo una relación de 1 enfermera por cada 3 neonatos. de acuerdo con el puntaje promedio obtenido, los neonatos que más tiempo demandan para la realización de las intervenciones contempladas en el índice son los que presentan problemas quirúrgicos. 134 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 diligenciamiento del ntiss y actitud frente al índice la escala likert construida constaba de 8 ítems, tanto positivos como negativos, para valorar la actitud de las enfermeras frente al índice ntiss y su diligenciamiento. el mínimo puntaje de la escala era de 8 (desfavorable), y el máximo era de 40 (favorable). las 8 enfermeras encuestadas manifestaron tener una actitud favorable hacia la aplicación de la escala, destacando que los ítems con menor puntuación hacían alusión a que el diligenciamiento del índice implicaba una carga adicional de trabajo (28 puntos) y no contemplaba todas las intervenciones (28 puntos). en contraste, el tiempo requerido para el diligenciamiento fue el aspecto mejor valorado por las enfermeras. el lapso promedio empleado para diligenciar la escala fue de 36 segundos. el gráfico 2 muestra las valoraciones hechas a los reactivos de la escala. discusión el objetivo del presente estudio fue determinar la utilidad de la escala ntiss para el cálculo del personal de enfermería de la ucin y ucen de la cub, para tal fin se realizó una caracterización demográfica básica, y se determinó el tiempo requerido para el diligenciamiento de la escala y la actitud de las enfermeras hacia el instrumento. de manera creciente se han tratado de establecer parámetros y herramientas para hacer el cálculo de personal de forma efectiva; en el ámbito norteamericano, el consejo internacional de enfermeras (cie) (12) ha señalado criterios como la cantidad de pacientes, la intensidad de los cuidados suministrados, el contexto, el diseño de espacios, la capacidad y experiencia de los profesionales de enfermería, para que el cálculo de personal trascienda los números y considere aspectos propios del cuidado de enfermería y sus especificidades. algunos estudios realizados en latinoamérica (13, 14, 15) han probado instrumentos para el cálculo y la asignación del personal de enfermería en unidades de hospitalización y cirugía; no siendo así en unidades neonatales, en las que tampoco se ha analizado la conexión entre los instrumentos y los coeficientes para medir las cargas de trabajo y la calidad del cuidado. en contraste, hamilton y redshaw, en el reino unido, encontraron que la supervivencia de los recién nacidos de bajo peso estaba relacionada con la cantidad y la cualificación de los integrantes del equipo de enfermería (16). por tal razón, existe una preocupación creciente por establecer índices que permitan medir las cargas de trabajo y relacionarlas con el entorno como estrategias para mejorar la atención de enfermería (12). en la cub no se contaba con ninguna herramienta para medir la carga de trabajo, calcular las necesidades de dotación de personal y realizar una asignación de funciones con base en los criterios de gravedad y complejidad. la aplicación del índice ntiss hizo posible una aproximación a esta realidad, toda vez que permitió valorar el número de intervenciones realizadas, el tiempo y la complejidad de las mismas para ofrecer una visión amplia de los neonatos, sus condiciones de salud y las necesidades de cuidado. en el presente estudio, el promedio general del ntiss fue de 12,3 puntos, en contraste con el reportado por mendes de 13,7 hamilton y redshaw, en el reino unido, encontraron que la supervivencia de los recién nacidos de bajo peso estaba relacionada con la cantidad y la cualificación de los integrantes del equipo de enfermería. 135 herramienta para el cálculo de personal de cuidado intensivo neonatal l juan guillermo rojas, natalia andrea henao-murillo, alexandra quirós-jaramillo puntos en brasil (6); tal diferencia entre los puntajes podría asociarse con la tendencia a la mínima invasión que se practica en la cub y que incide en las actividades realizadas por el equipo de enfermería. ambos estudios coinciden también en el predominio de intervenciones para el monitoreo, que se refieren al seguimiento hemodinámico, la toma de muestras para laboratorio y la valoración continua de constantes fisiológicas en los recién nacidos. en el manual de funciones de la cub se describen las actividades que son responsabilidad de la enfermera, en su mayoría intervenciones complejas; al contrastar esta información con los puntajes obtenidos de los ntiss, se determinó que el 62% de la intervenciones, en efecto, son responsabilidad de estas profesionales, hecho que coincide con el planteamiento de whitman en cuanto a que, dada la especialidad y particularidad de los cuidados neonatales, se requiere mayor participación directa del personal profesional (17). además, no puede dejarse de lado que las profesionales encuestadas tenían a su cargo las labores de la unidad de cuidados neonatales básicos y otras no descritas en el índice como la educación, el acompañamiento, la entrega y recibo de turno, los ingresos y egresos, la planeación del cuidado, la participación en la ronda médica, la asignación y supervisión del personal a cargo, y la coordinación con otros profesionales, entre otras. en este trabajo, el análisis de los puntajes del ntiss en relación con los días de hospitalización y la clasificación de los neonatos de acuerdo con los problemas de salud (respiratorios, cardiovasculares, quirúrgicos, riesgo global por prematurez) mostró variabilidad a lo largo del periodo de hospitalización, con puntajes altos al inicio que disminuyeron progresivamente; no ocurrió igual en el estudio de mendes (6), quien reportó un aumento de los mismos ligado al incremento de intervenciones, y las comorbilidades asociadas en los recién nacidos en una ucin pública de brasil, comparando la utilización de tecnologías e intervenciones con la efectividad para establecer un indicador de complicaciones. si bien la unidad neonatal de la cub se orienta a la mínima invasión de los neonatos, no deja de ser un servicio de referencia especializado para las instituciones del área metropolitana de medellín y del departamento de antioquia, razón por la cual los niños ingresados principalmente con problemas quirúrgicos y respiratorios tienen puntajes altos en los índices ntiss porque con frecuencia requieren ventilación mecánica o sistema de presión constante en la vía aérea (cpap), intervenciones que demandan mayor consumo de los servicios de enfermería y, por ende, mayor carga de trabajo. en esta unidad neonatal la dotación del personal de enfermería se ha hecho bajo las recomendaciones de la sociedad colombiana de neonatología, y aunque no se procesaron índices para medir la carga de trabajo del personal auxiliar, el número de personas con este perfil parece ser suficiente de acuerdo con las intervenciones que realizan, relacionadas con la comodidad de los recién nacidos; no ocurre igual con el número de enfermeras, quienes resultan insuficientes para la cantidad de funciones y actividades que les delegan, lo que coincide con el planteamiento de zupancic y richardson (18), quienes concluyeron que las enfermeras eran las que invertían mayor tiempo en cuidados directos e indirectos a los neonatos. 136 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 cabe destacar que hay una serie de intervenciones de enfermería y actividades de cuidado indirectas no contempladas en el índice (educación, acompañamiento, gestión del cuidado y del servicio), y otras que, aunque están descritas en la escala, no se realizan en la unidad neonatal (cuidados de la traqueostomía, oxigenación por membrana extracorpórea, ventilación de alta frecuencia, pericardiocentesis e inserción de tubo pericárdico), razón por la cual el presente análisis puede tener limitaciones. finalmente, en cuanto a la actitud del grupo de enfermeras hacia la utilización del índice, la disposición favorable podría estar influenciada por la facilidad en el diligenciamiento, la rapidez para hacerlo y el interés individual y colectivo por enriquecer su práctica profesional, haciendo uso de estrategias para mejorar la gestión y, por tanto, la calidad del cuidado que brindan. conclusiones de acuerdo con la experiencia del presente estudio, la aplicación del índice ntiss es útil para el cálculo de personal de enfermería porque la estimación permitió, en forma objetiva, considerar el incremento de 2 a 4 enfermeras en cada turno, mejorando la relación enfermeraneonato (1:3) en servicios críticos como la ucin y la ucen de la clínica universitaria bolivariana. el número de auxiliares de enfermería no tuvo variación, teniendo en cuenta que el personal designado por turno era suficiente para llevar a cabo la proporción de labores asignadas según el manual de funciones. esta caracterización, hecha a los pacientes de acuerdo con las intervenciones y los cuidados dispensados, refleja las acciones de cuidado directo realizadas en la unidad neonatal en general; sin embargo, no incluye otras actividades llevadas a cabo por los profesionales de enfermería en cuanto a la educación, el acompañamiento a la familia, la preparación para el alta, y los asuntos administrativos necesarios para el cuidado. es necesario avanzar en la realización de otros estudios sobre la utilización del índice ntiss, y evaluar la relación directa entre los puntajes obtenidos, las condiciones individuales de cada neonato y las situaciones propias del contexto en que se indague, con el objeto de mostrar la contribución de las enfermeras en el cuidado a la recuperación de los neonatos en condiciones críticas de salud mediante indicadores de gestión. referencias bibliográficas 1. fanaroff a, kaus m. cuidado del recién nacido de alto riesgo. 5 edición. méxico: mcgraw-hill; 2003. pp. 246-267. 2. kérouac a, pepin j, ducharme f, duquette a, major f. el pensamiento enfermero. barcelona: masson; 1996. 3. zárate r. la gestión del cuidado de enfermería. index enferm granada 2004; 44 (45): 42-46. 4. ferrara e. índices en neonatología. rev hospital maternoinfantil ramón sardá 1998; (17): 3-7. 5. gray j, richardson d, mccormick m, workman k, goldmann d. neonatal therapeutic interventions scoring system: a therapy based severity of illness index. pediatrics 1992; 90 (4): 561-567. 6. mendes i, carvalho m, almeida t, moreira e. use of technology as an evaluation tool of clinical care in preterm newborns. j pediatr 2006; 82 (5): 371-376. 7. piñeros g. criterios de ingreso uci neonatal [internet]. bogotá: sociedad colombiana de neonatología; 2003. disponible en: http://www.scon.org.co/index. php?option=com_wrapper&view=wrapper&itemid [fecha de consulta: 22 de abril de 2006]. 8. normas de habilitación. resolución 1043/2006 de abril 3. diario oficial de colombia, 46271, mayo 17 de 2006. 9. ramírez p, hernández o, sáenz a, reguera a, meneses m. enfermería de práctica avanzada: historia y definición. enferm clin 2002; 12 (6): 286-289. 10. ricardo s, echeverry j. validating scales used for measuring factors in medicine. rev salud pública [revista on line]. 2004 oct; 6 (3): 302-317. disponible en: http://www.scielo.org.co/pdf/rsap/ v6n3/a06v6n3.pdf [fecha de consulta: 10 de mayo de 2007]. 137 herramienta para el cálculo de personal de cuidado intensivo neonatal l juan guillermo rojas, natalia andrea henao-murillo, alexandra quirós-jaramillo 11. normas para la investigación en salud. rev colomb psiaquiatr 1996; 25 (1): 38-59. 12. consejo internacional de enfermeras (cie). personal fiable, vidas salvadas [internet]. ginebra: consejo internacional de enfermeras (cie); 2006 disponible en: http://www.icn.ch/indkit2006sp.pdf [fecha de consulta: 10 de mayo de 2007]. 13. garcía m, castillo l. categorización de usuarios: una herramienta para evaluar las cargas de trabajo en enfermería. rev med chile 2000; 128 (2): 177-183. 14. padrón a, gutiérrez c, enríquez p. escala de evaluación de la carga de trabajo de enfermería (evecte): propuesta de una nueva escala. rev cub med int emer 2003; 2 (3): 50-58. 15. pérez l, castañeda m. diseño de instrumento para el estudio de dotación de enfermería en las categorías profesional y auxiliar para los servicios de médico-quirúrgica en siete instituciones de salud privadas. medellín, 1994. facultad de enfermería. universidad de antioquia. documento inédito suministrado por las autoras. 16. hamilton k, redshaw m, tarnow-mordi w. nurse staffing in relation to risk adjusted mortality in neonatal care; archives of disease in childhoodfetal an neonatal edition 2007; (92): 99-103. 17. whitman g, kim y, davidson l, wolf g, wang s. the impact of staffing on patient outcomes across specialty units. j nurs adm 2002; 32 (12): 633-639. 18. zupanic j, richardson d. characerization of neonatal personnel time inputs and prediction from clinical variables. j perinatol 2002; 22 (8): 658-663. tabla 1. datos del peso al nacer de los neonatos admitidos en la ucin/ucen de la clínica universitaria bolivariana, abril de 2007. peso al nacer (gramos) número porcentaje 1000 1500 6 27,2 1501 2000 5 22,7 2001 2500 2 9,0 2501 3000 3 13,6 3001 3500 4 18,2 3501 4000 0 0 4001 4500 1 4,5 peso desconocido 1 4,5 n = 22 fuente: encuestas de aplicación del ntiss en ucin de la cub (de: 1.002). 138 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 gráfico 1. semanas de gestación de los neonatos admitidos a la ucin de la cub, abril de 2007. n = 22 fuente: encuestas de aplicación del ntiss en ucin de la cub. tabla 2. puntaje obtenido en los ntiss de los neonatos admitidos en la ucin de la cub, abril de 2007 neonato no. de ntiss diligenciados % puntaje total ntiss promedio de 1 12 2,8 210 17,5 3,5 2 20 4,7 269 13,4 6,4 3 8 1,8 70 8,2 1,1 4 22 5,8 179 7,4 2,2 5 10 2,3 129 12,9 3,2 6 22 5,8 200 8 1,4 7 12 2,8 125 10,4 2 8 14 3,2 163 11,6 1,5 9 10 2,3 118 11,5 1,9 10 2 0,5 22 11 1,4 11 10 2,3 85 7,6 1,7 12 28 6,5 425 15,1 3,9 13 20 4,7 285 14,2 2,5 14 54 12,7 636 11,7 2,2 15 10 2,3 86 8,6 2 16 24 5,6 310 12,9 2,6 17 6 1,4 89 14,8 1,3 18 78 18,3 1115 14,2 3,4 19 11 2,5 137 12,4 3,7 20 10 2,3 86 8,6 1,07 21 32 7,5 390 12,1 3,7 22 10 2,3 71 7,1 0,88 total 425 100 5200 n = 2 fuente: encuestas de aplicación del ntiss en ucin de la cub (de: 70.10). 139 herramienta para el cálculo de personal de cuidado intensivo neonatal l juan guillermo rojas, natalia andrea henao-murillo, alexandra quirós-jaramillo tabla 3. promedios de puntaje del ntiss y el tiempo de enfermería requerido en los neonatos de la ucin de la cub, abril de 2007 grupos de neonatos por problemas de salud promedio del ntiss tiempo de enfermería requerido (minutos) enfermedades respiratorias 13,5 135 problemas cardiovasculares 10,2 102 problemas quirúrgicos 14 140 riesgo asociado a la prematurez 11,5 115 n = 22 fuente: encuestas de aplicación del ntiss en ucin de la cub. gráfico 2. puntuación de los reactivos de la escala de actitud frente al diligenciamiento del ntiss en las enfermeras de la ucin de la cub, abril de 2007 n = 8 fuente: escala de actitud frente al diligenciamiento del ntiss. ´ in st it ut io na l v io le nc e ag ai ns t h os pi ta liz ed c hi ld re n: t he p er ce pt io n of n ur si ng p ro fe ss io na ls 1 artículo institutional violence against hospitalized children: the perception of nursing professionals* received: 09/02/2022 sent to peers: 11/05/2022 approved by peers: 16/02/2023 accepted: 28/02/2023 * this research was funded by universidade federal da bahia under the student assistance dean office program (proae 4/2018). support was also obtained from the academic excellence program of the coordination for the improvement of higher education personnel (proex-capes 364/2021), in the context of the graduate program in nursing at universidade federal de santa catarina, brazil. article extracted from the phd thesis entitled “institutional violence against hospitalized children from the perspective of companions and health professionals”, presented in 2021 at the graduate program in nursing and health of the nursing school at universidade federal da bahia, brazil. doi: 10.5294/aqui.2023.23.2.3 to reference this article / para citar este artigo / para citar este artículo santos acpo, piton tn, camargo cl, vargas mao, almeida lmjs, dias mgpg. institutional violence against hospitalized children: the perception of nursing professionals. aquichán. 2023;23(2):e2323. doi: https://doi.org/10.5294/aqui.2023.23.2.3 ana carla petersen de oliveira santos https://orcid.org /0000-0002-9816-1560 hospitalar universitário professor edgard santos, universidade federal da bahia, brazil. carlapetersen@ufba.br thais nogueira piton https://orcid.org /0000-0002-6363-4428 universidade federal da bahia, brazil. climene laura de camargo https://orcid.org /0000-0002-4880-3916 escola de enfermagem, universidade federal da bahia, brazil. mara ambrosina de oliveira vargas https://orcid.org /0000-0003-4721-4260 universidade federal de santa catarina, brazil. lara máyra jesus da silva almeida https://orcid.org /0000-0002-9076-0286 universidade federal da bahia, brazil. mirna gabriela prado gonçalves dias https://orcid.org /0000-0003-2162-830x universidade federal da bahia, brazil. https://doi.org/10.5294/aqui.2023.23.2.3 https://doi.org/10.5294/aqui.2023.23.2.3 https://orcid.org/0000-0002-9816-1560 mailto:carlapetersen@ufba.br https://orcid.org/0000-0002-6363-4428 https://orcid.org/0000-0002-4880-3916 https://orcid.org/0000-0003-4721-4260 https://orcid.org/0000-0002-9076-0286 https://orcid.org/0000-0003-2162-830x https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2023.23.2.3&amp;domain=pdf&amp;date_stamp=2023-06-07 theme: promotion and prevention contribution to the discipline: this study offers significant contributions to nursing teaching, research, management, and care, as identifying institutional violence against children in health services is fundamental to promoting safe, humanized, and good-quality care for them and their families. in addition, the article contributes to strengthening the advocacy practice within health services and helps fill a large gap in studies of this nature. in st it ut io na l v io le nc e ag ai ns t h os pi ta liz ed c hi ld re n: t he p er ce pt io n of n ur si ng p ro fe ss io na ls 3 abstract objective: to understand the perception of the nursing team about institutional violence against hospitalized children. materials and method: a qualitative, descriptive and exploratory study, performed at a large-size public hospital in salvador, bahia, brazil, with 17 nursing professionals working in the pediatrics unit, to whom semi-structured interviews were applied between march and may 2019. the collected data were categorized in the nvivo12 software and submitted for content analysis. results: the results are presented in four categories: the professionals’ lack of knowledge about institutional violence against hospitalized children; recognition of institutional violence related to problems in the hospital infrastructure, recognition of institutional violence in interpersonal relationships and recognition of institutional violence in the care practices. conclusions: it becomes necessary to apply policies to confront institutional violence, ranging from training the professionals to adapting the spaces and care practices to favor the children’s hospitalization environment. keywords (source: decs) pediatric nursing; child violence; nursing care; in-hospital care; child. 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 23 violencia institucional hacia al niño hospitalizado: percepción de los profesionales de enfermería resumen objetivo: comprender la percepción del equipo de enfermería acerca de la violencia institucional hacia el niño hospitalizado. materiales y método: estudio cualitativo, descriptivo y exploratorio, realizado en hospital público de gran tamaño, en salvador, bahia, brasil, a 17 profesionales de enfermería que actuaban en la unidad pediátrica, a quienes se aplicó entrevista semiestructurada, entre marzo y mayo de 2019. se recolectaron los datos, los que se categorizaron en el software nvivo12 y se sometieron a análisis de contenido. resultados: se presentan los resultados en cuatro categorías — el desconocimiento de los profesionales acerca de la violencia institucional hacia el niño hospitalizado; el reconocimiento de la violencia institucional relacionada a los problemas en la infraestructura hospitalaria; en las relaciones interpersonales y en las prácticas de cuidado. conclusiones: es necesaria la aplicación de políticas para hacer frente a la violencia institucional que van desde la capacitación de profesionales hasta la adecuación de espacios y prácticas de cuidado como forma de favorecer el entorno en que el niño se encuentra hospitalizado. palabras clave (fuente: decs) enfermería pediátrica; violencia infantil; cuidados en enfermería; asistencia hospitalaria; niñez. * esta investigación fue financiada por la universidade federal da bahia gracias a la vicerrectoría de asistencia estudiantil, con el código (proae 4/2018). también, se obtuvo el apoyo del programa de excelencia académica de la coordinación de perfeccionamiento del personal de educación superior (proex-capes 364/2021), en el contexto del programa de posgrado en enfermería de la universidade federal de santa catarina, brasil. este artículo es derivado de la tesis doctoral titulada “ violência institucional à criança hospitalizada na perspectiva de acompanhantes e profissionais da saúde”, presentada al programa de posgrado en enfermagem e saúde de la escola de enfermagem de la universidade federal da bahia. in st it ut io na l v io le nc e ag ai ns t h os pi ta liz ed c hi ld re n: t he p er ce pt io n of n ur si ng p ro fe ss io na ls 5 violência institucional contra a criança hospitalizada: percepção dos profissionais de enfermagem resumo objetivo: compreender a percepção da equipe de enfermagem sobre a violência institucional contra a criança hospitalizada.  materiais e método: estudo qualitativo, descritivo e exploratório, realizado em hospital público de grande porte, em salvador, bahia, brasil, com 17 profissionais de enfermagem que atuavam na unidade pediátrica, com os quais foi aplicada entrevista semiestruturada, entre março e maio de 2019. os dados coletados foram categorizados no software nvivo12 e submetidos à análise de conteúdo. resultados: os resultados são apresentados em quatro categorias — o desconhecimento dos profissionais sobre violência institucional contra a criança hospitalizada; o reconhecimento da violência institucional relacionada aos problemas na infraestrutura hospitalar; nas relações interpessoais e nas práticas de cuidado.  conclusões: faz-se necessária a aplicação de políticas para o enfrentamento da violência institucional que vão desde o treinamento de profissionais até a adequação de espaços e práticas de cuidado como forma de favorecer o ambiente em que a criança se encontra hospitalizada. palavras-chave (fonte decs) enfermagem pediátrica; violência infantil; cuidados de enfermagem; assistência hospitalar; criança. * esta pesquisa foi financiada pela universidade federal da bahia no âmbito do programa da pró-reitoria de assistência estudantil (proae 4/2018). ainda, obteve-se apoio do programa de excelência acadêmica da coordenação de aperfeiçoamento de pessoal de nível superior (proex-capes 364/2021), no contexto do programa de pós-graduação em enfermagem da universidade federal de santa catarina, brasil. artigo extraído da tese de doutorado intitulada “ violência institucional à criança hospitalizada na perspectiva de acompanhantes e profissionais da saúde”, apresentada ao programa de pós-graduação em enfermagem e saúde da escola de enfermagem da universidade federal da bahia, brasil, em 2021. 6 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 23 introduction institutional violence (iv) in health services is defined as the type that occurs within institutions, which is evident from care omissions to poor quality of the services due to the asymmetric power relations between users and professionals. in practice, this type of violence can be characterized by a lack of listening and time for the clientele, neglect, power abuse, and mistreatment resulting from prejudice and discrimination, denial of assistance, pilgrimage, violation of users’ rights, poor care quality, inaccurate diagnoses, disqualification of the life experience and medications to adapt the patient to the conditions of the service (1). several research studies that evidence the occurrence of harm in hospitalized children show that maltreatment occurs mainly as a result of abusive care practices, which compromises care and the quality of pediatric assistance (2, 3). however, although maltreatment is identified in health institutions, the professionals’ difficulty in recognizing it persists, which precludes the development of actions for coping with it (4, 5). in addition, this problem becomes worrisome when it is found in studies (6-9) that health professionals revealed that they lack sufficient knowledge about children’s rights in health services, which can make the pediatric hospital care environment conducive to iv situations. nursing professionals, as a profession that is directly related to the health care of individuals, need to know iv to identify it and, thus, ensure good quality care to children and families (10). therefore, understanding the perception of the nursing team regarding iv becomes relevant, as some surveys show that studies of this nature in pediatric environments are still scarce, although necessary to formulate coping policies and actions (1-4). given these considerations, the objective of this study was to understand the perception of nursing professionals about iv against hospitalized children. materials and method a qualitative, descriptive, and exploratory research study, developed as part of the ph.d. thesis “institutional violence against hospitalized children from the perspective of companions and health professionals,” conducted from march to may 2019 at a large-size university public hospital in the city of salvador, bahia, brazil. the research participants were nurses and nursing technicians who worked in the pediatric inpatient unit, with a capacity for 26 beds and who welcome children from 3 months to 14 years old for clinical and surgical treatment. the participants were intentionally selected by consulting the professionals’ schedules. the criterion for inclusion of the participants was to have more than two years of experience in pediatric hospital care (considering this as a minimum period to acquire experiences) and the exclusion criterion corresponded to being away (leave) from the service during data collection. in st it ut io na l v io le nc e ag ai ns t h os pi ta liz ed c hi ld re n: t he p er ce pt io n of n ur si ng p ro fe ss io na ls 7 as a data collection technique, a semi-structured interview was used, with closed questions (for the participants’ sociodemographic profile) and open questions (to understand the participants’ perception of iv against hospitalized children). the guiding questions were the following: “have you heard about iv?” and “what do you understand about that?” after the interviewees answered, an information folder was presented in which the definition of iv and its main characteristics were described. the interviewer then asked the following questions: do you identify any type of iv against hospitalized children? and which one(s)?. the interviews were previously scheduled in a reserved place within the pediatrics unit and conducted in person by a scientific initiation scholarship fellow and a nursing undergraduate student, previously trained, under the supervision of a phd student. the semi-structured script was previously tested (pilot) by the research team to identify if there was duplicity or distortions in the questions. data collection was described according to the consolidated criteria for qualitative research (coreq [11]). the interviews ended after data saturation, which occurred when the thematic content became repetitive. the interviews were recorded in an audio app on a mobile device and were later transcribed into a word document. the interviews lasted a mean of 11 minutes. the maximum recording time was 34 minutes, with a minimum of 5. it is assumed that the variation in time was because the interviews were done in the workplace, which may have limited some participants’ testimonies. the analytical procedures took place after an exhaustive reading of the interviews. for the analysis, the content analysis technique was used, which employs three execution poles: pre-analysis (floating reading, preparation, and organization of the material); exploration of the material (choice of analysis units and the material); and treatment of the results (elaboration of inferences and interpretation [12]). the interview data were read and validated by the research team, consisting of the researcher in charge and other researchers involved in the study. at that moment, the researcher triangulation strategy was chosen to allow several points of view to be discussed collectively, minimizing the risk of bias. both data collection and analysis were guided by criteria and strategies to ensure rigor in qualitative research studies: credibility —presented from the recording and transcription of the testimonies in full to data triangulation; dependability —documentation of the entire conduction of the research, and confirmability —review of the excerpts from the interviews conducted by peers (13). the data were grouped into categories within the nvivo 12 qualitative analysis software, which enabled greater data exploration, word frequency measurement, and production of visual resources (12). 8 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 23 the research complied with the guidelines contained in the declaration of helsinki and in the brazilian national council of ethics in research (14). the right to the subjects’ secrecy, anonymity and privacy was ensured; therefore, the interviews continued with the presentation of the free and informed consent form, signed by the participants and the researcher. to ensure anonymity, the participants’ names were identified by professional category and by a number, which indicated the order of the interviews. the study was approved by the research ethics committee of the study field under certificate of presentation for ethical appraisal no. 99681518.0.0000.5531. results the research participants were 17 nursing professionals. according to the participants’ sociodemographic profile, it is noted that all interviewees were female, with a mean age of 40 years (from 27 to 60); black skin majority (99 %); 64 % with family incomes of up to five minimum wages, 23 % earning from 5 to 10 minimum wages and 11 %, from 10 to 20 minimum wages. regarding the professional category, 11 were nursing technicians (64.7 %) and 6 were nurses (35.3 %). among the nursing technicians, 7 (46.66 %) had higher education, of which 1 (6.67 %) was a graduate with a specialization in nursing; 4 (26.67 %) had an incomplete undergraduate degree in nursing; 1 (6.67 %) had a bachelor’s degree and a specialization in law, and 1 (6.67 %) had an incomplete undergraduate degree in the administration area. among the nurses, all had studied some specialization and 1 (6.67 %) had a master’s degree. regarding the time of experience in pediatric in-hospital care, the mean was 9 years (minimum of 3, maximum of 34) among the nursing technicians. the nurses had a mean time of experience in pediatrics of 8 years (minimum of 2, maximum of 9). the second part of the interview enabled us to understand the nursing professionals’ perception of iv against hospitalized children. thus, the results found were divided into four categories: a) unawareness of iv against hospitalized children; b) recognition of iv related to problems in the hospital infrastructure; c) recognition of iv in interpersonal relationships, and d) recognition of iv in the care practices. it is important to highlight that the first category (“unawareness of iv against hospitalized children”) was the most mentioned by the participants, which shows the lack of information about this type of violence among the nursing professionals who worked in this pediatric hospital environment. the “recognition of iv related to problems in the hospital infrastructure,” “recognition of iv in interpersonal relationships,” and in st it ut io na l v io le nc e ag ai ns t h os pi ta liz ed c hi ld re n: t he p er ce pt io n of n ur si ng p ro fe ss io na ls 9 “recognition of iv in the care practices” categories were reproduced in the reports after the participants were informed about the definition and characteristics of iv contained in the folder. unawareness of iv against hospitalized children in this study, it was found that most of the nursing professionals (86 %) were unaware or had limited knowledge about iv in the pediatric care environment, which can be confirmed in the reports below: that’s all that happens to assault the patient inside the institution. (nursing technician 9) i haven’t heard talking about this much, no. (nurse 1) some professionals initially denied the existence of iv; however, when encouraged to talk about problems in the work environment, they made visible in their testimonies the presence of this type of violence in the pediatric care environment: i haven’t identified institutional violence. i often notice that there was a failure in the system and some diseases that could have a treatment, even a cure, it’s made difficult because the child is left without care, when he/she’s not referred, or a late diagnosis, or was hospitalized in another institution and the doctor who examined him/her found that it was a simpler thing and did not investigate. (nurse 1) here i don’t see it, i think the children are well-assisted. it’s proper assistance. as for the materials, some are missing, right? some things are missing. (nursing technician 2) recognition of iv related to problems in the hospital infrastructure in the second category, it was found that, after being informed about the definition and characteristics of iv, the participants related this type of violence to problems in the hospital infrastructure, caused by lack of materials, scrapping of devices and furniture, inadequacies in physical space and staff deficits. such situations determined delays in procedures and exams, which exert a negative impact on health care, resulting in poor care quality. from the data contained in the interviews, figure 1 was elaborated, which presents the word cloud generated by the nvivo 12 software. it is noted that the words with greater prominence in the figure are the most frequent of this category, contained in the participants’ testimonies. the reports below also present the nursing professionals’ testimonies and describe the structure problems experienced by the children during their hospitalization: 10 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 23 today you only have one stretcher-man during the weekends, you end up not taking exams those days. (nurse 1) specific polyfix for children is missing, sometimes there’s only adult polyfix, which is heavy. in a child with central access, the adult polyfix may pull and lose the access. we work with what we have and sometimes we don’t have the right materials. (nursing technician 6) the lack of working devices hinders our work and the care we give to the patients, the children and the families. (nursing technician 11) figure 1. perception of iv against hospitalized children based on infrastructure problems. salvador, bahia, brazil, 2022 source: prepared by the authors with the nvivo 12 software. recognition of iv in interpersonal relationships in the third category, situations in which professionals perceived iv from the problems in the relationships between professionals, children and families, characterized by lack of communication, inattention and discrimination were described. figure 2 shows the word cloud, where the words with greater prominence are the most frequent in the excerpts of this category. the excerpts below confirm the perception of iv in the relationships between professionals, children and families. there’s no clear conversation with the children. sometimes we think children don’t understand, but they understand everything. (nurse 5) in st it ut io na l v io le nc e ag ai ns t h os pi ta liz ed c hi ld re n: t he p er ce pt io n of n ur si ng p ro fe ss io na ls 11 acting with prejudice, when the professional says: “ah, what a crying boy, such a big boy!” many times we think that children have to be here and already understand everything they have to go through. (nursing technician 8) many times, children are seen as if they’re not going to understand anything, that there is no need to talk to them. there are professionals who say that this is nonsense and that it is to do what has to be done, because of time and issues inherent to hospital dynamics. (nurse 4) figure 2. perception of iv against hospitalized children from interpersonal relationship problems. salvador, bahia, brazil, 2022 source: prepared by the authors with the nvivo 12 software. recognition of iv in the care practices in the fourth category, the health professionals also understood iv based on problems related to the care practice, evidenced by multiple manipulations, imprecise diagnoses, imposition of norms and routines of the service and omissions, as can be identified in the reports presented below: maybe the routines also harm these children a little, no matter how hard we try to adapt, sometimes we can’t do it in a way that is better for them. (nurse 4) if his/her diagnosis came out well earlier, he/she [the patient] wouldn’t have gone through so much that he/she went through, he/she got really worse, a long time in the hospital. (nurse 2) it’s you not providing adequate assistance to the patient. for example, i can see that patient has an infiltrated access, i saw that infiltrated access and pretended i didn’t see it, then the boy’s arm starts to swell, because i think i shouldn’t get the access, because it’s the end of the shift. (nursing technician 1) 12 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 23 discussion the nursing professionals’ reports revealed that most of them are still unaware of iv or misunderstand its concept. this fact is confirmed by other research findings that have shown that, over the years, iv in health services has been discussed in a basic and fragmented way, due to a scarcity of information, scientific studies and discussions in this regard, which hinders its real understanding and negatively affects the engagement of managers and health professionals alike (1-4). regarding the approach to iv in health by the united nations and the world health organization, it is important to note that it has been discussed to a limited extent in such agendas, which further limits the mobilization of resources in actions related to monitoring and its coping. in addition to that, most of the studies related to child protection in health services proposed by several countries have focused on identifying and acting on the notification of cases of violence that reach such institutions; however, it appears that there is still a large gap in studies on violence in or by health services (5, 15-18). similarly, in brazil, iv has also been approached incipiently. data from the report by the ministry of women, family and human rights in 2021 disclosed the record of 8,500 complaints of infringements committed in health institutions; although relevant, this data does not detail how the practice of iv has been taking place in these services (19). also in brazil, some studies prove that, although iv exists in the most varied forms within hospitals, the lack of knowledge of those involved (professionals and users) allows attitudes of abuse of authority to be produced and understood as necessary to provide health care (20, 21). attitudes of disrespect and power abuse were also described in a survey carried out in public health services in brazil, revealing that violence in the services’ routine is consented to by the users cared for and silenced by nursing professionals (22). it is important to highlight that, by denying or silencing iv in health services, the professionals may be inhibited from revealing the embarrassing content of this practice; therefore, it is possible nursing professionals are still afraid to acknowledge the presence of iv in their work environments in front of a health team and of the user (22). therefore, there is a need for investments in training and engagement of health teams to monitor and deal with the violence practiced in health services (23). regarding the characteristics of the infringements committed by the nursing team in pediatric inpatient units, several studies confirm that they take place through conflicts, aggression and neglect (2, 3). other research studies in transylvania and italy confirm the existence of other types of infringements and reveal that hospitalized children do not have their rights fully guaranteed during the in st it ut io na l v io le nc e ag ai ns t h os pi ta liz ed c hi ld re n: t he p er ce pt io n of n ur si ng p ro fe ss io na ls 13 hospitalization period. the main violations cited were treatments based on obsolete medical practice principles, disrespect for the rights of agreement or disagreement in their treatment and disrespect for the right to continue school monitoring, as well as the right not to feel pain (7, 8). in this study, when recognizing iv situations in the pediatric care environment, nursing professionals confirmed that they were mainly related to infrastructure problems such as lack of materials, problems in physical structure, staff deficits, and scrapping of devices. the evidence of this problem and the recognition of iv in the hospital environment in the participants’ reports indicate that they perceive it predominantly in its structural form. a similar perception to the findings of this study was detected in a research study that interviewed professionals and managers, where both understood structural violence as the main type of iv found in health services (22). the presence of structural violence in health services has been highlighted in research studies, confirming its existence in institutions and its relationship with service precariousness (1, 20, 22, 24). in the third category, situations were described where the nursing professionals perceived iv from the problems in the relationships between professionals, children and families, characterized by lack of communication, inattention and discrimination. lack of communication can mask a problem intensely rooted in the health professionals’ paternalistic attitudes, which results in the loss of users’ autonomy. this situation infringes patients’ dignity and well-being, in addition to clearly and explicitly constituting the asymmetric power relations present in the iv theoretical framework (25, 26). therefore, it is important to highlight the need for the nursing team to inform children about procedures and exams to respect their autonomy, as such interventions cause them pain, leaving them sad and anxious (10). in this sense, it is worth reflecting on and proposing strategies so children and families become active subjects of the care process through clear communication, according to the needs and specificities of their age group, diagnosis, physical condition, and cognitive ability (25-28). the problems related to the care practices, the last category described by the nursing professionals, resulted from their difficulty dealing with ethical issues involving the autonomy and consent of the children and families. the problems pointed out by the participants were as follows: multiple manipulations, imposition of norms and routines, and omissions. the situations involving multiple manipulations and the imposition of norms and routines reflect the influence of the model centered on medical professionals, based on body control and 14 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 23 discipline as something fundamental for the treatment of hospitalized individuals (21). thus, the body is considered an object of power, which is available to the professionals. therefore, in this conception, the routine is established by obedience, passivity and silence, without respecting the uniqueness of each patient and family (20). according to foucault, this conception originated in the eighteenth century, when he glimpsed the scientific bases of medicine, which structures its actions from the perspective of the body and disease. thus, the body of the individual becomes an object of domination, as well as the various forms of medical knowledge constitute positive notions of health and normality, in which the definition of the model man is described as a non-sick man (29). some research studies corroborate this finding, assuming that iv is also much more linked to the unrestricted disciplinary issue of norms, technology management, bureaucracy and work routines than merely to subjective, personal or relational aspects (30, 31). likewise, the overvaluation of hospital norms, routines, and procedures makes individuals perceive the hospital as a space marked by enclosure and confinement (30-32). overvaluing norms and routines, as in the cases of carrying out procedures at restricted times, result in situations of discomfort and child agitation (30, 31). in the long term, these adverse situations experienced in childhood can produce psychological distress and disorders (33). in this study, despite care omissions, the participants perceived its relationship to the problems of work overload and the reduced number of professionals. care omissions were also found in other studies conducted in germany and nepal, which confirm the presence of this type of violence in general, in pediatric, psychiatric and neonatal care units alike (2, 3, 34). regarding the propositional actions to cope with iv in pediatric care hospital environments, many studies show the need for training professionals and managers to develop a peace culture and a health advocacy practice (35, 36). it was noted that this research obtained restricted representativeness, considering that it was performed in a single hospital in northeastern brazil, which is a limitation of this study. conclusions in this study, it was possible to understand that nursing professionals are unaware of iv and that, when perceiving it, they recognize it from the problems related to hospital structure, interpersonal relationships and adverse situations in the care practices. to cope with iv, it becomes necessary to apply policies that range from training professionals to expand the knowledge about this in st it ut io na l v io le nc e ag ai ns t h os pi ta liz ed c hi ld re n: t he p er ce pt io n of n ur si ng p ro fe ss io na ls 15 theme to adapting 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27(1):141-51. doi: https://doi.org /10.1177/0969733019832950 https://doi.org/10.1542/peds.2021-050555 https://doi.org/10.1542/peds.2021-050555 https://doi.org/10.1371/journal.pone.0212395 https://doi.org/10.1371/journal.pone.0212395 https://doi.org/10.1186/s40985-017-0054-7 https://doi.org/10.1590/1983-1447.2022.20210244.en https://doi.org/10.1590/1983-1447.2022.20210244.en https://doi.org/10.1016/j.enfcli.2019.04.109 https://doi.org/10.1016/j.enfcli.2019.04.109 https://doi.org/10.3390/ijerph16101774 https://doi.org/10.3390/ijerph16101774 https://doi.org/10.12788/jhm.3291 https://doi.org/10.12788/jhm.3291 https://doi.org/10.1001/jama.2018.2202 https://doi.org/10.1001/jama.2018.2202 https://doi.org/10.37689/acta-ape/2023ao009931 https://doi.org/10.37689/acta-ape/2023ao009931 187 198 cirugia entre angustia y alegria.indd 187 ángela maría salazar-maya1 cirugía: entre la angustia y la alegría a la vez2 1 doctora en enfermería; profesora asociada, universidad de antioquia, medellín, colombia. amsalazar@tone.udea.edu.co 2 el presente artículo hace parte de la investigación titulada “conviviendo con la ambivalencia en las interacciones de cuidado”, para obtener el título de doctora en enfermería en la universidad nacional de colombia. recibido: 14 de mayo de 2010 aceptado: 14 de junio de 2011 resumen objetivo: describir las categorías que hacen parte de los factores causales de un esquema teórico que emergió durante la investigación: conviviendo con la ambivalencia en las interacciones de cuidado. método: cualitativa con enfoque en la teoría fundamentada. se utilizaron técnicas como la observación, las entrevistas informales y formales a 20 pacientes, 19 auxiliares de enfermería y 8 enfermeras que laboran en diferentes centros quirúrgicos de segundo nivel del valle de aburrá. resultados: se presentan las categorías relacionadas con los sentimientos y las emociones del paciente y del personal de enfermería al ingreso al centro quirúrgico, que hacen parte de los factores causales. los pacientes desean la normalidad porque sienten molestias no solo físicas sino emocionales, pero también sienten ambivalencia frente al procedimiento quirúrgico. desde el equipo de enfermería hay una disposición al cuidado porque las enfermeras se identifican en el trabajo para y con seres humanos y se responsabilizan del cuidado del paciente en este periodo. conclusiones: el equipo de enfermería en cirugía debe estar consciente de la importancia de las dimensiones emocional, social y humana del cuidado y poner especial atención al temor y la ansiedad a los cuales están expuestos los pacientes; por tanto, el cuidado humano en este escenario es vital al ver al otro como un sujeto de atención en su contexto, con sus creencias y valores, aceptándolo tal cual es. palabras clave paciente, cuidado de enfermería, investigación cualitativa, emociones. año 11 vol. 11 nº 2 chía, colombia agosto 2011 l 187-198 188 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 surgery: between both anguish and joy abstract objective: to describe the categories constituting part of the factors responsible for a theoretical framework that emerged during the study: living with ambivalence in the interactions surrounding care. method: a qualitative method with an approach grounded in theory was used, along with techniques such as observation and formal and informal interviews with 20 patients and 19 nursing assistants and nurses who work at eight different second-tier surgical centers in the aburrá valley (colombia). results: the categories related to the feelings and emotions of the patient and the nursing staff upon admission to a surgical center are presented as part of the causal factors. patients want normality, because they are experiencing both physical and emotional discomfort, but also have feelings of ambivalence about the surgical procedure. the nursing team is disposed to providing care, because nurses identify themselves as working for and with human beings and being responsible for the patient’s care during this period. conclusions: the nursing team in a surgical facility must be aware of the importance of the emotional, social and human dimensions of care, giving special attention to the fear and anxiety to which patients are exposed. therefore, in terms of humane care in this scenario, it is vital to see the other person as the object of care and attention in his or her context, with their beliefs and values, and accepting that context for what it is. key words patient, nursing care, cualitative research, emotions. cirurgia: entre a angústia e a alegria simultâneas resumo objetivo: descrever as categorias que fazem parte dos fatores causais de um quadro teórico que surgiu durante a pesquisa: conviver na ambivalência das interações de cuidado. método: qualitativa com base na teoria fundamentada. utilizaram-se técnicas como observação, entrevistas informais e formais com 20 pacientes, 19 auxiliares de enfermagem e 8 enfermeiras que trabalham em centros cirúrgicos de segundo nível no vale de aburrá. resultados: apresentam-se as categorias relacionadas com os sentimentos e as emoções do paciente e da equipe de enfermagem na admissão ao centro cirúrgico, que fazem parte dos fatores causais. pacientes desejam estar bem, porque eles sentem desconforto físico e emocional, mas também mostram uma atitude ambivalente para o procedimento cirúrgico. a equipe de enfermagem está disposta ao cuidado porque as enfermeiras são identificadas por trabalhar para e com os seres humanos, e são responsáveis do cuidado do paciente neste período. conclusões: a equipe de enfermagem cirúrgica deve estar ciente da importância do cuidado emocional, social e humana para prestar especial atenção ao medo e à ansiedade dos pacientes. portanto, nesta situação é vital o cuidado humano, para ver o outro como um objeto de atenção no seu contexto, suas crenças e valores, aceitando-o como ele é. palavras-chave paciente, cuidados de enfermagem, pesquisa qualitativa, emoções. 189 cirugía: entre la angustia y la alegría a la vez l ángela maría salazar-maya introducción el new dictionary of christian ethics and pastoral theology (1) declara que la palabra cuidado y cuidar provienen del latín cura, la cual tiene un rango de significados que incluyen aflicción, protección, interés, solicitud y cura. the concise oxford dictionary (2) y el new modern etymological dictionary (3), por otro lado, declaran que el término tiene sus raíces en el antiguo inglés caru o carian, que significa “pena”. etimológicamente, la palabra cuidado no tiene el mismo significado; sin embargo, se asocia a características como honestidad, paciencia, coraje, sentimiento, compasión, empatía, respeto y proximidad; otros elementos suyos son la responsabilidad frente a las necesidades del otro, los recursos disponibles y el contexto donde ocurre; además, comprende las habilidades de valoración, planeación, acción y evaluación de todos los factores (4, 5, 6). en colombia, el capítulo ii, artículo 3 de la ley 0911 de 2004 define el acto de cuidado de enfermería como: el ser y esencia del ejercicio de la profesión. se fundamenta en sus propias teorías y tecnologías y en conocimientos actualizados de las ciencias biológicas, sociales y humanísticas […] se da a partir de la comunicación y relación interpersonal humanizada entre el profesional de enfermería y el ser humano, sujeto de cuidado, la familia o grupo social, en las distintas etapas de la vida, situación de salud y del entorno, e implica un juicio de valor y un proceso dinámico y participativo para identificar y dar prioridad a las necesidades y decidir el plan de cuidado de enfermería, con el propósito de promover la vida, prevenir la enfermedad, intervenir en el tratamiento, en la rehabilitación y dar cuidado paliativo con el fin de desarrollar, en lo posible, las potencialidades individuales y colectivas (7). así, el cuidado de enfermería se fundamenta en las interacciones que establecen el paciente y el equipo de enfermería en diferentes escenarios. el de interés para el estudio es el quirúrgico, denominado por la literatura como “periodo perioperatorio”, definido como un proceso temporal que el paciente experimenta durante las fases preoperatoria, transoperatoria y posoperatoria (8) dentro del centro quirúrgico. el contexto en que se dan las interacciones de cuidado tiene influencia potencial en los procesos comportamentales, cognitivos y emocionales de ambos (9). infortunadamente, el periodo perioperatorio en el contexto quirúrgico ha sido poco estudiado, y ello se evidencia en la literatura existente (10); investigaciones como las de leionen, leino-kilpi y katajisto (11); fernández y griffiths (12); idvall y rooke (13); junttila, salantera y hupi (14) en enfermería han sido diseñadas para validar los aspectos visuales de la práctica; o los indicadores empíricos del comportamiento de la enfermera (15) relacionados con la higiene, la medicación, la ventilación y los signos vitales. por otro lado, el paciente no puede evidenciar el cuidado porque transita bajo los efectos de la anestesia o la sedación (2), y su estado físico y mental le impide juzgarlo objetivamente; además, pasa rápidamente por las unidades quirúrgicas (11). por lo anterior, surge como objetivo para el presente artículo describir las categorías que hacen parte de los factores causales del esquema teórico que emergió durante la investigación: conviviendo con la ambivalencia en las interacciones de cuidado. 190 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 método dada la naturaleza del problema de investigación y el objetivo propuesto en el estudio se seleccionó un diseño cualitativo con enfoque en la teoría fundamentada. esta metodología fue desarrollada desde el interaccionismo simbólico. es un modo de encarar el mundo desde la interioridad de los sujetos y desde la interacción con los actores sociales, medio por el que se constituyen los significados que asignamos al mundo que nos rodea (16). los procesos de recolección y análisis de datos estuvieron indisolublemente unidos. después de que el proyecto fue aprobado por la dirección de posgrados y el comité de ética de la facultad de enfermería de la universidad nacional de colombia, y por las direcciones científicas de dos hospitales de segundo nivel del valle de aburrá, se inició el trabajo de campo, que consistió en 7 meses de observación participante; se realizaron entrevistas informales y formales a 20 pacientes que fueron intervenidos quirúrgicamente, 19 auxiliares de enfermería que trabajan en diferentes centros quirúrgicos de segundo nivel, y 8 enfermeras que laboran en dichos centros. antes de cada entrevista se le informó y se le dio a leer a cada uno de los participantes el propósito del estudio, la naturaleza de su participación y su autorización para ser grabado; luego firmaron el consentimiento informado. la duración de las entrevistas osciló entre 20 minutos y 2 horas. se cumplió una fase exploratoria en la cual se entrevistaron tres pacientes y nueve del equipo de enfermería, se revisó la pertinencia de los temas orientadores, la oportunidad, el ambiente de la entrevista, la calidad de la grabación y la transcripción de la misma. en cuanto a la observación participante, se revisó su pertinencia con las prácticas de cuidado del paciente quirúrgico. en esta etapa se pretendió afinar y organizar el proceso de recolección y análisis de los datos a la luz de la teoría fundamentada. el muestreo teórico estuvo determinado por los datos generados por las observaciones, los participantes y su análisis; además, fue acumulativo, es decir, cada acontecimiento que entró se sumó al análisis y a la recolección de los datos previos y los aumentó. a medida que evolucionó la investigación se volvió más específica, porque estuvo dirigida por la evolución de los datos. inicialmente se generaron el mayor número de categorías posibles; de ahí que se recopilaron datos en una gran variedad de áreas pertinentes. una vez se tuvieron algunas categorías, el muestreo apuntó a desarrollarlas, a hacerlas más densas y saturadas en términos de sus propiedades y dimensiones, buscando similitudes y diferencias (17, 18, 19) hasta cuando los datos adicionales recolectados no agregaron información significativa a lo que ya se tenía y hubo redundancia en la información obtenida (17). el análisis de los datos se realizó manualmente con la ayuda de un computador. estuvo constituido por tres momentos indisolubles y no lineales: 1. descriptivo, en el cual se realizó la transcripción exacta de las entrevistas. se realizó codificación abierta línea por línea de la información descrita, se examinaron concienzudamente, se compararon en busca de diferencias y similitudes (17), se utilizaron códigos en vivo y sustantivos que dieron origen a categorías. 191 cirugía: entre la angustia y la alegría a la vez l ángela maría salazar-maya 2. analítico, en este proceso se relacionaron las categorías con sus subcategorías para encontrar explicaciones más precisas y completas sobre los fenómenos. la codificación ocurrió alrededor del eje de una categoría, se enlazaron las categorías en cuanto a sus propiedades y dimensiones (17), y la manera como se entrelazaban y relacionaban. cada categoría representó un fenómeno, un problema, un asunto, o un suceso que los participantes consideraron significativo (17). 3. interpretativo, una vez categorizada y codificada la información, se dio paso a la recomposición parcial de los datos, etapa en la que se seleccionaron las categorías consideradas más relevantes que dieron respuesta a la pregunta del estudio, las cuales fueron validadas con los mismos datos y con cada participante. esta codificación fue más selectiva hasta que se construyó el fenómeno de estudio (20). a lo largo de este estudio se utilizaron diversas estrategias para mantener el rigor: la adhesión a la perspectiva filosófica, la minuciosidad en la recolección de los datos y la consideración de todos ellos en la fase de desarrollo de las categorías (21); la transcripción literal de cada una de las entrevistas, un muestreo teórico apropiado, la validación de los datos con los participantes, con otros profesionales de enfermería y con la asesora para ver si los hallazgos las representan en su quehacer en el servicio de cirugía. las ideas que emergieron de los datos fueron reconfirmadas con nueva información; esto dio nuevas ideas, las cuales fueron verificadas en los datos ya recolectados. se requirió un chequeo constante para construir unas bases sólidas (22). resultados la investigación da cuenta de un fenómeno central de cuidado —conviviendo con la ambivalencia en las interacciones—, y doce categorías, a saber: desear la normalidad; sentir ambivalencia: entre el temor y la tranquilidad; estar dispuesta a cuidar; trabajar y estar en un área diferente; haciéndome sentir como en casa; informando e informando-me; cumplir los rituales de enfermería; dar cuenta de todo y de todos; desde dandome cuenta de todo hasta estar a merced del otro; despertar diferente; desde sintiendo-me ignorado hasta único; y sintiendo-me satisfecho. en este artículo se presentan las categorías que hacen parte de los factores causales del esquema teórico (definidos como los eventos, incidentes o acontecimientos que influyen sobre el fenómeno, pueden ser causal, interviniente o contextual; además, macro o micro, y cambiar a lo largo del tiempo) (17) que emergió durante la investigación. así que después de identificar el fenómeno de estudio, surgieron muchas preguntas, principalmente: ¿qué lleva a que se presente el fenómeno de estudio? desear la normalidad; sentir ambivalencia: entre el temor y la tranquilidad; estar dispuesta a cuidar. desear la normalidad: indiscutiblemente la razón que lleva al paciente al acto quirúrgico es que está sintiendo molestias. tiene una necesidad física, espiritual y psicosocial de recuperarse del estado en que se encuentra, pues le genera dolor, temor, e incluso impedimentos: […] si uno está buscando el bienestar, hay que hacer hasta lo imposible; eso [la hernia] a mí me tenía muy confundido, es que estaba muy grande. fíjese la razón que lleva al paciente al acto quirúrgico es que está sintiendo molestias. tiene una necesidad física, espiritual y psicosocial de recuperarse del estado en que se encuentra, pues le genera dolor, temor, e incluso impedimentos. 192 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 que yo era el enemigo número uno de andar con las camisas por fuera y tenía que andar con la camisa por fuera porque era una cosa impresionante (gerardo, paciente). […] ya no podía hacer fuerza por esa hernia; yo le dije a mi mamá: me van a operar, mamá, para librarme de esto, para volver a ser normal pues, para trabajar normal (virgilio, paciente) estos padecimientos no solo afectan a nivel biológico sino también emocional y estético, y les impiden llevar una vida normal, o como la llevaban en épocas anteriores. tomar la decisión del procedimiento quirúrgico les genera una valoración y reflexión sobre la vida, el futuro y el proyecto de vida. […] eso mismo [la cirugía] me ayuda a superarme, que yo tenía que estar bien porque tenía que continuar lo que no he terminado en mi vida y me pareció muy bueno, porque inclusive en estos días de recuperación me evalué profundamente y vi que me faltan unas cosas por hacer y mejorar (alicia, paciente). […] lo viví, pues los nervios muy horribles y todo y valore más la vida, para mí la vida es algo muy grande, oré mucho (emilia, paciente). por otro lado, les implica correr riesgos al someterse a un procedimiento quirúrgico, riesgos que conocen, pero por el bienestar “uno hace lo que sea”: […] toda cirugía trae sus riesgos, todo el mundo dice eso y uno lo escucha y sabe que es así, por boba que sea. cuántas veces se ven cirugías que no son nada importantes y se complican, o dejan secuela (débora, paciente). sentir ambivalencia: entre el temor y la tranquilidad: la cirugía despierta emociones completamente opuestas, por un lado la tranquilidad y la alegría de mejorar y, por otro lado el miedo a enfrentar el proceso quirúrgico. […] para mí, la cirugía era algo muy importante, algo muy valioso y me causaba entre angustia y alegría a la vez, porque me iba a aliviar de mi dolor, porque me encantan mis vestidos y quiero volverme a ponérmelos con mis tacones (débora, paciente). el temor puede deberse al procedimiento quirúrgico, al anestésico, a las experiencias pasadas, a lo desconocido. cualquier procedimiento, por pequeño que sea, es muy significativo para cada uno de los pacientes y se afronta de una manera diferente. […] cualquier clase de operación que le vayan a hacer, uno se pone nervioso, es que es a uno al que van a tocar (ricardo, paciente). los participantes hablan del temor en términos del susto, los nervios, el miedo, el desasosiego, la angustia, el estrés, la ansiedad, la tensión por todo lo que conlleva un procedimiento quirúrgico (el dolor, la anestesia, el sangrado, entre otros). así, los participantes van formando sus propios conceptos de lo que implica vivir un proceso quirúrgico, y esto es un antecedente de gran valor frente al siguiente procedimiento. el paciente siente preocupación acerca del tiempo de la cirugía, el tiempo que estará inconsciente, es decir, está presente el temor a la anestesia, pero su mayor temor es la muerte. la mayoría de los pacientes necesitan asegurarse de que los participantes hablan del temor en términos del susto, los nervios, el miedo, el desasosiego, la angustia, el estrés, la ansiedad, la tensión por todo lo que conlleva un procedimiento quirúrgico (el dolor, la anestesia, el sangrado, entre otros). 193 cirugía: entre la angustia y la alegría a la vez l ángela maría salazar-maya despertarán de la anestesia (23) por la pérdida de control desde las perspectivas física y psicológica (24). para otros, en cambio, el temor es a estar despiertos, a ver, escuchar, sentir lo que están haciendo en su cuerpo. para estos participantes es mucho más cómodo estar bajo los efectos de la anestesia. aunque se cree que el estrés frente al procedimiento quirúrgico depende de la severidad de la cirugía, esto es una simplificación excesiva. la cirugía y la anestesia producen cambios en las rutinas de la vida que, asociados a las características individuales, son estímulos desencadenadores de alteraciones emocionales como ansiedad, temor o miedo. el temor puede desencadenar diferentes reacciones como el cansancio, la dificultad para conciliar el sueño, la vasoconstricción, la descarga de adrenalina, la taquicardia, el temblor, el llanto, entre muchas otras. la forma como una persona afronta una situación se debe a sus recursos: la energía, las creencias existenciales, las habilidades en la solución de problemas, las habilidades sociales, el soporte social, los recursos materiales. las emociones involucradas en esta experiencia han sido refrendadas por muchos autores en estudios relativos al miedo a la muerte, a la anestesia, a la deformación, al dolor, a la incertidumbre relacionada con el pronóstico, al tratamiento, a las preocupaciones con la familia, entre otras (25, 26, 27, 28). sintiendo-me tranquilo: otros, en cambio, afirman estar tranquilos para el procedimiento quirúrgico. muchos de ellos ya sabían para qué iban. a pesar de ser conscientes de que cualquier procedimiento tiene sus riesgos, se sienten sosegados: […] uno no sabe cuándo se va a quedar, pero yo entré tranquilo; yo le dije a mi mamá que me iba a ir bien (virgilio, paciente). la actitud del médico y las enfermeras juega un papel importante. pero a la gran mayoría esa tranquilidad se las otorga un ser superior. encomendando y encomendandome a dios: la espiritualidad es, simplemente, saber que nuestro cuerpo y nuestro entorno no están gobernados por nosotros mismos. hay una fuerza espiritual o material que los gobierna, que puede ser llamada destino, dios, extranatural, lo que sea, pero el hombre siempre ha creído y siempre creerá en algo. esto se manifiesta más cuando nos sentimos presionados por la adversidad o lo inesperado: pues como yo oro tanto, dije: “señor, como yo te pedí tanto en la casa, las manos del cirujano y de los que están acá conmigo van a hacer todo esto muy bien”, y me tranquilicé, y ya salí muy bien, muy contenta (emilia, paciente). la presencia de ese ser superior se manifiesta, según los pacientes, especialmente en las manos del cirujano y del personal que está con él. además de encomendarse, encomiendan a otras personas. la oración o diálogo profundo con dios es para solicitarle y encomendarle que todo resulte bien, ya que es de él de quien se espera todo, en quien se confía y a quien se le entrega la vida. así, la espiritualidad juega un papel importante porque las manos del personal están gobernadas por una fuerza espiritual y esa fuerza está en la mente del paciente y solo existe en su interior. la dimensión espiritual ha estado relacionada con la religión y, según esta, se la forma como una persona afronta una situación se debe a sus recursos: la energía, las creencias existenciales, las habilidades en la solución de problemas, las habilidades sociales, el soporte social, los recursos materiales. 194 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 inicia con el conocimiento de dios, quien dictamina los ideales de vida. en cambio en el humanismo, la espiritualidad es un aspecto innato de cada persona, una dimensión importante que integra y da significado a la vida, pero es intangible e individual (29, 30). en la espiritualidad algunos de los participantes encuentran la esperanza, el alivio y la paz interior durante este proceso; estos hallazgos son compatibles con los de otros estudios que examinaron la asociación entre la participación religiosa, la espiritualidad y la salud. encontraron que la participación religiosa y la espiritualidad están asociadas con mejores resultados de salud (31, 32, 33). poner de su parte: hace referencia a un comportamiento adecuado al dar su cuerpo para que trabajen en él, cooperando en lo que esté a su alcance para lograr éxito en el procedimiento quirúrgico, pues el paciente debe estar tranquilo y dispuesto para evitar cualquier complicación, así esté sintiendo dolor: […] me dijeron: de su comportamiento dependen los chuzones que le peguemos (adolfo, paciente). a pesar de enfrentarse a procedimientos muy incómodos, el participante siempre está tratando de poner de su parte, porque ve que es para su propio beneficio. ante la intervención quirúrgica y otros procedimientos el paciente entrega su cuerpo sabiendo que le causará dolor, mientras que mantiene la compostura y no obstaculiza. en el contexto clínico, este se considera un componente del dolor clínicamente infligido. tener el control adecuado del cuerpo es cooperar. los pacientes restringen el cuerpo y la voz como una manera especial de facilitar el trabajo de otros y de mantener la compostura, mientras que al mismo tiempo son incapaces de compartir la experiencia de dolor (34). estar dispuesta a cuidar: esta categoría se refiere al equipo de enfermería al identificarse con su labor en el centro quirúrgico, porque están trabajando para y con seres humanos: por tanto, es un reto. trabajar para seres humanos implica considerarlos como únicos, dignos de respeto: […] que fuera que uno estuviera trabajando en una fábrica de gaseosas y que tapona una gaseosa mala, se repone el líquido, el envase, lo que sea, pero nosotros trabajamos con vidas (imelda, auxiliar de enfermería). el trabajo cotidiano es con sujetos y con subjetividades. si bien el sujeto es complejo en estado de bienestar; en estado de enfermedad la subjetividad se complejiza aún más y se presentan reacciones y comportamientos inesperados: […] a mí me parece que trabajar con personas es difícil, y más con personas enfermas (imelda, auxiliar de enfermería). el personal de enfermería percibe al paciente como “lo primero” (al referirse a las vidas), lo consideran el centro de su trabajo porque se entrega a otros para su cuidado. es así como cada uno de los pacientes se convierte en un reto único. el estar dispuesto es la actitud positiva, necesaria en el proceso de cuidado; de hecho, el concepto de cuidado representa una disposición particular, o actitud hacia el otro. cuidar no es simplemente una serie de acciones, sino una manera de actuar, un componente ontológico de la enfermería, que incluye un acercamiento en el humanismo, la espiritualidad es un aspecto innato de cada persona, una dimensión importante que integra y da significado a la vida, pero es intangible e individual. 195 cirugía: entre la angustia y la alegría a la vez l ángela maría salazar-maya positivo a la gente y a la vida. el estilo de trabajo es una expresión de la actitud y un indicador de cuidado. el personal de enfermería posee dos atributos indispensables para entrar en contacto con el paciente: saber tratar a las personas y saber contestar. los pacientes esperan que las enfermeras los preparen para la experiencia quirúrgica dándoles información que les permitirá comprender su situación (35). así, el equipo de enfermería toma un lugar único para asistir al paciente y su familia, valorar sus necesidades y desarrollar intervenciones apropiadas para disminuir los niveles de ansiedad que son determinantes claves en la satisfacción con los servicios de salud (35). por consiguiente, la comunicación (en todas sus formas, verbal y no verbal) en la relación equipo de enfermería-paciente fortalece y enriquece el cuidado porque permite múltiples intercambios de información, sentimientos y preocupaciones si esta se da de manera adecuada; pero menudo la comunicación en el cuidado de enfermería es apresurada y unidireccional hacia el paciente. por tanto, en preciso tener en cuenta que la comunicación es una interacción multidimensional y compleja que requiere de habilidades por parte del equipo de enfermería (36). una de las habilidades es el cuidado individualizado encaminado a conocer las necesidades, experiencias, comportamientos y percepciones del paciente; a reconocer su unicidad y la de su familia (37, 38, 39, 40, 41, 42), y una responsabilidad con la calidad de su práctica por las acciones que llevan a cabo, las que delega y por el mantenimiento de los estándares de la práctica de enfermería (43). el cuidado se inicia cuando el equipo de enfermería identifica las necesidades del otro y demuestra una habilidad particular, o actitud, que se funda en una predisposición humana para el cuidado, comprometida y mediatizada tanto por la razón como por la preocupación y la solicitud del otro, al no poderse cuidar a sí mismo (44, 45, 46, 47, 48). en la literatura esa disposición para el cuidado es una condición conformada por un personal abierto, con sensibilidad interpersonal y pacientes necesitados de cuidado por enfrentarse al procedimiento quirúrgico (49, 50, 51). de igual manera, trabajar con seres humanos es un reto, ya que puede ser uno de los factores generadores de conflictos, divergencias, insatisfacciones, estrés y eventos desfavorables como la falta de compañerismo: […] me ha pasado muchas veces que de tú a tú se ponen delante del paciente y más si es con raqui […] ¡qué, jefe, que él me contaminó!, bueno, eso se arman aquí unos despelotes hasta raros (paulina, enfermera). los estudios de diddle y boughton (52), y el de fernandes stumm (53) muestran cómo el ambiente de trabajo y la relación con los otros tienen una influencia directa en la satisfacción y los resultados del paciente. es necesario interactuar armónicamente para que el trabajo pueda ser realizado de una forma eficiente y eficaz, y reconocer en ese otro lo humano (45). en síntesis, las situaciones y las relaciones vividas diariamente en el centro quirúrgico por el equipo de enfermería desencadenan situaciones de placer y de sufrimiento. la comunicación (en todas sus formas, verbal y no verbal) en la relación equipo de enfermeríapaciente fortalece y enriquece el cuidado porque permite múltiples intercambios de información, sentimientos y preocupaciones si esta se da de manera adecuada. 196 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 consideraciones finales el paciente que se somete a un procedimiento quirúrgico lo hace principalmente porque está sintiendo molestias físicas que tienen consecuencias emocionales. esto implica un riesgo para él independientemente del tipo de procedimiento quirúrgico; asimismo, es necesario que el paciente ponga de su parte, es decir, debe dejar que le realicen todo lo que sea necesario manteniendo un buen comportamiento así le cause dolor. concomitante a esto, el paciente está valorando su existencia, lo que ha realizado y lo que le falta por realizar. esto puede ser un aspecto positivo que lo lleva a aferrarse a la vida. pero el procedimiento genera una ambivalencia, hay temor para enfrentarse a la cirugía, al anestésico, a dejar la familia, o simplemente un miedo inexplicable. otros, en cambio, se sienten tranquilos y la mayoría atribuyen esa tranquilidad a su ser superior porque se encomendaron y encomendaron al equipo quirúrgico. el temor se manifiesta de diversas maneras y es detectado por el equipo de enfermería que está dispuesto a cuidar; este equipo reconoce que su labor es para y con los seres humanos, por tanto, es de mucha responsabilidad porque se está trabajando con vidas y personas; aunque dicha responsabilidad varía durante el periodo perioperatorio, el equipo de enfermería la considera vital durante la recuperación del paciente porque es cuando está más vulnerable. pero a la vez, trabajar con personas es sinónimo de conflicto y disgusto lo que lo hace más complejo y retador. a pesar de la complejidad y la responsabilidad que el cuidado amerita, el equipo de enfermería asume el reto, le satisface y muestra una predisposición hacia el otro, que lo identifica con lo que hace. este estudio demuestra que el cuidado en el centro quirúrgico lo conforman no solo la dimensión técnico-científica sino la humana. que a pesar de que en el imaginario de la comunidad académica y profesional de enfermería el servicio de cirugía está lleno de rituales, la enfermería perioperatoria es una especialidad que parece reducirse a lo físico y biológico, que explica cada vez menos las complejidades existentes que actúan en el paciente. este estudio nos enseña que, en este contexto, las dimensiones social, emocional y humana, y las complejidades están presentes en las categorías ya expuestas. por tanto, los resultados del estudio aportan a la práctica de la enfermería quirúrgica en relación a que, en cirugía, el equipo debe estar consciente de la importancia de las dimensiones emocional, social y humana del cuidado al hacer especial énfasis sobre el temor y la ansiedad a los cuales están expuestos los pacientes, por lo que el cuidado humano en este escenario es vital al ver al otro como un sujeto susceptible de atención, en su contexto, con sus creencias y valores, aceptándolo tal cual es. es decir, teniendo la capacidad de ponernos en el lugar del otro al reconocerlo como una persona única, ayudarlo, escucharlo, mirarlo a los ojos, prestarle toda la atención, el interés y el apoyo necesario con respeto, seguridad, confianza y esperanza en cada una de las actividades realizadas con el paciente, entablando un diálogo genuino, demostrando preocupación y satisfaciendo las necesidades expresadas por los pacientes durante este periodo en el contexto quirúrgico. es decir, cuidándolo como nos gustaría que nos cuidaran durante este periodo. por otro lado, las enfermeras en este contexto deben reconocer la importancia del cuidado espiritual indagando e identificando lo que es significativo en la vida de cada paciente, estar abiertas y favorecer la expresión de sentimientos, miedos y ansiedades en relación con la cirugía, la enfermedad y la muerte. reforzar su fe y creencias religiosas de manera que suministren consuelo, confort y tranquilidad durante este periodo vulnerable y estresante para que el cuidado sea verdaderamente holístico. 197 cirugía: entre la angustia y la alegría a la vez l ángela maría salazar-maya referencias bibliográficas 1. atkinson dj, field df, holmes af, o’donovan o. the new dictionary of christian ethics and pastoral theology. leicester: inter-varsity; 1995. 2. fowler hw, fowler f. the concise oxford dictionary. oxford: clarendon press; 1967. 3. maine g. new modern ethymological dictionary. london: collins; 1960. 4. webb c. caring, curing, coping: toward an integrated model. j adv nurs 1996; 23 (5): 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intraprofessional relations in nursing. j adv nurs 2007; 59 (1): 29-37. 53. fernandes em. dificultades enfrentadas por enfermeiros em um centro cirúrgico. texto contexto enferm 2006; 15 (3): 464-471. 263 ana lucía noreña1 noemi alcaraz-moreno2 juan guillermo rojas3 dinora rebolledo-malpica4 aplicabilidad de los criterios de rigor y éticos en la investigación cualitativa 1 doctora en enfermería. departamento de enfermería universidad de alicante, españa. ana.norena@ua.es 2 doctora en enfermería. facultad de enfermería. universidad de colima, méxico. almoreno@ucol.mx 3 facultad de enfermería. universidad de antioquia, colombia. doctorando del programa "enfermería y cultura de los cuidados". departamento de enfermería. universidad de alicante, españa. rojitas620@hotmial.com 4 doctora en enfermería. profesora de la facultad de enfermería. universidad de barquisimeto, venezuela. dinorarebolledomalpica@hotmail.com recibido: 24 de mayo de 2011 aceptado: 11 de septiembre de 2012 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 l 263-274 resumen este trabajo tiene como propósito realizar una reflexión acerca de cómo garantizar la calidad de un estudio cualitativo. se destacan como conceptos básicos los criterios de rigor y los aspectos éticos que necesitan ser considerados en el desarrollo de una investigación bajo este paradigma. a su vez, se describen la fiabilidad y la validez, y los respectivos criterios que permiten su verificación. también, se detallan aquellos componentes éticos que requieren ser vigilados en el proceso de la investigación y que contribuyen a que exista un cuidado riguroso de la calidad y el rigor científico. en conclusión, el artículo resalta como pilares fundamentales los criterios de rigor y éticos, y su respectiva vinculación, para la evaluación de estudios que busquen explorar aspectos subjetivos de naturaleza humana. palabras clave investigación cualitativa, ética, evaluación, investigación en enfermería (fuente: decs, bireme). applicability of the criteria of rigor and ethics in qualitative research abstract the purpose of this paper is to reflect on how to guarantee quality in a qualitative study. the criteria of rigor and ethics that need to be considered in research pursuant to this model are highlighted as basic concepts. reliability and validity, and the respective criteria that allow for their verification, also are described. details are provided on some of the ethical elements that require careful oversight during the research process and contribute to quality and scientific rigor. in conclusion, the article cites the criteria of rigor and ethics, and their respective interrelationship, as fundamental pillars in evaluating research intended to explore subjective aspects of human nature. key words qualitative research, ethics, evaluation, nursing research (source: decs, bireme). 264 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 aplicabilidade dos critérios de rigor e éticos na pesquisa qualitativa resumo este trabalho tem como propósito realizar uma reflexão sobre como garantir a qualidade de um estudo qualitativo. destacam-se como conceitos básicos os critérios de rigor e os aspectos éticos que precisam ser considerados no desenvolvimento de uma pesquisa sob este paradigma. ao mesmo tempo, descrevem-se a fiabilidade e a validade, bem como os respectivos critérios que permitem sua verificação. também se detalham aqueles componentes éticos que requerem ser controlados no processo da pesquisa e que contribuem para que exista um cuidado rigoroso da qualidade e do rigor científico. em conclusão, o artigo ressalta como pilares fundamentais os critérios de rigor e éticos, e sua respectiva vinculação para a avaliação dos estudos que buscam explorar aspectos subjetivos de natureza humana. palavras-chave pesquisa qualitativa, ética, avaliação, pesquisa em enfermagem (fonte: decs, bireme). 265 aplicabilidad de los criterios de rigor y éticos en la investigación cualitativa l ana lucía noreña, noemi alcaraz-moreno, juan guillermo rojas, dinora rebolledo-malpica introducción la calidad de la investigación cualitativa ha sido un asunto que ha generado un amplio debate entre los investigadores, a la vez que se ha convertido en un motivo de preocupación para aquellos que deciden iniciarse en el campo de la investigación utilizando como referente metodológico este paradigma. desde la perspectiva cualitativa, los fenómenos son estudiados en su contexto, intentando encontrar el sentido o la interpretación de los mismos a partir de los significados que las personas les conceden (1). por tanto, “para evaluar estudios cualitativos se deben tener en cuenta las realidades de la investigación cualitativa y las complejidades del fenómeno humano que se busca entender” (2). se reconoce que las investigaciones cualitativas no pueden ser evaluadas bajo los parámetros del paradigma positivista ya que ambas difieren en sus enfoques ontológicos, epistemológicos y metodológicos, y se sitúan en paradigmas diferentes (3). en este sentido, se ha debatido que los estándares para valorar la calidad de los estudios cuantitativos están definidos con precisión y son ampliamente conocidos por los integrantes de los grupos de investigación y de los comités de ética clínica; en cambio, los parámetros para valorar la calidad de los estudios cualitativos parecen estar sometidos a continuos debates, en parte porque algunos investigadores —bajo una mentalidad positivista— aplican los cánones de la metodología cuantitativa a la valoración de estudios cualitativos, siendo muy distante la manera de plantearse los interrogantes y el diseño de la investigación, un paradigma del otro (4). específicamente, si hablamos de la ética de la investigación cualitativa existe un debate centrado en la idea de que utilizar métodos afines a este paradigma hace que la investigación llegue a considerarse moralmente superior o de carácter más humano y, contrario a este planteamiento, hay necesidad de enfatizar que, para ajustar un diseño cualitativo bajo los cánones éticos establecidos para la investigación con seres humanos, se requiere algo más que la cercanía con los participantes, la aplicación del consentimiento informado o que la investigación pueda o no conllevar, por medio de los métodos que emplea para recoger los datos, efectos terapéuticos, como se puede llegar afirmar en el caso de las entrevistas (5). por otra parte, los criterios éticos de una investigación cualitativa deben responder a la reflexión que el investigador debe realizarse acerca de los efectos, los alcances, las consecuencias, las relaciones que se establecen con los sujetos involucrados en el estudio y la manera en que escribe sus resultados. además, estas reflexiones requieren estar presentes durante todo el proceso de investigación, desde los ajustes del diseño hasta la elaboración del informe final. cabe recordar que las etapas del proceso de investigación cualitativa son dinámicas y flexibles, es decir, no se guían por un proceso lineal sino que son interactivas y se solapan una a la otra. la construcción de un estudio cualitativo opera como un sistema donde cada etapa —la definición del tema que se va a investigar, el planteamiento del problema y los objetivos, el diseño, el trabajo de campo, el análisis de los datos y su interpretación, así como la presentación de los resultados y del informe final— debe estar en sincronía y formar parte activa de un todo (6). por tanto, se hace indispensable cuidar la calidad del estudio en general a partir de los criterios de rigor, así como de las consideraciones éticas que rigen el quehacer del investigador según las características del paradigma en que se inscribe. a partir de lo expuesto, este artículo tiene como objetivo reflexionar sobre el cuidado de la calidad en el desarrollo de un estudio cualitativo a través de los criterios de rigor y de la importancia de la ética como un componente fundamental de estos criterios, y busca dar respuesta a las preguntas que conviene plantearse durante el proceso de elaboración de un estudio cualitativo: ¿cómo daré credibilidad a mi estudio?, ¿cómo otros investigadores juzgarán los criterios de rigor y éticos de la investigación realizada? (1) . criterios de rigor en la investigación cualitativa el rigor es un concepto transversal en el desarrollo de un proyecto de investigación y permite valorar la aplicación escrupulosa y científica de los métodos de investigación, y de las técnicas de análisis para la obtención y el procesamiento de los datos (7). al hablar de rigor en investigación cualitativa hay corrientes que defienden diversas posturas, unas van desde la no aplicación de normas de evaluación de la calidad, pasando por algunas intermedias, hasta otras que apuntan por la evaluación con los mismos criterios que la investigación cuantitativa (8). esta variabilidad en los conceptos y la discusión científica sobre el tema ha llevado a 266 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 que, desde hace varios años, se publique un número importante de documentos sobre la calidad de la investigación cualitativa; sin embargo, a pesar de esta difusión, no todos los estudios cualitativos explican qué criterios de rigor emplearon y cómo estos fueron incorporados a lo largo del proceso investigativo (9). frente al debate de los aspectos de rigor, algunos autores sugieren que la búsqueda de la calidad en sí misma podría llevar a una obsesión por demostrarla, haciendo demasiado estricto el proceso de evaluación de la investigación cualitativa (10) o, en algunos casos, a impregnar los diseños de los estudios cualitativos de poca flexibilidad y dureza amenazando el ingenio, la versatilidad y la sensibilidad de dar significado y contextualizar los fenómenos, como si se sucumbiera a la ilusión de la técnica con el propósito de dar validez, en vez de proporcionar retratos significativos, fieles a la vida, evocadores de historias y paisajes de experiencia humana que, finalmente, constituyen la mejor prueba de rigor (11). los investigadores, al estar amparados en el paradigma cualitativo, deben ser conscientes de que cuando se exploran fenómenos humanos, las realidades que observan o analizan con múltiples explicaciones y significados se convierten en realidades tangibles y singulares reconstruidas a través de la versatilidad del investigador. esto hace que el rigor adquiera un valor, ya que no solo se trata de la adherencia a las normas y reglas establecidas, sino que se relaciona con la preservación y la fidelidad del espíritu del trabajo cualitativo (12). fiabilidad y validez como ejes del rigor la fiabilidad y la validez son cualidades esenciales que deben tener las pruebas o los instrumentos de carácter científico para la recogida de datos, debido a que garantizan que los resultados que se presentan son merecedores de crédito y confianza. aunque estos planteamientos acerca de la fiabilidad y la validez sean dados desde un paradigma positivista, han fundamentado los criterios que se han venido estableciendo para incrementar la credibilidad de los estudios cualitativos (4). dicha situación ha suscitado controversia al considerar que los estudios deben ser valorados por criterios generados desde el enfoque cualitativo con el argumento de que cada uno de los métodos cualitativos y su manera de abordar una realidad puede aportar con suficiencia criterios que permitan asegurar la calidad de la investigación, partiendo siempre de preguntas tales como: ¿por qué y para qué investigar esta realidad?, ¿cuál es el objetivo final?, ¿qué pretendo conseguir?, ¿cómo puedo conocer el fenómeno en su totalidad? de hecho, a nivel científico se ha realizado un esfuerzo por definir la fiabilidad y la validez, a pesar de que algunos exponentes clásicos de la investigación cualitativa, con el tiempo, los han llegado a reformular y han propuesto planteamientos alternativos (13). ahora bien, nuestro fin es poder mostrar lo que la literatura (1-4, 8, 11-13) recoge de estos pilares fundamentales que soportan el rigor de la investigación cualitativa y, a su vez, exponer algunos criterios que garantizan su cumplimiento. entre estos describiremos la credibilidad, transferibilidad, consistencia, confirmabilidad, relevancia y la adecuación teórico-epistemológica (tabla 1). fiabilidad o consistencia la fiabilidad se refiere a la posibilidad de replicar estudios, esto es, que un investigador emplee los mismos métodos o estrategias de recolección de datos que otro, y obtenga resultados similares. este criterio asegura que los resultados representan algo verdadero e inequívoco, y que las respuestas que dan los participantes son independientes de las circunstancias de la investigación. en un estudio cualitativo la fiabilidad es un asunto complejo tanto por la naturaleza de los datos, del propio proceso de investigación y de la presentación de los resultados. por tanto, se puede recurrir a un investigador externo que dé su opinión sobre todo el proceso seguido, a fin de indicar si este se ha conducido correctamente o no, y si las estrategias utilizadas para la reconstrucción de las categorías analíticas son las apropiadas; por eso se sugiere en los estudios que se llevan a cabo por varios investigadores realicen registros sistematizados y acudan a la discusión del proceso con otros investigadores que estén interesados en líneas de trabajo similares. se afirma que si los resultados se repiten la fiabilidad se puede asegurar, por eso es que en la investigación cualitativa es recomendable trabajar con diferentes métodos de recolección de la información (14). validez la validez concierne a la interpretación correcta de los resultados y se convierte en un soporte fundamental de las investigaciones cualitativas. el modo de recoger los datos, de llegar a captar los sucesos y las experiencias desde distintos puntos de vista, el poder analizar e interpretar la realidad a partir de un 267 aplicabilidad de los criterios de rigor y éticos en la investigación cualitativa l ana lucía noreña, noemi alcaraz-moreno, juan guillermo rojas, dinora rebolledo-malpica bagaje teórico y experiencial, el ser cuidadoso en revisar permanentemente los hallazgos, ofrece al investigador un rigor y una seguridad en sus resultados (15). la validez da cuenta del grado de fidelidad con que se muestra el fenómeno investigado y puede obtenerse a través de diferentes métodos, entre los más usuales se encuentran: la triangulación, la saturación y el contraste con otros investigadores. en definitiva, debe ser reconocida como una construcción social de los datos y una retórica organizada de las teorías que soportan un estudio cualitativo (16, 17). por tanto, se dice que existe validez cuando hay un cuidado exhaustivo del proceso metodológico, de modo que la investigación se hace creíble. el establecer unos marcos concretos y sistemáticos de cómo se han recolectado y tratado los datos permite que otros investigadores puedan preguntarse si los resultados obtenidos son válidos o no en otras circunstancias similares. credibilidad o valor de la verdad el criterio de credibilidad o valor de la verdad, también denominado como autenticidad, es un requisito importante debido a que permite evidenciar los fenómenos y las experiencias humanas, tal y como son percibidos por los sujetos. se refiere a la aproximación que los resultados de una investigación deben tener en relación con el fenómeno observado, así el investigador evita realizar conjeturas a priori sobre la realidad estudiada. este criterio se logra cuando los hallazgos son reconocidos como “reales” o “verdaderos” por las personas que participaron en el estudio, por aquellas que han servido como informantes clave, y por otros profesionales sensibles a la temática estudiada. además, está determinado por la relevancia que tenga el estudio y los aportes que sus resultados generen en la consecución o comprobación de nuevas teorías. en definitiva, es importante que exista una relación entre los datos obtenidos por el investigador y la realidad que cuentan los relatos de los participantes. una de las amenazas que puede afectar la credibilidad del estudio cualitativo podría ser la cercana relación entre el investigador y el sujeto investigado, o incluso que el investigador llegue a convertirse en un nativo. por tanto, una estrategia para afianzar la credibilidad es que el investigador describa e intérprete su propio comportamiento y experiencia en relación con los comportamientos y las experiencias de los sujetos que investiga. esto puede reflejarse en su habilidad para describirse como un sujeto activo dentro del propio estudio. transferibilidad o aplicabilidad la transferibilidad o aplicabilidad consiste en poder trasferir los resultados de la investigación a otros contextos. si se habla de transferibilidad se tiene en cuenta que los fenómenos estudiados están íntimamente vinculados a los momentos, a las situaciones del contexto y a los sujetos participantes de la investigación. la manera de lograr este criterio es a través de una descripción exhaustiva de las características del contexto en que se realiza la investigación y de los sujetos participantes. dicha descripción servirá para realizar comparaciones y descubrir lo común y lo específico con otros estudios. de ahí se deriva la importancia de la aplicación del muestreo teórico o intencional que permite maximizar los objetos conceptuales que emergen del estudio e identificar factores comparables con otros contextos. podríamos decir que los resultados derivados de la investigación cualitativa no son generalizables sino transferibles de acuerdo con el contexto en que se apliquen. si se compara este criterio con el muestreo que se realiza en la investigación cuantitativa, más que una representatividad estadística lo que se busca es la saturación de los datos. la aplicabilidad en los estudios cualitativos puede verse amenazada por el sobredimensionamiento de los relatos o por no ponerlos en la perspectiva que les corresponde. esto sucedería, por ejemplo, si quienes actúan como informantes pertenecen a un grupo de personas que presentan un mayor estatus dentro del contexto estudiado o resultan ser más accesibles que otras, ya sea por el cargo que ostentan o por la condición de que gozan, esto llegaría a conformar una especie de “grupo élite” de informantes que conllevaría un sesgo en la información. otra amenaza al criterio de aplicabilidad es la “falacia holística”, es decir, la tendencia a mostrar un patrón de regularidad o congruencia mayor que el obtenido en los datos recogidos y en las conclusiones. por tanto, aunque los resultados no estén saturados se construyen patrones comunes. también sucede que, si no se obtiene suficiente información, sea por la cantidad de participantes o por problemas con la recolección de la información, se muestran descripciones engrandecidas, como si estas de algún modo representaran la totalidad de las experiencias de los informantes o los hallazgos. consistencia o dependencia conocido a su vez como replicabilidad, este criterio hace referencia a la estabilidad de los datos. en la investigación cualitativa, 268 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 por su complejidad, la estabilidad de los datos no está asegurada, como tampoco es posible la replicabilidad exacta de un estudio realizado bajo este paradigma debido a la amplia diversidad de situaciones o realidades analizadas por el investigador. sin embargo, a pesar de la variabilidad de los datos, el investigador debe procurar una relativa estabilidad en la información que recoge y analiza sin perder de vista que por la naturaleza de la investigación cualitativa siempre tendrá un cierto grado de inestabilidad. para lograr la consistencia de los datos se emplean procedimientos específicos tales como: la triangulación de investigadores, de métodos y de resultados; el empleo de un evaluador externo, y la descripción detallada del proceso de recogida, análisis e interpretación de los datos; además, la estrategia de comparación constante que permite revisar y comparar los resultados emergentes con teorías previamente formuladas. todos estos mecanismos aseguran tanto la credibilidad como la consistencia. en razón de que la investigación cualitativa enfatiza en el carácter único de las situaciones humanas y en la importancia de las experiencias de los sujetos, surge el criterio de auditabilidad que denota el rigor de un estudio cuando otro investigador debe seguir la ruta de decisiones empleada por el autor de la investigación y llegar a conclusiones similares o comparables. confirmabilidad o reflexividad denominado también neutralidad u objetividad, bajo este criterio los resultados de la investigación deben garantizar la veracidad de las descripciones realizadas por los participantes. la confirmabilidad permite conocer el papel del investigador durante el trabajo de campo e identificar sus alcances y limitaciones para controlar los posibles juicios o críticas que suscita el fenómeno o los sujetos participantes. el investigador cualitativo tiene el compromiso ético de informar a los responsables de los sitios donde realizará su trabajo de campo y dentro del protocolo presentado al comité de investigación, qué actuaciones profesionales mantendrá durante la investigación. así deja claro el papel que desempeñará durante las observaciones y en las interacciones con los participantes del estudio. para lograr la objetividad se requiere que el instrumento de recolección de datos refleje los objetivos del estudio, que el investigador realice transcripciones textuales de las entrevistas, y que la escritura de los resultados se contraste con la literatura existente sobre el tema, respetando la citación de las fuentes. asimismo, se recomienda que se tenga en cuenta la revisión de los hallazgos por parte de otros investigadores. vigilar la veracidad de los datos y cuidar bien los asuntos de rigor en una investigación cualitativa debe ir de la mano de la reflexividad del investigador que posibilita que este sea consciente de la influencia de sus planteamientos y de la perspectiva con la que aborda el fenómeno de estudio. además, ayuda a que desarrolle una conciencia autocrítica que le permita obtener una mejor comprensión del fenómeno, de modo que deje claro cómo ha logrado la pretendida neutralidad en la actividad investigadora y qué reflexiones realizó en todo el proceso para concluir sus resultados. relevancia la relevancia permite evaluar el logro de los objetivos planteados en el proyecto y da cuenta de si finalmente se obtuvo un mejor conocimiento del fenómeno o hubo alguna repercusión positiva en el contexto estudiando, por ejemplo, un cambio en la actividad desarrollada o en las actuaciones de los sujetos participantes. este criterio también se refiere a la contribución con nuevos hallazgos y a la configuración de nuevos planteamientos teóricos o conceptuales. se podría afirmar que la relevancia ayuda a verificar si dentro de la investigación hubo correspondencia entre la justificación y los resultados que fueron obtenidos en el proceso investigativo. adecuación o concordancia teórico-epistemológica el criterio de adecuación o concordancia teórico-epistemológica se debe tomar en cuenta desde el momento en que se decide trabajar con la metodología cualitativa. la coherencia epistemológica de una investigación cualitativa está determinada por la consistencia entre el problema o tema que se va a investigar y la teoría empleada para la comprensión del fenómeno. es importante, por tanto, considerar que la manera como se realice la pregunta definirá el diseño y tipo de conocimiento generado (6). además, la aplicación de este criterio debe estar presente durante el proceso de investigación, en la forma en que se recogen, analizan y presentan los datos, de tal modo que exista una correspondencia entre los presupuestos teóricos y la forma en que son encuadrados los asuntos metodológicos y de carácter práctico que articulan una investigación. este criterio da cuenta de cómo el investigador hace visibles sus referentes teóricos a lo largo de todo el proceso investigativo (18). 269 aplicabilidad de los criterios de rigor y éticos en la investigación cualitativa l ana lucía noreña, noemi alcaraz-moreno, juan guillermo rojas, dinora rebolledo-malpica tabla 1. criterios de rigor en la investigación cualitativa tanto, las cuestiones éticas que surgen en estos procesos son más o menos visibles y mucho más sutiles que las presentes en otras metodologías. claramente, el enfoque cualitativo trae consigo un complejo contexto de relaciones, compromisos, conflictos y colaboraciones que, necesariamente, hacen que el investigador deba esforzarse por preservar las condiciones éticas de su estudio reflejadas en las intenciones de los investigadores, los fines que persiguen, los resultados que de forma intencionada o no produce el estudio, y el modo en que se reflejan los valores, los sentimientos y las percepciones de los informantes (13). uno de los puntos críticos de la ética en investigación cualitativa es lograr que los discursos de los participantes transmitan nítidamente sus experiencias. en el análisis, se corre el riesgo de perder su voz por el tratamiento que se les da a estos, al ser recortados, descritos e interpretados. en este sentido, el investigador debe tratar que los discursos emerjan en su plena dimensión social (19). continuamente, el investigador que utiliza enfoques cualitativos está expuesto a confrontar dilemas éticos por las características del proceso, donde la interacción social y los significados que se otorgan a esta relación pueden condicionar reacciones ante el fenómeno estudiado. el conocer a fondo las características del paradigma cualitativo y tener una posición que le permita ver con objetividad las vivencias y los sucesos durante el trabajo de campo le permitirá resolver de manera más eficaz los conflictos éticos. al enfrentar un dilema ético el investigador debe echar mano de sus propios valores éticos, de sus juicios morales y de su capacidad en la toma de decisiones (20). como se ha podido constatar, muchas cuestiones éticas impregnan el quehacer de los investigadores cualitativos. sin embargo, muchas situaciones no se abordan desde la perspectiva ética, sino que llegan a ser consideradas como medidas prácticas, metodológicas o simples estrategias necesarias de adoptar dentro del proceso de investigación. de ahí se deriva la importancia de la reflexividad del investigador para identificar las elecciones éticas que debe adoptar, y las consecuencias que derivan sus decisiones y actuaciones (13). principales criterios éticos relacionados con la investigación cualitativa los investigadores deben tener presente algunos criterios éticos a la hora del diseño del estudio y en el momento de la recriterios característica del criterio procedimientos credibilidad valor de la verdad/ autenticidad aproximación de los resultados de una investigación frente al fenómeno observado los resultados son reconocidos “verdaderos” por los participantes observación continua y prolongada del fenómeno triangulación trasferibilidad aplicabilidad los resultados derivados de la investigación cualitativa no son generalizables sino transferibles descripción detallada del contexto y de los participantes muestreo teórico recogida exhaustiva de datos consistencia dependencia/replicabilidad la complejidad de la investigación cualitativa dificulta la estabilidad de los datos. tampoco es posible la replicabilidad exacta del estudio triangulación empleo de evaluador externo descripción detallada del proceso de recogida, análisis e interpretación de los datos reflexividad del investigador confirmabilidad o reflexividad neutralidad/ objetividad los resultados de la investigación deben garantizar la veracidad de las descripciones realizadas por los participantes. transcripciones textuales de las entrevistas contrastación de los resultados con la literatura existente revisión de hallazgos por otros investigadores identificación y descripción de limitaciones y alcances del investigador relevancia permite evaluar el logro de los objetivos planteados y saber si se obtuvo un mejor conocimiento del fenómeno de estudio configuración de nuevos planteamientos teóricos o conceptuales comprensión amplia del fenómeno correspondencia entre la justificación y los resultados obtenidos adecuación teórico-epistemológica correspondencia adecuada del problema por investigar y la teoría existente contrastación de la pregunta con los métodos ajustes de diseño los criterios éticos dentro del rigor científico de la investigación cualitativa la investigación cualitativa reconoce la subjetividad de las personas como parte constitutiva de su proceso indagador. ello implica que las ideologías, las identidades y los elementos de la cultura impregnan todas las fases de la investigación. la ética cualitativa busca el acercamiento a la realidad del ser humano de manera holística y con mínima intrusión, otorgando libertad a los participantes y considerándolos sujetos, no objetos de estudio (5). los estudios cualitativos suponen en mayor o menor grado una interacción y un diálogo con las personas participantes, por 270 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 colección de datos de la investigación cualitativa. estos requisitos están relacionados con: la aplicación del consentimiento informado y el manejo de la confidencialidad y de los posibles riesgos a los que se enfrentan los participantes del estudio (13, 21-23). todos estos deben ser abordados en la pregunta, los objetivos, los referenciales teóricos, las estrategias de recolección de datos y en la divulgación de los resultados. además, a la hora de realizar la inmersión en el campo el investigador necesita saber cómo llevar a cabo desde una perspectiva ética la observación participante, las entrevistas y el uso de grabaciones en audio o video (22-25) (tabla 2). a continuación se expondrán algunos puntos esenciales para tener en cuenta en la aplicación de estos elementos y se dará cuenta de cómo su correcta aplicación permite mejorar la calidad de la investigación cualitativa. el consentimiento informado el uso del consentimiento informado responde a una ética kantiana donde los seres humanos deben ser tratados como un fin en sí mismos y nunca como un medio para conseguir algo. así, los participantes del estudio deben estar de acuerdo con ser informantes y, a su vez, deben conocer tanto sus derechos como sus responsabilidades dentro de la investigación (26). un aspecto para tener en cuenta es cuánta información debe darse a los informantes, ya que existe el riesgo de que se les predisponga de manera positiva o negativa para los objetivos de la investigación. la responsabilidad moral del investigador será la que determine la implicación metodológica en este punto. es importante reconocer que la información suministrada se convierte en un elemento que influye en la autenticidad del estudio debido a que, al tener el informante conocimiento de la intencionalidad de la recolección de los datos, puede dar respuestas socialmente aceptables. la finalidad del consentimiento es que los individuos acepten participar en la investigación cuando esta concuerda tanto con sus valores y principios como con el interés que les despierta el aportar su experiencia frente al fenómeno estudiado, sin que esta participación les signifique algún perjuicio moral. la confidencialidad los códigos de ética hacen énfasis en la seguridad y protección de la identidad de las personas que participan como informantes de la investigación. la confidencialidad se refiere tanto al anonimato en la identidad de las personas participantes en el estudio, como a la privacidad de la información que es revelada por los mismos, por tanto, para mantenerla se asigna un número o un pseudónimo a los entrevistados. el pseudónimo puede ser elegido por el participante, lo cual permitirá que este sienta confianza en el proceso y tenga credibilidad en la confidencialidad en los resultados de la investigación (27). además, frente a la confidencialidad es importante que los investigadores se planteen la cuestión ética de si puede ser que los informantes deseen ser reconocidos e identificados, o los centros donde se han realizado los estudios deben ser mencionados o no, y cuándo se debe dar reconocimiento a ciertas fuentes de información. en sí, la práctica de la investigación cualitativa presupone una amplia dimensión ética y moral que supera en ocasiones los simples requerimientos técnicos para la recolección de la información, prevaleciendo el bienestar de las personas sobre los fines académicos y científicos. manejo de riesgos dos aspectos se deben considerar para minimizar los riesgos a los participantes en la investigación. el primero se refiere a que el investigador deberá cumplir con cada una de las responsabilidades y obligaciones adquiridas con los informantes; el segundo está relacionado con el manejo posterior de los datos proporcionados. una investigación cualitativa se justifica cuando cumple con los siguientes requisitos: “los riesgos potenciales para los sujetos individuales se minimizan; los beneficios potenciales para los sujetos individuales y para la sociedad se maximizan; los beneficios potenciales son proporcionales o exceden a los riesgos” (24). estos requisitos tienen relación con los principios bioéticos de no maleficencia y beneficencia establecidos para realizar investigaciones en seres humanos. dentro de las consecuencias también se estimarán los perjuicios que pudieran derivarse de la investigación. se deberá explicar a los informantes que los resultados de estudio no generarán ningún perjuicio o daño institucional, profesional o personal a efectos de la información recabada; en este sentido, debe quedar claro para el investigador que los hallazgos del estudio no deberán ser utilizados con fines distintos a los que inicialmente se han proyectado. observación participante al emplear la observación participante hay que considerar dos aspectos: la interacción que establece el investigador con los informantes y su papel como instrumento para la recolección de los datos. la incursión del investigador en el campo de estudio 271 aplicabilidad de los criterios de rigor y éticos en la investigación cualitativa l ana lucía noreña, noemi alcaraz-moreno, juan guillermo rojas, dinora rebolledo-malpica implica una responsabilidad ética por los efectos y las consecuencias que pueden derivarse de la interacción establecida con los sujetos. esta responsabilidad está determinada por la intromisión del investigador en la vida cotidiana de los participantes y por las características de la información que recoge tanto del contexto como de las personas (28). ciertamente, el investigador debe mantener una mirada crítica para intentar generar el equilibrio entre su rol como “investigador” y, a su vez, ser una persona cercana hacia la realidad que intenta describir, comprender e interpretar (13). el establecer compromisos implícitos o explícitos sobre las consideraciones que se tendrán frente a la privacidad, confidencialidad y el trabajo o la actividad de los sujetos observados ayuda a preservar la responsabilidad ética del investigador. dentro del trabajo de campo se corre el riesgo de presenciar situaciones difíciles, por lo que deben prevalecer los criterios de justicia, beneficencia y no maleficencia, y el respeto por los informantes. las recomendaciones acerca de cómo orientar la observación están ampliamente descritas en la literatura, y estas directrices están encaminadas a describir cómo realizar el acceso al campo, el establecimiento de las fuentes de información, la presentación de la investigación, la identificación de los informantes clave, el grado de participación dentro de la observación, el abandono del escenario, entre otras. hay que considerar que los dilemas que emergen al realizar una observación en determinado escenario suscitan cuestionamientos razonables al pensar que se traspasan ciertos límites con la información que se desvela de los contextos, las interacciones, los modos de actuación, entre otros aspectos que son observados y posteriormente reflejados en notas de campo. cuando el investigador opta por este tipo de estrategia metodológica, estas situaciones deben servir de alerta para que sea cuidadoso en el manejo de la información y oriente desde una perspectiva ética sus decisiones y, sobre todo, la forma en que mostrará los resultados. entrevistas en la entrevista cualitativa el investigador debe crear un ambiente donde el entrevistado se sienta confortable y tenga la confianza de exponer sus opiniones e ideas de forma libre. la entrevista debe semejarse a una conversación en la que el entrevistador no deberá realizar ningún tipo de juicio sobre las ideas o los sentimientos expuestos por los informantes, ni tampoco limitar su participación por medio de intervenciones de carácter hostil o que denoten sentimientos negativos hacia lo expuesto. durante la entrevista el investigador no puede ser intrusivo, debe respetar los silencios del participante evitando realizar interrupciones abruptas y discusiones sobre lo que el otro quiere expresar; el objetivo es que las personas manifiesten libremente sus sentimientos y percepciones de las experiencias vividas frente al fenómeno estudiado. además, durante la entrevista, el investigador puede enfrentar situaciones donde el entrevistado manifieste emociones como alegría, tristeza, angustia, frustración, enfado, entre otras, por lo que este debe poseer habilidades para manejar este tipo de situaciones y estar preparado para acallar sus propias opiniones acerca de las vivencias y los sentimientos que expresan los participantes. asimismo, no debe emitir juicios de valor o expresar autoritarismo u opiniones tajantes o fanáticas que lleguen a afectar o herir al entrevistado (29). precisamente, se ha considerado que las entrevistas en los estudios cualitativos pueden llegar a ser benéficas o terapéuticas (5). se trata de una interacción social donde no se deben provocar actitudes que condicionen las respuestas, lo que daría lugar a un grave dilema ético al querer manipular los resultados. videos o audios al emplear herramientas como videos o audios puede suceder que durante el tiempo de grabación el informante haga referencia a sucesos delicados o que se traten temas que no están alineados con el objetivo de la investigación. esta información, no obstante, puede generar un dilema ético: el investigador puede considerar inicialmente que estos datos aportan algún tipo de información al estudio y lo enriquecen, pero siempre debe anteponer la confidencialidad, el respeto y el anonimato de los participantes (30, 31). sin embargo, si fuera indispensable incluir la información como resultado del estudio, debe asegurarse que el participante esté de acuerdo. de no ser así, deberá eliminar la parte de grabación en conflicto. cuando se hace uso de grabaciones, ya sea de audio o video, es necesario dar a conocer a los participantes el empleo de este tipo de métodos, informándoles sobre su desarrollo y el modo en que se manejará la información recolectada. no ser cautelosos dando este preámbulo puede propiciar que el entrevistado se sienta inhibido o incómodo y desee retirarse del proyecto de manera inesperada. posterior a la escritura del informe final, las 272 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 grabaciones, entrevistas o la base de datos que se generó en el trabajo de campo deben resguardarse en archivos confidenciales a los cuales el acceso esté restringido exclusivamente a los investigadores. pasado un tiempo prudencial, y cuando los investigadores crean pertinente, o consideren que no necesitan utilizar dicha información, deben destruirse los archivos correspondientes. tabla 2. criterios éticos de la investigación cualitativa sincronía permite asegurar la calidad de los estudios cualitativos. cuando se habla de velar por la calidad de los estudios cualitativos se abordan asuntos tanto de rigor científico, metodológico y de sensibilidad ética, como la conservación de unos supuestos epistemológicos determinados por el paradigma naturalístico e interpretativo en el que se sumerge la investigación cualitativa. la discusión del rigor científico de la investigación cualitativa y de sus principios éticos debe continuarse con la comunidad académica y debe ampliarse a personas que participen en los comités de ética clínica generándose espacios de debate y, al mismo tiempo, acercando a las instituciones y personas clave en la gestión al desarrollo de proyectos cualitativos. esto propiciará una mayor participación en la aplicación del paradigma cualitativo en la investigación clínica (25). asimismo, el ejercicio de la reflexividad por parte de los investigadores es la clave para hacer que la investigación cualitativa sea reconocida como pilar metodológico y científico en la comprensión de los fenómenos humanos. el tener una actitud conservadora y vigilar por el cumplimiento de estos criterios permite reducir los sesgos de la información obtenida, cuidar de interpretar eventos aislados como si fueran patrones generalizables, evita sobredimensionar los datos o guiarse por percepciones y explicaciones dadas por los informantes que no apoyan los objetivos de la investigación y logra, finalmente, de manera atenta y plausible, la calidad teórica, metodológica y epistemológica de la investigación cualitativa (32). a fin de dar rigor a un estudio cualitativo el investigador debe ser cuidadoso en actuar a lo largo de todo el proceso de indagación en concordancia con sus principios y valores, especialmente, debe conocer a fondo los criterios de rigor establecidos, las perspectivas que se generan frente a ellos y las amenazas que les rondan, sin dejar de lado que realizar una investigación cualitativa es una mezcla de reglas científicas con imaginación artística (12). además, todas las críticas o dificultades por las que puede atravesar un estudio cualitativo se pueden resolver al socializar la naturaleza, el sentido epistemológico y los métodos en que se basa la investigación cualitativa. criterios características éticas del criterio consentimiento informado los participantes deben estar de acuerdo con ser informantes y conocer sus derechos y responsabilidades. confidencialidad asegurar la protección de la identidad de las personas que participan como informantes de la investigación. manejo de riesgos este requisito tiene relación con los principios de no maleficencia y beneficencia establecidos para hacer investigación con seres humanos. observación participante la incursión del investigador en el campo exige una responsabilidad ética por los efectos y las consecuencias que pueden derivarse de la interacción establecida con los sujetos participantes del estudio. entrevistas se trata de una interacción social donde no se deben provocar actitudes que condicionen las respuestas de los participantes. grabaciones de audio o video deben resguardarse en archivos confidenciales y el investigador necesita ser cauteloso anteponiendo la confidencialidad, el respeto y el anonimato de los participantes. consideraciones finales los criterios de evaluación de calidad expuestos en el presente artículo no deben analizarse ni comprenderse de manera separada o excluyente. todos ellos están íntimamente conectados, es decir, un solo criterio puede inferir en todos los otros. esto da cuenta de la sinergia existente entre ellos y, especialmente, esta 273 aplicabilidad de los criterios de rigor y éticos en la investigación cualitativa l ana lucía noreña, noemi alcaraz-moreno, juan guillermo rojas, dinora rebolledo-malpica referencias 1. calderón c. criterios de calidad en la investigación cualitativa en salud. rev esp salud pública 2002;76(5):473-482. 2. castillo e, vásquez m. el rigor metodológico de la investigación cualitativa. colomb med 2003;34(3):164-7. 3. guba 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en línea para brasil** tecnologia educacional sobre incontinência urinária gestacional: desenvolvimento e validação de curso on-line para o brasil*** 10.5294/aqui.2023.23.1.3  jaiana rocha vaz tanaka1 kayo henrique jardel feitosa sousa2 paulo jorge pereira alves3 maria joão jacinto guerra4 patrícia daniela barata gonçalves5 camila aparecida pinheiro landim almeida6 1 0000-0003-3112-5343 centro universitário dom bosco, brazil jaiana.tanaka@undb.edu.br 2 0000-0002-0901-7752 universidade federal do rio de janeiro, brazil kayojardelfeitosasousa@phb.uespi.br 3 0000-0002-6348-3316 universidade católica portuguesa, portugal pjalves@ucp.pt 4 0000-0002-2510-5955 universidade católica portuguesa, portugal mguerra@ucp.pt 5 0000-0002-6329-3897 universidade católica portuguesa, portugal pdgoncalves@ucp.pt 6 0000-0003-4843-4572 universidade católica portuguesa, portugal clalmeida@ucp.pt * extracted from the master’s thesis entitled “development and validation of a virtual teaching-learning environment on urinary incontinence during pregnancy,” submitted to the family health professional master’s degree program of the centro universitário uninovafapi, brazil, in 2020. ** originado de la tesis de maestría “construcción y validación de un entorno virtual de enseñanza y aprendizaje acerca de la incontinencia urinaria durante el embarazo”, presentada al programa de maestría profesional en salud familiar del centro universitário uninovafapi, brasil, en el 2020. *** extraído da dissertação de mestrado “construção e validação de ambiente virtual de ensino-aprendizagem acerca da incontinência urinária gestacional”, apresentada ao programa de mestrado profissional em saúde da família, do centro universitário uninovafapi, brasil, em 2020. theme: promotion and prevention contribution to the subject: the development and validation of this online course for brazil are expected to further education to promote strategies in brazilian educational institutions for student qualification in the physical therapy course and professionals who provide care to patients experiencing urinary incontinence during pregnancy through distance education, highlighting the quality of life at this unique moment in a woman’s life. when considering the cultural diversity of the brazilian population studied, the continuity of research in this area involving other target audiences in brazil or other countries becomes paramount to confirm the suitability of this online course for other languages. received: 12/07/2022 sent to peers: 07/09/2022 approved by peers: 18/11/2022 accepted: 22/11/2022 para citar este artículo / to reference this article / para citar este artigo: tanaka jrv, sousa khjf, alves pjp, guerra mjj, gonçalves pdb, almeida capl. educational technology on urinary incontinence during pregnancy: development and validation of an online course for the brazilian population. aquichan. 2023;23(1):e2313. doi: https://doi.org/10.5294/aqui.2023.23.1.3 abstract objective: to describe the development and validation process of an online course on urinary incontinence during pregnancy in brazil. materials and methods: this methodological study followed an online course’s literature search, development, and validation steps. a total of 22 specialists participated in the validation step, and the content validity index (cvi) was used. fifty-one physical therapy students (target audience) also participated in the suitability assessment of materials. results: the synthesis reached in the integrative review provided the basis for the course’s theoretical content, which was regarded as suitable by the specialists regarding its content, language, presentation, stimulation/motivation, and cultural adequacy (cvi = 0.99). the target audience considered the course organized, easily understandable, engaging, and motivational, with a positive response index ranging from 84.3 % to 100 %. conclusions: the brazilian version of the online course was considered sufficiently adequate in content and interface quality by both specialists and the target audience. keywords (source: decs): validation study; teaching materials; educational technology; health education; pelvic floor disorders. resumen objetivo: describir el proceso de desarrollo y validación de un curso en línea sobre incontinencia urinaria durante el embarazo en brasil. materiales y método: se trata de un estudio metodológico que contempló las etapas de recolección bibliográfica, elaboración y validación de un curso en línea. la validación contó con la participación de 22 expertos y se empleó el índice de validación de contenido (ivc). además, participaron 51 estudiantes del pregrado en fisioterapia (público objetivo) en la evaluación de idoneidad de los materiales. resultados: la síntesis adquirida en la revisión integrativa fundamentó el contenido teórico del curso, considerado adecuado por los expertos en cuanto al contenido, el lenguaje, la presentación, la estimulación/motivación y la adecuación cultural (ivc = 0,99), así como la apariencia/interfaz (ivc = 0,95). el público objetivo consideró el curso organizado, de fácil entendimiento, atractivo y motivador, con un índice de concordancia en respuestas positivas entre 84,3 % y 100 %. conclusiones: la versión brasileña del curso en línea desarrollado se consideró lo suficientemente adecuada en términos de contenido y calidad de la interfaz, tanto por parte de los expertos como del público objetivo. palabras clave (fuente: decs): estudios de validación; materiales de enseñanza; tecnología educativa; educación en salud; trastornos del suelo pélvico. resumo objetivo: descrever o processo de desenvolvimento e validação de um curso on-line sobre incontinência urinária gestacional no brasil. materiais e método: trata-se de um estudo metodológico que contemplou as etapas de levantamento bibliográfico, elaboração e validação de um curso on-line. a validação teve a participação de 22 especialistas e foi empregado o índice de validade de conteúdo (ivc). também participaram 51 estudantes de graduação em fisioterapia (público-alvo), considerando o suitability assessment of materials. resultados: a síntese adquirida na revisão integrativa subsidiou o conteúdo teórico do curso, considerado adequado pelos especialistas quanto ao conteúdo, à linguagem, à apresentação, à estimulação/motivação e à adequação cultural (ivc = 0,99), bem como à aparência/interface (ivc = 0,95). o público-alvo considerou o curso organizado, de fácil entendimento, atrativo e motivador, com índice de concordância em repostas positivas a variar de 84,3 % a 100 %. conclusões: informa-se que a versão brasileira do curso on-line desenvolvido foi considerada suficientemente adequada em termos de conteúdo e qualidade da interface, tanto pelos especialistas quanto pelo público-alvo. palavras-chave (fonte: decs): estudos de validação; materiais de ensino; tecnologia educacional; educação em saúde; distúrbios do assoalho pélvico. introduction any abnormality that compromises the function, capacity, biomechanics, and kinesiology of the pelvic floor musculofascial structure may be termed “pelvic floor dysfunction” (pfd). this clinical picture includes bladder disorders, anorectal disorders, pelvic organ prolapse, sexual disorders, and chronic pelvic pain (1). among the risk factors for developing pfd, the most relevant for women are those related to the pregnancy-puerperal cycle. hormonal, anatomical, and biomechanical changes are constantly associated with pfd during pregnancy (2). the most commonly occurring pfd during pregnancy is urinary incontinence (ui). its prevalence is quite controversial due to the underdiagnosis of cases. in a study with a sample of 407 pregnant women, 66.8 % presented with ui, of which 70.1 % were in the third trimester (3). the most significant risk factor for ui development is urinary loss, even if occasional, before gestation (4). its remission occurs approximately six months postpartum (5); however, the manifestation of ui during pregnancy increases the risk for women to remain with the same clinical condition up to five years after delivery (4). therefore, the management of procedures that can prevent this potentially preventable and treatable condition with non-invasive methods and improve pelvic floor function during the pregnancy-puerperal cycle is essential (6). ui does not pose death risks; however, its negative impact on quality of life is considerable since affected people are constantly burdened with social isolation, depression, anxiety, loss of self-esteem, and difficulties in sexual relationships (7-10). thus, a different approach toward pregnant women is significant and necessary through changes in educational models, providing better training for future healthcare professionals, especially physical therapists, as in this study. such models should provide quality information, improving women’s knowledge of the possibility of pfd occurrence during pregnancy and the forms of prevention and treatment when necessary (4). information and communications technologies (ict) and new information systems devices represent the most diverse technological resources used for information production, processing, and communication, providing the spread of knowledge in a variety of spaces and forms (11). one of the educational methodologies made available by the icts was distance education (de)—through online courses—, which democratized brazilian higher education, overcoming the physical and temporal barriers of those who could not study. de represents one of health professionals’ most used continuing education tools (12). the continuing education of students through distance learning is considered a significant breakthrough. it is already consolidated and recognized in the scientific literature since it provides access to updated content using innovative technologies. moreover, the increasing globalization and spread of information and the need for comprehensive care recommended by the brazilian unified health system (better known by its acronym, sus) require professionals’ continuous updates and improvement to qualify further their work regarding the population’s health needs (12). the literature indicates difficulties in using ict in the professors’ training process related to the lack of informational infrastructure in higher education institutions (hei), the gaps in the professors’ qualification for the use of ict, and, significantly, the lack of motivation to change the teaching routines that they have adopted over the years (13). a study has added that college students perceive that using ict could maximize the professor-student interaction and mediate formative teaching; however, the professors’ lack of in-depth knowledge of active learning methodologies has hindered this process (14). thus, the need and relevance of evaluating the ict used in physical therapists’ training process are evident to reduce these gaps and provide a socially and scientifically relevant technology. thus, developing a distance learning teaching resource for healthcare professionals and students with a current and relevant theme can minimize the consequences of a health condition that causes significant impacts on the lives of pregnant women. in light of the above, the present study aims to describe the development and validation process of an online course on ui during pregnancy for healthcare professionals and healthcare students in brazil. materials and methods this methodological study (15) aims to develop a technological product of the online course category, having as its target audience physical therapy undergraduate students of an hei in teresina, piauí, brazil. this institution offers undergraduate, graduate, and post-graduate courses, both lato and stricto sensu. the technological product was created as the conclusion project of a professional master’s program. the development and validation process of the online course on ui during pregnancy followed these steps: 1) integrative literature review; 2) online course organization; 3) course content validation by specialists; 4) design validation; and 5) validation by representatives of the target audience. integrative literature review initially, an integrative review was carried out with the following research question: what is the scientific evidence on ui during pregnancy? the electronic databases pubmed database (pubmed®), latin american and caribbean literature on health sciences (lilacs), and scientific electronic library online (scielo) were searched. the controlled descriptors “incontinência urinária,” “gestação,” and “assoalho pélvico” and their equivalents in english (“urinary incontinence,” “pregnancy,” and “pelvic floor”) were used. the following inclusion criteria were established: full-text articles available online, published between 2014 and 2018 in english, portuguese, or spanish. editorials, letters to the editor, experience and informal case reports, book chapters, dissertations, theses, and non-scientific texts were excluded. the integrative review aimed to identify the scientific evidence on the knowledge gaps of students and healthcare professionals on the subject. they were identified and categorized to support the course planning according to these findings and stratification of themes to be addressed by complexity level. the results of the integrative review supported the development of a course plan. online course organization the syllabus to be addressed in the online course was segmented into modules with increasing complexity levels. the online course was provided in the distance learning format and hosted in a virtual environment. it was designed and developed by information technology professionals. all modules consisted of classes prepared in the powerpoint software, available in the microsoft office package, and also included support material, such as related videos and articles, chosen by the lead researcher. the online course was based on the moodle (modular object-oriented dynamic learning environment) free and open-source course management system. pre-existing software applications and how well they met the research needs were critically evaluated. this stage was supported by professionals from the núcleo de educação à distância tecnologia da informação (distance learning information technology center) of the research institution. course content validation by specialists the selection of content specialists was intentional. the professionals were eligible when they reached a minimum score of five points on the following criteria, considering the development of educational technologies or pfd as the field of interest: having a thesis or dissertation (2 points/work), supervising a thesis or dissertation (1 point/work), having a study published in an indexed journal (1 point/work), participating in research groups/projects (1 point/year), teaching (1 point/year), and professional activity (1 point/year) (16). the specialists were located on the lattes platform and were invited to participate in the study via e-mail. for the design evaluation, information technology professionals with experience in developing educational technologies participated and were invited by e-mail. there is no consensus in the literature regarding the recommended number of specialists to analyze educational resources. a study (17) suggests that this number should range from six to 20 specialists. an odd number was adopted in the present study to avoid a tie of opinions (18). thus, the “snowball” technique was adopted until 13 content specialists were reached. after developing the online course, entitled “pre-final version,” an e-mail message was sent to the selected content specialists requesting their participation, with information regarding the technological product and the evaluation criteria. the content specialists evaluated the content/proposal, presentation, language, stimulation/motivation, and cultural adequacy on a likert scale, where 1 totally inadequate, 2 inadequate, 3 partially adequate, and 4 adequate. the evaluation instrument offered options for negative, neutral, or positive responses. comments and suggestions were requested when the evaluation was not positive, i.e., different from “4.” the specialists’ recommendations were analyzed and, when relevant, incorporated into the final version of the online course. the evaluation forms were prepared in google forms and based on the suitability assessment of materials instrument (19). from the specialists’ evaluation, a second version was created and submitted for external validation. this evaluation aimed to verify the adequacy of the organization, writing style, presentation, and motivation of the technological product to the course objectives from the target audience’s perspective. design validation nine design specialists were also selected using the snowball strategy. the design specialists evaluated the course using an agreement scale on the aspects of the course presentation—colors, clarity, organization, logic—in the same gradation as the one presented to the previous group. graphic designers illustrated each class to provide more engaging and user-friendly content to support and consolidate the theory presented and adequately format and configure the content, aiming to achieve a logical and harmonic structure between design and information. validation by representatives of the target audience assessments were carried out with physical therapy undergraduate students. this phase was conducted as part of an extension program promoted in social media and among professors of the subject corresponding to the theme. it was extended to students of several brazilian heis. the inclusion criteria for the participants were: being an undergraduate physical therapy student, being regularly enrolled in an hei, having concluded the urogynecological and obstetric physical therapy subject or similar, or being enrolled from the sixth semester onward. fifty-one physical therapy undergraduate students participated; 60.8 % were under 25 years old, 92.1 % were female, and 39.2 % were in their seventh semester. after meeting the inclusion criteria, the sample size for this validation stage was defined by a specific mathematical formula, which aimed to estimate the minimum size necessary for performing particular statistical procedures, ensuring the study’s reliability (19, 20). data collection and data analysis instrument the content validity index (cvi) was used for content and design validation. the score allows the evaluation of the agreement ratio among the specialists, first related to each item and then to the content. the sum of the agreement of items marked as 3 or 4 was divided by the total number of responses. for the global coefficient, the sum of each item’s cvi was obtained and divided by the number of items. as a cutoff point, a value of 0.78 was adopted, considering that the level of agreement among specialists is inversely proportional to the number of participants (15). the target audience evaluated the pre-final version of the course. the concordance index was the ratio of the number of participants agreeing with the item to the total number of participants multiplied by 100. the items that reached a minimum agreement of 75 % in positive answers were adopted as validity evidence.(22). the data were organized in microsoft excel software, analyzed using descriptive statistics, and presented in a table format. the present study followed the ethical precepts of research involving human beings. the research ethics committee approved the project under legal opinion 2.822.830/2018. all participants were advised of the research objectives and methods and signed the informed consent form. results given the need for education and awareness of future professionals, especially physical therapists who provide care to pregnant women, the interest in developing and validating the content and presentation of an online course has emerged to prevent new cases and reduce the frequency and stage of clinical symptoms of ui in the future. the synthesis of knowledge obtained in the integrative review was used to identify the theoretical knowledge to be addressed. after defining the syllabus of the course and the strategies to be adopted to promote it, the course planning was divided into four modules, in increasing order of complexity, namely: the basic principles of perineal anatomy and pelvic floor function; quality of life and pelvic floor dysfunctions; pelvic floor in pregnancy; pelvic floor muscle training. with the assistance of a graphic designer, the proper artwork, formatting, and configuration were prepared. the language was chosen according to the target audience; the most relevant information was selected to produce an attractive, objective, and user-friendly tool, using several pictures and illustrations. the material was structured logically, and the most important information was presented first. in addition, colors that would attract the reader’s attention and adequate size and typography were adopted for clear reading comprehension. in addition, a balance was sought between the information and the design of resources. table 1 shows that all variables and items analyzed by the content specialists had an average cvi higher than the established cutoff point. table 1. specialists’ evaluation of content, language, presentation, stimulation/motivation, and cultural adequacy. teresina, piauí, brazil, 2019 (n = 13) criterion totally inadequate (n) inadequate (n) partially adequate (n) adequate (n) cvi* content does it have a clear objective that allows quick understanding? 10 3 1.0 does it address information related to pelvic floor dysfunctions, especially ui during pregnancy? 9 4 1.0 is the content limited to the objectives so that readers can reasonably understand it in the time allowed? 4 9 1.0 is the course planning organized according to the objective? 12 1 1.0 language is the reading level appropriate for the readers’ comprehension? 2 11 1.0 does the language style make the sentences easy to understand? 2 11 1.0 is the information conveyed within a clear context? 13 1.0 is the vocabulary composed of common words? 1 12 1.0 is the understanding made easier by topics? 3 10 1.0 presentation is the content organization adequate? 4 9 1.0 are the font size and typeface conducive to pleasant reading? 2 11 1.0 are the support resources relevant and in line with what is proposed in each module? 1 3 9 0.92 is the quiz at the end of each module adequate, stimulating, and consolidating each lesson’s learning? 2 11 1.0 are the images used well-designed and in line with the subject of each slide? 1 12 1.0 stimulation/motivation is there an interaction between the text and readers, leading them to reflect? 4 9 1.0 are pelvic floor dysfunctions, especially ui, well demonstrated? 4 9 1.0 cultural adequacy is the content culturally adequate to the target audience’s logic, language, and experience? 2 11 1.0 does it present culturally good examples? 4 9 1.0 global cvi* 0.99 source: prepared by the authors. the evaluation by the design specialists is presented in table 2. the specialists suggested some modifications: dynamic improvement of the lessons from slides in video-slides; improvement of the page layout also to be available for smartphones, and reformulation of some theoretical contents since they were not limited to gestation—as proposed by the course theme—, also covering the moment of childbirth. all recommendations were reviewed in the pre-final version of the online course. table 2. evaluation by the design specialists regarding the presentation/interface. teresina, piauí, brazil, 2019 (n = 9) evaluated items cvi* are the sentences sorted into color levels appropriate for drawing the target audience’s attention? 1.0 is the text clear and easily understood when read? 1.0 are the colors and shapes suitable for the type of media? 0.89 are the guidelines in strategic places for reflection? 1.0 does it contribute to changing the target audience’s behavior and actions? 0.89 global cvi 0.95 source: prepared by the authors. table 3 presents the evaluation of the target audience. the agreement rate in positive responses ranged from 84.3 % to 100 %, a satisfactory result to consolidate the final version of the online course. table 3. evaluation by the target audience regarding the agreement regarding the organization, writing style, presentation, and motivation. teresina, piauí, brazil, 2019 (n = 51) criterion option 1 option 2 option 3 n % n % n % organization did the virtual environment draw your attention? (1. yes; 2. no; 3. partially) 47 92.1 4 7.9 is the content sequence adequate? (1. yes; 2. no; 3. partially) 50 98 1 2 is the structure of the virtual environment adequate? (1. yes; 2. no; 3. partially) 49 96 2 4 writing style the sentences are: (1. easy to understand; 2. difficult to understand; 3. i do not know) 51 100 the written content is: (1. clear; 2. confusing; 3. i do not know) 50 98 1 2 presentation the colors in the virtual environment are: (1. adequate; 2. inadequate; 3. i do not know) 49 96 2 4 do the illustrations help to understand the content? (1. yes; 2. no; 3. partially) 47 92.1 4 7.9 is the structure of the virtual environment adequate? (1. yes; 2. no; 3. partially) 47 92.1 4 7.9 motivation in your opinion, will any student who sees this virtual environment understand what it is about? (1. yes; 2. no; 3. partially) 47 92.1 1 2 3 5.9 did you feel motivated to see the virtual environment all the way through? (1. yes; 2. no; 3. partially) 46 90.2 5 9.8 does the educational resource address issues necessary for students to identify clinical signs of ui during pregnancy? (1. yes; 2. no; 3. partially) 47 92.1 4 7.9 does the educational resource cover topics for students to learn how to manage cases of ui during pregnancy? (1. yes; 2. no; 3. partially) 43 84.3 01 2 7 13.7 did the virtual environment encourage you to act or think about ui during pregnancy? (1. yes; 2. no; 3. partially) 51 100 did you like the support resources for each module (videos, articles)? (1. yes; 2. no; 3. partially) 48 94.1 3 5.9 did you find the quiz at the end of each module important for consolidating the content? (1. yes; 2. no; 3. partially) 49 96 2 4 source: prepared by the authors. discussion ui represents the most frequent pfd during pregnancy, present in 58 % of women. this clinical picture can remain in 30 % of puerperal women, defining the pregnancy-puerperal cycle as a considerable risk factor for developing these dysfunctions. given its negative impact on quality of life at the personal, professional, social, and sexual levels, it must be considered (23). raising awareness among primary care professionals is paramount since they are responsible for prevention and treatment services in the public health setting (24). physical therapists were chosen as the target audience since they master techniques considered the first line for preventing or treating pfd. one way to improve the professionals’ knowledge of the theme is with training, proposed by the política nacional de educação em saúde (national health education policy), which aims primarily to transform the practices based on the needs of the professional setting and improve the quality of care (25). for this purpose, creating educational resources is a viable solution, particularly with the increase in digital technologies proposed in this study. the tool was considered adequate for improving care practices since it reached satisfactory scores among the evaluators with a cvi above the established cutoff point. the specialists represent a unique and singular universe when facing a given situation, which increases the scientific power and confidence of the instrument developed and approved (26). the literature review stage—aiming to provide educational resources according to the professionals’ needs—and the specialists’ analysis were essential for the successful evaluation of the course. the integrative review is a critical stage in this process. it allows for surveying the panorama of scientific production on the theme with various methodological approaches, including quantitative and qualitative studies, providing different perspectives on developing technological products. thus, scientific knowledge can guide valuable clinical decisions. other studies have adopted this strategy to identify the gaps to be bridged by ict (27). according to all categories evaluated by the specialists, the educational device can be considered straightforward in conveying information and logical in its sequence, with compatible visual and linguistic aspects, which are helpful for understanding and reflecting upon urinary loss during pregnancy. studies (28, 29) have shown that educational resources must be attractive tools, have adequate language for the target audience, and be cohesive and coherent in their structure and objectives with a theme following a logical succession to encourage and promote changes in the actions of the professionals being trained. the changes proposed by the specialists provided an accurate and improved course for the target audience, reflected in the agreement of more than 94 % of all participants. the incorporation of lessons in video format proved to be of notable importance due to the target audience’s profile—mostly university students and healthcare professionals—which demands dynamic activities to keep their interest with possibilities of flexibility in the study planning. it should be noted that, in addition to keeping the users’ interest, the dynamism of the video lessons with illustrations aimed to complement information (30). a relevant recommendation by the content specialists concerned the practicality of the course by adapting the layout for mobile devices, such as smartphones. the increased use of this technology, in addition to the growth of mobile internet, has made it possible to access educational resources anywhere at any time, a fact noted by the increased access to information via websites, blogs, and social media, among others. therefore, the proposed educational technologies must be adapted to this new context. furthermore, the quality of mobile internet networks and their cost are highlighted as barriers to effectively using these resources (31), and adaptations are necessary, such as the possibility of downloading video lessons and other files. educational resources have been used to improve users’ knowledge, actions, and practices (32); thus, the importance of the adequacy of digital technologies to the objectives of the resources under development is highlighted. it has been noted that this is primarily due to the integrative review and specialists’ participation in this technology’s validation process (33, 34). therefore, the importance of the convergence between the need to improve certain content and the target audience’s interest is reiterated. aiming to address gaps in the theoretical content to be covered in the course, the specialists in this study suggested adding themes such as the importance of preparation for childbirth. it was evident that the course layout in terms of organization and presentation was adequate, and the content structured in modules is written in an easily understandable way that sparks interest, with supplementary study resources and tests at the end of each module that helps to achieve the course objective. the preceding reflects the conformity between the proposal and what will be achieved by the course when carried out. the subsequent stage of technology evaluation, performed by the target audience, is a distinguishing factor for clarifying doubts and the remarks related to the use and relevance of the product to their professional practice. only they can judge what would be necessary for their clinical practice, which renders this technology precise, appropriate, and relevant to the group (31, 35). in light of the above, this tool provided a suitable level of usability for students and physical therapists who wish to apply the knowledge acquired, especially in preventive measures and early diagnosis of ui in the pregnant population. a benefit of this type of technology found in this study is the possibility of time management since users can flexibly organize and control their activities (36). thus, it is reiterated that educational technologies, such as the online course in this study, are creative and attractive tools that can be used to acquire skills and knowledge among students and future professionals to improve their care practices. conclusions the online course developed for brazil was considered sufficiently adequate in terms of content and interface quality, both by specialists and by the target audience; thus, it contributes to filling a gap concerning the development and validation of brazilian educational resources that address the studied theme. therefore, this research proposes that health education should constantly be stimulated among future physical therapy professionals with clear, educational, and dynamic resources to improve their clinical practice, always based on the integrality and well-being of patients and scientific evidence. as a limitation of this study, using a technique to evaluate content validity may have overestimated the results. another area for improvement is that the course was carried out at a private university; therefore, considering brazil’s cultural diversity and aiming to confirm the adequacy of this online course, we recommend conducting studies that include other target audiences. it is expected that the results obtained from the developed and validated online course can be applied to train physical therapy students through distance learning of ui, which contributes to improving the quality of life at this unique moment in women’s lives. conflicts of interest: none declared. references 1.    gajewski jb, schurch b, hamid r, averbeck m, sakakibara r, agrò ef et al. an international continence society (ics) report on the terminology for adult neurogenic lower urinary tract dysfunction (anlutd). neurourol urodyn. 2018;37(3):1152-61. doi: https://doi.org/10.1002/nau.23397 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to adjust for treatment drop-in when developing clinical prediction models. stat med. 2018.10;37(28):4142-54. doi: https://doi.org/10.1002/sim.7913 36.    awang h, wan rozaini, so, zahurin ma. model to evaluate virtual learning environment among malaysian teachers. international journal of innovative technology and exploring engineering (ijitee). 2019;8(5s):59-63. https://www.ijitee.org/wp-content/uploads/papers/v8i5s/es3389018319.pdf home cerrar 11. reseœa ok 61 callista roy y heather andrews. editorial appleton & lange, segunda edición, 1999. este libro se fundamenta en publicaciones anteriores, escritas por la doctora callista roy sobre el modelo de adaptación. se inicia con un capítulo de análisis de la naturaleza y desarrollo del conocimiento de enfermería, donde se describen algunos modelos conceptuales vigentes. en los capítulos siguientes, las autoras profundizan en los conceptos fundamentales del modelo de roy, la proyección de la enfermería para el siglo xxi y la aplicación del proceso de enfermería; así, a través de cada uno de ellos, se realiza un análisis detallado de los modos adaptativos. como aspectos novedosos con relación a ediciones anteriores, se destaca el desarrollo de algunos conceptos, como el del nivel de adaptación, y se incluye una clasificación de los modos de adaptación para grupos: modo físico, modo de identidad grupal, rol e interdependencia. vale la pena resaltar la expansión que han tenido los conceptos principales y los supuestos filosóficos del modelo, desde su primera publicación hasta hoy, los cuales, como lo expresa la autora actualmente, están enfocados hacia la mutualidad de las personas con otros, con el mundo y con la figura de dios. esta modificación provee unos lineamientos sobre cómo interpretar y desarrollar el quehacer profesional, así como una actitud frente al cuidado de enfermería para lograr la adaptación. maría elisa moreno fergusson 1 fernanda manuela loureiro1 beatriz rodrigues araújo2 zaida borges charepe3 adaptação e validação do instrumento children care quality at hospital para o português 1 https://orcid.org/0000-0002-5600-2422. escola superior de saúde egas moniz, centro de investigação interdisciplinar egas moniz, portugal. floureiro@egasmoniz.edu.pt 2 https://orcid.org/0000-0003-0266-2449. instituto de ciências da saúde, centro de investigação interdisciplinar em saúde, universidade católica portuguesa, porto, portugal. baraujo@porto.ucp.pt 3 https://orcid.org/0000-0003-0080-4482. instituto de ciências da saúde, centro de investigação interdisciplinar em saúde, universidade católica portuguesa, lisboa, portugal. zaidacharepe@ics.lisboa.ucp.pt recebido: 13/07/2019 submetido: 19/09/2019 aceito por pares: 03/10/2019 aceito: 12/11/2019 doi: 10.5294/aqui.2019.19.4.7 para citar este artigo / para citar este artículo / to reference this article loureiro fm, araújo br, charepe zb. adaptation and validation of the instrument ‘children care quality at hospital’ for portuguese. aquichan 2019; 19(4): e1947. doi: https://doi.org/10.5294/aqui.2019.19.4.7 resumo objetivo: adaptar e validar o instrumento children care quality at hospital (ccqh) de avaliação da qualidade dos cuidados de enfermagem à criança hospitalizada para o idioma português de portugal. materiais e método: estudo metodológico de validação de conteúdo, linguística e conceptual, com tradução, retrotradução e reflexão falada. recorreu-se a uma amostra não probabilística de 252 crianças entre 7 e 11 anos, hospitalizadas por doença aguda em nove serviços de seis hospitais portugueses. determinaram-se a confiabilidade e a validade dos resultados para aferir as propriedades psicométricas do instrumento. foi calculada a validade de construto pela análise fatorial exploratória de componentes principais com rotação varimax e a consistência interna pela determinação do coeficiente alfa de cronbach. resultados: a consistência interna apresenta características psicométricas adequadas para a população portuguesa (valores de alfa de cronbach entre 0,66 e 0,82). o instrumento manteve 49 itens agrupados em três categorias: características, atividades e ambiente. as características psicométricas do ccqh, adaptado e validado para o idioma português, garantem-lhe a confiabilidade e a año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1947 tema: prática baseada em evidência. contribuição para a disciplina: tradicionalmente, recorre-se a adultos (como os profissionais de saúde e os cuidadores) para avaliar a satisfação da criança com a hospitalização. a existência de instrumentos adaptados e validados para a criança em idade escolar permite um conhecimento aprofundado na hospitalização na primeira pessoa e, simultaneamente, a comparação de dados entre diferentes contextos culturais. após a adaptação e a validação para o idioma português, as características psicométricas do instrumento children care quality at hospital (ccqh) garantem-lhe a confiabilidade e a validade para ser utilizado para avaliar a satisfação com a qualidade dos cuidados de enfermagem na perspetiva das crianças em idade escolar. poderá, assim, ser utilizado no idioma português e comparado com os resultados de aplicação em outros contextos culturais. https://orcid.org/0000-0002-5600-2422 mailto:floureiro@egasmoniz.edu.pt https://orcid.org/0000-0003-0266-2449 mailto:baraujo@porto.ucp.pt https://orcid.org/0000-0003-0080-4482 mailto:zaidacharepe@ics.lisboa.ucp.pt https://doi.org/10.5294/aqui.2019.19.4.7 https://orcid.org/0000-0002-5600-2422 https://orcid.org/0000-0003-0266-2449 https://orcid.org/0000-0003-0080-4482 https://doi.org/10.5294/aqui.2019.19.4.7 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1947 validade para medir a satisfação com a qualidade dos cuidados de enfermagem na perspetiva das crianças em idade escolar. conclusões: esse instrumento poderá ser utilizado para avaliar a satisfação das crianças com a qualidade dos cuidados de enfermagem durante sua hospitalização. palavras-chave (fonte: decs) enfermagem; criança; hospitalização; satisfação do paciente; inquéritos e questionários. adaptación y validación del instrumento children care quality at hospital para el portugués resumen objetivo: adaptar y validar el instrumento children care quality at hospital (ccqh) de evaluación de la calidad de los cuidados de enfermería al niño hospitalizado para el idioma portugués de portugal. materiales y método: estudio metodológico de validación de contenido, lingüística y conceptual, con traducción, retrotraducción y reflexión. se recurrió a una muestra no probabilística de 252 niños entre 7 y 11 años, hospitalizados por enfermedad aguda en nueve servicios de seis hospitales portugueses. se determinaron la fiabilidad y validez de los resultados para medir las propiedades psicométricas del instrumento. se calculó la validez de constructo mediante análisis factorial exploratorio de componentes principales con rotación varimax y la consistencia interna por la determinación del coeficiente alfa de cronbach. resultados: la consistencia interna presenta características psicométricas adecuadas a la población portuguesa (valores de alfa de cronbach entre 0,66 y 0,82). el instrumento mantuvo 49 ítems agrupados en tres categorías: características, actividades y ambiente. las características psicométricas del ccqh, adaptado y validado para el portugués, le garantiza la fiabilidad y validez para medir la satisfacción con la calidad de los cuidados de enfermería desde la perspectiva de los escolares. conclusiones: el instrumento podrá utilizarse en la evaluación de la satisfacción de los niños con la calidad de los cuidados de enfermería durante su hospitalización. palabras clave (fuente: decs) enfermería; niño; hospitalización; satisfacción del paciente; encuestas y cuestionarios. 3 adaptação e validação do instrumento children care quality at hospital para o português l fernanda manuela loureiro e outros adaptation and validation of the instrument ‘children care quality at hospital’ for portuguese abstract objective: adapt and validate the instrument children care quality at hospital (ccqh) to assess the quality of nursing care of hospitalized children for the portuguese language of portugal. materials and methods: content, language, and conceptual validity methodological study, with translation, feedback, and reflection. a non-probabilistic simple was used of 252 children between 7 and 11 years of age, hospitalized due to acute disease in nine services of six portuguese hospitals. the reliability and validity of the results were determined to measure the psychometric properties of the instrument. construct validity was calculated through exploratory factor analysis of main components with varimax rotation and the internal consistency by determining the cronbach’s alpha coefficient. results: the internal consistency has adequate psychometric characteristics suitable for the portuguese population (cronbach’s alpha values between 0.66 and 0.82). the instrument maintained 49 items grouped into three categories: characteristics, activities, and environment. the psychometric characteristics of the ccqh, adapted and validated for portuguese, guarantees its reliability and validity to measure satisfaction with the quality of nursing care from the perspective of school-aged children. conclusions: the instrument could be used to assess children’s satisfaction with the quality of nursing care during their hospitalization. keywords (source: decs) nursing; child; hospitalization; patient satisfaction; surveys and questionnaires. año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1947 4 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1947 aquichan issn 1657-5997 eissn 2027-5374 introdução a satisfação do cliente com os cuidados de enfermagem é um tema transversal a todos os contextos do cuidar. a sua definição não é unânime na literatura por se tratar de um conceito multidimensional e difícil de operacionalizar (1). no entanto, é consensual a influência da experiência profissional dos enfermeiros na satisfação dos pacientes, sendo apontado como o fator que mais influencia a satisfação como um todo (2). na enfermagem, a avaliação da satisfação do paciente precede a sua definição. o primeiro instrumento para medir a satisfação foi desenvolvido em 1957, altura em que os cuidados de enfermagem eram avaliados por horas totais de cuidados de enfermagem e horas de cuidados disponíveis (3). mais tarde, em 1975, surge um instrumento para medir a satisfação que incluía as dimensões: comportamento técnico profissional, expressões intra e interpessoais e relações de confiança e educacionais (4). esse instrumento veio salientar a associação entre expectativas e satisfação, definindo satisfação do paciente como o grau de congruência entre as expectativas dele acerca dos cuidados ideais e os cuidados efetivamente recebidos. nos anos 1980, houve um aumento de estudos que versam a qualidade dos cuidados e que incluíam como indicador de qualidade a satisfação. no entanto, foi na última década que as pesquisas proliferaram exponencialmente, facto que é atribuído ao papel ativo dos pacientes nos cuidados de saúde (1). atualmente, é frequente a avaliação da satisfação com os cuidados nos diversos contextos e podemos, de uma forma genérica, considerar esse conceito como a opinião do paciente acerca dos cuidados de enfermagem recebidos (5). trata-se de um indicador da qualidade dos cuidados prestados, sendo mais comum na sua avaliação a utilização de questionários para aferir a satisfação dos clientes no contexto da hospitalização (6). no que concerne à hospitalização infantil, tradicionalmente, recorre-se a adultos, profissionais e cuidadores para avaliar a satisfação, e a opinião da criança tem sido pouco estudada (7-13). contudo, é consensualmente aceite a necessidade de envolver as crianças nas decisões que a afetam (14-16) e de considerar a sua opinião. tem existido um esforço crescente em procurar formas de escutar a criança e integrar a sua perspetiva (17). resulta do crescente reconhecimento dos direitos da criança, em particular, no contexto internacional e em ambiente hospitalar (12). além disso, as crianças têm sido excluídas de participar em investigação científica por questões éticas/legais e pela necessidade de as proteger (18). no contexto hospitalar, as crianças apresentam o risco de ver os seus direitos negligenciados ou desvalorizados devido à perceção de que são imaturas e /ou incapazes de expressar a sua opinião (19). assim, este artigo assenta na convicção de que as crianças, tal como os adultos, têm perspetivas particulares, competências, direito a serem ouvidas e a falarem por si próprias desde que sejam utilizadas as metodologias apropriadas (20). tem como grande temática a satisfação com a qualidade dos cuidados de enfermagem durante a hospitalização. o desenvolvimento de instrumentos de medida construídos e validados especificamente para a população pediátrica permite um conhecimento mais realista da sua opinião. verifica-se que existem poucos instrumentos válidos que considerem as crianças enquanto utilizadores dos serviços de saúde (7). além disso, é particularmente importante aferir a satisfação em grupos mais vulneráveis, como as crianças (21), na medida em que são os mais dependentes dos cuidados de enfermagem. a revisão da literatura permitiu a identificação do instrumento children care quality at hospital (ccqh) aplicado especificamente à criança em idade escolar (22-23). esse instrumento possibilita a recolha de informação básica acerca da satisfação da criança com o decorrer da sua experiência com os cuidados de enfermagem e auxilia na identificação de áreas-chave para a melhoria da qualidade dos cuidados, quando os cuidados não correspondem às suas expectativas. nesse sentido, justifica-se a sua aplicação a outros contextos culturais pelo potencial de obter conhecimento acerca da visão da criança sobre cuidados de enfermagem, o que contribui para a melhoria da qualidade na prática com uma abordagem genuinamente centrada na criança. o ccqh foi desenvolvido na finlândia para medir a qualidade dos cuidados de enfermagem na perspetiva das crianças. baseia-se nas expectativas das crianças e nas definições relativas à qualidade dos cuidados de enfermagem pediátricos (24-25), em indicadores de qualidade de estudos prévios e, parcialmente, na definição de qualidade de cuidados de enfermagem de pacientes adultos (26). o instrumento desenvolveu-se em três fases: na fase i, construiu-se uma primeira versão com base na revisão da literatura que foi submetida a painel de peritos; na fase ii, o instrumento foi aplicado a uma amostra de 41 crianças e avaliado por 19 enfermeiras; em seguida, foi reformulado e novamente aplicado a uma amostra de 16 crianças; na fase iii, foram aferidas as características psicométricas do instrumento, nomeadamente 5 adaptação e validação do instrumento children care quality at hospital para o português l fernanda manuela loureiro e outros validade de construto pelo método dos componentes principais e consistência interna pelo cálculo de alfa de cronbach: características dos enfermeiros (0,557), atividades dos enfermeiros (0,809) e ambiente de enfermagem (0,761) (22). na sua versão final, o ccqh é composto por 49 itens divididos em três categorias: características dos enfermeiros, atividades dos enfermeiros e ambiente de enfermagem, categorizados segundo uma escala de likert de 1 a 3, em 30 itens, com a utilização de palavras e faces (1 = nunca = ; 2 = algumas vezes = ; 3 = sempre = ), e de 1 a 4 nos restantes 19 itens, com a escala de concordância e a utilização de imagens de ursos de peluche. um escore maior é indicativo de maior satisfação. atendendo à relevância e atualidade do tema, consideramos pertinente a adaptação do instrumento ao português para que possa ser utilizado no contexto da hospitalização infantil. assim, o objetivo deste estudo foi adaptar transculturalmente e validar o questionário ccqh para esse idioma. metodologia trata-se de um estudo metodológico que incluiu a tradução, a adaptação transcultural e a obtenção de propriedades psicométricas iniciais de um instrumento que permite medir a satisfação da criança em idade escolar (7-11 anos) com os cuidados de enfermagem em contexto de internamento hospitalar. este estudo é parte integrante de uma tese de doutoramento em enfermagem, em curso no instituto de ciências da saúde da universidade católica portuguesa, portugal. após a autorização formal da autora original do ccqh, na primeira fase, procedeu-se à adaptação transcultural do instrumento para o português de portugal, segundo procedimentos metodológicos internacionalmente estabelecidos, em cinco etapas: tradução inicial feita por dois tradutores, síntese das duas traduções, retroversão, painel de peritos e aplicação do pré-teste (27), como se pode verificar pela figura 1. numa segunda fase, realizou-se a avaliação das propriedades psicométricas do instrumento com a aplicação do questionário em português a uma amostra de 252 crianças com idades entre 7 e 11 anos. na primeira fase, pretendeu-se garantir a equivalência linguística e conceptual, de modo a assegurar a validade de conteúdo da versão portuguesa do instrumento, pelo que se seguiram os procedimentos metodológicos de tradução, adaptação e validação cultural. o processo de tradução visou à produção de um documento do idioma original (inglês) para o idioma que se pretendia utilizar (português) (28). o instrumento foi traduzido por duas pessoas, ambas fluentes no idioma inglês: um tradutor da área de enfermagem e um tradutor sem conhecimento da área, conforme recomendado (27). as traduções foram sintetizadas num único documento pelos investigadores e pelos tradutores, e produzida posteriormente uma versão de consenso. passou-se à etapa de retrotradução, que foi efetuada por duas pessoas, ambas com língua nativa de inglês e sem formação científica em saúde. essas versões foram sintetizadas mais uma vez pelos tradutores e pelos investigadores num único documento de consenso. figura 1. fluxograma do procedimento de adaptação cultural do instrumento ccqh fonte: elaboração própria. seguiu-se a fase de adaptação do instrumento em análise, definida como um processo de consideração das diferenças entre as duas culturas de forma a assegurar a equivalência de significado (28). o documento foi enviado à autora original do ccqh, assim como o relatório detalhado dos resultados associados às fases mencionadas. na terceira fase, foi constituído um painel de peritos (27) para efeitos de validação cultural. o painel foi constituído por dois docentes da área científica de enfermagem com experiência na utilização do método de adaptação transcultural, duas enfermeiras especialistas em saúde infantil e pediátrica, uma professora de português e um tradutor. esta etapa teve como objetivo asseguetapa 1 etapa 2 etapa 3 etapa 4 etapa 5  tradução inicial para o português de portugal (tradutor 1 e tradutor 2).  síntesis das traduções pelos investigadores e pelos tradutores numa versão de consenso.  retrotradução para inglês (tradutor 1 e tradutor 2).  síntesis de retrotraduções numa versão de consenso.  envío de relatório escrito à autora original.  revisão de todos os instrumentos por painel de seis peritos.  aplicação de préteste a uma amostra de tipo não probabilístico e acidental de 30 crianças. 6 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1947 aquichan issn 1657-5997 eissn 2027-5374 rar que o instrumento tivesse as mesmas propriedades que o instrumento original para que pudesse ser aplicado da mesma forma (28). foi calculado o índice de validade de conteúdo que mede a concordância entre avaliadores, considerando-se o valor acima de 0,9 como referência (6). entre os 49 itens que constituem esse instrumento, constatou-se que apenas dois itens (“protegem a minha intimidade” e “há privacidade”) não foram concordantes entre todos os peritos. verificou-se um índice de validade de conteúdo de 0,96. após a revisão e aferição das questões linguísticas por uma professora de português, constituiu-se a versão pré-teste, submetida a uma amostra de tipo não probabilístico e acidental (6), constituída por 30 crianças internadas num serviço de pediatria hospitalar, mantendo-se os mesmos critérios de aplicação enumerados na versão original: crianças do grupo etário dos 7 aos 11 anos, com pelo menos 24 horas de internamento hospitalar, que soubessem falar e escrever em português e que tivessem a capacidade de responder aos itens do instrumento (sozinhas ou com ajuda). estabeleceram-se como critérios de exclusão: crianças com patologia psiquiátrica ou neurológica, com atraso de desenvolvimento e crianças em regime de ambulatório. para a aplicação de procedimentos metodológicos de validação de instrumentos, o tamanho da amostra deve ser definido a priori e deve variar entre 2 e 20 respostas válidas por variável (29). neste caso, o instrumento apresenta 49 itens e definiu-se um número de cinco respostas por cada variável, pretendendo uma amostra > 245. assim, após o pré-teste, o instrumento foi aplicado entre janeiro de 2015 e dezembro de 2016, por um período médio de três meses por cada instituição. esse período foi selecionado por considerarmos ser adequado para a obtenção do número de criança pretendido. a população foi constituída por crianças hospitalizadas, tendo sido selecionada uma amostra de 252 crianças, que manteve os mesmos critérios de inclusão e exclusão. os instrumentos foram aplicados diretamente pela principal investigadora, tendo sido acordada a forma de acesso à amostra e de aplicação dos instrumentos com a chefia de enfermagem em cada serviço. para a análise estatística, recorreu-se ao programa estatístico statistical package for social sciences, versão 24. para a avaliação da validade de construto do ccqh, empregou-se o método de análise de componentes principais, com a aplicação do método de kaiser e dos testes de kaiser-meyer-olkin (kmo > 0,6) e de esfericidade de bartlett (teb < 0,05). estes últimos para garantir a adequação do modelo fatorial à matriz de correlações para a realização da análise fatorial (cálculo do grau de homogeneidade ou semelhança dos diversos itens ou questões do instrumento). verificamos que se manteve o número de itens do instrumento original. para a avaliação da consistência interna, recorreu-se ao cálculo do coeficiente alfa de cronbach. sabendo que o valor do coeficiente alfa pode variar de 0 a 1 e que uma consistência interna adequada se situa com valores superiores a 0,70, o que indica que as questões são semelhantes ou homogéneas sem serem redundantes (6, 30). trata-se de uma das medidas mais utilizadas e é definida como a correlação que se espera obter entre o instrumento utilizado e outros instrumentos do mesmo universo e com o número de itens que mensurem a mesma característica (6). este estudo foi registado na comissão nacional de proteção de dados (parecer 1.644/2015) e aprovado pelas comissões de ética dos hospitais envolvidos. na aplicação do instrumento, foi solicitado o consentimento verbal e escrito tanto aos pais como às crianças participantes. o anonimato e a confidencialidade das respostas foram assegurados, sendo fornecido o termo de consentimento informado, livre e esclarecido. utilizando uma linguagem simples, o estudo foi explicado às crianças, de forma a que pudessem efetuar uma decisão fundamentada acerca da sua participação (15, 18). foi apresentado o objetivo assim como o que lhes era pedido e o tempo de preenchimento expectável. foi, igualmente, assegurado a todas as crianças que a sua não participação não traria quaisquer consequências ou riscos, sendo salientada, enquanto benefícios, a importância em participar e expressar a sua opinião. não se verificaram situações de recusa em participar, quer por parte dos pais, quer por parte das crianças. resultados na primeira fase, foram aplicados 30 questionários, e as crianças, de uma forma geral, verbalizaram ter compreendido o instrumento e as perguntas. verificou-se que uma criança de 8 anos referiu não compreender as palavras “programada” e “honestidade”, e duas crianças de 7 anos referiram não compreender a palavra “intimidade”. recorreu-se à definição dos termos como estratégia de clarificação. as palavras foram explicadas pela investigadora com terminologia mais simples. dado que o número de crianças (n = 3) que verbalizou dificuldades foi inferior a 15 % do total de crianças inquiridas, optou-se por manter o instrumento (31) após o pré-teste. 7 adaptação e validação do instrumento children care quality at hospital para o português l fernanda manuela loureiro e outros as 252 crianças participantes no estudo tinham uma média de idades de 8,9 anos (dp = 1,4), sendo maioritariamente do género masculino (52,8 %). no que se refere ao motivo de hospitalização, a maioria das crianças referiu como motivos da sua hospitalização a doença súbita (n = 247), 17,4 %, porque se magoaram (n = 44), e 66,8 %, porque ficaram muito doentes (n = 165). no que se refere à duração do internamento (n = 252), verifica-se mdn = 3 e iqq = 3. o instrumento é composto por três domínios: “características dos enfermeiros”, “atividades dos enfermeiros” e “ambiente de enfermagem”. no que concerne ao domínio “características dos enfermeiros”, foi efetuada a análise fatorial exploratória, com recurso ao método de análise de componentes principais; aplicado o método de kaiser, tendo sido identificada uma estrutura fatorial com um domínio (valores próprios ≥ 1 e saturação do item no fator ≥ 0,35) (tabela 1). tabela 1. análise fatorial do domínio “características dos enfermeiros” n.º do item item abreviado valor de saturação do item no fator do domínio “características dos enfermeiros” 2 “simpáticos” 0,80 5 “honestos” 0,75 1 “bondosos” 0,72 2 “competentes” 0,67 4 “divertidos” 0,61 raiz própria variância explicada 2,57 51,29 % fonte: elaboração própria. através da análise, confirmamos a existência unidimensional, cujo total da variância explicada é de 51,29 %; na aplicação do teste de kmo, obteve-se um valor de 0,79, situando-se num intervalo de variância adequada (32). por sua vez, a saturação do item no fator varia entre um máximo de 0,80 na afirmação “os meus enfermeiros são simpáticos” e um mínimo de 0,61 na afirmação “os meus enfermeiros são divertidos”. verificamos que o alfa de cronbach apresenta um valor 0,75, que nos permite considerar que apresenta consistência interna (33). o domínio “atividades dos enfermeiros” é constituído por três subescalas: “cuidar, entretenimento e suporte”, “cuidado físico e tratamento” e “educação”. foi efetuada a análise fatorial exploratória à subescala “cuidar, entretenimento e suporte”, tendo sido considerados 238 participantes com respostas válidas. como se pode verificar na tabela 2, confirmamos a existência unidimensional, cujo total da variância explicada é de 31,09 %. tabela 2. análise fatorial do domínio “atividade dos enfermeiros”, subescala “cuidar, entretenimento e suporte” n.º do item item abreviado valor de saturação do item no fator na subescala “cuidar, entretenimento e suporte” 5 “consideram as minhas opiniões” 0,67 7 “dão-me conforto” 0,62 4 “escutam-me” 0,60 10 “cuidam de mim como os meus pais” 0,60 2 “conversam sobre coisas interessantes” 0,59 6 “dão-me coragem” 0,58 8 “informaram-me sobre o que podia fazer no hospital” 0,54 9 “encorajam-me a participar nos cuidados” 0,53 3 “protegem a minha intimidade” 0,46 1 “brincam comigo” 0,50 11 “têm em atenção a minha comida favorita” 0,39 raiz própria variância explicada 3,42 31,09 % fonte: elaboração própria. da aplicação do teste de kmo para determinar a adequação da amostra e a possibilidade de efetuar a análise fatorial, obteve-se um valor de 0,72, situando-se num intervalo de variância adequada (32). a saturação do item no fator varia entre um máximo de 0,67 na afirmação “consideram as minhas opiniões” e um mínimo de 0,39 na afirmação “têm em atenção a minha comida preferida”. o valor de alfa de cronbach é de 0,76, pelo que podemos considerar que a subescala em estudo apresenta consistência interna (33). a subescala seguinte, “cuidado físico e tratamento”, foi também sujeita à análise fatorial exploratória e, como se pode verificar na tabela 3, confirmamos a existência unidimensional, cujo total da variância explicada é de 49,64 %. 8 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1947 aquichan issn 1657-5997 eissn 2027-5374 tabela 3. análise fatorial do domínio “atividade dos enfermeiros”, subescala “cuidado físico e tratamento” n.º do item item abreviado valor de saturação do item no fator na subescala “cuidado físico e tratamento” 2 “ajudam-me a comer” 0,82 3 “ajudam-me a tomar banho” 0,78 4 “ajudam-me a ir à casa de banho” 0,76 1 “aliviam-me a dor” 0,34 raiz própria variância explicada 1,99 49,64 % fonte: elaboração própria. para essa subescala, o valor da aplicação do teste de kmo é de 0,61, situando-se num intervalo de variância adequada (32). por sua vez, a saturação do item no fator varia entre um máximo de 0,82 na afirmação “ajudam-me a comer” e um mínimo de 0,34 na afirmação “aliviam-me a dor”. esse valor é marginal ao limite inferior, no entanto trata-se de um item relevante na relação criança-enfermeiro, pelo que se aceita na análise. no que se refere à consistência interna, o valor de alfa de cronbach é de 0,66. trata-se de um valor marginal, portanto, de acordo com os critérios (33), podemos considerar que a subescala apresenta consistência interna aceitável. a terceira subescala desse domínio é “educação” e, através da análise fatorial exploratória, com recurso ao método de análise de componentes principais, confirmamos a sua unidimensionalidade, cujo total da variância explicada é de 37,82 % (tabela 4). a aplicação do teste de kmo revelou um valor de 0,72, situando -se num intervalo de variância adequada (32). a saturação do item no fator varia entre um máximo de 0,69 na afirmação “quando posso voltar às minhas brincadeiras” e um mínimo de 0,48 na afirmação “os meus procedimentos (como tirar sangue ou fazer raio-x)”. o valor do coeficiente alfa de cronbach é de 0,82, o que permite considerar que a subescala apresenta boa consistência interna (33). no que se refere ao terceiro e último domínio do questionário, “ambiente de enfermagem”, a análise fatorial exploratória revelou uma estrutura fatorial com três fatores: “ambiente social”, “ambiente físico” e “ambiente emocional” (tabela 5). tabela 4. análise fatorial do domínio “atividade dos enfermeiros”, subescala “educação” n.º do item item abreviado valor de saturação do item no fator na subescala “educação” 10 “quando posso voltar às minhas brincadeiras” 0,69 8 “os cuidados a ter em casa” 0,68 9 “quando posso voltar para a escola” 0,65 6 “como movimentar-me no hospital” 0,65 2 “o meu tratamento” 0,65 7 “a duração do meu internamento” 0,61 5 “o que posso comer e beber” 0,60 1 “o motivo da minha hospitalização” 0,59 3 “a minha medicação” 0,50 4 “os meus procedimentos (como tirar sangue ou fazer raio-x)” 0,48 raiz própria variância explicada 3,78 37,82 % fonte: elaboração própria. tabela 5. análise fatorial do domínio “ambiente de enfermagem” n.º do item item abreviado fator 1 ambiente social fator 2 ambiente físico fator 3 ambiente emocional 9 “há privacidade” 0,72 10 “os meus pais acompanham-me” 0,65 0,13 11 “os meus familiares podem visitar-me” 0,61 0,14 7 “a minha estadia tem sido agradável e confortável” 0,60 0,30 8 “é fácil encontrar locais como a casa de banho” 0,51 0,15 9 adaptação e validação do instrumento children care quality at hospital para o português l fernanda manuela loureiro e outros n.º do item item abreviado fator 1 ambiente social fator 2 ambiente físico fator 3 ambiente emocional 13 “os enfermeiros fazemme companhia” 0,39 0,359 12 “os meus amigos podem visitar-me” 0,30 0,14 3 “há vídeos e jogos suficientes” 0,13 0,76 0,23 4 “há trabalhos manuais suficientes” 0,36 0,69 2 “há livros e revistas suficientes” 0,53 0,62 5 “há brinquedos suficientes” 0,58 14 “outras crianças internadas fazem-me companhia” 0,39 0,51 0,11 6 “há locais próprios para estar com a minha família” 0,48 1 “o tempo passa depressa” 0,34 18 “tenho medo dos médicos” 0,80 19 “tenho medo da dor” -0,14 0,12 0,76 15 “tenho medo de ficar sozinho” 0,26 0,65 17 “tenho medo dos enfermeiros” 0,42 -0,36 0,57 16 “tenho medo das injeções” 0,42 -0,37 0,50 raiz própria variância explicada 3,19 16,80 % 3,03 15,93 % 2,34 12,31 % fonte: elaboração própria. através da análise fatorial, confirmamos a existência multidimensional, com três fatores, cujo total da variância explicada é de 45,05 %. o valor da aplicação do teste de kmo é 0,71, situando-se num intervalo de variância adequada (32). quanto à consistência interna, recorreu-se novamente ao cálculo do coeficiente alfa de cronbach, obtendo-se valores entre 0,77 e 0,68 (valor marginal que pode ser considerado como válido), o que nos permite confirmar a consistência interna (33) como se pode verificar na tabela 6. tabela 6. análise da consistência interna do domínio “ambiente de enfermagem” fatores domínio “ambiente de enfermagem alfa de cronbach” fator 1 0,68 fator 2 0,77 fator 3 0,73 fonte: elaboração própria. discussão o desenvolvimento do ccqh na versão original decorreu em três fases e constituiu-se como um instrumento de interesse para a utilização junto de crianças hospitalizadas (22). com este estudo, pretendeu-se traduzir e adaptar o instrumento ccqh para o idioma português de portugal, enquanto ferramenta que permite aferir a satisfação com a qualidade dos cuidados de enfermagem prestados num contexto de hospitalização na criança em idade escolar (7-11 anos), a partir das suas próprias perspetivas. no processo inicial, obteve-se a equivalência de significado pelo cumprimento do processo metodológico e pela validação do percurso com a autora do instrumento original. atendendo à especificidade de alguns termos e o seu significado cultural e linguístico, o recurso ao procedimento de tradução inicial, síntese das duas traduções, retroversão, painel de peritos e aplicação de pré-teste foram fulcrais para garantir a equivalência do ccqh. salienta-se que o processo de tradução e adaptação de instrumentos de pesquisa exige um menor dispêndio de tempo e custos do que a criação de instrumentos. adicionalmente, permite a comparação de resultados entre população, o que se traduz no progresso científico fundamental para o desenvolvimento do conhecimento (27). na adaptação do instrumento para o idioma português de portugal, mantiveram-se os 49 itens que constam do instrumento original. esse número de itens pode ser considerado demasiado longo para algumas crianças (22); contudo, nesta amostra, nenhuma das crianças referiu esse aspeto. no processo de adaptação, foram mantidas as designações do instrumento original e, de uma forma geral, verificou-se um aumento dos valores de consistência interna em todos os domínios e subescalas do ccqh. no primeiro 10 año 19 vol. 19 nº 4 chía, colombia octubre-diciembre 2019 l e1947 aquichan issn 1657-5997 eissn 2027-5374 domínio, “características dos enfermeiros”, houve um aumento no valor do alfa de cronbach (0,75) em relação ao instrumento original (0,56) (22), o que demonstra que os itens medem o atributo. na literatura, identifica-se que as características pessoais dos enfermeiros são reconhecidas pelas crianças em idade escolar (34). valorizam conhecer os enfermeiros enquanto pessoas (19), sendo um aspeto identificado como a melhor experiência durante a hospitalização (7), mas também como expectativa de cuidados. as características que integram o instrumento, bondosos (19), competentes (23), simpáticos (16), divertidos e honestos (15, 24), são identificadas nas pesquisas sobre esse tema. em relação ao segundo domínio, “atividades dos enfermeiros”, no instrumento original, a autora considerou cinco subescalas: “entretenimento”, “cuidar e comunicação”, “suporte à iniciativa”, “educação”, “cuidado físico e tratamento”. na versão traduzida, identificaram-se três subescalas nesse domínio: “cuidar, entretenimento e suporte”, que inclui todos os itens das subescalas “entretenimento”, “cuidar e comunicação” e “suporte à iniciativa”, assim como o item “têm em atenção a minha comida preferida”, enquadrado na subescala “cuidado físico e tratamento” no instrumento original. a segunda subescala inclui todos os itens da subescala no instrumento original, “cuidado físico e tratamento”, exceto o item já indicado acima. por sua vez, a terceira subescala identificada (“educação”) nesse domínio é coincidente com a do instrumento original e inclui todos os itens da subescala. o domínio “atividades dos enfermeiros” é referido na literatura como relevante e importante para as crianças (16-17); contudo, trata-se de uma categoria ampla em que se podem englobar diversos itens. inclui aspetos relacionados com o desenvolvimento de atividades pelos profissionais de enfermagem durante a prática clínica. salientamos que os aspetos que constituem essa categoria estão inter-relacionados. por exemplo, as crianças têm a expectativa de fornecimento de informação previamente aos procedimentos num ambiente de respeito enquanto lhes proporcionam distração (19), o que se enquadra na subescala “cuidar, entretenimento e suporte”, que integra a versão traduzida do ccqh. as diferenças encontradas relacionam-se, provavelmente, com esse aspeto, mas também com questões culturais que são fonte de satisfação/insatisfação nas crianças portuguesas. entre os aspetos mais valorizados nesse domínio, encontramos o fornecimento de informação e o entretenimento (7, 17). as crianças expressam satisfação quando lhes é dada informação acerca dos cuidados de uma forma que possam compreender (35) e que lhes permita serem ativas no processo de cuidar. quando não lhes são explicados os cuidados, por exemplo, no que diz respeito ao momento de realizar os procedimentos (18), expressam a sua insatisfação. esperam também que os enfermeiros desenvolvam atividades de entretenimento que os ajudem a encarar de forma mais positiva os procedimentos (36) e a passar o tempo (11). relativamente ao terceiro domínio, “ambiente de enfermagem”, a autora original considerou três subescalas: “ambiente físico”, “ambiente social” e “ambiente emocional”. na versão do instrumento no idioma português de portugal, identificaram-se igualmente três subescalas, mas com variação nos itens. assim, na primeira subescala, “ambiente físico” (fator 1), verificou-se que: os itens são sobreponíveis aos da subescala original, exceto os itens “a minha estadia tem sido confortável e agradável” e “é fácil encontrar locais como a casa de banho e sala de brincar”, passaram para a segunda subescala (“ambiente social” — fator 2); e o item “outras crianças internadas fazem-me companhia” passou da subescala “ambiente social” para essa subescala. em relação à segunda subescala, os itens são também sobreponíveis, exceto o item já referido; por fim, na subescala “ambiente emocional” (fator 3), os itens são integralmente sobreponíveis. o ambiente durante a hospitalização infantil é também referido na literatura como fonte de satisfação/insatisfação entre as crianças (23, 3638). estas salientam os aspetos físicos como o equipamento associado à prestação de cuidados (como as bombas infusoras) por ser desconhecido e ameaçador (39). identifica-se, ainda, o ambiente social, relacionado com a interação com os profissionais e com outras crianças, hospitalizadas e o ambiente emocional. este refere-se ao sentimento de bem-estar que lhes permite vivenciar a experiência de hospitalização de uma forma mais agradável. permite à criança ser mais autónoma e participativa nos cuidados (40) e, consequentemente, é gerador de satisfação. os resultados encontrados revelam a possibilidade de o ccqh ser utilizado para avaliar a satisfação da criança hospitalizada com a qualidade dos cuidados de enfermagem. os testes estatísticos efetuados para validar o construto dos domínios da qualidade dos cuidados às crianças no hospital, através dos três domínios, mostram relações lógicas e a contribuição dos 49 itens para o instrumento na sua globalidade. 11 adaptação e validação do instrumento children care quality at hospital para o português l fernanda manuela loureiro e outros conclusão o instrumento ccqh permite o aporte de novo conhecimento na medida em que fornece a perspetiva única da criança em idade escolar acerca da sua experiência de hospitalização. permite a identificação de aspetos-chave, valorizados pela criança, que podem ser trabalhados pelos enfermeiros de forma a tornar os cuidados de enfermagem mais adaptados e satisfatórios para a criança. optou-se pela adaptação e validação do questionário ccqh para o idioma português com o objetivo de estudar os seus domínios. a versão final do instrumento ficou constituída por 49 itens distribuídos por três domínios: características dos enfermeiros, atividades dos enfermeiros e ambiente de enfermagem. a análise efetuada demonstrou evidência empírica do questionário ccqh no idioma português. o processo de adaptação e validação, segundo as orientações internacionais, bem como a análise das propriedades psicométricas de validade de construto e de consistência interna, permitem-nos concluir que se trata de um instrumento confiável e válido para avaliar a satisfação com a qualidade dos cuidados de enfermagem na perspetiva das crianças hospitalizadas. a versão adaptada do ccqh para o português de portugal é um instrumento que pode ser utilizado por enfermeiros, no contexto hospitalar, para aferirem a satisfação das crianças com a qualidade dos cuidados de enfermagem, o que contribui para a melhoria dos cuidados. agradecimentos: os autores gostariam de 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2018 [cited 2019 jul 18]. available from: https://www.era.lib.ed.ac.uk/handle/1842/31008 https://doi.org/10.1186/s12955-014-0176-2 http://www.ufjf.br/renato_nunes/files/2014/03/validação-do-questionário-de-qualidade-de-vida-sf-36.pdf http://www.ufjf.br/renato_nunes/files/2014/03/validação-do-questionário-de-qualidade-de-vida-sf-36.pdf https://doi.org/10.1590/0034-7167.2016690405i https://doi.org/10.1177/1367493513496912 https://doi.org/10.1111/cch.12016 https://doi.org/10.1177/1043454216631308 https://doi.org/10.1016/j.appet.2017.01.035 https://doi.org/10.1016/j.ejon.2014.01.006 https://www.era.lib.ed.ac.uk/handle/1842/31008 1 editorial práctica basada en la evidencia científica como fundamento de la práctica clínica practice based on scientific evidence as the foundation of clinical practice prática baseada em evidências científicas como base da prática clínica maría guadalupe moreno-monsiváis1 1 orcid.org/0000-0002-7152-0244. universidad autónoma de nuevo león. facultad de enfermería. monterrey, nuevo león. méxico. maria.morenom@uanl.mx doi: 10.5294/aqui.2019.19.3.1 para citar este artículo / to reference this article / para citar este artigo moreno-monsiváis mg. practice-based on scientific evidence as foundation of clinical practice. aquichan; 19(3): e1931. doi: https://doi.org/10.5294/aqui.2019.19.3.1 palabras clave (fuente: decs) práctica clínica basada en la evidencia; educación en enfermería; calidad de la atención de salud; enfermería; toma de decisiones clínicas; transición de la salud; investigación. keywords (source: decs) evidence-based practice; education, nursing; quality of health care; nursing; clinical decision-making; health transition; research. palavras-chave (fonte: decs) prática clínica baseada em evidências; educação em enfermagem; qualidade da assistência à saúde; enfermagem; tomada de decisão clínica; transição epidemiológica; pesquisa. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1931 https://orcid.org/0000-0002-7152-0244 https://doi.org/10.5294/aqui.2019.19.3.1 https://orcid.org/0000-0002-7152-0244 https://doi.org/10.5294/aqui.2019.19.3.1 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1931 seguramente, todos los que pertenecemos al área de la salud escuchamos, en algún momento de nuestra formación académica y práctica profesional, la siguiente frase: “la práctica clínica debe ser fundamentada con evidencia científica, producto de resultados de investigación de buena calidad metodológica”. por lo tanto, esto nos invita a transitar a una práctica basada en la evidencia (pbe), así como a desarrollar investigación con diseños de tipo experimental y a utilizar los resultados obtenidos con altos estándares de calidad, que permitan disponer de evidencia que pueda ser transferida a la práctica y generar un impacto positivo en la salud (1). cada vez hay más literatura que respalda la trascendencia de la aplicación de la pbe: logra que la atención produzca los mejores resultados para los pacientes; mejora la calidad de la atención; reduce las variaciones en la práctica; disminuye el error en las intervenciones clínicas; y logra un menor costo de la atención médica, mayor seguridad en la atención y satisfacción profesional. se puede puntualizar que la pbe permite proporcionar cuidados de salud de manera equitativa y efectiva para toda la población (2). los profesionales de la salud reconocen la necesidad y el beneficio de que en el ámbito clínico se transite de una práctica tradicional a una pbe. sin embargo, es evidente que existe una brecha entre la evidencia científica y su uso en la práctica clínica, que demanda analizar por qué a la fecha, cuando el conocimiento es cada vez más accesible, aún se identifican instituciones de salud donde impera una atención basada en la tradición. algunos estudios reportan que la mayoría de las enfermeras clínicas utiliza su propio conocimiento —adquirido durante su educación de enfermería o por experiencia—, el conocimiento y consejo de sus colegas y literatura de enfermería, pero rara vez la evidencia basada en investigación (3, 4). entre las barreras que dificultan la implementación de la pbe se señalan la carga de trabajo; la falta de tiempo para la lectura, así como de conocimiento y habilidades para buscar bibliografía, analizar y sintetizar la evidencia científica para poder trasladarla a la práctica clínica; un deficiente apoyo organizacional y de recursos que faciliten el acceso a las bases de datos electrónicas; conocimiento insuficiente sobre cómo manejar esas bases de datos y evaluar críticamente los resultados de la investigación. todo esto dificulta cerrar la brecha que aún existe para que la fundamentación del cuidado de enfermería esté basada en la evidencia (3, 4). las restricciones que interfieren en dicha transición pueden ser individuales, profesionales y organizacionales (4, 5). entre las individuales, se destacan el conocimiento limitado de la pbe, el peso del hábito y la actitud de resistencia al cambio. las profesionales están vinculadas con la preparación académica (se debe tener claro que no todos los profesionales de enfermería que ejercen en la práctica clínica se formaron con un paradigma de pbe). las institucionales corresponden a la organización: entornos complejos, estilo de liderazgo, intereses particulares de la organización, estructuras, comunicación y recursos disponibles. si reconocemos que la evidencia científica es cada vez más accesible a los profesionales de la salud, y que es necesario transferirla a la práctica, además de conocer cuáles son los principales beneficios y barreras que limitan su uso en los entornos clínicos, es relevante cuestionarnos por qué esta transición sigue siendo un gran reto, qué medidas se deben tomar y quiénes son los responsables de ejecutarlas. para responder a estos cuestionamientos, se puede señalar que se requiere un mayor esfuerzo de todos los involucrados: el profesional de la salud, investigadores, instituciones educativas y organizaciones de salud, donde cada uno participe activamente, con una meta en común: lograr que las decisiones clínicas se fundamenten en la evidencia. respecto a qué medidas se deben tomar, una de las principales estrategias que ha demostrado ser útil para transitar a una pbe es la educación, por lo cual las instituciones educativas formadoras de profesionales de enfermería desempeñan un rol fundamental. dicho esto, se recomienda introducir la educación de pbe en los planes de estudio de enfermería de una manera dosificada a lo largo de la formación, de manera que los estudiantes puedan desarrollar las competencias requeridas en los diferentes niveles. en el pregrado, el objetivo es estimular el pensamiento crítico y la curiosidad intelectual sobre la práctica clínica, aprender a formular buenas preguntas clínicas, desarrollar el conocimiento y la habilidad para localizar, leer y evaluar las evidencias encontradas (su validez, confiabilidad metodológica y aplicabilidad clínica). es decir, habilitar a los estudiantes para seleccionar la mejor evidencia, aplicarla en la práctica de enfermería y evaluar sus resultados. en la maestría, las competencias deben dirigirse a desarrollar en los futuros profesionales un rol de liderazgo en la atención que les permita identificar y priorizar los principales problemas de la práctica, localizar la mejor evidencia disponible y aplicarla. 3 práctica basada en la evidencia científica como fundamento de la práctica clínica l maría guadalupe moreno-monsiváis en el doctorado, se busca desarrollar habilidades avanzadas para revisar, evaluar y sintetizar la evidencia, para hacer recomendaciones en la práctica y liderar equipos que diseminen y apliquen la mejor evidencia posible en la práctica clínica (6). si bien la educación es una estrategia esencial, el compromiso organizacional y el apoyo administrativo son fundamentales. es importante considerar que en las organizaciones se tendrán profesionales de enfermería con diferentes niveles de avance en conocimientos y habilidades para pbe, lo cual demanda una planeación estratégica que permita la integración de todos en diferentes niveles. al respecto, fisher, cusack, cox, feigenbaum y wallen (7) señalan que las organizaciones requieren contar con un plan estructurado metodológicamente que permita desarrollar, de manera escalonada, las competencias de los profesionales de la salud, así como con un programa de mentoría en pbe que acompañe al personal y lo empodere para asegurar un rol activo y la sostenibilidad de la pbe. para esto, el primer paso es evaluar el conocimiento actual y las creencias de los profesionales de enfermería, así como la preparación de la organización para implementar la pbe. se debe determinar el nivel en el que se encuentra el personal y, según esto, avanzar a través de cinco niveles, congruentes con la clasificación de los niveles de adquisición de habilidades de benner (8). el nivel 1 corresponde al de orientación: aquí se espera que las enfermeras aprendan el concepto de pbe; el nivel 2, al de principiante: el propósito es que la enfermera desarrolle las competencias necesarias para aplicar habilidades específicas, como hacer una pregunta clínica y acceder a la literatura a través del uso de bases de datos; el nivel 3 es el intermedio: aquí se espera que la mayoría de las enfermeras alcancen, dentro de un año de práctica, las competencias básicas para desarrollar una pregunta clínica que especifique una población y una intervención, con la claridad sobre con qué intervención se compara, y los resultados esperados (pregunta pico). el nivel 4 es el avanzado: la meta es que las enfermeras tengan la capacidad de hacer una pregunta pico clínicamente relevante, acceder a la literatura, evaluar de manera crítica los artículos de investigación, transferir la intervención con las adecuaciones necesarias al contexto y evaluar sus resultados. las enfermeras que logran este nivel pueden dirigir las actividades de pbe en su área de práctica, identificar y desarrollar los cambios necesarios y evaluar su efectividad en la práctica. el nivel 5 es el campeón (experto): se espera que las enfermeras de este nivel realicen búsquedas bibliográficas avanzadas y evalúen críticamente la literatura, desarrollen guías de práctica clínica, difundan intervenciones basadas en la evidencia y evalúen y superen las barreras para la adopción de la evidencia en la práctica (7). en cuanto a la preparación de la organización, se debe contar con el compromiso organizacional y el apoyo administrativo que permitan otorgar los recursos y el tiempo necesarios para que se desarrolle un programa sistemático a largo plazo, con una metodología que permita el cambio. los líderes deben estar involucrados para fortalecer una cultura que apoye la transición a una pbe, con la convicción de que esta tiene un impacto positivo en la calidad y en la seguridad de la atención (9). el fin último de la pbe es desarrollar una cultura en las instituciones de salud que permita introducir nuevas prácticas o modificar las ya existentes, de manera que se beneficie la salud de la población de una manera sostenible. por lo tanto, el reto y el compromiso de transitar a una pbe es de todos los profesionales de la salud, en conjunto con los investigadores, el sector educativo y el organizacional. los esfuerzos individuales no son la solución; 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27:2052-2061. doi: https://doi.org/10.1111/ jocn.14348 5. muñoz d. from evidence-based nursing to healthcare practice: the evaluation of results as an integrating element. enferm clin [internet]. 2018 my.-jun.; 28(3):149-153. doi: https://doi.org/10.1016/j.enfcli.2018.04.004 6. chan s. taking evidence-based nursing practice to the next level. int j nurs pract [internet]. 2013 oct.; 19(3):1-2. doi: https://doi.org/10.1111/ijn.12208 7. fisher c, cusack g, cox k, feigenbaum k, wallen g. developing competency to sustain evidence-based practice. j. nurs adm [internet]. 2016 nov.; 46(11):581-585. doi: https://doi.org/10.1097/nna.0000000000000408 8. benner p. from novice to expert. american j nurs [internet]. 1982 mzo. 82(3): 402-407. disponible en: https://journals. lww.com/ajnonline/citation/1982/82030/from_novice_to_expert.4.aspx 9. smith a, farrington, m. matthews g. monitoring sedation in patients receiving opioids for pain management. j nurs care qual [internet]. 2014 oct. 29(4):345-353. doi: https://doi.org/10.1097/ncq.0000000000000059 10. fitzpatrick jj, reed pg, smith mc, smith mj, roy c. guest editorial. the nursing disciplinary perspective-50 years ago and the view forward. advances in nursing science [internet]. 2019 en. 42(1):2. doi: https://doi.org/10.1097/ ans.0000000000000251 https://doi.org/10.1111/inr.12075 https://doi.org/10.1016/j.apnr.2015.11.016 https://doi.org/10.1111/jocn.14348 https://doi.org/10.1111/jocn.14348 https://doi.org/10.1016/j.enfcli.2018.04.004 https://doi.org/10.1111/ijn.12208 https://doi.org/10.1097/nna.0000000000000408 https://journals.lww.com/ajnonline/citation/1982/82030/from_novice_to_expert.4.aspx https://journals.lww.com/ajnonline/citation/1982/82030/from_novice_to_expert.4.aspx https://doi.org/10.1097/ncq.0000000000000059 https://doi.org/10.1097/ans.0000000000000251 https://doi.org/10.1097/ans.0000000000000251 levels of anxiety and stress experienced by nurses in inpatient units articles  levels of anxiety and stress experienced by nurses in inpatient units* niveles de ansiedad y de estrés en el trabajo de enfermería en unidades de hospitalización** níveis de ansiedade e de estresse no trabalho da enfermagem em unidades de internação*** 10.5294/aqui.2023.23.1.6  edwing alberto urrea vega1 andréia barcellos teixeira macedo2 liliana antoniolli3 jéssica morgana gediel pinheiro4 astrid nathalia páez esteban5 sônia beatriz cócaro de souza6 1 0000-0002-9578-4252 universidade federal do rio grande do sul, brasil. 00305254@ufrgs.br 2 0000-0003-4219-4731 universidade federal do rio grande do sul, brasil. enfandreiabarcellos@gmail.com 3 0000-0003-0806-9910 universidade federal do rio grande do sul, brasil. l.antoniolli@hotmail.com 4 0000-0003-1530-7198 universidade federal do rio grande do sul, brasil. jessica.mpinheiro@gmail.com 5 0000-0003-0010-7564 universidad de santander, facultad de ciencias médicas y de la salud, instituto de investigación masira, colombia. ast.paez@mail.udes.edu.co 6 0000-0001-9394-5465 universidade federal do rio grande do sul, brasil. sbcs2001@gmail.com * this article stems from the dissertation entitled: “the effect of heart rate variability biofeedback on state-trait anxiety levels in nursing professionals: a randomized clinical trial,” submitted to the graduate nursing program at the universidade federal do rio grande do sul, brazil. ** este artículo es derivado de la tesis de doctorado “efeito do biofeedback da variabilidade da frequência cardíaca sobre os níveis de ansiedade traço-estado dos profissionais de enfermagem: ensaio clínico randomizado”, sometida al programa de posgrado en enfermería de la universidade federal do rio grande do sul, brasil. *** este artigo é derivado da tese de doutorado intitulada: “efeito do biofeedback da variabilidade da frequência cardíaca sobre os níveis de ansiedade traço-estado dos profissionais de enfermagem: ensaio clínico randomizado”, submetida ao programa de pós-graduação em enfermagem da universidade federal do rio grande do sul, brasil. theme: evidence-based practice; occupational health. contribution to the subject: the present study provides data on the risk conditions to which nursing professionals in inpatient units are exposed, the potential outcomes regarding the psychoemotional distress experienced by this population, and the need for interventions that favor the preservation of the mental health of nursing teams. in addition, the relevance of more robust studies on the protective factors for anxiety is emphasized. received: 23/08/2022 sent to peers: 20/09/2022 approved by peers: 26/11/2022 accepted: 29/11/2022 para citar este artículo / to reference this article / para citar este artigo: vega eau, macedo abt, antoniolli l, pinheiro jmg, esteban anp, souza sbcd. levels of anxiety and stress experienced by nurses in inpatient units. aquichan. 2023;23(1):e2316. doi: https://doi.org/10.5294/aqui.2023.23.1.6 abstract objective: to assess state-trait anxiety levels and their correlation with occupational stress and socio-biographical and occupational factors in nursing professionals. materials and methods: this quantitative, cross-sectional, analytical study was conducted in the inpatient units of a university hospital in southern brazil, with the participation of 162 nursing professionals. for data collection, socio-biographical and occupational forms, the stress-symptom scale, the workplace stress scale, and the state-trait anxiety inventory were used. the data were analyzed based on descriptive and inferential statistics. results: nursing professionals have moderate levels of state-trait anxiety. there is a positive correlation between state-trait anxiety scores, stress scores, and stress dimensions (rho = 0.811, p < 0.001). “trait” anxiety is associated with years of experience in nursing (pr 0.97) and psychic-mental health follow-up (pr 1.97). “state” anxiety is associated with sex (pr 0.54), education (pr 2.26), and hours of sleep (pr 0.92). conclusions: “state” anxiety is associated with sex, age, higher education level, and psychic-mental health follow-up; however, years of experience in nursing and hours of sleep were found to be protective factors. keywords (source: decs): anxiety; occupational stress; inpatient care units; work; nursing. resumen objetivo: evaluar los niveles de ansiedad estado-rasgo y su correlación con el estrés ocupacional y los factores sociobiográfico y ocupacional en profesionales de enfermería. materiales y método: estudio cuantitativo, analítico y transversal realizado en las unidades de hospitalización de un hospital universitario del sur de brasil, con la participación de 162 profesionales de enfermería. para la recolección de datos, se utilizó un formulario sociobiográfico y ocupacional, la escala de síntomas de estrés, la escala de estrés laboral y el inventario de ansiedad estado-rasgo. los datos se analizaron con base en la estadística descriptiva e inferencial. resultados: los profesionales de enfermería presentan niveles moderados de ansiedad estado-rasgo. existe una correlación positiva entre las puntuaciones de ansiedad estado-rasgo, las puntuaciones de estrés y las dimensiones de estrés (rho = 0,811, p < 0,001). la ansiedad “rasgo” se asoció con los años de experiencia en enfermería (rp 0,97) y el seguimiento de la salud psíquico-mental (rp 1,97). por otra parte, la ansiedad “estado” se asoció con el sexo (rp 0,54), la educación (rp 2,26) y las horas de sueño (rp 0,92). conclusiones: la ansiedad “estado” se asoció con el sexo, la edad, el nivel educativo superior y el seguimiento de la salud psíquico-mental; sin embargo, los años de experiencia en enfermería y las horas de sueño actuaron como factor protector. palabras clave (fuente: decs): ansiedad; estrés laboral; unidades de internación; trabajo; enfermería. resumo objetivo: avaliar os níveis de ansiedade traço-estado e sua correlação com o estresse ocupacional e com os fatores sociobiográficos e ocupacionais nos profissionais de enfermagem. materiais e método: estudo quantitativo, transversal analítico, realizado nas unidades de internação de um hospital universitário do sul do brasil, com a participação de 162 profissionais de enfermagem. para a coleta de dados, utilizaram-se formulário sociobiográfico e ocupacional, escala de sintomas de estresse, escala de estresse no trabalho e inventário de ansiedade traço-estado. os dados foram analisados com base na estatística descritiva e inferencial. resultados: os profissionais de enfermagem apresentam níveis moderados de ansiedade traço-estado. existe uma correlação positiva entre os escores de ansiedade traço-estado, os escores de estresse e as dimensões do estresse (rho = 0,811, p < 0,001). a ansiedade “traço” mostrou-se associada aos anos de experiência na enfermagem (rp 0,97) e ao acompanhamento para saúde psíquico-mental (rp 1,97). a ansiedade “estado” também mostrou associação com o sexo (rp 0,54), a escolaridade (rp 2,26) e as horas de sono (rp 0,92). conclusões: a ansiedade “estado” mostrou-se associada ao sexo, à idade, ao nível de escolaridade superior, ao acompanhamento para a saúde psíquico-mental; no entanto, os anos de experiência na enfermagem e as horas de sono comportaram-se como um fator protetor. palavras-chave (fonte: decs): ansiedade; estresse ocupacional; unidades de internação; trabalho; enfermagem. introduction anxiety is an adaptive response inherent to human existence, defined by an emotionally based subjective experience stemming from exposure to risky situations or fearful anticipation of danger; however, disproportionate reactions that vary in intensity and duration contribute to the pathogenesis of anxiety (1, 2). mental disorders are among the leading causes of diseases worldwide. anxiety is one of the most disabling disorders due to its direct psychological effects and economic and social consequences. the global burden of diseases, injuries, and risk factors study (gbd) estimated a global prevalence of anxiety disorders in 2020 of 3825 cases per 100,000 people, totaling 298 million people worldwide; however, after adjusting for the covid-19 pandemic, the estimated global prevalence was 4,802, corresponding to 374 million people, showing a 25.6 % increase in cases of anxiety disorders in 2020 (3). the prevalence of causal factors for mental disorders in healthcare professionals has reached a remarkable relevance, highlighting the association of anxiety and occupational stress with an increased workload, physical exhaustion, and some aspects of workplace environments that can have dramatic effects on the physical and mental well-being of professionals (1). in the covid-19 pandemic context, which involves the entire healthcare network and workforce, the determining role of nursing in providing humanized care in responding to the disease has been highlighted and recognized in several social and academic spheres; nonetheless, the interaction of numerous institutional, professional, and personal factors intensified by the humanitarian crisis may have influenced these professionals’ tendencies of becoming ill (4). in brazil, this mental disorder has reached higher proportions and affects 9.3 % of the population, being the country with the highest number of anxiety cases worldwide (5). anxiety prevalence varies among cultures, ethnicities, age groups, and social, economic, and working conditions (5, 6). the routine experience of stressful conditions can lead to severe suffering, burnout, or psychosomatic diseases with impairment in quality of life and service provision (7, 8). regarding the effects of anxiety and occupational stress on nursing professionals, continuous exposure to person-centered care, living with pain, experiencing suffering and death processes, work-related demands, and interaction with environmental and social factors expose nursing teams to stressful situations that contribute to acute or chronic anxiety symptoms (9, 10). all these considerations suggest that nursing professionals have had to face an adverse reality caused by the changes in the perception of anxiety and occupational stress, and they have had to adapt to it. thus, the importance of data dissemination processes regarding emerging problems in moments of crisis to support evidence-based intervention strategies and decision-making in institutional, democratic, or legislative settings is emphasized. in light of the above, this study aimed to evaluate state-trait anxiety levels and their correlation with occupational stress, along with the socio-biographical and occupational factors associated with state-trait anxiety in nursing professionals. materials and methods study design this work is a quantitative, cross-sectional, analytical study. population and sample the study population consisted of 520 nursing professionals working in the inpatient units of a referral university hospital in porto alegre, rio grande do sul, brazil. for sample calculation, a simple random probability sampling was used, stratified by professional category, and a confidence level of 95 %, power of 80 %, and a minimum correlation of 0.25 were considered. thus, the sample consisted of 162 nursing professionals, retaining a proportionality and representativeness of 32 % (52) nurses and 68 % (110) nursing technicians and assistants. it is noteworthy that, according to the regulation of nursing practice in brazil, differences exist between each professional category per level of qualification. thus, nurses perform all activities and attributions exclusive to nursing; nursing technicians perform mid-level activities, which involve guiding and monitoring nursing work at an assistance level and participating in nursing care planning. finally, nursing assistants perform mid-level activities of a repetitive nature, which involve auxiliary nursing services provided under supervision and simple execution in treatment processes (11, 12). selection and eligibility criteria for selecting participants, the following inclusion criteria were used: nursing professionals who were active in their positions and had been hired for more than 30 days in any of the work shifts. those professionals on extended leave (sick leave, social security benefits), maternity leave, vacation, or who had returned from leave less than 15 days ago were excluded from the study. data collection data collection was carried out between april and august 2020. four instruments were used for data collection: a sociobiographical and occupational form, the stress-symptom scale (sss), the workplace stress scale (wss), and the state-trait anxiety inventory (stai). the authors developed the socio-biographical form based on data that, according to the literature and the subject matter investigated, can present a statistically significant correlation. it contained, in addition to socio-biographical data (sex, age, marital status, education), socio-occupational data (professional category, time in the profession, the field of work in the institution, work shift, which is a form of optimizing time and valuation of the workforce, divided into the morning—7 am-1 pm—, afternoon—1-7 pm—, night—7 pm-7 am—, and intermediate—7 pm-1 am—, work on weekends and holidays only, family income as presented in the instituto brasileiro de geografia e estatística data, and reference value in reais—the official currency of the federative republic of brazil), health conditions and chronic diseases. cronbach’s alpha coefficient was 0.74. the sss aims to evaluate physical and psychological symptoms and determine the general stress level (gsl); it consists of 13 physical symptom items and 18 psychological symptom items, with likert-type answers. the calculation is made through the arithmetic mean, in which values greater than 1 indicate stress, ranging from 1.1 (least stress) to 5 (maximum stress). the wss is a self-report instrument that evaluates organizational stress of a psychosocial nature and can be used in several work environments and various occupations. in 2004, the instrument was translated into portuguese and validated by professionals from different organizations, public and private, in the state of são paulo, demonstrating good psychometric properties (13); moreover, due to its practical utility, it has been used with nursing teams or similar populations (14, 15). the instrument consists of 23 items analyzed based on a five-point likert scale, in which each item presents a stressor and a type of reaction to this stressor; the scores range from 23 to 115 points. the instrument validation had a cronbach’s alpha coefficient of 0.91, which suggests good psychometric properties (13). the stai is a self-report instrument that has been adapted, translated, and validated into brazilian portuguese (16) and is considered one of the most used instruments in research and clinical settings in several cultures and nursing teams or equivalent. the instrument consists of 40 items with likert-type responses, which assess trait anxiety (20 items) with scores ranging from 1—almost never— to 4—almost always, and state anxiety (20 items) with scores ranging from 1—absolutely not— to 4—very much. the estimated scores range from 20 to 80 points and, according to the results, can be classified as low anxiety (20-30), moderate anxiety (31-49), and severe anxiety (greater than or equal to 50). the internal consistency described in the literature for the state anxiety component was µ = 0.89, and for trait anxiety, µ = 0.88 (16). data analysis and processing the analyses were carried out in the stata software version 14.0, with descriptive analysis having frequencies (absolute and relative) for qualitative variables. continuous variables were summarized via the means and standard deviation, followed by univariate analysis using the chi-squared test, fisher’s exact test, and student’s t-test. the prevalence ratios were calculated using robust poisson regression to examine the association between moderate/high versus low trait-state anxiety and the independent variables. the significance level adopted was 5 %. ethical aspects this study was approved by the ethics committee and scientific committee of the hospital de clínicas de porto alegre, with the ethical appreciation submission certificate 23346619.0.0000.5327 and legal opinion 3.796.246. the informed consent form was included with the questionnaire, following the recommendations of resolution 466/2012 issued by the conselho nacional de saúde do brasil, which regulates research with human beings. results a total of 162 nursing professionals participated in the study, with a prevalence of females (n = 138; 85.2 %), with a mean age of 43 years (sd ± 8.9), who were married/had a consensual union (n = 105; 64.8 %), and with a mean number of children of 2.1 (sd ± 1). regarding their level of education, 61 (37.7 %) participants had completed high school; 29 (17.9 %) had incomplete higher education; 23 (14.2 %) had completed higher education; 36 (22.2 %) had a specialization, and 13 (8 %) had a master’s/doctorate. the participants’ mean time working in nursing was 18 years (sd ± 7.7). when asked about their perception of how stressed they felt, 48 (29.6 %) reported feeling slightly stressed, 75 (46.3 %) felt moderately stressed, and 27 (16.7 %) felt quite stressed (table 1). table 1. sociodemographic and occupational profiles of the nursing professionals included in the study (n = 162). porto alegre, rio grande do sul, brazil, 2022 factor nurse nursing assistant nursing technician total p-value n 52 29 81 162   sex female 45 (86.5 %) 28 (96.6 %) 65 (80.2 %) 138 (85.2 %) 0.100 male 7 (13.5 %) 1 (3.4 %) 16 (19.8 %) 24 (14.8 %) age, mean (sd) 39.3 (8.0) 52.8 (6.4) 41.8 (7.6) 43.0 (8.9) < 0.001 education < 0.001 high school 0 (0.0 %) 20 (69.0 %) 41 (50.6 %) 61 (37.7 %) incomplete higher education 0 (0.0 %) 4 (13.8 %) 25 (30.9 %) 29 (17.9 %) complete higher education 5 (9.6 %) 4 (13.8 %) 14 (17.3 %) 23 (14.2 %) specialization 34 (65.4 %) 1 (3.4 %) 1 (1.2 %) 36 (22.2 %) master’s/doctorate 13 (25.0 %) 0 (0.0 %) 0 (0.0 %) 13 (8.0 %) marital status  < 0.001 married or with a partner 37 (71.2 %) 10 (34.5 %) 58 (71.6 %) 105 (64.8 %) without a partner 15 (28.8 %) 19 (65.5 %) 23 (28.4 %) 57 (35.2 %) family income  < 0.001 up to brl 2,500 0 (0 %) 0 (0 %) 3 (3.7 %) 3 (1.9 %) brl 2,501 to brl 4,500 0 (0 %) 14 (48.3 %) 30 (37.0 %) 44 (27.2 %) brl 4,501 to brl 6,500 11 (21.2 %) 9 (31 %) 33 (40.7 %) 53 (32.7 %) more than brl 6,500 41 (78.8 %) 6 (20.7 %) 15 (18.5 %) 62 (38.3 %) physical activity 0.63 no 28 (53.8 %) 16 (55.2 %) 50 (61.7 %) 94 (58 %) yes 24 (46.2 %) 13 (44.8 %) 31 (38.3 %) 68 (42 %) bmi, mean (sd) 25.5 (3.7) 28.1 (4.9) 27.3 (4.6) 26.9 (4.5) 0.020 work shift at the institution  < 0.001 morning 16 (%) 2 (%) 36 (%) 54 (%) afternoon 18 (%) 11 (%) 32 (%) 61 (%) night 9 (%) 16 (%) 12 (%) 37 (%) intermediate 1 (%) 0 (%) 1 (%) 2 (%) mainly on weekends and holidays 8 (%) 0 (%) 0 (%) 8 (%) time working in nursing in years, mean (sd) 15.1 (7.9) 25.6 (5.0) 16.9 (6.5) 17.9 (7.7) < 0.001 time working in the institution in years, mean (sd) 9.4 (8.3) 19.0 (4.8) 8.0 (7.0) 10.4 (8.2) < 0.001 time working in the sector, mean (sd) 5.6 (5.2) 13.9 (6.5) 5.5 (5.8) 7.0 (6.6) < 0.001 integrative therapies 0.16 no 33 (63.5 %) 20 (69 %) 62 (76.5 %) 115 (71 %) yes 19 (36.5 %) 9 (31 %) 17 (21 %) 45 (27.8 %) feels stressed 0.57 not at all 2 (3.8 %) 0 (0 %) 7 (8.6 %) 9 (5.6 %) slightly 14 (26.9 %) 10 (34.5 %) 24 (29.6 %) 48 (29.6 %) moderately 28 (53.8 %) 11 (37.9 %) 36 (44.4 %) 75 (46.3 %) quite 7 (13.5 %) 7 (24.1 %) 13 (16 %) 27 (16.7 %) totally 1 (1.9 %) 1 (3.4 %) 1 (1.2 %) 3 (1.9 %) brl: brazilian real short for the official currency of the federative republic of brazil; bmi: body mass index; sd: standard deviation. source: prepared by the authors. regarding the sss, considering the instrument’s minimum and maximum scores (0-5), it was noted in the “physical symptoms” category that the highest scores were for muscular pain, with a mean of 3.3 (sd ± 1.8) and for the psychological symptoms, anxiety scored a mean of 3.23 (sd ± 1.82; table 2). table 2. stress symptoms of the nursing professionals in the study (n = 162). porto alegre, rio grande do sul, brazil, 2022   mean sd min max physical symptoms increased blood pressure 1.68 1.41 1.00 5 increased respiratory rate 1.41 1.12 1.00 5 shortness of breath 1.44 1.18 1.00 5 dermatological conditions 2.09 1.65 1.00 5 higher incidence of diseases 1.9 1.57 1.00 5 insomnia 2.59 1.87 1.00 5 gastritis and ulcers 1.8 1.56 1.00 5 nausea and vomiting 1.38 1.1 1.00 5 constant tiredness 2.7 1.85 1.00 5 muscle pain 3.33 1.8 1.00 5 dizziness 1.64 1.38 1.00 5 increased cholesterol 1.68 1.48 1.00 5 sexual disorders 2.08 1.71 1.00 5 psychological symptoms reduced ability to focus 2.58 1.86 1.00 5 demotivation 2.3 1.75 1.00 5 anxiety 3.23 1.82 1.00 5 carelessness with appearance 1.88 1.54 1.00 5 fear 2.09 1.7 1.00 5 mood swings 2.72 1.83 1.00 5 nervousness 1.63 1.41 1.00 5 constant thoughts on a specific subject 2.38 1.77 1.00 5 i feel insecure 2.15 1.67 1.00 5 change in apetite 2.71 1.87 1.00 5 i am easily irritated 2.52 1.81 1.00 5 i feel distressed 2.75 1.8 1.00 5 i worry excessively 2.7 1.83 1.00 5 i am more emotional 2.6 1.79 1.00 5 i am more nervous 2.52 1.79 1.00 5 i forget appointments 1.62 1.34 1.00 5 i cry more often 1.98 1.57 1.00 5 i feel intense loneliness 1.49 1.23 1.00 5 source: prepared by the authors. table 3 shows wss (m = 1.88, sd ± 0.69), gsl (m = 2.15, sd ± 0.88), trait anxiety (m = 37.75, sd ± 10.01), and state anxiety (m = 40.04, sd ± 10.54) classified as moderate for nursing professionals. regarding the dimensions of occupational stress, the highest means were found in autonomy and control (m = 2.05, sd ± 0.8) and interpersonal relationships (m = 1.87, sd ± 0.84). table 3. descriptive analysis of the general scores and dimensions of the wss, sss, and stai for the nursing professionals included in the study (n = 162). porto alegre, rio grande do sul, brazil, 2022  dimensions n % wss   low 52 32.1 moderate 96 59.26 high 14 8.64 score 1.88* 0.69** wss dimensions autonomy and control 2.05* 0.8** roles and work environment 1.83* 0.7** relationship with the boss 1.8* 0.8** interpersonal relationships 1.87* 0.84** growth and appreciation 1.8* 0.8** sss   physical level 1.98* 0.83** psychological level 2.33* 1.11** gsl 2.15* 0.88** trait anxiety score 37.75* 10.01** low (l) 103 63.58 moderate (m) 56 34.57 high (h) 3 1.85 state anxiety  score 40.04* 10.54** low (l) 88 54.32 moderate (m) 70 43.21 high (h) 4 2.47 *mean; ** sd source: prepared by the authors. spearman’s correlation was carried out to understand the performance pattern between the scores of the scales, finding a positive correlation between the stress symptoms, gsl, workplace stress, and their associated domains with the stai scores (table 4). table 4. correlation between the general scores and dimensions of the wss, the sss, and the stai scores for the nursing professionals included in the study (n = 162). porto alegre, rio grande do sul, brazil, 2022 scores  (1)  (2)  (3)  (4)  (5)  (6)  (7)  (8)  (9)  (10)  (11) eet  (1) score 1.00                     dimensions (wss)  (2) autonomy and control 0.90 1.00                    (3) roles and work environment 0.87 0.79 1.00                  (4) relationship with the boss 0.90 0.72 0.73 1.00                (5) interpersonal relationships 0.85 0.69 0.67 0.75 1.00              (6) growth and appreciation 0.84 0.64 0.68 0.80 0.73 1.00           sss  (7) physical level 0.38 0.41 0.30 0.26 0.36 0.28 1.00          (8) psychological level 0.46 0.48 0.39 0.34 0.41 0.39 0.65 1.00        (9) gsl 0.47 0.49 0.39 0.34 0.43 0.38 0.86 0.94 1.00     stai  (10) state score 0.51 0.50 0.42 0.41 0.50 0.45 0.51 0.67 0.66 1.00    (11) trait score 0.56 0.53 0.49 0.43 0.52 0.51 0.51 0.67 0.67 0.81 1.00 spearman’s rho = 0.811; *p < 0.001 source: prepared by the authors. table 5 presents the means and standard deviations between the stress and anxiety scales and the sociodemographic and labor variables included in the study. it is noteworthy that females have higher gsl (p = 0.03), trait anxiety (p = 0.05), and state anxiety (p = 0.05) scores. participants who reported practicing no physical activities (p = 0.006) and those with complete higher education (p = 0.05) presented higher trait anxiety levels. regarding psychic-mental health follow-up, there was a significant difference between participants who received follow-up in their gsl (p = 0.003), wss (p = 0.008), and trait anxiety (< 0.001) scores. table 5. the association between stress and anxiety according to nursing professionals’ sociodemographic and occupational variables. porto alegre, rio grande do sul, brazil, 2022 variable gsl wss trait anxiety state anxiety   mean sd mean sd mean sd mean sd sex female 2.22 0.91 1.91 0.68 38.40 10.10 40.69 10.67 male 1.77 0.62 1.77 0.73 34.04 8.79 36.29 9.03 p-value 0.03 0.27 0.05 0.05 education high school 2.02 0.81 1.73 0.59 35.64 9.05 38.43 9.93 incomplete higher education 2.33 1.14 1.91 0.73 36.10 9.16 38.86 10.36 complete higher education 2.34 0.96 2.20 0.72 42.13 10.30 43.78 9.30 specialization 2.13 0.80 1.93 0.72 38.69 10.28 40.92 11.30 master’s/doctorate 2.10 0.62 1.86 0.76 41.00 12.55 41.15 12.95 p-value 0.65 0.08 0.05 0.30 marital status married or with a partner 2.22 0.88 1.90 0.66 38.62 10.50 40.91 11.01 without a partner 2.03 0.89 1.85 0.74 36.16 8.91 38.42 9.49 p-value 0.14 0.46 0.13 0.19 family income up to brl 2,500 3.18 0.66 2.81 1.25 49.33 8.08 49.33 1.15 brl 2,501 to brl 4,500 2.27 1.09 1.94 0.67 36.70 8.34 39.30 9.01 brl 4,501 to brl 6,500 2.11 0.81 1.81 0.65 37.43 10.75 40.43 10.83 more than brl 6,500 2.05 0.77 1.86 0.69 38.21 10.36 39.77 11.44 p-value 0.23 0.32 0.20 0.34 physical activity no 2.36 0.92 1.89 0.64 39.48 9.96 41.29 10.79 yes 1.86 0.74 1.87 0.75 35.37 9.66 38.31 9.99 p-value < 0.001 0.56 0.006 0.12 smoker yes 2.45 1.19 1.88 0.64 39.69 9.65 42.81 8.17 p-value 0.41 0.89 0.37 0.18 alcoholic beverages yes 2.23 0.95 1.93 0.69 38.05 11.03 41.04 10.79 p-value 0.54 0.54 0.94 0.43 stimulating beverages yes 2.22 0.90 1.90 0.70 37.50 9.96 40.25 10.52 p-value 0.16 0.68 0.56 0.64 professional category nurse 2.08 0.74 1.91 0.70 39.79 10.66 40.90 11.46 nursing assistant 2.08 0.96 1.82 0.59 35.21 8.91 38.66 10.13 nursing technician 2.23 0.95 1.89 0.72 37.36 9.81 39.98 10.13 p-value 0.70 0.96 0.13 0.85 work shift in the institution morning 2.31 0.93 2.02 0.73 38.17 9.48 40.39 10.29 afternoon 2.17 0.87 1.87 0.74 39.62 9.99 41.39 10.49 night 1.92 0.85 1.73 0.56 34.08 9.58 37.65 11.00 intermediate 1.76 0.59 1.74 0.74 36.00 21.21 38.50 19.09 weekends and holidays 2.13 0.83 1.82 0.47 38.13 11.39 38.75 9.16 p-value 0.28 0.43 0.11 0.64 professional with more than one job yes 2.06 0.79 1.70 0.72 37.58 11.81 38.77 12.48 p-value 0.67   0.08   0.53   0.25   physical health problema no 2.09 0.86 1.82 0.68 37.30 9.87 39.43 10.55 yes 2.36 0.93 2.08 0.68 39.13 10.45 41.90 10.40 p-value 0.08 0.02 0.38 0.17 psychic-mental follow-up no 2.04 0.86 1.80 0.65 36.19 9.54 38.87 10.24 yes 2.49 0.88 2.15 0.76 42.69 9.98 43.72 10.73 p-value 0.003 0.008 < 0.001 0.12 source: prepared by the authors. in the poisson regression model, for each year of experience in nursing, a 0.97 times lower prevalence of trait anxiety in the moderate-high levels was found compared to professionals with low levels of anxiety. psychic-mental health follow-up had a 1.97 times higher prevalence of trait anxiety in the moderate-high levels compared to the low levels (table 6). table 6. multivariate analysis between anxiety and sociodemographic and labor variables. porto alegre, rio grande do sul, brazil, 2022 variables pr* p [ci 95 % pr] trait anxiety time working in nursing in years 0.97 0.037 0.94 1 psychic-mental follow-up 1.97 0.001 1.32 2.93 state anxiety sex (male) 0.54 0.078 0.27 1.07 age 1.04 0.062 1 1.08 education incomplete higher education 1.21 0.495 0.7 2.08 complete higher education 2.26 0.001 1.37 3.71 specialization 1.49 0.151 0.86 2.57 master’s/doctorate 1.01 0.986 0.44 2.33 time working in nursing in years 0.97 0.14 0.92 1.01 psychic-mental follow-up 1.35 0.117 0.93 1.98 alcoholic beverages 1.3 0.156 0.91 1.86 hours of sleep 0.92 0.166 0.83 1.03 * pr: prevalence ratio, calculated through multivariate poisson regression; ci: confidence interval. source: prepared by the authors. nursing professionals with complete higher education had a 2.26 times higher prevalence of state anxiety than those with high school education. in turn, the male sex and hours of sleep also showed a trend of 0.54 and 0.92 times lower prevalence of state anxiety in the moderate-high levels, respectively (table 6). discussion the present study evaluated state-trait anxiety levels and their correlation with occupational stress in nursing professionals working in inpatient units. this study found a positive correlation between occupational stress and state-trait anxiety in this group of nursing professionals. a similar study conducted in turkey found a statistically significant positive correlation between anxiety and depression scores and perceived stress scores (r = 0.487, p = 0.001; r = 0.537, p = 0.001, respectively) in healthcare professionals (17). the nursing professionals in this study had a higher prevalence of muscle pain and anxiety as manifestations of stress, which aligns with the literature (18, 19). a study conducted in denmark found that high stress was consistently associated with a greater probability of lower back pain episodes in healthcare professionals (moderate stress: or [odds ratio] = 1.44, 95 % ci = 1.12-1.86; high stress: or = 2.30, 95 % ci = 1.61-3.29 [20]). another study carried out in jordan indicated that anxiety was significantly associated with increased cumulative trauma disorders in the shoulder (β = 0.10; p = 0.003) and wrist (β = 0.08; p = 0.003 [19]). a study conducted in a hospital in guangxi city, china, with 180 nursing professionals identified a positive correlation between the dimensions of stress load and total anxiety score (r = 0.676; 95 % ci = 0.667 and 0.663), which indicates that the higher the stress load, the higher the total anxiety score; therefore, anxiety can be considered a significant factor affecting nurses’ stress load (21). in the present study, a similar correlation was found, which supports the relationship between the stress and anxiety variables regarding the physical and psychological impact caused by the covid-19 pandemic. this study found that participants who stated they did not practice physical activities had higher levels of trait anxiety, corroborating the findings of the study conducted with nurses in hong kong, which found a significant association between anxiety symptoms and physical inactivity (or = 2.658; 95 % ci = 1.833-3.854 [22]). the same study revealed that nurses who reported having poor physical health were 2.9 times more likely to have anxiety symptoms than those who reported having good physical health (22). the results presented here are consistent with those found in previous studies (23-25), which have shown that women are more prone to develop sleep disorders (or = 1.36; 95 % ci = 1.00-1.86; p = 0.04) and moderate/high levels of anxiety (or = 1.96; 95 % ci = 1.45-2.64; p = 0.0001) than men (25). the present study showed that nurses working in inpatient units with higher levels of education had higher levels of anxiety when compared to those professionals with a medium level of education. a similar study conducted in bangladesh found that nurses were significantly associated with lower scores on the anxiety and stress subscale (p < 0.001) compared to nursing professionals with a master’s degree (26). a study in greece reported that nurses with graduate degrees were 3.44 and 4.24 times more likely to experience anxiety symptoms than nursing assistants. these findings may be attributed to the level of responsibility, professional expectations, and self-assessment processes in the professional practice of nurses who have attained a higher level of education, which creates a predisposition to anxiety (27). in this sample, women had higher anxiety and stress scores than men, which is consistent with the prevalence of anxiety disorders being twice as high in women in the general population (25). the results of a recent study demonstrated a significant difference in the levels of psychological symptoms for anxiety, depression, and stress among nurses, being more prevalent in female nurses than in male nurses (26). in the context of the covid-19 pandemic, several authors suggest that exposure to stressful conditions and adverse work experiences may lead to an increased risk of psychological effects associated with progressive deterioration in mental health among healthcare professionals (26, 28). although several studies describe the increase in anxiety associated with the length of experience described in healthcare professionals and especially in nurses (19, 21, 22), this study found that having experience in nursing reduces the prevalence of anxiety by 0.97 times. in this sense, a study carried out in israel reported that nurses with more years of professional experience had better subjective health (β = 0.086; p = < 0.01 [29]). however, the multivariate analysis of a study in greece showed that work experience in nursing did not emerge as a significant predictor of elevated anxiety symptoms (27); these findings may indicate the importance of further research on the theme. while the study has achieved its objective, the data should be viewed in light of some limitations. first, the cross-sectional design hinders adequately assessing causal relationships. second, the present study used self-administered psychometric instruments, in which responses may have been influenced by social and institutional desirability. finally, the sample belongs to a single healthcare institution, which may limit the generalizability of the data. the present study provides evidence of the prevalence of anxiety and stress in nursing professionals working in inpatient units and its multifactorial. it has been proven that the interaction of some factors assessed in anxiety and stress symptomatology presents similar properties between the study population and nursing professionals in other contexts. based on the data identified, the need to establish complementary interventions in the work environment to address such factors comprehensively is restated. conclusions this study has shown that nurses working in inpatient units had moderate trait anxiety, state anxiety, and workplace stress. the main stress symptoms were muscle pain and anxiety; furthermore, a directly proportional correlation exists between the stai and wss. in turn, years of nursing experience had a positive association with trait anxiety, while psychic-mental health follow-up had a negative association with it. the main factors that tended to increase state anxiety were having completed higher education, not practicing physical activities, and psychic-mental health follow-up. however, other factors such as being male, having experience in nursing, and hours of sleep showed a tendency towards reducing state anxiety. finally, this study’s results suggest a psychosocial risk condition and the need to develop strategies to prevent health problems for nursing professionals. acknowledgements we are grateful to the bolsa brasil program (programa de alianças para educação e capacitação [paec] edital organização dos estados americanos [oas]-grupo coimbra de universidades brasileiras [gcub] 001/2017), under the cooperation agreement between the oea and the gcub, and to the graduate nursing program of the universidade federal do rio grande do sul, brazil. conflict of interest: none declared. references 1.   salari n, khazaie h, hosseinian-far a, khaledi-paveh b, kazeminia m, mohammadi m et al. the prevalence of stress, anxiety and depression within front-line healthcare workers caring for covid-19 patients: a systematic review and meta-regression. hum resour health. 2020;18(100). doi: https://doi.org/10.1186/s12960-020-00544-1 2.   sadock bj, sadock va, ruiz p. compêndio de psiquiatria. 11a ed. porto alegre: artmed; 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99(26). doi: https://doi.org/10.1097/md.0000000000020769 25. simonetti v, durante a, ambrosca r, arcadi p, graziano g, pucciarelli g et al. anxiety, sleep disorders and self-efficacy among nurses during covid-19 pandemic: a large cross-sectional study. journal of clinical nursing. 2021;30(9-10). doi: https://doi.org/10.1111/jocn.15685 26. chowdhury sr, sunna tc, das dc, kabir h, hossain a, mahmud s et al. mental health symptoms among the nurses of bangladesh during the covid-19 pandemic. middle east curr psychiatry. 2021;28(23). doi: https://doi.org/10.1186/s43045-021-00103-x 27. tsaras k, papathanasiou i, vus v, panagiotopoulou a, katsou ma, kelesi m et al. predicting factors of depression and anxiety in mental health nurses: a quantitative cross-sectional study. med arch. 2018;72(1):62-7. doi: https://doi.org/10.5455/medarh.2017.72.62-67 28. khanal p, devkota n, dahal m, paudel k, joshi d. mental health impacts among health workers during covid-19 in a low resource setting: a cross-sectional survey from nepal. global health. 2020;16(89). doi: https://doi.org/10.1186/s12992-020-00621-z 29. kagan m. social support moderates the relationship between death anxiety and psychological distress among israeli nurses. psychological reports. 2020;124(4):1502-14. doi: https://doi.org/10.1177/0033294120945593 home cerrar 48 aquichan issn 1657-5997 fernanda maria do carmo da silveira neves de oliveira2 emiliane cunha ferreira3 neide angelica rufino4 maria da soledade simeão dos santos5 educação permanente e qualidade da assistência à saúde: aprendizagem significativa no trabalho da enfermagem1 1 trabalho de conclusão da disciplina seminário de metodologia do ensino de enfermagem da eean/ufrj – 2010/1. 2 especialista em enfermagem pediátrica e em enfermagem oncológica. enfermeira da unidade de terapia intensiva pediátrica do instituto fernandes figueira. brasil. fmcsno@yahoo.com.br 3 enfermeira. suplente da gerência de enfermagem e precetora do instituto de psiquiatria da universidade federal do rio de janeiro, brasil. 4 enfermeira. gerente do programa de resíduos do instituto de psiquiatria da universidade federal do rio de janeiro, brasil. 5 doutora em enfermagem. docente da universidade federal do rio de janeiro, escola de enfermagem anna nery, brasil. recibido: 01 de noviembre de 2009 aceptado: 28 de marzo de 2011 resumo este trabalho tem como objeto a educação permanente na prática de enfermagem. atualmente, há uma preocupação com a mudança da estrutura de ensino e a aplicação das metodologias ativas para capacitar profissionais de saúde. refletimos sobre o cotidiano da enfermagem e as atuais maneiras de subsidiar/fornecer informações técnico-científicas ao enfermeiro na prática hospitalar, visando enriquecer a assistência de enfermagem através da educação permanente. objetivamos descrever as práticas transformadoras aplicadas pelo enfermeiro assistencial como elemento facilitador do processo ensino-aprendizagem. trata-se de uma revisão integrativa, realizada nas bases de dados informatizadas. para tanto, a seleção dos textos atenderam aos critérios de inclusão e exclusão, resultando em 50 artigos científicos. a educação permanente emergiu recentemente como um método em saúde, sendo indispensável para as práticas de formação, atenção, gestão, formulação de políticas públicas e controle social, estabelecendo uma integralidade do cuidar, e em conseqüência, transformar e interagir saberes e prática, no cenário real do público alvo. concluímos que a motivação para atualizarmos permanentemente a prática profissional da equipe de enfermagem prevê a aplicação de um instrumento interdisciplinar de resolutividade que promova a visibilidade das ações pelos clientes e suas famílias. palavras-chave enfermagem, educação em enfermagem, qualidade da assistência à saúde, educação em saúde. (fonte: decs). año 11 vol. 11 nº 1 chía, colombia abril 2011 l 48-65 49 educação permanente e qualidade da assistência à saúde l fernanda maria do carmo da silveira neves de oliveira, emiliane cunha ferreira et al. educación permanente y calidad de la asistencia a la salud: aprendizaje significativo en el trabajo de enfermería resumen el objetivo de este artículo es analizar la educación permanente en la práctica de la enfermería. en la actualidad, existe preocupación por los cambios introducidos en la estructura de enseñanza y la aplicación de metodologías activas para capacitar profesionales de salud. en el artículo se reflexiona sobre aspectos cotidianos de la enfermería y la manera actual de suministrar o proporcionar información tecnocientífica al enfermero durante la práctica en el hospital, tratando de enriquecer la asistencia de enfermería mediante la educación permanente. se describen las prácticas trasformadoras aplicadas por el enfermero asistencial como elemento facilitador del proceso enseñanza-aprendizaje. se lleva a cabo una revisión amplia de las bases de datos informáticas. en consecuencia, la selección de los textos se basa en los criterios de inclusión y exclusión, y dio origen a 50 artículos científicos. en años recientes, la educación permanente se introdujo como un método en el área de la salud, convirtiéndose en un aspecto indispensable en las prácticas de formación, atención, gestión, formulación de políticas públicas y control social. así se estableció la idea de cuidado total y se trasformaron e integraron los saberes y las prácticas en el ámbito real del público al que va dirigido. se concluye que la motivación para actualizar permanentemente la práctica profesional del equipo de enfermería prevé la aplicación de un instrumento interdisciplinario de solubilidad que promueva la visibilidad de las acciones por los clientes y sus familias. palabras clave enfermería, educación em enfermería, calidad de la asistencia a la salud, educación en salud. (fuente: decs). 50 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 continuing education and the quality of health care: meaningful learning in nursing practice abstract the objective of this article is to analyze continuing education in nursing practice. there is concern nowadays about the changes introduced in the structure of teaching and the application of active methods to train health care professionals. the everyday aspects of nursing practice are examined, as is the way technological-scientific information now is being supplied to practicing nurses in hospitals, so as to enrich nursing care through continuing education. the transformative practices applied by nurse caregivers are described as an element that facilitates the teaching-learning process. there is a wide-ranging review of computer databases. consequently, the choice of texts is based on inclusion and exclusion criteria, giving rise to 50 scientific articles. recent years have seen the introduction of continuing education as a method in the field of health, having become an indispensable feature in practices for training, care, management, the development of public policy and social control. what has emerged is the concept of total care, with know-how and practices having been transformed and included in the real environment of those for whom they are intended. in conclusion, it is the motivation to continually up-date the professional practice of the nursing staff that provides for the application of an interdisciplinary instrument of solubility that makes actions more visible to clients and their families. key words nursing, nursing education, quality of health care, health education. (source: decs). 51 educação permanente e qualidade da assistência à saúde l fernanda maria do carmo da silveira neves de oliveira, emiliane cunha ferreira et al. introdução a enfermagem organiza-se enquanto profissão e expressa sua ação no cuidado ao indivíduo em diversas condições de saúde nos mais variados ambientes. para a expressão deste cuidado, observamos como necessário definir o marco para sua análise: a saúde. a saúde é um fenômeno multidimensional, com características individuais e coletivas, que envolve aspectos físicos, psicológicos e sociais da natureza humana. as multiplicidades de fatores que condicionam os aspectos destacados são objeto de preocupação do profissional de enfermagem, que vê o cuidar como mais que um ato, uma atitude (1). a educação não é apenas um processo institucional e instrucional, mas também um instrumento formativo do humano, seja na particularidade da relação pedagógica pessoal, seja no âmbito da relação social coletiva sem perder as referências éticas e políticas, tendo como premissa que o processo de formação de um sujeito ético, ou de um cidadão, vai depender da própria construção do sujeito humano (2). a preocupação em elaborar programas para capacitar a equipe de saúde nos levou a algumas reflexões sobre as questões atuais da educação permanente, considerando a necessidade de qualificação da assistência de enfermagem atrelada a um modelo transformador do cotidiano. a educação permanente em saúde constitui-se em estratégia fundamental às transformações do trabalho no setor para que venha a ser lugar de atuação crítica, reflexiva, compromissada e tecnicamente competente (3). atualmente, a educação permanente tem sido considerada uma importante ferramenta na construção da competência do profissional, contribuindo para a organização do trabalho. o principal desafio da educação permanente é estimular o desenvolvimento da consciência nos profissionais sobre seu contexto, pela sua responsabilidade em seu processo permanente de capacitação (4). a abordagem generalista na formação de auxiliares, técnicos e enfermeiros torna necessários os programas de capacitação em áreas específicas. a atualização técnicocientífica é apenas um dos aspectos da qualificação das práticas. a formação profissional engloba aspectos de produção de subjetividade, habilidades técnicas e de pensamento crítico sobre a prática exercida. a formação para a área da saúde deve ter como objetivo a transformação das práticas profissionais e da própria organização do trabalho, que permita a sua estruturação a partir da problematização do processo de trabalho e sua capacidade de dar acolhimento e cuidado às várias dimensões e necessidades de saúde das pessoas, dos coletivos e das populações. no campo das ações de saúde existe uma diversidade de modelos de educação em saúde que permite a aplicação dos métodos de ensino-aprendizagem ao reconhecimento da necessidade de renovação de conhecimentos na prática da assistência de enfermagem. diante desta afirmativa, definimos como objeto de estudo a educação permanente no âmbito da prática de enfermagem. a preocupação em elaborar programas para capacitar a equipe de saúde nos levou a algumas reflexões sobre as questões atuais da educação permanente, considerando a necessidade de qualificação da assistência de enfermagem atrelada a um modelo transformador do cotidiano. 52 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 a relevância do estudo está em estimular a reflexão sobre o desenvolvimento da capacidade de aprendizagem e necessária formação de um indivíduo crítico transformador de sua práxis, contribuindo para a melhoria contínua da qualidade do cuidado à saúde. o objetivo do estudo foi refletir sobre o processo de educação em saúde para a transformação do enfermeiro assistencial em um profissional facilitador do processo ensino-aprendizagem. método trata-se de uma revisão integrativa, realizada nas bases de dados informatizadas lilacs, medline, pubmed e scielo, além de consulta à bibliografia impressa. para guiar a revisão integrativa, formulou-se a seguinte questão: quais são as produções relacionadas à educação permanente em enfermagem? os critérios de inclusão dos artigos para esta revisão integrativa foram: artigos publicados em português e espanhol, com resumos disponíveis nas bases de dados selecionadas, no período entre maio e julho de 2010, que trouxessem a tona o objeto do presente estudo. foram critérios de exclusão: estudos que não tiveram relação a conceitos, métodos e finalidades deste estudo. iniciamos a pesquisa com a identificação das fontes documentais com posterior análise e levantamento das informações para reconhecimento das idéias sobre o objeto de estudo. a busca foi realizada tomando-se por base os descritores em ciências da saúde da biblioteca virtual em saúde. são eles: educação em enfermagem, educação em saúde, qualidade de assistência à saúde. após a identificação do conteúdo constante nas bases de dados, refinamos as buscas com artigos que trouxessem a temática: educação permanente, educação continuada, educação em serviço, qualidade na assistência, políticas públicas de saúde e sistema único de saúde. selecionamos 98 artigos e realizamos leitura exploratória para seleção dos textos para análise. a amostra final desta revisão integrativa foi de 50 artigos citados no estudo. a análise de dados foi realizada em duas etapas: na primeira foram identificados os dados de localização do artigo, autoria, objetivos, metodologia, principais resultados, utilizando observação rigorosa do estudo com base nas questões da pesquisa. na segunda etapa, analisamos os artigos, cujos resultados foram sintetizados pelo conteúdo acerca do conceito, do método, da finalidade e da base legal. buscamos a problematização da pesquisa a partir das referências publicadas com sucessiva análise e reflexão sobre suas contribuições para a construção do saber em enfermagem. durante a reflexão correlacionamos o processo ensino-aprendizagem no cotidiano da prática de enfermagem com a melhoria da qualidade da assistência prestada. política nacional de educação permanente para entendermos as questões que envolvem hoje a educação permanente na área da saúde, verificamos através da história que este não é um processo atual. a educação em saúde vem sofrendo atualizações ao longo dos tempos através de discussões em conferências, na busca de melhoria da qualidade dos serviços de saúde. a relevância do estudo está em estimular a reflexão sobre o desenvolvimento da capacidade de aprendizagem e necessária formação de um indivíduo crítico transformador de sua práxis, contribuindo para a melhoria contínua da qualidade do cuidado à saúde. 53 educação permanente e qualidade da assistência à saúde l fernanda maria do carmo da silveira neves de oliveira, emiliane cunha ferreira et al. a preocupação com a educação dos profissionais de saúde vem sendo referendada desde a iii conferência nacional de saúde em 1963, onde diz que “o adestramento de pessoal técnico, o aperfeiçoamento e a especialização de profissionais que se dedicam ao trabalho sanitário, representam tópico de relevo no programa executado pelo ministério da saúde” (5). a iv conferência nacional de saúde, intitulada recursos humanos para as atividades de saúde, expõe a importância do profissional de saúde como recurso que deve ser desenvolvido para promover o progresso e o bem-estar social (6): a tese de que o homem...deve ser considerado um recurso econômico com que pode contar a sociedade para o seu desenvolvimento, o que ganha cada vez maior aceitação. diferentemente, porém dos demais recursos, toca especialmente ao homem a tarefa de promover o progresso e o bem-estar social, e sua atuação será tanto mais adequada quanto sua utilização. a saúde, um elemento integrante do bem-estar humano, além de ser meta, é principalmente, e acima de tudo, um poderoso fator de desenvolvimento. a educação em serviço foi o primeiro conceito posto em marcha de acordo com as conferências nacionais de saúde, como forma de ajustamento dos profissionais às necessidades de saúde nos serviços públicos, principalmente nas décadas de 60 e 70 (7). a educação em serviço constitui-se em um conjunto de práticas educacionais planejadas com a finalidade de ajudar o funcionário a atuar mais eficazmente para atingir diretamente os objetivos da instituição (8). com a regulamentação do sistema único de saúde (sus), através da lei 8080/90, tornou-se indispensável a organização de processos educativos para atender a implantação dos princípios de integralidade do sus (9). a partir desta normatização, surgem vários programas, um conceituado como “educação continuada”, na prática da enfermagem, com a finalidade de capacitar a equipe para atender às necessidades da população. a educação continuada foi conceituada como o conjunto de experiências subseqüentes à formação inicial, que permitem ao trabalhador manter, aumentar ou melhorar sua competência, para que esta seja compatível com o desenvolvimento de suas responsabilidades, caracterizando, assim, a competência por atributo individual (10). é um conjunto de práticas educativas contínuas, destinadas ao desenvolvimento de potencialidades, para uma mudança de atitudes e comportamentos nas áreas cognitiva, afetiva e psicomotora do ser humano, na perspectiva de transformação de sua prática (11). a organização panamericana de saúde (ops) normatiza a educação contínua como um processo dinâmico de ensinoaprendizagem, ativo e permanente, destinado a atualizar e melhorar a capacidade de pessoas, ou grupos, face à evolução científico-tecnológica, às necessidades sociais e aos objetivos e metas institucionais (12). em 1980, por inspiração freireana, emerge o conceito de competência processual, incluindo tanto as experiências de nível individual quanto coletiva. esta abordagem contribuiu para a ampliação do conceito de educação permanente (ep), orientada para enriquecer a essêna organização panamericana de saúde (ops) normatiza a educação contínua como um processo dinâmico de ensino-aprendizagem, ativo e permanente, destinado a atualizar e melhorar a capacidade de pessoas, ou grupos, face à evolução científico-tecnológica, às necessidades sociais e aos objetivos e metas institucionais. 54 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 cia humana e suas subjetividades em qualquer etapa da existência de todos os seres humanos e não somente de trabalhadores. esta parece ser a ótica atual do ministério da saúde (ms), pois a escolha da terminologia educação permanente é dada como justificativa para integrar as múltiplas abordagens pretendidas (13). visando atender a uma demanda de consolidação do sus, através da transformação do profissional em sujeito, em fevereiro de 2004 foi instituída a política nacional de educação permanente, através da portaria 198/gm/ms (14) com a finalidade de formar e capacitar profissionais da saúde para atenderem às reais necessidades da população. a educação serve, então, como proposta de mudança dos serviços de saúde, contínua, válida e atual, motivando a ação de trabalhadores, gestores e usuários do sus (15). assim, a ep ao mesmo tempo que disputa a atualização cotidiana das práticas, se insere em uma necessária construção de relações e processos que vão do interior das equipes em atuação conjunta, implicando seus agentes e as políticas nas quais se inscrevem os atos de saúde (16). o governo federal adotou a política de educação permanente como estratégia fundamental para a recomposição das práticas de formação, atenção, gestão e controle social no setor da saúde, criando em 2003 o departamento de gestão da educação na saúde e instituindo em 2004, os pólos de educação permanente (14, 17). a discussão sobre a ep dos profissionais passa a ser fundamental e estratégica para a consolidação do sus. o plano de reordenação política de recursos humanos no sus preconiza a ep no trabalho visando alcançar perfis profissionais orientados pelas necessidades da população em cada realidade regional e em cada nível de complexidade. a educação permanente parte do pressuposto que a aprendizagem deva ser significativa. os processos de capacitação do pessoal da saúde devem ser estruturados a partir da problematização do processo de trabalho, visando a transformação das práticas profissionais e a organização do trabalho, tomando como referência as necessidades de saúde das pessoas e das populações, da gestão setorial e o controle social em saúde (14). o programa de educação permanente do ministério da saúde (17) (plano anual de capacitação) está direcionado para o desenvolvimento do servidor seguindo as diretrizes das políticas de educação para o setor saúde e da política nacional de desenvolvimento de recursos humanos. internamente, se divide em quatro níveis de atenção: básico – disseminação de conhecimentos gerais exigíveis para todos os servidores, em especial, temas relacionados à estrutura e ao funcionamento do ms; específico – conhecimentos, informações e habilidades exigíveis para operação dos sistemas produtivos próprios de cada área de atuação; gestão –desenvolvimento de competências para gestão de processos e pessoas; avançado –investimento na geração de oportunidades de aprendizagem em áreas estratégicas. em cada nível de atenção deverão priorizar-se ações que contemplem os aspectos institucional, tecnológico e comportamental como foco da aprendizagem, propiciando o desenvolvimento das competências pessoais e profissionais requeridas para o desempenho da força de trabalho do ms. os processos de capacitação do pessoal da saúde devem ser estruturados a partir da problematização do processo de trabalho, visando a transformação das práticas profissionais e a organização do trabalho, tomando como referência as necessidades de saúde das pessoas e das populações, da gestão setorial e o controle social em saúde. 55 educação permanente e qualidade da assistência à saúde l fernanda maria do carmo da silveira neves de oliveira, emiliane cunha ferreira et al. a ep tem como pressuposto a utilização da aprendizagem significativa (que promove e produz sentido) e propõe a transformação das práticas profissionais baseadas na crítica sobre as reais atividades executadas na rede de serviços. a atualização técnico-científica é apenas um aspecto da transformação das práticas e não seu foco central. a formação e o desenvolvimento das pessoas envolvem aspectos de produção de subjetividade, de habilidades técnicas e de conhecimento do sus (18). a criação de um setor voltado especificamente à educação e formação de recursos humanos no ms emergiu da constatação de que os modelos de capacitação se limitavam a introduzir mudanças pontuais nas instituições, relacionados a problemas locais. isto ocorreu porque se constatou que o modelo de educação continuada com enfoque em temas, praticado de forma fragmentada, voltado apenas para a atualização técnico-científica e utilizando a pedagogia da transmissão e memorização de conhecimentos, reproduzia os vieses negativos da formação tradicional, contribuindo para a manutenção dos modelos hegemônicos, ao invés de favorecer mudanças significativas das práticas, da gestão e do controle social (19). da educação continuada à educação permanente: expectativas de mudanças da prática de enfermagem é imprescindível neste estudo conhecer a definição da palavra educação, que se constitui no ato de educar (20), uma ação de desenvolvimento das faculdades psíquicas, intelectuais e morais (21). no cenário da enfermagem, podemos relacioná-la com o conceito de educação profissional, que enfatiza a atividade processual que tem a função de desenvolver e aperfeiçoar o próprio exercício das funções. a relação do homem com a educação é conhecida desde nossa longínqua história existencial. aprendemos com o meio social, cultural e profissional a estabelecer relações com a natureza; produzir técnicas, artes, folclore, crenças; organizar-se politicamente e economicamente; desenvolver a moral, seus costumes, filosofia, sua ciência etc. (22) no contexto da prática e do necessário desenvolvimento profissional, a questão educativa pode ser percebida em diferentes vertentes e situações como: educação permanente (ep), educação continuada (ec) e educação em serviço (es) (11). a ec destaca-se como um conjunto de práticas educacionais que visam melhorar e atualizar a capacidade funcional do indivíduo no trabalho, favorecendo seu desenvolvimento e a sua participação eficaz na vida institucional (23). foi caracterizada como qualquer aprendizagem, formal ou informal, promovida a partir da primeira graduação (24). constitui-se como um conjunto de práticas educativas contínuas, destinadas ao desenvolvimento de potencialidades nas áreas cognitiva, afetiva e psicomotora do ser humano, na perspectiva de transformação de sua prática. esta modalidade de educação apresentou-se como um veículo para que os enfermeiros respondessem as rápidas mudanças no conhecimento, aperfeiçoando seu desempenho no cuidado à saúde, mas também contribuindo para a elevação dos padrões profissionais de sua prática (25). a atualização técnico-científica é apenas um aspecto da transformação das práticas e não seu foco central. a formação e o desenvolvimento das pessoas envolvem aspectos de produção de subjetividade, de habilidades técnicas e de conhecimento do sus. 56 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 em concordância com essas idéias, a ec é pautada pela concepção de educação como transmissão de conhecimento e pela valorização da ciência como fonte do conhecimento, é pontual, fragmentada e construída de forma não articulada à gestão e ao controle social, com enfoque nas categorias profissionais e no conhecimento técnico-científico de cada área, com ênfase no diagnóstico de necessidades individuais. se coloca na perspectiva de transformação da organização em que está inserido o profissional (26). das vantagens que emergem da es e da ec temos um profissional esclarecido, mesmo que com déficit na integralidade e resolutividade dos problemas de saúde. para atender a estas demandas, no contexto atual é necessário que ocorram profundas transformações na política de formação dos profissionais de saúde orientada pelos princípios do sus. a introdução da ep na saúde seria estratégia fundamental para a recomposição das práticas de formação, atenção, gestão, formulação de políticas e controle social no setor da saúde, estabelecendo ações intersetoriais oficiais e regulares integrados com o setor da educação, submetendo os processos de mudança na graduação, nas residências, na pós-graduação e na educação técnica à ampla permeabilidade das necessidades/direitos de saúde da população e da universalização e eqüidade das ações e dos serviços de saúde (3). a ep constitui-se em um quadrilátero formado por diferentes atores do processo de trabalho: atenção, ensino, gestão e controle social que norteiam as ações. as propostas de mudanças nos processos de formação são construídas de forma circular considerando necessidades locais, buscando a articulação de diversos segmentos através da problematização (27). compõe-se de um conjunto de ações de promoção, prevenção e recuperação da saúde, articulado à apreensão ampliada e contextualizada das necessidades de saúde dos usuários e população e à organização dos serviços integrados em rede de atenção à saúde, com íntima articulação com as ações no trabalho em equipe interprofissional e interdisciplinar e na intersetorialidade (28). para ratificar a importância da ep no ambiente hospitalar, torna-se necessário retomar o processo de trabalho da enfermagem. as instituições hospitalares são sistemas complexos que absorvem grande parte dos profissionais da saúde e também disponibilizam empregos para diversos trabalhadores, que atuam na administração, higienização, manutenção, entre outras áreas. o trabalho, porém, se executa de forma fragmentada, o que intensifica a lacuna existente entre as ações desenvolvidas pelos profissionais de enfermagem, acarretando a compartimentalização da pessoa a ser cuidada (29). a ep é o encontro entre o mundo da formação e do trabalho, no qual o aprender e o ensinar incorporam-se ao cotidiano das organizações (30). do mesmo modo, a educação engloba os processos de ensinar e aprender, ou seja, é uma forma de transformar o indivíduo e a sociedade. seguindo a idéia da existência de educação, o quadro 1 explicita as principais diferenças na dinâmica da educação continuada e da educação permanente. a análise do quadro 1 leva a refletir sobre a ep que se estrutura a partir de dois elementos: as necessidades do proa educação permanente é o encontro entre o mundo da formação e do trabalho, no qual o aprender e o ensinar incorporamse ao cotidiano das organizações. do mesmo modo, a educação engloba os processos de ensinar e aprender, ou seja, é uma forma de transformar o indivíduo e a sociedade. 57 educação permanente e qualidade da assistência à saúde l fernanda maria do carmo da silveira neves de oliveira, emiliane cunha ferreira et al. cesso de trabalho e o processo crítico como inclusivo ao trabalho. comparativamente, a ec envolve atividades de ensino com duração definida e metodologia tradicional. a ep segue uma proposta de processo educativo dinâmico, dialógico e contínuo, de revitalização e superação pessoal e profissional, de modo individual e coletivo, buscando qualificação, postura ética, exercício da cidadania, conscientização, reformulação de valores, construindo relações integradoras entre os sujeitos para uma práxis crítica e criadora (31). o ms normatizou a ep como estratégia para a transformação das práticas de formação, de atenção, de gestão, de formulação de políticas, de participação popular e de controle social no setor da saúde. a ep se baseia na aprendizagem significativa. a possibilidade de transformar as práticas profissionais existe porque perguntas e respostas são construídas a partir da reflexão de trabalhadores e estudantes sobre o trabalho que realizam ou para o qual se preparam. a ep pode ser entendida como aprendizagem-trabalho, ou seja, ela acontece no cotidiano das pessoas e das organizações. origina-se dos problemas enfrentados na realidade e leva em consideração os conhecimentos e as experiências prévias do indivíduo. a portaria gm/ms nº 1.996 de agosto de 2007 descreve as diretrizes para a ep, a saber (32): destina-se a públicos multiprofissionais; objetiva transformações das práticas técnicas e sociais; preocupa-se com os problemas cotidianos das práticas nas equipes de saúde; insere-se de forma institucionalizada no processo de trabalho, gerando compromissos entre os trabalhadores, gestores, instituições de ensino e usuários para o desenvolvimento institucional e individual; utiliza práticas pedagógicas centradas na resolução de problemas, geralmente por meio de supervisão dialogada e oficinas de trabalho realizadas, preferencialmente, no próprio ambiente de trabalho; é contínua dentro de um projeto de consolidação e desenvolvimento do sus. é primordial considerarmos a existência de diferentes concepções que devem orientar a prática educativa nas instituições de saúde. apesar das diferenças existentes entre os conceitos citados, entendemos que os métodos para a posta em prática da educação em serviço estão compreendidos em um argumento único de complementaridade. o quadrilátero da formação do profissional de saúde: ensino, gestão, atenção e controle social o relatório final da xi conferência nacional de saúde descreve que as políticas de informação, educação e comunicação devem estar voltadas para a promoção da saúde. as políticas devem abranger prevenção de doenças, educação para a saúde, proteção da vida, assistência curativa e reabilitação sob responsabilidade das três esferas do governo. recomendam utilizar pedagogia crítica que leve o usuário a ter conhecimento de seus direitos; dar visibilidade à oferta de serviços e ações de saúde do sus; motivar cidadãos a exercer os seus direitos (33). a partir dessas reflexões nasce o conceito do quadrilátero da formação. a qualidade da formação passa a resultar da apreciação de critérios de relevância para o desenvolvimento tecnoprofissional, o ordenamento da rede de atenção e a identidade com os usuários. o quadrilátero da formação para a área da saúde – ensino/gestão setorial/ práticas de atenção/controle social – nos remete à construção de caminhos desafiadores. propõe-se a construir e organizar uma educação responsável utilizando processos interativos e de ação na realidade para provocar mudanças, mobilizar caminhos, convocar protagonismos e detectar a paisagem interativa e móvel dos indivíduos, coletividades e instituições como cenário de conhecimento e invenções (34). assim, para discutirmos a qualidade na formação temos que retratar o discurso na questão central das políticas públicas de educação. a formação dos profissionais de saúde tem se mostrado alheia à organização da gestão setorial e ao debate critico sobre os sistemas que estruturam o cuidado em saúde. as instituições que formam os profissionais vêm mantendo um ensino dominado por modelos essencialmente conservadores, voltados para a educação que focaliza o domínio técnico-científico da profissão. a formação do profissional de saúde como um projeto educativo deve se estender pelos aspectos estruturantes de relações e práticas em todos os componentes de interesse ou relevância social que contribuam à elevação da qualidade da saúde da população (34). quando iniciamos a reflexão sobre o processo de trabalho das equipes e das organizações de saúde, percebemos a importância de englobar os cidadãos, como integrantes do sus, com uma função além da recebedora das ações, mas como participantes do processo de debate e decisão sobre a formulação, execução e avaliação da política nacional de saúde. essa participação, definida como controle social, confere ao sus uma característica singular: os usuários não são meros auxiliares mas sim parte integrante do processo decisório. 58 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 cabe ao sus e às instituições formadoras coletar, sistematizar, analisar e interpretar permanentemente informações oriundas da realidade, problematizar o trabalho das organizações de saúde e de ensino, e construir significados e práticas com orientação social, mediante a participação ativa dos gestores setoriais, formadores, usuários e estudantes. encontramos registros sobre a integração ensino-serviço, mas pouco sobre a relevância e necessidade de articulação entre ensino-serviço-gestão-controle social. ainda nos parece partes que funcionam de forma isolada pela incompreensão dos sujeitos e desarticulação na gestão dos processos. buscamos bases para descrever que o aspecto serviço deve revelar uma estrutura de condução das políticas, gerência do sistema e organização de conhecimentos do setor e não se deter apenas à noção de práticas de atenção. as informações relacionadas à atenção à saúde devem ser disseminadas às autoridades, aos usuários e aos serviços de saúde, na busca da produção de sentidos nos atos de cuidar, tratar e acompanhar, quer sejam problemas de saúde, quer sejam aspectos da promoção de melhor qualidade de vida. para compreensão destes fatores, entendemos que a educação deve ser a base deste processo de integração. destacamos que houve uma preocupação e esforço investidos em mudanças na educação básica brasileira nas últimas décadas, principalmente com a consolidação da constituição federal de 1988, e durante todo o período dos anos noventa, repleto de reformas educacionais (35). com a renovação da legislação, preocupou-se em direcionar regras para o público docente, sobressaindo então a lei de diretrizes e bases da educação nacional de n.9.394/96 (36) onde se torna necessário pensar a formação de um profissional que compreenda os processos humanos mais globais, seja ele um professor da educação infantil ou dos últimos anos da escola básica. a intenção é ter um profissional capaz de refletir sobre as seguintes indagações: como o indivíduo aprende na infância, na adolescência e na fase adulta? (37). ainda em 1990, a implantação do sus, através da promulgação da nova constituição e das leis orgânicas em 1990, suscitou discussão sobre as novas formas de abordar o processo saúde-doença, dentro de um contexto sócio-histórico-políticoeconômico que promoveu amplos debates por parte dos profissionais de saúde, governo e sociedade civil organizada (38). é preciso mencionar que desde a constituição de 1988 até a instituição da portaria 198/gm/ms, em 2004, houve uma evolução do modelo de normatização do currículo de ensino para profissionais de saúde. os educadores, ao trabalharem com a pedagogia dos projetos, presenciam uma forma de retirar os educandos da passividade, tornando-os mais ativos no processo de construção do conhecimento em um contexto dinâmico e fecundo de oportunidades, para que os alunos experimentem situações nas distintas áreas do conhecimento (39), entendendo que os fenômenos da vida e da saúde são altamente complexos (40). a interdisciplinaridade é, portanto, um desafio posto pela própria complexidade do processo saúde-doença, implicando no desenvolvimento da imaginação cuidadosa no processo do educar (41). a enfermagem é uma profissão da área de saúde cuja essência é o cuidado holístico ao ser a enfermagem se responsabiliza através do cuidado, pelo conforto, acolhimento e bem estar dos pacientes, seja prestando o cuidado, seja coordenando a prestação da assistência ou através da educação em saúde. 59 educação permanente e qualidade da assistência à saúde l fernanda maria do carmo da silveira neves de oliveira, emiliane cunha ferreira et al. humano. a enfermagem se responsabiliza através do cuidado, pelo conforto, acolhimento e bem estar dos pacientes, seja prestando o cuidado, seja coordenando a prestação da assistência ou através da educação em saúde (42). quanto ao elemento ensino, deve ser pensado como essencial para a produção do conhecimento em torno do processo saúde-doença, para a compreensão de como a sociedade responde frente a ele. a proposta é criar uma mudança do modelo biomédico da compartimentalização do cuidado ao cliente para um ensino de enfermagem com uma visão interdisciplinar, seguindo os preceitos do sus, e agindo em um cenário próprio do paciente. insere-se no componente do ensino o movimento estudantil, um ator político diferente no processo de formação possibilitarem a construção de inovações ao ensino (43). frente a essa situação, a enfermagem necessita de docentes qualificados para promover uma aprendizagem na qual o profissional assuma seu papel de protagonista no desenvolvimento da humanidade (40), que será refletido na forma como educamos para a saúde da população. no âmbito da gestão, as unidades de saúde organizam-se segundo múltiplos sistemas de autoridade e formas de poder profissional, cujo funcionamento exclui a referência para um conjunto bem definido de objetivos ou a uma única linha de direção (44). esse caminhar em direções opostas acentua o distanciamento entre a atuação profissional e as necessidades dos sus, já que os interesses não se relacionam. a produção do conhecimento, portanto não se volta para a atenção em saúde de seus usuários e não contribui para as transformações da prática, dado que não se integra com o objeto de trabalho. é necessária a organização da gestão setorial e a estruturação do cuidado à saúde que incorpore o aprender e o ensinar, formando profissionais da área da saúde para a efetiva posta em marcha do sus. colocar em evidência a formação para a área da saúde como estratégia para a construção da educação em serviço/educação continuada/educação permanente requer uma associação entre desenvolvimento individual e institucional, entre serviços e gestão setorial, e entre atenção à saúde e controle social. quando refletimos sobre a relação da educação dos profissionais com o trabalho no sus percebemos uma dicotomia que a relega à condição secundária, quando o verdadeiro objeto da educação em saúde vem a ser o desenvolvimento de uma atenção integral. por isso a prática educativa em saúde não se restringe às ações no campo da atenção primária. o referencial das concepções de saúde e de educação devem estar pautado no desenvolvimento das potencialidades humanas, na transformação da realidade, integradas aos direitos fundamentais da pessoa humana (45). a área de formação como um lugar não mais secundário, mas sim central e finalístico às políticas de saúde tornaria os trabalhadores em atores sociais das reformas de trabalho, das lutas pelo direito à saúde e do ordenamento de práticas acolhedoras e resolutivas de gestão à saúde. essa análise nos leva a contextualizar um novo desafio proposto por merhy (46): produzir auto-interrogação de si mesmo no agir produtor do cuidado e colocar-se ético-politicamente em discussão, no plano individual e coletivo, do trabalho. esta a enfermagem necessita de docentes qualificados para promover uma aprendizagem na qual o profissional assuma seu papel de protagonista no desenvolvimento da humanidade, que será refletido na forma como educamos para a saúde da população. 60 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 situação não pode ser considerada fácil, nem óbvia. e ainda, quando fala da pedagogia que possa estar articulada neste novo modo de se posicionar, o quadrilátero da formação é apontado como um dispositivo analisador que pode instituir uma nova lógica no agir do trabalhador cumprindo este núcleo do desafio. vários autores apóiam a necessidade de reforma das estratégias de atuação do sus, que vem sendo instituídas pela política nacional de educação. há necessidade de formar profissionais que atendam aos interesses públicos no cumprimento das responsabilidades de formação acadêmico-científica, ética e humanística, para o desempenho tecnoprofissional. é verdade que muitas iniciativas propiciam certo desenvolvimento de pensamento crítico e estimulam o fortalecimento por mudanças no processo de formação, mas diante do quadro atual de formação em nosso país, voltado para as habilidades técnicoprofissionais sem repensar a integralidade da atenção à saúde do indivíduo nos questionamos: estamos formando para quê? estamos formando para quem? o desafio da educação permanente para a qualidade na assistência de enfermagem com as mudanças ocorridas no cenário da prestação de serviços de saúde e no padrão de comportamento da sociedade, onde o cidadão começa a ter consciência política de seus direitos e deveres, cabe ao profissional de enfermagem refletir sobre sua prática para oferecer qualidade a sua assistência. o termo qualidade ou melhoria contínua da qualidade diz respeito a um fenômeno continuado de aprimoramento, que estabelece padrões, resultado dos estudos de séries históricas na mesma organização ou de comparação com outras instituições semelhantes, em busca do defeito zero. esta busca pelo efeito zero, embora não atingível na prática, orienta e filtra toda ação e gestão da qualidade. é também caracterizado como um processo dinâmico, ininterrupto e essencialmente cultural e desta forma envolve motivação, compromisso e educação dos participantes da entidade, que são assim estimulados a uma participação de longo prazo no desenvolvimento progressivo dos processos, padrões e dos produtos da entidade (47). a organização mundial da saúde definiu qualidade da assistência à saúde em função de um conjunto de elementos que incluem: um alto grau de competência profissional, a eficiência na utilização dos recursos, um mínimo de riscos, um alto grau de satisfação dos pacientes e um efeito favorável na saúde (48). diante destes elementos constitutivos da qualidade, destacamos como necessário que os profissionais de enfermagem desenvolvam ações de saúde com conhecimento, habilidade e competência, objetivando atender às expectativas dos clientes e alcançar a almejada qualidade assistencial (49). a ep como ferramenta auxiliar ao processo de qualificação utiliza como princípios: competência profissional, motivação organizacional e avaliação contínua, que serão alcançados a partir de uma transformação do profissional de saúde para atuar de forma crítica e reflexiva no seu cotidiano. o desafio da ep é estimular o desenvolvimento da consciência nos profissionais sobre o seu contexto, pela sua responsapara promover insumos para a ep, destaca-se como necessário reconhecer que as práticas rotineiras, descontextualizadas dos reais problemas, dificilmente permitirão o desenvolvimento da capacidade de reflexão. 61 educação permanente e qualidade da assistência à saúde l fernanda maria do carmo da silveira neves de oliveira, emiliane cunha ferreira et al. bilidade em seu processo permanente de capacitação. por isso, é necessária a revisão dos métodos utilizados nos serviços de saúde para que a ep seja, para todos, um processo sistematizado e participativo, tendo como cenário o próprio espaço de trabalho, no qual o pensar e o fazer são insumos fundamentais do aprender e do trabalhar. para promover insumos para a ep, destaca-se como necessário reconhecer que as práticas rotineiras, descontextualizadas dos reais problemas, dificilmente permitirão o desenvolvimento da capacidade de reflexão. pensar propostas inovadoras de ep supõe um desafio de gerenciar experiências de aprendizagem que interessem as pessoas envolvidas, que possibilitem elos no processo de compreensão e construção do conhecimento, que promovam modos de pensar inteligentes, criativos e profundos para favorecer o desenvolvimento pessoal e social, a capacidade reflexiva dos trabalhadores em serviço. esses processos devem permitir aos trabalhadores aprender, no complexo mundo contemporâneo, no contexto de uma aprendizagem solidária e democrática que oferece ao profissional o fortalecimento dos processos de crescimento pessoal e transformação no âmbito profissional. a autonomia na aprendizagem desenvolve a capacidade de aprender a aprender e a consciência da necessidade da formação permanente (4). considerações finais no mundo contemporâneo, percebemos necessário adquirir e aplicar os conhecimentos na área de educação, com bom senso, para promover o processo de aprendizagem, desenvolvendo habilidades para que os profissionais da saúde possam tornar-se facilitadores na transmissão de informações técnico-científicas. destacamos este aspecto por ter em mente a assistência de enfermagem, que exige diariamente do profissional a percepção das necessidades do cliente com o foco no cuidado do ser cidadão, que necessita interagir com equipe interdisciplinar. neste cenário específico da saúde, figura a ep como facilitadora para resolução dos déficits relacionados a compreensão dos problemas de saúde dos clientes, devido ao trabalho contínuo de integralidade realizada por enfermeiros motivados rumo a qualidade da assistência. este profissionalfacilitador construirá um saber apropriado para atender a sua clientela, sem perder o olhar de outras dimensões do cuidado, pois são “pessoas cuidando de pessoas”. com base neste estudo, integrado a vivências das autoras na área de enfermagem, consideramos que a educação permanente é um processo de capacitação necessário que permite o crescimento pessoal e intelectual para construção de um saber diversificado e resolutivo, diminuindo suas inquietações junto à prática cotidiana. este profissional promoverá informação de qualidade, sendo facilitador no aprendizado de sua equipe, cliente, família e comunidade. esta parceria de responsabilidade compartilhada do enfermeiro com os demais profissionais e clientela estabelecerá um melhor desempenho profissional, e consequentemente, mudanças que trarão benefícios para a instituição e os clientes. o processo educativo estabelecido através da educação permanente deverá contribuir para a construção de um modelo de assistência à saúde, no qual as adaptações do conhecimento possam ser incorporadas como uma nova visão e prática no trabalho em saúde (50). a educação permanente tem que provocar nos sujeitos e no seu cotidiano de produção do cuidado em saúde, transformação de sua prática, o que implicaria força de produzir a reflexão sobre si mesmo no agir, pela geração de problematização(51). a educação permanente deve trazer um olhar da integralidade para as ações da assistência/cuidado e contribuir para a articulação de estratégias da equipe multiprofissional na resolutividade de problemas do paciente, facilitando a transformação das práticas de ensino-aprendizagem na produção do conhecimento. 62 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 referências 1. henrique dcs, cavalheri sc, pavani mcm. educação permanente: perspectiva de capacitação do enfermeiro de centro de atenção psicossocial (caps). in: (re) construção de cenários na atenção básica em saúde. anais do 2º seminário nacional de diretrizes de enfermagem na atenção básica em saúde: 2009 ago 20-22; recife. recife: associação brasileira de enfermagem; 2009. p. 254-7. 2. reppetto ma, souza mf. avaliação da realização e do 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57(5):605-10 (19). aspectos educação continuada educação permanente público-alvo uniprofissional multiprofissional inserção no mercado de trabalho prática autônoma prática institucionalizada enfoque temas de especialidades problemas de saúde objetivo principal atualização técnico-científica transformação das práticas teóricas e sociais periodicidade esporádica contínua metodologia pedagogia da transmissão pedagogia centrada na resolução de problemas resultados apropriação mudança anexo 207 211 primeras paginas.indd 271 adalberto campo-arias1 gloria johanna bustos-leiton2 aristóbulo romero-chaparro3 consistencia interna y dimensionalidad de la escala de estrés percibido (eep-10 y eep-14) en una muestra de universitarias de bogotá, colombia 1 especialista en psiquiatría. instituto de investigación del comportamiento humano. bogotá, colombia. campoarias@comportamientohumano.org 2 especialista en promoción en salud y desarrollo humano. universidad colegio mayor de cundinamarca. bogotá, colombia. hannacay@gmail.com 3 especialista en promoción en salud y desarrollo humano. universidad colegio mayor de cundinamarca. bogotá, colombia. aromerochaparro@yahoo.com recibido: 30 de junio de 2009 aceptado: 7 de octubre de 2009 resumen objetivo. conocer la consistencia interna y la dimensionalidad de la escala de estrés percibido de 14 y 10 ítems (eep-14 y eep-10) en universitarias de bogotá, colombia. método. se diseñó un estudio de validación de una escala sin el uso de un criterio de referencia. participaron 175 mujeres mayores de 18 años, estudiantes de una universidad oficial. la media para la edad fue de 19,5 años (de=1,9). las participantes diligenciaron la eep-14 que incluye a la eep-10. para ambas versiones se determinó consistencia interna mediante la prueba de alfa de cronbach; se realizó análisis factorial confirmatorio mediante el método de máxima verosimilitud y rotación oblicua. resultados. la consistencia interna para la eep-14 fue 0,87; y la eep-10, 0,86. la eep-14 mostró dos factores (afrontamiento y percepción de estrés) que explican el 49,6% de la varianza; y la eep-10, un único factor que daba cuenta del 45,0% de la varianza. conclusiones. la eep-14 y la eep-10 muestran aceptable consistencia interna y estructura factorial en una muestra de estudiantes universitarias. es necesario corroborar estos hallazgos en otras poblaciones colombianas. palabras clave estrés psicológico, estudiantes, mujeres, estudios de validación. (fuente: decs, bireme). año 9 vol. 9 nº 3 chía, colombia diciembre 2009 271 280 272 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 internal consistency and dimensionality of the perceived stress scale (pss-10 and pss-14) in a sample of female university students in bogotá, colombia abstract purpose. identify the internal consistency and dimensionality of the 14-point and 10-point perceived stress scale (pss-14 and pss-10) in a sample of female university students from bogotá, colombia. method. the authors designed a validation study of a scale without the use of reference criteria. the sample included 175 women over age 18, all students at a public university. the average age was 19.5 years (de=1.9). the participants filled out the version of pss-14 that includes pss-10. cronbach’s alph was used to measure the internal consistency of both versions; a confirmatory factor analysis was done with the method of maximum likelihood and oblique rotation. results. the internal consistency for pss-14 was 0.87; for pss-10, it was 0.86. pss-14 showed two factors (coping and perception of stress) that explain 49.6% of the variance. pss-10 showed a single factor that explains 45.0% of the variance. conclusions. pss-14 and pss-10 show acceptable internal consistency and factor structure in a sample of female university students. these findings need to be corroborated in other colombian populations. key words psychological stress, students, women, validation studies. (source: decs, bireme). consistência interna e dimensionalidade da escala de estresse percebida (eep-10 eep14) em uma amostra de universitários em bogotá, colômbia resumo objetivo. conhecer a consistência interna e a dimensionalidade da escala de estresse percebido de 14 e 10 itens (eep-14 eep-10) em universitárias de bogotá, colômbia. método. projetamos um estudo para validar uma escala sem o uso de um critério de referência. participaram 175 mulheres com idade superior a 18 anos, estudantes de uma universidade pública. a média de idade foi 19,5 anos (dp = 1,9). os participantes preencheram a eep-14, que inclui o eep-10. para as duas versões, se aplicou o teste de consistência interna mediante o teste alfa de cronbach; se realizou análise fatorial confirmatória utilizando o método de máxima verossimilhança e rotação oblíqua. resultados. a consistência interna para a eep-14 foi 0,87, e a eep-10 foi 0,86. a eep-14 apresentou dois fatores (afrontamento e stress percebido) que explicam 49,6% da variância. o eep-10 apresentou apenas um fator que pode medir 45,0% da variância. conclusões. a eep-14 e a eep-10 mostram consistência interna e estrutura fatorial aceitáveis em uma amostra de estudantes universitárias. é necessário confirmar estes resultados em outras populações colombianas. palavras-chave estresse psicológico, estudantes, mulheres, estudos de validação. (fonte: decs, bireme). 273 consistencia interna y dimensionalidad de la escala de estrés percibido... adalberto campo-arias, gloria johanna bustos-leiton, aristóbulo romero-chaparro introducción en forma general, el estrés es una respuesta adaptativa física y psicológica ante las demandas y amenazas del entorno. las características de la respuesta guardan una relación importante con aspectos individuales, sociales y culturales que dan un aspecto particular a la experiencia percibida de cada persona (1). la escala de estrés percibido (eep) se diseñó con el propósito de conocer qué tan estresantes perciben las personas los eventos de la vida cotidiana (2). hay disponibles dos versiones de este instrumento, la versión original de 14 puntos (eep-14), y una versión más breve con diez puntos (eep-10) que omite los ítems 4, 5, 12 y 13 de la versión extensa. ambas versiones muestran excelente consistencia interna y estructura bidimensional en población de habla inglesa (2-5). en diferentes estudios la versión inglesa de catorce puntos mostró consistencia interna en el rango deseable entre 0,84 y 0,89 (2-4). una versión de catorce ítems en japonés alcanzó un coeficiente de alfa de cronbach de 0,74 en estudiantes de enfermería y de farmacia (4). la versión en español alcanzó un alfa de cronbach de 0,81 para la versión de catorce puntos; y 0,82, para la versión de diez puntos en una muestra heterogénea de adultos españoles, 52% de ellos eran estudiantes universitarios (5). en una muestra de estudiantes mexicanos de psicología, la escala mostró un coeficiente de alfa de cronbach de 0,83 (6). la estructura factorial de la versión de catorce ítems muestra dos factores, el primero para las frases positivas y el segundo para las frases negativas. la versión en inglés mostró datos disímiles. en un primer estudio se encontró que el primer factor era responsable del 25,9% de la varianza total, y el segundo, del 15,7% (3). en una investigación más reciente se observó que el primer factor explicaba el 42,7% de la varianza, y el segundo, el 11,1% (4). la versión en japonés mostró que el primer factor era responsable del 23,8% de la varianza, y el segundo, del 18,8% (4). la versión en español mostró una estructura bidimensional, el primer factor explicaba el 32,6% de la varianza total, y el segundo, el 15,4% (6). para la evaluación de constructos —como el estrés percibido—, que no cuenta con un criterio de referencia universalmente aceptado (gold standard), es necesario corroborar el comportamiento psicométrico en poblaciones con diferentes características (7). un desempeño psicométrico consistentemente favorable es una aproximación a la validez de la medición (8). la ees se utilizó para cuantificar estrés percibido en estudiantes colombianos de medicina; sin embargo, en esta investigación se omitió la información acerca del comportamiento psicométrico de la escala, y no se informó el alfa de cronbach en dicha población (9). de tal suerte que se desconocen las propiedades psicométricas de la ees en universitarios colombianos. el objetivo de esta investigación fue conocer la consistencia interna y realizar un análisis factorial confirmatorio de la eep en universitarias adultas de bogotá, colombia. método se diseñó un estudio de validación de una escala sin el uso de un criterio de referencia. las participantes dieron consentimiento informado escrito, de acuerdo con las normas el estrés es una respuesta adaptativa física y psicológica ante las demandas y amenazas del entorno. las características de la respuesta guardan una relación importante con aspectos individuales, sociales y culturales que dan un aspecto particular a la experiencia percibida de cada persona. 274 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 colombianas contenidas en la resolución 8430 para la investigación en salud. el proyecto lo aprobó un comité de ética de una institución de bogotá (10). características de la población participaron voluntariamente 175 universitarias estudiantes de bacteriología (carrera con un mayor porcentaje de mujeres), mayores de 18 años; la media para la edad de 19,5 años (de=1,9). por conveniencia, se tomaron estudiantes de primero, segundo y tercer semestre . esta muestra fue suficiente para calcular la consistencia interna y hacer un análisis factorial confirmatorio. se necesitaban por lo menos cien personas o diez personas por cada ítem de la escala (11, 12). instrumento las participantes diligenciaron la eep14 en el salón de clase. la ees-14 es una escala que consta de catorce puntos que evalúan la percepción de estrés durante el último mes. cada pregunta tiene un patrón de respuesta politómica de cinco opciones: nunca, casi nunca, de vez en cuando, a menudo y muy a menudo, que dan puntuaciones de cero a cuatro. sin embargo, los puntos 4, 5, 6, 7, 9, 10 y 13 tienen un patrón de puntuación reverso de cuatro a cero. da puntuaciones entre 0 y 56, a una mayor puntuación corresponde un mayor nivel de estrés percibido. la versión de diez puntos (eep-10) omite los puntos 4, 5, 12 y 13 y las puntuaciones posibles están entre 0 y 40 (2, 3). se usó, con permiso, la versión en español de remor con mínimas adaptaciones lingüísticas (5). la versión que se empleó se presenta en la tabla 1. análisis estadístico los datos se procesaron en el paquete paws statistics 17 (13). para cada ítem se determinó la media y la desviación estándar (de). para cada versión se estimó la correlación de pearson de cada ítem con la puntuación total (14), la consistencia interna de la escala mediante la prueba de alfa de cronbach, y la consistencia interna si el ítem se omitiera (15). se realizó un análisis factorial confirmatorio para conocer la estructura de factores, se calculó la prueba de esfericidad de bartlett (16) y la prueba de adecuación de la muestra kaiser-meyer-olkin (kmo) (17). la extracción de factores se realizó mediante el método de máxima verosimilitud; se determinaron comunalidades, autovalores y el porcentaje de varianza explicada. se realizó una rotación oblicua (promax) porque de antemano se pensaba que los factores estarían altamente correlacionados. se retuvieron los factores con valor propio superior a 1,41 (criterio de gorsuch) (18). se consideró que un ítem aportaba en forma significativa a un factor si mostraba un coeficiente mayor de 0,392 (criterio de stevens que considera el posible error en relación con el tamaño de la muestra) (19). se determinó la correlación entre los componentes o factores. finalmente, se estimó la bondad del ajuste de la estructura factorial (20). resultados eep-14 consistencia interna la confiabilidad hace alusión a la observación de puntuaciones similares si las condiciones de medición y el constructo la ees se utilizó para cuantificar estrés percibido en estudiantes colombianos de medicina; sin embargo, en esta investigación se omitió la información acerca del comportamiento psicométrico de la escala, y no se informó el alfa de cronbach en dicha población. 275 consistencia interna y dimensionalidad de la escala de estrés percibido... adalberto campo-arias, gloria johanna bustos-leiton, aristóbulo romero-chaparro nunca casi de vez a menudo muy nunca en cuando a menudo en el último mes, ¿con qué frecuencia ha estado afectado por algo que ha ocurrido inesperadamente? 0 1 2 3 4 en el último mes, ¿con qué frecuencia se ha sentido incapaz de controlar las cosas importantes en su vida? 0 1 2 3 4 en el último mes, ¿con qué frecuencia se ha sentido nervioso o estresado? 0 1 2 3 4 en el último mes, ¿con qué frecuencia ha manejado con éxito los pequeños problemas irritantes de la vida? 0 1 2 3 4 en el último mes, ¿con qué frecuencia ha sentido que ha afrontado efectivamente los cambios importantes que han estado ocurriendo en su vida? 0 1 2 3 4 en el último mes, ¿con qué frecuencia ha estado seguro sobre su capacidad para manejar sus problemas personales? 0 1 2 3 4 en el último mes, ¿con qué frecuencia ha sentido que las cosas le van bien? 0 1 2 3 4 en el último mes, ¿con qué frecuencia ha sentido que no podía afrontar todas las cosas que tenía que hacer? 0 1 2 3 4 en el último mes, ¿con qué frecuencia ha podido controlar las dificultades de su vida? 0 1 2 3 4 en el último mes, ¿con qué frecuencia se ha sentido que tenía todo bajo control? 0 1 2 3 4 en el último mes, ¿con qué frecuencia ha estado enfadado porque las cosas que le han ocurrido estaban fuera de su control? 0 1 2 3 4 en el último mes, ¿con qué frecuencia ha pensado sobre las cosas que le quedan por hacer? 0 1 2 3 4 en el último mes, ¿con qué frecuencia ha podido controlar la forma de pasar el tiempo? 0 1 2 3 4 en el último mes, ¿con qué frecuencia ha sentido que las dificultades se acumulan tanto que no puede superarlas? 0 1 2 3 4 tabla 1. escala de estrés percibido 276 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 se mantienen estables. la consistencia interna es una medida de confiabilidad que sugiere la homogeneidad de una escala, y estima la correlación que existe entre los ítems que hacen parte de ésta. dado que mide la correlación entre los ítems que forman un constructo, es una medida indirecta de la validez. se espera que el coeficiente se encuentre entre 0,70 y 0,90. si un ítem muestra baja correlación con el constructo, la eliminación del mismo mejora sustancialmente el coeficiente de consistencia interna. la consistencia interna para escalas dicotómicas se estima con la fórmula 20 de kuder-richardson, y para escala politómica con la prueba alfa de cronbach. la media y desviación estándar para cada ítem se presenta en la tabla 2. la consistencia interna de la escala fue 0,87. la correlación corregida entre cada ítem, la puntuación total y la consistencia interna si el ítem se omitiera se muestran en la tabla 3. dimensionalidad aunque una escala muestre un coeficiente de consistencia interna que sugiere alta homogeneidad, es necesario corroborar dicha homogeneidad (unidimensionalidad) mediante pruebas que muestren el número de dimensiones, dominios o factores latentes en un grupo de ítems. el análisis de factores es la prueba que se emplea para conocer la dimensionalidad de una escala. la prueba de kaiser meier olkin, y la prueba de la esfericidad de bartlett indican si es posible encontrar dimensiones en un grupo de ítems que aparentemente miden un mismo constructo. la prueba de esfericidad de bartlett mostró un chi-cuadrado = 833,2; grados de libertad = 91, p < 0,001, y la prueba de adecuación muestral de kaiser meyer olkin alcanzó un coeficiente de 0,898. en el análisis factorial confirmatorio se identificaron dos factores. el factor 1 (“afrontamiento de los estresores”) mostró un valor propio de 5,394 que explicaba el 38,5% de la varianza; y el factor 2 (“percepción de estrés”) alcanzó un valor propio de 1,556 que daba cuenta del 11,1% de la varianza. estos factores explicaban el 49,6% de la varianza. la correlación entre los factores fue r = 0,649. la prueba de bondad del ajuste mostró un chi-cuadrado = 73,1; grados de libertad = 64, p = 0,205. la matriz de coeficientes se presenta en la tabla 4. eep-10 consistencia interna la consistencia interna de la eep-10 fue 0,86. la correlación corregida entre cada ítem, y la puntuación total y la consistencia interna si el ítem se omitiera se muestran en la tabla 5. dimensionalidad la prueba de esfericidad de bartlett mostró un chi-cuadrado = 601,6; grados de libertad = 45, p < 0,001, y la prueba de adecuación muestral de kaiser meyer olkin presentó un coeficiente de 0,885. en el análisis factorial confirmatorio se identificó un único factor relevante, un valor propio de 4,499 que explicaba el 45,0% de la varianza. dado el hecho de este único factor, no era posible hacer rotación de la solución factorial, el cálculo de la correlación entre los factores y la estimación de una prueba de bondad del ajuste. la matriz de coeficientes se presenta en la tabla 6. todos los coeficientes alcanzaron valores superiores a 0,392. aunque una escala muestre un coeficiente de consistencia interna que sugiere alta homogeneidad, es necesario corroborar dicha homogeneidad (unidimensionalidad) mediante pruebas que muestren el número de dimensiones, dominios o factores latentes en un grupo de ítems. 277 consistencia interna y dimensionalidad de la escala de estrés percibido... adalberto campo-arias, gloria johanna bustos-leiton, aristóbulo romero-chaparro tabla 2. media y desviación estándar para cada ítem de la ees-14 ítem media de afectado 2,14 1,04 incapacidad 1,59 1,15 nerviosismo 2,95 0,88 éxito 1,32 0,68 afrontamiento efectivo 1,23 0,73 seguridad 1,13 0,79 cosas van bien 1,42 0,74 no afrontar 1,98 0,99 controlar dificultades 1,18 0,69 todo bajo control 1,74 0,78 enfado 2,21 0,99 cosas por hacer 3,17 0,87 pasar el tiempo 1,51 0,95 acumulación de dificultades 1,91 1,05 tabla 3. correlación corregida entre cada ítem, y la puntuación total y consistencia interna si el ítem se omitiera de la ees-14 ítem ccit* ciio** afectado 0,471 0,86 incapacidad 0,654 0,85 nerviosismo 0,565 0,85 éxito 0,439 0,86 afrontamiento efectivo 0,545 0,85 seguridad 0,535 0,85 cosas van bien 0,542 0,85 no afrontar 0,584 0,85 controlar dificultades 0,657 0,85 todo bajo control 0,653 0,85 enfado 0,447 0,86 cosas por hacer 0,206 0,87 pasar el tiempo 0,415 0,86 acumulación de dificultades 0,667 0,85 * correlación corregida entre el ítem y la puntuación total. ** consistencia interna si el ítem se omitiera. 278 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 tabla 4. comunalidades y matriz de coeficientes de la ess-14 con rotación oblicua ítem comunalidad factor 1 factor 2 afectado 0,326 0,384 0,568 incapacidad 0,477 0,632 0,628 nerviosismo 0,391 0,462 0,642 éxito 0,364 0,603 0,262 afrontamiento efectivo 0,409 0,651 0,397 seguridad 0,422 0,664 0,399 cosas van bien 0,383 0,615 0,419 no afrontar 0,465 0,431 0,755 controlar dificultades 0,557 0,800 0,495 todo bajo control 0,497 0,703 0,562 enfado 0,276 0,367 0,501 cosas por hacer 0,124 0,076 0,350 pasar el tiempo 0,298 0,505 0,332 acumulación de dificultades 0,508 0,599 0,728 los coeficientes mayores de 0,392 aparecen en negrita. tabla 5. correlación corregida entre cada ítem y la puntuación total y consistencia interna si el ítem se omitiera de la ees-10 ítem ccit* ciio** afectado 0,486 0,85 incapacidad 0,660 0,83 nerviosismo 0,558 0,84 seguridad 0,506 0,85 cosas van bien 0,515 0,85 no afrontar 0,599 0,84 controlar dificultades 0,611 0,84 todo bajo control 0,641 0,84 enfado 0,443 0,85 acumulación de dificultades 0,682 0,83 * correlación corregida entre el ítem y la puntuación total. ** consistencia interna si el ítem se omitiera. 279 consistencia interna y dimensionalidad de la escala de estrés percibido... adalberto campo-arias, gloria johanna bustos-leiton, aristóbulo romero-chaparro discusión las versiones de la eep muestran aceptable consistencia interna y estructura factorial que explica aproximadamente el 50% de la varianza en mujeres universitarias de una universidad de bogotá, colombia. la eep-14 muestra consistencia interna en el rango deseable en diferentes contextos e idiomas como español, inglés y japonés. similar a los datos que se presentan, cohen y kamarck, cohen y williamson, minura y griffiths, remor y gonzález y landero informaron coeficientes de alfa de cronbach entre 0,74 y 0,89 (2-6). de la misma forma, la estructura bidimensional para la esp-14 es consistente con un primer factor responsable del mayor porcentaje de la varianza (3, 4, 6). sin embargo, existen diferencias en la varianza que explica la estructura factorial. en el presente estudio se observó que los dos factores daban cuenta del 49,6% de eep-14, y un solo factor era responsable del 45,0% para la eep-10. para la eep-14, gonzález y landero, en una investigación con estudiantes mexicanos, observaron que la solución factorial explicaba el 48,0% de la varianza total (6). no obstante, un par de estudios informaron un porcentaje menor de la varianza total. cohen y williamson informaron que los dos factores daban cuenta del 41,6% de la varianza en adultos de estados unidos (3), y minura y griffiths hallaron que los factores retenidos sólo explicaban el 42,6% de la varianza total en estudiantes de habla japonesa (4). igualmente, según minura y griffiths, en otra población de estudiantes ingleses la varianza que explicaban los factores alcanzaba el 53,7% (4). por lo general, se acepta que una solución factorial es satisfactoria si explica por lo menos el 50% de la varianza total, y generalmente se espera que el primer factor reúna los aspectos más relevantes del constructo y acumule el mayor porcentaje de la varianza (11, 18). la eep-10 tiene la ventaja de que posee menos ítems, lo que reduce unos minutos el tiempo de diligenciamiento y calificación. la ees-10 presenta un mejor comportamiento psicométrico dado el menor número de ítems. la consistencia interna es un coeficiente al que afecta el número de ítems: a mayor número de ítems es mayor la consistencia interna; el coeficiente se sobrestima cuando la escala tiene más de veinte puntos (12). asimismo, los diez puntos de la eep-10 que muestran altos coeficientes en un único factor. streiner, entre otros autores, prefiere las escalas unidimensionales, con un único factor que refleje lo esencial del constructo, y que explique por lo menos el 50% de la varianza (11). se debe tener presente que el número de factores es directamente proporcional al número de ítems, y siempre se espera que un factor o dimensión esté formada por al menos entre tres y cinco puntos (11, 18). tanto la consistencia interna como la solución factorial de una escala varían, algunas veces en forma significativa, de una población a otra (11, 12, 18, 20). por tanto, siempre es necesario corroborar el comportamiento psicométrico de una escala en una población particular antes de iniciar su uso en diferentes contextos de la atención y el cuidado de los servicios de salud (21). los hallazgos de este estudio sugieren que la eep-14 y la eep-10 muestran consistencia interna y dimensionalidad que exploran en forma adecuada el constructo de estrés psicológico en esta muestra. es posible que estas escalas muestren un desempeño similar en otros grupos de estudiantes universitarias colombianas. se concluye que las versiones de la eep, de 10 y 14 ítems, muestran excelente consistencia interna y aceptable estructura factorial en una muestra de mujeres universitarias de una universidad pública de bogotá. es necesario corroborar estos hallazgos en otras poblaciones. tabla 6. comunalidades y matriz de coeficientes de la ess-10 con rotación oblicua ítem comunalidad factor 1 afectado 0,309 0,525 incapacidad 0,461 0,707 nerviosismo 0,368 0,587 seguridad 0,406 0,584 cosas van bien 0,350 0,577 no afrontar 0,431 0,633 controlar dificultades 0,471 0,686 todo bajo control 0,465 0,710 enfado 0,266 0,469 acumulación de dificultades 0,497 0,734 280 año 9 vol. 9 nº 3 chía, colombia diciembre 2009 aquichan issn 1657-5997 referencias bibliográficas 1. cohen s, kessler rc, gordon lu. measuring stress: a guide for health and social scientists. new york: oxford university press; 1997. 2. cohen s, kamarck t, mermelstein r. a global measure of perceived stress. j health social behav 1983; 24: 385-96. 3. cohen s, williamson gm. perceived stress in a probability sample of the united states. in: spacapan s, oskamp s. the social psychology of health. newbury park, ca: sage; 1988. 4. minura c, griffiths p. a japanese version of the perceived stress scale: cross-cultural translations and equivalence assessment. bmc psychiatry 2008; 8: 85 (doi:10.1186/1471-244x-8-85). 5. remor e. psychometric properties of a european spanish version of the perceived stress scale (pss). span j psychol 2006; 9: 86-93. 6. gonzález mt, landero r. factor structure of the perceived stress scale (pss) in a sample from mexico. span j psychol 2007; 10: 199-206. 7. rubio-stipec m, hicks mhr, tsuang mt. cultural factors influencing the selection, use, and interpretation of psychiatric measures. in: rush aj, pincus ha, first mb, zarin da, blacker d, endicott j, et ál. handbook of psychiatric measures. washington. american psychiatric association; 2002 (cd-rom). 8. morgan ga, gliner ja, harmon rj. measurement validity. j am acad child adolesc psychiatry 2001; 40: 729-31. 9. vengoechea j, ruiz a, moreno s. estrés y conductas antidisciplinarias en estudiantes de una facultad de medicina de bogotá. rev colomb psiquiatr 2006; 35: 340-51. 10. ministerio de salud. resolución 008430 por la cual se establecen las normas científicas, técnicas y administrativas para la investigación en salud. santa f-e de bogotá: ministerio de salud; 1993. 11. streiner dl. figuring out factors: the use and misuse of factor analysis. can j psychiatry 1994; 39: 135-40. 12. campo-arias a, oviedo hc. propiedades psicométricas de una escala: la consistencia interna. rev salud pública 2008; 10: 831-9. 13. pasw statistics 17. chicago: spss. inc.; 2009. 14. pearson k. determination of the coefficient of correlation. science 1909; 30 (757): 23-5. 15. cronbach j. coefficient alpha and the internal structure of test. psychometrika 1951; 16: 297-334. 16. bartlett ms. test of significance in factor analysis. br j psychol 1950; 3: 77-85. 17. kaiser hf. an index of factorial simplicity. psychometrica 1974; 34:31-6. 18. gorsuch rl. exploratory factor analysis: its role in item analysis. j pers asses 1997; 68: 532-60. 19. stevens j. power of the multivariate analysis of variance tests. psychol bull 1980; 88: 728-37. 20. batista-foguet jm, coenders g, alonso j. análisis factorial confirmatorio. su utilidad en la validación de cuestionarios relacionados con la salud. med clin (barc.) 2004; 122 (supl. 1): 21-7. 21. sánchez r, echeverry j. validación de escalas de medición en salud. rev salud pública 2004; 6: 302-18. 228 aquichan issn 1657-5997 marta ximena león-delgado1 sandra patricia flórez-rojas2 marcela torres3 maría leonor rengifo-varona4 diana prada5 la importancia de evaluar síntomas y alteraciones funcionales en enfermedades neurológicas crónicas: experiencia en cuidado paliativo y rehabilitación en una institución colombiana 1 profesor asociado. grupo de dolor y cuidado paliativo, facultad de medicina, universidad de la sabana, chía, colombia. martha.leon@unisabana.edu.co 2 profesor asociado. grupo de dolor y cuidado paliativo, facultad de medicina, universidad de la sabana, chía, colombia. sandradoc@gmail.com 3 epidemióloga. grupo de investigación, facultad de medicina, universidad de la sabana, chía, colombia. ana.torres14@unisabana.edu.co 4 especialista en medicina física y rehabilitación, clínica universitaria teletón, chía, colombia. maria.rengifo@clinicauniversitariateleton.edu.co 5 neuróloga. clínica de la policía, colombia. dianampradag@yahoo.com recibido: 02 de marzo de 2010 aceptado: 16 de noviembre de 2010 resumen existe un incremento en la prevalencia de enfermedades neurológicas y su carga de enfermedad. debido a ello, identificar la frecuencia de síntomas y las alteraciones funcionales es de vital importancia para definir un adecuado plan de tratamiento. se llevó a cabo un estudio de corte transversal para identificar los síntomas principales y las alteraciones funcionales en pacientes neurológicos de un centro de referencia colombiano para manejo de rehabilitación. se encontraron como síntomas y alteraciones funcionales más frecuentes: alteraciones de la marcha (65,5%), desórdenes de comunicación (36,98%), alteraciones emocionales y de memoria (38%), dolor (29,45%) y alteraciones en las actividades básicas cotidianas (24,3%). el 50% de los pacientes que reportaron dolor, el 30% de los que manifestaron insomnio y el 80% de los que refirieron estreñimiento no recibieron tratamiento en la primera consulta. algunos de los síntomas identificados no son características que definen la enfermedad, y no siempre son objeto de intervención. los resultados de este estudio pueden contribuir a reconocer la carga de los síntomas de las enfermedades neurológicas, sensibilizando a los profesionales de la salud acerca de la importancia del cuidado paliativo en pacientes con enfermedades progresivas no oncológicas. palabras clave síntomas, prevalencia, cuidado paliativo, rehabilitación, salud pública. (fuente: decs, bireme). año 10 vol. 10 nº 3 chía, colombia diciembre 2010 l 228-243 229 la importancia de evaluar síntomas y alteraciones funcionales en enfermedades neurológicas crónicas: ... l marta ximena león-delgado, sandra patricia flórez-rojas y otros. the importance of evaluating symptoms and functional alterations in chronic neurological diseases: experiences in palliative care and rehabilitation at a colombian institution abstract there is an increase in the prevalence of neurological diseases and the burden they impose. therefore, identifying the frequency of symptoms and the functional alterations is of paramount importance to develop an adequate treatment plan. a cross-sectional study was carried out to pinpoint the main symptoms and functional alterations in neurological patients at a rehabilitation center in colombia. the five most frequent symptoms and functional alterations identified were: walking disorders (65.5%), communication disorders (36.98%), memory and emotional alterations (38%), pain (29.45%), and alterations in activities of daily living (24.3%). fifty percent of the patients who reported pain, 30% of those who complained of insomnia, and 80% of those who mentioned constipation did not receive treatment during the first consultation. some of the identified symptoms are not characteristics that define the disease, and are not always the subject of intervention. the results of this study can contribute to recognition of the burden of the symptoms of neurological diseases, by making health professionals more aware of the importance of palliative care for patients with non-oncological progressive diseases. key words symptoms, prevalence, palliative care, rehabilitation, public health. (source: decs, bireme). 230 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 a importância da avaliação de sintomas e limitações funcionais nas doenças neurológicas crônicas: experiência em cuidados paliativos e de reabilitação em uma instituição na colõmbia resumo a prevalência de doenças neurológicas e sua carga de doença têm aumentado. portanto, é de importância vital identificar a freqüência dos sintomas e o comprometimento funcional para definir um plano de tratamento adequado. para identificar os principais sintomas e a limitação funcional em pacientes neurológicos de um centro de referência para manejo da reabilitação na colômbia se realizou um estudo transversal. os sintomas e as limitações funcionais mais freqüentes foram: distúrbio da marcha (65,5%), distúrbios da comunicação (36,98%), distúrbios emocionais e da memória (38%), dor (29,45%) e alterações em atividades básicas diárias (24,3%). o 50% dos pacientes que relataram dor, 30% das pessoas que manifestaram insônia e 80% daqueles que relataram constipação não foram tratados na primeira consulta. alguns dos sintomas identificados não são características que definem a doença, nem sempre eles são objeto de intervenção. os resultados deste estudo podem ajudar a reconhecer o peso dos sintomas da doença neurológica através da sensibilização de profissionais da saúde sobre a importância dos cuidados paliativos em pacientes com doenças progressivas não cancerosas. palavras-chave sintomas, prevalência, cuidado paliativo, reabilitação, saúde pública. (fonte: decs, bireme). 231 la importancia de evaluar síntomas y alteraciones funcionales en enfermedades neurológicas crónicas: ... l marta ximena león-delgado, sandra patricia flórez-rojas y otros. introducción las enfermedades crónicas son un problema de salud pública, siendo las responsables del 60% de todas las muertes en el mundo, y de estos el 80% de ellas ocurren en países en vías de desarrollo. está proyectado que en los próximos 10 años, las muertes debidas a enfermedades crónicas se incrementarán en un 17%, generando la necesidad de políticas en salud diseñadas para el control de estas patologías (1). el incremento en la esperanza de vida ha ocasionado que patologías neurológicas que afectan a los adultos mayores, como la enfermedad cerebro-vascular y las demencias, aumenten su incidencia a nivel mundial. la frecuencia de secuelas neurológicas de enfermedades crónicas como la diabetes e hipertensión también vienen en aumento (2). en grupos etarios más jóvenes, la incidencia de trauma craneoencefálico y raquimedular con sus secuelas correspondientes, cobra mayor importancia cada día (3). en el 2005, un estudio de la organización mundial de la salud (oms) mostró que un 30% de la mortalidad mundial se debe a enfermedades crónicas, además de un incremento del 10% en los años de vida saludable perdidos (daly, por su sigla en inglés). en países en vía de desarrollo, la mortalidad por enfermedades crónicas es de un 27%, con un 9% de incremento en los daly, lo cual tiene un impacto en la productividad de una sociedad. estos estudios muestran que reconocer el impacto de la enfermedad crónica podría contribuir a salvar vidas; se estima que para el 2015 aproximadamente se podrían salvar 36 millones de vidas. la carga de la enfermedad es uno de los indicadores más importantes del impacto de una patología sobre la sociedad, pues afecta pacientes, instituciones hospitalarias y el sistema de salud. un estudio que estima la incidencia y prevalencia de enfermedades neurológicas en estados unidos y otros países muestra que la carga de enfermedad de estas patologías afecta millones de personas (3). los reportes de incidencia y prevalencia en latinoamérica y colombia son escasos, y algunos de ellos mencionan la dificultad para establecer estas cifras por el gran subregistro de las patologías (4, 5, 6, 7, 8, 9, 10, 11, 12). el trauma y las enfermedades mentales son las dos primeras causas de años de vida saludables perdidos por discapacidad, lo cual tiene un impacto en la pérdida de la productividad para la sociedad (3). la prevalencia de síntomas depende de la patología y del estadio de la enfermedad; en esclerosis múltiple la fatiga tiene una prevalencia reportada entre 75-90%, el dolor 65%, la incontinencia urinaria 80%, el estreñimiento 60%, la espasticidad 40%, siendo la alteración visual uno de los síntomas iniciales; 70% de los pacientes presentan nistagmus, disfagia en 33%, trastornos de comunicación en 44%, y alteraciones cognitivas 50-70% (13). la mayoría de las enfermedades neurológicas crónicas son incurables y su tratamiento se basa principalmente en el manejo de los síntomas para mejorar la calidad de vida (14). de ello se desprende la necesidad de un abordaje integral tanto en el manejo de las alteraciones motoras, neurocomunicativas, cognoscitivas y emocionales que interfieren está proyectado que en los próximos 10 años, las muertes debidas a enfermedades crónicas se incrementarán en un 17%, generando la necesidad de políticas en salud diseñadas para el control de estas patologías. 232 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 en la funcionalidad e independencia del paciente, como el que ofrece la rehabilitación, y en el manejo de síntomas como el que ofrece el cuidado paliativo; ambas disciplinas suponen una importante atención al paciente y su familia, e involucran aspectos físicos, emocionales y sociales tomando en cuenta al paciente, la familia y la comunidad. dicho abordaje supone la implementación de políticas en salud, programas de educación y disponibilidad de medicamentos como lo indica la estrategia de salud pública de la oms (15). un diagnóstico de la frecuencia de síntomas de una enfermedad crónica en una población es el primer paso para diseñar estudios encaminados a un adecuado plan de manejo. en colombia, una revisión preliminar de la literatura no reveló datos acerca de la prevalencia de síntomas de enfermedad neurológica crónica. el objetivo de este estudio es determinar la prevalencia de síntomas en enfermedades neurológicas en un centro de referencia colombiano, un análisis de su tratamiento, y su asociación con patologías neurológicas específicas. metodología estudio y población se desarrolló un estudio de corte transversal. se llevó a cabo una revisión retrospectiva de las historias clínicas para todos los pacientes diagnosticados con patologías neurológicas crónicas de la clínica universitaria teletón en chía, colombia, de enero a diciembre de 2008. la clínica universitaria teletón es un centro de referencia en rehabilitación para pacientes neurológicos, y tiene un grupo multidisciplinario para el manejo de diferentes patologías. recolección de datos a través del código internacional de enfermedades versión 10 (cie 10) se seleccionaron los diagnósticos correspondientes a las enfermedades neurológicas que en la literatura mundial se relacionan con cronicidad, cuidados paliativos y rehabilitación (16). se revisó la base de datos de las historias clínicas de la clínica universitaria teletón entre enero y diciembre de 2008, para posteriormente escoger las cinco patologías más frecuentes atendidas en esta institución: enfermedad cerebro-vascular, enfermedades desmielinizantes, demencias, trauma craneoencefálico y raquimedular, y enfermedad de parkinson. se diseñó un cuestionario estructurado para recolectar la información de las historias clínicas de los pacientes en su primer registro de consulta médica especializada por fisiatría, neurología o cuidado paliativo, incluyendo datos demográficos (como edad, género), y síntomas asociados a las patologías neurológicas descritas. la información fue recolectada por médicos especialistas en cuidado paliativo o neurología. características del cuestionario el cuestionario pretende identificar los siguientes datos: características demográficas, síntomas y alteraciones funcionales asociadas como dolor, sudoración, fatiga, estreñimiento, diarrea, incontinencia urinaria, náusea y vómito, sialorrea, alteraciones de sueño, palpitaciones, alteraciones auditivas, alteraciones cognitivas, debilidad, disnea, alteraciones comportamentales, tos, disfagia, rigidez, disfunción sexual, alteraciones visuales, lesiones de la piel, un diagnóstico de la frecuencia de síntomas de una enfermedad crónica en una población es el primer paso para diseñar estudios encaminados a un adecuado plan de manejo. en colombia, una revisión preliminar de la literatura no reveló datos acerca de la prevalencia de síntomas de enfermedad neurológica crónica. 233 la importancia de evaluar síntomas y alteraciones funcionales en enfermedades neurológicas crónicas: ... l marta ximena león-delgado, sandra patricia flórez-rojas y otros. alteraciones del apetito, convulsiones, lesiones orales, alteraciones de la marcha, alteraciones sensitivas, alteraciones de la independencia en actividades básicas cotidianas y actividades de la vida diaria, caídas y alteraciones de la memoria. análisis estadístico la información recolectada alimentó una base de datos usada para determinar la prevalencia de los síntomas, el tipo de tratamientos recibidos para cada síntoma y alteraciones funcionales referidas por los pacientes asociados con las patologías identificadas. los datos fueron analizados usando el programa stata 10.0. el análisis de las variables se hizo a través de estadística descriptiva. se estableció la significancia estadística a < 0,05. el análisis de regresión logística bivariado fue utilizado para identificar asociaciones entre las patologías y los síntomas. resultados se identificaron las historias clínicas de todos los pacientes con patologías neurológicas (292 pacientes). las patologías atendidas corresponden a enfermedad cerebrovascular (50,68%), demencias (20,89%), enfermedad de parkinson (10,95%), trauma cráneo-encefálico (7,53%), enfermedades desmielinizantes (6,50%), esclerosis lateral amiotrófica (ela) (1,71%) y trauma raquimedular (1,71%). el 54,8% de las historias evaluadas fueron de mujeres. el trauma craneoencefálico, el trauma raquimedular y las enfermedades desmielinizantes se presentan con mayor frecuencia en menores de 50 años (85,7, 80 y 60%, respectivamente). las enfermedades cerebro-vasculares (73,4%), la enfermedad de parkinson (82,8%) y demencia (96,7%) en personas mayores de 50 años. en relación con el género ela, trauma raquimedular, trauma craneoencefálico y enfermedad de parkinson son más frecuentes en hombres (80%, 66,7% y 65,5%). enfermedades desmielinizantes y cerebrovasculares se presentan más en mujeres (79 y 60%), y la demencia es ligeramente más frecuente en hombres (59%). prevalencia de los síntomas los síntomas y la alteraciones funcionales más frecuentes son: se observan en la tabla 1, siendo los más prevalentes las alteraciones de la marcha (65,8%), seguidos por alteraciones de memoria (38%), alteraciones en la comunicación (37%) y dolor (29,4%). otros síntomas y alteraciones funcionales menos frecuentes fueron caídas (5,8%), alteraciones visuales (6,2%) y estreñimiento (6,5%) (datos no mostrados). prevalencia de los síntomas por patología al clasificar la prevalencia de los síntomas por patología y alteraciones funcionales encontramos que los más frecuentes para enfermedad cerebro-vascular son alteraciones en la marcha (79,7%), comunicación (53%), dolor (38,8%), espasticidad (34%), disminución en la independencia para actividades básicas cotidianas (26,5%) y actividades de la vida diaria (26,7%); memoria (24,5%) y disfagia (22,4%). en los pacientes con demencia, los síntomas más prevalentes son alteraciones de memoria y cognitivas, del comportamiento y de la marcha (88,5, 55,7, 39,3 y 32,7% respectivamente). los síntomas más frecuentes en los pacientes con trauma craneoencefálico son alteraciones en la marcha (61,9%), los síntomas y la alteraciones funcionales más frecuentes son: alteraciones de la marcha (65,8%), seguidos por alteraciones de memoria (38%), alteraciones en la comunicación (37%) y dolor (29,4%). 234 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 en memoria (57,14%), dolor (42,86%) y alteraciones emocionales (28,57%). para enfermedades desmielinizantes los principales síntomas son alteraciones de la marcha, debilidad, dolor y alteraciones sensitivas (52,6, 47,4, 31,6 y 31,6%). para ela, los síntomas más frecuentes corresponden a alteraciones en la marcha (100%), debilidad (80%), alteraciones en la comunicación (60%) y dolor (40%). el 80% de los pacientes con trauma raquimedular presentan dolor, incontinencia urinaria y alteraciones de la independencia en las actividades de la vida diaria; en este último grupo de pacientes se encontraron alteración de la independencia en las actividades básicas cotidianas en un 60% y desórdenes del sueño en un 40%. la prevalencia de síntomas por patología está discriminada en la tabla 2. asociaciones entre patologías y síntomas para identificar las posibles asociaciones entre patologías y síntomas se realizó un análisis de regresión logística bivariado asumiendo la ocurrencia del síntoma como una variable independiente y la ocurrencia de la patología como variable dependiente. con el fin de identificar las posibles asociaciones entre patología y síntomas, condujimos un análisis de regresión logística bivariado asumiendo la ocurrencia de un síntoma como variables independientes y la ocurrencia de una patología como variables dependientes (tabla 3). se determinó la significancia estadística con p<0,05. los resultados del análisis muestran que se encuentra una asociación significativa entre la presencia de enfermedad cerebro-vascular y alteraciones de la comunicación (or: 4,82), dolor (or: 2,59), alteraciones comportamentales (or: 0,45), alteraciones de memoria (or: 0,27), disfagia (or: 2,26) y rigidez (or: 2,22). para demencia, se observa una asociación entre alteraciones del sueño (or: 2,34), disfagia (or: 0,32), alteraciones de la comunicación (or: 0,27), alteraciones de la marcha (or: 0,16), dolor (or: 0,13). para enfermedad de parkinson, las asociaciones presentadas fueron comunicación (or: 0,38) y dolor (or: 0,15). en el caso de enfermedades desmielinizantes encontramos una asociación con alteraciones de memoria (or: 0,18). para trauma raquimedular la asociación fue dolor (or: 10,44). para trauma craneoencefálico ninguna asociación fue estadísticamente significativa. tratamiento de los síntomas se ha reportado que pacientes con enfermedades avanzadas no tienen un adecuado tratamiento de sus síntomas (17). en el 50% de los pacientes que refirieron dolor, 30% de los que manifestaron insomnio y 80% de quienes refirieron estreñimiento no tienen registro en la historia clínica de haber recibido tratamiento en la primera consulta. discusión la patología más prevalente en la población estudiada fue la enfermedad cerebro-vascular, que se encuentra entre las cinco enfermedades crónicas incluidas por la oms en su reporte de enfermedades crónicas, una inversión vital. es por esto que existe la recomendación de generar un abordaje de salud pública para disminuir la carga de la enfermedad. las se ha reportado que pacientes con enfermedades avanzadas no tienen un adecuado tratamiento de sus síntomas. en el 50% de los pacientes que refirieron dolor, 30% de los que manifestaron insomnio y 80% de quienes refirieron estreñimiento no tienen registro en la historia clínica de haber recibido tratamiento en la primera consulta. 235 la importancia de evaluar síntomas y alteraciones funcionales en enfermedades neurológicas crónicas: ... l marta ximena león-delgado, sandra patricia flórez-rojas y otros. patologías analizadas en este estudio se presentan en varios grupos etarios, lo cual contradice uno de los mitos en relación con las patologías crónicas que menciona que afectan principalmente a las personas mayores. la distribución por género del estudio muestra una frecuencia similar entre hombres y mujeres, lo cual coincide con la tendencia mundial (1). patologías como el trauma craneoencefálico, trauma raquimedular y enfermedades desmielinizantes se presentaron en pacientes menores de 50 años que se encuentran en etapas productivas de la vida, por tanto, se sugiere desarrollar políticas en salud que garanticen la implementación de atención integral sostenible a los pacientes y sus familias de acuerdo con su pronóstico y expectativa de vida. el estudio enfatiza acerca de la existencia de síntomas que no siempre son el principal motivo de consulta de estas enfermedades, pero que adquieren una importancia relevante para diseñar estrategias de tratamiento toda vez que deterioran la calidad de vida de quienes los padecen. estos síntomas incluyen alteraciones de la memoria en enfermedades desmielinizantes; disfagia en enfermedades cerebro-vasculares; demencia y alteraciones de la comunicación en enfermedades cerebro-vasculares; esclerosis lateral amiotrófica, enfermedades desmielinizantes y enfermedad de parkinson. es importante anotar que si bien se exploró la presencia de disfunción sexual, no se encontró dicho registro en las historias clínicas, ello puede ser en parte debido a que el personal médico no preguntó de manera activa por este tópico o por la dificultad de los pacientes para referirse al tema. debe buscarse mejorar las estrategias de comunicación médico-paciente para optimizar el registro de estos síntomas. para esclerosis lateral amiotrófica hay síntomas comúnmente descritos en la literatura que incluyen debilidad y atrofia, fasciculaciones y calambres, espasticidad, disartria, disfagia, disnea e incontinencia emocional, y otros síntomas menos reportados que agrupan alteraciones psíquicas, sueño, dolor musculoesquelético y estreñimiento (18). en el presente trabajo se encontró que los síntomas que con más frecuencia se documentaron en la población de estudio fueron la debilidad y alteración de la marcha, junto con los trastornos de la comunicación y el dolor. una revisión sistemática de solano buscando la prevalencia de síntomas en pacientes terminales con cáncer, sida, falla cardíaca, enfermedad pulmonar obstructiva crónica y enfermedad renal concluyó que el dolor, la disnea y la fatiga se presentaron en más del 50% de los pacientes (19). la disnea y el dolor han sido reportadas en un 40% de pacientes con demencia en estadios terminales (20). en contraste, los datos del presente estudio evidencian que las alteraciones funcionales más frecuentes son para la marcha, memoria y comunicación. algunos de los síntomas y las alteraciones funcionales identificados no son las principales características de las enfermedades descritas, y no siempre son intervenidos en la primera consulta, por ello es importante diseñar estrategias que permitan explorar y dar tratamiento a síntomas subestimados como la tristeza, ansiedad e irritabilidad, que algunas veces son causadas por la localización de las lesiones neurológicas, y otras veces son debidas a la condición médica, afectando la percepción de los síntomas. el estudio enfatiza acerca de la existencia de síntomas que no siempre son el principal motivo de consulta de estas enfermedades, pero que adquieren una importancia relevante para diseñar estrategias de tratamiento toda vez que deterioran la calidad de vida de quienes los padecen. 236 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 es importante resaltar que estos síntomas no son de manejo exclusivamente farmacológico y es por esto que se hace imperativa la conformación de grupos multidisciplinarios donde otros profesionales de la salud como enfermeros, fisioterapeutas, terapeutas ocupacionales, fonoaudiólogos, psicopedagogos, psicólogos, bajo la orientación del área médica, tomen un rol fundamental para dar respuesta a las necesidades particulares de estos pacientes. se debe resaltar la importancia de capacitar al cuerpo médico en herramientas para el manejo de estos síntomas, lo cual permite hacer una remisión adecuada de los pacientes a otros profesionales de la salud con el propósito de realizar un manejo temprano que retarde el deterioro en la calidad de vida. se ha mencionado que una de las diferencias entre los pacientes oncológicos y los no oncológicos es la prevalencia de los síntomas (16). los resultados de este estudio pueden contribuir a reconocer la carga de los síntomas de las enfermedades neurológicas, aumentando la sensibilidad de los profesionales de la salud alrededor del cuidado paliativo y la rehabilitación, y su uso apropiado en pacientes con enfermedades progresivas no oncológicas, como ha sido propuesto por otros autores (21, 22). planteamos entonces la necesidad de establecer guías de manejo que tengan en cuenta las similitudes y diferencias del cuidado paliativo y la rehabilitación en pacientes neurológicos y oncológicos; entre las similitudes están los dilemas éticos, la toma de decisiones como el uso de gastrostomía, soporte ventilatorio o antibióticos en fase terminal (23, 24), la comunicación del pronóstico, la relación con la familia y la sobrecarga de cuidadores (25). entre las diferencias se encuentra la evolución de la enfermedad y la prevalencia de los síntomas; algunas enfermedades neurológicas como las demencias, las enfermedades desmielinizantes y la esclerosis lateral amiotrófica presentan una evolución variable, pero comparten la pérdida progresiva de la funcionalidad; su pronóstico se puede ver alterado por complicaciones infecciosas o respiratorias (16). en la enfermedad de alzheimer, la sobrevida después del diagnóstico inicial puede ser de 5 años (26), en enfermedad de parkinson los síntomas con un declive exponencial son la bradkinesia y la rigidez, mientras que otros síntomas como el deterioro de la marcha, el habla, la cognición, la discriminación al calor y la calidad de vida, comprometen todos los estadios de esta patología, y presentan un declive lineal (27, 28). en esclerosis lateral amiotrófica se observa un curso más corto y catastrófico pero con gran pérdida de funcionalidad (29, 30). el dolor, contrario a las patologías oncológicas, es menos frecuente, pero es un desenlace importante relacionado con la calidad de vida. otros síntomas como alteraciones cognitivas, neurocomunicativas y motoras tienen una gran prevalencia en patologías neurológicas (16). dentro de los aspectos que ocasionan la muerte en los pacientes neurológicos, las infecciones ocupan un lugar preponderante (25,28); en pacientes institucionalizados con demencia, la tasa de mortalidad por neumonía y fiebre ha sido reportada en 46,7 y 44,5% (20). en la investigación no se evaluó la prevalencia de infecciones pero se conoce que la incontinencia urinaria es un factor que predispone a ellas (31). en el presente estudio, un 11,64% presentó incontinencia urinaria, lo cual sugiere diseñar estrategias preventivas donde la en la investigación no se evaluó la prevalencia de infecciones pero se conoce que la incontinencia urinaria es un factor que predispone a ellas. 237 la importancia de evaluar síntomas y alteraciones funcionales en enfermedades neurológicas crónicas: ... l marta ximena león-delgado, sandra patricia flórez-rojas y otros. enfermera, como parte del equipo multidisciplinario, adquiere una gran importancia. otro factor que predispone a infecciones son los trastornos de deglución (32) y un 15,4% de la población evaluada reportó disfagia, en contraste con una prevalencia reportada de disfagia en un 85,5% por otros autores (20); este síntoma se beneficia de intervenciones en equipo que incluyan fonoaudióloga, nutricionista y el entrenamiento de los cuidadores. las alteraciones sensitivas pueden ser una causa de lesiones en la piel y el 9,93% de los pacientes las presentaron. estas alteraciones, sumadas a inmovilidad y alteraciones nutricionales, hacen que estas poblaciones estén en mayor riego de úlceras de presión (13). dentro de las políticas en salud se deberían desarrollar guías de manejo que tengan en cuenta la instauración temprana de medidas efectivas para prevenir complicaciones derivadas de estos síntomas, como las reportadas por turner-stokes (33). otra de las causas que deteriora el pronóstico de los pacientes neurológicos son las fracturas (34, 35). en la población estudiada solo el 5,82% reportó caídas al momento de la primera entrevista. se encontraron factores de riesgo para caídas tales como alteraciones de la marcha en un 65,7%, espasticidad en 21,9%, desorientación en 8,9%, vértigo en 7,6%, debilidad en 6,9% y alteraciones visuales en 6,2%. la hipotensión puede ser otro factor de riesgo para caídas en estos pacientes y no fue encontrada en la revisión de las historias clínicas. la mayoría de estos pacientes se encuentran en sus casas y son los cuidadores quienes juegan un papel vital en la prevención de caídas, motivo por el cual se deben entrenar en este y otros aspectos del cuidado. se debe tener especial atención al desgaste de los cuidadores, pues un gran número de estos pacientes no se encuentran institucionalizados y suponen una importante carga para la familia. entre los síntomas que pueden incrementar la carga de los cuidadores se encuentran alteraciones de la memoria, que se presentó en 38%; alteraciones en la independencia para realizar las actividades básicas cotidianas en 29%, y de la vida diaria 21,2%; trastornos del sueño en 16%, y alteraciones comportamentales en 15%. futuros estudios deberían medir la carga del cuidado con instrumentos validados en nuestro idioma para conocer el impacto de los programas multidisciplinarios en la atención de estos pacientes, como ha sido reportado en otras lenguas (36, 37). este aspecto proporciona nuevas perspectivas para estudiar en el futuro en relación con el cuidado paliativo y la rehabilitación en pacientes no oncológicos. un 36,98% de los pacientes reportaron trastornos de la comunicación y esto puede subdimensionar la expresión de síntomas como el dolor y la fatiga. los or para dolor en enfermedad cerebrovascular y trauma raquimedular, y para disfagia en enfermedad cerebrovascular, hacen sugerir la evaluación rutinaria de estos síntomas. es necesario utilizar instrumentos de evaluación apropiados en pacientes no verbales, tales como el non communicative patients pain assesment instrument (noppain) (38). adicionalmente, se debería tener una lista de chequeo de los síntomas de mayor prevalencia en los pacientes neurológicos similar a la edmonton symptom assessment system para que se realice un reporte activo pues el autorreporte puede no ser eficaz en estos pacientes. llama la atención que la fatiga no aparece como uno de los se debe tener especial atención al desgaste de los cuidadores, pues un gran número de estos pacientes no se encuentran institucionalizados y suponen una importante carga para la familia. 238 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 síntomas más importantes aunque está reportada con frecuencias entre 40-65% en parkinson por ejemplo (39). ello podría deberse a que los médicos no interrogan el síntoma y no lo registran en la historia clínica (40). el promedio de síntomas por paciente encontrado en este estudio es de 4.225, lo cual se encuentra muy por debajo del estudio de borgsteede (41). otra contribución de este estudio es que es el primero que describe en latinoamérica el promedio de síntomas en patologías neurológicas crónicas. el presente estudio describe los síntomas más frecuentes en las patologías escogidas. estamos de acuerdo con strömgren cuando sugiere priorizar los síntomas y hacer una evaluación longitudinal, y ello debería tenerse en cuenta para futuras propuestas de manejo (42). dichas propuestas pueden plantear dilemas éticos en el manejo de síntomas como disfagia y rutas alternas de alimentación, como ha sido reportado (43); disnea y la pertinencia de ventilación mecánica, y el manejo de infecciones. futuros estudios deberían determinar la frecuencia de pacientes neurológicos en instituciones de cuidado crónico, pues se ha reportado que hasta un 91,9% de los pacientes institucionalizados remitidos a hospitalización tienen demencia (44). se debe resaltar que los síntomas que podían tener tratamiento desde la primera consulta, como son el dolor, el estreñimiento y el insomnio no fueron manejados en forma temprana por el médico tratante, lo cual nos hace reflexionar sobre la importancia de un abordaje adecuado y la evaluación de síntomas en forma precoz para mejorar calidad de vida. en patologías crónicas como las descritas en el presente artículo, se ha propuesto diseñar estrategias de salud pública que incluyen intervenciones educativas y diseño de políticas públicas (15). tal y como lo ha dicho la academia americana de neurología, se evidencia la importancia de una capacitación en cuidado paliativo a los neurólogos (2). aunque es importante que los especialistas tengan competencias en cuidado paliativo, es imperativo que los médicos de atención primaria las adquieran dado que son la puerta de entrada al sistema de salud y atienden la mayor parte de la población (45). en relación con las políticas públicas, los sistemas de salud tienen recursos limitados y es importante definir métodos justos para asignarlos (46, 47). muchos países no han considerado el cuidado paliativo como un problema de salud pública (48). teniendo en cuenta las recomendaciones para promover un abordaje de cuidado paliativo y rehabilitación en el que se incluyan programas integrados a los sistemas de salud y adaptados a los contextos específicos, hemos presentado los resultados del presente estudio para recomendar que en iniciativa legislativa que se cursa en el senado de la república se incluyan las patologías crónicas no oncológicas en el aseguramiento de la atención (49). el presente trabajo tiene limitaciones por ser un estudio retrospectivo donde se presentaron dificultades para la recolección de la información por falta de un diligenciamiento adecuado de las historias clínicas. en el instrumento no se consignó el estadio de las diferentes enfermedades y esto puede variar la prevalencia de los síntomas. otra de las limitaciones fue la evaluación de los síntomas, se desconoce futuros estudios deberían determinar la frecuencia de pacientes neurológicos en instituciones de cuidado crónico, pues se ha reportado que hasta un 91,9% de los pacientes institucionalizados remitidos a hospitalización tienen demencia. 239 la importancia de evaluar síntomas y alteraciones funcionales en enfermedades neurológicas crónicas: ... l marta ximena león-delgado, sandra patricia flórez-rojas y otros. si fue un autorreporte o un reporte activo de ellos. es importante resaltar que la clínica universitaria teletón tiene conformado un grupo interdisciplinario para la atención de estos pacientes, lo cual facilita el manejo integral y la rápida remisión a todas las áreas. se debe tener en cuenta que no en todas las instituciones se puede contar con grupos conformados por todas las áreas médicas y terapéuticas necesarias, pero se debe propender por vincularlas, en el fin de buscar un mejor enfoque terapéutico y unos óptimos resultados en estos pacientes. las patologías crónicas son un problema de salud pública, muchas de las patologías neurológicas no son curables, haciendo del manejo de síntomas un abordaje apropiado para lograr una mejor calidad de vida. tabla 1. frecuencia de síntomas síntoma frecuencia n (%) trastornos de la marcha 192 (65,75) trastornos de la comunicación 108 (36,98) alteraciones de la memoria 111 (38) dolor 86 (29,45) alteración en la independencia para abc 71 (24,3) espasticidad 64 (21,91) alteración en la independencia para avd 62 (21,23) alteraciones emocionales 61 (20,89) alteraciones del sueño 46 (16,09) disfagia 45 (15,41) alteraciones del comportamiento 44 (15) incontinencia urinaria 34 (11,64) temblor 34 (11,64) náusea y vómito 30 (10,27) alteraciones sensitivas 29 (9,93) debilidad 22 (7,53) vértigo 21 (7,19) conclusiones las patologías crónicas son un problema de salud pública, muchas de las patologías neurológicas no son curables, haciendo del manejo de síntomas un abordaje apropiado para lograr una mejor calidad de vida. algunos de los síntomas más prevalentes encontrados en este estudio no se tienen en cuenta en la caracterización de las patologías, pero pueden contribuir al impacto de la enfermedad y, debido a ello, es imperativo establecer un plan de manejo adecuado. los síntomas más prevalentes de los pacientes neurológicos no son de manejo exclusivamente farmacológico y es por eso que se vuelve prioritario un equipo multidisciplinario formado tanto por áreas médicas como terapéuticas. la comunicación continua entre los rehabilitadores, los paliativistas y los neurólogos, al igual que con todas las áreas que intervengan en el tratamiento, se fortalecen en el manejo de los síntomas de los pacientes con enfermedades neurológicas, brindando un mejor apoyo a quienes sufren dichas patologías y sus familias. los resultados del presente estudio aportan argumentos para soportar cambios en la agenda legislativa de nuestro país. 240 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 tabla 2. frecuencia de síntomas por patología síntoma enfermedad demencia trauma parkinson enfermedades ela trauma cerebrovascular (%) craneoencefalico (%) desmielinizantes (%) raquimedular (%) (%) (%) (%) alteraciones en la marcha 79,67 32,77 61,90 68,96 52,63 100 80 alteraciones en la comunicación 53,06 18,03 33,33 13,79 15,79 60 0 alteraciones en la memoria 24,49 88,52 57,14 20,69 10,53 0 alteración en la independencia 26,54 26,22 23,70 13,79 10,53 20 60 para abc espasticidad 34,01 3,28 9,52 44,83 26,32 20 0 alteración en la independencia 26,72 26,22 13,9 0 10,53 20 80 para avd alteraciones emocionales 19,72 24,58 28,57 24,13 5,26 20 20 sueño 14,28 26,22 9,52 13,79 0 20 40 disfagia 22,44 8,19 14,28 3,45 10,53 60 0 alteraciones de comportamiento 9,52 39,35 23,81 3,45 0 0 20 incontinencia urinaria 12,24 18,03 14,28 0 5,26 0 80 temblor 1,36 3,28 4,76 96,55 5,26 0 0 náusea-vómito 0,68 0 4,76 0 0 0 0 alteraciones sensitivas 14,29 0 4,76 0 31,58 0 40 debilidad 4,76 1,64 0 3,45 47,37 80 0 vértigo 11,56 0 9,52 0 10,53 0 0 241 la importancia de evaluar síntomas y alteraciones funcionales en enfermedades neurológicas crónicas: ... l marta ximena león-delgado, sandra patricia flórez-rojas y otros. * estadísticamente significativo p<0,05. tabla 3. odds ratio para las patologías con relación a los factores síntoma enfermedad demencia trauma parkinson enfermedades ela trauma cerebrovascular craneoencefalico desmielinizantes raquimedular dolor 2,59* 0,13* 1,98 0,15* 1,16 1,68 10,44* incontinencia urinaria 0,92 1,65 1,11 0,35 29,57 náusea-vómito 0,98 3,00 alteraciones emocionales 1,10 1,45 0,89 0,78 0,30 1,36 alteraciones sueño 0,76 2,34* 0,53 0,78 1,31 3,66 alteraciones cognitivas 0,59* 6,26* 0,64 0,27 0,22 alteraciones de comportamiento 0,45* 4,59* 1,71 0,18 1,35 debilidad 0,26* 1,01 25,50* 75,44* disfagia 2,66* 0,32* 0,82 0,17 0,63 1,21 espasticidad 2,22* 0,08* 0,32 2,71* 1,18 0,81 vértigo 3,67* 2,12 0,38 1,42 alteraciones en la comunicación 4,82* 0,27* 0,86 0,24* 0,30 2,65 alteraciones sensitivas 2,38 0,42 0,30 4,81* 6,17 alteraciones visuales 2,52 0,21 0,76 3,35 alteración en la independencia para abc 1,34 1,08 1,02 0,33 0,37 0,81 5,09 alteración en la independencia para avd 1,18 1,52 0,69 0,48 1,05 18,06* alteraciones en la memoria 0,27* 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equity health 2008; (7): 4. 47. sanchez f, abellán jm, martínez je. how should health and healthcare priorities be set an evaluated? prioritization methods and regional disparities. 2008 sespas report. gac sanit 2008; 22 (1): 126-36. 48. sepulveda c, marlin a, yoshida t, ullrich a. palliative care: the world health organization´s global perspective. j pain symptom manage 2002; 24 (2): 91-96. 49. proyecto de ley 15 senado de la república de colombia. gaceta del senado 2008; 905. a do pt in g th e ro le o f c ar eg iv er o f c hr on ic p at ie nt s: s pe ci fic s it ua ti on t he or y 1 lorena chaparro-díaz https://orcid.org /0000-0001-8241-8694 universidad nacional de colombia, sede bogotá, colombia olchaparrod@unal.edu.co sonia carreño-moreno https://orcid.org /0000-0002-4386-6053 universidad nacional de colombia, sede bogotá, colombia spcarrenom@unal.edu.co jennifer rojas-reyes https://orcid.org /0000-0001-8962-5135 universidad de antioquia, colombia jennifer.rojasr@udea.edu.co article adopting the role of caregiver of chronic patients: specific situation theory* received: 04/02/2022 sent to peers: 16/05/2022 accepted by peers: 20/06/2022 approved: 14/07/2022 doi: 10.5294/aqui.2022.22.4.2 to reference this article / para citar este artículo / para citar este artigo chaparro-díaz l, carreño-moreno s, rojas-reyes j. adopting the role of caregiver of chronic patients: specific situation theory. aquichan. 2022;22(4):e2242. doi: https://doi.org/10.5294/aqui.2022.22.4.2 * funding: nursing school, universidad nacional de colombia. call for support to health research projects 60 years of the nursing school 2019, code: 45048. https://orcid.org/0000-0001-8241-8694 mailto:olchaparrod@unal.edu.co https://orcid.org/0000-0002-4386-6053 mailto:spcarrenom@unal.edu.co https://orcid.org/0000-0001-8962-5135 mailto:jennifer.rojasr@udea.edu.co https://doi.org/10.5294/aqui.2022.22.4.2 https://doi.org/10.5294/aqui.2022.22.4.2 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2022.22.4.2&amp;domain=pdf&amp;date_stamp=2022-09-30 theme: epistemology contribution to the discipline: this proposal for a specific situation theory advances theoretical knowledge and acknowledges that the caregiver role represents a transition that requires nursing support. a do pt in g th e ro le o f c ar eg iv er o f c hr on ic p at ie nt s: s pe ci fic s it ua ti on t he or y 3 abstract objective: to present the proposal for a specific situation theory on adopting the role of caregiver of chronic patients. materials and methods: based on meleis and im’s integrating strategy, multiple information sources were employed to develop this theory. results: this prescriptive theory derives from meleis’ mid-range theory based on an exhaustive literature review and the authors’ practical and research experience. the information was integrated into core concepts such as caregiver’s transition, caregiver role insufficiency, nature and conditions of the transition, nursing transitional care for the caregiver, and healthy transition. assertions were also derived, such as the adoption of the caregiver role influencing the response patterns or the result indicators related to the caregiver’s quality of life and perception of burden. finally, a theoretical process and an empirical indicator called role are described. conclusions: this theoretical development recognizes the process faced by caregivers in adopting their role in the care of chronic patients and guides possible nursing interventions to favor a healthy transition. keywords (source: decs) caregivers; chronic disease; nurse; nursing theory; role; transitional care. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 42 4 resumen objetivo: dar a conocer una propuesta de teoría de situación específica sobre la adopción del rol del cuidador del paciente crónico. materiales y métodos: basados en la estrategia integradora de meleis e im, se emplearon múltiples fuentes de información para el desarrollo de esta teoría. resultados: esta teoría de carácter prescriptivo se deriva de la teoría de rango medio de las transiciones de meleis, a partir de una exhaustiva revisión de literatura y de la experiencia práctica e investigativa de las autoras. se integró la información en conceptos centrales como: transición del cuidador, insuficiencia del rol de cuidador, naturaleza de la transición, condiciones de transición, cuidado transicional de enfermería al cuidador y transición saludable; se derivaron afirmaciones como que la adopción del rol de cuidador influencia los patrones de respuesta o indicadores de resultado relacionados con la calidad de vida y la percepción de sobrecarga del cuidador; se describe un proceso teórico y un indicador empírico denominado rol. conclusiones: este desarrollo teórico permite reconocer el proceso que el cuidador enfrenta para adoptar su rol en el cuidado al paciente crónico y orientar posibles intervenciones de enfermería para favorecer una transición saludable. palabras clave (fuente decs) cuidado de transición; cuidadores; enfermedad crónica; enfermería; rol; teoría de enfermería. adopción del rol del cuidador del paciente crónico: teoría de situación específica* * financiación: facultad de enfermería, universidad nacional de colombia. convocatoria para el apoyo a proyectos de investigación en salud 60 años facultad de enfermería 2019, código: 45048. a do pt in g th e ro le o f c ar eg iv er o f c hr on ic p at ie nt s: s pe ci fic s it ua ti on t he or y 5 adoção do papel do cuidador do paciente crônico: teoria de situação específica* resumo objetivo: apresentar uma proposta de teoria de uma situação específica sobre a adoção do papel de cuidador do paciente crônico. materiais e métodos: com base na estratégia integrativa de meleis e im, foram utilizadas múltiplas fontes de informação para o desenvolvimento desta teoria. resultados: esta teoria prescritiva deriva da teoria de médio alcance das transições de meleis, a partir de uma exaustiva revisão da literatura e da experiência prática e de pesquisa dos autores. as informações foram integradas em conceitos centrais como: transição do cuidador, insuficiência do papel do cuidador, natureza da transição, condições de transição, cuidados de transição de enfermagem para o cuidador e transição saudável; com afirmações que indicam que a adoção do papel de cuidador influencia os padrões de resposta ou indicadores de resultados relacionados à qualidade de vida e à percepção de sobrecarga do cuidador; apresenta-se a descrição de um processo teórico e um indicador empírico denominado rol. conclusões: este desenvolvimento teórico permite reconhecer o processo que o cuidador enfrenta para adotar seu papel no cuidado ao paciente crônico e orientar possíveis intervenções de enfermagem para favorecer uma transição saudável. palavras-chave (fonte: decs) cuidadores; cuidado transicional; doença crônica; enfermagem; papel (figurativo); teoria de enfermagem. *financiamento pela faculdade de enfermagem, universidad nacional de colombia. edital para o apoio de projetos de pesquisa em saúde — 60 anos da faculdade de enfermagem, em 2019. código: 45048. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 42 6 introduction in its 2020 report on deaths between 2000 and 2018, the world health organization  (who)  (1) reveals a considerable increase in deaths due to heart diseases, dementia, and diabetes. this epidemiological profile evolved during those years and is now prevalent in the population. it also states that people live longer when given access to health services and treatments, although with more disabilities; consequently, cardiovascular diseases, diabetes, strokes, lung cancer, and chronic obstructive pulmonary disease caused 100 million healthy life years lost compared to 2000. the panorama above proves that chronic non-communicable diseases  (cncds) create some degree of disability and dependence; thus, constant patient monitoring is necessary to manage the disease and even for self-care. here, the family caregiver role arises  (2,  3). there is extensive evidence of the impact of chronic diseases not only on people but also on their families and caregivers. generally, family caregivers have a kinship or closeness tie with the people with cncds. when they decide to assume the care responsibility, they transform their entire life and routine, facing the loss of their jobs due to the role transition, a situation frequently associated with the perception of burden (4-6). family caregivers are often not prepared to perform the new role (710); however, all roles can be learned (11), and it is, therefore, possible to advance from ineffective performance towards a favorable transition in role adoption (12). some authors have found that new skills  (8,  9), relationships, and coping strategies  (13) are developed during the transition. adopting the caregiver role is the response to a transition process, which has been addressed from different theoretical perspectives, such as roy’s adaptation model  (14) and meleis’ theory of transitions (15). however, considering the conceptual progress, the empirical evidence, and the practical experience in the role of the family caregiver of a person with a cncd, the concept represents a specific construct for this population segment. accordingly, this article aims to present a proposal for a specific situation theory about adopting the role of caregiver of chronic patients, following meleis and im’s postulates (16) for theoretical progress in the discipline. background the concept of adopting the caregiver role emerges from several research studies about caring for chronic patients and their families. in this search about the experiences in caring for these people, two qualitative research studies were consolidated  (17,  18). they showed a series of categories that conclude that chronic disease a do pt in g th e ro le o f c ar eg iv er o f c hr on ic p at ie nt s: s pe ci fic s it ua ti on t he or y 7 situations are associated with role adoption phases (17), evidenced when caregivers state that they do not feel prepared to take on the new role. although they fulfill these complex duties with insecurity and fatigue, then, with repetition, the instrumental tasks are performed more skillfully, allowing the reorganization of life (18). thus, the caregiver role transition is characterized by the organization, performance of, and responses toward the role (19). when determining that role adoption is related to a caregiver transition process, an exploration was made from different nursing theoretical approaches to link concepts that met the definition of this concept. in this respect, meleis’ mid-range theory of transitions (12) was the one that could best describe this construct; therefore, it will be the theoretical grounds to develop the theory herein presented. according to several authors  (20-22), situational theories are a novelty, and those that have been developed in the last few decades have followed different paths; some derive from practice, others from research, and others from systematic literature reviews and models or theories inherent to nursing. in this plurality of theorization paths, some integrate several perspectives that make them more strict and valid, making it necessary to explain a specific phenomenon in a particular context  (20) and that the nursing community identifies itself with what is therein presented. such being the case, this situational theory derives from an integrative process between research, practice, and an already established mid-range theory. methodology to elaborate on this specific situation theory, meleis and im’s integrative strategy (16) was considered, as explained in figure  1. this integrated strategy meets the “multiple truths” criterion as an essential assumption to develop specific situation theories in nursing. the integrative approach proposed the points to the process of developing the theory as being dynamic, cyclic, and changing over time. thus, it is necessary to welcome this plurality and remain open to the potential growth of theoretical nursing, with flexibility in the application of the steps presented by various authors. consequently, the results will present most of the proposed steps to meet the objective. ethical considerations this proposal for a specific situation theory is the result of integrating various research studies that have allowed elaborating a thematic line; therefore, this article gathers this information and respects intellectual property rights by following the applicable citation style (23). a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 42 8 results in consonance with the methodology selected, the context and target population of this theoretical proposal are described within the results. subsequently, the verification of the assumptions is presented, setting out the situational theory meta-paradigm’s philosophical stance and concepts. the next stage is the exploration of multiple sources, where the elements taken from the theoretical derivation, the literature review, and the authors’ practical experience in building this proposal are explained. from this point, theorization is conducted, integrating this information into concepts and theoretical hypotheses; a theoretical process is also completed to describe how this phenomenon manifests itself. finally, an approach to verifying and validating the theory is made, presenting the empirical indicator linked to this specific situation theory. context and population caregivers of people with cncds can be characterized by gender, age, schooling, occupation, economic level, bond with the sick figure 1. steps of the integrative strategy to develop the situational theory source: own elaboration based on the meleis and im’s steps (16). context and population target population of the theory caregivers of people with cncds in latin america post-modernism and post-structuralism reciprocal interaction view socially constructed and contextualized realities theoretical derivation: concepts of the mrt of transitions theorization: integrate (see figure 2) veri�cation and validation “adoption of the role of family caregiver of chronic patients” role literature review: 8 reviews publishes on the topic practical experience: 17 years of the cuidando a cuidadores® program veri�cation of assumptions to devlop the theory multiple truths philosophical stance exploring multiple sources information that builds the theory a do pt in g th e ro le o f c ar eg iv er o f c hr on ic p at ie nt s: s pe ci fic s it ua ti on t he or y 9 person, health status, and time devoted to care. in latin america, eight out of ten people who care for a family member are women; the studies reveal that nearly 90 % belong to this gender and are the ones performing the heaviest routine care actions that require more dedication (24). regarding age, most caregivers are younger than the person cared for, except in the case of children, where the mothers provide such care, and the age relationship is inverted (25). in this sense, the caregiver’s bond with the sick person is primarily out of kinship (daughter/son or spouse); however, in other cultures, the caregivers can be friends, neighbors, or institutions (24, 25). most of these caregivers state having low or mid schooling levels, which corresponds to incomplete elementary or high school; this is also associated with the socioeconomic difficulties generated by the care provided and the exclusive dedication it often demands, thus limiting development opportunities for the caregiver in other spheres (6). consequently, caregivers experience a burden associated with depression symptoms, with a 0.14 % risk (26). regarding working life, the care task and the job generate conflicts; low work performance also influences the onset of depression, manifested in female caregivers  (27). in this accumulation of multiple responsibilities and caregiver roles, being a spouse, mother/father, or son/daughter also implies dedication and time (28). for some, having a partner is a facilitating factor, whereas, for others, it is but another demand; even so, 80 % of these caregivers state counting on other people’s support for care activities (29) to better cope with the role transition. 2. verification of assumptions to develop the theory from the philosophical perspective under which this specific situation theory is advanced, the principles of post-modernism and post-structuralism are recognized, responding to a pluralist stance regarding knowledge  (30). these two approaches accept the socially-constructed realities, reflecting on how the meanings of specific experiences have been transformed and conveyed, a process in which there is room for deconstructing what already exists and exploring multiple interpretations (30). in relating these postulates to adopting the caregiver role, acting as a family caregiver is considered a social representation built on the prevalence of chronic diseases. this role emerged and has gradually been transformed as it gained recognition. this role comes with different care meanings, where, as experience increases, the beliefs about care are deconstructed, others are built, and the caregiver is empowered  (31); in summary, there is a plurality of perspectives about adopting the caregiver role. from the nursing disciplinary perspective, the structure of this theoretical proposal is in line with the organization of nursing knowla q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 42 10 edge put forward by fawcett  (32) with the concept of knowledge holarchy, involving the worldview and meta-paradigm concepts. the worldview on which this theoretical proposal is grounded is reciprocal interaction (32), coinciding with its conception; according to this perspective, the concepts of the nursing meta-paradigm in this situational theory can be defined as follows: • human being: family caregivers are human beings with multiple needs to perform their role correctly, which impair their integrality as holistic beings. they are vulnerable beings, though active in their process, counting on autonomy and determination to learn, relate to other people, make decisions, solve problems, anticipate the care needs of their family members, and attribute meaning to the adoption of the caregiver role. • health: a process in which family caregivers interact with significant others in constructing their role. it also depends on the caregivers’ perception of burden, social support, and satisfaction with performing other roles in their everyday life. • nursing: care with solid knowledge about the needs of chronic patients and their family caregivers. the goal of the care process is to achieve a healthy transition to the family caregiver role in its adoption. • environment: the place where significant interactions between human beings occur in constructing the caregiver role. the socio political context in which the caregiver role has been built is also considered. currently, society acknowledges family caregivers, and laws have been enacted to favor their work (33), supporting the adoption of the role when these provisions are followed. 3. exploring through multiples sources several sources were employed to elaborate this proposal for a specific situation theory, such as a mid-range theory, a literature review, and practical experience, observing plurality of the knowledge that must be collected to build theories (16). theoretical derivation from the conceptual point of view, this specific situation theory derives from meleis’ theory of transitions. this nursing mid-range theory (mrt) emerges from the theory of the role, symbolic interactionism, the clinical practice experience, the systematic literature review, and four qualitative research studies (12). the concept of the role that grounds meleis’ mrt of transitions refers to a set of conducts or behaviors, feelings, and goals that confer unity to a set of actions (11). the role is built up in the interaction with other people, as human behavior does not respond to an isolated stimulus a do pt in g th e ro le o f c ar eg iv er o f c hr on ic p at ie nt s: s pe ci fic s it ua ti on t he or y 11 but to a complex interaction with significant others, where each person’s roles are constructed, highlighting the importance of reciprocity in understanding the concept of role (34, 35). some assumptions and proposals from afaf meleis’ theory of transitions are condensed to understand the experience of transition in adopting the family caregiver role (34): • transition occurs when an individual ceases to be a family member of a healthy person to become the family caregiver of a chronic patient. • transition implies certain insufficiency of the family caregiver role, defined as difficulty knowing or performing the function or regarding the associated feelings and goals perceived by the caregiver or other people. this deficit is related to starting to complete the caregiver role. • in essence, the transition is of the health-disease type because it occurs as a result of a change in the health status and implies facing the change and making adjustments to the roles, both of the sick person and the individual assuming the care responsibility. it is also situational, as it manifests itself in different stages of the life cycle. • the transition pattern is multiple, simultaneous, and related, as it occurs concomitantly with other transitions such as hospital admission-stay-discharge, employed-unemployed, and being the former head of the home, among many others that could be listed and which are characteristic of the population of family caregivers. • the response pattern to be evaluated is dexterity, measured based on the result indicator called “adoption of the role of family caregiver of chronic patients” (19, 36). • nursing therapy offers interventions for the caregivers’ knowledge and preparedness in this transition, generating a response pattern in adopting the family caregiver role. literature review multiple literature reviews (systematic and integrative) have been conducted about this phenomenon of care transition and family care in the group for the care of chronic patients and their families research path. these reviews have already been published (18, 19, 37-42) and are synthesized to prepare this proposal for a specific situation theory. the family caregiver transition is initiated abruptly by a significant event or specific change (a chronic disease of the pera q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 42 12 son with a kinship or closeness tie) that requires new response patterns  (38,  43,  44). depending on the context and conditions in which this transition occurs, it can ease or hinder role adoption. knowledge, beliefs, meanings, attitudes, and factors of the social system in which the caregiver acts are among these conditions (45). the time required for this transition is variable and depends on the nature of the change and its influences. likewise, the transition flow is characterized by a period of confusion and denial regarding the task; it then presents a chaotic phase in which the meaning of the task is lost, and disorientation emerges. finally, a new perspective is found in which the meaning of the task is different and new (46, 47). the evident transition patterns are unique in each caregiver’s experience and are also multiple and sequential because they exert a wave effect over time. each chronic patient’s crisis can pose new challenges and difficulties in the role, with the presence of simultaneous and unrelated patterns, because, in addition to the tasks with their sick family member, family caregivers must do chores inherent to other spheres, such as marriage, work, and development (46-48). family caregivers frequently display insufficiency in their role, derived from an incorrect definition of their functions, knowledge deficits, inadequate dynamics in their relationships with others, or adverse feelings related to the role. regarding the functions and knowledge, the caregivers need more education in aspects related to the disease (44, 49), household chores, nutrition, reorganization of everyday life, and emotional elements  (47,  48). the relationship with the rest of the family is affected by the caregivers’ isolation, who devote most of their time, attention, motivation, and energy to the care task  (45,  48,  50). regarding the feelings, family caregivers significantly impact their emotional sphere, which triggers depression, anxiety, and stress (47, 51), in addition to burden and adverse feelings such as uncertainty, anguish, pain, despair, fear, and hopelessness (50, 52). the caregivers can also have difficulties performing their role, as it is a function that depends not only on them but also on interactions with other people, such as the sick person, the family, and the health team  (53). several indicators of caregiver role insufficiency have been reported in the literature, among which are adverse feelings, dysfunctional relationships, and lack of specific knowledge and skills to perform the role, especially regarding its organization (35, 54). the expected result for the caregivers is that they are competent enough to perform their role, which is translated into their well being and that of the significant others as a response pattern in an adequate transition of their role. the following are the primary response patterns of this transition: control of the sick person’s disease (54), problem-solving skills, mood (55, 56), and the caregiver’s quality of life perception. a do pt in g th e ro le o f c ar eg iv er o f c hr on ic p at ie nt s: s pe ci fic s it ua ti on t he or y 13 experiences based on practice in its studies with family caregivers, the nursing care for chronic patients research group from the nursing school at universidad nacional de colombia recognized that the care burden was vital for them and involved their poor quality of life. therefore, they designed the program called “cuidando a cuidadores®” (“taking care of caregivers”) to meet the need for knowledge to provide care and adequately adopt the role, in addition to representing social support for the caregivers as care networks are created (57). the program was created following ngozy nkongo’s three conceptual guidelines: 1. knowledge, which implies knowing the needs, strengths, and weaknesses of the person cared for and the caregiver. 2. value, which is obtained from the experience to become open to the needs of the present; it implies making decisions and seeking support and self-empowerment as subjects of rights. 3. patience, which comprises the search for growth and meaning through exploration, expression, reflection, tolerance, and self-control in the face of disorganization of their role. the program includes two levels. the first helps family caregivers of chronic patients to recognize themselves as such and to understand and value their experience in this role. it also motivates them to act as a support network for other caregivers, thus strengthening knowledge, value, and patience (57, 58). at the second level, the caregivers advance in their role to nurture themselves in terms of competencies based on knowledge, being, and doing, such as in the management of emotions, conflicts and grief, drug administration, healthy lifestyles, financial management, social support, care continuity, and use of care technologies, among others. these activities allow the caregivers to have time for themselves and reduce their perception of the burden of care (58). the program was designed based on the available evidence, practical experience, and research-related contributions (57, 59). in general, the program expects that the caregivers discover their care experience and analyze it, identify their potentialities and limitations, recognize the gains from being caregivers, and get empowered in their role (59). 1. theorizing: concepts and theoretical hypotheses although it contains descriptive and predictive elements, this proposal for a specific situation theory is prescriptive. in this sense, it describes the role transition process in family caregiva q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 42 14 ers of chronic patients and the nature of the transition  (18,  38); it acknowledges the gender, age, dependence level, cognitive level, perception of a threat to life, spirituality, and social support factors as predictors of role adoption. similarly, adopting the role predicts the response patterns or outcome indicators (6, 15, 60, 61). it is also prescriptive because it indicates how to provide transitional nursing care to caregivers through strategies such as role clarification, role trial, and role modeling (15, 59). core concepts role transition: a process that, for human beings, implies changes in their relationships with others, their expectations, and multidimensional skills (20). caregiver role insufficiency: the inadequate development of some of the processes implied in a role transition. it can result from a poor definition of functions, the internal dynamics in the role relationships, or lack of knowledge about the role behaviors and the associated feelings and goals. role insufficiency hinders progression towards health and well-being and, consequently, to a healthy transition (62). nature of the transition: the pattern that rules the transition, characterized as multiple and related; in other words, the most usual is for each person to experience numerous related transitions at the same time  (34). it is both of the health-disease and situational type, with multiple, simultaneous, and associated patterns. it has critical points such as the caregiver’s gender, age, previous experiences as a caregiver, the daily hours devoted to care, the time as a caregiver, the dependence level of the person cared for, the cognitive state of the person cared for, and the perception of a threat to life imposed by the disease. conditions of the transition: influential conditions in a person’s path towards a transition. they can facilitate or inhibit factors, including meanings, beliefs, cultural attitudes, socioeconomic level, preparedness, and knowledge (63). transitional nursing care for caregivers: nursing can favor the adoption of the role through strategies such as role clarification, role trial, and role modeling (15, 20, 34): • role clarification: it responds to the cognitive sphere, where caregivers must be clear about what to do and how. this activity is helpful in the initial stages when caregivers need simple and concrete instructions for the activities they should carry out, focused on the instrumental aspect. • role trial: once caregivers are faced with the role, they need to put it into practice to be able to progress. thus, trying out the role is a valuable tool to prepare the caregivers to cope with frequent care-related problems, as it will always be easier to face a situation to which they have at least been exposed. the family caregiver role can be learned in simulated scenarios. a do pt in g th e ro le o f c ar eg iv er o f c hr on ic p at ie nt s: s pe ci fic s it ua ti on t he or y 15 • role modeling: the role is performed through interaction with others, which is why it is helpful to interact with people with similar functions. based on this principle, it is beneficial for the caregivers to interact as much as possible with the health team and other caregivers. learning from examples and experiences ensures knowledge integration and availability to perform the role adequately. healthy transition: the transition is when people change their behavior and acquire a certain degree of self-awareness and mastery of new knowledge and skills to adapt to the new condition or role positively. theoretical hypotheses 1. regarding the transition conditions, women and older people enjoy healthier transitions towards adopting the caregiver role (64). 2. regarding age, the best transitions occur in caregivers of children and older adults since, due to their development stage, they are more used to being cared for (65, 66). 3. more complex and challenging transitions have been documented in the case of diseases that impair cognition compared to those that affect the physique of a person with a cncd (67). 4. low incomes imply worse conditions to perform the caregiver role, mainly when the family’s financial resources are mobilized towards the needs of the person cared for, forgetting that the caregiver also has needs (17, 61). 5. the role is a social construction resulting from interacting with significant others in such a context. in this case, the first significant other is the person cared for, followed by the family, the health team, and support networks (68). 6. although the expected behaviors can be precise, people may not act accordingly to adopt a given role. for example, it is frequent for family caregivers to know that it is healthy to have a break from care; however, many of them refuse to be relieved (69). 7. spirituality and social support favor interactions with other people that go through similar health situations; therefore, counting on these aspects assists in a healthy transition to adopting the caregiver role (70). 8. whether adoption of the caregiver role is healthy will exert a direct influence on the response patterns or outcome indicators related to quality of life and the caregiver’s perception of burden, anxiety, depression, and loneliness (71). 9. transitional nursing care offers the caregivers several tools based on teaching the role through clarification, training, trial, interaction with others, and role modeling (15). a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 42 16 2. theoretical process the scheme shown in figure 2 summarizes concepts from electronics: there is an input related to the intrinsic factors of the actors involved in the process; subsequently, there are three phases that can be sequential and which account for a caregiver’s possibilities until adopting their role. transitional care is the intervention modality in each of the phases. it can be integrated into the caregivers’ expertise, which, over time and due to adequate coping and self-efficacy strategies, can achieve higher awareness of their role. figure 2. scheme of the specific situation theory called “adopting the role of family caregiver of a chronic patient” care transcendence resilience w ell-being life project relational support role recognition relie f in te rp er so na l re lat ion shi ps – extrinsic factors caregiver´s intrinsic factors support network dependence level age gender degree of kinship nursing role supplementation clari�cation trial the role can be taught and learned social construction adopting the caregiver role is a transition self-e�cacy quality of life care rewards burden anxiety depression loneliness modeling transitional care role organization role adoption expert caregiver quality of the relathionschip co-living disease stage cognitive capacity work contract horas dia/cuidado time as caregiver financial support family functioning accese to health services access to care systems social recognition of the caregiver model of the provision of health services patient´s intrinsic factors time months 0 3 6 dyad su p p or t a nd le ad er sh ip n et w or k ro le m od el in g e m p ow er economic level cognitive capacity schooling level knowledge and training age gender cultural beliefs and practices about care sup po rt fo r a ct iv iti es o f d ai ly liv ing diveces instrum ental sup p ort m edications role imposition source: own elaboration. the theory’s scheme consists of three inter-related parts that account for a caregiver’s role adoption process from moment zero: diagnosis of the person cared for and the goal of becoming an expert caregiver. the first part simulates a container with input elements from the dyad (person with a chronic condition and caregiver) that can be classified into intrinsic or own factors and extrinsic or context related factors. the factors act as a starting point and correspond to the transition conditions, which can ease or hinder role adoption according to the theoretical postulates. the second component consists in the role adoption phases or moments, which are presented as a timeline but also as a process line; consequently, it is predicted that there will be role imposition a do pt in g th e ro le o f c ar eg iv er o f c hr on ic p at ie nt s: s pe ci fic s it ua ti on t he or y 17 between months zero and three, role organization between months three and six and, finally, role adoption itself from month six onwards. each phase has several concentric squares that indicate the key activities where the caregivers should be supported to advance to the next step. the third component corresponds to transitional care, its characteristics, strategies, and results; among the latter, the process of becoming an expert caregiver stands out as the primary outcome, with the self-efficacy level, quality of life, perception of care rewards, burden, anxiety, depression, and loneliness as its indicators. 3. validation and verification of the theory regarding verification of this specific situation theory, there is an empirical indicator called “adoption of the role of family caregiver of chronic patients”  (19), which derives from this theoretical proposal. according to hopcey and morse  (72), it is necessary to acknowledge that the maturity of a concept follows the pragmatism criterion; in other words, the empirical indicators are manifestations of the concept. this is a way to validate a theory, and, in our case, the instrument in question derives from the concepts that constitute this theoretical proposal, objectifying the role adoption process. in parallel to the theory, this instrument was published in a previous study (19, 36), describing its preparation and validation. for this empirical indicator, the conceptual bases of meleis’ theory of transitions and the empirical evidence were employed, which indicated that role adoption has three attributes: performance of the role (tasks), role organization, and responses towards the role. it has 22 items assessed on a likert-type scale with five answer options that vary from “never” to “always.” its validation was performed in 2017 with eight experts from colombia, chile, mexico, peru, and argentina for content validity, 60 caregivers for face validity, and 110 caregivers for construct validity. the results showed construct validity through a kaiser-meyer-olkin (kmo) test result of 0.835 and reliability through a cronbach alpha of 0.816 (19, 36). to the present day, this instrument has been employed in several research studies in the cncd context; however, no results are yet available, as some surveys are ongoing and others are in the publication submission process. implications for nursing nursing professionals working in the care of people with chronic diseases and their caregivers can use this theory to understand the process undergone by the dyad, in addition to retargeting a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 42 18 their interventions to ensure the adoption of the caregiver role. in the long-term, this improves quality of life, the perception of the care burden, anxiety, depression, and loneliness, as there is proper role response, organization, and performance. for research, this theory can guide future studies that explore various intervention strategies in populations comprised of people with chronic diseases and their caregivers, with characteristics inherent to each disease and even of each culture in which the caregiver role is adopted as a differentiating factor. regarding education in nursing, it can be considered that the theory would not only allow undergraduate and graduate students to see the theory-practice gap reduced but also enhance their participation in monitoring the dyad during their practice in any context where they perform their learning activities. there are already initial experiences on teaching in practice scenarios where this situational theory guides interventions in programs targeted at caregivers. conclusions it was possible to set out a specific situation theory on adopting the role of caregiver of chronic patients derived from multiple sources. prescriptive in nature, this theory presents the transition process followed by the caregivers to adopt this role healthily. the transitional care provided to the caregiver also progresses and ceases to be centered on instrumental and fundamental aspects to start focusing on role organization, life restructuring, and, finally, reflection and signification of the role. so, the care approach from the transitional perspective goes beyond the educational and cognitive interventions, as it is from strategies to teach the role that a healthy transition can be achieved. limitations. as this theoretical proposal is based on evidence and practical expertise, it will require future changes because theoretical knowledge is continuously growing. it is not possible to delimit the theoretical and practical paths only with this theoretical approach. with the conceptual evolution in the development of nursing theories, this proposal will continue to be validated or rejected (21, 22). acknowledgments. we thank the caregivers from the “cuidando a cuidadores®” program of universidad nacional de colombia, undergraduate and graduate students, and colleagues from colombia and latin america. they invited us to reflect on the fact that theoretical developments allow positioning our continent as a disciplinary knowledge niche that improves the care provided to people with chronic diseases and their caregivers. conflict of interest: the authors declare no conflict of interests. a do pt in g th e ro le o f c ar eg iv er o f c hr on ic p at ie nt s: s pe ci fic s it ua ti on t he or y 19 this paper derives from the authors’ experience in research, extension, innovation, and teaching in the “family caregivers of chronic patients” research line. references 1. organización mundial de la salud (oms). principales causas de muerte y discapacidad en el mundo: 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análisis de datos. coach empresarial asociado certificado. consultora internacional para americancol inc. carrera 17 no. 136 – 19. ap. 104. bogotá, d.c. colombia. amfmdej@yahoo.com, ana.fajardo@ americancol.com 2 estudiantes de x semestre. semillero de investigación. universidad el bosque. facultad de enfermería. carrera 7b bis no. 132 11. bogotá. colombia. gomelotitis@hotmail.com, amfmdej@yahoo.com, diego09_87@yahoo.com, mondragongina@hotmail.com, jeffiner3003@hotmail.com, leoto7@hotmail.com recibido: 19 de agosto de 2008 aceptado: 17 de febrero de 2009 resumen con el fin de conocer el comportamiento ante emergencias escolares de niñas y adolescentes, se realizó una investigación descriptiva sobre el impacto de un proceso educativo de un programa de salud al colegio. el estudio se adelantó entre el 2007 y el 2008, en la localidad de suba, en bogotá, con un grupo de 120 estudiantes, de 6 a 18 años, de estratos cero, uno y dos. mediante una metodología lúdica, pedagógica y de experiencias se evaluaron los conocimientos impartidos a esta población, en la que se observaron cambios en los estilos de vida y hábitos individuales y grupales. el 95% de las niñas validaron los conocimientos en salud sobre el manejo de emergencias escolares, el 100% de la población participó en la construcción del plan y trabajó en las prácticas, lo que crea conciencia acerca de la importancia del programa de salud escolar con el desarrollo de este tipo de planes. palabras clave salud escolar, emergencias, enfermería, educación en salud, actitud, conducta. (fuente: decs, bireme). educational module on school emergencies abstract a descriptive study on the impact of an educational module in a school health program was developed to find out how young girls and teenagers respond to emergencies at school. conducted between 2007 and 2008 in the suba district of bogotá, the study featured a group of 120 students between the ages of 6 and 18. the participants in the sample were from income brackets zero, one and two. using a method involving recreation, education and experiences, the know-how imparted to this population was evaluated, and changes in individual and group lifestyles and habits were observed. ninety-five percent (95%) of the girls endorsed the health information on response to school emergencies, 100% took part in constructing the plan and worked in the practice sessions, all of which creates an awareness of the importance of the school health program with the development of plans of this type. key words school health, emergencies, nursing, health education, attitude, conduct. (source: mesh, bireme). año 9 vol. 9 nº 1 chía, colombia abril 2009 50 61 ana maría fajardo-maldonado1 iván mauricio gómez-gonzález2 diego alexis corredor-peñaranda2 gina milena mondragón-romero2 jennifer paola ortegón-rodríguez2 david leonardo tovar-cortés2 51 módulo educativo sobre emergencias escolares ana maría fajardo-maldonado, iván mauricio gómez-gonzález y otros. módulo educativo sobre emergências escolares resumo para conhecer o comportamento frente a emergências escolares, foi realizada uma pesquisa descritiva sobre o efeito de um processo educativo em um programa de saúde na escola. o estudo foi levado a cabo entre 2007 e 2008 no distrito de suba em bogotá com um grupo de 120 estudantes de 6 a 18 anos de estratos zero, uno e dois. com uma metodologia lúdica, pedagógica e de experiências, foram avaliados os conhecimentos dados a esta população, na que foram observados alterações dos estilos de vida e dos hábitos individuais e grupais. o 95% das meninas validaram os conhecimentos em saúde sobre o manejo de emergências escolares. o 100% da população contribuiu à elaboração do plano e participou nas práticas. isso faz tomar consciência da importância do programa de saúde escolar. palavras-chave saúde escolar, emergência, enfermagem, educação em saúde, atitude, comportamento. (fonte: decs, bireme). 52 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 introducción el presente artículo presenta parte de los resultados de una investigación multidimensional “impacto de un proceso educativo en salud con enfoque biopsicosocial sobre los hábitos saludables en niñas dentro de un programa de salud al colegio, bogota d.c., 2007 a 2008” (1), en el cual se tomaron diferentes dimensiones en salud, relevantes para el bienestar integral de la población objeto. dentro de los componentes trabajados en la investigación principal, se implementaron módulos educativos, uno de los cuales se enfocó en la prevención y manejo de emergencias en el nivel escolar (2). para el desarrollo de este módulo se tomaron en cuenta varios principios pedagógicos: la transmisión de conocimientos y la construcción participativa desde la cotidianidad de la vida social y familiar de las escolares para generar bienestar, fomentar la formación de valores e incentivar las buenas prácticas de salud desde un contexto integral, social, cultural y ambiental (3). el constructivismo (4) es fundamental en el desarrollo conceptual y social del ser humano, de manera que la prevención de situaciones que alteren el bienestar individual y colectivo es una práctica importante en la cual se pueden mezclar componentes del área de la educación y del área de la salud (5). además, con ella se logra una cultura de protección y auxilio, que toda persona desde temprana edad debería tener como parte de su acervo cultural, y se mitiga el dolor o sus efectos, al tiempo que se promueven medidas preventivas que reduzcan los accidentes en los niños (6). para lograr una educación fundamentada, en el tema de emergencias escolares, se siguió un modelo pedagógico lúdico experiencial. con él se logra que la mayor parte de lo que la escolar aprende sea construido por ella misma a partir de sus vivencias y de los conocimientos adquiridos de experiencias que suceden en su entorno, y que esto sea afianzado por las personas que orientan el encuentro con el conocimiento por parte de la escolar (7). la psicología social distingue tres componentes en la actitud de las personas: el componente cognitivo (modo en que se percibe un objeto, suceso o situación, que con frecuencia es un estereotipo), el componente afectivo (sentimientos o emociones que suscita en un individuo la presentación afectiva de un objeto, suceso o situación, o su representación simbólica) y el componente conductual (tendencia o disposición a actuar de determinadas maneras con referencia a algún objeto, suceso o situación, discriminación…) (8). por tanto, en el momento de plantear un cambio actitudinal, debemos tener en cuenta estas tres dimensiones como punto de partida para construir hábitos saludables. también se ha corroborado que los niños tienen la capacidad lúdica asociada a cualquier acción que realizan dentro de los procesos de aprendizaje, generando sensaciones placenteras y displacenteras y, en consecuencia, mayor recordación de lo aprendido. el modelo pedagógico lúdico se sustenta en el desarrollo de la inteligencia emocional, propia del área cerebral de activación de las emociones y de la capacidad de relacionarse con el medio y las personas. el desarrollo de la inteligencia emocional, ampliamente investigado por psiquiatras y psicólogos, expresa que el éxito del aprendizaje, la realización y la satisfacción de las personas se debe en un 80% al grado de inteligencia emocional alcanzado y solo un 20% al coeficiente intelectual (9). la psicología social distingue tres componentes en la actitud de las personas: el cognitivo, el afectivo y el conductual. 53 módulo educativo sobre emergencias escolares ana maría fajardo-maldonado, iván mauricio gómez-gonzález y otros. según estos postulados, la educación en salud sobre emergencias escolares, el realizarla a través de la lúdica, permite: mayores grados de aprendizaje, por su efecto placentero, al activar las emociones asociadas a situaciones que protegen o ponen en riesgo la vida; y mayor recordación y desarrollo de actitudes de protección asociadas al autocuidado, que en su día a día llegan a convertirse en un hábito (10). es en este punto donde consideramos que se logra impactar y generar cambios favorables y saludables. la inversión en educación en salud sobre emergencias escolares (11), para este efecto, es importante, ya que al presentarse un accidente en el ambiente escolar, la atención que se brinde donde ocurre el accidente en los primeros minutos del incidente es esencial para la supervivencia y recuperación satisfactoria y su calidad de vida. por ejemplo, en méxico los accidentes constituyen un problema de salud pública, ya que han ocupado los primeros lugares como causa de muerte desde la década del ochenta. en 1998, estos continuaron como primera causa de mortalidad en el grupo de preescolares y escolares, con una tasa de 9,7 y 9,3 por 100.000 habitantes, respectivamente. en el estado de jalisco, en el año 2000, este problema ocupó el primer lugar como causa de muerte en los escolares, con 174 defunciones, lo que representó una tasa de 11,8 por 100.000 habitantes (12). esto justifica que la educación escolar deba contribuir en la formación integral de la niñez y la juventud teniendo como bases fundamentales la solidaridad y el respeto por la vida, y también permitiendo la libertad de expresión de conocimientos, para cambiar o mejorar comportamientos que lesionen la salud personal, familiar, comunitaria y ambiental, y, de alguna manera, valida la pedagogía a través de la lúdica (13). estos cambios se pueden lograr aprovechando las cualidades de esta población, ya que todo lo que pasa a su alrededor, comportamientos, situaciones, expresiones artísticas, culturales, musicales, deportivas, etc., es asimilado y expresado en el medio en el cual ella se desenvuelve (14). por esta razón, se pretende crear una conciencia de autoprotección, aprendizaje, prevención y fomento para evitar situaciones negativas en caso de emergencias (15). encontrar esos líderes que en un futuro no muy lejano sean capaces de crear estrategias de salud desde la prevención y promoción en lo cotidiano, no solo para un pequeño grupo poblacional, sino también a nivel nacional e internacional, en un proceso continuo que debe cimentarse desde los primeros años de vida y moldearse en la infancia y adolescencia (16). materiales y métodos la implementación del módulo educativo para la enseñanza de buenas prácticas en el tema de emergencias escolares se desarrolló con un grupo de niñas y adolescentes de 6 a 18 años, por medio de sesiones educativas con metodología lúdica, dentro del programa de salud escolar de una fundación para la protección de niñas de estratos cero, 1 y 2, de la localidad de suba de bogotá, para desarrollar hábitos protectores en el ambiente escolar extensivos a sus familias. el grupo de 120 niñas se distribuyó por grupos de edad (tabla 1). se realizó una primera aproximación con juegos y dinámicas para conocer el pensamiento de las niñas acerca de su autocuidado, y saber de los accidentes, riesgos escolares, expectativas e inquietudes sobre conocimientos en primeros auxilios (17). posteriormente se aplicó un cuestionario de preguntas abiertas y cerradas referentes al tema de la inversión en educación en salud sobre emergencias escolares es importante, ya que al presentarse un accidente en el ambiente escolar, la atención que se brinde en los primeros minutos del incidente es esencial para la supervivencia y recuperación satisfactoria y su calidad de vida. 54 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 emergencias escolares, para establecer su nivel de entrada previo y elaborar los contenidos a partir de los cuales construir los talleres y sesiones educativas. la indagación inicial permitió ponderar las necesidades cognitivas por grupo de edad, escoger la actividad lúdica a través de teatro, dramatizados, juego de roles, música, danza, pintura, por edad y grado de escolaridad (18). con las actividades anteriores se construyeron materiales y experiencias alrededor de la temática de emergencias escolares, lo que permitió generar escenarios para la expresión de emociones con mayor aprendizaje, percibido por ellas al “aprender jugando” (19). al realizar el taller se aplicaba un cuestionario previo al test, con el fin de valorar el conocimiento inicial en el tema de emergencias. luego de valorar estos conocimientos, se realizaron talleres experienciales simulando situaciones de emergencia, tales como incendios, terremotos, inundaciones, accidentes; y crearon eventos de salud secundarios con temas como quemaduras, fracturas, paros cardiorespiratorios, accidentes de tránsito, traumatismos en diferentes grados de complejidad, apoyados en el manual de primeros auxilios y autocuidado de la cruz roja colombiana (20). una vez vivenciado el taller, se aplicaba el cuestionario postest, el cual nos permitió valorar el grado de aprendizaje, recordación y satisfacción y así estimar en las niñas la efectividad de la metodología lúdica empleada en el módulo. la metodología que seguimos para desarrollar el módulo educativo en emergencias escolares con pedagogía lúdica experiencial se puede sintetizar en el siguiente mapa: figura 1. pedagogía con metodología lúdica experiencial (21). se realizaron talleres simulando situaciones de emergencia y se crearon eventos de salud secundarios, apoyados en el manual de primeros auxilios y autocuidado de la cruz roja colombiana. 55 módulo educativo sobre emergencias escolares ana maría fajardo-maldonado, iván mauricio gómez-gonzález y otros. para la construcción del módulo, nos apoyamos en temas específicos de emergencias a partir de la exploración inicial realizada con las niñas, los profesores (pedagogos, trabajadora social, psicóloga, músico) y administrativos (religiosas), y también organizamos la información según la ponderación y mayor frecuencia establecida, elaboramos un objetivo para cada taller, seleccionamos la lúdica según el subtema y el grupo de edad, trabajamos en zonas abiertas y zonas cerradas, evaluamos nivel de entrada y salida, con cuestionarios referentes al área cognitiva. para el área emocional, observamos las actitudes y comportamientos, valorados directamente, con filmaciones, fotografías y grado de satisfacción manifestado por cada una de las escolares, profesores y administrativos. parte del desarrollo de este módulo de emergencias escolares lo constituyó el reconocimiento de las zonas de riesgo de las estructuras físicas que conforman la fundación, como instalaciones eléctricas y de gas, tuberías de agua, sitios de almacenaje de residuos y objetos potencialmente peligrosos, bodegas, sótanos, basureros, oficinas, comedor, dormitorios, baños, cocina, vestidores, zona de lavaderos, enfermería, ventanas, puertas de salida, escaleras, zonas verdes, explanadas, empedrado, entre otros, para luego proceder a construir conjuntamente el plan de emergencias escolares, demarcar con letreros fluorescentes en la oscuridad las rutas de evacuación y realizar recorridos dinámicos lúdicos con las niñas. en estas actividades se fomentó la formación de líderes para coordinar y manejar a las niñas más pequeñas. este escenario fue uno de los más propicios para “aprender jugando”, pues se experimentaban muchas emociones, como miedo, temor, alegría, satisfacción, y se despertaba la competencia sana, la colaboración, la solidaridad, el trabajo en equipo, la disciplina, la escucha, el respeto y la protección de la vida, el ambiente y el entorno. la participación de docentes y administrativos de la institución fue un factor importante para facilitar la implementación del plan escolar de emergencias de la fundación, de lo que se obtuvo un documento final que recoge la normatividad, el panorama de riesgos, los comités, las funciones, los roles, las rutas y mapas de evacuación, el cronograma de simulaciones por año y las cartillas educativas, entre otros aspectos (22). resultados la distribución de las 120 niñas por edad se puede observar en la tabla 1. la mayor representación estuvo dada por niñas de 9 a 11 años. tabla 1. distribución de las escolares de la fol por edad. número de participantes 6 8 25 9 11 43 12 13 23 14 15 19 16 18 10 total 120 en el tema de emergencias escolares, se encontró relación con accidentes, caídas, fracturas, golpes, intoxicaciones, dificultades respiratorias, agresiones físicas y verbales. rango de edad 56 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 la tabla 2 presenta la distribución de las 120 niñas en cinco (5) grupos de edad y los hallazgos más significativos, para realizar los talleres lúdicos experienciales como parte del aseguramiento de nuestra metodología de aprendizaje, pues encontramos que es mayor, más rápido y efectivo el trabajo con grupos pequeños de máximo 20 personas. en la etapa de indagación, encontramos muchas inquietudes, relacionadas con el qué, el cómo, el para qué, y hallamos el o las responsables de determinados comportamientos. en el tema de emergencias escolares, se encontró relación con accidentes, caídas, fracturas, golpes, intoxicaciones, dificultades respiratorias, agresiones físicas y verbales. fue interesante descubrir menor grado de conocimiento sobre temas de emergencias escolares. menor desarrollo de lectura y escritura. mayor expresión de sentimientos, miedos y temores personales. mayor número de expresiones artísticas. mayor nivel en las expresiones verbales. preguntas sobre manejo de fracturas, sangre nasal, mal de estómago. moderado grado de conocimiento sobre temas de emergencias escolares. manejo de lectura y escritura. mayor expresión de sentimientos, miedos y temores personales. expresiones de experiencias ocurridas en la casa y el colegio. preguntas sobre manejo de accidentes camino al colegio, robos con puñal y robos dentro del salón de clase. conocimientos básicos sobre emergencias escolares. manejo de lectura, escritura, números. pensamiento más elaborado. presencia de mitos y leyendas sociales en sus narraciones. lenguaje corporal y verbal agresivo. preguntas sobre manejo de golpes, afrentas y burlas de otras niñas en el salón. conocimientos sobre emergencias escolares asociados a primeros auxilios. mayor nivel cognitivo desarrollado; capacidad de análisis. establecimiento de amistades. lenguajes corporales seductores, amables, agresivos y defensivos. preguntas sobre manejo de accidentes en casa, quemaduras, incendios. conocimientos sobre emergencias escolares relacionadas con la violencia y la forma de relacionarse con las otras personas. pensamientos más elaborados: autonomía, respeto, autoridad; establecimiento de emociones más evidentes: rabia, tristeza, ira, amor. preguntas sobre detección de peligros en la casa, el colegio y los sitios de recreación y “rumba”. rango de edad 6 a 8 años 9 a 11 años 12 a 13 años 14 a 15 años 16 a 18 años hallazgos significativosgrupo 1 2 3 4 5 tabla 2. grupos de escolares y hallazgos significativos expresiones de las niñas, como “ella usa la falda muy corta y los niños la miran”, “me di puños con mi amiga porque es una mostrona”, detrás de varias expresiones encontramos disparadores de agresividad que terminaban en agresiones físicas y psicológicas y en varios casos se acompañaban de incidentes y accidentes en el ámbito escolar. también encontramos co57 módulo educativo sobre emergencias escolares ana maría fajardo-maldonado, iván mauricio gómez-gonzález y otros. nocimientos básicos de primeros auxilios, temores, creencias, mitos y leyendas. en este sentido, aparecieron otros elementos relacionados con la convivencia familiar y social, donde estos actores influyen en las actitudes y comportamientos de las niñas en su forma de sentir, pensar y reaccionar ante una situación determinada. se aplicaron 120 test previos que fueron contestados por las escolares. además de corroborar nuestros hallazgos iniciales, estos indicaron que los conocimientos sobre emergencias los han adquirido de forma empírica, en el núcleo familiar, social y educativo del que hacen parte en su ámbito de educación formal de centros educativos públicos. en los 120 postest analizados se obtuvieron resultados referentes a la adhesión y prácticas de los conocimientos sobre emergencias escolares después de las actividades educativas con metodología lúdica. a lo largo de los primeros talleres se evidenció la dificultad del grupo para organizarse, especialmente en las niñas de 6 a 12 años, lo cual se tuvo en cuenta como uno de los componentes esenciales a la hora de afrontar una emergencia. de esta circunstancia surgieron comportamientos espontáneos en las niñas mayores, quienes fueron demostrando sus aptitudes de liderazgo y en quienes nos apoyamos para formar las líderes de las brigadas grupales. del grupo de 15 a 18 años salieron tres líderes claramente aceptadas por las niñas de los otros grupos, que de alguna manera organizaron cada grupo y permitieron ir construyendo los roles dentro del plan de emergencias escolares. otros hallazgos significativos referentes a los subtemas manejados en los talleres, según los objetivos establecidos, fueron: el 90% de las escolares manifestaron desconocer cómo responder en caso de presentarse una hemorragia y cómo reconocer el tipo y grado de gravedad; el 88% desconoce cómo se puede reconocer una fractura y cómo responder en caso de presentarse; el 96% no sabe cómo reconocer una intoxicación ni qué hacer en estos casos; y el 98% desconoce qué hacer en caso de presentarse algún tipo de dificultad respiratoria y cómo saber si proviene de una obstrucción. durante las sesiones educativas se abordaron estos temas, además de otro sugerido por las escolares y el personal docente y administrativo de la institución referente a la elaboración de un plan de evacuación en emergencias, en caso de catástrofes naturales, como terremotos, inundaciones, deslizamientos de tierra e incendios de combustibles. se pudo establecer que estas inquietudes estaban directamente relacionadas con eventos climáticos y sociales que les ocurrían en sus ámbitos de crecimiento y desarrollo: el colegio, la casa, la fundación, el barrio, la vereda y en general en la ciudad y el país. para el tiempo en que se llevaba a cabo el módulo educativo sobre emergencias escolares, las noticias de incendios, deslizamientos de tierra, inundaciones, escolares heridos dentro y fuera del colegio, agresiones por profesores a sus estudiantes, situaciones violentas entre los escolares en los colegios públicos, ocupaban los primeros puestos en información noticiosa. durante la realización de los talleres se destacó el interés por parte de las niñas y el personal docente en la metodología implementada: lúdica experiencial. los profesores manifestaron la importancia del modelo constructivista como fundamento para impartir conocimiento a este los resultados evidenciaron aumento de los conocimientos en emergencias, impartidos por el personal de enfermería a la población escolar. 58 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 tipo de población y lograr más y mayor satisfacción en el aprendizaje. los resultados de los test aplicados después de la finalización de los talleres (que se llevaron a cabo los días lunes, durante el año 2007) evidenciaron aumento de los conocimientos en emergencias, impartidos por el personal de enfermería a la población escolar, ya que en el tema de hemorragias, el 75% demostró conocimientos en cuanto a su gravedad y lo que se debe hacer para detenerlas; en el tema de fracturas, el 90% de la población identificó qué son, cómo se reconocen y qué se debe hacer en caso de presentarse una; y el 85% de la población escolar supo lo que se debe hacer en caso de presentarse personas con algún tipo de dificultad respiratoria; además, se capacitó a la población en temas de atención y prevención de emergencias, activación de sistemas de emergencias y publicación de números de emergencias, según las disposiciones y redes locales de bogotá, información fácilmente recordada por las niñas después de varios meses de haber transcurrido las actividades. como producto final del desarrollo del módulo educativo en emergencias escolares se elaboró el plan escolar de emergencias, se estableció el comité de emergencias con sus respectivas funciones, se dio a conocer la importancia de designar la brigada de emergencias para las internass, con sus respectivas funciones y se generó la formación de líderes tutoras: las de 15 a 18 años trabajaron en el liderazgo de procesos de atención y evacuación de las menores de 6 a 14 años, para internas y semiinternas. destacamos como principal logro el que la totalidad de la población de la fundación (142 personas entre niñas, adolescentes, profesores y personal administrativo) hubiera participado en el módulo en emergencias escolares. fue tan importante la metodología lúdica experiencial desarrollada, que se logró identificar reacciones y emociones clave al momento de afrontar una emergencia y evacuación escolar; por ejemplo, una de las profesoras manifestó abiertamente que se “paralizaba” en estas situaciones, por lo que los participantes del módulo fueron aclarando quiénes podrían ser los lideres más eficaces, las personas que despertaban tranquilidad, y quiénes eran más hábiles para actuar bajo presión y en presencia de miedo y temor, en forma favorable para cuidar y proteger la vida de los demás. teniendo en cuenta que en la modalidad de internado los profesores no estaban presentes durante la noche, se fortaleció el liderazgo de las mayores en la figura de tutoras, para apoyar y constituir los comités internos y asegurar el correcto proceder, en caso de tener que evacuar las instalaciones. así mismo, se reforzaron actitudes en las niñas de 6 a 14 años, de modo que en la activación de una evacuación supieran que había una responsable de las niñas de un dormitorio, lo cual se logro al solicitarles que se calzaran y se tomaran de la mano en cadena para seguir la voz de la tutora, quien, además de asegurarse de que no faltara nadie, daba las instrucciones para movilizarse y llegar al punto de encuentro, establecido en la cancha de baloncesto. se percibieron comportamientos seguros y comportamientos evasivos, miedos, temores y capacidad de autocontrol ante la presencia de una figura guía mayor, fuerte y enérgica. en el caso de las niñas y adolescentes semiinternas, el impacto del módulo surgió efecto en ellas, dado que se recibió relas niñas llegaron a sus casas a revisar las instalaciones y a comentar prácticas de seguridad para evitar accidentes en el hogar. 59 módulo educativo sobre emergencias escolares ana maría fajardo-maldonado, iván mauricio gómez-gonzález y otros. troalimentación positiva por parte de los padres y acudientes en las reuniones dominicales, en donde expresaron lo que las niñas aprendieron y cómo habían llegado a sus casas a revisar las instalaciones y a comentar prácticas de seguridad para evitar accidentes en el hogar, en cosas sencillas como no prender velas, el manejo del cocinol, del gas, de detergentes, el almacenamiento de los alimentos, el manejo de sustancias como alcohol, creolina, insecticidas, venenos para ratas, pastillas, remedios caseros, y de la seguridad de ellas y de sus hermanos. además, comentaban que habían aprendido de sus hijas muchas cosas sobre las emergencias escolares. otra dificultad que se evidenció durante la realización de los talleres se dio con la disponibilidad de los bomberos de la localidad para desplazarse a las instalaciones de la fundación a realizar los simulacros de incendio y manejo de extintores, con la inclusión de actores externos: padres y acudientes de las niñas; sin embargo, las autoridades de bomberos plantearon la posibilidad de que las niñas asistieran a la estación para realizar allí la simulación y capacitación en el manejo de extintores, dentro de la programación académica del siguiente año. conclusiones a la luz de los resultados obtenidos, se hace imperativo continuar ofreciendo a la población escolar esta enseñanza participativa constructivista con metodología lúdica, acerca de estos temas, pues en los niveles de educación preescolar y secundaria media se ha venido impartiendo hasta la fecha una educación tradicional y conservadora, a través de la enfermería, la salud ocupacional y el desarrollo de comités paritarios en las empresas y los colegios, al amparo de lo que ordena la ley 1016 de 1989, que reglamenta la organización, funcionamiento y forma de programas de salud ocupacional; sin embargo, son actividades de carácter más administrativo, político y documental que de enseñanza aprendizaje simulado en la que participen todos los actores escolares. esta investigación permitió la participación activa de las escolares de 6 a 18 años, de los docentes y del personal directivo y administrativo de la fundación, en la construcción del plan de emergencias escolares, perspectiva que a la vez permitió validar el plan, pues cada una de las personas, del total de 142, aportaron aspectos que en algún momento los investigadores no abarcamos, con lo que se logró obtener un plan funcional, de fácil aprendizaje por su presentación lúdica. se pudieron comprobar los efectos exponenciales que provoca la educación con propósitos de cambio de actitudes y comportamientos de las escolares a sus padres, acudientes y otros compañeros de la formación escolar institucional, pues se recibió retroalimentación y las niñas compartieron, revisaron su casa, detectaron factores de riesgo y conversaron sobre qué hacer en situaciones de emergencia que se puedan presentar en sus hogares o en otros sitios donde convergen muchas personas. al explorar este tipo de población e impartir educación desde el modelo constructivista para beneficios presentes y futuros, se da la oportunidad del surgimiento de líderes que en el presente y en el futuro pueden implementar estrategias de promoción, prevención y educación, seguir este círculo de enseñanza en su esfera social y abarcar nuevos procesos, como los propuestos en el programa de salud al colegio, de la secretaría distrital de bogotá, se pudieron comprobar los efectos exponenciales que provoca la educación con propósitos de cambio de actitudes y comportamientos de las escolares a sus padres, acudientes y otros compañeros de la formación escolar institucional. 60 año 9 vol. 9 nº 1 chía, colombia abril 2009 aquichan issn 1657-5997 en el que se contempla la accidentalidad escolar, con el propósito de promover una cultura del cuidado y creación de una ruta de acceso para la atención de urgencias con calidad para todas y todos los alumnos de colegios públicos de bogotá, a través del convenio 137. pudimos establecer que en la educación en salud a través de módulos específicos de metodología lúdica se hace visible la multicausalidad de los incidentes y accidentes escolares, cuyo común denominador era la parte actitudinal y emocional de las personas en su esfera personal, familiar y social, tanto en lo físico como emocional. esto confirma la importancia de trabajar el desarrollo de la inteligencia emocional desde edades tempranas, dentro de los proyectos educativos institucionales, en las familias y en la sociedad en general. establecimos que el impacto del proceso enseñanza aprendizaje está relacionado con las influencias procedentes de los comportamientos de género originados en escenarios escolares, familiares, culturales, sociales y ambientales (23). de alguna forma, la solidaridad identificada en las niñas se hacía más fuerte cuando había situaciones cercanas que eran como espejos para su vida, instante en que se tocaba más la esfera emocional y se construía una experiencia que se depositaba en su cerebro límbico, emocional y racional, desarrollando una memoria emocional que se activaba de manera protectora y reactiva ante situaciones de evidente peligro (24). como falencia de la investigación, la población con la que se trabajó es exclusivamente femenina. esto se constituye en una oportunidad para desarrollar investigaciones con población masculina y mixta de manera paralela, para contrastar y observar nuevos o iguales hallazgos actitudinales y comportamentales relacionados con las emergencias escolares. como conclusión general, rompimos un paradigma con respecto a las emergencias escolares, pues hasta ahora se había circunscrito en un área muy externa y física y de primeros auxilios. llegamos a la conclusión de que las emergencias escolares se inician en una dimensión interna actitudinal de la persona, y que están relacionadas con su manera de pensar y sentir, así como con el grado de conocimiento y el nivel de inteligencia emocional desarrollados, que involucra además de la accidentalidad física, los incidentes del orden psicosocial, cultural y espiritual (25). referencias 1. fajardo a, corredor d, garcía j, gómez i, mondragón g, ortegón j, tovar l. impacto de un proceso educativo en salud con enfoque biopsicosocial sobre los hábitos saludables en niñas dentro de un programa de salud al colegio, bogotá d.c., 2007 a 2008. ana maría fajardo (ed.). libro electrónico: isbn:978-958-44-4234-5. 2008; 3-90. 2. organización panamericana de la salud. la enseñanza de la salud infantil en las escuelas y facultades de enfermería de américa latina. programa aiepi; 2005. [sitio en internet]. disponible en: http:// www.paho.org/spanish/ad/fch/ca/si-enfermeria. pdf. consultado: 20 de marzo de 2007. 3. alcaldía mayor de santafé de bogotá, secretaría de tránsito y transporte. evaluación del plan de acción del proyecto 1165 “educación y prevención de la accidentalidad”, 2001-2003. [sitio en internet]. disponible en: http://www.movilidadbogota.gov. co/admin/contenido/documentos/evaluacionb3n1165_2001_2003_11_11_8.pdf. consultado: 13 de junio de 2007. 4. valeiras n, meneses v. modelo constructivista para la enseñanza de las ciencias en línea. 2005. [sitio en internet]. disponible en: http//ensciencias.uab. es/webblues/www/congres2005/material/comuni_orales/4_procesos_comuni/4_3/valeiras_758. consultado: 4 de junio de 2007. 5. ii congreso mundial de la internacional de la educación. resolución sobre la promoción de la salud y la salud escolar washington d.c., 25-29 de julio de 1998. washington d.c.: resolución internacional de la educación; 2008. 6. aldrete m, landázuri m, mendoza p, aranda c. la actitud de los profesores de educación primaria ante los primeros auxilios. revista de educación y desarrollo 2004; i(1): 20. 7. gabari mi, buitrago he. simulación y entrenamiento en hábitos de prevención de accidentes infantiles, demanda docente de recursos multimedia en navarra (españa). norte de santander, colombia: universidad de pamplona; 2006. 61 módulo educativo sobre emergencias escolares ana maría fajardo-maldonado, iván mauricio gómez-gonzález y otros. 8. wander jw. manual de psicología social. barcelona: paidós; 1994. 9. goleman, d. inteligencia emocional. colección ensayo. barcelona: kairos. 10. comisión nacional de prevención de riesgos y atención de emergencias. taller de entrenamiento para brigadas escolares; brigada de primeros auxilios. [sitio en internet]. disponible en pdf: http:// www.cne.go.cr/cedo-riesgo/docs/2877/2877. consultado: 15 de octubre de 2007. 11. montenegro l. ¿por qué es importante la inversión en educación para la niñez en colombia? revista divergencia 2006 agosto: 4. 12. grisales h, caicedo b, serna c, uribe d. causas de mortalidad en jóvenes y su contribución al cambio en la esperanza de vida: cali, 1989-1999. biomédica 2005; 36(2): 3-4. 13. giraldo l, mera r, clima social escolar. percepción del estudiante. revista colombia médica 2000; 31 (1): 1-2. 14. medina n. boletín electrónico de salud escolar. tipica 2005; 1(1): 2. 15. departamento nacional de planeación; felipe barrera, camilo domínguez. educación básica en colombia. opciones futuras de políticas 2006. [sitio en internet]. disponible en: http://www.dnp.gov.co/ archivos/documentos/mp_en_que_vamos/educacion_basica.pdf. consultado: 14 de enero de 2008. 16. gavidia c. la transversalidad y la escuela promotora de salud. revista especializada de salud pública 2001; 75(6):1-3. 17. cazull i, rodríguez a, sanabria g, hernández r. enseñanza de los primeros auxilios a escolares de cuarto a noveno grados. revista cubana de salud pública 2007; 33(2): 3-5. 18. cruz roja de la juventud; manual del alumno, equipos escolares de emergencia 2002. [sitio en internet]. disponible en: http://desastres.ceprode. org.sv/noticias/iniciativagestion/fichainiciativa/ cruzroja_archivos/planescolar-crs.pdf. consultado: 3 de marzo de 2008. 19. montes r. ¿una pedagogía distinta? cambios paradigmáticos en el proceso educativo. cuadernos de iberoamérica. madrid: oei; 2001. 20. saludencolombia.com. guía de primeros auxilios. cruz roja colombiana. [sitio en internet]. disponible en: http://www.saludencolombia.com/pages/ primeros_auxilios/index.ph. consultado: 22 de noviembre de 2007. 21. fajardo am (ed.). atención de enfermería en el ámbito educativo. bogotá; 2008. 22. corredor da, fajardo am, gómez im, mondragón gm, ortegón jp, tovar dl. documento institucional. plan de emergencias escolares fol, bogotá; 2007-2009. 23. warinerman c. familia, trabajo y género. méxico: fce-unicef; 2002. 24. bradberry t, greaves j. las claves de la inteligencia emocional. bogotá: norma; 2007. 25. fajardo am. modelo biopsicosocial, cultural y espiritual: aplicación en un programa de enfermería. revista colombiana de enfermería 2006; 1: 41-47. 100 108 necessidades espirituais.indd 100 aquichan issn 1657-5997 maria zita castelo-branco1 dalila brito2 clementina fernandes-sousa3 necessidades espirituais da pessoa doente hospitalizada: revisão integrativa 1 enfermeira. mestre em ciências de enfermagem, professor adjunta, universidade de trás-os-montes e alto douro, brasil. mbranco@utad.pt 2 enfermeira. mestre em ciências de enfermagem. enfermeira chefe, centro hospitalar de vila nova de gaia – espinho, brasil. dalilacbrito@gmail.com 3 enfermeira. mestre em ciências de enfermagem. professor adjunta, instituto politécnico de viana do castelo, brasil. clementinasousa@ess.ipvc.pt recibido: 8 de marzo de 2012 enviado a pares: 4 de junio de 2012 aceptado por pares: 13 de septiembre de 2013 aprobado: 17 de septiembre de 2014 año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 100-108 para citar este artí culo / to reference this article / para citar este artigo castelo-branco, m., brito, d., fernandes-sousa, c. (2014). necessidades espirituais da pessoa doente hospitalizada: revisão integrativa. aquichan. vol. 14, no. 1, 100-108. resumo a espiritualidade é intrínseca ao ser humano e manifesta-se também associada à doença, à perda ou quando o ser humano é confrontado com o sofrimento ou a morte. como a expressão das necessidades espirituais não se processa de igual forma na pessoa saudável ou doente, a sua atenção requer uma intervenção rigorosa e profissional. objetivos: identificar necessidades espirituais da pessoa hospitalizada e conceitos de espiritualidade. método: revisão integrativa de dez estudos quantitativos e qualitativos sobre necessidades espirituais, publicados no período de 2004 a 2011 nas bases de dados (ebsco, medline, sage e b-on), orientada pelas questões: quais as necessidades espirituais da pessoa hospitalizada e os conceitos de espiritualidade utilizados nos estudos selecionados? resultados: da análise dos artigos emergiram as seguintes necessidades espirituais: procura de sentido na doença e sofrimento; estar em relação com os outros e com o ser superior, o que indica presença evidente de valores, crenças espirituais, fé, esperança e necessidades religiosas, associadas aos conceitos: sentido de vida, relacionamentos, transcendência e práticas religiosas. conclusões: os doentes podem expressar as suas necessidades espirituais por meio das formas mais sutis. os enfermeiros devem avaliar as necessidades espirituais de “mente aberta” e serem capazes de proporcionar a assistência mais adequada. palavras-chave espiritualidade, religião e medicina, papel do doente, enfermagem, hospitalização (fonte: decs, bireme). 101 necessidades espirituais da pessoa doente hospitalizada: revisão integrativa l maria zita castelo-branco, dalila brito, clementina fernandes-sousa año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 100-108 necesidades espirituales de la persona enferma hospitalizada: revisión integrativa resumen la espiritualidad es intrínseca al ser humano y se manifiesta también asociada a la enfermedad, la pérdida o cuando el ser humano se enfrenta con el sufrimiento o la muerte. como la expresión de las necesidades espirituales no se procesa de igual forma en la persona sana o enferma, su atención requiere una intervención rigurosa y profesional. objetivos: identificar necesidades espirituales de la persona hospitalizada y conceptos de espiritualidad. método: revisión integrativa de diez estudios cuantitativos y cualitativos sobre necesidades espirituales, publicados en el período del 2004 al 2011 en las bases de datos (ebsco, medline, sage y b-on), orientada por las interrogantes: ¿cuáles son las necesidades espirituales de la persona hospitalizada y los conceptos de espiritualidad utilizados en los estudios seleccionados? resultados: del análisis de los artículos emergieron las siguientes necesidades espirituales: busca de sentido en la enfermedad y sufrimiento; estar en relación con los otros y con el ser superior, lo que señala presencia evidente de valores, creencias espirituales, fe, esperanza y necesidades religiosas, asociadas a los conceptos: sentido de vida, relaciones, transcendencia y prácticas religiosas. conclusiones: los enfermos pueden expresar sus necesidades espirituales por medio de las formas más sutiles. los enfermeros deben evaluar las necesidades espirituales de “mente abierta” y ser capaces de proporcionar la asistencia más adecuada. palabras clave espiritualidad, religión y medicina, rol del enfermo, enfermería, hospitalización (fuente: decs, bireme). 102 aquichan issn 1657-5997 the spiritual needs of ailing hospitalized patients: an integrative review abstract spirituality is intrinsic to human beings and is also manifest in association with illness, loss or when man is faced with suffering or death. because those who are ill do not process the expression of spiritual needs the same way as healthy persons, their care requires thorough and professional intervention. objectives: this study is designed to identify the spiritual needs of hospitalized patients and concepts of spirituality. methodology: it involves an integrative review of ten quantitative studies on spiritual needs published from 2004 to 2011 in databases (ebsco, medline, sage and b –on). the guiding question was: what are the spiritual needs of a hospitalized person and the concepts of spirituality used in the selected studies? results: an analysis of the articles revealed several spiritual needs; namely, the search for meaning in illness and suffering, and being in relationship with others and with god, signaling the obvious presence of values, spiritual beliefs, faith, hope and religious needs associated with the concepts of the meaning of life, relationships, transcendence and religious practices. conclusions: patients are able to express their spiritual needs through the most subtle of ways. nurses must assess spiritual needs with an "open mind" and be able to provide the appropriate assistance. key words spirituality, religion and medicine, sick role, nursing, hospitalization (source: decs, bireme). año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 100-108 103 necessidades espirituais da pessoa doente hospitalizada: revisão integrativa l maria zita castelo-branco, dalila brito, clementina fernandes-sousa introdução as necessidades espirituais são indissociáveis das necessidades fundamentais do ser humano. na realidade, integram aspectos cognitivos, experienciais e comportamentais, que podem incluir sentimentos de esperança, conforto e paz interior, com profundas implicações no bem-estar, sendo que, a sua expressão e intensidade não se processa de igual forma na pessoa saudável e doente. a importância da espiritualidade nos processos de saúde/ doença é reconhecida pelos profissionais de saúde e demonstrada pela evidência científica, embora continue a ser esquecida na assistência de enfermagem (1, 2). as classificações de linguagem científica de enfermagem que, por si só afirmam o conteúdo e a finalidade da profissão, também consideram a dimensão espiritual. é exemplo disso a north american nursing diagnosis association (3), que identificou e operacionalizou, entre outros, os seguintes diagnósticos de enfermagem: disposição para o aumento do bem espiritual, angústia espiritual e religiosidade prejudicada. the international council of nurses (4) também definiu fenômenos como bem-estar espiritual, angústia espiritual e crença espiritual. a direção geral de saúde, através dos direitos do doente internado (5) apresenta linhas de orientação dirigidas aos enfermeiros para a promoção de um ambiente respeitador dos direitos humanos, dos valores, das tradições e das crenças espirituais individuais, familiares e da comunidade. esta revisão integrativa tem como objetivo identificar e analisar as necessidades espirituais do doente hospitalizado e os conceitos de espiritualidade utilizados nos estudos selecionados. método a amostra foi constituída por estudos de investigação publicados, selecionados a partir das bases de dados: ebsco, medline, sage e b-on. definiram-se cinco termos de pesquisa: spirituality; religiosity; spiritual needs, inpatient or hospitalized. foram excluídos os estudos que não identificavam ou não descreviam as necessidades espirituais dos doentes durante a hospitalização, os que estavam relacionados com os cuidados às crianças e os artigos de revisão. deu-se preferência aos estudos realizados por enfermeiros e publicados em revistas de enfermagem. numa primeira etapa foi feita uma primeira leitura dos resumos dos artigos para verificar a sua importância. da análise crítica do conjunto dos documentos encontrados, a amostra foi constituída por 10 estudos de investigação, publicados sob a forma de artigo no período de 2004 a 2011. nos estudos de natureza quantitativa foram utilizadas as escalas the spiritual needs inventory (sni) (6, 7), a spiritual transcendence measure (stm) (8), spiritual interests related to illness tool (9), spiritual perspective scale (sps) e duas questões abertas (10) e a escala valorativa del diagnóstico enfermero “sufrimiento espiritual” (11). nos estudos com metodologia qualitativa foram utilizadas a entrevista semiestruturada (12), a entrevista em profundidade com abordagem fenomenológica (13, 14) e o metassumário (15). na análise temática foram construídos quadros com o resumo dos resultados dos estudos que descreviam as necessidades espirituais, sendo sucessivamente comparados e filtrados de forma a excluir aspectos sem relevância. sem pretendermos desenvolver uma meta-análise ou uma meta-síntese, mas uma revisão integrativa da literatura, apresentam-se a seguir os resultados e as conclusões mais relevantes para os estudos selecionados. resultados todos os estudos analisados apresentavam objetivos dirigidos à identificação das necessidades espirituais de doentes hospitalizados, segundo a metodologia: quantitativa (6 estudos) e qualitativa (4 estudos). os participantes dos estudos apresentavam como motivo da hospitalização as doenças médicas e cirúrgicas agudas, doença oncológica avançada e as doenças avançadas não oncológicas. resumem-se os dados que nos permitem apresentar as necessidades espirituais identificadas pelos participantes dos estudos durante a hospitalização (quadro 1). discussão dos resultados o crescente interesse pela dimensão espiritual demonstrado na literatura empírica nas diferentes áreas do conhecimento, particularmente na enfermagem, tem demonstrado a importância 104 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 referência necessidades espirituais conner ne, eller ls. spiritual prespective needs and nursing interventions of christian african-americans. journal advanced nursing 2004; 46(6): 624-632 estar em relação com deus, com o próprio e com os outros através de atividades espirituais. williams a. perspectives on spirituality at the end of life: a metasummary. palliative and supportive care 2006; 4 (4) : 407-417 angústia espiritual (desinteresse, perda do autocontrolo); domínio espiritual (perdão e busca de sentido) e bem-estar espiritual (união, a autorrealização, e harmonia). taylor e. prevalence and associated factors of spiritual needs among patients with cancer and family caregivers. oncology nursing forum 2006.33 (3): 239-44 atitude positiva, esperança e gratidão; dar e receber amor; rever as crenças; encontrar significado; relacionar-se com deus; religiosidade e preparar para etapa final de vida. leung ct, chen c.y. the influence of awareness of terminal condition on spiritual well-being in terminal cancer patient. journal of pain and. symptom management 2006; 31 (5): 449456 necessidades situacionais (a partir de experiências pessoais e sociais num contexto de doença); morais e biográficas (perdão, paz e reconciliação, resolução de problemas passados e presentes; religiosas (reconciliação religiosa, perdão divino; oração; leitura de textos sagrados; e pratica religiosa). hermann, c. development and testing of the spiritual needs inventory for patients near the end of life. oncology nursing forum 2007; 33 (4): 737-744 estar com a família, amigos e pessoas significativas; partilhar crenças espirituais; atitude positiva perante a doença. analisar os aspectos espirituais; frequentar práticas religiosas; falar com orientador espiritual; orar; receber comunhão. hampton d, hollis d, lloyd d, taylor j, mcmillan s. spiritual needs of persons with advanced cancer. american journal of hospice palliative medicine 2007;24 (1):42-48 ter uma atitude positiva perante a vida; estar com a família; amigos e significativos, orar; assistir às práticas religiosas. as necessidades menos satisfeitas foram assistir às práticas religiosas. karimollahi m, abedi, a h, yousefi a. spiritual needs as experienced by mulslim patients in iran: a qualitative study. research journal of medical sciences 2007;1(3):183-190 necessidades religiosas: conexão com o sagrado; apoio religioso; necessidades existenciais: atenção e presença, significado e propósito, comunicação, transcendência, conhecimento sobre a situação de doença, presença, paz, privacidade e esperança. ortega m. validación de una escala valorativa del diagnóstico enfermero “sufrimiento espiritual” en los enfermos oncológicos en fase terminal. biblioteca las casas 2008; 4 (1) perda de sentido de vida; perda de esperança; necessidade de perdão; sentimentos de raiva de ter sido abandonado por deus; perda de interesse pela natureza; sentimentos de culpa. shih fj, lin hr, gau ml, chen ch, hsiao sm, shih sn, et al. spiritual needs of taiwan’s older patients with terminal cancer. oncology nursing forum 2009; 36(1):3138 manter a integridade física e espiritual; companheirismo associado com o constrangimento e vulnerabilidade; transcendência; manter uma relação estreita com o deus em quem acredita. yousefi, hojjatollah; abedi h a. spiritual care in hospitalized patients. iranian journal of nursing and midwifery research 2011; 16(1): 125–132 esperança: estima e conforto; relação compreensiva: comunicar, simpatia no atendimento, conexão com deus; praticas religiosas: necessidades de condições para o culto, respeito pelas suas crenças. quadro 1. necessidades espirituais em função da referência 105 necessidades espirituais da pessoa doente hospitalizada: revisão integrativa l maria zita castelo-branco, dalila brito, clementina fernandes-sousa da dimensão nas respostas humanas aos processos de transição saúde e doença. a espiritualidade, como fator integrador das diferentes dimensões do ser humano, manifesta-se associada à doença, à perda ou quando o ser humano é confrontado com o sofrimento físico ou a morte. os conceitos de espiritualidade utilizados pelos autores dos artigos estão inscritos num registo holístico, fortemente influenciados pela tradição judaico-cristã. este fato pode estar relacionado com as características socioculturais dos participantes dos estudos, que na sua maioria professava uma religião de raiz cristã. embora, não exista um conceito universal de espiritualidade e religiosidade é consensual a sua importância nos processos de saúde/doença. alguns autores associam a espiritualidade a uma qualidade intrínseca ao ser humano, que motiva a procura de sentido de vida (6, 7, 9). é um fenômeno multidimensional universalmente experimentado, socialmente e individualmente desenvolvido ao longo da vida (16). de fato, o ser humano cresce em grupos sociais e os seus modos de ver o mundo são profundamente influenciados pelo grupo de pertença. na generalidade, as pessoas consideram-se seres espirituais e religiosos, outras, mais religiosas do que espirituais. algumas assumem que são ateias (pessoas que não acreditam na existência de deus) ou agnósticas (acreditam que não pode ser demonstrada a existência de deus), no entanto todas elas têm sistemas de crenças que de alguma forma lhe dá sentido de vida (1). para alguns autores os conceitos de espiritualidade e religiosidade são sinônimos, sobretudo se professam algumas religiões, como a islâmica, não fazendo sentido a existência de espiritualidade sem religiosidade e práticas religiosas (12). a referência à religião também foi identificada como recurso da vivência plena da espiritualidade em três estudos (7, 9, 12). na realidade, durante a hospitalização, os doentes podem sentir a necessidade de aprofundar a sua relação com deus ou outras expressões e manifestações religiosas. da análise dos conceitos de espiritualidade identificados, podemos considerar que a espiritualidade é constituída por três elementos principais: a procura de sentido de vida, os relacionamentos e a transcendência, embora alguns autores (12, 14) também incluam as práticas religiosas. a religião como fonte de crença e de práticas, que auxiliam os indivíduos no encontro de sentido de vida, segundo a sua própria visão do mundo, pode ou não servir de recurso para atender os propósitos espirituais (6). a procura de apoio espiritual depende da gravidade da doença ou incapacidade, do suporte social e familiar, das experiências de perda e luto e do estádio de desenvolvimento pessoal. ao confrontarem-se com a mortalidade as pessoas reavaliam a sua vida e as necessidades espirituais sobrepõem-se às necessidades físicas. ao saber da situação de terminalidade, a esperança pode ajudar o doente a centrar-se “no ser e não no fazer”, assim como explorar as suas crenças com deus e a vida além da morte (8, 14). as necessidades espirituais identificadas foram organizadas em quatro categorias: procura de sentido de vida, relacionamentos, transcendência e práticas religiosas (quadro 2). para a maioria dos doentes hospitalizados, existe algum risco de sofrimento espiritual, como a alteração da procura de sentido, da relação harmoniosa com a família, com os amigos, com deus ou ser superior e com a transcendência do ser espiritual. alguns dos fatores de risco incluem: o medo e a ansiedade, a doença, a perda, a alteração dos relacionamentos, o isolamento, a falta de informação e a baixa autoestima (14). a pessoa com doença avançada considera a assistência espiritual uma prioridade e quando as suas necessidades espirituais são atendidas, apresenta melhores resultados em saúde e qualidade de vida (17). os obstáculos que subjazem à avaliação das necessidades espirituais e apoio espiritual estão relacionados com a dificuldade que a pessoa doente tem na sua abordagem, devido ao carácter íntimo e subjetivo e à falta de competências assumida pelos profissionais de enfermagem na sua avaliação e resposta adequada (14, 18). deste modo, a importância de ir ao encontro das necessidades espirituais manifestadas pela pessoa doente, a fim de lhe proporcionar cuidados holísticos, requer que os obstáculos referenciados nos estudos, tais como: a falta de tempo, os recursos 106 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 humanos escassos (14), a organização e gestão dos cuidados de enfermagem, a falta de conhecimentos e competências necessárias para a abordagem desta dimensão e a delegação de funções (capelão, ou ministro de culto), sejam ultrapassados (1, 2, 19). os estudos evidenciam a posição privilegiada dos profissionais de enfermagem na assistência espiritual às pessoas doentes que estão sob seu cuidado (2, 7). os profissionais de enfermagem devem estar conscientes do impacto da espiritualidade na vida da pessoa doente e por isso devem tornar-se mais qualificados na prestação desse atendimento (2, 20) e, sobretudo, compreenderem a singularidade de cada ser humano no que diz respeito à ligação entre a mente, o corpo e o espírito durante o processo de doença e hospitalização (12). assim, considera-se necessário um maior investimento por parte dos enfermeiros na avaliação sistemática e rigorosa da dimensão física, psicológica, social e espiritual da pessoa doente, de forma a identificar as suas necessidades e prestar-lhe assistência adequada. este posicionamento deve assentar na identificação das crenças e práticas religiosas, que são importantes para o doente. pode ser necessário que o enfermeiro reconheça a sua espiritualidade pessoal e utilize como estratégia a reflexão sobre a prática, com o propósito de responder adequadamente às necessidades espirituais da pessoa doente (19, 20). as práticas religiosas podem servir de recurso para gerir as alterações que resultam da experiência de doença (14, 20). esses dados só confirmam a importância que têm as práticas religiosas no bem-estar e na melhoria da qualidade de vida dos doentes (16, 22). nos países ocidentais como o nosso, a educação e as crenças culturais estão tradicionalmente assentes nos valores de influência judaico-cristã, ainda que alguns não sejam praticantes habituais de uma religião convencional, a sua espiritualidade pode ser expressa através de atos religiosos como orar, meditar, ler textos religiosos, frequentar o culto entre outros (23, 24). os estudos analisados revelaram padrões culturais significativos que influenciam as necessidades espirituais, que justificam a complexidade da dimensão espiritual. a satisfação das necessidades espirituais durante a doença ou fase final da vida, converte-se num fenômeno dinâmico acompanhado de uma sequência de mudanças que integram os processos transacionais da vida, que envolvem a pessoa doente, as pessoas significativas e os prestadores de cuidados de saúde. ignorar as necessidades espirituais pode conduzir a pessoa doente à não adesão terapêutica, falta ou diminuição de resiliência perante um sistema de cuidados de saúde tradicional e impedi-los do acesso a uma poderosa fonte interna de saúde e de “healing” (22). avaliar as necessidades dos doentes hospitalizados e providenciar a sua satisfação, mesmo que seja uma necessidade religiosa, falar com o capelão ou outro ministro de culto, assistir a uma atividade religiosa ou receber a comunhão, pode ser fundamental para o seu bem-estar e qualidade de vida. os enfermeiros devem estar cientes de que as pessoas doentes têm necessidades espirituais diferentes, que dependem da sua singularidade. assim, a pessoa doente e a família podem beneficiar da assistência espiritual, se os enfermeiros valorizarem essa dimensão categorias necessidades espirituais sentido de vida procura de sentido na doença; atitude positiva; esperança; autodescoberta; ter certeza, estima, conforto; perda de identidade e de papéis sociais e familiares; medo de morrer; perda de autocontrolo sobre a sua vida. relacionamentos necessidade de dar e receber amor; gratidão; pertença; companheirismo; perdoar e ser perdoado; presença; comunicação; cuidados físicos; privacidade; necessidade de estar com a família, amigos e outras pessoas significativas; estar em harmonia com o próprio e com os outros. transcendência estar em paz com deus, com a natureza e com a sua consciência; sentimentos de ser abandonado por deus; sentimentos de raiva ; perda de interesse pela natureza; sentimentos de culpa; dificuldade de transcendência do ser espiritual; agir em conformidade com os princípios divinos. práticas religiosas frequência de práticas religiosas; apoio religioso; necessidade de orar e de rever as suas crenças. quadro 2. categorização das necessidades espirituais 107 necessidades espirituais da pessoa doente hospitalizada: revisão integrativa l maria zita castelo-branco, dalila brito, clementina fernandes-sousa de cuidados e realizarem uma abordagem sistematizada, competente, rigorosa e profissional. conclusões em situação de doença, as pessoas podem expressar as suas necessidades espirituais nas formas mais sutis. o enfermeiro deve avaliar as necessidades espirituais com a “mente aberta” (6) e ser capaz de ajudar as pessoas doentes, religiosas ou não, a refletir sobre as suas necessidades espirituais de um modo mais abrangente. as necessidades espirituais mais referidas pelos doentes nos estudos analisados incluem: compreender a situação de doença e atribuir-lhe sentido; relacionamento harmonioso com ele mesmo, com a família, os amigos, outros significativos e com deus ou poder supremo; a capacidade de perdoar e ser perdoado; procurar soluções e energia para manter o autocontrole. são necessidades humanas e fundamentais, independentemente da filiação religiosa e os participantes dos estudos colocaram-nas ao mesmo nível do alívio da dor. parece claro que, para a enfermagem os cuidados espirituais são considerados importantes e relevantes, mas carecem de uma atenção mais cuidada e sistematizada. um dos constrangimentos mais referenciados pelos enfermeiros relaciona-se com a insuficiente formação acadêmica, que os habilite a uma assistência espiritual mais adequada às necessidades de quem cuidam. referências 1. mcsherry w, ross l. dilemmas of spiritual assessment: considerations for nursing practice. journal advanced nursing 2002; 38 (5): 479-88. 2. ross l. spiritual care in nursing: an overview of the research to date. journal of clinical nursing 2006; (15): 852-62. 3. north american nursing diagnosis association. diagnósticos de enfermagem da nanda: definições e classificação 20092011. porto alegre: artmed; 2010. 4. international council of nurses. cipe: classificação internacional para a prática de enfermagem. versão 2. lisboa: ordem dos enfermeiros; 2011. 5. portugal. ministério da saúde. direção-geral da saúde carta dos direitos do doente internado. lisboa: dgs; 2009. 6. hermann c. development and testing of the spiritual needs inventory for patients near the end of life. oncology nursing forum 2007; 33 (4): 737-44. 7. hampton d, hollis d, lloyd d, taylor j, mcmillan s. spiritual needs of persons with advanced cancer. american journal of hospice palliative medicine 2007; 24 (1): 42-8. 8. leung k, chiu ty, chen cy. the influence of awareness of terminal condition on spiritual well-being in terminal cancer patient. journal of pain and symptom management 2006; 31 (5): 449-56. 9. taylor e . prevalence and associated factors of spiritual needs among patients with cancer and family caregivers. oncology nursing forum 2006; 3; 33 (2): 239-44. 10. conner ne, eller ls. spiritual perspectives, needs and nursing interventions of christian african-americans. journal advanced nursing 2004; 46 (6): 624-32. 11. ortega m .validación de una escala valorativa del diagnóstico enfermero “sufrimiento espiritual” en los enfermos oncológicos en fase terminal. biblioteca las casas [série on-line] 2008; [citado 5 set. 2011]; 4 (1). recuperado de: http:// www.index-f.com/lascasas/documentos/lc0309 12. karimollahi m, abedi h, yousefy a. spiritual needs as experienced by mulslim patients in iran: a qualitative study. research journal of medical science [série on-line] 2008; [citado 5 set. 2011]; 1 (3): 183-90. recuperado de: http://www. annals-general-psychiatry.com/content/7/s1/s147 13. shih fj, lin hr, gau ml, chen ch, hsiao sm, shih sn, sheu sj. spiritual needs of taiwan’s older patients with terminal cancer. oncology nursing forum 2009; 36 (1): 318. 108 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 14. yousefi h, abedi h a. spiritual care in hospitalized patients. iranian journal of nursing and midwifery research [série on-line] 2011; [citado 20 jan. 2012]; 16 (1): 125-32. recuperado de: http://www.ncbi.nlm.nih.gov/pmc/articles/ pmc3203292/?report=printable 15. williams a. perspectives on spirituality at the end of life: a meta-summary. palliative and supportive care [série on-line] 2006; [citado 20 maio 2011]; 4 (4): 407-17. recuperado de: www.ncbi.nlm.nih.gov/pubmed/17133899 16. delaney c human spiritual dimension the spirituality scale: development and psychometric testing of a holistic instrument to assess the human spiritual dimension. journal holistic nursing 2005; 23: 145-67. 17. balboni a, vanderwerker c, blockd, paulk e, lathan s, peteet r et al. religiousness and spiritual support among advanced cancer patients and associations with end-of-life treatment preferences and quality of life. journal of clinical oncology 2007; 25 (8): 555-60. 18. villagomeza l. spiritual distress in adult cancer patients. toward conceptual clarity. holistic nursing practice [série on-line] 2005; [citado 2 jan. 2011]; 19 (6): 285-94. recuperado de: http://www.nursingcenter.com/library/journalarticle.asp?article_id=610035 19. baldacchino r. spiritual care is it the nurse’s role? spirituality and health internacional [série on-line] 2009 [citado 23 maio 2011]; (9): 270-84. recuperado de: http://onlinelibrary.wiley.com/doi/10.1002/shi.363/pdf 20. tanyi ra, werner js, recine ac, sperstad ra. perceptions of incorporating spirituality into their care: a phenomenological study of female patients on hemodialys. nephrology nursing journal [série on-line] 2006; [citado 4 nov. 2011] set.-out. 33 (5): 532-8. recuperado de: http://www.ncbi.nlm.nih.gov/pubmed/17044437 21. tzengt h-m, yin cy. religious activities of inpatients and their family visitors in taiwan. american holistic nurse association research [série on-line] 2008; [citado 20 maio 2011]; 28 (2): 98-106. recuperado de: jhn.sagepub.com/ content/26/2/98.full.pdf 22. puchalski m, dorff e, hendi y. spirituality, religion, and healing in palliative care. clinics in geriatric medicine [série on-line] 2004; [citado 5 set. 2011]; 20 (4): 689-714. recuperado de: http://www.ncbi.nlm.nih.gov/pmc/articles/ pmc1305900/ 23. o`brien e. spirituality in nursing. standing on holy ground. 2 ed. sudbury. ma: jones e bartlett publishers; 2007. 24. sulmasy d a. biopsychosocial-spiritual model for the care of patients at the end of life. the gerontological society of america 2002; 42 (special issue iii 24-33). 207 215 efectividad para reducir el miedo a caer.indd 207 juan carlos meléndez-moral1 tatiana garzón-soler2 alicia sales-galán3 teresa mayordomo-rodríguez4 efectividad de una intervención para reducir el miedo a caer en las personas mayores 1 profesor titular, universidad de valencia, españa. melendez@uv.es 2 hospital universitario y politécnico la fe, valencia. tagarso@alumni.uv.es 3 departamento de psicología evolutiva y de la educación, facultad de psicología, universidad de valencia. alica.sales@uv.es 4 psicóloga. departamento de psicología evolutiva y de la educación, facultad de psicología, universidad de valencia. teresamayordomor@gmail.com recibido: 9 de julio de 2012 enviado a pares: 26 de agosto de 2012 aceptado por pares: 17 de julio de 2013 aprobado: 16 de marzo de 2014 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 207-215 para citar este artículo / to reference this article / para citar este artigo meléndez-moral jc, garzón-soler t, sales-galán a, mayordomo-rodríguez t. efectividad de una intervención para reducir el miedo a caer en las personas mayores. aquichan 2014; 14(2): 207-215. resumen objetivo: las caídas y el miedo a caerse se relacionan entre sí, siendo cada uno de ellos factor de riesgo del otro. este trabajo pretende analizar la efectividad de una intervención para reducir el miedo a caer y sus consecuencias dado que la aplicación de este tipo de tratamientos ha mostrado resultados satisfactorios. método: mediante un diseño cuasi-experimental, con medidas pre-pos, se evaluó a 53 sujetos, con edades comprendidas entre 65 y 89 años y que habían sufrido una caída anterior. la muestra fue dividida en grupo control y tratamiento, poniéndose en marcha un método combinado de ejercicios y educación sanitaria para la prevención de caídas. resultados: se obtuvieron resultados significativos en la calidad de vida relacionada con la salud, el equilibrio y el miedo a caer, observándose mejoras en el grupo tratamiento. conclusión: la aplicación de intervenciones para la reducción del miedo a caerse en población anciana se plantea como un tratamiento cuyos efectos serían dobles, pues no solo se reduciría el propio miedo sino que, dada la asociación existente, se reduciría la posible caída por repetición. palabras clave miedo, terapéutica, envejecimiento, calidad de vida, enfermería (fuente: decs, bireme). 208 aquichan issn 1657-5997 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 207-215 effectiveness of an intervention to reduce the fear of falling in elderly persons abstract objective: falling and the fear of falling are interrelated, with each being a risk factor of the other. this study is an attempt to analyze the effectiveness of an intervention to reduce the fear of falling and its consequences, since treatments of this type have demonstrated satisfactory results. method: a quasi-experimental study with pre-post measurements was used to evaluate 53 subjects between the ages of 65 and 89 who had suffered a prior fall. the sample was divided into a control group and a treatment group. the latter was subject to treatment featuring a combination of exercises and health education to prevent falling. results: the results obtained with respect to quality of life were significant for health, balance and fear of falling, with the treatment group showing progress. conclusion: the application of interventions to reduce the fear of falling in the elderly population is proposed as a treatment with a twofold effect, not only on reducing fear itself, but also – given the association that exists on reducing the potential for falling through repetition. key words fear, therapeutics, aging, quality of life, nursing (source: decs, bireme). 209 efectividad de una intervención para reducir el miedo a caer en las personas mayores l juan carlos meléndez-moral y otros. año 14 vol. 14 nº 2 chía, colombia junio 2014 l 207-215 efetividade de uma intervenção para reduzir o medo de cair nas pessoas idosas resumo objetivo: as quedas e o medo de cair se relacionam entre si, sendo cada um deles fator de risco do outro. este trabalho pretende analisar a efetividade de uma intervenção para reduzir o medo de cair e suas consequências, já que a aplicação desse tipo de tratamentos vem mostrando resultados satisfatórios. método: mediante um desenho quase experimental, com medidas pré e pós, avaliaram-se 53 sujeitos, na faixa de 65 a 89 anos, que sofreram uma queda. a amostra foi dividida em grupo controle e tratamento, iniciando-se um método combinado de exercícios e educação sanitária para a prevenção de quedas. resultados: obtiveram-se resultados significativos na qualidade de vida relacionada com a saúde, o equilíbrio e o medo de cair, e observaram-se melhoras no grupo tratamento. conclusão: a aplicação de intervenções para a redução do medo de cair em população idosa se propõe como tratamento cujos efeitos seriam duplos, uma vez que não só se reduziria o próprio medo, mas também, dada a associação existente, se reduziria a possível queda por repetição. palavras-chave medo, terapêutica, envelhecimento, qualidade de vida, enfermagem (fonte: decs, bireme). 210 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 introducción las caídas representan uno de los grandes síndromes geriátricos, y un importante y complejo problema de salud por su frecuencia y graves complicaciones asociadas como son las lesiones, la incapacidad e incluso la muerte. en españa, la incidencia (1) de caídas en sujetos no institucionalizados es del 30-35 %, planteándose como un importante problema de salud pública, con notables consecuencias médicas y económicas. la organización mundial de la salud (oms) define caída como la consecuencia de cualquier acontecimiento que precipita al paciente al suelo, contra su voluntad (2), siendo su etiología multifactorial y pudiendo clasificar sus factores de riesgo en extrínsecos e intrínsecos (3). entre sus consecuencias se destacan la mortalidad, morbilidad y reducción de funcionalidad, junto a un ingreso prematuro a centros asistenciales, siendo la etiología principal de muertes accidentales, llegando al 70 % en sujetos mayores de 75 años (4). en cuanto a consecuencias físicas un 30-50 % son complicaciones menores (5) y un 5-6 % son mayores (6). respecto a las consecuencias psicológicas se destaca el síndrome poscaída o miedo a caerse, cuya prevalencia oscila entre el 20-85 % (7), siendo definido como un intenso miedo a volver a caer y alteraciones en la marcha tras un episodio de caída (8). así, puede considerarse como una respuesta protectora a una amenaza real, en la que se previene el inicio de actividades que presenten el riesgo de riesgo de caerse nuevamente, lo cual conlleva a largo plazo una restricción de las actividades, y se relaciona con alteraciones posturales y dificultades para realizar las actividades cotidianas (9). de este modo, la caída actúa primero como elemento limitante de la movilidad y pérdida de las capacidades para realizar las actividades de la vida diaria, y posteriormente genera ansiedad y miedo a presentar una nueva caída, con la consecuente pérdida de calidad de vida y de las relaciones interpersonales (10). de esta forma, las caídas y el miedo a caerse se relacionan entre sí, siendo cada uno factor de riesgo del otro (11). la aplicación de tratamientos para la reducción del miedo a caerse ha mostrado resultados satisfactorios a partir de diferentes técnicas, existiendo algunos basados en ejercicio físico, educación sanitaria y aquellos que combinan ambas intervenciones. este trabajo puso en marcha un tratamiento con ancianos que han sufrido una caída anterior, aplicando de forma combinada ejercicios y un programa de educación sanitaria para la prevención de caídas. así, pues, pretende analizar la efectividad de un tratamiento combinado para minimizar el miedo a caer y sus consecuencias frente a un grupo control, dado que otros trabajos obtuvieron resultados significativos y han comprobado su alta efectividad (12). materiales y métodos participantes los participantes son 53 sujetos con edades comprendidas entre 65 y 89 años, con una media de 75,96 (dt = 5,76). los sujetos se dividieron en dos grupos quedando compuesto el grupo tratamiento por 25 sujetos con una media de edad de 74,68 (dt = 4,40). el grupo control consta de 28 sujetos con una edad media de 77,10 (dt = 6,61). en relación al género, un 80 % del grupo tratamiento y un 71,4 % del grupo control son mujeres. respecto al estado civil, en el grupo tratamiento un 60 % está casado, un 28 % es viudo y el 12 % está soltero o divorciado. en el grupo control un 57,1 % está casado, un 35,7 % es viudo y un 7,1 % está soltero o divorciado. el diseño es de carácter cuasi-experimental, con medidas pre-pos, comparándose un grupo tratamiento con un grupo control no asignados aleatoriamente. este estudio se realizó de acuerdo con los principios de declaración de helsinki, obteniéndose el consentimiento informado de los participantes. criterios de inclusión-exclusión era necesario tener una edad mayor o igual a 65 años, residir en la zona básica de salud del estudio, no estar institucionalizado, no practicar ejercicio físico, obtener una puntuación superior a 23 en el mmse, tener una puntuación superior a 65 en el índice de barthel y debía existir un suceso de caída en los últimos doce meses. como criterios de exclusión se tuvo en cuenta que en la valoración clínica individualizada presentaran alguna contraindicación para la realización del programa de ejercicios, presentar algún tipo de patología intercurrente, no realizar al menos cuatro sesiones semanales del programa de ejercicios, no recordar las circunstancias de la caída, no asistir a alguna de las revisiones programadas para la recogida de la información, y mantener una permanencia en la zona básica de salud inferior a tres meses. instrumentos para los criterios de inclusión se aplicaron el mini-mental state examination (mmse) (13) como cribado de posible deterioro 211 efectividad de una intervención para reducir el miedo a caer en las personas mayores l juan carlos meléndez-moral y otros. cognitivo y el índice de barthel (14) para la valoración de la capacidad funcional. para la valoración clínica individualizada se utilizó el cuestionario de la oms para el estudio de las caídas en el anciano (15). la evaluación de la calidad de vida relacionada con la salud se realizó mediante el euroqol-5d (16) que ofrece un análisis general del estado de salud, así como la escala visual analógica (eva) donde se evalúa el estado de salud en comparación con sujetos de su propia edad. para el análisis de equilibrio se aplicaron la berg balance scale (17), que evalúa los equilibrios estático y dinámico, y la timed up and go (tug) (18), que evalúa el equilibrio dinámico y detecta el riesgo de caídas. para estudiar los efectos del miedo a caer se aplicaron tres medidas: la fall efficacy scale (fes) (19) que analiza la confianza y habilidad para evitar una caída mientras realiza las actividades básicas de la vida diaria; la activities-specific balance and confidence scale (abc) (20) que evalúa la tasa de confianza a partir de actividades realizadas fuera del domicilio. finalmente, los sujetos evaluaban su miedo a caer mediante una escala tipo likert de cuatro alternativas (1 = ningún miedo; 2 = poco miedo; 3 = algo de miedo; 4 = mucho miedo). procedimiento el tratamiento que se aplicó tenía una doble vertiente: tabla de ejercicios específicos y educación sanitaria con aspectos de prevención, protección y seguridad para evitar las caídas por repetición. la tabla de ejercicios tenía una duración aproximada de veinte minutos diarios durante un mes que los participantes realizaron de forma individual. las actividades se plantearon haciendo cuatro series de cinco repeticiones. los ejercicios tenían como objetivo: la mejora de los miembros inferiores mediante ejercicios isométricos; el aumento de la resistencia y la fuerza muscular de los miembros inferiores y superiores, y el desarrollo del equilibrio, la coordinación y la marcha. de este modo se pretendía que se sintieran más seguros para moverse y desplazarse, disminuyendo el posible miedo a caerse. los ancianos llevaban un registro diario de estas actividades en formato sí-no. además se realizó un control telefónico aleatorio. en la parte de educación sanitaria se informó a través de dos sesiones individualizadas de treinta minutos acerca de las caídas y las lesiones relacionadas y cómo actuar ante estas. en ellas, entre otros aspectos, se ofreció consejo sobre cómo levantarse tras una caída, cómo entrar y salir de la cama, cómo sentarse-levantarse, cómo vestirse-desvestirse, etc. al ser necesaria la asistencia a estas sesiones, se utilizó como control de los registros. análisis para el análisis de la homogeneidad de grupos se ha utilizado la prueba de chi-cuadrado y el test t-student para muestras independientes. el estudio de los efectos de la intervención se realizó mediante análisis de varianza de medidas repetidas con ajuste bonferroni estudiando tanto los efectos simples como los de la interacción (grupo x tiempo) y calculando el tamaño del efecto mediante eta-cuadrado (h2). los análisis se realizaron mediante el programa spss19. resultados en primer lugar, y como se muestra en la tabla 1, no se observan diferencias en ninguno de los aspectos sociodemográficos, lo que indica la homogeneidad de los grupos respecto a estas características, a aspectos generales de salud y a las caídas. tabla 1. comparación de las puntuaciones basales de los grupos en las principales características grupo tratamiento grupo control p edad 74,68 (4,4) 77,1 (6,61) 0,127 género hombres (%) 20 28,6 0,469 mujeres (%) 80 71,4 estado civil casado/a 60 57,1 0,743viudo/a 28 35,7 soltero/a o divorciado/a 12 7,1 profesión ama de casa 56 50,0 0,891autónomo 8 10,7 trabajador cuenta ajena 36 39,3 nº de fármacos diarios 3,64 (0,63) 3,4 (0,74) 0,274 nº de enfermedades 3,4 (0,65) 3,2 (0,15) 0,281 212 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 en cualquier caso, parece interesante destacar que en ambos grupos los participantes son mayoritariamente mujeres. además, e independientemente de haber sufrido un incidente previo de caída, los participantes presentan niveles óptimos en la realización de las actividades de la vida diaria así como bajos niveles de depresión. por el contrario, se observa un alto porcentaje de miedo a volver a caerse, destacando además que las caídas anteriores han provocado cambios en la actividad cotidiana. en relación al objetivo principal de este trabajo, se presentan a continuación los resultados estadísticos de los efectos de la intervención en cada una de las variables estudiadas; las medias de cada grupo y de cada momento temporal se muestran en la tabla 2. en la evaluación de la calidad de vida mediante el euroqol-5d, el análisis de los efectos del tratamiento solo mostró efectos para la ansiedad/depresión, observándose a partir del análisis de los efectos simples con ajuste bonferroni que no existían diferencias entre los grupos en las medidas pretratamiento. en relación a la comparación por pares de cada grupo en los dos momentos temporales, se observaron diferencias significativas para el grupo control (f1,40 = 15,42, p < 0,001, h2 = 0,278) con un aumento de las puntuaciones. por lo que se refiere al análisis del efecto del tratamiento evaluado a partir de las diferencias en los grupos, las pruebas de efectos intra-sujetos en la interacción tiempo-grupo mostraron diferencias significativas (f1,40 = 6,97, p = 0,012, h2 = 0,149), observándose un mantenimiento de las puntuaciones del grupo tratamiento frente al empeoramiento de síntomas del grupo control. el análisis de los efectos simples de la escala visual analógica (eva) indicó que no existían diferencias entre los grupos en las medidas pretratamiento; no obstante, la comparación por pares de cada grupo en los dos momentos temporales mostró diferencias para el grupo tratamiento (f1,40 = 6,36, p < 0,016, h2 = 0,137) con un aumento de las puntuaciones y del control (f1,40 = 6,74, p < 0,013, h2 = 0,144) con un descenso. el análisis del efecto del tratamiento mediante las pruebas intrasujetos en la interacción tiempo-grupo mostró diferencias significativas (f1,40 = 13,06, p < 0,001, h2 = 0,246). en relación con las pruebas de equilibrio, escala berg balance scale y timed up and go (tug), el análisis de los efectos simples de las medidas con ajuste bonferroni indicó que no existían diferencias en las medidas pretratamiento. en la comparación por pares, la escala de berg mostró efectos significativos para el grupo tratamiento (f1,40 = 14,97; p < 0,001; h2 = 0,272), observándose un aumento de sus puntuaciones; además, el análisis del efecto del tratamiento para la interacción tiempo-grupo fue significativo (f = 6,09; p = 0,018; h2 = 0,132). del mismo modo, la timed up and go (tug) mostró efectos en la comparación por pares para el grupo tratamiento (f1,40 = 31,86; p < 0,001; h2 = 0,443) mostrando una reducción significativa en el tiempo de realización. en relación al efecto, al comparar los grupos en los dos momentos temporales, la aplicación del tratamiento resultó significativa (f = 24,89; p < 0,001; h2 = 0,384). finalmente, y por lo que respecta a las medidas de evaluación del miedo a caerse, el análisis de los efectos simples de dichas medidas con ajuste bonferroni indicó que no existían diferencias entre los grupos en aquellas pretratamiento de la fall efficacy scale (fes), activities-specific balance and confidence scale (abc) y la evaluación del nivel de miedo. la fall efficacy scale (fes) mostró efectos significativos en la comparación del grupo tratamiento en los dos momentos temporales (f1,40 = 25,59; p < 0,001; h2 = 0,390), observándose una reducción de sus puntuaciones, siendo además significativo el efecto del tratamiento para la interacción tiempo-grupo (f = 17,89; p < 0,001; h2 = 0,309). la comparación por pares en la activities-specific balance and confidence scale (abc) del grupo tratamiento en los dos momentos temporales obtuvo diferencias grupo tratamiento grupo control p depresión sí 32 25 0,572 no 68 75 índice de barthel 95,6 (9,50) 93,75 (11,6) 0,493 caídas anteriores sí 76 85,7 0,367 no 24 14,3 nº de caídas últimos 12 meses 1,2 (0,43) 1,4 (0,69) 0,395 miedo a caer sí 100 92,9 0,173 no 7,1 cambio de vida sí 80 82,1 0,842 no 20 17,9 213 efectividad de una intervención para reducir el miedo a caer en las personas mayores l juan carlos meléndez-moral y otros. significativas (f1,40 = 30,82; p < 0,001; h2 = 0,435) observándose una mejora de sus puntuaciones y siendo significativo el efecto de la intervención para la interacción tiempo-grupo (f= 22,21; p < 0,001; h2 = 0,357). finalmente, la evaluación del grado de miedo a caerse mostró efectos significativos en la comparación del grupo tratamiento en los dos momentos temporales (f1,40 = 55,00; p < 0,001; h2 = 0,579) observándose una reducción de sus puntuaciones, siendo además significativo el análisis de los efectos del tratamiento en la interacción tiempo-grupo (f = 30,11; p < 0,001; h2 = 0,430). tabla 2. media de los grupos tratamiento y control en los dos momentos temporales: tiempo 1 y tiempo 2 mas solo de ejercicio no produce efectos significativos sobre el miedo, mientras que aquellos que combinan ejercicio y educación son más eficaces dado que el temor a caer está influenciado no solo por problemas físicos, sino también psicológicos y cognitivos. respecto a la calidad de vida relacionada con la salud, se ha comprobado como el efecto del tratamiento se producía exclusivamente en la variable ansiedad/depresión. conceptualmente se supone que el miedo no es perjudicial si no va acompañado por la restricción de algún tipo de actividad importante o es una fuente de distracción para una persona, si bien el miedo a las caídas ha sido identificado como un factor de riesgo para la reducción de la calidad de vida (21). de acuerdo con bandura (22), la percepción que tiene una persona acerca de sus habilidades está recíprocamente relacionada con su capacidad funcional, aspecto que implica que el miedo a las caídas afecta los niveles de eficacia, lo que a su vez influye en el equilibrio y la capacidad física (23), y que puede precipitar el deterioro de la salud (24). en este sentido, la aplicación de la intervención también ha mostrado un efecto significativo en la mejora de la percepción de la salud mientras que el grupo control mantendrá o empeorará esta percepción, resultado similar al obtenido en otro trabajo (25). respecto al equilibrio, la implementación de programas sugiere la mejora de la flexibilidad y la velocidad en la marcha. los resultados obtenidos muestran cómo la aplicación de un tratamiento combinado de ejercicios y educación para la salud, evaluado mediante berg balance scale y timed up and go (tug), ha sido efectivo para la mejora del equilibrio. de hecho, no solo es importante trabajar el equilibrio, sino que además se debe tener en cuenta la posible reducción de la actividad como consecuencia del miedo, con sus efectos en la aparición de la fragilidad física y la caída en los ancianos (10). en relación con la mejora del equilibrio existen otro tipo de programas entre los que se destaca el tai-chi y aquellos que integran componentes físicos y cognitivos, representando un valor añadido al compararlos con programas que establecen su principal foco en lo físico (26). esta disciplina presenta un efecto positivo sobre el miedo a caerse y el equilibrio frente a los que solo se han aplicado ejercicios (26), y si bien la evidencia del efecto del tai-chi sigue siendo poco clara (26), algunos estudios que emplean esta técnica (27, 28) obtienen un efecto en la prevención de caídas al mejorar el equilibrio, la flexibilidad y la reducción del miedo a caer. en relación con la eficacia percibida evaluada mediante fall efficacy scale (fes), activities-specific balance and confidence gr. tratamiento gr. control t1 t2 t1 t2 ansiedad/depresión 1,47 1,48 1,34 1,69 escala visual analógica 65,21 69,57 70,04 65,95 escala de berg 48,73 49,05 45,95 46,00 timed up and go 16,00 15,10 17,43 17,60 fall efficacy scale 37,31 32,63 35,17 35,78 activities-specific balance and confidence scale 74,01 77,33 70,97 70,48 grado de miedo a caerse 3,21 2,63 3,00 3,00 discusión la relación entre caídas y miedo a caerse ha mostrado en diversos estudios relaciones significativas comprobándose cómo la presencia de cualquiera de ellas implica un mayor riesgo de aparición de la otra; así mismo, se debe tener en cuenta que hasta una cuarta parte de las personas de edad avanzada cree tener más facilidad para caerse que otras de su edad, y que aproximadamente la mitad manifiesta mucho miedo a que ocurra tal evento (11). así, la aplicación de intervenciones para la reducción del miedo a caerse en población anciana se plantea como un tratamiento cuyos efectos serían dobles, no solo se reduciría el propio miedo sino que, dada la asociación existente, se reduciría la posible caída por repetición. este trabajo ha comprobado cómo una intervención combinada de práctica de ejercicio y educación para la salud en población anciana con sucesos de caídas anteriores genera un efecto positivo y significativo en la percepción de la salud, equilibrio y miedo a las caídas. así, se confirma lo planteado en trabajos de metaanálisis (12) donde la aplicación de progra214 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 scale (abc) y la autoevaluación del miedo a caerse, se han obtenido resultados positivos tras la aplicación del tratamiento observándose en el tamaño del efecto magnitudes relevantes (29), viéndose de este modo la implicación que la autoeficacia tiene sobre el miedo a caerse y como a través de este tratamiento se ha mejorado este aspecto. finalmente, se concluye que se ha conseguido el objetivo principal de este trabajo que era reducir el miedo a caerse en ancianos con historia previa de caída mediante la aplicación de un programa combinado de ejercicios y educación sanitaria. en este sentido, la obtención de este tipo de efectos supondría una reducción de las caídas por repetición dada la relación recíproca existente entre las variables, de este modo el sujeto podría reanudar un estilo de vida activo, reducir la ansiedad o mejorar el equilibrio, optimizando la calidad de vida y la percepción de la salud (11). por último, cabe señalar la necesidad de desarrollar programas que incluyan medidas de seguimiento a largo plazo para conocer hasta qué punto estas mejoras se mantienen. del mismo modo, y partiendo de los resultados obtenidos, como futura línea de trabajo se plantea la inclusión de programas cognitivo-conductuales, dado que otros estudios (30) presentan resultados significativos en la reducción del miedo a caer y de las restricciones asociadas a la actividad física y social a partir de la inclusión de técnicas cognitivo-conductuales para aumentar la autoeficacia y el control mediante reestructuración cognitiva. referencias 1. da silva za, gómez conesa a, sobral m. epidemiología de caídas de ancianos en españa. una revisión sistemática. rev esp salud pública. 2008;82:43-56. 2. world health organization. global report on 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measuring balance in the elderly: validation of an instrument. can j public health. 1992;83(suppl 2):7-11. 215 efectividad de una intervención para reducir el miedo a caer en las personas mayores l juan carlos meléndez-moral y otros. 18. podsiadlo d, richardson s. the timed up and go: a test of basic functional mobility for frail elderly persons. j am geriatr soc. 1991;39:142-8. 19. tinetti me, richman d, powell l. falls efficacy as a measure of fear of falling. j gerontol. 1990;45:239-43. 20. powell le, myers am. the activities-specific balance and confidence (abc) scale. j gerontol med sci. 1995;50:28-34. 21. brouwer b, musselman k, culham e. physical function and health status among seniors with and without a fear of falling. gerontology. 2004;50:135-41. 22. bandura a. self-efficacy mechanism in human agency. am psychol. 1982;37:122-47. 23. li f, mcauley e, fisher kj, harmer p, chaumeton n, wilson nl. self-efficacy as a mediator between fear of falling and functional ability in the elderly. j aging health. 2002;14:452-66. 24. cumming rg, salkeld g, thomas m, szonyi g. prospective study of the impact of fear of falling on activities of daily living, sf-36 scores, and nursing home admission. j gerontol a biol sci med sci. 2000;55:299-305. 25. zijlstra ga, van haastregt jc, van eijk jt, van rossum e, stalenhoef pa, kempen gi. prevalence and correlates of fear of falling, and associated avoidance of activity in the general population of community-living older people. age ageing. 2007;36:304-9. 26. logghe ih, verhagen ap, rademaker ac, bierma-zeinstra sm, van rossum e, faber mj, et al. the effects of tai chi on fall prevention, fear of falling and balance in older people: a meta-analysis. prev med. 2010;51:222-7. 27. wolf sl, barnhart hx, kutner ng, mcneely e, coogler c, xu t. reducing frailty and falls in older persons: an investigation of tai chi and computerized balance training. j am geriatr soc. 1996;44:489-97. 28. zhang jg, ishikawa-takata k, yamazaki h, morita t, ohta t. the effects of tai chi chuan on physiological function and fear of falling in the less robust elderly: an intervention study for preventing falls. arch gerontol geriatr. 2006:42:107-16. 29. valentine j, cooper h. effect size substantive interpretation guidelines: issues in the interpretation of effect sizes. washington, d.c.: what works clearing house; 2003. 30. tennstedt s, howland j, lachman m, peterson e, kasten l, jette a. a randomized, controlled trial of a group intervention to reduce fear of falling and associated activity restriction in older adults. j gerontol b psychol sci soc sci. 1998;53:384-92. 290 300 la enfermeria orden san juan.indd 290 aquichan issn 1657-5997 julia cristobalina huaiquián-silva1 josé siles-gonzález2 ana luisa velandia-mora3 la enfermería de la orden de san juan de dios en el chile colonial 1. historiadora de enfermería. profesora asociada, universidad de concepción, chile. jhuaiquiansilva@yahoo.com 2. licenciado en pedagogía. doctor en historia. profesor catedrático, universidad de alicante, españa. jose.siles@ua.es 3. enfermera. phd. en ciencias médicas con mención en salud pública. profesor especial, emérito y honorario, universidad nacional de colombia, colombia. alvelandiam@yahoo.com recibido: 2 de febrero de 2012 enviado a pares: 14 de marzo de 2012 aceptado por pares: 8 de abril de 2013 aprobado: 9 de abril de 2013 año 13 vol. 13 nº 2 chía, colombia agosto 2013  290-300 resumen objetivo: describir las prácticas de enfermería en chile durante la época colonial, prestando especial atención a la influencia de españa en dicho proceso. método: investigación cualitativa de abordaje socio-histórico; las fuentes primarias corresponden a textos históricos de chile recuperados en la biblioteca virtual memoria chilena, y a 34 documentos recopilados en el archivo museo san juan de dios, casa de los pisa, en granada, españa, titulados “listado de los hermanos de san juan de dios que vivían en chile (207 años) y un índice de documentos inéditos copiados de los archivos histórico nacional y del antiguo hospital, por faustino calvo”. la recolección de la información se efectuó con ficha documental confeccionada por la investigadora, complementada con fotografías. el análisis de los datos se realizó a través de análisis de contenido. resultados: la orden de san juan de dios llegó a chile en el año 1617 a los hospitales de santiago y concepción y se expandió a las ciudades de la serena, valparaíso, san juan de la frontera, talca, chillan, concepción y valdivia. por más de doscientos años la orden permaneció en chile brindando asistencia hospitalaria y de enfermería a través de los cuidados religiosos. conclusión: con la llegada de la orden al país mejoró indiscutiblemente la organización de los cuidados de salud al interior de los hospitales, que a partir de esa fecha se administraron de forma organizada, con altos estándares de higiene y limpieza, vigilando sigilosamente la alimentación de sus pacientes y con una gran preocupación por brindar asistencia espiritual a quienes necesitasen de sus servicios. palabras clave chile, enfermería, hospitales, historia de la enfermería, investigación en enfermería. (fuente: decs, bireme). the hospitaller order of saint john of god in colonial chile abstract objective: nursing practices in chile during the colonial era are described in this research, with special attention to spain’s influence on the process. method: it is a qualitative study with a social-historical approach. the primary sources are historical texts retrieved from the so-called chilean memory in the national virtual library of chile and 34 documents collected from the archives of the saint john of god museum, pisa house, in granada, spain, entitled “list of the brothers of saint john of god who lived in chile (207 years) and an index of para citar este artículo / to reference this article / para citar este artigo huaiquián silva, j. c., siles gonzález, j., velandia mora, a. l. (2013). la enfermería de la orden de san juan de dios en el chile colonial. aquichan. vol. 13, no. 2, 290-300. 291 la enfermería de la orden de san juan de dios en el chile colonial l julia cristobalina huaiquián-silva, josé siles-gonzález, ana luisa velandia-mora unpublished documents copied from the national historical archives and those of the old hospital by faustino calvo.” the data, collected through the use of a documentary record designed by the researcher and supplemented with photographs, was studied via content analysis. results: the order of saint john of god arrived in chile in 1617 at hospitals in santiago and concepcion. later, it spread to the cities of la serena, valparaiso, san juan de la frontera, talca, chillan, concepcion and valdivia. the order remained in chile for over two hundred years, providing hospital and nursing services through religious care. conclusion: the arrival in chile of the order of saint john of god undoubtedly improved the organization of health care within hospitals, which were managed thereafter in an organized way, with high standards of hygiene and cleanliness, careful surveillance of patients’ diets, and great concern for providing spiritual assistance to those in need of its services. keywords chile, nursing, hospitals, history of nursing, nursing research. (source: decs, bireme). a enfermagem da ordem de san juan de dios no chile colonial resumo objetivo: descrever as práticas de enfermagem no chile durante a época colonial enfatizando a influência da espanha nesse processo. método: pesquisa qualitativa de abordagem sócio-histórica; as fontes primárias correspondem a textos históricos do chile, recuperados na biblioteca virtual memória chilena, e a 34 documentos recopilados no arquivo museu san juan de dios, casa de los pisa, em granada, espanha, intitulados “lista dos irmãos de san juan de dios que moravam no chile (207 anos) e um índice de documentos inéditos copiados dos arquivos histórico nacional e do antigo hospital, por faustino calvo”. a coleta da informação foi realizada com ficha documental confeccionada pela pesquisadora, complementada com fotografias. a análise dos dados se realizou por meio de análise de conteúdo. resultados: a ordem de san juan de dios chegou ao chile em 1617 aos hospitais de santiago e concepción, e se expandiu às cidades de la serena, valparaíso, san juan de la frontera, talca, chillan, concepción e valdivia. por mais de duzentos anos, a ordem permaneceu no chile oferecendo assistência hospitalar e de enfermagem por meio dos cuidados religiosos. conclusão: com a chegada da ordem ao país, melhorou indiscutivelmente a organização dos cuidados de saúde no interior dos hospitais que, a partir dessa data, foram administrados de forma organizada, com altos padrões de higiene e limpeza, vigilando sigilosamente a alimentação de seus pacientes e com uma grande preocupação por oferecer assistência espiritual aos que necessitassem de seus serviços. palavras-chave chile, enfermagem, hospitais, história da enfermagem, pesquisa em enfermagem. (fonte: decs, bireme). 292 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 introducción el desarrollo de la investigación histórica en enfermería se instituye como una herramienta imprescindible cuando se quiere fundamentar el quehacer de la profesión y los alcances de su disciplina. conocer la evolución histórica que ha tenido la enfermería permite pensar su situación presente, intervenir en ella, transformarla y proporcionar una respuesta coherente a las necesidades profesionales y disciplinares del momento actual. de este modo la historia se constituye en una disciplina crítica que desmonta y devela mitos y mistificaciones construyendo y administrando la memoria del grupo profesional. memoria que como reconstrucción del pasado no es fiel con todos los elementos de la realidad porque se elabora siempre con experiencias nuevas y diferentes y se reproduce seleccionando; además, es la parte de la historia que se establece como un referente de la identidad. la memoria legítima suministra y cohesiona la identidad del grupo al otorgarle un sentido y a través de ella se refuerza la idea de continuidad en el colectivo (1). los fundamentos teóricos expuestos que avalan la investigación histórica como una herramienta eficaz para construir la memoria de un grupo social y fortalecer su identidad respaldan la realización de este estudio cualitativo de corte sociohistórico que tuvo como propósito principal analizar la influencia que españa ejerció en los cuidados de enfermería en chile durante la época colonial. los antecedentes bibliográficos, por su parte, revelan que en chile no se ha desarrollado una investigación histórica profunda que pueda dar cuenta de forma articulada de los orígenes de la profesión y las etapas que ha debido superar para llegar a la situación actual. una revisión de la literatura reciente en busca de publicaciones de género histórico en la enfermería chilena verifica escaso material publicado en relación con otros países iberoamericanos como brasil, colombia y españa. la mayoría de las publicaciones históricas sobre enfermería en chile ofrecen acercamientos generales en relación con los avances en la enseñanza y la profesionalización, predominando en ellas la visión cronológica que en su mayoría abarca desde el inicio de la profesión en el país (año 1902) hasta nuestros días. igualmente, el aspecto temático se desarrolla sobre la enfermería en general sin precisar su objeto de estudio en aspectos más concretos de la misma. no se han encontrado investigaciones de enfermería en relación con el tiempo histórico comprendido entre los siglos xvi, xvii y xviii y que corresponden al periodo del chile colonial. por tanto, se utilizó como referencia central el contexto sociohistórico del periodo colonial chileno, espacio de la historia en que chile era gobernado por la corona española y formaba parte del imperio español. indagar sobre la colonia remite a un tiempo del pasado de gran importancia para la historia de chile, el que encina (2) caracteriza como la época “de formación de la raza chilena”. en esta etapa se produce el encuentro de dos culturas que se destacan por su gran espíritu guerrero. el ejército de españa que luchaba por conquistar nuevos territorios para la corona española frente al pueblo mapuche que combatía por mantener la soberanía de sus tierras. estudiar los hechos históricos que dan cuenta de cómo se fue consolidando la enfermería en el ámbito chileno es fundamental para la construcción de una memoria colectiva de la disciplina y de las enfermeras y, sin duda, fortalecerá la autoconstrucción de la identidad profesional. así, el presente estudio se justifica por la ausencia de trabajos que den cuenta de la historia de enfermería en la época colonial chilena y también porque busca construir las fuentes históricas de un aspecto de la enfermería en el país como fue la influencia de españa en la época colonial. desarrollo de la investigación histórica de enfermería en chile en chile ya desde la década de los sesenta existe una inquietud de las enfermeras docentes por estudiar el pasado de enfermería, y es en el año 1965 cuando rosalba flores publica su trabajo historia de enfermería en chile. síntesis de su evolución educacional (3). sin embargo, el desarrollo de la investigación histórica de enfermería ha sido escaso, aislado y en su totalidad asociado a enfermeras docentes vinculadas a centros universitarios localizados en la zona centro-sur del país. la temática de estudio ha sido en general en relación con los avances en la educación, en la investigación y en la profesión y, en su mayoría, corresponden a estudios cronológicos que abarcan desde los inicios de la profesionalización de enfermería en chile (1902) hasta la actualidad. en general se trata de estudios que corresponden a la historia total, es decir, solo se dedican a contar los hechos sin incluir el contexto social en que se desarrollan. a continuación se cita el material encontrado: se ha consultado un trabajo cronológico elaborado por el colegio de enfermeras de chile (4) que hace una reseña histórica de los hitos más importantes que ha tenido la profesión en el país desde que se 293 la enfermería de la orden de san juan de dios en el chile colonial l julia cristobalina huaiquián-silva, josé siles-gonzález, ana luisa velandia-mora inicio la educación formal de enfermería en el año 1902. también se han analizado varios artículos que se refieren a los avances de la profesionalización de enfermería y a la evolución que ha tenido la profesión en la educación de pre y posgrado en chile (5, 6, 7, 8, 9, 10, 11,12). en un estudio cronológico realizado por la asociación chilena de educación en enfermería (13) se hace una reseña histórica desde el año 1954 a 1968 en que se destacan los logros de esa asociación en los inicios de la investigación en enfermería. otros artículos consultados se refieren al estado de la investigación de enfermería en el país (14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24). también ha arrojado luz sobre el tema el libro escrito por docentes de enfermería (25) acerca de la historia de la escuela de enfermería de la universidad de valparaíso. en esa misma línea se han valorado varios artículos en relación con historias de diferentes escuelas de enfermería (26, 27, 28, 29, 30, 31, 32). por otro lado, se han podido revisar diversas historias de vida de enfermeras en el contexto de un hospital dado (5, 33). por último se debe destacar que, según nuestros datos, solamente en el capítulo: chile, del libro nursing in the américas: a critical view (34), los autores (35) elaboran una reflexión de los aspectos más críticos de la política de chilena que han afectado a la gestión de salud en general y a la gestión de los cuidados de enfermería en particular. además, hacen una cronología a grandes rasgos de la enfermería en chile partiendo desde la época colonial hasta el año 2008. no se encontraron estudios que den cuenta de cómo se desarrollaron los cuidados de enfermería en chile durante la época colonial. historia de la salud y de los cuidados de enfermería en el chile colonial la mayoría de los textos encontrados se refieren en general a la influencia de los cuidados de religiosos españoles en los territorios americanos conquistados. en el caso de chile, los historiadores destacan la participación de inés de suárez en el cuidado de los soldados españoles heridos durante la conquista, la fundación del primer hospital por pedro de valdivia y la llegada de los hermanos de la orden de san juan de dios en el siglo xvii. a continuación se relaciona el material encontrado describiendo sus correspondientes aportaciones: son varios los autores que coinciden en que en los comienzos de la conquista chile se caracterizó por una ausencia de la medicina hispánica (2, 36, 37, 38). otros autores destacan la fundación del primer hospital en chile en el siglo xvi (36, 37, 38, 39, 40). historiadoras de enfermería (41, 42) mencionan los cuidados religiosos como un gran aporte de la salud española a los países conquistados. son, asimismo, varios los autores que describen la llegada de los enfermeros de la congregación de san juan de dios a los hospitales de chile en siglo xvii (2, 36, 37, 38, 39, 42, 43, 44, 45). además, investigadores de enfermería (46, 43) relatan que de la bula papal de gregorio xiii de 1576 in supereminenti se puede deducir la expansión de la misión de los hermanos hospitalarios en diversas provincias de las indias del mar océano. por último, cabe señalar que existe bibliografía que menciona a inés de suárez como la primera médica-enfermera española en chile (37, 38, 47). material y métodos investigación cualitativa con abordaje sociohistórico cuyo marco referencial y metodológico corresponde a la nueva historia que se interesa por todo lo que involucre la actividad humana y entiende que para todo hay una historia, y que todo lo del pasado puede ser reconstruido y problematizado. para la obtención de la información se efectuó búsqueda de las fuentes en las bases de datos, bibliotecas virtuales y textos de historia de enfermería. las fuentes primarias se recopilaron en el archivo museo san juan de dios “casa de los pisa” en la ciudad de granada, españa, y en la biblioteca virtual memoria chilena. la recolección de la información se ejecutó con fichas documentales complementadas con fotografías de los archivos históricos. el análisis de la información se realizó a través de la técnica de análisis de contenido a partir de la cual emergieron las categorías temáticas que permitieron la construcción del relato. se utilizó como referencia central el contexto sociohistórico del periodo colonial, espacio de la historia en que chile era gobernado por la corona española y formaba parte del imperio español, y que corresponde a los siglos xvii, xviii e inicios del xix. las fuentes primarias corresponden a 34 archivos históricos titulados listado de los hermanos de san juan de dios que vivían en chile (207 años) y un índice de documentos inéditos copiados de los archivos histórico nacional y del antiguo hospital, por faustino calvo4, y los textos: historia física y política de chile5, los médicos de antaño en el reino de chile6, historia de chile7, historia del hospital san juan de dios8, historia de chile9. 4 documentos inéditos copiados en el año 1928 por faustino calvo para la orden de san juan de dios en españa, y que fueron recopilados por la investigadora en el archivo-museo san juan de dios “casa de los pisa” en la ciudad de granada, españa. 5 por claudio gay, bajo los auspicios del supremo gobierno, tomo i (1847); tomo ii (1845); tomo iii (1846); tomo iv (1847). 6 benjamín vicuña-mackena (1877). 7 josé pérez garcía, tomo iii (1900). 8 enrique laval (1949). 9 francisco encina, tomo vi (1948). 294 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 resultados contexto histórico de chile colonial se señala como colonia a la extensión imperial, política, social y religiosa que se estableció en las américas durante los siglos xvi, xvii, xviii e inicios del xix. en este periodo la corona española reprodujo en sus colonias el mismo sistema social que existía en españa (2, 36, 38, 48). en chile incluyó los siglos xvii, xviii e inicios del xix. esta etapa, que se prolongó hasta la revolución de la independencia, se caracterizó por un constante cambio de gobernadores, cuya inquietud principal fue persistir en la guerra de arauco, contienda que hizo fracasar el sistema bélico privado de los conquistadores porque demandó un gran gasto, debiendo intervenir el rey felipe iii quien destinó un ejército profesional y permanente para que protegiera la frontera. sería financiado con un impuesto especial, el real situado. probablemente el hito más importante de este periodo fue la fundación de la ciudad de santiago el 12 de febrero de 1541, punto de partida de las expediciones que iniciaron el reconocimiento y la ocupación de nuevos territorios. su fundador, pedro de valdivia, escogió asentarse en el valle del río mapocho, pues consideraba que la numerosa población nativa que allí vivía era un signo evidente de la fertilidad de esas tierras. además, para garantizar la provisión de agua y su protección, la villa fue levantada entre dos brazos del río, y al amparo del cerro huelen, desde donde se podía vigilar al enemigo (49). la vida colonial de chile se desarrolló en los territorios ubicados al norte del río biobío. allí se consolidaron los diferentes grupos sociales, cada uno con un modo de vida propio. estos grupos se diferenciaban por su origen y por los medios económicos de que disponían. debido a ello, las clases sociales estaban muy bien definidas. el siglo xvii en chile fue una época azotada por grandes desastres como: el desastre de curalaba, ocurrido el 23 de diciembre de 1598, en donde los mapuches al mando del toqui pelantaro dan muerte al gobernador de chile don martín garcía oñez de loyola, originando la más grande sublevación araucana que produjo la destrucción de las ciudades ubicadas al sur del biobío —arauco, angol, cañete, imperial, osorno, valdivia y villarrica—. además, en este siglo ocurre el terremoto de 1647 que deja la ciudad de santiago destruida y en el que mueren alrededor de mil personas. y por último, la sublevación de 1655 que aniquiló todos los establecimientos españoles entre el biobío y el maule. estas desgracias provocan en la población un gran ímpetu religioso, la devoción se adueña de sus almas y la corte abdica el gobierno en manos de los jesuitas (2). la política de colonización establecía en las leyes de indias la obligación de los conquistadores y gobernadores de fundar ciudades y establecer sitios para ubicar hospitales y proveer su construcción y mantenimiento. debido a los desastres fue muy difícil para los conquistadores establecer sus nuevos hospitales. uno de los primeros hospitales fundados en chile fue el de nuestra señora de la asunción en la ciudad de la serena en el año 1.544 para atender a indios naturales, cristianos y españoles, financiado con el oro obtenido de la mina de andacollo y dirigido por el cabildo sin que se entrometieran en su dirección “ni fraile, ni clérigo, ni persona de religión, ni arzobispo”; fue parcialmente destruido por el corsario bartolomé sharp en 1680 (36). existen historias similares de fundación y destrucción de hospitales en concepción, valdivia, villarrica, osorno, angol y arica. quizás el más famoso de los hospitales coloniales fue el de nuestra señora del socorro fundado en la ciudad de santiago por pedro de valdivia en 1.554. su administración corrió por cuenta del cabildo que dictó las ordenanzas y constituciones del establecimiento. el principal problema del hospital era su manutención económica que dependía de la caridad cristiana. en cuanto al método curativo estaban los protomédicos, que no sabían ni vendar una herida, y los facultativos, que podían curar de todo, menos del cuerpo de los enfermos. en el antiguo hospital del socorro no había camas, ni utensilios, ni guardianes, ni cocinas, ni siquiera enfermos, sino cadáveres envueltos en los toscos chamantos de los indios (38). llegada de la orden de san juan de dios a chile (inicios del siglo xvii) a inicios del siglo xvii la influencia de la asistencia hospitalaria y de enfermería de la orden de san juan de dios ya se había extendido a varios rincones de américa llegando hasta el perú (37). en chile, el cabildo y sus diputados demostraron una mala administración de los hospitales de santiago y concepción en donde se presentaban constantes quejas por la mala atención de los enfermos. como respuesta a esta situación de miseria en que se encontraban los hospitales de chile al gobernador don alonso de ribera, en su segundo gobierno, le pareció que estarían mejor atendidos en manos de los que por voto e instituto se emplean en ello, y pidió al virrey del perú le enviase para ese fin religiosos de san juan de dios (sjdd) (36, 44). las palabras del padre santos (fd36)10 son un buen testimonio histórico de lo que acontecía en esa época: 10 fd36: relación histórica de la fundación del hospital y convento de la misericordia de la ciudad de concepción del reino de chile, 1617. corresponde a documento obtenido de los archivos de la municipalidad, intendencia y otros papeles particulares. 295 la enfermería de la orden de san juan de dios en el chile colonial l julia cristobalina huaiquián-silva, josé siles-gonzález, ana luisa velandia-mora …es imperial esta ciudad de la concepción y está fundada en un pequeño valle que se llama penco […] había en esta ciudad un hospital que llamaban de la misericordia y era real […] corría su administración por diferentes manos y quedábase lo que tenía en ellas, con que no tenían que llegar a la boca de los pobres, y morían más de necesidad que de enfermedad […] llegó a noticias de la ciudad, lo bien que habían probado los hospitales, que a nuestros religiosos se habían entregado y cómo todos iban en mayores aumentos cada día, por su mucha diligencia y cuidado. el virrey del perú, don francisco de borja, príncipe de esquilache, autorizó el traslado y los hermanos fray gabriel molina, francisco velazco, francisco gómez y pedro jijaba, bajo la dirección del primero, llegaron a concepción en enero de 1617. el 9 de marzo de ese mismo año, en el día de su fallecimiento, el gobernador firmó la orden de traspaso de bienes y la dirección a fray gabriel molina. pese a que la orden se hiciera cargo de la administración interna del hospital, el cabildo quedó con los poderes para contratar a los médicos y cirujanos, para controlar las donaciones y supervigilar el financiamiento del establecimiento (2, 36, 40). a partir de esa fecha el hospital del socorro cambió su nombre por el de san juan de dios y sus nuevos administradores, que vestían un traje blanco y pardo, fueron conocidos como los “padres capachos” por la gran capucha que llevaban sobre su cabeza que ocultaba su rostro (36). con la llegada de fray molina (1617-1627) a la administración mejoró considerablemente la atención de los pacientes, se invirtió en la construcción y el equipamiento de todo lo necesario para un establecimiento hospitalario. reparó las salas de los enfermos, construyó una capilla, un establo, un molino y adquirió una serie de implementos para el trabajo del predio. la propiedad del hospital era gigantesca, el edificio estaba rodeado de chacras y más tarde tendría un viñedo. todas estas estancias con animales que eran de su posesión financiaban al hospital y alimentaban directamente a los enfermos, hermanos y sirvientes. todos los vegetales que se consumían en el hospital eran cultivados por ellos mismos por lo que la alimentación de los pacientes era buena, con abundante carne, cereales, fruta y hasta vino de su propio predio. las entradas alcanzaban a 3 mil pesos, de los cuales mil provenían del noveno y medio del diezmo y el resto entradas propias. el hospital era un verdadero fundo, contaba con 50 camas y en 1630 atendía en promedio unos 700 enfermos al año (36). por su parte, los documentos históricos escritos por el padre santos (1617) describen la llegada a concepción de dos religiosos que tomaron posesión del hospital y pusieron orden porque no tenía ninguno. reformaron todo lo necesario, a los pocos días comenzaron a recibir y curar a los pobres enfermos. contaban con una botica, con buenas enfermerías que ocupaban setenta camas atendidas por diez religiosos y un sacerdote que administraba los sacramentos. había un cirujano religioso que curaba los enfermos hospitalizados y a cuanto llagado o herido llegara a portería a solicitarlo. en el año 1617 tomaron posesión de este hospital que conservó el nombre de la misericordia (fd36)10. para vicuña-mackena (39) el llamamiento al país de los miembros del hospital sjdd produjo un cambio extraordinariamente favorable al servicio hospitalario. a partir de esta fecha en chile se inician los cuidados religiosos. la siguiente cita es una descripción de la llegada de la orden al país y permite recrear en el lector una imagen del impacto positivo que provocaron los primeros enfermeros españoles en la sociedad colonial: luego que el año 1616 llegaron a la ciudad de santiago y se recibieron del hospital, mostraron que iba en ellos el abrasado espíritu de caridad de su santo fundador en el esmero con que se aplicaron a la asistencia corporal y espiritual de los pobres enfermos, de los cuales se juntaron tantos con el dulce atractivo de sus nuevos enfermeros (sic) (44). asentamiento y expansión de la orden en chile (segunda mitad siglo xvii y xviii) dados los buenos resultados que mostraron los hermanos de sjdd en la administración de los hospitales de concepción y santiago era indudable que se demandaría la presencia de la orden en otras ciudades. en concordancia con esta afirmación, las fuentes históricas revelan la presencia de la orden en las ciudades de valdivia, la serena, san juan de la frontera, valparaíso, santiago, talca, chillan y arica. los hechos históricos más relevantes son: valdivia, la ciudad más austral, más alejada de la capital y rodeada por territorios mapuches: en el año 1645 y después de ser recuperada por el conde de mancera ya contaba con un pequeño hospital que era atendido por cuatro hermanos de la orden de sjdd, sin médico residente y completamente aislados del resto de la colonia chilena. las fuentes históricas revelan que permanecieron por más de un siglo proporcionado cuidados de salud en valdivia pero sumidos en el más completo abandono y con un salario tan ínfimo que no cubría sus necesidades (fd32a-fd32b)11. los segundos en solicitar la presencia de la orden fueron los vecinos de la ciudad de coquimbo quienes 11 fd32a: carta del superior del hospital. el padre fray antonio de cubillas, prior del hospital sjdd valdivia. capitanía general de la república, 1754. fd32b: superintendencia general, 1772, nombramiento de médico en la plaza de valdivia en fray pedro manuel chaparro por separación de fray daniel botello. capitanía general de la república, 1772. 296 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 donaron un “tomín de oro”12 (50) para la creación de un hospital en la serena. tras diversos obstáculos que puso el cabildo de la ciudad para cumplir la voluntad de los pobladores, en el año 1716 el rey ordena que se inicien las gestiones para la construcción del hospital. los hermanos de la orden de san juan de dios participaron en la construcción, implementación y puesta en marcha del hospital de la serena. en el año 1745 reciben decreto real que les entrega la administración y las leyes de funcionamiento (fd6)13. transcurrido un siglo y medio de la llegada de la orden a santiago las autoridades de la real audiencia solicitan al rey la creación de un nuevo hospital destinado a la asistencia de mujeres y solicitan autorización para desviar parte de los recursos que tiene asignado el hospital sjdd para su financiamiento. a continuacion se cita cédula real (fd17b)14 que relata los hechos: presidente y oidores de mi real audiencia de la ciudad de santiago del reino de chile. en carta del seis de abril de 1767 da cuenta con autos ese presidente […] y expone que seria conveniente separar el hospital de mujeres del de los hombres por las contenjencias al que están expuestos en el actual de san juan de dios, así por la proximidad de las salas en que residen ambos sexos con solo el resguardo de una débil puerta que las divide, como por la precisa asistencia de los religiosos a la curación y demás necesidades de las mujeres con conocido riesgo y peligro de su estado (sic). en aranjuez, el 20 de mayo de 1778, el rey autoriza erigir el hospital san francisco de borja y la manutención de las cincuenta camas con el desvío de 1500 reales del hospital sjdd (fd17b)13. finalizando el siglo xviii se funda otro hospital de la orden de sjdd en la ciudad de valparaíso puerto principal de chile colonial desde donde zarpaban y atracaban barcos desde y hacia españa con todo lo necesario para continuar con la guerra de arauco y mantener a la población española. la creación de un hospital era absolutamente necesaria. el 23 de junio de 1777 se decretó su fundación en la quebrada de elías. la administración estaría a cargo de la orden de sjdd. se donaron los terrenos y todos los recursos necesarios para su funcionamiento. entre sus obligaciones estaba la atención de los soldados de la guarnición y de las tripulaciones de todos los barcos del imperio (fd28)15. las fuentes históricas 12 tomín de oro: en hispanoamérica colonial correspondía a una fracción del real que era la base del sistema monetario español. 13 fd6: fundación de hospital de la serena 1716. capitanía general de la república, 1716. 14 fd17b: constituciones del real hospital de san francisco de borja. capitanía general de la república, 1783. 15 fd28: valparaíso, chile, 1788. historia eclesiástica de valparaíso. hacen referencia a la visita de inspección que hiciera luis de álava el 14 de junio de 1791 al real hospital de sjdd (fd28)14: …en la sala de los enfermos se observó sumo aseo y limpieza en las camas y particular esmero en su asistencia y servicio, y en la ropería mucho orden y bastante acopio de sabanas y demás ropas con la reparación conveniente para las enfermedades contagiosas. en la obra del convento ha habido considerable renovación y aumento, debidas como las demás ventajas del hospital al celo del reverendo padre fundador prior fray josé zenzano. la botica se ha hecho más capaz y provista de medicinas. se ha aumentado un cuarto oportuno para el padre enfermero y una sala para éticos, se ha cercado con pared y puerta el campo santo y levantado un cuarto para el depósito de difuntos, se han renovado dos celdas; la cocina con otras oficinas y cerrado el patio principal con paredes y la clausura del convento por una entrada de portada decente […] el particular esmero con el que el referido padre atiende a el mayor acrecentamiento del hospital y las ventajas que el pueblo y las demás gentes de mar experimenta en el cuidado y buena asistencia de sus enfermedades en este piadoso asilo le hacen acreedor a que se le den las gracias. en las proximidades del siglo xix en talca la creación del hospital surge como iniciativa de un benefactor de la ciudad, don juan manuel de la cruz, capitán de caballería del regimiento del príncipe, quien escribe al rey (fd34)16: con mi mayor rendimiento parezco ante v.e. y digo: que anhelando el mayor adelantamiento y decoro de mi patria, la nueva ciudad de talca entre varios objetos de la mayor atención y que reúne en sí las recomendaciones de religión y humanidad es el hospital para curar enfermos, de que carece su población, cuyo importantísimo proyecto, mediando la venia y superior protección de v.e. espero entablar en breve […] he comprado a mis expensas un sitio cuadrado de noventa y seis varas […] mas cuento principalmente con el piadoso superior influjo de v.e. a fin de conseguir […]elevar este proyecto a los pies del trono para que merezca la inmediata real protección […] año 1796. en madrid, a 8 de julio de 1803, el rey apoya la iniciativa indicando que deben servir la regla de sjdd y les envía las normas para la constitución de una junta que administre el hospital (fd34a)17. para finalizar, es oportuno comentar que se encontró documentación histórica que permite avalar la creación de hospi16 fd34: don juan manuel de la cruz ofrece fundar un hospital de su propio caudal en la ciudad de san agustín de talca. capitanía general de la república, 1796. 17 fd34a: constituciones año 1803. capitanía general de la república, 1803. 297 la enfermería de la orden de san juan de dios en el chile colonial l julia cristobalina huaiquián-silva, josé siles-gonzález, ana luisa velandia-mora tales de la orden de sjdd en la ciudad de san juan de la frontera en el año 1762 (fd39 y fd39a)18, y en la ciudad de chillan en el año 1786 (fd32c)19. discusión a manera de conclusión en concordancia con varios autores (2, 36, 37, 38), los antecedentes históricos recopilados en esta investigación verifican que la época colonial fue azotada por grandes catástrofes convulsiones que caracterizaron a chile por la ausencia de la medicina hispánica (fd32a)2. el primer hospital fundado en chile fue el de nuestra señora de la asunción en la ciudad de la serena en el año 1559, lo que es concordante con varios autores (37, 38, 39, 40) que destacan la fundación del primer hospital chileno en el siglo xvi. como relatan las fuentes históricas, la mala administración que tuvieron los hospitales hasta iniciado el siglo xvii, y las buenas referencias que llegaban de la orden de san juan de dios que ya se había establecido en el virreinato de perú, motivaron al gobernador de chile para que solicitara al virrey del perú enviase el envío de hermanos de la orden de sjdd a hacerse cargo de los hospitales en chile. es así como el año 1617 llegan a chile cuatro hermanos de la orden a hacerse cargo de la administración de los hospitales de santiago y concepción. de esta forma se iniciarían los cuidados religiosos en el reino de chile. estos resultados coinciden con autores (41, 42) que destacan los cuidados religiosos de enfermería como un gran aporte de españa a los países conquistados y también coinciden con otros autores (2, 36-, 37, 38, 39, 40, 42, 43, 44, 45) que describen la llegada de los enfermeros de la congregación de san juan de dios a los hospitales de chile en siglo xvii. los resultados de este estudio evidencian la permanencia de la orden de sjdd en chile durante toda la época colonial (1617-1812). lo que sin duda debe considerarse un gran aporte social ya que con su llegada al país mejoró indiscutiblemente la organización de los cuidados de salud al interior de los hospitales, que a partir de esa fecha se administraron 18 fd39: testimonio de los autos obrados sobre la erección del hospital de la ciudad de san juan de la frontera. capitanía general de la república, 1762. fd39a: el hospital de sjdd de la ciudad de san juan de la frontera, demandando el noveno y medio correspondiente al año de mil setecientos sesenta y cuatro. capitanía general de la república, 1770. 19 fd32c: expediente sobre fundación del hospital de chillan (incompleto). capitanía general de la república, 1786. de forma organizada, con altos estándares de higiene y limpieza, vigilando sigilosamente la alimentación de sus pacientes y con una gran preocupación por brindar asistencia espiritual a quienes necesitasen de sus servicios. cuidados que como describen diversos historiadores de enfermería (46, 51, 52, 53, 54) estaban fundamentados en la filosofía cristiana, lo que los tornaba humanitarios, caritativos, solidarios y hospitalarios. además eran altamente calificados y, según los describe nogales (55), mostraban una correcta administración, unos conocimientos y una buena práctica que sin duda era fruto de una formación programada. es importante destacar también que la permanencia de la orden en chile coincidió con una etapa de gran decadencia y, en ocasiones, de total ausencia de asistencia médica en los hospitales chilenos (fd32a)2, es así como por largos periodos de tiempo y en los lugares más apartados y peligrosos la orden de sjdd constituyó la única esperanza de salud para un pueblo azotado por terremotos, pestes y guerras, esto en concordancia con cruz-coke (36) quien relata que durante un gran periodo del siglo xvii santiago no tuvo médicos residentes porque “era una ciudad peligrosa, que estaba renaciendo de las ruinas del terremoto de 1647, sometida a los rigores de la inquisición, sufriendo epidemias recurrentes cada década y subyugada por la fuerte hegemonía y autoritarismo que el gobernador, el ejército y la iglesia imponían“. si bien la literatura consultada solo describe la ciudad de santiago y de concepción como lugares en donde se estableció la orden, 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[visitado jun. 2012]. disponible en: http://www.revistareduca.es/index.php/reducaenfermería/article/view/251 55. nogales a. pensamiento enfermero e historia. necesidad de vertebración filosófica e histórica en enfermería. cul cuid. 2006;x(20):14-21. 185 192 reflexiones sobre la filisofia.indd 185 keyla cristiane do nascimento1 alacoque lorenzini erdmann2 refl exões sobre a fi losofi a do límite e suas implicações para o cuidar em enfermagem 1 doutoranda do programa de pós-graduação em enfermagem. universidade federal do santa catarina. florianopolis, brasil. keyla_nascimento@hotmail.com 2 doutora em filosofia da enfermagem. universidade federal do santa catarina. florianopolis, brasil. alacoque@newsite.com.br recibido: 4 de diciembre de 2008 aceptado: 17 de junio de 2009 resumo trata-se de um estudo reflexivo que tem por objetivo apresentar a proposta filosófica do espanhol eugênio trías, a teoria do limite, e aproximar suas idéias à disciplina da enfermagem. o estudo aborda a ontologia do limite, o limite do ser e o uso da teoria do limite para a enfermagem. acredita-se que os limites em saúde decorrem dos direitos e valores humanos e estão presentes em nosso dia-a-dia profissional. refletir no limite da vida, respaldado pela ética, pauta, portanto, o exercício adequado da técnica para o bem-estar e o respeito dos seres humanos que cuidamos. palavras-chave ética em enfermagem, filosofia em enfermagem, teoria ética. (fonte: decs, bireme). refl ections on the philosophy of limit and its implications for nursing care abstract this is a reflective study intended to present the philosophical proposal of the spanish philosopher eugênio trias: the theory of limit, and to apply his ideas to the field of nursing. it addresses the ontology of limit, the limit of being, and uses of the theory of the limit for nursing. it is believed that limits to health stem from human rights and values, and are present in our day-to-day activity. as a reflection of life’s limits and supported by ethics, the study tries to relate the application of appropriate technology for well-being to respect for the human beings who are being cared for. key words ethics, nursing; philosophy, nursing; ethical theory. (source: decs, bireme). año 9 vol. 9 nº 2 chía, colombia agosto 2009 185-192 186 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 refl exiones sobre la fi losofía del límite y sus implicaciones en el cuidado en enfermería resumen se trata de un estudio reflexivo que tiene como objetivo presentar la propuesta filosófica del español eugenio trías (la teoría del límite) y llevar sus ideas a la disciplina de enfermería. el estudio aborda la ontología del límite, el límite del ser y la utilización de la teoría del límite en enfermería. en materia de salud, se cree que los límites se derivan de los derechos humanos y los valores, y están presentes en nuestro día a día. reflexionar sobre los límites de la vida, con el apoyo de la ética, regula el empleo de la tecnología apropiada para brindar bienestar y respeto a los seres humanos que cuidamos. palabras clave ética de enfermería, filosofía en enfermería, teoría ética. (fuente: decs, bireme). 187 reflexões sobre a filosofia do límite e suas implicações para o cuidar em enfermagem keyla cristiane do nascimento, alacoque lorenzini erdmann introdução como toda filosofia digna de um nome, a teoria do limite é um mapa do mundo, um dos muitos mapas –ou recreações– possíveis de uma realidade completa, literalmente inesgotável em sua dinamicidade construtiva, de onde ninguém poderá procurar por um mapa total. em palavras do próprio eugenio trías: a filosofia é uma proposta ativa e criadora, sempre em construção, sempre em processo de revisão, “uma síntese capaz de plantar em forma de idéia filosófica, o esboço vivo do que existe” (1). neste artigo apresentamos a proposta filosófica do espanhol eugenio trías –a teoria do limite– e aproximarmos suas idéias à disciplina da enfermagem. o presente estudo aborda de maneira sucinta alguns dos elementos considerados centrais para analisar e dar conta da argumentação de trías em sua teoria. em seguida, antes de passar a ontologia do limite, aborda-se uma breve caracterização do trabalho de trías. a proposta filosófica de eugênio trías diferente dos atuais discursos filosóficos que abordam os sistemas filosóficos, os discursos normativos e ontológicos, trías constrói pacientemente uma resposta a pergunta “quem é o ser?” a resposta do pensador a primeira pergunta da filosofia forma um trabalho meticuloso através do qual desenvolve um sistema filosófico com implicações normativas, éticas, estéticas, religiosas e inclusive políticas. a obra de eugenio trías é muito ampla. desde a publicação do seu primeiro livro, la filosofia y su sombra (1969), até esta data, tem escrito pouco mais de uma quinzena de livros, alguns deles elogiados na espanha por suas contribuições e reflexões filosóficas. algumas de suas reflexões são construídas a partir da relação oposição e busca de mediações entre categorias distintas que formam parte de uma totalidade de análise. por exemplo, as reflexões de trías sobre a filosofia e sua sombra, o poder e a paixão, o belo e o sinistro, o “cerco fenomênico” e o “cerco do encerrado em si”, ilustram o proceder desse autor, assim como sua proximidade a metodologia estruturalista (2). para alguns estudiosos, existe na obra de eugênio trías uma coincidência com o estruturalismo, que talvez se deva à crítica que tanto um como outro fazem a visão ocidental moderna do mundo, ao racionalismo cartesiano, ao etnocentrismo ocidental, assim como aos grandes relatos da cultura moderna: a fé na razão, no progresso e na técnica. outros qualificam sua trajetória dentro do pensamento hispânico “neonietzscheano”. a expressão é ambígua porque não existe nenhuma escola ou corrente dentro da filosofia que se possa chamar como tal. em todo caso, a expressão refere-se a um conjunto de autores hispânicos que seguem o exemplo do autor de zaratustra (3). em suas obras, outros autores estão presentes, como hegel, sobre quem realizou sua tese de doutorado; wittgenstein e kant, de quem recupera a idéia de limite, assim como de mundo fenomenológico; husserl, de quem prossegue o método fenomenológico como método de investigação privilegiado. para alguns estudiosos, existe na obra de eugênio trías uma coincidência com o estruturalismo, que talvez se deva à crítica que tanto um como outro fazem a visão ocidental moderna do mundo, ao racionalismo cartesiano, ao etnocentrismo ocidental. 188 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 qualificar uma obra tão vasta, alimentada de diversas tradições e sem final, é uma tarefa impossível. portanto, é mais oportuno distinguir etapas do pensamento do filósofo com a idéia de estreitarmos suas reflexões mais recentes e estudarmos as que apresentam evidente proposta filosófica. em seus escritos expressa que (1) existe um período de formação, de busca por criar um estilo de pensamento e de escritura, um período de desenvolvimento de uma filosofia que aborda monograficamente temas como o poder, a paixão, o belo, e o sinistro, e um período de condensação de uma proposta ou idéia filosófica. neste ultimo centramos a atenção deste artigo. trías sustenta que um dos motores vitais de um filósofo é produzir uma idéia clara e distinta ao modo cartesiano. para trías, essa idéia filosófica começou a ser parte de sua obra há alguns anos, quando sustentou a teoria do limite; desde então, torna a escrever constantemente sobre ela, a tal ponto que é chamado o filósofo do limite. a idéia de limite começa a ser exposta primeiramente em seus livros los limites del mundo, mas tem maior claridade em la aventura filosófica e em lógica del limite. os livros posteriores aos recém citados é uma continuação da ontologia do limite. a ontologia do limite no dicionário de português, são diversos os sinônimos de limite, entre eles, beirar, demarcar, delimitar, limiar, restringir, confinar, contentar-se, não passar além de, ou ainda, término (4). ao buscar a definição de limite no dicionário de filosofia, aristóteles estabelece que o limite fixa o término de uma coisa fora do qual não tem existência, mas é também começo de outra coisa diferente; o limite é, portanto, ponto de finitude e de partida (5). considerando a perspectiva de aristóteles, na geografia o limite refere-se aos confins de um lugar, assinala sua finitude, marca e encerra um lugar que além dele nosso caminhar se restringe. mas o limite não só determina a finitude do lugar, também inicia outro espaço; por tanto, é ao mesmo tempo o ponto de união de um espaço que se finda e de outro que inicia. eugenio trías propõe resgatar as idéias aristotélicas, mas também explorar uma terceira que resgate o limite como uma zona possível de indagar, refletir e, finalmente, de colonizar. trías, no livro lo bello y lo siniestro (6), defende que o sinistro constitui condição e limite do belo. como condição, temse que não se dá o efeito estético sem que o sinistro, de alguma maneira, esteja presente na obra de arte. no entanto, como limite, tem-se que a revelação do sinistro destrói ipso facto o efeito estético. em conseqüência, o sinistro é condição e limite do belo: deve estar presente sob forma de ausência, deve estar velado; não pode ser desvelado. no livro limite do mundo (1), trías recorda que o limite romano era o último território do império e, portanto, da civilização. na fronteira, os exércitos estavam em vigilância permanente, de olho nas forças que provinham do território não conquistado. o limite era um ponto estratégico que resguardava das invasões dos povos chamados bárbaros pelos romanos. não obstante, o limite era uma zona habitável e de contato fértil. na fronteira, eugenio trías propõe resgatar as idéias aristotélicas, mas também explorar uma terceira que resgate o limite como uma zona possível de indagar, refletir e, finalmente, de colonizar. 189 reflexões sobre a filosofia do límite e suas implicações para o cuidar em enfermagem keyla cristiane do nascimento, alacoque lorenzini erdmann o trato com o inimigo representava não só um ponto de distância, mas também de encontro com o desconhecido. as invasões bárbaras não necessariamente significavam uma ameaça para a civilização; também eram uma possibilidade de enriquecerse com elementos culturais alheios. visto o limite como o lugar de florescimento cultural, para trías, este pode representar uma figura filosófica com a qual construímos e alcancemos concepções do mundo que permitam captar sua riqueza e enigma. em sua ontologia do limite, trías quer deixar bem claro que este desvelamento é seu e que quando os filósofos falam de limite, falam de outra coisa: dar al limes este estatuto ontológico es, hasta donde llega mi información, algo que hasta ahora ningún discurso filosófico ha acometido. cierto que desde descartes a kant y de este a wittgenstein y a heidegger se insiste en la idea de límite o frontera (grenze): límite del conocer (kant) o límite del pensar-decir, o límite del lenguaje y del mundo (wittgenstein) o límite del mundo como mundo (heidegger). cierto que se usa, en la tradición trascendentalista, la metáfora del horizonte. ciertamente que platón piensa la idea como horos, “límite que permite definir y delimitar su contenido”. trías volta a insistir nesse parágrafo: “pero hasta donde llega mi conocimiento, no ha habido ninguna filosofía que trate de concebir y conceptuar el ser en tanto que ser como limes, como límite y frontera” (1). a originalidade de trías está na inflexão que faz à metafísica. os limites geralmente haviam sido planejados em termos de limite de conhecimento, mas trías lhes da uma atribuição ontológica; essa é uma grande mudança que tenta passar: propriamente o limite é metafísico. para trías está na essência do ser –ser de limite–, portanto, o limite do conhecimento é do homem, para ele, não decorre da percepção, senão que é algo de natureza mais “primária”. por isso a teoria do limite abre uma referência para ir além de “más allá”, pensando no espaço próprio do limite. assim, começa a ontologia que quer elaborar: uma ontologia de limite, a qual denomina filosofia do limite. então, não fala do limite em termos ontológicos, com ser, como lógica; senão que utiliza o conceito de razão, ou de inteligência racional, que para essa filosofia do limite corresponde ao que chama de “razón fronteriza”, gerando o conceito de fronteira da razão. frente a uma razão dogmática, ou frente às propostas pós-modernas de dissolução da razão, propõe uma razão crítica que se expande de forma transversal pelos âmbitos específicos da filosofia: no âmbito da estética e da filosofia da religião, no âmbito da ética e da reflexão cívico-política. porém, essa proposta de razão permite uma reflexão sobre nossa própria condição humana, permite esclarecer o que somos (7). para o autor, a filosofia é unitária; não existem especialidades filosóficas. tratase de empregar uma idéia sobre os distintos âmbitos nos quais circula a reflexão filosófica, para o qual é preciso formular e elaborar do melhor modo essa idéia como proposta. tal proposta é filosófica sempre que permita entender de forma renovada a realidade e o mundo em que estamos, toda vez que nos possibilite clarificar nossa própria capacidade (inteligência) e dotá-la de sentido e significação. o limite do ser trías propõe compreender o que somos através da idéia de limite. somos o limite do mundo; em razão de nossas emoos limites geralmente haviam sido planejados em termos de limite de conhecimento, mas trías lhes da uma atribuição ontológica; essa é uma grande mudança que tenta passar: propriamente o limite é metafísico. 190 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 ções, paixões e usos lingüísticos, dotamos de sentido e significação o mundo em que habitamos. abandonamos a simples natureza e ingressamos no universo do sentido –universo do mundo. mas, constituímos um limite entre esse “mundo de vida” em que habitamos e seu próprio “más allá”: o círculo de mistério que nos transcende é que determina nossa condição mortal (1). encontramos em sua filosofia, em seu desvendar o limite e o “limite do ser” como conceito ontológico central, o limite concebido como uma fronteira entre o ser e o mundo de sua existência e para além dele mesmo. em sua mais profunda evidência, de reconhecimento do limite do ser, este se situa frente a si mesmo e, ao existir transparente, em sua plenitude prodigiosa. a filosofia do limite nos oferece conceitos que se interconectam entre eles, como o marco do surgimento, o limite hermético e a zona limítrofe como áreas de experiência humana. a capacidade de “olhar para além de” seria o traço essencial dessa experiência limítrofe e para o ser humano que assumira sua condição de limite, um ser humano capaz de uma dupla possibilidade de conhecimento: aquelas regidas pela necessidade dos seres vivos (personalidade de um sujeito frente a um mundo de objetos) e aquela que se situa na consciência do existir, pondo entre parênteses a necessidade, que permite transcender ao mundo sujeito-objeto para situar-se na realidade do ser de limite. refletir sobre a possibilidade de “olhar para além de” se concretiza numa reflexão sobre a ética fronteiriça, sobre a opção ética que favorece a condição de limite e do ser de limite. nossa condição limítrofe e fronteiriça nos estabelece a infinita distância da natureza (pré-humana) e do mistério (suprahumano). nossa condição marca suas diferenças em relação ao físico (a vida vegetal ou animal) e em relação ao metafísico ou teológico (a vida divina). aprofundar no reconhecimento dessa condição humana de caráter limítrofe e fronteiriço é o objetivo de uma filosofia que aspira a ser a mais adaptada às reflexões dessa mudança de século e de milênio, e que conecte com as grandes tradições da filosofia (6). até aqui, trago o posicionamento de trías. em nosso dia-a-dia, na hora da procura por uma decisão boa ou correta perante um conflito, a respeito do uso de uma determinada técnica a serviço do ser humano na área da saúde, a solução não me parece simples. a pessoa prudente irá refletir cuidadosamente sobre os limites da ciência e a sua aplicação; entretanto, dificilmente concordará em uma única solução, uma única razão (boa ou melhor). quais os critérios para o estabelecimento ou fixação dos limites humanos o tecnológicos para uma ação boa ou adequada no campo da saúde? são diversos a os critérios que irão nos ajudar no discernimento dos limites. a teoria do limite na enfermagem parece-me que os limites de caráter ético que devem orientar o uso adequado ou bom uso da ciência, particularmente da ciência biomédica, estão diretamente relacionados com os direitos humanos. estes têm, por sua vez, um denominador comum: a dignidade humana. esta é um elemento nuclear da ética. a dignidade humana deveria ser o fundamento dos códigos deontológicos, das constituições nacionais. a dignidade humana deveria ser a filosofia do limite nos oferece conceitos que se interconectam entre eles, como o marco do surgimento, o limite hermético e a zona limítrofe como áreas de experiência humana. 191 reflexões sobre a filosofia do límite e suas implicações para o cuidar em enfermagem keyla cristiane do nascimento, alacoque lorenzini erdmann o ultimo critério para julgar toda norma deontológica e preceito legal de qualquer canto do mundo. porque o homem e a mulher têm dignidade, independentemente da sua idade, cor da pele e condição social. em palavras de kant, na sua obra fundamentação da metafísica dos costumes, ele e ela merecem respeito (8). esse princípio tem as suas fronteiras, limites e áreas de indeterminação, discussão e conflito. a final, quando existe o ser humano, a pessoa humana? outro limite de caráter ético são as diversas aplicações da tecnologia na área da saúde, decorrentes do progresso da ciência é da autonomia do ser humano. o termo autonomia, derivado dos vocábulos gregos auto (próprio) e nomos (lei ou regra), significa a capacidade de definir as suas próprias regras e limites, sem que estes precisem ser impostos por outro (9). a autonomia é um processo gradativo de amadurecimento que ocorre durante toda a vida, propiciando ao ser humano a capacidade de decidir e, ao mesmo tempo, de arcar com as conseqüências dessa decisão, assumindo, portanto, responsabilidades. a prática de saúde em situações limítrofes permite ao ser humano a estruturação de sua autonomia? tem na prática tal poder e tal possibilidade? ou será uma prática necessariamente fundamentada na coerção, como pensava kant? pode a prática de saúde, da enfermagem, ser uma prática aberta à liberdade? se refletirmos sobre esta questão, e procurarmos sentir a sua densidade, veremos que está em discussão a própria possibilidade da liberdade humana, analisada neste pequeno texto em uma situação específica –a prática de saúde– apenas por uma necessidade de recorte do tema para tornar possível a reflexão. em outras palavras, não há uma liberdade social e uma liberdade de cuidados, distintas e separadas; trata-se do mesmo fenômeno em situações diferentes. para falar da autonomia do cliente, é imprescindível uma melhor compreensão do ser humano e seus direitos na sociedade. na área da saúde, reconhecer que os indivíduos são seres livres e autônomos para determinarem seu próprio destino implica oferecer alternativas terapêuticas e de cuidado (10), explicitar os riscos e benefícios inerentes a cada uma delas e certificar-se de que os clientes tenham compreendido claramente todas as informações prestadas e respeitar sua decisão final. outro limite é o auto-respeito. autorespeito significa ter certeza dos nossos valores; uma atitude afirmativa diante de nosso direito de viver e de ser feliz; a sensação de conforto ao reafirmar de maneira apropriada os nossos pensamentos, as nossas vontades, as nossas necessidades (11); o sentimento de que a alegria é o nosso direito natural por termos sido criados e existirmos no mundo. o auto-respeito é, sobretudo, a garantia do respeito ao outro. entretanto, nem todas as pessoas possuem verdadeiro auto-respeito. precisamos estar sempre preparados para agir com compreensão e tranqüilidade diante dos acontecimentos. o diálogo e a discussão das normas, dos problemas ligados aos valores: o que fundamenta a ação dos profissionais de saúde, a pesquisa científica, as experiências com animais e seres humanos, as questões sociais relativas à saúde, ou seja, o que diz respeito à vida, são limites outro limite de caráter ético são as diversas aplicações da tecnologia na área da saúde, decorrentes do progresso da ciência é da autonomia do ser humano. 192 año 9 vol. 9 nº 2 chía, colombia agosto 2009 aquichan issn 1657-5997 que nos remetem à dignidade humana, ao caráter ético, ao limiar da vida. sendo assim, a ética, como uma área de pesquisa, pode valer-se da contribuição de outras ciências que também se dedicam a produção do conhecimento. reconhecendo essa interação, pode-se dizer que o pensar-refletir-ponderar o limite da vida em saúde, aliado ao posicionamento ético, produz características distintas: origina-se em um ambiente científico pela necessidade dos próprios profissionais de saúde se protegerem e protegerem a vida humana; surge de um esforço interdisciplinar, uma vez que não se trata de uma ciência feita, clara e definida. parte-se dos princípios e dos valores tradicionais e com eles trata-se de encontrar soluções ou problemas novos, propostos pela biologia e por outras ciências; busca humanizar o ambiente hospitalar, extra-hospitalar e, em particular, promover o direito das pessoas a exercer uma sadia liberdade, especialmente, no que tange o limiar da vida; ocupa-se em buscar a dimensão ética dos problemas novos relacionados ao tema em questão, criados pelas ciências biomédicas. os limites, os quais estão presentes em nosso dia-a-dia, são respaldados pela ética, e pautam, por tanto, o exercício adequado da técnica para o bem-estar e respeito dos seres humanos que cuidamos. considerações finais as questões sobre a vida e o ser humano formuladas em ciências só podem compreender-se a partir das diversas formas de relação entre a visibilidade, o olhar e o conhecimento, ou seja, a maneira de olhar o seu objeto, ou ainda, a partir dos diversos modos de enfocarmos determinado assunto. a ontologia do limite de eugenio trías tem como intenção principal submeter a razão a um diálogo constante com aquilo que a desafia. ela oferece um novo conceito crítico de razão que emerge na fronteira entre ela mesma e aquilo que a cerca e que é concebido por trías como fronteira da razão, a qual convive no âmbito da estética, da religião, da teoria do conhecimento, da ética. a descrição de sua teoria nos leva a compreender que “ser de limite” ou “limite do ser” significa reconhecer a condição fronteiriça da nossa existência e a dupla natureza do ser humano: as regidas pela necessidade dos seres vivos e as situadas na consciência do existir. a filosofia de trías oferece a chave para abordar fenômenos diversos da natureza, cada âmbito da vida e a relação entre eles, mediante sua descrição minuciosa, refletida, pensada acerca da filosofia e o encontro desta com a razão, trazendo à tona o conceito do limite ou fronteira. ao olhar para a saúde, para a disciplina enfermagem, percebe-se que os limites que acompanham o desenvolvimento e aplicação das tecnologias e ciências, decorrentes dos direitos e valores humanos (autonomia, dignidade, liberdade) não a destroem nem a aniquilam, mas orientam, pautam e desafiam o seu bom desempenho. referências 1. trías e. los límites del mundo. barcelona: destino; 2000. 2. grave c. el uso práctico de la razón fronteriza. barcelona: destino; 2000. 3. lamana dc. itinerário filosófico de eugenio trías; 2002. disponível em: http://serbal.pntic.mec.es/ aparterei/ [consulta em 05 de agosto de 2007]. 4. ferreira abh. dicionário da língua portuguesa. 2ª ed. rio de janeiro: nova fronteira; 1986. 5. abbagnano n. dicionário de filosofia. 4ª ed. são paulo: martins fortes; 2003. 6. trías e. lo bello y lo siniestro. barcelona: ariel; 2001. 7. trías e. ética y condición humana. península; 2000. 8. kant i. crítica da razão pura. 4ª ed. prefácio à tradução portuguesa, introdução e notas: mourujão af. tradução: santos mp; mourujão af. lisboa: fundação calouste gulbenkian, 1997. 9. beauchamp tl, childress jf. princípios de ética biomédica. são paulo: loyola; 2002. 10. ann seago, j. autonomy: a realistic goal for the practice of hospital nursing? aquichán. jan./dec. 2006; (6)1: 92-103. 11. santos lr, beneri rl, lunardi vl. questões éticas no trabalho da equipe de saúde: o (des)respeito aos direitos do cliente. rev gaúcha enferm. 2005; (26)3: 403-13. 253 virginia inés soto-lesmes1 maría mercedes durán de villalobos2 el trabajo de campo: clave en la investigación cualitativa 1 enfermera, rn, msc, phd. profesora asociada, facultad de enfermería, universidad nacional de colombia. directora programa doctorado en enfermería. universidad nacional de colombia. visotol@unal.edu.co 2 enfermera, rn, msc. profesora titular, facultad de enfermería universidad nacional de colombia; profesora emérita universidad nacional de colombia; docente programa doctorado en enfermería, universidad nacional de colombia. mmvillalobos@gmail.com recibido: 1 de julio de 2009 aceptado: 4 de agosto de 2010 resumen objetivo: destacar la experiencia de la inserción al campo no sólo como la forma de recolectar información y determinar la calidad de los datos en que se basan los hallazgos, análisis y conclusiones, sino, también como elemento integrador del proceso de investigación que permita realizar una lectura de la realidad más específica. método: a través de la investigación experiencias de las adolescentes embarazadas en la localidad de kennedy en la ciudad de bogotá. deseando el embarazo pero no tan pronto, se describen el estudio cualitativo y los antecedentes de la investigación, y se presentan las fases propias de la inserción. conclusión: como método, la inserción al campo trasciende el acceso al dato; exige una acción dialéctica entre la teoría y la práctica, ya que el trabajo de campo requiere una formación teórico-metodológica y, al mismo tiempo, se sustenta en diversas técnicas y herramientas para la investigación. palabras clave inserción al campo, investigación cualitativa, gestión, adolescente, embarazo. (fuente: decs, bireme). field work: key to qualitative research abstract objective: highlight the experience of going into the field, not only as a way to gather information and to determine the quality of the data on which findings, analysis and conclusions are based, but also as an integrating element of the research process that allows for a more specific interpretation of reality. method: experiences of pregnant teens in the kennedy district of bogota: wanting to become pregnant but not so soon describes the qualitative study and the background for the research, in addition outlining the stages that involved field work. conclusion: as a method, going into the field implies more than access to data. it demands dialectic action between theory and practice, as field work requires theoretical-methodological training and preparation, besides being based on a variety of research techniques and tools. key words going into the field, qualitative research, steps taken, adolescent, pregnancy. (source: decs, bireme). año 10 vol. 10 nº 3 chía, colombia diciembre 2010 l 253-266 254 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 o trabalho de campo: fondamento da pesquisa qualitativa resumo objetivo: realçar a experiência de integração no campo não apenas como uma maneira de coletar informação e determinar a qualidade dos dados que sustentam as descobertas, análises e conclusões, mas também como um elemento do processo de pesquisa que permite uma leitura específica da realidade. método: na investigação experiências de adolescentes grávidas na localidade de kennedy, em bogotá. desejando a gravidez, mas não tão cedo, descrevemos o estudo qualitativo e os antecedentes da investigação e apresentamos os estágios da inserção. conclusão: como método, a inserçã no campo vai além do acesso aos dados, exige ação dialética entre teoria e prática, posto que o trabalho de campo requer formação teórica e metodológica porque se baseia em várias técnicas e ferramentas de pesquisa. palavras-chave inserção no campo, pesquisa qualitativa, gestão, adolescente, gravidez. (fonte: decs, bireme). 255 el trabajo de campo: clave en la investigación cualitativa l virginia inés soto-lesmes, maría mercedes durán de villalobos introducción el objetivo de este artículo es compartir las experiencias de inserción al campo de esta investigación, que además de constituirse en un método (1), para reconstruir las experiencias y vivencias de un grupo de adolescentes embarazadas en la localidad3 de kennedy4 de la ciudad de bogotá colombia (2, 3), también aporta elementos para comprender el fenómeno de estudio. así como en la investigación cualitativa es preciso establecer de una manera rigurosa el problema de investigación, el diseño metodológico y el análisis de los datos, también lo es la inserción al campo (4, 5), que se realiza con el fin de planear deliberadamente un ingreso adecuado que permita al investigador optimizar tiempo y recursos, conocer y comprender el entorno que envuelve la realidad de los sujetos de investigación, recolectar de manera apropiada los datos, y validar ampliamente la pregunta de investigación. primero, se presenta una breve descripción de la investigación cualitativa, incluida la metodología y algunos antecedentes relacionados con los sujetos de investigación, aspectos estos que ponen en contexto el fenómeno de estudio. luego, se exponen las estrategias de inserción al campo propiamente dichas; posteriormente se hablará sobre las entrevistas de prueba y los métodos de aplicación, para finalizar con la consecución de información y datos secundarios. la investigación cualitativa en enfermería permite el avance de la disciplina al explorar, desde un enfoque holístico, los fenómenos de la misma (6). desde la visión de enfermería, se reconoce el paradigma interpretativo caracterizado por los supuestos ontológicos, de que la realidad es compleja, holística y dependiente del contexto. para el fenómeno por estudiar, el núcleo de enfoque de la investigación está sobre las experiencias de las adolescentes embarazadas. dado que la realidad y la experiencia humana son variables, se aprecian como valiosas múltiples formas de comprensión para descubrir el conocimiento que está incrustado en dicha experiencia. agrupado este conocimiento bajo el método interpretativo, cuya meta es comprender y derivar significados de la experiencia humana (7). desde la producción de conocimiento, investigar en enfermería exige, además de determinar el paradigma con que se mirará esa realidad, tener presente la situación y el tema de estudio (8). esto es, valorar y discutir todos los aspectos que forman parte de su historicidad, su entorno y la realidad donde está inmersa; sus valores, creencias y tradiciones, y diferentes modos de vivir relacionados con su construcción social (9). dadas las características psicológicas y sociales de las adolescentes embarazadas, y por la misma naturaleza del fenómeno, es posible su comprensión desde el interaccionismo simbólico al reconocer que la conducta individual no se puede analizar sin tener en 3 el decreto 1421 (ministerio de gobierno nacional, 1993), definió que la estructura administrativa del distrito capital comprende el sector central, el sector descentralizado, y el de las localidades, y en su artículo 62 determinó la creación de localidades, sus límites y atribuciones administrativas y dictó las demás disposiciones necesarias para su organización y funcionamiento, teniendo en cuenta la cobertura de los servicios básicos, comunitarios e institucionales, y las características sociales de sus habitantes. 4 ubicada al sur-occidente de la ciudad, con una extensión de 3.857 hectáreas y cerca de un millón de habitantes. la investigación cualitativa en enfermería permite el avance de la disciplina al explorar, desde un enfoque holístico, los fenómenos de la misma. desde la visión de enfermería, se reconoce el paradigma interpretativo caracterizado por los supuestos ontológicos, de que la realidad es compleja, holística y dependiente del contexto. 256 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 cuenta el contexto social en el que el individuo desenvuelve su vida (10); este vive en interacción con otros individuos y tiene la capacidad de reflexionar sobre sí mismo, y son estos procesos de interrelación los que contribuyen de forma decisiva a la configuración de símbolos que le permiten el sentido de “ser social” (11). entonces, la teoría fundamentada como método de investigación reposó sobre la tesis ontológica de que la experiencia vivida de la adolescente embarazada permite múltiples interpretaciones y realidades (12), y como metodología es un modo de manejar las interpretaciones de manera sistemática y explicativa (13). antecedentes la oms define adolescencia como “el periodo de la vida en el cual el individuo adquiere la capacidad de reproducirse, transita de los patrones psicológicos de la niñez a la adultez y consolida su independencia económica”. es considerada como un periodo de la vida libre de problemas de salud pero, desde el punto de vista de los cuidados de la salud reproductiva, el adolescente es, en muchos aspectos, un caso especial (14, 15). los cambios en la adolescencia abarcan un amplio periodo de crecimiento físico y psicológico dirigido hacia la madurez cognoscitiva, funcional, emocional, sexual y social. esta etapa transcurre entre los 10 y 19 años, y su corte ha sido asumida, como criterio estadístico, en subgrupos: de 10 a 14 años y de 15 a 19 años (16). en colombia, para el 2005 los adolescentes entre los 10 y los 19 años representaron el 19,6% de la población total, es decir, un poco más de nueve millones de jóvenes, de los cuales las mujeres ascienden a cuatro millones y medio, que representa el 32,9% de las mujeres en edad reproductiva (17). a nivel mundial, las adolescentes entre 15 y 19 años de edad dieron a luz a 17 millones de infantes en 1997, de los cuales 16 millones (cerca del 95%) nacieron en países en vía de desarrollo. adicionalmente, el 25% de todas las muertes maternas ocurren en este grupo de edad. aunque los índices de natalidad han caído para las adolescentes en la mayoría de los países desarrollados, en américa latina y el caribe sólo han sido reportadas declinaciones modestas, de tal modo que el embarazo en las adolescentes continúa siendo un desafío para la salud pública alrededor del mundo, principalmente en países en vías de desarrollo (18). en colombia, mientras la fecundidad disminuyó entre 1990 y 2000 (11), la población adolescente cuyas edades están entre los 15 y 19 años, prácticamente la duplicaron; esta pasó del 11% en 1990 al 19% en el año 2000. actualmente, una de cada cinco adolescentes a los 19 años de edad ya es mamá, está embarazada, o ha estado alguna vez embarazada (19). el estudio ends 2005 (20), advierte que la edad promedio de adolescentes al momento de su primer embarazo es de 16 años, y la edad promedio al nacimiento de su primer hijo / hija es de 17,1 años. más de la mitad de las adolescentes que estuvieron embarazadas en los últimos cinco años no deseaban el embarazo al momento de la concepción, y una de cada tres adolescentes estuvo hospitalizada en el último año por causa del embarazo. para el caso de bogotá, es alarmante en los últimos tres años el incremento de embarazos en adolescentes tempranas (10 a 14 años); así, mientras en el 2002 la tasa de nacimientos para este grupo de madres fue de 1,48 nacimientos por mil habitantes, para el año 2004 ascendió a 1,62 por mil. tendenlos cambios en la adolescencia abarcan un amplio periodo de crecimiento físico y psicológico dirigido hacia la madurez cognoscitiva, funcional, emocional, sexual y social. esta etapa transcurre entre los 10 y 19 años. 257 el trabajo de campo: clave en la investigación cualitativa l virginia inés soto-lesmes, maría mercedes durán de villalobos cia contraria mantiene el grupo de 15 a 19 años, que para el mismo año la tasa alcanzó el 65,7 por mil, mientras para el año 2004 disminuyó al 61,3 por mil habitantes (21). la inserción al trabajo de campo (22) implica la observación y el estudio de cómo viene y va la vida de grupos y personas en la cotidianidad, y se adentra en el ambiente social con la intención de interpretar las actividades de la gente que se encuentra inmersa en él (23). dicha inserción permitió a la investigadora hacer una lectura de cómo son las relaciones, cómo interactúan las personas —y específicamente las adolecentes embarazadas que son objeto de este estudio—, cómo se las arreglan para vivir la experiencia del embarazo, y cuáles fueron las dinámicas más significativas que se manejaron en esta realidad concreta. a continuación se describen cada una de las fases de esta experiencia. en las reuniones se buscó conocer de buena tinta el entorno donde viven su cotidianeidad las adolescentes embarazadas, cómo es el barrio, el colegio, la casa, los servicios de salud y de bienestar social donde viven y conviven las participantes; cuáles son las políticas existentes para brindar atención a este grupo; cómo perciben a las adolescentes embarazadas los funcionarios que les garantizan algún tipo de atención y, por último, legalizar a través de convenios entre la universidad nacional de colombia programa de doctorado en enfermería y la institucionalidad asentada en el sector, la ejecución del proyecto de investigación. estas reuniones se llevaron a cabo con: sector salud los primeros encuentros se realizaron con funcionarios del sector salud, específicamente de la empresa social del estado5hospital del sur6 (24, 25). dos razones llevan a este encuentro, primero por ser la institución con mayor afinidad a la disciplina de enfermería, y segundo por contar con convenio docente asistencial vigente entre la facultad de enfermería y el hospital. se sostuvieron reuniones inicialmente con la directora del plan de atención básica, con el objetivo de presentar informe ejecutivo del proyecto de investigación y revisar posibles escenarios para el desarrollo del mismo; como resultado de este primer encuentro se programó una reunión con la enfermera referente del programas de salud sexual, el coordinador del programa "salud a su hogar" y la enfermera de la unidad básica de atención del hospital. para el logro del objetivo del proyecto de investigación se destacó el programa “salud a su hogar”7 (26) como el medio para acceder al entorno de las adolescentes embarazadas, el cual permitió conocer los apoyos y servicios con que cuentan, como fueron: las condiciones del barrio, de las viviendas, accesibilidad a servicios educativos, de salud y recreativos, soporte familiar y social. 5 en el distrito capital, el proceso de transformación de los hospitales públicos en empresas sociales del estado (ese) se llevó a cabo a finales de 1997, ubicando a las ese dentro de una categoría especial de entidad pública, descentralizada, con personería jurídica, patrimonio propio y autonomía administrativa y financiera. 6 el hospital del sur es una ese de i nivel, allí se llevan a cabo actividades de promoción y prevención, el plan de atención básica (pab), hospitalización y atención de urgencias y de partos de baja complejidad. 7 la denominación “salud a su hogar” implica la intención de aproximar el sector salud a la vida cotidiana de las personas, superando las barreras de acceso a los servicios hoy reconocidas. en efecto, se propone un modo promocional de la calidad de vida y la salud que permita superar las restricciones del enfoque de los servicios hacia la enfermedad y la atención individual, y avance en una perspectiva colectiva de la salud, es decir, de una verdadera salud pública. para el logro del objetivo del proyecto de investigación se destacó el programa “salud a su hogar” como el medio para acceder al entorno de las adolescentes embarazadas, el cual permitió conocer los apoyos y servicios con que cuentan. 258 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 después de adentrarse en el conocimiento del modo como trabaja esta institución, se reconoció a través de la consulta de enfermería la percepción que los profesionales tenían frente al embarazo en las adolescentes, según la cual: “es una opción de vida porque no tienen otra forma de proyectarse”. este momento del proceso de inserción al trabajo de campo permite al investigador incorporar elementos contextuales donde se desarrollan las experiencias del embarazo de estas adolescentes. sector social l secretaría de integración social (sis)8: las reuniones se realizaron con la subdirección local de integración social kennedy, que a lo largo del documento se identificará como: sis local kennedy (27). el área de influencia es la localidad de kennedy con tres centros de desarrollo comunitario (cdc) ubicados en los barrios timiza, kennedy y bellavista. para efectos de este proyecto de investigación se realizó inserción en el cdc de bellavista con el proyecto “modalidad para la formación de las familias de niños y niñas de la primera infancia”, dirigido a mujeres gestantes y lactantes pertenecientes a los niveles 1 y 2 del sisben9 en condiciones de vulnerabilidad social (28). este proyecto maneja un promedio de 750 beneficiarias por mes. se resalta el hecho de ser la entidad que cuenta con la mayor concentración de adolescentes gestantes atendidas; mensualmente ingresan entre 8 y 12 niñas escolarizadas y no escolarizadas, incluso ingresan ocasionalmente adolescentes menores de 15 años. este escenario permitió la participación en los comités de gestantes cuyo objetivo era la asignación de los bonos previo estudio de vulnerabilidad, lo mismo que a talleres de inducción al proyecto, captando en cada sesión entre 6 y 8 adolescentes gestantes que expresaron su voluntad de participar en el proyecto. este ejercicio facilitó al investigador ubicar a los sujetos que mejor pueden dar respuesta a los requerimientos de la muestra teórica del estudio (13). l redes sociales organizadas subcomité local de mujer y género. participaron funcionarios representantes de entidades como: la sis local kennedy, responsable de la política local de mujer y género. hospital del sur, responsable del programa de salud sexual; alcaldía local de kennedy, responsable de la política social de mujer y género. ong´s responsables de proyectos que garanticen igualdades y oportunidades para las mujeres, líderes comunitarias para promover los derechos sexuales y procreativos, y la productividad de las mujeres en la localidad de kennedy. 8 el sector integración social tiene la misión de liderar y formular, en la perspectiva del reconocimiento y la garantía de los derechos, las políticas sociales del distrito capital para la integración social de las personas, las familias y las comunidades, con especial atención para aquellas que estén en mayor situación de pobreza y vulnerabilidad; asimismo, ejecutar las acciones que permitan la promoción, prevención, protección, rehabilitación y restablecimiento de sus derechos, mediante el ejercicio de la corresponsabilidad y la cogestión entre la familia, la sociedad y el estado. 9 el sisbén es el sistema de identificación de potenciales beneficiarios de programas sociales. esta es una herramienta de identificación que organiza a los individuos de acuerdo con su estándar de vida y permite la selección técnica, objetiva, uniforme y equitativa de beneficiarios de los programas sociales que maneja el estado, de acuerdo con su condición socioeconómica particular. el proceso de inserción al trabajo de campo permite al investigador incorporar elementos contextuales donde se desarrollan las experiencias del embarazo de estas adolescentes. 259 el trabajo de campo: clave en la investigación cualitativa l virginia inés soto-lesmes, maría mercedes durán de villalobos comité local de salud sexual y procreativa. participaron funcionarios representantes de entidades como el hospital del sur, responsables del programa de salud sexual: el centro de administración educativa local –cadel10kennedy (29); las coordinadoras responsables de los programas de educción sexual en los colegios del distrito ubicados en la localidad, para un total de 20 colegios; la subgerencia local de juventud, y la coordinación del proyecto “modalidad para la formación de las familias de niños y niñas de la primera infancia” de la sis local kennedy. de las reuniones en estos comités se destacó un aspecto importante para tener en cuenta en el desarrollo del proyecto, como fue el reconocer que existían dos perfiles de adolescentes embarazadas: las adolescentes escolarizadas y las no escolarizadas. la participación en este tipo de reuniones en medio de la inserción al trabajo de campo, aportó elementos para caracterizar a las participantes, pues es en estos escenarios donde se direccionan las políticas locales sobre juventud y género. la actividad de las visitas domiciliarias tuvo dos objetivos. el primero fue conocer la realidad de los barrios y los espacios donde habitan las adolescentes embarazadas. el segundo objetivo fue ser reconocida en la zona de tal manera que se legitimaran los recorridos por el sector, esto facilitó el acceso a las adolescentes embarazadas y por ende su captación. se realizaron visitas a los barrios palmeras, la rivera, las acacias, el amparo y patio bonito, y a invasiones ubicadas en la ronda del río bogotá. después de varios recorridos se resuelve la facilidad de acceso a la zona gracias a la pertenencia y legitimidad de que goza el promotor adscrito al programa “salud a su hogar”, liderado por el hospital del sur. se logró captar adolescentes embarazadas de 17 y 16 años de edad, siendo este su primer embarazo. previa explicación del proyecto, autorización de los representantes legales y firma del consentimiento y el asentimiento informado, se realizaron entrevistas a profundidad de prueba. algunas de las entrevistas se realizaron con la presencia de familiares y otras sin acompañante. desde la formalización institucional para recolección de datos se realizaron trámites administrativos que llevaron a la legalización del convenio entre la subsecretaría de integración social sis local kennedy y el programa de doctorado en enfermería. este permitía la recolección de información a través de entrevistas y datos complementarios que aportaran a la investigación. el proceso se desarrolló de la siguiente manera: l reuniones administrativas con docentes del grupo académico de anciano de la facultad de enfermería de la universidad nacional de colombia, que ya se encontraban asentadas en la zona, para facilitar la inserción a la entidad. l solicitud por parte del doctorado de enfermería de participación en las actividades del sis local kennedy para iniciar proyecto. l autorización por parte de la directora de tesis para presentar el informe ejecutivo y el consentimiento informado a las entidades seleccionadas. 10 el cadel es la instancia técnica de gestión educativa ubicada en el nivel local, a través de la cual la secretaría de educación desconcentra la administración del servicio educativo en cada una de las localidades de bogotá, d.c. es claro que la inserción al trabajo de campo no sólo es un aporte desde lo metodológico sino que, también, permite hacer visible y real la incorporación de los aspectos éticos en las investigaciones que involucran a los seres humanos. 260 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 l presentación formal a las directivas de la sis local kennedy, entrega de la carta de presentación y del resumen ejecutivo del proyecto; de manera formal se da la bienvenida a la investigadora. l manifestación escrita de aceptación formal por parte de la subgerencia de la sis local kennedy a la coordinación del doctorado y a la directora de la tesis. es claro que la inserción al trabajo de campo no sólo es un aporte desde lo metodológico sino que, también, permite hacer visible y real la incorporación de los aspectos éticos en las investigaciones que compromete a los seres humanos. para realizar las entrevistas de prueba fue necesario reconocer que la entrevista a profundidad en lo posible es una conversación dirigida; permite una exploración profunda de un asunto o de una experiencia particular y, por tanto, es un método útil para la pregunta interpretativa; fomenta obtener de cada participante la interpretación de su experiencia (30). el entrevistador busca comprender el tema, y los participantes de la entrevista tienen las experiencias pertinentes para verter la luz en él. por tanto, una entrevista es inevitablemente, en algún nivel, un encuentro tan personal y a veces íntimo como público (31). desde el punto de vista del análisis temático, la entrevista permite, por un lado, la exploración de asuntos que pueden ser demasiado complejos por lo que es posible ajustar las preguntas según la postura y los comentarios del participante. en este sentido, la entrevista como herramienta de investigación es más abierta y flexible, y puede documentar perspectivas que no se representan comúnmente. por otro lado, la entrevista es una lección saludable de participación y práctica en la investigación, dado que como entrevistadores somos forzados a confrontar nuestra propia participación dentro de la misma (31). esta labor fue importante en cuanto permitió integrar el paradigma interpretativo y el cúmulo de datos cualitativos que surgieron de las entrevistas. su construcción se soportó sobre tres orientaciones que son básicas y complementarias entre sí para el apropiado desarrollo del proceso de investigación. la primera se relaciona con adquirir la experticia en esta técnica, la segunda con el hallazgo de las preguntas pertinentes y la última con los aspectos éticos. experticia en la técnica. realizar entrevistas a adolescentes gestantes ha requerido introducirse en la lógica que ellas manejan, y encontrar cuál es la mejor estrategia para conducirla a fin de lograr el máximo de información y conseguir la habilidad para identificar que sus respuestas fueran sinceras y realmente las sintieran. a lo largo de las seis entrevistas de prueba realizadas se encontraron algunas posturas que las adolescentes participantes expresan en sus testimonios, como: l “no pasa nada, todo está bien”, pero al preguntar a la madre de la participante se aprecia que la realidad es muy distinta, pues su testimonio deja percibir cómo la adolescente rompe abruptamente con su proyecto de vida al abandonar los estudios. l “no me importa nada, la llegada del bebe está muy lejos y no se piensa en ese momento”, esta postura viene acompañada de relaciones tensas con su madre, abuelos paternos y el no compartir la experiencia con el padre del bebé. por otro lado, la entrevista es una lección saludable de participación y práctica en la investigación, dado que como entrevistadores somos forzados a confrontar nuestra propia participación dentro de la misma. 261 el trabajo de campo: clave en la investigación cualitativa l virginia inés soto-lesmes, maría mercedes durán de villalobos las estrategias para identificar estas posturas fueron la grabación, trascripción y limpieza de la entrevista (32), para que el investigador se centre en la interacción, en los problemas y en los procesos sociales (33), a juicio de la investigadora. la habilidad para encontrar preguntas apropiadas se presentó simultáneamente con la habilidad para identificar sinceridad en las respuestas. este ejercicio permitió al investigador enrumbar las preguntas y así alcanzar el logro de los objetivos. para las dos primeras entrevistas de prueba se prepararon cinco preguntas que bastaran para conocer la experiencia del embarazo, los cambios sucedidos, las cosas buenas y no buenas que habían acontecido. se permitió a las madres de las participantes asistir, y se indagó sobre los cambios sobrevenidos a ellas a causa del embarazo de sus hijas. se concluye que: l la presencia del representante legal no permitió que las adolescentes se expresaran libre y sinceramente. l reconocer lo difícil que es para la participantes dar información, sus respuestas son cortas y en algunos casos son monosílabas como: “sí, no, sí señora, no señora”. se ajustaron las preguntas buscando conocer en forma más precisa las experiencias y vivencias del embarazo. fue necesario profundizar sobre qué sintió o qué pensó cuando la adolescente supo que estaba embarazada. se indagó sobre sus formas de interacción social, por ejemplo: la relación con compañeros de colegio, amigos, padre del bebé, padres, hermanos, y cómo ven el efecto del embarazo en los padres. en las últimas dos entrevistas se partió de una sola pregunta: ¿qué sintió la adolecente cuando supo que estaba embarazada?, y de acuerdo con lo que la investigadora determinó como testimonios significativos, se plantearon preguntas que permitieron profundizar en la comprensión de la experiencia. las entrevistas, además de hacer parte de la inserción al trabajo de campo, también forman parte de la preparación de la investigadora para lograr, a través de las mismas, recabar información lo más refinada posible, de tal manera que en el proceso de análisis de estos datos se logre construir un planteamiento hipotético (34) a partir de la experiencia del embarazo de las adolescentes participantes. desde los aspectos éticos se buscó dar cumplimiento a dos premisas esenciales: entregar siempre información clara y transparente a las participantes y contar con el asentimiento informado de las adolescentes y el consentimiento informado de los representantes legales de aquellas participantes menores de edad (35, 36). para la captación de adolescentes participantes los escenarios más significativos fueron los talleres de inducción de gestantes beneficiarias del proyecto “modalidad para la formación de las familias de niños y niñas de la primera infancia”, y las visitas domiciliarias realizadas en el marco del programa “salud a su hogar” desarrollado por el hospital del sur. l inicialmente se buscó la autorización de la adolescente donde manifestó voluntariamente su deseo de participar. l se explicaron los objetivos del proyecto, las estrategias de recolección de la información y los resultados esperados. l se registraron datos de las adolescentes que voluntariamente desearon participar tales como: nombre, edad, edad gestacional, dirección, teléfono, las entrevistas, además de hacer parte de la inserción al trabajo de campo, también forman parte de la preparación de la investigadora para lograr, a través de las mismas, recabar información lo más refinada posible, de tal manera que en el proceso de análisis de estos datos se logre construir un planteamiento hipotético. 262 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 barrio, con quién vive, nombre y edad del representante legal. l se informó que serían llamadas telefónicamente para concertar la próxima cita. si las participantes eran menores de edad se citaron con el representante legal. l una vez concertado el encuentro para la entrevista, se llamó 12 horas antes para reconfirmar la asistencia a la entrevista. para la construcción del consentimiento informado (35) se llevó a cabo un proceso concertado y riguroso descrito así: l se diseñaron varias propuestas que fueron discutidas con la directora de tesis, estas incluían: voluntad de ingreso al proyecto, libertad de ingresar o salir cuando lo creyeran pertinente, uso de grabadora y filmadora por parte de la investigadora, confidencialidad y privacidad de la información. l se recibieron observaciones por parte de las directivas de la sis local kennedy, relacionadas con diferenciar muy bien el hecho de que el proyecto de investigación no interfería con los compromisos y las acciones acordados a través del proyecto “modalidad para la formación de las familias de niños y niñas de la primera infancia”. l se presentó el documento del consentimiento a un miembro del comité de ética de la facultad de enfermería de la universidad nacional de colombia, se recibieron recomendaciones y se realizaron ajustes para su aprobación final. l todas las entrevistas con menores de edad, cuentan con los respectivos asentimientos y consentimientos informados avalados con las firmas de la adolescente participante y su representante legal. desde los datos secundarios, para glaser y strauss (37) la teoría fundamentada permite tener en cuenta datos adicionales, siempre y cuando estos sean útiles para la o las categorías que emergen. a medida que los conceptos y las relaciones emergen de los datos por medio del análisis cualitativo, el investigador puede usar esa información adicional para el avance posterior de la teoría (13); en el marco del convenio una de las contraprestaciones fue la de analizar la base de datos disponible en la sis local kennedy, la cual midió 12 variables sobre el total de gestantes beneficiarias del programa desde febrero de 2005 hasta mayo de 2006. datos relevantes sobre las adolescentes embarazadas para efectos del presente artículo se presentan los hallazgos derivados del análisis de las bases de datos que atañen a las adolescentes y su comparación con las gestantes adultas, ilustrando visualmente algunas diferencias importantes entre estos dos grupos de gestantes. la figura 1 muestra, a modo de síntesis, algunas relaciones de acuerdo con el ciclo vital de las madres. se presenta el primer plano factorial de un análisis de correspondencias múltiples (38), técnica estadística que se utiliza para analizar, desde un punto de vista gráfico, las relaciones de dependencia e independencia de un conjunto de variables categóricas a partir de un conjunto de datos. adicionalmente, es importante mencionar que entre más grande sean las figuras del primer plano factorial (triángulos y círculos), mejor es la asociación entre las variables involucradas en dicho plano. desde los aspectos éticos se buscó dar cumplimiento a dos premisas esenciales: entregar siempre información clara y transparente a las participantes y contar con el asentimiento informado de las adolescentes y el consentimiento informado de los representantes legales de aquellas participantes menores de edad. 263 el trabajo de campo: clave en la investigación cualitativa l virginia inés soto-lesmes, maría mercedes durán de villalobos figura 1. representación de algunas características de las madres y sus relaciones con su ciclo vital (1). los padres. segundo, ser adulta se asocia con convivir con hijos o con compañero padre de bebé. tercero, ser adulta se asocia con haber presentado abortos. cuarto, en relación con las actividades a las que principalmente se dedican las madres, el ser madre adulta se asocia con trabajo y con oficios del hogar. quinto, estar estudiando como principal actividad no se asocia con ser madre adulta. adicionalmente, la representación muestra que ser soltera se asocia con no recibir apoyo del padre del bebé y, al mismo tiempo, con no convivir con éste, aunque estas características no tienden a asociarse ni con adultas ni con adolescentes. la inserción al trabajo de campo no sólo aportó conceptual y metodológicamente a la investigación, también permitió a la investigadora balancear los beneficios para los diferentes actores, así: por un lado, contar con un permiso institucional para captar las participantes del estudio permite optimizar tiempo y recursos dupueden apreciarse tres características importantes de las madres adolescentes. primero, ser una madre adolescente del programa (círculo parte izquierda) se asocia principalmente con convivir con padres y hermanos, y con recibir apoyo económico de sus padres. segundo, ser una madre adolescente del programa (círculo rojo parte izquierda) se asocia con presentar a lo sumo una gestación y con tener un compañero padre del bebé cuya edad es menor o igual a los 18 años. tercero, ser una madre adolescente del programa (círculo parte izquierda) se asocia con estar estudiando y, a su vez, la actividad estudiar se corresponde con el grupo de adolescentes. con respecto a las madres adultas del programa (círculo parte derecha), en la figura se detectan cinco características sobresalientes. primero, ser una madre adulta en el programa se asocia con no convivir con padres y hermanos y, a su vez, con no depender económicamente de ser soltera se asocia con no recibir apoyo del padre del bebé y, al mismo tiempo, con no convivir con éste, aunque estas características no tienden a asociarse ni con adultas ni con adolescentes. 264 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 rante el proceso investigativo, por otro lado, sistematiza y analiza información relevante que le permita a las directivas de la institución tomar decisiones pertinentes. con relación a la devolución de la información, la entrega de los resultados del análisis de los datos se realizó antes de la defensa y publicación de la investigación. la pertinencia de esta decisión aplicó, en términos tales, que la información fuera utilizada por los funcionarios para definir el plan de desarrollo de la localidad. fue un aporte que permitió sustentar la construcción de políticas públicas dirigidas a jóvenes en la localidad. para efectos de validar los derechos de autor se acordó conjuntamente la utilización de la información suministrada de una manera amplia reconociendo la autoría de la investigadora. para dejar evidencia del proceso que soporte esta descripción es necesario que en los informes se anexen: las notas de campo, las actas de reuniones y de comités con el respectivo control de asistencia, los asentimientos y consentimientos informados firmados por las participantes y sus representantes legales, la construcción de preguntas para entrevistas y archivos de audio. consideraciones finales como método, la inserción al campo no es sólo una forma de acceso al dato, sino que también es una acción dialéctica entre la teoría y la práctica, puesto que para realizar el trabajo de campo se requiere una formación teórico-metodológica y, al mismo tiempo, se sustenta en diversas técnicas y herramientas para la investigación (1). llevar a cabo este ejercicio de manera rigurosa, incluido el análisis de las bases de datos, permitió inicialmente ubicar la pregunta central de investigación, validando la necesidad de comprender la experiencia y vivencia de las adolescente embarazadas, pues aunque es un tema ampliamente estudiado como problemática de salud pública, cada vez el número de embarazos en este grupo etario va en aumento. es menester, entonces, penetrar las experiencias de las adolecentes a fin de entender cuál es su realidad, para así garantizar un cuidado holístico a la adolecente embarazada. finalmente, demostrar que la inserción al campo demanda, además del rigor, la optimización de tiempo y recursos para un feliz término de la investigación. referencias bibliográficas 1. garcía j. el trabajo de campo y la investigación antropológica. en: higuera b. trabajo de campo: 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si s in t he n ur si ng c on te xt 1 gabriele santos do nascimento https://orcid.org /0000-0002-0872-9854 unifacisa , centro universitário, brazil. gabriele.santos@maisunifacisa.com.br vitória ribeiro dos santos https://orcid.org /0000-0003-3798-3453 unifacisa , centro universitário, brazil. vitoria.santos@maisunifacisa.com.br emanuella de castro marcolino https://orcid.org /0000-0002-6135-8853 unifacisa , centro universitário, brazil. emanuella.marcolino@maisunifacisa.com.br gleicy karine nascimento de araújo-monteiro https://orcid.org /0000-0002-4395-6518 universidade federal da paraíba, brazil. gleicy.monteiro@maisunifacisa.com.br ana márcia nóbrega dantas https://orcid.org /0000-0001-5729-8512 universidade federal da paraíba, brazil. amnd@academico.ufpb.br renata clemente dos santos-rodrigues https://orcid.org /0000-0003-2916-6832 universidade federal da paraíba, brazil. renata.santos@maisunifacisa.com.br artículo obstetric violence: a conceptual analysis in the nursing context received: 20/05/2022 sent to peers: 19/07/2022 approved by peers: 01/11/2022 accepted: 09/11/2022 doi: 10.5294/aqui.2022.22.4.8 to reference this article / para citar este artigo / para citar este artículo nascimento gs, santos vr, marcolino ec, araújo-monteiro gkn, dantas amn, santos-rodrigues rc. obstetric violence: a conceptual analysis in the nursing context. aquichan. 2022;22(4):e2248. doi: https://doi.org/10.5294/aqui.2022.22.4.8 https://orcid.org/0000-0002-0872-9854 mailto:gabriele.santos@maisunifacisa.com.br https://orcid.org/0000-0003-3798-3453 mailto:vitoria.santos@maisunifacisa.com.br https://orcid.org/0000-0002-6135-8853 https://orcid.org/0000-0002-4395-6518 https://orcid.org/0000-0001-5729-8512 mailto:amnd@academico.ufpb.br https://orcid.org/0000-0003-2916-6832 https://doi.org/10.5294/aqui.2022.22.4.8 https://doi.org/10.5294/aqui.2022.22.4.8 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2022.22.4.8&amp;domain=pdf&amp;date_stamp=2022-12-14 theme: epistemology contribution to the subject: a conceptual analysis of phenomena found in the professional practice that contributes to advancing nursing as a science and profession. analyzing the concept of “obstetric violence” assists in clarifying the phenomenon, as it treats it in detail, identifying its essential attributes, antecedents, and consequents in the nursing context. discussion of the theme is relevant so that nursing professionals have subsidies to identify the cases, ensure better bonds with the patients, promote humanized, standardized, and good quality assistance, and guarantee women a dignified and safe service. in addition, it provides information and solves doubts about the theme and their rights because there is an evident need for changes in these professionals’ training and qualification in terms of the absence of procedures based on scientific evidence. o bs te tr ic v io le nc e: a c on ce pt ua l a na ly si s in t he n ur si ng c on te xt 3 abstract objective: to analyze the concept of “obstetric violence” in the nursing context based on identifying its antecedents, attributes, and consequences. materials and method: it is a conceptual analysis that follows the method proposed by the walker and avant model, which consists of eight stages. six stages were used to contemplate the study objective, namely: selection of the concept; delimitation of the analysis objectives; identification of different uses of the concept in the literature; determination of the essential attributes; identification of the concept’s antecedents and consequents, and definition of the concept’s empirical references. results: the sample was comprised of 22 studies. a total of 31 antecedents were evidenced: 24 attributes for physical violence; 35 for psychological/emotional violence; 6 for institutional and sexual violence, and 5 for structural violence. regarding the consequences, 39 elements were found. conclusions: the study contributes to nursing science, research, and clinical practice, providing scientific support with a deep discussion of the phenomenon and presenting the antecedents, attributes, and consequences of obstetric violence in detail. it enables nursing professionals to recognize the empirical indicators of the concept; thus, it is likely that they will have more knowledge that will lead them to more precise nursing care, in addition to subsidies to prevent obstetric violence. keywords (source: decs) nursing; concept formation; obstetric violence; violence against women; women’s health. 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 48 resumen objetivo: analizar el concepto de violencia obstétrica en el marco de la enfermería, desde la identificación de sus antecedentes, atributos y consecuentes. materiales y método: se trata de un análisis conceptual, que sigue el método planteado por el modelo de walker y avant, el que consiste en ocho etapas. para lograr el propósito del estudio, se emplearon seis etapas: selección del concepto; delimitación de los objetivos del análisis; identificación de los usos del concepto en la literatura; determinación de los atributos esenciales; identificación de los antecedentes y consecuentes del concepto, y definición de las referencias empíricas del concepto. resultados: la muestra estuvo compuesta por 22 estudios. se evidenciaron 31 antecedentes: 24 atributos para violencia física; 35, para psicológica/ emocional; 6, para institucional; 6, para violencia sexual y 5, para violencia estructural. en cuanto a los consecuentes, se encontraron 39 elementos. conclusiones: el estudio aporta a la ciencia de la enfermería, la investigación y la práctica clínica, debido a que brinda soporte científico con discusión profunda acerca del fenómeno, además de presentar, de forma detallada, los antecedentes, atributos y consecuentes de la violencia obstétrica. lo anterior posibilita al profesional de enfermería reconocer los indicadores empíricos del concepto; así, es probable que cuente con más conocimiento que lo conduzca a una atención en enfermería más precisa, además de subsidios para prevenir la violencia obstétrica. palabras clave (fuente: decs) enfermería; formación de concepto; violencia obstétrica; violencia contra la mujer; salud de la mujer. violencia obstétrica: análisis conceptual en el marco de la enfermería o bs te tr ic v io le nc e: a c on ce pt ua l a na ly si s in t he n ur si ng c on te xt 5 violência obstétrica: análise conceitual no contexto da enfermagem resumo objetivo: analisar o conceito de “violência obstétrica” no contexto da enfermagem, a partir da identificação de seus antecedentes, atributos e consequentes. materiais e método: trata-se de uma análise conceitual, a qual segue o método proposto pelo modelo de walker e avant, que consiste em oito etapas. para contemplar o objetivo do estudo, foram utilizadas seis etapas: seleção do conceito; delimitação dos objetivos da análise; identificação dos usos do conceito na literatura; determinação dos atributos essenciais; identificação dos antecedentes e consequentes do conceito, e definição das referências empíricas do conceito. resultados: a amostra foi composta de 22 estudos. foram evidenciados 31 antecedentes: 24 atributos para a violência física; 35, para a psicológica/emocional; 6, para a institucional; 6, para a violência sexual e 5, para a violência estrutural. no tocante aos consequentes, foram encontrados 39 elementos. conclusões: o estudo contribui para a ciência da enfermagem, a pesquisa e a prática clínica, uma vez que fornece suporte científico com discussão profunda do fenômeno, apresentando, de forma detalhada, os antecedentes, atributos e consequentes da violência obstétrica. isso possibilita ao profissional de enfermagem reconhecer os indicadores empíricos do conceito; assim, é provável que ele conte com mais conhecimento que o conduza a uma assistência de enfermagem mais precisa, além de subsídios para prevenir a violência obstétrica. palavras-chave (fonte: decs) enfermagem; formação de conceito; violência obstétrica; violência contra mulher; saúde da mulher. 6 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 48 introduction the obstetric violence (ov) phenomenon has several titles, such as violence during labor, cruel treatment during delivery, disrespect and abuse, institutional violence, and violence in cases of abortion and post-abortion, among others (1). the concept’s framework is not only found in the medical area but also in human rights and in other health professions. such significant complexity generates semantic and conceptual discussions (2). although a complex phenomenon, it is understood ov relates to the acts of violence committed during prenatal care, at delivery, in postpartum, and during the puerperium, in which there is disrespect for women’s physical integrity and mental health, as well as loss of autonomy in terms of choices, feelings, or both (3). since 2014, the world health organization (who) has considered ov a public health problem directly affecting women and newborns (4). corroborating the who statement, a study carried out with 409 puerperal women at a specialized comprehensive hospital in the amhara region, northwestern ethiopia, evidenced that three out of four (75.1 %) women reported having suffered at least one type of ov during labor and delivery. the ov types were as follows: non-consensual care —260 women (63.6 %); undignified care —226 women (55.3 %); physical abuse —192 women (46.9 %); non-confidential care —132 women (32.3 %); neglected care —52 women (12.7 %), and discriminated care —38 women (9.3 %) (5). it is noted that these numbers can be significantly higher due to women’s lack of understanding to identify the acts of violence, which leads to the under reporting of cases. the need for changes in care during pre-delivery, delivery, and birth, as well as professional training regarding the phenomenon, are essential to combat, minimize, or eradicate ov, an increasingly growing action (3). as essential players in a woman’s prenatal, delivery, and puerperium care, nurses should guarantee comprehensive care, emotional support, commitment to health, and exchange of knowledge and experiences, in addition to having scientific knowledge focused on the needs of each pregnant woman and evidence-based practices. to promote qualified, humanized, welcoming, and systematized assistance, it is indispensable to understand the ov phenomenon (6). knowledge about the concept of ov needs to be expanded and improved, considering that there is no precise definition in the scientific field (7), only complementary definitions, which makes it difficult to advance the knowledge of this phenomenon and its application. despite the high recurrence of the phenomenon, no studies indicate its antecedents, attributes, and consequents, which hinders the professionals’ understanding, with the possibility of triggering o bs te tr ic v io le nc e: a c on ce pt ua l a na ly si s in t he n ur si ng c on te xt 7 consequences in the clinical practice (7). thus, it becomes indispensable to clarify the concept. that said, the study presents the following guiding question: what are the essential attributes, antecedents, and consequents to determine the concept of ov in the nursing context? in search of answers to the question, the study aims at identifying the essential attributes, antecedents, and consequents to determine the concept of ov in the nursing context. materials and methods this conceptual analysis followed the method proposed by the walker and avant model (8), which consists of eight sequential or simultaneous stages. six stages were used in this study, as they specifically contemplated the study object, with no need to build a model case or additional cases. each stage is described below. l first stage: selection of the concept — a concept that is important and useful to deepen the theoretical developments in the area of interest should be chosen. l second stage: delimitation of the analysis objectives — in this stage, the researchers should define the analysis scope (8). l third stage: identification of different uses of the concept in the literature — a broad literature review is done using dictionaries, thesaurus, available literature, and even friends and colleagues, identifying as many uses of the concept as possible. in this initial phase, the analysis is not restricted to a single concept aspect. there is the possibility of considering all uses of the term in question. the authors indicate that it is necessary not to limit the research merely to the medical or nursing literature, as this can influence their understanding of the true nature of the concept (8). l forth stage: determination of the essential attributes — in this phase, the researchers must determine the attributes, which are words or expressions that characterize the phenomenon. in other words, they are the defining characteristics that express the phenomenon’s essence (8). l fifth stage: identification of the concept’s antecedents and consequents — they are useful to further refine the attributes. the authors define ‘antecedents’ as events or incidents that must occur or be present before the occurrence of the concept and ‘consequents’ as events or incidents resulting from the occurrence of the concept. in other words, the results of the concept (8). l sixth stage: definition of the concept’s empirical references — it is the final stage of concept analysis. when a concept analysis is in its concluding phase, the question is how to measure 8 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 48 this concept or determine its existence in the real world. they are categories or classes of observable phenomena that show the occurrence of the concept using an operational definition (8). in the first stage, the ov concept was selected considering the relevance in the professional practice and research of the authors of this study who investigate violence and vulnerability. the second stage is in line with the research objective. the third, fourth, fifth, and sixth stages were developed simultaneously. in the third stage —identification of the different uses of the concept in the literature, a systematic scoping literature review was carried out, as proposed by the recommendations outlined in the joanna briggs institute reviewer’s manual (jbi [9]) and the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews checklist (prisma-scr [10]). the review was registered in the open science framework (osf) platform at https://osf.io/682fr/. the research question —what are the essential attributes, antecedents, and consequents to determine the concept of ov in the nursing context?— was determined through the pcc mnemonic, in which ‘p’ refers to participants (pregnant, parturient, and postpartum women). the first ‘c’ refers to the concept (ov, attributes, antecedents, and consequences) and the second one to the context (nursing), following the prisma-scr recommendations (10). as for the eligibility criteria, all types of studies related to pregnant, parturient, and puerperal women addressed the theme of ov. its attributes, antecedents, and consequents linked to the nursing area were included. in addition, studies of any nature, available in full without a time frame and in any language, were considered, excluding duplicates indexed in more than one database. the search followed the recommendations proposed by the jbi (9) through three stages: the first corresponds to the initial search, developed in the theses and dissertations catalog of coordenação de aperfeiçoamento de pessoal de nível superior (capes) and literatura latino-americana e do caribe em ciências da saúde (lilacs), using the following health descriptors (decs): gestantes (pregnant women), parto (parturition), período pós-parto (postpartum period), violência (violence), and enfermagem (nursing) with crossings using the or and and boolean operators. the second stage corresponds to the secondary search. it was conducted in the databases grouped according to the characteristics of each database, namely: lilacs (bvs), medline (pubmed), scientific electronic library online (scielo), american psychological association psycinfo and institute of education sciences (eric), grouping the previously defined keywords. therefore, the initial search string was as follows: (“saúde da mulher” or parto or “trabalho de parto” or “parto humanizado” or “mulheres” or “parto obstétrico”) o bs te tr ic v io le nc e: a c on ce pt ua l a na ly si s in t he n ur si ng c on te xt 9 and (“violência contra a mulher” or “violência” or “obstetrícia” or “violações dos direitos humanos” or “exposição à violência”) and (“enfermagem” or “assistência à saúde” or “humanização da assistência” or “enfermagem obstétrica”). subsequently, in the third stage, which consists of the list of references, the bibliographic references were analyzed and selected to choose the documents to be included and excluded from the study, as well as incorporating additional information. the selection of the relevant documents was carried out by two reviewers in a paired, thorough, and independent manner. initially, the titles and abstracts were read, excluding those papers that were incomplete or did not answer the questions established. subsequently, the studies selected were read in full, excluding those that did not substantially portray the concept, antecedents, attributes, and consequences of ov in the nursing context. any and all divergences between the reviewers were discussed to reach a consensus, considering the study eligibility criteria and methodological rigor. the selection of the corresponding words in the databases resulted in 22 final articles according to the respective crossing strategy (figure 1). figure 1. flowchart of the summary of the studies source: own elaboration. total studies found (n = 4,237) duplicated articles removed (n = 269) studies selected to read their titles and abstracts (n = 3,968) studies selected for complete reading (n = 98) studies selected from the lists of references (n = 01) final sample (n = 22) in cl u si o n sc re en in g id en ti � ca ti o n studies excluded for not answering the research question or not meeting the inclusion criteria (n = 3,870) studies excluded for not answering the research question (n = 76) lilacs (n = 782) medline (n = 3063) scielo (n = 317) psycinfo (n = 44) eric (n = 31) 10 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 48 after selecting the studies included to comprise the sample, the extracted data were analyzed according to the stages of determining the essential attributes, identifying the antecedents and consequents of the concept, and defining the empirical references of it. the essential antecedents and consequents were critically analyzed and distributed according to what was addressed in the articles. the attributes were classified according to the ov typification. only in the last stage the ov concept was extracted from the manuscripts and transformed into a textual corpus for processing and analysis in the r interface pour les analyzes multidimensionnelles de textes et de questionnaires (ir amuteq) software. this program clearly structures the distribution of the vocabulary. by employing the similarity analysis, the results indicate the connection between the words, also distinguishing the common parts and the specificities, resulting in a maximum tree (11). consequently, it was possible to observe the terms that operationally define the concept of ov. it is worth noting that, as it is a review, it was not necessary to submit this study to any research ethics committee. results the sample comprised 22 studies from the national and international literature published in journals devoted to nursing or other related areas between 2013 and 2021 (table 1). table 1. classification of the articles included in the review author title (in its original language) year type of study aguiar jm, d’oliveira afpl, schraiber lb (12) violência institucional, autoridade médica e poder nas maternidades sob a ótica dos profissionais de saúde 2013 qualitative research silva mg, marcelino mc, rodrigues lsp, toro rc, shimo akk (13) violência obstétrica na visão de enfermeiras obstetras 2014 experience report souza ab, silva lcs, alves rn, alarcão acj (14) fatores associados à ocorrência de violência obstétrica institucional: uma revisão integrativa da literatura 2016 integrative literature review antunes tcs (15) violência obstétrica expressa no contexto das enfermeiras de uma maternidade pública do município do rio de janeiro 2017 descriptive, exploratory, and qualitative oliveira vj, penna cmm (16) o discurso da violência obstétrica na voz das mulheres e dos profissionais de saúde 2017 interpretive, with a qualitative approach zanardo glp, calderón m, nadal ahr, habigzang lf (17) violência obstétrica no brasil: uma revisão narrativa 2017 literature review marrero l, brüggemann om (18) violência institucional durante o processo parturitivo no brasil: revisão integrativa 2018 integrative review moura rcm, pereira tf, rebouças fj, costa cm, lernades amg, silva lk a et al. (19) cuidados de enfermagem na prevenção da violência obstétrica 2018 integrative literature review perera d, lund r, swahnberg k, schei b, infanti jj (20) ‘ when helpers hurt’: women’s and midwives’ stories of obstetric violence in state health institutions, colombo district, sri lanka 2018 field work miranda fl, velloso gs, lima po, rangel sc, almeida hf, pinheiro mlp et al. (21) violência obstétrica: percepções de enfermeiros obstétricos em uma maternidade de minas gerais 2019 descriptive and exploratory, with a qualitative approach o bs te tr ic v io le nc e: a c on ce pt ua l a na ly si s in t he n ur si ng c on te xt 11 author title (in its original language) year type of study nascimento sl, pires vmmm, santos na , machado jc, meira ls, palmarella vpr (22) conocimiento y vivencias de violencia obstétrica en mujeres que han vivido la experiencia del parto 2019 descriptive and of a qualitative nature souza acat, lucas phcs, lana tc, lindner sr, amorim t, felisbino-mendes ms (23) obstetric violence: integrative review 2019 integrative review campos vs, morais ac, souza zcsn, araújo po (24) conventional practices of childbirth and obstetric violence under the perspective of puerperal women 2020 qualitative, descriptive, and exploratory castro atb, rocha sp (25) violência obstétrica e os cuidados de enfermagem: reflexões a partir da literatura 2020 literature review menezes fr, reis gm, sales a as, jardim dmb, lopes tc (26) o olhar de residentes em enfermagem obstétrica para o contexto da violência obstétrica nas instituições 2020 descriptive and exploratory, with a qualitative approach mena-tudela d, gaschcervera a , alemany-anchel mj, andreu-pejó l, gonzálzes-chordá vm (27) design and validation of the percov-s questionnaire for measuring perceived obstetric violence in nursing, midwifery and medical students 2020 instrumental design pascoal kcf, filgueiras tf, carvalho ma , candeia rms, pereira jb, cruz r ao (28) violência obstétrica na percepção de puérperas 2020 field study paula e, alves vh, rodrigues dp, felicio fc, araújo rcb, chamilco r asi et al. (29) obstetric violence and the current obstetric model, in the perception of health managers 2020 descriptive and exploratory, with a qualitative approach ribeiro do, gomes gc, oliveira amn, alvarez sq, gonçalves bg, acosta df ( 30) obstetric violence in the perception of multiparous women 2020 qualitative, of a descriptive and exploratory nature silva mi, aguiar rs ( 31) knowledge of nurses of primary care about obstetric violence 2020 descriptiveexploratory, with a qualitative approach texeira pc, antunes ls, duamarde ltl, velloso v, faria gpg, oliveira ts ( 32) percepção das parturientes sobre violência obstétrica: a dor que querem calar 2020 descriptive and exploratory, with a quali-quantitative approach zancheta ms, santos ws, souza k v, pina vr, hwu h, stahl h et al. ( 33) amplifying voices on obstetric violence: recommendations for advocacy by an obstetric nurse 2021 exploratory research source: own elaboration. regarding the analysis of the empirical indicators, the term ‘woman’ was identified as the most prevalent in the documents, followed by ‘autonomy,’ ‘body,’ ‘reproductive processes,’ ‘delivery,’ ‘natural process,’ ‘medicalization,’ ‘abusive,’ ‘unnecessary,’ ‘pathologization,’ ‘medication abuse,’ ‘body appropriation,’ ‘dehumanized,’ ‘postpartum,’ ‘assistance,’ ‘ability,’ ‘decision,’ ‘health professionals,’ ‘loss,’ and ‘physical integrity’ (figure 2). the antecedents related to ov were organized (table 2), representing the main risk factors that led to the occurrence of these instances. antecedents associated with the women themselves, health professionals, institutions, and legislation were identified. the most frequent elements were ‘unfavorable financial conditions,’ ‘black-skinned women,’ and ‘lack of knowledge about the theme.’ 12 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 48 figure 2. similarity analysis source: ir amuteq, 2021 (11). table 2. concept analysis antecedents antecedents of the ov concept elements numbers of the references frequency unfavorable financial conditions (12, 15, 17, 18, 20, 23, 26, 27, 29, 30) 10 black-skinned women (12, 15, 17, 18, 20, 23, 26, 30, 32, 33) 10 lack of knowledge about the theme (15-18, 22, 25, 26, 28, 31, 32) 10 inadequate infrastructure (13-16, 20, 21, 23, 26) 8 lower schooling levels (15, 17, 20, 23, 26, 27, 32) 7 unqualified professionals (14, 15, 21, 22, 26, 27, 29) 7 naturalization and perpetuation of the practices (12, 15, 17, 24-26) 6 precariousness in terms of materials and resources (12, 14, 15, 23, 26, 33) 6 o bs te tr ic v io le nc e: a c on ce pt ua l a na ly si s in t he n ur si ng c on te xt 13 antecedents of the ov concept elements numbers of the references frequency women’s lack of knowledge in relation to their sexual and reproductive rights (20, 22, 23, 30, 32) 5 ethnic minorities (15, 18, 20, 27, 32) 5 adolescents (12, 15, 20, 30) 4 work overload (14, 20, 23, 26) 4 non-existence of specific legislation addressing ov (17, 23, 24) 3 lack of knowledge about own body and the delivery-physiological processes (15, 24, 25) 3 impunity of acts (12, 16, 21) 3 stress/authoritarianism on the part of the professionals (15, 23, 30) 3 in abortion situation (15, 26) 2 homosexuals (15, 32) 2 inmates (15, 30) 2 high number of children (12, 30) 2 immigrants (15, 20) 2 professionals’ low wages (14, 16) 2 sex workers (30) 1 drug users (30) 1 living on the street (30) 1 protestants (32) 1 single women (15) 1 unwanted pregnancy (15) 1 hiv-positive women (15) 1 family culture (25) 1 women with no companion (30) 1 source: the authors’. the attributes identified were organized according to the typologies (table 3). the following terms stood out in physical violence: ‘episiotomy/episiorrhaphy,’ ‘unwarranted cesarean sections,’ ‘oxytocin use;’ in psychological/emotional violence, the most prevalent attributes highlighted were ‘humiliations’ and ‘providing false information or omitting information.’ in turn, institutional violence had the following as its main attribute: ‘not allowing the presence of a companion;’ the sexual violence typology had ‘repetitive vaginal touch examination’ as an attribute; finally, the ‘lack of human and material resources’ attribute stands out in structural violence. 14 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 48 table 3. concept analysis attributes attributes of the ov concept physical violence elements numbers of the references frequency episiotomy/episiorrhaphy (13, 14, 17, 18, 20, 22-26, 28, 32) 12 unwarranted cesarean sections (12, 13, 15, 17, 18, 20, 22, 25, 26, 28, 32, 33) 12 oxytocin use (13, 15, 18, 22, 23-26, 32) 9 kristeller maneuver (15, 18, 22, 23, 25, 26, 27, 32) 8 lithotomy position at birth (17, 18, 23-25, 28, 29, 32) 8 unnecessary interventions or procedures or performed without due consent (14, 15, 17, 21, 27, 28, 30, 33) 8 denial of any type of pain relief (14, 17, 18, 25, 29, 30, 32) 7 restriction to the bed (18, 23-25, 26, 29, 30) 7 trichotomy (17, 22, 23, 25, 26, 30, 32) 7 not using analgesics when indicated (12, 15, 16, 21, 27, 31, 33) 7 aggressions (12, 14, 15, 18, 24, 27) 6 performance of enema (15, 17, 22, 25, 28) 5 prohibition of eating or drinking (23, 25, 32) 3 excessive medicalization (14, 17, 21) 3 amniotomy (23, 24, 32) 3 preventing skin-to-skin contact (15, 17, 32) 3 trivialization of pain (20, 30) 2 use of forceps (25, 32) 2 prolonged bed rest (22, 32) 2 valsalva maneuver (23, 24) 2 causing pain (12, 18) 2 walking in the last stage of delivery (30) 1 not allowing immediate mother-infant contact immediately after birth (29) 1 invasive procedures performed on newborns that show good vitality (15) 1 psychological/emotional violence elements numbers of the references frequency humiliations (14, 17, 18, 23, 25, 27, 28, 31, 32) 9 providing false information or omitting information (15, 18, 19, 23, 24, 29, 30, 32) 8 threats (16, 18, 25, 28, 30, 31) 7 yelling (14, 16, 18, 25, 31, 32) 6 abandonment (18, 20, 24, 26, 32) 5 disrespect (12, 26, 27, 28, 30) 5 reproaches (14, 16, 18, 31, 32) 5 imposition of decisions/values (15, 18, 19, 26) 4 rude manners (12, 30, 31, 32) 4 curses (14, 18, 25) 3 disqualification of the woman’s choices (18, 30) 2 denial of care (18, 26) 2 trivialization of the woman’s suffering or needs (18, 20) 2 teasing (15, 17) 2 devaluation of women complaints (15, 24) 2 impatience (26, 30) 2 o bs te tr ic v io le nc e: a c on ce pt ua l a na ly si s in t he n ur si ng c on te xt 15 embarrassment (18) 1 hostile treatment (17) 1 irony (17) 1 coercion (17) 1 disrespect towards beliefs and cultures (15) 1 judgment (26) 1 lack of welcoming (29) 1 coldness (15) 1 harshness (15) 1 ironic phrases (26) 1 harsh speeches (26) 1 authoritarian behaviors (16) 1 derogatory words (16) 1 mockery (28) 1 moralistic speeches (30) 1 changes in the tone of the voice (23) 1 coarse treatment (18) 1 offenses (27) 1 pejorative comments (26) 1 institutional violence elements numbers of the references frequency not allowing the presence of a companion (12, 14, 15, 17, 23-26, 28, 29, 32, 33) 12 pilgrimage in search of assistance (15, 18, 25) 3 refusal of admission to health institutions and retention of women and their newborns in the institutions (27, 32, 33) 3 not allowing breastfeeding (15, 32) 2 not having the opportunity to get to know the maternity ward and the professionals who will assist them (19) 1 difficulty accessing prenatal services or poorquality care (15) 1 sexual violence elements numbers of the references frequency repetitive vaginal touch examination (15, 18, 22, 25, 28, 32) 6 invasion to the woman’s privacy (17, 26, 27, 33) 4 sexual abuse (17, 30-32) 4 sexual harassment (17) 1 unnecessary exposure of intimacy (30) 1 breast clinical examination without due consent and without information (15) 1 structural violence elements numbers of the references frequency lack of human and material resources (18) 1 inadequate infrastructure (18) 1 insufficient number of beds (18) 1 imposition of institutional routines (18) 1 shortage of professionals (12) 1 source: the authors’. 16 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 48 the main ov consequences found in the literature were organized (table 4). it was observed that the interventions performed caused significant physical and psychological sequelae for women’s life and marital and maternal relationships, as well as traumas. in addition, they had consequences for the newborns, which could lead to their death. the following stand out among the consequents: ‘maternal and child morbidity and mortality,’ ‘loss of the woman’s autonomy at delivery,’ ‘emotional and psychological harms,’ and ‘physical harms.’ table 4. concept analysis consequents consequents of the ov concept elements numbers of the references frequency maternal-child morbidity and mortality (13-17, 19, 25, 26, 28, 30) 10 loss of the woman’s autonomy at delivery (15-17, 23-26, 29, 32) 9 emotional and psychological harms (12, 14, 22, 25-28, 32) 8 physical harms (12, 14, 26, 27, 28, 30, 32) 7 pain (15, 26, 27, 32) 4 repercussions for the woman’s sexual and reproductive health (14, 15, 27, 32) 4 negative influence on the pregnancy and delivery physiological process (21, 29, 31) 3 thirdand fourth-degree perineal laceration (14, 15, 22) 3 infection (14, 15, 22) 3 hemorrhage (14, 15, 22) 3 trauma (16, 32) 2 depersonalization of the woman (29, 30) 2 urinary and fecal incontinence (14, 22) 2 fetal distress (24, 32) 2 fear (15, 18) 2 insecurity (15, 18) 2 negative effects on the mother-child bond (15, 25) 2 negative impact on women’s quality of life (25) 1 discrediting women and their physiological ability to give birth (21) 1 loss of privacy (16) 1 child’s developmental inability (28) 1 early hospitalization of women (32) 1 it can lead to surgical delivery (32) 1 it impairs blood flow and oxygen to the infant (32) 1 it hinders and increases duration of labor and pain intensity during contractions (32) 1 low self-esteem (32) 1 loss of trust in the professionals (32) 1 tachysystole (24) 1 hypertonia (24) 1 o bs te tr ic v io le nc e: a c on ce pt ua l a na ly si s in t he n ur si ng c on te xt 17 consequents of the ov concept elements numbers of the references frequency uterine hyperstimulation, uterine rupture or both (24) 1 loneliness (18) 1 loss of the uterus (27) 1 stress (27) 1 edema (15) 1 episiorrhaphy endometriosis (15) 1 it makes it difficult to initiate breastfeeding, as well as duration of exclusive breastfeeding (15) 1 respiratory problems for the newborn (15) 1 difficulty in the care targeted at the newborns and their development (15) 1 intensification of the difficulty to access health services (14) 1 source: own elaboration. discussion the expressions or terms presented using the similarity analysis evidence that the phenomenon can occur during prenatal care, delivery, the puerperium, in case of abortion, and when there are violations of the woman’s human rights and integrity, loss of autonomy and decision-making. the findings of this research point to empirical indicators that operationally define the concept of ov, which contributes to clarifying the phenomenon and providing theoretical support for nurses to timely identify the occurrence and intervene appropriately. the category of the antecedents identifies that, for the occurrence of ov, several factors involved are related not only to the woman but to the entire pregnancy-puerperal process. the following stand out, unfavorable financial conditions, skin color, schooling level, lack of knowledge about the theme, inadequate infrastructure, precariousness in terms of materials and resources, and unqualified professionals. black-skinned women (12, 15, 17, 18, 20, 23, 26, 30, 32, 33) with unfavorable financial conditions (12, 15, 17, 18, 20, 23, 26, 27, 29, 30), lower schooling levels (15, 17, 20, 23, 26, 27, 32), and ethnic minorities (15, 18, 20, 27, 32) are targets more prone to violent practices, mainly routine interventions and absence of a companion. in addition, many women of low socioeconomic status with low schooling levels had limited access to prenatal consultations, which further led to disinformation about labor and delivery (34). in a study carried out with nine low-income and black-skinned women in northeastern brazil, physical, verbal, and institutional ov instances were reported. there were practically no reports of respect 18 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 48 for women during delivery and minimal obstetric interventions (2). the greater a woman’s vulnerability, the ruder and more derogatory the treatment she was offered (35). secondly, adolescents (12, 15, 20, 30), sex workers (30), drug users (30), homeless women (30), homosexuals (15, 32), and inmates (15, 30) are more prone to negligence and omission of care (30). a research study conducted with chilean women evidenced that those with low schooling levels, minors, homosexuals, and indigenous reported more ov cases, mainly those treated in the public health system (36). lack of knowledge about the theme (15-18, 22, 25, 26, 28, 31, 32) was a significant finding of an ov antecedent. a study conducted in india with 305 women identified that 257 suffered some disrespect and abuse; of this total, 89.1 % answered “no” when asked about any treatment they considered humiliating. this reveals that this type of violence is seen as something normal when knowledge is inadequate (37). however, when understanding the act, the answers were notably different, as revealed by a survey carried out in spain, in which 17,541 questionnaires were delivered, 38.3 % realized that they had suffered ov and 44.4 % perceived that they were subjected to unnecessary or painful procedures, of which 83.4 % were not asked for their due informed consent (7). naturalization and perpetuation of the practices (12, 15, 17, 24-26), an ov antecedent, such as pain related to delivery (38), is also associated with a lack of knowledge on the topic. it is believed that delivery is a painful process, naturalizing the unfavorable situations experienced by the women and not recognizing some procedures as violence but common and routine situations (39). knowledge about the body and the physiology of delivery favors the reduction of vulnerability, the fight against ov and women’s empowerment, ensuring their rights and autonomy and counteracting abusive actions performed by professionals. the following stand out among the antecedents related to health professionals and institutions: unqualified professionals (14, 15, 21, 22, 26, 27, 29), work overload (14, 20, 23, 26), the professionals’ low wages (14, 16), stress/authoritarianism on the part of the professionals (15, 23, 30), inadequate infrastructure (13-16, 20, 21, 23, 26), precariousness in terms of materials and resources (12, 14, 15, 23, 26, 33) and impunity of acts (12, 16, 21). due to a lack of training and adequate working conditions —especially associated with insufficient materials and resources, obstetric care quality becomes increasingly dehumanized, causing emotional stress and overload in professionals (40). the professionals’ inability to offer qualified assistance, which allows for predicting violence and intervening, reflects a society that has always naturalized violent behaviors and procedures as non-violent. in o bs te tr ic v io le nc e: a c on ce pt ua l a na ly si s in t he n ur si ng c on te xt 19 addition, the professional-user hierarchy, with unilateral authority, tends to lead professionals to verbalize and perform violent techniques or both without noticing that they are, in fact, violent (41). therefore, it is fundamental that professionals know the ov antecedents, attributes, and consequents to provide good quality care throughout the pregnancy-puerperal process. the attributes, which are essential characteristics of the phenomenon, were grouped according to the type of violence into physical, psychological or emotional, institutional, sexual, and structural, which allowed for a better understanding of ov. among the attributes included in the category of physical ov, interventions and procedures that are unnecessary or performed without due consent (14, 15, 17, 21, 27, 28, 30, 33) stand out, as well as oxytocin use (13, 15, 18, 22-26, 32), episiotomy and episiorrhaphy (13, 14, 17, 18, 20, 22-26, 28, 32), kristeller maneuver (15, 18, 22, 23, 25-27, 32), constant use of forceps (25, 32), denial of any type of pain relief (14, 17, 18, 25, 29, 30, 32) whether by means of non-pharmacological methods or not, restriction to the bed (18, 23, 24-26, 29, 30), prohibition of eating or drinking (23, 25, 32), enema (15, 17, 22, 25, 28), trichotomy (17, 22, 23, 25, 26, 30, 32), which includes unnecessary removal of pubic hair, and mandatory lithotomy position at birth (17, 18, 23-25, 28, 29, 32), which causes increased pain and slows down the delivery process. these attributes are mentioned in several interviews with women in maternity hospitals in the czech republic (42). in another research study carried out in a hospital in azuay, ecuador, the women also reported these attributes they characterized as types of physical violence (43). these studies corroborate the results found in the current one, validating the essence of the phenomenon. some women point out another perception about the kristeller maneuver and oxytocin administration. in a research study carried out with 57 puerperal women in the central area of the huasteca region of san luis potosí, mexico, it was reported that these procedures are an act of gratitude towards the mothers at delivery, as they help the infant to descend more quickly and minimize moments of prolonged suffering (44). however, when episiotomy and episiorrhaphy were mentioned (44), the women’s reports of actually feeling ov were unanimous, mainly in cases where they were not informed. this agreement is observed in several pieces of scientific evidence (16, 43, 44). despite the efforts to seek humanization in obstetric care, the following is clearly noticeable: predominance of interventional procedures such as excessive medicalization (14, 17, 21), trivialization of the pain felt by the women (20, 30), not using analgesics when indicated (12, 15, 16, 21, 27, 31, 33), forcing parturient women to walk in the last stage of delivery (30) without their consent, 20 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 48 prolonged bed rest (22, 32), aggressiveness (12, 14, 15, 18, 24, 27), and performing an amniotomy (23, 24, 32) and the valsalva maneuver (23, 24), which refers to encouraging voluntary push, with unequal power relations between professionals and women prevailing (16). physical violence is more prevalent because it is more easily identifiable among women, as shown by a research study carried out at a public hospital in north shewa, amhara, ethiopia. it was pointed out that 100 % (435) of the women identified some of these attributes that characterize ov related to physical characteristics (45). the following attributes stand out in the psychological ov category: humiliation (14, 17, 18, 23, 25, 27, 28, 31, 32), teasing (15, 17), providing false information or omitting information (15, 18, 19, 23, 24, 29, 30, 32), yelling (14, 16, 18, 25, 31, 32), threats (16, 18, 25, 28, 30-32), disqualification of women’s decisions (18, 30), denial of care (18, 26), abandonment (18, 20, 24, 26, 32), embarrassment (18), imposition of decisions/ values (15, 18, 19, 26), trivialization of women’s suffering or needs (18, 20), reproaches (14, 16, 18, 31, 32), ironic phrases (17), and coldness (15). the harms caused by psychological ov go beyond the physical aspect, leaving emotional and psychological scars for a long time, undermining the emotional realm and bringing about consequences that negatively interfere with the puerperal period, a delicate moment for puerperal women (46). it should be noted that these problems can lead to postpartum depression (47). in an analysis of the notifications of pregnant women in brazil between 2011 and 2018, with 2,033,026 cases, the type of violence with the highest incidence was physical (61.9 %), followed by psychological (31.2 %) and lastly, sexual (27 % [48]). the incidence of reports that mention the essential characteristics of the phenomenon, that is, the attributes, is considerably high. a multicenter survey carried out in the united states with 2,138 women indicates that one out of six (17.3 %) mentions some type of abuse, such as yelling, disrespect, unknown or erroneous information, denial of care, embarrassment, and loss of decision-making autonomy. it is believed that more women have suffered psychological violence, although they could not identify it (49). from the institutional category perspective, the attribute with the highest incidence was not allowing the presence of a companion (12, 14, 15, 17, 23-26, 28, 29, 32, 33). brazilian women are supported by the companion law (law 11,108) of april 7th, 2005, which allows for the presence of a companion during delivery, childbirth, and the immediate postpartum period, either in private or public health services (50). although supported by law, qualitative studies (51, 52) still notice reports of brazilian women who claimed they were not allowed to have a companion and accepted so due to lack of information, even with distress. o bs te tr ic v io le nc e: a c on ce pt ua l a na ly si s in t he n ur si ng c on te xt 21 in the sexual ov category, the most characteristic attributes were a repetitive vaginal touch (15, 18, 22, 25, 28, 32), invasion of privacy (17, 26, 27, 33), sexual abuse (17, 30-32), and unnecessary exposure of intimacy (30). repeatedly touching the vagina can cause harm, such as inciting premature birth and infection in the infant (53) and inducing pain and discomfort. in a study, mexican women mentioned that they feel unnecessarily invaded in their privacy and exposed, with several touches practically at the same time, reporting that there seems to be no communication between the health professionals (44). a shocking report in a research study conducted in northern brazil reveals that the health professional performed the vaginal touch examination and asked all the students present to repeat the procedure, causing discomfort, invasion of privacy and exposure of the woman’s intimacy (53). this scenario proves to be totally inhuman to the woman. that is a reality not only in brazil but also in other countries, such as iran, where the prevalence of sexual ov stands out in relation to the other types. this assertion is indicated in a study conducted with 725 women, in which 14.8 % suffered sexual violence, 9.9 % were victims of psychological violence, and 6.5 % of physical violence. domestic sexual abuse was also very evident (48). finally, the structural ov attributes refer to precarious assistance or omission to the detriment of the infrastructure (18), lack of human and material resources (18), lack of beds (18), imposition of institutional routines (18) and shortage of professionals (12). this is more likely to occur in public institutions before the woman’s hospitalization, affecting both her and the professionals, which entails overload and undignified working conditions (18). these attributes are proven through diverse evidence in practice. during data collection, nurse-researchers noticed a deficit in terms of equipment and a lack of necessary maintenance, especially in the public sector, in addition to communication difficulties between professionals and the absence of adequate signs in the environment (14). in the category of the ov phenomenon consequents, resulting events or incidents were detected, such as loss of women’s autonomy, emotional and psychological harms, and maternal and child morbidity and mortality. when a woman loses her autonomy during delivery (15-17, 23-26, 29, 32), her primary role is obliterated, in addition to her decision-making power. for this gap, it is recommended that women look for a support network during prenatal care to acquire knowledge (54). 22 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 48 the formation of groups of pregnant women in southern brazil showed that those who regularly participated in the meetings were able to enjoy significant autonomy and were willing to argue and impose their wishes, showing greater awareness of the delivery moment (55). other terms presented as ov consequents were emotional and psychological harms (12, 14, 22, 25-28, 32), fear (15, 18), insecurity (15, 18) and loneliness (18). these terms corroborate a research study conducted in northeastern brazil, in which the puerperal women mentioned having suffered emotional and psychological consequences, resulting in frustration, anger, anguish, and impotence. in the interviews, it is possible to see hints of postpartum depression and trauma after the episiotomy procedure. consequently, the same women reported that these problems affected their sex lives (52). in the findings of the current study, episiotomy, an ov attribute, refers to the following consequences: thirdand fourth-degree perineal laceration (14, 15, 22), infection (14, 15, 22), intense bleeding (14, 15, 22), urinary and fecal incontinence (14, 22), edema (15), and episiorrhaphy endometriosis (15). although uncommon, episiorrhaphy endometriosis is more prevalent in women who have undergone at least one episiotomy and in cases of vaginal deliveries with curettage to avoid hemorrhages and uterine subinvolution (56). procedures considered routine and standardized in health services, without indication, can cause or intensify pain (15, 26, 27, 32), physical harm (12, 14, 26-28, 30, 32), and unnecessary suffering. in view of this, the importance of dialogue between professionals, especially nurses, and pregnant women is emphasized, in addition to providing fundamental information about the pregnancy-puerperal process and encouraging self-knowledge about their bodies, role, and decision-making power (57). an important ov consequence is maternal and child morbidity and mortality (13-17, 19, 25, 26, 28, 30) during labor and the puerperium, mainly due to cesarean sections without indication, which intensifies the likelihood of respiratory problems for the newborn (15) and triples the mother’s mortality risk, in addition to the possibility of also causing loss of the uterus (27). ov can lead to maternal morbidity and mortality due to several factors, such as adverse events related to aggressive management of vaginal and cesarean deliveries, neglect to perceive the suffering experienced by the woman, hostility, negligence, and delay in assisting women who are having an abortion —spontaneous or desired— and not allowing the presence of a companion (51). finally, it is crucial that nurses are aware of the ov phenomenon and duly trained and able to identify it and intervene in a timely o bs te tr ic v io le nc e: a c on ce pt ua l a na ly si s in t he n ur si ng c on te xt 23 manner, offering humanized, comprehensive, empathetic, and qualified assistance. it is believed that this concept analysis contributes to nursing science, research, and clinical practice, considering that it provides scientific support with a deep discussion of the phenomenon, presenting the ov antecedents, attributes, and consequents in detail. this enables nurses to recognize the empirical indicators of the concept; thus, it is likely that they will have a greater knowledge that will lead them to more precise nursing care in the clinical practice. as a limitation, we cite non-elaboration of the model case and additional cases; however, there was an in-depth analysis of empirical bases and compliance with methodological rigor. conclusions in this research, it was possible to analyze the ov concept, identifying 76 related attributes, 31 antecedents, and 39 consequents. the study made it possible to contribute greater clarity to the phenomenon, offering theoretical and scientific support for nurses to identify ov cases and contributing to the evolution of nursing epistemology. the multidimensionality of the topic studied was comprehensively observed, as it presents several typifications, each with their respective essential characteristics, in 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desenvolvimento das teorias de médio alcance para o progresso da atenção de enfermagem na colômbia 10.5294/aqui.2021.21.4.6 janice m. morse1 1 0000-0002-9017-1940 distinguished emerita, university of utah, college of nursing, united states of america; emerita, university of alberta, canada. janice.morse@nurs.utah.edu received: 14/09/2021 sent to peers: 29/09/2021 approved by peers: 21/10/2021 accepted: 03/11/2021 theme: epistemology. contribution to the discipline: mid-range theories target specific patient problems and enable the identification of nursing interventions, thus enhance patient care. by identifying the patient's psychosocial problem(s) and selecting from the compendium of related concepts, nurses may then select a mid-range theory as a therapeutic strategy, thereby systematically changing the patient's course of illness. to reference this article / para citar este artículo / para citar este artigo: morse jm. developing mid-range theories for the maturation of nursing care in colombia. aquichan. 2021;21(4):e2146 doi: https://doi.org/10.5294/aqui.2021.21.4.6 abstract nursing theory has evolved since the 1960s, from conceptual models to concept analysis to mid-range theories. mid-range theories are developed primarily for qualitative research, to target patient problems, to respond to patient needs, to identify interventions and the changing patterns of patient care. these mid-range theories cluster in various patterns to provide valid, coherent, and significant interventions. examples of programs that have dramatically impacted our understanding of nursing and patient care are presented. thus, by developing and implementing the findings of midrange theories, nursing care matures, and the standards advance. keywords (source decs): nursing theories; nursing care; knowledge development; research; nursing. resumen la teoría de enfermería ha venido evolucionando a partir de la década de 1960, desde los modelos conceptuales, pasando por el análisis de conceptos, hasta las teorías de rango medio. las teorías de rango medio se desarrollan principalmente para realizar investigación cualitativa, enfocarse en los problemas del paciente, responder a las necesidades del paciente, identificar intervenciones y los patrones cambiantes de la atención al paciente. estas teorías de rango medio se agrupan en varios patrones para brindar intervenciones válidas, coherentes y significativas. en este artículo, se presentan ejemplos de programas que han tenido un gran impacto en nuestra comprensión de la enfermería y el cuidado del paciente. así, al desarrollar e implementar los hallazgos de las teorías de rango medio, la atención de enfermería madura y los estándares avanzan. palabra clave (fuente decs): teoría de enfermería; atención de enfermería; mejora; conocimiento; investigación; enfermería. resumo a teoria de enfermagem vem evoluindo desde a década de 1960, dos modelos conceituais, passando pela análise de conceitos, até as teorias de médio alcance. as teorias de médio alcance são desenvolvidas principalmente para realizar pesquisa qualitativa, para focar nos problemas do paciente, atender às necessidades do paciente, identificar intervenções e padrões oscilantes da atenção ao paciente. essas teorias são agrupadas em vários parâmetros para oferecer intervenções válidas, coerentes e significativas. neste artigo, são apresentados exemplos de programas que vêm tendo grande impacto em nossa compreensão da enfermagem e no cuidado do paciente. assim, ao desenvolver e implementar os achados das teorias de médio alcance, a atenção de enfermagem progride e os parâmetros avançam. palavras-chave (fonte decs): teoria de enfermagem; cuidados de enfermagem; conhecimento; pesquisa; enfermagem. in 2008, i visited the universidad nacional de colombia, bogotá, and was amazed at the development and utilization of nursing theory in patient care. further, the integration of nursing theory/ frameworks into nursing research in colombia is clear in aquichan, where most research articles have used clinically relevant nursing frameworks, in particular, those developed by dorothea orem (1) and callista roy (2). nursing is entering another transitional wave: that of the development and application of mid-range theories. these theories differ from the conceptual models, as defined by fawcett and desanoto-madeya (3), which are used for the nursing care organization at the unit and institutional level and are not necessarily under the rubric of a conceptual model. yet they work in a complementary manner with those conceptual models described by (3) to provide nurses with the tools for an individual's patient care, assessment, and interventions, according to the identified individual patient's problem(s), but they are not restricted to the narrow definition of nursing concepts. the purpose of theories within and for nursing has much been discussed in the nursing literature and changed over time. first, and most influential, was the rise of nursing theories, primarily in the middle of the last century, when nursing was struggling to become a profession in its own right. nursing theories, largely developed in the 1960s and 1970s, were theories of broad scope that delineated nursing practice (3). the most frequently cited conceptual models of these nursing theories are: johnson's behavioral system model, king's conceptual system, levine's conservation model, neuman's systems model, orem's self-care framework, rogers' science of unitary human beings, and roy's adaptation model (4). but in our haste to become a profession, we forgot that theories are a facilitating tool, and we are "masters" controlling such theories intended to facilitate our work. thus, we previously molded our perspective according to the theory we selected to focus all of our care. it is a concern that some nursing schools dictate that, to be considered nursing, research must contain a nursing conceptual model (5). this often forced an artificial fit, for the selected model may have been too abstract for the proposed project1. further, such an approach restricted the nursing perspective of research, the use of such research clinically, and ultimately the creativity of nursing research in our rapidly changing contexts of care, or was an add-on placed in the research to meet the requirement than to facilitate the research. yet fawcett insists that mid-range theories must be couched within conceptual models to be considered nursing research (5). the second movement (for two decades from the 1990s) was the identification of concepts critical for patient care. concept analysis may use the literature and reflexive qualitative inquiry to explore ways the concepts are used and even interview data to verify the emerging conceptualizations of these concepts (6). while the research is generalizable, the theoretical structure remains basic and with the conceptual components and the interaction of these components integrated into the theory. researchers actively incorporated concepts from other disciplines and contexts into nursing when appropriate, and this research further defined and enriched our understanding of nursing and contributed to the development of mid-range theories. the third and present phase in our professional evolution, commencing about the mid-1900s, is the construction and utilization of mid-range theories2. these mid-range theories, largely developed from or initiated by qualitative inquiry, are at various levels of development and scope and directly targeted towards specific patient problems and concerns, nursing interventions, and patient care outcomes. mid-range theories may address different levels of specificity, for instance, from the microanalytic descriptions of interactions, of emotional responsiveness, touch, facial expressions, and dialogue to abstract ideas that jar us out of our routine perspectives. in this article, i strongly suggest nursing recognize this shift to the pragmatic definitions of mid-range theory and move beyond the focus of conceptual models. these qualitatively-derived mid-range theories are primarily developed from qualitative research methods that directly use interviews and observations of patients, caregiving situations from nurses, families, and communities. such qualitative research provides the tools to recognize patterns in patient states, needs, and abilities/disabilities. qualitative research provides descriptions of interventions and modes of interactions that are comforting, therapeutic, and may even be harmful. qualitative research findings are pragmatic, recognizable, and readily integrated into nursing care. qualitative research provides us with the tools to evaluate patient conditions and even enhance patient access, and the administration of care. qualitative research may be prescriptive in its identification care problems and solutions and is generalizable through its links to concepts and theories. qualitative research is solid and complete in itself3. nursing research must develop—and implement—these more specific, targeted mid-range theories to benefit patient care. even though fawcett agrees that "all nursing research may be considered a middle range theory" (4; see also 3 p17), astonishingly, fawcett states that "shared theories"—mid-range theories using concepts developed in other disciplines (such as social support in social psychology)— do not advance our discipline "as much as nurse-specific theories" (4, p4). to devalue, ignore or exclude theories encom­passing concepts inherent in our humanness is absurd4, 5. it is time to move nursing research to its optimal level. thus, the question remains, how do we determine the most useful, valid, and generalizable research for the clinical area? more importantly, how do we formally transfer/implement these results clinically and across perceived ability/disability, gender, age, and cultural boundaries in various patient populations? moreover, who is responsible for conducting and implementing this research? the scope of mid-range theories mid-range theories explore nursing and the context from the most descriptive level to the most abstract, using a myriad of sources of data and a host of qualitative (and some quantitative) methods. the methodological goal is to develop a theory applicable to patient care that provides in-depth insight into patient problems, nursing interventions, and outcomes. a valuable way to categorize these "types" of mid-range theories follows. level 1, as descriptive: the most descriptive level of mid-range theories is studies of microanalytic processes that provide insight into what is actually occurring. these are studies of observable interactions, of emotional responsiveness, of touch, facial expressions, and of dialogue. they are basic studies that may include interview and observational data and even video recordings. examples are the use and meaning of touch in patients with cancer (7) and comforting strategies during nasogastric tube insertions (8). level 2, as exploration of concepts: the next level of abstraction is studies targeted toward the role, function, and even the utilization of concepts commonly occurring in the patients' experiences of illness and treatments. these analyses may use the literature and reflexive inquiry exploring ways the concepts are used and even interview data to verify the emerging conceptualizations of these concepts. while the research is generalizable, the theoretical structure remains basic and focused on the conceptual components. such research may be an examination of hope to determine the structure of hope in various contexts (9) or the use of a frame or scaffold that data fills inductively (see, for instance, the use of resilience (10)). level 3, as the identification of trajectories: the third level is the identification of trajectories explicating patient experiences over time (11). methods, such as grounded theory, enable the identification of stages and phases of responses and the changing dynamic and interactions of relevant concepts as the patients move through the illness. these trajectories at this level of development, are usually particular to one patient group, explicating the course of recovery or decline, patients with particular needs or problems; others may identify the course of the recovery. some of these mid-range theories are general and may be used to conceptualize and organize minor concepts within their frame; many will identify nursing therapies that mitigate patient problems or facilitate, ease, and relieve discomfort. qualitative documentation of any interventions may be used for the development and evaluation of these mid-range theories. level 4: increasing scope: the fourth level consists of studies of broader scope that may be linked, or a comparative analysis of studies that explore the same experiences or concepts in different participant groups, in different situations; research that is seeking similar (or disparate) patterns, comparing patient responses, the occurrences of similar concepts in different contexts, or variations/ similarities of patient groups. this research is still at the developmental/exploratory stage, but the increasing evidence obtained from separate studies builds credence, validity, and certainty into the research program. increasing emphasis is placed on the identification and efficacy of interventions. emerging concepts are linked with the literature; the research is increasingly developed as conceptual and abstract, and mid-range theories, from the linking of concepts, are developed from the linking of concepts. an example is the development of the praxis theory of comfort and comforting from the synthesis of level 1 descriptive studies of touch, presence, and interaction such as talking through (12). level 5, multiple overlapping projects: finally, level 5 is solid individual qualitative studies, conducted as individual projects using different methods but within a cohesive topic. these projects are linked by the same general topic conducted in various stages of the disease process, in different patient age groups, in different illness experiences, developing and increasing our understanding of the concepts and confirming the theory. these projects may have been developed over time by a single investigator or team and consist of multiple qualitative studies conceptually linked to increasing understanding of the depth and scope of the topic. these qualitative research programs are powerful, pragmatic, significant, and generalizable. the findings are valid, rigorous, impactful, and, importantly, do not require quantitative validation, but quantitative methods may be used, for instance, to develop measure instruments. it is this research that now provides therapeutic strategies, is implemented as standard practice, directs our profession, and provides the tools that will make nursing, nursing6. examples of this last phase are research programs conducted using multiple methods. the first is a multiple method research program developed by canadians judith wuest, marilyn ford-gilboe, colleen varcoe, and their colleagues. using a program of multiple methods, they have developed a mid-range theory as a basis for instrument and/ in which they used or intervention development and testing: study 1: wuest et al. developed a grounded theory of health promotion in the process of leaving an abusive partner (13, 14). study 2: a four-year longitudinal quantitative study to capture the trajectory of women's health after leaving (15, 16). study 3: used strategies of theoretical sampling and constant comparison of quantitative findings to further develop the grounded theory, to develop the intervention for health enhancement after leaving (iheal) (17, 18). study 4: feasibility studies of the iheal (19). study 5: in process. researchers are presently conducting a randomized control trial testing the intervention in three canadian provinces (20). downloading all these studies and following the researcher's development of the project is an excellent way to appreciate the increasing abstraction and significance of a research program. a second approach is to develop a cluster of qualitative studies to determine the scope of a phenomenon. once completed, they are placed horizontally, linked by common concepts (rather like a puzzle). this method, theoretical cohesion, has been used by beck to explore traumatic childbirth (21) and by morse to explore the concept of enduring (22). in this way, you are developing theoretical coalescence model (21, 22), from what dickoff and james (23) described as a "theory of theories." developing these methods for the colombian nursing context how can these midrange theories be evaluated and used or modified, or redeveloped for the cultural context in colombian or other south american countries? how can these results be clinically transferred to different patient populations? are these mid-range theories specific, transferrable, or must we develop our own? the first task of conducting solid single studies is already attained and are published in aquichan and internationally. as noted above, these level 1 descriptive studies may not be ready for implementation as a mid-range theory, as the content may be too specific. nevertheless, they sensitize our clinical observation, which may provide an important foundation for identifying and analyzing more complex phenomena and further research. further, as you obtain results, researchers must carefully compare their results to the other studies on the same topic conducted elsewhere. ask: are the result the same? similar or different? why? are these procedural or structural differences in the provision of care? or cultural differences? differences within this institution, or more generally in colombia? even asking such questions may trigger the next project or give you confidence in your practice. nevertheless, all studies must be conducted with caution and care. avoid studies with inadequate data (too small a sample or limitations in recruiting) or that have not been developed theoretically7. if your study "holds up," is consistent with the external study, and has developed an intervention, then apply the findings, and if appropriate, conduct an evaluation study. furthermore, if you find similarities or differences, compare these in your published research. the last word this plea for the maturation of research, the utilization of qualitative inquiry, and the development of mid-range theory directly applicable to your clinical practice. from the above, we can see that qualitative inquiry is much more than a study of "the patient experience" (24); it provides a means for documenting the minute actions within the nurse-patient interaction; to identify the subjective, responsive components of care. it provides us with the means to "read" non-verbal patient behavior; to evaluate the efficacy of our interventions. it enables us to develop theories that recognize and predict patient behaviors, meet patient needs, and provide interventions. it is an essential and vital part of the development of nursing, one that systematically may change the patient's course of illness. as our knowledge base for nursing is continually evolving, the responsibility for developing safe and effective care is in your hands. conflicts of interest: the author declares no interest conflict. notes: 1 "the propositions of a conceptual model are so abstract and general that they are not amenable to direct empirical observation or test" (3, p13). 2 merton (25) describes this level of theory a "middle-range" theory, but this term has been abbreviated to the less pedantic term, 'mid-range.' 3 quantitative verification is unnecessary for strong qualitative inquiry, just as it is often unnecessary for qualitative inquiry to supplement quantitative work. it may do so with mixed methods design, but it is not necessary. 4 it is not clear why fawcett (4) targeted several of these concepts. her own criteria is that concepts must be derived from nursing, yet most of the theories in this list include concepts that are not derived from nursing, including some critical to nursing, such as empathy, chronic sorrow, and even comfort. 5 consider the origin of conceptual models: fawcett and desanoto-madeya write "they evolve(d) from empirical observations and intuitive insights of scholars or from deductions that creatively combine ideas from several fields of inquiry" (3 p13). of greater concern, they continue "a conceptual model is inductively developed when generalizations about specific observations are formulated in specific situations are seen as examples of other more general events" (3 p13]. yet fawcett and desanoto-madeya propose that "shared theories do not advance our discipline." 6 however, note that the 'meta-methods' (such as meta-synthesis and metaanalysis) do not qualify in this category, as they are primarily methods of label smoothing to develop a published model, and as such, they are not as powerful and do not expand the concept. 7 perhaps the research has not used a method, has restricted their study to the use of a strategy (such as thematic analysis), and not developed the themes. even the labels of each theme may only be a phrase taken from a quotation. this research in incomplete, not conceptually or theoretically developed, not replicable, and not implementable. references 1. denyes mj, orem de, bekel g. self-care: a foundational science. nurs sci q. 2001;14(1):48-54. doi: https://doi.org/10.1177/089431840101400113 2. roy c. research based on the roy adaptation model: last 25 years. nurs sci q. 2011;24(4):312-20. doi: https://doi.org/10.1177/0894318411419218 3. fawcett j, desanoto-madeya s. contemporary nursing knowledge: analysis and evaluation of nursing models and theories. 3rd ed. philadelphia: f. a. davis; 2013. 4. fawcett j. middle range nursing theories are necessary for the advancement of the discipline. aquichan. 2005;5(1):32-43. available from https://aquichan.unisabana.edu.co/index.php/aquich an/articl e/view/57 5. fawcett j. using the roy adaptation model to guide research and/or practice: construction of conceptual-theoretical-empirical systems of knowledge. aquichan. 2009;9(3):297-306. available from: https://aquichan.unisabana.edu.co/index.php/aquichan/article/view/1527 6. morse jm. analyzing and conceptualizing the theoretical basis of nursing. new york: springer; 2017. doi: https://doi.org/10.1891/9780826161024 7. bottorff jl. the use and meaning of touch in caring for patients with cancer. oncol nurs forum. 1993;20(10):1531-1538. available from: https://pubmed.ncbi.nlm.nih.gov/8278279/ 8. penrod j, morse jm, wilson s. comforting strategies used during nasogastric tube insertion. j clin nurs. 1999;8(1):31-8. doi: https://doi.org/10.1046/j.1365-2702.1999.00229.x 9. morse jm, doberneck b. delineating the concept of hope. j nurs scholarsh. 1995;27(4):277-85. doi: https://doi.org/10.1111/j.1547-5069.1995.tb00888.x 10. morse jm, kent-marvick j, barry la, harvey j, okang en, rudd ea, wang cy, williams mr. developing the resilience framework for nursing and healthcare. glob qual nurs res. 2021;8:1-21. doi: https://doi.org/10.1177/23333936211005475 11. vann-ward t, morse jm, charmaz k. preserving self: theorizing the social and psychological processes of living with parkinson disease. qual health res. 2017;27(7):964-82. doi: https://doi.org/10.1177/1049732317707494 12. morse jm. toward understanding comfort and comforting. in analyzing and conceptualizing the theoretical basis of nursing. new york: springer; 2017. 13. wuest j, ford-gilboe m, merritt-gray m, berman h. intrusion: the central problem for family health promotion among children and single mothers after leaving an abusive partner. qual health res.2003;13(5):597-622. doi: https://doi.org/10.1177/1049732303013005002 14. ford-gilboe m, wuest j, merritt-gray m. strengthening capacity to limit intrusion: theorizing family health promotion in the aftermath of woman abuse. qual health res. 2005;15(4):477-501. doi: https://doi.org/10.1177/1049732305274590 15. ford-gilboe m, wuest j, varcoe c, davies l, merritt-gray m, hammerton j, wilk p, campbell j. modelling the effects of intimate partner violence and access to resources on women's health in the early years after leaving an abusive partner. soc sci med. 2009;68(6):1021-1029. doi: https://doi.org/10.1016/j.socscimed.2009.01.003 16. scott-storey ka, hodgins m, wuest j. modeling lifetime abuse and cardiovascular disease risk among women. bmc cardiovasc disord. 2019 dec;19(1):1-4. doi: https://doi.org/10.1186/s12872-019-1196-y 17. ford-gilboe m, merritt-gray m, varcoe c, wuest j. a theory-based primary health care intervention for women who have left abusive partners. ans adv nurs sci. 2011;34(3)198-214. doi: https://doi.org/10.1097/ans.0b013e3182228cdc 18. wuest j, ford-gilboe m, merritt-gray m, varcoe c. exemplar: building on "grab," attending to "fit," and being prepared to "modify": how grounded theory "works" to guide a health intervention for abused women. in: morse jm, bowers bj, charmaz k, clarke ae, corbin j, porr cj, noerager stern p, editors. developing grounded theory. ny: routledge; 2021. p.90-107. doi: https://doi.org/10.4324/9781315169170-8 19. wuest j, merritt-gray m, dubé n, hodgins m, malcolm j, majerovich j, scott-storey k, ford-gilboe m, varcoe c. the process, outcomes, and challenges of feasibility studies conducted in partnership with stakeholders; a health intervention for women survivors of intimate partner violence. res nurs health. 2015;38(1):82-96. doi: https://doi.org/10.1002/nur.21636 20. ford-gilboe m. iheal trial: effectiveness of a health promotion intervention for women who have experienced intimate partner violence. u.s. national library of medicine; 2021. available from: https://clinicaltrials.gov/ct2/show/nct03573778 21. beck ct. middle range theory of traumatic childbirth: the ever-widening ripple effect. glob qual nurs res. 2015. doi: https://doi.org/10.1177/2333393615575313 22. morse jm. theoretical coalescence: a method to develop qualitative theory: the example of enduring. nurs res. 2018;67(2):177-187. doi: https://doi.org/10.1097/nnr.0000000000000263 23. dickoff j, james p. a theory of theories: a position paper. nurs res. 1968;17(3):197-203. doi: https://doi.org/10.1097/00006199-196805000-00004 24. fawcett j. tendencias de investigación en enfermería. aquichan. 2014;14(3):289-93. doi: https://doi.org/10.5294/aqui.2014.143.1 25. merton rk. on sociological theories of the middle range; 1949. available from: http://www.csun.edu/~snk1966/robert%20k%20merton%20-%20on%20sociological%20theories%20of%20the%20middle%20range.pdf home 118 127 influencia del marco regulatorio.indd 118 aquichan issn 1657-5997 fernando jiménez-valderrama1 infl uencia del marco regulatorio de los productos farmacéuticos en la salud pública2 análisis a partir de la ratifi cación por colombia del convenio adpic y de los tratados de libre comercio con los estados unidos y la unión europea 1 doctor en derecho, abogado. profesor, universidad de la sabana, colombia. fernando.jiménez@unisabana.edu.co 2 este artículo se elaboró en el marco del proyecto de investigación titulado: “transformaciones del ordenamiento jurídico colombiano a partir de la vigencia de los tratados de libre comercio con los estados unidos y la unión europea: el transporte marítimo, la protección de la propiedad industrial, la contratación pública, la actividad financiera y aseguradora, y los derechos laborales de los trabajadores”, realizado en la universidad de la sabana. recibido: 16 de febrero de 2012 aceptado: 3 de septiembre de 2012 año 13 vol. 13 nº 1 chía, colombia abril 2013  118-127 resumen este artículo tiene por objetivo estudiar la relación entre la disponibilidad, los precios de los medicamentos y los intereses de salud pública. para ello hemos utilizado una metodología de análisis de los intereses económicos implicados y también un método sistemático de tratamiento de la legislación nacional, comunitaria andina e internacional vigente. igualmente hemos acudido a metodologías de derecho comparado entre nuestro ordenamiento jurídico nacional con los de otros países de mundo occidental. existe un estrecho vínculo entre la disponibilidad y los precios de los medicamentos y los intereses de salud pública. nuestro actual sistema legal reconoce a los inventores de nuevos medicamentos como un “monopolio” para negociar en el mercado farmacéutico. para proteger los intereses públicos nuestra regulación establece algunos límites a los derechos de los inventores. los derechos de propiedad se limitan en el tiempo y bajo algunas circunstancias es obligatorio autorizar a otros a usar la patente bajo un contrato de licenciamiento. la organización mundial del comercio ha establecido (decisión del consejo de la omc, ronda doha 2003) otros límites a estos derechos en caso de condiciones excepcionales. nuestra constitución nacional otorga prevalencia a los intereses públicos sobre los privados. es un deber de los gobiernos establecer un sistema justo en el cual los inventores puedan obtener una recompensa económica por sus creaciones y la sociedad pueda satisfacer sus necesidades de salud. palabras clave salud pública, química farmacéutica, control de medicamentos y narcóticos, economía de la salud. (fuente: decs, bireme). 119 influencia del marco regulatorio de los productos farmacéuticos en la salud pública l fernando jiménez-valderrama influence of the regulatory framework for pharmaceuticals in public health analysis from colombia’s ratification of the agreement on intellectual property rights trade-related (trips) and the free trade agreements with the united states and the european union abstract this article aims to study the relationship between availability, prices of medicines and public health interests. we have used an analysis methodology of the economic interests involved and a systematic method of treatment of national, international, community and andean current legislation. also we have relied on comparative law methodologies between our domestic law and the ones of other countries in the western world. there is a close link between the availability and prices of medicines and public health interests. our current legal system recognizes to the inventors of new medicines as a “monopoly” to negotiate in the pharmaceutical market. to protect public interests, our regulation establishes some limits to the rights of inventors. property rights are limited in time and under some circumstances it is mandatory to authorize others to use the patent under a licensing agreement. the world trade organization (wto) has established (decision of the council of the wto doha round, 2003.) other limits to these rights in case of exceptional conditions. our constitution gives prevalence to public interests over private ones. it is the duty of governments to establish a fair system in which inventors can obtain a financial reward for their creations and society can satisfy its health needs. keywords public health, pharmaceutical chemistry, medicines and narcotic control, health economy. (source: decs, bireme). influência do marco regulatório dos produtos farmacêuticos na saúde pública análise a partir da ratificação pela colômbia do convênio adpic e dos tratados de livre comércio com os estados unidos e a união europeia resumo este artigo tem por objetivo estudar a relação entre a disponibilidade, os preços dos medicamentos e os interesses de saúde pública. para isso, utilizamos uma metodologia de análise dos interesses econômicos implicados e também um método sistemático de tratamento da legislação nacional, comunitária andina e internacional vigente. da mesma maneira, recorremos a metodologias de direito comparado entre nosso ordenamento jurídico nacional com os de outros países de mundo ocidental. existe um estreito vínculo entre a disponibilidade e os preços dos medicamentos e os interesses de saúde pública. nosso atual sistema legal reconhece aos inventores de novos medicamentos como um “monopólio” para negociar no mercado farmacêutico. para proteger os interesses públicos, nossa regulação estabelece alguns limites aos direitos dos inventores. os direitos de propriedade se limitam no tempo e, sob algumas circunstâncias, é obrigatório autorizar outros a usarem a patente sob um contrato de licenciamento. a organização mundial do comércio estabeleceu (decisão do conselho da omc, ronda doha 2003) outros limites a esses direitos em caso de condições excepcionais. nossa constituição nacional outorga prevalência aos interesses públicos sobre os privados. é um dever dos governos estabelecer um sistema justo no qual os inventores possam obter uma recompensa econômica por suas criações e a sociedade possa satisfazer suas necessidades de saúde. palavras-chave saúde pública, química farmacêutica, controle de medicamentos e narcóticos, economia da saúde. (fonte: decs, bireme). 120 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 introducción existe una relación directa entre el precio de los medicamentos y el acceso de la población a los mismos, con los niveles de salud pública de un país. un país que no tenga a su disposición los medicamentos, o bien cuando teniéndolos los recibe a un precio inaccesible para su sistema de salud o para la población en general, ve afectadas seriamente sus condiciones de bienestar. en entrevista realizada al señor mbithe munyao (kenya, 2010) (1) este afirmaba: sufro de presión alta por el estrés… pero no tengo dinero para comprar medicinas. le he pedido a mi hija y ella me ha dado 100 shillings que no me ayudan porque la medicina cuesta 500 shillings. con los 100 shillings podría comprar solamente algunas medicinas. no ayuda mucho… me dijeron que mascar ajo ayudaría. pero mis úlceras empeoran. me pidieron que pagara 300 shillings para conseguir tabletas para las úlceras pero no tengo dinero. ahora tengo úlceras y presión alta. entonces con el poco dinero pude tratar estas complicaciones, dejando que las otras empeoraran. las personas a las que acudí pidiendo ayuda tampoco tenían dinero… en el centro de salud del gobierno más cercano yo pago 20 shillings pero rara vez tengo todas las medicinas. ellos me dijeron que comprara el resto en otra parte pero no tengo dinero. tomo ajo pero empeoran mis úlceras. no tengo opción y lo uso para reducir mi presión arterial y soporto el dolor posterior. la situación descrita en la entrevista anterior pone en evidencia los profundos desajustes que tiene el sistema de provisión de medicamentos a nivel mundial, e infortunadamente no podemos afirmar que situaciones similares no se presenten en nuestro país2. 2 en colombia, “los tratamientos considerados inasequibles aun si se usan los genéricos son: hipercolesterolemia con simvastatina, 20 mg cáp. por 30 días (más de 3 días de salario), osteoporosis con alendronato sódico, 10 mg por 30 días (1,1-1,2 días de salario), y diabetes con metformina, 850 mg por 30 días (1,23-1,25 días de salario). si se prescriben y dispensan marcas originales, el trabajador gubernamental de menor salario necesitará gastar entre 1,02 (captopril, 25 mg por 30 días) y 16,26 (omeprazol, 20 mg por 30 días) días de salario para comprar los medicamentos. todos los tratamientos estándar se consideran inasequibles si se compran las marcas originales. de acuerdo con cálculos de la escuela nacional sindical de 2005, en colombia más de la mitad de la población ocupada, el 52,29 %, recibe ingresos inferiores a un salario mínimo legal, y el 85 % recibe ingresos inferiores a dos salarios mínimos legales vigentes; así, incluso los tratamientos que pueden parecer asequibles son demasiado costosos para los segmentos más pobres de la población. dado que 7 % de la población vive por debajo de la línea internacional de pobreza de menos de us$1/día y 17,8 % con menos de 2 us$/día, incluso los tratamientos que pueden parecer asequibles están fuera del alcance financiero para un número sustancial de personas. los resultados obtenidos permiten afirmar que la compra de medicamentos de marca implica para el 60 % de la población gastar más del 7,5 % de sus ingresos considerándose inasequibles. sin embargo es más preocupante que incluso en sus versiones genéricas, todos los medicamentos seleccionados, sean inasequibles para el 10 % de la población más pobre, siendo excepcionalmente preocupante el caso de la amoxicilina que sería inasequible aún la regulación jurídica sobre los medicamentos, que compartimos con los ordenamientos jurídicos de los demás países occidentales, se construye sobre la base de un "monopolio legal" que la sociedad otorga a los titulares registrales de las patentes, normalmente industrias farmacéuticas, en virtud del cual se garantiza a estas empresas el control de la producción, distribución y venta de los medicamentos a nivel global. un monopolio legal a los titulares de las patentes les permitirá igualmente establecer quiénes son los fabricantes y distribuidores cuando ellos mismos decidan no asumir directamente la producción, distribución y venta de dichos productos. los intereses en el sector farmacéutico no solamente se manifiestan a nivel local sino también internacional debido principalmente a que las multinacionales diseñadoras de los nuevos medicamentos están domiciliadas en países industrializados. el negocio farmacéutico representa, según cálculos de la organización de las naciones unidas (transacciones internacionales) para el año 2010, cerca de 456.000 millones de dólares americanos, teniendo un incremento continuado durante los últimos 5 años de en su versión genérica para el 40 % de la población. de otra parte, pero en concordancia con lo anterior, los resultados de este estudio permiten afirmar que un porcentaje de la población es llevado por debajo de las líneas de pobreza y pauperización por la compra de medicamentos. la compra de los genéricos de menor precio, de los medicamentos seleccionados para este análisis, lleva entre un 0,9 y un 7,7 % de la población por debajo de la línea de pauperización (us 1 diario) dificultando el acceso a otros bienes básicos para su supervivencia. en el caso de que se adquieran medicamentos con su marca original entre un 4,9 y un 51 % de la población sería llevada por debajo de la línea de 1 dólar diario” (2). igualmente, en colombia “diferentes estudios establecen insatisfacción en la entrega de medicamentos dentro del sistema. no se ha garantizado el acceso universal y, particularmente en medicamentos la demanda insatisfecha dentro del sistema de salud alcanza el 48,4 %. un estudio realizado por la defensoría del pueblo mostró que del total de medidas judiciales para demandar derechos fundamentales (tutelas) instauradas por los colombianos en el periodo analizado, el 25,7 % invocaron el derecho a la salud (como derecho fundamental o en conexidad con otros derechos fundamentales). las tutelas por medicamentos constituyen la tercera causa numérica de tutelas en salud. las más frecuentes se relacionan con tratamientos oncológicos (23 %), cardiovasculares (15,7 %), de sida (11 %) y de insuficiencia renal (6,5 %), que corresponden a patologías de alto costo. el 90,8 % de estas tutelas recae sobre tratamientos de patologías incluidas en el plan obligatorio de salud (pos), de los cuales la mitad corresponde a patologías de alto costo. las tutelas en salud relacionadas con patologías de alto costo constituyen el 21,04 % dentro del periodo analizado. las tutelas que reclaman medicamentos son las que proporcionalmente han tenido mayor crecimiento desde el año 1999 y se ubican en el cuarto lugar de las actuaciones contenciosas más frecuentes. comparativamente, entre el año 1999 y el 2003, el requerimiento judicial de medicamentos ha sido el de mayor crecimiento, al pasar del 9,3 % al 17,9 % en el último año. las medicinas no incluidas en el pos son las más solicitadas (47 %) en general se demandan medicamentos de costo elevado y marca específica solicitada para tratamientos determinados. la defensoría del pueblo, en un estudio anterior, estableció que el 47 % de los usuarios manifestaron tener problemas con la entrega de medicamentos, bien porque no lo recibieron o su entrega fue parcial…, situación que afecta los costos de la canasta médica de la familia al incrementar los gastos de bolsillo, dado que una persona no puede sincronizar sus dolencias a la voluntad o a la oportunidad que se defina administrativamente para la entrega de medicamentos” (2). 121 influencia del marco regulatorio de los productos farmacéuticos en la salud pública l fernando jiménez-valderrama 9,8 % anual en medicamentos y 16,4 % anual en productos medicinales y farmacéuticos distintos de medicamentos3. se trata, por tanto, de un sector importante en términos económicos y muy poderoso a nivel mundial, que a su vez reitera la necesidad de continuar financiando la investigación en nuevos productos que ofrezcan mejores condiciones de salud en los tratamientos sanitarios, a partir de los beneficios económicos que se obtengan por la venta de los medicamentos actualmente a disposición en el mercado. los distintos intereses en juego el panorama descrito en el apartado anterior nos sugiere la presencia de distintos niveles de intereses en esta materia (3-5). podríamos así distinguir de manera general dos niveles: en un ámbito nacional surge la necesidad de proteger los derechos de los particulares que han diseñado nuevos medicamentos frente al derecho de la sociedad, representada por el estado, a disfrutar de los beneficios de la utilización de estos nuevos productos farmacéuticos. mientras que en el nivel local la necesidad de una recompensa económica a los inventores de nuevos fármacos se debe conciliar con los intereses generales de salud pública y de difusión de conocimiento para la generación de nuevos fármacos, en el nivel internacional el desarrollo de la tecnología farmacéutica ha supuesto un profundo abismo entre aquellos países que se encuentran en la vanguardia de estas innovaciones y aquellos otros que se han convertido en meros “usuarios” de la tecnología. esta situación ha devenido en una polarización global cuyos intereses contrapuestos se ponen en evidencia, entre otros escenarios, en las reuniones de negociación de los instrumentos internacionales que regulan estas materias, en las cuales intervienen los países detentadores del conocimiento y la tecnología farmacéutica interesados en crear normas que garanticen el monopolio sobre la riqueza y los beneficios económicos que su utilización genera, frente a aquellos países que importan productos terminados o los fabrican a partir de autorizaciones otorgadas por los titulares de las patentes farmacéuticas, cuyo interés se concentra en lograr mecanismos de desarrollo tecnológico propio y transferencia de la tecnología a su ámbito territorial. 3 ver: http://comtrade.un.org. configuración de las actuales instituciones jurídicas protectoras del conocimiento la conciliación, equivalencia o prevalencia de estos intereses se materializa en la expedición de normas jurídicas que regulan estas materias. para entender la configuración actual del sistema regulador y protector de las patentes farmacéuticas es de especial interés examinar los primeros pasos en esta regulación. si bien históricamente se ha considerado al conocimiento como relevante en el desarrollo de nuestra civilización, no ha sido sino hasta el surgimiento y posterior desarrollo de una economía basada en el comercio y la industria cuando se ha entendido la necesidad de protegerlo jurídicamente4. en este sentido ya garrigues (7) resaltaba la íntima vinculación entre las normas reguladoras de la propiedad industrial y la existencia de la empresa capitalista. la protección del conocimiento a través de las normas de propiedad intelectual e industrial cumple a su vez un papel protector del patrimonio del empresario. entre las primeras normativas sobre esta materia podemos mencionar a la ley francesa de 1791 que reconocía que “todo descubrimiento o nueva invención, en todo género de industria, es propiedad de su autor”, calificándola así como “la más inatacable, la más sagrada, la más legítima, la más personal de las propiedades” (7). la opción jurídica de proteger el conocimiento que se pone en evidencia en la norma mencionada inscribe la protección de estos bienes dentro de la institución del derecho de propiedad, calificándola como industrial, y poniendo en evidencia su importancia en el desarrollo del sistema económico industrial capitalista5. ¿por qué los juristas de esa época deciden acudir a las normas que el derecho tradicional había dedicado a la propiedad privada individual? su opción tenía un propósito: otorgar el máximo nivel 4 a pesar de que algunos autores señalan la existencia de normas en materia de creaciones intelectuales en la edad media, concretamente marcas comerciales (6), esta normativa se produjo de forma que pudiéramos llamar aislada y con finalidades diversas a la que tiene esta regulación hoy en día, acordes con el desarrollo apenas incipiente, en ese momento, del proceso de economía capitalista. realmente no podemos entender una regulación sobre la propiedad intelectual e industrial, con la dimensión propia de una institución jurídica, sino a partir de la aparición de la empresa capitalista. 5 en nuestra época empieza a reconocerse el valor patrimonial de otro tipo de bienes que, a pesar de no poseer una materialidad, tienen una indudable trascendencia económica. para un análisis más detallado de este proceso ver georges ripert, aspects juridiques du capitalisme moderne (8). 122 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 de protección al resultado del trabajo intelectual porque lo consideraban como digno del máximo soporte y consideración como base del desarrollo de la nueva economía basada en la industria. para ello, qué mejor que proteger estos nuevos bienes patrimonialmente valiosos a través del derecho que otorga la máxima garantía y reconocimiento en nuestro sistema económico, como es el derecho de propiedad. de esta concepción surge la nueva terminología: propiedad intelectual, propiedad industrial, a pesar de la evidente incongruencia con el concepto tradicional de propiedad (9). en efecto, en nuestro ordenamiento jurídico la propiedad que ejercemos sobre todos los bienes proviene de las instituciones consagradas en el derecho romano. siguiendo la regulación tradicional del derecho de propiedad, los bienes sobre los cuales ejercemos este derecho tenían siempre una materialidad física que nos permitía ejercer su posesión impidiendo de esta forma a otras personas tenerlos y utilizarlos en su beneficio salvo que contasen con el consentimiento de su legítimo propietario. por el contrario, las normas en materia de propiedad intelectual o industrial, protectoras del conocimiento humano que carece de materialidad física, debieran entonces configurarse de forma distinta en cuanto el conocimiento podía ser poseído simultáneamente por un sinnúmero de personas impidiendo que el concepto tradicional de posesión ejerciese una función de garantía del disfrute de estos bienes exclusivamente por sus legítimos propietarios. en este sentido, los juristas que configuraron el sistema tuvieron que acudir a otro esquema que permitiese otorgar un monopolio en el uso de ese conocimiento por el hecho de su creación intelectual. de esta forma, las normas sobre propiedad intelectual e industrial se orientan a otorgar no solamente la facultad de “usar” en sentido positivo el bien inmaterial, sino, más importante aún, en la posibilidad de impedir, en sentido negativo mediante la consagración del ius prohibendi, la utilización o explotación de la obra o de la invención por personas diferentes, sin la autorización por parte del titular del derecho6. es decir, si somos creadores de una invención, en nuestro caso de un medicamento o de un producto farmacéutico, el derecho nos reconoce la propiedad sobre el mismo, aunque ella no entendida en el esquema tradicional de la propiedad que ejercemos sobre bienes materiales como puede ser nuestro carro 6 en cuanto a la conformación del “derecho de exclusiva” con referencia a los signos distintivos de la empresa ver a j. m. gondra romero (10). o nuestra casa, sino en un sentido particular que denominamos industrial y que nos permite adicionalmente a la facultad de usar y obtener rentabilidad de ella, la posibilidad de impedir, prohibir la utilización, producción o distribución de nuestro invento a todas aquellas personas que no estén autorizadas por nosotros7. existen por otro lado diferencias importantes con la denominada propiedad tradicional. las facultades que se otorgan en el marco del derecho de propiedad sobre los bienes materiales se caracterizan por su intemporalidad. ello quiere decir que si ejerzo la propiedad sobre mi casa, por ejemplo, el ordenamiento jurídico me garantiza el ejercicio del derecho por un tiempo ilimitado, a tal punto que, salvo que yo la quiera vender, puedo poseerla como propietario durante toda mi vida. por el contrario, las normas que regulan la propiedad sobre el conocimiento humano garantizan por regla general el ejercicio de unas facultades o derechos marcados por una temporalidad, es decir, limitadas en el tiempo. así, los derechos del autor sobre su obra se garantizan por la vida del autor y ochenta años más, y los que se ejercen sobre invenciones patentables, como es el caso de las registradas de medicamentos y productos farmacéuticos, se otorgan por veinte años. la razón de la temporalidad es permitir a la sociedad, luego del vencimiento del correspondiente plazo, utilizar de manera libre y sin ninguna restricción los avances en el conocimiento. se entiende que otorgar el monopolio sobre dicho conocimiento al inventor durante cierto tiempo constituye un premio suficiente que encuentra sus límites en el derecho de la sociedad a beneficiarse libremente del invento, así como permitir que la última tecnología sirva sin ningún tipo de restricciones a los nuevos desarrollos investigativos que hagan posible el mejoramiento del invento o el desarrollo de nuevas invenciones. protección jurídica en el marco del régimen de patentes una vez examinado en el apartado anterior, el marco configurador de la protección jurídica del conocimiento, procede 7 bajo esta nueva concepción es relevante la configuración de los denominados “bienes inmateriales”, a los cuales pertenecen las invenciones y que fueron configurados paralelamente a los tradicionales “bienes materiales”. existe una indudable relevancia económica de las creaciones del intelecto humano aplicadas a la industria a pesar de su falta de corporeidad, siendo necesaria su incorporación al patrimonio de la empresa. no podemos negar la importancia que tiene para un empresario ser titular, por ejemplo, de una patente, de una marca comercial o de un secreto industrial, en la medida que, sin duda, lo coloca en unas condiciones competitivas más favorables frente a los demás empresarios. 123 influencia del marco regulatorio de los productos farmacéuticos en la salud pública l fernando jiménez-valderrama ahora entrar a analizar su aplicación cuando hablamos de procedimientos industriales para la producción de nuevos fármacos y medicamentos. en este sentido, los procedimientos para la elaboración de nuevos fármacos tienen un tratamiento similar a otros tipos de conocimientos relativos a otros sectores de la tecnología8. las particularidades vienen dadas por los intereses especialmente relevantes en el ámbito de la salud pública que se presentan en el manejo y la utilización de este tipo de tecnología. tradicionalmente, la regulación del monopolio legal sobre las patentes farmacéuticas ha tenido distintos enfoques atendiendo a los intereses particulares de los países en cuestión. esta regulación ha ido desde esquemas que niegan todo reconocimiento monopolístico a este tipo de tecnología o bien prescinden de cualquier regulación al respecto, hasta aquellos otros que ofrecen la máxima garantía de protección jurídica a través de la institución del derecho de la propiedad, bajo los criterios mencionados anteriormente. nuestro sistema jurídico, que en este punto tiene su base en la decisión 486 de 2000 de la comunidad andina, ampara en el marco del derecho de propiedad todo tipo de invención, dentro de ella la consistente en productos o procedimientos farmacéuticos. de esta manera, para gozar de la protección jurídica, el titular de los derechos de propiedad sobre la invención debe probar que el producto o procedimiento farmacéutico reúne las características de toda invención, esto es, que tenga novedad, altura inventiva y aplicación industrial. la normativa comunitaria andina y las decisiones de los jueces en este punto se orientan por tanto a reconocer los derechos de la invención farmacéutica bajo los criterios anteriormente enunciados. sin embargo, ante la necesaria defensa de los intereses de salud pública esta normativa, y las decisiones de los jueces que la aplican, ha establecido limitaciones a la titularidad y el ejercicio del monopolio legal para hacerlo compatible con las necesidades de interés general. estas limitaciones no solamente se basan en los criterios de temporalidad propios de la ley de patentes, sino que también 8 en el momento originario de la regulación el legislador optó por establecer la protección jurídica de los medicamentos y productos farmacéuticos a través del régimen de patentes de invención siguiendo la tradición jurídica occidental en esta materia, a pesar de que habría podido establecer un estatuto especial tal como se dio, por ejemplo, en el caso de los obtentores vegetales. se extienden a supuestos que intentan conciliar la injusticia que representaría una defensa a ultranza de los derechos de los titulares de las patentes farmacéuticas frente a los intereses de los estados, especialmente aquellos que representan a las naciones más pobres del planeta, como lo veremos en el siguiente apartado. regulación de las patentes farmacéuticas en el convenio adpic y tratados de libre comercio la protección de las patentes farmacéuticas en el sentido antes mencionado, en virtud del cual se reconoce un monopolio a favor de los titulares registrales con limitaciones en el ámbito temporal y licenciamientos obligatorios, también está reconocida y reafirmada como tal en los tratados de libre comercio pactados con los estados unidos y con la unión europea, aunque se amplíen tímidamente algunos supuestos de limitación. en este sentido, los textos de ambos tratados establecen los siguientes puntos relevantes: principios de trato nacional, nación más favorecida y convenio adpic9 en materia de patentes farmacéuticas, tanto el principio de trato nacional como el de nación más favorecida pretenden garantizar que los medicamentos producidos o que se encuentren en condiciones legales de comercialización en cualquiera de los territorios que hacen parte de las respectivas zonas de libre comercio 9 la organización mundial del comercio (omc) es una organización internacional con sede en ginebra (suiza), establecida en el año 1995 a partir de la firma del acuerdo general sobre aranceles y comercio (gatt 1994). a fecha 10 de mayo de 2012, a ella pertenecen 155 países y tiene como funciones generales: administrar los acuerdos comerciales de la omc, servir como foro para negociaciones comerciales, servir como mecanismo de resolución de diferencias comerciales, supervisar las políticas nacionales y prestar asistencia técnica a países en desarrollo. el gatt es un acuerdo multilateral, creado en la conferencia de la habana en 1947, cuyo objetivo es crear un marco institucional y jurídico a nivel global para facilitar el comercio. su funcionamiento se ha realizado a través de reuniones periódicas en las denominadas “rondas”, dentro de las cuales la última más relevante ha sido la ronda uruguay que culminó en el año 1994 con la firma de los acuerdos gatt y la creación de la omc. dentro de los acuerdos gatt debemos destacar el acuerdo sobre aspectos de los derechos de propiedad intelectual relacionados con el comercio (convenio adpic, en su versión inglesa trips agreement) cuya finalidad es crear un adecuado marco jurídico protector del conocimiento y la tecnología a través de las instituciones reguladoras de la propiedad intelectual e industrial siguiendo los parámetros y criterios mencionados en este artículo. 124 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 colombia/ee.uu. y colombia/ue, no solamente tengan la posibilidad de circular libremente, sino que reciban por los países implicados una adecuada protección legal como propiedad industrial. particularmente, el principio de trato nacional pretende garantizar que las mercancías, entre ellas los medicamentos, producidos en un estado parte y que circulen en el mercado de los otros países tengan el mismo tratamiento de las mercancías nacionales, sin sufrir ningún tipo de discriminación u obstáculo directo o encubierto para su comercialización. a su vez, el principio de nación más favorecida pretende que las relaciones comerciales que se establezcan con un país tengan el mismo tratamiento y beneficios que se otorgan a otros países o bloques económicos con los cuales se hayan celebrado o se celebren en el futuro acuerdos comerciales más beneficiosos, excluyendo los tratados que impliquen procesos de integración económica como el comunitario andino, por su reconocido componente político de unificacion supranacional. reafirmación de convenios y compromiso de crear nuevos sobre propiedad industrial ambos tratados utilizan como recurso normativo, cuando se regula la propiedad intelectual e industrial, una remisión expresa a otros convenios en la materia que incorporan un tratamiento más detallado, estableciendo, particularmente para el caso de colombia, la obligación de su firma y ratificación. así por ejemplo, el tratado de libre comercio con los estados unidos de américa establece en materia de patentes (art. 16.1) como criterio de interpretación el acuerdo adpic 1994 y la obligación para ambas partes de ratificación del tratado de budapest sobre el reconocimiento internacional del depósito de microorganismos para fines del procedimiento en materia de patentes (1977), enmendado en 1980, y el tratado de cooperación en materia de patentes (1970), enmendado en 1979. igualmente, establece la obligación de realizar “esfuerzos razonables” (arts. 16.1 y 16.9) para ratificar el tratado de derecho de patentes (2000) y “proteger las plantas”10, hasta ahora no protegidas en el marco comunitario andino. a su vez, el tratado de libre comercio con la unión europea hace referencia al convenio adpic y a los acuerdos de la organi10 si bien el derecho de patentes nació históricamente vinculado a la revolución industrial, hoy en día debe hacer frente a nuevos desafíos, dentro de ellos la llamada revolución biotecnológica, que afecta actividades agrícolas y ganaderas (11). zación mundial de la propiedad intelectual (ompi) de los cuales tanto colombia como la unión europea son parte, y en el artículo 196 a la “reafirmación” del convenio sobre diversidad biológica (cdb de junio 5 de 1992) y protección frente a la “competencia desleal”, y el convenio de parís en su artículo 10 bis. ambos tratados contienen referencias al convenio de la unión de parís11. colombia, al firmar los tratados de libre comercio, asume la obligación de incorporar en su legislación el contenido normativo de todos estos otros tratados internacionales que establecen los máximos niveles de protección para los titulares de las patentes farmacéuticas, dentro de ellos el principio de reconocimiento universal de la invención, en virtud del cual todo inventor o empresa farmacéutica puede patentar su producto o procedimiento industrial en cualquier país, y esa patente es reconocida en nuestro ordenamiento jurídico para efectos de protección y de impedir que se patente un producto o procedimiento igual o similar en nuestro país. flexibilización del sistema de protección y establecimiento de límites a los derechos de propiedad como hemos mencionado, el derecho de patentes tiene por objetivo conciliar, cuando no existen criterios claros de prevalencia, los distintos intereses en juego en materia de apropiación del conocimiento y la tecnología. en este sentido se ha entendido que debe otorgarse un beneficio económico a los generadores de dicho conocimiento, garantizándoles el derecho de propiedad sobre su invento si bien limitado con distintos mecanismos para compaginarlo con los intereses generales. todo sistema de patentes, y en particular la regulación de productos farmacéuticos, indudablemente debe fomentar el desarrollo investigativo para la elaboración de nuevos medicamentos. así, es de interés público manifiesto que permanentemente 11 el convenio de parís para la protección de la propiedad industrial, del 20 de marzo de 1883, revisado en bruselas el 14 de diciembre de 1900, en washington el 2 de junio de 1911, en la haya el 6 de noviembre de 1925, en londres el 2 de junio de 1934, en lisboa el 31 de octubre de 1958, en estocolmo el 14 de julio de 1967, y enmendado el 2 de octubre de 1979, establece, entre otras, las siguientes reglas: el principio de trato nacional (art. 2), el reconocimiento del derecho de prioridad de solicitudes presentadas en alguno de los países de la unión (art. 4), el derecho del titular a introducción de productos patentados procedentes de otros países de la unión, y el derecho de los países de la unión a poner ciertos límites al derecho de patente como la concesión de licencias obligatorias en ciertos casos como la falta de explotación de la patente (art. 5). 125 influencia del marco regulatorio de los productos farmacéuticos en la salud pública l fernando jiménez-valderrama se avance en el diseño de nuevos productos farmacéuticos que beneficien la salud de la población, ello a pesar de los costes y las dificultades que estos procesos implican y que normalmente, al menos en nuestro sistema económico, es asumido y realizado por operadores privados. el mundo actual plantea permanentes desafíos a la investigación farmacéutica que exige realizar esfuerzos continuos para diseñar nuevos medicamentos que permitan un mejor tratamiento de las enfermedades existentes y hagan frente a nuevas patologías que amenazan la salud humana. constituye por tanto una necesidad social y pública mantener los mecanismos y estímulos adecuados a los investigadores para que desarrollen su actividad de perfeccionamiento del conocimiento y la tecnología en estas materias. estas circunstancias y consideraciones han estado presentes en el debate y la configuración internacional de las patentes farmacéuticas, en forma tal que se han integrado mecanismos de flexibilización y limitación al derecho del titular de este tipo de patentes, en nuestro concepto todavía muy restringidos en cuanto constituyen mecanismos ciertamente excepcionales que mantienen una posición de privilegio de los intereses de los titulares de las patentes. así por ejemplo, en el tratado de libre comercio con la unión europea se establece que ambos países pueden imponer límites en caso de “abuso de los derechos de propiedad intelectual” o cuando los derechos de las patentes constituyan “limitaciones injustificadas del comercio” o se utilicen en “detrimento de transferencia de tecnología” (art. 197). en el tratado de libre comercio con los estados unidos se permite establecer límites a los derechos sobre las patentes en caso de que se presenten “prácticas anticompetitivas” que puedan resultar del “abuso de los derechos de propiedad intelectual”, ello en cuanto estas medidas “no afecten de manera injustificada con la explotación normal de la patente”, “ni causen perjuicios injustificados a los titulares de la patente y los legítimos intereses de terceros” (arts. 16.1.5 y 16.9). igualmente, ambos tratados tienen una referencia expresa a las disposiciones sobre la materia pactadas en materia de salud pública en la organización mundial del comercio, particularmente a la decisión adoptada en relación con la aplicación del párrafo 6 de la declaración de doha relativa al acuerdo sobre los adpic y la salud pública (art. 197 del tratado de libre comercio con la unión europea y memorando de entendimiento respecto de ciertas medidas de salud pública de fecha 22 de noviembre de 2006, anexo al tratado de libre comercio con los estados unidos). esta referencia a la declaración de doha sobre los adpic y la salud pública es de gran importancia en la medida que brinda un instrumento jurídico válido para amparar situaciones extremas en las cuales se exija flexibilizar el reconocimiento de los derechos de propiedad industrial. la organización mundial del comercio, organismo rector en materia de actualización y reforma de los convenios adpic, celebró en el año 2003, en sede consejo ronda doha, una serie de reuniones con la finalidad de modificar el párrafo 6 del convenio adpic referido a la salud pública. como resultado de dichas reuniones se emitió una decisión12 en la cual se permitía a los países miembros de la omc y signatarios del convenio adpic limitar los derechos de propiedad sobre productos farmacéuticos a situaciones que impliquen la defensa de los intereses de la salud pública. para que dicha limitación resulte válida, la decisión establece una serie de condiciones que deben llenarse: en primer lugar, se establece que su implementación siempre debe realizarse siguiendo los criterios de la buena fe para proteger los intereses de la salud pública y no como instrumento para perseguir otros objetivos comerciales o industriales. en segundo lugar, la decisión exige evitar que los productos farmacéuticos que se suministren en virtud la situación excepcional se desvíen de los mercados a los cuales estén destinados, por lo cual deben adoptarse todas las medidas razonables para prevenir tal desviación. una vez establecidos los criterios generales de limitación de los derechos de propiedad industrial sobre las patentes farmacéuticas, la decisión prevé que cualquier aplicación de esta excepción tiene que notificarse a la organización mundial del comercio y, a través de ella, a los demás estados miembros de esa organización, debiendo el estado que la pretende utilizar demostrar una "capacidad insuficiente o inexistente de fabricación de medicamentos en su territorio". 12 acta de reunión consejo doha 2003, wt/bfa/w/105/rev. 1 126 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 una vez aplicadas las limitaciones correspondientes, y hechas las notificaciones respectivas, cualquier país de la organización podrá plantear las cuestiones que considere convenientes acogiéndose a los buenos oficios del director general o del presidente del consejo de los adpic, con miras a encontrar una solución mutuamente aceptable o bien activando los mecanismos de solución de controversias fijados en el sistema gatt13. hasta acá hemos hecho un bosquejo general del sistema actual de protección jurídica de los productos farmacéuticos basados en el esquema de patentes de invención que reconoce un “monopolio” sobre la producción, distribución y venta de medicamentos a favor de los titulares registrales de los mismos. también hemos mencionado que estos derechos tienen algunas limitaciones articuladas principalmente a través de la temporalidad de los derechos y el establecimiento de licenciamientos obligatorios, todo ello para conciliar el ejercicio de estos derechos con los intereses públicos implicados. esta doctrina que reconoce y reafirma los tratados de libre comercio con los estados unidos y con la unión europea se ve brevemente ampliada, como lo hemos expuesto, por medio de la decisión del consejo de la omc 2003, sobre el artículo 6 del convenio adpic que reconoce límites adicionales en situaciones extremas. sin embargo, debemos afirmar que, en nuestro concepto, estos mecanismos todavía son insuficientes. en el caso particular colombiano debemos también mencionar los principios generales establecidos en nuestro ordenamiento jurídico y plasmados en nuestra constitución política de 1991. específicamente, el artículo 58 de la constitución que establece: se garantizan la propiedad privada y los demás derechos adquiridos con arreglo a las leyes civiles, los cuales no pueden ser desconocidos ni vulnerados por leyes posteriores. cuando de la aplica13 además, como se señala en la nota 3 al párrafo 1 b) de la decisión, los siguientes miembros de la omc han acordado que no se acogerán como importadores habilitados al sistema de excepcionalidad: alemania, australia, austria, bélgica, canadá, dinamarca, españa, estados unidos, finlandia, francia, grecia, irlanda, islandia, italia, japón, luxemburgo, noruega, nueva zelanda, países bajos, portugal, reino unido, suecia y suiza. hasta su adhesión a la unión europea, chipre, eslovenia, estonia, hungría, letonia, lituania, malta, polonia, república checa, república eslovaca acuerdan que solo utilizarán el sistema como importadores habilitados en situaciones de emergencia nacional o en otras circunstancias de extrema urgencia. estos países acuerdan asimismo que en el momento de su adhesión a la unión europea dejarán de acogerse al sistema como importadores habilitados. otros países han acordado que solo utilizarían el sistema como importadores habilitados en situaciones de emergencia nacional o en otras circunstancias de extrema urgencia: corea, emiratos árabes unidos, hong kong, china, israel, kuwait, macao, china, méxico, qatar, singapur, territorio aduanero distinto de taiwán, penghu, kinmen y matsu, y turquía. ción de una ley expedida por motivos de utilidad pública o interés social, resultaren en conflicto los derechos de los particulares con la necesidad por ella reconocida, el interés privado deberá ceder al interés público o social. la propiedad es una función social que implica obligaciones. como tal, le es inherente una función ecológica. el estado protegerá y promoverá las formas asociativas y solidarias de propiedad. por motivos de utilidad pública o de interés social definidos por el legislador, podrá haber expropiación mediante sentencia judicial e indemnización previa. esta se fijará consultando los intereses de la comunidad y del afectado. en los casos que determine el legislador, dicha expropiación podrá adelantarse por vía administrativa, sujeta a posterior acción contenciosa administrativa, incluso respecto del precio. en este sentido, esta doctrina constitucional impone la necesidad de interpretar la normativa vigente teniendo en cuenta la prevalencia de los intereses públicos de la salud amparados en el artículo 58 antes mencionado, aunque ello debe hacerse, no sin ciertas dificultades, en el marco del régimen comunitario andino vigente y los compromisos asumidos por el país en los distintos convenios internacionales sobre la materia del que es parte. conclusiones el suministro y los precios de los medicamentos en un país tienen una influencia directa en las condiciones de su sistema de salud y en el bienestar de su población. la falta de disposición de medicamentos o sus precios elevados se traducen en una afectación directa del nivel de vida de los ciudadanos y también de los presupuestos públicos y privados destinados a financiar las necesidades de salud en la sociedad. las condiciones de producción, distribución y venta de los medicamentos vienen determinadas de manera principal por la regulación jurídica de los mismos. en este sentido colombia, en el marco de la comunidad andina de naciones, ha establecido una regulación utilizando el régimen de patentes de invención que exige como requisitos de protección que se demuestre que el nuevo producto farmacéutico reúne los requisitos de novedad, altura inventiva y aplicación industrial. el diseño y procedimiento de elaboración de un nuevo medicamento, como producto del conocimiento humano que es, ha recibido protección a través del instituto del derecho de propiedad por entenderse que este marco era el que mejores condiciones de protección ofrecía. 127 influencia del marco regulatorio de los productos farmacéuticos en la salud pública l fernando jiménez-valderrama en este sentido, cuando se reconoce registralmente la titularidad de un derecho de patente sobre un medicamento, se establece jurídica y económicamente un monopolio a favor del titular que le permite explotar económicamente el invento (producto farmacéutico) e impedir (ius prohibendi) que otras personas sin su autorización lo exploten. el monopolio que goza el titular de una patente encuentra limitaciones en la temporalidad del derecho (20 años) y en el establecimiento de mecanismos de licenciamiento obligatorios en favor de los derechos de la sociedad a disfrutar los beneficios que ofrece la patente, así como permitir desarrollos ulteriores a partir de los procedimientos ya existentes. particularmente en materia de patentes farmacéuticas existen criterios de interés público, principalmente asociados a la salud pública, que obligan a una consideración especial. en este sentido, la organización mundial del comercio, sede consejo – ronda doha, autorizó en el año 2003 medidas de limitación de los derechos de propiedad industrial sobre medicamentos y productos farmacéuticos a aplicar por parte de los países miembros en situaciones de riesgo excepcional de la salud pública. tanto el convenio adpic ratificado por colombia, como los tratados de libre comercio celebrados con los estados unidos y con la unión europea, incluyen el compromiso de nuestro país de incorporar una estructura completa de protección de los derechos de los titulares de las patentes farmacéuticas. ello se ha hecho por medio de la remisión a los contenidos de convenios internacionales que colombia deberá ratificar e incorporar a su legislación. por otro lado, estos instrumentos jurídicos integran las disposiciones de la decisión del consejo de la omc, doha 2003, todo ello en un marco de limitación de derechos que en nuestro concepto aún es insuficiente para lograr un adecuado equilibrio entre los intereses públicos de la salud y los intereses privados. en nuestro ordenamiento jurídico existen instrumentos interpretativos, como el establecido en el artículo 58 de la constitución nacional, que deben ser tenidos en cuenta en la aplicación de esta normativa en cuanto establecen criterios claros de prevalencia del interés público sobre el privado en caso de conflicto entre ellos. referencias 1. health action international (hai). briefing note for delegates to the non – communicable diseases (ndc) high level meeting; september 2011. [consultado: 2011 ago. 16]. disponible en: www.haiweb.org 2. infarma, health action international (hai). precio, disponibilidad y asequibilidad de medicamentos y componentes del precio en colombia. informe de 7 de abril 2009, pp. 94-5. 3. correa cm. las nuevas reglas sobre propiedad intelectual y sus consecuencias para el comercio de tecnología. revista de derecho industrial – transferencia de tecnología 1991;13(37):3-15. 4. de almeida pr. la economía política de las nuevas tecnologías (confidencialidad tecnológica y transferencia de recursos entre las naciones). revista de derecho industrial – transferencia de tecnología 1991;13(37):17-35. 5. czar de zalduendo s. el régimen común andino sobre inversiones extranjeras y transferencia de tecnología. revista de derecho industrial – transferencia de tecnología 1991;13(37):37-59. 6. bercovitz a. la formación del derecho de la competencia. actas de derecho industrial (españa); 1975. pp. 65-81. 7. garrigues j. la propiedad industrial y la empresa. actas de derecho industrial (españa) 1977; 13-24. 8. ripert g. aspects juridiques du capitalisme moderne. paris: librairie générale de droit et de jurisprudence; 1992. 9. montes v. notas preliminares sobre la protección jurídica de los bienes inmateriales. revista general de derecho (españa) 1990;445. 10. gondra jm. teoría general de los signos de empresa. estudios jurídicos en homenaje al prof. aurelio menéndez, tomo i. madrid: cívitas; 1996. pp. 829-68. 11. bercovitz a. problemática de la protección de las invenciones biotecnológicas desde una perspectiva europea. biotecnología y patentes. revista de derecho industrial 1990;12(34):81. continuity of care challenges for professional nursing practice editorial continuity of care challenges for professional nursing practice desafíos en la continuidad de cuidados para la práctica profesional de enfermería desafios na continuidade de cuidados para a prática profissional de enfermagem 10.5294/aqui.2022.22.1.1 cristina garcía-vivar1 nelia soto-ruiz2 paula escalada-hernández3 marta ferraz-torres4 maria rosario orzanco-garralda5 leticia san martín-rodríguez6 1 0000-0002-6022-559x health sciences department, universidad pública de navarra (upna), spain; instituto de investigación sanitaria de navarra (idisna), spain. cristina.garciavivar@unavarra.es 2 0000-0002-5161-2272 health sciences department, universidad pública de navarra (upna), spain; instituto de investigación sanitaria de navarra (idisna), spain. nelia.soto@unavarra.es 3 0000-0003-2263-156x health sciences department, universidad pública de navarra (upna), spain; instituto de investigación sanitaria de navarra (idisna), spain. paula.escalada@unavarra.es 4 0000-0002-7740-2572 health sciences department, universidad pública de navarra (upna), spain; hospital universitario de navarra, spain. marta.ferraz@unavarra.es 5 0000-0003-0283-5741 health sciences department, universidad pública de navarra (upna), spain; navarra primary care service, centro de salud burlada, spain. mrosario.orzanco@unavarra.es 6 0000-0002-9097-7493 health sciences department, universidad pública de navarra (upna); instituto de investigación sanitaria de navarra (idisna), spain. leticia.sanmartin@unavarra.es keywords (source decs): nursing care; leadership; innovation; nursing shared governance; nurses role. palabras clave (fuente decs): cuidados de enfermería; liderazgo; innovación; gobernanza compartida en enfermería; perfil de competencias de los profesionales de enfermería. palavras-chave (fonte decs): cuidados de enfermagem; liderança; inovação; governança compartilhada de enfermagem; papel do profissional de enfermagem. to reference this editorial / para citar este editorial / para citar este editorial: garcía-vivar c, soto-ruiz n, escalada-hernández p, ferraz-torres m, orzanco-garralda mr, san martín-rodríguez l. continuity of care challenges for professional nursing practice. aquichan. 2022;22(1):e2211. doi: https://doi.org/10.5294/aqui.2022.22.1.1 in recent decades, health systems have faced the need to transform their vertical structure, conceived under the paradigm of fragmentation between various departments and different care levels, into a more horizontal structure in which healthcare organization is more consistent with the natural transfer of a patient between care levels and services or departments and caters to the needs of users. mainly, continuity of care constitutes one of the mainstays on which care programs for chronic and multi-pathological patients are based. this type of patient has complex needs that require long-term care and specific guidelines to deal with the multiple transitions between care levels (1). the transformation of health services has developed and implemented new functional and care areas, such as home hospitalization units or chronic or multi-pathological patient care units, to respond to the growing health demand of chronic processes. these new resources are vital to promoting continuity of chronic care and show positive results at multiple levels, such as fewer rehospitalizations (2). besides, new nursing profiles, such as case management nurses or liaison nurses, and many other nursing initiatives and innovations are emerging to foster continuity of healthcare, avoid care fragmentation, obtain positive effects on the quality of care for chronic patients, and reduce hospital readmissions (3). in this global commitment to attach further importance to continuity of care —understood as care coherent, connected, and consistent with the needs of the patient and their family—, there should be a strategic design that considers the three dimensions of continuity of care and maintains a hierarchical relationship between them, each being fundamental for the operation of the others (4). the relational dimension refers to the interaction between professionals and patients and their families over time; the informational dimension means the use and transmission of information, and the managerial dimension is related to the coordination between professionals and services. thus, several challenges are associated with these three dimensions of continuity of care for nurses' professional practice, as addressed below. effective communication and collaboration among healthcare professionals are critical to appropriate continuity of care. one of the challenges for nurses, related to the relational dimension of continuity of care, is establishing collaborative relationships between the health professionals who care for the patient in multiple clinical contexts (5). displaying leadership and trust is essential to make the rest of the professionals understand nurses' skills in continuity of care while recognizing and respecting the functions of other health workers. another fundamental aspect of collaboration is shared access to complete patient information, which includes querying the patient's various electronic records and transmitting information in a systematic and structured manner when transferring the patient to other care levels. the emergence of new professional profiles, such as the liaison nurse or case manager, facilitates the relationship of the patient and their family with health professionals. thus, the therapeutic relationship must be established with the same person (liaison nurse or case manager) to build trust. in turn, professionals may gain more detailed patient knowledge to favor comprehensive care by meeting individual needs. the transmission of information and communication with the patient and their family will benefit from the bond forged between them. without a doubt, the digital transformation of health organizations is one of the tough challenges. it is about incorporating technological innovations —such as wearables or smart clothing to control and quickly obtain body data from the patient at home— and managing a change in guaranteeing adequate data reception, registration, use, security, and protection. furthermore, the covid-19 pandemic accelerated our understanding of the potential technology for continuity of care. indeed, the use of information and communication technologies (ict) in health, known as e-health, to meet the needs of patients, families, communities, and health professionals is already a reality. under the concept of "mobile health" or m-health, mobile devices —widely used in the worst moments of the pandemic— encourage communication among professionals and with the patient and their family. regarding ict implementation in the health field, we cannot ignore the enormous challenge of educating and training nurses and other health professionals in innovation and ict (6). similarly, patients and families must be educated to maximize the potential for efficient health systems. greater empowerment of the patient and their family stimulates participation in decision-making and, undoubtedly, optimizes the transmission of information between them, resulting in better management of the disease. the development of nurses' teaching skills is essential for adequate health literacy, identifying the degree of acceptance of these technologies by patients and families and their concerns about the use of applications, and offering strategies to improve access to ict, especially by the most vulnerable groups. nurses, particularly those in formal leadership positions in organizations, play a crucial role in managing health services and the care provided. nurse managers collaborate with other professionals and other knowledge domains and care levels. thus, transformational nursing leadership is always sought to uphold positive work environments and the well-being of individuals. in this context of nursing leadership, the advanced practice nurse (apn) has appeared to a greater or lesser extent in numerous countries. this nurse has expert knowledge, leadership, complex decision-making skills, and advanced clinical abilities to improve nursing practice (7, 8). although these new professional profiles and roles are demonstrating high efficiency in user satisfaction and managing the demand and needs of patients with chronic diseases, it is complicated to implement and adapt current clinical management and coordination structures, such as the recognition and delimitation of responsibilities and an appropriate academic and economic as­sessment of apns. therefore, this situation constitutes a significant challenge for nurse managers. finally, the covid-19 pandemic has entailed the redesign of care management processes: defining new guidelines for action, redistributing staffing and staff rotation to care for covid-19 patients without neglecting the rest of patients, promoting nurse training in record time for patient safety, and adapting nurses' work dynamics to respond to new health circumstances. indisputably, this experience has been a worldwide pilot of creative, committed, and even resilient management in which nurse managers have become a cornerstone. now it is time to recover and re-adapt to serve the increasing volume of patients with acute and chronic diseases due to the deficit of care and tackle the impact of a lack of physical activity in elderly, frail, or disabled people because of lockdown. we have a new challenge that requires implementing innovative organizational strategies that respond effectively and efficiently to the current healthcare context. continuity of care is critical in caring for individuals and families with complex health needs who require professional care over time. the digital transformation of health organizations supports a more continuous and closer relationship between the professional and the patients and their families, the better transmission of information, and the improved coordination between medical attention and nursing care. thus, as usual, every challenge becomes an opportunity. nursing research is fundamental for the profession and necessary to promote innovative quality care and influence health policies. so, the inno-care research group on new nursing practices at the universidad pública de navarra (spain) is working to improve continuity of care, both from nursing innovation and new technologies and from knowledge generation, to develop new care models centered on the patient with complex chronic diseases and their family. we understand that translational research not only requires collaboration between diverse nursing profiles (care nurses, researchers, and managers) and between different health workers but also transformational leadership to produce a change in the health system, currently oriented to professionals, toward a user-centered care system, focused on the patient and their family at different healthcare levels. unquestionably, this is a tremendous challenge for nurses across the globe. references 1. kianfar s, carayon p, hundt as, hoonakker p. care coordination for chronically ill patients: identifying coordination activities and interdependencies. appl ergon. 2019;80:9-16. doi: https://doi.org/10.1016/j.apergo.2019.05.002 2. yang f, xiong zf, yang c, li l, qiao g, wang y, et al. continuity of care to prevent readmissions for patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. copd. 2017; 14(2):251-261. doi: https://doi.org/10.1080/15412555.2016.1256384 3. facchinetti g, d'angelo d, piredda m, petitti t, matarese m, oliveti a, et al. continuity of care interventions for preventing hospital readmission of older people with chronic diseases: a meta-analysis. int j nurs stud. 2020; 101 :103396. doi: https://doi.org/10.1016/j.ijnurstu.2019.103396 4. bahr sj, weiss me. clarifying model for continuity of care: a concept analysis. int j nurs pract. 2019;5(2):e12704. doi: https://doi.org/10.1111/ijn.12704 5. östman m, bàck-pettersson s, sundler aj, sandvik ah. nurses' experiences of continuity of care for patients with heart failure: a thematic analysis. j clin nurs. 2021;30(1-2):276-286. doi: https://doi.org/10.1111/jocn.15547 6. escalada-hernández p, soto ruiz n, san martín-rodríguez l. design and evaluation of a prototype of augmented reality applied to medical devices. int j med inform. 2019;128:87-92. doi: https://doi.org/10.1016/j.ijmedinf.2019.05.004 7. vivar cg, pardavila belio mi, del barrio linares m, canga armayor n. enfermería de práctica avanzada: desarrollo de un modelo emergente. rev rol enferm. 2013;36(10):660-666. disponible en: https://medes.com/publication/85878 8. san martín-rodríguez, l. práctica avanzada en enfermería y nuevos modelos de organización sanitaria. enf clin. 2016;26(3):155-157. doi: https://doi.org/10.1016/j.enfcli.2016.04.007 home 266 284 estilo de vida.indd 266 aquichan issn 1657-5997 myriam patricia pardo-torres1 nicolás arturo núñez-gómez2 estilo de vida y salud en la mujer adulta joven 1 enfermera. candidata a doctora en ciencias de la salud. especialista en enfermería perinatal. coordinadora grupo académico materno perinatal. universidad nacional de colombia. facultad de enfermería. campus universitario universidad nacional. torre de enfermería oficina 708. bogotá. colombia. mppardot@unal.edu.co 2 psicólogo. doctor en ciencias de la salud. magíster en filosofía. especialista en psicología de la salud. especialista en estadística. profesor escuela de psicología. coordinador proyección social. universidad surcolombiana. facultad de salud. avenida pastrana borrero carrera 1 neiva, huila. colombia. ninugo@usco.edu.co recibido: 7 de abril de 2008 aceptado: 23 de septiembre de 2008 resumen este trabajo fue realizado en la localidad cuarta de bogotá, con un grupo de 100 mujeres entre 20 y 40 años de edad, en los años 2004-2005, con el propósito de analizar su estilo de vida y procesos de salud. se trata de un estudio de intervención cuasi-experimental, con mediciones antes y después de un año. se realizaron entrevistas estructuradas y se aplicó el instrumento de valoración del estilo de vida antes y después de participar en un plan de promoción de la salud con enfoque sanológico. la estrategia de intervención surtió efecto para mejorar la salud y el estilo de vida del grupo de mujeres participantes. palabras clave salud, mujer, promoción de la salud, estilo de vida, condiciones de vida, salud de la mujer. (fuente: decs) lifestyle and health among young adult women abstract the study was carried out in the san cristobal district of bogotá (borough no. 4) during 2004-2005, with a group of 100 women between 20 and 40 years of age, to analyze their lifestyle and health processes. it is a quasi-experimental intervention study with measurements taken before and after one year. structured interviews were conducted and the lifestyle evaluation instrument was applied before and after participation in a health-promotion plan with a sanological approach. the strategy for intervention had an effect in terms of improving the health and lifestyle of the group of participating women. key words health, women, promoting health, lifestyle, living conditions, woman’s health. año 8 vol. 8 nº 2 chía, colombia octubre 2008 266-284 267 estilo de vida y salud en la mujer adulta joven myriam patricia pardo-torres, nicolás arturo núñez-gómez estilo de vida e saúde na mulher adulta joven resumo este trabalho foi levado ao cabo em 2004-2005 em um grupo de 100 mulheres de 20 a 40 anos de idade na localidade quarta de bogotá para analisar seus estilos de vida e os processos de saúde. é um estudo de intervenção quase experimental. as medições foram feitas antes e depois de um ano. foram feitas pesquisas estruturadas e foi aplicado o instrumento de valoração do estilo de vida antes e depois de participar em um plano de promoção da saúde com um enfoque sanólogico. a estratégia de intervenção teve êxito em melhorar a saúde e o estilo de vida das mulheres que participaram no grupo. palavras-chave salud, mujer, promoción de la salud, estilo de vida, condiciones de vida, salud de la mujer. 268 año 8 vol. 8 nº 2 chía, colombia octubre 2008 266-284 aquichan issn 1657-5997 introducción la mujer en colombia se enfrenta a cambios importantes en su estilo de vida producidos por factores sociales, culturales, ambientales y económicos que afectan su estado de salud; transformaciones no siempre positivas, por ejemplo, la adopción de conductas de riesgo relacionadas con adicciones, alteración de hábitos alimentarios, modificación en los patrones de la actividad sexual, victimización por violencia, y cambios en la dinámica familiar causados por desplazamientos forzados o migraciones en busca de mejores condiciones de vida. el estilo de vida, al igual que lo biológico, lo ambiental y los servicios de salud son elementos básicos del campo de salud (1). por estilo de vida se entiende “la manera general de vivir, basada en la interacción entre las condiciones de vida, en un sentido más amplio, y las pautas individuales de conducta, determinada por factores socioculturales y características individuales” (2); un estilo de vida saludable implica conductas y hábitos que influyen de manera positiva en la salud de la persona. parra focaliza la necesidad de estudiar esta categoría desde la visión de género (3). aldereguía (4) consideró que el impacto del estilo de vida sobre el mejoramiento de la salud poblacional depende, en un quinto de factores genéticos, otro quinto del estado del medioambiente, y sólo un décimo de la atención médica, situación que desde hace más de dos décadas cuestiona la necesidad de cambiar los abordajes de promoción de la salud y prevención de la enfermedad, motivándonos a la búsqueda de estrategias que aporten resultados en el mejoramiento y la adopción de estilos de vida sanos por parte de la población. los estudios sobre estilo de vida han utilizado el enfoque epidemiológico de riesgo, y han estado encaminados a demostrar la relación entre el comportamiento individual y grupal con la aparición de enfermedades tales como cáncer y hábito de fumar (5); cardiopatías y ejercicio físico (6, 7); hábitos alimenticios (8); tabaquismo (9) y cardiopatía; lesiones autoinfligidas (10); osteoporosis y hábitos alimenticios (11); conducta sexual de rieso en vih/sida (12); estrés y enfermedad mental (13); abuso de sustancias y muerte violenta (14). la evidencia indica que el estilo de vida se asocia con mayor frecuencia a riesgo de enfermedad, dejando de lado su aporte a la salud. para lograr un aporte a la salud con un enfoque integral se consideran las siguientes dimensiones del estilo de vida: nutrición, práctica de actividad física, liberación de estrés, eliminación de hábitos como tabaquismo, sedentarismo, malnutrición, agresividad, ingesta excesiva de alcohol o de sustancias psicoactivas, prácticas de higiene personal adecuada, salud sexual e higiene de la funcion del sueño (15, 16). por otra parte, teniendo en cuenta que la mujer adulta joven atraviesa por una etapa de su ciclo vital que le imprime exigencias en la salud que tienen que ver con las dimensiones planteadas en el estilo de vida, entre otras una nutrición que responda a sus expectativas de mantener la figura, reducir el peso con comidas sencillas y rápidas que por estilo de vida se entiende “la manera general de vivir, basada en la interacción entre las condiciones de vida, en un sentido más amplio, y las pautas individuales de conducta, determinada por factores socioculturales y características individuales”. si deseas alcanzar el mayor nivel de salud sé feliz si deseas ser feliz cuida tu salud. 269 estilo de vida y salud en la mujer adulta joven myriam patricia pardo-torres, nicolás arturo núñez-gómez le faciliten dar respuesta a sus diferentes tareas, la práctica de una actividad física regular incentivada por el deseo de mantenerse esbelta, pero a la vez con dificultades en disponibilidad de tiempo porque, además de los conflictos económicos, su necesidad de autonomía e independencia la enfrentan al reto de sumar a sus roles de madre y ama de casa el rol de trabajadora, elemento que afecta de manera indirecta su salud mental y física por la sobrecarga que se genera. de esta manera, la relación entre estilo de vida y salud de la mujer adulta joven parte de su reconocimiento como elemento determinante y sujeto activo del desarrollo de la sociedad debido a su papel en el cumplimiento de la gestión en salud de la familia y la comunidad (17, 18); dentro de este contexto a la enfermería, como profesión del área de la salud con larga tradición de trabajo en la comunidad (19), e interesada en el desarrollo de la promoción de la salud con estrategias novedosas y estructuradas que garanticen impacto en la población (20), le urge adentrarse en la construcción y puesta en práctica de una estrategia metodológica para el abordaje de la promoción de salud de la mujer, centrada en la comprensión y el estudio de la salud de las personas en una realidad, desde una visión de salud cuyo acento sea la modificación del estilo de vida con una mirada integral. como respuesta a la necesidad planteada, se desarrolló una estrategia de promoción de la salud con enfoque sanológico, sustentada en la corriente higiénico-humanista de la sanología que busca superar el énfasis biomédico de abordaje de la promoción de la salud imperante en el modelo sanitario en colombia, que conceptualiza a la salud de la mujer adulta joven desde la orientación biomédica con énfasis en la prevención y el tratamiento de la enfermedad relacionada con la salud sexual y reproductiva, esta última especialmente en su acepción biológica. el enfoque sanológico, cuya orientación rectora es el desarrollo de la salud de los sanos (21), posibilita concebir la salud de la mujer adulta joven como un evento complejo, más allá del modelo clásico sanitario, y entrar a considerar los aspectos objetivos y subjetivos de su vida social, la cultura, la felicidad y la posibilidad del control de su propia existencia en busca del bienestar. la sanología compromete espacios de reflexión y acción sobre la base de dos pilares: uno teórico-crítico de redimensionamiento del ser humano, y otro como práctica liberadora de la medicalización enajenante en el proceso de salud; tiene una orientación conceptual en el humanismo, parte de un concepto holístico que interpreta la salud sin dicotomía con la enfermedad, desde la dinámica de la vida, los valores que el hombre construye en su cotidianidad y las prácticas socioculturales que le dan sentido. desarrolla su práctica en una dinámica que reconoce la interacción compleja entre los múltiples determinantes de salud, lo biológico, el estilo de vida, las relaciones con el ambiente y los servicios de salud en un modelo social, económico y cultural, con una perspectiva de la salud que corresponde a un ámbito comunitario. en sanología “el diálogo y la negociación” acompañan el proceso de manera continua con los elementos éticos implícitos en la relación del personal de salud y la persona involucrada, donde la persona es el centro y su participación es activa la relación entre estilo de vida y salud de la mujer adulta joven parte de su reconocimiento como elemento determinante y sujeto activo del desarrollo de la sociedad debido a su papel en el cumplimiento de la gestión en salud de la familia y la comunidad. 270 año 8 vol. 8 nº 2 chía, colombia octubre 2008 266-284 aquichan issn 1657-5997 durante todo el proceso, y el profesional de salud es un facilitador y un agente de cambio. los momentos que integran la estrategia sanológica son: momento de autoevaluaciones en el que la persona o grupo reflexionan sobre el concepto de salud y su percepción, el estilo de vida, los hábitos higiénicos sanitarios y el proyecto de vida. momento de examen físico rescatado de la clínica clásica que permite establecer de forma paulatina alguna de las características de los niveles de salud, que vayan más allá de la interpretación dicotómica de lo normal y lo patológico. momento de presunción de la salud, que se refiere a la reflexión sobre el nivel de salud alcanzado que rompe con la oposición dicotómica de sano o enfermo, considerando a la salud como el estado natural del ser humano con diferentes expresiones. momento de establecimiento de la ruta de salud, a la que se llega después de un proceso de negociación entre el facilitador y la persona, y se refiere a la construcción del mejor camino hacia el cambio en salud. se definen las áreas sobre las cuales se plantea actuar, se priorizan, se trazan los objetivos, las actividades y las formas de control de cada una de ellas. esta ruta puede comprender estrategias de trabajo individual o grupal. con elementos teóricos orientadores de sigerist (22); oms (23, 24), mark lalonde (1), edgar morin (25), donde confluye un amplio sentido de la salud, esta investigación parte de que la salud de la mujer adulta joven es la capacidad y el compromiso de ésta para desarrollar su potencial personal con el propósito de adaptarse y responder de forma positiva y feliz a los retos de género a partir de sus recursos físicos, psicológicos, culturales y sociales (26), y se plantea el interrogante: ¿podría una estrategia de promoción de la salud con enfoque sanológico modificar el estilo de vida para fortalecer la salud de un grupo de mujeres adultas jóvenes de un área social y económicamente deprimida? para dar respuesta a esta pregunta se implementa una estrategia de promoción de la salud dirigida a un grupo de mujeres adultas jóvenes de la localidad de san cristóbal de bogotá, con el propósito de aportar a las ciencias de la salud y su práctica en colombia una alternativa multidisciplinaria de intervención en promoción de la salud de la mujer adulta joven, enfocada a la salud como aspecto poco acentuado del proceso salud-enfermedad. el objetivo es modificar el estilo de vida de un grupo de mujeres adultas jóvenes de un área social y económicamente deprimida para fortalecer los procesos de salud. material y métodos muestra grupo de cien mujeres adultas jóvenes de la localidad cuarta (san cristóbal) del distrito capital de bogotá afiliadas al sistema de seguridad social integral, que recibían servicios de salud en el hospital empresa social del estado san cristóbal, en las upas la victoria y bello horizonte. se trabajó con la totalidad de mujeres que aceptaron vincularse después de un proceso de convocatoria, que obedece a los principios de voluntariedad y sustentabilidad de la estrategia de promoción de la sanología compromete espacios de reflexión y acción sobre la base de dos pilares: uno teórico-crítico de redimensionamiento del ser humano, y otro como práctica liberadora de la medicalización enajenante en el proceso de salud. 271 estilo de vida y salud en la mujer adulta joven myriam patricia pardo-torres, nicolás arturo núñez-gómez la salud implementada (26). los criterios de inclusión fueron: edad entre 20 y 40 años, voluntariedad en la participación, alfabetas, y compromiso de participar activamente en el programa durante un año. criterios de exclusión: analfabetas y con enfermedad metal. tipo de investigación se realizó un estudio de intervención de tipo cuasi-experimental, con mediciones antes-después de la aplicación de una estrategia de promoción de la salud con enfoque sanológico dirigida a modificar el estilo de vida como aspecto importante en el fortalecimiento de la salud. aspectos éticos la investigación fue aprobada por el comité de ética del centro de estudios de salud y bienestar humano de la universidad de la habana y el comité científico del hospital san cristóbal de bogotá. así mismo, los autores tuvieron en consideración respetar los principios éticos de la investigación con seres humanos: el respeto por la autonomía y la privacidad de las participantes, y la búsqueda del bien y la justicia, contenidos en las pautas éticas internacionales para investigación y experimentación biomédica en seres humanos, preparadas por el consejo de organizaciones internacionales de las ciencias médicas en colaboración con la organización mundial de la salud (oms) en 2002. procedimientos se realizó una valoración del estilo de vida de la mujer adulta joven a través de una entrevista estructurada durante la consulta sanológica (26), utilizando el instrumento de valoración “cómo es mi estilo de vida”. posterior a la primera evaluación, cada una de las mujeres participó durante un año en una estrategia de promoción de la salud con enfoque sanológico; a través de intercambios en escenarios individuales y grupales se trabajó en el fortalecimiento de los elementos sanógenos del estilo de vida, y la modificación de aquellos factores adversos a la salud, mediante una ruta de salud trazada en conjunto facilitador (en este caso enfermera) y mujer, tomando como punto de partida los hallazgos en la valoración del estilo de vida. una vez terminado el año de participación se valoró nuevamente el estilo de vida con el objetivo de identificar las modificaciones establecidas. instrumentos se utilizó el instrumento “cómo es mi estilo de vida” creado por la sociedad de cáncer de canadá (1986), modificado y utilizado por el seminario de salud periódico de trabajadores de cuba en 1989, que posteriormente ha sido utilizado por amable y aldereguía (27) dentro del proyecto de sanología del centro de estudios de salud y bienestar humanos (cesbh) de la universidad de la habana, en la línea de investigación de promoción de la salud a nivel transcultural. el instrumento fue traducido, adaptado y evaluado psicométricamente en en países como colombia, cuba, méxico y venezuela, en población general, familias, adulto mayor, escolares, estudiantes universitarios y mujeres médicas de consultorios de familia, lo que ha permitido determinar su validez y confiabilidad transcultural. al instrumento original se le hicieron modificaciones mínimas, con el propósito de que los enunciados de la pregunta se ajustaran al género y el español colombiano, con el fin de personalizar el interrogatorio, y además se colocó se trabajó con la totalidad de mujeres que aceptaron vincularse después de un proceso de convocatoria, que obedece a los principios de voluntariedad y sustentabilidad de la estrategia de promoción de la salud implementada. 272 año 8 vol. 8 nº 2 chía, colombia octubre 2008 266-284 aquichan issn 1657-5997 a cada una de las dimensiones una figura alusiva para mejorar la apariencia facial del instrumento. la versión modificada del instrumento fue sometida a criterio de expertos. para efectos de esta investigación se consideró experto al profesional del área de la salud con experiencia de investigación y trabajo en el área de cinco años o más, profesionales dedicados a la promoción de la salud y específicamente en la aplicación de la estrategia sanológica en cuba y en colombia. para la valoración del instrumento se diseñó un cuestionario a fin de que fuese diligenciado por cada uno de los expertos (10 en total, 5 expertos en cuba y 5 en colombia), en términos de pertinencia y relevancia de cada ítem, además de las observaciones sugeridas. cuadro. expertos evaluadores de la estrategia de intervención en promoción de la salud para la mujer adulta joven institución expertos categoría científica cuba 5 un especialista de pediatría y magíster. policlínico municipio 10 de octubre tres especialistas en mgi y magíster. una psicóloga y magíster. colombia 5 una enfermera magíster y candidata a doctor. universidad surcolombiana un médico cirujano y magíster, candidato a doctor. una enfermera magíster en gerencia en servicios de salud y candidata a doctor. universidad nacional de colombia una enfermera especialista en enfermería perinatal y magíster. una enfermera especialista en enfermería perinatal y magíster. los aportes sugeridos por los expertos fueron tenidos en cuenta, y el instrumento resultante fue sometido a prueba piloto a un total de 20 mujeres de la upa san blas, con similares características de las mujeres que conformaron el estudio. los resultados de la prueba piloto revelaron que es un instrumento sencillo y de fácil comprensión por parte de las mujeres, cuya aplicación toma entre 5 y 10 minutos, mide lo que se quiere medir en cada una de las dimensiones en la misma escala, las preguntas son claras; en aquellas preguntas que inician con la sílaba “no” las mujeres demoraron un poco más en su diligenciamiento. en conclusión, las dimensiones de alcohol y orden no permitieron cumplir con el requerimiento de intervalo en las respuestas ya que en su mayoría las mujeres dieron la misma respuesta. la dimensión relacionada con el uso de alcohol mostró una frecuencia de respuesta hacia el no consumo del 100% de las mujeres, sin embargo, la presencia de un sólo caso es significativa estadísticamente para los efectos del estudio, y el hecho de eliminarla del instrumento afectaría el constructo del mismo, por tanto, no fue eliminada para su aplicación. se realizó una valoración del estilo de vida de la mujer adulta joven a través de una entrevista estructurada durante la consulta sanológica, utilizando el instrumento de valoración “cómo es mi estilo de vida”. 273 estilo de vida y salud en la mujer adulta joven myriam patricia pardo-torres, nicolás arturo núñez-gómez el instrumento contiene diez dimensiones del estilo de vida, a saber: familiares y amigos, actividad física, nutrición, toxicidad, alcohol, sueño y estrés, tipo de personalidad, imagen interior, carrera y orden. cada una de estas dimensiones contiene entre dos y tres preguntas con un diseño gráfico que las identifica y cada pregunta se califica en una escala de likert con una puntuación que oscila entre 0 y 2. entre mayor puntaje la dimensión es más positiva hacia la salud. después de diligenciado el instrumento por cada una de las participantes, se procedió a totalizar cada una de las dimensiones, el resultado final correspondía al total del puntaje que se clasificó en rangos cualitativos: excelente (85-100), bueno (70-84), regular (60-69), malo (40-59) y muy malo (0-39). análisis estadísticos para explorar y comparar los datos se utilizó la gráfica de caja y bigotes que permite comparar información de varios grupos mediante los conceptos de mediana, cuartiles, valor mínimo y máximo para determinar si existieron diferencias entre los resultados obtenidos en la prueba “cómo es mi estilo de vida” antes y después de participar en la estrategia de promoción de la salud con enfoque sanológico para modificar el estilo de vida (28). resultados la gráfica permite visualizar el cambio en la medición del estilo de vida entre el pretest y el postest, así, la mediana cambia de 80 a 92, es decir el 50% de la mujeres pasaron de tener un estilo de vida “bueno” a “excelente”; en relación con la medida mínima, pasa de 54 a 80, es decir, de la categoría “malo” a ”bueno”; la dispersión fue menor en el postest, y la diferencia intercuartílica se reduce en la última medición. gráfica evaluación antes-después del estilo de vida de las mujeres adultas jóvenes que participaron en la estrategia de promoción de la salud. localidad cuarta de bogotá, 2000-2004 fuente: base de datos autores, 2007. la tabla permite visualizar el nivel de cambio en las diez dimensiones medidas con el instrumento “cómo es mi estilo de vida”, según la escala formada por los valores de los cuartiles, la cual se dividió en cuatro categorías: cambio alto, cambio medio, cambio mínimo y sin cambio. tabla nivel de cambio en las dimensiones del instrumento “cómo es mi estilo de vida” antesdespués de la participación de las mujeres adultas jóvenes en la estrategia de promoción de la salud. localidad cuarta de bogotá, 2000-2004 nivel del cambio dimensiones pretest postest q1 mediana q3 q1 mediana q3 cambio alto familiares y amigos 50 67 83 83 100 nutrición 67 83 100 83 100 cambio medio actividad física 67 67 83 83 83 100 sueño y estrés 50 75 75 75 75 100 cambio mínimo tipo de personalidad 75 100 100 imagen interior 83 100 100 sin cambio toxicidad 98 100 alcohol 100 100 orden 100 100 carrera 100 100 fuente: base de datos autores, 2007. 274 año 8 vol. 8 nº 2 chía, colombia octubre 2008 266-284 aquichan issn 1657-5997 la figura y la tabla serán analizadas el el siguiente apartado. discusión la estrategia de promoción de salud aplicada modificó positivamente el estilo de vida de un grupo de mujeres adultas jóvenes de un área social y económicamente deprimida, y fortaleció los procesos de salud de las mismas. este logro se asocia al enfoque metodológico utilizado –la sanología–, cuyo eje orientador es el “humanista de la salud”, propuesta que acentúa el papel activo y protagónico de la mujer, y busca disminuir la brecha de la iniquidad en salud asociada al género; este enfoque presupone la existencia de un conjunto de factores personales, sociales, económicos, ambientales y culturales que determinan el estado de salud individual o colectiva, superando el modelo biomédico con énfasis en la prevención y el tratamiento de la enfermedad, en especial la relacionada con la salud sexual y reproductiva de la mujer. las modificaciones positivas en el estilo de vida de las mujeres adultas jóvenes que participaron en la estrategia de intervención en promoción de la salud, localidad cuarta de bogotá, pueden ser comprendidas por: • autorreflexión acerca de la percepción, concepto de salud y práctica de autocuidado, integrada a nivel biológico, emocional, económico, social y cultural. • creación de un nivel de presunción de salud que supera la dicotomia sanoenfermo, para construir la salud como un estado de la vida cotidiana. • autonomía de la mujer adulta joven para establecer su propia ruta de la salud que contribuye a mantener su libertad y potencializar la capacidad creativa y de conducción de su proceso individual de salud. • facilitadora, apoya y respeta el compromiso de la mujer en procesos activos en la búsqueda de su propia salud. • dirección y control de las actividades que conllevó al cumplimiento de sus metas planteadas en la ruta de salud. • participación activa y continua en los diferentes encuentros sanológicos y talleres, y cumplimiento de las propias metas fuera del espacio de encuentro sanológico: facilitadora y mujer adulta joven. • estructuración del ambiente familiar, cultural y laboral por parte de la mujer adulta joven para promocionar la salud. • enfoque interdisciplinario de la promoción de la salud, participación de enfermera, médico, psicólogo, nutricionista, trabajador social, terapeuta, educador físico, licenciado en educación, reeducador laboral. • sistema de salud, localidad cuarta de bogotá, que acepta nuevos modelos de intervención en promoción de la salud. la estrategia de promoción de la salud con enfoque sanológico con el propósito de modificar el estilo de vida también ha sido puesta en práctica en la ciudad de la habana (29, 30, 31) donde se obtuvieron resultados homólogos. al discriminar las diez dimensiones del instrumento “¿cómo es mi estilo de vida?” se encuentra que cada una de ellas aportó al discriminar las diez dimensiones del instrumento “¿cómo es mi estilo de vida?” se encuentra que cada una de ellas aportó cambios positivos en forma diferencial. 275 estilo de vida y salud en la mujer adulta joven myriam patricia pardo-torres, nicolás arturo núñez-gómez cambios positivos en forma diferencial. a continuación se analizan las dimensiones y su nivel de cambio aportado en el estilo de vida de las mujeres que participaron en la estrategía de promoción de salud con enfoque sanológico. cambio alto dimensión familiares y amigos. los cambios se explican a partir de los logros en el desarrollo de la capacidad personal de la mujer adulta joven que conducen a tener un equilibrio con su entorno social; la participación en redes de apoyo comunitarias como parte del entorno, y el fortalecimiento de la red de apoyo familiar y la salud (32). se reportó que básicamente los cambios se relacionan con encontrar una persona para expresar pensamientos, sentimientos y emociones significativas en la vida –en la mayoría de los casos fue la pareja–, lo que estuvo asociado en forma directa y positiva a la esfera sexual; al respecto, en el estudio de tilden (19831984) citado por muñoz (33), se observó mayor estrés y ansiedad en mujeres solteras comparadas con un grupo de mujeres con pareja. por otra parte, las acciones individuales y colectivas en las que participó la mujer adulta joven, tales como: talleres de autoestima, manejo de estrés, utilización del tiempo libre, encuentro sanológico, facilitaron el logro de los cambios en la dimensión familiares y amigos. los logros positivos de esta dimensión se orientaron en tres niveles: individual, familiares y amigos. en el primero se fortaleció la capacidad de la mujer para analizar situaciones, expresar sus necesidades, emociones y sentimientos. en el segundo nivel se enriquecieron las oportunidades y fortalezas de tener una familia, se incentivaron las expresiones de afecto y el diálogo con la pareja, y se trabajó en la distribución equitativa de la responsabilidad en el cuidado y la educación de los hijos. referente a los amigos se trabajó la comunicación y el ejercicio de la tolerancia. es de acotar que estos niveles fueron construidos por la misma mujer según su percepción y necesidad en salud, y se evidenció el mayor impacto en la salud del grupo de mujeres participantes en los casos en que el apoyo social era percibido (34, 35). dimensión nutrición. los cambios se expresaron en la adopción de prácticas de ingesta de alimentos de los tres grupos de nutrientes, además del control del exceso de consumo de sal, azúcar y grasa animal. las mujeres percibieron los cambios en el índice de masa corporal, lo cual fue reportado durante las entrevistas como una forma de superar la obesidad y la enfermedad (36, 37, 38, 39). la nutrición es una de las áreas consideradas críticas en la salud de la mujer por la especificidad de género, dado que los cambios hormonales influyen en la distribución de la grasa corporal, y la función reproductiva en la mujer origina un incremento en las necesidades de algunos nutrientes con relación al hombre, entre ellos, el hierro y el calcio. el logro del cambio de las prácticas nutricionales se propició con un proceso que inició con la sensibilización de las mujeres participantes frente a la necesidad de modificar hábitos, como parte de la responsabilidad para mantenerse sanas. durante los encuentros individuales y colectivos se enfatizó la asesoría en hábitos nutricionales y consumo de una dieta balanceada, con ingesta de alimentos ricos en fibra, hierro y calcio, y se facilitó adese reportó que básicamente los cambios se relacionan con encontrar una persona para expresar pensamientos, sentimientos y emociones significativas en la vida –en la mayoría de los casos fue la pareja–, lo que estuvo asociado en forma directa y positiva a la esfera sexual. 276 año 8 vol. 8 nº 2 chía, colombia octubre 2008 266-284 aquichan issn 1657-5997 más la adquisición de recetas alimentarias fáciles de preparar y accesibles económicamente. aquellas mujeres que así lo requerían fueron remitidas a la consulta de nutrición con verificación permanente de la adopción de las prescripciones hechas por la nutricionista en cada encuentro facilitadora-mujer. la motivación para mantener la adherencia a las recomendaciones del equipo de salud en relación con la nutrición se puede resumir en: el apoyo familiar, la autopercepción de salud en oposición a la enfermedad, es decir, ser obeso significa estar próximo a enfermar, y la influencia de los medios masivos de comunicación que proyectan un imaginario social en el que bajo peso es igual a belleza. cambio medio dimensión actividad física. los cambios se asocian a la comprensión de la mujer adulta joven de las ganancias en salud; una actividad física regular se expresa en el mantenimiento del tono, la potencia y la flexibilidad muscular, la cual fortalece la capacidad física, mejora las funciones corporales y proporcionalidad de la figura corporal (40). al inicio de la estrategia se tomaron las medidas básicas corporales y se calculó el índice de masa corporal, para que las mismas mujeres determinaran las metas de cambio a lo largo de la estrategia sanológica de promoción de la salud. en acompañamiento con la terapeuta ocupacional se conformó un grupo de mujeres con necesidad específica de actividad física con las que se realizó un taller; igualmente, durante los encuentros individuales y colectivos se invitó a las mujeres a que en compañía de sus vecinas conformaran colectivos de actividad física regular, y que hicieran uso de los recursos comunitarios, tales como parque, paseos ecológicos y piscina. la actividad física regular (caminar rápido y subir escaleras), contribuye a reducir el estrés, la ansiedad, la depresión (41) y el sentimiento de soledad, lo que es particularmente importante para las mujeres (42, 43). la actividad física ayuda también a desarrollar la autoestima y la confianza, y promueve el bienestar psicológico, la integración social (39), y coadyuva en el manejo de la obesidad (44, 45, 46). la presión social de juventud y belleza apoyó este programa, en la medida que algunas mujeres conceptualizaron que estos elementos son parte de la salud (47), además en colombia, como en otros países, se observa el aumento significativo de la cirugía con fines estéticos, pero no valorada en términos de salud. muchas mujeres jóvenes después de la maternidad priorizan actividades en su rol de género diferentes al cuidado físico, lo cual afecta su autoimagen y capacidad de logro. dimensión sueño y estrés. los cambios presentados en el grupo de mujeres participantes en esta dimensión están relacionados con las modificaciones en los hábitos de sueño; así mismo, ellas manifestaron al final de la estrategia poderse relajar y disfrutar del tiempo libre. sin embargo, uno de los elementos contenidos en esta dimensión que fue el relativo a enfrentar su cotidianidad no presentó cambios significativos después de culminada la intervención, elemento que puede estar asociado a las adversidades por pertenecer a un la actividad física regular (caminar rápido y subir escaleras), contribuye a reducir el estrés, la ansiedad, la depresión y el sentimiento de soledad, lo que es particularmente importante para las mujeres. 277 estilo de vida y salud en la mujer adulta joven myriam patricia pardo-torres, nicolás arturo núñez-gómez grupo económicamente vulnerable, en el que la mujer se enfrenta a la necesidad de aportar para el sustento de su familia sin tener vinculación laboral o, en otros casos, estar desempeñando un oficio sin vinculación formal, en muchas ocasiones mal remunerado y sin garantías laborales. los logros en el área del sueño se relacionan con el concepto de higiene del sueño, mediante la creación de rutinas diarias para lograr que la mujer construyera un ciclo que estuviera de acuerdo con su ritmo circadiano. la medicina del sueño considera que el tiempo ideal para mantener el bienestar físico y mental de cada mujer es personal, cerca de 7 a 8 horas por día. ellas reportaron que al crear estas rutinas se sentían descansadas, con energía para afrontar la vida cotidiana y sensación de bienestar. los trabajos de buela casal (48) reportaron la asociación entre horas de sueño y depresión, ansiedad, abuso de sustancias y cáncer, además aya y cols. (49) encontraron asociación entre patrón de sueño corto y el riesgo de padecer diabetes y cardiopatías. por otra parte, la somnolencia, el insomnio y la apnea durante el sueño están asociados al estrés, la ansiedad y la depresión, afectan negativamente la salud, y ponen en riesgo vital a la mujer (50). el estrés como elemento que dificulta el bienestar emocional se asoció en el grupo de mujeres con una relación de pareja conflictiva, el trabajo doméstico o el trabajo fuera de casa, la relación con sus hijos u otros miembros de la familia, problemas económicos y presiones sociales. en conjunto con la terapeuta ocupacional se planeó y ejecutó un taller de manejo de estrés y utilización del tiempo libre, en el que las mujeres que tenían dificultades a ese nivel participaron activamente en el fortalecimiento de los propios recursos y el desarrollo de habilidades y destrezas manuales para mejor utilización del tiempo libre. cambio mínimos dimensión tipo de personalidad. al terminar el programa el grupo de mujeres manifestó un autocontrol de la molestia y la irritabilidad, pero continuó sintiendo urgencia de tiempo, posiblemente asociado a la vida cotidiana que las enfrenta a actividades como el uso del transporte público, el trabajo, las filas para realizar tareas como pagos, compras, y la necesidad de cumplir con horarios laborales o educativos, elementos que concuerdan con los hallazgos de rosseti (51). para lograr el cambio en la dimensión tipo de personalidad se trabajó con las mujeres la práctica de valores como la tolerancia y el respeto por el otro con ayuda de las redes de apoyo familiar. con respecto a este punto, durante los encuentros individuales se promovió la manifestación de sentimientos y la autorreflexión frente a las dificultades en la convivencia e identificación de las circunstancias o los hechos que tienen que ver con las relaciones sociales en la comunidad, y que afectan la percepción de la salud, con el fin de que la mujer encontrara alternativas de solución frente a las mismas (52). este grupo de mujeres manejan altos niveles de hostilidad producto de la vida cotidiana en la medida que se sienten con altos grados de frustración, que no siempre se maneja adecuadamente, lo cual lleva a conflicto con el grupo primario. las principales tensiones con el grupo primario aparecen en las mujeres que la medicina del sueño considera que el tiempo ideal para mantener el bienestar físico y mental de cada mujer es personal, cerca de 7 a 8 horas por día. 278 año 8 vol. 8 nº 2 chía, colombia octubre 2008 266-284 aquichan issn 1657-5997 desempeñan múltiples roles y responsabilidades frente a la familia, educación y trabajo, lo mismo que aquellas mujeres que tienen mucho tiempo libre, y se expresa en conflictos con la comunidad por causa de sucesos poco significativos. las características de este trabajo no permiten esperar cambio en la estructura de personalidad, sólo modificaciones en la estrategia de afrontar el mundo cotidiano con menor nivel de agresividad y mayor tolerancia, aunque se evidencia para el grupo de trabajo la relación ira, angustia, urgencia de tiempo con enfermedad cardiovascular (53, 54). dimensión imagen interior. los cambios en esta área están asociados con la comprensión de sí misma como una persona optimista; en los relatos al final de la experiencia las mujeres comentaron que empezaron a sentirse con mayor control sobre sus vidas; capaces de manejar la tensión y las sensaciones desagradables como la tristeza y la depresión; el cambio cualitativo en muchas de ellas fue notorio con respecto al porte y la imagen corporal que proyectaban, mientras que al inicio su actitud era de mantenerse con la mirada oculta, mostraban desarreglo en su imagen corporal y tendencia a utilizar colores oscuros en su vestuario, después de asistir a los primeros encuentros, tanto individuales como de grupo, se notó cambio hacia una actitud desinhibida y mejora en el arreglo personal. para el logro del cambio en esta dimensión del estilo de vida el trabajo conjunto mujer-facilitadora, tanto en los encuentros individuales como en los talleres, se orientó a: propiciar la identificación y conciencia de fortalezas, cualidades, habilidades y logros experimentados en su vida personal, con la familia, amigos y demás redes de apoyo; facilitar la autorreflexión, reconocimiento y aceptación de la imagen corporal; reconocimiento de la individualidad y unicidad como ser humano; descubrimiento de la creatividad, iniciativa, capacidad y talentos para realizar y alcanzar el proyecto de vida, y la motivación para el establecimiento de metas concretas y claras a corto, mediano y largo plazo. al respecto, los trabajos de intervención en esta área con mujeres adolescentes han demostrado resultados positivos en el incremento de los niveles de autoestima (55). por otra parte, se ha investigado en la búsqueda de la asociación de la variable autoestima y la aparición de trastornos en la conducta alimentaria (56), y el riesgo de consumo de alcohol (57). sin cambios dimensión alcohol y toxicidad. como aspecto positivo para el grupo de mujeres se resalta que desde el inicio de la estrategia estas dos dimensiones fueron referidas como factores sanógenos en el colectivo de participantes. ellas en su totalidad no consumían alcohol, y si lo hacían era solo en ocasiones especiales y en escasa cantidad, conducta que se mantiene desde la infancia hasta la adultez, además niegan antecedentes familiares de consumo de alcohol; al respecto, el banco mundial (58) reporta la relación entre consumo de alcohol, género y medioambiente social, con resultados desalentadores para el hombre, que tiene más probabilidad de beber y menos posibilidad de abstenerse en respuesta a la presión social (59, 60). otra característica para resaltar en el grupo de participantes fue la escasa el banco mundial reporta la relación entre consumo de alcohol, género y medioambiente social, con resultados desalentadores para el hombre, que tiene más probabilidad de beber y menos posibilidad de abstenerse en respuesta a la presión social. 279 estilo de vida y salud en la mujer adulta joven myriam patricia pardo-torres, nicolás arturo núñez-gómez proporción de mujeres que fumaban, y la conciencia que en ellas existía del no uso de prácticas como la automedicación y el consumo exagerado de café, té o bebidas con cafeína, tal vez este conocimiento sea propiciado por el énfasis de la educación impartida por los organismos de salud sobre los efectos dañinos para el ser humano del uso de este tipo de sustancias. de todas formas, debido a que el consumo de alcohol, el cigarrillo y otras sustancias no beneficiosas, traen consecuencias en la salud de la mujer (61, 62, 63, 64, 65) es importante mantener estas dimensiones en la valoración del estilo de vida para seguir creando conciencia respecto a lo dañino de estas prácticas y de esta manera desanimar su uso (66, 67). dimensiones de carrera y orden. las dimensiones carrera y orden del estilo de vida no mostraron cambios cuantitativos en los resultados de la intervención. desde el inicio de la misma la dimensión orden se resaltaba como un factor sanógeno, en la medida que hace parte de la vida de este grupo de mujeres, conducta aprendida en la casa materna que constituye una fortaleza para mejorar su vida personal y familiar. al analizar por separado los elementos que contenía la dimensión carrera, se observó que al inicio de la estrategia una parte del grupo de mujeres no tenía total satisfacción con sus roles, insatisfacción relacionada con la percepción que se tiene frente a la subvaloración y el no reconocimiento social de la tarea de ama de casa, y la falta de apoyo social porque en muchas ocasiones la pareja no colabora en las tareas del hogar (68). en la época actual muchas mujeres de estrato socioeconómico bajo tienen una doble jornada laboral constituida por un trabajo de tipo informal y mal remunerado, que junto con el rol de ama de casa representan una sobrecarga física y emocional, que además de poner en riesgo su salud (69, 70) las enfrenta a un conflicto que no les permite determinar claramente la satisfacción en este espacio. por el contrario, las mujeres que trabajaban fuera del hogar en labores de tipo formal, en su mayor parte refirieron satisfacción en los roles, éstas percibían beneficios no solo económicos sino psicológicos que redundaban en su desarrollo personal y profesional. la modificación del estilo de vida de un grupo de mujeres adultas jóvenes de un área social y económicamente deprimida para fortalecer los procesos de salud fue posible por un cambio alto en las dimensiones familiares y amigos, y nutrición; cambio medio en las dimensiones actividad física, y sueño y estrés, y cambio mínimo en las dimensiones tipo de personalidad e imagen interior, logro que se favoreció por la inclusión de una estrategia de promoción de la salud para la mujer adulta joven con enfoque sanológico que se basa en el humanismo como eje orientador que acentúa el papel protagónico de la mujer en la búsqueda y el desarrollo de su propia salud. conclusiones la sanología es una estrategía metodológica para implementar programas de promoción de la salud basados en el reconocimiento de la capacidad de la persona para crear estilo de vida, y modificar el ambiente en busca de una ruta de salud propia, enmarcada en la felicidad personal y colectiva. la propuesta de una estrategía de promoción de salud orientada desde el estilo de vida y salud en la mujer adulta joven tiene un enfoque poblacional, basado en los determinantes de salud y gestión social del riesgo, razón por la cual es un aporte al plan nacional de salud pública 2007-2010 de colombia. la salud de la mujer adulta joven debe ser estudiada desde una perspectiva de género que parta de la capacidad activa, responsabilidad social y creativa de la mujer en su propia vida. agradecimientos para nosotros participar de las actividades científico-humanista del centro de estudios de salud y bienestar humanos de la universidad de la habana ha sido de enorme valor, en especial la orientación y las enseñanzas de la doctora ruth daisy henriques rodríguez y el doctor jorge aldereguía henriques. agradecemos los aportes de la facultad de enfermería de la universidad nacional de colombia y de la facultad de salud de la universidad surcolombiana. resaltamos el apoyo científico de la doctora zoraida amable ambros y el aporte de la secretaría de salud del distrito especial de bogotá, localidad san cristóbal. 280 año 8 vol. 8 nº 2 chía, colombia octubre 2008 266-284 aquichan issn 1657-5997 referencia 1 lalonde m. new perspective on the health of canadians a working document. ontario; 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salud. universidad complutense de madrid, facultad de psicología. españa. 2001 [citado 09/07/04]; 1-7. disponible en: http://www.mtas.es/mujer/ mujeres/estud_inves/2001/518p.pdf 256 273 perspectiva espiritual de la mujer.indd 256 aquichan issn 1657-5997 milena alexandra galvis-lópez1 beatriz pérez-giraldo2 perspectiva espiritual de la mujer con cáncer 1 magíster en enfermería. profesora, universidad pedagógica y tecnológica de colombia, tunja, colombia. milenga@hotmail.com 2 magíster en enfermería con énfasis en salud familiar. directora de posgrados, facultad de enfermería y rehabilitación, universidad de la sabana, colombia. beatriz.perez@unisabana.edu.co recibido: 16 de julio de 2011 aceptado: 7 de octubre de 2011 resumen objetivo: comparar la perspectiva espiritual de las mujeres diagnosticadas con cáncer propio de su género (seno, útero, ovarios) y de las mujeres diagnosticadas con otros tipos de cáncer. método: diseño cuantitativo de tipo descriptivo comparativo, de corte transversal. se empleó una encuesta sociodemográfica para caracterizar la población y la escala de perspectiva espiritual de pamela reed, a la cual se le realizó el análisis de confiabilidad que reportó un alfa de cronbach de 0,799 en el grupo 1 y 0,763 en el grupo 2. la muestra incluyó a 100 mujeres que se encuentran en tratamiento contra el cáncer. resultados: la perspectiva espiritual de las mujeres con cáncer propio de su género es moderada al igual que la de las mujeres con otros tipos de cáncer; al hacer la comparación de estos dos grupos no se encontró evidencia estadística que demostrara una diferencia significativa. discusión: los resultados de este estudio aportan nuevos elementos para el cuidado de las mujeres con enfermedad oncológica y señalan que una perspectiva espiritual moderada puede ser un potencial para su cuidado integral, en el que la enfermera reconozca sus objetivos en el cuidado de la mujer como un ser total, más que el tipo de cáncer que tiene. palabras clave espiritualidad, mujeres, neoplasias (fuente: decs, bireme). the spiritual perspective of women with cancer abstract objective: to compare the spiritual perspective of women diagnosed with types of cancer particular to their gender (breast, uterus, ovarian) to that of women diagnosed with other types of cancer. method: this is a qualitative, cross-sectional, descriptive comparative study. pamela reed’s spiritual perspective scale was used and its reliability with a cronbach’s alpha of 0.799 for 1 and 0.763, for group 2. the sample included 100 women who are receiving treatment for cancer. a socio-demographic survey was applied to characterize the population. results: the spiritual perspective of women with types of cancer particular to their gender is moderate to equal that of women with other types of cancer. a comparison between the two groups showed no statistical evidence to demonstrate a significant difference. año 11 vol. 11 nº 3 chía, colombia diciembre 2011 l 256-273 257 perspectiva espiritual de la mujer con cáncer l milena alexandra galvis-lópez, beatriz pérez-giraldo discussion: the results of this research provide new insights into care for women with oncological diseases. it also indicates a moderate spiritual perspective can contribute to comprehensive care in which nursing recognizes its objectives in terms of providing women with holistic attention, rather than focusing specifically on the type of cancer they have. key words spirituality, women neoplasias (source: decs, bireme). perspectiva espiritual da mulher com câncer resumo objetivo: comparar a perspectiva espiritual das mulheres diagnosticadas com câncer próprio de seu gênero (seio, útero, ovários) e das mulheres diagnosticadas com outros tipos de câncer que vão à clínica cancerológica de boyacá, em tunja-boyacá, colômbia. método: estudo quantitativo de tipo descritivo comparativo, de corte transversal. empregou-se a escala de perspectiva espiritual de pamela reed, com a qual se realizou a análise de validade com o alfa de cronbach obtendo-se resultados de 0,799 para o grupo 1e para o grupo 2 de 0,763. a mostra inclui 100 mulheres que se encontram em tratamento contra o câncer. aplicou-se uma enquete sociodemográfica para caracterizar a população. resultados: a perspectiva espiritual das mulheres com câncer próprio de seu gênero é moderada assim como as mulheres com outros tipos de câncer; ao fazer a comparação desses dois grupos não se encontrou evidência estatística que demonstre uma diferença significativa. discussão: a literatura aponta um aumento na espiritualidade nos indivíduos com câncer; os resultados desse estudo não permitem corroborar essa afirmação. com base nos dados recopilados com a escala de perspectiva espiritual de reed, não se pode afirmar que exista diferença na perspectiva espiritual dos grupos estudados. o presente estudo colabora com um novo conhecimento para a construção do cuidado das mulheres com enfermidade oncológica e aponta que uma perspectiva espiritual moderada pode ser um potencial para seu cuidado integral, no qual a enfermeira reconhece seus objetivos no cuidado da mulher como um ser total, mais que o tipo de câncer que tem. palavras-chave espiritualidade, mulheres, neoplasias (fonte: decs, bireme). 258 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 introducción el ser humano posee todas las herramientas para desarrollar sus potencialidades y para interactuar con el medio que lo rodea, de allí parten sus expresiones que dependen de los significados que haya otorgado a estas experiencias de vida. lo anterior se ve alterado con la aparición de una enfermedad crónica, ya que esta se acompaña de la incertidumbre por las pérdidas, el dolor, la vulnerabilidad y el miedo a la muerte. es cuando el paciente busca estrategias para hacer frente a la enfermedad y lograr la trascendencia para ir más allá de su estado actual de salud. la respuesta de una persona a la enfermedad varía ostensiblemente según si padece una enfermedad de corta duración (aguda) o si, por el contrario, se trata de una enfermedad de larga evolución; o si además su tratamiento no es resolutivo sino paliativo, y la enfermedad trae consigo invalidez o mutilación, como en el cáncer; su diagnóstico y tratamiento afectan al individuo en su totalidad, principalmente porque tiene la característica de estar asociado con la muerte, lo cual lleva a la persona que lo padece a hacerse una serie de preguntas de carácter existencial (1). diversos estudios han demostrado una implicación importante de la dimensión espiritual a la hora de hacer frente a la enfermedad crónica y terminal, y se han encontrado correlaciones positivas entre los índices de recuperación y la espiritualidad (2, 3, 4). estas investigaciones demuestran que, en un alto porcentaje, los individuos creen en un ser superior, y creen en el poder de este para mejorar el curso de la enfermedad (5, 6, 7, 8, 9). la espiritualidad se asocia con la enfermedad oncológica en varios aspectos: de una parte, la misma cercanía a la muerte parece modificarla y algunos informes reportan un mayor nivel de perspectiva espiritual en las personas en esta situación (9). de otra, la reacción frente a decisiones sobre la muerte ha demostrado depender en gran proporción de las creencias, la esperanza y el contexto de la persona enferma (10). más aún, la espiritualidad empieza a ser vista como una herramienta de trabajo en el cuidado paliativo y como un apoyo para el equipo interdisciplinario (11). es así como el profesional de enfermería no puede pasar por alto el proveer cuidado espiritual reconociendo las creencias y los valores espirituales del paciente, para así poder identificar sus necesidades y ofrecer el cuidado de acuerdo con estas. el reto es reconocer al paciente como una totalidad; el enfoque holístico supone que su bienestar se alcanza cuando la espiritualidad es incorporada en el cuidado, es un proceso más complicado que trasciende la enfermedad misma y que integra el cuerpo, la mente y el espíritu (12). estado del arte espiritualidad la espiritualidad, como fenómeno universal, tiene múltiples definiciones, pero cada ser humano la experimenta de forma diferente según sus experiencias y creencias. a través de diversos estudios han demostrado una implicación importante de la dimensión espiritual a la hora de hacer frente a la enfermedad crónica y terminal, y se han encontrado correlaciones positivas entre los índices de recuperación y la espiritualidad. 259 perspectiva espiritual de la mujer con cáncer l milena alexandra galvis-lópez, beatriz pérez-giraldo la revisión de la literatura se encuentran numerosas definiciones de este concepto: la palabra espiritualidad se deriva del latín “espiritus”, que se refiere a aliento, aire, viento. en general, se puede establecer que se define como una energía o impulso que mueve al ser y que se manifiesta según creencias y valores individuales, es la esencia del ser humano en la búsqueda de sus significados y en la búsqueda de sí mismo (13). durante mucho tiempo se le asignó a la espiritualidad un significado religioso, lo que afectaba su reconocimiento e importancia para el cuidado de enfermería, afectando la dimensión holística del ser humano. espiritualidad y religión se ha establecido que cualquier discusión sobre la definición de espiritualidad debe considerar su relación con la religión. una idea común y errada es que los dos conceptos son sinónimos. sin embargo, aunque haya una superposición, la religión y la espiritualidad son dos constructos separados y no permutables (4). la religión se define como un fenómeno social y cultural; lo espiritual es individual y personal (13, 14). de esta manera, la religión se define como un sistema organizado de creencias y de prácticas compartidas por una determinada colectividad (15). ellison describió el concepto de bienestar espiritual (asociado a espiritualidad) como un estado doble, con un componente religioso y otro espiritual o existencial; este aspecto otorga un sentido de propósito y satisfacción con la vida personal. se han desarrollado múltiples investigaciones (4, 5, 6, 7, 8, 9) donde se pretende demostrar esta conexión positiva y todas las implicaciones que se dan en materia de cuidado y bienestar del paciente en todas sus dimensiones y en su trascendencia. espiritualidad y salud en relación con la asociación de este concepto y la salud, investigaciones coinciden en señalar que existe una conexión entre una espiritualidad fuerte y una mejoría en la salud mental, con la habilidad para afrontar el estrés de una enfermedad y el duelo; y se describe la espiritualidad como la inclinación por encontrar significado en la vida por medio de un sentido de interrelación con algo mayor, que trasciende el yo y lo fortalece (3). a continuación se presentan algunos autores que han demostrado esta relación significativa. emblen analizó las definiciones de bienestar espiritual (como un concepto asociado a la espiritualidad) en la literatura de enfermería, coincidiendo en que la falta de una definición unificada sobre espiritualidad para la disciplina entorpece la investigación y el desarrollo de intervenciones espirituales (16). burkhardt definió la espiritualidad como “el misterio revelado por medio de una interconexión armoniosa que nace de la fortaleza íntima”, utilizó la palabra “espiritualidad” como un concepto que connota un proceso y como tal se considera más útil para enfermería (4). goddard, mediante un análisis filosófico del concepto, propone una definición de espiritualidad como una energía integradora que es capaz de producir armonía interna y holística, que combina cuerpo, mente y espíritu. algunos atributos de la espiritualidad que goddard identifica son la corporeidad, la vitalidad y la fortaleza (17). la espiritualidad, como fenómeno universal, tiene múltiples definiciones, pero cada ser humano la experimenta de forma diferente según sus experiencias y creencias. 260 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 en lo pertinente a este trabajo de investigación se revisaron las definiciones establecidas por reed a lo largo de los diferentes estudios realizados sobre espiritualidad. en 1987, la autora amplió el número de investigaciones sobre la espiritualidad y el bienestar de los enfermos terminales adultos. sobre la base de las conclusiones de su estudio de 1986, reed modificó la denominación rps (escala de perspectiva religiosa) y la denominó sps (escala de perspectiva espiritual) (18). reed define la espiritualidad como puntos de vista personales (creencias) y comportamientos que expresan un sentido de relación con una dimensión trascendente o algo mayor que sí mismo. las creencias religiosas o espirituales asumen gran importancia en el momento de la enfermedad y en momentos transcendentales en la vida del individuo. estas lo ayudan a aceptar su enfermedad y poder compartir con otras personas sobre su condición de salud (18). posteriormente, en 1991 reed amplió la conceptualización de la espiritualidad, describiendo la capacidad del ser humano para encontrar significados a través de lo ordinario y lo extraordinario reed estableció que la “espiritualidad se refiere a la predisposición para hacer significados a través de un sentido de conexión con un ser de naturaleza superior o a la existencia de un propósito supremo, superior a uno mismo”, y conceptualizó que es una experiencia humana particularmente relevante en las fases tardías del desarrollo de la vida y en momentos en donde se aumenta la conciencia de la mortalidad (19). en resumen, en la mayoría de los conceptos mencionados la espiritualidad es asociada con un ser superior y un poder mayor que uno mismo. la totalidad, la fe en un poder mayor, y el esfuerzo por el logro de un gran ideal son vistos como la expresión de la espiritualidad en los seres humanos. desde estas dimensiones se concibe entonces una continua interrelación que lleva a la “necesidad espiritual”, que es aquello que siente la persona para mantener, aumentar o recuperar creencias, la fe o llevar a cabo obligaciones religiosas con el fin de llenar vacíos que hay en su interior. la identificación de la necesidad espiritual, según shelly y fish (20), en la mayoría de las personas se orienta a la búsqueda de un propósito o significado como la necesidad de amar, de relacionarse y de perdonar, lo cual tiene una gran trascendencia en la vida de las personas e influye en sus condiciones, modos, y estilos de vida, actitudes y sentimientos respecto a la enfermedad y la muerte. dentro de este contexto teórico, la meta de todo profesional de enfermería es el cuidado comprehensivo del paciente, es decir, visualizándolo como una totalidad, para poder así determinar sus necesidades espirituales (21). lo anterior demuestra cómo la espiritualidad abarca a toda la persona y está presente en las actitudes, los comportamientos y las relaciones y, por tanto, se vive, ya que nace de la experiencia personal, y es un referente del sentido de vida en las personas y su plenitud (22). el desafío está en que la profesión de enfermería se apropie de este aspecto del cuidado en la práctica diaria. para que los profesionales de enfermería puedan brindar un buen cuidado espiritual, deben apoyar a su paciente e identificar y explorar lo que es significativo en sus vidas. además de conocer cuáles son las formas en que ellos se ajustan al dolor y al sufrimiento la meta de todo profesional de enfermería es el cuidado comprehensivo del paciente, es decir, visualizándolo como una totalidad, para poder así determinar sus necesidades espirituales. 261 perspectiva espiritual de la mujer con cáncer l milena alexandra galvis-lópez, beatriz pérez-giraldo de las enfermedades. se deben tener en cuenta, además, los problemas relacionados con “el sufrimiento espiritual” definido como una alteración en el principio vital que integra y trasciende la naturaleza biológica y psicológica del individuo; o experimenta un trastorno en el sistema de valores y creencias que le da fuerza, esperanza y significado a la vida. este aspecto se refleja en la actitud, en el afecto, en sus expresiones verbales, en sus relaciones interpersonales y en el entorno (12). la espiritualidad en la profesión de enfermería implica la preocupación por el paciente en su necesidad de cuidado físico, de información, y su reconocimiento como persona. es la mezcla del arte de la profesión de enfermería con la ciencia humana. la espiritualidad y la enfermedad crónica el padecer una enfermedad crónica no solo afecta física, sino también emocional, social y, a veces, económicamente; la forma en que a un paciente le afecta una enfermedad crónica depende de la enfermedad en particular y cómo repercute sobre su cuerpo, la gravedad de esta y el tipo de tratamientos que requiere (23). las enfermedades crónicas, como el cáncer, no solo alteran al paciente por el proceso de adaptación que implican, sino que pueden producir dificultades económicas, cambiar la visión que la persona tiene de sí misma, y afectar las relaciones con los miembros de la familia y los amigos. los individuos con enfermedad crónica utilizan recursos espirituales tales como: pertenecer a un grupo u organización religiosa, el rezo, la lectura espiritual, la meditación y la conexión con la naturaleza. la espiritualidad es el medio que permite superar estados en la enfermedad y proporciona un sentido o propósito acerca de la vida (24). la espiritualidad y el proceso de afrontamiento de la enfermedad crónica la mayoría de los pacientes atraviesan varias fases en el proceso de asumir que padecen una enfermedad crónica y de aprender a vivir con ella. cuando a una persona le diagnostican una enfermedad crónica en concreto, puede sentir muchas emociones y sentimientos encontrados (23). estos sentimientos forman parte del principio del proceso de afrontamiento. en la etapa crítica de la enfermedad crónica se identifican una serie de reacciones comunes, las cuales están dirigidas a mantener un equilibrio emocional, mantenimiento o conservación de la autoimagen de forma satisfactoria, preservación de las relaciones familiares y sociales, y la preparación para el futuro (23). en esta fase, las personas asumen diferentes estrategias de afrontamiento; la más frecuente es la negación o minimización de la gravedad de la enfermedad y de sus consecuencias; otra estrategia frecuente es la búsqueda de información acerca de la enfermedad y el apoyo social-familiar (23). la espiritualidad se constituye como una forma de afrontamiento para los pacientes, más que una forma de negación o evitación, algunas investigaciones han mostrado que muchos pacientes desean el reconocimiento de esta dimensión (5). la enfermedad, las experiencias del cuidado de la salud y los eventos que a esto se asocian, tienen con frecuencia más de un significado. el significado de enfermar no es estático. algunas veces en la etapa crítica de la enfermedad crónica se identifican una serie de reacciones comunes, las cuales están dirigidas a mantener un equilibrio emocional, mantenimiento o conservación de la autoimagen de forma satisfactoria, preservación de las relaciones familiares y sociales, y la preparación para el futuro. 262 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 puede cambiar a medida que las creencias culturales, los valores e ideologías dominantes cambian. otras veces puede cambiar a lo largo del curso de la enfermedad crónica y se combina con un significado personal de la enfermedad que se deriva de la experiencia de vida de la persona enferma (24). la adaptación a la enfermedad crónica puede ser difícil, pero para ello es posible utilizar estrategias frente a su desarrollo, una es reconocer la espiritualidad. la trascendencia de la enfermedad es importante porque ayuda a la persona a mirar más allá de su estado actual de salud para conectarse con una energía más alta, y utilizar la fuerza de esa conexión para manejar su enfermedad y, en última instancia, alcanzar su propósito en la vida. todos estos aspectos de la espiritualidad contribuyen a encontrar sentido y esperanza, actitudes que ayudan y motivan a la gente a superar sus limitaciones (25). mujer y cáncer el cáncer es una enfermedad que a menudo cambia el futuro, y el punto de vista acerca de la vida y la muerte, por la naturaleza existencial que a esto concierne. aunque muchas personas logran adaptarse a este proceso, ocurre también que los síntomas se prolonguen e intensifiquen, dificultándolo y causando una fuerte alteración ante la inminencia de la muerte. para la mujer hay una multitud de factores estresantes, que van desde el impacto inicial generado por la noticia de la enfermedad, lo imprevisible de su evolución, el pronóstico de la misma, el efecto de la quimioterapia, hasta la toma de conciencia de la posibilidad de morir (26). en muchos casos hay una gran variación del estado de ánimo y su progreso en el tiempo, se percibe una autoimagen negativa por los cambios corporales y las pérdidas, se presenta desesperanza, una pobre respuesta al apoyo recibido, agitación y deseos de acelerar la muerte (26). estudios realizados en los aspectos emocionales de la mujer con cáncer han puesto de manifiesto que la dinámica familiar se ve muy afectada, lo que genera sentimientos de aislamiento, falta de comunicación, falta de apoyo emocional, alteración de la interacción “padres-hijos”, soledad y represión emocional, lo que trae como consecuencia una pérdida afectiva importante, la inestabilidad en el aspecto laboral, y la carencia de planes para el futuro (27). también llega a presentarse restricción de las relaciones humanas, una sexualidad insatisfactoria e incapacidad de manifestar sus sentimientos a los otros. la ansiedad y la depresión suelen ser las respuestas psicológicas más comunes y las que más estudios han generado (28). por otra parte, tratamientos como la radioterapia y la quimioterapia, que pueden conseguir aumentar la expectativa de vida e incluso la curación de la mujer enferma de cáncer, empeoran su calidad de vida, ya que suelen aparecer efectos colaterales negativos, tales como náuseas y vómitos, pérdida de pelo, fatiga y ansiedad, sentimientos de culpabilidad, estados de inhibición y adinamia por todo el componente de rol sociofamiliar que desempeña; asimismo, surge la incertidumbre hacia el futuro, hacia su supervivencia y al desarrollo normal de su actividad familiar, social y laboral, todo lo anterior debido a la gran confrontación existencial sobre la vida y la muerte que se produce como consecuencia de la enfermedad (26). estos aspectos van a ser influidos también por el tipo de cáncer que afecta a la mujer, según se relacione con su género o no. la trascendencia de la enfermedad es importante porque ayuda a la persona a mirar más allá de su estado actual de salud para conectarse con una energía más alta y utilizar la fuerza de esa conexión para manejar su enfermedad y, en última instancia, alcanzar su propósito en la vida. 263 perspectiva espiritual de la mujer con cáncer l milena alexandra galvis-lópez, beatriz pérez-giraldo la mujer con cáncer contextualiza los significados sobre su enfermedad según sus concepciones desde la sexualidad ya que algunas problemáticas de salud son exclusivas del género femenino y están influidas por la percepción que tienen las mujeres de su cuerpo como centro y origen de su enfermedad (26). por lo anteriormente mencionado, la pretensión no debe ser únicamente paliativa, se deben fomentar y fortalecer estrategias de afrontamiento y habilidades que buscan conseguir la tranquila y progresiva adaptación a los cambios de la enfermedad o a la aceptación de la cercanía de la muerte (12, 25). materiales y método el presente estudio tuvo un diseño cuantitativo de tipo descriptivo comparativo de corte transversal. se aplicó la escala de perspectiva espiritual de reed. la muestra se definió estadísticamente después de la realización de la prueba piloto y la constituyeron 100 mujeres entre 18 y 65 años; se conformaron dos grupos para lo cual se utilizó muestreo aleatorio simple a partir de un marco muestral conformado por los registros de las pacientes que asistían a la clínica cancerológica de boyacá, cada uno compuesto por 50 mujeres diagnosticadas con cáncer propio de su género y otro grupo con mujeres diagnosticadas con otros tipos de cáncer, que se encuentran en tratamiento y que voluntariamente accedieron a participar en el estudio. estos grupos se conformaron con la finalidad de establecer la diferencia en la perspectiva espiritual según el tipo de cáncer resaltando que el tema de investigación tiene gran importancia debido a que, en sentido general, la mujer en su integridad física y espiritual tiene un especial cuidado de su salud brindando atención a diferentes partes de su cuerpo. puede ser común que sienta sus senos como el centro de su feminidad. sin embargo, muchas veces ni la propia mujer alcanza a intuir la trascendencia que tienen para sí misma, hasta que se enfrenta a una enfermedad que amenaza su integridad (24). vinculado con el anterior punto, szasz en 1999 (28) señala que es relevante considerar la percepción que tienen las mujeres de su cuerpo como origen de su enfermedad, como espacio donde se manifiesta la identidad de su género, en donde centran el padecimiento y el sufrimiento y, además, lo vinculan con eventos relacionados con la reproducción y la sexualidad, lo que indica que la vivencia del cáncer se percibe desde las experiencias y los significados de su corporalidad, lo que influirá en su proceso de afrontamiento. la aplicación del instrumento tomó en promedio 40 minutos, tiempo para obtener los datos sociodemográficos, desarrollar la escala de perspectiva espiritual y diligenciar el consentimiento informado. la aplicación de la escala fue realizada por la investigadora principal. en todos los casos, se acompañó al participante en la investigación y se permitió que quienes quisieran y pudieran diligenciar su encuesta lo hicieran por sí mismos. el instrumento empleado para la recolección de la información fue la escala de perspectiva espiritual de reed, la cual consta de 10 ítems, que miden las creencias y los comportamientos espirituales de la persona, con una escala likert de 6 puntos, con una puntuación total que puede ir de 10 a 60. las cuatro estudios realizados en los aspectos emocionales de la mujer con cáncer han puesto de manifiesto que la dinámica familiar se ve muy afectada, lo que genera sentimientos de aislamiento, falta de comunicación, falta de apoyo emocional, alteración de la interacción “padreshijos”, soledad y represión emocional. 264 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 primeras preguntas hacen referencia a la frecuencia de actividades espirituales que son practicadas por la persona (meditación y oración privada), valoradas a través de una escala likert que oscila entre nunca y hasta más o menos una vez al día. las seis últimas preguntas hacen referencia a los acuerdos o desacuerdos con relación a diferentes aspectos espirituales (perdón o cercanía con dios), se evalúa también por medio de una escala likert que tiene un puntaje que varía entre extremadamente en desacuerdo hasta extremadamente de acuerdo; ambas subescalas se califican en un rango de 1 a 6 para un puntaje total de 24 la primera y de 36 la segunda. reed examinó la validez del constructo a través del estudio en donde 165 mujeres reportaron fortaleza religiosa asociada con altos puntajes con relación con el instrumento escala de perspectiva espiritual (sps). reed, en 1987, comprobó la validez discriminante a partir del estudio, con tres grupos de pacientes (300 sujetos de estudio): el primer grupo, adultos hospitalizados con enfermedad terminal (100); el segundo grupo, pacientes hospitalizados sin enfermedad terminal (100); el tercer grupo, pacientes sanos no hospitalizados (100), indicando diferencias significativas entre los pacientes con enfermedad terminal y los otros dos grupos de pacientes. este es un instrumento confiable ya que en la literatura científica se encuentran sus aplicaciones en diferentes poblaciones dando un alto margen de confiabilidad en colombia se han realizado dos estudios aplicando la escala de perspectiva espiritual de reed. el primero sobre resiliencia, espiritualidad, aflicción y tácticas de resolución de conflictos en mujeres maltratadas en la universidad de antioquia. la escala de perspectiva espiritual mostró una consistencia interna de 0,8 (30). el segundo estudio, realizado en la universidad del valle sobre resiliencia, con un alfa de cronbach de 0,90 para la escala en general, 0,87 para la subescala de prácticas espirituales, y 0,79 para la subescala de creencias espirituales (31). en el presente estudio, la escala se validó con la realización del análisis del alfa de cronbach con resultados de 0,799 para la base de datos del grupo 1, y 0,763 para la base de datos del grupo 2. los datos de este estudio fueron procesados utilizando el paquete estadístico spss versión 17.0; se empleó estadística descriptiva, principalmente promedios y distribución de frecuencias (32). para describir las características sociodemográficas de la población se utilizó una encuesta identificando 11 aspectos tales como edad, estrato socioeconómico, escolaridad, ocupación, estado civil, diagnóstico, tipo de tratamiento y religión que practica. el análisis estadístico consistió en elegir y aplicar una técnica que permitiera juzgar la hipótesis nula de igualdad de dos promedios; para la prueba de comparación entre grupos se utilizó la prueba no paramétrica test de mann whitney (33). las hipótesis planteadas sobre la diferencia en los niveles de perspectiva espiritual entre los grupos estudiados, o la no diferencia entre ellos (hipótesis nula), fueron verificadas con un nivel de confianza del 95% (valor de p menor o igual a 0,5). el estudio consideró los aspectos éticos (34) referentes a la autonomía, la jusel estudio consideró los aspectos éticos referentes a la autonomía, la justicia, la beneficencia, la no maleficencia, la confidencialidad, el consentimiento informado, la autorización de las instituciones y la del autor del instrumento. 265 perspectiva espiritual de la mujer con cáncer l milena alexandra galvis-lópez, beatriz pérez-giraldo ticia, la beneficencia, la no maleficencia, la confidencialidad, el consentimiento informado, la autorización de las instituciones y la del autor del instrumento, a quien se le solicitó el permiso para la utilización de la escala. resultados y análisis perfil sociodemográfico de la muestra se hizo un análisis descriptivo, principalmente de promedios y frecuencias absolutas (32) de las variables relacionadas con edad, diagnóstico y religión que practica. el perfil sociodemográfico de los dos grupos, según los datos arrojados por la encuesta sociodemográfica, es muy homogéneo y tiene datos muy relacionados que nos indican que se originan en un mismo grupo de población con características similares. la edad promedio de las mujeres participantes para el grupo 1 fue de 52 años y para el grupo 2 fue de 48; en el caso del grupo 1 de mujeres con cáncer propio de su género (seno, útero, endocérvix y ovario), esta edad es en la que según la literatura se detectan en un mayor porcentaje los casos de cáncer de seno (35); para el grupo 2 el cáncer con mayor porcentaje fue el gástrico, lo cual coincide con los reportes del instituto nacional de cancerología que lo ubica con la mayor incidencia tanto en hombres como en mujeres en boyacá (35). niveles de perspectiva espiritual para clasificar a las mujeres según el nivel de perspectiva espiritual se tomaron los niveles establecidos por zavala et al., en su estudio sobre perspectiva espiritual en pacientes diabéticos (7), en el cual presentan los siguientes: bajo nivel de espiritualidad de 10-30 puntos, nivel moderado de 31-45 puntos, y nivel alto de espiritualidad de 46-60 puntos. en la tabla 1 se presenta el promedio de la perspectiva espiritual general que fue de 46,12 para el grupo 1 y 43,92 para el grupo 2, lo que evidencia la similitud de los dos grupos en dicha perspectiva estableciendo un nivel moderado para los dos. en la misma tabla se comparan los niveles de perspectiva espiritual del grupo 1, mujeres con cáncer propio de su género, y el grupo 2, mujeres con otros tipos de cáncer; no se aprecia diferencia significativa en los dos grupos; el promedio de la suma total de los enunciados fue de 46,25 para el grupo 1 y de 43,98 para el grupo 2, con un valor mínimo de 39 para el grupo 1 y de 21 para el 2, lo que ubica un nivel moderado de espiritualidad en uno de los totales del grupo 2, un máximo de 60 para el grupo 1, y de 57 para el grupo 2, en el cual no se alcanzó el puntaje máximo del nivel espiritual que es de 60. lo anterior señala que aunque la diferencia no es significativa, sí se evidencian valores de puntajes más bajos en el grupo 2 en contraste con el grupo 1. los resultados en general son muy similares, y esto es corroborado por el test para la prueba de hipótesis (prueba de mann whitney) de la cual se presentan los resultados a continuación (tabla 2): los ítems con mayor puntaje para el grupo 1 correspondieron al 5: “tratar de obtener perdón es una parte importante de mi creencia espiritual”, con un promedio de 5,24 en el grupo 1, seguido del ítem la edad promedio de las mujeres participantes para el grupo 1 fue de 52 años y para el grupo 2 fue de 48; en el caso del grupo 1 de mujeres con cáncer propio de su género (seno, útero, endocérvix y ovario), esta edad es en la que según la literatura se detectan en un mayor porcentaje los casos de cáncer de seno. 266 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 10: “mis creencias espirituales son especialmente importantes porque responden a muchas de las preguntas que tengo sobre el significado de la vida”, con un promedio de 5,14; estos ítems hacen parte de la valoración de los comportamientos espirituales en la escala. en el grupo 2 el ítem de la escala con mayor puntaje fue el 10, con un promedio de 5,06, seguido del ítem 5, con un promedio de 5,04; estos dos ítems hacen referencia a la valoración de los comportamientos espirituales en la escala. lo anterior señala que en la comparación de los grupos 1 y 2, los ítems con mayor puntaje se relacionan con las actividades espirituales que son practicadas por la persona, tales como la meditación y la oración privada, y evidencian las reflexiones existenciales que se presentan cuando se vive la enfermedad oncológica (8, 5). también presenta un componente de la espiritualidad que hace referencia al significado (como búsqueda del sentido de la vida y de lo que representan la enfermedad, el dolor, etc., para su trascendencia y su felicidad interior) (12). en las tablas 3 y 4 se evidencia un valor más bajo del grupo 2 respecto al grupo 1 en lo correspondiente a creencias, en estos ítems se hace referencia a los acuerdos o desacuerdos con relación a diferentes aspectos espirituales como son el perdón o la cercanía con dios, lo que indicaría un rango menor en el reconocimiento de estos aspectos para este grupo, hecho que afectaría el nivel óptimo de perspectiva espiritual, ya que según la literatura (18) estas creencias son fuentes de soporte y fortaleza interior que promueven al individúo hacia un óptimo nivel de bienestar. las creencias espirituales también ayudan a resolver conflictos internos del individuo aun cuando pueden estar influenciadas o no por los aspectos religiosos, y ayudar a la solución de conflictos en la vida de los seres humanos (18), lo cual puede verse afectado en este grupo. en los ítems que están relacionados con los comportamientos espirituales, aunque la diferencia no es significativa, sí se presenta un puntaje menor en el grupo 2, respecto al grupo 1; en esta parte de la escala se hace referencia a las actividades espirituales que son practicadas por la persona, tales como la meditación y la oración. en el grupo de edad de 18-40 años se presentó el nivel de perspectiva espiritual más alto respecto a los otros dos grupos de edad —en los cuales la perspectiva espiritual se mantiene en un nivel moderado—, considerando que en este grupo se encuentran las mujeres diagnosticadas con cáncer propio de su género (seno, útero, ovario, endocérvix), que aún están en una etapa de vida sexual y reproductiva más activa que los otros dos grupos; según la revisión de la literatura, en estos tipos de diagnóstico y en estas edades, este aspecto puede afectar notablemente el estado de ánimo de la mujer; se presenta además, como se mencionó, una percepción negativa de la autoimagen por los cambios corporales y las pérdidas, desesperanza, una pobre respuesta al apoyo recibido, agitación y deseos de acelerar la muerte (28), lo que afecta el proceso de afrontamiento y puede llevar a la reflexión existencial, lo que hace surgir o incrementar las creencias y los valores espirituales; otro componente importante de la espiritualidad (valores y creencias), ya que la conexión de estos dan el significado de la vida y llevan a la fe, la esperanza, la paz y el fortalecimiento (5). en la comparación de los grupos 1 y 2, los ítems con mayor puntaje se relacionan con las actividades espirituales que son practicadas por la persona, tales como la meditación y la oración privada, y evidencian las reflexiones existenciales que se presentan cuando se vive la enfermedad oncológica. 267 perspectiva espiritual de la mujer con cáncer l milena alexandra galvis-lópez, beatriz pérez-giraldo en este grupo se evidencia que los niveles de creencias, comportamientos y perspectiva espiritual total se encuentran en moderado en los dos grupos. con este ítem se esperaba contrastar la parte de prácticas religiosas con las creencias y los comportamientos espirituales y, asimismo, con la perspectiva espiritual del grupo 1; en este grupo se presenta una leve diferencia en la perspectiva espiritual, entre los que sí asisten a prácticas religiosas y los que no, resaltando una de las dimensiones de la espiritualidad como es la parte de religiosidad. en el grupo 2 la diferencia es mayor dos puntos entre las mujeres que sí asisten a prácticas religiosas y las que no; la perspectiva espiritual total, al comparar los dos grupos, se encuentra en su máximo valor en el grupo 1, lo que se manifiesta en un mayor sentido de trascendencia vertical (de las personas hacia dios, un ser superior o una fuerza superior) que horizontal (de ellas hacia sí mismas, hacia los demás y hacia el entorno).se evidencian algunos componentes de la espiritualidad: la conexión, en este caso con un ser superior, y la trascendencia (12). tanto en el grupo uno como en el dos el mayor porcentaje de la población se clasificó como católica. al hacer la comparación, las católicas no tuvieron la perspectiva espiritual más alta, y en las cristianas se encontró un nivel ligeramente más alto, lo cual nos reafirma que la religión y la espiritualidad son constructos diferentes y no permutables, y se ratifica que la espiritualidad no es prerrogativa de los creyentes, pues puede estar desvinculada de la religión y no ser expresada como una práctica religiosa (5). se observa, entonces, que el tipo de religión que se practique no establece con certeza que una mujer sea más espiritual que otra. discusión puesto que la literatura señala que con la enfermedad oncológica (crónica) se genera un impacto en la espiritualidad, y que esta a su vez tiene efectos en la vivencia de la enfermedad, sería de esperar que la diferencia encontrada entre los grupos fuera mayor. algunos de los argumentos que podrían explicar que el estudio apoye la hipótesis nula, que estableció que no hay diferencias entre los grupos, se enuncian a continuación: en primer lugar, los dos grupos tenían el mismo diagnostico (cáncer) y la diferencia se establecía en el lugar o sistema del organismo que afectaba; en el caso del grupo 1, mujeres con cáncer propio de su género, que se asociaba con su dimensión sexual y reproductiva, y en el grupo 2 a otros tipos de cáncer en otras partes del cuerpo. tal vez en la conciencia de las mujeres de ambos grupos la enfermedad no se asociaba a la parte del cuerpo en la que se desarrollaba el cáncer, sino al diagnóstico de esta enfermedad y su estrecha relación con la muerte (26, 28, 29). es decir, una persona puede encontrar significado y propósito en su experiencia de salud (enfermedad oncológica, sin importar qué parte afecte) que la lleve a la construcción de cambios en la vida y la reorganización de los valores personales, y otra puede no hacerlo. secoli et al. (29), en su artículo “el cuidado de la persona con cáncer: un abordaje psicosocial”, manifiestan que el cáncer no es una enfermedad homogénea; en ella se presentan una enorme variedad de tipos que afectan a las personas en su diel presente estudio aporta nuevo conocimiento a la construcción del cuidado de las mujeres con enfermedad oncológica y señala que una perspectiva espiritual moderada puede ser un potencial para su cuidado integral, en el que la enfermera reconozca sus objetivos en el cuidado de la mujer como un ser total, más que al tipo de cáncer que tiene. 268 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 versidad determinada por la edad, el sexo, el momento de la vida en que esta acontece, el soporte emocional que posee, entre otros, situación que dificulta “englobar en una simple palabra el universo de acontecimientos físicos y mentales”. otra posible explicación es que las edades promedio para los dos grupos oscilaban entre los 45 y los 55 años, en los que la vida reproductiva de la mujer ya está finalizando, y tal vez su dimensión espiritual en relación consigo misma no se ve significativamente deteriorada, por lo cual su perspectiva espiritual no se ve muy afectada. la falta de estudios que muestren y relacionen los niveles de perspectiva espiritual en las mujeres con cáncer en el contexto colombiano y departamental impide hacer un contraste del presente trabajo con otros similares para poder relacionar si el hecho de estar en un contexto de tradición religiosa influye en el significado que hace la mujer de su enfermedad oncológica. conclusiones y recomendaciones en las mujeres con enfermedad oncológica que asistieron a la clínica cancerológica de boyacá en la ciudad de tunja, en los meses de junio a septiembre de 2009, se encontró que el nivel de perspectiva espiritual del grupo 1 es moderado, al igual que el de las mujeres con diagnóstico de otro tipo de cáncer. al comparar la perspectiva espiritual de estos dos grupos no se encontró evidencia estadística que señale diferencias significativas. con base en los datos recopilados en la escala de perspectiva espiritual de reed no se puede afirmar que exista diferencia en la perspectiva espiritual de los grupos estudiados; el presente estudio aporta nuevo conocimiento a la construcción del cuidado de las mujeres con enfermedad oncológica y señala que una perspectiva espiritual moderada puede ser un potencial para su cuidado integral, en el que la enfermera reconozca sus objetivos en el cuidado de la mujer como un ser total, más que al tipo de cáncer que tiene. este estudio hace un reconocimiento de la importancia de explorar la espiritualidad en la mujer con enfermedad oncológica, ya que esta puede convertirse en una herramienta para un mejor afrontamiento y trascendencia de su enfermedad; cuando la enfermera haga este reconocimiento a tiempo podrá guiarlo a fin de ayudar a fomentar su desarrollo espiritual para alcanzar un estado óptimo de bienestar, lo cual le dará un enfoque particular a la práctica y ayudará a la enfermera a reconocer cuál es su aporte en la recuperación de la salud de las personas (5). son pocos los estudios sobre perspectiva espiritual y sus implicaciones en el cuidado de enfermería de la mujer con cáncer, por lo cual es un campo rico en oportunidades para implementar trabajos de investigación en diferentes contextos, regiones e idiosincrasias que permitan contrastar resultados y, al mismo tiempo, incrementar el conocimiento de enfermería para dar un mejor sustento a la práctica. referencias 1. novel g, lluch ty, rourera a. enfermería psicosocial y salud mental. aspectos psicosociales de los cuidados. madrid: barcelona: masson – salvat; 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[consultada el 28 de julio de 2008]. 30. jaramillo d, ospina d, cabarcas g, humpreys j. resiliencia, espiritualidad, aflicción y tácticas de resolución de conflictos en mujeres maltratadas. rev. salud pública 2005, 7 (3): 281-292. 31. canaval ge, gonzález mc, sánchez mo. proyecto resiliencia, espiritualidad y diestrés en mujeres maltratadas. registro 1510. vicerrectoría de investigaciones universidad del valle 2005-2007 (se espera aprobación de artículo en revista colombia médica). 32. polit d. investigación científica en ciencias de la salud. 6 ed. mc graw-hill interamericana; 2000. 33. conover wj. practical nonparametric statistics. 3 ed. wiley and sons; 1999. 34. rumbold g. ética en enfermería. 3 ed. méxico: mcgraw-hill interamericana; 2000. 35. ochoa fl, montoya lp. mortalidad por cáncer en colombia. cuando aumentar no es mejorar. revista ces medicina 2003; 17 (1). 270 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 tabla 1. perspectiva espiritual general de los grupos 1 y 2 fuente: datos del estudio. resultados grupo 1 grupo 2 mujeres con cáncer mujeres con propio de su género otros tipos de cáncer nivel promedio de perspectiva espiritual general 46,12 43,92 valor máximo 60 57 valor mínimo 39 21 desviación estándar 5.956 5.809 número de la muestra 50 50 tabla 2. prueba de la hipótesis para establecer la diferencia de la perspectiva espiritual de los dos grupos fuente: análisis estadístico del estudio. técnica utilizada estadística utilizada hipótesis nula (ho) conclusión test de man-whitney t1, por presentar demasiados empates en la asignación de rangos f (x) = f (y) frente a la hipótesis alterna ho: f (x) ≠ f (y), siendo f(x) la función de distribución para el grupo 1 y f (y) la función de distribución para el grupo dos no existe evidencia estadística para rechazar la hipótesis nula, lo que puede entenderse como la carencia de argumentos para identificar niveles de espiritualidad distintos en los grupos tabla 3. compilación de valores máximos, mínimos, promedios y tamaño de la muestra correspondientes a los ítems creencias espirituales de los grupos de comparación fuente: datos del estudio. resultados grupo 1 grupo 2 valor máximo 24 24 valor mínimo 15 21 valor promedio 17,90 16,68 número de la muestra 50 50 271 perspectiva espiritual de la mujer con cáncer l milena alexandra galvis-lópez, beatriz pérez-giraldo tabla 4. compilación de valores máximos, mínimos, promedios y tamaño de la muestra correspondientes a los ítems comportamientos espirituales de los grupos de comparación tabla 5. compilación de promedios por grupos de edad de creencias, comportamientos y perspectiva espiritual del grupo 1 tabla 6. compilación de promedios por grupos de edad de creencias, comportamientos y perspectiva espiritual del grupo 2 fuente: datos del estudio. resultados grupo 1 grupo 2 valor máximo 36 36 valor mínimo 23 13 valor promedio 28,42 27,4 número de la muestra 50 50 fuente: datos del estudio. grupo de edad promedio promedio promedio perspectiva de edad creencias espirituales comportamientos espiritual espirituales 18-40 35 19,5 30 50 40-60 53 16 26 43 60 y más 62 16 27 42 fuente: datos del estudio. grupo de edad promedio promedio promedio perspectiva de edad creencias espirituales comportamientos espiritual espirituales 18-40 32 16 26 42 40-60 50 17 27 44 60 y más 62 16 26 42 272 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 tabla 7. compilación de promedios del ítem asistencia a prácticas religiosas y nivel de creencias, comportamientos y perspectiva espiritual del grupo 1 tabla 8. compilación de promedios del ítem asistencia a prácticas religiosas y niveles de creencias, comportamientos espirituales y perspectiva espiritual del grupo 2 fuente: datos del estudio. fuente: datos del estudio. asiste a prácticas promedio promedio perspectiva espiritual religiosas creencias espirituales comportamientos espirituales sí 17 28 46 no 16 25 41 fuente: datos del estudio. asiste a prácticas promedio promedio perspectiva espiritual religiosas creencias espirituales comportamientos espirituales sí 16 29 45 no 16 27 43 tabla 9. compilación de promedios del ítem religión y niveles de creencias, comportamientos espirituales y perspectiva espiritual del grupo 1 religión promedio promedio perspectiva espiritual creencias espirituales comportamientos espirituales católica 18 29 47 evangélica 16 26 42 cristiana 19 28 47 t. jehová 20 30 50 273 perspectiva espiritual de la mujer con cáncer l milena alexandra galvis-lópez, beatriz pérez-giraldo tabla 10. compilación de promedios del ítem religión y niveles de creencias, comportamientos espirituales y perspectiva espiritual del grupo 2 fuente: datos del estudio. religión promedio promedio perspectiva espiritual creencias espirituales comportamientos espirituales católica 17 28 44 evangélica 18 26 43 cristiana 16 35 51 t. jehová 13 24 37 00. editorial 2003. año 3 nº 3 • bogotá, colombia octubre 2003 revista aquichan issn 1657-5997 4 l tercer número de la revista aquichan, publicación anual de la facultad de enfermería, está orientado al abordaje de la promoción de la salud y la prevención de la enfermedad desde la perspectiva de cuidado, esencia del quehacer profesional. la práctica de la enfermería y de todas las actividades relacionadas con el cuidado de la salud de las personas, familias y grupos demanda la formación de profesionales idóneos y competentes, con una sólida formación científica, disciplinar, humanística y ética, que permita el abordaje holístico en los procesos sociales y culturales que intervienen en la salud de las poblaciones. los profundos cambios económicos, políticos y sociales, enmarcados en la situación actual del país, han tenido una gran repercusión en las condiciones de vida, salud y bienestar de los colombianos. en medio de este panorama, muchas veces desolador y complejo, resurge de manera significativa el trabajo de los profesionales de la enfermería en la construcción y reconstrucción de nuevas alternativas de salud. uno de los grandes retos de la academia, a través de la formación de nuevos profesionales, es lograr acciones y estrategias impactantes, que desde de la promoción y prevención contribuyan a mantener o restablecer aquellas condiciones determinantes en la calidad de vida. los procesos anteriores deben estar fundamentados en trabajos de investigación y sus resultados, lo cual nos lleva a generar aportes y nuevas rutas en el abordaje del cuidado. en este sentido, la integración docente asistencial y el trabajo cooperativo de pares nacionales e internacionales han contribuido de manera significativa en este proceso. en las últimas décadas, la disciplina de la enfermería ha logrado un importante desarrollo, resultado de los procesos de conceptualización de su quehacer y del aporte de modelos y teorías. se hace necesario que el esfuerzo colectivo de docentes, estudiantes y enfermeras de servicio no se limite a la explicación del proceso salud-enfermedad, sino a la búsqueda de verdaderas transformaciones; por lo tanto, debemos retomar el cuidado más allá de la acción curativa, para llegar integralmente a la persona: “para curar hay que conocer la enfermedad, para cuidar hay que conocer a la persona”. cuidar holísticamente significa: pensar, acoger y asistir. para curar, la persona no es más que la portadora del objeto: la enfermedad; para cuidar, la persona es el objeto en sí mismo. con el compromiso de avanzar en el camino de la calidad, de la búsqueda de la excelencia y frente al desafío de contribuir al desarrollo científico y disciplinar de la enfermería, se pone en circulación este nuevo ejemplar. con la portada, obra del autor impresionista francés george de la tour, quien destaca a la persona, la relación interpersonal y el cuidado enmarcado bajo la luz, símbolo del conocimiento y esencia de la enfermería, hemos querido hacer un reconocimiento al legado de florence nightingale, quien a través del tiempo y más de 130 años de historia de la enfermería ha logrado que su herencia continúe vigente. maría clara quintero laverde nursing theory makes a practice turn in the 21st century. article nursing theory makes a practice turn in the 21st century la teoría de la enfermería da un giro hacia la práctica en el siglo xxi teoria de enfermagem: virada à prática no século xxi 10.5294/aqui.2021.21.4.2 sister callista roy1 1 0000-0002-0064-5517 professor emerita, boston college and mount saint mary's university, united states of america. croyi@msmu.edu received: 04/10/2021 sent to peers: 04/10/2021 approved by peers: 27/10/2021 accepted: 28/10/2021 theme: epistemology contribution to the discipline: provides evidence of the connection between theory and practice by showing that the data for theory is found in the nurse and patient relationship. to reference this article / para citar este artículo / para citar este artigo: roy c. nursing theory makes a practice turn in the 21st century. aquichan. 2021;21(4):e2142. doi: https://doi.org/10.5294/aqui.2021.21.4.2 abstract the author assumes that practice became prominent in nursing theory in the first two decades of the 21st century. the end of the last century saw a burgeoning of literature on what is known as grand theories, their implementation, and evaluation. the era of healthcare quality research began when the institute of medicine issued a report on building a safer health system. at this time, the 21st-century literature in nursing took a distinct turn toward practice, influencing nursing theory. the movement to individualize care acted to further this influence. the nurse and patient relationship is the source of data for knowledge development. established research approaches such as grounded theory and new approaches such as story theory were being used to create nursing theory from practice. grand theory work moved to the development of instruments to measure the effects of theory in practice, such as that of watson and roy. the middle-range theories were developed and seen as closer to and easier to use in practice. the evidence-based practice movement also contributed to the role of theory in practice. these knowledge developments led to nurses having expanded roles in nursing. keywords (source decs): nursing theory; nursing practice; quality of health care; grounded theory; experimental studies, experimental epidemiology. resumen la autora asume que la práctica se volvió prominente en la teoría de la enfermería en las dos primeras décadas del siglo xxi. al final del siglo pasado, se vio un florecimiento de la literatura sobre lo que se conoce como grandes teorías, su implementación y evaluación. además, la era de la investigación sobre la calidad de la atención médica comenzó cuando el instituto de medicina publicó un informe sobre la construcción de un sistema de salud más seguro. en ese momento, la literatura de enfermería del siglo xxi dio un giro distinto hacia la práctica, que influyó en la teoría de la enfermería y el movimiento para individualizar el cuidado actuó para promover esta influencia. la relación enfermera-paciente se convierte en la fuente de datos para el desarrollo del conocimiento. se estaban utilizando enfoques de investigación establecidos, como la teoría fundamentada, y nuevos enfoques, como la teoría de historias, para crear la teoría de la enfermería a partir de la práctica. el trabajo de la gran teoría se trasladó al desarrollo de instrumentos para medir los efectos de la teoría en la práctica, como el de watson y roy. por otra parte, las teorías de rango medio se desarrollaron y se consideraron más cercanas y más fáciles de usar en la práctica. el movimiento de la práctica basada en la evidencia también contribuyó al papel de la teoría en la práctica. estos desarrollos de conocimiento llevaron a las enfermeras a ampliar sus funciones en la enfermería. palabras clave (fuente decs): teoría de enfermería; práctica de enfermería; calidad de la atención de salud; teoría fundamentada; estudios experimentales; epidemiología experimental. resumo neste texto, assume-se que a prática se tornou predominante na teoria de enfermagem nas duas primeiras décadas do século xxi. no final do século passado, viu-se o florescimento da literatura sobre o que se conhece como "grandes teorias", sua implementação e evolução. além disso, a era da pesquisa sobre a qualidade da atenção médica começou quando o instituto de medicina publicou um relatório acerca da construção de um sistema de saúde mais seguro. nesse contexto, a literatura de enfermagem do século xxi deu uma reviravolta diferente no sentido da prática, o que influenciou a teoria de enfermagem, e o movimento para individualizar o cuidado agiu para promover essa influência. a relação enfermeiro-paciente se converteu na fonte de dados para o desenvolvimento do conhecimento. eram utilizadas abordagens de pesquisa estabelecidas, como a teoria fundamentada, e novas abordagens, como a teoria de histórias, para criar a teoria de enfermagem a partir da prática. o trabalho da grande teoria passou ao desenvolvimento de instrumentos para medir os efeitos da teoria na prática, como o de watson e roy. por sua vez, as teorias de médio alcance foram desenvolvidas e consideradas mais próximas e mais fáceis de usar na prática. o movimento da prática baseada em evidências também contribuiu para o papel da teoria na prática. esse desenvolvimento de conhecimento levou os profissionais de enfermagem a ampliar suas funções na área. palavras-chave (fonte decs): teoria de enfermagem; prática de enfermagem; qualidade da assistência à saúde; teoria fundamentada; estudos experimentais; epidemiologia experimental. introduction nursing theory in the 21st century took a decided turn toward nursing practice. coinciding with the founding of the aquichan journal, there are signs of a practice turn for nursing theory taking place in many ways throughout nursing publications. as early as 1969, ellis wrote about the practitioner as a theorist. she noted that the nurse selects an approach, uses it, modifies it, and expands it with every patient (1). ellis pleaded for making nursing theory explicit by having it emerge from practice. unfortunately, these pleas lay dormant for three decades. this delay was noted when i identified the contributions of theoretical work in nursing in the 20th century (1). by the end of the last century, theory developments included maturing of the discipline, clarifying the theoretical focus of nursing as holistic persons with processes and patterns for environmental integration to attain health, a plurality of grand theories for articulating and testing theories in practice and research, identification of the mutual impact of theory and education, major conferences, and contributions globally. by the 21st century, given several influencing factors, the role of practice became prominent in nursing theory. this reflection article aims to identify these factors and examine their effect on nursing as a science and as a profession. factors influencing nursing theory development at the turn of the century, changes in health care brought about significant changes in nursing theory development. in 1999, the united states of america institute of medicine issued a report to err is human: building a safer health system (2). this report ushered in an era of healthcare quality research. growing information technology made it possible to use administrative data to identify preventable adverse events. at the same time, computers went from health care business offices to clinical units. the initial stage of the human genome project was completed in february 2001, which provided a whole new kind of information for knowledge development. patients were brought closer to their own data. nurses in practice were on the front line of these changes. nurses relating concepts into theories responded with a heightened awareness of these changes and put practice central to their thinking. clinical practice as basis of theory development scholars have called theory the carrier of scientific knowledge. in nursing, theory has a pragmatic meaning. the relevant phenomena are explained by describing the patterns, processes, or mechanisms considered to be producing or influencing them in significant ways (3). further, as a social practice, nursing science deals with patterns and processes of human and environment interactions. in any approach to individualize health care, including precision health, the nurse and patient interactions are the key source of data for such care. nursing theory describes the phenomenon of nursing, which occurs in practice as nurses interact with patients. well-established and newer research approaches look at nurse-patient relationships to develop new theories. for example, as a qualitative approach to research, grounded theory has long been used to develop nursing theories for practice. grounded theory was developed in sociology and moved quickly into nursing knowledge development (4, 5). in this approach, the theorist begins with some general ideas about the area of interest. these ideas may be abandoned as the theorist moves back and forth from practice to thinking about practice. observations are made and then coded. this approach is still widely used. for example, alyousef et al. used grounded theory to explore the contributory factors toward childhood obesity and being overweight in saudi arabia and the gulf states (6). more recently, smith and liehr developed story theory from their practice and research experience (7). they found that health-promoting change was fostered when a person told the story of a meaningful event such as teen pregnancy or living through a cardiac event. newman's unitary-transformative world view provides assumptions about persons and their interaction with the environment, which affords connection in the developing story (8). the nurse provides the opportunity for intentional dialogue. the storyteller makes explicit what has been tacit, and this creates moments of ease. with this movement, the person can resolve the health challenge. the authors provide specific guidelines for nurses to use story theory, and at the same time, generalizations are made to create new theories from practice. other developments of the practice turn in nursing theory in the 21st century derive from the theory developments of the last century. as noted, the late 20th century was rich in the creation of what was called grand theories. the work of johnson, orem, king, roy, neuman, rogers, parse, newman, leininger, and watson became widely known and studied (9-18). in the 21st century these theories, derived from practice were implemented and tested in practice. younas and quennell noted that theory-guided practice improves practice by articulating what nurses do and why (8). based on this belief, the author reviewed experimental studies of orem, roy, and peplau conducted in iran, the united states, and turkey (10, 12, 19). among the 35 studies, all study outcomes were improved in 26 studies, and at least one improvement was noted in the remaining nine studies. of the grand theorists, parse, watson, and roy continue publishing related to their theory work. for others, what i have called second-generation theorists have taken over. nursing as a profession and discipline is fortunate that these successors have continued the work of major theorists and made modifications in today's clinical world. for example, taylor extended orem's concepts to families, groups, and communities with self-care deficits and additional conditioning factors (20). parse has published ten editions of an introductory book on her view of nursing as a human becoming, the latest being 2010 and a significant article in 2021 that expands on her central concept of living quality (15,21). watson has updated the basic book on her nursing theory as caring over several years, specifically in 1985, 1999, 2006, and 2008 (22-25). further, she and others have authored related works developing her caritas concepts (11). roy has five editions of her introductory textbook published [the roy adaptation model] in 1976, 1984, 1991, 1999, and 2009. in addition, she has published books in 1999 and 2014 that review research based on the roy adaptation model. with other authors, roy also has numerous articles on the use of the model. relative to our view of theory derived from practice, parse noted that living quality occurs when the human universe is living in the moment of the emerging now (26). parse would thus find new nursing theory in a current nurse-patient relationship. for both watson and roy, the practice turn included the development of instruments to measure patient outcomes. watson's current work focuses on an instrument developed from practice and used in practice and research. scholars have identified the watson caritas patient score® (wcps) as a reliable and valid instrument used in hospitals and health care systems to assess patient perspectives of caring practices of hospital staff (27). measurements from the patient's perspective is an important turn for nursing theory in the 21st century. roy has initiated a research program with the core concept of coping that includes the development and use of the coping and adaptation processing scale: short form (caps: sf) (28). the development of the caps: sf, in particular, reflects the relationship between practice and theory. stress and coping were long used as concepts in psychology. in 2007, aldwin noted that dealing with measurement was still the most controversial issue in the field (29). given the centrality of the concept of coping in the roy adaptation model, roy began working on clarifying this concept through theoretical and empiric work over decades (12). simple interviews with hospitalized patients were her starting point. for patients newly admitted to the hospital, she asked them to describe how they had handled the situation when the doctor told them they had to go to the hospital. probes involved what they thought; how they felt. for patients admitted to the hospital for diagnostic tests, she asked how they had handled the threat of such tests. inferences were made of the coping processes considering the cognator and regulator, the self-concept adaptive mode, and language from a literature review. patients who were in the hospital longer were asked about how they handled being in the hospital. a similar analysis for both groups (n = 10) resulted in 16 different coping processes in the self-concept adaptive mode, six in role function, and four in interdependence. another approach to identifying coping was examining nursing care plans written by student nurses in schools where the roy adaptation model was used as the basis of the curriculum (n = 37). sixteen coping processes were identified in the self-concept mode, 11 in role function, and seven in interdependence in the resulting analysis. in developing a middle-range theory of coping and reflecting on her advanced clinical practice in neuroscience nursing, the theorist developed a total of 72 coping processes (30). two ph.d. students gave the list of strategies along with each one's dissertation work. each study had over 300 subjects. one sample of patients with chronic neurologic deficits filled out the instrument in english in the usa. the second group with cardiac conditions was in central america and used the spanish version. with these large samples, it was possible to develop a 47-item coping and adaptation processing scale. the instrument had good psychometric properties and was widely used. the need to shorten the scale became evident from use with older populations and varying cultures globally. to avoid the limitations of classical test theory (ctt), item response theory (irt) was used to create a 15-item scale that was metrically equivalent across samples while maximizing precision and ensuring adequate content coverage of middle-range theory. the caps: sf has been widely used in both practice and research. the nursing practice influence on this instrument development is clear from the original short interviews with ten patients to the large samples of people with frequently occurring chronic conditions (31). further evidence in the literature of the last 20 years of a turn toward theory related to practice is noted in middle-range theory (mrt) development. middle-range theory had long been identified as significant for nursing knowledge development. however, as late as 1999, chinn and kramer selected middle-range theories in an appendix of the fifth edition of this popular nursing theory book (32). by definition, middle-range theory is closer to practice. theories at this level have a limited number of variables and are limited in scope. they can be used in given practice settings, yet some mrts can be generalized across populations and settings. examples are mishel's theory of uncertainty and pender's health promotion model. in 2014, mcewen and wills noted that the number of mrts developed and used by nurses grew significantly over the previous two decades (33). the authors cite examples of social support, quality of life, and health promotion. smith and liehr edited books on middle-range theories. in the first edition of their book in 2003 (34), eight middle-range nursing theories were presented, and in the 2018 edition of the book, 13 theories (35). in 2010, meleis put together in book form the writings on transition to bring theoretical coherence to this central middle-range concept (36). the level of generality of middle-range theories makes it possible to develop interventions for practice. in addition, mrts are used to generate hypotheses about practice phenomena to be tested in research. another area of literature development that reflects nursing theory related to practice in the 21st century is evidence-based practice. in medicine, the evidence-based practice movement began in the late 1980s. the aim was for practice to be grounded in quantitative research based primarily on randomized clinical trials, meta-analyses, or outcome studies. by the first decade of the 21st century, nurses began to challenge this narrow view of knowledge for practice. based on the nature of nursing, nurse authors called for beginning with questions from practice and using multiple methods of knowledge development. in 2010, melnyk and colleagues offered a simplified problem-solving method to delivering health care that integrates the best evidence from studies and patient-care data combined with clinician expertise and patient preferences and values (37). roy developed criteria for levels of evidence-based practice (12). the theorist recognized that some propositions were unequivocally supported by more than one study, were low risk, and had a high clinical need. these could have a high potential for implementation in practice, given clinical judgments based on the other sources of evidence. for propositions that are supported, but generalizability or risk is unclear and there is high clinical need, further clinical evaluation may be needed before implementation. the theorist recognizes the significant role of practice in knowledge implementation. changes in nursing education in the 21st century also show evidence of a turn toward practice. in 2004, the american association of colleges of nursing (aacn) endorsed a decision to move the preparation necessary for advanced nursing practice from the master's degree to the doctorate level. in 2014, the rand corporation was commissioned to conduct a national study on the doctor of nursing practice (dnp) and found many programs developed and graduates effectively being used on practice and education (38). however, most advanced practice education was still in master's programs. conclusions the 21st century has been rich in knowledge development for nursing. the richness has been enhanced because nursing theory in the 21st century has taken a distinct turn toward practice. this brief review provides clear and convincing evidence from methods used, to the level of theory created, to new practice roles, that the literature shows a decisive turn for theory development to be rooted in nursing practice. this development was needed and has been effective for knowledge development in nursing as a practice and academic discipline. conflicts of interest: none declared. references 1. rosemary e. the practitioner as theorist. am j nurs. 1969;69(7)33. doi: https://doi.org/10.1097/00000446-196907000-00014 2. institute of medicine (us) committee on quality of health care in america. to err is human: building a safer health system. kohn lt, corrigan jm, donaldson ms, editors. washington (dc): national academies press (us); 2000. 3. reed pg. explanatory power and nursing theory. nurs sci q. 2020;33(3):229-233. doi: 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post-baccalaureate doctor of nursing practice program. santa monica, ca: rand corporation; 2015. available from: https://www.rand.org/pubs/research_reports/rr730.html home 17 26 como describen las mujeres.indd 17 claudia cecilia álvarez-franco1 cómo describen el cuidado de enfermería las mujeres que presentaron hemorragia postparto magíster en enfermería materno infantil. profesora asociada. universidad de antioquia. claudiaalvarezfranco@yahoo.es recibido: 29 de mayo de 2012 aceptado: 5 de marzo de 2013 año 13 vol. 13 nº 1 chía, colombia abril 2013  17-26 resumen la hemorragia postparto ocupa los primeros lugares de morbilidad y mortalidad obstétrica en el mundo. el personal de enfermería, profesional y auxiliar, es el encargado de brindar a la mujer y a su hijo un cuidado de calidad durante el trabajo de parto, parto y postparto, ya sea normal o complicado. es fundamental que el personal de enfermería tenga claro los cuidados que las mujeres esperan recibir desde una mirada de cuidado humanizado. objetivo: describir cómo las mujeres, que presentaron hemorragia postparto, perciben el cuidado prestado por el personal de enfermería durante el trabajo de parto, parto y postparto. método: es una investigación cualitativa de tipo fenomenológico interpretativo, basada en la teoría de heidegger. resultados: la población estuvo compuesta por mujeres que tuvieron hemorragia postparto inmediata. luego de las entrevistas, ellas identificaron tres temas: el cuidado como un todo, la otra cara de la enfermera: acciones de no cuidado, y el proceder de las pacientes que condicionan el comportamiento de las enfermeras. para este artículo se abordó el tema del “cuidado como un todo”, en donde las mujeres reconocen el cuidado ofrecido por las enfermeras y auxiliares durante el trabajo de parto, parto y postparto, cuando estas, por ejemplo, están pendientes del bienestar físico y emocional de la madre y del bebé o apoyan a la mujer en su rol maternal. el personal de enfermería también es visto como amigos y como los responsables del personal médico. conclusión: la investigación mostró que las mujeres receptoras del cuidado de enfermería percibieron la importancia del mismo, a través de los comportamientos y acciones de las enfermeras y auxiliares durante el trabajo de parto, parto y postparto. sus narraciones expresan agrado cuando el personal de enfermería ofreció comodidad y bienestar a ella, su bebé y su familia, desde lo físico y lo emocional. también se identificó la reciprocidad que hay entre el comportamiento de las mujeres y el personal de enfermería cuando se ofrece un cuidado humanizado. palabras clave hemorragia postparto, humanización de la atención, atención de enfermería, período de postparto (fuente decs, bireme). 18 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 how women who had postpartum hemorrhage (pph) describe the nursing care abstract post-partum hemorrhage is the worldwide leading cause of obstetric morbidity and death. both professional nurses and attendants are responsible for providing nursing care to mother and child during the labor, delivery and post-partum stages. it is essential for the nursing staff to have a clear understanding of the care women expect from a more humane perspective. objective: describe how women who had postpartum hemorrhage, perceive the care provided by the nursing staff during labor, delivery and postpartum. method: this is a qualitative case-based and interpreted study based on heidegger’s philosophy. results: the women were interviewed upon their release after experiencing immediate post-partum hemorrhage; during the interviews, they identified three main issues: comprehensive nursing care; the other side of the nursing staff: actions leading to lack of care and patient behaviors that condition nursing staff behavior. this article deals with comprehensive care, where women acknowledge the care provided by nurses and nursing attendants during the labor, delivery and post-partum stages such as: caring for the physical and emotional well being of both mother and child; supporting women in their role as mothers; finally, the role of nurses as friends and as professionals responsible for the medical staff. conclusion: the study revealed how women receiving this type of nursing care were able to perceive its importance through the nursing staff’s behavior and actions during the labor, delivery and post-partum stages. their testimonies evidenced pleasure whenever the nursing staff had provided emotional and physical comfort and well being to them, their child and their families. the study also revealed the reciprocity between women’s behavior and that of the nursing staff whenever humane care is provided. key words post-partum hemorrhage, humanization of assistance, nursing care, postpartum period. (source: decs, bireme). 19 cómo describen las mujeres que presentaron hemorragia postparto inmediata el cuidado de enfermería l claudia cecilia álvarez-franco como as mulheres que apresentam hemorragia pós-parto descrevem o cuidado de enfermagem resumo a hemorragia pós-parto ocupa os primeiros lugares de morbidade e mortalidade obstétrica no âmbito mundial. o pessoal de enfermagem – profissional e auxiliar – é o encarregado de dar à mulher e ao seu filho cuidados com qualidade durante o processo de trabalho de parto, parto e pós-parto. é fundamental que o pessoal de enfermagem tenha claros os cuidados que as mulheres esperam receber do ponto de vista do cuidado humanizado. objetivo: a abordagem deste tema surge como produto da pesquisa sobre o significado que as mulheres que tiveram hemorragia pós-parto dão aos cuidados recebidos pelo pessoal de enfermagem durante o trabalho de parto, parto e pós-parto. método: esta é uma pesquisa qualitativa de tipo fenomenológico interpretativo, baseada na filosofia de heidegger. resultados: as mulheres foram entrevistadas depois da alta pela complicação por causa da hemorragia pós-parto imediata, e nestes encontros elas identificaram três temas: o cuidado como um todo, o outro lado da enfermagem e o comportamento dos pacientes que determina a conduta das enfermeiras. para este artigo, abordou-se o tema do cuidado como um todo, no qual as mulheres reconhecem a atenção oferecida pelas enfermeiras e auxiliares durante o processo de trabalho de parto, parto e pós-parto em momentos como: estar ciente do bem-estar físico e emocional da mãe e do bebê; apoiar a mulher em seu papel maternal; a enfermeira como amiga e as enfermeiras como responsáveis do pessoal médico. conclusão: a pesquisa mostrou que as mulheres que recebem cuidados de enfermagem perceberam a importância deles nos comportamentos e nas ações deste pessoal durante o trabalho de parto, parto e pós-parto. seus relatos expressam satisfação quando o pessoal de enfermagem ofereceram comodidade e bem-estar a ela, a seu bebê e a sua família, tanto física quanto emocionalmente. igualmente, identifica-se a reciprocidade que há entre o comportamento das mulheres e o pessoal de enfermagem quando se oferece um cuidado humanizado. palavras-chave hemorragia pós-parto, humanização da assistência, cuidados de enfermagem, período pós-parto. (fonte: decs, bireme). 20 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 introducción la organización mundial de la salud (oms) considera que cada año en el mundo mueren 575.000 mujeres por complicaciones del embarazo, parto y puerperio. el 99 % de estos eventos ocurre en países no desarrollados (1). así mismo, el 75 % de las muertes maternas se deben a causas como hemorragia, infección, hipertensión, parto obstruido, complicaciones del aborto y hemorragia postparto, siendo esta última la principal causa de muerte materna a nivel mundial y la responsable de casi la mitad de las muertes maternas en los países en desarrollo (2). la hemorragia postparto se define como un sangrado anormal de hasta dos horas luego del nacimiento del bebé, y cuya severidad se determina en conjunto con la evaluación de otras manifestaciones clínicas (2). el personal de enfermería puede constituirse en un factor clave para garantizar la calidad de la atención a través del cuidado, que debe estar fundamentado en el respeto por la dignidad y las necesidades de las mujeres y sus familias. así mismo, se debe entender que el concepto de salud tiene un significado diferente para cada persona, dependiendo del contexto, los estilos de vida, la cultura y la situación de salud vivida. por tanto, el cuidado de enfermería para las mujeres durante el trabajo de parto, el parto y el postparto debe estar encaminado a promover el bienestar de la mujer y de su hijo, teniendo en cuenta las necesidades individuales y las complicaciones que se puedan presentar. el cuidado es intrínseco al quehacer de enfermería porque permite la interacción entre el personal de enfermería y la persona sujeto del cuidado, tanto en su aspecto físico, como emocional y social. el concepto de cuidado ha evolucionado a través del tiempo y de las culturas (3), redefiniendo así el cuidado en enfermería y planteando la enfermería como una disciplina independiente que apoya a las personas en los momentos de salud y enfermedad (4). diferentes pensadoras de la disciplina han definido el cuidado desde diversas perspectivas (5). sin embargo, para este artículo se utilizó la teoría de jean watson (6) quien en 1979 definió su filosofía del cuidado como una forma de ver e interpretar el mundo, y concibió el cuidado humano como un proceso de cuidar-sanar, el cual es transpersonal y está dirigido a la promoción de la armonía cuerpo-alma de la persona cuidadora y la persona sujeto de cuidado, integrando los valores y las creencias de cada una. en el cuidado es significativo tanto el conocimiento científico como el conocimiento innato de que cada persona, siendo de gran relevancia, en el contexto científico, la investigación y la preparación como compromiso ético del personal de enfermería. watson desarrolló su teoría de cuidado teniendo en cuenta los siguientes diez factores, también definidos por ella en 1979 (7): 1. formación de un sistema humanístico-altruista de valores. 2. vinculación de la fe-esperanza, buscando promover en las personas sistemas positivos de cuidado que puedan mejorar su salud. 3. cultivar la sensibilidad para uno mismo y para los demás. la enfermera y el paciente tienen que ser conscientes de que existen sentimientos que deben ser aceptados por ambas partes. 4. desarrollo de una relación de ayuda-confianza que permite manifestar sentimientos positivos y negativos con respeto. la expresión de los sentimientos admite desarrollar una relación de confianza, honestidad y empatía. 5. promoción y aceptación de la expresión de los sentimientos positivos y negativos, lo que exige a la enfermera estar preparada para asumir los sentimientos negativos y entenderlos como una situación distinta a las demás. 6. uso sistemático del método científico de solución de problemas para la toma de decisiones. 7. promoción de la enseñanza-aprendizaje interpersonal que facilita que la enfermera enseñe a la persona el autocuidado. 8. provisión de un entorno de apoyo, protección y corrección mental, física, sociocultural y espiritual. 9. asistencia para la satisfacción de las necesidades humanas. la enfermera apoya al paciente en el bienestar físico, emocional y social teniendo en cuenta las necesidades que tienen los pacientes y la misma enfermera. 10. reconocimiento de las fuerzas existenciales fenomenológicas. en el 2008 el proceso caritas surgió de manera adicional, como una revisión a la teoría de watson, el cual busca que la enfermera evidencie la conexión entre el cuidado y el amor, definido este como sentir y mostrar afecto, aprecio y dar especial atención, y que representa generosidad de espíritu, caridad y compasión. 21 cómo describen las mujeres que presentaron hemorragia postparto inmediata el cuidado de enfermería l claudia cecilia álvarez-franco objetivo con esta investigación se buscó entender la percepción de las mujeres respecto a los cuidados ofrecidos por el personal de enfermería, durante hospitalización por la hemorragia postparto. método diseño se utilizó la investigación cualitativa con la metodología fenomenológica interpretativa, según la teoría de heidegger de 1927. esta teoría permite conocer la percepción de una persona con respecto a la vivencia de un evento o experiencia, ya que el sujeto expresa su acontecimiento de forma espontánea. mediante entrevistas en profundidad, el investigador solicita a los participantes descripciones detalladas de la vivencia del fenómeno, las transcribe, y posteriormente analiza o interpreta el texto resultante de estas transcripciones; describe el fenómeno mediante la identificación de los aspectos o elementos que lo componen, y devuelve los hallazgos a los entrevistados para que ellos expresen su conformidad o inconformidad con lo descrito (7). la investigación se realizó con mujeres que fueron atendidas en instituciones de salud, públicas y privadas, de medellín, colombia, con diagnóstico de hemorragia postparto inmediata y que debido a esta complicación recibieron cuidados de enfermeras profesionales y auxiliares. muestra para seleccionar las participantes se utilizó la base de datos de nacer/nodo clap smr/oms-ops que presenta, entre otros, información sobre las mujeres atendidas en los diferentes hospitales de la ciudad de medellín por morbilidad obstétrica severa a causa de una hemorragia postparto, durante el año 2006 y 2007. los anteriores fueron los únicos criterios de selección, y es de anotar que en el momento de la entrevista las participantes ya habían sido dadas de alta. el tamaño de la muestra se obtuvo aplicando el criterio de saturación de datos, que consiste en recolectar información hasta que se llegue al punto de no obtener nueva información. recolección y análisis de la información se contactó a las participantes vía telefónica y se indagó sobre su interés de participar en la presente investigación. en la primera visita se obtuvo el consentimiento informado por escrito, el cual explicaba a la mujer en qué consistía la investigación, la libertad que tenía de elegir participar y de no responder las preguntas que le parecieran inoportunas. posteriormente se realizaron las entrevistas a cada una de las participantes, en total ocho. a cinco de ellas se les realizaron dos entrevistas, y a tres solamente una, porque la investigadora consideró que ya tenía suficiente información. los encuentros se realizaron con seis mujeres en su hogar, con una de las participantes en un parque cercano a su casa por petición de ella y con otra en su sitio laboral. la duración promedio de las entrevistas fue de una hora y treinta minutos. durante las entrevistas, se creó un ambiente de empatía con las mujeres, transmitiéndoles interés, motivación y confianza para que ellas se sintieran tranquilas y pudieran hablar sin restricciones (8). las entrevistas iniciaron con una conversación informal y posteriormente se abordaron las preguntas de interés siguiendo una guía elaborada. sin embargo, la entrevistadora tuvo especial cuidado de procurar una conversación flexible, abierta y siguiendo la secuencia que las participantes establecieron en la conversación. las entrevistas fueron grabadas y transcritas textualmente por la entrevistadora o por una persona con experiencia en esta actividad. así mismo, la transcripción de las entrevistas fue revisada por la investigadora para garantizar que el texto correspondiera con la grabación; también se hizo un registro detallado de los aspectos ambientales y de los comportamientos no verbales de las mujeres durante cada una de las entrevistas, para lo cual se llevó un cuaderno de notas de campo. para el análisis de la información inmediatamente después de transcribir cada entrevista, la investigadora analizó el texto para identificar aquellos aspectos o temas que necesitaban aclaración o ampliación para ser abordados de manera posterior. finalizada la recolección de la información, se realizó el análisis o interpretación profunda de la misma. la investigadora leyó varias veces la transcripción de las entrevistas de cada partici22 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 pante para comprender y describir su historia, con el objeto de descubrir el significado del cuidado proporcionado por el personal de enfermería a cada una de ellas. posteriormente, la investigadora comparó las historias de las participantes para identificar las semejanzas entre cada una de ellas, lo cual permitió establecer los temas y subtemas para describir el fenómeno en estudio. después, la investigadora describió estos temas y subtemas basándose en la información o texto de las entrevistas a profundidad. luego de una primera construcción o descripción de los temas y subtemas, se realizó una reunión con un grupo de cuatro mujeres, conformado por participantes de la investigación y mujeres que tenían la experiencia de la hemorragia postparto, pero que no habían participado en las entrevistas. en este espacio se presentaron los hallazgos de la investigación, pidiendo a las mujeres que validaran dichos resultados, expresando su acuerdo, desacuerdo o sugerencias en cada uno de los aspectos planteados. luego de esta reunión y atendiendo algunas recomendaciones de las participantes, la investigadora continuó la lectura de las historias y entrevistas de las mujeres para poder describir sus vivencias sobre el cuidado brindado por el personal de enfermería. resultados en el estudio participaron ocho mujeres con edades que oscilaron entre 18 y 38 años, que pertenecían a los estratos uno, dos y tres. seis de ellas estaban adscritas al régimen contributivo y dos al régimen subsidiado. siete participantes tenían pareja y de estas, seis compartían la vivienda con su pareja. en cuanto a la paridad, cinco mujeres no tenían más de dos hijos, dos de ellas tuvieron parto gemelar y una presentó ocho gestaciones. las participantes consideraron que había cuidado por parte del personal de enfermería, cuando enfermeras y auxiliares estuvieron atentas a las necesidades de la mujer y de su bebé, lo que pudo contribuir a su recuperación; pues ellas sienten que es un contexto extraño, en el que experimentan cierta debilidad emocional y física para el cuidado propio y el de su bebé. las enfermeras que estaban pendientes del bienestar del bebé y de la madre ofrecieron compañía a la mujer y al bebé durante la hospitalización. este consistió en acciones asociadas no solamente con el suministro de medicamentos o la realización de exámenes diagnósticos o de laboratorio, sino con actividades que proporcionaron comodidad emocional, como por ejemplo hablar de temas cotidianos no relacionados con el estado de salud, sino temas como la familia, las noticias del día y la farándula, entre otros, así como acompañar a la mujer al baño o a la hora de ingerir los alimentos. las mujeres describieron estos momentos de diferentes maneras, como por ejemplo estar pendientes del bienestar físico de la madre y del bebé. para cada una de ellas fue importante que las enfermeras realizaran las labores propias del quehacer hospitalario como el suministro de medicamentos y la toma de muestras para exámenes de laboratorio, pero fue igualmente importante que las enfermeras realizaran de manera adecuada y delicada sus tareas, mostraran especial interés para que los alimentos les llegaran a cada una de las pacientes, se les dieran de manera oportuna y las ayudarán en lo que ellas necesitaban. también fue importante que el personal de enfermería ayudara a la mujer en el momento del nacimiento del bebé, cuando ella estaba agotada y no sentía fuerzas para pujar. otra acción de las enfermeras que tuvo un impacto positivo en las madres fue generarles bienestar después del parto mediante la humectación de los labios con agua y un algodón. ellas ya iban y me colaboraban pues… o era pa’ entrar al baño… o a bañame… o a lo que necesitara, o a comer… (45,6). ellas me colaboraban a darme la comida, y… y, y me daban el fresco todo, pues en ningún momento me decían “no, es que usted se tiene que esforzar”; nunca me decían, pues nunca me llegaron a decir eso… (45,6). me decía “¿qué querés?”... “eh, voy a ir allí a traerte una gelatinita o alguna cosa”… porque a mí me dio hiperémesis, yo vomitaba mucho… (242,2). la categoría estar pendientes del bienestar emocional, fue percibida por las mujeres participantes cuando las enfermeras se preocupaban de aliviar con medicamentos analgésicos a tiempo el dolor que sentían, les preguntaban frecuentemente por su comodidad, les realizaban los procedimientos con cuidado, retiraban elementos o equipos que eran innecesarios y que generaban molestias, les daban información sobre el estado de salud del bebé y les ayudaban con el cuidado de este. estas acciones de las enfermeras generaron en las participantes una sensación de seguridad y de que ellas eran valiosas e importantes, lo cual fue percibido por las mujeres como algo que favorecía la relación madre-hijo. durante la hospitalización, el cuidado del recién nacido fue percibido por las mujeres como una responsabilidad exclusiva de 23 cómo describen las mujeres que presentaron hemorragia postparto inmediata el cuidado de enfermería l claudia cecilia álvarez-franco ellas. no obstante, las actividades realizadas por las enfermeras con el bebé como bañarlo, alimentarlo y cambiarle el pañal fueron consideradas por las mujeres como cuidados que les proporcionaban bienestar emocional a ellas porque favorecían el vínculo con sus bebés y las tranquilizaba. es decir, las mujeres asignaron una importancia significativa al cuidado que las enfermeras dispensaron a los bebés, pues para ellas esto fue apoyarlas en su rol maternal. además, las mujeres consideraron que las enfermeras las reemplazaban en el cuidado del bebé cuando ellas no podían estar con sus hijos por causa de la hemorragia. este especial cuidado disminuyó la angustia de la madre y contribuyó con su tranquilidad y recuperación. para la mujer era importante saber que su hijo no estaba desprotegido ni que sus cuidados estaban a la deriva, y por lo tanto contar con el apoyo de la enfermera en este caso fue muy significativo. algunas mujeres participantes asignaron un gran valor al apoyo que ellas y sus familias recibieron durante todo el proceso del trabajo de parto, parto y postparto. este apoyo se manifestó cuando la enfermera mantenía una comunicación continua con la familia, explicándoles cómo evolucionaba el trabajo de parto y cuál era el estado de salud de la madre y del bebé. es decir, las mujeres valoraron positivamente el hecho de que la enfermera fue un canal de comunicación entre ella y su familia en la sala de espera. las mujeres también percibieron el apoyo de la enfermera cuando, durante el trabajo de parto, ellas les recordaban la forma correcta de respirar y controlar el dolor en cada contracción y hacían el seguimiento del estado del bebé; igualmente cuando apoyaban el desempeño de la mujer al aproximarse el momento del parto buscando que la madre tuviera un nacimiento sin complicaciones y con compañía. el actuar de las enfermeras fue considerado por algunas de las participantes como el comportamiento de una amiga que hace parte de la familia, ya que satisfizo las necesidades de ellos y procuró el bienestar de la mujer al propiciar el primer contacto con el bebé luego del parto. las enfermeras también realizaron los procedimientos evitando ocasionar dolor o sufrimiento a las mujeres, estuvieron pendientes de su bienestar y el del bebé y compartieron sus alimentos con la madre a la que no le traían comida. hablar sobre temas diferentes al padecimiento y a lo que sucedía en el hospital, incluyendo sentimientos, gustos, lo que les molestaba o preocupaba a las mujeres, es decir hablar de otras cosas, permitió que surgiera un conocimiento mutuo, y fue una razón más para que las enfermeras fuera consideradas como amigas. me decían cosas, me cantaban, un poco de cosas y estaban bastante pendientes de mi allá en el hospital y acá en la otra clínica cuando me trasladaron; allá cada ratico, allá no se despegaron del lado mío, cada rato pasaba una doctora [enfermera] allá a verme y a ver cómo estaba, preguntaba cómo me sentía, cómo había dormido (79,11). siempre era, era, era, doña…, mi amiguita, y esto por aquí pues, muy nobles, a ver nobles que pues como que se ponían en el lugar de uno… (635,3). las mujeres participantes asignaron a las enfermeras la responsabilidad de garantizar que lo que hacían los médicos era lo que ellas necesitaban. las enfermeras estaban encargadas de buscar al médico para obtener la información necesaria acerca del estado de salud de la mujer y de la forma como su cuerpo se recuperaba de la hemorragia y del periodo de postparto. dieron especial importancia a una comunicación continua entre la enfermera y el médico, que facilitara la toma de decisiones en aspectos como el tratamiento y la realización oportuna de procedimientos o intervenciones para prevenir complicaciones a la mujer y al bebé. "o sea, ellas deben de acosar a los médicos, si ven que uno… que uno no pasa… que vos estás x tiempo en la camilla y nada...". las mujeres consideraron además que la enfermera era la responsable directa de conservar el orden y la ética del personal de salud, evitando los excesos en todos los actos o intervenciones, como por ejemplo los docentes y estudiantes de diferentes áreas de formación, garantizando que cada procedimiento fuera supervisado por el docente para que no representara riesgo para la mujer o su hijo. la enfermera debía estar pendiente de cada uno de los procedimientos, medicamentos o decisiones que se tomaban para intervenir a la mujer y su bebé durante el parto. discusión las participantes expresaron que los comportamientos y las acciones de las enfermeras las hicieron sentir bien a ellas, a sus bebés y a los miembros de la familia, en lo físico y emocional. ade24 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 más, las mujeres vieron a una enfermera auténticamente presente en el cuidado de la mujer y su bebé, y que además entendió que este cuidado se debe extender a los otros miembros de la familia. en otras palabras, las mujeres percibieron expresiones del factor de cuidado proveer un ambiente de apoyo y protección para ellas y sus bebés; la integración de la familia en dicho proceso aporta al cumplimiento del mencionado factor. de los cuidados físicos y emocionales que procuraron las enfermeras, las participantes resaltaron: interés en aliviar el dolor, preguntarle por su estado, realizar los procedimientos con delicadeza, hablar de temas cotidianos no relacionados con el estado de salud, estar pendiente de la alimentación, cogerle la mano en el momento del parto, humedecer los labios en el periodo postparto e informarle sobre el estado del bebé, administrar a tiempo los medicamentos, retirar los equipos innecesarios y tomar muestras para exámenes de laboratorio. estas acciones se corresponden con los siguientes procesos y factores de cuidado caritas: desarrollar y mantener una relación de ayuda-confianza, crear un ambiente de sanación a todo nivel, estar auténticamente presente con la persona en cuerpo y espíritu, y asistir a la persona en la satisfacción de las necesidades humanas. cuando la enfermera toma la mano de la mujer o le humedece los labios le está demostrando su apoyo y compromiso para ayudarla durante el trabajo de parto, parto y postparto. mediante las acciones mencionadas, las enfermeras también aplican factores de cuidado como promoción y aceptación de sentimientos positivos y negativos, uso sistemático del método científico y uso creativo del sentir y el conocer para la solución de problemas. la respuesta de la enfermera ante las expresiones de dolor y angustia experimentadas por la mujer durante el parto indica que esta reconoce que el trabajo de parto y el parto son procesos que generan dolor, miedo e incomodidad en ella, así como también acepta comportamientos de las pacientes que otros podrían considerar inadecuados e inaceptables; como por ejemplo que ellas recurran frecuentemente al personal de enfermería para obtener compañía, que solicite de manera repetida la terminación rápida del trabajo de parto por el dolor que siente, o que de manera reiterada manifieste su imposibilidad para terminar el trabajo de parto, entre otros. el bienestar físico y emocional que experimenta la mujer cuando la enfermera satisface sus necesidades fisiológicas y emocionales al aliviarle el dolor mediante el suministro de medicamentos, evitarle dolor adicional al realizarle los procedimientos con delicadeza, proporcionarle alimentos, mitigarle la sed mojándole los labios o cogerle la mano en el momento del parto, mejora la capacidad de afrontamiento de la mujer y disminuye los tiempos del proceso, redundando en beneficios físicos para la mujer y su bebé (9). es decir, si la enfermera no realiza estas acciones que promueven el bienestar de la mujer, la duración del trabajo de parto y parto puede ser mayor debido a la angustia, preocupación, incomodidad y malestar que experimenta la mujer. la percepción que tiene la mujer de la enfermera como una amiga en quien puede confiar puede verse como expresión de la auténtica relación de ayuda-confianza que se establece entre ambas. la enfermera amiga mantiene la comunicación entre la mujer y los miembros de su familia que esperan el desarrollo de los acontecimientos en el hospital, acompaña y apoya a la mujer durante el trabajo de parto y el parto y está dispuesta a compartir sus alimentos con ella. esta percepción también evidencia el proceso caritas, estar presente, apoyar la expresión de sentimientos negativos y positivos, pues la actitud de la enfermera indica a las mujeres su disposición a comprender y tolerar su comportamiento sin importar cuál sea. las mujeres participantes además consideraron valioso el apoyo de las enfermeras en el desempeño de su rol maternal, lo que indica que las enfermeras ponen en práctica el factor de cuidado promoción de la enseñanza-aprendizaje interpersonal, que ofrece a la enfermera la posibilidad de comprometerse con un proceso de enseñanza-aprendizaje desde la subjetividad de la mujer y no solamente desde lo que ella considera necesario para que la mujer desempeñe su rol de madre. el apoyo ofrecido por las enfermeras para que la mujer pueda cuidar a su bebé en aspectos como cambiar el pañal, el baño y la alimentación también se puede considerar como aplicación de los factores de cuidado desarrollo de una autentica relación de ayuda-confianza. la práctica de cada uno de los factores de cuidado antes mencionados representa un acto de amor de la enfermera hacia la mujer, que refuerza la confianza y el bienestar mutuos dados los efectos del cuidado tanto para la persona receptora (la mujer) como para la persona proveedora del cuidado (la enfermera). a pesar de que estas consecuencias no han sido suficientemente estudiadas, el meta-análisis de la literatura efectuado por swanson (9) muestra que los efectos del cuidado para la persona receptora incluyen múltiples indicadores de incremento en el bienestar 25 cómo describen las mujeres que presentaron hemorragia postparto inmediata el cuidado de enfermería l claudia cecilia álvarez-franco general, entre los que se mencionan a) efectos positivos en la autoestima, el estado anímico, la auto eficacia, la satisfacción y la sanación física dado que el cuidado libera las fuerzas interiores y el potencial sanador de la persona, b) beneficios sociales como menor dependencia y por ende una mayor capacidad de la persona receptora del cuidado para tomar decisiones y asumir su cuidado, a la par que aumenta su confianza en el cuidador. entre las consecuencias para la persona proveedora del cuidado se han reportado: bienestar personal y profesional derivados del sentirse valioso e importante, realizado, y con un propósito en la vida. profesionalmente, la práctica del cuidado provoca en la enfermera un incremento de la capacidad intuitiva y de sentir empatía, aumento en el juicio clínico, la capacidad de cuidar, la satisfacción con el trabajo y la conexión con colegas y pacientes. la responsabilidad que las mujeres asignaron a las enfermeras de estar pendiente de lo que hace el personal médico y los estudiantes puede relacionarse con el proceso caritas creación de un ambiente de sanación físico y espiritual. las mujeres vieron el compromiso que tiene enfermería de velar por la seguridad de ellas y de los bebés durante todo el proceso del parto, lo cual incluye asegurar que el personal médico esté atento a todos los cambios que ocurren y de esta manera las decisiones que se tomen sean oportunas y acordes con la situación que vive la mujer. además, la enfermera tiene el deber de cerciorarse que el docente acompañe a sus estudiantes en cada una de las actividades que realicen, minimizando así los riesgos que puede generar para la mujer y su bebé cuando son atendidos por una persona en proceso de aprendizaje. respecto al cuidado, la enfermera que logra que la mujer que acaba de tener un hijo se sienta bien física y emocionalmente, genera sentimientos positivos hacia sí misma y puede estar promoviendo su futuro desempeño del rol materno al fortalecerle la autoeficacia para cuidar a su hijo, así como una actitud positiva hacia el personal y las instituciones de salud, lo cual garantizará mejores posibilidades para la salud mental y física de ella y del hijo. la relación intersubjetiva que se establece en estos casos, según halldorsdottit (10) es a) bioactiva o sustentadora de vida; es la clásica relación enfermera-paciente caracterizada por la benevolencia, amabilidad y preocupación que mantiene los niveles de vida y energía en el paciente y b) biogénica o generadora de vida, que involucra estar totalmente presentes con amor sanador, reconocer al paciente como persona y establecer intimidad respetuosa y compasiva con él, lo que lleva a la libertad espiritual de las personas. conclusiones las mujeres participantes manifestaron que es importante un acompañamiento permanente en los aspectos relacionados con los tratamientos y procedimientos que ayudan a su recuperación de manera oportuna y delicada, e igualmente importante que el personal de enfermería se interese por la alimentación, manejo del dolor, retirada de elementos innecesarios y otros cuidados que puedan generar comodidad y le ayuden a tranquilizarse para continuar el proceso de recuperación. en reuniones, es recomendable hacer particular énfasis en el actuar del personal de enfermería y el cuidado humanizado, pues según lo expresaron las participantes, estos cuidados disminuyen las molestias fisiológicas del trabajo de parto, parto y postparto. otro hallazgo relacionado con la hemorragia es que este parece no cobrar relevancia en los relatos, pues las participantes se enfocaron principalmente en las atenciones recibidas por enfermería, más que en la causa de su condición médica 26 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 referencias 1. organización panamericana de la salud (ops). boletín informativo de la organización panamericana de la salud. [en línea]. [consultado el 1 de junio de 2006]. disponible en: http://www.paho.org/spanish/dd/pin/ahora04_mar04.htm 2. ministerio de la protección social y universidad nacional de colombia sede bogotá d.c. guías de promoción de la salud y prevención de enfermedades en la salud pública. guía 8. guía de atención del parto. 2007. bogotá d.c. (colombia): ministerio de la protección social. [en línea]. [consultado el 19 de febrero de 2011]. disponible en: http://www.nacer. udea.edu.co/pdf/libros/guiamps/guias08.pdf 3. collière m.f. promover la vida: de la práctica de las mujeres cuidadoras a los cuidados de enfermería. españa: mc graw hill; 1993. p 236, 240. 5. acebedo urdiales s, rodero sánchez v. la mirada de watson, parse y benner. para el análisis complejo y la buena práctica. índex de enfermería 2007; 16 (56): 40-44. 6. watson j. nursing: the philosophy and science of caring. colorado: university press of colorado; 2008. p. 15-27. 7. morse jm. asuntos críticos en los métodos de investigación cualitativa. medellín: universidad de antioquia; 2003. p. 447. 8. castillo espitia e. la fenomenología interpretativa como alternativa apropiada para estudiar los fenómenos humanos. investigación y educación en enfermería 2000; 18 (1): 27-35. 9. swanson, k. what is known about caring in nursing science? en: hinshaw as, fleetham s, shaver jlf. handbook of clinical nursing research. thousand oaks: sage, 1999. p. 31-60. 10. watson j. halldorsdottir model: biocidic to biogenic (caritas) caring. en: nursing: the philosophy and science of caring. colorado: university press of colorado, 2008. p. 85. 237 250 tendencias de investigacion en salud.indd 237 adriana isabel delgado-bravo1 miguel naranjo-toro2 rocío castillo3 yudy basante4 mildred rosero-otero5 tendencias de investigación en salud. análisis y refl exiones 1 enfermera. especialista en cuidado del paciente en estado crítico. coordinadora de investigación, universidad técnica del norte, ecuador. isadelgado99@gmail.com 2 msc. rector, universidad técnica del norte, ecuador. ment1957@yahoo.com 3 licenciado. subdecana, facultad ciencias de la salud, universidad técnica del norte, ecuador. infogravitar@hotmail.com 4 msc. directora de posgrados en salud, universidad mariana, colombia. ybasante@umariana.edu.co 5 msc. coordinadora de investigación, universidad mariana, colombia. mrosero@umariana.edu.co recibido: 23 de abril de 2012 enviado a pares: 23 de abril de 2012 aceptado por pares: 23 de octubre de 2013 aprobado: 25 de noviembre de 2013 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 237-250 para citar este artículo / to reference this article / para citar este artigo delgado-bravo ai, naranjo-toro m, castillo r, basante y, rosero-otero m. tendencias de investigación en salud. análisis y reflexiones. aquichan 2014; 14(2): 237-250. resumen objetivo: analizar el estado de la investigación en salud en colombia, ecuador y en latinoamérica; sus implicaciones, la importancia de esta para tratar de impactar en políticas y estrategias de salud que mejoren el nivel de vida de las poblaciones y los asentamientos urbanos. método: se realizó una revisión de la literatura en las bases de datos latinoamericanas scielo, redalyc, bireme y pubmed en los últimos 8 años. resultados: se evidencia la trascendencia de las universidades como instituciones, que tienen la obligación de influir en lo social, lo humano y lo cultural, y transformen en entornos ligados a programas sociales y de gobierno en pro de una comunidad. igualmente, se hace un análisis de las políticas de investigación, de organismos rectores y sus implicaciones en las instituciones formadoras de recurso humano a nivel superior. conclusiones: es necesario fortalecer la reflexión crítica en los espacios académicos comprometidos con la transformación de las condiciones colectivas de la comunidad en los procesos de salud, enfermedad, promoción, prevención y atención, que tocan los hilos de la conciencia, afirmando que el individuo y la colectividad son responsables de “cuidar su salud”, mediante el abordaje transdisciplinario, teniendo en cuenta la normatividad ética que rige las investigaciones; fortaleciéndola mediante la consolidación de redes, divulgando los hallazgos. palabras clave tendencias, investigación, salud, enfermería, américa latina (fuente: decs, bireme). 238 aquichan issn 1657-5997 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 237-250 trends in health research: analysis and reflections abstract objective: analyze the state of health research in colombia, ecuador and latin america, its implications and the importance of health research in attempting to impact health policies and strategies that will improve the standard of living in urban communities. method: the study involved a review of the literature contained in the latin american databases scielo, redalyc, medicine ® and pubmed during the last eight years. results: it provides evidence on the importance of universities as institutions that are obliged to influence social, human and cultural aspects and become environs linked to social and government program developed in the interest of a community. research policies, governing bodies and their implications in institutions of higher learning are analyzed as well. conclusions: it is necessary to strengthen critical thinking in academic circles that are committed to transforming the social conditions of the community in processes concerning health, disease, promotion, prevention and care. in doing to, it is important to affect awareness by affirming that both the individual and the community are responsible for their “health care,” through a trans-disciplinary approach that takes into account the ethical standards governing research and strengthens it by consolidating networks and reporting research findings. key words trends, research, health, nursing, latin america (source: decs, bireme). 239 tendencias de investigación en salud. análisis y reflexiones l adriana isabel delgado-bravo, miguel naranjo-toro, rocío castillo, yudy basante, mildred rosero-otero año 14 vol. 14 nº 2 chía, colombia junio 2014 l 237-250 tendências de pesquisa em saúde. análise e reflexões resumo objetivo: analisar o estado da pesquisa em saúde na colômbia, equador e na américa latina, suas implicações, a importância desta na tentativa de impactar políticas e estratégias de saúde que melhorem o nível de vida das populações e dos assentamentos urbanos. método: realizou-se uma revisão da literatura nas bases de dados latino-americanas scielo, redalyc, bireme e pubmed nos últimos oito anos. resultados: evidencia-se a transcendência das universidades como instituições que têm a obrigação de influenciar no âmbito social, humano e cultural, e de se transformar em ambientes ligados a programas sociais e de governo em prol de uma comunidade. além disso, faz-se uma análise das políticas de pesquisa, de organismos diretivos e de suas implicações nas instituições formadoras de recurso humano em nível superior. conclusões: é necessário fortalecer a reflexão crítica nos espaços acadêmicos comprometidos com a transformação das condições coletivas da comunidade nos processos de saúde, doença, promoção, prevenção e atendimento, afirmando que o indivíduo e a coletividade são responsáveis por “cuidar da sua saúde”, mediante a abordagem transdisciplinar, que considera a normatividade ética que rege as pesquisas, fortalecendo-a por meio da consolidação de redes que divulgam as novas constatações. palavras-chave: tendências, pesquisa, saúde, enfermagem, américa latina (fonte: decs, bireme). 240 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 introducción es importante analizar la investigación en salud (1), lo que implica a futuro considerar aspectos del pasado y del presente a partir de su diferenciación como campo de conocimiento que ha evolucionado desde la detección de factores de riesgo inmediato, biológico, en la producción de enfermedades, hasta la explicación de cómo influye en los determinantes sociales producto de las formas de organización de las sociedades contemporáneas. los conceptos han evolucionado y hoy se entiende la salud como un recurso para la vida y no como el objetivo de la vida, en el cual estar sano es “la capacidad […] para mantener un estado de equilibrio apropiado a la edad y a las necesidades sociales” (2). las representaciones y prácticas de salud no son hechos aislados ni espontáneos, tienen un desarrollo y una ubicación en el tiempo y en el espacio, en estrecha relación con la realidad económica, política, social y cultural de una comunidad o de un grupo social. por ello, la problemática de la salud no debe afrontarse en forma individual, sino dentro de la sociedad de la cual hace parte cada persona. desde esta perspectiva, el modelo por trabajar es la triada agente-huésped-medioambiente, los que participan en procesos de interacción recíproca. este es considerado como el modelo epidemiológico que hoy por hoy aún persiste tratando de identificar el elemento causante del desequilibrio del bienestar de la persona o de una comunidad como tal. históricamente, el conocimiento en salud ha sido construido sobre las bases experimentales del método científico establecido por las ciencias naturales, con el predominio del enfoque positivista expresado en el modelo flexneriano, permanece aún como elemento epistemológico y metodológico, prueba de ello es considerar el aspecto social como un elemento anexo y secundario, y no como componente integral de la enfermedad (3). en américa latina, con la introducción de la educación como una premisa fundamental a partir de políticas de gobierno y de universidad se emprendieron actividades relacionadas con la salud y la educación. no obstante los esfuerzos realizados, que son innegables, aún persisten condiciones de desigualdad y miseria que influyen notablemente sobre la salud, que por ende son generacionales, en donde se perpetúan estas condiciones de iniquidad social. el enfoque médico-biológico ha tenido un peso preponderante dada su capacidad explicativa (4) en el nivel individual, y por los aportes científicos que fielmente ha construido para entender y resolver problemas de salud en los individuos; sin embargo, el traslado mecánico de explicaciones e intervenciones hacia los niveles particular y general, es decir, hacia los grupos y las colectividades humanas, ha mostrado su insuficiencia para explicar y generar intervenciones evidenciando la necesidad de incorporar otras racionalidades y cuerpos conceptuales. en estas condiciones en el ámbito social, se perfila que la contribución de las ciencias sociales es aún escasa, los modelos conceptuales de que se dispone son incompletos y las explicaciones no logran permear el arraigado discurso natural biológico; por ello, el debate en torno a la dimensión social sigue siendo un espacio prolífico para avanzar en propuestas que, sin ignorar los aportes existentes, indaguen en los planos conceptual, metodológico y empírico para mejorar nuestra comprensión del problema y especialmente para generar propuestas de acción que permitan incidir en los problemas de salud de los grupos humanos. pensar la dimensión del cuidado a los colectivos desde una perspectiva amplia y positiva abre la posibilidad de orientar el cuidado hacia el desarrollo humano entendido como “el proceso de construcción de los sujetos individuales y colectivos, dentro de unas condiciones históricas y culturales específicas, ser sujeto significa tener conciencia de sí, de sus acciones, sus características y circunstancias”. el sujeto adquiere conciencia de sí mismo y del mundo que lo rodea para transformarlo (4). rojas soriano (5) afirma que “la investigación es una búsqueda ordenada de conocimientos, coherente, de reflexión, analítica, confrontación continua de los datos empíricos y del pensamiento abstracto, a fin de explicar los fenómenos de la naturaleza”. por esta razón, para la formación en las profesiones y los servicios de salud es necesario además entender, conocer y marcar “la tendencia de investigación” de acuerdo no solo con las necesidades sociolaborales, sino también con las necesidades de desarrollo humano y social más allá de lo que se tiene en el presente. la investigación para la salud debe ser contemplada como una herramienta adecuada para fortalecer y evaluar los determinantes económicos, sociales, históricos y culturales de la salud, para permitir una mejor articulación con otros ámbitos como la economía, la ciencia y la tecnología, así como también aprovechar y enriquecer los planes de desarrollo tanto regionales como nacionales. es así como el panorama mundial de la investigación 241 tendencias de investigación en salud. análisis y reflexiones l adriana isabel delgado-bravo, miguel naranjo-toro, rocío castillo, yudy basante, mildred rosero-otero (6) para la salud debe estar concentrado en los problemas globales teniendo en cuenta su impacto en la sociedad. en la mayoría de los países de latinoamérica, en vía de desarrollo, difícilmente pueden lograrse las metas propuestas en los objetivos de desarrollo del milenio. la reducción de la mortalidad materna e infantil son los objetivos que más lejos están de obtenerse, la desnutrición es el “objetivo olvidado”, con gran impacto en niños menores de cinco años y madres embarazadas; existe, además, un gran porcentaje de enfermedades transmisibles y no transmisibles. los cambios demográficos tienen un gran impacto; en los últimos cincuenta años se duplicó la población del mundo, que volverá a duplicarse en las próximas décadas; en 68 países más del 40% de la población es menor de 15 años. desde 2007, y por primera vez en la historia, la población urbana es más numerosa que la rural; pero las ciudades carecen de infraestructura y servicios, lo que aumenta el riesgo de enfermedades transmisibles. el calentamiento global está provocando un aumento de los desastres meteorológicos, con mayor impacto en los países en desarrollo. bajo este panorama, en 1990 la comisión de investigaciones sanitarias para el desarrollo recomendó que estos países invirtieran al menos el 2 % del presupuesto nacional de salud en investigaciones y en el fortalecimiento de la capacidad de investigación, y que al menos el 5 % de la ayuda para proyectos y programas del sector de la salud procedente de organismos nacionales e internacionales se destinara a estos propósitos. los ministros de salud de más de 58 países, reunidos en la cumbre ministerial de investigación en salud realizada en méxico, en el 2004, formularon la declaración de méxico sobre investigaciones sanitarias, donde instaron a los gobiernos nacionales a establecer y aplicar una política nacional de investigación sanitaria. en el 2008 se realizó la otra cumbre de ministros, en donde se esperaba que los países hubieran dado cumplimiento a estos preceptos internacionales. sin embargo, en esta misma cumbre ministerial se reconoció que para alcanzar las metas del milenio se requiere, por una parte, superar el desbalance de la producción de conocimiento orientado a los problemas de salud que afectan mayoritariamente a las poblaciones de los países en desarrollo y, por otra, cerrar la creciente brecha entre el conocimiento existente y la acción en salud (7). dado lo anterior, este artículo pretende hacer un ligero esbozo de cómo se encuentra la investigación, sus implicaciones, y la importancia de esta para tratar de impactar en políticas y estrategias de salud que mejoren el nivel de vida de las poblaciones y los asentamientos urbanos; asimismo, analiza la trascendencia de las universidades como instituciones que tienen la obligación de influir en lo social, lo humano y lo cultural, para que de alguna forma se transformen entornos ligados a programas sociales y de gobierno en pro de una comunidad. igualmente, se hace un análisis de las políticas de investigación de organismos rectores y sus implicaciones a nivel de las instituciones formadoras de recurso humano a nivel superior y otros grupos investigativos. método se realizó una revisión de la literatura científica en las bases de datos scielo, redalyc, bireme y pubmed, desde el año 2004 hasta la actualidad. los criterios de inclusión se basaron en publicaciones del habla hispana y visibles en bases de datos que nos aportaron en la historia y evolución de investigación . el resultado de la búsqueda fueron 46 referencias bibliográficas incluyendo la de organismos internacionales, abarcando europa, latinoamerica y a nivel nacional, cuyos elementos aportan a los conceptos históricos y actuales y tendencias en la investigación, tanto en colombia, ecuador, como en algunos países de latinoamérica. resultados los resultados de la revisión permiten identificar unos antecedentes históricos y las implicaciones de la investigación en salud. antecedentes históricos: en la década de los cincuenta, algunos países de américa latina expresan de manera más orgánica la preocupación por promover y fortalecer la capacidad de investigación científica (8). así, se crean organismos estatales con este fin en países como argentina y brasil, en respuesta a iniciativas de científicos de alto nivel. la orientación inicial de estos organismos, fuertemente influenciada por la comunidad científica vinculada a universidades, es la de fortalecer la capacidad de investigación a través de becas y subvenciones a proyectos, teniendo como preocupación central la calidad científica de los mismos. a partir de la mitad de la década de los sesenta y particularmente en la década de los setenta, estimulados por recomendaciones de conferencias auspiciadas por la organización de las naciones unidas para la educación, la ciencia y la cultura (unesco) y la organización de estados americanos (oea), diversos países crean sus organismos centrales. a diferencia de la tendencia anterior, estos organismos no se denominan consejos de investigación, sino de ciencia y tecnología, y no se vinculan 242 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 a los ministerios de educación, sino a los de planificación. estos cambios de nombre y de ubicación no son triviales; al contrario, reflejan el reconocimiento de la necesidad de una relación más estrecha entre la ciencia y la tecnología con la planificación del desarrollo económico y social. en esa época surge también el concepto de sistema de ciencia y tecnología (c&t), con miras a buscar la coordinación entre las distintas instituciones que actúan en estos campos. a fines de la década de los setenta empiezan a aparecer indicios de limitaciones de ese enfoque, por los conflictos generados debido a las resistencias de la comunidad científica a la influencia creciente de economistas y planificadores en el proceso de elaboración de las políticas científicas. el propósito de crear un sistema de c&t orgánicamente articulado con las políticas de desarrollo económico y social nunca se ha cumplido, a pesar de las reiteradas manifestaciones de esa intención en planes y programas de desarrollo de la mayoría de los países de la región. con excepción de algunos éxitos puntuales, las políticas en este campo siguieron orientadas fundamentalmente al fortalecimiento de la oferta, es decir, fueron dirigidas a apoyar con recursos públicos proyectos y grupos de investigación, sin que se lograran establecer mecanismos de articulación institucional entre la investigación, el desarrollo y la producción de bienes y servicios. en los años noventa, una serie de cambios en los ámbitos mundial y regional tanto a nivel macroeconómico como en la dinámica del desarrollo científico-técnico, determinan nuevas tendencias en la organización y el desarrollo de la actividad científica en américa latina y el caribe, agregándose en el caso de la c&t en salud, la influencia de los cambios en los perfiles demográficos de morbimortalidad y de organización de la atención a la salud. por otro lado, la globalización de la actividad económica, la constitución de megamercados, el aumento de la participación en el mercado de bienes intensivos en tecnología y el establecimiento de patrones de competitividad basados en el dominio de nuevas tecnologías son algunas de las tendencias a nivel mundial que vienen teniendo un gran impacto en la aceleración del cambio técnico, promoviendo cambios institucionales, acceso mundial a innovaciones, alianzas entre redes, y el fortalecimiento de los mecanismos internacionales de protección de la propiedad intelectual. implicaciones de la investigación en salud situada en la confluencia de las políticas de c&t y de salud, en la organización y el desarrollo de la actividad científico-tecnológica en esta área, surge la influencia de esos determinantes generales a los cuales se agregan los cambios sectoriales específicos. algunos de esos son los nuevos problemas derivados de la transición demográfica y epidemiológica, el impacto sobre la salud de las modificaciones en las condiciones, los estilos de vida de individuos y grupos sociales, y las implicaciones políticas y económicas de los cambios en la organización y el financiamiento de los servicios de salud. debe destacarse también que los servicios e insumos para la salud, además de su función fundamental de contribuir a mejorar la situación del individuo o de las colectividades, adquieren cada vez más una dimensión económica y tecnológica, constituyéndose en un sector privilegiado para el desarrollo, la incorporación y la adaptación de nuevas tecnologías de interés para otros sectores, como las biotecnologías, la microelectrónica, la química fina, los nuevos materiales, entre otras. tratar estos temas exige no solamente el desarrollo de capacidades científico-técnicas, sino también profundos cambios en las características de la comunidad científica en salud y en los arreglos institucionales que permitan el desarrollo, la difusión y la utilización de los conocimientos y las tecnologías. algunos de estos cambios ya están en curso. el campo de la c&t en salud viene dejando de limitarse al proceso de investigación desarrollado por médicos en el ámbito de los servicios de salud o las escuelas de medicina. la investigación en salud se acompaña de la ampliación del universo de problemas y de la diversificación de disciplinas, enfoques, tipos de investigación, formación profesional de los investigadores, del ámbito institucional donde se desarrollan las investigaciones, los mecanismos de difusión e incorporación de conocimientos y tecnologías (9). de acuerdo con la divulgación de los productos de investigación, la publicación en países como colombia ha tenido resultados bastante positivos en los últimos años, así lo refleja el estudio de lópez-jaramillo (10) para departamentos como santander. sin embargo, los esfuerzos no han sido suficientes ya que el informe de educación superior en iberoamérica de 2006 muestra que en ciencias de la salud en 2003, países como australia publicaron 644 artículos, brasil reportó 122, mientras colombia llegó solo a 5 (11). en colombia, en las últimas décadas en ciencias de la salud se han diseñado algunos estudios sobre producción científica y tendencias en investigación que todavía no son comparables con la producción de otros países (12). 243 tendencias de investigación en salud. análisis y reflexiones l adriana isabel delgado-bravo, miguel naranjo-toro, rocío castillo, yudy basante, mildred rosero-otero es importante destacar que en colombia en las últimas décadas hay estudios que parten de evidencias documentales, que no permiten visualizar las fases evolutivas de la investigación, lo que sí se observa en otros países como brasil, argentina, méxico y chile, pero se supone que presenta características similares con estos países. un informe realizado conjuntamente entre el ministerio de salud y el consejo nacional de salud en ecuador, a través de su comisión de ciencia y tecnología, registro oficial 87 de 23 de agosto 2005, con base en el acuerdo ministerial 209, y publicada en el registro oficial 292 de 11 de marzo de 2008, mediante acuerdo ministerial 066, establece la política de investigación en salud, cobrando total vigencia para el país, siendo de aplicación obligatoria para todos los actores que forman parte del sistema nacional de salud (13). en el informe sobre competitividad de 2011 la onu, señala que en los países de américa latina existen siete veces menos investigadores que en los desarrollados; de los cuales en desarrollo e investigación, ecuador ocupa el puesto 121 de 127 países. sin embargo, del total de 139 países analizados bajo distintos índices, ecuador se ubicó en el puesto 105 de índice de competitividad. otros datos del informe señalan que en la relación industria-universidad estamos en el puesto 122, y en la calidad de instituciones de investigación científica estamos en el puesto 139, es decir, el último (13). en este contexto, y dado que los indicadores bibliométricos son un método eficaz para el análisis de la actividad de las comunidades científicas de un país, el ministerio de salud pública y el consejo nacional de salud desarrollaron el portafolio de prioridades en investigación de salud en ecuador, partiendo precisamente de una argumentación técnica sobre la realidad del país (13). según la información recogida por pellegrini, la magnitud de la producción científica total latinoamericana es casi insignificante es del 0,97 % del total de artículos publicados en el mundo. a su vez, esta escasa producción se concentra en un número reducido de países de américa latina. argentina, brasil, méxico y venezuela aportaron para ese mismo año el 73,8 % de las publicaciones científicas de la región, y 78,6 % en 1984. el 90% de los artículos registrados como producción científica están concentrados en los países de argentina, brasil, méxico, entre los años de 1973 y 1992. de los cuales, el 28,1 % proviene de argentina; el 32,9 % de brasil, el 29 % de méxico. esta concentración presenta una tendencia al aumento durante este periodo. tomando los dos años extremos, observamos que argentina y brasil que respondían por 57 % de los artículos en 1973, pasan a contribuir con 68 % en 1992 (9). el grado de concentración de la producción científica entre los seis países —brasil, argentina, méxico, chile, venezuela y colombia— según las tres áreas —biomédica, clínica y de salud pública— no es homogéneo. la investigación clínica, que es la de mayor tradición en la región, se distribuye de manera más uniforme, mientras las investigaciones biomédica y de salud pública presentan un alto grado de concentración en brasil y argentina, responsables por cerca de 70 % de los artículos publicados en cada una de estas dos áreas. los autores de brasil representan el 60,7 % de los 1.107 artículos de salud pública, con tendencia a incrementar. en cuanto a áreas temáticas de las publicaciones, en la investigación básica colombia se mantiene con una participación de 47,9 % (ic: 95 %) y la investigación epidemiológica registra una participación de 29,1 % (ic: 95 %). para el mismo periodo la participación de la investigación en sistemas de salud fue de 13,5 % (ic: 95 %), y la de investigación clínica de 9,6 % (ic: 95 %) (14). según pellegrini, la distribución de los artículos por área, muestra el predominio del enfoque individual sobre el poblacional en el análisis de los problemas de salud; el 2,7 % de los artículos fueron clasificados como investigación de salud pública, mientras la investigación clínica responde por 53,4 %, y la biomédica por 43,9 %. cuando se analiza el promedio de citaciones recibidas por artículos, la situación de la investigación en salud pública es todavía peor. mientras el promedio de citaciones de los artículos de los seis países citados es de tres por artículo (menos de la mitad del promedio de citaciones recibidas por el total de artículos de la base de isi que es de 7,78 %), los artículos de investigación biomédica reciben un promedio de 4,03 % y los de salud pública de 1,61%. no obstante lo anterior, la tendencia a lo largo del periodo es de un crecimiento relativo de la investigación en salud pública y de la investigación biomédica, con la consecuente disminución de la importancia relativa de la investigación clínica. este último hecho es bastante significativo y motivo de preocupación, dado que la investigación en salud pública incluye la investigación epidemiológica y de servicios de salud, fundamentales para la toma de decisiones sobre políticas de salud. por 244 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 la diversidad de situaciones y problemas a nivel poblacional, la capacidad de investigación en salud pública debería estar ampliamente difundida, hecho que no se advierte, por lo menos en la producción de excelencia registrada en la base del institute for scientific information (isi). sin embargo, se observa que recursos públicos destinados para la ejecución de proyectos y grupos de investigación no logran aún establecer mecanismos claros de articulación institucional entre la investigación, el desarrollo y la producción de bienes y servicios en cuanto a presupuesto investigativo se refiere. es aquí donde surge la necesidad de articular en investigación los campos disciplinarios que abordan una problemática, que ha marcado la necesidad de trabajar en conjunto para dar respuesta a la serie de interrogantes que se plantea frente a un determinado problema, esto hace que haya un diálogo entre las disciplinas con prácticas transformadoras que logran tocar los hilos de la conciencia de colectividades para poder transformar entornos y comunidades mediante vivencias, experiencias, estilos, anécdotas que necesariamente deben ser repetitivas e instauradas como estilos de vida (15). en colombia, al igual que en otros países de latinoamérica, varios escenarios han favorecido la puesta en la agenda pública de algunos de los problemas más importantes de la investigación en salud, como la pertinencia, la articulación de los resultados de la investigación al proceso de toma de decisiones y los retos analizados desde una visión prospectiva. se ha visto la conveniencia de reorientar y fortalecer la investigación en salud, de manera tal que las agendas de investigación obedezcan a las necesidades nacionales y sus resultados sean efectivamente utilizados en generar conocimiento social a través de la investigación. en cuanto a estas iniciativas, desde hace algunos años también se viene planteando por parte de diversos actores la urgencia de formular una política que oriente la investigación en salud. en el año 2004, colciencias promovió un proceso de construcción de lineamientos para una política de investigación en salud pública con el apoyo de la red nacional de investigación; paralelamente, esta experiencia permitió la formación inicial de una masa crítica en nuestro país (16). frente a este panorama de la investigación en salud es necesario promover el uso de la evidencia científica en la toma de decisiones y el diseño de políticas para reducir las brechas de conocimiento mediante el fomento del aprendizaje y la investigación. asimismo, es importante considerarla como una herramienta adecuada para alcanzar las condiciones más favorables a fin de que haya un desarrollo integral tanto en lo social como en lo económico, político y cultural; es por esta razón que las áreas fundamentales de la investigación y la innovación, en el sistema nacional de ciencia, tecnología e innovación (sncti), son indispensables para este despliegue y actúan como plataforma para el lanzamiento de nuevas propuestas competitivas de colombia. la visión hacia el 2019 tiene como propósito “producir, difundir, usar e integrar el conocimiento para contribuir a la transformación productiva y social del país”, proponiendo soluciones a problemas sociales fundamentales como son el empleo, la seguridad, la pobreza y la salud, mediante el apoyo al desarrollo científico-tecnológico y la innovación. el plan nacional de salud pública 2007-2010 enfatizó la necesidad de generación de conocimiento a través de la investigación de problemas prioritarios en salud, buscando la solución de estos a corto, mediano y largo plazo, tarea que fomentan conjuntamente el ministerio de la protección social y colciencias, con los recursos del fondo de investigaciones en salud (fis). en consecuencia, se reconoce a la ciencia, la tecnología y la innovación como las bases para el incremento de la productividad y competitividad, para lo cual se debe contar con los recursos suficientes para la generación, el uso y la apropiación del conocimiento necesario para la transformación productiva y social que requiere adelantar el país, así como el fortalecimiento en las universidades, lo cual se consideraría un asunto de “supervivencia política”. en este sentido, la primera conferencia latinoamericana sobre investigación e innovación (17) debe atender las prioridades de salud de los países y contribuir al desarrollo equitativo en américa latina. pese a lo anterior encontramos que “la industria ha robado el protagonismo a la universidad en la generación de la innovación y la tecnología, debiendo importar el conocimiento para su desarrollo” (18), lo que nos lleva a reflexionar que es necesario incrementar los recursos en investigación tanto presupuestalmente como el recurso humano destinado a esta, asumiendo como reto la responsabilidad social de avanzar en el conocimiento, la transformación del entorno y la respuesta de las universidades frente a las diversas problemáticas del medio que la rodea. sin embargo, para ferrer y pelekais las universidades se siguen comportando como instituciones conservadoras, por lo que se necesita adoptar nuevos enfoques con procesos de innovación en forma continua (19). 245 tendencias de investigación en salud. análisis y reflexiones l adriana isabel delgado-bravo, miguel naranjo-toro, rocío castillo, yudy basante, mildred rosero-otero más allá de que la investigación ha tomado auge y empoderamiento, se ha identificado una dispersión de intereses temáticos que dificultan la acumulación del conocimiento y, consecuentemente, la elaboración de teorías y marcos de comprensión e interpretación que contengan la fortaleza suficiente para afectar de alguna forma la estructura curricular, la formulación de políticas institucionales y publicas, así como también las líneas de investigación. es imprescindible, para quienes hemos tenido la experiencia de dirigir y participar en la investigación, aunar todos los esfuerzos para diseñar y proponer alternativas que la incrementen estableciendo una dinámica académica de trabajo estrechamente vinculada con los entes territoriales, a fin de lograr recursos económicos o fuentes de financiación, tan precarias en los ámbitos universitarios —se destina tan solo el 2 % del producto interno bruto (pib)—; en realidad, la inversión calculada en el año 2006 para la investigación en colombia fue de tan solo el 0,25 % (20) del pib, siendo menor que la empleada por chile de 0,7 % (21) de su pib. por otra parte, no se vislumbra una mejor situación en relación con el número de investigadores, porque se asume que solo para 2016 se completaría el número de personas que se necesitan. por otro lado, se requiere diseñar proyectos de investigación que cumplan con los criterios de orden científico, técnico y ético en su elaboración, que reflejen un proceso sistemático, organizado, que responda y lleve al avance de la ciencia en cualquier campo de estudio de la salud, bajo los principios de protección, seguridad y respeto por los seres humanos (22). de esta manera, es necesario realizar una evaluación de la producción científica y de las tendencias en investigación, con un monitoreo y evaluación de aspectos éticos, científicos y técnicos, mediante el diseño e implementación de métodos, procesos y procedimientos que garanticen, en gran medida, el seguimiento de la puesta en marcha, ejecución y cierre de los proyectos de investigación, logrando resultados con altos estándares de calidad, sin dejar a un lado la posibilidad de promover incentivos a los investigadores. respecto a esta productividad, también es importante mencionar que si bien la ciencia de esta comunidad científica requiere de un lenguaje especializado para tener la precisión y exactitud que se esperan de la ciencia, se sugiere un lenguaje cotidiano que facilite la comunicación y divulgación, sin perder la esencia del contenido, los conceptos y las teorías (23). este crecimiento en las actividades de investigación y desarrollo prevé dentro de los sistemas nuevos saberes y ciencias, así como también recurso humano con maestrías y doctorados, movilizando un flujo de proyectos dentro de un sistema de financiación, comercialización, demanda creciente de la producción intelectual, consolidándose a niveles de excelencia, nueva tecnología, nuevo conocimiento, patentes y, por ende, la protección de la propiedad intelectual. según colciencias, la investigación debe contribuir a solucionar problemas prioritarios de salud a partir del enfoque de los determinantes sociales de esta área que afectan el proceso salud-enfermedad de las poblaciones basadas en el enfoque de riesgo, control y prevención de enfermedades, promoción en la salud y calidad de vida. por tanto, la investigación es un elemento de transformación social, y es en este ambiente donde se puede comprender el papel que juega la (i+d) como un componente fundamental de la innovación de productos y procesos, tanto en empresas establecidas como en nuevos negocios de base tecnológica, tipo spin off o start up, con posibilidades de comercialización (24). en la asamblea mundial de la salud celebrada en 2004, el director general de la organización mundial de la salud (oms), doctor lee jong-wook, pidió que se estableciera la comisión sobre estos determinantes mediante recomendaciones basadas en evidencia, que van dirigidas a la revisión sistemática y construcción de metaanalisis de ensayos clínicos randomizados, para determinar el manejo de tratamiento y evaluación de intervenciones; sin embargo, también se ha proyectado este tipo de revisiones en la investigación cualitativa dando paso a los estudios metaetnográficos (25, 26) y políticas apoyadas en acciones, con la finalidad de mejorar la salud y disminuir las inequidades sanitarias (27). en ese contexto la oms, en la asamblea general del 2004, lanza la directriz de trabajar en los determinantes sociales y económicos de la salud, en donde se trata de aplicar el conocimiento científico con relación a las causas estructurales de problemas en salud (28). entre los determinantes identificados tenemos: ingresos y nivel social, redes de apoyo social, educación, empleo, condiciones de trabajo, entornos sociales, entornos físicos, prácticas de salud personales y aptitudes de adaptación, desarrollo social del niño, características biológicas y genéticas, servicio de salud, y género y cultura. estos determinantes críticos para la salud se toman a partir de la formulación de un conjunto de doce factores que sirven de marco actual para comprender las instancias críticas por abordar para la mejora de la salud (29). igualmente, se retoma el término de inequidades sociales con base en un estudio realizado por la universidad de las naciones unidas en el año 246 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 2006, donde se señala que el 10 % de los más ricos concentra la riqueza de cerca del 85 % del planeta, y la mitad de la población mundial tiene tan solo el 1 % de la riqueza. todo este conjunto hace que se determine la situación de salud-enfermedad y la búsqueda constante del equilibrio y el bienestar. porter afirma que la investigación le da la potencialidad de competir como nación mediante la innovación y las mejoras en el medio empresarial, de gestión y de servicios (30). por tanto, la universidad tiene como finalidad lograr que la investigación pueda aportar al desarrollo social, económico y cultural de una sociedad y, por ende, al mejoramiento de las condiciones de vida de una población específica. para delimitar mejor la función de la investigación en la universidad, mintrom (31), sustentado en las ideas de frischmann y piore, identifica cuatro elementos fundamentales: entradas de la investigación. transformaciones. resultados de la investigación y subproductos. desarrollo de productos y servicios. el modelo vincula la docencia, la administración y el servicio con los stakeholders (32). igualmente, la evidencia científica se debe traducir en políticas y acciones en beneficio de una comunidad, tratando de disminuir las inequidades sociales que influyen en las formas de vida individual y colectiva; para esto es necesario que se unan las disciplinas a fin de abordar las problemáticas de la comunidad, desde su respectivo conocimiento (15). aquí subyacen como aspectos o principios transversales a los niveles de intervención las consideraciones por el contexto, la participación ciudadana en las decisiones y la acción intersectorial que sustentan acciones efectivas. para ello es necesario utilizar métodos como la medicina basada en la evidencia (mbe) (33), una respuesta natural a la necesidad de crear un nuevo modelo de asistencia en salud capaz de integrar los resultados sólidos y clínicamente útiles de las investigaciones que tienen lugar en el sector, con la práctica clínica diaria, con miras a lograr una atención de alta calidad, soportada en los avances más recientes en las áreas de la biomedicina, química, tecnología, humanidades, etcétera. la medicina basada en la evidencia no es más que el uso concienzudo, explícito y juicioso de la mejor evidencia existente para tomar decisiones sobre el cuidado de pacientes. existen varias propuestas para la clasificación de las evidencias, la más conocida y tal vez la más sencilla es la del us preventive task force, que clasifica las evidencias en tres niveles: 10 ievidencia obtenida a partir de, al menos, un ensayo aleatorio y controlado, diseñado de forma apropiada. ii1. evidencia obtenida de ensayos controlados bien diseñados, sin aleatorización. 2. evidencia obtenida a partir de estudios de cohorte o casocontrol bien diseñados, realizados preferentemente en más de un centro o por un grupo de investigación. 3. evidencia obtenida a partir de múltiples series comparadas en el tiempo con intervención o sin ella (34). por tanto, la medicina basada en la evidencia no es más que la manifestación particular de un nuevo paradigma en el sector de la salud inmersa en la gestión de la calidad y del conocimiento. la evidencia es un pilar tan fuerte en este modelo, como la satisfacción del cliente en el modelo de calidad y ambos se integran en un modelo mucho más eficaz de atención al paciente, como lo afirma acevedo (35) en su escrito “construcción metodológica para la enseñanza de la disciplina en enfermería, aspectos históricos y reflexiones”, donde cita a lewis et al. y afirma: la práctica basada en evidencia […] es el uso concienzudo, explícito y crítico de la información derivada de la teoría basada en la investigación para tomar decisiones sobre la administración de cuidado a individuos de grupos de pacientes y en consideración con las necesidades y preferencias individuales. frente a estos cambios es necesario ampliar la conciencia de la necesidad de un mejor conocimiento de los mismos a través de la investigación. conclusiones los resultados de este análisis permiten concluir que es necesario fortalecer la reflexión crítica en los espacios académicos y formar profesionales (mediadores estratégicos) con capacidades teóricas y competencias técnicas, comprometidos con la transformación de las condiciones colectivas de la comunidad en los procesos de la salud, la enfermedad, la promoción, la prevención y atención, impulsando procesos de cambio y transformaciones significativas que toquen los hilos de la conciencia, afirmando que el individuo y la colectividad son responsables de “cuidar su salud, el medioambiente, la sociedad y familia” (36). el análisis de facto247 tendencias de investigación en salud. análisis y reflexiones l adriana isabel delgado-bravo, miguel naranjo-toro, rocío castillo, yudy basante, mildred rosero-otero res a partir de la propia estructura social implica trabajar en función de estos eventos que inciden en la forma de vida, “factores tales como migración, educación, nutrición, trabajo y empleo, vivienda, y su componente más evidente: la pobreza, significan un gran desafío para la investigación en la medida en que exigen un abordaje transdisciplinario y un complejo esfuerzo metodológico” (37). de la misma forma, es pertinente rescatar lo que afirma el profesor héctor darío abad, de la facultad de salud pública de la universidad de antioquia: “los profesionales del sector salud se han dedicado a lo técnico y han descuidado lo político, por esta razón son otros los que toman las decisiones y definen las políticas del sector salud”, estas sabias palabras implican un reto para todas las profesiones de la salud y exigen que nos responsabilicemos por la parte de legislación vigente, a fin de hacer un replanteamiento en la proyección que se tiene como profesión, un reto para no limitarse y adaptarse a los cambios en el sistema de salud. con lo anterior es necesario contar con profesionales de salud fortalecidos como gremios en enfermería y medicina, integrantes de una sociedad civil, comprometidos en lo político y social, promotores de bienestar individual y colectivo con conocimiento de los derechos y deberes en salud de una población (38). se sugiere igualmente capacitar a los funcionarios de acuerdo con las necesidades detectadas en los resultados de investigación, empoderando a la empresa, el estado y la universidad. así mismo, los grupos de investigación deben divulgar los hallazgos encontrados en la misma, con la finalidad de incrementar la masa crítica del país, mejorando sustancialmente la calidad de vida de la población e impactando sobre los determinantes sociales, que son condicionantes de vulnerabilidad de una población. sin lugar a dudas es importante recordar un valor agregado a la investigación, como es la responsabilidad social, la cual propende por la solución de los principales problemas de salud y sus determinantes en la sociedad. en ese escenario surge la gestión pública como un desafío adicional frente a los procesos de globalización y desarrollo de la sociedad del conocimiento. ello genera la necesidad para la gestión pública de enfrentar dos nuevos desafíos adicionales: la transversalidad y la intersectorialidad, entendiéndose la primera como la atención especial a los grupos minoritarios y marginados de la sociedad, y la segunda como la relación de diferentes sectores tanto públicos y privados. estos son los habituales desafíos que debe asumir la gestión pública de cualquier estado en cuanto a la implementación de políticas encaminadas a la solución de problemas como la pobreza, la delincuencia, el desempleo, la exclusión, la salud y la educación, para responder a las demandas emergentes (39). de esta forma es prioritario resolver las inequidades presentes en el plan obligatorio de salud, que se ven reflejadas en la unidad de pago por capitación (upc), en donde se reconoce un valor de pago por servicios que se puede evidenciar en la calidad de los mismos, y la falta de garantía de avances en salud publica en el país, a la vez que se restringen acciones de promoción y prevención útiles para mantener comunidades sanas (40). los indicadores bibliométricos buscan medir la cantidad y el impacto de las publicaciones científicas dentro de toda la investigación en términos de cantidad y citaciones. estas, y la obtención de patentes, son los indicadores resultados de investigación y desarrollo experimental así como también han sido usados para medir la capacidad científica y de conexión al mundo de la ciencia en países desarrollados y en desarrollo, aunque colombia continúa rezagada en comparación con la media de otros países latinoamericanos que presentan similitudes en sus condiciones sociodemográficas (41). a todo lo mencionado se debe agregar el imprescindible cumplimiento en cuanto a la normatividad ética que rige las investigaciones, en donde se vigile la aplicabilidad de la resolución 8430 de 1993 y la declaración de helsinki de 1964, para guiar a los médicos mediante los comités de bioética; este es un recurso indispensable para garantizar la integridad ética de la investigación en humanos y es esencial para el desarrollo de la capacidad de respuesta de un país a la necesidad de producir conocimiento (42). además, estos comités buscan alcanzar objetivos fundamentales de ética en la investigación científica que son defender la dignidad, los derechos, la seguridad y el bienestar de todos los participantes de una investigación bajo un principio de equidad y justicia. por otra parte, una de las funciones es determinar si la evaluación de nuevos procedimientos, métodos o hipótesis en humanos supera el dilema riesgo-beneficio, en especial en el contexto de la investigación clínica (43). nancy milio, profesora de la universidad de michigan, ha escrito sobre salud pública y reitera la relación entre las decisiones de las personas sobre cuidado y la situación de salud con opciones establecidas de políticas públicas y corporativas. este planteamiento es semejante al de daniel callahan al definir la bioética como la disciplina que va desde la angustia privada y los 248 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 dilemas individuales que enfrenta el personal de salud hasta las decisiones públicas y sociales de ciudadanos y legisladores cuando tratan de planear políticas equitativas en salud (44). asumir el reto de la construcción de indicadores cuantitativos y cualitativos positivos con relación a la salud y el desarrollo humano permitirá realizar estudios socioepidemiológicos por grupos, localidades y regiones con características económicas y de desarrollo humano y social que logren impactar en política pública desde las realidades sociales, con sus necesidades y sus determinantes en la sociedad, que hacen de esta una comunidad única con características propias y, por ende, con 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(2). disponible en: www.csiic.ca/pdf/ uis_bulletin_sept2005_en.pdf 42. miranda mc. comités de ética de investigación en humanos: una experiencia colombiana. revista colombiana de bioética. 2006;1:141-8. 43. informe especial: fortalezas y debilidades de la nueva ley que reforma la salud. actualidad laboral y seguridad social. 2011;1(63):6. 44. salazar e. estrategias de la salud pública y consideraciones éticas y bioéticas en el cuidado de la salud y la vida. investigación en enfermería. imagen y desarrollo. 2005;7(1-2):78. 45. castro r, bronfman m. salud, cambio social y política. perspectivas desde américa latina. problemas no resueltos en la integración de métodos cualitativos y cuantitativos en la investigación social en salud. méxico: instituto nacional de salud pública; 1999. p. 47-64. 46. moreno-ferguron me, alvarado-garcía am. aplicación del modelo de adaptación de callista roy en latinoamerica: revisión de literatura. aquichan. 2009; 9(1):62-72. co nc ep t a na ly si s of t he n ur si ng d ia gn os is o f i m pa ir ed s po nt an eo us v en ti la ti on in c ri ti ca l p at ie nt s 1 emanuele gouveia de albuquerque https://orcid.org /0000-0001-9456-8382 universidade federal do rio grande do norte, brasil egouveiaufrn@yahoo.com.br jéssica naiara de medeiros araújo https://orcid.org /0000-0002-9115-3285 universidade do estado do rio grande do norte, brasil jessicanaiara@uern.br amanda barbosa da silva https://orcid.org /0000-0002-5410-7060 universidade federal do rio grande do norte, brasil amanda.b.silva@animaeducacao.com.br dase luyza barbosa de sousa alves https://orcid.org /0000-0003-0462-9220 universidade federal do rio grande do norte, brasil dase.alves@animaeducacao.com.br barbara ebilizarda coutinho borges https://orcid.org /0000-0001-6922-1475 universidade federal do rio grande do norte, brasil barbara.borges.099@ufrn.edu.br allyne fortes vitor https://orcid.org /0000-0002-4672-2303 universidade federal do rio grande do norte, brasil allyne.vitor@ufrn.br article concept analysis of the nursing diagnosis of impaired spontaneous ventilation in critical patients recibido: 15/09/2022 enviado a pares: 25/11/2022 aceptado por pares: 15/06/2023 aprobado: 22/06/2023 doi: 10.5294/aqui.2023.23.3.7 para citar este artículo / to reference this article / para citar este artigo albuquerque eg, araújo jnm, silva ab, alves dlbs, borges bec, vitor af. concept analysis of the nursing diagnosis of impaired spontaneous ventilation in critical patients. aquichán. 2023;23(3):e2337. doi: https://doi.org/10.5294/aqui.2023.23.3.7 https://orcid.org/0000-0001-9456-8382 mailto:egouveiaufrn@yahoo.com.br https://orcid.org/0000-0002-9115-3285 mailto:jessicanaiara@uern.br https://orcid.org/0000-0002-5410-7060 mailto:amanda.b.silva@animaeducacao.com.br https://orcid.org/0000-0003-0462-9220 mailto:dase.alves@animaeducacao.com.br https://orcid.org/0000-0001-6922-1475 mailto:barbara.borges.099@ufrn.edu.br https://orcid.org/0000-0002-4672-2303 mailto:allyne.vitor@ufrn.br https://doi.org/10.5294/aqui.2023.23.3.7 https://doi.org/10.5294/aqui.2023.23.3.7 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2023.23.3.6&amp;domain=pdf&amp;date_stamp=2023-07-23 theme: epistemology contribution to the discipline: concept analyses are types of theoretical studies that contribute to advances in nursing knowledge. thus, this study enabled a better understanding of the nursing diagnosis impaired spontaneous ventilation in critically ill patients based on antecedents, critical and consequent attributes. co nc ep t a na ly si s of t he n ur si ng d ia gn os is o f i m pa ir ed s po nt an eo us v en ti la ti on in c ri ti ca l p at ie nt s 3 abstract introduction: in nursing practice, this concept has been identified in studies that address the nursing diagnosis of impaired spontaneous ventilation. nursing performance facing this unwanted human response is considered essential for the maintenance and control of vital signs, cardiovascular monitoring, gas exchange and respiratory pattern, as well as constant surveillance aimed at signs of hypoventilation and inadequate ventilation. objective: to analyze the concept of impaired spontaneous ventilation in critically ill patients in an intensive care unit. methodology: this study is a concept analysis, according to walker’s and avant’s method, conducted using an integrative review. all the referential steps were followed: concept selection, determining the objectives and proposals for concept analysis, identifying the possible uses of the concept, determining the defining attributes, identifying a model case, identifying a contrary case, and identifying the precedents and consequences of the concept. results: a sample of 38 studies was selected. the following were identified as attributes: distress and fatigue, respiratory distress, tachycardia, hemodynamic instability, altered mental status, abnormal arterial blood gas results, dyspnea, anxiety, agitation, sweating, hypoxemia and hypercapnia. antecedents: sex, age, oxygen saturation lower than 90%, diseases of the respiratory, cardiovascular, neurological, gastrointestinal, neuromuscular, and metabolic systems, respiratory infections, trauma, poisons, toxins, and sedatives. consequences: increased heart rate, decreased partial oxygen saturation, increased use of respiratory muscles, dyspnea, increased metabolic rate and restlessness. the model case and the contrary case were used to illustrate the attributes, antecedents, and consequences. conclusion: the study directed the strengthening of evidence about the phenomenon and demonstrated a strong occurrence in patients who need assistance in intensive care units, thus demanding critical care. keywords (fonte: decs) pulmonary ventilation; respiratory failure; intensive care units; nursing; nursing diagnoses. 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e 23 37 resumen introducción: en la práctica de enfermería, este concepto fue identificado en estudios que abordan el diagnóstico de la ventilación espontánea deteriorada. la actuación desde enfermería para enfrentar esta indeseada respuesta humana es esencial para el mantenimiento y el control de los signos vitales, el monitoreo cardiovascular, el intercambio de gases y el patrón de respiración, así como para la vigilancia constante de los signos de hipoventilación y ventilación inadecuada. objetivo: analizar el concepto de ventilación espontánea deteriorada en pacientes críticos en una unidad de cuidado intensivo. metodología: este estudio es un análisis de concepto, de acuerdo con el método de walker y avant, conducido usando una revisión integrada. se siguieron todos los pasos referenciales: selección del concepto, determinación de los objetivos y propuestas para el análisis de conceptos, identificación de los posibles usos del concepto, determinar los atributos definitorios, identificación del caso modelo, identificación del caso contrario e identificación de precedentes y consecuencias del concepto. resultados: se seleccionó una muestra de 38 estudios. se identificaron como atributos: angustia y fatiga, dificultad respiratoria, taquicardia, inestabilidad hemodinámica, estado mental alterado, gasometría arterial anormal, disnea, ansiedad, agitación, sudoración, hipoxemia e hipercapnia. antecedentes: sexo; edad; saturación de oxígeno inferior al 90%; enfermedades de los sistemas respiratorio, cardiovascular, neurológico, gastrointestinal, neuromuscular y metabólico; infecciones respiratorias; traumatismos, y venenos, toxinas y sedantes. consecuencias: aumento del ritmo cardíaco, disminución de la saturación parcial de oxígeno, aumento del uso de los músculos respiratorios, disnea, aumento del índice metabólico e inquietud. se utilizaron el caso modelo y el caso contrario para ilustrar los atributos, antecedentes y consecuencias. conclusión: el estudio dirigió el fortalecimiento de la evidencia sobre el fenómeno y demostró una fuerte ocurrencia en pacientes que necesitan asistencia en unidades de cuidados intensivos, quienes requieren, en consecuencia, de cuidados críticos. palabras clave (fuente: decs) ventilación pulmonar; falla respiratoria; unidad de cuidados intensivos; enfermería; diagnósticos de enfermería. análisis de concepto del diagnóstico de la ventilación espontánea deteriorada en pacientes críticos co nc ep t a na ly si s of t he n ur si ng d ia gn os is o f i m pa ir ed s po nt an eo us v en ti la ti on in c ri ti ca l p at ie nt s 5 análise conceitual do diagnóstico de ventilação espontânea prejudicada em pacientes críticos resumo introdução: na prática da enfermagem, esse conceito foi identificado em estudos que abordaram o diagnóstico de ventilação espontânea prejudicada. a atuação da enfermagem para enfrentar essa resposta humana indesejável é essencial para a manutenção e o controle dos sinais vitais, da monitorização cardiovascular, das trocas gasosas e do padrão respiratório, bem como para a vigilância constante dos sinais de hipoventilação e ventilação inadequada. objetivo: analisar o conceito de ventilação espontânea prejudicada em pacientes graves internados em uma unidade de terapia intensiva. materiais e método: este estudo é uma análise conceitual, de acordo com o método de walker e avant, realizada por meio de uma revisão integrada. todas as etapas referenciais foram seguidas: seleção do conceito, determinação dos objetivos e proposições para a análise do conceito, identificação dos possíveis usos do conceito, determinação dos atributos definidores, identificação do caso-modelo, identificação do contracaso e identificação dos precedentes e consequências do conceito. resultados: foi selecionada uma amostra de 38 estudos. os atributos identificados foram angústia e fadiga, angústia respiratória, taquicardia, instabilidade hemodinâmica, estado mental alterado, gases sanguíneos arteriais anormais, dispneia, ansiedade, agitação, sudorese, hipoxemia e hipercapnia. antecedentes: sexo; idade; saturação de oxigênio inferior a 90%; doenças dos sistemas respiratório, cardiovascular, neurológico, gastrointestinal, neuromuscular e metabólico; infecções respiratórias; trauma; e venenos, toxinas e sedativos. consequências: aumento da frequência cardíaca, diminuição da saturação parcial de oxigênio, aumento do uso dos músculos respiratórios, dispneia, aumento da taxa metabólica e inquietação. o caso-modelo e o caso oposto foram usados para ilustrar os atributos, os antecedentes e as consequências. conclusões: o estudo teve como objetivo fortalecer as evidências sobre o fenômeno e demonstrou uma forte ocorrência em pacientes que necessitam de assistência em unidades de terapia intensiva e que, consequentemente, requerem cuidados críticos. palavras-chave (fonte decs) ventilação pulmonar; insuficiência respiratória; unidade de terapia intensiva; enfermagem; diagnósticos de enfermagem. 6 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e 23 37 introduction this research has as its object of study the analysis of the concept of impaired spontaneous ventilation (isv). in nursing practice, this concept has been identified in studies that address the nursing diagnosis of impaired spontaneous ventilation, often attributed in clinical practice to patients with a higher level of severity, who are usually assisted in intensive care units and using invasive mechanical ventilation (1). the nursing diagnosis (nd) of isv was added to the taxonomy “nanda-international nursing diagnoses” in 1992, in domain 4, “activity/rest,” and is defined as the “inability to initiate and/or maintain independent breathing that is adequate to support life” (2). as a clinical condition that predisposes to isv, acute respiratory failure (arf) stands out as the main indication for mechanical ventilation. nursing performance facing this unwanted human response is considered essential for the maintenance and control of vital signs, cardiovascular monitoring, gas exchange and respiratory pattern, as well as constant surveillance aimed at signs of hypoventilation and inadequate ventilation, in addition to assessing the level of anxiety (3). therefore, it requires from the nurses, scientific knowledge and sufficient skills for decision-making, from the theoretical-conceptual level to the management of this clinical condition through critical reasoning. nursing care for patients with isv in a scenario where there is indisputably a demand for the implementation of resolution 358/2009, must be based on the nursing process (np), a working instrument for nurses that materializes the systematization of nursing care. the use of standardized language systems, such as nanda-i in the np, contributes to standardizing the knowledge of the profession, in addition to bringing legitimacy to nursing records (4). taxonomy ii proposed by nanda-i classifies nursing diagnoses (nd) and guides nurses in clinical decision-making. in the current edition, nanda-i points out the need to review nd with more recent scientific investigations to raise the level of evidence (loe) of some diagnoses present in the taxonomy. for the nd of isv (00333), there is a need for studies so that it remains in the next edition of the nanda-i (2). linked to this, it appears that the diagnosis is regularly inferred in adult patients and several units of the health service, particularly in the intensive care unit. however, there are still gaps in the literature regarding studies focused on this diagnosis. therefore, it is important to note the diagnosis’s present definition and clinical indicators are still little explored, without contemplating broader and clearer aspects of the individual’s needs. in this perspective, regarding the respiratory function assessment scenario, accurately defining a nd becomes a potential confounder co nc ep t a na ly si s of t he n ur si ng d ia gn os is o f i m pa ir ed s po nt an eo us v en ti la ti on in c ri ti ca l p at ie nt s 7 due to the existence of several diagnoses with similar characteristics. therefore, questions converge by relating groups of similar clinical manifestations, related to the same defining characteristics and used in a similar context (1, 2). with that, it becomes essential to favor a precise and accurate evaluation in the recognition of the phenomenon as impaired spontaneous ventilation. thus, understanding concepts that are closely related to nursing practice is necessary to minimize doubts when choosing between one or more diagnoses (2). because of this and based on the homonymous nd present in nanda-i, the study aimed to analyze the concept of impaired spontaneous ventilation in patients in the context of an intensive care unit. methodology this is a concept analysis based on the framework proposed by walker and avant (5) and for theoretical composition, an integrative literature review was carried out (6). the model chosen as analysis is justified by clarifying ambiguities and clarifying important concepts, with the expectation of favoring the development of nursing. in addition, the approach comprises the concept with characteristics and attributes capable of defining the corresponding phenomenon. therefore, it enables the expression of attributes frequently related to the concept, which will allow the researcher to have a broad view of the elements that compose it (5). the isv concept was chosen to investigate it as an undesirable human response in nursing. therefore, the decision to study it was based on the researchers’ recognition of clinical practice and previous research, mainly based on previous readings and previous experiences in studies focused on critical care, intensive care unit and nursing diagnoses. thus, it represents a phenomenon that demands precise investigation and clarification of the knowledge produced. to this end, this framework suggests the selection of a concept that highlights the researchers’ greatest interest while at the same time approaching their needs (5). the analytical model proposed by walker and avant analyzes the concept in eight steps. the first one is the selection of the concept; it should reflect the area of greatest interest to the researcher. in the present study, the area of interest was the nd of isv. the second step is the objective of the analysis, which aims to answer the question of why the analysis will be performed (5). thus, this study aims to analyze the conceptual core of the nd of isv. in the third stage, which is the identification of the use of the concept, it is recommended to use all available literature to verify the possibilities of identifying the different attributes of the concept (5). in this way, the use of the isv concept. the fourth step is determining the attributes, which are the characteristics that will determine the presence of the concept (5). thus, the attributes 8 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e 23 37 that define the nd of isv. the fifth one is the identification of a model case, which is an example of using the concept that demonstrates all its attributes or defining characteristics (5). the sixth step is the identification of a contrary case and consists of clear examples that do not represent the concept (5). the seventh step is the identification of the antecedents and consequences of the phenomenon, which are the events commonly occurring before the identification of the phenomenon and all those events or occurrences that arise as a result of the phenomenon, respectively (5). the eighth step is the definition of empirical references, that is, the empirical references for the attributes, which constitute categories of real phenomena that demonstrate the occurrence of the concept (5). despite the reference proposing the identification of borderline, related, invented and illegitimate cases, in this study, only the model case and the opposite case were used, as these are believed to be sufficient to clarify the concept. regarding the integrative literature review, the recommended stages were followed for the systematization of the knowledge produced and available in electronic sources of data on isv. the stages were the identification of research questions, literature search, data assessment, analysis of results and presentation of the review. the following research questions were elaborated: what are the definitions of isv? what are the uses of isv? what are the attributes of the concept of isv? what are the antecedents and consequences of the concept of isv? what are the empirical references of isv? the selection of studies was conducted respecting the eligibility criteria according to table 1. it is noteworthy that a time frame was not included for the research to identify the largest number of publications related to the subject under study. table 1. eligibility criteria. natal, rn, brazil, 2021 inclusion exclusion full articles available in the databases editorials, abstracts, letters to the editor, reviews, previous notes, and expert opinions. articles in portuguese, english or spanish articles addressing the theme and objectives of the study, including bibliographic reviews, guidelines, and book chapters. source: prepared by the authors. the search was performed from march to september 2021 by a pair of researchers at the same time, using the same internet network and on different machines, in eight data sources: scielo, sciencedirect, pubmed (medline), cochrane, scopus, cumulative index to nursing and allied health literature (cinahl), web of science and virtual health library, accessed through the portal of the coco nc ep t a na ly si s of t he n ur si ng d ia gn os is o f i m pa ir ed s po nt an eo us v en ti la ti on in c ri ti ca l p at ie nt s 9 ordination for the improvement of higher education personnel (capes). the following descriptors indexed in the mesh (medical subject headings) and decs (descriptors in health sciences) in portuguese, english, and spanish were used: “pulmonary ventilation”, “respiratory failure” and “artificial respiration”, using the four crossings: (ventilação pulmonar or pulmonary ventilation or ventilación pulmonar) and (insuficiência respiratória or respiratory insufficiency or insuficiencia respiratoria) and (respiração artificial or respiration, artificial or respiración artificial); (ventilação pulmonar or pulmonary ventilation or ventilación pulmonar) and (insuficiência respiratória or respiratory insufficiency or insuficiencia respiratoria); (ventilação pulmonar or pulmonary ventilation or ventilación pulmonar) and (respiração artificial or respiration, artificial or respiración artificial); (insuficiência respiratória or respiratory insufficiency or insuficiencia respiratória) and (respiração artificial or respiration, artificial or respiración artificial). after these crossings, other new crossings were conducted to collect more data that could reach the greatest possible number of studies focused on nursing. the following descriptors indexed in mesh (medical subject headings) and decs (descriptors in health sciences), in portuguese, english and spanish were used: “pulmonary ventilation”, “intensive care units”, “nursing diagnoses” and “nursing”, using the three crossings: (ventilação pulmonar or pulmonary ventilation or ventilación pulmonar) and (unidades de terapia intensiva or intensive care units or unidades de cuidados intensivo) and (diagnósticos de enfermagem or nursing diagnosis or diagnóstico de enfermería) and (enfermagem or nursing or enfermería); (ventilação pulmonar or pulmonary ventilation or ventilación pulmonar) and (unidades de terapia intensiva or intensive care units or unidades de cuidados intensivo) and (diagnósticos de enfermagem or nursing diagnosis or diagnóstico de enfermería); (ventilação pulmonar or pulmonary ventilation or ventilación pulmonar) and (diagnósticos de enfermagem or nursing diagnosis or diagnóstico de enfermería) and (enfermagem or nursing or enfermería). a total of 26,014 titles were found in the databases. considering the inclusion criteria, 1,773 titles were read and selected for the second stage. of these articles, 1,651 were excluded (1,629 did not meet the inclusion criteria and 22 were duplicated), totaling 122 publications for full reading. the final sample was composed of 38 studies (figure 1). after obtaining the sample, data extraction began using two instruments: a worksheet containing items related to concept analysis (uses, definitions, attributes, antecedents, consequents, and empirical references) and other items that made it possible to the characterization of the studies (title, authors, year, journal in which the study was published, country of origin, and method). 10 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e 23 37 each sample study was read in detail to extract the elements addressed in the cited instruments, which were recorded on cards. for each study in the sample, a characterization form of the studies was prepared with the elements recommended for the concept analysis and, finally, the final analysis was carried out to compile the results. this study was conducted in public domain databases, which do not require submission to a research ethics committee. figure 1. flowchart of the literature search and article selection according to the prisma-scr guidelines. natal rn, brazil, 2021 source: prepared by the authors. results the sample comprises 38 studies. among the different countries identified in the sample, the united states of america (usa) stands out with seven articles (18,4%). other countries were identified, namely: brazil, the united kingdom, denmark, canada, taiwan, france, china, tunisia, spain, the netherlands, india, austria, turkey, england, sweden, italy, egypt, and mexico. as for the year of publication, the articles date from 1987 to 2020. of these articles, 26 (68,4%) were published in the last 10 years (2011-2020), indicating greater interest in the subject in the last decade. regarding the method used by the studies comprising the final sample, observational studies stand out, totaling 22 articles (57,9%), as in table 2. studies identi�ed in the data sources (n=26,014). studies selected by title and abstract (n=1,773) studies excluded due to duplication (n=22) studies excluded due to exclusion criteria (n=1,629) studies excluded due to exclusion criteria (n=84) studies selected for full reading: (n=122) studies selected to compose the sample: (n=38) id en ti � ca ti o n sc re en in g el ig ib ili ty se le ct io n co nc ep t a na ly si s of t he n ur si ng d ia gn os is o f i m pa ir ed s po nt an eo us v en ti la ti on in c ri ti ca l p at ie nt s 11 table 2. characterization of studies according to authors, year of publication, journal, country, and method. natal, rn, brazil, 2021 authors year journal country of origin method perkins gd et al. (7) 2018 jama united kingdom randomized clinical trial diaz-abad m, brown je (8) 2014 j bras pneumol usa case report antonio acp et al. (9) 2017 rev bras ter intensiva brazil comparative clinical trial girault c et al. (10) 2011 am j respir crit care med tunisia randomized multicenter trial ferreira jc et al. (11) 2017 bmc pulm med brazil randomized crossover trial hennus mp et al. (12) 2013 plos one the netherlands case control study teixeira sn et al. (13) 2015 respir care brazil prospective randomized, unblinded, controlled trial figueroa-casas jb et al. (14) 2010 respir care usa prospective randomized controlled study raurich jm et al. (15) 2008 respir care spain prospective controlled study mokhlesi b et al. (16) 2007 respir care usa prospective observational cohort study gnanapandithana k et al. (17) 2011 rev por pneumologia india randomized study putensen c et al. (18) 2001 am j respir crit care med austria randomized prospective study ely ew et al. (19) 1996 n engl j med. usa randomized and controlled trial deslisle s et al. (20) 2011 respir care canada prospective study andrade lzc et al. (21) 2012 acta paul. enferm brazil observational study campbell ml (22) 2018 am j crit care usa observational study storm ds, baumgartner rg (23) 1987 int j nurs stud usa case study sørensen d et al. (24) 2013 int j nurs stud denmark observational study sørensen d et al. (25) 2013 intensive crit care nurs denmark qualitative descriptive observational study manfredini gmsg, machado rg, mantovani r (26) 2013 journal of nursing ufpe brazil study quantitative, exploratory, descriptive pertab d (27) 2009 br j nurs united kingdom simple review 12 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e 23 37 authors year journal country of origin method yücel şç et al. (28) 2011 int j nurs pract turkey descriptive observational study pattison n, watson j (29) 2009 nurs crit care united kingdom case study cools f, offringa m (30) 2000 cochrane database syst rev usa systematic review greenough a et al. (31) 2008 cochrane database syst rev england systematic review prado pr, bettencourt arc, lopes jl (32) 2019 rev. latino-am. enfermagem brazil observational study hsu jc et al. (33) 2013 biomed eng online taiwan randomized controlled clinical trial kauppi w et al. (34) 2020 bmc emerg med sweden retrospective observational study jellington mo et al. (35) 2016 bmc nurs denmark observational study tonnelier jm et al. (36) 2005 crit care france prospective study li w et al. (37) 2016 exp ther med china retrospective study yanga l et al. (38) 2019 medicine china retrospective study vitacca m et al. (39) 2014 respir care italy observational cohort study rose l, gerdtz mf (40) 2009 j clin nurs canada integrative review belveyre t, auchet t, levy b (41) 2019 respir med case rep france case report mohammed h, abdelatief d (42) 2016 egyptian journal of chest diseases and tuberculosis egypt simple review liang yr et al. (43) 2020 asian nurs res (korean soc nurs sci) taiwan prospective study hernández-hernández g, reynoso-garcía jg (44) 2019 enferm univ mexico case study source: prepared by the authors. by analyzing the articles, it was possible to identify the components of the concept, as described below. identification of uses of the concept the main definitions of isv according to the literature. the definitions, authors, research source and context of use are shown in table 3. most definitions were used in the context of mechanically ventilated patients. co nc ep t a na ly si s of t he n ur si ng d ia gn os is o f i m pa ir ed s po nt an eo us v en ti la ti on in c ri ti ca l p at ie nt s 13 table 3. summary of the main definitions of isv according to the literature. natal, rn, brazil, 2021 definitions authors research source context of use “failure of the spontaneous breathing trial that makes it difficult to wean from invasive mechanical ventilation” perkins gd et al. (7) cinahl adults who received invasive mechanical ventilation for more than 48 hours and in whom a spontaneous breathing trial failed. “inability to tolerate an attempt at spontaneous breathing showing signs of respiratory distress (respiratory rate above 35 breaths per minute, arterial oxyhemoglobin saturation less than 90%, use of accessory respiratory muscles or paradoxical thoracoabdominal ventilation), tachycardia (heart rate > 140 beats per minute), hemodynamic instability (systolic blood pressure < 90 mmhg or 20% above baseline levels) or altered mental status (drowsiness, coma and anxiety)” antonio acp et al. (9) virtual health library adults eligible for mechanical ventilation liberation. “inability to sustain pulmonary function and protect the airway” deslisle s et al. (20) scopus mechanically ventilated patients recovering from a respiratory failure of various causes. “inability to initiate and/or maintain adequate independent breathing to support life” herdman th, kamitsuru s, lopes ct (2) book definition of the nursing diagnosis isv (nandainternational). source: prepared by the authors. therefore, the synthesis of the definition for isv can be understood as “an inability to maintain spontaneous breathing and sustain pulmonary function to protect the airway.” identification of empirical references the spontaneous breathing trial (sbt), respiratory distress observation scale (rdos), and arterial blood gas were selected according to the possibility of demonstrating the occurrence of isv. the latter two are empirical references capable of application by nurses, which will be described below. 14 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e 23 37 spontaneous breathing trial (sbt) the spontaneous breathing trial consists of the use of a t-piece by the patient, in which the patient is disconnected from mechanical ventilation, and can be connected to supplemental oxygen, lasting from 30 to 120 minutes. the patient is observed for signs of intolerance to the trial, such as tachypnea, tachycardia, agitation, or diaphoresis. if these signals are present during the previously mentioned time interval of two minutes, the test result is faulty. sbt can also be performed with low levels of pressure support (5 to 7cmh2o), use of cpap, proportional assisted ventilation (pav) and atc (automatic tube compensation) mode. although clinical decisions related to the weaning process from mechanical ventilation are taken by the medical professional, in uk countries, for example, the initiation of sbt and its respective monitoring are performed by nurses together with the respiratory therapist (19). respiratory distress observation scale (rdos) the rdos is an ordinal scale used to measure the respiratory difficulty of critically ill or near-death adult patients who are unable to self-report dyspnea, being widely used in patients who are in the intensive care unit (icu). it consists of 8 items, where each variable is scored from 0 to 2 points, at the end the points are added, and may range from 0 to 16. the scale scores range from 0 to 2, which suggests the absence of respiratory distress, a score of 3 indicates mild distress, a score of 4 to 6 suggests moderate distress, and a score of 7 or more indicates a severe level of distress (22). arterial blood gas arterial blood gas is constantly used in icu and emergency departments to check the patient’s respiratory status. nurses, in turn, are directly related to obtaining and analyzing the results of arterial blood gas, and it is essential that nurses working in the icu are aware of the interpretation to identify ventilation disorders and avoid inappropriate treatments (42). critical attributes the attributes found were distress and fatigue, respiratory distress, tachycardia, hemodynamic instability, altered mental status, abnormal arterial blood gas results, dyspnea, anxiety, agitation, sweating, hypoxemia, and hypercapnia. distress and fatigue they are characterized by physiological changes [signs of respiratory distress, tidal volume (l) greater than 105 min-¹1-¹, hemodynamic co nc ep t a na ly si s of t he n ur si ng d ia gn os is o f i m pa ir ed s po nt an eo us v en ti la ti on in c ri ti ca l p at ie nt s 15 instability, tachycardia and cardiac arrhythmias], clinical changes (anxiety, depressed mental state, sweating, cyanosis and increased respiratory effort – dyspnea, facial expression of distress and use of accessory muscles) and arterial blood gases (partial oxygen less than 8 kpa, fio2 greater than 0.5 or partial oxygen saturation less than 90%, partial carbon dioxide greater than 6.5 kpa or an increase greater than 1kpa and ph less than 7.32) (7). respiratory distress the signs of respiratory distress are respiratory rate above 35 breaths per minute, arterial oxyhemoglobin saturation below 90%, use of accessory respiratory muscles or paradoxical thoracoabdominal ventilation (9). tachycardia it is characterized as >140 heartbeats per minute (9). hemodynamic instability it occurs when systolic blood pressure is less than 90 mmh or 20% above baseline levels (9). altered mental status it is characterized by drowsiness, coma, and anxiety (9). abnormal arterial blood gas results it is characterized as abnormal when there are changes in the standardized values for gas exchange, ventilatory disorders and acid-base balance in arterial blood (42). dyspnea it is characterized by a subjective experience of respiratory distress that presents itself in different sensations and may vary in intensity (22). the other attributes found were anxiety (9, 13, 15, 16, 19, 25, 29), agitation (10, 13, 15, 16, 17), sweating (10, 13, 15), hypoxemia (11, 27), and hypercapnia (37). antecedents and consequences antecedents intrinsic factors are male sex and mean age of 53.3 years (older age: 71 years; younger age: 90 days), oxygen saturation lower than 90% (16), acute or chronic hypercapnic respiratory failure 16 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e 23 37 (10) of different etiologies, being more common chronic obstructive pulmonary disease and acute respiratory distress syndrome (9, 14, 10, 17, 13). other comorbidities or clinical conditions predispose the emergence of isv, such as amyotrophic lateral sclerosis (8); congestive heart failure with an ejection fraction less than 45%, left ventricular diastolic dysfunction, kidney replacement therapy, ascites (9); respiratory syncytial virus with infection in the lower respiratory tract (12); head trauma, obesity (13), multiple traumas, neurological urgency (14); imbalance between ventilatory demand and work capacity and work endurance(15); neuromuscular disorders, poisons and toxins (17); use of sedatives such as sufentanil and midazolam (18); pneumonia, gastrointestinal tract diseases, cancer, overdose or ketoacidosis (19); tachypnea, hypertension and hypercapnia (20). consequences this analysis found some implications, namely: increased heart rate (7, 9, 13, 14, 18), decreased partial oxygen saturation (9, 13, 18), increased use of respiratory muscles (9, 18), dyspnea (7), increased metabolic rate (14, 18) and agitation (14). it should be noted that these consequences are in line with the defining characteristics of the isv diagnosis present in the nanda-i diagnostics taxonomy (2). identification of a model case and a contrary case for this stage, the following fictitious case was constructed: model case mr. josé, 53 years old, was admitted to the icu due to respiratory failure. during hospitalization, he had oxygen saturation <90% and was unable to sustain breathing spontaneously, requiring invasive mechanical ventilation. after a week in the icu, he was screened to perform the sbt but was unsuccessful. at the time of the trial, he presented sweating, agitation, tachycardia, use of accessory muscles and dyspnea. he returned to mv, but even so, he developed severe hypoxemia with respiratory acidosis. contrary case lúcia, 25 years old, presented cough, afternoon fever, night sweats, tiredness and fatigue for more than 15 days. she went to the family health unit in her neighborhood and the nurse requested a smear. the examination detected the presence of koch’s bacillus and lúcia was referred to a medical consultation to continue the treatment and start the use of tuberculostatic drugs. despite her tiredness and fatigue, lúcia was able to breathe spontaneously in ambient oxyco nc ep t a na ly si s of t he n ur si ng d ia gn os is o f i m pa ir ed s po nt an eo us v en ti la ti on in c ri ti ca l p at ie nt s 17 gen, saturating at 96% and does not require hospitalization. her follow-up occurs on an outpatient basis with medical consultations and through home visits by nurses. discussion the advancement of knowledge on the subject allowed us to identify a strong trend in research on the phenomenon, with emphasis on the last ten years. it is believed that in the current health context, where there is a predominance of diseases with patterns of respiratory tract involvement, the nd of isv tends to be frequently attributed to patients, which makes it necessary to clarify the concept. the need for clarification regarding the diagnostic concept of isv was pointed out by a study that showed this conceptual core caused confusion when confronted with another nd, which could compromise diagnostic accuracy (1). the selected studies identified that the phenomenon of isv has been strongly associated with critical environments as a care context, especially in patients using mv. this finding corroborates a study that showed that nurses commonly infer the nd of isv in patients using mv in the icu (4-1). added to these considerations, factors such as agitation, dyspnea, hypoxemia, irritability, decreased cooperation, increased heart rate and decreased partial pressure of oxygen and increased use of accessory muscles are commonly identified in patients with isv (21). in addition, patients undergoing deep sedation for surgical procedures may present isv (45). the literature points to empirical references of isv that can be measured by other health professionals, in addition to nurses. among them is pulmonary ultrasound, which can be used during spontaneous breathing attempts to check for impediments to successful extubation. this imaging method is based on the interpretation of artifacts, that is elements resulting from the interaction between air and fluids in the lungs, such as the loss of pulmonary aeration (9). also noteworthy is the daily screening to assess mechanical ventilator parameters, cough reflex and use of sedatives and vasopressors. and it can be used together and in a stage prior to sbt (19). as in the current health pandemic scenario caused by covid-19, the role of nurses in critical patients with isv is essential. this is because the virus named sars-cov-2 is responsible for causing acute respiratory distress syndrome (ards) in about 70% of patients admitted to the icu. in addition, among those requiring invasive mechanical ventilation, there are records of a 97% mortality rate, and of these deaths, 53% are caused by respiratory failure (46). the role of nursing becomes essential for patients who develop isv. nurses are responsible for identifying health/disease situations, implementing results, interventions and nursing care (47). 18 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e 23 37 for the isv nd contained in nanda-i, the nursing outcomes classification (noc) suggests some of the following nursing outcomes: response to mechanical ventilation in adults (alveolar changes and tissue perfusion are expected to be effectively served by the mv); response to weaning from mechanical ventilation in adults (it is expected that there will be a respiratory and psychological adaptation to weaning from mechanical ventilation); drug response (the therapeutic effects of prescribed drugs are expected to be achieved); prevention of aspiration (intended to prevent the passage of liquids and solid particles to the lung); pulmonary tissue perfusion (adequate blood flow through the pulmonary vasculature must be maintained to perfuse alveoli/capillary unit); state of psycho-spiritual comfort; and cardiopulmonary status (adequacy of the volume of blood ejected from the ventricles and exchange of carbon dioxide and oxygen at the alveolar level is expected (48). in addition, incorporating the stages of the np, the sixth edition of the classification of nursing interventions (nic) brings as interventions for the isv nd, which can be performed by nurses: medication administration, emotional support, aspiration of the airways, assistance ventilation, control of invasive and non-invasive mechanical ventilation, control of artificial airways and respiratory monitoring (49). furthermore, the research favors the strengthening of the level of evidence of the nursing diagnosis based on the analysis of the concept, and thus allows the solidification of knowledge, presenting the representativeness of its components, constituting higher and desired levels of scientific evidence to promote its permanence in the taxonomy. for this reason, it facilitates the standardization of language among nursing professionals, based on communication and decision making through the development of taxonomies with the precise and accurate recognition of this human response. thus, it promotes a solidified classification arrangement, based on evidence, and with conceptual organization resulting from continuous evaluation, clarification and refinement, essential aspects for promoting the consolidation of the nursing process. conclusion the study found, as essential attributes for the occurrence of the phenomenon, distress and fatigue, respiratory distress, tachycardia, hemodynamic instability, altered mental status, abnormal arterial blood gas results, dyspnea, anxiety, agitation, sweating, hypoxemia and hypercapnia. the definition identified for the concept specifies the understanding of the phenomenon since the analysis reveals the relevance and emphasis of a harmful and disabling condition, which can be avoided through accessible nursing interventions. thus, understanding this human response represents progress in its study by defining and synthesizing isv in a typical and predisposed scenario. co nc ep t a na ly si s of t he n ur si ng d ia gn os is o f i m pa ir ed s po nt an eo us v en ti la ti on in c ri ti ca l p at ie nt s 19 this analysis of the concept of isv provided the strengthening of evidence about a phenomenon commonly identified in nursing care practice that is little debated regarding the diagnostic concept. the antecedents found through the integrative literature review indicate that isv is not uni-causal and can be triggered by critical and varied pathological processes. based on the consequences, it is evident that this phenomenon can trigger long periods of hospitalization in critical environments for the patients, requiring a technological apparatus to maintain life and respiratory function. in addition, this study will strengthen the level of evidence and the feedback of nursing theory and practice, as it allows the recognition of the phenomenon in clinical practice, through the identification of its attributes, antecedents, consequences and empirical references. furthermore, it allows the standardization of language, by providing the enrichment of nursing taxonomies, facilitating communication and decision-making. in this way, it also contributes to the consolidation of the nursing process. therefore, it is suggested the continuity of studies on the subject with research that can understand the phenomenon in the context of the clinical practice of nurses in different research designs. as a limitation of the study, the integrative review method chosen to operationalize the concept analysis stands out, since the information was restricted to what was in the data sources and published in the previously selected languages. another limitation found refers to the methodological quality of the selected studies, because to cover the maximum amount of information about the selected concept, studies with lower scientific evidence were admitted, such as case reports. conflict of interest: none declared references 1. seganfredo dh, beltrão ba , silva vm, lopes mvo, castro smj, almeida ma . analysis of ineffective breathing pattern and impaired spontaneous ventilation of adults with oxygen therapy. rev. latino-am enfermagem. 2017; 25:e2954. doi: 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te rv en ti on s to f os te r h ea lt h in p at ie nt s u nd er go in g ca rd ia c re ha bi lit at io n: a s ys te m at ic r ev ie w 1 jhon alexander rojas-caballero https://orcid.org /0000-0002-5094-4777 universidad de santander, colombia jho.rojas@mail.udes.edu.co elizabeth romero massa https://orcid.org /0000-0001-5504-7410 universidad de cartagena, colombia eromerom@unicartagena.edu.co zuleima cogollo-milanés https://orcid.org /0000-0003-3310-4052 universidad de cartagena, colombia zcogollom@unicartagena.edu.co article impact of educational interventions to foster health in patients undergoing cardiac rehabilitation: a systematic review* received: 15/12/2022 sent to peers: 24/02/2023 approved by peers: 27/04/2023 accepted: 23/05/2023 doi: 10.5294/aqui.2023.23.3.3 to reference this article / para citar este artículo / para citar este artigo rojas-caballero ja, romero e, cogollo-milanés z. impact of educational interventions to foster health in patients undergoing cardiac rehabilitation: a systematic review. aquichan. 23(3):e2333. doi: https://doi.org/10.5294/aqui.2023.23.3.3 * this article derives from the master’s degree thesis entitled “effectiveness of educational interventions for cardiac rehabilitation in patients with ischemic heart disease: an integrative review”, presented to the master’s degree program program in nursing of universidad de cartagena, colombia. https://orcid.org/0000-0002-5094-4777 mailto:jho.rojas@mail.udes.edu.co https://orcid.org/0000-0001-5504-7410 mailto:eromerom@unicartagena.edu.co https://orcid.org/0000-0003-3310-4052 mailto:zcogollom@unicartagena.edu.co https://doi.org/10.5294/aqui.2023.23.3.3 https://doi.org/10.5294/aqui.2023.23.3.3 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2023.23.3.3&amp;domain=pdf&amp;date_stamp=2023-08-24 theme: well-being and quality of life contribution to the nursing discipline: the present manuscript documents the impact of educational interventions during cardiac rehabilitation as a health-strengthening strategy, which represents a fundamental resource for the discipline since, as part of interdisciplinary teams in patient care for cardiac rehabilitation, nursing professionals are an important link during the design and application of educational strategies that allow mitigating morbidity and mortality. in turn, updated evidence on educational strategies is contributed, as well as a tool to use methods with higher cost-effectiveness ratios. im pa ct o f e du ca ti on al in te rv en ti on s to f os te r h ea lt h in p at ie nt s u nd er go in g ca rd ia c re ha bi lit at io n: a s ys te m at ic r ev ie w 3 abstract introduction: cardiovascular diseases represent the leading cause of death worldwide, and education interventions are an effective measure to control modifiable risk factors in patients undergoing cardiac rehabilitation; therefore, studying this phenomenon allows expanding the tools to face this situation. objective: to determine the impact of educational interventions to foster health in patients undergoing cardiac rehabilitation. materials and methods: a scientific literature review was conducted in the pubmed, scielo, lilacs, ebsco, medes, cuiden, dialnet, sciencedirect and cuidatge databases, based on the prisma statement proposal for systematic reviews, registered in the prospero database (crd42023398444). the jadad scale was used for the methodological assessment, according to the peer approach. results: the initial search yielded 14,849 publications, with 10 of them meeting the inclusion criteria. the mean age of the sample population was 63 years old, male gender. telemedicine and education software design were resources to implement the interventions, finding a reduction in hospitalizations for cardiac reasons. regarding mental health, long-term reductions in anxiety and depression were found. conclusions: the time until the first cardiovascular hospitalization was 502 (469-535) days in the intervention group, against 445 (400-491) days in the control group. when evaluating medication adherence, it was evidenced that 94 % of the participants had improvements. regarding cardiovascular risk stratification, both the intervention (26 %) and the control (6 %) groups shifted to the lower-risk class. keywords (fonte: decs) cardiac rehabilitation; health impact assessment; coronary heart disease; education; rehabilitation nursing. 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 3 resumen introducción: las enfermedades cardiovasculares representan la primera causa de muerte a nivel mundial, y las intervenciones educativas representan una medida eficaz para controlar factores de riesgo modificables en pacientes en rehabilitación cardiaca, por ello estudiar este fenómeno permite ampliar las herramientas frente a esta situación. objetivo: determinar el impacto de las intervenciones educativas para fomentar la salud en pacientes en rehabilitación cardiaca. materiales y métodos: se realizó una revisión de la literatura científica en las bases de datos pudmed, scielo, lilacs, ebsco, medes, cuiden, dialnet, science direct y cuidatge, basada en la propuesta de la declaración prisma para revisiones sistemáticas, y se registró en la base prospero (crd42023398444). la escala jadad se usó para la evaluación metodológica, bajo el enfoque de dos pares. resultados: la búsqueda inicial arrojó 14 849 publicaciones, de las cuales al final 10 cumplieron los criterios de inclusión. la edad promedio de la población de la muestra fue 63 años, de sexo masculino. la telemedicina y el diseño de software para educación fueron recursos para implementar las intervenciones, encontrando disminución de las rehospitalizaciones por causas coronarias. respecto a la salud mental, se encontró disminución de la ansiedad y depresión a largo plazo. conclusiones: el tiempo hasta la primera rehospitalización cardiovascular fue de 502 (469-535) días en el grupo de intervención, frente a 445 (400-491) días en el grupo control. al evaluar la adherencia a la medicación, se evidenció que el 94  % de los participantes tuvo mejoras. en cuanto a la estratificación del riesgo cardiovascular, tanto el grupo de intervención (26 %) como el grupo control (6 %) cambiaron a clase de menor riesgo. palabras clave (fuente: decs) rehabilitación cardiaca; evaluación del impacto en la salud; enfermedad cardiaca coronaria; educación; enfermería en rehabilitación. impacto de las intervenciones educativas para fomentar la salud en pacientes en rehabilitación cardiaca: revisión sistemática* * este artículo es derivado de la tesis de maestría titulada “efectividad de las intervenciones educativas para la rehabilitación cardiaca en pacientes con enfermedad cardiaca isquémica: una revisión sistemática”, presentada al programa de maestría en enfermería de la universidad de cartagena, colombia. im pa ct o f e du ca ti on al in te rv en ti on s to f os te r h ea lt h in p at ie nt s u nd er go in g ca rd ia c re ha bi lit at io n: a s ys te m at ic r ev ie w 5 impacto das intervenções educativas para promover a saúde em pacientes de reabilitação cardíaca: uma revisão sistemática* resumo introdução: as doenças cardiovasculares são a principal causa de morte em todo o mundo, e as intervenções educativas representam uma medida eficaz no controle dos fatores de risco modificáveis em pacientes de reabilitação cardíaca, razão pela qual o estudo deste fenómeno permite ampliar as ferramentas perante esta situação. objetivo: determinar o impacto das intervenções educativas na promoção da saúde em pacientes de reabilitação cardíaca. materiais e métodos: foi realizada uma revisão da literatura científica nas bases de dados pubmed, scielo, lilacs, ebsco, medes, cuiden, dialnet, sciencedirect e cuidatge, baseada na proposta da declaração prisma para revisões sistemáticas, sendo registrada na base prospero (crd42023398444). a escala jadad foi utilizada para avaliação metodológica, sob a abordagem de dois pares. resultados: a pesquisa inicial envolveu 14.849 publicações, das quais 10 cumpriram com os critérios de inclusão. a média de idade da população da amostra foi de 63 anos, do sexo masculino. telemedicina e design de software educativo foram os recursos utilizados para implementar as intervenções, constatando-se uma diminuição nas rehospitalizações por causas coronárias. em relação à saúde mental, verificou-se uma diminuição da ansiedade e da depressão a longo prazo. conclusões: o tempo até a primeira rehospitalização cardiovascular foi de 502 (469-535) dias no grupo de intervenção, comparado com 445 (400-491) dias no grupo de controle. na avaliação da adesão à medicação, 94  % dos participantes registaram melhorias. em termos de estratificação do risco cardiovascular, tanto o grupo de intervenção (26  %) como o grupo de controle (6  %) passaram para uma classe de risco inferior. palavras-chave (fonte decs) reabilitação cardíaca; avaliação do impacto na saúde; doença cardíaca coronária; educação; enfermagem em reabilitação. este artigo é derivado da tese de mestrado intitulada “efetividade das intervenções educacionais para a reabilitação cardíaca em pacientes com doença crônica isquêmica: uma revisão sistemática”, defendida no âmbito do programa de mestrado em enfermagem da universidad de cartagena, colômbia. 6 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 3 introduction currently, the world health organization  (who) defines cardiovascular diseases  (cvds) as a group of cardiac and blood vessel disorders  (1) constituting one of the main causes of morbidity and mortality worldwide in the group of chronic non-communicable diseases (cncds) (2). in april 2021, during the socialization of the global health status report, the who documented that cncds represented approximately 71 % of the total number of deaths in the world, a worrisome situation considering the comparison of this phenomenon ten years ago, as this cause of death only represented 63 % in 2011. in addition, this report emphasizes that, among cncds, cvds caused 55.24 % of deaths in the age groups of adults and older adults (3). this becomes a public health problem and a risk to comply with one of the targets established in the sustainable development goals regarding a maximum 33  % reduction in the number of premature deaths due to cncds by 2030 (4). these diseases disproportionately affect middleand low-income countries when compared to high-income ones, as their onset is associated with factors such as globalization (integration of external habits from one country to another), unhealthy ways of living and eating habits, population aging and rapid unplanned urbanization, all associated with harmful health habits such as sedentary lifestyles (5). at the world economic forum, the economic wear out that cvd development causes in the countries was evidenced, describing that the losses in middleand low-income countries were over us$ 3 million for 2010 and that they are projected at us$ 8.6 million for 2030  (6), which affects the direct and indirect cost estimations due to cvds in the world, making them rise from us$ 863,000 million in 2010 to us$ 1,040,000 million for 2030. in the united states, according to the summary of heart diseases statistics published in 2021, approximately 2,200 people die due to cvds every year, which represents one out of three deaths in the cncd group; however, there is an additional problem as around 90 million americans live with some type of cvd or their sequelae (7). the national observatory belonging to the colombian national health institute established that cvs represented the leading cause of death in the group of cncds in the country. in 2019, cvds were the trigger for 69 % of all deaths, and a 15 % increase was projected for the 2010-2020 period, which would total 73 % and 60 % of the mortality and morbidity burdens, respectively  (8). this generates disability life years in people, as the colombian female and male populations currently hope to live a mean of 76.1 and 70.6 years, respectively, of which 18.2 and 17.8 years will represent disability life years, mostly secondary to cncds, with a significant percentage corresponding to cvds (9). im pa ct o f e du ca ti on al in te rv en ti on s to f os te r h ea lt h in p at ie nt s u nd er go in g ca rd ia c re ha bi lit at io n: a s ys te m at ic r ev ie w 7 in colombia, the proportion of deaths due to the cvd group is as follows: 30.6 % for stroke; 0.5 % for chronic rheumatic heart disease; and 12.4  % for hypertension, whereas the highest percentage (56.3 %) corresponds to ischemic heart disease (10). this shows the need to interact with patients with ischemic heart disease, defined by the who as blood vessel narrowing or blockage (11), with two presentations: a chronic and stable clinical condition and another acute (acute coronary syndrome or acs), which requires specific clinical management and treatments, mainly angioplasty and coronary bypass (12). in addition, it is not only necessary to discard mortality based on ischemic heart disease but it is also important to mention the high rate of sequelae that may be developed in people who suffer or have suffered the illness, the reason why it is opportune to address these patients since they cardiovascular rehabilitation. this concept emerges now as the result of years of observation and evidence that began in 1957, when hellerstein and ford (13) spoke for the first time about cardiac rehabilitation and its components, followed by the who in 1963, which defines it as “the set of necessary activities to ensure optimum physical, mental and social conditions for people with cvds, allowing them to occupy by their own means the most normal place in society as they can” (14). based on the aforementioned, the revista uruguaya de cardiología (15) describes the phases of cardiac rehabilitation programs: the first one, known as the hospital period, takes place during the patient’s admission to the care center, in the acute stage of the disease or decompensation. their main difficulty is that the hospitalization periods are increasingly shorter, impairing actions in this stage. the second phase (active or outpatient rehabilitation) encompasses the 2-3 first post-discharge months, after the initial effort test, and is performed in hospital units or heart centers according to each patient’s baseline risk; this is the best moment to counsel on adequate control of the risk factors. the third phase (maintenance) is limited in terms of duration and is usually conducted at the patient’s homes, either in heart centers or duly equipped gyms. the main objective of this phase is to keep the patients motivated to continue practicing the healthy lifestyles acquired (15). as stated by the inter-american cardiology society, the south american cardiology society and the cardiovascular prevention and rehabilitation inter-american committee in the consensus on cardiovascular rehabilitation and secondary prevention of the interand south american cardiology societies (16), cardiac rehabilitation programs are essential in the secondary prevention axis for cardiovascular events, as their objectives are targeted at assisting patients at a high risk of developing coronary diseases, 8 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 3 comprehensively rehabilitating them and educating them so that they maintain healthy habits, as well as to prevent cardiovascular events and ensure adequate control of the risk factors. these programs are designed to limit the physiological and psychological effects of heart diseases, mainly reducing the sudden death risk based on controlling cardiac symptoms, stabilizing or reverting the atherosclerotic process and increasing the psychosocial well-being state  (17), defined by the who as the well-being condition in which a person can put their capabilities into practice and can face normal life-related stress, as well as to work productively and contribute to their community  (18). a cardiac rehabilitation program (crp) is characterized by interdisciplinary and structured management, adequate prescription and monitoring of physical exercises, and education, follow-up and motivation of the patients for them to sustain healthy habits and adhere to the treatment (19). organizations such as the american heart association (20) and the american cardiology college  (21) agree upon the importance of crps and recognize them as an essential part of the care of cardiovascular patients, the reason why they are recommended as useful and effective  (class  i). on the other hand, the consensus achieved between the pulmonary and cardiovascular rehabilitation american association, the agency for the medical care policy and the american heart association established that to comply with the objectives of creating these programs, they should be offered in a multifaceted and multidisciplinary fashion, carrying out interventions targeted at reducing cardiovascular risk, so that they not only offer physical training but also educational interventions (22). the evidence shows that these programs have proven to reduce mortality by 20  % to 25  % among patients who have suffered an acute myocardial infarction, lowering the number of re-infarctions  (23); in addition, they have also proven to reduce the rate of major cardiovascular events after performing coronary angioplasties (24). in patients with heart failure, they have also shown efficacy both in achieving a reduction in terms of mortality and in reducing the number of hospitalizations (25). consequently, this review gains importance in searching scientific literature in spanish with a suitable information validation process, which includes studies assessed based on their methodological quality to have the best available evidence and contribute to reinforcing how people with cvds are intervened on. based on this, it is possible to document the information regarding the effect of these educational interventions, so that the phenomenon can be known in depth and strategies can be devised for patients undergoing rehabilitation processes. given the above, the following research question emerges: what is the effect of educational interventions during cardiac rehabilitation to foster health in patients with ischemic coronary disease? im pa ct o f e du ca ti on al in te rv en ti on s to f os te r h ea lt h in p at ie nt s u nd er go in g ca rd ia c re ha bi lit at io n: a s ys te m at ic r ev ie w 9 materials and methods a systematic review was conducted in the pubmed, scielo, lilacs, ebsco, medes, cuiden, dialnet, sciencedirect and cuidatge databases, with no restriction in terms of results. to create the search equations, the words ‘rehabilitación cardiaca, enfermedad cardiovascular and intervención educativa were used, which were combined with the and boolean operator for the setup and adapted to the english and portuguese languages, as follows: ‹cardiac rehabilitation‹ / ‹reabilitação cardíaca;’ ‹cardiovascular disease› / ‹doença cardiovascular;’ and ‹educational intervention› / ‹intervenção educativa.’ the bibliographic search was scheduled between february and september 2022, considering the protocol established in the prisma statement (26), which serves as a guide to provide information on how the question is formulated, data extraction, quality of the studies and risks of bias in systematic reviews. in addition, the project was registered in the prospero database (27) (crd42023398444). the results were extracted, selected and analyzed in october and november  2022; this phase was performed by implementing a blinded evaluation in charge of the lead and deputy researchers. table 1. inclusion criteria participants patients with ischemic heart disease who underwent cardiac rehabilitation. result measures physical, psychological or social clinical evaluations in the patients after cardiac rehabilitation. comparison conventional cardiac rehabilitation interventions versus conventional cardiac rehabilitation interventions + additional educational project. intervention educational strategies used during cardiac rehabilitation in patients with ischemic heart disease. language publications in spanish, english, and portuguese. design randomized controlled trials or clinical trials investigating an experimental group and a control group. source: prepared by the authors. studies published in the last ten years (2011-2021) were selected for the analysis to have updated scientific literature, considering that the concept of cardiac rehabilitation as known today was started to be worked on at the end of the 1970s; however, forty years after being implemented, underutilization of this service was described and, during the period selected, the patient’s adherence and the professionals’ interest in showing the benefits referring to the topic were evidenced. the studies included had to be quantitative, of the experimental or quasi-experimental type, and assess the effectiveness of the cardiac rehabilitation educational interventions in patients 10 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 3 with ischemic heart disease. the studies had to be in full-text format, although sample size and/or number of interventions were not considered to select the articles. the materials excluded from the review were studies belonging to the gray literature and/or systematic reviews, as well as those that presented a rating below  3 according to the jadad scale  (28), which allows for evaluating the methodological quality of clinical trials based on criteria described in the articles’ methodological section. the first step for their selection was to read titles and abstracts; subsequently, duplicate texts were removed, and the articles were read in full. finally, the jadad scale was applied to assess their quality and mitigate possible methodological and/or publication biases, a procedure with which the randomization criteria for the participants’ allocation and their losses and withdrawals were evaluated and scored, assigning these values: 1, 0 or -1. based on the sum of all five criteria, if the score is greater than 3 it can be inferred that the methodological quality is optimal (figure 1). of all 25 full-text articles assessed for eligibility, 7 were removed after full-reading for not meeting the inclusion criteria; the remaining 18 were submitted to bias and methodological quality assessments using the jadad scale, from where it was observed that 8  studies were of low methodological quality (1  point each), thus being excluded, with a total of 10 studies remaining to prepare the narrative synthesis table corresponding to the selection. figure 1. article selection process: identification, selection, analysis, and inclusion source: prepared by the authors based on the prisma statement guide. identi�cation of studies through databases and records records identi�ed in databases (articles found after the search in sciencedirect, pubmed, scielo, dialnet, medes, lilacs, and cuiden) (n=14,849). records removed before reviewing them. duplicate records removed (n=11,858). records removed for other reasons (n=0). records reviewed (n=2,994). records excluded (n=2,964). reports assessed for eligibility (n=25). articles excluded for not meeting the inclusion criteria (n=7). full-text articles excluded for low or average internal validity and global quality according to the critical reading performed following the jadad guide (n=8). studies included in the review (n=10). id en ti �c at io n r ev ie w in cl u si o n im pa ct o f e du ca ti on al in te rv en ti on s to f os te r h ea lt h in p at ie nt s u nd er go in g ca rd ia c re ha bi lit at io n: a s ys te m at ic r ev ie w 11 the data extracted were stored in a microsoft excel spreadsheet where the population characteristics, the type of intervention, the randomization procedure, the results of the intervention and the follow-up performed in each study were described. finally, the authors adhere to the ethical criteria and responsibilities outlined in resolution no. 8,430 of 1993 by the colombian ministry of health  (29), which categorizes this study as no-risk research, in addition to stating that no experiments with human beings or animals were conducted in this survey. regarding data confidentiality, no personal identification data from the patients are included in this article. the analysis unit derives from the findings in the publications and, for that purpose, aspects referring to quality of life, self efficacy, anxiety and depression were observed, in addition to biomarkers (lipid profile, weight, hospitalizations due to cardiovascular reasons during the study period). the descriptive statistical analysis was based on frequency, mean and standard deviation tables, and only two articles presented variance and covariance results. results regarding the general characteristics of the studies, they were randomized clinical trials from the methodological point of view. regarding the loci, the studies were developed in different world areas, the reason why four of all ten articles are from latin america and the caribbean (brazil, chile, cuba) and one article from north america  (canada) was selected, as well as two studies from the european continent (spain and germany), another two from asia (china and india) and one from oceania (australia)  (figure  2). referring to the year of publication, it is evidenced that most of the articles  (three) were published in 2014, followed by two in 2020 and one in 2011, 2016, 2017, 2018 and 2021. finally, in terms of language, all the articles selected are written in english (table 2). figure 2. worldwide distribution of the selected articles canada brazil, chile, cuba china, india spain, germany australia source: image traveling project. 12 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 3 table 2. narrative synthesis corresponding to the selection article main author year of publication country language methodological quality assessment jadad analysis method berenguel et al, 2017, spain (30) 1 excluded. does not apply. martínez et al, 2015 (31) 1 excluded. does not apply. i frederix et al – 2016 – spain – english (32) 3 selected. multicenter, prospective, and randomized and controlled clinical trial. ii furuya et al – 2014 – brazil – english (33) 3 selected. randomized controlled clinical trial. de melo et al, 2015, canada (34) 2 excluded. does not apply. de melo et al, 2015, canada (35) 2 excluded. does not apply. iii lumertz et al – 2014 – brazil – english (36) 3 selected. randomized controlled clinical trial. widmer et al, 2017, usa (37) 2 excluded. does not apply. naranjo et al, 2012, colombia (38) 2 excluded. does not apply. iv hwang et al – 2017 – australia – english (39) 3 selected. parallel non-inferiority trial of two groups with blinded result evaluators. v peng et al – 2018 – china – english (40) 3 selected. randomized controlled clinical trial. vi stoevesandt – 2020 – germany– english (41) 3 selected. randomized controlled clinical trial. vii de melo et al – 2020 – canada – english (42) 3 selected. multicenter trial. viii guerra et al – 2011 – cuba – english (43) 3 selected. randomized controlled clinical trial. ix brevis et al – 2014 – chile – english (44) 3 selected. randomized controlled clinical trial. x arjunan et al – 2021 – india – english (45) 4 selected. randomized controlled clinical trial. does not apply: excluded for not meeting the methodological quality criterion after applying the jadad scale. source: prepared by the authors based on the reviewed articles. im pa ct o f e du ca ti on al in te rv en ti on s to f os te r h ea lt h in p at ie nt s u nd er go in g ca rd ia c re ha bi lit at io n: a s ys te m at ic r ev ie w 13 as for the sociodemographic data recorded in the articles, we found that the participants included in the studies were mostly male (60 %-70 %) and with average and high schooling levels; in terms of occupation, they were retirees  (65  %) and assigned to phases  ii and  iii of the rehabilitation program; finally, regarding their age, the mean was 63 years old (table 3). the following inclusion criteria were established as requirements to participate in the studies: voluntary participation of candidates for coronary angioplasty treatments: patients with ischemic coronary disease; and patients requiring rehabilitation programs, although not necessarily hospitalized. it was found that six studies (32, 33, 36, 39, 40, 41) were developed in the telemedicine modality, resorting to voice calls, text messages, own software programs and digital platforms for synchronous and asynchronous meetings. as for the participants’ allocation to the intervention or control groups, they were randomly assigned by professionals that would not develop any intervention directly with the participants. table 3. characterization regarding the sociodemographic data of the selected studies a rt ic le age (years old) gender connection to the rehabilitation program intervention control intervention control intervention control male female male female i 62 63 86 % 14 % 79 % 21 % phase ii phase ii ii 63 60 60 % 40 % 53 % 47 % phase ii phase ii iii 60 60 56 % 44 % 41 % 59 % phase ii phase ii iv 68 67 57.1 % 42.9 % 61.2 % 38.8 % phase ii phase ii v 61 68 79 % 21 % 71 % 29 % phase ii phase ii vi 62 64 80 % 20 % 75 % 25 % phase i phase i vii 60 62 71 % 39 % 68 % 32 % phase ii phase ii viii 64 60 54 % 46 % 60 % 40 % phase ii phase ii ix 67 68 72 % 28 % 49 % 51 % phase ii phase ii x 63 64 52 % 48 % 65 % 35 % phase ii phase ii mean 63 63.3 source: prepared by the authors based on the articles reviewed. educational interventions implemented during cardiac rehabilitation the educational interventions were developed during a mean of twenty-four weeks. according to the new technologies to implement the interventions, two sessions per week were conducted before applying the pre-test (baseline). 14 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 3 aplication of the educational interventions telerehabilitation telemedicine phone follow-up individualized education m et h o d 0 0,5 1 1,5 2 2,5 3 3,5 4 4,5 figure 3. method used to develop the intervention in the designated group source: prepared by the authors based on the articles reviewed. the individualized education projects were designed to contribute to health literacy and self-management on the part of patients and family members, according to the needs detected during each patient’s initial evaluation when entering the program. regarding the topics developed in the interventions, they were focused on surgical and pharmacological treatments, education on heart diseases, nutrition and healthy habits (such as smoking cessation, performing physical activity and weight control), wound healing and management, and the need to change life habits and cardiovascular risk factors. table 4. synthesis of the educational interventions implemented in the selected studies article population intervention duration i 139 patients randomly allocated to two groups: intervention (ig) and control (cg). cg: they took part in a conventional crp. ig: they took part in a 24-week telerehabilitation program based on physical activity telemonitoring and telecoaching on nutrition, healthy habits and physical activity from the sixth week onwards. 24 weeks ii 60 patients randomly allocated to two groups: ig and cg. cg: they were offered education at discharge and took part in conventional control outpatient appointments. ig: they took part in an individualized educational program based on healthy habits, adherence to the treatment and education about the disease, by means of telephone follow-up. the program sessions were on the first, eighth and sixteenth week after hospital discharge. 18 weeks iii 74 patients randomly allocated to two groups: ig and cg. cg: they were offered conventional medical follow-up and general and unstructured counseling on lifestyles. ig: they were offered individual counseling sessions for one year about cvds, modification of risk factors, healthy habits and nutritional control; in addition, they received counseling once a month via telephone calls. 12 months im pa ct o f e du ca ti on al in te rv en ti on s to f os te r h ea lt h in p at ie nt s u nd er go in g ca rd ia c re ha bi lit at io n: a s ys te m at ic r ev ie w 15 article population intervention duration iv 53 patients randomly allocated to two groups: ig and cg. cg: they were offered conventional follow-up with a crp consisting of two sessions per week for twelve weeks. ig: they took part in a home-based telerehabilitation program that included an additional physical exercise plan to be performed three times a week, plus education through a video call platform that favored two-way communication. 24 weeks v 83 patients randomly allocated to two groups: ig and cg. cg: they were offered habitual care, planned education before discharge and periodic follow-up visits. ig: they took part in a telemedicine training program that consisted of a two-month intervention based on 32 physical training sessions with prior structured education on physical exercise, self-care and lifestyles, as well as on relevant aspects of coronary disease. 16 weeks vi 260 inpatients randomly allocated to two groups: ig and cg. cg: they were offered conventional follow-up with a crp. ig: they had a device to receive and evaluate additional information about the prevention of cncds and coronary heart disease, their treatments, risk factors and lifestyles. after each session (8 in total), all made a brief assessment. 3 weeks vii 162 patients that were crp candidates in three health centers. the participants were offered weekly classes of supervised physical exercises for 12-24 weeks, in addition to physical activity prescriptions for the other days of the week. asynchronous classes were also taught via a website and a standardized guide for patients, although adapted to meet the participants’ needs regarding eating habits, risk factors and treatments for cardiac diseases. 24 weeks viii 20 participants with heart diseases, angina pectoris, acute myocardial infarction and hypertensive heart disease. they attended a program in three phases. in the first phase, the learning needs were identified and the questionnaire was applied to assess the knowledge level before the intervention. the following variables were considered and categorized as adequate or inadequate: the concept of cardiovascular rehabilitation; risk factors; most frequent cardiovascular diseases; the influence of physical exercise on these pathologies, and treatment. 16 weeks ix 63 patients randomly allocated to two groups: ig and cg. cg: they were only offered habitual education before discharge. ig: they received an educational intervention targeted at nursing care in cardiac rehabilitation. 9 weeks x 200 patients with heart failure. cg: they took part in a conventional crp. ig: they took part in a structured educational program in charge of nurses, whose components included recommendations on diet, medication, physical exercise, weight control, smoking cessation, sodium restriction; and lifestyle changes. they were also shown an educational video for 5 days and subjected to telephone follow-up every 15 days for 6 months. 24 weeks source: prepared by the authors based on the articles reviewed. 16 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 3 the aforementioned allows for identifying the application of new technologies in the development of crps, which are of vital importance because they ease follow-up and development of educational interventions, contributing to ensuring their effectiveness when compared to traditional rehabilitation (table 4). table 5. synthesis regarding the impact of the educational interventions during cardiac rehabilitation article effect i one year after participating in the intervention, the number of rehospitalizations due to cardiovascular reasons was reduced in the intervention group when compared to the control group (7:13); likewise, improvements in the number of days until the first rehospitalization were found (502:445), as well as in the hospitalization times. the mean hospital care cost was lower in the intervention group; in addition, significant improvements were found in this group. finally, the profitability analysis showed that adding telerehabilitation to the crp in the centers (intervention group) was both more economical and effective than cardiac rehabilitation based on the center alone (control group). ii the result corresponding to the perception of the health status between the groups was not statistically significant at baseline (when initiating the intervention); however, once the intervention was concluded, the intervention group presented improvements in the social functioning domain and the role of emotions. referring to self-efficacy, no statistically significant differences were found. in terms of anxiety, a reduction was found over time in the intervention group when compared to the control group. both groups presented high adherence to medication. a statistically significant group-by-time interaction effect was observed for anxiety (p=0.04), which was reduced over time in the intervention group but was increased in the control group. iii when the patients’ participation in the intervention group was ended, a 1.7-point reduction was evidenced in cardiovascular risk, as well as a 1.2-point increase in the control group, both calculated according to framingham’s risk score. as secondary results in the intervention group, improvements were found in the laboratory parameters (lipid profile, glycated hemoglobin and glycemia), as well as in the anthropometric measures, especially weight. both groups presented high adherence to medication, although it was more predominant in the intervention group. iv at the cutoff moments of the evaluations made, it was found that there were no statistically significant differences between the groups at weeks 0 and 24 in relation to aerobic exercises, as well as for other functional measures, such as balance, strength, quality of life and urinary incontinence. however, during the evaluation at week 12, a difference in favor of the intervention group was evidenced in physical exercises. v statistically significant differences were found between the groups: the quality of life score assessed increased over time, achieving a sustained improvement after four months of the intervention; likewise, the functional physical exercise capacity increased in the intervention group, with no adverse events. referring to anxiety and depression, no interactions or significant changes were found between the intervention and control groups, as was the case of heart rate, of the new york heart association classification, and of the left ventricular ejection fraction, where no significant changes were detected. finally, it was concluded that the educational intervention is a feasible and effective method that improved the quality of life and functional capacity for physical exercise in the patients intervened. im pa ct o f e du ca ti on al in te rv en ti on s to f os te r h ea lt h in p at ie nt s u nd er go in g ca rd ia c re ha bi lit at io n: a s ys te m at ic r ev ie w 17 article effect vi a significant short-term effect on learning about the disease was observed in the intervention group. in the long-term, no relevant statistical significance was found regarding learning ability in the groups. finally, it was concluded that, although no statistical significance was found in any of the observations, a positive short-term effect was in fact identified on the learning ability, as well as positive trends in physical and mental health after the patients’ discharge, post-intervention. vii regarding physical activity, the mean number of steps walked per day increased significantly over time (p<0.001). in turn, regarding food intake, there were important differences in the scores over time (p<0.001), with more participants adhering to the mediterranean diet; in addition, a significant improvement was recorded in the physical exercise self-efficacy score (p<0.001). once the intervention was concluded, a significant improvement was found in the patient’s general knowledge in relation to food intake, self-efficacy and physical exercise; in addition, the results showed a significant and positive correlation between knowledge after the intervention, food intake and self-efficacy. on the other hand, schooling level and prior knowledge exerted an influence on the subsequent changes. viii the participants significantly improved their knowledge about cardiac rehabilitation, modification of risk factors and the importance of physical exercises. in general, before applying the educational program there was predominance of inadequate knowledge about the treatment among the patients with cvds (14, 70.0 %); however, after the program, it was corroborated that 17 patients (85.0 %) had properly acquired such knowledge. ix in this research it was possible to evidence that, followed by an evaluation at one and three months, the educational intervention generated changes in the modifiable risk factors, which were associated with better lifestyles. significant differences were found between the intervention and control groups in weight, waist circumference, bmi and systolic blood pressure among the female patients, whereas these differences were only observed for weight, bmi and waist circumference among the male patients. referring to the smoking habit, alcohol consumption and physical activity, statistically significant differences were found for tobacco and physical exercises. x when evaluating adherence efficacy, it was found that the mean difference between the intervention and control groups before the test was 0.680 (p<0.002). post-test 1 and post-test 2 presented a high mean difference (0.830 [p<0.001] and 0.876 [p<0.000], respectively) between the intervention and control groups. the mean scores in the pre-test (y=3.01±1.381), post-test 1 (y=3.89±1.83) and post-test 2 (y=4.18±1.041) were statistically significant for the intervention group (p<0.004) when compared to the control group (y=2.39, y=3.1 and y=3.3). in the intervention group, adherence to cardiac rehabilitation showed a statistically significant increase after the educational program interventions, as well as improvements in terms of health actions and behaviors. source: prepared by the authors based on the articles reviewed. impact of the educational intervention on the patients’ health after rehabilitation the effects or consequences after implementing the interventions targeted at the participants’ health evidenced a reduction in the number of rehospitalizations due to cardiac reasons, as well as a reduction in the days lost due to hospitalization related to these events; in addition, another favorable finding was the change in the cardiovascular risk factors (control regarding overweight, alcohol consumption, blood pressure, consumption 18 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 3 of fats and sugars and smoking habit). thus, the positive impact is not only denoted in the physical aspect; mental health was also favored, as the interventions contribute to strengthening it in aspects such as anxiety and depression reduction and management, as social and emotional support is found in crps. however, these interventions fail to achieve changes in the new york heart association (nyha) classification in the short-term (46). it is deemed relevant to note that, in the medium-term, the intervened patients achieve statistically significant improvements in the assessment corresponding to the framingham criteria (table 5). discussion through this systematic review, it was possible to identify the effect of educational interventions on patients with ischemic cardiac disease undergoing rehabilitation, considering that this program is targeted at reducing morbidity and mortality with this type of intervention. after the review that was conducted, it was possible to find the necessary documentation in the updated scientific literature to fully meet the objective proposed, which was defining the impact of educational interventions on fostering the health of cardiac rehabilitation candidates or patients undergoing it, thus identifying how favorable it is to early address this type of patients, due to the positive changes reflected in their health. the heterogeneity of the studies selected stands out among their characteristics, implying significant demographic and social changes in the study populations, which can have significance in the results, mainly when characterizing the populations. eventually, the studies that contributed to documenting the systematic review came from various countries, with brazil, spain, australia, china, germany and canada among them, which present different population typologies implying heterogeneous habits and lifestyles across the populations; however, all conclude on the effectiveness of the interventions and the benefits they reflect on the health of the patients addressed. in their study, roldan  et  al. pointed out similar results referring to the psychological, emotional and attitudinal changes described in the current systematic review. regarding the knowledge about and behavior of the patient’s cardiovascular risk factors, mild levels were found in the first measurement and considerable improvements were shown after the educational intervention. the patients’ healthy lifestyles also improved after the intervention  (47). these findings emphasize the importance of educational interventions in reducing cvd modifiable risk factors. in opposition to what has been mentioned in this article, mora et al. describe that 26 % of the study population intervened im pa ct o f e du ca ti on al in te rv en ti on s to f os te r h ea lt h in p at ie nt s u nd er go in g ca rd ia c re ha bi lit at io n: a s ys te m at ic r ev ie w 19 on presented some angina episode in the initial assessment to enter the cardiovascular rehabilitation program and that 15% of them did not require any type of treatment, whereas 5% had rehospitalizations (48). regarding the effect of the interventions, brevis et al. (49) concluded that, despite the good results of the educational interventions, the basic principle that continuous contact is required to achieve lifestyle changes is confirmed, which is similar to what was found in this study; in addition, it allowed establishing that there is no need for a specialized center to apply rehabilitation programs to coronary patients, arguing the need to incorporate them already in primary care. among the aspects to note, the support offered by the new technologies (telemedicine, tele-education, and telemonitoring) turns out to be beneficial in the patients’ follow-up and, for ibáñez et al. (50), they contribute to improving healthcare processes. in turn, stanberry (51) argues that telemedicine offers unique opportunities both for patients and for health professionals, which is evidenced in the results of applying this care method while the educational interventions are developed; however, it is noted that this occurs when the method is implemented as a direct response to clear clinical needs. the strengths of this systematic review lie first and foremost in recognizing the effect of educational interventions on improving the health of patients with ischemic coronary disease undergoing cardiac rehabilitation, considering that no research studies of this type referring to the theme addressed were found in the literature. likewise, knowing the educational interventions, their design towards cardiac rehabilitation and their effectiveness allows for improving nursing performance when managing these patients; in addition, it represents a reference point to continue implementing strategies and new effective interventions in the treatment of these ever-increasing pathologies. the literature review yielded a limited number of studies; however, the methodological quality assessment allowed for selecting the most adequate materials in terms of methodological design to reduce biases. according to this, this research becomes an input for the nursing discipline and the scientific community in general, so that decision-making in the management of people with cardiovascular diseases can be improved. even if the results of this research meet the objective proposed, it is important for future surveys not to limit the search to the english and portuguese languages but that more languages can be added; in addition, it is recommended to conduct a scoping review that allows including other types of designs, especially around the users’ perceptions and experiences. 20 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 3 conclusions based on the systematic review of the scientific articles about the effect of educational interventions for cardiac rehabilitation on patients with ischemic coronary disease, it is concluded that such interventions improve quality of life, reducing morbidity and rehospitalizations in people with this background; however, in terms of anxiety and depression symptoms and self-efficacy, there is no significant statistical evidence showing how educational interventions can modify these aspects in the short-term. the most outstanding effect exerted no impact on the participants’ health conditions but it was framed on the improvement of the patients’ general knowledge about ischemic coronary disease, cardiac rehabilitation and lifestyle changes, showing that the patients’ rehabilitation process is fundamental when it comes to fostering cognitive strengthening that favors the behavioral approach required to correct the risk factors. it is important to note that, although statistically significant changes were evidenced in all the studies in terms of the knowledge acquired after the intervention, they would only be in the short-term and the initial effect is lost in subsequent evaluations without new interventions; the exact opposite occurs concerning adherence to medication, which is maintained over time. there is scientific evidence of high methodological quality around the effectiveness of the educational interventions in this review, which allows health professionals to propose actions since the cardiac rehabilitation initial phases that contribute to empowering patients in their recovery and in changing unhealthy habits. although it was shown that educational interventions improve the health of people who have suffered ischemic coronary disease, it is necessary to continue conducting research studies in this line, as the number of papers found was limited. this strategy will allow for strengthening nursing professionals’ work, as they will have scientific evidence for decision-making. conflict of interest statement the authors declare having no conflict of interests. im pa ct o f e du ca ti on al in te rv en ti on s to f os te r h ea lt h in p at ie nt s u nd er go in g ca rd 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https://www.redalyc.org/pdf/2611/261120984009.pdf https://www.redalyc.org/pdf/2611/261120984009.pdf https://doi.org/10.1046/j.1365-2796.2000.00699.x https://doi.org/10.1046/j.1365-2796.2000.00699.x 286 aquichan issn 1657-5997 arleth herrera1 inna e. flórez2 elizabeth romero3 amparo montalvo4 soporte social a cuidadores familiares de personas con enfermedad crónica en cartagena5 1 magíster en enfermería, facultad de enfermería, universidad de cartagena, colombia. aherreral@unicartagena.edu.co 2 magíster en enfermería, facultad de enfermería, universidad de cartagena, colombia. iflorezt@unicartagena.edu.co 3 magíster en enfermería, facultad de enfermería, universidad de cartagena, colombia. eromerom@unicartagena.edu.co 4 magíster en enfermería, facultad de enfermería, universidad de cartagena, colombia. amontalvop1@unicaragen.edu.co 5 esta investigación hace parte del estudio multicéntrico “soporte social con tecnología de la información y la comunicación (tic) para cuidadores familiares de personas con enfermedad crónica en américa latina", liderado por el grupo de cuidado al paciente crónico y su familia, de la universidad nacional de colombia. recibido: 28 de mayo de 2012 aceptado: 24 de septiembre de 2012 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 l 286-297 resumen objetivo: determinar el soporte social percibido en cuidadores familiares de personas con enfermedad crónica en la ciudad de cartagena, colombia. método: estudio descriptivo en 222 cuidadores de familiares, entre octubre de 2009 y octubre 2010; se utilizó el instrumento "inventario" de soporte social en enfermedad crónica, propuesto por hilbert, integrado por cinco categorías. los datos se expresan por medio de la estadística descriptiva. resultados: el 91.4% de los cuidadores son mujeres, 54,35% con edades comprendidas entre los 36 y 59 años y una edad promedio de 43,7 años. los cuidadores presentaron una percepción de apoyo social satisfactoria, con una media de 148.97 y una desviación estándar de 33.94, la puntuación mínima obtenida fue de 35 puntos, la máxima de 204. en mayor proporción el apoyo a los cuidadores fue brindado por los hermanos (24%), la pareja (22,2%) y los hijos (17.6%). conclusión: los cuidadores están satisfechos con el apoyo social percibido, especialmente en las categorías: "interacción personal" y "educación e información", recibida por quienes integran su red. se requieren propuestas innovadoras desde la enfermería para apoyar a las personas en situación de enfermedad crónica y sus cuidadores. palabras clave cuidadores, enfermedad crónica, apoyo social, enfermería (fuente: decs de bireme). social support for family caregivers of chronically ill persons in cartagena abstract objective: determine the social support perceived by family caregivers of chronically ill persons in the city of cartagena, colombia. method: a descriptive study of 222 persons serving, during the period from october 2009 to october 2010, using the social support in chronic illness "inventory" tool proposed by hilbert, which consists of five categories. the data are expressed through descriptive statis287 soporte social a cuidadores familiares de personas con enfermedad crónica en cartagena l arleth herrera, amparo montalvo, inna, e. flórez, elizabeth romero tics. results: 91.4% of the caregivers are women, 54.35% are between 36 and 59 years of age, and their average age is 43.7 years. the caregivers displayed a satisfactory perception of the social support they receive, with a mean of 148.97 and a standard deviation of 33.94. the lowest score was 35 points and the highest was 204. the most support for caregivers was provided by their siblings (24%),spouses (22.2%) and sons and daughters (17.6%). conclusion: caregivers are satisfied with their perceived social support, especially in the categories of "personal interaction" and "education and information" received from those who make up their network. innovative proposals from nursing are required to support chronically ill persons and their caregivers. key words caregivers, chronically ill, social support, nursing (source: decs de bireme). suporte social para cuidadores familiares de pessoas com doença crônica em cartagena resumo objetivo: determinar o suporte percebido em cuidadores familiares de pessoas com doença crônica na cidade de cartagena, colômbia. método: estudo descritivo, em 222 cuidadores familiares durante outubro de 2009 a outubro de 2010. utilizou-se o instrumento “inventário” de suporte social em doença crônica, proposto por hilbert, integrado por cinco categorias. os dados se expressam por meio da estatística descritiva. resultados: 91,4% dos cuidadores são mulheres; 54,35% com idade compreendida entre 36 e 59 anos e uma idade média de 43,7 anos. os cuidadores apresentaram uma percepção de apoio social satisfatória, com uma média de 148,97 e uma desviaçao padrão de 33,94; a pontuação mínima obtida foi de 35 pontos, e a máxima de 204. em maior proporção, o apoio aos cuidadores foi oferecido pelos irmãos (24%), pelo companheiro (22,2%) e pelos filhos (17,6%). conclusão: os cuidadores estão satisfeitos com o apoio social percebido, especialmente nas categorias “interação pessoal” e “educação e informação”, recebida pelos que integram sua rede. requerem-se propostas inovadoras da enfermagem para apoiar as pessoas em situação de doença crônica e seus cuidadores. palavras-chave cuidadores, doença crônica, apoio social, enfergagem (fonte: decs de bireme). 288 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 introducción el aumento de la esperanza de vida y la demanda de más y mejores servicios sociales y sanitarios suponen un reto para la sociedad del conocimiento. como consecuencia del alargamiento de la vida, aumenta también el número de adultos con discapacidades y enfermedades crónicas (1). con el gradual envejecimiento de la población y la mayor supervivencia de personas con enfermedades crónicas y discapacidades, no solo aumenta el número de casos que necesitan cuidados sino que, además, este incremento de la demanda se acompaña de mayor exigencia en su prestación (2-4). la enfermedad crónica genera en el paciente incertidumbre, desgaste físico, dependencia y cambios en el estilo de vida, y tiene repercusiones en las áreas personal y social del individuo, de modo que si el paciente no cuenta con el suficiente apoyo o soporte social no logrará la readaptación a la crisis circunstancial que vive (5). solo una comunicación empática y comprensiva, en la que en algún momento se expliciten las reticencias y se hagan aflorar los sentimientos negativos facilita que se pueda ofrecer compañía, ayuda o consuelo (6). se observa que a medida que los enfermos se hacen más dependientes recae una mayor responsabilidad sobre el cuidador principal, quien a su vez está expuesto a un mayor trabajo, limitando el tiempo disponible para establecer o mantener sus relaciones sociales (7). el cuidado de un familiar en casa tiene importantes consecuencias emocionales; crespo (8), en su estudio con cuidadores con problemas emocionales, informó compromisos en más de la mitad de ellos: 56% presentan niveles de depresión, un 18% llegan a ser moderados o graves, el 42% presentan ansiedad. la mayoría de los cuidadores (61%) señalan que tienen o han tenido problemas emocionales (nervios, ansiedad, estrés) desde que cuidan a su familiar, un 32% de los casos han tenido que buscar ayuda, y un 23% han debido seguir un tratamiento. arango (9) encontró en cuidadores de pacientes con demencia del contexto colombiano puntuaciones significativamente más bajas en cada una de las dimensiones de la calidad de vida relacionadas con la salud, frente al grupo control de individuos sanos, quienes presentaron mejores niveles de educación, socioeconómico y mayor número de participantes masculinos. se han abordado las implicaciones del cuidado en el cuidador y su relación con variables como la sobrecarga, la depresión y el soporte social percibido. arango (10) informó asociación entre los problemas cognitivos y de comportamiento/emocionales de la persona con demencia, con mayores niveles de depresión y sobrecarga del cuidador; asimismo, los problemas de conducta/ emocionales se asociaron con una menor puntuación del soporte social percibido por el cuidador. investigaciones en diversos países muestran que el apoyo informal continúa siendo una fortaleza para quienes necesitan cuidados, además de ser un gran ahorro para el estado (11). en su estudio roure (12) confirma la existencia de una clara relación entre la percepción de apoyo social por parte del enfermo y la de los cuidadores informales. los cuidadores informales presentaron una percepción de apoyo social global con una media de 43,9. el papel del cuidador informal se valora como muy imprescindible para el 51% de los enfermos, el 37,3% de los propios cuidadores informales y el 25,6% de los profesionales. hay relación entre el apoyo social percibido por el enfermo y por el cuidador informal: cuando el enfermo percibe un apoyo social adecuado tiene un cuidador informal que, habitualmente, también lo percibe así. el estar sometido a situaciones estresantes puede dar como resultado que el cuidador experimente problemas emocionales, sociales e incluso físicos; no obstante, existen una serie de variables moduladoras que mediatizan las consecuencias de los estresores y pueden aliviar su efecto en la persona: se trata de los recursos personales del propio cuidador, entre los que juega un papel especialmente relevante el apoyo social. desde este punto de vista, resulta esencial prestar apoyo a los cuidadores, ayudarles a cuidar y a cuidarse mejor; para ello crespo y lópez plantearon el programa de intervención psicoterapéutica “como mantener su bienestar”, dirigido a cuidadores familiares de personas mayores dependientes, con el objetivo de mejorar su calidad de vida e, indirectamente, la de los mayores a los que prestan apoyo a partir de las características, los problemas y las necesidades de los cuidadores (8). el apoyo social es un concepto inherente a los cuidados familiares que se intercambian en las familias, tanto en situaciones cotidianas como de crisis. sin embargo, cuando estos cuidados se desarrollan de forma prolongada en alguno de los miembros de la familia por motivos de enfermedad o dependencia, se producen situaciones de estrés crónico que afectan los sistemas de apoyo 289 soporte social a cuidadores familiares de personas con enfermedad crónica en cartagena l arleth herrera, amparo montalvo, inna, e. flórez, elizabeth romero de los cuidadores (13, 14). el apoyo social es considerada la variable más importante para la familia, ya que es una fuente de ayuda para los cuidadores al momento de hacer frente a situaciones que le son propias (15). el concepto de soporte social en la interacción de los seres humanos es un elemento esencial en situaciones de enfermedad crónica. es calificado como una ayuda para que el cuidador afronte mejor la experiencia de cuidar a su familiar (16), y en el paciente amortigua los efectos adversos de la enfermedad; numerosos datos apoyan la idea de que las personas que cuentan con buenas redes sociales se adaptan fácilmente a su situación; de la misma manera, el contar estas redes protege contra el estrés generado por la enfermedad y capacita al paciente para reevaluar la situación y adaptarse mejor a ella, ayudándolo a desarrollar respuestas de afrontamiento (17). hilbert (16) clasifica el soporte social en cinco categorías: l interacción personal: apoyo de tipo emocional referido para el afrontamiento adecuado en diversas situaciones de enfermad crónica. l guía: principales ayudas que percibe el cuidador con educación e información. l retroalimentación: sentir que quienes les brindan apoyo están de acuerdo con ellos y apoyan sus pensamientos y acciones. l ayuda tangible: ayuda material y ayuda en tareas físicas y labores desempeñados por el rol del cuidador. l interacción social: apoyo para permitir que los cuidadores rescaten sus relaciones con otros grupos, familias e instituciones que respondan a sus necesidades (16). el apoyo social debe considerarse como un proceso interactivo en el que puede obtenerse ayuda emocional, instrumental o financiera a partir de una red social (18). thoits (19) lo considera como el grado en que las necesidades básicas de una persona son satisfechas a través de la interacción con otros, las cuales incluyen el afecto, la estimación, el consentimiento, la pertenencia, la identidad y la seguridad. con relación a los tipos de apoyo, la mayoría de autores coinciden en al menos tres categorías: emocional, instrumental e informacional (20-22). el apoyo emocional se concreta en términos de expresiones de afecto, cariño, empatía, etc.; el instrumental supone realizar acciones o proporcionar materiales o servicios que sirven para resolver problemas prácticos, como por ejemplo prestar dinero o ayudar en las tareas de la casa, y el informacional son aquellas intervenciones que implican aconsejar, informar o guiar. las fuentes o proveedores de apoyo son todas aquellas personas de las que el sujeto recibe apoyo (parientes, vecinos, parejas, conocidos, compañeros de trabajo, profesionales de la salud o miembros de instituciones religiosas o asociaciones). el apoyo emocional, y particularmente la percepción que de él se tiene, es el más claramente relacionado con la salud; el apoyo informacional aparece como capaz de modificar la severidad de la enfermedad; el apoyo instrumental se relaciona con resultados positivos cuando se suministra en cantidades moderadas (23, 24). el término red social hace referencia al conjunto de relaciones entre miembros de un grupo o colectivo, así como a la descripción de los vínculos establecidos entre los componentes de ellas. la calidad del apoyo refleja la adecuación del apoyo social y se refiere al equilibrio entre las necesidades del receptor y la medida en que estas son cubiertas (25). los cuidados familiares se ofrecen normalmente por una red de cuidadores compuesta por un cuidador principal, varios cuidadores secundarios que ofrecen ayuda indirecta, y otros miembros de las redes, lo que señala bowling como círculos de apoyo en torno a los cuidadores principales en los que aparecen familiares, amigos, voluntarios etc., más o menos cercanos a los cuidadores en función de la implicación, intimidad y cercanía a estos (18). en términos generales se asume que la presencia de relaciones personales cercanas con otros, el grado de integración del individuo con su entorno, y contar con ciertos recursos sociales y psíquicos permanentemente se encuentran relacionados positivamente con la salud (26). el concepto de red social sirve para describir la estructura de los vínculos entre los individuos, en tanto que el apoyo social se refiere al soporte que es suministrado precisamente a través de las conductas o acciones de los miembros que forman parte de una red (27, 28). si bien se ha documentado la situación de los cuidadores en la ciudad de cartagena, y las implicaciones de su rol sobre la calidad de vida, evidenciándose la necesidad de apoyo, no se cuenta con investigaciones sobre soporte social a cuidadores familiares 290 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 tendentes a potenciar el establecimiento de redes, y desde enfermería desarrollar propuestas frente a las demandas del cuidado informal. el objetivo del presente estudio fue determinar el soporte social percibido en cuidadores familiares de personas con enfermedad crónica en la ciudad de cartagena. método estudio descriptivo, cuantitativo de corte transversal, realizado en cartagena a una muestra de 222 cuidadores familiares de pacientes con enfermedad crónica (nivel de confianza del 95%, proporción de 5,5%, con un error de 3%), del total de cuidadores de pacientes con enfermedad crónica existentes en la ciudad de cartagena. fueron seleccionados cuidadores mayores de 18 años, sin alteración del estado de conciencia, sin remuneración económica y que convivieran con la persona cuidada por un tiempo mayor de un mes. la investigación mantuvo los parámetros éticos para estudios con seres humanos incluyendo el consentimiento informado, la participación voluntaria, el manejo confidencial de la información, el empleo de la evidencia disponible para la intervención terapéutica a los cuidadores familiares, y la autorización del comité de ética de la universidad de cartagena. no presentó riesgos importantes para los participantes. la información fue recolectada por los investigadores previo conocimiento por parte de cada uno de los cuidadores del propósito del estudio, de su participación voluntaria y de la firma del consentimiento informado. se aplicó la encuesta de caracterización de los cuidadores familiares de personas con enfermedad crónica (29) elaborada por el grupo de cuidado al paciente crónico de la facultad de enfermería de la universidad nacional de colombia, la cual consta de 13 ítems que describen aspectos sociodemográficos y de relación de cuidado. los cuidadores seleccionados se ubicaron a través de las organizaciones dedicadas a trabajar con grupos de pacientes con determinada enfermedad crónica (alzheimer, parálisis cerebral, niños con leucemia y fibrosis quística), a quienes se les solicitó autorización, previo conocimiento de la propuesta de investigación, y a cuidadores de pacientes con enfermedad crónica (accidente cerebro vascular) localizados en sus lugares de residencia. el promedio de tiempo utilizado para recolectar la información con cada cuidador fue de veinte minutos, fueron utilizados códigos para mantener el anonimato de los participantes. a un cuidador no se le recolectó el total de la información por dificultades personales. para medir el soporte social se empleó el instrumento “inventario de soporte social en enfermedad crónica de hilbert”, integrado por cinco subescalas: interacción personal (1-10), guía (11-17,30-36), retroalimentación (18-21, 37, 38), ayuda tangible (21-24) e interacción social (25-29). cada ítem se califica mediante una escala tipo likert, que va de 1 insatisfecho hasta 6 muy satisfecho. la puntuación total oscila entre 38 y 228, a mayor puntaje mayor grado de satisfacción con el apoyo brindado por la persona nombrada como la más importante por el cuidador (30). para el presente estudio no se utilizaron los ítems que corresponden a la subescala ayuda tangible, dado que la investigación no proporcionó apoyo material, y el de las tareas físicas y labores desempeñadas por el cuidador, tomándose como rangos de puntuación 34 y 204. la confiabilidad del instrumento para el presente estudio a través del alfa de cronbach fue: interacción personal 0,93; guía 0,95; retroalimentación 0,89; interacción social 0,88 (31). este instrumento ha sido utilizado en población colombiana (32), en la investigación multicéntrica “soporte social con tecnología de la información y la comunicación (tic) para cuidadores familiares de personas con enfermedad crónica en américa latina” liderado por el grupo de cuidado al paciente crónico y su familia, de la universidad nacional de colombia. permite determinar la efectividad del soporte social brindado a través de las tic a cuidadores familiares de personas con enfermedad crónica. los datos fueron analizados en el paquete estadístico spss versión 16.0® del cual se obtuvieron las frecuencias absolutas y relativas, medias y desviación estándar. resultados características sociodemográficas y relación de cuidado de los cuidadores de los cuidadores que hicieron parte del estudio, el 91,4% son mujeres, 54,35% con edades comprendidas entre los 36 y 59 años, y una edad promedio de 43,7 años. el 95,5% sabe leer, han alcanzado un grado de escolaridad igual o inferior al técnico en un 86,5%, están casados o en unión libre el 61,1% de ellos, se dedican a actividades del hogar o trabajo formal el 78,5%, pertenecen al estrato 1 el 42,6%, y el 52% de los sujetos de cuidado es mayor que el cuidador. el 79,4% de los participantes cuida desde el momento del diagnóstico, el 61% de ellos lleva más de 19 meses en esta labor, 291 soporte social a cuidadores familiares de personas con enfermedad crónica en cartagena l arleth herrera, amparo montalvo, inna, e. flórez, elizabeth romero el 67,8% dedican más de 13 horas diarias al cuidado, el 42,6% son únicos cuidadores, la responsabilidad del cuidado recae sobre los progenitores y los hijos en más del 60%, y reciben apoyo de familiares en un 64,2%. soporte social percibido por los cuidadores la puntuación mínima obtenida por los cuidadores fue de 35 puntos, la máxima de 204, con una media de 148,97 y una desviación estándar de 33,94. el apoyo social recibido por los cuidadores fue satisfactorio, la totalidad puntuó por encima del valor medio; en mayor proporción el apoyo es brindado por hermanos (24%), la pareja (22,2%) y los hijos (17,6%) (tabla 1). tabla 1. persona que brinda apoyo social al cuidador tabla 2. interacciones personales de los cuidadores persona que le ayuda a resolver problemas diarios ¿qué relación tiene con usted? n° % hermana/hermano 53 24,0 pareja 49 22,2 hija/hijo 39 17,6 padres 28 12,7 otro familiar 25 11,3 amigo/amiga 15 6,8 compañera/compañero 6 2,7 fuente: datos del estudio. categorías del soporte social a cuidadores interacciones personales de los cuidadores en esta categoría los cuidadores puntuaron una media de 44,63 y una desviación estándar de 9,88. reportaron satisfacción en los aspectos relacionados con: me hace saber que puedo contar con ella (él) si necesito su ayuda en el 73,4%, expresan interés y preocupación por su bienestar en un 70,9%, y cuando quieren hablar su familiar está disponible para escucharlos en un 66, 8% (tabla 2). item insatisfecho (%) parcialmente satisfecho (%) algo satisfecho (%) satisfecho (%) dice que estoy bien como estoy 16,3 16 16 51,2 me conforta mostrándome algo de afecto físico 5,9 11 19 64,4 me hace saber que puedo contar con ella (él) si necesito ayuda 8,6 5 13 73,4 expresa interés y preocupación por mi bienestar 7,7 8,6 13 70,9 me dice que se siente muy cercana (o) a mí 10 9 17 64,3 está disponible para escuchar cuando yo quiero hablarle 7,7 8,1 17 66,8 disfruta escuchando lo que yo pienso 7,2 8,1 19 65,7 me consuela cuando estoy molesta (o) 10 13 18 59,7 permite que yo vaya donde ella (él) cuando me siento deprimido 9,5 9 16 65,9 me acepta totalmente, incluyendo lo mejor o peor de mí 9,5 8,6 20 62,5 fuente: datos del estudio. guía de los cuidadores en esta categoría las puntuaciones se ubicaron por encima del punto medio (media de 61,15 y desviación estándar de 11,22). los cuidadores percibieron satisfacción en un 65,2% en la orientación de cómo hacer las cosas, el 67% en la motivación a tener cuidado de sí mismo, el 64,3% les enseñan a cómo actuar ante una situación, el 64,1% les comparten información sobre las recomendaciones dadas por el equipo de salud. el mayor grado de insatisfacción (que no alcanza al 15% de los encuestados) se encontró en aspectos relacionados con el hablar acerca de los problemas presentados en materia de recomendaciones en salud, y en las orientaciones dadas acerca de la persona a quien se debe buscar cuando se presentan problemas con las recomendaciones hechas por parte del equipo de salud (tabla 3). 292 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 tabla 3. guía de los cuidadores retroalimentación de los cuidadores la media en esta categoría se ubicó en 21,24 y una desviación estándar de 5,81, presentando un comportamiento altamente positivo. la existencia de un adecuado soporte social en los cuidadores de la ciudad de cartagena, en relación con la retroalimentación, está dada por la satisfacción en un 63,3 y 62,9% de los cuidadores al reconocerles que ejecutan y siguen en forma favorable las recomendaciones más importantes del equipo de salud. están satisfechos en gran porcentaje al sentir que la persona que los apoya los reafirma, les confirma e interactúa positivamente cuando se cumplen las recomendaciones en materia de salud. en menores porcentajes, con el 52,5 y 51,6%, a los cuidadores les retroalimentan acerca de cómo hacer las cosas y revisan los consejos dados (tabla 4). tabla 4. retroalimentación de los cuidadores item insatisfecho (%) parcialmente satisfecho (%) algo satisfecho (%) muy satisfecho (%) me dejó claro lo qué se esperaba de mí 8,1 7,7 22,6 61,6 me orientó sobre cómo tenía que hacer ciertas cosas 9,5 10,9 14,5 65,2 me dio información para ayudarme a entender la situación en que me encontraba. 9,9 10,4 18,1 61,6 me dijo cómo buscar asistencia 10,9 11,3 16,7 60,2 me dijo qué esperar en una situación que estaba a punto de ocurrir 10,9 8,6 17,2 62, 4 me enseñó cómo hacer algo (en una situación) 10,9 8,6 16,3 64,3 me habló sobre un problema para ayudar a resolverlo 10,4 13,6 16,7 59,4 compartía información conmigo sobre las recomendaciones que hacía el equipo de salud 9,0 8,6 17,2 64,1 me ayudó a comprender mi enfermedad 11,7 10,9 16,3 51,1 me dijo a quién debo buscar para que me asista cuando tengo problemas con las recomendaciones del equipo de salud 13,6 10,4 18,1 58,0 me dijo qué tan útiles eran las recomendaciones del equipo de salud para evitar complicaciones 10,8 8,6 17,6 62,9 me enseñó cómo llevar a cabo las recomendaciones dadas por el equipo de salud 10,9 11,3 16,3 62,6 habló conmigo acerca de los problemas que he estado teniendo con las recomendaciones del equipo de salud 11,8 7,2 21,7 59,4 me motivó a tener un cuidado de mí mismo 10,0 10,4 12,7 67,0 fuente: datos del estudio. item insatisfecho (%) parcialmente satisfecho (%) algo satisfecho (%) satisfecho (%) revisa conmigo si he seguido los consejos que me da 10,8 15,8 21,7 51,6 me ayuda a entender por qué no hago algo bien 13,6 14,5 14 58,0 me retroalimenta acerca de cómo estoy haciendo las cosas, sin decirme si está bien o no 13,5 13,1 20,8 52,5 revisa si he seguido las recomendaciones que considero importantes 13,5 9,5 14 62,9 hace comentarios favorables cuando ejecuto recomendaciones del equipo de salud 8,6 10,4 17,6 63,3 fuente: datos del estudio. interacción social de los cuidadores la puntuación media se ubicó en 21,95 con una desviación estándar de 5,70. los cuidadores en un 63,0% presentan satisfacción en aspectos relacionados con compartir algún interés con la persona que les brinda apoyo social, igualmente el 60,6% están satisfechos por recibir ánimo mediante chistes o bromas, y 293 soporte social a cuidadores familiares de personas con enfermedad crónica en cartagena l arleth herrera, amparo montalvo, inna, e. flórez, elizabeth romero distraerse de las preocupaciones. en el 57,0% los cuidadores se sienten satisfechos por poder hablar sobre los intereses personales con quien les brinda el soporte, no obstante, el aspecto en el que reportan mayor insatisfacción fue en el de recibir alternativas de distracción y recreación, en un 20,4% (tabla 5). tabla 5. interacción social de los cuidadores ofrecen (figuras múltiples), y los más preocupados por ayudar y apoyar material y emocionalmente. la evaluación del soporte social a través de las categorías propuestas por hilbert mostró un comportamiento similar en cada una de ellas, con mejores resultados en las categorías interacción personal y guía. los cuidadores sienten satisfacción con la información recibida, la educación, el que compartan información acerca de las recomendaciones del equipo de salud y la motivación para el cuidado. astudillo (36) señala que a los cuidadores, especialmente al que ejerce de cuidador principal, se les informa por parte del equipo de salud sobre cómo va a ser la evolución de la enfermedad, cómo proceder para mantener o mejorar su calidad de vida, controlar sus síntomas y posibles complicaciones, y proveerse de los elementos necesarios para su asistencia. debido a las múltiples tareas que las personas ocupadas de un enfermo deben realizar, requiere que se sientan entendidas y acompañadas por los familiares para poder abordar desde la acogida y el respeto sus temores, deseos y necesidades. artnian (37) afirma que los familiares cuidadores de los adultos se mostraron menos satisfechos con la información que se les da sobre los cuidados, el tratamiento, las complicaciones y la enfermedad. la falta de información puede contribuir a la ansiedad y el desconcierto del familiar cuidador al no saber cómo actuar en las diferentes situaciones que se le presentan en el transcurso de la enfermedad. durante las crisis de una enfermedad grave las familias quieren, más que nunca, recibir una información honesta sobre la condición del paciente, su progreso diario, los cambios en su estado clínico y pronóstico, y se quejan a menudo de la falta de información o de problemas para comunicarse con el equipo de salud (36). el tiempo que se le dedique a los familiares cuidadores para escucharlos y dar respuesta a sus necesidades de información es fundamental a fin de disminuir la ansiedad y la incertidumbre que presentan y mejorar el cuidado que se brinda en el hogar al enfermo (38). en cuanto a las interacciones personales, en el presente estudio los cuidadores están satisfechos porque son conscientes de que cuentan con un tipo de apoyo que les expresa interés y preocupación por su bienestar, y disposición para escucharlos. es básico que los cuidadores mantengan sus vínculos afectivos que amortiguan el estrés y la tensión, a pesar del exceso de trabajo, y que no se alejen de sus amigos y familiares, por lo que deben disponer siempre de algún tiempo libre para hacer las actividades que les gustan (36). item insatisfecho (%) parcialmente satisfecho (%) algo satisfecho (%) satisfecho (%) me ofrece alternativas de distracción y recreación 20,4 11,8 15,4 52,5 habla conmigo sobre algunos de mis intereses 12,2 10,9 19,9 57,0 me hace bromas o chistes para darme ánimo 11,8 13,6 14 60,6 comparte conmigo algún interés 11,7 9,5 15,8 63,0 puedo contar con ella o él para distraerme de las preocupaciones 12,6 8,6 18,1 60,6 fuente: datos del estudio. discusión nuevamente se reafirma la presencia de la mujer como cuidadora con edades comprendidas entre los 36 y 59 años, condición que la sitúa en el cumplimiento de diferentes roles. en el presente estudio, el principal soporte lo reciben de hermanos, pareja e hijos, destacándose la participación de los hijos e hijas como cuidadores y responsables del cuidado, contrario a los hallazgos de wellman (33), donde el apoyo cotidiano fue provisto por vecinos y compañeros de trabajo más que por familiares. otros estudios orientados a la estimación de las redes personales globales sugieren que la proporción de familiares se sitúa, en promedio, en torno al 25%, la proporción de compañeros de trabajo alrededor 20% y la de vecinos alrededor del 6% (34). para villalba (35), los hijos/as cumplen funciones de apoyo similares en las distintas categorías y dimensiones. escuchan, acompañan, ayudan económicamente y con tareas a los sujetos, teniendo una presencia significativa en las funciones de orientación, guía, consejo y tiempo de ocio. son los que más tipos de apoyo 294 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 asimismo, minkler (39) encontró que las abuelas cuidadoras estaban implicadas en redes densas de mutua ayuda caracterizadas por un nivel alto de contacto y reciprocidad; el 92% de su muestra tenía una persona confidente. la percepción de apoyo ofrecido por los confidentes tiene unos efectos potenciales de protección de salud física y mental según demostraron lowenthal y haven (40) al poner de manifiesto la importancia de las relaciones íntimas como un factor de adaptación positiva en los adultos mayores. heller (41) planteó la importancia de favorecer la calidad de relaciones con confidentes en las intervenciones con mayores, por el componente de apoyo de estas relaciones de intercambio de intimidades. los cuidadores del estudio disponen de personas que les proporcionan soporte social en lo que se refiere a la reafirmación, confirmación e interacción positiva entre las personas. al respecto, freedman (42) sostiene que la interacción dinámica desarrollada en la familia, junto con una serie de elementos estructurales que la condicionan, son elementos que generan un clima que contribuye al desarrollo personal de sus miembros (42). en este sentido, williams (43) considera al clima social familiar como el ambiente de interacción que coadyuva al desarrollo y adaptación personal de sus miembros o, por el contrario, los perjudica. diversos estudios han demostrado que las personas que disponen de un sistema de apoyo familiar efectivo soportan mejor las crisis de la vida, y que el impacto del estrés es mucho menor que en las que no tienen este tipo de apoyo disponible (44). en la interacción social los cuidadores del estudio se mostraron satisfechos al compartir, por la distracción y el entretenimiento recibido por las personas que les brindan apoyo, por las bromas y los chistes, y el compartir intereses. astudillo (36) expresa que cuanto mejor funcione el apoyo al cuidador del enfermo oncológico, más protegidos estarán los enfermos y sus cuidadores, que además de atenderles, deben poder intervenir en el cuidado de sus hijos y atender muchas de las tareas que la persona que se ocupa de un enfermo debe realizar pero que ahora no lo puede hacer. su presencia permite que la familia y los cuidadores se sientan entendidos y acompañados para poder abordar desde la acogida y el respeto sus temores, deseos y necesidades. moreno (45) informó como necesidades más frecuentes de los cuidadores familiares la de discutir los sentimientos con amigos y otros familiares (90%), necesidad de discutir los sentimientos con otros cuidadores o personas que hayan vivido una experiencia similar (93%), necesidad de recibir ayuda de organizaciones dentro de la comunidad (93%), de recibir información completa sobre el estado del paciente (92%), y de recibir información especializada sobre el mismo (97%). con menos frecuencia, las de mejorar la apariencia personal (2%), ayuda económica (5%), ayuda para el cuidado de los niños (16%), ayuda para cuidar al paciente con demencia (17%), tiempo para pasar con los amigos (17%) y tiempo para dormir (26%). conclusiones dentro del soporte social a cuidadores de la ciudad de cartagena, los resultados encontrados permiten evidenciar que los cuidadores presentan satisfacción con el apoyo percibido, especialmente el de tipo emocional, y educación e información. se destaca como principal sistema a la familia. el estudio aporta elementos teóricos y metodológicos que permitirán el desarrollo de propuestas innovadoras desde la disciplina de enfermería para mantener o mejorar el apoyo que reciben las personas en situación de enfermedad crónica y sus cuidadores, a fin de potenciar y apoyar la constitución de grupos y redes de apoyo social que a su vez permitan visibilizar su condición. implicaciones para enfermería: los resultados del estudio aportan a la cualificación del cuidado, especialmente del cuidado informal, toda vez que el incremento de las enfermedades crónicas trae consigo el aumento de los cuidadores y de su morbilidad asociada con el rol. los resultados precisan la necesidad de intervenciones desde enfermería tendentes a la utilización de las tic como estrategias de soporte social. se requiere investigación disciplinar e interdisciplinar, y líneas que implementen programas de cuidado a los cuidadores, midan su efectividad y generan propuestas de cuidado novedosas. limitaciones: la estrategia de soporte social no permitió evaluar la totalidad de las dimensiones propuestas por hilbert, toda vez que no se brindó ayuda material ni apoyo en las tareas físicas para determinar la efectividad de la dimensión ayuda tangible. agradecimientos las autoras presentan sus agradecimientos a la vicerrectoría 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[consultado: enero 2 de 2012]. 280 289 gerentes de escuelas de enfermeria.indd 280 aquichan issn 1657-5997 danelia gómez-torres1 vianey méndez-salazar2 martha velasco-whetsell3 gerentes de escuelas de enfermería: una discusión sobre su adaptación al entorno social según la teoría de roy 1 doctora en enfermería. profesora, universidad autónoma del estado de méxico, méxico. gomezdanelia@usa.net 2 doctora en educación. profesora, universidad autónoma del estado de méxico, méxico. vianneyms@usa.net 3 phd. rn, arnp. associated professor, lehman college, estados unidos. marwhet@hotmail.com recibido: 10 de julio de 2012 enviado a pares: 27 de julio de 2012 aceptado por pares: 25 de marzo de 2013 aprobado: 4 de abril de 2013 año 13 vol. 13 nº 2 chía, colombia agosto 2013  280-289 resumen objetivo: la investigación aborda el desempeño gerencial de las primeras directoras enfermeras en la región central de méxico, con el objetivo de analizar los retos afrontados por ellas en su entorno social durante su gestión en las escuelas de enfermería en la década de los setenta. método: se llevó a cabo un estudio cualitativo de corte histórico-social, sustentado en la teoría de adaptación; los sujetos de estudio fueron las directoras o sus colaboradoras cercanas. para la recolección de datos se utilizó la entrevista; los datos se analizaron con la técnica colorimétrica. resultados: los resultados revelaron que sus retos fueron: sociales, de género y erradicar el estigma social. los mecanismos innatos: ser visionarias; los adquiridos: vencer el miedo al cargo, adaptarse a la organización universitaria. conclusión: la investigación ofrece aportes a la teoría, y señala su aplicabilidad en el ámbito gerencial. se refleja el significado de adaptación en la posición gerencial, mostrando que el nivel de adaptación fue integrado. palabras clave: enfermería, gerencia, adaptación, historia, méxico. (fuente: decs, bireme). para citar este artículo / to reference this article / para citar este artigo gómez torres, d., méndez salazar, v., whestell, m. (2013). gerentes de escuelas de enfermería: una discusión sobre su adaptación al entorno social según la teoría de roy. aquichan. vol. 13, no. 2, 280-289. 281 gerentes de escuelas de enfermería: una discusión sobre su adaptación al entorno social según la teoría de roy l danelia gómez-torres, vianey méndez-salazar, martha velazco-whestell nursing school directors: a discussion on adapting to the social environment based on the roy theory abstract objective: the study addresses the managerial performance of the first nursing directors in mexico’s central region, so as to analyze the challenges they faced in their social environment while managing nursing schools in the seventies. methods: a qualitative, socialhistorical approach was used, based on the theory of adaptation. the subjects were directors or their close collaborators. the data was collected through interviews and analyzed with the colorimetric technique. results: the results showed their challenges were social, gender related and involved eradicating social stigma. the inherent mechanisms were: being visionary; those acquired; overcoming fear of being in charge; and adapting to the university organization. conclusion: this research contributes to the theory and signals its applicability in the field of management. it reflects the importance of adaptation in managerial positions and shows the level of adaptation was comprehensive. keywords nursing, management, adaptation, history, mexico. (source: decs, bireme). diretores de escolas de enfermagem: uma discussão sobre sua adaptação ao contexto social segundo a teoria de roy resumo objetivo: a pesquisa aborda o desempenho gerencial das primeiras diretoras enfermeiras na região central do méxico, com o objetivo de analisar os desafios enfrentados por elas em seu contexto social durante sua gestão nas escolas de enfermagem na década de setenta. método: realizou-se um estudo qualitativo de corte histórico-social, sustentado na teoria de adaptação; os sujeitos de estudo foram as diretoras ou suas colaboradoras mais próximas. para a coleta de dados, utilizou-se a entrevista; os dados foram analisados com a técnica colorimétrica. resultados: os resultados revelaram que seus desafios foram: sociais, de gênero e de erradicação do estigma social. os mecanismos inatos: serem visionárias; os adquiridos: vencerem o medo do cargo e se adaptarem à organização universitária. conclusão: a pesquisa oferece contribuições à teoria e sinaliza sua aplicabilidade no âmbito gerencial. reflete-se o significado de adaptação na posição gerencial ao mostrar que o nível de adaptação foi integrado. palavras-chave enfermagem, gerência, adaptação, história, méxico. (fonte: decs, bireme). 282 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 introducción el conocimiento de enfermería se desarrolla para facilitar la comprensión de lo que ocurre en el encuentro entre la enfermera y la sociedad. su construcción se fundamenta en la utilización de modelos teóricos que aportan enseñanza y respuestas a la investigación, posibilitando su aplicación al desarrollo de la profesión como ciencia y su reestructuración en la práctica por estar intrínsecamente relacionadas. de ahí que la utilización de una teoría de enfermería define claramente cuál es el camino, conduciéndonos o guiándonos en la realización del proceso investigativo. algunas proposiciones teóricas nos marcan directrices, tanto en la aplicación de la práctica como en el comportamiento del método de investigación y, consecuentemente, en el establecimiento de metas e intervenciones para las acciones de enfermería. por ello, el orientar esta investigación con la teoría de adaptación de roy, cuya meta de enfermería es la adaptación al cambio, permite amalgamar la teoría con el objeto de estudio: la adaptación durante el cambio gerencial, ya que las escuelas eran dirigidas por médicos y la enfermera generó mecanismos de adaptación para ejercer dicho cargo. para conocer esa etapa de adaptación de la enfermera al asumir la gerencia de las instituciones de educación superior nuestro propósito de investigación fue: analizar los afrontamientos presentados por dirigentes enfermeras en su entorno social durante su gestión en las escuelas de enfermería en la década de los setenta, ya que en esta época se consolida la transición de médicos a enfermeras en la dirección de escuelas en la mayor parte de méxico. esa etapa nos ofreció los insumos para visualizar el nivel de adaptación en la posición gerencial, mostrando también los alcances y la proyección de gerencia ejercida por las enfermeras. marco teórico la teoría de adaptación de calixta roy se centra en la adaptación del hombre; en su metaparadigma comprende los conceptos de persona, salud, enfermería y entorno, los cuales están relacionados en un todo global. roy (1) considera al hombre un ser bio-psico-social, en relación constante con el entorno —el cual es cambiante, pues un hombre es un complejo sistema biológico que trata de adaptarse a los aspectos de la vida—, bajo el contexto de cuatro modos de adaptación (1), de los cuales, para los fines de esta investigación se consideraron tres: 1. la autoimagen. el yo del hombre debe responder también a los cambios del entorno (1). 2. el domino de un rol. cada persona cumple un papel distinto en la sociedad según su situación —madre, docente, enfermera, gerente—, este papel cambia en ocasiones y debe adaptarse al nuevo papel que tiene. 3. la interdependencia. se centra en las reacciones cercanas de las personas, ya sea como individuos o como parte de un colectivo, es su finalidad, estructura o desarrollo. la interdependencia es un rol temporal o particular; en esta investigación se denota que cada persona cumple un papel distinto en la sociedad según su situación —madre, docente, enfermera, gerente—. el dominio del rol implica conductas de razón de la posición de la persona en la sociedad y depende de cómo una persona interactúa con otras en una situación concreta. existen roles primarios y secundarios, el secundario es lo que una persona asume para terminar las tareas, este último se conjuga con el rol social, donde para los individuos existe la necesidad de saber quién es uno respecto a otros a fin de poder actuar (1). por ello se consideró que en la gestión el rol cambió, de subordinada, a adaptarse al nuevo papel de gerente. los problemas de adaptación son áreas que describen las dificultades que presentan los indicadores de la adaptación positiva. así, estos problemas son áreas de interés de las enfermeras en relación con la persona o el grupo al que se tienen que adaptar. pero lograr esa adaptación requiere afrontar estímulos contextuales, que hacen referencia a todos los factores del entorno que se le presentan a la persona, tanto interna como externamente. asimismo, se deben generar procesos de afrontamiento a través de mecanismos innatos que se determinan genéticamente o son comunes a las especies —por lo general se perciben como procesos automáticos—, y mecanismos adquiridos —se crean por medio de métodos, como el aprendizaje—. las experiencias vividas a lo largo de la vida contribuyen a que se presenten reacciones habituales ante estímulos particulares que se desarrollan por medio de procesos de aprendizaje, de tal manera que el afrontamiento es importante para poder actuar ante los cambios producidos en el entorno porque en él actúan cuatro canales, tanto cognitivos como emotivos, estos son: el perceptivo y de procesamiento de la información, el aprendizaje, el juicio personal y las emociones. 283 gerentes de escuelas de enfermería: una discusión sobre su adaptación al entorno social según la teoría de roy l danelia gómez-torres, vianey méndez-salazar, martha velazco-whestell la teoría de adaptación refleja que en este gran sistema existen respuestas adaptativas, las cuales mueven todos los sistemas humanos; en términos de adaptación, esas respuestas producen crecimiento, desarrollo, destrezas y transformación de la persona. para estudiar esas respuestas adaptativas, contrastarlas y mostrar cuáles fueron los procesos de afrontamiento que debieron salvar las enfermeras dentro de su entorno social vigente fue que se aplicó este referente, el cual reflejó el nivel de adaptación gerencial para proyectar su significado en la gestión de enfermería. método esta es una investigación de tipo cualitativo, dado que pretende captar lo subjetivo como un medio de comprender e interpretar las experiencias personales (2), con enfoque histórico-social, ya que para comprender su contexto profesional fue imprescindible conocer su ayer histórico; tal enfoque comprende el estudio de los grupos humanos en un tiempo determinado, y se preocupa en discutir los variados aspectos cotidianos de las diferentes clases y grupos sociales; para este caso el grupo social es el de enfermería. de ahí que la investigación fue instrumentada sistemáticamente mediante los tres pasos considerados esenciales por coelho y susskind (3): recolección de datos, evaluación crítica de los datos, presentación de hechos y conclusiones. fue seleccionada la historia oral temática ya que hace referencia a los proyectos que tienen como propósito central en el conocimiento de un problema o tema de investigación, constituyéndose como el objeto del conocimiento, debido a que la historia inferida en los escenarios sociales, que a lo largo de los tiempos se torna abierta a las aproximaciones y los distanciamientos de las verdades y sus significados, y con el afán de abordar fenómenos y cuerpos de evidencias específicos con fuentes nuevas y plurales, como son estudios referentes a la vida social de las personas, este tipo de información acerca de la transformación social en el tiempo se obtiene de registros o fuentes que pueden ser las personas que vivenciaron y participaron del proceso histórico; ante lo referido se tomó como fuente viva a la cronista o historiadora de cada escuela o facultad. el estudio está fundamentado en la teoría de adaptación de roy, la cual se centra en la adaptación del hombre y sus conceptos de persona, salud, enfermería y entorno, relacionados en un todo global; esta teoría se cimienta en la de sistemas para estudiar esas respuestas adaptativas, en donde se consideró como punto central en la investigación el entorno social del fenómeno, estableciéndose tres categorías afrontamientos, modos de adaptación, adaptación. los escenarios de estudio en esta investigación se ubican en facultades de enfermería universitarias, en el contexto regional central de méxico, siendo siete las instituciones de educación superior que circundan al estado de méxico. la investigación fue desarrollada en dos etapas: en primer lugar, para la construcción del proyecto de investigación se determinó su registro ante la universidad autónoma del estado de méxico —el cual quedó asentado con el número 2772/2009— y su financiamiento, después se remitió el proyecto al comité de ética de la universidad para su aprobación. en segundo lugar, se efectuó la recolección de datos los cuales fueron recogidos a través de una entrevista semiestructurada definida previamente en una guía de entrevista, con preguntas fundamentadas por la teoría de adaptación de roy, pero la secuencia, así como su formulación, tuvo un grado de elasticidad en función de cada sujeto entrevistado. la técnica de recolección de datos cualitativos presentó las siguientes ventajas: oportunidad para motivar y aclarar al informante; libertad para el investigador de ampliar las preguntas, en el sentido de profundizar y descifrar puntos considerados importantes para los objetivos del estudio; flexibilidad al ampliar al máximo las posibilidades de captación del mayor número de información. para la validación de la guía a fin de determinar la claridad y el entendimiento en el lenguaje utilizado en dicho instrumento se aplicaron tres entrevistas a docentes cercanas a las primeras directoras que vivieron el proceso de transición de la gestión, con una guía que contenía siete preguntas semiestructuradas y una pregunta abierta, que incluían los referentes de tres categorías. las exdirectoras de cada escuela o facultad se contactaron vía telefónica o por correo electrónico para formalizar fecha y lugar de la entrevista. para la obtención de información en casos de exdirectoras ya fallecidas se contactaron las colegas de las exdirectoras que vivenciaron y participaron de ese proceso histórico. como criterio de inclusión se tuvo en cuenta que la facultad en el momento del estudio contara con el puesto de dirección dentro de su estructura organizacional institucional. dado que son estudios referentes a la vida social de las personas —porque el tipo de información es acerca de la transformación social durante una determinada etapa—, las aportaciones fueron de tipo historia oral, por ello se les consideró a estas como fuentes primarias. 284 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 para cumplir lo establecido en la ley general de salud mexicana en materia de investigación de seres humanos en su capítulo 100, apartados 12 al 20, se les entregó un formulario de consentimiento libre e informado, el cual fue leído y firmado por las entrevistadas previamente. por las características del estudio esta fue considerada una investigación sin riesgo para los participantes. para el tratamiento de datos se procedió a la búsqueda de los significantes más trascendentes, se organizó la información recolectada y se le asignó una letra a cada entrevista; después de ser leídas y releídas se trabajó con la técnica colorimétrica para seleccionar las unidades de análisis más sobresalientes, con la finalidad de obtener datos que reflejaran los afrontamientos y modos de adaptación, hasta llegar al nivel de adaptación en el ámbito social durante el periodo de gestión. para la evaluación crítica de la información metodológicamente fue necesario validar los datos para poder determinar la calidad e importancia de los mismos, esto desde la elaboración de la guía de entrevista, hasta la interpretación el comportamiento de la directora-enfermera. en la fase de estudio fue utilizada la técnica de análisis de contenido a fin de investigar el significado profundo y la estructura de un mensaje o comunicación (4) para determinar la calidad y relevancia de la información, con el objetivo de evaluar y validar el contenido a través de la lectura crítica interna de datos, determinando así la validez de los hechos, viabilizando la aprehensión del significado de la declaración y determinando la credibilidad de lo ocurrido, lo cual posibilitó interpretar el comportamiento de la directora-enfermera en su entorno social, centrándose de esta manera en el estudio del fenómeno. posteriormente a la interpretación de los datos, y para plasmar lo que ocurrió y por qué ocurrió, es decir, las relaciones entre las ideas, las personas y las instituciones de educación durante el periodo de transición, se hace la presentación de los hechos, desplegándose por subcategorías: afrontamiento / retos sociales, afrontamiento / género, afrontamiento/estigma social; mecanismos innatos / ser visionaria, mecanismos de adquiridos / alianzas; contrastando con las áreas de autoimagen, domino de rol, e interdependencia, congruentemente con lo establecido dentro de la teoría de adaptación. resultados para desarrollar la investigación fue necesario acercarnos a los actores sociales que presenciaron el momento histórico de la transición, por ello a las once entrevistadas se les ha considerado como fuentes primarias, ya que ofrecieron datos de sus propias vivencias, las entrevistas se desarrollaron en un clima de cordialidad y de remembranza del pasado. los datos se presentan según las categorías que surgieron. afrontamientos. durante la etapa de empoderamiento de la dirección de escuelas de enfermería en la parte central de méxico en los años setenta, cuando se da la transición del médicodirector a la enfermera-directora de la escuela de enfermería, se presentaron varios procesos de afrontamiento desde múltiples aristas, concibiendo esta categoría como un proceso en donde la interacción permanente del individuo y el ambiente desencadena múltiples estrategias según situaciones particulares, las que no pueden ser valoradas en primera instancia como buenas o malas, sino como una relación con los resultados obtenidos en términos de estabilidad y adaptación para el individuo. afrontamiento / estigma social. como esencial para el desarrollo de enfermería ha sido, es y será la función gerencial de las enfermeras en la formación de nuevas generaciones de estas profesionales, lo cual permitió fortalecer la autonomía, mejorar la visibilidad, así como el desarrollo y la transformación de la profesión en su entorno social, entendiendo por este último todas las circunstancias e influencias que rodean y afectan el desarrollo de las conductas de las personas y los grupos (1), de tal manera que el poder creativo de la enfermera buscó mantener su integridad y eliminar el estigma social en beneficio de cambios significativos en el entorno de la enfermería. como lo exterioriza una de las entrevistadas: “fue un reto de figurar como algo distinto, o sea como algo que no se había cuidado, nosotros queremos a nuestra carrera, a nuestra profesión, entonces sí costó mucho trabajo quitar ese estigma local, social, que había en nuestro estado” (e-c). en el ámbito social se manifiestan claramente los afrontamientos de mujeres que han tenido que luchar por su autonomía académica, por el reconocimiento que lleve a la soberanía e identidad de grupo, de donde las expectativas de unos y otras se alejan porque se parte de un déficit de capital social especialmente dentro de un campo dominado por varones (5), hecho que se refleja en la necesidad de la revalorización y legitimación como vía de acceso reconocido por y para la profesión, que se convierten en elementos de fomento para la igualdad entre las mujeres y los varones. 285 gerentes de escuelas de enfermería: una discusión sobre su adaptación al entorno social según la teoría de roy l danelia gómez-torres, vianey méndez-salazar, martha velazco-whestell cuando hablamos de identidad de grupo nos referimos al campo social del profesional, donde lo social es determinado por roy como el movimiento dirigido por mujeres que van a favor de la independencia y el orden, obteniendo cambios superiores en lo social (1). esa decisión de lograr un cambio positivo y novedoso para la disciplina debió ser un móvil de las nuevas gerentes, con la visión de crear mecanismos compensatorios congruentemente con el desarrollo de su función gerencial, pues existían retos por afrontar como el de posesionarse en el campo universitario, como es señalado: pues creo que no era un espacio para la mujer, era un espacio más bien para los médicos. la enfermera debería de estar si no en su casa, en el hospital, como que íbamos hacer lo que se hacen en la casa, el cuidar, el atender, pero no a nivel universitario, creían que no teníamos la capacidad (e-q). era evidente que en la época de los años setenta la actuación primordial del profesional de la enfermera estaba delegada al cuidado de paciente y no a la gerencia. la falta de oportunidades y demás factores desdibujaban la práctica; sin embargo, es a partir de la toma de la gerencia de las escuelas de enfermería por enfermeras que se despliega la necesidad de buscar un punto de equilibrio entre asistencia y gerencia en los ámbitos del ejercicio profesional y no solo el control administrativo. roy (1) menciona en los postulados de su teoría que una persona gasta mucha energía en los procesos de afrontamiento dejando poca energía para el logro de metas de crecimiento y dominio, lo cual es altamente compatible con el ámbito de la gerencia. afrontamiento / género. para adaptarse al nuevo rol la gerente enfermera tuvo que afrontar la resistencia al cambio de género masculino a femenino. gutiérrez (6) sostiene que el afrontamiento es parte del proceso de adaptación, y esos procesos y transiciones de la vida diaria se ajustan a otras experiencias amenazantes que producen desestabilización. lo anterior se reflejó en las opiniones plasmadas por una de las exdirectoras al mencionar los problemas para aceptar al profesional de enfermería, ya que la gerencia era ejercida en su mayoría por el género masculino: se acostumbraron a la presencia del médico, […] yo pienso que en ese momento era problema de género, entonces no querían que una mujer las dirigiera y sí hubo resistencia de algunas y sí hubo personas que no la aceptaron dentro del mismo personal de enfermería […] pero en general las enfermeras a lo mejor todavía no nos sentíamos muy fuertes, nos sentíamos débiles y nos afianzábamos del fuerte, por eso queríamos a un médico y que sea hombre para que nos dirija, sí (e-p). en el cambio influyen múltiples factores, en general las personas responden a situaciones a partir de su educación, de experiencias anteriores, o de la forma como ellas las descifran, sabiendo que en su comportamiento se refleja la interpretación que hacen de la situación en un momento determinado, siendo este un aspecto fundamental en el proceso de adaptación. roy (1) sostiene que la persona tiene un poder creativo de autodeterminación y que de su integración con el ambiente resulta la adaptación. de ahí que para lograrla se requiere reunir características específicas y poder franquear estos retos, e indiscutiblemente se requiere un marco referencial sustentado en valores, creencias, conocimientos y habilidades que puedan respaldar una adaptación en los puestos gerenciales. así, al cuestionar si el hecho de ser mujer y enfermera propició afrontamientos específicos para poder asumir la posición jerárquica ya que el género masculino era el que predominaba, la respuesta fue contundente: sí, sí definitivamente, yo incluso hasta ahora lo he recordado; yo utilizaba mi nombre de casada, cuando pasaban lista en el consejo universitario siempre me decían “señora enfermera r. m. de la vega l. de salinas”, entonces para ellos, como que el respaldo del esposo, en ese momento era así como algo de estatus, porque a lo mejor si yo hubiese estado sola, como que no […] entonces tanto me reconocían mi persona, como el hecho de que yo estuviera casada […] se me hacía muy curioso, y a las maestras de bellas artes no (e-q). como lo manifestó la entrevistada, indiscutiblemente se observa una querella de género, porque para hacer visible la presencia y las contribuciones de las mujeres en la tarea humana un importante componente es la persistencia de normas sociales y valores tradicionales relacionados con los roles que deberían tener los hombres y las mujeres en la sociedad —el hombre debe estar relativamente centrado en el trabajo y la mujer no necesariamente— (7). al explicarnos las relaciones sociales en las que se construyen las ciencias y se toman las decisiones de importancia sobre su naturaleza (5). en este argumento el mecanismo compensatorio es inherente con lo profesional, pues roy a lo profesional lo considera como un modo de adaptación al rol, con singularidades como ser una categoría con profesionalismo, haciendo alusión de experiencia, de decisión por mujeres que van a favor de la soberanía. 286 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 afrontamiento / retos sociales. una dirigente tiene que generar habilidades para manejar situaciones con orientación de sistemas humanos, porque estos tienen capacidad para pensar, sentir y se basan en la conciencia y significado (1), debiendo ajustarse de manera adecuada a él, para influir en los cambios de ese mismo entorno generando modos adaptativos, ya sean innatos o adquiridos, ganando espacio y confianza con su intervención, tal cual era el reto que debían demostrar las directoras de aquel entonces en las entidades universitarias según lo expresado por una entrevistada: primero que el rector confiara en una mujer, […] pues ya llevaba camino abierto al haber precedido a una médica y con el apoyo de los directivos de la institución, […] entonces prácticamente el reto era que se confiara en alguien de enfermería, ese era un reto (e-c). las enfermeras realizaron actividades que promovieron respuestas de adaptación efectivas o positivas al modo de desempeño de roles, y mostraron una adaptación a la gerencia a través del tiempo, reflejando una mejoría en la relación con otras personas, así como la capacidad de promover el desarrollo y la transformación disciplinaria. autoconcepto. al analizar los datos de la investigación, uno de los hallazgos interesantes fue que una de las entrevistadas tenía dificultad para valorar su autoconcepto, el cual se define como el conjunto de creencias y sensaciones que una persona tiene de sí misma (8). este se relaciona con la percepción acerca de la capacidad de desempeño gerencial, tal situación se develó de esta manera: … creo que lo más fuerte a lo que me enfrenté […] lo que yo pude visualizar en ese momento, es que yo estaba abriendo un camino […] yo tuve algunas cosas para poder aceptar o no el cargo, porque cuando me lo propusieron yo pensé en mil cosas desde el concepto de poder o no poder en el cargo, las dudas de un poco de meterme a la organización universitaria (e-c). descubrimos que la postulante a la dirección se encontraba con la incertidumbre de poseer la capacidad para ejercer ese nuevo rol de gerente, aspecto ligado al papel que tiene la persona en la sociedad y la opinión interna y de otros, lo cual genera reacciones que influyen en el comportamiento, de tal manera que el modo de adaptación debe ser interpretado como la unidad de funcionamiento de la sociedad, conceptualizado en la teoría de adaptación como: el conjunto de expectativas que se tienen del comportamiento de una persona que ocupa una posición hacia otra persona que ocupa otra posición. la necesidad básica en la que subyace el modo de adaptación de la función de rol se ha identificado como integridad social, a saber, la necesidad que se tiene de saber quién es uno mismo con respecto a los demás, para así saber cómo actuar (1). para llegar a estos modos de adaptación debe haber un autorreconocimiento del potencial que se posee (o sea del autoconcepto), así como de la posición jerárquica que se sustenta. este proceso de afrontamiento es una de las características para lograr la adaptación a través de los mecanismos de afrontamiento adquiridos, como son el aprendizaje y las experiencias vividas, aspectos que fueron aplicados tal como lo manifiesta la siguiente entrevistada: “… yo creo que se va venciendo ese temor a medida que uno va teniendo la confianza y de alguna manera pues el reconocimiento de los demás; pues éramos iguales, éramos todos directores” (e-q). esta respuesta en el modo de adaptación de la función del rol se identifica como integridad social, que se define como la necesidad de saber quién es uno mismo con respecto a los demás, para así saber cómo actuar (8). aquí se visualiza que la adaptación de la enfermera gerente se debió al reconocimiento del grupo con base en las reacciones ante el entorno. porque a partir de las creencias en sus propias capacidades y competencias, se postula que la autoeficacia se forma a partir de cuatro fuentes: los logros de ejecución, la experiencia vicaria, la persuasión verbal y el estado fisiológico (10). en cuanto a los logros de ejecución, es una de las más importantes porque la percepción de eficacia se debe al éxito o fracaso repetido en determinadas tareas, no solo académicas sino también de las individuales. de ahí que las personas como seres adaptativos holísticos funcionan como una entidad con algún propósito, además de ser interactuantes con el ambiente, tales planteamientos tienen congruencia con la declaración de exdirectora y la posición de roy. mecanismo innatos / ser visionaria. el ambiente está directamente relacionado con los estímulos. roy (1) define los estímulos como todo aquello que provoca una respuesta y es el punto de interacción del individuo con el ambiente. para lograr esas respuestas adaptativas emergen los mecanismos de afrontamiento, que son las formas innatas o adquiridas de respuesta ante los cambios del entorno. este factor que desencadena una respuesta inmediata contribuye al logro de la meta de adaptación de las per287 gerentes de escuelas de enfermería: una discusión sobre su adaptación al entorno social según la teoría de roy l danelia gómez-torres, vianey méndez-salazar, martha velazco-whestell sonas en el mundo. en el caso concreto de enfermeras-gerentes, estas expresan que para mejorar la calidad de actuación dentro del marco de la gerencia lo deseable es que la gerente sea visionaria, convirtiéndose en un mecanismo innato básico como se refleja en las siguientes respuestas: … nos preparó a un grupo de personas y estábamos con ella de entre las dos de la tarde que terminaban las clases hasta las cinco o seis de la tarde nos tenía en sesión continua ahí en el hospital, lo que era la castañeda, ahí trabajando, preparándonos, por eso les digo que era muy visionaria, muy capaz; eso es aparte de que fuera enfermera, yo creo que ya como persona es brillante (e-p). se percibe que las competencias de las enfermeras son un pilar fundamental para establecer una relación sistemática de su función, obteniéndose logros tanto cualitativos como cuantitativos dentro de la organización así como para los profesionales de enfermería (11, 12) ya que estas son apegadas a las necesidades reales y vistas de manera interdisciplinaria por estas directoras enfermeras. ella estaba muy preparada porque siempre había manejado la escuela entonces cuando se quedó de directora pues tenía la preparación, tenía la práctica, tenía la visión, sabía muy bien hacia dónde quería ir, objetivos y todo (e-t). … para mi muy particular punto de vista fue una visionaria, que para su tiempo trataba siempre de mejorar la calidad de la atención, de mejorar la calidad de la enseñanza, que las enfermeras fueran mejores (e-d). en las aportaciones de las participantes se observa que el ser visionarias fue uno de los mecanismos innatos que debieron emplear las enfermeras mexicanas, lo que redundó fundamentalmente en el impacto social. de la mano con la teoría de roy, la persona tiene la capacidad de decidir y participar activamente en su proceso de adaptación, por eso debe sentir que se le toma en cuenta y que sus aportaciones son importantes (13). también es relevante señalar que la enfermera, para lograr una adaptación gerencial, debe tener una respuesta de afrontamiento en su función de rol terciario, el cual se relaciona con el papel que desempeña la persona en su entorno social, quedando evidente que el ser visionaria contribuye positivamente al proceso de adaptación. mecanismos adquiridos / alianzas. si los mecanismos de afrontamiento adquiridos se desarrollan por medio de procesos como el aprendizaje y las experiencias vividas, y contribuyen a que se reaccione con respuestas propias, adaptadas ante estímulos concretos, los resultados permiten patentizar que una de las habilidades para el logro del puesto gerencial de las directoras fue la capacidad de hacer alianzas interpersonales, como lo refieren las siguientes entrevistas: aquí dentro de la escuela no tuvo problemas, […] se comentaba que ella convivía mucho con las esposas de los médicos, era muy llamada para atender en los partos […] y entonces tenía muchos nexos […] ella tenía el permiso incluso por salubridad y tenía físicamente instalado un consultorio, pero también atendía a domicilio. entonces, siento que con las esposas de los médicos se empezó a ganar la confianza de la gente y de varios más, después hasta fueron obstetras, así fue metiéndose con los maestros de esta escuela (e-td). las alianzas con directoras de otros espacios académicos y esposas de médicos y profesores ayudaron a forjar los mecanismos de adaptación de la enfermera para la gerencia de escuelas. dichas alianzas, y las luchas que se presentan, son establecidas con el propósito de asegurar y ampliar las posiciones de poder y prestigio al interior de los espacios sociales (14), generando de esta manera respuestas adaptativas, las cuales mueven la integridad de los sistemas humanos en términos de adaptación; esas alianzas producen destrezas, desarrollo y transformación de la persona. los afrontamientos de las líderes de enfermería pueden ser atribuidos al hecho que en los espacios sociales se establecían continuos embates de diferentes formas, como el ocupar las posiciones dominantes y salir de los espacios dominados. adaptación a la gerencia. la adaptación es el proceso y el resultado por el que las personas piensan y sienten como grupos o individuos usando conscientemente el conocimiento selecto para crear la integración humana y ambiental. este concepto se enfoca en cinco dimensiones: supervivencia, desarrollo, reproducción, dominio o competencia, y transformación ambiental y personal. para conseguir esas dimensiones se requiere de periodos considerables, a fin de que se puedan desarrollar planes estratégicos; sin embargo, a las entrevistadas se les pronosticaba una permanencia reducida en la gerencia de las escuelas, como se muestra en seguida. … me auguraron muy poco tiempo, decían que probablemente duraría tres meses, después de que se dio favorable el voto en la sesión de consejo universitario y no fue así, [...] fueron dos pe288 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 riodos, uno de dos años que era lo que marcaba en ese momento la legislación y con el cambio a tres años, duré cinco años en la dirección, del año 77 al 82 (e-p). roy señala que el cambio es probabilístico e influyen en él múltiples factores, como el conocimiento, las habilidades, las aptitudes y, desde luego, los valores; las competencias profesionales constituyen el elemento central en el desarrollo de las profesiones, siendo la clave para garantizar la calidad de los servicios (15). el logro de esas transformaciones, y la adaptación de los individuos a ellas se hace a través de procesos de aprendizaje adquiridos con el tiempo, por esta razón la enfermera-gerente debió considerarse un ser digno, autónomo y libre, y de esta forma llegar a su adaptación dentro de su entorno gerencial, como resultado de sus pensamientos y sentimientos, según como lo reflejó en sus funciones como directora. a partir del desarrollo gerencial en la dirección de los organismos académicos de enfermería en la región central de méxico se puede observar el crecimiento y desarrollo de estas organizaciones con características netamente disciplinarias. se deduce que el nivel de adaptación fue integrado ya que pudo satisfacer las necesidades educativas de ese momento histórico y aportar al crecimiento y desarrollo de la organización. conclusiones aportación a la teoría. los resultados de esta investigación permiten constatar la aplicación de la teoría de adaptación al confrontar algunas de sus proposiciones planteadas. estos resultados adquieren importancia en el ámbito gerencial al conocer su aplicación para la fundamentación de la práctica gerencial, ya que existía un vacío en el conocimiento respecto a su empleo dentro de este campo de actuación de la enfermera. la forma de aplicar esos mecanismos de afrontamiento se reflejó en aquellas enfermeras que tuvieron que gerenciar por primera vez las instituciones educativas de enfermería. se muestra que para enfrentar los problemas de adaptación se contó con mecanismos de afrontamiento en sus formas innatas o adquiridas, a fin de responder a los estímulos del entorno social. si la teoría de adaptación se apoya en la de sistemas, en un paralelismo con los resultados de la investigación, se observó que, de entrada, nos encontramos con el estímulo del ámbito social, que se denota como factor residual convertido en contextual; lo anterior nos lleva a la transformación, donde se dan cambios importantes, propiciándose una gestión innovadora en las escuelas de enfermería debido los modos de adaptación de identidad de grupo y al rol profesional, que fueron los factores intervinientes dentro del proceso, lo que dio como resultado un nivel de adaptación compensatorio. finalmente, se señala que los profesionales de la enfermería deben ser conscientes de los patrones que se deben imitar dado que las actitudes y el desempeño de estas enfermeras se constituyó en un ejemplo del modelo ideal que cualquier dirigente puede alcanzar. referencias 1. roy c. the roy adaptation model, 3 ed. boston: pearson; 2009. 2. dyniewics am. metodologia da pesquisa em saúde para iniciantes. 2 ed. brasil: difusão editora; 2011. 3. coelho spmi, susskind bm, o método de pesquisa histórica na enfermagem. texto contexto enferm 2005;14(04):575-81. 4. mackernan j. investigación, acción y currículum. 3ª. ed. madrid: morata; 2008. 5. álvarez gr. reseña de cine y género en españa. una investigación empírica. revista española de investigaciones sociológicas 2011;135:123-126. [visitado abr. 2012]. disponible en: http://www.redalyc.org/src/inicio/artpdfred. jsp?icve=99722248007 6. gutiérrez amc et al. adaptación y cuidado en el ser humano: una visión de enfermería. bogotá: el manual moderno; 2007. 7. lópez-ibor r, escot mangas l, fernández cornejo j. la predisposición de las estudiantes universitarias a autolimitarse profesionalmente en el futuro por razones de conciliación. estudios de economía aplicada 2010;28(1):32. [visitado abr. 2012]. disponible en: http://www.redalyc.org/src/inicio/artpdfred.jsp?icve=30120313013 289 gerentes de escuelas de enfermería: una discusión sobre su adaptación al entorno social según la teoría de roy l danelia gómez-torres, vianey méndez-salazar, martha velazco-whestell 8. castro r, bronfman m. teoría feminista y sociología médica: bases para una discusión. cad. saúde públ.1993;(3):375-394. 9. roy c et al. análisis de los conceptos del modelo de adaptación de callista roy. 2 ed. [visitado ago. 2010]. disponible en: http://redalyc.uaemex.mx/redalyc/pdf/741/74120204.pdf 10. zabalegui a. el rol del profesional en enfermería. aquichan 2003;3:16-20. [visitado mar. 2012]. disponible en: http:// www.redalyc.uaemex.mx/src/inicio/artpdfred 11. carmona rc, sánchez dp, bakieva m. actividades extraescolares y rendimiento académico: diferencias en autoconcepto y género. revista de investigación educativa 2011;29(2):447-465. [visitado ene. 2013]. disponible en: http://www. redalyc.org/src/inicio/artpdfred.jsp?icve=283322847012 12. araújo pk, de melo mm. a prática da enfermeira em auditoria em saúde. revista da escola de enfermagem da usp. 2010;44(3):674. 13. moreno fme. importancia de los modelos conceptuales y teorías de enfermería: experiencia de la facultad de enfermería de la universidad de la sabana. aquichan 2005;5(5):44-55. 14. rufo ls, salazar ma. aplicación del proceso de enfermería según el modelo de roy en pacientes con diabetes mellitus. rev enfermería global 2008;14. [visitado abr. 2012]. disponible en: http://www.um.es/eglobal 15. latrach-ammar c, febré n, demandes i, araneda ja, gonzález i. importancia de las competencias en la formación de enfermería. aquichan 2011;11(3):311. [visitado abr. 2012]. disponible en: http://www.redalyc.org/src/inicio/artpdfred. jsp?icve=74121424006 234 246 consumo de alcohol.indd 234 aquichan issn 1657-5997 miguel ángel villegas-pantoja1 maría magdalena alonso-castillo2 raquel a. benavides-torres3 francisco rafael guzmán-facundo4 consumo de alcohol y funciones ejecutivas en adolescentes: una revisión sistemática 1. enfermero. doctorando en ciencias de enfermería, universidad autónoma de nuevo león, méxico. miguel_vp@msn.com 2. doctora en filosofía. profesora de tiempo completo, universidad autónoma de nuevo león, méxico. magdalena_alonso@hotmail.com 3. doctora en filosofía. profesor de tiempo completo, universidad autónoma de nuevo león, méxico. rabenavi@gmail.com 4. doctor en enfermería psiquiátrica. profesor de tiempo completo, universidad autónoma de nuevo león, méxico. francisco.guzmanf@uanl.mx recibido: 15 de junio de 2012 enviado a pares: 17 de agosto de 2012 aceptado por pares: 18 de junio de 2013 aprobado: 19 de junio de 2013 año 13 vol. 13 nº 2 chía, colombia agosto 2013  234-246 resumen objetivo: el consumo de alcohol es un problema de salud pública que puede implicar riesgos para la integridad del córtex prefrontal, especialmente lo relacionado al funcionamiento ejecutivo. aunque se han estudiado los efectos negativos sobre la región prefrontal de adultos, la evidencia en la población adolescente es menor. el objetivo de este artículo es conocer el estado del arte de la relación entre el consumo de alcohol y las funciones ejecutivas de adolescentes. materiales y métodos: se realizó una búsqueda en las bases de datos academic onefile, academic search complete, dialnet, doyma, journal@ovid, mediclatina, medline, proquest, psycarticles, sage y springer para identificar artículos publicados entre enero de 2006 y noviembre de 2011. la muestra final fue de trece artículos. resultados: los estudios mostraron divergencia de resultados en los componentes de las funciones ejecutivas; sin embargo, los componentes de inhibición de respuestas y toma de decisiones parecen ser alterados por diferentes patrones de consumo de alcohol en más del 70 % de las investigaciones. conclusiones: los hallazgos indican que la investigación de este fenómeno en población adolescente aún se encuentra en etapas de exploración; no obstante, existe evidencia de que el consumo de alcohol puede ser peligroso para el funcionamiento cognitivo adolescente. palabras clave función ejecutiva, adolescente, etanol, corteza prefrontal, revisión, enfermería. (fuente: decs, bireme). para citar este artículo / to reference this article / para citar este artigo villegas pantoja, m. á., alonso castillo, m. m., benavides torres, r. guzmán facundo, f. r. (2013). consumo de alcohol y funciones ejecutivas en adolescentes: una revisión sistemática. aquichan. vol. 13, no. 2, 234-246. 235 consumo de alcohol y funciones ejecutivas en adolescentes: una revisión sistemática l miguel ángel villegas-pantoja, maría magdalena alonso-castillo y otros. alcohol consumption and executive functions in adolescents: a systematic review abstract objective: alcohol consumption is a public health problem that can involve risks to the integrity of the prefrontal cortex, especially with respect to executive functioning. although the negative effects on the prefrontal region have been studied in adults, there is less evidence concerning the adolescent population. the objective of this articles it to understand the state of the art with respect to the relationship between alcohol consumption and executive functions in adolescents. materials and methods: academiconefile, academicsearch complete, dialnet, doyma, journal @ ovid, mediclatina, medline, proquest, psycarticles, sage and springer were subject to a database search for articles published between january 2006 and november 2011. the final sample was comprised of thirteen articles. results: the studies showed inconsistent results for the components of executive functions; however, the components that deal with response inhibition and decision-making appear to be altered by different patterns of alcohol consumption in more than 70% of the studies. conclusions: the findings indicate the research on this phenomenon in adolescents is still in the exploratory staged. nevertheless, there is evidence that alcohol can be dangerous for adolescent cognitive functioning. key words executive function, adolescent, ethanol, prefrontal cortex, review, nursing. (source: decs, bireme) consumo de álcool e funções executivas em adolescentes: uma revisão sistemática resumo objetivo: o consumo de álcool é um problema de saúde pública que pode implicar riscos para a integridade do córtex pré-frontal, especialmente o relacionado ao funcionamento executivo. embora os efeitos negativos sobre a região pré-frontal de adultos tenham sido estudados, a evidência na população adolescente é menor. o objetivo deste artigo é conhecer o estado da arte da relação entre consumo de álcool e as funções executivas de adolescentes. materiais e métodos: realizou-se uma busca nas bases de dados academic onefile, academic search complete, dialnet, doyma, journal@ovid, mediclatina, medline, proquest, psycarticles, sage e springer para identificar artigos publicados entre janeiro de 2006 e novembro de 2011. a amostra final foi de treze artigos. resultados: os estudos mostraram divergência de resultados nos componentes das funções executivas; contudo, os componentes de inibição de respostas e tomada de decisões parecem ser alterados por diferentes padrões de consumo de álcool em mais de 70% das pesquisas. conclusões: as descobertas indicam que a pesquisa deste fenômeno em população adolescente ainda se encontra em etapas de exploração, mas existe evidência de que o consumo de álcool pode ser perigoso para o funcionamento cognitivo adolescente. palavras-chave função executiva, adolescente, etanol, córtex pré-frontal, revisão, enfermagem. (fonte: decs, bireme) 236 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 introducción el consumo de alcohol es considerado un grave problema de salud pública por las alteraciones físicas, psicológicas, emocionales y sociales que provoca. se ha reportado asociación de este consumo con accidentes de tráfico, homicidios, suicidios, actividad sexual temprana de riesgo, fracaso escolar; dificultades en habilidades psicológicas como percepción y razonamiento, y afecciones en la salud adulta representadas por enfermedades cardiovasculares, mentales y diversos tipos de neoplasias (1-3), por lo que es considerado como una sustancia dañina para la salud humana. sin embargo, a pesar de los riesgos que implica el consumo de bebidas alcohólicas, esta conducta tiene alta prevalencia (4). el alcohol o etanol es la sustancia adictiva de uso más extendido en la población mundial. el uso excesivo de esta droga lícita causa cerca de 2,5 millones de muertes por año en el mundo y en orden de importancia es considerado como el tercer factor de riesgo para enfermedad y discapacidad. de hecho, se estima que cerca del 4 % de todas las muertes alrededor del mundo son atribuibles al consumo de alcohol (4). no obstante, la adolescencia por ser un periodo crítico donde los individuos sufren múltiples cambios (2, 5-8) se convierte en una etapa vulnerable para este grupo, donde la probabilidad de llevar cabo conductas de riesgo como el consumo de alcohol se incrementa (9). prueba de lo anterior es que los registros de la encuesta global de alcohol reportada por la organización mundial de la salud (oms) en 2011 indicaron que en un lapso de cinco años el 71 % de los países encuestados registró un incremento en el consumo de alcohol por parte de la población menor de edad. por el contrario, solo el 11 % de los países registraron una disminución en el consumo de bebidas alcohólicas (4). asimismo, es preocupante que en la actualidad los adolescentes comienzan a reproducir los patrones de consumo excesivo de la población adulta (10). existen revisiones de literatura que han explorado los efectos que puede causar el consumo de alcohol a nivel cerebral, donde anatómicamente se destaca que el cerebro de individuos alcohólicos crónicos ha mostrado un alto grado de pérdida de neuronas del córtex prefrontal (11, 12), de modo que el funcionamiento neuropsicológico resulta afectado (13), en particular las funciones ejecutivas (ff. ee.), ya que se vinculan a esta área anatómica específica (14). en este sentido, se destacan alteraciones en la planeación estratégica, organización perceptual, razonamiento abstracto, atención y la organización de información en la memoria de trabajo (11). los anteriores daños cerebrales, aunados al poder reforzante del alcohol, el papel de la tolerancia, la dependencia, el síndrome de abstinencia y la sensibilización del sistema de la recompensa, confieren a las bebidas alcohólicas un valor motivacional mayor que el de cualquier otro reforzador natural (15). cabe señalar que el consumo de alcohol en los menores de edad se asocia con mayores daños cerebrales con implicaciones en el aprendizaje, memoria y desarrollo intelectual en comparación con los adultos (16) debido a que durante la adolescencia tardía el cerebro se encuentra aún en etapas de desarrollo (17-19). de este modo, el consumo de alcohol podría tener repercusiones en el desarrollo neurológico adolescente y, consecuentemente, en la salud y el funcionamiento cognitivo en la vida adulta. las ff. ee. son un constructo controvertido, bajo el cual se agrupan diferentes procesos asociados al control del pensamiento, comportamiento y afectividad (14, 20-22). su importancia radica en que estos procesos neuropsicológicos se dirigen a la resolución eficaz de problemas internos y externos novedosos derivados de la interacción con el medio (23-26), por lo que son necesarios para el desenvolvimiento pleno de cualquier ser humano en diversos aspectos de su vida diaria. algunos de los componentes de las ff. ee. son la flexibilidad mental, generación de hipótesis, resolución de problemas, formación de conceptos, planificación, organización, fluidez, inhibición, automonitoreo, anticipación, regulación de la conducta, cambio de atención y control emocional (14, 27, 28), mismos que son fundamentales en la toma de decisiones. no obstante, aunque se ha desarrollado un variado marco teórico desde los puntos de vista psicológico y neuroquímico sobre el consumo de las sustancias psicoactivas en la población adulta y sus repercusiones cognitivas (29), aún hay vacíos del conocimiento por explicar en la adolescencia (30-32) ya que en esta etapa de la vida aún existen cambios importantes en las áreas corticales prefrontales, lo cual la convierte en un periodo de alto riesgo para el cerebro por las agresiones externas (26, 33). es importante señalar que escasos estudios han abordado el consumo de alcohol en la población adolescente desde el punto de vista neuropsicológico, particularmente el consumo no crónico donde el efecto de interés sean los componentes de las ff. ee. (31). asimismo, con frecuencia la literatura aborda el estudio del consumo de alcohol considerando solo la parte cognitiva/neurológica o la psicológica, por lo que es necesario realizar una revisión exhaustiva de aquellas investigaciones que consideran la visión neuropsicológica. 237 consumo de alcohol y funciones ejecutivas en adolescentes: una revisión sistemática l miguel ángel villegas-pantoja, maría magdalena alonso-castillo y otros. en los últimos años, el uso de las revisiones sistemáticas ha sido de especial utilidad para la práctica de enfermería basada en evidencia, ya que a través de estas se pueden desarrollar intervenciones eficaces y guías de la práctica que mejoran la atención, pero que también contribuyen al aumento del conocimiento científico de enfermería y propician una cultura a favor de la investigación. en este sentido, y en convergencia con la visión holística del personal de enfermería, la disfunción ejecutiva simultánea a otros padecimientos, como las adicciones, debiera ser motivo de preocupación y ocupar un lugar importante en nuestros quehaceres y en la rehabilitación. por tal razón resulta preciso reunir los resultados de investigaciones recientes realizadas en población adolescente que nos den una visión general de los efectos de cualquier patrón de consumo de alcohol en la salud neuropsicológica de los adolescentes. por este motivo se propuso realizar una revisión del estado de la investigación sobre la relación del consumo de alcohol y los efectos en las ff. ee. de los adolescentes. materiales y métodos para la elaboración de esta revisión sistemática se llevó a cabo el siguiente plan de trabajo de acuerdo con lo sugerido en la literatura (34): 1) se estableció el propósito de investigación con base en una revisión de literatura para responder a un vacío del conocimiento; 2) se definieron criterios de exclusión e inclusión para los artículos; se estableció la estrategia de búsqueda y se ejecutó la búsqueda; 3) se definió la información de interés para ser extraída de las publicaciones y se seleccionaron los artículos; 4) los artículos seleccionados fueron analizados; 5) se realizó la interpretación, discusión y conclusión de los hallazgos, y 6) se presentaron los resultados. el criterio de inclusión para las búsquedas se limitó a los artículos publicados a partir del mes de enero de 2006 al mes de noviembre de 2011, debido a que el estudio del fenómeno de interés es relativamente reciente. las publicaciones consideradas fueron realizadas por profesionales de diferentes disciplinas de la salud de cualquier país, no obstante las bases de datos seleccionadas tuvieron principalmente contenidos referentes a la medicina, psicología y psiquiatría, disciplinas que con mayor frecuencia estudian este fenómeno. se eligieron estudios en inglés o español que estuvieran en texto completo y que incluyeran las variables de estudio. debido a que el objetivo de la revisión fue conocer el estado del arte, se incluyeron estudios que pertenecieran a los siguientes niveles de investigación: i (metaanálisis de estudios controlados), ii (investigaciones experimentales aleatorizadas), iii (investigaciones cuasiexperimentales, como los estudios controlados de un solo grupo y series de tiempo) y iv (estudios no experimentales, como los estudios descriptivos correlacionales) (35). en relación con los participantes, se consideraron publicaciones con población adolescente y joven de entre 10 y 20 años de edad (de ambos sexos), escolarizados o no escolarizados, de cualquier nacionalidad y con antecedente de ingesta de cualquier tipo de bebida alcohólica alguna vez en la vida. también se incluyeron estudios realizados en animales de experimentación en etapa de la adolescencia debido a la dificultad que conlleva la rigidez de los protocolos experimentales (17) en humanos y a que éticamente no es posible realizar estudios con el fin de conocer los efectos del alcohol, sabiendo que no se beneficiará al participante. en relación con el tipo de consumo de alcohol se incluyeron investigaciones que contemplaran consumo de alcohol desde una vez en la vida hasta consumo diario. por otra parte, en lo que concierne a las ff. ee., los artículos pudieron evaluar más de un componente, donde se utilizaron diferentes pruebas psicológicas, aditamentos electrónicos o pruebas en laboratorio. como criterios de exclusión, se eliminaron estudios realizados exclusivamente en individuos con patologías psiquiátricas o retraso mental, ya que no permiten la generalización en la población de interés. como primera fuente para la búsqueda se procedió a indagar dentro de las bases de datos academic onefile, academic search complete (ebsco), dialnet, doyma, journal@ovid, mediclatina (ebsco), medline full text (ebsco), proquest, psycarticles, sage premier y springer. adicionalmente, se recurrió al buscador web google académico para encontrar artículos que no aparecieron en texto completo en las anteriores bases de datos. se emplearon descriptores del decs y mesh, así como truncadores dentro de los campos de título y resumen: adolesc*, adolesc$, adolescencia or adolescente, adolescent, etanol or ethanol, función ejecutiva or executive function y pre* córtex. al realizar las búsquedas se identificaron 5.108 artículos entre todas las bases de datos; posteriormente se procedió a leer los títulos y resúmenes para seleccionar los artículos para ser analizados. después de leer los títulos y resúmenes se seleccionaron 44 publicaciones para un análisis crítico ya que evaluaron las variables de interés. se buscaron resultados que demostraran relación entre el consumo de alcohol y el desempeño en los diferentes componentes que comprenden las ff. ee., poniendo énfasis en la 238 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 congruencia entre el propósito del estudio, el diseño, la metodología y los resultados. como herramientas de análisis se empleó la lectura crítica, el subrayado y la nota teórica en el margen izquierdo del artículo. después de la evaluación y el análisis se descartaron catorce artículos por no pertenecer al tipo de publicación requerida, doce por enfocarse en otros procesos cognitivos no relativos a las ff. ee., y cinco por no definir las edades de los participantes, de forma que solo trece artículos cumplieron con los criterios establecidos y son los que se presentan en los resultados a continuación. resultados los trece artículos que fueron seleccionados para la presente revisión se presentan en la tabla 1. las publicaciones abordaron diferentes componentes de las ff. ee. por lo que se agruparon de acuerdo con los siguientes componentes: toma de decisiones, planificación, flexibilidad cognitiva, inhibición de respuestas, velocidad de procesamiento y memoria de trabajo (incluido el componente de memoria visoespacial). además, se incluyeron tres habilidades cognitivas íntimamente ligadas a las ff. ee.: atención, memoria y lenguaje. autor y año país nivel de evidencia* diseño muestreo factor de impacto de la revista† crego et al. 2009 españa iv comparativo no probabilístico 3.468 ferret et al. 2010 sudáfrica iv comparativo no probabilístico 3.365 field et al. 2007 reino unido iv comparativo no probabilístico 4.145 garcía-moreno et al. 2008 españa iv comparativo no probabilístico 1.127 goudriaan et al. 2007 ee. uu. iii cohorte prospectiva probabilístico 3.468 johnson et al. 2008 china iv comparativo probabilístico 3.949 mahmood et al. 2010 ee. uu. iv comparativo no probabilístico 2.128 schulteis et al. 2008 ee. uu. iii ensayo clínico no probabilístico 2.423 semenova, 2011 ee. uu. iii ensayo clínico no especificado 3.817 solowij et al. 2011 australia iv comparativo no probabilístico 3.817 squeglia et al. 2011 ee. uu. iii cohorte prospectiva no probabilístico 3.817 squeglia et al. 2009. ee. uu. iv comparativo no especificado 2.101 thoma et al. 2011 ee. uu. iv comparativo no probabilístico 3.468 se encontró que en mayor proporción los estudios (53,84 %) fueron realizados en estados unidos, seguidos por un 15,38 % realizados en españa; el resto fueron llevados a cabo en diversas regiones. asimismo, cuatro artículos (30,76 %) abordaron solo ff. ee., mientras que nueve (69,24 %) evaluaron ff. ee. en conjunto con alguna de las tres habilidades cognitivas asociadas (atención, memoria y lenguaje). el nivel de evidencia que prevaleció (69,23 %) fue el iv, que corresponde a estudios con delineamiento no experimental. en cuanto a la población de estudio, una mayor proporción de las investigaciones se realizaron en adolescentes (84,61 %) en comparación con las desarrolladas con animales de experimentación en la etapa de la adolescencia (edad biológica de 26 a 28 días; 15,39 %). se detectó que la mayor proporción de estudios (84,61 %) no emplearon algún método de aleatorización en la selección o asignación de los participantes o, en su defecto, no fue especificado. respecto a las fechas de publicación, ocho (61,54 %) artículos fueron publicados en el periodo 2009-2011 frente a cinco (38,46 %) publicados en el periodo 2006-2008. cabe destacar que la totalidad de los artículos fueron publicados en revistas con factores de impacto entre 1.127 hasta 4.145. tabla 1. características de los artículos seleccionados * de acuerdo con la agencia para la investigación y calidad en salud (ahrq); † de acuerdo con el journal citation reports 2010. 239 consumo de alcohol y funciones ejecutivas en adolescentes: una revisión sistemática l miguel ángel villegas-pantoja, maría magdalena alonso-castillo y otros. a continuación se presentan los hallazgos clasificados en cada uno de los componentes de las ff. ee. en la tabla 2, se pueden apreciar los hallazgos en detalle por artículo en relación con los componentes de la función ejecutiva. el componente de toma de decisiones consiste en la capacidad de elegir una opción ventajosa ante un problema que implica informar acerca de la elección, considerar los tipos de errores cometidos y los riesgos que implica la elección. del número total de estudios encontrados, 30,76 % evaluaron este aspecto (36-39). el 75 % de los artículos encontraron que el consumo de alcohol, ya sea alguna vez en los últimos seis meses o el consumo binge (consumo intensivo de alcohol) probablemente afectó la toma de decisiones. el componente de planificación se refiere a la capacidad para organizar una serie de eventos con el fin de completar una meta específica. el 38,46 % de los trece artículos encontrados evaluaron dicho componente (31, 40-43). una elevada proporción (80 %) no encontró resultados significativos respecto al efecto del consumo de alcohol en la planificación, solo uno (4) dirigido a evaluar el consumo excesivo y dependiente de alcohol encontró que el número de bebidas consumidas en un día típico puede alterar esta función. la flexibilidad cognitiva es la habilidad para hacer transiciones y tolerar cambios para resolver problemas, además de pasar tabla 2. publicaciones que abordan la relación entre el consumo de alcohol y las funciones ejecutivas de adolescentes autor y año población, rango de edad, muestra tipo de consumo de alcohol instrumentos funciones ejecutivas tom a de decisiones p lanificación flexibilidad cognitiva inhibición de respuestas v elocidad de procesam iento memoria de trabajo m em oria viso-espacial m em oria de trabajo crego et al. 2009 estudiantes de 18 a 20 años (n = 95). consumo intensivo (binge drinking). consumo de alcohol: audit. ff. ee.: cpt versión de pares idénticos. * ferret et al. 2010 adolescentes de 13 a 15 años, de habla inglesa o africana (n = 52). consumo dependiente. consumo de alcohol: tlfb. ff. ee. avlt, cctt, clox 1 y 2, cms, rocf, stroop de colores y palabras, torre de londres, wasi (subtests: números en reversa, diseño de bloques). ns * * ns field et al. 2007 estudiantes de 16 a 18 años (n = 90). consumo al menos una vez en los últimos seis meses. consumo de alcohol: aais, audit, daq. ff. ee.: stroop de colores y palabras, tarea de descuento por demora * * garcíamoreno et al. 2008 estudiantes menores de 20 años (n = 62). consumo excesivo y consumo sensato. consumo de alcohol: esaj. ff. ee.: cubos de corsi, recitado de series, stroop de colores y palabras, tavec, torre de hanoi, wms. ns * goudriaan et al. 2007 adolescentes menores de 21 años (n = 200). consumo intensivo. consumo de alcohol: instrumento ex profeso. ff. ee.: igt. * johnson et al. 2008 estudiantes menores de 18 años (n = 207). consumo intensivo. consumo de alcohol: instrumento ex profeso. ff. ee.: igt, sopt. * ns mahmood et al. 2010 adolescentes de 15 a 19 años (n = 53). abuso y dependencia al alcohol. consumo de alcohol: registro de uso de drogas y bebidas, tlfb modificado. ff. ee.: cvlt-2, rocf, wasi. ns 240 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 autor y año población, rango de edad, muestra tipo de consumo de alcohol instrumentos funciones ejecutivas tom a de decisiones p lanificación flexibilidad cognitiva inhibición de respuestas v elocidad de procesam iento memoria de trabajo m em oria viso-espacial m em oria de trabajo schulteis et al. 2008 ratas winstar macho en etapa de peri-adolescencia (n = 63). consumo intensivo. consumo de alcohol: nivel de alcohol en sangre. ff. ee.: laberinto de agua de morris y laberinto elevado en cruz. * semenova, 2011 ratas wistar macho adolescentes (n = 23). consumo intensivo. consumo de alcohol: cuatro días de exposición a etanol (25%) diluido en agua, administrado a través de sonda intragástrica a razón de 5 g/kg cada 8h. ff. ee.: 5-csrtt. ns ns solowij et al. 2011 adolescentes de 16 a 20 años (n = 175). consumo de alcohol al menos 2 veces por mes durante 6 meses. consumo de alcohol: audit y tlfb. ff. ee.: ist. ns squeglia et al. 2011 adolescentes de 16 a 19 años (n = 59). consumo intensivo. consumo de alcohol: alcoholímetro, instrumento ex profeso, prueba de alcohol en orina, tlfb. ff. ee.: d-kefs (torres, interferencia palabra-color), wais-iii (subtest: dígitos), rocf (exactitud y retraso de 30 min), wrat-3 (puntuación en lectura). ns † † squeglia et al. 2009 adolescentes de 12 a 14 años (n = 76). consumo excesivo y moderado. consumo de alcohol: cddr y hss. ff. ee.: dvt, d-kefs (secuencia alfanumérica, torres, interferencia palabra-color), cvlt-2, cvlt-c, rocf (retraso de 30 min), wasi (diseño de bloques, similitudes), wais-iii, wisc-iii (subtest: códigos y dígitos), sistema de puntuación de taylor, wrat-3. ns ns † ns thoma et al. 2011 adolescentes de 12 a 18 años (n = 48). consumo excesivo y dependiente. consumo de alcohol: form 90. ff. ee.: act, cowat, cpt, d-kefs, secuencia alfanumérica (a, b), rbans, torre de londres, wais-iii (subtest: dígitos), wasi, wcst (computarizado). * * * ns ns nota: ns: relación estadísticamente no significativa; *: probable relación perjudicial; †: probable relación perjudicial en el sexo femenino; -: no se evaluó 5-csrtt = tarea de tiempo de reacción de cinco alternativas; aais = escala de involucramiento del adolescente con el alcohol; act = prueba auditiva de los trigramas de consonantes; audit = cuestionario de identificación de los trastornos debidos al consumo de alcohol; avlt = prueba de aprendizaje auditivo verbal; cctt = prueba de trazos en color para niños; cddr = customary drinking and drug use record; clox = prueba de dibujo del reloj; cms = escala de memoria para niños; cowat = prueba de asociación controlada de palabras; cpt = prueba de rendimiento continuo; cvlt-2 = prueba de aprendizaje verbal de california, 2ª edición; cvlt-c = prueba de aprendizaje verbal de california, edición para niños; daq = desires for alcohol questionnaire; d-kefs = sistema de función ejecutiva de delis-kaplan; dvt = prueba de vigilancia de dígitos; esaj = encuesta sobre actitudes en la juventud; hss = hangover symptoms scale; igt = juego de azar de iowa; ist = tarea de reflexión-impulsividad; rbans = batería repetible para la evaluación del estado neuropsicológico; rocf = prueba de la figura copmleja de rey-osterrieth; sopt = self ordered pointing test; tavec = test de aprendizaje verbal españa-complutense; tlfb = alcohol timeline followback; wais-iii = escala de inteligencia de wechsler para adultos, 3ª edición; wasi = escala abreviada de inteligencia de wechsler; wcst = prueba de clasificación de tarjetas de wisconsin; wisc-iii = escala de inteligencia de wechsler para niños, 3ª edición; wms = escala de memoria de wechsler; wrat-3 = prueba de logros con intervalo amplio-3. 241 consumo de alcohol y funciones ejecutivas en adolescentes: una revisión sistemática l miguel ángel villegas-pantoja, maría magdalena alonso-castillo y otros. de un foco de atención hacia otro cuando es necesario. el 15,38 % (2 publicaciones) evaluó este componente, el cual fue el menos frecuente dentro de la muestra de artículos en esta revisión. solo una publicación informó que el número de bebidas alcohólicas consumidas en un día típico probablemente altera este proceso. cabe destacar que en el estudio que no reportó hallazgos con significancia estadística se empleó una muestra de ratas macho adolescentes de tipo wistar bajo administración de alcohol en patrón tipo binge (44). por el contrario, el componente de inhibición de respuestas fue el más evaluado por las investigaciones en la presente revisión, ya que el 46,14 % aplicó algún instrumento para estudiar este aspecto (31, 36, 40, 41, 43, 44). la inhibición de respuestas es un proceso que consiste en la habilidad para resistir ante los impulsos e interrumpir una conducta en el momento adecuado. de los seis artículos englobados en este componente, una alta proporción (83,33 %) encontró que el consumo de alcohol —desde alguna vez en los últimos seis meses hasta el consumo dependiente— probablemente altera la capacidad de inhibir respuestas. otro componente incluido fue la velocidad de procesamiento, que es definido como el tiempo de respuesta ante una tarea e implica una secuencia temporal de operaciones cognitivas; aquí se destaca la toma de decisiones. de la muestra total, el 23 % midió este componente (31, 42, 43), sin embargo la mayoría (66,66 %) no encontró disminución en el desempeño de este proceso ante el consumo de alcohol. la memoria de trabajo es la capacidad de mantener y manipular información en la memoria a corto plazo con el propósito de poder terminar una tarea, almacenar información o generar objetivos. sin embargo, aunque se activa en la corteza prefrontal, requiere la activación de estructuras neuroanatómicas ubicadas en otras secciones del cerebro, como el lóbulo occipital, donde se adquiere el significado de la información visual. algunos estudios reportan a la memoria visoespacial como una parte de la memoria de trabajo, por este motivo se presentó como un elemento independiente pero integrado al componente de la memoria de trabajo. considerando la inclusión de la memoria visoespacial, este componente fue el más estudiado por los artículos localizados en la presente revisión: de la totalidad de las publicaciones localizadas, nueve (69,23 %) evaluaron este componente, de las cuales cuatro estudiaron la memoria de trabajo (38, 42, 45, 46) y cinco el desempeño y la memoria visoespacial (31, 41-43, 47). respecto a la memoria de trabajo, el 50 % encontró que el consumo de alcohol con patrón binge puede alterar el desempeño de este proceso (45, 46). cabe señalar que uno de estos estudios se realizó en ratas wistar. por otra parte, en relación con la memoria visoespacial, el 40 % encontró que en las mujeres consumidoras de alcohol el grosor de la estructura cortical prefrontal se correlacionó con un peor desempeño visoespacial. a continuación se presenta lo identificado respecto a la atención, la memoria y el lenguaje (tabla 3). la atención es un proceso cognitivo que consiste en enfocar los sentidos hacia un punto específico mientras se ignoran otros. está muy relacionada con las ff. ee. por su ubicación anatómica. de la muestra total de artículos, el 46,15 % estudiaron esta capacidad cognitiva, lo cual la convierte en el aspecto más estudiado dentro de los artículos dirigidos a la investigación de las ff. ee. de los anteriores, un 66,66 % encontró que la atención es afectada por el consumo de alcohol en patrones de consumo binge, excesivo o dependiente. la memoria es un proceso cognitivo que permite codificar, almacenar y recuperar información útil en cualquier tarea. por su ubicación anatómica también se encuentra relacionada con las funciones ejecutivas y es probable que estas influencien su funcionamiento. un 30,76 % de las investigaciones realizaron pruebas para evaluar la memoria de los participantes, y de estos el 75 % concluyeron que el consumo de alcohol, desde alguna vez en los últimos seis meses hasta el consumo dependiente, se asoció con algún déficit en la memoria de los participantes. finalmente, el lenguaje es una tarea que demanda el empleo, la selección y la inhibición de palabras pertenecientes o no a una categoría especifica, así como la implementación de estrategias que generan el mayor número posible de palabras dentro de un tiempo determinado. más del 30 % del total de la muestra evaluó algún aspecto del desempeño del lenguaje de los participantes. se encontró que una baja proporción (25 %) identificó alguna relación significativa entre el consumo de alcohol y un probable deterioro en el lenguaje de los adolescentes. discusión los hallazgos de la presente revisión ponen de manifiesto que existe un limitado número de investigaciones relacionadas con el consumo de alcohol en adolescentes y sus consecuencias negativas en el funcionamiento cognitivo, especialmente en el estudio a profundidad de las ff. ee., lo cual ya ha sido señalado con 242 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 anterioridad (31). prueba de esto es que fueron pocos los estudios identificados que abordaron esta temática y muchos de ellos suelen citarse mutuamente. también se aprecia heterogeneidad en el desarrollo de investigaciones en torno a los diferentes componentes de las funciones ejecutivas, ya que mientras algunas tareas fueron objeto de múltiple investigación, como la inhibición de respuestas (31, 36, 40, 43-45), otras fueron evaluadas en menos ocasiones, como la flexibilidad cognitiva (43, 44). es importante mencionar que una posible limitante en el estudio de las ff. ee. provenga de la conceptualización de este fenómeno (14, 48, 49), ya que se debate la existencia de cierto grado de solapamiento entre las ff. ee y otros procesos cognitivos —como la atención o la memoria— (50-53). de igual manera se discute si las ff.ee. se constituyen como un constructo unitario o como un sistema de diversos componentes independientes pero interrelacionados (23, 50, 51, 53). es probable que debido a estas dos situaciones se aprecia, por un lado, una alta proporción de publicaciones donde se incluye la medición de aspectos de memoria o atención, y por otro lado, diversas conceptualizaciones de componentes de las ff. ee. otro hallazgo importante es la divergencia de resultados entre los distintos componentes de las ff. ee. a pesar de que las diferentes investigaciones fueron realizadas con adolescentes de edad semejante, en la mayoría de los componentes se presentaron evidencias poco concluyentes, lo cual también se ha constatado en población adulta (49). solo se apreció que la inhibición de respuestas y la toma de decisiones son alteradas por diversos patrones de consumo de alcohol, lo cual se constató en más del 70 % de las investigaciones. sin embargo, es preciso considerar que se evaluaron diferentes patrones de consumo de alcohol, se emplearon diversos instrumentos, e incluso algunos de los estudios se realizaron en población animal, lo cual podría explicar la diversidad de resultados (13). por esta razón y, probablemente debido a la inconsistencia con los hallazgos en la población adulta (28, 49, 52), no es posible descartar los efectos dañinos que puede causar el alcohol en el funcionamiento ejecutivo del adolescente. en cuanto a la atención, la memoria y el lenguaje, más de dos terceras partes de las publicaciones evaluaron alguna de estas habilidades cognitivas. aunque existe polémica en relación con dónde terminan estas habilidades cognitivas y dónde comienzan las funciones ejecutivas (53), se acepta que interactúan en algunas tareas que se llevan a cabo en la corteza prefrontal (50, 5456), de modo que es importante considerar los efectos negativos en dichas habilidades cognitivas y la posible repercusión sobre el funcionamiento de la corteza prefrontal. tabla 3. relación del consumo de alcohol con la atención, la memoria y el lenguaje autor y año tipo de consumo de alcohol habilidades cognitivas relacionadas atención memoria lenguaje crego et al. 2009 consumo intensivo (binge). * ferret et al. 2010 consumo dependiente ns * ns field et al. 2007 consumo de alcohol al menos una vez en los últimos seis meses garcía-moreno et al. 2008 consumo excesivo y consumo sensato * goudriaan et al. 2007 consumo intensivo johnson et al. 2008 consumo intensivo mahmood et al. 2010 abuso y dependencia al alcohol ns * schulteis et al. 2008 consumo intensivo semenova, 2011 consumo intensivo ns solowij et al. 2011 consumo de alcohol al menos dos veces por mes durante seis meses squeglia et al. 2011 consumo intensivo * squeglia et al. 2009. consumo excesivo y moderado de alcohol † ns thoma et al. 2011 consumo excesivo y dependiente * ns ns nota: ns: relación estadísticamente no significativa; *: probable relación perjudicial; †: probable relación perjudicial en el sexo masculino; -: no se evaluó 243 consumo de alcohol y funciones ejecutivas en adolescentes: una revisión sistemática l miguel ángel villegas-pantoja, maría magdalena alonso-castillo y otros. es preciso señalar que la presente revisión es un intento sistematizado para reunir la mayor evidencia que refleje el estado de la investigación y los posibles vacíos de conocimientos en el estudio de las ff. ee. y el consumo de alcohol en los adolescentes, fenómeno que afecta seriamente la salud de este grupo poblacional y que implica un alto costo social, por lo que representa una prioridad de acción para los profesionales sanitarios. la evidencia presentada puede ser de utilidad para investigadores y personal de salud enfocados en individuos con problemas de adicción a las drogas, ya que los hallazgos sugieren que el funcionamiento ejecutivo es una variable alterada por el consumo de alcohol, de modo que podría suponer implicaciones para la práctica clínica, como el individualizar el cuidado y replantear la importancia del tratamiento neuropsicológico en las drogodependencias. el personal de enfermería, con amplia presencia en el primer nivel de atención para la salud, podría ser una pieza clave en la incorporación de instrumentos neuropsicológicos como herramientas adicionales de diagnóstico y de selección de tratamiento. esto con el fin de perfeccionar las intervenciones terapéuticas hacia un cuidado que permita mejorar la disfunción ejecutiva del adolescente mediante entrenamiento cognitivo, desarrollo de habilidades del pensamiento, uso de técnicas de comunicación terapéutica, entre otras intervenciones. el daño en el funcionamiento ejecutivo, además de que podría retrasar o limitar los resultados del tratamiento o la rehabilitación por la probable alteración en el seguimiento de indicaciones y toma de decisiones (alteraciones que aumentan la probabilidad de recaídas y abandono del tratamiento), debería ser considerado en toda intervención bajo el argumento de que cualquier individuo se beneficiaría por el solo hecho de recuperar de forma temprana sus funciones cognitivas (30), lo cual concuerda con la búsqueda del cuidado integral por parte del personal de enfermería. sin embargo, existen condicionantes para tener en cuenta. la escasa producción científica sobre este fenómeno puede no ser suficiente para representar la realidad, ya que solo se accedió a un número limitado de bases de datos disponibles, por lo que sería necesaria la indagación en otras fuentes de información. asimismo, el empleo de diseños con bajo nivel de evidencia —como los estudios descriptivos— o muestras pequeñas continúan siendo una limitante para ampliar y profundizar en el estudio de esta temática (31, 57). no obstante, se sugiere continuar la investigación del funcionamiento ejecutivo en adolescentes como una variable crucial en el abuso de las bebidas alcohólicas. conclusiones la investigación del fenómeno del consumo de alcohol durante la adolescencia y sus repercusiones negativas en las ff. ee. aún se encuentra en desarrollo. con frecuencia los estudios evalúan más de un componente de las ff. ee. a través de baterías neuropsicológicas extensamente aceptadas e incluyen habilidades cognitivas relacionadas como la memoria, la atención y el lenguaje, pero cabe señalar que son pocos los estudios recientes identificados que se enfocaron a esta temática. además, entre las publicaciones recuperadas se apreció una divergencia de resultados que no permite la generalización de los efectos negativos del consumo de alcohol hacia todos los componentes de las ff. ee. sin embargo, es posible apoyar las premisas de que la adolescencia per se es una etapa donde existe mayor sensibilidad para sufrir los efectos negativos del consumo de alcohol a nivel cerebral, y que dicho consumo puede ser peligroso para el funcionamiento cognitivo del adolescente. en este sentido, se concluyó que en procesos como la inhibición de respuestas y la toma de decisiones parece existir un deterioro asociado con el consumo de alcohol en la adolescencia, el cual se apreció en más del 70 % de las investigaciones. por otra parte, también se identificaron vacíos que posiblemente restringen la generalización de los resultados: falta de unificación en los criterios de clasificación de los componentes de la función ejecutiva, el empleo de diseños de estudio que no permiten demostrar causalidad y el uso de muestreos no probabilísticos. a pesar de las limitantes, el conocer la implicación de las ff. ee. en problemáticas específicas —como el consumo de alcohol en la adolescencia— podría revolucionar los abordajes terapéuticos disponibles. es posible que un abordaje integral donde el personal de la salud y enfermería involucren un enfoque neuropsicológico tenga mayor probabilidad de éxito en el retiro de la adicción, ya que el entrenamiento en la toma de decisiones podría coadyuvar en el mantenimiento del estado de recuperación y disminución de las cifras de abuso y dependencia al alcohol. también, es posible que se limite el involucramiento con otras drogas, lo cual se reflejaría como una reducción a largo plazo de los costos de la atención de la población drogodependiente, particularmente los adolescentes, quienes tienen el riesgo de perder más años de vida saludable. por último, para futuras investigaciones de enfermería se sugiere profundizar en la evaluación de instrumentos para diagnosticar la disfunción ejecutiva. los hallazgos encontrados en la presente revisión sistemática contribuyen a enriquecer el 244 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 cuerpo de conocimientos de enfermería y se recomienda considerarlos para crear teorías de rango medio en torno al fenómeno de las adicciones, considerando particularmente el rol que juegan las ff. ee. referencias 1. brook js, saar ns, zhang c, brook, dw. psychological antecedents and adverse health consequences related to substance use. american journal of public health. 2009;99(3):563-8. 2. hidalgo mi, redondo am. consumo de drogas en la adolescencia. pediatr integral. 2009;13(3):252-74. 3. lansford je, erath s, yu t, pettit gs, dodge ka, bates je. the development course of ilicit substance use from 12 to 22: links links with depressive, anxiety, and behavior disorders at age 18. journal 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afectación de la memoria y las funciones ejecutivas. adicciones. 2004;16(1):41-52. 50. tirapu-ustárroz j, muñoz-céspedes jm, pelegrín-valero c. funciones ejecutivas: necesidad de una integración conceptual. rev neurol. 2002;34(7):673-85. 51. best jr, miller ph, jones ll. executive functions after age 5: changes and correlates. dev rev. 2009;29(3):180-200. 52. glass jm, buu a, adams km, nigg jt, puttler li, jester jm, et al. effects of alcoholism severity and smoking on executive neurocognitive function. addiction. 2009;104(1):38-48. 53. verdejo-garcía a, bechara, a. neuropsicología de las funciones ejecutivas. psicothema. 2010;22(2):227-35. 54. rebollo ma, montiel s. atención y funciones ejecutivas. rev neurol. 2006;42 (suppl 2: s3-7). 55. barkley ra. behavioral inhibition, sustained attention, and executive functions: constructing a unifying theory of adhd. psychol bull. 1997;121(1):65-94. 56. moscovitch m, winocur g. the frontal cortex and working with memory. in: stuss dt, knight rt. editors. principles of frontal lobe function. new york: oxford university press; 2002. p. 188-209. 57. clark db, thatcher dl, tapert sf. alcohol, psychological dysregulation, and adolescent brain development. alcohol clin exp res. 2008;32(3):375-85. 442 453 do governo dos vivos.indd 442 aquichan issn 1657-5997 franciele roberta cordeiro1 do governo dos vivos ao governo dos mortos: discursos que operam para a governamentalidade da morte 1 enfermeira. mestranda e doutoranda do programa de pó s-graduaç ã o em enfermagem, universidade federal do rio grande do sul, brasil. francielefrc@gmail.com recibido: 31 de agosto de 2012 enviado a pares: 10 de septiembre de 2012 aceptado por pares: 4 de octubre de 2013 aprobado: 4 de octubre de 2013 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 442-453 para citar este artículo / to reference this article / para citar este artigo cordeiro, f. r. (2013). do governo dos vivos ao governo dos mortos: discursos que operam para a governamentalidade da morte. aquichan. vol. 13, no. 3, 442-453. resumo objetivo: conhecer os discursos sobre a morte e o morrer que circulam nos artefatos disponíveis on-line na biblioteca virtual em saúde (bvs). método: foram selecionados, por meio da busca integrada na base de dados bvs, 16 artigos a partir dos descritores: morte, enfermagem e cuidados paliativos. após constituído o corpus da pesquisa, por aproximação temática, os dados produzidos foram submetidos à análise textual. a discussão dos dados foi operada a partir das noções de normalização e a governamentalidade, propostas pelo filósofo michel foucault. resultados: os resultados apontam uma tendência em normalizar o processo de morrer, a partir da filosofia dos cuidados paliativos. visa-se à aceitação da morte, de forma que aqueles que não estão atravessados e subjetivados por esse discurso estão fora de um padrão considerado o ideal. além disso, esse novo modelo de cuidados desponta como uma estratégia de governamento dos corpos, favorecido pelo ambiente do domicílio e respaldado pelos diferentes saberes, como o religioso e o científico. conclusão: que a constituição desse modo de cuidar, enquanto um saber incorporado pelo discurso científico captura as enfermeiras numa trama de poder em relação aos sujeitos em processo de morrer. palavras-chave tanatologia, enfermagem, cuidados paliativos, morte, brasil. (fonte: decs, bireme). 443 do governo dos vivos ao governo dos mortos: discursos que operam para a governamentalidade da morte l franciele roberta cordeiro del gobierno de los vivos al gobierno de los muertos: discursos que operan para la gobernabilidad de la muerte resumen objetivo: conocer los discursos acerca de la muerte y el morir que circulan en los artefactos disponibles online en la biblioteca virtual en salud (bvs). método: se seleccionaron, por medio de la búsqueda integrada en la base de datos bvx, 16 artículos con los descriptores: muerte, enfermería y cuidados paliativos. tras constituido el corpus de la investigación, por acercamiento temático, los datos producidos fueron sometidos al análisis textual. la discusión de los datos se llevó a cabo desde las nociones de normalización y la gubernamentalidad, planteadas por el filósofo michel foucault. resultados: los resultados señalan una tendencia en normalizar el proceso de morir desde la filosofía de los cuidados paliativos. se objetiva la aceptación de la muerte, de forma que aquellos que no están atravesados y subjetivados por ese discurso están fuera de un estándar considerado lo ideal. además, ese nuevo modelo de cuidados despunta como una estrategia de gubernamiento de los cuerpos, favorecido por el ambiente del domicilio y respaldado por los diferentes saberes, como el religioso y el científico. conclusiones: la constitución de ese modo de cuidar, como un saber incorporado por el discurso científico, captura las enfermeras en una trama de poder ante los sujetos en proceso de morir. palabras clave tanatología, enfermería, cuidados paliativos, muerte, brasil. (fuente: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 442-453 444 aquichan issn 1657-5997 from government of the living to government of the dead: discourses that operate for the governance of death abstract objective: know the discourses on death and dying that in the artifacts available online in the virtual health library (vhl ). method: through an integrated search in the vhl database, 16 articles were selected with the following descriptors: death, nursing and palliative care. once the body of the research was formed along the lines of a thematic approach, the data produced were subjected to a textual analysis. the discussion of the data was undertaken in light of the notions of standardization and governmentality raised by the philosopher michel foucault. results: the results show a tendency to standardize the process of dying pursuant to the philosophy of palliative care. acceptance of death is perceived in objective terms, so those who are not experiencing and subjectified by that discourse are outside a standard that is considered ideal. moreover, this new model of care is emerging as a strategy for governance of the body, favored by a home environment and backed by different knowledge, such as religious and scientific. conclusions: the establishment of this mode of care, as know-how built on scientific discourse, catches nurses in a weave of power when dealing with those who are in the process of dying. key words thanatology, nursing, palliative care, death, brazil. (source: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 442-453 445 do governo dos vivos ao governo dos mortos: discursos que operam para a governamentalidade da morte l franciele roberta cordeiro introdução morrer. um ato natural, significado culturalmente e ao mesmo tempo cercado de mistérios, superstições, cientificidade, espiritualidade e de desafios. a morte na contemporaneidade se mostra tal e qual o momento em que vivemos: volátil, efêmera, cercada pela tecnologia e discursos que buscam (re) introduzi-la na “docilidade” do lar. a enfermagem, enquanto ciência ou arte que atua junto do ser humano, acompanha o sujeito desde o nascimento até os momentos finais da vida. nesse sentido, o modo como as enfermeiras cuidam no processo de morrer acompanha as modificações socioculturais e são por elas constituídas. a maneira como vivenciamos e problematizamos a morte, desde os anos de 1950, sofre modificações concomitantes à dinâmica social, que impulsionaram os avanços da tecnologia e garantiram o status de verdade e legitimação à ciência. além disso, a invenção dos discursos sobre direitos humanos contribuíram com o desenvolvimento de novas perspectivas sobre os modos de pensar a vida e a morte (1). os modelos de cuidado que, desde o século xix, vinham sofrendo influência do diagrama da medicalização, passam a ser problematizados visando ao resgate do humanismo na saúde. temos, como exemplo, os discursos sobre o parto humanizado, que busca um retorno do nascimento à forma natural, sem intervenções cirúrgicas em um ambiente confortável, de preferência ou domicílio. com relação ao término da vida, observa-se, igualmente, uma tendência em desinstitucionalizar esse processo. a morte, que em momentos anteriores era considerada um ritual do lar e naturalizado aos sujeitos, manifesta-se a partir da modernidade, de forma discreta, sendo expressa pelos sentimentos de negação, raiva e luta do homem moderno contra essa vivência (2). sob esse aspecto, vale ressaltar que não se busca aqui apresentar em qual período histórico era ou é correta a forma como se morre, mas atentarmos para o fato de que o modo como se vivencia a morte está intimamente ligado aos discursos e verdades de uma dada época, e que atende às demandas e necessidades do modelo social, econômico e cultural vigente. dessa forma, visualizam-se os discursos sobre a morte e o morrer na contemporaneidade ligados à filosofia dos cuidados paliativos2. esse modelo busca proporcionar uma morte sob o controle de sinais e sintomas desagradáveis, relacionados ao avanço do quadro clínico das doenças fora de possibilidades de cura. visa, ainda, à aproximação da família ao cenário da morte, seja ele o hospital ou o domicílio, propõe o trabalho em equipe multidisciplinar de saúde, o que potencializa a resolução dos conflitos e necessidades na hora da morte (3). os cuidados paliativos ganharam representatividade e se fortaleceram a partir do movimento hospice, que teve como sujeito fundante desse discurso a enfermeira, médica e assistente social cicely saunders. esse movimento buscava desenvolver cuidados direcionados aos pacientes com doença fora de possibilidade de cura, especialmente os oncológicos, em hospitais preparados para receber os moribundos. os hospices constituíram-se inicialmente na inglaterra e disseminaram-se na frança, e posteriormente nos estados unidos (4). neste último país, o movimento ganhou força e os discursos sobre a morte e o morrer despontaram como um elemento de observação e intervenção da ciência, especialmente na área médica, após os estudos observacionais da médica psiquiatra elizabeth kübler-ross, que ordenou e sistematizou as cinco fases pelas quais passavam os moribundos antes da sua morte, a citar: negação, raiva, barganha, depressão e aceitação (5). observa-se a aproximação entre morte e saber científico, que tenta transformar o final da vida passível da experimentação médica. assim como a loucura e a delinquência, a morte passa a ser alvo das intervenções para ser corrigida e inserida dentro dos padrões aceitáveis para uma boa morte, em que ela deve ocorrer sem dor, junto da família, vivenciada sob a filosofia dos cuidados paliativos. normaliza-se a morte visando a seu governamento3, já que esse processo interfere diretamente nas relações de produção e estruturação social. a partir da constituição de um saber em 2 cuidados paliativos será escrito com iniciais maiúsculas no decorrer do manuscrito, por ser entendido aqui como um campo de saber que institui o modo como se deve cuidar dos pacientes com doença fora de possibilidade de cura. 3 utilizo o termo governamento para me referir ao conjunto de estratégias dispostas para o governo dos sujeitos, para a condução das condutas inspiradas em um modelo hebraico-cristão que também nos séculos xv e xvi orienta as práticas dos estados-nação na condução da vida das populações. essas estratégias de governo são exercidas a partir do conhecimento dos sujeitos, por meio dos dados epidemiológicos, estatísticos, entre outros, que permitem conhecer melhor para governar por meio da potencialização da vida. exemplo disso, no campo da saúde, temos as políticas públicas, as campanhas de vacinação, a criação de programas assistenciais entre outras. o termo governo também remete a essas práticas, sendo utilizado por michel foucault em seus manuscritos. difere-se essas estratégias de governo/governamento das palavras governo, escrita com inicial maiúscula, que está relacionada à estrutura do estado, à instância política em si. para mais informação, consultar a obra: segurança, território e população (2008). 446 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 torno da morte, torna-se relevante olharmos para esse processo como um local de atuação da equipe de saúde e, neste estudo, da enfermagem. olhar para a morte com lentes problematizadoras a partir das noções de normalização e governamentalidade, desenvolvidas por michel foucault, nos proporciona desnaturalizar discursos que são tidos como verdades concretas e irredutíveis, além de atentarmos para a constituição dos discursos acerca da morte e do morrer produzidos por dispositivos utilizados para governar a vida dos familiares que ficam e a morte dos que partem. a noção de governamentalidade refere-se ao “conjunto constituído pelas instituições, os procedimentos, as análises e reflexões, os cálculos e as táticas que permitem exercer essa forma bem específica, embora muito complexa, de poder que tem por alvo principal a população, por principal forma de saber a economia política e por instrumento técnico essencial os dispositivos de segurança” (6:143). no âmbito da morte e do morrer, operar com as lentes teóricas da governamentalidade auxilia na identificação e compreensão das estratégias utilizadas para legitimar os discursos sobre um saber que direciona os cuidados de enfermagem nessa etapa da vida, os cuidados paliativos. por meio dessas lentes, é possível conhecer como se articulam as tramas de poder (dos profissionais, dos familiares, dos sujeitos, da religião, das relações de gênero) em torno dos corpos dos sujeitos que cuidam e dos que são cuidados. é possível também observarmos como se dá o governamento da morte a partir das práticas constituídas no cotidiano dos serviços de enfermagem, com base nos inúmeros discursos que atravessam as enfermeiras. a noção de normalização pode ser percebida quando apontamos aquilo que se apresenta como “normal” dentro do processo de morrer a partir dos discursos dos cuidados paliativos, que visam primordialmente, à boa morte, apontando comportamentos e meios por onde alcançá-la. nesse sentido, percebe-se que aquilo ou aquele que não se enquadra nos padrões estabelecidos por essa filosofia pode ser considerado um moribundo anormal e deve, portanto, ser capturado pelos dispositivos de normalização que irão pulverizar o incorrigível e os desvios nas condutas esperadas por esses sujeitos (7). neste artigo, pretendo conhecer e apresentar algumas verdades que têm sido enunciadas nos artefatos brasileiros, a respeito do cuidado aos pacientes em processo de morrer. para tal, questiono: que discursos interpelam as enfermeiras nas produções científicas brasileiras a respeito do final da vida? de que lugar as enfermeiras falam nos manuscritos? como se constitui o cuidado às pessoas que morrem e suas famílias, a partir dos discursos circulantes? partindo dessas inquietações, elaborou-se o seguinte objetivo: conhecer os discursos sobre a morte e o morrer que circulam nos artefatos disponíveis on-line na biblioteca virtual em saúde (bvs). materiais e métodos este estudo compreende uma análise textual relacionada ao campo dos estudos culturais, na vertente pós-estruturalista, com inspiração foucaultiana. a vertente pós-estruturalista compõe um conjunto de ações descentradas e instáveis que propõe uma análise externa às racionalidades modernas e define-se como uma multiplicidade de tendências em vários meios da cultura, o que coloca em suspeita as verdades e grandes narrativas da modernidade (8). olhar para os artefatos partindo da inspiração foucaultiana representa desprender-se de toda a forma que busca formular conceitos estáticos. assim, analisar discursos sob esse olhar significa (re) inventar e (re) significar os acontecimentos e os espaços a partir de desdobramentos infinitos (8). deixo claro que em minhas análises não pretendo apontar qual o modo correto de cuidar daqueles que morrem, indicando limitações ou possíveis erros nas filosofias atuais, como os cuidados paliativos. minha pretensão é conhecer como somos constituídas enquanto enfermeiras que são formadas para cuidar de determinado tipo daqueles que morrem, a partir de certas relações de poder/saber com outros discursos, outros sujeitos, outras instituições. ressalto que a hipótese de leitura que faço dos materiais com os quais entrei em contato não são únicas e apresentam a minha perspectiva como enfermeira que já atuou no campo da oncologia, ou seja, que já cuidou de pacientes em processo de morrer, e que desenvolve, no momento atual, estudos acerca da temática do final da vida e suas perspectivas na contemporaneidade. direcionei meu olhar para os manuscritos disponíveis on-line, na bvs. esta se constitui em uma biblioteca virtual que agrega manuscritos publicados em periódicos indexados em diversas bases de dados, tais como: base de dados de literatura latino americana de ciências da saúde (lilacs), índice bibliográfico espanhol em ciências da saúde (ibec), scientific eletronic library online (scielo), entre outras. a biblioteca é organizada pela biblioteca regional de medicina (bireme), a qual é responsável pela 447 do governo dos vivos ao governo dos mortos: discursos que operam para a governamentalidade da morte l franciele roberta cordeiro circulação e disponibilização dos manuscritos na bvs. além disso, a organização panamericana de saúde (opas) norteia os modelos de produção e constituição da saúde e, dessa forma, estimula a produção e livre circulação das informações e estudos produzidos nos artefatos indexados, visando à adoção de novas estratégias para o aprimoramento dos sistemas e serviços de saúde nos países da américa latina. no brasil, essa biblioteca é uma das principais fontes de acesso aos periódicos e seus manuscritos. além disso, apresenta um número representativo de publicações de enfermeiras e atinge um elevado número de leitoras na área, o que a torna uma ferramenta de disseminação de informação e conhecimento na enfermagem. escolhi a bvs como fonte dos manuscritos que foram utilizados para a leitura interessada a respeito da morte e do morrer em virtude de sua abrangência com relação à área da saúde, especialmente a enfermagem. para a seleção dos artefatos utilizei, por meio da busca integrada, as palavras morte, enfermagem e cuidados paliativos. foram encontrados 74 trabalhos, dos quais foram selecionados 16 para compor o corpus empírico de análise (quadro 1), pois estavam disponíveis em versão completa para acesso on-line e relacionavam-se ao tema. nas análises, os manuscritos foram identificados com a inicial m, seguido da numeração conforme disposta no quadro 1. a captura dos manuscritos nas bases de dados se deu no período de maio de 2012 e não houve uma delimitação temporal. para a composição do corpus e das unidades de análise, realizei uma aproximação temática, um tipo de mapeamento discursivo no qual busquei associar os discursos que falavam sobre a religião, a disciplina com relação aos corpos das enfermeiras, aos cuidados paliativos e ao domicílio. esses elementos foram os que se mostravam visíveis nos discursos e possuíam relação um com o outro, sendo que juntos foram/são articulados para favorecer as táticas sobre os corpos dos sujeitos que morrem no contemporâneo. a análise textual buscou compreender as estratégias para o governamento da morte no desenvolvimento do cuidado pelas enfermeiras e atentou para as estratégias que definem o modo de cuidar, a maneira de agir e de responder diante da vida e da morte. nesse sentido, buscouse realizar uma hipótese de leitura dos manuscritos encontrados operando as noções foucaultianas de normalização e governamentalidade. nesta análise, compreendo os discursos como dispositivos que favorecem os acontecimentos e as manifestações de verdades neles contidos. para tanto, ao se propor uma análise dos materiais históricos, deve haver um desprendimento da superficialidade dos signos e da linguagem, para que se possa adentrar nas verdades emitidas pelos sujeitos que enunciam os discursos (9). assim, com vistas a atingir a proposta de análise, seguiu-se a sugestão de foucault de [...] não mais tratar os discursos como sendo signos (elementos significantes que remetem a conteúdos), mas como práticas que formam sistematicamente os objetos de que falam. certamente os discursos são feitos de signos; mas o que fazem é mais que utilizar esses signos para designar coisas. é esse mais que os torna irredutíveis à língua e ao ato da fala. é esse “mais” que é preciso fazer aparecer e que é preciso descrever (10: 5). dessa forma, não busco neste estudo interpretar ou desvendar alguma verdade obscura por trás dos discursos, nem ao menos apontar intenções ocultas. pretendo problematizar as materialidades e os efeitos daquilo que é dito/escrito sobre a morte e o morrer e que conforma as práticas das enfermeiras durante o cuidado às pessoas que estão morrendo. resultados e discussões após a seleção do corpus realizei a caracterização dos artefatos descrevendo o lugar de onde são enunciados os discursos sobre a morte e o morrer. dos artigos analisados, 13 foram oriundos da região sudeste brasileira, concentrando-se as publicações nos estados de são paulo e rio de janeiro os outros três manuscritos eram do rio grande do sul. assim, percebe-se uma concentração de publicações nessas regiões que reflete no modelo de cuidados proposto, o que denota estarem ligados aos discursos das escolas de onde falam os sujeitos nos manuscritos, escolas com importantes trabalhos sob as perspectivas emancipatórias e compreensivas. com relação aos sujeitos enunciadores, em sua maioria foram enfermeiras, porém evidenciaram-se algumas produções de médicos e psicólogos que relacionavam ou abordavam o trabalho da enfermagem. os periódicos com publicações mais frequentes foram a revista da escola de enfermagem da usp com três, a online brazilian of journal nursing (objn) com três e a revista gaúcha de enfermagem com duas. os estudos, em sua maioria, eram de natureza qualitativa e de revisão bibliográfica ou reflexão acerca do conceito e desenvolvimento dos cuidados paliativos. os anos com publicações mais frequentes foram 2007 com três, 2009 com três e 2010 também com três. essa tendência aos cuidados paliativos e à preocupação com os cuidados da hora do morrer é evidenciada a partir de 2000, quando as publicações que abordam a temática passam a circular mais frequentemente entre os periódicos (2). 448 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 é necessário atentarmos para aos acontecimentos em um dado contexto histórico para pensarmos as condições de possibilidades de emergência desses discursos em torno do morrer. observar as descontinuidades que permitiram o surgimento, a disseminação e as modificações dessa filosofia de cuidados apontam para alguns acontecimentos no brasil, como a criação da política nacional de humanização (2004); o programa melhor em casa (2011); as diretivas antecipadas de vontade (2012); instituições que passam a problematizar a morte, como a academia nacional dos cuidados paliativos, além do esgotamento dos leitos hospitalares que passam a ser disputados entre aqueles que têm mais chances de sobreviver e aqueles que estão em condições finais de vida. a seguir, apresento as duas unidades de análise que emergiram das leituras, nas quais foi possível observar as estratégias de governamento e as tramas de poder estabelecidas nas relações entre os envolvidos no processo de morrer: enfermeiros, equipe multidisciplinar, familiares e pacientes. elas foram articuladas por meio da operação com os discursos, em que eram aproximados aqueles que possuíam semelhanças naquilo em que enunciavam e nos campos de saber e relações de poder que os atravessavam. destaco que os discursos que trago para as análises referem-se aos textos escritos nos artigos, aos comentários e interpretações dos autores dos manuscritos manuseados e não às falas de terceiros, dos sujeitos de pesquisas investigados nesses estudos. enfermeira: o corpo dócil ante os que morrem por meio das enunciações verificou-se que são solicitadas às enfermeiras atitudes de otimismo, alegria, boa apresentação e habilidade da comunicação com os pacientes. o papel de destaque da comunicação e do relacionamento interpessoal no contexto da terminalidade, a relação de confiança estabelecida com os profissionais de saúde e cuidadores a partir da leitura dos sinais não verbais dos mesmos, reafirmam o desejo de não conversar apenas sobre a doença e valorizam a comunicação verbal otimista e alegre e a presença compassiva que consola e conforta. [m1] para que os enfermeiros possam responder aos outros com uma abordagem genuína e sensível é necessária a exploração das suas atitudes, sentimentos e valores pessoais (autoavaliação). [m3] as enfermeiras devem estar dispostas ao atendimento dos doentes. aponta-se que nas relações de cuidado e poder, entre pacientes e enfermeiras, prevalece o imperativo da contemporaneidade, no qual a tristeza deve ser afastada, e o sujeito deve estar disposto e alegre na execução de suas funções e nas relações. no mundo atual, é preciso estar feliz e disposto. a lógica neoliberal exige a flexibilidade dos corpos que se tornam passíveis de modulação para as diferentes situações a que são chamados a enfrentar (11). a solicitação desse tipo de comportamento mostra a conformação de um padrão de enfermeira: aquela que cuida, que é amorosa e sensível. remeto-me à história da profissão que, em sua constituição, foi alvo dos discursos sobre caridade, bondade, humildade, entre outros preconizados pela religião, campo de saber que envolve e atravessa o cuidado nos diferentes períodos e que continua presente no contemporâneo. por mais que se tenha afastado o domínio religioso em torno das práticas de saúde e da morte no século xix, ainda reconhecemos vestígios ou atualização dos discursos religiosos na constituição dos sujeitos no século xxi, não só daqueles que cuidam, mas também da população como um todo (12). a enfermagem foi e ainda é considerada uma prática desenvolvida essencialmente por mulheres. é interessante, nesse sentido, problematizar as questões de gênero em torno da profissão que por vezes é vista de forma sacralizada e associada com o papel de mãe. sob essa perspectiva, a enfermeira tem de ser prestativa, reconhecer o sujeito em primeiro lugar e cuidar com afago, conforto, incondicionalmente, assim como faz a mulher-mãe. para tal, o sujeito que cuida precisa conhecer-se e reconhecer-se, para que assim possa governar a si (seus sentimentos, emoções, expressões) e aos outros (13). dessa forma, concomitante às transformações dos sujeitos, observo solicitações diferenciadas sobre o cuidado que é prestado nos serviços de saúde, conforme demonstra a fala a seguir: nestas falas o cuidado aparece somente com dimensão técnica e ainda como “o melhor que se possa fazer”. será que não ficou claro o conceito de cuidar, aquele que dá essência à enfermagem? [m11] noto que, apesar dos deslocamentos em volta do processo de cuidar, que vai de uma dimensão cartesiana para um modelo de cuidado integral e holístico, ainda estamos em processo de instauração de um novo paradigma de cuidado. se, por um lado, exige-se o atendimento primordial aos aspectos físicos, como a dor, as náuseas e as necessidades básicas dos sujeitos em processo de morrer, por outro, ainda é limitante a inserção de outros 449 do governo dos vivos ao governo dos mortos: discursos que operam para a governamentalidade da morte l franciele roberta cordeiro modos de cuidar respaldados na integralidade (14). talvez, em parte, podemos considerar essas limitações em virtude da transição pela qual passamos, na formação de enfermeiros e também dos demais profissionais de saúde. de qualquer forma, a inserção de novos modelos de educação para a morte nos cursos de graduação na área da saúde possui a centralidade no corpo, que é objeto de intervenção nas diferentes fases de vida e sob as diferentes perspectivas. o corpo é o alvo dos cuidados, e nele se inscrevem as prescrições. por meio dele é que se dão as relações entre profissionais de saúde e sujeito, independentemente da perspectiva de cuidado que se adote. assim, considero o corpo o local que abriga as experiências sobre a morte. ele pode ser considerado a “origem” dos acontecimentos, dá significado às eventualidades, como o nascimento, o falecimento, os erros, os acertos, a partir de lutas travadas entre um campo de si e um campo exterior, que permite a constante atualização do corpo enquanto produtor de materialidades e realidade de uma época (15). reconheço a instauração de um regime de verdade, a partir dos discursos que circulam nos artefatos, em que as enfermeiras são, entre os profissionais de saúde, aquelas que mais permanecem junto dos pacientes, o que justificaria a comunicação e a relação de qualidade entre estes. esse aspecto pode indicar a valorização do contato e das relações em função do tempo em que elas se dão, e não em relação à intensidade com que ocorrem. alguns artigos enfocaram o papel do enfermeiro e de toda equipe da enfermagem como primordial na avaliação da dor, afirmando que, estando esses profissionais 24h ao lado dos pacientes, podem mais que os outros profissionais. [m4] desconfio da premissa de que, pelo fato de as enfermeiras permanecerem por maior tempo junto aos pacientes, elas consigam desenvolver uma relação holística. por vezes, outros profissionais também se relacionam tanto quanto a enfermeira, com vínculo e respeito. nesse âmbito, acredito que o favorecimento das relações entre sujeito que recebe o cuidado e aqueles que cuidam depende mais da experiência que acontece e que perpassa a cada um dos envolvidos no cuidado do que da cronologia. indiscutivelmente, o tempo quantitativo pode beneficiar positivamente as relações e o cuidado, nas questões relativas ao controle de sinais e sintomas das patologias, no diálogo, na observação, na anamnese. entretanto, a forma como ocorrem esses eventos sobressaem-se ao fator quantitativo do tempo. o que marca é as experiências. experiência como aquilo que nos passa e nos toca, em que “o sujeito da experiência seria como um território de passagem, algo como uma superfície sensível, que aquilo que acontece afeta de algum modo, produz afetos, inscreve algumas marcas, deixa alguns vestígios, alguns efeitos” (16:24). nas relações entre sujeitos, torna-se relevante pensarmos o contato e a aproximação a partir de um tempo puro, de um tempo que é memória e duração, questionando uma cronologia que delimita o modo de cuidar e apresenta uma falsa intensidade nas relações de cuidado no momento da morte. nesta unidade de análise, apresento ainda o modelo de confissão, que se remete ao modo pastoral de governar e totalizar os indivíduos. nos discursos, propõem-se às enfermeiras que conheçam os sujeitos com os quais estão relacionando-se, para que assim possam cuidar de forma a atender às necessidades daqueles e talvez, ainda, consigam ter em suas mãos o controle dos riscos e o mínimo de imprevistos durante a morte. ao cuidarmos de uma pessoa em fim de vida, precisamos saber quem é essa pessoa e a sua família, quais são as suas capacidades, as suas necessidades e limitações. [m3] ao me remeter às formas de governar e aos desdobramentos do poder propostos por michel foucault no curso intitulado segurança, território e população (1978), observo que, no exercício do poder pastoral, a confissão era a atividade fundamental para o reconhecimento das pessoas que estavam sob a proteção do pastor. é por meio da confissão que se pode conhecer as fraquezas, potencialidades e qualidades dos sujeitos e, dessa forma, intervir em aspectos singulares que repercutem significativamente no controle e governamento das populações (7). nesse sentido, os discursos sugerem às enfermeiras que desenvolvam esse conhecimento sobre os corpos, por meio de perguntas que estimulem os sujeitos a falarem sobre sua situação familiar, física e emocional, visando à prevenção de riscos, ao planejamento e à efetividade dos cuidados. no cotidiano dos serviços de enfermagem, observamos esses rituais por meio da sistematização da assistência de enfermagem (sae), especialmente nas consultas de enfermagem e nos demais questionamentos realizados para elaborar a evolução diária e os cuidados dos pacientes, o que inclui seus familiares. verifica-se ainda que a abordagem dos cuidados paliativos, de forma multidisciplinar, favorece o exercício do governamento dos corpos dos pacientes e de seus familiares, uma vez que o psi450 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 cólogo, o nutricionista, o médico, entre outros, buscam conhecer o paciente por meio da confissão, estruturada pelas anamneses e questionários multidimensionais que favorecem o controle das condutas, comportamentos e hábitos. o trabalho em equipe torna-se quase um imperativo, pois a enfermeira, a fisioterapeuta e a psicóloga passam a ser referências destes pacientes. [...] conversar com o paciente foi salientado como cuidado que o enfermeiro presta ao paciente terminal por 4 (33,3 %) entrevistados e dois também incluíram o escutar como cuidado. estes elementos são considerados básicos para o cuidado humano, pois a comunicação aberta permite expressão de sentimentos e pensamentos que podem e devem ser partilhados durante o cuidar. [m9] exemplo dessa forma de governamento são as reuniões em grupos ou as consultas individuais com psicólogos e enfermeiros. nesses ambientes, os profissionais ouvem e orientam pacientes e familiares, não somente com relação aos aspectos que englobam a doença, mas também aos demais fatores componentes da vida privada. dessa forma, se articulam estratégias que buscam conduzir esses sujeitos por meio de um poder que “não coincide nem com uma política, nem com uma pedagogia, nem com uma retórica [...] é uma arte de governar os homens” (6:219). normalizando o processo de morrer nos manuscritos reconheci algumas estratégias dispostas para normalizar o processo de morrer que legitimavam os discursos dos cuidados paliativos enquanto a opção e o modelo de cuidado verdadeiro para a “boa morte”, ou a morte “normal”. acredito que essa filosofia constitui um modo diferenciado de cuidar dos sujeitos com doença fora de possibilidade de cura. os cuidados paliativos emergem como uma necessidade do mundo contemporâneo, ante as configurações de saúde que apontam o aumento na expectativa de vida, que vem acompanhado das doenças crônico-degenerativas não transmissíveis, as quais requerem novas organizações dos sistemas de saúde. a organização mundial da saúde (oms) aparece como uma das instituições enunciadoras das verdades sobre os princípios dos cuidados paliativos, sendo que a sua conceituação a respeito dessa filosofia de cuidados é citada em grande parte dos trabalhos. estas respostas nos mostram que estes enfermeiros parecem não conhecer e realizar um cuidado paliativo integral, conforme conceitua a oms. [m11] para essa instituição, os cuidados paliativos buscam a qualidade de vida de pacientes com doença fora de possibilidade de cura e de seus familiares por meio da prevenção e do alívio do sofrimento, ao integrar problemas de natureza física, psicossocial e espiritual e intervir de forma holística (18). nessa perspectiva, as enfermeiras que não desempenham tais cuidados estão fora da normalidade e dos padrões de cuidados propostos. faz-se necessário que todos os profissionais de saúde compreendam que este tipo de cuidados deve abranger todas as pessoas que padecem de doenças em fase terminal. [m3] só não é possível aplicar os princípios dos cuidados paliativos quando há morte súbita por doenças, acidente ou violência, no entanto, depende em que fase se encontra a doença e a história natural de cada um. [m4] a partir das enunciações, apreende-se que os cuidados paliativos surgem enquanto um diagrama de poder que procura capturar aqueles que morrem independentemente da doença que acomete o sujeito. nesse sentido, morrer sob os cuidados paliativos constitui-se em um padrão de normalidade para a busca da boa morte no contemporâneo, de modo que, progressivamente, os únicos passíveis de escapar dessa trama são as vítimas acidentes fatais ou morte súbita. essa filosofia de cuidados tem por princípios a integração da família no processo de morrer, além de promover a aceitação da morte enquanto um processo natural. dessa forma, busca-se a abrangência dos aspectos multidimensionais do ser humano no cuidado prestado aos sujeitos em processo de morrer. o enfermeiro tem papel fundamental nos cuidados paliativos como na aceitação do diagnóstico e auxílio para conviver com a doença. [m2] assim, a aceitação da morte por parte do cliente e familiares leva a uma maior resolução de pendências da vida. [m7] aceitar a morte apresenta-se como um elemento característico da normalização do final da vida. as enfermeiras procuram auxiliar o paciente a encarar e superar os medos e as angústias 451 do governo dos vivos ao governo dos mortos: discursos que operam para a governamentalidade da morte l franciele roberta cordeiro inerentes a esse evento utilizando-se especialmente de discursos confortantes, com diálogos otimistas e positivos que proponham a vivência tranquila dessa etapa da vida. caso esse processo não seja encarado como natural, o sujeito estará fora da “normalidade” e será alvo de novas intervenções. a espiritualidade e religiosidade são recorrentes, o que sugestiona a subjetivação das enfermeiras para realizar o cuidado por meio desses discursos que pretendem levar conforto e esperança aos doentes. um dos grandes objetivos dos cuidados paliativos é acrescentar vida (qualidade) aos dias e não dias à vida, dando-se primazia aos cuidados emocionais, psicológicos e espirituais. [m3] esses dois aspectos são utilizados como estratégias que acalmam e confortam. ganham legitimidade terapêutica, a partir de discursos que tentam, por meio da ciência, comprovar os benefícios da religião e da espiritualidade para os processos físicos e emocionais. ao observarmos os manuais de cuidados paliativos, os manuscritos e os livros de enfermagem, podemos reconhecer a orientação da aplicação de questionários que buscam conhecer os sujeitos, identificar suas crenças e, a partir de então, inserir esses outros aspectos na prescrição dos cuidados de enfermagem. os dispositivos citados contribuem para normalizar o processo de morrer, à medida que apresentam, em muitas doutrinas, a ideia de continuidade da vida em um mundo posterior, ao se fundamentarem na transcendentalidade para auxiliar a aceitação da morte como um evento natural, que converge com a proposta dos cuidados paliativos (19). entretanto, esses rituais ainda são questionados quando são instituídos como uma alternativa e não como complementariedade ao tratamento médico. às vezes as famílias abandonam a equipe médica e vão à procura de outros recursos, pensando encontrar outras perspectivas ou formas de tratamento. dessa forma, acabam afastando a criança da equipe com quem ela conviveu tanto tempo, durante seu tratamento e que poderia dar-lhe o suporte psicológico e emocional de que precisa. [m8] apesar da forte e crescente inserção, os discursos associados ao misticismo, às práticas complementares, à religiosidade e à espiritualidade não detêm um estatuto de verdade e por vezes são postos em cheque, visando à (re) afirmação do discurso médico, tecnológico e científico como o verdadeiro, assegurando à equipe de saúde a referência nos cuidados diante da morte. por fim, o local sugestionado como o ideal para proporcionar o conforto na hora da morte é o domicílio. considerando a nossa experiência profissional em contexto hospitalar, constatamos que uma grande maioria dos doentes em situação terminal vivencia esse processo no hospital, o que o torna um pouco diferente do vivenciado no aconchego do lar. [m3] há necessidade de incluir as crianças/adolescente na tomada de decisões para desenvolver autonomia e a preferência pelo cuidado no domicílio. [m2] o domicílio tem sido indicado como o local de escolha para a morte. ele representa o conforto, a afetividade e garante a aproximação entre paciente e família nos momentos finais da vida. em se tratando de configurações familiares para recepcionar os moribundos, compreende-se que o modelo de cuidados paliativos se originou no contexto europeu, que apresenta relações sociais diferentes das encontradas no brasil. assim, questionamse a preparação dos pacientes, da família e a abordagem utilizada junto às famílias brasileiras para o cuidado de pessoas em processo de morrer no ambiente domiciliar. na realidade brasileira, esses pacientes acabam sendo admitidos em serviços de internação domiciliar, em que algumas tecnologias e investimentos terapêuticos, especialmente de alívio da dor, passam a ser utilizados. os sujeitos são retirados dos hospitais e encaminhados ao domicílio, muitas vezes contra a sua vontade e de seus familiares que se sentem inseguros diante da possibilidade de sofrimento, em detrimento da preocupação com a redução dos custos com internações em leitos hospitalares (17). por meio de visitas semanais ou quinzenais, realizadas pelos profissionais da equipe de saúde, o controle e o governo sobre as condutas e o corpo das pessoas em processo de morrer é assegurado, apesar das mudanças de cenário. considerações finais os discursos evidenciam que as verdades produzidas sobre cuidados paliativos subjetivam as enfermeiras no processo de cuidar e direcionam-nas para atitudes que visam ao controle dos corpos e da morte em torno de um saber. o corpo do paciente é alvo desse governamento, por meio de técnicas de alívio da 452 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 dor, de confissões sobre o estado físico e emocional que, pelas intervenções e aceitação desse processo, garantirão uma morte serena e “normal”. verifica-se que os manuscritos corroboram com a legitimação dos discursos sobre cuidados paliativos. essa filosofia é considerada como o verdadeiro modelo de cuidado a ser oferecido aos pacientes em processo de morrer, em que todos devem ser capturados e inseridos. algumas instituições têm buscado a introdução dos aspectos ligados à religiosidade e à espiritualidade, no cuidado dos pacientes e nas ações das enfermeiras, como forma de proporcionar conforto. apesar dessa tendência, as verdades emitidas pela ciência, pela medicina e pela tecnologia ainda asseguram às equipes de saúde o poder e o governo dos corpos que morrem, por meio de intervenções técnicas e dialógicas. por fim, a constituição desse modo de cuidar enquanto um saber incorporado pelo discurso científico captura as enfermeiras numa trama de poder a respeito dos corpos dos sujeitos que morrem. desse modo, sugere-se um olhar com lentes problematizadoras sobre essa filosofia, que desconfie das verdades produzidas sobre o morrer, as quais atravessam e subjetivam o modo de cuidar das enfermeiras e impactam diretamente nas relações e configurações dos sujeitos com a morte. referências 1. marinho s, arán m. as práticas de cuidado e a normalização das condutas: algumas considerações sobre a gestão sóciobiomédica da “boa morte” em cuidados paliativos. interface – comunic, saúde, educ 2011; 15(36): 7-19. 2. silva ks, ribeiro rg, kruse mhl. discursos de enfermeiras sobre morte e morrer: vontade ou verdade? rev bras enferm 2009; 62(3): 451-6. 3. floriani ca, scharamm fr. cuidados paliativos: interfaces, conflitos e necessidades. ciência & saúde coletiva 2008; 13(2): 123-32. 4. kruse mhl, vieira rw, ambrosini l, niemeyer f, silva fp. cuidados paliativos: uma experiência. rev hcpa 2007; 27(2): 49-52. 5. kübler-ross, e. sobre a morte e o morrer. são paulo: martins fontes; 2008. 6. foucault, m. segurança, território e população: curso no collège de france: 1977-1978. são paulo: martins fontes; 2008. 7. lockmann, k. inclusão escolar: saberes que operam para governar a população [dissertação]. porto alegre: universidade federal do rio grande do sul. faculdade de educação; 2010. 8. veiga-neto a. foucault e a educação. 2 ed. belo horizonte: autêntica; 2007. 9. silva ks. em defesa da sociedade: a invenção dos cuidados paliativos [dissertação]. porto alegre: universidade federal do rio grande do sul. escola de enfermagem; 2010. 10. foucault m. a arqueologia do saber. 7 ed. rio de janeiro: forense universitária; 2004. 11. bracht v, almeida qf, gomes mi. baumann e a educação. belo horizonte: autêntica; 2009. 12. rodrigues jc. o tabu da morte. 2 ed. rio de janeiro: editora fiocruz; 2006. 13. foucault m. o governo de si e dos outros. são paulo: martins fontes; 2010. 14. cordeiro fr, beuter m, roso cc, kruse mhl. pain and the dying process: nurses’ perspectives using the creative and sensible method. online brazilian journal of nursing [publicado na internet] 2013. 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rev bras enferm, brasília 2009 maio-jun.; 62(3): 451-6. m13 susaki tt, silva mjp, possari jf. identificação das fases do processo de morrer pelos profissionais de enfermagem. acta paul enferm 2006; 19(2): 144-9. m14 poles k, bousso rs. morte digna da criança: análise de conceito. rev esc enferm usp 2009; 43(1): 215-22. m15 shimizu he, guitierrez bao. participação de enfermeiros na implantação e desenvolvimento de um grupo multidisciplinar de assistência a pacientes crônicos e terminais. rev esc enferm usp 1997; 31(2): 251-8. m16 silva dis. significados e práticas da espiritualidade no contexto dos cuidados paliativos em pacientes oncológicos adultos. revista hcpa 2011; 31(3): 353-8. 132 aquichan issn 1657-5997 marléa chagas-moreira1 joséte luzia leite2 marcelle miranda da silva3 marceli vincler da silva4 frederico gomes-drunond4 marcos andré félix da silva5 estratégias de apoio de enfermagem na atenção à saúde de portadores de câncer: expectativas de moradores de uma comunidade brasileira 1 doutora em enfermagem. professora adjunta escola de enfermagem anna nery da universidade federal do rio de janeiro, rio de janeiro, brasil. marleachagas@gmail.com. 2 doutora. professora titular emérita da universidade federal do estado do rio de janeiro, rio de janeiro, brasil. joluzia@gmail.com. 3 doutoranda da escola de enfermagem anna nery da universidade federal do rio de janeiro, rio de janeiro, brasil. enfermeira hospital universitário clementino fraga filho. mmarcelle@ig.com.br 4 estudante 8º período curso de graduação escola de enfermagem anna nery da universidade federal do rio de janeiro, rio de janeiro, brasil. mmarcelle@ig.com.br 5 mestre em ensino da saúde. enfermeiro instituto nacional do câncer. membro grupo de pesquisa gerência e processo de cuidar na enfermagem em oncologia. mfsilva@yahoo.com.br recibido: 17 de junio de 2009 aceptado: 23 de julio de 2010 resumo objetivo: analisar as prioridades estabelecidas por moradores de uma comunidade do rio de janeiro (brasil), acerca de estratégias de apoio a pessoas portadoras de câncer, e os indicativos para o planejamento de ações de enfermagem. método: o quadro referencial está pautado no modelo de cuidados inovadores em situações crônicas de saúde (organização mundial de saúde) e abordagem sistêmica da saúde. pesquisa descritiva, qualitativa que utiliza como técnica de coleta de dados a entrevista semi estruturada. resultados: a maioria dos entrevistados referiu como expectativa de apoio a pessoas com câncer a informação quanto à mudança de estilo de vida, como se autocuidar e diminuir o estigma da doença. os entrevistados que informam conhecer alguém com câncer referiram como expectativa a necessidade de incluir o apoio emocional, a ajuda para não desistir do tratamento, além de criar espaço para as pessoas doentes e suas famílias compartilharem experiências. conclusões: os resultados indicam a importância dos enfermeiros planejarem ações junto à comunidade que favoreça sua participação na formulação de estratégias e que contribuam para a sensibilização e motivação dos portadores de câncer ao gerenciamento do autocuidado para promoção da qualidade de vida. palavras-chave enfermagem oncológica, políticas, planejamento e administração em saúde, atenção à saúde, participação comunitária. (fonte: decs, bireme). año 10 vol. 10 nº 2 chía, colombia agosto 2010 l 132-145 133 estratégias de apoio de enfermagem na atenção à saúde de portadores de câncer... l marléa chagas-moreira, joséte luzia leite, marcelle miranda da silva y otros. nursing support strategies in the care of cancer patients: expectations found among the residents of a brazilian community abstract objective: the objective was to describe the priorities set by residents of a community in rio de janeiro (brazil) concerning support strategies for patients with cancer and to analyze the indications for planning nursing action based on those expectations. method: the frame of reference is based on the innovative care for chronic health framework (world health organization) and on the systemic guidelines for health. this is a qualitative, descriptive study that used semi-structured interviews for data collection. results: most of those interviewed said they expected support in the form of information on changes in lifestyle for patients with cancer (i.e. self-care and help to reduce the stigma of the disease). those who reported knowing someone with cancer voiced the need for emotional support and for help to avoid abandoning treatment. they also stressed the importance of making room for patients and their families to share experiences. conclusions: the results point to the necessity of establishing a plan for nursing action within the community that encourages grassroots participation in laying out strategies, in helping to raise awareness, in motivating patients with cancer to deal with self-care and in encouraging a better quality of life. key words oncologic nursing, health policy, planning and management, health care, community participation. (source: decs, bireme). estrategias de apoyo de enfermería en la atención de la salud de los pacientes con cáncer: expectativas de los residentes de una comunidad brasilera resumen objetivos: describir las prioridades establecidas por los moradores de una comunidad de río de janeiro (brasil), acerca de las estrategias de apoyo a las personas con cáncer, y analizar los indicativos para la planificación de las acciones de enfermería a partir de las expectativas referidas. método: el marco de referencia se basa en el modelo de cuidados innovadores en situaciones crónicas de salud 134 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 (organización mundial de la salud) y en las directrices sistémicas de la salud. investigación cualitativa y descriptiva que utiliza como técnica de recolección de datos la entrevista semiestructurada. resultados: la mayoría de los encuestados declaró como expectativa para apoyar a las personas con cáncer la información sobre el cambio de estilo de vida; por ejemplo, el autocuidado y reducir el estigma de la enfermedad. además, los encuestados que declaran conocer a alguien con cáncer declararon la necesidad de apoyo emocional, ayuda para no dejar el tratamiento y creación de un espacio para los pacientes y sus familias para compartir experiencias. conclusiones: los resultados indican la importancia de establecer un plan de acción de enfermería en la comunidad que alienta su participación en la formulación de estrategias y contribuir a la sensibilización y la motivación de los pacientes con cáncer a manejar el autocuidado y la promoción de la calidad de vida. palabras clave enfermería oncológica, políticas, planificación y administración en salud, cuidado de la salud, participación comunitaria. (fuente: decs, bireme). 135 estratégias de apoio de enfermagem na atenção à saúde de portadores de câncer... l marléa chagas-moreira, joséte luzia leite, marcelle miranda da silva y otros. introdução o problema das doenças crônicas representa uma preocupação prioritária no contexto internacional. dados da organização mundial da saúde (oms) ressaltam que, de um total previsto de 58 milhões de óbitos por todas as causas em 2005, estimou-se que 35 milhões deles seriam causados por doenças crônicas. assim, as condições crônicas de saúde se constituem na maior causa de morte e incapacidade física na maioria dos países desenvolvidos e em desenvolvimento, vitimando milhões de homens e mulheres, muitos dos quais se situam numa faixa etária mais jovem e no auge de sua capacidade produtiva (1). os dados brasileiros indicam que tais doenças são responsáveis pelas maiores proporções de anos de vida perdidos por morte prematura, por anos de vida vividos com alguma incapacidade. por serem doenças de longa duração, estão entre as que mais requerem ações, procedimentos e serviços de saúde com demanda de altos custos diretos. além disso, são significativos os custos indiretos, decorrentes do absenteísmo, as aposentadorias precoces e a perda de produtividade (2). nesse contexto, o câncer é uma das doenças crônicas que têm assumido grande repercussão epidemiológica, social e emocional no campo internacional, devido aos significativos efeitos do adoecimento para a pessoa doente, os familiares e a comunidade em que está inserida. assim mesmo, exige dos profissionais de saúde atualização constante do conhecimento específico e habilidades para desenvolver uma prática humanizada. em encontro recente coordenado pela oms para definir um plano de ação para prevenção e controle do câncer na américa latina e o caribe, foram analisados dados epidemiológicos que revelaram que, em 2005, cerca de 1,15 milhões de pessoas morreram de câncer nas regiões das américas; 480.000 dos casos eram de países da américa latina e do caribe. nessas regiões, as maiores taxas de mortalidade pela doença são observadas no uruguai, barbados, peru, argentina e chile. contudo, nos diversos países, a crescente carga provocada pela doença exige o reconhecimento da necessidade da adoção de políticas públicas, bem como sensibilização dos profissionais de saúde para desenvolver estratégias que contribuam para o controle global do câncer. portanto, a oms recomenda um processo de três etapas para o planejamento de programas de controle: investigação do problema nas regiões, formulação de políticas, definindo populações-alvo e identificação dos passos para pôr em andamento os programas elaborados (3). são alarmantes as estimativas elaboradas pela agência internacional para pesquisa em câncer (iarc)/oms para a américa do sul, central e caribe quando se estimou, em 2008, cerca de um milhão de casos novos de câncer e 589 mil óbitos nessas regiões (4). a magnitude do câncer no cenário internacional reflete diretamente na organização da atenção à saúde. o sistema único de saúde (sus) do brasil registrou um aumento do atendimento dessa clientela no último qüinqüênio. o que se comprova na estimativa de incidência de câncer no país para 2010-2011 realizada pelo instituto nacional do câncer, que aponta para a ocorrência de 489.270 casos novos de câncer (4). o problema das doenças crônicas representa uma preocupação prioritária no contexto internacional. dados da organização mundial da saúde (oms) ressaltam que, de um total previsto de 58 milhões de óbitos por todas as causas em 2005, estimou-se que 35 milhões deles seriam causados por doenças crônicas. 136 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 diante de tal problemática, o ministério da saúde do brasil vem envidando esforços para a prevenção e o controle do câncer através da política nacional de atenção oncológica. esta estabelece as diretrizes para o atendimento em oncologia no país, e suas ações são orientadas por um modelo assistencial que deve organizar e articular recursos em diferentes níveis de atenção para garantir acesso aos serviços e integralidade do cuidado. ou seja, as pessoas devem ser vistas na singularidade de sua história de vida, condições socioculturais, anseios e expectativas. além disso, a abordagem dos doentes deve contemplar o controle do câncer com preservação da qualidade de vida (5). no entanto, há entendimento de que para aplicar essas práticas é necessário o estabelecimento de parcerias com outros setores governamentais e não governamentais, como a comunidade. torna-se ainda importante o desenvolvendo de parcerias com órgãos formadores e instituições de pesquisa que, além de contribuir com a capacitação dos profissionais, podem incrementar avaliações que tem como principal finalidade retroalimentar e corrigir as ações e programas em curso (2). o estado do rio de janeiro, acompanhando os dados epidemiológicos internacionais, também mantém nas pautas de discussão as condições crônicas de saúde. entre as prioridades apontadas no plano estadual de saúde do estado (2001-2004), destaca-se a problemática da região da baixada llitorânea (6). de acordo com estimativas do departamento de informática do sus (datasus), houve aumento significativo do índice de mortalidade por neoplasia na referida região nos últimos anos, com destaque para os cânceres de mama e pulmão, cujo número de óbitos chegou a 1751 e 2396, respectivamente, em 2007 (7). pela magnitude da problemática nessa região do rio de janeiro e a premência para empreender ações de promoção e educação em saúde, em 2004 se iniciaram atividades com líderes comunitários, voluntários, professores e estudantes da escola de enfermagem anna nery da universidade federal do rio de janeiro, vinculados ao projeto de extensão. nos últimos seis anos, temos estabelecido parcerias com instituições não governamentais como a renascer –obras sociais, culturais e educacionais (município de saquarema) e a associação das amigas da mama (município de cabo frio), que desenvolvem serviços sociais na região e representam uma aproximação com as reais necessidades de saúde dos moradores. essa iniciativa concorda com as idéias de estudiosos de intervenções em situações crônicas quando ressaltam a importância de “estar sensível ao movimento espontâneo da própria comunidade, avaliando sua realidade e seus códigos culturais, e à aceitabilidade ou não das ações propostas, para perceber a necessidade do desenvolvimento de ações de saúde” (8). dessa forma, as ações se orientaram por um diálogo interativo e participativo entre sujeitos realmente envolvidos no processo, o que culminou em investigações que indicaram como uma das prioridades de cuidado, referidas pelos moradores, a melhoria de atendimento a pessoas com câncer e a suas famílias. as reflexões sobre a problemática partem das seguintes premissas: 1. o adoecimento deve ser compreendido como um processo que reflete as complexas interações entre as pessoas e o ambiente em que vivem. 2. as estratégias para controle de doenças crônicas devem estar centradas na ajuda às pessoas a fim de autogerir suas condições para adotar uma vida o ministério da saúde do brasil vem envidando esforços para a prevenção e o controle do câncer através da política nacional de atenção oncológica. esta estabelece as diretrizes para o atendimento em oncologia no país, e suas ações são orientadas por um modelo assistencial que deve organizar e articular recursos em diferentes níveis de atenção para garantir acesso aos serviços e integralidade do cuidado. 137 estratégias de apoio de enfermagem na atenção à saúde de portadores de câncer... l marléa chagas-moreira, joséte luzia leite, marcelle miranda da silva y otros. mais saudável, o que reflete uma responsabilidade individual e coletiva. tais premissas indicam uma abordagem integrada da saúde, pois o binômio saúde-doença se constitui como um processo coletivo; portanto, é preciso recuperar nesse coletivo, em cada situação específica, as relações entre as condições de saúde e seus determinantes culturais, sociais e ambientais nos ecossistemas modificados pelo trabalho e pela intervenção humana (9). tal perspectiva nos parece apropriada a uma maior compreensão da problemática ao se considerar que na atenção a pessoas com câncer devem ser privilegiadas ações que, baseadas na relação sujeitosujeito, superam o clássico intervencionismo. esta posição estimula as pessoas problematizarem suas experiências e reconhecerem a melhor maneira de compreender e se engajar nas situações em que se encontram. o estudo visa analisar as prioridades estabelecidas por moradores de uma comunidade do rio de janeiro (brasil), acerca de estratégias de apoio a pessoas portadoras de câncer, como subsídios para o planejamento de ações de enfermagem porque entendemos a comunidade como um grupo social ter limites geográficos, valores e interesses comuns. além do mais, nas interações de seus membros, pode-se perceber a influência mútua das vivências, principalmente nos casos de situações que, mesmo do âmbito individual, influenciam o cotidiano da comunidade, como no caso do adoecimento por câncer. o que requer a elaboração de planos de ação voltados para prevenir ou controlar os fatores de impacto social que coloquem em risco a saúde comunitária (10). fundamentação teórica por um novo paradigma para a atenção à saúde pode-se entender a saúde como a busca constante pelo melhor bem estar físico, psicológico, social e espiritual, na medida em que cada ser é único com diferentes necessidades e desejos. portanto, é possível um indivíduo, mesmo com uma doença crônica, sentir-se e ser considerado saudável, quando o mesmo apresentase equilibrado física e psicologicamente, aprendendo a conviver com a sua patologia e possíveis limitações, integrado a sua família, comunidade e ambiente. tal perspectiva sistêmica de saúde nos remete à noção de equilíbrio dinâmico nos níveis individual, social e ecológico. o que implica dizer que não sendo saudável para a pessoa tampouco é saudável, geralmente, para a sociedade e para o ecossistema global. assim, “a saúde é uma experiência de bem estar resultante de um equilíbrio dinâmico que envolve os aspectos físicos e psicológicos do organismo, assim como suas interações com o meio ambiente natural e social” (11). a partir desse entendimento, o câncer e outras doenças crônicas focalizam-se como objetos sociais na medida em que trazem implicações biológicas, emocionais, espirituais e sociais para os clientes, suas famílias e a comunidade (12). além disso, requer reflexões e reformulações acerca dos modelos de assistir e de formação profissional que contemple a valorização das necessidades e expectativas das pessoas na dinâmica dos processos de promoção da vida e da saúde. é possível um indivíduo, mesmo com uma doença crônica, sentir-se e ser considerado saudável, quando o mesmo apresentase equilibrado física e psicologicamente, aprendendo a conviver com a sua patologia e possíveis limitações, integrado a sua família, comunidade e ambiente. 138 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 cuidados inovadores para condições crônicas de saúde a magnitude da problemática das doenças crônicas tem conduzido a práticas de cuidado à saúde enfatizando a auto-gestão, e cuidados pré-hospitalares, centrados na pessoa e prestados na comunidade. assim, práticas voltadas à redução de riscos em interdependência com medidas para proteger o meio ambiente e a modificação, através da mudança de hábitos, são as bases de uma proposta de intervenção apresentada pela oms a partir de experiências bem sucedidas no contexto internacional. o modelo de cuidados inovadores para condições crônicas de saúde (13) ressalta a necessidade urgente, nos níveis nacional e internacional, de serem tomadas ações efetivas para a redução dos riscos e seu impacto sobre a saúde pública e econômica das nações. além disso, visa também estabelecer orientações práticas para modificação deste quadro negativo e influenciar os países a combater o aumento crescente das doenças crônicas; por exemplo, as doenças cardíacas, o acidente vascular cerebral, o câncer, a diabetes e a obesidade. de acordo com tal modelo, no controle das situações crônicas de saúde é imprescindível integrar os componentes estruturais dos níveis micro (a pessoa doente e sua família, grupos de apoio da comunidade e equipes de atenção à saúde), meso (conformado por componentes estruturais da organização da atenção à saúde) e macro do sistema de saúde (o ambiente político que direciona os planos e tomadas de decisão). isso ocorre porque, segundo as diretrizes de tal modelo, o tratamento otimizado para esse grupo de doenças requer que as pessoas recebam atenção integrada que envolva treinamento para autogerenciarem suas condições de saúde, e não apenas intervenções clínicas. além disso, há necessidade de apoio das famílias e comunidades, assim como de políticas abrangentes para prevenção ou gerenciamento eficaz das condições crônicas. o modelo se fundamenta em seis princípios norteadores: 1. tomada de decisão referente à formulação de políticas, planejamento de serviços e gerenciamento clínico das condições crônicas com base em evidências científicas. 2. enfoque em estratégias pró-ativas para melhoria da qualidade de tratamento em populações com necessidades comuns. 3. enfoque na prevenção através de informação e capacitação sistemáticas para redução de riscos à saúde. 4. enfoque na qualidade da utilização adequada de recursos, oferta de serviços e resultados favoráveis para as pessoas e comunidade. 5. integração dos níveis estruturais do sistema, bem como nos níveis de atenção primária, especializada e hospitalar. 6. flexibilidade e adaptabilidade a situações instáveis, informação nova e eventos imprevistos. o que requer vigilância, monitoramento e avaliação para possibilitar adaptação dos sistemas a contextos variáveis. de acordo com o referido modelo, para controlar e prevenir as condições crônicas, no controle das situações crônicas de saúde é imprescindível integrar os componentes estruturais dos níveis micro (a pessoa doente e sua família, grupos de apoio da comunidade e equipes de atenção à saúde), meso (conformado por componentes estruturais da organização da atenção à saúde) e macro do sistema de saúde (o ambiente político que direciona os planos e tomadas de decisão). 139 estratégias de apoio de enfermagem na atenção à saúde de portadores de câncer... l marléa chagas-moreira, joséte luzia leite, marcelle miranda da silva y otros. os moradores e suas famílias devem estar: informados sobre as condições crônicas em relação ao seu ciclo, as complicações esperadas e as estratégias eficazes para prevenir complicações e administrar os sintomas; motivados para mudar seus comportamentos e manter estilos de vidas saudáveis, aderirem tratamentos de longo prazo e autogerenciar suas condições de saúde; além de estarem preparados com habilidades para administrar suas necessidades de cuidado e terapêuticas no domicílio. o grupo de apoio da comunidade é outro elemento chave do modelo no nível micro de atuação. as experiências internacionais têm demonstrado que a atuação de voluntários informados e mobilizados junto a profissionais de saúde tem sido um recurso para reduzir demandas desnecessárias por serviços de seguimento e atenção terciária para atendimento de complicações. a expectativa é de que as estratégias que compõem esse plano global possam salvar 36 milhões de vidas até 2015, se houver diminuição em apenas 2% da mortalidade por estas doenças em todo o mundo nos próximos 10 anos. por isso é considerado um projeto ambicioso, a fim de desmistificar o conhecimento sobre as doenças crônicas, além de oferecer diretrizes eficazes que possam reduzir as mortes se melhorar as vidas de milhões de pessoas. metodologia o estudo se insere em um projeto de extensão institucional da escola de enfermagem anna nery da universidade federal do rio de janeiro (brasil). desenvolveu-se na região da baixada litorânea do estado com o propósito de contribuir para a reformulação e o monitoramento de estratégias que favoreçam a mobilização da comunidade, profissionais de saúde e gestores para a promoção do autogerenciamento das condições de saúde dos portadores de câncer. esta pesquisa descritiva com abordagem qualitativa foi desenvolvida com participantes de dois eventos comunitários (feira de saúde) realizados em um dos municípios da região em 2008. nestes eventos foram realizadas palestras acerca de promoção da saúde e prevenção de situações crônicas, além de consulta de enfermagem pelos docentes e estudantes que integram a equipe do projeto. além disso, foram atendidas 130 pessoas, das quais 57 participaram voluntariamente do estudo após o convite. para os concordantes, foi apresentado o termo de consentimento livre e esclarecido para ciência e assinatura, de acordo com o estabelecido na resolução 196/96 do conselho nacional de saúde (brasil). a pesquisa foi aprovada pelo comitê de ética e pesquisa da escola de enfermagem anna nery e o hospital escola são francisco de assis da universidade federal do rio de janeiro sob o protocolo 21/08. para delineamento do método, tomamos como base os argumentos de estudiosos da pesquisa qualitativa (14) quando indicam que, no caso de interesse em investigar realidades complexas ou pouco conhecidas, a pesquisa poderá ter um plano flexível que favoreça a imersão do pesquisador no contexto a ser estudado. assim, optamos por adotar uma abordagem em que alguns dados foram quantificados para caracterização dos depoentes e codificação de nuances do fenômeno e posterior interpretação “com o objetivo de descobrir conceitos e relações nos dados brutos e de organizar esses conceitos e relações em um esquema explanatório teórico” (15). o grupo de apoio da comunidade é outro elemento chave do modelo no nível micro de atuação. as experiências internacionais têm demonstrado que a atuação de voluntários informados e mobilizados junto a profissionais de saúde tem sido um recurso para reduzir demandas desnecessárias por serviços de seguimento e atenção terciária para atendimento de complicações. 140 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 a coleta de dados foi realizada mediante entrevista, em sala privativa, utilizando-se instrumento semi-estruturado aplicado por estudantes e docentes durante o referido evento. a duração média das entrevistas foi de vinte e cinco minutos. os dados estruturados referentes a sexo, faixa etária, renda familiar, local de nascimento e vínculo com pessoa com câncer foram armazenados em banco de dados criado no programa microsoft office excel 2007 (microsoft corporation, eua). tais variáveis foram analisadas qualitativamente frente a elementos que emergiram dos depoimentos às seguintes questões: que tipo de atividade a equipe de saúde poderia realizar para ajudar pessoas portadoras de câncer aqui na comunidade?, como essas atividades poderiam ajudar? a intenção da estratégia de produção dos dados foi de alcançar uma interpretação que sinalize um sentido mais aproximado das expectativas dos moradores para estratégias de apoio a pessoas portadoras de câncer. após codificação dos dados estruturados e transcrição dos depoimentos, seguiu-se com os procedimentos de análise utilizando a análise de conteúdo, ou seja, a extração das unidades de significação de cada fala e agrupamento em uma unidade temática analisada e discutida seguindo os princípios dos cuidados inovadores em situações crônicas: reconhecendo as prioridades de apoio ao portador de câncer e a família para motivar o enfrentamento da doença. resultados e discussão a análise dos dados obtidos com os 57 moradores integrantes do estudo revelou maior participação de pessoas do sexo feminino (32) em relação ao sexo masculino (25). o que pode indicar a maior tendência das mulheres adotarem práticas de cuidado à saúde em relação aos homens, tendo em vista que o evento tinha o propósito de discutir a promoção da vida e saúde. do total de entrevistados, a maioria (36) conviveu com algum portador de câncer nas interações familiares ou de amigos. o grupo de moradores referiu a faixa etária mediana entre 41e 50 anos, com escolaridade mediana até a terceira série do ensino médio e renda familiar de 1a 5 salários mínimos. a maioria dos moradores desenvolve alguma ocupação sem vínculo empregatício. esse perfil social reflete uma representação da população de um dos treze municípios da região da baixada litorânea do estado que, após a década de setenta do século xx, passou a vivenciar o impacto da exploração e da produção de petróleo na bacia de campos (rj). isto ocorre porque o crescimento populacional e suas implicações no planejamento urbano –acesso a serviços públicos (saúde e educação) e o grande número de trabalhadores menos qualificados ocupando postos de trabalho temporário– contribuem para demandas sociais que refletem diretamente nas condições de saúde da comunidade (16) apesar dos aspectos favoráveis aos municípios relativos ao desenvolvimento econômico e social, dentre outros,. em relação às expectativas dos participantes do estudo acerca de estratégias de apoio a pessoas portadoras de câncer, os resultados indicam que a totalidade dos participantes considerou necessário algum tipo de apoio para ajudá-las. na nossa perspectiva, os depoimentos indicaram o reconhecendo das prioridades a análise dos dados obtidos com os 57 moradores integrantes do estudo revelou maior participação de pessoas do sexo feminino em relação ao sexo masculino. o que pode indicar a maior tendência das mulheres adotarem práticas de cuidado à saúde em relação aos homens, tendo em vista que o evento tinha o propósito de discutir a promoção da vida e saúde. 141 estratégias de apoio de enfermagem na atenção à saúde de portadores de câncer... l marléa chagas-moreira, joséte luzia leite, marcelle miranda da silva y otros. de apoio ao portador de câncer e a família para motivar o enfrentamento da doença. ao ser questionados quanto ao tipo de atividade de apoio que consideravam prioritárias, foram mencionadas a informação (39), o apoio emocional (15), criação de um espaço para as pessoas compartilharem experiências (6), o melhoramento à atendimento à saúde (6), a ajuda as pessoas a não desistir do tratamento (3). alguns não deram nenhuma sugestão (4), conforme é detalhado na gráfico 1. a necessidade de informação se destaca como prioritária entre os dois grupos de participantes, conforme os depoimentos a seguir: é preciso ter informação. eu não sou daqui, vim morar há pouco tempo. vejo na comunidade ‘nativa’ uma extrema necessidade de conhecimento e assistência pra prevenção das doenças. e aí piora quando a pessoa já tem o diagnóstico (e10 – não conhece portador de câncer). as pessoas que tem câncer precisam de muita informação. tem que explicar sobre a doença. às vezes a pessoa tem e não sabe e, quando vai descobrir, já é tarde e ta muito avançado (e43conhece portador de câncer). nesses depoimentos, identifica-se aproximação do entendimento dos participantes com o terceiro princípio do modelo de cuidados inovadores nas situações crônicas (oms) ao destacar a necessidade de “enfoque na prevenção através de informação e capacitação sistemáticas para redução de riscos à saúde”. tal resultado vai ao encontro de evidências de investigações que destacam a importância da informação no planejamento do cuidado a pessoas com câncer. em pesquisa acerca das necessidades de informação a essa clientela, contempladas em estudos internacionais, no período de 1980 a 2003, observou-se que as prioridades estão relacionadas a dúgráfico 1. distribuição das prioridades de apoio a pessoas com câncer referidas por moradores da comunidade, saquarema –rj, brasil (2008) 142 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 vidas referentes às fases de diagnóstico e tratamento, diante das preocupações relativas à insegurança quanto ao estágio da doença, na fase de diagnóstico. de outra forma, antes e durante o tratamento, a maioria se preocupa com as reações adversas da terapêutica, com a incerteza da cura e reabilitação (17). um aspecto relevante apontado por um dos depoentes foi a possível diferença de necessidade de informação entre os membros da comunidade quando refere à palavra “nativos”. tal aspecto é significativo para o planejamento de atividades de educação para a saúde, considerando a crescente migração nas comunidades nacionais e internacionais. além disso, implica a relevância de compreender os diferentes ambientes micro-sociais em que atuamos, pois esses ambientes contemplam aspectos físicos, culturais, ideológicos, dentre outros, que interferem no comportamento das pessoas para adoção de práticas de prevenção e autogerenciamento de suas condições de saúde oms (13). sobre essa situação, a american cancer society declarou que a américa latina e o caribe configuram uma região de interesse estratégico para sua atuação pela situação epidemiológica do câncer nesses países. além disso, dada a sua proximidade com os estados unidos e a atual imigração, as pessoas provenientes dos países de tal região representam mais da metade dos estrangeiros residentes naquele país. assim, a instituição tem investido em estratégias de colaboração com as principais sociedades de cada país através de atividades de formação profissional e pesquisa com vista a fortalecer os programas nacionais e internacionais voltados para a prevenção e o controle do câncer (18). outro aspecto de destaque evidenciado foi a diferença das prioridades estabelecidas por moradores que conheciam, ou não, pessoas portadoras de câncer. podese perceber que, além de informação, aqueles que interagem com portadores de câncer na convivência familiar ou do grupo social apontam expectativas de atividades de apoio mais específicas ao adoecimento; por exemplo: apoio emocional ao doente e família, à criação de espaço para compartilhar experiências e ajudar a não desistir do tratamento, conforme apontam os depoimentos a seguir: minha prima tem câncer ... (pausa longa). toda ajuda é importante, pois ela e a família precisam de muito apoio mesmo. os amigos tentam dar apoio, aquela força, mas é difícil. várias vezes ela quis desistir do tratamento. seria muito bom ter um lugar para compartilhar o que passou com outras pessoas (e1 –conhece portador de câncer). acho que o câncer faz a pessoa viver retraída, não convive com os outros, é sempre indo pro médico por causa do tratamento e muita gente não entende. é muito importante ter um espaço com profissionais nos ouvindo e esclarecendo a todos que convivem com a pessoa. isso pode diminuir o preconceito. e aqui isso é difícil, não tem recurso nenhum. ela trata lá no rio e é um problema danado quando tem que ir pra lá fazer a quimioterapia (e21conhece portador de câncer). tais depoimentos concordam com intervenções já recomendadas para essa clientela porque o impacto que a doença e as diferentes modalidades de tratamento provocam interferem na qualidade de vida; portanto, requer atenção às necessidades de ajuda dos portadores de câncer nas dimensões física, social, emocional e um aspecto relevante apontado por um dos depoentes foi a possível diferença de necessidade de informação entre os membros da comunidade quando refere à palavra “nativos”. tal aspecto é significativo para o planejamento de atividades de educação para a saúde, considerando a crescente migração nas comunidades nacionais e internacionais. 143 estratégias de apoio de enfermagem na atenção à saúde de portadores de câncer... l marléa chagas-moreira, joséte luzia leite, marcelle miranda da silva y otros. espiritual, principalmente quando se apresentam fragilizados pelo tratamento. o que torna imprescindível que os profissionais de enfermagem acreditem e tenham confiança de que o cuidado de enfermagem é capaz de restaurar o bem-estar das pessoas favorecendo a configuração de espaços de discussão para reivindicar com maior fundamentação, melhores condições para cuidar dos clientes, visando a manutenção de uma proposta assistencial de qualidade frente à diversidade de necessidades de ajuda manifestadas pelos doentes e a família (19). por conseqüência, é necessário adotar diferentes estratégias de cuidado. em estudo recente (20) acerca das intervenções utilizadas na promoção de estratégias de coping na depressão de mulheres com câncer de mama foi evidenciado que são adotadas com evidências de sucesso intervenções individuais e grupais, com significativa participação do enfermeiro. as de cunho individual são arte terapia, ioga, sessões de educação e nutrição, meditação, massagem, convicções e envolvimento espiritual e coping espiritual, apoio familiar, auto-ajuda, terapia por telefone, ventilação emocional, advogar pelo paciente e terapia comportamental/ cognitiva. as intervenções grupais adotadas foram: grupo de apoio cognitivoexistencial, apoio psicossocial, programa de capacitação de corpo-mente-espírito, grupo de apoio eletrônico, medicina complementar e alternativa, efeitos de participação em grupos de apoio, expressão de emoções negativas através da internet. os resultados apontados pelos autores indicam que os estudos experimentais realizados na américa do norte, europa, austrália e ásia, e analisados, evidenciaram que as intervenções adotadas possibilitaram a melhora na qualidade de vida no uso de coping emocional, no humor, maior entendimento das opções de tratamento, a redução de estresse, aumento de respostas imunes (marcadores celulares) e o alcance do estado meditativo, a redução imediata da irritabilidade e o aumento da serotonina, dopamina e de linfócitos, além da diminuição dos sintomas depressivos e melhora dos níveis de funcionamento físico e mental. estas estratégias podem favorecer o manejo da dor e da fadiga, assim como o distúrbio do sono, as náuseas, os vômitos e outros sintomas clínicos; no âmbito social, podem estimular ações referentes ao afeto, auto-imagem, interação com familiares e amigos, além de reduzir a preocupação com trabalho e a exclusão social. no âmbito emocional, as ações relacionadas ao apoio e o controle da ansiedade, do estresse e da angústia podem ser favorecidas com ações que visem o bem-estar espiritual, com o fortalecimento da fé, das crenças em algo significativo e da esperança (21). e diante da complexidade dessas necessidades e possibilidades de intervenção, a situação se agrava com a falta de recursos para atendimento, como é o caso do local onde o estudo foi realizado. trata-se de um pequeno município litorâneo do interior do estado cuja rede de atenção é caracterizada pelo atendimento de situações de média complexidade e, portanto, não possui atendimento especializado em oncologia. no contexto da política de atenção oncológica no país, esses clientes são atendidos nos centros de referência regionais. contudo, a criação de estratégias locais, junto à comunidade, para proporcionar condições que permitam atender as necessidades dos portadores de câncer. assim mesmo, que os profissionais de saúde no âmbito social, são estimuladas ações referentes ao afeto, auto-imagem, interação com familiares e amigos, preocupação com trabalho e exclusão social. as ações recomendadas no âmbito emocional estão relacionadas ao apoio e ao controle da ansiedade, do estresse e da angústia. 144 año 10 vol. 10 nº 2 chía, colombia agosto 2010 aquichan issn 1657-5997 possam estar sensibilizados e capacitados para atendê-los, de acordo com as diretrizes da oms baseadas em experiências de sucesso no brasil e outros países, conforme está destacado no quarto princípio do modelo, que enfoca a valorização da qualidade na utilização adequada de recursos, oferta de serviços e resultados favoráveis para as pessoas e comunidade. para tanto devem ser adotadas ações que favoreçam o manejo da dor, da fadiga, do distúrbio do sono, das náuseas, dos vômitos, e doutros sintomas. no âmbito social, são estimuladas ações referentes ao afeto, auto-imagem, interação com familiares e amigos, preocupação com trabalho e exclusão social. as ações recomendadas no âmbito emocional estão relacionadas ao apoio e ao controle da ansiedade, do estresse e da angústia. para o bem-estar espiritual, as ações visam fortalecer nas pessoas a fé, as crenças em algo significativo e a esperança (21). considerações finais a pesquisa objetivou analisar as expectativas de moradores de uma comunidade do rio de janeiro (brasil) acerca de estratégias de apoio a pessoas portadoras de câncer com vistas a indicativos para o planejamento de ações de enfermagem. adotou-se a abordagem qualitativa na perspectiva interpretativa. as expectativas dos moradores foram apreendidas a partir de seus depoimentos, considerados uma forma de manifestação de alguns elementos que podem representar o sentido que dão ao fenômeno investigado. pode-se evidenciar que a informação é uma estratégia indispensável para lidar com o adoecimento por câncer, o que reitera resultados de estudos internacionais, além de ir ao encontro das diretrizes da oms para prevenção e controle do câncer. contudo, essa informação se especifica diante do sentido que cada depoente manifesta a partir das interações vivenciadas, ou não, com portadores de câncer no seu contexto social. conseqüentemente, devem desenvolver-se na comunidade atividades como palestras e grupos de apoio. outros elementos que emergiram dos depoimentos foram interpretados como manifestação de preocupação com as condições necessárias às pessoas com câncer e suas famílias, principalmente a dificuldade de acesso da população aos serviços de diagnóstico e tratamento. além disso, circunstancias relacionados à cultura do próprio município surgiram como fatores de alerta para a formulação de atividades assistenciais. tais resultados confirmam nossas premissas de que o adoecimento deve ser compreendido como um processo que reflete as complexas interações entre as pessoas e o ambiente em que vivem. isto sugere a necessidade de realizar estudos para melhor compreender o fenômeno nesse contexto microssocial para ampliar o entendimento de aspectos recorrentes e fatores condicionantes que contribuam para a formulação de estratégias de enfermagem e de políticas públicas. isso por que, no nosso entendimento, para controle do câncer, as práticas devem estar centradas na ajuda às pessoas a fim de autogerir suas condições para adotar uma vida mais saudável, o que reflete uma responsabilidade individual e coletiva. é fundamental reconhecer que o tratamento do câncer deve transcender o enfoque biologicista e contemplar as exigências impostas aos portadores e seus familiares, a comunidade e aos profissionais de saúde que devem estar articulados para o propósito da prevenção e controle do câncer. temos a convicção que, na busca em atender às necessidades de ajuda das pessoas com situações crônicas de saúde, inclusive o câncer, a enfermagem avançou para a aplicação de teorias e modelos assistenciais, na prática cotidiana, orientados para a promoção e recuperação da saúde, conforme ressaltado por estudiosos da temática (21). portanto, é preciso fortalecer um saber-fazer que assegure nossa posição de líderes no gerenciamento de condutas saudáveis que ajudem as pessoas a enfrentar situações de estresse e crises proporcionando qualidade de vida aos doentes. 145 estratégias de apoio de enfermagem na atenção à saúde de portadores de câncer... l marléa chagas-moreira, joséte luzia leite, marcelle miranda da silva y otros. referencias bibliográficas 1. organização mundial da saúde (oms). organização pan americana de saúde. prevenção de doenças crônicas: um investimento vital. 2005. disponível em: <http://www.who.int/chp/chronic_disease_report/part1_port.pdf> 2. brasil. ministério da saúde. a vigilância, o controle e a prevenção das doenças crônicas não-transmissíveis: dcnt no contexto do sistema único de saúde brasileiro (brasil). brasília:ministério da saúde, –organização pan-americana da saúde; 2005. 3. paho. plan of action for cancer prevention & control: cancer 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[acesso em 18/02/2009]. disponível em: <http://www.cancer.org/docroot/aa/content/ aa_2_5_8x_latin_america_and_the_caribbean. asp&prev=/translat> 19. moreira mc, carvalho v. a relação de ajuda e sua aplicabilidade na prática da enfermagem. esc. anna nery rev. enferm 2004; 8(3): 372-380. disponível em http:// www.eean.ufrj.br/revista_enf/2004_vol08/2004_ vol08n03dezembro.pdf 20. moreli l, stacciarini jmr, cardoso af, campos de carvalho e. intervenciones utilizadas para promover estrategias de coping para la depresión entre mujeres con cáncer. ciencia y enfermería 2009, xv(2): 41-54. 21. zaider g, triviño v, olivia sanhueza a. teorías y modelos relacionados con calidad de vida en cáncer y enfermería. aquichan 2005; 5(5): 20-31. 316 326 modelo de direccion de hospitales.indd 316 aquichan issn 1657-5997 danelia gómez-torres1 gloria ángeles-ávila2 marí a dolores martínez-garduño3 modelo de dirección de hospitales por enfermeras 1 doctora en enfermería. investigadora, universidad autónoma del estado de méxico. gomezdanelia@usa.net 2 magíster en administración de servicios en salud. profesora de tiempo completo, uaem. 3 magíster en administración de servicios en salud. profesora de tiempo completo, uaem. recibido: 15 de enero de 2010 aceptado: 1 de septiembre de 2011 resumen con el propósito de comprender los comportamientos y procesos organizacionales, operacionales y de gestión, se realizó una investigación sustentada en la teoría del pensamiento estratégico; el objeto de estudio fue el sistema de administración hospitalario. se empleó un método cualitativo y de estudio de caso aplicando las siguientes etapas: adaptación a los procesos, construcción de explicaciones, análisis temporales, modelos lógicos y presentación de casos cruzados, lo que permitió desarrollar sistemáticamente el procesamiento de información y análisis de datos. la última etapa guía la presentación de resultados logrando el objetivo propuesto: discutir el paradigma del sistema de administración ejercido por las enfermeras gerentes desde la perspectiva de sus subalternas. los resultados revelan que estas últimas reconocieron una gestión innovadora, con una supervisión directa y central, resaltando el modelo de gestión innovadora/ gestión por programas/leve y flexible, que a la par que exige mayor profesionalismo, propicia autonomía. la comunicación fue horizontal, de puertas abiertas hacia la dirección; la función de las directoras consistió en evaluar la actividad personal en forma directa. finalmente, se emprendieron cambios con base en concepciones teórico-metodológicas socializadas de administración descentralizada, al romper comportamientos individuales de resistencia, y asegurar el cumplimiento de metas y objetivos comunes. palabras clave enfermería, gerencia, organización y administración, directores de hospitales (fuente: decs, bireme). a hospital management model for nurses abstract research based on the theory of strategic thinking to understand organizational, operational and administrative behavior and processes is the subject of this article. with the hospital administrative system as the object of study, this research used a qualitative approach and a case-study method by applying a series of stages; namely, adaptation to the roster, construction of explanations, temporal analysis, logical models and cross-case presentation, which made it possible to process the information and to analyze the data systematically. the final stage guided the presentation of results and achieved the proposed objective; that is, to discuss the paradigm of the administrative system applied by managing nurses, based on the perception of their subordinates. the results show the subordinate nurses recognized innovative management, with direct and central supervision, and emphasized the model for innovative management/management-byaño 11 vol. 11 nº 3 chía, colombia diciembre 2011 l 316-326 317 modelo de dirección de hospitales por enfermeras l danelia gómez-torres, gloria ángeles-ávila, maría dolores martínez-garduño programs, which is light and flexible. it also requires a higher degree of professionalism and fosters autonomy. communication was horizontal, leaving the door open to management. the function of the supervisors was to evaluate personal activity in a direct way. lastly, changes based on socialized theoretical-methodological ideas of decentralized administration were instituted by breaking down individual resistance and ensuring the accomplishment of common goals and objectives. key words nursing, management, organization and administration, hospital administrators (source: decs, bireme). modelo de endereço dos hospitais por enfermeiras resumo conhecer os comportamentos de uma organização e processos de gestão tem como objetivo de estudo o sistema de administração hospitalar, desenvolveu-se a pesquisa com enfoque qualitativo. esta foi sustentada pela teoria do pensamento estratégico, utilizando-se o método de estudo de caso, com as seguintes etapas: adequação ao padrão, construção de explanações, análises temporais, modelos lógicos e interpretação da interrelação de casos, o que permitiu desenvolver sistematicamente o processamento de informação e de análise do dados. esta última etapa orientam os resultados com objetivo proposto: discutir o paradigma do sistema de administração exercido pela gerência das enfermeiras, sob a perspectiva de suas subordinadas. os resultados revelam que as enfermeiras subordinadas reconheceram uma gestão inovadora, onde se envolveram no diagnóstico institucional a todos os integrantes, com uma supervisão direta e central, ressaltando o modelo de gestão inovadora/gestão por programas/leve e flexível, que exige maior profissionalismo e autonomia. a comunicação foi horizontal, abertas à direção; a função das diretoras consistiu em avaliar a atividade pessoal de forma direta. conclusão: as mudanças foram empreendidas com base em concepções teórico-metodológicas socializadas de administração descentralizada, rompendo comportamentos individuais de resistência e garantir o cumprimento de metas e objetivos comuns. palavras-chave enfermagem, gerência, organização e administração, diretores de hospitais (fonte: decs, bireme). 318 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 consideraciones iniciales este artículo muestra comportamientos organizacionales, el funcionamiento de procesos de gestión característicos de las instituciones de salud dirigidas por enfermeras, así como la percepción de las enfermeras subordinadas acerca del modelo de gestión instrumentado por quienes dirigen hospitales, teniendo como objetivo discutir el sistema de administración, a fin de reflejar cómo se vivió dicho sistema durante la gestión de una enfermera. se estudiaron cuatro instituciones de salud a partir del hecho administrativo (1) entendido como el procedimiento que facilita dicha práctica, mediante la gestión estratégica. al estudiar sus fortalezas se observa un proceso de aprendizaje sobre discusiones, negociaciones y conquistas que otorgan reconocimiento personal, profesional e institucional. se trabaja con un enfoque de sistemas, lo que permite visualizar aquellos cambios que llevaron a cabo las directoras en el hospital. el desarrollo se fundamentó en concepciones teórico-metodológicas socializadas de administración descentralizada, teniendo como objeto de estudio el modelo de gestión instrumentado por las enfermeras durante su actividad como directoras generales de hospitales públicos, para determinar tanto el apoyo como la aceptación de sus subordinadas, ya que para lograr el éxito, aun una gestora bien preparada requiere de la colaboración comprometida de su equipo de trabajo. pensamiento estratégico la teoría de pensamiento estratégico de mario testa (1), en su propuesta teórica, muestra los elementos que abordan el poder: político, técnico y administrativo; examina los espacios de actuación permitiendo ubicar problemas, estrategias institucionales, programáticas y sociales, así como acciones políticas y administrativas. la aplicación del pensamiento estratégico, para el caso de la salud, presenta tres tipos de ejercicio de poder basados en su organización y relacionados con la producción de servicios, donde el poder político tiene la capacidad de desencadenar movilizaciones que dependerán, en cierta forma, de conocer con exactitud la realidad, saber generado como experiencia frente a situaciones concretas, acrecentado por sentimientos producto de prácticas personales, y como reflexión sobre estas. el poder técnico comprende diversas formas de conocimiento científico —formal, informal o popular— tanto del campo de la salud, como de la administración y de otras disciplinas, que permiten configurar un modelo teórico integral relacionado con la práctica de actividades de salud e intereses de grupo. el poder administrativo se refiere a las formas de funcionamiento y financiamiento cuyos elementos centrales pueden experimentar modificaciones sustanciales en el terreno de la organización institucional, donde también pueden identificarse situaciones coyunturales que permiten inducir propuestas de reforma que impliquen avances en atención de necesidades de grupos de población no atendidos. un punto central en la teoría son los actores sociales, que testa (1) describe como sujetos de la acción y objeto del pensamiento estratégico, e intenta articular varios aspectos relacionados con características que intervienen en las relaciones personales. en opinión del autor, la teoría debe estar determinada por prácticas profesionales y cambios epistemológicos. 319 modelo de dirección de hospitales por enfermeras l danelia gómez-torres, gloria ángeles-ávila, maría dolores martínez-garduño si consideramos que todo conocimiento se inicia con una práctica, las prácticas profesionales proponen a la ciencia nuevos objetos de análisis; en ese abordaje, para asumir sus competencias, la enfermera necesita desarrollar e incrementar su formación en habilidades gerenciales relacionadas con las dimensiones técnica, humano-social, conceptual y política. la habilidad humana y social corresponde a las capacidades psico-físico-sociales de la enfermera para trabajar de manera coordinada en la construcción de un proyecto hombre-sociedad; la habilidad conceptual comprende la formación teórica acerca de la administración, además de las áreas relacionadas con la atención a la salud. en cuanto a la habilidad política, esta significa estar conscientes de su posición y asumirla en el trabajo, el sindicato, las asociaciones, las entidades de clase y dentro de cualquier partido político, para sus logros personales, así como conocer los objetivos de la organización. la enfermera-directora requiere habilidades en la política, ya que solamente así las administradoras comprenderán las funciones de poder, al reconocer tanto sus limitaciones como el potencial de cambio. como se señaló, esas potencialidades, según testa (1), son consideradas como cualidades con efectos de poder y ubica tres campos de acción esenciales: político, técnico y administrativo. este último se refiere al procedimiento que facilita esa práctica mediante la gestión estratégica. las fortalezas indican un proceso de aprendizaje sobre las discusiones, negociaciones y conquistas, estas últimas comprenden reconocimiento personal, profesional, institucional y aumento de opciones de recursos materiales. la competencia administrativa de la enfermera se entiende como el conjunto de capacidades para articular medios con miras a una atención sistematizada hacia los usuarios de servicios de salud (2). por tanto, la función de la enfermera gerente está orientada a diversas áreas, no solo a la administración de la asistencia o de cuidados, sino de unidades de salud. esta situación permite sustentar y presentar un paradigma de administración basado en el pensamiento estratégico, lo que posibilita la comprensión de comportamientos organizacionales, humanos y económicos para el logro de esta tarea colectiva. método el método cualitativo utilizado permitió la aplicación de la teoría de pensamiento estratégico establecida por testa en su enfoque administrativo, la cual sirvió de hilo conductor de la investigación, así como de sustento epistémico, concatenándose con el método de estudio de caso en su modalidad de casos múltiples, con base en las cinco etapas para el tratamiento de datos presentadas por yin (3). en la primera, adecuación al padrón, se desarrolló una estrategia de análisis general, con la creación de una matriz de categorías para clasificar los datos más significativos y disponer de evidencias en cuatro categorías: previsión, planeación, dirección y control, en paralelo con el proceso administrativo; en la segunda, se construyó una estrategia de explanaciones concurrentes simples y directas para organizar esos datos. en la tercera etapa se llevó a cabo el análisis en series, con la finalidad de desarrollar una aglutinación de datos por casos y categorías para su estudio; esta agrupación favoreció la discusión en diferentes series de las variables delimitadas según cada uno de los cuatro casos estudiados, dando dirección a la generación de los modelos lógicos, cuarta etapa del método. de esta la habilidad humana y social corresponde a las capacidades psico-físico-sociales de la enfermera para trabajar de manera coordinada en la construcción de un proyecto hombresociedad; la habilidad conceptual comprende la formación teórica acerca de la administración, además de las áreas relacionadas con la atención a la salud. 320 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 manera se favoreció la discusión, realizada a la luz de la teoría de pensamiento estratégico de testa. para la presentación de resultados se utilizó la quinta y última etapa: síntesis de casos cruzados, donde los resultados de la investigación son esquematizados para exponerlos por categorías en cuatro de los cinco elementos del proceso administrativo ya mencionados, presentándose los resultados más sobresalientes en la percepción de las enfermeras subordinadas en los diversos escenarios estudiados. la técnica utilizada fue la entrevista; se aplicó únicamente a quienes vivieron la gestión de enfermera directora, convirtiéndose así en el criterio de inclusión. el referido instrumento aducía al ámbito administrativo, constando de diez preguntas para obtener una panorámica específica de la gestión ejercida por enfermeras directoras. la entrevista recogió la vivencia del proceso de gestión en los diferentes hospitales, escenarios de estudio donde se desarrolló la acción. de conformidad con la resolución 196/96 del consejo nacional de salud que señala el aspecto de investigación donde se involucra a seres humanos, se garantizó el anonimato de las participantes; su identificación fue respetada, señalando a cada institución con un número. la adhesión de las participantes fue voluntaria; se les solicitó una lectura, previa a la aplicación del instrumento, del consentimiento libre e informado; al estar de acuerdo, se les solicitó firmarlo. la investigación fue aprobada por el comité de ética e investigación, conforme al protocolo 091-05. resultados y discusión los resultados demuestran cómo perciben la gestión hospitalaria las enfermeras subordinadas quienes la señalaron en sentido positivo, de apoyo y aceptación total. se reflejan también cambios en la forma de dirigir las instituciones, siendo estos un modelo de gestión innovadora/ gestión por programas/leve y flexible, para el cual se requiere mayor profesionalismo, propiciando por consiguiente autonomía. el cuadro 1 muestra los modelos identificados durante la investigación en las diferentes instituciones. en estos modelos de gestión se reflejan de manera general las formas de ejercer la gerencia por enfermeras de instituciones hospitalarias, que en su totalidad refirieron un cambio importante, requiriendo demostrar mayor competencia al ser notorias las transformaciones; esto se refleja de manera explícita en la siguiente respuesta: "se abrieron las puertas ya que existió mayor coordinación e integración de la comunidad con una gran participación con las organizaciones sociales considerando que esta dirección es basada en la humanización con visión holística" (p2). cuando se analizan los cambios, las actuaciones, así como la eficacia de los dirigentes en una nueva administración, se debe tener en cuenta que, para ser eficaz, el liderazgo deberá ajustarse a la complejidad de las tareas en gestión; dentro de estas están los conocimientos y las destrezas de los trabajadores, así como el tipo de estructura formal en la que se encuentran involucrados, dado que todo acto administrativo (1, 2) debe estar enmarcado en la lógica de programación y guiado por la voluntad de introducir cambios, ya que es necesario ejercer autoridad para hacerlos, dado que cualquier transformación que no provenga de la propia dinámica del proceso histórico en que se inserta, cuando se analizan los cambios, las actuaciones, así como la eficacia de los dirigentes en una nueva administración, se debe tener en cuenta que, para ser eficaz, el liderazgo deberá ajustarse a la complejidad de las tareas en gestión. 321 modelo de dirección de hospitales por enfermeras l danelia gómez-torres, gloria ángeles-ávila, maría dolores martínez-garduño será rechazada por los grupos sociales afectados. en consecuencia, el estilo de gestión de la gerente deberá modificarse en función de los cambios que se produzcan respecto a los servicios al paciente, la organización del personal de la institución y la estructura organizacional. paradigma administrativo en toda función administrativa es indispensable identificar las características económicas, gerenciales, políticas, culturales y sociales que determinan la realidad sobre la cual se pretende planear, destacando así los elementos más significativos en el desarrollo de las actividades institucionales, por tanto, es determinante realizar un diagnóstico situacional de la institución al iniciar una gestión, aspecto mostrado en el siguiente caso cruzado (cuadro 2). debemos resaltar dos de las instituciones que involucran a la comunidad al crear corresponsabilidad y bloquear la resistencia al cambio, por ello la necesidad de aplicar estrategias (4) que desafíen la identificación de caminos futuros de expansión y desarrollo que busquen condiciones que aseguren el mejor avance a lo largo del tiempo para, finalmente, buscar y obtener buenas oportunidades. debemos considerar que la estrategia busca abrazar el futuro con competencia, al mismo tiempo que defender el presente, contemplando siempre las experiencias pasadas con disciplina analítica y profundo criterio, además de obtener información en forma organizada para posteriormente utilizarla en el proceso de gestión. cabe enfatizar que los administradores deben desarrollar planes para alcanzar sus metas institucionales con programas de acción que contengan tareas y cronogramas específicos necesarios para el logro de objetivos (1-4). en este sentido, cada gestión y acto administrativo es el inicio o la continuación de un proceso, es decir, una cadena de acciones cuyo propósito final es la realización de un servicio como parte de los objetivos institucionales. el comportamiento humano está guiado por planes que conducen a metas, en la enfermería no puede ser diferente, sobre todo en las instituciones de salud, de tal manera que la planeación, como plataforma de las demás funciones, requiere de ideas creadoras y compromiso (5). las instituciones no trabajan con base en la improvisación, sino con el establecimiento de un modelo teórico de acción futura. para conocer de manera específica el paradigma de administración de la enfermera-directora, y siendo la planeación el primer elemento del proceso administrativo, se procedió a interrogar a las participantes en la investigación; sus respuestas se muestran en cuadro 3. la tarea de la enfermera gestora fue planificar, organizar, dirigir y controlar los recursos humanos, económicos y materiales disponibles, a fin de proporcionar los servicios de forma eficaz a los grupos de pacientes y a sus familias. por ello la importancia de establecer planes estratégicos que remarcaran el conocimiento administrativo y la aplicación de estas competencias (6). debido a que para conseguir cambios en una organización es necesario redefinir su misión, visión, objetivos y formas de identificar y seleccionar alternativas de acción, la dirigente es responsable de facilitar la adaptación en el camino, atender diversas áreas para transformar, identificar tendencias, dar significados y proyectar los cambios necesarios aceptando incertidumbres y riesgos. una directora tiene como objeuna directora tiene como objetivo, dentro de sus atribuciones, guiar el desarrollo de la institución, por lo que debe valorar aspectos filosóficos, valores, estructura, entre otros, estimulando al personal en la consecución de objetivos y metas, comparando los resultados conseguidos a fin de evaluar los logros. 322 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 tivo, dentro de sus atribuciones, guiar el desarrollo de la institución, por lo que debe valorar aspectos filosóficos, valores, estructura, entre otros, estimulando al personal en la consecución de objetivos y metas, comparando los resultados conseguidos a fin de evaluar los logros. para enfrentar los desafíos y retos del entorno organizacional, se requiere de la acción común de todos sus miembros, esto a su vez implica la labor de alguien que abra el camino y oriente el esfuerzo de todos. en este sentido, hacen acto de presencia individuos que a través de sus comportamientos movilizan a otros para la solución de problemas, facilitando su progreso para afrontar y adaptarse a las transformaciones de las organizaciones (7). estos aspectos ejercidos durante la gestión de las enfermeras en las instituciones se muestran en el cuadro 4. a través de estas respuestas se conoce el desempeño de las directoras; en su mayoría son afirmativas y la consideran apta para ejercer la dirección. cabe señalar que un cambio en la estructura altera la forma en que los empleados perciben cómo es valorado su desempeño por el dirigente, ya sea por autoevaluación o por sus colegas (8); la evaluación permite la detección de fallas, lo que facilita al director realizar cambios necesarios para obtener el máximo de calidad, eficiencia y efectividad. otro aspecto por considerar respecto a las funciones directivas es la supervisión que permite asesorar al personal sobre los cambios; al supervisar las actividades en el hospital, sus respuestas fueron las que se muestran en cuadro 5: los resultados muestran cambios en la forma de dirigir las instituciones, reflejan cómo se ejerció la supervisión, siendo cercana al trabajador y a su ámbito de trabajo. al respecto, es importante ubicar a la asesoría como un acto preventivo que se realiza en cualquier proceso administrativo, y a la supervisión como un ejercicio de control con el único propósito de lograr el perfeccionamiento de la gestión. la asesoría se realiza con apego a las normas o procesos de trabajo; a su vez, la supervisión tiene como punto focal el capital humano y el resultado de las tareas para lograr metas, por lo que es deseable asesorar antes de supervisar (8), a fin de generar actos llamados subsidiarios: la supervisión y el control. la última etapa del proceso de gestión es la más complicada y corresponde a la evaluación; la finalidad que persiguió la enfermera directora fue evaluar la actuación del personal, con el propósito de prevenir los errores, antes que identificar la infrautilización y las deficiencias que se hubieran producido. consideraciones finales con base en el pensamiento estratégico de testa se evidenciaron las características funcionales del paradigma de la gestión de las enfermeras en el cargo de directoras generales de hospital, a partir de las respuestas de las subordinadas. las enfermeras-directoras utilizaron varias acciones estratégicas que fortalecieron, de cierta forma, al referido cargo tales como la elaboración de un diagnóstico situacional de la institución y la caracterización del trabajo en equipo. la supervisión directa fue central en ese tipo de gestión, así como la adopción de un la supervisión tiene como punto focal el capital humano y el resultado de las tareas para lograr metas, por lo que es deseable asesorar antes de supervisar, a fin de generar actos llamados subsidiarios: la supervisión y el control. 323 modelo de dirección de hospitales por enfermeras l danelia gómez-torres, gloria ángeles-ávila, maría dolores martínez-garduño discurso conciliador y participativo dentro de la organización. el estudio permitió asimismo comprender los aspectos más significativos del paradigma de la administración, debido a que las directoras realizaron cambios en la gestión general del hospital con base en concepciones teóricas y metodológicas socializadas de administración descentralizada, con características de flexibilidad y consenso, al romper conductas individuales y de resistencia para asegurar el cumplimiento de metas y objetivos comunes. las enfermeras reconocieron que la gestión de la dirección general llevada a cabo fue innovadora, con cambios relacionados con la participación de los involucrados y de la comunidad. las enfermeras aplicaron competencias y habilidades gerenciales en las dimensiones técnica, humana, social, conceptual y política como parte de su formación reflejada en su modelo de dirección, al mostrarse un proceso de gestión exitoso, resultado de una inteligente combinación de acciones estratégicas y operacionales, necesarias en una organización coordinada y estable. de igual forma, este estudio permitió desarrollar la aplicación del pensamiento estratégico, así como comprender que para efectuar cambios del paradigma en la gerencia de las enfermeras dentro de los hospitales no es suficiente la presencia física del individuo en un tiempo y lugar determinado para constituirse como sujeto social, sino que es esencial una transformación de las características que lo definen apto como productor o receptor de todo aquello que representa la vida; asimismo, es importante adoptar estrategias de saber-poder en el ámbito político. recomendaciones en estos tiempos, donde las comunicaciones no tienen límites, las enfermeras que logren ocupar puestos gerenciales deben servir de modelo, demostrando una conducta íntegra, de tal manera que sean reconocidos sus éxitos, y se hagan visibles sus conquistas. de la misma forma, es necesario estar dispuestas siempre para atender las expectativas y demandas de la población, por lo que la práctica profesional significa no solo la obtención de estatus en el ámbito del sector salud, sino el logro de relaciones sociales, aprovechando toda la gama de servicios materiales o intelectuales que se tiene a disposición. además, es fundamental adoptar las ideas del pensamiento estratégico para enfrentar situaciones difíciles de manera hábil y decidida, de tal forma que se impulse un cambio en el paradigma de la gerencia ejercida por enfermeras. referencias 1. testa m. pensamiento estratégico y lógico de programación. el caso de salud. buenos aires: hucitec; 1995. 2. vieira tsb. o ensino da administração em enfermagem na formação das enfermeiras: da teoria à realidade. rio de janeiro: ufrj; 2009. 3. yin rk. estudo de caso: planejamento e métodos. 5 ed. são paulo: bookman; 2009. 4. silva lf. a revolução estratégica. 10 ed. brasília: senac; 2006. 5. marriner ta. gestión y administración de enfermería. 8 ed. méxico: mosby; 2009. 6. madrigal tbe. habilidades directivas. 2 ed. méxico: mcgraw-hill; 2009. 7. zamora, á, poriet y. prácticas de liderazgo en una empresa manufacturera venezolana del sector cervecero. revista venezolana de gerencia [en línea] 2011, enero-marzo [fecha de consulta: 12 de julio de 2011]. disponible en: <http://www.redalyc.org/ src/inicio/artpdfred.jsp?icve=29018414006> issn 1315 8. malangón l et al. administración hospitalaria. 3 ed. bogotá: panamericana: 2008. 324 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 cuadro 1. tipificación de los modelos de gestión fuente: elaboración propia de acuerdo con resultados de la investigación. tipo de hospital público universitario público estatal público federal público federal tipo de gestión gestión innovadora/ humanizada/ sistematizada humanizada/ gestión por programas/ transformadora controladora de integradora leve y flexible recursos fuente: elaboración propia con base en instrumentos aplicados. institución 4 casi en su totalidad manifestaron afirmativamente haber realizado el diagnóstico, además, se percibió la integración de todo el personal. cuadro 2. caso cruzado 1 realización del diagnóstico situacional institución 1 todas manifestaron no saber y la mayoría desconocía si existió planteamiento de los objetivos institucionales, así como de la formulación de nuevas políticas. institución 2 la respuesta fue, casi en su totalidad, sí, mencionando que se involucró a todos los sectores en el diagnóstico institucional y la planificación estratégica del hospital. institución 3 la mayoría contestó que se efectuó un nuevo proyecto hospitalario, considerándose como nueva etapa de vida institucional, coincidiendo todas en que se instrumentó una nueva forma de dirigencia al establecer nuevos objetivos y políticas, y con la formulación de nuevos planes y programas institucionales, teniendo como característica los proyectos por programa. 325 modelo de dirección de hospitales por enfermeras l danelia gómez-torres, gloria ángeles-ávila, maría dolores martínez-garduño cuadro 3. caso cruzado 2 planeación durante la gestión de la directora fuente: elaboración propia con base en instrumentos aplicados. institución 3 la planeación atendía las necesidades de la comunidad, guiada por las políticas públicas de salud establecidas por el ministerio de salud. institución 1 las enfermeras manifestaron no saber del establecimiento de planes y programas. institución 2 la respuesta fue afirmativa refiriéndose a la organización, además de coordinar, realizar actividades así como designar y delegar funciones. la directora demostró tener suficientes conocimientos al planear los servicios clínicos. institución 4 respecto a la planeación de las actividades en la institución, las participantes contestaron afirmativamente, mencionando que la directora-enfermera planeaba y coordinaba sus acciones con base en las necesidades, y organizaba la atención, así como el diseño de programas institucionales. cuadro 4. caso cruzado 3 ejercicio de la dirección fuente: elaboración propia con base en instrumentos aplicados. institución 4 en su mayoría indicaron que el ejercicio de la dirección de la enfermera-directora fue de tiempo completo. el ejercicio del control de la enfermera directora era continuo, vigilando en forma sistemática la información. institución 1 delega funciones y establece actividades a los funcionarios. dirige y toma decisiones individualmente. el control lo realiza de forma directa. institución 2 la manera de ejercer la dirección se refleja en la forma de trabajar en equipo, pues colabora con otros profesionales en sus actividades, designa tareas a sus colaboradores interesándose por la persona trabajadora. la comunicación es horizontal y siempre con puertas abiertas. institución 3 la mayoría contestó afirmativamente; además de organizar y coordinar delega funciones y designa actividades. existió un nuevo tipo de dirección participativa al dirigir la institución de forma colegiada. 326 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 cuadro 5. caso cruzado 4 supervisión como método de control fuente: elaboración propia con base en instrumentos aplicados. institución 1 las profesionales mencionaron que existió una nueva forma de administrar; la mayoría contestó que fue autoritaria. supervisión mencionaron que la supervisión era total. institución 4 fue afirmativa, considerando que estaba basada en la humanización con visón holística. supervisión la mayoría de las enfermeras percibieron cambios en la supervisión del hospital. institución 2 la respuesta positiva fue unánime, agregando que se abrieron las puertas ya que existió mayor coordinación e integración de la comunidad con una gran participación de las organizaciones sociales. se dio una difusión e interiorización del nuevo modelo de salud con enfoque familiar. existió colaboración del comité de relaciones públicas, dando gran difusión al hacer del hospital. en la forma de supervisar manifestaron tener más cercanía con las funciones. institución 3 todas las enfermeras refirieron un cambio importante, se necesitaba demostrar mayor competencia. en la supervisión los cambios fueron totales, se solicitaba que la enfermera participase, mas no supervisada; se exigía más de la categoría en términos de profesionalismo. existía más autonomía que en otras instituciones. 571 581 a influencia das caracteristicas.indd 571 franciéle marabotti costa leite1 tatiane kely de oliveira barbosa2 larissa regina bravim3 maria helena costa amorim4 cândida caniçali primo5 a infl uência das características socioeconômicas no perfi l obstétrico de puérperas 1 enfermera. universidade federal do espírito santo (brasil). emaildafran@ig.com.br 2 enfermera. universidade federal do espírito santo (brasil). tkbarbosa@msn.com 3 enfermera. universidade federal do espírito santo (brasil). larissa_bravim_29@hotmail.com 4 doutora em enfermagem. universidade federal do espírito santo (brasil). mhcamorim@yahoo.com.br 5 mestre em saúde coletiva. universidade federal do espírito santo (brasil). candidaprimo@gmail.com recibido: 30 de septiembre de 2012 enviado a pares: 3 de octubre de 2012 aceptado por pares: 25 de mayo de 2013 aprobado: 15 de julio de 2013 doi: 10.5294/aqui.2014.14.4.11 para citar este artículo / to reference this article / para citar este artigo leite fmc, barbosa tko, bravim lr, amorim mhc, primo cc. a influência das características socioeconômicas no perfil obstétrico de puérperas. aquichan. 2014; 14 (4): 571-581. doi: 10.5294/aqui.2014.14.4.11 resumo objetivo: examinar a relação entre o número de consultas de pré-natal, tipo de parto e número de gestação e variáveis socioeconômicas. métodos: estudo transversal, quantitativo, realizado em uma maternidade, no município de são mateus, norte do estado do espírito santo, brasil. a amostra foi de 323 puérperas. resultados: houve significância estatística (p < 0,05) ao relacionar o número de consultas de pré-natal com a faixa etária, situação conjugal, raça/cor, renda familiar, escolaridade, ocupação e categoria de admissão. não houve significância estatística entre a variável classe econômica e número de consulta de pré-natal (p > 0,05). nota-se que não houve associação significante (p > 0,05), entre o tipo de parto e as variáveis: faixa etária, raça/cor e ocupação. o tipo de parto apresentou significância estatística ao ser associado com situação conjugal, renda familiar, classe econômica, escolaridade e categoria de admissão (p < 0,05). houve significância estatística ao associar o número de gestação com as variáveis: faixa etária, situação conjugal, escolaridade e ocupação (p < 0,05). não houve significância estatística ao relacionar o número de gestação com a raça/cor, renda familiar, classe econômica e categoria de admissão (p > 0,05). conclusões: as características socioeconômicas podem influenciar no número de consultas de pré-natal, número de gestação e tipo de parto. palavras-chave parto, gravidez, cuidado pré-natal, epidemiologia, saúde da mulher. (fonte: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 571-581 572 aquichan issn 1657-5997 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 571-581 la influencia de las características socioeconómicas en el perfil obstétrico de puérperas resumen objetivo: examinar la relación entre el número de consultas de prenatal, tipo de parto y número de embarazos y variables socioeconómicas. métodos: estudio transversal, cuantitativo, realizado en una maternidad, en el municipio de são mateus, norte del departamento de espírito santo (brasil). la muestra fue de 323 puérperas. resultados: hubo significancia estadística (p < 0,05) al relacionar el número de consultas de prenatal con el rango de edad, situación conyugal, raza/color, ingresos de la familia, escolaridad, ocupación y categoría de admisión. no hubo significancia estadística entre la variable clase económica y número de consultas de prenatal (p > 0,05). se nota que no hubo asociación significante (p > 0,05) entre el tipo de parto y las variables: rango de edad, raza/color y ocupación. el tipo de parto presentó significancia estadística al ser asociado con situación conyugal, ingresos de la familia, clase económica, escolaridad y categoría de admisión (p < 0,05). hubo significancia estadística al asociar el número de embarazos con la raza/color, ingresos de la familia, clase económica y categoría de admisión (p > 0,05). conclusiones: las características socioeconómicas pueden influir en el número de consultas de prenatal, número de embarazos y tipo de parto. palabras clave parto, embarazo, cuidado prenatal, epidemiología, salud de la mujer. (fuente: decs, bireme). 573 a influência das características socioeconômicas no perfil obstétrico de puérperas l franciéle marabotti costa-leite e outros the influence of socioeconomic characteristics on the obstetric profile of new mothers abstract objective: the purpose of this study is to examine the relationship between the number of prenatal consultations, the type of delivery, the number of pregnancies, and a set of socioeconomic variables. methods: a quantitative, cross-sectional study was conducted at a maternity facility in the town of são mateus, which is located in the northern region of the department of espirito santo (brazil). the sample was comprised 323 new mothers. results: there was a statistical significance (p <0.05) when the number of prenatal consultations was related to age range, marital status, race/color, family income, level of education, occupation, and admission status. there was no statistical significance between the variables of economic level and number of prenatal consultations (p> 0.05). it is noteworthy that no significant association (p> 0.05) was found between the type of delivery and the variables of age group, race/color, and occupation. the type of delivery was statistically significant when it was associated with marital status, family income, economic level, level of education, and admission status (p <0.05). there was statistical significance when the number of pregnancies was linked to race/color, family income, economic level, and admission status (p> 0.05). conclusions: socioeconomic characteristics can influence the number of prenatal consultations, the number of pregnancies and the type of delivery. key words delivery, pregnancy, prenatal care, epidemiology, women’s health. (sources: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 571-581 574 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 introdução no brasil, no ano de 2000, o ministério da saúde (ms), iniciou a implantação do programa de humanização no pré-natal e nascimento (phpn), objetivando que houvesse uma maior promoção de ações às gestantes, com foco na redução da morbimortalidade materna e melhora nos resultados perinatais (1), destacando-se, a assistência pré-natal como um dos meios mais relevantes do atendimento à mulher no ciclo grávido-puerperal (2). a consulta de pré-natal objetiva a promoção da saúde da mulher gestante e do feto, assegurando uma evolução normal da gravidez e preparando a mãe para o parto, o puerpério e a lactação (2). o ms preconiza que a primeira consulta de pré-natal deve ser feita com até 120 dias de gestação, realizando ao longo de toda a gestação no mínimo seis consultas, sendo, preferencialmente, uma no primeiro trimestre, duas no segundo trimestre e três no terceiro trimestre (3). segundo a organização mundial da saúde (oms), durante o pré-natal inicia-se o preparo para o parto, procurando garantir à mulher o direito de escolha, contribuindo para o seu empoderamento com vistas ao parto normal (3). entretanto, o que tem sido observado é a elevação da taxa de cesariana, hoje um fenômeno quase mundial que ocorre tanto nos países desenvolvidos, quanto naqueles em desenvolvimento, ultrapassando o limite de 15% estabelecido pela oms como aceitável para justificar indicações estritamente médicas (4). vale enfatizar, que o acesso tardio ou a inadequação da assistência pré-natal e o tipo de parto, tem sido influenciado pelo perfil socioeconômico da gestante (5, 6). assim sendo, considerando a importância do conhecimento de fatores que interferem na promoção do cuidado e acesso ao serviço, justifica-se a realização do presente estudo que teve por objetivo examinar a relação entre a variável dependente (número de consultas de pré-natal, tipo de parto e número de gestação) e as variáveis independentes (faixa etária, situação conjugal, raça/cor, renda familiar, classe econômica, categoria de admissão e ocupação). métodos trata-se de um estudo transversal, com abordagem quantitativa, realizado em uma maternidade filantrópica, no município de são mateus, ao norte do estado do espírito santo (es). foram incluídas na pesquisa, através de sorteio, 323 puérperas internadas na referida instituição para parturição, que haviam realizado pré-natal, independente do número de consultas. as mulheres foram convidadas a participar do estudo, sendo esclarecidas e orientadas quanto ao objetivo do mesmo. posteriormente, questionava-se à paciente se concordaria ou não em assinar o termo de consentimento livre e esclarecido (tcle). em caso positivo, as mulheres assinavam o tcle, e posteriormente, os entrevistadores, de forma individual, aplicavam o questionário estruturado com registro em formulário, que foi pré-testado. foram estudadas as seguintes variáveis: faixa etária, situação conjugal, raça/cor, renda familiar, classe econômica, categoria de admissão e ocupação. para a variável classe econômica foi aplicado o instrumento da associação brasileira de empresas e pesquisa (7). a coleta de dados foi realizada no período de julho a outubro de 2010. a análise foi feita por meio do pacote spss 17.0. para a elaboração da tabela cruzada de relação das variáveis, foi utilizado o teste qui-quadrado. o intervalo de confiança de 95% para a razão de prevalências foi calculado pelo software medcalc 11.3. este estudo foi aprovado pelo comitê de ética em pesquisa (cep) do centro universitário do norte do espírito santo, sob o parecer 044/2010. resultados na tabela 1 observa-se a relação entre o número de consultas de pré-natal e as variáveis socioeconômicas. nota-se que houve significância estatística (p < 0,05) ao relacionar as variáveis: faixa etária e situação conjugal com o número de consultas de pré-natal, entretanto, não se constataram razão de prevalência significativa, uma vez que o valor um está contido no intervalo de confiança de 95%. no que se refere à associação entre a variável raça/cor e o número de consultas de pré-natal, verifica-se significância (p = 0,049), ou seja, podemos afirmar que a raça/cor influencia no número de consultas realizadas. observa-se que mulheres negras tem razão de prevalência 1,92 vezes maior de ser submetida a seis consultas ou menos de pré-natal do que as mulheres de raça/cor branca. quanto à variável renda familiar esta também apresentou significância estatística ao ser associada ao número de consultas de 575 a influência das características socioeconômicas no perfil obstétrico de puérperas l franciéle marabotti costa-leite e outros pré-natal (p = 0,002). evidencia-se no grupo de mulheres que tem renda de até um salário mínimo a razão de prevalências de 2,20 vezes maior de realização de seis consultas ou menos de pré-natal do que mulheres de maior salário, enquanto, na faixa de renda de dois salários mínimos a razão de prevalências foi de 1,96. notase que não houve significância estatística entre a variável classe econômica e número de consulta de pré-natal (p > 0,05). os resultados apresentados demonstram que a variável escolaridade esteve associada ao número de consultas de pré-natal (p = 0,000). o grupo de mulheres com até fundamental incompleto apresentaram razão de prevalência de 5,56 vezes maior de realização de seis consultas ou menos, quando comparado às mulheres de maior escolaridade. já as mulheres com ensino fundamental completo e com ensino médio incompleto, a razão de prevalência de se ter feito seis consultas ou menos de pré-natal foi de 5,75 e 4,69, respectivamente, do que as mulheres de maior escolaridade. no grupo com ensino médio completo a rp não foi significativa, pois contém o um em seu intervalo de confiança. no que tange a relação entre a variável categoria de admissão e o número de consultas de pré-natal, esta se apresentou significativa (p = 0,000). observa-se uma razão de prevalências de 3,80 vezes maior de mulheres com seis consultas ou menos na rede do sistema único de saúde (sus) do que na rede particular/ convênio. da mesma forma, apresenta-se estatisticamente significativa a relação entre o número de consultas de pré-natal e a variável ocupação (p = 0,005). demonstra-se razão de prevalências de 1,57 vezes maior de mulheres com seis consultas ou menos, entre as mulheres que possuem alguma ocupação do que no grupo de mulheres sem ocupação. apresenta-se na tabela 2 a relação entre o tipo de parto e as variáveis socioeconômicas. nota-se que não houve associação significância (p > 0,05), entre o tipo de parto e as variáveis: faixa etária, raça/cor e ocupação. entretanto o tipo de parto apresentou significância estatística ao ser associado situação conjugal, renda familiar, classe econômica, escolaridade e categoria de admissão (p < 0,05). observa-se no grupo de mulheres que referem ser solteiras/ separadas uma razão de prevalências de 1,87 vezes mais partos normais nesta categoria do que entre as mulheres casadas. já no grupo que declara viver junto com o parceiro, a razão das prevalências foi de 1,72 vezes, mais partos normais do que no grupo de mulheres casadas. quanto à renda familiar identifica-se no grupo de mulheres que possuem renda de dois salários mínimos razão de prevalência de 2,41 vezes mais de parto normal do que mulheres com renda familiar superior. no que tange à classe econômica, apesar da significância estatística, suas razões de prevalência não são estatisticamente significantes, pois contém o valor um no intervalo de confiança de 95%. no caso da variável escolaridade, apesar da significância estatística as razões de prevalência só são estatisticamente significantes nas categorias “até fundamental incompleto” e “ensino médio incompleto”. nota-se que mulheres que tem até o ensino fundamental incompleto a razão entre as prevalências é de 5,56 vezes mais partos normais nesta categoria do que nas com ensino superior. já nas com ensino médio incompleto, a razão das prevalências é de 4,48, o que mostra 4,48 vezes mais partos normais nesta faixa do que nas com ensino superior. em relação à variável categoria de admissão a razão de prevalências é de 2,35 vezes, maior de partos normais na rede sus do que na particular/convênio. demonstra-se na tabela 3 a relação entre o número de gestação e as variáveis socioeconômicas. verifica-se que houve significância estatística a associar as variáveis faixa etária e situação conjugal com o número de gestação (p < 0,05). mulheres de 20 a 29 anos apresentam razão de prevalências de 2,84 vezes maior de duas gestações ou mais quando comparado à faixa 13 a 19 anos. já entre as mulheres de 30 a 45 anos a razão é de 3,23, o que expressa 3,23 vezes mais mulheres com duas gestações ou mais neste grupo do que a faixa de 13 a 19 anos. quanto à variável situação conjugal, observa-se no grupo de mulheres que declararam que vivem junto com o parceiro uma razão de prevalências de 1,72 vezes maior de mulheres com duas gestações ou mais do que entre as mulheres solteiras/divorciadas. no grupo de mulheres que referem ser casadas não foi encontrada significância, pois a razão de prevalência contém o valor um no intervalo de confiança de 95%. não houve significância estatística ao relacionar o número de gestação com as variáveis raça/cor, renda familiar, classe econômica e categoria de admissão (p > 0,05). entretanto, para as variáveis escolaridade e ocupação, apesar da relação com o número de gestações apresentarem significância estatística (p < 0,05), 576 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 tabela 1. a relação entre o número de consulta pré-natal e as variáveis socioeconômicas. são mateus/es, 2010 variáveis número de consultas pré-natal p-valor rp intervalo de confiança de 95% até 6 7 ou mais faixa etária 0,029 13 a 19 anos 45 43 1,64 0,94-2,97 20 a 29 anos 65 109 1,20 0,71-2,12 30 a 45 anos 19 42 situação conjugal 0,036 solteira / separada / divorciada 26 27 1,60 0,92-2,75 vive junto 69 90 1,42 0,93-2,20 casada 34 77 raça / cor 0,049 branca 13 38 negra 45 47 1,92 1,02-3,88 parda 62 98 1,52 0,83-3,01 amarela / indígena 9 11 1,77 0,67-4,46 renda familiar 0,002 1 salário mínimo ou menos 75 86 2,20 1,23-4,21 2 salários mínimos 40 56 1,96 1,05-3,91 mais que 2 salários mínimos 14 52 classe econômica 0,142 classe a2 / b1 / b2 10 27 classe c 79 120 1,47 0,76-3,18 classe d / e 40 47 1,70 0,84-3,81 escolaridade 0,000 até fundamental incompleto 49 48 5,56 1,46-47,17 fundamental completo 23 21 5,75 1,42-50,32 ensino médio incompleto 23 31 4,69 1,16-41,00 ensino médio completo 32 74 3,32 0,85-28,60 superior incompleto / completo 2 20 categoria de admissão 0,000 sus 125 163 3,80 1,45-14,16 convênio / particular 4 31 ocupação 0,005 sim 31 76 não 98 118 1,57 1,04-2,43 rp: razão de prevalência. 577 a influência das características socioeconômicas no perfil obstétrico de puérperas l franciéle marabotti costa-leite e outros tabela 2. a relação entre o tipo de parto e as variáveis socioeconômicas. são mateus/es, 2010 variáveis tipo de parto p-valor rp intervalo de confiança de 95% normal cesárea faixa etária 0,125 13 a 19 anos 39 49 1,59 0,88-3,00 20 a 29 anos 66 108 1,36 0,79-2,47 30 a 45 anos 17 44 situação conjugal 0,003 solteira / separada / divorciada 25 28 1,87 1,05-3,33 vive junto 69 90 1,72 1,09-2,77 casada 28 83 raça / cor 0,582 branca 16 35 negra 38 54 1,32 0,72-2,53 parda 92 98 1,54 0,90-2,81 amarela / indígena 6 14 0,96 0,31-2,57 renda familiar 0,001 1 salário mínimo ou menos 68 93 2,32 1,25-4,72 2 salários mínimos 42 54 2,41 1,24-5,02 mais que 2 salários mínimos 12 54 classe econômica 0,043 classe a2 / b1 / b2 9 28 37 classe c 72 127 199 1,49 0,74-3,38 classe d / e 41 46 87 1,94 0,93-4,53 escolaridade 0,002 até fundamental incompleto 49 48 5,56 1,46-47,17 fundamental completo 16 28 4,00 0,94-35,86 ensino médio incompleto 22 32 4,48 1,11-39,32 ensino médio completo 33 73 3,42 0,88-24,46 superior incompleto / completo 2 20 categoria de admissão 0,008 sus 116 172 2,35 1,05-6,53 convênio / particular 6 29 ocupação 0,282 sim 36 71 não 86 130 1,18 0,79-1,80 rp: razão de prevalência. 578 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 tabela 3. a relação entre o número de gestação e as variáveis socioeconômicas. são mateus/es, 2010 rp: razão de prevalência. variáveis número de gestação p-valor rp intervalo de confiança de 95% duas ou mais uma faixa etária 0,000 13 a 19 anos 21 67 20 a 29 anos 118 56 2,84 1,78-4,76 30 a 45 anos 47 14 3,23 1,89-5,69 situação conjugal 0,003 solteira / separada / divorciada 20 33 vive junto 103 56 1,72 1,06-2,93 casada 63 48 1,50 0,90-2,63 raça / cor 0,128 branca 23 28 negra 50 42 1,21 0,72-2,07 parda 100 60 1,39 0,87-2,29 amarela / indígena 13 7 1,44 0,67-2,97 renda familiar 0,211 1 salário mínimo ou menos 90 71 1,09 0,72-1,66 2 salários mínimos 62 34 1,25 0,81-1,96 mais que 2 salários mínimos 34 32 classe econômica 0,310 classe a2 / b1 / b2 23 14 classe c 108 91 0,87 0,55-1,44 classe d / e 55 32 1,02 0,61-1,73 escolaridade 0,019 até fundamental incompleto 63 34 fundamental completo 29 15 1,01 0,63-1,60 ensino médio incompleto 23 31 0,66 0,39-1,07 ensino médio completo 55 51 0,80 0,55-1,17 superior incompleto / completo 16 6 1,12 0,60-1,96 categoria de admissão 0,253 sus 169 119 1,21 0,73-2,12 convênio / particular 17 18 ocupação 0,045 sim 70 37 1,22 0,89-1,65 não 116 100 579 a influência das características socioeconômicas no perfil obstétrico de puérperas l franciéle marabotti costa-leite e outros não foi evidenciada razão de prevalências significativa, pois todas contém o valor um em seus intervalos de confiança. discussão o presente estudo demonstra significância estatística entre o número de consultas de pré-natal com a faixa etária e situação conjugal das puérperas, entretanto, não se observa razão de prevalência significativa. pesquisa desenvolvida em pelotas/rs pontua um risco maior de realização de menos de seis consultas, entre adolescentes e mulheres sem companheiro (8). vale destacar nesta investigação, a relação entre o número de consultas de pré-natal e a variável raça/cor, que evidencia que mulheres negras têm cerca de duas vezes mais chance de ser submetida a seis consultas ou menos de pré-natal do que as mulheres de raça/cor branca. estudo (8) realizado demonstra que mulheres negras ou pardas possuem maiores riscos para realizar um pré-natal inadequado, ou seja, ser submetida a menos de seis consultas. no que tange à relevância estatisticamente significativa entre a variável renda familiar e o número de consultas de pré-natal, nota-se, aproximadamente, cerca de duas vezes mais chance de mulheres com renda de até um salário mínimo realizar seis consultas ou menos. este achado vai ao encontro dos resultados apresentados por pesquisa desenvolvida em maternidades, no município de são luís, ma, que assinala que mulheres que possuem baixa renda familiar iniciam tardiamente o pré-natal ou realizam um número de consultas abaixo do mínimo recomendado (9). ressalta-se que o ministério da saúde recomenda, no mínimo, seis consultas pré-natais para uma gestação a termo, em gestantes sem fatores de riscos detectados, com início precoce, até o quarto mês de gestação (3). nota-se que não houve significância estatística entre a variável classe econômica e número de consulta de pré-natal. vale lembrar, que a universalidade no acesso aos serviços de saúde é condição fundamental para a equidade. no sus, a universalidade é garantida pela gratuidade no uso de serviços, evitando-se assim que, barreiras econômicas restrinjam o consumo (10). observa-se a influência da escolaridade no número de consultas de pré-natal realizadas, esse achado também é demonstrado em outro estudo9, que revela um maior risco de uma assistência de pré-natal inadequada entre mulheres que apresentam menos de nove anos de escolaridade. em nossa pesquisa verifica-se que as mulheres com até o ensino fundamental incompleto foram as mais propícias, com 5,56 de chance de realizarem seis consultas ou menos de pré-natal. a baixa escolaridade está relacionada à menor oportunidade de realização de consultas de pré-natal. a maior prevalência, entre as mulheres atendidas no sus, de seis consultas ou menos de pré-natal, quando comparadas ao grupo de mulheres atendidas na rede particular/convênio, se assemelha a estudo (11) realizado sobre a percepção das puérperas a respeito da atenção que lhe foi atribuída durante o pré-natal que confirma maior percentual de realização de seis consultas ou mais de pré-natal entre mulheres atendidas na rede particular. quanto à associação entre as variáveis ocupação e número de consultas de pré-natal, nota-se em nosso estudo uma relação de significância entre essas variáveis, indo dessa forma ao encontro de pesquisa que contatou risco duas vezes maior de mulheres sem ocupação remunerada não realizar o mínimo de seis consultas de pré-natal (8). nota-se na presente pesquisa que não houve associação significativa entre o tipo de parto e variável faixa etária, semelhante ao evidenciado por estudo realizado em um centro de parto normal intra-hospitalar em são paulo (sp), que apesar de constatar que mulheres com 35 anos ou mais tiveram chance 20% maior de ter cesariana, quando comparadas às com 20 a 34 anos, esta associação não foi estatisticamente significante (12). entretanto, um recorte da pesquisa nacional de demografia e saúde destacou que mulheres com idade entre 36 e 49 anos apresentaram maiores taxas de cesarianas (p ≤ 0,01) (13). quanto às variáveis raça/cor e ocupação, estas também não apresentaram associação significativa neste estudo, outros autores constataram significância na associação da raça/cor com o tipo de parto, assim como, do tipo de parto com a ocupação. nota-se que a chance de realizar cesárea é potencialmente maior em mulheres que apresentam ocupação fora do lar6 e cor de pele branca (p ≤ 0,01) (13). com intuito de avaliar a prevalência de cesariana em hospitais brasileiros, pesquisadores realizaram um estudo nos estados de são paulo, pernambuco e distrito federal que mostrou ao associar a variável situação conjugal com tipo de parto que a prevalência de parto cesárea em mulheres casadas ou que vivem 580 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 em união consensual foi sete pontos percentual maior que entre as não unidas (14). da mesma forma, a presente pesquisa revelou maiores chances de cesárea no grupo de mulheres casadas. vale destacar a maior prevalência de realização de parto normal entre as mulheres que apresentavam renda de até dois salários. pesquisa desenvolvida em são leopoldo (rs) aponta que mulheres com renda familiar de até um salário mínimo apresentam prevalência de cesariana 63% menor do que as de maior renda (15). evidencia-se, em nosso estudo, associação estatística entre o tipo de parto e a classe econômica, porém não houve razão de prevalência significativa. pesquisa recente aponta que as mulheres inseridas nas classes d e e tinham 58% menos probabilidade de realização de cesariana quando comparadas com as pertencentes às de classes a, b e c (15). no que se refere à relação entre a o tipo de parto e a escolaridade das puérperas, nossos resultados demonstram razão de prevalência estatisticamente significante apenas nas categorias “até fundamental incompleto” e “ensino médio incompleto”, ou seja, estas categorias apresentam mais chance de realizarem partos normais quando comparadas às mulheres com ensino superior. em contrapartida, outros autores não evidenciaram diferença significativa entre o tipo de parto e o grau de escolaridade da mulher (14, 15). vale enfatizar que mulheres atendidas pelo sus tiveram 63% de proteção à ocorrência de cesárea e dentre aquelas que recorreram ao sistema privado, nenhuma teve parto normal (15). corroborando a isso, verifica-se em nossa pesquisa que ao relacionar a variável categoria de admissão e o tipo de parto houve prevalência de partos normais em admissões que foram realizadas pelo sus, quando comparado à rede particular/convênio. o presente estudo encontrou significância estatística ao associar a variável faixa etária com número de gestação das puérperas abordadas. mulheres entre 30 a 45 anos apresentaram mais de três vezes a chance de terem duas ou mais gestação, do que o grupo com a faixa etária entre 13 a 19 anos. pesquisa realizada no subúrbio sanitário de salvador, com mulheres cadastradas na estratégia de saúde da família, evidenciou associação da idade com a ocorrência de gravidez (16). mulheres que declararam que vivem junto com o parceiro tiveram uma razão de prevalência 1,72 maior de terem duas gestações ou mais do que entre as mulheres solteiras/divorciada, esse achado é interessante, pois pesquisa destaca que mulheres que vivem a experiência da gravidez em sua maioria apresentamse casadas ou se encontravam em união estável (16). no presente estudo não houve significância estatística entre o número de gestação e as variáveis raça/cor, renda familiar, classe econômica e categoria de admissão. pesquisa acerca do perfil sociodemográfico de puérperas usuárias do sistema único de saúde em salvador, ba, demonstrou que apesar de predominar na sociedade brasileira ideias e representações de que tanto mulheres de baixa renda como negras tenham maior fertilidade e, consequentemente, maior número de filhos, não foi isto o que se observou na avaliação dos seus dados, uma vez que dentre as 449 usuárias do sus pesquisadas são predominantemente negras, de baixa renda e possuem em sua maioria até dois filhos (17). vale destacar que as mulheres com menor renda per capita, são justamente aquelas que pertencem às classes econômicas mais baixas c, d e e (18). levando em conta a correlação da escolaridade materna com os indicadores obstétricos, pesquisadores observaram em um estudo na região de guaratinguetá, são paulo, que mulheres com maior escolaridade têm uma chance três vezes maior de terem até dois filhos, quando comparadas com aquelas com ensino fundamental incompleto. isto pode está relacionado à falta de informação e acesso aos serviços de saúde dessas mulheres com menor escolaridade (19). esses dados vão de encontro com a presente pesquisa, que não evidenciou ração de prevalência significativa ao relacionar o número de gestações com a variável escolaridade. quando avaliado a relação entre o número de gestações com a ocupação das participantes, notou-se associação estatística entre essas duas variáveis, porém não houve razão de prevalência significativa. diferentemente disto, o estudo intitulado: “comportamento reprodutivo das trabalhadoras urbanas brasileiras” chamou a atenção para a chance cinco vezes maior de se ter três ou mais filhos entre as mulheres do grupo ocupacional do lar (20). concluindo, as características socioeconômicas podem apresentar relação com o número de consultas de pré-natal, número de gestação e tipo de parto. o número de gestação é maior na faixa etária de 30 a 45 anos. observa-se que puérperas da raça negra, que possuem alguma ocupação e com menor renda familiar são mais vulneráveis a realização de um menor número de consultas de pré-natal, bem como as mulheres com menor 581 a influência das características socioeconômicas no perfil obstétrico de puérperas l franciéle marabotti costa-leite e outros escolaridade e assistidas pelo sus. nota-se ainda, prevalência de partos normais entre as mulheres solteiras/separadas, que possuem renda de dois salários mínimos, com baixa escolaridade e assistidas pelo sus. referência 1. serruya sj, lago tg, cecatti jg. o panorama da atenção pré-natal no brasil e o programa de humanização do pré-natal e nascimento. rev bras saúde matern infant. 2004;4(3):269-79. 2. puccini rf, pedroso gc, silva emk, araújo ns, silva nn. equidade na atenção pré-natal e ao parto em área da região metropolitana de são paulo em 1996. cad saúde pública. 2003;19(1):35-45. 3. ministério da saúde. secretaria de atenção à saúde. departamento de ações programáticas estratégicas. manual técnico. pré-natal em puerpério: atenção qualificada e humanizada. brasília: ministério da saúde; 2006. 4. ronsmans c, de brouwere v, dubourg d, dieltiens g. measuring the need for life-saving obstetric surgery in developing countries. br j obstet gynaecol. 2004;111:1027-30. 5. kogan md, alexander gr, mor jm, kieffer ec. ethnic-specific preditors of prenatal care utilisation in hawaii. paediatr perinat epidemiol. 1998;12(2):152-62. 6. carnel ef, zanolli ml, morcillo am. fatores de risco para indicação do parto cesáreo em campinas (sp). rev bras ginecol obstet. 2007;29(1):34-40. 7. associação brasileira de empresas de pesquisa. critério de classificação econômica brasil [internet]. 2009 [citado 2009 nov 10]. disponível em: http://www.abep.org/novo/content.aspx?contentid=302 8. rasia icrb, albernaz e. atenção pré-natal na cidade de pelotas, rio grande do sul, brasil. rev bras saúde matern infant. 2008;8(4):401-10. 9. coimbra lc, silva aam, mochel eg, alves mtssb, ribeiro vs, aragão vmf, bettiol h. fatores associados à inadequação do uso da assistência pré-natal. rev saúde pública. 2003;37(4):456-62. 10. travassos c. equidade e o sistema único de saúde: uma contribuição para debate. cad saúde pública. 1997;13(2):325-30. 11. barbieri a, fonseca lm, ceron mi, fedosse e. análise da atenção pré-natal na percepção de puérperas. distúrb comum. 2012;24(1):29-39. 12. osava rh, silva fmb, tuesta ef, oliveira smjv, amaral mce. caracterização das cesarianas em centro de parto normal. rev saúde pública. 2011;45(6):1036-43. 13. meller fo, schafer aa. fatores associados ao tipo de parto em mulheres brasileiras: pnds 2006. ciência & saúde coletiva. 2011;16(9):3829-35. 14. pádua ks, osis mjd, faúndes a, barbosa ah, filho obm. fatores associados à realização de cesariana em hospitais brasileiros. rev saúde pública. 2010;44(1):70-9. 15. schreiner m, costa jsd, olinto mta, meneghel sn. assistência ao parto em são leopoldo (rs): um estudo de base populacional. ciência & saúde coletiva. 2010;15(1):1411-16. 16. coelho eac et al. associação entre gravidez não planejada e o contexto socioeconômico de mulheres em área da estratégia saúde da família. acta paul enferm. 2012;25(3):415-22. (citado 2010 nov 24). disponível em: http://www.scielo. br/pdf/ape/v25n3/v25n3a15.pdf 17. rodrigues qp, domingues pml, nascimento er. perfil sociodemográfico de puérperas usuárias do sistema único de saúde. rev enferm. 2011;19(2):242-8. 18. dias-da-costa js et al. utilização dos serviços ambulatoriais de saúde por mulheres: estudo de base populacional no sul do brasil. cad saúde pública. 2008;24(12):2843-51. 19. haidar fh, oliveira uf, nascimento lfc. escolaridade materna: correlação com os indicadores obstétricos. cad saúde pública. 2001;17(4):1025-29. 20. júnior csd, verona apa. comportamento reprodutivo das trabalhadoras brasileiras. teoria e sociedade. 2009;17(2):10-29. 27 40 ict as a social support mechanism.indd 27 lorena chaparro-díaz1 beatriz sánchez-herrera2 gloria mabel carrillo3 lucy barrera-ortiz4 ict as a social support mechanism for family caregivers of people with chronic illness: a case study 1. phd in nursing. assistant professor, national university of colombia. olchaparrod@unal.edu.co 2. master of science in nursing (msn). professor, national university of colombia. cbsanchezh@unal.edu.co 3. mg in nursing (msn). assistant professor, national university of colombia. gmcarrillog@unal.edu.co 4. mg in nursing (msn). professor, national university of colombia. lbarrerao@unal.edu.co recibido: 26 de junio de 2012 aceptado: 11 de marzo de 2013 año 13 vol. 13 nº 1 chía, colombia abril 2013  27-40 abstract introduction: social support encouraged by nurses and as a strategy for family caregivers (fcs) is a phenomenon that, although old, is currently challenged to promote care through online social networks. objective: to describe and analyze the use of information and communication technology (ict) as a social support mechanism for fcs of individuals with chronic illnesses. design: the method was a descriptive exploratory study with a qualitative approach undertaken in bogota in 2010. the case study included 20 fcs of individuals with chronic illnesses who used a blog. based on rodger´s theoretical model the ict strategy “diffusion of innovations” was created in three phases: 1) blog design allowing interactions through chat, forum, and email consultation. 2) implementing the strategy for 4 months with 16 hours a day caregiver support service; the information was obtained through field diaries and a final interview. 3) analysis of the information to describe how caregivers perceived the social support obtained through blog use. results: the results describe the way in which they perceived their technological abilities and their ability to use the blog. the main categories found were care, interaction, experience, and technology. discussion: results were compared with those from social support reports addressing e-learning for health and theoretical perspectives on online social support. keywords nursing, caregivers, medical informatics, chronic disease, health. (source: decs, bireme). 28 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 las tic como un mecanismo de apoyo social para cuidadores de familia de pacientes con enfermedad crónica: un estudio de caso resumen introducción: el apoyo social respaldado por las enfermeras como una estrategia para los cuidadores de familia es un fenómeno que aunque viene de tiempo atrás, en la actualidad tiene el reto de promover el cuidado a través de las redes sociales en línea. objetivo: describir y analizar el uso de las tecnologías de información y comunicación (tic) como un mecanismo de apoyo social para los cuidadores familiares de pacientes con enfermedades crónicas. diseño: el método que se utilizó fue un estudio exploratorio descriptivo con un enfoque cualitativo que se llevó a cabo en bogotá en el año 2010. el estudio de caso incluyó a veinte cuidadores de familia de pacientes con enfermedades crónicas y que usaron un blog. con base en el modelo teórico de rodger, se creó la estrategia de tic “difusión de innovaciones” en tres fases: 1) diseño del blog de manera que permita las interacciones a través del chat, foros y consulta por correo electrónico. 2) implementación de la estrategia durante cuatro meses con un servicio de apoyo del cuidador de dieciséis horas al día. la información se obtuvo por medio de diarios de campo y una entrevista final. 3) análisis de la información para describir de qué modo perciben los cuidadores el apoyo social que se obtiene a través del uso del blog. resultados: los resultados describen la forma en la que ellos perciben sus habilidades tecnológicas y su capacidad para usar el blog. las principales categorías que se encontraron fueron cuidado, interacción, experiencia y tecnología. discusión: los resultados se compararon con los de los informes de apoyo social que abordan el aprendizaje virtual para la salud y perspectivas teóricas sobre el apoyo social en línea. palabras clave enfermería, cuidadores, informática médica, enfermedad crónica, salud. (fuente: decs, bireme). 29 ict as a social support mechanism for family caregivers of people with chronic illness: a case study l lorena chaparro-díaz, beatriz sánchez-herrera and others. as tic como um mecanismo de apoio social para cuidadores de família de pacientes com doença crônica: um estudo de caso resumo introdução: o apoio social respaldado pelas enfermeiras como uma estratégia para os cuidadores de família é um fenômeno que, embora venha de tempo atrás, na atualidade tem o desafio de promover o cuidado por meio das redes sociais on-line. objetivo: descrever e analisar o uso das tecnologias de informação e comunicação (tic) como um mecanismo de apoio social para os cuidadores familiares de pacientes com doenças crônicas. desenho: o método que se utilizou foi um estudo exploratório descritivo com um enfoque qualitativo que se realizou em bogotá em 2010. o estudo de caso incluiu a vinte cuidadores de família de pacientes com doenças crônicas e que usaram um blog. com base no modelo teórico de rodger, criou-se a estratégia de tic “difusão de inovações” em três fases: 1) desenho do blog de maneira que permita as interações por meio de chat, fóruns e consulta por correio eletrônico. 2) implementação da estratégia durante quatro meses com um serviço de apoio do cuidador de dezesseis horas por dia (a informação se obteve por meio de diários de campo e uma entrevista final). 3) análise da informação para descrever de que modo os cuidadores percebem o apoio social que se obtém pelo uso do blog. resultados: os resultados descrevem a forma na qual eles percebem suas habilidades tecnológicas e sua capacidade para usar o blog. as principais categorias que se encontraram foram: cuidado, interação, experiência e tecnologia. discussão: os resultados se compararam com os dos relatórios de apoio social que abordam a aprendizagem virtual para a saúde e perspectivas teóricas sobre o apoio social on-line. palavras-chave enfermagem, cuidadores, informática médica, doença crônica, saúde. (fonte: decs, bireme). 30 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 introduction latin america has been attempting to find the most useful strategies to address and manage the progressive increase in chronic illnesses (pan american health organization, 2007). chronic illnesses entail major social and economic costs and significantly reduce productive years. the required long-term care, frequent hospitalizations and risks resulting from ignoring the condition, alter interpersonal relationships and generate isolation and a great sense of discomfort with health and life in general (kane et al., 2005 and barrera, pinto, & sanchez, 2010). the significance of chronic illness as a social phenomenon (newman, 1994) and the philosophy of how to approach chronic illness can be viewed from three perspectives: classification, experience, and perceptions (barrera, et al., 2010). coping with a chronic illness pertains not only to the patient but to the family caregiver (fc) who is alongside him/her and becomes an important agent for the healthcare system; they undertake the responsibility of caring for their loved one and participating in decision making even though they have no social or legal recognition. “he performs or supervises the activities of daily life to compensate the existing dysfunctions of the recipient of care.” (barrera, galvis, pinto, moreno, pinzon, romero, et al., 2006). we must recognize that providing care creates special needs that continue over time (pinto, & sanchez, 2000). when caregivers have social support to ease their workload, they can usually strengthen their skills, thus contributing to their loved ones’ quality of life as they care for them. social support (ss) has been widely described, and its relevance in looking after individuals with chronic illness has been recognized (lindsey, & yates, 2004, tilden, 1985; hupcey, 1998 & finfgeld-connett, 2005). ss involves the sharing of information and provides feelings of being cared for, loved, esteemed, and valued as a member of a network (cobb, 1976 quoted by lindsey, et al. 2003). the concept includes four functional dimensions: emotional, instrumental, informational, and validation (house, 1981). it can have a positive impact mostly on health and welfare (hinson, bowsher, maloney, & lillis, 1997), and it differs from merely being looked after (finfgeld-connett, 2007). it is explicit in the context of chronic illness (vrabec, 1997), and there are different categories in how this support performs (hilbert, 1990). humans have an essential need to connect with others, and connections are enhanced where there is timely and effective communication. this need is perhaps why one of the millennium objectives considers enhancing the use of technological devices through “building a global partnership for development” (united nations organization, 2010) to promote a global society. with technological advances, social networks have had great economic, social, and scientific impacts that can support healthcare. in this sense, information and communication technologies (icts) have three possible developmental fronts that must be studied and promoted: the institution, the system itself, and users and professional agents (peña, 2004; nadal, 2007; ramos, 2007; torrente, escarrabill, & martí, 2010). healthcare users today are not passive individuals, and cutting-edge technologies are a means of guiding them to a healthier and happier lifestyle. thanks to technology, patients and their families encourage research and seek to improve treatments and quality of life (armayones and sanchez, 2011). the e-patient concept was introduced by fergusson et al. (2004) as a “proactive patient with good knowledge of technologies, involved in maintaining their health and interested in contributing not only to treatment and research on specific health conditions but also to improve the health care system”. this concept extends to health service users, including patients with chronic illnesses and their fc (schachinger, 2010). the legislative perspective worldwide has been changing to accommodate ict in healthcare (vélez. 2010). in colombia, more changes have happened at the institutional level than in the system itself or among professionals. telemedicine is the main focus of legal standards (res. 1448 of 2006 ministry of social protection), especially in areas of the country that are difficult to access (law 1122 of 2007 ministry of social protection) and for the specific goals included in the national public health plan 2007-2010 (ict plan colombia). information technology and communication (ict), has been described as a tool with which to provide social support; it is defined as “strategies to create support networks and provide a support system with better monitoring, integrated through connections media and online support, facilitating permanent interactions among people with chronic illness, their caregivers and the health systems” (cardenas et al, 2010). 31 ict as a social support mechanism for family caregivers of people with chronic illness: a case study l lorena chaparro-díaz, beatriz sánchez-herrera and others. ict enables collecting, systematizing and disseminating information in order to promote learning and skills in people with chronic illness and their caregivers (struk et al, 2009). this forwards how they learn to cope with the situation regarding oncoming behavioral changes and an altered lifestyle (barrera et al, 2007) thus decreasing accessibility barriers and high service fees. (barrera et al, 2008, weiner et al, 2005). although the use icts appears to have increased, access to specialty-based information provided through institutional websites, the use of call centers, the use of e-mail for communicating laboratory results and diagnostic images, access to a treating physician´s cellphone, health chat services, and phone-made appointments have not been well described in colombia. healthcare and its relationship with the use of ict as a key element in supporting the care of people with chronic illnesses have not been systematically addressed. materials and methods an exploratory descriptive study with a qualitative approach and a case study design described and analyzed the use of ict (using a blog) as a social support mechanism for fc of people with chronic illnesses. it was necessary to start with a conceptual approach that would allow observing the phenomenon of a social support network as an essential element of care to meet the challenge of having a relative with a chronic illness (lacoursiere, 2001, brennan, moore, & smyth, 1991). rogers’ “diffusion of innovations” theory (1983) reinforced how the study developed in the understanding that support should be comprehensive, innovative, affordable, compatible, and beneficial. it should also respond to the characteristics of the caregiver in the situation that he or she is facing, including the workload, degree of isolation, and decision-making process, and the response to the caregiver’s interaction with technology. therefore, the study proceeded in three stages: an initial stage, in which we designed an online social media strategy for fcs of individuals with a chronic illness that eases the interaction between participants through chat, forums, and video forums. access can be free or restricted depending on the group’s decision; it was structured as a blog named “paratucuidadoenlinea”. the second stage is the intermediate stage, in which we implemented a strategy to link the participants into the blog through training in tool use and developing a tracking system to identify indicators of ict use, access, and ownership. the stage lasted for four months and included 16-hour daily availability for consultation, advice to the fc via chat, and using a visit counter to monitor forum participation. the informants were selected based on those involved in strategies used for social support technologies. information was obtained through observations registered in the field diary of each of the cases and open-ended interviews conducted after this stage of the study. interviews were conducted by the same blog and chat, as well as through phone calls. all of the participants’ activities whether via chat and/or the forum were transcribed verbatim in the field diaries. last of all, is the final stage, during which information was analyzed. this process began with organizing the field diary of each case, the transcripts of the studies via chat and/or forum, and interviews. elements were then extracted, and codes and categories were built regarding the fc’s experiences and perceptions while using the tools. finally, the codes and categories were grouped into dimensions and due to the large number of categories the qualitative research program atlasti was used to consolidate the information, (national university of colombia. atlasti. version 6.0.12). credibility, trustworthiness, transferability, dependability and confirmability (lincoln & guba, 1985) guided this process. for example, carefully rereading the interview and field notes in order to compare cases assured credibility. interpretations were shared with other researchers of this study. thus, holding discussions with the research group checked codes and categories. ethical issues such as informed consent, voluntary participation, handling confidential information, and the approval of relevant authorities in support of the ethics committee of the school of nursing at the national university of colombia were considered in this study. environmental impact was assessed and considered positive because the strategy implemented reduces the use of both paper and ground transportation. results a blog under the name “paratucuidadoenlinea” was structured using questions to characterize the information needs of the caregivers and guide their role. twenty fcs of people with chronic illness (ci) were given access to the blog. 19 were females between 30 and 63 years old, while the remaining one 32 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 was a 70-year-old male. their education levels varied from being unable to complete elementary school (1), unable to finish high school (3), high school graduates (3), technical apprentices (2), college dropouts (2), and college graduates (8). regarding marital status, one was separated, three were single, two lived in civil union, four were widows, and nine were married (including the male). in regards to occupation, one was a student, two were employed, four were retired, six worked free-lance, and seven worked from home. caregivers were of varied kinships including daughter in-law (1), granddaughter (1), friend (2), sister (2), niece (2), husband/wife (3), and daughter (8). from this characterization, rogers’ theory indicates that intermediate ages are more easily motivated towards using ict, which is contrary to what one might think that is true of young adults. although not exclusive, the educational background is a beneficial influential factor. in a previous knowledge survey, skills in computer use were self-rated on a scale from 0 (not at all) to 10 (very knowledgeable). three fcs rated themselves as very low (0 to 1), seven as low (2 to 4), seven as fair (5 to 7), and three as good (8 to 10). for internet use, 16 fcs stated that they occasionally used the internet and 4 did not. likewise, 4 fcs said they had no computer or internet at home, 3 had a computer at home but no internet, and 13 had a computer and internet. three people used hourly internet rooms, and all had access to rooms provided by the project on campus at colombia’s national university if they so required. self-rating between low and very low reflects that access may be limited in a stage prior to these types of interventions; however, that does not minimize its innovative nature at all. on the contrary, when they recognize the benefits they prefer them to some of the aspects involved in sessions held on site. training was organized at the most convenient times for the fc, either in person or with the use of general internet and blog management guidebooks. a 6 to 28 hour range was required with an average of 13.4 hours, and the general guidebook provision was required for 12 of the 20 fcs. one caregiver received additional training by email. five fcs stated that they always used the blog management guidebook, 5 used it infrequently, and 10 almost always used it (table 1. fcs of people with a chronic illness who participated in the study). the fcs showed interest in getting involved with the blog, and although some of them had difficulties accessing it, the problem was overcome with support and training. the participants’ names were used as their identification on the blog. one of the activities was publishing videos of interest, which generally evoked feelings, memories, or good wishes for others. it was common to form couples to use the training or provide feedback because having a partner who had greater knowledge in the use of the blog could be more effective than the use of the supporting material. finally, not all of the participants became permanent users. however, the greatest benefits identified included the counselor’s perception in each case and the positive assessment of the learning achieved as well as having space on campus (institutional facility) to give fcs the opportunity to enter the world of ict at least once a week. the participation and interaction on proposed topics motivated the fcs to request more information or information on new issues and to express feeling confident about the knowledge acquired. also, they were encouraged to give recommendations that were monitored by the nurse (counselor). the validation of the information received and requested was paramount for the fcs because they were certain that the person responding to their requests was a highly skilled nurse with institutional support and special communication features to understand complex issues. providing step-by-step guidelines and instructions, drawing attention to inappropriate practices, and providing timely, relevant, and easy to perform solutions were necessary to reinforce this knowledge. the blog offered themes such as first aid and skin care. innovation from rogers’ perspective is consistent with classifying ict users in: a) innovative caregivers: those who cope adequately with having to face, ask for or go to the directory to solve concerns, b) those who adopt ict in an early stage, who are caregivers claiming that they occasionally use additional information on the use of ict or a counterpart to guide them; c) those who start and use it regularly, but only when there are specific concerns or under a motivating factor such as a videos or topics of general interest, d) those starting later, who must first understand the guidelines to make them operational and have constant validation on the use of ict and e) those who definitely show mistrust but who are also occasional ict users; these include those who used the rooms available on campus. case analysis was based on the field diaries (from telephone conversations and reflections of the counselor), information recorded on the blog, and open questions asked at the end of blog participation. based on these sources, the information was organized in nouns and nominal codes that were grouped into categories after reaffirming their names. there were a total of 193 codes representing the core of participants’ testimonies just as they were interpreted, without preconceptions, and based on the 33 ict as a social support mechanism for family caregivers of people with chronic illness: a case study l lorena chaparro-díaz, beatriz sánchez-herrera and others. descriptions and the reflections of the investigator. finally, the codes were grouped into four dimensions: care, interaction, experience, and technology (table 2. fc categories organized into dimensions). overall, these four dimensions define the use of a blog as a social support mechanism for the fcs of individuals with a chronic illness. care. this dimension refers to the ways in which the family caregiver takes from his or her innermost human essence the skills needed to face committing to a chronically ill loved one, what he or she should know about the disease, how to meet oncoming challenges, and the ability to establish interpersonal relationships that will forward human development; it also refers to understanding the difficulties that this experience brings to everyday life where social support becomes an opportunity. fcs feel that this work involves being constantly updated, looking for different ways to find the necessary information about the disease, coming closer to what their loved one feels regarding their situation, occasionally identifying similarities between the patient’s condition with his or her personal health status; they also feels it requires gaining knowledge regarding specialty care and the specific terminology required to discuss topics such as “pressure sores” or “take your blood pressure” even when, prior to their role as fc they were even unaware of how to spell them. knowledge is closely related to self-improvement as a caregiver because the valuing the knowledge acquired reveals that appreciates receiving tangible input to support his or her work. this desire for improvement is evidenced through a two-way interaction between the caregiver and counselor and by the opportunity to assess the knowledge and experience of other fcs. in this regard, care is closely related to the dimension of interaction. it is only possible to improve as a caregiver when there is interaction with others and when the caregiver expresses the need and desire to implement what has been learned into expanding this knowledge into everyday life. interaction. the interaction dimension was observed starting from the process of training in the use of ict. the fcs expressed interest in retaining the offer to receive training in accordance with each fc’s needs. the fcs kept in contact with their peers and with the counselor with phrases of good wishes and by establishing meetings or commitments either virtually or in-person. other forms of interaction involved establishing communication patterns, such as welcome greetings, invitations to follow the blog, integration, remembering special days, and greeting at the beginning and at the end of each session. the “desired link” is a key element of an online support group to be considered. participants were already part of an in-person support group, and they established a stronger bond through the use of ict. interactions also involved feedback from others and self-reflection. language, including phrases created or evoked by each individual, was an essential part of this dimension. in addition, essential parts of the interaction include expressions of satisfaction regarding the information learned, assessments as human beings, identifying possible solutions, and recognizing the network. how feelings were expressed was qualified by the gratitude and empathy between the counselor and the fc. counselor interactions were evaluated according to their patience, time, dedication, and accessibility to the fc. in this dimension, the blog was perceived as a meeting place, comparable to in-person support, which helped to identify and exchange experiences, provide virtual entertainment, display preferences, and answer questions. moreover, the fcs can receive training, develop skills, receive support; meet others, identify their strengths, be recognized as peers, and establish a shared body of work. experience. the experience dimension has two categories that reflect the intangible aspects of caregiving. recorded phrases, whether evoked or created, reflect the caregiver’s spirituality and his or her ideas on friendship, with which the caregiver gives meaning to his or her work. in addition, religious phrases are offered to protect the caregiver and the individual suffering from chronic illness. interaction and knowledge about care are intertwined with the fc’s experience, generating greater security and a greater ability to recognize that once knowledge is acquired, it should be shared. experience provides security in anticipation of tougher times that are sure to come. technology. in this dimension, the categories reflect the outcome of the information provided: how to take risks and submit questions about the care of a family member, explore the network, give identity to their space (profile picture), identify the supporting material, and use ict as the basis to determine appropriate solutions. in some cases, access did not require support from a counselor, and the fcs acknowledged having support from peers that had more knowledge. they appreciated different communication channels (telephone) and advantages, such as not having a precise timetable to participate. 34 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 difficulties using the blog were associated with the fear of using technology. at first, fcs harbored the myth of “damaging” the computer, but as they received training, they became less afraid, and their anxiety was reduced. however, other difficulties were evidenced, such as not using the guidelines provided at the appropriate times, identifying very similar visual images from the internet across multiple platforms, not having their own computer, having to share a computer with other relatives or caregivers, and requiring special software for video applications. opportunities were also recognized such as the learning of something unplanned. they were eager to inform other fcs about the existence of these tools, and they appreciated that the strategies were not only to read documents but also to play, interact, publish, receive feedback, lose their fear of technology, be motivated, develop typing skills, access, and connect. this led them to consider the need to organize ict support, seek clarifications, acquire greater psychomotor skills, seek support from a younger relative, and continue training. at the same time, they required monitoring and support to learn the material, manage schedules and availability, and combine in-person and virtual sessions in order to participate. evidently, the fcs performed strategies to appropriate ict. by contrasting the use of the blog section versus telephone follow-up, it became clear that the better-developed strategies were related to the use of the chat and forum, which focused on the interaction of the counselor with peers, encouraging ongoing reflection and recognizing the potential use of the tool. appropriation is classified as intermediate regarding reference topics because the fcs were allowed to suggest topics; new concerns arose from these suggestions and were related to care, interactions, and the use of ict information for living as a fc. virtual consultations and e-mail (the latter was almost null) had the lowest use. the fcs focused on expressing interest but lacked feedback on knowledge acquired. finally, telephone follow-up participation was punctual and associated with questions about care, commitment to continuing the use of ict, or requests for in-person meetings. in sum, the analytical categories were grouped into the dimensions of care, interaction, experience, and technology, which summarize how the use of icts, in this case the blog “paratucuidadoenlinea”, developed as a social support mechanism for fcs. discussion the discussion presents three perspectives on the current state of knowledge: social support, the use of ict in healthcare, and theoretical perspectives on innovation and social online media. as for social support, and regarding vrabec’s proposal (1997), “maintain contact” is from the structural dimension, the category that supports the network or the relationship between peers; with regard to the functional dimension, emotional support is based on the “space to deliver care”, “space for meetings”, “maintain contact”, “food for thought” and “re-emphasis of experience” categories. for instrumental-information support, the categories are “knowledge for caregiving” and “difficulties associated with the caregiving”. in validation, the support categories found were “strengthen ourselves as caregivers” and “give each other feedback”. finally, the results in regard to satisfaction are “results from ict” and “gratitude”. in this same dimension, the technology categories contribute towards understanding the concept in the context of using technology, as proposed by williams, barclay, & schmied (2004). social support depends on a group of caregivers, who know and wish to remain as such, and where emotional elements are prioritized in order to weave the threads of the network; each caregiver exposes that his/her experience and expertise is in the direct care and should be accompanied by a formal or more skilled caregiver. this indicates that social support interventions must have basic elements of social networks, in order to help reduce the burden, share with others and allow people to see that they are not alone and should be assessed mainly by a health care professional, thus integrating care within social support. concerning the use of ict in health defined as a social media strategy, the blog “paratucuidadoenlinea”, allowed valuing fcs as individuals who despite their education level can still undertake a new learning process, as each of these fcs was able to acquire valuable new knowledge at the right time. fcs commonly require formal spaces in which to participate, and this was perceived as an opportunity to interact differently, to share resources simultaneously, and to express their thoughts. some care needs arose from the interaction between the fc and the counselor. in this regard, pierce, steiner, & govoni (2002), in a care-related internet tool (which is not strictly social support), also found the need to suggest websites and games that promote abilities and leisure activities, draw attention to the importance of going to a medical facility, provide information on the 35 ict as a social support mechanism for family caregivers of people with chronic illness: a case study l lorena chaparro-díaz, beatriz sánchez-herrera and others. proper use of medications and their indications and side effects, and provide information systems and social support resources that can be consulted later. kernisan, sweat, & knight (2010) synthesized information on healthcare practices, behaviors, and support and obtained similar results. the dimension experience categories are related to the findings of klemm & wheeler (2005), who identified hope as a part of the learning experience. klemm et al. (2005) found that emotional aspects fluctuated; on the contrary, in the present study, the expression of negative aspects of the experience were not as explicit, as noted by the difficulties category associated with caregiving. although this intervention was not essentially based on the telephone as a strategy for monitoring blog use, some telephone contacts were included. kerr et al. (2006) found with an intervention of this kind that this strategy allows the fc to respond to difficulties in the use of ict, such as not being able to attend the internet lounge and visual confusion (such as differences between email, webpages, and software required to view resources). another advantage of having telephone contact was the ability to respond to concerns about health services and provide more intimate emotional support. one dimension that is directly related to technology is interaction, thus confirming that strong bonds between the fc, the counselor, the formal support group, and even the institution that provided the intervention are created and expressed through the constant gratitude shown in messages and thoughts. sullivan (2008) found a link in caregivers for children with asthma in a category called “we are here to provide support when needed”. based on the findings, ict -in healthcan be defined as an opportunity to interact with peers in innovative and entertaining environments; it shows new needs that are not perceived in consultation or workshops (inadequate care practices), maintains ongoing analysis that encourages the caregivers and generates new links to recognize the other person from what he/she feels and expresses, not only from their physical appearance or compatibility in social relationships. finally, regarding the theoretical prospects for online innovation and social support, great relationships exist to develop a strategy based on the results and the projections of telenursing online. in the theory of diffusion of innovations1 , rogers (1983) states that participants’ characteristics are key factors that influence how innovation is adopted. this was a characterization study corresponding to the profile of fcs in the global and local context, including middle-aged women (35-65 years) with high educational levels. therefore, a short and effective training period was expected, but the use of new tools required more time to respond to concerns arising in regard to their proper use. this means that educational level did not create differences within the fc group because in this regard, they were all at the same level. in general, the fcs were middle-aged and in an upper socioeconomic stratum. most of them had technological resources at home. however, ignorance hindered them from using this technology, thus confirming that despite having the resources, their training and guidance regarding their proper use had been inadequate. the most persuasive aspect of the blog was how fcs perceived that the knowledge expressed caregivers and that the opportunity to interact and share their experiences will enrich their lives and provide security. the decision to continue or not in the blog depended on participation in different strategies: forums, e-mail, virtual consultations, reference topics, chats, and telephone follow-ups. in this study, some issues limiting the adoption of blog use other than care giving, were going to medical appointments (their own or that of the patient) and attending to leisure activities and family meetings. it was not possible to determine the personal factors underlying the lack of adoption of some fcs; however, the chat and the forum were the most consistently accepted strategies while reference materials were accepted to a lesser extent. other nursing theories can contribute to a better understanding of the results. in an investigation by brennan, moore, & smyth (1991), results were limited in comparison with this study because the ict examined in this study not only provides emotional support but also has a direct influence on how knowledge is acquired regarding an individual with a chronic illness. the concerns of the fc were not limited to searching for information on diseases but included a social space to be recognized as human beings, both for remembrance as well as and to regain their identity. as for lacoursiere’s (2001), mid-range theory there is greater affinity in the validation of the results. the main phenomenon of this theory is the “interaction between people” rather than the exchange of information, which is consistent with the results in the interaction dimension. this perspective reveals that there is a cognitive and perceptual background that depends on online social support. in search of the deepest connection, fcs who adopt ict(rogers 1983) become more experienced (the experience dimension) and begin to feel able to support others (ben36 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 ner 1984). in this theory, the concept of the meta-paradigmatic environment is a virtual approach, and that of nursing is a part of cyberspace (the concept of pan dimensionality; m. rogers 1992). the counselor who described the fc’s participation is simply a facilitator who must also have thoughts and behaviors of online social support. at this point, it is useful to reflect on the technological competence for care proposed by locsin (2009), the goal of which is to increase the understanding of technology and capture genuine care, defined as “a reflection of change, belief and commitment that a professional nurse makes with each person having an autonomous act with personal commitment and intention”. with this perspective, we begin to think that the role of the nurse regarding online social support is geared towards what we refer to as telenursing, which is an innovation in nursing care that integrates knowledge with social practice. based on the analysis of the blog concept about disease proposed by heilferty (2009), a proposal on the mid-range theory of online communications on disease states that this strategy corresponds to the background, attributes, and consequences of the concept. in it, narratives are paramount to the concept, and although they were not the main focus of this study, such narratives were reconstructed from reference topic of care experiences, which were provided by the fc as feedback. similarly, their participation was strengthened by the caregiver’s recognition (resulting from the use of blogs) of the “evolution of identity”, feeling welcome to a virtual space, and feeling supported when they post messages, feelings, or words of encouragement to other fcs or when uploading their faces with a personal photo. heilferty (2009), represented interaction was as another dimension with the author-reader interaction improving the relationship and reducing isolation. finally, it is worth noting that this study provides and acknowledges the need to continue developing nursing knowledge in the context of ict as a central element in fc care. there are weaknesses in terms of the access and availability of technological resources, but clear concepts were identified in this study in favor of defining the role of nursing in the social network as a facilitating agent rather than as part of the social support network. it is the duty of the nurse to provide care that is innovative in outlook, so it is expected that work with mid-range theories, which are still not well understood in the context of colombia, will continue. references 1. armayones, m., sánchez, c.l. 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(2005) social support in cyberspace. the next generation. computers informatics nursing, 23(1): 715 39 ict as a social support mechanism for family caregivers of people with chronic illness: a case study l lorena chaparro-díaz, beatriz sánchez-herrera and others. case name of the blog case analysis 1 life style the caregiver sees blog training as a new opportunity, participates actively in scheduled virtual sessions, and shows a commitment to the use of technology and its integration with healthcare. however, for various personal reasons fc has some difficulties in scheduling. 2 flowing in love the caregiver shows interest in the use of the blog and maintains active communication with the group, although at times he or she evidences problems in appropriating technology. 3 living day to day the caregiver begins with dynamic active participation in the blog, characterized by being punctual, natural, gentle, and thoughtful. however, a lack of appropriation of technology makes the blog difficult to use outside the training space given by the group. 4 my care the caregiver has an interest in self-care, and the blog label reflects that. however, there are troubles with staying on the blog and receiving feedback. feedback has not been given to other caregivers. due to a lack of knowledge, developing concrete self-care actions has been difficult. 5 did not mention the caregiver began with low participation in the intervention. interest was developed by training and the use of ict. the caregiver has skills, but classroom sessions are required to complete the training due to the demands of caregiving. 6 fidelity a caregiver who has low direct involvement in the blog but maintains the desire to participate in the support group. there is good feedback on topics of interest based on experience, and security can be appreciated. 7 anolaima is my city the caregiver starts participating in the blog with matters of their own interest and then moves on to other care issues, seeking to increase knowledge and strengthen abilities as a caregiver of a chronic illness. they require other caregivers’ company, and they do not use physical material because it is not their learning style. they show interest in learning to use the blog. 8 happy days a motivated caregiver with skills that are shown while accompanying other caregivers. they are interested in maintaining interest outside the support group, and there is interest in appropriating, reflecting about self-care and decision-making motivated by the counselor´s feedback. 9 tony a caregiver with difficulties and few skills in computer management, which further limits his or her use of the internet. ongoing support is required, but they identify their concerns, which are resolved through training and use of the blog. eventually, greater appropriation is identified and valued very positively through the use of the blog. 10 loves the caregiver a caregiver that did not stay in the blog from the beginning, which is evidenced time and time again in her participation. fc gives more importance to face-toface interaction, and she perceives herself in that scenario. fc encounters several challenges with the appropriation of the virtual tool. 11 live healthily a caregiver characterized by active participation in the blog, who seeks to give feedback and shows interest in spite of the difficult situations she lives in while caregiving. her participation is permanent and a positive influence on the group. 12 did not mention the caregiver is interested in participating in the blog; however, an urgent trip arose that prevented her from actively participating in the use of the tool. participation was proposed to continue monitoring through email, but this was not evident in the development of the project because the caregiver did not answer messages. 13 i care nursing the caregiver is interested in the blog and participates actively. she reports receiving feedback from professionals and peers, facilitating the use of the virtual tool. she is interested in both virtual and face-to-face interactions. 14 did not mention at the beginning of the blog, the caretaker did not show equal participation with their peers, but they progressed favorably in the process of training and in the use of the blog. the increased appropriation was evident, although it was always necessary to combine the virtual with face-to-face interactions. 15 technology in 200 years the caregiver uses the blog for very specific interests and to expand topics. fc welcomes peer feedback. she has good levels of technology appropriation. 16 transcending in general, a high level of appropriation. caregiver uses the virtual tool properly and checks for responses to their requests. interested in knowing the perceptions of the counselor and values their skills highly, as well as the process undertaken and the work of the support group 17 caring is loving the caregiver begins motivated, appropriating elements that communicate appreciation, such as giving thanks to the other team members and support professionals. they seek to maintain consultation with themes of self-interest. the fc values the qualities of the counselor, and this keeps them on the blog. 18 i will help you and you will help me the caregiver is interested in participating in the blog but participation is sporadic rather than consistent and the effectiveness of the intervention could not be appreciated. 19 mr (proper name) the caregiver was not active when using the blog and perceives it as positive information. she values support as the contribution made by the use of the blog. 20 sharing dreams the caregiver seeks to maintain participation in the blog motivated by reflection, and looks to appeal to peer feedback. it becomes clear that the support of others improves her appropriation of the technology. table 1. chronic disease fcs who participated in the intervention source: study data. 40 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 acknowledgments the research division of bogota (drb) at the national university of colombia is acknowledged for funding this study under project code 9567 for 2009-2011. the cf program “caring for the caregivers” is also acknowledged for their participation in the project and for sincerely expressing their opinions. we’d like to give a special mention to mrs. natividad pinto, professor and leader of the chronic patient care investigation group and her family. mrs pinto sadly passed away earlier this year, but actively supported the investigation process for this article. table 2. categories of fcs organized in dimensions. source: study data. dimension categories care knowledge regarding caregiving strengthen oneself as a caregiver difficulties associated with caregiving space to convey care interaction keep in touch give each other feedback gratitude space for meetings meet others experience cause for reflection re-emphasis of experience technology results from ict ict accessibility difficulties in the use of ict opportunities for ict organizing the use of ict 7 16 significados durante el puerperio.indd 7 brigitte m. prieto b.1 carmen helena ruiz2 signifi cados durante el puerperio: a partir de prácticas y creencias culturales 1. enfermera. magíster en enfermería con énfasis en cuidado materno perinatal. docente, universidad pedagógica y tecnológica de colombia. brillis025@yahoo.com 2. enfermera. magíster en enfermería con énfasis en cuidado materno perinatal. docente asociado, universidad nacional de colombia. ccruizd@unal.edu.co recibido: 3 de noviembre de 2012 aceptado: 22 de febrero de 2013 año 13 vol. 13 nº 1 chía, colombia abril 2013  7-16 resumen objetivo: describir el significado que le asigna la madre al cuidado cultural de ella misma y su recién nacido durante el puerperio, a partir de sus prácticas y creencias. método: estudio con abordaje cualitativo de tipo etnográfico, realizado en tunja, colombia, en el que participaron ocho puérperas con parto normal y cuatro informantes generales, entre profesionales de enfermería y familiares de las puérperas. los datos fueron analizados utilizando la guía de cuatro pasos de etnoenfermería de leininger, y por medio de esta se identificaron códigos, patrones recurrentes, y temas principales. resultados y discusión: el significado que le asigna la madre al cuidado cultural en el puerperio a partir de sus prácticas es diverso y está representado en cada uno de los cinco temas que emergieron del estudio: el poder secreto de las plantas, el peligro de la recaída, descubriendo el mundo de su hijo, el cuidado de sí misma, y alimentos protectores. en contraste con el modelo del sol naciente, los factores de la estructura social que tuvieron mayor influencia corresponden a las creencias, valores culturales y estilos de vida; así como el factor social de parentesco. se identifica entonces el predominio del componente emic en el cuidado cultural durante el puerperio con relación al componente etic. palabras clave periodo postparto, cultura, atención en enfermería, enfermería, recién nacido (fuente: decs, bireme). 8 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 meanings during the postpartum period: from practices and cultural beliefs abstract objective: to describe the meaning that a mother gives to the cultural care of herself and her newborn during the postpartum period, from her practices and beliefs. methodology: ethnographic qualitative study made in tunja, colombia, in which eight postpartum women with normal delivery and four general informants, conformed by nurses and relatives of postpartum women. data were analyzed using the ethnonursing four-step guide by leininger, and through it we identified codes, recurring patterns and themes. results and discussion: the meaning that a mother gives to the cultural care in the postpartum from her practice is diverse and is represented in each of the five themes that emerged from the study: the secret power of the plants, the risk of relapse, discovering her child’s world, her self-care, and protective foods. in contrast to the sunrise model, the factors of social structure that had greater influence correspond to beliefs, cultural values and lifestyles as well as the social factor of kinship. then, we can identify the prevalence of the emic component in the cultural care during the postpartum period in relation with the etic component. keywords postpartum period, culture, nursing care, nursing, newborn. (source: decs, bireme.) significados durante o puerpério: a partir de práticas e crenças culturais resumo objetivo: descrever o significado que a mãe atribui ao cuidado cultural dela mesma e de seu recém-nascido durante o puerpério, a partir de suas práticas e crenças. método: estudo com abordagem qualitativa, de tipo etnográfico, realizado em tunja, colômbia, do qual participaram oito puérperas com parto normal e quatro informantes gerais, conformadas por profissionais de enfermagem e familiares das puérperas. os dados foram analisados utilizando o guia de quatro passos da etnoenfermagem de leininger e, por meio desta, identificaram-se códigos, padrões recorrentes e temas principais. resultados e discussão: o significado que a mãe atribui ao cuidado cultural no puerpério a partir de suas práticas é diverso e está representado em cada um dos cinco temas que emergiram do estudo: o poder secreto das plantas, o perigo da recaída, descobrindo o mundo de seu filho, o cuidado de si mesma e alimentos protetores. em contraste com o modelo do sol nascente, os fatores da estrutura social que tiveram maior influência correspondem às crenças, valores culturais e estilos de vida, bem como o fator social de parentesco. identifica-se, então, o predomínio do componente emic no cuidado cultural durante o puerpério com relação ao componente etic. palavras-chave período pós-parto, cultura, atendimento em enfermagem, enfermagem, recém-nascido. (fonte: decs, bireme). 9 significados durante el puerperio: a partir de prácticas y creencias culturales l brigitte m. prieto b., carmen h. ruiz introducción el puerperio es una etapa que se caracteriza por diversos cambios bio-psicosociales que afectan la estabilidad de la mujer y del recién nacido. este periodo se ha visto influenciado desde siempre por prácticas y creencias culturales transmitidas de generación en generación. identificar y conocer las creencias, valores y significados presentes en la mujer durante el puerperio permite fomentar efectivamente las intervenciones de cuidado que brinda el profesional de enfermería, y que están encaminadas a garantizar el bienestar y mejorar la adaptación del binomio madre-hijo, dentro de su contexto social y cultural. en efecto, las estrategias para la promoción de la salud deben considerar e incluir el aspecto cultural que, además de ser determinante en el proceso salud-enfermedad, permite un mayor acercamiento a la realidad e imaginarios de la mujer durante la fase de puerperio. como referente teórico para este estudio se tuvo en cuenta los conceptos de leininger (1) en su teoría de la diversidad y universalidad del cuidado. desde este enfoque, los cuidados culturales toman en consideración la totalidad de la vida humana y su existencia a lo largo del tiempo, incluyendo la estructura social, visión del mundo, valores culturales, contextos ambientales, expresiones lingüísticas y los sistemas de cuidado popular y profesional. el modelo del sol naciente, propuesto por leininger (2), permitió realizar el contraste entre las dimensiones socioculturales que influyen en el significado que le asigna la madre a las prácticas que realiza durante el puerperio. este modelo destaca la importancia de identificar las influencias que, sobre el cuidado y la cultura, ejercen algunos factores como el educativo y económico, las creencias y los estilos de vida, así como factores tecnológicos, sociales y de parentesco, políticos, religiosos y filosóficos. para el estudio se adoptó el concepto de significado propuesto por leininger, el cual define como el conocimiento que se obtiene de los seres humanos en su contexto cultural y que permea el significado de cuidado a partir de los valores, creencias y prácticas con respecto a sí mismas, cuidado de sí y con respecto a otros (2). otros estudios (3, 4) también han abordado los significados, prácticas de cuidado y creencias de tipo cultural durante el puerperio en diferentes contextos. los resultados evidencian la universalidad y diversidad en el cuidado en torno al puerperio; refiriéndose a la lactancia materna, el equilibrio calor y frío, la alimentación, el día cuarenta y el reposo y protección del recién nacido contra malas energías. a pesar de estas semejanzas, se reconoce cómo cada cultura tiene creencias propias las cuales diferencian el significado que se tiene en torno al cuidado de la madre y el recién nacido durante la fase del puerperio. dicho esto, el objetivo del presente trabajo fue describir el significado que le asigna la madre al cuidado cultural de ella misma y su recién nacido durante el puerperio, a partir de sus prácticas y creencias. método la investigación se abordó desde un enfoque cualitativo etnográfico el cual aplicó los elementos básicos de la etnoenfermería (1). este método proporciona un marco teórico para estudiar los significados, los patrones y las experiencias de un grupo cultural determinado. se centra en la persona y no en el investigador, en el descubrimiento de los significados de cuidado según la cultura y la influencia del contexto, y en cómo las personas ven el mundo, incluyendo los diferentes significados que le dan a este. también se relaciona con el descubrimiento y el hallazgo más que con la sola verificación o comprobación. como técnicas de investigación se utilizaron la entrevista abierta a profundidad, el diario de campo y la observación participante. en el estudio participaron ocho mujeres puérperas (informantes clave) que fueron atendidas por parto normal en un hospital de tercer nivel de la ciudad de tunja, departamento de boyacá, colombia. se realizaron 24 entrevistas con un promedio por caso de dos a tres entrevistas. las participantes presentaron postparto normal, sin ninguna complicación tanto en la madre como en el recién nacido. las mujeres nacieron en el departamento de boyacá, y residían en la ciudad de tunja, en la zona urbana y rural, de cualquier edad cronológica, primíparas o multíparas. se les informó sobre el estudio y, después de solicitarles su participación voluntaria previo consentimiento informado, se programaron las visitas para la realización de las entrevistas. durante todo el proceso investigativo se garantizaron los principios éticos de respeto, autonomía, beneficencia, veracidad, fidelidad y justicia. 10 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 la muestra fue de tipo teórico y se dio por la saturación de la información suministrada por las puérperas participantes. igualmente se tuvieron en cuenta los principios de pertinencia, adecuación, conveniencia, oportunidad y disponibilidad (2). en cuanto a la pertinencia, se seleccionaron las personas que mejor poseían el conocimiento que se buscaba obtener, es decir, mujeres durante el puerperio que obviamente conocían la experiencia del mismo. respecto a la adecuación, se hizo por medio de la obtención de la mayor y mejor información, lo cual se consiguió por saturación teórica. el principio de conveniencia se satisfizo realizando las entrevistas en el contexto natural del puerperio, como por ejemplo el hogar de cada una de las participantes, lo que permitió, además de identificar el contexto y cultura de la puérpera, facilitar la recolección de la información. la oportunidad y disponibilidad se cumplieron tomando como periodo de inicio, para la recolección de datos, el puerperio mediato; es decir a partir del décimo día, lo que facilitó una mayor disposición y disponibilidad por parte de la puérpera, pues a partir de este día la mujer se encuentra en una fase dependiente – independiente. esto permitió una mayor colaboración por parte de las mujeres para la recolección de los datos. la edad de las participantes osciló entre los 19 y 33 años. el nivel educativo encontrado fue: dos informantes clave con nivel de escolaridad primaria, tres con bachillerato, una que se encontraba cursando bachillerato y dos más con nivel técnico de educación. seis de las participantes son amas de casa, y algunas comparten este oficio con la atención de tienda de víveres, administrado por ellas mismas; una de las participantes se dedica a terminar sus estudios de bachillerato y la otra tiene un trabajo formal como auxiliar de odontología. de las ocho mujeres, siete fueron del área urbana y una del área rural. las informantes clave han tenido entre uno y seis embarazos. cinco de las participantes fueron primigestantes y tres fueron multigestantes. la primera entrevista se realizó entre el día 10 al 12 posterior al parto, teniendo en cuenta la mencionada etapa dependiente-independiente del postparto (5). también hicieron parte de este estudio cuatro informantes generales y, aunque mostraron un conocimiento parcial sobre el dominio de investigación, compartieron visiones y puntos de vista culturales relevantes. dentro de este grupo de informantes participaron dos madres de las puérperas participantes, puesto que son ellas las que asistieron a las madres y dieron a conocer muchas de las prácticas de cuidado en torno al puerperio. así mismo, se seleccionaron dos profesionales con experiencia en la atención a la mujer durante el puerperio, (responsables de dar cuidado desde la práctica profesional), con el objeto de identificar el conocimiento cultural que se tenía en torno a prácticas encontradas en las informantes. resultados surgieron cinco temas centrales, en los que se refleja el significado de los cuidados que realiza la puérpera a partir de las prácticas y creencias durante el puerperio. a continuación se presentan los temas con cada uno de los patrones recurrentes hallados en la investigación: tema 1. el poder secreto de las plantas durante el postparto se ha documentado el amplio uso de plantas medicinales para diferentes fines relacionados con el cuidado de la madre y el recién nacido (6). en boyacá, la mujer en etapa de puerperio tiene diversas creencias en cuanto al uso de las plantas medicinales, y es así como en este periodo las utiliza en abundancia. por otro lado, la medicina popular tradicional presenta una gran difusión en este departamento, que se relaciona con el curanderismo y el yerbaterismo y, que a su vez, tienen hondas raíces indígenas y españolas (7). una de las características en el uso de estas plantas es que este sucede por tradición o porque ha sido enseñado de generación en generación, desconociendo muchas veces el efecto específico de estas. en este tema se identificaron cuatro patrones recurrentes en donde se identifica el uso que se le da a estas plantas durante el periodo de puerperio: uno es en el baño del recién nacido, con toronjil, manzanilla y hierbabuena. otro es para aumentar la producción de leche, recurriendo al hinojo y la canela. por medio de infusiones, estas plantas también se utilizan para la limpieza y sanación de los senos y puntos de la episiorrafia. finalmente, se encontró cómo el poleo es utilizado para sacar el frío tanto de la puérpera como del neonato, ya sea en infusión para el recién nacido o para la madre mediante el uso externo, esto es, por medio de baños corporales. para las informantes clave el baño del recién nacido con plantas medicinales es una práctica importante, pues además de ser parte de la higiene del bebé, estas les provee descanso, permite el buen dormir, los protege de las malas energías y saca el calor 11 significados durante el puerperio: a partir de prácticas y creencias culturales l brigitte m. prieto b., carmen h. ruiz producido por la exposición al sol, evitando así enfermedades en el recién nacido. por estas razones las madres utilizan plantas como el hinojo, el toronjil, la manzanilla y la hierbabuena, siendo el hinojo la de mayor uso. así mismo, se considera que la leche de vaca tiene propiedades benéficas para el bebé, y es por ello que se acostumbra a usar una copita de leche mezclada con las plantas medicinales en el agua del baño. el uso de la leche se extiende durante los primeros días, después se hace el baño con plantas únicamente. así lo expresa una de las informantes: “la estoy bañando con agüita de hinojo y manzanilla, mi mami me dice que eso le ayuda para que ellos duerman más y se relajen”. i1e1p59 de otro lado, para las puérperas es esencial la producción abundante de leche materna para garantizar una alimentación efectiva para el recién nacido. para tal fin usan las infusiones de plantas mezcladas con leche de vaca. así lo refiere una de las informantes clave: “se hace el agua de panela normal con papayuela o con hinojo y después se hierve la leche y se revuelven los dos para que la leche no se corte, esto ayuda a dar más leche para la bebé”. i1e1p22 otro uso que se les da a las plantas medicinales durante el puerperio es para el cuidado de los senos y los puntos de la episorrafia. las mujeres utilizan la caléndula, manzanilla y toronjil para el baño de los genitales y puntos de unión así como para desinflamar y limpiar el cuerpo (8). en el estudio de cardozo (9), se menciona que para el aseo genital las adolescentes utilizan agua de hierbas como la caléndula y la manzanilla, debido a que conocen sus propiedades antiinflamatorias y cicatrizantes. “yo me bañaba con agua de caléndula cada vez que entraba al baño, si entraba diez veces al baño, diez veces me bañaba, baños de asiento”. i5e2p4 las plantas medicinales también son utilizadas para sacar el frío tanto del cuerpo de la de la madre como del recién nacido: pues de vez en cuando le doy una o dos cucharaditas de agüita de poleo, y sí he notado que eso le expulsa ese frío, se le nota porque la popis huele más a feo y es como más sueltica, entonces está como resfriadita. sí, he notado que le ha ayudado un poquito, y es que le sonaba mucho la barriguita. i1e2p25 tema 2. el peligro de la recaída en este tema se destacan dos patrones recurrentes: evitar la recaída y las manifestaciones que presenta esta recaída. las puérperas del estudio identifican la recaída como un estado peor que el mismo parto. para evitarla ellas mantienen reposo durante los primeros quince días de la dieta y eluden la realización de actividades como planchar, lavar, trapear, barrer. la recaída tiene diferentes manifestaciones, por ejemplo sobreparto, fiebre inexplicable, desmayos, hemorragias, cólicos, dolor de huesos, y dolor de cabeza y espalda. algunas participantes expresaron que otra de las manifestaciones es “que todo les fastidia”. también mencionaron que de no guardar el reposo requerido pueden aparecer dolores de cabeza, dolor de estómago y sangrados vaginales abundantes, lo cual está relacionado con los síntomas de la recaída. así lo expresan: permanezco acostada, me abrigo y me protejo del sol para no sufrir una recaída y me toque ingresar al hospital por no cuidarse uno”. “uno por ejemplo no puede estar parado le dan como desmayos, así con dolor de cabeza. i4e1p14 i4e3p3 de acuerdo con pérez (10), la denominada recaída correspondería a lo que se llama puerperio patológico y está constituido por diversas afecciones que pueden complicar el postparto, tales como hemorragias, fiebres y malestar general. otras veces esta recaída es por no respetar ciertas reglas sobre el parto y el puerperio. “la recaída es porque las madres son descuidadas: lavarse la cabeza, por ejemplo, solo hacerse después de cuarenta días” (10). son diversas las manifestaciones que produce la recaída, algunas informantes lo relacionaron con aparición de hemorragias y dolor de cabeza, y otras refieren entuertos demasiado fuertes como las contracciones del parto. varias manifiestan fiebre inexplicable o la presencia de desmayos. no se tiene una definición clara de las manifestaciones propias de la recaída; sin embargo todas coinciden en realizar diferentes prácticas de cuidado para evitarla. por ejemplo: “la recaída son desmayos, yo en el embarazo anterior en la camilla me desmayé, entonces me da cosa salir al frío, al sol, entonces mejor se cuida uno”. i4e3p3 12 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 gavilán (11) enuncia algunas manifestaciones de la recaída las cuales se caracterizan por la presencia de fiebre y subida de presión, que puede hacer delirar a la persona. la recaída también está relacionada con el concepto de sobreparto el cual produce mucha aprensión entre las mujeres; se manifiesta con dolores de cabeza, espalda, sangramientos o dolores menstruales, y que pueden aparecer años después de producido el parto. tema 3. descubriendo el mundo de su hijo para la madre, descubrir el mundo de su hijo se convierte en un aprendizaje continuo tanto para ella en su nuevo rol como para su hijo, el cual inicia una travesía por un mundo desconocido y lleno de vivencias nuevas. en el estudio se identificaron dos patrones: acercarse al cuidado de su hijo y la protección hacia su hijo. las participantes experimentaron diferentes inquietudes cuando empezaron su nuevo rol dentro del puerperio, cuando se acercaron por vez primera a ese nuevo tipo de cuidado. dentro de este patrón se encontraron los siguientes códigos: no conoce las causas del llanto, expone solamente los pies y la cara del recién nacido al sol, desconoce por qué el bebé rechaza la leche materna, faja y aprieta el ombligo, duda de cómo cuidar los cólicos del recién nacido o no bañarlo. otro de los cuidados que se debe brindar al recién nacido durante el puerperio es el del cordón umbilical. este procedimiento está envuelto en diversas creencias, como por ejemplo fajarlo, apretar el ombligo para evitar que se salga, colocarle botones o cubrirlo durante el baño por miedo a que este se moje y se pueda lesionar. esto demuestra que la madre provee todos los cuidados para protegerlo y así evitar cualquier daño. el siguiente ejemplo así lo expresa: con un botón y la faja para que no les quede el ombligo salido, se le coloca un botón grande en el ombligo y un trapito se le amarra, para que no les quede el ombligo así feíto por fuera i2e1p49. por otro lado, las informantes clave declararon que dentro de las situaciones que les generaron angustia y estrés está el desconocer el llanto del recién nacido. esta angustia se refleja aún más en las mujeres primerizas, pues experimentan miedos y diversas dudas en su nuevo rol. ante el desconocimiento de las causas, ellas se sienten impotentes y no saben cómo actuar frente a determinadas manifestaciones del recién nacido, y esto hace que la madre llore y se preocupe. munévar y muñoz identificaron cómo las emociones que experimenta la madre son la expresión de un organismo vivo frente a los cambios de su propia esfera interior y de los factores del entorno, y que se manifiestan de diferentes maneras, pero que además si no puede cumplir con las necesidades del hijo en forma crónica o aguda, entra en conflicto (12). entregarle el recién nacido al esposo o a la madre de la puérpera es un mecanismo para reducir la angustia que le produce a la mujer el desconocimiento las manifestaciones de llanto del hijo: “cuando llora la bebé me angustia porque no sé si es que le duele la barriguita, no sé si es hambre, no sé si es sueño, no sé, entonces me dan nervios, me estreso” i1e3p8. en cuanto a la exposición al sol del recién nacido se destaca el desconocimiento por parte de la puérpera de la forma adecuada en que debe hacerlo. ellas manifiestan temor a exponer todo el cuerpo del bebé, algunas lo colocan con ropa liviana y otras solamente permiten el sol en la cara y pies, por temor al enfriamiento del bebé o afectar la cicatrización del ombligo. una de las informantes considera que el sol es benéfico porque evita que el niño se amarille; sin embargo realiza baños con plantas medicinales al recién nacido para “sacarle” el sol y así evitar el daño de éste. con respecto a este tema las madres refieren: pues así, no tan arropada, solo con la ropita que tiene, que no esté haciendo mucho, pues dicen que de ocho a diez de la mañana es el sol que uno tiene que darles, pero la dejo así, con ropita y eso i3e1p44. en el estudio de bohórquez (13), se encontraron lactantes con ictericia debido a al uso inadecuado de las técnica para realizar solterapia. este cuidado es esencial durante el puerperio pues la ictericia es causa frecuente de hospitalización en neonatos. de otra parte, las informantes claves del estudio realizaron diferentes prácticas respecto a la protección del recién nacido, específicamente para librarlo de diferentes riesgos en su salud producto de las “malas miradas” de personas que tienen “mala energía”. esta creencia es bastante conocida y respetada por un gran número de informantes del estudio quienes refieren que esto ya hace parte de la cultura y que la mayoría de personas la conocen. una de las informantes comentó: “que hay que com13 significados durante el puerperio: a partir de prácticas y creencias culturales l brigitte m. prieto b., carmen h. ruiz prarle una manilla de yo no sé qué cosas, para lo mismo para que no lo vayan a entecar, que para el mal de ojo que dicen por ahí las abuelitas” i1e1p63. para proteger al neonato de ser “entecado” las mujeres utilizan diferentes amuletos o “contras”. estos amuletos, como los corozos, son regalados por la familia de la puérpera para la protección del bebé y son usados en las manos o en los pies. en efecto, la protección contra la “enfermedad del mal de ojo” se deriva de los conceptos de áfrica occidental sobre el “bloqueo” por medio de objetos los cuales obstruyen los pasajes por donde el mal puede fluir (14). tema 4. el cuidado de sí misma este es uno de principales los aspectos durante el puerperio, pues la madre practica diferentes cuidados que le permitirán conservar su salud tanto en la actualidad como en el futuro. en este tema se encuentran cuatro patrones recurrentes: la protección del frío y del calor, vivencias con la lactancia, ajustar el cuerpo, y cuidados en el día cuarenta. en primer lugar, el equilibrio calor y frío tiene un enorme significado durante el puerperio. en las culturas orientales se piensa que la sangre es caliente pero después del parto se pasa a un estado frío (14). las informantes del estudio consideran que la exposición al frío por diferentes medios puede ocasionarles problemas de salud durante la fase del postparto y otras consecuencias futuras. “porque si uno sale al frío le duele más el estómago no sé si es por el frío o porque uno lo cree” i2e2p11. concuerda esta creencia con la mujer inga3 pues esta no debe comer alimentos que se consideran fríos durante el embarazo y postparto porque en la vejez estos descuidos serán la causa de las enfermedades (15). de hecho las informantes de este estudio también se protegen del frío, pues consideran que exponerse a éste puede afectar al recién nacido, ocasionándole cólicos o resfríos. al respecto, ellas mencionan: “pues por ejemplo uno cuando hace mucho frío y empieza a dolerle a uno el estómago entonces uno piensa que es lo mismo para la bebé” i6e2p2. 3 la comunidad inga es una de las más representativas del país; se establecieron en el territorio colombiano desde antes de la llegada de los españoles. viven al suroccidente de colombia en el valle de sibundoy a una altura de 2000 msnm. estudios realizados en colombia (16) evidencian cómo el equilibrio entre frío y calor está en diferentes culturas, considerándose como uno de los cuidados esenciales que tiene la mujer durante los primeros días de postparto. frente a la lactancia materna existen muchas creencias y prácticas que influyen en el significado de la misma. la experiencia con la lactancia materna es diferente para cada mujer, y está influenciada por la paridad, pues para la primeriza es un evento muy doloroso y traumático, diferente al experimentado por la mujer que ya ha tenido la experiencia de amamantamiento. así lo narran: “la lactancia puedo decir que fue lo más duro por los senos porque se me abrieron, de resto no, no he tenido como ese shock no” i1e1p81. al respecto talayero (17), describe cómo las cifras de incidencia y duración de lactancia materna tienen significativamente que ver con factores como la edad, la paridad, el nivel de educación, el grupo étnico, el trabajo de la madre, y el nivel sociocultural y de ingresos. por otra parte, para las mujeres puérperas es esencial recuperar la figura corporal que tenían antes de la gestación, y por esto muchas realizan prácticas de cuidado dirigidas a este fin, como por ejemplo “mandarse a sobar la barriga”4. esta práctica es muy frecuente en el periodo postparto, pues las mujeres consideran que además de ayudar a recuperar la figura anterior evita que el estómago o el útero queden sueltos. volver a recuperar el aspecto corporal anterior al parto es un motivo para tomar la decisión de realizar esta práctica; pero también la madre y la familia de la puérpera influyen en esta decisión, pues culturalmente es una práctica antigua y hace parte de la recuperación adecuada del puerperio. para algunas de las informantes el día cuarenta de la dieta es especial y se considera el día clave del cuidado, pues de los cuidados realizados durante este día dependerán muchos de los efectos de la salud en el futuro. este día es tan importante que incluso se considera más importante que todo el cuidado realizado durante en los días anteriores. estudios como los de parada (18) describen cómo en el día cuarenta la mujer se debe resguardar 4 sobar: práctica realizada durante el puerperio la cual consiste en realizar masaje en el estómago y posteriormente apretarlo con sabanas durante tres días. tiene por objetivo volver a la posición inicial de la matriz. 14 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 y realizar ciertas prácticas de cuidado; por ejemplo permanecer todo el día en la cama y tranquila, no salir al frío, realizar baños corporales de siete hierbas y consumir caldos de gallina. “el día 40 me estuve con mi bebé todo el día en la cama. pues dicen que es importante para que uno después no le dé una recaída y eso” i3e2p36. tema 5. los alimentos protectores alrededor de la alimentación también se genera una serie de creencias y prácticas de cuidados especiales, según el contexto cultural. herrera (19), en su estudio realizado con comadronas, identificó la importancia que estas le dan a la alimentación de la puérpera pues se considera que esto contribuye a recuperar la sangre perdida durante el parto, recuperar energías, y garantizar el equilibrio calor-frío. dentro de los alimentos que prefieren las puérperas del estudio se encuentra el pollo campesino, que es considerado benéfico para la recuperación ya que carece de sustancias químicas las cuales puede afectar negativamente a la puérpera y al recién nacido. la gallina es un alimento muy preciado en varias culturas, es considerado importante pues les permite recuperar las fuerzas perdidas durante el embarazo y el parto, y hace que la leche sea de mejor calidad (9) (19). “dicen que el pollo campesino es primordial para las mamitas recién que dan a luz a sus hijos, entonces mi mami me mandó traer un pollo y todos los días me hace calditos o sopitas con ese pollito, o las cabezas de pescado o así. pues que eso es como la fuerza que le da a uno cuando después de que tiene el bebé que uno queda muy débil”. i1e1p1. durante el puerperio se introducen otros alimentos considerados esenciales para los primeros días. como las infusiones con plantas medicinales, el consumo de chocolate caliente con ruda y huevos tibios con ruda, pues se considera que éstos evitan la anemia por la sangre perdida en el parto. este hallazgo concuerda con el estudio realizado por acosta con mujeres en la ciudad de cali, quienes toman chocolate caliente para sudar y sacar todo el frío recogido durante el nacimiento del bebé. este procedimiento dura los cuarenta días de la dieta (3). la informante del presente estudio describe así la forma de preparación: pues el chocolate es sin leche, es apenas el agua, las pastillas de chocolate, y las hojitas de ruda que van dentro del chocolate, y pues uno se lo tiene que tomar así como dicen, a sorbo y sorbo, o sea bien caliente; y pues uno suda, el chocolate lo hace a uno sudar harto, y pues mi mami dice que con eso una retoma otra vez fuerzas y la ruda ayuda para que, como uno está sangrando, ayuda para que la sangre se limpie eso que a veces le queda a uno, residuos de por dentro i4e3p6. en efecto, la cultura ejerce una gran influencia en las creencias que giran alrededor de la alimentación durante el puerperio, pues si bien hay muchas creencias universales en culturas hispanas y colombianas, existen otras en las cuales la diversidad es característica. algunos alimentos son considerados irritantes por la puérpera y por tanto suprimidos de la dieta. según las informantes clave, estos alimentos son aquellos que pueden retardar la cicatrización e infectar los puntos de la episiorrafia, demorar la caída del cordón umbilical e influir en la aparición de cólicos en el recién nacido. una de las informantes del estudio suspendió el consumo de todos los alimentos de color amarillo, pues ella lo relacionó con la aparición del tinte amarillo en sus hijos. así lo expresa: “yo digo, si ellos están reamarillos y uno les da más zanahoria, pueda hacer que no sea como tan bueno, digamos en lo amarillito, y dicen por lo menos que la criolla es irritante para los puntos” i8e1p17. discusión desde antaño las prácticas de cuidado en torno al puerperio han tenido una influencia cultural significativa. así mismo, el cuidador, representado por el esposo, madre, abuela o suegra, ejerce una gran influencia en este cuidado. el grupo de cuidado materno perinatal de la universidad nacional de colombia ha realizado estudios los cuales se han acercado al componente cultural en varias regiones del país, se han identificado aspectos del cuidado universal como la importancia del equilibrio frío-calor, las restricciones en la alimentación o la importancia del reposo. la diversidad en el cuidado se ve representada en cada una de las regiones en donde se han llevado a cabo las investigaciones. en boyacá, los significados que la mujer le asigna al cuidado de sí misma y de su hijo recién nacido a partir de sus prácticas y 15 significados durante el puerperio: a partir de prácticas y creencias culturales l brigitte m. prieto b., carmen h. ruiz creencias son diversos, y están determinados por múltiples factores culturales. investigaciones en torno a las creencias durante el puerperio (3, 4, 9, 18) coinciden en afirmar que la cultura es un factor determinante en muchos de los cuidados que la madre realiza para sí misma y para su recién nacido. aunque algunas de estas prácticas son benéficas y representan una tradición alrededor de una cultura la cual debe respetarse, otras representan un riesgo para el neonato y la madre. de acuerdo con leininger, identificar las prácticas que pueden preservarse, negociarse o reestructurarse es indispensable en la búsqueda un cuidado culturalmente congruente. los hallazgos de esta investigación reflejan la necesidad de establecer espacios de diálogo que permitan construir una mediación cultural entre el personal de salud y el sujeto de cuidado, el cual debe convertirse en sujeto activo y no solo en receptor de una información que en ocasiones pueda alterar el contexto cultural. precisamente esa diversidad cultural hace indispensable conocer, compartir e identificar las ventajas de este conocimiento emic. ¿cómo garantizar entonces un cuidado culturalmente coherente y sensible, en un medio en el cual se valora más el conocimiento científico que cultural? ¿cómo fortalecer la importancia del conocimiento etic, y a partir de este generar estrategias de cuidado que faciliten un cuidado en el que se respete no solo la cultura sino las tradiciones familiares las cuales forman parte del paciente? en efecto, uno de los aspectos importantes para garantizar un cuidado congruente con la cultura es conocerla y reflexionar sobre la influencia que esta ejerce en el cuidado. igualmente, poner en práctica los modos de acción que describe leininger en su teoría (preservar, negociar y reestructurar), permitirá establecer un diálogo de saberes que conduzca, de manera sensible, a un cuidado culturalmente congruente. conclusiones el significado que le asigna la mujer a su cuidado durante el puerperio es diverso y está influenciado en gran medida por el componente cultural, pues las prácticas y creencias emergen de esta dimensión. los factores socioculturales que determinan en forma significativa este cuidado corresponden a los valores, creencias y estilos de vida; así como los factores sociales y de parentesco. cada uno de ellos permea los comportamientos de la puérpera en torno al cuidado de sí misma y de su hijo, y en una menor proporción se encuentran los factores religiosos, políticos y económicos. la lactancia es un punto crítico durante el puerperio, el cual requiere apoyo tanto de la familia como del profesional de enfermería, debido a las múltiples dificultades que se presentan en los primeros días de lactancia. el apoyo social y familiar es esencial en este proceso, pues para la madre, especialmente para la mujer primeriza, es una experiencia dolorosa; y se constituye en un proceso aprendizaje tanto para ella como para su hijo, por esto es vital el apoyo de sus cuidadores. agradecimientos los autores agradecen al hospital san rafael de tunja, a los informates clave y generales del estudio. este trabajo estuvo enmarcado en los proyectos del grupo de investigación en cuidado materno-perinatal y contó con el apoyo financiero de la división de investigación bogotá (dib) de la universidad nacional de colombia. 16 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 referencias 1. leininger m, mcfarland m. culture care diversity and universality. a worldwide nursing theory. 2nd. ed. new york: jones and barlett publishers; 2006. 2. sagar pl. madeleine leininger´s theory of culture care diversity and universality. in: transcultural nursing theory and models education, practice and administration. 1ª ed. new york: springer; 2012. p. 2-13. 3. cajiao ge, acosta m, alegria m, llano am, valencia c, zuluaga p. creencias populares sobre el autocuidado durante el puerperio, en las instituciones de salud de nivel 1. colombia médica 1997; 28 (1): 42-50. 4. medin a, mayca j. creencias y costumbres relacionadas con el embarazo, parto y puerperio en comunidades nativas awajun y wampis. rev. perú med exp salud pública. 2006; 23 (1): 22-32. 5. olds s. enfermería materno-infantil. un concepto integral familiar. 4a. ed. méxico: interamericana mcgraw-hill; 1995. 6. lópez l, cataño n, lópez h, velásquez v. diversidad cultural de sanadores tradicionales afrocolombianas. preservación y conciliación de saberes. aquichan 2011; 11 (3): 287-304. 7. ocampo j. el pueblo boyacense y su folclor. tunja: corporación de promoción cultural de boyacá; 1997. 8. laza c, puerto mi. cuidados genéricos para restablecer el equilibrio durante el puerperio. revista cubana de enfermería 2011; 27 (1): 88-97. 9. cardozo s. adolescentes en puerperio y sus prácticas de cuidado. av. enferm. 2009; 27 (2): 82-91. 10. pérez a. la medicina tradicional del noroeste argentino: historia y presente. 1ª ed. buenos aires: serie antropológica ediciones del sol; 2005. 11. gavilán v, madariaga c, morales n, parra n, arratia a, andrade r, vigueras p. conocimiento y prácticas en salud; patrimonio cultural de los pueblos originarios tarapaqueños. 1ª. ed. chile: iquique; 2009. 12. lazetic b, sudakov k, drapsin m, karaba d. emotional stress as an illness-related factor. medicinski pregled 2003; 56 (7-8): 341-345. citado por: munévar ry, muñoz l. la madre dice: el dolor de mi bebé es mi dolor. av. enferm. 2010; 28: 73-82. 13. bohórquez o, santana a, pérez l. seguimiento de enfermería a la madre y al recién nacido durante el puerperio: traspasando las barreras hospitalarias. av.enferm. 2009; 27 (2): 139-149. 14. soo-king y. postpartum, beliefs and practices among non-western cultures. the american journal of maternal/child nursing 2003; 28 (2): 79-80. 15. giraldo tc. medicina tradicional de la mujer inga. rev. acad. colomb. cienc. 2000; 24 (90): 5-23. 16. argote la, bejarano nl, ruiz ch, muñoz l, vásquez ml. transitando la adolescente por el puerperio. amenazas, peligros y acciones de protección durante la dieta. aquichan 2004; 4 (1):18-29. 17. talayero j. aspectos históricos de la alimentación al seno materno. lactancia materna. guía para profesionales. españa, 2004. [consultado el 22 de mayo de 2012]. disponible en: http://www.ministeriodesalud.go.cr/gestores_en_salud/ lactancia/cnlm_guia_de_lactancia_materna_aep.pdf 18. parada da. cuidado de las puérperas en el siglo xxi. av. enferm. 2006; 26( 2): 6-12 19. herrera r. prácticas de cuidado que brindan las comadronas tradicionales durante el parto y postparto [tesis de maestría]. bogotá d.c.: universidad nacional de colombia, 2004. 32 41 consentimiento informado.indd 32 aquichan issn 1657-5997 paola carrasco-aldunate1 miriam rubio-acuña2 daniela fuentes-olavarría3 consentimiento informado: un pilar de la investigación clínica 1 enfermera-matrona, magíster en educación. pontificia universidad católica de chile, chile. dcarrasa@uc.cl 2 enfermera con diploma académico en el adulto mayor. pontificia universidad católica de chile, chile. merubioa@uc.cl 3 enfermera-matrona, pontificia universidad católica de chile, chile. dfuenteo@uc.cl recibido: 3 de enero de 2012 aceptado: 12 de marzo de 2012 resumen objetivo: dar a conocer los principales aspectos del concentimiento informado (ci) en la investigación en salud a través de una revisión de literatura en bases de datos. método: se analizaron los elementos de su origen y evolución, los principios éticos involucrados (autonomía, beneficencia y justicia), elementos característicos claves como divulgación, comprensión, capacidad de consentir o decidir y voluntariedad. resultados: en enfermería y otras disciplinas, la aplicación del ci no se encuentra exenta de conflictos tales como validez del proceso a través del tiempo, capacidad de comprender la información entregada, coerción con minorías, miedo a los efectos de la intervención o el procedimiento, y desconfianza respecto a lo que realmente se hará. conclusión: se concluye que contar con la manifestación expresa de una persona a participar libre y voluntariamente de una investigación, y conocer las condiciones, los beneficios y los riesgos que esta involucra; garantiza la completa consideración de los principios éticos en el cuidado holístico de las personas. palabras clave consentimiento informado, ética, enfermería. (fuente: decs, bireme). informed consent: a cornerstone of clinical research abstract objective: the purpose of the study was to shed light on the main aspects of informed consent (ic) in health research, through a literature review of databases. method: the elements of its origin and development were analyzed, along with the ethical principles involved (autonomy, benefit and fairness), the key characteristic essentials such as dissemination, understanding, capacity to consent or decide, and voluntariness. results: in nursing and other disciplines, the application of ic is not exempt from conflicts, such as those involving the validity of the process over the course of time, the capacity to understand the information that is given, coercion with minorities, fear of año 12 vol. 12 nº 1 chía, colombia abril 2012 l 32-41 33 consentimiento informado: un pilar de la investigación clínica l paola carrasco-aldunate, miriam rubio-acuña, daniela fuentes-olavarría the effects of intervention or the procedure, and mistrust or misgivings about what really will be done. conclusion: having the expressed manifestation of a person’s willingness to participate freely and voluntarily in a study, with knowledge of the conditions, benefits and risks doing so entails, guarantees full consideration of the ethical principles involved in the holistic care of individuals. key words informed consent, ethics, nursing (source: soscdes, bireme). consentimento informado: um pilar da pesquisa clínica resumo objetivo: dar a conhecer os principais aspectos do consentimento informado (ci) na pesquisa em saúde por meio de uma revisão de literatura em bases de dados. método: analisaram-se os elementos de sua origem e evolução, os princípios éticos envolvidos (autonomia, beneficência e justiça), elementos característicos-chave como divulgação, compreensão, capacidade de consentir ou decidir e voluntariedade. resultados: na enfermagem e em outras disciplinas, a aplicação do ci não se encontra isenta de conflitos, tais como validade do processo através do tempo, capacidade de compreender a informação entregue, coerção com minorias, medo dos efeitos da intervenção ou do procedimento e desconfiança a respeito do que realmente se fará. conclusão: conclui-se que contar com a manifestação expressa de uma pessoa em participar livre e voluntariamente de uma pesquisa, e conhecer as condições, os benefícios e os riscos que esta envolve; garantir a completa consideração dos princípios éticos no cuidado holístico das pessoas. palavras-chave consentimento informado, ética, enfermagem (fonte: decs, bireme). 34 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 introducción la investigación en salud —actividad que genera conocimiento y nuevos descubrimientos que benefician el quehacer de una disciplina— y la publicación de sus resultados involucra aspectos éticos indispensables de considerar. el consentimiento informado (ci) es la manifestación expresa de una persona a participar en estas actividades, aceptando libre y voluntariamente las condiciones, los beneficios y los riesgos que esta involucra. este es el resultado evolutivo del cambio cultural de la relación entre el investigador y la población investigada, del llamado al respeto a la autonomía y responsabilidad en las prácticas investigativas. el objetivo del presente trabajo es dar a conocer los principales aspectos del ci en investigación en salud. el propósito es incorporar en la práctica investigativa de enfermería las reflexiones en torno al ci. método se realizó una búsqueda en las bases de datos medline/pubmed, proquest y scielo entre los meses de agosto a noviembre de 2010. los términos de búsqueda fueron consentimiento informado, principios éticos e investigación en salud y sus homólogos en el idioma inglés. resultados el ci es un proceso que consiste en la manifestación expresa de una persona competente física, mental y moralmente para tomar la decisión de participar en un proceso que involucre decisiones en torno a su salud, en condiciones tales que sea capaz de comprender los riesgos, los beneficios, las consecuencias o los problemas que se puedan presentar (1). surge de la relación profesional de la salud-usuario, en la cual la persona expresa su voluntad y ejerce su libertad al aceptar o rechazar la inclusión en una investigación, un diagnóstico y un plan terapéutico, entre otros, propuesto por el profesional para actuar sobre su persona, posterior a la entrega de información suficiente sobre la naturaleza de los mismos, los riesgos y las alternativas que existan (2). la información debe ser brindada de manera comprensible y adecuada a las necesidades de la persona para poseer la certeza de que esta ha comprendido bien el mensaje (3, 4). involucra un acuerdo de tipo verbal o escrito mediante el cual la persona o el representante legal autoriza la intervención en salud con pleno conocimiento de la naturaleza de los procedimientos, beneficios y riesgos a los cuales se someterá, con la capacidad de libre elección y sin coerción alguna. en el contexto de una intervención terapéutica, el colegio médico americano plantea que el ci es la explicación a un paciente, atento y mentalmente competente, de la naturaleza de su enfermedad, así como del balance entre los efectos de la misma, y los riesgos y beneficios de los procedimientos terapéuticos recomendados (2, 3). en españa, el ci es considerado una ley básica de autonomía de los pacientes, como la conformidad libre, voluntaria y consciente manifestada en pleno uso de sus facultades después de recibir la información adecuada, para que tenga lugar una actuación que afecte su salud (2). alfaro menciona que el ci es una de las máximas manifestaciones del respeto a la autonomía del paciente, ya que no puede llevarse a cabo ninguna intervención terapéutica o de investigación si el usuario no ha prestado su consentimiento (2). intenta, además, devolver a la relación profesional de la salud-paciente el significado original de relación de confianza frente a la deshumanización de la medicina general. a partir de lo anteriormente mencionado se puede decir que el ci se aplica tanto a la intervención terapéutica como a la investigación en salud. origen del consentimiento informado el ci se modifica a lo largo de la historia en forma paralela a la evolución del concepto de autonomía individual. de acuerdo con ilfeld (5), distintos son los hechos históricos que marcan este desarrollo. la historia de la investigación biomédica está llena de hechos dolorosos donde los investigadores han olvidado que los sujetos de investigación poseen una dignidad única y, por tanto, merecen todo el respeto. por ejemplo, ya en la antigua grecia, roma y egipto, los médicos parecían estar indiferentes a tal noción, un ejemplo de esto es hipócrates, quien sugería proporcionar a sus pacientes solo la información necesaria para asegurar la cooperación de los mismos y no revelar nada de su condición futura o actual. del mismo modo, médicos en alejandría practicaban la vivisección en criminales condenados sin ningún tipo de precaución ni menos su autorización. 35 consentimiento informado: un pilar de la investigación clínica l paola carrasco-aldunate, miriam rubio-acuña, daniela fuentes-olavarría solo después de transcurrido el tiempo, en el año 1767, un tribunal inglés prohibió que los médicos practicaran investigaciones sin antes obtener el consentimiento de sus pacientes. esta prohibición se generó luego de que un cirujano y un boticario de la ciudad intencionalmente refracturaran las piernas de un paciente para realizar una prueba de investigación (5). existen reportes que a finales de 1800 en estados unidos los médicos limitaron la administración de tuberculina a los pacientes que entregaban su consentimiento a este tratamiento temprano de la tuberculosis. hacia 1900, un médico del ejército instó a voluntarios de su investigación a firmar por escrito “contratos” que describían los riesgos de participar en sus estudios, en los que confirmó a los mosquitos como vectores para la fiebre amarilla. ese mismo año, el gobierno alemán aprueba las primeras leyes que regulan la investigación médica a raíz de las consecuencias de los experimentos de albert neisser, científico que infectó con sífilis deliberadamente a sujetos sanos (6). por otro lado, ilfeld describe que en contraste con lo que ocurría en europa, durante la misma década el senado de estados unidos rechazó un proyecto de ley que habría obligado a los investigadores a explicar sus objetivos experimentales a los sujetos potenciales de estudio y a solicitar por escrito un ci. posteriormente, el parlamento de ese país determinó que “todos los seres humanos de edad adulta y en su sano juicio tienen derecho a determinar qué se hará con su propio cuerpo, y un cirujano que realiza una operación sin el consentimiento de su paciente comete un asalto” (5). un hecho singular de retroceso en los avances en la materia ocurre en el año 1902, cuando la asociación médica americana se niega a considerar la recomendación de “respaldar la importancia de obtener el consentimiento del paciente y la cooperación en la experimentación humana”, hecho que se debía a la creciente preocupación por la autonomía del ejercicio médico. no es hasta fines de la segunda guerra mundial que en este país la asociación de médicos establece las directrices para el consentimiento de sujetos de investigación (7). los avances en la materia también se hacen evidentes en europa, luego de la segunda guerra mundial, periodo en el que salen a la luz pública los experimentos médicos realizados con prisioneros de los campos de concentración a manos de médicos nazis, hecho que estimuló la formulación del código de nuremberg (1946), primer código ético reconocido internacionalmente para la realización de investigaciones con seres humanos, el cual hace énfasis en la autonomía de los sujetos y en la calificación del investigador (8). según urrutia, cuatro hechos marcaron la evolución del código de nüremberg y señalaron violaciones de los derechos de los sujetos de investigación. el primero de ellos fue el estudio realizado en 1956 en el colegio de willowbrook, ciudad de nueva york, en donde niños con retraso mental fueron inyectados con el virus de la hepatitis. el segundo, en 1963, en el hospital judío de enfermedades crónicas en la ciudad de nueva york, en el cual se inyectaron células cancerosas a pacientes hospitalizados esperando la respuesta inmune a la enfermedad. el tercero ocurrió durante la guerra fría en estados unidos, en el cual se expuso a un grupo de militares a un alto nivel de radiación tratando de estudiar los efectos de dicha exposición como una forma de prepararse para una posible guerra nuclear. el último es el estudio de sífilis realizado en la ciudad de tuskegee (1932 y 1972), en el cual se consideró investigar a un grupo de hombres afroamericanos que padecían sífilis y documentar los efectos de la enfermedad sin tratamiento a lo largo del tiempo. según la autora, los cuatro sucesos compartían la no preocupación acerca del real significado de los derechos que tienen los sujetos que participan en una investigación (9). el código de nuremberg incluye una definición de ci, y una lista de diez principios que establecen las condiciones que deben cumplirse para la investigación ética en humanos. estipula que un sujeto debe comprender la naturaleza, la duración y el propósito del experimento, el método y los medios por los que se va a realizar, todos los inconvenientes y riesgos razonablemente esperables, y los efectos que sobre su salud o personalidad podrían derivarse de la participación en el experimento (5). menciona además que el deber y la responsabilidad para determinar la calidad del consentimiento recaen sobre el individuo que inicia, dirige o participa en la investigación, y que ninguna prueba se debe llevar a cabo cuando a priori se cree que puede producir la muerte de pacientes (10). en el año 1953, el congreso de ee.uu. aprueba el proyecto de ley kefauver-harris, documento que relevó la importancia del ci de los sujetos involucrados en investigaciones relacionadas con drogas, hecho que en el año de 1964 da origen a la declaración de helsinki realizada por la asociación médica mundial. en esta 36 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 declaración se define como población vulnerable a los menores, presos, mujeres embarazadas, los fetos humanos, o los adultos física o mentalmente incapaces de dar su consentimiento, así como también a estudiantes de medicina, internos, residentes y becados por las relaciones potencialmente coercitivas entre investigador/profesor y estudiante (5). la declaración de helsinki plantea los principios para toda investigación médica. en el punto 11 refiere que “es deber del médico proteger la vida, la salud, la dignidad, la integridad, el derecho a la autodeterminación, la intimidad y la dignidad” del ser humano (11). además, esta declaración establece que en el campo de la investigación biomédica debe hacerse una distinción fundamental entre el estudio cuyo objetivo es esencialmente diagnóstico o terapéutico para el paciente, y aquel cuyo objetivo esencial es puramente científico y no representa un beneficio diagnóstico o terapéutico directo para la persona que participa en la investigación (12). esta declaración incluye tres secciones, la primera de ellas dedicada a abordar lo que significa la investigación en seres humanos, por qué es necesaria y la importancia de priorizar la salud de los participantes; la segunda discute los principios básicos para la investigación reafirmando el código de nüremberg, y la tercera discute el cuidado en salud asociado a la investigación (9). fundamental en la consolidación de la declaración fue el informe elaborado por beecher, quien publicó un artículo que describía más de veinte investigaciones no éticas realizadas dentro de los estados unidos, muchas de las cuales no obtuvieron el ci de los participantes antes del reclutamiento para la investigación (5). luego de la promulgación de la ley nacional de investigación de ee.uu. en 1974, que normó por escrito el uso del ci y estableció una comisión nacional para desarrollar los estándares éticos, en 1978 surge el informe belmont, pieza doctrinaria clave para la regulación ética de las investigaciones en salud. este reporte retoma las fuentes anteriores y enriquece la conceptualización acerca de la autonomía del sujeto en estudio, ofrece elementos de juicio para evaluar la validez del ci, y también profundiza en los aspectos referidos a la valoración de riesgos y beneficios (13). de acuerdo con gallardo y collado (8), el ci surge con la finalidad de dar cumplimiento a la autonomía y voluntariedad de los sujetos. principios éticos la investigación científica ha producido grandes beneficios sociales; sin embargo, ha planteado algunos dilemas éticos, los cuales motivaron la redacción del informe belmont (1978), documento que presenta por primera vez elementos que posteriormente se constituirían como los principios de la bioética. es una declaración de principios éticos básicos y directrices que ayudan a resolver los problemas éticos que acompañan la ejecución de investigaciones que incluyen sujetos humanos, en que la autonomía es entendida como el derecho del paciente a ser reconocido como persona libre y con capacidad de tomar sus propias decisiones (14). en este informe se identifican tres principios éticos, los cuales son abordados de manera amplia y están redactados a un nivel general, pretendiendo ayudar a científicos, sujetos, inspectores y personas interesadas a entender las consideraciones éticas inherentes a la investigación que incluya sujetos humanos. su objetivo es proporcionar un marco analítico que dirija la resolución de problemas éticos originados en este tipo de investigación (15). los principios éticos que son parte de un ci son el respeto a las personas (autonomía), la beneficencia y la justicia. el principio de respeto a las personas plantea la convicción de que los individuos deben ser tratados como agentes autónomos. aquellos que posean una autonomía disminuida tienen derecho a ser protegidos. se centra en que los mejores intereses del paciente son los que él mismo interprete, aunque estos difieran de los objetivos médicos. este principio se sustenta moralmente en el respeto de los profesionales de la salud hacia los valores y las creencias de los pacientes, quienes son considerados como agentes morales que pueden o no ser autónomos (15, 16). según acevedo, la autonomía se cumple cuando existe ausencia de control externo, intencionalidad y conocimiento. una persona autónoma es capaz de deliberar acerca de sus metas personales y de actuar en el sentido de tales deliberaciones (17). respetar la autonomía significa dar valor a las opiniones y elecciones de personas autónomas al mismo tiempo que se evita obstruir sus acciones, a menos que estas vayan claramente en menoscabo o perjuicio de otros. mostrar falta de respeto por un agente autónomo es repudiar las decisiones de esa persona, negar a un individuo la libertad de actuar según sus disposiciones o retener información necesaria cuando no existen razones apremiantes para ello (16). 37 consentimiento informado: un pilar de la investigación clínica l paola carrasco-aldunate, miriam rubio-acuña, daniela fuentes-olavarría es importante considerar que no todos los seres humanos son capaces de tomar decisiones propias. esta capacidad madura en el transcurso de la vida del individuo, como en el caso de los niños recién nacidos, preescolares, entre otros. en la adultez, este derecho se puede perder total o parcialmente debido a enfermedad, incapacidad mental o circunstancias que limitan su libertad. estos grupos de personas pueden requerir protección en lo que se refiere al respeto que merecen mientras esta condición se mantenga. algunos de ellos pueden requerir protección completa al punto de excluirlos de actividades que puedan lastimarlos; otras personas requieren escasa protección más allá de asegurarse de que participan en actividades por su propia voluntad y con conciencia de las posibles consecuencias adversas. la cantidad de protección suministrada debe depender del riesgo de daño y la probabilidad de beneficio, por lo que la decisión de que algún individuo carece de autonomía deberá evaluarse periódicamente (16). la beneficencia, segundo principio involucrado, es el acto de procurar el bienestar de un individuo. según mondragón et al., se entiende también como actos de bondad o caridad que van más allá de la estricta obligación (15). incluye el hecho de no hacer daño a otros, acrecentar al máximo los beneficios y disminuir los daños posibles. según acevedo, persigue maximizar los beneficios y minimizar los daños, por tanto los participantes en una investigación o sus representantes deben conocer los riesgos y los beneficios que lograrán con su participación en los ensayos clínicos (17). en el caso de la investigación científica, los miembros de la sociedad están obligados a reconocer los beneficios y riesgos a largo plazo que puedan resultar del desarrollo del conocimiento y de nuevos procedimientos médicos, psicoterapéuticos y sociales (15, 16). del principio anterior se deriva el de no maleficencia, que obliga moralmente al investigador a buscar los menores riesgos posibles para los sujetos de experimentación (17). la no maleficencia pretende no dañar al paciente y se traduce como una obligación a todos los involucrados y, por tanto, es anterior a cualquier tipo de información o consentimiento (15). la justicia, entendida como una distribución equitativa de bienes, se refiere al derecho que toda persona posee de ser beneficiada con los resultados del experimento en que participa, que dicha investigación se realice realmente en el grupo que se requiere investigar, y que solo se utilice una población vulnerable cuando en esta sean beneficiosas las consecuencias (17). una injusticia ocurre cuando un beneficio al que una persona tiene derecho se niega sin razón válida, cuando se impone una responsabilidad indebidamente o cuando a los iguales se les trata con desigualdad (16). características de un ci según cahana y hurts, un ci adecuado tanto en la investigación como en la atención clínica debe cumplir con diversos elementos como son la divulgación, la comprensión, la capacidad de decisión y la voluntariedad (18). en relación con la divulgación del ci, se puede decir que esta no siempre se realiza de manera masiva, ya que para algunos es una pérdida de tiempo (19), y el grado de información dada a los pacientes depende de quién sea el encargado de entregarla (18). la comprensión (literacidad), elemento que puede resultar difícil de evaluar, puede ser medida a través de la memoria (18), es decir, si la persona es capaz de recordar la información contenida en el ci. esta se puede ver limitada de acuerdo con la complejidad de la información, por lo que el lenguaje tanto verbal como escrito del ci debe ser comprensible para el sujeto en investigación, evitando tecnicismos (13). según pantoja, la comprensión de los pacientes y sujetos de investigación es a menudo deficiente. algunas de las razones podrían ser la falta de tiempo y el bajo entrenamiento médico para explicar la complejidad de la información (20). cahana y hurts mencionan que el mejoramiento de los formularios de ci no presenta un efecto claro en la comprensión (18). sin embargo, la mejora del proceso de transmisión del consentimiento, especialmente al dar más tiempo para entregar la información y hacer preguntas, parece útil. por otra parte, el consentimiento solo será verdaderamente informado si el sujeto ha recibido esa información en un lenguaje accesible para él, adaptado a su situación sociocultural, de tal forma que se garantice la comprensibilidad (20). kripalany, bengtzen, henderson y jacobson evaluaron el grado de comprensión del consentimiento a través de la devolución de la información entregada en el ci. solo el 39,8% de los sujetos de estudio entregó la información completa de todos aspectos que incluía el ci en una primera instancia de evaluación. los puntos del ci más difíciles de explicar fueron dos: la asignación al azar de los grupos de estudio (57,1%), y la denominación de las personas o 38 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 entidades que tendrían acceso a la información (68,6%). el autor concluyó que el grado de comprensión se relaciona directamente con la edad, el nivel de instrucción y la función cognitiva (medida por el puntaje en el test minimental) (21). el tercer elemento clave del ci es la capacidad de decisión o para consentir. solo los sujetos considerados como “competentes” tienen el derecho ético y legal de aceptar o negarse a participar en la investigación (13, 14), en caso contrario serán otras personas quienes tomen las decisiones por ellos, por ejemplo, si es menor de edad o no tiene capacidad para decidir, debe ser representado por sus padres o su representante legal (14). así, aun cuando su voluntad es subrogada por estos, se hace necesario que sean informados y consultada su opinión, respetando sus condiciones de desarrollo psíquico, competencia cognitiva y situación personal. la voluntariedad, último elemento y el más importante, debe ser un proceso libre, sin coerción ni manipulado (13, 20). será evaluado centrándose en la comprensión de que la participación es voluntaria. en relación con esto, la motivación de los pacientes por participar en investigación puede estar basada en la posibilidad de algún beneficio, altruismo, insuficiente información, comprensión errónea de la situación o pensar que el poner en duda su participación puede representar un posible problema posterior (18). por otra parte, respecto a la estructura y el contenido el ci debe incluir información en relación con los objetivos, riesgos y beneficios previsibles (2, 4). debe ser entregada en un lenguaje comprensible, claro y preciso, considerando las características biológicas y socioculturales, evitando terminología médica o explicando su significado (2). otros autores señalan que un ci debe estructurarse de la siguiente forma: título de la investigación (22). fecha del consentimiento (19, 22). invitación a participar. por ejemplo: antes de aceptar participar en este estudio, es importante que lea y comprenda las explicaciones de los procedimientos del estudio propuesto. la siguiente información describe el propósito, procedimientos, beneficios, incomodidades y riesgos asociados con este estudio. usted debe entender esta información antes de decidir si desea o no participar. esto se conoce como ci. por favor, pregunte al asistente de investigación para explicar cualquier cosa que usted no entiende. asegúrese de que todas sus preguntas han sido contestadas a su satisfacción antes de firmar este formulario de consentimiento (22). objetivo del estudio (19, 22, 23). metodología utilizada (19, 23). por ejemplo: si usted se ofrece voluntariamente para participar en este estudio, se le entrevistará en su idioma de preferencia (chino, inglés, portugués y español) en relación a su dieta, el ejercicio físico, hábitos de consumo, los patrones de tabaquismo, los niveles de estrés, ritmo cardiaco, presión arterial y el peso corporal. su nivel de colesterol se puede medir con una prueba de pinchazo en el dedo, lo que supondrá pincharse el dedo para extraer un poco de sangre. todo el procedimiento toma unos 30 minutos (22). tratamiento que puede serle administrado, haciendo referencia al placebo si es que se utilizará (19). fecha en que se llevará a cabo el estudio (19). beneficios derivados del estudio (19, 22, 23). incomodidades y riesgo derivados del estudio (número de visitas, pruebas complementarias a que se someterá) (19, 22, 23). posibles acontecimientos adversos (19). tratamientos alternativos disponibles (19). carácter voluntario de su participación, así como la posibilidad de retirarse del estudio en cualquier momento sin que ello altere la relación médico-paciente, ni se produzca perjuicio en su tratamiento (19, 22). personas que tendrán acceso a los datos y forma en que se mantendrá la confidencialidad (19). por ejemplo: “toda la información obtenida en este estudio es confidencial. no hay información de identificación en los cuestionarios y los formularios de consentimiento se almacenan por separado de los cuestionarios. ninguno de los nombres o datos de identificación serán utilizados en publicaciones o presentaciones” (22). modo de compensación económica y tratamiento en caso de daño o lesión por su participación en la investigación (19). nombre del investigador responsable del ensayo y modo de comunicarse con él (19, 22). participación voluntaria y retiro de la investigación o tratamiento. por ejemplo:“usted puede elegir si desea o no participar en este estudio. si usted se ofrece voluntariamente en 39 consentimiento informado: un pilar de la investigación clínica l paola carrasco-aldunate, miriam rubio-acuña, daniela fuentes-olavarría este estudio, puede retirarse en cualquier momento sin consecuencias, y puede negarse a contestar cualquier pregunta que no quiera contestar y seguir participando en el estudio” (22). consentimiento de participar. por ejemplo: “entiendo la información entregada en este ci. mis preguntas han sido contestadas de forma satisfactoria y doy mi consentimiento para participar en el estudio con el entendimiento de que puedo retirarme en cualquier momento. he recibido una copia firmada de este formulario de consentimiento” (22). nombre y firma del participante (22). principales conflictos relacionados con los ci una de las situaciones conflictivas en el uso del ci es la validez de este en el tiempo, ya que los sujetos podrían olvidar algunos aspectos. prentice et al. señalan en su estudio seis elementos que mantienen la validez del consentimiento en el tiempo (24): conocimiento de la participación en la investigación. comprensión del derecho de retirarse. entendimiento de que el retiro no influenciará otras opciones del tratamiento. conocimiento de los fines generales de la investigación. conocimiento de riesgos potenciales de participación. comprensión de las diferencias entre el cuidado clínico tradicional, individualizado y el tratamiento estandarizado durante la participación en la investigación. otro aspecto por considerar, y que puede causar conflicto, es el lenguaje que se utilice en el ci, elemento esencial para asegurar una adecuada comprensión de la información en los potenciales sujetos de investigación. por lo general es demasiado complejo y los participantes no comprenden la terminología utilizada en investigación (22). el tipo (verbal o escrito) y la extensión del ci pueden resultar conflictivos en relación con la aceptación de participación. un estudio cuyo objetivo era medir el impacto del tipo y la longitud de ci en la participación de los sujetos en una investigación encontró que cuando se aplicaba consentimiento verbal había menos rechazo a la participación que al ser escrito. un ci escrito de manera extensa y con firma del participante demostró presentar un mayor rechazo y menos participación. por otro lado, no hay acuerdo en la literatura en relación con la extensión del ci (23). otro aspecto por evaluar para evitar el conflicto es identificar, previo a dar a conocer el ci, la capacidad de comprensión (literacidad) o estado cognitivo de los participantes, como por ejemplo los estudios en pacientes con demencia (24). otro conflicto tiene relación con la coerción de minorías étnicas que participan en la investigación médica, ya que el reclutamiento es insensible a las diferencias culturales y los procedimientos de autorización, lo que provoca una disminución en el tamaño muestral (22). por otro lado, el miedo de los pacientes debido a los efectos de la intervención o el procedimiento, y la desconfianza respecto a lo que realmente se les hará, es otro de los conflictos que se presentan (22). esta desconfianza puede verse agravada debido a que los procedimientos de autorización son ajenos a los participantes y requieren de una firma, lo que puede connotar una obligación de carácter legal (22). el establecimiento de la confianza interpersonal y la confirmación de la validez de la investigación son importantes. la sospecha que genera en los individuos algo que perciben como extraño, y las preocupaciones acerca de ser engañados son elementos importantes de considerar (22). conclusión luego de conocer los principales aspectos éticos comprometidos en el uso del ci en investigación en salud se puede señalar que la elaboración de dicho instrumento resulta compleja. en su elaboración se deben considerar ciertos elementos constitutivos, así como algunas condiciones del investigador y del participante que garanticen la completa consideración de los principios éticos de autonomía, beneficencia, no maleficencia y justicia. en la práctica y en investigaciones clínicas la generación de conocimiento y nuevos descubrimientos que benefician el quehacer no está exenta de conflictos éticos que deben ser resueltos para no incurrir en los errores que por muchos años dañaron a las personas. los sujetos de investigación poseen una dignidad única muchas veces olvidada. al realizar un recorrido por la historia de la investigación biomédica muchos son los eventos en que la dignidad humana ha sido relegada a un segundo plano. es fundamental 40 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 plantear que se solicita el consentimiento informado a los sujetos de investigación porque son personas revestidas de dignidad y no por las posibles consecuencias legales o los requisitos que impone un tercero. es importante considerar el uso del ci como un proceso y no solo como un requerimiento para iniciar la investigación. este comienza con el primer contacto entre el investigador y el o los sujetos de investigación, en este contacto se entrega toda la información; los riesgos y beneficios del estudio, la posibilidad de retirarse de este en cualquier momento, y los datos del investigador responsable, entre otros, constituyen la información que todo sujeto de investigación o el responsable debe conocer para tomar la decisión de participar o no en el estudio. esta información debe ser entregada en un lenguaje comprensible, reconociendo los aspectos biológicos y psicosociales del participante. posteriormente, y durante la investigación, es importante monitorear que los principios éticos del sujeto sigan respetándose, y estar atento a su cumplimiento así como a eventuales cambios de decisión sobre la participación en la investigación. es un hecho que la investigación en enfermería ha evolucionado, lo que se ve reflejado en el aumento del número de enfermeras liderando proyectos de investigación, por lo cual resulta imprescindible formarlas en aspectos éticos relacionados a esta, con la finalidad de salvaguardar los derechos de las personas que participan de ellas. la adquisición de estos conceptos es de vital importancia en la formación profesional de pregrado, a fin de que el estudiante se aproxime a de manera gradual y pueda hacer de la investigación una tarea en la que se dé cumplimiento tanto a los principios éticos como a todas las condiciones necesarias para velar por el sujeto de investigación y sus derechos. enfermería es garante del cuidado holístico a los usuarios, por lo que debe salvaguardar la manifestación expresa de una persona a participar en un estudio, que acepta libre y voluntariamente las condiciones, los beneficios y los riesgos que esta involucra. así como también poner en el debate, mantener vigente y hacer consciente que como profesionales de la salud y potenciales investigadores, el ci es el elemento que marca la diferencia con investigaciones de otras ciencias. referencias bibliográficas 1. montenegro a, monreal m. revisión del procedimiento del ci por los comités de ética de la investigación clínica. rev cubana invest biomed 2007; 26 (2). recuperado de: http://scielo.sld.cu/scielo.php?pid=s0864-03002007000200010&script=sci_ arttext 2. alfaro f. el ci en la práctica anestésica. rev mex anes 2006; 29 (1): 106-8. 3. blank a. derechos humanos y ci en las investigaciones biomédicas en colombia. colomb med 2004; 35 (4): 224-30. 4. remón c, gonzález e, martínez a. consentimiento informado. nefrología 2008; supl. 3, 113-8. 5. ilfeld b. informed consent for medical research: an ethical imperative. reg anesth pain med 2006; 31 (4): 353-7. 6. suárez-obando f, ordóñez a. ética de la investigación científica: la fiebre amarilla, la comisión reed y el origen del consentimiento informado. infectio 2010; 14 (3): 206-6. 7. baker r, emanuel l. the efficacy of professional ethics the ama code of ethis in historical and current perspective. jstor 2000; s13-s17. 8. gallardo a, collado f. ética en la investigación médica. rev soc andaluza traumatol ortop 2008; 26 (2): 119-22. 9. urrutia mt. investigación en sujetos humanos: los derechos y el desarrollo de la investigación. horiz enferm 2009; 20 (1): 95-101. 10. centro interdisciplinario de estudios en bioética de la universidad de chile [homepage on the internet]. código de nüremberg de 1946 [updated 2002; cited 2010 oct 8]. recuperado de: http://www.bioetica.uchile.cl/doc/nurem.htm 11. asociación médica mundial [homepage on the internet]. declaración de helsinki de la asociación médica mundial. principios éticos para las investigaciones médicas en seres humanos. [updated 2008; cited 2011 mar 23]. recuperado de: http://www.wma.net/es/30publications/10policies/b3/index.html.pdf?print-media-type&footer-right=[page]/[topage] 41 consentimiento informado: un pilar de la investigación clínica l paola carrasco-aldunate, miriam rubio-acuña, daniela fuentes-olavarría 12. centro interdisciplinario de estudios en bioética de la universidad de chile [homepage on the internet]. declaración de helsinki de la asociación médica mundial [updated 2002; cited 2010 nov 22]. recuperado de: http://www.bioetica. uchile.cl/doc/helsink.htm 13. mondragon l. consentimiento informado: una praxis dialógica para la investigación. rev invest clin 2009; 61 (1): 73-82. 14. palomer l. consentimiento informado en odontología: un análisis teórico-práctico. acta bioeth 2009; 15 (1): 100-5. 15. mondragón l, monroy z, medina me. disyuntivas en las concepciones sobre autonomía y beneficencia que afectan la terapéutica del intento suicida. acta bioeth 2010; 16 (1): 77-86. 16. institutional review board [homepage on the internet]. belmont report in spanish. east tennessee state university [cited 2010 oct 11]. recuperado de: http://www.etsu.edu/irb/belmont%20report%20in %20spanish.pdf 17. acevedo i. aspectos éticos en la investigación científica. cienc enferm 2002; 8 (1): 15-8. 18. cahana a, hurst s. voluntary informed consent in research and clinical care: an update. pain pract 2008; 8 (6): 446-51. 19. mendoza ma, nava n, escalante j. aspectos éticos y legales del consentimiento informado en la práctica e investigación médica. gac med mex 2003; 139 (2): 184-7. 20. pantoja l. el consentimiento informado: ¿sólo un requisito legal? revista española de reumatología 2004; 31 (8): 475-8. 21. kripalani s, bengtzen r, henderson l, jacobson t. clinical research in low-literacy populations: using teach-back to assess comprehension of informed consent and privacy information. irb 2008; 30 (2): 13-8. 22. barataa p, gucciardia e, ahmadc f, stewart d. cross-cultural perspectives on research participation and informed consent. soc sci med 2006; 62: 479-90. 23. marco c. impact of detailed informed consent on research subjects participation: a prospective, randomized trial. j emerg med 2008; 34 (3): 269-75. 24. prentice k, appelbaum p, conley r, carpenter w. maintaining informed consent validity during lengthy research protocols. irb 2007; 29 (6): 1-6. ef fe ct s of c an ce r tr ea tm en t o n th e co m fo rt o f c hi ld re n an d a do le sc en ts w it h ca nc er : a s co pi ng r ev ie w 1 vagner josé lopes https://orcid.org /0000-0002-6635-4325 universidade federal do paraná, brazil. centro universitário unidombosco, brazil vagner.lopes@ufpr.br nen nalú alves das mercês https://orcid.org /0000-0001-5843-8329 universidade federal do paraná, brazil. nennalu@ufpr.br silvia francine sartor https://orcid.org /0000-0002-3270-5916 universidade federal do paraná, brazil. silviasartor@ufpr.br marli aparecida rocha de souza https://orcid.org /0000-0003-3032-9619 centro universitário unidombosco, brazil. marlisouza@unidombosco.edu.br lara adrianne garcia paiano da silva https://orcid.org /0000-0003-4419-6984 prefeitura municipal de cascavel, brazil. laraagps@gmail.com artículo effects of cancer treatment on the comfort of children and adolescents with cancer: a scoping review received: 23/03/2022 sent to peers: 23/05/2022 approved by peers: 23/08/2022 accepted: 25/08/2022 doi: 10.5294/aqui.2022.22.4.4 para citar este artículo / to reference this article / para citar este artigo lopes vj, mercês nna, sartor sf, souza mar, silva lagp. effects of cancer treatment on the comfort of children and adolescents with cancer: a scoping review. aquichan. 2022;22(4):e2244. doi: https://doi.org/10.5294/aqui.2022.22.4.4 https://orcid.org/0000-0002-6635-4325 https://orcid.org/0000-0002-6635-4325 mailto:vagner.lopes@ufpr.br mailto:vagner.lopes@ufpr.br https://orcid.org/0000-0001-5843-8329 https://orcid.org/0000-0001-5843-8329 mailto:nennalu@ufpr.br mailto:nennalu@ufpr.br https://orcid.org/0000-0002-3270-5916 https://orcid.org/0000-0002-3270-5916 mailto:silviasartor@ufpr.br mailto:silviasartor@ufpr.br https://orcid.org/0000-0003-3032-9619 https://orcid.org/0000-0003-3032-9619 mailto:marlisouza@unidombosco.edu.br mailto:marlisouza@unidombosco.edu.br https://orcid.org/0000-0003-4419-6984 https://orcid.org/0000-0003-4419-6984 mailto:laraagps@gmail.com mailto:laraagps@gmail.com https://doi.org/10.5294/aqui.2022.22.4.4 https://doi.org/10.5294/aqui.2022.22.4.4 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2022.22.4.4&amp;domain=pdf&amp;date_stamp=2022-10-24 subject: chronic care. contribution to the subject: this scoping review allowed mapping the scientific evidence on the effects of cancer treatment on the comfort of children and adolescents with cancer. the collection of articles from informational resources enables nurses and healthcare professionals to access knowledge through up-to-date literature of the main effects of cancer treatment and how these events affect the comfort of children and adolescents with cancer. thus, the knowledge of the impacts of treatment is a resource for these professionals to develop care measures, reducing aggravations and improving the comfort of these patients. ef fe ct s of c an ce r tr ea tm en t o n th e co m fo rt o f c hi ld re n an d a do le sc en ts w it h ca nc er : a s co pi ng r ev ie w 3 abstract objectives: to map and examine the scientific evidence concerning the effects of cancer treatment on the comfort of children and adolescents with cancer. materials and methods: this scoping review was carried out in the following electronic information resources: bvs, pubmed, cinahl, sciverse scopus, lilacs, web of science, and google scholar. two independent reviewers analyzed the studies’ relevance. results: the search yielded 4,295 publications, of which 20 comprised the final sample. following evidence mapping, the effects (20; 100 %) on comfort were found, and the most prevalent were pain (12; 60 %), fear (9; 45 %), nausea (5; 25 %), difficulty eating (4; 20 %), and distress (4; 20 %). regarding the oncologic treatment modality, antineoplastic therapy prevailed in 11 (55 %) of the selected articles. conclusions: cancer treatment affects the comfort of children and adolescents with cancer, causing suffering and changing their well-being. it indicates the need to evaluate its impact and take nursing care measures to reduce complications and improve these patients’ adaptation to treatment. keywords (fonte: decs) child; adolescent; patient comfort; medical oncology; nursing. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 4 4 4 resumen objetivos: mapear y examinar las evidencias científicas acerca de los efectos del tratamiento oncológico en la comodidad de niños y adolescente con cáncer. materiales y método: se realizó una revisión de alcance en los siguientes recursos informativos electrónicos: bvs, pubmed, cinahl, sciverse scopus, lilacs, web of science y google scholar. dos pares independientes analizaron la relevancia de los estudios. resultados: la búsqueda dio como resultado 4295 publicaciones, de las que 20 conformaron la muestra final. luego de mapear las evidencias, se hallaron efectos (20; 100 %) en la comodidad, y los de mayor prevalencia fueron dolor (12; 60 %), miedo (9; 45 %), náuseas (5; 25 %), dificultad en la ingesta de alimentos (4; 20 %) y angustia (4; 20 %). en relación con la modalidad del tratamiento oncológico, prevaleció entre los estudios la terapia antineoplásica en 11 (55 %) de los artículos seleccionados. conclusiones: se evidenció que el tratamiento oncológico afecta la comodidad de los niños y adolescentes con cáncer, llevándolos al sufrimiento y alterando su bienestar, lo que señala la necesidad de evaluar su impacto y el desarrollo de acciones de cuidado por parte de los profesionales de enfermería para reducir las complicaciones y mejorar la adaptación de estos pacientes al tratamiento. palabras clave (fuente: decs) niño; adolescente; comodidad del paciente; oncología médica; enfermería. efectos del tratamiento oncológico en la comodidad de niños y adolescentes con cáncer: revisión de alcance ef fe ct s of c an ce r tr ea tm en t o n th e co m fo rt o f c hi ld re n an d a do le sc en ts w it h ca nc er : a s co pi ng r ev ie w 5 efeitos do tratamento oncológico no conforto de crianças e adolescentes com câncer: scoping review resumo objetivos: mapear e examinar as evidências científicas acerca dos efeitos do tratamento oncológico no conforto da criança e do adolescente com câncer. materiais e método: realizou-se uma scoping review nos seguintes recursos informacionais eletrônicos: bvs, pubmed, cinahl, sciverse scopus, lilacs, web of science e google scholar. dois revisores independentes analisaram a relevância dos estudos. resultados: a busca resultou em 4295 publicações, das quais 20 compuseram a amostra final. após o mapeamento de evidências, foram achados efeitos (20; 100 %) no conforto, e os de maior prevalência foram dor (12; 60 %), medo (9; 45 %), náusea (5; 25 %), dificuldade na ingesta alimentar (4; 20 %) e angústia (4; 20 %). quanto à modalidade do tratamento oncológico, prevaleceu, entre os estudos, a terapia antineoplásica em 11 (55 %) dos artigos selecionados. conclusões: evidenciou-se que o tratamento oncológico afeta o conforto da criança e do adolescente com câncer, acarretando sofrimento e alterando seu bem-estar, o que indica a necessidade de avaliar o seu impacto e o desenvolvimento de ações de cuidado por parte dos enfermeiros para reduzir os agravos e melhorar a adaptação desses pacientes ao tratamento. palavras-chave (fonte: decs) criança; adolescente; conforto do paciente; oncologia; enfermagem. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 4 4 6 introduction “comfort” is defined as a living being’s immediate experience augmented by the need for relief, calm, and transcendence in the four contexts of experience, namely, physical, psychospiritual, sociocultural, and environmental. furthermore, it is in line with the holistic theory, where human beings have global responses to complex stimuli, and the physical body relates to mind, spirit, emotion, environment, and society (1, 2). studies indicate that healthcare professionals’ knowledge of comfort is essential when monitoring children and adolescents undergoing cancer treatment (3). its evaluation provides resources for managing these patients during treatment, aiming to improve their comfort and quality of life (4, 5). “childhood and adolescence cancer” corresponds to a group of diseases that have in common the uncontrolled proliferation of abnormal cells, anywhere in the body, among children and adolescents, in the age group from 0 to 19 years (6, 7). the most frequent types of cancer in childhood and adolescence are leukemia, followed by central nervous system tumors, and lymphomas. it is estimated that in brazil, for each year from 2020 to 2022, approximately 8460 new cases of childhood and adolescence cancer will occur (4310 in males and 4150 in females) (7). worldwide, it is estimated that approximately 400,000 new cases per year will be diagnosed among children and adolescents aged 0 to 19 years (8). in addition, childhood and adolescence cancer causes harmful physiological changes to the body, which leads to difficulties in physical activities, functional performance, and social interaction. even when treated successfully, it may have unfavorable physical and psychological consequences for the development of children and adolescents according to their age (9, 10). surgery, chemotherapy, and radiotherapy, which are frequent modalities in oncologic therapy for children and adolescents (6, 11-13), besides their expected benefits for the management and potential cure of the disease, may lead to adverse effects, such as clinical, functional, and labor changes in biopsychosocial aspects. these effects may result in difficulty sleeping and eating, nausea, pain, diarrhea, preoccupation, and sadness (10, 14). these changes trigger distress and can escalate to impact comfort and lead to negative outcomes in the adaptation of children and adolescents to oncologic treatment (3). additionally, the evaluation of comfort provides healthcare professionals with more effective assistance by prioritizing health activities in patient care and improving the provision of individualized and comprehensivve care within the clinical process (15). therefore, in the face of the effects that the oncologic treatment can have on the comfort of children and adolescents with cancer, the search for knowlef fe ct s of c an ce r tr ea tm en t o n th e co m fo rt o f c hi ld re n an d a do le sc en ts w it h ca nc er : a s co pi ng r ev ie w 7 edge of this fact becomes relevant in the hope of developing strategies to promote the comfort of this population during therapy (3-5). thus, the following research question emerged: what is the scientific evidence available regarding the effects of cancer treatment on the comfort of children and adolescents with cancer? therefore, this study aimed to map and examine the scientific evidence regarding the effects of cancer treatment on the comfort of children and adolescents with cancer. materials and methods this scoping review revolves around the effects of cancer treatment on the comfort of children and adolescents with cancer. for this study, a protocol was created and registered in the open science framework (osf) under the code osf.io/dwy9f. the osf is an online tool that promotes workflow for researchers, promoting improvements in replicability, transparency, and research data management practices (16). the methodological reference used was the joanna briggs institute (jbi) to map the evidence that supports a certain research area. in other words it enables the possibility of describing, summarizing, and synthesizing knowledge based on the systematic selection and condensation of the health literature, in addition to identifying gaps in existing research (17). to identify scoping reviews with an objective similar to this study’s, a search was carried out in the following databases: jbi clinical online network of evidence for care and therapeutics (connect+), database of abstracts of reviews of effects (dare), and the cochrane library. the results indicated that no scoping reviews on the subject existed. this report has been revised according to the preferred reporting items for systematic reviews-extension for scoping reviews (prisma-scr) checklist and operationalized in six phases, namely: 1. research question development; 2. inclusion and exclusion criteria definition; 3. keyword identification and article search strategy design; 4. database selection; 5. a screening and selection; 6. article mapping and result synthesis (18, 19). the pcc strategy, a mnemonic acronym that helps identify the key topics, where “p” stands for population, “c” for concept, and “c” for context, was used to develop the review question (17). in this study, the following definitions were used: p — children and adolescents with cancer; c — comfort; c —cancer treatment. for the study search and selection, the following question was established: what is the scientific evidence regarding the effects of cancer treatment on the comfort of children and adolescents with cancer? regarding the article inclusion criteria, abstracts and objectives should correspond to the proposed subject—the effects of cancer a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 4 4 8 treatment on the comfort of children and adolescents with cancer—, national and international studies, with qualitative, quantitative, and mixed methods approaches. the exclusion criteria were literature review articles for being secondary studies, studies that included young adults in the sample, and articles that described the opinion of healthcare professionals, that is, children and adolescents were not included. no time cut was applied to the research to provide the largest number of studies on the subject. the pcc strategy was used to search for results using controlled terms from the medical subject headings (mesh) of the health sciences descriptors (decs), along with uncontrolled terms: “criança”/“child”; “adolescente”/“adolescent”; “neoplasias”/“neoplasms”; “câncer”/“cancer”; “oncologia”/“medical oncology”; “tumor”/“tumor”; “conforto do paciente”/“patient comfort”; “bem-estar da criança”/“child welfare”; “bem-estar do adolescente”/“adolescent welfare”. the search strategy was developed using the boolean operators “and” and “or”, as follows: (criança or adolescente) and (conforto do paciente or bem-estar da criança or bem-estar do adolescente) and (neoplasias or oncologia or câncer or tumor); (child or adolescent) and (patient comfort or child welfare or adolescent welfare) and (neoplasms or medical oncology or cancer or tumor). the literature research was conducted in the following electronic information resources: virtual health library (vhl); national institutes of health’s national library of medicine (pubmed); cumulative index to nursing & allied health literature (cinahl); sciverse scopus; latin american and caribbean literature on health sciences (lilacs); web of science; google scholar, and references in the gray literature, available at greylit.org. this a website provides a list of recognized sources for this type of search and reference lists of selected relevant studies. the jbi recommends searching all reference lists of selected studies to identify any potential additional studies not mapped in the strategy used (17). the searches were performed from september to october 2021, by two reviewers in a paired and independent process. the search results of both were compared in the electronic information resources, verifying the differences among the findings to encompass the largest number of information relevant to the subject. to verify if there were subsequent publications in the chronological period, a new search was performed in january 2022. after checking the studies and analyzing the results, the reviewers reached a consensus and listed the studies that comprised the final sample of this review. it was not necessary to request additional information or data from the authors of the selected studies. the screening and selection process of evidence sources used was based on prisma-scr (18), considering the four proposed steps ef fe ct s of c an ce r tr ea tm en t o n th e co m fo rt o f c hi ld re n an d a do le sc en ts w it h ca nc er : a s co pi ng r ev ie w 9 namely: identification, screening, eligibility, and inclusion, which aim to contribute to the quality of results in the generation of knowledge. the selected articles were read in full, identifying more precisely their relevance to the research, which resulted in the final number of texts included in the review. the final extraction and delimitation steps of key information from the evidence were followed based on numerical descriptive analysis to categorize the studies and the selected evidence for thematic analysis. the aim was to summarize the information and align it to the study objective and guiding question. the data from the selected articles were extracted with a tool developed by the researchers according to the jbi guidelines (17, 19), which included authors, year of publication, study country, language, design, participants, treatment and the effects of cancer treatment on the comfort of children and adolescents with cancer. the studies were grouped and the synthesized data were discussed with the literature. all ethical and scientific requirements for the research were respected based on legal regulations. we ensured methodological rigor in the data treatment and presentation and faithfulness of the information contained in the original documents that supported the results. results the search resulted in 4295 articles selected, of which 52 were discarded for being duplicates in the information resources, and 4243 articles remained for title and abstract reading. in this new step, 4125 articles were excluded, which resulted in a total of 118 articles for selection regarding the inclusion and exclusion criteria. of these, 32 articles were selected for reading in full, excluding 12 for not specifying the effects of cancer treatment on the comfort of children and adolescents with cancer. thus, in the final sample, 20 articles were obtained to map evidence according to this study’s objective, as shown in figure 1. in this review, the selected studies were published between 2007 and 2020. of the 20 (100 %) published, nine (45 %) were brazilian studies published in portuguese and carried out between 2009 and 2020 (3, 20-27). the remaining 11 (55 %) studies are international articles published in english, with a prevalence of two (10 %) in sweden (28, 29), five (25 %) in the united states (30-34), one (5 %) in indonesia (35), one (5 %) in australia (36), one (5 %) in turkey (4), and one (5 %) in canada (37). regarding study design, 12 (60 %) were qualitative (4, 20-28, 33, 35) studies, and the remaining eight (40 %) were identified as follows: two (10 %) were retrospective studies (31, 32), three (15 %) were cross-sectional studies (3, 36, 37), one (5 %) was a mixed methods study (29), one (5 %) was a case-control study (34), and one (5 %) was a case study (30). table 1 presents the characteristics of the selected studies. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 4 4 10 articles identi�ed through website and database search bvs (n = 103); cinahl: (n = 390); lilacs (n = 14); pubmed: (n = 2013); scopus (n = 237); google scholar (617); web of science (n = 921) articles excluded through title and abstract reading (n = 4125) articles excluded using the inclusion and exclusion criteria (n = 86) articles included in the review (n = 20) articles analyzed through full text (n = 32) articles for eligibility analysis (n = 118) selected articles (n = 4243) duplicate articles excluded (n = 52) id en ti � ca ti o n sc re en in g el ig ib ili ty in cl u si o n table 1. characterization of the selected studies according to authors, year, country of publication and language, and design. curitiba, paraná, brazil, 2021 article authors country/year/language design i (27) guimarães tm, pacheco sta, nunes mdr, silva lf brazil/2020/portuguese qualitative ii (30) levy k, grant pc, kerr cw the united states/2020/ english case study iii (4) bicakli dh, sari hy, yilmaz m, cetingul n, kantar m turkey/2019/english qualitative iv (31) chen el, yoo ch, gutkin pm, merriot dj, avedian rs, steffner rj, et al. the united states/2019/ english retrospective v (3) leandro ta, silva vm, lopes mvo, guedes ng, nunes mm, sousa tm, et al. brazil/2018/portuguese cross-sectional vi (25) sá-frança jfr, costa sfg, lopes mel, nóbrega mml, batista pss, oliveira rc brazil/2018/portuguese qualitative vii (35) mahayati sl, allenidekania, happy h indonesia/2018/english qualitative figure 1. article screening process: identification, screening, eligibility, and inclusion. curitiba, paraná, brazil, 2021 source: research data and adapted from (18). ef fe ct s of c an ce r tr ea tm en t o n th e co m fo rt o f c hi ld re n an d a do le sc en ts w it h ca nc er : a s co pi ng r ev ie w 11 article authors country/year/language design viii (32) warma s, friedman dl, stavas mj the united states/2017/ english retrospective ix (20) freitas nbc, santos jlf, estanislau am, palitot rm, fonsêca pn brazil/2016/portuguese qualitative x (33) jacobs s, perez j, cheng yi, sill a, wang j, lyon me the united states/2015/ english quantitative xi (21) silva gm, kameo sy, sawada no brazil/2014/portuguese qualitative xii (28) ångström-brännström c, norberg a sweden/2014/english qualitative xiii (22) gomes ip, lima k a, rodrigues lv, lima r ag, collet n brazil/2013/portuguese qualitative xiv (36) mccarthy m, glick r, green j, plummer k, peters k, johnsey l, et al. australia/2012/english cross-sectional xv (26) lombardo ms, popim rc, suman a brazil/2011/portuguese qualitative xvi (23) cicogna ec, nascimento lc, lima r ag brazil/2010/portuguese qualitative xvii (37) zupanec s, jones h, stremler r canada/2010/english cross-sectional xviii (24) ribeiro ac, coutinho rm, araújo tf, souza vs brazil/2009/portuguese qualitative xix (29) nilsson s, finnström b, kokinsky e, enskär k sweden/2009/ english mixed methods xx (34) windich-biermeier a, sjoberg i, dale jc, eshelman d, guzzetta ce the united states/2007/ english case-control source: own elaboration based on the research data. based on the selected studies, a prevalence of participants was found in 11 (55 %) studies with children and adolescents (3, 20-25, 29, 31, 32, 34). the other nine studies (45 %) were carried out with three (15 %) family members, children, and adolescents (4, 36, 37), three (15 %) with adolescents (26, 27, 35), two (10 %) with adolescents and family members (30, 33), and one (5 %) with children and their family members (28). regarding the treatment modality provided to the children and adolescents in each study, of the 20 (100 %) articles, 11 (55 %) addressed antineoplastic treatment (3, 4, 20, 22, 23, 26, 28, 34-37), three (15 %) general oncology (21, 24, 29) and did not specify the treatment modality; two (10 %) radiotherapy (31, 32), three (15 %) palliative care (27, 30, 33), and one (5 %) antineoplastic treatment, surgery, and radiotherapy (25). regarding the effects of cancer treatment that affect the comfort of children and adolescents with cancer, 20 manifestations were evidenced in this population. table 2 presents the synthesis of the evidence mapped in the selected studies. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 4 4 12 table 2. synthesis of the evidence regarding the participants and the effects of cancer treatment on the comfort of children and adolescents with cancer. curitiba, paraná, brazil, 2021 article participants/study sample treatment treatment effects i (27) nine adolescents, aged 12 to 20 years palliative care nausea, difficulty eating, emesis, modified body image, suffering, withdrawal from formal education, withdrawal from family and friends ii (30) one adolescent aged 15 and their family member palliative care fear iii (4) fourteen mothers and three children and adolescents aged 11 months to 18 years antineoplastic difficulty eating, anxiety, fear, and modified body image iv (31) twenty children and adolescents aged 17.9 years on average radiotherapy pain and dyspnea v (3) one hundred ninety-two children and adolescents aged 11 years on average antineoplastic crying, feeling cold, fear, and not feeling at ease with the situation vi (25) eleven children and adolescents aged 7 to 11 years antineoplastic, surgery, and radiotherapy fear, sadness, distress, pain, and suffering vii (35) nine adolescents aged 14 to 18 years antineoplastic withdrawal from family and friends, nausea viii (32) fifty children and adolescents aged 0 to 18 years radiotherapy pain and dyspnea ix (20) four children and adolescents aged 9 to 13 years antineoplastic shame and sadness x (33) seventeen adolescents aged 14 to 21 years and their family members palliative care fear and pain xi (21) forty children and adolescents aged 10 to 18 years *general cancer treatment withdrawal from formal education xii (28) nine children aged 3 to 9 years and their family members antineoplastic fear, withdrawal from family and friends, and pain xiii (22) seven children and adolescents aged 6 to 11 years antineoplastic difficulty eating and length of hospitalization xiv (36) one hundred thirty-five children and adolescents aged 5 months to 19 years and their family members antineoplastic distress, pain, and suffering xv (26) seven adolescents aged 11 to 18 years antineoplastic pain, alopecia, and nausea xvi (23) ten children and adolescents aged 8 to 18 years antineoplastic pain, nausea, alopecia, and modified body image xvii (37) sixty-four children and adolescents aged 4 to 18 years and their family members antineoplastic pain, difficulty eating, nausea, emesis, and fear ef fe ct s of c an ce r tr ea tm en t o n th e co m fo rt o f c hi ld re n an d a do le sc en ts w it h ca nc er : a s co pi ng r ev ie w 13 article participants/study sample treatment treatment effects xviii (24) seven children and adolescents aged 6 to 14 years *general cancer treatment pain, fear, and preoccupation xix (29) forty-two children and adolescents aged 5 to 18 years *general cancer treatment distress and pain xx (34) fifty children and adolescents aged 5 to 18 years antineoplastic distress, pain, and fear note. *studies that did not specify the treatment provided to the participants. source: own elaboration based on the research data, 2021. after mapping the evidence related to the effects of cancer treatment, we grouped them by citation frequency of the selected studies to analyze the prevalence of these events in the comfort of children and adolescents with cancer. it was found that, of the 20 (100 %) manifestations evidenced, the ones that became more prevalent among the studies were pain (n = 12; 60 % [23-26, 28, 29, 31-34, 36, 37]), fear (n = 9; 45 % [3, 4, 24, 25, 28, 30, 33, 34, 37]), nausea (n = 5; 25 % [23, 26, 27, 35, 37]), difficulty eating (n = 4; 20 % [4, 22, 27, 37]), and distress (n = 4; 20 % [25, 29, 34, 36]), according to the data presented in table 3. table 3. frequency and percentage of the prevalence of the effects of cancer treatment on the comfort of children and adolescents with cancer in the selected studies. curitiba, paraná, brazil, 2021 the effects of cancer treatment frequency (n = 20) absolute (f ) relative (%) pain (23-26, 28, 29, 31-34, 36, 37) 12 60 fear (3, 4, 24, 25, 28, 30, 33, 34, 37) 9 45 nausea (23, 26, 27, 35, 37) 5 25 difficulty eating (4, 22, 27, 37) 4 20 distress (25, 29, 34, 36) 4 20 modified body image (4, 23, 27) 3 15 suffering (25-27) 3 15 withdrawal from family and friends (27, 28, 35) 3 15 withdrawal from formal education (21, 27) 2 10 sadness (20, 25) 2 10 dyspnea (31, 32) 2 10 alopecia (23, 26) 2 10 emesis (27, 37) 2 10 crying (3) 1 5 preoccupation (24) 1 5 feeling cold (3) 1 5 shame (20) 1 5 hospitalization time (22) 1 5 anxiety (4) 1 5 not feeling at ease with the situation (3) 1 5 source: own elaboration based on the research data, 2021. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 4 4 14 discussion the objective of this scoping review was to map and examine the scientific evidence regarding the effects of cancer treatment on the comfort of children and adolescents with cancer. for this purpose, 20 primary studies published in various national and international settings were selected through informational resources, which indicates that nurses need to analyze the evidence presented. moreover, it is important to relate them to the impact of changes on the comfort of children and adolescents with cancer undergoing treatment to obtain input for treatment strategies to manage the manifestations in the aforementioned population and improve the adaptation of patients throughout the cancer treatment. of all the articles, 12 (60 %) reported pain as the most prevalent effect of cancer treatment in children and adolescents with cancer (23-26, 28, 29, 31-34, 36, 37). these frequencies can be compared with the results of a study in lebanon (38), in which pain was the most frequent and debilitating symptom. thus, this symptom may lead to changes in the well-being of this population and in their adaptation to treatment. likewise, other evidence reports that the pain experienced by children and adolescents with cancer causes an unpleasant sensation, of a multi-factor origin, which is difficult to manage, and may lead to physical and emotional changes (11, 12, 39). thus, the management of pain represents a challenge for professionals who work in the area, especially in its identification and management prior to the cancer treatment to which this population is submitted (13-15, 39). in addition to pain, in nine (45 %) mapped studies, fear had a significant frequency in the effects of cancer treatment on the comfort of children and adolescents (3, 4, 24, 25, 28, 30, 33, 34, 37). fear means, for this population, the daily overload of negative feelings and emotions, uncertainties, and insecurity of being in an unknown world, where suffering emerges in their lives unexpectedly and with no prospect of coming to an end (5, 14). it is highlighted that the findings related to fear coincide with those of a review study, which investigated the change in the comfort of children and adolescents in critical conditions (15). the authors stated that intensive treatment in the hospital environment, the absence of close family members, and invasive procedures trigger the feeling of fear in these patients (15). another effect of cancer treatment that prevailed in the selected and mapped articles was nausea, which reached a citation frequency in five (25 %) of the studies (23, 26, 27, 35, 37). nausea is one of the signs and symptoms that cause increased discomfort to patients in cancer treatment, specifically secondary to gastrointestinal toxicities stemming from antineoplastic therapy. they can affect the nuef fe ct s of c an ce r tr ea tm en t o n th e co m fo rt o f c hi ld re n an d a do le sc en ts w it h ca nc er : a s co pi ng r ev ie w 15 tritional status, hydro-electrolyte balance, well-being, and quality of life of children and adolescents with cancer (40). these findings corroborate the results of a symptom management study conducted with family caregivers of children and adolescents with cancer undergoing antineoplastic treatment (41). the authors stated that nausea was one of the most prevalent symptoms in the pediatric population, leading to changes in eating patterns, inappetence, and weight loss (41). in addition, difficulty eating was present in four (20 %) of the studies (4, 22, 27, 37). in this context, difficulty eating is understood as any problem that negatively affects the process of healthcare professionals, parents, or caregivers to supply food or nutrients to their children or patients (42). children and adolescents are used to a particular type of food at home, which regards their wishes and desires, unlike what happens in the hospital environment. the supply of inappropriate food by the family and the hospital rules regarding meals are the main difficulties, often becoming a limiting factor for accepting adequate meals (43). therefore, these findings corroborate a study conducted on the evaluation of the perception of parents of children diagnosed with cancer regarding the food provided in the hospital environment (44). the authors demonstrated that 76.5 % of children did not like the food taste, and 52.9 % did not like the appearance of the food plating. it has been demonstrated that an unbalanced diet can cause discomfort to patients and increase the risk of malnutrition (44). in addition to the difficulty eating, another effect on treatment that prevailed in the selected and mapped articles was distress, which had a citation frequency in four (20 %) of the studies (25, 29, 34, 36). distress is triggered because children and adolescents with cancer often experience a severe and uncertain process of illness, which represents the unknown, especially because of the treatment and separation from their parents and siblings when hospitalization is necessary (25, 45). thus, these findings are consistent with a pilot intervention study conducted in brazil with children and adolescents with type 1 diabetes mellitus, which used a therapy toy versus standard guidelines for administering insulin (46). the authors identified that decreased parental involvement with children and adolescents in diabetes management may cause psychosocial issues such as depression symptoms and distress (46). finally, regarding the cancer treatment modality 11 (55 %) of the articles addressed antineoplastic therapy (3, 4, 20, 22, 23, 26, 28, 34-37). this therapy is the most prevalent treatment modality for childhood and adolescence cancer, leading to immediate responses, since pedia q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 4 4 16 atric tumor cells are sensitive to antineoplastic therapy (47, 48). the child or adolescent with cancer receives antineoplastic therapy at the hospital level —inpatient or outpatient— or at home under the supervision and close monitoring of healthcare professionals (47-50). evidence is consistent with a retrospective study that analyzed the clinical and epidemiological profile of children and adolescents with cancer (51). from the 146 medical records analyzed, 65 (45 %) of the patients were specifically on cancer treatment. thus, the authors stated that antineoplastic therapy was the most prevalent therapy in this study, compared with other treatment modalities for this population, such as radiotherapy, surgery, and hematopoietic stem cell transplantation (51). finally, this research has as a limitation the search in seven electronic informational resources with the selected descriptors and keywords. they may not have expanded the number of eligible studies for this research, even though the terms selected cover the universe of the effects of cancer treatment on the comfort of children and adolescents with cancer. therefore, this review highlights the need for studies that develop indicators of the effects of cancer treatment on this population to operationalize the evaluation of the effectiveness of care provided in clinical practice. enabling adaptation and coping by children and adolescents with cancer undergoing treatment, based on the involvement of these patients’ healthcare professionals, family members, and close friends will provide them with well-being. conclusions this study’s findings provided scientific evidence regarding the effects of cancer treatment on the comfort of children and adolescents with cancer. pain, fear, nausea, difficulty eating, and distress were prevalent. these effects lead to suffering, low adherence to cancer treatment, and worsened quality of life in this population. regarding the treatment, it was found that the one with the highest prevalence among the analyzed studies was antineoplastic therapy. for this reason, the results presented in this study may raise nurses, awareness of the effects on the comfort of children and adolescents with cancer during cancer treatment, as they are vulnerable in the care settings. therefore, comfort is an aspect that should be routinely evaluated in clinical practice to promote the well-being of children and adolescents with cancer. conflicts of interest: none declared. ef fe ct s of c an ce r tr ea tm en t o n th e co m fo rt o f c hi ld re n an d a do le sc en ts w it h ca nc er : a s co pi ng r ev ie w 17 references 1. kolcaba k y. a taxonomic structure for the concept comfort. image j nurs sch. 1991;23(4):237-40. doi: https://doi. org /10.1111/j.1547-5069.1991.tb00678.x 2. kolcaba k y. comfort theory and practice: a vision for holistic health care and research. new york: springer; 2003. 3. leandro ta , silva vm, lopes mvo, guedes ng, nunes mm, sousa tm et al. conforto prejudicado em crianças e adolescentes com câncer. rev bras enferm. 2018;71( 3):995-1002. doi: https://doi.org 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https://doi.org/10.5902/2179769231138 https://doi.org/10.12873/401fernandes https://doi.org/10.12873/401fernandes https://doi.org/10.5294/aqui.2019.19.4.7 https://doi.org/10.5294/aqui.2019.19.4.7 https://doi.org/10.1111/jspn.12309 https://doi.org/10.1111/jspn.12309 https://doi.org/10.1188/17.onf.31-43 https://doi.org/10.1188/17.onf.31-43 https://doi.org/10.15448/1983-652x.2019.1.30329 https://doi.org/10.15448/1983-652x.2019.1.30329 https://doi.org/10.1590/2177-9465-ean-2020-0239 https://doi.org/10.1590/2177-9465-ean-2020-0239 https://doi.org/10.12957/reuerj.2019.37458 https://doi.org/10.32635/2176-9745.rbc.2018v64n3.26 https://doi.org/10.32635/2176-9745.rbc.2018v64n3.26 palliative care for the elderly in the healthcare system: a scoping review article palliative care for the elderly in the healthcare system: a scoping review cuidado paliativo al anciano en la red de atención de salud: una revisión de alcance cuidado paliativo à pessoa idosa na rede de atenção à saúde: uma revisão de escopo 10.5294/aqui.2022.22.3.8 isabela silva câncio velloso 1 carolina da silva caram 2 isabela rodrigues pego de almeida 3 maria josé silva souza 4 matheus henrique silva 5 carolina sales galdino 6 1 0000-0001-5408-0825 universidade federal de minas gerais, brazil. isavelloso@ufmg.br 2 0000-0001-6219-3301 universidade federal de minas gerais, brazil. carolcaram@ufmg.br 3 0000-0001-8395-0148 universidade federal de minas gerais, brazil. belinharp08@ufmg.br 4 0000-0002-1640-7441 universidade federal de minas gerais, brazil. mariasouza@ufmg.br 5 0000-0003-0406-4418 universidade federal de minas gerais, brazil. mhs2017@ufmg.br 6 0000-0003-1813-9724 universidade federal de minas gerais, brazil. carolina.galdino@ebserh.gov.br received: 10/02/2022 sent to peers: 03/05/2022 approved by peers: 19/06/2022 accepted: 13/07/2022 subject: chronic care. contribution to the subject: the present study results highlight the relevance of discussions addressing palliative care for elderly individuals and their families in the healthcare system. such discussions are groundbreaking in contributing to solid national policies and guidelines that integrate and improve palliative care practices at all levels of care, especially primary healthcare and homecare. in addition, it provides an opportunity for the nursing team and other healthcare professionals to reflect on the relevance of palliative care practices for the elderly on a humanized and comprehensive basis. para citar este artículo / to reference this article / para citar este artigo: velloso isc, caram cs, almeida irp, souza mjs, silva mh, galindo cs. palliative care for the elderly in the healthcare system: a scoping review. aquichan. 2022;22(3):e2238. doi: https://doi.org/10.5294/aqui.2022.22.3.8 abstract objective: to map the scientific evidence related to the organization of palliative care practices provided for the elderly in the healthcare system. materials and methods: this is a scoping review following the joanna briggs institute's method. the search was conducted in the pubmed, cinahl, web of science, scopus, vhl/lilacs, embase, and cochrane databases, identifying 1,150 articles managed using the endnote software. after the selection, the study sample consisted of 12 articles. the data were organized in microsoft excel spreadsheets, submitted to descriptive analysis, and discussed with the literature. results: the relevance of palliative care practices for older adults to be organized in the healthcare system was noted, focusing on primary healthcare, at home, and interdisciplinary coordination. however, there is still a fragmented offer of this care with limited considerations regarding the challenges and possibilities of its effectiveness. conclusions: the mapping of scientific evidence on the subject shows that discussions regarding the insertion of palliative care in the healthcare system are modest. the studies explore the role of primary care as the organizer of these practices, although in a fragmented perspective, with limited coordination between the healthcare system services. keywords (source decs): aged; frail elderly; palliative care; primary health care; comprehensive health care. resumen objetivo: mapear las evidencias científicas relacionadas con la organización de las prácticas de cuidado paliativo al anciano en la red de atención de salud. materiales y método: scoping review por el método joanna briggs institute. la búsqueda se realizó en las bases de datos pubmed, cinahl, web of science, scopus, bvs/lilacs, embase y cochrane, con identificación de 1150 artículos, los cuales fueron gerenciados por el software endnote. luego de la selección, 12 artículos compusieron la amuestra del estudio. los datos se ordenaron en planilla del microsoft excel, se sometieron a análisis descriptivo y se discutieron con la literatura. resultados: se observó que la organización de las prácticas de cuidado paliativo al adulto mayor desde la red de atención de salud, con enfoque en la atención primaria de salud, en la residencia y en la articulación interdisciplinaria es importante. sin embargo, aun hay fragmentación en la oferta de este cuidado, con limitadas consideraciones en cuanto a los retos y posibilidades de su efectuación en todos los niveles de atención. conclusiones: el mapeo de las evidencias científicas sobre el tema demuestra que son modestas las discusiones en torno de la inserción de los cuidados paliativos en la red. los estudios exploran el rol de la atención primaria de salud como ordenadora de estas prácticas, aunque en una perspectiva fragmentada, con poca articulación entre los servicios de la red. palabras clave (fuente decs): anciano; anciano frágil; cuidados paliativos; atención primaria de salud; atención integral de salud. resumo objetivo: mapear as evidências científicas relacionadas à organização das práticas do cuidado paliativo à pessoa idosa na rede de atenção à saúde. materiais e método: scoping review pelo método joanna briggs institute. a busca foi realizada nas bases de dados pubmed, cinahl, web of science, scopus, bvs/lilacs, embase e cochrane, sendo identificados 1150 artigos, os quais foram gerenciados pelo software endnote. após a seleção, 12 artigos compuseram a amostra do estudo. os dados foram organizados em planilha do microsoft excel, submetidos à análise descritiva e discutidos com a literatura. resultados: observou-se a importância de as práticas de cuidado paliativo à pessoa idosa serem organizadas na rede de atenção à saúde, com foco na atenção primária à saúde, no domicílio e na articulação interdisciplinar. contudo, ainda há fragmentação na oferta desse cuidado, com limitadas considerações quanto aos desafios e possibilidades da sua efetivação em todos os níveis de atenção. conclusões: o mapeamento das evidências científicas sobre o tema mostra que são modestas as discussões em torno da inserção dos cuidados paliativos na rede. os estudos exploram o papel da atenção primária como ordenadora dessas práticas, ainda que em uma perspectiva fragmentada, com pouca articulação entre os serviços da rede. palavras-chave (fonte decs): idosos; idoso fragilizado; cuidados paliativos; atenção primária à saúde; assistência integral à saúde. introduction population aging is now a phenomenon in developed and developing countries (1). the proportion of people in their 60s and older worldwide is growing faster than the other age groups. it is estimated that by 2050 there will be two billion older people, of which 80 % will live in developing countries (2). despite these estimates, the pan american health organization (3) published the world report on aging in 2022, expressing concern over widespread age-related healthcare rationing and indicating that health research tends to exclude older adults, even though several health conditions are more prevalent in elderly individuals. the population's longevity, associated with social and family changes, such as the increasing insertion of women in the workplace and the reduction in the size of families, raise concerns regarding the care provided to the elderly who depend on third parties (4). it stands out that the increase in life expectancy and the high morbidity rate due to chronic-degenerative diseases are some of the most significant challenges for public health today (5-7). although the disease affects the individual, its consequences also affect the family and the people who live and work with the patient, in a process that challenges and modifies family roles and group dynamics (8). in addition, the older adult's aging process leads to feelings that involve the perspective of life terminality, both for their families and the professional team (9-11). thus, with an aging population that will live and die under more complex conditions, the demand for care tends to increase, along with the demand for palliative care (-). palliative care (pc) was defined in the 1990s and restated in 2002 by the world health organization (who) as a multidisciplinary approach that aims to improve the quality of life of patients and their families in the presence of a life-threatening illness through the prevention and relief of suffering, accurate and careful assessment, treatment of pain, and other demands (physical, psychosocial, or spiritual) (5, 8). more recently, this concept has been redefined, and pc now includes chronic conditions that are progressive from diagnosis, along with therapies that can modify or potentially cure the disease (15, 16). pc must be regarded as a fundamental right of individuals and an essential component of comprehensive and integrated care throughout life, including at the end of life (10). although a relatively new component of modern healthcare, it is becoming increasingly recognized as an essential part of all health systems (12). it should be available in any healthcare setting, such as hospitals, long-term care facilities, health centers, and even in patients' homes (16, 17). in 2018, recognizing the need to improve and implement evidence-based pc policies and to support the comprehensive improvement of health systems at all levels, the ministério da saúde (ministry of health) of brazil published resolution 41, which provides guidelines for the organization of pc in light of integrated continuous care within the scope of brazil's sistema único de saúde (unified health system) (18). however, the implementation of comprehensive care in the rede de atenção à saúde ras (healthcare network system hns) implies strategies that anticipate the transition of this type of care across various levels within this system. the transition of care is a strategy that involves a group of planned measures to ensure the continuity and safe coordination of the care provided, which can increase the quality of life of patients and their families (19, 20). therefore, conducting studies that allow a broader view of pc in the hns is considered relevant, so patients and their families can receive comprehensive care. given the above, this study aims to map the scientific evidence related to the organization of pc practices for older adults in the hns. materials and methods this scoping review is based on the international guidelines of the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr [21]), whose protocol was registered in the open science framework (https://osf.io/83p7u/). the review was conducted according to the joanna briggs institute (22) methodological guidelines, with the following steps: 1) identification of the research question; 2) identification of relevant studies; 3) study selection; 4) data analysis; 5) data grouping, synthesis, and presentation. the review question and the inclusion and exclusion criteria were discussed and agreed upon by the researchers. the guiding question was defined using the pcc strategy, where p (population) is older adults, c (concept) is pc, and c (context) is the hns. the question was: "how are pc practices organized for the elderly in the hns?" the sample was composed of studies that met the following inclusion criteria: articles published in national and international journals from january 2010 to march 2021 in portuguese, english, and spanish. articles that were not available in full-text were excluded, as well as gray literature, such as monographs, dissertations, theses, books, blogs, editorials, and guidelines. it is noteworthy that the gray literature was excluded to eliminate possible biases related to the inclusion of evidence with value judgment or opinions that failed to represent the subject matter; furthermore, due to the possibility of excessive volume of material, it would require the expansion of the inclusion criteria, possibly affecting the sample of scientific articles found. studies that described and discussed the organization of pc practices for the elderly from the perspective of the hns were considered eligible. the search strategy was carried out by a librarian at the biblioteca baeta vianna (baeta vianna library) of the universidade federal de minas gerais (federal university of minas gerais), brazil. the articles found were managed using the endnote software, which allowed peer review to be carried out independently. the search was conducted in april 2021 in the following databases: medline®/ national library of medicine (pubmed), scopus, cumulative index to nursing and allied health literature (cinahl), web of science (wos), embase, cochrane, and biblioteca virtual de saúde (bvs). the health sciences descriptors (decs) and medical subject headings (mesh) related to the elements of the research question were used, as shown in table 1. table 1.definition of database search strategies, belo horizonte, 2022 database search strategy bvs* (idoso or idosos or "pessoa idosa" or "pessoa de idade" or "pessoas idosas" or "pessoas de idade" or "população idosa" or "idoso fragilizado") and ("cuidados paliativos" or "assistência paliativa" or "cuidado paliativo" or "cuidado paliativo de apoio" or "tratamento paliativo" or "cuidados paliativos na terminalidade da vida" or "cuidado paliativo a doentes terminais" or "cuidados a doentes terminais" or "cuidados de conforto" or "programas de cuidados intermitentes" or "programas de cuidados paliativos" or "estado terminal" or "doença terminal" or "estado crítico") and ("assistência integral à saúde" or "atenção primária à saúde" or "atenção secundária à saúde" or "atenção terciária à saúde" or "colaboração intersetorial" or "serviços de saúde para idosos") medline/pubmed cochrane cinahl scopus wos (aged or "frail elderly") and ("palliative care" or "hospice care" or "critical illness") and ("comprehensive health care" or "primary health care" or "secondary care" or "tertiary healthcare" or "intersectoral collaboration" or "health services for the aged") embase (aged or "frail elderly") and ("palliative therapy") and ("primary health care" or "secondary health care" or "tertiary care center" or "intersectoral collaboration" or "elderly care") source: elaborated by the authors. the first step involved searching the databases and extracting the identified articles into the endnote® software. the articles then had their titles and abstracts read and analyzed by six reviewers, who worked in pairs in a double-blind format to select the potential eligible articles. in cases of doubts regarding inclusion, the researchers performed the inclusion analysis jointly. the articles that composed the final sample were read in full by all reviewers independently, aiming to answer the review question and extract the data of interest. it should be noted that the reference lists of the article sample included in the review were examined for additional sources. however, no articles were added. subsequently, the data were organized in a spreadsheet created in microsoft excel 2016, whose structure contemplated essential elements of the studies: publication year, country of origin, objectives, study type, population, study site, and main results. the data synthesis is descriptively presented in this article and discussed with the relevant literature. results a total of 1,150 articles were identified in the database search, and the final sample consisted of 12 articles, as shown in figure 1. figure 1. study selection flowchart, adapted from prisma-scr, belo horizonte, minas gerais, brazil, 2022 source: elaborated by the authors. the 12 articles included in this review were organized into a bibliographic framework presented in table 2, containing the article title, country of origin, publication year, type of study, and result synthesis. table 2. articles included in the scoping review, belo horizonte, minas gerais, brazil, 2022 author(s) title location, year type of study article result synthesis albers g, froggatt k, van den block l, gambassi g, vanden berghe p, pautex s, et al.(23) a qualitative exploration of the collaborative working between palliative care and geriatric medicine: barriers and facilitators from a european perspective europe, 2016 qualitative study • states that the care system for the elderly in pc should be based on the premise of interdisciplinary coordination • points to the fragmentation of care for the elderly in pc and the frailty of communication between disciplines • stresses the relevance of interdisciplinary teamwork as an opportunity for mutual and collaborative learning ankuda ck, petterson sm, wingrove p, bazemore aw (24) regional variation in primary care involvement at the end of life the united states of america, 2017 cross-sectional study • discusses how the participation of primary care medical professionals in pc for the elderly reduces health system costs, the length of stay in hospital institutions, and invasive procedures • indicates that care at the primary level reduces the fragmentation of care for the elderly in end-of-life care brasil k, galway k, carter g, van der steen jt (25) providing optimal palliative care for persons living with dementia: a comparison of physician perceptions in the netherlands and the united kingdom the netherlands and the united kingdom, 2017 cross-sectional study • states that the main obstacles faced by the healthcare system in managing older adults with dementia in pc are professionals' limited education and limited access to specialized care • suggests that care for older people with dementia in pc should be person-centered, with family involvement and staff training on effective communication ahia c, blais cm (26) primary palliative care for the general internist: integrating goals of care discussions into the outpatient setting the united states of america, 2014 case study • discusses that accompanying the elderly in pc at the primary level contributes to their trajectory in the healthcare system and effective communication and assists in decision making • reports that general practitioners and family physicians at the primary level are crucial to discussing the treatment objective and achieving better outcomes lanza cc, o'shea cjc, herrera jl, pena cg (27) cuidados paliativos: la opción para el adulto en edad avanzada mexico, 2015 review study • states the need for pc for the elderly to be coordinated and integrated into the health system • cites primary care as the organizer of care and highlights its proximity to the patient's home in pc • highlights that, in the primary care context, it is necessary to guide caregivers and family members in collaborative interdisciplinary care with the health team toye c, blackwell s, maher s, currow dc, holloway k, tieman j, et al. (28) guidelines for a palliative approach for aged care in the community setting: a suite of resources australia, 2012 systematic review • highlights primary care in the center of care in the health system and the importance of considering the home for pc practice • stresses that the home is a preferred pc locus for the elderly, as it integrates family and relational elements that already exist and reduces expenses and avoidable procedures • contextualizes that many older people spend their end of life in hospital institutions against their wishes and notes that there are unnecessary transfers tuckett a, parker d, clifton k, walker h, reymond e, prior t, et al. (29) what general practitioners said about the palliative care case conference in residential aged care: an australian perspective. part 2 australia, 2015 qualitative study • states the importance of the multi-professional primary care team in the care provided to the elderly in pc • highlights the role of nurses as powerful agents for reducing the frailty of pc supply • emphasizes the home as the preferred locus of pc for the elderly, emphasizing the need for a formalized care plan, effective communication, teamwork with the family, and prioritization of the bond with the team instead of a professional van der steen jt, dekker nl, gijsberts mjhe, vermeulen lh, mahler mm, the bam (30) palliative care for people with dementia in the terminal phase: a mixed-methods qualitative study to inform service development australia, 2017 qualitative study • discusses the relevance of primary care as settings for pc practices for the elderly • highlights the importance of providing pc to the elderly at home, especially in the terminal phase • states that the elderly spend the end of life in hospital institutions against their will and justifies that this is due to the health system's frailty, as it fails to focus on chronic diseases, the long wait for consultations, and the lack of dedicated pc professionals • suggests specialized mobile teams that accompany the elderly in pc and their families instead of unnecessary transfers to hospitals ayyar a, varman s, de bhaldraithe s, singh i (31) the journey of care for the frail older person the united kingdom, 2010 review study • recognizes that the healthcare of the elderly in pc needs to be provided in an expanded format in the different devices of the health system • stresses the importance of the interface between primary and secondary care of the elderly based on information exchange and reliable and quality care. • suggests an integrated care model for the frail elderly, composed of a multi-professional team in the different healthcare devices, which should be prepared to promote bonding and perform safe transfers jadhav av (32) rural elderly and access to palliative care: a public health perspective india, 2020 review study • identifies frailty in the organization of pc in the public health system • highlights that pc for the elderly is neglected in the health system context, especially regarding the patients' access and the investment allocated to oncologic hospitals • states the importance of primary care as the organizer of care deborah r, waterworth s, merryn g (33) the role of practice nurses in providing palliative and end-of-life care to older patients with long-term conditions australia, 2014 qualitative study • highlights the role of primary care nurses in pc and end-of-life in the elderly • states the professionals' need to develop pc skills and knowledge • criticizes the nurses' limited autonomy in pc participation, conditioned to the referring physician • recognizes the importance of nurses and multi-professional performance in pc for the elderly hermans s, sevenants a, declercq a, broeck nv, deliens l, cohen j, audenhove cv (34) inter-organisational collaboration in palliative care trajectories for nursing home residents: a nation-wide mixed methods study among key persons belgium, 2019 sequential mixed method • discusses the relationship between the pc system devices such as nursing homes, hospitals, and home • reflects on the limited production of research in this field • states that the collaboration process in pc for the elderly at the inter-organizational level is fragile • reports that the frailties of the inter-organizational relationship are the divergence of routines, poor communication, lack of a unified information system between services, and the professionals' wrong perception of pc source: elaborated by the authors. the results, in general, demonstrated the importance of pc practices for the elderly to be organized in the hns, with primary healthcare, home care, and interdisciplinary coordination with the geriatrics specialty as key to the comprehensiveness and continuity of care. discussion although the articles analyzed mention the importance of inserting and discussing pc in an integrated health system, in practice, there is still fragmentation in the provision of this care, with limited considerations regarding the challenges and possibilities of the effectiveness of pc at all levels of care. we noticed that most of them choose to emphasize one of the levels of healthcare, prioritizing primary healthcare and home care. from this perspective, they understand that primary care explores the light care technologies, which include communication, welcoming, bonding, listening (35), establishing trust, and allowing more significant interaction with the elderly and their families/caregivers in the development and implementation of the care plan. the increase in life expectancy and population aging leads the elderly to die primarily due to chronic diseases (36). with aging and the progression of these diseases, older adults tend to be subjected to unnecessary suffering, resulting in a compromised quality of life at the end of life (37, 38). this happens because public health has failed to manage and follow up on the burden of non-communicable diseases in the aging population, such as chronic diseases, whose challenge is the loss of functional health (36). from this perspective, the who suggests integrating and providing pc throughout the lifespan (27, 39). in this review, we inferred that the insertion of pc throughout the entire hns is a powerful strategy to promote the integration of pc practices for the elderly. in this sense, it was possible to identify in the sample initiatives and reflections that propose pc to the elderly from the perspective of an integrated healthcare system. it is highlighted that care is a continuous process, where an individual may, at any given time, need to access more than one health system service, especially in aging populations that face the challenges of chronic diseases (40). moreover, the continuity of care is more than only the connection between the different levels, but it also depends on the information flow regarding the assistance provided between the different services (40). in this regard, the authors (31) point out that the care provided in the different scenarios should be coordinated and easily transferable, constituting a safe and seamless care journey for the elderly and ensuring the patient's holistic experience. the successful joint operation of this system depends on an active interface between the various parts of the system (31). a study (34) conducted in belgium suggests that the organization of a care system is essential for the provision of integrated pc. this description is like the proposed care model of the brazilian health system organized from the perspective of care integration through the hns (18). however, it is noteworthy that pc integration in a system requires administrative, organizational, clinical, and service aspects that enable the continuity of care throughout all agents involved (34). moreover, formalizing the system structure through government policies is insufficient to ensure successful inter-organizational collaboration. in practice, the collaboration process is complex. it entails overcoming challenges such as leadership, coordination, lack of critical organizational members to drive the cooperation, power imbalances, agents' varying expectations, cultural diversity, corporate governance, means of communication, and opportunities for interaction (34). given these challenges mentioned by the authors, it is understandable why primary healthcare has been indicated in several of the studies analyzed as the care organizer in the care system (24, 26-28, 31, 32). primary healthcare was recognized in such studies for its relevance in developing pc measures for the elderly. the articles explored primary healthcare considering its role as a care organizer in the system, its properties of integrating different services and prioritizing light care technologies, and its proximity and relationship with the region and home setting. primary healthcare engagement and participation in the coordination and continuity of care are factors that operate to maximize general health outcomes (24). patient-centered care and continuity of care improve discussions, resulting in the unity of patient and health provider objectives for future care and improved end-of-life outcomes (26). regarding pc at the primary level, a study carried out in the united states (24) indicated that primary care physicians are vital to providing competent pc at this level of care, with preliminary evidence that the engagement of these professionals is a source of regional variation in the standard of care offered at the end of life. the study results (24) indicate that patients who received greater engagement in primary care provided by physicians experienced fewer hospitalizations and intensive care procedures in the last six months of life and, consequently, lower healthcare costs. also of note is that the care provided to the frail elderly at this level of care improves patient satisfaction and reduces the transfer of the elderly to long-stay institutions and inadequate hospital admissions (31). the present study results corroborate a literature review (41) conducted on the role of primary healthcare in pc for the elderly, which indicates as benefits of pc at this level of care factors such as the improvement of symptoms manifested by patients, their satisfaction, and the reduction of hospitalizations at the tertiary level and expenses with specialized services. however, challenges remain in the organization of the health system in primary healthcare to be overcome for incorporating pc in its scope of action, especially regarding the lack of professional training and educational activities aimed at the patients and their families (42). the importance of nurses and managers at this level of care to recognize pc opportunities that offer families and patients adequate and quality care is highlighted. therefore, they suggest two fronts of action in this scenario: the training and discussion forum on the topic and community awareness regarding the importance of pc (42). still, on the importance of primary healthcare in pc, the study analyzed (27) in this review indicates that pc for the elderly should include the promotion, prevention, and rehabilitation measures, with guidelines for training volunteers and caregivers for the elderly at the primary level and considering the participation of family and society in the interdisciplinary work with the health team (27). in this sense, it is essential to emphasize that primary healthcare in pc needs a healthcare network system that offers specialized services in pc, among the other services, whose criteria for referral are the patients' needs and not only their limiting characteristics (43, 44). it was highlighted in the studies as the basic level of care for the continuity of healthcare between the different levels of care, considering the role of primary healthcare in the health system (26). it can be attributed to the fact that primary healthcare is the closest to patients, their families, and homes, the favored care location for the elderly in pc, with the possibility of better bonding and resolution (43). regarding the continuity of care, a study (26) analyzed in this review states the importance of every care transition of the older adults in pc (specialized consultation, hospital discharge, performance of procedures, or referral to long-term care facilities) as an opportunity for monitoring, adjustment, and definition of care goals. the authors emphasize that this is a potential developed by primary healthcare professionals, as it implies the availability of the physician's time for consultation and contact with specialists who provide care to the patient. this process is assisted by professionals at the primary level, as it is perceived that they have the time, ability, and willingness to discuss pc with patients and their families, in addition to a dynamic health team (26). primary healthcare, in addition to centering patient care, also improves the emotional support provided to patients and their families since the professionals engage in empathic communication, promoting the discussion of the objectives of pc (26, 30). however, it should be considered that the continuity of care for the elderly in pc is still fragile due to the professionals' lack of knowledge concerning this type of care, the health system's lack of planning for the epidemiological transition with population aging, and the lack of integration between health services (41, 44, 45), especially when patients are transferred to hospital care and in the processes related to discharge from this service (45). continuity of care happens effectively when the dimensions of time/environment, patient-professional relationship, communication, and management are aligned (44, 45). in addition, planning, information exchange (face-to-face, telecommunication, or electronic medical records), ongoing interaction and coordination, and clear roles between services, whether for home or another level of care, are essential for the transition of care (44, 45). it is also noteworthy the emphasis of studies (29, 33) on the role of primary healthcare nurses in promoting pc to the elderly. although the multi-professional team is considered relevant, the nurses are recognized as critical agents in overcoming the limitation of pc availability in different contexts (46). several aspects were mentioned regarding the nurses' attributes that favor their participation in end-of-life care: their greater availability of time than physicians to be with patients; the promotion for patients to receive the best pc possible; the centrality of patients in holistic care; the competence to manage pain and other symptoms; the ability to share care with other professionals and services, focusing on the continuity of care and not only on transfer (29, 33). however, the nurses' autonomy in pc is still limited, primarily associated with the referring physician, and their participation in care depends on them (33). other studies (47-49) corroborate the present review, as they recognize the importance of nurses in pc for the elderly, especially considering their relational and technical skills. however, they emphasize the limitations of nursing work due to the lack of specialized qualifications and limited recognition by the health team. that said, considering the epidemiological and demographic overview of the population, it is increasingly necessary to focus on healthy aging, with the comfort and well-being of patients in line with a sustainable health system, which has the home as the primary location for care (27-30). these authors indicate the importance of the home being part of the care network for the elderly in pc. in addition to being a strategy to reduce avoidable expenses for the system, society, and family, it is an environment defined by the patients and their families capable of meeting the patients' demands, which encompass more than the physical aspect, including existing relationships. an analysis of the operational viability of pc intervention at home offered to elderly returning from intensive care units showed improvements in physical functioning, quality of life, and symptom management, leading to patient satisfaction (50). in this regard, studies (28, 30) indicate that most elderly eligible for pc currently spends their end of life in hospital institutions, often against their will, due to unnecessary transfers. the health system's frailties include the absence of a health system designed for the care of chronic diseases, the impaired relationship between professionals and patients due to the short consultation time, the long wait for appointments, and the limited number of professionals dedicated to pc (27). overcoming these frailties implies forming a system in a network, with the primary level of healthcare as the structuring line of care, with improved range, home, and families (27). for good practices to be established at home, the authors (28-31) mention the importance of a formalized care plan with supporting information for the elderly, caregiver, and family; the need for communication, teamwork, and the availability of time and interaction with the family; the integration of a multi-professional approach rather than a physician-centered approach; the monitoring of the quality of care, requiring robust clinical governance, research, and adequate professional training; the prioritization of the bond with a team rather than several professionals and single specialists in the treatment (28-31) pc at home increases patients' and caregivers' sense of security as they must deal with life-threatening diseases in this environment (51). another vital aspect mentioned in studies (23, 31) regarding the health network for elderly care in pc is the importance of services having interdisciplinary coordination with the geriatrics specialty as a connection to best practices, providing an integrated care approach. regarding this coordination, a study that sought to identify barriers and enablers of integration in the european context (23) indicated that the form of organization and fragmentation of healthcare, along with the participation of several health professionals in care, seem to hinder this process. in contrast, strong leadership was identified as an enabler at both the clinical practice and the strategic and political levels. strong leadership locally and nationally can support ongoing communication between organization members and the development of new initiatives in the integration of pc and geriatrics (23). in a prospective controlled study (52) that compared elderly patients in home pc, followed up by primary healthcare and elderly patients who, in addition to this follow-up, received a geriatric home intervention and the availability of 24-hour geriatric service, the rate of hospitalizations and emergency care, as well as unnecessary hospitalizations after the first year of intervention, were reduced. there was an increase in the proportion of patients who died at home. the authors emphasize that although death at home was considered a favorable outcome, an integrated care model in the service network is essential so that patients who prefer or need to be hospitalized have easy access to this resource. also worth highlighting is the care provided to older people with dementia. in an aging society, dementia, a chronic, progressive, and terminal disease leading to complex care needs, is increasingly present. the cognitive decline caused by this disease weakens the patients' leading role in their care process, requiring intense family participation (30). authors (25) indicate that dementia is still neglected mainly from the perspective of pc for the elderly since it is considered a natural aging condition. person-centered care, with family participation for optimal communication and decision making, as well as training in communication skills and orientation for professionals, are still barriers to the consolidation of pc for the elderly with dementia (25). from this perspective, the ideal pc for the elderly with dementia includes discussing the prognosis and care plan with patients and caregivers, patient access to services, and standardized guidelines, as these can contribute to the first approach but may lead to the loss of patient-centered care (53). as a study limitation, it is worth mentioning that the theme is still nascent in the literature, and only 12 articles were selected from the researched databases. in addition, the option to use decs and mesh may have limited the search scope and resulted in the loss of essential documents that discussed the theme in question. conclusions when mapping the scientific evidence related to the organization of pc practices for the elderly in the hns, it is noted that, given the impact of aging on society, discussions around pc for the elderly and their families are still modest. although the studies indicate the importance of the insertion of pc within a care network, having primary healthcare as the organizer of these practices, the concept of a network effectively established is still developing, which indicates fragmented assistance. however, the coordination between more than one level of care is eventually addressed. they also address the importance of pc being provided in the home/residence of the elderly, which favors the interface with primary care. at this level, it has the location and people's homes as the object of care. one of the gaps identified in this review was the low number of studies published by countries that have been facing the challenges of aging, highlighting the limited discussion around solid national policies and guidelines that direct these practices. it is believed that this study can contribute to shedding light on the theme, broadening discussions that reach society, multi-professional teams, and health system managers in the search for an hns that integrates pc at all levels of care. acknowledgments we would like to thank the brazilian national council for scientific and technological development (conselho nacional de desenvolvimento científico e tecnológico do brasil) for granting us a scholarship to conduct this research through the programa institucional de bolsas de iniciação científica pibic (institutional program for scientific initiation scholarships), and the dean of research of the federal university of minas gerais (pró-reitoria de pesquisa da universidade federal de minas gerais), brazil. conflict of interest: none declared. 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[internet]. 2022;68(1):e-071383. doi: https://doi.org/10.32635/2176-9745.rbc.2022v68n1.1383 48. pavlic rd, aarendonk d, wens j, simões jar, lynch m, murray s. palliative care in primary care: european forum for primary care position paper. prim health care res dev. 2019;20(e133):1-6. doi: https://doi.org/10.1017/s1463423619000641 49. karam m, chouinard mc, poitras me, couturier y, vedel i, grgurevic n, et al. nursing care coordination for patients with complex needs in primary healthcare: a scoping review. int j integr care.2021;21(1):1-21. doi: https://doi.org/10.5334/ijic.5518 50. mayr fb, plowman jl, blakowski s, sell-shemansky k, young jm, yende s. feasibility of a home-based palliative care intervention for elderly multimorbid survivors of critical illness. am j crit care. 2021;30(1):12-31. doi: https://doi.org/10.4037/ajcc2021117 51. sarmento vp, gysels m, higginson ij, gomes b. home palliative care works: but how? a meta-ethnography of the experiences of patients and family caregivers. bmj support palliat care. 2017;7(4):390-403. doi: https://doi.org/10.1136/bmjspcare-2016-001141 52. pollina l, guessous i, petoud v, combescure c, buchs b, schaller p, et al. integrated care at home reduces unnecessary hospitalizations of community-dwelling frail older adults: a prospective controlled trial. bmc geriatr. 2017;17(1):53. doi: https://doi.org/10.1186/s12877-017-0449-9 53. stewart jt, schultz sk. palliative care for dementia. psychiatr clin north am. 2018;41(1):141-51. doi: https://doi.org/10.1016/j.psc.2017.10.011 home 66 aquichan issn 1657-5997 magali rodríguez-vidal1 manuel castro-salas2 valentina sanhueza-escobar3 andrea del valle-utreras4 josé martínez-arriagada5 calidad de vida en pacientes esquizofrénicos 1 magíster en enfermería. profesor asistente, universidad concepción, chile. magrodri@udec 2 magíster en enfermería. profesor asociado, universidad de concepción, chile. mcastro@udec 3 licenciada en enfermería, universidad san sebastián, chile. 4 licenciada en enfermería, universidad san sebastián. 5 licenciado en enfermería, universidad san sebastián. recibido: 08 de septiembre de 2010 aceptado: 11 de marzo de 2011 resumen la presente investigación tuvo como objetivo conocer la calidad de vida y los factores relacionados de los pacientes esquizofrénicos que se controlan en los servicios de salud concepción y arauco de chile durante los meses de abril-junio de 2009. estudio cuantitativo, descriptivo, correlacional de corte transversal. la población incluida en este trabajo comprendió al total de los pacientes esquizofrénicos (40) bajo régimen de corta estadía. el instrumento utilizado fue la variable principal —calidad de vida (cv)—, que se midió a través del cuestionario sf-36, además se incorporaron variables sociodemográficas y de apoyo social, esta última medida a través del cuestionario dukeunc-11. los resuiltados del estudio reflejan aceptable calidad de vida, lo cual puede asociarse con las condiciones socioculturales de la región. palabras clave calidad de vida, esquizofrenia, pacientes mentales, apoyo social, trastornos psicóticos. (fuente: decs). quality of life in schizophrenic patients abstract the objective of this study was to identify quality of life and related factors in schizophrenic patients who were being monitored by health-care services in concepción and arauca (chile) during april-june 2009. it is a quantitative, correlational, cross-sectional descriptive study. the population in question included all schizophrenic patients (40) who were subject to a short-term stay. the principal variablequality of life (qol) was the instrument used and was measured with the sf-36 questionnaire. socio-demographic and social support variables were included as well, the latter through application of the duke-unc-11 questionnaire. the findings of the study reflect an acceptable quality of life, which may be associated with the socio-cultural conditions in the region. key words quality of life, schizophrenia, mental health patients, social support, psychotic disorders. (source: decs). año 11 vol. 11 nº 1 chía, colombia abril 2011 l 66-76 67 calidad de vida en pacientes esquizofrénicos l magali rodríguez-vidal, manuel castro-salas, valentina sanhueza-escobar et al. qualidade de vida em pacientes esquizofrênicos resumo este estudo teve como objetivo determinar a qualidade de vida e os fatores relacionados de pacientes esquizofrênicos controlados nos serviços de saúde de concepción e arauco no chile durante os meses de abril a junho de 2009. estudo quantitativo, descritivo, correlacional, transversal. neste estudo, a população incluiu os pacientes com esquizofrenia (40) sob o regime de curta permanência. o instrumento utilizado foi a variável principal – a qualidade de vida (qv) –, medida através do questionário sf-36. também se integraram variáveis sócio-demográficas e de suporte social. esta última foi medida pelo questionário duke-unc-11. os resultados do estudo mostram uma qualidade de vida aceitável. isso pode associar-se com as condições socioculturais da região. palavras-chave qualidade de vida, esquizofrenia, doente mental, apoio social, transtornos psicóticos. (fonte: decs). 68 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 introducción la calidad de vida (cv) o de la "buena vida" está presente desde la época de los antiguos griegos (aristóteles), la instalación del concepto dentro del campo de la salud es relativamente reciente, con un auge evidente en la década de los noventa, que se mantiene en estos años del siglo xxi. la organización mundial de la salud (oms) (1) define cv como "la percepción que tienen los individuos acerca de su posición en la vida, teniendo en cuenta el contexto del sistema cultural y de valores en que viven y en relación con sus metas, expectativas, normas e intereses" (2). la calidad de vida relacionada con la salud (cvrs) en un paciente representa el impacto que una enfermedad y su tratamiento tienen sobre la percepción del paciente en su bienestar. patrick y erickson (3) la definen como la medida en que se modifica el valor asignado a la duración de la vida en función de la percepción de limitaciones físicas, psicológicas, sociales y de disminución de oportunidades a causa de la enfermedad, sus secuelas, el tratamiento o las políticas de salud. para schumaker y naughton (4) la calidad de vida relacionada con la salud (cvrs) es la percepción subjetiva, influenciada por el estado de salud actual, de la capacidad para realizar aquellas actividades importantes para el individuo. la esencia de este concepto está en reconocer que la percepción de las personas sobre su estado de bienestar físico, psíquico, social y espiritual depende en gran parte de sus propios valores y creencias, su contexto cultural e historia personal. la cvrs es la resultante del tipo de enfermedad, su evolución, la personalidad del paciente, el grado de cambio que inevitablemente se produce en su vida, el apoyo social percibido y la etapa de la vida en que se produce la enfermedad (5). si bien la incorporación de las medidas de cvrs representan uno de los avances más importantes en materia de evaluaciones en salud, no existe aún la claridad suficiente respecto a una base conceptual compartida; por otra parte, se debe aceptar la dificultad de medir integralmente un fenómeno tan multidimensional como es la autoevaluación de la percepción individual, tratando de generar una base empírica que permita pasar de un discurso genérico e inconmensurable a datos que provean evidencia científica de adecuada calidad. implica además aceptar que, hasta el momento, las evaluaciones de cvrs asumen que las personas son capaces de analizar aspectos de su estado de salud en forma aislada, separándolos de otros aspectos de la vida humana (ingresos, situación laboral, relaciones interpersonales, estrategias personales de afrontamiento). hay numerosas evidencias de que, a medida que la enfermedad progresa, ocurren ajustes internos que preservan la satisfacción que la persona siente con la vida, por lo que podemos encontrar personas con grados importantes de limitación física que consideran que su cv es buena (6). la organización mundial de la salud (oms) define calidad de vida como "la percepción que tienen los individuos acerca de su posición en la vida, teniendo en cuenta el contexto del sistema cultural y de valores en que viven y en relación con sus metas, expectativas, normas e intereses". 69 calidad de vida en pacientes esquizofrénicos l magali rodríguez-vidal, manuel castro-salas, valentina sanhueza-escobar et al. dentro del bienestar psíquico, la salud mental se conoce como el estado de equilibrio entre una persona y su entorno sociocultural, lo que garantiza su participación laboral, intelectual y de relaciones para alcanzar bienestar y cv. la salud mental es la capacidad del individuo, el grupo y el ambiente, de interactuar de forma tal que se promueva el bienestar subjetivo, el óptimo desarrollo y el uso de las habilidades mentales (cognitivas, afectivas y relacionales); la adquisición de las metas individuales y colectivas en forma congruente con la justicia y la preservación de equidad fundamental (7). la enfermedad psiquiátrica es una alteración de los procesos cognitivos y afectivos del desarrollo, considerados como anormales con respecto al grupo social de referencia del cual proviene el individuo. esta alteración se manifiesta en trastornos del razonamiento, del comportamiento, de la facultad de reconocer la realidad y de adaptarse a las condiciones de la vida (8). la esquizofrenia (eqz), también llamada “demencia precoz”, es una enfermedad mental prematura, de comienzo agudo e insidioso, de evolución crónica por brotes, caracterizada por una disociación cognoscitivo-afectiva-cognitiva que produce deterioro de la personalidad con la consecuente afectación de la capacidad creadora y relacional del individuo con su medio circundante (9). la enfermedad se caracteriza por un tipo específico de alteración del pensamiento y los sentimientos, y la relación con el mundo exterior (10). a nivel mundial, para esta enfermedad se calcula una prevalencia de entre el 0,5 y 1,5 % de la población, existiendo en general poca variación cultural. la motivación de este estudio es indagar en aquellos factores modificables que estarían afectando negativamente la calidad de vida de los pacientes con esta enfermedad, a fin de mejorar la adherencia al tratamiento y la rehabilitación para, de acuerdo con los resultados obtenidos, plantear intervenciones a futuro destinadas a mejorar o mantener una óptima calidad de vida. por lo anteriormente expuesto, el problema que aborda esta investigación está orientado a conocer la calidad de vida y los factores relacionados de los pacientes esquizofrénicos, que se controlan en los servicios de salud de concepción y arauco, chile, durante los meses de abril-junio de 2009. diseño metodológico este es un estudio cuantitativo, descriptivo, correlaciónal y de corte transversal. la población incluida en este trabajo comprendió al total de los pacientes esquizofrénicos bajo régimen de corta estadía (40 pacientes) que acuden al hospital de día del servicio de salud concepción, y los pacientes que se controlan en el programa de salud mental (prosam) del servicio de salud arauco entre los abril y junio de 2009, previa autorización de los directores de los centros de salud mencionados, y la obtención del consentimiento informado otorgado por los pacientes que fueron estudiados. los criterios de inclusión consideraron pacientes esquizofrénicos compensados, que estaban en tratamiento y rehabilitación en los centros citados anteriormente. se excluyeron de este estudio todos los pacientes esquizofrénicos menores de 20 años y mayores de 65, personas sordomudas, portadores de hipoacusia bilateral, no videntes y pacientes en etapa aguda de la enfermedad. la salud mental es la capacidad del individuo, el grupo y el ambiente, de interactuar de forma tal que se promueva el bienestar subjetivo, el óptimo desarrollo y el uso de las habilidades mentales. 70 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 el instrumento utilizado estuvo constituido por la variable principal —calidad de vida—, que se midió a través del cuestionario sf-36, el cual consta de 36 preguntas que se agrupan en 8 dimensiones con respuestas tipo likert, cuyos puntajes sumados van de 36 a 100 puntos. se establecieron las siguientes categorías, basadas en los percentiles de la distribución observada: mala cv <45 puntos; regular cv de 46 a 79; buena cv >80. además, se incorporaron variables sociodemográficas y de apoyo social, esta última medida a través del cuestionario duke-unc-11 que consta de 11 ítems en total, con respuestas tipo likert que puntúan de 0 a 4 cada una. se establecieron las siguientes categorías: mal apoyo social: 0-11, regular apoyo social: 12-22, buen apoyo social: 23-33, excelente apoyo social: 34-44. la prueba piloto se realizó en el hospital de día de una comuna perteneciente al servicio de salud concepción. el instrumento fue validado por expertos y la confiabilidad medida a través del alfa de cronbach, que dio un resultado de 0,85 para el cuestionario duke-unc-11, y de 0,91 para el cuestionario sf-36. para el procesamiento de los datos se usó el programa estadístico computacional spss 15.0 utilizando análisis descriptivo bivariado, más pruebas paramétricas y no paramétricas, con un nivel de confianza de 95 %. resultados la tabla 1 (ver anexo) muestra el análisis de los puntajes obtenidos de la escala de cv aplicada a 40 pacientes esquizofrénicos, el promedio de puntaje obtenido es de 74,4 más menos 18 puntos, calificado como regular cv. el 50 % de los pacientes obtuvo un puntaje menor o igual a 80 y el 50 % restante mayor a 80, calificado como buena cv. el puntaje que más se repite corresponde a 72 (regular cv). el puntaje mínimo observado fue de 36, calificado como mala cv, y el máximo observado fue de 99 (buena cv). las edades fluctuaron entre 25 y 63 años, con un promedio de 44,3; un 55 % correspondió al sexo masculino, y el 45 % al sexo femenino; en cuanto a relación de pareja, el 77,5 % manifiesta no tenerla. un 35 % corresponde a nivel educacional básico incompleto (ver anexo, tablas 2 y 3), y el 65 % informa más de 5 años de tratamiento. en relación con el apoyo social, un 30 % de los encuestados afirma contar con un mal apoyo, y un 30 % lo califica de excelente. los datos presentados nos muestran que los pacientes que presentaban mala cv tenían una media de 29 años, mientras que los que tenían regular cv se ubicaban en una media de 51,4 años; los que percibían una buena cv tenían una media de 42,1 años. el análisis de anova muestra que existen diferencias estadísticamente significativas entre ambas variables (f=9,25). debido a la disparidad entre los rangos de edades, se realizó un test de comparaciones múltiples el cual muestra que las diferencias en las medias está dada por el grupo de los jóvenes, la cual fue muy significativa con una p de 0,001 (ver anexo, tabla 4). se pudo apreciar que los pacientes de sexo masculino y femenino presentaban una media de cv calificada como regular, la docimacia de hipótesis con un 95 % de confianza nos revela que no existen diferencias estadísticamente significativas entre las medias de cv en relación con el sexo. en relación con la calidad de vida y el nivel educacional, de un total de 40 pacientes analizados, los que presentaban una mejor calidad de vida fueron los que cursaron enseñanza media completa. 71 calidad de vida en pacientes esquizofrénicos l magali rodríguez-vidal, manuel castro-salas, valentina sanhueza-escobar et al. el análisis de asociación muestra que no existen diferencias significativas entre cv y existencia de pareja. en relación con la cv y el nivel educacional, de un total de 40 pacientes analizados, los que presentaban una mejor cv fueron los que cursaron enseñanza media completa. para saber si existen diferencias estadísticamente significativas se realizó la prueba estadística de c2, cuyo valor fue de 30,23, con un p de 0,001, lo que significa que existe asociación entre ambas variables. con el objeto de saber si la asociación era fuerte o débil se calculó una v. de cramer y coeficiente de contingencia, cuyos valores fueron de 0,61 y 0,65 respectivamente, mostrando una fuerte asociación (tabla 5). al relacionar la cv con años de tratamiento se observa que los que informan menos de 5 años de tratamiento tienen una media de 78 puntos, y con más de 5 años la media es de 72 puntos, lo que representa una regular cv, la docimasia de hipótesis muestra que no existen diferencias estadísticamente significativas. el análisis descriptivo muestra que el promedio de calidad de vida fue de 74 puntos calificado como regular, y el promedio de la escala de ducke-unc-11 fue de 24,38 calificado como buen apoyo social. la correlación calculada nos dio como resultado un 0,46 y una significancia de 0,003; como se puede apreciar la relación resultó ser estadísticamente significativa, existiendo una baja relación lineal entre ambas variables. el r2 muestra que la variación de los puntajes de cv está explicada en un 21,5 % por las diferencias en los puntajes de la escala de apoyo social. a fin de cuantificar esta asociación se utilizó un coeficiente beta y este muestra que por cada unidad que aumenta la escala de ducke-unc-11, la escala de c. de v. aumenta en un 0,789 (ver anexo, tabla 6). discusión los trastornos psicóticos, y entre ellos especialmente la esquizofrenia, están caracterizados por un importante menoscabo en el funcionamiento diario (social, cognitivo y afectivo) de aquellos que los padecen (11). la relación entre calidad de vida y esquizofrenia es actualmente un problema de investigación que ha adquirido gran importancia dado el interés en conocer la apreciación que hacen los pacientes de su situación. debemos destacar el hecho de que en el enfermo esquizofrénico se presenta una dificultad considerable en la validez de las autoevaluaciones que ellos hacen de su situación. no obstante lo dicho, skantze (12), en un trabajo realizado en suecia, demostró que los enfermos esquizofrénicos son capaces de sentir y de comunicar sus propios déficit sociales. por su parte lehman (13), en el año 1983, afirmaba que los pacientes esquizofrénicos son competentes para informar sobre su cv y que estos datos pueden considerarse fiables. en todo caso, este autor recomienda prudencia ante la validez de las evaluaciones de cv realizadas por enfermos mentales graves. podemos agregar que es muy importante el estadio de la enfermedad al momento de responder el cuestionario (14). la esquizofrenia es una patología mental grave que afecta a todas las poblalos trastornos psicóticos, y entre ellos especialmente la esquizofrenia, están caracterizados por un importante menoscabo en el funcionamiento diario (social, cognitivo y afectivo) de aquellos que los padecen. 72 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 ciones. se estima que su prevalencia fluctúa entre un 0,2 a 2 %, y su incidencia anual sería de aproximadamente 1 por 1.000 (15). en chile, 5 de cada 1.000 personas mayores de 15 años presentan este trastorno (16). quienes se ven en esta situación deben hacer frente a los costos económicos, sociales y psicológicos que ella significa, por lo anterior, es posible anticipar que la calidad de vida en estos pacientes esté alterada respecto del resto de la población. la relación eqz y cv es un problema sobre el cual existe poca información en nuestro medio, la que tenemos proviene de países desarrollados con características sociales, económicas y culturales distintas de las nuestras, por lo que esos resultados no son aplicables a nuestra realidad (17). en relación con la cv no se encontraron niveles bajos en los pacientes con esquizofrenia que conformaron esta muestra ya que más de un 50 % de la población presentó una regular cv, resultados que coinciden con los obtenidos por autores de la universidad de tarapacá (chile) quienes se plantean las siguientes interrogantes: ¿cómo estos pacientes con escasos recursos económicos, sanitarios y comunitarios pueden estar experimentando adecuados niveles de calidad de vida? ¿cuáles serían las variables que existen en esta región específica que, a diferencia de lo que pudiese encontrarse en países desarrollados, hacen que los niveles de calidad de vida sean diferentes? cabe pensar que las condiciones socioculturales de esta región, donde existe un ritmo de vida poco competitivo, con expectativas más modestas, menor ambición y menos necesidades creadas en sus habitantes, menor carestía de la vida, clima agradable y fácil acceso a apoyo religioso, marcan una diferencia notable si se comparan con las grandes ciudades de donde se derivan los otros estudios. en relación con la edad se observa que existen diferencias estadísticamente significativas según rango de edad, y estas estarían dadas por los más jóvenes con una media de 42,14 años. en relación con el sexo los hallazgos de otra investigación (18) reportan que los pacientes varones presentaban peor calidad de vida que las mujeres, lo que no es coincidente con los hallazgos de esta investigación, ya que la cv en ambos sexos era similar, probablemente esto se deba a la muestra seleccionada. en cuanto a la situación de pareja, podemos afirmar que 77,5 % de estos pacientes está sin pareja, resultados que coinciden con los de mayoral (19) donde un 74 % no la tenía, lo que puede ser una muestra de la estigmatización que sufren todavía estos pacientes. los pacientes esquizofrénicos con mayor apoyo social tienen mejor calidad de vida que aquellos pacientes esquizofrénicos que tienen menor apoyo social. sería interesante realizar esta investigación con un número mayor de pacientes que presenten esta patología para asegurar resultados más confiables. referencias bibliográficas 1. organización mundial de la salud. international classification of impairments, disabilities and handicaps: a manual of classification relating to the consequences of disease. genova; 1980. 2. nomen l, navarro c. calidad de vida en pacientes esquizofrénicos a través de un proceso rehabilitador. revista de treball social; 2002. 3. patrick d, erickson p. health status and healt policy: quality of life in health care evaluation and resource allocation. new york: oxford university press; 1993. 4. naughton mj, shumaker, anderson rt, czajkowski sm. psychological aspects of health-related quality of life measurement: tests and scales. quality of life and pharmaco economics in clinical trials. 2 ed. new york: lippincott-raven; 1996, pp. 117-132. 5. schwartzmann l. calidad de vida relacionada con la salud: aspectos conceptuales. ciencia y enfermería 2003; 9 (2): 09-21. 6. leplège a, hunt s. el problema de la calidad de vida en medicina. jama 1998; 7 (1): 19-23. 7. ministerio de salud. guía clínica primer episodio esquizofrenia, santiago de chile; 2005. 8. caviares a, valdebenito m. funcionamiento cognitivo y calidad de vida en la esquizofrenia. revista chilena de neuro-psiquiatría 2005; 43 (2): 97-106. 73 calidad de vida en pacientes esquizofrénicos l magali rodríguez-vidal, manuel castro-salas, valentina sanhueza-escobar et al. 9. carvajal c. esquizofrenia y trastornos relacionados. in: florenzano r, carvajal c weil k editores. psiquiatria. santiago chile: mediterráneo; 1999, pp. 82-91. 10. bleuler e. demencia precoz. el grupo de las esquizofrenias. revista chilena de neurosiquiatría 1966; 153: 321-30. 11. farriol n, palma c, ramos m, fernández m, chamorro a et al. efectividad de un programa de intervención psicosocial en pacientes psicóticos crónicos. clínica y salud 2006; 2 (17): 171-185. 12. skantze k, malm u, dencker s, may p. quality of life in schizophrenia. nordic journal of psychiatry 1995; 49 (5): 323-323. 13. lehman a, postrado lt, rachuba lt. convergent validation of quality of life assessment for persons with severe mental illnesses. quality of life research 1993; 5 (2): 327-333. 14. mingues m, gonzález p, alonso del teso f, sanguino a, garcía a. efectos adversos de los antipsicóticos y calidad de vida. actas españolas de psiquiatría 2005; 33 (1): 1-6. 15. american psychiatric association diagnostic and statistical. manual of mental disorders. washington dc; 1994. 16. minoletti a, zaccaria a. plan nacional de salud mental en chile: 10 años de experiencia. revista panamericana de salud 2005; 18: 346-358. 17. caqueo a, lemos s. calidad de vida y funcionamiento familiar de pacientes con esquizofrenia en una comunidad latinoamericana. universidad de tarapacá (chile) y universidad de oviedo españa. psicothema 2008; 4 (20): 577-582. 18. browne s, roe m, lane a, gervin m, morris m et al. quality of life in schizophrenia: relationship to socio-demographic factors, symptomatology and tardive dyskinesia. acta psychiatrica scandinavica 1996; 2 (94): 118-124. 19. mayoral f et al. calidad de vida y funcionamiento social en pacientes con esquizofrenia en monoterapia con olanzapina: estudio naturalístico de 1 año de seguimiento. actas españolas de psiquiatría 2006; 34 (1): 7-15. 74 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 estadísticos descriptivos media 74,42 mediana 80,83 moda 72(a) desv. estándar 18,051 mínimo 36 máximo 99 percentiles 25 62,36 tabla 1. resultados de la aplicación de la escala de cv sf-36 a pacientes esquizofrénicos del servicio de salud concepción y prosam de cañete perteneciente al servicio de salud arauco chile. abril-junio de 2009. fuente: estudio de calidad de vida de pacientes esquizofrénicos hospital de día de coronel, abril-junio de 2009. fuente: estudio de calidad de vida de pacientes esquizofrénicos hospital de día de coronel, abril-junio de 2009. tabla 2. distribución de los pacientes esquizofrénicos según edad media 44,3 mediana 46 moda 39 desv. estándar 11,735 mínimo 25 máximo 63 percentiles 25 35,25 tabla 3. distribución de los pacientes esquizofrénicos según nivel educacional. fuente: estudio de calidad de vida de pacientes esquizofrénicos hospital de día de coronel, abril-junio de 2009. nivel educacional no. de pacientes % básico incompleto 14 35 básico completo 4 10 enseñanza media incompleta 6 15 enseñanza media completa 12 30 técnico nivel superior 2 5 estudio universitario incompleto 2 5 total 40 100 anexo 75 calidad de vida en pacientes esquizofrénicos l magali rodríguez-vidal, manuel castro-salas, valentina sanhueza-escobar et al. tabla 5. calidad de vida según nivel educacional de pacientes esquizofrénicos fuente: estudio de calidad de vida de pacientes esquizofrénicos hospital de día de coronel, abril-junio de 2009. nivel educacional mala calidad regular calidad buena calidad total de vida (%) de vida (%) de vida (%) (%) básico incompleto 0,00 53,30 28,60 35,00 básico completo 25,00 13,30 4,80 10,00 enseñanza media incompleta 25,00 20,00 9,50 15,00 enseñanza media completa 0,00 13,30 47,60 30,00 técnico nivel superior completo 50,00 0,00 0,00 5,00 estudio universitario incompleto 0,00 0,00 9,50 5,00 no. de pacientes 4 15 21 40 c2 30,239 0,001* v de cramer 0,615 0,001* coeficiente de contingencia 0,656 0,001* tabla 6. calidad de vida según apoyo social fuente: estudio de calidad de vida de pacientes esquizofrénicos hospital de día de coronel, abril-junio de 2009. media desviación estándar n calidad de vida 74,42 18,051 40 duke-unc11 24,38 10,604 40 correlaciones r 0,463 r-2 0,215 coeficiente beta 0,789* p* significativo p = 0,003* fuente: estudio de calidad de vida de pacientes esquizofrénicos hospital de día de coronel, abril-junio de 2009. tabla 4. calidad de vida según edad de pacientes esquizofrénicos. no. de pacientes media desviación estándar mala calidad de vida 4 29 4,546 regular calidad de vida 15 51,4 10,842 buena calidad de vida 21 42,14 9,676 total 40 44,3 11,735 f calculado = 9,25 p = 0,001 76 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 gráfico 1. calidad de vida y apoyo social fuente: estudio de calidad de vida de pacientes esquizofrénicos hospital de día de coronel, abril-junio de 2009. 421 432 incontinencia y enfermedad cronica.indd 421 beatriz sánchez-herrera1 gloria mabel carrillo2 lucy barrera-ortiz3 incontinencia y enfermedad crónica 1 enfermera. master in science of nursing. profesora titular, universidad nacional de colombia, colombia. cbsanchezh@unal.edu.co 2 enfermera. magíster en enfermería. profesora asociada, universidad nacional de colombia, colombia. gmcarrillog@unal.edu.co 3 enfermera. magíster en enfermería. profesora titular, universidad nacional de colombia, colombia. lbarrero@unal.edu.co recibido: 18 de agosto de 2012 enviado a pares: 30 de agosto de 2012 aceptado por pares: 17 de junio de 2013 aprobado: 17 de junio de 2013 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 421-432 para citar este artículo / to reference this article / para citar este artigo sá nchez-herrera, b., carrillo, g. m., barrera-ortiz, l. (2013). incontinencia y enfermedad cró nica. aquichan. vol. 13, no. 3, 421-432. resumen objetivo: explorar la producción y contenido de la información disponible a nivel mundial sobre el abordaje de la incontinencia urinaria (iu) e incontinencia fecal (if) y su relación con la enfermedad crónica (ec). materiales y métodos: a partir de una revisión de literatura en las bases de datos cinahl, ovid, scielo, medline y psychoinfo, entre los años 2009 y 2012, bajo los descriptores de incontinencia urinaria e incontinencia fecal, en combinación con enfermedad crónica, con su traducción al inglés, se identificaron, analizaron y clasificaron los planteamientos sobre el tema de la incontinencia según relevancia para la comprensión de la misma en la situación de ec. resultados: se presentan los estudios encontrados clasificados en cinco grandes grupos sobre iu e if que incluyen los que ilustran la magnitud del problema por su frecuencia y tipología, los que establecen relación directa entre la incontinencia y la ec, los que describen otros factores asociados con la incontinencia y con la ec, los que abordan la forma de valorar la incontinencia y los que dan aportes respecto al manejo de la iu o if en la ec. conclusiones: la literatura tiene abundante producción científica en sus dos últimos años y a nivel mundial sobre la iu pero no en igual proporción sobre la if. existen modelos para la valoración, medición y comprensión del fenómeno así como para la intervención y atención puntual sobre la misma. no se reportan abordajes integrales al problema de la iu e if en personas con ec. palabras clave incontinencia urinaria, incontinencia fecal, enfermedad crónica, enfermería. (fuente: decs, bireme). 422 aquichan issn 1657-5997 incontinence and chronic illness abstract objective: the production and content of the information available globally on the problem of urinary incontinence (ui) and fecal incontinence (fi) and their relationship to chronic illness (chd) are examined in this study. materials and methods: a database literature review was conducted in cinahl, ovid, scielo, medline and psychoinfo, between 2009 and 2012, using the descriptors “urinary incontinence” and “fecal incontinence” in combination with “chronic illness”. the approaches to the issue of incontinence were identified, analyzed and classified according to relevance for understanding them in a situation involving chronic illness. results: the studies found were presented classified into five main groups with respect to ui and fc; namely, those illustrating the magnitude of the problem because of its frequency and type, those establishing a direct relationship between incontinence and chronic illness, studies describing other factors associated with incontinence and with chronic illness, those on how to assess incontinence, and studies that offer input on how to manage ui and fi during chronic illness. conclusions: the literature reflects abundant scientific production in the last two years and worldwide with respect to ui, but not for fi. there are models for assessing, measuring and understanding the phenomenon, and for specific intervention and care. however, no comprehensive approaches to the problem of ui and fi in persons with chronic illness were reported. key words urinary incontinence, fecal incontinence, chronic illness, nursing. (source: decs, bireme). incontinência e doença crônica resumo objetivo: explorar a produção e conteúdo da informação disponível no âmbito mundial sobre a abordagem da incontinência urinária (iu) e incontinência fecal (if) e sua relação com a doença crônica (dc). materiais e métodos: a partir de uma revisão de literatura nas bases de dados cinahl, ovid, scielo, medline e psychoinfo, entre 2009 e 2012, sob os descritores de incontinência urinária e incontinência fecal, em combinação com doença crônica, com sua tradução inglês, identificaram-se, analisaram e classificaram as proposições sobre o tema da incontinência segundo a relevância para compreensão desta na situação de dc. resultados: apresentam-se os estudos encontrados classificados em cinco grandes grupos sobre iu e if que incluem os que ilustram a magnitude do problema por sua frequência e tipologia, os que estabelecem relação direta entre a incontinência e a dc, os que descrevem outros fatores associados com a incontinência e com a dc, os que abordam a forma de valorar a incontinência e os que dão contribuições a respeito do manejo da iu ou if na dc. conclusões: a literatura tem abundante produção científica em seus dois últimos anos e no âmbito mundial sobre a iu, mas não na mesma proporção sobre a if. existem modelos para a valoração, medição e compreensão do fenômeno, bem como para a intervenção e atendimento pontual sobre a ela. não se relatam abordagens integrais ao problema da iu e if em pessoas com dc. palavras-chave incontinência urinária, incontinência fecal, doença crónica, enfermagen. (fonte: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 421-432 423 incontinencia y enfermedad crónica l beatriz sánchez-herrera, gloria mabel carrillo, lucy barrera-ortiz introducción para comprender la relación entre la incontinencia y la enfermedad crónica es preciso recordar que tanto la micción como la defecación son procesos dinámicos que requieren la coordinación de varios mecanismos. en primer lugar, estos son controlados por un reflejo en el centro ubicado a nivel del sacro. en el caso de la micción las vías de salida somáticas y autonómicas conducen información vía médula sobre el volumen vesical a medida que la vejiga se llena. frente a ello se genera una respuesta motora. de esta forma, a medida que la vejiga se llena, el estímulo simpático cierra el cuello vesical, relaja la parte superior de la vejiga e inhibe el tono parasimpático; la inervación somática mantiene el tono en el piso de la musculatura pélvica, incluyendo el músculo estriado alrededor de la uretra. cuando se presenta la micción, el tono simpático y somático disminuyen y el impulso parasimpático causa contracción vesical. un mecanismo similar ocurre en la defecación, en donde interactúan fuerzas parasimpáticas para la evacuación y simpáticas y somáticas para la retención de la materia fecal. los dos procesos, urinario y fecal, se encuentran orientados por los centros nerviosos mayores incluida la corteza cerebral, el cerebelo y el tallo cerebral, que cumplen un papel predominantemente inhibitorio. la alteración de estos complejos mecanismos puede generar incontinencia. en circunstancias normales, a medida que la vejiga se va llenando la presión se mantiene baja hasta que llega a 250-300 ml (siendo la capacidad de 400 a 600 ml). al iniciar la micción normal, la presión del músculo vesical aumenta hasta exceder la resistencia de la uretra y la orina puede salir. por ello, la alteración de la función o la falta de coordinación entre estos procesos puede contribuir a la incontinencia urinaria (iu). no hay reportes similares para los volúmenes de materia fecal (1). el término incontinencia significa imposibilidad de contener. en el campo de la salud, incontinencia se refiere a la eliminación corporal involuntaria que puede ser de orina, denominada incontinencia urinaria (iu) o de materia fecal llamada incontinencia fecal (if). la incontinencia es una condición heterogénea y potencialmente incapacitante de alta prevalencia en personas con enfermedad crónica (ec), que es difícil de curar pero puede manejarse y mejorar (1). el presente trabajo buscó explorar el nivel de producción y contenido de la información disponible mundialmente entre los años 2009 al 2012, sobre el abordaje de la incontinencia urinaria (iu) e incontinencia fecal (if), y su relación con la enfermedad crónica (ec). materiales y métodos se revisó la literatura reportada en las bases de datos cinahl, ovid, scielo, medline y psychoinfo, entre los años 2009 y 2012, bajo los descriptores de incontinencia urinaria e incontinencia fecal, en combinación con enfermedad crónica, con su traducción al inglés, y se identificaron y analizaron planteamientos del significado, la presentación y el abordaje de este tema. la búsqueda sistemática reportó para este periodo 307 artículos, de los cuales 40 cumplieron los criterios de inclusión por documentar, reseñar o representar específicamente la iu o la if en situaciones de enfermedad crónica o que tuvieran relevancia para comprender o cualificar la práctica clínica. una vez seleccionados los artículos se clasificaron y organizaron por temáticas similares. en tres casos, y con el ánimo de dar una mejor explicación o ilustración del tema, fue necesario regresar a las fuentes primarias en las que se basaron los estudios para ampliar la ilustración. este documento incluye las tres referencias adicionales consultadas. resultados con base en el análisis de las referencias reportadas en la literatura mundial sobre la iu e if en relación con la ec entre 2009 y 2012, se establecieron cinco grupos de estudios que incluyeron: 1) reportes que ilustran la magnitud del problema por su frecuencia y tipología; 2) reportes que establecen relación entre la incontinencia y la ec; 3) reportes que ilustran otros factores asociados con la incontinencia y con la ec; 4) reportes que precisan cómo valorar la incontinencia; 5) estudios sobre el manejo de la incontinencia en la ec. a continuación se detalla cada uno de ellos: 1. frecuencia y tipología de la incontinencia ergul et al. (2) señalan, con base en un estudio en el que participaron 694 personas ancianas institucionalizadas, que la iu y la if son frecuentes y que tienden a confundirse con los cambios propios del envejecimiento y, en tal sentido, es preciso clarificar sus diferencias para lograr apoyo terapéutico adecuado y oportuno (2). roe et al. (3), complementan lo anterior estableciendo que la iu es un problema de salud frecuente, que se incrementa con la edad y se presenta más en las mujeres, en las personas ancianas y en quienes están institucionalizados. año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 421-432 424 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 arzu y fatma (4), reportan la frecuencia de la incontinencia en personas ancianas institucionalizadas por diferentes problemas de salud en turquía con un 98 % de iu y 29,1 % de if. uslu et al. (5) también estudiaron el fenómeno en turquía y además de determinar la alta prevalencia de la iu en personas institucionalizadas, revisaron su impacto en la calidad de vida. la iu fue reportada en 23,2 % de las personas del estudio y de ellas solo el 14,3 % buscó ayuda, con lo cual se pone en evidencia que podría haber subregistro del problema con un impacto negativo en la calidad de vida en aspectos físicos, económicos y psicosociales. ojengbede et al. (6) revisaron la prevalencia de la iu en áfrica con 5001 mujeres de raza negra, adultas, con una edad promedio de 32 años y que vivían en nigeria. ellos encontraron que el 2,3 % tenía iu de estrés, el 1 % de urgencia y el 0,6 % mixta. calificando los niveles de severidad encontraron que para el 0,5 % la iu fue severa, para el 0,1 % moderada y para el 2,2 % leve. la presencia de iu fue más frecuente en quienes tuvieron partos naturales especialmente con los casos de multiparidad. brito et al. (7) reportan la iu de estrés en el norte de brasil señalando que el 15,34 % la tiene y que esta prevalencia no cambia con la edad. el 57,92 % señalaron haber pedido ayuda terapéutica. sus hallazgos no mostraron asociación con variables socioeconómicas ni ginecológicas. fiegen et al. (8) evaluaron la prevalencia de la iu en mujeres indígenas del norte de los estados unidos para lo cual revisaron en un grupo de 234 mujeres de 18 a 80 años encontrando que en el 15,4 % se presentaba iu de estrés, en el 2,14 % iu de urgencia y en el 20,5 %, mixta. aitola et al. (9) estudiaron la prevalencia en finlandia con un grupo de 8000 personas entre los 30 y 81 años de edad. la prevalencia de if en el último año fue del 10,6 %, siendo más frecuente en mujeres. las mujeres emplearon protección de la ropa interior con 9 veces más frecuencia y el 23,6 % la usó en forma permanente. sus hallazgos señalan alta relación entre la iu y la if. de los afectados, el 66 % sintió requerir ayuda pero solo el 27,2 % la pidió y el 10 % la recibió. de mello portella et al. (10) estudiaron la prevalencia de if en 190 mujeres con iu o con prolapso de un órgano pélvico. la if se presenta en el 40,54 % de las mujeres con iu y en 27,91 % de las que tenían un prolapso. estos autores documentan un impacto negativo de la if en la calidad de vida. en resumen, estos estudios revelan que además de que la iu y la if son frecuentes en poblaciones de diferentes partes del mundo estas se asocian de manera negativa con la calidad de vida. la incontinencia es una condición heterogénea que va desde salida de gotas de orina al toser hasta iu total o mixta que implica iu e if. la incontinencia afecta los aspectos físicos, psicológicos y sociales, y genera altos costos en el cuidado de la salud. incontinencia aguda frente a incontinencia establecida. a partir de la literatura se pudo establecer una diferencia fundamental en la incontinencia y es su carácter de aguda frente a establecida, así como de la importancia de clasificarla para poder abordar su manejo. la incontinencia aguda se relaciona generalmente con una enfermedad pasajera o una nueva medicación, y se resuelve al tratarla o retirar el medicamento. la incontinencia establecida o de largo plazo, por el contrario, es la que persiste y se tiende a convertir en un problema crónico de salud. se encuentran también reportados cinco grandes grupos de causas posibles de incontinencia que incluyen las urológicas, las neurológicas, las locomotoras y ambientales y las psicológicas. comprender las causas permite hacer un manejo adecuado del problema. incontinencia establecida. se puede clasificar en cuatro grupos: i) de estrés, ii) de urgencia, iii) de sobre flujo y iv) formas combinadas entre ellas (11). incontinencia de estrés es muy frecuente en personas mayores de ambos sexos y en mujeres jóvenes, puede ser de muy pequeñas cantidades de orina y no requerir de un tratamiento específico. con frecuencia se asocia a soporte debilitado de tejidos que rodean la salida de la vejiga y la uretra, generados por la falta de estrógenos, por secuelas de los partos o de cirugías como la histerectomía. los hombres eventualmente, luego de una prostatectomía transuretral, presentan este tipo de incontinencia y esta se asocia a daño en la uretra proximal. incontinencia de urgencia puede ser ocasionada por una variedad de desórdenes genitourinarios y neurológicos. se asocia con vejigas inestables que tienen contracciones involuntarias, o a vejigas de baja capacidad de adaptación y que exceden las resistencias a la salida de orina generando incontinencia. en estos 425 incontinencia y enfermedad crónica l beatriz sánchez-herrera, gloria mabel carrillo, lucy barrera-ortiz casos una contracción franca puede no ocurrir, pero la presión del músculo detrusor se incrementa hasta con bajos volúmenes de orina en la vejiga. de otra parte, cuando estos síntomas se suman a un desorden neurológico se genera el denominado hiper reflejo del detrusor. los cambios por edad o enfermedad en la postura corporal o sus movimientos como en el caso de la tos, pueden generar contracciones vesicales involuntarias, por ello un paciente que tiene una incontinencia de estrés puede tener una vejiga inestable. por su parte, la vejiga inestable puede ser tratada farmacológicamente y la vaginitis atrófica y la uretritis con inflamación y resequedad de la mucosa puede generar irritación crónica, frecuencia urinaria, disuria, urgencia e incontinencia de urgencia. los signos y síntomas, excepto por hallazgos microbiológicos de bacterias, son iguales a los de la infección urinaria, e incluso la bacteriuria y la poliuria algunas veces se presentan en personas con vaginitis atrófica y uretritis (11). la retención urinaria con incontinencia de sobreflujo puede resultar de obstrucción funcional o anatómica de salida de orina, o de una vejiga hipotónica o no contráctil o de ambas. las causas más frecuentes incluyen agrandamiento prostático, vejiga neuropática diabética y obstrucción uretral. el trauma raquimedular y la obstrucción anatómica en las mujeres generados por prolapso y distorsión uretral, son causas menos comunes de esta incontinencia. varios tipos de medicamentos como anticolinérgicos, narcóticos y relajantes del músculo liso pueden contribuir a este tipo de incontinencia establecida (11). las incontinencias mixtas (de estrés, urgencia y sobreflujo) son aquellas que se presentan en combinación. por ejemplo, una mujer con incontinencia de estrés puede tener además una vejiga inestable (11). incontinencia urinaria funcional o pseudoincontinencia por otra parte, la incontinencia funcional o pseudoincontinencia resulta cuando una persona que no tiene una afección genitourinaria no puede o no quiere ir al baño de forma oportuna. esto puede ser por aspectos psicológicos o por baños de difícil acceso, entre otros. incontinencia fecal. la defecación es un proceso fisiológico que involucra múltiples mecanismos de músculos liso y estriado, inervación central y periférica, coordinación de respuestas reflejo, conciencia mental y habilidad física para llegar al baño. la alteración de cualquiera de estos mecanismos puede generar if. la if es menos frecuente que la iu (3). sin embargo, quienes tienen iu con alguna eventualidad pueden presentar episodios de if. 2. asociación de la incontinencia con la enfermedad crónica la relación entre la incontinencia y la ec es muy alta. la incontinencia es una condición muy frecuente en personas con enfermedad crónica y debe ser tenida en cuenta en su cuidado. al respecto, von gontard et al. (12) revisaron la iu en las personas con síndrome de prader-willi, caracterizado por retardo mental, baja estatura, obesidad e hipogonadismo. en su estudio incluyeron a 118 personas con dicho síndrome encontrando que la iu es más frecuente en ellos que en personas sanas. su estudio aporta a una nueva mirada del cuidado que las personas con el síndrome de prader-willi requieren. foley et al. (13) estudiaron 5.474 personas mayores de 70 años que vivían en la comunidad con el propósito de determinar la relación entre la iu y el riesgo aumentado de caídas, encontrando que hay una relación positiva en todos los tipos de iu que se presentaron, señalando además que cuanto más amplia es la pérdida de orina, mayor es el riesgo de caída. más aún, las caídas se asociaron con una peor calidad de vida en quienes tenían iu. busuttil-leaver (14) señala que la iu no es una enfermedad, es un síntoma de alguna causa subyacente y que se asocia con enfermedades crónicas como diabetes y depresión. las personas con iu reportan sentimientos de aislamiento social, soledad y estrés, sin embargo, los autores encontraron que al tratar la causa de base y manejar el síntoma mejora la calidad de vida. sinclair y ramsay (15) estudiaron el impacto psicosocial de la incontinencia y documentan, entre otros, que entre 25-50 % de las mujeres con iu tienen disfunción sexual. jha et al. (16) corroboran con su estudio estos hallazgos reflejando cómo se genera un círculo vicioso que tiende a la cronicidad. el estudio adelantado por hrisanfow y hägglund (17), en suecia, buscó la prevalencia y el estatus de la iu entre 728 personas de 50-75 años con enfermedad pulmonar obstructiva crónica (epoc) atendidas en programas de atención primaria. ellos encontraron que en este, como en otros casos, la prevalencia es mayor 426 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 en mujeres y en cualquier caso, elevada, con 49,6 % en el caso femenino y 30,3 % en los hombres. sus resultados muestran asociación positiva del sobrepeso y los accesos de tos con predominio de la iu de estrés, con 52,4 % de los casos positivos y se encontró goteo posmicción en el 66,3 % de los hombres. la iu alteró las actividades cotidianas en la mayor parte de los casos, en especial en las mujeres; sin embargo, fueron ellas quienes más ayuda pidieron. recomiendan los autores que en los planes de cuidado de los pacientes con epoc se incluyan la cuidadosa valoración de la presencia de iu y su manejo consecuente. en resumen, a pesar de la elevada frecuencia de la incontinencia y su asociación con la ec, solo aparecen reportes de casos muy especiales en algunas ec. 3. factores asociados la vejez como época de la vida en que hay mayor ec. uno de los factores que más se relaciona con la iu y la if es el envejecimiento. envejecer genera modificaciones que pueden favorecer la aparición de incontinencia sin que esta sea parte normal del mismo. dentro de estos cambios están la disminución de la capacidad vesical, el incremento de la orina residual, las contracciones vesicales involuntarias que pueden llegar a generar frecuencia y urgencia, lo cual con la falta de movilidad puede generar incontinencia. la disminución de la presión uretral máxima, especialmente en las mujeres, se relaciona a su vez con la disminución de los estrógenos y pérdida de elasticidad en las estructuras pélvicas femeninas, predisponiendo a la incontinencia de estrés. la pérdida de estrógenos puede ocasionar también vaginitis atrófica, lo cual genera síntomas de disuria y urgencia, y predispone al desarrollo de infección urinaria e incontinencia de urgencia. en los hombres el agrandamiento prostático puede generar incontinencias de urgencia o sobreflujo (1). infección urinaria como un factor de riesgo. la infección urinaria y sus síntomas de urgencia, frecuencia y disuria, se asocian con la incontinencia (1). los medicamentos que reciben algunas personas con ec como factor de riesgo. los medicamentos que se dan a las personas con enfermedad crónica como: i) diuréticos que incrementan el volumen y la frecuencia urinaria; ii) los que afectan la inervación vesical autónoma, el vaciamiento vesical y la uretra, como los anticolinérgicos, que causan retención con incontinencia de sobre flujo, y los bloqueadores alfa adrenérgicos que disminuyen la resistencia de la salida de orina y el tono uretral; iii) las drogas sedantes e hipnóticas que disminuyen la conciencia sobre la necesidad de evacuar o la habilidad de llegar al baño (1). cambios por edad y multiparidad. khori y alkhateeb (18), en su estudio adelantado en un hospital de jordania sobre la incidencia de iu y sus factores de riesgo con 500 participantes señalan que en ellas el 36,4 % reportó tener algún tipo de iu, aunque la mayor parte de estas mujeres no tenía problemas de salud relacionados. de ellas, el 73,6 % presentó iu de estrés, asociada con la edad, la paridad por vía vaginal y la menopausia. esta iu se presentó con goteo al toser o estornudar en 76,4 %. el estreñimiento. en el caso de la if, las causas más comunes se relacionan con desórdenes neurológicos y colorrectales así como con problemas de estreñimiento frecuentes en la ec asociada a baja movilidad o a uso de laxantes. la limitación en el movimiento unida a baja ingesta de líquido y fibra hace que se endurezca la materia fecal, se irrite el recto y resulta generando moco y líquido. este líquido gotea alrededor de la masa impactada de materia fecal y precipita la incontinencia. el estreñimiento es difícil de definir, técnicamente indica menos de tres deposiciones por semana, aunque muchas veces el término se utiliza para describir un paso difícil de las heces por el recto y ano o una percepción de evacuación incompleta (19). 4. valoración clínica en la incontinencia a continuación se enuncian los aspectos genéricos más significativos para tener en cuenta en la valoración clínica de los casos de incontinencia (tabla 1). ness (19) estudió cómo la if afecta la calidad de vida de las personas y la experiencia positiva de hacer una valoración adecuada para definir las causas del problema y poderlo manejar de manera efectiva. con respecto a la disponibilidad de instrumentos de validación han sido reportados y pueden ser útiles para clínicas de asesoría urológica. chang et al. (20) tradujeron el cuestionario internacional de asesoría en incontinencia – versión corta (iciq-ui sf), del inglés al taiwanés y reportan altos niveles de validez y confiabilidad. puede decirse que la valoración de una persona con ec que tenga iu o if debe ser general puesto que sus causas se asocian 427 incontinencia y enfermedad crónica l beatriz sánchez-herrera, gloria mabel carrillo, lucy barrera-ortiz a diferentes razones y se manifiestan de formas distintas. la sistematización puede ser útil para no perderse en este procedimiento. 5. manejo de la incontinencia aunque con mucha frecuencia la incontinencia no es curable, siempre puede ser manejada de forma que los pacientes estén más cómodos, los cuidadores menos sobrecargados y se minimice el costo del cuidado y las complicaciones. para el manejo de la incontinencia es fundamental determinar las necesidades de los pacientes, plantear los problemas prioritarios sobre los que se desea intervenir, y determinar los resultados esperados, que sean consecuentes con la condición clínica del usuario, el impacto a corto y largo plazo, y los recursos con los que se cuente. miller y miller (21), con base en su estudio de iu en los hombres, asociada a la hiperplasia prostática benigna, proponen el uso de la herramienta de valoración índice de síntomas de la asociación americana de urología (auasi, por sus siglas en inglés) como base para definir el tratamiento. señalan las autoras que este tipo de iu se asocia al goteo involuntario y a síntomas del tracto urinario bajo de urgencia, frecuencia y nicturia. medidas de soporte. dentro de las medidas de soporte se cuentan la actitud positiva, la disponibilidad de baños alternos (pato, cómoda), el entrenamiento vesical, evitar complicación iatrogénica, las ropas protectoras, los pañales, las técnicas comportamentales (entrenamiento vesical, horarios, condicionamiento), los cuidados de la piel, los horarios y el seguimiento. a continuación se detallan algunas de las más utilizadas. con frecuencia las personas mayores o quienes tienen su movilidad limitada manejan bien la incontinencia con horarios y limitan sus actividades sociales. cuando tienen un problema adicional agudo o se encuentran en un medio restrictivo como el hospital, por lo general el balance se rompe. es también frecuente que problemas de salud que generan poliuria (p. e. diabetes o hipercalcemia), ocasionen incontinencia (1). de otra parte, la impactación fecal es un problema frecuente en las personas con enfermedad crónica que genera limitación. no es muy claro por qué esta se socia a la iu pero muchas veces al resolver los problemas de defecación la incontinencia mejora. jain et al. (22), con base en una revisión de la literatura, señalan que hay conflicto en la evidencia entre la efectividad del sling transuretral en la iu mixta. en el caso de la iu de urgencia la curación reportada es en promedio del 56,4 % mientras que en la iu de estrés varió entre el 85-97 %. aunque recomiendan el empleo de estos aditamentos, sugieren seguimientos longitudinales a estos tratamientos. tabla 1. aspectos generales para tener en cuenta en la valoración clínica de la incontinencia fuente: elaboración propia con base en la revisión de la literatura. herramientas de valoración aspectos para tener en cuenta historia clínicaanamnesis características de la incontinencia aguda frente a establecida. problemas de salud actuales. medicamentos. impacto de la incontinencia en el paciente y en el cuidador. aparición de la incontinencia, frecuencia, tiempo (horario) en el que se presenta, cantidad de orina evacuada, sensación vesical, síntomas de urgencia frente a estrés, síntomas genitourinarios asociados (disuria, hematuria, tenesmo) o síntomas gastrointestinales asociados (estreñimiento, diarrea, dolor, distensión). nivel de movilidad, estado mental, acceso a los baños. examen físico general, movilidad, piel, abdominal, rectal, genital, inervación lumbosacra. laboratorios clínicos uroanálisis, urocultivo, glucosa sérica, calcio sérico. 428 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 petros (23), buscando separar la iu de urgencia con la de estrés conocida y manejada como iu mixta, señala que si coexisten deben ser identificadas y manejadas de manera individual con el fin de lograr un mejor impacto. solo puede hablarse, según este autor, de iu mixta si ambos síntomas son generados por laxitud en el ligamento pubouretral. ejercicio y fortalecimiento vesical. tanto el ejercicio de la musculatura pélvica como el reentrenamiento vesical con seguimiento y horarios han sido documentados. roe et al. (3), en la revisión de manejo de la iu, señalan que el manejo más usado de la incontinencia fue el uso de pañales y acceso al baño con horario y recordación frecuente. aunque se ven avances al documentar la práctica y la valoración de la incontinencia en las últimas tres décadas, aún se requiere mucho más. hanzaree y steggall (24) describen el manejo de la iu. dentro de sus aportes señalan los ejercicios de kegell y cómo realizarlos (tabla 2). liebergall-wischnitzer et al. (25) compararon la efectividad de los ejercicios musculares circulares (método paula) con el método de entrenamiento de músculos del piso pélvico desarrollados ambos durante doce semanas, frente a la función sexual y la calidad de vida de mujeres con iu de estrés. los dos métodos resultaron efectivos, sin diferencias significativas entre ellos. los medicamentos. inhiben o mejoran la contracción vesical, fortalecen o relajan el esfínter o mejoran el nivel hormonal (estrógenos). la cirugía. se realizan entre otras la suspensión del cuello vesical, la prostatectomía, la implantación de esfínteres, el cabestrillo o anillo uretral y el ensanchamiento vesical. malak (26) estudió el papel de la cirugía antiincontinencia en la iu de estrés señalando que esta debe ser una opción para quienes requieren o tienen antecedente de una cirugía de prolapso vaginal. svenningsen et al. (27) revisaron 137 casos de iu oculta como un factor predictor de iu de estrés posterior a la cirugía del prolapso de un órgano pélvico y encontraron una asociación significativa entre estos factores. sin embargo, la iu no es un factor de identificación para la necesidad quirúrgica. la universidad de maryland medical center ofrece información pública y evidencia sobre los diferentes tratamientos quirúrgicos para manejo de la iu de estrés (esfuerzo) (28). glavind et al. (29) hicieron seguimiento de largo término (1-5 años) a la operación de cabestrillo suburetral (tensión free vaginal tape®) en 173 pacientes y encontraron que a pesar de algunas quejas, las pruebas objetivas mostraron resultados definitivos de mejoría. bekker et al. (30) revisaron la cirugía para la iu en la función sexual de las mujeres sin encontrar cambios posquirúrgicos sobre la frecuencia o satisfacción en sus relaciones pero sí una disminución en la iu durante las mismas. inyección de macroplástico. varios clínicos investigadores han evaluado métodos de inyección de macroplástico que puede hacerse bajo anestesia local en un procedimiento ambulatorio para corregir la iu de estrés en mujeres y señalan que este implante es efectivo a corto, mediano y largo plazo, que es bien aceptado para corregir este síntoma y que tiene pocos efectos colaterales (30-33). tabla 2. ejercicios de kegell para fortalecer el piso pélvico propósito fortalecer la musculatura del piso pélvico para ayudar a aumentar el soporte de la vejiga y la uretra. mejorar la circulación al periné y mejorar el tono del piso muscular. pasos contraer los músculos del periné o piso pélvico como si se tratara de evitar que salga un gas intestinal. los músculos subirán y se centrarán. empleando el mismo grupo de músculos simule interrumpir un chorro de orina. no debe ser real para evitar evacuación incompleta. evite pujar o agacharse mientras hace el ejercicio. exhale aire con la boca abierta mientras realiza el ejercicio. la contracción debe ser intensa sin involucrar los muslos o las nalgas. la contracción debe durar de 5-10 segundos y si no se logra, trabajar para llegar a ello. descansar 10 segundos entre cada contracción. realice este ejercicio 10 veces cuando esté sentada. luego haga varias contracciones rápidas-subiendo el piso pélvico, reteniendo un segundo y soltando. busque hacerlo por 10 veces cada vez. estos ejercicios de contracciones lentas y rápidas deben hacerse 3-4 veces por día. fuente: adaptado de hanzaree y steggall (24). 429 incontinencia y enfermedad crónica l beatriz sánchez-herrera, gloria mabel carrillo, lucy barrera-ortiz los aparatos mecánicos o estimulación eléctrica. hay diferentes tipos de estimulación. entre estos se encuentra la estimulación percutánea del nervio tibial que se realiza con una aguja-electrodo fina sobre el tobillo mientras el paciente está sentado durante 30 minutos. al terminar, e inmediatamente después del tratamiento, estará en condiciones de reanudar la actividad regular. esta estimulación se usa para la vejiga hiperactiva y los síntomas asociados de urgencia urinaria, frecuencia urinaria e incontinencia de urgencia. el mecanismo lleva impulso eléctrico a lo largo del nervio tibial y luego al plexo del nervio sacro, los nervios responsables del control de la función vesical o fecal. no puede ser usado en quienes tienen marcapasos, desfibriladores o implantables, individuos con tendencia a hemorragia excesiva, individuos con daño nervioso que pudiera impactar en el funcionamiento del nervio tibial o del piso pélvico percutáneo, o en mujeres embarazadas o que planean quedar embarazadas. ghoniem et al. (34) adelantaron un piloto para manejar síntomas de if con estimulación cutánea del nervio tibial que es un procedimiento ambulatorio sencillo. este estímulo demostró importante mejoría mientras se mantuvo el tratamiento bajando episodios de entre 19,6 más o menos 21,0 a 9,9 más o menos 15 a las seis semanas y a 3,6 más o menos 4,8 al año. caremel et al. (35) buscaron describir los efectos de una modulación en el centro sacro en 51 pacientes que entre 2005 y 2010 recibieron este manejo. la principal indicación para esta modulación fue la iu de urgencia y 59,5 % con if. encontraron que aproximadamente la mitad de los pacientes (48,7 %) recibieron beneficio con este tipo de tratamiento. en especial se beneficiaron los que tenían incontinencia urinaria y fecal. leroi (36) hizo una revisión de la literatura sobre el rol de la neuromodulación sacra en la incontinencia doble, encontrando reportes de eficiencia entre el 30 y el 100 % de efectividad en pacientes con seguimiento de mediano plazo. sugiere el autor que se trabaje en la investigación de estos mismos efectos a largo plazo. knorst et al. (37) estudiaron un grupo de 48 mujeres de edades entre los 35 y los 78 años en quienes la iu se asociaba al prolapso, a quienes hicieron estimulación eléctrica transvaginal y ejercicios del piso pélvico durante 15 sesiones semanales. los autores encontraron que el 87,5 % de las participantes lograron la continencia, independientemente del tipo de iu que tuvieran. hogewoning et al. (38) valoraron la eficiencia del miniarco (miniarc) para curar la iu de estrés. para ello estudiaron a 77 pacientes operadas con seguimiento de un año, tiempo después del cual el 68 % mostró mejoría y 44 % continencia. la cinta vaginal sin tensión (tvt) por sus siglas en inglés, mostró mayor efectividad. los catéteres. hay de varios tipos: suprapúbicos, externos y sondas o catéter temporal o sonda vesical permanente. las sondas solo para medición de orina estricta, por problemas de piel o para cuando hay retención que no puede corregirse por otra vía y no es factible cateterización intermitente. ouslander (39) y schnelle (40) estudiaron los costos del cuidado de la iu. ellos señalan que el uso de sondas es más costoso que el de pañales. sin embargo, las horas dedicadas al cuidado pueden reflejar una realidad diferente frente a este hallazgo. baker y ward-smith (41) describen las condiciones especiales para el manejo de la iu en la cercanía a la muerte. señalan que el manejo de la iu en los pacientes terminales debe tener consideraciones especiales que den dignidad y mejoren la calidad de vida. sin importar la causa, generalmente la iu es estresante para el paciente y por ello las intervenciones deben satisfacer sus preferencias sociales, emocionales, psicológicas y sus necesidades físicas. las intervenciones, además de ser apropiadas, deben ser respetuosas y acatar el deseo de cada individuo. el estreñimiento y la impactación fecal. el manejo adecuado del estreñimiento previene la impactación fecal y la if resultante. lo primero para manejar el estreñimiento es revisar qué lo puede generar y cuando es un problema relativamente agudo es necesario mirar si hay enfermedad del colon, desórdenes endocrinos o metabólicos, depresión o efectos colaterales de las drogas. la dieta adecuada, incluidos líquidos y fibra, es importante para prevenir el estreñimiento. mejorar la movilidad, la postura corporal y el tiempo y espacio adecuados para la defecación son pasos importantes. la privacidad y aprovechar el reflejo gastrocólico (presente pocos minutos después de comer) es importante. los medicamentos para el estreñimiento deben ser empleados con cautela para prevenir que se genere un colon atónico o catártico. la if de origen neurológico es algunas veces susceptible de mejorar con terapia de retroalimentación, aunque cuando hay demencias de por medio es difícil obtener cooperación del paciente. para algunos de estos pacientes es a veces necesario programar enemas un número determinado de veces a la semana. por últi430 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 mo, los aditamentos especiales para las personas que tienen if pueden ser de utilidad para prevenir complicaciones y desgaste a los cuidadores. markland et al. (42) revisaron los efectos de la pérdida de peso en la if en 338 mujeres y encontraron una relación positiva entre la disminución de peso, los mejores hábitos nutricionales y el control de la if. conclusiones el tema de la iu y la if ha sido ampliamente documentado en la literatura mundial entre los años 2009-2012. hay más literatura disponible sobre la iu que sobre la if. los estudios que reportan frecuencia y tipología en conjunto muestran que las iu e if son problemas importantes asociados con la ec. los estudios que establecen relación directa entre la incontinencia y la ec muestran cómo esta es un factor de riesgo para la aparición de iu e if. los estudios que ilustran otros factores asociados con la incontinencia y con la ec se vinculan a la edad, la enfermedad aguda sobreagregada y la historia ginecológica. no se tienen reportes en el género masculino. los que abordan la forma de valorar la incontinencia permiten en conjunto señalan que a partir de una adecuada valoración se puede establecer un adecuado enfoque del problema. por último, los estudios que dan aportes con respecto al manejo de la iu o if en la ec señalan tendencias terapéuticas múltiples sobre las que se continúa construyendo evidencia. llaman la atención dos aspectos especiales: 1) no se establece en algunos estudios clara diferencia entre la vejez y la ec; 2) no se reporten abordajes integrales al problema de la iu e if en personas con ec. teniendo en cuenta el impacto de la iu e if en la vida de las personas con ec el tema debe continuar explorándose en estudios posteriores. referencias 1. kane r, ouslanter j, abrass i. essentials of clinical geriatrics. 6th edition. usa: mc graw hill; 2008. 2. ergul a, nezihe b, habibe e, onay y, funda g. the prevalence of and the related factors for urinary and fecal incontinence among older residing in nursing homes. journal of clinical nursing. 2009;18(23):3290-3298. 3. roe b, flanagan l, jack b, barrett j, chung a, shaw c, et al. systematic review of the management of incontinence and promotion of continence in older people in care homes: descriptive studies with urinary incontinence as primary focus. journal of advanced nursing. 2010;67(2):228-250. 4. arzu i, fatma a. the identification of urinary and fecal incontinence in older people and its effects over life quality: briefing and training. anatolian journal of clinical investigation. 2011;5(1):15-23. 5. uslu s, uysal y, sari d, ahin s, tekin n, enuzun f. urinary incontinence at the women living in a nursing home and the quality of life of the women with urinary incontinence. healthmed. 2011;5(5):1050-1057. 6. ojengbede o, morhason-bello i, adedokun b, okonkwo n, kolade c. prevalence and the associated trigger factors of urinary incontinence among 5000 black women in sub-saharan africa: findings from a community survey. bju international. 2011;107(11):1793-1800. 7. brito l, brito l, chein m, malheiros e, duarte t, pinto-neto a. stress urinary incontinence in climacteric women in a northeastern brazilian municipality: a household survey. international urogynecology journal. 2012;23(5):639-645. 8. fiegen m, benson k, hanson j, prasek j hansen k, vaneerden p. the prevalence of urinary incontinence in american indian women from a south dakota tribe. international urogynecology journal. 2012;23(4):473-479. 9. aitola p, lehto k, fonsell r, huhtala h. prevalence of faecal incontinence in adults aged 30 years or more in general population. colorectal disease. 2010;12(7):687-691. 10. de mello portella p, feldner pc, da conceição jc, castro ra, sartori gf, girão m. prevalence of and quality of life related to anal incontinence in women with urinary incontinence and pelvic organ prolapse. european journal of obstetrics & gynecology & reproductive biology. 2012;160(2):228-231. 431 incontinencia y enfermedad crónica l beatriz sánchez-herrera, gloria mabel carrillo, lucy barrera-ortiz 11. jean m. shultz, urinary incontinence. nursing. 2010;33. 12. von gontard a, didden r, sinnema m, curfs l. urinary incontinence in persons with prader-willi syndrome von gontard et al. urinary incontinence in persons with prader-willi syndrome. bju international. 2010;106(11):1758-1762. 13. foley a, loharuka s, barrett j, mathews r, williams k, mcgrother k, et al. association between the geriatric giants of urinary incontinence and falls in older people using data from the leicestershire mrc incontinence study. age & ageing. 2012;41(1):35-40. 14. busuttil-leaver r. chronic diseases and incontinence. practice nurse: 2011;41(14):32-36. 15. sinclair aj, ramsay in. the psychosocial impact of urinary incontinence in women. obstetrician & gynaecologist. 2011;13(3):143-148. 16. jha s, strelley k, radley s. incontinence during intercourse: myths unravelled. international urogynecology journal. 2012;23(5):633-637. 17. hrisanfow e, hägglund d. the prevalence of urinary incontinence among women and men with chronic obstructive pulmonary disease in sweden. journal of clinical nursing. 2011; 20(13/14):1895-1905. 18. khori f, alkhateeb m. the incidence and risk factors of urinary incontinence. middle east journal of age & ageing. 2012;9(2):3-7. 19. ness w. fecal incontinence: causes, assessment and management. nursing standard. 2012;26(42):52-60. 20. shiow-ru c, kuang-ho c, ting-chen c, ho-hsiung l. a taiwanese version of the international consultation on incontinence questionnaire urinary incontinence short form for pregnant women: instrument validation. journal of clinical nursing. 2011;20(5/6):714-722. 21. miller s, miller m. urological disorders in men: urinary incontinence and benign prostatic hyperplasia. journal of pharmacy practice. 2011;24(4):374-385. 22. jain p, jirschele k, botros s, latthe p. effectiveness of midurethral slings in mixed urinary incontinence: a systematic review and meta-analysis. international urogynecology journal. 2011;22(8):923-932. 23. petros p. mixed urinary incontinence-time to uncouple urgency from stress? international urogynecology journal. 2011;22(8):919-921. 24. hanzaree z, steggall m. treatment of patients with urge or stress urinary incontinence. nursing standard. 2010;25 (3):41-46. 25. liebergall-wischnitzer m, paltiel o, hochner d, lavy y, manor o, woloski ac. sexual function and quality of life of women with stress urinary incontinence: a randomized controlled trial comparing the paula method (circular muscle exercises) to pelvic floor muscle training (pfmt) exercises. journal of sexual medicine. 2012;9(6):1613-1623. 26. malak m. the role of anti-incontinence surgery in management of occult urinary stress incontinence. international urogynecology journal. 2012;23(7):823-825. 27. svenningsen r, borstad e, spydslaug a, sandvik l, staff a. occult incontinence as predictor for postoperative stress urinary incontinence following pelvic organ prolapse surgery. international urogynecology journal. 2012;23(17):843-849. 28. university of maryland medical center. obstetrics, gynecology and reproductive health. minimally invasive bladder repair for stress urinary incontinence. [citado 2012 jun 25]. disponible en: http://www.umm.edu/womenscenter/ bladder_repair.htm 29. glavind k, glavind e, fenger-gron m. long-term subjective results of tension-free vaginal tape operation for female urinary stress incontinence. international urogynecology journal. 2012;23(5):585-588. 30. bekker m, beck j, putter h, venema p, nijeholt al, pelger r, et al. sexual function improvement following surgery for stress incontinence: the relevance of coital incontinence. journal of sexual medicine. 2009;6(11):3208-3213. 31. gumus, ilknur inegol; kaygusuz, ikbal; derbent, aysel; simavli, serap; kafali, hasan. effect of the macroplastique implantation system for stress urinary incontinence in women with or without a history of an anti-incontinence operation. international urogynecology journal. 2011;22(6):743-749. 432 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 32. peeker r, edlund c, wennberg l, fall m. the treatment of sphincter incontinence with periurethral silicone implants (macroplastique). scand j urol nephrol. 2001;36:194-198. 33. meulen h, berghmans m, nieman m, kerrebroeck v. effects of macroplastique implantation system for stress urinary incontinence and urethral hypermobility in women. int urogynecol j. 2009;20:177-183. 34. ghoniem g, corcos j, comiter c, westney ol, herschorn s. durability of urethral bulking agent injection for female stress urinary incontinence: 2-year multicenter study results. j urol. 2010;183:1444-1449. 35. caremel r, damon h, ruffion a, chartier-kastler e, gourcerol g, michot f, et al. can sacral neuromodulation improve minor incontinence symptoms in doubly incontinent patients successfully treated for major incontinence symptoms? urology. 2012;79(1):80-85. 36. leroi a. the role of sacral neuromodulation in double incontinence. colorectal disease. supplement. 2011;13:15-18. 37. knorst m, cavazzotto k, henrique m, resende t. physical therapy intervention in women with urinary incontinence associated with pelvic organ prolapse. brazilian journal of physical therapy / revista brasileira de fisioterapia. 2012;16(2):102-107. 38. hogewoning c, ruhe i, bekker m, putter h, deruiter m, pelger r, et al. the miniarc sling for female stress urinary incontinence: clinical results after 1-year follow-up. international urogynecology journal. 2012;23(5):589-595. 39. ouslander jg, kane rl. the costs of urinary incontinence in nursing homes. medical care. 1984;22(1):69-79. 40. schnelle jf, sowell va, traughber b, hu tw. a behavioural analysis of the labour cost of managing continence and incontinence in nursing home patients. journal of organizational behaviour management. 1988;9(2):137-153. 41. baker b, ward-smith p. urinary incontinence nursing considerations at the end of life. urologic nursing. 2011;31(3): 169-172. 42. markland a, richter h, burgio k, myers d, hernandez a, subak l. weight loss improves fecal incontinence severity in overweight and obese women with urinary incontinence. international urogynecology journal. 2011;22(9):1151-1157. 1 leonel dos santos silva1 bruna eloise lenhani2 dabna hellen tomim3 paulo ricardo bittencourt guimarães4 luciana puchalski kalinke5 qualidade de vida de pacientes com câncer avançado na terapêutica paliativa e no cuidado paliativo 1 orcid.org/0000-0002-8359-5622. universidade federal do paraná (ufpr), brasil. leonel.silva@hc.ufpr.br 2 orcid.org/0000-0002-6009-3400. hospital erasto gaertner, brasil. blenhani@erastogaertner.com.br 3 orcid.org/0000-0003-3199-0740. universidade federal do paraná (ufpr), brasil. dabnatomim@ufpr.br 4 orcid.org/0000-0002-9852-6777. universidade federal do paraná (ufpr), brasil. prbg@ufpr.br 5 orcid.org/0000-0003-4868-8193. universidade federal do paraná (ufpr), brasil. lucianakalinke@ufpr.br recibiddo: 23/02/2019 enviado a pares: 12/03/2019 aceptado por pares: 16/04/2019 aprobado: 09/05/2019 doi: 10.5294/aqui.2019.19.3.7 para citar este artigo / para citar este artículo / to reference this article silva lds, lenhani be, tomim dh, bittencourt pr, kalinke lp. quality of life of patients with advanced cancer in palliative therapy and in palliative care. aquichan 2019; 19(3): e1937. doi: https://doi.org/10.5294/aqui.2019.19.3.7 resumo objetivo: avaliar a qualidade de vida de pacientes com câncer avançado em terapêutica paliativa e em cuidado paliativo. material e método: estudo quantitativo, observacional, transversal e analítico, desenvolvido num hospital de ensino no paraná, brasil, de janeiro a junho de 2018, com 126 pacientes, sendo 107 em terapêutica paliativa e 19 no cuidado paliativo exclusivo. os questionários para a coleta de dados foram: quality of life questionnaire-core 15-palliative, functional assessment of chronic ilness therapy-palliative care 14 e edmonton symptom assessment system. o teste de coeficiente não paramétrico de spearman foi utilizado para a análise. resultados: a qualidade de vida global na terapêutica paliativa e no cuidado paliativo foi respectivamente 71,54/59,65; quando correlacionados o escore total de qualidade de vida do quality of life questionnaire-core 15-palliative com o functional assessment of chronic illness therapy-palliative care 14 (p = 0,001) e a edmonton symptom assessment system (p = 0,001), observou-se diferença significativa de melhor qualidade de vida na terapêutica paliativa. conclusão: os pacientes em terapia paliativa possuem qualidade de vida global boa, enquanto o grupo cuidado paliativo, regular. os sintomas foram mais leves na terapia paliativa e mais intensos e com maior significância no cuidado paliativo; portanto, conhecer o comprometimento da qualidade de vida auxiliará os profissionais no planejamento de intervenções com enfoque transdisciplinar para o paciente e para sua família. palavras-chave (fonte: decs) qualidade de vida; câncer avançado; neoplasias; dor do câncer; cuidados paliativos; cuidados paliativos na terminalidade da vida; enfermagem oncológica. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1937 temática: cuidado crônico. contribuição para a disciplina: o câncer avançado resulta em alterações multidimensionais da qualidade de vida. nesse cenário, identificar tais alterações é uma prioridade global de saúde, uma vez que conhecer para intervir na pluralidade dos sofrimentos vivenciados pelos pacientes e por suas famílias é um dos princípios da intenção paliativa. para a enfermagem, fomentar o processo de cuidar pautado em instrumentos validados e factíveis, e apontar as alterações comuns na terapêutica e no cuidado paliativo auxiliará na assistência holística e poderá favorecer a qualidade de vida. quanto ao ensino, contribui para a formação de profissionais cientes das necessidades dos pacientes com câncer avançado, suportados por uma filosofia de cuidados paliativos. mailto:leonel.silva@hc.ufpr.br https://doi.org/10.5294/aqui.2019.19.3.7 https://orcid.org/0000-0002-8359-5622 https://orcid.org/0000-0002-6009-3400 https://orcid.org/0000-0003-3199-0740 https://orcid.org/0000-0002-9852-6777 https://orcid.org/0000-0003-4868-8193 https://doi.org/10.5294/aqui.2019.19.3.7 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1937 calidad de vida de pacientes con cáncer avanzado en tratamiento paliativo y cuidado paliativo resumen objetivo: evaluar la calidad de vida de pacientes con cáncer avanzado en tratamiento paliativo y cuidado paliativo. material y método: estudio cuantitativo, observacional, transversal y analítico, desarrollado en un hospital de enseñanza en el departamento de paraná, brasil, de enero a junio del 2018, con 126 pacientes, siendo 107 en tratamiento paliativo y 19 en cuidado paliativo exclusivo. los cuestionarios para recolectar datos fueron: quality of life questionnaire-core 15-palliative, functional assessment of chronic ilness therapy-palliative care 14 y edmonton symptom assessment system. la prueba de coeficiente no paramétrico de spearman se utilizó para el análisis. resultados: la calidad de vida global en el tratamiento paliativo y el cuidado paliativo fue respectivamente 71,54/59,65; cuando correlacionados la puntuación total de calidad de vida del quality of life questionnaire-core 15-palliative con el functional assessment of chronic illness therapy-palliative care 14 (p = 0,001) y la edmonton symptom assessment system (p = 0,001), se encontró diferencia significativa de mejor calidad de vida en el tratamiento paliativo. conclusión: los pacientes en tratamiento paliativo poseen calidad de vida global buena, mientras que el grupo cuidado paliativo, regular. los síntomas fueron más suaves en el tratamiento paliativo y más intensos y con más significancia en el cuidado paliativo; por lo tanto, conocer el comprometimiento de la calidad de vida auxiliará a los profesionales a que planeen intervenciones con enfoque transdisciplinario para el paciente y su familia. palabras clave (fuente: decs) calidad de vida; cáncer avanzado; neoplasias; dolor en cáncer; cuidados paliativos; cuidados paliativos al final de la vida; enfermería oncológica. 3 qualidade de vida de pacientes com câncer avançado na terapêutica paliativa e no cuidado paliativo l leonel dos santos silva e outros quality of life of patients with advanced cancer in palliative therapy and in palliative care abstract objective: to assess the quality of life of patients with advanced cancer in palliative therapy and in palliative care. materials and methods: quantitative, observational, cross-sectional, and analytic study conducted in a teaching hospital in paraná, brazil, from january to june 2018, with 126 patients: 107 in palliative therapy; 19 in exclusive palliative care. the questionnaires for data collection were: quality of life questionnaire-core 15-palliative, functional assessment of chronic illness therapy-palliative care 14, and edmonton symptom assessment system. the spearman non-parametric coefficient test was used for the analysis. results: the overall quality of life in palliative therapy and in palliative care was, respectively, 71.54/59.65; when correlating the total score of quality of life of the quality of life questionnaire-core 15-palliative with the functional assessment of chronic illness therapy-palliative care 14 (p = 0.001), and the edmonton symptom assessment system (p = 0.001), significant difference of better quality of life was observed in the palliative therapy. conclusion: patients in palliative therapy have good overall quality of life, while the palliative care group reports regular quality of life. the symptoms were milder in the palliative therapy and more intense and with greater significance in palliative care; hence, knowing the compromise of quality of life will help professionals in planning interventions with transdisciplinary approach for patients and for their families. keywords (source: decs): quality of life; advanced cancer; neoplasm; cancer pain; palliative care; hospice care; oncology nursing. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1937 4 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1937 aquichan issn 1657-5997 eissn 2027-5374 introdução aproximadamente 90 % das mortes de pacientes com câncer estão relacionadas ao estadiamento avançado da doença, as quais são decorrentes do diagnóstico e do tratamento tardio. o câncer avançado (ca) se torna progressivo e incurável, resulta em declínio da capacidade funcional, no aumento da carga de sintomas e compromete significativamente a qualidade de vida (qv) (1, 2). para os pacientes com ca, o tratamento ofertado é a terapêutica paliativa (tp) e/ou o cuidado paliativo (cp). a tp objetiva minimizar os sintomas, controlar os efeitos colaterais e melhorar a qv, porém sem prolongar a sobrevida. indica o uso de tratamentos sistêmicos (quimioterapia, hormonioterapia e imunoterapia), a radiação e a cirurgia (3). as concepções de cp estão ancoradas numa filosofia de cuidados que promovem a qv de pacientes e seus familiares no enfrentamento de doenças que ameacem a continuidade da vida, por meio da prevenção e do alívio do sofrimento (4). trata-se de um cuidado integral com enfoque no alívio do sofrimento e requer a identificação da dor, sua avaliação e tratamento, além de outros problemas de natureza física, psicossocial e espiritual para proporcionar melhor qv (5). o conceito de qv é um elemento central e um dos objetivos do cp; profissionais, pacientes, suas famílias e a comunidade devem ter alguma compreensão compartilhada dessa filosofia de cuidados (5). a qv é compreendida como “a percepção do indivíduo de sua posição na vida, no contexto da cultura e sistemas de valores nos quais vive e em relação aos seus objetivos, expectativas, padrões e preocupações” (6). trata-se de um constructo complexo que considera aspectos subjetivos, multidimensionais e bipolares (7), que, com o auxílio de instrumentos validados, é possível sua identificação e mensuração. mesmo quando se refere a doenças fora das possibilidades de cura, pacientes e profissionais devem decidir por medidas terapêuticas que visem maximizar a qv (7). as diferenças entre a tp e o cp são frequentemente incompreendidas por pacientes e profissionais devido a falhas na comunicação, na aceitação e nos aspectos psicoculturais relacionados ao ca (8). esta pesquisa justifica-se pela necessidade de identificar os domínios alterados como uma estratégia de avaliação para nortear as práticas assistenciais na manutenção da capacidade funcional e no controle de sintomas nas modalidades paliativas em oncologia, bem como contribuir para a formulação de políticas públicas de saúde voltados à temática. nesse sentido, o presente estudo tem por objetivo avaliar a qualidade de vida de pacientes com ca em tp e cp. material e método trata-se de uma pesquisa quantitativa, observacional, transversal e analítica. desenvolveu-se com pacientes internados ou em atendimento ambulatorial, assistidos por equipes multiprofissionais especializadas em oncologia e cp de um hospital público localizado na região sul do brasil. os critérios de inclusão utilizados foram: pacientes com idade superior a 18 anos, com ca, cientes sobre sua modalidade de tratamento e que apresentassem capacidade funcional de acordo com a escala eastern cooperative oncology group (ecog) 0, 1, 2, 3 ou 4 (9). também foi considerado o registro no prontuário da modalidade de tratamento. a ecog é uma escala que descreve o nível de funcionamento de um paciente em termos de sua capacidade de cuidar de si mesmo, atividade diária e capacidade física; possui classificação de 0 (zero) a 5 (cinco). no 0 (zero), o paciente está totalmente ativo, capaz de realizar todo o desempenho pré-doença sem restrição; 5 (cinco) é o paciente morto (9). foram excluídos os pacientes que não se comunicavam verbalmente e os que já tinham participado do estudo em outro momento durante a internação ou no ambulatório, uma vez que os pacientes ambulatoriais eram referenciados para o internamento e, posteriormente, designados para o seguimento ambulatorial quando apresentavam evolução satisfatória. a amostragem foi não probabilística, coletada no período de janeiro a junho de 2018, com uma população de 126 pacientes, sendo 107 na tp e 19 no cp exclusivo. optou-se por esse tipo de amostragem devido à indisponibilidade de um número preciso de pacientes atendidos nos anos anteriores, já que a inserção da equipe de cp é relativamente nova na instituição, o que impossibilitou realizar o cálculo amostral. a coleta de dados foi realizada nas unidades de atendimento, na sala de espera e/ou nos procedimentos do ambulatório ou na 5 qualidade de vida de pacientes com câncer avançado na terapêutica paliativa e no cuidado paliativo l leonel dos santos silva e outros enfermaria durante o internamento. após a confirmação dos critérios de inclusão e a autorização para participar da pesquisa, o paciente respondia ao questionário ou este era lido pelo pesquisador, sem proferir explicações e/ou expressões, para evitar interferir nas respostas e assegurar a imparcialidade. tal estratégia viabilizou que os participantes com limitações da capacidade funcional reduzida impostas pela doença e pelos tratamentos fossem incluídos no estudo. durante a coleta de dados, foram aplicados quatro instrumentos distintos: o questionário de variáveis sociodemográficas e clínicas, o quality of life questionnaire care 15 palliative (eortc qlq-c15-pal), o functional assessment of chronic illness therapy-palliative care 14 (facit-pal-14) e a edmonton symptom assessment system (esas). o instrumento eortc qlq-c15-pal, desenvolvido pela european organization for research and treatment of cancer (eortc), foi traduzido e validado no brasil. composto por 15 questões no formato de escala de likert, os escores variam de 0 a 100 para a função física, emocional, sintomas (maiores pontuação nas escalas funcionais indicam melhor qv, contrário é observado na escala de sintomas) e qv global (de 1 a 7 pontos, quanto maior a pontuação, melhor a qv) (10). o facit-pal-14, desenvolvido pelo grupo americano functional assessment of chronic illness terapy (facit), contém 14 itens no formato de escala de likert, com afirmações sobre os últimos sete dias, com respectivas pontuações para bem-estar físico e funcional (0-16 pontos), bem-estar social/familiar (0-4), bem-estar emocional (0-8) e preocupações adicionais (0-20), que resulta no escore total (0-56). a maior pontuação é indicativo de melhor percepção de qv (11). para viabilizar a comparação, os escores do facit-pal-14 foram transportados para uma escala de 100 pontos. a esas foi utilizada para avaliar os sintomas: dor, cansaço, náusea, depressão, ansiedade, sonolência, apetite, bem-estar, falta de ar e algum sintoma específico (12). é uma escala visual numérica com 11 pontos (0 a 10) e, quanto maior o escore, pior a intensidade dos sintomas; classificados como leves (1-3), moderados (4-6) ou intensos (≥ 7) (13). a utilização dos questionários eortc qlq-c15-pal, facit pal-14 e da esas é justificada pela ausência de uma ferramenta psicométrica que avalie todos os domínios alterados em pacientes paliativos (14). todos os dados coletados foram tabulados microsoft excel® 2016, analisados por estatística descritiva expressa em frequência relativa, absoluta (%), média, mínimo, máximo e desvio-padrão. as correlações foram avaliadas pelo coeficiente não paramétrico de spearman, devido aos dados analisados não seguirem uma distribuição normal. consideraram-se significativos todos os efeitos e as relações associados a valores de p < 0,05. foram considerados pontuações nos escores de qv ruim (0-25), regular (26-50), boa (51-75) e ótima (76-100). esta pesquisa foi aprovada no comitê de ética e pesquisa da instituição com o parecer 2.461.307. resultados a caracterização sociodemográfica e clínica da amostra disposta na tabela 1 mostra que a média de idade dos grupos tp/ cp foi de 58,3/62,6 anos, respectivamente; o sexo feminino foi prevalente 61,68 % (n = 66) no grupo tp e 57,89 % (n = 11) no cp; o estado civil casado ou em união estável representou 58,88 % (n = 63) no tp e 52,63 % (n = 10) no cp. em relação ao diagnóstico, 28,97 % (n = 31) no grupo tp e 15,79 % (n = 3) no cp apresentaram câncer de mama; a capacidade funcional foi classificada em 75,7 % (n = 81) (ecog 1 e 2) para o grupo tp e 89,47 % (n = 17) (ecog 2 e 3) para o cp. com relação ao questionário eortc qlq-c15-pal, foi possível observar que, na avaliação do estado global de saúde, os pacientes em tp apresentaram melhor escore de qv (71,54), se comparado com o grupo cp (59,65), porém sem significância entre os grupos. quando avaliada a função física e emocional, a tp apresenta escores 17,95 e 28,83, já o grupo cp, 53,67 e 43,87, respectivamente; isso representa melhor qv nesses domínios para os pacientes em cp, com significância na função física (p = 0,000). em relação à escala de sintomas, qv insatisfatória no grupo tp com maior sofrimento para náuseas/vômitos e fadiga, com escores 73,84 e 63,45; já os escores para os respectivos sintomas no grupo cp foram 38,58 e 48,25, o que indica melhor qv. quanto ao instrumento facit-pal-14, as médias do escore total e dos domínios indicaram melhor qv no grupo tp, se comparado com o cp. exceto para o item “estou preocupado/a que meu estado venha a piorar” da escala de bem-estar emocional, 34,35/55,26 (p = 0,022). 6 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1937 aquichan issn 1657-5997 eissn 2027-5374 variável terapêutica paliativa cuidado paliativo n (%) n (%) idade em anos (média) 58,3 62,6 sexo feminino 66 61,68 11 57,89 masculino 41 38,32 8 42,11 estado conjugal 107 19 casado/união estável 63 58,88 10 52,63 separado/divorciado 20 18,69 5 26,32 solteiro 19 17,76 2 10,53 viúvo 5 4,67 2 10,53 escolaridade 107 19 ensino fundamental 69 64,49 15 78,95 ensino médio 27 25,23 2 10,53 ensino superior 11 10,28 2 10,53 ocupação 107 19 aposentado 55 51,40 11 57,89 empregado 16 14,95 1 5,26 autônomo 18 16,82 1 5,26 do lar 10 9,35 3 15,79 outras 8 7,48 3 15,79 diagnóstico 107 19 mama 31 28,97 3 15,79 colorretal 16 14,95 1 5,26 pulmão 11 10,28 2 10,53 próstata 9 8,41 2 10,53 outros 40 37,38 11 57,89 performance status (ecog) 107 19 ecog 0 22 20,56 ecog 1 59 55,14 2 10,53 ecog 3 22 20,56 6 31,58 ecog 4 4 3,74 11 57,9 tabela 1. características sociodemográficas e clínicas dos pacientes com ca na tp e no cp fonte: elaboração própia. 7 qualidade de vida de pacientes com câncer avançado na terapêutica paliativa e no cuidado paliativo l leonel dos santos silva e outros a avaliação de sintomas com o questionário da esas apontou menor sofrimento no grupo tp em comparação aos pacientes em cp, tanto no escore total 27,99/39,3 (p = 0,014) quanto nos sintomas de maior intensidade sonolência 3,22/5,68 (p = 0,005), apetite 3,61/5,95 (p = 0,004), bem-estar 3,74/5,58 (p = 0,014). os escores de qualidade de vida geral (qvg) avaliados com o eortc qlq-c15-pal, descritos na tabela 2, quando correlacionados aos domínios do facit-pal-14 e ao escore total da esas, na tp, mostraram uma correlação significativa, exceto para as preocupações adicionais, o que indica que esse domínio não foi significativo na qv desse grupo. no cp, a correlação ocorreu nos domínios funcionais (p = 0,008 e p = 0,046), social/familiar (p = 0,001) e emocional para a piora do estado (p = 0,008); a correlação mostra a significância desses domínios na qv dos pacientes do estudo. ao avaliar a relação entre os escores do facit-pal-14 com o escore total da esas (tabela 3), percebeu-se que a função física e emocional foi melhor nos pacientes com a multidimensionalidade de sintomas diminuída; resultados semelhantes em ambos os grupos de pacientes. na correlação (tabela 4) do escore total de sintomas da escala esas com o escore total com os domínios do facit-pal-14, observou-se significância entre as variáveis para a tp nos domínios de bem-estar físico, funcional, social/familiar, emocional e preocupações adicionais. no cp, alguns itens foram correlatos como: bem-estar funcional (prazer em viver), bem-estar emocional (preocupação com a piora do seu estado) e preocupações adicionais (peso para a família). há também uma correlação significativa entre o escore total de sintomas da esas e o de qv do facit-pal-14 em ambos os grupos, o que indica a interferência da carga e da intensidade de sintomas na qv. qv/escalas/domínios terapêutica paliativa cuidado paliativo total spearman p spearman p spearman p bem-estar físico energia 0,252 0,009* -0,012 0,961 0,238 0,007* enjoo 0,225 0,020* 0,058 0,812 0,226 0,011* dores 0,333 0,000* 0,001 0,997 0,307 0,000* bem-estar funcional prazer em viver -0,393 0,000* -0,586 0,008* -0,430 0,000* padrão de sono 0,273 0,005* 0,463 0,046* 0,315 0,000* bem-estar social/familiar apoio da família 0,570 0,000* 0,709 0,001* 0,604 0,000* bem-estar emocional piora do estado 0,393 0,000* 0,586 0,008* 0,430 0,000* tristeza 0,378 0,000* 0,368 0,121 0,379 0,000* preocupações adicionais esperança (sp21) 0,097 0,322 0,400 0,090 0,138 0,125 peso para a família (pal4) 0,183 0,063 0,409 0,082 0,231 0,010* prisão de ventre (pal5) 0,188 0,054 -0,289 0,230 0,150 0,095 comunicação (pal14) 0,062 0,525 0,283 0,255 0,082 0,366 falta de ar (b1) 0,128 0,190 0,270 0,264 0,164 0,068 qvg (eortc qlq-c15-pal) e facit-pal-14 0,474 0,000* 0,455 0,050 0,480 0,000* qvg (eortc qlq-c15-pal) e esas -0,309 0,001* -0,270 0,263 -0,309 0,000* tabela 2. correlação de spearman entre qvg (eortc qlq-c15-pal) e domínios (facit-pal-14) e da esas dos pacientes com ca na tp e no cp fonte: elaborada pelos autores 8 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1937 aquichan issn 1657-5997 eissn 2027-5374 tabela 3. relação de escores dos domínios facit-pal-14 com o escore total da esas dos pacientes com ca na tp e no cp tabela 4. correlação de spearman entre escore total de sintomas da esas e domínios (facit-pal-14) dos pacientes com ca na tp e no cp facit-pal-14 escalas/domínios esas* escore total terapêutica paliativa cuidado paliativo total médias dp médias dp médias dp função física < 40 77,81 29,23 58,33 30,77 62,5 36,16 ≥ 40 29,63 28,62 21,43 26,73 função emocional < 40 81,25 23,36 64,58 24,91 73,61 29,72 ≥ 40 60,19 39,38 53,57 33,63 prazer em viver (gf3) < 40 62,50 32,07 60,42 29,11 58,73 31,04 ≥ 40 51,85 26,79 39,29 31,81 padrão de sono (gf5) < 40 64,06 31,28 41,67 38,92 52,78 35,81 ≥ 40 29,63 33,99 32,14 34,50 qualidade de vida (gf7) < 40 76,25 25,75 68,75 35,56 73,81 28,44 ≥ 40 67,59 34,54 78,57 17,25 esperança (sp21) < 40 83,13 29,44 72,92 34,47 75 34,79 ≥ 40 60,19 39,99 42,86 40,09 peso para a família (pal4) < 40 59,38 32,16 47,92 29,11 57,34 32,57 ≥ 40 55,56 36,91 57,14 27,82 comunicação (pal14) < 40 73,37 10,98 61,46 14,01 67,32 13,85 ≥ 40 56,48 10,28 50,00 12,46 escore total < 40 41,12 6,13 34,42 7,84 37,73 7,73 ≥ 40 31,69 5,65 28,00 6,98 *esas escore total: < 40, sintomas leves e ≥ 40, sintomas moderados e intensos. fonte: elaboração própia. escalas/domínios terapêutica paliativa cuidado paliativo total spearman p spearman p spearman p bem-estar físico energia (gp1) -0,55 0,000* -0,41 0,081 -0,558 0,000* enjoo (gp2) -0,459 0,000* -0,227 0,349 -0,443 0,000* dores (gp4) -0,383 0,000* 0,3 0,212 -0,314 0,000* bem-estar funcional prazer em viver (gf3) 0,533 0,000* 0,616 0,005* 0,566 0,000* padrão de sono (gf5) -0,164 0,091 -0,277 0,251 -0,221 0,013* qualidade de vida (gf7) -0,285 0,003* -0,315 0,19 -0,299 0,001* bem-estar social/familiar apoio emocional (gs2) -0,462 0,000* -0,232 0,34 -0,457 0,000* bem-estar emocional piora do estado (ge6) -0,533 0,000* -0,616 0,005* -0,566 0,000* tristeza (ge1) -0,572 0,000* -0,571 0,011 -0,574 0,000* 9 qualidade de vida de pacientes com câncer avançado na terapêutica paliativa e no cuidado paliativo l leonel dos santos silva e outros discussão o ca traz para a vida de pacientes e familiares alterações em aspectos multidimensionais que afetam a qv. portanto, faz-se necessário considerar a interferência das características sociodemográficas nas pesquisas e nas práticas assistenciais. a percepção de qv pode ser alterada pelo sexo, pela idade, pela escolaridade, pelas atividades de vida diária, pela escolarização e pelo número de filhos; cabe aos enfermeiros conhecer tais preditores que impactam na qv para propor um planejamento assistencial (15, 16). a predominância do sexo feminino na pesquisa não corrobora com a estimativa do câncer de 2018 no brasil (17), nem com o estudo realizado no taiwan com pacientes em tp e cp, em que o sexo masculino foi prevalente em ambos os grupos, 73,7 % e 61,6 %, respectivamente (18). fato possivelmente relacionado com a distribuição geográfica, com a densidade populacional, com os fatores de risco e com as políticas públicas de saúde. para o estado civil, há semelhança com o estudo realizado em são paulo, brasil, em que 61,5 % possuem um companheiro (19). estudo coreano evidenciou que as mulheres casadas com ca possuem menos sintomas, consequentemente, melhor qv do que as solteiras (20). um fator de impacto para a escolha de tratamento é o escore de qv e a capacidade funcional. no presente estudo, os pacientes em tp tinham melhor ecog, enquanto os da cp se encontravam mais debilitados clinicamente. na prática, percebe-se que, quanto maior o declínio na capacidade funcional, maior a probabilidade de indicação de cp exclusivo ao paciente. num estudo retrospectivo conduzido em são paulo, brasil, realizado com 301 pacientes em tp classificados com ecog maior ou igual a 2, evidenciou a necessidade de cautela na indicação de quimioterapia paliativa, pois não tiveram benefícios na sobrevida global e na qvg (21). a qvg na presente pesquisa teve um melhor escore total no grupo tp em relação ao cp. esse dado corroborou com o estudo realizado na região sudeste do brasil, que evidenciou que os pacientes em tp (média 66,7) possuem melhor qvg do que em cp (média 50) (p > 0,01). na tradução do qlq-c15-pal com pacientes em tp realizado na china, o escore médio foi de 46,63, com variações significativas (p = 0,000), baseadas na capacidade funcional, médias de 50,81 (ecog 0-2) e 37,66 (ecog 3-4) (22). esses dados reforçam que um pior desempenho funcional resulta em decréscimo na qvg, função física e emocional, e aumenta o sofrimento pela intensidade de sintomas. entretanto, no ca, os benefícios da tp na sobrevida e na qv podem ser modestos, se comparado com o elevado custo e com a toxicidade, o que pode ser minimizado com a inserção precoce do cp. medidas psicométricas podem identificar precocemente o descontrole de sintomas, bem como outros desfechos clínicos que declinam a qv (23). assim, o enfermeiro deve atuar continuamente na identificação dos aspectos multidimensionais alterados que declinam a qv e participar ativamente da oferta de cp, especialmente nos pacientes que vivenciam o ca. a qvg dos pacientes em cp exclusivo, que participaram da presente pesquisa, foi classificada como regular. melhores resultados (68,45) foram encontrados no estudo realizado com 29 pacientes internados na região centro-oeste do brasil (24). porém, na validação psicométrica do eortc qlq-c15-pal, realizada na turquia, com 150 pacientes internados e com limitação da capacidade funcional (ecog ≥ 3), o escore foi de 30 na qvg, associado a pior função física e emocional (p = 0,026) (25). tal divergência está provavelmente relacionada ao ca, fator que impacta na qv dos indivíduos, devido à progressão da doença escalas/domínios terapêutica paliativa cuidado paliativo total spearman p spearman p spearman p preocupações adicionais esperança (sp21) -0,046 0,636 -0,151 0,538 -0,067 0,457 peso para a família (pal4) -0,422 0,000* -0,622 0,004* -0,468 0,000* prisão de ventre (pal5) -0,099 0,309 -0,056 0,82 -0,164 0,067 comunicação (pal14) -0,199 0,040* 0,022 0,93 -0,176 0,05 falta de ar (b1) -0,449 0,000* -0,364 0,126 -0,438 0,000* facit-pal-14 e esas -0,702 0,000* -0,494 0,031* -0,699 0,000* fonte: elaboração própia. 10 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1937 aquichan issn 1657-5997 eissn 2027-5374 ou ao tratamento recomendado (26). a evolução de condições clínicas modificadoras está diretamente associada ao declínio da capacidade funcional e da qv, as quais requerem identificação e intervenção precoces. num estudo realizado na região sudeste do brasil, com o objetivo de avaliar a qv de nove pacientes inseridos no cp exclusivo e internados em unidade de oncologia, evidenciou escore total de 84/184, o que demonstra qv regular. as autoras relacionaram o escore com a inexistência de um serviço, e o incipiente quantitativo de recursos humanos, com formação paliativista na instituição pesquisada (27). quando se compara o estudo de figueiredo, souza, coelho e souza (27) com os pacientes em cp da presente pesquisa, verifica-se um escore total de qv semelhante; além disso, observa-se que o tempo de atuação da equipe paliativista (médicos e enfermeiros com especialização na área de atuação) na instituição é relativamente novo e evolui gradativamente na integração com a equipe de oncologia. alinhadas aos princípios do cp, ações integradas e interdisciplinares que promovam a qv podem impactar positivamente no curso da doença, sem o objetivo de antecipar ou postergar o processo de morrer (4). quando confrontados com os dados do presente estudo, fica evidente o manejo de pacientes na intenção paliativa em condições não satisfatórias de qv; ressalta-se a necessidade contínua de ampliar a oferta de serviços institucionais e ações profissionais que coadunem com essa filosofia de cuidados, ancoradas na melhor qv. quanto aos domínios físico e emocional com o eortc qlq-c15-pal, o grupo tp apresentou piores escores quando comparado com o grupo de pacientes no cp, visto que são as funções que mais impactam no tratamento (28). na tp, variações da função física estão relacionadas com a capacidade funcional (29), enquanto, no cp, escores foram melhores e divergiram do esperado por apresentarem maiores limitações e predominantemente por estarem internados (25). na avaliação do bem-estar físico e funcional mensurado com o facit-pal-14, melhores escores foram identificados nos pacientes em tp se comparados com o grupo cp. a inserção precoce de cp resulta em melhor qv, (30); os escores alterados precisam ser identificados e controlados com intervenções de enfermagem direcionadas às capacidades e limitações dos pacientes e dos familiares (27). incentivar o enfrentamento positivo, o desenvolvimento mínimo de atividades laborativas/distrativas e a conscientização das limitações podem contribuir para a melhora da qv (31). o instrumento eortc qlq-c15-pal apontou uma qv insatisfatória em ambos os grupos para a função emocional. o declínio no domínio que resulta em pior qv está associado à capacidade funcional (25, 29). esse domínio apresenta um constructo complexo por envolver sentimentos e afetos, relacionado ao adequado suporte psicossocial disponibilizado por familiares e equipe. é relevante considerar a interferência e o adequado manejo de outros sintomas que afetam a comunicação do paciente, a dispneia, por exemplo (24). na avaliação com o instrumento facit-pal-14, o bem-estar emocional apresentou significância no grupo cp em relação com a tp; o declínio nesse domínio também pode estar associado à progressão das condições de saúde e ao descontrole sintomático (fadiga, insônia, dificuldades alimentares, gastrintestinais, aparência e dor) (27). no que tange à dimensão emocional, os profissionais podem lançar algumas estratégias para melhorar a qv: incentivar os pacientes a visualizarem os aspectos positivos no enfrentamento da doença, incentivar o combate às emoções negativas e estimular a presença de entes queridos. a melhoria do bem-estar emocional está relacionada ao bem-estar social; os profissionais poderão promover essas estratégias com o apoio de outras pessoas (31). em relação ao bem-estar social/familiar, a qv em ambos os grupos apresentou semelhanças satisfatórias no grupo de tp e no cp; tal informação reforça a importância do apoio percebido nas interações sociais (familiares, amigos e equipe de saúde). o bem-estar social compreende a percepção de apoio, que está associado ao suporte emocional, informacional, assistencial e ser acompanhado; tais medidas resultam em melhoria da qv, benefícios físicos e psicológicos (32). os profissionais que assistem esse público precisam refinar as habilidades de comunicação e percepção para identificar tais alterações, com vistas ao melhor suporte para o paciente. nesse contexto, uma das metas prioritárias do cp é o alívio do sofrimento emocional e a melhoria do bem-estar para pacientes e cuidadores (4). dada a importância da adequada avaliação para evitar que o sofrimento emocional seja subestimado, quando este for identificado, necessita de intervenções terapêuticas específicas com profissionais qualificados (33). 11 qualidade de vida de pacientes com câncer avançado na terapêutica paliativa e no cuidado paliativo l leonel dos santos silva e outros a escala de sintomas, avaliada com o instrumento eortc qlq-c15-pal, mostra que maior pontuação no escore indica pior qv. no grupo tp, náuseas/vômitos e fadiga, este último foi o sintoma mais intenso na avaliação com esse instrumento e com a esas, possivelmente associado ao tratamento sistêmico ativo. no cp, os sintomas diferem, ao apontar a dor e as náuseas/vômitos como responsáveis pelo declínio na qv, e pior intensidade para a perda de apetite na avaliação com a esas. dentre os sintomas desagradáveis, a percepção de náusea/vômito pode resultar em complicações fisiológicas, e a fadiga é frequentemente presente com dificuldades de manejo; em consequência, ambas deterioram a qv (2, 34). na avaliação de sintomas com a esas, resultados da literatura nacional (35) e internacional (36, 37) diferem quanto aos sintomas e à intensidade nos grupos tp e cp da presente pesquisa; tais divergências estão relacionadas ao tipo de câncer, à presença de metástases, ao tratamento utilizado, ao adequado manejo dos sintomas, entre outros. avaliar a carga sintomática e identificar o declínio na capacidade funcional são formas indiretas de mensuração da qv. controlar os sintomas desagradáveis é o cerne do arcabouço filosófico do cp; tal necessidade é prioritária nos pacientes e extensível aos familiares (4). essa estratégia é corroborada por especialistas no ca, os quais apontam que a avaliação e a gestão dos sintomas devem ser realizadas de forma periódica e norteada por instrumentos validados, bem como a referência para serviços especializados quando descontrolados (38). no entanto, esta pesquisa evidencia que, mesmo em serviços especializados, os pacientes apresentam sintomas não totalmente controlados, fato que aponta discrepâncias entre a prática clínica e os princípios do cp. no que tange à dimensão subjetiva e multidimensional da percepção individual de qv, uma diversidade de fatores interfere na sua mensuração e, dentre os anteriormente citados, a capacidade funcional, o descontrole de sintomas e os tratamentos propostos podem interferir na avaliação de forma positiva ou negativa. tal evidência permite refletir sobre a necessidade periódica de avaliação, visto que os pacientes na tp realizam algum tratamento ativo e, no cp, a meta é o controle de sintomas; no entanto, a premissa de ambos é maximizar a qv. dada a importância da temática, a mensuração da carga sintomática e da qv são imprescindíveis para nortear as necessidades de cuidado, avaliar a eficácia das implementações e apontar as melhores evidências a serem propostas aos pacientes com ca. contudo, no brasil, a escassez de pesquisas e dados abrangentes sobre qv em pacientes paliativos dificulta o confronto com o contexto cultural e com os sistemas de saúde (26). conclusão na avaliação com o instrumento eortc qlq-c15-pal, a qv global foi indicada como boa no grupo tp e regular no cp. em relação à função física e emocional e à escala de sintomas, os escores indicam melhor qv no grupo cp. já o instrumento facit-pal-14 mostra melhor qv no grupo tp, com maiores médias no escore total, diversos itens da escala de bem-estar físico, funcional, social/ familiar e paliativa. na correlação do escore da qvg do eortc qlq-c15-pal com os domínios do facit-pal-14 e com o escore total da esas, o grupo tp apresentou significância apenas nos domínios de bem-estar físico, funcional e social/familiar. na relação entre os escores do facit-pal-14 com o escore total da esas, corrobora-se que a função física e emocional é melhor no grupo tp para os pacientes com sintomas leves. quanto à avaliação da esas, o grupo tp apresenta sintomas leves; já no grupo cp, maior intensidade e significância (sonolência, apetite, bem-estar e escore total), possivelmente relacionado ao declínio da capacidade funcional e acompanhados tardiamente por profissionais paliativistas, os quais precisam ser periodicamente avaliados e controlados para melhorar a qv, principal objetivo dessa filosofia de cuidados. na correlação da esas com o facit-pal-14, os domínios são significativos no grupo tp. dentre as contribuições do estudo, ressalta-se a existência de diferenças na carga de sintomas e na qv dos pacientes com ca inseridos na tp e cp, as quais precisam ser avaliadas para a implementação no processo de cuidar pelos profissionais de saúde e, consequentemente, adotadas intervenções na prática clínica para proporcionar melhora da qv, baseadas nos princípios de cp. dentre as limitações do estudo, são apontados o tamanho reduzido da amostra de pacientes no grupo cp e o fato de ter sido conduzido em um único centro. estudos futuros devem ser conduzidos com a finalidade de elucidar a pluralidade das avaliações e das intervenções paliativistas, principalmente com o uso do facit-pal-14, dada a escassez de pesquisas com esse instrumento. conflito de interesse: nenhum declarado. 12 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1937 aquichan issn 1657-5997 eissn 2027-5374 referências 1. weinberg ra. the biology of cancer. 2nd ed. new york: garland science, 2014. 728 p. 2. dong st, costa dsj, butow pn, lovell mr, agar m, velikova g et al. symptom clusters in advanced cancer patients: an empirical comparison of statistical methods and the impact on quality of life. j pain symptom manage. 2016; 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10(7): e0132073. doi: http://dx.doi.org/10.1371/journal.pone.0132073 36. yokomichi n, morita t, nitto a, takahashi n, miyamoto s, nishie h et al. validation of the japanese version of the edmonton symptom assessment system-revised. j pain symptom manage. 2015; 50(5):718-23. doi: http://dx.doi. org/10.1016/j.jpainsymman.2015.05.014 37. hannon b, dyck m, pope a, swami n, banerjee s. modified edmonton symptom assessment system including constipation and sleep: validation in outpatients with cancer. j pain symptom manage. 2015; 49(5):945-52. doi: http://dx.doi. org/10.1016/j.jpainsymman.2014.10.013 38. bickel ke, mcniff k, buss mk, kamal a, lupu d, abernethy ap et al. defining high-quality palliative care in oncology practice: an american society of clinical oncology/american academy of hospice and palliative medicine guidance statement. j oncol pract, alexandria. 2016;12(9): 828-38. doi: https://doi.org/10.1200/jop.2016.010686 http://dx.doi.org/10.1371/journal.pone.0132073 http://dx.doi.org/10.1016/j.jpainsymman.2015.05.014 http://dx.doi.org/10.1016/j.jpainsymman.2015.05.014 http://dx.doi.org/10.1016/j.jpainsymman.2014.10.013 http://dx.doi.org/10.1016/j.jpainsymman.2014.10.013 https://doi.org/10.1200/jop.2016.010686 09. reflexiones-el entorno ok año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 44 resumen reflexiones sobre la importancia de la educación laboral y la competitividad dentro de la organización laboral. el término ‘competencia’ es el elemento articulador entre el conocimiento científico y el conocimiento técnico, para llegar a un saber-hacer. se resalta, además, la importancia de la formación basada en competencias, sustentada en un diagnóstico realizado entre empresarios y académicos, donde se expresen las necesidades reales del mercado. palabras clave competencias, conocimiento, empresa, academia, saber-hacer, saber, sector educativo, sector empresarial. thoughts about the importance of labor’s education and the competitiveness within working organizations. the term competencies is the linking element between scientific and technical knowledge, to reach a know-how. moreover, the importance of education based on competencies is marked out, sustained on a diagnosis among managers and academics, where the real marketing necessities are expressed. key word competencies, knowledge,enterprise, academy, know-how, knowledge, educational sector, enterprise world. maria eulalia buenahora profesora asistente facultad de enfermería • universidad de la sabana abstract 45 el entorno empresarial y el desarrollo de competencias reflexiones existen diversas conceptualizaciones sobre las competencias laborales; a continuación se presentan algunas sustentaciones dadas en diferentes países: conocer (méxico): capacidad productiva de un individuo, que se define y mide en términos de desempeño en un determinado contexto laboral, y no solamente de conocimientos, habilidades destrezas y actitudes; estas son necesarias, pero no suficientes por sí mismas para su desempeño efectivo. inem (españa): las competencias profesionales definen el ejercicio eficaz de las capacidades que permiten el desempeño de una ocupación, respecto a los niveles requeridos en el empleo. “es algo más que el conocimiento técnico que hace referencia al saber y al saber-hacer”. el concepto de competencia engloba no solo las capacidades requeridas para el ejercicio de una actividad profesional, sino también un conjunto de comportamientos, facultad de análisis, toma de decisiones, transmisión de información, etc., considerados necesarios para el pleno desempeño de la ocupación. polform/oit: la competencia laboral es la construcción social de aprendizajes significativos y útiles para el desempeño productivo en una situación real de trabajo, que se obtiene no solo a través de la instrucción, sino también, y en gran medida, mediante el aprendizaje por experiencia en situaciones concretas de trabajo. oit: idoneidad para realizar una tarea o desempeñar un puesto de trabajo eficazmente, por poseer las calificaciones requeridas para ello. en este caso, los conceptos competencia y calificación se asocian fuertemente, dado que la calificación se considera una capacidad adquirida para realizar un trabajo o desempeñar un puesto de trabajo. provincia de quebec (canadá): una competencia es el conjunto de comportamientos socioafectivos y habilidades cognoscitivas, psicológicas, sensoriales y motoras que permiten llevar a cabo adecuadamente un papel, una función, una actividad o una tarea. consejo federal de cultura y educación (argentina): un conjunto identificable y evaluable de conocimientos, actitudes, valores y habilidades relacionadas entre sí, que permiten desempeños satisfactorios en situaciones reales de trabajo, según estándares utilizados en el área ocupacional. australia: la competencia se concibe como una estructura de atributos necesarios para el desempeño de situaciones específicas. es una compleja combinación de atributos, conocimientos, actitudes, valores y habilidades, y las tareas que se n un mundo dinámico, caracterizado por la globalización, la apertura económica y los grandes avances científicos y tecnológicos, el conocimiento se considera como uno de los principales factores de avance y desarrollo económico y social. en este contexto, la educación laboral adquiere un lugar preponderante, mientras la organización laboral se convierte en el espacio en el cual todas las aplicaciones científicas y tecnológicas deben difundirse para mejorar los niveles de competitividad y productividad, tanto a escala nacional como internacional. el concepto de competencia es el elemento articulador entre el conocimiento científico y el conocimiento técnico, base para la implementaron de un saber hacer. año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 46 tienen que desempeñar en determinadas situaciones. este ha sido llamado un enfoque holístico, en la medida que integra y relaciona atributos y tareas, permite que ocurran varias acciones intencionadas simultáneamente y toma en cuenta el contexto y la cultura del lugar del trabajo. nos permite incorporar la ética y los valores como elementos del desempeño competente. alemania: posee competencia profesional quien dispone de los conocimientos, destrezas y actitudes necesarios para ejercer una profesión, puede resolver los problemas profesionales de forma autónoma y flexible y está capacitado para colaborar en su entorno profesional y en la organización del trabajo. national council for vocational qualifications (ncvq): en el sistema inglés, más que encontrar una definición de competencia laboral, el concepto se encuentra latente en la estructura del sistema normalizado. la competencia laboral se identifica en las normas, a través de la definición de elementos de competencia (logros laborales que un trabajador es capaz de conseguir), criterios de desempeño (definiciones acerca de la calidad), el campo de aplicación y los conocimientos requeridos1 . esta multiplicidad de conceptualizaciones demuestra la preocupación existente en los distintos países y organismos internacionales por su desarrollo e implementacion en el ámbito laboral, y la inquietud por la formación profesional impartida y su relación con el trabajo desempeñado, sin ignorar que debe existir una articulación entre el sector educativo y el sector productivo (es decir, la empresa) para definir el perfil que debe tener la persona que ocupará el cargo en un futuro. las empresas han empezado a reconocer que su principal fuente de diferenciación y competitividad es su gente, y orientan todos sus esfuerzos a fortalecer su activo humano; de ahí la importancia de generar ambientes propicios a la innovación y al aprendizaje continuo, con estrategias que se soportan en claros procesos de capacitación para el desarrollo de las mismas. en colombia, en los últimos años, el tema de la formación profesional basado en competencias ha sido trabajado por el sena, el ministerio de educación y el icfes, quienes han investigado qué pueden desempeñar sus egresados en el sector productivo, en empresas tales como la industria gráfica, las artesanías, la construcción, el sector gas, el de agua potable y saneamiento básico, entre otros; todo ello en acción conjunta, con miras a articular la formación profesional y el trabajo. las publicaciones sobre el tema que circulan en el país también provienen de méxico, españa, inglaterra y estados unidos, orientaciones y experiencias que proveen de herramientas para articular la formación educativa y el trabajo, y a la vez, a través de su análisis, diseñar y reconocer la importancia de las competencias en los planes, para responder a una necesidad propia y no simplemente hacer transferencia de modelos extranjeros. en colombia se deben identificar cuáles son las competencias que deberían tener nuestros profesionales, de acuerdo con nuestras características, cultura, mercado de trabajo y tecnología imperante. por estas y muchas otras razones, no puede desestimarse la importancia del sector educativo, las reformas curriculares acordes con las necesidades del medio, la sensibilización a los docentes, donde no impere la parte teórica sino la práctica, la solución de problemas, el liderazgo, la toma de decisiones; en ese momento estaríamos articulando la formación educativa y la empresarial o campo de acción del egresado. como muy bien lo define el doctor rafael ramírez en el discurso de instalación del primer encuentro andino sobre formación con base en competencias laborales, realizado en bogotá en mayo de 1998: “aprendizaje es el nuevo paradigma que debe presidir la acción formativa de los trabajadores: aprendizaje en el aula, aprendizaje fuera del aula, aprendizaje en la empresa, aprendizaje desescolarizado, aprendizaje a distancia, aprendizaje continuo. ”lo anterior plantea serios desafíos a los responsables de orientar e impartir la formación profesional; requiere la participación concertada de todos los actores, especialmente empresarios y trabajadores…”. la correspondencia entre el sistema educativo y el mundo del trabajo siempre se ha caracterizado por ser compleja; una de las razones fundamentales es que a pesar de estar tan relacionados, el uno y el otro tienen objetivos y metas distintos, los cuales se evidencian en que la persona formada desde el sistema educativo, para una tarea específica, no siempre se desempeña en ella. lo que la formación le debe dar a esta persona es una 1 documento de cinterfor (centro interamericano de investigación y documentación sobre formación profesional). competencia laboral: sistemas, surgimiento y modelos. 47 el entorno empresarial y el desarrollo de competencias reflexiones preparación para el mundo del trabajo, no solo enseñarle contenidos del área profesional específica, sino capacidades de gestión, solución de problemas y mercadeo, entre otras. por lo tanto, la responsabilidad del docente y su institución es involucrarse con la empresa, que constituye el sostén de la economía de cualquier país. los empresarios son los que conocen sus necesidades, saben el perfil del egresado que requieren para ser competitivos. solo acercándonos y trabajando conjuntamente podremos resolver los problemas de formación y, por ende, de desempleo. se reducirá el gasto de las empresas en miles de millones de pesos en capacitación de personal, que admiten con un título profesional, pero que no sabe cómo desempeñarse adecuadamente en su puesto de trabajo. como se mencionaba anteriormente, se tiene el “saber”, pero no se articula convenientemente con el “saber-hacer”, y el “saber” sin el “saber-hacer” es parte fundamental, no solo de las competencias sino del ser competitivo. ¿cómo queremos que nuestros profesionales lo sean si existe esa dicotomía? esta pregunta exige una reflexión, que enfoque hacia la acción intencionada de educandos, educadores y empleadores, cuyo fin sea mejorar la calidad de la educación para responder a las exigencias del siglo xxi. todo lo anterior se sustenta en el pensamiento del profesor miguel ángel maldonado garcía, especialista en pedagogía del trabajo: “¿es posible articular la educación con la producción? ”el desempleo estructural es una figura que los economistas utilizan para contrastar la diferencia de los perfiles de quienes buscan un empleo con quienes lo ofrecen, es decir, desajuste entre la oferta y la demanda. ”es una, pero no la única, de las causas de esas diferencias tan marcadas en nuestro país; es la incompetencia de los trabajadores para cumplir con las funciones asignadas por los empresarios, en cuya base se encuentra la educación. es como si el caudaloso río de la competitividad, el desarrollo tecnológico, la violencia generalizada y otros factores pusieran en su loca carrera en orillas separadas a la educación y al trabajo, impidiendo que una y otro avancen en la misma dirección”. para determinar la competencia laboral de una persona se requieren criterios o parámetros, con los cuales se podrán confrontar y juzgar el desempeño y los dominios; estas competencias se identifican sobre la realidad del trabajo, lo cual implica que el trabajador participa del propio diseño, siendo responsable de su formación. el trabajador viene a ser el beneficiario e impulsor del cambio, es una vivencia que le permite vislumbrar los objetivos que va a alcanzar. para trabajar no solo se requieren más conocimientos y competencias, habilidades, actitudes y valores, sino saber trabajar en equipo, tener noción de conjunto y de grupo. por ello, es obsoleta la concepción del trabajo en serie, donde la producción se parcializa y cada uno es especialista de su parte, pero ninguna persona resuelve problemas, ni tiene conocimiento de la totalidad del producto. hoy se aspira a formar integralmente al trabajador a través de las competencias. vale la pena tener en cuenta la declaración de la doctora cresson, comisionada europea para recursos humanos, sobre la importancia de la capacitación laboral en las empresas, aunque sea considerada un intangible: “el desempeño económico en europa, hoy, gira en torno a la calidad de la educación, la capacitación y la investigación; incrementar estos factores es una forma de inversión intangible. la educación y la capacitación deberían ser consideradas como un desarrollo progresivo de las destrezas a lo largo de la vida, y en la unión europea la capacitación educativa es cada día más importante, no solo para el progreso económico, sino también por otros beneficios, tales como la cohesión social. el énfasis sobre la capacitación educativa ha influido, por cambios repentinos en las estructuras socioeconómicas, y se ha acelerado por el impacto de la tecnología. así que para ser competitivas, las naciones europeas ven en el futuro la necesidad no solo de aumentar la capacitación en las destrezas técnicas y los conocimientos, sino también en las destrezas más prácticas, tales como el uso de la tecnología de información, la aplicación de los números y la destreza de la comunicación”2. la persona formada en competencias tiene que ser versátil, debe ser capaz de aplicar sus conocimientos, tener habilidades, valores, actitudes, motivación en el desempeño de su vida, no solo en su trabajo sino también en su vida personal. la empresa tiene la obligación y la responsabilidad de motivar la capacitación, después de la educación obliga2 documento sobre el seminario formación basada en competencias. situación actual y perspectivas para los paises del mercosur. año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 48 toria o formal; de esta manera existirá mayor compromiso, mejores y efectivas capacitaciones, con un excelente resultado en el desempeño y, por ende, una gestión más eficiente. el enfoque de competencias aclara el panorama para los empresarios. la gestión de recursos humanos y la selección de personal se apoyarán ya no en los diplomas y títulos solamente, sino sobre capacidades demostradas; el desafío es que todas las empresas tendrán que dedicarse a trabajar con las personas en su formación; será de alguna manera algo innovador en el trabajo y una forma de asegurar el resultado. las competencias no se enseñan en un curso solamente, son el reflejo de un ambiente productivo, inmerso dentro de la atmósfera de la empresa, con los códigos de conducta que operan en la realidad de la misma; en fin, una propuesta donde esté articulada la formación con el trabajo y la tecnología, en un inmejorable ambiente de trabajo, en el cual se transmitan valores, hábitos, compromiso y pertenencia a la organización. uno de los principales objetivos de las competencias laborales es ayudar a romper las inercias y obstáculos que hasta la fecha han inhibido que las empresas dinamizaran la capacitación de su personal. esto cobra especial importancia en américa latina, donde las investigaciones realizadas indican que la capacitación sigue siendo muy limitada, en términos generales; ello obedece en parte a los problemas que las empresas enfrentan al poner en práctica programas de capacitación, debido a que no saben cómo dirigirlos para alcanzar los objetivos que se proponen; es decir, no existe claridad sobre sus necesidades reales. otras consideran que se generan costos, pues no se identifican las ventajas. a continuación se enunciarán algunas reflexiones sobre la conveniencia de la capacitación. centrar su enfoque en la demanda, más que en el interés particular. desarrollar los conceptos de formación y capacitación como procesos continuos. posibilitar una mejor coordinación institucional entre centros de trabajo y oferta de capacitación y formación. proveer al mercado laboral de personal formado, veraz y oportuno. favorecer la aplicación de programas de formación y capacitación, con la calidad, flexibilidad y pertinencia requeridas. permitir alcanzar más rápido la adaptación y la actualización del sistema de formación y capacitación a las necesidades del cambio tecnológico y productivo. estimular el aprendizaje y motivar al trabajador. el individuo es competente si desarrolla representaciones positivas de sí mismo y de su entorno (autoestima). la formación que se imparte en competencias predice unas conductas, que a su vez predicen unos resultados. impulsar la capacitación y la actualización permanentes. fomentar el uso de métodos formativos. fomentar el trabajo en equipo y la formación integral y competitiva. además, el enfoque de la formación en competencias puede ayudar a establecer mecanismos que permitan evaluar las diversas formas como el ser humano aprende a desempeñarse en el trabajo, para otorgarle reconocimientos en el mercado laboral, mediante certificaciones o acreditaciones. las tendencias actuales del mercado laboral imponen nuevas exigencias a la economía nacional y obligan a buscar alternativas para que los trabajadores desarrollen los conocimientos y habilidades que se requieren en la empresa. para enfrentar estos retos se requiere un sistema educativo de calidad, donde las personas busquen y desarrollen, además, la capacidad de aprender por sí mismas, pero motivadas en todo momento por los empleadores; es decir, la empresa debe ser en todo momento un facilitador del aprendizaje, debe ser flexible; para lograr esta flexibilidad, ha de ser capaz de otorgar validez a formas de aprendizaje diferentes de las tradicionales y concebir el aprendizaje como un proceso que no termina con la educación formal, como mencionábamos anteriormente, sino que se extiende a lo largo de toda la vida de las personas. nuestra sociedad se enfrenta a un cambio de paradigmas en todos los órdenes, pero el que nos compete es el del conocimiento, valor que se convierte en ser competitivo para sobrevivir en el mercado laboral, donde no solo se desarrolle el talento humano, sino la innovación y la productividad de las empresas. 02. el rol de la en. (16 a 20) año 3 nº 3 • bogotá, colombia octubre 2003 16 resumen el desarrollo de las teorías de enfermería ha cambiado irreversiblemente el desarrollo de la ciencia de la enfermería. la teoría ha contribuido no solo a definir las competencias profesionales, sino también al desarrollo de su cuerpo de conocimientos, los cuales reflejan lo que es específico de la profesión: su enfoque en la persona, su comportamiento y el significado de sus experiencias, considerados de manera holística. por lo tanto, las transacciones biopsicosocioculturales y espirituales del ser humano son centrales a la disciplina de la enfermería. este trabajo presenta una visión de la enfermería que analiza los conceptos fundamentales de ser humano, salud-enfermedad, entorno y enfermería. el desarrollo teórico también ha ayudado al entendimiento y aceptación de la complejidad de la enfermería y la inevitabilidad de sus múltiples teorías. el pluralismo paradigmático del desarrollo de la disciplina refleja la diversidad de su enfoque, la persona, la diversidad de sus interacciones en la salud y en la enfermedad, y la diversidad de las intervenciones de enfermería. palabras clave: ser humano, enfermería, salud, enfermedad y teorías. abstract the development of nursing theories has changed the development of nursing science. the theory has contributed not only to define professional competencies, but also to the development of knowledge, which reflects specific aspects of the profession: its focus on the person, its behavior and the meaning of its experiences, considered in a holistic way. in consequence, the bio psycho socio cultural and spiritual transactions of the human being are the center of nursing discipline. this work presents a nursing view, analyzing main concepts of the human being, health-disease, environment and nursing. the theoretical development helped also to the comprehension and acceptation of nursing and its multiple theories. the paradigmatic pluralism of the development of the discipline shows the diversity of its focus, the person, different interactions in health and disease and different nursing interventions. key words: human being, nursery, health, pathology and theories. adelaida zabalegui yárnoz r.n., ph.d., directora de la facultad de enfermería, universidad internacional de cataluña. barcelona, españa el rol del profesional en enfermería 17 a naturaleza del ser humano consiste en un grupo de rasgos dinámicos que unen a los seres humanos de todos los tiempos. el ser humano está constantemente en proceso de autocreación, y su último objetivo es el describir y entender el mundo que le rodea y, al mismo tiempo, hacerlo más sensible a los ideales de la persona, utilizando su característica específica: la racionalidad. las acciones del ser humano son responsables en el sentido de que él elige intencionadamente entre las diversas opciones. por otra parte, la persona está en constante interacción con su entorno y con otras personas para conseguir su objetivo. el ser humano actúa con base en su experiencia, manifestando sus capacidades de funcionar efectiva y eficazmente, afrontar y adaptarse a la vida. cada persona tiene su propia “realidad”, basada en sus experiencias. cada uno interpreta y le da su propio significado a la realidad, con una relación de interdependencia entre las experiencias vividas. para maslow (4), cada persona tiene una jerarquía de necesidades que debe ser satisfecha, y el poder para cambiar el mundo de acuerdo con sus intereses. el estudio histórico de la evolución de la naturaleza humana nos da la perspectiva necesaria para poner en contexto y enfocar los problemas asociados a la existencia del ser humano. es obvia la necesidad de conocer nuestra propia historia, nuestra evolución cultural, social, política y económica, la evolución de las acciones, costumbres y creencias del ser humano, y las teorías filosóficas que han moldeado las relaciones entre los seres humanos. el entender las causas de los cambios en el pasado nos capacitará para afrontar mejor los retos del presente y para que nuestra contribución al bienestar de las generaciones futuras sea más eficaz. si analizamos la historia, podemos identificar diferentes conceptos de salud. por ejemplo, para las teóricas de la enfermería, como orem (1971), la salud se define como un estado dinámico de integridad de la estructura y función. roy (10) enfatiza la necesidad de la continua adaptación a los estresores del entorno interno o externo. newman (7) contempla la salud como una conciencia en expansión. watson (11) define la salud como la congruencia entre la autopercepción y la vida diaria de la persona. la capacidad de realizar funciones independientes es la visión del concepto de salud para virginia henderson (2). para la organización mundial de la salud (12), por otra parte, este concepto se define como un estado de completo bienestar físico, mental y social, y no solamente la ausencia de enfermedad. la autora ve la salud como un estilo de vida dinámico satisfactorio, que incluye una adaptación al entorno satisfactoria y un estado de libertad de las alteraciones fisiológicas, psicológicas o de comportamiento que entendemos como molestas o perturbadoras. la salud nunca es completa o absoluta, pero representa un objetivo deseado. la obtención de este objetivo es el eje de las intervenciones de enfermería para prevenir la pérdida, promover o restaurar la autonomía de las personas desde el estado de restricción que representa la enfermedad. en general, el concepto de enfermedad se define como una limitación concreta del ser humano, pero que varía dependiendo de los valores personales, que están influenciados por las características del individuo y de su entorno. las la persona está en constante interacción con su entorno y con otras personas para conseguir su objetivo. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 18 personas, con sus antecedentes característicos, ven la enfermedad y la salud de diferentes maneras y, consecuentemente, existe una variabilidad de comportamientos en sus acciones hacia la salud. las características individuales, como edad, género, origen étnico, antecedentes genéticos, nivel intelectual y motivación, valores éticos y socioculturales, que varían entre personas y a lo largo del tiempo, han demostrado su influencia en las respuestas fisiológicas y en el comportamiento humano hacia la adaptación al entorno. se reconoce tanto la influencia genética como la del entorno, en relación con el comportamiento humano (5). los factores del entorno, que influencian la manera como las personas perciben y centran sus acciones en relación con la salud, los podemos clasificar en tres grupos: el entorno físico, los patrones culturales y los patrones sociales. estos factores han sido agrupados de diferentes maneras, dependiendo del interés específico de la autora, así como desde el punto de vista de la relación enfermero-cliente o de los principios del sistema de salud pública. el entorno físico incluye las variables físicas, químicas y biológicas que influencian la salud humana. el entorno deseable proporciona una gran variedad de estímulos compatibles, que son necesarios para el desarrollo mental y físico. además, también provee lo indispensable para satisfacer las necesidades básicas o fundamentales, como agua, alimentos, etc. los peligros potenciales de las actividades humanas, como desechos, contaminación o destrucción de materiales tóxicos de labores industriales, como asbestos, monóxido de carbono o derrames de petróleo, son el principal centro de atención, ya que están claramente identificados como factores negativos relacionados con la exposición a toxicidad (6). entre los patrones culturales encontramos la religión, la organización familiar, el lenguaje, el uso de medicamentos, el cuidado de los niños y de los ancianos, los hábitos alimentarios, etc. dentro de estos patrones podemos identificar una amplia variedad de conceptos, que tienen significado saludable para unos, mientras que no es así para otros. los patrones sociales, como el nivel de educación, el estatus socioeconómico, el empleo y los patrones de relación entre las personas, influencian significativamente la accesibilidad al cuidado de la salud y la capacidad de tomar decisiones informadas. en algunos de los patrones culturales o sociales se han podido identificar factores de riesgo para enfermedades específicas. por ejemplo, el estrés, la obesidad, la falta de ejercicio físico y el consumo de tabaco se han relacionado con las enfermedades cardiovasculares. a pesar de que el abandono de estos hábitos requiere cambios lentos de conducta, y en algunos casos son muy difíciles al enfrentarse a los valores específicos de grupos sociales determinados, los resultados de la actividad de enfermería son muy satisfactorios y generan mejoras significativas en los niveles de salud de la población. el papel de los valores grupales y personales en el entendimiento de la salud y la enfermedad es un tema central en la práctica del cuidado de la salud. la enfermería, al igual que otras profesiones de la salud, debe asegurarse de que se consideran justamente los valores de cada persona y que no se abuse de sus derechos y privilegios. los valores definen la salud-enfermedad y establecen funciones sociales, como la de paciente o enfermera, y además interconectan estas funciones con las expectativas estructuradas, como los derechos y las obligaciones. ¿cuál es la función del profesional en enfermería en el sistema actual de cuidado de la salud? ¿y cuál debe ser el ámbito de la intervención en nuestra interacción con el cliente y su entorno? el consejo internacional de enfermería, como la más antigua organización profesional internacional, ha clasificado las funciones fundamentales de la enfermería en cuatro áreas: promover la salud, prevenir la enfermedad, restaurar la salud y aliviar el sufrimiento. esta organización apolítica reúne personas de diferentes países, con un interés profesional y un propósito común de desarrollo de la enfermería a nivel internacional (3). la enfermería se ha autoidentificado como una profesión humanista, que se adhiere a una filosofía básica centrada los factores del entorno han sido agrupados de diferentes maneras, dependiendo del interés específico de la autora, así como del punto de vista de la relación enfermera-cliente o de los principios del sistema de salud pública. ¿cuál es la función del profesional en enfermería en el sistema actual de cuidado de la salud? ¿y cuál debe ser el ámbito de la intervención en nuestra interacción con el cliente y su entorno? el rol del profesional en enfermería 19 en el ser humano y su interacción con el entorno, donde la persona elige, se autodetermina y es un ser activo. el objetivo de la enfermería debe ser, esencialmente, para el beneficio del paciente, y su trabajo debe estar centrado en él. desde el punto de vista de la autora, las intervenciones de enfermería se pueden clasificar principalmente en cuatro categorías, que afrontan las demandas del cliente: 1) cuidado; 2) competencia; 3) servicios de información y asistencia jurídica, y 4) conexión. el objetivo del cuidado debe ser promover el proceso de aprendizaje que permita al paciente ser activo en su rehabilitación o promoción de su propia salud, mediante cambios en sus hábitos o transformando las condiciones ambientales que le afectan. la función de la enfermera, como cuidadora, implica la participación activa en la promoción, mantenimiento y recuperación de la salud, mediante medidas preventivas para evitar la aparición de la enfermedad, su progresión o prevenir secuelas asegurando la continuidad del cuidado. esta cuidadora debe estar abierta a las percepciones y preocupaciones del paciente y su familia, ser moralmente responsable, estar dedicada como profesional y permanecer dispuesta para escuchar, dialogar y responder en situaciones holísticas complejas. además, debe estar basada en la evidencia empírica existente. el profesional en enfermería competente es aquel que utiliza sus conocimientos, habilidades y actitudes para emitir juicios clínicos, solucionar problemas y realizar tareas costo-eficaces. la función de la enfermería, al igual que la de otras profesiones de la salud, debe incluir la información y educación del cliente sobre la salud, para que él pueda elegir entre las diversas opciones posibles, una vez considerados los distintos riesgos y beneficios de cada alternativa. esta función de educación se está convirtiendo en prioritaria, ya que la tendencia del cuidado de la salud se centra en el cliente, como centro de la atención y como persona que toma la decisión del tratamiento y el tipo de cuidado que se va a realizar. además, el profesional en enfermería debe ser la conexión o unión entre los profesionales de la salud, el paciente y su familia. esta función tiene por objetivo la integración de los esfuerzos y la prevención de la fragmentación de los servicios de salud asociada a la especialización. es la enfermera quien crea relaciones, mediante el reconocimiento mutuo enfermera-paciente, conociendo sus percepciones y necesidades, y negociando el cuidado para alcanzar los objetivos propuestos en el plan de cuidados holísticos. como v. henderson (2) dijo, la enfermera debe conocer qué es lo que el enfermo necesita. debemos colaborar con nuestros pacientes en la identificación de sus necesidades (físicas, mentales, emocionales, socioculturales y espirituales) y en el desarrollo de soluciones. la enfermería, desde su comienzo, ha reconocido la importancia de la intervención familiar en el cuidado del paciente para promover la salud. esta necesidad de intervención debe expandirse a otros grupos, comunidades, organizaciones, colegios, etc. para alcanzar el equilibrio entre la persona y el entorno, debemos reconocer la importancia de los sistemas de apoyo social y los aspectos holísticos del cuidado físico, social, económico, político, espiritual y cultural. la enfermería debe participar en la búsqueda de medios para lograr la potenciación de la salud comunitaria. actualmente, las enfermedades predominantes son principalmente alteraciones debilitantes crónicas, en donde la promoción de la salud y la prevención de la enfermedad se reconocen como estrategias efectivas. se puede decir que la mayor parte de las muertes son el resultado de enfermedades coronarias, cáncer e infartos cerebrales. así, la enfermería debe intentar anticiparse a las situaciones que surgen y prevenir aquellas que dan lugar a riesgos para la salud. para alcanzar los objetivos anteriormente mencionados, la enfermera debe: • conocer qué es lo mejor para el paciente. • responder a las necesidades del paciente. • ser técnicamente competente, científicamente conocedora, prácticamente responsable y emocionalmente capaz de afrontar las situaciones de crisis en el cuidado de la salud. • ser competente en habilidades de comunicación y tener la capacidad de explicar la fundamentación empírica y filosófica de sus acciones en relación con el cuidado del paciente. • ser capaz de controlar las situaciones del paciente, con actividades y con el manejo de sus propias emociones. • reconocer que en cualquier momento una persona puede necesitar ayuda de otra. la enfermera(o) puede requerir ayuda para el mantenimiento o desarrollo de habilidades, para el autoconocimiento o la comprensión de otros. • potenciar la dignidad y el valor de las personas. • enfatizar y apoyar la contribución revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 20 del paciente y la familia al cuidado y a la adaptación. cuando la enfermería surge como profesión, en el siglo xix, florence nightingale (1859) (8) procuró no solo establecerla con unos fundamentos firmes sobre conocimientos científicos, sino también identificar e insistir sobre el comportamiento ético de la enfermería. posteriormente, en 1980, la asociación americana de enfermería define la función independiente de la profesión como el diagnóstico y tratamiento de las respuestas humanas a problemas de salud reales o potenciales. a medida que comenzamos el siglo xxi, surgen preguntas sobre la dirección hacia donde la profesión se mueve. en este nuevo contexto, la investigación de enfermería es necesaria para ser profesionales competentes dentro de la compleja realidad del sistema actual de cuidado de la salud. esta complejidad deriva del envejecimiento de la población, la disminución de las estancias hospitalarias, con un aumento del grado de gravedad de los pacientes ingresados, el progreso de la tecnología y los cambios sociales en el ámbito familiar. el análisis de la función de la enfermera en la planificación, realización y evaluación de la investigación, la divulgación de resultados y la aplicación en la práctica, proporcionan las bases para entender el rápido crecimiento de la investigación de enfermería en el cuidado del paciente oncológico. creemos que es importante definir la enfermería como una ciencia, en el sentido de adquisición de conocimientos mediante la observación y la experimentación, y la práctica basada en la evidencia científica. asimismo, la enfermería es un arte y una filosofía, compatibles con la visión científica. en la actualidad, el modelo de cuidado es fundamentalmente biomédico, centrado en la enfermedad, y deja poco espacio para las dimensiones sociales, psicológicas, culturales y espirituales de la salud. la enorme inversión existente y prevista en tecnología, para el diagnóstico y tratamiento de las enfermedades, favorece la tendencia hacia un cuidado impersonal y mecánico. el cambio necesario debe enfatizar el análisis de los valores sociales, culturales y personales de los seres humanos, y la función que ellos desempeñan en el análisis de la salud, como variables determinantes de intervenciones preventivas y terapéuticas. por otra parte, en el desarrollo de nuestra función como enfermeros, existen aspectos relacionados con la teoría y la práctica, que resultan problemáticos y necesitan ser solucionados; estos son la separación crónica de la teoría y la práctica, y la realidad frente al ideal de la enfermería. por lo tanto, debemos hacer un esfuerzo por alcanzar un objetivo importante: la práctica y la teoría de la enfermería deben unificarse y ambas fundamentarse firmemente en la realidad, en la evidencia científica y en el desarrollo de la humanidad. bibliografía 1. american nurses association. nursing: a social policy statement, kansas city, mo, autor, 1980. 2. henderson, v. the nature of nursing, new york, mcmillan, 1955. 3. kelly, l. y., & joel, l. a. dimensions of professional nursing, 8thed., new york, mcgraw-hill, 1999. 4. maslow, a. h. motivation and personality, 2nd ed., new york, harper & row, 1970. 5. mcgue, m. “nature-nurture and intelligence”, nature, 340: 507508,1989. 6. miller, a., & miller, m. options for health and health care, new york, john willey and sons, 1981. 7. newman, m. a. “theory for nursing practice”, nursing science quarterly, 7 (4): 153-157, 1994. 8. nightingale, f. n. notes on nursing: what it is and what it is not?, philadelphia, j. b. lippincott (documento original publicado en 1859),1992. 9. orem, d. e. modelo de orem: conceptos de enfermería en la práctica, 4ª ed., barcelona, masson-salvat, 1993. 10. roy, c., y andrews, a. the roy adaptation model, 2nd ed., stamford, ct, appleton & lange, 1999. 11. watson, j. nursing: the philosophy and science of caring, boulder, co, university press, 1985. 12. world health organization. constitution of the world health organization, chronicles of who, 1: 1-2, 1947. contributions of systematic reviews and meta-analyses to nursing education, research, and practice article contributions of systematic reviews and meta-analyses to nursing education, research, and practice contribuciones de las revisiones sistemáticas y los metaanálisis en la educación, la investigación y la práctica de la enfermería contribuições das revisões sistemáticas e das metanálises na educação, na pesquisa e na prática da enfermagem 10.5294/aqui.2021.21.4.3 wilson cañón-montañez1 alba luz rodríguez-acelas2 1 0000-0003-0729-5342 universidad de antioquia, nursing faculty, colombia. wilson.canon@udea.edu.co 2 0000-0002-7384-3522 universidad de antioquia, nursing faculty, colombia. aluz.rodriguez@udea.edu.co received: 14/09/2021 sent to peers: 09/29/2021 approved by peers: 01/11/2021 accepted: 08/11/2021 theme: evidence-based practice. contribution to the discipline: systematic reviews and meta-analyses have contributed significantly to nursing education, research, and practice. synthesizing evidence through quality systematic reviews and meta-analyses adds to the disciplinary development of nursing and helps in decision-making regarding the care needs of patients. para citar este artículo / to reference this article / para citar este artigo: cañón-montañez w, rodríguez-acelas al. contributions of systematic reviews and meta-analyses to nursing education, research, and practice. aquichan. 2021;21(4):e2143. doi: https://doi.org/10.5294/aqui.2021.21.4.3 abstract systematic reviews and meta-analyses are helpful methodological alternatives that combine, discuss, and assess the quality of the best available evidence through adequate and exhaustive searches of the literature. in the last decade, there has been an increase in systematic reviews and meta-analyses in nursing research. this article intends to reflect on the contributions of systematic reviews and meta-analyses to nursing education, research, and practice. synthesizing the evidence through high-quality systematic reviews and meta-analyses adds to the disciplinary development of nursing; therefore, students and professionals in the field should be encouraged to employ these methodological tools in education and research and implement the results of these methods in clinical practice for making better decisions regarding the individual needs of patients. keywords (source decs): systematic review; meta-analysis; nursing education; evidencebased practice; nursing research. resumen las revisiones sistemáticas y los metaanálisis son alternativas metodológicas útiles que, mediante búsquedas adecuadas y exhaustivas de la literatura, consiguen combinar, analizar y evaluar la calidad de la mejor evidencia disponible. en la última década ha habido un aumento en la publicación de revisiones sistemáticas y metaanálisis en la investigación en enfermería. este artículo tiene como propósito realizar una reflexión sobre las contribuciones de las revisiones sistemáticas y los metaanálisis en la educación, la investigación y la práctica de la enfermería. sintetizar la evidencia a través de revisiones sistemáticas y metaanálisis de buena calidad aporta al desarrollo disciplinar de la enfermería, razón por la cual se debe estimular a estudiantes y profesionales de la disciplina a hacer uso de estas herramientas metodológicas en la educación y la investigación, así como la implementación de los resultados de estas metodologías en la práctica clínica, para la toma de mejores decisiones frente a las necesidades individuales de los pacientes. palabras clave (fuente: decs): revisión sistemática; metaanálisis; educación en enfermería; práctica clínica basada en la evidencia; investigación en enfermería. resumo as revisões sistemáticas e as metanálises são alternativas metodológicas úteis que, por meio de buscas adequadas e exaustivas da literatura, conseguem combinar, analisar e avaliar a qualidade da melhor evidência disponível. na última década, houve um aumento na publicação de revisões sistemáticas e metanálises na pesquisa em enfermagem. nesse sentido, o objetivo deste artigo é realizar uma reflexão sobre as contribuições das revisões sistemáticas e das metanálises na educação, na pesquisa e na prática da enfermagem. sintetizar a evidência a partir de revisões sistemáticas e metanálise de boa qualidade contribui para o desenvolvimento da disciplina de enfermagem, razão pela qual estudantes e profissionais da área devem ser estimulados a fazer uso dessas ferramentas metodológicas na educação e na pesquisa, bem como a implementar os resultados dessas metodologias na prática clínica, para a tomada de melhores decisões diante das necessidades individuais dos pacientes. palavras-chave (fonte: decs): revisão sistemática; metanálise; educação em enfermagem; prática clínica baseada em evidências; pesquisa em enfermagem. introduction in recent years, research and scientific production in health sciences has increased significantly, which has not been different for nursing. each year more than two million scientific articles are published, estimating that a health professional should read an average of 17 articles per day to be up-to-date, which may not have the best methodological quality (1). additionally, health professionals who wish to access evidence may face some limitations: i) difficulties in adequately searching for relevant clinical evidence; ii) language barriers; iii) little experience in critical reading of literature; iv) problems in analyzing the internal and external validity of studies; and v) little or limited time. for these reasons, systematic reviews (sr) and meta-analyses (ma) emerge as a methodological alternative that makes it possible to group, analyze, and assess the quality of available evidence through an exhaustive search of the literature. furthermore, this research method can produce new knowledge by consolidating findings from previous primary studies (2). of note is that, although the first uses of the term sr date back to the 1930s in the 20th century (3), it was not until 1989 that it began to be used more, after the creation of the cochrane collaboration (4). the latter aims to promote interest in conducting secondary research to group available primary studies on a particular topic, synthesizing the information and answering a specific research question. the main characteristics of this type of study include assessing the risk of bias and the reproducibility of the search strategy (5). because they integrate primary research or studies with different sources of information—which in turn use different methods—, srs have been considered within the hierarchy of scientific evidence (6). some authors who use the hierarchy of evidence pyramid classify srs and mas of randomized clinical trials as the type of study with the highest level of scientific evidence. however, some researchers recently suggested a new pyramid to hierarchize scientific evidence, in which srs are a 'lens' through which evidence is viewed or applied (7), thus overcoming the limitations of narrative reviews given their high level of subjectivity (8) and making srs and mas reliable tools for clinical decision-making. some srs include an ma that incorporates a statistical analysis to evaluate the association or combined effect of studies; initially, when mas arose, they were used to analyze the results of intervention studies (9, 10). the term 'meta-analysis' was proposed by gene v. glass in 1976, who defined it as "the statistical analysis of a large collection of analysis results from individual studies for the purpose of integrating the findings" (9). in the last decade, the increase in the publication of srs and mas in nursing has been noticeable, as suggested by the results of a search in pubmed for the period between 1996 and july 31, 2021, using the mesh terms "nursing," "systematic review" and "meta-analysis" and the boolean operator "and," yielding 7,579 results (figure 1). figure 1. increase in nursing publications using the systematic review and meta-analysis methods. source: own elaboration based on a pubmed search. contributions to evidence-based practice we can currently find nursing professionals who need to bring together practice and scientific development to guide congruent and pertinent care. this constant concern has caused an increase in the production of knowledge on various issues and with various methods that are sometimes challenging to address wholly and individually due to the circumstances and difficulties mentioned above. so, the question arises, what sources of information can be used to access new scientific production comprehensively? the response to this need to gather, integrate, and analyze primary studies results in an sr that synthesizes evidence, increases the validation of individual studies, identifies knowledge gaps, and generates new hypotheses for new studies (11). one of the fundamental principles of evidence-based practice (ebp) is a hierarchy of reliable evidence based on the methodological design elements of studies, minimizing the effect of bias on the results (12). in the new conceptualization proposed for the prioritization of ebp, srs and mas are represented by a 'magnifying glass' or 'lens' whose interpretation refers to the observation and analysis of available evidence (7) and wavy lines that symbolize the variations that may exist according to the methodological quality of the selected studies (figure 2). figure 2. new proposal for hierarchizing evidence in quantitative research. source: adapted from murad et al. (7) accordingly, evidence-based nursing (ebn) promotes the incorporation of research into the care activity by searching for the best available evidence, producing new disciplinary knowledge. the preceding is achieved by employing a systematic and exhaustive literature search and a more rigorous selection of evidence for a specific problem. in this sense, practice can be much more effective since it is based on critical judgments that help delineate care planning and seek to meet the needs of the patient, family, caregivers, and the community, strengthening the profession of nursing as a discipline and science (6, 13). bear in mind that the results of an sr or an ma should not be taken as a rigid guideline since these findings, for example, can be helpful to determine the most appropriate intervention for the patient (14), an approach that favors the applicability and usefulness of results (12). therefore, besides facilitating the incorporation of studies to the different scenarios where nursing is present, ebn fosters a research interest that leads to holistic care and increases nursing's body of knowledge (13). contributions to postgraduate nursing education srs and mas are increasingly used to adequately review the literature on the study phenomenon of research projects of nursing graduate students (3, 15). indeed, several master's and doctorate programs in nursing from various world universities include sr and ma courses in their curricula as an education and training strategy to develop students' skills on research methods. there are divided opinions among researchers and student supervisors at the doctoral level regarding srs or mas during doctoral training. one of the arguments for this 'disagreement' is that doctoral students are expected to produce new knowledge by conducting primary studies without synthesizing and implementing secondary analysis results of individual studies. furthermore, there seems to be a consensus among researchers in favor, who argue that the inclusion of sr and ma in doctoral programs in nursing would allow well-structured research questions, critical reading skills, better methodological competence, and more significant appropriation of ebn and ebp (3, 15). however, given the advancement and development of srs and mas, students, professors, and researchers must update their knowledge about the different stages of this type of study and follow the current methodological recommendations of experts from the collaboration. cochrane and the joanna briggs institute. contributions for the practice and improvement of results in patients and nursing professionals it is increasingly common to find that srs and mas are used as mainstays for preparing and updating management protocols and clinical practice guidelines in health institutions. when these srs and mas rely on the results of randomized clinical trials, it is possible to 'close' the clinical uncertainty about the effectiveness or impact of a given intervention on the patient and their therapeutic process (16). similarly, the results of srs and mas can serve as input for decision-makers to suggest changes in public policies for the benefit of the population. in addition, they support the nursing professional's endeavors and care itself, reinforcing each role of the discipline and the need to work with multidisciplinary teams. some examples of recent results from srs and mas show the effectiveness of intervention studies in decreasing hospital re-admissions in patients with heart failure (17) and improving nursing students' mental health (18). other studies use the sr and ma methods to identify the factors that determine the emergence of healthcare-associated infections in hospitalized adults (19) and demonstrate the benefit of lifestyle interventions in women with gestational diabetes (20). through srs and mas, it has also been shown that adequate nursing staffing in health institutions can lead to better results in patients and nurses (21, 22). conclusions srs and mas are considered rigorous research methods, with the possibility of having a high degree of evidence and applicability in various knowledge domains. they are considered of great importance in nursing because they contribute to substantiating care, given their ability to condense scientific evidence, increase the degree of validity of studies, and point out the gaps that need bridging, either because there are not enough studies, because of their low methodological rigor, or because they are inconclusive. synthesizing evidence through quality srs and mas, following the methodological recommendations of experts (23-25), adds to the disciplinary development of nursing. thus, students and professionals should be encouraged to use these methods in education and research and implement the results of srs and mas in daily care activities to make better decisions regarding patients' individual needs. references 1. manterola c, astudillo p, arias e, claros n, grupo mincir (metodología e investigación en cirugía). revisiones sistemáticas de la literatura. qué se debe saber acerca de ellas. cir esp. 2013;91(3):149-155. doi: https://doi.org/10.1016/j.ciresp.2011.07.009 2. garcía-perdomo ha. conceptos fundamentales de las revisiones sistemáticas/metaanálisis. urol colomb. 2015;24(1):28-34. doi: https://doi.org/10.1016/j.uroco.2015.03.005 3. olsson c, ringnér a, borglin g. including systematic reviews in phd programmes and candidatures in nursing 'hobson's choice'? nurse educ pract. 2014;14(2):102-105. doi: https://doi.org/10.1016/j.nepr.2014.01.005 4. chalmers i, hedges lv, cooper h. a brief history of research synthesis. eval health prof. 2002;25(1):12-37. doi: https://doi.org/10.1177/0163278702025001003 5. marín f, sánchez j, lópez ja. el metaanálisis en el ámbito de las ciencias de la salud: una metodología imprescindible para la eficiente acumulación del conocimiento. fisioterapia. 2009;31(3):107-114. doi: https://doi.org/10.1016/j.ft.2009.02.002 6. manterola c, asenjo-lobos c, otzen t. jerarquización de la evidencia. niveles de evidencia y grados de recomendación de uso actual. rev chil infectol. 201431(6)705-718. doi: https://doiorg/10.4067/s0716-10182014000600011 7. murad mh, asi n, alsawas m, alahdab f. new evidence pyramid bmj evidence-based med. 2016;21(4):125-127. doi: https://doi.org/10.1136/ebmed-2016-110401 8. guirao goris sja. utilidad y tipos de revisión de literatura. jan. 2015;9(2). doi: https://doi.org/10.4321/s1988-348x2015000200002 9. glass gv. primary, secondary, and meta-analysis of research. educ res. 19765(10)3-8. doi: https://doi.org/10.2307/1174772 10. akobeng ak. understanding systematic reviews and meta-analysis. bmj arch dis child. 2005^0(8^845-848. doi: https://doi.org/10.1136/adc.2004.058230 11. garcía j, rodríguez jl, subirana m. revisiones sistemáticas de la evidencia científica: algunos apuntes prácticos. enferm clínica. 2003;13(3):159-163. doi: https://doi.org/10.1016/s1130-8621(03)73799-1 12. mcnamara er, scales cd. role of systematic reviews and meta-analysis in evidence-based clinical practice. indian j urol. 2011;27(4):520-524. doi: https://doi.org/10.4103/0970-1591.9144; 13. cañon-montañez w, durán niño ey, hernández beltrán ja. enfermería basada en la evidencia: un pilar esencial en el currículo. rev cuidarte. 2010;1(1):82-85. doi: https://doi.org/10.15649/cuidarte.v1 i1.77 14. ferreira i, urrútia g, alonso-coello p. revisiones sistemáticas y metaanálisis: bases conceptuales e interpretación. rev esp cardiol. 2011;64(8):688-696. doi: https://doi.org/10.1016/j.recesp.2011.03.029 15. ham-baloyi w, jordan p. systematic review as a research method in postgraduate nursing education. health sa gesondheid. 2016;21:120-128. doi: https://doi.org/10.4102/hsag.v21i0.942 16. villasis-keever má, rendón-macías me, garcía h, miranda-novales mg, escamilla-núñez a. la revisión sistemática y el metaanálisis como herramientas de apoyo para la clínica y la investigación. rev alerg mex. 2020;6700:62-72. doi: https://doi.org/10.29262/ram.v67i1.733 17. cañon-montañez w, duque-cartagena t, rodríguez-acelas al. effect of educational interventions to reduce readmissions due to heart failure decompensation in adults: a systematic review and meta-analysis. invest. educ. enferm. 202139(2)^05. doi: https://doi.org/10.17533/udea.iee.v39n2e05 18. li c, yin h, zhao j, shang b, hu m, zhang p, et al. interventions to promote mental health in nursing students: a systematic review and meta-analysis of randomized controlled trials. j adv nurs. 2018;74(12):2727-2741. doi: https://doi.org/10.1111/jan.13808 19. rodríguez-acelas al, almeida ma, engelman b, cañon-montañez w. risk factors for health care-associated infection in hospitalized adults: systematic review and meta-analysis. am j infect control. 2017;45(12):e149-e156. doi: https://doi.org/10.1016/j.ajic.2017.08.016 20. goveia p, cañon-montañez w, santos dp, lopes gw, ma rcw, duncan bb, et al. lifestyle intervention for the prevention of diabetes in women with previous gestational diabetes mellitus: a systematic review and meta-analysis. front endocrinol. 2018;9:a583. doi: https://doi.org/10.3389/fendo.2018.00583 21. twigg de, whitehead l, doleman g, el-zaemey s. the impact of nurse staffing methodologies on nurse and patient outcomes: a systematic review. j adv nurs. 2021;77(12):4599-4611. doi: https://doi.org/10.1111/jan.14909 22. shin s, park jh, bae sh. nurse staffing and nurse outcomes: a systematic review and meta-analysis. nurs outlook. 2018;66(3):273-282. doi: https://doi.org/10.1016/j.outlook.2017.12.002 23. higgins jpt, thomas j, chandler j, cumpston m, li t, page mj, welch va (editors). cochrane handbook for systematic reviews of interventions [internet]. version 6.2 (updated february 2021). cochrane, 2021. available from: http://www.training.cochrane.org/handbook 24. santos wm, secoli sr, püschel vaa. the joanna briggs institute approach for systematic reviews. rev. latino-am. enfermagem. 2018;26:e3 074. doi: https://doi.org/10.1590/1518-8345.2885.3074 25. muka t, glisic m, milic j, verhoog s, bohlius j, bramer w, et al. a 24-step guide on how to design, conduct, and successfully publish a systematic review and meta-analysis in medical research. eur j epidemiol. 2020; 35(1) 49-60. doi: https://doi.org/10.1007/s10654-019-00576-5 home 294 302 aspectos significativos surgidos.indd 294 aquichan issn 1657-5997 augusto hernán ferreira-umpiérrez1 virginia chiminelli-tomás2 aspectos signifi cativos surgidos de la experiencia de haber sido responsable de un evento adverso en salud 1 doctor en enfermería. profesor titular facultad de enfermería y tecnologías de la salud. universidad católica de uruguay. uruguay. auferrei@ucu.edu.uy 2 especialista en gestión en salud. profesora facultad de enfermería y tecnologías de la salud. universidad católica de uruguay. uruguay. virchiminelli@gmail.com recibido: 12 de diciembre de 2012 enviado a pares: 12 de febrero de 2013 aceptado por pares: 17 de febrero de 2014 aprobado: 11 de abril de 2014 doi: 10.5294/aqui.2014.14.3.2 para citar este artículo / to reference this article / para citar este artigo ferreira-umpiérrez ah, chiminelli-tomás v. (2014). aspectos significativos surgidos de la experiencia de haber sido responsable de un evento adverso en salud. aquichan. 2014; 14 (3): 294-302. doi: 10.5294/aqui.2014.14.3.2 resumen objetivo: conocer los aspectos significativos para las enfermeras sobre su experiencia de haber sido responsables de un evento adverso en salud. materiales y métodos: estudio cualitativo exploratorio, con el enfoque de la hermenéutica dialéctica. se utilizó la técnica de análisis de contenido. muestra constituida por doce enfermeras que tuvieron al menos una experiencia de responsabilidad ante un evento adverso con un paciente, y por cuatro supervisores de enfermería con responsabilidad de supervisión al ocurrir el evento adverso. resultados: bajo el enfoque de la hermenéutica dialéctica, el análisis de los datos permitió construir las siguientes categorías relacionadas con la organización de salud y los recursos humanos: el contexto organizacional, el desconocimiento del proceso de notificación, la sobrecarga de trabajo, la ausencia de descanso. conclusiones: reconocer la importancia del contexto organizacional donde se desarrollan los cuidados, el desconocimiento del proceso de notificación como aspecto por mejorar, la sobrecarga de trabajo y la ausencia de descanso del personal. es necesario profundizar en el tema mediante investigaciones y desarrollo de intervenciones que promuevan la cultura de seguridad en la atención sanitaria, con implicaciones en la práctica y para la formación de las enfermeras. palabras clave seguridad del paciente, cuidados de enfermería, personal de enfermería, calidad de la atención de salud, investigación cualitativa. (fuente: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 294-302 295 aspectos significativos surgidos de la experiencia de haber sido responsable de un evento adverso en salud l augusto hernán ferreira-umpiérrez, virginia chiminelli-tomás año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 294-302 significant aspects arising from the experience of having been responsible for an adverse health event abstract objective: know what nurses regard as the significant aspects of their experience with being responsible for an adverse health event. materials and methods: this is an exploratory qualitative study based on hermeneutics with a dialectical approach. the content analysis technique was used. the sample consisted of twelve nurses who had at least one experience with being responsible for an adverse event involving a patient, and four nursing supervisors with supervisory responsibility when an adverse event occurred. results: using a dialectical approach to hermeneutics, the analysis of the data allowed for construction of the following categories related to the health organization and its human resources: the organizational context, ignorance of the notification process, overwork and lack of rest. conclusions: the importance of the organizational context in which care is provided must be recognized. ignorance about the notification process is an aspect that requires improvement, as do situations involving overwork and lack of rest for staff members. this issue needs to be examined in greater depth through research and the development of interventions that promote a culture of safety in health care, with implications for nursing practice and training. key words patient safety, nursing, nurses, quality health care, qualitative research. (source: decs, bireme). 296 aquichan issn 1657-5997 aspectos significativos surgidos da experiência de ter sido responsável por um evento adverso em saúde resumo objetivo: conhecer os aspectos significativos para as enfermeiras sobre sua experiência de ter sido responsáveis por um evento adverso em saúde. materiais e métodos: estudo qualitativo exploratório, com o enfoque da hermenêutica dialética. utilizou-se a técnica de análise de conteúdo. amostra constituída por 12 enfermeiras que tiveram pelo menos uma experiência de responsabilidade ante um evento adverso com um paciente, e por quatro supervisores de enfermagem com responsabilidade de supervisão ao ocorrer o evento adverso. resultados: sob o enfoque da hermenêutica dialética, a análise dos dados permitiu construir as seguintes categorias relacionadas com a organização de saúde e dos recursos humanos: o contexto organizacional, o desconhecimento do processo de notificação, o excesso de trabalho, a ausência de descanso. conclusões: reconhecer a importância do contexto organizacional em que se desenvolvem os cuidados, o desconhecimento do processo de notificação como aspecto para melhorar, o excesso de trabalho e a ausência de descanso do pessoal. é necessário aprofundar no tema por meio de pesquisas e desenvolvimento de intervenções que promovam a cultura de segurança no atendimento sanitário, com implicações na prática e para a formação das enfermeiras. palavras-chave segurança do paciente, cuidados de enfermagem, pessoal de enfermagem, qualidade do atendimento de saúde, pesquisa qualitativa. (fonte: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 294-302 297 aspectos significativos surgidos de la experiencia de haber sido responsable de un evento adverso en salud l augusto hernán ferreira-umpiérrez, virginia chiminelli-tomás introducción la seguridad de los pacientes es un tema de la agenda actual en el ámbito de la salud, y es determinante en la calidad de la atención de las instituciones sanitarias. la atención en salud ofrecida de forma insegura tiene como resultado el aumento de la morbilidad y mortalidad evitables, además de aumento del gasto, lo cual repercute en la eficacia y eficiencia de los sistemas sanitarios, por lo que se constituye en una gran preocupación en la actualidad, como lo indica la organización mundial de la salud (oms) (1). en ese entendido, en los últimos años ha aumentado el interés de las organizaciones en promover una atención segura, para lo cual los recursos humanos en salud desempeñan un rol de relevancia, dado que ellos forman parte de un sistema en cadena que puede terminar en un incidente que cause algún tipo de daño a las personas receptoras de cuidados sanitarios. dentro del equipo de salud, las enfermeras juegan un rol fundamental por ser las profesionales que más tiempo dedican al proceso de atención sanitaria, a la vez de realizar los cuidados directos. el cuidado de enfermería supone establecer una atención al paciente que se compone, entre otras cosas, de técnicas, procedimientos, manejo de tecnología y equipos complejos. el diseño de un plan de enfermería entraña, entonces, el tener en cuenta el riesgo específico de cada paciente, así como el contexto organizacional en el cual se actúa profesionalmente (2). en esa línea, un estudio realizado en brasil, con el objetivo de conocer las barreras y oportunidades que los profesionales de enfermería detectan en su práctica clínica para el pleno desarrollo de la cultura de la seguridad del paciente, muestra la necesidad que sienten las enfermeras de promover una cultura de seguridad, asumiendo el liderazgo en la temática (3). es así que la evidencia muestra el involucramiento del personal de enfermería en este tema y la importancia del estudio de diversos tipos de eventos (4-6). por tal motivo, dada la relevancia del recurso humano en este tipo de sucesos sanitarios, las percepciones de las enfermeras y el significado que atribuyen al tema en cuestión, se torna un objeto de estudio de relevancia que justifica el indagar en torno a la seguridad de los pacientes desde la óptica de quien brinda los cuidados (6). los responsables de la prestación de la asistencia sanitaria en todos los países pueden tomar medidas para reducir la carga humana y económica que suponen los eventos adversos, para lo que sin duda colaborará el compartir experiencias y resultados de investigación desde diferentes enfoques (7). en uruguay existe una preocupación de las autoridades sanitarias en torno a la seguridad del paciente, para lo cual se ha constituido a nivel ministerial el comité de seguridad de los pacientes y se ha solicitado a las instituciones prestadoras de servicios de salud que constituyan el suyo. sin embargo, no existen investigaciones de soporte sobre el tema, por lo cual entendemos que la generación de conocimiento contextualizado en este sentido permitirá explorar, comprender e interpretar significados, lo cual es de relevancia a la hora de la toma de decisiones acertadas. en esa línea, este estudio tuvo como objetivo conocer los aspectos significativos que surgen de las enfermeras acerca de la experiencia de haber sido responsables de un evento adverso en salud. materiales y métodos se realizó un estudio cualitativo exploratorio con abordaje hermenéutico dialéctico. se utilizó la técnica de análisis de contenido, teniendo en cuenta el contexto donde las enfermeras desarrollan sus funciones e interactúan con sus colegas. la opción por el método cualitativo se definió con base en la premisa de que los conocimientos profundos sobre los individuos solo son posibles con una descripción de la experiencia humana, tal como ella es vivida y definida por sus actores (8), a la vez de aportar a la comprensión de los procesos de las personas centrados en un enfoque humanista (9). en esa línea, la hermenéutica se fundamenta en la interpretación de situaciones históricamente situadas, considerando la historicidad, la tradición y la autoridad como elementos que determinan la comprensión de un fenómeno de estudio (10). mediante este enfoque se logra la comprensión a partir del entendimiento de los hechos históricos, de lo cotidiano y de la realidad (11). es de destacar que se tiene presente que aquello que es factible de interpretación no puede ser entendido de una sola vez sino que se obliga al investigador a llevar adelante un proceso de descubrimiento de las diferentes situaciones objeto de estudio (12). respecto a la hermenéutica dialéctica establece una actitud crítica al abordar un objeto de estudio reflejando relaciones reales. ve la realidad como un todo integrado, comprendiendo y 298 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 analizando sus partes, formando correlaciones concretas de conjuntos y unidades siempre determinadas (13). la contribución del intérprete es una parte fundamental para poder comprender la situación estudiada, siendo solo posible cuando el que comprende pone en juego sus propios preconceptos (14). en la línea de lo expuesto, se buscó a los sujetos de estudio teniendo en cuenta la visión totalizadora e integradora del contexto del referencial elegido. así, la muestra estuvo constituida por doce enfermeras que se desempeñan en el segundo y tercer nivel de atención de una institución de salud y que tuvieron al menos una experiencia de responsabilidad ante un evento adverso con un paciente, y cuatro supervisoras de enfermería con responsabilidad de supervisión al ocurrir el evento adverso, teniendo en cuenta las relaciones y el contexto donde interactúan. la selección de los sujetos de estudio se basó en el criterio de búsqueda de informantes que aportaran significados ricos a la investigación por sus experiencias profesionales; ninguno de los seleccionados se negó a participar. se delimitó el número de sujetos del estudio sobre la base de haber alcanzado redundancias en la información brindada a la vez que fueron respondidas las inquietudes del investigador (15, 16). la recolección de los datos se realizó mediante entrevistas en profundidad de aproximadamente 90 minutos cada una. las mismas fueron realizadas por los investigadores del estudio, los cuales cuentan con formación de especialista y doctorado, y desarrollan la línea de investigación sobre la temática de estudio; no hubo relación jerárquica entre entrevistadores y sujetos de estudio. se realizaron en un lugar reservado, en un contexto natural y de privacidad en el que participaron solo los investigadores y cada sujeto. se promovió una actitud abierta para que los sujetos se expresaran fácilmente (17). las preguntas que guiaron las entrevistas fueron cuidadosamente definidas de manera que no tuvieran orientaciones de ningún tipo, siendo estas: ¿cómo has vivenciado la experiencia de haber sido responsable de un evento adverso en la atención a los pacientes? ¿cuál es tu percepción sobre el tema relacionado con tu trabajo? este proceso se llevó a cabo en una institución de salud de la ciudad de montevideo en los meses de julio y agosto de 2012; las entrevistas fueron grabadas y transcritas íntegramente por los investigadores, los cuales realizaron la codificación de los datos. cada entrevista fue identificada con una letra y un número a fin de mantener el anonimato de los sujetos. las entrevistas realizadas a las enfermeras se identificaron con la letra e seguida en forma secuencial de los números del 1 al 12, y las entrevistas realizadas a las supervisoras se marcaron de la misma manera, pero con la letra s. las entrevistas fueron establecidas de común acuerdo con los sujetos participantes, garantizando el anonimato, la privacidad y la confidencialidad de la información entregada. se respetaron las consideraciones éticas establecidas en el decreto 379/008 (18) para las investigaciones con seres humanos, por lo que se informó a los participantes los objetivos del estudio, sus alcances y todos los aspectos relativos al consentimiento libre e informado, el cual firmaron. el estudio fue autorizado por el comité asesor de ética de la facultad de enfermería y tecnologías de la salud de la universidad católica del uruguay, con el número de protocolo 006-2013. el análisis de contenido, como técnica de proceso de análisis de los datos, permite el estudio de los mismos en un determinado contexto, buscando la interpretación cifrada del material (11, 19). se siguió la trayectoria de organización, clasificación de los datos y análisis final. se realizaron lecturas atentas de las entrevistas para identificar los aspectos significativos del objeto de estudio. se encontraron núcleos de sentido común, construyendo luego las categorías de análisis, las cuales fueron nominadas por el investigador. luego de este proceso, y bajo el enfoque de la hermenéutica dialéctica, en este estudio se presentan las categorías relacionadas con la organización de salud y los recursos humanos, las cuales fueron: el contexto organizacional, el desconocimiento del proceso de notificación, la sobrecarga de trabajo, la ausencia de descanso. resultados respecto a la categoría contexto organizacional los sujetos expresan que el entorno de trabajo, tanto en relación con el ambiente como con la estructura de la institución, influye en la generación de eventos adversos. algunas expresiones son las siguientes: “… el tema es que la mesada donde se prepara la medicación es bastante chica y todos preparamos la medicación ahí. yo ese día andaba a mil, preparé todo y me llevé los sobres de los comprimidos de mi compañera. ya sé que yo igualmente debería haber tenido más cuidado, pero estoy segura que eso influyó...” (e2). 299 aspectos significativos surgidos de la experiencia de haber sido responsable de un evento adverso en salud l augusto hernán ferreira-umpiérrez, virginia chiminelli-tomás “la organización me parece algo fundamental, pero muchas veces no es posible hasta avanzada la guardia, porque estamos esperando y hay decisiones que se toman sobre la marcha…” (s4). la categoría desconocimiento del proceso de notificación se centra en aspectos que relataron las enfermeras respecto a que cuando habían incurrido en un evento adverso no sabían qué hacer, ni cómo era el proceso de informar sobre lo ocurrido. las enfermeras y las supervisoras entrevistadas expresan: “la verdad que cuando el paciente me dijo que me había equivocado al darle la insulina casi me muero, corrió un frío por dentro mío… pensaba y pensaba qué debía hacer, quedé paralizada, entre otras cosas porque nunca me habían dicho qué hacer si algo así me pasaba…” (e8). “yo estaba a cargo del hospital ese día, porque era fin de semana y el fin de semana queda todo en manos de la supervisora. cuando me llamaron del piso ya hacía rato que el paciente se había caído y a mí no me habían informado nada. la responsable del sector me dijo que no sabía que tenía que informarme…” (s2). “fue una vergüenza tremenda cuando pasé visita y el familiar me dijo que se habían equivocado en darle la medicación al paciente. fui hasta el puesto de enfermería y la licenciada me dijo que no sabía que debía informar… y tampoco sabía que debía hacerse un formulario especial para eventos adversos…” (s3). tanto las supervisoras como las enfermeras coinciden en que muchas veces el evento adverso sucede porque el personal está sobrecargado. de esa manera se conformó la categoría sobrecarga de trabajo: “y bueno, algún día me iba a pasar, siempre me tocan muchos pacientes… bueno, quizá no tanto siempre, pero ese día me habían dado más pacientes a mi cargo porque había faltado gente y el sector quedó con menos personal…” (e6). “me pasó dos veces en mi vida de enfermera y las dos veces fue porque estaba llena de trabajo… venía cansada y me cansé más al asumir más de lo que podía…” (e8). “yo entiendo… trato de entender al menos, están sobrecargadas a veces, muchas veces voy a los sectores y me quedo trabajando porque acá la dotación es buena, cumple con todas las normas, pero la cantidad de trabajo por enfermera a veces es mucha, no por la dotación ni por la cantidad de pacientes, sino por todo lo que hay que hacer por fuera del cuidado de los pacientes…” (s4). la ausencia de descanso fue un factor común en los discursos, así como la necesidad del personal de tener un mejor descanso antes de comenzar su guardia, como se expresa a continuación: “fue complicado, fue una semana complicada esa… estaba realmente cansada, no había dormido bien, venía de otro trabajo de hacer doce horas, era obvio que algún día me iba a equivocar…” (e4). “me dormía esa noche, estaba muy cansada… fui a la habitación, ayudé a la señora a levantarse al baño, me fui y no subí las barandas… fue un descuido por no prestar atención…” (e8). “yo le dije a ella que prestara más atención pues la veía con los ojos rojos, muerta de cansada; pero bueno, qué atención iba a prestar si no podía mantenerse despierta…” (s3). discusión el análisis de las entrevistas permitió construir las categorías mencionadas develando algunos aspectos susceptibles de ser interpretados y discutidos a la luz de estudios relacionados con el tema. uno de los tópicos que emerge surge tiene que ver con aspectos relacionados con el contexto organizacional. se ha encontrado que este influye en la ocurrencia del evento adverso (2). los datos que arroja este estudio muestran aspectos que tienen que ver con el ambiente físico de trabajo, así como con distracciones en el desempeño de las funciones. esto es de especial importancia pues las prácticas diarias para la solución de problemas, muchas veces en el ejercicio de múltiples roles, traen como resultado las deficiencias en el sistema o en el proceso de trabajo (20). las condiciones de infraestructura, las áreas, los equipos y la organización de procesos típicos, como los relacionados con la administración de medicamentos, pueden colaborar o entorpecer el trabajo de las enfermeras. en esa línea, un estudio sobre la organización, el estoqueado y la distribución de la medicación muestra las carencias que pueden presentar los servicios de salud, a la vez de brindar recomendaciones para disminuir los eventos adversos con gestiones tácticas de organización del tra300 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 bajo (21). en varios estudios se reafirma la idea de que los contextos institucionales deben proporcionar a los profesionales la capacidad de resolver los problemas de su ejercicio diario, para lo cual la organización del trabajo y un entorno favorable juegan un rol fundamental (3, 4). relacionado con el contexto organizacional aparece como categoría el desconocimiento del proceso de notificación. las enfermeras resaltan como un aspecto significativo la falta de conocimiento sobre cómo actuar ante un evento adverso. esto coincide con los resultados de un estudio multicéntrico donde se destaca la necesidad de reforzar la cultura de notificación de los eventos adversos y el clima de seguridad del paciente (22). la cultura de seguridad del paciente es un fenómeno complejo que es difícil de implementar en el día a día de las organizaciones sanitarias. sin embargo, merece una especial atención dadas las implicancias que suponen este tipo de problemas de la atención en salud y la manera en como afectan a la calidad en la atención sanitaria. en otros contextos, también los resultados indican que la principal área de mejora tiene que ver con la comunicación abierta de los eventos adversos (23). las respuestas de las supervisoras, sin embargo, convergen en la claridad del proceso de notificación, argumentando que el hospital cuenta con supervisión las 24 horas del día, con presencia en todos los sectores a lo largo de la jornada. esta contraposición de opiniones entre las enfermeras operativas y las supervisoras resulta de especial interés para el estudio, coincidentemente con investigaciones que evidencian una amplia variación en el clima de seguridad entre las enfermeras con cargos de gestión y las asistenciales (24). relacionado con la percepción de cada sujeto del estudio, la sobrecarga de trabajo aparece como un dato emergente, coincidiendo con autores que refuerzan la evidencia sobre cómo los patrones de dotaciones de enfermería influyen en la seguridad de los pacientes (4, 25). sin duda, la relación de cantidad de pacientes por enfermera repercute en la organización del trabajo, el enfoque del cuidado y la interacción enfermera-paciente. con un enfoque de calidad, el ofrecer cuidados oportunos y libres de riesgo forma parte de la responsabilidad en el acto de cuidar (26). en esa línea, el proceso de enfermería desarrollado en todas sus etapas impacta en la seguridad de los pacientes, al detectar en cada fase los riesgos a los que estos se enfrentan, para lo cual la sobrecarga de trabajo observada en este y otros estudios (27) opera como una dificultad para llevar adelante una gestión del cuidado adecuada. los sujetos involucrados en este estudio, en algunos casos, mantuvieron guardias por más de doce horas en dos instituciones de salud lo cual, sumado a la sobrecarga en la cantidad de pacientes atendidos, opera como un riesgo que aumenta notoriamente al no tener un descanso adecuado tanto físico como mental. las supervisoras opinan que la dotación es adecuada pero, a la vez, indican que el personal podría estar sobrecargado. surge la inquietud, entonces, de si no sería necesario adaptar los padrones de dotación a las nuevas demandas de atención. en esa línea, otra categoría que aparece es la ausencia de descanso de los sujetos entrevistados. en todos los casos relatan la necesidad de contar con más horas de sueño y de momentos recreativos. la evidencia muestra cómo la fatiga del proveedor de cuidados influye en la salud del trabajador y en la incidencia de eventos adversos (28), articulándose con aspectos relacionados con la salud laboral de las enfermeras y la seguridad de los pacientes (29). revisiones sobre el tema enfatizan en la relevancia de abordar el desgaste del personal ante las condiciones de trabajo desfavorables (30). ante las necesidades de cobertura para lograr la dotación estipulada para los servicios, en muchas oportunidades se pone énfasis en contar con las cantidades necesarias de enfermeros, sin pensar en la calidad de la atención que los profesionales pueden brindar al no evaluar aspectos básicos como el descanso oportuno. el abordaje de este aspecto es relevante, pues es latente la necesidad de recursos humanos de enfermería, lo que lleva en algunas oportunidades a no tener en cuenta los derechos profesionales y de los clientes, lo cual podría desembocar en problemas institucionales de soporte. los resultados de este estudio son un aporte para la gestión y la práctica en torno a la seguridad de los pacientes que se vienen desarrollando en el país, iluminando —aunque parcialmente por el tipo de estudio— la toma de decisiones respecto a un tema vigente a nivel nacional e internacional. de hecho, este estudio no pretende la generalización de sus resultados, dado que se buscó indagar en profundidad las particularidades en torno a los sujetos involucrados en un evento adverso en salud. sin embargo, los datos encontrados resultan de interés y abren las puertas para continuar profundizando en el tema mediante investigaciones y puesta en práctica de intervenciones tendentes a colaborar con el logro de una cultura de seguridad en la atención sanitaria, con implicancias para la práctica y la formación de las enfermeras. 301 aspectos significativos surgidos de la experiencia de haber sido responsable de un evento adverso en salud l augusto hernán ferreira-umpiérrez, virginia chiminelli-tomás conclusiones el estudio permitió que surgieran aspectos significativos desde la experiencia de las enfermeras responsables de un evento adverso, dando lugar a la importancia del contexto organizacional donde desarrollan los cuidados, el desconocimiento del proceso de notificación como aspecto por mejorar, la sobrecarga de trabajo y la ausencia de descanso del personal. las observaciones resultan de interés tanto para los profesionales como para los gestores que toman decisiones, y aportan a una mejor interpretación de estos fenómenos para desarrollar intervenciones adaptadas a cada contexto particular. se contribuye, de esta manera, con conocimientos contextualizados en torno a la seguridad de los pacientes, colaborando con la gestión en salud desde la ética y la calidad de la atención sanitaria. referencias 1. world health organization/world alliance for patient safety. summary of the evidence on patient safety: implications for research. the research priority setting working group of the world alliance for patien safety. geneva: world health organization; 2008. 2. maxson pm, derby km, wrobleski dm, foss dm. bedside nurse-to-nurse handoff promotes patient safety. medsurg nurs. 2012;21(3):140-4. 3. martínez aa, hueso c, gálvez g. fortalezas y amenazas en torno a la seguridad del paciente según la opinión de los profesionales de enfermería. rev latino-am enfermagem. 2010;18(3):42-29. 4. lake e, shang j, klaus s, dunton n. patient falls: association with hospital magnet status and nursing unit staffing. res nurs health. 2010;33(5):413-425. 5. mark b, jones ch, lindley l. an examination of technical efficiency, quality and patient safety in acute care nursing units. policy politics nursing practice. 2009;10(3)180-186. 6. auer c, schwendimann r, koch r, de geest s, ausserhofer d. how hospital leaders contribute to patient safety through the development of trust. j nurs adm. 2014;44(1): 23-9. 7. mcgill l. patient safety: a european union priority. clin med. 2009;9(2):136-9. 8. polit d, beck ct, hungler f. fundamentos da pesquisa em enfermagem. 5ª ed. porto alegre: artes médicas; 2004. 9. sanhueza o. qualitative research contribution to nursing. cienc enferm. 2009;15(3):5-20. 10. gadamer hg. verdade e método. 2 ed. rio de janeiro: editorial vozes; 1998. 11. minayo mcs. o desafio do conhecimiento. pesquisa qualitativa em saúde. sao paulo: hiucitec; 2010. 12. osorio-murillo o, amaya-rey m. teenage diet: context and companions determine eating habits. revista aquichán. 2011;11(2):199-216. 13. minayo mcs. hermenêutica – dialética como caminho do pensamento social. en: caminhos do pensamento: epistemologia e método. rio de janeiro (rj): editora fiocruz; 2002. 14. cortés n. descaminhos do método: notas sobre historia e tradicao em hans-george gadamer. varia hist. 2006;(22)36:274-90. 15. arias mm, giraldo cv. scientific rigor in qualitative research. invest educ enferm. 2011;29(3):500-514. 16. martínez-salgado c. sampling in qualitative research: basic principles and some controversies. ciênc saúde coletiva. 2012;17(3):613-619. 17. fontanella b, campos j, turato e. data collection in clinical-qualitative research: use of non-directed interviews with open-ended questions by health professionals. rev latino-am enfermagem. 2006;14(5):812-820. 18. uruguay. decreto de ley 379/008. investigaciones con seres humanos. diario oficial 4573/08, diciembre de 2008. 302 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 19. campos j, turato e. content analysis in studies using the clinical-qualitative method: application and perspectives. rev latino-am enfermagem. 2009;17(2):259-264. 20. sherwood g, zomorodi m. a new mindset for quality and safety: the qsen competencies redefine nurses’ roles in practice. nephrol nurs j. 2014;41(1):15-22. 21. raduenz a, hoffmann p, radunz v, dal sasso g, maliska i, marck, p. nursing care and patient safety: visualizing medication organization, storage and distribution with photographic research methods. rev latino-am enfermagem. 2010;18(6):1045-1054. 22. aranaz-andrés jm, aibar-remón c, limón-ramírez r, amarilla a, restrepo fr, urroz o et al. bmj qual saf. prevalence of adverse events in the hospitals of five latin american countries: results of the ‘iberoamerican study of adverse events’ (ibeas). 2011;20(12):1043-1051. 23. škodová m, velasco rodríguez mj, fernández sierra ma. opinión de los profesionales sanitarios sobre seguridad del paciente en un hospital de primer nivel. rev calidad asistencial. 2011;26 (1):33-8. 24. campbell eg, singer s, kitch bt, iezzoni li, meyer gs. patient safety climate in hospitals: act locally on variation across units. jt comm j qual patient saf. 2010;36(7):319-26. 25. gómez o, arenas w, gonzález l, garzón j, mateus erika, soto a. cultura de seguridad del paciente por personal de enfermería en bogotá, colombia. cienc enferm. 2011;17(3):97-111. 26. sutton d, windsor j, husk j. a care bundle approach to falls prevention. nurs times. 2014;110(20):21-3. 27. ferreira a, merighi mab, muñoz la. perceptions and expectations of nurses concerning their professional activity. acta paul enferm. 2013; 26(2):165-71. 28. maynardes dcd, sarquis lmm, kirchhof alc. trabalho noturno e morbidades de trabalhadores de enfermagem. cogitare enferm. 2009;14(4):703-708. 29. witkoski a, vaughan v. hospital staff nurses’ work hours, meal periods, and rest breaks: a review from an occupational health nurse perspective. aaohn journal. 2010;58(11):489-497. 30. lima j, campos a, reis l. discussão sobre as causas da síndrome de burnout e suas implicações à saúde do profissional de enfermagem. revista aquichán. 2012,12 (2):144-159. 226 233 consumo de bebidas alcoolicas.indd 226 aquichan issn 1657-5997 rafael tavares-jomar1 enéas dos santos-silva2 consumo de bebidas alcoólicas entre estudantes de enfermagem 1. enfermeiro. doutorando em saúde coletiva. instituto nacional de câncer josé alencar gomes da silva, rio de janeiro, brasil. rafaeljomar@yahoo.com.br 2. enfermeiro. especialista em enfermagem intensiva de alta complexidade. instituto nacional de câncer josé alencar gomes da silva, rio de janeiro, brasil. eneas2109@yahoo.com.br recibido: 3 de diciembre de 2012 enviado a pares: 11 de febrero de 2013 aceptado por pares: 23 de mayo de 2013 aprobado: 6 de junio de 2013 año 13 vol. 13 nº 2 chía, colombia agosto 2013  226-233 para citar este artículo / to reference this article / para citar este artigo tavares jomar, r., dos santos silva, e. (2013). consumo de bebidas alcoólicas entre estudantes de enfermagem. aquichan. vol. 13, no. 2, 226-233. resumo objetivo: o consumo de bebidas alcoólicas entre os estudantes universitários tem se tornado uma preocupação crescente nos últimos anos, por isso este estudo foi desenvolvido com o objetivo de identificar o consumo dessa substância psicoativa entre estudantes de enfermagem. método: trata-se de estudo epidemiológico descritivo do tipo transversal desenvolvido em uma universidade privada da cidade do rio de janeiro, brasil, com 161 estudantes que responderam a um questionário autoaplicável que continha informações sociodemográficas, perguntas selecionadas do alcohol use disorders identification test e outras sobre aspectos relacionados ao consumo de bebidas alcoólicas. resultados: alta proporção (67,7%) dos estudantes de enfermagem entrevistados referiu ser consumidora de bebida alcoólica, sendo que 32,1% deles faziam consumo no padrão binge, e quase metade (45,9%) dos consumidores estava exposta ao risco de desenvolvimento de problemas relacionados ao consumo dessa substância. são preocupantes as informações sobre o consumo de bebidas alcoólicas dos estudantes de enfermagem participantes desse estudo, já que eles são futuros profissionais que, inevitavelmente, atuarão como educadores e motivadores para a adoção de condutas saudáveis pela população. conclusão: portanto, são necessárias políticas e programas de prevenção ao consumo excessivo de álcool para este segmento populacional. palavras-chave consumo de bebidas alcoólicas, estudantes de enfermagem, estudos transversais, brasil, enfermagem. (fuente: decs, bireme). 227 consumo de bebidas alcoólicas entre estudantes de enfermagem l rafael tavares-jomar, enéas dos santos-silva consumo de bebidas alcohólicas en estudiantes de enfermería resumen objetivo: el consumo de alcohol entre los estudiantes universitarios se ha convertido en una preocupación creciente en los últimos años, por lo que este estudio fue desarrollado con el objetivo de identificar el consumo de esta sustancia entre los estudiantes de enfermería. método: se trata de un estudio transversal desarrollado en una universidad privada en la ciudad de río de janeiro, brasil, con 161 estudiantes que respondieron a un cuestionario autoadministrado que contiene información sociodemográfica, preguntas seleccionadas del alcohol use disorders identification test y otros aspectos relacionados con el consumo de bebidas alcohólicas. resultados: alta proporción (67,7 %) de los estudiantes de enfermería entrevistados reportó ser consumidores de alcohol, y el 32,1 % de ellos estaban en la orgía de consumo estándar, y casi la mitad (45,9 %) de los consumidores están expuestos al riesgo de desarrollar problemas relacionados con el consumo de esta sustancia. resultados: están preocupados por el consumo de bebidas alcohólicas de los estudiantes de enfermería que participaron en este estudio, ya que son los futuros profesionales que inevitablemente actúan como educadores y motivadores para la adopción de conductas saludables en la población. conclusión: por lo tanto, se necesitan políticas y programas para prevenir el consumo excesivo de alcohol en esta población. palabras clave consumo de bebidas alcohólicas, estudiantes de enfermería, estudios transversales, brasil, enfermería. (fuente: decs, bireme). consumption of alcoholic beverages among nursing students abstract objective: alcohol use among college students has become a growing concern in recent years, and this research was developed specifically to identify alcohol consumption among nursing students. method: it is a cross-sectional study conducted at a private university in the city of rio de janeiro (brazil), with 161 students who answered a self-administered questionnaire containing socio-demographic information, questions selected from the alcohol use disorders identification test, and other aspects related to the consumption of alcoholic beverages. results: a high proportion of the nursing students interviewed (67.7%) reported being drinkers, with 32.1% being in the binge-drinking category. nearly half (45.9%) are at risk of developing problems related to alcohol consumption. there is concern about drinking among the nursing students who participated in the study, as they are future professionals who inevitably will serve as educators and motivators for the adoption of healthy behavior on the part of the population. conclusion: therefore, policies and programs are needed to prevent excessive alcohol consumption among nursing students. keywords alcohol drinking, students, nursing, cross-sectional studies, brazil, nursing. (source: decs, bireme). 228 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 introdução o consumo de álcool e suas consequências adversas é um tema de relevante preocupação para a saúde pública, dados os quase 2 bilhões de pessoas consumidoras existentes no planeta e seu impacto sobre os indivíduos e sociedade, expresso por cerca de 2,5 milhões de mortes anuais em todo o mundo, incluindo as de 320 mil jovens com idades entre 15 e 29 anos, devido ao seu consumo abusivo (1). em alguns países, há evidências de que os jovens estão começando a beber cada vez mais cedo (2). isso torna a problemática do consumo de álcool ainda mais grave, visto que seu início precoce está associado a uma maior probabilidade de problemas relacionados ao seu consumo e de desenvolvimento de dependência alcoólica na vida adulta (3). no brasil, o beber precoce e regular também está acontecendo entre os jovens, de tal forma que a primeira vez de uso tem ocorrido aos 13,9 anos; enquanto o consumo regular é realizado aos 14,6 anos. ao intensificar a problemática desta situação, 16% dos adolescentes brasileiros engajam-se em episódios de beber pesado episódico ou binge drinking, um comportamento de beber intenso em um curto espaço de tempo que predispõe o indivíduo a uma série de problemas sociais e de saúde (4). nesse sentido, entre a população jovem, os estudantes universitários têm merecido especial atenção, isso porque a entrada na universidade muitas vezes inaugura um período de maior autonomia, o que possibilita novas experiências e também por se constituir em um momento de maior vulnerabilidade, o que torna esta população mais susceptível ao uso de álcool e suas consequências (5-10). o consumo de álcool entre os estudantes universitários tem se tornado, portanto, uma preocupação crescente nos últimos anos. em um período caracterizado por muitas transições, os universitários estão mais vulneráveis ao início e manutenção do uso de álcool, substância da qual eles subestimam os efeitos negativos e, assim, ao consumi-la em altas doses e frequência, se expõem mais a situações de risco e prejuízos à saúde (5, 11). vale destacar que o consumo de álcool entre estudantes universitários é mais frequente e intenso que na população em geral, o que reforça a necessidade de um maior conhecimento desse fenômeno para o desenvolvimento de ações de prevenção e elaboração de políticas específicas dirigidas para esse segmento (5, 12). além disso, a determinação da prevalência de uso e de opiniões sobre álcool entre os universitários é fonte potencial de informações sobre o comportamento e compreensão dessa população (5, 8-11, 13). portanto, o objetivo deste estudo foi identificar o consumo de bebidas alcoólicas entre estudantes de enfermagem de uma universidade privada na cidade do rio de janeiro, brasil. material e método trata-se de estudo epidemiológico descritivo do tipo transversal desenvolvido em uma universidade privada da cidade do rio de janeiro, brasil. no mês de maio de 2008, quando da coleta de dados, a universidade em questão tinha 998 estudantes de enfermagem regularmente matriculados. em um único dia, estudantes dos três turnos do curso de enfermagem (matutino, vespertino e noturno) foram abordados em todas as salas de aula em uso, após autorização da coordenação do curso e do professor em sala. ali foram prestadas informações sobre a natureza e os objetivos do estudo e, voluntariamente, 161 estudantes de ambos os sexos e de idade ≥ 18 anos aceitaram participar dele, ao assinar o termo de consentimento livre e esclarecido, compondo, assim, sua amostra de conveniência. em seguida, os estudantes responderam individualmente a um questionário fechado, autoaplicável e anônimo que continha informações sociodemográficas (sexo, idade, exercício de atividade remunerada, renda familiar mensal e religião), perguntas selecionadas do alcohol use disorders identification test instrumento desenvolvido pela organização mundial da saúde que permite uma melhor compreensão do consumo de álcool entre estudantes universitários (9) e outras sobre aspectos relacionados ao consumo de bebidas alcoólicas (idade de experimentação, companhia na experimentação, tipo de bebida mais consumida, local habitual de consumo, problemas decorrentes do consumo, influência do ingresso na universidade sobre a frequência de consumo). na fase analítica dos dados, a revisão e codificação das questões foram realizadas e, em seguida, as informações contidas nos instrumentos de coleta dos dados foram digitadas no programa 229 consumo de bebidas alcoólicas entre estudantes de enfermagem l rafael tavares-jomar, enéas dos santos-silva excel (windows xp/2000), no qual também foram realizadas as análises univariadas com distribuição de frequências simples para a descrição dos dados. os procedimentos éticos deste estudo são representados pela assinatura do termo de consentimento livre e esclarecido pelos estudantes que aceitaram participar dele e pelo atendimento aos preceitos éticos constantes da declaração de helsinki (2008), pelos quais os princípios básicos da pesquisa com seres humanos (beneficência, respeito à pessoa e justiça) foram completamente atendidos, buscando salvaguardar o bem-estar, os direitos e a dignidade dos sujeitos. resultados a amostra foi constituída em sua maioria por estudantes do 1º ano do curso de enfermagem (37,3%), do sexo feminino (84,5%), na faixa etária de 20-24 anos de idade (40,9%), de religião evangélica (34,8%), que não exerciam atividade remunerada (55,3%) e possuíam renda familiar mensal entre r$ 1530 e r$ 2550 (35%). entre os estudantes da amostra, 32,3% afirmaram nunca consumir bebidas alcoólicas e 10,6% afirmaram consumi-las de duas a três vezes por semana (tabela 1). tabela 1. frequência de consumo de bebidas alcoólicas da amostra de estudantes de enfermagem (n=161) tabela 2. características de consumo de bebidas alcoólicas dos estudantes de enfermagem consumidores (n=109) variáveis n % frequência de consumo nunca 52 32,3 mensalmente ou menos 55 34,2 2 a 4 x/mês 30 18,6 2 a 3 x/semana 17 10,6 ≥ 4 x/semana 07 4,3 fonte: elaboração própria a bebida referida como a mais consumida pelos estudantes foi a cerveja/chope (33,1%), seguida de perto pelo vinho (28,4%). habitualmente eles afirmaram consumir bebidas alcoólicas em festas (50,4%), sendo que 32,1% deles afirmaram ingerir ≥ 5 doses-padrão de álcool em um dia típico de consumo (tabela 2). variáveis n % bebida mais consumida cerveja/chope 36 33,1 vinho 31 28,4 destilados 07 6,4 mais de uma 21 19,3 outras 14 12,8 local habitual de consumo própria casa/casa de amigos 22 20,2 bares 17 15,6 festas 55 50,4 outros 15 13,8 doses-padrão* ingeridas em dia típico de consumo 1-2 59 54,1 3-4 15 13,8 ≥ 5 35 32,1 fonte: elaboração própria * 1 dose-padrão de álcool corresponde, em média, a uma latinha de cerveja/chope de 350 ml, uma taça de vinho de 90 ml, uma dose de destilado de 30 ml, uma lata ou uma garrafa pequena de qualquer bebida ice. afirmaram experimentar bebidas alcoólicas antes dos 18 anos de idade 83,5% dos estudantes, sendo que 39,5% as experimentaram entre 14 e 15 anos; nesta experimentação, 17,4% deles afirmaram estar acompanhados dos pais. 22,1% dos estudantes afirmaram que o ingresso na universidade influenciou o aumento da frequência de consumo de bebidas alcoólicas e 19,3% deles afirmaram ter sofrido algum problema decorrente de seu consumo (tabela 3). discussão no que tange ao consumo de bebidas alcoólicas, alta proporção (67,7%) dos estudantes de enfermagem entrevistados referiu ser consumidora, sendo que 32,1% deles fazem consumo no padrão binge (≥ 5 doses-padrão de álcool em única ocasião), o que corrobora o amplamente descrito pela literatura a respeito 230 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 dos estudantes de enfermagem (9-10, 14-15), bem como sobre estudantes universitários em geral (5, 8, 12-13). vale ressaltar que, para que problemas com o consumo de bebidas alcoólicas sejam evitados, homens saudáveis podem consumir não mais que três doses-padrão/dia e mulheres saudáveis não mais que duas doses-padrão/dia (1). como neste estudo 45,9% dos entrevistados afirmaram consumir pelo menos três doses-padrão de álcool em dia típico de consumo, eles já estariam, portanto, expostos ao risco de desenvolvimento de problemas relacionados ao consumo dessa substância. conforme resultados do i levantamento nacional sobre o uso de álcool, tabaco e outras drogas entre universitários das 27 capitais brasileiras (5), no que diz respeito às consequências agudas, o fato de um em cada quatro universitários relatar consumo do álcool no padrão binge nos 30 dias anteriores à entrevista mostra que essa população está frequentemente exposta a riscos, especialmente acidentes de trânsito, intoxicação, a atos de violência e abuso sexual sob influência do álcool, sexo desprotegido, problemas acadêmicos (aprendizado e comportamentos inadequados e diminuição de produtividade) e problemas legais (3-4, 5, 7, 12). entre estudantes universitários de ciências da saúde de uma instituição privada brasileira, participantes de um estudo (16) que teve por objetivo entender os padrões de policonsumo simultâneo de drogas (pcsd) e suas implicações de gênero, sociais e legais, o pcsd foi realizado por 27,9% dos estudantes, sendo predominante a combinação de bebidas alcoólicas a outras drogas para lidar com situações sociais, facilitar a realização de atividades pouco prazerosas e perder as inibições naturais da idade. a combinação e o conjunto dessas razões de pcsd entre estudantes universitários, além de preocupantes, apontam para a necessidade de medidas que sirvam de suporte para lidar com os estressores cotidianos, como também despertar sensações que tragam bem estar geral (16). logo, é necessário o acompanhamento sistemático da evolução dos padrões de consumo de bebidas alcoólicas entre estudantes universitários, uma vez que, na medida em que se mantém a disponibilidade dessa substância e dependendo da frequência às festas na universidade, da pressão social para consumi-la e do estresse decorrente do cotidiano universitário, o hábito de beber tende a se modificar ao longo do tempo. assim, os universitários que atualmente não consomem no padrão binge podem passar a beber desse modo prejudicial, o que os levaria, a médio ou longo prazo, a desenvolverem consequências severas (15). especialistas recomendam, portanto, que programas educativos sejam desenvolvidos a fim de alertar essa população a respeito dos limites de consumo de baixo risco de álcool e dos problemas que podem ser causados pelo seu consumo excessivo, além de sugestões para, caso queiram continuar consumindo bebida alcoólica, que tal consumo seja feito com responsabilidade (9). a cerveja/chope foi apontada como a bebida alcoólica mais consumida pelos estudantes consumidores de álcool entrevistados. resultados semelhantes foram encontrados em outros estabela 3. aspectos relacionados ao consumo de bebidas alcoólicas dos estudantes de enfermagem consumidores (n=109) fonte: elaboração própria variáveis n % idade de experimentação (anos) < 10 06 5,5 10 – 13 17 15,6 14 – 15 43 39,5 16 – 17 25 22,9 > 18 18 16,5 companhia na experimentação pai/mãe 19 17,4 amigos 71 65,2 namorado(a) 05 4,6 sozinho 06 5,5 outros 08 7,3 influência da universidade no aumento da frequência de consumo sim 24 22,1 não 85 77,9 problemas decorrentes do consumo sim 21 19,3 não 88 80,7 231 consumo de bebidas alcoólicas entre estudantes de enfermagem l rafael tavares-jomar, enéas dos santos-silva tudos desenvolvidos com estudantes de enfermagem (10) e de outras carreiras universitárias (13-14). a população brasileira também consome mais cerveja/chope que outros tipos de bebida alcoólica, pois de todas as doses-padrão anuais consumidas por brasileiros adultos dos dois gêneros, de qualquer idade e região do país, em torno de 61% são de cerveja/chope (4). o local habitual de consumo de bebidas alcoólicas apontado por pouco mais da metade dos estudantes consumidores da amostra foram as festas. resultados semelhantes foram encontrados em estudo também realizado com estudantes de enfermagem, no qual os autores afirmam que o álcool tornou-se algo presente na maioria das ocasiões sociais, e tornou-se, assim, difícil realizar festas e comemorações entre estudantes universitários sem a presença de bebidas alcoólicas (10). no entanto, vale destacar, que, quanto mais o estudante frequenta festas, maior é o risco para o consumo prejudicial de bebidas alcoólicas (9). o clima social do ambiente universitário é festivo. é fácil verificar isso nos campus campi, ao se observar o elevado número de cartazes de propaganda de festas universitárias que, além da festa propriamente anunciada, conteúdos referentes ao consumo excessivo de álcool estão presentes neles, o que oportuniza sua aceitação e apologia, e contribui para a publicidade indireta. a tendência é a aceitação do consumo excessivo de álcool como certo e natural, promovendo assim dessensibilização quanto aos possíveis prejuízos advindos dele, o que favorece atitudes imprudentes quanto ao consumo dessa substância (7). a respeito da idade de experimentação de bebidas alcoólicas dos estudantes consumidores, 83,5% deles fizeram experimentação com idade inferior a 18 anos. estudo conduzido entre estudantes de enfermagem de uma universidade do oeste do estado de santa catarina (brasil) apontou que 56% deles fizeram consumo pela primeira vez entre os 7 e 17 anos e 4% com 6 anos de idade (10). a idade média de experimentação do álcool encontrada em estudo conduzido entre estudantes de enfermagem da universidade de passo fundo, rio grande do sul (brasil), foi de 15 anos (14). outro estudo realizado com estudantes de direito de uma universidade da capital do maranhão (brasil) evidenciou que 42% dos consumidores tiveram o primeiro contato com bebida alcoólica na faixa etária dos 16 aos 20 anos e que, dentre os que iniciaram o consumo antes dos 14 anos de idade, 47% tornaramse dependentes, enquanto dentre os que o iniciaram após os 21 anos, apenas 9% tornaram-se dependentes (13). tal qual encontrada neste estudo, a idade de início para o consumo do álcool se dá antes dos 16 anos de idade em mais de 50% dos estudantes universitários brasileiros. a precocidade para o consumo de álcool é preocupante visto que expõe essa população aos prejuízos agudos e crônicos decorrentes dessa substância de forma notável (5). ademais, quanto mais precoce o consumo de álcool, maiores as chances de desenvolver dependência alcoólica, especialmente pela interferência sobre a etapa da vida em que acontece o processo de maturação do sistema nervoso central e da personalidade (3, 17). quanto à companhia na experimentação, 65,2% dos estudantes consumidores afirmaram estar acompanhados de amigos e 17,4% afirmaram acompanhados dos pais. estudo apontou amigos e familiares como os responsáveis pela introdução no consumo de bebidas alcoólicas em estudantes de enfermagem, numa proporção de 49,2% e 20%, respectivamente (14). outro estudo também realizado entre estudantes de enfermagem apontou que 65% dos consumidores responderam que foi na família o primeiro contato com bebidas alcoólicas (10). a sociedade brasileira, de certa forma, incentiva o consumo de bebidas alcoólicas pelo fato de ela ser encarada de forma diferente, quando comparada às outras drogas. além disso, família e sociedade aceitam com certa naturalidade um jovem consumir bebidas alcoólicas, podendo ocorrer alguma censura, se houver abuso, mas seu uso na família é bem tolerado com o primeiro contato geralmente acontecendo neste contexto, passando a fazer parte de todas as comemorações e confraternizações (10). afirmaram ter experimentado problemas decorrentes do consumo de bebidas alcoólicas 19,3% dos consumidores de nossa amostra. problemas recentes na vida relacionados ao consumo de bebidas alcoólicas entre estudantes universitários da área da saúde, tais como culpa/remorso depois de beber, apagamentos (blackouts) e recebimentos de críticas por suas bebedeiras foram constatados em 35,7%, 37% e 42,4% dos consumidores, respectivamente, em estudo realizado na universidade federal do rio grande do sul (brasil) (8). análise detalhada da amostra de estudantes de enfermagem da universidade de passo fundo (brasil) ‒ consumidores de bebidas alcoólicas ‒ revelou que 69,7% deles relataram chegar à embriaguez, sendo que essa situação ocorreu para 31,8% no mês 232 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 anterior à entrevista, e, após ter bebido, 21% admitem ter faltado à escola; 16,5%, ter dirigido e 2,3%, sofrido acidentes ou ter faltado ao trabalho (14). estudo realizado com estudantes de enfermagem da universidade nacional da colômbia, sede bogotá (colômbia), que viveram uma gravidez precoce buscou relacionar esta gravidez com o consumo de bebida alcoólica. metade das estudantes entrevistadas relatou a influência do consumo dessa substância sobre a relação sexual que gerou a gravidez não planejada, o que estabelece uma possível relação entre o consumo de álcool e os comportamentos sexuais de risco (18). apesar de a maioria dos estudantes da nossa amostra (77,9%) negar a influência do ingresso na universidade no aumento da frequência de consumo de bebidas alcoólicas, sabe-se que, em geral, o ingresso na universidade ocorre em um momento difícil de mudanças e adaptações ao novo ambiente, momento esse em que a necessidade de aceitação e pertencimento grupal pode levar a mudanças de atitudes não adequadas (7), como o consumo excessivo de bebidas alcoólicas. muitas vezes o acesso à universidade é encarado como um passaporte para a libertação individual do jugo familiar e, em busca de integração grupal e de novas experiências, os estudantes universitários podem expor-se à experimentação de drogas lícitas e ilícitas (14). adolescentes e adultos jovens constituem a população de maior risco para o consumo de bebidas alcoólicas, e a legitimação cultural ao consumo conferida por várias sociedades (14), inclusive a brasileira, contribui para essa situação. o álcool como bebida é de baixo custo e fácil obtenção no brasil e, independentemente da quantidade consumida, é a substância psicoativa mais consumida pelo homem (13). as bebidas alcoólicas são facilmente encontradas por preços acessíveis, o que facilita ainda mais para os estudantes o seu consumo. a necessidade de se socializar e pertencer ao grupo pode fazer com que o consumo de álcool aumente, e, assim, os estudantes não percebam que, aos poucos, estão ingerindo álcool excessivamente (10). particularmente entre estudantes universitários, as festas com disponibilização de bebidas do tipo open bar facilitam o consumo excessivo (7, 9). por isso, há necessidade de políticas que controlem a venda de bebidas alcoólicas para a população de jovens universitários, que regulamentem a promoção de festas com open bar, a venda de bebidas baratas em eventos universitários, assim como a venda de bebidas nos campi. essas políticas também devem incentivar atividades e eventos voltados para esta população nos quais a bebida alcoólica não esteja incluída (9). em síntese, os resultados apontaram que o consumo de bebidas alcoólicas pelos estudantes de enfermagem da universidade em que este estudo foi desenvolvido não difere dos encontrados em outros grupos de estudantes universitários. no entanto, acreditamos que o presente estudo poderá somar-se aos já realizados e viabilizar comparações, além de contribuir para o conhecimento da magnitude do consumo de bebidas alcoólicas entre estudantes universitários, especialmente entre aqueles da área de saúde, futuros profissionais que, inevitavelmente, atuarão como educadores e motivadores para a adoção de condutas saudáveis pela população em geral e deverão cuidar de pessoas acometidas por doenças/agravos advindos do consumo de bebidas alcoólicas. apesar de estes resultados não poderem ser extrapolados para populações clínicas ou participantes com menor nível educacional, eles apresentam importante contribuição para o entendimento do consumo de bebidas alcoólicas entre estudantes de enfermagem no contexto sociocultural brasileiro, além de apontarem a necessidade de políticas e programas de prevenção ao consumo excessivo de álcool voltadas para essa população. apontamos como limitações deste estudo a aplicação do instrumento somente em alunos que estavam presentes em sala de aula, e assim não obter informações sobre consumo de bebidas alcoólicas dos que não estavam; ter sido desenvolvido com amostra não probabilística, o que não permite fazer generalizações para a população de estudantes de enfermagem da universidade em que foi desenvolvido; a possibilidade do viés de memória e; a coleta de dados ter sido realizada em apenas um dia. 233 consumo de bebidas alcoólicas entre estudantes de enfermagem l rafael tavares-jomar, enéas dos santos-silva referências 1. world health organization. global status report on alcohol and health. geneva: world health organization; 2011. 2. schulte mt, ramo d, brown sa. gender diferences in factors inluencing alcohol use and drinking progression among adolescents. clin psychol rev. 2009; 29 (6): 535-47. 3. hingson rw, zha w. age of drinking onset, alcohol use disorders, frequent heavy drinking, and unintentionally injuring oneself and others after drinking. pediatrics 2009; 123 (6): 1477-84. 4. laranjeira r, pinsky i, zaleski m, caetano r (org.). i levantamento nacional sobre os padrões de consumo de álcool na população brasileira. brasília: senad; 2007. 5. andrade ag, duarte pcav, oliveira lg (org.). i levantamento nacional sobre o uso de álcool, tabaco e outras drogas entre universitários das 27 capitais brasileiras. brasília: senad; 2010. 6. franca c, colares v. validação do national college health risk behavior survey para utilização com universitários brasileiros. cien saúde 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cienc cuid saúde 2011; 10 (3): 571-7. 14. picolotto e, libardoni lfc, migott amb, geib ltc. prevalência e fatores associados com o consumo de substâncias psicoativas por acadêmicos de enfermagem da universidade de passo fundo. cien saúde colet. 2010; 15 (3): 645-54. 15. pillon sc, santos ma, gonçalves ams, araujo km. uso de álcool e espiritualidade entre estudantes de enfermagem. rev esc enferm usp 2011; 45 (1): 100-7 16. nóbrega mpss, simich l, strike c, brands b, giesbrecht n, khenti a. policonsumo simultâneo de drogas entre estudantes de graduação da área de ciências da saúde de uma universidade: implicações de gênero, sociais e legais, santo andré – brasil. texto contexto enferm. 2012; 21 (spe): 25-33. 17. zucker ra. anticipating problem alcohol use developmentally from childhood into middle adulthood: what have we learned? addiction. 2008; 103 (supl.1): 100-8. 18. alvarez ml. gravidez precoce de estudantes de enfermagem e o consumo de álcool. rev latino-am enfermagem 2008; 16 (spe): 577-83. 08. valoracišn neurolšgica ok año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 40 a través de la valoración física se descubren condiciones de la persona como ser integral, lo que permite planear los cuidados de enfermería y, por lo tanto, promover la adaptación del individuo, como lo expresa callista roy. el modelo de roy está basado en la teoría de sistemas, según la cual los estímulos (entradas) son los que provocan una respuesta (salidas). lo anterior lo hace a través de unos mecanismos de enfrentamiento, que son el subsistema cognitivo, que se refiere a la valoración del juicio, la emoción, la memoria y el raciocinio, e incluye la función del rol, la interdependencia y el autoconcepto del individuo, y el subsistema regulador, que involucra toda la parte fisiológica del ser y lo hace por medio de las funciones, que para roy serán los efectores: la función de oxigenación y circulación, la neurológica, los órganos de los sentidos, la función endocrina y reproductora, la protección, la nutrición, la actividad y el descanso, la eliminación de líquidos y los electrolitos. resumen en este artículo se muestra cómo a través de la aplicación de un modelo conceptual la enfermera emplea herramientas en la valoración neurológica del individuo, para identificar, analizar e interpretar, por medio de los mecanismos de enfrentamiento, cognitivo y regulador, todas aquellas respuestas efectivas e inefectivas, y los estímulos que las desencadenan. de esta forma identifica los problemas de adaptación y genera un diagnóstico de enfermería, para finalmente poder dar un cuidado oportuno y eficaz, que le permita al individuo lograr su adaptación, y a la enfermera evaluar, de manera objetiva y pertinente, el cuidado que está proporcionando. palabras clave modelo de callista roy, valoración neurológica, cuidado de enfermería, mecanismos de enfrentamiento, efectores, estímulos, respuestas. abstract this article shows the application of a conceptual model, in which the nurse uses tools to evaluate, identify, analyze and interpret all effective and non effective answers and the stimuli of neurologic function. it gives information to identify adaptation problems and obtain a nursing diagnosis giving an adequate care, to reach adaptation in the person and evaluate in a proper way the care given. key words callista roy’s model, neurologic evaluation, nursing care, coping mechanisms, effectors, stimuli, answers. blanca cecilia venegas bustos esde sus inicios, la facultad de enfermería de la universidad de la sabana ha implementado en su currículum el modelo de callista roy, mediante el cual, en cada una de las asignaturas de enfermería, se profundiza no solo en la parte conceptual del modelo sino en su aplicación para brindar cuidado de enfermería. profesora asistente facultad de enfermería • universidad de la sabana 41 la valoración neurológica: un soporte fundamental para el cuidado de enfermería los mecanismos de enfrentamiento (el cognitivo y el regulador) están basados en procesos de la función neurológica1. “los canales neurales intactos afectan el procesamiento regulador. en forma similar, el procesamiento perceptual, la información, el aprendizaje, el juicio y las emociones son procesos cognitivos, con una base neurológica”. el manejar unos buenos conocimientos sobre la anatomía y la fisiología de la función neurológica da elementos suficientes para comprender el pensamiento, el sentimiento, el movimiento y la interacción del individuo sujeto a adaptación en el medio ambiente cambiante. los efectores, que son el modo psicosocial y el fisiológico, contribuyen al funcionamiento holístico de la persona. en la función neurológica hay dos procesos vitales básicos: la cognición y la conciencia. los procesos de cognición, que hacen posible relacionar las experiencias pasadas con las presentes, actúan como un regulador de eventos vitales. recordemos que la cognición abarca las habilidades humanas de pensar, sentir y actuar. “el modelo de roy muestra que los procesos cognitivos ocurren dentro del campo de la conciencia. la conciencia se caracteriza por el despertar y el estar alerta. el ambiente para el procesamiento cognitivo incluye estímulos focales, como la experiencia sensorial inmediata, y estímulos contextuales y residuales, considerados primariamente en términos de educación y experiencia”2. esto confirma la importancia de realizar una anamnesis completa del individuo sujeto de ser valorado, ya que nos puede dar elementos fundamentales para su cuidado, entre otros, la influencia directa del medio ambiente que lo rodea. este puede llegar a afectarlo de forma efectiva o inefectiva. no podemos olvidarnos de indagar sus antecedentes familiares y personales, ya que de la familia y sus propias vivencias se obtienen la mayoría de las conductas aprendidas en el transcurso de la vida, y el individuo las puede emplear cuando se encuentra en un proceso de enfermedad. guía para realizar la valoración de la función neurológica con el ánimo de orientar una buena y completa valoración de enfermería en la función neurológica, debemos contemplar unos pasos que nos pueden guiar para encontrar con mayor claridad las respuestas en dicha función, así como los estímulos que las producen. los elementos mínimos que se emplean son el fonendoscopio, el tensiómetro, el martillo de reflejos, el equipo de órganos de los sentidos, los aplicadores, las esencias de diferentes olores, las sustancias para la percepción de sabores, los oclusores oculares, un diapasón, la carta de snell, una linterna, un bajalenguas, elementos fríos, calientes, punzantes y suaves. también se debe poseer habilidad en la técnica de la entrevista para obtener los datos que el paciente o su familia pueden proporcionar. para realizar la valoración física de la función neurológica se emplea la técnica de la observación permanente desde que el individuo entra a la consulta o desde que se lo identifica en la unidad. si el paciente se encuentra hospitalizado, el examinador debe tener una gran capacidad de observación. otra de las técnicas empleadas es la palpación, que permite obtener información sobre forma, tamaño, fuerza, sensibilidad, desplazamiento y vibraciones. finalmente, mediante la técnica de medición se obtienen datos de cantidad, como la agudeza visual, la fuerza, el trofismo muscular y la actividad refleja. una vez se inicia la valoración se debe realizar una anamnesis para determinar la edad, el sexo, la ocupación, la procedencia, el estado civil, los nombres de los acudientes o la persona responsable, eps a la que está afiliado, residencia actual, hábitos o costumbres dentro y fuera de casa, como recreación, deporte, interacción social; antecedentes personales, como enfermedades que el individuo haya sufrido o esté padeciendo; medicamentos que consuma habitualmente, bien sea medicados o automedicados, o si consume alguna sustancia psicoactiva; consumo de cigarrillo y alcohol; antecedentes de traumas, cirugías u hospitalizaciones anteriores; antecedentes importantes de la familia, bien sea materna o paterna; enfermedades crónicas o del sistema nervioso de uno de los miembros de la familia. como lo que se pretende es brindar un cuidado holístico al individuo, debemos tener en cuenta los efectores, es decir, valorar los modos psicosocial y 1 roy, callista, y andrews, heather. modelo de adaptación de callista roy, capítulo 12, editorial appleton y lange, 1999. traducido por maría e. moreno. 2 op. cit. año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 42 fisiológico. a continuación se lleva a cabo la valoración de la función del rol, la interdependencia y el autoconcepto, ya que estos pueden suministrar elementos claves para analizar los mecanismos de enfrentamiento (cognitivo y regulador). el modo psicosocial se determina por medio de los instrumentos de valoración familiar: el apgar familiar, el familiograma y el ecomapa, que muestran de manera general la funcionalidad de la familia del individuo valorado, así como las relaciones de este como miembro de una familia y la forma como interactúa con el medio que lo rodea. hay que ahondar en el concepto que él tiene de sí mismo, en cómo se siente su yo físico, ético, moral y espiritual; indagar sobre los roles que desempeña y sobre cómo se siente realizando cada uno de estos. para complementar, se debe obtener información sobre la forma de relacionarse con los demás y la necesidad que tiene de los demás para convivir. no olvidar que esta información suministra datos importantes sobre la función neurológica, como memoria, juicio, emoción, raciocinio, afecto, aspectos que se valoran para establecer la capacidad intelectual del individuo. para organizar la información y continuar con la valoración de la función neurológica se debe seguir con el examen mental, en el cual se identifican los niveles de alerta del individuo y su forma de reaccionar ante el medio. estos niveles son: consciente: el paciente responde coherentemente al llamado y el medio ambiente que lo rodea; somnolencia: el paciente despierta ante diversos estímulos, sus respuestas motrices y verbales son adecuadas, mentalmente aparece despejado, pero, al retirarse el estímulo, regresa a la somnolencia; confusión: el paciente presenta alteración de sus respuestas a los estímulos externos, no es capaz de reconocer y entender el mundo que lo rodea, ni hay claridad en el pensamiento ni en los recuerdos; estupor: el paciente responde a estímulos dolorosos y táctiles, así como a estímulos auditivos fuertes, y puede responder a algunas preguntas o ejecutar órdenes sencillas; al retirarse el estímulo, entra nuevamente en letargo y con frecuencia presenta movimientos espontáneos; coma: este puede ser superficial o profundo; en el superficial hay reacción a estímulos dolorosos y respuestas a estímulos táctiles persistentes; puede responder emitiendo sonidos o quejándose; cuando cesa el estímulo vuelve al estado inicial. en el coma profundo, no hay respuesta a ningún estímulo, sino ligeras reacciones a estímulos muy dolorosos, como presión sobre las apófisis estiloides o por debajo del pabellón auricular; se presentan relajación muscular, arreflexia tendinosa, cutánea y pupilar, incontinencia de esfínteres y hasta respiraciones con periodos de apnea. el siguiente paso es la valoración de la capacidad intelectual, considerada “como la capacidad de hacer abstracción, de usar símbolos y de valorar nuevas experiencias a la luz de experiencias pasadas”3. esta valoración necesariamente lleva a hacer un análisis del mecanismo de enfrentamiento, el subsistema cognitivo, para lo cual se valoran: • la orientación. que depende de la memoria y la atención. se debe indagar si el paciente sabe quién es él, cuál es la fecha o día en que está y dónde se encuentra. • la atención. se observa la capacidad del paciente de concentrarse en una actividad o tarea, o el hecho de responder a las preguntas del entrevistador. • la memoria. se evalúa el registro mental reciente o remoto; debe describir hechos históricos recientes y también hechos históricos o relevantes pasados. • el pensamiento. se valora la secuencia lógica, coherente y relevante del individuo al dirigirse a un objeto seleccionado; por ejemplo, con la pregunta ¿qué observa en el cuadro? • el afecto. es un sentimiento que se puede observar de inmediato en el paciente, como un episodio de llanto o de risa. 3 cediel ángel, ricardo. semiología médica, editorial ortice, 3ª. ed., colombia, 1993. 43 la valoración neurológica: un soporte fundamental para el cuidado de enfermería • el cálculo. se valora la capacidad de hacer cálculos matemáticos, como sumas o en su defecto identificando billetes. • el juicio. se mide la capacidad de abstracción o de interpretación pidiéndole que interprete, por ejemplo, un refrán. • y, finalmente, el lenguaje. este debe ser comprensible y coherente; tabién se evalúa la forma de pronunciar las palabras. con esto concluye la primera parte de la valoración neurológica. el segundo paso consiste en la valoración de los pares craneales, donde además se involucra a los órganos de los sentidos. algunos de estos pares craneales son sensitivos, otros motores y otros mixtos. por lo tanto, de la valoración correcta de cada uno depende la identificación de las respuestas tanto efectivas como inefectivas del individuo. en el tercer paso se valoran: • la función motriz, que es definida como la organización neurológica del movimiento e involucra la movilidad física, la marcha, la coordinación de todos los movimientos del individuo y el sincronismo. • la fuerza muscular, que va de ausencia completa de fuerza a fuerza normal (de 0 a 5). • el tono muscular, que se puede apreciar observando la actitud del paciente en el lecho o en la forma de manipular elementos, en la posición de las extremidades, en el relieve de las masas musculares, en la consistencia de los músculos al palparlos y en la resistencia que estos presentan a los movimientos; las respuestas pueden ser la hipotonía o la hipertonía. • el trofismo muscular, observable en el desarrollo muscular. la mejor manera de descubrir su disminución o aumento es midiendo simétricamente los músculos de las extremidades, sin olvidar que hay mayor desarrollo de los músculos del hemisferio dominante, dependiendo de si el individuo es diestro o zurdo; la diferencia no debe ser mayor de un centímetro. • la coordinación o adecuada utilización de las vías motrices y sensitivas, que depende del buen funcionamiento del cerebelo y el aparato vestibular. la va loración de la coordinación, según callista roy, se hace más minuciosa en las funciones de actividad y descanso. • los reflejos, que son la respuesta motriz involuntaria desencadenada por un estímulo sensorial específico. entre estos tenemos los tendinomusculares, consistentes en el estiramiento brusco de un músculo, que se obtiene golpeando el tendón del músculo cerca de su inserción; la respuesta es el rápido movimiento de la parte del cuerpo accionada. su valoración se representa por medio de cruces, que van desde reflejo ausente (cero cruces) hasta reflejo hiperactivo “clonus” (cuatro cruces). finalmente, se valora la sensibilidad, que es de dos tipos: la superficial y la profunda. la superficial se evalúa por medio de la temperatura, el dolor y el tacto, y la segunda, en la que se experimenta el dolor profundo, por medio de la presión, la vibración y la propiocepción. la valoración neurológica nos permite identificar fácilmente los estímulos y las respuestas y, por lo tanto, analizar en forma completa los mecanismos de enfrentamiento, que se enmarcan más en la cognición, ya que, gracias al conocimiento y al hecho de que el individuo se haga consciente de sus propios problemas de adaptación, este puede contribuir a mejorarlos e involucrarse por medio del autocuidado. para la enfermera, la planeación del cuidado se fundamenta en lo encontrado en la valoración, lo que debe redundar en beneficio del individuo, su familia y las personas que lo rodean. igualmente, la valoración le facilita ejecutar y evaluar el plan de cuidado, buscando su efectividad. bibliografia cediel ángel, ricardo. semiología médica, editorial ortice, 4ª. ed., bogotá, colombia, 1993. seidel y otros. exploración física, harcour ediciones, 3ª. ed., españa, 1997. bates, bárbara. propedéutica médica, editorial harla, 4ª. ed., méxico, 1990. roy, callista, y andrews, heather. modelo de adaptación de callista roy, editorial appleton y lange, 2ª. ed., 1999. 417 429 calidad de vida en cuidadores.indd 417 josé hernando ávila-toscano1 marylolys vergara-mercado2 calidad de vida en cuidadores informales de personas con enfermedades crónicas 1 doctorando en ciencias sociales y humanas. director grupo de investigación psicus (psicología, cultura y sociedad), corporación universitaria reformada barranquilla, colombia. investigaciones@unireformada.edu.co 2 magíster en enfermería. coordinación de enfermería, clínica del río. montería, colombia. ky_mary@hotmail.com recibido: 10 de enero de 2013 enviado a pares: 18 de enero de 2013 aceptado por pares: 02 de abril de 2014 aprobado: 11 de abril de 2014 doi: 10.5294/aqui.2014.14.3.11 para citar este artículo / to reference this article / para citar este artigo ávila-toscano jh, vergara-mercado m. calidad de vida en cuidadores informales de personas con enfermedades crónicas. aquichan. 2014;14(3): 417-429. doi: 10.5294/ aqui.2014.14.3.11 resumen objetivo: evaluar la calidad de vida de cuidadores informales de personas que viven en situación de enfermedad crónica determinando si la misma se relaciona con las características sociodemográficas de los participantes. materiales y métodos: se evaluaron 127 cuidadores informales residentes en montería (córdoba, colombia), durante el segundo semestre de 2012, por medio de un diseño ex post facto con el cuestionario whoqol-bref de la organización mundial de la salud (oms). para la evaluación de calidad de vida se consideraron cuatro dominios: a) salud física, b) salud psicológica, c) relaciones sociales y d) medioambiente. los datos se analizaron con spss 18,0 aplicando chi cuadrado de pearson y pruebas de diferencias entre grupos. resultados: se observaron bajos niveles de salud física y psicológica, deterioro de los procesos de participación social y niveles moderados de interacción con el medioambiente. condiciones como el género del cuidador, su ocupación y la relación con el paciente tuvieron una correspondencia significativa (p < 0,05) con la calidad de vida en relación con los dominios de medioambiente, vida social y salud psicológica. conclusiones: los cuidadores informales presentan un deterioro general de su calidad de vida con déficit marcado en la esfera relacional. palabras clave calidad de vida, cuidadores, enfermedad crónica, medio social, enfermería. (fuente: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 417-429 418 aquichan issn 1657-5997 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 417-429 quality of life of informal caregivers of chronically ill persons abstract objective: evaluate the quality of life of informal caregivers of persons living with chronic illness by determining if it is related to the socio-demographic characteristics of the participants. materials and methods: one hundred twenty-seven (127) in informal caregivers residing in monteria (cordoba, colombia) were evaluated during the second half of 2012, through an ex post facto study using the world health organization quality of life questionnaire (whoqol-bref). four broad domains were considered to measure quality of life; namely, a) physical health, b) psychological health, c) social relationships and d) environment. the data were analyzed with spss 18.0 using pearson’s chi-square and tests of differences among the groups. results: low levels of physical and psychological health, impaired social participation processes and moderate levels of interaction with the environment were observed. conditions such as the caregiver’s gender, occupation and relationship with the patient showed a significant match (p <0.05) with quality of life in relation to the domains of environment, social life and psychological health. conclusions: informal caregivers experience a general deterioration in their quality of life with marked deficits in terms of social relationships. key words quality of life, caregivers, chronic illness, social environment, nursing (source: decs, bireme). 419 calidad de vida en cuidadores informales de personas con enfermedades crónicas l josé hernando ávila-toscano, marylolys vergara-mercado qualidade de vida de cuidadores informais de pessoas com doenças crônicas resumo objetivo: avaliar a qualidade de vida de cuidadores informais de pessoas que vivem em situação de doença crônica determinando se esta se relaciona com as características sociodemográficas dos participantes. materiais e métodos: avaliaram-se 127 cuidadores informais residentes em montería (córdoba, colômbia), durante o segundo semestre de 2012, por meio de um desenho ex post facto com o questionário whoqol-bref da organização mundial da saúde (oms). para a avaliação de qualidade de vida, consideraram-se quatro domínios: a) saúde física; b) saúde psicológica; c) relações sociais e d) meio ambiente. os dados foram analisados com spss 18,0 aplicando qhi-quadrado de pearson e provas de diferenças entre grupos. resultados: observaram-se baixos níveis de saúde física e psicológica, deterioro dos processos de participação social e níveis moderados de interação com o meio ambiente. condições como o gênero do cuidador, sua ocupação e a relação com o paciente tiveram uma correspondência significativa (p < 0,05) com a qualidade de vida no que se refere aos domínios de meio ambiente, vida social e saúde psicológica. conclusões: os cuidadores informais apresentam um deterioro geral de sua qualidade de vida com déficit marcado na esfera relacional. palavras-chave qualidade de vida, cuidadores, doença crônica, meio social, enfermagem. (fonte: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 417-429 420 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 introducción las enfermedades crónicas son un problema de salud pública debido a su creciente aumento y al impacto negativo que generan en el bienestar de las personas que las padecen, como también en su grupo familiar. las implicaciones que generan a nivel sistémico en los pacientes causan limitaciones y dependencia de otras personas para realizar actividades de la vida cotidiana, esta situación afecta la calidad de vida de quienes los rodean y especialmente de quienes les brindan cuidado (1), producto de la carga física y emocional que representa dicha tarea (2). los riesgos para la salud del cuidador están relacionados con la transformación en los roles y en el desempeño de actividades cotidianas debido a que este se somete a un cambio en su estilo de vida (3) en función de la atención del paciente con enfermedad crónica. esta actividad consume gran parte del tiempo del cuidador y acarrea la experimentación de una multiplicidad de síntomas emocionales, psicológicos y físicos que desencadenan en la denominada experiencia de sobrecarga o síndrome del cuidador (4), la cual se acrecienta con frecuencia ante el aumento de la necesidad de apoyo del paciente en las actividades de la vida cotidiana y la cantidad de tiempo requerido para su atención (5). el cuidado implica un nivel elevado de dedicación, aumento de las responsabilidades individuales, sentimientos de obligación de proporcionar apoyo (6) pérdida de la sensación de libertad y efectos psicoemocionales, conductuales y fisiológicos adversos (7), condiciones que empeoran con el paso del tiempo dado que el estado de salud del paciente tiende a deteriorarse y con ello aumenta la demanda de atención, lo que interfiere negativamente con el bienestar y funcionamiento psicológico, personal y afectivo del cuidador, generándole insatisfacción en sus necesidades y deterioro de sus redes sociales (8,9). diversos estudios, además de mostrar el impacto de la actividad del cuidado, han permitido construir un perfil del individuo dedicado a esta tarea, resultado que ha mostrado consenso entre los investigadores de diversas latitudes. se ha observado que la responsabilidad de cuidar a los pacientes recae esencialmente sobre la propia familia (10-12), y en particular sobre las mujeres (13), quienes suelen contar con un nivel medio-bajo de formación educativa y combinar el cuidado del familiar durante un número elevado de horas diarias, con las responsabilidades del hogar y las demandas conyugales. otros estudios han permitido identificar la interrelación de las condiciones demográficas del cuidador, el nivel de carga del cuidado y el estado de sus indicadores psicológicos y físicos de calidad de vida (14,15), analizando el rendimiento general de las diversas dimensiones de esta última variable en los cuidadores, en especial porque la calidad de vida es una condición psicosocial de implicaciones importantes en la salud, desde la cual se puede determinar el grado de satisfacción o insatisfacción de la persona en relación con su estado físico y emocional, al igual que con su salud mental (16). algunos reportes señalan que los cuidadores mujeres muestran mayor deterioro de su calidad de vida y experimentan más síntomas depresivos que los cuidadores hombres (15,16), otros estudios han señalado un nivel de rendimiento notoriamente reducido en relación con la calidad de vida física del cuidador, con quejas somáticas frecuentes por fatiga y alteraciones en el sueño (17,18), así como por otros malestares que incluyen cefaleas, cansancio y dolor de espalda (19), incluso, en algunas enfermedades como las demencias se ha postulado el impacto del cuidado en la salud nutricional de la diada paciente-cuidador (20). también se han identificado resultados similares a nivel psicológico en los que se reporta una mayor tendencia a la aparición de problemas de ansiedad y depresión (21,22), es común, además, la presencia de sentimientos de miedo e inseguridad, generalmente producidos por la preocupación que genera el estado de salud del paciente y por el temor a la progresión de la enfermedad (23); precisamente, parece ser que la salud mental, el estado emocional y la vitalidad del cuidador son los elementos de la calidad de vida psicológica más frecuentemente afectados. en resumen, los cuidadores ven afectada desfavorablemente su salud y su calidad vida experimentando cambios en sus patrones de conducta, su socialización e integración familiar. en gran medida las condiciones del cuidado ofrecido sirven de predictores del nivel de afectación, por lo cual resulta indispensable analizar desde un enfoque interdisciplinario, con la participación de enfermería, todas aquellas variables que influyen en la carga que sufren los cuidadores, sus características y su funcionamiento físico, psíquico y moral (22). si bien es cierto que lo expuesto se reconoce como una necesidad sanitaria importante producto de sus efectos para la salud del cuidador y del paciente, también es común que en la práctica sanitaria, tanto a nivel institucional como del trabajo que cumplen los profesionales de la salud, la 421 calidad de vida en cuidadores informales de personas con enfermedades crónicas l josé hernando ávila-toscano, marylolys vergara-mercado atención se centre en los cuidados del paciente, desplazando a un segundo plano a quien lo cuida de manera informal (24) durante gran parte del día; en tal sentido, reconocer al cuidador como parte esencial del servicio de salud constituye un aporte tanto a la prevención de la protección de su salud como al impacto indirecto sobre los pacientes. en atención a este panorama, en el desarrollo de este estudio se planteó como objetivo la evaluación de las condiciones físicas, psicológicas y sociales, y las interacciones con el medioambiente como dimensiones de la calidad de vida en cuidadores informales de pacientes con diversas enfermedades crónicas no transmisibles que residían en la ciudad de montería, córdoba, ubicada en el caribe colombiano, durante el segundo semestre del año 2012, reconociendo además las interacciones entre la calidad de vida y las condiciones sociodemográficas de los cuidadores. si bien es cierto que se ha venido presentando un aumento del interés por estudios de este tipo, también lo es que las investigaciones en el área siguen requiriendo mayor desarrollo e inclusión de muestras y variables diversas a partir de las cuales se puedan lograr resultados importantes que contribuyan a la delimitación real del estado vital de los cuidadores y a la generación de programas y propuestas sociales que ayuden a reducir el costo socioeconómico y de salud que representa este fenómeno. materiales y métodos participantes se desarrolló un estudio ex post facto, retrospectivo, de un grupo, simple (25), el cual facilita el análisis de las variables independientes dentro de contextos intactos sin recurrir a su manipulación, realizando el registro de las interacciones (en diferentes niveles: asociativo, predictivo) en un grupo determinado de participantes. la muestra estuvo conformada por 127 cuidadores informales de personas con enfermedad crónica seleccionadas de forma intencional. los participantes pertenecían a un centro de atención psicosocial ubicado en una comunidad urbana de la ciudad de montería, capital del departamento costero de córdoba perteneciente al caribe colombiano. se incluyeron individuos que cumplían con la tarea de cuidado informal de pacientes adultos con enfermedades crónicas no transmisibles; la selección se realizó independientemente del vínculo con el paciente (familiar, conocido, etc.) y el género del cuidador, buscando que se tratara de personas que dedicaran al menos tres cuartas partes del día a la tarea de cuidado, durante un mínimo de cuatro días semanales y que llevaran al menos ocho semanas cumpliendo dicha labor. se excluyeron aquellas personas que contaban con formación técnica o profesional en asistencia sanitaria, dado que el interés del análisis se basaba en el cuidado informal. instrumentos la evaluación de la calidad de vida en los participantes se realizó con la aplicación del whoqol-bref, instrumento desarrollado por la organización mundial de la salud (oms), consistente en la versión reducida del whoqol-100, que cuenta con validación transcultural y traducción a 20 idiomas con óptimas propiedades semánticas, esto lo hace uno de los cuestionarios de mayor uso y difusión. adicionalmente puede ser aplicado en individuos con edades entre los 12 y los 97 años, lo que muestra adecuada capacidad para ofrecer resultados significativamente diferentes entre individuos sanos y enfermos (26). el instrumento está constituido por 26 ítems situando el marco temporal de análisis en las dos semanas anteriores a la evaluación en las cuales se miden las siguientes dimensiones: salud física: incluye la valoración del nivel de funcionamiento físico, la energía del individuo o la manifestación de dolor y fatiga física, la calidad del sueño y la necesidad de consumir medicamentos. salud psicológica: incluye la valoración personal de los sentimientos, la satisfacción con la vida y las creencias respecto a la misma. relaciones sociales: en esta dimensión se valoran las relaciones personales, la esfera sexual del individuo y los canales de soporte social o ayuda. medioambiente: incluye la valoración personal sobre los recursos y medios que ofrece el ambiente del individuo, el acceso a servicios de transporte, la posibilidad de participación en actividades recreativas y de ocio al igual que el acceso a sustento económico. cuenta con escala de respuesta tipo likert de cinco puntos que van de 1 hasta 5, de modo que las puntuaciones más altas indican un mejor nivel de la calidad de vida. los informes interna422 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 cionales del whoqol-bref señalan un buen rendimiento en sus propiedades psicométricas (alfa de cronbach por dimensión: salud física = 0,82; salud psicológica = 0,81; relaciones sociales = 0,68; medioambiente = 0,80) (24); además, las puntuaciones de cada dimensión del whoqol-bref es su versión de 26 ítems se correlacionan altamente (0,89 o superior) con las dimensiones del whoqol-100 (27). en colombia en particular ha sido popular el uso de este cuestionario en diversas poblaciones con resultados psicométricos muy favorables (28-30). por su parte, las características sociodemográficas fueron registradas mediante la aplicación de una encuesta diseñada para tal fin, con la cual se recopiló información como edad, género, nivel educativo, estrato socioeconómico, estado civil, ocupación, edad del paciente, tiempo de ser cuidador, horas dedicadas al cuidado, relación con el paciente y diagnóstico del mismo. procedimiento este estudio se basó en el cumplimiento de los lineamientos internacionales de investigación con seres humanos. dado el carácter interdisciplinario del enfoque asumido y del cuerpo de investigadores se dio cumplimiento a los fundamentos éticos definidos por la declaración de helsinki de la asociación médica mundial (amm), el capítulo iv y conexos de la ley 911 de 2004 y por el decreto 1090 de 2006, ambos emanados del congreso de la república de colombia. para el desarrollo del estudio inicialmente se hizo contacto con organismos sanitarios públicos para la referenciación de grupos de pacientes con enfermedades crónicas que recibieran atención en diferentes instituciones ubicadas en la zona urbana donde se llevó a cabo el estudio; posteriormente se seleccionó de manera intencional uno de estos grupos debido a que reunía un número amplio de individuos. tras la identificación del grupo se hizo un acercamiento con las autoridades sanitarias encargadas de su coordinación exponiendo los objetivos y fines del estudio e indicando que el acceso al proceso de medición se daría con los cuidadores de los pacientes. con la autorización de esta instancia se procedió a establecer reuniones informativas con la totalidad de cuidadores adscritos al grupo, cuyo número ascendía a 211. a los asistentes se les señalaron los objetivos y métodos propuestos para la investigación y, por último, 127 individuos aceptaron vincularse de manera voluntaria firmando el consentimiento informado. posteriormente se establecieron dos subgrupos para la aplicación de los instrumentos de medición, proceso que se desarrolló en un espacio privado, con un ambiente adecuado y bajo el acompañamiento de un equipo interdisciplinario de dos enfermeras y un psicólogo coordinados por un magíster en enfermería y otro en psicología. inicialmente se aplicó el cuestionario de datos demográficos y por último el whoqol-bref; los instrumentos se emplearon de forma heteroaplicada a excepción de 15 participantes quienes reportaron no poseer habilidades de lecto-escritura. en estos casos, los instrumentos fueron desarrollados mediante entrevista estructurada por parte de los integrantes del equipo seleccionado y entrenado para el tamizaje. los datos fueron analizados con el paquete estadístico spss 18,0 a través del cual se cumplió con el respectivo análisis descriptivo para evaluar las características demográficas de los participantes y el rendimiento general en cada una de las dimensiones de calidad de vida. posteriormente se ejecutó un análisis de posibles relaciones entre las variables que definen el perfil del cuidador con el estadístico no paramétrico chi cuadrado (x2). con el propósito de comprobar si las dimensiones de calidad de vida mostraban diferencias significativas según el perfil de los cuidadores, se cumplió con un análisis de diferencias entre grupos definidos por las características demográficas de los participantes. la comparación de las dimensiones de calidad de vida (variables criterio) se desarrolló mediante pruebas no paramétricas utilizando la u de mann-whitney para las variables demográficas que definían dos grupos (género, estado civil, relación con el paciente, tiempo cuidando al paciente, tiempo diario de cuidado) y la prueba de kruskall-wallis para k muestras independientes en los casos en que la agrupación incluía más de dos grupos (edad del cuidador, nivel de formación educativa, ocupación, edad del paciente, diagnóstico del paciente). en este último caso, tras el análisis de las k muestras se hizo necesario el reconocimiento de los grupos donde se identificaron diferencias significativas, por lo cual se aplicó la u de mann-whitney como procedimiento post hoc con la respectiva corrección de bonferroni para reducir el error alfa. resultados caracterización de los cuidadores informales la muestra se dividió en 28 hombres (22%) y 99 mujeres (78%), casi todos residentes en comunidades de baja estratifi423 calidad de vida en cuidadores informales de personas con enfermedades crónicas l josé hernando ávila-toscano, marylolys vergara-mercado cación social (n = 126; 99,2%). respecto a sus edades, 5,5% (n = 7) fueron individuos menores de 18 años, 22% (n = 28) tenía edades entre 18 y 35 años, 44,9% (n = 57) estaba en el rango de 36 a 59 años y 27,6% (n = 35) superaba los 60 años. la formación académica de los participantes mostró niveles bajos, con un porcentaje importante de cuidadores sin habilidad para la lecto-escritura (n = 9; 15%), mientras que 42,6% (n = 54) inició estudios pero nunca los terminó. la culminación de formación elemental (escuela primaria) se registró en 11,8% (n = 15) y el bachillerato o educación media en 18,1% (n = 23); por su parte, solo 12,5% (n = 16) de los evaluados adelantó estudios a nivel técnico o profesional. los cuidadores evaluados sostenían en su mayoría relaciones conyugales (66,9%), 22,8% eran solteros y 10,3% separados. en cuanto a la ocupación, 48% (n = 61) se dedicaba principalmente a las labores del hogar, 22,8% (n = 29) trabajaba de forma independiente y solo 4,7% (n = 6) contaba con empleo formal; 8% (n = 10) de los cuidadores eran estudiantes y 16,5% (n = 21) realizaba diversas tareas informales. los cuidadores compartían vínculos familiares con los pacientes en 91,3% de los casos (n = 116), se identificó además con elevada frecuencia que la actividad de asistencia la han venido realizando desde el momento en que los pacientes fueron diagnosticados (n = 113, 89 %), mientras que 11 % (n = 14) de los evaluados asumió esta responsabilidad tiempo después de haber sido realizado el diagnóstico. alrededor de 72,4 % (n = 92) de los cuidadores reportaron también dedicación al cuidado del paciente durante más de 12 horas de la jornada diaria, seguido de 27,6 % (n = 35) que manifestó cumplir con la tarea de cuidado menos de 12 horas al día. en cuanto a las características de los pacientes se evaluaron dos variables esenciales: la edad y la enfermedad padecida. frente a la primera la mayoría de los pacientes mostró un rango de edad superior al de sus cuidadores (62,2%; n = 79) y cerca de 30,7% (n = 39) un rango menor, solo 7,1% (n = 9) de los pacientes contaba con edad similar a la de su cuidador. así mismo, se presentó un predominio de enfermedades crónicas no transmisibles como hipertensión (80,3%; n = 102) y diabetes (14,2%; n = 18), mientras que en menor medida los cuidadores atendían a personas afectadas por enfermedades crónicas terminales como cáncer (2,4%; n = 3), enfermedad pulmonar crónica (1,6%; n = 2) e insuficiencia renal crónica (0,8%; n = 1), o neurodegenerativas como la enfermedad de parkinson (0,8%; n = 1). con el fin de tener una caracterización más clara del perfil del cuidador se realizó un análisis de relaciones entre las variables sociodemográficas estudiadas teniendo en cuenta la edad, el sexo y el número de horas dedicadas al trabajo como referencia para el cálculo de relaciones con las demás condiciones demográficas. los resultados no mostraron relaciones significativas entre el sexo y el tiempo que se lleva cuidando al paciente (x2[1] = 2,034 p = 0,136 > 0,05), pero sí hubo relación significativa con el número de horas dedicadas al cuidado (x2[1] = 6,406 p = 0,013 < 0,01) siendo mayor el porcentaje de personas que realiza esta actividad por más de 12 horas diarias, y entre estas, el porcentaje de mujeres es más elevado (77,8%) que el de cuidadores varones (53,6%). también se observó relación significativa entre el sexo y el parentesco (x2[5] = 17,103 p = 0,004 < 0,01), siendo mayor entre los hombres el porcentaje de sujetos que cuida de su pareja sentimental (64,3%) y en porcentajes similares de un progenitor o un hijo (10,7%). entre las mujeres es mayor el porcentaje de participantes que cuida de uno de sus progenitores (30,3%), y en porcentajes muy similares de un hijo (29,3%) o de la pareja (24,2%). en relación con la edad del cuidador no se hallaron relaciones entre esta variable y el tiempo que lleva cuidando al paciente (x2[3] = 3,298 p = 0,348 > 0,05), ni con las horas diarias dedicadas al cuidado (x2[3] = 6,061 p = 0,109 > 0,05), aunque sí se registró relación estadísticamente significativa con el parentesco (x2[15] = 83,406 p = 0,000 < 0,001). entre las personas menores de 17 años se registró que mayoritariamente aparecen como cuidadores de sus abuelos (57,1 %) y de otros individuos no familiares (42,9 %), mientras que en los sujetos con edades entre 18 y 35 años sobresalió el rol de cuidador de algún hijo (42,9 %), seguido de algún progenitor (39,3 %); por su parte, las personas entre 36 y 59 años se dedican en porcentajes idénticos al cuidado de su pareja o de un progenitor (31,6 %), y finalmente los cuidadores mayores de 60 años en 68,6 % de los casos cumplen el rol de asistencia, seguido del cuidado de su pareja o de un progenitor (11,4 %). la edad del cuidador también mostró relaciones significativas a nivel estadístico con la edad del paciente (x2[6] = 17,382 p = 0,008 < 0,01), siendo mayor el promedio de edad de este último 424 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 para los casos de los cuidadores en los rangos de 17 a 59 años, mientras que entre los cuidadores mayores de 60 años predominó la tendencia a ser mayor que el paciente (45,7%). valoración de la calidad de vida el rendimiento de la calidad de vida evaluado mediante la aplicación del whoqol-bref reportó niveles reducidos. en la tabla 1 se recoge la información correspondiente a los estadísticos descriptivos de cada uno de los dominios, apreciándose un rendimiento reducido de las dimensiones de relaciones sociales, salud física y psicológica de los cuidadores, mientras que la de mejor rendimiento fue medioambiente, aunque sus valores oscilan entre un rango muy amplio (m ín : 30,0-m áx : 95,0) con una desviación igualmente amplia (de = 9,68). tabla 1. estadísticos descriptivos de los dominios de calidad de vida evaluados con el whoqol-bref y las características del perfil sociodemográfico de los cuidadores informales analizados se realizó un análisis con la u de mann whitney y la kruskall wallis cuyos datos se aprecian en la tabla 3. en el caso de la salud física no se hallaron diferencias significativas con ninguna de las variables criterio (p > 0,05) por lo cual se asume que el rendimiento en dicha dimensión se da de forma independiente de las condiciones del cuidador en la muestra. se observaron datos llamativos en la dimensión de relaciones sociales la cual mostró valores significativos en relación con el género, con rangos medios (rm) de mejor rendimiento en los hombres (76,70) que en las mujeres (60,41); por su parte, la relación con el paciente también expresó diferencias estadísticamente significativas frente a la dimensión de salud psicológica, la cual mostró valores más elevados entre los cuidadores que no comparten parentesco con el paciente (rm = 91,23) que entre los cuidadores familiares (rm = 61,42). esta dimensión —la salud psicológica— fue la que mostró mayor cantidad de diferencias significativas puesto que las mismas también se observaron en relación con la ocupación del cuidador y con la edad del paciente. para el primer caso, la comparación post hoc mostró rangos más elevados entre los cuidadores que se desempeñan bajo el rol de estudiantes frente a quienes se dedican al hogar (rm = 48,85/33,89) (u = 176,5; p = 0,033), y frente a quienes trabajan de manera independiente (rm = 26,45/17,78) (u = 80,50; p = 0,037). así mismo, los cuidadores que cumplen actividades productivas informales diversas expresaron mejor salud psicológica (rm = 52,12) que los cuidadores dedicados exclusivamente al hogar (rm = 37,84) (u = 417,5: p = 0,017). descriptivos salud física salud psicológica relaciones sociales medioambiente media 47,46 44,68 19,58 50,88 de 7,68 6,92 6,86 9,68 mínimo 30,0 27,5 10,0 30,0 máximo 67,5 60,0 75,0 95,0 fuente: elaboración propia. en relación con la salud física, 81,1% de los participantes la juzgó de forma negativa frente a un 18,9% que la asumió con una valoración favorable; una situación similar ocurrió con la salud psicológica puesto que 94,5% la valoró negativamente con calificativos que van de regular a deficiente, mientras que solo 5,5% asumió una percepción positiva de su salud mental (tabla 2). la dimensión que valora las relaciones sociales fue la de más bajo rendimiento entre los participantes con 99,2% (n = 126) de los individuos que la consideraron como deficiente, frente a un único sujeto (0,8%) que la juzgó como excelente. finalmente, en el medioambiente 63,8% de los sujetos expresó valoraciones desfavorables (entre regular y deficiente), mientras que 46,2% aseguró tener rendimiento positivo en este dominio con calificativos de buena, muy buena o excelente (tabla 2). con el fin de identificar la existencia de diferencias significativas entre las diversas dimensiones o dominios de calidad de vida tabla 2. evaluación de los niveles de calidad de vida de acuerdo con la percepción de los cuidadores dimensión calidad de vida deficiente regular buena muy buena excelente f % f % f % f % f % salud física 70 55,1 33 26 18 14,2 5 3,9 1 0,8 salud psicológica 85 66,9 35 27,6 5 3,9 2 1,6 0,0 0,0 relaciones sociales 125 99,2 0,0 0,0 0,0 0,0 0,0 0,0 1 0,8 medioambiente 56 44,1 25 19,7 20 15,7 22 17,3 4 3,1 fuente: elaboración propia. 425 calidad de vida en cuidadores informales de personas con enfermedades crónicas l josé hernando ávila-toscano, marylolys vergara-mercado contraste para dos muestras independientes (prueba u mann-whitney) variables aleatorias variables demográficas (independientes) salud física salud psicológica relaciones sociales medioambiente género 1312,5 (0,667) 1375,0 (0,949) 1030,5 (0,036)* 1325,5 (0,724) estado civil 1676,5 (0,576) 1743,0 (0,829) 1739,0 (0,811) 1714,5 (0,717) relación con el paciente 563,5 (0,521) 338,5 (0,010)* 426,0 (0,066) 554,5 (0,472) tiempo cuidando al paciente 646,5 (0,263) 785,0 (0,963) 779,5 (0,929) 687,5 (0,423) tiempo diario de cuidado 1534,0 (0,680) 1477,0 (0,470) 1542,0 (0,710) 1541,5 (0,710) contrastes para k muestras (prueba de kruskall wallis) variables demográficas (independientes) salud física salud psicológica relaciones sociales medioambiente edad del cuidador 1,027 (0,795) 1,921 (0,589) 1,563 (0,668) 4,671 (0,198) nivel de formación educativa 2,888 (0,409) 6,104 (0,107) 4,409 (0,221) 8,127 (0,043)* ocupación 1,213 (0,876) 10,014 (0,040)* 3,003 (0,557) 1,609 (0,807) edad del paciente 3,916 (0,141) 6,010 (0,050)* 3,069 (0,216) 4,962 (0,084) diagnóstico del paciente 5,043 (0,411) 2,150 (0,828) 3,791 (0,580) 6,764 (0,239) grupos: 1hombre-mujer; 2sin relación-con relación; 3familiar-no familiar; 4desde el diagnóstico-después del diagnóstico; 56 o menos horas-de 7 a 12 horas; 6menor de 18-18 a 35-36 a 59-60 o más; 7primaria-bachillerato-técnico/universitario-preletrado; 8hogar-empleado-independiente-estudiante-varios; 9menor que el cuidador-igual al cuidador-mayor que el cuidador, 10hipertensión-diabetescáncer-parkinson-irc-epc. tabla 3. estadísticos de contraste entre características demográficas de los cuidadores y dimensiones de calidad de vida *p < 0,05. fuente: elaboración propia. en el segundo caso (edad del paciente) se hallaron diferencias entre la salud psicológica de cuidadores con rango de edad mayor que el del paciente (rm = 64,38) frente a cuidadores con menor edad que el paciente (rm = 49,32) (u = 1155,0; p = 0,026). finalmente, en la dimensión de medioambiente la valoración favorable fue menor entre los cuidadores sin nivel de formación educativa en comparación con aquellos que contaban con estudios de formación básica (rm = 22,08/36,90) (u = 229,5; p = 0,003) o de bachillerato (rm = 23,18/33,24) (u = 250,5; p = 0,035). discusión el propósito central de este estudio consistió en evaluar la calidad de vida de un grupo de cuidadores informales de pacientes con diversas enfermedades crónicas estableciendo relaciones entre el rendimiento de su calidad de vida y el perfil o las características sociodemográficas de dichos cuidadores. en este empeño, inicialmente sobresale que los hallazgos redundan sobre la evidencia previa relacionada con el perfil del cuidador informal, toda vez que resultan confirmatorios respecto a la identificación del perfil de la persona que asume la responsabilidad de cuidar de manera informal al paciente crónico (13,14,20). a su vez, los datos identificados permiten enfatizar sobre los riesgos a los que se exponen los cuidadores, en especial las mujeres quienes con más frecuencia asumen esta responsabilidad durante periodos de tiempo mayores (más de 12 horas al día) a los cumplidos por los hombres. esto representa un riesgo psicosocial para las mujeres (13,15) producto de las cargas físicas y emocionales que acompañan el cuidado, sumado a los efectos que pueda implicar reconocer el deterioro —regularmente progresivo— que tiene el paciente, con quien se construye un lazo afectivo usualmente ligado a la vinculación filial. 426 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 parece ser que el sexo es una variable primordial para la definición del rol como cuidador y de su relación con el tiempo del cuidado o la vinculación con el paciente, mientras que otras condiciones como la edad no parecen ser tan relevantes en la delimitación del perfil de cuidador. esta diferencia puede estar relacionada con las actitudes y la disposición de las personas dedicadas al cuidado, las cuales se presentan independientemente de la edad; en este estudio, por ejemplo, se observó que los hombres dedican el cuidado esencialmente a sus parejas mientras que las mujeres lo hacen con los progenitores, con sus hijos o sus compañeros sentimentales, es decir, la mujer tiene un margen más amplio de cobertura en materia de ofrecimiento de soporte ante la presencia de enfermedad dentro del núcleo familiar. respecto a la edad no se observan mayores diferencias dado que, como es de esperarse, entre los cuidadores más jóvenes se atiende a pacientes más adultos, mientras que la discrepancia de edades se va reduciendo a medida que el cuidador es de mayor edad. por otro lado, los esfuerzos que supone el cuidado se reflejan en un deterioro de las condiciones generales de calidad de vida de los participantes del estudio, al registrarse un nivel bajo en tres de los dominios de la misma incluidos en esta investigación. condiciones como el deterioro de la salud física y psicológica percibida por los cuidadores parecen señalar el nivel de afectación que genera la experiencia de cuidar (14-17), actividad que debido a su exigencia y a la modificación de los roles individuales puede inducir insatisfacción y déficit funcional entre los participantes de la muestra, lo cual coincide con reportes previos (3,7,21). sin embargo, los resultados relacionados con el rendimiento de la salud física deben abordarse con reserva dado que en el análisis realizado no se observó relación con ninguna de las características del cuidador; en este sentido es posible que otras condiciones de índole psicológico puedan asociarse a la aparición del deterioro físico, de hecho, esta reducción de la calidad de vida física puede obedecer a una percepción subjetiva del cuidador dado que incluso condiciones como el tiempo de cuidado diario, la enfermedad del paciente y el tiempo que llevan ejerciendo esta actividad no fueron significativos frente a los aspectos físicos de los participantes. por su parte, cada vez resulta más evidente que los cuidadores ven expuesto su desarrollo personal y social producto del compromiso adquirido con los pacientes, el cual suele ser asumido a expensas del deficitario estado de rendimiento de la propia vida. el escenario social es uno de los más afectados entre los diversos cuidadores, quienes con frecuencia ven reducido el margen de participación social (9,10) y la construcción de interacciones flexibles que permitan tanto la comunicación y socialización como el intercambio de experiencias, ocio y disfrute. la pérdida de funcionalidad de la vida social ha sido una condición comúnmente relacionada con el deterioro de la calidad de vida del cuidador (9-11), lo cual representa uno de los más alarmantes factores de riesgo para la salud general de estos individuos, en la medida que el compromiso de su actividad paliativa y el prolongado tiempo dedicado a la misma conduce a la marginación del plano social y familiar (3,7), condición que puede llevar a la ausencia de recursos sociales de apoyo con los efectos adversos que ello representa para la salud, en especial si se considera que para las personas mayores dedicadas al cuidado, el manejo de la vida social y las interacciones con su medio ambiente resultan aún más problemáticas, máxime si se trata de personas con una baja formación educativa tal y como lo muestran los datos del presente estudio. este es un hecho reiterativo en la investigación sobre cuidadores dado que análisis previos demuestran que las personas dedicadas al cuidado que poseen un bajo nivel cognitivo se exponen más a diversas condiciones de orden social y psicológico que afectan su vida (15). resultados como los hallados, advierten sobre la necesidad declarada en estudios previos de desarrollar procesos de intervención dirigidos a la conservación de la salud del cuidador (31) enfocados en múltiples elementos que superen la preocupación por la relación salud-enfermedad, que integren elementos con un margen mayor de amplitud en donde se vinculen las intervenciones en red involucrando en las acciones preventivas y remediales la participación en micronúcleos de socialización e intercambio psicosocial que permitan que las personas dedicadas al cuidado vean cumplida su responsabilidad a la par que contribuyen a su propio desarrollo. adicionalmente, la evidencia (32) resalta que las intervenciones que consideran la participación de redes de apoyo en el plano social cuentan con mayor nivel de efectividad al incluir en las estrategias de aplicación vínculos socioafectivos y mecanismos de intercambio emocional, los cuales redundan en beneficios para las personas como la reducción de manifestaciones de depresión la carga o los problemas sociales. en este estudio, entre tanto, se reconoce la existencia de limitantes. por un lado, a pesar de contar con una muestra relativamente amplia, en la misma hubo cuidadores de pacientes con enfermedades muy diversas y, en algunos casos, con un número muy menor entre un tipo y otro de cuidador, sobresaliendo aque427 calidad de vida en cuidadores informales de personas con enfermedades crónicas l josé hernando ávila-toscano, marylolys vergara-mercado llos que atendían a pacientes con diabetes o hipertensión, cuya carga física o emocional puede incluso ser menor que la de cuidadores de pacientes con enfermedades que revisten una marcada gravedad como el caso de la insuficiencia renal o el parkinson. esta diferencia podría generar variaciones en los resultados de los niveles de calidad de vida entre uno y otro cuidador, lo cual conduce a juzgar con discreción los resultados. adicionalmente, en este estudio solo se consideraron condiciones demográficas que pudieron relacionarse con el perfil de los cuidadores y con su calidad de vida; sin embargo, no fueron incluidas otras condiciones como el historial de cuidado, la existencia de enfermedades en los participantes, la historia mental previa, la percepción sobre la salud del paciente o incluso las redes de apoyo social y familiar. pese a lo anterior, los resultados obtenidos coinciden en muchos aspectos con reportes empíricos previos que aportan al reconocimiento de esta problemática psicosocial, desde lo cual es posible contribuir a la comprensión de este fenómeno como un problema de importancia para la salud pública. conclusiones los hallazgos de este estudio expresan su principal aporte al conocimiento científico relacionado con el abordaje de los cuidadores informales respecto al impacto de la carga de cuidar sobre la vida social como elemento constitutivo de la su calidad de vida, de hecho, parecer ser cada vez más claro que variables demográficas y otras propias del perfil del cuidador (edad, tiempo de estar cuidando al paciente, horas diarias dedicadas al cuidado) son menos significativas que aquellas relacionadas con la deprivación de espacios y estímulos sociales. este es un elemento de mucha relevancia de cara a la formulación de programas de atención sanitarios para la protección y recuperación del cuidador, pues el análisis y adecuado manejo de sus relaciones sociales y de los recursos inherentes a las mismas pueden representar claves para la realización de la tarea del cuidado informal de manera exitosa. las prácticas informales de cuidado de pacientes con enfermedades crónicas conllevan la experimentación de alteraciones en el funcionamiento de las personas dedicadas a dicho cuidado, quienes se exponen a problemas personales, psíquicos y sociales producto de las exigencias de la actividad de atención, llegando incluso al deterioro significativo de las diversas dimensiones que componen su calidad de vida. este es un fenómeno con implicaciones relevantes en la salud física y psicológica a nivel público, dado que es creciente el número de pacientes con enfermedades crónicas, y con ello resulta esperable el aumento de cuidadores informales que pese a su disposición carecen de la cualificación para esta actividad, lo cual los expone al deterioro progresivo de su salud y de su calidad de vida envolviéndolos en un círculo de riesgo sanitario complejo y creciente. una situación que emerge con carácter de urgencia es la atención especializada de la mujer desde muy diversos frentes (cultural, sanitario, político), dado que el cuidado ha ido sufriendo de manera creciente una feminización (33) que requiere la perentoria atención integral de la cuidadora, en virtud de las desigualdades en la distribución del cuidado frente a los hombres, y la vulneración social y cultural de la que incluso el estado es partícipe al carecer de políticas y sistemas de protección sanitarios para quien cuida de un enfermo. esta realidad conduce al desarrollo de prácticas de enfermería capaces de interactuar con diversos enfoques y disciplinas con el fin de construir modelos de prevención e intervención que se ajusten a la realidad psicosocial de los cuidadores, a fin de generar un impacto significativo en la construcción de ambientes de cuidado y soporte en los que tanto el paciente como el cuidador se vean beneficiados. en tales propuestas es esencial el acercamiento del cuidador informal a habilidades y conocimientos mínimos de la ciencia de enfermería para que el cuidado ofrecido constituya una continuación del cuidado profesional de manera que con ello se contribuya de la mejor forma al bienestar del paciente, si bien esto implica también que desde la intervención sanitaria de enfermería se promuevan las prácticas de autocuidado en el cuidador como elemento sustancial para contribuir a la elevación de su calidad de vida (34). 428 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 referencias 1. song ji, shin dw, choi jy, kang j, baik yj, mo h et al. quality of life and mental health in family caregivers of patients with terminal cancer. support care cancer. 2010;19(10):1519-26. 2. morales-cariño e, jiménez-herrera b, serrano-miranda t. evaluación del colapso del cuidador primario de pacientes adultos mayores con síndrome de inmovilidad. rev invest clin. 2010;64(3):240-246. 3. stenberg u, ruland cm, miaskowski c. review of the literature on the effects of caring for a patient with cancer. psychooncology. 2010;19(10):1013-25. 4. vélez j, berbesí d, cardona d, segura a, ordóñez j. validación de escalas abreviadas de zarit para la medición de síndrome del cuidador primario del adulto mayor en medellín. aten primaria. 2012;44(7):411-16. 5. garlo k, o’leary jr, van ness ph, fried tr. burden in caregivers of 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study. received: february 4, 2013 sent to for review: february 14, 2013 accepted by the reviewers: june 18, 2015 approved: july 6, 2015 doi: 10.5294/aqui.2015.15.4.5 para citar este artículo / to reference this article / para citar este artigo urrutia mt. poupin l. women with cervical cancer: perceptions about the papanicolaou test, aquichan. 2015;15(4):499-507. doi: 10.5294/aqui.2015.15.4.5 abstract objective: examine perceptions about the papanicolaou (pap) test from the perspectives of chilean women with cervical cancer. design: a descriptive, cross-sectional study conducted in santiago, chile. participants: 127 chilean women. results: the principal reasons for not having had a pap test were procrastination and barriers related to fear, embarrassment, discomfort, not caring, lack of time, and lack of knowledge. conclusion: all the reasons given by the chilean women who took part in the study must be considered by health care professionals who are in a position to advocate for education and cervical cancer screening for women, especially in countries where the disease is still prevalent. these results can serve as a guide for education programs and can be applied in intervention research. keywords pap test, cancer, barriers (source: decs, bireme). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 499-507 500 aquichan issn 1657-5997 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 499-507 las mujeres con cáncer de cuello uterino: percepciones acerca de la prueba de papanicolaou resumen objetivo: examinar las percepciones acerca de la prueba de papanicolaou (pap) desde la perspectiva de las mujeres chilenas con cáncer cervical. diseño: un estudio descriptivo, transversal realizado en santiago, chile. participantes: ciento veintisiete mujeres chilenas. resultados: las principales razones para no haber hecho la prueba de pap fueron dilación y obstáculos relacionados con el miedo, la vergüenza, la incomodidad, el hecho de no estar preocupada, la falta de tiempo y la falta de conocimiento. conclusión: todas las razones dadas por las mujeres chilenas que participaron en el estudio deben ser considerados por los profesionales de la salud que están en una posición para abogar por la educación y la detección del cáncer cervical para las mujeres, especialmente en países donde la enfermedad sigue siendo prevalente. los resultados pueden servir como una guía para los programas de educación y pueden ser aplicados en la investigación sobre la intervención. palabras clave prueba de papanicolaou, el cáncer, las barreras (fuente: decs, bireme). 501 women with cervical cancer: perceptions about the papanicolaou test l maria-teresa urrutia, lauren poupin as mulheres com câncer de colo do útero: percepções sobre o exame papanicolaou resumo objetivo: examinar as percepções sobre o exame papanicolaou do ponto de vista das mulheres chilenas com câncer cervical. desenho: estudo descritivo, transversal, realizado em santiago (chile), com 127 mulheres chilenas. resultados: as principais razões para não terem feito o exame papanicolaou foram dilação e obstáculos relacionados com o medo, a vergonha, o desconforto, o fato de não estar preocupada, a falta de tempo e a falta de conhecimento. conclusão: todas as razões dadas pelas mulheres chilenas que participaram do estudo devem ser consideradas pelos profissionais da saúde que estão em condição de defender a educação e a detenção do câncer cervical, especialmente em países onde a doença continua sendo prevalente. os resultados podem servir como um guia para os programas de educação e podem ser aplicados na pesquisa sobre a intervenção. palavras-chave exame papanicolaou, câncer, barreiras (fonte: decs, bireme). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 499-507 502 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 introduction cervical cancer (cc) accounts for approximately 10% of all new cases of cancer worldwide (1). cc is one of the cancers with the highest mortality rate in the world (2). in 2005, there were over 500,000 new cases of cc, and over 90% of them were in developing countries (3). every year, there are 33,000 women who die of cc in latin america and the caribbean (4). over the past three decades, cc rates have fallen in most of the developed world. in contrast, these rates in most developing countries have risen or remained unchanged (3). experience in developed countries has shown organized screening programs can significantly reduce cc incidence and mortality (3, 5). the difference between developed and developing countries reflects inequalities in health care and, therefore, is a challenge for global health (3). although several tests can be used in screening for cc, the papanicolaou (pap test) is the only one that has been shown to reduce cc incidence and mortality (3). in fact, it is still considered the principal method for early detection of carcinoma of cervix (6). cervical cancer control can be achieved if screening is organized and as many women as possible in the target group are screened (3). for this reason, it is important to know what barriers exist to participating in pap testing. in studies of central and south american women, the factors found to be related to participation in cc screening include: knowledge about the pap test (7, 8), gynecological symptoms (7,8), being over age 30, a higher socioeconomic level (9), higher education, having medical insurance, and having a primary health care provider (9, 10). the aim of this study was to examine chilean women’s perceptions concerning the pap test. methods design and sample the ethics committees from the pontificia universidad católica de chile school of nursing and the southeast metropolitan public health service (servicio de salud metropolitano sur-oriente, santiago, chile) reviewed and approved this research. written informed consent was obtained from the women participants. women’s perceptions about participating in pap testing, from the perspective of chilean women with cc, were examined using a descriptive, cross sectional design. content analysis of personal interviews generated a thematic description of the women’s perceptions about obtaining pap testing. the sample included 127 women who sought care at urban health clinics of the southeast metropolitan public health service in santiago, chile. the women who go to these clinics are low-income and receive health care at two public hospitals. the women all had a diagnosis of cc, confirmed by biopsy, and received health care from the cervical cancer “auge” program during 2004 and 2005. auge is a new program in chile; the acronym stands for “universal access to explicit guaranties in health” [acceso universal a garantías explícitas en salud]. the women were enrolled in the study between may 2006 and october 2006. data collection and analysis data collection was conducted by twelve baccalaureateprepared nurse midwives who interviewed the women in their homes. the interviewers were trained in a one-day educational session. the training included content about cc, an explanation about the study, and an introduction to the questionnaire. the nurse midwives role-played conducting the interviews, and rehearsed how to elicit responses. this study analyzed the answer to two questions: 1) “why do you think women do not get a pap test?” and 2) “why do you think women do not return to the clinic for the results of their pap test?” the answers were recorded verbatim on the interview form. content analysis was used according to the methods described by krippendorf (11). the unit of analysis was a sentence or phrase that represented one idea. the first level of analysis involved identifying the common ideas; the second level of analysis was to group the common ideas into like themes. the criterion for a theme was that each theme demonstrated an originally different topic with respect to the others. the themes describe the responses the women gave to the questions about having a pap test and obtaining the results of the test. the first and second levels of analysis were performed by the two authors separately, then discussed until a consensus was reached. the number of women who contributed to each theme was calculated. 503 women with cervical cancer: perceptions about the papanicolaou test l maria-teresa urrutia, lauren poupin findings the 127 participants ranged in age from 25 to 81; the mean age was 49 (sd ± 13). twenty-eight percent of the women had never had a pap smear before being diagnosed with cc. the analysis of the responses to the questions about why women do not get a pap test and why women do not return to the clinic for their results was summarized into three themes. the themes were: 1) procrastination, 2) barriers, and 3) lack of knowledge. procrastination was a tactic used to put off obtaining the pap test and/or claiming the test results. barriers to having a pap test included embarrassment, discomfort, lack of caring by health professionals, and lack of time. the barrier to obtaining pap test results was fear of a cancer diagnosis. lack of knowledge was related to the need for information about cc screening and diagnosis (see table 1). procrastination procrastination was the tactic used by a majority of the women to delay getting a pap test and to put off claiming the results. forty-eight percent (n=61) of the women used procrastination excuses to postpone getting a pap test, and 52% (n=66) used procrastination excuses for not claiming their pap test results. these characteristics are individual attributes that would prevent women from performing any health behavior. some women attributed their procrastination to a lack concern about their health over the demands of caring for others. chilean women put the needs of family members first, before their own . one woman said “las mujeres no se preocupan por si mismas, siempre son otros más importantes que ella.” [women don’t worry about themselves, others are always more important.] other women attributed their procrastination to “laziness”. one woman said, ‘algunas veces la mujer se olvida y dice …cuando vaya a control, voy a pedirlo…pero eso nunca pasa.” [sometimes, a woman forgets and says to herself, “when i go for a routine check-up, i will request it…but it never happens”]. barriers thirty-eight percent (n=48) of the women reported barriers to having a pap test, and 20% (n=35) reported barriers to claiming pap test results. the barriers are related to negative common ideas theme responses question 1* n (%) question 2* n (%) laziness procrastination 61 (48%) 66 (52%) lack of concern embarrassment barriers 48 (38%) 35 (20%) fear discomfort uncaring health professionals lack of time lack of information about cervical cancer lack of knowledge 18 (14%) 26 (28%)lack of knowledge about the purpose of the pap test lack of symptoms question 1: why do you think women do not get a pap test? question 2: why do you think women do not return to the clinic for the results of their pap test? table 1 common ideas and themes (n = 127). 504 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 experiences the women had. embarrassment, discomfort, and an uncaring attitude on the part of health professionals were the barriers reported by the women. one woman said, “es muy vergonzoso para la mujer. algunas veces duele y es incómodo. además los profesionales no la tratan bien.” [it (pap test) is very embarrassing for a woman. it is sometimes painful and you feel uncomfortable. also, health care professionals aren’t very kind or considerate to women.] fear was identified as a reason why the women did not return to the clinic to get their results. women were afraid the pap test result would show cancer. women said, “algo puede estar mal.” [something could be wrong.] as for the pap test result, it was said, “las mujeres tienen temor a lo que el pap pueda encontrar.” [women fear what the pap test might find. ] one woman said, “…miedo a la palabra cáncer, a saber que ellas tienen algo malo.” […fear of the word cancer, fear if knowing they have something bad]. lack of time also was reported as a reason for not having the pap test and for not getting the results of the test. one woman said. “la mujer tiene problemas para ir al médico, porque la mujer trabaja, y no puede pedir permiso.” [it is a problem for a woman to go to the doctor’s office, because if the woman works, she can’t get time off]. lack of knowledge about cc fourteen percent of the participants (n=18) reported a lack of knowledge about cc as a reason why women do not get a pap test, and 28% (n=26) said lack of knowledge contributed to not claiming pap test results. women expressed the need for more information about cervical cancer, including screening and diagnosis. one woman said, “falta información; las mujeres ven distante la posibilidad de tener cáncer.” [women lack information and do not consider cancer as a possible diagnosis for themselves]. the women reported they did not think a pap test was necessary if one had no symptoms that indicated something was wrong. one of the women said,“…porque ella cree que está bien, que está sana.” […because she thinks she is healthy and well.] “…si ellas se sienten bien, ¿por qué necesitan ir?”[if they feel fine, why do they need to go?], “si ella está sana, no necesita el examen.” [if she is healthy, she does not need the test]. discussion chile is a south american country where cc claims the lives of many women. the incidence of cc in chile was 18.7/100,000 women in 2003, with a mortality rate of 8.5 /100,000. this study sought to explain what chilean women understand about the pap test, which is the major screening test for cc. it is the first qualitative study designed to ask chilean women with cervical cancer about their views on the pap test. one limitation of the study is that only women with cc were interviewed and the results are not representative of the chilean context, owing to the methodology used. because these women were diagnosed and treated for cc, this group is more sensitive to the topic. therefore, these women may have given a great deal of thought as to how their cancer might have been prevented. however, a similar study was conducted with a group of women in chile who do not have cc , and the results were very similar to those of this study (12). the theme of procrastination found in this sample is similar to the finding of mcfarland (13), who detected a “lack of motivation” to obtain the pap test among women in botswana. byrd and colleagues also reported procrastination among hispanic women in texas (14). the procrastination noted in this study was the principal answer to both study questions; therefore, it should be considered in future nursing education interventions. the women in this study reported barriers to getting a pap test and to claiming the test results; these include fear, embarrassment, discomfort, uncaring professionals, and lack of time. fear has been reported as related to pain, and to the diagnosis as well (12,15,16). it also has been cited as a reason for not taking the pap test (17). similar to our finding, fear was related to the test result and to the pain associated with the pelvic exam (14, 18). in fact, some women believed a piece of the uterus would be cut during the exam (19). as in the study described here, others have reported women expressed embarrassment about exposing their genitals during a pap test (18-22). some women said they would like to substitute the pap test for another, less embarrassing procedure (14). the percentage of hispanic women who have cited embarrassment as a barrier is nearly 50% (20); it was as high as 87% in a study of brazilian women (23). 505 women with cervical cancer: perceptions about the papanicolaou test l maria-teresa urrutia, lauren poupin the women in our study said uncaring behavior by health care professionals was a barrier to getting a pap test. others have reported similar issues, such as long waiting times (19, 24), poor physical facilities (24), poor communication on the part of health care professionals (13, 19), lack of continuity with health care professionals (21), and difficulty in pap test scheduling (21). long waiting times to obtain health care is a common situation in latin american countries, and women have reported long waiting times as a barrier to obtaining health care (25). with respect to the waiting time for health care, it is a situation previously described in other latin american countries, where women said it has been a factor in lessening their interest to come back again for health care (25). women have reported that having a male health care professional is a barrier to getting a pap test (13,15, and 26). if women are not comfortable with a health care provider or the environment at a clinic, they may not want to return for the results of a pap test. this is an important point to bear in mind. not having enough time to obtain a pap test was reported by the women in our study, as well as by others (14,24). the reasons included long waiting times at clinics (15, 23), not being able to take time off from work (27) or difficulty in scheduling appointments. the issue of taking time off from work is becoming more important, because 40.3% of chilean women are now employed (28).the increase in the work force can explain the lack of time or the difficulties women have with the pap test. the solution to scheduling appointments at convenient times for women with family responsibilities and for working women rests with the chilean health care system. the health care system must become responsive to women’s need for flexibility in scheduling appointments on saturdays and in the evening. a lack of knowledge about cc symptoms and screening was reported by the women in our sample. others have reported that lack of knowledge about pap testing is found worldwide (13, 2933). women reported not knowing about the importance of screening (14, 18) and about how to obtain a pap test (14,18). they also reported a lack of knowledge about their reproductive anatomy (30). in a sample of adolescents, some believed the pap test was the same as a pelvic exam (29). in a south african study (34), women thought a pap test was a treatment for infertility, or that it was a “cleaning of the womb”. some women believed a piece of the uterus would be cut during the exam (19). clearly, there is a need for education to help women understand what cc is, its anatomic location, screening for cc, and the importance of detection. the same as was reported by others, the women in our sample interpreted a lack of symptoms to mean there was no need for a pap test (13, 17, and 34). the women thought pain or abnormal bleeding were necessary indicators for a pap test. this belief indicates a lack of knowledge about the preventive purpose of the pap test to detect cervical cancer. conclusion the us centers for disease control (cdc) has identified the need to increase access to cc early detection and treatment services, to develop strategies for better screening for women, and to implement public education (35). who has charged health professionals with designing and implementing interventions to reduce cc in the latina population (3). this study provides insights into how chilean women view pap testing. the chilean women in this study reported: a) using procrastination to delay obtaining a pap test, b) barriers to obtaining a pap test, including embarrassment and lack of time, and c) a lack of knowledge about cc and the purpose of the pap test. health care professionals are in a good position to address the concerns expressed by women about pap testing. first, they must lead information campaigns about cervical cancer and the need for screening. this could be accomplished by securing funding and creating posters to be displayed in public transportation systems. secondly, they can provide education programs to increase knowledge about cc. education can be imparted on a one-to-one basis during primary or obstetrics and gynecology care. third, they can protect women’s need for privacy to minimize embarrassment during pap testing. finally, clinical environments need to be changed to provide timely and sensitive care. health care professionals can be advocates for making changes in the health care delivery system. the health care professional’s role is to empower women with respect to their responsibility and participation in self-care, without forgetting the responsibility health care providers have to convey test results appropriately. it is necessary to be sure women understand the procedures at clinics. understanding and shielding or protecting women is a task nurses must perform. women’s health is an important issue, and it is necessary for health care professionals to work in the best way possible to achieve that goal. 506 año 15 vol. 15 nº 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(2000). the pap test: george n. papanicolaou (1883-1962). a screening test for the prevention of cancer of uterine cervix. european journal of obstetrics, gynecology,and reprodustive biology, 90(2), 135-138. 7. aguilar-perez, j. a., leyva-lopez, a. g., angulo-najera, d., salinas, a., & lazcano-ponce, e. c. (2003). [cervical cancer screening: knowledge of pap smear benefits and utilization in mexico]. revista saude publica, 37(1), 100-106. 8. lazcano-ponce, e., moss, s., cruz-valdez, a., alonso de ruiz, p., casares-queralt, s., martinez-leon, c., et al. (1999). factores que determinan la participación en el tamizaje de cáncer cervical en el estado de moreros. salud publica de méxico, 41(4), 278-285. 9. lucumi, d., & gomez, l. (2004). accesibilidad a los servicios de salud en la práctica de citología reciente de cuello uterino en una zona urbana de colombia. revista espanola de salud publica, 78, 367-377. 10. oliveira, m. m., silva, a., oliveira, l., & l., c. 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(2004). perceived barriers and benefits to cervical cancer screening in latin america. preventive medicine, 39(1), 91-98. 16. hunter, j. l. (2005). emelda’s story: applying ethnographic insights to cultural assessment and cervical cancer control. journal of transcultural nursing, 16(4), 322-330. 17. lee-lin, f., pett, m., menon, u., lee, s., nail, l., mooney, k., et al. (2007). cervical cancer beliefs and pap test screening practices among chinese american immigrants. oncology nursing forum, 34(6), 1203-1209. 18. ho, v., yamal, j. m., atkinson, e. n., basen-engquist, k., tortolero-luna, g., & follen, m. (2005). predictors of breast and cervical screening in vietnamese women in harris county, houston, texas. cancer nursing, 28(2), 119-129; quiz 130-111. 19. wiesner -ceballos, c., vejarano -velandia, m., caicedo -mera, j. c., tovar -murillo, s. l., & cendales -duarte, r. 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(2008). avanza participacion femenina. retrieved may 29, 2008, from www.sernam.cl/opencms/opencms/ sernam/regiones/2/noticias/news_0036.html 29. blake, d. r., weber, b. m., & fletcher, k. e. (2004). adolescent and young adult women’s misunderstanding of the term pap smear. archives of pediatric & adolescent medicine, 158(10), 966-970. 30. mcmullin, j., de-alba, i., chavez, l., & hubell, a. (2005). influence of beliefs about cervical cancer etiology on pap smear use among latina immigrants. ethnicity and disease, 10(1), 3-18. 31. rico, ana maría, & iriart, jorge alberto bernstein. (2013). “where there’s a woman, there’s a pap smear”: the meanings assigned to cervical cancer prevention among women in salvador, bahia state, brazil. cadernos de saúde pública, 29(9), 1763-1773. retrieved september 20, 2014, from http://www.scielosp.org/scielo.php?script=sci_arttext&pid=s0102311 x2013001300016&lng=en&tlng=en. 10.1590/0102-311x00146512. 32. oshima, s., masaji., m. (2013). perception of cervical cancer screening among japanese university students who have never had a pap smear: a qualitative study. asian pacific journal of cancer prevention, 14(7), 4313-4318. 33. laranjeira., c.a. (2013). portuguese women’s knowledge and health beliefs about cervical cancer and its screening. social work in public health, 28(2), 150-7 34. lartey, m., joubert, g., & cronje, h. s. (2003). knowledge, attitudes and practices of rural women in south africa regarding the pap smear. international journal of gynecology and obstetrics, 83(3), 315-316. 35. cdc. (2005 ). breast and cervical cancer early detection. retrieved december 3, 2006, from http: //www.cdc.gov/programs/cancer01.htm to w ar ds t he t ra ns it io n to a n em po w er ed a nd r es ili en t l ea de rs hi p of n ur si ng p ro fe ss io na ls 1 maría guadalupe moreno monsiváis https://orcid.org /0000-0002-7152-0244 universidad autónoma de nuevo león, méxico. maria.morenom@uanl.mx editorial towards the transition to an empowered and resilient leadership of nursing professionals keywords (source: decs) empowerment; health facilities; leadership; nursing staff; psychological resilience. palabras clave (fuente: decs) empoderamiento; instituciones de salud; liderazgo; personal de enfermería; resiliencia psicológica. palavras-chave (fonte: decs) empoderamento; instalações de saúde; liderança; recursos humanos de enfermagem; resiliência psicológica. hacia la transición a un liderazgo empoderado y resiliente en los profesionales de enfermería rumo à transição de uma liderança empoderada e resiliente nos profissionais de enfermagem doi: 10.5294/aqui.2022.22.4.1 para citar este editorial / to reference this editorial / para citar este editorial moreno-monsiváis mg. towards the transition to an empowered and resilient leadership of nursing professionals. aquichan. 2022; 22(4): e2241. doi: https://doi. org /10.5294/aqui.2022.22.4.1 https://orcid.org/0000-0002-7152-0244 mailto:maria.morenom@uanl.mx https://doi.org/10.5294/aqui.2022.22.4.1 https://doi.org/10.5294/aqui.2022.22.4.1 https://doi.org/10.5294/aqui.2022.22.4.1 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2022.22.4.1&amp;domain=pdf&amp;date_stamp=2022-10-21 2 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 41 introduction one of the priority goals of health systems internationally is to guarantee services that are safe, sustainable, fair, equitable, and accepted by the community, which demands health professionals leading those organizations to be agents of change and to have adequate abilities. a competent workforce is essential to accomplish quality health attention. the world health organization recognizes sanitary workers are fundamental for establishing solid and resilient health systems that contribute to reaching their objectives. however, it is also evident the need to strengthen the institutions’ capacities to promote efficient health human resource leadership with professional abilities that respond to the population’s health needs (1). nursing professionals represent the majority group within health systems and play an essential role in all attention levels, with a central axis around care, result evaluation, and efficiency. they are firsthand witnesses of the challenges sanitary organizations face. nevertheless, internationally there are areas of opportunity that limit their transition to effective transformational leadership due to the organization demands’ complexity and the dominant leadership style that influences decision-making processes (2). these complicated organizational environments challenge the institutions while they also create opportunities to develop strategies looking to strengthen nursing leadership (3). empowered and resilient leadership nursing professionals face complex and even more demanding situations in their working environments, which is why it is fundamental to promote their leadership regionally, nationally, and internationally, as well as to have as a principal objective the development of abilities that support their health decision-making. it is relevant to consolidate a transformational, empowered, and resilient leadership that contributes to establishing quality, stable, and efficient health systems, which are the product of a transformative, flexible, and proactive vision. there is a need for leaders that can recognize the dangers of adversities and search for the best alternatives and face them. it is also determinant they have capacities, abilities, and initiatives to act before prospective scenarios and to support and strengthen those around them (2, 4). it is considered relevant to inspire the development of leadership abilities in nursing professionals that allow them to influence decision-making at all levels and implement innovative and evolutionary management, occupying a central position to reach the organizational and collective objectives in the work-life with responsibility, autonomy, trust, and transparency to improve health attention quality (5). to w ar ds t he t ra ns it io n to a n em po w er ed a nd r es ili en t l ea de rs hi p of n ur si ng p ro fe ss io na ls 3 according to literature revision, empowerment favors resilient leadership and autonomy. empowerment is the capacity to promote development, improve performance and attitudes, and create autonomy and added commitment and satisfaction (6). resilience is people’s ability to face adversity, overcome obstacles, and generate even more growth, professional and personal. resilient leaders allow the building of positive interpersonal relationships, the development of emotional intelligence, the creation of balance—at work and personal, and the reflection on successes as effective strategies for overcoming challenges (7). the most empowered nursing professionals are capable of driving and consolidating resilient leadership (2, 4). other variables associated with empowerment and resilience are self-leadership (6) and self-efficacy (8). self-leadership refers to a person’s ability to reach their objectives and obtain good results, which generates a feeling of satisfaction for the accomplished goals and the overcame difficulties, favors autonomous leadership, and contributes to being resilient (9). self-efficacy is people’s believes in their ability to perform a task or an activity regarding the knowledge and the course of action needed to control life’s different activities and events. nursing professionals that perceive themselves as self-efficient have empowered and resilient leadership; additionally, they keep a balance between their thoughts and emotions to overcome adversities, negative reactions, and exhaustion, which increments resilient leadership and work satisfaction. a resilient leader is always considered to be efficient (8). education level is another relevant aspect associated with empowerment and resilience. nursing professionals with doctorates and master’s degrees are more empowered and resilient. a higher professional level is associated with more autonomy and being more competent and resilient even if there are difficulties at work or personal environment (10). before the evidence that empowered and resilient leadership of health professionals contributes to the transformation of organizations into strong and committed institutions and inspires accomplishing innovative goals that leave uncertainty and instability behind to develop competent, stable, positive, and improved work environments, there is a requirement to develop actions that, from early training stages, promote effective leadership to guarantee, in the future—short, medium, and long term—health systems with empowered and resilient nursing leaders that face adversities and strengthen the population’s health attention quality (4). conclusion health systems’ transformation requires guaranteeing that nursing professionals have effective, empowered, and resilient leadership. this process has already started, we are on our way towards the 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 41 transition, and there is evidence of the successful positioning of nursing in the different fields of action; however, more effort and investment are required. empowered leadership is necessary for sanitary systems. even though the emphasis must be on impulsing empowered sanitary systems, not resilient, it is a fact that health institutions face multiple demands and requirements that force them to face obstacles, which is why the need nursing professionals able to face challenges and make the best decisions that contribute to the population’s health. it is essential that educational institutions training nursing human resources include in their academic programs and continuing education, content, and learning strategies in real and simulated scenarios that contribute to the develop of resilience, self-efficacy, and self-leadership because of their association with empowerment. moreover, it is advisable to motivate clinical professionals to have master’s and doctorate training that expands their disciplinary knowledge and advanced practice to favor the transition toward the consolidation of nursing leadership. referencias 1. organización mundial de la salud. situación de la enfermería en el mundo: resumen de orientación [internet]. [lugar de publicación desconocido]: 2020 [citado el 2 de septiembre de 2022]. disponible en: https://apps.who.int/iris/bitstream/hand le/10665/331675/9789240003392-spa.pdf 2. comisión internacional de enfermería. el papel de las enfermeras en el logro de los objetivos de desarrollo sostenible [internet]. [lugar de publicación desconocido]: 2017 [citado el 2 de septiembre de 2022]. disponible en: https://www. icnvoicetolead.com/wp-content/uploads/2017/04/icn_ guidance_pages_ sp_lowres.pdf 3. ortega k. liderazgo y desempeño laboral de los profesionales de enfermería del servicio de emergencia del hospital ii essalud huánuco-2016 [internet]. [lugar de publicación desconocido]: 2016 [citado el 2 de septiembre de 2022]. disponible en: http://repositorio.udh.edu.pe/123456789/260 4. ramírez r, lay n, villa i, herrera b. liderazgo resiliente como competencia potenciadora del talento humano. rev cienc hum soc [internet]. 2018 [citado el 5 de septiembre de 2022]; 34(86):826-854. disponible en: http://hdl.handle.net/11323/5266 5. riaño cal, rodríguez pme, gaytán hd. autoevaluación y evaluación en los estilos de liderazgo de dirigentes de enfermería. rev latino-am enfermagem. [internet]. 2021 [citado el 5 de septiembre de 2022]; 29:e3393. doi: https://doi. org /10.1590/1518-8345.3435.3393 6. tau b, du plessis e, koen d, ellis s. the relationship between resilience and empowering leader behaviour of nurse managers in the mining healthcare sector. curationis [internet]. 2018 [citado el 6 de septiembre de 2022]; 41(1):1-10. doi: https://doi. org /10.4102/curationis.v41i1.1775 7. american association of colleges of nursing. the voice academic nursing. lo esencial: competencias básicas para educación profesional en enfermería [internet]. [lugar de publicación desconocido]: 2021 [citado el 5 de septiembre de 2022]. disponible en: https://www.aacnnursing.org / 8. de la garza m, guzmán e, aguilar m. el autoliderazgo y la inteligencia emocional: un estudio de la generación de los millenials. ciencia y sociedad [internet]. 2018 [citado el 6 de septiembre de 2022]; 43(2):51-65. doi: https://doi.org /10.22206/ cys.2018.v43i2.pp51-65 9. foster k, roche m, delgado c, cuzzillo c, giandinoto ja , furness t. resilience and mental health nursing: an integrative review of international literature. j ment health nurs [internet]. 2019 [citado el 7 de septiembre de 2022]; 28(1):71-85. doi: https://doi.org /10.1111/inm.12548 10. manomenidis g, panagopoulou e, montgomery a . resilience in nursing: the role of internal and external factors. j nurs manag [internet]. 2019 [citado el 7 de septiembre de 2022]; 27(1):172-178. doi: https://doi.org /10.1111/jonm.12662 https://apps.who.int/iris/bitstream/handle/10665/331675/9789240003392-spa.pdf https://apps.who.int/iris/bitstream/handle/10665/331675/9789240003392-spa.pdf https://www.icnvoicetolead.com/wp-content/uploads/2017/04/icn_guidance_pages_sp_lowres.pdf https://www.icnvoicetolead.com/wp-content/uploads/2017/04/icn_guidance_pages_sp_lowres.pdf https://www.icnvoicetolead.com/wp-content/uploads/2017/04/icn_guidance_pages_sp_lowres.pdf http://repositorio.udh.edu.pe/123456789/260 http://hdl.handle.net/11323/5266 https://doi.org/10.1590/1518-8345.3435.3393 https://doi.org/10.1590/1518-8345.3435.3393 https://doi.org/10.4102/curationis.v41i1.1775 https://doi.org/10.4102/curationis.v41i1.1775 https://www.aacnnursing.org/ https://doi.org/10.22206/cys.2018.v43i2.pp51-65 https://doi.org/10.22206/cys.2018.v43i2.pp51-65 https://doi.org/10.1111/inm.12548 https://doi.org/10.1111/jonm.12662 03 climaterio y menupausa.indd 33 climaterio y menopausia en mujeres afrodescendientes: una aproximación al cuidado desde su cultura luz ángela argote o.1 maría elena mejía r.2 martha lucía vásquez t.3 maría eugenia villaquirán de gonzález4 climaterio y menopausia en mujeres afrodescendientes: una aproximación al cuidado desde su cultura recibido: 19 de noviembre de 2007 aceptado: 29 de enero de 2008 1. profesora titular. escuela de enfermería, universidad del valle. cali, colombia. luargote@univalle.edu.co 2. profesora asociada. escuela de enfermería, universidad del valle. cali, colombia. maemejia@univalle.edu.co 3. profesora titular. escuela de enfermería, universidad del valle. cali, colombia. maluvasq@telesat.com.co 4. profesora asociada. escuela de enfermería universidad del valle. cali, colombia. resumen para explorar las prácticas sobre protección y cuidado durante la transición del climaterio a la menopausia se llevó a cabo un estudio en mujeres colombianas afrodescendientes que viven en el distrito de aguablanca, cali, colombia, a fin de evaluar los factores socioculturales que influyen en su cuidado. se siguió la etnoenfermería con el objeto de averiguar la perspectiva femenina étnica, e identificar las prácticas beneficiosas y de riesgo para su salud. la investigación tuvo como participantes claves a 17 mujeres. en la consolidación de la muestra se aplicaron los criterios de saturación de datos. en los resultados se evidenció la relación de las mujeres con su propio cuerpo, su defensa y fortificación desde la menarquia como fase preparatoria de sus funciones reproductivas, hasta cuando aparece la menopausia. de acuerdo con su cultura, si no tienen en cuenta estas prácticas tradicionales, sufrirán diversas dolencias en la etapa final de su periodo de procreación. los cuidados sobresalientes se relacionan con el significado de la sangre, así como con el ejercicio de la sexualidad, la limpieza, la alimentación especial y el equilibrio que se debe guardar entre el calor y el frío. las entrevistadas atribuyen a la menopausia cambios en su cuerpo, en sus diferencias emocionales de conducta y en las expectativas de la sexualidad. para el presente estudio estos hallazgos se agruparon en tres temas principales: sentir los profundos cambios en la vida: el cuerpo; sentir los cambios en los estados de ánimo; y vivir la sexualidad. palabras clave menopausia, climaterio, cultura, mujeres, salud sexual y reproductiva. issn 1657-5997 año 8 vol. 8 nº 1 chía, colombia abril 2008 33-49 34 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 climacteric and menopause in afro-colombian women: a culturebased approach to health care abstract a study was conducted with afro-colombian women who live at the aguablanca district of cali to explore practices for protection and self-care during the transition from climacteric to menopause. the aim was to evaluate the social-cultural factors that influence those practices. an ethno-nursing approach was used to discover the participants’ ethnic perspective as females and to identify practices that are positive and detrimental to their health. seventeen women were the key participants in this research, and data saturation criteria were applied to consolidate the sample. the results show how women view their own bodies and how they defend and strengthen themselves from menarche (as preparation for their reproductive function) to the onset of menopause. according to their culture, if traditional practices are not taken into account, they will suffer a variety of disorders during the final stage of menstruation, which brings an end to the reproductive cycle. the predominant care practices deal with the significance of blood, sexual activity, cleanliness, special nutrition and the balance to be achieved between hot and cold. the women interviewed blame menopause for certain changes in their bodies, their emotional behavior and their expectations regarding sexuality. the principal findings of the study were classified into three areas: feeling profound changes in life: the body; feeling changes in mood; feelings about sexuality. key words menopause, climacteric, culture, women, sexual and reproductive health. climatério e menopausa em mulheres afro-descendientes: uma aproximação ao cuidado desde a sua cultura resumo para explorar as práticas sobre proteção e cuidado na transição do climatério à menopausa, foi realizado um estudo em mulheres colombianas afro-descendientes do distrito aguablanca na cidade de cali para avaliar os fatores socioculturais que influenciam no seu cuidado. foi utilizada a etnoenfermagem para buscar a perspectiva étnica feminina, e identificar as práticas benéficas ou de risco para a sua saúde. nesta pesquisa participaram 17 mulheres. para consolidação da amostra foram aplicados os critérios de saturação de dados. os resultados revelaram a relação das mulheres com o seu próprio corpo, a sua defesa e fortificação desde a menarquia como fase preparatória de suas funções reprodutivas até quando aparece a menopausa. segundo a sua cultura, se não levam em conta estas práticas tradicionais, sofrerão várias doenças na etapa final do seu período de procriação. os cuidados importantes são relacionados com o seu significado da sangue, o exercício da sexualidade, a limpeza, a alimentação especial e o equilíbrio que deve se guardar entre o calor e o frio. as entrevistadas responsabilizam à menopausa de alterações no seu corpo, nas suas diferenças emocionais de conduta e nas suas expectações da sexualidade. no presente estudo, estes resultados se agruparam em três temas principais: sentir as profundas alterações na vida: o corpo; sentir as alterações nos estados do animo; e viver a sexualidade. palavras-chave menopausa, climatério, cultura, mulheres, saúde sexual e reprodutiva. 35 climaterio y menopausia en mujeres afrodescendientes: una aproximación al cuidado desde su cultura introducción la menopausia significa última menstruación, y corresponde a un evento fisiológico en la vida de la mujer que implica la finalización de su ciclo reproductivo. se acompaña de diversas modificaciones de tipo orgánico, psicológico y social, algunas de ellas de inicio inmediato y otras de tardía instauración. todas esas manifestaciones en su conjunto constituyen el climaterio (1). al inicio de éste, la declinación en la producción de estradiol endógeno puede causar bochorno, somnolencia diurna, insomnio, manifestaciones vasomotoras, dificultades para la concentración, alteraciones del estado de ánimo y atrofia del epitelio urogenital que conduce a dispareunia y a incontinencia urinaria afectando la actividad coital. el descenso del estradiol endógeno afecta también la calidad de la piel, la densidad ósea, y altera el metabolismo de las lipoproteínas, lo que aumenta la incidencia de enfermedad cardiovascular (2). otros cambios que pueden ocurrir en las mujeres durante el climaterio están relacionados con la disminución de la libido y con la esfera socio-afectiva y, en ese sentido, puede haber tendencia a la depresión, acompañada de un sentimiento de incapacidad e impotencia (3). no obstante los cambios mencionados, la menopausia puede variar de mujer a mujer no solo desde el ámbito fisiológico, sino desde el contexto cultural. las normas, los hábitos, los valores, los ritos, las creencias y las tradiciones de cada cultura pueden explicar lo permisible y aceptable en cada una de ellas. por ejemplo, algunas tribus aborígenes del continente africano creen que las mujeres se vuelven sensatas cuando dejan de menstruar y en lo sucesivo pueden ocupar un nivel superior en la sociedad, e incluso, desempeñar puestos de liderazgo. a pesar de que en esas comunidades a las mujeres posmenopáusicas se les confiere más poder dentro y fuera del hogar, pueden tener prohibiciones como negarles el derecho a las relaciones sexuales con su pareja (4). la edad promedio en que se presenta la menopausia oscila entre 46 y 55 años. en colombia, un trabajo prospectivo reportó la edad promedio de la llegada de la menopausia así: bogotá, 53 años; barranquilla, 52 años; bucaramanga, 46 años; cali, 52 años y medellín: 57 años (5). los estudios de luzardo y rojas, citados en ese mismo estudio, señalan que en colombia el promedio de la aparición de la última menstruación es de 47,0 años. en colombia, entre 95 mujeres de raza negra del palenque de san basilio, se encontró que la edad promedio de la última regla fue los 49,4 años de edad (6). varios estudios (7, 8, 9) fundamentan que después de la menopausia la mujer puede seguir siendo activa dentro de su núcleo familiar y social, potenciando su capacidad mediante el tratamiento farmacológico que reemplaza las hormonas femeninas dejadas de producir por el ovario; tomando medidas generales que pueden ser aportadas por medio de programas de educación a la comunidad; haciendo conciencia de una adecuada y balanceada nutrición a todo lo largo de la vida, especialmente con el consumo de una dieta rica en calcio y vitamina d, y realizando una actividad física constante y rutinaria. pero estas actividades aisladas no son suficientes. se requiere comprender el significado que para las mujeres tienen el climaterio y la menopausia, sus creencias y prácticas de cuida36 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 do y, a partir de ello, buscar explicaciones a los cambios que experimentan para así favorecer el cuidado que ellas mismas se prodigan. cuidar, desconociendo la piedra angular de la cultura de quien es cuidado, nos llevaría como profesionales, de un lado, a desconocer a las personas como seres culturales, y de otro lado, a abolir el carácter relacional que tiene el cuidado. el conocimiento de los fenómenos culturales alrededor del climaterio y la menopausia permitirá entender los estilos de vida y las prácticas de cuidado de la salud, para orientar mejor las intervenciones de las mismas y fomentar estilos de vida saludables. el estudio del cuidado, desde la perspectiva cultural, implica por tanto, describir qué piensan las personas que son, qué están haciendo y con qué finalidad piensan que lo están haciendo. este abordaje del conocimiento y comprensión del otro, esto es, de nuestro sujeto de cuidado, requiere adquirir una formalidad operacional con los conjuntos de significados en medio de los cuales el transita con su vida. diferentes trabajos de investigación en comunidades urbano-marginales de cali se han venido desarrollando desde la perspectiva transcultural. dichos trabajos han permitido descubrir y comprender las acciones de cuidado de las mujeres en torno a su salud sexual y reproductiva en diferentes comunidades (10, 11, 12, 13). los hallazgos han brindado una luz para reflexionar y ajustar los planes de estudio de enfermería, particularmente en los de posgrado, con propuestas de cuidado diseñadas para aplicar en la docencia y en la asistencia. el explorar y documentar cómo interactúan las personas entre sí, y cómo interpretan y se relacionan con ese mundo que las rodea ha facilitado la sistematización del conocimiento acerca de acontecimientos y procesos sociales al determinar lo que significa para las personas su visión del mundo. este trabajo permitió la identificación de las creencias y prácticas que se encuentran en los procesos de cuidado durante la transición del climaterio y la menopausia, en algunas mujeres afrodescendientes residentes en el distrito de aguablanca (da), cali, para reconocer, desde las mismas mujeres, los cuidados que ellas se prodigan, inmersos en el contexto sociocultural donde nacieron, crecieron y aprendieron. el reconocimiento de este proceso facilitará el desarrollo de intervenciones, acompañamientos y cuidados de enfermería contextualizados, posibilitando con ello las modificaciones que el grupo de mujeres esté dispuesto a llevar a cabo. esta investigación se convirtió en una oportunidad de acercamiento al mundo imaginario de un grupo de mujeres provenientes del litoral pacífico, relacionado con el cuidado durante el climaterio y la menopausia en el contexto en que viven las protagonistas. se logró explorar el significado que la mujer afrodescendiente residente en un área urbana marginal de cali tiene con relación a su cuidado durante este periodo de la vida. se identificaron prácticas de cuidado, reconociendo desde ellas lo que hacen con su cuerpo en un momento crucial de sus vidas cuando la fecundidad declina y se aproximan a su última etapa vital: la vejez. marco conceptual algunas concepciones de mujer y etnia en colombia hay aproximadamente 40 millones de habitantes pertenecientes en colombia, un trabajo prospectivo reportó la edad promedio de la llegada de la menopausia así: bogotá, 53 años; barranquilla, 52 años; bucaramanga, 46 años; cali, 52 años y medellín, 57 años 37 climaterio y menopausia en mujeres afrodescendientes: una aproximación al cuidado desde su cultura a distintos grupos étnicos: etnia negra 20%, etnia indígena 5%, mestizos y blancos, el resto. la población negra colombiana situada en el litoral pacífico constituye el 92% de esa población, y es una de las más marginadas del país (14). según estudios del programa del banco interamericano de desarrollo (bid) plan pacífico, referido por barbery y urrea (15), el 38% de la población del valle es afrocolombiana. de esa cifra, solo 10.000 personas tienen acceso a asistencia médica. el mismo estudio puntualiza que cali es la ciudad con mayor población afro en colombia, y la segunda en suramérica después de salvador, capital del estado de bahía, en brasil. el estudio gente negra en colombia (15) señala que el 75% del total de afrodescendientes en cali se encuentran asentados en las comunas 6, 7, 13 14, 15, 16, 18, 20 y 21, pero el corazón histórico de la inserción residencial de quienes llegan de la costa pacífica es primordialmente la comuna 15. algunos autores (16) muestran que la imagen que se tiene de la mujer negra es la de un objeto sexual. los estereotipos culturales que nos han acompañado son portadores de prejuicios raciales que suelen ser negados socialmente. en las prácticas sociales cotidianas se detectan sutiles formas de discriminación, como “pelo quieto”, convirtiendo el ser negro en estigma o discriminación; en el lenguaje corriente lo blanco es equiparado a lo bello, a lo digno, a lo limpio, mientras que lo negro es sinónimo de sucio, feo, malo. con frecuencia los estereotipos asignados a la mujer negra son los de mujer sumisa, lavandera, cocinera, niñera y objeto de ostentación de familia rica (17). en relación con las mujeres negras existen concepciones culturales acerca de su cuerpo, diferentes a las de los cuerpos de mujeres de otras etnias. en el caso concreto de la etnia negra, el cuerpo de la mujer es un objeto hecho para el placer y el disfrute sexual de los hombres. transición y cultura enfermería está comprometida con el proceso y la experiencia de los seres humanos durante sus transiciones. el concepto de transición podría pensarse como congruente o relacionado con conceptos como adaptación, autocuidado y desarrollo del ser humano. la misión de enfermería podría ser redefinida en términos de facilitar o relacionarse con las personas que están pasando por una transición; esta misión refleja su práctica. el término transición ha sido definido como “un pasaje de una fase de la vida, condición o estado a otro” (18). la transición se refiere tanto al proceso como al resultado de las interacciones complejas persona-ambiente. una transición denota un eslabón en el estado de salud, en las relaciones, expectativas y habilidades. en ese sentido, requiere que la persona incorpore un nuevo conocimiento, altere el comportamiento y cambie la definición de sí misma en el contexto social. cualquiera que sea el tipo de transición implica la necesidad, por parte del personal de enfermería, de conocer las creencias y prácticas en cada una de las situaciones transicionales de las personas para ofrecer un cuidado culturalmente congruente. ello implica conocer cómo los seres humanos se adaptan a la transición, y cómo el ambiente afecta esa adaptación. esa importancia se deriva del hecho de que enfermería busca maximizar las fortalezas y los potenciales de las personas para contribuir a su restauración y cualquiera que sea el tipo de transición implica la necesidad, por parte del personal de enfermería, de conocer las creencias y prácticas en cada una de las situaciones transicionales de las personas para ofrecer un cuidado culturalmente congruente. 38 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 optimizar los niveles de salud, su funcionalidad, confort y autorrealización (19). cuidado cultural de enfermería la teoría del cuidado cultural denominada “teoría de la diversidad y universalidad del cuidado” se centra en un estudio comparativo y en el análisis de diferentes culturas en relación con conductas asistenciales, cuidado de enfermería, valores respecto a la salud y enfermedad, creencias y patrones de conducta (20, 21). como aspectos centrales de la teoría se enuncia que el cuidado es esencial para el crecimiento y desarrollo de los seres humanos. los valores, las creencias y las prácticas del cuidado son importantes e influyentes, y los cuidados deben estudiarse para preservarlos y emplearlos como componente esencial para la curación, el bienestar y la supervivencia de las personas y su cultura. las prácticas de cuidado existen en todas las culturas pero sus manifestaciones son diversas; por tanto, si se entienden de forma plena los cuidados se puede predecir el bienestar o la salud de los individuos, las familias o los grupos. determinar las visiones émicas o internas de las personas sobre los cuidados, tal y como éstas los entienden y practican, y estudiar estos conocimientos a la luz de las perspectivas éticas de los enfermeros/as, permite proporcionar unos cuidados que se ajusten a las necesidades y las realidades de las personas. el cuidado desde este referencial es entendido como un conjunto de fenómenos relacionados con la asistencia y las conductas de apoyo y capacitación hacia otros individuos con necesidades reales o potenciales para atenuar o mejorar su situación humana, en este caso, la mujer en la transición del climaterio. metodología para el presente estudio se escogió como metodología la etnoenfermería (22), que se centra en el estudio y la clasificación sistemáticos de las creencias, los valores y la práctica de los cuidados de enfermería, tal y como éstos son conocidos cognitiva o subjetivamente por una determinada cultura a través de su lenguaje local, experiencias, creencias y sistema de valores, respecto a los fenómenos reales o potenciales de la enfermería como son los cuidados, la salud y los factores ambientales. el investigador de enfermería obtiene inductivamente de sus informadores datos sobre relatos descriptivos e interpretativos, documentados sobre la conducta observada y verificada para así identificar la esencia, la naturaleza y los atributos de las conductas cuidadoras y los cuidados terapéuticos de enfermería dentro de una determinada cultura. este método implica la clasificación de los datos de modo que reflejen la visión de las personas. el número de informantes clave en este estudio fue de 17, y se obtuvo aplicando el criterio de saturación de datos que, como leininger indica (22), se alcanza cuando hay una redundancia en la información en la que el investigador consigue la misma o similar información y los informantes no aportan nada diferente a lo dicho o hecho anteriormente. las mujeres afrodescendientes se contactaron de la comunidad del distrito de aguablanca en el hospital carlos holmes trujillo, del programa de atención a la mujer. a través de ellas se contactaron otras mujeres que, aunque no acudían a estos servicios, estaban en la transición del climaterio. estas personas conformaron el grupo de informantes clave. las informantes generales fueron integrantes de las redes sociales de apoyo de la misma comunidad (grupo de la tercera edad), que habían vivido la experiencia de la menopausia y que igualmente pertenecían a la comunidad afrodescendiente procedente de la zona del litoral pacífico residente en este distrito. las informantes generales participaron para contrastar la similitud o diferencia de las ideas de las informantes clave. el trabajo de campo se realizó durante un año simultáneamente con el análisis de la información obtenida. el rigor del estudio (23) se estableció con las personas participantes para conseguir un alto grado de validez en las características recogidas sobre la cultura estudiada, y en las formulaciones teóricas derivadas de los datos analizados confirmándose la credibilidad cuando las participantes reconocieron, en los hallazgos reportados, sus propias experiencias. igualmente, las mujeres afrodescendientes se describieron dentro de su propia perspectiva sobre el climaterio y la menopausia, con los elementos típicos y atípicos. es importante destacar que, al ser el presente estudio una etnografía focalizada, no se considera que sus resultados puedan ser construcciones universales extrapolables a otros escenarios culturales, sino que deben ser entendidos dentro de los límites temporo-espaciales en que se desarrolló la investigación y como generadores de hipótesis para otros estudios. procedimiento para la recolección de la información con el aval del comité de ética humana de la facultad de salud de la universidad del valle, y previo a la recolección 39 climaterio y menopausia en mujeres afrodescendientes: una aproximación al cuidado desde su cultura de la información, se elaboró una guía de información a las participantes que incluyó los principales aspectos del consentimiento informado que deben considerarse desde el punto de vista ético. para la recolección de los datos se siguió el modelo opr (observación, participación, reflexión) propuesto por leininger. se inició escuchando y observando la mayor parte del tiempo, captando sólo la impresión general de las mujeres que asisten al programa “atención a la mujer” sobre el tema de la menopausia; después se dio la interacción con las personas a través de entrevistas en profundidad. posteriormente, en un tercer momento, cuando se había logrado mayor familiaridad con las participantes, se empezó a aprender de las mujeres y, a partir de estas vivencias, a describir, explicar y documentar lo que ocurre en la menopausia. al final del proceso de observación reflexiva se reconfirmaron los hallazgos con las participantes. además de la información obtenida a través de las entrevistas, la observación fue relevante puesto que muchas veces en la entrevista no se podía detectar toda la información necesaria y la observación contribuyó de manera eficaz a precisar mejor el verdadero sentido de las palabras (24). también se tomaron notas de campo pormenorizadas en el mismo escenario. para compartir y sumergirse en el mundo de las mujeres, las investigadoras trataron de responder las preguntas de dónde, cuándo, cómo y por qué las mujeres afrodescendientes se cuidan durante la menopausia, y de establecer cómo es la relación con los servicios de nivel primario en cuanto a la búsqueda de apoyo para el cuidado de su salud durante esta etapa. análisis de la información los datos para la presente investigación se analizaron desde el momento mismo de la recolección de la información siguiendo el método de spradley (25), y teniendo en cuenta las cuatro grandes fases que leininger propone para el análisis de las investigaciones de tipo cualitativo. en la primera de ellas se recolectaron, registraron y describieron los datos. durante esta etapa se hicieron las observaciones, entrevistas y experiencias participativas, y algunas interpretaciones preliminares. durante la segunda fase se inició la identificación de dominios desde la perspectiva émica. en la tercera fase se elaboraron las preguntas de contraste que permitieron la identificación de taxonomías a través de las cuales se pudo encontrar la saturación de ideas y patrones recurrentes y, finalmente, en la cuarta fase se delimitaron los grandes temas. los datos fueron presentados a las informantes en las diferentes fases, con el fin de asegurar que lo descrito correspondía a la visión que ellas tenían respecto a la menopausia. descripción de la cultura mientras el bus avanza por la carretera, y el sol se va ocultando detrás de las montañas como si ya fuera la hora de descansar, ella recorre con su mirada ese paisaje del camino de regreso, el mismo que emprendió muchos años atrás cuando aún siendo adolescente dejó su litoral pacífico para ir a buscar nuevas y mejores oportunidades en la ciudad. sonríe para sí misma al pensar que, finalmente, esta etapa de la vida que está empezando la emprenderá con las mejores condiciones de salud, gracias a los cuidados que tuvo siempre, desde la aparición de su primera menstruación, siguiendo todas las recoal ser el presente estudio una etnografía focalizada, no se considera que sus resultados puedan ser construcciones universales extrapolables a otros escenarios culturales, sino que deben ser entendidos dentro de los límites temporo-espaciales en que se desarrolló la investigación y como generadores de hipótesis para otros estudios. 40 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 mendaciones que le dieron en su momento las tías y su madre. rememora sus primeros recuerdos, cuando le “llegó la sangre” y apareció la fuerza sexual como un imán, y luego a través de la vida siempre supo cuándo iba a llegarle el “sangrado mensual” porque le daban más deseos del compañero con el que estuviera; esa sangre caliente que llegaba con fuerza, como la vida misma, y que le hacía desear tanto a su pareja. en este momento de su vida, cuando “el sangrado mensual” ya no le viene, sus hijos ya han crecido y ya no desea como antes a su compañero, empieza a sentir el cansancio de los años vividos, tiene sentimientos de soledad y de inutilidad, y siente que esta etapa es la más dura de su vida. este relato intenta hacer una semblanza del proceso que, a través de la vida, llevan a cabo algunas mujeres afrodescendientes residentes en el da, y a través del cual se preparan para su función procreactiva y para la aparición de la menopausia. adicionalmente, durante el proceso que se describe más adelante se muestra la relación de las mujeres con su cuerpo, y cómo desarrollan las prácticas de cuidado. sus vivencias y los cuidados que se prodigan configuran una cadena de prácticas iniciadas desde el mismo momento de la menarquia, y se prolongan durante el embarazo y el posparto donde enfatizan en cuidar el cuerpo y tener un hijo sano. la consecuencia de no observar con dedicación y cautela estas tradiciones propias de la cultura consiste en que la mujer puede llegar a padecer dolencias durante la etapa final de su periodo procreativo. para las mujeres del da, la menopausia es solo una etapa de la vida que se asume como tal y se enfrenta con la serenidad inconsciente de quienes saben esto ancestralmente y han seguido de manera juiciosa las prácticas de cuidado necesarias a través de la vida que les garantizan, de alguna manera, que su aparición se encuentra lejos de ser un momento traumático, sino uno que viven sencillamente como lo que es: parte del proceso de la vida. al analizar las concepciones de cuidado en este periodo de la vida se encuentra que algunas de ellas se repiten a lo largo de las diferentes etapas del periodo procreativo como son el significado de la sangre, la limpieza, la alimentación especial y la dicotomía calor-frío (12). no considerar los cuidados en relación con las concepciones indicadas puede predisponer para que en la mujer aparezcan enfermedades. el siguiente relato de una de las mujeres entrevistadas ilustra este aspecto: uno no se cuida cuando está con el periodo, cuando se moja la ropa lavando y eso, el cuerpo lo va absorbiendo y se llena de frío el vientre. pues, como le digo, cuando tenía el periodo yo sentía cólico bajito, una orinadera y ardor también. ese frío, imagínese, me decían las mujeres, las señoras mayores de mi, pongamos mi abuela, mi mamá, que a las mujeres les atacaban esas enfermedades. igual sucede si uno no se cuida en los partos, y entonces cuando ya llega el tiempo de la menopausia está descontrolada, mejor dicho, no está el cuerpo bien, ya está enferma uno. de otra parte, el cuidado de sí mismas encierra una serie de procedimientos que no se circunscriben de manera exclusiva al cuidado del cuerpo físico, sino que incluyen medidas para su entorno familiar inmediato, considerando conductas apropiadas según el conocimiento de sus tradiciones, y que no se dan al llegar la menopausia sino, como se indicó, durante toda la vida como un camino que recorren para las mujeres del distrito de aguablanca, la menopausia es solo una etapa de la vida que se asume como tal y se enfrenta con la serenidad inconsciente de quienes saben esto ancestralmente y han seguido de manera juiciosa las prácticas de cuidado necesarias. 41 climaterio y menopausia en mujeres afrodescendientes: una aproximación al cuidado desde su cultura a través de los años y que se inicia con la aparición de la menstruación. describamos el camino. la primera menstruación la llegada de la menstruación, como en casi todas las culturas, es la entrada formal a la sexualidad y a todo lo que gira alrededor de ella, es decir, la actividad sexual, la maternidad y su cierre final con la llegada de la menopausia. la menstruación se hizo símbolo de la transformación de niña en mujer, celebrado de distintos modos según las épocas y los lugares, pero con un único significado real: “ya puedes ser madre”, y la consiguiente orden o prohibición: “ten cuidado, no te vayas a embarazar”, y en algunos casos, enmarcada con tabúes y prohibiciones creando un concepto confuso y vergonzante de una realidad. en la cultura tradicional de las mujeres afrodescendientes entrevistadas, las menstruaciones son sinónimo de enfermedad, “cuando estoy menstruando estoy enferma”, y los cambios físicos y emocionales que ocurren en ella son transmitidos como algo negativo “produce dolor bajito, dolor de cabeza, se botan coágulos, la mujer se siente sucia”. en general, en algunas culturas se han encontrado varias prohibiciones relacionadas con el sangrado menstrual como aquellas que prescriben el aislamiento de la mujer menstruante, las que proscriben las relaciones sexuales en este periodo, las que impiden preparar alimentos, sobre todo para sus parejas (26). es de resaltar que las mujeres afrodescendientes del da entrevistadas describen la menstruación como la llegada de la sangre caliente que representa “la naturaleza viva” y el despertar del deseo sexual por el compañero. explican que previo a la llegada del periodo menstrual o, como lo expresan ellas, antes del tiempo de “enfermar”, llega la “caloría”; la sangre comienza a trabajar más fuerte, lo que puede ocasionar además del deseo sexual, dolor de cabeza y “dolor bajito”, reiterando lo que expresa arriaga (27) respecto a la sexualidad y virilidad del negro, que es considerada como valor cultural diferente del erotismo, y que hace parte de aquellas fantasías que él mismo creía. se refiere al mito o creencia de la fortaleza viril del negro, como de un “macho cabrío”, y a la “fogosidad de la hembra” a la que se le considera ardiente en la cama. sus prominentes y bien formadas nalgas, sus senos voluptuosos, con sus humores y olores propios de la raza negra, lo mismo que el color de su piel, se los considera como afrodisíacos o excitantes del amor. de otra parte, la menstruación le permite a la mujer tener esa sensación de desahogo, y cuando ésta pasa, quedar más fría y menos deseosa. el sangrar en la menstruación significa esa fuerza sexual que es “como un imán”, como lo comenta una de las mujeres entrevistadas: “cuando la mujer no menstrua pierde fuerza; si no hay fuerza, pierde como atracción porque la sangre es como un imán que trae mucho la parte sexual”. es precisamente esa fuerza o imán la que se pierde con la llegada de la menopausia, reiterando los hallazgos de esta investigación en el sentido de que la salud de la mujer en la menopausia y, consecuentemente, los cuidados que deben prodigarse en esta etapa no son aislados sino una consecuencia de las otras etapas de la vida procreativa. los cuidados durante la menstruación giran alrededor de dos aspectos fundamentales: la dieta, que incluye lo que toman y lo que comen, y los cuidados de su cuerpo. en la cultura tradicional de las mujeres afrodescendientes entrevistadas, las menstruaciones son sinónimo de enfermedad. 42 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 lo que toman y lo que comen mantener horarios ordenados con las comidas es la primera medida que observan. durante el sangrado menstrual no se deben tomar bebidas gaseosas ni heladas. las mujeres consideran prudente evitar el consumo de frutas ácidas o agrias, tales como guayaba, piña, naranja o maracuyá, ya que la ingestión de este tipo de frutas “aguan” la sangre y, por tanto, puede llegar a producir anemia al volver la sangre más líquida. las personas afrodescendientes basan buena parte de su dieta en el consumo de productos del mar como pescados y crustáceos, por ello el consumo de cierto tipo de pescados como el atún, el mero, el gualojo y el chimbi deben evitarse ya que oscurecen la sangre, poniéndola negra y, adicionalmente, dándole mal olor, es “hedionda”. tampoco deben consumirse harinas, alimentos fritos o huevo. cuidado del cuerpo durante el sangrado menstrual durante el sangrado menstrual evitan alzar o levantar objetos pesados, y también posponen la asistencia a las citas odontológicas si éstas coinciden con la menstruación. no recomiendan mojarse, y evitan que el vientre “coja frío”, ya que esto puede causar cólicos, tampoco deben fumar durante la llegada de la sangre. además de estos cuidados que mantienen para sí mismas, cada mes, desde la aparición de la primera menstruación y a través de toda la vida, establecen unas rutinas de cuidados ligeramente diferentes durante los embarazos; estos procedimientos y rituales de cuidado se diversifican incluyendo normas o medidas de cuidado dirigidas a garantizar el bienestar las mujeres consideran prudente evitar el consumo de frutas ácidas o agrias, tales como guayaba, piña, naranja o maracuyá, ya que la ingestión de este tipo de frutas “aguan” la sangre y, por tanto, puede llegar a producir anemia al volver la sangre más líquida. para el nuevo ser que va a nacer; por tanto, en los embarazos hay cuidados alrededor de sus propios cuerpos pero también orientados a procurar las mejores condiciones para el nacimiento de su hijo. sin embargo, lo más sobresaliente y lo que vamos a resaltar en esta ocasión, son los cuidados en el posparto que, de acuerdo con sus creencias, les garantizan una menopausia tranquila y sin problemas, unidos por supuesto a los cuidados mantenidos durante la menstruación. cuidado del cuerpo durante el embarazo y el parto para las mujeres del da, el embarazo representa la retención de la sangre y su fuerza vital durante los nueve meses que dura la gestación, y esto hace que una buena parte de los cuidados en esta etapa estén dirigidos a la recuperación de las condiciones de salud que presentaba el cuerpo antes de estar en embarazo. así, en el posparto las mujeres realizan unas acciones de cuidado que pueden clasificarse de la siguiente manera, según sea su característica primordial: infusiones, comidas, su propio cuerpo, y con su compañero. los significados de bienestar y malestar que tienen los alimentos desde una concepción cultural en la mujer en su condición de gestante, son quizás los eventos de mayor representación del papel de la cultura. infusiones: las prácticas alrededor de las infusiones o bebedizos5 que aconsejan ingerir las mujeres afrodescendien5 infusión: bebida de plantas medicinales que se utilizan para mantener del bienestar o para tratar algunas dolencias. en el bebedizo se mezcla la bebida de planta medicinal con otros ingredientes como el aguardiente, y el azufre. 43 climaterio y menopausia en mujeres afrodescendientes: una aproximación al cuidado desde su cultura tes después del parto, y que les permiten anticipar el cuidado durante la menopausia garantizándoles llegar sin dolencias y “completas”, están dirigidas a generar un proceso de limpieza de la matriz y la vagina que sufren alteraciones y deterioros después del parto, y a evitar algunos malestares y consecuencias negativas, que en sus creencias culturales no deben permitirse y que pueden prevenirse. así, estas infusiones muestran la primera preocupación y el primer cuidado en el posparto para sacar del cuerpo o ayudarlo a expulsar los residuos de sangre y coágulos que quedan en los órganos internos femeninos después de vivir el embarazo y el parto. para ellas, la sangre retenida en nueve meses debe botarse y hacerse una “purga” que, como en el puerperio, les permita la expulsión de los coágulos. la bebida preferida y la más recomendada es la de nacedera y también la de azufre, consumidos en una especie de bebedizo mezclado con aguardiente, y al que le atribuyen no solo sus bondades para eliminar los coágulos y los residuos de sangre, sino para ayudarles a prevenir la formación de gases y la penetración de vientos y frío en el cuerpo. aun cuando puede haber un tercer ingrediente para este importante bebedizo, siempre aparecen la nacedera y el azufre; así, puede ser una infusión de solo nacedera, como puede también venir unida al azufre y al aguardiente como bebedizo. para otro grupo de mujeres lo ideal es nacedera, azufre y pimienta en agua de hierbabuena que limpia el frío del vientre y la vagina. esta limpieza la denominan “purga”; de no poder llevar a cabo esa purga, recomiendan tomar el “purgato”, que es la mezcla de tres aceites (castor, almendra y cocina) en agua de manzanilla. el “purgato” garantiza la limpieza de todos los cuidados en el posparto les garantizan una menopausia tranquila y sin problemas, unidos por supuesto a los cuidados mantenidos durante la menstruación. los órganos femeninos: matriz y vagina, que no han logrado su total limpieza con los otros bebedizos, y que durante el embarazo quedan muy comprometidos. a los bebedizos de azufre también le atribuyen beneficios preventivos contra la generación de gases y la penetración de frío, y sirven como barrera que impide la formación de “entuertos”. para muchas de ellas el azufre, en un bebedizo con aguardiente, ayuda a evitar las hemorragias en el posparto. con el fin de evitar el frío y los entuertos también recomiendan tomar un bebedizo de aguardiente, azufre y panela quemada; así lo manifestó una informante: el aguardiente es un elemento caliente y, combinado con el azufre también caliente aumentan el calor en el cuerpo y contrarrestan el frío que entra a la matriz ayudando a que salgan los coágulos de sangre que se acumulan después del parto; también sirve para evitar los gases. en el estómago hay mucho viento cuando la mujer está parida por eso se tapan los oídos con el algodón y por la mañana se toman ese bebedizo que es como un cuidado para el resto del día, como un protector. la descripción anterior es similar a los hallazgos de otro estudio realizado en cali en el cual se encontró que adolescentes de una comunidad urbano-marginal perciben que el cuerpo se abre y es vulnerable a la entrada de frío. en el puerperio continúa la entrada del mismo a través de los poros, la vagina, la cabeza y los oídos, y puede producir en la mujer desde leves malestares hasta dolencias mayores (13). para otro grupo de mujeres lo ideal es tomar un bebedizo de borraja con manzanilla y mezclarlas con panela y quinua, que es una semilla; otra infusión es la elaborada con agua de trébol con ruda, clavos 44 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 las prácticas alrededor de las infusiones o bebedizos que aconsejan ingerir las mujeres afrodescendientes después del parto, y que les permiten anticipar el cuidado durante la menopausia garantizándoles llegar sin dolencias y “completas”, están dirigidas a generar un proceso de limpieza de la matriz y la vagina que sufren alteraciones y deterioros después del parto. y canela, o alguna otra hecha con agua de comino molido por siete días consecutivos, que según ellas, garantiza la expulsión de los “troncos” de sangre; otras mujeres prefieren tomar una copa de aguardiente por quince días seguidos para hacerse la “purga”. las prácticas alrededor del consumo de infusiones y brebajes (28) reafirman el legado cultural de las costumbres africanas en las tradiciones de las mujeres afrodescendientes para el cuidado de la salud en el sentido de que son vitalistas, existencialistas, panteístas y espiritualistas, y de ninguna manera materialistas. lo que comen: las recomendaciones se orientan en los dos sentidos, las que benefician el proceso de recuperación y aquellas que deben evitarse por el daño que ocasionan. el consumo de algunos pescados o alimentos de mar, tales como los mariscos, el “pescado barbudo” –al que se le atribuyen invaluables beneficios como el fósforo y el calcio–, o el “pescado cubo”, son altamente recomendados. otros alimentos con alto valor proteínico como las “carnes de monte” (carne de animales salvajes) y la gallina son de alta estima para estas mujeres. otras recomendaron el consumo de una mezcla de champiñones tostados y revueltos en aguardiente. también previnieron sobre la necesidad de evitar el consumo de pescados “sangrinos” como el curel, el toyo, el curere o sangrino, ya que por tratarse de pescados de “carne negra” y aguas profundas son peces de mayor tamaño que pueden atacar y comerse al hombre, y además pueden producir hemorragias y la inflamación de la matriz en los cuarenta días iniciales. al igual que las infusiones y las comidas constituyen el primer círculo de recomendaciones para el cuidado de sí mismas, estas mujeres realizan una serie de procedimientos para ayudar al cuerpo a recuperarse después de un embarazo y un parto. por esto, recomiendan no bañarse los primeros días para evitar que el cuerpo coja frío y para permitir la reacomodación de los órganos femeninos internos que se han desplazado con el embarazo. recomiendan guardar algo de reposo, no levantarse precozmente de la cama, esperando los primeros tres días a que el cuerpo se reponga ligeramente del proceso físico que le significa el parto. una vez pasado este lapso deben aplicarse, durante cuarenta días seguidos, “pringues” o lavados vaginales como los de malva o los de chirara u otras hierbas, por un largo periodo de tiempo (más de un mes mínimo). “hasta para bañarse uno tiene que coger yerbas como la nacedera y el barejón, ponerse así en el sol con agua hervida, cernirlas y ahora sí bañarse adentro”. cuidados en la relación sexual con el compañero la sexualidad en la familia negra del litoral pacífico colombiano tiene normas familiares y sociales; se tiene derecho a ella cuando se establecen relaciones económicas, y son clandestinas hasta que aparezca el hecho de un embarazo que es cuando se adquiere un compromiso con la familia y con el pueblo (29). la recomendación en relación con este tópico es que durante el puerperio no se debe dormir con el compañero, a fin de evitar que se lastime la matriz y que se produzcan enfermedades. 45 climaterio y menopausia en mujeres afrodescendientes: una aproximación al cuidado desde su cultura uno dormía sola en su cama, tenía su bebé, a veces hasta los dos meses estaba durmiendo por fuera, el marido dormía por allá si, porque ¡ay pué!… ¡la tentación allí junto, imagínese!… usted sabe que el hombre es hombre y la mujer es mujer, sobajándolo y eso… hay puede pasar algo, puede sufrir de algo en la matriz, como uno está fresquito le pueden lastimar la matriz, de ahí vienen las enfermedades. con los cuidados que llevan a cabo las mujeres a través de la vida, y que abarcan las etapas de su vida sexual y reproductiva, ellas se preparan para la llegada de la menopausia. en este periodo también tienen algunas recomendaciones sobre el cuidado de sí mismas, pero es evidente que la garantía de la llegada de una menopausia que no implique traumas y un deterioro corporal importante, no está determinada por los cuidados de salud en ese periodo específicamente, sino que empiezan desde la llegada de la menstruación y se prolongan durante toda la vida, como quien recorre un camino minuciosa y metódicamente. llegar al final: finalización del sangrado menstrual al respecto, las mujeres afrodescendientes entrevistadas atribuyen a la menopausia una serie de características que se relacionan con tres aspectos esencialmente: las que corresponden a los cambios de su cuerpo, las que están relacionadas con su comportamiento emocional, y las que implican a su vida y expectativas de índole sexual. sentir la profundidad de los cambios en la vida: el cuerpo la primera característica mencionada es que con la llegada de la menopausia se produce una disminución de la capacidad de trabajo como consecuencia de que “la naturaleza se va”, desencadenando una serie de dolencias6 que cambian la vida, puesto que según sus afirmaciones, hay menos vitalidad. muchas de las mujeres entrevistadas hicieron referencia a un “cansancio notorio”, a una sensación de “flojera”, que les había aparecido con la menopausia. pero los cambios en su vida no solo se evidencian en la disminución de la capacidad de trabajo, sino que al tener más edad, las mujeres perciben la dureza del trato de una sociedad que no les da oportunidad de trabajar. pero no es la sensación de tener menos posibilidades de trabajo la única característica de la menopausia que ellas constatan en su cuerpo sino que, por el contrario, le adjudican una extensa lista de “dolencias” que clasificamos en dos tipos: las que se refieren al cuerpo en general, y las que se localizan en algún lugar de él. la dolencia más frecuentemente sentida por estas mujeres, y que se manifiesta como molestia generalizada es el frío en todo el cuerpo, contrastando con sus creencias de que en cualquier periodo de su vida hay que evitar la entrada del frío. unida a esta sensación aparece la de escalofrío, en contraste con la molestia más común de la menopausia expresada por las mujeres de cualquier cultura, que son los calores. otra dolencia relacionada en esta categoría es el resquebrajamiento o la debilidad de los huesos, que les trae como consecuencia una limitación en sus movimientos y fragilidad en su cuerpo. sin embargo, la acepción más común del término fragilidad para estas mujeres es un aumento en la sensibilidad y un estado de tristeza. las dolencias físicas localizadas, mencionadas con mayor frecuencia, fueron: dolor de cabeza, dolor en las piernas y las rodillas, asociadas con oleadas de calor. igualmente, refirieron calambres y la aparición de várices. otra molestia física es la resequedad en la piel y en la matriz (“sangrados, dolores bajitos y tumores”) que algunas mencionaron como síntoma definitivo de la menopausia. también se mencionó una cierta opacidad en la vista. sentir los cambios con el estado de ánimo esta categoría de cambios en el estado de ánimo surgidos durante la menopausia se relaciona con los cambios en el cuerpo, así como con los que son consecuencia de las dificultades asociadas al entorno. algunas expresaron su desencanto por la imposibilidad de ser escuchadas por los jóvenes, especialmente por las hijas. esta sensación en sí misma podría no resultar tan importante sino fuera porque va relacionada con una clara sensación de desamparo, casi de desprotección. reconocen que el hecho de llegar a los cincuenta años las hace más “prevenidas, más maduras”, porque la mujer “es más pensante” y toma conciencia de su salud. sin embargo, algunas mujeres opinaron que estas características las limitan en otras formas de expresión, como en su forma de vestir, la apariencia personal y las relaciones sociales. la sociedad lo trata duro a uno por eso digo que es duro, porque va uno a buscar 6 dolencias: todos aquellos cambios que están en el cuerpo de manera permanente y no requieren o no se tratan con droga. 46 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 un trabajo, que está consciente que si lo va a desempeñar no le dan el trabajo a uno, con decir uno que tiene cincuenta años, es una etapa dura, porque uno es capaz de hacer las cosas y no lo dejan. si uno va a buscar una ropa, eso no es para ti porque ya tienes cincuenta años, qué te vas a meter en eso. no usted ya está vieja para eso… como comprar un par de zapatos que usan las peladitas para hacer ejercicio, no esa vieja que se va a meter en eso, vea esa vieja que va ahí… entonces es una etapa dura. los otros síntomas emocionales asociados a su propio sentir fueron: cambios en el estado de ánimo, que en ocasiones les generaba “irritabilidad”, y en algunos momentos podía llegar a convertirse en verdadero “mal humor”. también, y dentro de esta misma categoría de sensaciones, mencionaron la “tristeza”, unas “ganas de llorar” sin razón, gran “sensibilidad” y la sensación de “estar acuchada”, o “arrinconada”. cierto nerviosismo sin motivo evidente que en ocasiones puede llegar a producir insomnio; algunas de ellas anotaron una pérdida de memoria como consecuencia de la menopausia. en aquellas mujeres para quienes la maternidad ha sido la actividad de mayor reafirmación narcisista, el crecimiento e independencia de los hijos y la llegada de la menopausia, entendida como el fin de su vida reproductora, las empuja a situaciones depresivas porque se pierden tanto las actividades como los objetos del sistema narcisista. les queda la salida de reiniciar el ciclo como abuelas si sus hijas las dejan. me he vuelto floja, la tristeza, el mal humor que a veces me dan ganas de llorar o de pelear con algún inocente que se cruce en mi camino. a uno los hijos… uno les da consejo y echan el consejo al tarro de la basura; entonces a uno le da tristeza y se deprime mucho al ver que lo que uno dice no lo aprecian. vivencia de la sexualidad al desaparecer la menstruación también se eclipsa la “naturaleza viva”, esa que apareció con la llegada de la misma y, por tanto, ya no se siente lo mismo que cuando se tenía la menstruación. desaparece el apetito sexual y por eso, como lo manifestaron varias informantes: se quita el imán que atrae la parte sexual; ya no se siente la misma emoción y como no tiene la misma caloría, no tiene el cuerpo para aceptar al hombre o no lo tiene dispuesto para estar a todas horas por lo que se debe huir del marido, puesto que no le corresponde hacerle el amor. como hemos visto en todo el proceso de las manifestaciones de inicio de la vida sexual de la mujer, que incluye no solo la vida sexual en pareja, sino el embarazo y la llegada mensual de la menstruación con sus respectivos cuidados de salud, con la llegada de la menopausia también se establecen una serie de acciones de cuidado que, como en la menstruación y en el posparto, dividiremos en infusiones, comidas y cuidados para su cuerpo. lo que toman y lo que comen durante la menopausia infusiones: están orientadas a tres aspectos básicos, las de carácter preventivo, las que ayudan a aliviar las dolencias de índole física y las que se dirigen a mejorar las sensaciones emocionales. las infusiones preventivas se hacen de algunas plantas tales como el agua de nacedera, desbaratadora o desvanecedora, que evita los “dolores bajitos”, las inflamaciones, “los tumores” y el “coraje” o mal genio. también recomiendan tomar leche de soya para evitar el “descalcificamiento”, al igual que el yingo biloba, consumo motivado mediante publicidad radial. las infusiones que ayudan a aliviar las dolencias físicas son hierbas de plantas como agua de manzanilla, hierbabuena o caléndula. el agua de linaza combate los calores, la de caléndula alivia la inflamación, la de nacedera también ayuda a disminuir el sobrepeso que se ocasiona con la menopausia. las que les permiten mejorar su estado anímico y que combaten el desaliento emocional son: agua de toronjil, de hierbabuena o de manzanilla. cualquiera de ellas sirve contra la depresión. comidas: los cuidados en este aspecto están dirigidos hacia lo que se recomienda comer para ayudar a la mujer en la transición del climaterio, y aquellos que no aconsejan por las desventajas y los daños que pueden ocasionar. son muy elogiadas las verduras, el consumo de brócoli y ajo, al igual que se aconseja el consumo de plátano y pescado, dieta que tradicionalmente consumen las mujeres en el litoral pacífico. el consumo de mariscos y de pescados que ayudan a evitar las hemorragias y los “cálculos en la matriz”. el cuidado de la matriz evita que la extraigan ya que, según ellas, la mujer debe mantenerse siempre completa. el pescado curere, tan elogiado durante las menstruaciones y los pospartos para disminuir los sangrados, en la menopausia también se aconseja para controlar el aumento de peso. los que no recomiendan son: tilapia, colombina o burique, ya que aumentan el sangrado porque “cortan 47 climaterio y menopausia en mujeres afrodescendientes: una aproximación al cuidado desde su cultura la sangre”, la vuelven hilachosa. estos son los mismos pescados que retiran de sus dietas cuando las mujeres presentan irregularidades en las menstruaciones. entre las comidas que no se recomiendan están: las irritantes, fritos, harinas, bebidas gaseosas ni bebidas alcohólicas para evitar “engordar”. igualmente, mantienen el mito de no consumir las frutas ácidas como la naranja o el mango biche porque se incrementan las molestias y el sangrado. cuidado del cuerpo durante la menopausia a diferencia de las recomendaciones en los pospartos y las menstruaciones, en las que se aconseja de manera clara el no bañarse, en la menopausia se aconseja hacerlo con frecuencia y varias veces al día, con el fin de extremar las condiciones de aseo. aconsejan echarse en la cabeza agua serenada con flores cresta de gallo para ayudar a bajar la temperatura, es decir, dejar el agua por una noche a la intemperie para luego, en la mañana, usarla a fin de disminuir los calores. se deben mantener horarios fijos para las comidas y, en lo posible, comer junto con la familia y dedicarse a los trabajos del hogar, evitar la promiscuidad sexual y las caídas por el debilitamiento debido que como los huesos se ponen débiles, pueden “desboronarse”; es necesario hacer ejercicio para evitar el cáncer en los huesos. también se recomienda dormir en ropa interior para ayudar con los calores, al igual que untarse pomadas como de caléndula. no aconsejan el consumo de hormonas por las consecuencias dañinas que les atribuyen, como los “pelos en la cara y en los senos”, al igual que el riesgo de un ataque al corazón. conclusiones los cuidados que las mujeres del litoral pacífico dispensan a sus cuerpos durante la menopausia van dirigidos no tanto a la obtención de admiración por los otros, como a la conservación de unas condiciones de salud que les garanticen un “buen vivir” y una buena menopausia. en ese sentido, el cuerpo es imagen y es símbolo que permite constructividad, que deja realizar clasificaciones como las encontradas en el presente estudio, en el cual se evidenció que, a pesar de que la naturaleza viva se va, la mujer se vuelve más pensante. de otra parte, la atención para sí mismas encierra una serie de cuidados que no se circunscriben solo al cuerpo, sino que adicionalmente incluyen medidas para su entorno familiar inmediato, considerando conductas apropiadas según el conocimiento de sus tradiciones, y que no se dan al llegar a la menopausia sino durante toda la vida como un camino que recorren a través de los años y que se inicia con la aparición de la menstruación. el significado que tiene el cuidado que las mujeres afrodescendientes se prodigan durante el climaterio y la menopausia debe entenderse como provisional, ya que depende del dinamismo entre ellas y entre su estructura social. no obstante, es importante resaltar que estos hallazgos proveen una base epistémica para futuras investigaciones que consideren el entorno cultural y la forma como los profesionales de enfermería pueden abordar el cuidado para que sea congruente con la visión de mundo de las personas. los cuidados que las mujeres del litoral pacífico dispensan a sus cuerpos durante la menopausia van dirigidos no tanto a la obtención de admiración por los otros, como a la conservación de unas condiciones de salud que les garanticen un “buen vivir” y una buena menopausia. 48 año 8 vol. 8 nº 1 chía, colombia abril 2008 aquichan issn 1657-5997 referencias 1. roa r, regueiro a. manejo integral del climaterio. abordaje diagnóstico terapéutico. programa iberoamericano de actualización continua en medicina familiar. bogotá: cilag janssen; 2003. p. 179-182. 2. penagos gs. vivencias de la sexualidad en la menopausia: concepciones históricas sociales y médicas sobre la menopausia. rev col de menop 1996; 2 (1). disponible en: www.encolombia.com/comite. htm [fecha de consulta abril 4 de 2006]. 3. gonzález d. aspectos bio-psico-social-familiares del climaterio. rev col de menop 1996; 2 (1). disponible en: www.encolombia.com/comite.htm [fecha de consulta mayo 5 de 2006]. 4. best k. los múltiples significados de la menopausia. network en español. 2002; 22 (1). disponible en: www.fho.org [fecha de consulta abril 10 de 2006]. 5. onatra w. epidemiología de la menopausia en colombia. estudio cooperativo. rev col de obs gin 1994; 45 (4): 20-28. 6. monterrosa a, barrios j, bello am. conocimientos y creencias sobre menopausia en mujeres mayores de 40 años de edad, naturales del palenque de san basilio, bolívar. rev col de menop; 2006. disponible en: http://encolombia.com/conocimientos1_ meno5-1.htm [fecha de consulta abril de 2006]. 7. sánchez f, álvarez r. vivir con plenitud y calidad en la madurez de la vida. rev col de menop 1997; 3 (1). disponible en: www.encolombia.com/comite. htm [fecha de consulta enero 15 de 2006]. 8. sánchez f. terapia de sustitución hormonal, cíclica y oral. rev col de menop 1998; 4 (2). disponible en www.encolombia.com/comite.htm [fecha de consulta enero 20 de 2006]. 9. monterrosa a, barón g, gómez g. pronunciamiento de la asociación colombiana de menopausia respecto al uso de terapia hormonal en la menopausia. rev col de menop 2004; 10 (4). disponible en: www.encolombia.com/comite.htm [fecha de consulta febrero 20 de 2006]. 10. vásquez ml. significado da regulação da fecundidade numa comunidade urbano marginal. florianópolis: editora da ufsc; 2001. 11. argote la, vásquez ml. ante la desesperanza del desplazamiento: un hijo sano el mayor anhelo de la mujer gestante. colomb med 2007; 38 (supl 2): 27-43. 12. argote la, vásquez, ml. “la dieta” como camino para asegurar un hijo sano: una mirada desde el mundo urbano de las adolescentes. colomb med 2005; 36 (supl 2): 58-64. 13. argote la, bejarano nl, ruiz ch, muñoz l, vásquez ml. transitando la adolescencia por el puerperio: amenazas, peligros y acciones de protección durante la dieta. rev. aquichan 2004; 4: 18-29. disponible en: http://aquichan.unisabana.edu.co [fecha de consulta diciembre de 2005]. 14. barbery o, urrea f. la población negra en la colombia de hoy: dinámicas sociodemográficas, culturales y políticas. rev estudos afro-asiáticos 2003; 25 (1): 9-21. disponible en: www.scielo.br/pdf/eaa/ v25n1/a02v25n1.pdf. [fecha de consulta febrero de 2006]. 15. barbery o, urrea f. gente negra en colombia. dinámicas sociopolíticas en cali y el pacífico. cali: cidse/ universidad del valle. editorial lealon; 2004. p. 181. 16. ramírez s. asumir la negritud. informe del primer encuentro de mujeres negras de latinoamérica y del caribe. santo domingo. agosto de 1992. revista especial/fempres. p. 43. 17. arriaga l. cátedra de estudios afrocolombianos. bogotá: igasa ingenieros gráficos andinos sa; 2002. p. 321. 18. meleis a. theoretical nursing: development & progress. philadelphia: lippincott; 1997. p. 665. 19. chick n, meleis a. transitions: a nursing concern. in: chinn pl, editor. nursing research methodology. boulder, co: aspen; 1986. 20. leininger m. culture care diversity and universality: a theory of nursing. new york: national league for nursing press; 1991. 21. leininger m. transcultural nursing: concepts, theories and practices. new york: john wiley and sons; 1978. 22. leininger m. ethnography and ethno nursing: models and modes of qualitative data analysis. in: leininger m, editor. qualitative research methods in nursing. orlando fl: grune & stratton; 1985. p. 33-75. 23. castillo e, vásquez ml. el rigor metodológico en la investigación cualitativa. rev colomb méd 2003; 34 (3): 164-167. 49 climaterio y menopausia en mujeres afrodescendientes: una aproximación al cuidado desde su cultura 24. spradley j. participant observation. orlando: library of congress; 1980. 25. spradley j. the ethnographic interview. orlando: library congress; 1991. 26. alarcón m. algunas consideraciones antropológicas y religiosas alrededor de la menstruación. rev col de obs y gin, 2005; 56 (1): 35-45. 27. arriaga l. cátedra de estudios afro colombianos. cali: igasa-ingenieros gráficos andinos s.a.; 2002. p. 92-93. 28. yoon s, horne c, adams c. herbal product use by african american older women. clinical nursing research 2004; 13 (4). pp. 271-288. 29. ceballos d. la familia negra del litoral pacífico colombiano. un mundo palpitante, una familia universal. cali: universidad del valle; 1995. p. 114-115. 7 lorena chaparro1 cómo se constituye el “vínculo especial” de cuidado entre la persona con enfermedad crónica y el cuidador familiar 1 doctora en enfermería. profesora asistente. universidad nacional de colombia, bogotá. olchaparrod@unal.edu.co recibido: 06 de septiembre de 2010 aceptado: 23 de marzo de 2011 resumen la formación de vínculos en el ser humano tiene su origen en las relaciones de cuidado existentes a lo largo de la vida. existen teorías que aplican para las situaciones en que el ser humano se encuentra en riesgo o al límite como la situación de enfermedad crónica. objetivo: describir la forma como se constituye el “vínculo especial” de cuidado entre la díada cuidador familiar-persona con enfermedad crónica. método: corresponde a la conclusión central de una investigación cualitativa en la que se construyó una teoría sustantiva que describe el proceso por el cual se constituye el “vínculo especial” que surgió con un abordaje de teoría fundamentada. hallazgos: una estructura teórica que muestra el patrón construido en las díadas frente al significado del cuidado en un diagrama representativo producto de una investigación doctoral. conclusiones: el esquema construido muestra al inicio una separación entre las dos personas de la díada, y a medida que se comparte la experiencia y van haciéndose más cercanos los intereses, la díada alcanza mayor expansión de su conciencia en el cuidado. en el mismo sentido, la funcionalidad de la persona con enfermedad crónica disminuye y el nivel de habilidad de cuidado aumenta. palabras clave cuidadores de familia, enfermedad crónica, vínculo, enfermería, teoría de enfermería (fuente: decs). año 11 vol. 11 nº 1 chía, colombia abril 2011 l 7-22 8 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 how a “special caring bond“ is formed between the chronically ill patient and the family caregiver abstract the formation of bonds in human beings stems from the caring relationships that exist throughout life. there are theories that apply to situations where the human being is at risk or has reached a limit, as in the case of chronic illness. objective: describe how a “special caring bond” is constructed in the dyad involving a family caregiver and a chronically ill patient. method: the grounded theory methodology was used to arrive at the central conclusion of a qualitative study in which a substantive theory was constructed to describe the process whereby a “special caring bond” is formed. findings: a theoretical structure showing the pattern formed in the dyads with respect to the significance of care is displayed in a representative diagram that was the product of doctoral research. conclusions: the constructed pattern shows an initial separation between the two persons in the dyad. however, to the extent the experience is shared and interests increasingly coincide, the dyad achieves more awareness or consciousness with respect to the care being provided. along the same lines, the functionality of the chronically ill person declines and the level of care-giving skill increases. key words family caregivers, chronic illness, bond, nursing, nursing theory (source: decs). como se forma o “vínculo especial” de cuidado entre as pessoas com doenças crônicas e o cuidador familiar resumo a formação de vínculos do ser humano nascem de relações de cuidados providos na sua vida. há teorias que se aplicam às situações em que os seres humanos está em risco ou ao limite – por exemplo, uma doença crônica. objetivo: descrever como nasce ou "vínculo especial" do cuidado entre a díade cuidador familiar-pessoa com doença crônica. método: conclusão de um estudo qualitativo em que se construiu uma teoria substantiva que descreve o processo de nascimento do "vínculo especial", surgido com uma abordagem de teoria fundamentada. resultados: um arcabouço teórico que mostra o padrão de díades construído em frente ao significado do cuidar em uma 9 cómo se constituye el “vínculo especial” de cuidado entre la persona con enfermedad crónica y el cuidador familiar l lorena chaparro representação gráfica produzido em uma pesquisa de doutorado. conclusões: ao começo, o padrão mostra uma separação entre as duas pessoas da dupla. a medida que elas compartilham suas experiências e aproximam os seus interesses, a dupla chega a uma maior expansão da sua consciência do cuidado. na mesma linha, se reduze a funcionalidade da pessoa com doenças crônicas e aumenta o nível de habilidade de cuidado. palavras-chave cuidadores familiares, doença crônica, vínculo, enfermagem, teoria de enfermagem (fonte: decs). 10 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 antecedentes el cuidado del ser humano, visto como opción para el crecimiento de las personas, ha sido asociado a la relación entre dos o más sujetos que favorecen los espacios y crean mecanismos muy particulares que lo hacen único y particular en el mundo. la enfermedad crónica, como fenómeno social y de importancia en salud pública, representa gran interés y desde enfermería se ha relacionado con la significancia social asociada a aspectos epidemiológicos. sin embargo, el fenómeno real que enfermería debe abordar son las situaciones de enfermedad crónica que representan una experiencia y una vivencia. cambiar el paradigma desde el paciente crónico y retomar elementos del cuidado para reconocer a la “persona con enfermedad crónica” en todas sus dimensiones y complejidades, hace que la enfermería cambie hacia un paradigma de reciprocidad (crecer en la relación con otros) y de simultaneidad (trascender espiritualmente hacia la comprensión de la enfermedad como parte de sí mismo). la persona con enfermedad crónica puede sentir impotencia, exacerbación del síntoma, fallas en la terapia médica y deterioro físico, entre otros aspectos, que le implican manejar muchos factores al tiempo. pierde confianza en sus capacidades corporales y en la salud, así como en habilidades de funcionamiento laboral y en las relaciones familiares (1). el significado y las experiencias de la persona con enfermedad crónica se manifiestan en una constante situación amenazante para la vida; hay mayor importancia de los síntomas y las incapacidades generadas, los periodos de exacerbación demandan más cuidado, y es difícil mitigar posibles daños con secuelas permanentes. ser un cuidador familiar es una respuesta innata de las familias para atender una situación nueva y bastante estresante. los cuidadores familiares apoyan en gran medida la sobrevivencia del ser humano en varias etapas del ciclo vital. al presentarse una enfermedad crónica, las dinámicas familiares incitan a que uno de sus miembros tome la decisión, ya sea propia o por sugerencia de la familia, de asumir el rol cuidador, lo que hace que se inicie una relación caracterizada por intercambios, conexión, trato familiar especial y sentimientos. la experiencia es valorada dependiendo del nivel de confianza y entrega de cada una de las partes, y del significado que se dé a la labor. este rol de cuidadores, por lo general, lo asumen las mujeres por su tradición de cuidado en las familias (2, 3). la literatura alrededor del fenómeno de dar cuidado en situaciones crónicas de salud ha descrito dos sujetos de cuidado que tradicionalmente se abordan por separado: la persona con enfermedad crónica y el cuidador familiar. sin embargo, existen propuestas teóricas y conclusiones de estudios, principalmente en enfermería (4), que están dando importancia a la denominación de las relaciones diádicas y, por tanto, a la conformación de díadas o binomios de cuidado. ser una díada, según thompson et al. (5), representa tener permanencia en el tiempo, es decir, ser duradero, tener presencia de acciones mutuas y un contrato de elemenla persona con enfermedad crónica puede sentir impotencia, exacerbación del síntoma, fallas en la terapia médica y deterioro físico, entre otros aspectos, que le implican manejar muchos factores al tiempo. pierde confianza en sus capacidades corporales y en la salud. 11 cómo se constituye el “vínculo especial” de cuidado entre la persona con enfermedad crónica y el cuidador familiar l lorena chaparro tos personales de los dos participantes; la principal característica de la díada es la interdependencia personal, es decir, la mutualidad y reciprocidad a través de la relación interpersonal. existen elementos esenciales dentro de una relación que van desde lo que motiva el cuidado hasta lo que debe ponerse en el tapete de una experiencia subjetiva. pasar de ser un binomio a ser una díada es adentrarse en una relación de mutualidad. más que lo material, involucra elementos intangibles como “crecer, evolucionar y trascender”, que permiten el efecto deseado del cuidado (6). concebir la relación de cuidado evidencia la existencia de más de una vía de comunicación y de acción. al inicio pueden influir los niveles jerárquicos, como el tipo de vínculo; sin embargo, en la medida en que se reconozcan como díada en una relación de cuidado, se desdibujan las jerarquías y se encuentran los elementos mencionados. en cuanto a las investigaciones sobre la relación de díadas en situaciones de enfermedad crónica se parte del debate metodológico sobre los análisis realizados en estudios de díadas, donde se hace un llamado a tener desde el inicio claridad conceptual y consistencia de las propiedades individuales y de la relación. thompson et al. (5) afirman que hay datos de primer y segundo orden; los primeros parten de sí mismo (de una parte de la díada); los segundos son inferencias que hacen los investigadores con base en lo que responde uno o los dos miembros de la díada. la invitación es considerar la diversidad de construcción de díada, antes que tender a la generalización e ir más allá de una construcción particular, segmentar o inferir sin la información suficiente, podría ser un sesgo para estudios a futuro. en investigaciones cuantitativas se encontró que una díada parte de manifestarse en aspectos como cohesión, satisfacción, tensión, conflicto en etapas iniciales de la enfermedad (7), impacto físico y existencial (8), lo que hace que a medida que avanza la enfermedad se vayan sumando características personales junto con el impacto que generan en la calidad de vida (9); existen diferencias entre el rol de cuidador-receptor de cuidado (10), y se ha encontrado que las intervenciones en díada dan mejores resultados en que a nivel individual (11). con este panorama se puede concluir que así como hay efectos negativos, hay posibilidades de intervenciones en díada para fortalecerla como cuidadora y enriquecer esta área del conocimiento. desde los abordajes cualitativos se aprecian elementos que describen la experiencia y vivencia sobre el impacto emocional e individual. en la definición de díada para la convivencia hay un inicio incierto y lleno de dificultades, pero a medida que pasa el tiempo, o en la convivencia con la enfermedad, se encuentra mayor trascendencia. un elemento clave en la conformación de las díadas es el proceso de remisión al hogar, que por lo general se centra en actividades de tipo instrumental que requieren de dos meses para la adopción de las rutinas necesarias (12). esta etapa instrumental es clave en la adopción del rol y para ir conformando la díada. el proceso de formación de las díadas fue descrito por wilson et al. (13), quienes reconocieron la creación de un vínculo, el cual se da por un compromiso absoluto que requiere de habilidades como la aceptación de responsabilidades, la esperanza, la toma de decisiones, la enseñanza, el aprendizaje, el manejo y la coordinación, concebir la relación de cuidado evidencia la existencia de más de una vía de comunicación y de acción. al inicio pueden influir los niveles jerárquicos, como el tipo de vínculo; sin embargo, en la medida en que se reconozcan como díada en una relación de cuidado, se desdibujan las jerarquías. 12 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 al igual que estrategias como ajustarse en la lucha, retomar el tiempo, estar presente en el hospital, tener sentido de la realidad, facilitar la vida familiar, expandir la labor de cuidar y rechazar el “rendirse”. dando cumplimiento a las habilidades y a las estrategias se aprecia el impacto de sí mismo y la relación con otros en situaciones de cronicidad. estos autores también mencionan que el vínculo entre el cuidador y la persona con enfermedad también ha sido tergiversado con acciones de no cuidado, como el ser una fuente de abuso y la consecuente victimización, los cuales, como se estableció, no forman parte de relaciones de cuidado. otro de los elementos presentes en este tipo de relación de cuidado es la conformación de transacciones que ayudan a la adquisición de las habilidades para cuidar y que permiten la conformación de patrones de cuidado como el colaborativo y el familiar (14). en las relaciones entre cuidador y persona con enfermedad crónica se han encontrado fases del cuidado importantes dentro de la díada (15), ya que el éxito del cuidado en el hogar depende en gran media del seguimiento en cada una de ellas. no es lo mismo intervenir al principio de la experiencia que al final cuando, por lo general, hay mayor habilidad instrumental y, en ocasiones, la situación se asume como parte de la vida. según el tipo de abordaje en el sujeto de cuidado, los estudios en díadas en situaciones de enfermedad crónica se clasifican en cuatro niveles: 1) entre el cuidador familiar y la persona con enfermedad (7, 8, 10, 11, 12, 14, 16, 17, 18, 19 20); 5) entre el cuidador familiar y la enfermera (21); 3) entre los cuidadores (22), y 4) entre la persona con enfermedad y el cuidador profesional (23). dentro de las conclusiones más relevantes se encontró que las relaciones en situaciones de enfermedad crónica tienen una trayectoria y están asociadas a fases de adopción de roles y perfeccionamiento de la labor de cuidado que, en la medida de su mutualidad, permiten el crecimiento de las personas y la díada. estas relaciones están moduladas por el tiempo, el contexto, las redes familiares y las sociales. el cuidado depende en gran medida de la calidad de la díada, la capacidad de relación y la existencia de elementos que la fortalezcan. desde disciplinas distintas a enfermería se ha permitido identificar la asociación y correlación entre las personas y las relaciones como tal. hay que resaltar que mucha de la indagación ha partido de los estudios realizados desde la terapia familiar y, por tanto, deben ser reindagados en las díadas que no tienen vínculo marital ya que se puede generalizar a situaciones de enfermedad crónica en las que puede haber otra realidad. también se debe mencionar que los estudios realizados desde enfermería permiten encontrar en la investigación cualitativa elementos que son la base de la construcción de herramientas contundentes para el diagnóstico y la planeación del cuidado. se puede concluir que el cuidado es visto como un rasgo humano, parte del desarrollo y la supervivencia del ser. sin embargo, el ser en su proceso de desarrollo está en permanente interacción con otros seres humanos que pueden genera modificaciones en los significados frente a situaciones cotidianas y trascendentales (24, 25) como es, por ejemplo, la enfermedad crónica. resulta importante conocer cómo es el proceso interno de construcción de significados de la labor de cuidarse (en la díada) en caso de enfermedad crónica. aunque se han identifiestudios realizados desde enfermería permiten encontrar en la investigación cualitativa elementos que son la base de la construcción de herramientas contundentes para el diagnóstico y la planeación del cuidado. 13 cómo se constituye el “vínculo especial” de cuidado entre la persona con enfermedad crónica y el cuidador familiar l lorena chaparro cado aspectos vistos desde cada individuo y características de ellos enmarcadas en la experiencia de cuidado, no se conoce cómo se da este fenómeno desde los dos sujetos como díada. esta identificación es necesaria, puesto que contribuye a descubrir las explicaciones acerca del cuidado, indispensables para avanzar en el desarrollo teórico, con el fin último de llegar a cualificar la práctica, lo que sucederá una vez descritas y validadas las teorías que se propongan en el campo. método y procedimiento con los anteriores argumentos se dedujo que era necesario comprender el significado del cuidado construido a partir de la relación entre la díada cuidador familiar-persona con enfermedad crónica, que hizo parte de una investigación cualitativa con abordaje de teoría fundamentada, desarrollada en el marco del trabajo del grupo de cuidado al paciente crónico y la familia en la formación doctoral de uno de sus integrantes. aquí se describe la teoría sustantiva construida que muestra la forma en la que se constituye el “vínculo especial” de cuidado entre la persona con enfermedad crónica y el cuidador familiar: trascender en un “vínculo especial” de cuidado: el paso de lo evidente a lo intangible (26, 27). la muestra estuvo compuesta de datos suministrados por 10 díadas (20 informantes), integradas por dos sujetos: la persona con enfermedad crónica y su cuidador familiar. los informantes residían en bogotá, colombia. en total se desarrollaron y analizaron 28 entrevistas a profundidad que permitieron reconocer los elementos centrales del “vínculo especial” (26). el perfil de los informantes en género y en tipo de relación se describe en el cuadro 1 (ver anexo). las situaciones de enfermedad más comunes fueron las de origen respiratorio, inmunológico, renal, cardiovascular en etapas no tan avanzadas y secuelas de enfermedades de la niñez. se incluyeron informantes que convivían juntos (7 díadas), así como otros que no lo hacían (3 díadas). la mayoría llevaba más de 37 meses de cuidado. en cuanto a la red social cercana, como la familia y otro cuidador, se incluyeron informantes que se apoyaban en los hijos, las hermanas y los esposos. la investigación base de este reporte se rigió por los principios éticos de investigación en salud para colombia, y las consideraciones internacionales con el uso de consentimiento informado y participación voluntaria. se contó con el aval del comité de ética de la facultad de enfermería de la universidad nacional de colombia para el desarrollo de la misma. de acuerdo con el método de teoría fundamentada, la construcción de la teoría sustantiva contempla etapas y mecanismos de extracción a partir del acúmulo de información (28, 29, 30, 31). uno de los fines de dicho método de investigación interpretativo es la construcción teórica que permite comprender fenómenos inexplorados que guían el estudio futuro para los procesos de validación y refinamiento, los cuales son continuos. para el proceso de construcción se realizaron desarrollos simultáneos de extracción a partir de los elementos que definían el cuidado a partir de las díadas. se inició con la construcción de códigos sustantivos y códigos nominales que fueron recodificados en dos oportunidades. estos códigos luego se agruparon, de las situaciones de enfermedad más comunes fueron las de origen respiratorio, inmunológico, renal, cardiovascular en etapas no tan avanzadas y secuelas de enfermedades de la niñez. 14 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 acuerdo con la similitud, en subprocesos; a manera de ejemplo, los códigos “negación, rabia, shock” demostrarían una categoría como el “duelo frente a la muerte”. la siguiente etapa fue la agrupación de procesos más amplios (variables). para esto fue clave la organización de datos a partir de las tres modalidades de entrevistas. se construyó un proceso a partir de los datos de entrevistas realizadas a las personas con enfermedad crónica, otro para las de los cuidadores familiares y el último para las realizadas a díadas de manera simultánea (cuidador-persona con enfermedad crónica, en el mismo espacio). para la definición de la variable central fue útil la elaboración de narrativas. al respecto, se ha descrito que el uso de metáforas permite el desarrollo del conocimiento de la investigación en enfermería, en especial desde el enfoque cualitativo (32), por permitir el paso de ser figuras de discursos a ser modelos de cartografía mental que permiten mostrar cómo las personas piensan, razonan e imaginan en la vida cotidiana; estas también han mostrado ser útiles en la construcción teórica de la ciencia y se pueden expresar a través de modelos analógicos (33). del resultado de estos elementos teóricos surge la teoría sustantiva “trascender en un ‘vínculo especial’ de cuidado: el paso de lo evidente a lo intangible” (26, 27). resultados la teoría sustantiva “trascender en un ‘vínculo especial’ de cuidado: el paso de lo evidente a lo intangible”, tiene como indicador empírico el “vínculo especial” que se establece entre la persona con enfermedad crónica y su cuidador familiar (con o sin lazos de consanguinidad), en lo que se ha denominado una díada de cuidado. sobre ese “vínculo especial” gira todo el proceso de cuidado (figura 1). el “vínculo especial” no existe en cualquier relación de cuidado. este se construye a partir de la conformación de la díada cuidador-persona cuidada; cuando está presente, empiezan algunas diferencias con otros tipos de relación y otras formas de cuidar. por ejemplo, en el cuidado que ofrece un profesional a una persona con enfermedad no se identifica este “vínculo especial”. este “vínculo especial” surge de la introspección, de la reflexión y de encontrar significado en la vivencia de cada uno de los integrantes de la díada de cuidado. la necesidad de enfrentar una experiencia difícil que modifica el curso de la vida parece abrir en cada uno de los integrantes de la díada de cuidado un margen de vulnerabilidad, un vacío, una necesidad de apoyo que permita superar las necesidades evidentes que plantea el cambio de la rutina. frente al desorden inicial, cada integrante de la díada siente malestar, preocupación y temor, el cual se acompaña de la búsqueda intensa de mayor estabilidad. poco a poco se aprende a superar las dificultades en medio del camino, y se reconoce en el otro a un aliado, alguien que en medio de la situación siempre está allí, conviviendo y acompañando a su compañero en esta experiencia de vivir o cuidar en la enfermedad. en la díada cada uno comienza a percibir al otro como aquel con quien todo es más familiar, con quien se sufre y por quien se sufre, ese que comienza a llenar la vida y a darle sentido, ese con quien se construye y fortalece un “vínculo especial” la teoría sustantiva “trascender en un ‘vínculo especial’ de cuidado: el paso de lo evidente a lo intangible”, tiene como indicador empírico el “vínculo especial” que se establece entre la persona con enfermedad crónica y su cuidador familiar. 15 cómo se constituye el “vínculo especial” de cuidado entre la persona con enfermedad crónica y el cuidador familiar l lorena chaparro diferente a otro tipo de vínculos porque transforma el propio nivel de conciencia. el “vínculo especial” no es estático; de manera tímida se insinúa al inicio de la relación como una mera posibilidad. se va reconociendo en la rutina, y en las crisis, cuando la pérdida y el riesgo están presentes, se manifiesta casi con furor. muchas veces tiene un papel tan prioritario que inhabilita, genera dependencia, es difícil de manejar, pero con el tiempo ese “vínculo especial” madura, se desarrolla, aprende. cada día y cada paso en medio de la dificultad parecen fortalecer ese “vínculo especial” que caracteriza la experiencia de cuidado. antes de que este aparezca, la díada hace tareas, asume responsabilidades, pero con el tiempo, cuando el “vínculo especial” se identifica, la díada vive el cuidado, aprende de manera progresiva y se fortalece de tal forma que se hace complejo comprender quién cuida a quién. el “vínculo especial” complementa a los miembros de la díada, los deja sentirse acompañados, los cobija en su dolor y, al no estar solos, lo que parecía imposible de vivir se va superando día a día. el “vínculo especial” da fuerza y hace que cada cual se sienta importante para el otro, permite aprender y comprender para que lo que aparentaba ser un caos en una situación de enfermedad pase a tener significado. en este viaje constante se redimensiona la propia vida; en este “vínculo especial” es posible que quienes viven la experiencia puedan trascender. en la descripción teórica del proceso encontrado hay tres variables que surgieron en el estudio y que en conjunto dieron paso a plantear el “vínculo especial”. cada una describe cómo se manifiesta y como aporta en la construcción, estas son: 1) limitación y necesidad de ayuda, 2) el paso del reto o compromiso al logro, y 3) la forma de trascender en un “vínculo especial”. para que un esquema represente y tenga el suficiente valor en una teoría fundamentada debe entenderse y leerse por el consumidor de la investigación; sin embargo, a continuación en el recuadro se amplía el esquema con un ejemplo de las díadas entrevistadas: díada: l (cuidadora) era una mujer que vivía con su esposo n (pec) desde hacía más de 30 años. n (pec) había sido alcohólico por un tiempo considerable, adicción que había superado gracias a un grupo de apoyo de alcohólicos anónimos (antecedentes). n (pec) había sido diagnosticado con enfermedad pulmonar obstructiva crónica (epoc) desde hacía más de tres años, todo había comenzado con una crisis respiratoria mientras trabajaba, lo que desencadenó una serie de restricciones para salir y para continuar su vida como la llevaba (crisis). sin embargo, buscó formas para continuar su vida laboral, claro está disminuyendo su funcionalidad y horas laborales, y recurriendo al uso de elementos como el oxígeno y los inhaladores. para este momento de la enfermedad él siente que debe asumir solo su situación, es decir, empieza a tener una lucha entre sus estilos de vida y la enfermedad de manera personal. al mismo tiempo, está l (cuidadora), quien había vivido la experiencia del alcoholismo como algo significativo que quizás nunca volvería a retomar (cierta habilidad de cuidado reconocida). a ella, que se considera una persona muy cariñosa con su esposo, le impacta la crisis inicial y siente mucha angustia y confusión en este proceso, sin embargo, al principio permite que n (pec) tome sus decisiones, así sepa que algunas no son las mejores, como seguir fumando. asume que como n (pec) sabe del tema de la salud, sabrá manejar su salud y enfermedad. sin embargo, surge un nuevo incidente por los espacios de socialización con su familia, por salidas que tenían habitualmente y que se negaban a perder por la enfermedad, a pesar de tomar las medidas correspondientes (crisis). luego de superar esta etapa, aunque decae más la funcionalidad de n (pec), hay una estabilidad de la enfermedad (reposo y ajuste) que permite a l (cuidadora) empezar a comprender cómo se comporta la epoc, qué le exacerba los síntomas, y comienza a buscar apoyo en otros o en esas experiencias pasadas; este proceso se va haciendo más evidente a medida que la funcionalidad de n (pec) va disminuyendo. al principio l (cuidadora) se veía aturdida con información que no comprendía acerca de la enfermedad, luego de algún tiempo de convivencia y de dar cuidado, va adquiriendo mayor habilidad, al comienzo muy desorganizada y luego más organizada, al punto que permite a n (pec) asumir algunas labores que al principio había limitado (aumento de la habilidad de cuidado), pero que gracias a las enseñanzas en los grupos de apoyo mejoraban su nivel de expansión de la conciencia (línea de alto nivel de conciencia). con cada nueva crisis que presentaba n (pec), aunque se disminuía su socialización con el mundo y la epoc se manifestaba con nuevos síntomas y surgían nuevas enfermedades que modificaban sus estilos de vida, había un acercamiento y aprendizajes para cada uno que se compartían y se manejaban en díada. al principio se apreciaba que cada uno iba por su lado, sin comprender que los dos se estaban involucrando en esta labor. luego fueron comprendiendo que los estilos de vida los afectaban a 16 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 los dos, que debían hacer cosas juntos que ayudaran a mejorar su convivencia, este límite se fue perdiendo hasta que el mismo n (pec) generaba acciones para ayudar a l (cuidadora) a fin de que no se afectara físicamente por su cuidado, buscaba la forma en que le dejara asumir labores por mínimas que fueran hasta que se fueron haciendo más cercanos, convirtiéndose realmente en una díada. luego de las entrevistas hemos visto que a pesar de que n (pec) ya no la acompaña, esta experiencia trascendió hacia el mejoramiento de la calidad de vida de l (cuidadora), ahora se preocupa más por su bienestar, mejoró sus estilos de vida y acompaña a otros en la labor de cuidado (manifestación de trascendencia) (34). el proceso encontrado evidenció que el “vínculo especial” se caracteriza por el afecto, el respeto, la entrega mutua, el acompañamiento, el compartir sentimientos y la reflexión constante. los elementos ambientales interactúan con la díada, y en ocasiones se requiere que el cuidador familiar (por su nivel de funcionalidad) los reconozca e introyecte para transmitir aprendizajes en la labor de cuidado dado que estos tienen impacto porque logran enriquecer el vínculo. la enfermedad crónica que llegó de manera inesperada, y que no es curable, genera temor. la díada percibe cuándo aparecen los síntomas que generan limitación, pérdida de funciones y asilamiento. la vivencia es desagradable, sin embargo, a medida que la díada forma el “vínculo especial”, se fortalece alrededor del tratamiento, del manejo de los factores de riesgo y la prevención de otros. la intuición se desarrolla como parte de la vivencia. la situación de enfermedad se convierte en el espacio donde está la convivencia y hay adecuación, se adecua todo, hasta los hábitos alimenticios. entonces el cuidado se hace más cercano a la díada; le permite comprender que es una situación especial que genera pérdidas y también trae ganancias. los integrantes de la díada ven de forma distinta la vida y esto les permite encontrar significados no disponibles en otras situaciones rutinarias. el cambio es progresivo; hablar de una enfermedad crónica comienza a asociarse con la muerte. no obstante, la díada se pregunta qué hacer mientras llega. y responde: vivir la vida. llegar a estas respuestas implica un nivel de desarrollo para el cual se requiere tiempo, acercamiento con la situación de enfermedad y con el cuidado, y convivir como díada. cada crisis traerá de nuevo el ambiente hostil del inicio; sin embargo, la existencia de la “díada” se irá fortaleciendo. el hogar es sin duda el espacio ideal para la reflexión constante que se requiere para identificar el “vínculo especial”, los aprendizajes y las ganancias, para encontrarse. el profesional de enfermería puede facilitar este encuentro con un ambiente educativo y sensitivo que refleje apoyo y respeto por la condición humana de la cual él (o ella) también aprende. el profesional de enfermería, como aprendiz y apoyo de la díada, facilita su trascendencia, se retroalimenta y genera crecimiento propio y compartido. un ejemplo de ello son los grupos de apoyo para los cuidadores familiares, en los cuales la experiencia ha mostrado que el “vínculo especial” se fortalece. los cuidadores familiares no se olvidan de la persona a quien cuidan a pesar de que no estén presentes; son una parte de esa totalidad que retoma cada aprendizaje para incorporarlo como parte del fortalecimiento de su realización. el “vínculo especial” se caracteriza por el afecto, el respeto, la entrega mutua, el acompañamiento, el compartir sentimientos y la reflexión constante. 17 cómo se constituye el “vínculo especial” de cuidado entre la persona con enfermedad crónica y el cuidador familiar l lorena chaparro discusión con los resultados encontrados y expresados en la teoría sustantiva, el cuidado inicia con cierto desorden hasta el máximo nivel de conciencia que es la trascendencia, el cual tiene relación con el desarrollo del concepto desde la educación, la filosofía y la enfermería misma. se encontraron elementos del concepto de cuidado en los binomios basados en la relación, la espiritualidad, la adaptación al estrés vivido en esta experiencia y la necesidad de cambiar a un paradigma cualitativo para abordar la enfermedad crónica. se puede decir que las diferencias que el estudio mostró son parte de la particularidad que enmarca a la díada de cuidado: persona con enfermedad crónica-cuidador familiar. esta díada ha sido muy poco explorada en la literatura de enfermería y en la de cuidado en general. en cuanto a otros vínculos reportados en la literatura, para la teoría sustantiva encontrada aquí, el enriquecimiento descrito por cartwright et al. (6) es el elemento que permite a las díadas mantenerse adquiriendo mayor habilidad y mayor nivel de conciencia. la mutualidad permite pasar de ser una pareja o dos personas juntas a ser díada. esta teoría también reafirma lo planteado por wilson et al. (13) sobre díadas pec-c en cuanto a la conformación de vínculos, que tiene formas universales; sin embargo, lo que la hace especial es el estar en una experiencia, alcanzar metas que, para el caso, no son la cura de la enfermedad, sino la valoración de una vivencia llena de oportunidades de crecimiento. los resultados encontrados en la experiencia de otras díadas se acercan a lo reportado por connell (19). sin embargo, en los resultados expuestos se buscó conocer el elemento central que permite la construcción alrededor del cuidado. por lo general, los reportes que describen la experiencia de cuidado en la enfermedad crónica parten del reconocimiento de la necesidad de este hasta el logro de ganancias no esperadas. en la teoría sustantiva reportada en este informe el eje transversal del proceso de construcción de significados fue el “vínculo especial”. lo que lo hace diferente a otros y el aporte que deberá ser tenido en cuenta en las intervenciones de enfermería con díadas es la valoración de este vínculo, encontrando las oportunidades y resolviendo dificultades para mantener y fortalecer los componentes físicos y espirituales, y favorecer el nuevo sujeto de cuidado en paso a la trascendencia. se puede decir también que la relación, como un espacio para que existan binomios de cuidado, puede dar paso al surgimiento de díadas, lo que responde a los elementos planteados por archbold et al. (4). este concepto se amplía en el estudio con el producto esperado, que es la trascendencia inmersa en algo que para cada sujeto de cuidado es “especial”, y que los convierte en nuevos sujetos: “las díadas”. la creación del constructo cuidado, que contempla elementos espirituales en los significados descritos por frankl (35) y leontiev (36), se hizo evidente a partir del momento en que se supera la adquisición de habilidades técnicas que requiere el cuidado en situación de enfermedad crónica. en este proceso las ganancias espirituales y el aumento progresivo del nivel de conciencia de la díada ejemplifican las propuestas teóricas de estos autores. con respecto a la espiritualidad, y de acuerdo con lo planteado por sánchez por lo general, los reportes que describen la experiencia de cuidado en la enfermedad crónica parten del reconocimiento de la necesidad de este hasta el logro de ganancias no esperadas. 18 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 (37) acerca de sus diferentes expresiones, este estudio demuestra que la espiritualidad se manifiesta en un sentido horizontal, frente al mismo cuidador y a la persona con enfermedad crónica con cuestionamientos de tipo existencial, y en un sentido vertical con cuestionamientos y acercamientos a dios o a un ser superior, que son de carácter religioso. otro elemento relacionado fue la reflexión que hicieron las díadas consigo mismas. en el plano espiritual horizontal permitió, al igual que moch (38), reconocer que la experiencia contaba con aspectos del “vínculo especial” como encontrar la perspectiva positiva, las ganancias conjuntas, ver la oportunidad de ayudar a otros y trascender. fue posible también reconocer que la enfermedad y la sintomatología se aprenden a controlar y se modifica el estilo de vida para que su impacto no sea devastador. las díadas enfrentadas a esta situación muestran su fortaleza para continuar y lograr trascender. la teoría expuesta en el estudio tuvo relación con lo planteado por lindsey (39) en ese proceso de encontrar las ganancias de la experiencia. el aporte de este estudio es comprender que los significados dados al cuidado van más allá de aspectos instrumentales, fue el de reconocer el regalo (la oportunidad) y la trascendencia que impacta a las díadas. el “vínculo especial” de cuidado encontrado en las díadas del estudio también se relacionó con el concepto de lo transpersonal descrito por watson (40, 41) desde el momento en que estas reflexionaron acerca de que estaban cuidando “seres humanos”. desde esta perspectiva, se movieron en el cuidado y el vínculo con manifestaciones de acciones calurosas y de agrado para los dos. esta perspectiva permitió vivir y reconocer la autotrascendencia mencionada. la teoría encontrada en el estudio confirma la perspectiva de interacción del ser humano con su naturaleza o universo que afirmó jonas (42), al considerar la existencia del diálogo interno que establecen las díadas para proponer alternativas que mejoren su interacción y compartir con otros sus aprendizajes hasta llegar a concebir ambientes propios para convivir en un “vínculo especial”. la reflexión que impregna la relación de cuidado contempla ese diálogo interno y externo que hace cada individuo, y es transmitido hacia la díada para su trascendencia. en cuanto al proceso de la enfermedad crónica y la funcionalidad, este se asemeja a lo encontrado por krail et al. (43). en los resultados expuestos se encontró que a media que disminuía la funcionalidad física, la persona con enfermedad crónica, el cuidador y las díadas encontraban un acercamiento y reflexión positiva acerca de su condición. el hecho de hacerla parte de ellos se reflejó en expresiones como: “nos hospitalizamos”, “nos enfermamos”, que aunque representan despersonalización, evidencian un cambio en el plano de la identidad individual. las etapas iniciales de la experiencia en las díadas del estudio contemplaron las fases propuestas por williams (44); sin embargo, el estudio aporta elementos que van más allá de la negociación, de reconocer beneficios, de la proyección y de la trascendencia. para finalizar, se encontró que las díadas también experimentan momentos de sobrecarga y generan mecanismos de enfrentamiento y de adaptación como los que planteó tsai (45). los grupos de apoyo la reflexión que impregna la relación de cuidado contempla ese diálogo interno y externo que hace cada individuo, y es transmitido hacia la díada para su trascendencia. 19 cómo se constituye el “vínculo especial” de cuidado entre la persona con enfermedad crónica y el cuidador familiar l lorena chaparro aquí fueron determinantes para reconocer y manejar dichos momentos. de igual forma, la angustia descrita por mathews (10), fue reportada y manifestada por estas díadas, en algunos casos, a través de la intuición. se puede decir que en la forma en que se construye este “vínculo especial”, visto desde lo físico y espiritual, se desdibuja una relación jerárquica o altruista entre el que cuida y el que es cuidado. prima el ser humano con su pandimensionalidad que lo hace único y capaz de establecer los vínculos necesarios con el mundo y trascender a otros espacios dejando en los que convive una marca importante y las enseñanzas más significativas en especial para situaciones difíciles como la de tener una enfermedad crónica. la teoría sustantiva generada a partir de los datos analizados con el método de teoría fundamentada, y de acuerdo con fawcett (46), es de tipo descriptivo, y apunta a ser una “teoría de nombre” (naming theory) considerada como una descripción de las dimensiones o características del fenómeno “significado del cuidado en la díada alrededor de la experiencia de la enfermedad crónica” (46). el estudio base se construyó a partir de procesos identificados en una situación (la experiencia de la enfermedad crónica) en la que su concepto principal (vínculo especial) será validado en el futuro con investigación de tipo descriptivo para ir aumentando la complejidad teórica. conclusiones 1. la conformación del vínculo es un proceso dependiente de la temporalidad y del tipo de relación previa que se tenga. 2. la relación interpersonal sí puede construir un concepto particular de cuidado, que se caracteriza por el tránsito de lo evidente, con el cuidado instrumental y la atención a las crisis, hacia lo intangible, que son los aprendizajes y las ganancias. ese paso genera trascendencia. 3. cada sujeto miembro de la díada tiene una perspectiva de la experiencia que, al conjugarse, adquiere una dimensión que no era percibida por cada uno de sus integrantes. 4. existen unos significados pragmáticos del cuidado que estuvieron presentes al inicio de la experiencia y de la relación cuando el elemento motivador era de tipo instrumental, con la búsqueda de confort, respuesta afectiva y superación de crisis. a medida que se vivía la experiencia, el significado cambió y generó mayor experticia y nivel de conciencia, a pesar de que se enfrentó mayor disfuncionalidad física de la persona con enfermedad crónica y mayor carga para el cuidador. 5. tener dos perspectivas permite comparar y comprender los significados evidentes e intangibles de las díadas que viven la situación de enfermedad crónica y corroborar que los enfoques teóricos de enfermería son susceptibles de integrar en el manejo de una experiencia que refleje la totalidad. 6. dentro de las reflexiones para la práctica de enfermería se han realizado acciones concretas de formación en la universidad nacional de colombia, tales como el cambio de paradigma hacia a una visión basada en el cuidado humano, en asignaturas concretas como la de “cuidado de enfermería se puede decir que en la forma en que se construye este “vínculo especial”, visto desde lo físico y espiritual, se desdibuja una relación jerárquica o altruista entre el que cuida y el que es cuidado. 20 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 en situaciones crónicas de salud”, del programa de enfermería. esto ha permitido que el profesional en formación reflexione frente al sujeto de cuidado dentro de una visión de reciprocidad que va más allá de la holística. abordar díadas y no sujetos por separado permite adelantarse a necesidades de las personas que son invisibles como el cuidador familiar, y atender situaciones en la labor como el cuidar-sen (sin límites entre quien da y quien recibe), conocer la trayectoria y contar con planes de preparación para el cuidado en casa que tengan comunicación permanente con el equipo de salud. 7. finalmente, contar con tres fuentes de información (pec, cf y díada) dificultó la identificación rápida del proceso social básico, pero se convirtió en el reto de la investigación. agradecimientos a la universidad nacional de colombia, la facultad de enfermería y el grupo de cuidado al paciente crónico y la familia, que apoyaron el desarrollo de formación doctoral y profesional como investigadora. referencias bibliográficas 1. pinto n. comprender la situación de cronicidad que viven nuestros pacientes. en: grupo de cuidado. la investigación y el cuidado en américa latina. bogotá: universidad nacional de colombia, facultad de enfermería, unibiblos; 2004. pp. 303-322. 2. barrera l et al. la habilidad de cuidado de los cuidadores familiares de personas con enfermedad crónica. en: investigación y educación en enfermería 2006; 24 (1): 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39. lindsey e. the gift of healing in chronic illness/ disability. j holist nurs 1995: 13 (4): 287-305. 40. watson j. nursing: human science and human care. a theory of nursing. new york: national league for nursing; 1988. 41. watson j. caring as sacred. philadelphia: davis company; 2005. 42. jonas h. the phenomenon of life: toward a philosophical biology. chicago: northwestern university press; 2001. 43. kralik d et al. chronic illness self-management: taking action to create order. journal of clinical nursing 2004; 13 (2): 259-267. 44. williams l. theory of caregiving dynamics. in: liehr p, smith m (eds.). middle range theory of nursing. springer publishing company; 2008. pp. 261-276. 45. tsai pf, jirovec m. the relationships between depression and other outcomes of chronic illness caregiving. bmc nurs [serial on line] 2005, feb 4 (3). disponible en: http://www.biomedcentral. com/1472-6955/4/3/ [consultada el 5 de octubre de 2005]. 46. fawcett j. the relationship of theory and research. 3 ed. davis company; 1999. 22 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 pec: persona con enfermedad crónica; c: cuidador familiar; f: femenino; m: masculino. fuente: datos de la investigación “trascender en un ‘vínculo especial’ de cuidado: el paso de lo evidente a lo intangible”, 2009. díada pec c relación (pec/c) 1 f m esposos 2 f m madre/hija 3 m f amigo/amiga 4 f m esposos 5 m f esposos 6 m f esposos 7 f m madre/hijo 8 m m padre/hijo 9 f f madre/hija 10 f f hija/madre cuadro 1. caracterización de los informantes por género y tipo de relación de las díadas. fuente: datos de la investigación “trascender en un ‘vínculo especial’ de cuidado: el paso de lo evidente a lo intangible”. figura 1. diagrama de la teoría sustantiva “trascender en un ‘vínculo especial’ de cuidado: el paso de lo evidente a lo intangible". anexo 199 216 la alimentacion de los adolescentes.indd 199 olga osorio-murillo1 maría consuelo del pilar amaya-rey2 la alimentación de los adolescentes: el lugar y la compañía determinan las prácticas alimentarias3 1 doctora; docente universidad santiago de cali, cali, colombia. olgaosoriomurillo64@gmail.com 2 doctora en filosofía; profesora titular, universidad nacional de colombia. mcamayad@unal.edu.co, p_amaya_rey @yahoo.com 3 el presente artículo se generó como producto de la tesis de doctorado en enfermería denominada “trama de la alimentación: prácticas alimenticias y alimentarias de los adolescentes escolarizados del colegio nuestra señora de guadalupe, cali, colombia”. recibido: 08 de junio de 2010 aceptado: 17 de mayo de 2011 resumen objetivo: presentar los significados de la alimentación y las prácticas relacionadas de un grupo de adolescentes escolarizados del colegio nuestra señora de guadalupe, de cali, colombia. método: estudio con abordaje cualitativo de tipo exploratorio, orientado por la hermenéutica dialéctica, utilizando como técnica el análisis de contenido. se tuvieron en cuenta los espacios familiares, escolares y de la calle, donde los adolescentes interactúan con sus pares o amigos. participaron 31 adolescentes (17 mujeres y 14 hombres), 10 familiares (6 madres, 2 padres y 2 abuelas), 3 profesores y la administradora de la cafetería. resultados: de acuerdo con el espacio y la compañía se establecieron subcategorías que determinan e influyen en el tipo de alimentos que consumen los adolescentes, así: en la familia, las tradiciones; en el colegio, la autonomía, la disponibilidad económica, las preferencias del grupo y la oferta de alimentos en la cafetería; en la calle, el género, la amistad y el amor inciden en la elección e ingesta de alimentos. conclusiones: el espacio y la compañía determinan el tipo y la calidad de los alimentos ingeridos por los adolescentes. palabras clave enfermería, adolescentes, familia, colegio, amigos, conducta alimentaria. año 11 vol. 11 nº 2 chía, colombia agosto 2011 l 199-216 200 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 teenage diet: context and companions determine eating habits abstract objective: to show the significance of diet and related habits in a group of teenage students at our lady of guadalupe school in cali (colombia). method: this is an exploratory study with a qualitative approach that is guided by dialectical hermeneutics and uses a content analysis technique. the study took into account family, school and street environs where teenagers interact with their peers or friends. the sample was comprised of 31 teenagers (17 females and 14 males), 10 family members (six mothers, two fathers and two grandparents), three teachers and the manager of the school cafeteria. results: sub-categories that determine and influence the type of food these teenagers consume were established on the basis of context and companions. food choices and intake are influenced in the family, by tradition; in the school, by autonomy, economic availability, group preferences and the supply of food at the cafeteria; and on the street, by gender, friendship and love. conclusions: context and companions determine the type and quality of foods teenagers consume. key words nursing, teenagers, family, school, friends, feeding behavior. a alimentação dos adolescentes: o lugar e a companhia determinam as práticas alimentares resumo objetivo: apresentar os significados da alimentação e as práticas de um grupo de alunos da escola de nuestra señora de guadalupe, em cali, colômbia. método: estudo exploratório qualitativo, orientado pela hermenêutica dialética, utilizando a técnica de análise de conteúdo. levou em conta o do espaço da família, a escola e a rua, onde os adolescentes interagem com os pares ou amigos. participaram 31 adolescentes (17 mulheres e 14 homens), 10 familiares (6 mães, dois pais e duas avós), 3 professores e a administradora da lanchonete. resultados: de acordo com o espaço e a companhia, criaram-se subcategorias que determinam e influenciam o tipo de alimentos consumidos por adolescentes, assim: na família, as tradições; na escola, a autonomia, a disponibilidade econômica, as preferências grupo e a oferta de alimentos na lanchonete. na rua, a amizade, o sexo e o amor afetam a escolha e ingestão de alimentos. conclusões: o espaço e a companhia determinam o tipo e a qualidade dos alimentos consumidos por adolescentes. palavras-chave adolescentes, amigos, enfermagem, escola, família, comportamento alimentar. 201 la alimentación de los adolescentes: el lugar y la compañía determinan las prácticas alimentarias l olga osorio-murillo, maría consuelo del pilar amaya-rey introducción la alimentación constituye una práctica fundamental en el mantenimiento de la vida y en el desarrollo de las actividades diarias de los seres humanos, unida a todos los procesos vitales, condicionando su salud y su calidad de vida, por lo que está ligada al cuidado de enfermería en la cotidianidad. particularmente en los adolescentes, la alimentación constituye un tema de interés para la disciplina debido al efecto de las acciones de promoción de la salud y prevención de la enfermedad que se pueden realizar durante esta etapa, y al impacto que tienen en la salud actual y futura de estos jóvenes. tradicionalmente, la alimentación se ha abordado desde la perspectiva biológica, en la que priman la descripción de las ingestas de alimentos y su efecto en el estado nutricional y en la salud, dejando a un lado la comprensión de aspectos que guían las prácticas, como son los significados que las personas dan a los alimentos. la alimentación, como aspecto prioritario para la salud y la vida de los adolescentes, ha sido objeto de políticas internacionales y nacionales, por lo cual se han estructurado diferentes programas de promoción orientados a fomentar en ellos hábitos alimenticios saludables, pero con éxitos parciales, ya que predomina el consumo de alimentos no adecuados, convirtiéndose en factor de riesgo para enfermedades por exceso o por déficit de nutrientes (1). las prácticas relacionadas con la alimentación de los adolescentes han sufrido cambios en los últimos tiempos, con una tendencia hacia lo no saludable, que consiste en el incremento del consumo de gaseosas, meriendas, comidas rápidas y azúcares, y por una disminución del consumo de frutas, verduras, leche y leguminosas (2, 3, 4, 5, 6, 7, 8). como resultado de la alteración de las prácticas relacionadas con la alimentación se desarrollan trastornos como la obesidad, y la anorexia y la bulimia nerviosas, cuya incidencia ha aumentado (9, 10,11, 12, 13, 14) con un impacto negativo. estos trastornos se convierten en factores de riesgo de aparición de enfermedades crónicas, tales como las cardiovasculares, diabetes, osteoporosis, cáncer, artritis (10, 15, 15, 16, 17, 18, 19, 20, 21, 22). en la adolescencia se adquieren y se afianzan comportamientos alimentarios que resultan de la interacción con el contexto sociocultural, de la familia, los amigos, el colegio y, últimamente, los medios de comunicación, todos los cuales influyen en las prácticas relacionadas con la alimentación de los adolescentes (23, 24, 25). en esta etapa de la vida la familia constituye una gran influencia en las creencias (26), en las prácticas alimentarias, y en la selección y consumo de alimentos (23, 27, 28, 29, 30). en el contexto familiar la madre ejerce la mayor influencia (31, 32, 33), en gran parte porque es la encargada de comprar y preparar los alimentos (34, 35). la escuela constituye otro espacio que puede influenciar de forma negativa o positiva los hábitos alimentarios de los adolescentes; de forma negativa por la tendencia actual de muchos planteles educativos que ofrecen y venden meriendas con niveles elevados de grasa y bebidas con alto contenido calórico (gaseosas y jugos artificiales) que están desplazando el consumo de frutas y vegetales en las dietas de los adolescentes, y contribuyen a la ingesta de grasas saturadas que exceden los niveles recomendados (36). también la 202 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 escuela influye de forma positiva mediante intervenciones ambientales incrementando la disponibilidad y la promoción de alimentos bajos en grasa (2). finalmente, los pares o amigos ejercen influencia en las creencias y en las prácticas relacionadas con la alimentación de los adolescentes (26, 27) a través de la elección y el consumo de los alimentos (26). con el fin de generar cambios en este grupo poblacional, en el ámbito colombiano se han establecido las obligaciones que tienen el gobierno y los diferentes estamentos nacionales en relación con la alimentación y la nutrición de este grupo poblacional (37), esas obligaciones consisten en el fomento de estilos de vida saludables, seguridad alimentaria, evaluación nutricional y suministro de complementos alimentarios, las cuales son asumidas principalmente por el sector salud mediante acciones de promoción de la salud y prevención de la enfermedad, donde el profesional de enfermería tiene un papel fundamental. pero a pesar de las acciones realizadas los adolescentes continúan consumiendo en mayor cantidad alimentos no sanos. por lo anterior, y dada la importancia de un fenómeno tan complejo como es el de la alimentación de los adolescentes, y teniendo en cuenta su efecto en la salud, la presente investigación tiene como propósito describir los significados de los alimentos y las prácticas relacionadas con la alimentación de un grupo de adolescentes escolarizados de la ciudad de cali, recogiendo los espacios de la familia, el colegio y la calle donde interactúan con sus pares o amigos. materiales y métodos este estudio comprende un abordaje cualitativo de tipo exploratorio y participativo, fundamentado en la hermenéutica dialéctica. la hermenéutica se fundamenta en la comprensión, entendida por gadamer como un movimiento abarcador y universal del pensamiento del ser humano, originado a partir de un proceso de intersubjetividad y objetividad (38). por tanto, no es un proceso mecánico ni concluido, al contrario, tiene presente que todo lo que se interpreta no puede ser entendido de una sola vez y totalmente, se obliga al investigador a llevar a cabo un proceso de descubrimiento que muchas veces es inconsciente. de otro lado, la dialéctica implica una relación entre contrarios, interpretada desde platón (39) como la relación del todo y las partes, retomada por los neomarxistas como el carácter total de la existencia humana y de la ligación indisoluble entre la historia de los hechos económicos y sociales, y la historia de las ideas; por tanto, el concepto de totalidad es utilizado como instrumento interpretativo a partir del cual se entiende no la invariabilidad de la realidad social, sino las diferencias en la unidad, como son engendradas en una realidad determinada (40). la hermenéutica dialéctica se fundamenta en una perspectiva totalizadora heurística que según de souza minayo (40) “refleja relaciones reales, es decir, al mismo tiempo que ve la realidad como un todo coherente; comprende y analiza las partes del todo formando correlaciones concretas de conjuntos y unidades siempre determinadas. afirma los principios de complejidad y de diferenciación”. como técnica se utilizó el análisis de contenido de los textos grabados en au203 la alimentación de los adolescentes: el lugar y la compañía determinan las prácticas alimentarias l olga osorio-murillo, maría consuelo del pilar amaya-rey dio y transcritos. en esta etapa se generó un proceso de reflexión tanto individual como colectiva con los adolescentes y los otros actores, estos últimos integrados por familiares significativos para ellos, fundamentado en la hermenéutica dialéctica. el tamaño de la muestra se determinó con base en el criterio de casos ricos en información que demostraran diversidad en sus categorías (41, 42)4, y estuvo conformada por los datos aportados por 31 adolescentes (14 hombres y 17 mujeres), 10 familiares (6 madres, 2 padres, 2 abuelas), 3 profesores y la administradora de la cafetería del colegio. este grupo se consolidó aplicando el criterio de saturación de datos que se alcanza cuando hay una redundancia en la información, es decir, cuando se obtuvo información similar y los informantes no aportaron nada diferente a lo dicho o hecho anteriormente. la información se recolectó mediante entrevistas semiestructuradas a adolescentes, familiares, profesores y administradora de cafetería, y la observación participante en la cafetería y los grupos focales con los adolescentes. los criterios de inclusión fueron: para los adolescentes, pertenecer a los grados 9, 10 y 11 del colegio nuestra señora de guadalupe, haber sido valorados previamente por antropometría, estar clasificados en las categorías de bajo peso, normal, sobrepeso y obesidad, y aceptar participar en el estudio; en cuanto a los familiares y profesores, se incluyeron los que determinaron los adolescentes y que aceptaron participar en el estudio. la administradora de la cafetería se incluyó al aceptar participar en la investigación. el consentimiento informado fue diligenciado por todos los participantes. actividades previas al desarrollo de la investigación. una vez seleccionados los adolescentes para la fase cualitativa se realizaron varios encuentros en los salones, en los cuales se llevaron a cabo actividades grupales de integración con el objetivo de conocerlos más. posteriormente, se realizaron entrevistas para diligenciar el familiograma y el ecomapa con los 31 adolescentes seleccionados para esta fase cualitativa, allí se identificaron los familiares y profesores significativos en la alimentación. estrategia de recolección de información. la recolección de la información se llevó a cabo mediante entrevistas, grupos focales y observaciones en diferentes áreas del colegio en el tiempo de descanso de los estudiantes. este proceso se llevó a cabo en el colegio y las viviendas de los adolescentes en el periodo entre marzo y junio del año 2008. rigor metodológico. esta investigación aborda un tema de la cotidianidad, de la vida práctica de los individuos, por lo cual se fundamenta en las opiniones de los actores involucrados en este proceso. el rigor de este trabajo se aseguró mediante los criterios de credibilidad, auditabilidad y transferibilidad (43, 44). esta investigación garantiza la credibilidad mediante la transparencia y la fidelidad en relación con los datos encontrados; los datos fueron recolectados durante un periodo de tiempo amplio, y fueron construidos e interpretados de forma cuidadosa y ejemplificados 4 patton (42) describe 13 estrategias para seleccionar intencionalmente casos ricos en información, los cuales deben ser listados como: muestreo de caso desviado o extremo, muestreo intensivo, muestreo de máxima variación, muestras homogéneas, muestreo de caso típico, muestreo intencional estratificado, muestreo de bola de nieve o encadenado, muestreo de criterio, muestreo de teoría basada en constructo operacional, casos conformes y disconformes, muestreo oportunístico, muestreo intencional aleatorio, casos de muestreo políticamente importante. esta investigación aborda un tema de la cotidianidad, de la vida práctica de los individuos, por lo cual se fundamenta en las opiniones de los actores involucrados en este proceso. 204 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 a través de las respuestas de los actores participantes. igualmente, la credibilidad se asegura mediante la triangulación de la información obtenida a través de múltiples fuentes (entrevistas individuales, grupos focales y observaciones); diferentes contextos (casa, colegio, calle), y los diferentes actores (adolescentes, familiares, profesores y administradora de la cafetería) que ampliaron la visión sobre el fenómeno central de la investigación: la alimentación. finalmente, con la devolución de la información a los actores participantes se aseguró la credibilidad de este trabajo, pues permitió corroborar lo establecido por ellos. la auditabilidad o confirmabilidad de esta investigación se garantizó mediante la existencia de grabaciones de las entrevistas realizadas, los registros de las entrevistas crudas, la transcripción fiel de los diálogos, las notas de campo y las observaciones y la descripción de los contextos sociales e históricos donde se llevó a cabo esta etapa. igualmente, esta investigación ha mostrado congruencia entre la definición del tema, la recolección de la información y los resultados. la transferibilidad o aplicabilidad se aseguró al presentar los resultados que identifican al grupo de adolescentes en su contexto social e histórico. resultados el análisis de los textos producidos por las fuentes listadas en la interacción con los diferentes actores permitió construir en la etapa cualitativa la categoría denominada: el espacio y la compañía determinan lo que comen los adolescentes; aquí se recogen los espacios de la familia, el colegio y la calle, los cuales se describen en las siguientes subcategorías: en la casa, las tradiciones, la compañía familiar y tener o no quién les prepare las comidas determinan lo que comen los adolescentes; en el colegio los determinantes son la autonomía, la disponibilidad económica y la preferencia de los adolescentes, además de la oferta de alimentos en la cafetería; en la calle, el género, la amistad y el amor determinan lo que comen los adolescentes (figura 1). subcategoría: en la casa, las tradiciones, la compañía familiar y tener o no quién les prepare las comidas determinan lo que comen los adolescentes. en la casa los adolescentes consumen frutas, verduras, carnes, lácteos, gaseosas, comidas rápidas y cereales (se refieren al cereal del desayuno). los hombres consumen leguminosas, las mujeres no. entre la compañía y la soledad a las horas de las comidas de los adolescentes. la mayoría de los adolescentes tiene la compañía de padres, hermanos o abuelos a la hora de las comidas, lo cual es similar a los resultados de un estudio con adolescentes turcos (45). cuando la madre permanece en la casa, o cuando la familia es extensa y conviven con familiares como el papá o la abuela, los adolescentes consumen alimentos tradicionales (carnes, lácteos, frutas, verduras, cereales y leguminosas), igual pasa con adolescentes de costa rica y estados unidos, donde se encontraron correlaciones positivas entre los tiempos de comida compartidos con la familia y la calidad de las dietas de los adolescentes (46, 47). algunos adolescentes, hombres y mujeres, comen solos normalmente. los horarios del colegio, el trabajo de ambos padres y diferentes actividades de las madres llevan a que los jóvenes estén solos a las horas de las comidas; igual situación se presenta en adolescentes de estados en la casa, las tradiciones, la compañía familiar y tener o no quién les prepare las comidas determinan lo que comen los adolescentes. 205 la alimentación de los adolescentes: el lugar y la compañía determinan las prácticas alimentarias l olga osorio-murillo, maría consuelo del pilar amaya-rey unidos, donde las comidas en familia raramente se dan debido a la programación de los adolescentes y de sus padres (46), esto lleva a que en algunos casos estos jóvenes no consuman los alimentos y a que se aumente el riesgo de trastornos de la conducta alimentaria (48). en otros casos, los adolescentes compran y consumen en la calle alimentos diferentes a los tradicionales (generalmente comidas rápidas y gaseosas); en estos casos no hay control del consumo por parte de los padres o adultos responsables. las prácticas relacionadas con la alimentación tienen dentro de sus funciones el establecimiento y mantenimiento de relaciones sociales y culturales con los miembros de la familia, amigos, extraños y otros (49). el alimento es un símbolo que indica unos patrones culturales y ensaya o mantiene relaciones con otros seres humanos. los rituales alimenticios son importantes para unir a la gente o iniciar y mantener creencias y valores culturales especialmente en las familias, por lo tanto la presencia de compañía en los momentos en que los adolescentes comen es un vehículo importante de socialización y aprendizaje. se constituye en el espacio de comunicación con los padres o con otros miembros de la familia (28, 29, 50). la familia, por tanto, genera gran influencia en los comportamientos alimentarios de los adolescentes, los padres les proporcionan los alimentos y el contexto social de las comidas (51). el comer viendo televisión. la mayoría de los adolescentes comen viendo televisión; generalmente, cuando el adolescente está solo come viendo la televisión; este aparato se convierte en su compañía, esto pasa también con jóvenes de estados unidos (46) y australia (52) que se describen comiendo solos en sus cuartos. […] pero de pronto no, porque de pronto hay veces que uno llega a la casa y no hay nadie, entonces uno mismo se sirve el almuerzo y como por no sentirse solo uno prende el televisor y sigue viendo y cuando ya termina, seguís viendo tele o escuchando música el caso es no sentirse sola. mientras que si estás con una persona al lado vos conversás con ella y a la vez ves televisión pero te sentís más acompañada (gf-mb-03, 219-224). cuando los adolescentes ven televisión no se concentran en lo que comen, no se dan cuenta lo que están ingiriendo. oom: ¿qué pasa cuando uno está comiendo y viendo televisión? está pendiente uno del televisor y no de lo que está comiendo (gf-hb-03, 118-120). incluso algunos adolescentes prefieren comer viendo televisión que hablar con los amigos. este tipo de práctica limita la función social de la alimentación que implica la interacción con otras personas, conduciendo al adolescente a la soledad. ver televisión a las horas de las comidas se volvió costumbre, lo hacen desde la infancia. cuando se come viendo televisión se seleccionan alimentos diferentes a los tradicionales que se consumen en la familia, esto implica la posibilidad de comer solo y comer lo que prefiere. estudios realizados con adolescentes de australia y estados unidos reportaron situaciones similares, en donde los adolescentes que permanecen viendo televisión tienden más a comer alimentos no saludables (52, 53). la televisión transmite un mensaje encontrado con respecto a los hábitos alimenticios, apoya el consumo de ciertas comidas y bebidas presentadas como “socialmente prestigiosas”, “sanas” y “sabrosas”, conlos rituales alimenticios son importantes para unir a la gente o iniciar y mantener creencias y valores culturales especialmente en las familias, por lo tanto, la presencia de compañía en los momentos en que los adolescentes comen es un vehículo importante de socialización y aprendizaje. 206 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 fundiendo a los adolescentes, pues en realidad contienen grandes proporciones de alimentos procesados con valor nutritivo limitado pero con contenido calórico elevado y con grandes cantidades de grasa. la tolerancia de muchos padres colabora en la tendencia de los adolescentes a “comer viendo televisión” (54). los adolescentes que se saltan las comidas y aquellos que no lo hacen. una práctica común en los adolescentes es el saltarse las comidas; los hombres, y en mayor proporción las mujeres, usualmente se saltan una de las comidas principales, con mayor frecuencia la cena, seguida del desayuno y el almuerzo. el saltarse las comidas constituye una práctica realizada por adolescentes de diferentes regiones como lo reportan investigaciones hechas en países como italia (55), noruega (32, 56) y turquía (45). los adolescentes omiten las comidas cuando en la familia no les preparan los alimentos y les toca cocinar. ngm: pues los martes, miércoles sí desayuno porque ella está y me hace el desayuno y los lunes, pero los viernes son los días que más, no desayuno porque se va muy temprano y no me deja nada y me deja galletas y entonces no me dan ganas de hacer nada oo: no te dan ganas de preparar. ngm: si (ea101-ngm/bbs-01, 72-80). los adolescentes dejan de comer por problemas familiares, especialmente con las madres, estos problemas incluyen peleas, discusiones. también dejan de comer porque quieren adelgazar, esta práctica la realizan en su mayoría las mujeres (55), pero también se presenta en hombres, presionados por los cánones de la estética (57). la práctica de no comer para adelgazar ha sido aprendida en la familia, generalmente de la madre. particularmente se ha encontrado que la mujer tiene una influencia relevante en las hijas al transmitirles su insatisfacción con el cuerpo (57) y llevarlas a conductas restrictivas como no comer. cuando los adolescentes se saltan las comidas las reemplazan por productos de bajo valor nutritivo y de alto contenido calórico tales como gaseosas y productos empaquetados. de otro lado, cuando los padres ejercen control sobre los adolescentes no permiten que se salten las comidas, y usualmente influyen en el consumo de alimentos tanto en cantidad como en frecuencia y calidad (51). cuando se cocina para los adolescentes y cuando estos tienen que comprar la comida. en la mayoría de las familias de los adolescentes se preparan los alimentos que ellos consumen diariamente. en pocas familias de hombres y mujeres no se cocina en casa, por lo cual ellos tienen que comprar las comidas. respecto a las personas que cocinan para los adolescentes, la madre es quien con mayor frecuencia lo hace, ya sea que permanezca en la casa o que esté por fuera y deje la comida preparada. esta situación coincide con lo reportado por estudios hechos con familias de jóvenes en investigaciones llevadas a cabo en dos municipios de cundinamarca (34, 35). también participan de la preparación de los alimentos los padres y las abuelas, generalmente apoyando a las madres que laboran fuera de la casa, dejando a estas la responsabilidad de la cocina en el fin de semana. cuando no se puede cocinar para los adolescentes en la casa estos recurren se ha encontrado que la mujer tiene una influencia relevante en las hijas al transmitirles su insatisfacción con el cuerpo y llevarlas a conductas restrictivas como no comer. 207 la alimentación de los adolescentes: el lugar y la compañía determinan las prácticas alimentarias l olga osorio-murillo, maría consuelo del pilar amaya-rey a los restaurantes y a otros sitios para la compra de los alimentos, lo que genera que consuman diversos tipos de comidas con alta carga de harinas y grasas, pero también con presencia de leguminosas y carnes. cuando a los adolescentes les toca cocinar y cuando no lo hacen. cuando los padres o los adultos responsables no están en el hogar en la semana, en ocasiones a los adolescentes les toca preparar su comida. la mayoría de ellos, hombres y mujeres, cocinan en sus casas. de otro lado, existe un grupo de adolescentes —mujeres y hombres— que no cocinan, bien sea porque en la familia hay un encargado de hacerlo, porque les dejan preparado o porque les dan dinero para comprar alimentos. para algunos el cocinar es una imposición, por lo tanto, lo hacen por obligación debido a la ausencia de un adulto en la casa a las horas de las comidas. oom: ¿cocina tu mamá? ao: sí. oom: ¿tú cocinas? ao: pues cuando estoy solo me toca a mí solo. oom: ¿qué haces? ao: a veces hago arroz compro salchichón, hago un huevo y hago el arroz yo a veces… (ea-901-ao/bbs-01, 143-149). generalmente, cuando los adolescentes cocinan hacen preparaciones fáciles, las cuales no tienen un aporte equilibrado de nutrientes; esta situación es diferente a la reportada por larson et al. (58) con un grupo de adolescentes estadounidenses donde el preparar alimentos está relacionado con el consumo de comida sana. oom: ¿tú cocinas? jpp: hay veces, pero es que yo cocino cosas que son fáciles, pero si me frito unos huevos con salchicha y ya y como eso. oom: ahh. jpp: o me hago un sándwich, o arroz que todo el mundo en la casa como es algo esencial aunque nadie lo come uno siempre hace arroz, entonces ya me pongo a hacer el arroz pero o un sudado, que yo siempre hago sudados para todas las comidas (ea-902-jpp/ebs-01, 442-449). tradicionalmente, la familia ha tenido la responsabilidad de hacer cumplir las normas relacionadas con la alimentación de los adolescentes (30), pero los cambios en los modos de vida, las transformaciones sociales y económicas, y las innovaciones tecnológicas en la producción de alimentos contribuyen a las variaciones continuas en las prácticas relacionadas con la alimentación. los adolescentes son diferentes a sus padres: cambian los alimentos consumidos, los modos de prepararlos y las maneras de consumirlos. las dietas se han homogeneizado producto de los avances tecnológicos y de la influencia de los medios de comunicación (25); además, la tendencia familiar es a comprar en supermercados de grandes superficies donde existe una gran presión por la venta de productos alimenticios. la vinculación al trabajo de las madres de esta investigación conlleva cambios en la preparación de los alimentos tradicionales por otros que necesitan menos procesamiento —tanto si los preparan ellas o los mismos adolescentes—, cambios en los horarios de comida, y se pierde el espacio de comer juntos, cada uno come a diferentes horas, generalmente el adolescente come solo y en espacios diferentes al comedor, normalmente realizando otras actividades como ver televisión, navegar en internet, etc. cuando no se puede cocinar para los adolescentes en la casa estos recurren a los restaurantes y a otros sitios para la compra de los alimentos, lo que genera que consuman diversos tipos de comidas con alta carga de harinas y grasas, pero también con presencia de leguminosas y carnes. 208 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 subcategoría: en el colegio la autonomía, la disponibilidad económica y la preferencia de los adolescentes, además de la oferta de alimentos en la cafetería, determinan lo que comen los adolescentes. el descanso en el colegio es el espacio donde los adolescentes ingieren alimentos y comparten con sus compañeros. en el colegio el adolescente adquiere y afianza prácticas relacionadas con la alimentación a través de la información recibida en su formación, la imitación de los compañeros y la habituación a consumir los productos que venden en las cafeterías o los restaurantes escolares. el consumo de alimentos entre los hombres y las mujeres en el colegio no es homogéneo. en el colegio, los adolescentes hombres y mujeres consumen frutas, gaseosas, dulces y comidas rápidas. es mayor el número de adolescentes hombres que consumen comidas rápidas. solamente las mujeres consumen lácteos en el colegio. los gustos son diferentes entre hombres y mujeres, para los primeros es esencial la cantidad de alimento que se consume, prefieren aquellos de gran densidad, mientras que las mujeres prefieren consumir productos pequeños y de aporte calórico no muy elevado. oom: ¿usted encuentra alguna diferencia de alimentación entre los hombres y las mujeres? ag: sí. oom: ¿cuál sería? ag: a los hombres les gusta más la pizza, la hamburguesa y el perro, las niñas son más dadas a la chocolatina, a la nucita, al chicle, al bombón, que otra cosa es que yo cada rato les digo a ellas que comen y comen, eso rojo, las mentas son más de ellas (ep-ag-01, 41-48). los hombres compran en las cafeterías mientras que las mujeres traen de la casa o no comen por ahorrar. la mayoría de los hombres compran en la cafetería, algunas mujeres también lo hacen. las mujeres generalmente traen alimentos de la casa. un grupo de ellas no come en el colegio a fin de ahorrar dinero para otros gastos. en la cafetería del colegio los hombres compran preferentemente alimentos del tipo de comidas rápidas y gaseosas, igual situación se presenta en adolescentes escolarizados mejicanos (59). las mujeres llevan alimentos al colegio, en especial frutas, prefieren hacerlo por comodidad, ya que no tienen que hacer las filas en la cafetería, además porque es una costumbre familiar. oom: ah, traes de tu casa. pero algo especial porque comas siempre frutas. mfm: no, pues mi mama siempre nos compra y me empaca en el maletín (ea901-mfm1/mbs-01,175-176). igualmente, el llevar alimentos como frutas y compartirlas en el colegio les sirve a las adolescentes para bajar de peso o simplemente controlar el que tienen. esta es una práctica común entre ellas, incluso en otras culturas (55). oom: bueno, en esos grandes, hombres y mujeres comen diferente. ie: en los grandes los hombres y mujeres comen diferente, los hombres porque comparten de esa manera que le explicaba antes y las mujeres porque ellas frente al hecho a veces de cuidar los gustos son diferentes entre hombres y mujeres, para los primeros es esencial la cantidad de alimento que se consume, prefieren aquellos de gran densidad, mientras que las mujeres prefieren consumir productos pequeños y de aporte calórico no muy elevado. 209 la alimentación de los adolescentes: el lugar y la compañía determinan las prácticas alimentarias l olga osorio-murillo, maría consuelo del pilar amaya-rey la figura prefieren cederle el alimento a otro, las que están muy preocupadas y uno las nota que quieren, que se sienten afectadas por el gordito acá o por este otro, ellas en la casa de pronto les dan y ellas regalan los alimentos (ep-ie-01, 90-96). otra práctica común de las mujeres es la de no comprar a fin de ahorrar para otros gastos, normalmente lo que hacen es comer una menta o un chicle. igualmente, no compran en el colegio porque prefieren otro tipo de alimentos bajos en caloría que no se venden en la cafetería, tales como frutas, pan integral, avena y agua. los adolescentes viven un porcentaje importante de su tiempo en el colegio (ocho horas diarias en promedio). desde el punto de vista nutricional no solamente tienen la oportunidad de ingerir alimentos para satisfacer una necesidad, sino que también desde una dimensión social comparten, adquieren e imitan hábitos de alimentación de sus profesores y de sus pares. estudios realizados con adolescentes de áreas urbanas de brasil muestran cómo en el colegio en mayor medida los amigos, y en menor medida los profesores, tienen gran influencia en el consumo de productos empaquetados o snacks (meriendas) (60). por tanto, el ambiente escolar puede reforzar en forma positiva o negativa las elecciones que haga el adolescente de los alimentos que ingiere y la forma en que lo hace (2, 36). si bien es responsabilidad de los padres el educar a sus hijos, también lo es de la sociedad el apoyar su labor, y de los directivos y profesores de los colegios el favorecer una mejor alimentación entre los jóvenes. subcategoría: en la calle el género, la amistad y el amor determinan lo que comen los adolescentes. la selección de alimentos en los adolescentes se produce en una red de significados sociales donde los pares tienen gran influencia; el adolescente, en su búsqueda de identidad, adopta prácticas que buscan pertenencia a los grupos y que se alejan de las de su familia (26, 51). en la calle: lo que comen y en donde comen los adolescentes. los adolescentes hombres y mujeres consumen comidas rápidas en la calle con sus pares. algunos consumen frutas y lácteos. los hombres consumen licor y las mujeres snacks (meriendas) o productos empaquetados. los adolescentes, en su empeño por distinguirse de los adultos y de los niños, buscan formar y fortalecer su identidad generando prácticas diversas relacionadas con la alimentación, las cuales se pueden caracterizar desde la normatividad como no adecuadas, los pares tienen mucha influencia en la generación de estas prácticas (2). la mayoría uno va con los amigos a comer y digamos, uno que va a comer verduras uno aspira es a comer algo rápido, hamburguesas, pizzas, lo que quiere siempre es eso (gf-mb-01, 359-361). con los amigos del mismo género se come más relajado, con los amigos de diferente género y con los novios o las novias se cuidan más. la mayoría de los adolescentes hombres, y algunas mujeres, se sienten más en confianza comiendo con los pares del mismo género. con los amigos del mismo género los adolescentes comen comidas rápidas y carnes. asimismo, se sienten más en confianza, relajados, y no tienen que cumplir las normas de los adultos. la selección de alimentos en los adolescentes se produce en una red de significados sociales donde los pares tienen gran influencia; el adolescente, en su búsqueda de identidad, adopta prácticas que buscan pertenencia a los grupos y que se alejan de las de su familia. 210 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 dmo: bueno, una pregunta, ¿con quién se sienten más cómodos comiendo, con los amigos o con la familia? con los amigos. dmo: ¿pero por qué? por más confianza. sí, porque uno medio riega el jugo y vea traiga el trapeador. oom: con los amigos sí comen y hablan. sí oom: eso sí lo hacen todos. uno se ríe. lo mismo (gf-he-03, 212-221). con los amigos consumen principalmente sus comidas preferidas, tales como comidas rápidas y snacks (meriendas). estos alimentos tienen el significado de autonomía y de amistad, de compartir libremente con sus pares, de estar más relajados y alegres. otros alimentos como las verduras son considerados como obligación, por tanto les generan rechazo. la mayoría uno va con los amigos a comer y digamos uno que va a comer verduras uno aspira es a comer algo rápido, hamburguesas, pizzas, lo que quiera, siempre es eso (gf-mb-01, 359-361). los adolescentes, hombres y mujeres, son más cuidadosos cuando salen a comer con sus amigos especiales, novios o novias. en estas situaciones los hombres y las mujeres comen helados y algunas veces frutas. cuando se trata del amor se come diferente, siempre se busca verse bien, por lo cual las hamburguesas y los perros no se consumen con los novios o las novias. cita oom: ¿y con los amigos sales? jhv: sí oom: ¿qué diferencia hay entre helado, sándwich y hamburguesa? dfp: pues porque, es que por lo menos uno va a ir a comer con la novia hamburguesa perro o algo así, entonces uno pues, es algo como muy feo porque uno todo embutido ahí, ¿si me entiende?, es mejor comer algo como suave pero que sea rico y que sea fácil de comer (ea101-dfp/mes-02, 199-203). el helado tiene una connotación romántica para los adolescentes de ambos géneros, algunos también prefieren comer pizza en estas situaciones. las mujeres de peso elevado se limitan en el consumo de alimentos durante la semana para poder salir a comer un helado el fin de semana. oom: […] helados? ¿cuándo? en las fiestas. oom: ¿en las fiestas? cuando sale con la novia. oom: cuando salen. cuando salen (gf-hb-02, 198-203). que de pronto digamos sales con un amigo y por decir digamos estás en un parque no vas a pedir otras cosa que no sea un helado, una paleta (gf-mb-03, 131.132). las prácticas relacionadas con la alimentación son procesos complejos que están condicionados por la realidad biológica, psicológica y social que viven los adolescentes (61). ellos comen lo que les sienta bien, lo que han aprendido a comer a lo largo de sus vidas, y lo que les brinda placer en circunstancias que para ellos son favorables. los adolescentes consumen diferentes alimentos de acuerdo con el espacio y la compañía que tienen e incluso el tiempo, el comer con la familia se relaciona con la rutina que se tiene durante la semana, por el contrario, el comer con los amigos o los novios o las novias se lleva a con los amigos consumen principalmente sus comidas preferidas, tales como comidas rápidas y snacks (meriendas). estos alimentos tienen el significado de autonomía y de amistad. 211 la alimentación de los adolescentes: el lugar y la compañía determinan las prácticas alimentarias l olga osorio-murillo, maría consuelo del pilar amaya-rey cabo los fines de semana y en espacios de la calle, implica cambio, variedad para los adolescentes: es como los diferentes espacios donde uno se encuentre, es como saber que en la casa hay una rutina de alimentos y que cuando es sábado cambia de espacio, de ambiente, que lo que se va a comer es algo diferente (gf-mb-01, 364-366). el espacio constituye una dimensión importante en la alimentación de los adolescentes, envuelve un conjunto de rituales que cercan el acto alimentar en el sentido estricto (62). al igual que es importante tener en cuenta los tipos de alimentos que se consumen y los horarios, los espacios donde se lleva a cabo el consumo de alimentos varían de una cultura a otra y de un grupo a otro (61), como es el caso de los adolescentes cuando comen con los adultos y cuando lo hacen con sus pares. que por el parche, que uno esté con los amigos y le tocó comerse algo así por diversión, bien… pero que usted todos los días al desayuno sea una hamburguesa (gf-me-02, 207-209). durante la semana los adolescentes hombres y mujeres consumen en la casa alimentos tales como frutas, jugos de frutas, verduras, carnes, lácteos, cereales y leguminosas, estos alimentos hacen parte de la rutina de la familia establecida por los adultos, allí no tienen la posibilidad de elegir cuáles consumir; de otro lado, los fines de semana ellos consumen otros alimentos, preferentemente comida chatarra, dulces, helados y gaseosas, este es el espacio que comparten con los pares y en el que pueden elegir. además del tipo de alimentos que consumen es importante el comportamiento que tienen y en ello influyen no solamente el espacio y la compañía, sino también el tipo de relación que tengan con esta última, y el grado de confianza; así, el adolescente presenta un comportamiento diferente cuando come con la familia y cuando lo hace con los amigos, con estos últimos se siente más relajado y disfruta más de lo que come. pues, yo creo que cuando uno está con los amigos de confianza uno come normal […] pues que uno puede estar “recochando”, molestando, en cambio cuando uno está con alguien, un amigo o algo uno come lo más decente, lo más correcto. con la familia siempre sucede que uno es más cuidadoso, mientras que con los amigos a uno no le importa si se regó porque, porque es gente si, gente de la misma edad de uno […] no con los (amigos) especiales yo creo que ya uno es como más moderado cuando va a comer (gf-mb-03, 140-151). la familia, por tanto, es la generadora de normas de comportamiento en la alimentación (51), al contrario, al comer con los amigos no hay un sistema de normas establecidas, lo que hace que se sientan más tranquilos y en confianza comiendo con ellos. conclusiones y recomendaciones el lugar y la compañía determinan las prácticas alimentarias en los adolescentes. los alimentos que consumen en la casa, el colegio y los espacios de la calle son diferentes. de otro lado, para el joven el comer con la familia significa la rutina de la semana, por el contrario, hacerlo con los amigos, los novios o las novias se relaciona con la variedad y la autonomía de los fines de semana. 212 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 el control a las horas de las comidas constituye un factor protector de hábitos adecuados en los adolescentes, cuando este come acompañado de su madre o de adultos preserva las tradiciones de la familia mediante el consumo de alimentos sanos como las frutas, los jugos de frutas, las verduras, las carnes, los lácteos, los cereales y las leguminosas. el alimento se constituye en un elemento de unión e interacción con otros, en este caso la familia. el comer solo constituye un factor de riesgo en la alimentación de los adolescentes, pues o consumen alimentos con poco valor nutritivo como son las comidas rápidas, los dulces y las gaseosas, o no los consumen, aumentando el riesgo de trastornos de la conducta alimentaria. el adolescente que come solo tiende más a ver televisión y a comer alimentos no adecuados para la salud de los adolescentes. en el colegio se observan diferentes comportamientos en adolescentes hombres y mujeres relacionados con la alimentación; para los hombres es esencial la cantidad de alimento que se consume, se inclinan por aquellos de gran densidad y prefieren comprar en la cafetería escolar; mientras que las mujeres prefieren consumir productos pequeños, de aporte calórico no muy elevado, que les sirvan para bajar de peso y traídos de la casa, o simplemente no comen. en la calle, en su búsqueda de identidad, los adolescentes adoptan prácticas que buscan pertenencia a los grupos y que se alejan de las de sus familias. los alimentos tienen varios significados, entre ellos, la producción de placer y el ser un medio para el establecimiento y mantenimiento de la sociabilidad. se puede afirmar que es importante tener en cuenta lo que comen los adolescentes y las circunstancias en que lo hacen, ya que al consumir alimentos están proporcionando al cuerpo sustancias bioquímicas y la energía necesaria para subsistir y desarrollar las actividades diarias, adquiriendo con ello las características físicas que los asemejan y los distinguen de otros y, al mismo tiempo, al consumir los alimentos están incorporando sus significados, sus propiedades sociales y comportamentales, contribuyendo a conformar su identidad individual y cultural. para enfermería es de suma importancia conocer los significados que los adolescentes dan a los alimentos en los espacios de la familia, el colegio y los amigos, ya que esto permitirá plantear acciones conjuntas de promoción de la salud con participación de los adolescentes, sus familias, los integrantes de la comunidad escolar y los amigos. la promoción de la salud se aplica en la cotidianidad del cuidado de enfermería, implica la visibilización del adolescente como sujeto activo que puede sostener estilos de vida adecuados o puede cambiar conductas de riesgo, contando con la participación de las familias, los pares, los profesores y la comunidad en general. para ello se debe realizar un trabajo articulado que involucre cambios de conducta en los adolescentes y sus familias, intervención en la cafetería del colegio, intervenciones educativas con padres, profesores y estudiantes, intervenciones en la comunidad y participación en las políticas relacionadas con alimentación. 213 la alimentación de los adolescentes: el lugar y la compañía determinan las prácticas alimentarias l olga osorio-murillo, maría consuelo del pilar amaya-rey referencias bibliográficas 1. mahon n, yarcheski tj, yarcheski a. the revised personal lifestyle questionnaire for early adolescents. western journal of nursing research 2002; 25 (5): 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family cohesion and healthy eating behaviors in adolescent girls. international journal of eating disorders 2008: 41 (4): 360-367. 52. macfarlane a, crawford d, ball k, saviger g, worsley a. adolescent home food environments and socioeconomic position. asia pac j clin nutr 2007; 16 (4): 748-756. 53. utter j, neumark-sztainer d, jeffery r, story m. couch potatoes or french fries: are sedentary behaviors associated with body mass index, physical activity, and dietary behaviors among adolescents? american dietetic association journal 2003; 103 (10): 8. 54. fernandez sjpm. dietary habits and nutritional status of school aged children in spain. nutr hosp. madrid mayo-jun 2006; 21 (3): 374-378. 55. messina f, saba a, vollono c, leclercq c, piccinelli r. beliefs and attitudes towards the consumption of sugar-free products in a simple of italian adolescents. european journal of clinical nutrition 2004; 58: 420-428. 56. samuelson g. dietary habits and nutritional status in adolescents over europe. an overview of current studies in the nordic countries. european journal of clinical nutrition 2000; 54 (1): 21-28. 57. ogden j. insatisfacción corporal. en: psicología de la alimentación. comportamientos saludables y trastornos alimenticios. capítulo vi. traducción de pablo manzano. madrid: ediciones morata; 2003. 58. larson n, story m, eisenberg me, neaumark-sztainer d. food preparation and purchasing roles among adolescents: associations with sociodemographic characteristics and diet quality. journal of the american dietetic association 2006; 106 (2): 211-218. 59. castaneda so, rocha dj, ramos-aispuro, mg. evaluación de los hábitos alimenticios y estado nutricional en adolescentes de sonora, méxico. archivos de medicina familiar 2008; 10 (1): 7-9. 60. doyle ei, feldman rh. factors affecting nutrition behavior among middle-class adolescents in urban area of northern region of brazil. rev saúde pública. são paulo 1997; 31 (4): 342-350. 61. garcía am. los condicionamientos contextuales y la variabilidad cultural de los comportamientos alimentarios. en: contreras j, garcía am (eds.). alimentación y cultura. perspectivas antropológicas. barcelona: ariel antropología; 2005. pp. 86-87. 62. pulain jp. o espaço social alimentar: um instrumento para o estudo dos modelos alimentares. in: sociologias da alimentação. capítulo ii. florianópolis: editora da ufsc; 2006. p. 256. 216 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 en la casa: las tradiciones, la compañía familiar y tener o no quién les prepare las comidas determinan lo que comen los adolescentes. en el colegio: la autonomía, la disponibilidad económica y la preferencia de los adolescentes, además de la oferta de alimentos en la cafetería, determinan lo que comen los adolescentes. en la calle: el género, la amistad y el amor determinan lo que comen los adolescentes. el lugar y la compañía determinan lo que comen los adolescentes. figura 1. el espacio y la compañía determinan lo que comen los adolescentes. 97 108 investigacion que prueba teoria.indd 97 viviana marycel céspedes-cuevas1 investigación que prueba teoría: una aproximación desde enfermería cardiovascular 1 doctora en enfermería. profesora asociada. universidad nacional de colombia. vmcespedesc@unal.edu.co recibido: 19 de octubre de 2011 aceptado: 2 de febrero de 2012 resumen el presente artículo reporta los resultados de una investigación descriptiva de comprobación teórica que prueba y verifica los planteamientos del modelo conceptual del manejo del síntoma en la primera dimensión. la muestra fue de 380 mujeres hospitalizadas con diagnóstico confirmado de síndrome coronario agudo. las ecuaciones estructurales fueron utilizadas para el análisis. usando la técnica de análisis factorial confirmatorio los componentes de percepción, evaluación y respuesta, fueron tratados como funciones conjuntas de la variable latente “experiencia del síntoma”. a partir de todas las posibles combinaciones de las agrupaciones identificadas, se expusieron tres (3) modelos con un adecuado ajuste entre el modelo hipotetizado y los datos, los cuales mostraron que el componente de evaluación se manifiesta en la experiencia del síntoma. los resultados de este estudio generan un aporte a la teoría y a la investigación, además de mostrar la importancia de las intervenciones de tipo cognitivo para promover una respuesta favorable de la mujer con síndrome coronario agudo, en el proceso de afrontamiento ante la enfermedad. palabras clave sistema cardiovascular, enfermería, investigación sobre servicios de salud, investigación. (fuente: decs, bireme). research to test theory: an approach from cardiovascular nursing abstract this article reports the results of a descriptive research of testing that tested and verified the proposed theoretical approaches of the conceptual model of symptom management in the first dimension. the sample included 380 women hospitalized with confirmed diagnosis of acute coronary syndrome. structural equations were used for the analysis. using the technique of confirmatory factor analysis, components of perception, evaluation and response, were treated as joint functions of the latent variable “symptom experience”. from año 12 vol. 12 nº 2 chía, colombia agosto 2012 l 97-108 98 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 all possible combinations of the cluster identified, were presented three (3) models with a proper fit between the hypothesized model and data, which showed that the evaluation component is manifested in the experience symptoms. the results of this study generate a contribution to theory and research, also showing the importance of the cognitive interventions to promote a favorable response from women with acute coronary syndrome in the process of coping with the disease. key words cardiovascular system, nursing, health services research, research. (source: decs, bireme). pesquisa que prova teoria: uma aproximação a partir da enfermagem cardiovascular resumo o presente artigo relata os resultados de uma pesquisa descritiva de comprovação teórica que prova e verifica as propostas do modelo conceitual da gestão do sintoma na primeira dimensão. a amostra foi de 380 mulheres hospitalizadas com diagnóstico confirmado de síndrome coronariana aguda. as equações estruturais foram utilizadas para a análise. usando a técnica de análise fatorial confirmatória, os componentes de percepção, avaliação e resposta foram tratados como funções conjuntas da variável latente “experiência do sintoma”. a partir de todas as possíveis combinações das agrupações identificadas, expuseram-se três modelos com um adequado ajuste entre o modelo hipotetizado e os dados, os quais mostraram que o componente de avaliação se manifesta na experiência do sintoma. os resultados deste estudo geram uma contribuição para a teoria e para a pesquisa, além de mostrarem a importância das intervenções de tipo cognitivo para promover uma resposta favorável da mulher com síndrome coronariana aguda, no processo de enfrentamento da doença. palavras-chave sistema cardiovascular, enfermagem, pesquisa sobre serviços de saúde, pesquisa. (fonte: decs, bireme). 99 investigación que prueba teoría: una aproximación desde enfermería cardiovascular l viviana marycel céspedes-cuevas introducción los diseños de investigación reflejan las diversas posturas filosóficas con las cuales el conocimiento puede ser desarrollado. es así como reciben influencia desde los paradigmas naturalista, crítico-emancipatorio o postpositivista, con el fin de llegar a niveles de alcance ya sea descriptivos, interpretativos, explicativos o predictivos (1). de aquí surge la división un tanto arbitraria de dos categorías mayores para los diseños de investigación, la cualitativa y la cuantitativa. la primera típicamente utilizada para generar teoría descriptiva y la segunda frecuentemente desarrollada para probar teoría en todos sus niveles de desarrollo. en este sentido “probar teoría” puede significar ponerla a prueba con el fin de confirmarla, refutarla o expardirla, lo cual supone la utilización de los postulados pospositivistas sustentados en la falseabilidad de la hipótesis (2). una variedad de opciones metodológicas para derivar comprobación teórica pueden ser utilizadas desde la investigación, es así como se puede hacer uso desde modelos estadísticos básicos univariados o bivariados hasta diseños de experimentación verdadera. en el presente artículo se abordarán los resultados obtenidos de un diseño descriptivo que expande los postulados para el manejo de los síntomas cardiovasculares desde enfermería, a partir del proceso de comprobación de los supuestos de la primera dimensión del modelo conceptual del manejo del síntoma (smc) (3). modelo conceptual el smc utilizado en el presente estudio, específicamente en su primera dimensión teórica denominada “experiencia del síntoma”, se encuentra vinculado al centro para el manejo del síntoma (csm) de la facultad de enfermería de la universidad de california san francisco (4), que propone que los síntomas deben ser vistos como experiencias subjetivas que reflejan un cambio en la función biopsicosocial, sensación o cognición de una persona. a partir de la conceptualización realizada entorno a los síntomas, el csm propuso el smc con el fin de plasmar a profundidad el trabajo de investigación ya realizado. el modelo original fue publicado en 1994; posteriormente en el 2001 se publicó su contexto filosófico, capturado en los estamentos proposicionales y se plasmó la modificación inicial. cada uno de los miembros del csm tiene sus programas individuales de investigación donde se prueban diferentes partes del modelo con poblaciones clínicas específicas. los equipos de investigación son interdisciplinarios y en total el csm cuenta con 174 participantes (3). hasta el momento el modelo es de carácter descriptivo, con algunas verificaciones de tipo correlacional que se han explorado con el estudio de conglomerados de síntomas y su efecto en el estatus funcional de pacientes con cáncer (5). el foco primario del modelo es la persona con síntomas, circunscrita entorno a 3 dimensiones: la experiencia del síntoma, las estrategias de manejo del síntoma y los resultados del síntoma. así mismo se fundamenta en la premisa que las tres dimensiones se encuentran interrelacionadas e influidas por variables contextuales externas. las relaciones entre una dimensión y otra, los componentes particulares y las variables contextuales correspondientes a los dominios de la ciencia de enfermería, fueron revisadas mediante reportes de investigación y hallazgos experimentales, en congruencia con las conceptualizaciones del csm, sin embargo, aún no han sido probadas (3). a continuación se presentan las definiciones centrales de la dimensión estudiada. primera dimensión: la experiencia de los síntomas. incluye la percepción individual de los síntomas, la evaluación del significado y la respuesta; elementos que se relacionan de forma bidireccional (3), (4). es así como si existe una creencia individual de que los síntomas tienen un significado importante, la percepción de intensidad puede también ser alta. en el modelo estos procesos son concebidos como interactivos y pueden ocurrir simultáneamente. los componentes de esta dimensión se definen a continuación: percepción de los síntomas: proceso de recibir entradas sensitivas. es descrita en el smc como la notificación de un cambio en la forma como un individuo usualmente siente o se comporta. se define como una interpretación consciente y cognitiva de la información dada por señales del contexto en un ambiente o situación particular (3). este concepto incluye: 100 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 l conciencia somática: definida como estar consciente del cuerpo o de alguna función fisiológica. l descriptores de los síntomas: actúan como el puente entre la percepción del paciente y el reporte de los síntomas al evaluador. l intensidad y umbral de los síntomas: definidos como la sensibilidad a un estímulo. l localización: ubicación de los síntomas. l comorbilidades: eventos concomitantes que contribuyen a atenuar o confundir la percepción de los síntomas. evaluación de los síntomas: juicio que una persona hace acerca de los síntomas, tal como la intensidad, localización, naturaleza temporal, frecuencia, severidad, seriedad, causa, posibilidad de recibir tratamiento y efecto de los síntomas en la vida (4). de igual manera incluye la evaluación de amenaza que poseen los síntomas, así como si son o no peligrosos o tienen un efecto discapacitante. a diferencia de la percepción, la evaluación involucra un alto proceso cognitivo para añadir significado a los síntomas. respuesta a los síntomas: incluye componentes fisiológicos, sicológicos y comportamentales (4). las respuestas fisiológicas son manifestaciones físicas de los síntomas. las respuesta sicológicas están reflejadas en cambios cognitivos o afectivos. las respuestas comportamentales son las expresiones objetivas de los síntomas e incluyen comunicación verbal o social. como se había enunciado, las dimensiones del modelo se encuentran contextualizadas por variables externas, las cuales se mencionan a continuación: variables personales: las variables del dominio de persona –demográfico, psicológico, sociológico y fisiológico– son intrínsecas a las visiones y respuestas individuales de la experiencia de los síntomas. su alcance depende del nivel de desarrollo o maduración del individuo, influencian la percepción de los síntomas y pueden ser influenciadas por ellos (4). las variables demográficas básicas son edad, sexo, etnicidad, estado marital y estatus financiero. las variables psicológicas incluyen los rasgos de personalidad, capacidad cognitiva y motivación. la categoría sociológica incorpora la unidad familiar, la cultura y la religión. las variables fisiológicas son patrones de actividad y descanso y capacidad física. variables ambientales: el ambiente se refiere al agregado de condiciones o al contexto en el cual ocurren los síntomas. incluye variables físicas, sociales y culturales (4). el ambiente físico puede incluir la casa, el trabajo y el hospital. el ambiente social incluye el soporte social y las relaciones interpersonales. los aspectos culturales del ambiente son las creencias, los valores y las prácticas que son únicos a un grupo étnico, racial o religioso. variables relacionadas con el proceso salud-enfermedad: el dominio de salud y enfermedad está comprendido por variables únicas del estado de salud o enfermedad de un individuo e incluye factores de riesgo, estatus de salud y enfermedad o daño (4). los factores de riesgo pueden ser comportamientos heredados o comportamientos no heredados. el estado de salud incorpora ritmos fisiológicos, estructura corporal y función. la enfermedad o daño refleja desviaciones agudas y crónicas debido a patologías. las variables incluidas en el dominio de salud-enfermedad tienen directos e indirectos efectos en la experiencia de los síntomas, manejo y resultados. supuestos teóricos y evaluación del modelo conceptual el smc está basado en 5 supuestos mayores (4): l la meta para el estudio de los síntomas está basada en la percepción de la experiencia individual y en su auto-reporte. l los síntomas no deben haber sido experimentados por un individuo para utilizar el modelo. el individuo puede estar a riesgo de desarrollar los síntomas. las estrategias de intervención pueden ser iniciadas antes de que el individuo experimente los síntomas. l en los pacientes que no pueden establecer una comunicación verbal, la interpretación por parte de los parientes o cuidadores es asumida para orientar la intervención. l las estrategias de manejo pueden ser aplicadas de forma individual o grupal. l el manejo del síntoma es un proceso dinámico, que es modificado de acuerdo con los resultados individuales y la influencia de los dominios de enfermería de persona, salud/enfermedad o ambiente. conforme a la postura filosófica del modelo, se asume al ser humano como un ser holístico, donde las partes se consideran 101 investigación que prueba teoría: una aproximación desde enfermería cardiovascular l viviana marycel céspedes-cuevas solamente en el contexto del todo. fawcett (6) afirma que bajo la visión holística el ser humano es una entidad integrada, organizada y no reducible a partes discretas. aún cuando las partes se reconocen, solamente tienen significado dentro del contexto de la persona total que mantiene interacciones recíprocas con otros seres humanos y con sus ambientes. el cambio de comportamientos ocurre a través de la vida como resultado de múltiples factores del individuo y del ambiente y a consecuencia de ello, las metas del cuidado deben derivarse siempre de las necesidades del individuo y su entorno. por lo anterior, la realidad es considerada multidimensional dependiente del contexto. los anteriores elementos ubican al smc dentro de una visión del mundo de interacción reciproca. a continuación se exponen los criterios de evaluación del modelo conceptual a partir de la estructura propuesta por fawcett (6). 1. explicación de orígenes: el surgimiento del modelo recibió una fuerte influencia de la práctica de enfermería y de la docencia debido a la motivación surgida por crear un andamiaje conceptual del manejo de los síntomas, desde una visión holística. sin embargo, la mayor influencia la recibe de modelos basados en la investigación antropológica, sociológica y sicológica como fueron las posturas centradas en la definición del síntoma (7), en la búsqueda de la salud (8), en los comportamientos sociales (9), en la autorregulación del síntoma (10), (11), en los procesos cognitivos para el manejo del síntoma (12), (13) y de modelos de autocuidado que han interesado a las enfermeras por más de 20 años, dentro de los cuales se encuentra el modelo de autocuidado propuesto por orem (14) y teorías de mediano rango como la teoría de síntomas desagradables (15), (16) que aboga por la ocurrencia sincrónica de más de un síntoma y desarrolla un enfoque basado en las comunalidades existentes entre ellos. amaya y céspedes (17) exponen los encuentros conceptuales de estos abordajes alrededor del estudio de los síntomas. los supuestos presentados dentro del modelo conceptual son de origen teórico en su gran mayoría. no se reportan proposiciones empíricas comprobadas por investigación, por un lado por el alcance descriptivo del modelo, pero principalmente por ser uno de los modelos conceptuales más recientemente derivados y publicados en enfermería, lo cual supone un corto desarrollo en cuanto a la congruencia empírica y credibilidad en la práctica. 2. comprensión del modelo: es amplia en contenido y profundidad. todos los conceptos mayores y menores se encuentran claramente definidos. los dominios de la ciencia de enfermería persona, salud-enfermedad y ambiente son variables contextuales que influencian las tres dimensiones mayores del modelo: experiencia del síntoma, estrategias de manejo y resultados. el modelo posee una representación gráfica como diagrama de venn compleja como se puede valorar en la gráfica publicada en el 2001 (3) ya que presenta intersecciones bidireccionales entre las dimensiones mayores y menores (percepción, evaluación y respuesta como elementos constituyentes de la experiencia del síntoma). debido a que las flechas en dos direcciones representan poca precisión en la interacción entre los elementos conceptuales, fue pertinente para el presente estudio abordar una representación gráfica rediseñada para facilitar el desarrollo de las escalas de medición y la verificación de las relaciones entre los conceptos de la dimensión estudiada. es por ello que con base en la representación propuesta por cadwell m.a y miaskowski c (18) para estudiar la experiencia del síntoma de la mujer con angina, se propone una representación algorítmica o analítica (gráfica 1) en la cual, los conceptos de la primera dimensión interactúan pero pueden separarse y organizarse en un esquema que representa un flujo de información en donde la medición se pueda hacer por cada subconcepto y concepto menor. esta modificación se justifica en función de la construcción de las escalas de medición y el análisis de los datos derivados de la verificación del modelo. 3. congruencia lógica y generación de teoría: las autoras del smc realizan una excelente derivación y síntesis de conceptos y se evidencia una profunda revisión bibliográfica. el contenido de la estructura es lógico y congruente con el pensamiento filosófico plasmado. se evidencia claramente una visión de mundo de reciprocidad, una realidad contextualizada en la cual se negocian las metas de cuidado a partir del punto de vista de la persona y no solamente del profesional de enfermería. este modelo conceptual no ha derivado grandes teorías ni teorías de mediano rango. 4. credibilidad del modelo: se explora según los criterios de utilidad, congruencia y significancia social. 102 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 a. utilidad social: el modelo ha sido útil principalmente para la investigación y la docencia. en la investigación se ha utilizado en estudios descriptivos, correlacionales y experimentales en pacientes con cáncer (5) (19). se han desarrollado instrumentos de medición para la experiencia del síntoma, específicamente diseñados para el concepto menor de percepción y el subconcepto de intensidad en pacientes con cardiopatías (20). la investigación se ha concentrando principalmente en la primera dimensión del modelo. en la docencia el modelo se ha utilizado para el desarrollo del centro de investigación del manejo del síntoma, que a su vez dirige líneas formales de investigación en la facultad de enfermería de la universidad de california san francisco. en la asistencia y la administración, el modelo ha sido útil para hacer investigación en la práctica con individuos de todas las edades y diferentes condiciones de salud. además, se han derivado protocolos para la práctica y herramientas de valoración del estado de la salud en pacientes oncológicos y cardiovasculares. b. congruencia social: no se ha verificado hasta el momento. es importante que se valide a través de investigación. el resultado será un único sistema conceptual y teórico del conocimiento de enfermería, probado e implementado en la práctica a partir de los hallazgos científicos adquiridos empíricamente y factibles de ser instaurados como tradiciones duraderas aceptadas por las comunidades científicas y la sociedad en general. los autores del modelo (3) proponen que un proceso de interacción-transacción basado en metas conjuntas, será una herramienta atractiva para que los profesionales de salud y los usuarios incorporen los resultados de investigación en las prácticas clínicas y en la vida cotidiana. c. significancia social: existe eficacia demostrada de algunas intervenciones a partir de procesos investigativos en unidades de oncología (5) (19). no se ha comprobado que disminuya costos ni se han demostrado resultados en la práctica disciplinar de enfermería. 5. contribuciones para la disciplina de enfermería: el modelo conceptual provee una vía de pensamiento para la práctica, la investigación, la docencia y la administración de enfermería. el sistema conceptual requiere mayor investigación para el desarrollo de teorías de rango medio que favorezcan la predicción de resultados de la práctica de la enfermería. en síntesis se puede afirmar que el modelo conceptual del manejo del síntoma favorece la comprensión de la experiencia de los síntomas para el caso del presente estudio, en mujeres con síndrome coronario agudo (sca), por las siguientes razones: l el modelo contempla los componentes (percepción, evaluación, respuesta) concernientes al complejo fenómeno comportamental que antecede la búsqueda de ayuda profesional, los cuales son claves para el direccionamiento de la práctica disciplinar clínica. gráfica 1. representación algorítmica de la experiencia del síntoma fuente. céspedes, v.m. (2009) modelo conceptual del manejo del síntoma: clasificación por percepción, evaluación y respuesta de mujeres con síndrome coronario agudo; originada por la construcción de un instrumento validado en bogotá, colombia. universidad nacional de colombia. tesis doctoral, doctorado en enfermería, p. 37. percepción síntomas típicos síntomas atípicos evaluación origen de los síntomas seriedad de los síntomas respuesta acciones de respuesta tiempos de demora 103 investigación que prueba teoría: una aproximación desde enfermería cardiovascular l viviana marycel céspedes-cuevas l al ser demostrada la credibilidad del modelo, su aplicación permitirá los cambios deseables en la práctica disciplinar a través de la implementación de planes de acción basados en la teoría. diseño y método un diseño de investigación descriptivo útil para probar teoría es el desarrollo de instrumentos, a partir de la denominada investigación metodológica. el desarrollo de instrumentos permite medir las definiciones de los conceptos que constituyen una teoría. en este sentido este tipo de metodologías se convierten en una herramienta por excelencia para el desarrollo de investigación que prueba teoría. los resultados psicométricos derivados del presente estudio (21), (22) garantizan la construcción de un instrumento válido y confiable para la medición de la experiencia del síntoma de la mujer con sca, como primer garante de puesta a prueba del modelo conceptual por investigación. en el presente artículo se presentan los resultados específicos del modelo estadístico de comprobación teórica utilizado, producto de una investigación de tipo cuantitativa, descriptiva y exploratoria de corte transversal, la cual se desarrolló como tesis doctoral (23). se estudiaron 380 mujeres mayores de 20 años, hospitalizadas con diagnóstico confirmado de sca (evidenciado por cateterismo coronario con más del 75% de lesión), previa aprobación del estudio y consentimiento informado de las participantes. como punto de aproximación al proceso de comprobación de teoría, se tomó como foco primario de evaluación de la primera dimensión del smc, la determinación del ajuste entre el modelo hipotetizado y los datos obtenidos. se utilizaron las ecuaciones estructurales como abordaje de análisis; mediante la técnica de análisis factorial confirmatorio los componentes observables (percepción, evaluación y respuesta) fueron tratados como funciones conjuntas de variables no observables o latentes (experiencia del síntoma). aunque las ecuaciones estructurales constituyen un enfoque para la predicción (24), en el presente estudio se utilizaron con fines descriptivos debido al nivel de desarrollo del modelo. el fin último de este tipo de análisis es determinar si los ítemes diseñados para medir un factor particular (en este caso la variable latente de la experiencia del síntoma), lo hace de la misma forma como la teoría lo propone (25). en este estudio se consideró el criterio de la media de error inferior a 0.08 (25), el cual toma en cuenta el error de aproximación en la población, expresado en grados de libertad, lo que lo hace sensible al número de parámetros estimados en el modelo. valores inferiores a 0.05 indican buen ajuste y valores más altos que 0.08 representan errores razonables en la población (26). adicionalmente se consideró el reporte del intervalo de confianza alrededor del valor de error y el valor de p para la prueba, el cual debe ser superior a 0.50 (26). los datos se procesaron en el programa amos graphics 5.0, analysis of moment structures, adecuado para resolver situaciones complejas de interrelaciones que exigen utilizar modelos estructurales para realizar análisis factoriales confirmatorios que se orientan a explorar y confirmar modelos teóricos. resultados el procedimiento utilizado para el manejo de los datos se hizo mediante la ejecución de análisis factorial confirmatorio con todas las posibles combinaciones entre las agrupaciones identificadas por cada uno de los componentes. en total se obtuvieron treinta y seis (36) combinaciones, de las cuales solo tres (3) cumplieron con los parámetros establecidos para el ajuste. a continuación se presentan los tres (3) modelos de ajuste derivados. las siglas utilizadas en el programa corresponden a los siguientes significados: per = percepción eper = error de percepción eval = evaluación eeval = error de evaluación rta = respuesta erta = error de respuesta exp sint = experiencia del síntoma eexp sint = error de la experiencia del síntoma factpsicosociales, enfcoronaria, tiempo de demora: variables contextuales 104 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 gráfica 2. primer ajuste del modelo fuente. céspedes, v.m. (2009). tabla 1. primer ajuste del modelo fuente. céspedes, v.m. (2009). en la gráfica 2 se observa que se han obtenido los betas estandarizados en cada variable independiente, es decir se cuenta con coeficientes que exponen la medida de la contribución de cada elemento conceptual, en la experiencia del síntoma. los betas corresponden al valor de 1 para la percepción (grupo 1) influida por los factores psicosociales (con un valor de beta de 7.65), 3.74 para la evaluación (grupo 1) influida por la enfermedad coronaria previa (con un valor de beta de -9.27) y 2.38 para la respuesta (grupo 3) no influida por factores clínicos ni sociodemográficos. la evaluación aparece como el concepto más importante, por lo tanto la experiencia del síntoma se manifiesta con mayor fuerza en la evaluación. en la tabla 1 se muestra que el valor del error es 0.000, con 90% de intervalo de confianza entre 0.000 y 0.049 y con un valor de p para la prueba de ajuste igual a 0.954. con lo anterior se puede afirmar que el error en la población se encuentra entre 0.000 y 0.049, lo cual representa un grado satisfactorio de precisión. dado que el error estimado es <0.05 (0.000) y el valor de probabilidad asociado con la prueba de ajuste es >0.50 (p=0.95), se puede concluir que lo hipotetizado en el modelo, ajusta de manera correcta a los datos en la presente representación gráfica. gráfica 3. segundo ajuste del modelo fuente. céspedes, v.m. (2009). tabla 2. segundo ajuste del modelo fuente. céspedes, v.m. (2009). en la gráfica 3 los coeficientes betas corresponden al valor de 1 para la percepción (grupo 2) influida por los factores psicosociales (con un valor de beta de 7.33), 3.43 para la evaluación límite límite valor de inferior superior probabilidad modelo ajustado 0,000 0,000 0,049 0,954 modelo independiente 0,153 0,127 0,181 0,000 modelo error límite límite valor de inferior superior probabilidad modelo ajustado 0,000 0,000 0,036 0,977 modelo independiente 0,143 0,116 0,171 0,000 modelo error 105 investigación que prueba teoría: una aproximación desde enfermería cardiovascular l viviana marycel céspedes-cuevas en la gráfica 4 los coeficientes betas corresponden al valor de 1 para la percepción (grupo 3) influida por los factores psicosociales (con un valor de beta de 1.73), 4.80 para la evaluación (grupo 1) influida por la enfermedad coronaria previa (con un valor de beta de -9.11) y 1.13 para la respuesta (grupo 3) no influida por factores clínicos ni sociodemográficos. llama la atención que el componente de evaluación aparece de nuevo como el concepto más importante, por lo tanto la experiencia del síntoma se manifiesta con mayor fuerza en la evaluación. el valor del índice de error es 0.000, con 90% de intervalo de confianza entre 0.000 y 0.021 y con un valor de p para la prueba de ajuste igual a 0.998. con lo anterior se puede afirmar que existe 90% de confianza que el valor de error en la población se encuentra entre 0.000 y 0.021, lo cual representa un grado satisfactorio de precisión. dado que el error estimado es <0.05 (0.000) y el valor de probabilidad asociado con la prueba de ajuste es >0.50 (p=0.998), se puede concluir que lo hipotetizado en el modelo, ajusta de manera correcta a los datos en la presente representación gráfica. a partir de los valores asociados con las pruebas de ajuste de los tres modelos derivados se genera la representación de la gráfica 5. las relaciones causales de los componentes deben ser exploradas en futuros procesos investigativos de comprobación teórica que aborden modelos logísticos. gráfica 5. propuesta de ajuste al modelo (grupo 1) influida por la enfermedad coronaria previa (con un valor de beta de -8.93) y 1.10 para la respuesta (grupo 3) no influida por factores clínicos ni sociodemográficos. la evaluación aparece como el concepto más importante, por lo tanto la experiencia del síntoma se manifiesta con mayor fuerza en la evaluación. en la tabla 2 se muestra que el valor del error es 0.000, con 90% de intervalo de confianza entre 0.000 y 0.036 y con el valor de p para la prueba de ajuste igual a 0.977. con lo anterior se puede afirmar que existe 90% de confianza que el valor del error en la población, se encuentre entre 0.000 y 0.049, lo cual representa un grado satisfactorio de precisión. dado que el error estimado es <0.05 (0.000) y el valor de probabilidad asociado con la prueba de ajuste es >0.50 (p=0.95), se puede concluir que lo hipotetizado en el modelo, ajusta de manera correcta a los datos en la presente representación gráfica. gráfica 4. tercer ajuste del modelo fuente. céspedes, v.m. (2009). tabla 3. tercer ajuste del modelo fuente. céspedes, v.m. (2009). límite límite valor de inferior superior probabilidad modelo ajustado 0,000 0,000 0,021 0,998 modelo independiente 0,150 0,123 0,178 0,000 modelo error fuente. céspedes, v.m. (2009). eval = evaluación rta = respuesta per = percepción exp sint = experiencia del síntoma ep = error de percepción ee = error de evaluación er = error de respuesta ees = error de experiencia del síntoma 106 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 discusión como se puede apreciar en la fase evaluativa del smc, en la representación holística original del modelo todos los componentes y variables internas interactúan simultáneamente y se espera que la medición de la experiencia del síntoma se refiera a experiencias integradas en la conducta del paciente. con esto se advierte el inconveniente en la representación holística por no parecer una representación clara de la interacción de las variables con la experiencia del síntoma. por ello se sugirió un modelo de tipo analítico, donde se pudiera identificar la interacción entre las variables, pero que al mismo tiempo estuvieran separadas con una mejor organización y un esquema de tipo diagrama de flujo, que permitiera obtener información de cada variable y que la medición se pudiera hacer por cada subvariable de interés. la representación gráfica de los modelos y las teorías en forma de diagramas de venn (como conjuntos), puede incluir intersecciones incompatibles entre las variables, relaciones no explicadas y asignaciones equívocas. en particular para el smc se puede señalar que las subvariables requerían una definición más precisa, para que la categoría o nombre de la subvariable quedara definida unívocamente y que formara un esquema de clasificación con un mismo criterio, exhaustivo y ordenado. la representación generada con el proceso de análisis factorial confirmatorio incluyó la variable latente experiencia del síntoma como elemento que incide en las tres variables observables de la dimensión. este modelo puede ser sustancialmente diferente del original ya que plantea relaciones causales unidireccionales entre la variable latente y cada una de las variables que integran la experiencia del síntoma, incluyendo un primer esbozo de la participación de las variables contextuales. así mismo, a partir de todas las posibilidades de combinación de las agrupaciones identificadas, se expusieron 3 modelos con un adecuado ajuste entre el modelo hipotetizado y los datos, los cuales permitieron evidenciar cómo la experiencia del síntoma se manifiesta con mayor fuerza en el componente de evaluación. con lo anterior se propone una nueva representación gráfica que posee un dominio denominado experiencia del síntoma, dentro del cual se hace una clasificación de los tres componentes que lo constituyen. en términos generales, se define como “dominio” a cada campo (conjunto, esfera) que constituye la experiencia del síntoma (27). esta clasificación es interesante porque de entrada, diferencia dimensiones y a su vez garantiza la influencia permanente entre unas y otras. es importante poner a prueba estos planeamientos mediante estudios correlacionales que favorezcan la comprobación de hipótesis. el proceso de comprobación teórica por métodos exploratorios permitió confirmar la existencia de una dimensión conceptual denominada “experiencia del síntoma” que antecede la búsqueda de ayuda profesional tal y como lo exponen los autores. de igual forma favoreció la expansión de los planteamientos teóricos al identificar la categoría cognitiva denominada “evaluación” como la más influyente sobre la experiencia. los resultados de este estudio además de generar un aporte a la teoría y a la investigación, derivan reflexiones para la práctica de enfermería, al considerar la importancia que poseen las intervenciones de tipo cognitivo que favorezcan los procesos de afrontamiento en situaciones que amenazan la salud. es posible que cuando la mujer se dé a la tarea de considerar los síntomas de síndrome coronario agudo con mayor seriedad, se produzcan cambios favorables en las respuestas de acción. conclusiones los resultados del presente estudio confirman la presencia de tres componentes observables denominados: percepción, evaluación y respuesta, los cuales se comportan como tres elementos distintos. se confirma la presencia de una variable no observable o latente denominada experiencia del síntoma, la cual se encuentra influenciada de forma directa por el componente observable denominado evaluación. se presume que el modelo varía de acuerdo con el síntoma. en este caso, al estudiar las agrupaciones de los síntomas de sca en la mujer, se aprecian variaciones en el peso que le aporta cada uno de los componentes a la experiencia del síntoma, dependiendo de la agrupación de síntomas que se considere. es posible que al estudiar un nuevo síntoma o agrupaciones de síntomas, las relaciones entre variables latentes y observables varíen. 107 investigación que prueba teoría: una aproximación desde enfermería cardiovascular l viviana marycel céspedes-cuevas con el análisis de los datos la representación gráfica holística del modelo y la 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aprendizajes de los dominios educativos. capítulo 1. san luis potosí, méxico: instituto de evaluación e ingeniería avanzada, s.c; 2000. evaluation of covid-19 patient safety compared to non-covid-19 patients and predisposing factors of nursing errors article evaluation of covid-19 patient safety compared to non-covid-19 patients and predisposing factors of nursing errors evaluación de la seguridad del paciente con covid-19 en comparación con pacientes sin covid-19 y factores predisponentes de los errores de enfermería avaliação da segurança do paciente com covid-19 em comparação com o paciente sem covid-19 e fatores predisponentes de erros de enfermagem 10.5294/aqui.2022.22.3.2 leila mohammad nahal 1 abasat mirzaei 2 mohammad javad khezeli 3 1 0000-0002-0221-0381 faculty of health, university of medical sciences, islamic azad university, iran mohammadnahall@yahoo.com 2 0000-0002-1422-5193 faculty of health, tehran university of medical sciences, islamic azad university, iran amacademic@iautmu.ac.or 3 0000-0002-1865-7313 faculty of health, university of medical sciences, islamic azad university, iran mj.khezeli@gmail.com recibido: 27/12/2021 enviado a pares: 23/03/2022 aceptado por pares: 17/06/2022 aprobado: 23/06/2022 theme: promotion and prevention. contribution to the discipline: nurses play a critical role in protecting and supporting patients because of the nature of their job. acknowledging these safety factors is the cornerstone in improving the safety performance of healthcare providers. therefore, improving the performance of nurses increases patient safety and quality of care. one of the ways to improve nurses' performance is empowerment and one of the ways to empower them is identifying the incidents and analyzing the trend of events and the possibility of errors and their effects. this article has been able to reveal the gaps in health system nursing by evaluating the basic indicators of patient safety and finding the predisposing factors of nursing errors in hospitals. since the formation of the concept of nursing is made and paid by the educational system, it is possible to empower nurses to improve the quality of nursing care using this article in nursing education institutions and according to the predisposing factors of nursing errors and examining the strengths and weaknesses of nurses in the field of patient safety indicators. para citar este artículo / to reference this article / para citar este artigo: mohammad nahal l, mirzaei a, khezeli mj. evaluation of covid-19 patient safety compared to non-covid-19 patients and predisposing factors of nursing errors. aquichan. 2022;22(3):e2232. doi: https://doi.org/10.5294/aqui.2022.22.3.2 abstract objectives: the present study aims to determine patient safety in hospitalized patients with covid-19 compared to non-covid-19 ones and find predisposing factors of nursing errors according to nurses' perceptions. methods: this descriptive-comparative research employed data from 800 nurses in eight iranian hospitals in 2021 using three researcher-made questionnaires of sociodemographic, patient safety indicators, and predisposing factors of nursing errors, with high reliability and validity. the collected data were analyzed using anova, independent t-test, and the spss22 software. results: the mean patient safety scores in patients with and without covid-19 were 3.42 ± 0.17 and 3.74 ± 0.06, respectively. the highest differences in patient safety were attributed to infection control (0.66) and patient fall (0.56) dimensions. the most common causes of nursing errors were related to management (2.67 ± 1.39), and the most common predisposing factors of nursing errors were high workload, low ratio of nurses to patients, and fatigue. conclusions: covid-19 patients have lower safety than non-covid ones. also, improper management and high workload lead to nursing errors. therefore, the authorities must devise appropriate strategies to reduce the nurses' workload and improve patient safety, especially in covid-19 patients. keywords (source decs): covid-19; medical errors; nurse; patient safety; patient isolation. resumen objetivos: el presente estudio tuvo como objetivo determinar la seguridad en pacientes hospitalizados con covid-19 en comparación con los que no tenían covid-19 y encontrar factores predisponentes de errores de enfermería según la percepción de los enfermeros. métodos: esta investigación descriptiva-comparativa empleó datos de encuestas de 800 enfermeros en ocho hospitales iraníes en 2021 mediante tres cuestionarios con alta confiabilidad y validez elaborados por investigadores que incluían datos sociodemográficos, indicadores de seguridad del paciente y factores predisponentes de errores de enfermería. los datos recopilados se analizaron mediante anova, prueba t independiente y el software spss22. resultados: las puntuaciones medias de seguridad de los pacientes con y sin covid-19 fueron 3,42 ± 0,17 y 3,74 ± 0,06, respectivamente. las mayores diferencias en seguridad del paciente se atribuyeron a las dimensiones de control de infecciones (0,66) y caída del paciente (0,56). por otra parte, las causas más comunes de los errores de enfermería estuvieron relacionadas con el aspecto gerencial (2,67 ± 1,39), y los factores predisponentes más comunes de los errores de enfermería fueron la alta carga de trabajo, la baja proporción de enfermeros por pacientes y la fatiga. conclusiones: los pacientes con covid-19 tienen menor seguridad que los que no presentan la enfermedad. además, la gestión inadecuada y la alta carga de trabajo conducen a errores de enfermería. por lo tanto, las autoridades deben diseñar estrategias adecuadas para reducir la carga de trabajo de los enfermeros y mejorar la seguridad del paciente, en especial en aquellos con covid-19. palabras clave (fuente decs): covid-19; errores médicos; enfermera; seguridad del paciente; aislamiento de pacientes. resumo objetivo: o objetivo deste estudo foi determinar a segurança em pacientes internados com covid-19 em comparação com os que não tinham covid-19 e encontrar fatores predisponentes de erros de enfermagem segundo a percepção de enfermeiros. materiais e método: trata-se de pesquisa descritivo-comparativa, que utilizou dados de pesquisas com 800 enfermeiros em oito hospitais iranianos em 2021, com base em três questionários com alta confiabilidade e validade, elaborados por pesquisadores, que incluíam dados sociodemográficos, índices de segurança do paciente e fatores predisponentes de erros de enfermagem. os dados coletados foram analisados com anova, teste t independente e software spss22. resultados: as pontuações médias de segurança dos pacientes com e sem covid-19 foram 3,42 ± 0,17 e 3,74 ± 0,06, respectivamente. as maiores diferenças em segurança do paciente foram atribuídas às dimensões de controle de infecções (0,66) e queda do paciente (0,56). as causas mais comuns dos erros de enfermagem estiveram relacionadas com o aspecto gerencial (2,67 ± 1,39) e os fatores predisponentes mais comuns dos erros de enfermagem foram a alta carga de trabalho, a baixa proporção de enfermeiros por paciente e a fadiga. conclusões: os pacientes com covid-19 têm menor segurança do que os que não apresentam a doença. além disso, a gestão inadequada e a alta carga de trabalho levam a erros de enfermagem. portanto, as autoridades devem elaborar estratégias adequadas para reduzir a carga de trabalho dos profissionais de saúde e melhorar a segurança do paciente, em especial daqueles com covid-19. palavras-chave (fonte decs): covid-19; erros médicos; segurança do paciente; isolamento de paciente; enfermeira. introduction since march 2020, the world has faced a severe threat called covid-19. according to the who, the covid-19 pandemic is currently the most critical health crisis in the world and the most significant challenge and threat facing the world and humanity (1, 2). this disease is a public health problem that has claimed the lives of many men, women, and children worldwide. until august 6, 2021 (when this article was written), over 201 million people worldwide had been diagnosed with the disease, and 4,284,467 had died, as confirmed by the who (3). the sudden increase in the demand for health care led to overload and the collapse of health systems (4). covid-19 is an emerging disease with unknown clinical and therapeutic symptoms (5, 6) transmitted through close person-to-person contact. infection control experts consider patient isolation an essential and straightforward way to control the infection and spread of the disease; therefore, hospitalized covid-19 patients are isolated in separate wards. however, using such a precaution may not be totally safe (7). isolation for infection control is a process that makes the patients subject to medical errors and side effects (8). in addition, unmeasured organizational factors, such as the prevalence of new diseases, high patient turnover in medical centers, and unit-level workload, may contribute to the variance in missed nursing care, increased medical errors, and threaten safety of the patients (9). nursing error is a type of error by healthcare team members that can result in irreparable and irremediable damage (e.g., permanent disability or death) (10). nurses comprise the largest group of healthcare professionals who interact most with patients. promoting a safe environment is an essential nursing task and plays a significant role in care management (11). during the covid-19 pandemic, nurses have been at the frontline of fighting against the disease, and critically-ill patients rely on them more than ever (12, 13). studies have shown a significant relationship between the prevalence of covid-19 and the problems such as stress, depression, burnout, anxiety, and reduced productivity in health workers (13-17). medical workers' mental health problems impair their attention, cognitive functioning, and clinical decision-making (18), consequently increasing medical errors and incidents and, ultimately, putting the patients at risk (19). health worker safety and patient safety are inseparably connected domains. health and safety risks to health workers can lead to risks for patients, patient harm, and adverse patient outcomes. the risks to patients and healthcare workers during this pandemic are more significant than usual (20, 21). thus, health workers cannot provide quality and safe patient care in environments where their safety is threatened (22). error is inevitable in all professions, particularly healthand treatment-related jobs. care provision in clinical settings is associated with var­ious concerns, including adverse effects of treatment, accidents, and medical errors (23). the most common nursing errors in a hospital setting are falls, pressure ulcers, infections, medication errors, documenting errors, and equipment injuries (24). every year, 134 million side effects occur in hospitals of lowand middle-income countries due to unsafe care, leading to 2.6 million deaths (25). in high-income countries, it is estimated that one-tenth of patients get injured while receiving hospital care (26), about 50 % of which are preventable (27). failure to maintain patient safety significantly increases the cost of care, morbidity, and mortality. patient safety is a priority in the healthcare system to improve treatment outcomes and prevent complications (23). patient safety is a critical element of quality in healthcare and is considered an indicator of the quality of care (28). nurses' priorities include patient safety and improving the quality of delivered care to patients. improving patient safety involves identifying the incidents, analyzing the trend of events, and developing corrective solutions for promoting the system. there are several mechanisms to reduce adverse events and improve patient safety, but implementing them requires studies to identify the current situation. due to the novelty of covid-19, the studies in this field are limited. to plan for preventing and decreasing the rate of nursing errors and increasing patient safety, especially for covid-19 patients, evaluation of fundamental patient safety indicators and predisposing factors in nursing errors can reveal the gaps in this area in the health system and might be very helpful. therefore, the present study was conducted to determine the patient safety in hospitalized patients with covid-19 compared to non-covid patients and identify the predisposing factors of nursing errors according to the nurses' perceptions. methods this descriptive-comparative research used convenient sampling to collect information from 800 frontline nurses of different levels in eight hospitals in iran from april 1 to august 7, 2021. according to cochran's formula and the studies conducted on limited populations using convenient sampling, one way to determine the sample size for confirmative factor analysis (cfa) is to use the number of parameters and assign at least five cases per parameter. because the questionnaire has 100 parameters, we estimated 800 samples (eight cases per parameter) to be appropriate, but 880 individuals were selected as the sample size to be closer to the community distribution and random sampling, considering a loss rate of 10 °% (29, 30). the exclusion criteria were staff reluctance to participate in the study, having less than six months of experience, and having a managerial position. to follow ethical considerations, necessary permission was obtained from the hospital authorities to conduct the study. anonymous questionnaires were provided to the nurses once the researcher explained the research objective, the option-ality of participating in the study, and how to cooperate after obtaining their written consent. the confidentiality of the information was emphasized when distributing and collecting the research data. in this study, the nurses were divided into two groups: working in covid-19 units (covid-19 general units, covid-19 intensive care units) and other units (inpatient non-covid-19 units). data collection tools this study used three questionnaires, the first dealing with the nurses' sociodemographic characteristics, and included nine items. the second questionnaire was on the patient safety indicators (self-designed) extracted upon reviewing the literature (31, 32). the patient safety indicators questionnaire included nine scales: pharmacological measures (14 questions), nursing care (22 questions), patient injury during care (seven questions), patient identification (seven questions), patient fall (seven questions), patient training (14 questions), diagnostic-therapeutic methods (seven questions), infection control (ten questions), and safe blood transfusion (12 questions). five of the scales and their 60 subscales were adapted from fakhrodin's research, four and 36 subscales were taken from the validation booklet of patient safety friendly hospitals (psfhi), and four questions on oxygenation of patients were added. the questionnaire was designed to assess the number of nursing care errors during the previous month, and the items were measured based on the negative four-point likert scale: never (score 1), 1-3 times (score 2), 3-5 times (score 3), and more than five times (score 4). the third questionnaire addressed the predisposing factors of nursing errors (self-designed) extracted upon reviewing the literature (33). the questionnaire included five items: mental and physical conditions of nurses and their skills (six questions), team coordination (four questions), management (nine questions), patients (three questions), unit's physical and environmental conditions (seven questions), and the shifts in which medical errors occurred. the scoring method was as follows: very low (score 1), low (score 2), medium (score 3), high (score 4), and very high (score 5). ten faculty members confirmed the face validity and qualitative content of the questionnaire in this study. cronbach's alpha was also used to measure the questionnaires' overall reliability, dimensions, and variables. to this end, the questionnaires were first provided to 30 people to measure overall and component reliability. the reliability of the predisposing factors of the nursing errors questionnaire (0.87) and that of the patient safety indicators questionnaire (0.85) were obtained as well (table 1). the cronbach's alpha was more significant than 0.7, indicating the high reliability of the questionnaires. the kolmogorov-smirnov test was also used to evaluate the normality of the research data. the significant numbers obtained were greater than 0.5, showing the normality of the data distribution. table 1. reliability coefficients of the patient safety indicator questionnaire components reliability coefficient dimensions 0/77 pharmacological measures 0/83 providing nursing care 0/73 injury to the patient during care 0/75 patient identification 0/77 patient fall 0/76 patient training by nurses 0/78 diagnostic-therapeutic methods 0/82 infection control 0/79 safe blood transfusion 0/85 the whole questionnaire source: own elaboration the collected data were analyzed using the spss22 software. the analysis of variance, independent t-test, spearman's correlation, and descriptive statistics such as frequency, mean, and standard deviation with a significance level of p < 0.005 were also used to analyze the data. results of the 880 questionnaires, 80 were excluded from the study due to incomplete answers, and 800 individuals remained as the final samples. according to the demographic information, 502 (75.5 °%) of the participants were female, and 298 (24.5 °%) were male. most participants were 31-35 years old (n = 264, 41 °%) and 434 were married (58.4 %). half of the participants (n = 400) were working in non-covid-19 wards and caring for non-covid-19 patients and 400 others (50 °%) were caring for the patients in covid-19 wards, including general wards of covid-19 (n = 280; 35 %) and intensive care units of covid-19 (n = 120; 15 %). of all the nurses, 408 (52 %) had contracted the disease. the detailed personal information collected is listed in table 2. table 2. demographic characteristics of study participants (n = 800) variable categories frequency percentage(%) age (years) 30 ≥ 31-35 36-40 > 40 247 264 163 126 36.8 41 15.7 6.5 gender male female 298 502 24.5 75.5 marital status single married 366 434 42.6 58.4 years of experience ≤ 5 years 6-15 years > 15 years 250 316 234 31.25 39.5 29.25 working unit non-covid-19 units covid-19 intensive care units covid-19 general units 400 120 280 50 15 35 employment status permanent contractual temporary 322 234 244 40.25 29.25 30.5 highest level of education bachelor's master's 768 32 96 4 affected by covid-19 yes no 408 392 52 48 number of patients cared for in shifts ≤  5 patients 6-10 patients > 10 patients 188 554 58 23.5 69.25 7.25 source: own elaboration analysis of nurses' sociodemographic factors on patient safety/p> the results of the study in terms of the effect of the nurses' gender on patient safety showed no significant difference between the safety of the patients and male (3.58 ± 0.22) and female (3.57 ± 0.22) genders. considering the effect of the nurses' disease on patient safety, the safety of the patients cared for by the nurses who previously contracted covid-19 and those who did not contract the disease was 3.45 ± 0.25 and 0.65 ± 0.16, respectively. the patients receiving care from the nurses whom covid-19 did not infect had higher safety than those under care by the nurses previously infected by the disease. patient safety was higher in the units where the number of patients under the care of a nurse was ≤ 5 (3.63 ± 0.15) compared to the units where more than five patients were cared for by a nurse (3.01 ± 0.23), and the independent t-test (df = 413, p = 0.00, t = 4) showed a significant difference. according to the results, patient safety was affected by the number of patients cared for by a nurse, and it was higher in the units with fewer patients. the results also showed that working extra shifts affected patient safety, and the patients cared for by the nurses who worked overtime had lower safety (3.43 ± 0.23) than those under the care of the nurses who did not (3.61 ± 0.05). analysis of patient safety indicators in hospitalized patients with covid-19 and patients without covid-19 table 3 shows the findings related to identifying different patient safety dimensions from the perspective of the nurses working in covid-19 and non-covid-19 units. as shown in the table, the mean score and standard deviation of patient safety in all hospitalized patients were 3.56 ± 0.22, while those of the patients admitted to non-covid-19 units were 3.74 ± 0.06. in addition, the mean score and standard deviation of the patients admitted to covid-19 units were 3.42 ± 0.17. table 3. comparison of patient safety indicators scores of covid-19 and non-covid-19 patients patient safety indicators scores of all hospitalized patients covid-19 patients' safety scores non-covid-19 patients' safety score p-value patients in covid-19 general units patients in covid-19 intensive care units all covid-19 patients   mean.sd mean.sd mean.sd mean.sd mean.sd   pharmacological measures 0.42±3.18 0.38±2.87 0.38 ±3.07 0.39±2.97 0.22±3.40 < 0.005 provide nursing care 0.35±3.52 0.33±3.22 0.22 ±3.47 0.33±3.34 0.18±3.76 < 0.005 injury to the patient during care 0.17±3.56 0.22 ±3.46 0.12±3.48 0.19±3.47 0.07±3.68 < 0.005 patient identification 0.16±3.82 0.18±3.71 0.12±3.80 0.19±3.75 0.09±3.92 < 0.005 patient fall 0.27±3.61 0.21±3.40 0.13±3.81 0.26±3.60 0.12±3.96 < 0.005 nurse-to-patient training 0.18±3.57 0.21±3.46 0.17±3.55 0.12±3.48 0.23±3.64 < 0.005 diagnostic-therapeutic methods 0.31±3.56 0.32±3.44 0.29±3.58 0.32±3.51 0.13±3.60 < 0.005 infection control 0.42±3.31 0.27±2.98 0.39±3.02 0.33±2.99 0.15±3.67 < 0.005 safe blood transfusion 0.24±3.86 0.28±3.65 0.13±3.87 0.20±3.74 0.11±3.98 < 0.005 patient safety 0.22±3.56 0.21±3.35 0.14±3.51 0.17±3.42 0.06±3.74 < 0.005 sd: standard deviation. a four-point scoring method with points ranging from 1 to 4. source: own elaboration. according to the results, the mean scores of patient safety indicators in covid-19 and non-covid-19 patients admitted to hospitals were 3.42 ± 0.17 and 3.74 ± 0.06, respectively, and the safety of the patients admitted to covid-19 units was lower than those admitted to non-covid-19 units. in this regard, the independent t-test (df = 463; p =0.00; t = 28) showed a significant difference. the safety of the patients admitted to general units of covid-19 was lower than those admitted to intensive care units of covid-19, and the independent t-test (df = 230; p = 0.00; t = 8.) showed a significant difference in patient safety based on hospitalization in intensive care and general units of covid-19. blood transfusion (3.86) and pharmacological measures (3.18) respectively accounted for the highest and lowest patient safety scores of all the patients. the nurses determined that the highest mean differences between the patient safety scores of covid-19 and non-covid-19 patients were those of infection control (0.66) and patient fall (0.56), respectively. the most significant mean differences between the patient safety scores of the patients admitted to non-covid-19 units and intensive care units of covid-19, determined by the nurses, were those of infection control (0.65) and pharmacological measures (0.33) the results of the anova test in table 3 show a significant difference between the mean scores of pharmacological measures, provision of nursing care, injury to patients during care, patient identification, patient falls, nurse-to-patient training, diagnostic-therapeutic methods, infection control, and safe blood transfusion among covid-19 and non-covid-19 patients admitted to the hospitals. analysis of common causes of nursing errors as shown in table 4, the most and the least common predisposing factors of nursing errors determined by the nurses were mental and physical conditions of nurses and their skills (category 1), i.e., fatigue and lack of acquaintance with professional rules and regulations, team coordination (category 2), i.e., inappropriate relationships between team members and lack of patient involvement in the care process, management aspects (category 3), i.e., high workloads for nurses and lack of policies and guidelines, patient conditions (category 4) , i.e., a large number of patients and im­proper behavior of patients and their relatives, and physical and environmental conditions of the unit (category 5), i.e., working night shifts, drowsiness, and poor lighting. table 4. common causes of nursing errors from nurses' viewpoints items predisposing factors of nursing errors very low low medium high very high mean±sd frequency (%) frequency (%) frequency (%) frequency (%) frequency (%) nurses' responses to items related to mental and physical conditions of nurses and their skills stress 128(16.1) 198(24.1) 178(22.3) 158(19.5) 138(17.3) 2.61 ± 1.09 fatigue 188(23) 208(25.3) 118(13.8) 148(18.5) 148(18.4) 2.83 ± 1.44 distraction 218(26.4) 261(32.6) 178(22.3) 88(11.5) 55(6.9) 2.44 ± 1.28 lack of adequate skills in performing some procedures 278(33.3) 178(22.3) 198(24.1) 128(16.1) 28(3.4) 2.33 ± 1.12 lack of personal motivation and interest in the profession 268(32.2) 178(22.3) 128(16.1) 88(11.5) 138(17.2) 2.59 ± 1.48 lack of acquaintance with the professional rules and regulations 338(40.2) 208(25.3) 148(18.5) 78(10.3) 28(3.4) 2.09 ± 1.05 nurses' responses to items related to team coordination inappropriate relationships between team members 158(19.5) 148(18.4) 218(25.3) 138(17.2) 138(17.2) 2.72 ± 1.11 trust in others' judgments 138(17.2) 238(28.7) 228(27.6) 179(22.6) 31(3.9) 2.51 ± 1.46 improper division of duties beyond work abilities by the unit supervisor 148(18.5) 263(32.7) 198(24.1) 154(19.2) 37(4.6) 2.42 ± 1.06 no involvement of patient in the care process 338(40.2) 208(25.3) 148(18.5) 78(10.3) 28(3.4) 2.09 ± 1.05 nurses' responses to items related to management low ratio of nurses to patients 238(28.7) 138(17.2) 118(14.9) 128(16.1) 178(21.8) 2.84 ± 1.47 lack of policies and guidelines 178(21.8) 258(31) 188(23) 68(9.2) 28(3.4) 2.33 ± 1.15 inappropriate organization of nursing personnel in the unit 188(23) 198(24.1) 128(16.1) 168(20.7) 118(14.9) 2.80 ± 1.40 compulsion to perform several tasks simultaneously 128(16.1) 198(24.1) 218(26.4) 158(19.5) 28(3.4) 2.66 ± 1.40 long and burst shifts 158(19.5) 198(24.1) 178(22.3) 158(19.5) 108(13.5) 2.61 ± 1.19 lack of exact job description for nursing personnel 218(26.4) 218(26.4) 128(16.1) 98(12.6) 138(17.3) 2.67 ± 1.43 high workloads for nurses 68(9.2) 138(17.2) 128(16.1) 198(24.1) 188(23) 2.89 ± 1.51 lack of proper education system in the hospital 268(32.2) 158(19.5) 148(18.5) 118(14.9) 108(13.8) 2.58 ± 1.46 absence of staff trained and expert in the specialized care 268(32.2) 178(22.3) 128(16.1) 98(12.6) 138(17.2) 2.59 ± 1.48 nurses' responses to items related to conditions of patients unstable patient status 138(17.2) 238(28.7) 228(27.6) 98(12.6) 28(3.4) 2.51 ± 1.07 large number of patients 268(32.2) 108(13.8) 98(12.6) 158(19.5) 168(20.7) 2.82 ± 1.57 improper behavior of patients and their relatives 285(35.6) 239(29.9) 148(18.5) 108(13.8) 20(2.3) 2.12 ± 1.16 nurses' responses to items related to the unit's environmental conditions working night shifts and drowsiness 118(14.9) 208(25.3) 208(25.3) 128(16.1) 138(17.2) 2.74 ± 1.14 no visibility of all nursing units from the nursing station 218(26.4) 218(26.4) 128(16.1) 98(12.6) 138(17.2) 2.67 ± 1.43 lack of standard devices and advanced medical supplies 268(32.2) 158(19.5) 148(18.5) 118(14.9) 108(13.8) 2.58 ± 1.43 lack of suffi cient time to evaluate and monitor patients 288(34.5) 168(21) 158(19.5) 140(17.5) 46(5.7) 2.39 ± 1.26 small area of medication room 338(40.2) 208(25.3) 148(18.5) 68(9.2) 37(4.6) 2.10 ± 1.16 poor lighting 338(4.2) 208(25.3) 148(18.5) 78(10.3) 28(3.4) 2.09 ± 1.16 inappropriate organization and placement of medical supplies 298(35.4) 248(31) 158(19.5) 59(7.5) 37(4.6) 2.13 ± 1.14 sd: standard deviation. a five-point scoring method with points ranging from 1 to 5 source: own elaboration from the nurses' viewpoint, the most and the least common causes of nursing errors were related to management aspects (2.67 ± 1.39) and the environmental conditions of the unit (2.38 ± 1.25), respectively. the most common reasons for nursing errors were high workload, low ratio of nurses to patients, and fatigue. according to the results, most errors occurred during night shifts (71 °%). correlation analysis of patient safety questionnaire dimensions with each other and with the result of the study (patient safety) in table 5, the results of the spearman's test show that all dimensions of the patient safety questionnaire significantly correlated with each other and with the study outcome (patient safety). the correlation scores of the questionnaire dimensions and patient safety ranged from r = 0.46 to r = 0.87. table 5. findings on the correlation between the scores of safety dimensions and the total score of patient safety j i h g f e d c b a safety indicators                   1 a: pharmacological measures                 1 0.571 b: providing nursing care               1 0.596 0.432 c: injury to patient during care             1 0.420 0.268 0.435 d: patient identification           1 0.483 0.596 0.689 0.471 e: patient fall         1 0.519 0.406 0.494 0.601 0.775 f: nurse-to-patient training       1 0.532 0.238 0.454 0.496 0.295 0.478 g: diagnostic-therapeutic methods     1 0.410 0.763 0.629 0.396 0.547 0.693 0.611 h: infection control   1 0.498 0.469 0.433 0.349 0.426 0.579 0.610 0.375 i: safe blood transfusion 1 0.558 0.876 0.598 0.866 0.695 0.463 0.631 0.739 0.740 j: total score of patient safety source: own elaboration discussion this study mainly discussed the patient safety indicators in hospitalized patients with covid-19 compared to those without covid-19 and the most common predisposing factors of nursing errors. unfortunately, due to the novelty of the disease, the researcher could not find any domestic or foreign articles or research on the safety of hospitalized covid-19 patients compared to other admitted ones to compare results. the findings of this study showed a significant difference between the mean scores of patient safety indicators (pharmacological measures, providing nursing care, injury to the patient during care, patient identification, patient fall, nurse-to-patient training, diagnostic-therapeutic methods, infection control, and safe blood transfusion) in covid-19 patients compared to non-covid-19 ones admitted to hospitals. according to the results, the mean score of safety indicators of the patients admitted to non-covid-19 units was higher than those admitted to covid-19 units, showing better observance of patient safety indicators in non-covid-19 patients compared to the other group. similar studies on covid-19 patients hospitalized and isolated in the under-pressure health care system showed that isolation could be associated with patient safety incidents (34-36). in line with the results of this study, the study by henry thomas stelfox et al. (2003) found out that isolated patients had experienced twice as many preventable side effects as non-isolated ones and expressed greater dissatisfaction with treatment (37). the findings of the study by jiménez-pericás et al. (2020) showed more adverse effects in isolated patients than non-isolated ones (38). in their study, bruyneel et al. (2021) stated that covid-19 patients admitted to the intensive care unit (icu) required more nursing time than those without covid-19 in the icu (39). in addition, the findings by hamamoto al. (2021) indicated that more nursing staff was required to care for patients critically ill with coronavirus disease in intensive care units (40). health care workers have struggled to connect, touch, engage, and communicate with covid-19 patients behind their protective equipment (41). lower safety of covid-19 patients compared to non-covid-19 patients could be due to the need for more nursing time and nurses' high workload and fear of getting the disease. based on the results, the mean score of patient safety indicators in the patients admitted to covid-19 intensive care units was higher than those admitted to covid-19 available units, showing better observance of patient safety indicators in intensive care units compared with the inpatient ones. the results of the study by marzban et al. (2013) showed that the mean rate of injury to patients due to hospital errors was lower in inpatient units than in icus, which is not consistent with the results of the present study on the safety of the patients hospitalized in inpatient units and special units (42). lower safety of the patients admitted to general units of covid-19 compared to those admitted to intensive care units of covid-19 could be due to the lack of beds in icus and hospitalization of critically-ill patients in general units, and the inappropriate ratio of nurses to patients in general units compared to icus. the results also showed that the number of patients under care by a nurse affected patient safety. in other words, patient safety was higher in the units where the number of patients under care by a nurse was smaller, and in icus, there was an optimal ratio between the number of nurses and patients. in their study, saleh et al. (2015) stated that sufficient nursing personnel and appropriate nurse-to-patient ratios were related to improved patient outcomes, including lower mortality rates, which is consistent with the results of the present study (43). the results of this study showed that blood transfusion and pharmacological measures accounted for the highest and the lowest scores of patient safety indicators in all admitted patients, respectively. aranaz-andre et al. (2008) studied the adverse effects of health care in spain and stated that most errors were attributed to pharmacological care, which is consistent with the results of the present study (44). the most remarkable mean differences in patient safety indicators among the patients admitted to non-covid-19 units and those admitted to general units of covid-19 were attributed to infection control and patient fall, respectively, which showed more errors in infection control and more falls of the patients admitted to general units of covid-19 compared to other units. in previous studies, nosocomial infections and patient falls were the most common medical errors (45). regarding infection control, decreased safety of the patients admitted to covid-19 units compared with those in non-covid-19 units could be due to the highly contagious nature of the disease and the fear of health care providers of getting infected. thus, they did not spend sufficient time caring for the patients to avoid catching the disease, did not observe hand hygiene, and did not change gloves when going from one patient to another. most patients admitted with covid-19 were elderly and unaccompanied (46). thus, the risk of falls in covid-19 patients was higher than in other patients due to age and lack of companions. burnout and low productivity rates among the nurses infected with covid-19 (13). the study by magnavita et al. (2020) showed a higher rate of physical symptoms, anxiety, and depression in health care providers infected with covid-19 (47). according to the results, if health care providers were not safe, they would not be able to provide quality and safe patient care. since all the processes of providing health services are associated with a degree of insecurity and risk, patient safety is one of the most basic principles of providing services in health centers. from nurses' viewpoint, the most and the least common causes of nursing errors were related to management aspects and the environmental conditions of the unit, respectively. cause and effect models indicate that at least 98 % of accidents occur due to human error and poor management (48). like the present study's findings, the most common cause of nursing errors determined by zeighami et al. (2016) was related to management aspects. managers played a crucial role in preventing nursing errors. they were usually responsible for guided and controlled use of protocols, policies, and standards to prevent nursing personnel errors (33). in a similar study conducted in 2012, baghaei et al. examined critical care nurses' perception of nursing errors and reported that environment was the most important predisposing factor in nursing errors. their finding contrasts with the present study's results (49). the organizations have been created to achieve some goals, and the success rate in achieving the organizational objectives is directly related to the performance of labor, especially managers. as the prominent people deciding on facing various within and outside organization problems, managers play a considerable and determining role in the success and failure of the organization and performing their duty. the higher the governance and leadership in the hospital, the higher the patient safety performance will be. the most common reasons for nurses' errors were high workload, low ratio of nurses to patients, and fatigue. in their study, azarabadi et al. (2018) reported that high workload, a large number of patients, and fatigue were the most contributing factors to errors, which is consistent with the results of the present study (50). in line with the results of this study, zarea et al. (2018) stated that the most common reasons for medical errors were low nurse-to-patient ratio, high workload, and fatigue caused by extra work (51). according to the results, most nursing errors occurred during night shifts. in line with the results of the present study, khammarnia et al. (2021) stated that the incidence of medical errors in night shifts was higher than in any other shifts (52). conclusion the covid-19 pandemic is a global crisis that has caused some gaps in the health systems and threatened the quality of patient care and the safety of the staff and patients. evaluation of fundamental patient safety indicators and predisposing factors in nursing errors in this study revealed the gaps in this area of the health system. the results of this study showed that the safety of the patients admitted with covid-19 was lower than that of other hospitalized patients, and they were more likely than other hospitalized patients to experience the adverse effects of health services. therefore, the safety of covid-19 patients needs to be seriously improved. it is advisable to develop strategies for better interventions and transformation procedures targeting the promotion of patient safety, especially in isolated patients. from the nurses' viewpoint, the most common causes of nursing errors were related to management aspects. the hospital managers' performance weakness wastes the financial and human resources and reduces efficiency. if the system for evaluating the performance of the hospitals' managers were efficient and there were tangible and computable indicators for evaluating their work, many costs in the hospitals could be reduced, and better services provided to covered hospitals since providing adequate services is related to sound and effective management. the results showed that the safety of nurses directly affected patient safety, and from the nurses' viewpoint, the most common predisposing factors of nursing errors were high workload, low ratio of nurses to patients, and fatigue. in addition, most nursing errors occur on the night shift. therefore, by improving work processes, creating safe and appropriate work environments, training the staff, and increasing nurses' motivation and safety, the authorities should pave the way to reduce nursing errors and increase patient safety. also, to reduce nurses' workload, the number of staff required to care for patients should be proportional to the number of patients, level of disease, care environment conditions, and work shifts. to increase the safety of the patients admitted with covid-19 and other infectious diseases, health officials need to be prepared and provide special wards to isolate such patients in appropriate conditions. finally, we hope that the authorities will use this research to reduce the predisposing factors of nursing errors and increase the safety of patients and nurses in hospitals. limitations of the study one limitation of the present research was the data collection method through a self-report questionnaire that might lead to over-re porting or under-reporting. we suggest that future studies review patient records and report errors to measure patient safety. the research tool (patient safety indicators questionnaire and predisposing factors 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de la abuela.indd 270 aquichan issn 1657-5997 marta elena losa-iglesias1 rocío rodríguez-vázquez2 ricardo becerro de bengoa-vallejo3 papel de la abuela en la lactancia materna 1. profesora titular, universidad rey juan carlos, madrid, españa. marta.losa@urjc.es 2. especialista obstétrico-ginecológica. unidad docente de la paz, universidad rey juan carlos, madrid, españa. rrodriguezvazquez@alumnos.urjc.es 3. profesor titular, universidad complutense de madrid, españa. ribebeva@enf.ucm.es recibido: 12 de marzo de 2012 enviado a pares: 14 de mayo de 2012 aceptado por pares: 15 de julio de 2013 aprobado: 17 de julio de 2013 año 13 vol. 13 nº 2 chía, colombia agosto 2013  270-279 para citar este artículo / to reference this article / para citar este artigo losa iglesias, m., rodríguez vázquez, r., becerro de bengoa vallejo, r. (2013). papel de la abuela en la lactancia materna. aquichan. vol. 13, no. 2, 270-279. resumen objetivo: investigar la influencia de la abuela sobre la madre que da lactancia materna y su relación con la incidencia y prevalencia de la misma. método: se realizó una revisión integral consultando de las bases de datos medline ovid, dialnet y cochrane library. tras el análisis de los textos, se escogieron once estudios de investigación que iban dirigidos directamente a comprobar la influencia de las abuelas en la incidencia y prevalencia de la lactancia materna en diferentes contextos. resultados: la abuela apareció como fuente de apoyo en población rural (41 %). en población urbana la abuela aparece entre los tres factores principales (intención de la madre de lactar o no, decisión de la madre del patrón de alimentación de su hijo e información objetiva sobre pautas de amamantamiento), tanto en el papel de apoyo (94,7 %), como en el de obstáculo (26,7 %). en cuanto a la decisión de la madre sobre el patrón de alimentación de sus hijos, el 78 % refiere haber tomado la decisión antes del embarazo o en el primer trimestre. la convivencia con la abuela tuvo asociación positiva con dar agua o infusiones (pr regresión de cox con ic 95 %: 1,51 [1,10-2,09]; p = 0,011). conclusiones: a la luz de la revisión, la influencia detractora o no que ejerce la abuela sobre la lactancia materna la da sobre los tres factores principales. la influencia detractora ejercida por los consejos de la abuela parece estar relacionada con conocimientos erróneos adquiridos como “generación del biberón” más que con la intencionalidad, y es susceptible de modificarse con información adecuada, con resultados favorables sobre el patrón de alimentación. palabras clave lactancia materna, relaciones madre-hijo, red social, enfermería. (fuente: decs, bireme). the grandmother’s role in breastfeeding abstract objective: to investigate the effect the grandmother has on the breastfeeding mother and how it relates to the incidence and prevalence of breastfeeding. materials and methods: a comprehensive database review was conducted in medlineovid, dialnet and the cochrane library. after analyzing the texts, eleven studies aimed directly at verifying the influence of grandmothers on the incidence and prevalence of breastfeeding in different contexts were selected. results: the grandmother emerges as a source of support among the rural population (41 %). in the urban population, the grandmother appears among the three main factors (mother’s intention to breastfeed or not, mother’s decision on a feeding pattern for her child, and objective information on breastfeeding patterns), in a supporting role (94, 7%) and in a hindering role (26.7 %). as for the mother’s decision on a feeding pattern for her children, 78 % reported having made 271 papel de la abuela en la lactancia materna l marta elena losa-iglesias, rocío rodríguez-vázquez, ricardo becerro de bengoa-vallejo the decision before pregnancy or in the first quarter. living with the grandmother is positively associated with providing water or teas (pr in cox regression with 95 % ci: 1.51 [1.10 to 2.09], p = 0.011). conclusions: in the light of the review, the detracting or non-detracting influence exerted by the grandmother with respect to breastfeeding affects the three main factors. the detracting influence exerted by the grandmother’s advice seems to be related to incorrect knowledge acquired more as part of the “bottle fed generation” rather than intentionality, and is susceptible to being modified through appropriate information, with favorable results on the feeding pattern. keywords breast feeding, mother-child relations, social network, nursing. (source: decs, bireme). o papel da avó na lactância materna resumo objetivo: pesquisar a influência da avó sobre a mãe que dá lactância materna e sua relação com a incidência e prevalência desta. materiais e métodos: realizou-se uma revisão integral consultando as bases de dados medline ovid, dialnet e cochrane library. após a análise dos textos, escolheram-se onze estudos de pesquisa que vão dirigidos diretamente a comprovar a influência das avós na incidência e prevalência da lactância materna em diferentes contextos. resultados: constatou-se que a avó apareceu como fonte de apoio na população rural (41%). na população urbana, a avó aparece entre os três fatores principais (intenção da mãe de lactar ou não, decisão da mãe do padrão de alimentação de seu filho e informação objetiva sobre pautas de amamentação), tanto no papel de apoio (94,7%) quanto no de obstáculo (26,7%). quanto à decisão da mãe sobre o padrão de alimentação de seus filhos, 78% referem ter tomado a decisão antes da gravidez ou no primeiro trimestre. a convivência com a avó teve associação positiva com dar água ou infusões (pr regressão de cox com ic 95%: 1,51 [1,10-2,09]; p = 0,011). conclusões: à luz da revisão, a influência detratora ou não que exerce a avó sobre a lactância materna se dá sobre os três fatores principais. a influência detratora exercida pelos conselhos avó parece estar mais relacionada com conhecimentos errôneos adquiridos como “geração da mamadeira” do que com a intencionalidade e é suscetível de ser modificado com informação adequada, com resultados favoráveis sobre o padrão de alimentação. palavras-chave aleitamento materno, relações mãe-filho, rede social, enfermagem. (fonte: decs, bireme). 272 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 introducción contrario a lo que pueda parecer, la lactancia materna (lm) no es instintiva (1). en la mayoría de países desarrollados se han puesto en marcha medidas para aumentar las tasas de incidencia y prevalencia de lactancia materna exclusiva durante al menos los seis primeros meses de vida del niño. la mayor parte de las veces es a través de estrategias que implican únicamente a instituciones y personal sanitario que consideran a la lm como un hecho aislado (2). sin embargo, el proceso de embarazo-partolm-crianza, es un proceso complejo y cultural que depende de los contextos social, económico y sanitario (1, 2), y sin una visión de conjunto, las políticas sanitarias encaminadas a la mejora de las tasas de lm no lograrán los resultados deseados. en sociedades donde la lactancia materna exclusiva (lme) no es la norma, las abuelas pueden ejercer un efecto detractor o de impulso en su instauración y mantenimiento. las madres necesitan y quieren el apoyo de las abuelas, pero sus consejos y preocupaciones pueden reflejar las creencias culturales ante la lactancia materna (3). se puede dar el caso de que hasta tres generaciones anteriores a la madre prelactante no hayan amamantado o visto amamantar eficazmente a sus hijos (4). incluso cuando lo han hecho, esta madres pueden estar rodeadas de mensajes contradictorios en los que se afirma que la lactancia con leches maternizadas es mejor que la lm (5). estos mensajes pueden ser emitidos por personal sanitario, hijo de la “generación del biberón”, que ahondando en este concepto, podemos definir como individuos adultos que no han sido amantados con leche materna y que entienden que su situación de salud física y afectiva es adecuada, por lo que marginan o no dan importancia a la instauración de la lm (6). la madre, por tanto, puede estar abrumada por las dudas, especialmente en las primeras seis semanas en las que debe consolidarse el proceso fisiológico de la lm (2). los consejos sobre lm suministrados por las abuelas suelen ir en consonancia con sus propias experiencias y no con los conocimientos de la misma (7, 8), lo que puede suponer un importante estímulo y aporte de seguridad para la madre en algunos casos o, por el contrario, un entorno hostil inmerso en un escenario moderno (9). existen muchas razones por las que las mujeres pueden tomar la decisión de alimentar a sus bebés con leches maternizadas, sin ni siquiera intentar la lactancia materna (10), entre ellas se incluyen el uso de medicamentos potencialmente nocivos para el bebé, la cirugía en mama previa al embarazo y parto, experiencias anteriores negativas en relación con la lactancia materna en partos anteriores, partos múltiples, tabaquismo y otras responsabilidades familiares o laborales que hacen difícil compaginar la lactancia materna (11, 12). pero la presión familiar en contra, ocasionada por la experiencia y la confusión heredada por la “generación del biberón”, es una de las más fuertes y hace que la madre pueda perder grandes cantidades de energía en mantener su decisión que suele acabar con el abandono de la lactancia, en el caso de haberla iniciado (7). lakshman et al. en su estudio (13) analizaron seis artículos cualitativos y 17 cuantitativos muy interesantes e ilustrativos sobre el tema, y concluyeron que las madres que alimentaban con biberón a sus bebés experimentaban emociones negativas como culpa, ira, preocupación, incertidumbre y finalmente una sensación de fracaso. estas madres afirmaban haber recibido poca información sobre la alimentación con biberón o con leche materna, y que esa desinformación las hacía sentirse incapaces de tomar la decisión de amamantar o no a su hijo (14). aun con intervenciones y seguimiento sanitario que clarifique las ideas sobre lm, las madres desean el apoyo, la cercanía y el consejo de la abuela materna o paterna (3). en ocasiones, el consejo de las abuelas no es contrario a la instauración de la lm, pero influye en la introducción de agua o infusiones (15, 16) en la ingesta diaria del bebé y esto interfiere en la lme y condiciona al abandono de la misma, o la producción de leche a posteriori. tanto en países desarrollados como en vías de desarrollo los mitos más frecuentemente transmitidos por las abuelas son los de cantidad insuficiente de leche ante el llanto del niño y la creencia de que la madre que da lm descansa menos o peor (8, 15). el mayor o menor poder de la abuela en el entorno familiar o sociocultural establece el impacto de su influencia en la lm, pudiendo dejar a la madre en una situación difícil para poder elegir en caso de que las indicaciones sanitarias sean contrarias a las de la tradición ya que habitualmente no se incluye a la abuela materna ni paterna en las actuaciones sanitarias de promoción y tampoco se integran dichas actuaciones en la cultura del lugar donde se desarrollan (17). la red social, por tanto, y particularmente la abuela materna o paterna, dependiendo de la sociedad y su cultura, podrían ser 273 papel de la abuela en la lactancia materna l marta elena losa-iglesias, rocío rodríguez-vázquez, ricardo becerro de bengoa-vallejo una red de apoyo o de abandono de la lm y por ello merece ser blanco de actuaciones sanitarias específicas teniendo en cuenta sus tradiciones, situación social (18,19), así como su nivel cultural y económico (20). en los países desarrollados el acceso a los servicios sanitarios y a las múltiples fuentes de información hacen que las madres no necesiten tanto el conocimiento de las abuelas como el apoyo y la comprensión de estas ante la decisión de dar lme. aun así el entorno cercano, liderado normalmente por las abuelas, es la principal fuente de información y apoyo en la mayoría de las ocasiones (21). por todo ello, se hace necesario investigar la influencia de la abuela sobre la madre que da lm y su relación con la incidencia y prevalencia de la misma, así como proyectar la necesidad o no de nuevas estrategias sanitarias para que las abuelas sean incluidas en los programas destinados a mejorar estas tasas. materiales y métodos para analizar la influencia de las abuelas sobre el inicio y mantenimiento de la lactancia materna se realizó una búsqueda bibliográfica centrada en aquellos estudios de investigación que contribuyesen aportando directamente datos sobre las mismas, y no en un contexto de estudio de toda la red social de la madre lactante. las búsquedas se realizaron en medline ovid, dialnet y cochrane library durante el mes de enero de 2012, con las palabras clave “lactancia materna” y “abuela”, en español e inglés. no se realizó restricción en la búsqueda en cuanto al año de publicación, en parte debido a la poca cantidad de estudios de investigación sobre este tema. tras analizar los resultados hallados en dialnet y cochrane library, los textos fueron eliminados del estudio por ser artículos de revisión, poco específicos o clarificadores para el tema de la investigación. de los 16 artículos obtenidos mediante medline ovid, se eliminaron del análisis tres de ellos por ser estudios cualitativos, aunque sirvieron para centrar el tema y aportar más información y conocimiento. también se eliminaron dos estudios por no ser pertinentes para el objeto de esta investigación al tratar de una forma parcial el tema. en cuanto a los tipos de estudio analizados en esta revisión integral, nueve de los diez artículos eran descriptivos y uno de ellos analítico. debido a esa escasez de estudios, tampoco se estableció un criterio de elegibilidad de textos en lo referente a la muestra, por lo que la población estudiada en su totalidad es heterogénea: primíparas y multíparas de diferentes edades y niveles socioculturales y económicos en poblaciones rurales y urbanas. algunas mujeres convivían con las abuelas materna o paterna y otras no. dependiendo del contexto cultural y las creencias tradicionales de la población en estudio, las investigaciones de los artículos incluidos se centraban en la influencia de la abuela materna, paterna, o ambas. en nueve de los diez artículos los datos fueron extraídos a partir de entrevistas o cuestionarios y en solo uno de ellos los datos fueron recogidos a través de registros nacionales oficiales. todos los artículos revisados para esta investigación cumplieron con los requerimientos éticos en la realización de las entrevistas por un lado, y en el procesamiento de los datos y publicación de los resultados, por otro. en lo referente a la comprensión de la lectura y el análisis de los textos en inglés, se debe señalar que el equipo de investigación posee un nivel alto y certificado en comprensión oral y escrita del idioma, hecho que minimizó el sesgo. posiblemente la revisión integral realizada se vio limitada por la exclusión de todos aquellos datos arrojados por los estudios que no iban dirigidos directamente a comprobar la influencia de las abuelas en la incidencia y prevalencia de la lactancia materna en diferentes contextos; es decir, que fueron excluidos aquellos artículos en los que el objetivo principal era evaluar la influencia del entorno social en general, pero no centrado en el papel de la abuela materna o paterna. durante la búsqueda bibliográfica se pudo comprobar la presencia de la influencia del factor del entorno social en múltiples estudios, pero no como tema principal, lo cual no excluye la posibilidad de extraer de ellos conclusiones interesantes para el objetivo de esta investigación. otra posible limitación puede derivarse de la no realización de subgrupos según los años en los que se llevaron a cabo los estudios, ya que en investigaciones más actuales pueden influir las políticas sanitarias prolactancia materna o los medios de comunicación en la propia influencia de las abuelas, especialmente en el medio urbano, pero insistimos en la imposibilidad de hacerlo debido a los pocos textos que cumplían criterios de inclusión. 274 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 respecto a las consideraciones éticas de la presente revisión integral es necesario apuntar que se han seguido las recomendaciones del national research council of the national academies en lo que respecta a la integridad y buenas prácticas en investigación (22). resultados la población y las variables de estudio de los artículos incluidos en esta revisión integral son muy heterogéneos; la composición demográfica y variables de los mismos se muestra en la tabla 1. analizando un estudio sobre una muestra de población rural en kentucky (ee.uu.) (23), cuyo patrón de alimentación se detalla en la tabla 2, se obtuvo que la fuente principal de apoyo referido por las mujeres era la abuela materna o paterna (41 %), por delante de la pareja (38 %), otros miembros de la familia (7 %) o los profesionales sanitarios (14 %). el 42,3 % de esas mujeres confiaron en el consejo de las abuelas sobre alimentación, frente al 26,9 % que confió principalmente en el pediatra. en otro estudio con población urbana de méxico d.f. (8) se identificaron fuentes de apoyo y fuentes de obstáculo para la instauración de la lm (tabla 3). tanto la abuela materna como paterna se situaron entre las tres frecuencias y saliencias4 más altas. en el estudio de arora et al. (21) con mujeres norteamericanas que daban lm el apoyo/consejo de la abuela apareció como fuente de refuerzo en la decisión de dar lm con el 23,5 % (8º lugar de 11 ítems) entre los que el principal era la creencia de que es lo mejor para la salud del bebé (61,8 %) y que es la forma de alimentación más natural (59,7 %). sin embargo, el 78 % reconoció haber tomado la decisión del patrón de alimentación de sus hijos antes del embarazo o en el 1º trimestre del mismo. en cuanto a la identificación de las fuentes de información objetivas, la familia (padre y abuelas en el estudio) apareció como la fuente principal con un 33,9 %. en otro estudio realizado en gestantes de población predominantemente rural de missouri (ee. uu.) (24), el 36,2 % de las abuelas habían dado lm a las gestantes objeto del estudio o a otros hijos, lo que se asoció con mayor probabilidad de intención de dar lm por parte de las gestantes según el análisis con chi-cuadrado (p < 0,004; or = 4,5 ic 95 % [1,55-13,09]), así como la aproba4 frecuencia sopesada con el rango promedio de mención de cada personaje y representando, por tanto, no solo la proporción, sino también si se menciona antes o después. ción masculina (p < 0,01; or = 6 ic 95 % [1,87-19,16]). el porcentaje de mujeres con intención de dar lm fue del 49,2 % (16). sin embargo, resultados ofrecidos por otros autores consultados (3) indican que menos de la mitad de las mujeres con lactantes menores a 6 meses admiten la influencia de las opiniones de la abuela (43,3 % abuela materna y 32,4 % abuela paterna). en este estudio, la mayoría de abuelas consideraban buena la lm (93,2 % abuelas maternas y 84,4 % abuela paterna). en el estudio realizado en bolivia (20) encontramos que en un 90,8 % de la muestra de abuelas, estas tuvieron una actitud positiva frente a la lm, pero en el análisis de regresión lineal no hubo asociación positiva entre la actitud de la abuela y el patrón de alimentación en términos de uso de calostro (or = 1,52; ic 95 % [0,4-5,36,]), lme (or = 0,91; ic 95 % [1,51-4,38]) ni lm a demanda (or = 0,99; ic 95 % [0,47-2,06]). en el estudio de kessler (25) se demostraron variables estadísticamente significativas (p ≤ 0,005) relacionadas con la intención de dar lm en mujeres con hijos menores de 7 días de vida, como la actitud previa positiva de la madre hacia la lm, relacionada significativamente con el inicio exitoso de la lm (or = 66,7; ic 95 % [64,1-69,3]), la preferencia de lm sobre la lactancia artificial (la) por parte de sus familiares y tener pareja estable (casada). la preferencia de los familiares (30 % compuesto por abuela materna) tuvo también un efecto significativo estadísticamente según el análisis multivariado (or = 58,82; ic 95 % [47,82-69,82]). en el único estudio de casos y controles analizado, tras una intervención de educación para la salud a las abuelas de lactantes en población rural senegalesa, se constató un aumento importante en el asesoramiento en conductas saludables por parte de la abuela hacia sus hijas en época de amamantamiento (29-46 % pretest al 92-98 % postest) y en el grupo de casos se observó un aumento de dichas conductas saludables respecto al de controles en las mujeres expuestas al consejo de la abuela materna (35-57 % frente al 93-98 %) (19). en cuanto a la administración de biberón a los lactantes (con leche maternizada, agua o infusiones) como prácticas contrarias al éxito de la lm, existe asociación positiva significativa entre la convivencia con la abuela materna y el uso de biberón, pero no con la abuela paterna, según se observa en la tabla 4, que arroja los resultados obtenidos en un análisis logístico multivariado en una población urbana de porto alegre (brasil) (15). 275 papel de la abuela en la lactancia materna l marta elena losa-iglesias, rocío rodríguez-vázquez, ricardo becerro de bengoa-vallejo otro estudio consultado y analizado revela la asociación entre la convivencia con las abuelas materna y paterna con la introducción de ingesta de agua o infusiones y con la introducción de la de forma independiente, y lo demuestra utilizando análisis de regresión multivariada de cox. de las variables sociales analizadas en este estudio, la convivencia con la abuela materna tenía una asociación positiva con la introducción de agua/infusiones (pr regresión de cox con ic 95 %: 1,51 [1,10-2,09]; p = 0,011) pero no la tenía con la introducción de la (pr regresión de cox con ic 95 %: 1,51 [0,89-2,54]), ni tampoco la convivencia con el padre (pr regresión de cox con ic 95 %: 0,96[0,59-1,55]). también se determinó que el abandono de lm en los primeros 6 meses era más frecuente en niños que tomaban lactancia mixta o que se les había introducido una ingesta de agua/infusiones en contraposición con los bebes que tomaban lme (p < 0,001) (17). los hallazgos relacionados con la convivencia con la abuela se investigan en el estudio de susin et al. (16), en el que se realizó un análisis bivariado y multivariado con el objetivo de buscar la relación entre el consejo de las abuelas materna y paterna en lo referente a introducir ingesta de agua/infusiones y el abandono de la lm en el primer mes. se demostró una asociación positiva para ambas: or aj. 2,22; ic 95 % [1,50-3,30] para la abuela materna y or aj. 1,83; ic 95 % [1,24-2,71] para la abuela paterna. este estudio se realizó en una población urbana de porto alegre en donde el contacto diario con la abuela paterna era del 30 % y con la abuela materna del 40 %. por último, se deben señalar los interesantes resultados arrojados por el estudio de investigación de casper y hogan (26) que encuentran asociación inversamente proporcional entre cercanía de la abuela u otro familiar y la probabilidad de dar lm, según muestra la tabla 5, extraída de este estudio. discusión tanto en medio urbano como rural, una fuente de apoyo u obstáculo importante para la lm referida por las mujeres es la abuela materna o paterna (23, 8), sin embargo, no parece que esta sea suficiente para que las mujeres tomen una decisión. a la luz de los resultados obtenidos por el estudio de investigación de turnbull-plaza (8) encontramos que la mayoría de las abuelas habían ejercido de apoyo ante la decisión de la lm. esto nos obliga como profesionales de la salud a prestar atención a ítems que están relacionados entre sí, como son la decisión, la intención y la información objetiva. en esta línea, otros estudios (21) defienden que la abuela es una fuente de refuerzo en mujeres que dan lm pero, en contraposición al estudio de turnbull-plaza (8), no aparece entre las fuentes principales. esto puede deberse a la conclusión alcanzada de que las mujeres toman la decisión de dar lm o antes de estar embarazadas o en el primer trimestre, periodos en los que habitualmente el personal sanitario no les da mucha información al respecto. esto está presente también en los resultados de kessler et al. (25) referidos, en este caso, a la intención de dar lm. la variable intención, íntimamente relacionada con la toma de decisión del patrón de alimentación, nuevamente parece influida por la simple opinión de la abuela, o que la madre haya sido amamantada, o la opinión de su pareja (24). por otro lado, el entorno familiar, incluyendo a la abuela, aparece como fuente de información objetiva (beneficios, técnica…) sobre lm. esto podría justificar la influencia negativa sobre las tasas de inicio y prevalencia de lm, ya que las abuelas de estos estudios pertenecen a la “generación del biberón” (21). incluso, aunque las abuelas apoyan positivamente la lm, esto no se traduce en mejores resultados de instauración o mantenimiento, como concluye la investigación de ludvingsson (20). entre las prácticas desaconsejadas para la lm según la oms aparece la de dar agua o infusiones al niño alimentado con lm. respecto a esto, la cercanía de la abuela ejerce una influencia importante al favorecer estas prácticas, lo cual lleva en ocasiones al abandono de la misma (16,17) probablemente hasta justificar el hecho de que a más cercanía de la abuela mayor probabilidad de baja tasa de lm (26). sin embargo, esta cercanía no parece traducirse en un aumento de decisión a favor de la por parte de la madre, lo que puede suponer un sustento a la teoría de que las abuelas “pro-lm” ejercen su influencia en la decisión pero también ejercen una influencia negativa en la prevalencia debido a sus conocimientos escasos o erróneos. en el único estudio de casos y controles (19) incluido en esta revisión integrativa y realizado en población rural, encontramos que la información de las abuelas sobre las prácticas para el inicio y mantenimiento de la lm fueron altamente efectivas, produciendo cambios en el manejo de la misma por parte de las madres. en cuanto a la diferenciación entre la influencia ejercida por las abuelas materna y paterna, los resultados muestran influencia de ambas (23), siendo las mayores tasas favorecedoras las de las abuelas maternas (3, 8, 15,16). 276 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 a la luz de la escasez y heterogeneidad de las variables incluidas en los estudios analizados, y también en lo que respecta a la población, sería recomendable encauzar próximas investigaciones a aclarar diversos puntos que han quedado poco clarificados en esta revisión integral, los cuales son: • cuantificar la influencia de la abuela materna sobre la intención, toma de decisión y prácticas de lm como variables que deben desglosarse. • clarificar el papel de la abuela en cuanto a influencia en las distintas culturas. • cuantificar el impacto de la información sobre lm previa al embarazo y en el primer trimestre del mismo. • comparar la influencia de las abuelas de la “generación del biberón” con las que pertenezcan la repunte de lm, especialmente en países con buenos datos de incidencia y prevalencia de la misma. • verificar la influencia de la abuela en las prácticas de lm en países con políticas activas pro-lm y acceso sanitario óptimo. conclusiones a tenor de la revisión realizada encontramos que la abuela (materna principalmente), puede ser considerada dentro de los factores de apoyo o dentro de los factores detractores para la lm en igual medida, pero no es el único factor influyente. su influencia depende del medio social y la cultura. el ámbito de influencia de la abuela sobre la lm se ejerce sobre tres ítems principales: intención de la madre de dar lm o no, decisión de la madre del patrón de alimentación de su hijo e información objetiva sobre pautas de amamantamiento, pudiendo afectar el inicio o el mantenimiento de la misma. sin embargo, la intención y la decisión suelen estar tomadas antes del embarazo o en su primer trimestre. la influencia negativa ejercida por los consejos de la abuela en materia de lm parecen estar relacionadas con conocimientos erróneos adquiridos más que con la intencionalidad, y es susceptible de modificarse con información adecuada, con resultados favorables sobre el patrón de alimentación ofrecido por las madres a sus lactantes. se hace necesario, entonces, que las políticas sanitarias para estimular y aumentar las tasas de lm incluyan información general a las futuras madres y abuelas antes del embarazo y no tanto durante el mismo o después y de manera contextualizada con la cultura a la que se dirija. los medios deben ser útiles para llegar a aquellas abuelas no amamantadas, susceptibles de ejercer influencia negativa sobre la lm, ya que serían muy útiles para reforzar y apoyar a la madre prelactante. conflicto de intereses: los autores declaran que no existe ningún tipo de conflicto de intereses. referencias 1. vinther t, helsing e. breastfeeding: how to support success. copenhagen: world health organization regional office for europe; 1997. 2. pallás cr, gómez a, aguayo j. maternidad, parto y crianza. en: aguayo j, gómez a, hernández mt, lasarte jj, lozano mj, pallás cr. manual de lactancia materna: de la teoría a la práctica. madrid: panamericana; 2008. p.1-7. 3. grassley j, eschiti v. grandmother breastfeeding support: what do mothers need and want? birth 2008;35(4):329-35. 4. paricio talayero jm. aspectos históricos de la alimentación al seno materno. en: lactancia materna: guía para profesionales. madrid: monografías de la aep, 5. ergon; 2004. pp 7-26. 5. renfrew jm, ansell p, mackeod kl. formula feed preparation: helping reduce the risks; a systematic review. arch dis child. 2003;88:855-858. 6. merewood a. raza, etnia y lactancia materna. pediatrics (ed esp). 2006; 62(4):649. 7. reid j, schmied v, beale b. ‘i only give advice if i am asked’: examining the grandmother’s potential to influence infant feeding decisions and parenting practices of new mothers. women & birth: aust j midwifery. 2010;23(2):74-80. 277 papel de la abuela en la lactancia materna l marta elena losa-iglesias, rocío rodríguez-vázquez, ricardo becerro de bengoa-vallejo 8. turnbull-plaza b, escalante-izeta é, klunder-klunder m. papel de las redes sociales en la lactancia materna exclusiva: una primera exploración. rev med inst mex seguro soc. 2006;44(2):97-104. 9. guizardi polido c, falleiros de mello d, garcia de lima parada cm, barros leite carvalhaes ma, pamplona tonete vl. maternal experiences associated with longer term exclusive breastfeeding: an ethnographic study. acta paul enferm. 2011;24(5):624-30. 10. shaker i, scott j a, reid m. infant feeding attitudes of expectant parent’s breastfeeding and formula feeding. j adv nurs. 2003;45(3):260-427. 11. ahluwalia ib, morrow b, hsia j. why do women stop breastfeeding? findings from the pregnancy risk assessment and monitoring system. paediatrics. 2005;116(6):1408-1412. 12. lee e. health, morality, and infant feeding: british mothers experiences of formula milk use in the early weeks. sociol health ill. 2007;29:1075-1090. 13. lakshman r, ogilvie d, ong kk. mothers’ experiences of bottle-feeding: a systematic review of qualitative and quantitative studies. arch dis child. 2009;94:596-601. 14. moore e. systematic review: mothers bottle feeding their babies feel negative emotions such as guilt and worry, and receive little information about bottle feeding. evid based nurs. 2010;13:27-28. 15. franca mc, giugliani er, oliveira ld, weigert em, santo lc, kohler cv, et al. bottle feeding during the first month of life: determinants and effect on breastfeeding technique.rev saude publica. 2008;42(4):607-14. 16. susin lr, giugliani er, kummer sc. influence of grandmothers on breastfeeding practices. rev saude publica. 2005; 39(2):141-7. 17. giugliani er, do espirito santo lc, de oliveira ld, aerts d. intake of water, herbal teas and non-breast milks during the first month of life: associated factors and impact on breastfeeding duration. early human development. 2008;84(5):305-10. 18. bezner r, dakishoni l, shumba l, msachi r, chirwa m. “we grandmothers know plenty”: breastfeeding, complementary feeding and the multifaceted role of grandmothers in malawi. soc sci med. 2008; 66(5):1095-105. 19. aubel j, toure i, diagne m. senegalese grandmothers promote improved maternal and child nutrition practices: the guardians of tradition are not averse to change. soc sci med. 2004;59(5):945-59. 20. ludvigsson jf. breastfeeding in bolivia information and attitudes. bmc pediatrics. 2003;3:4. 21. arora s, mcjunkin c, wehrer j, kuhn p. major factors influencing breastfeeding rates: mother’s perception of father’s attitude and milk supply. pediatrics. 2000;106(5):e67. 22. national research council of the national academies. integrity in scientific research: creating an environment that promotes responsible conduct. washington: the national academies press; 2002. 23. barton sj. infant feeding practices of low-income rural mothers. am j mat child nurs 2001;26(2):93-7. 24. libbus mk. kolostov ls. perceptions of breastfeeding and infant feeding choice in a group of low-income mid-missouri women. j hum lact. 1994; 10(1):17-23. 25. kessler la. gielen ac. diener-west m. paige dm. the effect of a woman’s significant other on her breastfeeding decision. j hum lact. 1995;11(2):103-9. 26. casper lm. hogan dp. family networks in prenatal and postnatal health. soc biology. 1990;37(1-2):84-101. 278 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 título población lugar tipo n edad paridad etnia n. cultural n.económico otros bottle feeding during the first month of life: determinants and effect on breastfeeding technique porto alegre (brasil) urbanas 211 75,8 % > 20 años primíparas: 46,9 % blanca: 70 % ≥ 8 años: 64 % convivencia con abuela materna: 30,8 % convivencia con abuela paterna: 18,9 % intake of water, herbal teas and non-breast milks during the first month of life: associated factors and impact on breastfeeding duration porto alegre (brasil) urbanas 220 25 % < 20 años 75 % > 20 años primíparas: 47,3 % blanca: 69,1 % ≥ 8 años: 64,1 % experiencia en lm 59,5 % convivencia con abuela materna o paterna: 19,1 %. > 6 consultas sanitarias gestacionales: 78,6 % preparación lm en el embarazo: 25,8 % the role of social networks in exclusive breastfeeding méxico d.f. (méxico) urbanas 19 heterogénea heterogénea heterogénea heterogénea heterogénea hijo < 6 meses influence of grandmothers on breastfeeding practices porto alegre (brasil) urbanas 571 58,3 %: 2030 años primíparas: 42,2 % blanca:58,8 % negra: 41,2 % < 4 años: 18,9 % 4-8 años: 45,7 % > 8 años: 35,4 % bajo: 18,4 % medio: 50,8 % alto: 30,8 % abuela materna viva/abuela paterna viva senegalese grandmothers promote improved maternal and child nutrition practices: the guardians of tradition are not averse to change senegal (13 pueblos) rural 76 mujeres 114 abuelas hijos < 12 meses breastfeeding in bolivia information and attitudes la paz (bolivia) urbana: 95,7 % rural: 4,3 % 502 13-45 años 62 % adolescentes latina < 5 años: 35,3 % > 5 años: 64,7 % bajo: 33 % media: 59,1 % alto: 7,9 % hijos < 12 meses otros criterios: religión, estado civil, conviviente con pareja. infant feeding practices of low-income rural mothers kentuky (ee.uu.) rural 52 16-38 años media 23,27 blanca instituto: 41 % universidad: 31 % título universitario: 8 % < 10000 $/año: 50 % a 20000$/año: 27 % >20000$/año: 23 % 75 % con pareja major factors influencing breastfeeding rates: mother's perception of father's attitude and milk supply pensilvania (ee.uu.) urbanas 245 < 12 meses the effect of a woman's significant other on her breastfeeding decision baltimore (ee.uu.) urbanas 133 blanca: 50 % negra: 50 % < instituto: 16 % instituto: 45 % > instituto: 38 % < 15000$: 32 % > 15000$:68 % sólo 30 % muestra con abuelas. resto con padres. intención previa lm: sí: 52 % no: 48 % perceptions of breastfeeding and infant feeding choice in a group of low-income mid-missouri women missouri (ee.uu.) predominio rural 69 media 22,7 blanca bajo bajo al menos 10 semanas de gestación family networks in prenatal and postnatal health ee.uu. muestra heterogénea 1226 21-28 años media 23 primíparas: 41,6 % blanca: 67,5 % instituto: 79,3 % no instituto: 20,7 % no pobres:64,9 % pobres: 35,1 % tabla 1. la población y las variables de los once estudios incluidos 279 papel de la abuela en la lactancia materna l marta elena losa-iglesias, rocío rodríguez-vázquez, ricardo becerro de bengoa-vallejo tabla 5. efectos de la cercanía de los familiares sobre la lm tabla 2. patrón de alimentación al nacimiento, 1 mes y 4-6 meses de vida patrón de alimentación lm (%) la (%) l mixta (%) nacimiento 41,2 52 8 1 mes 29 71 0 4-6 meses 20 80 0 tabla 3. fuentes de apoyo y obstáculo para lm referidos por madres con hijos < 6 m f = frecuencia; s = saliencia = frecuencia sopesada con el rango promedio de mención de cada personaje y representando, por tanto, no solo la proporción, sino también si se menciona antes o después. apoyo (%) obstáculo (%) f s f s abuela materna 94,7 0,777 26,7 0,27 abuela paterna 42,1 0,252 26,7 0,22 tabla 4. asociación entre la convivencia con las abuelas y el uso de biberón a los 7 y 30 días de vida variables n uso de biberón a los 7 días (n = 45) uso de biberón a los 30 días (n = 30) or aj* ic 95 % p or aj* ic 95 % p convivencia con abuela materna 65 2,58 1,145,87 0,023 2,33 1,184,60 0,015 convivencia con abuela paterna 40 1,58 0,584,34 0,374 0,77 0,351,68 0,505 * or ajustada para las variables contenidas. resultados de regresión logística que describen los efectos del acceso familiar sobre la lactancia maternaa variables proximidad abuela constante -2,804 (0,707)c proximidad de la abuela abuela en el hogar -0,699 (0,264) b abuela en el vecindario -0,660 (0,198) c abuela dentro de 50 millas -0,131 (0,193) datos perdidos proximidad abuela 0,007 (0,195) abuela lejos … grados de libertad 13 -2(log probabilidad x2) 273,47 (-2 log l.r.) p 0,000 a n = 1,336. errores estándar entre paréntesis. b p < 0,01 c p < 0,001 1 el comité editorial de la revista aquichan agradece a los siguientes investigadores, quienes brindaron su apoyo en calidad de revisores, en el volumen 22 del 2022, e hicieron posible la publicación de artículos con calidad científica. agradecimientos eva pilar lópez garcía universidad católica de ávila españa evapilarlopez@gmail.com ana karine costa monteiro hospital getúlio vargas: teresina brasil karinemonteiro2006@hotmail.com marcela carrillo pineda universidad de antioquia colombia marcela.carrillo@udea.edu.co stefany ortega-pérez universidad del norte colombia srortega@uninorte.edu.co eva pilar lópez garcía universidad católica de ávila españa evapilarlopez@gmail.com lorena paola bettancourt ortega universidad de valparaíso chile lorena.bettancourt@uv.cl lucas rossato universidade de são paulo brasil rossatousp@usp.br maría angélica arzuaga-salazar universidad de antioquia colombia maria.arzuaga@udea.edu.co lissette avilés reinoso universidad andrés bello chile llaviles21@gmail.com lydia gordon de isaacs universidad de panamá panamá isaacs@cwpanama.net luz mila hernández sampayo universidad del valle colombia luzmila.hernandez@correounivalle.edu.co rocío lópez instituto cancerológico de bogotá colombia rlopezr@cancer.gov patricia del tránsito jara concha universidad de concepción chile pjara@udec.cl antónio geraldo manso calha instituto politécnico de portalegre portugal antoniocalha@ipportalegre.pt lorena sánchez rubio universidad del tolima colombia lorenasanchez@ut.edu.co jhon henry osorio castaño universidad pontificia bolivariana colombia jhenry.osorio@udea.edu.co adriana-lucia valdez-fernández universidad del cauca colombia adrianitalvf@unicauca.edu.co amaya pavez lizarraga universidad de santiago de chile chile amaya.pavez@usach.cl 2 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 a gr ad ec im ie nt osmaría carmen delgado-alvarez universidad pontificia salamanca españa mcdelgadoal@upsa.es vanessa jiménez arroyo universidad michoacana de san nicolás de hidalgo méxico vanesa.jimenez@umich.mx jack roberto silva fhon universidade de são paulo brasil betofhon@usp.br daiana foggiato de siqueira universidade federal de santa maría brasil daianasiqueira@yahoo.com.br maría angélica arzuaga-salazar universidad de antioquia colombia maria.arzuaga@udea.edu.co arménio guardado cruz universidad de coimbra portugal acruz@esenfc.pt joão feliz duarte de moraes pontifícia universidade católica do rio grande do sul brasil brasil jfmoraes@pucrs.br rosa del rocío pinargote chancay universidad estatal del sur de manabí ecuador rosa.pinargote@unesum.edu.ec dirce stein backes universidad franciscana ufn: santa maría brasil backesdirce@ufn.edu.br claudia teresa solano perez universidad autónoma del estado de hidalgo méxico claudia_solano@uaeh.edu.mx oscar javier vergara escobar universidad juan n. corpas colombia oscar.vergara@juanncorpas.edu.co jaime alberto ramírez universidad nacional de colombia colombia jaramirezn@unal.edu.co julian andrés barragán becerra universidad pedagógica y tecnológica de colombia colombia julian.barragan@uptc.edu.co beatriz sánchez herrera universidad de la sabana colombia clara.sanchez@unisabana.edu.co ángela maría salazar maya universidad de antioquia colombia angela.salazar@udea.edu.co alix yaneth perdomo romero universidad surcolombiana colombia alixyaneth.perdomo@usco.edu.co paola sarmiento gonzález universidad de la sabana colombia paola.sarmiento@unisabana.edu.co maría florencia tartaglini consejo nacional de investigaciones científicas y técnicas instituto de neurociencias buenos aires argentina florenciatartaglini@conicet.gov.ar hortensia castañeda-hidalgo universidad autónoma de tamaulipas méxico hcastane@docentes.uat.edu.mx heloisa de carvalho torres universidade federal de minas gerais brasil heloisa.ufmg@gmail.com 3 a gr ad ec im ie nt osmiguel angel fuentealba torres universidad de los andes chile mafuentealba@uandes.cl iliana milena ulloa sabogal universidad de antioquia colombia iliana.ulloa@udea.edu.co ariel calderón ardila universidad de santander colombia ar.calderon@mail.udes.edu.co fanny rincon osorio universidad nacional de colombia colombia frincono@unal.edu.co joel rolim mancia universidade do vale do sinos brasil joelmancia@uol.com.br isabel quispe mendoza universidade federal de minas gerais brasil isabelyovana@gmail.com lissette avilés reinoso the university of edinburgh reino unido laviles@ed.ac.uk stefany ortega-pérez universidad del norte colombia srortega@uninorte.edu.co myriam gómez ortega universidad autónoma del estado de méxico méxico mgomezo@uaemex.mx denisse parra giordano universidad de chile chile drparra@uchile.cl alicia alvarez aguirre universidade de são paulo brasil alicia.alvarez@ugto.mx sandra guerrero gamboa universidad nacional de colombia colombia nsguerrerog@unal.edu.co lúcia nazareth amante federal university of santa catarina brasil lucia.amante@ufsc.br beatriz sánchez herrera universidad de la sabana colombia maryorygl@unisabana.edu.co maryory guevara lozano universidad de la sabana colombia clara.sanchez@unisabana.edu.co mauricio alberto angel macias universidad nacional de colombia colombia mauricioangelmac@gmail.com maría de lourdes garcía campos universidad de guanajuato méxico lulu.garcia@ugto.mx maría angélica arzuaga-salazar universidad de antioquia colombia maria.arzuaga@udea.edu.co maricela curisinche rojas universidad científica del sur perú maricelacurisinche@gmail.com juliana cristina lessmann reckziegel universidade do planalto catarinense brasil julianalessmann@gmail.com raphael raniere de oliveira universidade federal do rio grande do norte brasil raphaelraniere@hotmail.com luana tonin universidad federal do paraná brasil luanatonin@gmail.com 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 aquichan, revista científica de la facultad de enfermería y rehabilitación, editada por la universidad de la sabana, está orientada hacia la promoción y el estímulo del desarrollo teórico de enfermería. temática y alcance: aquichan, publicación de ciencias médicas y de la salud, del área ciencias de la salud, de la disciplina enfermería, publica artículos resultados de investigación desde el punto de vista epistemológico, práctica basada en la evidencia, cuidado crónico, y, promoción y prevención. se reciben artículos en español, inglés y portugués, originales e inéditos, producto de investigación o revisión que no se encuentren en proceso de evaluación por otras revistas científicas, ya sean impresas o electrónicas. los artículos aprobados deberán ser traducidos para publicar en inglés, este trámite estará a cargo de los autores y deberá ser avalado por el comité editorial de la revista. tipo de artículos que publica: de investigación: documento que presenta, de manera detallada, los resultados originales de proyectos de investigación terminados. la estructura utilizada debe contener: introducción, metodología, resultados y conclusiones. de revisión de literatura: documento producto del análisis crítico de la literatura científica, que presenta una síntesis de los resultados de investigación con el propósito de facilitar la comprensión de un fenómeno de estudio y proveer información sobre la evidencia científica relacionada con el tema. en esta categoría, se incluyen las revisiones sistemáticas e integrativas de la literatura. se caracteriza por presentar una cuidadosa revisión bibliográfica de mínimo 50 referencias. aquichan no acepta reportes de casos, editoriales, ni cartas al editor. periodicidad: aquichan circula trimestralmente, en enero, abril, julio y octubre. formato de publicación: impreso y electrónico en open acces, bajo la licencia creative commons. organización de los artículos título: es breve e indica el tema central del artículo, no incluye abreviaturas ni fórmulas. contiene máximo 15 palabras, escrito en español, inglés y portugués. información de los autores: cada autor debe relacionar la siguiente información: y nombre completo y id de investigador. se puede obtener a través del siguiente link: https://orcid.org/register. ejemplo: orcid.org/0000-0003-4037-6235 y filiación institucional y país y correo electrónico institucional normas para autores https://orcid.org/register https://orcid.org/register 5 n or m as p ar a au to re sel número máximo de autores permitido es 6, salvo en casos donde, a juicio del comité editorial, el impacto de la investigación o su carácter multi céntrico justifique exceder el número. información adicional: y nombre del autor de correspondencia. y agradecimientos, cuando haya lugar, y se ubican después de las conclusiones y financiación: cuando el artículo se deriva de un proyecto financiado, se debe dar cuenta de ello. en este caso, mediante asterisco en el título, en nota de pie de página, se escribe el nombre del proyecto y de las entidades financiadoras. y declaración de originalidad: adjuntar en formato pdf, la declaración diligenciada y firmada por todos los autores. y carta aval de comité de ética: adjuntar la carta de aval del comité de ética institucional que aprobó la investigación. y conflicto de interés: los autores declaran el conflicto de interés en un apartado al final del manuscrito. resumen: debe contener máximo 200 palabras, y debe seguir la estructura: objetivos, materiales y método, resultados y conclusiones. no debe incluir referencias bibliográficas. palabras clave: cinco términos normalizados en el thesauro mesh – medical subject headings. (disponible en http://www.ncbi.nlm.nih.gov/mesh). no se aceptan frases ni descriptores que no se encuentren en este thesauro. relacionar la temática en la cual desarrolló su artículo de investigación o revisión: y epistemología y práctica basada en la evidencia y cuidado crónico y promoción y prevención aporte a la disciplina: en un apartado de 150 caracteres evidenciar el aporte al nuevo conocimiento disciplinar del estudio presentado y el modelo o teoría de enfermería utilizada, en caso que lo aplique. tipo de artículo y presentación del cuerpo del trabajo: los tipos de artículos que recibe la revista aquichan son los siguientes: y investigación: la extensión de los manuscritos debe estar entre 3000 y 4000 palabras; los artículos de investigación se organizan de acuerdo con la guía establecida por el international committee of medical journal editors, disponible en: http://www.icmje.org/recommendations/browse/manuscript-preparation/preparing-for-submission.html#three para investigaciones con metodología cualitativa, debe cumplir con los requisitos establecidos en: (disponible http://www.cnfs.net/modules/module2/story_content/external_files/13 _coreq_checklist_000017.pdf ) para investigaciones con metodología cuantitativa, debe cumplir con los requisitos establecidos por consort (disponible http://www.consort-statement.org/) http://www.icmje.org/recommendations/browse/manuscript-preparation/preparing-for-submission.html#three http://www.icmje.org/recommendations/browse/manuscript-preparation/preparing-for-submission.html#three http://www.cnfs.net/modules/module2/story_content/external_files/13_coreq_checklist_000017.pdf http://www.cnfs.net/modules/module2/story_content/external_files/13_coreq_checklist_000017.pdf http://www.consort-statement.org/ 6 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 y revisiones sistemáticas, integrativas, meta-análisis y meta síntesis: se caracteriza por presentar una cuidadosa revisión bibliográfica de mínimo 50 referencias, salvo en casos en donde con previa justificación, esto no se cumpla. debe cumplir con los requisitos establecidos en prisma (disponible: http://www.prisma-statement.org/prismastatement/default.aspx) todos los artículos se deben presentar con fuente times new roman, 12 puntos interlineado doble. el número de palabras del cuerpo del documento no incluye: título, resumen, palabras clave, tablas, agradecimientos, conflicto de interés, financiación, bibliografía, ni el apartado aporte a la disciplina. notas a pie de página: son notas aclaratorias. aparecen numeradas en forma consecutiva en la parte inferior de las páginas. se utilizan para identificar la filiación institucional, para ampliar información inédita, o para dar explicaciones que interrumpen el desarrollo natural del texto. referencias bibliográficas: aquichan aplica las normas vancouver, actualizadas e internacionales. para mayor información, puede consultar las normas vancouver en el siguiente link: http:// www.nlm.nih.gov/bsd/uniform_requirements.html a continuación, se dan algunos ejemplos: artículos en revistas a. artículo estándar vega kj, pina i, krevsky b. heart transplantation is associated with an increased risk for pancreatobiliary disease. ann intern med. 1996;124(11):980-3. parkin dm, clayton d, black jr, masuyer e, friedl hp, ivanov e, et al. childhood leukaemia in europe after chernobyl: 5 year followup. br j cancer. 1996;73:1006-12. b. más de seis autores rose me, huerbin mb, melick j, marion dw, palmer am, schiding jk, et al. regulation of interstitial excitatory amino acid concentrations after cortical contusion injury. brain res. 2002;935(1-2):40-6. c. autor colectivo (el autor es un equipo) diabetes prevention program research group. hypertension. insulin, and proinsulin in participants with impaired glucose tolerance. hypertension. 2002;40(5):679-86. d. no se menciona el autor 21st century heart solution may have a sting in the tail. bmj. 2002;325(7357):184. e. suplemento de un volumen geraud g, spierings el, keywood c. tolerability and safety of frovatriptan with short and long-term use for treatment of migraine and in comparison with sumatriptan. headache. 2002;42(suppl 2: s93-9). n or m as p ar a au to re s http://www.prisma-statement.org/prismastatement/default.aspx http://www.prisma-statement.org/prismastatement/default.aspx http://www.nlm.nih.gov/bsd/uniform_requirements.html http://www.nlm.nih.gov/bsd/uniform_requirements.html 7 n or m as p ar a au to re s f. parte de un volumen abend sm, kulish n. the psychoanalytic method from an epistemological viewpoint. int j psychoanal. 2002;83(pt 2):491-5. g. parte de un número ahrar k, madoff dc, gupta s, wallace mj, price re, wright kc. development of a large animal model for lung tumors. j vasc interv radiol. 2002;13(9 pt 1):923-8. h. número sin volume banit dm, kaufer h, hartford jm. intraoperative frozen section analysis in revision total joint arthroplasty. clin orthop. 2002;(401):230-8. i. sin volumen ni número outreach: bringing hiv-positive individuals into care. hrsa careaction. 2002 jun: 1-6. j. páginas en números romanos chadwick r, schuklenk u. the politics of ethical consensus finding. bioethics. 2002;16(2):iii-v. k. indicación del tipo de artículo cuando sea necesario tor m, turker h. international approaches to the prescription of long-term oxygen therapy [letter]. eur respir j. 2002;20(1):242. lofwall mr, strain ec, brooner rk, kindbom k a, bigelow ge. characteristics of older methadone maintenance (mm) patients [abstract]. drug alcohol depend. 2002;66(suppl 1):s105. libros y otras monografías a. autores individuales ringsven mk, bond d. gerontology and leadership skills for nurses. 2nd ed. albany (ny): delmar publishers; 1996. b. editor(es). compilador(es) norman ij, redfern sj, editors. mental health care for elderly people. new york: churchill livingstone; 1996. c. capítulo de libro meltzer ps, kallioniemi a, trent jm. chromosome alterations in human solid tumors. in: vogelstein b, kinzler kw. editors. the genetic basis of human cancer. new york: mcgraw-hill; 2002. p. 93-113. d. organización(es) como autor royal adelaide hospital; university of adelaide, department of clinical nursing. compendium of nursing research and practice development, 1999-2000. adelaide (australia): adelaide university; 2001. e. memorias de conferencias kimura j, shibasaki h, editors. recent advances in clinical neurophisiology. proceedings of the 10th international congress of emg and clinical neurophisiology; 1995 oct 15-19; kyoto, japan. amsterdam: elsevier; 1996. 8 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 f. material electrónico morse ss. factors in the emergence of infectious diseases. emerg infect dis [serial on line] 1995 jan-mar [cited 1996 jun 5]; 1 (1): [24 screens]. disponible en: url: http://www. cdc.gov/ncidod/eid/eid.html ilustraciones: se pueden incluir cuadros, tablas, gráficos, diagramas, dibujos, fotografías o mapas, que complementen la información del manuscrito. el título debe ser corto, preciso y citar la fuente y autorización de donde fueron tomados, o aclarar si es una elaboración propia. las fotografías deben incluir la fuente y la fecha. los cuadros, las tablas, los gráficos y los diagramas se deben enviar en archivo word. las fotografías e imágenes se deben enviar en formato jpg de 300-400 dpi. indicaciones para el envío de los artículos 1. en la página de la revista http://aquichan.unisabana.edu.co/index.php/aquichan/index, ingrese a “registrarse”, si aún no cuenta con usuario y contraseña. diligencie el formato y active la casilla de autor. 2. si ya tiene usuario y contraseña, ingrese a envío original y dé clic en “vaya a identificación”. 3. seleccione la sección de la revista a la que desea hacer el envío, active las casillas de verificación si cumple con cada una de las recomendaciones, haga clic en “guardar y continuar”. 4. anexe el artículo si cumple con todas las características descritas en las normas para autores, haga clic en examinar, seleccione el archivo y presione el enlace “subir”. 5. incluya todos los metadatos del artículo, especialmente la información de los autores y coautores, sin omitir ninguno (será la información que se incluya en la publicación final). haga clic en “guardar y continuar”. 6. en la sección de archivos complementarios, incluya la “carta de declaración de originalidad”, en formato pdf, firmada por los autores y coautores (no se aceptan declaraciones incompletas); asimismo, debe incluir el listado de condiciones para la publicación, firmada por el autor de correspondencia y demás archivos adicionales que considere necesarios para el artículo. 7. confirmar envío. recibirá una notificación automática con el número asignado al artículo. para hacer seguimiento al proceso de su artículo, ingrese a la plataforma con el usuario y contraseña asignados, allí accede directamente al artículo y puede verficiar el estado en que se encuentra. si el artículo ha sido aceptado, a través de la misma plataforma envíe los ajustes y las correcciones solicitados. proceso de revisión a. por parte del comité editorial todos los artículos son revisados por el comité editorial, que verifica el cumplimiento de los criterios solicitados en las normas para autores, así como la pertinencia temática del artículo para la revista. en caso de no cumplir con cualquiera de estas directrices, se le informará al autor para su modificación o declinación. n or m as p ar a au to re s http://aquichan.unisabana.edu.co/index.php/aquichan/index 9 n or m as p ar a au to re s b. por parte de pares evaluadores cumplido el proceso por parte del comité editorial, se someten a revisión doble ciega por parte de dos árbitros, investigadores activos y externos a la institución, quienes evaluarán la calidad científica y académica de los manuscritos. el concepto de los evaluadores puede ser: aceptación, aceptación con ajustes o rechazo. si el artículo requiere ajustes, los autores dispondrán de 7 días calendario para hacer los ajustes sugeridos por los pares. c. decisión del editor el editor estudia las recomendaciones del comité editorial y los conceptos de los árbitros para tomar la decisión de publicar o rechazar. d. respuesta a los autores en un plazo máximo de 30 días calendario, aquichan informa a los autores la decisión del comité editorial de aceptación o rechazo para envío a pares. en un plazo máximo de 180 días calendario, aquichan informa a los autores el concepto de los pares (aceptación o rechazo) proceso de edición a. corrección de estilo: todos los manuscritos son sometidos a revisión ortotipográfica y de estilo según las normas vancouver. las observaciones realizadas por el corrector de estilo son enviadas a los autores, quienes, en un lapso de tres días calendario, deberán responder al editor, aceptando o rechazando y respondiendo las dudas o recomendaciones, si la hubiera. b. galeradas: una vez diagramado cada artículo, el pdf se envía al autor corresponsal para su revisión y aprobación final. el tiempo de respuesta es de 1 día. en caso de no recibir respuesta por parte del autor, se da por entendido su aceptación, y se publicará en formato impreso y electrónico. normas éticas y la revista aquichan asume las normas establecidas por el comité de ética para publicaciones (cope). y se solicita la carta aval de comité de ética que aprobó la investigación. y aquichan otorga a los autores un plazo de 30 días calendario para recibir los ajustes si los hubiera. si al cabo de este plazo el editor no recibe los ajustes sugeridos, el artículo sale del proceso editorial. y el envío de los artículos fragmentados de una misma investigación serán motivo de rechazo. autores y todos los autores asumen públicamente la responsabilidad del contenido del documento. y al someter su artículo a la revista aquichan, los autores asumen que han leído y aceptado las “normas para autores”. y de acuerdo con el comité de ética para publicaciones, los autores de alto prestigio deben abstenerse de facilitar su nombre para apoyar escritos en los que no han participado. 10 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 revisores y abstenerse de emitir concepto cuando exista conflictos de interés (personal o académico) en los artículos propuestos para su evaluación, y manifestarlo expresamente al editor. y mantener la confidencialidad en la evaluación del manuscrito. y no copiar ni retener el manuscrito entregado. y los revisores no deben hacer uso de datos, argumentos o interpretaciones sin la autorización de los autores. y emitir conceptos precisos, objetivos, corteses y justificables. y si sospechan de alguna conducta inadecuada o de plagio, deben escribir al editor de forma confidencial. editor y abstenerse de publicar artículos cuando se encuentre ante conflictos de interés personal y de lealtad controversial, que puedan influir o parcializar la calidad de la información científica y el prestigio de la revista. y mantener estricta confidencialidad de todos los documentos recibidos. y la decisión de aceptar o rechazar un documento para su publicación debe estar sustentada en la relevancia, originalidad, claridad y pertinencia del estudio para el campo de competencia de la revista. y no excluir estudios con resultados negativos. y cuando detecte un error grave en un documento ya publicado, debe asumir la responsabilidad y corregir en forma rápida y notoria. y cuando sospeche de una conducta inapropiada por parte de los autores, debe informar primero a los autores, antes de contactar a los directores de la institución a la que estén afiliados los autores. conflictos de interés los conflictos de interés surgen cuando autores, revisores o editores tienen intereses que afectan inapropiadamente los resultados de una investigación y su publicación. los intereses pueden ser personales, financieros, políticos y académicos. teniendo en cuenta lo anterior: y los autores y revisores informan a los editores los conflictos de interés que se puedan presentar. y los editores dan a conocer a sus lectores cualquier conflicto de interés que se presente. conducta inapropiada la conducta inapropiada es la intención de hacer creer algo que no es cierto a los lectores; por esto, el editor, el comité editorial y los revisores deben rechazar los documentos que susciten la posibilidad de una conducta inapropiada. plagio todas las fuentes deben citarse y cuando se citen textos extensos de material escrito o de ilustración, el autor debe solicitar autorización y dejar constancia de dicha autorización. n or m as p ar a au to re s 11 n or m as p ar a au to re sla identificación de plagio en el manuscrito es causal de rechazo por parte de aquichan. en este caso, se comunica a los autores el motivo de rechazo explicando de manera clara las evidencias del plagio. consideraciones medioambientales el autor, debe hacer explicitas las consideraciones medioambientales dentro de su artículo. derecho de reproducción la presente revista y su contenido son propiedad de la universidad de la sabana. cualquier forma de utilización, como reproducción, transformación, comunicación pública o distribución con fines lucrativos, requiere la autorización previa de la universidad de la sabana. los nombres y las direcciones de correo electrónico presentados en aquichan son usados exclusivamente para los fines declarados por esta revista, y no están disponibles para ningún otro propósito. los artículos que contiene esta revista representan la opinión de sus autores y no constituyen necesariamente la opinión oficial de la universidad de la sabana. la revista aquichan no realiza cobro alguno a los autores por el envío de artículos y procesamiento de los mismos, es una revista científica sin fines de lucro. fe de erratas cuando haya lugar, aquichan publica la fe de erratas en el número correspondiente del propio artículo en el formato electrónico. en el formato impreso, se publica un inserto en la página del artículo que corresponde. 12 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 instructions for authors aquichan, the scientific journal of the school of nursing and rehabilitation, edited by universidad de la sabana, aims to promote and encourage the theoretical development of nursing. focus and scope: aquichan, a journal of medical and health sciences from the field of health sciences and, more specifically, nursing, publishes articles resulting from investigations from a point of view of epistemology, evidence-based practice, chronic care, promotion and prevention. the articles are for the academic and scientific community, both in colombia and abroad. the journal accepts original, previously unpublished papers in spanish, english, and portuguese, which are the product of a research or a review and which are not being evaluated by other scientific journals, either in print or electronic form. all approved articles must be translated into english; this translation must be arranged by the authors and approved by the journal’s editorial committee. type of articles published: investigation: it is a document that discloses the original results of completed research projects in detail. it should have the following structure: introduction, methodology, results and conclusions. literature review: it is the product of the critical analysis of scientific literature, which summarizes the results of a research in order to facilitate the understanding of a phenomenon of study and provide information about the scientific evidence related to the subject. this category includes systematic, integrated literature review. it is known for presenting a careful bibliographic review of at least 50 references. aquichan does not accept case reports, editorials, or letters to the editor. periodicity: aquichan circulates on a quarterly basis, in january, april, july and october. publication format: printed and electronic in open access, under a creative commons license. structure of the articles title: it should be brief and reflect the content of the article; it should not include abbreviations or formulas. they should not exceed 15 words, and must be written in spanish, english and portuguese. author information: all authors should list the following information: y name(s) and last name(s) y researcher’s id. it is obtained from the following link: https://orcid.org/register. example: orcid.org/0000-0003-4037-6235 y institutional affiliation y city y country y institutional email address 13 in st ru ct io ns f or a ut ho rsthe maximum number of authors allowed is 6, except in cases where the editorial committee considers that the impact of the research or its multi-centric nature justifies exceeding the number. additional information: y name of corresponding author y acknowledgments, when appropriate, should go after the conclusions y funding: when the article is the result of a funded project, it should be acknowledged, in this case, through an asterisk in the title, followed by the name of the project and the sponsoring entities in a footnote y statement of originality: attach the statement in pdf format, duly completed and signed by all authors. y letter of endorsement of the ethics committee: attach the endorsement letter of the institutional ethics committee that approved the research. y conflict of interest: the authors declare conflict of interest in a paragraph at the end of the manuscript. abstract: it should be no longer than 200 words and have the following structure: objectives, materials and method, results and conclusions. it should not include bibliographic references. key words: five standardized terms in the thesaurus mesh thesauro mesh – medical subject headings. (available at http://www.ncbi.nlm.nih.gov/mesh). phrases or descriptors not included in this thesaurus will not be accepted. list the topic in which you developed your research or review article. y epistemology y evidence-based practice y chronic care y promotion and prevention contribution to the discipline: in 150 characters, explain your contribution to the new disciplinary knowledge of the presented study, as well as the nursing model or theory used, if applicable. type and structure of the article: aquichan accepts the following types of articles: y research: the manuscripts must be between 3000 and 4000 words in length; research papers should follow the guidelines established by the international committee of medical journal editors, available at: http://www.icmje.org/recommendations/browse/manuscript-preparation/preparing-for-submission.html#three researches with a qualitative methodology must comply with the requirements established in: (available at http://www.cnfs.net/modules/module2/story_content/external_files/13 _coreq_checklist_000017.pdf ) researches with a quantitative methodology must comply with the requirements established by consort (available at: http://www.consort-statement.org/) 14 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 y systematic, integrative reviews, meta-analysis and meta-synthesis are characterized by including a careful bibliographic review of at least 50 references, except in cases where, with prior justification, this requirement is not met. they must comply with the requirements established in prisma (available at: http://www.prisma-statement.org/ prismastatement/default.aspx) all articles must be submitted in 12-point times new roman with double line spacing. the number of words of the body of the document does not include: title, abstract, key words, tables, acknowledgements, conflict of interest, funding, bibliography, or the contribution to the discipline. body: manuscripts should be between 3000 and 4000 words in length. use 12-point times new roman, double spacing; research papers should follow the guidelines established by the international committee of medical journal editors, available at: http://www.icmje.org/ recommendations/browse/manuscript-preparation/preparing-for-submission.html#three qualitative research: (http://www.cnfs.net/modules/module2/story_content/external_ files/13 _coreq_checklist_000017.pdf ) randomized controlled trials (http://www.consort-statement.org/) systematic review or meta-analysis (http://www.prisma-statement.org/prismastatement/default.aspx) footnotes: they are explanatory notes and should be consecutively numbered at the bottom of the page. they are used to identify institutional affiliation, to expand on unpublished information, or to provide explanations that otherwise interrupt the natural flow of the text. references: aquichan uses the updated and international vancouver referencing style. references: the primary sources consulted for the development of the paper are cited according to the vancouver reference style. for more information, see the vancouver reference style in the following link: http://www. nlm.nih.gov/bsd/uniform_requirements.html below are some examples: journal articles: a. standard journal article vega kj, pina i, krevsky b. heart transplantation is associated with an increased risk for pancreatobiliary disease. ann intern med. 1996;124(11):980-3. parkin dm, clayton d, black jr, masuyer e, friedl hp, ivanov e, et al. childhood leukaemia in europe after chernobyl: 5 year followup. br j cancer. 1996;73:1006-12. b. more than six authors rose me, huerbin mb, melick j, marion dw, palmer am, schiding jk, et al. regulation of interstitial excitatory amino acid concentrations after cortical contusion injury. brain res. 2002;935(1-2):40-6. in st ru ct io ns f or a ut ho rs 15 in st ru ct io ns f or a ut ho rsc. organization as author (author is a group) diabetes prevention program research group. hypertension. insulin, and proinsulin in participants with impaired glucose tolerance. hypertension. 2002;40(5):679-86. d. no author given 21st century heart solution may have a sting in the tail. bmj. 2002;325(7357):184. e. volume with supplement geraud g, spierings el, keywood c. tolerability and safety of frovatriptan with short and long-term use for treatment of migraine and in comparison with sumatriptan. headache. 2002;42(suppl 2: s93-9). f. volume with part abend sm, kulish n. the psychoanalytic method from an epistemological viewpoint. int j psychoanal. 2002;83(pt 2):491-5. g. issue with part ahrar k, madoff dc, gupta s, wallace mj, price re, wright kc. development of a large animal model for lung tumors. j vasc interv radiol. 2002;13(9 pt 1):923-8. h. issue with no volume banit dm, kaufer h, hartford jm. intraoperative frozen section analysis in revision total joint arthroplasty. clin orthop. 2002;(401):230-8. i. no volume or issue outreach: bringing hiv-positive individuals into care. hrsa careaction. 2002 jun: 1-6. j. pagination in roman numerals chadwick r, schuklenk u. the politics of ethical consensus finding. bioethics. 2002;16(2):iii-v. k. type of article indicated as needed tor m, turker h. international approaches to the prescription of long-term oxygen therapy [letter]. eur respir j. 2002;20(1):242. lofwall mr, strain ec, brooner rk, kindbom k a, bigelow ge. characteristics of older methadone maintenance (mm) patients [abstract]. drug alcohol depend. 2002;66 (suppl 1):s105. books and other monographs a. personal author(s) ringsven mk, bond d. gerontology and leadership skills for nurses. 2nd ed. albany (ny): delmar publishers; 1996. b. editor(s), compiler(s) as author norman ij, redfern sj, editors. mental health care for elderly people. new york: churchill livingstone; 1996. c. chapter in a book meltzer ps, kallioniemi a, trent jm. chromosome alterations in human solid tumors. in: vogelstein b, kinzler kw. editors. the genetic basis of human cancer. new york: mcgraw-hill; 2002. p. 93-113. 16 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 d. organization(s) as author royal adelaide hospital; university of adelaide, department of clinical nursing. compendium of nursing research and practice development, 1999-2000. adelaide (australia): adelaide university; 2001. e. conference proceedings kimura j, shibasaki h, editors. recent advances in clinical neurophisiology. proceedings of the 10th international congress of emg and clinical neurophisiology; 1995 oct 15-19; kyoto, japan. amsterdam: elsevier; 1996. f. electronic material morse ss. factors in the emergence of infectious diseases. emerg infect dis [serial on line] 1995 jan-mar [cited 1996 jun 5]; 1 (1): [24 screens]. disponible en: url: http://www. cdc.gov/ncidod/eid/eid.html illustrations: charts, tables, graphs, diagrams, drawings, photographs or maps may be included to complement the information in the manuscript. titles should be short and precise, and include the sources and permissions, or indicate if it is attributed to the author. photographs should include the source and date. charts, tables, graphs and diagrams should be sent in a word file. photographs and images should be sent in jpg format of 300-400 dpi. instructions for submission of papers 1. go to the magazine’s website, http://aquichan.unisabana.edu.co/index.php/aquichan/index, and click on “register” if you do not have a username and password yet. fill out the form and check the author box. 2. if you already have a username and password, go to “submit your manuscript” and click on “go to login”. 3. select the section of the magazine to which you wish to make the submission. check the boxes if you comply with each of the recommendations, click on “save and continue”. 4. include all the metadata on the article, particularly information on the authors and co-authors, omitting none (this will be the information used in the publication). then click “save and continue”. 5. in the supporting files section, include the “statement of originality”, in pdf format, signed by the authors and co-authors (incomplete statements of originality will not be accepted); the list of conditions for publication, duly signed by the corresponding author, must also be included in this section. 6. confirm submission. you will receive an automatic notice with the number assigned to your article. for tracking purposes, enter the platform with your assigned user name and password; you will have direct access to the article, where you will be able to check its current status. if the article has been accepted, send the required adjustments and corrections through the same platform. in st ru ct io ns f or a ut ho rs 17 in st ru ct io ns f or a ut ho rsreview process a. by the editorial committee all articles are reviewed by the editorial committee, which verifies due compliance with the criteria requested in the instructions for authors and decides if the subject of the article is relevant to the journal. failure to comply with any of these guidelines will result in a request for modification of the article or its rejection. b. by peer reviewers after being reviewed by the editorial committee, articles are submitted for double-blind peer review. the reviewers are active researchers, not affiliated to the institution, who will evaluate the scientific and academic quality of the manuscripts. reviewers may advise whether the articles should be accepted, considered acceptable with revisions, or rejected. if the article requires revising, authors must make the adjustments suggested by the peers within the following 7 calendar days. c. editor’s decision the editor considers the editorial committee’s recommendations and the reviewers’ opinion before deciding whether an article should be published or rejected. d. response to authors aquichan will notify the authors about the editorial committee’s decision to accept or reject the article for peer review within a term of 30 calendar days. aquichan will notify the authors about the peers’ decision (acceptance or rejection) within a term of 180 calendar days. editing process a. copyediting: all manuscripts are subjected to copyediting according to vancouver style. the copyeditor’s comments are sent to the authors, who, within a term of three calendar days, must notify the editor of their acceptance or rejection of the comments, or answer any questions or suggestions. b. galley proofs: once every article is laid out, the pdf file is sent to the corresponding author for its review and final approval. turnaround time is 1 day. if an author fails to respond within the stipulated time, it will be understood that he accepts the suggestions and the article will be published in printed and electronic format.    ethical standards y aquichan follows the rules established by the committee on publication ethics (cope). y the letter of endorsement from the ethics committee approving the investigation must be submitted. y aquichan grants authors a term of 30 calendar days to make adjustments, if any. if, following that time, the editor does not receive the revised paper, it will be removed from the editorial process. y submission of fragmented articles of a same investigation will be grounds for rejection. 18 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 authors y all authors take public responsibility for the content of the document. y by submitting their articles to aquichan, it is assumed that authors have read and accepted the “instructions for authors”. y according to the committee on publication ethics, prestigious authors should refrain from providing their names in order to support those articles in which they have not participated. reviewers y declare any (personal or academic) conflict of interest regarding the articles suggested for evaluation and decline to review. y respect confidentiality during evaluation of the manuscript. y not copy or keep the received manuscript. y not use any data, arguments or interpretations without the express authorization of the authors. y be accurate, objective, polite and justifiable in their reviews. y notify the editor in confidence if they suspect any misconduct or plagiarism may have occurred. editors y refrain from publishing articles in case of personal conflict of interest or competing loyalties that may influence or bias the quality of the scientific information and the prestige of the journal. y maintain strict confidentiality of all received documents. y the decision to accept or reject a document for publication should be based on the relevance, originality, clarity and pertinence of the study for the subject matter of the journal. y not exclude studies with negative results. y take responsibility when serious errors are detected in a published work and issue corrections in a prompt and notorious manner. y notify the authors first if they suspect any misconduct may have occurred before contacting the directors of the institution to which authors are affiliated. conflicts of interest conflict of interest exists when authors, reviewers or editors have interests that inappropriately influence the results of a research and its publication. interests may be of personal, financial, political or academic in nature. accordingly: y authors and reviewers notify editors of any potential conflict of interest. y editors disclose any potential conflict of interest to their readers. in st ru ct io ns f or a ut ho rs 19 in st ru ct io ns f or a ut ho rsmisconduct misconduct is the intention to make readers believe something that is untrue; accordingly, the editor, the editorial committee and reviewers should reject any documents that raise the possibility of misconduct. plagiarism all sources must be cited and, in the case of extensive texts of written material or illustration, authors must request authorization and cite such authorization. aquichan may reject a manuscript in case of detection of plagiarism. in this case, authors are notified of the rejection, providing a clear explanation of the evidence of plagiarism. environmental considerations authors’ papers must make explicit the environmental considerations. copyright this journal and its contents are the property of universidad de la sabana. any use, including reproduction, transformation, distribution, public communication or distribution for a profit, requires the prior approval of universidad de la sabana. the names and e-mail addresses entered in aquichan will be used exclusively for the stated purposes of this journal and will not be made available for any other purpose. the views expressed in the articles contained in this journal represent the views of the authors and do not necessarily reflect the official opinion of universidad de la sabana. aquichan does not charge authors for submitting and processing the articles, as it is a nonprofit scientific journal. list of errata where appropriate, aquichan will publish the list of errata in the corresponding number of the article in electronic format. in printed format, an insert will be published on the page of the corresponding article. 20 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 aquichan, revista científica da faculdade de enfermagem e reabilitação, editada pela universidade de la sabana, está enfocada à promoção e estímulo do desenvolvimento teórico da enfermagem. temática e alcance: aquichan, publicação de ciências médicas e da saúde, da área de ciências da saúde, da disciplina de enfermagem, publica artigos resultados de pesquisa desde o ponto de vista: epistemológico, prática baseada em evidências, cuidado crônico, e promoção e prevenção. os artigos estão dirigidos à comunidade acadêmica e científica nacional e internacional. recebem-se artigos em espahol, inglês e português, originais e inéditos, produto de investigação ou revisão que não estejam em processo de avaliação por outras revistas científicas, impressas ou eletrônicas. os artigos aprovados devem ser traduzidos para publicação em inglês; os autores são responsáveis por este trâmite, o qual deve ser aprovado pelo comitê editorial da revista. publica artigos originais e inéditos em espanhol, inglês e português, produto de pesquisa ou revisão que não se encontrem em processo de avaliação por outras revistas científicas, sejam impressas ou eletrônicas. tipo de artigos que publica: de pesquisa: documento que apresenta detalhadamente os resultados originais de projetos de pesquisa concluídos. a estrutura utilizada deve conter: introdução, metodologia, resultados e conclusões. de revisão de literatura: documento resultado da análise crítica da literatura científica, que apresenta uma síntese dos resultados de pesquisa com o propósito de facilitar a compreensão de um fenômeno de estudo e prover informação sobre a evidência científica relacionada com o tema. nesta categoria, se incluem as revisões sistemáticas e integrativas da literatura. se caracteriza por apresentar uma cuidadosa revisão bibliográfica de no mínimo 50 referências. aquichan não aceita relatórios de casos, editoriais, nem cartas ao editor. periodicidade: aquichan circula quadrimestralmente, em janeiro, abril, julho e outubro. formato de publicação: impresso e eletrônico em open acces, com a licença creative commons. organização dos artigos título: é breve e indica o tema central do artigo, não inclui abreviaturas nem fórmulas. contém no máximo 15 palavras, escrito em espanhol, inglês e português. informação dos autores: cada autor deve relacionar a seguinte informação: y nomes e sobrenomes y id de pesquisador. é obtido através do seguinte link: https://orcid.org/register. exemplo: orcid.org/0000-0003-4037-6235 normas para autores 21 n or m as p ar a a ut or es y filiação institucional y cidade y país y correio eletrônico institucional o número máximo de autores permitido é 6, exceto nos casos em que, na opinião do comitê editorial, o impacto da pesquisa ou seu caráter multicêntrico justifique exceder o número. informação adicional: y nome do autor de correspondência. y agradecimentos, se for o caso, e se situam depois das conclusões y financiamento: quando o artigo se deriva de um projeto financiado, deve-se divulgar isso. neste caso, mediante asterisco no título, em nota de rodapé de página, se escreve o nome do projeto e das entidades financiadoras. y declaração de originalidade: anexar em formato pdf, a declaração preenchida e assinada por todos os autores. y carta aval de comitê de ética: anexar a carta de aprovação do comitê de ética institucional que aprovou a pesquisa. y conflito de interesses: os autores declaram o conflito de interesses em um anexo ao final do manuscrito. resumo: deve conter no máximo 200 palavras, e deve seguir a estrutura: objetivos, materiais e método, resultados e conclusões. não deve incluir referências bibliográficas. palavras chave:  cinco términos normalizados no thesauro mesh – medical subject headings. (disponível em http://www.ncbi.nlm.nih.gov/mesh). não se aceitam frases nem descritores que não se encontrem neste thesauro. relacionar a temática na qual desenvolveu seu artigo de pesquisa ou revisão: y epistemologia y prática baseada na evidência y cuidado crônico y promoção e prevenção contribuição à disciplina: em um anexo de 150 caracteres evidenciar a contribuição ao novo conhecimento disciplinar do estudo apresentado e o modelo ou teoria de enfermagem utilizada, se for o caso. tipo de artigo e apresentação do corpo do trabalho: os tipos de artigos que recebidos pela revista aquichan são os seguintes: y pesquisa: a extensão dos manuscritos deve estar entre 3000 e 4000 palavras; os artigos de pesquisa se organizam de acordo com a guia estabelecida pelo international committee of medical journal editors, disponível em: http://www.icmje.org/recommendations/ browse/manuscript-preparation/preparing-for-submission.html#three 22 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 para pesquisas com metodologia qualitativa, deve cumprir os requisitos estabelecidos em: (disponível http://www.cnfs.net/modules/module2/story_content/external_files/13 _coreq_checklist_000017.pdf ) para pesquisas com metodologia quantitativa, deve cumprir os requisitos estabelecidos por consort (disponível http://www.consort-statement.org/) y revisões sistemáticas, integrativas, meta-análise e meta síntese: se caracteriza por apresentar uma cuidadosa revisão bibliográfica de mínimo 50 referências, exceto em casos onde, com prévia justificativa, isto não se cumpra. deve cumprir os requisitos estabelecidos em prisma (disponível: http://www.prisma-statement.org/prismastatement/default.aspx) todos os artigos devem ser apresentados com fonte times new roman, tamanho 12 com espaço duplo. o número de palavras do corpo do documento não inclui: título, resumo, palavras chave, tabelas, agradecimentos, conflito de interesses, financiamento, bibliografia, nem a contribuição para a seção de disciplina. corpo do trabalho: a extensão dos manuscritos deve estar entre 3000 e 4000 palavras. fonte times new roman, 12 pontos, espaçamento duplo; os artigos de pesquisa se organizam de acordo à guia estabelecida pelo international committee of medical journal editors, disponível em: http://www.icmje.org/recommendations/browse/manuscript-preparation/ preparing-for-submission.html#three pesquisa qualitativa: (http://www.cnfs.net/modules/module2/story_content/external_files/13 _coreq_checklist_000017.pdf ) ensaios controlados aleatorizados (http://www.consort-statement.org/) revisões sistemáticas ou meta-análise (http://www.prisma-statement.org/prismastatement/default.aspx) notas no rodapé de página:  são notas esclarecedoras. aparecem enumeradas em forma consecutiva na parte inferior das páginas. se utilizam para identificar a afiliação institucional, para ampliar informação inédita, ou para dar explicações que interrompem o desenvolvimento natural do texto. referências bibliográficas: indicam as fontes primárias consultadas para o desenvolvimento do artigo, se mencionam seguindo as normas vancouver. referências bibliográficas: aquichan aplica as normas vancouver, atualizadas e internacionais. para mais informação, consulte as normas vancouver no seguinte link: http://www.nlm.nih. gov/bsd/uniform_requirements.html a seguir, alguns exemplos: n or m as p ar a a ut or es 23 n or m as p ar a a ut or esartigos em revistas a. artigo padrão vega kj, pina i, krevsky b. heart transplantation is associated with an increased risk for pancreatobiliary disease. ann intern med. 1996;124(11):980-3. parkin dm, clayton d, black jr, masuyer e, friedl hp, ivanov e, et al. childhood leukaemia in europe after chernobyl: 5 year followup. br j cancer. 1996;73:1006-12. b. mais de seis autores rose me, huerbin mb, melick j, marion dw, palmer am, schiding jk, et al. regulation of interstitial excitatory amino acid concentrations after cortical contusion injury. brain res. 2002;935(1-2):40-6. c. autor coletivo (o autor é uma equipe) diabetes prevention program research group. hypertension. insulin, and proinsulin in participants with impaired glucose tolerance. hypertension. 2002;40(5):679-86. d. não se menciona o autor 21st century heart solution may have a sting in the tail. bmj. 2002;325(7357):184. e. suplemento de um volume geraud g, spierings el, keywood c. tolerability and safety of frovatriptan with short and long-term use for treatment of migraine and in comparison with sumatriptan. headache. 2002;42(suppl 2: s93-9). f. parte de um volume abend sm, kulish n. the psychoanalytic method from an epistemological viewpoint. int j psychoanal. 2002;83(pt 2):491-5. g. parte de um número ahrar k, madoff dc, gupta s, wallace mj, price re, wright kc. development of a large animal model for lung tumors. j vasc interv radiol. 2002;13(9 pt 1):923-8. h. número sem volume banit dm, kaufer h, hartford jm. intraoperative frozen section analysis in revision total joint arthroplasty. clin orthop. 2002;(401):230-8. i. sem volume nem número outreach: bringing hiv-positive individuals into care. hrsa careaction. 2002 jun: 1-6. j. páginas em números romanos chadwick r, schuklenk u. the politics of ethical consensus finding. bioethics. 2002;16(2):iii-v. k. indicação do tipo de artigo quando for necessário tor m, turker h. international approaches to the prescription of long-term oxygen therapy [letter]. eur respir j. 2002;20(1):242. lofwall mr, strain ec, brooner rk, kindbom k a, bigelow ge. characteristics of older methadone maintenance (mm) patients [abstract]. drug alcohol depend. 2002;66(suppl 1):s105. 24 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 livros e outras monografias a. autores individuais ringsven mk, bond d. gerontology and leadership skills for nurses. 2nd ed. albany (ny): delmar publishers; 1996. b. editor(es). compilador(es) norman ij, redfern sj, editors. mental health care for elderly people. new york: churchill livingstone; 1996. c. capítulo de livro meltzer ps, kallioniemi a, trent jm. chromosome alterations in human solid tumors. in: vogelstein b, kinzler kw. editors. the genetic basis of human cancer. new york: mcgraw-hill; 2002. p. 93-113. d. organização(es) como autor royal adelaide hospital; university of adelaide, department of clinical nursing. compendium of nursing research and practice development, 1999-2000. adelaide (australia): adelaide university; 2001. e. memórias de conferências kimura j, shibasaki h, editors. recent advances in clinical neurophisiology. proceedings of the 10th international congress of emg and clinical neurophisiology; 1995 oct 15-19; kyoto, japan. amsterdam: elsevier; 1996. f. material eletrônico morse ss. factors in the emergence of infectious diseases. emerg infect dis [serial on line] 1995 jan-mar [cited 1996 jun 5]; 1 (1): [24 screens]. disponível em: url: http://www. cdc.gov/ncidod/eid/eid.html ilustrações: é possível incluir quadros, tabelas, gráficos, diagramas, desenhos, fotografias ou mapas, que complementem a informação do manuscrito. o título deve ser curto, preciso e citar a fonte e autorização de onde foram tomados, ou esclarecer se é uma elaboração própria. as fotografias devem incluir a fonte e a data. os quadros, as tabelas, os gráficos e os diagramas se devem enviar em arquivo word. as fotografias e imagens se devem enviar em formato jpg de 300-400 dpi. indicações para o envio dos artigos 1. na página da revista http://aquichan.unisabana.edu.co/index.php/aquichan/index, acesse “registrar-se”, se ainda não tiver usuário e senha. preencha o formato e ative a lacuna de autor. 2. se já tiver usuário e senha, acesse envio original e clique em “vá a identificação”. 3. selecione a seção da revista à qual deseja realizar o envio, ative as lacunas de verificação se cumprir com cada uma das recomendações, clique em “guardar e continuar”. 4. anexe o artigo se cumpre com todas as características descritas nas normas para autores, clique em examinar, selecione o arquivo e pressione o enlace “subir”. 5. inclua todos os metadados do artigo, especialmente a informação dos autores e coautores, sem omitir nenhum (será a informação que se inclua na publicação final). clique em “salvar e continuar”. n or m as p ar a a ut or es 25 n or m as p ar a a ut or es6. na seção de arquivos complementares inclua a “carta de declaração de originalidade”, em formato pdf, firmada pelos autores e coautores (não se aceitam declarações incompletas); da mesma forma, deve incluir a lista de condições para a publicação, assinada pelo autor de correspondência e demais arquivos adicionais que considere necessários para o artigo. 7. confirmar envio. receberá uma notificação automática com o número designado ao artigo. para fazer o seguimento o processo do seu artigo, acesse a plataforma com o usuário e senha designados, ali acesse diretamente o artigo e pode verificar o estado em que se encontra. se o artigo foi aceito, através da mesma plataforma envie os ajustes e as correções solicitados. processo de revisão a. por parte do comitê editorial todos os artigos são revisados pelo comitê editorial, que verifica o cumprimento dos critérios solicitados nas normas para autores, assim como também a pertinência temática do artigo para a revista. em caso de que não cumpra com qualquer uma destas diretrizes, se informará ao autor para a sua modificação ou declinação. b. por parte de pares avaliadores cumprido o processo por parte do comitê editorial, se submetem a revisão duplo cega por parte de dois árbitros, pesquisadores ativos e externos à instituição, que avaliarão a qualidade científica e acadêmica dos manuscritos. o conceito dos avaliadores pode ser: aceitação, aceitação com ajustes ou rejeição. se o artigo requer ajustes, os autores poderão dispor de 7 dias calendário para realizar os ajustes sugeridos pelos pares. c. decisão do editor o editor estuda as recomendações do comitê editorial e os conceitos dos árbitros para tomar a decisão de publicar ou rejeitar. d. resposta aos autores em um prazo no máximo de 90 dias calendário, aquichan informa aos autores se o seu artigo foi aceito ou rejeitado para a sua publicação. em um prazo máximo de 30 dias calendário, aquichan informa os autores sobre a decisão do comitê editorial de aceitação o rejeição para o envio de pares. em um prazo máximo de 180 dias calendário, aquichan informa os autores sobre o conceito dos pares (aceitação ou rejeição) processo de edição a. correção de estilo: todos os manuscritos são submetidos a revisão ortográfica e de estilo de acordo com as normas vancouver. as observações realizadas pelo corretor de estilo serão enviadas aos autores, que, em um lapso de três dias calendário, deverão responder ao editor, aceitando ou rejeitando e respondendo as dúvidas ou recomendações, se for o caso. 26 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 b. revisão de provas: uma vez diagramado cada artigo, o pdf será enviado ao autor correspondente para sua revisão e aprovação final. o tempo de resposta é de 1 dia. em caso de não receber resposta por parte do autor, se dará por entendido a sua aceitação, e se publicará em formato impresso e eletrônico. normas éticas y a revista aquichan assume as normas estabelecidas pelo comitê de ética para publicações (cope). y solicita-se a carta de aprovação do comitê de ética que aprovou a pesquisa. y aquichan outorga aos autores um prazo de 30 dias calendário para receber os ajustes, se for o caso. se ao finalizar este prazo o editor não receber os ajustes sugeridos, o artigo sai do processo editorial. y o envio dos artigos fragmentados de uma mesma pesquisa serão motivo de rejeição. autores y todos os autores assumem publicamente a responsabilidade do conteúdo do documento. y ao submeter o seu artigo à revista aquichan, os autores assumem que foram lidas e aceitas as “normas para autores”. y de acordo com o comitê de ética para publicações, os autores de alto prestígio devem abster-se de prestar o seu nome para apoiar escritos nos quais não tiveram nenhuma participação. revisores y abster-se de emitir conceito quando exista conflito de interesse (pessoal ou acadêmico) nos artigos propostos para sua avaliação, e manifestá-lo expressamente ao editor. y manter a confidencialidade na avaliação do manuscrito. y não copiar nem reter o manuscrito entregue. y os revisores não devem utilizar dados, argumentos ou interpretações sem a autorização dos autores. y emitir conceitos precisos, objetivos, corteses e justificáveis. y se houver suspeita de alguma conduta inadequada ou plágio, devem escrever ao editor de maneira confidencial. editor y abster-se de publicar artigos quando se encontre diante de conflitos de interesse pessoal e de lealdade controversa, que possam influir ou parcializar a qualidade da informação científica e o prestigio da revista. y manter estrita confidencialidade de todos os documentos recebidos. y a decisão de aceitar ou rejeitar um documento para publicação deve estar sustentada na relevância, originalidade, claridade e pertinência do estudo para o campo de competência da revista. y não excluir estudos com resultados negativos. n or m as p ar a a ut or es 27 n or m as p ar a a ut or es y quando detecte um erro grave em um documento já publicado, deve assumir a responsabilidade e corrigir de maneira rápida e notória. y quando haja suspeita de uma conduta inapropriada por parte dos autores, deve informar primeiro aos autores, antes de contatar os diretores da instituição à qual estejam afiliados os autores. conflitos de interesse os conflitos de interesse surgem quando autores, revisores ou editores têm interesses que afetam inapropriadamente os resultados de uma pesquisa e sua publicação. os interesses podem ser pessoais, financeiros, políticos e acadêmicos. tendo em conta o anterior: y os autores e revisores informam os editores dos conflitos de interesse que possam surgir. y os editores informam os seus leitores sobre qualquer conflito de interesse que possa surgir. conduta inapropriada a conduta inapropriada é a intenção de fazer que os leitores acreditem em algo que não é certo; por isto, o editor, o comitê editorial e os revisores devem rejeitar os documentos que suscitem a possibilidade de uma conduta inapropriada. plágio todas as fontes devem ser mencionadas e quando se mencionem textos extensos de material escrito ou de ilustração, o autor deve solicitar autorização e deixar constância desta autorização. a identificação de plágio no manuscrito é causal de rejeição por parte de aquichan. neste caso, comunica-se aos autores o motivo de rejeição explicando de maneira clara as evidências do plágio. considerações meio – ambientais o autor deve fazer explicitas as considerações meio – ambientais dentro de seu artigo. direito de reprodução a presente revista e seu conteúdo são propriedade da universidade de la sabana. qualquer forma de utilização, como reprodução, transformação, comunicação pública ou distribuição com fins lucrativos, requer a autorização prévia da universidade de la sabana. os nomes e os endereços de correio eletrônico apresentados em aquichan são usados exclusivamente para os fins declarados por esta revista, e não estão disponíveis para nenhum outro propósito. os artigos que contidos nesta revista representam a opinião de seus autores e não constituem necessariamente a opinião oficial da universidade de la sabana. 28 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 a revista aquichan não realiza cobrança alguma aos autores pelo envio de artigos e processamento dos mesmos, é uma revista científica sem fins lucrativos. erratas quando for o caso, aquichan publica a errata no número correspondente do próprio artigo no formato eletrônico. no formato impresso, se publica uma inserção na página do artigo que corresponde. n or m as p ar a a ut or es 29 por medio de esta comunicación certifico que soy(somos) autor/a(es) originario/a(s) del trabajo que estoy(estamos) presentando para posible publicación en la revista aquichan, de la universidad de la sabana, ya que sus contenidos son producto de mi(nuestra) directa contribución intelectual. todos los datos y las referencias a materiales ya publicados están debidamente identificadas con su respectivo crédito e incluidos en las notas bibliográficas y en las citas que se destacan como tal y, en los casos que así lo requieran, cuento(contamos) con las debidas autorizaciones de quienes poseen los derechos patrimoniales. por lo anterior, declaro(amos) que todos los materiales que se presentan están totalmente libres de derecho de autor y, por lo tanto, me(nos) hago(hacemos) responsable(s) de cualquier litigio o reclamación relacionada con derechos de propiedad intelectual, exonerando de responsabilidad a la universidad de la sabana. además, declaro(amos) que este artículo es inédito y no lo he(mos) presentado a otra publicación seriada, para su respectiva evaluación y posterior publicación. también, marco(amos) acá con una equis (x) si el manuscrito que estoy(estamos) enviando fue derivado de una: ( ) tesis de maestría ( ) tesis de doctorado en caso de haber marcado alguna de las opciones, colocaré(emos) como pie de página dentro del artículo la información apropiada de la fuente base. si el artículo “<nombre del artículo / name of the paper / nome do artigo>” es aprobado para su publicación: a) como autor/a (autores) y propietario/a(s) de los derechos de autor me permito autorizar de manera ilimitada en el tiempo a la universidad de la sabana para que incluya dicho texto en la revista aquichan, para que pueda reproducirlo, editarlo, distribuirlo, exhibirlo y 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de lo anteriormente expuesto, se firma esta declaración a los _ _ _ _ _ _ _ _ _ _ días del mes de _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ del año _ _ _ _ _ _ _ _ _ _ _ _ _, en la ciudad de _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _. nombre completo y apellidos de autor 1 nombre abreviado de cómo los citan en documentos citables correo electrónico institucional número orcid: financiación (si aplica): declaración de originalidad 30 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 49 i hereby certify that i am/we are the original author(s) of the paper i am/we are submitting for publishing in the universidad de la sabana’s aquichan journal since its contents are the result of my/our direct intellectual contribution. all data and references to already published works are duly identified with their relevant citation and included in the references section and quotations used and, where required, i/we have the appropriate authorizations from those who own their economic rights. therefore, i/we declare that all works involved are free of copyright and i/we shall take responsibility for any intellectual property right-related litigation or claim and hold the universidad de la sabana harmless. i/we further declare that this paper has not been previously published nor has been submitted to any other journal for peer reviewing and subsequent publishing. i/we also mark with an x whether the work i am/we are submitting derived from a: ( ) master’s dissertation ( ) doctoral dissertation having marked any of these options, i/we shall include the appropriate information of the base source as a footnote in the paper. if the paper “<name of the article / name of the paper / nome do artigo>” is approved for publishing: a) as the author(s) and copyright owner(s), i/we hereby authorize the universidad de la sabana, without time restriction, to include this paper in aquichan so that it can reproduce, edit, distribute, exhibit and disseminate it in the country and abroad by print, electronic, cd rom, internet, full text or any other means known or to be known. b) i/we acknowledge the requirements of the journal and attach to this letter these basic data for the publishing of my/our work: orcid of all authors of the paper institutional mail of all authors of the paper or the corresponding author only if research was funded: all data of the funding institution and its relevant identification number. according to the citation style of the journal: official name(s) in the academic-scientific sphere for citations attributed to me/us in order to unify my/our name(s) in all databases and promote my/our citation. for example, following the style of the journal, bruna ruoso da silva neutzling is da silva br; maria del carmen solano-ruiz is solano-ruiz mc. in witness whereof, this statement is signed on this _ _ _ _ _ _ _ _ _ _ _, _ _ _ _ in the city of _ _ _ _ _ _ _ _ _ _. full name of author 1 short name as cited in citable documents institutional e-mail orcid number: funding (if applicable): statement of originality 31 por meio desta declaração, certifico(certificamos) que sou(somos) autor/a(es/as) originário/a(s) do trabalho que estou(estamos) apresentando para possível publicação na revista aquichan, da universidad de la sabana, já que seu conteúdo é produto de minha(nossa) direta contribuição intelectual. todos os dados e as referências a materiais já publicados estão devidamente identificados com seu respectivo crédito e incluídos nas referências bibliográficas, nas citações em que aparecem e nos casos que assim o exigem; conto(contamos) com as devidas autorizações dos que possuem os direitos patrimoniais. por tudo isso, declaro(declaramos) que todos os materiais apresentados estão totalmente livres de direitos autorais e, portanto, me(nos) responsabilizo(responsabilizamos) por qualquer litígio ou reclamação relacionado com direitos de propriedade intelectual, isentando de responsabilidade a universidad de la sabana. além disso, declaro(declaramos) que este artigo é inédito e que não o submeti(submetemos) a outro periódico para sua respectiva avaliação e posterior publicação. também marco(marcamos) com um “x” se o texto que estou(estamos) submetendo foi derivado de uma: ( ) dissertação de mestrado; ( ) tese de doutorado. caso haja marcado alguma das opções, colocarei(colocaremos) a informação apropriada da fonte base como nota de rodapé no artigo. se o artigo “<nombre del artículo / name of the paper / nome do artigo>” for aceito para publicação: a) como autor/a(es/as) e proprietário/a(s) dos direitos autorais, autorizo(autorizamos), de maneira ilimitada no tempo, a universidad de la sabana para que inclua o texto na revista aquichan, a fim de que seja reproduzido, editado, distribuído, exibido e comunicado em texto integral no país e no exterior por meio impresso, eletrônico, cd rom, internet ou qualquer outro meio conhecido ou por conhecer; b) reconheço(reconhecemos) os requisitos da revista e deixo(deixamos) como anexo a esta carta os dados indispensáveis para publicar meu(nosso) texto: orcid de todos os autores do artigo; e-mail institucional de todos os autores do artigo ou o do/a(s) de correspondência; se a pesquisa foi financiada: todos os dados da instituição financiadora e seu respectivo número de identificação; segundo as normas de referência da revista: o(s) nome(s) oficial(is) no âmbito acadêmico-científico, com o qual me(nos) identifico(identificamos) nas citações, a fim de padronizá-lo(s) em todas as bases de dados e favorecer minha(nossa) citação. por exemplo, nas normas da revista, bruna ruoso da silva neutzling é: da silva br; maria del carmen solano-ruiz é: solano-ruiz mc. por ser verdade, firmo(firmamos) a presente e dou(damos) fé aos _ _ _ _ _ _ dias do mês de _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ do ano _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _, na cidade de _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ . nome completo do(a) autor(a) 1: nome como é citado em documentos acadêmico-científicos: e-mail institucional: número orcid: financiamento (se for o caso): declaração de originalidade 79 99 competencias para la enfermera.indd 79 paz soto-fuentes1 katiuska reynaldos-grandón2 dayann martínez-santana3 oscar jerez-yáñez4 competencias para la enfermera/o en el ámbito de gestión y administración: desafíos actuales de la profesión 1 enfermera matrona. magíster en administración en salud universidad de chile. profesor asociado, pontificia universidad católica de chile, chile. pesoto@uc.cl 2 enfermera matrona. ingeniera comercial. doctora en ciencias empresariales. profesor asistente adjunto, pontificia universidad católica de chile, chile. kreynaldos@uc.cl 3 enfermera matrona uc. instructora adjunta, escuela de enfermería, pontificia universidad católica de chile, santiago, chile. dcmartin@uc.cl 4 doctor en psicología y educación. profesor de filosofía, pontificia universidad católica de chile, chile. ojerezy@gmail.com recibido: 3 de octubre de 2012 enviado a pares: 4 de diciembre de 2012 aceptado por pares: 23 de octubre de 2013 aprobado: 24 de noviembre de 2013 año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 79-99 para citar este artículo / to reference this article / para citar este artigo soto-fuentes, p.; reynaldos-grandón, k.; martínez-santana, d.; jerez-yáñez, o. (2014). competencias para la enfermera/o en el ámbito de gestión y administración: desafíos actuales de la profesión. aquichan. vol. 14, no. 1, 79-99. resumen las competencias laborales de enfermería permiten disminuir inequidades, acceso limitado a los servicios y favorecen una atención segura y de calidad. la formación de enfermeras/os es fundamental en la composición y dinámica de la fuerza de trabajo en enfermería, la calidad y pertinencia de los cuidados y el desarrollo de la capacidad institucional en salud. objetivo: responder dos interrogantes: ¿cuáles son los requerimientos actuales para el/la enfermero/a en el ámbito de la gestión y administración?, y ¿cuáles son las competencias de gestión de enfermería más importantes y su relación con la gestión de cuidado? método: revisión de la literatura que parte con una exploración de campo desde los contextos y desafíos actuales de la profesión. la búsqueda bibliográfica se realizó en las bases de datos cochrane library, lilacs, cinhal, dialnet, universidad de la rioja, proquest, web of science, science direct, pubmed, business source premier, scielo, scopus. se encontraron 4.697 artículos. precisando la búsqueda se seleccionaron 51 artículos y documentos técnicos. resultados: los estudios que priorizan las competencias de gestión coinciden en colocar entre las más importantes: comunicación, trabajo en equipo, resolución de conflictos y habilidades interpersonales y de liderazgo. en liderazgo priorizan dominio personal, efectividad interpersonal, gestión financiera y de recursos humanos. conclusiones: las habilidades de gestión y liderazgo se deben basar en conocimientos sólidos y en la experiencia. asimismo, la concepción de gestión y liderazgo ocupa un lugar complementario al rol de cuidado que tiene la enfermera/o. el liderazgo transformacional y relacional son necesarios para mejorar la satisfacción de las/os enfermeras/os. palabras clave liderazgo, administración hospitalaria, atención de enfermería, enfermería, gestión en salud (fuente: decs, bireme). 80 aquichan issn 1657-5997 año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 79-99 skills for nurses in the field of management and administration: contemporary challenges to the profession abstract the job skills involved in nursing make it possible to reduce inequalities and limited access to services, and to support safe and quality care. the training nurses receive is fundamental to the composition and dynamics of the nursing work force, the quality and appropriateness of nursing care, and the development of institutional capacity in the health sector. objective: the study was designed to answer two questions: what are the current requirements for nurses in the field of management and administration; and what nursing management skills are most important and how do they relate to health care management? method: the literature review began by exploring the field in terms of current contexts and challenges to the profession. the bibliographic search involved several the databases; namely, the cochrane library, lilacs, cinahl, dialnet, the university of la rioja, proquest, web of science, sciencedirect, pubmed, business source premier, scielo and scopus. in all, 4,697 articles were found. when the search was narrowed, 51 technical papers were selected. results: the studies that prioritize management skills coincide in that the most important ones are: communication, teamwork, conflict resolution, and interpersonal and leadership skills. as for leadership, the priority is on personal mastery, interpersonal effectiveness, financial management and human resources. conclusions: management and leadership skills must be based on sound knowledge and experience. moreover, the concept of management and leadership is complementary to the role of nurses in providing care. transformational and relational leadership are needed to improve the satisfaction of nurses. key words leadership, hospital administration, nursing care, nursing, health management (source: decs, bireme). 81 competencias para la enfermera/o en el ámbito de gestión y administración: desafíos actuales de la profesión l paz soto-fuentes y otros. competências para a enfermeira/o no âmbito de gestão e administração: desafios atuais da profissão resumo as competências laborais de enfermagem permitem diminuir inequidades, acesso limitado aos serviços e favorecem um atendimento seguro e de qualidade. a formação de enfermeiras/os é fundamental na composição e dinâmica da força de trabalho em enfermagem, na qualidade e pertinência dos cuidados e no desenvolvimento da capacidade institucional em saúde. objetivo: responder a duas interrogantes: quais são os requerimentos atuais para a/o enfermeira/o no âmbito da gestão e da administração? quais são as competências de gestão de enfermagem mais importantes e sua relação com a gestão de cuidado? método: revisão da literatura que parte com uma exploração de campo a partir dos contextos e desafios atuais da profissão. a busca bibliográfica foi realizada nas bases de dados cochrane library, lilacs, cinhal, dialnet, universidad de la rioja, proquest, web of science, science direct, pubmed, business source premier, scielo, scopus. encontraram-se 4.697 artigos. precisando a busca, selecionaram-se 51 artigos e documentos técnicos. resultados: os estudos que priorizam as competências de gestão coincidem em colocar entre as mais importantes: comunicação, trabalho em equipe, resolução de conflitos e habilidades interpessoais e liderança. em liderança, priorizam domínio pessoal, efetividade interpessoal, gestão financeira e de recursos humanos. conclusões: as habilidades de gestão e liderança devem ser baseadas em conhecimentos sólidos e na experiência. além disso, a concepção de gestão e liderança ocupa um lugar complementar ao papel de cuidado que a/o enfermeira/o tem. a liderança transformacional e relacional são necessárias para melhorar a satisfação das/os enfermeiras/os. palavras-chave liderança, administração hospitalar, cuidados de enfermagem, enfermagem, gestão em saúde (fonte: decs, bireme). año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 79-99 82 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 introducción en los últimos años la salud es considerada cuestión central y condición del desarrollo. esto es consecuencia de múltiples factores, entre ellos el aumento de las inequidades en el mundo globalizado, el aumento de riesgos debido a cambios ecológicos, demográficos y socioeconómicos, la generación de alianzas globales para el desarrollo social, el control de enfermedades y una renovada acción a favor de la atención primaria en salud (1). en este contexto adquieren relevancia los recursos humanos en salud que actualmente, tanto en el mundo como en las américas, atraviesan por una triple problemática: “la distribución, la composición y competencias de la fuerza laboral en salud” (1). las competencias de la fuerza laboral de enfermería representan un componente central para la adecuación de la gestión del cuidado y las prácticas de atención. permiten disminuir las inequidades, el acceso limitado a los servicios y favorecen una atención segura y de calidad. la formación de enfermeras/os juega un rol fundamental en la composición y dinámica de la fuerza de trabajo en enfermería, en la calidad y pertinencia de los cuidados y en el desarrollo de la capacidad institucional en salud (1). la enfermera/o profesional demuestra competencia cuando aplica en forma efectiva una combinación de conocimientos, habilidades y juicio clínico en la práctica diaria o desempeño laboral. en las definiciones de enfermería hay amplio acuerdo respecto a las competencias que la enfermera/o debe reflejar en el desempeño de sus funciones y los estándares requeridos en el empleo, estas son: 1) conocimiento, comprensión y juicio; 2) una serie de habilidades cognitivas, técnicas o psicomotoras e interpersonales; 3) una serie de características y actitudes personales (2). de este modo, las competencias se definen como “un conjunto de comportamientos que incluye conocimientos, habilidades y los atributos personales que, en conjunto, son fundamentales para el logro de un trabajo exitoso”. los indicadores para evaluarlas son los comportamientos medibles que son esenciales para el buen desempeño de la enfermera gestora (2). asimismo, en chile se incorpora la gestión del cuidado como la esencia del rol profesional, entendiéndose como el ejercicio profesional de la enfermera sustentado en su disciplina, la ciencia del cuidar (3). gestionar los procesos de cuidado de enfermería implica que el cuidado de la salud se brinde de una manera racional, oportuna, equitativa, económica, que minimice los riesgos tanto al usuario, al equipo de salud, como a la institución y a la comunidad, y que maximice el beneficio generado por la actividad (3). a nivel mundial la mayoría de las teorías y modelos de enfermería colocan como centro de la profesión el cuidado de la salud de las personas (3). abarcan los cuidados, autónomos y en colaboración, que se prestan a las personas de todas las edades, familias, grupos y comunidades, enfermos o sanos, en todos los contextos. incluyen la promoción de la salud, la prevención de la enfermedad, los cuidados de personas discapacitadas y moribundas (4). tanto en chile como a nivel mundial una de las funciones esenciales de la enfermera/o es la participación en políticas de salud y en gestión de los sistemas de salud (4). en el cuerpo legislativo chileno, tanto de la profesión como de salud, se indica la responsabilidad que tiene la enfermera/o profesional en la administración de los recursos para la asistencia del paciente (5). en chile, según el artículo 113 del código sanitario (4), y la norma general administrativa n°19, gestión del cuidado de enfermería para la atención cerrada (5), esta responsabilidad debe estar a cargo de un profesional enfermero/a con formación y competencias técnicas y de gestión en el ámbito de los cuidados para tener las atribuciones de organizar, supervisar, evaluar y promover el mejoramiento de la calidad de los cuidados de enfermería (6). así surge el concepto de gestión del cuidado como “la unión estable de dos palabras gestión y cuidado, cuyo significado es propio y mayor que la suma de sus componentes”. es un proceso heurístico (de búsqueda de investigación), dirigido a movilizar los recursos humanos y del entorno con la intención de mantener y favorecer el cuidado de la persona que, en interacción con su entorno, vive experiencias de salud (7-8). de esta forma, para una adecuada gestión del cuidado de enfermería se requiere la ejecución de acciones de gestión y administración de enfermería. ceballos (9) establece que la gestión es importante para organizar los cuidados con los recursos suficientes, pero no lo es todo para la enfermería; se debe gestionar para cuidar, no existir solo para gestionar. leininger agrega que: “los cuidados culturalmente congruentes son los que dejan al paciente convencido de que recibió buenos cuidados, de calidad” (10). en gestión este planteamiento es muy importante ya que indica la mejor forma de organizar los recursos con el fin de entregar un cuidado humano (9). 83 competencias para la enfermera/o en el ámbito de gestión y administración: desafíos actuales de la profesión l paz soto-fuentes y otros. el propósito de esta revisión bibliográfica es responder a las dos interrogantes que surgen de este análisis que son: ¿cuáles son los requerimientos actuales en el ámbito de la gestión y administración?, y ¿cuáles son las competencias de gestión de enfermería más importantes y su relación con la gestión de cuidado? materiales y métodos según los objetivos propuestos se realizó una revisión bibliográfica que se inicia con una exploración de campo con el objetivo de guiar la revisión desde los contextos y desafíos actuales de la profesión, a partir de entrevistas semiestructuradas. se seleccionan diez informantes claves, enfermeras y enfermeras matronas chilenas, con experiencia laboral mayor a cinco años que se desempeñaran en el ámbito gremial, red asistencial pública (intra y extramural) y académico. todas con cargos directivos o jefaturas. se realizaron cinco entrevistas con las que se lograron las conclusiones preliminares, por saturación. en las entrevistas se buscaba establecer algunos supuestos o predefinir algunas categorías que orientaran la recolección de la información. se realizaron las siguientes preguntas: 1) ¿qué entiende por gestión de enfermería?, 2) ¿cuál es la diferencia entre gestión y administración de enfermería?, 3) ¿qué tareas desempeña o realiza una enfermera/o en el ámbito de gestión o administración en su institución?, 4) ¿qué cualidades personales requiere una enfermera/o en el ámbito de gestión o administración en su institución? y 5) ¿qué características (atributos) requiere tener un egresado enfermero/a en el ámbito de gestión o administración en su institución? posteriormente se realiza la búsqueda bibliográfica de acuerdo con las palabras clave identificadas: liderazgo, estilos de liderazgo, competencias, desarrollo de competencias, gestión de enfermería, gestión del cuidado de enfermería, habilidades de gestión y administración en enfermería, y competencias y calidad del cuidado. la búsqueda bibliográfica se realizó en las bases de datos cochrane library, lilacs, cinhal, dialnet, universidad de la rioja, proquest, academic search complete (ebsco), web of science (isi), science direct (elsevier), pubmed, business source premier, scielo y scopus durante los meses de septiembre de 2011 a julio de 2012. se encontraron inicialmente 4697 artículos. precisando en la búsqueda del tema, como universo se utilizaron 313 artículos y se seleccionaron 51 artículos y documentos técnicos. además, fue necesario incorporar textos para la revisión de conceptos. los criterios de selección fueron: artículos de investigación, documentos técnicos de organizaciones mundiales y gubernamentales en inglés y en español, los primeros publicados desde el año 2000 en adelante, cuyo texto completo se obtuviera de manera liberada. los criterios de selección respondieron al propósito del artículo (tabla 1). resultados se organizan presentando los cinco temas que dan respuesta al propósito de la revisión realizada: 1) las competencias de egreso y su relación con las competencias laborales, 2) la concepción de gestión y administración en enfermería de los informantes clave, 3) los requerimientos actuales para el desempeño de la enfermera/o en el ámbito de gestión y administración, 4) caracterización de la gestión, administración y liderazgo en enfermería, y 5) grado de importancia y nivel de experiencia requerido. las competencias de egreso y su relación con las competencias laborales actualmente es indiscutida la importancia de la competencia y la existencia de un importante cuerpo de conocimiento alrededor de su significado y su evaluación (11-15). cano (12) plantea tres características fundamentales que permiten comprender la trascendencia que tienen las competencias en la formación profesional: 1) además de articular conocimiento conceptual, procedimental y actitudinal, permiten desarrollar procesos de selección del conocimiento más adecuados para enfrentar una determinada situación o solucionar un problema de actuación; 2) se pueden aprender con formación inicial, con formación permanente y con experiencia a lo largo de la vida; un buen punto de partida es que se vinculan con rasgos de personalidad, por lo que su desarrollo es innato; 3) toman sentido en la acción, pero requiere reflexión. el perfil de egreso es el que describe las competencias mínimas que debe tener una persona al terminar sus estudios para incorporarse al ejercicio profesional (16). las competencias no están compuestas de conocimientos y habilidades fragmentadas, sino que son un conjunto de saberes combinados que no se transmiten porque el centro de la competencia es el sujeto-aprendiz que construye la competencia a partir de la secuencia de las actividades de aprendizaje que movilizan 84 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 múltiples conocimientos especializados. la persona competente es la que sabe construir saberes competentes para gestionar situaciones profesionales que cada vez son más complejas (11). es así como un estudiante de enfermería va construyendo sus competencias a partir de una combinación de recursos (conocimientos, saber hacer, cualidades o aptitudes, recursos del ambiente, relaciones, documentos, informaciones y otros) que son movilizados para lograr un desempeño (11). la formación universitaria como educación formal debe preocuparse de la persona en su integridad, como ser en desarrollo y como sujeto social (17). posee competencias profesionales quien dispone de los conocimientos, las destrezas y las actitudes necesarias para ejercer una profesión, puede revisar los problemas profesionales de forma autónoma y flexible, y está capacitado para colaborar en su entorno profesional y en la organización del trabajo (12, 18). perrenoud (13) agrega que la competencia tiene además un sentido amplio y creativo, desde una concepción más rica y profunda de la perspectiva cognitiva, y que implica elegir y movilizar recursos, tanto personales (conocimientos, procedimientos, actitudes) como de redes (bancos de datos, acceso documental) y realizar con ellos una atribución contextualizada (espacio, tiempo, relación). es una disposición para enfrentar eficazmente una familia de situaciones análogas, movilizando a conciencia y de manera rápida, pertinente y creativa múltiples recursos cognitivos: saberes, capacidades, micro-competencias, informaciones, valores, actitudes, esquemas de percepción, evaluación y razonamiento. las competencias laborales definen el ejercicio eficaz de las capacidades que permiten el desempeño de una ocupación en relación con los niveles requeridos en el empleo. es algo más que el conocimiento técnico que hace referencia al saber y al saber-hacer. el concepto de competencia engloba no solo las capacidades requeridas para el ejercicio de una actividad profesional sino también un conjunto de comportamientos, facultad de análisis, toma de decisiones, transmisión de información, etc., considerados necesarios para el pleno desempeño de la ocupación (12). esta capacidad para desempeñar una función productiva se realiza en diferentes contextos, de acuerdo con los requerimientos de calidad esperados por el sector productivo. a diferencia de los conocimientos y las aptitudes prácticas, que pueden ser validados a través de los diplomas y títulos del sistema de educación técnica y profesional, las competencias requieren de un sistema especial de evaluación y certificación (19). representan una combinación dinámica de atributos en relación con el conocimiento y su aplicación, con las actitudes y responsabilidades, o con la manera como los estudiantes serán capaces de desarrollarse al final del proceso educativo (20). la organización para la cooperación y el desarrollo económico (ocde) plantea como imprescindible que la formación profesional entregue competencias laborales para responder a demandas complejas y llevar a cabo tareas diversas de forma adecuada (21). a su vez, esta capacidad de actuar adecuadamente debe estar respaldada por los conocimientos pertinentes y en coherencia con los principios éticos que sustenta quien la ejerce (21). las competencias de egreso no son iguales a las competencias profesionales, son predecesoras de estas. es importante destacar que adquirir el estándar de desempeño adecuado en todas las competencias que requiere un profesional resulta muy difícil, de ahí que al término de su carrera el estudiante no cuenta con competencias laborales propiamente tal. la competencia laboral es la construcción social de aprendizajes significativos y útiles para el desempeño productivo en una situación real de trabajo que se obtiene, no solo a través de la instrucción, sino también —y en gran medida— mediante el aprendizaje por experiencia en situaciones concretas de trabajo (22).también es definida como la capacidad de aplicar conocimientos, destrezas y actitudes al desempeño de la ocupación que se trate, incluyendo la capacidad de respuesta a problemas, imprevistos, la autonomía, la flexibilidad, la colaboración con el entorno profesional y con la organización del trabajo (23). de acuerdo con bunk (18), posee competencia profesional quien dispone de los conocimientos, las destrezas y las aptitudes necesarios para ejercer una profesión, puede resolver los problemas profesionales de forma autónoma y flexible, está capacitada para colaborar en su entorno profesional y en la organización del trabajo. el perfil de egreso describe las competencias mínimas que debe tener una persona al terminar sus estudios para incorporarse al ejercicio profesional (16), mientras que el perfil profesional es el conjunto de competencias para el ejercicio de una profesión. describe “qué es el profesional”, “qué debe saber”, “qué debe ser capaz de hacer”, “qué actitudes debe reflejar en sus conductas” y “cuáles son sus obligaciones éticas y sociales”. con ellas un profesional es capaz de tomar decisiones fundadas en un cuerpo de conocimientos especializados para intervenir en situaciones complejas y variadas en un campo de acción (16). 85 competencias para la enfermera/o en el ámbito de gestión y administración: desafíos actuales de la profesión l paz soto-fuentes y otros. “las competencias de una enfermera/o licenciada/o comprenden conocimientos, capacidades, juicio y atributos personales específicos que se requieren para que la enfermera especialista ejerza su profesión de manera segura y ética en una función y contexto determinados” (24). el aumento de la gravedad de los pacientes, la disminución del tiempo de hospitalización y la proliferación de tecnologías del cuidado han incrementado la necesidad de contar con enfermeras con competencias específicas que les permitan adaptarse a estos cambios y enfrentar los desafíos que ello implica. en general, los estudios que analizan las competencias de enfermería las enfocan como un factor esencial para garantizar la atención de la salud que por su grado de preparación es segura y de calidad, aspecto esencial de la práctica que afecta a los usuarios, las familias y a otras enfermeras (15, 25-28). benner (26) establece cinco niveles de desarrollo de competencias en enfermería: novicia o principiante, principiante avanzado, competente, capaz y experto (26). reconoce en la enfermera novicia la competencia de ejecutar de tareas por medio del conocimiento de atributos que no requieren poseer experiencia previa, es decir, tareas que requieren solo del conocimiento teórico para su ejecución (conocimiento en acción). por otro lado, la enfermera principiante avanzada es aquella que demuestra un rendimiento de nivel aceptable, pudiendo ejecutar tareas de mayor complejidad en donde se requiere al menos un nivel mínimo de experiencia previa en alguna situación similar. en estos niveles las enfermeras necesitan apoyo en el desempeño clínico y ayuda para establecer prioridades, ya que aún no son capaces de identificar qué es lo más importante. la enfermera competente, en cambio, es aquella que tiene de dos a tres años de experiencia, es capaz de comenzar a ver sus acciones como planes o metas a largo plazo y contemplar de manera abstracta y analítica un problema. su práctica está basada en respuestas flexibles que se producen por los cambios y las necesidades de los pacientes. puede organizarse mejor en sus tareas y presenta una sensación de dominio y la capacidad de hacer frente y solucionar problemas contingentes de la práctica clínica, aunque aún no tiene la velocidad y la flexibilidad de la enfermera que ha alcanzado el nivel de competencia mayor. la enfermera competente es capaz de realizar una planificación consciente y deliberadamente ayuda a lograr un nivel de eficiencia y organización en el desempeño de su trabajo, puede coordinar demandas complejas y tomar decisiones (26). la enfermera capaz puede percibir las situaciones como un todo debido a la presencia de una agudeza perceptual y a la habilidad de captar la situación y el ambiente. esta profesional va guardando sus experiencias pasadas y puede adelantarse a la ocurrencia de eventos típicos ante situaciones determinadas. es capaz de analizar la situación y darse cuenta cuando la normalidad está ausente. también es capaz de comprender de manera holística una determinada situación lo que mejora la toma de decisiones (26). el nivel de enfermera experta es el más alto desarrollo de la competencia, se posee una comprensión intuitiva y profunda de la situación debido a la enorme experiencia y capacidad de adaptación. la actuación de la enfermera experta es integral, no de procedimiento fraccionado como la principiante, y existe un vínculo entre el razonamiento clínico y el ético (26). en el estudio de tabari, kiger y parsa (28) sobre el desarrollo de las competencias en enfermería concluyen que se trata de un proceso de constante interacción, muy integrado, en el cual la enfermera tiene la función principal en la conducción del mismo. el estudio demuestra que la competencia profesional se desarrolla mediante un proceso repetitivo y complejo, cuya dinámica se produce entre la enfermera y el contexto laboral que la rodea. este proceso de desarrollo de competencia en enfermería es denominado “el proceso de interacción constante”, y tiene cinco fases fundamentales: 1) reconocimiento de fuerza de conducción que actúa como el motivo del movimiento de las enfermeras hacia el desarrollo de la competencia; 2) proporcionar requisitos adecuados, suficientes conocimientos teóricos y apoyo para satisfacer necesidades mínimas a fin de participar en una actividad; 3) la experiencia como el corazón del proceso de desarrollo de competencia que proporciona una oportunidad para hacer un enlace entre la teoría y la práctica; 4) consolidación como el dominio completo del trabajo propuesto principalmente a través de la práctica repetida y enfrentar situaciones difíciles mediante la reflexión; 5) integración que incorpora las nuevas competencias con las antiguas, y prepara para enseñar y supervisar en otras áreas relacionadas. los autores reiteran que estas fases del proceso están interconectadas en lugar de tener un orden cronológico, y que la enfermera puede experimentar distintas etapas de este proceso en diferentes puestos de trabajo simultáneamente. la concepción de gestión y administración en enfermería de los informantes clave las entrevistas semiestructuradas permiten identificar en forma preliminar una concepción de gestión y administración en enfermería divida en tres dimensiones: 86 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 • dominio individual: centrado en la gestión del proceso de enfermería (propia de la enfermera, y tal vez propia de la formación inicial o de pregrado). • dominio compartido con otros profesionales: que se sitúa en la gestión de personas y recursos materiales. • liderazgo, autonomía y proactividad: como dimensiones propias de muchas profesiones y del nivel de formación de pre y posgrado. además, se identifican algunas diferencias entre gestión y administración; gestión es un concepto amplio y se relaciona con toma de decisiones sobre aspectos económicos, financieros y políticos. la administración consiste en asignar, optimizar recursos y ejecutar tareas con herramientas preestablecidas. también se reconocen algunas tareas clave como: planificación, programación, gestión de los servicios, coordinación, trabajo en equipo, negociación, manejo de insumos, supervisión, capacitación y selección de personal. los conocimientos requeridos como: sistema de salud, sus normativas legales, metas sanitarias y financiamiento; salud pública, control de gestión, manejo de conflictos, toma de decisiones y priorización de problemas. finalmente identifican algunas cualidades indispensables en una enfermera/o como: compromiso, responsabilidad, asertividad, empatía, perseverancia, resiliencia, proactividad y liderazgo. los requerimientos actuales para el desempeño de la enfermera/o en el ámbito de la gestión y administración las reformas en salud realizadas en la mayor parte de los países de américa latina durante el último decenio del siglo xx se enmarcaron en el objetivo de disminuir los costos y el tamaño del estado y mejorar la eficiencia, la cobertura y la calidad de los servicios. entre las estrategias está la descentralización administrativa y financiera del sistema de salud, la separación de presupuestos entre salud y pensiones, y entre las entidades que prestan servicios y las aseguradoras. a las reformas en el sector salud se sumaron otras reformas estatales como la fiscal, la educativa y la laboral; estos procesos en conjunto modificaron las condiciones de trabajo del personal de salud, las formas de contratación y los salarios; se introdujeron nuevas responsabilidades en la gestión de los servicios y de costos, de acuerdo con lo señalado por la organización panamericana de la salud (ops) (29). el consejo internacional de enfermeras (cie) plantea que las enfermeras deben desarrollar e implementar las políticas de salud tanto en los planos locales nacionales como internacionales mediante el desempeño de funciones de gestión y liderazgo. le otorga la responsabilidad de contribuir en la planificación de políticas de la salud, y en la coordinación y gestión de los servicios del área. para el cie las enfermeras gestoras han de ser directamente responsables de la gestión de los servicios de enfermería porque poseen las competencias para dirigir estos y otros servicios de salud (4). además, plantean otras funciones que pueden desempeñar las enfermeras gestoras como asesorar de otros gestores sobre cuestiones que corresponden a la enfermería profesional (4). en la actualidad, las enfermeras ocupan funciones esenciales de liderazgo en los sistemas de salud del mundo, son los profesionales que cuentan con mayor experiencia, con responsabilidad de gestionar y coordinar diariamente los cuidados de los pacientes y son los encargados de supervisar al personal de enfermería (4, 30). distintos trabajos han establecido las competencias que debe desarrollar la enfermera, entre las que se encuentran las de liderazgo como comunicación, trabajo en equipo y motivación; y las de gestión como delegación y supervisión (30-32). también se ha intentado identificar los factores que podrían estar asociados con la eficacia de las enfermeras directoras o ejecutivas, encontrándose una relación significativa en atributos como: colaboración en equipos multidisciplinarios, habilidad en negocios, habilidades en gestión de personas, proporcionar a las enfermeras las herramientas adecuadas y los recursos para hacer su trabajo, conocimiento de enfermería, gestión de calidad y de proyectos (33). en chile, las autoridades del ministerio de salud, en el contexto de la promulgación de la estrategia nacional de salud 2011-2020 (34), han hecho evidente la necesidad de un mayor desarrollo de la gestión como una competencia esencial de las enfermeras/os. esto se debe a que visualizan este proceso como una estrategia necesaria para la implementación y el monitoreo de los nueve objetivos estratégicos con sus respectivas acciones y resultados esperados en todos los niveles. cada uno de los objetivos estratégicos planteados responde a un proceso de gestión, el cual es llevado a cabo por distintos profesionales de la salud (34). asimismo, se plantea la importancia de la gestión clínica de los servicios de salud que puede desarrollar la enfermera/o, enfocándola específicamente en la capacidad de administrar y pla87 competencias para la enfermera/o en el ámbito de gestión y administración: desafíos actuales de la profesión l paz soto-fuentes y otros. nificar los recursos necesarios para el cuidado de la salud. se considera que la gestión clínica tiene como meta ofrecer a los pacientes los mejores resultados posibles en la práctica diaria (efectividad), acordes con la información científica disponible para cambiar de forma favorable el curso clínico de la enfermedad (eficacia), con la menor cantidad de inconvenientes y costos para el usuario y la sociedad en su conjunto (eficiencia) (35). la enfermera, en el desempeño laboral, utiliza el juicio clínico en la prestación de servicios para lograr que las personas mejoren, mantengan o recuperen su salud, que sean capaces hacer frente a problemas de salud, y para que de esta forma alcancen la mejor calidad posible de vida, cualquiera que sea su enfermedad o incapacidad, hasta la muerte (36). esto implica que realiza un modo particular de intervención de enfermería que se relaciona con empoderar a las personas y ayudarles a alcanzar, mantener o recuperar la independencia. la enfermería es un proceso intelectual, físico, emocional y moral que incluye la identificación de las necesidades de enfermería, intervenciones terapéuticas y el cuidado personal, información, educación, asesoramiento y promoción física, emocional y espiritual. además de dirigir la atención al paciente, la práctica de enfermería incluye el desarrollo de la gestión, la docencia, la política y el conocimiento (36). todas las enfermeras llevan en sus mentes un concepto personal de la disciplina respecto a lo que es, para qué sirve y cómo debe hacer su trabajo. el problema, al menos en el reino unido, es que este concepto no se ha descrito y analizado suficientemente. no se sabe, por lo tanto, si todas las enfermeras comparten un concepto común, y mucho menos si se ha compartido con los pacientes y el público (36). sin embargo amestoy et al. (37), en su estudio preliminar cualitativo, han identificado en las enfermeras que trabajan en hospitales la visión que tienen del liderazgo que ejercen, de la cual emergen cuatro categorías de liderazgo: agente de cambio, visionario, motivador y constructor de lazos de amistad. estas se consideran como un instrumento esencial para ayudar a las enfermeras/os en la dirección, toma de decisiones, las relaciones interpersonales y la solución de conflictos que pueden ocurrir en el trabajo. a nivel nacional el estudio de robles (38) identifica, clasifica y organiza los cuidados realizados por el personal de enfermería de tres hospitales públicos de alta complejidad de atención de chile. en la estructura de cuidados de enfermería validada se identifican tres dimensiones de cuidados: universales, terapéuticos e indirectos. los cuidados relacionados con gestión y administración se ubican en la dimensión de cuidados indirectos y consideran tres áreas de cuidados con sus respectivas intervenciones: 1) gestión y administración de la atención (administración operacional, calidad y seguridad, coordinación, desarrollo de la atención, dirección administrativa, extensión y docencia, gestión transversal del cuidado, manejo de insumos y consumos, y registros e informes); 2) seguridad del ambiente físico (manejo de ambientes laborales, de equipos y mobiliario); 3) administración del personal (capacitación, gestión, seguridad y supervisión). respecto a esta última área de cuidado, los desafíos a los que se enfrenta la enfermera son la escasez de los recursos humanos, una alta rotación y ausentismo laboral. esto hace necesario que las enfermeras cuenten con un conjunto de competencias que les permitan planificar, guiar, apoyar y facilitar el desarrollo eficiente del recurso humano, aspecto esencial para la buena prestación de los servicios de salud y atención de calidad (30). las enfermeras deben estar preparadas para gestionar rápidos cambios en un mundo globalizado dirigido por la tecnología y con limitados recursos humanos y económicos (30). en el área de la gestión, en el apoyo y el cuidado del personal, la enfermera debe brindar oportunidades para el aprendizaje y la formación continua, el desarrollo y el crecimiento profesional, aportar comentarios y revisiones constructivas, defender y apoyar al crear un trabajo en equipo y, finalmente, mantener una comunicación y negociación eficaces (30). entre las competencias por desarrollar en la planificación de los recursos humanos se encuentran: el análisis de datos, la gestión de la oferta de los recursos humanos, la gestión por competencias, y el desarrollo y la innovación (30). caracterización de la gestión, administración y liderazgo en enfermería la administración, como ciencia social, permite a las organizaciones humanas crear, producir y obtener satisfactores de sus necesidades. se aplica mediante principios y métodos que le son propios, orientando los esfuerzos hacia la obtención de óptimos resultados en el logro de los objetivos, tanto de los integrantes de la organización como de los usuarios, de los bienes o servicios que se prestan, contribuyendo así al desarrollo social (39). la administración es el proceso de estructurar y utilizar conjuntos de recursos orientados hacia el logro de metas para llevar a cabo las tareas en un entorno organizacional (40). por otra parte, la gestión se enfoca a la toma de decisiones para conseguir los objetivos, generalmente a través de otros, y responsabilizarse de lo que otros han hecho, dicho riesgo es menor si previamente 88 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 se ha planificado lo que se debe gestionar (41). el liderazgo se define como el proceso o arte que implica la influencia para hacer que las personas se esfuercen voluntariamente hacia el logro de los objetivos del grupo (39). incluye el conocimiento, las capacidades y las habilidades que permiten al líder dirigir las fuerzas de quienes se encuentran alrededor hacia un esfuerzo colectivo por medio de la colaboración eficaz y estratégica, las capacidades de negociación, de comunicación oral y escrita de alto nivel, desarrollo y motivación de equipo y adopción de decisiones (30). como parte de las competencias de liderazgo y trabajo en equipo se espera que la enfermera pueda comunicar un estilo y unos valores adecuados que apoyen al sistema de salud y a los recursos humanos de enfermería, y que sean coherentes con un entorno de trabajo saludable (30). según el cie, el liderazgo como componente esencial de la gestión determina la necesidad de preparar líderes para enfermería. el liderazgo de enfermería comprende las actividades de instruir a otras personas y ser sus mentores, crear un entorno y condiciones para el perfeccionamiento constante y la calidad de los cuidados. agrega que el liderazgo a través de las asociaciones profesionales de enfermeras mejora la profesión y la sitúa estratégicamente para influir en la planificación y en la política de salud (4). las capacidades de gestión y liderazgo son reconocidas como una parte esencial de la práctica, no solo de las enfermeras sino también para todos los profesionales de la salud cuyo desarrollo permitirá una sobresaliente asistencia sanitaria para el futuro (30, 42, 43). el objetivo de cualquier organización sanitaria debe ser influir en la calidad de la atención al paciente y el liderazgo de enfermería juega un papel clave en estimular al personal para obtener una mejor comprensión del paciente. germain y cummings (44) muestran en su investigación que el estilo de liderazgo de enfermería tiene un impacto en su rendimiento. a partir de esta revisión, los factores que las enfermeras perciben como motivadores para un buen desempeño incluyen la práctica autónoma, las relaciones de trabajo, accesibilidad a los recursos, las características individuales de enfermería y las prácticas de liderazgo. la comprensión de estos factores es una condición necesaria para la atención de enfermería de calidad y positiva para el paciente y los resultados organizacionales (44, 45). por tanto, es responsabilidad de los académicos de enfermería y de las organizaciones de salud seguir estudiando y enseñando este tema. al revisar la literatura e introducirnos en el análisis de las concepciones que se han desarrollado sobre liderazgo y gestión, surge de inmediato la cuestión respecto a si actualmente es pertinente distinguir estos dos conceptos. al respecto, mowinski (46) realiza una revisión de la literatura en la que encuentra que las competencias de liderazgo se abordaron casi dos veces más que las de gestión. a pesar de esto subraya la popularidad de los líderes, que contrasta con la similitud entre competencias de liderazgo y de gestión. de las 894 competencias en los 140 artículos revisados, 862 eran comunes a ambos, líderes y gestores. las diez más importantes son comunes para gestión y liderazgo: las habilidades y cualidades interpersonales, el pensamiento crítico, la comunicación, las habilidades de gestión (por ejemplo, planificación y organización), habilidades de negocios (por ejemplo, finanzas y marketing), iniciar el cambio y conocimientos sanitarios de atención de salud. a su vez, de las diez competencias más mencionadas, solo dos son identificadas como exclusivas del liderazgo: establecer la visión y la capacidad de desarrollar a las personas. también identifican solo dos competencias exclusivas de gestión: gestión de recursos humanos y de información. esta agrupación de competencias es importante porque proporciona evidencia que se opone a las distinciones anteriores entre liderazgo y gestión. algunos pueden argumentar que la fusión de las competencias de liderazgo y de gestión tiende a ignorar los diferentes objetivos a los que apunta cada una. por el contrario, mowinski (46) plantea que la convergencia de competencias de liderazgo y de gestión podría reflejar una dinámica diferente, determinada por los cambios en el contexto social de la salud. por otra parte, la amplia gama de competencias identificadas en esta revisión verifica que “el papel del administrador de enfermería se está expandiendo y el conjunto de habilidades necesarias es inmenso. la complejidad del papel administrador de la enfermera es también evidente en las competencias propuestas por la asociación de enfermeras americanas” (47). por otra parte, cummings et al. (42), en su revisión sistemática que incluyó diez bases de datos y 34.666 artículos, con el objetivo de explorar las relaciones entre varios estilos de liderazgo y los resultados para el personal de enfermería y sus entornos de trabajo, encontró que los estilos de liderazgo que se centraban en las personas y las relaciones como el liderazgo de transformación, de resonancia y de apoyo, entre otros, se asocian con una mayor satisfacción laboral de la enfermera. en otros estudios se encontró que los estilos de liderazgo que estaban centrados en las tareas, como el liderazgo disonante, instrumental y de gestión por excepción, se asociaron con menor satisfacción laboral (42). 89 competencias para la enfermera/o en el ámbito de gestión y administración: desafíos actuales de la profesión l paz soto-fuentes y otros. grado de importancia y nivel de experiencia requerido la formación del profesional de enfermería es amplia y diversa. en ella los estudiantes inician la adquisición del conocimiento científico teórico en combinación con el conocimiento práctico que se obtiene de una situación determinada y de las experiencias laborales de los enfermeros asistenciales. en la teoría de principiante a experto de patricia benner (26), que estudia la práctica de la enfermería clínica, con el fin de describir el conocimiento que sustenta, concluye que el saber práctico ha permitido el desarrollo de la investigación en enfermería, ha modificado estructuras de formación de futuros profesionales en diferentes materias y la creación de indicadores empíricos que ha favorecido la unión entre la teoría y la práctica. la misma autora señala que, a medida que el profesional adquiere experiencia, el conocimiento clínico se convierte en una mezcla de conocimiento práctico y teórico. la adquisición de habilidades basadas en la experiencia es más segura y rápida cuando se produce a partir de una base educativa sólida, y que dependiendo de en qué etapa se encuentre el profesional se crearán diversas estrategias de aprendizaje. clasifica las etapas de este aprendizaje práctico en orden creciente: principiante, principiante avanzado, competente, eficiente y experto (26). respecto al nivel de importancia de la gestión y el liderazgo de enfermería meteroja (48) reconoce siete categorías de competencias de la enfermera profesional basadas en el modelo de patricia benner. estas categorías fueron validadas por revisión de literatura y por seis grupos de expertas consultadas. se construyó una escala de competencias de enfermería que resultó con una validez muy fuerte. entre las siete categorías las funciones relacionadas con administración aparecen con la segunda frecuencia de uso, después del rol de ayuda (48, 49). en chile el estudio de robles (38), que valida una estructura de cuidados de enfermería, identifica un conjunto de acciones de gestión y administración y los clasifica en la dimensión de cuidados indirectos, después de las dimensiones de cuidados universales y terapéuticos. los cuidados indirectos son acciones que apoyan la eficacia de las intervenciones directas de enfermería que se realizan lejos del usuario pero dirigidas a su beneficio. incluyen acciones de cuidado dirigidas al ambiente y la colaboración interdisciplinaria. en el mismo estudio, al revisar los tiempos totales invertidos en cuidados indirectos se observa que corresponden al 26 %, es decir, al tercer lugar después de cuidados universales y terapéuticos, lo que refuerza la concepción de que la gestión y el liderazgo ocupan un lugar complementario al rol de cuidado que tiene la enfermera/o. en el estudio de barquero (50) se desarrolla un mapa de competencias para directivos de enfermería para ser utilizado como herramienta de gestión y evaluación. se identifican las competencias genéricas de gestión consideradas muy importantes: capacidad para planificar y gestionar el tiempo, preocupación por la calidad, trabajar en equipo, tomar decisiones y resolver problemas. mientras que las competencias específicas de gestión consideradas muy importantes son: habilidad de gestión para el cambio, identificar resultados por conseguir, habilidad para analizar problemas y diseñar soluciones, identificar el propósito fundamental del puesto, y conocer y respetar los deberes y derechos de los pacientes. de estas, se priorizan tres competencias: 1) identificar el propósito fundamental para el puesto, 2) habilidad de gestión para el cambio y 3) gestión de la organización a partir de la planificación. jeans y rowat (51) desarrollan un estudio para identificar las habilidades, los atributos personales y el conocimiento requerido para la gestión de enfermería en canadá. se realizó a enfermeras de tres niveles jerárquicos o de responsabilidad y autoridad: gerentes, ejecutivos y clínicas, a las que se les pidió completar una encuesta para evaluar la importancia de las competencias necesarias para las enfermeras gestoras. un total de 563 participantes completaron la encuesta (ejecutivos de enfermería, enfermeras gestoras y profesionales de enfermería). los ejecutivos de enfermería y las enfermeras gestoras eligieron las mismas cinco competencias de gestión como las más importantes: 1) rendición de cuentas del ejercicio profesional, 2) comunicación (verbal), 3) trabajo en equipo, 4) habilidades de liderazgo y 5) resolución de conflictos. a su vez, el personal de enfermería selecciona las cuatro primeras competencias antes descritas y agrega las relacionadas con cuestiones jurídicas y éticas. entre las competencias menos importantes a nivel ejecutivo se encuentran: marketing, gestión de sistemas de información, la alfabetización informática y la planificación estratégica. mientras que las enfermeras gestoras y clínicas, además del marketing y la gestión de sistemas de información, agregan la competencia docente, la experiencia clínica y la gestión de proyectos (51). de la misma manera, el instituto de liderazgo de enfermería de florida atlantic university (52) focaliza su investigación en la determinación de las competencias que requieren las enfermeras líderes e identifica grandes 90 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 conglomerados: el dominio personal, la efectividad interpersonal, la gestión financiera, la gestión de recursos humanos, el cuidado y los sistemas de pensamiento como el liderazgo crítico dentro de las competencias para las enfermeras gestoras actuales. a lo anterior se agrega que algunos estudios de canadá, australia e irlanda han realizado una serie de investigaciones técnicas que incluyen revisión de la literatura, consultas de grupos focales, observaciones en profundidad a personal de enfermería en situaciones laborales y encuestas en línea con el propósito de definir las competencias que las enfermeras/os requieren en diferentes contextos laborales, cargos, niveles de experiencia y desarrollo profesional. para establecer las prioridades recomiendan identificar las competencias y los niveles que son necesarios para todos y los que son necesarios solo para miembros específicos de los equipos de enfermeras/os de una organización, el tipo de cargo o los grupos de especialistas (53-60). discusión la complejidad y responsabilidad de la práctica de enfermería requiere hoy un desarrollo profesional continuo. adquirir el estándar de desempeño adecuado en todas las competencias laborales que requiere un profesional resulta muy difícil, de ahí que el estudiante, al término de su carrera, cuenta con las competencias de egreso mínimas que debe tener una persona para incorporarse al ejercicio profesional. esto es particularmente importante cuando se trata de competencias de gestión y liderazgo en enfermería ya que los autores concuerdan en que las responsabilidades y funciones de las enfermeras gestoras se redefinen constantemente en el contexto de los cambios del sector de salud. se reconoce que la formación de las enfermeras gestoras es compleja, y que la preparación para el liderazgo es un elemento crítico, además de ser una importante prioridad para la enfermería en general (4). de ahí que es importante resaltar la responsabilidad de las instituciones formadoras en el desarrollo de este tipo de competencias a través diferentes estrategias que van desde establecer una constante vinculación con los empleadores y el mercado laboral de la salud para mantener actualizados y validados los perfiles de competencias de egreso en este ámbito, hasta integrar el conocimiento teórico con experiencias prácticas de carácter laboral específicas para su desarrollo y fomentar la participación de los estudiantes en asociaciones estudiantiles, científicas y gremiales. el papel del aprendizaje a través de la experiencia profesional es esencial en el desarrollo de competencias de gestión y liderazgo efectivas (25). a su vez, las instituciones de salud y el sector productivo tienen también responsabilidad en este asunto ya que deben identificar claramente las competencias laborales que requieren y proporcionar al profesional espacios para profundizar su desarrollo con oportunidades de reflexión y análisis del quehacer diario, con programas de mentoría y especialmente con una dotación de personal en que se mezclen las competencias de enfermeras principiantes con enfermeras competentes y expertas. estas acciones permiten crear un entorno y condiciones para el perfeccionamiento constante en pro de la calidad y seguridad de los cuidados. también es importante armonizar las competencias profesionales de los egresados con las competencias que exige el mercado laboral a través de acuerdos conjuntos respecto al gradiente de desarrollo de las competencias de gestión y liderazgo requeridas entre la formación inicial y la formación continua de nivel de especialización y posgrado, junto a lo cual se deben desarrollar sistemas de incentivos y perfiles de competencias según niveles de autoridad y responsabilidad derivados de los cargos asociados a un sistema de certificación de competencias. conclusión el enfoque por competencias ha surgido como respuesta a la creciente necesidad impulsada por la globalización en la tecnología, en las comunicaciones, en la economía y en la cultura de los países. su finalidad es mejorar la calidad y pertinencia de la formación de profesionales, para que estos puedan desempeñarse de manera más eficiente en los nuevos escenarios del ámbito sanitario del presente siglo, finalidad que concuerda con las directrices señaladas por organismos internacionales (4, 9, 21, 24, 29, 47). las definiciones de competencias son diversas, tanto para la etapa formativa como laboral. es indiscutible la importancia de las competencias y la existencia de un importante cuerpo de conocimiento alrededor de su significado y su evaluación (11-15). las competencias de la etapa formativa o de egreso se enfocan a un conjunto de saberes combinados. el centro de este tipo de competencia es el estudiante que construye la competencia a partir de una secuencia de actividades de aprendizaje que movilizan múltiples conocimientos especializados. por tanto, requieren reflexión y aunque se vinculan a rasgos de personalidad se pueden aprender (11-13, 16, 17). en cambio, las competencias laborales definen el ejercicio eficaz de las capacidades que permiten el desempeño de una ocupación respecto a los niveles requeridos en el empleo. representan una combinación 91 competencias para la enfermera/o en el ámbito de gestión y administración: desafíos actuales de la profesión l paz soto-fuentes y otros. dinámica de atributos en relación con el conocimiento y su aplicación, y las actitudes y responsabilidades. las competencias laborales son, al igual que las de egreso, una construcción social de aprendizajes significativos y útiles para el desempeño productivo pero se diferencian en que se dan en una situación real de trabajo que se obtiene, no solo a través de la instrucción, sino también mediante el aprendizaje por experiencia en situaciones laborales (12, 20, 22-23). por otra parte, el alcance de la formación universitaria es más amplio que la formación por competencias específicas, abarca al estudiante en su integridad (13, 17). esto último permite que un profesional cuente con los conocimientos, las destrezas y actitudes necesarias para revisar los problemas profesionales de forma autónoma y flexible y colaborar en su entorno profesional y en la organización del trabajo (12, 18). las competencias de egreso no son iguales a las competencias laborales, si bien son predecesoras de estas. el perfil de egreso describe las competencias mínimas que debe tener una persona al terminar sus estudios para incorporarse al ejercicio laboral, mientras que el perfil laboral es el conjunto de competencias para el ejercicio de una profesión. es importante destacar que adquirir el estándar de desempeño adecuado en todas las competencias que requiere un profesional resulta muy difícil para el estudiante egresado. sin embargo, es imprescindible que la formación profesional esté involucrada con el mercado laboral para entregar las competencias laborales mínimas a fin de responder a demandas complejas. esta capacidad debe estar respaldada por conocimientos pertinentes y en coherencia con los principios éticos que sustenta quien la ejerce (12, 16). al revisar los estudios que se relacionan con el desarrollo de las competencias en enfermería existe una concordancia con las definiciones analizadas. en general, los que analizan las competencias de enfermería las enfocan como un factor esencial para garantizar una atención de la salud segura y de calidad. también mencionan que la complejidad y responsabilidad de la práctica de enfermería requiere de un desarrollo profesional continuo (15, 24-28). respecto a los requerimientos para el desarrollo de las competencias de la enfermera/o profesional, muchos estudios se basan en los postulados del modelo teórico de enfermería “de novicia a experta” de patricia benner. esta autora describe de cinco niveles progresivos de desarrollo de las competencias. los dos primeros niveles, novicia y principiante avanzado, están relacionados con el desarrollo de competencias de egreso, mientras que los tres restantes con las competencias laborales. en todos los niveles plantea que para el desarrollo de las competencias la enfermera/o requiere, además de conocimientos, la ejecución de los cuidados de manera gradual en complejidad y flexibilidad para que adquiera los niveles iniciales de experiencia, una visión integral para abordar los problemas de la práctica clínica y una compresión holística de determinadas situaciones para mejorar la toma de decisiones. en cambio, en el estudio de tabari et al. (28) concluyen que la enfermera tiene la función principal en la conducción del proceso de desarrollo de competencias cuyas fases están interconectadas en lugar de tener un orden cronológico, por lo que la enfermera puede experimentar diferentes etapas de este proceso en distintos puestos de trabajo simultáneamente. es un proceso repetitivo de adquisición de experiencias que se produce entre la enfermera y el contexto que la rodea donde el entorno laboral es fundamental (26,28). respecto a los requerimientos actuales para el desempeño de la enfermera las responsabilidades y funciones de las enfermeras gestoras se redefinen constantemente en el contexto de los cambios del sector de salud (4). para el cie las enfermeras gestoras son responsables de la gestión de los servicios de enfermería porque poseen las competencias para dirigirlos (4). la enfermería es un proceso intelectual, físico, emocional y moral que dirige la atención al paciente incluyendo el desarrollo de la gestión, la docencia, la política y el conocimiento (36). por ello, es necesario que las enfermeras cuenten con un conjunto de competencias que les permitan planificar, guiar, apoyar y facilitar el desarrollo eficiente del recurso humano, aspecto esencial para la buena prestación de los servicios de salud y atención de calidad (30). en chile se identifican tres dimensiones de cuidados: universales, terapéuticos e indirectos. los cuidados relacionados con gestión y administración se ubican en la dimensión de cuidados indirectos y consideran tres áreas de cuidados con sus respectivas intervenciones: 1) gestión y administración de la atención, 2) seguridad del ambiente físico y 3) administración del personal (capacitación, gestión, seguridad y supervisión) (38). según el cie, el liderazgo es esencial en la administración de enfermería y comprende las actividades de instruir a otras personas y ser sus mentores, crear un entorno y condiciones para el perfeccionamiento constante y la calidad de los cuidados. se reconoce que en la formación de enfermeras gestoras la preparación para el liderazgo es un elemento crítico, además de ser 92 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 una importante prioridad para la enfermería en general (4). mowinski (39) encuentra similitud entre competencias de liderazgo y de gestión como: las habilidades y cualidades interpersonales, el pensamiento crítico, la comunicación, las habilidades de gestión (por ejemplo, planificación y organización), habilidades de negocios (por ejemplo, finanzas y marketing), iniciar el cambio y conocimientos sanitarios de atención de salud. a su vez, identifica solo dos como exclusivas de liderazgo: establecer la visión y la capacidad de desarrollar a las personas, y solo dos competencias exclusivas de gestión: gestión de recursos humanos y de información. además, plantea que la convergencia de competencias de liderazgo y de gestión podría reflejar una dinámica diferente, determinada por los cambios en el contexto social de la salud. la asociación de enfermeras americanas también visualiza la complejidad del papel gestor de la enfermera dado que en la actualidad se les emplaza a ejecutar liderazgo para construir entornos de trabajo de calidad, poner en práctica nuevos modelos de atención, y contribuir al desarrollo de una fuerza laboral de enfermería saludable y con bienestar (47). los artículos revisados concuerdan en que el liderazgo centrado en la realización de las tareas no es suficiente para lograr resultados óptimos para enfermería. los esfuerzos de las organizaciones y los individuos para fomentar y desarrollar liderazgo transformacional y relacional son necesarios para mejorar la satisfacción de los/as enfermeros/as, la contratación, la retención y los ambientes de trabajo saludables (4, 30, 42, 47). de esto se desprende que la formación de enfermeras/os debe incluir el desarrollo de conocimientos, habilidades y actitudes que le permitan desarrollar estos estilos de liderazgo en el ejercicio laboral y así potenciar la función de gestión en el rol profesional. se destaca que hay concordancia en que la adquisición de habilidades basadas en la experiencia es fundamental. además, si se producen a partir de una base educativa sólida será más efectivo el logro de la competencia (26). respecto al nivel de importancia de la gestión y el liderazgo de enfermería las funciones relacionadas con administración aparecen con la segunda frecuencia de uso, después del rol de cuidados; son descritas como cuidados indirectos, es decir, acciones que apoyan la eficacia de las intervenciones directas de enfermería que se realizan lejos del usuario pero dirigidas a su beneficio. incluye acciones de cuidado dirigidas al ambiente y la colaboración interdisciplinaria (38, 48, 49). los estudios que priorizan las competencias de gestión coinciden en colocar entre las más importantes: comunicación, trabajo en equipo, habilidades interpersonales, habilidades de liderazgo y resolución de conflictos. en las competencias de liderazgo destacan el dominio personal, efectividad interpersonal, la gestión financiera y de recursos humanos y los sistemas de pensamiento (2, 50, 53, 54, 57). los autores que estudian las competencias de liderazgo y gestión en enfermería identifican las competencias específicas más que las genéricas, utilizando varios métodos de recolección de la información. las competencias son dinámicas, deben modificarse a medida que se producen cambios en las necesidades de cuidados de la salud y, por ello, la formación y el desarrollo de las enfermeras/os debe estar en una continua transición y adaptación al cambio. respecto al grado de importancia se puede concluir que algunas competencias pueden ser relevantes para varias organizaciones de salud, mientras que otras son específicas para un sector particular de ellas, que difieren según el nivel de experiencia o la etapa de desarrollo del profesional que las desempeña (2, 53-60). finalmente, es importante destacar que en la actualidad se emplaza a las enfermeras a desarrollar gestión y liderazgo para construir entornos de trabajo de calidad, poner en práctica nuevos modelos de atención, y contribuir al desarrollo de una fuerza laboral de enfermería saludable (4). 93 competencias para la enfermera/o en el ámbito de gestión y administración: desafíos actuales de la profesión l paz soto-fuentes y otros. referencias 1. malvarez s. recursos humanos de enfermería: desafíos para la próxima década [internet]. washington dc; 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2000. 96 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 anexos tipo cantidad descripción artículos científicos 30 22 en inglés, 7 en español y 1 en portugués. documento técnicos 24 11 en inglés y 13 en español organizaciones internacionales: cie, ops, oit, ocde ministerios de salud y del trabajo de chile asociaciones de enfermeras de canadá, australia, estados unidos y reino unido libros 06 teorías y modelos de enfermería, competencias de egreso y laborales, administración, administración en enfermería y gestión hospitalaria total 60 tabla 1. descripción de bibliografía por tipo de manuscrito tabla 2. descripción de bibliografía según categoría principal categorías bibliografía descripción importancia de los recursos humanos en enfermería y su rol gestor del cuidado 1. malvarez s. recursos humanos de enfermería: desafíos para la próxima década. washington dc; organización panamericana de la salud, organización mundial de la salud: 2005. p. 1-4. documento técnico 2. national council for the professional development of nursing and midewifery, ncnm. nurse and midwife: clinical competency determination and competency development planning, toolkit. dublin: national council for the professional development of nursing and midewifery; 2010. documento técnico 3. ibarra mx. aspectos cualitativos en la actividad gestora de los cuidados enfermeros. cultura de los cuidados. 2006;10(20):147-152. artículo científico 4. international council of nursing (cie). declaración de posición del cie: gestión de los servicios de enfermería y atención de salud. ginebra: cie; 2000. documento técnico 5. ministerio de salud de chile. norma general administrativa n° 19 gestión del cuidado de enfermería para la atención cerrada. resolución exenta n° 1127 14.12.2007. santiago: ministerio de salud; 2007. documento técnico 6. stefo s, paravic t. enfermería en el rol de gestora de los cuidados. cienc enferm. 2010;16(3):33-39. artículo científico 7. milos p, bórquez b, larraín a. la "gestión del cuidado" en la legislación chilena: interpretación y alcance. cienc enferm. 2010;16(1):17-29. artículo científico 8. kerouac s, jacinthe p, ducharme f. duquette a, major f. el pensamiento enfermero. madrid: elsevier masson; 1996. artículo científico 9. ceballos p. desde los ámbitos de enfermería, analizando el cuidado humanizado. cienc enferm. 2010;16(1):31-35. artículo científico 10. leninger m. cultura de los cuidados: teoría de la diversidad y de la universidad. en marriener a, alligood m. editores. modelos y teorías de enfermería. barcelona: elsevier science – mosby; 2003. p. 507-212. capítulo de libro 97 competencias para la enfermera/o en el ámbito de gestión y administración: desafíos actuales de la profesión l paz soto-fuentes y otros. categorías bibliografía descripción competencias de egreso y su relación con las competencias laborales 11. le boterf g. ingeniería de las competencias. barcelona: gestión 2000; 2001. capítulo de libro 12. cano me. la evaluación por competencias en la educación superior. profesorado. revista de curriculum y formación de profesorado. 2008;12(3):1-16. artículo científico 13. perrenoud p. diez nuevas competencias para enseñar. 2 ed. barcelona: graó; 2004. capítulo de libro 14. vargas f. 40 preguntas sobre competencia laboral. significados atribuídos ao líder na visão de enfermeiras. montevideo: cintefor-oit; 2004. documento técnico 15. meretoja r, leino-kilpi h, kaira am. comparison of nurse competence in different hospital work environments. j nurs manag. 2004;12(5):329-36. artículo científico 16. centro interuniversitario de desarrollo cinda. competencias de egresados en colección gestión universitaria. santiago: alfabeta artes gráficas; 2004. artículo científico 17. larraín a, gonzález l. formación universitaria por competencias. artículo científico 18. bunk, g. la transmisión de las competencias en la formación y perfeccionamiento profesionales en la rfa. revista europea de formación profesional. 1994;1(1):1-14. documento técnico 19. ministerio del trabajo de chile. nota de prensa a propósito del trámite de la ley sobre el sistema nacional de certificación de competencias en 2004. documento técnico 20. gonzález j, wagenaar r. tuning educational structures in europe: informe final, fase uno. bilbao: universidad de deusto; 2003. p. 60-80. documento técnico 21. organización para la cooperación y el desarrollo económico. proyectos sobre competencias en el contexto de la ocde: análisis de base teórica y conceptual. neuchâtel: organización para la cooperación y el desarrollo económico; 1999. documento técnico 22. ducci ma. el enfoque de competencia laboral en la perspectiva internacional. en oficina internacional del trabajo. editor. formación basada en competencia laboral: situación actual y perspectivas. montevideo: cinterfor/oit; 1997. p. 18-20. documento técnico 23. ministerio de trabajo y asuntos sociales. real decreto 797/1995. madrid: ministerio de trabajo y asuntos sociales; 1995. documento técnico 24. consejo internacional de enfermeras cie. la iniciativa del análisis mundial de la enfermería: desarrollo de la reglamentación, las funciones y la competencia. documento temático. ginebra: cie; 2006. documento técnico 25. cathcart eb, greenspan m, quin m. the making of a nurse manager: the role of experiential learning in leadership. j nurs manag. 2010;18(4):440-7. documento técnico 26. benner p. novice to expert. am j nurs. 1982;82(3):402-7. artículo científico 27. meretoja r, eriksson e, leino-kilpi h. indicators for competent nursing practice. j nurs manag. 2002;10(2):95-102. artículo científico 28. tabari r, kiger a, parsa, ahmadi f. competence development among nurses: the process of constant interaction. j contin educ nurs. 2007;38(5),211-8. artículo científico 98 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 categorías bibliografía descripción requerimientos actuales para el desempeño de la enfermera/o en el ámbito de gestión y administración 29. malvarez s, castrillón mc. panorama de la fuerza de trabajo en enfermería en américa latina. en organización panamericana de la salud, editor. serie desarrollo de recursos humanos. washington d.c.: organización panamericana de la salud; 2005. documento técnico 30. reid uv, weller b. nursing human resources planning and management competencies. ginebra: canadian nurses association; 2010. artículo científico 31. reid kb, dennison p. the clinical nurse leader (cnl) (r): point of care safety clinician. j issues nurs. 2011;16(3):4. artículo científico 32. supamanee t, krairiksh m, singhakhumfu, l, turale s. preliminary clinical nursing leadership competency model: a qualitative study from thailand. nurs health sci. 2011;13(4):433-9. artículo científico 33. kirk h. factors identified by nurse executive directors as important to their success. j nurs manag. 2009;17(8):956-64. artículo científico 34. ministerio de salud de chile. estrategia nacional de salud 2011-2020. santiago: ministerio de salud; 2006. documento técnico 35. pérez j, garcía j, tejedor m. gestión clínica: conceptos y metodología de implantación. rev calidad asistencial. 2002;17(5):305-11. artículo científico 36. royal college of nursing. defining nursing london: royal college of nursing; 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2003. p. 1-5. documento técnico 58. australian government department of health. ageing and managed by the australian nursing federation. competency standars for the advance enrolled nurse. australian nursing federation; 2005. documento técnico 59. campbell b, mackay g. continuing competence: an ontario nursing regulatory programme that supports nurses and employers. nurs adm q. 2001;25(2),22-30. artículo científico 60. canadian nurses association. a national framework for continuing competence programmes for registered nurses. ottawa: canadian nurses association; 2000. documento técnico 183 193 integracion de la medicina.indd 183 manuel ignacio pinto-barrero1 paola ruiz-díaz2 integración de la medicina alternativa en los servicios de salud de colombia 1 médico cirujano. universidad javeriana. director unidad materno-infantil hospital de tunjuelito, bogotá, colombia. manuelpinto52@yahoo.es, manuelpinto58@gmail.com 2 médico cirujano. universidad nacional de colombia, colombia. pruizd@unal.edu.co recibido: 9 de febrero de 2012 aceptado: 29 de junio de 2012 resumen objetivo: presentar, mediante el análisis de la literatura, el avance de la integración de la medicina alternativa y complementaria en la prestación de servicios de salud en colombia y que corresponde a la tendencia mundial en este sentido, lo cual es coherente con la “estrategia de la oms 2002-2005” que comprende cuatro objetivos: 1) integrar la medicina tradicional y la medicina alternativa y complementaria; 2) promover la seguridad, eficacia y calidad de la mt/mac; 3) aumentar la disponibilidad y asequibilidad de la mt/mac con énfasis en las poblaciones más pobres, y 4) fomentar el uso terapéutico sólido de la mt/mac por parte de consumidores y proveedores. método: estudio descriptivo basado en artículos encontrados en las bases de datos scielo, bireme, medline y pubmed para evaluar la integración de la mac en los servicios de salud en colombia, argentina, brasil y méxico. resultados: el uso de las mac se ha hecho frecuente en el mundo. pacientes, médicos y otros profesionales de la salud las consideran como opción para utilizarlas como tratamiento complementario o como otra forma de tratar a sus pacientes. conclusión: un modelo de atención en salud que incluya las mac puede traer ventajas sobre la humanización de la atención, costos de los medicamentos y uso de servicios de alta complejidad. es necesario realizar trabajos tendentes a evaluar esta inclusión y desarrollar espacios académicos y de formación en este campo. palabras clave terapias complementarias, prestación de atención de salud, servicios de salud. (fuente: decs, bireme). the integration of alternative medicine into colombian health care services abstract objective: to demonstrate, through an analysis of literature, the progress being made towards integrating alternative and complementary medicine into the delivery of health care services in colombia, pursuant to the worldwide trend in this respect, which is coherent with the who strategy for 2002-2005. that strategy has four objectives: 1) integrate traditional medicine and alternative and complementary medicine; 2) promote the safety, effectiveness and quality of tm/acm; 3) increase the availability and accessibility of tm/acm, with año 12 vol. 12 nº 2 chía, colombia agosto 2012 l 183-193 184 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 an emphasis on the poorest population groups; and 4) encourage sound therapeutic use of tm/acm by consumers and suppliers alike. method: this is a descriptive study based on articles found in the scielo, bireme, medline and pubmedpara databases to assess acm integration into health care services in colombia, argentina, brazil and mexico. results: the use of acm has become common throughout the world. patients, physicians and other health care professionals regard it as an option to be used as complementary therapy or another way to treat their patients. conclusion: a healthcare model that includes acm can offer advantages when it comes to more humanized care, the cost of medication and the use of highly complex services. further work is needed to evaluate this integration and to develop academic and training instances in this field. key words complementary therapies, delivery of health care, health services. (source: decs, bireme). integração da medicina alternativa nos serviços de saúde da colômbia resumo objetivo: apresentar, mediante a análise da literatura, o avanço da integração da medicina alternativa e complementar na prestação de serviços de saúde na colômbia. esse avanço corresponde à tendência mundial e está coerente com a “estratégia da oms 2002-2005”, que compreende quatro objetivos: 1) integrar a medicina tradicional e a medicina alternativa e complementar; 2) promover a segurança, eficácia e qualidade da mt/mac ; 3) aumentar a disponibilidade e acessibilidade da mt/mac com ênfase nas populações mais pobres, e 4) fomentar o uso terapêutico sólido da mt/mac por parte de consumidores e fornecedores. método: estudo descritivo baseado em artigos das bases de dados scielo, bireme, medline e pubmed para avaliar a integração da mac nos serviços de saúde na colômbia, argentina, brasil e méxico. resultados: o uso das mac se tornaram frequentes no mundo. pacientes, médicos e outros profissionais da saúde as consideram como opção para utilizá-las como tratamento complementar ou como outra forma de tratar seus pacientes. conclusão: um modelo de atendimento em saúde que inclua as mac pode trazer vantagens para a sua humanização, para os custos dos medicamentos e para o uso de serviços de alta complexidade. é necessário realizar trabalhos tendentes a avaliar essa inclusão e desenvolver espaços acadêmicos e de formação neste campo. palavras-chave terapias complementares, assistência à saúde, serviços de saúde. (fonte: decs, bireme). 185 integración de la medicina alternativa en los servicios de salud de colombia l manuel ignacio pinto-barrero, paola ruiz-díaz introducción según la organización mundial de la salud (oms), la medicina tradicional (mt) y la medicina alternativa y complementaria (mac) se definen como el “grupo de prácticas sanitarias que no forman parte de la tradición de un país o no están integradas en su sistema sanitario prevaleciente”. el término de medicina complementaria, a su vez, se refiere a las terapias o los tratamientos que son usadas de manera suplementaria a la medicina alopática (1). la medicina alternativa se utiliza en lugar de la medicina alopática y se entiende como aquellas técnicas, prácticas, procedimientos, enfoques o conocimientos que utilizan la estimulación del funcionamiento de las leyes naturales para la autorregulación del ser humano con el objeto de promover, prevenir, tratar y rehabilitar la salud de la población desde un pensamiento holístico. se consideran como medicinas alternativas la medicina homeopática, la tradicional china y la medicina ayurveda. dentro de las terapias alternativas se señalan, entre otras, la herbología, terapias manuales, ejercicios terapéuticos, enfoque sobre mente-cuerpo, terapias biológicas, terapias a partir de la energía como concepto genérico, puesto que se habla, por ejemplo, de que se puede interpretar y estudiar a los seres humanos como una organización de “energías biológicas” (bioenergías) según la bioenergética, de la energía vital según la homeopatía, de regulación de la corriente energética dentro de un sistema de circulación en el cuerpo (los meridianos) según la acupuntura, entre otras (2). en el caso colombiano, la mt comprende lo que se ha denominado medicina tradicional indígena colombiana (1, 2). para el tema planteado en esta revisión no se tiene en cuenta la medicina tradicional, y solamente se consideran las medicinas alternativas y complementarias. en colombia, la ley 1164-2007 de talento humano tiene por objeto establecer las disposiciones relacionadas con los procesos de planeación, formación, vigilancia y control del ejercicio, el desempeño y la ética del talento humano del área de la salud, mediante la articulación de los diferentes actores que intervienen en estos procesos. establece diferencias entre medicinas y terapias, así: “se consideran medicinas alternativas, entre otras, la medicina tradicional china, medicina ayurveda, medicina naturopática y la medicina homeopática; dentro de las terapias alternativas y complementarias se consideran, entre otras, la herbología, acupuntura, moxibustión, terapias manuales y ejercicios terapéuticos” (3). de acuerdo con las definiciones consignadas, la formación en las medicinas alternativas tales como la homeopatía y la medicina tradicional china, definidas como sistemas médicos complejos, se considera que deben ser exclusivamente para médicos con título obtenido en universidad reconocida. las terapias alternativas, por el contrario, pueden ser ejercidas por otros profesionales de la salud. método el propósito de este trabajo fue realizar una evaluación de artículos siguiendo los principios de la investigación descriptiva. los artículos revisados fueron identificados a través de las bases de datos scielo, bireme, medline y pubmed, y se incluyeron aquellos que hubieran sido publicados desde el 2005 hasta el 2011, desarrollados en colombia, argentina, brasil y méxico. los criterios para la selección de los artículos fueron: 1) su relación directa con el análisis de los efectos de las mac; 2) los avances que se demuestran en colombia y otros países latinoamericanos como argentina, brasil, méxico y chile con la utilización de la mac en la prestación de los servicios de salud; 3) artículos que presentaran el análisis de oferta y demanda en este tipo de medicina; 4) estudios de resultados de encuestas de calidad de vida y calidad de servicios de salud en colombia. para cumplir con el propósito del artículo se revisó el patrón de uso en el mundo, particularmente en algunos países latinoamericanos —argentina, brasil, méxico—, el marco legal para su práctica en colombia, las ventajas que se obtienen con su uso dentro de la prestación de servicios de salud y, finalmente, se presenta un modelo integral de aplicación dentro del sistema de salud. análisis e interpretación de la información se identificaron 39 artículos que exploraban la integración de las mac en aspectos como frecuencia de uso, preferencias y tipos de consulta. la frecuencia de uso de las mac es un indicador de qué tanto comienza a integrarse esta medicina con los servicios de salud en un país. en 1990, alrededor del 34 % de la población en estados unidos utilizaba los servicios de medicina alternativa, y para 1997 aumentó al 47 % (4, 5). los estudios muestran que cada año la población gasta más de 13 millones de dólares en servicios y tratamientos de las mac, lo cual es reflejo de la importancia que han tomado estos servicios en la sociedad estadounidense (6). existe poca información sobre la prevalencia del uso de las mac en países latinoamericanos; en chile y colombia el 70 y 40 % de la población respectivamente son usuarios de algún tipo de medicina tradicional o alternativa (7). en canadá el 70 % de la población ha utilizado una de estas medicinas al menos una vez; en francia el 186 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 49 %; en australia el 48 % y en bélgica el 70 %; en el resto de europa el uso de estas prácticas oscila entre el 20 y el 70 %. según la oms, el 80 % de los servicios de salud en el mundo en vías de desarrollo son de medicina complementaria (2). aspectos culturales de los pacientes se han estudiado algunos de los factores que motivan a las personas a acudir a los servicios de mac. las razones que con mayor frecuencia se mencionan son: la creencia en que los tratamientos convencionales no serán efectivos o son muy costosos, el interés que despierta la medicina alternativa y la recomendación que se hace por el médico tratante (8). es decir, las actitudes de los médicos alópatas hacia la mac pueden afectar la percepción y el uso que hagan las personas de esta medicina. la multiculturalidad y plurietnicidad de los países latinoamericanos se ve reflejada en la diversidad de sistemas médicos existentes. las prácticas propias de la medicina tradicional son un recurso buscado por muchas personas, especialmente las de estratos bajos. la mac es buscada por personas de estratos superiores y su uso está vinculado a la búsqueda de tratamientos integrales para las enfermedades y a la insatisfacción que algunas personas sienten frente a las características de la medicina occidental y el sistema de salud colombiano (9). aspectos cultuales de los médicos el tema de las actitudes de los profesionales médicos acerca de la mac ha mostrado resultados interesantes, y da luces sobre cómo estos pueden modificar el patrón de uso de ellas. un estudio realizado en estudiantes de medicina mostró que ellos responden de manera positiva ante sus principios conceptuales y menos positivamente a los tratamientos que se derivan de las mismas (10). otro estudio en pediatras documentó que existe un importante desconocimiento y ese factor era predictor de las actitudes hacia estas, es decir, a menor conocimiento actitudes más negativas. igualmente, el desconocimiento y las actitudes adversas tenían un impacto negativo sobre la recomendación de los servicios de estas medicinas (11). un estudio en colombia encontró que los conocimientos son bajos solo en el 15% de los médicos de atención primaria, y el 72% tenían una actitud favorable. no obstante estas actitudes, una baja proporción de estos médicos refería a sus pacientes a servicios de la mac (12). el médico occidental no se complementa con el saber de otros sistemas y prácticas porque los desconoce, duda de su eficacia, los subvalora, y cree que su medicina —siendo “la medicina”— no necesita ser complementada por otras. ignora y le da poca importancia al papel de lo emocional, lo social y lo cultural en el proceso salud/enfermedad. de la iniciativa del terapeuta, quien puede complementar o definir uno u otro tratamiento ya sea remitiendo al paciente, o haciéndolo él mismo si maneja más de una alternativa terapéutica como la homeopatía, la acupuntura, la terapia neural, la bioenergética y la quiropráctica, además de satisfacer la necesidad de oferta, depende una atención integral y en ocasiones más eficaz que la utilización de una sola alternativa (13). tipos de consulta una buena proporción de las personas que acuden a los servicios de medicina alternativa tiene enfermedades crónicas, incurables, y para las cuales el tratamiento convencional requiere del consumo de muchos medicamentos que tienen importantes reacciones adversas. los pacientes asisten a los servicios de la mac por enfermedades como la artritis, artrosis, cuadros de dolor crónico, hipertensión arterial y diabetes (14), ansiedad, depresión, obesidad, dolores de espalda, columna, dolor lumbar, alergias, contracturas, trastornos menstruales, cefaleas, asma, trastornos digestivos y enfermedades de la tiroides, entre otras (15). de otro lado, se realizó un estudio para establecer factores predictores del uso de la mac en pacientes con cuadros de dolor crónico y se encontró que su uso aumenta con factores como el pobre manejo del dolor, mayor severidad de la enfermedad y mayor limitación funcional comparados con aquellos individuos que no requirieron servicios de medicina alternativa. también se asoció el uso con una mayor edad y un alto nivel educativo del usuario (3). marco legal para el ejercicio y la educación de la mac en colombia, con la resolución 2997 de 1998 se empieza a tener en cuenta y a reglamentar la práctica de terapias alternativas, a partir de entonces se han venido generando cambios en el desarrollo y la aceptación de estas prácticas incluyendo otras normas relacionadas tales como: la resolución 1896 de 2001 que incluye en la clasificación única de procedimientos en salud (cups) la consulta de terapias alternativas; la sentencia t-206 de 2004 de la corte constitucional que confirma los requisitos para prestar servicios de medicinas alternativas, en particular el servicio de medicina por el sistema homeopático, y quienes lo presten deben 187 integración de la medicina alternativa en los servicios de salud de colombia l manuel ignacio pinto-barrero, paola ruiz-díaz contar con título profesional de medicina expedido por una universidad reconocida por el estado, encontrarse inscrito en el registro profesional de cada ente territorial donde oferte el servicio, y cumplir con el proceso de habilitación establecido en el decreto 2309 y la resolución 1439 de 2002; finalmente, la ley 1164 del 3 de octubre del 2007 dicta disposiciones en materia del talento humano en salud, crea el consejo nacional de talento humano en salud, y los siguientes comités: un comité por cada disciplina profesional del área de la salud, comité de talento humano en salud ocupacional, comité de las culturas médicas tradicionales, comité para las medicinas y terapias alternativas y complementarias, comité de ética y bioética, y los demás comités que el consejo nacional del talento humano en salud considere pertinentes para el cumplimiento de sus funciones. por su parte, según el artículo 19, que trata del ejercicio de las medicinas y terapias alternativas y complementarias: los profesionales autorizados para ejercer una profesión del área de la salud podrán utilizar la medicina alternativa y los procedimientos de las terapias alternativas y complementarias en el ámbito de sus disciplinas para lo cual deberán acreditar la respectiva certificación académica de esa norma de competencia expedida por una institución de educación superior legalmente reconocida por el estado. las ocupaciones del área de la salud de acuerdo con la respectiva certificación académica podrán ejercer las diferentes actividades funcionales de apoyo y complementación a la atención en salud que en materia de medicina y terapias alternativas y complementarias sean definidas. esta ley fue aprobada con el objetivo de regular aspectos relacionados con el ejercicio profesional en el área de la salud que habían sido descuidados en la ley 100 del año 1993, con la cual entró en vigencia el modelo de sistema de salud vigente en la actualidad (16). a través de esta ley se da un paso importante en la institucionalización y el reconocimiento de la mac puesto que se establece el marco regulador en colombia para el ejercicio profesional. es decir, tomando como referencia lo establecido en la ley de talento humano del área de la salud, para ejercer la medicina alternativa en colombia en lo que se refiere a los considerados sistemas médicos —homeopatía, medicina tradicional china, ayurveda— se hace necesario ser médico y haber realizado estudios de posgrado con especialización o maestría en un programa académico reconocido por el ministerio de educación nacional; sin embargo, el ejercicio de algunas de las consideradas terapias alternativas como: magnetoterapia, reiki, meditación, color terapia, esencias florales, masajes, quiropráctica, suplementos dietéticos, actividades creativas que emplean el arte, la música, la danza, la oración, puede realizarlo otro profesional de la salud (14). como puede apreciarse, todo este marco legal presentado establece criterios claros para el ejercicio profesional de las mac. este es un paso fundamental para avanzar dentro del proceso de integración de estas medicinas en los servicios de salud. formación la ley de talento humano plantea cambios en la estructuración de los programas académicos de manera tal que se garantice, según el nivel de formación, la mejora continua, las competencias, la calidad y el enfoque de contenidos e intensidad de los programas de educación en el ramo de la mac. a través de una investigación realizada recientemente se encontró que en colombia existen solo tres programas académicos de formación posgraduada en medicina alternativa que cumplen los requisitos de ley y están reconocidos por el ministerio de educación nacional (17). sin embargo, no todos estos programas académicos muestran la homogeneidad y calidad que se contempla a través del marco jurídico comprometiéndose en algunos casos la integralidad en el ejercicio de la mac (18, 19). la facultad de medicina de la universidad nacional de colombia tiene establecido el programa de maestría en medicina alternativa para médicos en las aéreas de homeopatía, medicina tradicional china y acupuntura, terapia neural y osteopatía; la universidad juan n. corpas ofrece la especialización en medicina alternativa y fitoterapia, y la universidad manuela beltrán la especialidad en terapias alternativas para profesionales de salud. complementariedad entre la mac y la medicina convencional en el sistema convencional la persona que necesita una consulta médica debe someterse a una serie de pasos (solicitud de citas para consulta médica, tiempos de asignación de la atención médica prolongados y realización de exámenes complementarios costosos, procedimientos de apoyo terapéutico y medicamentos no contemplados en el plan obligatorio de salud pos, disputas legales para confirmar sus derechos, tiempo de atención corto) que se constituyen algunas veces en una barrera de acceso y que se dan en un marco de atención dirigido a la enfermedad, no basado en las necesidades de los pacientes (20). estos problemas 188 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 lesionan de manera importante la forma como se construye la relación médico-paciente, la cual constituye un indicador de calidad en la prestación de los servicios de salud y es importante dentro de la adaptación y recuperación de los pacientes en sus enfermedades (21, 22). la insatisfacción de las personas con el servicio de salud convencional tiene relación con su preferencia por una visión holística, con elementos relacionados con la consulta médica, mayor confianza en los remedios naturales o temor hacia el uso de los medicamentos alopáticos, creencias en la responsabilidad individual y deterioro de la relación médico-paciente (23). el efecto placebo de la atención médica, que incluye la amabilidad y la calidez humana como base principal de esta relación, a menudo no es favorable y lesiona gravemente el objetivo de la atención humanizada de todas las personas (24). en la atención brindada en la mac, por su parte, el paciente es escuchado no solamente por el síntoma motivo de consulta, sino que se le enfoca de manera holística en sus sistemas biológico, mental, emocional y social, y en ese contexto se da la intervención, situación que descrita desde el punto de vista del usuario se refleja en una satisfacción por cuanto se siente reconocido y tratado de manera integral (25). a pesar de la hegemonía de la medicina occidental en términos de políticas y programas, otras alternativas terapéuticas como la homeopatía, la acupuntura y la medicina tradicional son utilizadas de manera creciente con mayor o menor intensidad, dependiendo de diferentes factores sociales. en nuestras sociedades latinoamericanas, la búsqueda de nuevas opciones de terapia en todos los estratos sociales obedece a las limitaciones de la medicina alopática tales como falta de accesibilidad, su limitada eficacia para tratar algunas enfermedades crónicas, o aquellas con fuertes componentes psicológicos. esta búsqueda también ha sido una respuesta al temor por los efectos adversos de los medicamentos, a la burocratización y despersonalización de la atención, y al creciente interés en lo natural y lo ecológico (13). la integración entre estos dos enfoques de la medicina comienza a darse en el mundo y colombia no es ajena a esta situación. un buen indicador del grado de complementariedad e integración que comienza a darse entre la mac y la medicina convencional es el impacto en investigación, publicaciones, reconocimiento social y actitudes hacia la medicina alternativa por parte de los médicos, y el desarrollo de marcos legales para el ejercicio y la educación (26). el proceso de complementariedad e integración nace de manera compleja mezclando aspectos de la percepción de los pacientes, actitudes de los médicos, socialización y necesidades de salud de las poblaciones. esta integración tiene como exponentes en latinoamérica a argentina, que desde 1999 cuenta con una legislación que norma y reglamenta el uso de plantas medicinales; chile, que a través del decreto 42 de 2004 reglamentó el ejercicio de las prácticas medicas alternativas; brasil, que ha generado un marco normativo con la estructuración de una política pública para el desarrollo de la mac (27). en europa, países como alemania —líder en medicina integrativa—, inglaterra, francia y españa, entre otros, consideran a la mac en la práctica de la medicina y los servicios de salud. en estados unidos se creó desde 1998 el national center for complementary and alternative medicine, dependiente de los institutos nacionales de salud. para conseguir esta integración entre la mac y la medicina convencional, el talento humano —que como sabemos es el recurso más valioso— desempeña un papel muy importante, es por eso que la actitud y la aceptación de los médicos formados en el modelo convencional debe hacer propio este objetivo, dado que la integración dentro del sistema médico va de la mano con la aceptación por parte de los profesionales (28). la medicalización social (seguridad social) es un concepto que disuade a las personas de buscar sus propias soluciones para los problemas de salud y genera un exceso de demanda en el sistema. una alternativa de solución es la ampliación de los servicios terapéuticos de las instituciones de salud, en particular mediante el reconocimiento y la práctica de la mac. el potencial de la estrategia es limitado per se, de no ser incluido como política en un sistema único de salud. en los modelos actuales la asistencia sanitaria está dominada por los principios del mercado por lo que hay una tendencia para transformar cualquier tipo de conocimiento o práctica relacionada con el proceso salud-enfermedad en bienes o servicios para ser consumidos. la medicalización social es un fenómeno complejo que conlleva significados diferentes según el enfoque o los estudios que lo investigan, que van desde lo científico, hasta trasformaciones socioculturales y políticas relacionadas con la incorporación a la sociedad en general de un comportamiento compatible con la medicina convencional (29). el enfoque médico-clínico empezó a cambiar a mediados del siglo xix, de modo que actualmente ya es muy clara la tendencia a usar la mac en el tratamiento de una serie de enfermedades (30). esta tendencia de la medicina convencional de manejar el concepto de enfermedad relacionado con “máquina humana”, y la cual será resuelta por la química, la cirugía o la tecnología, o cuando no es ese el caso, con la adopción de un “estilo de vida saludable”, ha generado un aumento en la solicitud de exámenes de ayudas diagnósticas y terapéuticas innecesarias y, al mismo 189 integración de la medicina alternativa en los servicios de salud de colombia l manuel ignacio pinto-barrero, paola ruiz-díaz tiempo, una desvalorización de los enfoques que dan cuenta de modos de vida, valores, sentimientos y factores sociales relacionados con el proceso salud-enfermedad (31). la medicina convencional es indispensable y necesaria, pero al mismo tiempo puede ser una inadecuada “iatrogenia cultural”, quiere esto decir que por su naturaleza de segmentar al enfermo por especialidades de acuerdo con el órgano o sistema por el cual consulta principalmente, puede pasar por alto otras alteraciones que afectan la salud en igual o mayor severidad que la del motivo de consulta y, por supuesto, disminuyen en las personas su capacidad para hacer frente de manera autónoma a las situaciones de enfermedad por cuanto no se les interviene, orienta o ayuda para entender que la salud es un concepto de integralidad entre la mente, los sentimientos, las relaciones con las otras personas, la naturaleza y el cuerpo (32). las mac, integradas al sistema de salud desde la complementariedad, permitirían ofrecer aspectos del servicio como atención personalizada dentro de un contexto de globalización económica y expansión de metodologías científicas que incrementan los costos de la prestación de los servicios; por otra parte, se debe aprovechar el apoyo social por la tendencia a la mayor demanda de la mac. la homeopatía, la medicina tradicional china y la medicina ayurvédica practicadas por médicos formados dentro de la medicina convencional, pero que tienen como principio fundamental la salud y no la enfermedad, facilitan el enfoque de integración y, por tanto, son las primeras candidatas para ser incorporadas en un sistema de salud que contemple la complementariedad. esta es posible, además, porque las contradicciones entre los sistemas médicos están más cerca del arte de curar que de la enfermedad, de tal manera que se ha producido lentamente una integración que ha permitido abrir los espacios en los servicios de salud (26). el modelo de prestación de servicios existen diferentes enfoques para comprender cómo debe realizarse el proceso de integración de la mac en los sistemas de salud. en ellos se resalta la necesidad de promover los espacios de formación, investigación, análisis económico y vinculación de la atención dentro de los seguros médicos (3, 26, 33), de manera tal que el sistema de salud debe permitir una política que garantice la pluralidad terapéutica no solamente para las personas con recursos económicos que pueden acceder a servicios que no cobija el sistema sino también a los más necesitados (34, 35). la oferta de la mac en el sistema de salud debe ser defendida como un apoyo para el desarrollo sostenible de la democracia y la estrategia para la gestión antimedicalización en la construcción de la universalidad, la igualdad y la atención integral en el servicio de salud, todos estos aspectos son necesarios para garantizar atención médica de calidad (26). haciendo un análisis dofa, encontramos: debilidades: falta de evidencia científica (paradigma de la medicina basada en la evidencia) para muchas de sus indicaciones; problemas con el desarrollo y la aplicación de metodologías adecuadas para investigarlas. las terapias de la mac a menudo entran en conflicto con las bases científicas de la medicina occidental, lo que hace que los médicos las vean con desdén y escepticismo (36). son escasos los datos resultantes de ensayos científicos destinados a evaluar la seguridad y eficacia de la mac comparados con la gran cantidad de estudios de medicina basada en la evidencia de la medicina convencional. oportunidades: a pesar de esto, y teniendo en cuenta las oportunidades que representa la mac para favorecer la salud de las poblaciones en el mundo, la oms ha resaltado la necesidad imperativa de los gobiernos de impulsar desde la política pública en salud el marco reglamentario y normativo que garantice el uso apropiado, seguro y efectivo de estas medicinas. además, debe impulsarse su integración progresiva dentro los sistemas nacionales de salud (37). el compromiso de la oms consiste en facilitar información técnica y general para que se utilice de manera segura, eficaz y sostenible. entre los resultados esperados por la oms en el marco de esta estrategia figuran: formación básica en terapias de mt/mac más comúnmente utilizadas para practicantes alopáticos, formación básica en atención sanitaria primaria para practicantes de mt, información fiable a los consumidores sobre el uso correcto de terapias de mt/mac, mejora de la comunicación entre los practicantes alopáticos y sus pacientes respecto al uso de mt/mac (1). fortalezas: la mac ha sido utilizada como parte del tratamiento de muchas enfermedades y eventos adversos relacionados con los tratamientos convencionales; poco a poco comienza a integrarse su uso en los países occidentales y en particular en los países latinoamericanos (1, 26). el interés por la integración de la mac en el mundo occidental se ha visto reflejado con el aumento en el número de grupos de investigación, publicaciones al año y recursos destinados para la investigación en este campo (38, 39). la utilización de la medicina holística va más allá de la formula tripartita occidental de considerar los aspectos biopsicosociales 190 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 de la salud y toma en cuenta, en todo diagnóstico, aspectos espirituales. de todo lo anterior ha surgido, según el national center for complementary and alternative medicine, la medicina integrativa, que combina las terapias formales con las complementarias y alternativas,dado que el todo parece tener propiedades que cada uno de estos tipos de medicina no posee por separado, para las cuales existen datos científicos de alta calidad sobre su seguridad y eficacia. tomar en cuenta esta medicina integrativa al menos puede coadyuvar al gran objetivo de humanizar nuestra práctica médica, la medicina convencional puede mejorar si imitamos a la mac, al menos, en la atención cuidadosa que resulta de emplear más tiempo con nuestros pacientes y mejorar el acercamiento con ellos por medio de un lenguaje más comprensivo (36). amenazas: no hay muchos países que cuenten con una política nacional en la materia (1). existen falencias en los parámetros legales de muchos países para su ejercicio profesional y la percepción por parte de numerosos profesionales, pacientes y familiares de que se libra una batalla constante por demostrar la hegemonía y perfección entre estos dos enfoques de la medicina (40-42). la estructura del modelo de prestación de servicios integrado contempla la definición de una política que incluya en los diferentes sectores —público, seguridad social y privado— aspectos del análisis de la atención médica tales como: la oportunidad para la consulta; el tiempo dedicado a esta; relación médico-paciente en ambos tipos de práctica; cumplimiento de estándares de habilitación y de acreditación; análisis de costos, riesgos y beneficios de ambos tipos de práctica, definición de los campos de cada práctica, y financiamiento de la atención en salud pública y de seguridad social. estos son elementos que han mostrado ser necesarios y útiles dentro la estructuración de diferentes modelos de atención en salud basados en el mejoramiento continuo de la calidad en el servicio (43). las instituciones prestadoras de servicios deben incluir en sus portafolios la mac, para ello se debe tener en cuenta el tiempo designado para la atención, el cumplimiento de todos los requisitos de habilitación establecidos en la norma correspondiente, una política institucional de calidad que incluya un plan de acción para el cumplimiento de estándares de calidad y logro de la acreditación, y ajustes en los procesos y procedimientos de atención. los profesionales de la salud que prestan servicios mac deben asegurar en primer lugar, y como requisito indispensable, tener la formación exigida por la ley; en segundo lugar, deben preocuparse por desarrollar la promoción de la mac en todos los niveles del equipo de salud, desarrollar la investigación y participar activamente en la estructuración de la política de inclusión de esta medicina en la prestación de los servicios de salud. asegurar el cumplimiento de las normas vigentes en materia de habilitación para la prestación de servicios de salud con unas condiciones óptimas en las instalaciones y los consultorios que les permitan ejercer sin dificultades, establecidas en el sistema único de habilitación. resoluciones: 1043 de 2006, 2608 y 3763 de 2007 del ministerio de la protección social (44-50). los pacientes y usuarios del servicio deben asegurar espacios de participación para que puedan intervenir en la definición de las políticas, en las condiciones en que se le van a prestar los servicios y, en general, en todos sus derechos en especial el respeto a su autonomía para solicitar la consulta y el tratamiento con la mac y también sus deberes (51). es posible y necesario la creación de un modelo de atención incluyente con espacio para la mac, que tenga como centro de interés el bienestar del paciente; en el organizacional, deberán abrirse cada vez más espacios institucionales concretos en los cuales se ofrezcan diferentes mac usualmente utilizados, que sean evaluadas y monitoreadas en su calidad, eficacia y seguridad, y vayan abriendo el paradigma de una sola práctica médica que integre institucionalmente las opciones que se requieran de acuerdo con la cultura y los padecimientos propios de la población por atender y ejercida por terapeutas que garanticen su idoneidad (3). conclusiones el creciente interés por la medicina alternativa complementaria se da desde instituciones importantes en el mundo en temas de salud y por profesionales de la salud haciendo necesaria su integración a los servicios médicos. la no integración de la mac al sistema general de aseguramiento supone barreras de acceso a los servicios para las personas de escasos recursos y les limita la oportunidad de acceder a una alternativa terapéutica válida. en colombia la normatividad reconoce la existencia de la mac y limita su ejercicio a los médicos para la homeopatía, la medicina tradicional china y la ayurveda. se reconoce además la necesidad de capacitación en el tema a través de instituciones de educación superior reconocidas por el ministerio de educación nacional. otras terapias alternativas complementarias pueden ser ejercidas por profesionales en las diferentes áreas de las ciencias de la salud. la integración de la mac en el sistema de salud permitirá 191 integración de la medicina alternativa en los servicios de salud 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2007. 45. resolución 3763 de 2007. por la cual se modifican parcialmente las resoluciones 1043 y 1448 de 2006 y la resolución 2680 de 2007 y se dictan otras disposición. diario oficial 46791; 2007. 46. resolución 1445 de 2006. por la cual se definen las funciones de la entidad acreditadora y se adoptan otras disposiciones. diario oficial 46271; 2006. 47. resolución 3960 de 2008. por la cual se modifica parcialmente la resolución 1445 de 2006 y los anexos técnicos. diario oficial 47152; 2008. 48. decreto 2309 de 2002. por el cual se define el sistema obligatorio de garantía de calidad de la atención de salud del sistema general de seguridad social en salud. diario oficial 44967; 2002. 49. decreto 1011 del 2006. por el cual se establece el sistema obligatorio de garantía de calidad de la atención de salud del sistema general de seguridad social en salud. diario oficial 46230; 2006. 50. ernst e, hung sk great expectations: what do patients using complementary and alternative medicine hope for? patient 2011; 4 (2): 89-101. 51. montes de oca-rosas d, montes de oca-fernández e. la medicina alternativa y complementaria, una opción institucional instituto mexicano del seguro social 2005; 59 (6): 385-388. adaptation to high-risk childbearing: extension of a preliminary situation-specific theory with focus on psychological state and functional status articles  adaptation to high-risk childbearing: extension of a preliminary situation-specific theory with focus on psychological state and functional status* adaptación a la maternidad de alto riesgo: ampliación de una teoría preliminar de situación específica con enfoque en la condición psicológica y el estado funcional** adaptação à maternidade de alto risco: ampliação de uma teoria preliminar de situação específica com foco na condição psicológica e no estado funcional*** 10.5294/aqui.2023.23.1.8  jacqueline fawcett1 lorraine tulman2 jennifer morgan3 1 0000-0002-1091-8873 university of massachusetts boston,  department of nursing, united states of america jacqueline.fawcett@umb.edu 2 0000-0002-1579-0602 university of pennsylvania, school of nursing (retired), united states of america tulman@nursing.upenn.edu 3 0000-0003-2988-1684  university of massachusetts boston,  department of nursing,  united states of america jennifer.morgan002@umb.edu * funding: the data analyses and writing of this paper were supported by an ann kibrick research award granted to jacqueline fawcett by theta alpha chapter of sigma theta tau international. ** financiación: los análisis de datos y escritura de este artículo fueron apoyadas por el ann kibrick research award concedido a jacqueline fawcett por theta alpha chapter of sigma theta tau international. *** financiamento: as análises de dados e a elaboração deste artigo foram apoiadas pelo prêmio de pesquisa de ann kibrick, concedido a jacqueline fawcett, por theta alpha center de sigma theta tau international. theme: epistemology, confrontation, and adaptation of health contribution to the discipline: this study was guided by the roy adaptation model. the findings represent the extension of a preliminary situation-specific theory of adaptation to high-risk childbearing. received: 28/10/2022 submitted to peers: 05/12/2022 accepted by peers: 27/11/2022 approved: 10/02/2023 para citar este artículo / to reference this article / para citar este artigo: fawcett j, tulman l, morgan j. adaptation to high-risk childbearing: extension of a preliminary situation-specific theory with focus on psychological state and functional status. aquichan. 2023;23(1):e2318. doi: https://doi.org/10.5294/aqui.2023.23.1.8 abstract introduction: little is known about expectant and new parents’ psychological experiences of high-risk childbearing. objective: the paper is a report analyses of data from a roy adaptation model-guided pilot study of women’s and their male partners’ adaptation to high-risk childbearing and thereby extends a preliminary situation-specific theory of adaptation to high-risk childbearing. materials and methods: a previous paper was a comprehensive report of the results of the pilot study except for psychological state, measured by the multiple affect adjective checklist-revised. the additional data analyses reported in this paper are for effect sizes of correlations between the multiple affect adjective checklist-revised subscales and maternal and paternal functional status inventories. results: correlations of small (r = 0.1), medium (r = 0.3), and large (r = 0.5) effect sizes were found for the measures of psychological state and functional status for both women and their male partners except for psychological state positive affect and maternal functional status during the postpartum, and psychological state anxiety and paternal functional status during the postpartum. conclusions: overall, no substantial differences were found in psychological state and functional status for women and their male partners during pregnancy and the postpartum. the findings of this secondary data analysis constitute an extension of the preliminary situation-specific theory reported in a previously published paper. keywords (source: decs): nursing theory; pregnancy; nursing; pregnancy, high-risk; functional status. resumen introducción: poco se conoce sobre las experiencias psicológicas de los futuros y nuevos padres en la maternidad de alto riesgo. objetivo: dar a conocer unos análisis de datos adicionales a partir de un estudio piloto guiado por el modelo de adaptación de roy sobre la adaptación de las mujeres y sus parejas masculinas a la maternidad de alto riesgo y, por lo tanto, ampliar una teoría preliminar de situación específica de la adaptación a la maternidad de alto riesgo. materiales y métodos: el artículo previo fue un informe completo de los resultados del estudio piloto, excepto por la condición psicológica, que se midió mediante la lista de verificación de adjetivos de afecto múltiple revisada. los análisis de datos adicionales suministrados en este documento corresponden a los tamaños del efecto de las correlaciones entre las subescalas de la lista de verificación de adjetivos de afecto múltiple revisadas y los inventarios de estado funcional materno y paterno. resultados: se encontraron correlaciones de tamaños de efecto pequeños (r = 0,1), medianos (r = 0,3) y grandes (r = 0,5) para las medidas de condición psicológica y estado funcional tanto para las mujeres como para sus parejas masculinas, excepto para el afecto positivo de la condición psicológica y el estado funcional materno durante el posparto y la condición psicológica de ansiedad y el estado funcional paterno durante el posparto. conclusiones: en general, no se encontraron diferencias sustanciales en la condición psicológica y el estado funcional de las mujeres y sus parejas masculinas durante el embarazo y el posparto. los hallazgos de este análisis de datos secundarios constituyen una extensión de la teoría preliminar de situación específica presentada en un artículo publicado con anterioridad. palabras clave (fuente: decs): teoría de enfermería; embarazo; enfermería; embarazo de alto riesgo; estado funcional. resumo introdução: pouco se sabe sobre as experiências psicológicas dos futuros e novos pais na maternidade de alto risco. objetivo: apresentar as análises de dados adicionais a partir de um estudo-piloto orientado pelo modelo de adaptação de roy sobre a adaptação das mulheres e seus companheiros à maternidade de alto risco e, portanto, ampliar uma teoria preliminar de situação específica da adaptação à maternidade de alto risco. materiais e método: tendo em vista que se trata de uma extensão de um artigo publicado anteriormente, o qual foi um relatório completo dos resultados do estudo-piloto, exceto pela condição psicológica, que foi medida mediante a checklist de adjetivos de afeto múltipla revisada, as análises de dados adicionais fornecidas neste documento correspondem aos tamanhos do efeito das correlações entre as subescalas da checklist de adjetivos de afeto múltipla revisada e os inventários de estado funcional materno e paterno. resultados: foram constatadas correlações de tamanhos de efeito pequenos r = 0,1), médios (r = 0,3) e grandes (r = 0,5) para as medidas de condição psicológica e estado funcional tanto para as mulheres quanto para seus companheiros, exceto para o afeto positivo da condição psicológica e o estado funcional materno durante o pós-parto, e a condição psicológica de ansiedade e o estado funcional paterno durante o pós-parto. conclusões: em geral, não foram encontradas diferenças substanciais na condição psicológica e no estado funcional das mulheres e seus companheiros durante a gestação e o pós-parto. palavras-chave (fonte: decs): teoria de enfermagem; gravidez; enfermagem; gravidez de alto risco; status funcional. introduction the purpose of this paper is to report an extension of a roy adaptation model (ram) (1)-guided preliminary situation-specific theory of correlates (physical and psychological symptoms, physical energy, relationship quality) of maternal and paternal functional status during high-risk childbearing (2). the content of this paper adds correlations between already collected data for psychological state and maternal and paternal functional status, as measured by maternal and paternal functional status inventories, to the theory. the ram depicts people as adaptive systems that adapt to focal and contextual environmental stimuli 1). adaptation occurs in physiological, self-concept, role function, and interdependence adaptive modes, which are thought to be interrelated. this paper presents the results of data analyses for the relation between the self-concept mode, represented by the psychological state as measured by three multiple affect adjective checklist-revised (maacl-r) subscales (anxiety, depression, positive affect) 3), and the role function mode, represented by functional status during high-risk childbearing, as measured by maternal and paternal functional status inventories (4, 5, 6). the definitions for the relevant ram concepts (self-concept mode, role function mode), the theory concepts (psychological state, functional status), and the empirical indicators used to measure the theoretical concepts are given in table 1. table 1. conceptual and theoretical concepts and empirical indicators roy adaptation model concepts preliminary theory concepts empirical indicators self-concept mode: concerned with the conception of the physical and personal self psychological state: an individual’s perceptions of affect/feelings, including multiple items for each of three dimensions—anxiety, depression, and positive affect multiple affect adjective checklist-revised (maacl-r) subscales for anxiety, depression, and positive affect (3, 7) role function mode: concerned with the performance of roles based on position within society functional status: continued performance of an individual’s usual household, social and community, family, personal care, occupational, and educational activities during pregnancy and the postpartum, with the addition of assumption of childcare activities during the postpartum inventory of functional status-antepartum period (4) inventory of functional status after childbirth (5) inventory of functional status-fathers (6)   source: own elaboration. materials and methods psychological state was not included in data analysis for the preliminary theory (2) due to the complexity of identifying and writing computer code for the maacl-r subscales at that time (the early 2000s), as the subscale scores were available only by paper and pencil calculations. considerable time and effort were involved in preparing maacl-r subscale data for analysis, which are now available. the addition of psychological state, measured by the multiple items maacl-r (3, 7), to the theory may provide a more comprehensive understanding of the influence of the parents’ psychological experience during high-risk childbearing than did the three single-item psychological symptoms (feeling anxious, feeling depressed, feeling better than usual) measured by the symptoms checklist (8). details of the pilot study sample, research methods, and results for the preliminary theory are available in fawcett and tulman’s (2) paper. university and hospital institutional review boards approved the pilot study, and participants gave either oral or written informed consent. briefly, the sample included 103 individuals: 48 pregnant women who had been classified as high-risk and 34 of their male partners, 11 postpartum women who had had high-risk pregnancies, and 10 of their male partners at 4-6 weeks postpartum at the time of data collection. “the typical study participant was 31 years of age; white, non-hispanic; had at least a high school education; and was employed outside the home or on maternity or paternity leave” (1,  p410). high-risk status was self-reported when the participants were recruited from clinics in teaching hospitals in a new england state (n = 34 total participants; 20 pregnant women and 13 of their male partners; one woman and no male partners during the postpartum) and a southeastern state (n = 69 total participants; 28 pregnant women and 21 of their male partners; ten women and ten of their male partners during the postpartum). results the results for correlational analyses of the measures of psychological state and maternal and paternal functional status are given in table 2. complete data were available for all 48 pregnant women, although for only 32 of the 34 male partners and all 11 women and 10 male partners during the postpartum. effect sizes (9) are reported rather than inferential statistical probabilities due to the small sample sizes. note that r is the metric for the effect size for correlational analyses. a small effect size is r = 0.1, a medium effect size is r = 0.3, and a large effect size is r= 0.5 (9). table 2. effect sizes for relations between psychological state and functional status functional status psychological state (maacl-r subscales) maternal functional status: inventory of functional status-antepartum period (n = 48) anxiety:  r = -.108* depression: r = -.139* positive affect: r = .294* paternal functional status: inventory of functional status—fathers (pregnancy) (n = 32) anxiety:  r = .589*** depression: r = .131* positive affect: r = -.229* maternal functional status: inventory of functional status after childbirth-revised (n = 11) anxiety:  r = -.241* depression: r = -.454** positive affect: r = -.007 paternal functional status: inventory of functional status-fathers (postpartum) (n = 10) anxiety:  r = .008 depression: r = -.196* positive affect: r = .269* * small effect sizes (r = .10) are considered relations of low magnitude. ** medium effect sizes (r = .30) are considered relations of moderate magnitude. *** large effect sizes (r = .50) are considered relations of large magnitude (9). effect sizes in bold font indicate no evidence of a relation. source: own elaboration. based on the analysis of maccl-r subscale scores with scores for inventories of maternal and paternal functional status (see table 2), the preliminary theory can now be extended to assert these propositions: during pregnancy, for women: •    there is a negative relation of low magnitude (small effect size) between psychological state anxiety and maternal functional status; so, the lower the psychological state anxiety, the higher the maternal functional status. •    there is a negative relation of low magnitude (small effect size) between psychological state depression and maternal functional status; so, the lower the psychological state depression, the higher the maternal functional status. •    there is a positive relation approaching moderate magnitude (small to medium effect size) between psychological state positive affect and maternal functional status; so, the higher the psychological state positive affect, the higher the maternal functional status. during pregnancy, for male partners: •    there is a positive relation of high magnitude (large effect size) between psychological state anxiety and paternal functional status; so, the higher the psychological state anxiety, the higher the paternal functional status. •    there is a positive relation of low magnitude (small effect size) between psychological state depression and paternal functional status; so, the higher the psychological state depression, the higher the paternal functional status. •    there is a negative relation of low magnitude (small effect size) between psychological state positive affect and paternal functional status; so, the lower the psychological state positive affect, the higher the paternal functional status. during the postpartum, for women: •    there is a negative relation of low magnitude (small effect size) between psychological state anxiety and maternal functional status; so, the lower the psychological state anxiety, the higher the maternal functional status. •    there is a negative relation of moderate magnitude (medium effect size) between psychological state depression and maternal functional status; so, the lower the psychological state depression, the higher the maternal functional status. during the postpartum, for male partners: •    there is a negative relation of low magnitude (small effect size) between psychological state depression and paternal functional status; so, the lower the psychological state depression, the higher the paternal functional status. •    there is a positive relation of low magnitude (small effect size) between psychological state positive affect and paternal functional status; so, the higher the psychological state positive affect, the higher the paternal functional status. the data indicate that the effect sizes for the relations between psychological state positive affect and maternal functional status during the postpartum, and psychological state anxiety and paternal functional status during the postpartum were too low to consider (see table 2). discussion the direction of the relations between psychological state anxiety, depression, and positive affect and paternal functional status during pregnancy are inconsistent with expectations. expected would have been negative relations between psychological state anxiety and depression and paternal functional status; so, the higher the anxiety and depression, the lower the functional status. similarly, expected would have been a positive relation between psychological state positive affect and paternal functional status; so, the higher the positive affect, the higher the paternal functional status. the reason for these unexpected results is elusive. inasmuch as effect size tends to be stable regardless of sample size, it is unclear whether obtaining a larger sample of male partners from the same population would yield different results. as seen in table 2, there is no substantial difference in effect sizes for maacl-r measured psychological state and functional status for women and their male partners during pregnancy and the postpartum. overall, there is a significant effect size for the positive relation between the male partner’s psychological state anxiety and paternal functional status during pregnancy. perhaps feelings of anxiety motivate the male partner to perform a high level of activities that comprise paternal functional status. furthermore, there is a medium effect size for the positive relation between the women’s psychological state depression and maternal functional status during the postpartum, for if a woman feels depressed, she probably will decrease the level of her performance of activities that comprise maternal functional status. a review of related literature revealed a few relevant journal articles for this study. regarding women, maloni and colleagues (10) found relatively high levels of depression among a sample of 89 primarily caucasian (82 %) or african american (14.6 %) pregnant women who were hospitalized on bed rest. their study did not include any measure of maternal functional status. mckee and colleagues (11) found a negative correlation between depression and maternal functional status during pregnancy for 114 hispanic and black women in the united states. mcveigh (12) reported a negative correlation between anxiety and maternal functional status for 200 australian women during the postpartum. posmontier (13) found a negative correlation between postpartum depression and maternal functional status for 23 women in the united states. barkin and colleagues (14, 15) also reported a negative correlation between postpartum depression and maternal functional status in their studies of women (n = 189; n = 128) in the united states. regarding male partners, sevil and özkan  (16) found that the paternal functional status of 155 expectant and 93 fathers residing in turkey was related to sociodemographic factors but did not study the relation between any measures of mood and paternal functional status. mcveigh, st. john, and cameron (17) reported that of the 165 australian fathers who participated in their study of the postpartum, most appeared to engage in a balancing act that required them to relinquish some personal activities to be an involved parent. they did not, however, report any correlates of paternal functional status in their descriptive study. no studies of the relation between positive affect and maternal or paternal functional status during pregnancy or the postpartum were located. conclusion the study findings support the utility of the roy adaptation model (1) as a guide for research and indicate, as proposed in the model, that the modes of adaptation (self-concept mode and role function mode in this study) are interrelated. as the fawcett and tulman’s (2) paper indicate, the theory is too preliminary to recommend application in nursing practice. more research with participants of diverse cultures is needed to determine whether the effect sizes are stable across diverse populations and which relations contribute to an empirically adequate situation-specific theory. disclaimer: the views expressed in this article are our own and not an official position of the institutions or funder. references 1.   fawcett j, tulman l. adaptation to high-risk childbearing: a preliminary situation-specific theory. aquichan. 2018;18(4):407-14. doi: https://doi.org/10.5294/aqui.2018.18.4.3 2.   roy c. the roy adaptation model (3rd ed.). upper saddle river, nj: pearson, 2009. 3.   zuckerman m, lubin b. manual for the multiple affect adjective checklist revised. san diego, ca: edits, 1985. 4.   tulman l, higgins k, fawcett j, nunno c, vansickel c, haas mb, speca mm. the inventory of functional status-antepartum period: development and testing. j nurs-midwif. 1991;36(2):117-23. doi: https://doi.org/10.1016/0091-2182(91)90061-s 5.   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lian b, wisniewski sr. correlates of postpartum maternal functioning in a low-income obstetric population. j am psych nurs assoc. 2017;23(2):149–158. doi: https://doi.org/10.1177/1078390317696783 16. sevil ü, ozkan s. fathers’ functional status during pregnancy and the early postnatal period. midwifery. 2009;25(6):665–672. doi: https://doi.org/10.1016/j.midw.2007.12.001 17. mcveigh c, st. john w, cameron c. fathers’ functional status six weeks following the birth of a baby: a queensland study. aust midwifery, 2005;18(1):25–28. doi: https://doi.org/10.1016/s1448-8272(05)80016-1 home cerrar q ua lit y ca re in o ut pa ti en t c he m ot he ra py . d es ig n an d va lid at io n of t he n ov el c ar e q ua lit y a m bu la to ry in st ru m en t 1 jhon henry osorio-castaño https://orcid.org /0000-0001-6272-722x universidad de antioquia, colombia jhenry.osorio@udea.edu.co herlin yeidy vallejo-mesa https://orcid.org /0000-0002-5375-598x instituto de cancerología, clínica las américas auna, colombia herlin.vallejo@lasamericas.com.co sandra eugenia adarve-gutiérrez https://orcid.org /0000-0002-6522-246x clínica vida, colombia sandra.adarveg@upb.edu.co serguei iglesias-moré http://orcid.org /0000-0002-3382-428x universidad de ciencias médicas de la habana, cuba simore@infomed.sld.cu jenny alejandra osorio-vargas https://orcid.org /0000-0002-0857-3079 clínica vida, colombia jenny.osorio@upb.edu.co artículo quality care in outpatient chemotherapy. design and validation of the novel care quality ambulatory instrument received: 16/11/2022 sent to peers: 14/12/2022 approved by peers: 22/02/2023 accepted: 22/03/2023 doi: 10.5294/aqui.2023.23.2.4 para citar este artículo / to reference this article / para citar este artigo osorio-castaño jh, vallejo-mesa hy, adarve-gutiérrez se, iglesias-moré s, osorio-vargas ja. quality care in outpatient chemotherapy. design and validation of the novel care quality ambulatory instrument. aquichán. 2023;23(2):e2324. doi: https://doi. org/10.5294/aqui.2023.23.2.4 https://orcid.org/0000-0001-6272-722x mailto:jhenry.osorio@udea.edu.co https://orcid.org/0000-0002-5375-598x mailto:herlin.vallejo@lasamericas.com.co https://orcid.org/0000-0002-6522-246x mailto:sandra.adarveg@upb.edu.co http://orcid.org/0000-0002-3382-428x mailto:simore@infomed.sld.cu https://orcid.org/0000-0002-0857-3079 mailto:jenny.osorio@upb.edu.co https://doi.org/10.5294/aqui.2023.23.2.4 https://doi.org/10.5294/aqui.2023.23.2.4 https://doi.org/10.5294/aqui.2023.23.2.4 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2023.23.2.4&amp;domain=pdf&amp;date_stamp=2023-05-18 theme: healthcare technologies contribution to the theme: the present study allowed expanding the theoretical conception of quality care and evidencing aspects such as the importance of companions for patients and the effects of providing care. it also provided a novel, valid, and reliable instrument that promotes the measurement of quality care in especially sensitive services due to the experiences of the people receiving care there, such as chemotherapy services. this study can provide a reference for research in other practice scenarios, as it is the first instrument in spanish that evaluates quality care. q ua lit y ca re in o ut pa ti en t c he m ot he ra py . d es ig n an d va lid at io n of t he n ov el c ar e q ua lit y a m bu la to ry in st ru m en t 3 abstract introduction: neither validated scales nor scales translated into spanish currently exist to evaluate the perception of quality care in people receiving outpatient chemotherapy, despite their usefulness in evaluating the care provided by nurses and in promoting changes in the delivery of these services. objective: to design and validate the novel care quality ambulatory-i (cqamb-i) instrument in outpatient chemotherapy services. materials and methods: this is an instrument validation study carried out in three stages: literature review, design, and validation of the instrument. content validation was performed with 14 specialists with at least a master’s degree and experience in chemotherapy or quality services; face validation was carried out through a pilot test with 31 participants diagnosed with cancer who received curative chemotherapy, and construct validation was carried out through an exploratory factor analysis with 436 users who received outpatient chemotherapy with curative intent. results: a total of 15 items were removed in the content validation stage; none were removed in face validation. in construct validation, participants had a median age of 56 years, a median treatment time of 5 months, and breast cancer was the most commonly diagnosed form of cancer. eighteen models were run, 30 items were removed, 6 factors emerged, and a kmo of 0.80 and a cronbach’s alpha of 0.82 were obtained. conclusion: the cqamb-i proved to be valid and reliable for the evaluation of quality care in outpatient chemotherapy services. additionally, it enabled expanding the conception of such care beyond the attributes of structure, process, and outcome. keywords (fonte: decs) total quality management; nursing; drug therapy; validation study; neoplasms. 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 24 resumen introducción: no existen escalas validadas, ni traducidas al español para evaluar la percepción del cuidado con calidad en personas que reciben quimioterapia ambulatoria, a pesar de su utilidad para evaluar la prestación de servicios enfermeros y generar cambios en la entrega de estos. objetivo: diseñar y validar el nuevo instrumento care quality ambulatory-i (cqamb-i) en servicios de quimioterapia ambulatoria. materiales y métodos: estudio de validación de instrumentos en tres fases: revisión de la literatura, diseño y validación del instrumento. se realizó validación de contenido con 14 expertos con formación mínima de maestría y experiencia en servicios de quimioterapia o calidad; validación facial a través de prueba piloto con 31 participantes con diagnóstico de cáncer que recibían quimioterapia curativa; y validación de constructo por medio de un análisis factorial exploratorio con 436 usuarios que recibían quimioterapia ambulatoria con intención curativa. resultados: en la validación de contenido se eliminaron 15 ítems; en la validación facial no se eliminó ninguno; y en la validación de constructo los participantes tuvieron una mediana de edad de 56 años, mediana de tiempo de tratamiento de 5 meses y cáncer de mama como el más diagnosticado. se ejecutaron 18 modelos, se eliminaron 30 ítems, emergieron 6 factores y se obtuvo un kmo de 0.80 y un alpha de cronbach de 0.82. conclusión: el instrumento cqamb-i demostró ser válido y confiable para evaluar el cuidado con calidad en servicios de quimioterapia ambulatoria y, adicionalmente, permitió ampliar la concepción de este más allá de los atributos de estructura, proceso y resultado. palabras clave (fuente: decs) gestión de la calidad total; enfermería; quimioterapia; estudio de validación; neoplasias. cuidado con calidad en quimioterapia ambulatoria. diseño y validación del nuevo instrumento care quality ambulatory q ua lit y ca re in o ut pa ti en t c he m ot he ra py . d es ig n an d va lid at io n of t he n ov el c ar e q ua lit y a m bu la to ry in st ru m en t 5 cuidado com qualidade em quimioterapia ambulatória. desenho e validação do novo instrumento care quality ambulatory resumo introdução: não existem escalas validadas nem traduzidas ao espanhol para avaliar a percepção do cuidado com qualidade em pessoas que recebem quimioterapia ambulatória, apesar de sua utilidade para avaliar a prestação de serviços de enfermagem e gerar mudanças na entrega destes. objetivo: desenhar e validar o novo instrumento care quality ambulatory-i (cqamb-i) em serviços de quimioterapia ambulatória. materiais e método: estudo de validação de instrumentos em três fases: revisão da literatura, desenho e validação do instrumento. foi realizada validação de conteúdo com 14 especialistas com formação mínima de mestrado e experiência em serviços de quimioterapia ou qualidade; validação facial por meio de teste-piloto com 31 participantes com diagnóstico de câncer que recebiam quimioterapia curativa e validação de constructo por meio de uma análise fatorial exploratória com 436 usuários que recebiam quimioterapia ambulatória com intenção curativa. resultados: na validação de conteúdo, foram eliminados 15 itens; na validação facial, não foi eliminado nenhum; na validação de constructo, os participantes tiveram uma média de idade de 56 anos, média de tempo de tratamento de 5 meses e câncer de mama como o mais diagnosticado. foram executados 18 modelos, foram eliminados 30 itens, emergidos 6 fatores e obtido um kmo de 0,80 e um alpha de cronbach de 0,82. conclusões: o instrumento cqamb-i demonstrou ser válido e confiável para avaliar o cuidado com qualidade em serviços de quimioterapia ambulatória e, além disso, permitiu ampliar a concepção deste mais além dos atributos de estrutura, processo e resultado. palavras-chave (fonte decs) gestão da qualidade total; enfermagem; tratamento farmacológico; estudo de validação; neoplasias. 6 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 24 introduction the quality of healthcare is a construct that has become more prominent with the proposal of avedis donabedian and his triad of process, structure, and results. bautista states that quality is a multidimensional construct, which can be understood as being integral and total, it is perceived when needs are met or satisfied, and it is subjective. the author also states that quality in healthcare services can be technical, depending on the institution, and subjective, depending on the service users (1). in their analysis of the concept of quality in healthcare services, allen and colleagues have identified four attributes: effectiveness, safety, excellence culture, and desired health outcomes (2). as one of the most relevant aspects of healthcare for users, quality must become objective to be measured and reflect the reality experienced by users. for this purpose, the literature indicates that the most widely used instrument has been the servqual, based on its five dimensions: reliability, responsiveness, safety, empathy, and tangible elements (3, 4). therefore, nursing is an essential component in the provision of services and, consequently, in the establishment of the perception of quality by the users. the quality of care has been associated mostly with patient safety, but it is not limited to this, and involves aspects related to technical, personal, and interpersonal skills and to the results that can be achieved through nursing interventions (5). varied and alternate definitions of quality of care can be found, and it can be understood at several levels. according to ebneter (6), quality of care starts at a level of safety considered the minimum level of perceived quality. it is followed by a level of comfort, which expresses a balance between perceived quality and resources. then, there is the level of perfection, understood as the absence of errors, flaws, or imperfections. also, from a qualitative perspective, quality care implies holistic care, which is an interpersonal aspect and a matter of leadership and responsibility to provide the best care (7). in light of the importance of nursing care in the context of healthcare services, instruments have also been designed to address this perception and experience (8, 9), with the cucace being the most widely used in a variety of nursing settings and services (10). on the other hand, one of the most devastating health-related experiences can be an oncological disease. the testimonies of people who have experienced cancer recount the suffering resulting from the loss of normality, the disruption of relationships with others, and the emotional impact (11). people who experience this condition require care that goes beyond technical aspects such as safety and the staff ’s technical skills: they require a different and transcendent sensitivity that allows them to identify, understand, and meet the q ua lit y ca re in o ut pa ti en t c he m ot he ra py . d es ig n an d va lid at io n of t he n ov el c ar e q ua lit y a m bu la to ry in st ru m en t 7 real needs stemming from a condition such as this (12). the experience of treatment, specifically chemotherapy, must be added to the diagnosis of an oncological disease. studies have shown how this experience can be an equal or greater source of suffering in people due to the lack of knowledge regarding the treatment, the changes, and the test of coping strategies that allow them to reach a temporary adaptation (13, 14). therefore, quality of care in oncology should be mandatory and its measurement unavoidable. thus, the literature identifies several instruments to measure the perception of quality in oncology services in general, and within them, some aspects of this construct in the field of oncology nursing specifically focused exclusively on care satisfaction (15, 16, 17, 18, 19, 20). however, no instruments for the evaluation of the quality of nursing care in oncology patients were found in the literature review in spanish, and there are no instruments that particularly evaluate the quality of care in outpatient chemotherapy services. hence, the objective of the present study was to design and validate a new instrument to measure the quality of care in patients undergoing outpatient chemotherapy. methodology this is a study for psychometric validation of scales, which was carried out in three stages: a literature review, the design of a new instrument, and the validation of the aforementioned instrument. for the literature review stage, primary articles with a qualitative approach were searched in the sage, scopus, pubmed, lilacs, ebsco, science direct, and springer databases, using the following keywords: quality (calidad), nursing care (cuidado de enfermería), and qualitative study (estudio cualitativo) in spanish and english, within the limits of the publication year (2009-2019), and which allowed answering the following guiding question: what are the dimensions that comprise the quality of nursing care identified from the perception of the subjects of care? for the design phase, a reflexive model was used, and the items were defined based on the categories and subcategories identified in the literature review studies. the items were not defined based on other instruments, since no instruments measuring quality care in outpatient chemotherapy services were identified in the literature. this implies clarifying that no existing instrument has been validated, therefore it was not necessary to resort to translation processes or cultural and semantic adaptation. a five-response, likert-type scale was used to evaluate each item’s frequency or intensity. subsequently, in the validation stage of the new instrument, content, face, and construct validations were carried out. for the content validation, an informal consensus method was used, 8 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 24 through the delphi technique, with ten specialists who met the following criteria: they were nurses with a master’s degree, with clinical experience providing care to people diagnosed with cancer undergoing chemotherapy or who worked in the quality field as professors or administrators. a link to the executive summary and the instrument drafted in google forms were sent by email, for rating the items in three criteria: simplicity, clarity, and relevance, assigning a score ranging from 1 to 5. with the ratings, the aiken v test was applied and a value of 0.7 and a 95 % ci ranging from 0.7 to 1 were defined as the cutoff point for retaining the item. for face validation, a pilot test was conducted with 10 % of the total estimated sample, as long as they were people with a diagnosis of cancer and were undergoing curative chemotherapy, intending to measure the estimated time for its completion, as well as to evaluate item comprehension and the rating scale. a cross-sectional design was chosen for the construct validation, which included patients aged over 18, with a cancer diagnosis, who were undergoing outpatient chemotherapy in a healthcare institution in the city of medellin (colombia), and who wished to participate in the study at least one month before the instrument was applied. patients aged over 18, who were receiving chemotherapy as palliative management were excluded. potential participants were approached in the waiting rooms of the healthcare institution after they had left their oncology medical appointments. the sample was estimated to consist of at least 200 patients, with a moderate condition, consisting of communalities ranging from 0.4 to 0.7 and 3 to 4 items per factor. the sampling was non-probabilistic by convenience. the following variables were defined as participant characterization variables: sex, age, marital status, occupation, level of education, type of cancer, and months of chemotherapy. a univariate analysis was conducted using the distribution frequency of the characterization variables, and then an exploratory factor analysis was carried out using the freely available jamovi 1.6.23 software. the pearson product-moment correlation matrix was reviewed first, considering there were five response options for each item. subsequently, the adequacy level of the exploratory factor analysis was calculated through bartlett’s sphericity test and the kaiser-meyer-olkin sample adequacy measurement, for which case a minimum value of 0.7 was adopted to define whether it was appropriate to perform an exploratory factor analysis. for the estimation of factors, the maximum probability option was selected, considering that the matrix to be analyzed was pearson’s product-momentum matrix and the item categories were a minimum of five, combining this with a parallel analysis to determine the number of factors to be retained, and considering the retention of larger factors, that is, with a minimum of 3 or 4 items, saturations of at q ua lit y ca re in o ut pa ti en t c he m ot he ra py . d es ig n an d va lid at io n of t he n ov el c ar e q ua lit y a m bu la to ry in st ru m en t 9 least 0.4 in the items and making theoretical sense. an oblique rotation of the factors was performed through the promax method, and each factor was named. finally, the instrument’s reliability was reviewed through internal consistency, measured via cronbach’s alpha, although it should be noted that sensitivity to change was not measured. the study was classified as of minimum risk, according to article 11 of the resolution 8430 of 1993, with the respect and protection of the privacy of the study participants prevailing, in addition to the fact that the respective informed consent form for participation in the study was provided, and each survey was labeled with its respective code for tabulation. this project was approved in the first instance by the research ethics committee of the school of health sciences of the universidad pontificia bolivariana, according to act 09 of may 20th, 2019, and in the second instance by the independent research ethics committee of the instituto de cancerología, as recorded in act 11-2020 of november 30th, 2020. results in the literature review, 215 articles were retrieved from all the databases, of which 141 were excluded based on their title or abstract, and 58 were excluded for not being qualitative studies or for not addressing the perception of the quality of nursing care, which resulted in a total of 16 articles included. from the review of these 16 articles related to the perception of the quality of nursing care in a variety of services and with different subjects of care, some preliminary dimensions or attributes comprising the construct of quality care were identified. based on these dimensions, the items that would compose version i of the new instrument to be validated were designed, consisting of 94 items, and then a review was performed by the researchers, which eliminated 23 items, resulting in version ii with 71 items, which was submitted to content validation by 14 specialists who performed a scoring round. after validation by the specialists, 15 items were removed as they failed to meet aiken’s v 95 % ci lower limit criterion of 0.7, and the format of 4 more items was changed, resulting in a total of 56 items in version iii. a pilot test was then carried out with 31 participants undergoing outpatient chemotherapy with curative purposes, in which the average time used to respond to the instrument was 9 minutes. based on this, the necessary adjustments were made, according to the feedback to develop the instrument’s final version iv. the median age of the study participants was 56 years (iqr=17), and the median time undergoing chemotherapy was 5 months (iqr= 6). all sociodemographic characteristics can be found in table 1. 10 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 24 table 1. participants’ sociodemographic characteristics sociodemographic characteristics n % sex female 349 80 male 87 20 marital status married 214 49.1 single 100 22.9 separated 51 11.7 free union 38 8.7 divorced 19 4.4 widowed 14 3.2 level of education incomplete high school 103 23.6 complete elementary school 92 21.1 incomplete elementary school 75 17.3 complete high school 54 12.4 technical 33 7.6 undergraduate 33 7.6 technological 23 5.3 specialization 18 4.1 master’s degree 4 0.9 phd 1 0.2 occupation housekeeper 172 39.4 employed 176 40.3 unemployed 44 21.9 independent 54 12.4 retired 31 7.1 student 3 0.7 type of cancer breast 196 44.8 colo-rectal 53 12.1 ovary 31 7.1 cervix 29 6.7 lung 25 5.7 note: prepared by the authors. for the final version of the instrument, 18 models were run, out of which 30 items were removed. the final model led to an instrument consisting of 6 dimensions and 26 items; the complete data from the analysis are presented only for this final model. the sample adequacy tests demonstrated the correlation matrix does not correspond to an identity matrix (bartlett’s sphericity test: 5523 degrees of freedom =325; p<0.001), also presenting excellent data adequacy, with a kmo (0.80) that indicated the relevance of the efa data, in addition to demonstrating an explained variance of 55.7 % (table 2). q ua lit y ca re in o ut pa ti en t c he m ot he ra py . d es ig n an d va lid at io n of t he n ov el c ar e q ua lit y a m bu la to ry in st ru m en t 11 table 2. explained variance of the instrument factors factor load variance % cumulative % 1 2.96 11.40 11.4 2 2.98 11.46 22.9 3 2.76 10.62 33.5 4 2.25 8.65 42.1 5 1.88 7.22 49.3 6 1.65 6.35 55.7 note: prepared by the authors. when the rotated factor structure matrix was analyzed, all correlations were found to be above 0.4 (table 3). the final model led to 6 factors, named as follows: factor 1 – person-centered care (6 items); factor 2 – interpersonal competencies (6 items); factor 3 – care effects (4 items); factor 4 – companion visibility (4 items); factor 5 – suffering relief (3 items), and factor 6 – care satisfaction (3 items). in the reliability assessment, an overall score of 0.82 was obtained for the instrument. table 3. rotated factor matrix with item loadings 1 2 3 4 5 6 uniqueness item_17 0.560 0.6362 item_18 0.739 0.4084 item_ 21 0.647 0.5580 item_ 22 0.802 0.3761 item_ 23 0.662 0.5354 item_ 24 0.458 0.7664 item_ 25 0.680 0.4337 item_ 27 0.463 0.5349 item_33 0.478 0.7373 item_34 0.849 0.2650 item_35 0.823 0.2364 item_36 0.544 0.6365 item_37 0.808 0.2387 item_38 0.564 0.5075 item_39 0.600 0.5569 item_ 40 0.591 0.4990 item_ 41 0.776 0.4295 item_ 42 0.789 0.3299 item_ 43 0.592 0.5311 item_ 46 0.501 0.6453 item_ 48 0.921 0.1516 item_ 49 0.664 0.3780 item_50 0.980 0.0717 item_51 0.771 0.2715 item_53 0.900 0.1870 item_54 0.630 0.5980 note: prepared by the authors. 12 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 24 discussion this study aimed to validate the cqamb-i instrument in people undergoing outpatient chemotherapy. this name, corresponding to the designation of care quality ambulatory, was defined strategically to favor the internationalization of the instrument, its use, and validation in american and european contexts. this instrument allowed the recognition of the multidimensionality of quality care by including dimensions that involve the professionals, the users, the companions, and the disease conditions. the first dimension, entitled “person-centered care”, contains items related to people’s needs, the information provided, and the proximity of the nursing staff. person-centered care involves changes in the model of care, multidisciplinary teams, reconceptualizing the use of resources, new care roles, and infrastructure changes (21). from a nursing perspective, person-centered care implies individualizing care, reaching care agreements, and considering and intervening in each user’s specific needs, with the resulting improvement in quality (22). the dimension entitled “interpersonal competencies” covers items related to respect, commitment, responsibility, and personal presentation. in nursing, interpersonal competencies entail, among other aspects, effective interpersonal relationships, considered to be the most relevant factor for the growth of care at a holistic level. interpersonal relationships also entail affection as an emotional commitment to others and recognition of others, in an authentic exchange that favors interaction, with implicit therapeutic properties and positive effects for both parties (23). the third dimension, entitled “care effects”, covers the intermediate nursing outcomes perceived by the users, such as teaching, management of side effects, improvement of the disease condition, and the reduction of complications. according to gao et al. (24), care interventions can have effects on users in several components, namely: they can improve self-care skills, reduce the occurrence of complications, and contribute to the improvement of quality of life and adherence to medical treatment. the dimension “companion visibility” consists of items on information, comfort, respect, and the companion’s involvement in the care of users. providing companionship to people receiving healthcare is vital, as this practice builds trust and security, in addition to the emotional and social support provided to patients. on the other hand, the companion can contribute to the care of those people and improve their stay in the healthcare institution (25), especially considering that one of the main concerns of people who experience a form of cancer is the impact on their family members or partners (26). another dimension of the instrument is entitled “suffering relief,” which consists of items that mention the relief of pain, physical and q ua lit y ca re in o ut pa ti en t c he m ot he ra py . d es ig n an d va lid at io n of t he n ov el c ar e q ua lit y a m bu la to ry in st ru m en t 13 emotional suffering, and distress. although suffering is probably intertwined with diagnosis and later with treatment, it is clear that users expect nurses to be able to contribute to alleviating the experience of suffering, especially because of what they consider to be the sources of suffering, such as the loss of health and, with it, the chain of losses that can involve work, among other aspects, to which the assessment and control of threats and the management of social contexts are added (27). finally, the dimension “care satisfaction” presents items related to the evaluation of satisfaction, expectations of care, and feelings of satisfaction. in general terms, people may feel satisfied with nursing care, and such satisfaction may be determined by the assignment of nurses for individualized care, previous contact with nursing care, and the admission process by these professionals (28). as limitations of this study, we found that the distribution of cancer etiology was centered on the female gender and breast cancer, thus the sample of male patients was smaller; furthermore, the study was carried out in a single institution. conclusions it can be concluded that the new cqamb-i instrument that was designed and validated complied with the content, face, and construct validation tests, through the results of the statistical tests applied. likewise, its reliability is acceptable, as it does not present low consistency or redundancy of its items. this novel instrument can be used to evaluate the perception of quality care in colombian oncology centers where outpatient chemotherapy services are provided. it highlights the importance of patient companions in the care provided to users undergoing chemotherapy, as well as the perception of the effects of care on the suffering stemming from the disease and treatment. it is 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10.5294/aqui.2023.23.1.4  lorena chaparro-díaz1 sonia carreño-moreno2 jeimy sofía alzate hernández3 camilo andrés acosta-pardo4 1 0000-0001-8241-8694 universidad nacional de colombia, colombia olchaparrod@unal.edu.co 2 0000-0002-4386-6053 universidad nacional de colombia, colombia spcarrenom@unal.edu.co 3 0000-0001-8765-141x universidad nacional de colombia, colombia jsalzateh@unal.edu.co 4 0000-0003-3472-4720 universidad nacional de colombia, colombia caaacostapa@unal.edu.co * this study was conducted under the project entitled “adoption of the role of family caregiver of a person with a chronic disease based on the community,” identified by code hermes 50,257. it was funded by the ministry of science, technology, and innovation (minciencias) through the “call for strengthening ongoing st&i projects in health sciences with young talent and regional impact” under covenant or contingent recovery funding contract no. 847/2020 between minciencias and universidad nacional de colombia. ** este estudio se realizó en el marco del proyecto “adopción del rol de cuidador familiar de la persona con enfermedad crónica con base en la comunidad” identificado con el código hermes 50257 y contó con la financiación del ministerio de ciencia, tecnología e innovación (minciencias) mediante la “convocatoria para el fortalecimiento de proyectos en ejecución de ctei en ciencias de la salud con talento joven e impacto regional”, bajo el convenio o contrato de financiamiento de recuperación contingente n.o 847 de 2020 celebrado entre el minciencias y la universidad nacional de colombia. *** este estudo foi realizado no âmbito do projeto “adoção do papel do cuidador familiar da pessoa com doença crônica baseada na comunidade” identificado com o código hermes 50257, financiado pelo ministério da ciência, tecnologia e inovação (minciencias), da “chamada para o fortalecimento de projetos em execução de ctei em ciências da saúde com talento jovem e impacto regional”, sob o convênio ou contrato de financiamento de recuperação contingente n. 847 de 2020 celebrado entre o minciencias e a universidad nacional de colombia. theme: chronic care contribution to the subject: from the nursing area, participation in the creation and restructuring of public policies should be fostered in the country to establish strategies for strengthening the social support provided to caregivers of people with chronic diseases, especially those with low income, thus improving their care skills and, simultaneously, preventing or reducing their burden. received: 25/11/2021 sent to peers: 12/02/2022 approved by peers: 27/11/2022 accepted: 29/11/2022 to reference this article / para citar este artículo / para citar este artigo: chaparro-díaz l, carreño-moreno s, alzate js, acosta-pardo ca. relationship between burden and perceived social support in low-income caregivers. aquichan. 2023;23(1):e2314. doi: https://doi.org/10.5294/aqui.2023.23.1.4 abstract objectives: to describe and correlate burden and social support in low-income caregivers of chronic patients. material and methods: a descriptive and cross-sectional study was conducted with 170 low-income family caregivers of people with chronic diseases who answered a survey on sociodemographic and care variables, in addition to the zarit scale to measure burden and the mos questionnaire on perceived social support. the analysis was performed using descriptive and differential statistics. results: most caregivers were female, and the predominant kinship was father-son. a significant and negative correlation (rs = -.307, p < 0.001) was identified between the caregivers’ burden and perceived social support, as well as a significant and positive correlation (rs = 0.278, p < 0.01) between the time devoted to care and the caregivers’ burden. conclusions: low-income family caregivers require more social support to reduce the burden levels. keywords (source: decs): caregivers; family caregiver; social support; cost of illness; chronic disease. resumen objetivos: describir y correlacionar la sobrecarga y el apoyo social de cuidadores de pacientes crónicos con bajos ingresos económicos. material y métodos: estudio descriptivo transversal realizado a 170 cuidadores familiares de personas con enfermedad crónica de bajos ingresos económicos a quienes se les aplicó una encuesta sobre variables sociodemográficas y de cuidado, además de la escala zarit para medir la sobrecarga y el cuestionario mos sobre apoyo social percibido. el análisis se realizó mediante estadística descriptiva y diferencial. resultados: la mayoría de los cuidadores fueron mujeres y el vínculo filial predominante fue de padre e hijo. se identificó una correlación significativa y negativa (rs = -0,307, p < 0,001) entre la sobrecarga del cuidador y el apoyo social percibido, como también una correlación significativa y positiva (rs = 0,278, p < 0,001) entre el tiempo dedicado al cuidado y la carga del cuidador. conclusiones: los cuidadores familiares de bajos ingresos económicos requieren mayor apoyo social para disminuir los niveles de sobrecarga. palabras clave (fuente: decs): cuidadores; cuidador familiar; apoyo social; carga de las enfermedades; enfermedad crónica. resumo objetivos: descrever e correlacionar a sobrecarga e o suporte social de cuidadores de baixa renda de pacientes crônicos. material e métodos: estudo descritivo e transversal, realizado com 170 cuidadores familiares de baixa renda de pessoas com doenças crônicas, que responderam a um questionário sobre variáveis sociodemográficas e assistenciais, além da escala de zarit para medir a sobrecarga e do questionário mos sobre suporte social percebido. a análise foi realizada por meio de estatística descritiva e diferencial. resultados: a maioria dos cuidadores era do sexo feminino e o vínculo filial predominante era entre pai e filho. foi identificada uma correlação significativa e negativa (rs = -0,307, p < 0,001) entre a sobrecarga do cuidador e o suporte social percebido, assim como uma correlação significativa e positiva (rs = 0,278, p < 0,001) entre o tempo dedicado ao cuidado e a carga do cuidador. conclusões: os cuidadores familiares de baixa renda necessitam de maior suporte social para reduzir os níveis de sobrecarga. palavras-chave (fonte: decs): cuidadores; cuidador familiar; apoio social; efeitos psicossociais da doença; doença crônica. introduction chronic non-communicable diseases (cncds) are characterized by progressive long-term consequences and are the leading causes of disability and death globally, given their high burden (1). according to the world health organization (who), 71 % of deaths each year can be attributed to these diseases, with 5.5 million annual deaths in the americas alone. in particular, cncds affect populations in a condition of vulnerability, as they are exposed to risk factors and enjoy limited access to health services. the cncd burden is estimated through life years lost (lyl) and years lived with disability (yld). these indicators have increased since 1990 to the extent that, by 2019, ylds due to cncds represented more than half of the entire morbidity burden (2). cncds affect not only the patients but also their caregivers, who are individuals that provide care and receive no economic remuneration in exchange (3). most of the time, this caregiver role is taken on by a family member, called a family caregiver, who is in charge of providing direct care to the person with a cncd,  making decisions related to the health needs, and supporting the health care system by favoring home-based care (4–6). however, family caregivers are generally not duly prepared to perform a new role and risk developing a burden if low satisfaction with social support and high demand in the care tasks are added (7). burden is understood as mental and emotional exhaustion that leads to stress, with repercussions on physical and psychological health and other spheres of everyday life, such as social relationships (8, 9). the burden levels can be determined by socioeconomic conditions, especially when dealing with a low-income context. family caregivers offer their care services without receiving any remuneration, and, as they devote themselves to these tasks, they find it challenging to earn a livelihood necessary to meet not only care-related needs but also those emerging from everyday life, also limiting access to long-term health services and support (10, 11). in colombia, most studies assessing burden have evidenced that caregivers have mild or nonexistent burden levels (10–12). on the other hand, it has been demonstrated that caregivers have higher burden levels when they perceive less social support (13, 14). social support is the system of formal and informal relationships from which a person receives instrumental and emotional help to face stressful situations (15). the perception of this support exerts an influence on caregivers’ responses and adaptation to take on the care experience more efficiently and reduce negative perceptions (16, 17). this perceived social support can be conditioned when the caregivers earn low incomes (18, 19). they and their family enjoy fewer chances of accessing health services and making rapid and early diagnoses, to which difficulties purchasing medications, transportation and mobility limitations to attend medical centers, and lack of clear and precise information about care and management of the disease are added (20). in colombia, various studies have proved that the social support provided to caregivers is insufficient to meet the care demands (21); it has also been reported that 96.1 % of caregivers from different regions of the national territory earn low incomes (12). these variables have been measured independently, and from them, it cannot be determined whether these low-income caregivers perceive sufficient social support or how this impacts caregivers’ burden levels. thus, the present study aims to describe and correlate sociodemographic and care variables, burden, and social support in low-income caregivers of chronic patients. materials and methods design a quantitative, descriptive, cross-sectional study was conducted during the first half of 2021 in bogotá, colombia. inclusion criteria we included come-of-age caregivers having already cared for a family member with a chronic disease for more than six months, with their mental function unaltered, as verified with the spmsq test (22). in addition, caregivers who stated that their homes were classified in strata 1, 2, and 3 based on the colombian socioeconomic classification (22) were included; in other words, the population segment that earns usd 250 or less per month (23). exclusion criteria caregivers who found difficulties answering the online questionnaire were excluded. participants and sample during the first half of 2021, an open call was made to family caregiving associations linked to the cuidando a los cuidadores® (taking care of caregivers) program from universidad nacional de colombia. the caregivers interested in participating wrote to the program’s email address. the reply to this email informed them about the study objective and methodology and provided an online google forms form for data collection. a total of 120 forms were sent, and 170 answers were received because the individuals that received the email message shared the survey with other interested participants that had missed the first notice. no incomplete forms were received because they were designed for all the questions to be answered mandatorily to enable submission. study variables and measurements the interested caregivers that wrote to the program’s email address were sent an online google forms form for data collection. this form, comprised of three sections, was designed to be answered by self-reporting, with a prior explanation in the email message. the first section was devoted to collecting sociodemographic data using the characterization survey for the care of the “person with a chronic disease-family caregiver” dyad, developed and validated to be used in the colombian context. the survey has 42 items that measure three general dimensions: sociodemographic profile and general conditions of the caregiver, perception of burden and support, and use of information and communication technologies (10). the following section measured the caregiver’s burden with the zarit burden instrument in its spanish version validated for colombia, with 0.92 validity, 0.81 reliability, and a cronbach’s alpha of 0.861. the tool has 22 items, which are assessed on a five-point likert-type scale: 0 (never), 1 (rarely), 2 (sometimes), 3 (often), and 4 (almost always). its possible score can vary between 0 and 88 points, and, in turn, the burden levels are established according to the range obtained: when below 46, it is classified as no burden; when between 46 and 56, the burden is considered mild; and when above 56, the burden is considered intense(24). finally, perceived social support was measured with the mos questionnaire, validated in colombia using confirmatory factor analysis, which shows gfi = 0.780, agfi = 0.713, rmsea = 0.113, aic = 566.98, and bic = 707.22 in addition to a cronbach’s alpha of 0.94 (25). this questionnaire has 20 items scored through a likert-type scale from 1 (never) to 5 (always); the first item evaluates the size of the social network, and the next 19 are grouped into four dimensions that consider affective, instrumental, and emotional/informational support, and positive social interaction. consequently, the higher the score, the greater the perceived social support. data analysis the information analysis was performed using descriptive statistics for continuous variables, whereas proportions were used for nominal and ordinal variables. data analysis was conducted in the r studio statistical program, version 4.0.5. pearson’s correlation coefficient was employed to determine data correlation upon fulfilling the normality requirements tested with the kolmogorov-smirnov test. correlations with p-values < 0.05 were considered significant. ethical considerations this study was approved by the ethics committee of the nursing school at universidad nacional de colombia under minutes 029/2019. in addition, the current study considered the ethical norms outlined in the 1973 declaration of helsinki at all times. it also met all the respect, autonomy, beneficence, and information confidentiality principles. the participants received an explanation of the research objectives before expressing their will to participate in the study, manifested in the informed consent included at the beginning of the google forms form. likewise, they were ensured that their data would be handled anonymously and confidentially, solely for research purposes. results sociodemographic characteristics of the patients with chronic diseases information was collected from 170 dyads comprised of caregivers and individuals cared for. the patients’ information can be found in table 1, where it is noted that most people with chronic diseases were female, and their mean age was 69 years old (sd = 22.7), in addition to a mean of 136.7 months with the chronic illness (sd = 126.3). regarding marital status, 34.7 % were widowed, and 39.4 % were married. in terms of occupation, 39.4 % were devoted to housework. among the chronic diseases that most prevailed were cardiovascular diseases with 48.8 %, while others such as cancer, respiratory, neurodegenerative, renal, and mental diseases jointly accounted for 49.4 %. table 1. sociodemographic characterization of the patients with chronic diseases variables n (n = 172) % gender male 73 42.9 female 97 57.1 marital status  married 67 39.4 consensual union 3 1.8 no partner 100 58.8 schooling  no studies  13 7.7 incomplete elementary school 27 15.9 complete elementary school 72 42.4 incomplete high school 2 1.2 complete high school 24 14.1 technician or technologist 10 5.9 complete higher education 19 11.2 incomplete higher education 2 1.2 graduate studies 1 0.6 occupation  employee 14 8.2 student 8 4.7 housework 67 39.4 freelance job 30 17.6 other 51 30 number of chronic diseases 1 101 59.4 2-3 56 32.9 3+ 13 7.6 type of chronic disease cardiovascular 83 48.8 metabolic 38 22.3 musculoskeletal 32 18.8 other 84 49.4   mean sd age in years 69 22.7 time with the disease in months 136.7 126.3 source: the authors. sociodemographic characteristics of the caregivers table 2 presents the information collected from the caregivers, where 87.6 % were female, with a mean age of 52.3 years old. their mean time in the role was between 88.0 and 119.4 months (95 % ci). regarding the number of hours devoted to care tasks, the mean was 12.6, varying between 11.7 and 13.5 daily hours (95 % ci); 57.6 % stated sharing the care tasks. kinship with the patients mainly corresponded to father or mother with 47.6 %, followed by 23.0 % for another type of kinship and 15.9 % for spouses. regarding the caregivers’ current occupation, 41.2 % stated that they were not working due to their housework, followed by 24 % with freelance jobs. table 2. sociodemographic characterization of the caregivers variables n (n = 172) % gender male 21 12.4 female 149 87.6 marital status  married 70 41.2 consensual union 13 7.6 no partner 87 51.2 schooling  incomplete elementary school 4 2.4 complete elementary school 21 12.4 incomplete high school 12 7.1 complete high school 44 25.9 technician or technologist 41 24.1 complete higher education 37 21.8 graduate studies 11 6.5 occupation  employee 31 18.2 student 7 4.1 housework 70 41.2 freelance job 42 24.0 other 20 11.7 stratum  1 6 3.5 2 62 36.5 3 102 60.0 kinship with the patient father or mother 81 47.6 son/daughter 23 13.5 spouse 27 15.9 other 39 23.0   mean sd age in years 52.3 13.2 time as a caregiver in months 103.7 103.2 number of daily hours devoted to care 12.3 7.8 source: the authors. description of the “burden” and “social support” variables the description of the caregivers’ burden variable as measured by the zarit questionnaire and the perceived social support variable as established by the mos questionnaire are shown in table 3. regarding the caregivers’ burden variable, the prevalence of a mild burden was obtained, with a mean of 53.16 (sd = 14.47). regarding the social support perceived by the caregivers, the mean was 67.21 (sd = 17.77), corresponding to a high level. table 3. descriptive statistics of the study variables variable min. max. mean standard deviation 95 % ci caregivers’ burden impact dimension 12 54 31.05 9.18 29.66-32.44 interpersonal dimension 6 27 11.17 4.06 10.55-11.79 competencies and expectations dimension 2 20 10.94 3.56 10.40-11.48 total zarit 22 101 53.16 14.47 50.97-55.35 perceived social support emotional/ informational social support 8 40 28.15 8.11 26.92-29.38 instrumental support 4 20 12.99 4.51 12.30-13.67 positive social interaction 4 20 14.46 4.02 13.86-15.07 effective support 3 15 11.61 3.35 11.10-12.11 total of all dimensions 24 95 67.21 17.77 64.52-69.90 source: the authors. correlations between variables table 4 presents the statistically significant correlations found between the different variables measured in the study. a statistically significant and positive correlation was found between the caregivers’ age and their time in the role and between the caregivers’ age and the number of daily hours devoted to care. a correlation between the “time as a caregiver” and “number of daily hours devoted to care” variables, the impact and interpersonal dimensions, and the overall zarit burden score was also identified. on the other hand, a negative and statistically significant correlation (p < 0.001) was established between the zarit burden dimensions and the different support dimensions from the mos questionnaire, indicating that a higher burden was significantly correlated with low support scores or vice versa. table 4. correlations between variables variables caregiver’s age no. of daily hours devoted to care impact dimension interpersonal dimension competencies and expectations dimension total zarit time as a caregiver 0.246** 0.151 0.159* 0.055 0.143 0.151* no. of daily hours devoted to care 0.321** 0.331** 0.176* 0.076 0.278** emotional/ informational social support -0.005 -0.100 -0.161* -0.236** -0.339** -0.252** instrumental support -0.121 -0.165* -0.264** -0.261** -0.236** -0.299** positive social interaction -0.039 -0.051 -0.226** -0.230** -0.244** -0.268** effective support -0.014 -0.040 -0.209** -0.305** -0.310** -0.294** total of all dimensions (mos) -0.045 -0.106 -0.232** -0.283** -0.328** -0.307** (*) p < 0.05, (**) p < 0.001 source: the authors. discussion according to the results, this low-income population group probably assumes the caregiver role facing more significant difficulties. as they spend more time on care tasks, they miss job opportunities and find it hard to earn a livelihood to meet their everyday needs and care demands (19, 26). as seen in this study, 70.0 % of the caregivers are unemployed and devote around twelve hours daily to housework. the caregivers’ low socioeconomic level impacts access to the health system and relevant information about their health status (27, 28). for the current study, the burden was reported as mild, with a mean of 53.16 and a standard deviation of 14.47; in general, the reported trend regarding a nonexistent or low burden that predominates in similar studies about caregivers’ burden in colombia is maintained, where 59.68 % and 20.97 % reported a null and mild burden, respectively (12, 29). although the burden levels were low, it is vital to prevent them from increasing by implementing a timely intervention to improve the quality of life for patients and their caregivers. a direct relationship was also found between the burden levels and the time that family caregivers devote to care tasks (0.151; p < 0.05), as well as a correlation between burden and the number of daily hours devoted to care (0.278; p < 0.01). carreño and chaparro had already reported these variables in their study (12), with which we agree. other research studies with similar results in terms of the daily hours devoted to care reveal that devoting much time to these tasks can cause physical and mental health problems in caregivers, as well as stress and a reduction in subjective well-being, which exerts a direct influence on the quality of life (30). regarding perceived social support, several authors agree that socioeconomic condition determines how this social support is perceived. in (20), low-income individuals enjoy less social support, a situation aggravated by a lack of knowledge about access to health services and social aids. the results obtained in this study about perceived social support are not far from what was found in others, as we got a high score with a mean of 67.21, whereas barrera et al. obtained a score of 75.2; in addition, they identified that the caregivers, mainly those from the amazonía and orinoquía regions, were satisfied with their perceived social support, with scores of 70.1 and 67.6, respectively (31). moreover, in (6), although perceived social support was measured with hilbert’s social support in chronic illness inventory (sscii), the results obtained were high, with an average of 110.7, which means that family caregivers of people with chronic diseases are somewhat satisfied with the social support they perceive (32). this study found an association between social support and burden levels, understanding that greater perceived social support of any type is related to lower burden levels, with a correlation of -0.307 (p < 0.001). these findings are consistent with those obtained in (13) with low-income afro-american caregivers living in the united states and (29) in  bucaramanga, colombia, where the caregivers with intense burden levels reported having no psychological or social support. considering the results obtained, the practical implications of this study evidence the need to seek strategies from the nursing area to strengthen social support, understanding this support as necessary for the caregivers to be able to face and adequately take on their role with no undesirable consequences and prevent burden. it has been shown that developing laws, decrees, and grants, among others, contributes to reducing the impacts imposed by the role and improving the caregivers’ socioeconomic conditions, as some countries already do with various programs, such as those granting a disability pension in india (19) or the economic aids funded by the government in canada, africa, and spain (20, 32, 33). a limitation identified in the current study is the possible selection bias due to intentional sampling to obtain the results; therefore, they will apply to the sample under investigation and may be extrapolated to population groups with similar characteristics. it is also worth noting that this study was conducted during the covid-19 pandemic period experienced in colombia, so the results obtained might be influenced by the caregivers’ aggravating factors due to the restrictions, isolation measures, and rules imposed by the colombian ministry of health and the direct socioeconomic consequences brought about by these restrictions. thus, a higher than the forecast number of answers was allowed to increase the results’ variability. lastly, these results represent a practical approach for nursing in colombia concerning perceived social support and burden among low-income caregivers, which allows working continuously on the design and validation of strategies to prioritize this population segment or improve the results herein obtained. conclusions the burden was significantly correlated with the number of hours devoted to care and time as a caregiver. a significant negative correlation was statistically obtained between perceived social support and the burden dimensions, which shows that the burden imposed by the role can be reduced if the social support provided to these caregivers is improved. however, for earning lower incomes, this population group faces more significant difficulties in receiving social support. based on the results obtained in this study, an intervention from different disciplines, such as nursing, is necessary to devise state interventions, programs, and aids directed to these caregivers to ease their role and improve health results, both in themselves and in their patients. conflict of interest: none declared. references 1.   ops. enfermedades no transmisibles ops/oms [internet]. enfermedades no transmisibles. 2021. disponible en: https://www.paho.org/es/temas/enfermedades-no-transmisibles 2.   vos t, lim ss, abbafati c, abbas km, abbasi m, abbasifard m, et al. global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: 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nakasujja n, winch pj, gallo jj, opoka r, et al. caregiver mental health and hiv-infected child wellness: perspectives from ugandan caregivers. aids care psychological and socio-medical aspects of aids/hiv [internet]. 2017 jun 3;29(6):793–9. doi: https://doi.org/10.1080/09540121.2016.1263722 28.   tilahun d, hanlon c, fekadu a, tekola b, baheretibeb y, hoekstra ra. stigma, explanatory models and unmet needs of caregivers of children with developmental disorders in a low-income african country: a cross-sectional facility-based survey. bmc health serv res [internet]. 2016 apr 27;16(1). doi: https://doi.org/10.1186/s12913-016-1383-9 29.   campos de aldana ms, durán niño ey, rivera carvajal r, páez esteban an, carrillo gonzález gm. sobrecarga y apoyos en el cuidador familiar de pacientes con enfermedad crónica. revista cuidarte. 2019 sep 13;10(3). doi: https://doi.org/10.15649/cuidarte.v10i3.649 30.   eterovic díaz c, mendoza parra s, sáez carrillo k. caring ability and overload level in informal caregivers of dependent people. enfermería global. 2015;14(2):235–48. doi: https://doi.org/10.6018/eglobal.14.2.198121 31.   barrera ortiz l, campos ms, gallardo solarte k, coral ibarra rdc, hernández bustos a. soporte social percibido por las personas con enfermedad crónica y sus cuidadores familiares en cinco macro regiones geográficas de colombia. univ salud. 2016 apr 29;18(1):102. doi: https://doi.org/10.22267/rus.161801.23 32.   del pino jar, signes es, mas ts, ruíz aem, traura sm. informal male caregivers in the city of valencia. an experience of reciprocity. obets. 2018;13(2):645-70. doi: https://doi.org/10.14198/obets2018.13.2.08 33.   yakubu yam, schutte dw. socio-economic determinants and environmental hygiene factors of female caregiver burden in two selected low-income communities in cape town, south africa. pan african medical journal [internet]. 2019;34:80. doi: https://doi.org/10.11604/pamj.2019.34.80.16719 home cerrar b e b ol d: u se n ur si ng k no w le dg e to g ui de t he p ra ct ic e 1 lorena sánchez-rubio https://orcid.org /0000-0001-8728-7283 universidad del tolima, colombia lorenasanchez@ut.edu.co editorial be bold: use nursing knowledge to guide the practice keywords (source: decs) nursing; nursing theory; knowledge; professional practice. palabras clave (fuente: decs) enfermería; teoría de enfermería; conocimiento; práctica profesional. palavras-chave (fonte: decs) enfermagem; teoria de enfermagem; conhecimento; prática profissional. sé audaz: utiliza el conocimiento de enfermería para guiar la práctica seja ousado: use o conhecimento de enfermagem para guiar a prática doi: 10.5294/aqui.2023.23.3.1 para citar este editorial / to reference this editorial / para citar este editorial sánchez-rubio l. be bold: use nursing knowledge to guide the practice. aquichan. 2023;23( 3):e2331. doi: https://doi.org /10.5294/aqui.2023.23.3.1 https://orcid.org/0000-0001-8728-7283 mailto:lorenasanchez@ut.edu.co https://doi.org/10.5294/aqui.2023.23.3.1 https://doi.org/10.5294/aqui.2023.23.3.1 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2023.23.3.1&amp;domain=pdf&amp;date_stamp=2023-08-17 2 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 1 our first journey is to find that special place for us... florence nightingale the challenge: be bold being bold implies facing the challenges presented in the current nursing situation. the sanitary crisis produced by the covid-19 pandemic evidenced the strengths and weaknesses of global public health, as well as the opportunities and threats for our profession (2). this and the other crises we are facing demand bold and immediate actions; actions that require nurses to be able to adapt, innovate, and lead the change needed to face the population’s health needs and challenges. we are working on it; our view goes beyond the identification of problems. besides having a body of knowledge that is better articulated with the practice, we are in a privileged position that not only brings us closer to the people, but it makes us be perceived as the most reliable professionals in the health system. these elements prepare the stage to work toward nursing visibility. now, more than ever, we need to be bold and contribute our experience and vision to participate in the qualification of education, the promotion of research, the generation of knowledge that guides the practice, and the transformation of the health systems in particular contexts. ken dion, international president of sigma, encourages nurses to be bold in three critical domains: economics, technology, and preservation. from economics, considered the science of making decisions, time and resources are fundamental, and value and confidence are power elements that nurses must know how to manage to influence in the decision stages. technology must be our ally to transform the health systems; a leader-nurse can contribute to implementing safer care, based on knowledge integrated and patient-centered knowledge (3). preservation consists of thinking about planetary health and how we, as leaders, can inspire communities with actions that empower them to prevent the effects environmental changes and emergencies have on health (4). practice, research, and theory: the triad that legitimizes, consolidates, and nurtures nursing knowledge nursing is a professional discipline that seeks to answer to the social and practice needs related to the healthcare experiences of human beings (5). the practice is the space where nurses become visible; in it, they communicate their knowledge and abilities, recognize the causal factors, and look for solutions to people’s problems. the change of direction and the loss of course in the practice (doing b e b ol d: u se n ur si ng k no w le dg e to g ui de t he p ra ct ic e 3 the practice outside of the nursing domain or without theoretical background, subordinate working, distancing from the patients, etc.) distort and turn the practice into a routinary and senseless technique with unfortunate consequences for the people (deficient health results) and for the discipline (frustration and quitting intentions). all of this was evidenced during the pandemic; to counteract it is imperative to guarantee that nurses can have an autonomous practice supported by theory. coordinated effort and participation in working networks that define common interests and influence political and social decisions are the way to accomplish it. table 1. some ideas on how to be bold implications be bold from the practice y recognize your abilities and knowledge; put them to the service of the patients and the team. y make joint decisions—recognize that you are part of a larger group of health professionals within the health system. y keep yourself updated, be critical, question what you see and feel is wrong, propose change, and act! y work towards the humanization of hospital contexts and do what only nursing can do—care professionally! y during your service make the nurse’s job visible and return to the direct care of your patient and the family; there is where the profession is most valued. y take a leadership role—do not be afraid of failure. y practice in the spaces where decisions are made, do not let any opportunity to be heard pass. y test the nursing theory to guide your practice. think as a theorist and propose a model or guide for care integrating your experience and research. from education y be the best role model for your colleagues and training professionals. y connect your students with other schools/universities to share learning experiences. y create work alliances with the institutions where practicums take place, this will guarantee an appropriate and welcoming environment for students’ training. y innovate using technology tools for learning. y learn and teach how to research, that your research generates knowledge for nursing. y give leadership opportunities to your students and cultivate their love for the profession by reinforcing the accomplished goals. y assume a mentoring role and establish affectionate relationships. besides being a teacher, a mentor must be a trusting friend that promotes the personal and professional development of the student. source: prepared by the author. how can we accomplish an autonomous practice supported by the theory? according to durán de villalobos, it is impossible to think about the practice without knowledge support (theory), and knowledge that has not been supported in the syntactic structure of research cannot be accepted (6, 7). 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 1 nursing theorists affirm that it is necessary to make changes in the training of nurses so that they create knowledge as well as apply it. a strategy for that is to foster the creation, transformation, and application of knowledge derived from the practice. in this way, it is possible to efficiently answer the growing demands to satisfy high-quality attention in changing contexts with limited financial resources (8). in this pluralist view, the nursing practice is recognized as a source of knowledge and theory that considers socio-cultural, political, and contextual (health and care) factors such as values, beliefs, diversity, equity, reflection around the nurses a theorist, and the researcher-researched relationship (8, 9). practice-based knowledge may be guided by two fundamental elements: knowledge (derived from multiple sources) and the transmission of that knowledge (i.e., using evidence-framed science, thought and criticized within particular contexts as a decision-making tool). practice-base knowledge reduces the gap between theory and practice because it encourages the nurse to innovate and be open to change using conceptual systems (ideas that influence and are, in turn, influenced by the context) (10). how can practicing nurses develop theory? nursing theory development must not be an exclusive task of specialists and researchers. after all, as meléis states: “the objective of nursing science is to develop theories to describe, explain, and understand the nature of phenomena, and anticipate the occurrence of events and situations direct or indirectly related to nursing care” (11), that is, with the nursing practice. the expertise gained through practice and postgraduate education prepares nurses to adapt the existing theories and to develop new ones from the meticulous observation of the practice; these theories will be applied, tested, and transformed into self-knowledge through research (10). one of the best strategies for a practicing nurse to develop theories is the specific situation theory, a type of theory that reflects on care phenomena from specific populations in particular contexts (12). to formulate a specific situation theory, nursing perspectives, links between theory, research and practice, and concepts organized in a creative fashion become of greater relevance. the products of these theories include action plans and integrative frameworks or guides for practice and research in nursing care (13, 14). discussion in the letter for change (15), the international nursing council urges governments, civil society, and health service providers to value, protect, respect, and invest in nurses for the sustainable future of health services. the voices of 28 million nurses worldwide demand b e b ol d: u se n ur si ng k no w le dg e to g ui de t he p ra ct ic e 5 the creation and maintenance of safe, affordable, and accessible healthcare systems. the commandment of fundamental political actions is an urgent call to humanity in which raising the voice is an act of courage that claims the fundamental right to health as an investment for the general well-being. to hold the structure of contemporary nursing knowledge and to avoid its fragmentation, it is essential to reflect on what nursing is, what it can do, and how what nursing is can influence what it does (16). in other words, we must take a step back and question who we are, where we come from, and where we are going. what shall we do to find our path? (i) respect and promote the nurses’ performance as health professionals (theorists, scientists, researchers, instructors, and leaders), (ii) invest in accredited high-quality training programs, (iii) empower nurses to work in the practice field, and (iv) actively cooperate in the construction of local and global alliances between different national nursing associations. there is a discernable emancipatory nursing movement in latin america. participation from unions (scientific, professional, managerial, etc.) is more important each time, we finally understood there is strength in numbers. in colombia, the governing entities in charge of directing, organizing, appointing, and controlling the nursing professional practice formulated for the 2020-2030 decade a national nursing policy that promotes knowledge development by practicing nurses for their practice to be more autonomous (17). if we want this plan to become a reality, all nurses must participate in it, also contributing to the development of new theoretical knowledge. conclusion nursing organization and mobilization are a priority we must consider if we want the development and practice of the profession to answer to society’s needs and the universal health access guarantee. to reach this goal, sigma invites us to be bold in practice, research, and education; it encourages us to be agents of change, develop theories, share knowledge, and cooperate with other professionals. it also inspires us to be leaders, influence public policies, stand up for our rights, and empower our colleagues. the benefit is invaluable—the training of bold leaders, who are creators of professional networks and are at the forefront of nursing knowledge. being bold is then a quality that must define nursing professionals to achieve excellence. 6 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 1 references 1. sigma. sigma theta tau international honor society of nursing [internet]; 2023. https://sigmanursing.org / 2. downey e, fokeladeh h, catton h. what the covid-19 pandemic has exposed: the findings of five global health workforce professions. 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https://doi.org/10.2307/3425219 https://doi.org/10.1097/00012272-199912000-00003 https://doi.org/10.1097/00012272-200504000-00006 https://doi.org/10.1097/00012272-200504000-00006 https://doi.org/10.1891/1541-6577.28.4.278 https://doi.org/10.1891/1541-6577.28.4.278 https://www.icn.ch/sites/default/files/2023-07/icn_ind_2023_report_en.pdf https://www.icn.ch/sites/default/files/2023-07/icn_ind_2023_report_en.pdf https://www.icn.ch/sites/default/files/2023-07/icn_ind_2023_report_en.pdf sa lie nt b el ie fs in t he in te nt io n fo r se lf -c ar e b eh av io rs w he n fa ci ng h yp er te ns iv e d is or de rs in p re gn an t w om en 1 iliana milena ulloa sabogal https://orcid.org /0000-0003-1605-6837 universidad de antioquia, colombia iliana.ulloa@udea.edu.co edier mauricio arias rojas https://orcid.org /0000-0003-2096-1792 universidad de antioquia, colombia emauricio.arias@udea.edu.co artículo salient beliefs in the intention for self-care behaviors when facing hypertensive disorders in pregnant women received: 07/12/2022 sent to peers: 12/01/2023 approved by peers: 22/04/2023 accepted: 23/05/2023 doi: 10.5294/aqui.2023.23.2.8 to reference this article / para citar este artículo / para citar este artigo ulloa im, arias em. salient beliefs in the intention for self-care behaviors when facing hypertensive disorders in pregnant women. aquichán. 2023;23(2):e2328. doi: https:// doi.org/10.5294/aqui.2023.23.2.8 https://orcid.org/0000-0003-1605-6837 mailto:iliana.ulloa@udea.edu.co https://orcid.org/0000-0003-2096-1792 https://doi.org/10.5294/aqui.2023.23.2.8 https://doi.org/10.5294/aqui.2023.23.2.8 https://doi.org/10.5294/aqui.2023.23.2.8 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2023.23.2.8&amp;domain=pdf&amp;date_stamp=2023-07-17 theme: promotion and prevention contribution to the subject: the behavioral, normative, and control salient beliefs represent indirect measures that will act on the previous determinants in the behavioral intention. consequently, identifying women’s salient beliefs about self-care behaviors when facing hypertensive disorders in pregnancy allows knowing the factors that exert positive and negative influences on maternal care and for which nursing actions should be strengthened during prenatal care. in addition, it contributes to the elaboration of measuring instruments that allow assessing the impact of health interventions targeted at preventing and reducing the risk of this obstetric complication based on theoretical constructs. sa lie nt b el ie fs in t he in te nt io n fo r se lf -c ar e b eh av io rs w he n fa ci ng h yp er te ns iv e d is or de rs in p re gn an t w om en 3 abstract introduction: hypertensive disorders of pregnancy represent a maternal and perinatal health problem. therefore, it is important to identify the beliefs preceding the determinants of health behaviors during pregnancy. objective: to identify the salient beliefs in the intention for selfcare behaviors when facing hypertensive disorders in pregnant women. materials and methods: a descriptive study with a quantitative approach guided by the theory of planned behavior. each questionnaire was designed and its semantic validity was assessed. the sample was convenience one and included 114 pregnant women enrolled in prenatal control at a health institution from piedecuesta, santander, who answered the questionnaire via telephone calls between january and february of 2022. data analysis was descriptive, resorting to absolute and relative frequencies. results: the positive behavioral beliefs were focused on the mother’s proper nutrition, the baby’s healthy growth and development, disease prevention and control during pregnancy, the mother’s relaxation and peace of mind, and blood pressure control and monitoring. regarding normative beliefs, health personnel, mothers, husbands, and family members exert positive influences on each behavior. the following were acknowledged among the control beliefs: visiting family members promotes the practice of physical exercises; at the nutritional level, there is a habit of preferring low-salt preparations; both family and social support and habit and preference favor the consumption of fruit, vegetables, legumes and meats; lack of habit avoids the consumption of fats, flours, sugars, caffeine, alcohol, and cigarettes; purchase power favors calcium intake; taking a previous shower promotes rest and sleep, and going to pharmacies allows controlling blood pressure. conclusions: identifying the salient beliefs allowed determining those that need to be reinforced, negotiated, or restructured in achieving self-care behaviors when facing hypertensive disorders in pregnancy. keywords (fonte: decs) self-care; beliefs; maternal health; health behaviors; hypertension, pregnancy-induced; intention; pregnant women; social theory. 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 28 resumen introducción: los trastornos hipertensivos del embarazo representan un problema en la salud materna y perinatal. por lo tanto, es importante identificar las creencias que preceden a los determinantes de los comportamientos en salud durante el embarazo. objetivo: identificar las creencias salientes en la intención de comportamientos de autocuidado ante los trastornos hipertensivos por parte de la mujer embarazada. materiales y métodos: estudio descriptivo de enfoque cuantitativo guiado por la teoría del comportamiento planificado. se diseñó y evaluó la validez semántica de cada cuestionario. la muestra por conveniencia fue de 114 embarazadas inscritas en el control prenatal de una institución de salud de piedecuesta, santander, las cuales respondieron el cuestionario a través de entrevista telefónica, entre enero y febrero de 2022. el análisis de los datos fue descriptivo, utilizando frecuencias absolutas y relativas. resultados: las creencias conductuales positivas se enfocaron en la adecuada nutrición de la madre; en el sano crecimiento y desarrollo del bebé; la prevención y control de enfermedades durante el embarazo; la relajación y la tranquilidad de la madre; y el control y seguimiento de la presión arterial. en las creencias normativas, el personal de salud, la madre, el esposo y familiares influyen positivamente en cada comportamiento. entre las creencias de control, se admite que: visitar familiares promueve la práctica del ejercicio; a nivel nutricional existe el hábito por preparaciones bajas en sal; tanto el apoyo familiar y social como el hábito y el gusto favorecen el consumo de frutas, verduras, legumbres y carnes; la falta de hábito evita el consumo de grasas, harinas, azúcares, cafeína, alcohol o cigarrillo; la capacidad económica favorece la ingesta del calcio; tomar una ducha previa promueve el sueño y descanso; y asistir a farmacias permite el control de la presión arterial. conclusiones: la identificación de las creencias salientes permitió demostrar aquellas que necesitan ser reforzadas, negociadas o reestructuradas en el logro de comportamientos de autocuidado ante los trastornos hipertensivos del embarazo. palabras clave (fuente: decs) autocuidado; creecias; cultura; salud materna; comportamientos relacionados con la salud; hipertensión inducida en el embarazo; intención; mujeres embarazadas; teoría social. creencias salientes en la intención de comportamientos de autocuidado ante los trastornos hipertensivos en mujeres embarazadas sa lie nt b el ie fs in t he in te nt io n fo r se lf -c ar e b eh av io rs w he n fa ci ng h yp er te ns iv e d is or de rs in p re gn an t w om en 5 crenças relevantes na intenção de comportamentos de autocuidado para síndromes hipertensivas gestacionais resumo introdução: as síndromes hipertensivas gestacionais representam um problema na saúde materna e perinatal. portanto, é importante identificar as crenças que precedem os determinantes dos comportamentos de saúde durante a gravidez. objetivo: identificar as crenças relevantes na intenção de comportamentos de autocuidado diante de distúrbios hipertensivos por parte das gestantes. materiais e método: estudo descritivo com abordagem quantitativa orientada pela teoria do comportamento planejado. a validade semântica de cada questionário foi elaborada e avaliada. a amostra de conveniência foi composta de 114 gestantes inscritas no pré-natal de uma instituição de saúde em piedecuesta, santander (colômbia), que responderam ao questionário por meio de entrevista telefônica entre janeiro e fevereiro de 2022. a análise dos dados foi descritiva, usando frequências absolutas e relativas. resultados: as crenças comportamentais positivas se concentraram em nutrição adequada para a mãe; crescimento e desenvolvimento saudáveis do bebê; prevenção e controle de doenças durante a gravidez; relaxamento e tranquilidade para a mãe; e controle e monitoramento da pressão arterial. nas crenças normativas, a equipe de saúde, a mãe, o companheiro e os membros da família influenciam positivamente cada comportamento. entre as crenças de controle, admite-se que visitar parentes promove a prática de exercícios; no nível nutricional, há o hábito de preparações com pouco sal; tanto o apoio familiar e social quanto o hábito e o gosto favorecem o consumo de frutas, verduras, legumes e carnes; a falta de hábito evita o consumo de gorduras, farinhas, açúcares, cafeína, álcool ou cigarros; a capacidade econômica favorece a ingestão de cálcio; tomar banho antes da gravidez promove o sono e o descanso; e ir a farmácias permite o controle da pressão arterial. conclusões: a identificação das crenças relevantes nos permitiu demonstrar aquelas que precisam ser reforçadas, negociadas ou reestruturadas na obtenção de comportamentos de autocuidado diante de síndromes hipertensivas gestacionais. palavras-chave (fonte decs) autocuidado; crenças; cultura; saúde materna; comportamentos relacionados com a saúde; hipertensão induzida pela gravidez; intenção; gestantes; teoria social. 6 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 28 introduction hypertensive disorders in pregnancy (hdp) are one of the main causes of maternal and fetal morbidity and mortality (1), especially in lowand middle-income countries (2). they affect approximately 10  % of all pregnancies and represent 14  % of all maternal deaths, which is why they are still an important public health problem globally (3). in latin america and the caribbean, hdp represents 25.7 % of all maternal deaths (4) and, in 2021, they were the leading direct cause of maternal death in colombia, with 14.6 % (5). studies conducted in different parts of the world have sought to establish the exact etiology of hdp; however, it is still unknown (3) and, therefore, both their prediction and prevention represent a major challenge  (6). in this sense, at the international  (6-9) and national (10) levels, guides for the clinical practice targeted at hdp prevention, detection, and treatment have been issued. among the preventive measures, calcium supplementation is established as the indication with the highest level of evidence and recommendation degree (9, 10). however, although more evidence is required to make recommendations related to diet, exercise, rest (7), restriction in the consumption of salt, alcohol and cigarettes, and workload or stress reduction (9), they are self-care behaviors that continue to be important in pregnant women and their family nucleus. the literature suggests that a large part of the complications related to hdp are the result of low knowledge levels, negative attitudes, and lack of sensitization among pregnant women towards the disease and health behaviors  (11). in the face of this problem, a theoretical proposal such as the theory of planned behavior (tpb) has been useful to understand, predict, and explain human behavior. according to the theory, behavior is determined by intention, which in turn is influenced by three determinants (12). the first one is attitude, which reflects the favorable or unfavorable assessment level towards a given behavior. the second one is subjective norms, which refer to the pressure exerted by significant people on the subject who approve or disapprove of a given behavior. finally, there is perceived behavioral control, defined as the personal ability to control the factors that ease or hinder performing a given behavior (12, 13). the tpb proposes that to predict the intention, it is indispensable to establish people’s salient beliefs about the behavior of interest; in other words, those that a person mentions more frequently and which are considered determinants of their actions. theoreticians distinguish three types of salient beliefs: 1) behavioral, which influence attitudes, 2) normative, which precede subjective norms, and 3) control, which constitute the grounds of behavioral control (12). in the context of caring for pregnant women, studies  (14-20) following the tpb approach have sought behavioral goals targeted at promoting health and preventing complications during pregnancy. however, research focused on establishing pregnant women’s besa lie nt b el ie fs in t he in te nt io n fo r se lf -c ar e b eh av io rs w he n fa ci ng h yp er te ns iv e d is or de rs in p re gn an t w om en 7 liefs towards self-care behaviors when facing hdp in the light of the tpb is still incipient in colombia and latin america. it is for that reason that it is fundamental to identify the beliefs preceding the determinant of behavioral intention in pregnant women. in addition, specifying the salient beliefs constitutes the first phase of the theoretical framework for the elaboration of measuring instruments and for planning interventions targeted at motivating the acquisition of health behaviors (21). consequently, the objective of the current study was to identify the salient beliefs in the intention for self-care behaviors when facing hypertensive disorders in pregnant women. materials and methods design a descriptive study with a quantitative approach guided by the tpb (12). it was conducted between january and february 2022 at a low-complexity public health institution from the municipality of piedecuesta, santander (colombia). sample considering the criteria of the tpb adopted in this study, a sample of 25 participants was selected to determine the salient beliefs about the behavior of interest (21). the population consisted of 289 women enrolled in the prenatal control program, of which 114 met the inclusion criteria and agreed to take part in the study. the inclusion criteria corresponded to pregnant women of at least 18 years old, enrolled in the prenatal control program at the health institution, with a gestational period equal to or less than 28 weeks, living in urban or rural areas. pregnant women with cognitive, linguistic or auditory limitations that hindered conducting the interviews were excluded. instruments the first instrument was a form with sociodemographic and clinical questions to define the participants’ characterization. the second instrument included a questionnaire for each selfcare behavior, targeted at obtaining the behavioral, normative, and control beliefs associated with hdp. the questionnaires were prepared and validated according to the guide for the elaboration of questionnaires outlined in the tpb from the author of the theory (22) and to the guide published by francis  (23), following three phases. the first phase involved identifying the self-care behaviors when facing hdp, based on a review of the scientific literature and clinical practice guides. after analyzing the information, the most relevant health behaviors for hdp risk prevention or control were extracted. the behaviors of interest included the 8 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 28 following: 1) practice of physical exercise, 2) sleep pattern and rest periods, 3)  salt consumption, 4)  consumption of fats, flours, and sugars, 5)  consumption of fruit, vegetables, and legumes, 6)  consumption of fish, chicken, and red meats, 7)  consumption of caffeinated drinks, alcohol, tobacco, or cigarettes, 8)  consumption of calcium supplements, and 9) blood pressure control. in the second phase and following the tpb recommendations  (12) and the author’s web page (22), each behavior was defined in terms of its objective, action, context, and time to know the advantages and disadvantages, the positive and negative referents, and the factors that ease or hinder its performance. consequently, each of the nine questionnaires was structured with six questions, two for each type of belief and in an open-answer format  (22, 23). the questions were designed by the study researchers, taking as reference examples from the authors of the tpb  (22) and the study by sousa et al. (21). subsequently, they were verified by a linguist and assessed by a group of researchers from universidad de antioquia. the final version of the instruments included the recommendations made by the experts. the questions formulated for the behavioral, normative, and control beliefs are stated below, taking the practice of physical exercises during pregnancy as an example. for the behavioral beliefs: “in your opinion, which are the advantages of practicing physical exercise at least for thirty minutes and five times a week in the next month?” and “which are the disadvantages of practicing physical exercise at least for thirty minutes and five times a week in the next month?”. for the normative beliefs: “in your opinion, which significant others would approve or believe that you should practice physical exercise at least for thirty minutes and five times a week in the next month?” and “which significant others would disapprove or believe that you should not practice physical exercise at least for thirty minutes and five times a week in the next month?”. for the control beliefs: “in your opinion, which are the factors or circumstances that would ease or allow you to practice physical exercise at least for thirty minutes and five times a week in the next month?” and “which are the factors or circumstances that would hinder or preclude you from practicing physical exercise at least for thirty minutes and five times a week in the next month?”. in the third phase, following the guidelines outlined in the tpb (22) and the guide by francis et al. (23), each questionnaire was submitted to a semantic validity test based on individual interviews with 5 pregnant women from the target population. they were asked to read the instrument and report any difficulty to understand the writing of each question. when a participant stated not understanding or not knowing the meaning of any term, she was asked to express what she understood and other terms that might replace the unknown word were proposed. subsequently, the researchers consolidated the observations made by the participants and, in the light of the theoretical conceptualization, adjustments were implemented in sa lie nt b el ie fs in t he in te nt io n fo r se lf -c ar e b eh av io rs w he n fa ci ng h yp er te ns iv e d is or de rs in p re gn an t w om en 9 the semantic structure of some questions along with a linguist, to improve clarity and understanding of each instrument. in synthesis, the pregnant women stated having difficulties understanding the following terms: ‘supplement,’ ‘caffeine,’ and ‘arterial tension,’ which were replaced by ‘pill,’ ‘caffeinated drinks,’ and ‘blood pressure,’ respectively. likewise, there was certain confusion when interpreting the term ‘diet;’ therefore, it was removed. data collection the participants that met the inclusion criteria were contacted by telephone, explained the study objective, and asked for their voluntary participation and verbal consent. the interviews were conducted by a nurse via telephone calls. during the interviews, the sociodemographic and clinical characterization form was applied, as well as the questionnaire about salient beliefs in the intention for self-care behaviors when facing hdp. each interview lasted between 20 and 25 minutes, and the participants’ answers were recorded in written form during the time of the telephone call. each participant answered two questionnaires. data analysis a database in microsoft office excel was designed to analyze the information obtained. a descriptive analysis was performed with the sociodemographic and clinical variables of the sample. the continuous variables were evaluated using frequency distributions and central tendency measures. the categorical variables were analyzed based on the calculation of absolute and percentage frequencies. the beliefs corresponding to each self-care behavior were submitted to thematic analysis, according to the recommendations proposed by the tpb  (22, 23). at first, the researchers independently analyzed the content of the answers to each belief and labeled them in topics, according to the similarity criterion and their frequency. subsequently, each of the topics was numbered from those containing the most mentioned salient beliefs to the least mentioned. as a criterion, it was adopted that the salient beliefs were those that were mentioned at least three times; in other words, beliefs with a representativeness percentage equal to or greater than 75  % of all those stated by the participants, an index with which proper coverage of the beliefs of the entire population is achieved (23). ethical considerations this research was approved by the health institution and by the research ethics committee of the nursing school belonging to universidad de antioquia (minute no. cei-fe 2021-31). in addition, it respected the scientific, technical and administrative norms for 10 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 28 health research contemplated in resolution no.  008430 of 1993 by the colombian ministry of health and social protection (24). results a total of 114 pregnant women took part in this study, with a mean age of 24.63 years, maximum gestational age of 27.4 weeks, mostly primigravidae, living in urban areas, in stable unions and belonging to socioeconomic strata  2  (low) according to the classification issued by the national statistics administration department (25). additional details regarding the participants’ sociodemographic and clinical characterization are presented in table 1. table 1. characterization of the study participants’ sociodemographic and clinical profile. piedecuesta, santander, 2022 variable n=114 (%) age (years old) mean median (sd iqr min max.) (24.63 24) (5.57 21 18 39) area of residence urban rural 91 (79.82) 23 (20.17) marital status single consensual union married 13 (11.40) 86 (75.43) 15 (13.15) schooling elementary school bachelor’s degree technical/technology university 8 (7.01) 87 (76.31) 13 (11.40) 6 (5.26) socioeconomic strata 1 low low 2 low 3 average low 41 (35.96) 51 (44.73) 22 (19.29) occupation house chores student independent employee 74 (64.91) 9 (7.89) 24 (21.05) 7 (6.14) number of pregnancies 1 2 3+ 48 (42.10) 42 (36.84) 24 (21.05) number of deliveries 0 1 2+ 74 (64.91) 29 (25.43) 11 (9.64) sa lie nt b el ie fs in t he in te nt io n fo r se lf -c ar e b eh av io rs w he n fa ci ng h yp er te ns iv e d is or de rs in p re gn an t w om en 11 variable n=114 (%) number of c-sections 0 1 2 91 (79.82) 17 (14.91) 6 (5.26) number of miscarriages 0 1 2 101 (88.59) 12 (10.52) 2 (1.75) gestational age (weeks) mean median (sd iqr min max.) 19.02 18.60 (5 24 19.40 8 27 40) sd: standard deviation; iqr: interquartile range; min: minimum value; max: maximum value source: prepared by the authors. the representativeness frequency and percentage corresponding to the behavioral, normative, and control beliefs mentioned in each of the nine self-care behaviors when facing hdp that were explored in this study are presented below. table  2 describes the behavioral salient beliefs related to the advantages and disadvantages perceived by the participants for each self-care behavior. the main advantages are focused on the mother’s proper nutrition, healthy growth and development of the baby, disease prevention and control during pregnancy, and relaxation, rest and tranquility of the mother and baby. table 2. frequency of behavioral beliefs about self-care behaviors when facing hdp self-care behavior advantages fr (%) disadvantages fr (%) physical exercise it improves the mother’s and baby’s health. 21 (32.30) no disadvantage 17 (62.96) it serves as preparation for delivery. 20 (30.76) it generates tiredness, pain and abdominal discomforts. 6 (22.22) it improves the respiratory, circulatory and musculoskeletal systems. 8 (12.30) it generates excessive and inadequate force or positions. 4 (14.81) other advantages. 16 (24.59) total 65 (100) 27 (100) behavioral salient beliefs 49 (75.36) 23 (85.18) reducing salt consumption it prevents high blood pressure. 14 (35) no disadvantage 18 (72) it prevents diseases in the mother. 10 (25) food taste loss 4 (16) it promotes the baby’s development and well-being. 6 (15) loss of appetite or taste for food 1 (4) other advantages 10 (30) other disadvantages 2 (8) 12 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 28 self-care behavior advantages fr (%) disadvantages fr (%) total 40 (100) 25 (100) behavioral salient beliefs 30 (75) 22 (88) consumption of fruit, vegetables and legumes it contributes vitamins and minerals that promote the healthy growth and development of the baby. 27 (51.92) no disadvantage 25 (100) it prevents diseases in the mother and contributes to her health. 12 (23.07) it contributes to maintaining healthy eating. 8 (15.38) other advantages 5 (9.6) total 52 (100) 25 (100) behavioral salient beliefs 39 (74.99) 25 (100) consumption of fish, chicken and red meats it contributes vitamins, minerals and proteins in the nutrition of the baby. 22 (42.30) no disadvantage 20 (80) it promotes baby’s growth. 9 (17.30) other disadvantages 5 (20) it promotes adequate nutrition in the mother. 8 (15.38) other advantages 13 (24.98) total 52 (100) 25 (100) behavioral salient beliefs 39 (74.98) 20 (80) calcium intake it promotes baby’s growth, development, and well-being. 25 (55.55) no disadvantage 19 (76) nutritional supplement for the mother and the baby. 8 (17.77) it increases nausea and acid reflux 2 (8) it prevents dental and bone decalcification in the mother. 6 (13.32) other disadvantages 4 (16) other advantages 6 (13.32) total 45 (100) 25 (100) behavioral salient beliefs 39 (86.64) 19 (76) reducing consumption of fats, flours and sugars it prevents health problems in the mother (diabetes and hypertension). 25 (41.66) no disadvantage 25 (100) it promotes baby’s growth, development and well-being. 16 (26.66) it maintains the mother’s healthy weight. 9 (15) it prevents complications during delivery 3 (5) other advantages 7 (11.66) total 60 (100) 25 (100) behavioral salient beliefs 50 (83.32) 25 (100) sa lie nt b el ie fs in t he in te nt io n fo r se lf -c ar e b eh av io rs w he n fa ci ng h yp er te ns iv e d is or de rs in p re gn an t w om en 13 self-care behavior advantages fr (%) disadvantages fr (%) avoiding caffeinated drinks, alcohol, tobacco or cigarettes it prevents malformations in the baby and promotes their growth and development. 18 (58.06) no disadvantage 25 (100) it contributes to preserving the mother’s health. 11 (35.48) it prevents high blood pressure. 2 (6.45) total 31 (100) 25 (100) behavioral salient beliefs 29 (93.54) 25 (100) sleep and rest it favors the mother’s rest, relaxation, and tranquility. 17 (33.33) no disadvantage 25 (100) it contributes to the baby’s development, rest, and relaxation. 16 (31.37) it improves the mother’s mood and energy levels. 8 (15.68) it reduces the mother’s stress levels. 4 (7.84) other advantages 6 (19.6) total 51 (100) 25 (100) behavioral salient beliefs 41 (80.38) 25 (100) blood pressure control it allows controlling the blood pressure levels. 18 (48.64) no disadvantage 25 (100) it eases controlling and monitoring the mother’s and baby’s health. 14 (37.83) it prevents complications during pregnancy. 3 (8.10) unknown advantages of performing blood pressure control. 2 (5.40) total 37 (100) 25 (100) behavioral salient beliefs 22 (86.47) 25 (100) source: prepared by the authors table  3 presents the normative salient beliefs related to the positive and negative referents; in other words, the people that are significant for the participants and who consider that they should or should not perform each of the self-care behaviors when facing hdp. in this type of belief, health personnel, mothers, husbands or spouses and other family members (sisters, uncles, grandmothers and mothers-in-law) are positive referents exerting a higher influence on women to adopt, change or discard self-care behaviors when facing hdp. 14 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 28 table 3. frequency of normative beliefs about self-care behaviors when facing hdp self-care behaviors positive referents fr (%) negative referents fr (%) physical exercise mother 12 (28.57) nobody 19 (73.07) husband/partner 10 (23.80) other family members 4 (15.37) nobody 8 (19.04) other referents 3 (11.53)other family members 6 (14.28) other referents 6 (14.28) total 42 (100) 26 (100) normative salient beliefs 36 (85.69) 23 (88.44) reducing salt consumption mother 11 (26.82) nobody 24 (96) other family members 10 (24.39) other family members 1 (4) health personnel 7 (17.07) nobody 7 (17.07) other referents 6 (14.62) total 41 (100) 25 (100) normative salient beliefs 35 (85.35) 24 (96) consumption of fruit, vegetables and legumes health personnel 17 (26.56) nobody 24 (96) mother 17 (26.56) other referents 1 (4) other family members 14 (21.87) husband/partner 11 (17.18) other referents 5 (7.8) total 64 (100) 25 (100) normative salient beliefs 48 (74.99) 24 (96) consumption of fish, chicken and red meats health personnel 17 (30.35) nobody 22 (88) mother 14 (25) other referents 3 (12) husband/partner 12 (21.42) other family members 11 (19.64) nobody 2 (3.57) total 56 (100) 25 (100) normative salient beliefs 43 (76.77) 22 (88) calcium intake husband/partner 12 (26.66) nobody 22 (84.61) mother 11 (24.44) other family members 2 (7.69) health personnel 10 (22.22) other referents 2 (7.69)other family members 5 (11.11) other referents 7 (15.54) total 45 (100) 26 (100) normative salient beliefs 38 (84.43) 22 (84.61) reducing consumption of fats, flours and sugars health personnel 15 (30) nobody 23 (92) mother 11 (22) other family members 1 (4) husband/partner 9 (18) other referents 1 (4)other family members 6 (12) other referents 9 (18) total 50 (100) 25 (100) normative salient beliefs 41 (82) 23 (92) sa lie nt b el ie fs in t he in te nt io n fo r se lf -c ar e b eh av io rs w he n fa ci ng h yp er te ns iv e d is or de rs in p re gn an t w om en 15 self-care behaviors positive referents fr (%) negative referents fr (%) avoiding caffeinated drinks, alcohol, tobacco or cigarettes health personnel 12 (23.07) nobody 21 (84) husband/partner 11 (21.15) other referents 3 (12) mother 10 (19.22) other family members 1 (4) other family members 9 (17.30) other referents 6 (11.52) nobody 4 (7.69) total 52 (100) 25 (100) normative salient beliefs 42 (80.74) 21 (84) sleep and rest husband/partner 14 (31.11) nobody 23 (92) mother 10 (22.22) mother 1 (4) other family members 10 (22.22) other family members 1 (4)nobody 6 (13.33) other referents 5 (11.1) total 45 (100) 25 (100) normative salient beliefs 24 (75.55) 23 (92) blood pressure control nobody 21 (70) nobody 23 (92) other family members 5 (16.66) other referents 2 (8)mother 2 (6.66) husband/partner 2 (6.66) total 30 (100) 25 (100) normative salient beliefs 26 (86.66) 23 (92) source: prepared by the authors. table 4 describes the control salient beliefs related to the factors that ease or hinder performing each of the self-care behaviors when facing hdp. the control belief that eases the most performing physical exercises during pregnancy corresponds to walking when visiting friends or family members. at the nutritional level, preparing food options with low salt content, social and family support when buying or offering fruit, vegetables and legumes, preference for the consumption of meats and purchasing power to buy calcium are factors that ease these behaviors. likewise, lack of habit or taste for the consumption of fats, flour, sugars, caffeinated drinks, alcohol, tobacco or cigarettes are factors that prevent these type of behaviors. the sleep and rest pattern improves after taking a previous shower, and frequent micturition desire becomes a barrier. going to a pharmacy allows for performing periodic blood pressure controls. 16 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 28 table 4. frequency of control beliefs about self-care behaviors when facing hdp self-care behavior facilitating factors fr (%) hindering factors fr (%) physical exercise visiting friends and family members 7 (16.27) pain 8 (24.24) walking with family members 6 (13.95) no factor 7 (21.21) taking their children to school 6 (13.95) discomforts during pregnancy 6 (18.18) having parks and sports spaces nearby 5 (11.62) medical recommendation 5 (15.15) walking pets 4 (9.30) other factors 7 (21.21) going different places 4 (9.30) work/home conditions 3 (6.97) other factors 8 (18.59) total 43 (100) 33 (100) control salient beliefs 35 (81.36) 26 (78.78) reducing salt consumption preparations with low salt content 18 (46.15) no factor 25 (100) habit of consuming low-salt products 6 (15.38) high blood pressure diagnosis during pregnancy or hdp history 5 (12.82) family history of high blood pressure 3 (7.69) other factors 7 (17.92) total 39 (100) 25 (100) control salient beliefs 32 (82.04) 25 (100) consumption of fruit, vegetables and legumes support by friends or family members when buying or offering them 10 (20.40) no factor 16 (55.17) the husband/partner buys them 9 (18.36) economic factor 9 (31.03) habit and taste for their consumption 9 (18.36) intolerance 3 (10.34) purchase ease 6 (12.24) fruit or vegetables not available in the supermarket 1 (3.44) the mother or mother-in-law prepares the food 3 (6.12) other factors 12 (24.48) total 49 (100) 29 (100) control salient beliefs 37 (75.48) 25 (86.20) consumption of fish, chicken and red meats taste for their consumption 9 (24.32) no factor 9 (30) economic factor to buy them 9 (24.32) economic factor 7 (23.33) the husband/partner buys them 9 (24.32) aversion to their consumption 7 (23.33) habit of consuming them in the diet 5 (13.51) other factors 7 (23.33) other factors 5 (13.51) total 37(100) 30 (100) control salient beliefs 32 (86.47) 23 (76.66) sa lie nt b el ie fs in t he in te nt io n fo r se lf -c ar e b eh av io rs w he n fa ci ng h yp er te ns iv e d is or de rs in p re gn an t w om en 17 self-care behavior facilitating factors fr (%) hindering factors fr (%) calcium intake economic factor to buy them 12 (30) no factor 9 (29.03) the baby’s well-being 10 (25) not provided in the hospital 8 (25.80) provided by the health institution 6 (15) forgetting to take it 6 (19.35) strict time to take it 5 (12.5) health problems 4 (12.90) family members remind about taking it 3 (7.5) other factors 4 (12.89) other factors 4 (10) total 40 (100) 31 (100) control salient beliefs 33 (82.5) 27 (87.08) reducing consumption of fats, flours and sugars habit of avoiding their consumption 10 (27.02) no factor 15 (60) the baby’s well-being 6 (16.21) pregnancy cravings 5 (20) aversion to their consumption 5 (13.51) purchase power 2 (8) medical recommendation or from family members 4 (10.81) other factors 2 (8) history or alteration in the glucose test 4 (10.81) consumption habit 1 (4) other factors 8 (21.60) total 37 (100) 25 (100) control salient beliefs 29 (78.36) 20 (80) avoiding caffeinated drinks, alcohol, tobacco or cigarettes habit of not consuming them 25 (55.55) no factor 24 (96) the baby’s well-being 12 (26.66) coffee cravings 1 (4) they generate insomnia, headache, nausea and vomiting 6 (13.33) other factors 2 (4.44) total 45 (100) 25 (100) control salient beliefs 37 (82.21) 24 (96) sleep and rest taking a shower before going to bed 12 (21.42) frequent micturition desire 14 (25) habit of going to bed early 8 (14.28) discomforts during pregnancy 9 (16.07) performing activities that favor sleep and rest 7 (12.5) abdominal discomfort 5 (8.92) sensation of tiredness 6 (10.71) concerns and stress 6 (10.71) increased sleep during pregnancy 4 (7.14) care of children 6 (10.71) avoiding activities that limit sleep 4 (7.14) getting up early in the morning 4 (7.14) support from the partner 3 (5.35) insomnia 4 (7.14) rest routine during the day 3 (5.35) other factors 8 (14.27) other factors 9 (16.05) total 56 (100) 56 (100) control salient beliefs 44 (78.54) 44 (78.55) 18 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 28 self-care behavior facilitating factors fr (%) hindering factors fr (%) blood pressure control going to a pharmacy 16 (40) no factor 11 (40.74) family member or acquaintance measures blood pressure 7 (17.5) long distances to the health institution or pharmacy 8 (29.62) low cost of the measuring procedure 5 (12.5) lack of time, concerns and forgetfulness 5 (18.51) having a tensiometer at home 3 (7.5) other factors 3 (11.10) other factors 9 (22.5) total 40 (100) 27 (100) control salient beliefs 31 (77.5) 24 (88.87) source: prepared by the authors. discussion the tpb sets forth that human behaviors are reasoned or planned actions, as they are consistent with a person’s beliefs  (26). in this sense, it can be asserted that it is through behavioral beliefs that people weigh the consequences of future actions in terms of their favorable or unfavorable nature (21). the behavioral beliefs related to physical exercises stand out as the ones with the greatest advantage in improving mothers’ and babies’ health during pregnancy. although this result is coherent, there is a limited perception of the benefits of physical exercises on blood pressure control, a finding that can be related not only to causal unawareness of these disorders in the obstetric population  (27) but also to women’s disinformation and lack of knowledge by the health personnel in terms of the effects of physical exercises during pregnancy, which results in not providing this type of recommendation and in few pregnant women benefiting from this behavior (28). physical exercises have been considered an important non-pharmacological strategy to reduce the risk of suffering hdp  (27). the findings of a systematic review and meta-analysis showed the beneficial effect of aerobic, strength and flexibility exercises (or = 0.50; 95 %ci: 0.33-0.75; p = 0.001) or yoga (or = 0.28; 95 %ci: 0.13-0.58; p = 0.001) in preventing or reducing the risk of developing hdp (29). currently, the recommendations proposed by the american college of obstetricians and gynecologists  (acog) suggest that, whether during pregnancy or in the postpartum period, all women should practice moderate-intensity physical exercises for at least thirty minutes a day and five or more days in the week  (30). among the negative behavioral beliefs, most of the participants state no disadvantages regarding physical exercises during pregnancy; such practice generates sensations of tiredness, pain and abdominal discomforts only for some women, in addition to the use of improper strength and positions. in this sense, the acog describes that physical exercises contribute to reducing body, back and sciatic pain in sa lie nt b el ie fs in t he in te nt io n fo r se lf -c ar e b eh av io rs w he n fa ci ng h yp er te ns iv e d is or de rs in p re gn an t w om en 19 pregnant women. in addition, it recommends motivating women undergoing uneventful pregnancies to perform aerobic and strength exercises before, during and after pregnancy (30). considerng nutritional behaviors, reducing salt consumption contributes to preventing high blood pressure and diseases in the mother. although, according to clinical practice guides, there is not enough evidence showing that reducing salt in the diet helps treat or prevent hypertension during pregnancy (7-9), such restriction can be beneficial for normotensive pregnant women with metabolic disorders or obesity, or with a chronic hypertension diagnosis (31). the unfavorable beliefs towards this behavior are related to losing taste, appetite and preference for food. these findings are similar to those described by sousa et al. (21), where it is highlighted that the changes in food palatability associated with salt usage in the preparation of meals represent negative aspects for reducing its consumption. in the consumption of fruit, vegetables, legumes and meats, the contribution of vitamins and minerals assisting in the baby’s proper growth and development and the mother’s nutrition and health stands out. several studies have found that eating fruit, vegetables and legumes is positively related to newborns’ size and weight  (32). likewise, food products of animal origin are iron, protein and vitamin sources that not only contribute to preventing maternal diseases but, due to their high nutritional value, also exert an influence on the baby’s development and protection (33). on the other hand, the participants included in this study did not describe the importance of eating fruit, vegetables and legumes on weight control during pregnancy. in this sense, it has been described that gestational weight gain higher than the recommended increases the risk of obstetric complications like hypertension. therefore, proper prenatal control, adequate nutritional classification, sound indications from the health personnel and elaborating a diet are key strategies to attain a food regime in pregnant women that allows for avoiding excessive weight gain and reduces the risk of developing hdp (34). likewise, the women included in this study consider that reducing the consumption of fats, flour and sugar would avoid diabetes, high blood pressure, and maternal overweight problems, in addition to promoting the baby’s healthy growth and development. these beliefs are in line with the scientific evidence, where it has been identified that maternal diets with high energy intake are associated with higher risks of hypertension, gestational diabetes, increased maternal weight, macrosomia, and c-sections (35). the favorable beliefs of calcium intake during pregnancy are related to the baby’s growth, development and well-being, as well as to its value as a nutritional supplement in mothers and babies 20 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 28 alike, which prevents dental and bone decalcification in women. although these findings are consistent with what is reported in the literature, the role of calcium in reducing hdp risk is unknown. a cochrane review has concluded that there is enough evidence to prove that calcium supplementation  (≥1  g/day) is significantly associated with a reduction in the risk of pre-eclampsia and other pregnancy hypertensive diseases, particularly in women on diets that are low in this mineral (36). among the advantages of avoiding caffeinated drinks, alcohol, tobacco or cigarettes, beliefs such as preventing malformations and promoting the baby’s healthy growth and development stand out, as well as preserving the mother’s health and preventing high blood pressure. there is evidence that prenatal exposure to alcohol, tobacco and caffeine exerts adverse effects on the health of the pregnant woman, the fetus and the newborn  (37,38). considering the development of hdp, a systematic review suggested an association between alcohol and pre-eclampsia, with a 13 % prevalence, although none of the studies included reported tobacco consumption as a risk factor  (39). likewise, kawanishi  et  al.  (40) showed that consuming 131 mg/day of caffeine, a value way below the amount recommended by the world health organization (300 mg/day), was associated with higher hdp risk (or=1.35; 95 %ci: 1.99-1.52; p = 0.001). both sleep and the periods during pregnancy are mentioned as behaviors that favor relaxation and peace of mind in the mother and the baby. however, there is a lack of knowledge about the importance of sleep quality and pregnancy results. some studies suggest that pregnant women are a population group at a higher risk of sleep disorders such as sleep apnea, restless leg syndrome and insomnia (41). in this sense, the findings by sharma et al. (42) indicated that sleep insufficiency or fragmentation can predispose pregnant women to several adverse results, such as gestational hypertension and c-section deliveries. finally, in the behavioral beliefs, blood pressure control is mentioned as a behavior that allows monitoring the blood pressure values, controlling and following up on the mother’s and baby’s health and preventing complications during pregnancy. although blood pressure monitoring plays no role in hdp prevention, it is in fact useful to determine alterations in the parameters considered normal and in early detection of hdp. regarding the normative beliefs, the findings emphasize that health personnel, mothers, husbands or partners and other family members are referents that might exert an influence on pregnant women’s motivation to perform a given self-care behavior when facing hdp. in this sense, malta  et  al. (43) describe that women are in frequent contact with physicians and nurses during their prenatal appointments. therefore, these professionals, as providers of knowledge, practices and support, play a relevant role in promoting changes in health behaviors. in the family context, the evidence has shown that sa lie nt b el ie fs in t he in te nt io n fo r se lf -c ar e b eh av io rs w he n fa ci ng h yp er te ns iv e d is or de rs in p re gn an t w om en 21 when partners, mothers and close family members are involved in the pregnancy, pregnant women are more likely to timely access prenatal care programs, avoid harmful behaviors for their health and develop self-care actions, all components that are associated with better results in maternal/perinatal health (44, 45). in the control beliefs, it is evident that visiting other people, going out for a walk with their partner and taking their children to school are facilitating factors for physical exercises during pregnancy. these findings highlight that there is a dependent relationship between the participants and their social referents, which contributes to adopting health behaviors during pregnancy that might be able to promote optimum results in the mothers’ and babies’ health (44). at the nutritional level, preparing meals with low salt content and the habit of low consumption to prevent diseases in the mother and the baby are beliefs that ease the behavior. in fact, the mothers’ knowledge about the benefits of reducing salt consumption during pregnancy and the strategies to do so can help reduce its use (46). eating fruit, vegetables, legumes and meats can be favored by the support from friends and family members, by the partner buying them and by the habit and preference for their consumption. in this sense, the study by hromi  et  al.  (47) showed that social, spouse and family support is the main source driving healthy eating behaviors, especially the consumption of fruit and vegetables. likewise, asiabar  et  al.  (48) reported that the partners are usually the financial support source in the family and, therefore, they play an important role in the food supply. in addition, it has been described that social support exerts a direct influence on pregnant women’s perceived self-efficacy, favoring access, preferences, knowledge and strategies required to increase consumption of this type of food products (47). on the other hand, the beliefs that contribute to reducing unhealthy nutritional behaviors during pregnancy emphasize the habit of avoiding fats, flours and sugars, aversion to meals, and lack of habit or preference for caffeinated drinks, alcohol or cigarettes, which are ways to promote the baby’s well-being and prevent health problems in the mother. these beliefs are consistent with the findings by forbes  et  al. (49), for whom the most common reasons for women to reduce or discard consumption of this type of food products include the baby’s health, concern about their own health, aversions, nausea and the intention to meet the dietary recommendations provided by the health professionals. regarding consumption of calcium supplements, the participants describe thinking about the baby’s well-being, provision by the health institution or purchasing power to buy them as the major facilitating factors. according to a study conducted in bangladesh, calcium supplementation during pregnancy depends on factors such as maternal knowledge, support from the hus22 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 28 band or partner, reminders by the household members to take it, early initiation and more prenatal visits, as well as the free provision by the health services (50). the control beliefs associated with sleep and rest are targeted at the habit of taking a previous shower, going to bed early and performing activities that favor sleep and rest. the activities described coincide with the findings by hashmi et al. (51), who emphasize that strategies that improve sleep quality should be implemented during pregnancy, such as going to bed and getting up at the same time every day, taking a warm bath and performing non-stimulating activities such as knitting, reading a book, etc. likewise, the participants describe beliefs that interfere with sleep duration and quality that are also identified in the literature, such as pollakiuria, discomforts caused by back pain, fetal movements and abdominal discomfort (51). finally, going to a nearby pharmacy, a family member or acquaintance measuring blood pressure and the low cost involved in the procedure are identified as beliefs that ease measuring it. the findings by tucker  et  al. (52) describe that pregnant women feel satisfied with monitoring blood pressure either in the self-control or outpatient modality and, therefore, it is possible that the beliefs stated by the participants included in this study contribute positively to this behavior. in terms of the implications for the nursing practice, the findings set forth the need to strengthen pregnant women’s self-care knowledge and actions when facing hdp, through education in prenatal consultations or by developing health education interventions or programs that promote a positive attitude, involve greater social or family support and reinforce in pregnant women the acknowledgment and control over their own resources and abilities, as well as their motivation to develop health behaviors when facing hdp. in addition, identifying the salient beliefs will support the elaboration of instruments that allow assessing the attitudes, subjective norms and perceived behavioral control as key determinants in pregnant women’s intention towards self-care behaviors when facing hdp. this study acknowledges the following as one of its limitations: the absence of more answers to the questions asked that would allow for a better understanding of the phenomenon, which may have been due to how the information was collected or to the participants’ refusal to provide more in-depth answers. another limitation corresponds to the fact that the study was conducted in a single environment, which entails carrying out new research studies in different colombian regions, acknowledging pregnant women’s cultural plurality, nutritional diversity and lifestyle habits, to expand, ratify or refute the findings of this study, as it deals with care behaviors during the prenatal stage that subjected to diverse influence from the pregnant women’s cultural and social contexts, thus precluding generalization of the findings. sa lie nt b el ie fs in t he in te nt io n fo r se lf -c ar e b eh av io rs w he n fa ci ng h yp er te ns 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psiquiatria da universidade federal fluminense. jorgeluizlima@vm.uff.br. 2 especialista em enfermagem do trabalho pela universidade federal fluminense. andrelcdias@gmail.com. 3 doutora em saúde pública pela universidade de são paulo (usp). pesquisadora do centro de estudos em saúde do trabalhador e ecologia humana da fundação instituto oswaldo cruz (fiocruz). lilianeteixeira@ensp.fiocruz.br. recibido: 18 de septiembre de 2011 aceptado: 20 de abril de 2012 resumo objetivos: descrever causas e implicações da síndrome de burnout, discutindo sobre possíveis consequências para o profissional de enfermagem. método: estudo descritivo e exploratório realizado por meio de revisão de literatura. a abordagem do tema ocorreu por meio de divisão em categorias que abordam os fatores causas e também as implicações síndrome. resultados: a partir da análise dos resultados, constata-se que o processo está intimamente relacionado a fatores organizacionais, pessoais, individuais e até mesmo os inerentes à profissão. as repercussões descritas são várias, envolvendo esferas físicas, psíquicas, emocionais, organizacionais e familiares. conclusão: trata-se de problema psicossocial atual que merece abordagens e estudos que permitam a tomada de medidas para minimização do sofrimento laboral deste profissional. palavras-chave esgotamento profissional, enfermagem, saúde do trabalhador, medicina do trabalho. (fonte: decs, bireme). discusión sobre las causas del síndrome burnout y sus implicaciones para la salud del personal de enfermería resumen objetivos: describir las causas y consecuencias de síndrome burnout, discutiendo las posibles consecuencias para el profesional de enfermería. método: estudio descriptivo y exploratorio, realizado a través de revisión de la literatura. el tema fue realizado por una división en categorías que aborden las causas y factores también el síndrome más amplio. resultados: a partir del análisis de los resultados, 145 discussão sobre as causas da síndrome de burnout e suas implicações à saúde do profissional de enfermagem l jorge luiz lima da silva, andré campos dias, liliane reis teixeira parece que el proceso está estrechamente relacionado con factores de organización, individuales personales, e incluso inherente a la profesión. los efectos descritos son numerosos, la participación de las esferas física, mental, emocional, organizacional y familiar. conclusión: este es el problema actual que merece enfoques psicosociales y estudios que permitan medidas para minimizar el sufrimiento de los profesionales que trabajan. palabras clave agotamiento profesional, enfermería, salud laboral, medicina del trabajo. (fuente: decs, bireme). discussion on the burnout syndrome: its causes and implications for the health of nursing personnel abstract objectives: to describe the causes and implications of burnout, discussing possible consequences for the nurses. method: this descriptive exploratory study conducted through literature review. the theme was performed by a division into categories that address the causes and factors also the implications syndrome. results: from the analysis of the results, it appears that the process is closely related to organizational factors, personal, individual and even inherent to the profession. the effects described are numerous, involving spheres physical, mental, emotional, organizational and family. conclusion: this is the current problem that deserves psychosocial approaches and studies that allow for measures to minimize the suffering of the working professional. key words burnout, professional, nursing, occupational health, occupational medicine. (source: decs, bireme). 146 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 introdução o estresse enquanto patologia, além de suas naturais implicações, tem levado a frequentes estudos sobre a qualidade de vida no meio profissional, em diversos grupos considerados estressantes, constituindo-se como importante problema de saúde pública na atualidade do mundo moderno. este pode ser definido como o estado produzido por determinada mudança no ambiente que é percebida como geradora de tensão para o balanço ou equilíbrio dinâmico da pessoa. além disso, é considerado como resposta fisiológica, e de comportamento do indivíduo que se esforça para adaptar-se e ajustar-se a pressões internas e externas de origens distintas e variáveis. como a energia necessária para essa adaptação é limitada, o organismo entra finalmente na fase do esgotamento, na qual as demandas energéticas são insuficientes para o enfrentamento (1). este fenômeno também pode ser definido como um conjunto de reações do organismo a agressões de ordem física e psíquica capazes de perturbar o equilíbrio orgânico, e apresenta sintomas como: perda de concentração mental, fadiga fácil, fraqueza, mal-estar, instabilidade emocional, descontrole, agressividade, irritabilidade, depressão, angústia, palpitações cardíacas, suores frios, tonturas, vertigens, dores musculares, de cabeça, estomacais, dentre outras (2). as reações descritas podem se exteriorizar de imediato ou permanecerem silenciosas, até o momento em que gerarem processos patológicos importantes no indivíduo. a reação de cada pessoa ao estresse é particularizada, e assume uma gama variada de afecções. em linhas gerais, o estresse pode ser dividido em três grandes grupos: o profissional, o situacional e o pessoal. estes ainda podem ser caracterizados como agudos ou crônicos. o estresse profissional, no qual se foca este estudo, associado aos processos de profissionalização e desenvolvimento na sociedade, é devido ao peso da responsabilidade profissional em lidar com situações difíceis e problemáticas geradas pelas pessoas (3). a adaptação a este processo, por vezes, pode se tornar difícil em condições ambientais desgastantes, o que pode interferir na tríade mente-corpo-espírito do trabalhador, e afetar seu desempenho, bem como outros aspectos não menos relevantes de sua vida, como a convivência em família e em comunidade. grande parte das pesquisas sobre o estresse aborda a saúde mental dos pacientes; nesses estudos relacionados aos profissionais de saúde, constata-se que o estresse acomete mais a equipe de enfermagem devido à escassez de recursos nos serviços de saúde, aos cortes no quadro funcional e ao contato com o sofrimento e a morte (4). o homem em constante interação com o meio ambiente, ao mesmo tempo em que modifica a natureza, também é modificado por esta. dentre as inúmeras modificações, encontram-se aquelas que têm consequências no aparelho psíquico, quando esta relação encontra-se em desequilíbrio (5). no aspecto social, o trabalho é considerado uma ação desempenhada por seres humanos, com finalidade determinada, conscientemente desejada, executada mediante investimento de energia física e de inteligência, geralmente com auxílio instrumental e que produz efeito sobre o agente (6). a síndrome de burnout (sb) constitui um dos grandes problemas psicossociais da atualidade, e reflete o modo de vida capitalista, baseado na lógica dos meios de produção e do consumo desenfreado. trata-se de um problema característico do homem moderno, que tem cada vez menos tempo para realizar atividades prazerosas, como lazer e estar na companhia da família em detrimento de ritmo de trabalho desconforme com os seus reais limites. com isso, sobressai o estresse, e o homem chega ao nível crítico de esgotamento. o termo inglês burnout significa burn: queimar e out: exterior; no entanto, semanticamente, descreve a sensação de exaustão, de combustão física e mental da pessoa acometida por esta patologia (7). a exaustão marcante provocada por essa síndrome, por sua vez, leva ao desajustamento das relações sociais praticadas por este indivíduo. a patologia mencionada vai muito além do estresse. a síndrome está mais intimamente ligada ao mundo do trabalho e ocorre pela cronificação do processo estressor, esta sendo considerada situação mais avançada (8). este processo patológico é definido como uma síndrome psicológica resultante de estressores interpessoais crônicos no trabalho e se caracteriza por três dimensões: exaustão emocional, despersonalização e diminuição da realização pessoal (9). a exaustão emocional é definida pela falta de energia e sentimento de esgotamento de recursos. a despersonalização se apresenta 147 discussão sobre as causas da síndrome de burnout e suas implicações à saúde do profissional de enfermagem l jorge luiz lima da silva, andré campos dias, liliane reis teixeira como um estado psíquico no qual prevalece a dissimulação afetiva, o distanciamento e a impessoalidade, com sentimento de indiferença completa. a baixa realização profissional caracteriza-se pela avaliação negativa que o indivíduo faz de si mesmo, com relação aos aspectos de sua vida profissional e também pessoal (9, 10). a incidência da patologia vem aumentando nos últimos anos, de maneira alarmante em diversos países. mesmo sem ter acesso a dados estatísticos concretos, existem razões para acreditar que a incidência, no brasil, deve estar próxima daquela apontada em outros países, tendo em vista que o quadro se repete: aumento do setor de serviços na economia, crescente aumento da instabilidade social e econômica, coexistência de diferentes modalidades de processos produtivos (da manufatura à automação), precarização das relações de produção, desemprego crescente, mudanças nos hábitos e estilos de vida dos trabalhadores influenciados pela implantação de programas de qualidade e reengenharia (7). a partir de uma perspectiva capitalista e neoliberal, pode-se afirmar que a problemática referida faz com que este profissional se descontextualize de sua realidade, deixe de ser produtivo, além de trazer inúmeros prejuízos ao seu bem-estar e à sua qualidade de vida, o que afeta sua relação familiar e também seu convívio social. trata-se de um dos agravos ocupacionais de caráter psicossocial mais importantes na sociedade atual. a sb tem sido considerada como sério processo de deterioração, uma vez que apresenta graves implicações para a saúde física e mental (10). ainda que o termo burnout esteja pouco disseminado e popularizado quando comparado ao estresse, a sb precisa ser considerada problema de ordem global, deixando de ser privilégio de específica realidade social, educacional ou cultural. é uma síndrome que vem acometendo os trabalhadores desde o final do século passado e continua neste novo milênio (5). a sb vem sendo conside rada problema de saúde pública, devido a suas implicações para a saúde física e mental do trabalhador, com evidente comprometimento de sua qualidade de vida no ambiente de trabalho (11). o interesse pela temática é recente data da década de 1970; contudo, ampliou-se rapidamente pelo poder explicativo dos transtornos profissionais (5). nesse contexto, sabe-se que a enfermagem é compreendida como profissão que acumula inúmeras responsabilidades, carga de trabalho e tarefas com variadas complexidades que exigem demandas físicas e psicológicas, muitas vezes aquém do suportado por estes profissionais. esses fatores ajudam a explicar a alta incidência de patologias relacionadas ao estresse laboral neste grupo. atualmente, existe maior preocupação com a saúde dos indivíduos que exercem suas atribuições em organizações de saúde. a instituição hospitalar é um dos cenários com significativo contexto de risco à saúde ocupacional (3). existem estudos sobre a sb em enfermeiros nos quais diferentes variáveis são analisadas e resultados diferentes apresentados, o que demonstra a complexidade do fenômeno. no entanto de modo geral, todos indicam que esses profissionais são particularmente vulneráveis a essa síndrome (12). no brasil, a maioria dos trabalhadores de enfermagem está concentrada nos hospitais, o que responde à tendência técnico-assistencialista do setor de saúde. também se encontram profissionais em programas de saúde coletiva, que devem atuar sob o enfoque do atendimento preventivo, mas que, diante das políticas de saúde “ainda” curativistas, acabam sendo assistencialistas. esses profissionais podem também ocupar cargos administrativos, geralmente em serviços de saúde, de ensino ou como gerentes dos serviços de enfermagem e da mesma forma, exercerem atividades de ensino em nível técnico, universitário ou elementar (13). enfermeiros e técnicos de enfermagem fazem parte de uma profissão caracterizada por ter, em sua essência, o cuidado; esses profissionais têm contato direto com pacientes e familiares, ou seja, lidam, constantemente, com pessoas com as mais diversas concepções e cultura (14). esse tipo de relação contribui fortemente para a gênese do estresse laboral. a síndrome surge nos profissionais de enfermagem de todo o mundo, em diferentes contextos de trabalho, levando-os a desenvolverem sentimentos de frustração, frieza e indiferença em relação às necessidades e ao sofrimento dos doentes (12). a respeito dessa problemática, são poucas as pesquisas realizadas no brasil que procuravam investigar os processos causais e problemas de saúde que esses trabalhadores enfrentam, associando-os com as características dessa enfermidade (15). os prejuízos trazidos pela síndrome se encontram vinculados a grandes custos organizacionais e pessoais. alguns desses devem-se à rotatividade de pessoal, absenteísmo, problemas de pro dutividade e de qualidade (16). o manual de doenças re148 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 lacionadas ao trabalho, do ministério da saúde brasileiro, indica que, quando o diagnóstico de burnout é confirmado, deve haver abordagem criteriosa com relação às possíveis causas; se estas estiverem relacionadas ao próprio ambiente de trabalho, medidas preventivas, bem como as de recuperação do estado de saúde desses trabalhadores, precisam ser tomadas (17). objetivos do estudo a partir do exposto, constituem-se como objetivos deste estudo descrever as causas e implicações da síndrome de burnout, discutindo sobre possíveis consequências ao profissional de enfermagem. justificativa os profissionais de enfermagem se encontram em situação de grande vulnerabilidade emocional; nesse sentido, é válido reforçar a importância de se pensar na criação, de espaços em que possam ser compartilhados os temas difíceis que circulam no contexto hospitalar (16). entender os processos envolvidos na constituição da sb pode ser relevante para a tomada de medidas que auxiliem no desenvolvimento da qualidade de vida e bem-estar da saúde do trabalhador. o reconhecimento dos efeitos do trabalho na determinação e evolução do processo saúde-doença dos trabalhadores tem implicações éticas, técnicas e legais, que se refletem sobre a organização e a qualidade da assistência prestada (18). a influência do trabalho como fator causal de dano ou agravo à saúde está estabelecida e dimensionada em sua importância e magnitude de maneira que o ministério da saúde brasileiro reconhece a relação entre o trabalho e o processo saúde-doença, com a classificação dessas doenças para os sistemas orgânicos do corpo humano (16). a teoria do burnout se dispõe a compreender as contradições da área de prestação de serviços, exatamente quando a produção do setor primário fica aquém e o setor terciário vem tomar seu lugar (19). quando se pensa nas três dimensões da síndrome, vem à cabeça a situação paradoxal com relação à teoria do ser humano solitário; em uma época em que parece se esvanecer a solidariedade, a ênfase na “despersonalização”, certa mecanização e a ruptura dos contratos sociais parecem ter eliminado o significado da palavra “pessoa”. o decreto 3.048/1999, atualizado em outubro de 2010, que regulamenta a previdência social, ao tratar em seu artigo ii dos agentes patogênicos causadores de doenças profissionais ou do trabalho, aponta a sb ou síndrome do esgotamento profissional (sep) como agente etiológico ou como um dos fatores de risco de natureza ocupacional, e apresenta como causa o ritmo de trabalho penoso (20). estudos relacionando a sb com o trabalho da saúde são comuns em países da américa do norte, europa e parte da américa latina; contudo, ainda, há escassez para estudos específicos de trabalhadores da área da enfermagem (14). o estudo da manifestação do estresse ocupacional entre enfermeiros pode ajudar a compreender melhor e a elucidar alguns dos problemas enfrentados pela profissão, tais como a insatisfação profissional, a produção no trabalho, o absenteísmo, os acidentes de trabalho e algumas doenças ocupacionais (13). o ambiente hospitalar funciona como gerador de estresse tanto aos pacientes e seus familiares, devido à enfermidade e à situação de internação, quanto aos profissionais que ali atuam (21). o profissional é suscetível ao fenômeno do estresse ocupacional. estudo com 1.800 enfermeiros mostra que 93,0% deles afirmaram se sentirem estressados no trabalho (22). estudar as repercussões da síndrome ou estresse ocupacional entre enfermeiros permite compreender e elucidar alguns problemas, tais como a insatisfação profissional, a produtividade do trabalho, o absenteísmo, os acidentes de trabalho e algumas doenças ocupacionais, além de permitir a proposição de intervenções e busca de soluções (12). logo, as implicações dessa enfermidade aos profissionais são variadas, e necessitam de estudos que as descriminem, a fim de tornar possível a tomada de decisões que minimizem o estresse, enfrentando e tentando reduzir as inúmeras repercussões que possa trazer sua forma mais grave. além disso, trazer uma assistência de melhor qualidade e mais humanizada aos pacientes perpassa pela humanização das ações em saúde (23). metodologia a pesquisa foi de natureza descritiva, realizada por meio de revisão bibliográfica analítica, baseada em obras secundárias que 149 discussão sobre as causas da síndrome de burnout e suas implicações à saúde do profissional de enfermagem l jorge luiz lima da silva, andré campos dias, liliane reis teixeira abordam a temática em questão, publicadas no período de 1996 a 2011, além de algumas outras de anos anteriores incluídas por possuírem relevância para este estudo. a coleta do material foi realizada no período de janeiro a abril de 2011. o levantamento foi realizado em ambiente virtual na biblioteca virtual de saúde (bvs), na qual as obras completas em língua espanhola, inglesa e/ou portuguesa foram localizadas a partir dos resultados da busca com os seguintes termos: “esgotamento profissional”; “burnout”; “enfermagem”. primeiramente, as obras foram armazenadas em formato digital; para que, em seguida, fosse realizada a pré-seleção de acordo com a leitura dos respectivos resumos. nesta fase, buscou-se a relação entre o conteúdo-título-resumo e se atendiam ao objeto de estudo. na fase de seleção, o material foi lido na íntegra pelos autores, com atenção especial para os resultados e conclusão. os trabalhos que não apresentavam qualquer relação com os processos causais da sb e suas implicações para o trabalho foram excluídos. por fim, foram consideradas 50 obras para construção de revisões neste periódico. realizada a triagem foram obtidos 29 artigos e 12 livros para construção da discussão, além de manuais, e outras fontes como guias e informes que também foram incluídos, contemplando nove obras. os resultados foram organizados em quadros que trazem as principais causas da síndrome descrita e suas implicações descritas por cada obra lida. o material selecionado foi enumerado na tabela a seguir (tabela 1). tabela 1. relação quantitativa de obras sobre a temática, levantadas em ambiente virtual, no ano de 2011 após a análise textual, os resultados e discussão da pesquisa foram divididos em duas categorias emergentes: 1) as causas da sb descritas na literatura e 2) suas implicações para a saúde e o bem-estar do profissional de enfermagem. discutindo sobre a temática as causas da sb segundo a literatura analisada inúmeros fatores são listados quando se buscam determinar as causas da síndrome. a maior parte, senão todos, reflete características do próprio sistema hospitalar, que evoluiu juntamente com a economia de consumo, e exigiu de seus trabalhadores cada vez mais produção. em contrapartida, esse aumento produtivo diminuiu o tempo antes despendido para outras atividades cotidianas desse profissional, como a dedicação à família e ao lazer, o que fez com que sua qualidade de vida decaísse, e consequentemente, sua saúde fosse afetada. é comprovada a relação entre os fatores causais da síndrome e as fontes organizacionais de desajuste indivíduo-trabalho. a ocorrência de níveis de burnout é evidente nesta ótica, na qual se verificam que fatores organizacionais do trabalho estão de alguma forma, relacionados ao desenvolvimento da doença (20). nesse processo, ainda inclui-se a vida em sociedade advinda da lógica capitalista, cada vez mais acirrada e competitiva, o que obriga as pessoas a buscarem a todo instante produzir mais e intensamente. como reflexo deste processo, percebe-se o número cada vez maior de profissionais de enfermagem com mais de um vínculo empregatício, com cargas horárias de trabalho cada vez mais elevadas e, muitas vezes, consideradas impraticáveis. o trabalho neste setor requer esforço emocional, mental e físico, do trabalhador e esses fatores repercutem na qualidade de vida, na saúde e no cuidado prestado (24). a partir da exposição ao estresse, advindo de inúmeras fontes, desenvolvem-se as patologias laborais como a sb. o entendimento adequado de seus fatores contributivos pode colaborar para a tomada de medidas, tanto em nível individual quanto coletivamente, que visem a minimizar os efeitos decorrentes do excesso de demandas físicas e psíquicas dentro do ambiente de trabalho. a partir desta lógica, buscou-se, por meio deste estudo, listar prováveis fatores descritos por autores para o desenvolvimento tipo material encontrados total excluídos aproveitados artigos 50 21 29 manuais e outros 14 5 9 livros 12 0 12 total 50 150 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 da sb que puderam ser enumerados, de acordo com a tabela a seguir (tabela 2): a condição enobrecedora do trabalho, ideologicamente decantada nos ditos populares, tem sido sistematicamente contestada pelos resultados das pesquisas que investigam a natureza do sofrimento proveniente das relações do homem moderno com o trabalho (21). existe certo “controle” praticado contra a grande massa de trabalhadores existentes em quase todo o planeta. trata-se de uma ameaça com objetivo certeiro, que leva milhares de pessoas acordarem ou dormirem sobressaltadas, pois a única coisa que de fato possuem, que é sua força de trabalho, pode ser solicitada a qualquer momento (21). é como se estivessem de eterno “sobre aviso” para trabalhar até fora de sua jornada formal. 1) reflexões sobre estresse e burnout e a relação com a enfermagem. 2) a síndrome de burnout e os valores organizacionais: um estudo comparativo em hospitais universitários. 3) síndrome de burnout e satisfação no trabalho em profissionais de uma instituição hospitalar. 4) burnout: implicação das fontes organizacionais de desajuste indivíduo trabalho em profissionais de enfermagem. 5) sofrimento psíquico em trabalhadores de enfermagem de uma unidade de oncologia. 6) análise de burnout em profissionais de uma emergência de um hospital geral. 7) estresse ocupacional entre profissionais do bloco cirúrgico. 8) a avaliação da síndrome de burnout com enfermeiros de um hospital geral. 9) estresse da equipe de enfermagem da emergência clínica. 10) estresse em profissional de saúde das unidades básicas de londrina. tabela 2. fatores para a sb, segundo a literatura analisada e coletada em ambiente virtual, em 2011 murofuse, neide tiemi;abranches, sueli saldati; napoleão, anamaria alves. rev latino-am de enfermagem, 2005. borges, livia oliveira et al. psicologia: reflexão e crítica, 2002. rosa, cristina da; carlotto, mary sandra. rev. sbph, 2005. tamayo, mauricio robayo. rev psicologia: reflexão e crítica, 2008. avellar, luziane zacché; iglesias, alexandra; valverde, priscila fernandes. rev psicologia em estudo, 2007. ritter, r.s.; stumm, e.m.f.; kircher, r.m. revista eletrônica de enfermagem, 2009. schimidt, denise rodrigues costa et al. rev texto contexto enfermagem,2009. lacerda, patrícia nunes de; hueb, martha franco. rev. da sociedade de psicologia do triângulo mineiro, 2005. panizzon, cristiane; luz, anna maria hecker; fensterseifer, lísia maria. rev gaúcha enferm, porto alegre (rs), 2008. lentine, edvilson cristiano; sonoda, tereza kiomi; biazin, tamares tamasin. londrina, terra e cultura, 2003. insatisfação e falta de reconhecimento profissional, produtividade no trabalho, desgaste provocado pelo contato direto com pacientes, sobretudo em condições debilitantes, a busca desenfreada por produtividade. cargos com atribuições mais variadas e mais complexas, estruturas com menos níveis hierárquicos e mais responsabilidades, maior atenção do trabalhador em relação ao usuário, demanda de novas competências. longas jornadas de trabalho, número ineficiente de pessoal, falta de reconhecimento profissional, alta exposição do profissional a riscos físicos e químicos, contato constante com sofrimento, dor e muitas vezes a morte, manejo de pacientes graves. o número reduzido de profissionais que trabalham no atendimento em saúde; as dificuldades em delimitar os diferentes papéis entre enfermeiros, técnicos e auxiliares de enfermagem; os conflitos interpessoais no trabalho; a falta de reconhecimento e valorização da profissão; o excesso de trabalho; o achatamento dos salários; a necessidade de vários vínculos empregatícios. o exercício profissional no âmbito hospitalar marcado por múltiplas exigências: lidar com dor, sofrimento, morte e perdas, condições desfavoráveis de trabalho, baixa remuneração e altos níveis de envolvimento emocional. conlitos e tensões do ambiente de trabalho, exigências da própria profissão, muitas vezes excendendo-as, contato contínuo com sofrimento e morte, pressão para a tomada de decisões rápidas. tipo de ambiente, complexidade de relações humanas e de trabalho, autonomia, grau elevado de exigências e habilidades, alta responsabilidade, planejamento adequado de recursos humanos e materiais. permanente contato com o paciente, pouco cuidado do profissional consigo, características internas como ansiedade, dificuldade no relacionamento interpessoal, fontes externas como a morte de alguém, perda do emprego ou até mesmo um nascimento. a complexidade dos cuidados de enfermagem prestados, fatores pessoais como idade, sexo, tempo de exercício profissional e experiência em emergência, carga semanal de trabalho. alta demanda, falta de apoio, motivação, a falta de consciência da população em relação ao trabalho no sus, pacientes estressados, entre outros. causas para a síndrome de burnout segundo literaturaautor (es), origem, anotítulo 151 discussão sobre as causas da síndrome de burnout e suas implicações à saúde do profissional de enfermagem l jorge luiz lima da silva, andré campos dias, liliane reis teixeira o ambiente hospitalar é potencialmente gerador de sofrimento psíquico, resultante da impossibilidade de subjetivação do indivíduo em seu trabalho (18). os estressores também podem ser fatores intrínsecos ao trabalho, os quais se referem a aspectos como repetição de tarefas, pressões de tempo e sobrecarga de trabalho (25). as características intrínsecas e extrínsecas do ambiente de trabalho, bem como a relação do profissional com o ambiente, levam aos desfechos de positivos ou negativos. o entendimento desses fatores pode levar à compreensão de suas consequências. estudo realizado em hospital universitário do rio grande do sul constatou que valores médios obtidos nas três dimensões da sb, segundo o maslach burnout inventory (mbi), foram: 17 pontos em esgotamento emocional, o que indica nível baixo; 7,79 pontos em despersonalização, o que aponta nível médio; e 36,6 pontos em realização pessoal (nível médio), o que constata a realidade observável da problemática abordada (16). nessa pesquisa, observa-se que a despersonificação possui destaque, sendo importante lembrar que os trabalhadores da área de saúde estão em constante contato com o sofrimento provocado pelo adoecimento. as áreas ou fontes estressoras são definidas da seguinte forma: (a) sobrecarga: apresenta-se quando as demandas no trabalho excedem os limites humanos; (b) falta de controle: acontece quando as pessoas têm pouco controle sobre o trabalho que executam; (c) recompensas insuficientes: refere-se à falta de incentivos; (d) ausência de coleguismo: ocorre quando as pessoas perdem o sentido de relacionamentos positivos com os outros no trabalho; (e) falta de justiça: apresentam-se quando existe inequidade e ausência de procedimentos justos no local de trabalho e (f) conflito de valores: envolve a discrepância entre os valores declarados e as práticas organizacionais. (9) foram observadas possíveis causas que contribuem para o desenvolvimento da síndrome, como as relações humanas, sobretudo, com o paciente em situação de debilidade, sofrimento ou morte iminente; com isso, conclui-se como fatores ou causas estressoras: “desgaste provocado pelo contato direto com pacientes, maior atenção do trabalhador em relação ao usuário, contato constante com sofrimento, dor e muitas vezes a morte”, entre outros (1, 2, 3, 5, 6, 7, 8, 10). outro dado relevante em um dos estudos diz respeito total de pesquisados em determinada instituição hospitalar: 34,2% referiam trabalhar diretamente com pessoas que os estressavam, algumas vezes ao mês, na semana ou diariamente. trata-se de um dado alarmante, pois a profissão de enfermagem está intimamente ligada às relações com o outro, o que demonstraria fragilidade de sua condição (24). cabe questionar os demais fatores relacionados à origem desse estresse e evitar analisar o fenômeno de forma unicausal. nesse sentido, a fala de um dos trabalhadores de unidade de oncologia, retirada de um dos estudos, relata seu ponto de vista; no qual afirma, em seu discurso, que “não se devem haver sentimentos nem envolvimento com o cliente”, o que pode desgastar o profissional. o afastamento e a negação de sentimentos são mencionados como estratégias para os trabalhadores se manterem “saudáveis”, emocionalmente, no ambiente de trabalho (17). trata-se de um fenômeno desgastante para o profissional de saúde, sobretudo o pertencente à equipe de enfermagem, que lida constantemente com suas percepções, sensações, culpas, desejos e medos. ao longo do tempo, são criados mecanismos próprios de defesa que podem prejudicar o aspecto humano da assistência prestada. a demanda do próprio trabalho em enfermagem (citada por todas as obras sob os mais diferentes aspectos) é outra fonte estressora para o trabalhador, visto que atividades que exigem habilidades variadas e excedem os limites do profissional fazem com que este profissional esteja sob constante pressão. uma pesquisa evidencia que determinados setores são tidos como estressores maiores do que outros, como o setor de emergência, que exige do trabalhador atenção redobrada e maior demanda de cuidados de enfermagem. trata-se de ambiente onde a responsabilidade perante as pessoas e o trabalho em contato contínuo com o sofrimento e a morte são pontos associados ao desgaste emocional e à despersonalização (4). especificamente com relação ao ambiente de emergência, demonstra-se que o nível de estresse em profissionais de determinado hospital é alto, pois 78,4% dos sujeitos referiram estresse médio ou alto. as variáveis estudadas que apresentaram associação significativa com estresse foram carga horária de trabalho semanal na emergência, e carga horária total de trabalho semanal (25). o tipo de instituição e o setor de atuação dos profissionais de enfermagem são fatores importantes na vida dos trabalhadores e 152 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 podem estar associados à percepção do estresse ocupacional, o que os torna de suma relevância (26). é possível notar que a forma de organização do trabalho e sua natureza estão relacionadas com o grau de estresse percebido e o adoecimento, variando de acordo com as características de cada setor. nessa lógica, pode-se constatar também que o tipo de paciente e a demanda de cuidados de enfermagem podem contribuir para a problemática referida. de acordo com a resolução 293/2004 do conselho federal de enfermagem brasileiro (cofen), consideram-se como horas destinadas à demanda de cuidados: 3,8 horas de enfermagem, por cliente, na assistência mínima ou autocuidado (cliente necessita de supervisão); 5,6 horas de enfermagem, por cliente, na assistência intermediária; 9,4 horas de enfermagem, por cliente, na assistência semi-intensiva; 17,9 horas de enfermagem, por cliente, na assistência intensiva (todas em um período base de 24 horas) (27). logo, nota-se que a demanda de cuidados pode agir/funcionar como fator contributivo para o desenvolvimento do estresse, uma vez que cada cliente determinará demanda maior ou menor de cuidados. citadas pelas obras a falta de reconhecimento e insatisfação profissionais contribuem para que parte dos profissionais perca gradativamente o interesse na realização de suas funções, que podem se tornar mecanizadas, exaustivas e geradoras de sofrimento psíquico (1, 3, 4, 10). este último, pouco percebido e, quando notado tardiamente, vem acompanhado de variadas alterações de saúde. outro fator concorrente para o estresse, no ambiente dos serviços de saúde, é a falta de recursos humanos e materiais (3, 4, 7). com o número crescente de leitos, o aumento dos atendimentos hospitalares e de outros serviços ao longo do tempo, alguns ambientes laborais parecem possuir quantidades insuficientes de profissionais de enfermagem para o atendimento das demandas, em face a condições estruturais inadequadas para o desenvolvimento de atividades de qualidade. em estudo a respeito do assunto, percebeu-se como resultado o estresse relacionado intimamente às condições físicas e humanas do ambiente de trabalho, que incitou os autores a refletir sobre as condições nas quais o trabalho é desenvolvido nestas instituições de saúde, condições que poderiam estar contribuindo para o estresse e o consequente agravamento (19). a longa jornada de trabalho exaustiva e que pode se somar a mais de um emprego, assim como as estruturas com menos níveis hierárquicos, com consequente geração de maior número de responsabilidades, são fontes geradoras de demandas, que contribuem para a exaustão física constante, importante na gênese do estresse laboral (2, 3). os conflitos e tensões no ambiente de trabalho e as dificuldades em delimitar os diferentes papéis entre enfermeiros, técnicos e auxiliares de enfermagem demonstram que a maioria das relações interpessoais pode, com o tempo, tornar-se estressoras e fatigantes, sobretudo, quando o papel de cada profissional dentro da equipe é pouco definido (4, 6). inclusive é ressaltado que grande parte dos conflitos da equipe de enfermagem decorre da postura autoritária e centralizadora do profissional de nível superior, em relação aos demais membros da equipe (28). além disso, o achatamento do trabalho ou a baixa remuneração faz com que o trabalhador busque aumentar sua produção, como se observa na causa listada pela obra 1: a busca desenfreada por produtividade. as fortes cargas psíquicas e emocionais geradas por este processo também contribuem para a problemática referida (4, 5). o atual momento político, com o corte de gastos (incluindo o achatamento dos salários), o estreitamento do mercado de trabalho e o desemprego são fatores agravantes para os profissionais que são obrigados a atuar em mais de um local de trabalho e a exercer carga horária mensal longa (29). esse fator também está relacionado à crescente oferta de novos profissionais graduados o que faz com que os contratadores regulem os salários pelos pisos mínimos de cada região do país. outros fatores como a alta exposição do profissional a riscos físicos e químicos e ambiente de trabalho fazem com que o trabalhador possua constante preocupação com sua segurança, ante uma gama de riscos proporcionados pelo trabalho no ambiente dos serviços de saúde, o que também merece atenção importante com relação ao desenvolvimento da patologia, foco deste artigo. diante de todas as características citadas anteriormente, relacionadas à adaptação do indivíduo às mais diversas condições e ambientes, encontram-se também como possíveis causas fatores relacionados ao próprio indivíduo, como observado respectivamente: “pouco cuidado do profissional consigo, características internas como ansiedade e fatores pessoais como idade, sexo, tempo de exercício profissional e experiência em emergência” (8, 9). 153 discussão sobre as causas da síndrome de burnout e suas implicações à saúde do profissional de enfermagem l jorge luiz lima da silva, andré campos dias, liliane reis teixeira constata-se, dessa forma, que a sb pode ter suas causas possivelmente relacionadas a dois grandes grupos: os relacionados às causas externas e os relacionados às internas, ambos interagindo de forma sinérgica, o que pode trazer prejuízos à qualidade de vida do profissional dentro do ambiente de trabalho. embora o estresse seja um fenômeno individual, as categorias identificadas sugerem que alguns estressores são comuns, independentemente da ocupação do enfermeiro, e as temáticas por onde giram os núcleos de sentido dos conteúdos analisados parecem refletir uma cultura profissional com ampla variedade de determinantes de estresse; relacionados ao indivíduo, ao cargo, tipo de atividade exercida e à organização. desde o surgimento da profissão até os dias atuais, o enfermeiro tem buscado uma autodefinição e tem se empenhado em construir sua identidade profissional e obter reconhecimento. nessa trajetória, tem enfrentado dificuldades que comprometem o desempenho do seu trabalho e também repercutem no seu lado pessoal. a profissão possui uma característica intrínseca, a qual é denominada de indefinição do papel profissional, que também pode ser relacionada como mais um de seus elementos estressores (13). entende-se este último como de grande peso no item realização pessoal, uma das dimensões da sb, pois mesmo se cumprindo à risca a lei de exercício profissional, há situações específicas em que há risco de morte de clientes e nas quais o enfermeiro assume papéis determinantes na recuperação e salvamento de uma vida. esse fato é visto em outros países como corriqueiro e necessário; contudo, no brasil, é banido e confundido ou sobreposto ao papel do profissional médico. logo, é fundamental descobrir e discutir as possíveis causas do problema e desenvolver estratégias de enfrentamento para lidar não só com o episódio presente, mas também com futuras ameaças de estresse laboral excessivo (30). as repercussões da síndrome de burnout ao profissional de enfermagem como foi mencionado, a patologia sobrevém de processo de estresse ocupacional. o estresse rompe com o equilíbrio psicofisiológico do indivíduo, obrigando que a pessoa utilize recursos extras de energia, bem como inibe as ações desnecessárias ou incompatíveis com as estratégias de enfrentamento desencadeadoras desse contexto. a intensidade e o tempo de duração deste estado podem levar o indivíduo a sofrer consequências graves, tanto física quanto psicologicamente, caso seja incapaz de restaurar ou desenvolver mecanismos adaptativos que lhe permitam restabelecer o equilíbrio perdido (30). a sb contribui fortemente para a perda da qualidade de vida do indivíduo, de sua família e do convívio social, além de trazer prejuízos ao ambiente de trabalho e às organizações como um todo. nessa ótica, listam-se a seguir as possíveis repercussões geradas por este processo patológico (tabela 3), descrita a seguir: 1) reflexões sobre estresse e burnout e a relação com a enfermagem. 2) a síndrome de burnout e os valores organizacionais: um estudo comparativo em hospitais universitários. 3) síndrome de burnout e satisfação no trabalho em profissionais de uma instituição hospitalar. 4) burnout: implicação das fontes organizacionais de desajuste indivíduo trabalho em profissionais de enfermagem. murofuse, neide tiemi;abranches, sueli saldati; napoleão, anamaria alves. rev latino-am de enfermagem, 2005. borges, livia oliveira et al. psicologia: reflexão e crítica, 2002. rosa, cristina da; carlotto, mary sandra. rev. sbph, 2005. tamayo, mauricio robayo. rev psicologia: reflexão e crítica, 2008. conseqüências sobre o estado de saúde e igualmente sobre desempenho, alterações e ou disfunções pessoais e organizacionais, com repercussões econômicas e sociais. atitudes e comportamentos negativos com respeito aos clientes, ao trabalho e à organização. relações interpessoais negativas entre colegas e entre estes e os superiores e interações problemáticas com os clientes; afeta a prestação de serviços e a qualidade do cuidado oferecido. conflitos nas equipes de trabalho, absenteísmo, diminuição da qualidade da assistência prestada. repercussões da síndrome de burnout segundo literaturaautor (es), origem, anotítulo tabela 3. repercussões da sb, segundo a literatura analisada e coletada em ambiente virtual, em 2011 154 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 o estresse pode desencadear uma série de doenças. se nada for feito para aliviar a tensão, a pessoa se sentirá cada vez mais exaurida, sem energia, depressiva, com crises de ansiedade e desânimo. na área física, muitos tipos de doenças podem ocorrer, conforme a herança genética da pessoa (31). a cultura popular e o senso comum há muito associa o estresse com o desenvolvimento de doenças, corroborado por estudos epidemiológicos e experimentais, que demonstram ligação entre o estresse mental e o aparecimento e curso de doenças, desde simples infecções virais, até úlceras gástricas e neoplasias (32). neste caso, ainda se trata de sintomas do estresse laboral possíveis, sendo a síndrome fenômeno crônico composto de três dimensões, como descrita na introdução deste artigo. o trabalhador que entra em burnout assume posição de frieza frente a seus clientes, evitando ao máximo envolver-se com os problemas e dificuldades emocionais. as relações interpessoais são cortadas, como se estivesse em contato apenas com objetos, ou seja, a relação torna-se desprovida de calor humano. isso, acrescido de grande irritabilidade por parte do profissional, leva a inúmeras repercussões, em seu cotidiano e em sua dinâmica de vida pessoal (18). a síndrome traz consequências físicas e pessoais que estão relacionadas aos sintomas que causam perdas para o indivíduo no campo administrativo, como a diminuição da produtividade e a grande rotatividade de pessoal em algumas instituições (33). as manifestações geradas pelo clima de mal-estar advindo do estresse laboral acabam por inibir atitudes positivas do trabalhador de saúde, fazendo com que este passe a avaliar negativamente seu desempenho, deixando de sentir prazer naquilo que pratica, gerando sofrimento que pode se exteriorizar em uma série de patologias físicas e psíquicas (34). diferentemente da ansiedade normal, a qual apresenta alterações fisiológicas, é necessária com adaptação eficiente; o estresse laboral constitui-se em uma resposta inadequada às solicitações de adaptação, tanto no que diz respeito à duração quanto à intensidade, e gera sintomas físicos e psíquicos para o organismo (35). as repercussões geradas pela síndrome começam no comprometimento das atividades executadas, como evidenciado nas obras analisadas. o trabalho é encarado com pessimismo ou mesmo indiferença, relações com superiores e equipe tendem a ser repercussões da síndrome de burnout segundo literaturaautor (es), origem, anotítulo 5) sofrimento psíquico em trabalhadores de enfermagem de uma unidade de oncologia. 6) análise de burnout em profissionais de uma emergência de um hospital geral. 7) estresse ocupacional entre profissionais do bloco cirúrgico. 8) a avaliação da síndrome de burnout com enfermeiros de um hospital geral. 9) estresse da equipe de enfermagem da emergência clínica. 10) estresse em profissional de saúde das unidades básicas de londrina. avellar, luziane zacché; iglesias, alexandra; valverde, priscila fernandes. rev psicologia em estudo, 2007. ritter, r.s.; stumm, e.m.f.; kircher, r.m. revista eletrônica de enfermagem, 2009. schimidt, denise rodrigues costa et al. rev texto contexto enfermagem, 2009. lacerda, patrícia nunes de; hueb, martha franco. rev. da sociedade de psicologia do triângulo mineiro, 2005. panizzon, cristiane; luz, anna maria hecker; fensterseifer, lísia maria. rev gaúcha enferm, porto alegre (rs), 2008. lentine, edvilson cristiano; sonoda, tereza kiomi; biazin, tamares tamasin. londrina, terra e cultura, 2003. comprometimento do trabalho em equipe, não-envolvimento com o sofrimento do paciente, indiferança. danos a saúde do paciente cuidado, desinteresse de realizar novas jornadas de trabalho. diminuição da qualidade do trabalho e desgaste com os colegas. diminuição da qualidade da assistência, aumento dos gastos hospitalares e da rotatividade do pessoal de enfermagem. repercussões negativas na vida em família e em comunidade. relações com o trabalho vividas com pessimismo. afetar seriamente o alcance de objetivos tanto de um setor quanto de toda a organização. queda na imunidade e o surgimento da maioria das doenças, como, por exemplo: dores vagas; taquicardia; alergias; psoríase; caspa e seborréia; hipertensão; diabetes; herpes; graves infecções; problemas respiratórios (asma, rinite, tuberculose pulmonar); intoxicações; distúrbios gastrointestinais (úlcera, gastrite, diarréia, náuseas); alteração de peso; depressão; ansiedade; fobias; hiperatividade; hipervigilância;entre outros. 155 discussão sobre as causas da síndrome de burnout e suas implicações à saúde do profissional de enfermagem l jorge luiz lima da silva, andré campos dias, liliane reis teixeira problemáticas, assim como o comprometimento e o desgaste do trabalho que são constantes (2, 3, 4, 5, 6, 8). isso também é evidenciado em estudo, no qual se demonstra que as decorrências do estresse nos profissionais de enfermagem e a incapacidade de enfrentá-los resultam em enfermidades físicas e psicológicas, insatisfação, desmotivação, queda da produtividade, além de outras manifestações como a diminuição do estado de alerta (36). esta última de extrema relevância, tanto para os clientes críticos quanto para a autoproteção do profissional. quando as relações deixam de ser motivantes no desenvolvimento do trabalho e entre a equipe, como ocorre nesta patologia, isso se reflete em diminuição da qualidade da assistência prestada. tal fato traz possíveis danos à saúde do cliente; o que, do ponto de vista assistencial, é extremamente grave, pois pode levar a erros e danos irreversíveis ou à morte, o que se observa no não-envolvimento com o sofrimento do paciente, indiferença e nas interações problemáticas com os clientes (4, 5, 37). a diminuição da qualidade da assistência somada à relação de indiferença entre o profissional e à atividade realizada leva a maiores gastos e problemas organizacionais, além de contribuírem para maior rotatividade do pessoal de enfermagem (7). em suma, a diminuição na qualidade do trabalho por mau atendimento, procedimentos equivocados, negligência e imprudência pode afetar o bem-estar do trabalhador, a saúde do cliente e a visão da população sobre a instituição de saúde. todos estes problemas prejudicam a tríade paciente-profissional-organização (38). logo, os clientes mal atendidos arcam com prejuízos emocionais, físicos e financeiros que podem se estender aos seus familiares e até ao seu ambiente de trabalho (39). entretanto, o trabalhador acometido por esta patologia é geralmente afastado da organização, em estágios mais avançados, em que o comprometimento da saúde psíquica e física o impossibilita de realizar atividades. esse fato deveria ser muito bem pensado com o objetivo de se promover uma detecção precoce. essa incapacidade para a realização de atividades se manifesta usualmente por afecções fisiológicas como queda na imunidade e o surgimento da maioria das doenças, como, por exemplo: dores vagas; taquicardia; alergias; psoríase; caspa e seborreia; hipertensão; diabetes; herpes; graves infecções; problemas respiratórios (asma, rinite, tuberculose pulmonar); intoxicações; distúrbios gastrointestinais (úlcera, gastrite, diarreia, náuseas); alteração de peso; depressão; ansiedade; fobias; hiperatividade; hipervigilância; entre outros (10). todas essas relacionadas direta ou indiretamente à sb. o estresse está associado à liberação de hormônios que, além de alterarem vários aspectos da fisiologia, têm ainda efeito modulador das defesas do organismo. em humanos, o principal hormônio com essas funções é o cortisol (glicocorticoide). os níveis de cortisol no sangue aumentam drasticamente após a ativação do eixo hipotálamo-hipófise adrenal, que ocorre durante o estresse, a depressão clínica e a sb. esse hormônio então se liga a receptores presentes no interior dos leucócitos e ocasiona imunossupressão na maioria dos casos (38). estudos têm relacionado o estresse crônico à diminuição das defesas do organismo, o que pode levar ao desenvolvimento de doenças (câncer e outras) e de reações alérgicas, bem como o aumento da susceptibilidade a infecções como herpes, gripe e resfriado (38). o sistema cardiovascular possui ampla participação na adaptação ao estresse, e sofre, por isso, as consequências de sua exacerbação. com isso, a suspeita de que estados de estresse ocupacional seja fator de risco para maior morbimortalidade por doença cardiovascular é antiga (33). outro destaque vai para o sistema cardiovascular que participa ativamente das adaptações ao estresse e está, portanto, sujeito às influências neuro-humorais. as respostas cardiovasculares resultam principalmente em aumento da frequência cardíaca, da contratilidade, débito cardíaco e pressão arterial (37). percebe-se que a adaptação do organismo ao estresse ocupacional agrega a participação de inúmeros eixos fisiológicos o que traz prejuízos a praticamente todas as estruturas orgânicas, seja de maneira direta ou indireta. com relação aos sintomas físicos, além dos supracitados, há também distúrbios do sono, disfunções sexuais e alterações menstruais em mulheres. percebe-se que uma gama de sintomas somatizados, por meio do estresse mais grave, poderá estar presente como decorrência da sb (30). destacam-se como decorrências do estresse psíquico a falta de atenção e de concentração, alterações da memória, lentifi156 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 cação do pensamento, sentimento de alienação, de solidão, de insuficiência, impaciência, desânimo, disforia, depressão, desconfiança e paranoia (40). os sintomas comportamentais compreenderiam a falta ou excesso de zelo, irritabilidade, incremento da agressividade, incapacidade para relaxar, dificuldade de aceitação de mudanças, perda de iniciativa, aumento do consumo de substâncias, comportamento de alto risco e aumento da probabilidade de suicídio. os sintomas defensivos caracterizam-se pela tendência ao isolamento, sentimento de onipotência, perda do interesse pelo trabalho ou pelo lazer, insônia e cinismo (41). concluindo-se, pela lógica das obras analisadas, que poderia ser fator contributivo para acidentes de trabalho. durante situações de estresse, o hipocampo pode sofrer modulação pelo complexo amigdaloide. esta estrutura reage ante ameaças que atribui determinado significado (positivo ou negativo) a novas experiências e modula processos plásticos sediados no hipocampo, envolvidos com o processamento de informações, especialmente durante situações de estresse (42). evidências experimentais obtidas em estudos farmacológicos, morfológicos, eletrofisiológicos e moleculares mostram que o complexo é alterado pela exposição a estressores significativos, e parece ter papel importante na mediação dos efeitos terapêuticos dos tratamentos para o estresse (43). outras decorrências como o abuso no consumo de álcool, suicídios e transtornos de ansiedade também possuem importantes repercussões sociais, bem como a dinâmica familiar pode ser afetada e tornar-se distorcida ou prejudicada (44). o indivíduo acometido pela sb pode sofrer distanciamento dos familiares, até filhos e cônjuge. o limite entre essas doenças é frequentemente impreciso; os diagnósticos podem delinear os estágios preliminares de doenças como angina pectoris e infarto do miocárdio (45). sem tratamento especializado e, de acordo com as características pessoais, existe o risco de ocorrerem problemas graves, como enfarte, acidente vascular encefálico, dentre outros. a sb não causa essas doenças, mas propicia o desencadeamento para as quais a pessoa tem predisposição ou, ao reduzir a defesa imunológica, abre espaço para que doenças oportunistas apareçam (46). a incidência de sintomas na área psicológica referida sugere que as fases de estresse apresentadas poderiam estar relacionadas à percepção de sua situação profissional e do trabalho com a comunidade (dinâmica interpessoal laboral). segundo pesquisa realizada com profissionais de unidade do programa de saúde da família (psf), os sintomas físicos mais referidos por profissionais foram: sensação de desgaste físico constante (síndrome de fadiga), o pensar e o falar constante direcionado para um único assunto. além desses, ansiedade generalizada e vontade de “fugir de tudo”. ambos os sintomas desagregam o ser biológico, sua interação familiar, social e também organizacional, o que interfere no desempenho do trabalho desenvolvido (47). além dos efeitos supracitados, o aumento do absenteísmo e todas as suas consequências são mencionados em um dos estudos acerca do tema (48). a relação parece também explícita em outro estudo em hospital universitário de grande porte (15). as consequências desse fato são variadas, e se juntam às anteriormente expostas. logo, nota-se a gama de efeitos oriundos do estresse ocupacional, percebido como amplo e relacionado, dinâmico em subsistemas orgânicos e sociais que vão muito além da esfera psicológica do indivíduo. nesse tocante, a abordagem da sintomatologia oriunda do estresse laboral se faz tão necessária quanto o combate intenso às suas causas e se permite, dessa forma, quebrar a cadeia de prejuízos ocasionados pela sb no ambiente hospitalar. a mudança da atual situação em que se encontram as patologias do trabalho passa pela construção de uma nova cultura organizacional dentro dos serviços de saúde. nesse tocante, perceber as crenças e valores prescritos dentro de uma organização como somente desta, mas também como aqueles nos quais se mostra a essência da cultura, o que fora apreendido em conjunto, o que é compartilhado e são tidos como parâmetros corretos e justos (49). para tal, os gestores devem propiciar o fortalecimento do pessoal e coletivo, desenvolvendo capacidades de lidar com o estresse, valorização pessoal e em grupo, controle das situações de conflito, modificando o contexto e canalizando necessidades e aspirações (50). considerações finais o estresse ocupacional decorrente de um processo de trabalho marcado por condições precárias e pelo aumento da jornada de trabalho tem importantes repercussões no cotidiano profis157 discussão sobre as causas da síndrome de burnout e suas implicações à saúde do profissional de enfermagem l jorge luiz lima da silva, andré campos dias, liliane reis teixeira sional e pessoal dos enfermeiros. constata-se que as condições de trabalho a que estão expostos os trabalhadores favorecem ao estresse ocupacional, pelas características inerentes à profissão e natureza do trabalho, constituindo-se como importante fonte causal para essa problemática, o que resulta em sb. as obras publicadas sobre a sb e sobre o estresse ocupacional do profissional de enfermagem ainda não responderam se há alguma função ocupacional ou especialidade mais estressante do que outra. existe entendimento de que as fontes de estresse são diferentes, embora algumas sejam consideradas comuns, independentemente do cargo que o trabalhador ocupa e da sua área de atuação. perceber as dificuldades que o membro da equipe enfrenta em seu cotidiano se faz tarefa difícil, uma vez que cada tipo de trabalho, seja no ensino, na pesquisa, na gerência ou mesmo na assistência possui características muito peculiares e dificulta o poder de medidas gerais que possam abranger todos os trabalhadores. embora possa ser entendido que é um tipo de função que atua sob constante pressão e demandas diversas. assim, a identificação do estresse ocupacional corresponde a um dos grandes agentes de mudança para o quadro atual, bem como refletir sobre as estratégias de enfrentamento a serem aplicadas. a visão da sb como multicausal traz reflexão sobre a magnitude do estresse e o impacto à saúde do trabalhador quer seja de ordem física e/ou mental. tal constatação pede medidas de intervenção interdisciplinar, uma vez que a visão do fenômeno é psicossocial. desenvolvidas as possíveis soluções para minimizar seus efeitos sobre os trabalhadores, podem tornar o cotidiano do trabalho da equipe mais produtivo, menos desgastante e, possivelmente, valorizando no que se refere aos aspectos humanos e profissionais. estratégias possíveis para minimizar a sb no trabalho seriam: a discussão sobre a carga de trabalho do profissional; número de horas trabalhadas; condições salariais, somadas às modificações no âmbito político; o acompanhamento psicológico dos trabalhadores que lidam com a dor, o sofrimento e morte; criação de condições para promoção do suporte emocional entre os colegas de trabalho, bem como incluir nos exames periódicos a análise das condições de saúde mental relacionada ao estresse no trabalho. a visão sobre o problema deve se voltar para a promoção da qualidade de vida no ambiente laboral e evitar observar somente a doença, ou a visão da patologia ocupacional, pois o trabalho deve trazer prazer e satisfação pessoal, pois muitos profissionais terão apoios social e emocional diversificado, evitando o desenvolvimento da síndrome. este estudo evidencia que há a necessidade de criação de mais pesquisas envolvendo as características do trabalho da enfermagem, estresse laboral e sua relação com a sb no brasil e no mundo. pois, as transformações do mundo moderno do trabalho são rápidas e dinâmicas, fato que pouco se nota no que se refere ao surgimento de novas patologias relacionadas ao trabalho. referências bibliográficas 1. smeltzer sc, bare bg. brunner & suddarth. tratado de enfermagem médico-cirúrgica. 8. ed. rio de janeiro: guanabarakoogan, v.1; 1998. 2. sabbatini rm. o estresse – 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comunidad y sociedad. buenos aires: piados, 2003. 298 aquichan issn 1657-5997 maría dolores martínez1 norma ivonne gonzález-arratia2 johannes oudhof van barneveld3 alejandra del carmen domínguez-espinosa4 micaela olivos-rubio5 factores psicosociales predictores de la satisfacción con la vida en la perimenopausia y posmenopausia 1 doctora en ciencias de la salud. universidad autonóma del estado de méxico, méxico. dolmaga@gmail.com 2 integrante del sistema nacional de investigadores en méxico. universidad autonóma del estado de méxico, méxico. nigalf@yahoo.com.mx 3 investigador. universidad autonóma del estado de méxico, méxico. hansovb@hotmail.com 4 investigadora. universidad iberoanericana, méxico. alejandra.dominguez@uia.mx 5 investigadora. universidad autonóma del estado de méxico, méxico. olivosmica@hotmail.com recibido: 17 de junio de 2012 aceptado: 24 de septiembre de 2012 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 l 298-307 resumen objetivo: analizar las variables que favorecen la adaptación de la mujer al climaterio, como son: autoconcepto, autoestima y percepción de apoyo familiar, factores predictores de la satisfacción con la vida en la perimenopausia y la posmenopausia, e identificar las diferencias entre grupos. materiales y métodos: la muestra fue no probabilística, con un total de 404 mujeres reunidas en: grupo i, perimenopausia y grupo ii, posmenopausia. se aplicaron las escala de 1) satisfacción con la vida (swls), 2) autoconcepto de valdez, 3) autoestima iga, 4) apoyo social percibido (ssp-fa) y cédula de datos sociodemográficos. resultados: se encontró que la autoestima, el apoyo familiar percibido y la dimensión expresivo-afectiva del autoconcepto predicen la satisfacción con la vida en 40,3% (r2 = 0,403 p < 0,005), sin diferencia entre los dos grupos. conclusiones: se concluye que estas variables están presentes positivamente en estos grupos de mujeres y deben ser consideradas como fortalezas de la salud mental para la atención integral en enfermería en este periodo de la vida. palabras clave satisfacción personal, perimenopausia, enfermería, posmenopausia (fuente: decs, bireme). psychosocial predictors of satisfaction with life during perimenopause and postmenopause abstract objective: analyze the variables that favor women’s adaptation to menopause, such as self-concept, self-esteem and perceived family support as the factors that predict satisfaction with life during perimenopause and postmenopause, and to identify differences among groups. materials and methods: the sample was non-probabilistic and included a total of 404 women, separated into two groups: group 299 factores psicosociales predictores de la satisfacción con la vida en la perimenopausia y posmenopausia l maría dolores martínez, norma ivonne gonzález-arratia y otros. i (perimenopause) and group ii (postmenopause). the following scales were applied: (1) satisfaction with life (sels), (2) the valdez self-concept scale, (3) self-esteem scale iga, (4) perceived social support (ssp-fa) and socio-demographic data. results: it was found that self-esteem, perceived family support and the expressive-affective dimension of self-concept predict life satisfaction in 40.3% (r2 = 0,403 p < 0,005), with no difference between the two groups. conclusions: the aforementioned variables are positively present in these groups of women and should be considered as mental health strengths for comprehensive nursing care during this stage of life. key words personal satisfaction, perimenopause, nursing, postmenopause (source: decs, bireme). fatores psicossociais preditores da satisfação com a vida na perimenopausa e pós-menopausa resumo objetivo: realizar as variáveis que favorecem a adaptação da mulher ao climatério, como são: autoconceito, autoestima e percepção de apoio familiar, fatores preditores da satisfação com a vida na perimenopausa e na pós-menopausa, e identificar as diferenças entre grupos. materiais e métodos: a amostra foi não probabilística, com um total de 404 mulheres reunidas em: grupo i, perimenopausa, e grupo ii, pós-menopausa. aplicaram-se as escalas de 1) satisfação com a vida (swls), 2) autoconceito de valdez, 3) autoestima iga, 4) apoio social percebido (ssp-fa) e ficha de dados sociodemográficos. resultados: constatou-se que a autoestima, o apoio familiar percebido e a dimensão expressivo-afetiva do autoconceito predizem a satisfação com a vida em 40,3% (r2 = 0,403 p < 0,005), sem diferença entre os dois grupos. conclusões: conclui-se que estas variáveis estão presentes positivamente nesses grupos de mulheres e devem ser consideradas como fortalezas da saúde mental para o atendimento integral na enfermagem nesse período da vida. palavras-chave satisfação pessoal, perimenopausa, emfermagem, pós-menopausa (fonte: decs, bireme). 300 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 introducción en los últimos años se le ha dado mayor importancia al estudio integral de la mujer, en especial en el periodo de perimenopausia y posmenopausia (1); no obstante, las investigaciones se han enfocado principalmente en la esfera biológica, y muy poco se han abordado los aspectos psicosociales, particularmente la satisfacción con la vida. en conjunto, la perimenopausia y posmenopausia son un evento biológico caracterizado por un decremento estrogénico que se manifiesta por síntomas vasomotores, palpitaciones, insomnio, sequedad vaginal y disminución de la libido (2); al mismo tiempo, se ha reportado que se acompaña de cambios psicológicos y sociales, donde existen importantes pérdidas, algunas de ellas son su capacidad reproductiva y la juventud, aspectos que han sido sobrevalorados por los estereotipos culturales que describen a esta etapa de la vida como negativa y a la persona adulta como infeliz, depresiva y malhumorada (3). sin embargo, numerosos estudios, tanto transversales como longitudinales, ponen de relieve que no existen diferencias de edad en el bienestar subjetivo, donde uno de sus componentes es la satisfacción con la vida, definida como la evaluación global que cada persona hace de sí misma con relación a su vida (4). el grado de realización necesaria para producir satisfacción depende del nivel de adaptación o de las aspiraciones, y está asociado a las experiencias pasadas, las comparaciones con los demás y los valores personales (5, 6). investigaciones sobre satisfacción con la vida sugieren que está asociada con múltiples variables, entre las que se encuentran el autoconcepto, la autoestima (4) y la percepción de apoyo familiar (7) que, en conjunto, potencian la predicción de la satisfacción con la vida. al respecto se han puesto de manifiesto una serie de modelos descriptivos generales que son útiles para la comprensión del funcionamiento psicológico óptimo, entre los que se encuentran la teoría de la selectividad socioemocional, llegando a la conclusión de que las personas mayores experimentan tantos sentimientos positivos como los más jóvenes, mientras que se reducen los sentimientos negativos. asimismo, se sabe que las emociones positivas y negativas son factores relevantes en estas edades (8). de hecho, en los últimos años, investigaciones han demostrado que la satisfacción es un factor protector de la salud mental. sin embargo, existen más estudios relativos a los efectos negativos de la tristeza, la depresión y la ansiedad que al bienestar, la satisfacción o la felicidad. específicamente, el autoconcepto ha mantenido su interés en la psicología porque desempeña una función relevante en la integración de la personalidad, la motivación del comportamiento y el desarrollo de la salud mental (9). por su parte, la autoestima se refiere a los sentimientos resultantes de la percepción; sin embargo, a menudo se utilizan como términos similares, dada su interrelación y causalidad recíproca. de este modo, la autoestima se fundamenta en una valoración positiva del propio autoconcepto (10). particularmente, el estudio del autoconcepto de la mujer en la perimenopausia y posmenopausia es escaso, no obstante, se identificó un estudio acerca de las características observadas en mujeres adultas mexicanas, donde se describen con una tendencia hacia la abnegación y la expresividad (9); mientras que en un estudio realizado con mujeres de taiwán se reporta que el autoconcepto es un factor importante para que la mujer se adapte más fácilmente a la menopausia, aun cuando las puntuaciones obtenidas fueron más bajas que el promedio de la población adulta de ese país (11). en cuanto a la autoestima, en este periodo de vida de la mujer es importante destacar que estudios realizados en méxico muestran variaciones de acuerdo con la edad y el rol que desempeñan socialmente, resaltando que las mujeres presentan niveles más bajos de autoestima en comparación con los hombres, debido a que estas enfrentan retos de autonomía y cambio de estereotipos tradicionales que han tenido a esta edad, como el sufrimiento y la dependencia (10). contrario a estos hallazgos, otro estudio en mujeres estadounidenses y de otros países describe un incremento en los niveles de autoestima en este periodo de la vida, declinando de manera importante a partir de los 60 a 80 años de edad (12). un factor, del que no hay duda acerca de su papel crucial, es el apoyo familiar percibido, ya que la familia es el núcleo más importante del desarrollo del individuo, independientemente de su configuración y funcionamiento (13), donde cada uno de sus integrantes es fuente o proveedor de apoyo y se espera que la percepción que se tenga de él favorezca la adaptación, eleve la autoestima y la satisfacción con la vida de todos sus integrantes. en este senti301 factores psicosociales predictores de la satisfacción con la vida en la perimenopausia y posmenopausia l maría dolores martínez, norma ivonne gonzález-arratia y otros. do, estudios han reportado que uno de los factores importantes asociado a la satisfacción con la vida, es el tener una familia con actitudes positivas hacia el envejecimiento (7, 14). en otro orden de ideas, la existencia de relaciones no implica la provisión de apoyo, todo lo contrario, puede suceder que estas relaciones pudieran ser fuente de conflicto y sufrimiento (14), convirtiendo, en ocasiones, a esta red social en un factor de riesgo para la salud mental. con base en estas consideraciones se plantea como objetivo analizar las variables de autoconcepto, autoestima y apoyo familiar como factores predictores de la satisfacción con la vida en la perimenopausia y posmenopausia; adicional a esto, se deben identificar las posibles diferencias entre ambos grupos con el fin de que la enfermera tenga más elementos de intervención con enfoque integral hacia las mujeres en esta etapa de la vida (15). materiales y métodos participantes. la muestra no probabilística de tipo intencional estuvo compuesta por un total de 404 mujeres (m = 50,95 años de edad; de = 4,045), de dos ciudades de la república mexicana (toluca, estado de méxico y ciudad del carmen, campeche), quienes aceptaron participar de forma voluntaria en el presente estudio. las participantes se clasificaron en dos grupos: grupo i, 200 mujeres consideradas en perimenopausia (m = 48,11 años de edad; de = 2,411) y grupo ii, 204 mujeres en posmenopausia (m = 53,63 años de edad; de = 3,403). esta clasificación se realizó con base en las definiciones descritas por la asociación internacional de menopausia (16). los criterios de inclusión fueron que las mujeres, en el momento de la aplicación, estuvieran sin tratamiento de terapia hormonal, sin falla ovárica y sin menopausia inducida. la tasa de respuesta fue del 95% (404/425), un índice que se consideró aceptable. instrumentos. los instrumentos que se aplicaron fueron los siguientes: escala de satisfacción con la vida (satisfaction with life scale swls), versión en español (4): es una escala de autoinforme, compuesta de cinco reactivos, con siete opciones de respuesta. de acuerdo con el autor, las puntuaciones de 30 a 35 indican muy alta satisfacción; 25 a 29 alta satisfacción; 20 a 24 promedio; 15 a 19 ligeramente inferior a la media; 9 a 14 insatisfecha; y un puntaje entre 5 a 9 extremadamente insatisfecha. la escala reporta una consistencia interna de alfa de cronbach de 0,85; para esta muestra, la confiabilidad calculada con el coeficiente alpha de cronbach con los cinco ítems fue de 0,74. escala de autoconcepto de valdez (9): es una escala validada en población mexicana que explica el 46,9% de la varianza. consta de 37 ítems, integrados por seis dimensiones: socialnormativa, social-expresiva, expresivo-afectiva, ético-moral, trabajo intelectual y rebeldía. las puntuaciones asignadas son de acuerdo con la identificación de adjetivos que la persona asume tener: 5 = tiene totalmente; 4 = tiene algo; 3 = ni tiene ni le falta; 2 = tiene muy poco; 1 = no tiene nada. los ítems negativos se califican de forma inversa. el alfa de cronbach reportado por el autor fue de 0,82. para esta muestra, la consistencia interna calculada con el coeficiente de alfa de cronbach fue de 0,86, con los 37 ítems. escala de autoestima iga (11): este instrumento fue utilizado inicialmente en adolescentes mexicanos, después se validó para población adulta. consta de 25 ítems integrados por seis dimensiones: yo, familia, éxito, trabajo intelectual, afectivoemocional y fracaso. las opciones de respuesta son cuatro: 4 = siempre; 3 = muchas veces; 2 = pocas veces; 1 = nunca. los ítems negativos se califican inversamente. las puntuaciones: 25-40 = muy baja autoestima; 41-55 = baja; 56-70 = promedio; 71-85 = alta; 86-100 = muy alta. la prueba de alfa de cronbach reportada por iga ha sido de 0,80 en población adulta; en el presente estudio fue de 0,90. escala de percepción de apoyo social familiar (perceived social support from family pss-fa) (17): consta de 20 ítems, con tres opciones de respuesta (sí, no, no sé), las puntuaciones de la escala son: 0 = no apoyo, 1 = apoyo. para efectos de este estudio, como criterio para la interpretación de los datos, se establecieron los siguientes niveles de percepción de apoyo familiar, para ello se consideraron los percentiles 25 (1-12, percepción de bajo apoyo familiar), percentil 50 (13-14, percepción media de apoyo familiar) y percentil 75 (15-16, percepción de alto apoyo familiar). el alfa de cronbach reportado por la autora fue de 0,90 y el obtenido en este estudio fue de 0,83. otra cédula aplicada fue la de datos sociodemográficos, que contiene información respecto a ocupación, escolaridad y tener pareja e hijos, variables que se consideraron para el análisis descriptivo. 302 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 procedimiento. la aplicación de los instrumentos se hizo de forma individual, autoadministrada, con supervisión por parte de los investigadores en un periodo de ocho meses. se captaron mujeres en población abierta y en instituciones de seguridad social en dos ciudades pertenecientes a los estados de méxico y campeche. el tiempo estimado fue de 30 a 40 minutos; todas las participantes accedieron de forma voluntaria, anónima y confidencial. se llevaron a cabo análisis de frecuencias absolutas y relativas para la descripción de las características sociodemográficas de las participantes y de los niveles de satisfacción con la vida, la autoestima y de percepción de apoyo familiar. para determinar las diferencias entre los grupos se utilizó la t de student, considerando las puntuaciones totales obtenidas de cada escala. asimismo, se establecieron correlaciones con la prueba de pearson entre los totales de satisfacción con la vida, autoestima, las seis dimensiones de autoconcepto y el apoyo familiar percibido. el último análisis realizado fue la regresión múltiple por pasos, donde el modelo propuesto fue que el total de las dimensiones de autoconcepto, autoestima y percepción del apoyo familiar predicen la satisfacción con la vida; las significancias se establecieron con una p ≤ 0,05. aspectos éticos. el comité de ética del centro de investigaciones en ciencias médicas (cicmed) de la universidad autónoma del estado de méxico aprobó el presente estudio, en el marco del reglamento de la ley general de la salud en materia de investigación y de la declaración de helsinki; de tal forma que las participantes firmaron el consentimiento informado, voluntario y garantizando a las mujeres la confidencialidad y el anonimato. resultados los datos sociodemográficos se presentan en la tabla 1, donde se observa que el porcentaje más alto lo ocupan las mujeres con estudios de preparatoria o carrera técnica (26,2%); la mayor proporción en ocupación es el trabajo no remunerado (41,6%); igualmente se observa alta la proporción de mujeres casadas (64,9%); con pareja (77,5%) y con hijos (93,8%). en el grupo de posmenopausia se observó que la edad promedio de aparición de la menopausia fue de 48,67 años (de = 3,409). para establecer las diferencias de estos datos se aplicó x2, encontrándose diferencia estadísticamente significativa solo en la variable de escolaridad (p ≤ 0,012). a partir de los puntajes totales para cada escala se procedió a obtener los siguientes resultados: la escala de satisfacción con la vida tiene un rango de 5 a 35, la media obtenida de este caso fue de 27,86 de 5,003 (mínima = 6 y máxima = 35). del total de la muestra, el 46,8% presentan un puntaje que corresponde a muy alta satisfacción con la vida, seguida de un nivel alto (30,9%), el resto se ubica por debajo del promedio. respecto a la puntuación de autoestima, la escala presenta un rango comprendido de 25 a 100, con una media de 85,08 de 10,508 (mínima = 49 y máxima = 100), donde el 55,2% presentó puntuaciones que corresponden a un nivel de autoestima muy alta; no se observaron diferencias estadísticamente significativas en los grupos estudiados. la puntuación de la escala de apoyo familiar tiene un rango entre 0 a 20, obteniéndose una media de 15,5 (mínima = 1 y máxima = 20). el mayor porcentaje observado (44%) corresponde a alta percepción de apoyo familiar (tabla 2). las dimensiones de autoconcepto, de manera general, se observaron con una media 4,046 de 0,421 (mínima = 2,49 y máxima = 4,95), puntuaciones que se encuentran por arriba de la media teórica (3). en el análisis realizado por dimensiones sobresalen características positivas correspondientes a la dimensión éticomoral; contrario a esto, las puntuaciones más bajas se observan en la dimensión de rebeldía. las diferencias significativas entre los grupos de perimenopausia y posmenopausia se observaron en las dimensiones expresivo-afectiva, social-expresiva y de rebeldía, ya que las puntuaciones más altas están en favor del grupo de perimenopausia. las diferencias entre los grupos de perimenopausia y posmenopausia se observan en las dimensiones expresivo-afectiva (t = 2.782, p ≤ 0,006) social-expresiva (t = 2.152, p ≤ 0,032) y rebeldía (t = 2.768, p ≤ 0,006) (tabla 3). asimismo, los totales de autoestima, apoyo familiar percibido y satisfacción con la vida fueron consideradas para analizar las diferencias entre los grupos, en donde no se observaron diferencias estadísticamente significativas. en cuanto a las interrelaciones entre las variables, se obtuvieron los siguientes resultados: percepción de apoyo familiar (r = 0,514, p ≤ 0,01), ético-moral (r = 0,213, p ≤ 0,01), expresivoafectiva (r = 0,303, p ≤ 0,01), social-expresiva (r = 0,250, p ≤ 0,01) y trabajo intelectual (r = 0,240, p ≤ 0,01); la satisfacción 303 factores psicosociales predictores de la satisfacción con la vida en la perimenopausia y posmenopausia l maría dolores martínez, norma ivonne gonzález-arratia y otros. con la vida se correlacionó con autoestima (r = 0,581, p ≤ 0,01) y el autoconcepto con la dimensión social-normativa (r = 0,231, p ≤ 0,01). posteriormente se realizó un análisis de regresión lineal múltiple por pasos, con el objetivo de determinar la(s) variables(s) que inciden sobre la satisfacción con la vida, para lo cual se consideraron como variables independientes las seis dimensiones de autoconcepto, el puntaje total de autoestima y de percepción de apoyo familiar. en el modelo de regresión se obtuvo que las variables que predicen la satisfacción con la vida en un 40,3% (r2 = 0,403; p = 0,005) son: la autoestima, seguida del apoyo familiar percibido y la dimensión expresivo-afectiva del autoconcepto; mientras que las variables que no contribuyen a explicar la satisfacción con la vida fueron las dimensiones de autoconcepto: social-normativa, social-expresiva, dimensión ético-moral, trabajo intelectual y rebeldía (tabla 4). discusión en este estudio se muestra que las variables que predicen la satisfacción con la vida son: la autoestima, seguida de la percepción del apoyo familiar y la dimensión expresivo-afectiva positiva de autoconcepto. contrario a lo que se esperaba, no se encontraron diferencias estadísticamente significativas entre los grupos de perimenopausia y posmenopausia, excepto en las dimensiones expresivo-afectiva, social-expresiva y de rebeldía, encontrándose una tendencia más positiva en el grupo de perimenopausia. se observa que los niveles de satisfacción con la vida son altos en el 77,7% de este grupo de mujeres en perimenopausia y posmenopausia, cifra mayor a la reportada por la organización para la cooperación y el desarrollo económico (ocde), donde en méxico el 66% de la población general refiere altos índices de satisfacción con la vida, en comparación con la media a nivel mundial que es de 55% (18). otros estudios relacionados con esta etapa de la vida describen alto nivel de satisfacción en mujeres japonesas en 48,2% (19), cifra mucho menor que la reportada en el presente estudio. según algunas investigaciones, el país de origen es uno de los factores que determinan el nivel de satisfacción con la vida, lo cual lleva a suponer que dicha satisfacción está influida por las diferencias culturales. otro estudio longitudinal con mujeres australianas (20) reporta altos niveles de satisfacción con la vida, predicha principalmente por las actitudes anteriores a esta etapa, lo que hace evidente que la satisfacción personal no necesariamente declina con el incremento de la edad (21), por la posible capacidad de adaptación de los individuos frente a los cambios propios físicos y sociales; aspecto importante para tenerlo presente, en función de que las mujeres muestran mayor atención a las emociones positivas que negativas (8), lo cual puede favorecer su salud mental, si bien esta puede cambiar de acuerdo con la personalidad de la mujer y las situaciones vivenciales tanto familiares y de pareja, como laborales y profesionales. por otro lado, se alude a que en esta etapa se ve afectada de manera especial la autoestima, en parte por los estereotipos tradicionales de desvalorización de la mujer en la perimenopausia y posmenopausia (22); sin embargo, pueden haber otros factores psicológicos y sociales; tal es el caso de un grupo de mujeres de ecuador participantes en un estudio, donde el factor de paridad y escolaridad tuvieron una relación importante (23); afortunadamente, esto es diferente en otras culturas, como es el caso de mujeres de austria (24) y alemania (25), donde se muestra que en este periodo de la vida no está afectada su autoestima, tal como se observó en la muestra bajo estudio, donde esta fue el primer predictor en el modelo de regresión para la satisfacción con la vida. de la misma forma, los cambios que enfrenta la mujer en la perimenopausia y posmenopausia, pese a que es un proceso natural, no dejan de estar posiblemente influidos por expectativas negativas difundidas por algunos medios de comunicación que la presentan como una experiencia indeseable o como una enfermedad, lo cual pudiera afectar su autoconcepto y autoestima (24). sin embargo, en la mayoría de las mujeres participantes se observa un autoconcepto positivo por ser: románticas, detallistas, cariñosas y sentimentales, hallazgos que coinciden con lo reportado en un estudio con una muestra similar de mujeres mexicanas (10). en contraste, reportes de investigación en taiwan indican puntuaciones generales de autoconcepto positivo por debajo de la media, lo cual es explicado por el impacto que tienen en ellas los cambios físicos, y los roles en su trabajo y en su familia (11). estas evidencias alentadoras pueden ser explicadas, en parte, porque presentan una visión positiva de la vida en general y una autoestima positiva (26). cabe señalar que las actitudes con las que se enfrentan los cambios inherentes al ciclo de vida no dependen de manera exclusiva de la persona, también es notable 304 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 el apoyo familiar percibido para la satisfacción con la vida. como bien se afirma en un estudio realizado en colombia, las mujeres asumen de manera natural esta etapa (27). de igual forma, en otro estudio realizado con una muestra de 300 mujeres mexicanas se reporta que el apoyo familiar, junto con la ocupación, son factores predictores de la satisfacción con la vida en los periodos de perimenopausia y posmenopausia, confirmando así que la satisfacción con la vida durante esta etapa es multifactorial, y que los aspectos psicosociales son elementos importantes para la mejor adaptación de la mujer hacia el envejecimiento (28). en este sentido, las mujeres que participaron en el presente estudio tuvieron una percepción alta de apoyo familiar, lo cual favorece no solo su salud mental, sino también la física; mientras que un estudio realizado con mujeres australianas (29) reporta baja percepción de apoyo familiar, señalando una mayor probabilidad de tener una percepción negativa de la menopausia. en este caso, los resultados llevan a pensar que la perimenopausia y la posmenopausia no representan una situación negativa en el grupo de mujeres analizado. conclusiones a partir de los resultados se concluye que la autoestima, el autoconcepto —en particular la dimensión expresivo-afectiva— y el apoyo familiar son predictores de satisfacción con la vida. las enfermeras, como profesionales de la salud, tienen entre otros roles el compromiso de desarrollar funciones educativas en el cuidado para la mujer a favor de una salud mental positiva, valorando sus capacidades, así como facilitar la confianza en sus cualidades de autoconcepto y autoestima y, por ende, su bienestar y satisfacción con la vida, con una visión de mejoramiento, en la medida de lo posible, de los estados físicos, emocionales, intelectuales, sociales y espirituales que se encuentren alterados. dadas las consideraciones anteriores, resulta oportuno decir que el estudio de esta etapa del ciclo vital requiere que desde la práctica profesional de enfermería, en el primer nivel de atención, sea visto y abordado de manera integral, con la finalidad de promover en la mujer una actitud activa, para lograr y mantener un buen estado de salud acorde con su ciclo vital, teniendo presente que la aproximación para la atención de estas mujeres debe ser multidimensional y, por tanto, multidisciplinaria. de lo anterior se desprende que la promoción de la salud mental no busca únicamente desaparecer las psicopatologías, sino que se encarga de promover la salud mediante la identificación de los elementos conductuales positivos que se pueden potenciar, e incidir en la transformación de aquellos comportamientos no saludables hacia un mejor estado de salud integral. en este marco de reflexión, las aportaciones del presente trabajo permitirán mantener estas fortalezas, al tomar en cuenta que para que exista autocuidado se requiere cierto grado de desarrollo personal, mediado de manera permanente por el fortalecimiento del autoconcepto y la autoestima, entre otros elementos como son la resiliencia, el autocontrol y la autoaceptación (30). finalmente, cabe mencionar que estos resultados pueden orientar al desarrollo de una investigacción longitudinal y construir modelos teóricos donde se hace necesario mencionar algunas limitaciones del presente estudio. en primer lugar, para tener la certeza de la etapa de transición a la menopausia, incluir una medida de la hormona folículo-estimulante (fsh), misma que no fue evaluada en las participantes; sería importante que en futuros estudios se contemple su asociación sobre las variables psicosociales. en segundo término, se sugiere incluir la asociación de la percepción de apoyo social del grupo de amigos con la satisfacción con la vida, dado que es una red social y puede favorecer la adaptación a esta etapa. asimismo, incluir otras variables psicológicas a fin de contar con modelos explicativos de la satisfacción con la vida en este periodo. conflicto de intereses: ninguno declarado. 305 factores psicosociales predictores de la satisfacción con la vida en la perimenopausia y posmenopausia l maría dolores martínez, norma ivonne gonzález-arratia y otros. referencias 1. cornachione lma. adultez. psicología del desarrollo. aspectos biológicos, psicológicos y sociales. argentina: brujas; 2006. 2. gonçalves r, merighi m, aparecida b. reflections on sexuality during the climacteric. rev. latino-am. enfermagem [periódico na internet]. 2009 abr [consultado el 26 de agosto de 2011]; 17(2): 160-166. disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=s0104-11692009000200004&lng=pt. doi: http://dx.doi.org/10.1590/s010411692009000200004 3. francés rl. análisis sobre los modelos culturales de la menopausia. departament d antropologia cultural i historiade america i africa. universitat de barcelona. 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[consultado el 12 de octubre de 2011] available from: http://www.imsociety.org/menopause_terminology.php 17. domínguez eac, salas mi, contreras bc, procidano me. validez concurrente de la versión mexicana de la escala de apoyo social percibido de la familia y los amigos (pss-fa& pss-fr) revista latinoamericana de psicología 2011;43(1):125-137. 18. organización para la cooperación y desarrollo económico. ocde. life satisfaction in detail by country [consultado el 28 de octubre de 2011] available from: http://www.oecdbetterlifeindex.org/topics/life-satisfaction/ 19. shiwaku k, yamane y, sugimura i, hayashi m, nojiri m, matsushima s. et al. vasomotor and other menopausal symptoms influenced by menopausal stage and psychosocial factors in japanese middle-aged women. journal of occupational health 2001;43:356-364. 306 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 20. deeks aa, mccabe mp. well-being and menopause: an investigation of purpose in life, self-acceptance and social roll in premenopausal, perimenopausal and postmenopausal women. qual life res 2004;13:389-398. 21. jocik g, álvarez m, bayarre h. construcción de un instrumento para medir bienestar subjetivo en adultos mayores; 2000. premio anual de salud, ministerio de salud pública de la república de cuba. 22. carter nd, friedrich d. age stereotypes in middle-aged through old-old adults. int´l j. aging and human development 2010;70(10):199-212. 23. chedraui p, pérez-lópez fr, mendoza m, leimberg ml, martínez m, vallarino v. hidalgo. assessment of self esteem in mid-aged women. maturitas 2010;66(2010):77-82. 24. bloch a. self awareness during the menopause. maturitas 2002;41:61-68. 25. beutel md, glaesmer h, decker o, fischbecck s, brähler e. life satisfaction, distress and resiliency across the life span of women. menopause 2009;16(6):1132-1138. 26. hunter m, rendall m. bio-psycho-socio-cultural perspectives on menopause. best practice & research clinical osbtetrics and gynecology 2007;21(2):261-274. doi: 10.1016/j.bpobgyn.2006.11.001. [consultado el 28 de octubre de 2011]. available online at http://www.sciencedirect.com 27. argote ola, mejía rme, vásquez tml, villaquiran gma. climaterio y menopausia en mujeres afrodescendientes: una aproximación al cuidado desde la cultura. aquichan 2008;8(1):33-49. 28. martínez gmd, gonzález-arratia lfni, oudhof bh, domínguez eac. satisfacción con la vida asociada al apoyo familiar en la perimenopausia y posmenopausia. salud mental 2012;35(2):91-98. 29. bauld r, brown rf. stress, psychological distress, psychosocial factors, menopause symptoms and physical health women. maturitas 2009;62:160-165. 30. tebón to. el autocuidado. una habilidad para vivir. universidad de caldas colombia [en línea] [consultado el 15 de enero de 2012]. disponible en: http://promocionsalud.ucaldas.edu.co/downloads/revista%208_5.pdf. 307 factores psicosociales predictores de la satisfacción con la vida en la perimenopausia y posmenopausia l maría dolores martínez, norma ivonne gonzález-arratia y otros. 109 121 saude e obesidade.indd 109 maria henriqueta luce kruse1 franciele da silveira schenini2 rúbia guimarães ribeiro3 stefanie griebeler oliveira4 aline fantin cervelin5 saúde e obesidade: discursos de enfermeiras6 1 doutora em educação. professora-associada da escola de enfermagem da ufrgs. pesquisadora do grupo de estudos culturais na educação em saúde e enfermagem (ufrgs). kruse@uol.com.br 2 especialista em enfermagem do trabalho. enfermeira do centro de diagnóstico por imagem (cdi) do hospital dom vicente scherer, santa casa de misericórdia, porto alegre (rs). franschenini@yahoo.com.br 3 mestranda em enfermagem pelo programa de pós-graduação em enfermagem (ppgenf) da ufrgs. bolsista da coordenaçao de aperfeiçoamento de pessoal de nível superior (capes). membro do grupo do grupo de estudos culturais na educação em saúde e enfermagem (ufrgs). rubiagribeiro@yahoo.com.br 4 mestre em enfermagem. doutoranda em enfermagem pelo ppgenf (ufrgs). bolsista da capes. membro dos grupos de pesquisa: estudos culturais na educação em saúde e enfermagem (ufrgs). stefaniegriebeler@yahoo.com.br 5 acadêmica em enfermagem. escola de enfermagem da ufrgs. bolsista do programa institucional de bolsas de iniciação científica/conselho nacional de desenvolvimento científico e tecnológico (pibic/cnpq). membro do grupo do grupo de estudos culturais na educação em saúde e enfermagem (ufrgs). alinefc_89@hotmail.com 6 texto inédito elaborado a partir do trabalho de conclusão de curso de graduação em enfermagem da universidade federal do rio grande do sul (ufrgs). recibido: 18 de noviembre de 2011 aceptado: 21 de mayo de 2012 resumo este estudo buscou conhecer os discursos de enfermeiras sobre obesidade veiculados nos periódicos brasileiros de enfermagem. para tanto, nos aproximamos do campo dos estudos culturais, na vertente pós-estruturalista, inspirada em michel foucault. o corpus da pesquisa se baseou em artigos encontrados nas bases de dados periódicos de enfermagem da biblioteca wanda de aguiar horta (perienf) e base de dados em enfermagem (bdenf). nas análises, utilizamos as ferramentas do saber, discurso e poder propostas por michel foucault. as análises dos artigos permitiram a construção de duas categorias: o corpo magro e saudável – um jogo de poder e saber –, e o corpo desejável e saudável – matizando a rede de discursos. inicialmente a obesidade é entendida como uma condição a ser combatida, com destaque para a perda de peso de forma saudável. com o decorrer dos anos, ela passou a ser entendida como um problema da modernidade, trazendo consigo um modelo de beleza que privilegia o corpo magro. palavras-chave obesidade, peso corporal, enfermagem, saúde. (fonte: decs, bireme). salud y obesidad: los discursos de las enfermeras resumen este estudio buscó conocer los discursos de las enfermeras sobre la obesidad publicados en las revistas brasileras de enfermería. para ello, nos aproximamos al campo de los estudios culturales, en la línea pos-estructuralista, inspirada en michel foucault. el corpus de la investigación se basó en artículos encontrados en las bases de datos periódicos de enfermería de la biblioteca wanda de aguiar horta (perienf) y base de datos en enfermería (bdenf). en los análisis utilizamos las herramientas de conocimiento, discurso y poder año 12 vol. 12 nº 2 chía, colombia agosto 2012 l 109-121 110 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 propuestos por michel foucault. el análisis de los artículos permitió la construcción de dos categorías: un cuerpo delgado y saludable: un juego de poder y saber, y un cuerpo deseable y sano: atravesando una red de discursos. inicialmente, la obesidad es entendida como una condición que debe ser combatida poniendo el énfasis en la pérdida de peso de manera saludable. con el correr de los años, pasó a ser considerada como un problema de la modernidad, trayendo consigo un modelo de belleza que privilegia el cuerpo delgado. palabras clave obesidad, peso corporal, enfermería, salud. (fuente: decs, bireme). health and obesity: the opinions of nurses abstract the objective of this study was to become familiar with nurses’ opinions on obesity published in brazilian nursing journals. to do so, the authors approached the field of cultural studies, pursuant to the poststructuralist line inspired by michel foucault. the body of the research was based on articles found in the nursing journal databases of the wanda de aguiar horta library (perienf) and the nursing database (bdenf). the tools of knowledge, discourse and power proposed by michel foucault were used in the analysis, which allowed for the construction of two categories: a lean and healthy body: a game of power and knowledge, and a desirable and health body: traversing a network of opinions. obesity was understood initially as a condition to be combated through an emphasis on healthy weight loss. over the years, obesity has come to be regarded as a problem of modernity, bringing with it a model of beauty that favors a slim body. key words obesity, body weight, nursing, health. (source: decs, bireme). 111 saúde e obesidade: discursos de enfermeiras l maria henriqueta luce kruse, franciele da silveira schenini, rúbia guimarães ribeiro, stefanie griebeler oliveira, aline fantin cervelin introdução o que significa ser obeso na modernidade? embora existam muitas respostas para essa questão, pensamos que seria possível problematizar algumas delas para dar conta desse significado. obesidade, excesso de gordura corporal e sobrepeso são condições físicas que têm despertado muita discussão na área da saúde. tal fato também está relacionado ao aumento da preocupação das enfermeiras7 e de outros profissionais da saúde com o crescimento dessa condição entre a população. comumente, encontramos muitas definições para o termo “obesidade”, mas observamos que os discursos sobre ela foram assumindo diferentes formatos com o passar do tempo, ao se articularem com outros discursos, como os de saúde e beleza, o que originou uma rede discursiva que tem efeitos de verdade. desde a antiguidade, o excesso de peso é um assunto que desperta interesse. naquela época, ser gordo era visto como um sinal de saúde e prosperidade, pois era preciso garantir uma ingesta energética favorável, a fim de manter as necessidades mínimas de sobrevivência e se proteger contra as doenças (1). a modernização e a revolução industrial provocaram o aumento da oferta de alimentos e a melhoria dos instrumentos de trabalho, como a mecanização e a automação (2). essas modificações ocorridas no padrão alimentar, com maior consumo de alimentos de alta densidade energética, associadas aos avanços tecnológicos e ao aumento do sedentarismo, estão sendo responsabilizadas pelo aumento de peso da população (3). em função disso, a obesidade tem sido definida como “doença da civilização” ou “síndrome do novo mundo” (2). o obeso, no mundo contemporâneo, é nomeado pelos considerados “normais” (aqueles que têm a silhueta magra) como uma espécie de inapto, de descuidado, de imoral, devendo ser excluído das imagens cotidianas estetizadas para que o mundo se torne mais belo (4). dessa maneira, o corpo obeso se apresenta negativamente ante as cobranças de um modelo de beleza magro construído pela/na cultura (5). nesse sentido, a obesidade tem sido vista de duas maneiras: como um estado desviante do padrão de normalidade, ou como doença (6), sendo que nesta última está a rede de discursos que nos incitou a pensar neste estudo. 7 embora a presença do sexo masculino venha aumentando na enfermagem, utilizaremos o termo “enfermeira” por entender que as mulheres ainda formam a maior parte do quadro de profissionais nessa área. as enfermeiras que, em sua prática diária, cuidam de pessoas obesas têm se ocupado dessa temática ao fazer circular, nas revistas científicas da área, discursos sobre o assunto que nos subjetivam e produzem efeitos de verdade. a partir disso, propomos uma aproximação com o campo dos estudos culturais, especificamente, a vertente pós-estruturalista, inspirada em michel foucault, para analisar tais discursos. acreditamos que os discursos sobre a obesidade são organizados em saberes, e que estes são produzidos de acordo com regimes de verdades, que obedecem a racionalidades históricas correspondentes a interesses datados (7). tomaremos “verdade” com o sentido dado por foucault (8), sendo um conjunto de regras onde se distingue o verdadeiro do falso, atribuindo ao verdadeiro efeitos de poder. ao analisar tais discursos, poderemos refletir sobre sua pretensão de subjetivar enfermeiras, mas destacamos que nosso objetivo neste artigo não consiste em buscar “verdades” sobre a obesidade, mas sim tentar entender como os discursos sobre obesidade circulam, de que modo subjetivam as enfermeiras, o que determina diferentes jeitos de cuidar e formar sentidos sobre o obeso. material e método este estudo é uma análise textual dos discursos de enfermeiras sobre a obesidade, publicados em periódicos brasileiros de enfermagem. nas análises, utilizamos os conceitos do pós-estruturalismo que nos permitem entender o corpo como um constructo sociocultural, produto e efeito de relações de saber-poder em uma perspectiva pós-moderna, que compõe um conjunto de ações descentradas e instáveis, propondo uma análise externa às racionalidades e “verdades” da modernidade (9). na coleta dos dados, procuramos identificar os discursos sobre a obesidade a partir da leitura interessada dos textos, que consiste em saber aquilo que podemos aproveitar e aquilo que podemos descartar (10). analisar discursos é operar sobre documentos e interrogar a linguagem, identificando as maneiras como as formações discursivas acontecem e determinam as condições de existência de um discurso (11). nas análises, utilizamos algumas ferramentas propostas por michel foucault, como discurso, saber, poder e sujeito. o discurso é entendido como uma série de acontecimentos, que se estabelece e descreve as relações mantidas com outros acontecimentos. o saber pode ser entendido como um conjunto de elementos formado de maneira regular por uma prática discursiva. além disso, ele é também o campo de coordenação e de subordinação dos 112 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 enunciados em que os conceitos aparecem, definem-se, aplicamse e transformam-se. por poder, entenderemos um conjunto de relações de forças estratégicas entre indivíduos ou grupos. por fim, sujeito será entendido como objeto-objetivo, como ser sujeitado e constituído, produto histórico e social produzido pelas relações de poder e saber (8). os artigos analisados foram localizados por meio da utilização das ferramentas de busca de periódicos indexados nas bases de dados dos periódicos de enfermagem da biblioteca wanda de aguiar horta (perienf – escola de enfermagem da universidade de são paulo) e da base de dados em enfermagem (bdenf). na busca, foi utilizado o descritor “obesidade”. tal busca permitiu identificar 28 publicações no perienf e 74 publicações na bdenf. das fontes localizadas no perienf, 14 artigos também apareciam na bdenf, portanto foram mantidos 14 artigos dessa base. das publicações da bdenf, oito eram teses, duas apareciam repetidas e três artigos pertenciam à revista somente em versão impressa. desse modo, ficaram 61 artigos da bdenf. a partir disso, os artigos foram lidos na íntegra e selecionados quando traziam o assunto da obesidade como centro da discussão. o corpus de análise (quadro 1), o qual se encontra no final deste artigo, foi constituído por 38 publicações, sendo oito do perienf e 30 da bdenf, publicadas entre 1941 e 2010. os artigos foram identificados no texto com a letra a, como código, seguida de um número, entre colchetes, que dá sequência à organização do corpus ([a1], [a2]). lembramos que as publicações utilizadas para a análise textual são de caráter público. resultados e discussão para apresentar os saberes sobre obesidade veiculados nas publicações de enfermagem, estabelecemos categorias a partir do modo como os discursos foram se apresentando, destacando suas modificações ao longo do tempo. desse modo, foram definidas duas categorias para apresentar esses discursos: o corpo magro e saudável – um jogo de poder e saber (artigos publicados de 1941 a 1999) –; e o corpo desejável, saudável e normal – matizando a rede de discursos (publicações de 2000 a 2010). o corpo magro e saudável: um jogo de poder e saber observamos que, até a década de 1990, os discursos sobre a obesidade enfatizavam a promoção de uma perda de peso saudável, por meio de ações educativas estabelecidas por estratégias, como a elaboração de manuais, a implementação da consulta de enfermagem e a criação de grupos de obesos. primeiramente, a obesidade era vista como uma condição do organismo em que o peso se encontra acima do normal em consequência do acúmulo excessivo de gordura, sendo o excesso de alimentação, a hereditariedade, a subatividade e os distúrbios endócrinos destacados como as causas dessa condição. a redução de 0,5 a 1kg por semana era suficiente para que a aparência e o vigor se mantivessem [a11] (12). observa-se que a preocupação das enfermeiras, nessa época, era a perda de peso sem riscos à saúde, com segurança e conforto. para tanto, a classificação utilizada era a de que os indivíduos cujo peso normal excedesse em 20, 30 ou 40% o tido como ideal, deveriam perder peso. essa classificação era utilizada para verificar o estado nutricional em adultos, sendo que o peso ideal era obtido pela comparação da massa corporal com a estatura (13). alguns anos depois, esse modo de classificar foi substituído pelo índice de massa corporal (imc), o qual é utilizado até hoje. entendemos que tal avaliação classifica os corpos dos indivíduos como se fossem todos iguais, como se não tivessem histórias, particularidades e individualidades, “um desfile de mesmices, passíveis de serem classificados, enquadrados, coordenados” (9). após 32 anos da primeira publicação, encontramos um artigo sobre assistência de enfermagem a pacientes obesos, onde é apontado o papel da enfermeira nas diferentes etapas pelas quais esses pacientes passam ao procurar os serviços de saúde, desde o acompanhamento ambulatorial até a internação e o preparo para a alta. de acordo com os excertos, a função da enfermeira é instruir acerca das dietas alimentares e da prática de atividades físicas, encorajando e apoiando os pacientes por meio de ações educativas, durante todo o período de internação [a8] (14). a enfermeira, subjetivada pelos discursos das revistas, promove orientações aos pacientes, prescrevendo e produzindo efeitos de verdade e determinando as maneiras de se ter um corpo dentro do padrão considerado adequado na nossa cultura, ou seja, um corpo magro e, consequentemente, saudável. esse comportamento engloba a ideia de que a educação pertence a um artifício em que os indivíduos se transformam em sujeitos de uma cultura, em que as revistas científicas fazem parte das diferentes instâncias sociais envolvidas no processo de educar (15). de acordo com os textos, essas orientações são intensificadas quando a alta é assinalada, uma vez que o paciente nem sempre consegue permanecer com o 113 saúde e obesidade: discursos de enfermeiras l maria henriqueta luce kruse, franciele da silveira schenini, rúbia guimarães ribeiro, stefanie griebeler oliveira, aline fantin cervelin peso adquirido no hospital após a alta. isso é devido a que, durante a internação, as técnicas disciplinares dos hospitais são mais eficazes, pois mantêm o corpo enclausurado e alvo de vigilância e registro constante da enfermeira, não permitindo que o paciente aja de maneira diferente à estipulada (9). a obesidade começa a ser relacionada com fatores metabólicos, exercícios físicos, psicológicos, familiares e socioeconômicos. dentre esses, o fator psicológico merece destaque, pois é citado que “indivíduos que apresentam frustrações e ansiedade podem ter apetite aumentado, uma vez que o ato de comer pode ser encarado como defesa a frustrações e tensões, sendo considerado um derivativo agradável” [a8](14). mediante diferentes e minuciosas técnicas, são definidos modos de transformar o corpo, exercendo uma coerção e regulação dele, utilizando como táticas dietas, exercícios, apoio psicológico, entre outras. o ditado popular “é melhor prevenir do que remediar” [a8] encerra o texto](14), concluindo que os discursos das enfermeiras com relação à obesidade começam a se direcionar para os aspectos preventivos da doença. o tratamento da obesidade também é apontado como difícil e prolongado e, muitas vezes, inatingível para algumas pessoas, por isso a importância de controlar os fatores que estão envolvidos na gênese da obesidade. para tanto, a prevenção da doença é sugerida como a melhor escolha, antecipando o discurso da prevenção que se tornaria muito forte anos depois, relacionado ao controle das doenças crônicas, com destaque para as ações de educação em alimentação e o desenvolvimento de atividades físicas [a8] ](14). tais ações educativas começam a ser contempladas na consulta de enfermagem, especialmente com o objetivo de proporcionar a participação do paciente com excesso de peso no seu autocuidado, reduzindo complicações e danos controláveis causados pela obesidade [a19] (16). desse modo, os artigos analisados permitem acompanhar o desenvolvimento da profissão, pois apontam os diferentes modos de trabalho da enfermagem, suas práticas e o arcabouço legal que as sustenta. em 1983, encontramos um relato de experiência realizado com um grupo de pacientes obesos, atendidos pelos cursos de educação para a saúde. apesar da prematuridade desse tipo de abordagem na época, os resultados foram significativos, promovendo mudanças no estilo de vida dos indivíduos que participaram do programa. assim, é proposta uma atividade que viria a ter vida longa entre as enfermeiras e demais profissionais da saúde: a educação em saúde em grupos de obesos, um tema que seria recorrentemente tratado nos anos seguintes [a20] (17). a enfermeira surge como profissional capacitada para desempenhar as funções de educação com grupos e com a comunidade, ela fala de um lugar privilegiado, pois é detentora de um saber científico e, por consequência, de poder, sendo seus ensinamentos considerados “verdades”. pelas análises percebemos que as enfermeiras utilizam diferentes estratégias educacionais, o que promove um investimento nos corpos dos pacientes, manipulando-os, regulando e treinando. em uma das publicações, é descrita a elaboração de um livro intitulado “saúde e sua forma de viver”, que pretende orientar indivíduos a respeito da necessidade de controle de peso e pressão arterial, visando à prevenção de doenças cardiovasculares. para tanto, é proposto o entrelaçamento de três práticas diversas e combinadas entre si: a consulta de enfermagem, os grupos e o uso de manuais [a1](18). tais estratégias permitem avaliar o disciplinamento proposto pelas enfermeiras, compondo uma verdadeira rede que captura os pacientes com diferentes discursos sobre os males da obesidade. foucault (19) chamou de disciplina os métodos que permitem o controle minucioso das operações do corpo, realizando sua sujeição constante e lhe impondo uma relação de docilidade-utilidade. assim, esse corpo pode ser submetido, utilizado, transformado e aperfeiçoado por meio de tais estratégias. percebemos que, nessa época, os enunciados incitam as pessoas a se alimentar de determinado modo e a praticar exercícios físicos, acionando o discurso do viver bem. ainda não tínhamos o cruzamento dos discursos da saúde com os da beleza que caracterizam os saberes sobre a obesidade que circulam atualmente. a enfermeira agia zelando pelas atividades mais do que sobre seu resultado, exercia técnicas que permitiam um esquadrinhamento do tempo, espaço e movimento dos pacientes, utilizava estratégias para disciplinar os corpos, que os tornava obedientes e úteis, enfim, fabricava “corpos submissos e exercitados, corpos dóceis” (19). o corpo desejável, saudável e normal: matizando a rede discursiva com o decorrer do tempo, o assunto da obesidade passa a ganhar maior relevância nas publicações de enfermagem. a partir do ano 2000, os enunciados sobre o tema assumem diferen114 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 tes contornos. ainda que as publicações continuem destacando a necessidade de se ter um corpo magro para ser saudável, uma série de outras discursividades é apresentada, tais como: obesidade como um afrontamento à beleza do corpo, como fator de risco para o surgimento de doenças crônicas, obesidade infantil como fator preditivo de obesidade na vida adulta e, por fim, a obesidade mórbida. os discursos relacionados com a importância de se ter um corpo magro e, por consequência, esteticamente desejável, passam a ganhar mais importância. o imperativo do corpo magro e inatingível da cultura ocidental é um dos principais fatores que contribuem para essa importância dada à imagem corporal. como parte da cultura, as enfermeiras também são subjetivadas pela repulsa ao corpo obeso; elas fazem circular, através das revistas científicas, discursos que abordam a prevenção e tratamento da obesidade, agora ligados também à estética corporal. outros estudos (20, 21) mostram que, apesar de a cultura ocidental enfatizar o corpo magro como esteticamente adequado, aceitável e belo, aparece nos artigos que é justamente a dieta dessa cultura o fator que mais favorece a obesidade. no brasil, o aumento da obesidade se dá devido a um declínio no gasto energético, resultante de um estilo de vida menos ativo e de uma mudança na dieta, que vem aumentando a proporção de gorduras na alimentação. essa mudança na alimentacão é conhecida como “transição nutricional”, que aponta como evidência a crescente opção pela dieta ocidental – com um maior consumo de calorias e proteínas de origem animal, açúcar refinado e lipídios insaturados, dentre outros [a10] (22). um estudo com mulheres, que comparou a percepção do peso que estas tinham em relação ao diagnóstico antropométrico, revelou que elas superestimam a sua imagem corporal. assim, a principal causa atribuída para esse comportamento seria a influência do modelo de beleza feminina veiculada pela mídia, caracterizada por mulheres magras [a13] (23). somos constantemente bombardeados pelos discursos midiáticos que supervalorizam o corpo: a mídia informa qual é o corpo socialmente aceito, ela aponta a estética como o ponto de partida para o sucesso pessoal (24). ao ser obeso, isso se torna inviável. além disso, o discurso da beleza atrelado ao da saúde faz com que qualquer pessoa com o mínimo sobrepeso seja considerada gorda ou obesa (20). em outro estudo, foi examinada a percepção que o sujeito obeso tem de si, no sentido de entendê-lo na sua multidimensionalidade, para que seja possível que a enfermagem, ao coexistir com o corpo obeso na sociabilidade hospitalar, transcenda as ações de cuidado instrumentais (técnicas); essa transcendência irá possibilitar um mergulho no mundo privado do corpo obeso [a25] (25). assim, as táticas propostas anteriormente não são suficientes para atender os pacientes obesos, já que a enfermeira é incitada a adentrar no “mundo privado” dos pacientes, uma vez que que o indivíduo obeso se depara com diversos problemas, os quais não estão apenas relacionados aos danos físicos que a doença engloba, mas também aos psicológicos. aqui, adiciona-se mais uma questão ao problema: ser magro é um ideal a ser atingido para garantir a saúde e também pelos aspectos psicológicos que essa condição determina. vivemos em uma “cultura da aparência” na qual os padrões culturais de beleza que identificam o corpo magro como belo geram preconceito e discriminação aos sujeitos obesos. além disso, o obeso é visto como responsável pela sua condição, já que apresentaria falta de vontade para controlar tal situação [a25] (25). essa ideia nos remete ao sentido de sujeito empresário de si, empregado por foucault (26). esse indivíduo deve ser capaz de autogovernar sua conduta, seu comportamento, seu tempo, suas atividades. esse sujeito se autorregula, pois sua vida tornase sua empresa, a qual ele precisa administrar. assim, ele é seu próprio “cartão de visita” e, por isso, é preciso gerir-se cuidando da saúde, nesse caso, prevenir-se/tratar a obesidade. tal sujeito deve ser autônomo, pois será o responsável pelo seu sucesso ou fracasso. e fracasso é ser obeso. com efeito, nós nos criamos na medida da informação que construímos e transmitimos sobre nós mesmos, bem como, nos articulamos dentro de jogos representacionais de competição e qualidade. quanto mais magro somos, mais saúde – e qualidade – temos (27). a partir disso, emerge um excesso de obediência às normas ideais do corpo padrão, que quando não cumpridas engendram sentimentos de fracasso, provocam sérios distúrbios alimentares e produzem forte exclusão social dirigida àqueles que muito se distanciam de tais normas (28). um estudo (29) realizado com alunos e profissionais da educação física e com outros externos a esse grupo revelou que ambos, percebem o corpo obeso como o menos belo. diante desse cenário, os enunciados relacionados à obesidade também trazem o reconhecimento da complexidade dos aspectos envolvidos na adoção de estilos de vida mais saudáveis e apontam a necessidade de um trabalho integrado da equipe multiprofissional com o cliente obeso e a família. outra estratégia discursiva importante também é apontada: a equipe multiprofis115 saúde e obesidade: discursos de enfermeiras l maria henriqueta luce kruse, franciele da silveira schenini, rúbia guimarães ribeiro, stefanie griebeler oliveira, aline fantin cervelin sional [a3] (30). ou seja, os artigos mostram a importância dos “detentores do saber”, dos “experts” no processo de “salvação” desse sujeito obeso. para foucault (31), existem sujeitos que têm a permissão de falar sobre determinados assuntos, os denominados “experts”. o autor afirma que possuímos consciência de que não temos o direito de dizer o que nos apetece, que não podemos falar de tudo em qualquer circunstância, que quem quer que seja, finalmente, não pode falar do que quer que seja (31). além dos discursos que relacionam a obesidade como um afrontamento à beleza corporal, emergem enunciados que a citam como fator de risco para doenças. inúmeros estudos são publicados pelas enfermeiras, os quais associam a obesidade com o risco para desenvolver doenças crônicas, como diabetes, hipertensão arterial, acidentes vasculares cerebrais, coronariopatias e insuficiência renal, entre outras [a10; a4; a5; a6; a9; a14; a16; a18] (22, 32-38). outra pesquisa (39) demonstra que um dos fatores da adesão das mulheres às orientações nutricionais se dá pela percepção da obesidade como doença (39). assim, tais pesquisas têm como objetivo demonstrar a importância de elaborar estratégias educacionais que possibilitem a adesão ao tratamento, prevenindo a obesidade e, com isso, inúmeras doenças decorrentes dessa situação. dessa forma, percebe-se que os discursos das revistas buscam produzir uma orientação linear e didática de como as enfermeiras devem agir para ensinar os pacientes a conduzirem suas vidas e educarem seus corpos, para que se tornem “magros e saudáveis”. as enfermeiras e outros profissionais da saúde passam a evidenciar, em seus textos, a preocupação existente no cenário da saúde em relação ao aumento da prevalência da obesidade em crianças e adolescentes. apesar de esse fato ser um evento recente no brasil, revela crescimento acelerado nessas faixas etárias (40, 41). a obesidade infantil é citada como preditiva de obesidade na vida adulta, por isso é necessário que ela seja diagnosticada, prevenida e tratada precocemente (42, 22). destacase que, atualmente, as crianças apresentam um comportamento sedentário, pois passam muito tempo em frente da televisão, computadores e smartphones, praticam menos atividade física e mantêm um consumo de alimentos de alta densidade energética. a família é apontada como responsável pela obesidade infantil. seu estilo de vida, representado por hábitos alimentares inadequados, desmame precoce, inatividade física e a obesidade dos pais, pode predispor a criança ao aumento de peso, o que é uma situação de alerta para a saúde pública [a2; a24] (43-44). outros estudos relatam ainda que a nutrição na infância tem relação com o desenvolvimento de determinadas doenças na vida adulta, como a hipertensão arterial, diabetes e doenças cardiovasculares (45). os saberes sobre obesidade, além de serem objeto de investimento frequente, vão assumindo diferentes formatos na ordem dos discursos científicos sobre saúde e doença. assim, uma nova discursividade passa a ser objeto de pesquisa das profissionais de enfermagem: a obesidade mórbida. diversos autores preocupam-se em determinar que pacientes são patologicamente obesos, que riscos apresentam e as complicações que podem advir dessa condição. a obesidade mórbida é classificada como doença de origem multifatorial, geralmente associada a comorbidades, com elevadas taxas de mortalidade (46). a normalização tenta moldar as pessoas a um modelo previamente estabelecido: a norma. depois de estabelecida a norma, define-se a “régua”, ou seja, as medidas, que deixarão dentro da norma aqueles que se enquadram nos padrões e, fora dela, aqueles que não forem “capazes” de moldar-se de acordo com os parâmetros. é a partir da norma que se torna possível a normalização, ou seja, a sistematização. portanto, a norma surge a partir dos normais para constituir os chamados anormais (31). as enfermeiras apontam o tratamento baseado em abordagens terapêuticas para redução do peso, com consequente melhora das comorbidades associadas e da qualidade de vida do paciente, como a primeira escolha a ser feita em busca da normalização (42). todavia, essas autoras, a partir de dados numéricos, os quais têm “efeitos de verdade” na assistência à saúde, citam esse tratamento “convencional” como falho e pouco eficiente para os pacientes patologicamente obesos. assim, abrem-se as condições de possibilidades para o surgimento de outras tecnologias normalizadoras e outros saberes sobre o tratamento da obesidade que permitem que as enfermeiras se apropriem dessas “novas” discursividades e (re)estruturem seus saberes e fazeres, como o surgimento da cirurgia bariátrica. essas novas racionalidades que se organizam para normalizar o obeso originam um campo de atuação profissional para a enfermagem. a partir de então, as enfermeiras passam a se preocupar com os cuidados do obeso mórbido no pré e pós-operatório e com o enquadramento deste na sistematização da assistência de enfermagem, ao lhe atribuir diagnósticos e intervenções de enfermagem. tal fato pode ser observado nos principais diagnósticos e intervenções de enfermagem, baseados na taxonomia 116 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 da associação norte-americana de diagnósticos de enfermagem (nanda – sigla em inglês) e do national institute of clinical studies (nics – classificação das intervenções de enfermagem), possíveis de serem aplicados ao obeso mórbido. estes seriam os diagnósticos de enfermagem: intolerância à atividade; interação social prejudicada; isolamento social; manutenção ineficaz da saúde; mobilidade física prejudicada; nutrição desequilibrada: mais do que as necessidades corporais, risco para solidão, entre outros [a12] (47). na modernidade, temos necessidade de ordem. essa ideia é muito produtiva, pois podemos calcular a probabilidade de determinados eventos voltarem a acontecer em um mundo em ordem (48). nessa perspectiva, acreditamos que tais diagnósticos ajudam a atender essa necessidade moderna de se organizar. os diagnósticos de enfermagem classificam os indivíduos a partir de fatores que relacionam a possibilidade de adoecer ou de ser saudável. essa classificação tem a pretensão de representar uma totalidade ao enquadrar diferentes possibilidades humanas, como se todas as diferenças dos seres humanos pudessem ser categorizadas (49). a cirurgia bariátrica é uma estratégia de enquadrar esse individuo obeso na normalidade. a cirurgia proporcionará “o nascimento de um novo indivíduo, com personalidades e sonhos” [a15] (50). percebemos que, mesmo que se fale sobre conflitos, ao referir que o paciente será “um novo indivíduo com personalidades e sonhos” após enfrentar a cirurgia, fica claro que vale a pena enfrentar todas as dificuldades para alcançar um corpo magro, já que os sacrifícios serão recompensados com uma nova vida. conclusão quando analisamos os discursos sobre obesidade veiculados nas revistas científicas de enfermagem, podemos observar que foram se modificando ao longo do tempo. inicialmente, a obesidade era entendida como uma condição a ser combatida, com destaque para a perda de peso de forma saudável. com o decorrer dos anos, a obesidade passa a ser vista como um problema da modernidade, que traz consigo um modelo de beleza que privilegia o corpo magro, submetido à ditadura da beleza. as revistas científicas de enfermagem desempenham o papel de veicular conceitos e comportamentos que subjetivam as enfermeiras com diferentes discursos que se cruzam, como os de saúde, beleza corporal e saúde mental; esses discursos objetivam a produção de um corpo com medidas determinadas, enquadradas em tabelas e padrões estabelecidos. dessa forma, organiza-se uma rede discursiva que aponta estratégias com foco na manutenção de um corpo magro e saudável. nas análises, percebemos que as enfermeiras utilizam diferentes táticas educacionais, entrelaçadas e combinadas, as quais promovem um investimento nos corpos dos pacientes. estes devem ser manipulados, regulados e treinados na consulta de enfermagem, nos grupos de obesos e por meio de manuais. tais estratégias são acompanhadas de um discurso autoritário, com imposições e regras que estabelecem o campo de ação dos pacientes a que se dirigem. estas estratégias compõem uma rede que captura os pacientes com diferentes discursos sobre os males da obesidade. para isso, as enfermeiras utilizam os diferentes saberes como indispensáveis para manutenção da saúde, com o intuito de tornar os sujeitos capazes de modelar o corpo de acordo com os padrões vigentes na cultura. esses ensinamentos, organizados na cultura e veiculados nos discursos das enfermeiras, são tidos como verdades que têm o poder de regular e treinar os corpos, tanto dos pacientes como das enfermeiras. assim, os pacientes são subjetivados a se tornarem capazes de cuidar de si próprios, o que promove um investimento sobre seu corpo de forma constante e detalhada. as enfermeiras entendem que a prevenção da obesidade deve começar nos primeiros meses de vida ao destacar a importância do aleitamento materno. na idade adulta, é enfatizada a relevância de programas educativos elaborados pela equipe multiprofissional para a promoção de estilos de vidas mais saudáveis e a prevenção de doenças crônicas. assim, as prescrições para se ter um corpo magro e saudável regulam os sujeitos desde o nascimento até a idade adulta, o que incentiva determinados comportamentos e condena outros, pois o que interessa não é apenas o resultado, mas todo o desenvolvimento das atividades na direção de uma vida mais saudável. no século xxi, os artigos que abordam a obesidade são mais frequentes e muitos deles enfocam uma nova discursividade que passa a estampar a revista e a ser objeto de pesquisa das profissionais de enfermagem: a da obesidade mórbida. a participação das enfermeiras nessa discursividade proporcionou a inclusão delas em um novo campo de saber. este apresenta a modernidade como responsável por proporcionar estilos de vida que favorecem o desenvolvimento da obesidade; são destacados os 117 saúde e obesidade: discursos de enfermeiras l maria henriqueta luce kruse, franciele da silveira schenini, rúbia guimarães ribeiro, stefanie griebeler oliveira, aline fantin cervelin discursos relacionados com a importância de se ter um corpo magro e esteticamente desejável, provavelmente influenciado pela cultura da aparência, característica da pós-modernidade. o imperativo do corpo magro na cultura ocidental é um dos principais fatores que contribuem para essa importância dada à imagem corporal. é possível afirmar que a mídia, da qual fazem parte as revistas científicas, desempenha um importante papel na constituição desta identidade moderna. seus conceitos e comportamentos compõem um jogo de poder que atua disciplinarmente nos corpos. as análises também remeteram ao sentido de sujeito empresário de si, empregado por foucault. ele seria capaz de autogovernar sua conduta, pois sua vida seria a empresa a qual ele precisa administrar, principalmente no que se refere ao cuidado da saúde, nesse caso, prevenir-se/tratar a obesidade. dessa forma, o paciente é subjetivado para que tenha “bom comportamento”, que se manifesta por 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a24 zanotti mdu, pina jc, manetti ml. correlação entre pressão arterial e peso em crianças e adolescentes de uma escola municipal do noroeste paulista. esc. anna nery 2009; 13 (4): 879-85. a25 zottis c, lambrocini ml. o corpo obeso e a percepção de si. cogitare enferm. 2002; 7 (2): 21-9. a26 alves jt, vianna la. obesidade em uma população portadora de hipertensão arterial. acta paul. enferm. 2000; 3 (pt 2): 90. 121 saúde e obesidade: discursos de enfermeiras l maria henriqueta luce kruse, franciele da silveira schenini, rúbia guimarães ribeiro, stefanie griebeler oliveira, aline fantin cervelin quadro 1. corpus da análise a27 araújo mfm, lemos acs, chaves es. creche comunitária: um cenário para a detecção da obesidade infantil. cienc. cuid. saúde 2006; 5 (1): 24-31. a28 araújo mfm, lemos acs, chaves es. o papel da amamentação ineficaz na gênese da obesidade infantil. acta paul. enferm. 2006; 19 (4): 450-5. a29 capelli jcs, koifman s. a avaliação do estado nutricional na comunidade 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icm. prevalência de sobrepeso e obesidade e fatores associados em escolares de área urbana de chilpancingo, guerrero, méxico, 2004. cad. saúde pública 2006; 22 (6): 1289-301. a36 nascimento lc, mendez ijm. perfil de saúde dos trabalhadores de um centro de saúde-escola. rev. latino-am. enfermagem 2002; 10 (4): 502-8. a37 sáenz-soto ne, gallegos ec. efecto de intervención física sobre alimentación y actividad física en adolescentes mexicanos con obesidad. texto & contexto enferm. 2004; 13 (1): 17-25. a38 sebold lf, radunz v, rocha pk. acupuntura e enfermagem no cuidado à pessoa obesa, cogitare enferm. 2006; 11 (3): 234-8. 140 157 autobarreras de las mujeres.indd 140 aquichan issn 1657-5997 grey yuliet ceballos-garcía1 clara victoria giraldo-mora2 “autobarreras” de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama3 1 enfermera, universidad de antioquia. gceballos @cuidandote.com.co 2 doctora en sociología médica; coordinadora del grupo de investigación salud de las mujeres, universidad de antioquia, medellín, colombia. clarag@tone.udea.edu.co 3 este artículo es producto de la investigación titulada “barreras para el diagnóstico y tratamiento oportuno de cáncer de mama”, registrada en el comité de apoyo a la investigación codi de la universidad de antioquia y con el apoyo del grupo de salud de las mujeres de la facultad de enfermería de la universidad de antioquia, medellín, colombia. recibido: 10 de febrero de 2009 aceptado: 14 de mayo de 2011 resumen objetivo: describir las barreras que impiden a las mujeres con cáncer de mama (cama) acceder a los servicios de salud y adoptar hábitos favorables para la detección precoz y el tratamiento oportuno. materiales y métodos: estudio cualitativo basado en la teoría fundamentada; la recolección de los datos se hizo a través de entrevistas semiestructuradas a 13 mujeres entre los 24 y 77 años de edad, con diagnóstico de cama, realizado entre el 2006 y 2008 en medellín, colombia. resultados: se describen “autobarreras” como:el temor a los ámbitos y tratamientos médicos, el retraso para consultar por considerar prioritarios los compromisos laborales y familiares, y las experiencias terapéuticas negativas. conclusiones: el estudio muestra que las “autobarreras” impiden el diagnóstico y tratamiento oportuno de cama, estas no pueden ser explicadas desde una visión simplista y aislada; el ser humano es el resultado de su contexto, sus vivencias personales y su relación con los otros. uno de los principales hallazgos fue la descripción de un proceso en el que las mujeres finalmente desarrollan una nueva lógica frente al riesgo del cama que les permite pensar en el autocuidado y el cuidado de los otros como sujetos de riesgo. palabras clave neoplasias de la mama, conducta de riesgo, enfermería. año 11 vol. 11 nº 2 chía, colombia agosto 2011 l 140-157 141 “autobarreras” de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama l grey yuliet ceballos-garcía, clara victoria giraldo-mora women’s self-imposed barriers to timely diagnosis and treatment of breast cancer abstract objective: to describe the barriers that prevent women with breast cancer (bc) from seeking health care and adopting habits conducive to early detection and timely treatment. materials and methods: this is a qualitative study based on grounded theory. the data were collected through semi-structured interviews with 13 women between 24 and 77 years of age who had been diagnosed with breast cancer. the interviews were conducted between 2006 and 2008 in medellin, colombia. results: “self-imposed barriers” are described, such as a fear of medical environments and treatment, delays in consulting a physician because work and family are considered a priority, and negative therapeutic experiences. conclusions: the study shows “self-imposed barriers” prevent timely bc diagnosis and treatment. however, these barriers cannot be explained from a simplistic and isolated standpoint. human beings are the result of their background, context, personal experiences and relationships with others. one of the main findings was the description of a process whereby women eventually develop a new logic concerning the risk of bc, specifically one that allows them to think about self-care and the care of others as subjects at risk. key words breast neoplasms, risk-taking, nursing. “auto barreiras” das mulheres para o diagnóstico e o tratamento do câncer de mama resumo objetivo: descrever as barreiras que impedem as mulheres com câncer de mama (cama) para acessar os serviços de saúde e adotar hábitos conducentes à detecção precoce e o tratamento oportuno. materiais e métodos: estudo qualitativo com base na teoria fundamentada. na coleta de dados utilizaram-se entrevistas semi-estruturadas com 13 mulheres entre 24 e 77 anos de idade, com diagnóstico de cama, levado a cabo entre 2006 e 2008 em medellín, colômbia. resultados: descrevem-se "auto barreiras" como temor aos espaços e tratamentos médicos, a demora para consultar por dar prioridade ao trabalho e aos compromissos familiares, e as experiências terapêuticas negativas. conclusões: o estudo mostra que as "auto barreras" evitam o diagnóstico e o tratamento oportuno do cama. estas auto barreiras não são simples nem estão isoladas, já que o ser humano é fruto do seu contexto, suas vivências pessoais e sua relação com os demais. uma das principais conclusões foi a descrição de um processo em que as mulheres, eventualmente, desenvolvem uma nova lógica contra o risco de cama, que lhes permite pensar no auto cuidado e o cuidado dos demais como sujeitos de risco. palavras-chave neoplasias da mama, assunção de riesgo, enfermagem. 142 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 introducción el cáncer de mama (cama) es una de las formas de cáncer más viejas entre los seres humanos. para los antiguos, el cama era “el cáncer”; la gente moría de otros tumores malignos como el de ovario, de hueso, tejido blando, mielomas, múltiples leucemias y linfomas; sin embargo, estos tumores eran invisibles, mientras que el cama era evidente, progresando de un pequeño nódulo a grandes tumores, causando estragos en la mama y el cuerpo (1). el aspecto del cáncer indujo a hipócrates a llamarlo “karkinos”, la palabra griega para cangrejo, pues al examinarlo de cerca el tumor parecía tener tentáculos, como las patas de un cangrejo, que se extendían y agarraban tejidos normales (2). datos de la sociedad americana de cáncer (3) muestran que el cama es la primera localización tumoral (1’301.867 nuevos casos) y la primera causa de muerte entre las mujeres (464.854 muertes) a nivel mundial. su incidencia ha aumentado en todos los países del mundo (679.682 nuevos casos en países desarrollados y 593.528 nuevos casos en países en desarrollo), constituyéndose no solo en un problema de salud pública, sino también político, médico, social, psicológico y económico debido al dolor y al sufrimiento personal, los costos médicos crecientes, las muertes prematuras, y la pérdida de años productivos de vida (4). según la iniciativa mundial de salud de mama (breast health global initiative / bhgi), este cáncer se constituye en un problema de salud pública en regiones de altos recursos y es una problemática cada vez más urgente en las regiones de bajos recursos, con un aumento del 5% en las tasas de incidencia (5). en américa latina y el caribe, durante el año 2002, el cama causó diariamente la muerte de 83 mujeres, o sea, cada hora fallecían tres mujeres víctimas de este cáncer (6). la situación para colombia no es muy alentadora, el cama es un problema de salud pública creciente (7); la mortalidad por esta causa, según la organización mundial de la salud (oms) (8), fue de 11,3 por cada 100.000 mujeres en el año 2004, y en antioquia fue de 10,8 por cada 100.000 mujeres en el 2003 (9), por lo que se considera la principal causa de muerte ginecológica, por encima del cáncer de cuello uterino que representó el 8,7 por cada 100.000 mujeres (10). la principal estrategia contra el cama es la detección precoz, es decir, la identificación de la enfermedad en un punto en el que pueda ser tratada con técnicas que tengan el menor impacto físico y la mayor probabilidad de curación (7); además, el diagnóstico temprano disminuye considerablemente los costos económicos, psicológicos, familiares, sociales y laborales de esta enfermedad. autoridades nacionales como el instituto nacional de cancerología (11), y otras internacionales como la international union against cancer (uicc) y la organización mundial de la salud (oms), a través del programa bhgi (12), se han preocupado por disminuir las crecientes cifras de mortalidad por cama emprendiendo campañas para estimular su detección precoz. en colombia, la detección temprana del cama se fomenta mediante la mamografía; también se recomienda brindar, a todas las mujeres mayores de 20 años, educación en autoexamen de mama y se estipula la realización del examen clínico duranla principal estrategia contra el cama es la detección precoz, es decir, la identificación de la enfermedad en un punto en el que pueda ser tratada con técnicas que tengan el menor impacto físico y la mayor probabilidad de curación. 143 “autobarreras” de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama l grey yuliet ceballos-garcía, clara victoria giraldo-mora te la consulta médica o ginecológica (13). como estrategias para la lucha contra el cama es importante recordar que su efectividad es contundente, demostrada con la mayor supervivencia y la posibilidad de curación cuando es diagnosticado y tratado tempranamente (7). según la oms, cuando se dispone de las pruebas e instalaciones necesarias, el tamizaje de mujeres en apariencia sanas puede revelar la presencia de estadios tempranos o precursores de neoplasias malignas, lo que es sumamente eficaz para un tratamiento oportuno; sin embargo, a pesar de la existencia de políticas internacionales y nacionales como las mencionadas para la detección precoz, el descubrimiento tardío del cama y la muerte por esta causa siguen en aumento. para algunos autores, la tardanza en el diagnóstico y el tratamiento del cama tiene tres categorías: el paciente, los proveedores y un conjunto de estructuras del sistema de asistencia médica (14). en este sentido, surge el interrogante acerca de si existen barreras, y de qué tipo, que les impidan a las mujeres acceder a los servicios de salud y adoptar hábitos que les permitan realizar una detección precoz y, por consiguiente, un tratamiento oportuno, que disminuya significativamente las tasas de mortalidad por esta enfermedad. múltiples investigadores en diversos lugares del mundo se han preocupado por explorar las barreras que impiden a las mujeres acceder a un diagnóstico oportuno (14, 15, 16, 17, 18). para hewitt et al., las barreras son todas las condiciones psicológicas y sociales que impiden o retrasan el acceso a los servicios de salud a las mujeres con cama, tales como, carecer de seguro médico o de la cobertura de estos servicios; el miedo al estigma que el diagnóstico de cama produce en estas personas; la falta de comunicación del proveedor de salud con las pacientes; las fallas para poner en práctica las pautas de práctica clínica, diagnóstica y de tratamiento; la inexperiencia del proveedor para evaluar la urgencia de la asistencia y la presencia de ansiedad por esta causa; el uso de ayudas y métodos de diagnóstico demasiado rápidos; la inadecuada coordinación y fragmentación del cuidado que estas pacientes requieren; el desconocimiento del proveedor acerca de los recursos que existen en la comunidad y, finalmente, un pobre sistema de garantía de calidad y responsabilidad en la prestación de los servicios de salud (16). otras de las barreras que la oms refiere, están relacionadas con las deficiencias en la organización y el establecimiento de prioridades, y el uso poco eficiente de los recursos, que son obstáculos para la eficacia de los programas en países tanto industrializados como en desarrollo. en muchas ocasiones se descuidan la prevención primaria, el descubrimiento temprano y los cuidados paliativos para dar preferencia a enfoques orientados al tratamiento, independientemente de su eficacia real, en función de los costos, o de una mejor calidad de vida de las pacientes. en un estudio realizado en colombia se encontró evidencia contundente en relación con la mayor supervivencia y la posibilidad de curación de las mujeres con cama cuando es diagnosticado a tiempo, aunado al creciente desarrollo de tecnologías de imágenes que han promovido su detección temprana (7). en nuestro estudio, las “autobarreras” se entienden como aquellos obstáculos que en un momento pueden ser tanto o más determinantes que las barreras de acceso físico o financieras, estas están relacionadas con las creencias, actitudes, conductas o situaciones sociales que según la oms, cuando se dispone de las pruebas e instalaciones necesarias, el tamizaje de mujeres en apariencia sanas puede revelar la presencia de estadios tempranos o precursores de neoplasias malignas, lo que es sumamente eficaz para un tratamiento oportuno. 144 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 no permiten la acción requerida; en un concepto más amplio, las barreras pueden ser el temor, el pudor, las creencias erróneas, los problemas sexuales, las angustias relacionadas con la imagen del cuerpo, el estado cognoscitivo, el contexto, la edad de las mujeres, las situaciones familiares, entre otras (14, 15, 16, 17, 18). con este trabajo se pretende alcanzar un enfoque integral de las barreras que existen entre las mujeres de la ciudad de medellín, colombia, que les impiden acudir a un diagnóstico y tratamiento oportuno para el cama, ya que esta realidad se analiza desde la perspectiva de la paciente. método este estudio fue realizado en la ciudad de medellín, colombia, durante un periodo de 15 meses, entre el 2006 y el 2008. se utilizó el método cualitativo enmarcado en la perspectiva de la teoría fundada de strauss (19). las participantes fueron 13 mujeres entre los 24 y 77 años de edad, a quienes se les había diagnosticado cama, y que voluntariamente quisieron narrar sus experiencias. la técnica de recolección de la información fue la entrevista semiestructurada (20), durante la cual se intentó crear un ambiente de confianza y empatía (21). este estudio fue clasificado como una investigación sin riesgo para las participantes de acuerdo con la resolución 8430 de 1993 del ministerio de salud colombiano, en tanto se emplean técnicas y métodos de investigación documental retrospectivos, y no se realizó ninguna intervención o modificación intencionada de las variables biológicas, fisiológicas, psicológicas o sociales de los individuos que participaron en el estudio, diferentes a las propias de una entrevista médica (22). para preservar la identidad de las participantes se utilizaron nombres ficticios y se desarrolló un formato de consentimiento informado que fue diligenciado de manera voluntaria por las participantes, también se les explicó previamente el tipo de investigación, los objetivos, el propósito y los posibles beneficios y riesgos derivados de su participación. el grupo de informantes se constituyó a partir de las siguientes técnicas: contactos personales con usuarias de programas de las instituciones de salud, tanto públicas como privadas, utilizando la técnica de la bola de nieve descrita por strauss y corbin (19). esta muestra responde a la técnica de máxima variación (23), la selección y el número de personas entrevistadas se orientó utilizando la estrategia del muestreo teórico que permite una la saturación sugerida por strauss (19). cada una de las entrevistas fue grabada, para luego ser transcrita, lo que permitió conservar la fidelidad de lo narrado por las participantes. las entrevistas fueron transcritas textualmente, para después iniciar la codificación abierta, analizando línea por línea para extraer los significados apuntados por cada una de las mujeres (24). para el análisis se utilizó principalmente el enfoque straussiano de la teoría fundamentada, buscando que “la teoría emergiera a partir de los datos” (19). además, desde la corriente glaseriana conceptualizamos lo que estaba pasando con el fenómeno estudiado, y a partir del relato de las experiencias de las mujeres pudimos comprender las barreras que tuvieron para el diagnóstico y el tratamiento oportuno del cáncer, y desde allí describir este fenómeno a fin de, como lo afirma corbin según cisneros (25), “conocer y mejorar el mundo”. en nuestro estudio, las “autobarreras” se entienden como aquellos obstáculos que en un momento pueden ser tanto o más determinantes que las barreras de acceso físico o financieras, estas están relacionadas con las creencias, actitudes, conductas o situaciones sociales que no permiten la acción requerida. 145 “autobarreras” de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama l grey yuliet ceballos-garcía, clara victoria giraldo-mora utilizamos este enfoque puesto que pretendíamos no solo identificar las barreras para el diagnóstico y tratamiento oportuno de cama, sino también, entender y describir cómo las mujeres las enfrentan. la recolección de los datos fue guiada por los conceptos derivados de la teoría en construcción y la comparación constante (19). es importante aclarar que en un principio el estudio estuvo orientado a identificar las barreras solo en el diagnóstico; sin embargo, al estar abiertas a los datos, comprendimos que no solo existían barreras para el diagnóstico, sino también para el tratamiento. una vez iniciada la codificación abierta se logró identificar un gran interés entre las mujeres por hablar sobre los efectos de tratamientos como la quimioterapia, la radioterapia y la mastectomía, además de las decisiones en cuanto a cómo comunicar el diagnóstico y a cuáles miembros de la familia, lo cual es comprensible dado el dolor causado por el tratamiento y el impacto sobre su autoestima y su autoimagen. al respecto, lima y ferreira (26) afirman que el cáncer de mama es una marca sociocorporal repentina con la que tiene que aprender a convivir la persona diagnosticada. el interés de las mujeres en hablar sobre estos aspectos nos llevó a modificar la guía de preguntas para la entrevista con el fin de incluir aquellas referentes al tratamiento (27). el análisis de las entrevistas se inició con la codificación abierta, donde el proceso de recolección era accesible a todas las posibilidades; se buscó que las participantes tuvieran condiciones diferentes aunque no existía una orientación específica. el análisis de los datos nos llevó a entender que existían dos grupos de barreras, uno relacionado con las “autobarreras”, y otro relacionado con las barreras del sistema de salud. a su vez, el trabajo analítico nos condujo a la conceptualización de dos categorías principales. la primera la denominamos desarrollo de una nueva lógica, que hace referencia a los cambios de percepción de riesgo en las mujeres, y la segunda la llamarnos normalización de las barreras y da cuenta del proceso de invisibilización de las barreras del sistema de salud y el arduo camino que existe para asumirse como sujetos de derechos (gráfico 1). las últimas entrevistas se orientaron a tratar de establecer las conexiones entre las dos categorías encontradas y las hipótesis. es importante anotar que, aunque no se realizó un muestreo de las personas per se (19), las condiciones de las mujeres se consideraron como un criterio de muestreo. a medida que se analizaron los datos se buscó comparar a las mujeres en términos socioeconómicos, educativos y religiosos tratando de determinar otros posibles factores que pudieran incidir en la aparición de las barreras, tales como el diagnóstico y la severidad del cáncer. a medida que fueron emergiendo las categorías, y que las participantes introdujeron nuevos elementos, las entrevistas se redireccionaron. en la mayoría de los relatos se encontraban presentes diversas formas de “autobarreras”. la calidad de los datos, según john creswell (28), se garantiza cuando las categorías emergen de manera natural, se saturan y son validadas por personas que participaron como informantes en el estudio. se utilizaron dos formas de triangulación sugeridas por castillo y vásquez (29), la primera fue la auditoría de expertos, con quienes se discutieron las categorías se logró identificar un gran interés entre las mujeres por hablar sobre los efectos de tratamientos como la quimioterapia, la radioterapia y la mastectomía, además de las decisiones en cuanto a cómo comunicar el diagnóstico y a cuáles miembros de la familia, lo cual es comprensible dado el dolor causado por el tratamiento y el impacto sobre su autoestima y su autoimagen. 146 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 que iban surgiendo y los hilos conductores que permitían establecer una postura teórica, y la segunda fue la presentación de los resultados de la investigación a las participantes. durante la presentación de los resultados las participantes vieron reflejadas cada una de sus experiencias y la de otras mujeres, validando así las categorías y sus relaciones. las primeras dos entrevistas se constituyeron en el estudio exploratorio, que permitió refinar la guía de preguntas para el acercamiento a las mujeres y también fueron parte del estudio (29). el análisis de la información se realizó a través del software atlas ti, con el fin de tener un mejor dominio de los datos y una mayor organización. resultados las edades de las 13 participantes estuvieron entre los 24 y los 77 años, su nivel educativo osciló entre básica primaria, estudios secundarios completos, algunas con tecnologías, y otras con estudios universitarios; en relación con el estado civil también se pudo establecer gran variación; en cuanto a la religión, la mayoría era católica y solo dos de ellas profesaban la religión budista; el estrato socioeconómico varió entre el 2 y el 5 (siendo 1 el menor y 6 el mayor) (tabla 1). las mujeres del presente estudio, una vez diagnosticado el cama, viven un proceso que pasa de una no percepción del riesgo frente al cáncer, a una conciencia de riesgo frente a la enfermedad, que finalmente lleva a desarrollar en la mujer una “nueva lógica”, en la cual el autocuidado y el cuidado de otros se vuelve un asunto central. este proceso lo vivencian de diversas formas de acuerdo con sus propias experiencias y el apoyo familiar. en el gráfico 1 se puede ver la relación entre las dos categorías principales del estudio: percepción de riesgo: desarrollo de una nueva lógica y normalización de las barreras: ver las barreras como constantes; esta última categoría hace parte de otra publicación. en este proceso las mujeres pasan de la invisibilización o normalización de las barreras, a desarrollar mayor capacidad de empoderamiento para poder asumirse como sujetos de derechos en salud, proceso que también se refiere a pasar de la conciencia individual a una de los derechos del colectivo y de la importancia de la organización social (gráfico 1). las “autobarreras” las “autobarreras” son consideradas en este estudio como los comportamientos y las actitudes que, consciente o inconscientemente, tienen algunas mujeres frente al cama. estos comportamientos y actitudes tienen su fundamento en los conocimientos, las creencias o experiencias previas de las mujeres, y determinan las actitudes, conductas o situaciones sociales que les impiden una atención oportuna (16, 18). los datos nos permiten establecer tres formas de expresar las barreras, a saber: los compromisos inaplazables para algunas de las mujeres del estudio los asuntos laborales y familiares primaban sobre aquellos relacionados con su propia salud, pues, aun sabiendo sobre la enfermedad presente en sus cuerpos, no iniciaron el tratamiento con la celeridad necesaria por considerar que debían solucionar estos asuntos laborales y familia147 “autobarreras” de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama l grey yuliet ceballos-garcía, clara victoria giraldo-mora res antes de ello, situación reflejada en el testimonio de marta: “[…] yo me demoré para consultar, yo me demoré un poquito porque tenía mucho trabajo, yo no quería como dejar cosas de trabajo”. margarita reflexiona sobre esta situación cuando dice: “[…] en mi caso, como tenía tantos problemas, le di más importancia a esos otros problemas que a mi caso, entonces me escudé en otros problemas personales […], pienso que si yo hubiera estado más pendiente de mi problema me hubiera aliviado más […], yo decía tengo cáncer, pero tengo que hacer esto primero, tengo que solucionar este problema primero”. la información y el imaginario colectivo frente a la enfermedad la información y la interpretación errada del proceso de la enfermedad hace que las mujeres sientan temor a consultar e iniciar los tratamientos, retrasos que facilitan la propagación del tumor. al respecto, laura cuenta que consultó un año después de iniciada la sintomatología: “[…] pero yo me descuidé, no fui donde el médico ni nada, hace por lo menos un año que vengo con ese problemita en el pezón y […] me daba como miedo ir donde el médico, porque […] que se lo alborotan [el cáncer] a uno y que se vuelve agresivo, que si lo operan a uno, que se muere más ligero, entonces con todos esos temores me dejé, me descuidé y avanzó” . debido a esta inadecuada información, algunas mujeres solo consultaron cuando los signos y síntomas de la enfermedad fueron muy evidentes, así lo narra laura: “porque me empezó a salir un líquido como verde, otras veces azul, otras veces como agua sangre […] y tenía un olor muy fétido, entonces ahí sí me empezó a dar miedo”. experiencias negativas previas algunas mujeres vivenciaron junto a sus familiares el tratamiento de cama, estas experiencias influenciaron su decisión a la hora de iniciar sus propios tratamientos; una de ellas continúa el tratamiento tradicional pero otra optó por uno alternativo, esta es la experiencia de maría: “yo soy la sexta de la familia mía que me da un cama, de entre las hermanas, y tres de ellas se hicieron quimio, varias operaciones y en seis meses se fueron con mucho sufrimiento y yo no quería eso para mí, entonces por eso decidí que no […] ellas tuvieron un sufrimiento horroroso y yo no quería tener esa experiencia”. por el miedo a ser diagnosticada de cama, y temiendo un desenlace similar al de sus cinco hermanas, maría decidió no realizarse en tratamiento médico convencional, lo que le produjo un efecto paradójico: lograr una sobrevida de ocho años, mayor no solo a la de sus hermanas, sino a la del común de las mujeres diagnosticadas con cama; sin embargo, es claro que el miedo fue el que la llevó a tomar esta determinación. en síntesis, la decisión de no someterse a tratamientos puede estar influenciada por experiencias dolorosas previas que finalmente llevan a algunas mujeres a buscar otras alternativas. para maría el efecto pudo ser beneficioso, pero otras mujeres pueden no correr con la misma suerte. un asunto que emergió de los datos es la percepción de riesgo frente a la enfermedad; en general las mujeres se perciben a sí mismas como personas saludables, y podemos decir que esta es una constante en la población, pero ello puede convertirse en autobarrera para aquellas susceptibles de desarrollar cama. la decisión de no someterse a tratamientos puede estar influenciada por experiencias dolorosas previas que finalmente llevan a algunas mujeres a buscar otras alternativas. 148 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 no existe un concepto claro y definitivo sobre la percepción de riesgo que frente al cama tienen la mayoría de las mujeres. para tratar de entender este concepto es necesario hablar de percepción y de riesgo por separado. en el apartado de la discusión se desarrollará este tema. no percepción de riesgo en este estudio todas las mujeres se percibieron a sí mismas como personas saludables antes de ser diagnosticadas, no pensaron nunca en la posibilidad de tener una enfermedad que comprometiera sus vidas, lo que expresaron en frases como la de lucía, de 56 años: “nunca se piensa en la posibilidad de tener cáncer”; y marta, también de 56 años, “en ese entonces no pasó por mi mente que me iba a dar eso”; “a los más ancianitos es a los que les da cáncer”; ellas afirman haber tenido información previa sobre la enfermedad, sin embargo, coinciden en que jamás pensaron que pudieran sufrirla, pues al sentirse saludables se consideraban libres de cualquier riesgo, es decir, se tiene la información pero esta no se traduce en prácticas de autocuidado. al respecto lucía dice: “[…] uno es muy despreocupado, nunca cree que le van a llegar las cosas a uno, sinceramente se lo digo, yo no me preocupé por eso, no sentía nada y yo estaba bien, entonces, no me preocupaba”. la mayoría de las mujeres de este estudio pasaron por esta etapa. esta no percepción de riesgo continúa después del inicio de la sintomatología, pues mantienen la idea de que el cáncer es una enfermedad catastrófica que no es posible que se presente en una persona saludable; así lo afirma patricia, de 49 años: “[…] como yo era tan aliviada y no sentía problemas, así como de tener que estar consultando a una clínica, ni nada de eso, entonces no le daba como mucha importancia”. incluso aquellas mujeres con antecedentes familiares de cama en sus propias madres no se consideraron vulnerables a la enfermedad, así lo manifestó claudia: “[…] yo pienso que fue como un preaviso, como un alerta, póngase las pilas que aquí puede pasar algo, algo que a la vez era tan cerquita, porque era mi mamá, como que no pensé que en un momento determinado me pudiera dar a mí”. días antes de asistir a los controles con su madre claudia se realizó una mamografía de rutina y en esta apareció el tumor. en el momento en que los síntomas se hacen evidentes existe la tendencia a minimizarlos e interpretarlos como menos graves de lo que realmente son; con frecuencia, la sintomatología inicial está relacionada con el estrés o la tensión premenstrual, entre otros. esto hace que las mujeres consulten al médico por otras causas, o no consulten, retrasando con ello la detección del cáncer, así lo relata margarita: “[…] uno siente dolorcito en los senos y se toma una pastilla y no le para como muchas bolas”, y oliva dice: “yo no sentía nada, solo aumento en la talla del brasier y tres bolitas”. en muchos casos, por un periodo de tiempo las mujeres se han palpado nódulos en sus mamas sin alterarse por su presencia, pero cambios en ellos (dolor, aumento de tamaño, etc.) las llevan a sospechar de una dolencia que puede comprometer sus vidas, como el cama, y las hace buscar ayuda profesional y acudir a los centros de salud. percepción de riesgo en el estudio no hay evidencia de cómo se produce el cambio en las mujeen general las mujeres se perciben a sí mismas como personas saludables, y podemos decir que esta es una constante en la población, pero ello puede convertirse en autobarrera para aquellas susceptibles de desarrollar cáncer de mama. 149 “autobarreras” de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama l grey yuliet ceballos-garcía, clara victoria giraldo-mora res de pasar de la no percepción de riesgo a una percepción del mismo frente al cama, pero sí se pueden describir los dos estados, y el hecho de que las mujeres, una vez viven la experiencia del primero, pasan al segundo estado —el de la percepción de riesgo de la enfermedad—, no solo a nivel individual, sino que además piensan en el colectivo. una vez que las mujeres se enfrentan al diagnóstico de cama y deciden iniciar los tratamientos, su vida toma una dirección diferente y sus prioridades cambian: adquieren conciencia de riesgo frente a la enfermedad, lo que las lleva a desarrollar una “nueva lógica” en la que el autocuidado y el cuidado de otros se vuelven un asunto central y se reflexiona sobre la importancia de un diagnóstico oportuno y sobre la vulnerabilidad de las mujeres como un colectivo frente al cama, así lo expresó lucía: “yo lo único que quisiera y lo digo siempre en los grupos y donde me dan la oportunidad de hablar, y ojalá toda la gente, todas las mujeres nos concientizáramos de estar preocupándonos por lo del cáncer de seno, y no solo del seno, hay muchos cánceres que le dan a uno, porque yo he tenido ya varios eventos de cáncer, porque el que tiene el conocimiento, no es tan horrible para uno, pero cuando uno está sin saber nada es más duro”; también maría nos dice: “ojalá esta experiencia que yo tuve sirviera a otras mujeres”, y mery recuerda: “ahora las mujeres estamos más conscientes de que nos tenemos que revisar”. el autocuidado y el cuidado del otro como asuntos centrales después de vivir con la enfermedad, las mujeres empiezan a recomendar a sus hijas, sobrinas y amigas la realización del autoexamen de mama y la mamografía de control; igualmente acuden, casi que religiosamente, a las consultas y los exámenes de control, pues para ellas el fantasma de la metástasis siempre existirá. la experiencia de vivir con cama penetra sus vidas en todas las esferas, muchas coinciden en afirmar que esta experiencia les cambió la existencia, y ahora piensan más en sus propias necesidades y en su autocuidado, carmen dice: “con el cáncer aprendí a quererme, a valorarme, a sacar tiempo para mí”. por su parte maría, aunque el cáncer le ha invadido su cuerpo, manifiesta que: “[…] yo lo que estoy buscando es tener una buena calidad de vida en este momento”. discusión para mariona portell (30) el riesgo es intrínsecamente subjetivo, los seres humanos han inventado este concepto para ayudarse a entender y a enfrentar los peligros y las incertidumbres de la vida. además, el riesgo tiene aspectos emocionales y cognoscitivos, depende de lo que el observador hace, de lo que sabe y de lo que no sabe (31) al valorar una situación o un comportamiento, el sujeto puede percibir un nivel de riesgo más bajo o más alto a partir de su valoración técnica. por su parte, la percepción es un proceso abiertamente cognitivo, de carácter espontáneo e inmediato, que permite hacer estimaciones o juicios más o menos básicos acerca de situaciones, personas u objetos en función de la información que inicialmente selecciona y posteriormente procesa la persona (32), es por esto por lo que la percepción del riesgo se presenta como un factor imprescindible a la hora de concretar la compleja gama de conductas que pueden surgir ante enfermedades o situapara mariona portell el riesgo es intrínsecamente subjetivo, los seres humanos han inventado este concepto para ayudarse a entender y a enfrentar los peligros y las incertidumbres de la vida. 150 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 ciones peligrosas en los múltiples contextos en los que está inmerso el individuo (33). los investigadores de este tema han estudiado las condiciones que influyen en tal percepción (34, 35, 36), entre ellas las que tienen mayor influencia en la manera de percibir los riesgos como: el miedo, la experiencia, el grado de control sobre el proceso o la situación, la conciencia del mismo y los eventos que se perciben como nuevos peligros pues, mientras más consciente se esté de un riesgo, es mejor percibido, y no hay mayor preocupación por los efectos en la seguridad personal (37). las emociones desempeñan un papel importante en la percepción de riesgos, así, la preocupación, la angustia y el temor pueden ser producto del conocimiento que se tenga sobre el riesgo, lo que influye en la percepción del mismo (38). en este estudio se describe cómo la mayoría de las mujeres afirma haber tenido conocimientos previos sobre la enfermedad, incluso, algunas de las entrevistadas eran profesionales de la salud, quienes explican que aunque tenían la información no la hicieron propia; estos hallazgos son similares a los reportados en la literatura, los que además destacan la importancia de la información sobre estos temas. asimismo, la organización panamericana de la salud (ops) y la organización mundial de la salud (oms) (39) consideran que la información acerca de la magnitud del riesgo es importante para que la gente tome conciencia de los mismos. thompson et al. (40) revelan en sus estudios que el término cama está asociado típicamente con campañas públicas que pueden ser efectivas aumentando la conciencia de las personas, pero que tal vez no son tan efectivas para motivar a las mujeres a que busquen controles y otro tipo de tratamientos preventivos (41); esto concuerda con los hallazgos de nuestro estudio, ya que las mujeres reconocen la existencia de información sobre el cama, pero afirman que esta no se hace propia. según la ops-oms (39), la información que se tenga acerca de la susceptibilidad personal frente a determinadas situaciones es importante en la transición que va de la conciencia a la decisión de actuar; en este sentido, es preciso que la información que proviene de las campañas publicitarias esté encaminada a modificar la conciencia de riesgo de las personas frente al cama, es decir, que más que la transmisión de información sobre esta enfermedad, se desarrollen estrategias de educación para la salud que impacten la percepción de riesgo de las mujeres frente al mismo, y que las lleve a actuar de forma oportuna frente a su detección; aunque es claro que para que se pueda dar este proceso se requiere de la interacción de otros factores tales como las creencias (35-36), la eficacia de comportamientos preventivos de la enfermedad (41), las amenazas percibidas (42-43), los sentimientos de susceptibilidad (44) y los métodos de comunicación de la información (45). las participantes en este estudio, antes de desarrollar el cama, se consideraban personas saludables y nunca pensaron en la posibilidad real de tener cáncer. según la ops-oms (37), las personas tienden a ser particularmente resistentes a la idea de que se encuentran en riesgo frente a un peligro, es una tendencia a sentirse infalibles, este “optimismo irreal” se sustenta en la información disponible y en un razonamiento que induce a pensar que el peligro no es una amenaza verdadera, aunque afecte a personas conocidas; otros estudios apoyan esta opinión, calvocoressi et al. (44) encontraron una no la percepción del riesgo se presenta como un factor imprescindible a la hora de concretar la compleja gama de conductas que pueden surgir ante enfermedades o situaciones peligrosas en los múltiples contextos en los que está inmerso el individuo. 151 “autobarreras” de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama l grey yuliet ceballos-garcía, clara victoria giraldo-mora susceptibilidad percibida y la creencia de que el cama no era una enfermedad seria; en un estudio realizado en bogotá, colombia, sobre las barreras para la toma de la citología, este hecho se presenta como un “vacío en la percepción del riesgo”, existe una tendencia entre las mujeres a percibir aquellos riesgos posibles como menos graves (45). otro estudio sobre cama concluye que las mujeres presentan una falta de percepción de riesgo a tal punto que, aunque existiera una masa tumoral, la interpretan como algo sin importancia (46). asimismo, cuando la enfermedad se manifiesta, la sintomatología inicial es relacionada con otras enfermedades, lo que se traduce en un retraso mayor para la detección temprana del cáncer. estos hallazgos concuerdan con un estudio, también realizado en bogotá, sobre cama, donde el 62,7% de las pacientes a quienes se les diagnosticó consultaron cuando iniciaron los síntomas; sin embargo, el 34,3% no asumió una conducta frente al síntoma y un porcentaje menor consultó a la farmacia o medicina alternativa; la autora de este estudio afirma que las mujeres no le dan suficiente importancia a la sintomatología, y por ello no acuden al médico de manera inmediata (47). varios trabajos valoran la influencia de “autobarreras” tales como: el estatus socioeconómico y las diferencias étnicas en el uso de la mamografía. en estos trabajos se encontró que los grupos étnicos caracterizados por baja educación, bajo ingreso y segregación étnica, a menudo tienen una conciencia disminuida acerca de la prevención de la enfermedad al tiempo que tienen menos acceso a los servicios de salud y a la información (17, 48, 49). en nuestra investigación se identificó que las mujeres con mayor acceso a la información y mejor estatus económico tienen una conciencia de autocuidado más desarrollada; sin embargo, ninguna de ellas tenía una percepción de riesgo aumentada frente a la posibilidad de tener cama, es decir, no se identificó una relación directa entre conciencia de autocuidado y percepción de riesgo aumentada. estos hallazgos contrastan con lo que otros afirman respecto a que la baja percepción de riesgo frente al cama es una condición que va más allá de las clases socioeconómicas, incluso en aquellas mujeres con antecedentes familiares o que fueron testigos de la enfermedad de sus propias madres (18); esto contradice a lipkus et al. (50) cuando afirman que individuos con una historia familiar de una enfermedad (riesgo objetivo) relatan mayores niveles de preocupación sobre el desarrollo de la misma que aquellos que no la tienen. no obstante, en un estudio con mujeres negras se encontró que aunque tuvieran un diagnóstico de cama en su familia en primer grado de consanguinidad, tendían a basar su diagnóstico en factores diferentes a la herencia (45), similar a lo que encontramos en nuestra investigación. otros estudios (51, 53) indican que las mujeres con mayor riesgo de presentar tardanzas tienen síntomas atípicos, pequeños tumores, trabajo de jornada completa y niveles educativos más altos, lo que puede estar relacionado con lo que otros autores denominan como una tranquilidad errónea frente a la enfermedad benigna. en colombia (47, 53), por ejemplo, encontraron que las barreras culturales para la toma de la citología se hacen evidentes cuando las mujeres actúan priorizando lo urgente (el cuidado de los demás, de la casa y del trabajo), en lugar de lo importante como debe ser el autocuidado de su salud. este asunto ha otro estudio sobre cáncer de mama concluye que las mujeres presentan una falta de percepción de riesgo a tal punto que, aunque existiera una masa tumoral, la interpretan como algo sin importancia. 152 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 sido revisado por importantes autoras feministas que ven el cuidado y las relaciones de cuidado como una tarea universal de recíproca dependencia, que tiene una base ontológica, pero que debido al entrenamiento social que reciben las mujeres, esta labor recae principalmente sobre ellas. asunto que debería estar sujeto un nuevo ordenamiento social y jurídico. si bien propone gilligan (54) que las mujeres en su desarrollo moral deben salir del egoísmo al altruismo para después lograr un balance entre los dos, se observa que muchas mujeres están atrapadas en una etapa del desarrollo moral temprano que las hace poner el cuidado de los otros por encima de la necesidad del cuidado de sí mismas (54, 55). algunas de las mujeres del estudio viven un proceso que parte del desconocimiento para luego desarrollar una nueva lógica frente a la enfermedad; ellas inician el proceso con una baja percepción de riesgo acompañada del desconocimiento y el sentido de invulnerabilidad frente al cama, pasando por momentos de crisis al ser diagnosticadas como positivas y tenerse que enfrentar a los tratamientos. muchas manifestaron que se sentían perdidas, desorientadas y angustiadas por tener que tomar decisiones que ponían en riesgo su vida. boehmke y dickerson, en su estudio sobre cama, describen el proceso de la salud a la enfermedad como la “borradura de un antiguo yo”, que tiene que ver con los cambios físicos y emocionales generados por la cirugía y los tratamientos, que no solo modifican el cuerpo, desarrollando una nueva conciencia del mismo, sino además la propia identidad, pero que al final se intensifican la capacidad y los deseos de estar preparadas para la recaída (56), proceso similar al vivido por las mujeres de nuestro estudio. retos para los profesionales de enfermería las enfermeras tienen grandes retos con la detección oportuna de las alteraciones de la mama desde que se fijó la norma técnica para la detección oportuna del cáncer de seno en la resolución 0412 de 2000, en la cual se dieron herramientas para materializar acciones de detección oportuna del cama en la atención del primer nivel (57). adicional a esto, existe el compromiso moral con la salud de las mujeres. la enfermera tiene la oportunidad de aportar a la salud de las mujeres mediante el seguimiento de los casos sospechosos y confirmados de cama, pues el sentido de invulnerabilidad de las mujeres frente a la enfermedad puede llevar a un retraso mayor en el diagnóstico y tratamiento de la misma. en la lucha contra el cama existe una gran oportunidad de trabajar en compañía de las mujeres que han desarrollado una nueva lógica frente a la enfermedad, pues ellas pueden generar una mayor sensibilización en las demás mujeres frente a la conciencia de riesgo. si se logra impactar en la conciencia de riesgo frente al cama en las mujeres, se podrán aumentar las prácticas de autocuidado como el autoexamen de mama, el examen clínico y la mamografía. es importante continuar el análisis acerca de la no percepción de riesgo, junto al sentido de invulnerabilidad frente al cama; este es un reto para el profesional de enfermería y los comunicadores en general, pues más que la transmisión de conosi se logra impactar en la conciencia de riesgo frente al cáncer de mama en las mujeres, se podrán aumentar las prácticas de autocuidado como el autoexamen de mama, el examen clínico y la mamografía. 153 “autobarreras” de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama l grey yuliet ceballos-garcía, clara victoria giraldo-mora cimientos sobre algunas enfermedades, es necesaria la generación de una conciencia de riesgo que permita modificar el ambiente y los estilos de vida de las personas (58). existe evidencia científica en relación con el cuidado de las mujeres con cama, en donde se reconoce que la enfermera ha incorporado componentes como la comunicación, la empatía, la disponibilidad, la tranquilidad, la información práctica y una conciencia de las necesidades femeninas, algo que vale la pena visibilizarse y poner en práctica en los planes de cuidado (16, 59). conclusiones esta investigación da cuenta de algunos de los eslabones que unen los anillos dentro del amplio mundo de las barreras para el diagnóstico y tratamiento oportuno del cama; en un principio parecía que entre uno y otro no existía una relación directa; sin embargo, uno de los principales hallazgos fue la descripción de un proceso en el que las mujeres finalmente desarrollan una nueva lógica frente al riesgo del cama, que les permite pensar en el autocuidado y el cuidado de los otros como sujetos de riesgo. el estudio muestra que las “autobarreras” impiden el diagnóstico y tratamiento oportuno de cama porque las mujeres, aun sabiendo sobre la enfermedad presente en sus cuerpos, no inician el tratamiento con la celeridad necesaria; la información y la interpretación errada del proceso de la enfermedad y su tratamiento hacen que las mujeres sientan temor a consultar e iniciar los mismos, y las experiencias previas negativas frente al tratamiento del cáncer pueden llevar a las mujeres a buscar otras alternativas de tratamiento. la “autobarreras” no pueden ser explicadas desde una visión simplista y aislada; el ser humano es el resultado de su contexto, sus vivencias personales y su relación con los otros; por esta razón, la no percepción de riesgo que tienen algunas mujeres frente a esta enfermedad requiere de la atención cercana y simultánea de sus contextos individuales y sociales, solo así se podrán identificar caminos que conduzcan hacia el cuidado de las mujeres con cama. referencias bibliográficas 1. olson j. bathsheba’s breast: women, cancer & history. baltimore: johns hopkins university press; 2002. p. 320. 2. american cancer society. the history of cancer 2002. 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33 (6): 1121-7. 57. halkett g, arbon p, scutter s, borg m. the role of the breast care nurse during treatment for early breast cancer: the patient’s perspective. contemp nurse 2006; 23 (1): 46-57. 58. ministerio de salud. resolución 412 de 2000. bogotá: ministerio de salud; 2000. 59. canadian breast cancer foundation. toward a kinder care: tracing women’s experience of breast cancer from risk awareness through detection, diagnosis, treatment and survivorship [internet]. disponible en: http://breastcancer.campbellfamilyinstitute.ca/pdfs/newsmedia/toward_kinder_ care.pdf [fecha de consulta: 12 de enero de 2008]. 157 “autobarreras” de las mujeres al diagnóstico y tratamiento oportuno del cáncer de mama l grey yuliet ceballos-garcía, clara victoria giraldo-mora tabla 1. descripción de las variables sociodemográficas de las mujeres que participaron en el estudio no. edad seudónimo escolaridad estado civil religión estrato socioeconómico 1 44 margarita secundaria completa divorciada católica 3 2 42 claudia universitaria casada católica 4 3 77 matilde primaria completa casada católica 4 4 56 marta universitaria casada católica 5 5 56 lucía primaria completa casada católica 3 6 49 patricia tecnológica soltera católica 3 7 59 oliva primaria completa casada católica 2 8 52 mery tecnológica casada católica 3 9 57 carmen primaria completa viuda católica 3 10 52 gloria universitaria soltera budista 5 11 24 sofía universitaria casada católica 5 12 62 laura secundaria completa soltera católica 4 13 66 maría secundaria completa divorciada budista 5 gráfico 1. relación entre categorías principales 213 joaquín jesús blanca-gutiérrez1 manuel linares-abad2 maría luisa grande-gascón3 maría del carmen jiménez-díaz4 luisa hidalgo-pedraza5 relación del cuidado que demandan las personas mayores en hogares para ancianos: metaestudio cualitativo 1 enfermero, magíster en gerontología. agencia sanitaria alto guadalquivir, españa. jjblanca@ephag.es 2 enfermero, doctor en antropología social y cultural. universidad de jaén, españa. mlinares@ujaen.es 3 enfermera, doctora en ciencia política. universidad de jaén, españa. mlgrande@ujaen.es 4 enfermera, doctora en antropología social y cultural. universidad de jaén, españa. 5 enfermera de la agencia sanitaria alto guadalquivir, españa. recibido: 16 de diciembre de 2011 aceptado: 24 de septiembre de 2012 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 l 213-227 resumen objetivo: describir que tipo de cuidados y de interacción humana demandan de sus enfermeras las personas mayores que viven en un hogar para ancianos, a partir de la síntesis y el reanálisis de los datos proporcionados por una serie de estudios primarios que han abordado la experiencia de vivir en un hogar para ancianos. antecedentes: los estudios de tipo cualitativo que han tratado el tema de las experiencias vitales en un hogar para ancianos se han centrado en aspectos como la vida diaria, la calidad de vida, las experiencias de sufrimiento, los cuidados recibidos, la proximidad de la muerte y las relaciones personales. materiales y métodos: metaestudio cualitativo de tipo análisis de metadatos. las bases de datos empleadas han sido: isi web of knowledge, cinahl, embase, lilacs y cuiden plus. se han seleccionado 29 estudios. resultados: las categorías centrales emergentes de los datos han sido: las cualidades personales demandadas al personal cuidador, las intervenciones cuidadoras, la relación personal con los cuidadores y la influencia de la relación persona mayor-cuidador en otros aspectos. conclusión: con este trabajo hemos pretendido sintetizar las evidencias proporcionadas por una serie de investigaciones primarias tratando de proporcionar un nivel de conocimientos mayor sobre las necesidades de atención de las personas residentes en un hogar para ancianos, siempre a partir de los testimonios, las experiencias y las vivencias de los protagonistas. palabras clave análisis cualitativo, hogares para ancianos, atención de enfermería, asistencia a los ancianos, servicios de salud para ancianos. (fuente: decs, bireme). the care relationship required by seniors in nursing homes: a qualitative meta-study abstract objective: the purpose of the study was to describe the type of care and human interaction required from nurses by elderly persons living in a nursing home, based on a synthesis and reanalysis of data from a number of primary studies on the experience of living in such 214 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 a facility. background: qualitative studies on the experience of living in a nursing home have focused on aspects such as daily life, quality of life, experiences of suffering, the care received, proximity to death and personal relationships. materials and methods: this is a qualitative meta-study based on meta-data-analysis. isi web of knowledge, cinahl, embase, lilacs and cuiden plus were the databases used. twenty-nine (29) studies were selected. results: the emerging central data categories were: the personal qualities required of the care-giving staff, the care and attention provided, the personal relationship with caregivers, and the influence the elderly person-caregiver relationship has on other aspects. conclusion: in synthesizing evidence from by a number of primary studies, this research attempts to provide a higher level of knowledge about the care needs of residents in a nursing home, based invariably on the testimonies, episodes and life experiences of the protagonists. key words qualitative analysis, nursing care, old age assistance, frail elderly, health services for the aged, homes for the aged (source: decs, bireme). relação do cuidado que exigem as pessoas mais velhas em lares para anciãos resumo objetivo: descrever que tipo de cuidados e de interação humana as pessoas idosas que moram em um lar para anciãos exigem de suas enfermeiras, a partir da síntese e da reanálise dos dados proporcionados por uma série de estudos primários que abordam a experiência de morar em um lar para anciãos. antecedentes: os estudos de tipo qualitativo que tratam o tema das experiências vitais em um lar para anciãos se centram em aspectos como a vida diária, a qualidade de vida, as experiências de sofrimento, os cuidados recebidos, a proximidade da morte e as relações pessoais. materiais e métodos: metaestudo qualitativo de tipo análise de metadados. as bases de dados empregadas foram: isi web of knowledge, cinahl, embase, lilacs e cuiden plus. foram selecionados 29 estudos. resultados: as categorias centrais emergentes dos dados foram: as qualidades pessoais exigidas do pessoal cuidador, as intervenções cuidadoras, a relação pessoal com os cuidadores e a influência da relação pessoa idosa-cuidador em outros aspectos. conclusão: com este trabalho pretendemos sintetizar as evidências proporcionadas por uma série de pesquisas primárias tentando proporcionar um nível de conhecimentos maior sobre as necessidades de atendimento das pessoas residentes em um lar para anciãos, sempre a partir dos testemunhos, das experiências e das vivências dos protagonistas. palavras-chave análise qualitativa, instituição de longa permanência para idoso, cuidados de enfermagem, assistência a idosos, idoso fragilizado, serviços de saúde para idosos (fonte: decs, bireme). 215 relación del cuidado que demandan las personas mayores en hogares para ancianos: metaestudio cualitativo l joaquín jesús blanca-gutiérrez, y otros introducción los hogares para ancianos son centros que prestan atención a las personas que viven en ellos durante un periodo de tiempo prolongado y durante las 24 horas del día. además de servicio médico y de enfermería pueden contar con otros miembros del equipo de salud y con otros departamentos o servicios. generalmente sus residentes son personas con algún déficit de autonomía que necesitan ayuda o suplencia para ejecutar las actividades básicas de la vida diaria. por razones económicas y culturales se ingresan en este tipo de instituciones a personas que no encuentran solución a sus problemas con otros recursos como los centros de día o la atención domiciliaria (1). el cuidado de las personas mayores y de otros grupos con necesidades específicas (niños y enfermos) dentro del seno familiar es tan antiguo como el propio ser humano, a lo largo de la historia se crearon instituciones dedicadas al cuidado de los ancianos cuando este no podía ser abordado por parte de los familiares: en roma los “gerontocomia”; los monasterios y los “hôtel dieu” durante la edad media; las casas de retiro de las organizaciones gremiales, los asilos a partir de la revolución industrial… ya en el siglo xx, a partir de la década de los cincuenta, los diversos estados comienzan a organizar la atención al anciano dentro de sus sistemas públicos de servicios sociales. la progresiva incorporación femenina al mundo del trabajo, así como la reducción del tamaño de las familias y del espacio físico de las viviendas, ha propiciado el desplazamiento del cuidado de los mayores desde un entorno familiar con la mujer como protagonista, a una serie de sistemas de apoyo regidos por estos sistemas públicos de servicios sociales: ayuda a domicilio, teleasistencia, centros de día y servicios de atención residencial entre los que se encuentran los hogares para ancianos (2, 3). encontramos en la literatura numerosos estudios que abordan el tema de las experiencias y vivencias de las personas mayores que viven en hogares para ancianos, empleando herramientas y diseños propios de la investigación cualitativa, con el objetivo priorizar el punto de vista de los protagonistas. si bien los aspectos concretos abordados por los distintos autores son diversos, los podemos clasificar en unas categorías temáticas principales: l vida cotidiana y experiencias de la vida diaria (4-12). l experiencias satisfactorias, bienestar y calidad de vida (13-16). l experiencias de sufrimiento, de dolor y de pérdida (17-19). l cuidados recibidos y autocuidados (20-22). l relaciones con los compañeros de dormitorio (23). l relaciones con los compañeros del hogar para ancianos (24-26). l relaciones de pareja (27, 28). l proximidad de la muerte (29-32). como hemos indicado, la literatura de corte cualitativo concerniente a la vida de las personas que viven en estos centros es amplia, encontrando investigaciones de este tipo llevadas a cabo en contextos geográficos diversos. las variadas temáticas tratadas hacen difícil para los profesionales traducir los resultados de estos estudios en una serie de recomendaciones prácticas globales que puedan guiar la asistencia sanitaria y humana que se presta a estas personas. por ello, consideramos pertinente integrar los resultados de estas investigaciones a través de un metaestudio cualitativo, con el objetivo de reunir en un solo informe de investigación una serie de evidencias que puedan guiar la relación cuidadora de los profesionales de este tipo de centros. la metodología de investigación cualitativa se refiere a un tipo de pesquisa que produce datos descriptivos, tales como las palabras de las personas y la conducta observable. el objetivo de esta metodología se centra en estudiar las experiencias, las vivencias, las percepciones, los sentimientos y las opiniones de los protagonistas de sus estudios, y a lo largo de los años ha demostrado su importancia en las ciencias sociales e incluso en las ciencias de la salud. tal y como ocurre en la metodología cuantitativa con el metaanálisis, se ha desarrollado también un tipo de investigación secundaria que toma como fuente de datos los propios estudios cualitativos, en los denominados genéricamente como metaestudios cualitativos. la metasíntesis podríamos considerarla como el máximo exponente dentro de los citados metaestudios cualitativos. se trata de una metodología novedosa y de gran utilidad que puede proporcionar a las diversas disciplinas científicas elementos para construir, describir o explicar teorías en relación con los fenómenos de interés para esas disciplinas (33). consiste en trascender el conocimiento particular producido en estudios cualitativos primarios para conseguir una comprensión más amplia de los fenómenos mediante el análisis y la interpretación de los resultados de los estudios primarios, produciendo de esta manera evidencias útiles que puedan fundamentar la práctica de las disciplinas científicas (34). para jensen y allen (35), “la metasíntesis de investigaciones cualitativas es una estrategia que facilita el desarrollo del cono216 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 cimiento, reuniendo los resultados cualitativos del fenómeno de interés para la disciplina”. gálvez (36) propone lo siguiente: el nivel más alto de complejidad en la investigación secundaria cualitativa se conoce con el nombre de metasíntesis cualitativa, y se define como la integración y síntesis de hallazgos realizada a partir de varios metaestudios cualitativos conducidos por distintas técnicas de análisis y de síntesis y que responden a un enfoque de investigación sociocultural. diversas corrientes teóricas y autores han propuesto métodos para desarrollar la metasíntesis. paterson et al. (37) establecen una serie de etapas no secuenciales para desarrollar un metaestudio cualitativo. la metasíntesis, de acuerdo con estas y otros autores, surge de la integración de tres niveles analíticos: el análisis de metadatos, el metamétodo y la metateoría (38). materiales y métodos objetivo el objetivo de este estudio es describir qué tipo de cuidados y de interacción humana necesitan de sus enfermeras las personas mayores que viven en un hogar para ancianos. para realizar el trabajo planteamos la siguiente pregunta de investigación: ¿cómo son los cuidados y la relación humana que las personas mayores que viven en un hogar para ancianos demandan de sus enfermeras? estrategia de búsqueda hemos realizado una revisión bibliográfica para obtener los estudios de investigación con orientación fenomenológica o metodología cualitativa que tratan el tema de las experiencias y vivencias de las personas mayores que viven en un hogar para ancianos. la búsqueda se llevó a cabo durante el mes de abril del 2010. con respecto al idioma, hemos aceptado para nuestra revisión estudios publicados en inglés, español, portugués, francés e italiano. no hemos establecido ningún límite temporal. hemos incluido estudios de investigación de tipo primario que dentro de las técnicas propias de la investigación cualitativa utilicen como instrumento principal de recogida de la información la entrevista. el algoritmo básico de búsqueda, adaptado al lenguaje controlado de cada base de datos, ha sido el siguiente (tabla 1): 1. phenomenolog* or qualitative stud* 2. aged or elder* or old* 3. nursing home* 4. interview* 5. 1 and 2 and 3 and 4 las bases de datos empleadas han sido las siguientes: isi web of knowledge, cinahl, embase, lilacs y cuiden plus. el siguiente paso consistió en examinar el título y el resumen de cada una de las referencias para discriminar los trabajos según los criterios de inclusión de la revisión expuestos anteriormente. con los trabajos que superaron esta primera selección se procedió a otro proceso de cribado por medio del análisis de su texto completo. diseño del estudio para este metaestudio los investigadores partimos de una serie de estudios cualitativos primarios que comparten una serie de características: l desde el punto de vista teórico: se trata de investigaciones que se centran en la descripción o interpretación del significado de las experiencias de las personas mayores institucionalizadas, a partir de su propio punto de vista y con un evidente protagonismo de los cuidados y de la disciplina enfermera. l desde el punto de vista metodológico: si bien a priori dentro de los 29 estudios encontramos diseños diferentes (descriptivos, de teoría fundamentada, etnográficos y relatos biográficos), con respecto a nuestro metaestudio los autores no hemos considerado como relevantes estas diferencias metodológicas. en definitiva, todos ellos son trabajos de tipo cualitativo que analizan mediante la construcción de sistemas categoriales temáticos la información recogida en una serie de entrevistas abiertas realizadas a unas poblaciones de características demográficas muy similares: las personas mayores que viven en hogares para ancianos. debido a esta relativa homogeneidad teórico-metodológica de las investigaciones primarias, nos decidimos a desarrollar nuestro trabajo como un metaestudio cualitativo de tipo análisis de metadatos, en el cual no hemos pretendido abordar las etapas del metamétodo y la metateoría (37). 217 relación del cuidado que demandan las personas mayores en hogares para ancianos: metaestudio cualitativo l joaquín jesús blanca-gutiérrez, y otros por tanto, el diseño de la investigación consiste en un metaestudio cualitativo de tipo análisis de metadatos: “el análisis de metadatos es el análisis de datos ya procesados procedentes de estudios de investigación cualitativa seleccionados, para crear un sistemáticamente desarrollado, integrado cuerpo de conocimientos acerca de un fenómeno específico” (39). en este procedimiento, “el análisis de los datos se realiza comparando cada informe de investigación individual con todos los otros informes que tienen un enfoque común o que comparten propiedades específicas y genéricas” (en nuestro caso, las investigaciones relacionadas con la experiencia de vivir en un hogar para ancianos, con las similitudes teórico-metodológicas que hemos indicado). se trata de proporcionar una comprensión mayor y original sobre el fenómeno de estudio que las investigaciones individuales en las que se basa (40). la principal ventaja del análisis de metadatos es que los investigadores evitamos el sesgo teórico y metodológico, partiendo de una homogeneidad que hará más factible el posterior análisis y síntesis (38). análisis de datos la estrategia analítica concreta empleada para trabajar con los datos ha sido el análisis de contenido (41), mediante el cual hemos ejecutado un proceso de síntesis, integración e interpretación de las aportaciones de las investigaciones primarias. hemos procedido a extraer de los textos indicados todos los datos, conceptos y metáforas relacionados con la pregunta de investigación. a cada una de estas unidades le hemos asignado un código que se completa con una serie de comentarios o enunciados, con la finalidad de “retener el significado del texto una vez que es extraído del contexto de su informe” (37). una vez completada la asignación de códigos, las unidades se han agrupado de forma consensuada en torno a subcategorías y categorías centrales, pretendiendo que las mismas fueran exhaustivas y mutuamente excluyentes. las cuatro categorías centrales obtenidas constituyen los epígrafes a partir de los cuales se exponen los resultados de nuestro trabajo: cualidades personales demandadas al personal cuidador, las intervenciones cuidadoras, relación personal con los cuidadores y la influencia de la relación persona mayorcuidador en otros aspectos. rigor científico algunos autores, como las citadas paterson et al. (37), optan por excluir informes de investigaciones primarias sobre la base de los méritos científicos de dichos trabajos, catalogando como cuestionables las aportaciones de estudios con muestras pequeñas de personas (incluso de una sola persona). en nuestro caso, preferimos seguir las sugerencias de jensen y allen (35), las cuales indican que hacer restricciones en función de la calidad científica de la investigación podría significar la pérdida de datos útiles para el metaestudio. en la tabla 2 incluimos los criterios seguidos por los autores de las investigaciones primarias contenidas en el presente metaestudio, para garantizar la calidad científica de sus informes. para el desarrollo del metaestudio nos hemos basado en las indicaciones de paterson et al. (37) respecto al “mantenimiento de la honestidad de tipo analítico” en al análisis de metadatos. tales indicaciones son las siguientes: l el análisis debe ser realizado en grupos de al menos tres personas. l inclusión de la máxima cantidad de información procedente de las investigaciones primarias en el desarrollo de los códigos y las categorías del metaestudio. l construcción de tablas en las que se identifiquen las categorías mayores y las fuentes de las que se derivan. l evitar la construcción rápida de las categorías en función de los primeros estudios primarios con los que se trabaja, ya que los investigadores tenderíamos a encontrar en los siguientes estudios evidencias que estén de acuerdo con nuestra primera categorización. l inclusión de explicaciones y metáforas con los códigos y las categorías que elegimos, ya que una misma palabra u oración puede tener significados muy distintos para cada uno de los miembros del equipo investigador. l precaución con las categorías o los códigos extensos que parecen dar cabida a todas las variaciones e incluso a las contradicciones de los datos. estas categorías amplias puede que no sean significativas o pueden inducirnos a los investigadores a ignorar datos que no se ajusten exactamente a ellas. resultados el total de referencias extraídas para cada una de las bases de datos fueron las siguientes (tabla 1): isi web of knowledge 218 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 (197), cinahl (409), embase (518), lilacs (21) y cuiden plus (226). tras el cribado realizado a través del análisis del título y del resumen se seleccionaron 49 estudios, los cuales procedimos a analizar a texto completo. las principales causas de exclusión en estas dos fases fueron: estudios que no estaban realizados en instituciones de tipo “hogares para ancianos”, participantes que no eran personas mayores, empleo exclusivo de metodología cuantitativa y estudios que no usaban la entrevista para recoger la información. por último, fueron un total de 29 los estudios consecuentes con los criterios de inclusión indicados anteriormente y, por tanto, integrados a través del posterior análisis de metadatos. en la tabla 2 reseñamos para cada uno de estos trabajos el número de informantes incluidos y su país de procedencia, la técnica utilizada para analizar los datos y los criterios seguidos para garantizar la calidad científica de cada uno de los informes. cualidades personales demandadas al personal cuidador el respeto es una cualidad muy referenciada por los participantes en los diversos estudios cuando dialogan sobre las características que tienen o deben de tener sus cuidadores. el respeto es definido como la ausencia de cualquier actitud que pueda ser considerada como maltrato. la indiferencia es otra actitud contraria al trato respetuoso, pero para los informantes de algunas instituciones suecas no es una cuestión referente a cualidades personales, sino que se trata de un problema de comunicación producido porque algunas de sus cuidadoras son extranjeras y desconocen el idioma (5). el respeto implica reconocer y tratar a los residentes de una forma personal (personalización), considerando y manteniendo sus valores propios, sus estilos de vida y su intimidad (13, 27). se trata de considerar a las personas mayores como seres humanos y de ser compasivos y receptivos hacia su situación (19). el trato respetuoso también supone que el personal no ponga en duda los comentarios realizados por los residentes o simplemente los considere como falsos o engañosos, sin otorgarles la importancia y la atención que requieren (7). el respeto también ha de ser protagonista en los momentos más cercanos a la muerte, precisamente permitiendo morir en el momento más adecuado y teniendo en cuenta los últimos deseos y el testamento de la persona moribunda (29). los cuidadores han de ser competentes (7), y se requiere que se mantengan atentos y vigilantes. por ejemplo, una enfermera atenta es aquella que ante cualquier desviación del estado de salud o tras dar cumplimiento a los controles rutinarios deriva y gestiona la consulta con el médico o un especialista (10). en el estudio de pilkington (17) se hace referencia a la “minuciosidad de la atención”. se confía en que estos profesionales de enfermería atentos y competentes “estén a su lado cuando ellos (las personas mayores), estén enfermos o muriendo” (14). a los cuidadores también se les demanda que sean buenos, agradables, simpáticos y amables. para explicar estas características se compara a las personas que sí las tienen con aquellas otras que no las poseen y que trabajan con los residentes “a disgusto” y como si fueran “obreros de una fábrica” (12). este es un personal cuidador desmotivado, que no quiere estar en ese lugar, y que ha perdido el interés por el desarrollo de su labor (32). es necesario, que el trato cordial se dispense a todas las personas mayores por igual (equidad), independientemente del desarrollo de afinidades personales más profundas entre algunos de los residentes con sus personas cuidadoras (12). en el trabajo de silva et al. (26) se definen las cualidades que deben caracterizar a las relaciones de amistad dentro de un hogar para ancianos, tales como la confianza. dicha característica puede ser añadida también a las requeridas en el personal asistencial. los participantes en el estudio de fiveash (9) consideran que el mantenimiento de una relación positiva entre ellos y el personal cuidador exige también una serie de cualidades y actitudes de su parte. asimismo, las personas mayores entrevistadas en el estudio de liukkonen (22) piensan que la falta de gratitud y, sobre de todo, de obediencia de su parte puede suponer incluso el tener que abandonar la institución. en definitiva, hay una serie de cualidades personales demandadas por los residentes a sus cuidadores, las cuales podemos considerar como conceptos que pueden ser dimensionados. por ejemplo, la dimensionalización del concepto “respeto” puede ir desde un trato “muy respetuoso”, hasta un trato “muy poco respetuoso” por parte del personal. niveles altos con respecto a este conjunto de atributos personales facilitarían el establecimiento de relaciones de tipo satisfactorio entre las personas mayores y sus cuidadores, mientras que los niveles bajos propiciarían el desarrollo de interacciones poco gratificantes. las intervenciones cuidadoras uno de los temas más referenciados en los diversos estudios con respecto a la prestación de unos cuidados de calidad es el de 219 relación del cuidado que demandan las personas mayores en hogares para ancianos: metaestudio cualitativo l joaquín jesús blanca-gutiérrez, y otros la rapidez con la que el personal debe atender a las demandas de las personas mayores. las intervenciones cuidadoras eficaces suponen “proporcionar cuidados de enfermería a tiempo y ayudar a los residentes tan pronto como lo necesitan” (4). se afirma con frecuencia que los profesionales de enfermería siempre tienen prisa, siempre están ocupados como para atenderlos adecuadamente, y que hay que esperar durante “eternidades” para tener respuesta a sus necesidades (5). la situación de espera provoca en los residentes la percepción de que las personas cuidadoras no les están prestando suficiente atención y les produce sentimientos y estados negativos como ansiedad, abandono, desequilibrio, dependencia, suciedad, miedo, enfado, agitación, dolor, frustración, humillación, tristeza, pena, agresividad, molestia, vergüenza, depresión, disgusto, desesperación y malestar (7, 8, 19-21, 29, 30, 32). las personas mayores apuntan algunas de las causas que pueden producir estas demoras en la atención: l la escasez de personal asistencial. dicha falta de personal hace que las personas cuidadoras se vean desbordadas y no sean capaces de atender a tiempo y adecuadamente todas las demandas (5, 6). l el hecho de que algunos de los cuidadores no tengan la formación académica o profesional necesaria para llevar a cabo su labor (6). l el excesivo reemplazo del personal. esta circunstancia va en detrimento también del establecimiento de relaciones de confianza entre las personas mayores y las personas cuidadoras, y de la capacidad de personalización de estas últimas (6, 19). si bien estos resentimientos por los retrasos en la atención son bastante frecuentes, son muy puntuales los comentarios acerca de situaciones en las que se haya producido un trato rudo o una supuesta situación de maltrato por parte del personal (9). para estas personas mayores es muy importante su seguridad. se trata de sentir que uno tendrá la ayuda que necesite y que sus necesidades diarias serán atendidas (15), especialmente en aquellas situaciones en las que los mayores consideran que su propia salud se encuentra en una situación de incertidumbre (20). los residentes necesitan tener evidencia de que se les están proporcionando unos cuidados seguros, y que el personal está vigilante y atento durante el día y la noche: me siento muy seguro aquí. ellos (el personal) nos vigilan incluso durante la noche. tenía un terrible dolor una noche y me temía que podría tratarse de algo en mi corazón. esperé durante un rato para ver si se me pasaba pero al final tuve que llamar a las enfermeras. ellas llegaron e inmediatamente tuve ayuda aquella noche. las enfermeras no duermen aquí durante la noche (5). las personas mayores confían más y se sienten más seguras con aquellos cuidadores que conocen, ya que indican que estos les pueden proporcionar una mayor continuidad en sus cuidados diarios, si bien también comprenden que es imposible que siempre les asista la misma persona. señalan que el personal debe tener sólidos conocimientos y habilidades con respecto a sus problemas de salud y enfermedades específicas, así como sobre los tratamientos médicos necesarios (15). a veces las personas cuidadoras son de origen extranjero, lo cual causa problemas de comunicación que a veces se traducen en una cierta sensación de inseguridad por parte de los residentes (5). algunas personas mayores que se encuentran en una situación de extrema dependencia hacia el personal asistencial sienten mermada su capacidad de autodeterminación (7, 13). en cambio, hay familiares de residentes que consideran que son excesivos los niveles de independencia y de autodeterminación que se les están exigiendo a sus familiares, por lo que demandan una provisión de cuidados más amplia con respecto a los que se les están dispensando en la actualidad (7). en definitiva, es necesario alcanzar un estado de equilibrio entre la ayuda prestada y permitir a los residentes hacer aquello que sean capaces de realizar por sí mismos (20, 15). en este sentido, es importante fomentar el establecimiento de negociaciones (30) entre las personas mayores y el personal asistencial (toma de decisiones compartidas) referentes a los cuidados diarios, al nivel de ayuda que se precisa para su ejecución y respecto a los resultados que se pretenden conseguir con los mismos. la realización de autocuidados aumenta la sensación de independencia de las personas mayores implicadas y eleva la percepción de calidad con respecto a los cuidados de enfermería. a su vez, el incremento de la independencia produce efectos beneficiosos en la autoestima, en la confianza y en el mantenimiento de la función física: en consecuencia, se produce un aumento de la felicidad de las personas mayores. para la realización de estos autocuidados es importante el apoyo de los familiares y, por supuesto, del propio personal asistencial (21). en ocasiones, la interacción y comunicación entre las personas mayores en los comedores y salones comunes es débil, co220 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 lapsándose totalmente cuando el personal abandona la estancia (25). por ello, una de las intervenciones demandadas al personal es la de la planificación de actividades recreativas o terapéuticas, sobre todo con el propósito de mantenerse en contacto y relacionarse con otras personas (26). los entrevistados indican que han de ser las personas cuidadoras quienes fomenten el contacto entre los participantes y las participantes cuando se realizan estas dinámicas (8). en definitiva, el personal del centro debe asumir un rol facilitador, y tener habilidades para fomentar el establecimiento de interacciones sociales positivas y significativas entre los residentes (24). por tanto, las personas mayores necesitan unos cuidados que den cobertura de una manera eficaz y rápida a sus necesidades, que se produzcan en unas condiciones óptimas de seguridad, y que estén enfocados al mantenimiento de su salud y al desarrollo de contactos sociales. todos estos cuidados deben ejecutarse con el consentimiento de los receptores, tras un proceso de negociación y toma de decisiones compartidas que garantice el protagonismo de la ejecución de autocuidados por parte de los residentes. la relación personal con los cuidadores y las cuidadoras “una relación de tipo positivo con los cuidadores y la sensación de que los cuidadores tenían tiempo para hablar con ellos era extremadamente importante para la mayoría de los residentes” (16). los informantes tienen una queja generalizada, y es que los miembros del personal asistencial no tienen tiempo para hablar con ellos. solamente les hablan cuando ocurre algo extraordinario o únicamente en relación con temas prácticos relacionados con la salud. una vez más se hace responsable de esta situación a la falta de personal. en algunas ocasiones se trata de un simple problema lingüístico que tiene lugar con personas cuidadoras que son contratadas en países extranjeros. la ausencia de conversación con las personas mayores se interpreta como una falta de atención hacia sus necesidades sociales, en consecuencia, sienten que sus días se hacen largos, solitarios y aburridos. a pesar de que se reconoce que hay cuidadores que hacen un esfuerzo por ser más cercanos y hablar con las personas mayores también sobre su vida y sus experiencias, esta falta de comunicación produce la sensación de ser invisibles y de que no se les está tratando de una forma individualizada, sino de manera estereotipada y descuidada. algunos informantes tratan de paliar esta circunstancia aprendiendo los nombres de las personas cuidadoras junto con sus intereses y aficiones para tratar de establecer un mayor diálogo con ellas, sin embargo, los cambios frecuentes de personal dificultan esta estrategia y hacen que muchas de las personas mayores opten por abandonarla (5, 6, 30). estas situaciones pueden derivar en el hecho de que algunos residentes solo consideren importantes los contactos sociales con los compañeros del hogar para ancianos o con los parientes que los visitan, dejando en un segundo plano la relación con sus cuidadores y cuidadoras (8). hay un comentario muy ilustrativo de todos estos fenómenos: “ellos (refiriéndose al personal asistencial) son mi salvación, pero ellos no pueden ser mis compañeros” (7). las personas mayores se muestran reacias a mantener con los cuidadores una relación estrictamente profesional, demandando el establecimiento de una interacción más personal, con un componente de reciprocidad (20) que estaría fundamentado en un tipo de contacto próximo al que se mantiene en la relación con los familiares, amigos y, en algunos casos, con los compañeros y las compañeras residentes. algunos informantes, refiriéndose a sus cuidadoras, comentan: “son como hermanas”, “como una madre”, “como una hija”, “como una amiga” (12). los residentes necesitan atribuir a sus personas cuidadoras características similares a las que tendría un amigo: se trata de alguien que contribuye a contrarrestar sus carencias en la vida de la institución, alguien que presta ayuda, que les ofrece atención y en quien se pueda confiar (26). la relación entre los residentes y los cuidadores, establecida a través de un trato más cercano, contribuye a que el mayor se sienta reconocido como una persona (14). es necesario alcanzar un estado de equilibrio entre el establecimiento de relaciones de confianza y el mantenimiento de la intimidad de las personas mayores (8). de nuevo, un proceso negociador y la toma de decisiones compartidas, deben guiar el grado de cercanía que se pretende conseguir en cada relación establecida entre una persona mayor y su cuidador. como síntesis de este apartado indicaremos que los residentes demandan el establecimiento de una relación más cercana a la de tipo familiar-amistoso con sus personas cuidadoras, frente a una relación en la que se produzcan únicamente interacciones de tipo profesional. la influencia de la relación persona mayor-cuidador en otros aspectos el hecho de que las personas cuidadoras traten a los mayores como las personas que ellos experimentan que son, así como 221 relación del cuidado que demandan las personas mayores en hogares para ancianos: metaestudio cualitativo l joaquín jesús blanca-gutiérrez, y otros que respeten sus valores y sus estilos de vida propios, tiene un papel determinante para que estos últimos puedan encontrar un sentido a su vida (meaning), permitiéndoles disfrutar de unas experiencias diarias significativas (13). las relaciones de tipo satisfactorio con el personal asistencial pueden formar parte de las “afiliaciones benevolentes” que se oponen al sentimiento de “ilimitada desolación” que surge en las personas mayores causado por las experiencias de sufrimiento y pérdida (17, 18). la calidad de los cuidados recibidos es uno de los aspectos esenciales que determinan el desarrollo del bienestar psíquico y la satisfacción emocional de los residentes (thriving). los cuidados inadecuados, además de las experiencias negativas con las y los cuidadores, pueden mermar los esfuerzos de las personas mayores por alcanzar ese estado de bienestar. por el contrario, los cuidados de calidad dispensados por un personal cercano y amistoso propician que los residentes establezcan sus propias estrategias para tratar de alcanzarlo. los informantes que han alcanzado ese estado de evolución psíquico y emocional afirman que los buenos cuidados y los buenos cuidadores tienen una importante influencia sobre su actitud mental, redireccionando esa disposición hacia la experiencia de crecimiento (15). cuando las personas cuidadoras facilitan el establecimiento de relaciones positivas y significativas entre los compañeros del hogar para ancianos, manteniendo un rol facilitador con respecto a estas interacciones, también se favorece la construcción de la experiencia de thriving (24). cuando los residentes enuncian los aspectos que influyen en el mantenimiento de su calidad de vida dentro de la institución incluyen los cuidados recibidos, las personas que les proporcionan esos cuidados, así como la habilidad para comunicarse con su personal cuidador (16). como se indicó en un apartado anterior, la realización de autocuidados por parte de las personas mayores aumenta su independencia, lo cual a su vez produce un incremento de la autoestima, de la confianza en sí mismos y de la funcionalidad física (21). la dignidad está muy relacionada con el mantenimiento de la capacidad de autodeterminación por parte de cada residente. también es importante que ellos mantengan un propósito y una utilidad en su vida, como se expresa en el siguiente testimonio: “soy una madre y una abuela y toda mi familia es encantadora. ayudo a los otros a la hora de las comidas. eso ayuda a mis compañeros y al personal” (30). el apoyo proporcionado por los familiares y por las personas cuidadoras “fortalece” mentalmente a las personas mayores y contribuye al mantenimiento de su dignidad. la construcción de la experiencia de la dignidad, dentro del concepto de dignidad relacional (29), está influenciada por la calidad y la cantidad de las relaciones que se mantienen con amigos, familiares, con los otros residentes y, por supuesto, también con las personas cuidadoras. en conclusión, una serie de cualidades favorecedoras en el personal asistencial, las intervenciones cuidadoras óptimas, y un tipo de relación persona mayor-cuidador más cercana que la exclusivamente profesional, son elementos facilitadores que contribuyen al desarrollo en los residentes de una serie de percepciones y estados beneficiosos: crecimiento psíquico y emocional, dignidad, independencia, calidad de vida, afiliaciones contrapuestas a la experiencia de sufrimiento y construcción de experiencias significativas. discusión el establecimiento de una comunicación óptima entre el profesional y la persona mayor institucionalizada es un aspecto clave en el desarrollo de su interacción personal. serrano (42) establece que la comunicación efectiva con los mayores que viven en un hogar para ancianos produce una serie de consecuencias beneficiosas. se trata de aspectos que hemos abordado a lo largo del apartado de resultados de nuestro metaestudio: l proporcionar tranquilidad a las personas que han participado en una situación conflictiva. l fomentar la independencia de la persona mayor, valorando por medio de la comunicación su nivel de autonomía y estableciendo un proceso de toma de decisiones compartidas. l satisfacer las necesidades de los residentes y de los cuidadores, a los primeros a través de la expresión de sus sentimientos y a los profesionales permitiendo valorar su ánimo y reconocer sus carencias. l crear un clima de confianza y seguridad. l identificar, por parte de la persona mayor, un ícono de referencia para su seguridad, que es el personal de enfermería. l valorar problemas psíquicos y emocionales en la persona mayor. 222 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 garcía et al. (43) exponen unas dificultades prácticas de tipo organizativo para el establecimiento de una adecuada relación terapéutica, que también son aplicables en el contexto de los hogares para ancianos: l la falta de una supervisión y una evaluación de la propia relación y de su calidad. l los intercambios relacionales mutuos que se establecen con los pacientes tampoco son supervisados, por lo que no son asimilados por la organización y se pueden crear prejuicios en los enfermeros y las enfermeras a la hora de establecer la relación. l carencias en la relación de ayuda estructurada a los pacientes, la familia y su entorno. l falta de comprensión hacia el paciente cuando procede de un entorno cultural diferente. l tensión profesional debido a la sobrecarga laboral y a la falta de identidad profesional en relación con otras profesiones. nascimento et al. (44) realizaron una revisión bibliográfica de la base de datos lilacs para resumir el conocimiento disponible sobre el cuidado dirigido a las personas mayores. con respecto a los cuidados de enfermería, las autoras indican que debemos crear para las personas mayores un ambiente de cuidado, el cual definen como: “aquel en el que prevalece el respeto, la confianza, la atención, el reconocimiento y la aceptación de las personas con sus limitaciones y dificultades, buscando ofrecerles apoyo y ayuda”. para anderberg y berglund (20), recibir cuidados en un hogar para ancianos “es un proceso continuo y gradual mediante el cual las personas mayores aspiran a estar en equilibrio consigo mismos y con el ambiente”. blanca et al. (45), al estudiar el concepto de intimidad en los pacientes hospitalizados, establecen un modelo explicativo según el cual la evolución óptima de las relaciones entre el pacientefamiliar hospitalizado, los compañeros o compañeras de cuarto y los profesionales sanitarios desemboca en la constitución de un núcleo de la intimidad más amplio en el que tendrían cabida todas estas personas. todo ello marcado por el cambio de una situación que el autor define como intimidad impuesta (hay personas que permanecen en los espacios privados del paciente, que se mueven en ellos sin ningún tipo de consentimiento), hacia una situación de intimidad consentida (en el espacio físico del paciente-familia hay otras personas ajenas, pero que han sido aceptadas de manera voluntaria en su núcleo de la intimidad). consideramos que este modelo es aplicable también al desarrollo de las relaciones humanas dentro de un hogar para ancianos y sería una situación ideal que propiciaría el establecimiento de unas relaciones de tipo más personal con los cuidadores, como precisamente demandan los informantes de los diversos estudios. el desarrollo de relaciones más estrechas entre los pacientes y los profesionales de enfermería o el personal sanitario en general puede producir consecuencias negativas para estos últimos, derivadas de la sobreimplicación de tipo emocional y subjetiva: estrés, efectos negativos en la distribución del trabajo en el área en cuestión, dificultades para las enfermeras en el cumplimiento de su rol institucional, descenso de la productividad, alejamiento del rol profesional, alteración de la capacidad de enjuiciamiento clínico, dolor emocional, sufrimiento, tensión y síndrome de “burnout” (46-49). miner-williams (50) indica que la relación enfermería-paciente tiene su origen en la intención del profesional de encontrarse con las necesidades del enfermo. estas suelen ser de tipo biopsicosocial, pero en ocasiones aparecen otras que emergen de la esencia de cada persona, las llamadas necesidades espirituales. su descubrimiento solo es posible a través del establecimiento de una interrelación estrecha de tipo significativo y que le otorgaría una característica de “conexión” a la relación enfermería-paciente. se trata por tanto de un nivel más alto con respecto a la interacción entre los profesionales y las personas a las que cuidan, un nivel que debemos pretender alcanzar en el contexto de los hogares para ancianos, donde no somos únicamente responsables del bienestar biopsicosocial de estas personas, sino también de dar cobertura a sus necesidades más espirituales. conclusión en este trabajo hemos pretendido sintetizar las evidencias proporcionadas por una serie de investigaciones primarias elaboradas a partir de los testimonios de los receptores de cuidados, en este caso las personas mayores que viven en hogares para ancianos. consideramos que estudios de este tipo pueden aportar un conocimiento más extensivo o en todo caso complementario al que proporcionan otro tipo de abordajes investigativos como el diseño y la cumplimentación de encuestas de satisfacción. 223 relación del cuidado que demandan las personas mayores en hogares para ancianos: metaestudio cualitativo l joaquín jesús blanca-gutiérrez, y otros todo el apartado de resultados puede ser considerado como un conjunto de recomendaciones prácticas que pueden constituirse en una herramienta de apoyo para la interacción que establecemos con las personas mayores institucionalizadas, las enfermeras, los estudiantes, otros profesionales, e incluso sus propios familiares. referencias 1. garcía m, torres mp, ballesteros e. enfermería geriátrica. barcelona: masson; 2000. 2. díaz r. informe 2008. las personas mayores en españa. madrid: instituto de mayores y servicios sociales (imserso); 2009. disponible en: http://www.imsersomayores.csic.es/estadisticas/informemayores/informe2008/index.html [consultado 2012 sept. 4]. 3. tobaruela jl. residencias: perfil del usuario e impacto del ingreso (memoria para optar al grado de doctor). madrid: universidad complutense de madrid; 2003. disponible en: http://eprints.ucm.es/tesis/med/ucm-t26425.pdf [consultado 2012 sept. 4]. 4. tsai h, tsai y. a temporary home to nurture health: lived experiences of older nursing home residents in taiwan. journal of clinical nursing 2008;17(14):1915-22. 5. slettebø a. safe, but lonely: living in a nursing home. nordic journal of nursing research & clinical studies / vård i norden 2008;28(1):22-5. 6. wadensten b. life situation and daily life in a nursing home as described by nursing home residents in sweden. international journal of older people nursing 2007;2(3):180-8. 7. andersson i, pettersson e, sidenvall b. daily life after moving into a care home -experiences from older people, relatives and contact persons. journal of clinical nursing 2007;16(9):1712-8. 8. van’t leven n, jonsson h. doing and being in the atmosphere of the doing: environmental influences on occupational performance in a nursing home. scandinavian journal of occupational therapy 2002;9(4):148-155. 9. fiveash b. the experience of nursing home life. international journal of nursing practice 1998;4(3):166-74. 10. lópez pérez mt. vivencias de una anciana hasta llegar a una residencia de mayores. archivos de la memoria 2006;3(2). disponible en: http://www.index-f.com/memoria/3/a20616.php [consultado 2010 abr. 15]. 11. álvarez leiva mi. mi vida en una residencia de mayores. ‘esa es mi vida. trabajar mucho para nada’. archivos de la memoria 2006;3(3). disponible en: http://www.index-f.com/memoria/3/a30607.php [consultado 2010 abr. 15]. 12. bazo mt. institucionalización de las personas ancianas: un reto sociológico. revista española de investigaciones sociológicas 1991;53:149-64. 13. dwyer l, nordenfelt l, ternestedt b. three nursing home residents speak about meaning at the end of life. nursing ethics 2008;15(1):97-109. 14. hjaltadóttir i, gústafsdóttir m. quality of life in nursing homes: perception of physically frail elderly residents. scandinavian journal of caring sciences 2007;21(1):48-55. 15. bergland a, kirkevold m. thriving in nursing homes in norway: contributing aspects described by residents. international journal of nursing studies 2006;43(6):681-91. 16. aller lj, van ess coeling h. quality of life: its meaning to the long-term care resident. journal of gerontological nursing 1995;21(2):20-5. 17. pilkington f, kilpatrick d. the lived experience of suffering: a parse research method study. nursing science quarterly 2008;21(3):228-37. 18. pilkington f. grieving a loss: the lived experience for elders residing in an institution. nursing science quarterly 2005;18(3):233-42. 224 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 19. forbes-thompson s, gessert c. nursing homes and suffering: part of the problem or part of the solution? journal of applied gerontology 2006;25(3):234-51. 20. anderberg p, berglund al. elderly persons’ experiences of striving to receive care on their own terms in nursing homes. international journal of nursing practice 2010;16(1):64-8. 21. chang s. beliefs about self-care among nursing home staff and residents in taiwan. geriatric nursing 2009;30(2):90-8. 22. liukkonen a. life in a nursing home for the frail elderly... including commentary by anderson m.c. clinical nursing research 1995;4(4):358-72. 23. oh j. stroke patients’ experiences of sharing rooms with dementia patients in a nursing home. international journal of nursing studies 2006;43(7):839-49. 24. bergland a, kirkevold m. the significance of peer relationships to thriving in nursing homes. journal of clinical nursing 2008;17(10):1295-302. 25. hauge s, heggen k. the nursing home as a home: a field study of residents’ daily life in the common living rooms. journal of clinical nursing 2008;17(4):460-7. 26. silva ca, menezes mr, santos ac, carvalho ls, barreiros ex. relacionamento de amizade na instituição asilar. revista gaúcha de enfermagem 2006;27(2):274-83. 27. mendoza e, martínez b, garcía m, ullivarri n. sexuality in institutionalized elderly people. gerokomos 2005;16(2):90-6. 28. nay r. sexuality and aged women in nursing homes. geriatric nursing 1992;13(6):312-4. 29. pleschberger s. dignity and the challenge of dying in nursing homes: the residents’ view. age & ageing; 36(2):197-202. 30. franklin l, ternestedt b, nordenfelt l. views on dignity of elderly nursing home residents. nursing ethics 2006;13(2):130-46. 31. garcía hernández a. & darias curvo s. elderly’s concepts about death. gerokomos 2003;14(2):74-9. 32. engle vf, fox-hill e, graney mj. the experience of living-dying in a nursing home: self-reports of black and white older adults. journal of the american geriatrics society 1998;46(9):1091-6. 33. walsh d, downe s. meta-synthesis method for qualitative research: a literature review. journal of advanced nursing 2005;50(2):204-11. 34. carrillo gonzález gm, gómez ramírez oj, vargas rosero e. metodologías en metasíntesis. ciencia y enfermería 2008;xiv(2):13-9. 35. jensen la, allen mn. meta-synthesis of qualitative findings. qualitative health research 1996;6(4):553-60. 36. gálvez toro a. clasificación de las evidencias por su diseño y utilidad la investigación secundaria cualitativa. index de enfermería (edición digital) 2003;43. disponible en: http://www.index-f.com/indexenfermeria/43revista/43_articulo_45-49.php [consultado 2010 dic. 1]. 37. paterson bl, thorne se, canam c, jillings c. meta-study of qualitative health research: a practical guide to metaanalysis and meta-synthesis. california: sage; 2001. 38. hueso c. metaestudio cualitativo a través del relato biográfico: un modelo de investigación secundaria cualitativa. archivos de la memoria 2008;5(3). disponible en: http://www.index-f.com/memoria/5/e30801.php [consultado 2010 dic. 1]. 39. zhao s. meta-theory, meta-method, meta-data-analysis: what, why and how? sociological perspectives 1991; 34: 377-90. 40. gálvez a, amezcua m, salido mp. la construcción social de los sentimientos. la muerte del sujeto que nace. index de enfermería 2002, 39. disponible en: http://www.index-f.com/index-enfermeria/39revista/39_sumario.php [consultado 2010 dic. 1]. 41. graneheim uh, lundman b. qualitative content analysis in nursing research: concepts, procederes and measures to achieve trustworthiness. nurse education today 2004;(24):105-12. 42. serrano aj. la importancia de la comunicación con el anciano institucionalizado. anales de la escuela universitaria de ciencias de la salud de zaragoza 2007;10:189-200. 225 relación del cuidado que demandan las personas mayores en hogares para ancianos: metaestudio cualitativo l joaquín jesús blanca-gutiérrez, y otros 43. garcía mi, lópez mn, vicente mj. reflexiones en torno a la relación terapéutica. ¿falta de tiempo? index de enfermería 2004, 47. disponible en: http://scielo.isciii.es/scielo.php?pid=s1132-12962004000300010&script=sci_arttext [consultado 2011 jun. 15]. 44. nascimento lc, moraes er, silva jc, veloso lc, rodrigues moura da costa a. cuidador de idosos: conhecimento disponível na base de dados lilacs. revista brasileira de enfermagem 2008;61(4):514-7. 45. blanca jj, muñoz r, caraballo ma, expósito mc, sáez r, fernández me. la intimidad en el hospital. la experiencia de los pacientes, sus familias y las enfermeras. index de enfermería 2008;17(2). disponible en: http://scielo.isciii.es/scielo. php?pid=s1132-12962008000200006&script=sci_arttext [consultado 2011 jun. 15]. 46. williams a. a literature review on the concept of intimacy in nursing. journal of advanced nursing 2001;33(5):660-7. 47. may c. affective neutrality and involvement in nurse-patient relationships: perceptions of appropriate behaviour among nurses in acute medical and surgical wards. journal of advanced nursing 1991;16:552-8. 48. morse jm. negotiating commitment and involvement in the nurse-patient relationship. journal of advanced nursing 1991;15:455-68. 49. ramos mc. the nurse patient relationship: theme and variation. journal of advanced nursing 1992;17:496-506. 50. miner-williams d. connectedness in the nurse-patient relationship: a grounded theory study. issues in mental health nursing 2007;28(11):1215-34. tabla 1. búsqueda bibliográfica 226 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 tabla 2. referencias bibliográficas incluidas en el metaestudio 227 relación del cuidado que demandan las personas mayores en hogares para ancianos: metaestudio cualitativo l joaquín jesús blanca-gutiérrez, y otros 06. fundamentos pedagšgicos ok 27 resumen la salud es entendida, a partir de las nuevas tendencias mundiales, como salud holística, según la cual se considera un fenómeno y un proceso global. en el término ‘salud’ se incluyen todos los procesos y vivencias humanas que apuntan hacia el desarrollo integral del individuo, desde la conciencia de su cuerpo hasta la toma de conciencia de sus relaciones personales y trascendentales. a partir de la definición de salud, se pretende mostrar su carácter como fenómeno social, basado en los fundamentos del modelo pedagógico humanista, la teoría constructivista y el aprendizaje significativo. frente a la crisis general, frente a este mundo que se deshumaniza día a día, frente a este sistema violento, es necesario reflexionar acerca de la necesidad de construir un nuevo sistema educativo en salud. un nuevo modelo de educación, que contemple la formación integral (social y personal) del ser humano, la comunicación consigo mismo y con los demás, el manejo corporal armónico, el pensar en su salud y en la de los que lo rodean de una forma coherente, el desenvolvimiento emotivo y la expresión creativa, será pilar del nuevo paradigma de educación integral humanista. en salud es de vital importancia conocer la estructura cognitiva, no tratar de saber la cantidad de información en salud que se posee, sino cuáles son los conceptos y proposiciones que maneja. esto permite orientar la acción educativa, ver que las personas poseen una serie de experiencias y conocimientos que afectan su aprendizaje y pueden ser aprovechados para su beneficio. educación en salud, pedagogía, constructivismo, aprendizaje significativo. abstract according to new world trends , health means holistic health, considering it as a global process. the term health includes all human processes and experiences of integral development, from the conscience of its own body to an identification of personal and transcendental relations. upon definition of health, it pretends to show its character as a social phenomena, based on a humanistic pedagogic model ground, the constructivism theory and meaningful learning. due to the current reality of the world, where violence and dehumanization increases everyday, it is necessary to make reflection to construct a new educational health system. a new educational model, containing an integral education (social and personal) of the human being, where personal and interpersonal communication, health, harmonic body management, emotions development and creative expression, will be the basis of a new paradigm of humanistic integral education. in health, instead of the quantity of information, it is very important to know concepts and propositions of cognitive structure to manage and direct the educational action; considering the experiences and educational knowledge of persons affecting learning, taking advantage for their own benefit. key words health education, pedagogy, constructivism, meaningful learning. clara rozo de arévalo profesora asistente facultad de enfermería • universidad de la sabana palabras clave año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 28 en la quinta conferencia mundial de promoción de la salud2 se declaró que “cuando una persona pueda decidir estar sana, primero necesita conocimientos precisos, fiables, sobre cómo alcanzar un buen estado de salud y sobre los riesgos para la salud que se presentan en su vida cotidiana. necesita conocimientos que la ayuden a hacer las mejores elecciones posibles y a ponerlas en práctica. necesita saber de qué manera puede disfrutar de una buena salud personal, y qué hace falta para que la familia se mantenga sana”. la educación para la salud es uno de los instrumentos para promoverla e impulsar su acción preventiva. “ayuda a los individuos o grupos a adquirir conocimientos sobre los problemas de salud y sobre los comportamientos útiles para alcanzar su objetivo”3. promover la salud significa reducir los riesgos que la amenazan y modificar los comportamientos que la afectan. el mejoramiento de la salud reduce la pobreza y hace posible el crecimiento. según la 36 asamblea mundial de la salud (1983), educación para la salud es “cualquier combinación de actividades de información y educación que lleve a una situación en la que la gente desee estar sana, sepa cómo alcanzar la salud, haga lo que pueda, individual y colectivamente, para mantenerla y busque ayuda cuando la necesite”. a partir de las definiciones de educación en salud, el presente escrito tiene como objetivo mostrar su carácter como fenómeno social, basado en los fundamentos del modelo pedagógico humanista, la teoría constructivista, con vigotsky como su principal representante, y el aprendizaje significativo de auzbel. entre los fundamentos del modelo pedagógico humanista se destaca, en primera instancia, la concepción del ser humano. para mario aguilar y rebeca bize4, el ser humano es conciencia activa y, por lo tanto, constructor de realidades. es un ser histórico y social y, por su reflexión de lo histórico-social como memoria personal, cada ser humano es un constructor. la intencionalidad humana es lo que mueve al mundo, lo transforma, lo mejora o lo empeora, lo hace evolucionar o involucionar. por ello, ya no puede sostenerse una educación cuya concepción del ser humano sea la de un ser pasivo, mero receptor o reflejo de un supuesto “orden natural” o de “condiciones objetivas” que lo determinan mecánicamente. desde la perspectiva del ser humano como conciencia activa, se considera 1 maripili, golpe. la salud en la escuela, universidad central de venezuela, caracas, 2001 2 quinta conferencia mundial de promoción de la salud. méxico, 5 de junio de 2000. 3 álvarez alba, rafael. educación para la salud, editorial manual moderno, méxico, 1995. 4 bize, rebeca; aguilar, mario. la pedagogía de la diversidad: una propuesta de inspiración humanista, ucme, 1994. en el término ‘salud’ se incluyen todos los procesos y vivencias humanas que apuntan hacia el desarrollo integral del individuo, desde la conciencia de su cuerpo hasta la toma de conciencia de sus relaciones personales y trascendentales. a salud es entendida, a partir de las nuevas tendencias mundiales, como salud holística, según la cual se considera un fenómeno y un proceso global, que no se puede desmembrar sin que la persona de quien se habla pierda sus cualidades sistémicas:físicas, psíquicas, sociales y espirituales. en el término ‘salud’ se incluyen todos los procesos y vivencias humanas que apuntan hacia el desarrollo integral del individuo, desde la conciencia de su cuerpo hasta la toma de conciencia de sus relaciones personales y trascendentales1. 29 fundamentos pedagógicos que sustentan el proceso de la educación en salud que lo que ese ser humano percibe del paisaje externo es desde su propia percepción, con el compromiso de su cuerpo y desde un particular modo emotivo de estar en el mundo. en esta interacción, el ser humano es el protagonista de su historia y, esencialmente, transformador incluso de su propia naturaleza (cuerpo). en tal concepción resulta inaceptable una educación meramente reproductora e insuficiente a la luz de las enormes potencialidades transformadoras y constructoras de realidad y sentido que posee el ser humano. ha llegado el momento de construir una nueva educación en salud, no sin antes hacer un recorrido por ópticas de autores como cirigliano, quien considera que “la renovación pedagógica no depende, pues, solamente de las técnicas nuevas, sino también, y muy especialmente, de ideas: ideas que son filosóficas en la medida en que expresan objetivos generales y, por ende, una concepción del hombre y de la vida”5. según deleim santos6, el hombre no aprende para vivir, sino además para existir, y existir no es solamente vivir. la noción de existencia constituye el punto de partida de la pedagogía. estar en el mundo es hallarse en contacto con el mundo inorgánico, con los otros seres vivientes y también consigo mismo. el hombre se ocupa de las cosas, se preocupa de los otros y de sí mismo. de esa ocupación y preocupación resultan situaciones diferenciadoras para el acto del aprendizaje. las cosas muestran en qué consisten; los otros, cómo subsisten, y él mismo, cómo existe. el actual sistema de educación en salud para la comunidad se basa en una concepción mercantilista, con programas que responden a un sistema de salud establecido, donde todo se rige por intereses economicistas. por lo tanto, la educación en salud termina considerándose un gasto y no una inversión, con las consecuencias lógicas que van en su detrimento. no olvidemos que la educación es un fenómeno social que, en las actuales condiciones, no deja posibilidades de crecimiento y desarrollo y mucho menos de una elevación de la calidad de vida de la población colombiana. nos encontramos hoy con que la falta de educación para la salud cuesta a la sociedad billones de pesos al año, y muchas personas desatienden su trabajo como resultado de problemas de salud, a veces creados por ellas mismas por un estilo de vida equivocado. a lo anterior pueden agregarse los días perdidos en el área laboral o académica por morbilidades menores, que se pueden evitar fácilmente por medio de la prevención y promoción de la salud. de estos planteamientos surge la siguiente consideración: ¿en esta época, en la que tantos recursos tenemos y se han alcanzado tantos conocimientos, es posible que tengamos que educarnos para vivir con salud? los profesionales encargados de mantenerla y fomentarla y quienes han realizado acciones que obedecen a la iniciativa de algunas instituciones, casi siempre se han limitado a algunos aspectos informativos o de formación en gestión y, en la mayoría de los casos, esta ha sido emprendida por razones relacionadas con el aprovechamiento de un mercado espontáneo y, por lo tanto, sin una planeación sistemática, basada en políticas estatales respecto de la cantidad y calidad de los profesionales requeridos. reconocida tal situación y previa reiteración de la necesidad de hacer una profusa pedagogía entre la población objeto de la educación en salud, resulta impostergable establecer claramente cuál es el tipo de profesionales de la salud requeridos, en qué aspectos existe un desfase entre tales requerimientos y la educación tradicional, y cuáles serán los escenarios futuros en que se debatirán dichos profesionales. frente a esta crisis general, frente a este mundo que se deshumaniza día a día, frente a este sistema violento, es necesario reflexionar acerca de la necesidad de construir un nuevo sistema educativo en salud, que permita formar profesionales de la salud a partir de la concepción del ser humano como valor y preocupación del proceso. un ser humano activo, histórico y social y transformador de la realidad. un nuevo modelo de educación, que contemple la formación integral (social y personal) del ser humano, la comunicación consigo mismo y con los demás, el manejo corporal armónico, el pensar en su salud y en la de los que lo rodean de una forma coherente, el desenvolvimiento emotivo y la expresión creativa, será 5 cirigliano, f.g.j educación y futuro, pág. 148, columba, buenos aires, 1967. 6 santos, deleim. fundamentación existencial de la pedagogía, san pablo. frente a esta crisis general, frente a este mundo que se deshumaniza día a día, frente a este sistema violento, es necesario reflexionar acerca de la necesidad de construir un nuevo sistema educativo en salud. año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 30 pilar del nuevo paradigma de educación integral humanista. enseñar dentro de este paradigma humanista requiere, entre otras cosas, que el profesor tome al individuo como la fuente de conocimientos más importante7. en la educación en general se habla de usar métodos de aprendizaje activos, que tengan en cuenta las influencias sociales, que refuercen los valores individuales y las normas grupales y que promuevan el desarrollo de habilidades sociales, fundamentalmente. por esto, la organización mundial de la salud (oms) dice: “si enfocáramos la educación sanitaria desde un modelo participativo y adaptado a las necesidades, la población objeto del cuidado adquiriría responsabilidad en su aprendizaje y este no estaría centrado en el saber, sino también en el saber hacer”. se habla de una responsabilidad en el aprendizaje de las personas a quienes se les presta atención de salud, pero se debe tener en cuenta que la acción de aprender se desarrolla en dos niveles: el del comportamiento y el del pensamiento, que está orientado por objetivos, dirigido al desarrollo global de la persona y delimitado por las necesidades personales y las convenciones sociales. en este proceso participan activa y conscientemente el profesor (profesional de enfermería) y el alumno (persona o personas de la comunidad objeto de cuidado). es aquí donde se considera que existe el factor determinante del fracaso de la educación que se brinda a la comunidad: la falta de preparación pedagógica de los profesionales de la salud responsables de impartirla. para poder llegar a una conclusión que aporte elementos de juicio a una propuesta que mejorará el proceso docente-educativo en salud y, por ende, la calidad de vida de las comunidades, es necesario revisar algunas teorías de aprendizaje que pueden orientar el nuevo rumbo que debe tomar la educación en salud. existen múltiples intentos de clasificación de las teorías de aprendizaje. pérez gómez8 elige como criterio la concepción intrínseca del aprendizaje, en la que se distinguen dos corrientes: • la primera concibe el aprendizaje, en mayor o menor grado, como un proceso ciego y mecánico de asociación de estímulos y respuestas, provocado y determinado por las condiciones externas, pero que ignora la intervención mediadora de variables referentes a la estructura interna. en este enfoque incluye las teorías asociacionistas tanto del condicionamiento clásico de pavlov y watson, como del condicionamiento instrumental u operante de hell, thorndike y skinner. • la segunda corriente considera que en todo aprendizaje intervienen las peculiaridades de la estructura interna. su propósito es explicar cómo se construyen, condicionados por el medio, los esquemas internos que intervienen en las respuestas conductuales. en el siglo xix predominaba la pedagogía basada en prácticas conductistas, influenciada por la pedagogía pragmática de william james, que se denominó mecanicismo pedagógico. en el siglo xx, brunner, jean piaget y vigotsky, como antagónicos, superaron la diferencia en la naturaleza de la construcción del conocimiento y ofrecieron una visión más práctica de los criterios constructivistas. de los autores mencionados se escogerá a vigotsky, porque su teoría pedagógica puede ser la que deba utilizarse en educación para la salud, al considerar la transformación del medio y apropiación de conocimientos en efectividad para la acción, que conducirá al desarrollo de las personas que reciban educación. parte del hecho de que el conocimiento es algo que se construye por medio de operaciones y habilidades cognoscitivas que se inducen en la interacción social; señala que el desarrollo intelectual del individuo no puede entenderse como independiente del medio social en el que está inmersa la persona y que el desarrollo de las funciones psicológicas superiores se da primero en el plano social y después en el individual. la transmisión y adquisición de conocimientos y de patrones culturales es posible cuando de la interacción, plano interpsicológico, se llega a la internalización, plano intrapsicológico. al proceso de pasar de lo interpersonal a lo intrapersonal se lo denomina internalización. los tres componentes de la interacción mediada son: el organismo receptor, el estímulo y el mediador. el efecto de la experiencia de aprendizaje mediado es la creación en los receptores de una dispo7 beech, geoff, y vargas rolando. el humanismo y la educación, cochabamba, bolivia, 1997. 8 pérez gómez. la educación a distancia, capítulo iv, cuba, 1992. enseñar dentro del nuevo paradigma de educación integral humanista requiere, entre otras cosas, que el profesor tome al individuo como la fuente de conocimientos más importante. 31 fundamentos pedagógicos que sustentan el proceso de la educación en salud sición, de una propensión actitudinal para beneficiarse de la exposición directa a los estímulos. esto se puede traducir en mediar para enseñar a aprender. para vigotsky, los mediadores son instrumentos que transforman la realidad en lugar de imitarla. su función no es adaptarse pasivamente a las condiciones del medio, sino modificarlas activamente, que debe ser el objetivo de los profesionales de enfermería que dan educación en salud: modificar situaciones del medio ambiente para generar conductas de vida saludables. la experiencia de aprendizaje mediado es la manera en la que los estímulos remitidos por el ambiente son transformados por un agente mediador. este, guiado por sus intenciones, su cultura y su inversión emocional, selecciona y organiza el mundo de los estímulos. una interacción que lleve al aprendizaje mediado, necesariamente incluye una intención del mediador (docente) de trascender las necesidades inmediatas o las preocupaciones del receptor, al ir más allá del aquí y el ahora. cualquier anticipación de los resultados es una construcción interna de la realidad, que depende de una representación y también de un pensamiento inferencial del educando. vigotsky distingue dos clases de instrumentos mediadores, en función del tipo de actividad que posibilitan: la herramienta y los signos. una herramienta modifica al entorno materialmente, mientras que el signo es un constituyente de la cultura y actúa como mediador de nuestras acciones. existen muchos sistemas de símbolos que nos permiten actuar sobre la realidad, entre ellos el lenguaje, los sistemas de medición, los sistemas de lectoescritura, etc. a diferencia de la herramienta, el signo o símbolo no modifica materialmente el estímulo, sino que modifica a la persona que lo utiliza como mediador y, en definitiva, actúa sobre la interacción de una persona con su entorno. sirven como medios de ayudar a la ejecución el modelamiento, el manejo de contingencias, la instrucción, las preguntas y la estructuración cognoscitiva. modelamiento de contingencias y retroalimentación son los principales mecanismos para ayudar a los aprendices a través de las zonas de desarrollo próximo (zdp). los medios de ayuda a la ejecución específicamente lingüísticos (signos) son: instrucción, pregunta y estructuración cognoscitiva. la estructuración cognoscitiva no pide una respuesta específica; más bien, provee una estructura para organizar los elementos unos con relación a otros, para el pensamiento y la acción. puede ser una estructura de creencias, de operaciones mentales o de comprensión, que evalúa, agrupa y secuencia la percepción, la memoria y la acción. en síntesis: • en contraste con piaget, vigotsky no habla de asimilación, sino de apropiación. • de influencia predominante del medio cultural, referida al origen social de los procesos psicológicos superiores (lenguaje oral, juego simbólico, lectoescritura). la mayoría de ellos no se forman sin intervención educativa. • de mediación semiótica. subraya el papel central de los instrumentos de mediación en la constitución del psiquismo: herramientas y signos. las herramientas están orientadas hacia los objetos físicos, mientras que los signos permiten organizar el pensamiento; son herramientas orientadas hacia el interior y el exterior del sujeto, que producen cambios en los otros. • de zona de desarrollo próximo (zdp): es la distancia entre el nivel de desarrollo, determinado por la capacidad de resolver independientemente un problema, y el nivel de desarrollo potencial, determinado a través de la resolución de un problema, bajo la guía de un adulto o en colaboración con un par más capacitado9. la transformación de la realidad da origen a un desarrollo que lleva a que el conocimiento parta de la estructura biológica del ser humano. el conocimiento humano como proceso de sobrevivencia de los seres vivos debemos concebirlo a el aprendizaje se concibe, en mayor o menor grado, como un proceso ciego y mecánico de asociación de estímulos y respuestas, provocado y determinado por las condiciones externas, pero que ignora la intervención mediadora de variables referentes a la estructura interna. 9 vigotsky y teorías del aprendizaje. monografías. año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 32 partir de una biología del conocimiento, en la perspectiva del constructivismo piagetano-vigotskiano. es aquí en donde, aplicando el pensamiento de vigotsky en la educación en salud a la comunidad, se observa que el rol del profesional de enfermería como educador debe ser activo, mientras que las habilidades mentales de las personas o comunidades a las cuales va dirigida la educación se desarrollan “naturalmente” a través de varias rutas de descubrimientos. los principales supuestos de vigotsky que son aplicables a la educación en salud son: • la comunidad tiene un rol central. en salud, la realidad social de los individuos es moverse en el mundo de los objetos y ejecutar sus actos en función de los mismos. en esta época ha habido cambios muy significativos en la percepción de la realidad, que condicionan las conductas grupales, los actos de las personas y, por consiguiente, las intervenciones institucionales. una de las consecuencias negativas radica en que vivimos una situación en la que mayormente las actividades y las intervenciones no se diseñan en función de los problemas y de los objetivos, sino en función de los intereses de personas y de grupos. el educador debe descubrir su fuerza movilizadora y las claves que ayuden a comprender mejor la realidad cambiante y, por ende, el rol de las personas en el autocuidado de su salud. • las personas que giran alrededor del educando se ven afectadas por la forma en que él o ella ve el mundo. al hablar de educación, generalmente la persona principal en recibirla en el aspecto sanitario es la mujer, quien es la que es objeto de visitas domiciliarias para cubrir sus necesidades educativas. a su vez, las personas que la rodean se benefician de la forma como ella ve el mundo durante y después del proceso educativo. por ello, cada familia tiene que encontrar su propio estilo educativo y es ella quien educa y transmite valores a los hijos. es en la familia en donde se adquieren y desarrollan las actitudes, creencias, valores, hábitos, estilos de vida y comportamientos que determinan la salud integral de cada uno de sus miembros. los padres transmiten a los hijos creencias y actitudes y enseñan valores. de ahí la importancia de reforzarlos o cambiarlos hacia hábitos de vida sanos, al mismo tiempo que se educa a los hijos. vale la pena aclarar qué son los valores. estos pueden considerarse como aspectos concretos a los que les damos una importancia especial, de modo que pasan a orientar lo que hacemos. por ejemplo, la salud puede ser un valor dominante para una persona, mientras que otros pueden valorar el dinero por encima de la salud o de otras cosas. las personas definen lo que está bien o mal en salud en función de los valores que tenemos. en cuanto a las creencias transmitidas por los padres a los hijos, estas son las ideas o convicciones que las personas tienen acerca de las cosas y que consideran como verdades indudables. se pueden tener creencias más o menos irracionales o racionales, como pensar que se puede enfermar por estar predestinados para ello, o creencias más ajustadas a la realidad, cuando se piensa que la enfermedad le puede corresponder a cualquiera si no se eliminan los factores de riesgo que la originan. la actitud es la predisposición que se tiene a pensar y comportarse de un modo determinado. las actitudes pueden ser positivas o negativas, optimistas o pesimistas. en el primer caso, se trata de pensar qué cosas hacer para mejorar la salud, y en el segundo caso, de no hacerse pruebas diagnósticas, pues de todas formas se va a enfermar. los hábitos son las costumbres, la capacidad y la habilidad que tenemos para hacer algo en repetidas ocasiones. el modo de vida es el modo característico de una persona. los comportamientos son las conductas, la manera de actuar ante cada situación. de acuerdo con la teoría del desarrollo de vigotsky, las capacidades de solución de problemas pueden ser de tres tipos: aquellas realizadas independientemente por el estudiante. aquellas que no puede realizar, aún con ayuda. aquellas que caen entre los dos extremos; las que puede realizar con la ayuda de otros. la actitud es la predisposición que se tiene a pensar y comportarse de un modo determinado. las actitudes pueden ser positivas o negativas, optimistas o pesimistas. 33 fundamentos pedagógicos que sustentan el proceso de la educación en salud en la educación en general, así como en la educación para la salud, estas capacidades son aplicables, puesto que la persona tiende a solucionar independientemente sus problemas de salud dentro del marco de sus creencias, hábitos, actitudes, y a tener problemas que no puede solucionar aun con la ayuda de la enfermera, como cuando se requiere contar con capacidad adquisitiva para medicamentos o mejora de las condiciones habitacionales. también hay aquellas capacidades que están en medio y que requieren la ayuda de otros, como es el caso de la educación, para modificar factores de riesgo que se desconocían. a partir de los principios vigotskianos, cuando se va a impartir educación a la comunidad, se considera que: • el aprendizaje y el desarrollo son actividades sociales y colaborativas, que no pueden ser enseñados a nadie pero que pueden ser desarrolladas con el apoyo del docente. cada uno construye su propia comprensión en su propia mente. • la zona de desarrollo próximo puede ser usada para diseñar situaciones apropiadas durante las cuales la persona podrá ser provista del apoyo apropiado para el aprendizaje óptimo. • cuando es provista por las situaciones apropiadas, se debe tomar en consideración que el aprendizaje debería tener lugar en contextos significativos, preferiblemente el contexto en el cual el conocimiento va a ser aplicado. sustentado de una forma sucinta el pensamiento de vigotsky, es importante considerar el aprendizaje significativo de david ausbel que, potencializando al primero, puede dar la clave para orientar el enfoque de la educación en salud a la comunidad. ausbel reconoció las bondades del aprendizaje por descubrimiento y consideró que no debía verse opuesto al aprendizaje que resulta de una exposición. plantea10 que el aprendizaje significativo del alumno depende de la estructura cognitiva previa que se relaciona con la nueva información, es decir, el conjunto de conceptos e ideas que ese alumno posee en un determinado campo del conocimiento. el aprendizaje significativo exige, en primer lugar, que su contenido sea potencialmente significativo y que la persona tenga voluntad de aprender significativamente. si el material informativo no tiene una estructura significativa (significatividad lógica) no es posible producir un aprendizaje en tal sentido. en segundo lugar, es necesario que la persona tenga una disposición favorable a aprender significativamente, o sea, de relacionar lo nuevo con lo almacenado en su memoria. en salud es de vital importancia conocer la estructura cognitiva, no tratar de saber la cantidad de información en salud que se posee, sino cuáles son los conceptos y proposiciones que maneja. esto permite orientar la acción educativa, ver que las personas poseen una serie de experiencias y conocimientos que afectan su aprendizaje y pueden ser aprovechados para su beneficio. el factor importante que influye en el aprendizaje es lo que la persona ya sabe. como característica fundamental se produce una interacción entre los conocimientos más relevantes de la estructura cognitiva y las nuevas informaciones (no una simple asociación), de tal modo que estas adquieren un significado y son integradas a la estructura cognitiva. el aprendizaje ocurre solo si se satisfacen una serie de condiciones, a saber: que la persona sea capaz de relacionar de manera no arbitraria y sustancial la nueva información con los conocimientos y experiencias previas y familiares que posee en su estructura de conocimientos; que tenga la disposición de aprender significativamente, y finalmente, que los materiales y contenidos de aprendizaje tengan significado potencial o lógico. la nueva información debe relacionarse de modo no arbitrario y sustancial con lo que el alumno ya sabe; ello depende también de la disposición, motivación y actitud de aquel por aprender, así como de los materiales o contenidos de aprendizaje con significado lógico. para lograr aprendizajes significativos en el trabajo educativo en salud con personas o grupos de la comunidad, no son útiles enfoques u orientaciones didácticas tradicionales, sino enfoques de pedagogía activa, interactiva o integradora. un aspecto de gran importancia para la consecución de estos aprendizajes es 10 castillo, jonathan. estrategias docentes para un aprendizaje significativo. monografías.com en salud es de vital importancia conocer la estructura cognitiva, no tratar de saber la cantidad de información en salud que se posee, sino cuáles son los conceptos y proposiciones que maneja. año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 34 el desarrollo de procesos de enseñanzaaprendizaje eficaces. se trata de procesos que posibiliten a los educandos expresar y/o investigar su propia realidad, partir de su situación específica, profundizar en el tema que se está trabajando, reorganizar conocimientos, analizar la situación general y algunos temas específicos, reflexionar sobre aspectos del área emocional y afrontar su situación, es decir, decidir la acción sobre su realidad, desarrollar los recursos y habilidades necesarios, realizarla en la práctica y evaluarla. en la práctica, se trata de facilitar a la persona o al grupo el conocimiento de su situación y hablar de ella en primer lugar, o sea, escuchar antes de informar o de planear y desarrollar el proceso educativo. hay que ayudarles a pensar más que pensar por ellos y no darles soluciones, sino apoyarlos para que se les facilite encontrar las suyas propias. no se trata de prescribir comportamientos, sino de promoverlos. una estrategia para el aprendizaje significativo es aprender a aprender. esto implica la capacidad de reflexionar sobre la forma en que se aprende, y actuar en consecuencia, autorregulando el propio proceso de aprendizaje, mediante el uso de estrategias flexibles y apropiadas, que se transfieren y adaptan a nuevas situaciones11. en personas adultas, el aprendizaje importante es el que permite aprender a aprender, pues la mayoría de ellas no han usado estrategias de aprendizaje, porque nadie se las ha enseñado, de tal forma que cuando van a enfrentarse a una tarea nueva, el método que utilizan es el que siempre intuitivamente han utilizado y este ya no les proporciona buenos resultados. aprender a aprender sería el procedimiento personal más adecuado para adquirir un conocimiento en conductas saludables, ya que es un impulso, una forma de acercamiento a los hechos, principios y conceptos, lo cual implica: el aprendizaje adecuado de estrategias cognitivas. el aprendizaje y uso adecuado de estrategias metacognitivas, o sea, el propio conocimiento. el aprendizaje y uso adecuado de modelos conceptuales de andamios del aprendizaje y del pensamiento, para generar estilos de vida saludables. en este momento, es indispensable hacer un alto para considerar más detalladamente el concepto de aprendizaje en esta estrategia: el aprendizaje consiste en asimilar las experiencias vividas y que ellas pasen a ser parte de nuestra vida y cambien la forma de concebir y actuar de las personas o grupos ante los problemas de salud. lo importante de este aprendizaje no consiste en compartir u oír experiencias, sino en vivirlas, de tal forma que puedan ser asimiladas e incorporadas a la vida. por eso se dice que aprender es cambiar. en algunos casos se debe desaprender lo aprendido y cambiar algunos aspectos del mal aprendizaje, lo que constituye la intencionalidad de la educación en salud. esto obliga a la persona a reflexionar con sinceridad sobre todo aquello que considera haber aprendido y comprendido, y reconocer que todo aprendizaje es progresivo y siempre incompleto. por ejemplo, el que aprendió a comer las frutas sin lavarlas previamente y desea aprender cómo no enfermarse de diarrea, debe modificar el hábito adquirido y desaprender lo aprendido, para adquirir nuevas habilidades y aptitudes que determinarán un estilo de vida saludable. en síntesis12, aprender a aprender es el proceso mediante el cual se obtienen conocimientos, habilidades o actitudes a través de experiencias vividas que producen algún cambio en nuestro modo de ser o actuar. el aprender da la oportunidad de crecer, de asimilar la realidad y transformarla, para lograr una existencia más plena y más profunda. toda experiencia puede producir un tipo de aprendizaje. sin embargo, ciertos aprendizajes se dan únicamente ante ciertos tipos de experiencias. para ello se consideran como puntos relevantes: el condicionamiento, que se produce cuando dos eventos o situaciones se asocian de tal manera que la aparición de uno genera la presencia de otro. se da un auténtico aprendizaje cuando a cada situación o problema de salud se responde adecuadamente, en función de tal situación, gracias a las habilidades o aptitudes adquiridas en el proceso. como ejemplo tenemos: aprendizaje por ensayo y error. las experiencias que llevan a la solución correcta se van imprimiendo en la memoria, se fortalecen, mientras que las otras las va eliminando, mediante la confrontación entre la práctica y los resultados 11 castillo jonathan. estrategias docentes para un aprendizaje significativo. www.monografías.com 12 michel, guillermo. aprende a aprender, trillas, méxico, 1999. 35 fundamentos pedagógicos que sustentan el proceso de la educación en salud bibliografía álvarez alva, rafael. educación para la salud, editorial manual moderno, méxico, 1995. beech, geoff, y vargas, rolando. el humanismo y la educación, cochabamba, bolivia, 1999. bize, rebeca, y aguilar, mario. la pedagogía de la diversidad: una propuesta de inspiración humanista, umce, 1994. cirigliano, f. g. j. educación y futuro, columba, buenos aires, pág. 148, 1967. fernández, david, s. j. nuevos paradigmas para una educación humanista, iteso, cátedra paulo freire, méxico, 2000. freire, paulo. ¿extensión o comunicación? la concientización en el medio rural, siglo veintiuno editores, uruguay, 1988. leirman, walter. la educación de adultos como proceso, editorial magisterio, bogotá, 1995. maripili, golpe. la salud en la escuela, universidad central de venezuela, caracas, 2001. michel, guillermo. aprende a aprender, trillas, méxico, 1999. ministerio de salud, colombia. promoción de la salud y prevención de la enfermedad en el sistema general de seguridad social en salud, san tafé de bogotá, 1996. posada, j. marco conceptual para una cultura de la salud, ministerio de salud, bogotá, 1993. puleda, salvatore. interpretaciones del humanismo, roma, italia, 1999. quinta conferencia mundial de promoción de la salud. méxico, 5 de junio de 2000. santos, deleim. fundamentación existencial de la pedagogía, san pablo. serrano, maría isabel. la educación para la salud del siglo xxi, editorial díaz de santos, españa, 1998. universidad de navarra. metodología de la educación para la salud individual y grupal, españa, octubre de 2001. obtenidos, pues ha logrado aprender a resolver problemas resolviéndolos. aprendizaje por comparación. sobre la experiencia vivida se reflexiona con alguna teoría, para hacer conscientes las distintas consecuencias que se dan en circunstancias diferentes. aprendizaje por imitación. supone la existencia de un modelo, ejemplo o demostración y la copia o repetición posterior del mismo. en la educación sobre salud, los contenidos son los factores relacionados con los comportamientos humanos en salud, que son de tres tipos: • factores del entorno social: condiciones de vida, recursos y servicios disponibles, modelos y valores socioculturales dominantes. • factores del entorno próximo: apoyo del grupo familiar e interdependencia con redes sociales. • factores personales: del área cognitiva: los conocimientos, habilidades de análisis y valoración de situaciones. del área emocional: creencias, valores, actitudes, autoestima. del área de hablidades: incluye las psicomotoras, como el ejercicio o la relajación. personales: el enfrentamiento de problemas o el manejo del tiempo. sociales: la escucha y la comunicación, el manejo de conflictos y la negociación. con lo expuesto se ayuda a las personas para que desarrollen capacidades que les permitan tomar decisiones conscientes y autónomas sobre su propia salud y la de las personas que están bajo su cuidado. de los planteamientos anteriores se puede deducir que, para efectos de la educación en salud, se debe educar en calidad de vida, proceso que contempla factores importantes y determinantes para el cambio que se debe dar en las personas y las comunidades. educar en salud es el proceso intencional por el cual las personas son más conscientes de su realidad y del entorno que las rodea y amplían sus conocimientos, valores y habilidades, que les permitirán desarrollar capacidades para adecuar sus comportamientos a la realidad vivida. latin american nursing and its social and cultural resignification editorial latin american nursing and its social and cultural resignification la enfermería latinoamericana y su resignificación social y cultural a enfermagem latino-americana e sua ressignificação social e cultural 10.5294/aqui.2022.22.3.1 claudia marcela velasquez jiménez 1 1 0000-0001-8353-0485. universidad de ciencias aplicadas y ambientales, colombia. mvelasquez@udca.edu.co keywords (source decs): nursing; latin america; leadership; health policy. palabras clave (fuente decs): enfermería; américa latina; liderazgo; política de salud. palavras-chave (fonte decs): enfermagem; américa latina; liderança; política de saúde. para citar este editorial / to reference this editorial / para citar este editorial: velásquez cm. latin american nursing and its social and cultural resignification aquichan [internet]. 2022;22(3):e2231. doi: https://doi.org/10.5294/aqui.2022.22.3.1 introduction in the diagnoses and guidelines related to nursing, the world health organization (who) and, particularly, the pan american health organization (paho) have repeatedly shown deep concern about the lack of human resources in nursing worldwide and regionally. the countries' governments must take responsibility not only to avoid the collapse of health systems, supported mainly by these health workers, as noted at the beginning of the pandemic, but also to recognize their contributions to the scientific and epistemological knowledge of what nursing care means to the quality of health care and invest in their development to ensure an adequate quantity and their suitability (1, 2). against this backdrop, this article proposes a reflection that not only focuses on the need for social, cultural, and economic retribution but also delves into the importance of leadership and empowerment in latin american nursing as a collective body of public action responsible for the participation in and making of health and professional talent policies. it spotlights the contribution that nursing, as a discipline based on research and theory, makes to knowledge, which relies upon the evidence of care in the health-disease processes of individuals, families, and groups. the current situation of nursing in latin america nursing in the americas region could be said to have been significantly influenced by a syncretism between biomedical and health cultures. the epistemological and epistemic tendencies of anglo-saxon and north american nursing and, lately, the recognition of autochthonous care practices of original latin american peoples' cultural heritage hidden by the logic and truth criteria of the science of knowledge society have given rise to a latin american movement of disciplinary criticism and self-reflection that seeks to establish the inputs to nursing practice from the latin american experience (3). the preceding has undoubtedly been a significant breakthrough in developing investigative skills that have allowed solid academic, scientific, and disciplinary arguments to enrich the epistemology of nursing, foster greater effectiveness, efficiency, and safety when providing care, and build rigorous scientific evidence to support nursing actions (4, 5). these aspects become a fundamental input to improve recognition, professional resignification, and social representation and move towards the social acknowledgment that scientific nursing has its own identity and contributes significantly to the sector and the care of people's health. however, nursing has not been able to have a practical impact on the global problem of critical economic conditions, resulting in a growing shortage of these health workers. it is not unknown that the issue of professional identity, low status, and social and economic recognition continue to be the most sensitive dimensions of the development of professionals in this field (6, 7). the latest report of the paho indicates that 30 % (8.4 million) of the total nursing personnel (including professionals, technicians, and assistants) are concentrated in the americas, estimating a worldwide shortage of 5.9 million professionals. it can be deduced that 89 °% (5.3 million) of this deficit is concentrated in lowand lower-middle-income countries and that the nursing problem in latin america is not particular but global. added to european countries' significant demand for latin american professionals, whose quality training becomes cheap labor for these countries in need of nurses, this problem will soon destabilize the region's health systems if not addressed as a priority (2, 5, 6). the progress in latin american professional development poses several challenges condensed in various aspects, some of which have already been described by the triple impact report and the who. therefore, emphasis is placed on the first three items and others proposed below, which are essential to achieving this goal (8). 1. the need to invest in nursing to create economic and social stimuli that impact status and, therefore, the increase in the number and retention of professionals (8, 9) 2. the improvement of professional training and graduate recognition in work settings (8) 3. the strengthening of nursing leadership translated into managerial and leadership positions in health institutions and government decision-making bodies (8) 4. the deployment, promotion, and development of research, which have contributed robustly to the knowledge of the disciplinary subject matter: nursing care. the results have consolidated, from scientific evidence, the best care practices to transform the ways of seeing, understanding, taking part in, and assisting the individual and collective processes of health, disease, life, and death relevant to global and local needs. nonetheless, they need greater social and scientific dissemination to better value this professional discipline (10, 11). 5. the need to become a collective body that devises joint strategies to take a critical look at training programs and determine the identity of latin american nursing and that searches for local and international methods that make visible the outstanding contributions to knowledge and the improvement of people's quality of life that build our profession from research and social outreach (12, 13). 6. the need to establish an honest interprofessional, interdisciplinary, and social dialogue that favors the knowledge of what nursing currently is and is not in order not to continue reinforcing social and interprofessional imaginaries that nursing is monological, speaks to itself, and remains trapped in the social representation of being health personnel supporting medicine instead of what it truly is: a discipline that sustains itself, does research, is critical, can participate in public health policy-making, and interacts with other health professionals. nursing understands that the complex care needs of individuals, families, communities, and groups only allow for multidimensional approaches, which have turned into knowledge in its disciplinary heritage (14). the last challenge is to reflect and accept that the poor notoriety of nursing and decision-making in the region's public health policy agenda can be transformed through various articulated strategies, as follows: a) the nursing undergraduate and graduate training processes in which professionals are prepared for disciplinary argumentation and interaction with interdisciplinary languages require diverse reasoning supported by indicators, scientific evidence, and tangible results in a globalized world. b) strengthening research, both in its consumption and in decisionm-aking, and improving clinical judgment, financial efficiency, and actual research projects on the disciplinary subject matter and development, the nursing action and its effect on care recipients, and the social dissemination of the contribution this production of knowledge makes to the health sector and people's quality of life (15). c) the search for work settings in which one is educated about the regulations and policies already put forward by and for nursing to exercise leadership in decision-making whose effects are better conditions of recognition, labor status, and retention (16). d) the strengthening of union, academic, ethical, and student organizations by the logic of active political engagement that impacts regulations and guidelines to create opportunities that favor the resignification of the profession. disciplinary argumentation and political action as transformation opportunities nursing is a necessary and increasingly relevant profession in the current world situation. disciplinary and professional advances have multiple strengths and opportunities. if the need for professionals in this area is leveraged, these aspects can be capitalized within a new paradigm that redefines the role of nursing in health care sectors and models. this will only be possible if nurses, in particular, understand the responsibility of having solid disciplinary training to propose nursing care models in institutions with autonomous settings, horizontal relationships with other professionals, and clearly defined roles. at the same time, they should account for the multidimensional impact of care to support the nursing organizations that represent them in demonstrating this impact publicly and demanding a leading (not subordinate) role in the decision-making of the health sector. the preceding involves collective organization to propose nursing talent policies, as in colombia, their operationalization through strategic plans with specific resources, and the demand from the public sector for the active participation of nurses in making health and education policies related to the role and training of nursing (17, 18). in conclusion, latin american nursing is called to its resignification from an active role in defining the direction that health and health worker policies should take. its strength is forming a collective body that identifies citizen and political participation settings without eliminating the particularities of each country or region and makes visible the contribution to scientific and disciplinary knowledge and its effect on improving health models. references 1. organización mundial de la salud. situación de la enfermería en el mundo: resumen de orientación [internet]. [lugar de publicación desconocido]: 2020 [citado el 10 de mayo de 2022]. disponible en https://www.paho.org/es/documentos/situacion-enfermeria-mundo-2020-resumen-orientacion 2. organización panamericana de la salud; organización mundial de la salud. orientación estratégica para enfermería en la región de las américas [internet]. washington: ops; 2019 [citado el 10 de mayo de 2022]. disponible en https://iris.paho.org/ 3. souza a. la formación en enfermería y el desarrollo socioeconómico en américa latina 1850-1950. adm. sanit. [internet]. 2003 oct. [citado el 10 de mayo de 2022];1(4):555-573. disponible en https://www.elsevier.es/es-revista-revista-administracion-sanitaria-siglo-xxi-261-articulo-la-formacion-enfermeria-el-desarrollo-13055235 4. gifford wa, squires je, angus de, ashley la, brosseau l, craik jm, domecq m-c, et al. managerial leadership for research use in nursing and allied health care professions: a systematic review. implemen. sci. [internet]. 2018 sept. 27;13:127. doi: https://doi.org/10.1186/s13012-018-0817-7 5. veldhuizen jd, hafsteinsdóttir tb, mikkers mc, bleijenberg n, schuurmans mj. evidence-based interventions and nursesensitive outcomes in district nursing care: a systematic review. int. j. nurs. stud. [internet]. 2021 nov. 233: 100053. doi: https://doi.org/10.1016/j.ijnsa.2021.100053 6. mena d, gonzález vm. imagen social de la enfermería, ¿estamos dónde queremos? index. enferm. [internet]. 2018 jun. [citado el 11 de mayo de 2022]; 27(1-2)5-7. disponible en http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s1132-12962018000100001&lng=es 7. franco ja. percepción social de la profesión de enfermería. enferm. actual costa rica [internet]. 2019 dic. 04 [citado el 10 de mayo de 2022]; 38:72-281. disponible en https://doi.org/10.15517/revenf.v0i38.36930 8. the all-party parliamentary group on global health. triple impacto: cómo el desarrollo de la enfermería mejorará la salud, promoverá la igualdad de género y apoyará el crecimiento económico [internet]. [lugar de publicación desconocido]: 2016 oct. disponible en https://www.enfermeriacanaria.com/wptfe/wp-content/uploads/triple-impacto_esp.pdf 9. buchan j, catton h, shaffer fa. apoyar y retener en 2022 y más allá: la fuerza laboral de enfermería global y la covid-19 [internet]. filadelfia: consejo internacional de enfermeras; cgfns international; 2022 [citado el 10 de mayo de 2022]. disponible en https://www.icn.ch/system/files/2022-02/sustain and retainin 2022 and beyondthe global nursing workforce and thecovid-19 pandemic_sp.pdf 10. bowers b. improving practice and informing policy development: the impact of gerontological nursing research. geriatr. nurs. [internet]. 2020 feb. 03. 41(1):32-37. doi: https://doi.org/10.1016/j.gerinurse.2020.01.010 11. nibbelink cw, brewer bb. decision-making in nursing practice: an integrative literature review. j. clin. nurs. [internet]. 2017 nov. 03. 27(5-6):917-928. doi: https://doi.org/10.1111/jocn.14151 12. velandia, al. presente de la enfermería de américa latina. temperamentvm. [internet]. 2007;3(6): t3107. disponible en http://ciberindex.com/c/t/t3107 13. camacho franco eduardo ricardo, rodríguez jiménez sofía. una mirada crítica de la formación del profesional de enfermería con perspectiva reflexiva. enferm. univ 2010 mar 7(1): 36-44. disponible en : http://www.scielo.org.mx/scielo.php?script=sci_arttext8pid=s1665-70632010000100005 14. gómez je. la enfermería como apertura a la interdisciplina. rev. latinoam. bioet. [internet]. 2017 nov. 21;18(34-1):191-204. doi: https://doi.org/10.18359/rlbi.3162 15. benítez j. la importancia de la investigación en enfermería. enfermería investiga. [internet]. 2020;5(1):1-2. disponible en: https://revistas.uta.edu.ec/erevista/index.php/enfi/article/view/826 16. arshia amiri, tytti solankallio-vahteri. analyzing economic feasibility for investing in nursing care: evidence from panel data analysis in 35 oecd countries-int-j. nur. sc. 2020;7(1):13-20, issn 2352-0132. doi: https://doi.org/10.1016/j.ijnss.2019.06.009 17. velásquez cm, rico g, ayala de calvo le, vargas bc, gutiérrez m del c, molina j, suárez e, munar ef. política nacional de enfermería y plan estratégico 2020-2030: resignificando la profesión de enfermería en colombia. [internet]. colombia: ministerio de salud y protección social. 2020. disponible en https://www.anec.org.co/images/plan_nacional_enfermeria.pdf 18. montaña, jp. participación de enfermería en la elaboración de políticas públicas de salud en latinoamérica participation of nursing in the elaboration of public policies of health in latin america. disponible en: https://revistas.unac.edu.co/ojs/index.php/unaciencia/article/view/563 home 403 416 el diario del estudiante de enfermeria.indd 403 sabiniana san rafael gutiérrez1 josé siles gonzález2 carmen solano-ruiz3 el diario del estudiante de enfermería en la práctica clínica frente a los diarios realizados en otras disciplinas. una revisión integradora 1 universidad autónoma de barcelona. españa. sabisanrafael@gmail.com 2 doctor en historia, profesor. universidad de alicante, españa. jose.siles@ua.es 3 doctor en antropología social y cultural, profesor. universidad de alicante, españa. carmen.solano@ua.es recibido: 25 de abril de 2012 enviado a pares: 18 de junio de 2012 aceptado por pares: 06 de marzo de 2014 aprobado: 04 de junio de 2014 doi: 10.5294/aqui.2014.14.3.10 para citar este artículo / to reference this article / para citar este artigo san rafael gutiérrez s, siles gonzález j, solano-ruiz c. el diario del estudiante de enfermería en la práctica clínica frente a los diarios realizados en otras disciplinas. una revisión integradora. aquichan. 2014; 14(3): 403-416. doi: 10.5294/aqui.2014.14.3.10 resumen el presente artículo es una revisión integradora de la literatura cuyo objetivo fue identificar, en revistas nacionales e internacionales indexadas en las bases de datos isi web of knowledge, eric, pubmed, ebscohost, scopus, scielo, cuiden, cuidatge y scirus, en el periodo comprendido entre 1995 y 2011, datos que contribuyeran a determinar cómo la escritura del diario reflexivo ayuda al estudiante de enfermería durante sus prácticas clínicas, así como a establecer diferencias y similitudes con los diarios realizados por estudiantes de otras disciplinas. se llevó a cabo una revisión amplia de la cual se seleccionaron 54 artículos científicos con base en criterios de inclusión y exclusión, sin descartar ninguna metodología de investigación e incluyendo aquellos que analizaran el diario del estudiante, fueran o no del ámbito de la enfermería. se concluye que la escritura del diario reflexivo que realiza el estudiante de enfermería durante sus prácticas clínicas tiene beneficios tales como la mejora de la comunicación con el paciente, fundamental para el cuidado. la escritura del diario debería ser incluida en todos los planes de estudio de grado en el ámbito de las prácticas clínicas. palabras clave estudiantes de enfermería, educación en enfermería, revisión integradora, prácticas clínicas. (fuente: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 403-416 404 aquichan issn 1657-5997 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 403-416 the diary of a nursing student in clinical practice compared diaries kept in other disciplines. an inclusive review abstract this article is an inclusive literature review intended to identify data in national and international journals indexed in several databases between 1995 and 2011. the databases consulted were isi web of knowledge, eric, pubmed, ebscohost, scopus, scielo, cuiden, cuidatge and scirus. the objective was to help determine how writing an introspective journal is of assistance to student nurses during their clinical practice, and to identify differences and similarities with the diaries kept by students in other disciplines. a broad review was conducted and 54 scientific articles were selected on the basis of inclusion and exclusion criteria, without ruling out any research methodology and including those that analyze student journals, in nursing or otherwise. it was concluded that writing an introspective diary during clinical practice has a number of benefits for nursing students, such as improved communication with the patient, which is fundamental for care. keeping a diary should be part of all undergraduate curricula in the field of clinical practice. key words nursing students, nursing education, inclusive review, clinical practice. (source: decs, bireme). 405 el diario del estudiante de enfermería en la práctica clínica frente a los diarios realizados en otras disciplinas: ... l sabiniana san rafael gutiérrez y otros. o diário do estudante de enfermagem no estágio clínico ante os diários realizados em outras disciplinas. uma revisão integradora resumo o presente artigo é uma revisão integradora da literatura cujo objetivo foi identificar, em revistas nacionais e internacionais indexadas nas bases de dados isi web of knowledge, eric, pubmed, ebscohost, scopus, scielo, cuiden, cuidatge e scirus, no período compreendido entre 1995 e 2011, dados que contribuíssem para determinar como a escrita do diário reflexivo ajuda o estudante de enfermagem durante seu estágio clínico, bem como para estabelecer diferenças e similitudes com os diários realizados por estudantes de outras disciplinas. realizou-se uma revisão ampla da qual foram selecionados 54 artigos científicos com base em critérios de inclusão e exclusão, sem destacar nenhuma metodologia de pesquisa e incluindo aqueles que analisaram o diário do estudante, fossem ou não do âmbito da enfermagem. conclui-se que a escrita do diário reflexivo que o estudante de enfermagem realiza durante seu estágio clínico tem benefícios como a melhora da comunicação com o paciente, fundamental para o cuidado. a escrita do diário deveria ser incluída em todos os planos de estudo de graduação no âmbito dos estágios clínicos. palavras-chave estudantes de enfermagem, educação em enfermagem, revisão integradora, estágio clínico. (fonte: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 403-416 406 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 introducción el diario del estudiante consiste en un informe periódico, como mínimo semanal, de la experiencia en que este está inmerso; en el caso de enfermería casi siempre está relacionado con la práctica clínica. en él se pueden incluir sentimientos, emociones, pensamientos, ideas y reacciones (1). es una estrategia de enseñanza-aprendizaje en que la responsabilidad es compartida entre el docente y el estudiante (2). puede ser llevado a cabo con diferentes niveles de reflexión, que van desde la descripción de hechos, por tanto sin reflexión, hasta una reflexión crítica, profunda y fundamentada de los mismos (3). las prácticas clínicas suponen enfrentar al estudiante a la realidad de la práctica enfermera, en estas puede aplicar los conocimientos adquiridos en el aula. no obstante, en este ámbito el estudiante puede detectar ciertas contradicciones entre el conocimiento teórico y su aplicación en la práctica asistencial. para la integración de este conocimiento sería necesaria una reflexión crítica, como la que se produciría en la escritura del diario (4). escribir proporciona la posibilidad de volver a la experiencia, analizarla y transformarla en aprendizaje a través de la construcción de significados (1). la finalidad que se persigue es que el estudiante desarrolle el pensamiento crítico, aspecto imprescindible para los futuros profesionales de enfermería, por lo que ha sido incluido en muchos planes de estudio de grado, sobretodo en el ámbito de las prácticas clínicas. en este ámbito se pretende crear oportunidades para dominar los procedimientos de enfermería, es decir, aprender haciendo, siendo más significativo el aprendizaje así construido que el realizado en el aula (5). el diario reflexivo no es exclusivo de la disciplina enfermera, su implementación en el contexto de enfermería es producto de un proceso de adaptación de esta herramienta didáctica desde otras disciplinas. esta visión más plural nos permite identificar las diferencias y semejanzas del diario del estudiante de enfermería en las prácticas clínicas con el de otras disciplinas (tabla 2), esto último ha favorecido la visualización de las peculiaridades del mismo. el objetivo que se persigue con esta revisión es dar respuesta a las siguientes preguntas: • ¿qué características tiene el diario del estudiante de enfermería? • ¿qué diferencias y semejanzas esenciales tiene este diario con el de estudiantes de otras disciplinas? • ¿qué beneficios proporciona la escritura del diario al estudiante de enfermería? • ¿qué dificultades presenta su escritura? • ¿mejora el rendimiento académico de los estudiantes? • ¿cómo se evalúa? materiales y métodos según las aportaciones de diversos autores que se han seguido para la realización de este trabajo (6-8), la revisión integradora posibilita la generación de nuevas perspectivas, ayuda en la determinación de las lagunas de conocimiento del hecho estudiado y permite la síntesis de los estudios publicados con la finalidad de extraer conclusiones generales. lo que se persigue es evidenciar las conclusiones de estudios anteriores y resumirlas para formular conclusiones de un tema específico, en nuestro caso, el diario del estudiante de enfermería en la práctica clínica. esto conlleva las siguientes fases: identificación del tema y cuestión de investigación; establecimiento de criterios de inclusión/exclusión así como las informaciones que deberán ser extraídas de los estudios seleccionados; evaluación de los estudios incluidos en la revisión y, por último, la interpretación de los resultados y la síntesis de conocimiento. se establece como objeto de estudio el diario del estudiante, diferenciando el realizado por los de enfermería durante sus prácticas clínicas y el realizado por estudiantes de otras disciplinas (tabla 2). se parte de las siguientes preguntas: ¿qué beneficios aporta y qué dificultades tiene la escritura del diario del estudiante? ¿cómo se evalúa el diario del estudiante? con esta finalidad se realizó una búsqueda de artículos científicos en los meses de mayo y junio de 2011 seleccionando aquellos que cumplían con los siguientes criterios de inclusión: artículos científicos indexados en las siguientes bases de datos: isi web of knowledge, eric, pubmed, ebscohost, scopus, scielo, cuiden, cuidatge y scirus, publicados entre el 1 de enero de 1995 y el 30 de abril de 2011 con las palabras clave “diaries writing & students” añadiendo, según el caso, “practice y journal”, así como su traducción al castellano en aquellas bases de 407 el diario del estudiante de enfermería en la práctica clínica frente a los diarios realizados en otras disciplinas: ... l sabiniana san rafael gutiérrez y otros. datos que así lo requerían. así mismo, debían contener las palabras “diaries writing” o “journal writing” en el título o en el resumen; el diario del estudiante era, además, la unidad de análisis; los artículos podían estar o no relacionados con el ámbito de la enfermería, sin descartar ninguna metodología de investigación. los criterios de exclusión son siguientes: artículos en los que el diario no es escrito por estudiantes y aquellos en los que no se analiza el contenido del mismo. para garantizar la idoneidad de los trabajos seleccionados estos fueron valorados con una guía de lectura crítica de artículos científicos rechazando aquellos que no poseían calidad suficiente. se construyó una tabla (tabla 1) con la finalidad de poner en práctica y cuantificar los criterios de inclusión y exclusión aplicados al realizar la lectura del título, resumen y texto completo respectivamente, hasta alcanzar el objetivo de investigación; 54 artículos representan los datos que responden a algunas de las preguntas de investigación realizadas respecto al diario del estudiante. los estudios incluidos tras la selección realizada en la etapa de organización y evaluación se archivaron en carpetas en el ordenador. aquellos artículos que se consideraron relevantes se rescataron de forma completa guardándolos en carpetas por año de publicación. se elaboró un instrumento con el programa excell for windows de microsoft, en el que se consignaron los siguientes datos de los artículos seleccionados: base de datos, código de referencia, título del artículo, autores, fuente de publicación, tipo de artículo, país y aportaciones relacionadas con los objetivos de búsqueda. así, los datos se fueron organizando en función de semejanzas y diferencias constituyendo un hallazgo que fue interpretado y analizado con la literatura pertinente. resultados se obtuvieron 302 artículos, de los cuales 54 resultaron útiles para el estudio, 18 son del ámbito de la enfermería y 36 pertenecen a otras disciplinas (tabla 2). cabe destacar la obtención de un número considerable de artículos en los que el diario es el medio usado para investigar aspectos relacionados con el aprendizaje del estudiante, pero cuyo objetivo no es el análisis del diario en sí, en los términos descritos como objeto de estudio, y por tanto no fueron incluidos en esta revisión. se obtuvieron, así mismo, un número considerable de artículos, excluidos del análisis, en los que el diario fue el medio usado por el profesor para mejorar la docencia impartida o bien fue usado por enfermos de diferentes patologías como medio para liberar tensiones. también son numerosos los trabajos que hablan del diario del estudiante como uno de los elementos que forma parte de los portafolios de aprendizaje o de práctica clínica, pero que no profundizan en el análisis respecto a qué aporta su escritura al alumno. para el análisis de los datos obtenidos se procede a su tabulación, en relación con el año de publicación y el país de origen, constatando que las publicaciones anteriores al año 2002, respecto al tema de estudio, son escasas, siendo mayor su producción a partir de 2007. el país en el que se realiza el mayor número de investigaciones relevantes es reino unido, seguido de estados unidos; no obstante, se constata la gran diversidad de países en que se está realizando investigación respecto al diario del estudiante (figura 1). discusión la reflexión es una actividad deliberada y consciente que permite a la persona contemplar el comportamiento, los acontecimientos y las respuestas a ellos (9). la reflexión en la acción es el proceso mediante el cual el practicante reconoce una nueva situación y piensa en actuar al mismo tiempo (10). este tipo de reflexión es el que debe realizar el estudiante de enfermería durante sus prácticas clínicas. el diario de práctica clínica consiste en un informe que realiza el estudiante respecto a la experiencia de enseñanza-aprendizaje en que este está inmerso. revela la experiencia vivida, sus procesos de pensamiento y lo que este determina como importante (9). el paradigma es “escribir para aprender”, es decir, desarrollar el pensamiento a medida que se escribe. se basa en la suposición de que el pensamiento del estudiante y su aprendizaje pueden crecer y clarificarse a través del proceso de escritura (11-13). el objetivo principal de la escritura del diario es que el estudiante contemple e integre la información de la experiencia de enseñanza-aprendizaje vivida, promover en este el pensamiento crítico y que comunique, de forma escrita, su percepción de esta experiencia (13, 14). además, puede describir sus sentimientos, pensamientos e ideas, y puede servir de instrumento de comuni408 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 cación con otras personas (15). permite al estudiante la exploración de las experiencias estresantes, así como de sus reacciones, y el afrontamiento que realiza ante estas (16), constituyendo el reflejo del aprendizaje o la experiencia docente documentada a través de entradas regulares (17). tipos de diario el diario es la forma de reflexión más extendida, siendo usado tanto en la enseñanza de pregrado como de posgrado. la finalidad que se persigue con su escritura es variada y va desde apoyar la retención de temas complejos o aumentar el desarrollo intelectual (18), cuando se trata del diario de aprendizaje, o bien estimular la reflexión crítica sobre la práctica profesional, en el caso del diario de práctica clínica del estudiante de enfermería. sea como sea, la escritura continua ofrece beneficios al estudiante que van desde aprender a escribir, hasta representar una ayuda para la estructuración del pensamiento (18). fundamentalmente, en la bibliografía consultada se describen dos tipos de diarios: el diario dialógico y el diario reflexivo. el diario dialógico. el estudiante envía el escrito realizado durante un periodo de tiempo al profesor y este le proporciona feedback, repitiendo el proceso con una frecuencia preestablecida. se trata de una “conversación” entre el profesor y el estudiante con la finalidad de desarrollar la autoconciencia de este y la comprensión de las situaciones (19). proporciona al estudiante la oportunidad de expresarse y desarrollar una “voz personal” difícil de lograr en la educación tradicional (20). esta modalidad se ve facilitada cuando el soporte del diario es un blog, ya sea usado de forma individual o en grupo. en este caso se convierte en una herramienta de comunicación entre profesor y estudiante que posibilita un feed-back frecuente (21). el diario dialógico entre estudiantes se ha experimentado con éxito, en este caso el feed-back es proporcionado por los pares. en esta modalidad de diario puede haber una cierta incomodidad en la persona que escribe (18). la clave del éxito del diario dialógico es la frecuencia de la interacción de los participantes (22). es la modalidad de diario escogida cuando se quiere fomentar el aprendizaje de un área determinada (12). el diario reflexivo. el estudiante envía el diario al profesor, casi siempre, al final de la experiencia de aprendizaje. generalmente es la forma de reflexión que, con frecuencia, se incluye en los portafolios. se describen dos modalidades principalmente: escritura libre (no estructurada): el estudiante escoge los aspectos sobre los que quiere escribir (1, 23, 24). la reflexión hecha se relaciona con actitudes, normas sociales, hábitos y expectativas del estudiante, vitales en la comprensión del comportamiento de este (25). esta forma de diario permite al estudiante alcanzar mayores niveles de reflexión que le llevarán al aprendizaje transformativo (3). hay autores que proponen una forma más estructurada, en la que cada hoja del diario se divide en dos partes, una para la escritura libre y otra para documentar la reflexión y el análisis (26, 27); no obstante, esta forma de escritura puede generar dificultades en la comprensión de los aspectos por consignar en cada apartado, como por ejemplo, si los sentimientos que acompañan a un acontecimiento deben ser consignados en la parte de descripción de los hechos o en la parte reservada a la reflexión (27). uno de los aspectos por tener en cuenta es que se considera que la descripción de los hechos observados es modificada con el paso del tiempo, por lo que hay autores que exigen al estudiante escribir inmediatamente tras el acontecimiento y hacerlo sobre los pensamientos y sentimientos que se han movilizado (28). escritura con temas predefinidos (estructurada): se propone a los estudiantes una serie de temas comunes y generales sobre los cuales escribir y reflexionar (1, 24). la preocupación en esta forma de escritura radica en la espontaneidad de la misma (23). hay autores que proponen identificar áreas de reflexión y dejar un margen de libertad a quien escribe ya que la rigidez en la estructura del diario se ha descrito como una de las barreras a la implementación del mismo (1, 29). en ocasiones se pide al estudiante que fundamente los temas propuestos mediante reseñas y referencias bibliográficas (30). el diario reflexivo ha sido usado en diferentes ámbitos, como por ejemplo, el diario de clase en el que se escribe respecto a la comprensión de lo sucedido en el aula, de la retroalimentación recibida, de la evaluación y, en general, del proceso de aprendizaje (25, 31, 32) o, como el diario de práctica clínica en enfermería, en que el estudiante explica su experiencia asistencial (28). 409 el diario del estudiante de enfermería en la práctica clínica frente a los diarios realizados en otras disciplinas: ... l sabiniana san rafael gutiérrez y otros. en la bibliografía consultada no siempre la escritura del diario hace referencia al diario del estudiante, sino que también se describe el diario del profesor, llamado en este caso diario de enseñanza, y en el que el foco de atención se sitúa en los procesos de enseñanza-aprendizaje de los estudiantes, pero desde el punto de vista del docente y que puede ser llevado paralelamente al solicitado a estos (33, 34). se describen dos tipos fundamentales de soporte para el diario del estudiante: el papel, que sería el soporte tradicional, y los registros web, tales como blogs (31), correo electrónico y los foros de discusión (22). beneficios del uso del diario muchos son los beneficios descritos de esta forma de reflexión, tanto en los trabajos consultados que se refieren a la disciplina enfermera, como a los que se refieren a otras disciplinas (tabla 2), entre ellos: • desarrollo de la autoconciencia (26, 35, 36), de la responsabilidad y la confianza en sí mismo (37). • estímulo de la creatividad (17, 38). • mejora del autoconocimiento, la comprensión de uno mismo y de los demás (9, 38) • mejora y promoción del análisis crítico (2, 13, 24, 29, 35, 38, 39). • ayuda para la liberación de tensiones así como para la expresión de las emociones y preocupaciones (13, 17, 23, 31, 39-42). • mejora de las habilidades de observación y autoevaluación (25, 36, 39). • descubrimiento del contexto social, histórico y cultural, permitiendo al estudiante acceder a la dimensión sociocultural del aprendizaje (25). • reflexión sobre los propios valores, pensamientos, creencias y actitudes, ya sea en el aula o en la práctica clínica en el caso de enfermería (25, 39, 43-45). • promoción del aprendizaje autodirigido (aprender a aprender) y del crecimiento personal (17, 24, 25, 38). • aumento de la conexión entre teoría y práctica (2, 9, 16, 26, 27, 36, 46-48). • promoción de la introspección, la reflexión y el cambio de conducta del estudiante (14). • mejora de la autoeficacia del estudiante (14). • facilita la expresión de los sentimientos, tanto positivos como negativos (14, 16). en el caso de enfermería, en el entorno de las prácticas clínicas, además de los anteriores beneficios se han descrito los siguientes: • aprendizaje de los principios éticos y otros aspectos difíciles de enseñar con métodos tradicionales (27, 40). • mejora de la empatía (26, 39, 40). • mayor conocimiento sobre la atención ofrecida al paciente, pudiendo llevarle a ser más competente, activo y asertivo (35). • determinar carencias de conocimiento (35, 49). • clarificar, profundizar y reforzar conocimientos, actitudes y habilidades (13, 48). • adquisición de valores personales y profesionales (26, 39, 40). • reflexión sobre aspectos comunicativos con el paciente y sus respuestas emocionales (50). • mejora de las habilidades para resolver problemas (36). • mejora del afrontamiento y de los niveles de estrés ante incidentes críticos (29). no solo se han descrito beneficios para el estudiante que escribe, sino también para el profesor. cuando este lee el diario de sus estudiantes se enfrenta a su propio hacer profesional, toma conciencia de las dificultades de estos para modificar las estrategias de enseñanza-aprendizaje, lo que mejora su práctica docente (9, 33, 51). cuando el diario es dialógico esto, además, le permite atender las necesidades más urgentes de sus estudiantes (17). no siempre el estudiante escribe el diario de forma reflexiva, con frecuencia se limita a la descripción de los hechos, especialmente al inicio de la escritura del mismo (27). escribir reflexivamente es una habilidad que puede ser enseñada y aprendida (9, 39, 52); no existen pruebas de que se aprenda de forma espontánea con el tiempo, sino que su aprendizaje, con frecuencia, depende de la guía de un buen facilitador (53). hay estudios que advierten que la escritura reflexiva tiene una elevada probabilidad de fracaso si no va acompañada del 410 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 feed-back del profesor, el cual debe desempeñar un papel de mentor o “entrenador” y no de juez (1, 11, 36). compartir pensamientos y sentimientos puede producir en el estudiante un cierto grado de incomodidad (19, 29, 35) que puede determinar que la experiencia descrita en el diario no sea completa (17, 36, 41). por tanto, es indispensable la creación de un ambiente de confianza en el que el estudiante pueda escribir de forma honesta y sin temor a represalias (2, 9, 24, 33, 36, 47). en las prácticas clínicas de enfermería se describen aspectos con mucha carga emocional, que podrían omitirse en el diario por falta de confianza con el profesor (26, 39, 40). escribir sobre la experiencia asistencial tiene la finalidad de construir un saber intuitivo y práctico extraído de la experiencia (1). el diario reflexivo se ha mostrado particularmente eficaz en lo referente a la recalificación o inserción profesional de las enfermeras extranjeras, ayudándoles a mejorar las competencias lingüísticas (1). los aspectos que con mayor frecuencia tratan los estudiantes de enfermería en sus diarios son los referentes a la inseguridad en la adquisición de las competencias profesionales, las reacciones de los pacientes cuando estos saben que son atendidos por un estudiante, la inexactitud de los datos que aporta la historia clínica, el miedo a cometer errores, la responsabilidad ante la práctica profesional (28) y la relación que se establece entre el estudiante y el paciente (47). dificultades en la escritura del diario una de las dificultades que con frecuencia aparece en la bibliografía consultada es la referida al tiempo necesario para escribir y que es percibido por el estudiante como muy elevado (9, 10, 36, 47, 54), lo que puede llevar a entender la escritura del diario como un trabajo más que le resta tiempo para realizar otros requerimientos de la enseñanza (39). entre las estrategias usadas para mejorar este problema ha sido reservar treinta minutos del final de la clase o de su práctica clínica para escribir, en el caso de enfermería (25, 26). así mismo, se ha recomendado asignar el tiempo necesario para la escritura del diario dentro del calendario académico o, en el caso que nos ocupa, dentro del tiempo destinado a la realización de las prácticas clínicas, lo que permitiría al estudiante tener tiempo ininterrumpido para reflexionar, además de transmitirle la importancia de la reflexión y hacerle consciente del tiempo que puede destinar a ello (9). hay que tener en cuenta que cuanto mayor es el tiempo que transcurre desde que acontece un hecho hasta que se describe, mayor riesgo existe de que la descripción del mismo se modifique (51). el estudiante puede exponer dificultades para encontrar aspectos sobre los cuales escribir y reflexionar, y cuando el diario se mantiene durante un periodo de tiempo prolongado, este puede manifestar pérdida de interés por la escritura (55). otra preocupación general es la referida a la confidencialidad de lo escrito en el diario (29, 43, 56, 57) y que podría condicionar su contenido, aspecto que se agrava cuando lo escrito es público, como es el caso de blogs compartidos para este fin (43, 57). hay estudiantes que han manifestado sentimientos negativos hacia la escritura del diario relacionados con no tener una idea clara de los objetivos que se persiguen con esta actividad (36). hay que tener en cuenta que, de cualquier manera, al estudiante se le pide que explique aspectos personales de su vivencia, que aunque sean tratados de forma confidencial, esta es una exigencia por parte del profesor (10, 30, 41). otros aspectos que pueden condicionar la escritura del diario son: 1. del estudiante • no querer que lo expuesto en el diario revele un mal trabajo y que influya en su nota (29, 36, 43, 58). para evitar esto, hay autores que pactan con el estudiante no leer sus entradas del diario hasta que se tenga la calificación final de la asignatura (32). • considerar que escribir el diario es una pérdida de tiempo (43). • utilizar el diario como medio para obtener asesoramiento del profesor que le pueda llevar a una dependencia (44). 2. del profesor • necesidad de gran cantidad de tiempo para leer y responder a los estudiantes (10, 12, 19, 21, 38) y para explicar los criterios de evaluación y calificación(38), lo que puede llevar a un dilema moral cuando el profesor no es capaz de dedicar al estudiante el tiempo suficiente (10). 411 el diario del estudiante de enfermería en la práctica clínica frente a los diarios realizados en otras disciplinas: ... l sabiniana san rafael gutiérrez y otros. el rendimiento académico si entendemos rendimiento académico como las calificaciones obtenidas en los exámenes, existen diferentes percepciones. mientras hay autores que exponen que no se ha observado que existan diferencias significativas entre los estudiantes que reflexionan y los que no (49), otros explican que el hecho de escribir conduce a mejores resultados y a un mayor nivel de aprendizaje (38). dada la disparidad de opiniones, este es un aspecto que requeriría nuevas investigaciones para determinar si realmente la escritura del diario mejora o no el rendimiento académico. este aspecto sería aplicable al ámbito de la enfermería, ya que durante las prácticas clínicas el estudiante no realiza examen, sino que es evaluado por el nivel de competencia alcanzado al finalizar el periodo de prácticas, y la evaluación del diario representa un porcentaje del total de la nota final de la práctica clínica. evaluación del diario un aspecto controvertido es el referido a la evaluación del diario reflexivo. por un lado, si al trabajo del estudiante no se le asigna ningún valor ni seguimiento, este deja de hacerlo, pero si lo hay, puede comportar que la escritura no sea honesta (52, 56). si, por el contrario, su realización tiene un efecto sobre la nota final, lo reflejado en las entradas del diario puede verse modificado por el deseo del estudiante de recibir una alta calificación (26, 58), intentando averiguar lo que el profesor quiere que se incluya (9, 30, 42). si el diario es un instrumento importante para el aprendizaje del estudiante ha de haber alguna forma de seguimiento de su efecto y, por tanto, deben establecerse criterios fiables para detectar que lo se está realizando (35). hay autores que han asignado un valor a la evaluación del diario que oscila entre el 10 y el 50% de la nota (3, 9, 38, 55); además, en el caso de diarios con escritura de temas predefinidos se informa a los estudiantes que en caso de no realizarlo según lo estipulado, se les restarán puntos de la evaluación final (9, 38). una recomendación de algunos autores es evaluarlo como apto/no apto, con base en el desempeño de la actividad (escritura del diario) sin evaluar el contenido (29). otros optan por no otorgar un porcentaje de la nota final al diario, pero este tiene un carácter obligatorio (31). cuando la escritura del diario representa un porcentaje de la nota, como suele suceder en el ámbito de la práctica clínica enfermera, en un principio la preocupación del estudiante gira en torno a qué se va a evaluar y cómo se hará; una vez aclarado este punto, se encuentran relativamente cómodos con esta forma de evaluación (30). esta requiere un seguimiento cuidadoso por parte del profesor, con la finalidad de conocer a fondo al estudiante y hacerle comentarios referidos a su progresión (30). cuando se investiga qué piensan los estudiantes respecto a si se debe evaluar o no esta forma de reflexión escrita, manifiestan estar en contra, puesto que el diario es personal (47). un aspecto por tener en cuenta es que la evaluación de esta actividad puede ser crucial para determinar si la reflexión mejora la práctica enfermera (10). se ha sugerido que evaluar lo escrito en el diario favorece a las mujeres, ya que están más familiarizadas con la escritura en la cultura occidental (30). en el entorno de las prácticas clínicas de enfermería, los aspectos subjetivos expresados son fundamentales en la evaluación del estudiante, donde las entradas pueden servir de referencia para valorar el logro de las competencias profesionales, sobre todo las relacionadas con los aspectos humanistas del cuidado, difíciles de medir objetivamente (26, 39, 40). conclusiones existe escasa bibliografía que aporte evidencias claras sobre cómo ayuda al estudiante la escritura del diario reflexivo, sobre todo en el ámbito de las prácticas clínicas de enfermería. en este ámbito se observa que tiene beneficios y dificultades comunes a los diarios realizados en otras disciplinas, y proporciona otras ventajas como son la mejora de la comunicación con el paciente, la empatía y la adquisición de valores personales y profesionales propios de la disciplina enfermera. uno de los aspectos que con frecuencia señalan los estudiantes de enfermería es la existencia de contradicciones entre la teoría explicada en el aula y la práctica clínica, siendo este un aspecto que la mayoría de los autores consultados, ya sean del ámbito de la enfermería o de otros ámbitos, aprecian que mejora con la escritura del diario. 412 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 si además tenemos en cuenta que un profesional competente es aquel que tiene muchos de los atributos de la práctica reflexiva, como es el desarrollo de la habilidad de resolver problemas y el pensamiento crítico, la escritura del diario debería ser incluida en los planes de estudio de grado en el ámbito de las prácticas clínicas. el diario facilita la reflexión sobre el proceso de enseñanzaaprendizaje que, a su vez, da lugar a la “metacognición” (conocimiento sobre el proceso de adquisición de conocimiento por parte del estudiante). no obstante, los diferentes estudios no responden a la cuestión de si la escritura del diario mejora el rendimiento académico del estudiante, además de determinar la mejor manera de evaluar lo escrito por este, aspecto que se muestra crucial para la obtención de los beneficios esperados por este ejercicio. referencias 1. montagna l, benaglio c, zannini l. reflective writing in nursing education: background, experiences and methods. assist inferm e ric. 2010;29(3):140-52. 2. rileydoucet c, wilson s. a three-step method of self-reflection using reflective journal writing. j adv nurs. 1997;25(5):964-8. 3. gulwadi gb. using reflective journals in a 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sutton j. a new way of reflecting in nursing: the peshkin approach. j adv nurs. 2009;65(11):2485-93. 57. hramiaka a, boultonb h, irwinc b. trainee teachers’ use of blogs as private reflections for professional development. learn media technol. 2009;34(3):259-69. 58. hargreaves j. so how do you feel about that? assessing reflective practice. nurse educ today. 2004;24(3):196-201. 415 el diario del estudiante de enfermería en la práctica clínica frente a los diarios realizados en otras disciplinas: ... l sabiniana san rafael gutiérrez y otros. tablas y figuras tabla 1. distribución de estudios según bases de datos y criterios de inclusión y exclusión en el periodo mayo-junio 2011 base de datos número de artículos número de artículos por refinamiento (título y abstract) número de artículos relevantes (artículos completos) número de artículos excluidos eric 60 33 23 37 isi web of knowledge 27 21 10 17 pubmed 23 14 1 22 scielo 30 6 0 30 scirus 70 25 8 62 cuidatge 0 0 0 0 cuiden 10 3 1 9 scopus 55 21 8 47 ebsco host 27 13 3 24 total 302 136 54 248 fuente: elaboración propia. tabla 2. relación de disciplinas a las que pertenecen los artículos revisados disciplinas diferentes a enfermería a las que pertenecen los artículos revisados nº de artículos psicología 2 enseñanza de idiomas 7 matemáticas 1 educación 17 económicas 1 musicoterapia 1 medicina 6 geografía 1 total otras disciplinas 36 enfermería 18 total artículos válidos 56 fuente: elaboración propia. 416 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 figura 1. artículos obtenidos por país y año fuente: elaboración propia. 21 30 consequencias do uso de fraldas.indd 21 thaís christini silva1 alessandra mazzo2 rachel cristina rodrigues santos3 beatriz maria jorge4 valtuir duarte souza júnior5 isabel amélia costa mendes6 consequências do uso de fraldas descartáveis em pacientes adultos: implicações para a assistência de enfermagem 1 enfermeira, escola de enfermagem de ribeirão preto, universidade de são paulo, brasil. thaiscobain@usp.br 2 professor doutor, escola de enfermagem de ribeirão preto, universidade de são paulo, brasil. amazzo@eerp.usp.br 3 enfermeira, hospital das clínicas, faculdade de medicina de ribeirão preto são paulo, universidade de são paulo, brasil. ra.cris24@yahoo.com.br 4 programa de pós-graduação em enfermagem fundamental, escola de enfermagem de ribeirão preto, universidade de são paulo, brasil. beatrizjorge@usp.br/valtuirduarte@gmail.com 5 escola de enfermagem de ribeirão preto, universidade de são paulo, centro colaborador da oms para o desenvolvimento da pesquisa em enfermagem valtuirduarte@gmail.com 6 professor titular, escola de enfermagem de ribeirão preto, universidade de são paulo, centro colaborador da oms para o desenvolvimento da pesquisa em enfermagem, brasil. iamendes@usp.br recibido: 17 de abril de 2013 enviado a pares: 20 de mayo de 2013 aceptado por pares: 30 de noviembre de 2013 aprobado: 19 de marzo de 2014 doi: 10.5294/aqui.2015.15.1.3 para citar este artículo / to reference this article / para citar este artigo silva tc, mazzo a, santos rcr, jorge bm, souza junior vd, mendes iac. consequências do uso de fraldas descartáveis em pacientes adultos: implicações para a assistência de enfermagem. aquichan. 2015; 15 (1): 21-30. doi: 10.5294/aqui.2015.15.1.3 resumo objetivo: verificar as consequências do uso de fraldas descartáveis em pacientes adultos e discutir suas implicações para a assistência de enfermagem. método: estudo de análise de sobrevivência realizado por observação direta e sistematizada. seguidos os preceitos éticos, durante um período de 30 dias, foram observados 43 pacientes maiores de 18 anos, usuários de fraldas descartáveis, na unidade de clínica médica de um hospital de grande porte do estado de são paulo. resultados: dentre os 43 (100 %) pacientes da amostra, todos apresentaram evento subsequente ao uso de fraldas descartáveis. os eventos observados foram uso de coletor urinário, uso do cateter urinário de demora, presença de infecção de trato urinário (itu), presença de dermatite e úlcera por pressão (upp), alterações do estado de consciência e do estado de orientação. conclusão: observou-se uma relação entre o uso de fraldas de maneira indiscriminada com a qualidade do cuidado e segurança do paciente. a observação das implicações do uso de fraldas descartáveis na assistência de enfermagem ao paciente é recente e necessita novos estudos. palavras-chave enfermagem, hospitalização, fraldas para adultos, segurança do paciente (fonte: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 21-30 22 aquichan issn 1657-5997 año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 21-30 consecuencias del uso de pañales desechables en pacientes adultos: implicaciones para la asistencia de enfermería resumen objetivo: averiguar las consecuencias del uso de pañales desechables en pacientes adultos y discutir sus implicaciones para la asistencia de enfermería. método: estudio de análisis de sobrevivencia realizado por observación directa y sistematizada. seguidos los preceptos éticos, durante un periodo de 30 días, se observaron 43 pacientes mayores de 18 años, usuarios de pañales desechables, en la unidad de clínica médica de un gran hospital del departamento de são paulo. resultados: de los 43 (100 %) pacientes de la muestra, todos presentaron evento subsecuente al uso de pañales desechables. los eventos observados fueron uso de colector urinario, uso de catéter urinario, presencia de dermatitis y úlcera por presión (upp), alteraciones del estado de conciencia y del estado de orientación. conclusión: se observó una relación entre el uso de pañales de manera indiscriminada con la calidad del cuidado y la seguridad del paciente. la observación de las implicaciones del uso de pañales desechables en la asistencia de enfermería al paciente es reciente y necesita nuevos estudios. palabras clave enfermería, hospitalización, pañales para adultos, seguridad del paciente (fuente: decs, bireme). 23 consequências do uso de fraldas descartáveis em pacientes adultos: implicações para a assistência de enfermagem l thaís christini silva y otros consequences of adult patients using disposable diapers: implications for nursing care abstract purpose: the study was designed to determine the consequences of adult patients using disposable diapers and to discuss the implications this has for nursing care. method: a survival analysis study was conducted through direct and systematized observation. forty-three patients over 18 years of age who use disposable diapers were observed for a period of 30 days at the medical unit of a large hospital in the department of são paulo. findings: all 43 patients in the sample (100 %) experienced events subsequent to the use of disposable diapers. the events observed include use of a urinary pouch, use of a delaying urinary catheter, the presence of dermatitis and pressure ulcers, and altered state of consciousness and orientation. conclusion: a relationship between the indiscriminate use of diapers and the quality of patient care and safety was detected. observance of the implications of the use of disposable diapers in nursing care for patients is recent and requires further studies. key words excretion disorders, nursing, hospitalization, adult diapers, patient, ethics (source: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 21-30 24 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 introdução ao longo dos últimos anos, o uso da tecnologia na assistência à saúde tem modificado as características do paciente hospitalizado, o que tem aumentado sua complexidade e, de maneira significativa, o número de idosos, de internações e re-internações nos diversos níveis de atendimento (1). no entanto, pouco avanço foi implementado nas tecnologias relacionadas aos cuidados de higiene e conforto, que incluem as eliminações urinárias e são de responsabilidade da enfermagem. conforme a teoria que embasa este estudo (2), as eliminações urinárias compõem as necessidades humanas básicas do indivíduo, de nível psicobiológico, e suas alterações são resultantes de desequilíbrio hemodinâmico dos fenômenos vitais (2). na realidade da enfermagem brasileira, dentre as inovações inseridas, pode-se observar o uso de fraldas descartáveis para o adulto. o uso desse dispositivo tem ocorrido de forma indiscriminada como estratégia, tanto para pacientes dependentes como para aqueles que teriam possibilidade de fazer uso do papagaio, comadre ou sanitário, o que se torna relevante ao serem consideradas as características da clientela atual. o envelhecimento interfere no ato da micção, pela perda fisiológica do tônus muscular da bexiga e comprometimento da habilidade de reter a urina. leva à fraqueza muscular, doença neurológica crônica, perda do controle mental, alterações no controle dos esfíncteres e funções renais, pelo declínio da taxa de filtração glomerular e diminuição de capacidade de concentração de urina (3). o aumento da complexidade do paciente amplia a possibilidade de realização de procedimentos invasivos, compromete a mobilidade, expõe-no ao risco da infecção hospitalar (ih), entre outras complicações. dentre as ihs mais recorrentes, a infecção de trato urinário (itu) ainda tem merecido destaque, pois embora amplamente explorada pela produção científica, continua como um dos principais problemas da prática clínica do enfermeiro, o que leva a um ônus de aproximadamente 14 % do valor total despendido com as infecções hospitalares e repercute de maneira negativa tanto para a visão da instituição como dos profissionais (4). a itu pode ser definida como a inflamação das vias urinárias e caracterizada por sintomas associados e presença de bactéria na urina. ocorre de forma sintomática e assintomática e seu agravo depende do estado de saúde e da idade do paciente. os fundamentais fatores de riscos associados a essa infecção estão relacionados ao sexo feminino, idade avançada, diabetes mellitus e uso do cateter urinário de demora (5, 6). destaca-se ainda que os principais micro-organismos que desencadeiam a itu fazem parte da flora transitória do períneo, o que remete a reflexões relacionadas à importância da higiene íntima e do autocuidado dos pacientes. esses micro-organismos podem ser representados pelo streptococcus faecalis, proteus mirabilis, pseudomonas aeruginosas e escherichia coli. a escherichia coli é considerada o micro-organismo mais detectado nas infecções bacterianas agudas não complicadas das vias urinárias (7-10). nesse contexto, os pacientes cada vez mais têm apresentado diferentes agravos durante o período de hospitalização, como por exemplo, o aparecimento de úlcera por pressão (upp), risco de queda, abandono pelos cuidadores, entre outros, e vêm sendo assistidos pela equipe de enfermagem com medidas que popularizam tecnologias, mas que também estimulam a sua restrição ao leito, como o uso de fraldas descartáveis. ao ser incorporado à prática clínica do paciente adulto, o uso de fraldas descartáveis não foi uma medida ruim; pelo contrário, veio substituir o uso do lençol impermeável e diminuir o número de troca de roupas do leito, o que gerou maior conforto ao paciente, entre outros fatores. no entanto, essa prática vem sendo realizada sem o embasamento científico necessário que demonstre sua positividade ou os efeitos negativos que por ventura possam ocasionar, como por exemplo, o aumento na incidência de úlceras por pressão, a diminuição da mobilidade do paciente, o aumento do risco de itu e/ou outros agravos. nesse sentido, este estudo teve como objetivo verificar as consequências do uso de fraldas descartáveis em pacientes adultos e discutir suas implicações para a assistência de enfermagem. metodologia estudo quantitativo de análise de sobrevivência. após autorização do comitê de ética em pesquisa da escola de enfermagem de ribeirão preto (parecer 1488/2011), os dados foram coletados numa unidade hospitalar pública, de nível terciário, atendimento geral e grande porte, localizada numa cidade do interior do estado de são paulo. 25 consequências do uso de fraldas descartáveis em pacientes adultos: implicações para a assistência de enfermagem l thaís christini silva y otros após assinatura do termo de consentimento livre e esclarecido, a coleta de dados foi realizada pelos próprios pesquisadores por meio de observação semiestruturada, com o apoio de um instrumento de coleta que indicava, além do uso de fraldas descartáveis, o estado de consciência do paciente, a presença de itu, upp, dermatite, cateter urinário de demora, coletor de urinário, ou outros. durante um período de 30 dias, diariamente foram inclusos na coleta pacientes hospitalizados na clínica médica, desde que estivessem fazendo uso de fraldas descartáveis e que fossem maiores de 18 anos. dentre os 94 pacientes internados na unidade no período, 43 (45,7 %) fizeram uso de fralda descartável e foram os que constituíram a amostra. para análise dos dados, utilizou-se estudo de análise de sobrevivência pelo método de kaplan-meier, com intervalo de tempo entre o ponto inicial (uso de fralda) e evento subsequente. o método de kaplan-meier trata-se de estatística não paramétrica que independe da distribuição de probabilidade. nele os intervalos de tempo não são fixos, e sim determinados pelo aparecimento de uma falha. os sobreviventes ao tempo (t) são ajustados pela censura, que ocorre quando os pacientes não são observados até a ocorrência do evento. os pacientes censurados entram no cálculo da função de probabilidade de sobrevida acumulada até serem considerados como perda, o que propicia o uso mais eficiente das informações disponíveis (11). resultados dentre os 43 (100 %) pacientes observados, 20 (46,5 %) eram femininos e 23 (53,5 %) masculinos, com média de idade de 65,59 anos (mediana de 68). quando observados, todos os pacientes 43 (100 %) tiveram algum tipo de evento subsequente ao uso da fralda descartável. os eventos considerados foram: a) uso de coletor urinário; b) uso do cateter urinário de demora; c) presença de itu; d) alterações do estado de consciência (consciente e inconsciente); e) alterações no estado de orientação quanto a tempo/estado e pessoa (orientado e não orientado); f) presença de dermatite e de upp. o número de eventos por paciente foi de um evento em cinco (11,6 %) pacientes, dois em 14 (32,6 %), três em nove (20,9 %), quatro em sete (16,3 %), cinco em quatro (9,3%), seis em três (7 %) e oito eventos em um (2,3 %) paciente. a tabela 1 apresenta o número de pacientes usuários de fraldas descartáveis e o número de dias para manifestação do evento de interesse. no período estudado, ocorreram alterações no estado de consciência e orientação dos pacientes. destaca-se, ainda, que todos os pacientes em estado não orientados ou inconscientes fizeram uso de fralda descartável. dentre os eventos que acometeram maior número de pacientes, merece destaque o uso do cateter urinário de demora (15 dias) e do coletor urinário (9 dias), concomitantes ao uso da fralda descartável. as alterações no estado de consciência e orientação do paciente foram fatores determinantes para o uso ou suspensão da fralda. a análise de sobrevivência dos fatores observados está representada nas figuras a seguir. a figura 1 demonstra a análise de sobrevivência e a figura 2, o aparecimento do evento itu por paciente. a figura 3 mostra a análise de sobrevivência do evento uso do cateter urinário de demora e uso do coletor urinário. a figura 4 mostra a análise de sobrevivência do evento, presença de dermatite e do evento upp. discussão a unidade de clínica é um serviço de hospitalização que deve proporcionar o atendimento integral ao indivíduo, de forma física, emocional, espiritual e social, envolvendo e capacitando-o junto aos seus familiares com o objetivo da prática do autocuidado. nesse setor, a dependência do paciente tem sido expressiva sobre a carga de trabalho da enfermagem, que está relacionada à segurança do paciente. assim, os profissionais da enfermagem com o quadro funcional com menor número de pacientes possuem melhores indicadores de qualidade de assistência (12). nesse contexto, dentre as diversas alternativas encontradas para o aprimoramento do trabalho, tem-se generalizado o uso de fraldas descartáveis para pacientes adultos. a fralda é utilizada para absorver o fluxo urinário e/ou fecal e acaba aumentando o conforto do paciente. se utilizada inadequadamente, pode levar ao comprometimento da integridade da pele e autoestima do paciente e/ou aumentar o risco de infecção hospitalar. devem ser indicadas unicamente para adultos e idosos com incontinência ou 26 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 tabela 1. número de pacientes e número de dias para manifestação do evento de interesse (ribeirão preto, 2012) houve mais de um evento de interesse por paciente. evento no. média dias desvio-padrão mínimo mediana máximo dermatite 3 6.67 9.81 1.00 1.00 18.00 coletor urinário 9 4.67 4.58 1.00 3.00 15.00 desenvolvimento de itu 13 3.31 3.07 1.00 2.00 10.00 upp 14 3.64 4.85 1.00 1.00 18.00 cateter urinário demora 15 3.80 4.81 1.00 1.00 15.00 conscientes 24 1.50 1.22 1.00 1.00 5.00 inconscientes 28 1.93 2.43 1.00 1.00 11.00 desorientados 8 2.88 2.53 1.00 2.00 8.00 orientados 20 1.75 1.62 1.00 1.00 7.00 figura 1. função de sobrevivência (ribeirão preto, 2012) 27 consequências do uso de fraldas descartáveis em pacientes adultos: implicações para a assistência de enfermagem l thaís christini silva y otros figura 2. evento por paciente para o desenvolvimento de itu (ribeirão preto, 2012) figura 3. função de sobrevivência dos eventos cateter urinário de demora e coletor de urina (ribeirão preto, 2012) figura 4. função de sobrevivência dos eventos dermatite e úlcera por pressão (ribeirão preto, 2012) 28 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 restrições de mobilização severa, impossibilitados do uso de utensílios de auxílio. todavia, na amostra estudada, assim como na prática clínica que vem sendo vivenciada, tem sido utilizada de forma indiscriminada e corriqueira (43 dos 94 pacientes), tanto em pacientes conscientes, inconscientes, orientados e não orientados, quanto naqueles que fazem uso de outros dispositivos urinários como cateter urinário de demora (15 pacientes) e coletor urinário (nove pacientes). foi ainda imediatamente (no primeiro dia) introduzida no cuidado de pacientes que apresentaram alterações no estado de orientação (de orientados para não orientados) e de consciência (de conscientes para não conscientes), o que restringia de imediato o paciente ao leito, sem qualquer tipo de avaliação prévia das reais necessidades e riscos decorrentes do seu uso, e assumia a única função de medida facilitadora, não fundamentada no raciocínio e julgamento clínico (13). dentre os diversos fatores subsequentes encontrados ao uso da fralda, o aparecimento de upp e a itu foram os mais significativos. a itu esteve presente em 30,2 % da amostra e foi diagnosticada em média com três dias após a observação do paciente. cumpre reforçar que, por se tratar de pacientes clínicos, idosos, hospitalizados numa unidade de nível terciário, além do uso das fraldas descartáveis, a amostra do estudo possuía diversas outras variáveis que poderiam levá-la ao desenvolvimento de itu. não constituíam objetivo deste estudo controlar as variáveis dos diversos fatores subsequentes ao uso da fralda encontrados (itu, upp, uso do cateter urinário de demora, uso de coletor urinário), o que pode ser entendido como um dos seus fatores limitantes. embora em outros estudos realizados com idosos (14) tenha sido encontrada associação entre a incontinência fecal e o aparecimento de itu originária de via ascendente, principalmente em mulheres usuárias de fraldas descartáveis, os dados encontrados alertam para o fato de que esse ponto deva ser melhor investigado. a upp foi evidenciada em 14 dos 43 pacientes observados numa média de 3,64 dias entre o início da observação e seu aparecimento. pode ser caracterizada por uma lesão da pele causada pela associação de fatores internos e externos, ocasionada após um período de fluxo sanguíneo deficiente que leva ao não carreamento dos nutrientes para a célula e ao acúmulo de produtos de degradação, o que ocasiona a isquemia, hiperemia, edema e necrose tecidual, que pode evoluir para a morte celular. no aparecimento da upp, a interrupção de suprimento sanguíneo para a área geralmente é provocada por pressão, cisalhamento e fricção que podem estar associados a outros fatores como idade avançada, estado nutricional deficitário, pressão arteriolar, temperatura corporal, mobilidade reduzida por patologias, incontinência urinária, fecal e obesidade (15-18). as upps causam ônus às instituições de saúde e refletem a qualidade do trabalho da enfermagem (19). tem estreita relação com áreas sujeitas à pressão, umidade, transpiração e urina (18). estudos indicam que as interações entre urina e enzimas de fezes podem levar a lesão da pele na presença da ureia urinária. acresça-se que a umidade da urina, a presença de fezes, de seus componentes e ph da pele também podem ocasionar o aparecimento de dermatites pelo uso de fraldas (20). nesse assunto, ainda é importante considerar que a presença de urina e fezes podem levar ao aprofundamento e à infecção de lesões já formadas, o que aumenta a necessidade da troca de fraldas com regularidade em lesões já formadas (20, 21). a dermatite ou “assadura” ocasionada pela fralda é uma dermatite de contato por irritante primário que chega a afetar cerca de 50 % dos pacientes (22), o que não foi encontrado na amostra deste estudo (três dos 43 pacientes observados). ocorre em pacientes de diversas idades que utilizam fraldas e/ou tenham incontinência urinária. possui etiologia multifatorial que inclui ainda o calor, a umidade, a fricção, a urina e as fezes. pode ser ocasionada pela umidade ocorrida no contato da pele com a urina e com as fezes retidas, o que aumenta a permeabilidade e susceptibilidade da pele com relação aos danos causados pelo atrito. nesse cenário, a pele perde a capacidade de fornecer uma barreira eficaz contra agentes irritantes e micróbios (22, 23). o diagnóstico e o tratamento na maioria dos casos não apresentam dificuldades. as intensidades das alterações cutâneas da dermatite da fralda variam de leve a grave. habitualmente, manifesta-se com quadro de leve intensidade, como uma erupção eritematosa típica; no entanto, quando associado à síndrome diarreica, o quadro frequentemente tem rápida evolução e é mais intenso (22). de forma aguda acomete doentes crônicos, que se encontram em maior risco devido ao uso de medicamentos, diarreia, patologias oncológicas e neurológicas, anomalias, síndromes genéticas e desnutrição (23). podem ainda ser encontradas pelo uso crônico em pacientes com incontinência urofecal (22). 29 consequências do uso de fraldas descartáveis em pacientes adultos: implicações para a assistência de enfermagem l thaís christini silva y otros para que sejam minimizadas, recomenda-se o uso de fraldas com materiais gelificantes à base de poliacrilato de sódio, que mantêm a umidade longe da pele, além da troca de fraldas a cada duas horas ou mais cedo se a fralda estiver úmida e/ou com fezes. a higiene íntima deve ser realizada em todas as trocas; no entanto, não deve ser realizada de maneira agressiva (fricção); recomenda-se que seja feita com sabão de coco ou sabonetes neutros e que na sequência sejam utilizados produtos de barreira (vaselina, lanolina e óxido de zinco), apropriados para a proteção da área perineal, a fim de reduzir o contato da pele com a urina e as fezes. todavia, essas ações nem sempre são observadas na prática clínica. é mais comum o uso de fraldas de menor custo, que não possuem materiais gelificantes ou ainda o uso de duas unidades de fraldas ou de um lençol sobre a fralda, para maximizar o tempo de troca e evitar que o leito fique molhado, o que mantém toda a umidade próxima à pele do paciente (22, 23). conclusão embora limitado ao tempo de coleta e à ausência de controle das variáveis relativas aos fatores subsequentes (mudanças de estado de orientação, consciência, uso de cateter urinário de demora, uso de coletor urinário, itu, upp e dermatite), os resultados deste estudo apontaram para uma relação entre o uso indiscriminado de fraldas com a qualidade do cuidado e a segurança do paciente. assim, se realizado sem embasamento científico, o uso de fraldas descartáveis deixa de assumir a sua eficácia no conforto do paciente; pelo contrário, limita sua mobilidade, diminui sua autoestima e pode ainda ser fator desencadeante de outros agravos à saúde. o estudo sobre as implicações do uso de fraldas descartáveis na assistência de enfermagem ao paciente é recente e necessita de novas pesquisas. referências 1. savas l, guvel s, onlen y, savas n, duran n. nosocomial urinary tract infections: micro-organisms, antibiotic sensitivities and risk factors. west indian medical journal 2006 [acesso 5 jul. 2012]; 55(3). disponível em: http://caribbean. scielo.org/scielo.php?script=sci_arttext&pid=s0043-31442006000300011&lng=pt&nrm=iso 2. horta wa. processo de enfermagem. colaboração de brigitta e. p. castellanos. são paulo. epu: ed. da universidade de são paulo; 1979. 3. corrao s, santalucia 2, argano c, djade cd, barone e, tettamanti m, et al. gender-differences in disease distribution and outcome in hospitalized elderly: data from the reposi study. eur j intern med 2014; 25(7):617-23. 4. nosova k, nuño m, mukherjee d, lad sp, boakye m, black kl, et al. urinary tract infections in meningioma patients: analysis of risk factors and outcomes. j hosp infect 2013; 83(2):132-9. 5. conner bt, kelechi tj, nemeth ls, mueller m, edlund bj, krein sl. exploring factors associated with nurses’ adoption of an evidence-based practice to reduce duration of catheterization. j nurs care qual 2013; 28(4):319-26. 6. fumincelli l, mazzo a, silva aat, pereira bjc, mendes iac. produção científica sobre eliminações urinárias em periódicos de enfermagem brasileiros. acta paulista de enfermagem 2011 [acesso 15 maio 2012]; 24(1):127-13. disponível em: http://www.scielo.br/pdf/ape/v24n1/v24n1a19.pdf 7. center for disease control and prevention. guideline for prevention of catheter-associated urinary tract infections. atlanta: cdc, 2009. retrieved february 2, 2012 [acesso 15 maio 2012]. disponível em: http://www.cdc.gov/hicpac/ pdf/cauti/cautiguideline2009final.pdf 8. umscheid ca, agarwal rk, brennan pj. updating the guideline development methodology of the healthcare infection control practices advisory committee (hicpac). american journal of infection control 2010; 38(4):264-73. 9. serrano m, barcenilla f, limon e. nosocomial infections in long-term health care facilities. enfermedades infecciosas y microbiología clínica 2014; 32(3):191-8. 10. assis gm, faro acm. autocateterismo vesical intermitente na lesão medular. rev esc enferm usp 2011; 45(1):289-93. 30 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 11. kaplan el, meier p. non parametric estimation from incomplete observation. journal of the american statistics association 1958; 53:457-81. 12. magalhaes amm, dall’agnol cm, marck pb. nursing workload and patient safety — a mixed method study with an ecological restorative approach. rev. latino-am. enfermagem 2013; 21(spec): 146-54. 13. alves laf, santana rf, brandão es. o uso de fraldas em idosos hospitalizados: implicações para o cuidado de enfermagem. in: anais do i encontro nacional sobest/sobende sobre feridas: “o cuidar em feridas no brasil”; 2009; salvador, brasil. 14. schmiemann g, gagyor i, hummers-pradier e, bleidorn j. resistance profiles of urinary tract infections in general practice — an observational study. bmc urology 2012; 12:33. 15. mattia al, rocha am, barbosa mh, guimarães mamc, borgato mo, silvia srr, et al. úlcera por pressão em uti: fatores de risco e medidas de prevenção. saúde coletiva 2010; 7 (46):296-9. 16. costa ig. incidência de úlcera por pressão em hospitais regionais de mato grosso, brasil. rev gaúcha enferm 2010; 31(4):693-700. 17. bavaresco t, medeiros rh, lucena af. implantação da escala de braden em uma unidade de terapia intensiva de um hospital universitário. rev gaúcha enferm 2011; 32(4):703-10. 18. lucena af, santos ct, pereira ags, almeida ma, dias vlm, friedrich ma. clinical profile and nursing diagnosis of patients at risk of pressure ulcers. rev. latino-am. enfermagem 2011; 19(3):523-30. 19. tchato l, putmam j, raup gh. a redesigned pressure ulcer program based on nurses’ beliefs about the braden scale. j nurs care qual 2013; 28(4):368-73. 20. mayrovitz hn, sims nrn. biophysical effects of water and synthetic urine on skin. advances in skin & wound care 2001; 14(6):302-8. 21. schindler ca, mikhailov ta, kuhn em, christopher j, conway p, ridling d, et al. protecting fragile skin: nursing interventions to decrease development of pressure ulcers in pediatric intensive care. am j crit care 2011; 20(1):26-34. 22. zanini m, wulkan c, pachoal lhc, paschoal fm. erupção pápulo-ulcerativa na região da fralda: relato de um caso de dermatite de jaquet. anbras dermatol 2003; 78(3):355-9. 23. heimall lm, storey b, stellar jj, davis kf. beginning at the bottom: evidence-based care of diaper dermatitis. mcn, american journal of maternal child nursing 2012; 37(1):10-6. 001. ponencia ok (5 a 8) 5 os hemos reunido hoy para divulgar los hallazgos de los trabajos de investigación y gestión desarrollados durante el curso de diseño y gestión de proyectos, una de las materias dentro de la especialización en enfermería en cuidado crítico pediátrico. a través de la divulgación, ustedes, tomadores de decisiones en sus respectivos servicios de salud, pueden apropiarse de los conocimientos que se generaron en estos estudios, y que confirman hallazgos preliminares de otras investigaciones o señalan derroteros que llevan a realizar nuevos estudios, para dilucidar los múltiples problemas que a diario encontramos en la actividad profesional o que permiten establecer programas necesarios para una óptima atención de salud. esta apropiación social del conocimiento es el último e importantísimo paso en el desarrollo de una investigación. durante años hemos oído decir que “lo que no se publica, no existe”, o que los trabajos de grado de estudiantes de pregrado, especializaciones o postgrados solamente sirven para estorbar en los anaqueles de las bibliotecas de las instituciones educativas o clínicas. los productos de una investigación sirven, en primer lugar, al conocimiento científico; en segundo, al sector académico, y en tercero, a los usuarios del conocimiento. veamos cada uno de ellos. en cuanto al conocimiento científico, en los últimos años se ha hecho un esfuerzo grande por publicar la producción científica de los colombianos en revistas internacionales arbitradas, y se ha incrementado (todavía no lo deseable) el número de artículos firmados por científicos colombianos en los índices internacionalmente aceptados, tales como el science cittation index, el current contens, el social science index o el medline. también se han aumentado y perfeccionado las revistas científicas nacionales, y en ellas se están publicando los resultados de las investigaciones del país. en relación con el sector académico, como lo plantea carlos augusto hernández en el libro educación superior, sociedad e investigación, la característica fundamental de la universidad moderna es precisamente la existencia de un espacio ideal para el ejercicio de la cultura académica: la investigación. la universidad moderna puede definirse como un espacio de producción y reproducción de conocimientos elaborados de nivel superior1. a nadie escapa la íntima relación que debe existir entre la docencia y la investigación. “se trata de formar a los estudiantes, desde los primeros semestres, en una relación con el conocimiento caracterizada por la indagación permanente, el diálogo intenso, la apropiación de la historia de los problemas y la sistematización del camino seguido a través de la escritura, la conciencia de los procesos involucrados en el aprendizaje, que permite diseñar estrategias para continuar aprendiendo, y la disposición a trabajar con entusiasmo para saber más y no solo para 1. hernández, carlos augusto. “universidad y excelencia”. en: educación superior, sociedad e investigación, servicios gráficos integrales ltda., 2002, pág. 47. ponencia presentada por la enfermera beatriz suárez de sarmiento, msn, en el acto académico llevado a cabo en el auditorio de la universidad de la sabana, el día 5 de julio de 2003, para divulgar los resultados de los proyectos de grado de la primera promoción de la especialización en enfermería en cuidado crítico pediátrico, de la misma universidad. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 6 obtener beneficios externos de la aplicación de los conocimientos”. la universidad actual no es solo el lugar donde se forman los profesionales, sirve a la sociedad y al conocimiento. no es universidad si no forma los profesionales que requiere el país, pero tampoco lo es si no dedica parte de sus esfuerzos más calificados a la investigación. veamos ahora qué sucede entre productores y usuarios del conocimiento. como lo planteaba el doctor alberto pellegrini, en el vi congreso regional de información en ciencias de la salud, reunido en puebla, méxico, en el mes de mayo de este año, están ocurriendo importantes cambios en las relaciones entre ciencia y sociedad, los cuales tienen que ver principalmente con el hecho de que los fenómenos que estudia la ciencia ya no se reducen a los ámbitos de los laboratorios, sino que está enfrentando con toda su plenitud los fenómenos naturales y sociales. “recientemente se viene consolidando la noción de que el conocimiento, además de confiable, debe ser también socialmente robusto, requiriendo la validación por una comunidad más amplia, preocupada no solamente con su confiabilidad, sino también con sus implicaciones sociales”2. la divulgación científica tradicional obedece al esquema de una sola vía, donde los científicos son los que dominan el conocimiento y el público es un objeto receptor, que va a ser educado, sin una perspectiva de participación en el quehacer científico. en la modalidad que algunos autores han llamado “socialmente distribuido”, la relación entre los diversos actores que participan del contexto de aplicación es fluida y permanente durante todas las etapas del proceso, desde la definición del problema, hasta la interpretación, evaluación y utilización de resultados. por lo tanto, desaparece la clara diferenciación entre los que están del lado de la oferta y los que se encuentran del lado de la demanda de conocimientos. como se puede ver, el elemento central que sostiene este nuevo modo de producción del conocimiento es la comunicación, y es por eso que las nuevas tecnologías de información y comunicación, particularmente la internet, vienen desempeñando un papel central para viabilizarlo. cabe ahora preguntarnos: ¿por qué la especialización en enfermería en cuidado crítico pediátrico tiene un curso sobre diseño y gestión de proyectos? espero responder a esta pregunta con otros interrogantes, que nos llevan a señalar que la enfermera especializada en un área clínica determinada debe haber desarrollado habilidades que le permitan identificar con claridad problemas, y formular preguntas que solamente pueden responderse con un proyecto, bien sea de investigación, de gestión o de cualquier otro tipo, y cuyos resultados sean tan válidos que le permitan seguir caminos que contribuyan a la solución del problema. en la disciplina de enfermería, la investigación constituye la actividad fundamental en los avances científicos de la misma. ¿cómo se pueden desarrollar, si no es a través de la investigación, las bases científicas para realizar actividades que fomenten la salud de los niños, y la respuesta óptima cuando estos la han perdido y están bajo nuestro cuidado? ¿cómo profundizar y aplicar en cuidado crítico pediátrico las teorías construidas en el campo de la enfermería y en los avances hechos, a partir de modelos específicos, si no es a través del planteamiento de hipótesis, cuya verificación solo es posible con el desarrollo de una investigación completa? ¿cómo pretender el diseño de modelos y propuestas de cuidado de enfermería apropiados a la realidad de nuestras unidades de cuidado crítico pediátrico, si no es mediante estudios realizados por grupos estables científicamente, financiados con solidez y gran experiencia en el tema? ¿cómo construir una comunidad científica de enfermería en cuidado crítico pediátrico, visible en el país, si no es a través de propuestas de investigación originales e innovadoras, cuyos resultados sean de gran impacto en el ámbito científico, académico y social? ¿cómo llamar la atención de pares nacionales e internacionales, si no es a través de publicaciones científicas en revistas 2. pellegrini, alberto. conferencia inaugural del vi congreso regional de información en ciencias de la salud, puebla, méxico, 2003. ponencia: importancia de la investigación para el desarrollo de la disciplina de enfermería 7 nacional e internacionalmente reconocidas, que sean productos de proyectos en enfermería en cuidado crítico pediátrico? ¿cómo desarrollar en colombia un programa de doctorado en enfermería, sin consolidar los grupos de investigación existentes, sin ampliar su trayectoria y sin multiplicar sus publicaciones a nivel internacional? los trabajos que vamos a presentar hoy a la comunidad de salud, y en particular a la de enfermería, reunidas en este auditorio, partieron de la formulación de una pregunta para investigar. fue satisfactorio comprobar que todos los estudiantes, durante su ejercicio profesional, habían venido haciendo observaciones muy válidas sobre la atención de enfermería, y llegaron a este curso con muchas inquietudes al respecto. fue entonces necesario concretar sus interrogantes, para acertar desde un principio en la formulación de las preguntas que se iban a investigar, ya que este es el paso más importante para el desarrollo de una propuesta. preguntas tales como: ¿qué tanta humanización tiene el cuidado de enfermería?, ¿cómo aplicar el modelo de callista roy en la valoración, diagnóstico y cuidado de enfermería del niño en estado crítico en unidades pediátricas?, ¿cómo reforzar el vínculo afectivo madre-niño prematuro de las madres del programa canguro?, ¿qué cambios se presentan en la temperatura corporal de los recién nacidos que están siendo sometidos al baño diario bajo temperaturas ambientales diferentes? o ¿cómo prevenir las úlceras por presión en los niños hospitalizados en las unidades de cuidado intensivo pediátrico?, fueron interrogantes que rondaron durante más de un año por nuestras mentes, por el salón de clases y por los hospitales, y que esperamos mostrarles hoy a ustedes, y posteriormente en otros escenarios, cómo fue posible, a partir de ellas, desarrollar cinco proyectos y obtener conocimientos válidos y acumulativos. una vez planteado el interrogante que se va a responder, seguimos con la revisión de la literatura existente y, sobre todo, la actual sobre el tema de cada uno de los grupos. tarea bastante difícil, ya que acertar requiere un conocimiento profundo del problema que se planea investigar; se revisaron y analizaron tanto la literatura nacional como internacional, para detectar los vacíos persistentes sobre el tema y precisar el problema y la justificación del estudio. en el caso del trabajo “diseño de un instrumento de valoración del niño en estado crítico, para el cuidado de enfermería basado en el modelo de adaptación de callista roy”, en la revisión de la literatura se encontró que solamente hay un estudio, todavía en ejecución, que está aplicando el modelo en cuidado intensivo pediátrico. clarificar los objetivos del proyecto fue la tarea siguiente; una propuesta que abarca objetivos importantes y alcanzables con los recursos disponibles, exige no solo conocimiento del problema, sino de los métodos, medios y dificultades que se encontrarán. en el caso del proyecto “reforzamiento del vínculo afectivo madre-hijo en el programa canguro”, la identificación de un solo objetivo fue bastante difícil, pero se facilitó la tarea al hacer el resumen narrativo del objetivo, el cual se describe en una matriz, a través del fin, el propósito, los componentes y las actividades, y se cruza con los indicadores verificables objetivamente, los medios de verificación y los supuestos que deben ocurrir; es esta la estructura del marco lógico, herramienta utilizada por el banco interamericano de desarrollo para evaluar la gestión y mejorar el desempeño de los proyectos. una vez identificados los objetivos, se continuó con la selección de los métodos, de las estrategias, de la recolección, análisis e interpretación de los datos. en la presentación de la propuesta, este capítulo es uno de los más difíciles y donde se encuentran las mayores fallas. sobre la humanización del cuidado de enfermería, el grupo de investigación seleccionó el abordaje cualitativo para la recolección de la información; además, entendió con claridad que explorar un fenómeno desconocido, o que es parcialmente conocido, no se ajustaba al abordaje cuantitativo, el cual describe, explica, predice y controla un fenómeno. en este trabajo se estudió un fenómeno complejo, para el cual una cuantificación correría el riesgo de desconocer aspectos importantes, y se obtuvieron datos e informaciones que no se hubieran podido conseguir a partir de métodos cuantitativos3. a continuación se planearon el cronograma y el presupuesto, dos aspectos indispensables en todo proyecto. una vez elaboradas las cinco propuestas, se procedió a hacer la evaluación por pares; en este caso, los pares fueron los grupos entre sí. la enfermería debe adoptar el sistema universal de evaluación por pares. someter las propuestas a la crítica por parte de colegas 3. ospina g., m. b., et al. “¿la investigación cuantitativa frente a la investigación cualitativa?”. en: investigación clínica: epidemiología clínica aplicada, ceja, 2001, cap. 20. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 8 idóneos y de investigadores de diferentes disciplinas pertinentes al problema enriquece sustancialmente el proyecto que se va a desarrollar. en el curso se revisó exhaustivamente todo lo relacionado con la ética en la investigación, ya que la gran mayoría de investigaciones en enfermería se hacen con seres humanos. las propuestas fueron presentadas y aprobadas en los comités de ética de investigación de los diferentes hospitales donde se llevaron a cabo los trabajos. la experiencia más enriquecedora, en cuanto al sometimiento de las propuestas a los comités de ética, fue la de la investigación “cambios en la temperatura corporal del recién nacido que está siendo sometido al baño diario bajo temperaturas ambientales diferentes”. antes de la aprobación definitiva de este proyecto, tanto por parte del comité de ética de la institución respectiva, como del comité de investigación, se plantearon algunos interrogantes, que fueron aclarados por el grupo investigador, quien también justificó y sustentó adecuadamente el proyecto. finalmente, este fue aprobado por ambos comités, y sus resultados serán presentados en próximas reuniones. en el caso del trabajo “evaluación del riesgo de presentar úlceras por presión en los niños que ingresan a la unidad de cuidado intensivo pediátrico”, la pregunta de investigación se respondió validando una escala científicamente probada en otros países y en otros pacientes, pero lo más valioso de los resultados de este estudio es poder derivar de ellos el cuidado de enfermería exacto que se requiere para evitar el riesgo y prevenir este problema; por lo tanto, se hace casi imperioso que la aplicación de la escala se introduzca dentro de las actividades diarias de enfermería, se evalúe el riesgo, se registre y se comunique, y alrededor de ella se desarrolle un verdadero trabajo en equipo. esperamos que los resúmenes que oirán a continuación, de cada uno de los trabajos, les den orientaciones para tomar decisiones basadas en hallazgos científicos, que contribuyan a mejorar los servicios de salud, a conocer qué esperan los niños y sus padres de la atención de enfermería, a brindar un cuidado de enfermería sustentado por teorías validadas, que son las que constituyen la base del conocimiento científico en enfermería. como bien pueden concluir, desarrollar la investigación en enfermería es un reto que nos compete a todos: políticos, administradores, clínicos, docentes, estudiantes. no queremos más proyectos de investigación irrelevantes, sin evaluación por pares, sin financiación externa y realizados a costa del tiempo libre. la enfermería en el siglo xxi debe entrar por la puerta grande en la sociedad del conocimiento, no solamente para desarrollar sus bases teóricas, sino también para contribuir a que los ciudadanos gocemos de una vida saludable. finalmente, quiero felicitar a los estudiantes que hicieron posible estos trabajos; como muy bien lo expresó uno de los grupos en la autoevaluación final: “en cada página de ellos hay esfuerzo, dedicación y amor”. bibliografía henao, m., et al. educación superior, sociedad e investigación, bogotá, d.c., servicios gráficos integrales ltda., 2002. pellegrini, a. conferencia inaugural del vi congreso regional de información en ciencias de la salud, puebla, méxico, 2003. http://www.crics.info/crics6/program ruiz, a., et al. investigación clínica: epidemiología clínica aplicada, bogotá, d.c., ceja, 2001. suárez de sarmiento, b. “la investigación en enfermería, un reto para la profesión”, actualizaciones en enfermería, vol. 2, no. 2, junio de 1999. 200 209 identificao dos diagnosticos.indd 200 lívia moreira barros1 rosa aparecida nogueira moreira2 natasha marques frota3 joselany áfio caetano4 identifi cação dos diagnósticos de enfermagem da classe de respostas cardiovasculares/pulmonares em pacientes submetidos à cirurgia bariátrica 1 fortaleza (ce), brasil. endereço para correspondência: rua padre valdevino, 1515, apto 1704. bairro: aldeota. cep: 60135041. fortaleza/ce. livia.moreirab@hotmail.com 2 fortaleza (ce), brasil. nogueiramoreira@bol.com.br 3 fortaleza (ce), brasil. enfanatashafrota@yahoo.com.br 4 fortaleza (ce), brasil. joselany@ufc.br recibido: 27 de marzo de 2013 enviado a pares: 4 de mayo de 2013 aceptado por pares: 26 enero de 2014 aprobado: 28 de junio de 2014 doi: 10.5294/aqui.2015.15.2.4 para citar este artículo / to reference this article / para citar este artigo barros lm, moreira ra, frota nm, caetano ja. identificação dos diagnósticos de enfermagem da classe de respostas cardiovasculares/pulmonares em pacientes submetidos à cirurgia bariátrica. aquichan. 2015; 15 (2): 200-209. doi: 10.5294/aqui.2015.15.2.4 resumo o objetivo deste estudo foi identificar as respostas humanas apresentadas por pacientes no pós-operatório de cirurgia bariátrica que se configurem como diagnósticos de enfermagem da classe respostas cardiovasculares/pulmonares. estudo observacional de caráter transversal realizado no período de julho de 2010 a maio de 2011, em um hospital referência em cirurgia bariátrica em fortaleza-ce. os diagnósticos de enfermagem identificados foram: risco de perfusão gastrintestinal ineficaz (87,9%), risco de intolerância à atividade (70,7%), perfusão tissular periférica ineficaz (67,2%), risco de choque (63,8%), débito cardíaco diminuído (60,3%), risco de perfusão tissular cardíaca diminuída (58,6%), intolerância à atividade (51,7%), risco de perfusão tissular cerebral ineficaz (48,3%), ventilação espontânea prejudicada (46,5%), risco de perfusão renal ineficaz (43,1%), padrão respiratório ineficaz (37,9%) e resposta disfuncional ao desmame ventilatório (36,2%). assim, com base nesses resultados será possível direcionar a assistência de enfermagem prestada aos pacientes submetidos à cirurgia bariátrica e, consequentemente, reduzir complicações pós-operatórias. palavras-chave cirurgia bariátrica, diagnóstico de enfermagem, enfermagem (fonte: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 200-209 201 identificação dos diagnósticos de enfermagem da classe de respostas cardiovasculares/pulmonares em pacientes submetidos à cirurgia bariátrica l lívia moreira barros e outros año 15 vol. 15 nº 2 chía, colombia junio 2015 l 200-209 identificación de los diagnósticos de enfermería de la clase de respuestas cardiovasculares/pulmonares en pacientes sometidos a la cirugía bariátrica resumen el objetivo de este estudio fue identificar las respuestas humanas presentadas por pacientes en el postoperatorio de cirugía bariátrica que se configuren como diagnósticos de enfermería de la clase de respuestas cardiovasculares/pulmonares. estudio observacional de carácter transversal realizado en el periodo de julio de 2010 a mayo de 2011, en un hospital referencia en cirugía bariátrica en fortaleza (ceará, brasil). los diagnósticos de enfermería identificados fueron: riesgo de perfusión gastrointestinal ineficaz (87,9%), riesgo de intolerancia a la actividad (70,7%), perfusión tisular periférica ineficaz (67,2%), riesgo de choque (63,8%), débito cardíaco disminuido (60,3%), riesgo de perfusión tisular cardíaca disminuida (58,6%), intolerancia a la actividad (51,7%), riesgo de perfusión tisular cerebral ineficaz (48,3%), ventilación espontánea perjudicada (46,5%), riesgo de perfusión renal ineficaz (43,1%), patrón respiratorio ineficaz (37,9%) y respuesta disfuncional al desmame ventilatorio (36,2%). palabras clave cirugía bariátrica, diagnóstico de enfermería, enfermería (fuente: decs, bireme). 202 aquichan issn 1657-5997 identification of the nursing diagnoses of the cardiovascular/pulmonary responses class in patients subject to bariatric surgery abstract this observational and cross-sectional study aimed to identify human responses presented by patients during the postoperative period for bariatric surgery classified into the cardiovascular/pulmonary responses class of the nursing diagnoses. the study was carried out between july 2010 and may 2011, in a reference hospital for bariatric surgery in fortaleza, state of ceará. the following nursing diagnoses were identified: risk for ineffective gastrointestinal perfusion (87.9%), risk for activity intolerance (70.7%), ineffective peripheral tissue perfusion (67.2%), risk for shock (63.8%), decreased cardiac output (60.3%), risk for decreased cardiac tissue perfusion (58.6%), activity intolerance (51.7%), risk for ineffective cerebral tissue perfusion (48.3%), impaired spontaneous ventilation (46.5%), risk for ineffective renal perfusion (43.1%), ineffective breathing pattern (37.9%) and dysfunctional ventilatory weaning response (36.2%). thus, based on these results, it will be possible to direct nursing care to patients subject to bariatric surgery and consequently reduce postoperative complications. keywords bariatric surgery, nursing diagnosis, nursing (source: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 200-209 203 identificação dos diagnósticos de enfermagem da classe de respostas cardiovasculares/pulmonares em pacientes submetidos à cirurgia bariátrica l lívia moreira barros e outros introdução atualmente, existem vários tipos de tratamento para a obesidade, dentre os quais os mais recomendados são: orientação dietética, realização de atividade física e uso de fármacos antiobesidade. em pacientes obesos com comorbidades associadas, a manutenção da perda de peso através dos tratamentos convencionais é uma tarefa difícil de se realizar e indivíduos com obesidade grave não podem simplesmente confiar nos resultados dos métodos convencionais para o tratamento da obesidade como um meio de manter a perda de peso a longo prazo (1,2). assim, quando esses métodos não são eficazes, surge a necessidade de uma intervenção cirúrgica para solucionar o problema do excesso de peso, denominada de cirurgia bariátrica (3). pacientes submetidos à cirurgia bariátrica necessitam de uma terapêutica especial. seu grande corpo e as comorbidades associadas fazem desses indivíduos morbidamente obesos candidatos de alto risco cirúrgico, os quais requerem um planejamento nos cuidados de enfermagem. a partir do pressuposto de que a assistência deve ser baseada na literatura científica, a enfermagem deve se armar de recursos para poder assistir esse paciente de modo a fazer com que todos os cuidados que, direta ou indiretamente, possam depender da assistência de enfermagem sejam seguidos, para um melhor desempenho da equipe que assiste esse paciente, a fim de que a sua recuperação tenha o sucesso esperado. nos últimos anos, a enfermagem vem aprimorando seus conhecimentos e propondo melhoras na sua prática assistencial, desenvolvendo uma metodologia própria de trabalho, baseada no método científico denominado processo de enfermagem (pe). o pe é visto como uma tecnologia do cuidado que orienta o raciocínio lógico e melhora a qualidade do cuidado por meio da sistematização da avaliação clínica, dos diagnósticos, das intervenções e dos resultados de enfermagem (4). assim, a sistematização da assistência de enfermagem possibilita que os enfermeiros identifiquem os diagnósticos de enfermagem e consequentemente estabeleçam as intervenções, de modo a prestar uma assistência planejada e fundamentada em conhecimentos científicos, o que viabiliza um cuidado objetivo e individualizado. o diagnóstico de enfermagem é domínio da enfermagem, ou seja, trata-se de uma atividade que os enfermeiros têm qualificação legal para tratar e responsabilizar-se. compete ao enfermeiro a responsabilidade de diagnosticar as respostas humanas relacionadas à saúde ou às atividades cotidianas. a partir do conhecimento dos problemas, o enfermeiro poderá prever as complicações e agir na sua prevenção ou no seu controle, se não for possível evitá-las. diante da análise situacional da assistência de enfermagem ao paciente bariátrico, surgem os questionamentos: quais os principais diagnósticos de enfermagem referentes à função cardíaca e pulmonar apresentados pelos obesos mórbidos durante o pós-operatório imediato? quais as características definidoras mais predominantes nesses diagnósticos? em indivíduos obesos, há uma sobrecarga muscular para realizar a ventilação, resultando em disfunção da musculatura respiratória. essas disfunções podem contribuir para o surgimento de complicações respiratórias no pós-operatório de cirurgia abdominal alta (caa), as quais prolongam a estadia hospitalar; as mais comuns são insuficiência respiratória, atelectasia, pneumonia, hipoventilação e embolia pulmonar (5). dessa forma, parece razoável esperar que alterações na função pulmonar possam ser mais intensas no doente obeso mórbido submetido à cirurgia bariátrica, o que pode favorecer uma maior incidência de complicações neste grupo de indivíduos e também problemas cardiovasculares. assim, acredita-se contribuir para o conhecimento desses diagnósticos, o que dará subsídios para planejar um cuidado de enfermagem mais efetivo e específico para os pacientes durante o pós-operatório nos serviços de saúde destinados a esse procedimento. diante do exposto, este estudo visou analisar os diagnósticos de enfermagem da classe respostas cardiovasculares/pulmonares em pacientes submetidos à cirurgia bariátrica, com o intuito de adequar a assistência de enfermagem de forma segura e eficaz, seguindo a taxonomia ii da north american nursing diagnosis association (nanda) 2009-2011. métodos trata-se de um estudo observacional de caráter transversal, realizado no período de julho de 2010 a maio de 2011, em um hospital referência de cirurgia bariátrica do sistema único de saúde (sus) localizado no município de fortaleza-ce-brasil. a amostra foi de 58 pacientes que estavam vivenciando o pósoperatório imediato. apenas um paciente não foi enquadrado nos critérios de inclusão, tendo idade superior a 60 anos. 204 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 os critérios adotados para a inclusão no grupo foram: estar cadastrado no serviço de cirurgia bariátrica da referida instituição; possuir imc ≥ 40 kg/m2 ou imc maior que 35 kg/m2 com comorbidades (hipertensão, diabetes, dislipidemias, apneia do sono, entre outras); estar no período pós-operatório. apesar de haver publicações que consideram o pós-operatório bariátrico até 30 dias após o procedimento, foi considerado apenas o pós-operatório imediato (72h), quando os pacientes ainda estão hospitalizados. já os critérios de exclusão foram: ter idade ≥ 60 anos, devido ao possível comprometimento cardiovascular e/ou pulmonar; ter histórico de cirurgia cardiovascular, já que os sinais e sintomas apresentam avaliação confusa quanto ao estado pós-operatório e/ou doença prévia; ter obesidade relacionada a distúrbios psiquiátricos. para a coleta de dados foi elaborado um instrumento organizado de acordo com o referencial da nanda (6) com questões abertas e fechadas, utilizando escala tipo likert. a primeira parte do instrumento é composta por dados de identificação e a segunda contém cada diagnóstico de enfermagem da classe de respostas cardiovasculares/pulmonares, presentes na versão brasileira 2009-2011 da classificação de diagnósticos de enfermagem da nanda, com suas respectivas características definidoras e fatores/riscos relacionados. as informações antropométricas dos obesos foram avaliadas conforme as preconizações da american society for bariatric surgery e da organização mundial de saúde. vale ressaltar que o instrumento foi avaliado por duas doutoras em enfermagem com prática clínica cirúrgica e, após, foi aplicado a seis pacientes, com necessidades de pequenos ajustes. para a análise dos dados, foram calculadas as frequências absolutas e relativas das variáveis de caracterização da amostra. os diagnósticos de enfermagem, as características definidoras e os fatores de risco foram determinados a partir dos dados contidos no instrumento, por duas especialistas em enfermagem clínica cirúrgica e com experiência no uso dos diagnósticos de enfermagem da nanda. a elaboração dos de deu-se mediante o raciocínio crítico proposto por lefevre (7), a saber: análise de agrupamentos de indicadores, criação de uma lista de problemas suspeitados, descarte de diagnósticos similares, escolha dos rótulos diagnósticos mais específicos, declaração dos problemas e suas causas e identificação de pontos fortes, recursos e áreas de melhoria. assim, os diagnósticos de enfermagem, características definidoras e fatores relacionados foram considerados presentes, quando havia consenso entre as especialistas. todos os participantes do estudo assinaram um termo de consentimento livre e esclarecido e a pesquisa foi aprovada pelo comitê de ética em pesquisa da instituição (cep294/2009). resultados foram avaliados 13 diagnósticos de enfermagem que foram classificados em duas categorias: reais e de risco. os diagnósticos reais são: débito cardíaco diminuído, ventilação espontânea prejudicada, padrão respiratório ineficaz, intolerância à atividade, resposta disfuncional ao desmame ventilatório e perfusão tissular periférica ineficaz (ver tabela 1). tabela 1. diagnósticos reais da classe cardiopulmonar apresentados pelos pacientes submetidos à cirurgia bariátrica em um hospital referência de fortaleza-ce, 2011 categorias diagnósticas características definidoras n % perfusão tissular periférica ineficaz edema, pulsos diminuídos, parestesia e dor em extremidades 39 67,2% débito cardíaco diminuído tosse, edema, fadiga, pulsos periféricos diminuídos, oligúria, variações nas leituras de pressão arterial, ortopneia, ansiedade 35 60,3% intolerância à atividade relato verbal de fadiga, desconforto aos esforços, resposta anormal da pressão sanguínea à atividade, dispneia aos esforços 30 51,7% ventilação espontânea prejudicada saturação de oxigênio diminuída, dispneia, cooperação diminuída 27 46,5% padrão respiratório ineficaz dispneia, ortopneia, alterações na profundidade respiratória 22 37,9% resposta disfuncional ao desmame ventilatório fadiga, aumento da frequência cardíaca em relação aos parâmetros basais, aumento da pressão sanguínea em relação aos parâmetros basais respiração 21 36,2% 205 identificação dos diagnósticos de enfermagem da classe de respostas cardiovasculares/pulmonares em pacientes submetidos à cirurgia bariátrica l lívia moreira barros e outros os diagnósticos de risco são: risco de intolerância à atividade, risco de perfusão tissular cardíaca diminuída, risco de perfusão tissular cerebral ineficaz, risco de perfusão gastrintestinal ineficaz, risco de perfusão renal ineficaz, risco de choque e risco de sangramento (ver tabela 2). tabela 2. diagnósticos de risco da classe cardiopulmonar apresentados pelos pacientes submetidos à cirurgia bariátrica em um hospital referência de fortaleza-ce se diagnóstico são: presença de problemas circulatórios (97,6%), estado de não condicionamento físico (92,7%), história prévia de intolerância (87,8%), inexperiência com a atividade (70,7%) e presença de problemas respiratórios (58,5%). os aspectos que envolvem esse diagnóstico associado aos pacientes bariátricos são: fadiga após pequenos esforços, sedentarismo, dificuldade para respirar após esforços, e inchaço, dor, formigamento ou peso nas pernas e/ou pés. o diagnóstico de enfermagem perfusão tissular periférica ineficaz apresentou uma frequência de 67,2% e foi o terceiro mais encontrado. a nanda o define como: diminuição na oxigenação, resultando na incapacidade de nutrir os tecidos no nível capilar (6). as características definidoras que predominaram para esse diagnóstico foram edema (84,6%), pulsos diminuídos (51,3%), parestesia (20,5%) e dor em extremidade (18%), enquanto que os fatores relacionados mais predominantes foram: diabetes melittus, estilo de vida sedentário e hipertensão. o débito cardíaco diminuído, definido pela nanda como quantidade insuficiente de sangue bombeado pelo coração para atender às demandas metabólicas corporais (6), foi o quinto diagnóstico e apresentou uma frequência de 60,3% entre os pacientes pesquisados. para a formulação deste diagnóstico, foram identificadas as principais características definidoras: tosse (97,1%), edema (94,3%), fadiga (80%), pulsos periféricos diminuídos (51,4%), oligúria (42,8%), variações nas leituras de pressão arterial (42,8%), ortopneia (37,%) e ansiedade (34,3%). os fatores relacionados foram: pré-carga alterada (97,1%), pós-carga alterada (85,7%), contratilidade alterada (31,4%), frequência cardíaca alterada (11,4%) e ritmo alterado (5,7%). a intolerância à atividade (51,7%) é definida como “energia fisiológica ou psicológica insuficiente para suportar ou completar as atividades diárias requeridas ou desejadas” (6). relato verbal de fadiga (96,7%), desconforto aos esforços (76,7%), resposta anormal da pressão sanguínea à atividade (53,3%) e dispneia aos esforços (53,3%) foram as características definidoras mais importantes apresentadas. já, entre os fatores relacionados, destacam-se o estilo de vida sedentário (83,4%), repouso no leito (66,6%), imobilidade (43,3%), fraqueza generalizada (6,6%) e desequilíbrio entre a oferta e a demanda de oxigênio (3,3%). a ventilação espontânea prejudicada, presente em 46,5% da população, é definida pela nanda como “reservas de energias categorias diagnósticas fatores de risco n % risco de perfusão gastrintestinal ineficaz sexo feminino, diabetes mellitus, tabagismo 51 87,9% risco de intolerância à atividade problemas circulatórios, estado de não condicionamento físico, história prévia de intolerância, inexperiência com atividade e presença de problemas respiratórios 41 70,7% risco de choque hiperlipidemia, hipertensão 37 63,8% risco de perfusão tissular cardíaca diminuída diabetes melitos, hiperlipidemia, hipertensão, hipovolemia, hipóxia, tabagismo 34 58,6% risco de perfusão tissular cerebral ineficaz hiperlipidemia, hipertensão 28 48,3% o diagnóstico de enfermagem que apresentou maior frequência entre a população estudada foi risco de perfusão gastrintestinal ineficaz (87,9%) que, para a taxonomia ii da nanda, é o “risco de diminuição na oxigenação, resultando na incapacidade de nutrir os tecidos no nível capilar” (6). os fatores de risco presentes nesse diagnóstico são: sexo feminino (96%), diabetes mellitus (19,6%) e tabagismo (9,8%). o segundo diagnóstico de enfermagem mais frequente foi risco de intolerância à atividade (70,7%) que, para a taxonomia ii da nanda, é o “risco de ter energia fisiológica ou psicológica insuficiente para suportar ou completar as atividades diárias requeridas ou desejadas” (6). os fatores de risco presentes nes206 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 diminuídas, resultando em uma incapacidade do indivíduo de manter respiração adequada para a sustentação da vida” (6). são características definidoras desse diagnóstico: agitação aumentada, apreensão, cooperação diminuída, dispneia, frequência cardíaca aumentada, pco 2 aumentada, po 2 diminuída, sao 2 diminuída, taxa metabólica aumentada, uso aumentado da musculatura acessória e volume corrente diminuído. sendo os fatores relacionados com a fadiga da musculatura respiratória e transtornos metabólicos. as características definidoras apresentadas foram: saturação de oxigênio diminuída (70,4%), dispneia (55,5%) e cooperação diminuída (18,5%). com relação aos fatores relacionados, temos: fadiga da musculatura respiratória (70,4%) e transtornos metabólicos (29,6%). o diagnóstico de enfermagem padrão respiratório ineficaz, que apareceu em 37,9% dos pacientes, é definido pela nanda como: inspiração e/ou expiração que não proporciona ventilação adequada (6). as principais características definidoras foram: dispneia (68,2%), ortopneia (59%) e alterações na profundidade respiratória (36,3%). destacam-se como fatores relacionados para esse diagnóstico: obesidade (86,4%), fadiga (77,3%), dor (63,6%), fadiga da musculatura respiratória (4,5%) e ansiedade (4,5%). o diagnóstico de enfermagem resposta disfuncional ao desmame ventilatório teve uma frequência de 36,2% e é definido como: incapacidade de ajustar-se a níveis diminuídos de suporte ventilatório mecânico, que interrompe e prolonga o processo de desmame (6). com relação às características definidoras, temos: fadiga (66,6%), aumento moderado da pressão sanguínea em relação aos parâmetros basais (61,9%) e aumento da pressão sanguínea em relação aos parâmetros basais (42,8%). e os fatores relacionados foram: nutrição inadequada (95,2%), motivação diminuída (28,6%), dor sem controle (23,8%), ansiedade (23,8%), medo (14,3%), autoestima diminuída (9,5%), ineficácia percebida do paciente quanto à capacidade de desmame (4,8%) e padrão do sono perturbado (4,8%). discussão os diagnósticos risco de intolerância à atividade (70,7%) e intolerância à atividade (50,7%) foram alguns dos mais predominantes. os obesos têm dificuldade para participar de qualquer atividade física planejada, estruturada e repetida, em decorrência da baixa capacidade física (8). a prática regular de atividade física aumenta o gasto de energia e de massa corporal e pode prevenir o excesso de peso, auxiliar na prevenção ou redução da has, do dm e da osteoporose, diminuir o risco de cardiopatias e acidente vascular cerebral, reduzir o estresse, a ansiedade e a depressão, melhorar a autoestima e, principalmente, promover o bem-estar (8). há também os benefícios biológicos, ou seja, a sobrecarga física imposta ao organismo provoca adaptações de órgãos e sistemas de modos distintos, dependendo da intensidade, frequência e duração do estímulo. alguns benefícios podem ser alcançados mesmo quando há apenas um pequeno incremento na atividade em indivíduos sedentários (9). a associação entre a prática de atividade física regular e os hábitos alimentares saudáveis é a forma mais indicada de prevenção de doenças cardiovasculares, obesidade e diabetes mellitus tipo 2. estudos recentes demonstram que a atividade física pode cumprir um importante papel preventivo e terapêutico, devendo ser incorporado nas práticas terapêuticas em saúde (10). a enfermagem pode se inserir nessas práticas com atividades de promoção da saúde que estimulem as mudanças no estilo de vida e reduzam o sedentarismo, o que contribuirá para a melhora na qualidade de vida desses pacientes. o débito cardíaco diminuído apareceu com uma frequência de 60,3%. os obesos mórbidos apresentam alterações cardíacas estruturais que podem associar-se ao desenvolvimento de insuficiência cardíaca, arritmias e morte súbita. na obesidade grave, o débito cardíaco eleva-se à custa de aumento no volume circulante, ocasionando um estado de pré-carga cronicamente elevada (11). em nosso estudo, houve o predomínio do débito cardíaco diminuído relacionado com a pré-carga alterada (97,1%) e com a pós-carga alterada (85,7%). adaptações hemodinâmicas são necessárias para suportar o intenso metabolismo do tecido adiposo e o elevado consumo de oxigênio (11). é importante que a equipe de enfermagem fique atenta ao quadro desse tipo de paciente, principalmente durante o pós-operatório imediato, pois é este o período em que as complicações mais graves, como a trombose venosa profunda e o tromboembolismo pulmonar podem se manifestar. os diagnósticos relacionados com a classe pulmonar são: ventilação espontânea prejudicada (46,5%), padrão respiratório ineficaz (37,9%) e resposta disfuncional ao desmame ventilatório (36,2%). 207 identificação dos diagnósticos de enfermagem da classe de respostas cardiovasculares/pulmonares em pacientes submetidos à cirurgia bariátrica l lívia moreira barros e outros são vários os fatores que interferem na mecânica respiratória do obeso, resultando em reduções dos volumes e capacidades pulmonares, principalmente volume de reserva expiratória e capacidade residual funcional (crf) (12,4). em indivíduos obesos, a função dos músculos respiratórios e a movimentação do diafragma já estão prejudicadas, pois a obesidade mórbida associa-se a alterações da função pulmonar (4), podendo afetar o tórax e o diafragma, o que modificará a função respiratória mesmo quando os pulmões estão normais, devido ao aumento do esforço respiratório e comprometimento do sistema de transporte dos gases. ou seja, a obesidade mórbida e o acúmulo de gordura resultam em alterações quanto à redução entre os volumes pulmonares, aumentando a resistência do fluxo aéreo e do trabalho respiratório (13). em determinadas cirurgias, a anestesia predispõe ao surgimento de alterações na mecânica respiratória, nos volumes pulmonares e nas trocas gasosas. no obeso, a anestesia acentua a redução da crf, promovendo o fechamento precoce das pequenas vias aéreas, o que aumenta a hipoxemia e contribui para a maior incidência de atelectasias. durante o pós-operatório, os pacientes obesos apresentam respirações mais superficiais, com aumento da frequência respiratória e diminuição do volume corrente, o que ocasiona uma sobrecarga inspiratória, aumentando o trabalho respiratório, o consumo de oxigênio e o custo energético da respiração (4). no pós-operatório, o enfermeiro deve estimular a prática dos exercícios respiratórios, a tosse e a deambulação precoce, para que o padrão respiratório seja normalizado e o indivíduo possa realizar as trocas gasosas de forma eficaz. as principais características definidoras do diagnóstico padrão respiratório ineficaz (70,6%) foram: dispneia (68,2%), ortopneia (59%) e alterações na profundidade respiratória (36,3%). os fatores de risco para depressão respiratória incluem a administração sistêmica de opioides, sedativos, local e invasão de procedimento cirúrgico e da gravidade subjacente da apnéia do sono (14). a anestesia diminui a capacidade residual funcional em até 50% em pacientes obesos que, combinado com a perda do tônus diafragmático, leva a um aumento da incidência de atelectasia (15). o padrão respiratório ineficaz e a ventilação espontânea prejudicada estão relacionados com a ventilação disfuncional, que é definida como o funcionamento anormal ou incompleto do movimento do ar para dentro e para fora dos pulmões com um padrão e ritmo respiratório, profundidade de inspiração e força de expiração (15), estando associado à mecânica da ventilação e não aos processos de troca gasosa e transporte de oxigênio/dióxido de carbono (16). os cuidados para estes diagnósticos em questão são: manter em semi-fowler; avaliar expansibilidade torácica (amplitude e simetria) e uso de musculatura acessória; realizar ausculta pulmonar; comunicar saturação de oxigênio pela oximetria de pulso (spo 2 ) inferior a 92%; avaliar sinais e sintomas de infecção pulmonar; avaliar complicações relacionadas à ventilação mecânica e observar sinais e sintomas de hipoxemia (16). o planejamento dos cuidados dos pacientes com ventilação espontânea prejudicada deve conter: a obtenção de uma ótima troca gasosa, a manutenção de uma via aérea permeável, a ausência de trauma ou infecção, a obtenção da mobilidade adequada, a adequação de métodos de comunicação e a incorporação de medidas de enfrentamento do estresse bem-sucedidas. a cabeceira da cama do paciente deve estar elevada a, pelo menos, 30° para aumentar a estabilidade da via aérea superior e melhorar o volume corrente de oxigênio (17). outros cuidados de enfermagem incluem o controle de sinais vitais, a monitoração cardiovascular e a monitoração das trocas gasosas e do padrão respiratório. comumente, os anestésicos promovem uma ação depressora na respiração, podendo alterar a frequência respiratória e o volume corrente. a obesidade é um fator de risco independente para o surgimento de complicações clínicas, após o período de extubação. o peso corpóreo elevado prejudica a incursão respiratória, devido à maior quantidade de gordura visceral no abdome, o que eleva a frequência respiratória e reduz o volume corrente como forma de compensação ante o padrão respiratório superficial (18). a falha do desmame é relacionada ao desequilíbrio entre a capacidade dos músculos respiratórios e a demanda respiratória. a relação entre a frequência respiratória e o volume corrente, durante a respiração espontânea, aumenta quando há esse desequilíbrio, podendo essa relação indicar o sucesso ou falha do desmame da ventilação mecânica (18). os cuidados de enfermagem para o diagnóstico de resposta disfuncional ao desmame ventilatório devem priorizar a verificação do padrão respiratório, principalmente a frequência. o paciente obeso mórbido que se submete ao ato cirúrgico requer cuidados específicos de enfermagem, principalmente devido à dificuldade de adesão ao tratamento, bem como pelos riscos 208 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 pré e pós-operatórios (19). a equipe de enfermagem atua diretamente na prevenção e minimização do aparecimento de complicações pós-operatórias, promovendo a deambulação precoce, incentivando a respiração profunda, monitorando os sinais de infecção na ferida cirúrgica e em inserção de drenos e cateteres, no controle da dor e das queixas apresentadas pelo paciente (20). sabe-se que a obesidade contribui para o surgimento de diversas complicações após a cirurgia. os cuidados de enfermagem são essenciais durante este período do pós-operatório, visto que é o primeiro momento de adaptação do paciente ao seu novo estilo de vida. a sae contribui para que esse cuidado seja individualizado e priorizado, a partir das necessidades do indivíduo, pois permite que os cuidados de enfermagem sejam ofertados a partir da identificação de problemas característicos do período pós-operatório. esses problemas devem nortear a elaboração do planejamento de enfermagem, de modo que se adapte às circunstâncias reais do paciente ao contemplar a sua esfera biológica, psicossocial e espiritual (21). a identificação dos diagnósticos de enfermagem da classe de respostas cardiovasculares/pulmonares permitiu o conhecimento de algumas prioridades na avaliação cardíaca e pulmonar (sinais vitais, padrão respiratório, resposta ao deambular), o que contribuirá na definição das intervenções de enfermagem. conclusões com a análise dos dados obtidos, conclui-se que a avaliação dos níveis de resposta humana para a formulação dos diagnósticos da classe de respostas cardiovasculares/pulmonares mais predominantes nos pacientes bariátricos é uma atribuição importante para os enfermeiros durante o perioperatório da cirurgia bariátrica, pois norteará os cuidados a serem prestados a essa clientela, visando à promoção de saúde e prevenção de complicações. verificou-se que houve uma prevalência de obesidade entre mulheres na faixa etária de 20 a 39 anos, período de maior desempenho reprodutivo. cerca de 89,6% dos participantes encontravam-se no estado de obesidade mórbida (obesidade grau iii). a associação entre a obesidade e as comorbidades foi presente em 56,9%, o que fortalece a obesidade como fator de risco para diversas doenças, principalmente as cardiovasculares. com base nos resultados, percebe-se a importância da sae e a necessidade da implementação de um protocolo na instituição que facilite os cuidados de enfermagem prestados a essa clientela, visando à identificação precoce dos diagnósticos de enfermagem e resolução de possíveis complicações. a partir dessa vivência, fica clara também a necessidade da educação continuada entre os membros da equipe de enfermagem para possibilitar orientações ao paciente no período transoperatório, reduzindo os sentimentos de medo e ansiedade, o que irá permitir que ele vivencie esse momento com maior tranquilidade e qualidade de vida. vale salientar que se torna evidente a importância da realização de futuras pesquisas que permitam um maior conhecimento acerca da temática, contribuindo para o conhecimento dos profissionais de saúde e para a melhora da assistência prestada. referências 1. koshy aa, bobe am, brady mj. potential mechanisms by which bariatric surgery improves systemic metabolism. translational research. 2013;161(2):63-72. 2. jensen jf, petersen mh, larsen tb, jørgensen dg, grønbaek hn, midtgaard j. young adult women’s experiences of body image after bariatric surgery: a descriptive phenomenological study. j adv nurs. 2014;70(5):1138-49. 3. neff kjh, le roux cw. bariatric surgery: a best practice article. j clin pathol. 2013;66(2):90-8. 4. dal sasso gtm, barra dcc, paese f, almeida srw, rios gc, marinho mm, debétio mg. computerized nursing process: methodology to establish associations between clinical assessment, diagnosis, interventions, and outcomes. rev esc enferm usp. 2013; 47(1):242-9. 5. nguyen n, champion jk, ponce j, quebbemann b, patterson e, pham b, et al. a review of unmet needs in obesity management. obes surg. 2012;22(6):956-66. 209 identificação dos diagnósticos de enfermagem da classe de respostas cardiovasculares/pulmonares em pacientes submetidos à cirurgia bariátrica l lívia moreira barros e outros 6. north american nursing. nanda international. nursing diagnoses: definitions and classification, 2009-2011. oxford: wiley blackwell; 2009. 7. alfaro-lefevre r. applying nursing process: a tool for critical thinking. 7. ed. philadelphia, pa: lippincott-williams & wikkins, 2009. 8. conceição e, mitchell je, vaz ar, bastos ap, ramalho s, silva c, et al. the presence of maladaptive eating behaviors after bariatric surgery in a cross sectional study: importance of picking or nibbling on weight regain. eat behav. 2014;15(4):558-62. 9. owers ce, abbas y, ackroyd r, barron n, khan m. perioperative optimization of patients undergoing bariatric surgery. journal of obesity. 2012;2012(2012);1-6. 10. goodpaster bh, delany jp, otto ad, kuller l, vockley j, south-paul je, et al. effects of diet and physical activity interventions on weight loss and cardiometabolic risk factors in severely obese adults: a randomized trial. jama. 2010;304(16):1795-1802. 11. smeltzer sc, bare bg, hinkle jl, cheever kh. brunner & suddarth: treaty of medical surgical nursing. guanabara, rio de janeiro; 2012. 12. tariq n, chand b. presurgical evaluation and postoperative care for the bariatric patient. gastrointest endosc clin n am. 2012;21(2):229-40. 13. ortega j, cassinello n, baltasar a, torres aj. recommendations for the peri-operative management of bariatric surgery patients: results of a national survey. cir espan. 2012;90(6):355-62. 14. lemanu dp, srinivasa s, singh pp, johannsen s, maccormick ad, hill ag. optimizing perioperative care in bariatric surgery patients. obes surg. 2012;22(6):979-90. 15. schachter l. respiratory assessment and management in bariatric surgery. respirology. 2012;17(7):1039-47. 16. branson rd. the scientific basis for postoperative respiratory care. respir care. 2013;58(11):1974-84. 17. gagnon le, sheff ejk. outcomes and complications after bariatric surgery. am j nurs. 2012;112(9):26-36. 18. takahashi am. obesity and considerations in the bariatric surgery patient. clin podiatr med surg. 2010;24(2):191-222. 19. neil ja. perioperative nursing care of the patient undergoing bariatric revision surgery. aorn j. 2013;97(2):210-29. 20. quidley am, bland cm, bookstaver pb, kuper k. perioperative management of bariatric surgery patients. am j healthsyst ph. 2014;71(15):1253-64. 21. thomé es, centena rc, behenck as, marini m, heldt e. applicability of the nanda-i and nursing interventions classification taxonomies to mental health nursing practice. int j nurs terminol classif. 2014;25(3):168-72. 41 52 percepcion de crianza.indd 41 miguel ángel villegas-pantoja1 maría magdalena alonso-castillo2 bertha alicia alonso-castillo3 raúl martínez-maldonado4 percepción de crianza parental y su relación con el inicio del consumo de drogas en adolescentes mexicanos 1 enfermero. doctorando en ciencias de enfermería, universidad autónoma de nuevo león, méxico. miguel_vp@msn.com 2 doctora en filosofía con especialidad en psicología. profesora de tiempo completo, universidad autónoma de nuevo león, méxico. magdalena_alonso@hotmail.com 3 doctora en bioética. profesora de tiempo completo, universidad autónoma de nuevo león, méxico. balonso_mx@yahoo.com.mx 4 magíster en enfermería. profesor de tiempo completo, universidad autónoma de nuevo león, méxico. raulmtz141@hotmail.com recibido: 1 de octubre de 2012 enviado a pares: 3 de octubre de 2012 aceptado por pares: 19 de diciembre de 2013 aprobado: 5 de febrero de 2014 año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 41-52 para citar este artículo / to reference this article / para citar este artigo villegas-pantoja, m. a.; alonso-castillo, m. m.; alonso-castillo, b. a.; martínez-maldonado, r. (2014). percepción de crianza parental y su relación con el inicio del consumo de drogas en adolescentes mexicanos. aquichan. vol. 14, no. 1, 41-52. resumen contra todo esfuerzo, el inicio del consumo de drogas continúa siendo precoz. se presumen asociaciones con factores relativos a la crianza, pero la escasa evidencia encontrada indica un vacío en el conocimiento de este fenómeno. objetivo: identificar la relación entre la percepción de crianza parental y la edad de inicio en el consumo de sustancias psicoactivas en adolescentes. materiales y método: diseño descriptivo correlacional con muestreo probabilístico. la muestra de adolescentes (n = 416) se estimó para ic 95 %. se empleó una cédula sobre consumo de drogas y el cuestionario “mis memorias de crianza” embu-i. resultados: se identificaron correlaciones positivas entre la percepción de crianza parental y la edad de inicio del consumo de tres drogas. por sexo del progenitor se encontraron ocho correlaciones entre la percepción de crianza paterna (todas las dimensiones de crianza) y la edad de inicio del consumo de cuatro drogas. en las madres, la dimensión de calidez se correlacionó positivamente con la edad de inicio del consumo de tabaco. conclusiones: posiblemente la crianza parental desempeña un papel importante en el inicio temprano del consumo de sustancias por los adolescentes, por lo que es preciso considerarla en la prevención de las adicciones. palabras clave crianza del niño, trastornos relacionados con sustancias, adolescentes, educación vocacional, estudios transversales, enfermería (fuente: decs, bireme). 42 aquichan issn 1657-5997 año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 41-52 perception of parenting and its relationship to the onset of drug use in mexican adolescents abstract despite all efforts, the onset of drug use continues to occur at an early age. it is presumed to be related to factors associated with parenting; however, the limited amount of evidence found points to a gap in what is known about this phenomenon. objective: the study was designed to identify the relationship between the perception of parenting and the age at which adolescents begin to consume drugs. materials and methods: a descriptive correlational approach was used in conjunction with probability sampling. the sample of adolescents (n = 416) was estimated for 95% ci. a document on drugs and a questionnaire entitled "memories of my upbringing" (embu –i) were used. results: positive correlations were identified between the perception of parenting and the age of first use of three drugs. based on the gender of the parent, eight correlations were found between perception of parenting (in all its dimensions) and the age of first use of four drugs. among mothers, there was a positive correlation between the warmth dimension and the age of first use of tobacco. conclusions: parenting possibly plays an important role in the early onset of substance use by teenagers. therefore, it is a necessary factor to consider in the prevention of addiction. key words child rearing, substance-related disorders, adolescent, vocational education, cross-sectional studies, nursing (source: decs, bireme). 43 percepción de crianza parental y su relación con el inicio del consumo de drogas en adolescentes mexicanos l miguel ángel villegas-pantoja y otros. percepção de criação parental e sua relação com o início do consumo de drogas em adolescentes mexicanos resumo contra todo esforço, o início do consumo de drogas continua sendo precoce. presumem-se associações com fatores relativos à criação, mas a escassa evidência constatada indica um vazio no conhecimento desse fenômeno. objetivo: identificar a relação entre a percepção de criação parental e a idade de início no consumo de substâncias psicoativas em adolescentes. materiais e métodos: desenho descritivo correlacional com amostragem probabilística. a amostra de adolescentes (n = 416) se estimou para ic 95 %. empregou-se uma cédula sobre consumo de drogas e o questionário “minhas memórias de criação” embu-i. resultados: identificaram-se correlações positivas entre a percepção de criação parental e a idade de início do consumo de três drogas. por sexo do progenitor, encontraram-se oito correlações entre a percepção de criação paternal (todas as dimensões de criação) e a idade de início do consumo de quatro drogas. nas mães, a dimensão de calidez se correlacionou positivamente com a idade de início do consumo de tabaco. conclusões: possivelmente, a criação parental desempenha um papel importante no início precoce do consumo de substâncias pelos adolescentes; portanto, é preciso considerá-la na prevenção dos vícios. palavras-chave educação infantil, transtornos relacionados ao uso de substâncias, adolescente, educação vocacional, estudos transversais, enfermagem (fonte: decs, bireme). año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 41-52 44 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 introducción el consumo de sustancias psicoactivas por adolescentes es un grave problema de salud pública que ha sido objeto de numerosas investigaciones y de diversas campañas de prevención a lo largo del mundo. sin embargo, y a pesar de los esfuerzos, el inicio del consumo de alcohol, tabaco y otras drogas continúa siendo temprano (1, 2). en el caso de méxico, esto también es una realidad. se estima que en la población general el inicio de consumo de las principales drogas se ubica en la adolescencia tardía (15 a 19 años), donde el de alcohol comienza a los 17,77 años (3), el consumo diario de tabaco a los 20,4 años (4) y el de sustancias ilícitas a los 18,8 años (1). no obstante, la historia es diferente en los individuos que son atendidos en centros de salud debido a las consecuencias del abuso de sustancias. los datos muestran que en ellos la media de edad de inicio para el consumo de alcohol es de 12,99 años, mientras que el tabaco lo comienzan a consumir a los 12,59 años, la marihuana a los 13,15 años y los inhalables a los 12,86 años (5). aquí cobran sentido los hallazgos que indican que el inicio temprano en el consumo de sustancias psicoactivas se asocia con diversas consecuencias a corto, mediano y largo plazo. en múltiples investigaciones se ha señalado que el uso de las drogas se asocia con accidentes, deficiencias en el aprendizaje, bajo desempeño académico, afiliación a grupos delictivos, altos niveles de violencia, mayor posibilidad de adquirir dependencia y de consumir otras sustancias más potentes (6, 7). por ejemplo, se calcula que 47 % de los individuos que consumen alcohol a los 14 años o antes sufren dependencia alguna vez en la vida, comparado con el 9 % de aquellos que inician el consumo a los 21 años o más tarde (8). así mismo, en méxico el servicio médico forense documentó que del total de defunciones a causa de intoxicación por uso de drogas, el 7,3 % correspondió a niños y adolescentes entre 5 y 19 años de edad, los cuales en su mayoría se encontraban fuera de casa (5). por estas razones, una tarea importante para los investigadores en ciencias de la salud es la identificación de los factores que se relacionan con la reducción del riesgo para involucrarse con sustancias, con el fin de incluirlos en programas e intervenciones preventivas dirigidas al retraso en el inicio del consumo de drogas (9). aunque la adolescencia en sí misma es una etapa donde los jóvenes son proclives a llevar a cabo conductas no saludables (10), algunas líneas de investigación se han dirigido al estudio de elementos externos que podrían ser fuentes de riesgo para el inicio del consumo de sustancias. en este sentido, uno de los factores psicosociales que ha recibido mayor atención en el ámbito de las drogodependencias es la crianza parental (11). la crianza parental está constituida por conductas específicas que los padres y las madres usan para la socialización de sus hijos (12), entendida esta última como un proceso donde se incorporan las normas, las costumbres o las ideologías que brindan al individuo las habilidades para adaptarse a la sociedad. en pocas palabras, la crianza parental es un conjunto de mecanismos a través de los cuales los progenitores ayudan a que sus hijos alcancen sus metas de socialización. ahora bien, los esfuerzos por obtener medidas estandarizadas de las múltiples prácticas o mecanismos parentales han resultado en el diseño de diversos instrumentos, algunos que han optado por evaluar la crianza desde la perspectiva de los padres y otros desde el punto de vista de los hijos. en este sentido, una escala que ha obtenido importante aceptación a nivel internacional es el egna minnen beträffande uppfostran (embu) (mis recuerdos de crianza), la cual permite un abordaje de la crianza parental desde la percepción de los hijos. el embu fue desarrollado por perris et al. (13) en suecia, y algunos de los avances más importantes en términos de la medición de la percepción de crianza surgieron del análisis del instrumento en sí. en la década de los ochenta, arrindell et al. (14) concluyeron que de forma inherente a las prácticas de crianza incluidas en el embu, subyacían cuatro factores de primer orden que eran replicados en numerosos países e idiomas: rechazo, calidez, control y favoritismo. la dimensión de rechazo consiste en la hostilidad, crítica, castigo y rudeza de los padres hacia el hijo, mientras que la calidez emocional es el grado en que los hijos se sienten apoyados, queridos y respetados por sus progenitores. por su parte, el control o la sobreprotección incluye un alto grado de intromisión del padre en la vida del hijo, imposición de estrictos límites conductuales, así como protección y control excesivo contra las experiencias negativas. finalmente, el favoritismo es el trato privilegiado de los padres hacia el hijo con respecto a sus hermanos, aunque esta dimensión parece ser específica solo en algunos países y es la que cuenta con menor replicabilidad (15). hoy en día, estas dimensiones son las que permiten la comprensión de la naturaleza de la crianza, y es a través de ellas como toman sentido las relaciones de la crianza parental con la psicopatología y las adicciones. 45 percepción de crianza parental y su relación con el inicio del consumo de drogas en adolescentes mexicanos l miguel ángel villegas-pantoja y otros. la evidencia internacional señala que la percepción de crianza parental positiva por parte de los hijos podría tener efectos protectores contra la aparición de conductas externalizadas como el consumo de drogas lícitas e ilícitas (16). se ha encontrado que una crianza con presencia de afecto, apoyo y monitoreo se relaciona con una menor probabilidad de consumir sustancias en la vida y también con un menor consumo reciente por parte de los hijos (17-19). por su parte, poca comunicación y apoyo para los hijos se asocia con mayor consumo de sustancias como el alcohol, el tabaco y la marihuana (20, 21). no obstante, hay ciertos aspectos por considerar al momento de transferir estos conocimientos al servicio de la práctica clínica con fines terapéuticos o preventivos. la mayoría de las investigaciones dirigidas al estudio de la crianza parental y el consumo de sustancias lo han hecho en términos de la cantidad o frecuencia de consumo, pero no así con el inicio precoz, el cual es preciso conocer para diseñar estrategias dirigidas a la prevención del consumo de drogas. además cabe señalar que, en general, el número de investigaciones latinoamericanas sobre crianza y adicciones es limitado. también se destaca cierta inconsistencia en la conceptualización de la crianza parental, particularmente al emplear de forma intercambiable los términos crianza parental con los estilos de crianza, que son un constructo relacionado pero que se limita al ámbito emocional de los procesos de socialización. y finalmente, persiste el empleo de instrumentos con validez cuestionable que no garantizan la equivalencia conceptual de las dimensiones de crianza. es conocido que la crianza parental posee significados sensibles a la cultura de los participantes (15), diferenciados de acuerdo con el sexo del progenitor (22), por lo que estas situaciones representan vacíos que no permiten la generalización de la evidencia y que obligan a profundizar esta temática. en este sentido, el estudio de la crianza puede ser una fuente de información que permita, a futuro, ampliar la base científica sobre factores que pueden asociarse con el inicio temprano en el consumo de drogas. así mismo, a través de la generación de nuevo conocimiento es posible modificar la práctica del personal sanitario en beneficio del adolescente. en estos aspectos los profesionales de enfermería pueden tener un rol importante ya que, además de ser los trabajadores de la salud con mayor número, también cuentan con una amplia distribución en los diferentes niveles de investigación y de atención a la salud. la contribución de enfermería podría dirigirse al fundamento, diseño y ejecución estratégica del cuidado en la prevención del uso de sustancias psicoactivas a partir de reconsiderar la importancia de las prácticas de los padres en lugar de solo dirigirse a los hijos. por estas razones, se estableció como propósito identificar la relación que existe entre la percepción de crianza parental (global, hacia los padres y hacia las madres) y la edad de inicio en el consumo de drogas lícitas (tabaco y alcohol) e ilícitas (marihuana, cocaína, inhalantes y anfetaminas) en adolescentes de preparatorias técnicas del área metropolitana de monterrey, méxico. materiales y método el estudio tuvo un diseño descriptivo correlacional (23). la población se conformó por 10.805 adolescentes de seis preparatorias técnicas del área metropolitana de monterrey, méxico. el muestreo fue probabilístico y estratificado por institución educativa. el tamaño de la muestra se estimó para un ic 95 %, límite de error de estimación de 0,05 y tasa de no respuesta del 10 %, de manera que se seleccionaron aleatoriamente 416 adolescentes de las listas de alumnos. sin embargo, debido a que el instrumento que mide la crianza parental requiere información sobre ambos padres del participante y, además, que este tenga hermanos o viva con otros adolescentes, se optó por excluir del análisis a los individuos que no pudieran proporcionar datos sobre alguno de sus padres (10 participantes) y a quienes no tuviesen hermanos (9 participantes). de este modo, la muestra final fueron 397 adolescentes, 48,9 % varones y 51,1 % mujeres, con media de edad de 16,4 años (de = 1,08). para recolectar la información se utilizó una cédula de datos personales y de prevalencias de consumo conformada por 16 reactivos dirigidos a reunir información sobre datos biológicos (sexo, edad), sociales (tipo de familia) y del consumo de sustancias (edad de inicio y prevalencia de consumo alguna vez en la vida). así mismo, se empleó la escala de estilos parentales percibidos embu-i “mis memorias de crianza” (13) adaptada para la población mexicana (24). este cuestionario evalúa la crianza parental a través de las memorias de crianza que los adolescentes tienen de sus padres. el cuestionario está compuesto por cuatro subescalas relativas a las cuatro dimensiones que subyacen a la crianza parental: rechazo (caracterizado por castigo, hostilidad y críticas hacia el hijo), calidez (representada por actitudes de afecto, atención, respeto y apoyo), control (protección exagerada, alta imposición de reglas y de obediencia hacia los hijos) y favoritismo (trato privilegiado del hijo en comparación con sus hermanos). 46 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 el instrumento está integrado por 82 reactivos tipo likert de cuatro opciones (no, nunca = 1; sí, algunas veces = 2; sí, frecuentemente = 3; sí, casi siempre = 4), donde 41 reactivos se dirigen a las memorias de crianza paternas y 41 a las maternas. de este modo, el valor mínimo de la escala global (considerando la percepción sobre la crianza materna y paterna) es de 82 puntos y el máximo de 328, donde a mayor puntaje mayor es la percepción de crianza. al considerar la percepción de un solo progenitor, la puntuación mínima es 41 puntos y la máxima 164. el embu-i es uno de los instrumentos de los cuales se ha confirmado mayor solidez psicométrica en diferentes países y grupos de edad, particularmente para las dimensiones de rechazo, calidez y control, que han sido replicadas en países como alemania, australia, españa, francia, holanda, japón, méxico y portugal (15, 25). así mismo, la evidencia indica que en este instrumento la percepción del adolescente corresponde con el reporte de los padres sobre sus prácticas de crianza (22). en la presente investigación se obtuvo un coeficiente alfa de cronbach general de 0,90, mientras que en las dimensiones de crianza se obtuvieron los siguientes coeficientes de consistencia interna: rechazo 0,81, calidez 0,94, control 0,79 y favoritismo 0,64. a excepción de la dimensión de favoritismo —que anteriormente se ha señalado que posee limitada consistencia interna en algunas culturas (15)—, los demás coeficientes son aceptables (23). de la misma manera, la confiabilidad de padres y madres es semejante a la encontrada en méxico por márquez-caraveo et al. (24), quienes obtuvieron coeficientes alfa de cronbach para padres y madres de 0,92 y 0,88 (dimensión de calidez), 0,75 y 0,75 (rechazo), 0,65 y 0,70 (control), y 0,40 y 0,44 (favoritismo) respectivamente. en el presente estudio los coeficientes respectivos para padres y madres fueron los siguientes: calidez, 0,93 y 0,91; rechazo, 0,70 y 0,73; control, 0,66 y 0,69; y favoritismo, 0,51 y 0,45. la presente investigación se apegó a lo dispuesto en méxico por la ley general de salud en materia de investigación para la salud (26). primero se obtuvo la aprobación de los comités de ética e investigación de la universidad autónoma de nuevo león, méxico, y luego se procedió a solicitar autorización a las autoridades de las instituciones educativas. posteriormente se acudió a solicitar las listas de los alumnos de primer a sexto semestre de preparatoria para realizar la selección aleatoria de los participantes por medio de la función para generación de números al azar aleatorio.entre (inferior, superior), incluida en la hoja de cálculo microsoft excel®. después de elegir a los participantes, estos fueron reunidos en un aula para comunicarles los objetivos de la investigación, el tiempo requerido, los horarios y entregar el consentimiento informado del padre o la madre y el asentimiento informado del estudiante (ambos para menores de 18 años) o el consentimiento informado para el estudiante (para mayores de edad). al día siguiente se reunió nuevamente a los participantes y se les solicitaron los documentos; quienes tuvieron ambos documentos firmados permanecieron en el aula y se les entregó un sobre con los cuestionarios, lápiz y papel dentro. posteriormente se dieron las instrucciones de los cuestionarios haciendo hincapié en que su participación sería voluntaria, anónima y confidencial. se trató de no afectar las actividades escolares. al término, los adolescentes introdujeron el cuestionario y la cédula de datos dentro del sobre y lo depositaron en una caja dispuesta en el fondo del aula. en ese momento se dio por finalizada su participación y se agradeció su colaboración. los datos colectados fueron analizados con el programa estadístico ibm spss® versión 20.0 para mac osx y se dio respuesta al propósito de estudio a través de estadística descriptiva e inferencial. la estadística descriptiva consistió en frecuencias, proporciones, medidas de tendencia central y dispersión, así como estimación puntual con ic 95 %. para conocer la distribución de los datos en las variables continuas se usó la prueba de kolmogorov-smirnov con corrección de lilliefors. en este sentido, debido a que no se encontró normalidad, se optó por emplear la prueba no paramétrica coeficiente de correlación de spearman para el análisis inferencial. resultados en lo referente al consumo de sustancias adictivas por parte de los participantes, el consumo de drogas lícitas (alguna vez en la vida) fue el más reportado, particularmente las bebidas alcohólicas, ya que fueron señaladas por más de la mitad de la muestra total. así mismo, en lo que concierne al inicio en el consumo de sustancias psicoactivas se destaca el inicio temprano en todas las drogas. aunque de forma similar a lo encontrado en las prevalencias, las primeras sustancias adictivas con las que tuvieron contacto los adolescentes fueron las lícitas. una excepción fueron las inhalables, droga ilícita con el menor promedio de edad de inicio (tabla 1). 47 percepción de crianza parental y su relación con el inicio del consumo de drogas en adolescentes mexicanos l miguel ángel villegas-pantoja y otros. con relación a los análisis con el coeficiente de correlación de spearman, se apreciaron correlaciones positivas de moderadas a fuertes entre la percepción de crianza parental global, específicamente entre la dimensión de calidez y las edades de inicio en el consumo de cigarrillos (r s = 0,321, p < 0,01), marihuana (r s = 0,479, p < 0,01) y cocaína (r s = 0,808, p < 0,05). estas relaciones indican que a mayor percepción por parte de los participantes, mayor o posterior es la edad de inicio en el consumo de dichas drogas (en la figura 1 se ilustra el comportamiento de la relación entre dichas variables). por otro lado, no se encontraron correlaciones significativas entre la edad de inicio de las diferentes sustancias y la percepción de crianza en las dimensiones de rechazo, control o favoritismo (p > 0,05). aunque no es el objetivo de esta investigación, se encontraron intensas correlaciones positivas entre las edades de inicio en el consumo de las diferentes sustancias adictivas. por ejemplo, la edad de inicio en el consumo de alcohol se correlacionó positivamente con las edades de inicio del consumo de tabaco (r s = 0,664, p < 0,01), marihuana (r s = 0,617, p < 0,01) y anfetaminas (r s = 0,679, p < 0,01); la edad de inicio del consumo de tabaco con las edades de inicio de la marihuana (r s = 0,632, p < 0,01) y las anfetaminas (r s = 0,779, p < 0,05), y la edad de inicio del consumo de marihuana con la edad de inicio en el consumo de cocaína (r s = 0,837, p < 0,01). esto indica que a mayor edad de inicio en el consumo de bebidas alcohólicas, mayor o más tardía será la edad de experimentación con estas tres sustancias psicoactivas. finalmente, al correlacionar la percepción de crianza paterna y materna con las edades de inicio del consumo de sustancias (tabla 2), el mayor número de correlaciones también se presentó en la dimensión de calidez. no obstante, se destaca que existieron tres correlaciones positivas entre la percepción de crianza paterna y el inicio del consumo de sustancias, frente a una correlación en la percepción de crianza materna. ambos casos indican que a mayor percepción de conductas de calidez, mayor o más tardía es la edad de inicio del consumo de sustancias. no obstante, a diferencia de la percepción de crianza global, se encontraron correlaciones significativas en las dimensiones de rechazo, control y favoritismo, aunque la mayoría de menor intensidad. en el caso de la crianza paterna se apreciaron correlaciones negativas en la dimensión de rechazo y positivas en las dimensiones de control y favoritismo. por otra parte, la crianza materna no se correlacionó con la edad de inicio de ninguna droga. en resumen, las edades de inicio del consumo de diferentes drogas se correlacionaron en ocho ocasiones con dimensiones de percepción de crianza paterna, mientras que solo una vez con la percepción de crianza materna. discusión los hallazgos de la presente investigación sugieren que existen relaciones entre la percepción de crianza parental y la edad de inicio del consumo de sustancias psicoactivas, aunque algunas de estas relaciones solo están presentes en las dimensiones de la percepción de crianza paterna. al analizar la crianza de los padres y las madres como un concepto unitario se destacaron relaciones positivas entre la dimensión de calidez y la edad de inicio del consumo de drogas por parte de los adolescentes. esto significa que tabla 1. edad de inicio y prevalencias de consumo de drogas droga edad de inicio prevalencia media de min max ƒ % ic 95% alcohol 14,2 2,0 5 20 280 70,5 [66,0 – 75,0] tabaco 14,4 2,0 5 19 143 36,0 [31,2 – 40,7] marihuana 15,1 1,6 11 18 33 8,3 [5,5-11,0] cocaína 16,0 1,5 14 19 7 1,8 [0,4-3,0] inhalables 14,2 1,7 10 17 17 4,3 [2,2-6,2] anfetaminas 15,3 1,5 13 17 10 2,5 [0,9-4,0] n = 397 figura 1. diagrama de dispersión entre la edad de inicio del consumo de sustancias y la dimensión de calidez 48 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 el hecho de que los hijos perciban un mayor número de prácticas relativas a la expresión física y verbal de aceptación, confianza, apoyo o respeto por parte de los dos padres, se asocia con una mayor edad en el inicio del consumo de sustancias adictivas como el tabaco, la marihuana y la cocaína. estos señalamientos convergen con los de otras investigaciones (17-19) donde se ha encontrado que los comportamientos parentales con predominio de muestras de afecto, respeto, apoyo e interés hacia los hijos constituyen factores protectores contra la cantidad de consumo de sustancias adictivas y otras conductas no saludables. cabe señalar que no se presentaron correlaciones significativas entre las dimensiones de rechazo, control o favoritismo con la edad de inicio en el consumo de drogas. esto quizá tenga relación con la variabilidad de resultados que se han reportado en investigaciones dirigidas a las prácticas parentales. algunos investigadores han encontrado que algunos aspectos relacionados con las dimensiones de rechazo y control —como la poca comunicación y la sobreprotección— se asocian de forma negativa con el consumo de sustancias, por lo que podrían considerarse como factores de riesgo (20, 21). sin embargo, en otros casos el monitoreo y la supervisión (cuando no son intrusivos) pueden prevenir un inicio temprano en el consumo de sustancias (27). estos hallazgos deben interpretarse solo como un punto de referencia tentativo, ya que aunque la sobreprotección, el monitoreo y la supervisión de alguna manera son conductas relacionadas con la dimensión de control del embu-i, en este instrumento no se limitan a esta subescala. además, a diferencia de las investigaciones realizadas con adolescentes de cultura anglosajona, se conoce que en poblaciones latinoamericanas los adolescentes tienden a percibir mayor monitoreo por parte de sus padres, lo cual podría tener un rol diferente en torno al inicio precoz en el consumo de sustancias (28). ahora bien, al realizar las correlaciones de manera independiente para la percepción de crianza paterna y materna, los datos indican que existe cierta diferenciación en relación con la edad de inicio en el consumo de sustancias por parte de los hijos. son destacables dos aspectos dentro de este hallazgo. el primero consiste en que al separar la percepción de crianza paterna y materna se identificaron correlaciones con el inicio del consumo de sustancias en las dimensiones de rechazo, control y favoritismo, mismas que no se presentaron al correlacionar la percepción de crianza vista de forma global. por su parte, en el segundo aspecto sobresale que son las dimensiones de crianza paternas las que tuvieron mayor intensidad y se correlacionaron en mayor número de ocasiones con la edad de inicio del consumo de drogas. el hecho de que existan correlaciones estadísticamente significativas en otras dimensiones diferentes a la calidez al separar los puntajes por sexo del progenitor puede sugerir que las conductas de padres y madres tienen roles diferentes en la iniciación del consumo de drogas por los hijos. esto es relevante ya que la evidencia indica que las diferencias en los puntajes de las escalas del embu-i en función del progenitor suelen ser pequeñas (15), por lo que es posible que existan aspectos inherentes al sexo de los padres que son determinantes en el inicio del consumo de drogas. en el caso de la dimensión de rechazo paterno, esta se correlacionó de forma negativa con la edad de inicio del tabaco y los inhalables, drogas con la edad de inicio más temprana, lo cual indica que a mayor percepción de prácticas que involucran características de hostilidad física y verbal, castigo, crítica o agresión, menor o más temprana es la edad de inicio en dichas drogas. esto coincide con la literatura que señala que experiencias adversas como el abuso físico y emocional, el conflicto y el bajo apego constituyen factores de riesgo para el involucramiento con sustancias psicoactivas (10, 29). sin embargo, también abre el interrogante de por qué no se presentó esta correlación en el caso de las dimensiones maternas ya que, como se señaló, las puntuaciones de rechazo entre padres y madres suelen ser no significativas (15). es posible que el significado de esta dimensión sea diferente para padres y madres de acuerdo con la perspectiva de los hijos, lo cual será necesario evaluar en futuras investigaciones. sin embargo, los datos indican que, al menos en los padres, la percepción de las prácticas de crianza inmersas en la dimensión tabla 2. matriz de correlación entre las dimensiones de crianza paternas, maternas y la edad de inicio del consumo de drogas edad de inicio dimensiones de prácticas de crianza rechazo calidez control favoritismo pa dr e m ad re pa dr e m ad re pa dr e m ad re pa dr e m ad re alcohol -,048 ,006 ,106 ,083 ,093 ,057 -,004 ,022 tabaco -,162* -,134 ,336** ,233** ,228** ,038 ,175* ,096 marihuana -,060 -,136 ,534** ,288 -,042 -,194 ,343* ,203 cocaína -,475 -,268 ,825* ,315 ,061 ,217 ,593 ,709 inhalables -,497* -,293 ,219 ,095 ,108 -,107 ,362 -,365 anfetaminas -,134 -,241 ,531 ,082 -,013 -,329 ,260 ,351 nota. * p < 0,05, **p < 0,01 n = 397 49 percepción de crianza parental y su relación con el inicio del consumo de drogas en adolescentes mexicanos l miguel ángel villegas-pantoja y otros. de rechazo son las que se correlacionan de forma negativa con el inicio del consumo de sustancias, por lo que es posible que estén involucradas en la experimentación temprana con sustancias por parte de los hijos. esto constituye un factor de riesgo mayor si se considera que las drogas de inicio más temprano posteriormente sirven de transición hacia sustancias ilícitas (30), y que entre más temprano inicia el consumo, mayor es la probabilidad de aumentar la cantidad y frecuencia de ingestión (10). por esta razón, es preciso que el personal de salud se dirija a evitar el consumo de drogas en etapas tempranas de la vida. en el caso de la dimensión de calidez se detectaron cuatro correlaciones positivas con la edad de inicio de drogas (tres en el caso de los padres y una para las madres). esto coincide con la relación encontrada en la dimensión de calidez global, donde a mayor puntuación en dicha escala mayor es la edad de inicio en el consumo de sustancias; sin embargo, revela que nuevamente es la percepción de la crianza paterna la que se correlaciona en mayor número e intensidad. esto es importante porque tradicionalmente se han reportado mayores puntuaciones con relación a la calidez emocional en las madres en comparación con los padres (14, 22) y, en muchas ocasiones, los estudios solo se han dirigido al estudio de la crianza materna. al igual que en otras investigaciones (16, 21), los hallazgos sugieren que la afectividad por parte de los progenitores posiblemente tiene un rol elemental en la experimentación con sustancias psicoactivas por parte de sus hijos, aunque nuestros datos apoyan la importancia de la implicación afectiva por parte de los padres y no solo de las madres. desde el punto de vista del profesional de enfermería esto puede tener importantes implicaciones terapéuticas, puesto que se puede actuar para promocionar conductas parentales pertenecientes a la dimensión de calidez, donde la implicación afectiva sea una herramienta de prevención contra comportamientos no saludables como las drogodependencias. así mismo, la modificación de las prácticas de crianza podría ser una estrategia a largo plazo, ya que hay evidencias que demuestran una posible transmisión de los estilos educativos de generación a generación (31). con respecto a la dimensión de control, la correlación positiva entre la percepción de crianza paterna y la edad de inicio en el consumo de tabaco también indica que, por ejemplo, a mayor percepción de imposición de obediencia, control de la conducta y sobreprotección, más tardía será la iniciación en el consumo de cigarrillos. esto concuerda de alguna manera con investigaciones (21, 27) que han descrito al monitoreo y la supervisión como un factor protector frente al consumo de sustancias. no obstante, también difiere de los hallazgos (16) que no indican asociaciones entre el monitoreo y un inicio temprano en el consumo de sustancias legales, y con aquellos donde una mayor imposición se asocia con mayor número de conductas no saludables por parte de los hijos (32). esta relación toma sentido al considerar que en el embu-i la escala de control tiene una correlación positiva con la dimensión de calidez e incluye aspectos como la preocupación de los padres por la seguridad de los hijos, imposición de obediencia o altas expectativas de logro, características de la alta implicación de los padres con los hijos. no obstante, sería necesario evaluar hasta qué punto estas conductas pueden ser benéficas para la formación de los adolescentes, puesto que es probable que las prácticas de crianza relativas a la dimensión de control tengan implicaciones a largo plazo en aspectos como la autorregulación y psicopatologías en los hijos (33). finalmente, en la subescala de favoritismo la percepción de crianza paterna se correlacionó positivamente con la edad de inicio del consumo de tabaco y marihuana. estas correlaciones señalan que a mayor predilección del padre por el adolescente, mayor es la edad de inicio en el consumo de cigarrillos o marihuana. dicho de otra forma, se posterga el inicio en el consumo de tabaco. aunque no hay estudios que permitan la comparación de la correlación en esta subescala, el hecho de que los padres tengan un trato favorable hacia un hijo en comparación con sus hermanos puede sugerir un tipo de implicación afectiva. esto, como se mencionó, constituye un factor de protección y podría postergar el inicio precoz en el consumo de sustancias (16, 21). no obstante, en investigaciones realizadas en otros países (14) se ha sugerido que algunos reactivos de la dimensión de favoritismo también son representativos de la dimensión de rechazo, donde el favorecimiento de los hermanos constituye una forma de rechazo al individuo y, por tanto, podría ser un factor de riesgo. esto quizás explica la baja consistencia interna obtenida en la dimensión de favoritismo en el presente estudio, por lo que se sugiere ser cautelosos en la interpretación de dichos hallazgos. sin embargo, esto debe motivar a continuar validando el contenido de la subescala de favoritismo y del embu-i, con el fin de comprobar la importancia de las relaciones entre la percepción de crianza parental y las adicciones, así como con otras psicopatologías presentes en los diferentes entornos sanitarios y comunitarios. 50 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 dentro de las limitaciones de este estudio se encuentra su naturaleza transversal, misma que limita la explicación de relaciones causales. en cuanto a los instrumentos empleados, estos se basan en el reporte de los participantes y no en observaciones directas, por lo cual la información no puede ser verificada y es susceptible de sesgo por parte de quienes participan. así mismo, aunque la muestra fue aleatorizada, incluyó adolescentes escolarizados de preparatorias técnicas de una misma región del norte de méxico, por lo que es posible que no representen efectivamente a poblaciones de adolescentes de otras regiones. como recomendaciones para futuras investigaciones se sugiere realizar réplicas en diferentes poblaciones de adolescentes, así como continuar contribuyendo a la validación del embu-i. también es preciso emplear diseños longitudinales que permitan conocer el comportamiento de padres e hijos a lo largo de tiempo, así como su influencia sobre conductas de riesgo como las drogodependencias, ya que es posible que la crianza parental percibida por los hijos varíe en función de la edad (34). finalmente, se recomienda controlar el efecto de variables como el consumo de sustancias por parte de los progenitores y, en lo posible, medir la crianza parental desde el punto de vista de los padres, esto con el fin de conocer la convergencia del reporte de padres-hijos. conclusión los resultados de la presente investigación aportan conocimientos sobre la relación de la percepción de la crianza parental y la edad de inicio en el consumo de sustancias psicoactivas por parte de los adolescentes. estos hallazgos indican que posiblemente la crianza que ejercen los padres y las madres hacia los hijos podría tener un papel importante en la vida de los adolescentes para el inicio del consumo en ciertas drogas. esto implica que el personal de enfermería y demás profesionales de la salud adopten un rol protagónico al contribuir a fundamentar y diseñar estratégicamente un cuidado efectivo —a nivel clínico y comunitario— en el retraso del inicio del consumo de sustancias mediante el desarrollo de programas de orientación e intervenciones preventivas dirigidas hacia el manejo de la crianza parental. con base en los hallazgos —donde la dimensión de calidez fue la que se correlacionó con mayor intensidad— se recomienda enfatizar la importancia de las muestras afectivas en la relación padre-hijo, el uso de estrategias de crianza no hostiles, el involucramiento parental y el monitoreo de los padres como factores protectores ante el inicio del consumo de drogas. a diferencia de las estrategias de prevención dominantes, es preciso dirigirse a la modificación de factores externos como las conductas parentales, en lugar de limitarse a las conductas de los adolescentes. así mismo, en el presente estudio se destaca el rol que tiene la crianza paterna, de modo que es preciso involucrar tanto a padres como a madres en la prevención de estas conductas de riesgo. sin embargo, es necesario continuar investigando la relación entre estas variables con el empleo de diferentes metodologías y aproximaciones, ya que aún existen vacíos de conocimiento. se recomienda realizar replicaciones utilizando el embu-i con adolescentes de diferentes contextos para contribuir a la validez del instrumento y así conocer si estos hallazgos son consistentes y generalizables. de igual manera, es preciso realizar estudios que permitan conocer el significado de las dimensiones de crianza y las relaciones causa-efecto que pueden existir con diversas psicopatologías. 51 percepción de crianza parental y su relación con el inicio del consumo de drogas en adolescentes mexicanos l miguel ángel villegas-pantoja y otros. referencias 1. instituto nacional de psiquiatría ramón de la fuente muñíz, instituto nacional de salud pública, secretaría de salud. encuesta nacional de adicciones 2011. reporte de drogas. 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[visitado 2012 febrero 25]. disponible en: http://www.salud.gob.mx/unidades/cdi/nom/compi/rlgsmis.html 27. kiesner j, poulin f, dishion tj. adolescent substance use with friends: moderating and mediating effects of parental monitoring and peer activity contexts. merrill palmer q (wayne state univ press). 2010;56(4):529:56. 28. shakib s, mouttapa m, anderson-johnson c, ritt-olson a, trinidad dr, gallaher pe, et al. ethnic variation in parenting characteristics and adolescent smoking. j adolesc health. 2003;33:88-97. 29. arteaga i, chen c, reynolds aj. chilhood predictors of adult substance abuse. child youth serv rev. 2010;32:1108-20. 30. hernández t, roldán j, jiménez a, mora c, sánchez-gárnica de, pérez mt. la edad de inicio en el consumo de drogas, un indicador de consumo problemático. interv psicosoc 2009;18(3):199-212. 31. lopes f, espirito-santo h, vicente h. intergenerational transmission of perceived parental rearing styles: a three generation families study. european psychiatry 2013;28(suppl 1):1. 32. palacios jr, andrade p. influencia de las prácticas parentales en las conductas problema en adolescentes. ciencias sociales y humanidades. 2008;7:7-18. 33. baker cn, hoerger m. parental child-rearing strategies influence self-regulation, socio-emotional adjustment, and psychopathology in early adulthood: evidence from a retrospective cohort study. pers individ dif. 2012;52:800-5. 34. deković m, have m, vollebergh wam, pels t, oosterwegel a, wissink ib, et al. the cross-cultural equivalence of parental rearing measure: embu-c. eur j psychol assess. 2006;22(2):85-91. nursing diagnoses and interventions in women with hypertensive disorders of pregnancy: a scoping review article nursing diagnoses and interventions in women with hypertensive disorders of pregnancy: a scoping review diagnósticos e intervenciones de enfermería en mujeres con hipertensión inducida en el embarazo: revisión de alcance diagnósticos e intervenções de enfermagem em mulheres com distúrbios hipertensivos da gravidez: revisão de escopo 10.5294/aqui.2022.22.3.6 joão cruz neto 1 paula suene pereira dos santos 2 maria clara barbosa e silva 3 rachel de sá barreto luna callou cruz 4 izabel cristina santiago lemos de beltrão 5 dayanne rakelly de oliveira 6 1 0000-0002-0972-2988 universidade regional do cariri, brazil. joao.cruz@urca.br 2 0000-0001-6463-7316 universidade regional do cariri, brazil. paulasuene.pereiradossantos@urca.br 3 0000-0002-1825-4493 universidade regional do cariri, brazil. mariaclara.barbosa@urca.br 4 0000-0002-4596-313x universidade regional do cariri, brazil. rachel.barreto@urca.br 5 0000-0002-3236-5616 universidade regional do cariri, brazil. izabel.lemos@urca.br 6 0000-0003-2911-141x universidade regional do cariri, brazil. dayanne.oliveira@urca.br received: 10/15/2021 sent to peers: 12/14/2021 approved by peers: 05/04/2022 accepted: 05/09/2022 theme: evidence-based practice. contribution to the subject: this study offers contributions to identifying diagnoses and interventions to formulate clinical indicators. however, it was possible to observe that the number of studies on the theme is still developing, which may indicate a probable devaluation in nurses' use of the nursing process. in addition, it is noted that the theme has been gradually implemented, and, with the findings, novel studies can promote care for women with pregnancy hypertensive disorders. to reference this article / para citar este artigo / para citar este artículo: cruz neto j, santos psp, silva mcb, cruz rsblc, beltão icsl, oliveira dr. nursing diagnoses and interventions in women with hypertensive disorders of pregnancy: a scoping review. aquichan. 2022;22(3):e2236. doi: https://doi.org/10.5294/aqui.2022.22.3.6 abstract objective: to map the diverse scientific evidence on nursing diagnoses and interventions in women with pregnancy hypertensive disorders under primary health care. materials and method: a scoping review was conducted through nine stages in seven databases and the thesis and dissertation catalog of the coordinating office for improving higher education personnel. the search was performed from january to march 2021. results: a total of 2,505 articles were retrieved, of which five were included in the final review. nine primary diagnoses from the 2009-2011 version of nanda-i were identified. each diagnosis was classified according to physical, psychological, behavioral, and environmental characteristics. the interventions were related to controlling pain, anxiety, hemodynamic dysfunctions, self-esteem level, fluid replacement, patient/environment hygiene, and sleep-rest ratio. conclusions: the nursing diagnoses and interventions presented in this study corroborate the clinical practice and aid nursing professionals' reasoning. keywords (source decs): pregnancy-induced hypertension; nursing diagnosis; standardized nursing terminology; primary health care; pregnant woman. resumen objetivo: mapear las evidencias científicas acerca de los diagnósticos e intervenciones de enfermería en mujeres con hipertensión inducida en el embarazo en la atención primaria de salud. materiales y método: scoping review en nueve etapas, en siete bases de datos y en el catálogo de tesis de la coordinación de perfeccionamiento de nivel superior de brasil. se realizó la búsqueda de enero a marzo de 2021. resultados: se recopilaron 2505 artículos, de los cuales cinco se excluyeron en la revisión final. nueve diagnósticos principales de la versión 2009-2011 de la nanda-i. se clasificó cada diagnóstico en cuanto a las características físicas, psicológicas, comportamentales y ambientales. las intervenciones se relacionaron con el control del dolor, de la ansiedad, de las disfunciones hemodinámicas, del nivel de autoestima, de la reposición hídrica, de la higienización del paciente/ambiente y a la relación sueño-reposo. conclusiones: los diagnósticos e intervenciones de enfermería presentados en el estudio corroboran la práctica clínica y auxilian en el razonamiento del profesional de enfermería. palabras clave (fuente decs): hipertensión inducida en el embarazo; diagnóstico de enfermería; terminología normalizada de enfermería; atención primaria de salud; mujeres embarazadas. resumo objetivo: mapear as evidências científicas sobre os diagnósticos e intervenções de enfermagem em mulheres com distúrbios hipertensivos da gravidez na atenção primária à saúde. materiais e método: scoping review em nove etapas, em sete bases de dados e no catálogo de teses e dissertações da coordenação de aperfeiçoamento de nível superior. realizou-se a busca de janeiro a março de 2021. resultados: 2505 artigos foram recuperados, dos quais cinco foram incluídos na revisão final. nove diagnósticos principais da versão 2009-2011 da nanda-i. classificou-se cada diagnóstico quanto às características físicas, psicológicas, comportamentais e ambientais. as intervenções foram relacionadas ao controle da dor, da ansiedade, das disfunções hemodinâmicas, do nível de autoestima, da reposição hídrica, da limpeza do paciente/ambiente e à relação sono-repouso. conclusões: os diagnósticos e intervenções de enfermagem apresentados neste estudo corroboram a prática clínica e auxiliam no raciocínio do profissional de enfermagem. palavras-chave (fonte decs): hipertensão induzida pela gravidez; diagnóstico de enfermagem; terminologia padronizada em enfermagem; atenção primária à saúde; gestantes. introduction global data reveal that hypertensive disorders of pregnancy (hdps) increased by 10.92 % in 30 years, with their incidence rising from 16.30 million to 18.08 million cases and 27,830 deaths. in latin america, the data on incidence and death are 3.29 x 104 and 0.42 x 103 million, respectively (1). in this sense, hypertensive disorders are significant pathologies that require specific care measures during pregnancy (1, 2). hdps constitute a group of clinical diseases that can interfere with the progression of pregnancy and, in some cases, lead to maternal and fetal death (3). the clinical spectra of these pathologies range from a chronic state, such as chronic arterial hypertension, to eclampsia, a cardioneural dysfunction with imminent seizures (4). in treating hdps and other conditions related to pregnancy, nurses play an essential role in prevention, identification, and health promotion activities, especially in primary prevention (5, 6). in the nurses' work process, the clinical and critical judgment stands out, highlighting human responses and culminating in formulating nursing diagnoses and interventions (7, 8). clinical judgment ability subsidized by standardized nursing languages applies. standardized languages or taxonomies are forms of communication among nursing professionals worldwide by standardizing the professional language and assisting in writing and prescribing care. in the case of nanda-i, in addition to standardization, there is the benefit of classifying human responses utilizing scientifically-validated diagnoses (8). systematizing care through diagnoses and interventions in clinical practice is related to the accuracy of health evidence, better patient quality of life, and reduced mortality (9). therefore, efforts are implemented in the services and systems that provide care to the most different life cycle phases, especially during pregnancy, to consolidate terminological structures that assist nurses in health-related decisions (10). a study that evaluated the difficulties nurses face in implementing the systematization of nursing care revealed that the nursing diagnosis is one of the most challenging phases in the execution of the nursing process. however, it is the most used in professional practice, which is mainly related to a lack of time and the wrong reasoning that many nurses still have regarding human responses; in addition, it makes use of the limited diffusion of specialized language, a good nursing history, and excess of activities, which highlights the need to improve care quality (11). however, even with the advances in standardized terminological languages and the use of international taxonomies, little has been produced about the care of pregnant women with hypertensive disorders, which has become an essential scientific gap, especially for professionals dealing with this population segment. it is through these health indicators, that is, nursing diagnoses, interventions, and records, that there is a possibility of scientific advancement in the profession with significant dissemination of knowledge, a wide crossing of data, and improvement of structures that promote the teaching, research, and propositional dialogic of critical judgment (9). thus, there is a need to unite nursing diagnoses and interventions as a complementary tool to the care practice, whose findings support nurses' critical and reflective judgment. from this perspective, scoping review studies analyze and identify knowledge gaps, becoming pertinent to the study. consequently, the objective is to map the diverse scientific evidence about the nursing diagnoses and interventions in women with hdps treated in primary health care. materials and method this scoping review is based on the guidelines proposed by the joanna briggs institute and developed in nine stages: title; title and question development; introduction; inclusion criteria; research strategy; selection of the evidence sources; data extraction; analysis of the evidence, and presentation of the results (12). the method follows the "pcc" acronym —population, concept, and context— which assists in elaborating the research guiding question, comprising the topics listed below: population — hypertensive pregnant women; concept — nursing diagnoses and interventions; and context — primary care. thus, the following guiding question was defined: "which is the diverse scientific evidence about the nursing diagnoses and interventions in women with hdps treated in primary care?" the research was conducted in the following databases: medical literature analysis and retrieval system (medline) via pubmed, web of science (wos), banco de dados da enfermagem (bdenf), literatura latino-americana e do caribe em ciências da saúde (lilacs), and cumulative index to nursing and allied health literature (cinahl) through access to the journals portal of the coordinating office for improving higher education personnel (coordenação de aperfeiçoamento de pessoal de nível superior, capes). in addition, the search was extended to the capes thesis and dissertation catalog, including the gray literature. data collection was conducted between january and march 2021. the articles were searched and analyzed by two different researchers, with a third being invited when there was disagreement regarding the inclusion of studies. descriptors from the medical subject headings (mesh) of the pubmed portal combined with the and and or operators were used for the medline and wos databases. the descriptors in health sciences (descritores en ciências da saúde, decs) were used for the lilacs and bdenf databases, and the cinahl titles were applied to the cinahl database. for the capes database, the "nursing diagnosis" and "pregnancy-induced hypertension" descriptors were combined with the and operator. table 1 presents the search terms with the crossings used. table 1. search strategy in the databases. brazil, 2021 database search strategy medline descriptors (mesh) [title/abstract]: "pregnant women" or "hypertension, pregnancy-induced" or "hypertensive pregnant women" and "nursing diagnosis" or "standardized nursing terminology" or "classification of nursing interventions" or "international classification for nursing practice" or "nanda-i" or "cipe terminology" or "terminology in nursing" and "primary care nursing" "primary health care"; "prenatal care." cinahl descriptors (mesh): "pregnant women" or "hypertension, pregnancy-induced" or "hypertensive pregnant women" and "nursing diagnosis" or "standardized nursing terminology" or "classification of nursing interventions" or "international classification for nursing practice" or "nanda-i" or "cipe terminology" or "terminology in nursing" and "primary care nursing"; "primary health care"; "prenatal care." wos descriptors (mesh): "pregnant women" or "hypertension, pregnancy-induced" or "hypertensive pregnant women" and "nursing diagnosis" or "standardized nursing terminology" or "classification of nursing interventions" or "international classification for nursing practice" or "nanda-i" or "cipe terminology" or "terminology in nursing" and "primary care nursing"; "primary health care"; "prenatal care." lilacs descriptors (decs): "pregnant women" or "hypertension, pregnancy-induced" or "hypertensive pregnant women" and "nursing diagnosis" or "standardized nursing terminology" or "classification of nursing interventions" or "international classification for nursing practice" or "nanda-i" or "cipe terminology" or "terminology in nursing" and "primary care nursing"; "primary health care"; "prenatal care." bdenf descriptors (decs): "pregnant women" or "hypertension, pregnancy-induced" or "hypertensive pregnant women" and "nursing diagnosis" or "standardized nursing terminology" or "classification of nursing interventions" or "international classification for nursing practice" or "nanda-i" or "cipe terminology" or "terminology in nursing" and "primary care nursing"; "primary health care"; "prenatal care." source: own elaboration. the inclusion criteria were established: complete studies available through capes electronic access, qualitative and quantitative empirical studies, literature reviews, and theoretical-reflective studies in portuguese, english, or spanish, which answered the guiding question. duplicate studies were counted only once. however, studies related to the hdp care measures performed by other health team members were excluded, as well as those not that were not associated with primary care. initially, duplicate studies were removed after two researchers independently read the titles and abstracts; subsequently, those that did not meet the inclusion criteria were discarded. the researchers then independently reviewed the full texts. a third reviewer was called upon in case of disagreements. after applying the criteria, the articles selected were read in full, evaluated, and selected following the analysis of their references through the mendeley manager in search of potential studies that could be incorporated. no period was predefined to find the highest possible number of articles related to the topic. for analysis purposes, the nanda-i diagnosis titles found in the studies were linked to the respective updates of the 2021-2023 version. consequently, five articles were included in this review after the analysis. the data were extracted into a microsoft excel® spreadsheet and later organized into tables: authors, year of publication, database, journal, country, design, sample, level of evidence, delivery type, gestational age, nursing judgment, and outcomes. each article was described and analyzed narratively according to the pertinent literature. the diverse evidence was classified into seven levels: i — evidence from systematic reviews or meta-analysis of clinical trials; ii — evidence from at least one well-designed controlled randomized clinical trial; iii — clinical trial studies without randomization; iv — cohort and case-control studies with a detailed design; v — systematic review of descriptive or qualitative studies; vi — including at least one qualitative study; and vii — opinion of authorities or experts' reports (13). the study's methodological quality was ensured by the preferred reporting items for systematic review and meta-analyses extension for scoping review — prisma-scr checklist [14]. the prisma recommendations and a flowchart arranged in four phases were observed for selecting the studies (15), as described in figure 1. figure 1. flowchart of the process of identification, selection, and inclusion of the studies according to the prisma recommendation. brazil, 2021 source: own elaboration. the study follows resolution 510/2016 issued by the national health council, which waives approval by a research ethics committee for review studies. however, the method, authorship, and fidelity of the data obtained are preserved. results the final sample comprised five studies published between 2004 and 2011, all from brazil. regarding the research design, all the studies are of the descriptive type. concerning the sample, the studies included 71, 15, 10, 3, and 1 pregnant woman. the population of the studies corresponded to women with hdp diagnoses. the characterization of the studies is described in table 2. table 2. characterization of the studies included in the review. brazil, 2021 author (year) country study design sample nursing judgment results level of evidence herculano, maria, sousa, emille, galvão, caetano, et al. (2011) (16) brazil descriptive pregnant women (n = 1) delivery type: c-section diagnoses and interventions six nursing diagnoses were identified: acute pain, anxiety, the risk of activity intolerance, readiness for enhanced self-care, the risk of disturbed maternal-fetal dyad, and impaired comfort vi aguiar, freire, cruz, linard, chaves, rolim (2010) (17) brazil descriptive pregnant women (n = 15) ga* = 24-40 weeks diagnoses and interventions eleven nursing diagnoses were found. the most frequent were: risk of infection, acute pain, low situational self-esteem, excess fluid volume, nausea, sleep deprivation, and risk of impaired liver function. prescription of the care measures was performed based on the nursing intervention classification. vi reiners, dióz, teixeira, gonçalves (2009) (18) brazil descriptive pregnant women (n = 10) diagnoses thirteen nursing diagnoses were identified, of which insufficient knowledge of their health problem, ineffective health maintenance, ineffective control of the therapeutic regime, anxiety, disturbed sleep pattern, disturbed self-image, disturbed sexuality patterns, and excess fluid volume were the most frequent. vi santos, silva, silva, aragão (2007) (19) brazil descriptive pregnant women (n = 3) diagnoses in addition to insufficient knowledge, 15 diagnoses were related to the physiological changes inherent to pregnancy. other diagnoses were related to the pathologies inherent to pregnancy, fatigue, sleep deprivation, and sleep pattern diagnoses. vi gouveia, lopes (2004) (20) brazil descriptive pregnant women (n = 71) delivery type: forty-five vaginal deliveries and 30 c-sections diagnoses the nursing diagnoses were determined according to the north american nursing diagnosis association taxonomy. the nursing diagnoses found in 50 % or more of the pregnant women were a risk of infection, impaired health maintenance, impaired comfort, the risk of ineffective breastfeeding, disturbed sexuality patterns, fear, and pain. vi * ga: gestational age. source: prepared by the authors. the diverse evidence was categorized according to the nursing judgment, represented by diagnoses or interventions. portuguese, english, and spanish publications on the theme investigated are scarce. as for the nursing diagnoses, all the studies used different editions of the nanda-i taxonomy, considering the 2009-2011 version (80 %) and one (20 %), the 1999-2000 version. the most frequent nursing diagnoses in women with hdps are acute pain (00132), excess fluid volume (00026), and anxiety (00146). the primary diagnoses were listed in table 3, and their characteristics were presented according to the literature. table 3. primary diagnoses shown in the literature according to nanda-i, crato, ceará, brazil, 2021 title acute pain domain domain 12 — comfort class/code physical comfort/00132 characteristics physical: headache (17), epigastralgia (17), pain in the right hypochondrium (17), pain in the lower abdomen (17), pain in the left lateral decubitus position (17), harmful biological agent (16), uterine contractions (18), spasms of lower back muscles (18) title excess fluid volume domain domain 2 — nutrition class/code hydration/00026 characteristics physical: urinary retention (17) and venous compression by gravid uterus (18) title anxiety domain domain 9 — coping/stress tolerance class/code coping responses/00146 characteristics psychological: concern with a clear threat to maternal-fetal state (16), problems in the family with an actual threat to the fetus (18) behavioral: sleep pattern (16), eating habits (16) environmental: infant's health status (18) physical: physiological eliminations (17), delivery (18) title impaired comfort domain domain 12 — comfort class/code physical comfort/00214 characteristics psychological: anxiety (16-18), fear (16-18) behavioral: lack of control over the situation (17, 18) physical: feeling uncomfortable (16, 18), increased volume due to pregnancy (16, 18) title ineffective health maintenance domain domain 1 — health promotion class/code health management/00099 characteristics psychological: anxiety, motivation (18) behavioral: lack of time, number of household chores (18) environmental: lack of time (18) physical: barrier due to secondary understanding (18) title fear domain domain 9 — coping/stress tolerance class/code coping responses/00148 characteristics psychological: delivery time (18) title risk of infection domain domain 11 — safety/protection class/code infection/00004 characteristics physical: invasive procedures with peripheral accesses and indwelling bladder catheterization (17) title disturbed sleep pattern domain domain 4 — activity/rest class/code sleep/rest/00198 characteristics psychological: anxiety (16-18) environmental: change of environment (16-18) behavioral: stress (16-18) physical: physical discomfort in the positions in bed (16-18) title constipation and risk of constipation domain domain 3 — elimination and exchange class/code gastrointestinal function/00011 and 00015 characteristics environmental: changes in diet (18) behavioral: low intake of fibers and liquids (17) physical: decreased peristalsis in the face of pregnancy (18); irregular bowel movements (17); impaired physical mobility (19) source: own elaboration. other less representative nursing diagnoses were the following: nausea associated with increased progesterone (17); ineffective sexuality pattern due to enlargement of the pregnant abdomen; dysfunction of urinary elimination and psychological problems (18); the risk of activity intolerance due to the presence of circulatory issues and clinical conditions such as pre-eclampsia and eclampsia (16), and fatigue (19, 20). less frequent diagnoses were low situational self-esteem (00153 [17]), insufficient knowledge (00126 [18]), ineffective health management (00078 [18]), bathing self-care deficit (00108 [20]), impaired dentition (00048 [20]), willingness to improve self-care (00182 [16]), disturbed body image (00118 [18]), impaired skin integrity (00046 [20]), impaired physical mobility (00085 [19]), disrupted family processes (00060 [18]), the risk of disturbed mother-fetus dyad (00209 [16]), the risk of impaired liver function (00178 [17]), ineffective breastfeeding (00104 [20]), and the chance for impaired fatherhood or motherhood (00057 [20]). in general, diagnoses such as low self-esteem, disturbed body image, and interrupted family processes are related to the partner's absence in the hospitalization process, changes in the body, and departure of the partner from the house, respectively (17, 18). in addition, insufficient knowledge and ineffective health management are related to a lack of access to information, a lack of time, anxiety, and the number of tasks to manage (18). regarding fetal and maternal vitality, there is a risk of the mother-fetus dyad being disturbed due to pregnancy and the chance of impaired liver function related to complications during pregnancy, such as increased liver enzymes (tgo and tgp), in addition to a reduction in oxygen flow. readiness for self-care is manifested in the search for independence in health maintenance (16). the nursing interventions are presented in figure 2. figure 2. primary nursing interventions implemented in women with hdps. ceará, brazil, 2021 nursing interventions monitoring hemodynamic dysfunctions (16, 17) • assessing the signs and symptoms of hepatic complications, instructing on low sodium and low protein diet, when necessary • catheterization to improve urinary elimination, if necessary • monitoring waste and taking down the characteristics • assessing constipation • elimination pattern • hydro-air sounds patient or environment hygiene (16, 17) • handwashing • monitoring closed drainage system and changing it every 15 days • watching urine characteristics • exchanging intravenous access every 72 hours • aseptically managing infection-prone sites to ease the hygiene measures fluid replacement (16, 17) • assessing edema/anasarca • assessing intake-elimination • assessing hydration • administering antiemetics • intervals between fluids and food • monitoring the vital signs and plasma and liver serum values anxiety management (16, 17) • early identification of the problem • calming the patient down • offering reliable information • favoring the family's comfort • promoting empathy and qualified listening • controlling environmental stimuli sleep/rest ratio (16, 17) • use of analgesics • controlling environmental stimuli • adapting the circadian rhythm • recording the sleep pattern pain management (16, 17) • observing the systematic evaluation of local pain • administering analgesics • monitoring side effects • monitoring lochia self-esteem level (16, 17) • maintaining self-esteem with an affirmation of positive points related to the pregnancy process; personalvalues are found, and new meanings are elaborated. source: own elaboration. the nursing interventions were related to the hemodynamic care of patients with hdps. thus, the care directed to hemodynamic issues with the characteristics of the disorders that affect the liver, kidneys, gastrointestinal and respiratory systems, both weakened by hdps, stands out. in addition, fluid replacement and anxiety and pain control are essential to improve pregnant women's quality of life. environmental cleaning and sleep and rest preservation are included in this type of care, in addition to better self-esteem levels. discussion monitoring pregnant women during the prenatal, delivery and postpartum periods is one of the nursing team's duties, especially for nurses who identify needs that can become health problems, such as hdps (21, 22). hdps have four clinical spectra, namely: chronic hypertension, chronic hypertension with superimposed pre-eclampsia, preeclampsia, and gestational hypertension (4). they all require substantial clinical knowledge to identify the needs inherent to human responses and determine the best diagnoses, with a view to interventions and results aligned and accurate to each condition. the systematization of nursing care is the framework used in the nursing care organizational process; however, these activities can only be supported by the nursing process, which marks five well-defined, interrelated, interdependent, and recurrent stages; that is, it employs an operational tool to strengthen the essence of the professional nursing practice (23). however, the studies showed the diagnoses and interventions as stages included in the nursing process. to support this practice, not only in the obstetrics area but also in all specialties, nursing has expanded the specialized terminologies and classification systems, with the nanda international taxonomy, the international classification for nursing practice, and classifications for nursing outcomes and interventions as some of their representatives (24, 25). in this case, this research revealed nanda-i as the most often used taxonomy among nursing professionals. in this study, nurses have dedicated part of the nursing diagnoses directed to women with hdps to the pain, fluid volume, and anxiety responses. a survey of 1,000 medical records of pregnant women in the pre-delivery and delivery rooms found that the pain diagnosis was the most frequent, related to uterine contractions (26). several studies relate anxiety and psychological problems in pregnant women to not having control over childbirth, dealing with premature, medicalized, and unexpected deliveries, and fearing for their life and their child's life (27, 28). regarding the excess fluid volume diagnosis, a study (29) proved the physiological factors that lead to the decrease in glomerular perfusion due to the increase in pressure as proposals for reducing the fluid volume; however, sodium intake and changes in the hormonal system can precipitate water retention. in pregnancies marked by hypertension, as in the studies found for the review, cardiography tests can reveal extracellular and cardiac output changes, which are different from pregnant women without complications due to increases in these parameters since the first gestational weeks (30). other diagnoses in the study were impaired comfort, ineffective health maintenance, fear, and risk of infection. the same diagnoses were noticed in a study conducted with parturient women in an obstetric center from bahia, brazil, in which all 152 women investigated had diagnoses of impaired comfort related to anxiety, fear, sleep deprivation, and others; risk of infection related to inadequate primary defenses; and fear related to increased tension. however, ineffective health management was only present in 40 % of pregnant women (31). the feeling of fear, even with the delivery moment approaching, is an integral part of the maternal feelings, as it reflects a moment of vulnerability and anxiety, which may or may not alter psychological and emotional well-being (32). in the risk of infection, it is vital to highlight the complications related to urinary tract infection during pregnancy, anesthesia, and the professional actions themselves, in addition to invasive devices (33). the constipation diagnosis was found in three studies included in this review. constipation is related to bad eating habits, such as low fiber and water intake, and a low or nonexistent relationship with physical activity (34). in turn, a research study (35) showed that a sedentary lifestyle and a body mass index greater than 24 influence intestinal transit, leading to constipation in pregnancy. nausea was another diagnosis found in this review. in this case, hyperemesis gravidarum is a major complication of nausea and vomiting in pregnancy. medications such as ondansetron and metoclopramide proved good for symptom remissions (36). the "ineffective sexuality pattern" and "risk of activity intolerance" diagnoses, cited in studies conducted with women with hdps, were also made in most pregnant women. the sexuality pattern is intertwined with positive and negative changes related to the discomforts of pregnancy and psychological changes, making it extremely necessary to change the sexual practices, as required by the pregnant woman, often linked to the fear of "touching the infant" (37). activity intolerance is based on the premise that weight interferes with exercise, a fact refuted by different studies showing that moderate to light physical activities have positive impacts both on the fetus and the mother, improving growth and development, even in activities of daily living (38, 39). fatigue was the last diagnosis most often quoted in the studies, reaching 40 %. a study conducted with 582 pregnant women in iran showed that this symptomatology is associated with low quality in the marital relationship and with little or no support from the husband in the puerperal-pregnancy process (40). other 5,079 pregnant women reported frequent fatigue at the beginning of their pregnancies, affecting sleep quality (41). other diagnoses were rarely mentioned by the authors of the studies included in the review: risk of impaired fatherhood or motherhood, ineffective health management, insufficient knowledge, interrupted family processes, the risk of disturbed mother-fetus dyad, and the risk of constipation. these diagnoses align with a review on high-risk pregnancies (42) and the concept of the mother-fetus dyad (43). this review also found low situational self-esteem, bathing self-care deficit, impaired skin integrity, disturbed body image, and ineffective breastfeeding. chronic or situational low self-esteem is reported as an association between suicidal ideation, loneliness, ineffective coping, rumination, hopelessness, insomnia, and the search for self-affirmation; this is related to readiness for the entire pregnancy process and has a direct impact on their decisions and emotions (44). a review with a sample of studies with nursing theories, such as king and orem, observed that the bathing self-care deficit and impaired skin integrity diagnoses are found in many of the women interviewed. it is caused by a lack of knowledge of agents interfering with the thermal stability of the skin and appendages. pregnant women end up using them due to widespread knowledge or because of the damage to the skeletal muscle caused by pregnancy (45). these data corroborate the study in question. regarding the disturbed body image diagnosis, previously reported as difficulty perceiving the body or interference from the partner, a longitudinal study (46) reports little association with depressive symptoms and eating disorders. it led us to consider that this diagnosis is associated with body mass index and psychological variables, in addition to eating behaviors. in this study, the "ineffective breastfeeding" diagnosis was associated with the puerperal phase. among 30 puerperal women analyzed in a study conducted in the primary care context, 40 % had an ineffective breastfeeding diagnosis. the main characteristics were anxiety and offering supplementary food to the infant (47). it shows significant weaknesses in breastfeeding in pregnant women with and without comorbidities. other diagnoses cited in the studies were "risk of impaired liver function," "impaired dentition," and "impaired physical mobility." regarding this last diagnosis, lumbosacral pain stands out as the morbidity with the highest incidence for pregnant women, who need physiotherapy, nerve stimulation, acupuncture, and pelvic cycles, in addition to non-pharmacological and pharmacological methods for pain relief (48). willingness to improve self-care, also reported in this review, can be associated with the use of scales, counseling, and home visits as more effective methods that directly affect care before, during, and after delivery. light technologies are the most effective care for pregnant women, given the inherent need for mental health, sexual life, and physical and biopsychosocial adaptation (49). the nursing interventions that stood out were those aimed at patient/environment hygiene, pain management, self-esteem level, fluid replacement, sleep-rest ratio, monitoring of hemodynamic dysfunctions, and anxiety management. these interventions can also be structured according to the literature (24, 26). as for the limitations, few studies still focus on nursing diagnoses and interventions for women with hdps, precluding generalizations. similarly, it may suggest the devaluing of nurses' use of the nursing process. the study offers contributions to finding diagnoses and interventions that enable the formulation of clinical indicators. it is noted that the theme has been gradually implemented, and, with the findings, novel studies can promote care for pregnant women with hdps. conclusions this study's nursing diagnoses and interventions corroborate the clinical practice and help nursing professionals' reasoning. the focus on human responses reveals a slight prevalence of diagnoses related to sensory perception and fluid dysfunction, in addition to those of an emotional nature. the diagnoses shown are implemented in the hospital environment. they can reveal a portrait of reality, influencing workable changes according to the needs of each pregnant woman, which aids in good, organized, and objective targeting of the priorities that should be the focus of nurses' interventions. based on the diagnoses, nurses meet the needs of women with hdps and can direct a therapeutic care plan that ensures good quality and scientifically-based care. it is expected that the study will encourage nurses to conduct research that includes diagnoses and interventions for women with hdp, favoring decision-making and aiding in clinical management. conflicts of interest: none declared. references 1. wang w, xie x, yuan t, wang y, zhao f, zhou z, et al. epidemiological trends of maternal hypertensive disorders of pregnancy at the global, regional, and 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de paula1 julia fontes-reis2 luciana da conceição-dias2 virgínia faria damásio-dutra3 andré luiz de souza-braga4 elaine antunes-cortez5 o sofrimento psíquico do profissional de enfermagem da unidade hospitalar 1 enfermeiro. aluno especial do mestrado acadêmico em mestrado acadêmico em ciências do cuidado da saúde na escola de enfermagem aurora de afonso costa da universidade federal fluminense. niterói, rio de janeiro, brasil. glaudston.silva@bol.com.br 2 enfermeiro graduado pelo centro universitário plínio leite, niterói, rio de janeiro. juliafontes@msn.com 3 doutoranda em saúde pública. mestre em saúde mental. professora do centro universitário plínio leite, niterói, rio de janeiro, brasil. virginia.damasio@gmail.com 4 mestre em ensino de ciências da saúde e do ambiente. professor assistente da escola de enfermagem aurora de afonso costa da universidade federal fluminense, niterói, rio de janeiro, brasil. andre.braga@globo.com 5 doutora em enfermagem pela universidade federal do rio de janeiro. professora adjunta da escola de enfermagem aurora de afonso costa da universidade federal fluminense, niterói, rio de janeiro. nanicortez@hotmail.com recibido: 24 de mayo de 2010 aceptado: 29 de octubre de 2010 resumo a equipe de enfermagem muitas vezes não percebe os problemas de saúde ao qual esta exposta. o objetivo do trabalho foi identificar as condições de trabalho que levam o profissional de enfermagem da unidade hospitalar ao sofrimento psíquico, para que a partir desta, possam surgir estratégias de mudanças a fim de obtermos melhoria nas condições de trabalho e consequentemente na saúde física e mental do profissional. esta pesquisa configura-se descritiva explicativa exploratória, com uma abordagem qualiquantitativa, realizada através de pesquisa de campo, no hospital e maternidade luiz palmier, onde entrevistamos profissionais técnicos de enfermagem e enfermeiros do setor hospitalar, através de um questionário com questões abertas e fechadas. na análise de dados, os resultados nos mostraram que o profissional em questão está satisfeito, realizado, com um a relação interpessoal satisfatória com a chefia. o resultado, apesar da satisfação, aponta que a visão do profissional técnico mediante a teu superior é de maneira inadequada. apesar dos resultados, da visão distorcida, forjada pela inexistência de conceitos como gerência e chefia, os profissionais atuam com o espírito da enfermagem: o cuidar. palavras-chave enfermagem, saúde mental, saúde do trabalhador, estresse psicológico, ambiente de trabalho. (fonte: decs, bireme). suffering of psychic training nursing unit hospital abstract the nursing staff often does not realize the dangers to which it is exposed. the objective of this study is to help identify elements in the work environment at hospitals that can cause psychological problems for nursing professionals and, on that basis, to facilitate strategies for changes to improve working conditions in the interest of better physical and mental health. this is an exploratory and explanatory año 10 vol. 10 nº 3 chía, colombia diciembre 2010 l 00-00 268 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 study of a descriptive nature, with a qualitativequantitative approach. it was conducted through field work at the luiz palmier maternity hospital, where nursing professionals were interviewed and asked to complete a standard form with open and closed questions. an analysis of the collected data showed the professionals who were interviewed are satisfied, to some degree, with the general conditions and with their superiors. however, in spite of that satisfaction, the results show technical personnel have a poor view of their superiors. regardless of the results and the distorted view, forged by the lack of concepts such as management and leadership, professional nurses perform in keeping with the spirit of nursing, which is based on care. key words nursing, mental health, employee health, stress, psychological, working environment. (source: decs, bireme). el sufrimiento psíquico del profesional de enfermería de centros hospitalarios resumen el personal de enfermería a menudo no es consciente de los problemas de salud a que está expuesto. el objetivo del trabajo fue identificar las condiciones laborales en los centros hospitalarios que llevan al profesional de enfermería a sufrir enfermedades psíquicas, para que a partir de ahí, puedan surgir estrategias de cambio para mejorar las condiciones de trabajo y, en consecuencia mejorar la salud física y mental del profesional. este estudio es descriptivo explicativo exploratorio, con un enfoque de cualicuantitativo, realizado a través de la investigación de campo en el hospital y la maternidad luiz palmier, donde se ha entrevistado técnicos de enfermería, enfermeros del sector hospitalário , a través de un cuestionario con cuestiones abiertas y cerradas. en el análisis de datos, los resultados mostraron que el profesional afectado está satisfecho, realizado con una relación interpersonal satisfactoria con el liderazgo. el resultado, a pesar de los puntos de satisfacción, apunta que la visión profesional técnica mediante su superior es inadecuada. a pesar de los resultados, de la visión distorsionada, forjada por la falta de conceptos tales como la gestión y liderazgo, los profesionales trabajan con el espíritu de enfermería: el cuidado. palabras clave enfermería, salud mental, trabajador de salud, estrés psicológico, ambiente de trabajo. (fuente: decs, bireme). 269 o sofrimento psíquico do profissional de enfermagem da unidade hospitalar l glaudston silva de paula, julia fontes-reis, luciana da conceição-dias e outros. introdução as relações entre saúde mental e trabalho despontaram a partir da década de 1970 como marco fundamental da nova abordagem da saúde do trabalhador (1). os profissionais mais suscetíveis aos problemas da saúde mental são aqueles que interagem, a maior parte do tempo, com indivíduos que necessitam de sua ajuda, como as enfermeiras, os professores, as assistentes sociais, entre outras profissões (2). com relação ao profissional de enfermagem da área hospitalar, alguns fatores interferem nas suas condições de trabalho. entre eles encontramos o desenvolvimento rápido e contínuo da tecnologia na área da saúde; a grande variedade de procedimentos realizados; o aumento constante do conhecimento teórico e prático exigido nessa área; a especialidade do trabalho; a hierarquização, dificuldade de circulação de informação; o clima de trabalho negativo; papéis ambíguos e falta de clareza das tarefas executadas; o ritmo de trabalho, ambiente físico, estresse do contato com o paciente e familiar; a dor e a morte como elementos que potencializam a carga de trabalho ocasionando riscos à saúde física e mental dos trabalhadores do hospital (3,4). o trabalho de enfermagem tem se apresentado como forma de prazer, mas também de sofrimento. apresenta-se como fonte de prazer quando traz satisfação pessoal, quando o profissional desenvolve suas potencialidades humanas através de seu ofício e sente-se útil a sociedade. no entanto, quando existe submissão e repressão, o trabalho passa a ser uma mercadoria ou mero serviço prestado, podendo haver repressão das potencialidades humanas, gerando insatisfação, angústia e sofrimento psíquico. a equipe de enfermagem muitas vezes não percebe os problemas de saúde ao qual esta exposta nem associa seus sintomas às doenças. dificilmente a equipe de enfermagem tem idéia do que ocorre com ela, a ponto de comprometer o seu humor e seu estilo de vida, não percebendo a influência do trabalho e seu estado geral de saúde. segundo a organização mundial de saúde (5) (oms) há um favorecimento da saúde física e mental quando o trabalho se adapta as condições do trabalhador e quando os riscos para a saúde estão sob controle. na enfermagem, vive-se uma realidade de trabalho cansativo e desgastante para os trabalhadores, em que as pessoas convivem com a dor e o sofrimento. a alienação, a impossibilidade de agir criativamente na relação cotidiana de trabalho e os estreitos limites colocados pela organização do trabalho ao uso de seu saber surgem também como causa de sofrimento e desgaste (6). o objeto deste estudo foi o sofrimento psíquico do profissional de enfermagem. o objetivo foi identificar e caracterizar o perfil dos trabalhadores de enfermagem e as condições de trabalho que levam o profissional de enfermagem da unidade hospitalar ao sofrimento psíquico. assim, podem surgir estratégias de mudanças a fim de obterem melhoria em suas condições de trabalho e conseqüentemente em sua saúde física e mental. atualmente temos dados de pesquisa suficientes para afirmar que o cotidiano hospitalar é gerador de sofrimento psíquico para os trabalhadores da área da saúde. o texto de 270 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 pitta é marcante neste sentido, pois identifica o trabalho no hospital como penoso e insalubre para toda a equipe envolvida (7). nosso desejo é que esta pesquisa contribua para mostrar onde há possibilidade de sofrimento psíquico no cotidiano dos profissionais de enfermagem decorrente do trabalho cansativo e desgastante onde convivem com a dor e sofrimento de outras pessoas e a partir disso possam pensar em estratégias de mudanças a fim obterem melhoria nas condições de trabalho. metodologia a pesquisa é descritiva explicativa e exploratória, com abordagem qualitativa realizada através de pesquisa de campo, no hospital e maternidade luiz palmier (hmlp) em são gonçalo (rj) com profissionais de enfermagem do referido hospital. o projeto de pesquisa foi encaminhado e aprovado pelo comitê de ética e pesquisa envolvendo seres humanos da eean/hesfa (ufrj), conforme resolução 196/96 (cns). respeitando os referenciais básicos da bioética, autonomia, não maleficência, beneficência e justiça (8). antes de iniciar a coleta dos dados, realizou-se esclarecimento sobre os objetivos gerais do estudo e os procedimentos da coleta, além de ser fornecido aos sujeitos que concordaram com a participação para assinarem o termo de consentimento livre e esclarecido. quanto aos sujeitos da pesquisa, entrevistamos 40 indivíduos, o que representou uma amostra de 42% dos profissionais, técnicos e enfermeiros do setor hospitalar no horário diurno. a coleta dos dados foi realizada através de um questionário com 23 questões, onde os sujeitos da pesquisa estiveram livres para responder as perguntas que lhes convieram, e também puderam expressar suas necessidades, dar sugestões e opiniões sobre o assunto abordado. ressalta-se que a amostragem qualitativa privilegia os sujeitos sociais que detêm os atributos que o investigador pretende conhecer, pois possibilita abranger a totalidade do problema investigado em suas múltiplas dimensões (9). de acordo com minayo, o questionário deve ser considerado um roteiro (ou guia) facilitador de abertura, de ampliação e de aprofundamento da comunicação. destaca ainda que as abordagens qualitativas e quantitativas não são antagônicas, mais sim complementares. portanto é possível uma interlocução entre ambas. além disso, o que caracteriza a diferença entre estas é a natureza dos dados coletados (10). quanto ao cenário da pesquisa, o hmlp localiza-se na cidade de são gonçalo, que segundo o ibge, conta como a terceira maior população do estado do rio de janeiro, com aproximadamente 1 milhão de habitantes (36). sua população é majoritariamente de classe média. no que tange a parte física, no térreo do hmlp se localiza a emergência, ao qual não tivemos acesso por falta de disponibilidade de funcionários. no segundo andar, fica a clínica médica de ambos os sexos, centro cirúrgico, centro de terapia intensiva e unidade coronária, já no terceiro andar localiza-se a parte administrativa do hmlp que se subdivide em administração geral e administração de enfermagem, bem como a sala de estudos de estudos. a equipe de enfermagem muitas vezes não percebe os problemas de saúde ao qual esta exposta nem associa seus sintomas às doenças. dificilmente a equipe de enfermagem tem idéia do que ocorre com ela, a ponto de comprometer o seu humor e seu estilo de vida, não percebendo a influência do trabalho e seu estado geral de saúde. 271 o sofrimento psíquico do profissional de enfermagem da unidade hospitalar l glaudston silva de paula, julia fontes-reis, luciana da conceição-dias e outros. para analisar os dados obtidos, adotamos os seguintes procedimentos: após a aplicação dos questionários, realizamos uma primeira leitura do material, organizamos os relatos e revimos o objetivo e questões teóricas discutidas no estudo. terminada esta etapa, mapeamos os discursos, segundo os temas emergentes (sempre guiados pelo objetivo da pesquisa). esses agrupamentos nos permitiram a apreensão dos significados, a associação de idéias e a captação da variedade de pensamentos. na análise final, utilizamos os passos de minayo (10): ordenamento dos dados, classificação dos dados e análise final. ressalta-se que o referencial que orientou para a análise dos dados foi dejours. referencial teórico de acordo com o ministério da saúde (11), no brasil a saúde do trabalhador constitui uma área da saúde pública que tem como objetivos a promoção e a proteção da saúde do trabalhador por meio do desenvolvimento de ações de vigilância dos riscos presentes nos ambientes e condições de trabalho, dos agravos à saúde do trabalhador e a organização e prestação da assistência aos trabalhadores, compreendendo procedimentos de diagnóstico, tratamento e reabilitação de forma integrada. a unidade hospitalar é parte integrante de uma organização médica e social cuja função básica consiste em proporcionar assistência médica sanitária completa, tanto curativa como preventiva (12), à população. no entanto, toda assistência deve ser humanizada. quando as conveniências da administração hospitalar e considerações econômicas pesam mais que o bem estar do paciente e o respeito a sua autonomia, podem acarretar a naturalização do sofrimento e a diminuição do compromisso e da responsabilidade na produção da saúde (13). na prática da enfermagem, o cuidado mais humano deve ser um elemento que se dá através da autenticidade, dignidade, solidariedade, afetividade e do respeito à individualidade humana (14). o código de ética dos profissionais de enfermagem (15) afirma que a enfermagem é uma profissão comprometida com a saúde do ser humano e da coletividade; atua na promoção, proteção, recuperação da saúde e reabilitação das pessoas, respeitando os preceitos éticos e legais. o profissional de enfermagem participa, como integrante da sociedade, das ações que visem satisfazer às necessidades de saúde da população; respeita a vida, a dignidade e os direitos da pessoa humana em todo o seu ciclo vital, sem discriminação de qualquer natureza; exerce suas atividades com justiça, competência, responsabilidade e honestidade; presta assistência a saúde visando a promoção do ser humano como um todo. o sistema de enfermagem hospitalar é definido pela resolução do conselho federal de enfermagem (16) como um conjunto de unidades de enfermagem constituídas pelos recursos físicos e humanos em uma instituição de assistência à saúde. os processos de atuação da enfermagem hospitalar estão inseridos diretamente nos processos assistenciais do hospital e suas ações estão relacionadas diretamente com as finalidades da instituição de saúde. todavia, interage com os demais processos da instituição para produzir o efeito principal que é o cuidado, cuja qualidade ao final depende da eficiência, eficácia e interação deles (17). na prática da enfermagem, o cuidado mais humano deve ser um elemento que se dá através da autenticidade, dignidade, solidariedade, afetividade e do respeito à individualidade humana. 272 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 os profissionais da enfermagem hospitalar são os responsáveis técnicos por este sistema e atuam em equipe, e ainda são os únicos profissionais dentro da instituição hospitalar, que atuam diretamente com o cliente, diuturnamente, em um trabalho contínuo e integrado. sua ação vai além do cuidado direto ao cliente, envolvendo ainda a gerência de todas as unidades assistenciais e afins da instituição hospitalar (17). com essas percepções diferentes, torna-se compreensível que emirja o sofrimento psíquico (18) ao instalar-se o conflito entre a organização do trabalho e o funcionamento psíquico dos profissionais quando estão bloqueadas todas as possibilidades de adaptação entre a organização do trabalho e desejo dos sujeitos. para dejours (19), a noção de sofrimento é central e implica um estado de luta do sujeito contra as forças que estão empurrando em direção à doença mental. e o sofrimento psíquico é uma vivência subjetiva intermediária entre a doença mental descompensada e o bem-estar psíquico. neste contexto, quando o profissional é impedido de ser sujeito de seu comportamento e surgem conflitos decorrentes do confronto entre a personalidade e o desejo do profissional e a organização do trabalho que não lhe oferece a liberdade necessária para que possa usar suas aptidões no exercício do trabalho, culmina no sofrimento e na alienação. as pressões no trabalho, como o conflito de interesses e a sobrecarga, contribuem para o desequilíbrio. e o estresse não resolvido leva à deterioração da saúde mental manifestada por depressão e pela síndrome de burnout (3), considerada por harrison (20) um tipo de estresse persistente, vinculado às situações de trabalho, resultante da constante e repetitiva pressão emocional associada com intenso envolvimento com pessoas por longos períodos. a partir das primeiras leituras que fizemos, consideramos que enquanto os profissionais não se conscientizarem dos riscos que correm e exigirem de suas chefias melhores condições de trabalho, esse quadro não mudará e só tende a se alastrar. fazse necessário que a chefia também tenha uma visualização do que ocorre com seus funcionários para que não se prejudique todo o trabalho de uma equipe. as chefias devem estar abertas às queixas de seus funcionários e tomar as devidas providências para que estes possam exercer de forma eficaz o seu ofício e não passem a ser cuidados ao invés de cuidadores. resultados e discussão dos dados resultados os dados dos 40 questionários respondidos foram organizados inicialmente em tabela, utilizando o software microsoft excel na versão 2003, que nos permitiu visualizar, formatar e analisar as informações coletadas que serão apresentadas. os resultados demonstram que a equipe de enfermagem do hospital e maternidade luiz palmier é representada por 77,5% de profissionais do sexo feminino, o que representa uma proporção de 3 mulheres para cada homem. ressaltamos que ao serem abordados por nós os sujeitos do estudo, observamos que 90% apresentaram relutância em contribuir com a pesquisa, sugerindo as pressões no trabalho, como o conflito de interesses e a sobrecarga, contribuem para o desequilíbrio. e o estresse não resolvido leva à deterioração da saúde mental manifestada por depressão e pela síndrome de burnout. 273 o sofrimento psíquico do profissional de enfermagem da unidade hospitalar l glaudston silva de paula, julia fontes-reis, luciana da conceição-dias e outros. o vínculo contratual com a instituição em questão. de acordo com o resultado supracitado evidencia-se a predominância do sexo feminino na equipe de enfermagem, reforçando o aspecto histórico da enfermagem como uma profissão feminina. dos entrevistados, 54% são da clínica médica, 10% do centro cirúrgico, 8% da coronária, 8% do centro de tratamento intensivo e 20% de outros setores. destes, 24 são solteiros, 13 são casados, 1 é viúvo e 2 são divorciados. referindo-se a patermaternidade, 50% dos entrevistados não têm filhos. no que concerne ao grau de instrução, dividem-se em dois grupos: a prevalência é o nível técnico (82%) e o grupo de nível superior (18%). no tocante ao tempo de atividade profissional dos participantes na pesquisa, os resultados mostram que os que se agrupam até 5 anos de atuação profissional somam 23%, de 6 a 10 anos equivale a 25%, 11 a 15 anos unem-se em 25% e acima de 16 anos somam 27%. sendo assim, denota-se que a maioria trabalha na clínica médica, são solteiros, do nível técnico e com mais de 16 anos de atuação profissional. porém, no que tange a freqüência do tempo de atividade profissional, observa-se que está bem distribuído. indagados quanto ao anseio que levavam à escolha profissional, observamos que 59% dos entrevistados tiveram como fator motivacional a aptidão; 18% se referiram a “outros motivos”, tais como a demanda profissional no mercado de trabalho e a facilidade de acesso pelo custo baixo; 13% chegaram ao denominador comum que a curiosidade foi fator preponderante na escolha e 10% direcionaram sua escolha pelas doenças familiares. ressalta-se desta forma que a maioria escolheu a profissão por aptidão, e a aptidão evidente sugere-nos a satisfação em fazer o que ama. quando abordados sob a segurança em seu trabalho relacionada à experiência prática, os que se sentem seguros totalizam 80%, enquanto que o 20% restante abrange o grupo de inseguros. como se observa, prevalecem os profissionais seguros com sua prática de trabalho. os resultados referentes à educação continuada ou permanente são 47,5% dos entrevistados participam de programas e cursos em favor da renovação do conhecimento e 52,5% não participam de nenhum meio em prol da atualização educacional. é instigante, porém preocupante, o relato dos profissionais no que se refere a falta de motivação dos profissionais, devido a desunião da equipe, o descaso com a profissão e a baixa remuneração. evidencia-se que a desunião da equipe não contribui para um ambiente salutar que se torna fator desencadeante no processo que culminará nos transtornos oriundos do estresse nos profissionais. desta forma, as mudanças essenciais no âmbito do trabalho devem focar em estratégias para a união da equipe, valorização da profissão e melhora na remuneração. entretanto, os resultados também mostram que a plenitude profissional nos retorna aos primórdios da profissão, quando os sujeitos dos estudos relatam que a melhora do paciente, a realização e o altruísmo são os elementos que trazem plenitude profissional. é instigante, porém preocupante, o relato dos profissionais no que se refere a falta de motivação dos profissionais, devido a desunião da equipe, o descaso com a profissão e a baixa remuneração. evidencia-se que a desunião da equipe não contribui para um ambiente salutar que se torna fator desencadeante no processo que culminará nos transtornos oriundos do estresse nos profissionais. 274 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 não obstante as dificuldades relatadas pelos profissionais, no que tange a satisfação pessoal em relação ao trabalho, observamos que encontram-se satisfeitos (80%) o não satisfeitos (20%). no cenário de realização profissional notamos que os realizados somam 65%; e 35% encontram-se no grupo de não realizados profissionalmente em sua área atuante. observa-se que a maioria dos profissionais estão satisfeitos e realizados profissionalmente, mas um percentual representativo não está. tal resultado subsidia uma intervenção junto aos profissionais não satisfeitos e não realizados profissionalmente, de forma que estes se satisfaçam e se realizem na profissão. quanto às questões inerentes a satisfação e a realização, nossos entrevistados dissertaram algumas justificativas, dentre as quais destacamos: “estou satisfeito e realizado, pois gosto do que faço” (questionário 17). “realizada eu sempre fico quando eu vejo um paciente sair do hospital recuperado, apesar de não estar satisfeita com os colegas que não se unem, com a falta de recursos que temos e com a remuneração que não equivale a nossa responsabilidade” (questionário 32). não obstante as notórias queixas referentes à remuneração, desunião, dentre outras, as taxas apontam que a realização e a satisfação se confirmam no âmbito de trabalho em questão. no que concerne a relação interpessoal, o interagir com a chefia foi questionado. os resultados mostram que 55% dos entrevistados mantém uma boa relação, enquanto que 45% responderam que não. destaca-se algumas expressões que nos direcionaram às exigências e aos paradigmas criados sob a gerência e chefia. “é dada a oportunidade, porém eles querem da forma deles, e nem sempre eles estão corretos” (questionário 09). “é muito autoritarismo aqui, eles até chegam a nos ouvir, mas colocam em prática o que querem e não o melhor para nós” (questionário 21). os entrevistados apontam o autoritarismo da chefia como um problema nas relações interpessoais no hospital. tal resultado é importante, pois uma relação autoritária influencia diretamente na saúde do trabalhador de enfermagem e consequentemente no cuidado. discussão dejours (21) define o sofrimento como o espaço de luta que cobre o campo situado entre o bem-estar e a doença mental. o sofrimento mental pode ser concebido como a experiência subjetiva intermediária entre doença mental descompensada e o conforto (ou bem estar) psíquico (18). cecagno e siqueira (22) afirmam que os danos acarretados ao ser humano e seu comportamento são devidos às tensões no ambiente de trabalho, levando ao estresse profissional, conseqüente da insatisfação profissional. mediante o resultado da pesquisa, notamos que o tempo de trabalho não interfere na satisfação do trabalhador, e sim na relação direta com a equipe e chefia. é notório que a pressão psicológica é fator desencadeante do sofrimento. justificamos a postura aversiva dos entreo sofrimento mental pode ser concebido como a experiência subjetiva intermediária entre doença mental descompensada e o conforto (ou bem estar) psíquico. 275 o sofrimento psíquico do profissional de enfermagem da unidade hospitalar l glaudston silva de paula, julia fontes-reis, luciana da conceição-dias e outros. vistados, pois não são respaldados, visto que sua inserção na instituição foi contratual, e o medo da perda do emprego leva à não exigência de um meio favorável, ou da participação ativa na organização do trabalho. sendo assim, vislumbra-se a realização da mesma pesquisa em um cenário e com sujeitos que estejam seguros, minimizando os vieses da pesquisa. porém, é relevante a realização de outras pesquisas com sujeitos que possuam as mesmas características de forma a corroborar ou não com os resultados evidenciados e que com esses, estratégias sejam elaboradas e implementadas para a promoção da saúde deste trabalhador. com a precarização das relações trabalhistas na área da saúde, estes profissionais representam um quantitativo expressivo nos cenários de cuidado e merecem condições dignas de trabalho. no que concerne ao posicionamento dos sujeitos do estudo, para tentar “contorcer” ou camuflar o sofrimento, os trabalhadores usam ideologias defensivas, como deixar de tomar iniciativas e assumir responsabilidades, se fechar, não se comunicam com os outros e passam a se preocupar somente consigo, desconfiando dos colegas de trabalho que poderiam tentar prejudicá-los de alguma maneira. assim, o relacionamento é rompido para evitar conflitos (23). o estudo de graça (24) corrobora a satisfação apontada pelos entrevistados quando disserta que a satisfação no trabalho resulta da avaliação periódica que cada um de nós faz, instantaneamente e empiricamente, do grau de realização dos seus valores, necessidades, preferências e expectativas profissionais. os enfermeiros apontam o autoritarismo da chefia como um problema nas relações interpessoais no hospital. a priori cabe-nos descrever alguns conceitos necessários para o entendimento das divisões dos labores inerentes a cada grupo dos profissionais da enfermagem. segundo o dicionário aurélio (25), chefia condiz à dignidade de chefe, repartição onde exerce suas funções, governo, direção, comando; administração significa a ação ou o feito de administrar, o conjunto de normas e funções que têm por fim ordenar a estrutura e funcionamento de uma organização; e gerência é a ação de gerir, assim como gestão e funções de gerente. posto que o conceito de gestão se confundir com o termo menos amplo – administração –, convém trazer à tona a dificuldade de conceituação. a gestão se preocupa com o controle da cadeia de suprimento, o conhecimento dos clientes e os seus desejos através da pesquisa de mercado, aproximando do conceito do sistema aberto (biologia). com relação à administração, entende que tem um foco operacional, principalmente no que tange à venda, à fabricação, à contabilidade, à engenharia e à compra. dessa forma, se na gestão existe a preocupação com o conhecimento e os desejos dos clientes e trabalhadores, deve-se pensar que a valorização dos destes aspectos, principalmente dos trabalhadores, possa interferir positivamente e diretamente nos cuidados. compreende-se que a função gerencial pode ser conceituada como um instrumento para desenhar políticas e, tecnicamente, organizar o processo de trabalho com o objetivo de torná-lo mais qualificado e produtivo na oferta de uma assistência, de um cuidado de enfermagem universal, igualitário e integral (26). no que concerne ao posicionamento dos sujeitos do estudo, para tentar “contorcer” ou camuflar o sofrimento, os trabalhadores usam ideologias defensivas, como deixar de tomar iniciativas e assumir responsabilidades, se fechar, não se comunicam com os outros e passam a se preocupar somente consigo, desconfiando dos colegas de trabalho que poderiam tentar prejudicá-los de alguma maneira. 276 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 deste modo, a gerência pode ser encarada como um instrumento para a efetivação das políticas, pois ela pode favorecer a manutenção ou a transformação de um determinado contexto. na enfermagem nos dias de hoje, gerência de unidade consiste na previsão, provisão, manutenção, controle de recursos materiais e humanos para o funcionamento do serviço, e gerência do cuidado que consiste no diagnóstico, planejamento, execução e avaliação da assistência (26). assim, gerenciar é cuidar, pois quando planejam, organizam, avaliam e coordenam se espera que o cuidado seja realizado da melhor forma possível (27). para aguiar (28), a liderança é algo essencial no processo de trabalho gerencial do enfermeiro. trata-se basicamente da coordenação de grupos, destacando que nas organizações, o significado atribuído à liderança, aos líderes e ao grupo reflete a filosofia, a política de pessoal e as propostas de trabalho dessas organizações. segundo esta autora, cabe também à gerência um caráter articulador e integrativo, desde quando a ação gerencial é determinada e determinante no processo de organização de serviços de saúde e fundamenta-se na efetivação de políticas sociais e, em específico, as de saúde. pelos resultados, observa-se que os subordinados vêem enfermeiro chefe se distancia do papel de gerente que o enfermeiro tem e se limita a administrar a unidade da que é responsável. neste ínterim, vale lembrar que a enfermagem galga o rol participativo e não supostamente designativo. no entanto, para os entrevistados a chefia tem sido um fator desmotivador, dificultador e que afasta dos princípios humanísticos proposto pelo cuidado, pois ela não tem a visão de gestão e sim de administração, ou seja, preocupa-se apenas com o foco operacional e não com o processo e o produto final, que no caso da enfermagem, é o processo de trabalho de enfermagem e o cuidado de enfermagem respectivamente. no que concerne à distância entre o nível técnico e superior na enfermagem, torna-se evidente, dentro da pesquisa que a hierarquia com seus paradigmas, trazem à luz conflitos entre as subdivisões profissionais, na execução das responsabilidades cotidianas, além de conflitos nas relações interpessoais. os conflitos são manifestações das configurações do poder na organização; portanto, devem compreender-se nas suas formas declaradas ou silenciosas e podem ser tratados ou negados (29). uma estratégia a ser pensada é a inclusão da educação permanente no cenário da pesquisa. a educação permanente é crucial para o trabalhador, pois mesmo com a segurança adquirida através do tempo de trabalho, as tecnologias utilizadas em unidade hospitalar se renovam a todo instante, as condições de vida e de saúde dos usuários se modificam cotidianamente. destaca-se que a educação permanente por ter como premissa a aprendizagem significativa, ou seja, baseada na experiência do profissional, na realidade vivenciada e na participação do profissional é benéfica para o cuidado, assim como para a relação interpessoal dos profissionais. a educação permanente em saúde foi elaborada para aprimorar o método educacional em saúde, tendo o processo de trabalho como seu objeto de transformadeste modo, a gerência pode ser encarada como um instrumento para a efetivação das políticas, pois ela pode favorecer a manutenção ou a transformação de um determinado contexto. 277 o sofrimento psíquico do profissional de enfermagem da unidade hospitalar l glaudston silva de paula, julia fontes-reis, luciana da conceição-dias e outros. ção, com o intuito de melhorar a qualidade dos serviços, visando alcançar equidade no cuidado, tornando os trabalhadores mais qualificados para o atendimento das necessidades da população (30). paixão (31) nos embasa dizendo que a educação é um processo global, que não é só fornecer conhecimentos, mas desenvolvimento pleno da pessoa permitindo conhecer a realidade. desta forma, a educação permanente não se preocupa somente com a transmissão de conhecimentos técnicos, mas também com a experiência real que o trabalhador vivencia e com as relações interpessoais no ambiente de trabalho, pois estas influenciam diretamente no cuidado de enfermagem. quando abordados quanto a motivação profissional, a prevalência rumou para a essência da profissão: o cuidar. ou seja, a maior motivação é o próprio cuidar do outro. segundo pacheco (32), a definição de cuidar abrange a prestação atenciosa e continuada de forma holística a uma pessoa enferma, realçando desta maneira o direito à dignidade da pessoa cuidada. este resultado nos leva a fonte da profissão, personificada em florence nightingale, que em seu imo fundamentavase nos conceitos religiosos de caridade, amor ao próximo, doação, humildade, assim como pelos preceitos de valorização do ambiente adequado para o cuidado, divisão social do trabalho em enfermagem e autoridade sobre o cuidado a ser prestado (33). o imo da profissão sobressai nas crises. a prevalência da essência da enfermagem, nos alerta para a satisfação do profissional. o mesmo culmina na plenitude da realização profissional, em fazer o que gosta, não obstante os dissabores e conflitos no meio. neste contexto, corroboramos com damásio, melo e esteves (34) quando afirmam que os enfermeiros desempenham atividades de assistência direta e indireta, por meio de ações individuais e coletivas atingidas em diferentes intervenções terapêuticas visando, à autonomia e a qualidade de vida dos usuários do serviço de saúde. deste modo, as atribuições do enfermeiro estão ligadas ao cuidado de enfermagem no âmbito individual, familiar e coletivo. ou seja, a realização das funções de cuidar e administrar atende as necessidades do modelo clínico de assistência à saúde, que marca a enfermagem hospitalar. a desunião dentro da equipe de enfermagem foi apontada como um problema gerador de sofrimento. segundo araujo, busnardo e marchiori (35) os profissionais chegam a este denominador comum por não abrirem mão de seus interesses pessoais para facilitar o trabalho do colega, no que se refere à carga horária de trabalho e à tarefa do cuidar. de tal modo, a equipe de enfermagem enfrenta no cotidiano do trabalho hospitalar o sofrimento gerado pelos problemas de relacionamento entre colegas, chefia e direção geral, e a dicotomia entre o cuidado humanizado que se propõem enquanto enfermeiros e a insatisfação com o vínculo e condições de trabalho. no entanto, se colocam como realizados, pois dizem gostar do que fazem e ressaltam a essência do cuidado como fator facilitador neste processo. por fim, evidencia-se que há uma contradição nesta análise, pois se os profisas atribuições do enfermeiro estão ligadas ao cuidado de enfermagem no âmbito individual, familiar e coletivo. ou seja, a realização das funções de cuidar e administrar atende as necessidades do modelo clínico de assistência à saúde, que marca a enfermagem hospitalar. 278 año 10 vol. 10 nº 3 chía, colombia diciembre 2010 aquichan issn 1657-5997 sionais se sentem realizados por gostarem de cuidar do outro, e se a essência do cuidado é um facilitador nesse processo, deve-se pensar em investimentos no cuidado do outro, mas do outro trabalhador, e não somente daquele que está internado, para que os mesmos mantenham essa essência de cuidar e cuidem uns dos outros, melhorando os problemas de relacionamento e minimizando a dicotomia supracitada. considerações finais na pesquisa que nos propusemos a fazer, atingimos o nosso objetivo, identificando os fatores que permitem o desencadear do sofrimento psíquico do profissional de enfermagem, onde nossos dados comprovam que o maior sofrimento está diretamente ligado a organização do trabalho e não com a profissão. percebemos que o orgulho de ser enfermeiro se conflita com uma condição de trabalho insatisfatória gerada pela dificuldade de relacionamento entre os profissionais, sejam eles chefes ou colegas de trabalho. nossos resultados nos levam a essência da profissão, que se fundamenta no cuidar com amor ao próximo, com doação e humildade, pois a grande maioria dos entrevistados se consideram realizados e felizes em sua profissão. desta maneira, retomamos aos primórdios da profissão, cujas bases foram erigidas por florence nightingale, galgadas pelo rol do altruísmo. o cuidado em enfermagem está diretamente ligado ao envolvimento e ao comprometimento da pessoa com a instituição e com a profissão. e a produtividade deste profissional não pode ser medida por quantidade de procedimentos, pois os resultados de sua atuação nem sempre serão visíveis, palpáveis ou mensuráveis. os resultados também nos mostram o quanto a educação permanente é imprescindível, pois promove um ambiente saudável, visando alcançar a equidade no cuidado com propostas educativas que motivam ao autoconhecimento e aperfeiçoamento. ademais, com a educação permanente, o cuidado não ficará limitado ao cliente, e sim a todos que participam do processo do cuidado, minimizando o sofrimento psíquico dos trabalhadores, ao pensar em estratégias de melhorias nas condições de trabalho gerada, principalmente, pela dificuldade de relacionamento entre os profissionais. referências 1. camarotti h, teixeira ha. saúde mental e trabalho: estudo da regional norte de saúde do df. revista de saúde do distrito federal (rsdf) 1996; 7(1): 29-40. 2. baba v, galaperin bl, lituchy tr. occupational mental health: a study of work-related depression among nurses in the caribbean. international journal of nursing studies. 1999; 36(1): 163-9. 3. santos ms, trevizan ma. sofrimento psíquico no trabalho do enfermeiro. nursing rev téc enf 2002; 52(1): 23-28. 4. moos rh, cronkite rc, finney, jw. health and daily living form manual. 2ª ed. california: mind garden; 1990. 5. brasil. organização mundial de saúde (oms). brasília: oms; 1985. 6. silva dmpp, marziale mhp. absenteísmo de trabalhadores de enfermagem em um hospital universitário. rev latino-am enferm 2000; 8(5): 20-33. 7. pitta am. hospital: dor e morte como ofício. são paulo: hucitec; 1990. 8. gil ac. como elaborar projeto de pesquisa. 4ª ed. são paulo: atlas; 2002. 9. minayo mcs. quantitativo e qualitativo em indicadores de saúde: revendo conceitos. in: costa mfl, souza rp. qualidade de vida: compromisso histórico da epidemiologia. belo horizonte: coopmed; 1994. p. 25-33. 10. minayo mcs. o desafio do conhecimento: pesquisa qualitativa em saúde. são paulo: hucitec; 2004. 11. brasil. ministério da saúde. portaria 1.125/gm dispõe sobre os propósitos da política de saúde do trabalhador para o sus. brasília; 2005. 12. brasil. ministério da saúde. programa de humanização da assistência hospitalar: programas e relatório 20. brasília: ms; 2001. 279 o sofrimento psíquico do profissional de enfermagem da unidade hospitalar l glaudston silva de paula, julia fontes-reis, luciana da conceição-dias e outros. 13. pessini l, bertachini l. humanização e cuidados paliativos. são paulo: edunisc/loyola; 2004. 14. erdmann al. sistema de cuidados de enfermagem. florianópolis: universitária; 1996. 15. conselho federal de enfermagem. resolução cofen 240/2000. código de ética dos profissionais de enfermagem. cap. i. dos princípios fundamentais. rio de janeiro: cofen; 2000. 16. conselho federal de enfermagem. resolução cofen 168/93. normas para anotação da responsabilidade técnica de enfermeiro, em virtude de chefia de serviço de enfermagem, nos estabelecimentos das instituições e empresas públicas, privadas e filantrópicas onde é realizada assistência à saúde. rio de janeiro: cofen; 1993. 17. silva ma, erdmann al, cardoso rs. o sistema de enfermagem hospitalar: visualizando o cenário das políticas 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portuguesa. rio de janeiro: editora nova fronteira; 1980. 26. greco rm. ensinando a administração em enfermagem através da educação em saúde. brasília: rev bras enferm 2004; 57(4): 504-7. 27. vaguetti h. percepções dos enfermeiros acerca das ações administrativas em seu processo de trabalho. brasília: rev bras enferm 2004; 57(3): 316-20. 28. aguiar ab, costa rsb, weirich cf, bezerra alq. gerência dos serviços de enfermagem: um estudo bibliográfico. rev elet enferm 2005; 7(3): 319-27. 29. cecílio lco, moreira me. disputa de interesses, mecanismos de controle e conflitos: a trama do poder nas organizações de saúde. rev adm publ 2002; 36(4): 587-608. 30. ceccim rb. educação permanente: desafio ambicioso e necessário. interface-comunic, saúde e educ 2005; 9(18): 161-77. 31. paixão w. páginas de história da enfermagem. rio de janeiro: universidade do brasil; 1951. 32. pacheco s. cuidar da pessoa em fase terminal: perspectiva ética. loures (portugal): editora lusociência; 2002. 33. padilha mics, mancia jr. florence nightingale e as irmãs de caridade: revisitando a história. rev. bras. enferm. 2005; 58(6): 723-26. 34. damásio vf, melo vc, esteves kb. atribuições do enfermeiro nos serviços de saúde metal no contexto da reforma psiquiátrica. rev enferm ufpe. 2008; 2(4): 367-73. 35. araújo md, busnardo ea, marchiori fm. formas de produzir saúde no trabalho hospitalar: uma intervenção em psicologia. cad psicol soc trab 2002; 5 (7): 37-49. 36. ibge. censo demográfico 2000. resultados do universo. disponível em: http://www.ibge.gov.br. acesso em: 20 out. 2009. 430 439 programa de apoyo al trabajador.indd 430 aquichan issn 1657-5997 luz maría herrera-lópez1 claudia alcayaga-rojas2 marisa torres-hidalgo3 regina funk buntemeyer4 claudia bustamante-troncoso5 giselle riquelme-hernández6 solange campos-romero7 mila urrutia-bunster8 ilta lange haensgen9 programa de apoyo al trabajador-cuidador familiar: fenómeno social emergente 1 magíster en enfermería. profesor asociado adjunto, pontificia universidad católica de chile, chile. luzma@uc.cl 2 magíster en psicología, mención salud. profesor asistente adjunto, pontificia universidad católica de chile. chile. caalcaya@uc.cl 3 magíster en salud pública, mención epidemiología. profesor asistente, pontificia universidad católica de chile, chile. marisa@med.puc.cl 4 phd en psicología. profesor asistente, pontificia universidad católica de chile, chile. rfunk@uc.cl 5 magíster en enfermería. profesor asistente, pontificia universidad católica de chile, chile. cqbustam@uc.cl 6 magíster en enfermería. profesor asistente adjunto, pontificia universidad católica de chile, chile. gfriquel@uc.cl 7 magíster en psicología, mención social comunitaria. profesor asociado, pontificia universidad católica de chile, chile. solangecampossr@gmail.com 8 magíster en salud de la comunidad. profesor titular, pontificia universidad católica de chile, chile. murrutia@uc.cl 9 master of science in nursing. profesor titular, pontificia universidad católica de chile, chile. ilange@uc.cl recibido: 06 de julio de 2012 enviado a pares: 18 de abril de 2013 aceptación por pares: 28 de noviembre de 2013 aprobado:18 de marzo de 2014 doi: 10.5294/aqui.2014.14.3.12 para citar este artículo / to reference this article / para citar este artigo herrera-lópez lm, alcayaga-rojas c, torres-hidalgo m, funk buntemeyer r, bustamante-troncoso c, riquelme-hernández g, et.al. programa de apoyo al trabajadorcuidador familiar: fenómeno social emergente. aquichan; 2014. 14(3): 430-439. doi: 10.5294/aqui.2014.14.3.12 resumen en el contexto demográfico actual de envejecimiento poblacional surge un nuevo rol: el funcionario-cuidador. la persona que trabaja y, además, cuida a un familiar con discapacidad, presenta problemas personales, laborales y menor compromiso con su autocuidado. entre las intervenciones eficaces se encuentra el mejorar la percepción del apoyo social. se presenta un programa interdisciplinario, iniciado en el año 2009, de apoyo a trabajadores-cuidadores familiares. su propósito es promover la salud y prevenir factores de riesgo de enfermedad a través del fortalecimiento de sus habilidades de autocuidado y el desarrollo de políticas institucionales que faciliten el cumplimiento de ambos roles en forma eficiente y saludable. como estrategias de promoción en salud se han utilizado: la educación para el autocuidado, el fortalecimiento de redes de apoyo familiar y social, la asesoría profesional y la comunidad de pares. en las últimas tres cohortes anuales han participado sesenta funcionarios, de los cuales el 83,4 % son mujeres, con un promedio de edad de cincuenta años. el programa ha cumplido con éxito los objetivos propuestos, aumentando la percepción de apoyo social manifestado por los propios participantes. palabras clave autocuidado, cuidadores, adulto mayor, enfermedad crónica, anciano frágil. (fuente: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 430-439 431 programa de apoyo al trabajador-cuidador familiar: fenómeno social emergente l luz maría herrera lópez, claudia alcayaga rojas, marisa torres hidalgo y otros. año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 430-439 a program to support family workercaregivers: an emerging social phenomenon abstract a new role has emerged within the current demographic context of an aging population; namely, that of the worker-caregiver. the person who works and also cares for a disabled family member has personal and work-related problems and is less committed to their own self-care. improving the perception of social support can be an effective intervention in this respect. the article describes an interdisciplinary program initiated in 2009 to support family workers-caregivers. its purpose is to promote health and prevent disease risk factors by strengthening self-care skills and the development of institutional policies that facilitate efficient and healthy compliance with both roles. some of the health promotion strategies that have been used include education for self-care, strengthening family and social support networks, professional counseling and a community of peers. sixty workers took part in the last three annual cohorts: 83.4% were women, with an average age of fifty. the program has successfully met its proposed objectives by increasing the perception of social support expressed by the participants themselves. key words self-care, caregivers, elderly person, chronic illness, frail elderly person. (source: decs, bireme). 432 aquichan issn 1657-5997 programa de apoio ao trabalhadorcuidador familiar: fenômeno social emergente resumo no contexto demográfico atual de envelhecimento populacional, surge um novo papel: o funcionário-cuidador. a pessoa que trabalha e, além disso, cuida de um familiar com necessidades especiais apresenta problemas pessoais, laborais e menor compromisso com seu autocuidado. entre as intervenções eficazes, encontra-se o melhorar a percepção do apoio social. apresenta-se um programa interdisciplinar, iniciado em 2009, de apoio a trabalhadores-cuidadores familiares. seu propósito é promover a saúde e prevenir fatores de risco de doenças por meio do fortalecimento de suas habilidades de autocuidado e o desenvolvimento de políticas institucionais que facilitem o cumprimento de ambos os papéis de forma eficiente e saudável. como estratégias de promoção da saúde têm sido utilizados: a educação para o autocuidado, o fortalecimento de redes de apoio familiar e social, a assessoria profissional e a comunidade de pares. nas últimas três coortes anuais, participaram 60 funcionários, dos quais 83,4% são mulheres, com uma média de idade de 50 anos. o programa tem cumprido com sucesso os objetivos propostos e, assim, tem aumentado a percepção de apoio social manifestado pelos próprios participantes. palavras-chave autocuidado, cuidadores, idoso, doença crônica, idoso frágil. (fonte: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 430-439 433 programa de apoyo al trabajador-cuidador familiar: fenómeno social emergente l luz maría herrera lópez, claudia alcayaga rojas, marisa torres hidalgo y otros. introducción se presenta una reflexión estructurada en el tema de trabajadores que son cuidadores familiares y un programa interdisciplinario de promoción de la salud basado en la educación para el autocuidado y el apoyo institucional. en este artículo se define como trabajador-cuidador familiar a aquella persona que tiene un vínculo contractual con la institución y cuya vida laboral y personal se ve afectada porque de manera simultánea trabaja y cuida a un familiar con limitaciones crónicas en su autovalencia (dependencia), ya sea en su propio hogar o fuera de este, pero que no se encuentra institucionalizado. la dependencia se define como el “estado en el que se encuentran las personas que por razones ligadas a la falta o la pérdida de autonomía física, psíquica o intelectual tienen necesidad de asistencia y/o ayudas importantes a fin de realizar los actos corrientes de la vida diaria” (1). el doble rol de trabajador-cuidador surge como un problema relevante de alcance personal, laboral, familiar y social que no ha sido considerado en las políticas públicas en chile. chile, como otros países de américa latina, vive un proceso de envejecimiento poblacional acelerado y un aumento de la participación de la mujer en la fuerza de trabajo (2, 3); ello en un contexto de inequidad social evidenciado por su índice gini (0,55) (4). este cambio demográfico es uno de los factores que ha generado aumento en la prevalencia de personas con enfermedades crónicas y discapacidades, con el consecuente aumento de sus cuidadores informales, los que, en la mayoría de los casos, son familiares (3, 5, 6). actualmente, cuidar un familiar adulto mayor se ha convertido en una forma de vida para las familias chilenas. en el año 2009, la dependencia de las personas mayores de 60 años alcanzó al 24,1 %, llegando a más del 30 % a partir de los 80 años de edad. los cuidadores de estos adultos mayores son mayoritariamente mujeres, hijas o esposas, dos tercios de las cuales no han tomado vacaciones hace más de 5 años, cuidan a su familiar más de 12 horas diarias, y se sienten solas y sobrepasadas por su situación (5). a menudo, con gran sacrificio, las familias chilenas se esfuerzan para mantener a sus familiares adultos mayores dependientes en casa y evitan la institucionalización. en este sentido, los cuidadores familiares de personas con problemas crónicos de salud constituyen poblaciones vulnerables con riesgo de caer en la pobreza, situación asociada muchas veces a la disminución de ingresos por renuncias laborales anticipadas y aumento en los gastos de salud (7). las razones más importantes para desarrollar sistemas de apoyo para los familiares cuidadores en chile son el deseo de los adultos mayores de mantenerse en sus hogares, en sus comunidades y con sus familias el mayor tiempo posible, reducir los costos de los servicios de salud para la familia, y reducir el impacto de la carga del cuidador familiar. este problema de salud pública requiere ser visibilizado y abordado desde todos los ámbitos, especialmente desde el de la salud. a continuación se presentan algunas reflexiones en torno a la carga del cuidador familiar y la problemática del trabajadorcuidador familiar. finalmente, se presenta el programa de apoyo institucional implementado. la carga del cuidador familiar la condición de cuidador familiar es una situación de vida que la mayor parte de las veces no es buscada por las personas y que deben asumir sin estar preparadas para ello. históricamente, los adultos mayores o las personas con alguna condición de dependencia han estado al cuidado de sus familiares cercanos (red de apoyo primaria). se reporta que los miembros de las familias otorgan entre el 60 al 80 % del cuidado de las personas con enfermedades crónicas, siendo la mayoría de ellos mujeres (8) quienes, en las últimas décadas, han aumentado significativamente su participación en la fuerza laboral con la consiguiente sobrecarga de roles y trabajo (9, 10). el cuidado otorgado por el familiar constituye un recurso valioso pues influye positivamente en el bienestar físico, psicológico y social de la persona cuidada. sin embargo, esta actividad puede generar estrés, depresión, aislamiento social y detrimento de la situación económica con el consecuente deterioro de la salud física, mental y social/familiar del cuidador, ya que requiere mucho tiempo: entre cuatro y cinco horas diarias durante los siete días de la semana (11-13). el mayor o menor impacto de esta sobrecarga en la salud del cuidador se relaciona fundamentalmente con el capital social y nivel económico y educacional de los cuidadores (14-16). el concepto de sobrecarga del cuidador hace referencia al conjunto de problemas de orden físico, psíquico, emocional, so434 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 cial o económico que pueden experimentar los cuidadores por el hecho de desempañar este rol (17). los costos que debe enfrentar el cuidador familiar se relacionan con las consecuencias negativas que esta tarea tiene en su vida, tanto a nivel físico o de salud, como a nivel del desarrollo personal, laboral y proyecto de vida. estos son los denominados costos de oportunidad (18,19). entre los costos laborales se encuentran el abandono del trabajo, la reducción de la jornada, la imposibilidad de plantearse un trabajo remunerado, entre otros; entre los costos personales están la reducción de las posibilidades de recreación, de tomar vacaciones, de interactuar con otras personas; y los de salud, los cuales son originados por el estrés psicosocial prolongado (18). finalmente, en este análisis de la carga del cuidador familiar es necesario considerar las dimensiones objetivas y subjetivas de los costos implicados en esta tarea, ya que son los que inciden en la percepción final de sobrecarga que tiene el cuidador. la dimensión objetiva se relaciona con el conjunto de demandas y actividades que recaen sobre el cuidador, y la dimensión subjetiva con los sentimientos y las percepciones negativas que este experimenta con su función de cuidador (19, 20). ello, porque a menudo el cuidador familiar se debate en una contradicción entre el “deber ser” y las expectativas de desarrollo personal, profesional y familiar que generan sentimientos contradictorios que se traducen finalmente en estrés y sensación de sobrecarga (19, 20). la condición de contar con escaso apoyo social se asocia con mayor riesgo de sobrecarga en la familia. se ha observado que el cuidador principal percibe menor sobrecarga cuando recibe apoyo social de parte de familiares o vecinos, en comparación con aquellos que no lo reciben (21-23). lo expuesto fundamenta la importancia del apoyo social y de la capacitación de los cuidadores familiares, pues su falta de entrenamiento se relaciona con menor compromiso con su autocuidado y conductas preventivas de salud, lo que les puede generar mayor riesgo de mortalidad (24, 25). de este modo, si bien existen muchos argumentos a favor de apoyar a los cuidadores familiares, el más importante es que este aumenta el riesgo de deterioro en su salud física y mental. en esa condición, probablemente llegará a ser un enfermo, que a su vez necesitará ser cuidado, utilizando para ello los limitados recursos familiares de salud, situación que se puede prevenir (18). las experiencias de apoyo a cuidadores informales se relacionan con la prevención del síndrome de burnout y con la disminución de la probabilidad de institucionalización (26). entre las estrategias que han resultado exitosas se encuentran: programas educativos con énfasis en consejos prácticos respecto del cuidado diario, grupos de apoyo de pares y psicoeducación que enfatizan en el desarrollo de habilidades y estrategias específicas de afrontamiento, consejerías respecto de los servicios disponibles en la comunidad y cómo acceder a ellos; servicios de respiro tendentes a aliviar la sobrecarga del cuidador y permitir a las familias continuar ejerciendo su función de cuidado a fin de prevenir la institucionalización (27-29). la carga del trabajador que es cuidador familiar el aumento de trabajadores cuidadores familiares se observa en todos los niveles socioeconómicos, pero con mayor fuerza en los niveles medios y bajos. de acuerdo con el us department of health and human services (7), la mitad de los cuidadores informales son empleados, y entre el 20 y 50 % de los trabajadores tiene que enfrentar, en algún momento, la situación de cuidar a otros. tanto los hombres como las mujeres cuidadores reportan la necesidad de tener que modificar sus horarios laborales, e incluso haber perdido algún trabajo debido a su condición de cuidadores. la evidencia científica señala que los familiares cuidadores que tienen un trabajo formal presentan con elevada frecuencia problemas de salud física y mental. estos son generados por el estrés, la angustia, el agobio, el insomnio y los sentimientos de culpa que surgen al verse enfrentados a cumplir este doble rol (11). los trabajadores-cuidadores familiares deben compatibilizar el tiempo que dedican a su trabajo con las demandas de cuidado del familiar dependiente. el impacto sobre su empleo se traduce en una disminución de la productividad, aumento del ausentismo y de los índices de rotación, pérdida de entre cinco a doce días de trabajo anual, y 73 % de retrasos o retiro del lugar de trabajo antes del término de la jornada (7, 19). por otro lado, se observa que una vez que los trabajadores se inician como cuidadores de un familiar con problemas crónicos de salud pierden oportunidades de “hacer carrera”, reducen su jornada laboral o renuncian a sus trabajos. esta situación representa una pérdida para la institución, para el empleado y para su familia (20). 435 programa de apoyo al trabajador-cuidador familiar: fenómeno social emergente l luz maría herrera lópez, claudia alcayaga rojas, marisa torres hidalgo y otros. lo expuesto sustenta la necesidad de ampliar y difundir servicios y programas accesibles, abordables e innovadores para apoyar a los familiares cuidadores en su tarea. ofrecer apoyo a los trabajadores que son familiares cuidadores puede contribuir a que mantengan su trabajo y a reducir el estrés del empleado, de sus colegas y también de la organización (30, 31). es importante reconocer que la estabilidad laboral es esencial para que los trabajadores que son familiares cuidadores puedan continuar brindando cuidado. programa de apoyo al trabajadorcuidador familiar uc el programa surge como proyecto piloto en el año 2008, en el contexto de la política institucional de universidad saludable (32, 33), liderado por académicos de la escuela de enfermería en alianza con el departamento de beneficios del personal, a través de sus trabajadoras sociales, con la participación de académicos de las escuelas de enfermería, medicina y psicología. el programa tiene como propósito generar un modelo de intervención en el lugar de trabajo para promover la salud de los trabajadores que son familiares cuidadores de personas con enfermedades crónicas o con discapacidades. se desea fortalecer sus habilidades de cuidado y el desarrollo de políticas institucionales que faciliten el cumplimiento de ambos roles en forma eficiente y saludable. entre sus objetivos específicos se encuentran: 1) apoyar la formación de vínculos cooperativos dentro de la red social, 2) reforzar habilidades de cuidado y autocuidado de los participantes de la red, y 3) implementar medios de comunicación fluidos para la utilización de la red. los cuatro componentes del programa surgieron de un diagnóstico participativo de necesidades de apoyo institucional y son: capacitación, acompañamiento, comunidad de pares y asesoría profesional. la capacitación considera un curso-taller de 18 sesiones presenciales de una hora y media de duración, en horario protegido, siendo sus principales objetivos: a) el desarrollo de habilidades personales tendientes a compatibilizar saludablemente ambos roles (alimentación saludable, higiene del sueño, comunicación asertiva, administración del tiempo, proceso de toma de decisiones y conflicto decisional, negociación, fortalecimiento de redes familiares y sociales, manejo de la ansiedad y estrés de la vida diaria, recursos disponibles en salud); b) el desarrollo de habilidades para el cuidado de su familiar (comprensión del proceso de envejecer, problemas de salud más frecuentes en la tercera edad, administración de medicamentos, técnicas básicas de cuidados, urgencias más frecuentes en la tercera edad y cómo afrontarlas). el acompañamiento implica orientación y guía a través de consejerías frente a dudas sobre cuidados del familiar. las consejerías se apoyan con una plataforma web que permite mantener la comunicación y motivación, y publicar el material educativo que apoya el aprendizaje. asimismo, los participantes pueden solicitar apoyo psicológico ante el dolor de la pérdida de su ser querido. la comunidad de pares, formada por los egresados del programa, constituye una red social de apoyo emocional e instrumental, con acompañamiento de la universidad. la temática que articula esta red es la vivencia del doble rol de las personas que la conforman, cuidador familiar y trabajador. para los egresados también se programan actividades de capacitación de acuerdo con sus intereses de profundizar en las áreas del conocimiento teórico/ práctico que el grupo determina cada año. la asesoría profesional consiste en una red virtual de profesionales de la universidad que presta atención en aspectos legales, médicos, cuidados de salud, entre otros. la universidad, a través del departamento de beneficios de personal, facilita y favorece la participación de los trabajadores en el programa, el uso de permisos especiales para llevar al médico o atender demandas de cuidados inesperados del familiar, orienta en la obtención de recursos en salud, provee apoyo psicológico ante el duelo, entre otros. el equipo coordinador y docente planifica anualmente las horas que destinará a este programa, siendo parte de sus actividades académicas. asimismo, constituye una actividad clave en la programación del departamento de beneficios al personal de cada año, con asignación de presupuesto protegido. respecto a las consideraciones éticas de este programa, el principio que guía su creación y desarrollo es la beneficencia, ya que su propósito es generar un modelo de intervención institucional para promover la salud de los trabajadores que son cuidadores de familiares con enfermedades crónicas o discapacidades. con cada nueva cohorte anual de participantes el equipo resguarda su autonomía a través del proceso de consentimiento informado. en él se explicitan los aspectos relevantes y necesarios de la decisión de participar, de modo que esta sea libre e informada. se 436 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 asegura que los participantes comprendan que su permanencia en el programa es absolutamente voluntaria, por tanto, pueden retirarse en el momento en que lo decidan. se invita a participar a todos los trabajadores de la universidad. los datos obtenidos de aquellos que lo hayan autorizado a través de la entrega firmada del consentimiento informado se utilizan con fines de investigación. la confidencialidad de los datos se resguarda a través de su manejo estricto a cargo del equipo de investigación. figura 1. representación del modelo institucional de apoyo al trabajador-familiar cuidador. fuente: elaboración propia. fortalezas y debilidades del programa desde la perspectiva de los trabajadores en los últimos tres años de desarrollo han participado 60 trabajadores del estamento administrativo de la universidad, de los cuales el 83,4 % son mujeres con un promedio de edad de 50 años. la mayoría de ellos (71,6 %) cuida a sus padres (promedio de edad de 76 años) y el resto cuida a un hijo, cónyuge u otro pariente. en un análisis foda del programa por parte de los trabajadores, estos destacan como fortalezas el apoyo de la institución, ser reconocido en su labor de cuidador, aprendizaje vivencial de tópicos como la empatía y disfrutar la vida, compartir con otros, reconocer necesidades y ser capaz de pedir ayuda; como oportunidades reconocen la capacitación obtenida, estrategias para fortalecer las redes de apoyo, crecer como persona, empoderarse en estrategias de cuidado, generar vínculos y formar redes de apoyo; entre las debilidades destacan la necesidad de contar con apoyo psicológico en el proceso de duelo, de compartir con otros trabajadores que viven su misma problemática y la falta de recursos económicos para contratar cuidadores de apoyo. por último, los participantes describen como amenazas que esta iniciativa no se institucionalice como un programa permanente, perder el contacto con pares del programa, miedo a enfermar, incapacidad económica, entre otras. a cada cohorte de participantes se le aplican instrumentos estandarizados, antes y después de la participación en el programa, para valorar el impacto en los ámbitos de apoyo social percibido, satisfacción con dicho apoyo social y percepción de carga del cuidador. los participantes reportan que el apoyo social percibido es mayor y mejor, y que la carga relacionada con su rol de cuidador disminuye. comentarios/proyecciones frente al fenómeno social descrito, que se incrementa con el envejecimiento de la población y el aumento de mujeres en la fuerza de trabajo, se requieren propuestas de intervención oportunas. es importante visibilizar el problema, valorando y reconociendo la nobleza de quienes asumen el cuidado de familiares a fin de fortalecer valores prosociales. frente a la urgente necesidad de apoyar a este grupo social vulnerable es importante socializar experiencias que ayuden a generar propuestas integradoras y eficientes. el innovador programa presentado está basado en las necesidades percibidas por los propios trabajadores, utiliza una variedad de estrategias de apoyo y tecnologías de la comunicación, y es abordado con una mirada interdisciplinaria con el fin de contribuir a mejorar la calidad de vida de quienes laboran en la institución que cumplen el doble rol de ser trabajadores y cuidadores de un familiar con limitación crónica de autovalencia. el equipo coordinador y los docentes del programa han valorado la experiencia como un proceso de desarrollo colectivo e institucional de gran envergadura, que debe continuar y fortalecerse. entre los pilares fundamentales que han contribuido al éxito de este programa están la alianza académico-administrativa; la participación de un equipo interdisciplinario de académicos en el rol de asesoría o de docencia; el apoyo de las autoridades, directores y subdirectores administrativos, y la confianza depositada por los propios funcionarios participantes, su generosidad de compartir sus vivencias y aportar al cuidado de los pares. 437 programa de apoyo al trabajador-cuidador familiar: fenómeno social emergente l luz maría herrera lópez, claudia alcayaga rojas, marisa torres hidalgo y otros. conocer a la persona que trabaja en la institución en esta nueva realidad permite dimensionarla y valorarla desde nuevas facetas. lo que se puede aportar al trabajador cuidador llegará potenciado en el tiempo al familiar cuidado y a él mismo como futuro adulto mayor, más aún cuando se reconoce que las necesidades de las personas mayores aumentan a medida que la edad avanza. entre las externalidades positivas de esta iniciativa se encuentran: su aporte a la protección del capital humano y a la prevención de la pobreza, ya que es bien conocido que los familiares cuidadores postergan su desarrollo o incluso dejan sus trabajos para asumir su nuevo rol. esto se ve reflejado en la disminución del nivel de ingresos familiares cuando el trabajador se ve obligado a reducir su jornada o renunciar a su trabajo. por otro lado, si bien el programa ha atendido a hombres y mujeres cuidadores, sin duda el mayor porcentaje han sido estas últimas, lo que es coherente con la situación familiar chilena ya que es la mujer la que mayoritariamente se hace cargo del cuidado de las personas mayores de su familia, por lo cual este programa además focaliza su acción en la protección de un grupo vulnerable, la mujer, aliviándole su carga como cuidadora. esta experiencia innovadora, con enfoque preventivo promocional, espera generar un cambio en las políticas organizacionales que permitan apoyar a los funcionarios que cumplen este doble rol. se presenta la oportunidad de que los profesionales de la salud incorporen a la atención clínica individual o familiar la realidad del familiar cuidador. este programa aporta a la necesidad de implementar cambios sistémicos en las organizaciones laborales cuyo cimiento es el valor del aporte del trabajador-cuidador familiar a la sociedad. este cambio de paradigma contribuye a generar nuevos valores dentro de una cultura organizacional que desea promover el desarrollo integral en su comunidad, ser cada vez más sana, inclusiva y solidaria. desde una perspectiva más general, se considera que este programa tiene un potencial impacto social en distintas dimensiones, en una perspectiva individual, por el beneficio directo a los usuarios participantes; en una perspectiva institucional, al fortalecer a la institución como un ente promotor de la salud, y desde una perspectiva más macro se cuenta con una experiencia que puede ser difundida a otras instituciones dentro y fuera del país. agradecimientos los autores agradecen a rosario undurraga, paz silva, carmen gloria carvacho y patricia iturriaga (servicio de bienestar ) quienes han incorporado estrategias institucionales para reducir los riesgos a los que están expuestos los funcionarios que cumplen este doble rol, y a maría rosa millán por su constante apoyo a la iniciativa. referencias 1. comité de ministros de europa. recomendación nº 98. reunión del comité de ministros a los estados miembros relativa a la dependencia. 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[cited 2011 may 15]. disponible en: http://www.aarp.org/ppi 27. sorrell jm. moving beyond caregiver burden: identifying helpful interventions for family caregivers. j psychosoc nurs ment health serv. 2014;52(3):15-8. 28. vecchio n. understanding the use of respite services among informal carers. australian health review. 2008;32(3):459-67. 439 programa de apoyo al trabajador-cuidador familiar: fenómeno social emergente l luz maría herrera lópez, claudia alcayaga rojas, marisa torres hidalgo y otros. 29. phillipson l, jones sc, magee c. a review of the factors associated with the non-use of respite services by carers of people with dementia: implications for policy and practice. health and social care in the community. 2014;22(1):1-12. 30. national alliance for caregiving/aarp. caregiving in the us. washington d.c: nac; 2005. 31. neves l, melo m, marques s, lima m, partezani r. burden in family caregivers of the elderly: prevalence and association with characteristics of the elderly and the caregivers. rev esc enferm usp. 2013;47(5):1129-36. 32. muñoz m, cabieses b. universidades y promoción de la salud: ¿cómo alcanzar el punto de encuentro? rev panam salud pública. 2008;24(2):139-46. 33. lange i, vio f. guía para universidades saludables y otras instituciones de educación superior. santiago: andros impresores; 2006. 316 326 maternidad un proceso.indd 316 aquichan issn 1657-5997 flor de maría cáceres-manrique1 gloria molina-marín2 myriam ruiz-rodríguez3 maternidad: un proceso con distintos matices y construcción de vínculos 1 msc en epidemiología. candidata a doctora en salud pública. profesora departamento de salud pública, escuela de medicina, universidad industrial de santander, bucaramanga, colombia. fmcacer@uis.edu.co 2 phd in health services management. profesora titular, facultad nacional de salud pública, universidad de antioquia, medellín, colombia. molinag@saludpublica.udea.edu.co. 3 doctora en ciencias de la salud pública con área de concentración en sistemas de salud. profesora titular, departamento de salud pública, escuela de medicina, universidad industrial de santander, bucaramanga, colombia. myriam@uis.edu.co recibido: 12 de noviembre de 2012 enviado a pares: 17 de enero de 2013 aceptado por pares: 16 de diciembre de 2013 aprobado: 16 de diciembre de 2013 doi: 10.5294/aqui.2014.14.3.4 para citar este artículo / to reference this article / para citar este artigo cáceres-manrique fm, molina-marín g, ruiz-rodríguez m. maternidad: un proceso con distintos matices y construcción de vínculos. aquichan; 2014. 14(3): 316-326. doi: 10.5294/aqui.2014.14.3.4 resumen objetivo: comprender los significados de la maternidad para las gestantes, con el fin de orientar la promoción de la salud maternoinfantil. materiales y métodos: investigación cualitativa, con sustento teórico en el interaccionismo simbólico y el método de la teoría fundamentada. previo consentimiento informado se realizaron entrevistas en profundidad a 18 gestantes mayores de 14 años, de diferentes estratos socioeconómicos, residentes en bucaramanga (colombia). también se observaron sus interacciones con otras gestantes y con personal de salud en las instituciones donde reciben atención prenatal. la información fue analizada paralelamente con su recolección mediante codificación abierta y categorización basada en el método de comparación constante y muestreo teórico, hasta lograr la saturación de las categorías. los resultados se validaron en grupos focales con gestantes. resultados: emergieron categorías que dan cuenta de la maternidad como proceso, con preocupación, responsabilidad, adaptación/acomodación y como una experiencia positiva. como categoría central surgió la maternidad como proceso transformador con experiencias positivas y construcción de vínculos. discusión: para las gestantes, la maternidad tiene distintos significados y matices, principalmente desde sus componentes socioculturales, aspectos que se deben tener en cuenta para orientar la promoción de la salud materno-infantil y el cuidado materno. conclusiones: la maternidad es un proceso complejo y de transformación personal que ayuda a las gestantes a formar vínculos con su hijo, con la pareja y con los familiares que la apoyan. durante esta experimentan sentimientos encontrados de alegría y satisfacción, junto con preocupación y angustia por los retos que implica la maternidad. entender este proceso orienta el quehacer de los profesionales de la salud hacia una atención prenatal armonizada con las expectativas de la gestante. palabras clave embarazo, mujeres embarazadas, bienestar materno, atención prenatal, enfermería materno-infantil. (fuente: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 316-326 317 maternidad: un proceso con distintos matices y construcción de vínculos l flor de maría cáceres-manrique, gloria molina-marín, myriam ruiz-rodríguez año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 316-326 motherhood: a process involving different nuances and the construction of ties abstract objective: understand what motherhood means to pregnant women as a basis for guiding maternal-infant health promotion. materials and methods: this is a qualitative study founded theoretically in symbolic interactionism and the grounded theory method. following prior informed consent, in-depth interviews were conducted with 18 pregnant women over 14 years of age in different socioeconomic brackets. all were residents of bucaramanga (colombia). their interactions with other pregnant women and with health workers also were observed at the institutions where they receive prenatal care. the information was analyzed in parallel to its collection, through open codification and categorization based on the constant comparative method and theoretical sampling, until saturation of the categories was achieved. the results were validated in focus groups with pregnant women. results: categories emerged that show motherhood as an affirmative experience and a process marked by concern, responsibility and adaptation / accommodation. motherhood as a transformative development with positive experiences and the building of ties emerged as the central category. discussion: motherhood has different meanings and nuances for pregnant women, based largely on their socio-cultural components. these aspects must be considered in efforts to guide the promotion of maternal-infant health and maternal care. conclusions: motherhood is a complex process and one of personal transformation that helps the pregnant woman to form a bond with her child, with her partner and with the family members who support her. during this process, she experiences feelings of joy and satisfaction, along with concern and anxiety about the challenges motherhood poses. understanding this process will help to orient the work of health professionals towards prenatal care that is consistent with the expectations of the pregnant woman. key words pregnancy, pregnant women, maternal well-being, prenatal care, maternal-infant nursing. (source: decs, birme). 318 aquichan issn 1657-5997 maternidade: um processo com diferentes nuances e construção de vínculos resumo objetivo: compreender os significados da maternidade para as gestantes a fim de orientar a promoção da saúde materno-infantil. materiais e métodos: pesquisa qualitativa, com base teórica no interacionismo simbólico e o método da teoria fundamentada. com prévio consentimento informado, realizaram-se entrevistas em profundidade a 18 gestantes maiores de 14 anos, de diferentes classes socioeconômicas, residentes em bucaramanga (colômbia). também se observaram suas interações com outras gestantes e com pessoal de saúde nas instituições onde recebem atendimento pré-natal. a informação foi analisada paralelamente com sua coleta mediante codificação aberta e categorização baseada no método de comparação constante e amostragem teórica, até atingir a saturação das categorias. os resultados foram validados em grupos focais com gestantes. resultados: emergiram categorias que dão conta da maternidade como processo, com preocupação, responsabilidade, adaptação/acomodação e como uma experiência positiva. como categoria central, surgiu a maternidade como processo transformador com experiências positivas e construção de vínculos. discussão: para as gestantes, a maternidade tem diferentes significados e nuances, principalmente de seus componentes socioculturais, aspectos que devem ser considerados para orientar a promoção da saúde materno-infantil e do cuidado materno. conclusões: a maternidade é um processo complexo e de transformação pessoal que ajuda as gestantes a formarem vínculos com seu filho, com seu companheiro(a) e com os familiares que a apoiam. durante esta, experimentam sentimentos encontrados de alegria e satisfação, junto com preocupação e angústia pelos desafios que a maternidade implica. entender esse processo orienta o fazer dos profissionais da saúde a um atendimento pré-natal harmonizado com as expectativas da gestante. palavras-chave gravidez, mulheres grávidas, bem-estar materno, atendimento pré-natal, enfermagem materno-infantil. (fonte: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 316-326 319 maternidad: un proceso con distintos matices y construcción de vínculos l flor de maría cáceres-manrique, gloria molina-marín, myriam ruiz-rodríguez introducción la maternidad es un fenómeno sociocultural complejo (1) que trasciende los aspectos biológicos de la gestación y del parto, pues tiene además componentes psicológicos, sociales, culturales y afectivos del ser madre que se construyen en la interacción de las mujeres con otras personas en escenarios particulares, donde se viven universos simbólicos con significados propios, tal como lo plantea la corriente teórica del interaccionismo simbólico (2). las investigaciones con relación a la maternidad han sido principalmente de carácter histórico, la mayoría llevadas a cabo por autoras de la corriente feminista en europa (1, 3) y estados unidos, o por algunos estudiosos que desde la psicología clínica se han preguntado por esta experiencia (4). en américa latina son escasos los abordajes del concepto de maternidad pues solo se cuenta con algunos estudios y aproximaciones tanto a su historia como a su vivencia (1, 5, 6). en colombia los estudios son aún más escasos y se han realizado en instituciones específicas con grupos definidos, de modo que no alcanzan a dar cuenta de lo que ocurre en otros contextos particulares; además, son muy pocos los estudios que abordan el significado de la maternidad para las gestantes y que a su vez logran ligar sus hallazgos con la promoción de la salud materno-infantil (7). la maternidad en los servicios de salud ha sido abordada, principalmente, desde su componente biológico, mediante el uso del paradigma empírico-analítico o modelo biomédico centrado en los factores de riesgo, cuyo indicador centinela es la mortalidad materna (mm), y cuyos insumos son las políticas de atención materna, los programas de atención prenatal y los indicadores de la vigilancia en salud pública de la mm y de la mortalidad perinatal. en igual sentido, los programas de atención materno-infantil han sido formulados casi exclusivamente desde el paradigma biomédico, sin dar importancia al significado que tiene la experiencia de la maternidad para las mujeres, lo cual ayudaría a propiciar su empoderamiento con los programas de promoción de la salud, sobre todo en aquellas mujeres en periodo de gestación que requieren acompañamiento, consejería y educación para el cuidado de la salud. ahora bien, el significado que una persona le da a un evento, en este caso las mujeres gestantes a la maternidad, se considera la fuerza que las impulsa a realizar acciones con respecto a dicho evento (2), por ejemplo, obtener información, solicitar atención, acudir a las instituciones de salud o seguir las recomendaciones que les hacen los profesionales de la salud que las atienden. la comprensión de los significados que tiene la maternidad para las gestantes es necesaria para aportar elementos que ayuden a cualificar los programas de atención prenatal y a orientar la promoción de la salud hacia una atención humanizada, productiva, reflexiva y acorde con las necesidades y expectativas de las mujeres, tal como lo sugieren las políticas internacionales a favor de la maternidad saludable (8, 9). entonces, se requiere intentar nuevas aproximaciones a la maternidad como objeto de estudio, incorporar postulados epistemológicos, teóricos y metodológicos propios de las ciencias sociales, para permitir la emergencia de distintas interpretaciones (10) que iluminen los significados de la maternidad a partir de las voces de las gestantes y de sus vivencias en los escenarios de atención prenatal. el objetivo del presente estudio es comprender los significados de la maternidad para las gestantes, con el fin de orientar la promoción de la salud materno-infantil. la investigación fue aprobada por los comités de ética de las universidades participantes y de las instituciones en donde se contactaron las gestantes. materiales y métodos se realizó un estudio cualitativo, siguiendo el método de la teoría fundamentada en los datos (11) con su sustento teórico en el interaccionismo simbólico (4, 5). como técnicas de recolección de información se utilizaron la entrevista en profundidad y la observación participante y no participante. para ingresar al estudio las mujeres debían estar embarazadas, ser mayores de 14 años, residir en la ciudad de bucaramanga, pertenecer a cualquiera de los regímenes de aseguramiento y dar su consentimiento para la realización de las entrevistas. ellas fueron contactadas en instituciones prestadoras de servicios de salud (ips) públicas y privadas, en la comunidad, por intermedio de las representantes del programa familia, mujer e infancia (fami) de los hogares comunitarios de bienestar del instituto colombiano de bienestar familiar (icbf), de líderes comunitarios y mediante una estrategia de bola de nieve que buscaba incluir embarazadas que no asisten regularmente a los programas de atención prenatal, así como gestantes de estrato alto, quienes generalmente acuden a consultorios particulares. las entrevistas se realizaron en los sitios y horarios que las participantes escogieron, de acuerdo con sus preferencias, de tal 320 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 manera que se sintieran cómodas y relajadas para el encuentro cara a cara con la entrevistadora y que se les garantizara la posibilidad de expresarse libremente. se siguió una guía con preguntas abiertas y amplias que indagaba sobre las experiencias de la maternidad y el significado que tenía para ellas en ese momento de sus vidas. antes de iniciar la recolección de la información se llevaron a cabo seis entrevistas exploratorias con el fin de ensayar el manejo de la entrevista, la claridad de las preguntas de la guía y la capacidad de la investigadora para realizar las entrevistas. también se realizaron visitas a las ips para afinar las guías de observación. la observación se llevó a cabo en ips, públicas y privadas, donde se realiza la atención prenatal, tanto en las salas de espera donde las gestantes ingresan y permanecen mientras les corresponde el turno para la atención, como directamente asistiendo con ellas a algunas consultas con los profesionales de la salud cuando hubo el consentimiento tanto de la gestante como del profesional de la salud que la atendía, para estar en la consulta. en la observación se hizo énfasis en la interacción de las gestantes entre sí, y de ellas con los profesionales de la salud durante la consulta o durante las actividades de encuentro. en un diario de campo se registraron las notas administrativas y los memos analíticos, además de los asuntos relacionados con los objetivos del estudio, con la descripción de los espacios de interacción, las características de los actores en interacción, las acciones, los gestos, los objetos presentes, los acontecimiento o las actividades que llevan a cabo, el tiempo, los fines que pretendían, y los sentimientos y las emociones que expresaban el análisis de la información se realizó en forma simultánea con su recolección, siguiendo los principios de la teoría fundamentada, lo cual implica un proceso de codificación abierta, axial y selectiva (11) cada entrevista fue transcrita, revisada, editada y codificada frase por frase, y luego párrafo por párrafo. igual procedimiento se siguió con los audios, las notas y los textos producto de las observaciones. fue así como se extrajeron códigos que luego se compararon para identificar similitudes entre ellos, relacionarlos y agruparlos por temas. es decir, se siguió el método de análisis de la comparación constante y la técnica de hacer preguntas a los datos para identificar patrones de los significados de maternidad que han construido las gestantes. se identificaron fenómenos emergentes, categorías descriptivas que permitieron el surgimiento de categorías analíticas, cuyas características y dimensiones fueron saturadas mediante muestreo teórico. las categorías analíticas se ubicaron como fenómenos centrales con sus posibles causas, contextos, acciones e interacciones entre los actores y las consecuencias para ellos (11, 12). resultados se realizaron 32 horas de observación y se entrevistaron 18 gestantes. con cada una de ellas se sostuvieron entre uno y cuatro encuentros cara a cara. once de las participantes residían en estratos socioeconómicos 1, 2 o 3 a los cuales denominamos como estrato bajo; mientras que siete residían en estratos 4 y 5, que denominamos estrato alto. la edad de las participantes osciló entre 14 y 38 años, con promedio de 28 años, pero con diferencias en los promedios de edad por estratos, así: 26,5 años en estrato bajo y 31,2 años en el alto. el rango de escolaridad en años cursados estuvo entre cinco y 16 años, con promedio de 12 años. también el promedio de años de escolaridad por estratos es diferente: 10 años para mujeres de estratos bajos y 16 para gestantes de estrato alto; las diferencias en edad y escolaridad entre las gestantes de estratos alto y bajo podrían corresponder al tiempo que las mujeres de estrato alto invierten en estudiar una carrera antes de iniciar su maternidad. el número de gestaciones de las entrevistadas estaba entre una y seis, con promedio de 1,5 en mujeres de estrato alto y de 2,2 para las de estrato bajo. de igual manera, las mujeres de estrato alto solo han tenido uno o dos embarazos, mientras que para quienes viven en estrato bajo el número de embarazo está entre uno y seis. de los discursos de las gestantes y de la observación realizada emergieron las siguientes categorías sobre el significado de la maternidad: la maternidad como un proceso, como una preocupación, una responsabilidad, como adaptación/resignación y como una experiencia positiva. como categoría principal emergió la maternidad como un proceso que transforma, con responsabilidades, experiencias positivas y construcción de vínculos. a continuación se presentan dichas categorías, siguiendo la lógica de la matriz paradigmática que muestra un fenómeno central con sus posibles causas, contextos, acciones e interacciones de los actores y sus consecuencias (11). la maternidad como un proceso para todas las gestantes entrevistadas, la maternidad es un proceso dinámico que está en constante construcción, decons321 maternidad: un proceso con distintos matices y construcción de vínculos l flor de maría cáceres-manrique, gloria molina-marín, myriam ruiz-rodríguez trucción y búsqueda de sentidos. tiene un inicio, generalmente situado con relación al embarazo. luego siguen una serie de etapas no bien diferenciadas, que pueden darse simultáneamente, que cambian muy rápido a medida que avanza el proceso, y que fueron descritas así: a) inicio con la sospecha de embarazo; b) confirmación, asimilación y acomodación del embarazo al proyecto de vida; c) verificación dada por los signos y síntomas de embarazo, los movimientos del bebé y la asistencia al cpn; d) cambios en la figura corporal y progresión del embarazo; e) parto, nacimiento del bebé; e) cuidado, protección, educación y acompañamiento del niño; f) formación con miras a conseguir que el hijo llegue a ser persona de bien. todas estas etapas se acompañan con cambios psicológicos que producen sentimientos encontrados: felicidad y angustia, alegría y tristeza, preocupación y satisfacción, temor y esperanza, según las circunstancias que vive la gestante en cada momento y en cada contexto. para las gestantes la maternidad dura toda la vida y es una vivencia particular, distinta para cada quien, en cada época de la gestación y con cada hijo. este proceso puede darse en un ambiente adverso de falta de empleo, baja escolaridad y barreras de acceso a los servicios de salud; pero también en un ambiente positivo donde se propicia la preparación, el acompañamiento y el apoyo a la gestante por parte de la pareja, la familia y la sociedad en general. la gestante desarrolla aprendizajes y se adapta a las vivencias y exigencias para proteger, cuidar y formar al hijo; ella vive la experiencia y se exige más con el fin de cumplir su rol de madre. de igual manera, ellas consideran que el proceso ayuda a formar a los ciudadanos para vivir en sociedad. a continuación se presentan algunos de los discursos que sustentan la maternidad como un proceso: la maternidad es formar a una persona, cuidar, proteger y formar… uno al principio está cuidando y luego protege y forma a un ser humano (28 años, casada, primer embarazo). estoy en una serie de pasos, por un tiempo lo llevo en mi vientre y lo cuido, luego sale al mundo, pero igual yo sigo cuidándolo, porque no tendría sentido, ser mamá solo por esos 9 meses no tendría razón de ser (35 años, casada, segundo embarazo). uno está pensando cómo quiere la educación de sus hijos, cómo los va criar, pero yo creo que también eso va cambiando a medida que pasa el tiempo (31 años, casada, primer embarazo). la maternidad como una responsabilidad la maternidad para las embarazadas significa una gran responsabilidad sobre todo por lo que implica la crianza, por la necesidad de formar al hijo en valores, velar para que no le falte nada, darle mucho amor y tratar de que pueda salir adelante. pero dar amor también significa cuidarse ella, como ser único, cuya presencia en la vida del hijo la considera muy importante para educarlo, enseñarle, dialogar y estar siempre presente; dado que esa responsabilidad va de la mano con su sueño de ser madre y que, en todo caso, la responsabilidad de la maternidad se delega más en las mujeres como madres, a ellas les afecta más que a los papás. en la vivencia de la maternidad como responsabilidad las mujeres están inmersas en diferentes tipos de escenarios que pueden ir desde un ambiente adverso de madre sola, desempleada, con baja escolaridad y relaciones conflictivas, hasta un medio de relaciones positivas de comprensión, acompañamiento y ayuda por parte del esposo y sus familias, y además, con la posibilidad de acceder a adecuados servicios de salud. el tipo de ambiente determina en la gestante el camino que debe seguir. en algunos casos la lleva a realizar grandes esfuerzos, a exigirse más, a veces cumpliendo doble jornada laboral para lograr autonomía económica, poder salir adelante, aprender sobre crianza, prepararse y buscar ayuda con paciencia, alegría y buenas relaciones con su familia. todo lo anterior le genera sentimientos encontrados de ansiedad, angustia y preocupación por los riesgos que puede correr el bebé debido a otros factores como la edad, el consumo de medicamentos o anticonceptivos previos al embarazo, los cambios en el estado psicológico, así como preocupaciones por el parto, en medio de expectativas, esperanzas, sensación de falta de ubicación y temor a no ser buena madre. la responsabilidad es calificada por ellas como “grande, enorme o gigante”. los siguientes testimonios dan sustento al significado de la maternidad como una responsabilidad: ser mamá es una responsabilidad gigante, yo creo que la más grande que hay, porque es el tener una vida a cargo y poder inculcarle a esa vida valores y criterios fuertes para que sea una gran persona (26 años, unión libre, primer embarazo). algunas mujeres les da miedo tener hijos por la responsabilidad (26 años, casada, tercer embarazo). 322 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 la maternidad es algo muy lindo, algo hermoso, pero de mucha responsabilidad (38 años, unión libre, quinto embarazo). …es la labor más demandante del mundo, desde que lo concibe, hasta que se muere (26 años, unión libre, primer embarazo). la maternidad como preocupación también la maternidad conlleva una preocupación, sobre todo por el cuidado del niño, por la falta de preparación para la crianza, la falta de autonomía, la dependencia económica, los temores generados por circunstancias como la posibilidad de malformaciones congénitas en el niño, o por perder o no conseguir empleo, y por no ser una buena madre. esta preocupación es más frecuente en un contexto de madre sola, desempleada, o aquella que tiene dificultades para conseguir un empleo por el hecho de estar embarazada. o cuando la mujer desempeña varios roles, así como cuando hay múltiples expectativas y tensiones sobre el final del embarazo, el parto y el hijo por nacer. la preocupación se acentúa cuando hay barreras de acceso a los servicios de salud, cuando hay desencuentros con el personal de salud que atiende a la mujer, o cuando la gestante conoce experiencias negativas de otras mujeres embarazadas, sobre todo en caso de complicación o muerte del bebé, falta de buen trato por parte del personal de salud, o fallas en la calidad de la atención durante el embarazo o al momento del parto. esta preocupación lleva a la gestante a tomar decisiones, a prepararse para cuidar al bebé, a reevaluar, innovar o imitar los patrones de crianza maternos, en un esfuerzo por salir adelante, a veces con sensación de incapacidad y culpa ante los múltiples roles y exigencias que la sociedad le impone. todo esto lleva a tener cierto grado de ansiedad, incluso con aparición de pesadillas, pero también a una reflexión sobre los elementos que le causan preocupación. los siguientes testimonios dan cuenta de la preocupación que significa la maternidad para algunas mujeres. me preocupa la crianza porque como está tan terrible el mundo, con quién dejarlo, quién lo cuide. me preocupa más la crianza que la maternidad en sí (31 años, casada, primer embarazo). me preocupa que me crezca la barriga, porque así no me dan trabajo (34 años, soltera, primer embarazo). me preocupa que el bebé no vaya a tener el apoyo del papá (34 años, soltera, primer embarazo). la maternidad como una experiencia positiva en los discursos de las entrevistadas la maternidad también emergió como una experiencia positiva para la mayoría de las gestantes, pero con diferentes matices. en algunos casos es compartida con el esposo o compañero y la familia, cuando ella cuenta con una pareja estable, y los dos consideran que es el momento adecuado para tener un hijo porque ya han vivido, planeado y decidido que es el tiempo propicio para dedicarse a ello. en este contexto el embarazo es deseado, programado, buscado y esperado, y la mujer tiene empleo estable, autonomía económica y acceso a los servicios de salud, además de una pareja que participa, una familia que la apoya, y cuenta además con servicios de salud de buena calidad. la mayoría de las mujeres que experimentan la maternidad compartida pertenecen al estrato socioeconómico alto. ellas gozan la maternidad, la disfrutan al máximo, viven cada momento, se preparan, averiguan, se informan, comparten con las demás mujeres de su entorno y reclaman sus derechos. el hecho de poder compartir la maternidad les da mayor autonomía tanto económica como en las decisiones de la crianza, también tienen mayor creatividad en cuanto a las decisiones de autocuidado, así como en la programación y preparación para la crianza; asimismo, les da mayor seguridad en su rol de madres, y les permite hacer innovaciones mediante el uso de recursos de aprendizaje como videos y libros, además de los cursos psicoprofilácticos y las consultas con los profesionales de salud. algunas de ellas ostentan cercanía con los profesionales que las atienden, bien sea porque pertenecen a su círculo social, o son sus mismos familiares y amigos, o porque durante el proceso de atención han logrado construir vínculos con ellos y eso les otorga mayor confianza. es así como hay gestantes que a pesar de las carencias hacen sus arreglos sociales y psicológicos y viven una maternidad armoniosa, feliz y productiva a partir de los avances y logros que ellas mismas construyen, a veces solas, a veces con ayuda de un familiar u otra persona de su entorno. la mayoría se dan aliento en los vínculos que logran establecer con otros, especialmente con su hijo por nacer. esto confirma los postulados del interaccionismo simbólico, según los cuales el ser humano es agente emergente que tiene capacidad de plantearse objetivos, hacer arreglos psicológicos y sacar sus metas adelante, a pesar de la adversidad, dada su capacidad de autointeracción y autogestión (2). 323 maternidad: un proceso con distintos matices y construcción de vínculos l flor de maría cáceres-manrique, gloria molina-marín, myriam ruiz-rodríguez algunos de los testimonios que dan cuenta de la vivencia de maternidad compartida son: es una experiencia muy bonita porque siempre he estado en compañía de mi esposo (37 años, casada, primer embarazo). es difícil para muchas que no cuentan con respaldo y apoyo de su pareja y de su familia (26 años, unión libre, primer embarazo). para mí la maternidad es lo más hermoso del mundo, como una bendición de dios (27 años, casada, segundo embarazo). la maternidad es “una etapa hermosa, si lo pongo en el plano de lo divino eso es algo que somos muy afortunadas, somos bendecidas, por poder gestar una vida (34 años, casada, segundo embarazo). “el poder sentir es algo como tan hermoso, que todo lo que uno haga repercute directamente en el bebé, entonces el proceso de la maternidad es único (34 años, casada, segundo embarazo). la maternidad como adaptación/ acomodación para algunas embarazadas la vivencia de la maternidad está acompañada de momentos de tensión entre el rechazo y la aceptación de la gestación, dado que el embarazo no era deseado, no estaba planeado, no había sido programado, o interfería con sus planes de seguir estudiando y construir su proyecto de vida. en quienes el embarazo no ha sido planeado o no es deseado confluyen sentimientos encontrados, sobre todo al inicio. por ejemplo, la gestante puede sentir frustración, pero este sentimiento va cambiando a medida que su proceso de gestación evoluciona y se van produciendo los arreglos psicológicos y sociales que le permiten pasar de la frustración y la negación a un proceso de aceptación, adaptación y acomodación de la maternidad en su proyecto de vida. este proceso se hace más complejo cuando hay rechazo del embarazo por parte del compañero, cuando hay conflictos de pareja, violencia intrafamiliar o abandono por parte del padre del bebé, que lleva a la gestante a la condición de madresolterismo. también en aquellas gestantes con limitadas redes de apoyo familiares y sociales, y con escasos recursos económicos, por ejemplo, cuando no cuentan con un empleo o un ingreso estable. pero sobre todo, cuando el compañero no responde a su rol de padre. dado que la gestante alberga una serie de sentimientos que pueden ir desde tristeza, angustia e incertidumbre, matizados con momentos de esperanza, alegría y felicidad, es fundamental el apoyo de familia y los servicios de salud para que ella logre rápidamente ubicar la maternidad en su proyecto de vida y hacerla más productiva. algunos testimonios que ilustran esta categoría son los siguientes: antes de estar embarazada estábamos perfecto [con el novio], pero le dije que estaba embarazada y me dijo que no estaba preparado, que era mejor que abortara (34 años, soltera, primer embarazo). tenía planes de irme a estudiar en el extranjero que tuve que posponer mientras se da lo del parto (26 años, unión libre, primer embarazo). … al principio cuando me enteré [del embarazo] fue duro, pero ya ahorita estoy muy emocionada (35 años, casada, segundo embarazo). categoría central: la maternidad como proceso transformador con distintos matices y construcción de vínculos una vez analizados los significados de la maternidad con sus causas, contextos, acciones/interacciones y consecuencias, se logró establecer que este es, en principio, un proceso dinámico que cambia en el tiempo y transforma a las gestantes en madres; las lleva, a pesar de las preocupaciones y su sentido de la responsabilidad, a buscar elementos y generar oportunidades de aprendizaje, de crecimiento personal en los aspectos psicológicos y sociales, alentada por la presencia de un nuevo ser en su vida, con quien inician la construcción de vínculos afectivos en diferentes épocas del embarazo, dependiendo de sus expectativas, sentimientos, acciones e interacciones con los demás. en los espacios de observación se pudo identificar que hay un ambiente propicio para la construcción de significados y de vínculos entre las gestantes con su pareja, sus familiares o con otras gestantes con quienes comparte experiencias, vivencias y preocupaciones, así como con los miembros del equipo de salud que la atienden. ellas tratan de satisfacer sus necesidades, buscan respuestas a sus inquietudes y preocupaciones, construyen conocimientos y se valen de los sentimientos positivos que les otorga la maternidad para construir significados que les ayudan a 324 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 disfrutar de la experiencia día a día y a prepararse para desarrollar su rol de madres. discusión darles la voz a las mujeres permitió la emergencia de significados de la maternidad como un proceso que a medida que avanza les permite crear vínculos afectivos. la maternidad para ellas es un proceso complejo y dinámico, con preocupaciones por la responsabilidad que acarrea, la necesidad de adaptación y acomodación a las nuevas exigencias, pero también a sentimientos positivos, mientras la gestante construye nuevos vínculos. por ejemplo, con el feto, con quien algunos estudios sostienen que el vínculo se construye desde el inicio de la gestación (13), pero también con sus parejas de quienes, en estudios previos, se ha reportado que la paternidad logra transformar sus vidas (14). también se estrechan relaciones con sus familiares y con quienes logren involucrarse con las gestantes en una relación de cambio, preparación y apoyo, denominada constelación maternal (4).estos vínculos llevan a las futuras madres a una transformación personal y a experimentar sentimientos de felicidad, alegría y satisfacción, matizados con preocupación y angustia por los retos que implica la maternidad. estos significados, a su vez, desempeñan su papel en las acciones de las gestantes, mediante el proceso de autointeracción, tal como lo proponen los teóricos del interaccionismo simbólico (2) no obstante los sentimientos positivos, en ocasiones las gestantes experimentan sentimientos negativos y, además, otorgan gran importancia al apoyo proveniente del padre del bebé (14). las jóvenes gestantes experimentan sentimientos negativos especialmente cuando no cuentan con un ambiente familiar de seguridad y confianza; cuando no tienen estabilidad emocional con su pareja y no se sienten seguras del afecto y apoyo que les pueda brindar, lo cual las lleva a sentirse solas, angustiadas y frustradas. las gestantes del presente estudio dieron gran relevancia a la noticia del embarazo y la identificaron como la primera etapa del proceso de la maternidad. también destacaron el rol del padre del bebé durante el proceso. los resultados del presente estudio concuerdan con otros hallazgos (15) respecto a que durante la gestación las mujeres experimentan sentimientos ambivalentes y encontrados, a veces de soledad, y momentos traumáticos debidos a la poca sensibilidad del personal de salud, al refuerzo de las relaciones de poder de los profesionales del área, incluso al temor a ser maltratadas durante el parto (7), situación que requiere que el equipo de salud desarrolle competencias que le permitan acercamiento personal, empatía y trato humanizado e individualizado en los escenarios de atención prenatal. esto último evitaría la sensación de trato distante, rutinario e impersonal que refieren en ocasiones las gestantes (7). de otro lado, los resultados de esta investigación muestran cómo ciertos contextos condicionan significados de maternidad distintos y acciones en salud también diferentes, con el desenlace de consecuencias a veces negativas sobre la salud de la madre y del niño. por ejemplo, las gestantes que no cuentan con apoyo de sus parejas tienden a demorar más en su proceso de adaptación al embarazo, a consultar más tardíamente a los servicios de salud, a presentar más síntomas y a requerir más hospitalizaciones. las condiciones socioculturales como el embarazo en adolescentes, la multiparidad, la pobreza y el hecho de no vivir en casa propia han sido relacionadas, en otros estudios, con el inicio tardío de la atención prenatal (16). también hay reportes de diferencias en las vivencias de la maternidad según el estrato socioeconómico de las gestantes. al respecto, pantelides (17) informa que el lugar de residencia encierra una realidad muy compleja, que va desde las posibilidades de acceso a educación, trabajo, medios de comunicación, aspectos culturales y sociales, tales como las perspectivas que se le ofrecen a las mujeres fuera del hogar y la mayor o menor igualdad entre hombres y mujeres. estos hallazgos están de acuerdo con los planteamientos de bourdieu (18) en relación con el estatus y la disponibilidad de diferentes tipos de capital según el estrato socioeconómico y cultural de las personas; pero sobre todo se vieron diferencias en la calidad de los servicios de salud que se les prestan a las gestantes según el estrato y el régimen de aseguramiento, lo cual configura inequidades. adicionalmente, cabe resaltar que algunas causas de los fenómenos y los contextos identificados en las distintas categorías pueden ser intervenidos antes de que las mujeres tengan un embarazo, lo cual señala la necesidad de reforzar las actividades de consejería antenatal, en donde se reconozca la maternidad como proceso transformador y a partir de allí se fortalezca la agencia de los actores en lo relacionado con la construcción de una maternidad más productiva y satisfactoria para cada uno, con la asunción de las responsabilidades y la promoción de los derechos a la salud y a una educación liberadora. esto conlleva 325 maternidad: un proceso con distintos matices y construcción de vínculos l flor de maría cáceres-manrique, gloria molina-marín, myriam ruiz-rodríguez la necesidad de repensar la atención de la embarazada, en su enfoque, en su proceso y en su dimensión humana, dado que es una vivencia que se configura a partir de muchas dimensiones, una de ellas la biológica. a la luz de los resultados de esta investigación vale la pena hacer una reflexión sobre el quehacer del profesional de la salud, sobre todo de las enfermeras, quienes son el primer contacto de la gestante con los servicios de atención prenatal. la reflexión debe hacerse desde el abordaje, la consejería, la educación, el acompañamiento y el seguimiento a las gestantes en el sentido de procurar siempre una atención con calidez, escucha y respeto hacia las necesidades de la mujer embarazada, sobre todo atendiendo sus expectativas, que en estudios previos se ha encontrado que principalmente están relacionadas con la educación (19). en ese sentido, el papel del la enfermera como educadora y gestora del cuidado de la salud debe repensarse desde la academia y desde la formación profesional que incluya elementos y paradigmas más allá del modelo biomédico, de tal manera que puedan orientar hacia la comprensión del complejo fenómeno de la maternidad en las gestantes y abordar las motivaciones que estas tienen para acudir a los servicios de salud. el punto clave para lograr una maternidad armónica e incluyente parece ser la educación y la promoción de la salud maternoinfantil, más que el énfasis en los factores de riesgo del embarazo. esta idea lleva a pensar la maternidad en todas sus dimensiones y a trascender el aspecto biológico; en el escenario de la atención en salud de la gestante, el modelo biomédico se configura como un universo de significados para comprender el comportamiento de los actores y sus relaciones, y la conformación de un sentido; en este caso de la maternidad. para legitimarse se basa en las evidencias producidas por estudios realizados desde el paradigma positivista, también en el poder que le otorga la sociedad al médico para diagnosticar y curar (20). el planteamiento anterior lleva, no a descartar de plano el paradigma positivista, sino a considerar una triangulación de métodos en pro de una atención prenatal integral y de calidad. una apuesta reciente da cuenta de que siguiendo esa línea de pensamiento algunas autoras han adelantado un trabajo sistematizado con el propósito de brindarle al profesional de enfermería un instrumento válido para evaluar la calidad del cuidado prenatal (21), lo cual se convierte en una ayuda para mejorar la atención. por último, de acuerdo con los resultados del presente estudio, el personal de salud, sobre todo la enfermera, puede recurrir al carácter transformador, a la conformación de vínculos y a las vivencias positivas de la maternidad para abrirle paso a una propuesta de promoción de la salud de carácter más humanizado, reflexivo e incluyente conclusión para las gestantes la maternidad es un proceso transformador y complejo que les ayuda a la formación de vínculos. entender estos significados de la maternidad orienta el quehacer de los profesionales de salud hacia una atención prenatal armonizada con los intereses y las expectativas de la gestante. el principal aporte del presente estudio es que al darle la voz a las mujeres gestantes emergen significados de maternidad que se convierten en una ayuda para orientar al profesional de salud con miras a llevar a cabo una atención prenatal más adecuada a las necesidades y expectativas de la gestante y, por lo tanto, más satisfactoria, armonizada e incluyente. 326 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 referencias 1. palomar c. maternidad: historia y cultura. 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educational program. colom médica. 2013;44(3):134-8. 20. peñaranda f, bastidas m, escobar g, torres n, arango a. educación para la salud: una mirada alternativa al modelo biomédico. experiencias basadas en la evaluación del programa de crecimiento y desarrollo. medellín: la carreta editores y universidad de antioquia; 2010. 21. heaman mi, sword wa, akhtar-danesh n, bradford a, tough s, janssen pa, et al. quality of prenatal care questionnaire: instrument development and testing. bmc pregnancy and childbirth. 2014;14:188. 245 255 factor de impacto de revistas.indd 245 cayetano fernández-sola1 josé granero-molina2 josé manuel hernández-padilla3 gabriel aguilera-manrique4 factor de impacto de revistas: ¿amenaza u oportunidad? 1 licenciado en humanidades. profesor, universidad de almería, españa. cfernan@ual.es 2 doctor. profesor, universidad de almería, españa. jgranero@ual.es 3 máster en ciencias de la enfermería, isis house. the order of st. john care trust, oxford. jm.hernandezpadilla@gmail.com. 4 doctor. profesor, universidad de almería, españa. gaguiler@ual.es recibido: 22 de septiembre de 2011 aceptado: 1 de noviembre de 2011 resumen este artículo contiene un resumen de las críticas a la utilización del factor de impacto (fi) como indicador de calidad de las publicaciones y de producción de investigadores. tales críticas alcanzan a los autores que intentan publicar en revistas con fi, argumentando que así renuncian a la propia identidad, primando su currículum sobre la utilidad de su investigación. en oposición a esas críticas se afirma que unos criterios de evaluación exigentes sirven de estímulo para la internacionalización del sistema científico. existe consenso en la comunidad académica sobre las imperfecciones del fi y su aceptación como recurso válido y necesario para la evaluación científica, como también en que el debate identitario contribuye poco a resolver la invisibilidad internacional de la investigación de enfermería en español. se esbozan propuestas que apuestan por aprovechar las fortalezas para incrementar y visibilizar dicha investigación, desarrollar estrategias para incluir y mantener a las revistas en español en el journal citation reports (jcr), fomentar la formación y cooperación interdisciplinar, promover la publicación de investigaciones desarrolladas en los programas de posgrado, y reclamar la apuesta editorial por la indexación de sus revistas en el jcr. se concluye que, aunque difícil, es posible aumentar la visibilidad de la producción científica de enfermería en español. palabras clave factor de impacto de revistas, investigación en enfermería, indicadores bibliométricos (fuente: decs, bireme). the journal impact factor: a threat or opportunity? abstract this paper contains a summary of criticism on use of the impact factor (if) as an indicator of the quality of work published by researchers. the criticism is directed to authors who are trying to publish in journals with if. the claim is they are renouncing their own identity and prioritizing their curriculum over the usefulness of their research. the authors challenge this criticism by arguing that stringent assessment criteria stimulate the internationalisation of science, that there is a consensus in the scientific community about the imperfections of fi and its acceptance as a valid and necessary tool for scientific evaluation, and that the debate over identity does little to resolve año 11 vol. 11 nº 3 chía, colombia diciembre 2011 l 245-255 246 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 the international invisibility of nursing research written up in spanish. proposals are outlined on how to benefit from the strengths of this system to increase the visibility of nursing research, to develop strategies for including journals written in spanish in the journal citation reports (jcr), to encourage professional training and interdisciplinary cooperation, to promote the publication of research conducted in postgraduate programs, and to claim an editorial commitment for indexing their journals in the jcr. it can be concluded that, although difficult, it would be possible to increase the visibility of nursing scientific research in spanish. key words journal impact factor, nursing research, bibliometric indicators (source: decs, bireme). fator de impacto de revistas: ameaça ou oportunidade? resumo este artigo contém um resumo das críticas ao uso do fator de impacto (fi) como um indicador da qualidade de publicações e produção dos pesquisadores. as críticas são direcionadas para os autores que publicam em revistas com fi, argumentando que renunciar à sua própria identidade, priorizando seus currículos sobre a utilidade de suas pesquisas. confrontado com as críticas, argumenta-se que os critérios rigorosos de avaliação constituem um estímulo à internacionalização da ciência, há consenso na comunidade científica nas imperfeições do fi e na sua aceitação como recurso válido e necessário para a avaliação científica de modo que o debate de identidade faz pouco para resolver a invisibilidade internacional da pesquisa em enfermagem em espanhol. a proposta é o aproveitamento de fortalezas para incrementar e visibilizar dita pesquisa, assim como desenvolver estratégias para incluir e manter as revistas em espanhol no journal citation reports (jcr), fomentar a formação e cooperação interdisciplinar, promover a publicação de pesquisas desenvolvidas nos programas de pós-graduação, e reivindicar a proposta editorial pela indexação de suas revistas no jcr. conclusão: é possível aumentar a visibilidade da produção científica de enfermagem em espanhol. palavras-chave fator de impacto de revistas, pesquisa em enfermagem, indicadores bibliométricos (fonte: decs, bireme). 247 factor de impacto de revistas: ¿amenaza u oportunidad? l cayetano fernández-sola, josé granero-molina, josé manuel hernández-padilla, gabriel aguilera-manrique críticas al factor de impacto son muchas las críticas que está recibiendo la aplicación de los criterios de evaluación de la calidad de las publicaciones científicas en ciencias de la salud. muchas de ellas han ido dirigidas a la utilización del factor impacto (fi) —indicador bibliométrico del science citation index (sci), base de datos del institute for scientific information (isi), hoy de la empresa thomson reuter— como criterio casi exclusivo para evaluar a investigadores determinando financiación de proyectos, acreditación para profesorado, etc. estas críticas consideran al fi un indicador obsoleto (1), manipulable (1, 2), representativo del culto a lo cuantificable, lastrado por la lentitud de los procesos editoriales (3), que no se hace cargo de la disparidad entre el impacto científico y la relevancia social o clínica de la investigación (2, 3, 4), ni es representativo de la calidad o el mérito de una publicación científica (5, 6, 7). por el contrario, se denuncia que en la consideración de este indicador priman la competencia sobre la cooperación (5, 8) o el currículum del autor sobre la utilidad de su investigación (2, 8). además, se opone a una investigación aplicable en la práctica clínica, por cuanto aleja la publicación de la investigación de su contexto de aplicabilidad (9, 10, 11) contribuyendo a un empobrecimiento del desarrollo profesional de la enfermería (12). asimismo, se esgrimen razones de identidad lingüística, disciplinar y geográfica para clamar contra el fi (8, 13, 14) y poner en valor una alternativa mediante la configuración del llamado espacio científico iberoamericano (eci) como un bloque documental y de gestión del conocimiento paralelo al anglosajón (13, 15). en ese contexto, las críticas alcanzan a los autores que tratan de abrirse espacio en el difícil y competitivo mundo del fi, presentándolos en torno a dos tendencias: una "identitaria" donde se sitúan las enfermeras que citan y publican en revistas del eci; y otra "disgregadora" (13) donde, por exclusión, estarían quienes consultan fuentes externas y tratan de publicar también fuera del eci. de manera más explícita se critica el pragmatismo y conformismo de buena parte de los investigadores y académicos afanados por publicar en revistas con fi en pro de los méritos curriculares frente a la utilidad del conocimiento, renunciando con ello al propio idioma, a las revistas cercanas disciplinar y geográficamente (8), y a que revierta sobre los ciudadanos el beneficio de una investigación financiada con sus impuestos (8, 16). apuntes para el debate sin detrimento de la razón que, en parte, les asiste, nos parece necesario señalar algunos aspectos ocultos bajo tal aluvión de críticas, esbozar las virtudes de un riguroso sistema de evaluación de la calidad de las publicaciones científicas, y apostar por no quedarnos al margen del vigente en tanto se disponga de otro más racional. objetividad y estímulo estamos en un entorno y una profesión donde tradicionalmente han primado los criterios subjetivos o, a lo sumo, la antigüedad frente a otros méritos curriculares o científicos como indicadores de la adecuación del perfil del candidato a un determinado puesto docente o asistencial. con la consideración de otros méritos científicos se produce una 248 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 laxitud en las buenas prácticas de autoría que, sin llegar al fraude (17), hizo necesaria la inclusión de indicadores de calidad de la producción científica frente al mero recuento de publicaciones (18). en ese sentido, se ha reconocido el valor de la bibliometría (15) y la objetividad del fi como indicador que cierra espacios a la arbitrariedad (19). por otra parte, existe una tendencia a emprender campañas de descrédito contra cualquier ranking por parte de quienes no quedan bien situados en el mismo (20). pero la apuesta de los gobiernos por mejorar la posición del sistema científico y la universidad ha conducido a la sobrevaloración del fi como criterio de excelencia de la investigación en ciencias de la salud. y aunque la situación respecto de la investigación está mejorando y países como españa o brasil, que empiezan a ocupar la posición que les corresponde a nivel internacional (21, 22), no puede decirse lo mismo en áreas como la enfermería (23, 24, 25). por ejemplo, en la universidad española los criterios de evaluación de la calidad investigadora y docente empiezan a tenerse en cuenta para la acreditación del profesorado universitario, con unos niveles de exigencia desconocidos hasta ahora. y aunque persisten antiguos privilegios logrados, en algunos casos, con unos méritos que hoy no alcanzarían para acreditarse en la figura profesional más baja, conforta pensar que un sistema de evaluación de la calidad (aunque imperfecto) pueda acabar con ese estatus, siendo deseable su extensión a más ámbitos, como estímulo para la mejora de la gestión, la práctica asistencial, la docencia y la investigación en enfermería. en esa línea, será inevitable abordar cuestiones como el reclutamiento y la promoción de profesionales e investigadores con base en el mérito, la evaluación periódica, el reconocimiento del esfuerzo y la rendición de cuentas (22). sobre la dicotomía utilidad-impacto el discurso sobre la incompatibilidad entre la utilidad de la investigación y el fi debe ser revisado, pues ambos pueden ser compatibles. además, con la apuesta de un país por la internacionalización de su sistema científico no se traiciona a sus ciudadanos; pudiendo argumentarse que estos, a través de sus representantes políticos, deciden que es útil para la ciencia (también la enfermera) salir de su invisibilidad internacional, incorporándose a los circuitos del sistema científico global, utilizando como criterio para asignar los recursos que salen de sus impuestos precisamente los indicadores que apunten a que esta internacionalización se está produciendo (19). por otra parte, aunque existe consenso en las perversiones y limitaciones que encierra su uso inapropiado, el fi se ha convertido en un índice de calidad asentado en el reconocimiento de su valor por la comunidad científica (6, 26), cobrando fuerza la opinión de que no hay nada que por sí solo lo mejore, por lo que debe ser considerado como un buen recurso técnico para la evaluación (27). así lo sugiere un estudio que encuentra una fuerte correlación entre la valoración que hacen los médicos sobre la calidad de las revistas y su factor de impacto, concluyendo que el fi puede ser un indicador razonable de calidad para las revistas generales de medicina (28). en otro estudio, realizado en cinco países (29), los investigadores enfermeros encuestados piensan que publicar en revistas internacionales aumenta el existe una tendencia a emprender campañas de descrédito contra cualquier ranking por parte de quienes no quedan bien situados en el mismo. pero la apuesta de los gobiernos por mejorar la posición del sistema científico y la universidad ha conducido a la sobrevaloración del factor de impacto (fi) como criterio de excelencia de la investigación en ciencias de la salud. 249 factor de impacto de revistas: ¿amenaza u oportunidad? l cayetano fernández-sola, josé granero-molina, josé manuel hernández-padilla, gabriel aguilera-manrique prestigio de sus instituciones, rechazando la dicotomía impacto-utilidad, dado que la investigación puede tener implicaciones globales incluso si se hace a nivel local. las políticas basadas en la consideración del fi como estímulo para la internacionalización del sistema científico han dado resultados positivos para la enfermería en los países que las adoptaron, mejorando la formación de posgrado (29), y aumentando el rigor teórico y metodológico de los trabajos publicados sin detrimento de su utilidad e interés local (23, 29). sobre la identidad y el idioma aun aceptando la presencia del eci (30) en enfermería, también niega lo evidente quien no reconozca la existencia de una comunidad científica global que lo incluye, rebasándolo. por ello, el debate sobre la identidad no debe plantearse en términos excluyentes, pues somos tan enfermeros como los enfermeros japoneses o australianos; tan latinos como los brasileños o italianos; tan sanitarios como los fisioterapeutas o médicos y, muchos a la vez, enfermeros y antropólogos o psicólogos. por ello, no supondría renuncia alguna publicar en revistas de esas disciplinas o países, máxime cuando algunas de ellas se editan también en español y todas se difunden globalmente. innegablemente, es una barrera añadida el dominio hegemónico del idioma inglés (1, 10, 25), y oponerse a ello ha sido comparado con pedir que vuelva el latín como idioma de la comunidad científica mundial (31). pero tal vez la solución sea intermedia y ya empieza a vislumbrarse al existir una tímida ruptura del monopolio norteamericano y del idioma inglés en el jcr, tal y como se comprueba en la tabla 1 elaborada con la consulta de la ficha de cada revista de enfermería del jcr science edition y sus normas de publicación. resultaba llamativo que de las pocas revistas de enfermería no anglosajonas del jcr, ninguna fuera del área hispanohablante hasta la feliz incorporación de la revista aquichan, lo que debería hacernos reflexionar para sacarnos del lamento y la autocompasión, poniéndonos a trabajar para consolidar y aumentar la presencia del español en el jcr. propuestas: de amenaza a oportunidad estamos de acuerdo en reclamar la diversificación de los índices bibliométricos para evaluar la calidad, reconociendo la existencia y validez de los elaborados por otras empresas, instituciones y fundaciones (8, 14, 32), con la consideración de otros medios de difusión de la información científica, como libros (7) o publicaciones abiertas (16, 21). pero esto no nos puede hacer olvidar que, pese a su imperfección, el fi seguirá vigente (1, 33), siendo hoy imprescindible para evaluar la producción científica (19, 27). en esa línea se hace precisa una labor de análisis y propuestas de aumento de la financiación y mejora de la calidad de la investigación, que fue acometida hace años por otras disciplinas (34) o la propia enfermería en países como brasil (25, 32). aceptar el reto se ha denunciado que la consideración del fi como criterio principal para la acreditación del profesorado universitario deja en desventaja a la enfermería (3, 10, 12), pero no es algo que afecte exclusivamente esta disciplina y, probablemente, no existan suficientes investigadores resultaba llamativo que de las pocas revistas de enfermería no anglosajonas del journal citation reports (jcr), ninguna fuera del área hispanohablante hasta la feliz incorporación de la revista aquichan, lo que debería hacernos reflexionar para sacarnos del lamento y la autocompasión, poniéndonos a trabajar para consolidar y aumentar la presencia del español en el jcr. 250 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 nacionales preparados para cubrir las plazas necesarias en varias áreas de conocimiento de la universidad (20). pero parece que la apuesta no irá por relajar los criterios de evaluación, sino por contratar investigadores preparados, aunque sean extranjeros, para que actúen de células dinamizadoras en los centros donde se incorporen (20). tal posibilidad ya se recoge en la figura de "investigador distinguido" de la nueva ley española de la ciencia (21). con todo ello, las modificaciones de los criterios que se propongan han de ser para todas las ciencias de la salud, sin excepciones o discriminaciones positivas para la enfermería (4). en españa reclamábamos desde antiguo la igualdad de estatus con otras ciencias, y hemos tropezado con los duros criterios de acreditación para todas las de la salud. las mencionadas condiciones de desventaja nos obligan a trabajar más, haciendo un esfuerzo que nos saque del ostracismo científico, diseñando estrategias que nos ayuden, estudiando y emulando lo que otros hicieron. en contra de lo que algunos denuncian (8), no ha de movernos nuestro currículum sino un objetivo más ambicioso: situar a la enfermería en español al nivel de la comunidad científica global; misión de largo alcance que corresponde emprender a la actual generación pero que se verá cumplida en las venideras. contamos con fortalezas entre las que cabe destacar: la proximidad al campo de las enfermeras asistenciales (deseada por otras disciplinas que no trabajan tan estrechamente con los pacientes), el desarrollo de la enfermería avanzada (un salto en el nivel asistencial que debería verse reflejado en el investigador), y jóvenes egresados con más tiempo y mejor preparación (dominio del inglés, de las tic y de la metodología de la investigación). a ello se añade la potencialidad de las universidades, con programas de máster y doctorado, personal investigador y financiación para la investigación. si se vence el recelo entre el ámbito asistencial y el universitario, capaz de dilapidar ese potencial (35), y se promueve una alianza estratégica entre profesionales universitarios y asistenciales, operaría una sinergia capaz de hacernos competitivos a nivel interdisciplinar e internacional. romper el monopolio como han advertido varios autores (7, 8, 11), ante la importancia que adquiere el fi en la evaluación de la actividad investigadora, en primer lugar tendemos a publicar nuestros artículos en revistas con impacto, con lo que las publicaciones de enfermería no incluidas corren el riesgo de quedar relegadas. pero, sin renunciar a publicar nuestras investigaciones en las revistas de mayor impacto, cabe desarrollar una doble estrategia: publicar en ambas (con y sin fi) esforzándose por incluir y mantener en el jcr a las revistas de enfermería en español mejor situadas para ello. no todo ha de ir a revistas con fi, pero sí aquello más general, menos local y con mayor proyección o interés internacional; sin olvidar la publicación de artículos de calidad en las otras revistas para no cerrarnos definitivamente la puerta y poder romper el círculo vicioso. para entrar y mantenerse en el jcr conviene saber cómo funciona, observando las estrategias desarrolladas por quienes nos precedieron y adoptando aquellas que sigan vigentes (26). publicamos poco en revistas de enfermería con fi (23, 24, 25), con menos citas que los investigadosin renunciar a publicar nuestras investigaciones en las revistas de mayor impacto, cabe desarrollar una doble estrategia: publicar en ambas (con y sin fi) esforzándose por incluir y mantener en el jcr a las revistas de enfermería en español mejor situadas para ello. 251 factor de impacto de revistas: ¿amenaza u oportunidad? l cayetano fernández-sola, josé granero-molina, josé manuel hernández-padilla, gabriel aguilera-manrique res de otros países, de las que casi ninguna es en español (36). sin embargo, las citas clásicas u obligadas, las autocitas y las citas selectivas aumentan la probabilidad de publicación e inciden en la base de cálculo del fi (2). por ello, para romper el oligopolio existente, han de incluirse las revistas de enfermería en español entre esas estrategias de citación. así se reclamó en su momento, con similar éxito, desde la comunidad enfermera lusoparlante (6) o la comunidad médica española (37). cabe escoger selectivamente algunas citas de las revistas que ya están incluidas y las mejor situadas para entrar en el jcr, es decir, aquellas que estén indexadas en más bases bibliográficas internacionales, pues ya gozarán de una buena visibilidad de partida; aquellas que publiquen, al menos, el abstract en inglés, que sean puntuales en su edición, y que estén mejor situadas en otros índices bibliométricos. citar artículos originales, especiales y de revisión, publicados el último año y el año en curso, pues el fi se calcula sobre los artículos citados que estén escritos en los dos años anteriores. por ejemplo, si un artículo publicado en 2011 en una revista del sci cita tres trabajos de aquichán fechados en 2005, 2008 y 2009, solo este último estaría contribuyendo a mantener la revista en el sci y a aumentar su impacto. aunque el tiempo de edición puede superar los dos años, siempre se puede actualizar alguna cita bibliográfica, si es pertinente, durante el proceso de revisión (37). formación y cooperación la necesidad de formación en investigación de los profesionales de la salud, particularmente de enfermería, ha sido señalada en varios estudios tanto españoles (38, 39) como internacionales (25, 40, 41). por tanto, deberíamos formarnos y colaborar con otras áreas —en equipos multidisciplinares o institutos de investigación— que nos hagan más competitivos en las convocatorias públicas (42), bien recurriendo, según lo requiera la naturaleza de nuestra investigación, a coautores estadísticos, epidemiólogos, anglohablantes o expertos en análisis cualitativo, por citar algún ejemplo. esto dejará menos margen al intercambio de autorías o favores (17), pero aumentará las posibilidades de éxito (23) contribuyendo a la consolidación de disciplinas emergentes (43) y a la formación de recursos humanos (29, 43). también es preciso incentivar a los alumnos y jóvenes egresados para el desarrollo de actividades de investigación, integrando a los mejores en los grupos de investigación establecidos (6). optimizar esfuerzos ya en las primeras décadas del siglo xx advertía james catell que "quien dedica menos de la mitad de su semana laboral a la investigación porque se ve obligado a dedicar más de la mitad de la misma a la enseñanza, con razón puede llamarse aficionado" (31). la polémica frase encierra un mensaje vigente, al menos respecto del tiempo dedicado a la formación de posgrado: contemplamos con optimismo los nuevos programas de máster y doctorado para enfermería, que siempre levantaron grandes expectativas donde se instauraron (44, 45, 46), con la esperanza de que bastarán para sacarnos del limbo de la investigación; pero no es así. si bien la competencia investigadora debe desarrollarse en los estudios de posgrado (47), esta no queda demostrada con la tesis de maestría o doctorado, sino con la incorporación del doctorando a la comunidad científica, es decir, publicando los resultados de sus investigaciones. si del trabajo de investigación con el que un doctorando ha ya en las primeras décadas del siglo xx advertía james catell que "quien dedica menos de la mitad de su semana laboral a la investigación porque se ve obligado a dedicar más de la mitad de la misma a la enseñanza, con razón puede llamarse aficionado". 252 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 convencido a un tribunal de que posee la competencia investigadora no sale una publicación de impacto podemos considerar, parafraseando a catell, que doctorando y directores “son aficionados”; o, en otros términos, que no han optimizado su esfuerzo. así lo entendieron en algunos países donde exigen que sus estudiantes hayan publicado en revistas para obtener su doctorado (27, 48), pues es en el proceso editorial donde, considerando el mérito de las investigaciones, se produce un diálogo ético-científico entre actores cualificados (autores, revisores, editores) en el que los evaluadores actúan de “certificadores” de la competencia investigadora (49). la apuesta editorial los editores son quienes mejor conocen el funcionamiento de las bases de datos y los cálculos del fi, por lo que sería pretencioso darles aquí consejos. pero sí se aprecia que la inclusión de una revista en el jcr pasa por una apuesta editorial (19, 37, 50, 51,52), por lo que cabe pedirles que, desde el compromiso ético y social que les caracteriza (49), adopten esfuerzos para la mejora de la calidad, la indexación de sus revistas en bases de datos nacionales e internacionales (6, 19), la adopción del sistema de revisión por pares, etc.; siendo deseable tanto la sana competencia como una colaboración entre ellos (8, 52), pero orientada a introducir sus revistas en el jcr (52) y no a sobrevivir al margen (8). en esa línea, la exitosa estrategia que se aprecia en las publicaciones latinoamericanas, con numerosas revistas que admiten y publican artículos en cualquiera de los dos idiomas oriundos (español y portugués) junto al inglés, no se produce en la península ibérica ni en el resto de europa, donde las publicaciones de cada país guardan con celo su identidad y se pliegan al inglés como único idioma común además del propio. conclusión es cierto que los criterios de evaluación de la actividad investigadora en ciencias de la salud son potencialmente perniciosos si conceden exclusividad al fi como criterio de calidad. apostamos por una diversificación de indicadores, sin que ello conduzca a la enfermería a una segunda vía, más relajada; sino que, como ciencia de la salud, debemos compartir criterios con el resto de disciplinas científicas del área. hechas las críticas y denuncias, es el momento de apostar por jugar la partida en un escenario global; hacer investigación de calidad, publicarla en revistas de impacto citando las revistas latinas (en español y portugués) con vocación internacional; superar viejos recelos para identificar y aprovechar las sinergias favorables (asistencial-universidad, enfermería-resto de disciplinas científicas), y optimizar esfuerzos y recursos. de ese modo se podrá, no ya alcanzar el equilibrio con el gigante norteamericano (53) o con el idioma inglés, pero sí al menos aumentar la visibilidad de la producción científica de la enfermería en español. referencias 1. silva lc. un indicador obsoleto pero lamentablemente vigente. enferm clin 2011; 21 (1): 59. 2. palencia e. la esquizofrenia de las publicaciones científicas: factor de impacto versus popularidad. remi 2004; 4 (1) [revista en internet]. [citado el 5 de marzo de 2011]. disponible en http://remi.uninet.edu/2004/01/remia012.htm. 3. barrio im. el culto a los números y el factor de impacto. enferm clin 2011; 21 (1): 60-1. 4. aizpuru f. a vueltas con el factor de impacto. enferm clin 2011; 21 (1): 64-5. 5. ketefian s, mendes iac. ambientes para pesquisa independente e fator de impacto das revistas no brasil: estudo de caso. objn 2010; 9 (1) [revista en internet]. 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l cayetano fernández-sola, josé granero-molina, josé manuel hernández-padilla, gabriel aguilera-manrique tabla 1. distribución por países, idioma de publicación e idioma de envío de artículos de las revistas del jcr science edition 2010, categoría "nursing" país nº de revistas idioma de publicación idioma para subir artículos ee.uu. 57 inglés inglés reino unido 13 inglés inglés australia 7* inglés inglés brasil 3 inglés, español y portugués inglés, español o portugués suiza 1 inglés, español y japonés inglés 1 alemán alemán holanda 1* inglés inglés corea del sur 1 inglés inglés 1 coreano coreano colombia 1 español, portugués o inglés español, portugués o inglés japón 1* inglés inglés italia 1 italiano italiano * hemos incluido como revista japonesa a la jpn j nurs sci, pues aunque se edita en australia se define como la publicación oficial en inglés de la japan academy of nursing science. el mismo criterio hemos seguido para la revista collegian editada en holanda por el royal college of nursing, australia (rcna). por ello holanda aparece con solo una revista (eur j cardiovasc nurs). 41 56 las experiencias de las personas mayores.indd 41 joaquín jesús blanca-gutiérrez1 maría luisa grande-gascón2 manuel linares-abad3 las experiencias de las personas mayores que viven en hogares para ancianos: la teoría de las “díadas de intercambio” 1. doctor, magíster en gerontología. enfermero de la agencia sanitaria alto guadalquivir, españa. jjblanca@ephag.es 2. doctora en ciencia política, enfermera. profesora titular, universidad de jaén, españa. mlgrande@ujaen.es 3. doctor en antropología social y cultural, enfermero, matrón. profesor titular, universidad de jaén, españa. mlinares@ujaen.es recibido: 4 de junio de 2012 aceptado: 25 de febrero de 2013 año 13 vol. 13 nº 1 chía, colombia abril 2013  41-56 resumen objetivo: estudiar las experiencias vitales y el proceso de adaptación social de las personas mayores que viven en hogares para ancianos. metodología: estudio cualitativo basado en los procedimientos propios de la teoría fundamentada. el emplazamiento han sido los 6 hogares para ancianos de la comarca de la campiña sur de córdoba, en el sur de españa. los participantes han sido 16 residentes de estos centros. la recogida de información se ha realizado a través de entrevistas en profundidad. resultados: la categoría central que emerge de los datos se ha denominado teoría de las “díadas de intercambio”: en el seno de los hogares para ancianos se establece una situación de intercambio, en la que la persona mayor cede la totalidad o parte de una serie de cualidades, obteniendo a cambio otras que son características de este tipo de instituciones. estas cualidades que se intercambian pueden organizarse en forma de díadas, siendo la principal la cesión del poder de decisión, a cambio de la obtención de unas condiciones más óptimas de seguridad, díada a través de la cual, incluso, se puede explicar el proceso de ingreso en la institución. palabras clave anciano, enfermería, hogares para ancianos, investigación cualitativa. (source: decs, bireme). 42 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 the experiences of older people living in nursing homes: the theory of “exchange dyads” abstract objective: to study the life experiences and the process of social adaptation of older people living in nursing homes. method: a qualitative study based on the procedures of grounded theory. the locations were in the 6 nursing homes in a region of the countryside of cordoba in southern spain. the participants were 16 residents of these centers. the collection of information has been carried through in-depth interviews. results: the main category emerging from the data is called “exchange dyads theory”: within nursing homes an exchange situation is established. in this one, the older person yields all or part of a series of qualities, obtaining in return other qualities that are typical of this kind of institution. these qualities that are exchanged can be organize in the form of dyads, being the most important the assignment of decision-making power for obtaining a more optimal safety conditions, dyad through which even can explain the process of admission to the institution. key words aged, nursing, homes for the aged, qualitative research. (source: decs, bireme). as experiências das pessoas idosas que vivem em casas de repousos: a teoria das “trocas diádicas” resumo objetivo: estudar as experiências vitais e o processo de adaptação social das pessoas idosas que vivem em casas de repouso. método: estudo qualitativo baseado nos procedimentos próprios da teoria fundamentada. foram escolhidas seis casas de repouso da comarca da campina sul de córdoba, no sul da espanha. os participantes foram 16 residentes desses centros. a coleta de informação se realizou por meio de entrevistas em profundidade. resultados: a categoria central que emerge dos dados se denominou teoria das “trocas diádicas”: no seio das casas de repouso, estabelece-se uma situação de intercâmbio, na qual a pessoa idosa cede a totalidade ou parte de uma série de qualidades, obtendo em troca outras que são características desse tipo de instituições. essas qualidades que se intercambiam podem se organizar em forma de díadas, sendo a principal cessão do poder de decisão, em troca da obtenção de umas condições melhores de segurança, díada pela qual, inclusive, pode-se explicar o processo de ingresso na instituição. palavras-chave idoso, enfermagem, casa de repouso, pesquisa qualitativa. (fonte: decs, bireme). 43 las experiencias de las personas mayores que viven en hogares para ancianos: la teoría de las “díadas de intercambio” l joaquín jesús blanca-gutiérrez y otros. introducción concepto y demografía de los hogares para ancianos en españa y europa el instituto de mayores y servicios sociales de españa (imserso) define a las “residencias de personas mayores”, también denominadas “hogares para ancianos”, como “establecimientos destinados al alojamiento temporal o permanente, con servicios y programas de intervención adecuados a las necesidades de las personas objeto de atención, dirigida a la consecución de una mejor calidad de vida y a la promoción de su autonomía personal” (1). kane, ouslander y abrass (2), definen los siguientes objetivos de la atención en estos centros: proporcionar un ambiente seguro y de apoyo para las personas con enfermedades crónicas, recuperar y mantener el mayor nivel posible de independencia funcional, conservar la autonomía personal, mejorar la calidad de vida, el bienestar percibido y la satisfacción vital; proporcionar unas condiciones y un ambiente cómodo y digno para las personas que padecen una enfermedad terminal y para sus familiares, estabilizar y retrasar el avance y el deterioro producido por las enfermedades crónicas, prevenir enfermedades agudas y la yatrogenia, identificándolas y tratándolas cuando se presenten. este tipo de instituciones, los hogares para ancianos, son en realidad una evolución de aquellos centros que dentro de la sociedad tenían la función de “custodiar”, “dar cobijo”, o “recluir” a distintos grupos de personas y con diferentes finalidades: cuidar, curar o castigar. por lo tanto, los objetivos de tipo social de cualquiera de estos centros son algo más ambiguos, lo cual sigue planteando interrogantes acerca de su verdadera función y en cuanto a su adecuación a las políticas de bienestar social (3,4). con respecto al volumen de personas mayores de 65 años que viven en españa y en el resto de europa en hogares para ancianos, se identificaron países en los que el porcentaje supera el 4 %, como bélgica, francia, luxemburgo, o los países bajos, hasta otros en los que es inferior al 1 % como bulgaria, grecia, lituania, polonia o rumanía. en españa el porcentaje es del 1,2 %(5). en españa, el 66 % de los usuarios son mujeres y el 62 % de ellos son personas de 80 o más años. el 70 % son personas mayores en situación de dependencia. si bien la información disponible sobre la edad media del residente y la edad media de ingreso es escasa, se puede establecer la edad media de los usuarios en 83 años y la edad media del ingreso en 80 años (5). la investigación cualitativa en los hogares para ancianos diversos autores han estudiado el tema de las experiencias vitales de las personas mayores institucionalizadas, empleando diseños basados en la investigación cualitativa, con el objetivo de aproximarnos al punto de vista de los propios protagonistas. vida diaria tsai y tsai (6) organizaron su estudio en torno a un tema central, ya que los informantes describían por lo general su vida en estas instituciones como “una estancia temporal para nutrir (fortalecer) su salud”. los participantes de slettebø (7) manifestaron que la vida en el centro les proporcionaba seguridad pero que se encontraban en una situación de soledad. consideraban como circunstancias positivas de este tipo de vida el sentirse respetados, la seguridad, los cuidados proporcionados por el personal y el mantenimiento de la autonomía personal. wadensten (8) destacó entre sus hallazgos cómo aquellos residentes que se encontraban satisfechos con su vida actual en el hogar para ancianos, también consideraban haber llevado una vida agradable anteriormente. en el trabajo de andersson, pettersson y sidenvall (9), los participantes se encontraban generalmente satisfechos con la vida que llevaban en el centro, excepto por la capacidad de libre determinación. van’t leven y jonsson (10) expusieron sus resultados a través de tres temas fundamentales: la continuación de actividades de tipo familiar que tengan un interés personal, la propia eleccióncontrol de las actividades y las relaciones sociales con la gente. en el estudio de fiveash (11), los asuntos tratados fueron: en contra de mi voluntad (refiriéndose al ingreso en el centro), la vida en un hogar público, implicaciones culturales de la vida con otras personas y el impacto de vivir en un hogar para ancianos. 44 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 lópez (12) y álvarez (13) recogieron sendos relatos biográficos de dos mujeres que vivían en hogares para ancianos en el sur de españa, el mismo entorno que el de este estudio. bazo (14), también desde españa, analizó diversos aspectos de la vida dentro de estos centros, como las causas del ingreso, los roles y las relaciones que se establecían, así como la imagen de la institución adquirida en el proceso de socialización. experiencias de sufrimiento, de dolor y de pérdida pilkington y kilpatrick (15) se centraron en el estudio de la estructura de la experiencia del sufrimiento de estas personas. identificaron tres temas centrales: la desolación ilimitada, la aquiescencia determinante y las afiliaciones benévolas. pilkington (16), en un estudio anterior, investigó como es el proceso de aflicción ante una pérdida dentro de estas instituciones. estableció dos núcleos temáticos fundamentales: el dolor que supone la soledad frente al confort que producen las afiliaciones personales y el estado de conformidad serena que se desarrolla ante las pérdidas dolorosas. forbes-thompson y gessert (17) estudiaron las experiencias de pacientes que estaban próximos a fallecer en hogares para ancianos. los testimonios de dos residentes en concreto fueron utilizados para ilustrar su investigación y mostrar los aspectos físicos, psicosociales y existenciales que conformaban sus experiencias de sufrimiento. pleschberger (18), se centró en los significados de la dignidad humana en los momentos próximos a la muerte de los residentes de estos centros. concluyó que la dignidad está constituida por una faceta intrapersonal y por otra que está fundamentada en las relaciones sociales interpersonales. los cuidados recibidos y los autocuidados anderberg y berglund (19), estudiaron las experiencias con respecto a las necesidades de cuidados y ayuda en su vida diaria. los participantes consideraban que estos cuidados son determinantes para: mantener un equilibrio entre el dolor y el bienestar, conservar el control de su propio cuerpo, vivir el presente sin preocuparse en demasía por el futuro y ocultar la vulnerabilidad propia ante una situación que consideraban comprometida. chang (20), estudió las percepciones referentes al autocuidado de los residentes de estos centros. las creencias de los informantes, las expuso organizadas en torno a tres grandes temas: la importancia de realizar autocuidados, las barreras que impiden recuperar la capacidad de autocuidarse y los aspectos facilitadores que permiten recuperar esta capacidad. para los informantes de liukkonen (21), los profesionales estaban siempre muy ocupados y presionados por el tiempo, por lo que demandaban que las personas cuidadoras pudieran hablar un poco más con ellos sobre sus esperanzas, sus deseos y sobre sus pensamientos diarios. bienestar, satisfacción, calidad de vida el trabajo de dwyer, nordenfelt y ternestedt (22), indica que las fuentes de significado en este tipo de centros son la capacidad física, la capacidad cognitiva, las necesidades y la pertenencia y que el significado se crea a través del diálogo interno, las relaciones con los otros y la comunicación. hjaltadóttir y gústafsdóttir (23), se aproximaron al tema de la calidad de vida dentro de estas instituciones. el estudio indica que el fenómeno de la calidad de vida para estas personas era complejo y multidimensional. los informantes necesitaban ser reconocidos como individuos propios que tienen sus raíces y pertenecen a una familia y también necesitaban mantenerse realizando actividades significativas. bergland y kirkevold (24), investigaron que aspectos contribuyen al desarrollo del bienestar psíquico y satisfacción emocional (“thriving”) en estos centros. dos aspectos fundamentales condicionaban este tipo de desarrollo: la actitud de las personas mayores acerca de vivir en estas instituciones y la calidad de los cuidados recibidos. los informantes del estudio de aller y van ess coeling (25), identificaron tres temas como determinantes de su calidad de vida: la habilidad para comunicarse con los otros, la habilidad para cuidarse por sí mismos y la habilidad de ayudar a los otros. objetivos la mayoría de estas investigaciones han ofrecido sus resultados desde una perspectiva exclusivamente descriptiva. los 45 las experiencias de las personas mayores que viven en hogares para ancianos: la teoría de las “díadas de intercambio” l joaquín jesús blanca-gutiérrez y otros. estudios que han trabajado desde una perspectiva interpretativa han teorizado sobre aspectos muy concretos, por ejemplo pleschberger (18), construyó su teoría sobre la base del concepto de la dignidad humana. con este trabajo se pretende ofrecer una visión interpretativa más amplia y, en definitiva, estudiar a través de los procedimientos propios de la teoría fundamentada las experiencias vitales y el proceso de adaptación social de las personas mayores que viven en un hogar para ancianos. método diseño el diseño de la investigación consiste en un estudio cualitativo de tipo interpretativo, basado en la construcción de teoría fundamentada. strauss y corbin definen este abordaje investigador como “una teoría derivada de datos recopilados de manera sistemática y analizados por medio de un proceso de investigación. en este método, la recolección de datos, el análisis y la teoría que surgirá de ellos guardan estrecha relación entre sí”. (26) emplazamiento y selección de los participantes el emplazamiento de realización del estudio han sido los 6 hogares para ancianos de la comarca de la campiña sur de córdoba, en el sur de españa. la selección de los informantes ha consistido en un muestreo de tipo intencional y teórico (26,27): se invitó a participar a aquellas personas a las que se consideraban de mayor relevancia para comprender los fenómenos en estudio, en este caso a las propias personas mayores que viven en hogares para ancianos, buscando variación en aspectos como la edad, el tiempo viviendo en la institución y el nivel de independencia (tabla 1). a medida que se iba avanzando en el análisis de los datos, se amplió el número de entrevistados para englobar una perspectiva lo más amplia posible de los códigos y categorías emergentes a partir del tratamiento de la información. cuando, a pesar de realizar más entrevistas, no se producían comprensiones nuevas y el análisis de datos no proporcionaba propiedades y dimensiones novedosas para cada una de las categorías y subcategorías en estudio, no se incorporaron más informantes: criterio de saturación teórica (26,27). en primer lugar, los investigadores concertaron citas individuales con las directoras de los centros en cuestión. en dichas citas, se expusieron los objetivos de la investigación, obteniendo su autorización para la realización de las entrevistas. las directoras, así como las enfermeras y profesionales de los hogares para ancianos asumieron la figura de “porteros”, propia de la investigación cualitativa y a través de la técnica de la “bola de nieve”, nos presentaron a algunos de los residentes de cada centro, los cuales pusieron a los investigadores en conocimiento de otras personas mayores y así sucesivamente (28). se han realizado entrevistas en profundidad a un total de 16 residentes de estos centros: 7 hombres y 9 mujeres. la edad de los entrevistados ha oscilado desde los 56 hasta los 98 años y el tiempo que llevan viviendo en el hogar para ancianos ha variado desde 8 días hasta 26 años (tabla 1). no se han incluido como participantes a personas mayores que estuvieran afectadas por enfermedades neurológicas degenerativas en estado avanzado. recolección de información la recogida de la información se ha efectuado a través de entrevistas en profundidad, desarrolladas por los propios investigadores firmantes de este estudio: la entrevista en profundidad o entrevista cualitativa tiene lugar cuando se producen reiterados encuentros cara a cara entre el entrevistador y los informantes, dirigidos hacia la comprensión de las perspectivas que tienen los entrevistados respecto de sus vidas, experiencias o situaciones, tal como las expresan con sus propias palabras (27). puesto que a la vez que se iban realizando las primeras entrevistas se ejecutó simultáneamente el análisis de los datos que proporcionaban, los encuentros se fueron estructurando mediante un guión de apoyo que quedó definido por las diversas categorías y subcategorías que fueron surgiendo a medida que se profundizaba en el tratamiento de la información, según el desarrollo inductivo propio de la metodología de investigación cualitativa, pero sin perder no obstante el carácter de “entrevista abierta” de los diálogos. los encuentros se mantenían en un despacho privado habilitado para que los residentes puedan recibir a sus visitas o bien en los propios dormitorios de los informantes. los testimonios de los participantes fueron grabados en formato digital a través de un dispositivo tipo mp3 y posteriormente transcritos literalmente por 46 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 los propios investigadores. la duración aproximada de las entrevistas osciló entre una y dos horas. análisis de datos diversos elementos son necesarios para el desarrollo de la teoría fundamentada (26, 29, 30). del muestreo teórico y de la saturación teórica ya se ha hablado en el apartado de “emplazamiento y selección de los participantes”. otro aspecto básico es el método de la comparación constante: los investigadores simultáneamente codificaron y analizaron los datos con la finalidad de desarrollar conceptos. se trataba de comparar continuamente los incidentes (unidades mínimas de análisis) de los datos para refinar estos conceptos, identificar sus propiedades, explorar como se relacionan unos con otros e integrarlos en una teoría coherente. otros recursos útiles fueron los memos o memorandos (anotaciones de ideas teóricas tal y como a los investigadores les iban surgiendo en el proceso de codificación) y los diagramas (representaciones gráficas de las relaciones entre conceptos). las tres etapas que en la práctica han constituido el análisis de nuestros datos han sido la codificación abierta, la codificación axial y la codificación selectiva. (26, 29, 30). en la codificación abierta, se realizó una lectura de la transcripción directa de cada una de las entrevistas, desglosándolas en unidades pequeñas a las que se les asignaban palabras o expresiones de los investigadores que constituyeron los códigos preliminares y que identificaban la temática del fragmento analizado. ejemplo: …yo me llevo con todos bien pero hago como decía el refrán: “con todos corro pero con ninguno me paro”. yo no soy rara, hablo con todo el mundo. código preliminar: relación con los compañeros de la residencia. memorando: tiene relaciones cordiales pero no son muy intensas. en la codificación axial, se ha procedido a reorganizar los códigos conforme a un mayor nivel de abstracción, con el objetivo de desarrollar sucesivamente códigos conceptuales, subcategorías y categorías, así como la formación de las conexiones que permitieran explicar los fenómenos estudiados. las categorías principales emergentes del análisis, en las que se persiguió un mayor grado de profundización a medida que se desarrollaron más entrevistas, hasta alcanzar la pretendida saturación teórica, han sido las siguientes: situación de intercambio en el hogar para ancianos, situación de adaptación social y circunstancias anteriores al ingreso en la institución. la jerarquización de las principales categorías, subcategorías y conceptos desarrollados, se muestran en la figura 1. en la codificación selectiva, se han refinado e integrado las diversas categorías, culminando el establecimiento de relaciones entre sí e identificando una central (situación de intercambio: teoría de las “díadas de intercambio”) que constituye el resultado principal de esta investigación. las relaciones entre las diversas categorías se desarrollan en el apartado de resultados y se muestran esquemáticamente en la figura 2. el soporte físico donde se ha desarrollado este proceso de análisis de datos ha sido el programa informático excel v. 2007. aspectos éticos emmanuell, wendler y grady (31), sintetizaron los requisitos que garantizan la ética en una investigación, que posteriormente fueron adaptados al campo de la investigación cualitativa por barrio y simón (32). con base en estos criterios se ha tratado de garantizar la corrección ética de la investigación: valor social o científico. el diseño metodológico debe ser coherente con los objetivos, seleccionando correctamente los contextos y los informantes. también la interpretación de los resultados. cociente entre riesgo y beneficio favorable. consentimiento informado: a cada una de las personas mayores partícipes de las entrevistas se le proporcionó un modelo de consentimiento informado, en el que daban la autorización expresa a su participación mediante la grabación de su testimonio. respeto por los participantes: protección de la intimidad y la confidencialidad. se informó a los entrevistados de la forma en que se protegerán los datos, como se almacenarán y quién accederá a ellos. en el caso de que los participantes citaran algún nombre propio, este ha sido sustituido por otro ficticio. 47 las experiencias de las personas mayores que viven en hogares para ancianos: la teoría de las “díadas de intercambio” l joaquín jesús blanca-gutiérrez y otros. evaluación independiente, que no ha de seguir los esquemas de evaluación típicos de los ensayos clínicos con medicamentos. el proyecto de investigación que fundamentó este estudio fue evaluado y aprobado por la comisión de estudios de postgrado de la universidad de jaén y como se ha comentado anteriormente, se contó con la autorización de las directoras de las 6 instituciones participantes. selección equitativa de los participantes. medidas para garantizar el rigor científico con el fin de tratar de garantizar el rigor científico del estudio, se tuvieron en cuenta una serie de criterios clave que según los diversos autores fundamentan la calidad científica de la investigación de tipo cualitativo: credibilidad, transferibilidad, consistencia y confirmabilidad (33-37). con respecto a la credibilidad, los investigadores se han apoyado en estrategias concretas como los métodos de la triangulación ( revisión y análisis algunos documentos escritos, tales como informes de incidencias de enfermería, hojas de tratamiento médico y planillas de distribución de las actividades de los cuidadores y cuidadoras) y los controles cruzados (cuando los informantes nos han relatado algún hecho concreto de su vida diaria, se han entrevistado también a otras personas que hayan participado de esa situación o que hayan sido testigos de la misma) (27). también se han proporcionado algunos de los hallazgos obtenidos en la presente investigación a varios de los participantes, los cuales han procedido a revisarlos para comprobar si los fenómenos en estudio se encontraban fielmente representados en el trabajo. en los apartados de introducción y metodología se han abordado y detallado el contexto de realización del estudio (hogares para ancianos) y cómo son las vivencias de los residentes en estos escenarios, así como caracterizado a los participantes del trabajo actual (transferibilidad). con la descripción detallada de los métodos y procedimientos empleados en la recogida de la información y su análisis, se pretende que otros investigadores puedan seguir los pasos de este trabajo (consistencia). la presentación de resultados se ha ilustrado con algunos de los comentarios textuales de los entrevistados, siendo así mismo contrastados con la bibliografía disponible sobre el tema y revisados por un investigador ajeno a este estudio (confirmabilidad). también se consideraron los 32 puntos de la herramienta coreq (38). no obstante, los criterios específicos para evaluar la calidad científica de la teoría fundamentada que los investigadores han considerado son cuatro (39, 40): el ajuste de los datos: debe existir una conexión evidente entre los datos y las categorías y las teorías que se generen a partir de ellos. la teoría debe funcionar: ha de ser capaz de explicar de manera fidedigna las relaciones y conexiones entre los fenómenos estudiados. relevancia: que sea significativa, pertinente en relación a los comportamientos sociales con los que se están trabajando. modificabilidad: que la teoría pueda incluir nuevos datos que se vayan generando con la investigación. resultados en este apartado, se expone en primer lugar cómo el proceso de adaptación de los adultos institucionalizados en este tipo de centros se articula a través de una serie de cesiones y ganancias establecidas con la institución (teoría de las “díadas de intercambio”). esta situación de trueque; de permuta, propicia la evolución hacia la adaptación social de estas personas (que se definirá posteriormente como un estado de “aceptada continuidad-resignado conformismo” y que está caracterizado por una serie de propiedades). a través del proceso principal de canje (poder de decisión frente a seguridad), se intentará explicar también el proceso secuencial que puede determinar el ingreso a este tipo de instituciones. (figura 2) la teoría de las “díadas de intercambio” para tratar de explicar el proceso de adaptación social del adulto mayor en los hogares para ancianos, se propone lo que los investigadores de este estudio han denominado teoría de las “díadas de intercambio”, según la cual, en el seno de estas instituciones se establecería una situación de intercambio, en la que la persona mayor cede la totalidad o parte de una serie de cualidades obteniendo a cambio otras que son características de este tipo de instituciones. las cesiones no siempre se producen de forma voluntaria y el hecho de que se produzcan estos intercambios, no quiere decir que los atributos que recibe la persona mayor 48 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 sean del todo deseables o satisfactorios por su parte. es decir, no se trata de un proceso demandado explícitamente por los residentes, sino que más bien se ven inmersos en esta situación. estas cualidades que se intercambian pueden organizarse en forma de díadas, parejas vinculadas de atributos a través de los que de forma implícita, no pactada de forma contractual, los participantes participan en una permuta con la institución. son las siguientes: poder de decisión-seguridad: las personas mayores pierden en el hogar para ancianos parte de su libertad para decidir y obtienen a cambio seguridad. el poder de decisión es cedido, las personas mayores han de acogerse a una disciplina horaria, a unas normas de comportamiento y a unas normas referidas a los espacios físicos. lo que la institución les ofrece a cambio de esta cesión con respecto a la toma de decisiones es seguridad: qué significa para las personas mayores estar en un entorno que comparan con un hospital, ya que tienen al personal de enfermería y al personal médico disponibles y además tienen las necesidades básicas cubiertas. m2: “hay un montón de reglas y horarios. a las nueve, tengo que estar lavada y lista para ir al comedor. el almuerzo es a las una…, lo que pasa es que en casa no me encuentro yo que pueda estar sola”. m8: “yo prefiero estar aquí antes que con mis hijos porque ellos son jóvenes, se van, me dejan encerrada en el piso porque yo no puedo estar con la puerta abierta y no puedo abrirle a nadie ni nada porque no veo y no sé quién es el que entra o el que sale. y aquí aunque tenga que estar pendiente de unos horarios y unas normas sé yo que estoy bien atendida, que me caigo, me da un mareo o cualquier cosa y sé que tengo gente aquí para atenderme”. en torno a esta díada de decisión-seguridad, considerada como el eje central de la teoría de las díadas propuesta en este estudio, se organizan otras tres parejas de intercambio: gestión de mi tiempo-apoyo en las actividades básicas de la vida diaria: los residentes ceden la gestión de su propio tiempo, para adaptarse a la disciplina horaria que se ha comentado anteriormente. la aceptación de esos horarios supone recibir cobertura específica para las actividades de la vida diaria. m3: “a las nueve en punto de la mañana tienes que estar despierta para ser aseada por el personal y luego entonces me acompañan ellos también al comedor”. relaciones familiares-relaciones con personal cuidador y compañeros residentes: antes de ingresar en el hogar para ancianos, la persona mayor estaba situada en un entorno dónde tenía relativa libertad para relacionarse con los amigos y familiares, a veces viviendo incluso en el mismo hogar que estos últimos. tras el ingreso en el centro se produce una cesión en cuánto a las relaciones con los familiares, pero se obtienen unas relaciones sustitutorias con otras personas como son el personal cuidador y los compañeros de la institución. h6: “las enfermeras me quieren porque yo soy muy cariñoso con ellas. las muchachas son muy buenas todas, lo mismo unas que otras. has visto que ahora me ha dado frío y como ha sacado una la manta y me la ha echado por lo alto de la cabeza”. propiedad privada-acompañamiento: la propiedad privada para la persona mayor dentro de estas instituciones se reduce al dormitorio, en el caso de los cuartos individuales, o a un armario o mueble dónde se guardan los objetos personales, en el caso de los dormitorios comunes. el resto de espacios físicos son compartidos. a cambio de esta cesión de propiedad privada, se obtiene el acompañamiento continuo de otras personas, el personal cuidador y los compañeros, lo que evita que el mayor se encuentre solo. la condición de acompañamiento determina también unas mayores condiciones de seguridad. h6: “yo tengo una mesita de noche donde tengo todo, tengo ropa, tengo un armario, camisetas y calzoncillos en los calzones de abajo y allí pongo la ropa y en una silla y me acuesta una muchacha, porque como tengo lo de la pierna, me mete en la cama vaya que vaya yo a caerme. tienen la cama siempre muy limpia y la ropa tardan un día o dos en lavarla, nos visten de limpio ellas, nos lavan, nos ponen en cueros las muchachas, ponen una cosa hay para sentarme para que no me pueda caer, por lo de las piernas”. la aceptada continuidad y el resignado conformismo como consecuencia del establecimiento de la situación de intercambio que se acabó de detallar, en la persona mayor institucionalizada se evoluciona de manera genérica, hacia un estado denominado “resignado conformismo y aceptada continuidad” y que 49 las experiencias de las personas mayores que viven en hogares para ancianos: la teoría de las “díadas de intercambio” l joaquín jesús blanca-gutiérrez y otros. se define como: la aceptación de las circunstancias vitales que les han tocado vivir como miembros de un hogar para ancianos, considerándolo como una etapa más de sus vidas y dónde la institución hace las veces de su hogar; no esperando apenas cambios para el futuro, al que se suele asociar en muchos casos con la muerte. m9: “yo no estoy a disgusto con nada, yo sola no puedo estar, dinero no tengo nada más que el de la pensión de inválida. yo si tuviera mi pisito o mi casa o lo que sea, pues tendría una mujer para que me hiciera las cosas porque yo esta mano no me sirve para nada, así que como yo sé que esto es lo que tengo para que voy a estar a disgusto con lo que me ha quedado. pasar los días y los días y tratar de molestar lo menos posible”. m5: “bueno, pues como, no sé, pues no tener nada que hacer. yo trato de molestar lo menos posible, las enfermeras me tratan bien, las muchachas son todas buenas, yo no quiero problemas con nadie y como yo sé que en mi casa no puedo estar y que otra cosa no tengo, yo estoy aquí a gusto, hay unas comidas muy buenas, me tratan tan bien, el patio es muy grande para estar para arriba y para abajo y todo eso y como el día que yo quiero pues salgo a la calle, para pasearme”. esta situación de continuidad-conformismo significaría la culminación del proceso de adaptación social de estos residentes. el grado de consecución de este proceso, su mantenimiento e incluso su percepción como satisfactorio por parte de las personas mayores institucionalizadas, está determinado por varias propiedades, derivadas también del proceso de intercambio expuesto anteriormente y que son las siguientes: la pérdida de responsabilidades: en el contexto de los hogares para ancianos, la pérdida de poder de decisión lleva asociada también una pérdida de responsabilidad (económica y del cuidado hacia algunos familiares, como las esposas o los hermanos enfermos). tiene mucho que ver en esta situación la historia vital de cada persona, en concreto, que el mayor quede desligado o no de las preocupaciones y responsabilidades que tenía fuera de la institución. m1: “lo bueno de aquí es que no tengo que preocuparme de los dineros, de la comida, de nada… yo ingresé aquí a la vez que mis hermanos, que estaban muy mayores y aquí cuidaban del todo de ellos y yo además podía estar a su lado. pero yo ya estaba muy mayor para estar todo el rato pendiente de ellos en nuestra casa”. la seguridad: como se ha indicado anteriormente en los resultados de este estudio, la seguridad significa para las personas mayores estar en un entorno comparado con un hospital, donde tienen al personal de enfermería y al médico disponibles y donde además tienen sus necesidades básicas cubiertas. h7: “me siento cómodo aquí. le pido a la enfermera una pastilla y me la da, ahora le he pedido también que me traiga un pañal”. h2: “yo estoy aquí encantado de la vida, tengo limpieza, tengo el alimento, de todo. yo estoy a gusto con el retiro que me ha dado el estado”. relaciones sociales satisfactorias: para ello la persona mayor ha de experimentar como gratificantes las interacciones sociales que tienen lugar en su vida diaria. estas relaciones satisfactorias no se las puede proporcionar exclusivamente uno u otro grupo humano, sino que se debe dar una “condición de complementariedad” en el contexto relacional de la persona mayor. es decir, que necesita de relaciones humanas significativas proporcionadas tanto por parte de las personas del hogar para ancianos (personal cuidador y compañeros), como por parte de los familiares, vecinos y amigos que ha dejado fuera de la institución. m5: “yo me parece que me llevo bien con todas las compañeras y también con todas las enfermeras y ellas son muy apañadas y hacen por todos los que estamos aquí lo que pueden... también paso algunos días de vez en cuando en casa de mis hermanas y ellas vienen a verme cuando pueden porque tienen que estar pendientes de sus casa y de sus hijos”. m1: “voy a ver a mi amiga que la tengo aquí en el cuarto de al lado…viene a visitarme mucha gente de fuera, amigas. ayer se me llenó la habitación, porque vinieron de un cursillo que hicieron aquí y vienen a visitarme de vez en cuando.” proceso de ingreso en el hogar para ancianos según la teoría de las “díadas de intercambio” el proceso que desemboca en el ingreso de la persona mayor en un hogar para ancianos se puede explicar de una forma sencilla a partir de la díada poder de decisión-seguridad, tal y como se ilustra de forma esquemática en la parte superior de la figura 2: partiendo de una situación ideal, en la que la persona mayor vive en su entorno natural, como es el domicilio propio o el de 50 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 alguno de sus familiares cercanos, el mayor tiene libertad para decidir sobre los diversos aspectos de su vida diaria y además se desenvuelve en un ambiente con unas condiciones de seguridad prácticamente óptimas. se ponen en escena unos factores causales que van modificar esta situación ideal y que son los siguientes: la disminución del nivel de independencia, la disminución o la pérdida de apoyo social, condiciones económicas adversas y la pérdida del rol dominante dentro de la propia familia. m5: “dios y yo sabemos lo que yo he ayudado a mis hermanas, pero nadie se acuerda de mí, o lo que solía ser. a veces pensaba que todavía estaba en mi casa, con el poder que tenía, no me daba cuenta de que yo ya no estaba en mi casa, sino que estaba en la casa de mis hermanas como de prestado, como una visita, y sólo mis hermanas tenían la razón y yo me tenía que callar”. la aparición de estos factores de forma individual o conjunta transforma la situación ideal citada anteriormente en otra en que se produce una merma de las condiciones de seguridad en el ambiente en que se desenvuelve la persona mayor, pero en el que su libertad de decisión por ahora está mantenida. si la actuación sobre estos factores causales no es posible o es insuficiente en el ambiente natural de la persona mayor, se puede producir como solución temporal o indefinida el ingreso en un hogar para ancianos, en la cual las experiencias vitales de las personas mayores estarían condicionadas por el intercambio entre la díada poder de decisión-seguridad, así como por otros intercambios citados anteriormente. h5: “cuando me puse malo mi hija fue la que me dijo, tienes que irte, porque he estado unos años viviendo solo en córdoba, pero me dijo que si me ponía malo o cualquier cosa que estaba solo y además tienes que hacer esfuerzos para limpiar la casa y limpiarte la ropa y todo, pero si te vas a la residencia...”. m6: “porque yo estaba sola en mi casa y una vez me dió un mareo y me caí, me descalabré y ya mis hijos no querían que estuviera allí, porque ellos estaban en su casa, aunque uno estaba muy cerca pero estaba cada uno en su casa y trabajar tenían que trabajar todos y se iban y me dejaban sola y ellos decían que ya no querían que estuviera yo así, que había que buscar un sitio donde yo estuviera acompañada, y me buscaron esto y me trajeron aquí. y aquí estoy”. de no producirse la citada intervención sobre los factores causales perjudiciales para la seguridad de la persona mayor o la alternativa del ingreso en el hogar para ancianos, se podría derivar hacia una situación extrema, en la que la persona mayor sufra tal deterioro físico y/o mental que se produzca la pérdida de la práctica totalidad de su poder decisión y viva además en un ambiente extremadamente inseguro. discusión la situación de “aceptada continuidad y resignado conformismo” a la que se ha equiparado la adaptación de tipo social de los adultos mayores institucionalizados, conlleva en realidad a una serie de connotaciones de conformismo, acatamiento, sumisión… cabe recordar que la institución exige implícitamente una serie de cesiones a sus residentes, a la que se unen unas pérdidas propias del envejecimiento social: pérdida de familiares y seres amados, de un rol predominante en el seno familiar, de otros roles asociados con la vida laboral (41)… a cambio, las personas mayores obtienen principalmente unas condiciones bastante aceptables de protección y seguridad. en un metaestudio cualitativo realizado por los autores del presente manuscrito a partir de las referencias incluidas en el apartado de “antecedentes investigadores” (42), se expone como uno de los aspectos claves demandados por los residentes de las instituciones geriátricas a sus enfermeras, el de la provisión de unos cuidados seguros, para lo cual se exige que los profesionales sean competentes y atentos. en esta misma línea, las personas entrevistadas por hjaltadóttir y gústafsdóttir (23), puntualizan que el ingreso en el hogar de ancianos ofrece la seguridad que necesitaban y que el traslado era inevitable. si bien esta opinión también es común para los participantes de este estudio, para algunos hay otras soluciones más deseables. slettebø (7), concluye en su trabajo respecto a la seguridad que “vivir en un hogar para ancianos es una experiencia segura, pero solitaria”. con respecto a la pérdida del poder de decisión de estas personas mayores que emerge en el desarrollo de la teoría fundamentada, pía (3) afirmaba que en estas instituciones se produce “un proceso paulatino de pérdida de control, el control que toda persona adulta ejerce sobre las circunstancias más habituales que le afectan como miembro de un grupo que participa plenamente de su vida social”. pía concluía que el envejecimiento institucionalizado fomenta en la persona mayor una actitud sumisa y 51 las experiencias de las personas mayores que viven en hogares para ancianos: la teoría de las “díadas de intercambio” l joaquín jesús blanca-gutiérrez y otros. pasiva y proponía como solución una flexibilización del medio institucional, permitiendo a las personas mayores un mayor control sobre su vida y actividades. los residentes del estudio de tsai y tsai (6) también describen su vida como altamente estructurada, de una manera similar a como los informantes de este estudio aluden a la inflexibilidad de los horarios que rigen a las diversas actividades de su vida diaria. los entrevistados por liukkonen (21) citan concretamente a los horarios de las comidas como principales determinantes de las rutinas diarias. otros trabajos parecen ser consecuentes con las connotaciones de aceptación, resignación que parece implicar el proceso de adaptación a este tipo de centros. las respuestas mostradas en la investigación de fiveash (11) reflejan un sentimiento de resignación de los entrevistados compatibles con la situación que se ha descrito aquí como “aceptada continuidad y resignado conformismo”. el hijo de un residente entrevistado por andersson et al. (9) dice que “probablemente no podría ser de otra forma”, haciendo referencia a la repetitiva y estructurada forma de vida de la institución. “es sólo comer y dormir”, añade otro de sus participantes. la teoría de plechsberger (18) acerca de la dignidad en los hogares para ancianos manifiesta la importancia de las relaciones sociales en relación con este concepto de dignidad. el autor señala la dificultad de establecer relaciones con el personal debido a la sobrecarga de trabajo, haciendo hincapié en la importancia de las relaciones con familiares y amigos que viven fuera de la institución. en este trabajo se ha establecido la llamada “condición de complementariedad” en virtud de la cual para producirse la adaptación social de los residentes se requieren aportaciones de cada grupo, la familia, los compañeros y los cuidadores. en el metaestudio citado anteriormente (42), se indica como los mayores institucionalizados necesitan de relaciones personales consolidadas con las cuidadoras y el personal de estos centros, demandando que estas interacciones sean más estrechas, casi a semejanza de las que se podría establecer con un familiar o un amigo y que no deben estar basadas exclusivamente en interacciones de tipo profesional. dentro del trabajo de bazo (14), el cual se desarrolla en un entorno social y cultural muy similar al del estudio, se ha encontrado varios aspectos comunes en los testimonios. en ambas investigaciones hay personas que han sido ingresadas por su propia voluntad, aunque también hay otras que ha sido a través de pequeños engaños de su familia. en definitiva, las personas mayores suelen ser ingresadas, por no tener hijos o parejas que se puedan dedicar a su cuidado, además muchos de ellos añaden que tienen mejores condiciones de seguridad en el hogar para ancianos que viviendo solos en sus casas. en cambio, la mayoría de los entrevistados de fiveash (11), puntualizan que han sido trasladados a la institución sin haber sido consultados o en contra de sus propios deseos. los entrevistados para este estudio, en cambio, son bastante comprensivos en relación con las causas que han propiciado su entrada en la institución, justificando a sus propias familias e indicando que el ingreso, en definitiva, ha sido necesario. la señora protagonista de la historia de vida del trabajo de lópez (12), reprocha que su hija la haya ingresado en el centro después de toda una vida cuidando de ella, mientras que en el trabajo actual los residentes se muestran más complacientes con respecto a los motivos que han propiciado que sus familiares hayan tenido que delegar su cuidado en este tipo de instituciones. la señora protagonista del trabajo de álvarez (13), pertenece a ese grupo de personas que ingresaron en el hogar para ancianos por encontrarse solas en casa, en unas condiciones donde se mantenía el poder de decisión pero estaban mermadas las condiciones de seguridad. los relatos de lópez (12) y álvarez (13) tienen lugar en un contexto muy próximo y similar al aquí presente, ya que se desarrollan ambos en hogares para ancianos de andalucía (españa). limitaciones del estudio las entrevistas y el contacto con los participantes han tenido lugar en el seno de las propias instituciones. este hecho quizás haya podido propiciar cierta reticencia de los entrevistados a expresarse con total libertad, sobre todo en aspectos comprometidos de la organización de estos centros, ya que por lo general estas personas están agradecidas y satisfechas con su personal cuidador. este sentimiento de gratitud es posible que pueda autolimitar en cierta forma su libertad a la hora de detallar aspectos relacionados con el estilo de vida altamente estructurado que parece regir en este tipo de instituciones. cada hogar para ancianos constituye una sociedad en miniatura con sus propias normas, costumbres, valores… los resultados obtenidos en este trabajo de investigación no pueden ser extrapolados por completo al contexto de cualquier otro hogar para ancianos: debido a las características particulares de cada uno de estos centros y sobre todo a la complejidad de las percepciones, viven52 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 cias y relaciones humanas que se establecen entre los miembros de estas instituciones, los datos obtenidos no pueden hacerse extensivos de manera exhaustiva a todas las instituciones de este tipo. no obstante, la revisión de los trabajos científicos realizados en hogares para ancianos de otros países y continentes, ofrecen unos resultados bastante similares en diversos aspectos de los testimonios de los informantes claves, como se ha mostrado en los apartados de antecedentes y discusión de los resultados. conclusión con este trabajo, se ha pretendido proporcionar una teoría sencilla y coherente que pueda ayudar a comprender mejor las experiencias vitales de las personas mayores en un hogar para ancianos, el proceso de adaptación sociológica que se produce en los residentes, así como otras circunstancias tales como el ingreso en la institución. con estas propuestas los autores intentan ampliar el cuerpo de conocimientos que las enfermeras y otros profesionales aportan dentro de este tipo de contextos. los trabajos de este tipo, construidos desde la propia perspectiva de los protagonistas han de ser claves para guiar la interacción personal y cuidadora que se establece entre los profesionales y los pacientes. las enfermeras deben trabajar para ofrecer a estos residentes las condiciones más seguras posibles, pero no tan condicionadas por un estilo de vida altamente estructurado que llega a comprometer la independencia de las personas mayores con respecto a sus decisiones vitales. así mismo, deben garantizar procesos más sistemáticos de negociación y de toma de decisiones compartidas en estos centros, a la hora de planificar y ejecutar los cuidados. se trataría en definitiva de potenciar los atributos positivos ofrecidos por las instituciones en las díadas de intercambio y de paliar todo lo posible el grado de cesión que a cambio están otorgando los mayores institucionalizados. como se ha comprobado en el apartado de discusión, las investigaciones previas en otros países también parecen sugerir esta situación de intercambio del poder de decisión frente a unas condiciones más óptimas de seguridad. sin embargo, se necesitan más estudios de este tipo en centros situados en contextos con características culturales y sociales diferentes, para confirmar o refutar definitivamente la aplicabilidad de estas proposiciones, desarrollarlas e incluso posibilitarlas para hacer aportaciones teóricas al proceso global de envejecimiento social del ser humano. referencias 1. instituto de mayores y servicios sociales de españa . centros residenciales para personas mayores. disponible en: http://www.imserso.es/imserso_01/centros/centros_personas_mayores/centros_residenciales/index.htm [consultado: 2011 feb. 15]. 2. kane rl, ouslander jg, abrass ib. geriatría clínica. 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[consultado: 2011 jul. 8]. 36. noreña al, alcaraz-moreno n, guillermo-rojas j, rebolledo-malpica d. aplicabilidad de los criterios de rigor y éticos en la investigación cualitativa. aquichan 2012; 12 (3): 263-274. 37. gálvez toro a. lectura crítica de un estudio cualitativo interpretativo. index de enfermería 2003; 42. disponible en: http://www.index-f.com/index-enfermeria/42revista/42_articulo_39-43.php [consultado: 2011 jul. 8]. 38. tong a, sainsbury p, craig j. consolidated criteria for reporting qualitative research (coreq): a 32-item checklist for interviews and focus groups. international journal for quality in health care 2007; 19 (6): 349-357. 39. glaser b. theoretical sensitivity: advances in the methodology of grounded theory. mill valley c.a.: sociology press; 1978. 40. de la cuesta benjumea c. la teoría fundamentada como herramienta de análisis. cultura de los cuidados 2006; año x (20): 136-140. 41. brandolín a. estereotipos sobre la vejez en noticieros televisivos. unirevista 2006; 1 (3): 1-17 42. blanca gutiérrez jj, linares abad m, grande gascón ml, et al. “relación del cuidado que demandan las personas mayores en hogares para ancianos: metaestudio cualitativo”. aquichan 2012; 12 (3): 213-227. tabla 1. muestra incluida en el estudio hogares para ancianos (6) número de residentes 10 a 80 media:52 tipo de gestión pública 1 privada 3 concertada con la administración pública 2 personas entrevistadas (16) nivel de independencia índice barthel > 60 puntos 8 índice barthel < 60 puntos 8 edad 56 a 98 años media: 80 tiempo viviendo en la institución 8 días hasta 26 años género 7 hombres, 9 mujeres número de hijos media: 1,13 nivel de estudios sin ningún tipo de estudios 2 estudios primarios sin completar 6 estudios primarios completados 6 educación secundaria 1 educación universitaria 1 estado civil soltero 6 viudo 8 separado 2 casado 0 55 las experiencias de las personas mayores que viven en hogares para ancianos: la teoría de las “díadas de intercambio” l joaquín jesús blanca-gutiérrez y otros. figura 1. jerarquización de las categorías. codificación axial 56 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 figura 2. integración de las categorías. codificación selectiva 31 43 prototipo de um software para registro.indd 31 luciana de medeiros lima1 sérgio ribeiro santos2 protótipo de um software para registro de enfermagem em unidade de terapia intensiva neonatal 1 mestre em enfermagem pelo programa de pós-graduação em enfermagem da universidade federal da paraíba. enfermeira da unidade de terapia intensiva neonatal do hospital universitário lauro wanderley. docente da faculdade de enfermagem são vicente de paula. membro do grupo de estudo e pesquisa em administração e informática em saúde. lucdmd1@yahoo.com.br 2 enfermeiro. doutor em sociologia. professor associado do departamento de enfermagem clínica e do programa de pós-graduação em enfermagem da universidade federal da paraíba. coordenador do grupo de estudo e pesquisa em administração e informática em saúde. srsantos207@gmail.com recibido: 28 de mayo de 2013 enviado a pares: 20 de junio de 2013 aceptado por pares: 25 de febrero de 2014 aprobado: 10 de mayo de 2014 doi: 10.5294/aqui.2015.15.1.4 para citar este artículo / to reference this article / para citar este artigo medeiros de lima l, ribeiro santos s. protótipo de um software para registro de enfermagem em unidade de terapia intensiva neonatal. aquichan. 2015;15(1):31-43. doi: 10.5294/aqui.2015.15.1.4 resumo introdução: o crescente volume de informações oriundas dos registros de enfermagem exige estratégias de tratamento do conhecimento produzido, de forma que as desvantagens do prontuário de papel sejam evitadas. objetivo: propõe-se neste estudo desenvolver um software aplicado à sistematização da assistência de enfermagem que proporcione aos enfermeiros o registro informatizado, eficiente e rápido. metodologia: trata-se de um estudo metodológico com produção tecnológica, dividido em três fases: construção das afirmativas de diagnósticos e intervenções de enfermagem, validação das afirmativas e desenvolvimento do software. o sistema foi desenvolvido sobre a plataforma java, com a utilização do framework jsf, incorporado à especificação j2ee, para desenvolver aplicações web de forma ágil. resultados: o banco de dados ficou composto por 143 afirmativas de diagnósticos de enfermagem e 130 referentes às intervenções de enfermagem. o software desenvolvido apresenta 17 telas que incluem dados de identificação, exame físico completo do recém-nascido, organizado de acordo com as necessidades humanas básicas, lista de diagnósticos e intervenções de enfermagem sugeridas pelo programa e folha final para impressão. considerações finais: o software proporciona a execução do processo de enfermagem com um registro completo, uniforme e rápido, e se constitui uma importante fonte de dados para pesquisa. palavras-chave enfermagem, software, neonatologia, informática, registros de enfermagem (fonte: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 31-43 32 aquichan issn 1657-5997 año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 31-43 prototipo de un software para registro de enfermería en unidad de terapia intensiva neonatal resumen introducción: el creciente volumen de informaciones originadas de los registros de enfermería exige estrategias de tratamiento del conocimiento producido, de forma que se eviten las desventajas del histórico de papel. objetivo: se plantea en este estudio desarrollar un software aplicado a la sistematización de la asistencia de enfermería que les brinde a los enfermeros el registro informatizado, eficiente y rápido. metodología: se trata de un estudio metodológico con producción tecnológica, dividido en tres fases: construcción de las afirmativas de diagnósticos e intervenciones de enfermería, validación de las afirmativas y desarrollo del software. el sistema se desarrolló sobre la plataforma java, con utilización de framework jsf, incorporado a la especificación j2ee, para desarrollar aplicaciones web de forma ágil. resultados: el banco de datos se compone de 143 afirmativas de diagnósticos de enfermería y 130 referentes a las intervenciones de enfermería. el software desarrollado presenta 17 pantallas que incluyen datos de identificación, examen físico completo del recién nacido, organizado de acuerdo con las necesidades humanas básicas, listado de diagnósticos e intervenciones de enfermería sugeridas por el programa y hoja final para impresión. consideraciones finales: el software proporciona la ejecución del proceso de enfermería con un registro completo, uniforme y rápido, y se constituye en una importante fuente de datos para investigación. palabras clave enfermería, software, neonatología, informática, registros de enfermería (fuente: decs, bireme). 33 protótipo de um software para registro de enfermagem em unidade de terapia intensiva neonatal l luciana de medeiros lima, sérgio ribeiro santos prototype software for nursing records in a neonatal intensive care unit abstract introduction: the growing volume of information originating with nursing records demands strategies for managing the data that is produced in a way that avoids the disadvantages of case histories kept on paper. purpose: the study was intended to develop software applicable to the systematization of nursing care, so as to provide nurses with efficient and quick computerized records. methodology: this is a methodological study, with technological production, and is divided into three phases: construction of diagnostic categories and nursing interventions, validation of diagnostic categories, and software development. the system was built on the java platform, using javaserver faces (jsf) as a framework and featuring the j2ee specification to readily develop web applications. findings: the database consists of 143 nursing diagnostic categories and 130 references to nursing interventions. the respective software shows 17 screens that include data on identification and complete physical examination of the newborn, organized according to basic human needs, along with a list of nursing diagnoses and interventions suggested by the program and a final sheet for printing. final considerations: the software provides the nursing process with a complete, uniform and quick record, and constitutes an important source of data for research. key words nursing, software, neonatology, information technology, nursing records (source: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 31-43 34 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 desestimulantes à leitura, com diversas informações desnecessárias e/ou repetidas, ao passo que outras são resumidas, omitindo informações essenciais para o cuidado. portanto, para serem úteis as informações contidas nos registros, devem ser objetivas, claras e completas, permitindo o acesso e a compreensão de tais informações por toda a equipe de saúde (5). no serviço estudado, percebe-se a necessidade de sistematizar os cuidados de enfermagem ao recém nascido (rn), através do processo de enfermagem, como também melhorar o método de registro utilizado, viabilizando a presença do enfermeiro junto ao rn sem, no entanto, afastá-lo das obrigações administrativas. acredita-se que isso seja possível com a redução do tempo gasto para as atividades burocráticas, deixando o enfermeiro disponível para atuar nas atividades assistenciais. dentre as diversas maneiras de otimizar o cuidado de enfermagem, pode-se apontar a utilização da tecnologia da informação (ti) e a implementação da sistematização da assistência de enfermagem (sae). tais ferramentas tecnológicas são indispensáveis para a prática de enfermagem nos dias atuais. é provável que a efetivação deste último seja promovida e facilitada com a utilização dos recursos da tecnologia da informação. com base nestas reflexões é fundamental que entenda como aplicar a tecnologia da informação à sistematização da assistência de enfermagem em uma unidade de terapia intensiva neonatal (utin)? durante a minha trajetória profissional, na qual vivencio a assistência de enfermagem numa utin, me leva a acreditar que a sistematização da assistência de enfermagem com a tecnologia da informação possa responder, além das expectativas da equipe de enfermagem, a um anseio institucional que tem o propósito de implementar o processo de enfermagem em todas as unidades de internamento, como também instituir o prontuário eletrônico. portanto, diante dos descritos, o estudo foi realizado com o objetivo de desenvolver um software aplicado à prática de enfermagem numa unidade de terapia intensiva neonatal, que proporcione o registro informatizado, de forma eficiente e rápida. metodologia o estudo foi desenvolvido na unidade de terapia intensiva neonatal (utin) do hospital universitário lauro wanderley (hulw), situado no campus i da universidade federal da paraíba, joão pessoa-pb, no brasil. introdução o atual modelo de sociedade, marcado pela necessidade e busca da comunicação, tem gerado uma grande quantidade de informações que, por sua vez, exigem novas estratégias de captação, armazenagem e utilização do conhecimento gerado. na enfermagem, seu cotidiano no processo de trabalho gera, a todo o momento, dados decorrentes das atividades assistenciais, gerenciais, de ensino e de pesquisa (1). parte dessas informações é oriunda dos próprios registros de enfermagem contidos nos prontuários do paciente e em outros relatórios pertinentes. em resposta a essa realidade crescem em todas as áreas do saber, inclusive na área de saúde, a utilização de recursos que tornem viável a administração de todos os dados produzidos. a tecnologia da informação, na qual estão incluídos os hardwares, os softwares, os sistemas de gerenciamento de banco de dados e as tecnologias de comunicação de dados, promove a gestão da informação com mais eficácia. porém, o fato de um sistema de computador coletar os dados, produzir e apresentar informações, ajudando a produzir conhecimento não garante a eficiência de um sistema de informação. para este fim as pessoas precisam da habilidade para usar o conhecimento adquirido para um propósito (2). apesar de todas as evidências de fragilidade do registro em papel, percebe-se que a maioria dos serviços permanece com o registro manual das informações, ficando susceptíveis às inúmeras desvantagens desse método de armazenamento de dados. as principais desvantagens do prontuário em papel são notórias, a saber: o fato de o conteúdo ser livre, algumas vezes ilegível, com preenchimento incompleto, predispondo a falta de dados ou ambiguidade; essa modalidade de registro dificulta o acesso à informação, e expõe à fragilidade do papel, podendo ainda ser perdido. o prontuário em papel só pode estar em um lugar por vez, dificultando a busca de dados, além de demandar grandes espaços físicos para ser armazenado (3). assim, na unidade de terapia intensiva (uti) onde é enorme o volume de informações, que podem ser descritas como heterogêneas, complexas e pouco estruturadas (4), percebe-se que a prioridade do que deve ser anotado fica ao critério de cada profissional, de maneira que algumas anotações são extensas, 35 protótipo de um software para registro de enfermagem em unidade de terapia intensiva neonatal l luciana de medeiros lima, sérgio ribeiro santos para facilitar a compreensão da sequência cronológica que a pesquisa seguiu, o trabalho foi dividido em três fases: 1ª fase: nessa fase fez-se a construção das afirmativas de diagnósticos e intervenções de enfermagem. os indicadores utilizados para compor as afirmativas foram retirados da classificação internacional para a prática de enfermagem (cipe®) versão 1.0, como também de dois outros estudos realizados na mesma unidade onde a presente pesquisa aconteceu (6, 7). realizou-se o cruzamento dos indicadores empíricos existentes nessas três fontes, a fim de excluir os termos repetidos e sinônimos. para elaboração das afirmativas de diagnósticos e intervenções de enfermagem seguiu-se as orientações do conselho internacional de enfermagem (cie), através do modelo de sete eixos da cipe®. recomenda-se que para a construção dos diagnósticos de enfermagem se utilize um termo do eixo foco e um termo do eixo julgamento, obrigatoriamente, podendo ser incluído termos adicionais dos eixos cliente, localização e tempo, caso seja necessário. na elaboração das intervenções de enfermagem deve ser utilizado um termo do eixo ação e um termo alvo, sendo este composto por qualquer termo dos demais eixos, exceto julgamento. 2ª fase: foi realizada a validação das afirmativas de diagnósticos e intervenções de enfermagem. de posse das afirmativas construídas pela pesquisadora, os enfermeiros da utin do hulw foram convidados para atuarem nesta etapa de validação das afirmativas de diagnósticos e intervenções de enfermagem, considerando a experiência clínica de toda a equipe. após a apresentação do estudo, concordaram em participar seis (06) enfermeiros; esse número corresponde ao total de enfermeiros existentes na utin, sendo excluindo apenas a pesquisadora que também desenvolve suas atividades assistenciais na referida unidade. solicitou-se a análise dos enfermeiros se concordavam ou não com a inclusão da respectiva afirmativa no banco de dados a ser composto para a operacionalização da sae na utin, tendo por base a importância da afirmativa para o registro das atividades desenvolvidas no trabalho diário. eles deveriam se guiar por uma escala de 2 pontos (concordo; não concordo). a opção “concordo” recebeu valor igual a 1 (um) e a opção “não concordo” recebeu valor igual a 0 (zero). o ponto de corte das afirmativas teve como índice de concordância (ic) ic ≥ 0,7 e as afirmativas que alcançaram esse valor foram incluídas no banco de dados do sistema de informação a ser construído. até aqui, a pesquisa caracterizou-se como um estudo metodológico, recomendado para as investigações dos métodos de obtenção, organização e análise dos dados, tratando da elaboração, validação e avaliação dos instrumentos e técnicas de pesquisa. nesse tipo de estudo a meta é a elaboração de um instrumento que seja confiável, preciso e utilizável, podendo ser empregado por outros pesquisadores (8). 3ª fase: essa etapa consistiu na produção tecnológica, objetivando desenvolver o software para auxiliar o enfermeiro no desenvolvimento da sistematização da assistência de enfermagem. nela os pesquisadores atuaram como usuários, especificando suas necessidades quanto às funções e interfaces do sistema a ser desenvolvido. a informática em enfermagem busca priorizar o atendimento às necessidades dos enfermeiros para o processamento das informações, a fim de apoiar a prática. nesse sentido, o sistema deve integrar pessoas, informação, procedimentos e recursos de computação buscando o máximo de benefícios ao cliente (9). dentre as especificações determinadas pelos pesquisadores, foi previsto que o software deveria permitir a consulta aos pacientes cadastrados a partir do seu nome ou número de prontuário. determinou-se ainda que a seleção de cada indicador empírico devesse acontecer com um único toque no dispositivo de entrada (mouse), de maneira que fosse dispensada a atividade de digitação. porém, em algumas telas ficou permitida a entrada limitada de texto livre em determinados campos. ao identificar os indicadores apresentados pelo neonato, o sistema deverá sugerir uma relação de diagnósticos de enfermagem na tela seguinte. uma vez selecionado o diagnóstico equivalente ao problema do paciente, o sistema também deverá disponibilizar uma relação de intervenções de enfermagem capazes de resolver o diagnóstico em questão. ao final deste processo ficou determinado, mais uma vez, a existência de um espaço para entrada de texto livre, garantindo que as particularidades do cliente sejam respeitadas, caso os dados preexistentes não consigam contemplar. encerrando o registro, o sistema apresentará um resumo contendo a situação clínica do neonato, seus principais diagnósticos de enfermagem, as intervenções determinadas para cada 36 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 diagnóstico e as anotações adicionais do enfermeiro responsável pelo processo. esse resumo fica disponível para impressão, caso solicitado. de posse destas informações e compreendida a construção das etapas do processo de enfermagem, o analista de sistemas organizou as informações de maneira lógica e implementou a arquitetura de entrada e saída de dados, restrições do sistema e a definição da linguagem. por fim, o desenvolvedor efetuou a representação dos dados traduzidos na linguagem escolhida pelo analista. o sistema foi desenvolvido sobre a plataforma java, com a utilização do framework jsf, incorporado à especificação j2ee, para desenvolver aplicações web de forma ágil. utilizou-se o pattern mvc (model and view controller) em uma arquitetura cliente-servidor. a escolha desse modelo se deu por ser altamente difundido entre a comunidade, o que gera facilidade para utilização. a partir do momento em que o sistema esteja disponível no servidor, o mesmo estará acessível, via internet ou intranet, em qualquer lugar bastando apenas um browser para o acesso. sua manutenção é simples (responsabilidade dividida entre as diversas camadas do mcv) e a escabilidade é alta. o projeto foi aprovado pelo comitê de ética em pesquisa do hospital universitário lauro wanderley da universidade federal da paraíba sob protocolo nº 504/11. de forma que foram observadas as normas éticas contempladas na resolução nº 466/12 do conselho nacional de saúde, principalmente no que diz respeito ao consentimento livre e esclarecido dos participantes, garantindo-lhes a liberdade e autonomia de desistir a qualquer momento de sua participação no estudo, assim como ao anonimato e sigilo quando da publicação da pesquisa (10, 11). resultados e discussão ao final da primeira fase do estudo, utilizando os critérios do conselho internacional de enfermagem (cie) foram catalogadas 159 afirmativas de diagnósticos de enfermagem e 378 afirmativas de intervenções de enfermagem, que foram submetidas à apreciação e validação pelos enfermeiros da unidade neonatal. aplicando o ponto de corte das afirmativas, resultou-se em 273 afirmativas, sendo 143 diagnósticos de enfermagem e 130 intervenções de enfermagem. apenas as afirmativas validadas foram incluídas no banco de dados do sistema. dentre os diagnósticos de enfermagem validados, observa-se uma predominância dos que se referem às necessidades de oxigenação. esse fato é devido ao grande número de recém-nascidos prematuros admitidos no serviço, que apresentam como principal complicação da prematuridade a imaturidade pulmonar. os diagnósticos relativos à condição venosa, envolvendo acesso venoso e infusão parenteral de soluções também obteve destaque pelos enfermeiros. sem dúvidas a obtenção e a manutenção de um acesso venoso no prematuro constituem um dos maiores desafios para a enfermagem neonatal. as afirmativas relacionadas à necessidade de nutrição apresentaram um índice de concordância médio em torno de 80 %, o que demonstra uma preocupação dos enfermeiros nesse aspecto. considera-se preocupante a não validação dos diagnósticos referentes ao controle da dor no neonato e à participação da família no processo de cuidar. isso sugere a necessidade de uma nova abordagem em trabalhos futuros. entendido o funcionamento das funções e com o banco de dados pronto, determinou-se a tecnologia que seria utilizada na engenharia de software. visando garantir confiabilidade e escabilidade sob a massa de dados necessária para o correto funcionamento do sistema, utilizou-se o sgbd postgresql, pois, trata-se de uma solução gratuita e confiável altamente utilizada no meio corporativo. para gerir os recursos do sistema e a disponibilização do mesmo para acesso via internet ou intranet, utilizou-se o servidor de aplicação tomcat, pois se trata de um servidor robusto, com pouca exigência de hardware e de fácil manutenção. uma vez definido o ciclo de vida para o desenvolvimento do software e cumpridas as etapas do processo de elaboração, chegamos ao sistema utineonatal que apresenta 17 telas em sua totalidade. para a tela inicial, procurou-se criar uma interface que fosse agradável e apresentasse uma imagem de criança capaz de motivar o desenvolvimento de uma assistência de qualidade. essa interface apresenta uma área que se destina ao login de acesso do profissional, constando o nome do usuário e senha, previamente cadastrados. nesse cadastramento está prevista a inclusão de toda a equipe de enfermagem, incluindo técnicos de enfermagem e en37 protótipo de um software para registro de enfermagem em unidade de terapia intensiva neonatal l luciana de medeiros lima, sérgio ribeiro santos fermeiros. porém, apenas os enfermeiros estão liberados para a inclusão ou exclusão de informações. o acesso do técnico de enfermagem encontra-se restrito às consultas dos dados para fins de leitura. encontra-se ainda uma saudação com o nome do usuário que efetuou o login, sua categoria profissional, aqui denominada de perfil e número de registro no conselho regional de enfermagem (coren). essas informações estão localizadas no canto direito da tela de gerenciamento de leitos e, a partir dela, é possível saber que usuário abriu o sistema pela última vez. destaca-se ainda a importância de personalizar o registro, de maneira a tornar mais humanizada uma atividade aparentemente mecânica e fria. a observação desses detalhes objetivou a prevenção da resistência ao sistema com a justificativa de que o mesmo possa tornar o cuidado mecanizado. é importante destacar que atualmente a enfermagem utiliza a tecnologia como um apoio e fonte de aprimoramento de suas ações, sem que haja alterações na essência do cuidar em enfermagem. os softwares são construídos para dar apoio aos cuidadores e aos pacientes e isso permite a obtenção de soluções mais eficazes para as necessidades desse usuário (12), aproximando o enfermeiro do cliente. escolhendo a opção “verificar os dados” ou acionando um quadro referente a um leito desocupado, abre-se a tela do histórico de enfermagem, iniciando com a identificação do recémnascido. esses dados serão registrados através de digitação de texto livre. concluindo esta tela, encontra-se o princípio do exame físico, dividido de acordo com as necessidades humanas básicas, segundo a teoria de horta. as necessidades humanas básicas incluídas no exame físico foram distribuídas da seguinte forma: necessidade de abrigo, necessidade de regulação térmica, necessidade de oxigenação, necessidade de hidratação, necessidade de nutrição, necessidade de integridade cutâneo mucosa, integridade física e cuidado corporal, necessidade de exercício, atividade física, motilidade, sono e repouso, necessidade de percepção, regulação endócrina, necessidade de eliminação, necessidade terapêutica e necessidade de comunicação. embora a elaboração das necessidades aqui abordadas tenha acontecido após uma vasta revisão da literatura e validada pela equipe de enfermeiros da utin, acredita-se ser indispensável manter a liberdade do enfermeiro para ir além do previsto. figura 1. tela inicial do sistema utineonatal. joão pessoa/pb, 2012 38 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 figura 2. tela de gerenciamento de leitos. joão pessoa/pb, 2012 figura 3. tela da necessidade de oxigenação. joão pessoa/pb, 2012 39 protótipo de um software para registro de enfermagem em unidade de terapia intensiva neonatal l luciana de medeiros lima, sérgio ribeiro santos por isso, reservou-se um espaço no qual poderão ser feitas anotações não contempladas pelo sistema. ao concluir o exame físico, tendo por orientação todos os indicadores selecionados, o sistema irá sugerir afirmativas de diagnósticos de enfermagem que se relacionem com os respectivos indicadores, possibilitando ao enfermeiro a capacidade para escolher a afirmativa que julgue retratar o problema do neonato. considerando a gravidade e a complexidade do cliente neonatal, é provável que a quantidade de indicadores presentes em cada exame físico seja sempre alta. isso acarreta dentro do funcionamento do sistema na indicação de inúmeros diagnósticos de enfermagem, alguns deles semelhantes entre si, mudando apenas a nomenclatura. diante dessa realidade, o sistema foi programado para aceitar apenas cinco afirmativas de diagnóstico de enfermagem por vez. essa medida proporciona ao enfermeiro o exercício do pensamento crítico para o estabelecimento de prioridades, reduzindo a quantidade de informações a serem trabalhadas e possibilitando manter o foco nos problemas mais importantes. à medida que os problemas do paciente forem sendo resolvidos se faz necessário rever os diagnósticos de enfermagem sugeridos pelo programa. isso garante que o processo seja refeito várias vezes, fazendo com que o enfermeiro esteja reavaliando o neonato com mais frequência. caso o enfermeiro insista em selecionar mais de cinco afirmativas de diagnóstico de enfermagem aparecerá uma mensagem indicando “erro” e o prosseguimento das telas fica bloqueado até que apenas cinco afirmativas, no máximo, estejam selecionadas. é recomendável que se estabeleçam prioridades diante de um montante de diagnósticos de enfermagem. para isso, é importante a adoção de um método que oriente o pensamento crítico do enfermeiro. aqui sugerimos a hierarquia das necessidades de maslow, que estabelece as prioridades em cinco grupos: necessidades fisiológicas (prioridade 1), segurança e proteção (prioridade 2), amor e pertinência (prioridade 3), auto-estima (prioridade 4) e metas pessoais (prioridade 5). no entanto, vale ainda atribuir importância aos problemas capazes de desencadear outros problemas (13). uma vez selecionadas as afirmativas de diagnóstico de enfermagem, na sequência das telas, o sistema indicará uma lista de afirmativas de intervenções de enfermagem, ficando o enfermeiro livre para escolher a que melhor possa atender às necessidades do recém-nascido. neste caso, não existe um limite de afirmativas a serem selecionadas, devendo o enfermeiro ser prudente e exato ao elaborar seu plano de cuidados. o estabelecimento das intervenções de enfermagem deve estar de acordo com a opinião de toda a equipe de enfermagem, baseada em princípios científicos e individualizada para cada figura 4. tela das anotações suplementares do enfermeiro. joão pessoa/pb, 2012 40 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 figura 5. tela de diagnósticos de enfermagem. joão pessoa/pb, 2012 figura 6. tela das intervenções de enfermagem. joão pessoa/pb, 2012 41 protótipo de um software para registro de enfermagem em unidade de terapia intensiva neonatal l luciana de medeiros lima, sérgio ribeiro santos situação específica. em sua execução, deve-se incluir a utilização de recursos apropriados, considerando os recursos disponíveis na unidade. concluído o processo pode-se solicitar a impressão dos registros de enfermagem. o enfermeiro obterá um impresso no formato pdf: figura 7. impresso final dos registros de enfermagem. joão pessoa/pb, 2012 esse impresso ficará no prontuário do paciente, podendo ser consultado por qualquer pessoa envolvida no processo de cuidado, seja profissional, familiar ou responsável pelo recém-nascido. todo o processo se repetirá a cada doze horas (período equivalente ao plantão), de maneira que as afirmativas de diagnósticos/ intervenções de enfermagem podem ser mantidas, retiradas ou acrescentadas, conforme a nova avaliação do enfermeiro e evolução do paciente. o resultado final do software corrobora com outras pesquisas desenvolvidas pelo mundo, nas quais fica evidenciado que o registro eletrônico torna o conteúdo mais acessível, legível e fácil de ser recuperado (14), permitindo o acesso imediato às informações (15), e consequentemente, melhorando a eficiência e a qualidade dos cuidados, além de agilizar a comunicação e evitar a duplicidade de informações (16). considerações finais podemos verificar neste estudo que, o desenvolvimento do software protótipo resultou num processo longo, complexo e criterioso, que exigiu a dedicação multiprofissional em sua execução. talvez essa junção de saberes tenha sido a parte mais difícil, pois se estava acostumado a querer resolver problemas de enfermagem utilizando apenas saberes de enfermagem. a utilização da abordagem sistêmica juntamente com a teoria das necessidades humanas básicas de horta veio contribuir para ampliação desse ponto de vista, reconhecendo a possibilidade de utilizar outros saberes para auxiliar nas atividades de enfermagem. para conseguir entender o que os outros profissionais diziam, foi preciso buscar um conhecimento básico da engenharia de softwares, o que proporcionou um embasamento para todo o decorrer da pesquisa. é interessante ressaltar que foi necessário realizar uma explanação geral sobre o processo de enfermagem para os profissionais da tecnologia da informação. durante todo o processo de desenvolvimento do software para sistematizar a assistência de enfermagem na utin, permaneceu o cuidado e a meta principal de tornar o serviço de enfermagem mais prático, rápido e eficaz, a partir de um esforço menor, gastando menos tempo. é possível que a utilização do sistema utineonatal possibilite melhora na qualidade de trabalho associada à qualidade da assistência prestada. os testes de simulação desenvolvidos na utin mostraram que a utilização do software proporciona um registro bem mais completo e uniforme que o realizado de maneira escrita. é importante destacar que mesmo o registro sendo uniformizado, a particularidade de cada enfermeiro foi preservada, através das anotações suplementares, corroborando para a individualidade do paciente. 42 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 obtém-se com o registro informatizado um padrão de escrita, além do perfeito entendimento do texto produzido. dessa maneira, os problemas de duplicidade de informações e a omissão de dados são totalmente resolvidos. além disso, o uso do recurso tecnológico contribui ainda para o nivelamento da equipe, uma vez que um plano assistencial mínimo é garantido pelo fluxo do programa. é possível que alguns enfermeiros consigam ir além do que está programado, no entanto, nenhum deles ficará abaixo do índice mínimo previsto. vale ressaltar que o software proporciona a execução do processo de enfermagem em todas as suas etapas, utilizando um sistema de classificação de enfermagem e seguindo os critérios do cie em sua totalidade. sabe-se que é difícil treinar toda a equipe de enfermagem para que alcance resultados semelhantes ao informatizado utilizando o registro manual. certamente, o tempo de elaboração do plano de cuidados para cada paciente despenderia muito tempo do profissional, o que muitas vezes é a causa da desmotivação para a implementação da sae. portanto, acredita-se que com o uso contínuo do sistema utineonatal, os enfermeiros poderão constatar na prática as vantagens do uso do processo de enfermagem e isso será um agente motivacional para o desenvolvimento de trabalhos científicos dentro da unidade e, consequentemente, a atualização profissional de toda a equipe. logo, o protótipo construído é um fator indispensável na busca da implementação da sae para a unidade neonatal do hulw. destaca-se ainda, que a partir deste, a utin torna-se o primeiro serviço dentro do hulw a apresentar o processo de enfermagem na íntegra de maneira informatizada. isso sem dúvidas é um grande avanço para a enfermagem desta instituição, mas certamente é o primeiro passo de um longo percurso para que se alcance o ideal na maneira de assistir e registrar. sendo o hulw um hospital escola, voltado para o ensino e a pesquisa, é necessário que disponha do que há de mais atual no campo de trabalho, de forma que a formação de pessoal seja adequada às necessidades de mercado. percebe-se que os dados gerados e armazenados de maneira informatizada contribuirão de maneira eficaz para a realização de estudos, pois facilita o resgate de informações e agiliza a localização das mesmas. conclui-se que a utin terá um rico material de registro, uma vasta fonte de pesquisa com dados de procedência garantida e de fácil acesso. reconhece-se que o software elaborado é simples e passível de muitas ampliações, o que certamente será alvo de estudos futuros. no momento, volta-se todo o esforço para utilização plena da ferramenta que se dispõe para então partir para o processo de avaliação e aprimoramento da mesma. referências 1. pereira im, gaidzinski rr, fugulin fmt, peres hhc, lima afc, castilhos v, et al. dimensionamento informatizado de profissionais de enfermagem: avaliação de um software. rev esc enferm usp [internet]. 2011; (visitado nov. 2012) 45 (esp): 1600-5. disponível em: www.ee.usp.br//reeusp/ 2. gordon sr, gordon jr. sistemas de informação – uma abordagem gerencial. 3nd ed. rio de janeiro(rj): ltc editora; 2006. 3. possari jf. prontuário do paciente e os registros de enfermagem. 2nd ed. são paulo(sp): iátria; 2010. 4. dal sasso gtm, barra dcc, paese f, almeida srw, rios gc, marinho mm, et al. processo de enfermagem informatizado: metodologia para associação da avaliação clínica, diagnósticos, intervenções e resultados. rev esc enferm usp [internet] 2013; (visitado ene. 2013) 47 (1): 242-9. disponível em: www.ee.usp.br//reeusp/ 5. marin hf. vocabulário: recurso para construção de base de dados em enfermagem. acta paul enf. 2000;13(1):86-89. 6. golvea ja. construção e validação de um instrumento de coleta de dados para recém-nascidos internados na unidade de terapia intensiva neonatal do hospital universitário lauro wanderley. [dissertação]. joão pessoa(pb): centro de ciências da saúde/ universidade federal da paraíba; 2007. 7. nóbrega mml, garcia tr, araruna jf, nunes wcan, dias gkg, beserra pfj. mapeamento de termos atribuídos aos fenômenos de enfermagem nos registros dos componentes da equipe de enfermagem. rev eletr enferm [internet] 2009; (visitado nov. 2012) 5 (2); 52-55. disponível em: http//www.fen.ufg.br/revista/revista5_2/pdf/mapa.pdf 43 protótipo de um software para registro de enfermagem em unidade de terapia intensiva neonatal l luciana de medeiros lima, sérgio ribeiro santos 8. polit df, hungler bp. fundamentos da pesquisa em enfermagem. porto alegre(rs): artes médicas; 2004. 9. hannah kj, ball mj, edwards mja. introdução à informática em enfermagem. porto alegre: artmed; 2009. 10. ministério da saúde, conselho nacional de saúde, comissão nacional de ética em pesquisa conep. resolução nº 466/12: dispõe sobre pesquisa envolvendo seres humanos. brasília; 2013. 11. conselho federal de enfermagem. resolução cofen nº358/2007: dispõe sobre a sistematização da assistência de enfermagem e a implementação do processo de enfermagem em ambientes, públicos ou privados, em que ocorre o cuidado profissional de enfermagem, e dá outras providências. brasília; 2009. 12. pereira im. dimensionamento informatizado de profissionais de enfermgem: avaliação de um software [dissertaçao]. são paulo: escola de enfermagem, universidade de são paulo; 2011. 13. alfaro-lefevre r. aplicação do processo de enfermagem: uma ferramenta para o pensamento crítico. porto alegre: editora artmed; 2010. 14. sheikh a, cornford t, barber n, avery a, takian a, lichtner v, et al. implementation and adoption of nationwide electronic health records in secondary care in england: final qualitative results from prospective national evaluation in “early adapter” hospitals. british medical journal [internet]. 2011; (visitado nov. 2012) 343:d6054. disponível em: www.bmj.com/content/343/bmj.d6054 15. baillie l, chadwick s, mann r, brook-read m. a survey of student nurses ‘ and midwives’ experiences of learning to use electronic health record systems in practice. nurse education in practice [internet]. 2013; (visitado ene. 2013) 13(5):437-41. disponível em: www.ncbi.nlm.nih.gov/pubmed/?term=a+survey+of+student+nurses+and+midwives+ex periences+of+learning+to+use+eletronic+health+record+systems+in+practice 16. zwaanswijk m, verheij ra, wiesman fl, friele rd. benefits and problems of eletronic information exchange as perceived by health care professionals: an interview study. bmc health services research [internet] 2011; (visitado nov. 2012) 11:256. disponível em: www.ncbi.nlm.nih.gov/pubmed/?term=benefits+and+problems+of+eletronic+informati on+exchange+as+perceived+by+health+care+professionals%3a+an+interview+study the importance of graduate education for nursing care editorial  the importance of graduate education for nursing care la importancia de la educación del postgrado en el cuidado de enfermería a importância da educação da pós-graduação no cuidado de enfermagem 10.5294/aqui.2023.23.1.1  raquel a. benavides-torres1 1 0000-0001-5113-4250.  universidad autónoma de nuevo león, nursing school, centro de investigación y desarrollo en ciencias de la salud. mexico, raquel.benavidestr@uanl.edu.mx keywords (source: decs): education; nursing; graduate; academies and institutes; health services research; evidence-based practice; innovation. palabras clave (fuente: decs): educación de postgrado de enfermería; academias e institutos; investigación sobre servicios de salud; práctica clínica basada en evidencia; innovación. palavras-chave (fonte: decs): educação de pós-graduação em enfermagem; academias e institutos; pesquisa sobre serviços de saúde; práctica clínica basada en la evidencia; inovação. para citar este editorial / to reference this editorial / para citar este editorial: benavides-torres ra. the importance of graduate education for nursing care. aquichan. 2023;23(1):e2311. doi: https://doi.org/10.5294/aqui.2023.23.1.1 graduate nursing education faces various challenges related to the competencies to be developed for graduating nurses that provide quality care. among the multiple levels are specialties, master’s degrees, and doctorates, the last two focused primarily on research. however, current trends point to graduate courses that must solve practical problems, making master’s degrees and doctorates disjointed, with an even more significant disadvantage: the type of delivery format. mostly, they are of school type and not accessible to practicing professionals (1). therefore, those with more advanced study degrees continue to be the scholars. it is imperative that those who work in academia, whether universities or institutes, focus on new ways of organizing the training of nurses with research skills that can be translated into practice (2). this means that innovation is one of the main characteristics that graduate programs should privilege, understanding innovation as the knowledge that solves a problem in practice and is helpful for the user. accordingly, the research products at this level must concentrate on practices, objects, products, services, or processes that must be innovative and creative. it implies not only new knowledge, but also previous knowledge with added value because it is new for those who adopt it and provides a solution to their practical problems. there are several types of innovations that are not exclusive to research. we can classify them into: • technological: aimed at developing new products, processes, or services that can be used in the clinic at different levels of care, with a high impact on the competitiveness and productivity of nurses. • organizational: essential for those programs aimed at training leaders in practice who will be decision-makers. these should focus on new organizational methods oriented to good practices and the patient-nurse-health institution relationship. • social: integrating the values ​​of nurses and covering the public, social, educational, and cultural sectors. they have loomed large since their impact is on social welfare. so, it is imperative that we reflect on the competencies graduate students must acquire to cater to the population’s needs and contribute to improving social well-being. this falls not only on the knowledge, attitudes, and skills that must be developed; products must give rise to technological developments that can be classified as inventions and copyrights. the former includes patents, utility models, and industrial designs, which have an added value since the knowledge transfer method is natural and allows the cycle of action that contributes to knowledge application to care to continue. thus, for the graduate program to impact nursing care, knowledge transfer must be critical in reference models and syllabi (3). knowledge transfer refers to a complex multidimensional process that requires various mechanisms, methods, and measurements to be considered in the training of advanced practice nurses. it should be noted that factors influencing individual and interaction levels are considered in the transfer process (4). put differently, it is necessary to generate innovative nursing knowledge made available to interested users, i.e., all those involved in the knowledge transfer process. with a more significant number of nurses with a graduate degree engaged in this transfer process, the products and tools to be used in practice will be more, so the nurses in the services may select those most appropriate to contribute to the solution of health problems. consequently, in recent years there has been talk about the importance of advanced practice nursing involving professionals with graduate training. we could place them in two positions according to the activity. the first is as users of protocols or clinical guidelines that may occur at the specialty, master’s, and doctoral levels. the second is as generators and processors of evidence after master’s degrees or doctorates. in the case of doctoral training, educational institutions could consider: 1. nursing professionalizing doctorates 2. doctorates specialized in research lines to solve practical problems 3. doctorates with high technology and innovation content 4. doctorates with high degrees of engagement and internationalization the research lines of the programs should focus on solving problems in practice to develop, refine, and expand knowledge for the benefit of health systems (5). generating clinically appropriate, cost-effective evidence with positive results is essential for graduate nurses. thus, we could frame the following training trends: using multiple strategies for evaluating knowledge, i.e., through qualitative, quantitative, or mixed methodologies at the individual, health professional, and organizational levels. graduates must have the skills to understand and synthesize the available evidence through systematic reviews and meta-analyses that allow them to generate or apply knowledge to nursing care. engagement becomes an indisputable ally to solving immediate problems resulting from the analysis of intervention needs, leading us to the implications of collaborative work (6). one of the main characteristics of nurses with graduate training is attributable to their roles within work teams to solve pressing health problems. educational institutions must have a support infrastructure and be responsible for developing interdisciplinary syllabi, coordinating management strategies that address student learning, and providing an environment for harmonized communication among those interested in problem-solving. on the other hand, nurses with graduate preparation must be sensitive to culture and consider the real contexts where practices occur, assessing patients’ beliefs, values, vulnerability, and diversity. in conclusion, graduate preparation is a continuous curricular revision process at all levels. it is necessary to review both the teachinglearning methods and the assessment instruments of knowledge transfer in nursing. the primary challenge we face is to change the traditional way of teaching to train highly collaborative nurses who have the necessary skills to meet the complexity of current health problems. academies and institutes must train graduate nurses capable of generating, applying, transferring, and disseminating knowledge that solves complex problems in convergence with multiple fields of expertise. references 1. thompson mr, schwartz barcott d. the role of the nurse scientist as a knowledge broker. j nurs scholarsh. 2019;51(1):26-39. doi: https://doi.org/10.1111/jnu.12439 2. graf ac, jacob e, twigg d, nattabi, b. contemporary nursing graduates’ transition to practice: a critical review of transition models. j clin nurs. 2020; 29(15-16):3097-3107. doi: https://doi.org/10.1111/jocn.15234 3. trautman de, idzik s, hammersla m, rosseter r. advancing scholarship through translational research: the role of phd and dnp prepared nurses. online j issues nurs. 2018;23(2). doi: https://doi.org/10.3912/ojin.vol23no02man02 4. ferreira r, sousa l, nobre c, nunes ac, fonseca c, ferreira ó, baixinho cl. the development of research skills in nursing postgraduate training. educ sci. 2022; 12(2):78. doi: https://doi.org/10.3390/educsci12020078 5. monsen ka, bush ra, jones j, manos el, skiba dj, johnson sb. alignment of american association of colleges of nursing graduate-level nursing informatics competencies with american medical informatics association health informatics core competencies. cin: comput inform nurs. 2019;37(8):396-404. doi: https://doi.org/10.1097/cin.0000000000000537 6. almekkawi m, el khalil r. new graduate nurses’ readiness to practise: a narrative literature review. health prof educ. 2020;6(3):304-316. doi: https://doi.org/10.1016/j.hpe.2020.05.008 home cerrar 560 570 significado da pratica social.indd 560 aquichan issn 1657-5997 dirce stein-backes1 marli stein-backes2 alacoque lorenzini-erdmann3 andreas büscher4 angela maría salazar-maya5 signifi cado da prática social do enfermeiro com e a partir do sistema único de saúde brasileiro6 1 rn, phd. professor and researcher of the nursing department at the franciscan university – unifra, santa maria/rs (brasil). backesdirce@ig.com.br 2 ph.d. in nursing. researcher of santa catarina federal university – ufsc/rs (brasil). marli.backes@bol.com.br 3 nursing ph.d. professor of the nursing department at federal university of santa catarina – ufsc – florianópolis/sc (brasil). alacoque@newsite.com.br 4 rn, phd. researcher and lecturer of the institute of nursing science at the university of bielefeld (germany). andreas.buescher@uni-bielefeld.de 5 rn, phd. professor and researcher of the nursing school at the universidad de antioquia medellín (colombia). angela.salazar@udea.edu.co 6 work produced from the bilateral research project brazil-germany: “developing principles for supporting health promotion activities with social vulnerable populations”. recibido: 30 de julio de 2013 enviado a pares: 30 de julio de 2013 aceptado por pares: 14 de julio de 2014 aprobado: 26 de agosto de 2014 doi: 10.5294/aqui.2014.14.4.10 para citar este artículo / to reference this article / para citar este artigo stein-backes ds, stein-backes ms, lorenzini-erdmann al, büscher a, salazar-maya am. significado da prática social do enfermeiro com e a partir do sistema único de saúde brasileiro. aquichan. 2014; 14(4): 560-570. doi: 10.5294/aqui.2014.14.4.10 resumo objetiva-se, com este trabalho, possibilitar olhar sobre o papel profissional do enfermeiro no e a partir do sistema único de saúde brasileiro, bem como compreender o significado de sua prática social neste campo de discussões e significações teórico-práticas. utilizouse como referencial metodológico a grounded theory e como técnica de coleta de dados a entrevista, realizada entre maio a dezembro de 2007, com 35 profissionais da saúde e outros. a análise dos dados evidenciou que o sistema único de saúde pode ser considerado uma estratégia facilitadora e estimuladora do processo de ampliação e consolidação do cuidado de enfermagem como prática social, à medida que sinaliza para uma nova abordagem de intervenção social, pela valorização do ser humano como ser singular e multidimensional, inserido em seu contexto real e concreto. palavras-chave papel do enfermeiro, enfermagem em saúde comunitária, saúde coletiva, sistema único de saúde, programa saúde da família. (fonte: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 560-570 561 significado da prática social do enfermeiro com e a partir do sistema único de saúde brasileiro l dirce stein-backes e outros año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 560-570 significado de la práctica social del enfermero con y desde el sistema único de salud brasileño resumen este trabajo tiene por fin posibilitar una mirada hacia el rol profesional del enfermero en el y desde el sistema único de salud brasileño; así mismo, comprender el significado de su práctica social en este campo de discusiones y significaciones teórico-prácticas. se utilizó como referencial metodológico la grounded theory y como técnicas de recolección de datos la entrevista, realizada de mayo a diciembre del 2007, con 35 profesionales de la salud y otros. el análisis de los datos evidenció que el sistema único de salud puede considerarse una estrategia facilitadora y estimulante del proceso de ampliación y consolidación del cuidado de enfermería como práctica social a medida que señala hacia un nuevo abordaje de intervención social, por la valoración del ser humano como ser singular y multidimensional, insertado en su contexto real y concreto. palabras clave rol del enfermero, enfermería en salud comunitaria, salud colectiva, sistema único de salud, programa salud de la familia. (fuente: decs, bireme). 562 aquichan issn 1657-5997 significance of the nurse’s social practice with and through the unified brazilian health care system abstract the purpose of this work is to facilitate a look into the professional role of nurses working with and through brazil’s unified health care system, and to understand the significance of their social practice in this field of theoretical-practical discussions and meanings. the grounded theory was used as a methodological framework, and interviews were conducted to collect the data. a total of 35 health care professionals were interviewed between may and december 2007. the analysis of the data showed the unified health care system can be considered a facilitating and stimulating strategy in the process to expand and consolidate nursing care as a social practice, inasmuch as it signals a new approach to social intervention based on valuing the person as a unique and multidimensional being immersed in a real and specific context. key words nurse’s role, nursing in community health, collective health, unified health care system, family health program. (sources: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 560-570 563 significado da prática social do enfermeiro com e a partir do sistema único de saúde brasileiro l dirce stein-backes e outros introdução a enfermagem vem ampliando, crescentemente, o seu espaço de atuação na área da saúde, tanto no contexto nacional quanto no cenário internacional. o enfermeiro assume um papel cada vez mais decisivo e proativo, no que se refere à identificação das necessidades de cuidado da população, bem como na promoção e proteção da saúde de indivíduos, famílias e comunidades. o cuidado de enfermagem é, portanto, um componente fundamental nos sistemas de saúde, considerando a complexidade e as expectativas em torno das demandas de saúde da população. a orientação para a promoção da saúde, ao contrário do foco na doença, implica novas habilidades e competências profissionais do enfermeiro na área social e política, e força-o ao desenvolvimento responsável (1), a promoção da saúde, o monitoramento e controle doenças crônicas, tanto em nível local, regional e nacional quanto internacional. mesmo que interligada e complementada por outros saberes profissionais, a enfermagem pode ser amplamente definida como a ciência do cuidado integral e integrador em saúde, por ter um corpo de conhecimento ampliado e contextualizado no cuidado em saúde. dessa forma, facilita e direciona o conhecimento necessário e suficiente para o desempenho satisfatório de suas práticas na promoção da saúde (2), pelas possibilidades interativas e associativas com os diferentes espaços, considerando que o enfermeiro está em contato mais direto com as pessoas, famílias e comunidade (3). evidências internacionais acenam para a importância do papel profissional do enfermeiro na saúde pública, tanto no espaço domiciliar quanto no espaço comunitário e social. a enfermagem tem a possibilidade de operar, de forma criativa e autônoma, nos diferentes níveis de inserção social, seja por meio da educação para a saúde, que se torna uma ferramenta importante para a promoção da saúde ou prevenção de doenças (4), ou na reabilitação da saúde dos indivíduos. esse processo se dá, particularmente, no esforço pelo levantamento de situações críticas e a intervenção sistematizada de um plano de cuidados, capaz de superar a fragmentação e assegurar a continuidade e a resolutividade do cuidado em saúde (2-4). nesse campo de discussões, o papel profissional do enfermeiro é ampliado pela estratégia da organização mundial da saúde “saúde 21”, saúde para todos no século xxi e prioridade número um para a região europeia, a qual se concentra em alcançar níveis cada vez mais amplos de saúde e, desse modo, favorecer ao ser humano uma vida social e economicamente produtiva e com mais qualidade (5-7). no brasil, vários estudiosos se empenham em dar visibilidade ao papel profissional do enfermeiro, seja como prática social comunitária, autônoma, ou como prática assistencial institucionalizada (8-13). é preciso levar em conta, no entanto, que a enfermagem como prática social se cunhou de novos significados conceituais, possibilitados pela concepção de saúde coletiva, campo ainda em constituição e que, gradativamente, vem assumindo diversas formas e abordagens. a expressão saúde coletiva, especificamente no contexto brasileiro, surgiu, no fim da década de 1970, em um momento de reordenamento de um conjunto de práticas assistenciais, diante da necessidade de ampliar a compreensão do processo saúdedoença dos indivíduos e comunidades, pela inserção e valorização dos diferentes saberes profissionais e a integração com os diferentes setores sociais. a compreensão do coletivo significa, a partir de então, a apreensão do individual em seu contexto estruturado de práticas e reconhecê-lo como sujeito social em constante interação com os outros indivíduos e com o seu entorno, ou seja, o indivíduo se transforma e é transformado continuamente, por meio das relações e interações; torna-se protagonista e autor do processo saúde-doença em seu contexto real e concreto (14). a mudança conceitual da expressão-saúde pública para saúde coletiva— é reflexo de um intenso engajamento dos movimentos sociais na luta pela democratização do país, além da centralidade assumida pela assembleia nacional constituinte, em 1977. emergida como parte dessa luta pela democracia, a reforma sanitária, no brasil, alcançou a garantia constitucional do direito universal à saúde e a construção institucional do sistema único de saúde (sus), aprovado na constituição federal de 1988 (15, 16). sistema único de saúde — novas possibilidades de inserção social o sus foi criado, nessa perspectiva, a partir das manifestações de um conjunto de necessidades sociais de saúde, as quais imprimem um caráter ético-moral que defende a saúde como direito de todo cidadão. enquanto conquista das lutas participativas e democráticas, o sus se desenvolve com base nos princípios de acesso, universalidade, equidade e integralidade e com base nas 564 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 diretrizes organizativas de descentralização, regionalização, hierarquização e participação da comunidade (17). como estratégia de reformulação do modelo brasileiro de atenção à saúde e o fortalecimento dos princípios e diretrizes do sus, o ministério da saúde criou, em 1994, a estratégia saúde da família (esf), inicialmente denominada programa de saúde da família. a estratégia nasceu na tentativa de repensar os padrões de pensamento e comportamento dos profissionais e cidadãos brasileiros, até então vigentes. sistematizada e orientada por equipes de saúde da família que envolve médicos, enfermeiros, técnicos de enfermagem, odontólogos e agentes comunitários de saúde (acs), a esf busca discutir e ampliar o tradicional modelo sanitário médico-curativista, para a compreensão de uma abordagem coletiva, multi e interprofissional, centrada na família e na comunidade, inserida em seu contexto real e concreto (8, 9). sendo a esf uma estratégia de fomento à participação da população, esta deve, crescentemente, promover uma nova relação entre os sujeitos, na qual tanto o profissional quanto o usuário possam/devam ser produtores e construtores de um viver mais saudável. esse envolvimento, no entanto, só é possível mediante um processo dialógico entre os diferentes saberes, no qual cada um contribui com o seu conhecimento peculiar e juntos possibilitam uma interação efetiva pela valorização das diferentes experiências e expectativas de vida (9). é nesse contexto de discussões, conquistas e desafios que o enfermeiro precisa delinear cada vez mais e melhor o seu campo de atuação profissional e desenvolver o seu projeto político-legal, coerente com os princípios e diretrizes do sus. um projeto profissional, portanto, que necessita considerar o ser humano-ser individual e coletivo— como sujeito e ator social. nessa direção, questiona-se: qual o significado do papel profissional do enfermeiro no sistema único de saúde brasileiro e qual o significado de sua prática social neste campo de discussões e significações teórico-práticas? pretende-se, a partir do exposto, situar a enfermagem ante as práticas em saúde coletiva, mais especificamente no sus, para compreender como esta vem se constituindo enquanto uma das áreas que contribui de forma decisiva para a consolidação dos princípios e diretrizes do sus. objetiva-se, assim, possibilitar olhar retrospectivo sobre o papel profissional do enfermeiro no sistema único de saúde brasileiro, bem como compreender o significado de sua prática social neste campo de discussões e significações teórico-práticas. método trata-se de um estudo de abordagem qualitativo-exploratória, orientado pelo método grounded theory. esse método permite explorar os dados de forma criativa, abrangente e interativa, por levar em conta que muitas coisas podem ser consideradas dados de pesquisa. constituiu-se num processo em que os dados coletados, codificados e comparados de forma simultânea e sistemática, possibilitam explorar os significados e hipóteses, nesse caso, do papel do enfermeiro, sob diferentes ângulos e espaços (18, 19). os dados foram coletados entre os meses de maio e dezembro de 2007, por meio de entrevistas realizadas com 35 participantes, inseridos nos mais diferentes cenários da saúde da região sul do brasil. dentre os participantes figuram enfermeiros, médicos, nutricionistas, farmacologistas, fisioterapeutas, psicólogos, administradores a profissionais de apoio técnico que, após serem orientados acerca dos objetivos da pesquisa, assinaram o termo de consentimento livre e esclarecido. em conformidade com o processo de amostragem teórica, o primeiro grupo amostral foi formado por nove enfermeiros docentes, considerados empreendedores em sua área de atuação. as entrevistas foram conduzidas com base nas seguintes perguntas: como você percebe a prática social do enfermeiro? qual o papel do enfermeiro no sus? as entrevistas foram gravadas e transcritas, e os dados foram organizados e analisados com o propósito de identificar os indicadores empíricos definidos como códigos, com base na técnica de análise comparativa. a análise dos dados coletados no primeiro grupo amostral permitiu a formação de propriedades iniciais e hipóteses que orientaram a formação do segundo grupo, composto por 12 enfermeiros assistenciais que atuam na assistência hospitalar ou em clínicas especializadas de saúde. as hipóteses que emergiram da análise dos dados do primeiro grupo evidenciaram que os enfermeiros, frequentemente, não conseguem perceber a importância e a necessidade do seu fazer profissional na prática assistencial nos cenários de saúde. assim, os questionamentos para as en565 significado da prática social do enfermeiro com e a partir do sistema único de saúde brasileiro l dirce stein-backes e outros trevistas para o próximo grupo foram: em seu local de trabalho, o que distingue você dos demais profissionais da saúde? como você percebe a sua prática social enquanto enfermeiro? os dados do segundo grupo permitiram aprofundar a estrutura do modelo teórico em maior profundidade, ampliaram a compreensão das categorias emergentes e possibilitaram informações suplementares que sinalizaram para as especificidades do sistema de enfermagem no contexto da formação e nos cenários da prática. já as hipóteses que emergiram da análise e comparação dos dados do segundo grupo evidenciaram fragmentação entre o pensar dos enfermeiros e outros profissionais da saúde, ideia que ficou explícita na seguinte indagação “o que os demais profissionais da saúde pensam e falam sobre a atuação do enfermeiro e sua prática social na saúde?” desse modo, optou-se por um terceiro grupo de entrevistas com 14 profissionais de diferentes cursos da área da saúde, os quais foram selecionados com base nas indicações do segundo grupo amostral. eles foram entrevistados a partir dos seguintes questionamentos: com base na sua formação, como você percebe a atuação do enfermeiro no sus? como você percebe a prática social do enfermeiro? a saturação teórica, portanto, foi alcançada com a análise comparativa dos dados dos três grupos amostrais. os dados empíricos foram analisados com base no processo de codificação aberta, axial e seletiva (18, 19). os códigos foram organizados de acordo com as suas respectivas similaridades e diferenças e agrupados em categorias e subcategorias. a partir da análise das relações entre as categorias, foi definida a categoria central e, após a estruturação do modelo teórico que representa a articulação entre as categorias e suas subcategorias, este foi validado. o projeto foi aprovado pelo comitê de ética em pesquisa da universidade federal de santa catarina (ufsc), sob o número 052/2007. para garantir o anonimato, os participantes da pesquisa foram identificados, ao longo do texto, pela letra “e” (entrevistado), seguida do número correspondente à ordem de realização das entrevistas (p1, p2, p3... p35). resultados neste artigo, mais especificamente, serão apresentadas e discutidas as categorias: sus — maior sistema de mobilização social; ampliação da intervenção comunitário-coletiva; novo modo de pensar e agir e ampliação das interações e associações profissionais, as quais emergiram como interveniências estratégicas para o fenômeno central: “vislumbrando o cuidado de enfermagem como prática social empreendedora”. sus — maior sistema de mobilização social o sus é reconhecido e ressaltado pelos entrevistados como um dos maiores sistemas de mobilização e prática social, pelo acesso, cobertura, garantia de continuidade, integração com os diversos setores e com as diversas políticas sociais, dentre outros. é reconhecido igualmente como um sistema empreendedor por promover a participação da comunidade nas discussões que dizem respeito à saúde, conforme expresso na fala, a seguir: o sistema único de saúde talvez seja um dos maiores setores de mobilização social. se considerarmos empreendedorismo como transformação, mobilização, produzimos grandes resultados, principalmente na saúde... os próprios conselhos de saúde que mobilizam a participação da população e o controle social devem ser considerados empreendedores [...] na lógica do social, os princípios do sus possuem a definição para o sucesso (e9). por meio dos princípios da universalidade, integralidade, equidade, o sus traz implícito um novo modelo de intervenção e participação social, especialmente com a criação da estratégia saúde da família, conforme refletem as falas a seguir: precisamos reconhecer que o sus trouxe novas oportunidades de mobilização e participação social, principalmente pelo programa estratégia saúde da família (e3). o sus representa para o enfermeiro e demais profissionais da saúde uma grande conquista, pela ampliação das oportunidades de atuação, principalmente na educação e promoção da saúde (e7). ampliação da intervenção comunitário-coletiva para os entrevistados, o sus também passou a dar um novo sentido à saúde como bem-social, com foco na promoção e intervenção comunitário-coletiva, com vistas a superar a fragmentação do modelo biomédico e hospitalocêntrico, conforme salientam as falas: anos atrás, o hospital era mais importante porque tinha 70% de trabalhadores empregados... isto mudou. a lógica hoje é a saúde 566 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 coletiva (e13). a ênfase a partir do sus é a promoção da saúde, a atenção básica, a saúde da família (e16). [...] temos uma amplitude de sistema que nenhum outro país tem (e17). o sus possibilitou um olhar mais ampliado sobre o processo saúde-doença pela valorização dos diferentes saberes profissionais. possibilitou compreender o indivíduo —ser singular e multidimensional— em seu contexto real e concreto. os entrevistados evidenciaram que, com a criação do sus, os profissionais da saúde, mais especificamente o profissional enfermeiro, ampliaram a sua atuação e inserção no campo comunitário e social. essa prática foi ampliada ainda mais com as oportunidades oferecidas pela esf, a qual proporcionou maior visibilidade e se apresenta como um espaço aberto, sensível e flexível para a emancipação e transformação social, como bem evidencia a fala a seguir: a esf deu maior visibilidade para o papel profissional do enfermeiro, principalmente no campo da saúde coletiva. o enfermeiro na saúde coletiva sempre existiu... mas hoje está tendo uma maior visibilidade. a esf se apresenta como um espaço aberto e sensível para atuar nas famílias, comunidades, associação de moradores, nas escolas, nos sindicatos, nas políticas públicas e outros. então, hoje, o enfermeiro tem um espaço aberto na sociedade para trabalhar a questão da cidadania, das políticas públicas, da educação em saúde (e27). novo modo de pensar e agir com a criação do sus e especialmente a esf, o enfermeiro tem o seu espaço de atuação garantido, mesmo que para alguns profissionais a emergência do novo modo de pensar e agir ainda represente certo desconforto e insegurança, pela necessidade de inserção ativa e responsável na vida das comunidades, como reflete a fala: mesmo sem a coragem de mudar, o enfermeiro e os outros profissionais são levados [provocados] pelo sistema de saúde a mudarem os seus comportamentos e o modo de pensar (e9). nessa direção, os entrevistados trazem à tona que independentemente da vontade pessoal/profissional, os enfermeiros, como os demais profissionais da saúde, são impulsionados pelo sistema a adotarem uma nova postura de intervenção nos diferentes cenários da saúde: mesmo que este profissional não ouse por conta própria, ele está sendo colocado num espaço que está cheio de oportunidades e desafios que precisam ser considerados (e31). o usuário da saúde ainda está muito acostumado a ser atendido em partes, então no início ele estranha muito [...]. ficou bastante visível nas primeiras visitas que o paciente e a família estão desacreditados (e7). o espaço social, caracterizado como espaço familiar e comunitário, possibilita um aprendizado instigador e contínuo, além de uma intensa troca de experiências tanto para enfermeiros e outros profissionais como para os usuários da saúde. possibilita, também, a realização e bem-estar profissional, pela conquista da autonomia e reconhecimento por parte dos usuários da saúde, conforme refletem as falas: eu preciso encontrar espaços onde eu possa fortalecer a autonomia, e a comunidade me proporciona isso. (e6). na família a gente precisa levar em conta a autonomia do usuário [...] tem a possibilidade de troca, de eu também aprender. então existe toda uma interação, o usuário passa a ser ator do processo (e13). pelo fato de ser um curso que tem uma formação universitária generalista, a enfermagem está qualificada, no entender dos entrevistados, para integrar e fomentar ativamente os princípios do sistema de saúde vigente, sobretudo, nas atividades interativas e gerenciais, as quais requerem maior envolvimento, sistematização e comprometimento com as reais necessidades de saúde da população. ampliação das interações e associações profissionais a partir da lógica do sus, o cuidado de enfermagem é visibilizado como prática interativa, multidimensional e interdisciplinar, ou seja, como prática social que integra uma rede de relações e associações comunitárias. nessa direção, os participantes entendem que é preciso ocorrer uma articulação crescente com os diferentes profissionais que atuam no sistema de saúde, para que a pessoa humana, em seu contexto singular e coletivo, seja compreendida como um ser integral —protagonista do seu processo saúde-doença—. o enfermeiro é reconhecido, nessa perspectiva, pela habilidade interativa e associativa, por compreender o ser humano como um todo, pela integralidade da assistência à saúde, pela capacidade de acolher. além disso, identifica-se com as necessidades e expectativas dos indivíduos pela capacidade de interagir diretamente com o usuário e a comunidade, bem como pela capacidade de promover o diálogo entre os usuários e a equipe de 567 significado da prática social do enfermeiro com e a partir do sistema único de saúde brasileiro l dirce stein-backes e outros saúde da família. no entender dos entrevistados, o enfermeiro se aproxima, identifica e procura criar uma relação de empatia com o usuário, independentemente das suas condições sociais. o enfermeiro é aquele que encaminha e otimiza as intervenções de cuidado em saúde de modo que integre e contemple tanto os saberes profissionais quanto os saberes dos usuários. os resultados evidenciam, em suma, que os profissionais de saúde se encontram, por meio do sus e mais especificamente pela esf, diante de um novo modelo assistencial, no qual o impacto do desconhecido e a insegurança ante o novo são inevitáveis, mas motivadores e animadores para o crescimento profissional e o desenvolvimento social integrado e integrador. desse modo, tanto o sus quanto a esf podem/devem ser considerados estratégias facilitadoras e estimuladoras do processo de ampliação e consolidação do cuidado de enfermagem como prática social empreendedora, comprometida com o desenvolvimento humano e a transformação social. discussão as discussões em torno da atuação dos profissionais da saúde no sus convergem para o reconhecimento de que o enfermeiro é o interlocutor e o principal agente catalisador das políticas e programas voltados para a saúde coletiva, em especial para a esf, que requer um envolvimento efetivo com as reais necessidades de saúde das famílias e comunidades (8). esse pensar é corroborado por profissionais da área, ao argumentarem que o enfermeiro, cuja essência e especificidade é o cuidado ao ser humano em todas as suas dimensões, individual ou coletivamente, de forma integral e holística, é formado para atuar em diferentes espaços sociais, tais como: na atenção, na gestão, no ensino, na pesquisa, no controle social, bem como no fomento de ações educativas e de promoção da saúde dos indivíduos, famílias e comunidades. nessa direção, a autonomia e o protagonismo social do enfermeiro são construídos por conquistas técnico-científicas, legais e políticas pela produção do conhecimento próprio (20, 21). o ministério da saúde brasileiro, por meio do departamento de gestão da educação na saúde, vem atuando, crescentemente, no sentido de reorientar e ampliar a formação dos profissionais da saúde, de modo geral, para atenção básica, com o intuito de fortalecer a cobertura da esf e aumentar a resolutividade da atenção à saúde no sus. a referida formação também faz parte da política nacional de educação permanente, que traz à tona aspectos como o conceito ampliado de saúde; a utilização de metodologias ativas de ensino-aprendizagem, que considerem o trabalho como eixo estruturante das atividades; o trabalho em equipe multiprofissional e transdisciplinar; a integração entre ensino e serviços de saúde; o aperfeiçoamento da atenção integral à saúde; a qualificação da gestão, dentre outros (20). a partir dessas iniciativas do ministério da saúde e da educação, o enfermeiro tem voltado, crescentemente, o seu foco de atenção para a educação, promoção e proteção da saúde. nessa direção, os gestores, usuários e demais profissionais da saúde visualizam a atuação da enfermagem como algo considerado imprescindível e que nos serviços há melhor desempenho quando estes são coordenados por enfermeiros. para alguns autores, no entanto, o potencial do enfermeiro precisa ainda ser evidenciado, para um melhor aproveitamento da sua força de trabalho, o que pode assim refletir na melhoria da qualidade da assistência prestada por esses profissionais junto aos serviços de saúde (9). no campo assistencial comunitário ou na esf, o enfermeiro lança mão tanto de uma série de tecnologias que incluem os equipamentos e o instrumental necessários ao desenvolvimento do trabalho —como, por exemplo, os aparelhos, a estrutura física, os procedimentos técnicos, os folhetos educativos, os conhecimentos estruturados acerca da epidemiologia, planejamento em saúde e outros— quanto de tecnologias que envolvem as relações, interações e associações entre os usuários e famílias, que dizem respeito ao vínculo, ao acolhimento, às relações humanizadas, dentre outros (4). nesse sentido, a atuação do enfermeiro vai além da dimensão técnico-assistencialista ou da aplicação imediata e direta dos conhecimentos técnico-científicos e se concentra em saberes que levam em consideração as inter-relações e a dinâmica coletivo-social de todos os envolvidos no processo. no campo gerencial, destacam-se as possibilidades de inserção na agenda municipal por meio das políticas públicas, as quais visam crescentemente atender tanto às necessidades de saúde da população quanto considerar os níveis de satisfação profissional e pessoal dos trabalhadores. deve-se considerar, no entanto, que o processo de trabalho ainda é marcado por diversos interesses, conflitos e necessidades, ou seja, por tensões e confrontos, nos quais, de um lado, se encontram os interesses políticos e, de outro, os interesses dos trabalhadores em geral, que nem sempre são equacionados de forma a atender aos anseios de ambas as partes envolvidas. 568 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 a partir do exposto, o enfermeiro não se apresenta neutro, como também não atua somente com saberes e práticas técnicas, ainda que necessite destas para constituir-se como prática social nos diferentes cenários da saúde. o espaço do enfermeiro, mais especificamente a partir do sus e da esf, apresenta-se como um campo aberto e sensível às necessidades sociais e de saúde. é evidente, porém, que esses esforços ainda são coroados pelo êxito apenas modesto, considerando a necessidade de ampliar as discussões em torno do modelo de saúde, ainda hegemônico nos serviços e práticas de saúde, a formação de profissionais qualificados e comprometidos para o sus e a esf e, principalmente, a ampliação do debate acerca da enfermagem como prática social empreendedora. considerações finais um olhar retrospectivo sobre o papel do profissional enfermeiro no sistema único de saúde brasileiro permite argumentar que o sus e, de modo especial a esf, podem ser considerados estratégias facilitadoras e estimuladoras do processo de mobilização social, da ampliação da intervenção comunitário-coletiva, de um novo modo de pensar e agir, bem como pelas novas possibilidades interativas e associativas, à medida que sinalizam para uma nova abordagem de intervenção social, não mais focada nos reducionismos do saber médico-curativista, mas centrada na educação, promoção e proteção da saúde. em outras palavras, sendo uma profissão fundamental no sistema de saúde, a enfermagem se destaca e diferencia pelo desenvolvimento de práticas interativas e integradoras de cuidado, as quais vêm adquirindo uma repercussão cada vez maior, tanto na educação e promoção da saúde quanto no fomento de políticas voltadas para o bem-estar social das famílias e comunidades. nessa direção, a enfermagem se configura, crescentemente, como a profissão do futuro pela possibilidade de compreender o indivíduo não mais de forma fragmentada, mas como um ser singular e complexo, capaz de continuamente autoorganizar-se e projetar-se como autor do processo saúde-doença. basta, no entanto, que a enfermagem invista em atitudes proativas, capazes de promover e emancipar o indivíduo e família como protagonistas da sua própria história. promovendo o cuidado ao ser humano em todas as suas dimensões, como essência e especificidade da profissão, a enfermagem tem a possibilidade de transitar pelos diferentes campos de conhecimento, bem como pelas diferentes realidades sociais. tendo como foco a pessoa humana, a família e a comunidade, a enfermagem apresenta grande possibilidade de contribuir para a construção de um saber interdisciplinar, além de estabelecer canais efetivos de comunicação com os diversos setores sociais e, dessa forma, possibilitar estratégias mais eficazes e resolutivas de cuidado em saúde. o papel do enfermeiro é reconhecido, em suma, pela capacidade e habilidade de compreender o ser humano como um todo, pela integralidade da assistência à saúde, pela capacidade de acolher e identificar-se com as necessidades e expectativas dos indivíduos e famílias, pela capacidade de acolher e compreender as diferenças sociais, bem como pela capacidade de promover a interação e associação entre os usuários, a equipe de saúde da família e a comunidade. a enfermagem se aproxima, identifica e procura criar uma relação efetiva com o usuário, independentemente das suas condições econômicas, culturais ou sociais, ou seja, busca otimizar as intervenções de cuidado em saúde de modo que integre e contemple tanto os saberes profissionais quanto os saberes dos usuários e da comunidade. 569 significado da prática social do enfermeiro com e a partir do sistema único de saúde brasileiro l dirce stein-backes e outros referências 1. carreras viñas m. nuevos rumbos en la enfermería. cuenta y razón [internet] 1999 [data da consulta 20 maio 2010]; 113: 81-8. disponível em: http://www.cuentayrazon.org/revista/pdf/113/num113_013.pdf. 2. trezza mcaf, santos rm, leite jl. enfermagem como prática social: um exercício de reflexão. rev bras enferm, brasília 2008; 61(6): 904-8. 3. costa gd, cotta rmm, ferreira mlm, reis jr, franceschini scc. family health: challenges in the 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educação em saúde. brasília: ministério da saúde; 2009. 570 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 21. silva fv. autonomia profissional na enfermagem é construída por conquistas técnico-científicas, legais e pelo desenvolvimento de uma prática cidadã. rev bras enfer 2007; 49 (2): 1-20. 22. silva cmc, meneghim mc, pereira ac, mialhe fl. educação em saúde: uma reflexão histórica de suas práticas. ciênc. saúde coletiva 2010; 15 (5): 2539-50. colaboradores ds backes – trabalhou na concepção, delineamento e interpretação dos dados. ms backes – trabalhou na redação do artigo e interpretação dos dados. al erdmann – trabalhou na pesquisa e provação da versão a ser publicada. a büscher — trabalhou na concepção, análise e revisão crítica do artigo. as salazar-maya – análise e revisão crítica do artigo, bem como encaminhamento para a revista. sa fe ty o f h ea lt hc ar e w or ke rs in t he c on te xt o f t he c o v id -1 9 pa nd em ic : n ur se s’ u nd er st an di ng 1 dirce stein backes https://orcid.org /0000-0001-9447-1126 universidade franciscana, santa maria, brasil backesdirce@ufn.edu.br karen ariane bär https://orcid.org /0000-0002-9573-6875 universidade franciscana, santa maria, brasil bar.karen@ufn.edu.br cristina dos santos de freitas rodrigues https://orcid.org /0000-0001-7246-8882 universidade franciscana, santa maria, brasil cristina.freitas@ufn.edu.br tanise pereira santini https://orcid.org /0000-0002-7040-2350 universidade franciscana, santa maria, brasil tanisesantini@hotmail.com maria de lurdes lopes de freitas lomba https://orcid.org /0000-0003-1505-5496 escola superior de enfermagem de coimbra, coimbra, portugal mlomba@esenfc.pt regina gema santini costenaro https://orcid.org /0000-0001-8657-2066 universidade franciscana, santa maria, brasil regina@ufn.edu.br article safety of healthcare workers in the context of the covid-19 pandemic: nurses’ understanding received: 03/03/2022 submitted to peers: 17/04/2022 accepted by peers: 28/06/2022 approved: 15/08/2022 doi: 10.5294/aqui.2022.22.4.3 para citar este artículo / to reference this article / para citar este artigo backes ds, bär ka, rodrigues csf, santini tp, lomba mllf, costenaro rgs. safety of healthcare workers in the context of the covid-19 pandemic: nurses’ understanding. aquichan. 2022;22(4):e2243. doi: https://doi.org/10.5294/aqui.2022.22.4.3 https://orcid.org/0000-0001-9447-1126 mailto:backesdirce@ufn.edu.br https://orcid.org/0000-0002-9573-6875 mailto:bar.karen@ufn.edu.br https://orcid.org/0000-0001-7246-8882 mailto:cristina.freitas@ufn.edu.br https://orcid.org/0000-0002-7040-2350 mailto:tanisesantini@hotmail.com https://orcid.org/0000-0003-1505-5496 mailto:mlomba@esenfc.pt https://orcid.org/0000-0001-8657-2066 mailto:regina@ufn.edu.br https://doi.org/10.5294/aqui.2022.22.4.3 https://doi.org/10.5294/aqui.2022.22.4.3 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2022.22.4.3&amp;domain=pdf&amp;date_stamp=2022-09-26 theme: health promotion contributions to the discipline: this study promotes innovative technologies to mediate the processes of continuing education in health. in addition to programs and policies, providing spaces for dialogue and reframing professional knowledge and practices is essential. new questions and reflections are raised aimed at innovation in nursing care in the light of complex thought. sa fe ty o f h ea lt hc ar e w or ke rs in t he c on te xt o f t he c o v id -1 9 pa nd em ic : n ur se s’ u nd er st an di ng 3 abstract objective: to understand the meaning of worker safety in healthcare during a pandemic from the perspective of nurses, based on interventions related to continuing education in health. materials and method: this action-research study is based on the constructivist paradigm. the study was conducted between august 2020 and april 2021 through open individual interviews, mediated by guiding questions without prior validation. the interviews were conducted with 19 nurse managers of inpatient units who had previously participated in a schedule of continuing education interventions in a university hospital in the south region of brazil. research data were analyzed based on minayo’s thematic content analysis. results: the research data resulted in two thematic categories: “reframing knowledge and professional practices” and “from banalization to resumption of preventive care.” the categories indicate that, in addition to specific and normative educational processes, it is necessary to promote self-reflection and individual and collective self-examination. conclusions: from the understanding of nurses, the pandemic period aroused greater reflection and self examination among nursing/health professionals, especially concerning preventive health care, which is addressed as secondary. keywords (source: decs ) nursing research; occupational health; continuing education; coronavirus; pandemic. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 43 4 resumen objetivo: comprender el significado de seguridad del profesional de salud en período pandémico desde la perspectiva de enfermeros, a partir de intervenciones relacionadas a la educación permanente en salud. materiales y método: se trata de una investigación acción fundamentada en el paradigma constructivista. el estudio se llevó a cabo entre agosto de 2020 y abril de 2021, por medio de entrevistas individuales abiertas, mediadas por cuestiones orientadoras, sin validación previa, con los 19 enfermeros gestores de unidades de hospitalización que previamente habían participado en un cronograma de intervenciones de educación permanente en salud, en un hospital de enseñanza del sur de brasil. se trataron los datos con base en el análisis de contenido temático de minayo. resultados: los datos de la investigación resultaron en dos categorías temáticas: “(re)significación de saberes y prácticas profesionales” y “de la banalización a la retomada de cuidados básicos”. tales categorías denotan que, más allá de procesos educativos puntuales y normativos, es necesario despertar la autorreflexión y autocrítica individual y colectiva. conclusiones: desde la comprensión de enfermeros, el período pandémico ha despertado mayor reflexión y autocrítica entre los profesionales de enfermería/salud, principalmente en relación con los cuidados básicos de salud, los que con frecuencia quedan relegados a un segundo plano. palabras clave (fuente: decs) investigación en enfermería; salud laboral; educación continua; coronavírus; pandemia. seguridad del profesional de salud en el marco de la pandemia de covid-19: comprensión de enfermeros sa fe ty o f h ea lt hc ar e w or ke rs in t he c on te xt o f t he c o v id -1 9 pa nd em ic : n ur se s’ u nd er st an di ng 5 segurança do trabalhador de saúde no contexto da pandemia da covid-19: compreensão de enfermeiros resumo objetivo: compreender o significado de segurança do trabalhador de saúde em período pandêmico na perspectiva de enfermeiros, a partir de intervenções relacionadas à educação permanente em saúde. materiais e método: trata-se de uma pesquisa-ação, fundamentada no paradigma construtivista. o estudo foi realizado entre agosto de 2020 e abril de 2021, por meio de entrevistas individuais abertas, mediadas por questões orientadoras, sem validação prévia, com os 19 enfermeiros gestores de unidades de internação que, previamente, haviam participado de um cronograma de intervenções de educação permanente em saúde, em um hospital de ensino do sul do brasil. os dados de pesquisa foram tratados com base na análise de conteúdo temática proposta por minayo. resultados: os dados de pesquisa resultaram em duas categorias temáticas: “(re) significação de saberes e práticas profissionais” e “da banalização à retomada de cuidados básicos”. as categorias denotam que, para além de processos educacionais pontuais e normativos, é preciso despertar a autorreflexão e a autocrítica individual e coletiva. conclusões: na compreensão dos enfermeiros, o período pandêmico despertou maior reflexão e autocrítica entre os profissionais de enfermagem/saúde, principalmente com relação aos cuidados básicos de saúde, frequentemente relegados a um segundo plano. palavras-chave (fonte: decs) pesquisa em enfermagem; segurança dos trabalhadores; educação continuada; coronavírus; pandemia. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 43 6 introduction in the context of the coronavirus pandemic (covid-19), brazil has been facing a worker safety crisis at various levels of the healthcare system. many workers spend extended periods in the workplace and, as they provide direct care to patients with the virus, become more vulnerable to risks and adverse events (1, 2). a study (3) showed that covid-19 caused intangible consequences on global health systems, the economy, daily life, education, travel, leisure, work, and health, especially for health professionals. in addition to negative impacts on the physical and mental health of nursing/health professionals, headaches were identified as one of the main symptoms associated with using personal protective equipment (ppe). due to the covid-19 pandemic, nursing workers and healthcare professionals face adverse situations that affect their physical, emotional, social, and spiritual health. besides, they must deal with direct exposure to infection, exhaustion at work, and restricted contact with family. these factors are not restricted to the individual dimension; they also interfere in decision-making and interprofessional relationships (4). therefore, the covid-19 pandemic unveiled the need to think about/rethink the work of nursing and healthcare professionals at the forefront of disease prevention programs and fighting against the most severe cases, as mentioned. among the healthcare professionals most exposed to contamination, the nursing team stands out in brazil, as 57,838 nursing professionals had died from the disease as of july 22, 2021 (5), which is a public health emergency and one of the most significant challenges to humanity and science (6). in this scenario, the world health organization and the international labour organization made recommendations to provide national and local governments, employers, and workers with practical guidance on preventing covid-19 outbreaks at work, aiming to minimize worker exposure and transmission of sars-cov-2 (7). considering the above, we wondered how nurses understand worker safety in healthcare amidst the covid-19 pandemic. therefore, this study aims to understand the meaning of worker safety in healthcare during a pandemic from the perspective of nurses, based on interventions related to continuing education in health. in this study, the pandemic will be regarded as a complex phenomenon that cannot be reduced to a predictable mathematical pattern. for edgar morin (8), author of complex thought, uncertainty, unpredictability, and contradictions are part of the human condition; thus, the author suggests solidarity and ethics as possiblepaths for reconnecting beings and professional knowledge. moreover, this study presents reflections to expand perspectives and enable new ways of thinking and acting for the nursing team. sa fe ty o f h ea lt hc ar e w or ke rs in t he c on te xt o f t he c o v id -1 9 pa nd em ic : n ur se s’ u nd er st an di ng 7 materials and method this qualitative action-research study (9) is based on the constructivist paradigm. it was conducted through continuing health education interventions in the work setting and individual interviews with nurses who had participated in these interventions. the study is part of the university research project “learning incubator,” approved by the research ethics committee with the submission for ethical appreciation certificate 11520312.3.0000.5306. the expanded research project “learning incubator” was implemented in 2012 in a university hospital in the south region of brazil with around 130 beds and 230 employees. it intended to welcome new employees and boost continuing education in health. the learning incubator is a tangible welcoming space and a teaching and learning technology capable of valuing talents, enhancing initiatives, and promoting critical-reflective thinking in the daily practice of nursing professionals (10). the first stages of action research (problem identification, survey, analysis, and meaning of the data) were conducted through interventions with the nursing team of the university hospital, between august 2020 and april 2021, and mediated by the learning incubator. the interventions identified in a previous survey with the nurses responsible for the inpatient units included correct use of ppe, donning and doffing procedures, (re)signification of hand washing, and measures to control covid-19. these interventions were organized on a timetable and conducted as previously scheduled with the nurses responsible for the inpatient units to include the most significant number of nursing professionals in each work shift. the interventions consisted of conversation circles, sharing of the participants’ practical experiences, and theoretical-practical simulations, in which the participants perceived themselves as actors of their process of reframing the practice. all interventions were promoted by university students and professors and mediated by the learning incubator. a total of 148 nursing professionals from the different hospital inpatient units actively participated in the interventions. an average of three professionals from each inpatient unit took part in each activity, according to the enrollment scale. all the interventions were in-person, observing sanitary protocols. at the end of the intervention schedule, data were collected through individual interviews with nurses who had participated in the continuing health education process. data collection did not follow a prior sampling method, as only 19 nurse managers of the institution’s inpatient units were included in this phase. the nurse managers were formally invited to the interview and responded affirmatively. nurse managers on vacation or away from work for some reason were excluded from the study. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 43 8 the interviews were conducted with the 19 nurse managers based on the following open-ended guiding questions, formulated by the researchers, with no prior validation: • tell us about your perception and evaluation of the interventions focused on the safety of the nursing worker. • what did this process awaken in you? • what has changed in your way of thinking and acting during the covid-19 pandemic? • what do you think can be different in your daily practice to ensure patient safety and yours? the interviews were conducted after the signature of the informed consent form by a researcher with experience in qualitative research, who helped guide the intervention schedule. the interviews, approximately 40 minutes long each, were recorded and subsequently transcribed for data analysis. the research data were analyzed according to minayo’s thematic content analysis technique (11), which is based on qualitative criteria systematized in three interconnected phases: description, analysis, and interpretation. the analysis process began with data collection when researchers looked for patterns of meaning and possible issues of research interest in the data. the analysis involved going back and forth from database to coded fragments to data analysis. this process culminated in data reporting. the notes taken in a field diary and the literature review were also considered. in the first stage, called “pre-analysis,” the subject matter and aims of the study were reviewed, constructing the initial analysis indicators, such as the definition of record and context units. the corpus was developed according to the validity rules: exhaustion, representativeness, homogeneity, and pertinence. in the second stage, “material exploration,” the text was broken down into units and, then, regrouped into categories of analysis according to the organization of messages and divided elements. in the third and final stage, “data processing and interpretation,” the raw data were interpreted, determining inferences of meaning that resulted in the delimitation of the final thematic categories (11). the intervention and data collection process followed the recommendations of resolution 466/2012 issued by the national health council (12). the recommendations of curricular letter 2/2021 issued by the national research ethics commission were also considered (13). the participants’ speeches were identified in the text by the letter “e” followed by a number corresponding to the order of speeches: e1, e2... e19, to maintain their anonymity. sa fe ty o f h ea lt hc ar e w or ke rs in t he c on te xt o f t he c o v id -1 9 pa nd em ic : n ur se s’ u nd er st an di ng 9 results the research data from the interviews conducted with the 19 nurse managers were organized and then analyzed based on minayo’s thematic content analysis. the analysis resulted in two thematic categories: “reframing knowledge and professional practices” and “from banalization to resumption of preventive care.” the categories show that, in addition to specific and normative educational processes, it is necessary to promote self-reflection and individual and collective self-examination. reframing knowledge and professional practices the covid-19 pandemic caused intense changes in healthcare settings. as frontline professionals, the participants of this study showed that the pandemic period aroused more reflection and self-examination among nursing/health professionals concerning knowledge and practices of health self-protection, as follows: to deal with the pandemic, i believe we must follow all the guidelines and reflect on individual and collective safety measures. we must take care of our safety first so we can take good care of patients. we all learn the right things, but they need to be put into practice. (e11) the interventions allowed discussions and personal reflections. nursing professionals who actively take part in the activities can have new perceptions and attitudes towards themselves and others. (e14) the participants’ speeches proved the importance of spaces for reflection promoted and mediated by the learning incubator. it is essential that professionals feel they are part of the work process and not mere reproducers of protocols, norms, and routines. from this approach, interventions on worker safety translated into prospective acts of self-examination of personal and collective attitudes and conduct and self-assessment of daily practices: this process aroused greater reflection on my attitudes and stands. we cannot become machines. moments of reflection and sharing make us grow and review our daily practice. theories change and need to translate into practice. (e10) in addition to a formal space for continuing education, the learning incubator allowed participants’ meaningful learning while perceiving and recognizing themselves as actors in constructing knowledge. professionals must recognize themselves as learners throughout their life, as in the following speech: learning must be continuous and permanent throughout life. there is always something to learn, and we will never know everything. each person needs to realize this, but the pandemic made us perceive this dynamic even more because we had to relearn and renew many theories in practice. (e5) it is interesting how the pandemic made us review preventive care such as hand washing. sometimes we act mechanically; we do not reflect on our actions. the pandemic made us rethink many things in our daily practice. (e9) a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 43 10 the speech of one participant demonstrated the relevance of having tangible spaces for dialogue and welcoming professionals in health institutions. this same interviewee recognizes that nursing work is technical, linear, and quotidian and demands new and continuous recreation and transformation. in this sense, continuing education in health goes beyond the idea of “passing on information” or “complying with rules and regulations” to meet legal requirements, as explained below: i increasingly realize that we need to renew the methodologies and approaches of continuing education in health. professionals can only rethink their practices when they feel part of the process, contribute ideas, and get involved. (e12) more than passing on information and following rules, continuing education involves the dynamics of life, of feeling part of the work process. work safety cannot be perceived as an external imposition but as an internal movement that starts in the conscience of each involved. (e17) based on the results presented, continuing education in health needs to promote, sensitivity, motivation, teamwork, and the desire for constant renewal, in addition to providing normative content. under this approach, stimulating work safety requires promoting self-motivation and self-awareness for unique and permanent learning, that is, throughout life. from banalization to resumption of preventive care according to the interviewees, the covid-19 pandemic favored the resumption of preventive care measures, often banalized or pushed to the background. the participants’ speech showed that reinforcing the importance of preventive care is not enough; it is also necessary to raise awareness and collaboration mechanisms that can ensure the correct and continuous use of ppe, such as face masks and others: it is difficult to define the atypical and adverse moment we are going through, in which we need continuous reinvention... every day, we have new processes. however, i think the pandemic promotes innovation and the resumption of essential care for individual and collective health. (e3) it was shown that the covid-19 pandemic reinforced the need to reframe health care, crystallized by techniques and routines. the speech of one participant indicated that health professionals easily “fall into a routine,” making the care provided technical and repetitive. another speech showed that many professionals are driven by the “norms and demands” of managers, which will not necessarily reflect in better professional practices: the pandemic allowed the resumption of elementary care measures and required new care practices that must be considered for worker safety. we cannot fall into a routine and keep providing specialized care. (e18) some professionals are driven by the demands of managers. nevertheless, these demands are no longer acceptable. many things have been banalized. i believe that professionals must be involved and actively participate in discussions and reflections. the motivation must be internal and not external. (e19) sa fe ty o f h ea lt hc ar e w or ke rs in t he c on te xt o f t he c o v id -1 9 pa nd em ic : n ur se s’ u nd er st an di ng 11 another recurring aspect is the construction of fertile environments/spaces for rethinking daily work practices. in addition to continuing education in health, it is necessary to create opportunities that welcome and encourage changes in individual and collective attitudes. it is essential that professionals feel encouraged and motivated to follow their process of rethinking health care. although this participatory intervention process has been underway for several years at the studied institution, we noted that, for some participants, interventions are a “waste of time”; that is, they still do not find meaning in this path. it is necessary to consider that continuing education in health is not an isolated and linear tool but a unique and complex process: it is necessary to raise awareness among workers who consider continuing education a waste of time. some still do not understand this dynamic, interfering in the whole process. (e1) i always wonder: “how do i reach all professionals?” i think the lack of time is related to a lack of understanding of health education dynamics. people are different and need to be regarded as different. (e7) with the expansion and institutionalization of restrictive protocols related to the covid-19 pandemic, multiple normative documents were issued, requiring even greater involvement from the nursing team. the participants realized, however, that the addition of normative documents did not necessarily lead to better work safety practices. they recognized that protocols and norms need to be accompanied by movements that allow each professional to feel part of the training course: more than making and following norms, flowcharts and protocols already well implemented and defined internally, the personal and collective awareness of those involved is necessary so that work can be done as a team. (e9) i feel that we need to reestablish some care measures that were banalized in our daily routine. this requires effort and involvement from each professional. (e12) we also noticed that interventions related to work safety are a tool to reorganize the ways of being and doing individually and collectively. participants recognize that this process will affect the service and, consequently, the welcoming and promotion of good practices in patient/user care and safety by colleagues and families: the interventions performed are crucial for the professional to realize again and again that their safety affects the safety of the patient and their family members. more than an external action, worker safety needs to be taken as a guiding principle in practice. (e13) the participants’ speech showed that the banalization of care is partly due to the approaches adopted in continuing education in health. in addition to normative training, lectures, and simulations, it is necessary to promote individual and collective self-reflection and self-examination. healthcare professionals must perceive themselves as protagonist and co-responsible for their training througha q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 43 12 out life. under this approach, worker health results from internal movements promoted and stimulated through significant spaces for teaching and learning. discussion the pandemic caused by the new coronavirus transformed all people’s lives, particularly healthcare professionals’, including the nursing team (14, 15). the pandemic also opened up possibilities for innovation and transformation, especially in professional practices crystallized by isolated and mechanical work. discussing safety in nursing/ health work under this approach reveals the need to revisit vertical and uncritical intervention approaches and explore theoretical and methodological frameworks for continuing education in health. therefore, in addition to its obvious negative repercussions, the covid-19 pandemic elicited the need for preventive care measures essential for life in society, such as hygiene, cleaning, and hand washing, among others. from morin’s understanding, one of the leading researchers of complex thought, all chaos, in this case, the ongoing pandemic, may give rise toa new order on personal, collective, and global levels (16, 17). among other purposes, complex thinking aims to question the opposition between facts and nature and encourage reflection on the meanings, values, and truths concerning science. for morin, science itself has forged, for decades, linear and simplifying logic that have disconnected the observer from the object. just as the objects were separated from their context and the observer’s reality, the disciplines were also fragmented, hindering inter-professional exchanges and dialogue between sciences (18). these and other reductions and simplifications have unified, quantified, and disregarded any “disorder” to keep health institutions’ normative and regulatory order (19). as in other areas, nursing has developed with the paradoxical belief that order needed to prevail over disorder and, just like that, any adverse advent was reduced and diverted from any interactive and (re)creative possibility. this absolute and regulatory order, generally regarded as an irrevocable truth, was expressed in caring, relating, leading, and promoting continuing education in health (20). institutionalizing this absolute and unquestionable order harmed the process of caring for and educating in health, especially in nursing. thus, everything predictably ordered and controllable was valued, contributing to leaving aside essential care. moreover, the following questions emerge: why have care measures considered essential to health and good human relationships been disregarded by nursing/healthcare professionals? what thoughts/ frameworks prevailed and were imposed in the daily life of nursing/ sa fe ty o f h ea lt hc ar e w or ke rs in t he c on te xt o f t he c o v id -1 9 pa nd em ic : n ur se s’ u nd er st an di ng 13 healthcare professionals so that fundamental care was neglected? how do we promote work safety responsibly and collaboratively? finally, what new knowledge and practices need to be revived and reframed in the daily life of nursing/health professionals in the light of novel approaches? without significant premeditation, nursing/health professionals organized and reinvented themselves in an agile and competent way in a short time, demonstrating that, disorder caused by the pandemic makes it possible to perceive outbursts, go beyond possibilities, enhance initiatives, and reframe theories and practices (21). one study showed that, beyond its adverse effects, the pandemic allowed reflections and resignifications, (re)creation of self-accomplishment strategies, and the leading role of new ventures (22). from the order-disorder-order perspective, complex thought promotes the expansion of knowledge, the connection of ideas, and the (re)signification of practices; thus, the possibility of finding new paths arises amidst uncertainty, complexity, and chaos (7). the speech “many things have been banalized. i believe that professionals need to be involved and actively participate in discussions and reflections. (e19)” indicates that, even in disorder and apparent failure, infinite possibilities for renewal emerge. understanding disorder from this approach does not mean looking at the pandemic and lamenting the lost opportunities but rather enhancing them to achieve a new and more promising social order. however, what is the new order desired for nursing/health? the covid-19 pandemic, characterized by morin as the disorder of disorder, could lead to contradictory processes, stimulating imagination and creativity in searching for innovative solutions and reactions and returning to the stability of the past. in a journal interview, morin declared that he does not know whether it is possible to expect the worst, the best, or both, but he believes that we are moving towards new uncertainties with the possibility of a new order (23). the pandemic calls us all to reflect and understand that nursing/ health science does not have a repertoire of absolute truths and lasting and unquestionable theories. instead, it invites us to reshape our thoughts and professional practice based on approaches that can question, expand, and explore new and more complex theoretical and practical interventions without deeming them as the truth or as conclusive (24). therefore, the aim here was not only to present specific answers and discussions but also to posit new questions. nursing/healthcare professionals must be open to new possibilities, use the pandemic period to reframe knowledge and practices related to care, and promote continuing education in health based on approaches that expand and instigate human thoughts. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 43 14 conclusions from the nurses’ understanding, the meaning of work safety in health during the pandemic aroused more professional reflection and self-examination, especially about preventive care, which is often neglected. in addition to resuming preventive care, such as washing hands and wearing a mask, it is also necessary to create mechanisms for raising awareness and reframing knowledge and practices. in conclusion, developing interventions to promote work safety requires much more than updating and reframing emergency norms and protocols in the context of the covid-19 pandemic. furthermore, it is necessary to create welcoming and stimulating spaces in which nursing/healthcare professionals feel comfortable and protected, recognized in their abilities, and strengthened in their convictions. in turn, a limitation of this study is the collection of data in a single hospital institution with only 19 nurse managers of the inpatient units. another limitation is associated with a lack of studies on the safety of health workers during a pandemic, which made it difficult to compare the results with earlier research. conflict of interest: none to declare. references 1. remuzzi a , remuzzi g. covid-19: protecting health-care workers. the lancet. 2020;395(10228):922. doi: https://doi. org /10.1016/s0140-6736(20)30644-9 2. michaels d, wagner gr. occupational safety and health administration (osha) and worker safety during the covid-19 pandemic. jama . 2020;324(14):1389-90. doi: https://doi. org /10.1001/jama.2020.16343 3. romero jgaj, salles-neto ft de, stuginski-barbosa j, conti pcr, almeida-leite cm. covid-19 pandemic impact on headache in healthcare workers: a narrative review. headache medicine. 2021;12(2):75-82. doi: https://doi.org /10.48208/headachemed.2021.17 4. teixeira cf de s, soares cm, souza ea , lisboa es, pinto icm, andrade lr et al. a saúde dos profissionais de saúde no enfrentamento da pandemia de covid-19. ciênc. saúde coletiva. 2020;25(9):3465-74. doi: https://doi.org /10.1590/141381232020259.19562020 5. duprat ip, melo gcm. análise de casos e óbitos pela covid-19 em profissionais de enfermagem no brasil. rev. bras. saúde ocup. 2020;45:e3045. doi: https://doi.org /10.1590/23176369000018220 6. world health organization. clinical management of severe acute respiratory infection (sari) when covid-19 disease is suspected [on-line]. available from: https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf 7. world health organization (who) and international labor organization. covid-19: occupational safety and health for healthcare professionals [on-line]. geneve; 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2001. 19. backes ds, zamberlan c, colomé j, souza mt, marchiori mt, erdmann al et al. systemic interactivity between interdependent concepts of nursing care. aquichan. 2016;16(1):24-31. doi: https://doi.org /10.5294/aqui.2016.16.1.4 20. backes ds, santini t, freitas cs, naujorks a a , backes mts, büscher a . the learning incubator: an innovative teaching and learning technology in nursing. rev esc enferm usp. 2021;55:e20200048. doi: https://doi.org /10.1590/1980-220xreeusp-2020-0048 21. osingada cp, porta cm. nursing and sustainable development goals (sdgs) in a covid‐19 world: the state of the science and a call for nursing to lead. public health nurs. 2020;37(5):799805. doi: https://doi.org /10.1111/phn.12776 22. lovato czl, dellazzana-zanon sm, wechsler rrf. covid-19: implications and applications of positive psychology in times of pandemic. estud. psicol. 2020;37. doi: https://doi. org /10.1590/1982-0275202037e200072 23. lecompte f. uncertainty is intrinsic to the human condition. [on-line]. 2020 [21 screens]. available from: https://news.cnrs.fr/ articles/uncertainty-is-intrinsic-to-the-human-condition 24. backes ds, malgarin c, erdmann al, büscher a . nursing now and nursing in the future: the experience of the unexpected irruptions. rev. latino-am. enfermagem. 2021;29:e3453. doi: https://doi.org /10.1590/1518-8345.4826.3453 https://doi.org/10.1136/bmj.m2641 https://doi.org/10.1177/135050849853003 https://doi.org/10.1016/j.leaqua.2019.07.002 https://doi.org/10.1016/j.leaqua.2019.07.002 https://doi.org/10.5294/aqui.2016.16.1.4 https://doi.org/10.1590/1980-220x-reeusp-2020-0048 https://doi.org/10.1590/1980-220x-reeusp-2020-0048 https://doi.org/10.1111/phn.12776 https://doi.org/10.1590/1982-0275202037e200072 https://doi.org/10.1590/1982-0275202037e200072 https://news.cnrs.fr/articles/uncertainty-is-intrinsic-to-the-human-condition https://news.cnrs.fr/articles/uncertainty-is-intrinsic-to-the-human-condition https://doi.org/10.1590/1518-8345.4826.3453 01. prom.de la salud (9 a 15) resumen la actual política social de corte neoliberal ha dado origen a la ley 715 de 2001, que distribuye los recursos para educación y salud en un contexto de disciplina fiscal y recorte al gasto público, (re)definiendo la reasignación de recursos de la nación a los entes territoriales. dicha ley se queda corta en materia de indicadores socioeconómicos, así como de acciones en promoción de la salud y prevención de la enfermedad, al poner énfasis en tan solo unos programas del plan obligatorio de salud y al desconocer en la reasignación de recursos a los entes territoriales el retroceso en indicadores socioeconómicos y de desarrollo humano para colombia. palabras clave: ley 715 de 2001, política de salud, promoción de la salud, prevención de la enfermedad. abstract the current neo liberal social policy has given origin to law 715 of 2001, which distributes the resources for education and health in a context of fiscal discipline and decrease of public expenses, defining the assignation of resources of the nation. such law is short in socioeconomic indicators, and actions of health promotion and prevention of disease, making emphasis only on some programs of obligatory health program and ignoring the assignation of resources to departments of socio economic and human development indicators for colombia. key words: law 715 of 2001, health policy, health promotion, disease prevention. 9 edilma m. suárez c. enfermera, magíster en administración en salud. magíster en estudios políticos. docente, facultad de enfermería, universidad javeriana. contexto socioeconómico la globalización, junto con la nueva etapa de acumulación de capital, “el neoliberalismo”, ha generado reformas estructurales en todos los sectores de la vida nacional. en el caso de colombia, estas reformas consistieron en: “disciplina fiscal, recortes al gasto público, reforma tributaria, liberalización financiera, un tipo de cambio competitivo, liberalización del comercio, inversión extranjera directa, privatización de las empresas estatales, desregulación y la protección a los derechos de propiedad” (1). ciertamente, la reforma que ha tenido mayor impacto en la sociedad colombiana ha sido la reducción del gasto público, junto con la modernización del estado, es decir, la reducción de sus funciones, ante el argumento de una mayor eficiencia del sector privado frente al sector público. es así como doce años después de la implantación del modelo de corte neoliberal en el país, los resultados obtenidos no podrían ser peores, mucho más si se comparan con los obtenidos en la década de los años 80, conocida como la década perdida. pues bien, en el componente social, la situación de colombia en esta década parece algo exitosa: evitó los grandes disbalances macroeconómicos que caracterizaron a los países de la región, y la nación experimentó, después de chile, el ritmo más alto de crecimiento económico durante las dos últimas décadas; por esta razón, se pudo evitar el aumento en la pobreza y el deterioro en la distribución del ingreso, que experimentaron otros países en la región (13). sin embargo, durante la década de los años 90 los indicadores sociales no han avanzado y, lo que es peor, algunos han retrocedido dos décadas, como ocurre con el índice de pobreza para colombia. en efecto, la pobreza medida por necesidades básicas insatisfechas –nbi– se redujo de 70,2% en 1973 a 32,2% en 1993. sin embargo, para el año 2002 “la pobreza cobija al 64% de la población, 27 millones de habitantes”3; el 59,8% de la población se encuentra por debajo de la línea de pobreza y el 23,4% está por debajo de la línea de indigencia (once millones), mientras que hace diez años era del 20%. asimismo, la pobreza en el campo es del 82,6% y el grado de indigencia, del 40%4. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 10 1. si bien es cierto que durante la década de los 90 se incrementaron los recursos para salud hasta un 11% del pib, también lo es que gran parte de estos recursos se han quedado en los bolsillos de las empresas aseguradoras, quienes para ampliar su margen de utilidad han impuesto medidas de contención de costos, que atentan contra la salud de la población. 2. estas empresas sociales del estado son instituciones prestadoras de servicios de salud de carácter estatal, que se han convertido en empresas autofinanciables, en el marco de la descentralización y modernizacón del estado. 3. “colombia tiene recursos para reducir la pobreza, afirma el banco mundial”. en el tiempo, 8 de mayo de 2002. 4. “la problemática social que recibe el próximo gobierno”. en el tiempo, 15 de junio de 2002. a ley 715 de 2001 es un componente más de la actual política de salud, que profundiza las medidas neoliberales en materia de política social y de ajuste fiscal y responde a exigencias de los organismos de financiación internacional, como el fondo monetario internacional y el banco mundial. por lo tanto, con esta ley el avance en indicadores de salud y mejora de la calidad de vida de la población no es muy claro a corto y mediano futuro, teniendo en cuenta la reducción de los recursos económicos1 y humanos destinados a los servicios de salud y la falta de claridad en la implementación de nuevas leyes. la ley 715 de 2001 regresa acciones de promoción de la salud y prevención de la enfermedad a los entes territoriales, decisión que es aplaudida desde la crisis que vive la red hospitalaria pública; sin embargo, las autoridades sanitarias exigen metas de cobertura a las empresas sociales del estado2 –ese–, que bajo la actual crisis hospitalaria tienen serias restricciones para ampliar la infraestructura y el recurso humano en salud, y de esta manera cubrir una mayor demanda de servicios. por otra parte, con la reasignación de los programas de promoción de la salud y prevención de la enfermedad se desarticula y desconcentra la prestación de servicios, por lo que los usuarios deben acudir a diferentes instituciones prestadoras de servicios de salud para acceder a los programas y servicios requeridos, lo que le genera a la población mayores barreras al acceso, por la desinformación, el incremento en los costos de transporte y las largas filas para lograr la facturación en cada centro de atención. por lo tanto, el presente artículo contextualiza la ley 715 de 2001 en el ambiente socioeconómico imperante en el país desde comienzos de la década de los 90, ubica la política de salud dentro de las exigencias de la nueva política social neoliberal y analiza las implicaciones de estos determinantes políticos en la promoción de la salud y la prevención de la enfermedad en el sector de la salud. introducción promoción de la salud y prevención de la enfermedad 11 en relación con la distribución del ingreso en colombia, en 1978 el decil más rico de la población recibía el 47,9% de los ingresos totales, mientras que las personas de los estratos medio y medio alto recibían el 12,4%; en 1995 esa proporción se había elevado, para el decil más rico, a 51,0% (13). después de doce años de implantación del modelo hay una grave concentración en el mercado de capitales: las diez empresas más grandes absorben el 75% del negocio, y el ingreso se concentra en los tres centros de producción del país –bogotá, antioquia y valle del cauca–; la propiedad del 53% de la tierra está en manos del 1,08% de la población, mientras que hace diez años el 1,4% de esta controlaba el 46% del territorio, es decir, que colombia ha retrocedido diez años en concentración de la riqueza5. la exclusión social ha llevado a que 2,5 millones de niños no puedan acceder a la educación, y el analfabetismo llega al 8% de la población mayor de 15 años –un incremento de tan solo 4% en casi 20 años, según cifras de 1985–. al finalizar el gobierno de pastrana, la cobertura educativa fue muy precaria, pues “alrededor de 270.000 niños accedieron a la escuela con los programas de ampliación de la cobertura, según el ministro de educación de la época, francisco lloreda, pero sin llegar a las aulas continúan 2.500.000 menores en todo el país, un índice alto frente a 7.500.000 niños y jóvenes escolarizados”6. el desempleo alcanzó en el año 2000 el 17,9%, especialmente en mujeres y jóvenes, es decir, 3.560.000 colombianos están desocupados, mientras que los empleados suman 16,4 millones7. en tanto la cifra de población empleada se reduce, se incrementa la de subempleados, que según el diario el tiempo pasó de 31,6% en el año 2001 al 34% en el 20028. se han obtenido buenos resultados en materia de ampliación de servicios: el acueducto pasó de 60% al 79%; el alcantarillado, del 50% al 60%; de ocho líneas telefónicas por cada 100 mil habitantes se pasó a 23; en menos de diez años, los usuarios del gas natural pasaron de 300 mil a 2,4 millones; sin embargo, continúa el calvario con los servicios públicos9, debido a que entre 1990 y 2001 el precio real de la energía subió por encima del 84%, y se acerca el desmonte del sistema de subsidios en la población de menores ingresos. a la ya crítica situación social hay que sumarle el desplazamiento que sufre el país, ocasionado en su mayoría por el conflicto armado, que afecta con mayor intensidad los departamentos de cundinamarca, bolívar, antioquia, santander, norte de santander, valle del cauca y córdoba. el desplazamiento se ha incrementado desde 1985, contabilizando que desde esta fecha, hasta 1994, afectó a 700.000 personas; entre 1995 y 1999, esta cifra superó el millón (89.000 en 1995, 181.000 en 1996, 257.000 en 1997, 308.000 en 1998 y 225.000 entre enero y septiembre de 1999), para un total de 1.843.000 colombianos desplazados por el conflicto armado entre 1985 y 199910(4). durante los últimos quince años, uno de cada cuarenta colombianos ha sido desplazado. las mujeres y los niños han sido los más afectados; en 1996, las mujeres desplazadas representaban el 53%, y los hombres el 47% del total de la población desplazada; asimismo, el 31% de las mujeres eran jefes de hogar11. en la actualidad, las familias desplazadas con mujeres jefes de hogar son el 44,1%12, situación que incrementa el riesgo de enfermar y morir para toda la familia. por otra parte, la deuda externa del país con los organismos de financiación internacional crece cada vez más, a tal punto de que para el año 2000 se encontraba en us$ 36.000 millones, que equivalían al 36% del pib; en el año 2001 llegó a us$ 38.752, debiendo destinar el país 47% del pib, y en el año 2002 representó el 54,2% del pib13. el incremento de la deuda externa, junto con los intereses y exigencias de las agencias de financiación, han propiciado permanentes recortes en inversión pública y han exigido a los países reformas en materia fiscal, como ocurre en colombia con la iniciativa del referendo, que busca la profundización en las ya continuas reformas fiscales, perpetuando la inequidad y la crisis social. pues bien, bajo este contexto socioeconómico surgen el acto legislativo 012 y la ley 715 de 2001, el primero como una reforma a la constitución de 1991, que proclama a colombia como un estado social de derecho, y la segunda como una ley que reforma la ley 60 de 1993 y que está por encima de la ley 100 de 1993. por lo tanto, la 715 de 2001 es una ley que 5. ibíd. 6. “retrovisor a los tres años del presidente pastrana”. en el colombiano, martes 18 de junio de 2002. 7. “desempleo récord de 17,9%”. en el tiempo, domingo 3 de marzo de 2002. 8. “subempleo aumenta de 31,6% al 34% en marzo”. el tiempo, martes 2 de abril de 2002. 9. “el calvario de los servicios públicos”. el tiempo, domingo 31 de marzo de 2002. 10. codhes. un país que huye, santa fe de bogotá, http://www.codhes.org.co. 11. conferencia episcopal colombiana. boletines de codhes y sisdes, no. 1 (agosto 2 de 1996) y no. 2 (septiembre 10 de 1996). citado por rafael rueda, 30 de mayo a 2 de junio de 2000. 12. defensoría del pueblo. tomado de el tiempo, 23 de abril de 2000, p. 14b, citado por rafael rueda bedoya, santa fe de bogotá, 30 de mayo de 2000. 13. colombia, “deuda pública y sostenibilidad fiscal”. en: informe de la junta directiva del banco de la república al congreso, marzo de 2002, p. 44. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 12 distribuye los recursos destinados a educación y a salud, y que está en concordancia con la política social neoliberal de recorte a la inversión social14. la política de salud asa cristina laurell15, en su artículo la política de salud en el contexto de las políticas sociales, hace una descripción acertada de la actual política de salud, en los siguientes términos: la política de salud concreta, que se desprende de la política social neoliberal, tiene dos grandes ejes: la mercantilización de la gestión del financiamiento y de la prestación de los servicios de salud, y la reducción de los servicios públicos gratuitos a un paquete mínimo de servicios esenciales para los comprobadamente pobres (10). en colombia, la implementación de esta política social neoliberal en materia de salud se inició con la constitución nacional de 1991 y la ley 100 de 1993. en el caso de la constitución nacional, se establece el derecho de la población al aseguramiento, en lugar del derecho a la salud, y se legitima la intervención de la empresa privada. con la ley 100 de 1993, que introduce reformas estructurales en el sector, se reduce la intervención del estado a un plan de atención básica y se deja en manos de las empresas privadas la administración y prestación de los servicios de salud por la vía del aseguramiento. asa cristina, en otro artículo, que titula la salud: de derecho social a mercancía16, analiza la política de salud propuesta por el banco mundial en su informe sobre el desarrollo mundial 1993. invertir en salud, señalando que este informe obedece a dos objetivos: “el primero compatibiliza la salud con la doctrina neoliberal, que ubica a la salud principalmente en el ámbito privado y solo bajo ciertas condiciones como tarea pública. y el segundo, que adecua el gasto público, incluyendo salud”. es en este marco donde se ubica la ley 715 de 2001, en especial en el contexto de los compromisos derivados de la deuda externa y ante la necesidad de nuevos préstamos y exigencias de las agencias de financiación internacional. ante esta situación, el gobierno de andrés pastrana firmó un acuerdo con el fondo monetario internacional (fmi), que establecía la política económica para los años 1999 a 2002, fijando metas para cada año y estableciendo un sistema de monitoreo del fmi al país. entre los diferentes compromisos acordados se encuentra la presentación al congreso de las siguientes iniciativas: “un proyecto de reforma de segunda generación a la seguridad social que modifique la ley 100, un proyecto de creación de un fondo pensional de las entidades territoriales y un proyecto de reforma constitucional para desatar las transferencias a los entes territoriales de los ingresos corrientes del gobierno central, (...)” (12). es así como este acuerdo dio origen al acto legislativo 012 de 2000 y la ley 715 de 2001. el acto legislativo reformó la constitución, al cambiar el sistema de transferencias a los entes territoriales, determinando una cantidad de los ingresos corrientes de la nación, que permanece fija en términos reales; es decir, las transferencias crecerán en relación directa con el producto interno bruto, la inflación, los reajustes tributarios y el recaudo de impuestos (9). esto fue posible con la modificación de los artículos 356, 357, 358 y 359 de la constitución nacional de 1991, que establecían el situado fiscal destinado a los departamentos y las transferencias a los municipios. según iván jaramillo, con esta reforma constitucional el estado conseguirá ahorrar $ 1,23 billones anuales y reducir las expectativas de expansión del gasto social en $ 1.227.926 millones de pesos anuales, reducción que traerá como consecuencia la limitación en 2.128.405 afiliaciones al régimen subsidiado de salud y la disminución de 1.252.000 cupos en las escuelas públicas (16). con la aprobación del acto legislativo 012/2000 se facilita la creación de la ley 715 de 2001, que reforma las leyes 10 de 14. el recorte en inversión social tiene dos explicaciones: por una parte, está relacionado con la modernización del estado y la reducción de sus funciones en el contexto de la lógica neoliberal. la segunda explicación se relaciona con la creciente deuda externa y los acuerdos suscritos entre colombia y el fondo monetario internacional para cumplir con el pago de los compromisos crediticios. 15. profesora-investigadora de la maestría de medicina social, uam-xochimilco. 16. publicado en nuevas tendencias y alternativas en el sector salud, fundación friedrich ebert. la política de salud concreta, que se desprende de la política social neoliberal, tiene dos grandes ejes: la mercantilización de la gestión del financiamiento y de la prestación de los servicios de salud, y la reducción de los servicios públicos gratuitos a un paquete mínimo de servicios esenciales para los comprobadamente pobres. promoción de la salud y prevención de la enfermedad 13 1990, 60 de 1993 y 100 de 1993. esta ley no solo determina las competencias de la nación, los departamentos y los municipios en el sector salud, sino que al transferir de las administradoras de régimen subsidiado (ars) a los entes territoriales los programas de vacunación, atención en planificación familiar y detección temprana del cáncer de cuello uterino, se visibiliza el poco interés que tienen las empresas aseguradoras en este tipo de programas, al considerarlos como no rentables y desconocer el efecto positivo que generan en la población y en el sistema de salud. ahora, si bien es cierto que la transferencia de algunos programas de promoción de la salud y prevención de la enfermedad tienen un efecto positivo para la red pública, es decir para las ese, al trasladarles el porcentaje de recursos destinado a estos programas, también lo es que, dadas las restrictivas condiciones económicas de estas entidades, se hace difícil el cumplimiento de las elevadas metas impuestas, ante la necesidad de ampliación en la infraestructura y recurso humano para la nueva demanda de servicios y el bajo costo que reciben por actividad –que para este año se aproxima a $ 4.800–. asimismo, resulta poco efectivo que se pretenda fortalecer los programas de promoción y prevención en los entes territoriales, con la condición del logro de las metas o la no transferencia de los respectivos recursos, cuando en por lo menos ocho o más años no se ejerció ningún tipo de vigilancia, control y/o sanción a las empresas aseguradoras responsables de estos programas17. además, el paso de los programas de promoción y prevención a las ese ha generado mayor demanda de estos, mayor congestión, por las largas filas de espera que tienen que hacer los usuarios para facturar los servicios, y la desarticulación de los programas. por ejemplo, si se detecta displasia cervical en la toma de la citología, se remite a la paciente (usuaria) a su aseguradora, pero se desconoce si ella acude a su entidad de salud y si recibe tratamiento. en el caso del examen de seno, pese a que se encuentra en la norma técnica18, como no hace parte de los servicios que son facturados y pagados no se realiza, lo cual es insólito si se tiene en cuenta que en los dos últimos años se ha incrementado la muerte de mujeres por cáncer de seno. por otra parte, dadas las actuales condiciones socioeconómicas que vive la población y que ya han sido descritas, se observa cómo la ley 715 de 2001 se queda corta para responder y aportar al mejoramiento de la calidad de vida de la población. la promoción de la salud y la prevención de la enfermedad ahora bien, para comprender la promoción de la salud en la ley 715 de 2001, es imprescindible citar la primera conferencia internacional en ottawa, canadá, en el año 1986, que estableció como política la promoción de la salud a través de la creación de políticas públicas saludables, creación de ambientes favorables, el reforzamiento de la acción comunitaria, el desarrollo de aptitudes personales y la reorientación de los servicios de salud (15). y es necesario ubicarla doce años después, en 1998, en la propuesta de la organización mundial de la salud, que determinó cinco prioridades para trabajar en promoción de la salud (15): • promover la responsabilidad social por la salud. • aumentar la capacidad de las comunidades y habilitar al individuo. • ampliar y consolidar las alianzas estratégicas en pro de la salud. • aumentar las inversiones en el desarrollo sanitario. • garantizar la infraestructura necesaria para la promoción de la salud. pues bien, como se observa, la promoción de la salud requiere de un trabajo intersectorial, interinstitucional e interdisciplinario, y no únicamente de las acciones del sector salud y de sus profesionales. sin embargo, pareciera que la promoción de la salud y la prevención de la enfermedad han sufrido transformaciones conceptuales y prácticas en la actual política de salud en colombia, ya que en una revisión en la hoja electrónica del departamento nacional de planeación se encontró la siguiente definición de promoción y prevención en el sistema general de seguridad social en salud (sgsss)19: el sgsss contempla la promoción de la salud como el conjunto de actividades, procedimientos, intervenciones y guías de atención de carácter educativo e informativo, individual o colectivo, tendientes a crear o reforzar conductas y estilos de vida saludables, y a modificar o suprimir aquellas que no lo sean; a informar sobre riesgos, factores, protectores, enfermedades, servicios de salud, derechos y deberes de los ciudadanos en salud, como también a promover y estimular la participación social en el manejo y la solución de sus problemas. 17. ver revista salud colombia: www.saludcolombia.com/actual/salud50htm. 18. por la resolución 412, de febrero 25 de 2000, el entonces ministerio de salud estableció las actividades, procedimientos e intervenciones de demanda inducida y obligatorio cumplimiento, y adoptó las normas técnicas y guías de atención para el desarrollo de las acciones de protección específica y detección temprana, y la atención de enfermedades de interés en salud pública. 19. http://www.dnp.gov.co/02_sec/salud/salud.htm. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 14 la prevención de la enfermedad se relaciona con todas aquellas actividades, procedimientos, intervenciones y guías de atención cuya finalidad es actuar sobre los factores de riesgo o condiciones específicas presentes en el individuo, la comunidad o el medio ambiente y que determinan la aparición de la enfermedad. esta concepción, centrada en la modificación de los estilos de vida, desconoce que el derecho a la salud y, por lo tanto, la promoción de la salud tienen relación con el aseguramiento de los derechos económicos, sociales y culturales que colombia se comprometió a garantizar de forma gradual en la década de los 60. sin embargo, este compromiso histórico parece cambiar con la nueva política social neoliberal y las reformas a la salud pública; por lo tanto: la llamada “nueva salud pública” tiende a centrarse en la elaboración y realización de programas de prevención de la enfermedad y promoción de la salud, destinados fundamentalmente a la modificación de conductas “poco saludables” de los “estilos de vida”, aunque también, al menos en teoría, a la introducción de cambios medioambientales y sociales no relacionados directamente con el sistema sanitario (8). en este sentido, menciona rafael huertas que se hace una utilización perversa del concepto “estilos de vida”, que lleva a responsabilizar y culpabilizar a la persona por estar enferma, desconociendo el contexto en el que vive. esto reafirma una vez más el planteamiento de asa cristina, al mencionar que la actual política de salud determina que “el bienestar social es una responsabilidad individual, que pertenece al ámbito de lo privado, y, por lo tanto, la satisfacción de las necesidades sociales debe resolverse en la familia o en el mercado” (10). se entiende, entonces, que un modelo de salud caracterizado por el aseguramiento, como ocurre en nuestro país, sea uno de atención de la enfermedad, en el que el sujeto compra un seguro para recibir los beneficios cuando pierde su salud, es decir, asegura un evento, como cuando compra un seguro para el carro; por lo tanto, es un modelo en el que la enfermedad es rentable. ¿o cómo podría entenderse la ausencia de acciones de promoción de la salud y prevención de la enfermedad por parte de las aseguradoras (empresas promotoras de salud, administradoras de régimen subsidiado e inclusive administradoras de riesgos profesionales)? en conclusión, la actual política social neoliberal propicia una legislación restrictiva en promoción de la salud y no favorece el trabajo en las cinco prioridades propuestas por la oms, y es también un llamado de atención a quienes elaboran las leyes, para que tengan en cuenta que la promoción y prevención no son de interés y responsabilidad única del sector salud, y que si bien este sector hace un gran aporte, se requiere de condiciones necesarias y de voluntad política para que sean efectivas y tengan un real impacto en la calidad de vida de la población; de lo contrario, continuarán siendo acciones desarticuladas. finalmente, puede decirse que en el país falta una política clara de promoción de la salud y prevención de la enfermedad y, por supuesto, una legislación coherente con la situación socioeconómica de la población colombiana. la llamada “nueva salud pública” tiende a centrarse en la elaboración y realización de programas de prevención de la enfermedad y promoción de la salud, destinados fundamentalmente a la modificación de conductas “poco saludables” de los “estilos de vida”. promoción de la salud y prevención de la enfermedad 15 bibliografía 1. ahumada, consuelo. “política social y reforma de salud en colombia”. en: revista papel político, nº 7, bogotá, abril de 1998, pp. 9-35. 2. ahumada, consuelo. el modelo neoliberal y su impacto en la sociedad colombiana, áncora editores, 3ª. reimpresión, bogotá, 2000. 3. codhes. un país que huye, santa fe de bogotá, http://www.codhes.org.co. 4. codhes. desplazados: lógicas de guerra, incertidumbres de paz, santa fe de bogotá, mayo 30 de 2000. 5. colombia. departamento nacional de planeación. información sectorial: salud, bogotá, 2003. http://www.dnp.gov.co/02_sec/salud/salud.htm 6. colombia. informe de la junta directiva del banco de la república al congreso de la república, julio de 2002. en: http://www.banrep.gov.co/ junta/congreso-jul2002.pdf. 7. constitución política de colombia, 1991. 8. huertas, rafael. “los informes del banco mundial”. en: neoliberalismo y políticas de salud, españa, editorial el viejo topo, 1998, p. 61. 9. jaramillo, iván. “el acto legislativo 012 de 2000. recorte o desaceleración en la política social y en la descentralización”. en: revista “http://www.saludcolombia.com”, no. 57, 2000. 10. laurell, asa cristina. “la política de salud en el contexto de las políticas sociales”. en: revista nueva gaceta, segundo semestre, año 1, no. 1, 2000, p. 44. 11. laurell, asa cristina. “la salud: de derecho a mercancía”. en: nuevas tendencias y alternativas en el sector salud, fundación friedrich ebert. http://www.boletinaps.org. 12. “memorando de políticas con el fmi”. en: revista dinero, nº 99, bogotá, diciembre 17 de 1999, pp. 62-71. 13. ocampo. j. a.; pérez, m. j.; tovar, c. e., y lasso, f. j. macroeconomía, ajuste y equidad en colombia. 1978-1996. documento preparado para el proyecto pnud-cepal-bid sobre política macroeconómica y pobreza en américa latina, 1996, p.5. 14. ocampo, josé antonio. colombia y la deuda externa, bogotá, tercer mundo editores, fedesarrollo, 1ª. edición, 1988. 15. ops. promoción de la salud: una antología, washington, publicación científica no. 557, 1996. 16. “con la reforma de la ley 60 se replantea todo el sector salud”. en: revista salud colombia, nº 57, bogotá. www.saludcolombia.com. 77 sara barrios-casas1 tatiana paravic-klijn2 aplicación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado 1 doctora en enfermería. universidad de la frontera, temuco, chile. sbarrios@ufro.cl 2 doctora en enfermería. académica, universidad de concepción, facultad de medicina, departamento de enfermería, concepción, chile. tparavic@udec.cl recibido: 10 de septiembre de 2010 aceptado: 23 de marzo de 2011 resumen la violencia es un fenómeno que involucra a seres humanos en diversas circunstancias y entornos, afectando la salud, el desarrollo social y económico de sectores de la población y a instituciones sanitarias. investigación cuantitativa descriptiva correlacional transversal, cuyos objetivos fueron: validar los factores del modelo de chappell y di martino en los usuarios hospitalizados, medir la violencia que estos perciben hacia ellos y construir una escala para medir violencia en el contexto hospitalario. la muestra no probabilística estuvo conformada por 510 usuarios hospitalizados durante el 2008, a quienes previo consentimiento informado se les aplicó el instrumento, que fue confeccionado y validado por las autoras. entre los resultados se encontró que al aplicar la escala de percepción de violencia, el 100 % de los usuarios manifestaron percibir violencia en las diversas dimensiones. las variables significativas en la percepción de violencia fueron: edad, sexo, previsión, situación laboral, ingreso familiar, calidad de atención, antecedentes de violencia en la adultez, consumo de alcohol, agente agresor, recursos humanos y físicos. se concluye que el modelo interactivo de violencia laboral de chappell y di martino tiene aplicación en los usuarios en ambientes hospitalarios, ya que las variables que componen los factores también se presentan en estos contextos de salud. palabras clave derechos de los pacientes, violencia, atención de salud, validación, enfermería. (fuente: decs). año 11 vol. 11 nº 1 chía, colombia abril 2011 l 77-93 78 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 application of the chappell and di martino model of violence at work to hospitalized users abstract violence is a phenomenon that affects human beings in different circumstances and surroundings, influencing health, the social and economic development of population groups, and health-care institutions. method: a descriptive, correlational, cross-sectional, quantitative study was done to validate the factors of the chappell and di martino model in hospitalized users, to measure the violence they perceive as being directed towards them, and to construct a scale for measuring violence in the hospital context. it featured a non-probability sample comprised of 510 hospital users in 2008, who gave prior informed consent to application of the instrument, which was designed and validated by the authors. in terms of the results, application of the violence perception scale showed 100% of the users indicated having perceived violence in various dimensions. the significant variables in violence perception were age, gender, sensation, job situation, family income, quality of care, history of violence in adulthood, alcohol consumption, aggressor agent, and human and fiscal resources. it was concluded chappell and di martino’s interactive model of violence at work is applicable to users in hospital environments, since the variables that comprise the factors also are found in these health-care contexts. key words patient’s rights, violence-health care, validation, nursing (source: decs). aplicação do modelo de violência no trabalho de chappell e di martino adaptado para o usuário hospitalizado resumo a violência, um fenômeno que envolve seres humanos em várias circunstâncias e ambientes, afeta a saúde, o desenvolvimento social e econômico de setores da população, e as instituições de saúde. método: pesquisa quantitativa descritiva, transversal, correlacional, cujos objetivos foram: validar os fatores do modelo de carvalho e di martino nos pacientes hospitalizados, medir a violência percebida contra eles e construir uma escala para medir a violência no hospital. a amostra não aleatória constou de 510 pacientes internados em 2008. depois assinar o consentimento informado, se lhes aplicou o instrumento elaborado e validado pelas autoras. os resultados mostraram que ao aplicar a escala de percepção da violência, 100% dos usuários percebem a violência expressa em várias dimensões. as variáveis 79 aplicación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado l sara barrios-casas, tatiana paravic-klijn significativas na percepção da violência foram: idade, sexo, segurança social, situação de emprego, renda familiar, qualidade de atendimento, história de violência na fase adulta, consumo de álcool, agente agressor, recursos humanos e físicos. concluímos que o modelo interativo de violência no trabalho de chappell e di martino pode aplicar-se aos usuários em ambientes hospitalares, porque as variáveis que compõem os fatores também se acham nestes contextos de saúde. palavras-chave direitos dos doentes, violência, atendimento de saúde, validação, enfermagem. (fonte: decs). 80 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 introducción la violencia se ha convertido en un problema para la salud pública debido a la magnitud que ha alcanzado en las últimas décadas. millones de personas mueren cada año por causas atribuibles a este fenómeno, y la mortalidad representa solo la parte más visible, ya que por cada muerte violenta se producen cientos de lesiones de diversa gravedad (1). por tanto, el estudio de la violencia interesa por su efecto deletéreo en las condiciones generales de salud y bienestar de la población (2). de todos los cambios del estado de salud debidos a las variaciones de las condiciones del medioambiente que se produjeron a lo largo del siglo xx, uno de los más complejos y profundos ha sido el aumento de la violencia (3). tanto desde el punto de vista individual, como desde la perspectiva de la salud pública, su carga ha experimentado un incremento espectacular, que afecta no solo el bienestar de los perjudicados, sino también a los servicios de la atención en salud que deben prestar cuidados y tratamientos. el hospital, además de ofrecer atención sanitaria, se constituye en un sistema social complejo y delicado, en el cual la presencia de multiplicidad de personas con distintos roles, como profesionales, técnicos, pacientes, alumnos, familiares, entre otros, conforman una red interactiva que puede inducir a desarrollar o modificar actitudes (4) que pueden llevar a hechos violentos. en dicha realidad, los pacientes receptores de los servicios sanitarios pueden ser violentados a través de variadas manifestaciones que vulneran sus derechos, los que muchas veces no son solamente ignorados por los dispensadores de la atención de salud, sino también por los mismos usuarios. es una atención que ha priorizado la tecnificación y los conocimientos teóricos que, aunque son elementos importantes en la atención en salud, no son suficientes si se vulneran los derechos a una atención basada en el trato humano, lo que permite otorgar ciertamente no sólo una mejor atención, sino un cuidado más digno (5). en esta realidad, la enfermera y el equipo de salud tienen un papel trascendental en la promoción de los ambientes libres de violencia (6). diversos autores señalan que la violencia la constituyen incidentes en donde se abusa de las personas a través de amenazas y conductas ofensivas en diferentes circunstancias (7, 8). di martino et al. (9) la definen como una forma negativa de conducta en la relación entre dos o más personas, caracterizada por agresividad con daños en la seguridad, la salud y el bienestar de empleados en su lugar de trabajo. para efectos de esta investigación, el referente teórico es el modelo de violencia laboral de chapell y di martino adaptado al usuario hospitalizado (10), que esquematiza los factores de riesgo que pueden desencadenar un episodio de algún tipo de violencia, ya sean estos factores individuales, sociales o ambientales, que se encuentran presentes en mayor o menor cantidad en una situación de violencia que provienen del agresor o victimario, de la víctima y del medioambiente en que se desarrollan las acciones. 81 aplicación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado l sara barrios-casas, tatiana paravic-klijn a través de este modelo se puede observar el fenómeno de la violencia, comprender su naturaleza polifacética y el alcance global que genera en la sociedad, involucrando a las instituciones de salud, en donde hay interacción de diversos agentes (usuarios, equipo de salud, familia), factores individuales (biodemográficos, salud, personales) y laborales de riesgo (ambientales, institucionales, grupos de vulnerabilidad). la interacción de estos factores podría tener consecuencias en la víctima, y la institución de salud en la cual se encuentra hospitalizado el usuario puede influenciar diversas formas en el proceso de salud / enfermedad, así como presentar disminución en la calidad de la atención, un ambiente de estrés y una evaluación negativa por parte de los usuarios (ver anexo, figura 1). conocer la situación de violencia percibida por los pacientes en los diversos contextos de atención en salud, y abordar esta problemática constituye una necesidad en que la enfermera debe intervenir creando estrategias para evitar este fenómeno, implicando a todos los agentes que participan en las instituciones de salud (equipo de salud, usuarios, autoridades), en un esfuerzo coordinado de todos; asimismo, se debe apoyar y fomentar el desarrollo de hábitos saludables para todos los trabajadores, que incluya la creación de oportunidades para generar, mantener y reforzar cambios de comportamiento (11) que ayuden al trabajo con los usuarios. además, realizar promoción de ambientes saludables y prevención de los factores relacionados con la violencia para promover su erradicación, ya que se ha ido perpetrando en la sociedad y en las instituciones de salud. en este marco, esta investigación tiene como objetivos validar los factores del modelo de chappell y di martino, describir la percepción de violencia de los usuarios hospitalizados en los servicios de cirugía y medicina de un hospital público de la región de la araucanía, y construir una escala para medir violencia en el contexto hospitalario. sujeto y método diseño cuantitativo, descriptivo correlacional transversal, cuya unidad de análisis fueron los usuarios hospitalizados de los servicios de medicina y cirugía. la muestra fue intencionada no probabilística (error de un 4,2 % y nivel de confianza de 95 %): 510 usuarios hospitalizados (88 del servicio de medicina y 422 de cirugía) de un hospital público de la región de la araucanía de chile durante el 2008. los datos fueron recolectados con el instrumento percepción de violencia en usuarios hospitalizados (elaborado y validado por las autoras), que consta de cuatro partes: a) antecedentes generales y de salud; b) escala de percepción de violencia compuesta por los cuatro aspectos de violencia: psicológica, física, sexual e institucional; c) otros antecedentes; d) antecedentes personales de riesgo, cuyas características psicométricas se realizaron a través de los siguientes pasos: 1) análisis descriptivo de las respuestas obtenidas del total de la escala constituida por 48 ítems que dieron como resultados promedios de 1,01 a 4,25 como valores mínimos y máximos respectivamente, con una desviación estándar entre 0,125 y 1,435; 2) correlación interítems por cada dimensión, en donde se observaron los tipos de relaciones que se producían entre cada ítem; 3) análisis factorial exploratorio; 4) análisis de fiabilidad a través del alfa de cronbach (0,74) y en las dimensiones de violencia psicológica (0,77), violencia física (0,6578), violencia sexual (0,70) y violencia institucional (0,64); 5) eliminación de ítems posterior al análisis factorial; 6) la versión final del instrumento da un alfa de cronbach de 0,75, quedando constituida en cada dimensión: violencia psicológica (16 ítems, alfa: 0,78), violencia física (5 ítems, alfa: 0,68), violencia sexual (5 ítems, alfa: 0,73), violencia institucional (10 ítems, alfa: 0,64); 7) validez de criterio, que se realizó entre los valores finales de la escala de percepción de violencia de la parte b del instrumento con la pregunta directa de si ha percibido violencia, resultando significativa en las dimensiones: psicológica (p: 0,000), física (0,038), sexual (0,050) y en la escala en su conjunto, sumando las cuatro dimensiones un valor p: 0,008. el estudio consideró todos los aspectos éticos, solicitando la autorización en los comités de ética del hospital y del servicio de salud; a los usuarios, previo a la recolección de los datos, se les aplicó un consentimiento informado, donde se les informaron los objetivos, los beneficios y que podían dejar de contestar el instrumento cuando ellos lo desearan. para el análisis de los datos se creó una base electrónica y luego se analizó en el programa spss.12. se aplicó estadística descriptiva para determinar el perfil de la muestra, como distribución de frecuencias, media y desviación estándar; para establecer asociación de variables se utilizó x2; para el análisis inferencial se trabajó con las pruebas de t-student y anova según el tipo de variable y para probar el modelo teórico se aplicó regresión logística. el nivel de significación utilizado en las pruebas estadísticas fue de un 5 %. 82 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 resultados las variables que se encontraron con diferencia estadísticamente significativa respecto al servicio de hospitalización fueron: edad, sexo, localidad de residencia, previsión y escolaridad (ver anexo, tabla 1). la enfermedad preexistente, el número de hospitalizaciones anteriores, la causa de hospitalización actual y la ayuda requerida fueron las variables que se encontraron con diferencia estadísticamente significativa respecto al servicio de hospitalización (ver anexo, tabla 2). en un bajo porcentaje los usuarios identificaron a los agentes agresores; en el servicio de cirugía señalaron al médico, la enfermera, el técnico paramédico, el auxiliar de aseo y los estudiantes de medicina, mientras que en medicina dos usuarios señalan como agresor a la enfermera; sin embargo, estos valores no son estadísticamente significativos (ver anexo, tabla 3). además, se consideraron otros agentes de salud en los que los usuarios no reconocieron violentadores: nutricionista, asistente social, alumnos de carreras de la salud (enfermería, nutrición, otras), familiares. entre las variables que resultaron significativas se encuentra el horario de percepción de violencia y las expectativas en la atención hospitalaria, siendo la variable de preocupación por el usuario la que tiene el mayor porcentaje (ver anexo, tabla 4). en el caso de la relación de la percepción de violencia se encontraron diferencias significativas en las variables: 1) grupos etarios en la dimensión psicológica entre los grupos de adulto joven y adulto maduro (p: 0,046); en la dimensión física entre los adultos jóvenes-maduros (p: 0,013), adultos jóvenes-mayores (p: 0,000) y adulto maduro-mayor (p: 0,023); en la dimensión sexual entre los adultos jóvenes-mayor (p: 0,026). 2) previsión en todas las dimensiones, específicamente en la psicológica entre los cotizantes del fondo nacional de salud (fonasa)-sin previsión (p: 0,005) y cotizante isapresin previsión (p: 0,042); en la dimensión física entre los cotizantes de fonasa-sin previsión (p: 0,002) y cotizante isapre-sin previsión (p: 0,048); y estado civil en la dimensión institucional (ver anexo, tabla 5). las variables que resultaron con diferencias fueron: 1) escolaridad en las dimensiones de violencia psicológica entre los grupos con estudios básicos-medios (p: 0,015) y estudios básicos-superiores (p: 0,033); dimensión física: sin estudios-estudios básicos (p: 0,002), sin estudios-estudios medios (p: 0,000), y sin estudios-estudios superiores (p: 0,000), e institucional entre estudios básicos-medios (p: 0,003). 2) situación laboral, en la dimensión física, entre los grupos de trabajador activojubilado (p: 0,000) y jubilado-dueña de casa (p: 0,031), y en la dimensión sexual entre el trabajador activo-jubilado (p: 0,001) y jubilado-dueña de casa (p: 0,004). 3) ingreso familiar en las dimensiones de violencia física entre los usuarios con ingresos bajos (menor a $159.000) – medios (entre $159.001 y $300.000) (p: 0,004), e ingresos mayores (entre $300.001 y $600.000) (p: 0,025); dimensión sexual entre ingresos medios e ingresos mayores (p: 0,000) (ver anexo, tabla 6). en cuanto a la percepción de violencia y los antecedentes de salud, solo se encontraron relaciones estadísticamente significativas en la variable de hospitalización anterior en la dimensión institucional, y en la variable de ayuda requerida por los usuarios durante su hospitalización en la dimensión de violencia sexual (ver anexo, tabla 7). en relación con las agresiones percibidas por los usuarios hospitalizados durante la niñez, se observó relación significativa en la dimensión de violencia institucional (ver anexo, tabla 8). al relacionar el consumo de drogas lícitas e ilícitas, y la percepción de violencia de los usuarios, en el caso del alcohol, se observaron relaciones estadísticamente significativa en la dimensión de violencia psicológica, sexual e institucional; en el consumo de tabaco, en la dimensión de violencia física (ver anexo, tabla 9). al realizar la regresión múltiple, en las variables que resultaron significativas en los factores individuales de riesgo del modelo de chapell y di martino que influyen en la percepción de violencia en las diversas dimensiones, se encuentra que en la violencia psicológica están: edad, sexo, previsión de salud, situación laboral, ingreso familiar y la calidad en la atención; en la dimensión física resultaron significativas las variables anteriores más los antecedentes de violencia en la adultez, y en la violencia sexual, todas las variables anteriores más el consumo de alcohol. en el caso de los factores laborales de riesgo, son importantes en todas las dimensiones el agente agresor, los recursos humanos y físicos. además, en esta percepción de violencia influye la inexistencia de recursos humanos, físicos e infraestructura en la atención. discusión y conclusión la violencia es un problema de salud pública porque afecta de manera grave la salud y el desarrollo social y económico 83 aplicación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado l sara barrios-casas, tatiana paravic-klijn de amplios sectores de la población (12), amenaza el desarrollo de los pueblos, la calidad de vida, las condiciones de salud y el bienestar de la población (13). la violencia es un comportamiento no deseado, pero cualquier individuo puede ser víctima de esta en algún momento de su vida, la mayoría de las veces esta violencia es provocada a través de palabras o acciones (14), y es una forma de relación social que tiene implícito el ejercicio del poder (15). un tipo de violencia es la hospitalaria, los pacientes receptores de los servicios sanitarios pueden ser violentados por variadas manifestaciones que vulneran sus derechos, que muchas veces no son solamente ignorados por los dispensadores de la atención de salud, sino también por los mismos usuarios (5). al aplicar la escala de percepción de violencia, el 100% de los usuarios manifestaron percibirla en las diversas dimensiones (psicológica, física, sexual e institucional). esta investigación encontró relaciones entre las dimensiones psicológica, física y sexual de la violencia y la variable edad, en donde el grupo de los adultos jóvenes percibió mayor violencia, razón que se debería a que este grupo etario, por su menor experiencia, es más sensible a situaciones nuevas como lo es la violencia, experiencia que seguramente no han vivido de la manera como lo han hecho los adultos mayores. respecto a la situación previsional, estudios realizados en servicios dependientes del sistema público muestran que los pacientes atendidos preferentemente pertenecen al fondo nacional de salud (fonasa) a y b (tramos de salud más deficitarios previsionalmente en donde están adscritas las personas con bajos ingresos económicos). dichos segmentos previsionales representan en la araucanía al 87,2 %, lo que se explica por la alta marginalidad de la población regional (16). en esta investigación, los resultados muestran que los usuarios que pertenecen a fonasa a y b percibieron mayor violencia que aquellos de los grupos fonasa c y d y de otros sistemas previsionales, lo que plantea un desafío a los agentes encargados de la gestión de la salud en chile, en el sentido de que la población más desprotegida de la sociedad en el ámbito previsional no tenga que sufrir violencia en las instituciones de salud. al respecto, fonasa (17) señala que los pacientes deben recibir atención de salud sin discriminación, ya sea en lo racial, religioso, político, económico, previsional, de tal manera que la atención no debe ser supeditada a alguna de esas condiciones. en la región de la araucanía existe casi un tercio de población mapuche (29,5 %); en chile los indígenas corresponden al 4,6 % de la población total, de estos el 87,3 % son mapuches y se ubican en primer lugar en la región de la araucanía (18). en relación con la variable etnia, se encontró que el 27,1 % de los usuarios eran mapuches, sin embargo, no resultó significativa con la percepción de violencia, a pesar de que en el contexto social está bastante arraigada la discriminación y falta de equidad hacia esta etnia (19). al relacionar la escolaridad con la percepción de violencia se encontró que los usuarios con enseñanza media son los que percibieron mayormente la violencia en sus cuatro dimensiones. vizcarra et al. (20) señalan la relación entre el nivel educacional y la violencia, y encontraron que las mujeres con más alto nivel educacional tienen mayor conciencia de sus la violencia es un problema de salud pública porque afecta de manera grave la salud y el desarrollo social y económico de amplios sectores de la población, amenaza el desarrollo de los pueblos, la calidad de vida, las condiciones de salud y el bienestar de la población. 84 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 derechos. asimismo, los pacientes sin educación, o con un nivel básico de instrucción, no reconocen o no posee el capital lingüístico para dar a conocer su descontento y exigir el derecho a una mejor atención. el número de hospitalizaciones previas a la actual señaladas por los usuarios indica que el 44,7 % ha estado internado en un establecimiento hospitalario, por lo que tendrían una vivencia previa respecto a ello, lo que significaría que pueden estar más acostumbrados a las actitudes violentas por parte del personal, no dándoles la importancia que estos hechos ameritan. por otro lado, diversos autores identifican al alcohol y al tabaco como un factor desencadenante de violencia (21, 22). así, el uso del tabaco, el alcohol y otras drogas constituye un serio problema de salud a nivel mundial por sus nefastos efectos en todas las áreas de las personas y su entorno (23), incluidas las instituciones que conforman la sociedad (24, 25, 26). al respecto, la onu y la oms caracterizan este fenómeno como una problemática que afecta negativamente a la humanidad en su conjunto y a los individuos consumidores en sus roles sociales, económicos y de salud (26, 27). además, en los usuarios hospitalizados que consumen drogas lícitas e ilícitas, como el alcohol y el tabaco, al estar internados se produce un síndrome de deprivación ya que estos, por su estatus de pacientes, dejan de consumir estas sustancias, situación que los deja más vulnerables a percibir violencia o ser perpetradores de este fenómeno, por la irritabilidad, ansiedad, dolores musculares, temblores, insomnio, pesadillas, entre otros síntomas, que presentan. el usuario hospitalizado se encuentra en un ambiente extraño, en el que no identifica los roles de los distintos miembros del equipo de salud, sumado a que en estas instituciones hospitalarias se dan las relaciones jerárquicas, los pacientes fueron capaces de identificar solo en un bajo porcentaje al agente agresor; sin embargo, a la que señalaron como agente agresora en ambos servicios fue a la enfermera; profesional que debe otorgar el cuidado de los pacientes hospitalizados y debe liderar a los equipos de salud brindando una atención libre de violencia dado que, además, es la profesional que permanece las 24 horas con el usuario, brindándole atenciones, interactuando con él y su familia, por lo que le es más fácil a los pacientes identificarla. al respecto, yela (25) refiere que la relación profesional sanitario-paciente es de poder; en un lado se encuentran el saber y el poder, y en el otro la ignorancia, el desarraigo y la dependencia. el paciente está en una situación de vulnerabilidad por el hecho de estar enfermo, especialmente el hospitalizado, porque además se alteran sus relaciones familiares, laborales, es desplazado de su territorio vital a otro desconocido y complejo, y pasa a tener un papel pasivo, dependiente de personas extrañas. todo ello le va a producir cambios emocionales intensos que alteran su autoestima, y los sentimientos de pertenencia, seguridad e identidad, lo que puede ser la causa de la pérdida del sentido del control físico o psicológico. por lo expuesto, y porque la relación profesional sanitario-paciente es asimétrica y jerárquica pueden convertir al paciente en víctima de actos considerados agresivos o violentos. uno de los factores que podría explicar que los funcionarios ejerzan violencia sería el estrés laboral. diversos autores señalan que este es identificado como el motivo más frecuente para ejercer violencia, es así que los actos agresivos surgen con mayor facilidad en entornos sometidos a el usuario hospitalizado se encuentra en un ambiente extraño, en el que no identifica los roles de los distintos miembros del equipo de salud. 85 aplicación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado l sara barrios-casas, tatiana paravic-klijn estrés que se genera en parte porque los pacientes tienen necesidades insatisfechas que exigen ser solucionadas por los funcionarios de la salud, quienes no siempre pueden satisfacerlas (10, 28, 29, 30). el sistema crea necesidades de servicios sanitarios colocando a los trabajadores en situaciones a veces imposibles, en donde la institución no proporciona los medios necesarios para la atención satisfactoria. el paciente ha pasado a ser un consumidor de servicios sanitarios, y la relación profesional-paciente se ha convertido en una relación entre proveedores de servicios y consumidores, generando insatisfacción en las dos partes (25). al realizar la regresión múltiple, las variables modeladas señalan que los usuarios que perciben mayor violencia son: jóvenes, mujeres, personas que pertenecen al fondo nacional de salud (fonasa), estado civil soltero o casado, que su situación laboral sea trabajador activo, con un ingreso familiar mínimo (menor a $159.000), con hospitalizaciones previas, que posea antecedentes de consumo de alcohol, y de violencia en la infancia y en la adultez. se concluye que los factores del modelo interactivo de violencia laboral de chapell y di martino (10), adaptado a un modelo de violencia en usuarios hospitalizados, tiene aplicación en los ambientes hospitalarios, ya que los factores que componen este modelo también se presentan en estos contextos de salud, por lo que se valida su uso. asimismo, se valida el instrumento construido para medir la percepción de violencia, que cumple con las condiciones psicométricas para su aplicación. de esta manera, como señalan chappell y di martino (10), es importante que el problema de la violencia se repudie, se haga visible, se instale como cuestión pública y se discutan estrategias concretas de acción para atenderla, tales como el fomento de una buena comunicación entre todos los actores comprometidos en la atención en salud, respetando la dignidad de los pacientes, promoviendo la equidad en la atención y dando a conocer los resultados de estas y otras investigaciones relacionadas con la temática de la violencia. en este aspecto, la enfermera tiene las herramientas para intervenir creando estrategias a fin de evitar la violencia en el contexto de salud, implicando a todos los agentes que participan en las instituciones de salud (equipo de salud, usuarios, autoridades), ya que se requiere el esfuerzo coordinado de todos estos actores; asimismo, se debe apoyar y fomentar el desarrollo de hábitos saludables para todos los trabajadores, que incluyan la creación de oportunidades para generar, mantener y reforzar cambios de comportamiento que ayuden al trabajo con los usuarios. además, se deben promover ambientes saludables y prevención de los factores relacionados con la violencia. referencias bibliográficas 1. gómez b, ramírez v. xxi ¿otro siglo violento? españa: editorial díaz santos; 2005. 2. filho a. la violencia y la salud pública. revista panamericana de salud pública 2005; 5 (4/5): 219-21. 3. organización mundial de la salud (oms). report on global violence and health. geneva, switzerland; 2002. 4. valenzuela s. factores que influyen en la actitud de los estudiantes de enfermería hacia el cuidado de pacientes durante sus experiencias clínicas médico-quirúrgicas [tesis magíster]. universidad de concepción, concepción, chile. 5. burgos m, paravic t. percepción de violencia de los pacientes hospitalizados en los servicios de medicina y cirugía de un hospital público. ciencia y enfermería 2003; 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[revista en internet]. 2005. disponible en: http://www.psiquiatricohph.sld.cu/hph0205/hphsu 0205.htm [fecha de acceso: 17 de noviembre de 2006]. 24. whinter mc, florenzano r. correlatos psicosociales de la farmacología: resultados de un estudio en santiago de chile. rev psiquiátrica 1998; 15: 10-22. 25. yela c. la violencia en el sector sanitario. ii plan director en prevención de riesgos laborales de la comunidad de madrid (2004-2007). comisiones obreras de madrid. secretaría de salud laboral de comisiones obreras de madrid; 2006. 26. organización mundial de la salud (oms). carta de ottawa para la prevención de la salud. ottawa, canadá; 1986. 27. rojo m, villela s, da silva e. concepción de los estudiantes de enfermería sobre promoción de la salud ante el uso de sustancias psicoactivas. revista latinoamericana de enfermagem 2008; 16: 627-33. 28. sánchez r, valenzuela s. percepción de violencia que afecta a profesionales de enfermería de un hospital de la octava región [tesis magíster]. universidad de concepción, concepción, chile. 29. burgos m, paravic t. violencia hospitalaria en pacientes. ciencia y enfermería 2003; ix (1): 9-14. 30. hirigoyen m. el acoso moral en el trabajo: distinguir lo verdadero de lo falso. barcelona: paidos iberica; 2001. 87 aplicación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado l sara barrios-casas, tatiana paravic-klijn figura 1. modelo interactivo de violencia laboral de chapell y di martino, adaptado a un modelo interactivo de violencia en usuarios hospitalizados. fuente: validación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado. tesis para optar al grado de doctor en enfermería, universidad de concepción. anexo 88 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 variables biosociodemográficas salud usuarios usuarios p medicina cirugía n % n % edad adulto joven 24 27,3 156 37,0 0,046 rango: 15-86 adulto maduro 30 34,1 156 37,0 sd: 18,3, media: 51,9 adulto mayor 34 38,6 110 26,1 sexo mujer 60 68,2 210 49,8 0,020 hombre 28 31,8 212 50,2 localidad de residencia temuco 44 50,0 152 36,0 0,021 padre las casas 4 4,5 28 6,6 lautaro 0 0 30 7,1 vilcun 2 2,3 20 4,7 otras 38 43,2 192 45,5 previsión fonasa 62 70,4 354 83,9 0,035 isapre 2 2,3 4 0,9 sin previsión 24 27,3 64 15,2 etnia mapuche 20 22,7 118 28,0 0,477 no mapuche 68 77,3 304 72,1 estado civil soltero 22 25,0 120 28,4 0,129 casado 42 47,7 232 55,0 separado/divorciado 4 4,5 18 4,3 viudo 20 22,7 52 12,3 escolaridad sin escolaridad 0 0 32 7,6 0,003 rango: 0-20 básica 46 52,3 164 43,6 sd,: 4,39 media 30 34,1 156 37,0 media: 8,2 superior 12 13,6 50 11,8 situación laboral trabajador activo 22 25,0 134 31,8 0,102 cesante 6 6,8 44 10,4 jubilado 18 20,5 86 20,4 dueña de casa 40 45,5 134 31,8 otro 2 2,3 24 5,7 ingreso familiar mensual < a $159.000 64 72,7 264 62,6 0,303 (en pesos chilenos: $), $159.001 $300.000 14 15,9 98 23,2 rango: $0 $1.500.000 $300.001 $600.000 10 11,4 60 14,2 sd: 187.541.76; media: 178.411.76 n° personas por hogar entre 1 y 4 58 65,9 256 60,7 0,498 rango: 1-13; sd: 1,89; más de 5 30 34,1 166 39,3 media: 4,0 fuente: validación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado. tesis doctoral. universidad de concepción, chile. n servicio de cirugía: 422; n servicio de medicina: 88 tabla 1. perfil biosociodemográfico de los usuarios de los servicios de cirugía y medicina 89 aplicación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado l sara barrios-casas, tatiana paravic-klijn variables salud usuarios usuarios p medicina cirugía n % n % enfermedad preexistente no presenta 24 27,3 158 37,4 0.003 pat. sist. endocrino 12 13,6 86 20,4 pat. sist. cardiovascular 32 36,4 88 20,9 otras 20 22,7 90 21,4 n° hospitalizaciones 0 40 45,5 240 56,9 0,002 anteriores 1 14 15,9 104 24,6 rango: 0-10 2 y más 32 36,3 78 18,4 sd: 1,68; media: 1 causa hospitalizaciones no presenta 42 47,7 240 56,9 0,311 anteriores pat. sist. digestivo 10 11,4 34 8,1 otras 36 40,9 148 35,1 causa de hospitalización pat. sist. digestivo 12 13,6 184 43,6 0,000 actual pat. sist. cardiovascular 18 20,5 54 12,8 pat. sist. tegumentario 6 6,8 54 12,8 pat. sist. respiratorio 6 6,8 44 10,4 otras 46 52,3 86 20,4 no. días de hospitalización 2 a 6 días 58 65,9 228 54,0 0,114 actual 7 a 12 días 16 18,2 112 26,5 rango: 2-90 13 y más días 14 15,9 82 19,4 sd: 10,9; media: 9 ayuda requerida no 32 36,4 204 48,3 0,046 sí 56 63,6 218 51,7 n servicio de cirugía: 422; n servicio de medicina: 88 fuente: validación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado. tesis doctoral. universidad de concepción, chile. tabla 2. perfil de salud de los usuarios de los servicios de cirugía y medicina fuente: validación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado. tesis doctoral. universidad de concepción, chile. tabla 3. frecuencia de respuestas positivas relacionadas con los agentes agresores de violencia de los servicios de cirugía y medicina agentes agresores usuarios medicina usuarios cirugía p n: 88 n: 422 f % f % médico 0 0 10 2,4 0,223 enfermera 2 2,3 6 1,4 0,632 técnico paramédico 0 0 14 3,3 0,143 auxiliar de aseo 0 0 4 0,9 0,468 alumno de medicina 0 0 4 0,9 0,468 90 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 fuente: validación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado. tesis doctoral. universidad de concepción, chile. tabla 4. frecuencia de razones, horario de percepción de violencia y expectativas en la atención hospitalaria de los usuarios. usuarios usuarios p medicina cirugía f % f % razones de percepción no percibe 80 90,9 364 86,2 0,147 de violencia por culpa del usuario 0 0 14 3,3 por personal de edad 0 0 4 0,9 falta de paciencia del personal 0 0 8 1,9 sobrecarga de trabajo del personal 6 6,8 10 2,3 discriminación hacia los usuarios de escasos recursos 0 0 4 0,9 personal con problemas personales 2 2,3 14 3,3 falta de comunicación con los usuarios 0 0 4 0,9 horario de percepción no percibe 80 90,9 364 86,2 0,020 de violencia todo horario 0 0 24 5,7 08 a 12 horas 1 1,1 9 2,1 12 a 20 horas 5 5,7 5 1,2 20 a 08 horas 2 2,3 20 4,7 expectativas en la atención preocupación por el usuario 82 93,1 363 86,1 0,003 hospitalaria existencia de recursos físicos y materiales 0 0 36 8,5 existencia de recursos humanos suficientes 6 6,8 23 5,5 91 aplicación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado l sara barrios-casas, tatiana paravic-klijn tabla 5. percepción de violencia en sus diversas dimensiones según grupos etarios, previsión, etnia y estado civil. valores obtenidos a través de la prueba de análisis de varianza (anova). fuente: validación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado. tesis doctoral. universidad de concepción, chile. variable dimensión p grupos etarios psicológica 0,050 física 0,000 sexual 0,026 institucional 0,786 previsión psicológica 0,001 física 0,000 sexual 0,039 institucional 0,033 etnia psicológica 0,125 física 0,395 sexual 0,720 institucional 0,094 estado civil psicológica 0,358 física 0,772 sexual 0,738 institucional 0,050 valores obtenidos a través de la prueba de análisis de varianza (anova) fuente: validación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado. tesis doctoral. universidad de concepción, chile. tabla 6. percepción de violencia en sus diversas dimensiones según escolaridad, situación laboral e ingreso familiar de los usuarios hospitalizados. variable dimensión p escolaridad psicológica 0,000 física 0,000 sexual 0,080 institucional 0,003 situación laboral psicológica 0,178 física 0,001 sexual 0,001 institucional 0,360 ingreso familiar psicológica 0,953 física 0,001 sexual 0,000 institucional 0,495 92 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 tabla 7. percepción de violencia en sus diversas dimensiones según la enfermedad preexistente, hospitalización en los últimos cinco años y ayuda requerida de los usuarios hospitalizados. valores obtenidos a través de la prueba de t-student. 1: valor asumido sobre varianzas iguales; 2: valor asumido sobre varianzas diferentes fuente: validación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado. tesis doctoral. universidad de concepción, chile. variable dimensión existencia n media desviación p de típ. variable enfermedad preexistente psicológica no 182 13,65 11,782 0,2941 sí 328 13,33 11,847 física no 182 14,78 16,669 0,3251 sí 328 16,37 17,888 sexual no 182 14,56 18,532 0,3201 sí 328 12,93 17,284 institucional no 182 26,04 10,343 0,1921 sí 328 24,86 9,573 hospitalización en los últimos cinco años psicológica no 280 13,05 11,217 0,4031 sí 230 13,93 12,508 física no 280 15,93 17,399 0,8591 sí 230 15,65 17,577 sexual no 280 12,64 16,618 0,2302 sí 230 14,57 18,999 institucional no 280 27,14 9,830 0,0001 sí 230 23,01 9,434 ayuda requerida psicológica no 236 13,39 11,189 0,9201 sí 274 13,49 12,346 física no 236 16,95 18,669 0,1701 sí 274 14,82 16,323 sexual no 236 15,64 20,343 0,0121 sí 274 11,68 14,939 institucional no 236 25,96 10,028 0,1461 sí 274 24,69 9,694 93 aplicación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado l sara barrios-casas, tatiana paravic-klijn tabla 8. percepción de violencia de los usuarios según si la ha sufrido durante diferentes etapas de su vida. valores obtenidos a través de la prueba de t-student. 1: valor asumido sobre varianzas iguales; 2: valor asumido sobre varianzas distintas fuente: validación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado. tesis doctoral. universidad de concepción, chile. variable dimensión violencia n media desviación típ. p violencia en la infancia psicológica no 378 13,69 12,427 0,3732 sí 132 12,74 9,853 física no 378 16,53 17,946 0,0912 sí 132 13,71 15,879 sexual no 378 13,76 18,250 0,5951 sí 132 12,80 16,231 institucional no 378 25,82 9,956 0,0361 sí 132 23,73 9,449 violencia en la adultez psicológica no 412 13,53 12,064 0,7311 sí 98 13,07 10,745 física no 412 15,83 17,649 0,9551 sí 98 15,71 16,746 sexual no 412 12,96 17,494 0,1521 sí 98 15,82 18,649 institucional no 412 25,56 9,804 0,1811 sí 98 24,08 10,060 tabla 9. percepción de violencia de los usuarios en sus diversas dimensiones según consumo de alcohol, tabaco y drogas ilícitas. variable dimensión consumo n media desviación típ. p de drogas consumo de alcohol psicológica no 286 12,40 12,234 0,0241 sí 224 14,77 11,138 física no 286 16,26 18,030 0,5032 sí 224 15,22 16,733 sexual no 286 11,68 16,157 0,0102 sí 224 15,85 19,361 institucional no 286 23,93 10,486 0,0001 sí 224 27,00 8,725 consumo de tabaco psicológica no 416 13,12 11,778 0,1881 sí 94 14,89 11,923 física no 416 16,44 18,092 0,0432 sí 94 12,98 14,091 sexual no 416 13,49 17,915 0,9481 sí 94 13,62 17,029 institucional no 416 25,22 9,873 0,7621 sí 94 25,56 9,854 consumo de drogas psicológica no 506 13,43 11,800 0,8121 ilícitas sí 4 14,84 15,336 física no 506 15,83 17,517 0,7041 sí 4 12,50 8,660 sexual no 506 13,36 17,558 0,3152 sí 4 32,50 31,754 institucional no 506 25,25 9,881 0,4051 sí 4 29,38 6,495 valores obtenidos a través de la prueba de t-student. 1: valor asumido sobre varianzas iguales; 2: valor asumido sobre varianzas distintas. fuente: validación del modelo de violencia laboral de chappell y di martino adaptado al usuario hospitalizado. tesis doctoral. universidad de concepción, chile. 1 kátia cordélia cunha cordeiro1 nadirlene pereira gomes2 fernanda matheus estrela3 andrey ferreira da silva4 júlia renata fernandes magalhães 5 josinete gonçalves dos santos lírio6 estratégias de educadoras no âmbito da escola para prevenção e enfrentamento da vivência de violência doméstica pelos adolescentes* 1 orcid.org/0000-0003-1850-8999. universidade federal da bahia, brasil. 2 orcid.org/0000-0002-6043-3997. universidade federal da bahia, brasil. 3 orcid.org/0000-0001-7501-6187. universidade estadual de feira de santana, brasil. fmestrela@uefs.br 4 orcid.org/0000-0002-1038-7443. universidade federal da bahia, brasil. 5 orcid.org/0000-0003-0631-2374. universidade federal da bahia, brasil. 6 orcid.org/0000-0001-7610-3186. universidade federal da bahia, brasil. * financiado pela fundação de amparo a pesquisa do estado da bahia, brasil. recebido: 26/02/2019 submetido: 12/03/2019 aceito por pares: 09/04/2019 aceito: 28/06/2019 doi: 10.5294/aqui.2019.19.3.8 para citar este artigo / para citar este artículo / to reference this article cordeiro kcc, gomes np, estrela fm, silva af, magalhães jrf, lírio jgds. strategies by educators within the school setting to prevent and cope with the experience of domestic violence by adolescents. aquichan 2019; 19(3): e1938. doi: https://doi.org/10.5294/aqui.2019.19.3.8 resumo objetivo: identificar, no discurso de educadoras, que estratégias elas podem implementar, no âmbito da escola, para prevenir e enfrentar a vivência de violência doméstica pelos adolescentes. método: estudo qualitativo, fundamentado na perspectiva crítico-libertadora de paulo freire, realizado com 20 educadoras de uma escola pública, em salvador, bahia, brasil. para a coleta de dados, utilizou-se a entrevista e, para a sistematização destes, o discurso do sujeito coletivo. resultados: os discursos revelam as seguintes estratégias de enfrentamento da violência doméstica vivenciada pelos adolescentes: acionar o conselho tutelar; criar espaços de acolhimento e escuta para os escolares; estreitar laços entre escola e família; promover ações educativas e articular saberes. conclusões: este estudo contribui para indicar caminhos para a prevenção e o enfrentamento de abusos familiares que comprometem a saúde física e mental de año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1938 temática: promoção e prevenção. contribuição para a disciplina: neste artigo, destaca-se a atuação do profissional de enfermagem, fundamental no processo de articulação intersetorial, por ocupar, com frequência, espaços de gerenciamento de programas para promover a saúde e prevenir a violência. esses profissionais são capacitados para reconhecer os sinais e os sintomas que identificam os adolescentes em situação de violência, o que os torna, portanto, coprotagonistas de ações que promovam a qualidade de vida desses indivíduos. http://orcid.org/0000-0003-1850-8999 http://orcid.org/0000-0002-6043-3997 http://orcid.org/0000-0001-7501-6187 mailto:fmestrela@uefs.br http://orcid.org/0000-0002-1038-7443 http://orcid.org/0000-0001-7610-3186 https://doi.org/10.5294/aqui.2019.19.3.8 http://orcid.org/0000-0003-1850-8999 http://orcid.org/0000-0002-6043-3997 http://orcid.org/0000-0001-7501-6187 http://orcid.org/0000-0002-1038-7443 http://orcid.org/0000-0003-0631-2374 http://orcid.org/0000-0001-7610-3186 https://doi.org/10.5294/aqui.2019.19.3.8 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1938 crianças e adolescentes, com impactos sobre o desempenho escolar. sugere-se a contribuição da atenção primária à saúde por meio de ações vinculadas ao programa saúde na escola e a inserção da temática da violência nos diversos cursos de graduação, visto que cuidar das crianças e dos adolescentes e defendê-los constituem obrigação de todos os cidadãos. palavras-chave (fonte: decs) violência doméstica; adolescente; adolescência; serviços de saúde escolar; instituições acadêmicas; professores escolares; docentes. estrategias de educadoras en el ámbito de la escuela para prevención y enfrentamiento de la vivencia de violencia doméstica por los adolescentes* resumen objetivo: identificar, en el discurso de educadoras, qué estrategias pueden implementar, en el ámbito de la escuela, para prevenir y enfrentar la vivencia de violencia doméstica por adolescentes. método: estudio cualitativo, basado en la perspectiva crítico-libertadora de paulo freire, llevado a cabo con 20 educadoras de una escuela pública, en salvador, bahía, brasil. para recolectar los datos, se empleó la entrevista y, para sistematizarlos, el discurso del sujeto colectivo. resultados: los discursos develan las siguientes estrategias de enfrentamiento de la violencia doméstica vivida por adolescentes: accionar el consejo tutelar; crear espacios de acogida y escucha para los escolares; estrechar vínculos entre escuela y familia; promover acciones educativas y articular saberes. conclusiones: el estudio aporta caminos para prevenir y enfrentar abusos familiares que comprometen la salud física y mental de niños y adolescentes, con impactos sobre el rendimiento escolar. se sugiere la contribución de la atención primaria a la salud por medio de acciones vinculadas al programa salud en la escuela y la inserción de la temática de la violencia en las diversas carreras universitarias, ya que cuidar a niños y adolescentes y defenderlos constituyen obligación de todos los ciudadanos. palabras clave (fuente: decs) violencia doméstica; adolescente; adolescencia; servicios de salud escolar; instituciones académicas; maestros; docentes. * financiado por la fundação de amparo a pesquisa do estado da bahia, brasil. 3 estratégias de educadoras no âmbito da escola para prevenção e enfrentamento da vivência de violência doméstica pelos adolescentes l kátia cordélia cunha cordeiro e outros strategies by educators within the school setting to prevent and cope with the experience of domestic violence by adolescents* abstract objective: this work sought to identify, in the discourse of educators, which strategies they can implement, within the school setting, to prevent and cope with the experience of domestic violence by adolescents. method: qualitative study based on the critical-liberating perspective of paulo freire, conducted with 20 educators from a public school in salvador, bahia, brazil. to collect the data, the interview was used and, to systematize them, the discourse of the collective subject. results: the discourses reveal the following coping strategies of domestic violence experienced by adolescents: place into action the guardianship council; create reception and listening spaces for students; strengthen bonds between the school and family; promote educational actions, and articulate knowledge. conclusions: the study provides paths to prevent and confront family abuses that compromise the physical and mental health of children and adolescents, with impact upon school performance. the study suggests the contribution of primary health care through actions linked to the health in school program and the insertion of the theme of violence in the different university careers, given that caring for children and adolescents and defending them constitutes an obligation for all citizens. keywords (source: decs) domestic violence; adolescent; adolescence; school health services; schools; school teachers; faculty. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1938 * financed by the fundação de amparo a pesquisa do estado da bahia, brazil. 4 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1938 aquichan issn 1657-5997 eissn 2027-5374 introdução a violência doméstica consiste em uma condição de opressão que adoece física e psicologicamente crianças e adolescentes. essa condição compromete seu desenvolvimento humano, sobretudo, pelas implicações sobre o desempenho escolar. a maior proximidade desse público com os educadores coloca-os em posição estratégica para o reconhecimento precoce do agravo; além disso, é importante a preocupação da escola em adotar medidas que favoreçam uma práxis profissional para enfrentar o fenômeno. perpetrada predominantemente no ambiente doméstico, o abuso intrafamiliar apresenta dados preocupantes. estudo realizado em 30 países revelou os altos índices de maus-tratos infantis e de casos recorrentes, situações que indicam a necessidade de ações preventivas (1). nos estados unidos, 2.203 escolares sofreram abusos infanto-juvenis vivenciados no lar e se expressaram por meio da negligência e da violência psicológica e física (2). independentemente da forma de expressão, crianças e adolescentes que experienciam violência no ambiente doméstico tendem a apresentar problemas de saúde físico e psíquico. pesquisa realizada nos serviços sentinela de urgência e emergência nos estados unidos apontou que fraturas, contusões e cortes correspondem aos tipos de lesões mais frequentes (2). os prejuízos se estendem, além das marcas visíveis, propiciando a ocorrência de depressão, medo, comportamentos de retração, delinquência ou agressividade. nesse contexto, é importante referir que, no sentido de conter a dor sofrida, muitos adolescentes apresentam a prática agressiva direcionada a si mesmo, que podem ir desde a autolesão até o pensamento suicida (3). salienta-se que as repercussões físicas e psicológicas decorrentes da vivência de violência doméstica são agravos que também vulnerabilizam crianças e adolescentes a outros adoecimentos, repercutindo no comprometimento do desempenho acadêmico. estudo realizado com 827 adolescentes de uma escola pública da califórnia evidenciou que o baixo rendimento, a falta de assiduidade e a evasão escolar são consequências da vivência de violência doméstica (4). tais repercussões podem ainda trazer problemas na vida adulta, como corrobora estudo internacional que sinaliza para a interface entre menor rendimento escolar e maior dificuldade em conseguir melhores cargos no emprego (5). percebe-se, pois, que a violência compromete o desenvolvimento dos indivíduos, com potencial de limitar suas conquistas pessoais e profissionais. em que pese tais danos, é importante referir que estes nem sempre estão associados à vivência de abusos intrafamiliares. estudo realizado na costa da áfrica oriental aponta justamente para a necessidade do preparo de profissionais que atuam junto ao público infanto-juvenil, a exemplo dos profissionais da saúde e da educação, para investigar e discernir se as lesões foram causadas por acidentes ou por violência (6). nesse processo, a educação permanente pode ser uma das estratégias utilizadas para que os profissionais possam se capacitar para reconhecer os casos e agir sobre eles (7). diante dos danos da vivência de violência doméstica, os quais trazem comprometimentos para a saúde física e psicológica dos adolescentes, refletindo, em consequência, no rendimento escolar, pontua-se a importância dos(as) educadores(as) como aliados(as) no processo de prevenção e enfrentamento dessa problemática, tendo em vista a sua maior proximidade com os escolares. assim, considerando a escola como lócus privilegiado para reconhecer o abuso intrafamiliar e realizar medidas preventivas e de combate ao agravo, este estudo objetiva identificar, no discurso de educadoras, que estratégias elas podem implantar para prevenir e enfrentar a vivência de violência doméstica pelos adolescentes. métodos trata-se de um estudo com abordagem qualitativa, fundamentado na perspectiva crítico-libertadora de paulo freire, que compreende a educação como uma forma de intervenção na vida coletiva, no sentido de atuar em uma determinada realidade para a manutenção ou a superação do vivido (8). este estudo está vinculado ao projeto matriz “universidade e escola pública: buscando estratégias para enfrentar os fatores que interferem no processo ensino/aprendizagem”, sob o financiamento da fundação de amparo à pesquisa do estado da bahia (fapesb). o cenário de estudo foi uma escola pública localizada na periferia da cidade de salvador, bahia, brasil. essa instituição de ensino oferta educação a adolescentes do 6º ao 9º ano do ensino fundamental, tendo a predominância (53,97 %) de estudantes homens, situação que justifica adotarmos em todo o estudo expressões relacionadas aos escolares no gênero masculino. a aproximação com a escola foi viabilizada por meio de ações extensionistas, previstas no projeto matriz, desenvolvidas no período de 2013 a 2017, em parceria com o componente ação 5 estratégias de educadoras no âmbito da escola para prevenção e enfrentamento da vivência de violência doméstica pelos adolescentes l kátia cordélia cunha cordeiro e outros curricular em comunidade e em sociedade (accs) intitulada “abordagem interdisciplinar e transdisciplinar dos problemas de saúde relacionados à violência”. esse componente faz parte da estrutura curricular dos cursos de graduação da universidade federal da bahia (ufba) e conta com a participação de estudantes de diversas áreas do conhecimento. a seleção das participantes da pesquisa se deu de forma intencional, de modo que todas as docentes permanentes do quadro de funcionárias que lecionavam há, pelo menos, seis meses na referida escola foram convidadas a participar do estudo. ressalta-se que apenas uma profissional foi excluída, após duas tentativas de contato sem sucesso. desse modo, 20 docentes integraram a pesquisa. todas as educadoras participantes da pesquisa foram informadas acerca do objetivo do estudo e dos preceitos éticos que o orientam, descritos na resolução 466/2012, do conselho nacional de saúde, e assinaram o termo de consentimento livre e esclarecido (tcle). salienta-se que esta pesquisa foi aprovada pelo comitê de ética em pesquisa (cep) da escola de enfermagem da ufba (parecer consubstanciado 384.208/2013). como técnica de coleta de dados, foi utilizada a entrevista semiestruturada, guiada por um formulário construído pela autora principal e validado por professoras doutoras, que continha aspectos relacionados à caracterização das colaboradoras e a seguinte questão orientadora: que estratégias podem ser implementadas, no âmbito da escola, para prevenir e enfrentar a vivência de violência doméstica pelos adolescentes? as entrevistas foram conduzidas pela pesquisadora principal e ocorreram nos meses de agosto a outubro de 2017, em uma sala reservada na escola-lócus, com o intuito de promover um espaço de privacidade, confiança e respeito entre entrevistadora e colaboradoras. as falas, que duraram entre 15 e 20 minutos, foram gravadas e transcritas, na íntegra, com o apoio do programa microsoft word ®. para fins de manutenção do rigor metodológico, as transcrições foram disponibilizadas às participantes da pesquisa para validar seu conteúdo. como ferramenta de apoio, consideraram-se os critérios preconizados pelo reporting qualitative research (coreq). os dados foram sistematizados por meio do discurso do sujeito coletivo (dsc) e validados pelas colaboradoras. esse método consiste no agrupamento de falas, a fim de construir um discurso único, em primeira pessoa, de modo a sintetizar o entendimento de uma coletividade (9). a partir das entrevistas transcritas, foram retiradas as ideias centrais e as suas expressões-chave. neste texto, as falas são referenciadas pelo código dsc mais o número de ordem da entrevista. resultados as 20 educadoras, colaboradoras deste estudo, foram, em sua maioria, mulheres (70 %), motivo pelo qual decidimos adotar o feminino, de modo que o termo “educadoras” remete às educadoras e aos educadores. a maioria das entrevistadas são solteiras (45 %), com idades entre 31 e 57 anos, que se autodeclararam negras (90 %), todas informaram ter nível superior completo e quase a totalidade referiu possuir especialização (90 %). no que tange ao conhecimento sobre violência, um pouco mais da metade (55 %) mencionou que a temática não foi abordada durante sua formação docente, o que contrastou com a grande parcela (90 %), que declarou ter trabalhado esse objeto durante a especialização em suas áreas de atuação. com o intuito de organizar o pensamento coletivo das educadoras acerca das estratégias identificadas, passíveis de serem implementadas no âmbito da escola para prevenir e enfrentar a vivência de violência doméstica pelos adolescentes, este estudo revelou as ideias centrais apresentadas nas próximas subseções. ideia central 1: acionar o conselho tutelar diante a identificação de casos de violência doméstica, o discurso coletivo assinala a necessidade de acionar o conselho tutelar, a fim de que possam adotar as medidas cabíveis. eu acredito que algumas situações de violência doméstica também cabem encaminhamento para o conselho tutelar resolver. se eu tivesse conhecimento de algum caso, falaria com a direção para encaminhar para o conselho tutelar. tem casos que só eles que têm condições de fazer alguma coisa: chamar os pais para conversar, os obrigariam a estarem mais próximos dos filhos. (dsc 1) ideia central 2: criar espaços de acolhimento e escuta para adolescentes o discurso das educadoras revelou que uma das estratégias para enfrentar a violência doméstica contra adolescentes consiste 6 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1938 aquichan issn 1657-5997 eissn 2027-5374 na criação de espaços com ênfase no acolhimento e na escuta. busca-se, com isso, possibilitar aos escolares dialogarem e compartilharem seus anseios e demandas. a gente tenta acolher e transmitir o carinho e atenção que eles não têm em casa, mas é preciso que haja um espaço como o núcleo de apoio psicopedagógico para que eles possam relatar as dificuldades. [...] um local para a comunicação mais aberta do aluno com o professor. acredito que se você souber conversar, é possível conseguir uma melhora. se houvesse esse espaço, acho que facilitaria. por incrível que pareça, às vezes, a escola é o único cenário que eles podem contar. (dsc 2) ideia central 3: estreitar laços entre escola e família para as educadoras, a escola deve criar estratégias que possibilitem a interação com a família. acredita-se que o elo escola-família favoreça o conhecimento e a compreensão acerca do comportamento dos escolares, bem como situações de vulnerabilidades as quais se encontram susceptíveis, a exemplo de abusos domésticos e o contexto para tal ocorrência. é importante ter um espaço de escuta para toda a família, pois não adianta trabalhar só com um filho. deve-se envolver a todos. tem famílias que nunca vão às reuniões, mas é papel da escola fazer essa aproximação. enquanto instituição, podemos pensar em promover ações que aproximem essa família da comunidade escolar. talvez até a escola visitar a casa do adolescente para tentar dialogar com os pais. [...] precisamos receber um “feedback” sobre como os alunos são em casa e na rua. dessa forma, podemos saber: se o adolescente é agredido, quais as circunstâncias que levam à violência, se tem relação com álcool e outras drogas ou se os pais são naturalmente agressivos. (dsc 3) ideia central 4: promover ações educativas outra estratégia de prevenção e/ou enfrentamento da violência doméstica consiste na promoção de ações educativas que, segundo as educadoras, podem ser realizadas sob o modelo de projeto pedagógico, inclusive através da linguagem do teatro. para as educadoras, esse processo educativo permite discutir a problemática e auxilia no autorreconhecimento e no encontro de caminhos para a superação, além de possibilitar melhorar a relação escolares-família. seria muito bom se houvesse na escola ações educativas ou um projeto específico para cuidar desses meninos que estão apanhando dentro de casa. poderiam ser organizados fóruns, espaços de debate e palestras sobre a violência, tanto para alunos como para a família. acho que o esporte e o teatro também podem ajudar. [...] trazer a discussão da violência para a sala de aula de modo teatral pode ajudar o aluno a se identificar e tomar medidas para sair da situação. muitas vezes, os pais não enxergam o potencial dos filhos, mas, quando participam destes projetos, percebem a capacidade deles e passam a valorizá-los. (dsc 4) ideia central 5: articular saberes considerando a complexidade da violência doméstica, as educadoras apontam à necessidade de a instituição escolar estabelecer parcerias no sentido de unir saberes para enfrentar o fenômeno. é importante que as articulações atentem para as necessidades do escolar, que transcendem as questões próprias da adolescência, perpassando pelas diversas demandas relativas à vivência do abuso. diante das situações de violência, seria necessário um trabalho de equipe com a parceria de profissionais de outras áreas porque o professor sozinho não dá conta de abordar esse tema. é necessária a participação de outras áreas do conhecimento. existem questões próprias da fase da adolescência e outras resultantes da violência que são mais apropriadas para psicólogos, médicos e enfermeiras. (dsc 5) discussão conforme o discurso das educadoras, uma estratégia a ser adotada no âmbito escolar, diante da identificação de casos de violência doméstica, consiste no encaminhamento ao conselho tutelar, conduta preconizada pelo estatuto da criança e do adolescente (eca). esse dispositivo jurídico determina a obrigatoriedade da notificação dos casos suspeitos ou confirmados de violência doméstica, sendo sua omissão entendida como infração administrativa, passível inclusive de penalidades (10). ressalta-se que a portaria do gabinete do ministro (gm)/ministério da saúde (ms) 1271/2014 orienta que as fichas de notificação nos casos de violência sejam preenchidas em três vias nos casos que envolvam crianças e/ou adolescentes: uma fica no serviço de saúde, outra deve ser encaminhada ao setor municipal 7 estratégias de educadoras no âmbito da escola para prevenção e enfrentamento da vivência de violência doméstica pelos adolescentes l kátia cordélia cunha cordeiro e outros responsável pela vigilância epidemiológica de doenças e agravos não transmissíveis (dant) e a terceira ao conselho tutelar e/ou a autoridades competentes, conforme exigência do eca. este orienta ainda que as situações de violência, de qualquer natureza, devam ser encaminhadas aos serviços de saúde, à assistência social em seu componente especializado, ao centro de referência especializado de assistência social (creas) e aos demais órgãos do sistema de garantia de direitos da criança e do adolescente, que deverão conferir máxima prioridade ao atendimento desse público, formulando projeto terapêutico singular que inclua intervenção em rede e, se necessário, acompanhamento domiciliar (10). o conselho tutelar é o órgão público encarregado de zelar pelo cumprimento dos direitos das crianças e dos adolescentes a partir da aplicação de medidas de proteção, atendimento e aconselhamento de pais ou responsáveis, requisição de serviços e realização de encaminhamentos à rede de referência (11). no entanto, vale ressaltar as dificuldades que esse órgão vem enfrentando, conforme demonstrou estudo realizado em minas gerais ao evidenciar limitações como: ausência de formação continuada para o exercício da função, ações pautadas segundo preceitos e convicções pessoais, excesso de burocracia no andamento dos casos e falta de estrutura física adequada (12). nesse sentido, ainda que se reconheça a importância do conselho tutelar, cabe considerar que a sua atuação é permeada por entraves, o que sinaliza a necessidade de a instituição de ensino criar outras estratégias de enfrentamento dos abusos. nessa perspectiva, outra estratégia elencada pelas educadoras para enfrentar a violência doméstica consiste na criação de espaços de acolhimento e escuta para os escolares. levando-se em conta que eles passam boa parte do tempo na escola, esse espaço deve ser um lugar seguro para a expressão de seus medos e preocupações com relação à violência vivenciada em casa (13). experiências na europa apontam que esses espaços favorecem a criação de laços e comunicação efetiva entre educando-educador, o que possibilita o estabelecimento de relações de confiança, essenciais para viabilizar a identificação de casos de abusos intrafamiliares e os encaminhamentos necessários (14). em que pesem as exitosas experiências mencionadas, é importante considerar que o reconhecimento do agravo, bem como de outras situações de vulnerabilidades a que os escolares se encontram expostos, não está condicionada à existência de um espaço físico, podendo tal identificação ocorrer em todo e qualquer processo de interação com o outro. a pedagogia freireana vem ratificar que a escola não é apenas um espaço físico com salas, lousas, horários e conceitos, mas um local de gente que lida com gente. portanto, a escola não é lugar apenas para estudar, mas também para construir amigos, trocar experiências, dialogar e, sobretudo, espaço privilegiado para a libertação (8). assim, mais importante que um espaço destinado para o acolhimento, é a postura profissional e sensível para tal. nesse sentido, estudo realizado na libéria destaca a importância de educadores e demais profissionais atuantes no ambiente escolar de, em todo e qualquer oportunidade de interação com os escolares, estarem atentos a comportamentos que indiquem situações de violência doméstica (15). segundo freire (8), essa interação torna-se possível quando a relação entre educador e educando acontece de forma horizontalizada, que favorece o vínculo e o afeto. nesse princípio da horizontalização, o processo de aprendizagem acontece de maneira dialógica e significativa, levando em consideração o contexto sociocultural do discente bem como suas vivências, o que possibilita a transformação da realidade e a superação da opressão. no entanto, a educação deixa de ser ferramenta para a libertação quando o(a) professor(a) acredita ser superior e detentor do conhecimento, e os discentes são meros depósitos de informações. nesse modelo tradicional, em que a forma de relação é verticalizada, o(a) professor(a) reprime elementos emocionais e afetivos dos alunos. nessa pedagogia, não há possibilidade de acolhimento, tampouco a possibilidade de o discente superar a opressão (8). para além da existência de espaços com fins no acolhimento dos escolares, as educadoras também assinalaram a necessidade de ações que viabilizassem a aproximação com os familiares, mencionando, inclusive, a realização de visitas domiciliares, já que alguns familiares não comparecem, quando solicitados, às reuniões escolares. a utilização da busca ativa de familiares e de escolares foi uma experiência desenvolvida na rede pública de ensino da cidade de recife, pernambuco, brasil. a inclusão da família no contexto escolar possibilita aos pais conhecerem as dificuldades de seus filhos, bem como participar de debates com os educadores. essa experiência dialógica promove a mudança de antigos hábitos e a construção de novas atitudes (8), além de denotar a preocupação da escola com os discentes, ao passo que favorece a aproximação entre educadores, estudantes e seus pais no intuito de estreitar os vínculos e formar uma parceria para enfrentar a violência, conforme estudo realizado em israel (16). 8 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1938 aquichan issn 1657-5997 eissn 2027-5374 considerando que o processo educativo é de responsabilidade de toda a sociedade, a lei de diretrizes e bases da educação nacional (ldb) de 1996 prevê, em seu artigo 12, o dever da escola em promover articulação com a comunidade e com a família do escolar. deve-se, ainda, existir a preocupação com o desempenho acadêmico do estudante, buscando compreender situações individuais e coletivas que podem estar afetando sua aprendizagem (17). essas preocupações também foram compartilhadas pelas educadoras entrevistadas, as quais defendem que o laço escola-família possibilita aos educadores estarem mais próximos das dificuldades que o discente enfrenta, de seu contexto, bem como de seus anseios e expectativas. assim, o espaço educacional, melhor articulado com pais e alunos, constitui-se como importante fonte de informação, o que permite identificar situações de vulnerabilidade e conflito (17). esses conflitos dentro do contexto familiar e social, muitas vezes, são próprios da adolescência, visto que essa fase é marcada pela busca de uma identidade própria, além das descobertas e emoções intensas (18). o anseio por novas experiências, com frequência, leva o jovem ao envolvimento com álcool e outras drogas ou a buscar uma identidade sexual condizente com seus desejos (18). na maioria das vezes, essas condutas geram embates dentro do contexto familiar que culminam em condutas de violência, uma vez que existe o entendimento pelos pais e/ou responsáveis de que essa é a melhor forma de resolução dessas situações (17). nesse sentido, instituições escolares sensibilizadas para as especificidades dessa fase de vida é essencial para o movimento de compartilhamento de estratégias para a resolução pacífica de conflitos e, em consequência, para a promoção de relações mais amistosas entre pais e filhos. para além de espaços de aproximação e escuta para discentes e seus familiares, as ações educativas, conforme sugerida no discurso coletivo, também representam importantes estratégias de enfrentamento dos abusos domésticos. estudo realizado no sudeste do brasil defende que ações educativas como discussões de situações-problema entre pais, filhos e escola, dramatizações e dinâmicas de grupo são de suma relevância para que os indivíduos resolvam situações conflituosas de forma respeitosa (19). estudo da áfrica do sul, realizado com adolescentes expostos a situações de violência, evidencia que as experiências educativas minimizaram questões de conflitos que geravam violência (20). no processo de utilizar ações educativas como meio de promoção à saúde, o teatro revela-se como tática que, no olhar das educadoras, favorece o reconhecimento dos conflitos por parte dos discentes e a elaboração criativa de soluções/saídas. estudos realizados na colômbia e na espanha evidenciaram que a dramatização, a exemplo do teatro, faz com que discentes participem de forma ativa, deixando que aflorem emoções, apareçam conflitos reprimidos, o que gera transformações e produz mudanças (21, 22). ademais, outro estudo espanhol revela que o uso de videogames educacionais proporciona ao discente a descoberta de potencialidades e habilidades, fazendo com que ele melhore seu desempenho escolar com benefícios inegáveis no aprimoramento do conhecimento linguístico, além de estimular o respeito ao próximo, visto que desenvolve formas de pensar e agir diante de suas vivências e práticas sociais (23). o discurso coletivo revela ainda que, para lidar com a complexidade que permeia os abusos intrafamiliares e as diversas demandas da pessoa vitimizada, urge a articulação de saberes, o que remete a parcerias com outros espaços. considerando que todo e qualquer profissional deve estar apto a reconhecer e intervir diante desse agravo, necessária se faz a inserção da temática no currículo básico dos cursos dos diferentes campos do saber. cabe destacar a experiência da ufba, que vem ofertando a disciplina optativa “abordagem interdisciplinar e transdisciplinar dos problemas de saúde relacionados à violência”. na modalidade de accs, esse componente já foi cursado por futuros profissionais da área de saúde, educação, dentre outras áreas (3). para além da formação de profissionais com aptidão para o reconhecimento, dentro do contexto escolar, de casos de violência doméstica, cabe referir acerca da importância de parcerias intersetoriais, com o enfoque na articulação entre os saberes interdisciplinares, para que haja ações que contemplem, de maneira holística, as demandas dos adolescentes (24). assim, a inserção de equipes multiprofissionais na escola, em estudo realizado em israel, oportuniza o trabalho com as demandas pessoais vivenciadas pelos estudantes e seus familiares, principalmente no que tange às experiências de violência doméstica, tendo em vista a bagagem teórico-metodológica que possuem (24). em estudo realizado em um município da bahia, constatou-se que a parceria com serviços socioassistenciais reduz o número de casos de violência, conflitos e até dificuldades de aprendizagem, uma vez que teriam os encaminhamentos e acompanhamentos adequados para o tratamento da questão (7). outra experiência de parceria intersetorial exitosa consiste no programa saúde na escola, que merece destaque devido à articulação das 9 estratégias de educadoras no âmbito da escola para prevenção e enfrentamento da vivência de violência doméstica pelos adolescentes l kátia cordélia cunha cordeiro e outros redes públicas de saúde e de educação que vem favorecendo o desenvolvimento da cidadania e da qualificação das políticas públicas brasileiras, além do reconhecimento dos casos de violência doméstica (19). importante salientar que os estabelecimentos de parcerias, assim como as demais estratégias pontuadas pelas educadoras, representam possibilidades a serem consideradas pela gestão educacional a fim de prevenir e enfrentar não só abusos intrafamiliares, como também outras situações de opressão a que os escolares se encontram expostos. o desvelamento de tais vulnerabilidades é essencial para que a escola repense seu planejamento de modo a criar condições para um pleno desenvolvimento humano desses adolescentes, conforme preconiza o eca. nesse sentido, entender a escola como um espaço de construções sociais e simbólicas requer a compreensão desse ambiente como formador não só de saberes, mas também de construção de cidadania. conclusões o discurso coletivo das educadoras revelou as seguintes estratégias possíveis de serem implementadas no âmbito da escola, no sentido de possibilitar a prevenção e o enfrentamento da vivência de violência doméstica pelos adolescentes: acionar o conselho tutelar, criar espaços de acolhimento e escuta para adolescentes, estreitar laços entre escola e família, promover ações educativas e articular saberes. embora este estudo seja limitado por não evidenciar a implementação de tais estratégias na escola investigada, contribui para indicar caminhos para a prevenção e o enfrentamento de abusos familiares que possam comprometer a saúde física e mental de crianças e adolescentes, com impactos sobre o desempenho escolar. considerando que a vivência de violência prejudica o desenvolvimento pleno do potencial das pessoas, é essencial a implementação de tais estratégias, sobretudo aquelas cujas interações com os adolescentes e familiares possibilitam a compreensão de que a violência doméstica tem sérias repercussões sobre a saúde e a qualidade de vida dos escolares. nesse sentido, destaca-se a promoção de espaços dialógicos, seja a partir do fortalecimento de vínculos com escolares e familiares, seja por meio de ações educativas voltadas para esses grupos. diante das repercussões da vivência de violência doméstica, salienta-se a relevância da atenção primária à saúde, por meio de ações vinculadas ao programa saúde na escola. tal parceria pode favorecer o reconhecimento dos casos mediante a inserção de profissionais da saúde na comunidade escolar ao tempo que envolvem os educadores em uma observação mais sensível para a possibilidade de ocorrência desse agravo. portanto, urge a necessidade de uma formação que contemple a temática nos diversos cursos de graduação, visto que cuidar das crianças e dos adolescentes e defendê-los constituem obrigação de todos os cidadãos. conflito de interesses: nenhum declarado.s 10 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1938 aquichan issn 1657-5997 eissn 2027-5374 referências 1. viola tw, salum ga, kluwe-schiavon b, sanvicente-vieira b, levandowski ml, grassi-oliveira r. the influence of geographical and economic factors in estimates of childhood abuse and neglect using the childhood trauma questionnaire: a 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http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s1578-84232017000200004&lng=es http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s1578-84232017000200004&lng=es https://doi.org/10.1007/s10826-015-0226-3 https://onlinelibrary.wiley.com/doi/pdf/10.1111/bjep.12212 https://onlinelibrary.wiley.com/doi/pdf/10.1111/bjep.12212 http://www.scielo.org.co/scielo.php?script=sci_abstract&pid=s1692-715x2017000200005&lng=en&nrm=iso&tlng=es http://www.scielo.org.co/scielo.php?script=sci_abstract&pid=s1692-715x2017000200005&lng=en&nrm=iso&tlng=es https://doi.org/10.1016/j.sbspro.2014.04.457 https://doi.org/10.1016/j.sbspro.2014.04.457 https://doi.org/10.1016/j.compedu.2015.06.006 https://doi.org/10.1016/j.compedu.2015.06.006 https://doi.org/10.1177/1066480718795121 https://doi.org/10.1177/1066480718795121 self-management program in adults with colorectal cancer: a pilot study articles  self-management program in adults with colorectal cancer: a pilot study* programa de automanejo en adultos con cáncer colorrectal: estudio piloto** programa de autogestão em adultos com câncer colorretal: estudo-piloto*** 10.5294/aqui.2023.23.1.7  óscar javier vergara escobar1 gloria mábel carrillo gonzález2 1 0000-0003-3158-9017 fundación universitaria juan n corpas, colombia oscar.vergara@juanncorpas.edu.co 2 0000-0003-4513-104x  universidad nacional de colombia, colombia gmcarrillog@unal.edu.co * extracted from the ph.d. thesis nursing intervention for self-management in adults with colorectal cancer undergoing surgical treatment, submitted to the ph.d. nursing program of the universidad nacional de colombia in 2020. ** extraído de la tesis de doctorado: intervención de enfermería para el automanejo en adultos con cáncer colorrectal en tratamiento quirúrgico, presentada al programa de doctorado en enfermería de la universidad nacional de colombia, en el año 2020. ***extraído da tese do doutorado “intervenção de enfermagem para a autogestão em adultos com câncer colorretal em tratamento cirúrgico”, defendida no âmbito do programa de doutorado em enfermagem da universidad nacional de colombia, em 2020. theme: evidence-based practice. contribution to the discipline: the study contributes to the design of a nursing intervention that takes up approaches from the theory of individual and family self-management through the integration of aspects not only of instruction, education, and follow-up but also the strengthening of the role of human talent as “facilitator” and guide of processes that the patient must consolidate. received: 30/12/2021 sent to peers: 31/05/2022 approved by peers: 12/08/2022 accepted: 12/12/2022 para citar este artículo / to reference this article / para citar este artigo: carrillo gm, vergara oj. self-management program in adults with colorectal cancer: a pilot study. aquichán. 2023;23(1):e2317. doi: https://doi.org/10.5294/aqui.2023.23.1.7 abstract objective: to design and validate a nursing intervention and its effect on improving self-management behaviors in patients with colorectal cancer following surgery within eight weeks after discharge. method: pilot study using sidane and braden’s intervention design proposal, which included determining the guiding theoretical model, characterization of the intervention, validation with eight experts through content validity, and a pilot test with ten patients during the second semester of 2020. results: the intervention obtained, called the program for self-management training in colorectal cancer (peaccr, by its acronym in spanish), is based on the theory of individual and family self-management in the dimensions proposed by ryan and sawin. the validity with experts indicates that it meets the criteria of clarity, precision, comprehension, relevance, and pertinence. the pilot reports an increase in self-management behaviors and the dimensions of knowledge, coping, and health personnel-patient alliance in months 1 and 2, with statistical significance. conclusions: the designed and validated intervention increases the self-management behaviors of patients with colorectal cancer. the proposed scheme is highly acceptable to participants. keywords (source: decs): self-management; colonic neoplasms; patient discharge; treatment outcome; evaluation of the efficacy-effectiveness of interventions; nursing. resumen objetivo: diseñar y validar una intervención de enfermería y su efecto para mejorar los comportamientos de automanejo en pacientes con cáncer colorrectal, después de una intervención quirúrgica dentro de las ocho semanas posteriores al alta. método: estudio piloto que acoge la propuesta de diseño de intervenciones de sidane y braden, lo que incluyó determinar el modelo teórico orientador, la caracterización de la intervención, la validación con ocho expertos a través de la validez de contenido, y una prueba piloto con diez pacientes, durante el segundo semestre del año 2020. resultados: la intervención obtenida, denominada programa para el entrenamiento en automanejo en cáncer colorrectal (peaccr), se basa en la teoría de automanejo individual y familiar en las dimensiones planteadas por ryan y sawin. la validez con expertos indica que cumple con los criterios de claridad, precisión, comprensión, relevancia y pertinencia. el piloto reporta un aumento en los comportamientos de automanejo y en las dimensiones de conocimiento, afrontamiento y alianza personal de salud-paciente en el mes 1 y en el mes 2, con significancia estadística. conclusiones: la intervención diseñada y validada aumenta los comportamientos de automanejo de pacientes con cáncer colorrectal. el esquema propuesto es de alta aceptabilidad para los participantes. palabras clave (fuente decs): automanejo; neoplasias del colon; alta del paciente; resultado del tratamiento; evaluación de eficacia-efectividad de intervenciones; enfermería. resumo objetivo: desenhar e validar uma intervenção de enfermagem e seu efeito para melhorar os comportamentos de autogestão em pacientes com câncer colorretal, depois de uma intervenção cirúrgica dentro das oito semanas posteriores à alta. materiais e método: estudo-piloto que utiliza a proposta de desenho de intervenções de sidane e braden, o que inclui determinar o modelo teórico orientador, a caracterização da intervenção, a validação com oitos especialistas por meio da validade de conteúdo e um teste-piloto com dez pacientes, durante o segundo semestre de 2020. resultados: a intervenção obtida, denominada “programa para o treinamento em autogestão em câncer colorretal”, está baseada na teoria de autogestão individual e familiar nas dimensões propostas por ryan e sawin. a validade com especialistas indica que cumpre com os critérios de clareza, precisão, compreensão, relevância e pertinência. o piloto relata um aumento nos comportamentos de autogestão e nas dimensões de conhecimento, enfrentamento e parceria pessoal de saúde-paciente no mês 1 e no mês 2, com significância estatística. conclusões: a intervenção desenhada e validada aumenta os comportamentos de autogestão de pacientes com câncer colorretal. o esquema proposto é de alta aceitabilidade para os participantes. palavras-chave (fonte: decs): autogestão; neoplasias do colo; alta do paciente; resultado do tratamento; avaliação de eficácia-efetividade de intervenções; enfermagem. introduction colorectal cancer (crc) is a neoplastic disease of public health interest of a preventable type; however, in colombia for the year 2020, it is estimated that 10,783 people suffered from this disease, corresponding to 10.4 % of crc cases in south america. compared to other countries in the region, colombia ranks third in the prevalence of crc, after brazil and argentina; by 2020, 54,987 people died of this cause in colombia. in addition, the carvalho study provides evidence that cancer is related to lifestyle, dietary changes, and variations in crc risk factor prevalence by sex. this epidemiological profile shows how, in both developed and developing countries, this disease is among the main causes of morbidity and mortality, causing economic consequences in the health system and deterioration in the quality of life of people in terms of physical, psychological, emotional, social and spiritual well-being (1). the treatment of crc includes surgery as the therapeutic option of choice in most cases. these treatments generate side effects, which involve modification of lifestyles, limitation, mutilation, and social and occupational readaptation (2). the experience of people with crc is a difficult experience that affects self-image since it involves learning to manage ostomies, adapting to the diet, facing a high emotional burden and uncertainty about the prognosis, as well as readapting to daily life without support and follow-up of the health team (3). the current regulatory framework and scientific associations report the need to consolidate follow-up interventions for cancer patients (4) that include all phases of the disease and impact quality of life, are cost-effective, and encourage self-management with follow-up after surgery. however, self-management is a strategy and one of the four goals of the strategic framework for improving the health status of individuals with multiple chronic diseases (5), which proposes to go beyond information to actively teach people to detect and solve the problems associated with the disease. self-management programs should facilitate decision-making that favors well-being and involve dynamic, interactive processes of time, repetition, and reflection; they are accompanied by follow-up with the use of information and communication technologies, as effective strategies to manage the most frequent symptoms, such as pain (6), adherence to treatment, tolerance, physical activity and satisfaction with care. for (7), self-management is defined as the assessment, planning, and implementation of appropriate care that allows the patient to cope with the disease until death through self-management and treatment of the disease and its side effects. a key aspect is that self-management support can provide more patientand family-centered care when dealing with life-threatening illnesses. for their part, (8) state that for self-management to be developed, the benefits of these programs must be identified in the populations involving health personnel and the health system to facilitate adherence and decision-making and to improve self-management skills to cope with a chronic disease. nursing has a fundamental role in implementing interventions aimed at promoting the self-management of patients with crc to mitigate consequences, such as uncertainty, lack of knowledge about the disease, isolation, fear of recurrence, lack of decision-making, and loss of control over health. in this sense, it is required to go beyond managing skin lesions, post-surgical stoma, chemotherapy management, or unpleasant symptoms in people with crc, as this is a determinant that allows taking a position in the context and becomes a challenge for health care. however, several theoretical references addressing self-management, among which the mid-range nursing theory (individual and family self-management theory [ifsmt]) of (9), define it as a complex and dynamic phenomenon consisting of three dimensions: context, process, and outcome. contextual factors are the dimensions that influence individual and family management of the self-management process and directly impact outcomes. they can be protective or risky and include: a) specific conditions: the complexity of the condition, treatment, and trajectory; b) the physical and social environment, including access to care, transition adjustment, providers, transportation, social and cultural capital; c) individual and family conditions: the family’s state of development, perspectives, level of schooling, information process and capabilities (9). the self-management process, in turn, includes a) knowledge and beliefs about self-efficacy, outcome expectancy, and goal congruence; b) self-regulation, skills, and abilities: goal setting, self-monitoring and reflective thinking, decision making, planning and action, self-evaluation, and emotional control; c) social facilitation, which involves influence, support, and collaboration between individuals, families, and health professionals. finally, the result can be proximal or distal. the proximal focuses on the self-management behavior of the specific condition and the cost of health services; the distal, on the other hand, on health status, quality of life or well-being, and the costs of both direct and indirect health services. accordingly, the study’s objective was to design and validate an intervention based on the postulates of the nursing theory of individual and family self-management according to the context and the characteristics of access to the system of people with crc (9). method a pilot study using the methodology of (10) regarding the design of interventions. it includes the following steps: a) definition of the problem; b) characteristics of the problem; c) definition of the intervention; d) characterization of the intervention; e) validation of the intervention by experts who validated the understanding of the intervention based on the theoretical conceptualization and the operationalization of the activities in the proposed sessions; f) pilot test of the implementation of the intervention. for the validation of the intervention, the sample consisted of eight experts in surgical oncology who reviewed the proposed content and format for the implementation of the intervention. the pilot implementation test included a sample of ten users who met the inclusion criteria to determine the instructional and predictive value of the intervention. the intervention was initially applied in a tertiary care hospital in bogota, and the follow-up was done through home visits. participants completed the intervention in its entirety and filled out the scale of self-management behaviors before the intervention and at one month and two months after hospital discharge. instruments and measurement for validation by the experts, an ad hoc sheet was prepared to rate the clarity, precision, comprehension, relevance, and pertinence of the proposed intervention and the content of the educational material. in the pilot test with patients, the pih (partners in health) instrument was used, which measures self-management behaviors and comprises the dimensions of self-management knowledge, with scores from 0 to a maximum of 16, physician/patient alliance, from 0 to a maximum of 32, symptom recognition, from 0 to 16, and coping, from 0 to 32 (11). the sum of minimum and maximum scores ranged from 0 to 96, the results being interpreted as higher scores implying greater self-management behaviors. finally, an ad hoc card was prepared to monitor the implementation of the intervention in terms of knowledge, understanding, satisfaction, and usefulness of the intervention, as well as the identified distractions or interruptions and the additional observations of the participants. data analysis content validation (12) of the main components of the intervention was carried out. the experts rated on a five-point likert-type scale, where 1 is total disagreement and 5 is total agreement, the clarity, accuracy, comprehension, relevance, and pertinence of the material’s content. the grade attributed for each of the components was considered and, based on this, the weighted average of the options indicated in the likert scale with a variation from 1 to 5 points, where 1=0; 2= 0.25; 3= 0.5; 4= 0.75 and 5=1. averages greater than or equal to 0.8 were considered “highly adequate,” between 0.5 and 0.79 “adequate,” and below 0.5 “not adequate.” for the data analysis of the pilot test with patients, the spss v23 package was used. for the comparison of the self-management behaviors variable, the friedman test was used. for significance (which allows establishing pretest differences concerning months 1 and 2), values of p < 0.05 were considered statistically significant. the follow-up components of the intervention were analyzed in percentages, according to the number of appraisals expressed by the participants. in relation to ethical aspects, those related to informed consent, voluntary participation, and confidential handling of information were considered. they also had the endorsement of the institutional ethics committee and the research ethics committee of the faculty of nursing of the universidad nacional de colombia in the session of september 11, 2017 – minute number 13, and the requirements demanded by the standard 8430 of 1993 by which the scientific, technical, and administrative guidelines for health research in colombia are established (13). results the results obtained from (10) are described below: a. definition of the problem: people with crc need to develop self-management behaviors once they leave the health care institution after surgery. b. problem characteristics: issues related to the determinants and levels that affect the state of health and that may be in the biopsychosocial, physical, psycho-behavioral, and social domains: 1) symptom management and activities of daily living; 2) knowledge and beliefs; 3) treatment adherence; 4) emotion and stress management; 5) decision making; 6) skills and abilities. c. definition of the intervention: program for self-management training in colorectal cancer (peaccr, by its acronym in spanish), based on individual and family theory and taking up the process elements that include knowledge and beliefs, self-regulation, skills and abilities, and social facilitation. d. characterization of the intervention: the intervention consists of five sessions, three face-to-face and two via telephone follow-up. each session takes place at a specific time, according to the phase of the surgical treatment, and with a specific objective (table 1). table 1. peaccr scheme session moment-process in which it is carried out objective duration 1 knowledge and beliefs before and during surgery weeks 1 and 2 after surgery to generate a space for getting to know people in the process of caring for their health condition and to explore beliefs, expectations, and the generation of a goal plan. 60 minutes 2 self-regulation, skills, and abilities inpatient (hospitalization) and outpatient services weeks 2-3 individual approach to generate an action plan for goal setting, self-monitoring, and reflective thinking regarding the health condition. indications on basic health condition care: diet and nutrition, exercise, and activities of daily living. 60 minutes 3 social facilitation postoperative control and outpatient clinic weeks 3-4 to generate a space that allows recognizing the social facilitation that the person has for the self-management of his/her health. 60 minutes 4 follow-up 1 postoperative control and outpatient clinic weeks 5-6 individual follow-up of the self-management plan and evaluation of compliance with goals. self-regulation support, skills, and abilities. 20-30 minutes 5 follow-up 2 postoperative control and outpatient clinic weeks 7-8 follow-up on goals achievement. 20-30 minutes note: according to the access conditions, there will be a telephone line and whatsapp to answer questions and guide patients and caregivers. source: prepared by the authors. e. validation of the intervention through expert opinion: experts indicate that the intervention meets the criteria of clarity, accuracy, comprehensibility, relevance, and pertinence (table 2). table 2. content validation by experts sessions clarity precision comprehension relevance pertinence knowledge and beliefs 0.80 0.83 0.83 0.88 0.80 self-regulation, skills, and abilities 0.83 0.80 0.83 0.80 0.80 social facilitation 0.86 0.86 0.91 0.88 0.88 self-management plan follow-up 0.72 0.86 0.88 0.91 0.88 self-management plan follow-up 0.80 0.86 0.94 0.88 0.88 source: prepared by the authors. as recommendations of the experts, it is suggested to a) provide a demonstration workshop to patients who leave with colostomies in the presence of the family; 2) provide education on nutrition and management of alarm signs and symptoms; 3) use various means of follow-up communication. f. pilot test of intervention implementation: the implementation of the intervention was carried out with ten patients diagnosed with adenocarcinoma of the colon, colorectal, or rectum, who were admitted to an oncology care center in bogotá, five of whom were female. ages ranged from 40 to 87 years; most were crc stage iiib; the type of treatment received was total colectomy, tumor resection, proctosigmoidectomy, or sigmoidectomy. most have a home occupation, with low levels of schooling and socioeconomic stratum 3; of the 10 participants, 6 had a colostomy (table 3). table 3. characteristics of the participants in the pilot intervention study participant level of education occupation socioeconomic stratum stage type of treatment 1. male, 60 years old, married low self-employed 2 iiib total colectomy 2. female, 63 years old, married average housewife 3 iia anterior tumor resection 3. female, 87 years old, married low housewife 3 iii anterior tumor resection 4. female, 55 years old, common-law marriage average housewife 2 iiib total colectomy 5. male, 69 years old, married average housewife 3 iia proctosigmoidectomy 6. male, 40 years old, single high employed 2 ii anterior rectal resection 7. female, 48 years old, separated high self-employed 3 iiib sigmoidectomy and bypass 8. male, 62 years old, married low self-employed 2 iiib colectomy 9. female, 66 years old, common-law marriage low retired 2 iiib hemicolectomy y anastomosis 10. male, 63 years old, married low self-employed 3 iia sigmoidectomy source: prepared by the authors. self-management behaviors in terms of self-management behaviors, a mean of 67.4 was reported at the beginning of the intervention (pretest). at month 1, an increase in these behaviors is identified (mean 78.6, sd 10.1), as well as in the second month (mean 86.6, sd 8.1), with statistically significant differences between the periods (p 0.000). in the analysis by dimensions, an increase in values was identified in all of them, both in months 1 and 2, and with statistical significance in self-management knowledge (p 0.003), coping (p 0.035), and health personnel-patient alliance (p 0.045) (table 4). table 4. self-management behaviors in the pretest, month 1, and month 2 of the intervention variable possible scores time average ds min max p value* self-management behaviors 0 to 96 pretest 67.4 17.5 37 92 0.002 month 1 78.6 10.1 56 93 month 2 86.6 8.1 74 96 coping 0 to 32 pretest 23.0 9.0 8 32 0.035 month 1 25.0 5.4 17 31 month 2 28.9 3.1 24 32 knowledge in self-management 0 to 16 pretest 8.5 4.1 2 16 0.003 month 1 10.8 3.5 5 16 month 2 12.9 2.2 10 16 health personnel-patient alliance 0 to 32 pretest 23.5 5.6 16 32 0.045 month 1 28.7 3.8 20 32 month 2 29.6 3.5 23 32 symptom recognition 0 to 16 pretest 12.4 4.8 2 16 0.291 month 1 14.1 1.7 11 16 month 2 15.2 0.8 14 16 * friedman test. statistical significance p 0.005 source: prepared by the authors. regarding the aspects evaluated during the implementation of the intervention, 100 % of the participants reported that a high level of knowledge was obtained, so they have a high level of impression, satisfaction with the proposed format, understanding, and perceive the usefulness of the information provided. among the distractors, in the health care institution, the procedures to be carried out for authorizations and medical appointments, and in the home, other tasks that arise daily, such as childcare and household responsibilities, are mentioned. the 20 % suggest more time for the sessions and accompaniment by the institution once they have left. discussion the study contributes to the design of an intervention that takes up approaches from the theory of individual and family self-management, not only through the integration of aspects of instruction, education, and follow-up but also by strengthening the role of human talent as “facilitator” and guide of processes that the patient must consolidate. the person with a health condition is assigned an active and leading role, which implies making decisions and developing skills based on the knowledge and beliefs derived from the context in which he/she is immersed. regarding how the intervention is provided, i.e., the number of sessions and the time allocated for them, acceptability is identified by the participants, with high satisfaction, comprehensibility, and perceived usefulness. the program offers a format that highlights the patient’s needs under the person-centered care model (14) and includes a self-management plan based on the goals and challenges that the patient reflects upon. although the instruction and information component is essential, the aim is to transcend to other issues, which will probably have a greater impact on the user in terms of reincorporation into daily activities and personal perspective. this scheme contrasts with interventions carried out at the local level, which maintain an outline towards conventional education and follow-up in the colombian context with chronic patients (15,16). regarding the efficacy of the intervention on the outcome variable, the study reported an increase in self-management behaviors and the dimensions of coping health personnel-patient alliance, and knowledge of the disease. these findings are consistent with those reported in other studies with chronic patients (17,18), in which the approach to specific conditions predominates in relation to information, medication administration, symptom management, improvement of self-regulation and social support. considering the timing of the intervention to achieve an impact on self-management outcomes, this pilot is close to the proposal of (19), who generated a six-week asynchronous online self-management program for chronic diseases (arthritis, asthma, cancer, copd, diabetes, heart disease, and mental health conditions). however, the effects were obtained only up to six and twelve months after the intervention; in contrast, with prostate cancer patients, the interventions were effective at eight months due to the direct contact of the health care team and monitoring (20) to achieve self-management behavior. according to (21), self-management interventions provide the necessary training for informed decision-making (22) for initial treatment and to assist in long-term symptom management in cancer survivors (21). this pilot study was able to recognize that satisfaction with health care was significant from the beginning of the intervention. it should be noted that the aim was to consolidate a comprehensive strategy that would be easy to apply and feasible to replicate in local health services, where the postoperative follow-up scheme is limited. this coincides with what carrillo et al. stated when they affirmed that the educational intervention carried out by nursing personnel with caregivers of adults with cancer undergoing coordinated surgery, which includes assessment upon admission to the institution, delivery of educational material, face-to-face instruction and specific information, demonstrative workshop, and telephone follow-up, increases home care competence in its six dimensions and decreases caregiver overload (23). however, online intervention studies (24) should be designed to provide a feasible and effective alternative to in-person support, with diversity in social and cultural aspects. regarding information, this should be precise, simple, and short, including aspects such as self-management, coping, psycho-educational support, lifestyles, body image, and mental health (25), on issues such as depression, fatigue, and distress during treatment (26) in cancer patients (27). skills and abilities require personalized instruction, simulation, and follow-up (28). the meta-analysis by medina et al. allowed grouping the assessment of the efficacy of self-management in relation to medication compliance, lifestyle changes, and modification of clinical variables (29), key variables to be taken into account in future intervention studies. this program also indicates the need for nurses —trained in innovative roles— who can provide ongoing support and feedback to participants using available support networks (30). for example, the provision of nurse navigators or case managers —who coordinate care and access to information— has demonstrated benefits in cancer patients who present emotional symptoms during diagnosis and treatment related to the impact on quality of life and psychosocial problems, which from the nurse’s role can be addressed, developing expected competencies to demonstrate results in care that will improve the quality of care and clinical outcomes (31,32). in this sense, effective implementation implies several challenges, for which it is necessary to visualize people in their context, considering not only their needs (33) but also the resources they possess and have acquired during their lives. hence, the educational role is essential to address self-management programs (34), with nurse navigators that facilitate the process of health recovery (35) from a human perspective. according to (36), people with cancer have poor self-management practices. and in this intervention, factors of self-management behaviors were identified that might, in future studies, be related to the quality of life, so it is suggested to continue researching and deepening to identify other factors associated with self-management in these people with crc. the present study confirms the importance and relevance of developing self-management programs in the care of cancer patients. the results may contribute to a better understanding of the self-management approach as a proximal health outcome indicator. it will serve as a reference for estimating effect and sample size calculations in randomized controlled clinical trials. on the other hand, contextual factors that may affect the successful implementation of this program to enrich follow-up approaches in the routine care of outpatients with complex health conditions are glimpsed. it is also necessary to explore the effects on service utilization and to determine whether the benefits obtained from participation in a self-management program can be sustained over time. likewise, it is necessary to design recruitment strategies to minimize attrition rates and ensure the participation and motivation of more people to analyze these results in other latin american contexts (37). conclusions the designed and validated intervention shows promising preliminary results in increasing patients with colon and rectal cancer self-management behaviors. the proposed scheme is highly acceptable to the participants, provides conceptual elements derived from a mid-range theory, as well as procedural aspects to determine effectiveness and impact in controlled clinical trials, intending to implement and replicate it in outpatient follow-up phases in cancer patients, where the role of the health worker allows guiding the decision making of patients in health services. conflict of interest: none declared. references 1. carvalho, tcd, borges, akdm, koifman, rj, da silva, ifd. time trends in colorectal cancer incidence in four regions of latin america: 1983-2012. cad saúde pública. 2021;37(10):e00175720. doi: https://doi.org/10.1590/0102-311x00175720 2. waller a, forshaw k, bryant j, carey m, boyes a, sanson-fisher r. preparatory education for cancer patients undergoing surgery: a systematic review of volume and quality of research output over time. patient education and counseling. 2015;98(12):1540-1549. doi: https://doi.org/10.1016/j.pec.2015.05.008 3. brown s, 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https://doi.org/10.4103/apjon.apjon_56_18 35. shusted cs, barta ja, lake m, brawer r, ruane b, et al. the case for patient navigation in lung cancer screening in vulnerable populations: a systematic review. popul health manag. 2019;22(4):347-361. doi: https://doi.org/10.1089/pop.2018.0128 36. gutiérrez-gómez t, peñarrieta-de córdova m, malibrán-luque d, piñones-martínez m, cosme-mendoza m, gaspar meza de nalvarte n. factores emocionales asociados al automanejo en personas con diagnóstico de cáncer. enferm univ 2021;18(2):63-77. doi: https://doi.org/10.22201/eneo.23958421e.2021.2.957 37. malibrán-luque dj, piñones-martínez ms, gutiérrez-gómez t, rivero-álvarez rp, lévano-cárdenas mg, vejarano-campos g.j. diferencias del automanejo en personas con enfermedades crónicas en población peruana. enferm univ 2021;18(1):43-55. doi: https://doi.org/10.22201/eneo.23958421e.2021.1.951 home cerrar a ro m at he ra py o n ps yc ho -e m ot io na l s ym pt om s an d fa ti gu e in n ur si ng p ro fe ss io na ls in t he c o v id -1 9 se tt in g 1 beatriz farias alves yamada  https://orcid.org /0000-0001-6673-6756 instituto beatriz yamada, brazil  iby@institutobeatrizyamada.com.br  paula helena caldas seixas  https://orcid.org /0000-0001-7737-042x universidade de são paulo, brazil  paulaa _seixas@usp.br isabelle lourenço fedel  https://orcid.org /0000-0002-0878-9793 universidade de são paulo, brazil  isafedel@usp.br ruth natalia teresa turrini  https://orcid.org /0000-0002-4910-7672 universidade de são paulo, brazil  rturrini@usp.br juliana rizzo gnatta  https://orcid.org /0000-0001-8689-5762 universidade de são paulo, brazil  juliana.gnatta@usp.br artículo aromatherapy on psychoemotional symptoms and fatigue in nursing professionals in the covid-19 setting received: 05/04/2022 sent to peers: 14/07/2022 approved by peers: 13/09/2022 accepted: 13/09/2022 doi: 10.5294/aqui.2022.22.4.5 para citar este artículo / to reference this article / para citar este artigo yamada bfa, seixas phc, fedel il, turrini rnt, gnatta jr. aromatherapy on psycho-emotional symptoms and fatigue in nursing professionals in the covid-19 setting. aquichan. 2022;22(4):e2245. doi: https://doi.org/10.5294/aqui.2022.22.4.5 https://orcid.org/0000-0001-6673-6756 https://orcid.org/0000-0001-7737-042x mailto:paulaa_seixas@usp.br https://orcid.org/0000-0002-0878-9793 mailto:isafedel@usp.br https://orcid.org/0000-0002-4910-7672 mailto:rturrini@usp.br https://orcid.org/0000-0001-8689-5762 mailto:juliana.gnatta@usp.br https://doi.org/10.5294/aqui.2022.22.4.5 https://doi.org/10.5294/aqui.2022.22.4.5 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2022.22.4.5&amp;domain=pdf&amp;date_stamp=2022-10-28 subject: health promotion and prevention contribution to the subject: this study contributes by increasing knowledge on aromatherapy and essential oils, especially their use among nurses who experience stress in times such as during the covid-19 pandemic. in addition, it encourages the production of more studies on alternative therapies. a ro m at he ra py o n ps yc ho -e m ot io na l s ym pt om s an d fa ti gu e in n ur si ng p ro fe ss io na ls in t he c o v id -1 9 se tt in g 3 abstract objective: to compare the effectiveness of aromatherapy with lavender essential oil (eo) versus an eo synergy on psycho-emotional symptoms and fatigue of nursing professionals in the covid-19 setting. materials and methods: this is a quasi-experimental pilot study conducted in 2020. the professionals were randomized in group 1 — lavender, and in group 2 — lavender and other eos synergy. the instruments were validated in brazil, namely the self-reporting questionnaire (srq-20) and the fatigue pictogram, which were applied at three moments: before the intervention, after 21 days of intervention, and three weeks after the end of the intervention follow-up. the data were evaluated using pearson’s x2 test or fisher’s exact test (dichotomous variables) and student’s t-test or mann-whitney test (continuous variables). results: a total of 18 professionals participated, and both groups presented improved srq-20 scores (p < 0.010), which was maintained in the follow-up for group 1 compared to the pre-intervention moment (p = 0.033). there was a significant decrease in fatigue in professionals in both groups (p = 0.010), but no difference was observed in the improvement of the impact of fatigue on daily life. conclusions: there was a reduction in psycho-emotional symptoms and fatigue in nursing professionals who used aromatherapy during the covid-19 pandemic in both groups. keywords (fonte: decs) aromatherapy; psychic symptoms; nursing staff; fatigue; disease prevention. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 45 4 resumen objetivo: comparar la efectividad de la aromaterapia con aceite esencial (ae) de lavanda versus una sinergia de ae en síntomas psicoemocionales y fadiga de profesionales de enfermería en el marco de la pandemia ocasionada por la covid-19. materiales y método: estudio piloto casi-experimental realizado en 2020. se hizo randomización de los profesionales en grupo 1 — lavanda y grupo 2 — sinergia lavanda y otros ae. instrumentos validados en brasil, self-reporting questionnaire (srq-20) y pictograma de fadiga, se aplicaron en tres momentos: antes de la intervención, luego de 21 días de intervención y tres semanas tras el término de la intervención follow-up. se evaluaron los datos por la prueba x2 de pearson o prueba exacta de fisher (variables dicotómicas) y por la prueba t de student o mann-whitney (variables continuas). resultados: participaron 18 profesionales y ambos grupos mostraron mejores puntuaciones del srq-20 (p < 0,010), que se mantuvo en el follow-up para el grupo 1, comparado al momento preintervención (p = 0,033). hubo disminución significativa de la fadiga de los profesionales en los dos grupos (p = 0,010), pero no se observó diferencia en la mejoría del impacto de la fadiga en la vida diaria. conclusiones: hubo reducción en los síntomas psicoemocionales y la fadiga de profesionales de enfermería que emplearon aromaterapia durante la pandemia de la covid-19 en ambos grupos.  palabras clave (fuente: decs) aromaterapia; síntomas psíquicos; equipo de enfermería; fatiga; prevención de enfermedades. aromaterapia en los síntomas psicoemocionales y fatiga en profesionales de enfermería en el marco de la covid-19 a ro m at he ra py o n ps yc ho -e m ot io na l s ym pt om s an d fa ti gu e in n ur si ng p ro fe ss io na ls in t he c o v id -1 9 se tt in g 5 aromaterapia nos sintomas psicoemocionais e fadiga em profissionais de enfermagem no contexto da covid-19 resumo objetivo: comparar a efetividade da aromaterapia com óleo essencial (oe) de lavanda versus uma sinergia de oe em sintomas psicoemocionais e fadiga de profissionais de enfermagem no contexto da covid-19. materiais e método: estudo-piloto quase-experimental realizado em 2020. os profissionais foram randomizados em grupo 1 — lavanda e grupo 2 — sinergia lavanda e outros oe. instrumentos validados no brasil, self-reporting questionnaire (srq-20) e pictograma de fadiga, foram aplicados em três momentos: antes da intervenção, após 21 dias de intervenção e três semanas após o fim da intervenção follow-up. os dados foram avaliados pelo teste x2 de pearson ou teste exato de fisher (variáveis dicotômicas) e pelo teste t de student ou mann-whitney (variáveis contínuas). resultados: participaram 18 profissionais e ambos os grupos mostraram melhora nos escores do srq-20 (p < 0,010), que se manteve no follow-up para o grupo 1, comparado ao momento pré-intervenção (p = 0,033). houve diminuição significativa da fadiga dos profissionais nos dois grupos (p = 0,010), porém não se observou diferença na melhora do impacto da fadiga na vida diária. conclusões: houve redução nos sintomas psicoemocionais e na fadiga de profissionais de enfermagem que utilizaram aromaterapia durante a pandemia da covid-19 em ambos os grupos. palavras-chave (fonte: decs) aromaterapia; sintomas psíquicos; equipe de enfermagem; fadiga; prevenção de doenças.  a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 45 6 introduction mass tragedies, such as those involving infectious diseases, can trigger psycho-emotional states such as depression, anxiety, and fear, influencing behavior and psychological well-being (1), as observed during the pandemic caused by the coronavirus disease (covid-19). as a result, frontline healthcare professionals have presented symptoms of depression, anxiety, anguish, and insomnia due to fear and concern over their own health and that of their colleagues and family members (2). an ethiopian study (3) found a 21.5 % prevalence of depression in healthcare professionals, and a chinese study (4) with medical and nursing participants in wuhan, china, who worked during the covid-19 epidemic, found a higher risk of mental health impairment in women, nurses, and frontline personnel. the work of nursing professionals in pandemic contexts, in addition to contributing to the onset of psycho-emotional symptoms and mental disorders, is marked by fatigue—which triggers a state of tiredness that is not relieved by usual strategies for restoring energy (5)—and can lead to exhaustion. professionals exposed to work during the covid-19 pandemic experience symptoms of stress, anxiety, fear, insomnia, anger, and denial, in addition to perceived well-being distress (6). among the approaches used to address wellness promotion and disease prevention, there is a growing interest in integrative and complementary health practices (icps), such as aromatherapy. aromatherapy consists of using essential oils (eo), which are volatile concentrates extracted from plants, to promote well-being in a physical, mental, and emotional approach (7); they are natural remedies with great potential for adjusting health conditions, including emotional ones. a clinical trial that evaluated the effects of inhaling an eo synergy composed of lemon, eucalyptus, tea tree, and mentha piperita on stress, sleep quality, and immunity found that there was a reduction in perceived stress, depression, and improved sleep quality (8). another study noted that an eo synergy composed of true lavender, sweet orange, and bergamot improves symptoms of depression (9). analysis of the effect of inhaling lavender eo on preoperative anxiety identified a decrease in mean anxiety scores in female patients prior to undergoing surgery (10). an integrative review of the therapeutic uses of lavandula angustifolia concluded it provides benefits, such as reducing blood pressure and heart and respiratory rates, in addition to reducing stress, fatigue, anxiety, pain, and insomnia (11). in this sense, aromatherapy may represent a simple self-care practice to manage psycho-emotional symptoms and fatigue in nursing professionals who experienced the pandemic in their care practices; it is easy to use in the professionals’ daily routine and of great value to reduce or avoid the need to use controlled medications. a ro m at he ra py o n ps yc ho -e m ot io na l s ym pt om s an d fa ti gu e in n ur si ng p ro fe ss io na ls in t he c o v id -1 9 se tt in g 7 when considering the nursing professionals’ work environment during the pandemic, can aromatherapy be beneficial to alleviate this physical and psycho-emotional state? in this sense, this study aimed to compare the effectiveness of aromatherapy with lavender eo (lavandula augustifolia) versus a synergy with lavender oil associated with other eos on psycho-emotional and fatigue symptoms of nursing professionals in the covid-19 setting. in the hypothesis of nullity, both formulas have equivalent effects. in the alternative hypothesis, the aromatic synergy was considered to be more effective in relieving physical and emotional symptoms than aromatherapy performed with the lavender eo alone. materials and methods type of study this is a quasi-experimental pilot study of the before-and-after type, conducted between september and december 2020. population and study site the non-probability, convenience sample consisted of nursing professionals from a public teaching hospital of secondary healthcare who met the following inclusion criteria: being part of the nursing team; obtaining a score > 8 in the self-reporting questionnaire instrument (srq-20 [12]), and a moderate to severe score in the fatigue pictogram (13). the exclusion criteria were being on vacation during the study period, being pregnant, or rejecting the eo aromas used in the study. intervention the two interventions described below were applied. • group 1 (lav): aromatherapy with lavender oil (lavandula augustifolia) with 2.5 %. this formula was prepared with 15 drops of lavender eo and fractionated coconut oil until it completed 30 ml. • group 2 (eosin): aromatherapy with a synergy composed of lavender (lavandula augustifolia) associated with sweet orange (citrus aurantium dulcis), sicilian lemon (citrus limonum), bergamot (citrus aurantium bergamia), eucalyptus globulus (eucalyptus globulus), basil (ocimum basilicum), peppermint (mentha piperita), and geranium (perlagonium graveolens) eos. the concentration of each oil was 2.5 %. the eos synergy was formulated as follows: 15 drops of the eos (7 of lavender, 2 of basil, and 1 drop each of the other eos) fractionated with coconut oil to complete 30 ml. the eo formulas were offered in an amber glass bottle with a roll-on valve with a 10 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 45 8 ml capacity of these solutions, according to the study group, for personal and individual use. the participants were instructed to apply them to their skin four times a day for 21 days. the preparation of the eos and the intervention were carried out by two nurses trained in aromatherapy. the participants were instructed to perform a five-step eo application technique: i. sanitize their hands with soap and running water or a liquid alcohol product; ii. clean the left and right retroauricular region with a gauze moistened with a small dab of soap and water or cleaning with liquid alcohol; iii. dry the right and left retroauricular region; iv. rub the eo roll onto one of their fingers until moist, and v. apply it in the left and right retroauricular region, massaging it gently, and then transfer the residual oil to the palm of one of the hands, rub the palms, and bring them close to the nose without touching it, forming a shell in order to inhale the aroma five times. outcome the reduction of psycho-emotional signs was measured by the srq-20 (12) and the fatigue ones by the fatigue pictogram (13). collection instruments the srq-20 instrument (12), validated in brazil (13), was used as a predictor of psycho-emotional symptoms. the srq is a dichotomous questionnaire, composed of 24 items, of which 20 are non-psychotic states and four are psychotic states, developed to identify mental disorders in primary healthcare services, with a sensitivity ranging from 73 % to 83 % and a specificity ranging from 72 % to 85 %, depending on the field of study (12). the srq with the 20 non-psychotic states items was translated and validated into portuguese using the standard psychiatric interview and obtained a sensitivity of 83 % and a specificity of 80 % (10 %) (13). the srq-20 score ranges from 0 to 20, and the higher the score, the higher the level of emotional stress. scores > 8 indicate the presence of emotional symptoms, and scores < 7 indicate their absence (12). fatigue was evaluated by the fatigue pictogram (14), with its psychometric properties validated in the brazilian portuguese version (5). this instrument is composed of two items, one for the impact and the other for the intensity of fatigue, with an illustrative likert scale for five response options. the higher the score, the greater the intensity or impact of fatigue (5). a questionnaire was applied for the sociodemographic profile (age, sex, underlying diseases, use of continuous medications, allergies, use of any integrative/complementary practice, number of people living in the same household), and occupational profile (specialty, level of education, time working in the unit and in the hospital). due to the covid-19 setting, it was verified if a participant, family member or close person became ill and required hospitalization for this illness. a ro m at he ra py o n ps yc ho -e m ot io na l s ym pt om s an d fa ti gu e in n ur si ng p ro fe ss io na ls in t he c o v id -1 9 se tt in g 9 randomization the eligible participants were randomized by simple randomization into two groups, lav and eosin, by the research randomizer quick tutorial program. the randomization was performed by a person outside the study, and two lists were generated, with one for each study group. recruitment the research was disseminated through the institution’s electronic communication system (intranet) and by sending e-mails to the nursing professionals, through posters placed in the elevators, and through a television monitor installed near the hospital’s cafeteria. collection procedure the srq-20, the fatigue pictogram, the biosociodemographic, and the occupational questionnaire instruments, in addition to the informed consent form, were sent via e-mail with a fixed deadline for return. based on the information received, the participants were evaluated according to the eligibility criteria. those eligible were assigned to the lav or eosin groups with the use of a randomization website. at the first meeting, which was held in a private room at the study hospital, an olfactory acceptance test was performed: the participant received a cotton swab soaked with one drop of oil from the lav or eosin formula, according to their study group, and performed three slow, consecutive inhalations. if the participant manifested olfactory acceptance, they would proceed in the study and receive guidelines on the application technique of the intervention, which were also sent electronically to each participant through a demonstration video. the bottles containing the eos were hand-delivered to the participants by the researchers at the work unit. the instruments were applied before the beginning of the intervention (pre-intervention), after 21 days of use (post-intervention), and three weeks after the end of the intervention (follow-up). data analysis the data collected through an electronic form were transferred to microsoft excel® spreadsheets and analyzed in the r 4.1.1. software by a statistical professional. the variables were described by using frequencies (gender, professional sector, age group, and fatigue pictogram), measures of central tendency, and variability (age, frequency of eos application, and srq-20). to compare group attributes, fisher’s exact test was used for age group and professional sector, and mann whitney’s was used for age and a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 45 10 frequency of eos application. the evaluation of the intra-group comparison of each time point was done using wilcoxon’s paired test. group comparison over time was evaluated using the anova mixed effects model for the srq-20 and the cumulative binomial family mixed effects model for the fatigue pictogram. the effect size was calculated using cohen’s d. the significance level adopted was 5 %. ethical aspects this study was approved by the research ethics committee of the university hospital of the university of são paulo under legal opinion 4.226.060. the participants who agreed to participate in the study filled out the informed consent form. despite prior testing for topical sensitivity to eos, the participants could present a delayed reaction or olfactory discomfort from daily use of the eo. the participants who maintained high srq-20 scores at the end of the intervention were referred to psychologists or psychiatrists for care by the welcoming professionals program, provided by the institution. results after the study was announced, 43 professionals expressed interest in participating in the research, and only 19 met the eligibility criteria. of those 19, only one was excluded from the analysis for not discontinuing the use of the eo at the end of the 21-day intervention (figure 1). figure 1. participant recruitment and allocation flowchart. são paulo, brazil, 2022 source: own preparation with research data. form responses (n = 43) allocated to the eosin group (n = 10) analyzed (n = 10) allocated to the lav group (n = 9) analyzed (n = 8) losses (n=1) failed to discontinue randomized (n=19) excluded (n = 24) failed to meet the cut-o� score (n = 23) unwilling to discontinue the use of icps (n = 1) id en ti � ca ti o n sc re en in g el ig ib ili ty in cl u si o n a ro m at he ra py o n ps yc ho -e m ot io na l s ym pt om s an d fa ti gu e in n ur si ng p ro fe ss io na ls in t he c o v id -1 9 se tt in g 11 both groups consisted of women; as a whole, there was greater participation of professionals from critical care units, characterized by emergency units, operating rooms, emergency rooms, intensive care units, and materials and sterilization centers (n = 11; 73 %). furthermore, the groups were homogeneous in relation to these variables. the profile of the study population is described in table 1. table 1. distribution of participants according to sex, age group, and professional sector, according to the study group and p-value (fisher’s exact test). são paulo, brazil, 2022 variable group 1 – lav group 2 – eosin total p-value n % n % n % sex 8 44 10 66 18 100 age group 28-45 3 43 4 57 7 100 1.000 45-58 5 46 6 54 11 100 work unit critical* 3 27 8 73 11 100 0.241 semi-critical** 4 67 2 33 6 100 non-critical*** 1 100 1 100 total 8 44 10 66 18 100 * operating room, obstetric center, child or adult intensive care unit, emergency room, or materials and sterilization center. ** medical clinic, surgical clinic, pediatric clinic, shared living quarters, or primary healthcare unit. *** nursing coordination, administrative area. source: own preparation with research data. however, when comparing groups, eosin presented a higher number of professionals from critical units (n = 8; 73 %) and lav from inpatient units (n = 4; 67 %). regarding age, both groups presented a mean of 47.5 (± 10.2) years, but different medians, namely 50.5 and 45.5 years, in the lav and eosin groups, respectively (p = 0.829). the mean srq-20 score was similar between groups (p = 0.893), with different variances according to levene’s test (p = 0.041). there was a reduction in srq-20 scores from the preto post-intervention stages in both groups, with a non-significant residual effect from post-intervention to follow-up, but with the maintenance of the effect reached within this period. when comparing the pre-intervention stage with the follow-up, a significant reduction was observed in the lav group (p = 0.033) but not in the eosin group (p = 0.082). a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 45 12 table 2. measures of central tendency and variability of srq-20 scores according to stage and study group and intragroup p-values (paired wilcoxon’s test). são paulo, brazil, 2022 groups/stage mean sd± ci 95 % median variation p (t 0 -t 1 ) p (t 1 -t 2 ) lav before (t0) 12.1 1.96 [10.5; 13.8] 12 9-15 after (t1) 8.1 3.3 [5.4; 10.9] 8 4-13 p = 0.021 follow-up (t2) 7.9 4.7 [4.0; 9.5] 9.5 0-13 p = 0.931 eosin before (t0) 12.8 3.9 [10.0; 15.0] 12 8-20 after (t1) 10.6 4.3 [7.5; 13.7] 11 5-19 p = 0.037 follow-up (t2) 9.7 4.9 [6.2; 13.2] 11 2-16 p = 0.590 source: own preparation with research data. in the comparative analysis between the groups via the mixed effects model, it was found that both presented a reduction in srq20 scores after three weeks of intervention (p < 0.010), although with no statistical difference between the groups (p = 0.285), which demonstrates similar effectiveness of the therapies (figure 2). the analysis of the interaction between the moment of evaluation and the group showed no statistical difference (p = 0.641). in both groups, a residual effect was noted in the follow-up evaluation. figure 2. mean srq-20 values according to group and time of evaluation. são paulo, brazil, 2022 13 12 11 10 9 8 before after stage group lavender synergy m ea n s r q follow-up source: own preparation with research data. the effect size between preand post-intervention was larger in the lav group with a huge effect size of 1.56 and a relative reduction of 33 %, while, in the eosin group, a medium effect size of 0.56 and a relative reduction of 17 % were observed. a ro m at he ra py o n ps yc ho -e m ot io na l s ym pt om s an d fa ti gu e in n ur si ng p ro fe ss io na ls in t he c o v id -1 9 se tt in g 13 in the analysis of the question regarding fatigue intensity in daily life from the fatigue pictogram (figure 3), it was found that, after the intervention, there was a reduction in fatigue intensity in both groups (p = 0.010), with a residual effect. however, there was no difference between the groups (p = 0.559) or the interaction between the groups and the time of evaluation (p = 0.641). for the question on the impact of fatigue (figure 4), there was no longitudinal difference between stages (p = 0.077), between groups (p = 0.666), or interaction between evaluation times and groups (p = 0.090). figure 3. fatigue pictogram response rate — intensity according to group and time of evaluation. são paulo, brazil, 2022 source: own preparation with research data. figure 4. fatigue pictogram response rate — impact according to the group and the time of evaluation. são paulo, brazil, 2022 before after 100% 75% 50% 25% 0% follow-up before stage after follow-up very tired moderately tired slightly tired not tired lavender group synergy group pictogram 1 100% 75% 50% 25% 0% cannot do much does only what is needed can do some things can do almost everything can do everything pictogram 2 lavender group synergy group before after follow-up before stage after follow-up source: own preparation with research data. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 45 14 when evaluating the interaction between fatigue and the srq-20, it was found that the higher the state of fatigue, the higher the srq20 score (p < 0.001), and the higher the impact of fatigue, the higher the srq-20 score (p < 0.001). discussion with the covid-19 pandemic, nursing professionals are experiencing a situation of uncertainty and fear, which impacts their quality of life and stress levels, leading to signs and symptoms such as depression, insomnia, anxiety, and suffering, which are more intense in women, nursing professionals, and those who work directly in covid-19 patient care (2, 15), which is precisely the population of the present study. through this study, it was found that nursing professionals from both intervention groups (lav and eosin) achieved significant improvement in the state of psycho-emotional symptoms measured by the srq-20, although the mean scores in all three times of evaluation had results close to 8 or higher, which is the cut-off value for the suspicion of non-psychotic mental disorders. no significant difference was observed in the reduction of emotional stress when comparing the two interventions, accepting the null hypothesis of the study. it is also noteworthy that the effect of the intervention in group 1 – lav was sustained during the follow-up period. the choice of eos was based on the premise of providing emotional support to these professionals. lavender eo (lavandula augustifolia) presents anxiolytic (16), antidepressant (9), and analgesic properties with indications for stress, anxiety, anguish, emotivity, insomnia, pain, and inflammation, among other properties. it is considered a harmonizing oil that is ready to provide relief from any aggression that destabilizes the individual (7, 10). for the formula with aromatic synergy, eos with information about their effects on psycho-emotional symptoms were used. the sweet orange eo (citrus aurantium dulcis) is known for its calming and balancing properties, indicated for stress, anxiety, nervousness, and depression (7, 9, 17). the sicilian lemon eo (citrus limonum) is a natural calming agent (18); its inhalation produces anti-stress, antidepressant, and anxiolytic effects (19). the basil eo (ocimum basilicum) helps reduce anxiety and feelings of restlessness and promotes a sense of focus and relief from stress and fatigue, in addition to its immunostimulatory, analgesic, and anti-inflammatory properties (20). the bergamot eo (citrus aurantium bergamia) is calming, relaxing, and soothing; it helps to build focus and concentration (9), it is beneficial in cases of distress, and it is also immunostimulating and mentally stimulating (18). its inhalation stimulates positive feelings and reduces depressive symptoms (10, 21). the geranium eo (perlagonium graveolens) has calming properties (20), relieves a ro m at he ra py o n ps yc ho -e m ot io na l s ym pt om s an d fa ti gu e in n ur si ng p ro fe ss io na ls in t he c o v id -1 9 se tt in g 15 depression, and elevates the mind, as it is a nerve tonic (22). the eucalyptus eo (eucalyptus globulus) provides relaxation (9), and the peppermint eo (mentha piperita) improves vigor and pro activity, is relaxing (9), mentally stimulating, a nerve tonic, and improves apathy and palpitations. since aromatherapy presents several variables not yet agreed upon in scientific literature concerning the application route, frequency, and duration of the treatment (23), an application technique was standardized that allowed for the administration of eos through the cutaneous and olfactory routes, potentiating their entrance into the body. a systematic review on the use of aromatherapy to improve work-related aspects, such as the burnout syndrome, found that 71.4 % of the studies analyzed were conducted with healthcare professionals and the use of lavender eo, with the improvement of burnout symptoms and increased job satisfaction (24). a double-blind, randomized clinical trial conducted with 120 nurses working in a hospital analyzed the effect of music therapy and aromatherapy using lavender and chamomile eos, which found that both icps used separately or in combination reduced anxiety in nurses (p < 0.0001) when compared to the control group (25). such studies, as well as the present one, highlight the potential of aromatherapy as a possible, easily applicable, and non-invasive strategy to help improve the emotional symptoms of nursing professionals. a pilot study randomized with two arms, control and intervention, in nursing professionals working in a surgical center to evaluate the effect of massages with a lavender 1 % (lavandula angustifolia) and geranium 2 % (perlargonium graveolens) eo-based cream did not present significant effects according to the list of stress symptoms and work stress scale, but significant differences in the evaluation of physiological parameters were found, namely: heart rate, diastolic and systolic blood pressure (26). a review study on the effects of lavandula angustifolia eo showed it improves people’s physical and emotional states when compared to non-aromatic therapies due to its effect on the limbic system by modulating n-methyl-d-aspartate and inhibiting serotonin transport and calcium channels (11). another review that focused on the relief of common symptoms during pregnancy noted that for anxiety, stress, and poor sleep quality, the most commonly used eo was lavender, although other eos, such as bergamot, lemon, orange, and tangerine, have also presented relaxation and mood-enhancing effects (27). an analysis of the effect of lavandula dentata and citrus sinensis eos on physical, emotional, and behavioral symptoms of occupational stress in office staff identified that both eos administered separately by inhalation through a diffuser were effective in reducing symptoms when compared to the control group (28). a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 45 16 regarding the intensity of fatigue felt by the professionals, there was a significant reduction in both groups, but when the interventions were compared, there were no statistically significant differences. the analysis of the reduction of the impact of fatigue on the participants’ daily lives also did not show statistical relevance, despite the improvement observed in the percentage of answers. a group of nursing students who used eos compared to a control group showed significant improvement in sleep as measured by the pittsburgh sleep quality index and in the total score and subjective perception of fatigue dimension as measured by the individual strength checklist. a stone made of lavender, stored in a closed glass jar, was handed to the students and should be placed 10-15 cm from their beds for seven nights, starting 10-15 min before they went to bed (29). a literature review on the use of eos for fatigue reduction in hemodialysis patients noted that the main eos used were lavender, orange, rosemary, chamomile, and almond; with the best effects found in formulas with aromatic synergy, and lavender was the main oil used. for almost all studies, the administration route was inhalation, with the exception of one that applied the eo in bath water (30). other effects of eos on fatigue have been explored in animal model experiments. one experiment subjected rats to chronic sleep deprivation to induce central fatigue, and one group also inhaled an eo synergy (santalum album, citrus aurantium, citrus limonum, styrax benzoin, citrus paradisi, mentha piperata, acori tatarinowii rhizoma,  rhodiolae crenulatae radix et rhizoma, and camellia sinensis (linn.) o. ktz), in addition to the control group of well-fed rats. from the results, the group that inhaled eo showed increased physical function in the forced swim test and better behavioral performance associated with anxiety and cognitive function in the open field test (31). another study compared the effect of citric oils (citrus sinensis l., citrus limon osbeck, citrus bergamia risso, and poit) with a control group in reducing fatigue in rats fatigued by forced swimming, which showed that the three citrus eos reduced exhaustive exercise-induced fatigue by inhibiting oxidative stress, preventing muscle injury, and promoting glycogen-dependent energy supply. also, the orange-bergamot eo was the best at relieving fatigue, and sweet orange was ineffective (32). the comparison between the scales showed that the higher the stress levels measured by the srq-20, the greater the impact and intensity of fatigue assessed by the pictogram. it is inferred that the covid-19 pandemic impacts both emotional and physical symptoms that are often related to each other, as we are holistic beings. the limitations included the small sample size, which undermined the power of the test, the possibility of a hawthorne effect due to the participant’s voluntary entry into the study, and the low use of eos throughout the day by most participants. although the tests showed significant differences after the intervention, the confidence intervals, especially for the eosin group, were somewhat wide. a ro m at he ra py o n ps yc ho -e m ot io na l s ym pt om s an d fa ti gu e in n ur si ng p ro fe ss io na ls in t he c o v id -1 9 se tt in g 17 conclusions the present study showed a reduction in the emotional stress experienced by nursing professionals working in a public teaching hospital through the use of aromatherapy, with both lavender eo and eos synergy, during the covid-19 pandemic setting. there was evidence of a significant reduction in the intensity of fatigue in this population in both groups. however, there was no statistically relevant difference in the impact of this physical symptom on daily life in either group. due to the limited sample, the development of randomized clinical trials with a larger sample is suggested for better exploration of the effect of this practice in restoring the mental health of nursing professionals, which is a relevant recommendation for the authors, as aromatherapy is part of the pics, is easily applicable, low-cost, non-invasive, and helps to reduce emotional stress. conflict of interest: none declared. references 1. galea s, merchant rm, lurie n. the mental health consequences of covid 19 and 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https://doi.org/10.1186/s12906-018-2375-6 https://doi.org/10.1186/s12906-018-2375-6 https://doi.org/10.3390/molecules27103239 24 31 interatividade sistemica.indd 24 dirce stein backes1 claudia zamberlan2 juliana colomé3 martha teixeira souza4 mara teixeira marchiori5 alacoque lorenzini erdmann6 angela maria salazar-maya7 interatividade sistêmica entre os conceitos interdependentes de cuidado de enfermagem 1 centro universitário franciscano (unifra), brasil. backesdirce@unifra.br, backesdirce@ig.com.br 2 unifra, brasil claudiazamberlanenator@gmail.com 3 unifra, brasil. juianacolome@yahoo.com.br 4 unifra, brasil marthats@unifra.br 5 unifra, brasil. maramarc@unifra.br 6 universidade federal de santa catarina (ufsc), brasil. alacoque@newsite.com.br 7 universidade de antioquia, colombia. amsalazar@udea.edu.co recibido: 18 de septiembre de 2014 enviado a pares: 20 de octubre de 2014 aceptado por pares: 07 de agosto de 2015 aprobado: 27 de septiembre de 2015 doi: 10.5294/aqui.2016.16.1.4 para citar este artículo / to reference this article / para citar este artigo backes ds, zamberlan c. colomé j. souza mt, marchiori mt, lorenzini erdmann a, salazar-maya a. interatividade sistêmica entre os conceitos interdependentes de cuidado de enfermagem. aquichan. 2016; 16 (1): 24-31. doi: 10.5294/aqui.2016.16.1.4 año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 24-31 resumo o presente estudo tem por objetivo apresentar e discutir a interatividade sistêmica entre os conceitos interdependentes de cuidado de enfermagem na perspectiva dos pressupostos teóricos de edgar morin. defende-se que o conceito sistêmico de cuidado de enfermagem pode ser concebido a partir de um conceito ampliado, antagônico, complementar, interdependente e de dinamicidade interativa de processos e contraprocessos de enfermagem, saúde, viver saudável, comunidade vulnerável e empreendedorismo social da enfermagem. a compreensão ampliada e interdependente desses conceitos possibilita, em suma, transcender a linearidade do processo saúde-doença e alcançar resultados mais efetivos de promoção e proteção da saúde. palavras-chave enfermagem; cuidado de enfermagem; saúde; sistemas de saúde; promoção da saúde (fonte: decs, bireme). 25 interatividade sistêmica entre os conceitos interdependentes de cuidado de enfermagem l dirce stein backes e outros año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 24-31 interactividad sistémica entre los conceptos interdependientes de cuidado de enfermería resumen el presente estudio tiene como fin presentar y discutir la interactividad sistémica entre los conceptos interdependientes de cuidado de enfermería en la perspectiva de los planteamientos teóricos de edgar morin. se defiende que el concepto sistémico de cuidado de enfermería puede concebirse desde un concepto ampliado, antagónico, complementario, interdependiente y de dinamicidad interactiva de procesos y contra-procesos de enfermería, salud, vivir sano, comunidad vulnerable y emprendimiento social de enfermería. la comprensión ampliada e interdependiente de tales conceptos posibilita, en suma, trascender la linealidad del proceso salud-enfermedad y lograr resultados más efectivos de promoción y protección de la salud. palabras-clave enfermería; cuidado de enfermería; salud; sistemas de salud; promoción de la salud (fuente: decs, bireme). 26 aquichan issn 1657-5997 año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 24-31 systemic interactivity between interdependent concepts of nursing care abstract the objective of this study is to outline and discuss the systemic interactivity between interdependent concepts of nursing care from the standpoint of edgar morin’s theoretical approach. it is argued that the systemic concept of nursing care can be conceived from an expanded, antagonistic, complementary, interdependent and dynamic interactive concept of processes and counter-processes from the standpoint of nursing, health, healthy living, vulnerable communities and social entrepreneurship in nursing. a broader and interdependent understanding of those concepts makes it possible, in short, to go beyond the linearity of the health-disease process and achieve more effective results in terms of health promotion and protection. keywords nursing; nursing care; health; health systems; health promotion (source: decs, bireme). 27 interatividade sistêmica entre os conceitos interdependentes de cuidado de enfermagem l dirce stein backes e outros considerações iniciais a enfermagem vem ampliando, a cada dia, o seu espaço de atuação na área de saúde, tanto no contexto nacional quanto internacional. como ciência em construção, a enfermagem tem um corpo de conhecimento que se desenvolve de forma independente, mas ao mesmo complementar às demais áreas da saúde, no sentido de apreender o cuidado em saúde como um fenômeno complexo e multidimensional (1, 2). o enfermeiro assume um papel decisivo e proativo no que se refere à identificação das necessidades de cuidado da população, bem como na promoção e proteção da saúde dos indivíduos em suas diferentes dimensões. o cuidado de enfermagem, na perspectiva sistêmica, configura-se como um componente definitivo no sistema de saúde e, por isso, também motivo de crescentes debates e novas significações (3). nesse sentido, a enfermagem vem contribuindo para a consolidação do sistema único de saúde (sus), no brasil, principalmente no redirecionamento das formas de pensar, conceber e sistematizar a assistência em saúde. isso vem ocorrendo, sobretudo, porque produz conhecimento científico nos mais variados temas em saúde e, assim, ultrapassa os limites institucionalizados que vão desde cuidados específicos de enfermagem, passando por avaliação de políticas e modelos de atenção à saúde, bem como a introdução de novas abordagens acerca do conceito saúde, de enfermagem, de cuidado de enfermagem, de viver saudável, de comunidade vulnerável, de empreendedorismo social em enfermagem, no sentido de alcançar uma nova compreensão sobre o cuidado em saúde. em decorrência dos debates em torno dos princípios e diretrizes do sus, emerge, crescentemente, a necessidade de se conceber a interatividade sistêmica entre os conceitos interdependentes de cuidado de enfermagem. de outro modo, a necessidade de se transcender o saber biomédico para o alcance do saber contextualizado, complexo e sistêmico, no qual as várias dimensões do indivíduo passaram a ser considerados, o que criou espaço para atuação de outros profissionais que buscam a promoção do ser humano como um ser integral (4, 5). nesse processo de construção e consolidação do sus, o enfermeiro ocupa um espaço importante pelos infinitos espaços de atuação profissional e pela possibilidade de compreender o ser humano como ser singular e multidimensional, e o cuidado de enfermagem como um fenômeno complexo. para tanto, questionase: como promover a interatividade sistêmica entre os conceitos interdependentes de cuidado de enfermagem? com base no exposto, o presente estudo tem por objetivo apresentar e discutir a interatividade sistêmica entre os conceitos interdependentes de cuidado de enfermagem na perspectiva dos pressupostos teóricos de edgar morin. pensamento complexo o termo complexidade vem do latim complexus, que significa o que é tecido em conjunto. logo, o termo reflete um agregado de elementos que compõe a unidade complexa. o todo, de acordo com petraglia (6), é uma unidade complexa que não é redutível à soma das partes, mas sim está na sua diferença e complementaridade. complexus refere-se a elementos diferentes que são inseparáveis constituintes do todo em uma rede interdependente, interativa e inter-retroativa entre as partes e o todo e a partes. portanto, a complexidade é a união entre unidade e multiplicidade (6). o pensamento complexo questiona o previsível, o absoluto e a linearidade dos fenômenos sociais. sob esse ponto de vista, o conceito de saúde, de enfermagem, de cuidado de enfermagem, de viver saudável, de comunidade vulnerável e de empreendedorismo social da enfermagem somente podem ser compreendidos a partir de um saber que os integra, articula e complementa. ou seja, alcançar uma perspectiva sistêmica no contexto da saúde implica perceber e prover a interatividade e a complementaridade daqueles fenômenos que compõem a unidade complexa. assim, o pensamento complexo possibilita repensar a realidade visto que a complexidade é capaz de reunir, contextualizar, globalizar, mas também de reconhecer o singular e o concreto. a complexidade propõe um olhar ampliado, simultâneo, multidimensional, dinâmico a respeito das realidades que pretende capturar (7). edgar morin (8, 9) descreve três princípios que possibilitam compreender a interatividade sistêmica entre os diferentes fenômenos sociais. o primeiro é a dialógica, que mantém a dualidade dentro da unidade. o termo significa que a dialógica compreende duas lógicas unidas sem dualidades e, ao mesmo tempo, complementares e antagonistas. a parte dialógica dá a ideia de que os antagonismos podem ser estimuladores e reguladores. 28 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 o segundo princípio é o do recurso organizacional, no qual os produtos e os efeitos são, ao mesmo tempo, a causa que os produzem. nesse sentido, uma sociedade é um produto de interações entre os indivíduos e age sobre estes, que a produzem. é por meio das interações que os indivíduos se desenvolvem e o cuidado de enfermagem se estabelece. o terceiro princípio é o hologramático. o todo é maior que a soma das partes. o todo está na parte, assim como a parte está no todo. essa ideia transcende o reducionismo que vê apenas partes ou o holismo que vê apenas o todo. a interatividade sistêmica se desenvolve a partir da noção do todo e da parte, ambos em interação mútua. a circularidade interativa e sistêmica, em morin (10), referese às interações que modificam o comportamento ou a natureza dos elementos, corpos, objetos e fenômenos, os quais influenciam e são influenciados. assim, os conceitos saúde, enfermagem, cuidado de enfermagem, viver saudável, comunidade vulnerável e empreendedorismo social em enfermagem são fenômenos que interagem, influenciam e se complementam com o propósito de formar a unidade complexa. processo de construção de conceitos saúde, enfermagem, cuidado de enfermagem, viver saudável, comunidade vulnerável e empreendedorismo social da enfermagem na busca pela compreensão do conceito ampliado de saúde, propósito do sus, com frequência, deparávamo-nos com a linearidade e os reducionismos com que eram concebidos e discutidos os demais conceitos que compõe a unidade complexa do sistema de saúde. assim, propomo-nos, enquanto pesquisadores do grupo de estudos e pesquisa em empreendedorismo social da enfermagem e saúde (gepeses/unifra), a desenvolver conceitos ampliados, na perspectiva sistêmica, de enfermagem, cuidado de enfermagem, viver saudável, comunidade vulnerável e empreendedorismo social da enfermagem, no sentido de conceber uma linha de raciocínio lógica, contextualizada e sistêmica de saúde. o gepeses é composto por docentes, discentes, bolsistas e profissionais enfermeiros inseridos nos cenários de prática. ele tem como propósito qualificar o ensino, a pesquisa e a extensão universitária por meio de referenciais e práticas sociais inovadoras e transformadoras, capazes de ampliar as possibilidades interativas e estimular o exercício da cidadania a partir do cuidado empreendedor de enfermagem. os encontros coletivos foram realizados semanalmente, no intuito de compartilhar e produzir conhecimentos, discutir novas perspectivas de inserção social, reafirmar-se como grupo de pesquisa e consolidar as linhas de pesquisa do grupo, quais sejam: cuidado sistêmico em saúde, empreendedorismo social e viver saudável. o processo de construção e validação dos conceitos se deu ao longo dos anos de 2011 e 2012 entre os integrantes do gepeses, mais especificamente seis pesquisadores, e em parceria com outros centros de pesquisa, dentre eles o grupo de estudos e pesquisas em administração e gerência do cuidado em enfermagem e saúde (gepades), florianópolis (sul do brasil) e o deutsches netzwerk für qualitätsentwicklung in der pflege (dnqp), alemanha. inicialmente, foram realizados estudos e aprofundamentos coletivos sobre as interconexões sistêmicas entre os diferentes conceitos, baseados no referencial da complexidade e, a seguir, cada integrante do grupo de pesquisa elaborou o seu conceito sobre saúde, enfermagem, cuidado de enfermagem, viver saudável, comunidade vulnerável e empreendedorismo social em enfermagem. posteriormente, os conceitos foram discutidos e ampliados coletivamente nos diferentes núcleos de estudo, mediante o exercício da reflexividade, ou seja, foram discutidos pelos núcleos de docentes, discentes, bolsistas e profissionais enfermeiros inseridos nos cenários de prática, em aproximadamente 15 encontros. e, por último, a validação se deu a partir do consenso do grande grupo em seminários ampliados de pesquisa do gepeses, reconhecidos como adequados e pertinentes por meio da compreensão dos sujeitos envolvidos nessa construção, como também submetidos à apreciação de pesquisadores de outros centros de pesquisa. quadro 1. as concepções anteriormente delineadas se sustentam em visões de mundo e bases teórico-filosóficas, como noções de sistemas complexos, ser humano, relações e interações humanas, sistemas sociais, sistema de saúde, saúde em dimensões múltiplas, saúde como fenômeno social, contexto social, ecológico e do viver coletivo. 29 interatividade sistêmica entre os conceitos interdependentes de cuidado de enfermagem l dirce stein backes e outros quadro 1. conceitos desenvolvidos pelos integrantes do grupo de estudos e pesquisa em empreendedorismo social da enfermagem/saúde, santa maria-rs fonte: elaboração própria. conceito descrição saúde sistema dinâmico, singular e auto-organizador, interligado aos diferentes sistemas sociais que visam promover o viver saudável de indivíduos, famílias e comunidades a partir de uma perspectiva socioecossistêmica. enfermagem a enfermagem é a ciência e a tecnologia/arte de promover o cuidado de enfermagem ao ser humano em sua singularidade e multidimensionalidade, articulada com os demais profissionais comprometidos com o fenômeno saúde, a partir de uma visão ecossistêmica, ética e socialmente responsável. cuidado de enfermagem é um fenômeno complexo, sistematizado por meio das múltiplas relações, interações e associações sistêmicas, com vistas a promover e recuperar a saúde do ser humano de forma integral e articulada com tudo que o cerca. viver saudável é um processo singular, circular e interativo, dinamizado por meio de vivências de ordem e de desordem, em busca de uma contínua auto-organização individual, familiar e social. comunidade vulnerável é uma comunidade que vivencia influências ambientais, econômicas, políticas sociais e culturais, as quais enfraquecem as relações, as interações e as associações individuais, familiares e sociais. empreendedorismo social da enfermagem é a atitude de promover o viver saudável de indivíduos, famílias e comunidades por meio de processos interativos e associativos com vistas à sua emancipação como protagonistas de sua própria história. interatividade sistêmica entre os conceitos interdependentes de cuidado de enfermagem as múltiplas relações, interações e associações sistêmicas, bem como a compreensão da pessoa humana como um ser singular e multidimensional, possibilitam distinguir o pensamento disjuntivo e redutor daquele que distingue e une. fazer a seleção e atribuir sentido, sob esse enfoque sistêmico, pode nem sempre ser uma tarefa fácil pela valorização das práticas tradicionais assistencialistas e curativistas, nas quais os fenômenos são apreendidos em separado e/ou de forma fragmentada e dicotômica. reconhece-se que a vida humana está ameaçada não somente por aquilo que a ameaça, mas também por aquilo que a protege: a ciência e a medicina. o enfrentamento de temas desse porte confere a possibilidade de barrar conceitos de eugenia que, na atualidade, ainda permanecem latentes (11, 12). o ser humano move-se como um ser social por meio de processos dialógicos e complementares que iniciam no ambiente familiar e se prolongam para os diversos espaços e eventos sociais. estes, por sua vez, são potencializados pela capacidade de ser único e diferente, singular, múltiplo e, ao mesmo tempo, de possibilitarem novas e sempre mais complexas comunicações associativas as quais também compreendem a saúde como um fenômeno complexo. assim, as interações entre os indivíduos produzem a sociedade, que testemunha o surgimento da cultura e que retroage sobre os indivíduos pela cultura (13). na complexidade dos fatos e fenômenos sociais, tudo se interliga a tudo por meio de uma rede de interações interdependentes, dialógicas, recursivas, hologramáticas e complexas (9, 14). nessa lógica, nada está isolado, sem identidade, sem nome, visto que os diferentes fenômenos se complementam a partir da interatividade sistêmica, nesse caso, saúde-enfermagemcuidado de enfermagem-viver saudável-comunidade vulnerávelempreendedorismo social da enfermagem. 30 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 o ser humano não se reduz à dimensão biológica ou física. sua natureza é por excelência relacional e associativa. ele é membro de uma sociedade, a qual é singular e sistêmica. dito de outro modo, há algo mais do que a singularidade ou a diferença de indivíduo para indivíduo: cada pessoa é um sujeito singular e multidimensional, logo, capaz de atribuir significados aos diferentes fenômenos sociais (14). compreender o humano, a partir de processos interativos e sistêmicos, significa compreender a sua unidade na diversidade e sua diversidade na unidade. significa conceber a unidade do múltiplo e a multiplicidade do uno (13). sob esse enfoque, o cuidado de enfermagem necessita considerar o ser humano em sua unidade e diversidade sistêmica e a saúde como um fenômeno amplo e interdependente, complementado pelos diferentes sistemas sociais. reconhecer, portanto, que o ser humano é um sujeito singular e multidimensional é fundamental e necessário para se alcançar resultados mais profícuos no que se refere à promoção e à proteção da saúde. respeitada essa unicidade, deve-se entender também que a qualidade de ser uno do sujeito será reconhecida quando ele se envolver com o todo. ele verá o distinto, o desigual, o dessemelhante a si e, então, se autoconhecerá. conhecer o humano não é separá-lo do universo, mas sim situá-lo nele (8). assim, todo indivíduo, desde a mais restrita até a mais banal das vidas, constitui-se, em si mesmo, um cosmos que, por meio da educação, torna-se capaz de compreender a real condição do humano e faz com que se viva a parte poética da vida (12). quando se situa o ser humano em determinado contexto social, haverá permuta entre o sujeito e o entorno socioecossistêmico. no relacionamento com o espaço social, busca-se a formação da identidade, gerada pelas circunstâncias momentâneas que podem ser positivas ou negativas. isso repercutirá no indivíduo e, consequentemente, afetará também o ambiente familiar em que ele está inserido e, futuramente, originará problemas para a sociedade, que se tornará referência para ele. inicia-se um ciclo de interações sistêmicas nas quais se inserem a saúde, a enfermagem e o cuidado de enfermagem, dentre outros fenômenos. na lógica da interatividade sistêmica entre os conceitos interdependentes de cuidado de enfermagem, as relações e interações, associações, retroações entre os seres, em vários planos são potencializadas pela compreensão do sentido de ser singular e autônomo. o que importa para a complexidade é a riqueza do olhar amplo e a dinâmica do processo interativo que se estabelece entre os diferentes modos de viver saudável e que são intensificadas pelas vivências singulares de cada indivíduo, família e comunidade. compreender tal lógica é, portanto, fundamental para o exercício do empreendedorismo social, sobretudo, em comunidades vulneráveis. faz-se necessário, desse modo, a discussão e a inter-relação entre esses conceitos no sentido de ampliar o campo de visão e contribuir para o fomento de um novo paradigma na área da saúde e enfermagem. a diversidade de interpretações e proposições políticas e teóricas faz com que não seja possível uma concordância sobre o modelo ideal de organização ou mesmo sobre quais componentes e responsabilidades relacionam-se com a saúde da população. assim, a desarticulação desses conceitos não compõe um sistema de saúde e tão pouco possui eficiência e eficácia que poderiam ter ao realizar suas ações. avançar em tais discussões sistêmicas implica, necessariamente, ampliar o campo de visão pessoal e profissional. defendese que o conceito de cuidado de enfermagem deve ser concebido a partir de um conceito ampliado, antagônico, complementar, interdependente e de dinamicidade interativa de processos e contraprocessos de enfermagem, saúde, viver saudável, comunidade vulnerável e empreendedorismo social da enfermagem. logo, a circularidade interativa entre esses conceitos possibilita apresentar uma nova concepção paradigmática no contexto da saúde e da enfermagem. considerações finais partindo-se da ideia de que o cuidado de enfermagem assume dimensões ampliadas nos diferentes cenários e áreas de atuação profissional do enfermeiro, tornam-se necessárias também a ampliação das questões conceituais e a discussão de referenciais que viabilizem novas formas de intervir no processo saúde-doença. enquanto fenômeno ampliado, a saúde envolve modos de ser e produzir e/ou recriar a vida em sua singularidade e multidimensionalidade. nessa perspectiva, somente processos dialógicos capazes de compreender a interatividade sistêmica e potencializar o viver saudável pelo desenvolvimento de práticas/ações empreendedoras podem efetivamente contribuir para um novo pensar e agir na saúde/cuidado de enfermagem. 31 interatividade sistêmica entre os conceitos interdependentes de cuidado de enfermagem l dirce stein backes e outros a interatividade sistêmica entre os conceitos representa o movimento constitutivo de religação de saberes interdependentes, de compreender o todo na parte, assim como a parte no todo. a compreensão ampliada e interdependente desses conceitos possibilita, em suma, transcender a linearidade do processo saúde-doença e alcançar resultados mais efetivos de promoção e proteção da saúde. trata-se, portanto, de um processo paradigmática dinâmico e gradual, o qual requer o engajamento efetivo e responsável do enfermeiro por meio de ações empreendedoras e propositoras de novos referenciais teórico-práticos. referências 1. dalmolin bb, backes ds, zamberlan c, colomé j, gehlen mh. significados do conceito de saúde na perspectiva de docentes da área da saúde. esc. anna nery. 2011;15(2):389-94. 2. backes mts, backes ds, drago lc, koerich ms, erdmann al. cuidado ecológico como um fenômeno amplo e complexo. rev. bras. enferm. 2011;64(5):876-81 . 3. backes ds, backes ms, erdman al, büscher a. o papel profissional do enfermeiro no sistema único de saúde: da saúde comunitária à estratégia de saúde da família. ciênc. saúde colet. 2012 jan;17(1):223-30. 4. lessa apg. o serviço social no sistema único de saúde fortaleza: uece; 2003. 5. apostolico mr et al. contribuição da cipesc® na execução das políticas de atenção à saúde da criança no município de curitiba, paraná. texto contexto — enferm. 2007 set; 16(3):453-62. 6. petraglia ic. edgar morin — a educação e a complexidade do ser e do saber. 8 ed. petrópolis: vozes; 2003. 7. ferrer v. complejidad y enfermería un encuentro necesario. em: ferrer v, medina moya jl, lloret c. (compiladores). la complejidad en enfermería. profesión, gestión formación. barcelona: alertes; 2003. 8. morin e. el método 3. el conocimiento del conocimiento. 6 ed. madri: cátedra; 2009. 9. anderson ra, crabtree bf, steele dj, mcdaniel rr. case study research: the view from complexity science. qual. health res. 2005; 15(5):669-85. 10. morin e. el método i, la naturaleza de la naturaleza. 8 ed. madri: cátedra; 2009. 11. santos bs. introdução a uma ciência pós-moderna. rio de janeiro: graal; 1989. 12. morin e. ciência com consciência. 7 ed. rio de janeiro: bertrand brasil; 2003. 13. morin e. cabeça bem-feita: repensar a reforma, reformar o pensamento. 4 ed. rio de janeiro: bertrand brasil; 2000. 14. morin e. introdução ao pensamento complexo. lisboa: instituto piaget; 1991. 81 91 develando el significado del proceso.indd 81 paula vega-vega1 rina gonzález-rodríguez2 chery palma-torres3 eugenia ahumada-jarufe4 javiera mandiola-bonilla5 claudia oyarzún-díaz6 soledad rivera-martínez7 develando el signifi cado del proceso de duelo en enfermeras(os) pediátricas(os) que se enfrentan a la muerte de un paciente a causa del cáncer 1. enfermera matrona. magíster en enfermería. profesora asistente, pontificia universidad católica de chile. pvegav@uc.cl 2. enfermera. magíster en sociología. profesora asociada, pontificia universidad católica de chile. rgonzalr@uc.cl 3. enfermera. especialista de oncología pediátrica y cuidados paliativos pediátricos. enfermera policlínica oncología, hospital roberto del río. chery.palma@redsalud.gov.cl 4. psicóloga clínica, hospital roberto del rio. eugenia.ahumada@gmail.com 5. psicóloga clínica, otec maría ayuda. javi.mandiola@gmail.com 6. enfermera. pediatría, clínica bicentenario. cdoyarzu@uc.cl 7. enfermera. doctora en enfermería. profesora asociado, pontificia universidad católica de chile. mriveram@uc.cl recibido: 8 de junio de 2012 aceptado: 2 de febrero de 2013 año 13 vol. 13 nº 1 chía, colombia abril 2013  81-91 resumen objetivo: develar el significado del duelo en enfermeras(os) que enfrentaron la muerte de niños con cáncer. la muerte de un niño(a) por cáncer genera un gran impacto en el equipo de enfermería, lo que produce impotencia, frustración y pena, que pueden llegar a causar burnout. método: se utilizó la investigación cualitativa fenomenológica basada en husserl; se recogió la experiencia de diez enfermeras(o) oncológicas(os) pediátricas que enfrentaron la muerte de pacientes con cáncer bajo su cuidado. los datos se obtuvieron de junio a noviembre del 2011 con entrevistas en profundidad grabadas y transcritas literalmente. el análisis fenomenológico se realizó según el método de streubert. resultado: los testimonios entregados develaron tres unidades de significado: las enfermeras vivencian la muerte de un paciente a través del transitar entre su propia forma de enfrentar la muerte y el cuidado profesional que otorgan. con ello aparece un aprendizaje de vida dado por la comprensión de lo que es trabajar en oncología y los vínculos que establece en este ámbito. esto permite desarrollar un cuidado con un sello particular. conclusión: el estudio concluye que las enfermeras experimentan el duelo como un proceso dinámico al que atribuyen sentido a través de la entrega de un cuidado amoroso. palabras clave dolor, enfermería, investigación cualitativa, atención de enfermería, cuidados paliativos, oncología. (fuente: decs, bireme). 82 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 revealing the meaning of the mourning process of pediatric nurses facing the death of cancer patients abstract objective: the purpose of this article is to reveal the meaning of the mourning period in nurses that have had to deal with the death of cancer-stricken children. the death of a cancer-stricken child affects the nursing staff deeply, bringing on feeling of powerlessness, frustration, and shame; these feelings can result in burnout. method: qualitative case-based research was undertaken based on husserl, and ten cases of pediatric oncology nurses who faced the death of child patients under their care were reported. the study took place from june to november 2011 through verbatim-reported in depth interviews. results: undertaken using streubert’s method, this case study revealed three essential issues: the nurses experience the death of a child by shifting between their own approaches to loss and the professional care they provide. this path brings life teachings, given the empathy of working in cancer units and the bonds created in this environment, thus allowing the nursing staff to provide unique nursing care. conclusion: the study concluded that by providing patients with loving care, nurses have a dynamic approach to their experience of loss. key words pain, nursing, qualitative research, nursing care, palliative care, oncology. (source: decs, bireme). revelando o significado do processo de luto em enfermeiros(as) pediátricos(as) que enfrentam a morte de um paciente por causa do câncer resumo objetivo: revelar o significado do luto em enfermeiros(as) que enfrentam a morte de crianças com câncer. a morte de uma criança por câncer gera um grande impacto na equipe de enfermagem, o que produz impotência, frustração e pena, que podem chegar a causar burnout. método: utilizou-se a pesquisa qualitativa fenomenológica baseada em husserl; foi coletada a experiência de dez enfermeiros(as) oncológicos pediátricos(as) que enfrentaram a morte de pacientes com câncer sob o seu cuidado. os dados obtiveram-se de junho a novembro de 2011 com entrevistas com profundidade, gravadas e transcritas literalmente. a análise fenomenológica realizou-se segundo o método de streubert. resultado: as declarações revelaram três elementos principais: as enfermeiras vivenciam a morte de um paciente por meio do transitar entre sua própria forma de enfrentar a morte e o cuidado profissional que outorgam. com isso se ganha um aprendizado de vida dado pela compreensão do que é trabalhar em oncologia e os vínculos que se estabelece neste âmbito. isso permite desenvolver um cuidado com um selo especial. conclusão: o estudo conclui que os(as) enfermeiros(as) experimentam o luto como um processo dinâmico que atribui sentido por meio da entrega de um cuidado amoroso. palavras-chave dor, enfermagem, pesquisa qualitativa, cuidados de enfermagem , cuidados paliativos, oncologia. (fonte: decs, bireme). 83 develando el significado del proceso de duelo en enfermeras(os) pediátricas(os) que se enfrentan a la muerte de un paciente a causa del cáncer l paula vega-vega y otros introducción se plantea que los fines de la medicina moderna están centrados en la curación de las enfermedades y en la prolongación de la vida, por lo que la muerte es considerada como un fracaso (1). para los profesionales de la salud dedicados a la atención y el cuidado de los niños, en especial aquellos con enfermedades crónicas, esta problemática se transforma en algo más complejo de abordar, por lo incomprensible y “contra natura” que puede ser el fallecimiento de un niño (2). esto trae consigo una sensación de impotencia y frustración por parte de médicos, enfermeras, técnicos, psicólogos y otros profesionales, quienes son los que brindan día a día el cuidado y la atención integral a estos niños(as). tales sensaciones pueden deteriorar el estado de ánimo de estos profesionales, lo que se traduce en menor rendimiento laboral y mayor riesgo de errores involuntarios u omisiones, que pueden generar el desgaste profesional o burnout (1). sin embargo, en el estudio de dunn, otten y stephens (3) se develó que las enfermeras que pasaban más tiempo con pacientes terminales mantenían actitudes más positivas frente a las dificultades, lo que les permitía entregar cuidados más personalizados y esperanzadores, ayudando a los pacientes a encontrar sentido y a brindar cuidados para una muerte en paz e íntima (3). en el caso particular de las enfermeras oncológicas que cuidan pacientes adultos, la entrega de un cuidado de alta calidad les genera una gran satisfacción profesional (4, 5). no obstante, algunos estudios han demostrado que estas reacciones se ven disminuidas en las enfermeras mayores, aquellas muy jóvenes y en las que tienen pocos estudios, presentando mayor cansancio emocional (6). en chile, el trabajo cooperativo dentro del programa nacional de cáncer infantil (pinda) dio prioridad por largo tiempo a aumentar la sobrevida del niño(a) con cáncer a través de la implementación y evaluación frecuente de protocolos de tratamiento, al uso adecuado de tecnología diagnósticas, terapias de soporte, lo que ha permitido resultados exitosos y semejantes a los logrados en países desarrollados (7). a pesar del aumento de la sobrevida, entre el 30 y 35 % de los niños(as) mueren (8). esta situación afecta a los integrantes del equipo de salud en su desempeño y bienestar ya que, por un lado, se sienten responsables de curar a la mayor cantidad de niños, y por otro, deben enfrentar la realidad de la muerte. actualmente, en chile no hay un trabajo formal de duelo con los equipos pediátricos oncológicos, lo que se ha transformado en un desafío para los miembros del pinda. dentro del equipo de salud, las enfermeras y los técnicos, dado el horario que cumplen, son los miembros que mantienen un mayor tiempo de contacto con los niños(as) en etapa terminal y su familia, implicándose afectivamente con ellos. este vínculo afectivo los expone a una dolorosa separación cuando el niño(a) muere, que puede generar problemas de salud física y mental (9). por ello, el propósito de este estudio es contribuir a la construcción de conocimiento comprensivo sobre el proceso de duelo de las enfermeras(os) que se desempeñan en estas unidades, a fin de promover su bienestar personal y profesional, en pro del cuidado integral de los niños(as) con cáncer y su familia. esta investigación cualitativa tiene como objetivo develar el significado del proceso de duelo en enfermeras(os) que trabajan en unidades de oncología pediátrica frente a la muerte de un paciente a causa del cáncer. método en el presente estudio se utilizó un diseño de investigación cualitativa de tipo fenomenológico, que se funda en la filosofía desarrollada por edmund husserl, donde se enfatiza en un “regreso a la intuición reflexiva para describir y clarificar la experiencia tal como se vive y se construye desde la conciencia de la persona que porta el fenómeno en estudio” (10, 11). este estudio se desarrolló a través del proceso fenomenológico formulado por streubert (12): al inicio las tres investigadoras y las dos entrevistadoras realizaron una descripción personal del fenómeno de interés para apartar sus suposiciones previas frente al fenómeno en estudio, y las propias vivencias de pérdida de pacientes con cáncer que han estado bajo su cuidado (braketing). realizada esta etapa se procedió en una primera instancia a contactar mediante una carta enviada por correo electrónico a todas(os) las(os) enfermeras(os) que trabajaban en unidades de atención intrahospitalarias de niños con cáncer en la capital y regiones del país. en seguida, las enfermeras(os) que aceptaron participar fueron contactadas(os) telefónicamente por una de las entrevistadoras, quienes confirmaron la voluntariedad de la participación, concertando fecha, hora y lugar de la entrevista. estas fueron realizadas por una de las dos psicólogas, las cuales no tenían ningún vínculo con las participantes. cabe destacar que previo a cada entrevista las personas que aceptaron participar firmaron un consentimiento informado, lo que permitió que las psicólogas realizaran entrevistas en profundidad, y que estas fueran grabadas. la pregunta que dio apertura a la entrevista fue: 84 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 ¿qué ha significado para usted la muerte de un niño(a) con cáncer bajo su cuidado? durante la entrevista se realizaron otras preguntas que permitieron profundizar en el diálogo, entre las que se destacan: ¿podría compartirme alguna situación de pérdida de un niño con cáncer que le haya marcado especialmente? ¿qué vivencias le han dificultado el enfrentar la muerte de los niños? ¿qué le ha ayudado a sobrepasar la pérdida de los niños y seguir trabajando en oncología? ¿quién le ha ayudado en este tipo de situaciones? además, se realizaron otras preguntas que permitieron caracterizar a los participantes y profundizar o aclarar las experiencias particulares. es importante señalar que durante el desarrollo de las entrevistas no se presentó ninguna situación de crisis por parte de los participantes que no pudiera ser contenida por las psicólogas. la grabación de estas permitió la transcripción literal, para luego realizar un análisis comprensivo de cada una de ellas y así poder develar las unidades de significado y estructurar el fenómeno de estudio. las investigadoras y las entrevistadoras realizaron cada análisis por separado, para luego triangular las unidades de significado develadas en tres sesiones de trabajo. el fenómeno develado se socializó con tres de las participantes, quienes reconocieron su experiencia en las unidades de significado y las descripciones mostradas. luego se realizó una revisión en extenso de la literatura relevante para situar el fenómeno descubierto. como en todo estudio fenomenológico, los participantes deben haber experimentado el fenómeno en estudio, cumpliendo con los aspectos metodológicos y éticos. en este caso en particular, se incluyó a enfermeras(os) que trabajan en unidades de oncología pediátrica y que tuvieron la experiencia de presenciar la muerte de un paciente a causa del cáncer. los criterios de inclusión por considerar fueron: enfermeras(os) que trabajaron por más de tres años en una unidad de oncología pediátrica, que vivenciaron la muerte de un paciente durante su cuidado y que accedieron a participar voluntariamente. el número de participantes se determinó aplicando el criterio clásico de saturación de significados, el cual se logró con la sexta entrevista, y se completó hasta la décima entrevista para confirmar las unidades develadas. los participantes fueron nueve enfermeras y un enfermero, dos de ellas trabajan en clínicas del sector privado, y los demás en hospitales públicos; nueve eran de la región metropolitana. el grupo tenía un rango de edad entre los 28 a 57 años. cuatro de ellos tenían más de quince años de ejercicio profesional, y seis tenían entre cuatro a diez años. todos habían presenciado por lo menos diez fallecimientos de niños a causa del cáncer. a su vez, todos señalan haber sufrido al menos una pérdida de alguna persona que fue significativa. siete de los participantes se desempeñan en la atención directa, y el resto actualmente cumple el rol de supervisor. todos tenían algún curso de profundización en el área, cinco eran especialistas en oncología pediátrica y siete tenían especialización en cuidados paliativos pediátricos. en relación con aspectos personales, siete de los participantes eran casados y cuatro tenían hijos. para resguardar el cumplimiento de los aspectos éticos de la presente investigación se utilizó parte de la guía elaborada por firby (12), considerando los criterios de justicia, autonomía, beneficencia y no maleficencia. además de contar con la aprobación del comité de ética de la escuela de enfermería de la pontificia universidad católica de chile, en mayo del 2011. resultados y análisis como resultado del análisis de los testimonios se develaron tres unidades de significado principales, dos de las cuales se revelan como procesos paralelos: el transitar entre su propia forma de enfrentar la muerte y el cuidado profesional que otorga, y un aprendizaje de vida, dado por la comprensión de lo que es trabajar en oncología y los vínculos que en ella se forman. la interrelación de estas dos unidades permite desarrollar en las enfermeras(os) un cuidado con un sello particular, entregando lo que para ellas(os) es un cuidado amoroso, siendo esta la tercera unidad: transitar entre su propia forma de enfrentar la muerte y el cuidado profesional que otorga. el enfrentar la muerte de un paciente, en especial si es un niño, genera en las enfermeras un proceso dinámico y continuo de múltiples vivencias entre lo profesional, a través de su cuidado, y lo personal, en la manera como encaran la muerte. esto las lleva a transitar por diferentes vivencias donde emergen sentimientos de impotencia, frustración, dolor y pena. para ellas, estos son sentimientos complejos que nacen al sentir que la muerte de un niño era injusta y evitable, lo que se agudiza cuando piensan que no se brindó atención o cuidado de calidad, generando en el niño una muerte dolorosa y traumática: para mí ha significado momentos de dolor, pena, un poco de impotencia, sobre todo al no poder cambiar el pronóstico de esa paciente… es como cursi, pero a uno le duele el corazón. es como una angustia, impotencia de no poder ayudarlo (e2). 85 develando el significado del proceso de duelo en enfermeras(os) pediátricas(os) que se enfrentan a la muerte de un paciente a causa del cáncer l paula vega-vega y otros en respuesta a estos sentimientos, los participantes reconocen que en ocasiones prefieren evadir el momento de la muerte de los niños, por lo que buscan diferentes excusa para huir del servicio o no estar presentes en el instante del fallecimiento: “ojalá no esté cuando muera un niño. yo cuando sé que un niño se va a morir… ojalá no sea en mi turno… porque prefiero quedarme con el recuerdo del niño cuando estaba vivo” (e4). este transitar los puede llevar a resignarse ante la muerte, sin juzgar ni cuestionar lo sucedido, reconociéndolo como una realidad inevitable: "tarde o temprano entiendes que los que se van, se tienen que ir… o sea, que por mucho que nosotros hayamos dado el tratamiento o todo el esfuerzo… ¡los niños tiene que partir, no más!” a su vez, van descubriendo que existen experiencias que les ayudan en este proceso, como es el poder despedirse de los niños(as), encontrando la manera de decir adiós y expresar mutuamente sus sentimientos de afecto, lo que les permite cerrar ciclos: …yo durante el proceso me voy despidiendo del niño… mientras le voy dando los cuidados post mórtem…, lo vestimos, lo dejamos listo para entregárselo a la familia… y en el fondo yo en ese momento me despido… mientras lo voy haciendo, le hago cariño, le pongo su ropa, le hecho cremita, le voy diciendo lo especial que fue para mí, lo que significó para mí (e7). las diferentes vivencias durante este transitar generan la necesidad de resignificar la muerte de los niños buscando un sentido a las situaciones de sufrimiento experimentadas: “es sentir que las muertes no son en vano. yo siempre que se muere un niño, lo veo como una oportunidad de aprender… las muertes tienen que tener un significado, no pueden pasar: ¡murió el niño y se enterró!...” (e3). es importante destacar que este transitar no es lineal y que estas unidades van apareciendo frente a experiencias particulares de cuidado. un aprendizaje de vida el trabajo del día a día con niños con cáncer, y el enfrentarse a la muerte de alguno de ellos, conlleva un aprendizaje que permite comprender y reconocer que el cáncer es una enfermedad que trae consigo sufrimiento y muerte. al trabajar en un servicio oncológico se asume que tarde o temprano se enfrentarán a la muerte de uno de los pacientes y, a la vez, al sufrimiento de los padres: nosotros estamos metidos en un submundo, absolutamente... trabajas todos los días en un lugar donde se mueren niños, trabajas todos los días con una enfermedad dramatiquísima, que se sienten horrorosos y uno va todos los días como si nada. o sea es un submundo, ¡tú te metes ahí en un submundo, eso no es normal!… no tiene nada de normal estar metida ahí, pero para uno ya es normal… es un submundo y no nos damos cuenta… quizás yo creo que solo gente sana pueden seguir trabajando ahí (e5). uno de los aprendizajes de vida que las enfermeras señalan es aceptar que, por encima de su rol profesional, son personas, especialmente cuando son capaces de reconocer sus emociones y valorar la importancia de la expresión de estas sin sentir vergüenza ni culpa: llorar no en lo estricto… como sufrir con ellos. ahora lo hago mucho más libre, antes me contenía un poco de expresar esas emociones. porque pensaba que uno debía ser una persona de apoyo, como que tenía que tener otro perfil… entonces si hay que llorar, lloramos. si hay que estar triste, estamos tristes… y si hay que sonreír, sonreímos todos (e2). las enfermeras señalan que en forma natural se establecen vínculos afectivos con alguno de los niños, que no solo se enmarcan en la relación enfermera-paciente. son relaciones afectivas, de confianza y de admiración hacia ellos, lo que genera lazos cercanos y significativos: yo creo que la relación que se da con ellos… la relación enfermera paciente. la oncología te permite otro tipo de relación, permite que tú conozcas todo el entorno familiar… como que logras compenetrarte de todo lo que rodea al paciente, al niño y a la familia. en ese sentido a mí me satisface trabajar…te da otra relación, otro tipo de vínculo con los pacientes… (e10). a su vez, las enfermeras(os) consideran a sus pacientes como seres especiales y únicos, y admiran la valentía con la cual enfrentan el cáncer, el dolor de los procedimientos y las complicaciones del tratamiento, transformándose en ejemplos de vida para ellas: yo los veo que son cabros tira para arriba, que les pueden poner miles, mil cosas… se ríen igual; son súper luchadores, ¡son unos viejos chicos!... las cosas les resbalan, son tan puros de alma, 86 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 porque en el fondo a ellos nada les puede pasar mientras se sientan bien, andan bien. cuando se sienten mal, igual te regalan una sonrisa, igual tratan de tirar para arriba. o los más grandes, te tiran “la talla”. entonces en ese sentido, a mí me gusta mucho trabajar con niños y en especial con niños oncológicos. yo encuentro que son niños especiales, ¡son muy especiales! (e7). los participantes señalan en sus testimonios que aprenden mucho de la relación que se establece con los padres de los niños(as) que cuidan, generando un vínculo que se funda en la empatía, el respeto y la admiración. ellos se proyectan en los padres, valoran su fuerza, amor y entereza, y la capacidad de consolar a otros, entre los que están los profesionales de la salud: yo siempre trato de aprender de la familia, y aunque no lo quiera… por ósmosis te entra algo. siempre hay una mamá que es súper fuerte… las mamás están siempre ahí. yo en cada muerte, cuando veo a la familia, como que aprendo harto, me agarro de eso. y siempre se los digo a las mamás… “qué valentía la suya, ¿cómo lo hace? la admiro, es una gran mujer…”. siempre le digo, porque siento que a ellas les hace falta eso (e3). entrega de un cuidado con un sello particular a través de la entrega de su cuidado las enfermeras se perciben como un aporte para los niños y sus padres, al ser capaces de entregar alegría, apoyo y acompañamiento, con lo que rescatan lo sano y natural de cada niño: yo creo que es como para darles alegría a los niños… es como estar en la otra parte… es como que tú a pesar de que le propicias dolor frente al sufrimiento que le haces, que son frecuentes y diarios, uno les proporciona juegos, risas… olvidarse del tema… (e1). … la ternura, la inocencia de un niño es diferente. ellos lo ven todo con alegría, ellos lo ven todo con juegos, ellos andan en un mundo mágico… yo creo que ellos me han ayudado a mi crecimiento personal y profesional. entonces yo devuelvo la mano con el cuidado, con el estar ahí, con el poder ayudarlos, en el intentar hacer las cosas lo mejor que pueda… ese es el arte de cuidar, porque nosotras gestionamos el cuidado. si puedo aportar para que se recupere y pueda vivir, disfrutar de la vida, lo voy a hacer. y si puedo entregar cuidado a esta personita para que pueda tener una muerte digna, lo voy a hacer (e9). las enfermeras manifiestan sentir la responsabilidad de brindar un cuidado de calidad, que se materializa en la entrega de cuidados paliativos formales, sintiendo no solo que pueden entregar los recursos materiales, sino también tiempo, dedicación, apoyo emocional y cariño: hay una gran diferencia con cuidados paliativos, un cien por ciento. los niños que fallecen en una uci conectados no alcanzan a vivir un proceso ni tampoco los papás… en cambio el paciente en cuidados paliativos tiene un poco más de tiempo, entonces los papás se despiden, maduran todo esto. uno les puede dar mucho más apoyo emocional… (e2). los participantes se valoran como enfermeros(as) oncológicos(as) y perciben su labor como importante, de calidad y exclusiva, la cual está mediada por una entrega amorosa e individualizada del cuidado: pero igual, cuando hay que hacer procedimientos, y esa parte igual me cuesta, hay que estar pensando que es para el bien del niño… por otro lado, igual yo digo: “yo puedo ayudar en tantas cosas, en esas cosas y a ese papá, y a ese niño”. puedo aliviar el dolor, acompañarlo mucho, y entonces eso es como un círculo. porque los papás de los niños que han fallecido lo manifiestan: “es importante que haya una persona ahí dedicada a ellos”, lo valoran (e6). todas las experiencias vividas al cuidar a niños con cáncer van transformando su cuidado profesional en un cuidado amoroso, que es individualizado, único e integral, en el que se plasma el amor que la enfermera siente por su paciente y por la familia: es que el feedback que tú siempre tienes es maravilloso. yo creo que en ningún lado tú recibes tanto cariño de los papás y de los niños. o sea en ningún lado… yo me siento de verdad súper querida por mis niños… me siento súper querida ¡¿qué mejor alimento?! entonces se mueren los niños, pero por un lado me quedo tranquilo que lo hice con el alma. haber, prefiero de repente pincharlos en vez que lo pinche otra, no porque yo lo voy a pinchar mejor, ¡sino porque yo le voy a poner el corazón a mi tema!, solamente por eso. ¿te fijas?... entonces se mueren, y me quedo tranquila de que por lo menos traté de hacerle lo mejor, lo hice de corazón… por lo menos traté y eso me deja súper tranquila (e5). el transitar y el aprendizaje que experimentan las enfermeras están sustentados en el apoyo incondicional de su propia familia y el equipo de salud de su unidad. sin embargo, son estos últimos 87 develando el significado del proceso de duelo en enfermeras(os) pediátricas(os) que se enfrentan a la muerte de un paciente a causa del cáncer l paula vega-vega y otros los que con el tiempo pasan a ser los actores fundamentales en el afrontamiento y consuelo frente a la pérdida de los niños: al final también con el tiempo lo va madurando, y uno se da cuenta que las mejores personas con las que puedes compartirlo es con tu equipo de trabajo. acá nosotras hemos llorado juntas como equipo: el técnico, el médico, la enfermera, los psicólogos… lloramos juntos o lloramos con los papás... logras tener esa confianza y afianzarte con ellos (e2). discusión las unidades develadas en este estudio confirman los hallazgos de anteriores investigaciones que sostienen que el proceso de duelo no solo es vivenciado por los familiares de un paciente, sino por todos aquellos que crearon un vínculo con el niño, entre los que se destacan los profesionales de la salud que atendieron y cuidaron de él (13, 14). es así como varios autores sostienen que el cuidado de pacientes pediátricos en fase terminal provoca una serie de reacciones fluctuantes y personales que pueden llevar a los profesionales que atienden a estos niños a desarrollar burnout, en caso de que no logren adaptarse a los diferentes mecanismos de enfrentamiento de la muerte o no encuentren significado a su vivencia (15, 16). en algunas investigaciones se destaca que las enfermaras que cuidan a pacientes con cáncer presentan un grado moderado a bajo de burnout, dado específicamente por la satisfacción en su rol, bajos niveles de estrés en su trabajo y percepción de soporte por parte de su entorno laboral (17). algunos investigadores identifican el “estrés moral”, es decir, el que aparece ante la imposibilidad de actuar frente al sufrimiento del paciente y tener que enfrentar a los familiares (18, 19). en los profesionales de enfermería además surgen sentimientos disonantes entre el cuidado que deben brindar según las indicaciones médicas —que son consideradas en algunas situaciones innecesarias, traumáticas y contrarias a una muerte digna— y el cuestionamiento de no haber hecho lo correcto para evitar la muerte (20-22). con respecto a la actitud evitativa de las enfermeras ante la muerte de los pacientes algunos autores sostienen que es una forma de enfrentar la situación, pudiendo ser tanto física como emocional. ellas se sumergen en sus tareas y bloquean sus sentimientos de tristeza y angustia con el objeto de no afectar sus competencias (9, 23). a su vez papadatou, martinson y chung destacan que existen diferencias que puede estar mediadas por los aspectos culturales, la edad, los años de experiencia y el ambiente donde se desenvuelven (23, 24). sin embargo, algunos expertos señalan que la reiteración de la conducta evitativa genera a largo plazo un duelo no afrontado que puede comprometer las capacidades laborales, incluso con el riesgo de abandonar al paciente en su cuidado (23). según los hallazgos de otros estudios, la resignación ante la muerte se presenta en los profesionales de enfermería, quienes comprenden que existen límites, por lo que prolongar el sufrimiento del niño está en contra de una filosofía de muerte digna (15, 23). según poles y bousso, este es el primer paso que se da para ser capaces de compartir la muerte con las familias y lograr modificar su cuidado más allá del aspecto físico (25). esto les permite tomar conciencia del “dejar ir” y enfocarse en el aspecto espiritual del niño moribundo (16). al igual que lo develado en este estudio, otras investigaciones demostraron que las enfermeras oncológicas pediátricas usan como estrategia de enfrentamiento el encontrar un significado a la muerte de los pacientes, disminuyendo así su estrés, permitiéndoles experimentar una transformación en la percepción de cómo entregan sus cuidados a lo largo de su vida laboral (19, 23, 25, 26). con respecto al aprendizaje de vida algunos autores sostienen que estas vivencias las llevan a analizar y tomar conciencia de sus creencias y de su mirada hacia la vida y la muerte, considerando esta última como un proceso normal, incluso en un niño. para ello, es necesario que integren aspectos psicológicos y espirituales en su cuidado, con el apoyo de su equipo (16, 27). sin embargo, wenzel sostiene que no siempre están las condiciones de apoyo suficientes, y que en algunas oportunidades se sienten solas (21). como se develó en este estudio, el vínculo afectivo que se forma con el niño y con los padres está mediado por el tiempo y la calidad de la relación que existió entre el paciente y la enfermera, y nace de una relación auténtica de cuidado (20). en el caso particular de los niños con cáncer varios autores sostienen que las enfermeras, al vincularse con ellos, los reconocen como especiales y establecen relaciones diferenciadas y singulares (19). esto las hace sentirse privilegiadas y recompensadas al poder cuidar a estos seres únicos (18, 27). 88 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 otro de los aprendizajes que compartieron las enfermeras(os) fue el aceptarse como personas. esto también fue develado en la teoría fundada desarrollada por davies que mostró que el enfrentamiento del duelo de las enfermeras está mediado por la aplicación de su autoconocimiento, al reconocer sus limitaciones personales y la necesidad de un descanso durante su jornada laboral, dejando que se abra un espacio para poder enfrentar tranquilamente lo vivido, y así aliviar su angustia (23). lo anterior se suma a la necesidad que tienen de ser honestas consigo misma y con sus pacientes, al compartir abiertamente sus pensamientos y sentimientos con el equipo de salud, pero sobre todo con el niño, lo que se condice con lo señalado por otros investigadores quienes sostienen que las enfermeras deben ser capaces de aceptar sus propios sentimientos, vulnerabilidades y limitaciones, y expresarlos dentro del equipo (19). es por ello que una de las estrategias descritas es estar abierto a la expresión del propio duelo y la “autoexpresión” de su tristeza, lo que las hace más humanas (28). son estos sentimientos los que en algunas situaciones les generan conflicto al estar regulados por un “código de comportamiento profesional” que limita la expresión de las emociones (19, 23). a lo anterior se suma el vínculo formado con los padres, donde la enfermera cumple un rol de “defensora” preocupándose de apoyar y aconsejar a los familiares, especialmente al momento de cambiar la perspectiva curativa del cuidado por la paliativa (18). esta relación genera un soporte emocional recíproco que provee de consuelo y apoyo, favoreciendo el enfrentamiento de la pérdida del paciente (25, 28). todas estas vivencias tienen un impacto único que lleva a las enfermeras a cambiar su propia filosofía de vida forjando una actitud más realista que les permite re-evaluar sus prioridades y encontrarle sentido a las situaciones difíciles del día a día (21, 29). a esto se suma el hecho de que ellas manifiestan satisfacción al sentir que contribuyeron en el momento de la muerte del niño, al procurar realizar un cuidado de la mejor manera posible, a pesar de las dificultades que se pudieron presentar (19, 25). para ellas, el compromiso de realizar un mejor cuidado va de la mano del ser comprensivo, solidario y no prejuicioso, lo que es valorado por los padres a través de la retroalimentación positiva que ellos les entregan tras la muerte de sus hijos (20, 21). particularmente, las enfermeras oncológicas se sienten satisfechas con su carrera al percibir que proporcionan un cuidado de excelencia, cercano y holístico, lo que se refleja en una actitud empática y esperanzadora que les permite dar significado a las distintas vivencias y reconocerse como valiosas (17, 29). esta actitud es más marcada en las enfermeras oncológicas que trabajan con niños, dada la íntima y natural relación que se desarrolla entre ellos (19). al igual que los participantes de este estudio, las enfermeras de la investigación de papadatou señalaron que su cuidado era distinto al entregado por las colegas que trabajan en otras unidades de pediatría, ya que eran capaces de bajar su estrés emocional al divertirse en su jornada laboral, especialmente al jugar y compartir su alegría con los niños (19). según esta investigadora, es un requisito que los profesionales adquieran herramientas en orden a relacionarse y comunicarse con los niños usando menos comunicación oral y más simbólica, con el fin de que ellos expresen sus pensamientos, sentimientos y deseos al final de la vida (2932). es importante destacar que para las enfermeras(os) de este estudio su cuidado tenía un sello particular, el cual estaba centrado en el amor y la dedicación que entregaban en lo que hacían, lo que sería uno de los hallazgos de la presente investigación. en este sentido, la doctora jean watson sugiere que el cuidado de enfermería sana se da cuando la enfermera es capaz de construir un momento en el cual ella logra encontrarse con el otro, cariñosa y espiritualmente, lo que implica comprender la vivencia del otro y autocomprenderse en el mismo proceso (33-35). una de las estrategias que más les servía a las enfermeras era compartir el proceso de duelo con otros profesionales, en especial entre colegas, y así afrontar juntos la fase terminal y luego la muerte del paciente (19). al compartir sus historias y su tristeza son capaces de enfrentar la angustia de la pérdida y, a su vez, sentirse valoradas por otro que las comprende de verdad. esto se suma a la necesidad de intercambiar ideas e información para la toma eficaz de decisiones, aceptar las elecciones hechas y realizar un cierre emocional dentro del equipo, lo que les permite la “auto-expresión” (20). cabe destacar que a pesar de que los participantes de este estudio se sienten apoyados por el equipo de salud de su servicio, no hacen referencia a la existencia de sistemas de apoyo profesional formal, lo que concuerda con los hallazgos del estudio de maza et al. realizado en chile (9). esta situación llama la atención ya que existen varias investigaciones en las cuales se ha demostrado que la aplicación de intervenciones de apoyo en profesionales de la salud que trabajan con personas en fase termi89 develando el significado del proceso de duelo en enfermeras(os) pediátricas(os) que se enfrentan a la muerte de un paciente a causa del cáncer l paula vega-vega y otros nal favorece la elaboración del duelo y, a su vez, genera rituales que están enmarcados en ambientes de confianza y respeto (29, 32, 34). lo anterior se potencia si existe una capacitación formal para el afrontamiento de los pacientes pediátricos en fase terminal, dado que además de disminuir la ansiedad ante su muerte, permite interactuar más activamente con ellos, entregando una atención de calidad (14). conclusiones el presente estudio permitió comprender que la experiencia de enfrentar la muerte de un paciente por parte de las enfermeras oncológicas es vivida como una pérdida y, por consiguiente, pasan por un proceso de duelo que las lleva a buscar un sentido a esta dolorosa experiencia. a través del cuidado se van formando lazos con los pacientes, siendo algunos de ellos muy fuertes y significativos. para ellas, estos niños son especiales y únicos, sintiéndose marcadas no solo desde lo profesional, sino también desde lo personal (23, 27). para que estas experiencias tengan sentido se requiere de reflexión constante sobre el tema, hablar de la muerte con los niños, crear significados y aceptar sus propios sentimientos y emociones de dolor (20). esto lleva a tomar conciencia acerca de que el duelo es personal, y que aunque existan muchas estrategias descritas en la literatura, en este proceso está implícita la identidad profesional integrada al concomimiento personal que toda enfermera debe desarrollar y transmitir. para algunos expertos esta reflexión es la que lleva a las enfermeras a sentir satisfacción por su desempeño profesional y las protege de desarrollar burnout (21-24). entre los momentos significativos que permitieron a los participantes elaborar su proceso de duelo se destacaba la oportunidad de despedirse de los niños, tener la posibilidad de resignificar la muerte, aceptar que el trabajar en un servicio oncológico conlleva sufrimiento y, por último, reconocer a los niños como seres especiales. todo esto les permitió valorarse como enfermeras(os) por el cuidado particular y único que brindaron. a su vez, se develaron factores facilitadores que las ayudaron en el trabajo activo de elaboración del duelo al reconocer que la vivencia del dolor trae consigo aprendizajes para su vida, como expresar sus sentimientos y emociones, y vincularse afectivamente con los niños y sus padres responsabilizándose de entregar cuidados de calidad únicos y personalizados. todo esto es posible por el apoyo continuo de sus propias familias y, sobre todo, del equipo de salud con el que trabajan, en especial sus colegas. por otra parte, los participantes describen vivencias que se transforman en factores obstaculizadores en el proceso de elaboración del duelo como son la frustración, la rabia y la pena cuando perciben que a los niños(as) no se les otorgó una atención adecuada por la falta de herramientas propias o por el ensañamiento terapéutico, y a la dificultad que manifiestan de poder expresar sus sentimientos y emociones frente a los padres y a los otros profesionales de la salud, debido a la exigencia del “deber ser” profesional. davies y gerow plantean que las experiencias significativas de muerte al inicio de la carrera de enfermería forman los cimientos de cómo estas profesionales brindarán cuidados a los pacientes moribundos en el futuro, y cómo impactará en sus futuras respuestas al duelo (16, 23). a su vez, el vivenciar experiencias positivas de muerte les permite ayudar a otras enfermeras a enfrentar el fallecimiento de los pacientes (16). desde lo disciplinar, quint (36) señala que la enfermería ha tenido una de las mayores participaciones en los cambios de enfrentamiento de las pérdidas y del duelo, tanto en las personas bajo su cuidado, como en los profesionales mismos, en especial durante los últimos sesenta años. un reflejo de esto es la aparición de teóricos en enfermería que han enaltecido los procesos que se vivencian durante el cuidado de los pacientes en fase terminal y los vínculos que se establecen. es jean watson quien plantea la importancia de un cuidado transpersonal, el cual integra fuertemente el aspecto espiritual y cariñoso en el cuidado (33, 35). para finalizar, es importante señalar que los hallazgos de este estudio podrán proporcionar una base para desarrollar nuevas estrategias en la formación de grupos de apoyo dentro de los equipos de salud y, a su vez, justificar la importancia de considerar estos contenidos dentro del currículo de pregrado. por otra parte, se hace necesario ampliar esta investigación a la vivencia con los otros integrantes del equipo de salud que trabajan en oncología, y con pacientes con enfermedades que requieren cuidados paliativos crónicos. limitaciones las autoras reconocen como una limitante de esta investigación que los participantes cuidan a niños oncológicos en áreas públicas y privadas, lo que puede generar diferencias en los ambientes de trabajo y en la relación con los padres. sin embargo, al analizar los relatos no hubo diferencias y a su vez se respeta el principio de justicia. 90 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 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[serie en internet]. 2011 [acceso 3 de enero de 2012]; 38(4);272-282. disponible en: http://www. medscape.com 91 develando el significado del proceso de duelo en enfermeras(os) pediátricas(os) que se enfrentan a la muerte de un paciente a causa del cáncer l paula vega-vega y otros 22. morgan d. caring for dying children: assessing the needs of the pediatric palliative care nurse. pn [serie en internet]. 2009 [acceso 27 de enero de 2012]; 35(2);86-90. disponible en: http://search.proquest.com/docview/199445740/ fulltextpdf?accountid=16788 23. davies b, clarke d, connaughty s, cook k, mackenzie b, mccormick j, et al. caring for dying children: nurses’ experiences. pn. 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[serie en internet]. 2006 [acceso 4 de enero de 2012]; 14(2); 207-213. disponible en: http://www. scielo.br 26. brown c, wood a. oncology nurses’ grief: a literature review. cjon [serie en internet]. 2009 [acceso 3 de enero de 2012]; 13(6);625-627. disponible en: http://ons.metapress.com 27. iranmanesh s, haggstrom t, axelsson k, savenstedt s. a caring relationship with people who have cancer 2009; 65(6):1300-008. 28. lee k, dupree c. staff experiences with end-of-life care in the pediatric intensive care unit. jpm [serie en internet]. 2008 [acceso 3 de enero de 2012]; 11(7);986-90. disponible en: http://online.liebertpub.com 29. papadatou d. a proposed model of health professionals´grieving process. omega. 2000;14:59-77. 30. cohen m, ferrell b, vrabel m, visovsky c, schaefer b. what does it mean to be an oncology nurse? reexamining the life cycle concepts. onf [serie en internet]. 2010 [acceso 3 de enero de 2012]; 37(5),561-570. disponible en: http://ons. metapress.com 31. saunders jm, valente sm. nurses’ grief. cancer nurse. [serie en internet]. 1994 [acceso 18 de junio 2012]; 17(4);318-25. disponible en: http://www.ncbi.nlm.nih.gov 32. brunelli, t. a concept analysis: the grieving process for nurses. nf [serie en internet]. 2005 [acceso 3 de enero 2012]; 40(4);123-8. disponible en: nlinelibrary.wiley.com 33. watson j. intentionality and caring-healing consciousness: a practice of transpersonal nursing. jhn 2002;16(4):12-9. 34. keene e, hutton n, hall b, rushton c. bereavement debriefing sessions: an intervention to support health care professionals in managing their grief after the death of a patient. pn [serie en internet]. 2010 [acceso 23 de marzo 2011]; 36(4);185-189. disponible en: http://www.pediatricnursing.net/ce/2012/article36185189.pdf 35. quinn j, smith m, ritenbaugh c, swanson k, watson j. research guidelines of assessing the impact of the healing relationship in clinical nursing. at 2003;9(3):6579. 36. quint j. loss and bereavement: perspectives, theories, challenges. cjnr [serie en internet]. 1999 [acceso 10 de enero 2012]; 30(4);263-72. disponible en: http://cjnr.mcgill.ca/archive 53 66 la identidad profesional.indd 53 jorge renán chuaqui-kettlun1 lorena paola bettancourt-ortega2 valentina javiera leal-román3 carlos alberto aguirre-gonzález4 la identidad profesional de la enfermería: un análisis cualitativo de la enfermería en valparaíso (1933-2010) 1 doctor en ciencias humanas. profesor asociado, universidad de valparaíso, chile. jorge.chuaqui@uv.cl 2 enfermera-matrona. magíster en enfermería. docente, universidad de valparaíso, chile. lorena.bettancourt@uv.cl 3 socióloga. universidad de valparaíso, chile. valentina.leal@uv.cl 4 sociólogo. universidad de valparaíso, chile. carlosaguigo@gmail.com recibido: 11 de julio de 2012 enviado a pares: 26 de agosto de 2012 aceptado por pares: 17 de septiembre de 2013 aprobado: 14 de noviembre de 2013 año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 53-66 para citar este artículo / to reference this article / para citar este artigo chuaqui-kettlun, j. r.; bettancourt-ortega, l. p.; leal-román, v. j.; aguirre-gonzález, c. a. (2014). la identidad profesional de la enfermería: un análisis cualitativo de la enfermería en valparaíso (1933-2010). aquichan. vol. 14, no. 1, 53-66. resumen objetivo: comprender la evolución de la identidad profesional de la enfermería en valparaíso, chile, en el periodo de 1933 hasta el 2010. materiales y métodos: se trabajó con un diseño cualitativo complementado con análisis documental, apoyado por el software de análisis cualitativo atlas ti. se realizaron 17 entrevistas en profundidad a enfermeras que ejercieron la profesión en distintas épocas de la enfermería en valparaíso, distribuidas en tres periodos que abarcan desde 1933 al 2010. resultados: los datos muestran que la identidad de la enfermería ha ido variando desde un rol caracterizado por una vocación desinteresada de lo económico e interesada en la ayuda al otro de manera incondicional, a una nueva etapa en que perdura una vocación en el servicio aunque, esta vez, desde un servicio más profesionalizado y complejo. conclusiones: esta investigación permite identificar que, al igual que las sociedades modernas, la enfermería está caracterizada por un creciente individualismo y complejización de sus procesos, por la exacerbación de la responsabilidad personal y los múltiples quehaceres de estos/as estimulados por el desarrollo científico y académico de la profesión. palabras clave profesiones en salud, sociología, enfermería, historia de la enfermería, rol profesional (fuente: decs, bireme). 54 aquichan issn 1657-5997 año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 53-66 the professional identity of nursing: a qualitative analysis of nursing in valparaiso (1933-2010) abstract objective: the study is designed to arrive at an understanding of how the professional identity of nursing in valparaiso, chile evolved during the period from 1933 to 2010. materials and methods: a qualitative design was used, supplemented with documentary analysis supported by atlas ti qualitative analysis software. seventeen (17) in-depth interviews were conducted with nurses who were active professionally during different eras of nursing in valparaiso, which were divided into three periods spanning from 1933 to 2010. results: the data show the identity of nursing has evolved from a role characterized by a selfless vocation in economic terms, coupled with an interest in unconditionally helping others, to a new phase that continues to involve a vocation to serve, but now from the standpoint of more professional and complex service. conclusions: the results show that nursing, like modern societies, is characterized by growing individualism and the complexity of its processes, an intensification of personal responsibility and the multiple tasks of nurses stimulated by scientific and academic development of the profession. key words health occupations, sociology, nursing, history of nursing, professional role (source: decs, bireme). 55 la identidad profesional de la enfermería: un análisis cualitativo de la enfermería en valparaíso (1933-2010) l jorge renán chuaqui-kettlun y otros. a identidade profissional da enfermagem: uma análise qualitativa da enfermagem em valparaíso (1933-2010) resumo objetivo: compreender a evolução da identidade profissional da enfermagem em valparaíso (chile) no período de 1933 a 2010. materiais e métodos: trabalhou-se com um desenho qualitativo complementado com análise documental, apoiado pelo software de análise qualitativa atlas ti. realizaram-se 17 entrevistas em profundidade com enfermeiras que exerceram a profissão em diferentes épocas da enfermagem em valparaíso, distribuídas em três períodos que abrangem de 1933 a 2010. resultados: os dados mostram que a identidade da enfermagem tem variado desde um papel caracterizado por uma vocação desinteressada do econômico e interessada na ajuda ao próximo de maneira incondicional até uma nova etapa em que perdura uma vocação no serviço que, nesse caso, é mais profissionalizado e complexo. conclusões: esta pesquisa permite identificar que, assim como as sociedades modernas, a enfermagem está caracterizada por um crescente individualismo e complexização de seus processos, pela exacerbação da responsabilidade pessoal e dos múltiplos fazeres desses/as estimulados/as pelo desenvolvimento científico e acadêmico da profissão. palavras-chave ocupações em saúde, sociologia, enfermagem, história da enfermagem, papel profissional (fonte: decs, bireme). año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 53-66 56 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 introducción la reforma de salud en chile y los recientes avances en la gestión del cuidado han derivado en una serie de nuevos desafíos para la enfermería, que se han manifestado en el aumento de responsabilidades en torno a la gestión de recursos humanos y financieros, y en mayores exigencias para planificar, tomar decisiones y ejercer el liderazgo, lo que ha puesto de relieve la necesidad de plantearse el problema de la identidad y el rol de la profesión de enfermería en la actualidad. estos aspectos podrían tener desavenencias frente a características tradicionales que prevalecen en la profesión. el estado del arte de las investigaciones que trabajan estos problemas ha dado cuenta de que los valores y las actitudes de la profesión de enfermería y su desarrollo histórico mantienen una prevalencia de una identidad profesional “débil” (1) a pesar de los cambios acontecidos en la profesión en las últimas décadas. otros autores han identificado que prevalecen una serie de tensiones y conflictos porque se mantiene un sistema de creencias basado en la subordinación y “el ser para otro” que vuelve compleja su interpretación sobre el rol y las expectativas (2), y que junto a otros factores, como la feminización del cuidado y la tendencia al respeto de las institucionalidades vigentes, volvería “invisible” a la profesión. también se ha reflexionado sobre las características tradicionales que ha tenido la profesión en el transcurso del tiempo, tales como la subyugación al poder médico, a la iglesia y las discriminaciones de género (3), y por último, se ha trabajado el desarrollo teórico de la identidad en enfermería reconociendo una baja autonomía y autodeterminación, una débil apropiación del acervo teórico y poco compromiso gremial, lo que plantea la necesidad urgente de asumir desde la academia un rol más protagónico en los programas de formación que fortalezcan la identidad de los egresados, permitiendo así la vinculación de la enfermería con las ciencias humanas y la existencia de una masa crítica de enfermeras/os para su desarrollo (4). particularmente, en el caso chileno, desde la investigación en enfermería contemporánea, la reflexión sobre estas problemáticas, como también las indagaciones de corte histórico, han estado relativamente ausentes, prevaleciendo una preocupación por problemáticas organizacionales, profesionales y académico-formativas (5, 6). se puede decir que pocos estudios se dedican a la reflexión sobre la evolución histórica de la profesión y su consecuencia en la identidad histórica; sin embargo, estos reconocen que es fundamental el estudio de la identidad ya que desde allí se podrían resolver las problemáticas actuales de la disciplina (6). se observa, además, un carácter “presentista”, donde los problemas que se enfrentan son producto de factores contingentes, dejando el hecho de que los procesos que afectan a la profesión tienen una larga data. es por ello que en este artículo se busca estudiar a la enfermería desde sus distintos momentos históricos en nuestro país, para identificar cómo los elementos identitarios han ido cambiando, considerando, además, lo importante del desarrollo de las historias disciplinares, ya que estas permiten valorar el trabajo científico en el propio campo de la enfermería, contribuyendo al desarrollo teórico de la disciplina, a la demarcación de las fronteras del dominio intelectual y a la legitimación de los patrones existentes (7). en este artículo analizaremos la evolución en la identidad de los profesionales de enfermería en tres periodos que van desde 1933 al año 2010, a través de una investigación cualitativa realizada a profesionales de la región de valparaíso. para abordar este objetivo comenzaremos refiriéndonos al concepto de profesión, luego al estatus profesional y al concepto de identidad vinculado a dicho estatus. las profesiones, la identidad y el estatus la literatura ha señalado que las profesiones modernas, y específicamente las de la salud, surgen en el siglo xix con la revolución industrial (8). en este proceso se ha destacado la complejización del campo laboral y su creciente especialización. en el área de la salud, es interesante destacar el papel central que ha tenido el estado durante gran parte del siglo xx en la definición de políticas públicas para delimitar los roles de profesionales y técnicos, con el propósito de satisfacer la demanda por una salud pública (9). las investigaciones en enfermería, desde una perspectiva teórica, han dado pocas pautas sobre cómo estudiar la identidad de la profesión, algunas de ellas han recurrido a la perspectiva sociológica y en este artículo lo haremos del mismo modo. la bibliografía en la sociología de las profesiones ha enfatizado los siguientes rasgos de las mismas: • las actividades que desarrollan son esenciales para asegurar la vida y el bienestar de la sociedad. 57 la identidad profesional de la enfermería: un análisis cualitativo de la enfermería en valparaíso (1933-2010) l jorge renán chuaqui-kettlun y otros. • ponen énfasis en el servicio rendido, o “espíritu de servicio”. el profesional antepone los intereses de los usuarios a toda otra consideración. • son regidas por códigos de ética en que se establecen las normas que deben seguir los miembros de la profesión en el desempeño de sus actividades. • requieren de un largo periodo de estudios altamente especializados que se basan fundamentalmente en un conjunto sistemático de conocimientos teóricos. esta preparación se obtiene en universidades u otras instituciones de enseñanza superior. • tienen derecho exclusivo, o monopolio, de ofrecer servicios en determinadas esferas de actividades. • son autónomas. las profesiones tienen el derecho a fijar sus propios objetivos, de organizar sus actividades y regirse por medio de reglas propias, formuladas por los miembros de la profesión respectiva. cada profesional es autónomo. • tienen una cultura propia —los valores, las normas, los símbolos y el lenguaje característicos de cada profesión—, que si bien está inserta en la cultura amplia de la comunidad nacional, constituye una especie de “subcultura” dentro de ella. este hecho produce un alto grado de identificación del individuo con su profesión, junto con un fuerte sentimiento de solidaridad con los miembros de ella. • gozan de elevado prestigio, superior al de la mayoría de las otras ocupaciones. • obtienen remuneración económica relativamente buena en relación con otras ocupaciones no profesionales, a menudo en combinación con un régimen especial de honorarios, asignaciones, condiciones de trabajo, etc. (10). si examinamos el cuadro anterior, la enfermería cumpliría con todas las condiciones, excepto algunas limitaciones en cuanto a su autonomía. sin embargo, esta caracterización tradicional se refiere a las denominadas “profesiones liberales” y, por tanto, se ha señalado que esta descripción no da cuenta de las relaciones de poder existentes entre las mismas ocupaciones, las que evolucionan junto con la sociedad. para analizar este problema, los autores proponen utilizar la idea de situs, que englobaría un conjunto de actividades en un área de la sociedad. algunas de estas áreas serían: salud, construcción, jurídica, etc., y habría una profesión dominante en cada situs: por ejemplo: médicos, arquitectos, etc. en este sentido, la profesión dominante del situs sería la que tendría la autoridad institucional, definiendo las tareas y prerrogativas del resto de las ocupaciones dentro del situs. por tanto, se propone reservar el término de profesión solo para las profesiones dominantes de cada situs, siendo las otras que colaboran ocupaciones complementarias. en nuestro caso, es pertinente señalar que la profesión médica sería el situs del campo de la salud y que la enfermería sería una ocupación complementaria (11). si bien podemos considerar que esta asimetría de poder entre los médicos y las enfermeras sigue vigente, con el desarrollo histórico de la enfermería y con el debate en torno al concepto de profesión y ocupación, nos parece cuestionable uno de los criterios con el cual se ha construido este modelo teórico, basado especialmente en la profesión médica. en este nuevo contexto sociohistórico el profesional manifiesta variaciones, ocupando nuevos campos en un complejo sistema de salud público-privado, por ejemplo, en administración y alta dirección pública. el debate hoy se centra en otros fenómenos: la “pérdida gradual e irreversible de la autonomía profesional, el deterioro de las condiciones de trabajo, el asalariamiento, la nueva división del trabajo, así como la incorporación de otros profesionales al equipo de salud, etc.” en este sentido, para machado el poder y el saber médico están siendo cuestionados y, en cierta forma, el poder está siendo repartido entre las enfermeras y otros profesionales (12). por lo anterior, si bien hay que tener en cuenta que la diferenciación entre profesiones y ocupaciones complementarias apunta a un hecho real e histórico en cuanto a la existencia de asimetrías en las relaciones de poder entre las profesiones —muchas veces desatendida por la propia enfermería—, consideraremos que esta debe ser conceptualizada más bien como una “profesión complementaria” que evolucionó desde una “ocupación complementaria”. en este sentido, es posible entender el lento proceso de profesionalización de la enfermería, su incorporación al sistema de educación superior, su mayor legitimidad en cuanto a su acción profesional cada vez más autónoma y a una continuidad en dependencia hacia la profesión médica, en términos de la dominación de situs. ahora bien, veamos el problema en términos de roles y estatus. en general, si se considera a los individuos ubicados en posiciones estructurales, emplearemos el concepto de rol social 58 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 y para referirnos a la posición del individuo en una situación que forma parte de situaciones complementarias, el concepto estatus social. la interacción de un sujeto transcurre en contextos complejos, esto significa que son más de dos las situaciones complementarias, o sea, el estatus del sujeto expresa un complejo de conductas de los otros hacia él. ello significa que a un estatus correspondería no uno sino diversos roles (un rol-set)” (13). esta complejidad del rol-set se evidencia en el carácter multifacético de la gestión del cuidado en enfermería. en el plano simbólico, el rol representaría los deberes, y el estatus los derechos y las limitaciones correspondientes a la posición. el estatus profesional de enfermería puede ser ocupado por las distintas personas que lo adquieran, a través de la educación superior; la configuración de este depende de los sistemas u organizaciones y del cargo que se ocupe en las mismas. ello involucrará distintos rol-set asociados a dichos estatus. sin embargo, hay aspectos que se mantienen en el tiempo, como el prestigio asociado a la profesión de enfermería, formas culturales asociadas al estatus profesional, y los valores y las creencias profesionales típicas de una subcultura. hay otros que varían, como las remuneraciones según el cargo. respecto a la identidad profesional hay un doble aspecto: cuánto se identifica una persona en particular con el estatus profesional y, por otra parte, cuál es el tipo y la intensidad de la identificación con el estatus profesional más frecuente. la identidad se entiende como un proceso de construcción en el que los individuos se van definiendo a sí mismos en estrecha relación simbólica con los otros (14). las características del grupo, entonces, son compartidas y comunes a todos quienes ejerzan la actividad y evolucionarán en el tiempo conforme ciertos factores. la identidad está compuesta por dos dimensiones: una objetiva y otra subjetiva (15). la primera de ellas se refiere a la posición concreta que se ocupa en una organización social, estatus profesional y un rol-set asignado. la segunda dimensión se refiere al sentido que los actores le entregan a sus relaciones sociales dentro del sistema. así, la identidad se configura en una transacción biográfica y relacional en el ejercicio del rol donde la persona, a partir de su experiencia cotidiana de vida, construye el sentido de su existencia personal y social, y gestiona su identidad ante sí y ante los demás. a su vez, actúa según lo esperado o lo exigido socialmente, siendo así sujeto de su identidad y actor de un rol, lo que contiene aspectos simbólicos tales como la búsqueda de reconocimiento o el temor a la sanción (16). ahora bien, nos adentraremos a identificar cómo estos elementos son vivenciados y representados por individuos en un contexto determinado, el cual está implicado en una historia cambiante que los va constituyendo. materiales y métodos esta investigación es de tipo descriptivo, exploratorio, de diseño cualitativo, que combinó además revisión de documentos de valor histórico emanados del colegio regional de la orden y de la escuela de enfermería más antigua de la región. un grupo de 17 enfermeras y enfermeros participaron como entrevistadas/os en este estudio, ellas/os fueron elegidos intencionalmente, considerándose que hubieran estudiado o trabajado en valparaíso en distintos periodos clasificados, a saber: primer periodo, inicio de la formación en la escuela de enfermería carlos van buren y la integración de esta institución a la universidad de chile, sede valparaíso, respectivamente (1933-1968); se entrevistaron cinco enfermeras de las áreas académica, comunitaria, gremial y clínica. en el segundo periodo, que inicia con la reforma universitaria y finaliza con el término de la dictadura militar (1968-1990), se entrevistaron seis enfermeras/os de las áreas académica, clínica, gremial y de gestión. el tercer periodo data del proceso de transición a la democracia definido por la profesionalización de la disciplina y el protagonismo que le infiere a la profesión el reconocimiento en el artículo 113 del código sanitario (1990-2010); se entrevistaron seis enfermeras/os de las áreas clínica, de gestión y académica. esta periodización buscó captar la mayor cantidad de voces posibles en los distintos ámbitos en que se desarrolla la enfermería. las entrevistas en profundidad se realizaron entre los años 2010 y 2011, en la ciudad de valparaíso, en el lugar que se acomodara a los participantes, tuvieron una duración promedio de una hora y se realizaron con el consentimiento de los participantes. en las entrevistas en profundidad (17) se logró ahondar en los sentidos que los actores dan a sus prácticas y permitió acercarnos a las interpretaciones de sus experiencias. la entrevista contempló los siguientes ejes: formación inicial, iniciación laboral, trabajos, funciones, visiones sobre la enfermería en general y autodefinición. el análisis que se utilizó fue de contenido cualitativo en la definición de ruiz (18). se utilizó el software de análisis cualitativo atlas ti mediante el cual se procedió a reducir la información a través de categorías basadas en los datos, las cuales se agrupa59 la identidad profesional de la enfermería: un análisis cualitativo de la enfermería en valparaíso (1933-2010) l jorge renán chuaqui-kettlun y otros. ron en temáticas generales por medio de la creación de familias de datos. a partir de esas familias se procedió a interpretar los contenidos y a describirlos, identificando los núcleos centrales y considerando el contexto histórico. esta investigación resguardó los aspectos éticos, el instituto de sociología de nuestra universidad aprobó las entrevistas realizadas y revisó el consentimiento informado. las identidades fueron resguardadas. resultados en nuestra investigación de la evolución de la identidad de las/os enfermeras/os en el periodo 1933-2010 los resultados muestran que esta ha ido variando desde un rol caracterizado por una vocación desinteresada por lo económico e interesada en la ayuda al otro de manera incondicional, una vocación de servicio en el ámbito de la enfermería, para pasar finalmente a una relación más profesionalizante y compleja. primer periodo (1933-1968): la emergencia del sistema público de salud y la enfermería el primer periodo de la enfermería en valparaíso se vincula al fortalecimiento de las políticas públicas en salud, donde se observa el paso de una política asistencial y caritativa a cargo de la iglesia y los grupos enriquecidos del país, a una política general de salud, liderada por el estado, que busca la universalidad. el periodo coincide con la creación de las primeras escuelas de enfermería en chile y en la ciudad de valparaíso. la disciplina se define por su carácter técnico, su vocación de servicio y su subordinación a la autoridad del médico. fue fundamental el aporte de agustín edwards5 en traer enfermeras de inglaterra para la atención de los hospitales, quien junto al médico alejandro del río crearon la escuela de enfermería de beneficencia en 1919 (19), la cual utilizó el modelo nigthingale. posteriormente, el benefactor carlos van buren formó la escuela de enfermería con el objeto de surtir de enfermeras al hospital san juan de dios en valparaíso. la escuela “carlos van buren” buscaba una similitud con la formación de las enfermeras inglesas. esta escuela, construida en 5 la primera directora enfermera hasta el año 1946 fue margaret bowie, quien fue traída por agustín edwards desde inglaterra, ella prestó servicios en la primera guerra y era especializada en enfermedades infecto-contagiosas. el mismo recinto del hospital, comienza a impartir sus primeros cursos en 1933. se determinó que esta “prepararía enfermeras para la atención de los pacientes en el hospital y para asistencia preventiva en el hogar” (19). la directora de la escuela de enfermería también sería una interna más y sus funciones serían ejercidas con gran autoridad y control sobre sus alumnas para “modelar a sus estudiantes” (19). núcleos figurativos de la formación en enfermería: fuertes exigencias morales para las enfermeras que estudiaron en este periodo una de las características destacadas de la escuela carlos van buren fue la rigurosa selección a la que eran sometidas las postulantes, la cual marcaba unos lineamientos especiales: se exigía provenir de una familia bien constituida, ser estudiante con buenas calificaciones y haber tenido características de liderazgo y de acción social, las que eran observadas en su participación en la escuela o en voluntariados generalmente religiosos. otra característica importante era la rigidez de la formación, el sistema en la escuela era de internado, que se caracterizaba por la enseñanza estricta y el control de la vida de las estudiantes en un complejo proceso de formación, en el que tanto ellas como sus maestras, llamadas “instructoras”, eran internas. las estudiantes desarrollaban su vida, estudiaban y ejercían prácticas en el mismo lugar. de ello podemos interpretar una cierta relación de dependencia con la autoridad formativa, lo que deriva en una disminución del área de influencia en la vida privada. observemos una cita de una entrevistada: el régimen era de internado relativamente estricto, donde las profesoras o instructoras, que se llamaban en ese tiempo, algunas vivían ahí y nosotras teníamos piezas individuales cada una, en un edificio que se había hecho especialmente para ser escuela de enfermería. un edificio sólido, que en realidad había sido a la imagen y semejanza de los edificios que había visto el administrador del hospital van buren, con el doctor de la fuente que fue el primer director. entonces ellos que habían tenido conocimiento de la preparación de las enfermeras en inglaterra, […] conocieron lo que era toda la trayectoria de la florencia nightingale, que es nuestra patrona prácticamente (e 2). este control también se plasmaba en la presentación física de las estudiantes: estas debían destacarse por su impecabilidad. al parecer la escuela van buren, más allá de enseñar una disciplina o de buscar suplir una necesidad en un hospital, buscaba imponer y crear un nuevo tipo de profesional hospitalario basado en la 60 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 imagen de formalidad, limpieza y control, cercano a los modelos militares y religiosos, de los cuales había emergido la propia enfermería en sus orígenes, especialmente británicos. en este punto es posible relacionar una identificación de estos aspectos y la constitución de una identidad-imagen fuerte. ... ahí nos llevaban en una micro que tenía la escuela, […] íbamos de uniforme […] llegábamos allá nos exigían capa, el uniforme tenía que ser impecable porque nos revisaban, nos medían, eran muy estrictos en eso del uniforme y por su puesto el pelo, o sea todo, teníamos que andar de punta en blanco, impecables, nos exigían el comportamiento, la conducta, o sea eran bien estrictos, nosotros teníamos que ser, nos decían de repente monjas porque eran muy estrictos (e 4). a pesar de estas exigencias, la percepción de las estudiantes sobre su formación es positiva, ellas consideran que recibieron una educación de excelencia, que se diferenciaba de la calidad de otras escuelas. visiones asociadas a la enfermería: el servicio para otro enfermo el núcleo central de las enfermeras de este periodo sobre su función es el cuidar a los pacientes y enfermos, pero también un concepto bastante frecuente es ayudar a una persona desvalida. es decir, esta visión general sobre la enfermería se vincula con las acciones de amparar y socorrer, por tanto, el otro se percibe desvalido, en malas condiciones; por ello, el sentido de la enfermería es mejorar el estado de vida de los más necesitados. desde allí prevalece una visión de servicio, de práctica humanitaria propia de una actividad desinteresada que nos habla también de una práctica más curativa que preventiva. según una enfermera: “la misión, yo creo que una sola palabra, ayudar […] esa es la esencia, ayudar a cubrir las necesidades al que no lo puede hacer por sí mismo, eso es lo que yo entregué, es ayuda…” (e 5). esta práctica humanitaria se plasma en la vocación, la entrega al paciente como eje del rol, lo que genera una preocupación por desarrollar elementos de empatía, buen trato y autoconocimiento, en tanto permiten entender al otro. autodefinición: la enfermera dueña y señora en la época de oro las enfermeras de este periodo se autodefinen de modo positivo, se sienten necesarias para su contexto; algunas expresiones destacan que fue la época de oro de la profesión. se observan a sí mismas como la “señora”, la “jefa del hogar”; junto con ello prevalecía cierta distinción con respecto a los otros profesionales, los documentos consultados identifican a la enfermera como “la salvadora”, profesión que tiene mucha relevancia para el país: “actividad indispensable en toda la nación y pueblo” (20). las expresiones dan cuenta de una valoración profunda del propio oficio, no se duda de su importancia. esta idea identificará a la enfermería como una salvación para la realidad de la salud de ese entonces, y esa visión será avalada por las expresiones de los médicos de ese momento, los que incluso tenían un marcado sesgo de género en sus afirmaciones: los sacrificios de los facultativos no darán ciertamente los benéficos resultados que deberían obtenerse si aquellos no cuentan con ayudantes o enfermeras suficientemente preparadas […] siempre se ha creído y no sin razón que la mujer era la llamada a velar al lado del lecho del enfermo y a contribuir con su paciencia, su abnegación y su suavidad al éxito de las prescripciones médicas, ¿quién mejor que el ángel del hogar, con su sensibilidad exquisita, con su caudal inagotable sabrá encontrar el consuelo de los dolores humanos? a la mujer le corresponde más propiamente y por muchos títulos consagrarse a esa noble y humanitaria profesión de enfermera (19). en la cita anterior se destaca el carácter de “ayudante” de la enfermera con respecto al médico, y se acentúa la idea de que esta es una profesión propia de mujeres: ellas serían las llamadas a cuidar y consolar “por naturaleza”, privilegiando un rol subordinado, incluso reconocido y reafirmado por estas, que si bien no se perciben como “ayudantes”, avalan su posición desde una definición limitada. las enfermeras consultadas describen su disciplina en términos de un espacio concreto que es el cuidado y lo que este implica: salas, recursos, pacientes, etc. así, la autonomía de la profesión se ejercía dentro de las posibilidades de acción en dependencia del médico, en similitud a lo que ocurre en el hogar desde una visión tradicional y conservadora: ella-mujer administra los recursos de la casa y él-hombre provee. en ese sentido, la enfermera se siente dueña y señora, pero de un espacio, sin entrometerse en lo que hace el que toma las decisiones importantes respecto a la salud. a continuación observemos una cita: ella [la enfermera] prácticamente tiene una enorme autonomía para su cuidado ella es digamos la dueña de casa, es lo mismo que yo aquí en mi casa, soy yo la que sé dónde están los platos, cuándo hay que recibir la leche o cuánto hay que pagarle a la 61 la identidad profesional de la enfermería: un análisis cualitativo de la enfermería en valparaíso (1933-2010) l jorge renán chuaqui-kettlun y otros. persona que trae el diario, etc. yo soy la que administro todo eso ¿no? que es la parte de gestión prácticamente (e 2). en síntesis, podemos señalar que las enfermeras de este periodo valoran en gran medida su práctica, la cual se caracteriza por la ayuda al otro y la claridad de su función, en subordinación al médico. segundo periodo (1968-1990): la vocación, el servicio público y los cambios sociales este periodo de la historia de la enfermería se enmarca en un contexto de importantes cambios sociales y políticos ocurridos en el país. comienza con el gobierno del presidente eduardo frei montalva, en el que se desarrolló el programa de promoción popular, enfocado al fortalecimiento de lo social, donde fueron creadas una serie de organizaciones que buscaban mejorar los niveles de vida de la población. al finalizar este gobierno muchas de esas reformas continúan con el de salvador allende, acompañadas de una serie de nuevas propuestas que pretendían ser la vía al socialismo. sin embargo, la dictadura militar terminó con un largo proceso de institucionalización de las crecientes demandas sociales e introdujo violentamente una nueva fisonomía del país. en este proceso es que se cruzan las experiencias de enfermeras/os, claramente es un periodo de importantes cambios y de diversas significaciones. en el caso de la enfermería es importante la relación que hubo entre el proceso de ampliación de los beneficios sociales básicos de la población y la demanda por mayores profesionales en el sistema público. en el caso de valparaíso se introdujo la formación común entre dos disciplinas antiguamente diferenciadas: la enfermería y la obstetricia. producto de esa experiencia egresan enfermeras-matronas que posteriormente, en la década de los noventa, se vuelven a separar en la región (20). otra característica de esta etapa tiene que ver con el aspecto económico, relacionado con los bajos salarios que recibían los profesionales. por esto es recurrente observar que los enfermeros/as de este periodo se ven a sí mismos como profesionales de vocación, interesados en mostrar su profesionalismo por sobre su ganancia y recibiendo otro tipo de reconocimientos, como la satisfacción del médico o el agradecimiento de las personas. núcleos de la enfermería: continuidad del sacrificio, autoexigencia y liderazgo la profesión continúa siendo definida como un servicio a la sociedad; ser enfermero, primero que todo, era ser alguien interesado en ayudar al otro. ahora bien, su experiencia los lleva a contrastar con lo que ocurre hoy en la disciplina, si bien existe un reconocimiento al avance en términos de importantes mejoras económicas, este es percibido como negativo ya que ha implicado la pérdida de ejes fundamentales en la profesión como la vocación de servicio, los valores de entrega al otro y, especialmente, la “deshumanización” en que ha caído la profesión, lo que se ha convertido en el principal problema para estos enfermeros/as. “ganábamos muy poco, muy poco, nos nutríamos del amor y el cariño de los enfermos y de la gente; trabajábamos muchas horas gratis al sistema […] muchas horas de capacitación, nosotros por nuestra parte en nuestros tiempos libres” (e 8). los profesionales se entregaron al cuidado del otro a través de turnos extensos que generaban un desgaste físico, el cual no tenía mucha retribución. a su vez, la cantidad de responsabilidades asumidas afectó a sus propias familias, en particular el cuidado de los hijos. sin embargo, estas dificultades en el oficio son representadas como insoslayables, son naturalizadas, comprendidas como parte de la esencia del ser enfermero/a. se asumen como mandato, mas no críticamente o con una intención transformadora, y en ocasiones se lleva como una carga personal y una evocación culposa. en palabras de una enfermera: creo que di más de lo que a veces prefería mi familia en algunas ocasiones, más de algunas ocasiones yo creo que fui más enfermera que mamá […] y eso también duele, el aspecto familia porque iba a buscar a mis hijos a las 6:30, me traía tarde y mi hijo estaba hasta las 6, 7 de la tarde en el jardín. entonces son costos, uno es súper exigente quiere ser la súper enfermera, la súper mama, la súper esposa, y eso también como persona te trae un costo (e10). a su vez este sacrificio, con alto grado de responsabilidad y de autoexigencia, se relaciona con la especialización del proceso de enfermería y la lenta incorporación de nuevas tecnologías de salud. esto implicó, desde la visión de las/os enfermeros, la imposibilidad de cometer errores y la disminución de los riesgos, a partir de ahí se plantea una visión de autoexigencia en los profesionales, en particular, en la atención hospitalaria. así, se impone una alta responsabilidad y una exigencia moral que hace de 62 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 la enfermería una disciplina estricta, a la que incluso subyace el concepto de castigo. hay otra característica del periodo relacionada con el liderazgo, el cual se enseña en la formación inicial. el liderazgo es saber dirigir a un equipo de salud, está relacionado con la posición intermedia que ocupa la enfermera en la estructura laboral hospitalaria, que está bajo la dirección de un médico que diagnostica y verifica el tratamiento, y la enfermera/o quien está a cargo de la gestión de los cuidados y del personal auxiliar. decíamos en el primer periodo que en esta estructura el estatus social está definido por patrones tradicionales de género donde se reproducen los roles del hogar, esta visión era reconocida por las enfermeras; sin embargo, en este periodo observamos que las relaciones de poder están más bien encubiertas bajo la idea de un trabajo “horizontal” en el ámbito hospitalario, donde todos son un equipo y cada quien hace lo suyo en un espacio determinado. es a partir de esos mismos roles donde se representan las diferencias y se ejecutan las críticas al otro. podemos observar que las enfermeras/os definen su rol según patrones tradicionales de género, los cuales tienen que ver, por ejemplo, con la desigualdad en términos de habilidades organizativas y humanas que tendrían los médicos-hombres. veamos una cita: no, a las enfermeras no nos cuesta nada controlar, ni dar órdenes, ni retar, nada, o sea, lo traemos en el adn… e: pero los médicos tendrían esta dificultad… porque ellos se preocupan de la excelencia en el hacer técnico clínico, pero por ejemplo en esto de tener que conversar con la familia, tener que explicarle al caballero, tener que sentarse, tener que atenderlos y darles una explicación que los demás puedan entender, porque es clásico hasta el día de hoy, hablan con el médico y después vienen donde ti y te dicen “señorita me puede explicar, no entendí nada lo que me quiso decir el doctor (e 11). autoimagen de las enfermeras del periodo: los enfermeros/as de la vocación y pioneros como mencionábamos anteriormente, en los enfermeros/as de este periodo hay una alta identificación con el trabajo de entrega abnegada y desinteresada, por ello tienen una clara identificación con el trabajo en el servicio público, donde están los más necesitados y las mayores adversidades. los de esta época son caracterizados como “los enfermeros de la vocación”, quienes creen simbolizar la verdadera imagen del enfermero; en este modelo hay una prevalencia de los valores humanistas cristianos de ayuda al débil, de solidaridad, de acciones desinteresadas y del desarrollo de la paciencia y la templanza, que incluso lleva a que algunos se identifiquen con la imagen del sacerdote o del apóstol. la enfermería para mí es un sacerdocio, estoy con el enfermo, con el que necesita y por esa razón, por lo tanto para mí tiene una relación espiritual, independientemente de que a lo mejor hubiera sido un mahometano, o hubiera sido un taoísta, existe una relación mía con el enfermo, con el cuerpo del enfermo, con el espíritu del enfermo, con la preocupación de que no solo tengo que sanar la enfermedad y el dolor, sino que más allá del dolor tengo que estar con él en el otro aspecto y por eso siempre me vas a ver riendo, siempre haciendo reír (e 7). por otro lado, en algunos casos las/os enfermeras/os se reconocen como actores creativos, gestores de propuestas y de cambios; eso las/os ha llevado a crear secciones en hospitales, nuevos programas, etc. pareciera ser que esta búsqueda de ayuda al otro lleva a pensar y a gestionar modelos para que los procesos puedan desarrollarse mejor, o bien para entregar más ayuda a los usuarios. por ello es que se encuentran varios casos de enfermeras gestoras de propuestas que se identifican con la expresión “fui la primera”. me veo enfrentada a un desafío importante de crear algo en este sistema y creo que fui la primera enfermera en valparaíso que empezó a trabajar con adulto, en atención primaria, entonces diseñamos con un médico que llegó a trabajar en ese momento conmigo un programa de atención para pacientes portadores de hipertensión y diabetes en atención primaria (e 6). estás expresiones dan cuenta de una fase donde la disciplina está más consolidada en su proceso de profesionalización, más que ser ellos los precursores, nos hablan de una nueva fase de afirmación de la enfermería, la que tenía que sustentarse en nuevas propuestas, en nuevos procesos de gestión; ahora la ayuda tenía que tener procedimientos estandarizados y focalizados. tercer periodo (1991-2010): la gestión del cuidado, el nuevo núcleo de la identidad la gestión del cuidado es un concepto que se desarrolló en chile en los años noventa y quedó estatuido en el código sanitario 63 la identidad profesional de la enfermería: un análisis cualitativo de la enfermería en valparaíso (1933-2010) l jorge renán chuaqui-kettlun y otros. (art. 113), después de una larga lucha gremial. en este código se definen las funciones específicas de la enfermera y le aporta una responsabilidad legal en los cuidados. claramente, tiene implicancias en la identidad profesional y su autoconcepto. la gestión del cuidado es percibida como un proceso positivo para la enfermería, y está relacionada con lograr mayores niveles de formalización de los procesos administrativos y clínicos de la disciplina. en este sentido podemos observar una diferencia con respecto a los periodos previos: los significados, los valores y las creencias que dieron mayor cohesión moral a la enfermería transitan entre una moralidad tradicional donde priman el valor del sacrificio, la vocación de servicio y la subordinación, a una nueva moral relacionada con las implicancias de la “gestión del cuidado”, su creciente autonomía y el intento por lograr mayores niveles de unificación de los criterios del proceso de enfermería. en palabras de una enfermera clínica: [una dimensión que favorece a la enfermería es el] modelo que hay ahora de gestión, que nos da más autonomía y que está perfeccionando todas las técnicas y todas las cosas que hacemos, las está […] estandarizando, nos ha hecho trabajar en pasar al papel las cosas que hacemos todo los días, y yo creo que eso es súper bueno […] ahora está todo estandarizado para no perder la continuidad de lo que uno ya ha hecho (e 12). esta nueva conceptualización es también fuente de críticas. se destacan tres tipos de visiones: para una primera, la gestión del cuidado es criticada ya que fortalece las competencias administrativas perdiéndose la capacidad “observadora” de la profesión; lo importante, en este caso, es proteger una cualidad fundamental de la enfermería que es ir más allá de la apariencia del paciente y descubrir las causas profundas de la enfermedad. una segunda visión señala que la gestión del cuidado es más bien una conceptualización que “nombra” una práctica profesional que ya existía y, por tanto, su valor recae más bien en la formalización de procesos y no en una innovación en la propia profesión. en palabras de esta misma enfermera: [en este nuevo concepto de gestión del cuidado] siempre lo hemos hecho, y las enfermeras viejas, […] hoy día le ponen nombre […] y me enseñaron en la escuela mis profesoras, muy viejitas, eso: la persona, el cuidado, sus necesidades, a este qué necesita, a este más allá, y tener la visión, siempre, no importa… siempre, y manteniendo la misma carita de risa voy a atender a los cien como atiendo a uno, “gestión del cuidado”, la hemos tenido, le pusimos un nombre (e 14). una tercera visión considera que la gestión del cuidado es una conquista que ha logrado mejorar el sentido de la profesión; sin embargo, su aplicación sigue siendo un desafío, especialmente en la atención primaria. desde la visión de las/os enfermeras/os, las relaciones con sus pares se observan a partir de una diferencia generacional: los/as jóvenes son vistos con menor carácter, más inseguros, más cómodos y que evitan el conflicto en el diagnóstico médico o en el proceso de enfermería; al contrario, las enfermeras adultas tendrían un mayor carácter para defender su punto de vista profesional. la gestión del cuidado ha permitido a la enfermería integrar nuevos roles a la profesión y, en especial, en puestos de mayor decisión e influencia. en este sentido, se comprueba una evolución con respecto a los periodos anteriores. también se reconocen temas pendientes vinculados con la capacidad de la propia profesión de asumir este nuevo desafío, se resalta la resistencia de los médicos para integrar este nuevo rol de la enfermería. en este caso se observa una disputa por la administración de los recursos de salud entre ambas profesiones, y las enfermeras/os se observan mejor preparadas en este aspecto. esta resistencia de los médicos es compartida con el personal técnico. observamos que el rol de la enfermería es una función intermedia entre la función de mayor poder del médico y la de menor poder del personal técnico. el rol de la enfermería es tensionado por dos polos, según menciona una enfermera: ellos [los médicos] te ven como su subalterno, […] no entienden nuestra autonomía, y los técnicos paramédicos tampoco, porque a ellos no los forman pensando en eso de nosotros, entonces es difícil, […] pero como te digo yo creo que eso también se da con que tú tengas una mirada, una parada en el tema diferente que no tiene que ver con gritar más o golpear la mesa pero esos han sido los conflictos en realidad o las cosas más difíciles (e 16). ahora bien, esta situación crítica de la enfermería en tanto ha logrado acceder a mayores puestos de poder ha implicado nuevos desafíos para la profesión: se le exige una disposición más empoderada, ser más directas/os en el trato profesional y “hacerse valer”. existe una actitud crítica de los consultados sobre el sentido de la profesión. en ellos/as también existe la percepción de que en la enfermería algo de la identidad se ha perdido. para una enfermera de atención primaria, el área asistencial relacionada con la atención directa con el paciente está siendo desplazada por una 64 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 función más gerencial de la enfermería; esto es percibido como una amenaza a la identidad. observemos la siguiente cita: me preocupa que nos hagamos más administrativas que asistenciales […] que hagamos más administración que asistencia, que el contacto directo con el paciente […] nunca más viste un paciente, te preocupas de los turnos de los médicos, los insumos, el cambio de las camas, que van a llegar unas camas nuevas… ¿dónde quedó lo otro? (e 14). valorizaciones de la enfermería: salud, educación y mayor equidad el actual sistema mixto de salud del país es valorado en su conjunto en lo que respecta a la provisión del servicio, aunque se mantiene una valoración crítica a la salud pública: la lentitud y burocracia de los procesos administrativos son áreas sensibles y propias del sector. ahora bien, según las entrevistadas, el sistema mixto de salud no es fuente de cuestionamientos dado que se indica que este debería tener el mismo nivel de calidad en el servicio, hecho que no sucede en la actualidad. en palabras de una de ellas: “yo creo que tienen la misma función que en el fondo es dar la atención de salud que necesita el paciente […] satisfacer lo que ellos necesitan y que debería ser con la misma habilidad y con la misma calidad y la misma rapidez en las dos” (e 12). de otro lado, la salud privada ha logrado mayor legitimidad como área de desarrollo de la enfermería. se ha perdido crecientemente el temor a la expulsión del trabajo y ha aumentado la convicción del esfuerzo personal de los profesionales y la calidad del servicio a los pacientes. autodefinición profesional: la enfermera/o exitosa/o en general, podemos señalar que la creciente especialización de roles de la salud ha tenido efectos positivos en la autodefinición profesional de la enfermería. ahora bien, esta mayor formalización de los roles genera una heterogeneidad de expresiones en las/os enfermeras/os. en un primer caso, esta nueva base institucional ha permitido que los profesionales de enfermería logren un crecimiento profesional en diferentes áreas. desde el ámbito académico, la disciplina también se destaca por dar un valor al servicio a los demás. por último, la autodefinición de las/os enfermeras/os se encuentra relacionada con la continuidad en la autoexigencia y con un mayor deseo de reconocimiento social. en palabras de una enfermera: …si tú estas en el trabajo tienes que cumplir con tu rol y ser quien dices que eres, cuando yo vi por primera vez mi nombre en la superintendencia de salud y […] decía que yo era enfermera […] y que tú demuestres que eres enfermera en todas partes, porque tienes una característica particular, tienes una preparación, respondes a esa preparación, y a lo que los demás esperan de ti, y eso como que no lo puedes dejar de lado (e 13). el otro significado: las relaciones profesionales uno de los tópicos más recurrentes es que los médicos se sienten amenazados en su autoridad debido al avance estratégico de la enfermería en las organizaciones de salud. ahora bien, las causas de esta nueva situación no son claras, las disputas por poder y prestigio social no son temáticas que estén en la reflexión de las enfermeras/os. [a los médicos] les ha costado aceptar como esto de la subdirección de gestión del cuidado, que haya una dirección paralela a la médica; por ejemplo, a veces indican curaciones, cambios de procesos y cosas que eran como obvias de enfermería pero igual las indican, o cosas que tienen que ver con gestión administrativa que están a cargo de enfermería y no están muy de acuerdo tampoco, lo que es gestión de cama etc. (e 12). en un segundo tópico se destaca una relación más bien horizontal y menos conflictiva con los médicos. esta se caracteriza por manifestar una neutralidad profesional entre médicos y enfermeras; de hecho, la distancia y la demarcación de roles presentan una especie de área de autonomía propia en la cual no se acepta ni se promueve la intervención del otro en ella. en este sentido, las reglas del juego están claras y si no son traspasadas, todo andará en orden. discusión al observar la evolución de los tres periodos es posible distinguir, desde la teoría sociológica de las profesiones, lo siguiente: en cuanto al estatus profesional, se ha avanzado de un primer periodo caracterizado por la rigidez en la formación y el control 65 la identidad profesional de la enfermería: un análisis cualitativo de la enfermería en valparaíso (1933-2010) l jorge renán chuaqui-kettlun y otros. sobre la vida personal de las enfermeras, a una mayor autonomía; en cuanto a la dimensión subjetiva del estatus, de una vocación de servicio exacerbada, expresada en el deseo de ayudar al otro sin condiciones, a un segundo periodo definido, también, por una vocación de servicio no enfocada a lo económico, de carácter más profesional. en relación con las limitaciones del estatus, aparece la subordinación al médico como algo natural, no cuestionado, que han internalizado, adoptando en el rol-set asociado al estatus roles de “administradora” del proceso, a diferencia del papel del médico de dirección, que tiende a reproducir roles tradicionales de género. el profesional enfermero/a, en su estatus-rol-set, se posiciona en un sitio “incómodo” como ocupación complementaria del situs dentro de esa estructura, ya que es quien tiene que administrar, transar, convencer, mover a su personal, lo que lo lleva a buscar una constante validación profesional, que incluso lo deja en una especie de aislamiento o soledad en su cargo, pero también lo lleva a una búsqueda de técnicas para trabajar con las personas, para lograr objetivos. junto a ello, en el área de ejercicio de la autoridad de su estatus, la enfermería ha perdido el autoritarismo de sus inicios adquirido en su formación de tradición inglesa, y ha pasado a una cooperación más consensuada con el resto del equipo de salud lo que es producto del empoderamiento del personal técnico y auxiliar subordinado, sin que por ello la enfermera/o pierda su rol-set determinante en dicho equipo. no podemos olvidar que durante la dictadura militar (1973-1989) que hubo en chile se le quitaron atribuciones a la enfermería como rectora del cuidado debilitando notablemente su estatus-rol-set, mas no así la dimensión subjetiva vocacional de este estatus. las atribuciones del rol-set se recuperaron posteriormente. en el tercer periodo se identifica el desarrollo del aspecto académico en su proceso de socialización, donde se amplía y fortalece la formación inicial en enfermería y, a su vez, se desarrollan múltiples funciones en el campo profesional ampliando notablemente el rol-set profesional, las cuales, en algunos casos, se perciben como amenaza o alejamiento de las funciones tradicionales de la enfermería. se eleva el nivel económico de la profesión reforzando la dimensión económica del estatus, y aparece menos notoria la vocación de servicio desinteresado debilitándose la dimensión subjetiva-vocacional, equiparando la enfermería con una actividad especializada en el sentido más tradicional de las profesiones. en las opiniones se percibe, a diferencia de la bibliografía consultada, una fuerte identificación con el estatus profesional desde el punto de vista vocacional (no una identidad “débil”). aunque en cuanto al poco desarrollo del plano gremial, la subordinación al médico y los roles de género se coincide con dicha bibliografía (21). respecto a la subordinación, esta se ha mitigado en el último tiempo con el logro de la exclusividad de la gestión del cuidado ampliando su rol-set legalmente, lo que provoca en algunos casos roces con el resto del equipo. también se ha aminorado la exclusiva dependencia en cuanto a los roles de género. en relación con las investigaciones vinculadas a la identidad de la enfermería, esta investigación confirma que la identidad histórica de la profesión en valparaíso está en un proceso de evolución, caracterizado por el fortalecimiento paulatino de la autonomía del estatus profesional en la relación con otros profesionales. conclusiones a partir de la teoría podemos observar que la enfermería, en sus inicios, se caracterizó por ser una ocupación complementaria y, en un largo periodo posterior, pasó a ser una profesión complementaria, desde la subordinación hasta una cierta horizontalidad de las relaciones. en el plano de la dimensión subjetiva ha evolucionado desde una visión de cuidado humanitario, de sacrificio, a internalizar una más profesional y tecnológica, basada en la legislación vigente y en el desarrollo disciplinar, y no tanto en las características femeninas de la profesión, lo que ha significado una complejización del rol-set. aunque no se ha perdido el valor del servicio desinteresado, pese a la penetración exacerbada de las relaciones mercantiles. ahora bien, los desafíos pendientes de la enfermería, a partir de lo observado en la realidad nacional, son desarrollar la investigación y la vinculación interdisciplinaria con las ciencias sociales desde el pregrado en adelante, lo que fortalecería aún más su carácter de profesión y así la identidad profesional desde la formación (22), a fin de proteger su campo de acción, y fortalecer su independencia y autonomía. 66 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 referencias 1. ramió a. valores y actitudes profesionales estudio de la práctica profesional enfermera en catalunya [tesis doctoral]. barcelona: departamento de sociología y análisis de las organizaciones, facultad de ciencias económicas y empresariales, universidad de barcelona; 2005. 2. domínguez c. para una sociología de la profesión de enfermería. madrid: revista española de investigaciones sociológicas. 1979;8:103-132. 3. torres a, sanhueza o. desarrollo de la autoestima profesional en enfermería. investigación educacional enfermería. 2006;24(2):112-119. 4. urra e. avances de la ciencia de enfermería y su relación con la disciplina. revista ciencia y enfermería. 2009;xv(2):9-18. 5. vvaa. libro resumen de las ix jornadas nacionales de investigación en enfermería. achien:valdivia; 2009. 6. breda k. nursing and globalization in the americas: a critical perspective. in: nursing in chile. new york: mcardle printing; 2009. p. 55-98. 7. levine d. visoes da tradiçao sociologica. rio de janeiro: jorge zahar editor; 1997. 8. castrillón mc. la dimensión social de la práctica de enfermería. medellín: universidad de antioquia; 1997. p. 104-115. 9. illanes m. en el nombre del pueblo, del estado y la ciencia. historia social de la salud pública, chile (1880/1973). santiago de chile: ministerio de salud; 2010. 10. gyarmati g. las profesiones, dilemas del conocimiento y del poder. santiago de chile: ediciones universidad católica de chile; 1984. 11. chuaqui j. microsociología y estructura social global. santiago de chile: lom; 2012. 12. machado me. sociología de las profesiones de la salud: un nuevo enfoque. educ med salud. 1991;25(1). 13. chuaqui j. microsociología y estructura social global. santiago de chile: lom; 2012. 14. lima vl, martins kc. configuração identitária de enfermeiros de um serviço de atendimento móvel de urgencia. rev bras enfermagem. 2010;63(6):1010-8. 15. mead g. mind self and society. en: larraín j ¿américa latina moderna? globalización e identidad. chile: lom; 2005. 16. gómez j, sandoval m. más allá del oficio del sociólogo. nuevas identidades, prácticas y competencias en el campo profesional. chile: ediciones universidad católica silva henríquez; 2004. 17. valles m. técnicas cualitativas de investigación social, reflexión metodológica y práctica profesional. madrid: síntesis; 2003. 18. ruiz j. metodología de la investigación cualitativa. bilbao: deusto; 1996. 19. flores r. la historia de la enfermería. síntesis de la evolución educacional de la enfermera. santiago de chile: universidad de chile; 1965. 20. escuela de enfermería. universidad de valparaíso: 75 años formando profesionales de enfermería al cuidado de la comunidad. valparaíso: ediciones universidad de valparaíso; 2010. 21. faccia k. estudio cualitativo y cuantitativo de la profesionalización de la enfermería desde una perspectiva antropológica. revista argentina de salud pública. 2009;1(1),12-17. 22. gómez em. la enfermería en colombia: una mirada desde la sociología de las profesiones. aquichan. 2013;12(1):42-52. 327 335 breastfeeding self-efficacy.indd 327 cinar nursan1 köse dilek2 altinkaynak sevin3 breastfeeding self-effi cacy of mothers and the affecting factors 1 sakarya university, school of health sciences, division of nursing, department of pediatric nursing, sakarya, turkey. ndede@sakarya.edu.tr 2 sakarya university, school of health sciences, turkey. dkose@sakarya.edu.tr 3 sakarya university, school of health sciences, turkey. saltinkaynak@sakarya.edu.tr recibido: 21 de julio de 2013 enviado a pares: 05 de noviembre de 2013 aceptación por pares: 11 de julio de 2014 aprobado: 15 de julio de 2014 doi: 10.5294/aqui.2014.14.3.5 para citar este artículo / to reference this article / para citar este artigo nursan c., dilek k. sevin a. breastfeeding self-efficacy of mothers and the affecting factors. aquichan; 2014. 14(3): 327-335. doi: 10.5294/aqui.2014.14.3.5 abstract objectives: the purpose of this study was to determine the breastfeeding self-efficacy of mothers in the 0-3 month period and the affecting factors. material and methods: the study was conducted between january-april 2011. the universe of the study consisted of all the mothers who were living in the center of sakarya province and had infants ages 0-3 months. the sample used in the study consisted of 152 mothers who agreed to participate. the data were collected through face-to-face interviews with the mothers, using the "personal information form" developed by the researchers and the "breast-feeding self-efficacy scale-short form / bses-sf" developed by dennis. turkish validity and reliability of the scale were done by tokat et al. (2010). the data were evaluated with the spss program, using percentages, averages, the t-test, chi-square and anova. results: the average total score from the “taken bses-sf" was determined as 58.61 ± 8.93, min = 16, max = 70. no significant differences were found between the scale score and maternal age (f = 0.437, p = 0.781), maternal education (f = 0.625, p = 0.645), economic status (f = 0.253, p = 0.777) and mode of delivery (t = 0.922, p = 0.358). the mean scores were determined as being higher for mothers who indicated having received training for breastfeeding compared to others who indicated having received no such training, and the difference between the scale score was statistically significant (x2 = 50.848, p = 0.010). conclusions: requirements for developing breastfeeding adequacy among mothers were determined. nurses can give the necessary support to low breast-feeding mothers by assessing and identifying those requirements with help of this scale. key words breastfeeding, self-efficacy, affecting factors, nursing, 0-3 month old infant. (source: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 327-335 328 aquichan issn 1657-5997 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 327-335 la autoeficacia de las madres en cuanto a la lactancia y los factores que la afectan resumen objetivos: el objetivo de este estudio fue determinar la autoeficacia de las madres en cuanto a la lactancia durante el período de 0-3 meses y los factores que la afectan. materiales y métodos: el estudio se realizó entre enero y abril de 2011. el universo del estudio estuvo compuesto por todas las madres que vivían en el centro de la provincia de sakarya y tenían niños lactantes de 0-3 meses. la muestra utilizada en el estudio estuvo conformada por 152 madres que aceptaron participar. los datos fueron recolectados a través de entrevistas cara a cara con las madres, utilizando el "formulario de información personal" desarrollado por los investigadores y el "formulario de escala de autoeficacia en lactancia – versión abreviada/ bses-sf" desarrollado por dennis. la validez y confiabilidad de la escala usada en turquía fueron medidas por tokat et al. (2010). los datos fueron evaluados a través del programa spss, utilizando los porcentajes, los promedios, la prueba t, el chi-cuadrado y anova. resultados: el puntaje total promedio de la "bses-sf tomada" se determinó como 58,61 ± 8,93, min. = 16, máx. = 70. no se hallaron diferencias significativas entre el puntaje de la escala y la edad materna (f = 0,437, p = 0,781), la educación materna (f = 0,625, p = 0,645), la situación económica (f = 0,253, p = 0,777) y el tipo de parto (t = 0,922, p = 0,358). los puntajes promedio fueron mayores para las madres que indicaron haber recibido capacitación para la lactancia materna en comparación con otras que indicaron no haber recibido dicha formación, y la diferencia entre el puntaje de la escala fue estadísticamente significativa (x2 = 50,848, p = 0,010). conclusiones: los requisitos para el desarrollo de un nivel adecuado de lactancia materna entre las madres fueron identificados. las enfermeras pueden dar el apoyo necesario a las madres con bajo nivel de lactancia mediante la evaluación y la identificación de los requisitos con la ayuda de esta escala. palabras clave lactancia materna, auto-eficacia, factores que la afectan, enfermería, niños de 0-3 meses de edad. (fuente: decs, bireme). 329 breastfeeding self-efficacy of mothers and the affecting factors l cinar nursan, köse dilek, altinkaynak sevin a autoeficácia das mães quanto à lactância e os fatores que a afetam resumo objetivos: o objetivo deste estudo foi determinar a autoeficácia das mães quanto à lactância durante o período de 0-3 meses e os fatores que a afetam. materiais e métodos: o estudo foi realizado entre janeiro e abril de 2011. o universo do estudo esteve composto por todas as mães que moravam no centro da província de sakarya e tinham crianças lactantes de 0-3 meses. a amostra utilizada no estudo esteve conformada por 152 mães que aceitaram participar. os dados foram coletados por meio de entrevistas cara a cara com as mães, utilizando o “formulário de informação pessoal” desenvolvido pelos pesquisadores e pelo “formulário de escala de autoeficácia em lactância – versão abreviada bses-sf” desenvolvido por dennis. a validade e confiabilidade da escala usada na turquia foram medidas por tokat et al. (2010). os dados foram avaliados por meio do programa spss, utilizando as porcentagens, as médias, a prova t, o qui-quadrado e anova. resultados: a pontuação total média da “bses-sf tomada” foi determinada como 58,61 ± 8,93, min. = 16, máx. = 70. não se constataram diferenças significativas entre a pontuação da escala e a da idade materna (f = 0,437, p = 0,781), da educação materna (f = 0,625, p = 0,645), da situação econômica (f = 0,253, p = 0,777) e do tipo de parto (t = 0,922, p = 0,358). as pontuações médias foram maiores para as mães que indicaram ter recebido capacitação para a lactância materna em comparação com outras que indicaram não ter recebido essa formação, e a diferença entre a pontuação da escala foi estatisticamente significativa (x2 = 50,848, p = 0,010). conclusões: os requisitos para o desenvolvimento de um nível adequado de lactância materna entre as mães foram identificados. as enfermeiras podem dar o apoio necessário às mães com baixo nível de lactância mediante a avaliação e a identificação dos requisitos com a ajuda dessa escala. palavras-chave lactância materna, autoeficácia, fatores que a afetam, enfermagem, crianças de 0-3 meses de idade. (fonte: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 327-335 330 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 introduction breastfeeding is an important health-promoting behavior, conferring numerous health benefits to both mothers and infants (1). mother’s milk is the most appropriate food for infants. there is no other food to replace it (2). breastfeeding is the normal way of providing young infants with the nutrients they need for healthy growth and development (3). today, many international and national organizations strongly advocate breastfeeding (4). according to the united nations children’s fund (unicef), breast milk is the baby’s “first immunization” and helps to protect against causes of diarrhea, ear and chest infections, and other health problems (5). exclusive breastfeeding is recommended up to six (6) months of age, with continued breastfeeding, along with appropriate complementary foods, up to two years of age or beyond (3). many programmes have been developed throughout the world to promote breastfeeding initiation and duration (6). launched by who and unicef in 1991, the baby-friendly hospital initiative (bfhi) was inspired by the innocenti declaration of 1990. the initiative is a global effort to implement practices that protect, promote and support breastfeeding, so as to ensure that all maternity wards become centres for breastfeeding support. to be designated as ‘baby-friendly,’ it is necessary to refuse free or low-cost breast milk substitutes, feeding bottles or teats, and to have implemented the “10 steps to support successful breastfeeding” (7). in turkey, data from a national demographic health survey (2008) showed that 41.6 % of infants are breastfed exclusively for the first six (6) months postpartum. unfortunately, breastfeeding rates decline rapidly in the first eight (8) to 12 weeks postpartum, with fewer than 68.9% of turkey’s mothers breastfeeding exclusively at <2 months and 42% of turkey’s mothers breastfeeding exclusively at 2-3 months (8). breastfeeding self-efficacy, in particular, is a potentially modifiable variable that has been shown to predict longer breastfeeding duration and increased exclusivity. breastfeeding self-efficacy is a concept based on bandura’s (1997) social cognitive theory (9). it is defined as a mother’s confidence in her ability to breastfeed her child. 10 efficacy beliefs are important to address in health promotion research, as people must have motivation and perseverance to maintain a health behavior, beyond simply the knowledge of the health benefits (1, 11). maternal breastfeeding self-efficacy is a mother’s perceived ability to breastfeed her infant and has been shown to predict breastfeeding duration and exclusivity rates among women in the immediate postpartum period. the breastfeeding self-efficacy scale-short form (bsessf) was developed to measure a mother’s confidence in her ability to breastfeed her new infant and has been successfully translated and psychometrically tested among women from diverse cultures (1, 3, 6, 12-14). in the turkish study, cronbach’s alpha coefficient for internal consistency was 0.86 postnatally (6). the purpose of this study was to determine the breastfeeding self-efficacy of mothers in the 0-3 month period and the affecting factors. methods ethical considerations this descriptive study was approved by the ethical board at sakarya university and the study began after approval was received from related local authorities. the data were collected subsequent to approval of the study by the ethics committee. the participating mothers were informed of the purpose of the study and the methods to be used, and signed an informed consent statement. participation was voluntary and could be terminated at any point in time. the mothers were asked to answer all the questions honestly, and were reassured about the anonymity and confidentiality of the information. design and sample the study was conducted between january-april 2011. the universe of the study consisted of all the mothers who were living in the center of sakarya province and had infants ages 0-3 months. the study sample consisted of 152 mothers who agreed to participate. 331 breastfeeding self-efficacy of mothers and the affecting factors l cinar nursan, köse dilek, altinkaynak sevin participants participation criteria: mothers who were over 18 years old and had healthy infants between ages 0-3 months, had no communication problems and agreed to participate voluntarily in the study. mothers with premature babies or multiple babies were excluded from the study. the data were obtained from mothers who came to two family health centers and outpatient clinics of a state hospital. data collection procedures and instruments the data were collected through face-to-face interviews with mothers, using the “personal information form” developed by the researchers and the “breast-feeding self-efficacy scaleshort form / bses-sf” developed by dennis. the personal information form included personal characteristics (gender, age, education, economical status), delivery postpartum characteristics (type of delivery, obstetric interventions/complications) and infant feeding characteristics (breast only, breast with occasional supplement, breast with supplement at every feeding, breastfeeding duration). the bses-sf is a 14-item instrument developed to measure breastfeeding confidence. all the items are preceded by the statement ‘‘i can always’’ and are anchored by a 5-point likert-type scale, with 1=not at all confident and 5=always confident. all the items are presented positively and the scores are summed up to produce a final score ranging from 14 to 70, with the higher scores indicating better breastfeeding self-efficacy. turkish validity and reliability of the scale were done by tokay, okumuş and dennis (2010). in the same study, cronbach’s alpha coefficient for internal consistency was 0.87 antenatally and 0.86 postnatally. the antenatal and postnatal bses-sf scores were significant predictors of breastfeeding duration and exclusivity at 12 weeks after birth (6). in our sample study, cronbach’s alpha coefficient was 0.87. data analysis the data were evaluated with the spss program (version 17), using percentages, averages, the t-test, chi-square and anova. results as for the mothers, 49.4% (n=75) were found to be between the ages of 18-26, 46.1% (n = 70) were primary school graduates and 89.5% (n=136) were unemployed. in addition, 62.5% (n=95) of the families described their economic situation as moderate, 36.2% (n=55) of the women were primiparous, 38.8% (n=38.8) of the multiparous mothers had just given birth to their second child, 17.8% (27) had just given birth to their third child, 7.2% (11) had just given birth to their fourth child or more than four. all of the multiparous mothers had breastfeeding experience. the majority of the deliveries (n=86, 56.6%) were by cesarean section and 43.4% (n=66) of the mothers had delivered vaginally. in this study, 81.6% (124) of the mothers indicated having received training for breastfeeding and 18.4% (n=28) indicated they had received no such training. cronbach’s alpha coefficient (internal reliability) for the general scale was 0.87. the average total score taken from the “bsessf” was (x= 58.61 ± 8.93, min = 16, max = 70), respectively. there was no significant difference between the scale score and maternal age (f = 0.437, p = 0.781), nor were significant differences found between scale score and maternal education (f = 0.625, p = 0.645) and economic status (f = 0.253, p = 0.777) (table 2). when mode of delivery was compared to the scale score, no significant differences were found (t = .922, p= .358). although there was no difference between the scale score and mode of delivery, caesarean the mothers who gave birth by section had higher scores for breastfeeding self-efficacy (m=59.20 sd=9.01) than those who had given birth vaginally (m=57.85 sd=8.84). there was a significant difference between the scale score and previous breastfeeding experience (t=2.055 p= .042). breastfeeding self-efficacy was found to be low among the mothers who had no prior breastfeeding experience. the mean scores were higher for the mothers who breastfed their infants exclusively compared to those who breastfed partially, and the difference between the scale score was statistically significant (t=4.036 p= .000). (table 3). the mean scores were found to be higher for mothers who indicated having received training in breastfeeding compared to others who indicated having received no such training, and the 332 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 item n ot a t a ll co nf id en t† n (% ) n ot c on fid en t n (% ) so m ew ha t c on fid en t n (% ) co nf id en t n (% ) al w ay s co nf id en t n (% ) m ea n (s d ) determine that my baby is getting enough milk 4 (2.6) 18 (11.8) 36 (23.7) 35 (23.0) 59 (38.8) 3.84 (1.14) successfully cope with breastfeeding like i have with other challenging tasks 2 (1.3) 8 (5.3) 23 (15.1) 49 (32.2) 70 (46.1) 4.16 (0.95) breastfeed my baby without using formula as a supplement 13 (8.6) 11 (7.2) 30 (19.7) 34 (22.4) 64 (42.1) 3.82 (1.28) ensure that my baby is properly latched on for the whole feeding 4 (2.6) 9 (5.9) 24 (15.8) 41 (27.0) 74 (48.7) 4.13 (1.05) manage the breastfeeding situation to my satisfaction 4 (2.6) 8 (5.3) 27 (17.8) 43 (28.3) 70 (46.1) 4.10 (1.04) manage to breastfeed even if my baby is crying 4 (2.6) 11 (7.2) 35 (23.0) 39 (25.7) 63 (41.4) 3.96 (1.08) keep wanting to breastfeed 2 (1.3) 2 (1.3) 8 (5.3) 26 (17.1) 114 (75.0) 4.63 (0.76) comfortably breastfeed with my family members present 11 (7.2) 15 (9.9) 24 (15.8) 28 (18.4) 74 (48.7) 3.91 (1.30) be satisfied with my breastfeeding experience 1 (0.7) 6 (3.9) 8 (5.3) 23 (15.1) 114 (75.0) 4.60 (0.81) deal with the fact that breastfeeding can be time-consuming 2 (1.3) 4 (2.6) 15 (9.9) 21 (13.8) 110 (72.4) 4.53 (0.87) finish feeding my baby on one breast before switching to the other breast 7 (4.6) 12 (7.9) 31 (20.4) 46 (30.3) 56 (36.8) 3.87 (1.13) continue to breastfeed my baby for every feeding 3 (2.0) 5 (3.3) 13 (8.6) 34 (22.4) 97 (63.8) 4.43 (0.92) manage to keep up with my baby’s breastfeeding demands 3 (2.0) 2 (1.3) 17 (11.2) 38 (25.0) 92 (60.5) 4.41 (0.88) tell when my baby is finished breastfeeding 6 (3.9) 9 (5.9) 18 (11.8) 32 (21.1) 87 (57.2) 4.22 (1.11) table 1. breastfeeding self-efficacy of mothers. breakdown of answers to the short form scale (bses-sf) (n=152) bses-sf mean 58.61, sd 8.93, range, 16 to 70, potential range 14 to 70; scale α = 0.87, n = 152 †1 = not at all confident 2 = not confident 3 = somewhat confident 4 = confident 5 = always confident 333 breastfeeding self-efficacy of mothers and the affecting factors l cinar nursan, köse dilek, altinkaynak sevin table 2. significant differences in the bses-sf, by maternal demographic variables (n=152) variable mean df f p maternal age 20 and under 21-26 27-32 33-38 39-44 59.90 (4.72) 57.51 (11.11) 59.28 (6.74) 59.52 (8.70) 59.44. (3.32) 4 .437 .781 maternal education illiterate primary school middle school lycee high school or university 54.50 (11.0) 58.79 (8.72) 58.61 (9.90) 59.69 (7.92) 58.69 (8.12) 4 .625 .645 economic status low-income middle-income high-income 59.33 (5.75) 58.21 (9.21) 59.27 (8.79) 2 .253 .777 ** significant at the 0.01 level; * significant at the 0.05 level table 3. significant differences in bses-sf, by variables (n=152) variables mean df t p mode of delivery vaginal cesarean 57.85 (8.84) 59.20 (9.01) 150 0.922 .358 previous breastfeeding experience yes no 59.72 (7.91) 56.65 (10.28) 150 2.055 .042* breastfeeding exclusively breastfeeding partially breastfeeding 59.70 (7.76) 51.45 (12.53) 150 4.036 .000** * significant at the 0.05 level; ** significant at the 0.01 level 334 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 difference between the scale score was statistically significant (x2=50.848 p= .010). discussion the bses-sf was developed to measure a mother’s confidence in her ability to breastfeed her baby. the cronbach’s alpha coefficient for the sample used in the study was 0.87. in the turkish study, cronbach’s alpha coefficient for internal consistency was 0.86 postnatally (6). the same result taken from the study by wutke and dennis (2007) was 0.89 (13). cronbach’s alpha coefficient for the scale was 0.94 (spaulding and dennis 2010), 0.90 (gregory et al. 2008) and 0.92 (roig et al. 2012) (1, 12, 15). nevertheless, the studies by dodt et al. 2012 and zubaran et al. 2010 showed 0.74 and 0.71 (7, 14), respectively. maternal demographic factors play a broad role in breastfeeding behaviour, with improvements seen with better schooling and previous breastfeeding experience (4, 7). there was no significant difference between the bses-sf score and maternal age in this study (f = 0.437, p = 0.781) (table 2). similarly, no relationship was found between the scale score and maternal age in the others studies (1, 4, 6, 12, 13, 15). however, the study by dodt et al. (2012) indicated a strong correlation (7). not only the study by dodt et al. (2012), but also the one by wutke and dennis (2010) identified a weak correlation between the scale score and maternal age (2010) (7, 13). in this study, no relationship was found between the bses-sf score and maternal education (f = 0.625, p = 0.645). although a relationship between the scale score and maternal education was indicated only in the study by tokat, okumuş and dennis (2010), the results of other studies (4, 7, 12-14) coincide with our result. when the bses-sf score was compared to economic status, there was no significant difference (f = 0.253, p = 0.777). this was similar to other studies (1, 4, 7, 14) in terms of economic status. however, the previous study in turkey indicated there is a relationship between the scale score and economic status (6). there was no significant difference in this study between the bses-sf score and mode of delivery (t = 0.922, p=0.358) (table 3). although a relationship between the scale score and mode of delivery was indicated in the study by tokat, okumuş and dennis (2010) (6) and in the one by dennis in 2003 (4), the results of other studies (1, 12-14) coincide with our result. in this study, the mothers who gave birth by caesarean section had higher breastfeeding self-efficacy scores (m=59.20 sd=9.01) than the mothers who gave birth vaginally (m=57.85 sd=8.84). however, in the studies by dennis (2003) and tokat, okumuş and dennis (2010), the women who gave birth vaginally showed higher bses-sf scores than mothers who had a caesarean section (4, 6). there was a significant difference between the scale score and previous breastfeeding experience (t=2.055 p=.042). the mean bses-sf score for women with previous breastfeeding experience was significantly higher (m=59.72 sd: =7.91) than the bses-sf scores for women who had no prior breastfeeding experience (m=56.65 sd=10.28). a relationship between the scale score and previous breastfeeding experience was found in the studies by tokat, okumuş and dennis (2010), gregory et al. (2008) and wutke and dennis (2007) (6,12,13). conclusion the turkish version of the bses is of diverse utility in clinical practice. use of this scale gives nurses and midwives an excellent opportunity to increase a mother’s breastfeeding selfefficacy. in addition, any mother who has been identified as having low breastfeeding self-efficacy should have the opportunity to receive additional support. in this study, breastfeeding self-efficacy was found to be low among mothers who had no prior breastfeeding experience. it is required that health practitioners provide more support to new mothers. limitations of the study the limitation of this study concerns the fact that its results are based on data from only the sakarya district. consequently, it cannot be generalized for turkey. similar studies on various populations in turkey and in other countries should be conducted. 335 breastfeeding self-efficacy of mothers and the affecting factors l cinar nursan, köse dilek, altinkaynak sevin acknowledgements the authors wish to thank the mothers who participated in this study. conflict of interest the authors declare they have no competing interests. authors’ contributions study concept and design: cınar n, kose d, altinkaynak s acquisition of subjects and data: cınar n, köse d data analysis and interpretation: cınar n preparation of the manuscript: cınar n, köse d, altinkaynak s all the authors have read and approved the final version of the manuscript. references 1. mccarterspaulding de, dennis cl. psychometric testing of the breastfeeding selfefficacy scaleshort form in a sample of black women in the united states. research in nursing & health 2010; 33: 111-9. 2. çınar nd, sözeri cu, altınkaynak s. başarılı nesiller için anne sütü. sağlıcakla aylık sağlık dergisi 2009; 12: 20-21. 3. dennis cl. the breastfeeding self-efficacy scale: psychometric assessment of the short form. jognn 2003; 32 (6): 73444. 4. world health organization (who). breastfeeding. available at: 28.06.2012 available from: url: http://www.who.int/ topics/breastfeeding/en/ 5. united nations children’s fund (uni̇cef). facts for life. new york: uni̇cef; 2002. 6. tokat ma, okumuş h, dennis cl. translation and psychometric assessment of the breastfeeding selfefficacy scaleshort form among pregnant and postnatal women in turkey. midwifery 2010; 26: 101-8. 7. dodt ecm, ximenes lb, almeida pc, oria mob, dennis cl. psychometric and maternal sociodemographic assessment of the breastfeeding self-efficacy scaleshort form in a brazilian sample. journal of nursing education and practice 2012; 2(3): 66-73. 8. türkiye nüfus ve sağlık araştırması (tnsa). ankara; 2008. 9. bandura a. self-efficacy: toward a unifying theory of behavioral change. psychological review 1977; 84(2): 191–215. 10. dennis c, faux s. development and psychometric testing of the breastfeeding selfefficacy scale. research in nursing & health 1999; 22(5): 399–409. 11. bandura a. health promotion from the perspective of social cognitive theory. in: p. norman, c. abraham, & c. conner (eds.), understanding and changing health behavior. amsterdam: overseas publishers association, 2000: (pp. 299–339). 12. gregory a, penrose k, morrison c, dennis cl, macarthur c. psychometric properties of the breastfeeding self-efficacy scale-short form in an ethnically diverse u.k. sample. public health nursing 2008; 25(3): 278–84. 13. wutke k, dennis c. the reliability and validity of the polish version of the breastfeeding self-efficacy scale-short form: translation and psychometric assessment. international journal of nursing studies 2007; 44(8): 143946. 14. zubaran c, foresti k, schumacher m, thorell mr, amoretti a, muller l, et al. the portuguese version of the breastfeeding self-efficacy scale short form. j hum lact 2010; 26: 297-303. 15. roig ao, d’anglade-gonza´ lez ml, garcia-garcia b, silva-tubio jr, martinez mr, dennis cl. the spanish version of the breastfeeding self-efficacy scale-short form: reliability and validity assessment. i̇nternational journal of nursing studies 2012; 49: 169-73. 226 236 variables consumo cigarrillo adolescentes.indd 226 aquichan issn 1657-5997 zuleima cogollo-milanés1 edna margarita gómez-bustamante2 variables asociadas al inicio del consumo de cigarrillo en adolescentes estudiantes de básica secundaria de los colegios ofi ciales de la ciudad de cartagena, colombia 1 enfermera. docente, universidad de cartagena. doctoranda de salud pública, universidad nacional de colombia, colombia. zcogollom@unicartagena.edu.co 2 enfermera. doctora en ciencias de la educación. docente asociada, universidad de cartagena. egomezb@unicartagena.edu.co recibido: 7 de marzo de 2013 enviado a pares: 16 de marzo de 2013 aprobado por pares: 19 de marzo de 2014 aceptado: 22 de abril de 2014 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 226-236 para citar este artículo / to reference this article / para citar este artigo cogollo-milané s z, gó mez-bustamante em. variables asociadas al inicio del consumo de cigarrillo en adolescentes estudiantes de básica secundaria de los colegios oficiales de la ciudad de cartagena, colombia. aquichan. 2014; 14(2): 226-236. resumen objetivo: determinar la prevalencia y las variables asociadas al inicio del consumo de cigarrillo en adolescentes de media vocacional de cartagena, colombia. materiales y método: estudio analítico observacional transversal con 1.100 estudiantes de básica secundaria de las instituciones educativas oficiales de la ciudad de cartagena, matriculados durante el año 2012; la información se recolectó a través de la ficha demográfica, el inventario de consumo de cigarrillo y actitudes frente al mismo de la encuesta mundial sobre tabaquismo en jóvenes (emta_joven), la escala apgar familiar, rosenberg para autoestima y la escala de zung de ansiedad. se realizó análisis estadístico univariado, bivariado y multivariado. resultados: participaron 1.090 estudiantes (de los 1.100 fueron descartados 10 por estar mal diligenciados) con edades entre 10 y 18 años, media = 12,3; 565 (51,8 %) estudiantes fueron de sexo masculino y 525 (48,2 %) de sexo femenino. el consumo de cigarrillo alguna vez en la vida se asoció a edades entre 13 y 18 años (or = 2,86; ic95 %: 1,96-4,18), ser de sexo masculino (or = 2,40; ic95 %: 1,63-3,56) y a alta intención de consumo de sustancias (cigarrillo, alcohol y marihuana) (or = 3,18; ic95 %: 2,18-4,64). conclusión: el consumo de cigarrillo alguna vez en la vida en estudiantes de media vocacional de cartagena, colombia, se asoció a tener alta intención de consumo de sustancias, ser adolescente y ser de sexo masculino. palabras clave trastorno por uso de tabaco, adolescentes, estudiantes, enfermería, productos de tabaco (fuente: decs de bireme). 227 variables asociadas al inicio del consumo de cigarrillo en adolescentes estudiantes de básica secundaria de los colegios oficiales l zuleima cogollo-milanés y otro. año 14 vol. 14 nº 2 chía, colombia junio 2014 l 226-236 variables associated with the onset of cigarette smoking among adolescent public middle-school students in cartagena, colombia abstract objective: determine the prevalence and the variables associated with the onset of cigarette smoking among vocational middleschool students in the city of cartagena (colombia). materials and methods: this is a cross-sectional, observational analytic study of 1,100 public middle-schools students in cartagena who were enrolled during 2012. the information was collected by means of a demographic fact sheet, the world youth tobacco survey (emta_joven) inventory on cigarette consumption and attitudes towards smoking, the family apgar scale, the rosenberg self-esteem questionnaire, and zung’s anxiety scale. univariate, bivariate and multivariate statistical analyzes were done. results: a total of 1,090 (10 were discarded be poorly filled out) students between the ages of 10 and 18 took part. the mean is 12.3; 565 of the students are male (51.8 % and 525 are female (48.2 %). cigarette smoking at some point during their lifetime was associated with the ages between 13 and 18 (or = 2.86; 95 % ci 1.96 to 4.18), being male (or = 2.40; 95 % 1.63 to 3.56) and a high intention of substance use (cigarettes, alcohol and marijuana) (or = 3.18; 95 % ci 2.18 to 4.64). conclusion: in the case of vocational middle-school students in cartagena (colombia), having smoked cigarettes at some point in their lifetime was associated with a high intention to use substances, being an adolescent and being a male. key words tobacco use disorder, students, adolescent, nursing, tobacco products (source: decs, bireme). 228 aquichan issn 1657-5997 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 226-236 variáveis associadas ao início do consumo de cigarro em adolescentes estudantes do ensino fundamental dos colégios oficiais da cidade de cartagena, colômbia resumo objetivo: determinar a prevalência e as variáveis associadas ao início do consumo de cigarro em adolescentes de média vocacional de cartagena, colômbia. materiais e método: estudo analítico observacional transversal com 1.100 estudantes do ensino fundamental das instituições educativas oficiais da cidade de cartagena, matriculados durante 2012; os dados foram coletados por meio da ficha demográfica, do inventário de consumo de cigarro e atitudes ante este do questionário mundial sobre tabagismo em jovens, a escala apgar familiar, rosenberg para autoestima e a escala de zung de ansiedade. realizou-se análise estatística bivariada e multivariada. resultados: participaram 1.090 estudantes (10 foram descartados ser mal preenchido), com idades entre 10 e 18 anos, média = 12,3; 565 (51,8 %) estudantes do sexo masculino e 525 (48,2 %) do feminino. o consumo de cigarro alguma vez na vida se associou a idades entre 13 e 18 anos (or = 2,86; ic 95%: 1,96-4,18), ser de sexo masculino (or = 2,40; ic 95 %: 1,63-3,56) e a alta intenção de consumo de substâncias (cigarro, álcool e maconha) (or = 3,18; ic 95%: 2,18-4,64). conclusão: o consumo de cigarro alguma vez na vida em estudantes de media vocacional de cartagena, colômbia, se associou a ter alta intenção de consumo de substâncias, ser adolescente e ser de sexo masculino. palavras-chave transtorno por uso de tabaco, adolescentes, estudantes, enfermagem, produtos do tabaco (fonte: decs de bireme). 229 variables asociadas al inicio del consumo de cigarrillo en adolescentes estudiantes de básica secundaria de los colegios oficiales l zuleima cogollo-milanés y otro. introducción es necesario considerar al tabaco como parte de las sustancias que provocan un incremento de morbilidad y de mortalidad evitable, con gran repercusión social y económica, constituyéndose en uno de los problemas de salud más graves en el mundo y uno de los principales retos que tiene planteados la salud pública (1). la encuesta mundial sobre consumo de tabaco en jóvenes estudiantes entre 13 a 15 años mostró que en el mundo aproximadamente 9,5 millones de adolescentes en estas edades son fumadores; según esta misma encuesta en el continente americano, los países suramericanos presentaron los valores más elevados en el consumo de cigarrillos en adolescentes, mientras que en estados unidos y canadá se observó una reducción considerable en el consumo de tabaco: 36,4 % en 1997 y 23 % en 2007 (2). esta misma encuesta se realizó en colombia en cinco ciudades (bogotá, bucaramanga, cali, manizales y valledupar) y las prevalencias oscilaron entre 7 y 30 % (3). el consumo de cigarrillo se inicia durante la adolescencia, antes de la mayoría de edad (1). las motivaciones que llevan a los adolescentes a fumar son diversas y están influidas por múltiples factores que favorecen el inicio del consumo de cigarrillos; estudios longitudinales han identificado factores socioeconómicos, familiares, cognitivos y emocionales (4). específicamente, diversos autores han señalado como factor relevante la presencia del tabaquismo en el entorno familiar y entre los amigos (5); se ha demostrado que el riesgo de fumar se multiplica por 6 entre los jóvenes en cuyo entorno de relación social hay muchos compañeros fumadores, factor este más influyente incluso que el grado de tabaquismo presente en su propia familia (6). otros autores, por su parte, han hecho mayor énfasis en los aspectos cognitivos, como las influencias percibidas, las actitudes a favor o en contra del tabaco, la autoeficacia para resistir la presión social hacia el consumo, la inclinación a conductas delincuenciales, el incumplimiento de las normas, la impulsividad, el bajo rendimiento académico y la fugas de las escuela o el abandono escolar (2). por su parte, otras investigaciones se han centrado en explorar los factores sociales, siendo la aceptación social, la disponibilidad, la publicidad y la presión social los aspectos más relevantes que se han asociado a la iniciación (7). el proceso que conduce a que un niño o adolescente se convierta en fumador es complejo y se caracteriza por varias etapas que transcurren desde el inicio hasta la consolidación del hábito, ellas son: precontemplación, contemplación, iniciación, experimentación, consumo regular, mantenimiento y abandono, cada una de ellas mediada por factores específicos (8). sin embargo, antes de la fase de experimentación existe un largo y complejo proceso de elaboración personal de las actitudes propias frente al tabaco, proceso que es poco conocido pero que ha sido asociado, según modelos de estudio, a aspectos que guardan relación con predictores de la conducta fumadora, basados en la hipótesis de que dicha conducta se puede explicar mediante la intención conductual, la cual es predecible a través de las actitudes del individuo, las influencias sociales y la propia autoeficacia para enfrentarse a las situaciones, es decir, que los factores que favorecen el inicio del consumo de cigarrillos descritos previamente modelan de manera importante la intención hacia el consumo como etapa previa a la experimentación (9). posteriormente, en etapas más avanzadas, en el mantenimiento del consumo intervienen también factores personales, condicionantes psicológicos y, además, adquieren importancia factores farmacológicos (la nicotina es una sustancia fuertemente adictiva) (6). se ha puesto de manifiesto que el consumo de tabaco entre los adolescentes tiene efectos perjudiciales para su salud ya en la misma adolescencia (peor estado de salud general, una mayor frecuencia de asma, bronquitis y alergias, hasta problemas tardíos como enfisema, cáncer de pulmón y enfermedades cardiovasculares) (10, 11). la población adolescente escolarizada, dadas las condiciones sociales, medioambientales y escolares, tiene una alta predisposición a iniciarse en el consumo de cigarrillo y, conocidos los efectos nocivos que se pueden derivar de esta conducta (12), se hace necesario ahondar en investigaciones acerca de los factores que inciden en el inicio, para de esta manera proponer desde la perspectiva de salud pública estrategias de prevención pertinentes, antes de que se inicie el consumo propiamente dicho. en la revisión de la literatura científica publicada se identificó que en la ciudad de cartagena los estudios realizados abordan la prevalencia y los factores asociados al consumo de cigarrillo, mas no la predisposición a la iniciación en jóvenes estudiantes de media vocacional, siendo un estudio que aporta a la comunidad científica y a los entes territoriales para la toma de decisiones. 230 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 el objetivo del estudio fue determinar la prevalencia y las variables asociadas al inicio del consumo de cigarrillo en adolescentes escolarizados de media vocacional de la ciudad cartagena, colombia. materiales y métodos se diseñó un estudio analítico observacional transversal. esta investigación contó con la aprobación del comité de ética de la universidad de cartagena, la secretaría de educación distrital y los directivos de las distintas instituciones educativas intervinientes. los padres firmaron un consentimiento informado, asimismo, los estudiantes asintieron participar en la investigación. la población la conformaron los estudiantes de básica secundaria de las instituciones educativas oficiales de la ciudad de cartagena matriculados durante el año 2012, que en su totalidad fueron 130.000 estudiantes. se estimó una muestra probabilística, con una prevalencia esperada de consumo de cigarrillo durante el último mes de 10 %, un margen de error del 2 % y error alfa del 5 %, para lo cual fue necesario contar con la participación de 1.100 estudiantes. se hizo un muestreo aleatorio por conglomerados en varias etapas. en el aula de clases los estudiantes diligenciaron un cuestionario anónimo que incluyó información demográfica (edad en años cumplidos, sexo, escolaridad, barrio y estrato de residencia, e ingresos económicos de la familia), intención de consumo de sustancias, experimentar con cigarrillo (consumo o experiencia con cigarrillo al menos alguna vez en la vida), función familiar y las variables autoestima y síntomas ansiosos. para evaluar el consumo de cigarrillo y las actitudes frente al mismo se utilizaron los ítems de la encuesta mundial sobre tabaquismo en jóvenes (emta-joven), diseñada y validada por el center for disease control and prevention, adaptada para colombia por el instituto colombiano de cancerología, que explica la conducta fumadora a través de la intención de fumar en el futuro y la relación de esta con las actitudes y creencias favorables ante el tabaco o ante los inconvenientes de fumar y las influencias sociales (13). la experimentación con cigarrillo se evaluó mediante preguntas que abordaban el consumo durante alguna vez en la vida, el último mes y diario durante el último mes. se consideraron experimentadores los adolescentes que informaron que habían probado cigarrillo por lo menos alguna vez en la vida (13). la intención de consumo de sustancias (cigarrillo, alcohol y marihuana) se evaluó con un cuestionario que costa de 9 ítems; 3 para medir intención de consumir cigarrillo, 3 para medir intención de consumir alcohol y 3 para medir intención de consumir marihuana. alta intención de consumo (0 a 8 en la escala) y baja (9 en la escala) (14). el funcionamiento familiar se cuantificó con el apgar familiar. esta escala contiene cinco ítemes que evalúan la percepción del sujeto sobre cinco dimensiones del funcionamiento familiar: estar satisfecho con la ayuda recibida por la familia, estar satisfecho con la forma en que la familia discute y comparte, creer que la familia acepta y apoya sus deseos, sentir que la familia le quiere, y estar satisfecho con el tiempo que la familia y el encuestado pasan juntos durante los seis últimos meses. se considera disfuncional (apgar de 0 a 15) y funcional (apgar de 16 a 20) (15). la autoestima se valoró con la escala de rosenberg para autoestima que consta de diez ítemes con un patrón de respuesta dicotómico, y un rango posible de puntuación entre 0 y 10; a mayor puntación mayor autoestima. autoestima baja (rosenberg de 0 a 5) y alta (rosenberg de 6 a 10) (16). para evaluar los síntomas ansiosos con importancia clínica (sacic) se utilizó la escala de zung de ansiedad: sacic presentes (zung de 21 a 40) y ausentes (zung de 10 a 20) (17). análisis estadístico los datos se analizaron en el paquete estadístico stata 9.0 (18). para las cuatro escalas que se usaron (zung para ansiedad, apgar familiar, rosenberg para autoestima e intención de consumo de sustancias) se estimó la confiabilidad (consistencia interna) en los estudiantes participantes (18-20). análisis descriptivo (univariado): se determinaron media y desviación estándar, frecuencia y porcentajes. en el análisis bivariado se exploraron las asociaciones entre las variables independientes y consumo de cigarrillo alguna vez en la vida como variable dependiente; se determinaron razones de disparidad o momios (or) con intervalos de confianza del 95 %. 231 variables asociadas al inicio del consumo de cigarrillo en adolescentes estudiantes de básica secundaria de los colegios oficiales l zuleima cogollo-milanés y otro. análisis multivariado: se realizó el ajuste de las asociaciones que mostraron valores de probabilidad menores de 0,200 mediante un modelo de regresión logística binaria. se siguieron recomendaciones de greenland y se estimó la bondad del ajuste con la prueba de hosmer-lemeshow (21). resultados análisis descriptivo en el presente estudio participaron 1.090 estudiantes, se descartaron 10 cuestionarios por mal diligenciamiento. las edades del grupo oscilaron entre 10 y 18 años, media = 12,3; desviación estándar 1,1. entre 10 y 12 años 676 (62,0 %) y entre 13 y 18 años, 414 (38,0 %). en cuanto al género, 565 (51,8 %) estudiantes fueron de sexo masculino y 525 (48,2 %) de sexo femenino. pertenecían a sexto grado: 629 (57,7 %) y grado séptimo 461 (42,3 %). respecto a los ingresos familiares, entre 0 a 2 salarios mínimos: 839 (77,0 %) y 3 o más: 251 (23,0 %). así mismo, 253 (23,2 %) adolescentes mostraron baja autoestima, síntomas de ansiedad con importancia clínica: 230 (21,1 %), disfunción familiar: 681 (62,5 %), 338 (31,0 %) alta intención de consumo y consumo de cigarrillo alguna vez en la vida (experimentó) 127 (11,7 %) adolescentes. las escalas mostraron las siguientes consistencias internas: zung para ansiedad, 0,830; apgar familiar, 0,850; rosenberg para autoestima, 0,572; intención de consumo de sustancias (alcohol, cigarrillo o marihuana), 0,840. análisis bivariado en el análisis bivariado se encontró que el consumo de cigarrillo alguna vez en la vida se asoció a edades entre 13 y 18 años (or = 2,86; ic95 %: 1,96-4,18), ser de sexo masculino (or = 2,40; ic95 %: 1,63-3,56) y a alta intención de consumo de sustancias (or = 3,18; ic95 %: 2,18-4,64) (tabla 1). análisis multivariado para incluir en el modelo multivariado se consideraron las variables: edad, sexo, grado de escolaridad, funcionamiento familiar e intención de consumo de sustancias (tabla 2). la intención de consumo de sustancias mostró la asociación más alta con consumo de cigarrillo alguna vez en la vida (or = 2,75; ic95 %: 1,87-4,05) (prueba de hosmer-lemeshow x2 = 9,143; gl = 6; p = 0,166) (21). tabla 1. asociaciones para consumo de cigarrillo alguna vez en la vida variable or ic95 % edad entre 13 y 18 años 2,86 1,96-4,18 sexo masculino 2,40 1,63-3,56 séptimo grado 1,40 0,96-2,02 ingreso de 3 o más salarios mínimos 1,20 0,78-1,83 baja autoestima 1,19 0,78-1,81 síntomas de ansiedad con importancia clínica 1,18 0,76-183 disfunción familiar 1,41 0,95-2,10 alta intención de consumo de sustancias 3,18 2,18-4,64 tabla 2. asociaciones ajustadas mediante regresión logística para consumo de cigarrillo alguna vez en la vida variable or ic95 % alta intención de consumo de sustancias 2,75 1,87-4,05 edad entre 13 y 18 años 2,36 1,60-3,48 sexo masculino 2,13 1,42-3,17 bondad de ajuste de hosmer-lemeshow: chi cuadrado = 9,143; grados de libertad = 6; probabilidad = 0,166. discusión y conclusiones en la presente investigación se observa una asociación estadísticamente significativa entre el consumo de cigarrillo alguna vez en la vida, la alta intención de consumo sustancias (alcohol, cigarrillo o marihuana) en adolescentes estudiantes, ser de sexo masculino y tener edades comprendidas entre 13 y 18 años. en este estudio el consumo de cigarrillo alguna vez en la vida mostró una asociación significativa con la alta intención de consumo de sustancias (alcohol, cigarrillo o marihuana), hallazgos similares a los de arillo-santillan et al., quienes documentaron una relación estadísticamente significativa entre actitud positiva 232 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 a fumar y alta susceptibilidad (intención de fumar en el futuro) en estudiantes mexicanos entre 12 a 15 años, en 10 ciudades del país (22). en este mismo sentido, ariza et al., en un estudio longitudinal, determinaron una asociación importante entre actitudes favorables hacia el consumo de cigarrillo e intención de fumar en el futuro, como uno de los mejores predictores de la iniciación del consumo de cigarrillo (23, 24). la intención es una variable influyente para el inicio temprano del consumo de cualquier sustancia (25). el inicio del uso de cualquier sustancia suele ir precedido por valores favorables hacia el mismo y se constituye en un factor mediador en la susceptibilidad de convertirse en fumador (26, 27). la elevada susceptibilidad cognitiva es un factor predictivo del uso de tabaco en adolescentes no fumadores, la predisposición cognitiva a fumar es una medida que incluye tanto la intención, como la expectativa de fumar en el futuro, es decir, el adolescente no tiene un compromiso firme de no fumar (28). los alumnos con actitudes favorables para fumar tienen cuatro veces más posibilidades de ser fumadores frente a los alumnos cuya actitud es contraria a fumar (29). estos datos plantean el riesgo de los estudiantes de convertirse en fumadores en los próximos años y la necesidad de evaluar esta conducta (intención de consumo) en estudiantes que inician los años de estudio de enseñanza secundaria para implementar medidas de prevención, especialmente de tipo selectivo, hacia el grupo de mayor vulnerabilidad e incluso desde los años de educación primaria. los resultados de este estudio muestran que ser adolescente con edades entre 13 y 18 años es un predictor que se relaciona significativamente con el consumo de cigarrillo alguna vez en la vida, la mayoría de los estudios informan que el consumo de cigarrillo se inicia en la adolescencia, con un incremento en la medida que aumenta la edad (30-33). cogollo et al., en un estudio realizado con adolescentes escolarizados en la ciudad de cartagena, observaron la edad media de inicio del consumo a los 13 años y un consumo habitual en mayores de 15 años (or = 3,71; ic95 %: 2,85-7,44) (33). sin embargo, otros estudios muestran edades más tempranas para haber probado tabaco (cigarrillo) alguna vez en la vida. el estudio nacional de consumo de sustancias psicoactivas en población escolar de colombia en el año 2011 reportó que la edad promedio para experimentar alguna vez en la vida con cigarrillo, para los chicos fue 12,4 años y para las mujeres fue de 13 años (34). por su parte, pardo et al., en un estudio realizado en cinco ciudades de colombia, determinaron la edad promedio de inicio de consumo de cigarrillo en 11,9 años (35). vale la pena resaltar que la evidencia sugiere que la mayoría de jóvenes consumen tabaco por primera vez entre los 10 y 14 años (36). los adolescentes que empiezan a consumir cigarrillo a una edad temprana tienen más probabilidad de fumar en la edad adulta, mayor será su riesgo de convertirse en fumador regular, desarrollar dependencia y sufrir consecuencias a largo plazo derivadas del consumo (37). en este estudio se encontró que el consumo de cigarrillo alguna vez en la vida se asoció con ser de sexo masculino, estos datos son similares a los documentados en el estudio nacional de consumo de sustancias psicoactivas en escolares de colombia, en donde los encuestados que indicaron haber consumido tabaco alguna vez en la vida fueron principalmente hombres, en un 28 %, en relación al 21 % de las mujeres (34). de igual manera, pardo y piñeros mostraron una proporción significativamente mayor en hombres de la ciudad de cali (colombia) (31,4 %) que en mujeres (22,2 %) (35). hallazgos similares se documentan en encuestas de otros países, como méxico, donde kuri-morales y gonzálezroldán encontraron mayor consumo de tabaco entre los adolescentes masculinos (38). por el contrario, en otros países como españa, según la encuesta nacional de drogas en estudiantes de secundaria (estudes) del 2010, las mujeres se incorporan al consumo de tabaco en una prevalencia superior al hombre (39). sin embargo, a pesar de que el consumo de tabaco por parte de las chicas está aumentando a nivel mundial, la diferencia entre hombres y mujeres no fue significativa en 60 % de los países que participaron en la encuesta mundial sobre el tabaquismo en jóvenes, global youth tobacco survey gyts 2002; solo en el 14 % de los países el tabaquismo fue significativamente más frecuente en chicas que en chicos adolescentes (40). por otro lado, en el presente estudio la baja autoestima (or = 1,19-0,78; ic95 %: 1,81), los síntomas de ansiedad (or = 1, 18-0,76 ic95 %: 183) y la disfunción familiar (or = 1,410,95 ic95 %: 2,10) no se relacionaron con el consumo de cigarrillo alguna vez en la vida; sin embargo, ariza et al. encontraron que tener un bajo nivel de autoestima se relacionó significativamente (or = 0,94; ic95 %, 0,88-0,99) con el consumo de tabaco en las mujeres (37). por su parte, rueda-jaimes et al. encontraron que la autoestima se constituyó en un factor protector para consumo diario de cigarrillo en adolescentes estudiantes (or = 0,89; 233 variables asociadas al inicio del consumo de cigarrillo en adolescentes estudiantes de básica secundaria de los colegios oficiales l zuleima cogollo-milanés y otro. ic95 %, 0,79-0,98; p: 0,030), pero no hallaron relación con la disfuncionalidad familiar (41). de otra parte, pérez et al. encontraron que la disfunción familiar grave se relacionó con un mayor consumo de tabaco (32 ± 5,9 %; p < 0,01 test de la x2), con un aumento del consumo de 4,3 ± 1,4 cigarrillos/día (p < 0,001; anova). de igual manera, el consumo de tabaco se relacionó con un aumento de malestar psíquico: ansiedad (92,0 ± 1,4 %; p < 0,01, test de la x2) (42). se conoce que la existencia de una vida familiar satisfactoria es un factor protector para el consumo de drogas, y que las disfunciones familiares actúan como factor de riesgo para el uso de cualquier tipo de sustancias, el buen funcionamiento familiar posibilita la adaptación a los cambios surgidos en la adolescencia (43). en lo que respecta a la autoestima la evidencia empírica es contradictoria, algunos autores sostienen que la alta autoestima puede actuar como factor protector para el consumo de sustancias; por el contario, hay quienes sugieren que favorece el consumo por parte de los adolescentes. desde esta perspectiva es importante considerar que la autoestima es un concepto multidimensional, lo que lleva al sujeto a tener altas valoraciones de sí mismo en algunos ámbitos de su vida, como el de los amigos, mientras que puede tener pobres valoraciones a nivel familiar o escolar. sin embargo, las personas con alta autoestima exhibirán conductas más integradas, lo que puede reducir la susceptibilidad a la presión de iguales para el consumo, y la baja autoestima, por el contario, actúa como un factor de riesgo (44, 45). en cuanto al aspecto emocional, en múltiples estudios los síntomas depresivos y la ansiedad han resultado ser predictores del inicio de fumar en adolescentes, y en fumadores predicen la persistencia del consumo de tabaco. sin embargo, aunque los resultados no son concluyentes en cuanto a determinar si la presencia de síntomas depresivos o el nivel de ansiedad son causa o consecuencia del consumo de sustancias, los datos parecen apuntar a que, en general, existe un nivel muy bajo de satisfacción personal que podría influir en la alta frecuencia de trastornos del estado de ánimo y de suicidio entre los adolescentes consumidores (46). los hallazgos de este estudio ponen de manifiesto que existen factores que predicen el consumo de cigarrillo en adolescentes, y a pesar de que el modelo de regresión logística solo mostró asociación estadísticamente significativa del consumo de cigarrillo alguna vez en la vida con tres variables, no hay que dejar de lado que los factores predictores del uso de tabaco son múltiples, por lo que habrá que valorar conjuntamente la importancia, en cada caso, de la familia, los pares y la comunidad donde vive el adolescente para retrasar, prevenir o reducir el consumo de esta sustancia legal que favorece el consumo de otras sustancias tanto legales como ilegales (47). el estudio buscó conocer las variables que favorecen el inicio del consumo para contar con la información que permita diseñar y ejecutar un programa de prevención del consumo de cigarrillo y sustancias lícitas, sustentado teórica y empíricamente en diagnósticos contextualizados. en este sentido el profesional de enfermería, dentro de su rol de promover la salud y prevenir la enfermedad, tiene el compromiso social de ejecutar funciones en torno a la identificación de factores predisponentes al inicio del consumo, estimular el fomento de factores protectores y plantear alternativas de intervención orientadas a la reducción del consumo de cigarrillos en esta población. este escenario se convierte en un espacio importante para que la enfermera(o) retome su liderazgo y responsabilidad frente a las acciones de atención primaria dirigidas a modificar creencias y actitudes favorables al consumo e intensificar el rechazo social ante el mismo (48). se concluye que el consumo de cigarrillo alguna vez en la vida se asoció a tener alta intención de consumo de sustancias, ser adolescente (13 a 18 años) y ser de sexo masculino. agradecimientos. esta investigación fue financiada por la vicerrectoría de investigaciones de la universidad de cartagena (acta de compromiso 073-2012, resolución: 1548 de mayo de 2012). agradecemos al doctor adalberto campo-arias, médico psiquiatra, director de investigaciones del instituto de investigación del comportamiento humano, bogotá, colombia, por la asesoría en el análisis de los datos. a los estudiantes de enfermería rocío amador herrera, elymer ayola marrugo, laura ballesteros estrada y yarlys orozco gómez por la colaboración en la recolección de los datos. a la secretaría distrital de educación de cartagena, colombia, por el respaldo para acceder a las instituciones educativas de la ciudad. 234 año 14 vol. 14 nº 2 chía, colombia junio 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psicoactivas en población escolar colombia; 2011. 35. pardo c, piñeros m. consumo de tabaco en cinco ciudades de colombia. encuesta mundial de tabaquismo en jóvenes, 2007. biomédica. 2010;30:509-18. 36. programa rumbos. encuesta nacional sobre consumo de sustancias psicoactivas en jóvenes de 10-24 años. bogotá; 2001. 37. ariza c, nebot m. factors associated with smoking progression among spanish adolescents. health educ res. 2002;17(6):750-60. 38. kuri-morales pa, gonzález-roldán jp, hoy mj, cortés-ramírez m. epidemiología del tabaquismo en méxico. salud pública mex. 2006;48(1):91-98. 39. plan nacional sobre drogas. encuesta estatal sobre uso de drogas en estudiantes de secundaria (estudes 2010). madrid: ministerio de sanidad y políticas sociales; 2011. [visitado 2012 sept. 7]. disponible en: http://www.pnsd.msc.es/ categoria2/observa/pdf /estudes_2010.pdf 40. warren cw, riley l, asma s et al. tobacco use by youth: a surveillance report from the global youth tobacco survey project (gyts). bull world health organ. 2000;78:868-876. 41. rueda-jaimes g, camacho p, rangel-martínez a, campo-arias a. prevalencia y factores asociados con el consumo diario de tabaco en estudiantes adolescentes. rev colomb psiquiat. 2009;38(4):669-680. 42. pérez milena a, pérez milena r, martínez fernández ml, leal helmling f j, mesa gallardo m i, jiménez pulido i. estructura y funcionalidad de la familia durante la adolescencia, relación con el apoyo social, el consumo de tóxicos y el malestar psíquico. atención primaria. publicación oficial de la sociedad española de familia y comunitaria. 2007;39(2):61-65. 43. garcía-campayo j, alda m. el ciclo vital familiar. en: garcía-campayo j, editor. la familia y el médico de familia: elementos básicos de intervención 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consumo de tabaco en adolescentes: factores de riesgo y factores protectores. cienc enferm. 2002;8(2). 252 aquichan issn 1657-5997 roberto lagunes-córdoba1 maría antonia hernández-manzanares2 escala de evaluación de la conducta ética del personal de enfermería en el cuidado de los pacientes 1 hospital regional de veracruz, méxico. rlc2001halt@hotmail.com 2 hospital regional de veracruz, méxico. antonia_hmz@yahoo.com.mx recibido: 20 de marzo de 2012 aceptado: 24 de septiembre de 2012 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 l 252-262 resumen el presente trabajo tiene el propósito de construir una escala de evaluación de la conducta ética del personal de enfermería en el cuidado de los pacientes basada en las tres premisas fundamentales de la teoría del cuidado de jean watson. la versión final del cuestionario consta de 13 reactivos tipo likert que reflejan los contenidos de las premisas fundamentales de la mencionada teoría. la validez del cuestionario se determinó por medio del análisis factorial con extracción de componentes principales y rotación varimax. del análisis surgieron cuatro factores que explican el 64% de la varianza. tres de los factores corresponden a las premisas fundamentales de la teoría, mientras que el cuarto factor está relacionado con la comunicación y la empatía. la adecuación de la muestra para el análisis factorial se confirmó mediante el cociente de kaiser-meyer-olkin (kmo = 0,848), la prueba de esfericidad de bartlett (p < 0,001) y el cálculo de la determinante de la matriz de correlaciones (0,006). la confiabilidad por consistencia interna de la escala global es alta ( = 0,85). se concluye que el instrumento es válido, confiable, y representa un medio conveniente para evaluar el comportamiento ético del personal de enfermería al proporcionar cuidado al paciente hospitalizado. palabras clave atención, cuidado, ética, teoría de enfermería, enfermería (fuente: decs, bireme). a scale to assess the ethical conduct of nurses in patient care abstract the purpose of this paper is to construct a scale to evaluate ethical conduct in nursing care, based on the three fundamental premises of jean watson’s caring theory. the final version of the questionnaire consists of 13 likert-type response categories that reflect the contents of the basic assumptions of that theory. the validity of the questionnaire was determined through factor analysis with principal component extraction and varimax rotation. the analysis suggested four factors that explain 64% of the variance. three of the factors 253 construcción de una escala de evaluación de la ética en el cuidado a pacientes... l roberto lagunes-córdoba, maría antonia hernández-manzanares pertain to the basic premises of the theory, while the fourth is related to communication and empathy. sampling adequacy for factor analysis was confirmed by means of the kaiser-meyer-olkin coefficient (kmo = 0.848), bartlett’s test of sphericity (p <0.001) and calculation of the determinant of the correlation matrix (0.006). the internal consistency reliability of the overall scale is high ( = 0.85). it was concluded the instrument is valid, reliable and represents a convenient way to assess the ethical behavior of nurses when providing care to hospitalized patients. key words attention, care, ethics (source: decs, bireme). escala de avaliação da conduta ética do pessoal de enfermagem no cuidado dos pacientes resumo o presente trabalho tem o propósito de construir uma escala de avaliação da conduta ética do pessoal de enfermagem no cuidado dos pacientes baseada nas três premissas fundamentais da teoria do cuidado de jean watson. a versão final do questionário consta de 13 reativos tipo likert que refletem os conteúdos das premissas fundamentais da mencionada teoria. a validade do questionário se determinou por meio da análise fatorial com extração de componentes principais e rotação varimax. da análise surgiram quatro fatores que explicam 64% da variação. três dos fatores correspondem às premissas fundamentais da teoria, enquanto o quarto fator está relacionado com a comunicação e a empatia. a adequação da amostra para a análise fatorial se confirmou mediante o cociente de kaiser-meyer-olkin (kmo = 0,848), a prova de esfericidade de bartlett (p < 0,001) e o cálculo da determinante da matriz de correlações (0,006). a confiabilidade por consistência interna da escala global é alta ( = 0,85). conclui-se que o instrumento é válido, confiável e representa um meio conveniente para avaliar o comportamento ético do pessoal de enfermagem ao proporcionar cuidado ao paciente hospitalizado. palavras-chave atenção, cuidado, ética, enfermagem, teoria de enfermagem (fonte: decs, bireme). 254 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 introducción desde sus inicios como disciplina independiente, el objetivo fundamental de la enfermería ha sido el cuidado del paciente (1, 2). a causa de ello, la evaluación de la conducta ética y la calidad del cuidado proporcionado por la enfermera son una preocupación permanente para profesionales, investigadores y autoridades por igual (2). el comportamiento adecuado, cálido y respetuoso del personal de enfermería es una condición necesaria para conseguir este objetivo, y un reclamo permanente de los pacientes (1-4). en la actualidad se cuenta con perfiles (5), enfoques teóricos (6-10) y cuestionarios estandarizados para evaluar el comportamiento ético, la calidad y los atributos del cuidado de enfermería (11-17). sin embargo, la inmensa mayoría de estos instrumentos están en idiomas distintos al español (11,13-18), han sido adaptados y validados en países latinoamericanos con características culturales e idiomáticas diferentes (12), o están dirigidos al personal de enfermería (7, 8, 13, 14). por otra parte, aunque se trata del sujeto del cuidado de enfermería, no se suele preguntar a los pacientes sobre la calidad del cuidado que reciben, ni sobre el comportamiento de las enfermeras que los atienden. la escasez de instrumentos válidos, confiables y dirigidos al paciente en el medio latinoamericano impide la evaluación objetiva del cuidado de enfermería, lo cual a su vez dificulta la evaluación de programas de calidad, desempeño y enseñanza. ante esta situación, se hace necesaria la elaboración de un cuestionario dirigido a subsanar esta deficiencia. un cuestionario válido debería satisfacer por lo menos dos requisitos: 1) basarse en criterios plenamente acreditados, en un amplio consenso de expertos, o en una teoría contrastada y robustecida por múltiples estudios(19, 20); 2) no debe ser muy largo, ya que eso afectaría la disposición del paciente para contestarlo o para otorgar respuestas fidedignas (21). en lo que respecta al cuidado del paciente, la teoría del cuidado propuesta por jean watson resulta muy adecuada para constituir la base de un instrumento de evaluación, ya que describe, enfatiza y contextualiza precisamente este constructo. la teoría de watson define el cuidado como una situación transpersonal que se caracteriza por: 1) “un compromiso moral de la enfermera por proteger y realzar la dignidad humana, así como el más profundo/más alto yo”, y 2) “el conocimiento del cuidado de la enfermera transmitido para conservar y honrar el espíritu incorporado, por tanto, no reducir a la persona al estado moral de un objeto” (9). la enfermera tiene la obligación de ir más allá de una evaluación objetiva de su paciente, mostrando preocupación hacia el significado subjetivo y más profundo de la persona y su propia situación de salud (9). en otras palabras, la enfermera debe ver e interactuar con “la persona”, más que con “el enfermo”. debe comprender a la persona como ser dotado de creencias, emociones, sentimientos y temores, sin olvidar su propia individualidad y su conocimiento; debe comprender y sentir profundamente las necesidades de su paciente para poder satisfacerlas. la aproximación de watson al cuidado de enfermería se basa en tres premisas teóricas fundamentales (7-9): • actitud de asistencia. esta actitud (o conjunto de actitudes) se transmite por medio de la cultura de la profesión y se considera como la única manera válida de hacer frente al entorno, la enfermera debe hacer por el paciente todo lo que este no puede realizar por sus propios medios. • claridad de expresión de ayuda y de los sentimientos. la claridad se percibe como la manera más eficaz de asegurar que el paciente y la enfermera se comprendan como personas. la enfermera debe dejar clara su misión de ayudar al paciente y expresar sus sentimientos de aceptación hacia él como persona, a la vez que demuestra que es capaz de comprender su situación. • trato genuino y sincero. la enfermera debe tener un deseo genuino y sincero de ayudar y procurar el cuidado del paciente. si esto no se logra el paciente lo percibirá, y la eficacia del cuidado que se proporciona podría resentirse debido a las sensaciones de hostilidad y rechazo entre el paciente y la enfermera. estas premisas plantean el deber ser y el deber actuar de la enfermera en el cuidado de sus pacientes: es precisamente en las premisas y no en los elementos del cuidado donde se enfatiza el aspecto ético del cuidado de enfermería. de acuerdo con la american association of colleges of nursing, en la práctica de 255 construcción de una escala de evaluación de la ética en el cuidado a pacientes... l roberto lagunes-córdoba, maría antonia hernández-manzanares la enfermería son necesarios los siguientes valores: estética (entendida como el interés por las cosas amables, la habilidad e iniciativa creadora), altruismo, igualdad, libertad, respeto a la dignidad humana, justicia, verdad, prudencia, tolerancia, responsabilidad personal y profesional, y atención al cuidado y la salud (22, 23). nuevamente, estos valores reflejan el deber ser, la manera en que debe comportarse el personal de enfermería, y con ello coinciden algunos sondeos de opinión de los profesionales y profesores de enfermería de diversos países (24). estos elementos coinciden con los descriptores de las premisas básicas de la teoría de watson. cuando se habla de estética, altruismo, responsabilidad, atención al cuidado y a la salud se están señalando elementos descriptores de la actitud de asistencia, de la disposición que la enfermera debe mostrar hacia el paciente. del mismo modo, la tolerancia, la igualdad, la libertad y el respeto a la dignidad humana describen la claridad de expresión de ayuda y de los sentimientos señalando el afán de aceptar al paciente tal como es y hacerle saber que se le comprende y acepta en cuanto a persona necesitada de cuidado. y la verdad, la prudencia y la justicia describen los elementos del trato genuino y sincero. los valores de la enfermera forman un todo que se refleja en la conducta de la persona, y es de esperar que algunos de ellos coincidan con más de una de las premisas básicas de la teoría. pero la idea fundamental es la siguiente: las premisas básicas de la teoría de watson reflejan los valores y actitudes que debe tener el personal de enfermería para ofrecer un cuidado basado en principios éticos. por lo anteriormente expuesto, se considera pertinente basarse en las premisas fundamentales de la teoría de watson para elaborar el instrumento de evaluación del cuidado ético de los pacientes por el personal de enfermería. el objetivo principal del presente trabajo es construir una escala de evaluación de la conducta ética del personal de enfermería que proporciona cuidados a pacientes hospitalizados. materiales y métodos en este estudio se llevó a cabo la construcción de un instrumento dirigido a los pacientes hospitalizados para evaluar el comportamiento ético del personal de enfermería que los atiende. para el logro de este objetivo se decidió que el cuestionario fuera breve, administrado al paciente, y basado en las premisas fundamentales de la teoría del cuidado de jean watson, tal como se expone en la introducción. construcción del banco de reactivos el instrumento se construyó por medio de una ronda inicial de cuatro enfermeras con un mínimo de veinte años de experiencia en la atención en pacientes, y versadas en la teoría del cuidado de jean watson por su trabajo en docencia y asesoría. las participantes redactaron seis reactivos para cada uno de los supuestos fundamentales de la teoría. cada uno de los reactivos se redactó en forma de pregunta, y se diseñó para ser contestado por medio de una escala tipo likert con cuatro opciones de respuesta: “siempre”, “frecuentemente”, “rara vez” y “nunca” (ver anexo). a continuación se llevó a cabo una segunda ronda de tres enfermeras independientes con características equiparables a las que realizaron las preguntas, las cuales evaluaron si cada reactivo reflejaba verdaderamente el supuesto correspondiente de la teoría de watson. terminado este proceso, se utilizó el coeficiente kappa para determinar la concordancia interjueces. todos los reactivos que obtuvieron un coeficiente kappa mayor o igual que 0,60 pasaron a formar parte de la versión del instrumento que se aplicó a los pacientes (25). por consideraciones de tiempo y recursos se tomó la decisión de prescindir del piloteo previo del cuestionario. en su lugar, para preparar la versión final se eliminaron los reactivos que no tuvieran una adecuada comunalidad (< 0,40), o que no se correlacionaran claramente con al menos uno de los factores encontrados. aplicación del cuestionario el instrumento se aplicó previo consentimiento informado a 150 pacientes hospitalizados (10 por reactivo) (21) de los servicios de ginecología, medicina interna, cirugía, traumatología, cuidados intermedios, unidad de cuidados intensivos neonatales y lactantes del hospital regional de alta especialidad de veracruz, méxico, entre agosto y octubre del 2010. a los pacientes se les informó que se trataba de un instrumento para evaluar el comportamiento de la enfermera y la calidad del cuidado que proporciona. los cuestionarios se llenaron con asistencia de uno de los investigadores, quien proporcionó explicaciones y aclaraciones a los pacientes cuando fue necesario. aspectos éticos el protocolo del presente estudio fue revisado y aprobado por el comité de investigación y ética del hospital regional de veracruz, con estricta observancia de la ley general de salud de los 256 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 estados unidos mexicanos. tanto las enfermeras que redactaron y revisaron los reactivos como los pacientes que contestaron los cuestionarios participaron libremente, previo consentimiento informado y con conocimiento de los propósitos de la investigación. cálculo de la confiabilidad y la validez para propósitos analíticos, los datos obtenidos se recodificaron a cifras, asignando un 3 a la respuesta “siempre”, un 2 a la respuesta “frecuentemente”, un 1 a respuesta “rara vez” y 0 a la respuesta “nunca”. las cifras así obtenidas se utilizaron para calcular la confiabilidad del cuestionario por consistencia interna con el coeficiente alfa de cronbach, y la validez por medio del análisis factorial confirmatorio con rotación varimax, para facilitar la interpretación de los resultados (máximo de 25 iteraciones). se descartaron los reactivos que saturaron en más de dos factores y con un valor absoluto menor que 0,20 (21). los análisis se realizaron con el programa ibm© spss© statistics 19. resultados versión y aplicación inicial de la escala la primera ronda de enfermeras redactó un total de 18 reactivos representativos (6 por cada una de las premisas fundamentales de la teoría). la segunda ronda determinó si los reactivos representaban o no las dimensiones teóricas y realizó correcciones mínimas en la redacción de 4 reactivos. de los 18 reactivos iniciales, 15 pasaron el corte al obtener un coeficiente kappa mayor que 0,60 (porcentaje de concordancia promedio = 78%). una vez obtenida la segunda versión del cuestionario, se aplicó a 150 pacientes (n = 10 por reactivo) (21), quienes lo contestaron íntegramente asistidos por uno de los investigadores. análisis de adecuación muestral con el fin de asegurar que el análisis factorial fuera la técnica adecuada para determinar la validez del cuestionario, se realizaron las pruebas de adecuación muestral de kaiser-meyer-olkin, la de esfericidad de bartlett y el cálculo de la determinante del sistema. el resultado de la prueba de adecuación muestral de kaisermeyer-olkin (kmo = 0,848) muestra que las correlaciones parciales entre las puntuaciones de los reactivos son pequeñas. esto se confirmó con el estudio de la matriz de correlaciones antiimagen, la cual mostró valores elevados solamente en la diagonal. fuera de esta, menos del 2% de valores encontrados fue de cero, lo cual demuestra que las correlaciones entre las puntuaciones de la mayor parte de los pares de reactivos pueden ser explicadas por las puntuaciones de otros, y confirma la pertinencia del análisis factorial para determinar la validez de la escala (26). la prueba de esfericidad de bartlett (p < 0,001) rechaza la hipótesis nula de que la matriz calculada corresponde en realidad a una matriz de identidad, lo cual hubiera hecho inadecuado el uso del análisis factorial con los datos de la muestra obtenida (26, 27). los resultados anteriores se ven reforzados con la obtención de la determinante del sistema, cuyo valor de 0,006 indica que existen reactivos cuyas puntuaciones se correlacionan fuertemente entre sí, lo cual es una condición necesaria para llevar a cabo la extracción de factores en el análisis (26, 27). estos resultados, en conjunto, demuestran que el análisis factorial es adecuado para determinar la validez de constructo del cuestionario. validez y confiabilidad las dos rondas de expertas aseguraron una medida de validez interjueces antes de la aplicación del cuestionario, ya que las participantes evaluaron las preguntas apegadas a las premisas fundamentales del enfoque teórico de jean watson. una vez que se demostró que la muestra obtenida es adecuada, se procedió a obtener la validez de constructo del instrumento por medio del análisis factorial confirmatorio mediante el método de extracción de componentes principales con rotación varimax, para facilitar la interpretación de los resultados. en un primer análisis se observó que los reactivos 12 y 13 de la versión inicial del cuestionario no se correlacionaban adecuadamente con ninguno de los factores deducidos, razón por la cual se eliminaron de la versión final del instrumento. con los 13 reactivos restantes se procedió a realizar un nuevo análisis que permitió obtener una versión definitiva de la escala. en la nueva versión, los 13 reactivos se agruparon en cuatro factores que en conjunto explicaron el 64% de la varianza (tabla 1). el gráfico de sedimentación (figura 1) muestra que solamente 257 construcción de una escala de evaluación de la ética en el cuidado a pacientes... l roberto lagunes-córdoba, maría antonia hernández-manzanares los cuatro primeros factores tienen valores superiores a uno, es decir, solamente estos cuatro factores tienen una raíz característica superior a la media de las raíces de los factores, y resultan adecuados para explicar la variabilidad de los datos. tabla 1. componentes principales del análisis factorial los factores están constituidos de la manera que se muestra en la tabla 2. las comunalidades de todos los reactivos fueron superiores a 0,40. la rotación alcanzó la convergencia en 6 iteraciones, y todos los reactivos tuvieron una correlación significativa con la puntuación total de la prueba (correlación de pearson, p = 0,000 para todos los casos; ver tabla 3). figura 1. gráfico de sedimentación del análisis factorial con rotación varimax. obsérvese que solamente los cuatro primeros factores tienen autovalores superiores a la unidad tres de estos factores se ajustan adecuadamente a las premisas de la teoría de watson. el cuarto factor obtenido se ha denominado comunicación y empatía, y queda implícito en los conceptos de la teoría (7-9). el coeficiente alfa de cronbach ( =0,85) muestra que la confiabilidad general del instrumento es alta (21, 28). las confiabilidades por factor son: factor 1, = 0,727; factor 2, = 0,739; factor 3, = 0,708; factor 4, = 0,451. los tres primeros coeficientes se consideran aceptables, y el último, bajo (28). tabla 2. factores encontrados en el análisis fuente: directa. factor nombre reactivos que lo representan 1 actitud de asistencia 10, 11, 13 2 claridad de la expresión de ayuda 3, 4, 6, 7 3 genuinidad y sinceridad en el trato 1, 2, 8, 12 4 comunicación y empatía 5, 9 fuente: directa. 258 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 tabla 3. correlación de cada reactivo con la puntuación total de la prueba (coeficiente de correlación de pearson) se recomienda ver los escritos de watson (8) y walker (9) para detalles adicionales. de acuerdo con walker (9), una de las influencias más importantes en la teoría de watson es carl rogers, especialmente por su terapia centrada en la persona. este enfoque terapéutico establece la importancia capital de la empatía en la relación tratante-paciente, y la define como: “la capacidad de sentir lo que otra persona siente” (29). esta definición de empatía proporciona un fundamento teórico para el concepto denominado “relación de cuidado transpersonal” de la teoría de watson. por otra parte, la comunicación es un pilar fundamental de todos los conceptos y las premisas de la teoría; sin comunicación el acto de cuidado no se realiza. en realidad, la comunicación y la empatía son tan importantes en la teoría de watson, que nos preguntamos si deben ser considerados como verdaderos metaconceptos o axiomas esenciales en este enfoque teórico. el análisis de confiabilidad muestra que la escala general es suficientemente estable y consistente para obtener medidas concurrentes entre evaluadores. los factores: “actitud de asistencia”, “claridad de la expresión de ayuda” y “trato genuino y sincero” muestran también una adecuada consistencia interna al considerarlos separadamente. la única excepción es el factor emergente: “comunicación y empatía”, que muestra un nivel de confiabilidad bajo. esto se explica en parte porque el factor solo consta de dos reactivos, y el nivel de confiabilidad está relacionado directamente con la cantidad de reactivos: a igualdad de condiciones, escalas y factores más largos, tendrán siempre mayor confiabilidad (30). otra explicación se basa en el hecho de que el reactivo 9 se correlaciona también con el factor uno. esta deficiencia podría subsanarse en un estudio posterior, de dos maneras: incrementando el número de reactivos representativos para este factor, o eliminando los dos reactivos representativos. pero se debe tomar en cuenta que un cuestionario largo disminuye el interés y la disposición de los pacientes para contestarlo, condicionando la veracidad de sus respuestas (21). por otra parte, la eliminación de un reactivo conlleva pérdida de información potencialmente valiosa (29). por estas razones se tomó la decisión de mantener el número de reactivos en la versión final. conclusión la presente escala de evaluación del comportamiento ético del personal de enfermería es un primer instrumento en español reactivo correlación p 1 0,505 0,000 2 0,641 0,000 3 0,612 0,000 4 0,630 0,000 5 0,362 0,000 6 0,648 0,000 7 0,733 0,000 8 0,701 0,000 9 0,603 0,000 10 0,674 0,000 11 0,663 0,000 12 0,569 0,000 13 0,586 0,000 fuente: directa. discusión ante la escasez de instrumentos adecuados para evaluar el comportamiento ético del personal de enfermería en lengua española, se considera que la escala cuya elaboración y análisis se ha detallado en el presente artículo contribuye a satisfacer la necesidad de tales instrumentos de evaluación. en la escala construida es el paciente quien valora el comportamiento ético de la enfermera que lo atiende y de quien depende para recuperar su estado de salud. es indudable que la persona más autorizada para hablar de la calidad del trato y la ética del cuidado es quien finalmente lo va a recibir. los resultados del análisis factorial indican que el cuestionario tiene una estructura factorial adecuada y similar a la de las premisas fundamentales del enfoque teórico de cuidado de jean watson. resulta de gran interés el hallazgo de un cuarto factor, al que se ha denominado comunicación y empatía, y que está representado por los reactivos 5 y 9 del cuestionario. aunque este factor no se encuentra en las premisas fundamentales, se utiliza de manera implícita en los conceptos de la teoría, concretamente en los que se denominan “interacción enfermera-paciente”, “campo fenomenológico” y “relación de cuidado transpersonal” (7-9). 259 construcción de una escala de evaluación de la ética en el cuidado a pacientes... l roberto lagunes-córdoba, maría antonia hernández-manzanares elaborado por profesionales mexicanos, sólidamente validado con análisis factorial y basado en un enfoque teórico de amplia utilización. la confiabilidad general del mismo es alta, lo que permite que sean los pacientes quienes evalúen el comportamiento ético y humanístico del personal de enfermería que proporciona el cuidado que reciben. referencias 1. nightingale f. letter to englishwoman review; 1869. pp. 15. 2. salcedo-álvarez ra, alba-leonel a, zarza-arizmendi md. la enseñanza de la ética en enfermería como un coadyuvante en la calidad del cuidado. revista conamed 2008;13:39-42. 3. jiménez vmc, ortega vmc, cruz ag, quintero vmm, mendoza re, antunes drr et al. satisfacción del usuario como indicador de calidad. revista mexicana de enfermería cardiológica 2003;11(2):58-65. 4. oncology nursing society. nurses’ responsability to patients requesting assistance in hastening death. oncol nurs forum 2010;37(3):249-250. 5. comisión interinstitucional de enfermería. perfiles de enfermería. méxico: secretaría de salud; 2005. 6. davis a. el cuidar y la ética del cuidar en el siglo xxi: qué sabemos y qué debemos cuestionar. recuperado de: http:// www.coib.org/uploadsbo/noticia/documents/anne%20davis%20castell%c3%a0_def.pdf. [consultado el 10 de julio de 2011]. collegi oficial infermeria de barcelona. 7. watson j. nursing, the philosophy and science of caring. 2 ed. boulder: associated university press; 1991. 8. watson j. nursing, human science and human care. a theory of nursing. new york: national league of nursing; 1988. 9. walker ca. coalescing the theories of two nurse visionaries: parse and watson. journal of advanced nursing 1996;24:988-996. 10. kozier b, erb g, berman a, snyder s. fundamentos de enfermería. conceptos, aplicaciones, prácticas. 7 ed. méxico: mcgraw hill; 2005. 11. larson p, ferketich. patients satisfaction with nurses caring during hospitalization. j nurs res 1993;15(6):690-707. 12. gonzález-ortega y. instrumento cuidado de comportamiento profesional: validez y confiabilidad. aquichan 2008;8(2):170-182. 13. fenton mv. development of the scale of humanistic nursing behaviors. nurs res 1987;36(2):82-7. 14. han ss, kim j, kim ys, ahn s. validation of a korean version of the moral sensitivity questionnaire. nurs ethics 2010;17(1):99-105. 15. weis d, schank mj. development and psychometric evaluation of the nurses professional values scale-revised. j nurs meas 2009;17(3):221-31. 16. acevedo pg, castañeda hh, garza hr, gonzález sf, meléndez mc, patiño mml et al. adaptación y validación de un instrumento para medir la satisfacción con el cuidado de enfermería en usuarios de servicios hospitalarios. foro universitario “investigación, sociedad y desarroll. avances y perspectivas; 2008. pp. 154-158. 17. poblete-troncoso mc, valenzuela-suazo sv, merino jm. validación de dos escalas utilizadas en la medición del cuidado humano transpersonal basadas en la teoría de jean watson. aquichán 2012;12(1):8-21. 18. cossette s, cote jk, pepin j, ricard n, d’aoust lx. a dimensional structure of nurse-patient interactions from a caring perspective: refinement of the caring nurse-patient interaction scale (cnpi-short scale). j adv nurs 2006;55(2):198-214. 19. muñiz j. teoría clásica de los tests. 2 ed. madrid: pirámide; 1998. 20. pérez-gil ja, chacón ms, moreno rr. validez de constructo: el uso de análisis factorial exploratorio-confirmatorio para obtener evidencias de validez. psicothema 2000;12(supl. 2):442-446. 260 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 21. anastasi a, urbina s. tests psicológicos. 7 ed. méxico: prentice hall; 1998. 22. hernández pas. algunas consideraciones acerca de los valores humanos y el profesional de enfermería. aquichan 2001;1(1):18-22. 23. american association of colleges of nursing. essentials of college and university education for professional nursing. washington, d.c.; 1986. 24. haigh c, johnson m. attitudes and values of nurse educators: an international survey. int j nurs educ scholarsh 2007;4(1):1-11. 25. cerda lj, villaroel pl. evaluación de la concordancia interobservador en investigación pediátrica: coeficiente de kappa. rev chil pediatr 2008;79(1):54-58. 26. pett ma, lackey nr, sullivan jj. making sense of factor analysis: the use of factor analysis for instrument development in health care research. usa: sage publications; 2003. 27. montoya so. aplicación del análisis factorial a la investigación de mercados. caso de estudio. scientia et technica 2007;13(35):281-286. 28. garcía cch. la medición en ciencias sociales y en la psicología. en: landeros hr, gonzález rmt (comps.). estadística con spss y metodología de la investigación. méxico: trillas; 2006. 29. rogers c. psicoterapia basada en el cliente. argentina: paidos; 1979. 30. aiken l. tests psicológicos y evaluación. 11 ed. méxico: pearson educación; 2003. anexo escala de evaluación del comportamiento ético del personal de enfermería el presente cuestionario tiene el objetivo de conocer si la enfermera que lo ha atendido se ha comportado de manera ética y profesional al proporcionarle cuidados. por favor, lea cuidadosamente cada una de las siguientes preguntas y marque la opción de respuesta que describa mejor el comportamiento de la enfermera que lo ha atendido. le pedimos atentamente que sea lo más sincero(a) posible en su respuesta. 1. ¿la enfermera acude amablemente a su llamado? 2. ¿la enfermera avisa inmediatamente lo grave que está un paciente? 3. ¿la enfermera le explica cómo debe tomar sus medicamentos? siempre frecuentemente rara vez nunca siempre frecuentemente rara vez nunca siempre frecuentemente rara vez nunca 261 construcción de una escala de evaluación de la ética en el cuidado a pacientes... l roberto lagunes-córdoba, maría antonia hernández-manzanares 4. ¿la enfermera procura tratarlo como persona? 5. ¿la enfermera le brinda palabras de apoyo durante su hospitalización? 6. ¿la enfermera le permite hablar de su padecimiento? 7. ¿le parece que la enfermera se comunica bien con todos sus pacientes? 8. ¿la enfermera acude de buena gana cuando debe realizarle un procedimiento? 9. ¿la enfermera le comunica rápidamente al médico cuando sufre un dolor o molestia? 10. ¿la enfermera tiene buenas relaciones con el resto del personal del hospital? siempre frecuentemente rara vez nunca siempre frecuentemente rara vez nunca siempre frecuentemente rara vez nunca siempre frecuentemente rara vez nunca siempre frecuentemente rara vez nunca siempre frecuentemente rara vez nunca siempre frecuentemente rara vez nunca 262 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 11. ¿la enfermera es respetuosa cuando debe realizarle un procedimiento? 12. ¿la enfermera se acerca a los pacientes que están infectados? 13. ¿considera que la actitud de la enfermera contribuye a su mejoría? observaciones: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ muchas gracias por su colaboración. siempre frecuentemente rara vez nunca siempre frecuentemente rara vez nunca siempre frecuentemente rara vez nunca 01. editorial -02.aquichan año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 4 a historia del programa de enfermería de la universidad de la sabana, que en el pasado mes de julio cumplió su décimo aniversario, es corta pero cargada de anécdotas y recuerdos, de esfuerzos y trabajo, de satisfacciones y sueños realizados, pero especialmente de esperanzas y metas por cumplir, y de proyectos educativos por realizar, que permitirán a quienes egresan de sus aulas ser líderes en la transformación y desarrollo del país, apoyándose siempre en la formación recibida, conscientes de su compromiso social y poniendo al servicio de los demás sus conocimientos y su espíritu de juventud. aquichan, la revista que publicamos como recuerdo de este décimo aniversario, contiene algunos artículos que ilustran al lector sobre los aspectos fundamentales de la historia del programa, y sobre lo que fue, es y seguirá siendo la esencia de la profesión, es decir, el cuidado de enfermería. hay otros cuyo contenido va dirigido hacia el proceso educativo, y dentro de él la formación de actitudes, valores y la ética en enfermería, así como la necesidad de practicar sus principios, máxime si se habla de un proceso de formación integral, como es el caso de nuestro programa. dentro de sus páginas hay también el espacio para quienes desde afuera han visto el programa crecer y desarrollarse, y además un espacio especial para aquellas personas que en su condición de altas directivas de la universidad fueron en su momento sus idearios, y para los que en la actualidad son sus más fervientes impulsores y mantienen viva la ilusión y el compromiso de trabajo de aquellos que tenemos el honor y la satisfacción de pertenecer a su cuerpo docente. aquichan pretende perpetuarse y enriquecerse publicando anualmente los avances que en materia de enfermería se logren, y se convertirá en un estímulo para quienes con dedicación y esmero deseen publicar sus logros y experiencias. 44 51 validation and standardization.indd 44 erick landeros-olvera1 bertha cecilia salazar-gonzález2 juan carlos lópez-alvarenga3 validation and standardization of the weight control perceived self-effi cacy inventory in a mexican college population 1 nursing sciences phd. graduate research coordinator, school of nursing, benemérita universidad autónoma de puebla, méxico. erick_landeross@hotmail.com 2 ph.d. in nursing sciences, doctorate program , uanl nursing school, méxico. bceci195@hotmail.com 3 post-doctorate in population genetics . head of the clinical research division, hospital general de méxico, méxico. jclalvar@yahoo.com recibido: 12 de julio de 2013 enviado a pares: 4 de agosto de 2013 aceptado por pares: 18 de mayo de 2014 aprobado: 18 de diciembre de 2014 doi: 10.5294/aqui.2015.15.1.5 para citar este artículo / to reference this article / para citar este artigo landeros-olvera e, salazar-gonzález bc, lópez-alvarenga jc. validation and standardization of the weight control perceived self-efficacy inventory in a mexican college population. aquichan. 2015;15(1):44-51. doi: 10.5294/aqui.2015.15.1.5 abstract purpose: the purpose of the study was to evaluate if the weight control perceived self-efficacy inventory (wc-pse) is reproducible in a mexican college population. methods and materials: this is an observational and prolective process study. sixty subjects from two geographical regions of mexico were invited to answer the wc-pse on two separate occasions. findings: the content validity index was 0.96. the mean difference in the test retest was <4 in all domains; the intra-class correlation coefficient was >0.7; cronbach’s coefficient was α=.95. the inventory was sensitive to detecting differences according to gender and degrees of body mass index. conclusion: the wc-pse inventory is reproducible and sensitive for application to a mexican college population. keywords self-efficacy, diet, physical activity, exercise, nursing. (source: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 44-51 45 validation and standardization of the weight control perceived self-efficacy inventory in a mexican college population l erick landeros-olvera and others año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 44-51 validación y estandarización del inventario auto-eficacia percibida para el control de peso en población mexicana universitaria resumen objetivo: evaluar si el inventario auto-eficacia percibida para el control de peso (ap-cp) es reproducible en población universitaria. material y métodos: estudio de proceso, observacional y prolectivo. se invitó a 60 sujetos de dos regiones geográficas de méxico para responder el ap-cp en dos ocasiones por separado. resultados: el índice de validez de contenido fue de 0.96. en la prueba re-prueba, la diferencia promedio fue < 4 en todos los dominios, coeficiente de correlación intra-clase > 0.7; coeficiente α=0.95. el inventario también fue sensible para detectar diferencias de acuerdo a género y grados de imc. conclusión: el inventario ap-cp es reproducible y sensible para aplicarse en población mexicana universitaria. palabras clave auto-eficacia, dieta, actividad física, ejercicio (fuente: decs, bireme). 46 aquichan issn 1657-5997 validação e padronização do inventário autoeficácia percebida para o controle de peso em população mexicana universitária resumo objetivo: avaliar se o inventário autoeficácia percebida para controle de peso (ap-cp) pode ser reproduzido em população universitária. material e métodos: estudo de processo, observacional e proletivo. sessenta sujeitos de duas regiões geográficas do méxico foram convidados para responder ao ap-cp em duas ocasiões separadamente. resultados: o índice de validade de conteúdo foi de 0,96%. na prova re-prova, a diferença média foi de < 4 em todos os domínios, coeficiente de correlação intraclasse > 0,7; coeficiente α=0,95. o inventário também foi sensível para detectar diferenças de acordo com o gênero e graus de imc. conclusão: o inventário ap-cp pode ser reproduzido e é sensível para ser aplicado na população mexicana universitária. palavras-chave autoeficácia, dieta, atividade física, exercício (fonte: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 44-51 47 validation and standardization of the weight control perceived self-efficacy inventory in a mexican college population l erick landeros-olvera and others introduction obesity is a worldwide public health problem (1) and is considered a causal factor in the leading causes of death, such as cancer, diabetes and cardiovascular disease (2). the etiology of obesity is multifactorial, including mainly genetic and environmental factors related to weight gain. the environmental factors include overeating (impulsive and excessive consumption of large portions of foods rich in carbohydrates and saturated fat) and a sedentary lifestyle (with little or no physical exercise that is planned and performed with specific goals in mind, such as fitness and good health) (3). evidence shows healthy nutrition and exercise are decisive to preventing and treating obesity (4). however, efforts to treat obesity commonly fail and, if weight is lost, it is regained in most cases (5, 6, 7). on the other hand, cognitive aspects also exert an influence on the success or failure of weight control. the concept of selfefficacy (se), rooted in bandura’s social cognitive theory (8, 9), is defined a person’s confidence or conviction about being able to succeed in performing a particular task or behaving in a particular way. se serves as an important mediator in the intention to pursue healthy behavior (10). bandura recommends the use of specific se concepts when studying particular behavior such as physical activity or diet, especially when the research interest is on weight control. according to bandura, se includes four principles: a) performance accomplishments, defined by an individual’s success or failure in personal experiences; b) vicarious experience, meaning the influence of other people´s behavior or achievements on one’s personal experiences (social comparison); the more an individual resembles the leading model, the stronger the expectations of self-efficacy; c) oral persuasion, which is a suggestion from someone other than the person to generate a positive change in beliefs; and d) emotional activation, which is the intensity or type of emotional experience that informs the person of his or her competence. scientific evidence shows there is an association between a high perception of se, healthy eating, and adherence to exercise (11, 12, 13). several instruments to measure se in the anglo-saxon population have been developed and applied to college students (14, 15), adolescents (16), adults (17), and senior citizens (18). other populations that have been studied are patients with chronic degenerative diseases, including obesity (19, 20, 21, 22, 23, 24, 25). spanish speaking groups such as ruiz et al (26, 27). have validated the eating self-efficacy scale (eses) (28) and the weight efficacy life style questionnaire (wel) (29) in the spanish population. however, instruments developed for the latin american population are scarce. the conclusions of these same authors point to the need for more research targeted to obtaining new tools to evaluate se for weight control (24). roman et al (30) structured an inventory known as perceived self-efficacy for weight control (wc-pse). it assesses se in three domains: diet (overeating), exercise (planned physical activity), and physical activity (everyday activity or that performed with no physical fitness goals in mind). reports on this tool reveal validity and reliability when applied in venezuela. considering these results, it would be interesting to apply the wc-pse inventory in a culturally different context, such as that of mexico. since the wc-pse inventory has yet to be used in clinical studies and there are no reports of its application to an adult mexican population, it is important to apply the wc-pse and validate it in different geographical areas of latin america. therefore, the objective of this study was to determine if the wc-pse questionnaire is reliable for use in a mexican college population. content validity was established through a panel of experts, leading to adaptations that are culturally appropriate to the mexican context. internal consistency was determined using student’s paired t test between the test and re-test means and sensitivity by detecting differences among groups, based on gender and bmi. materials and methods study design and sample. we designed an observational and prolective process study (31). a conveniently-sized sample size of 30 participants was planned to obtain 80% statistical power and less than 5% type i error. however, it was decided to increase data variability to enhance external validity; accordingly, two geographical areas were used, thus doubling the number of participants analyzed and increasing the statistical power (n=60). college student subgroups were merged for the statistical analysis, as they showed no differences in gender frequency and bmi figures. 48 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 wc-pse inventory the wc-pse inventory is comprised of 37 items distributed into three domains: diet with 20 assertions, exercise with nine, and physical activity with eight. all 37 items were designed to be answered on a likert-type format, ranging from 1= “incapable of doing so” to 4= “certain to do so”. the maximum score possible is 148 points and the minimum is 37 points. in all three domains, the greater the values, the greater the perceived se. cronbach´s α coefficient was 0.88, 0.91 and 0.88 for diet, exercise, and physicalactivity domains, in that order. factor analysis showed the diet, exercise and physical-activity domains explained 17.2%, 14.5% and 12.2% of the variance, respectively. to verify these results and validation of the original inventory, please refer to román et al., (30) since some of the items were adapted for our study. procedures. content validation, item adaptation, application of the inventory and test re-test were included in our investigation. content validation. the original (30) inventory was sent to a panel of five experts (with ph.d degree) to ensure each item corresponded to the concept of se and to the domain of either diet, exercise or physical activity, and to ensure language clarity according to the social context of the studied population. each expert judged each item according to a likert –type scale ranging from zero (definitely not related) to four (extremely related). the following indexes were calculated: validity index by item (ive=∑ total items<3/total judges) validity criterion (cv=ivi/total items). content validity index (ivc=∑ total items> 3/total items reviewed by all judges). ivc values near 1.0 are considered acceptable. additionally, each expert reported the items he or she considered confusing. it was decided beforehand that if three or more judges considered an item to be confusing, it would be modified. inventory application. participants were selected on a convenience basis from two mexican universities (méxico city = subgroup 1 and monterrey = subgroup 2). they gave their consent in writing. one of the researchers explained the instructions on how to answer the inventory to all participants. the participants completed the inventory in their classrooms, in the presence of their professor and one of the researchers. since perceived se is a changing cognitive state, brief time intervals between evaluations (<2 weeks) are recommended (33). a second application or retest of the inventory was conducted with subgroup one (s1) two hours after the first application and without any notification. an academic activity unrelated to the inventory was conducted during the interval between the first and second applications. the retest for subgroup two (s2) was also applied without any notification, but 24 hours after the test. both subgroups were free to ask questions and to offer suggestions on how to enhance any of the items, if they felt they were confusing. statistical analysis. spss software, version19, was used to analyze the data. the data from the groups were considered as one group when analyzing reproducibility and sensitivity of the perceived se inventory in the diet, physical activity and exercise domains. therefore, the sample size was 60 participants. cronbach’s alpha coefficients were calculated for each domain and for the se inventory overall. reproducibility was evaluated using student’s paired t test between the test and re-test means. it was decided beforehand that, if the difference was more than four points, the instrument would be considered nonreproducible. this was based on the maximum value (32) of the domain with fewer items (physical activity), where 4 points represent 12.5% variability. test re-test concordance was calculated with the inter-class correlation coefficient, and complemented with a bland-altman graph (34). if the interclass correlation coefficient was greater than 0.7, the questionnaire would be reproducible and concordant, as previously decided. ethical considerations. the study was conducted according to the general health law on research matters (35). approval was obtained from the ethics committee of the univesidad autónoma de nuevo león school of nursing, under registration number faen-d-648. results sample description. the data were combined into one group, as no significant differences were found between the two groups of college students in terms of gender, age and bmi (p= 0.11, 0.53 and 0.64, respectively). women accounted for 71.7% of the 49 validation and standardization of the weight control perceived self-efficacy inventory in a mexican college population l erick landeros-olvera and others total sample (n=43). the mean age was 22+5.1 years (in a range of 18-49 years) and bmi was 23.9+4.5 (in a range 18-40). the content validity index (ivc) obtained in the study was 0.96, which was considered acceptable. the results are presented in spanish, so this version can be considered for groups of mexican immigrants residing in anglo saxon contexts. the expert validation yielded modifications in five items in the diet domain: “evitar comer alimentos chatarra (perros calientes, hamburguesas, granjero, etc.)” instead of “evitar comer alimentos chatarra (hot dogs, hamburguesas, fritos, etc).” “estar en una panadería y comprar un yogurt en vez de una pizza.” instead of “estar en una tiendita y comprar un yogurt en vez de un gansito®.” “pensar que realizando las tres comidas diarias bajas en grasa contribuyes a controlar tu peso,” instead of “realizar tres comidas diarias bajas en grasa contribuye a controlar tu peso.” “creer que respetando los horarios de comida contribuyes a controlar tu peso.” instead of “respetar horarios de comida contribuye a controlar tu peso.” “evitar dejar de cenar si te sientes bajo presión.” instead of “cenar aunque estés bajo presión.” there were no modifications in the physical activity and exercise domains. internal consistency. cronbach’s alpha coefficients for the diet, exercise, and physical-activity domains were calculated in the test and the respective results were 0.92, 0.96 and 0.93. the scale, in general, was α= 0.95 with 95% ic (interval=0.932 – 0.967). reproducibility. the mean time to fill out the wc-pse questionnaire was 9+4 minutes. table 1 shows the averages for the difference (delta δ) between the test and re-test ranged from zero to four; these dimensions were established previously (see the statistical analysis). regarding concordance, the interclass correlation coefficient was 0.93 (ci=0.885-0.959, p<.001) for the average of the measures by pairs, which was greater than the previously established 0.7. this indicates the wc-pse has temporal stability. bland-altman’s correlation graphs corroborate this finding (graphs 1 and 2). sensitivity. the statistical analysis was able to detect differences between gender (feminine vs. masculine) in the se overall (114.6+1.2 vs. 125.1+9.7, t= -2.7, p=.007) and in the exercise domain (26.1±5.8 vs. 31.4±4.4, t= -1.3, p=.001). for physical activity, it was at the limit (26.8±4 vs. 29±3, t= -1.9, p=.053), and no differences were observed as to the diet domain (61.5±7.9 vs. 64.5±7.5, t= -1.3, p=.183). finally, we analyzed the sensitivity of the inventory associated with the bmi spectrum(graph 3), noting that the larger the bmi, the smaller the se score. discussion in this study, we determined the wc-pse questionnaire possibly is reliable for application to the mexican college population. the results of the study support this, at least in the selected sample. content validity and adaptation were done by a panel of se experts. the inventory also showed some sensitivity in detecting the difference between male-female and according to body mass index. the content validity performed by experts suggested five items in the original inventory that needed to be modified to adapt them into the mexican cultural context. with the modifications, we obtained an adequate internal consistency with cronbach’s alphas coefficients greater than 0.9 in each inventory domain, similar to those obtained in the original validation (30). however, the se results overall must be viewed with caution, since coefficients above 0.95 suggest redundancy in the items in the inventory. on the other hand, the wc-pse is reproducible and concordant in the test re-test for all domains, as well as for se overall. the degree of concordance obtained shows the inventory has temporal stability. this also is supported with the bland-altman method, which represents the differences between two measurements compared to their means. the inventory is sensitive in detecting differences in se overall and in the exercise domain, according to gender and bmi. these differences could help to conduct future projects where se is crucial to adherence to weight reduction treatment, as suggested by the work of nies (11), olivari (12) and sánchez (13). despite se perception being a cognitive aspect that does not necessarily represent action or performance of a particular behavior, it could be a crucial element as a predictor, and the wc-pse inventory could be used in experimental designs to measure the response of specific population groups to treatment or intervention aimed at changing habits in the interest of weight control. one of the most important aspects in the wc-pse inventory is precisely the fact that it includes the dimensions of diet, exercise, and physical activity, which are undoubtedly aspects related to weight control, according to systematic reviews (4). 50 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 the main limitations of the study are the following:, a) it was conducted in a college population, so the results cannot necessarily be generalized to other populations in mexico; b) a convenience sample is adequate to analyze the instrument, but cannot be used to make inferences for a general population, even a college one. the results of this study contribute to having a reliable instrument for the mexican adult population, since there are no reports of the wc-pse questionnaire being applied in the latin-american population outside of its original design. use of the inventory could contribute further to its validation in different groups and perhaps its generalizability. in future work, the inventory might be applied to overweight or obese subjects to identify the way se expectations influence modifying dietary habits and physical activity patterns through time. from an experimental point of view, groups of obese persons could be compared to different types of exercise or diet , and se could be used as a result variable and to show if scores after and before the intervention increase for the experimental group. we conclude this study shows the wc-pse inventory is reproducible and concordant for the mexican college population in question. its internal consistency is acceptable and it is sensitive to differences between gender and bmi. the authors state no source or institution has benefitted in terms of money, assets and hospitality or study grants. accordingly, there is no conflict of interest. references 1. organización mundial de la salud. descriptive note n°311, may 2012. [cited may 12, 2013]. available from url:http:// www.who.int/mediacentre/factsheets/fs311/es/ 2. wandell pe, carlsson ac, theobald, h. the association between bmi value and long-term mortality. international journey obesity 2009; (33):577-82. 3. american college of sport medicine. guidelines for exercise testing and prescription (8th ed.). philadelphia, usa: lippincott williams& wilkins; 2010. 4. shaw k, o’rourke p, del mar c, kenardy j. psychological interventions for overweight or obesity. the cochrane collaboration 2009; (1):1-76. 5. gallegos mj, lópez ajc, gonzález bj. dissertation for an advanced degree in endocrinology. resultados de el tratamiento quirúrgico de la obesidad mórbida. instituto nacional de ciencias médicas y nutrición salvador zubirán and unam school of medicine, 2000. 6. arellano ms, bastarrachea r, bourgues rh, calzada lr, dávalo, ia, garcía, ge, et al. la obesidad de méxico. posición de la sociedad mexicana de nutrición y endocrinología. grupo para el estudio y tratamiento de la obesidad (group for the study and treatment of obesity); 2004. 7. van bm, van me, astrup va, finer n, van gl, hilsted j, et al. leisure-time activity is an important determinant of longterm weight maintenance after weight loss in the sibutramine trial on obesity reduction and maintenance. saris for the storm study group (storm trial). am j clin nutr 2003; (78):209–14. 8. bandura a. social foundations of thought and action. a social cognitive theory. new jersey. usa: prentice hall, 390-453; 1986. 9. bandura a. recycling misconceptions of perceived self-efficacy. cognitive therapy and research 1984; (8):231-55. 10. schwazer r. self-efficacy in the adoption and maintenance of health behaviors: theoretical approaches and a new model. 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[cited december 1, 2011] available from url:http://www.salud.gob.mx/unidades/cdi/nom/compi/rlgsmis.html 10. ejercicio de enfermer™a ok 49 resumen este artículo hace referencia a los resultados de la investigación sobre el ejercicio liberal de la enfermera(o) en el área materno-infantil, donde se refleja cuál es el desempeño de la enfermera en el ejercicio liberal de su profesión en el área materno-infantil en santafé de bogotá. para realizar esta investigación se propusieron tres objetivos particulares: caracterizar el desempeño liberal de la enfermera en labores propias del área materno-infantil; identificar el papel que ha desempeñado la enfermera en el ejercicio liberal de la enfermería en el área materno-infantil; identificar las actividades que han realizado las enfermeras en el ejercicio liberal de la disciplina. la metodología utilizada corresponde a un diseño de tipo fenomenológico, descriptivo, analítico, cuya técnica central es el análisis de contenido. el universo del trabajo fueron las enfermeras que ejercen la enfermería en forma liberal en el área materno-infantil en santafé de bogotá. los hallazgos se presentaron acompañados de gráficas alusivas al tema, y se obtuvieron interesantes conclusiones. palabras clave ejercicio liberal, enfermera, rol en enfermería. abstract this article makes reference to the results of the nurse’s liberal practice in maternal-child area, showing the performance in the liberal practice of this profession in maternal-child area at santafé de bogotá. to develop this research, three objetives were proposed: characterize liberal nurse’s performance at maternal-child area; identify role of nurse practice in maternal-child area; nurse’s activities performed at liberal practice at of the discipline. the methodology has a phenomenological, descriptive, analytical design, with a central technique on content’s analysis. the nurse working in a liberal way in maternal-child services at santafé de bogotá, was the work’s universe. the results of the research are presented with graphics related to the theme obtaining interesting conclusions. key words liberal practice, nurse, and nurse role vilma cenit fandiño osorio profesora catedrática facultad de enfermería • universidad de la sabana 1 l.e., m.a., ph.d. profesora titular d.e. profesora emérita, universidad nacional de colombia. investigación realizada con la asesoría de la profesora ana luisa velandia1 año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 50 la investigación está dividida en tres grandes partes: la primera es el marco conceptual, donde se describen las circunstancias que motivaron a la investigadora a plantearse este estudio; la segunda es el marco referencial, en el cual se apoya la investigación, sustentada en una gran búsqueda de documentos, y la tercera es el marco metodológico, donde se explica cómo se desarrolló la investigación. finalmente, se presenta el análisis de los hallazgos. se espera que la presente investigación constituya un aporte para las enfermeras que estén buscando nuevos horizontes y una forma distinta de desempeñarse como profesionales de la salud. marco conceptual área problemática para construir el futuro de la enfermería es indispensable contar con el conocimiento logrado, el cual permite una reorganización laboral y gremial que dé a conocer los espacios de desempeño que las enfermeras(os) han obtenido, para que sirvan de guía a las(os) profesionales y las(os) estudiantes y orienten la carrera y la profesión en busca del cambio de las acciones de enfermería, a fin de satisfacer las necesidades de la sociedad y los requerimientos normativos. con el actual sistema de salud se crearon nuevas y mayores oportunidades para las(os) profesionales de enfermería; además, se promovió un mayor reconocimiento social y se incentivó a las(os) jóvenes a estudiar enfermería y a ejercerla como práctica liberal, con autonomía y autocontrol. para las enfermeras(os), el trabajo liberal es una alternativa legal de la profesión, a la cual tienen derecho en razón del título obtenido, lo que despierta interés informativo acerca de cómo está llevándose a cabo este trabajo y de qué manera puede fortalecer al gremio. esto acrecienta los conocimientos en las áreas de desempeño de la enfermera(o). el trabajo liberal requiere todas las destrezas, habilidades, capacidades, actitudes y aptitudes desarrolladas al máximo, para lograr el éxito en el ejercicio profesional. además, es fácil suponer que en enfermería, si se logra que un grupo cada vez mayor de enfermeras(os) se desempeñen liberalmente, se ganará un mejor cuerpo de conocimientos, que a su vez sustentarían el carácter liberal. varios años ha recorrido la enfermería, hasta llegar al punto en el que se encuentra hoy, con un bagaje de conocimientos que contribuye a tener un juicio y un fundamento para modificar los actos según las situaciones. l presente estudio tiene como centro el ejercicio liberal de las enfermeras en el área materno-infantil en santafé de bogotá, con el objetivo de identificar su desempeño en este campo. 51 ejercicio liberal de la enfermera(o) en el área materno infantil el presente estudio surge por el gran interés de conocer cómo está realizándose el ejercicio liberal, cómo se puede participar en él y asumirlo como una alternativa; esto a través de una mirada hacia lo que se ha hecho, para constituir una base más sólida al trabajar de manera autónoma e independiente. la enfermería es una profesión con una amplia gama de conocimientos y habilidades, que le permiten ayudar a la sociedad y lograr un amplio cubrimiento poblacional, de calidad y cantidad, acorde con las necesidades sociales. por esto, el panorama que se vislumbra para la enfermería llama a reflexionar acerca del papel que la enfermera debe desempeñar en el desarrollo y evolución de la profesión, y respecto de la oportunidad de adelantar un trabajo creativo propio, que desglose el camino hacia el ejercicio liberal de la profesión y permita retomar la función que le corresponde a la enfermera como cuidadora directa de las personas que la requieran. el estudio está orientado al área materno-infantil, por varias razones: la primera, por ser esta el área de interés de la investigadora y contar con reflexiones frente a su formación, en un marco conceptual de cuidadora; la segunda, porque esta área sigue siendo muy significativa para el país, en términos de morbimortalidad, y demanda del cuidado de la salud para la prevención de la enfermedad y la promoción de la vida. por último, vale la pena resaltar que el estudio se realiza en la ciudad de bogotá, porque en este sitio hay un desarrollo significativo de la enfermería, que permite ver con claridad el desempeño del ejercicio liberal en un área determinada. objetivo general identificar cuál es el desempeño de la enfermera(o) en el ejercicio liberal de su profesión, en el área materno-infantil en santafé de bogotá. objetivos específicos caracterizar el desempeño liberal de la enfermera(o) en las labores propias del área materno-infantil. identificar el papel que ha desempeñado la enfermera(o) en el ejercicio liberal de la enfermería en el área materno-infantil. identificar las actividades que están realizando las enfermeras(os) en el ejercicio liberal de la disciplina. justificación este es un estudio novedoso, porque está encaminado a conocer el desempeño liberal de la enfermera(o) en el área materno-infantil, y al respecto no se ha trabajado con detenimiento en colombia. el estudio es de interés, porque conocer el ejercicio liberal de la enfermería constituye una base para identificar las grandes posibilidades que tiene la profesión, al crear una visión de cómo ha sido y cómo es el ejercicio de la enfermería liberalmente, según las políticas actuales de salud, que le han dado una connotación más amplia y libre a los profesionales de la salud. es indispensable tomar conciencia de que el ejercicio liberal de la enfermería acarrea muchas responsabilidades, así como un amplio reconocimiento, por lo cual vale la pena el reto. se necesita identificar el proceso de su desarrollo, para intervenir en la construcción del futuro deseado, explorando la posibilidad de innovaciones y de generar más conocimientos, que contribuyan al crecimiento de la enfermería, con el fin de adecuar el ejercicio profesional a las necesidades de los usuarios. el bienestar materno-infantil ha sido preocupación y necesidad de todos los tiempos, por representar un grupo bastante grande por atender, y especialmente por ser una población con alta vulnerabilidad, derivada de la exigencia de los procesos de reproducción, crecimiento y desarrollo. además, a nivel mundial, constituye uno de los mayores retos para los trabajadores de la salud, por considerarlo como el mejor indicador del nivel de vida y desarrollo social de los pueblos, y es allí donde podemos encontrar una gran acción profesional, desde el punto de vista de administrar cuidado, educar e investigar, a cualquier nivel de prestación de servicios, donde la enfermera ha incursionado con gran participación e importancia en el ámbito nacional, siendo parte de la solución en la disminución de las tasas de morbimortalidad materno-infantil. para este estudio y en el contexto colombiano: surgimiento del estudio problema ¿cuál es el desempeño de la enfermera(o) en el ejercicio liberal de su profesión, en el área materno-infantil en santafé de bogotá? definición de conceptos año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 52 enfermera(o): es el profesional responsable de la atención en enfermería, que promueve, conserva o restablece la salud del individuo, la familia y la comunidad, en el área materno-infantil. posee conocimientos y capacidades, aprecia y conoce sus habilidades, e integra sus conocimientos académicos y personales para ejercer la enfermería. ejercicio liberal: desempeño de las(os) profesionales de enfermería, de forma independiente y autónoma, intelectual y financieramente, el cual genera su propia remuneración económica y su estabilidad profesional. área materno-infantil: área en la que las enfermeras(os) realizan sus labores liberalmente, encaminadas a la atención de la mujer, la madre, el recién nacido y/o los niños. con base en la información encontrada, la mayoría de origen extranjero, se establece un marco referencial, que permite la comprensión de la evolución y el desempeño de la práctica liberal de la enfermería en el área materno-infantil, en santafé de bogotá. ejercicio profesional de la enfermería desde que empezaron a establecerse los principios básicos de la enfermería, cada vez era más notorio que sus servicios deberían estar a disposición de todos los enfermos, sin importar el estado económico o las creencias. la distinción entre la enfermería y la beneficencia reconocía la importancia de los registros y la relación profesional con el cuerpo médico, y subrayaba la importancia de la colaboración con los grupos de servicios a la comunidad, para brindar la mejor atención a los pacientes. en 1886 se crearon, en boston y filadelfia, las primeras organizaciones de enfermería, para brindar atención a todos los enfermos, sin considerar su capacidad de pago. las enfermeras obedecían las órdenes médicas, aplicaban medicamentos, registraban signos vitales y enseñaban higiene al paciente y a su familia3. para el logro de un ambiente laboral adecuado, la enfermera(o) enfrenta la necesidad de poner en práctica sus valores profesionales, en un medio burocratizado; así, establece la necesidad de la continuidad de sus estudios para el desarrollo efectivo de sus acciones profesionales, como las habilidades adquiridas con la experiencia: el dominio de labores rutinarias y la creatividad para desarrollar innovaciones en la prestación de los servicios. para esto es necesario generar buenas relaciones con los usuarios, los colegas y el mismo medio, y conocer la cultura del equipo de salud y las necesidades de servicios de la comunidad, para lograr un desempeño sobresaliente4. para algunas enfermeras, el ejercicio liberal es una labor que brinda remuneración económica adecuada y cierto grado de satisfacción; por otro lado, exige un profundo y permanente conocimiento de propósitos y dirección, y no solo un conjunto de objetivos o de normas. brindar atención en enfermería liberal requiere un auténtico respeto a la dignidad y autonomía del ser; consiste en atender, ayudar, confortar y guiar, con la preocupación fundamental por los demás, idealizando el servicio mediante el propósito profesional con autonomía5. la(el) enfermera(o) con autonomía es aquella persona que controla las funciones en su ambiente de trabajo; esto implica independencia, disposición a correr el riesgo y responsabilidad de los propios actos, así como autodeterminación y autorregulación. el concepto de profesional incluye responsabilidad legal y moral en cuanto a los actos del individuo, con la autonomía que le brinda libertad y autoridad. puede realizar un juicio para tener buenas decisiones en la práctica; es decir, la autonomía del poder6. el desempeño de la enfermería liberal implica un alto grado de responsabilidad, en forma competente y segura, en marco referencial 3 moore, e. j. “visiting nursing”. am. j. nurs., pp. 17-21, octubre, 1990. 4 kramer, s. reality shock. why nurses leave nursing, st. louis, pp. 159-160, 1974. 5 bates, b. doctor and nurse. changing roles and relations, new england, pp. 124-129, julio, 1970. 6 fiesta, j. law and liability for nursing, new york, john wiley y sons, p. 1, 1983 53 ejercicio liberal de la enfermera(o) en el área materno infantil el cual la enfermera puede ser legalmente responsable, en caso de producirse un daño o sufrimiento innecesario. la enfermera(o) es legalmente responsable de sus actos; por lo tanto, debe ser razonable y prudente, de acuerdo con las circunstancias; cuanto más conocimientos y experiencias tenga, mayor deberá ser la responsabilidad7. ser una enfermera(o) profesional implica cambiar y crecer en diversas etapas de la carrera. la enfermera(o) en ejercicio liberal se socializa y resocializa, mediante la experiencia educativa y ocupacional; adquiere conocimientos, creencias y habilidades, que al integrarse a las normas legales y morales caracterizan el servicio profesional competente y comprometido de una enfermera(o) y su trabajo liberal. aspectos históricos y legales históricamente, la evolución de la enfermería se ha visto enmarcada por un amplio desarrollo sociológico y educativo, que ha llevado a un aumento de los conocimientos y ha forjado un cuerpo teórico que fortalece la profesión y la salud. en estudios realizados, se ha encontrado que para un mejor desempeño liberal de las enfermeras se hace necesaria una especialización y una continua actualización de conocimientos, así como la renovación de los mecanismos para la práctica. por lo general, las enfermeras trabajan en sociedad con colegas y profesionales de otras ramas de la salud; así forjan una atención más directa a los pacientes, y brindan una enfermería con mayor satisfacción profesional8. a través de los tiempos, a la enfermería se le ha venido dando el reconocimiento que se merece, por su papel en la reconstrucción del sistema de salud, así como el fortalecimiento de programas de prestación de servicios de salud a todos los niveles, y la gran entereza y compromiso con que se ejercen las distintas actividades; por esto, en los planes de desarrollo en salud es el profesional quien lleva el liderazgo en la ejecución de los programas. en la lucha por una mejor y más amplia identificación de posibilidades de desarrollar y extender el cuerpo de conocimientos de la enfermería, cuando se habla del trabajo liberal, es indispensable conocer los principios legales y el código de ética que guían la conducta de los profesionales en su desempeño. historia social de la evolución de la enfermería materno-infantil la historia del ejercicio liberal es común para todas las áreas de enfermería; sin embargo, a continuación se hace una revisión, para mirar lo pertinente al área materno-infantil. se toma como punto de partida la aparición del primer curso para preparar enfermeras, realizado en cartagena en 1903, dentro del marco de un desarrollo socioeconómico del país, que repercutió sobre la salud y la educación, y teniendo en cuenta que en 1894 aparece la reglamentación de la medicina en colombia, y en el artículo 8 de este año se hace referencia a que “las comadronas no podrán ejercer su arte sin tener un certificado de idoneidad, expedido por una facultad de medicina establecida en el país”, y el artículo 12 se refiere a que “son condiciones para obtener el certificado saber leer y escribir y haber asistido a la clínica de maternidad por lo menos por un año”. según la revista de medicina número 303 de 1905, el artículo 7 de este año dice: “podrán ejercer como comadronas las enfermeras que presenten certificado de dos o más doctores en medicina o cirugía”. se encontró así la forma de legalizar y formalizar la educación femenina, que hasta el momento había tenido como tradición el cuidado de la parturienta, los niños y, en general, la familia. aquí es importante recordar, como se enunció anteriormente, al grupo de seis señoritas que en 1915, con el diploma de “idoneidad en medicina y enfermería”, conferido en bogotá, organizaron un centro de enfermeras en una farmacia del centro de la ciudad. se podría decir que fue allí donde se inició el trabajo independiente o liberal de las enfermeras. de igual forma, fue significativo, como ya se dijo, el estudio de 1965, de recurso humano para la salud y educación médica en colombia, donde se “encontró que de las enfermeras, solo el 4.3% laboraban como enfermeras de planta, es decir, en cuidado directo, y menos del 1% estaban dedicadas al ejercicio privado”9. las enfermeras prestaban atención ambulatoria, en ejercicio liberal o privado, con nuevas formas de ejercicio profesional, como la atención a domicilio, el cuidado en casa, las instituciones de atención ambulatoria y la promoción de elementos de uso profesional, no solo de enfermería sino de otras profesiones de la salud. algo que contribuyó a ampliar el papel de las enfermeras fue la reorganización del sistema nacional de salud, en 1975, cuando se establecieron como responsables de todos los programas materno-infantiles, situación que llevó a orientar el perfil de las enfermeras hacia esta área en especial. 7 creghton, h. law every nurse should know, filadelfia, pp. 74-75, 1981. 8 martínez, m. “la enfermera mexicana: un estudio sociológico”, rev. inv. y edu., vol. vi, pp. 11-20, marzo, 1988. 9 velandia, ana luisa. historia de la enfermería en colombia, ediciones u.n.c., p. 121, 1995. año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 54 “según el estudio nacional de enfermería (ene), 72 enfermeras hacían la práctica liberal en 31 instituciones especiales para tal fin; de estas, el 71% se dedicaban a servicios ambulatorios, domiciliarios y gerontológicos; el 19.3%, a cuidados intermedios y de hospitalización, y el 9.7%, a asesoría y educación (ministerio de salud, 1989)”10. perspectivas actuales para el ejercicio liberal de la enfermería en el área materno-infantil la prestación de servicios de salud a la población continúa siendo un problema complejo para todos los gobiernos; el sector salud emplea un gran número de personal, y el de enfermería es un factor importante. estudios recientes muestran que la fuerza de trabajo en salud constituye aproximadamente el 70% del presupuesto global del sector11. el ambiente económico, social y cultural de los países es distinto, así como el desarrollo del ejercicio de la enfermería. parece no haber relación directa entre el avance socioeconómico y el alcance de la enfermería; en algunos países en desarrollo, por ejemplo, las enfermeras administran los servicios de atención primaria en salud, pero en otros se hace poco uso de la profesión. en algunos países industrializados tienen limitada la acción, y están mal preparadas, mientras que en otros las enfermeras están muy desarrolladas12. la calidad del trabajo de enfermería puede mantenerse con el monitoreo y la reglamentación de la práctica, la programación de educación continua, con estructura y legislación apropiada, apoyada por la investigación de procesos y resultados del cuidado de enfermería, que respondan a las reformas de salud de la nación.13 según las perspectivas futuras determinadas por los sectores político, económico y de salud, las profesionales de la enfermería tienen la oportunidad de fortalecerla como ciencia activa, con una prestación de servicios más amplia, ya que la misma sociedad, en medio de sus necesidades, lo requiere; por lo tanto, los profesionales egresados deben tomar conciencia de la necesidad de una constante actualización para continuar el liderazgo que les pertenece, el cual lo exige la comunidad de la salud. por ello, deben formarse unas enfermeras(os) de mente activa, crítica, analítica y constructivista, con deseos de liderar grandes masas, mediante el fortalecimiento de una sana competencia, que tienda al perfeccionamiento de la disciplina. la enfermera(o) de la nueva era deberá ser responsable, comprometida, emprendedora de grandes cambios, a través de los cuales busque la proyección de la ciencia, con la motivación para crear y perfeccionar el conocimiento; para ello deberá ser crítica y analítica, de modo que tome decisiones acertadas, acordes con la realidad que vive el país; en consecuencia, deberá tener en cuenta las leyes que rigen la nación y evitar alejarse de la realidad, para que todos los proyectos que emprenda den origen a un marco propio de la enfermería. con las nuevas exigencias de la ley colombiana se hace necesario continuar el fortalecimiento del conocimiento y mejorar la práctica profesional; así, lo adecuado es fomentar la actualización y el conocimiento de innovaciones, para mantener el servicio con principios de eficiencia y eficacia, y de gran competitividad entre el gremio, los diferentes profesionales de la salud y la población. los cambios en pro del desarrollo deberán ser acordes con las políticas de salud y coherentes con el desarrollo social y tecnológico. por ello la enfermera(o) deberá tener un espíritu empresarial, para que optimice los recursos, clasifique las necesidades prioritarias de las grandes mayorías y disminuya así los costos en el ámbito social; a través de los tiempos, este control se le ha delegado a la enfermería, cuyas profesionales poseen las habilidades propias del caso; por esto se le da el voto de confianza a las enfermeras(os), de lograr el trabajo liberal de manera exitosa, positiva y satisfactoria. el desempeño de las enfermeras(os) en el ámbito liberal es muy amplio, ya que puede variar desde las mismas asesorías, pasar por la consultoría y las visitas domiciliarias, hasta llegar a los diseños, la ejecución y la evaluación de estudios de factibilidad, proyectos, programas y protocolos, a cualquier nivel de atención de la salud14. para ello, las estrategias deberán ser constantes y basadas en la realidad, identificando las necesidades en los ámbitos educacional, asistencial e investigativo. la gestión de la enfermería será importante en la medida que se presente, se dé a conocer su efectividad y se socialice. en las expectativas de la población sobre un buen cuidado y quién lo debe prestar, desempeñan un papel importante las asociaciones académicas y gremiales, como organismos de información influyentes en la aceptación cultural. 10 velandia, ana luisa. historia de la enfermería en colombia, ediciones u.n.c., p. 178, 1995. 11 organización mundial de la salud. fortalecimiento de la enfermería y la partería, resolución wha 48.8. 12 organización mundial de la salud. comité de expertos. el ejercicio de la enfermera, ginebra, 1996. 13 organización mundial de la salud. grupo de estudio. la enfermería mas allá del año 2000, ginebra, 1994. 14 velandia, ana luisa. “análisis crítico de las áreas de desempeño del profesional de enfermería”, rev. avances en enfermería, bogotá, julio-diciembre, 1995. método para el presente trabajo se utilizó la metodología cualitativa, con un estudio descriptivo-analítico. a través del método descriptivo se da a conocer cómo se está desempeñando la enfermera en su ejercicio liberal y bajo qué condiciones. el análisis de contenido pretende hacer una interpretación de las expresiones en torno al fenómeno estudiado, el ejercicio liberal en el área maternoinfantil en santa fe de bogotá. población los sujetos de estudio fueron dieciséis enfermeras, que en la actualidad ejercen la profesión liberalmente en el área maternoinfantil, y tres que la practicaban con anterioridad en santafé de bogotá. la información se recolectó en el primer semestre de 1998. el tamaño de la muestra se dio por la saturación en las respuestas en los ítems de la entrevista; cada una de las enfermeras participantes fueron referidas por las colegas que conocían su trabajo liberal, teniendo en cuenta que este debería ser ejercido hacia la mujer gestante, el recién nacido o el niño. en total se entrevistaron diecinueve enfermeras. cada una tuvo la misma probabilidad de participar en el estudio. 55 ejercicio liberal de la enfermera(o) en el área materno infantil el trato con los individuos deberá estar encaminado al conocimiento de su estilo de vida, dentro de su contexto sociopolítico y cultural, actividad que le resulta efectiva a la enfermera que desea actuar de forma más humanizada e integral, según los fundamentos de los valores, conocimientos y tecnología existentes15. existen varias modalidades de funcionamiento del ejercicio de la enfermería, que apuntan a un panorama favorecedor para la disciplina; esta se encuentra en un proceso creciente, que transita a través de los instrumentos de renovación operacional y teórica reflexiva, la cual direcciona la evolución de la profesión. la transformación de la práctica se dirige hacia lo preventivo, lo evitable, lo dinámico, integral y creativo, orientado a la reflexión, la negociación democrática. qué tanto puedo hacer por las personas y qué tanto desean que se realice por ellas, es un proceso complejo y difícil de establecer mediante estándares. el instinto de cuidador y la intuición deberán ser unos de los delineamientos de los conocimientos que se desea poner en práctica para la mejoría y el mantenimiento de la salud que quiere tener el individuo que a nosotros acude, labor que deberá ser cotidiana para la enfermera(o) que busca ofrecer un servicio individualizado, autónomo y, ante todo, humanizado16. este tipo de labor social se desarrolla en la intimidad de los individuos; por esto, el reconocimiento de las actividades de enfermería no se ha dado a conocer y, por ende, a la sociedad le es difícil exaltarlas; por ello, es necesario establecer la cultura del cuidador dentro del gremio, para que así se vea reflejado en los grupos sociales, y lograr un estatus más acorde con su condición profesional. “es necesario volver al origen lejano de aquella enfermería vinculada con lo instintivo de cuidar, para reconocer que el principal compromiso de la enfermería es el género humano, ya que es el que nos permite pensar el cuidado de la salud y de la vida y, por lo tanto, es a la población, a los grupos sociales, a la gente en su vida cotidiana, a la que se debe retornar el conocimiento desarrollado y las prácticas de cuidado, como fin último de ofrecer nuevos apoyos para el ejercicio individual y autónomo de su propio cuidado”17. en el título análisis de los hallazgos se enriquece este estado del arte, con citas de artículos relacionados con los temas que se plantean en el marco referencial del estudio. marco metodológico 15 escobar saldarriaga, isabel. “propuesta de un modelo conceptual para la práctica de la enfermería”, rev. investigación y educación en enfermería, septiembre, 1994. 16 giraldo molina, clara inés. “aproximación a las tendencias en la formación de enfermería en colombia”, revista inv. y educ. en enfermería, vol. xi, no. 2, septiembre, 1993. 17 gómez serrano, consuelo. tendencia de la profesión de enfermería, asociación colombiana de facultades de enfermería, memorias del i congreso nacional de actualización en enfermería, pp. 205-210, septiembre, 1992. con ayuda del instrumento establecido se logró realizar una entrevista semiestructurada, que permitió a los profesionales compartir sus experiencias en forma activa, lo cual contribuyó a lograr, en forma clara, las metas propuestas para la investigación. para poder establecer con mayor claridad la historia del trabajo liberal de la enfermera en bogotá, y tener más información, se diseñaron dos tipos de entrevistas, que permitieran incluir a personas que anteriormente laboraban liberalmente, y así obtener sus impresiones. previa autorización, se realizó la grabación de todas las entrevistas, para evitar perder cada una de las expresiones originales, que se utilizaron y se plasmaron en la investigación. durante la realización de las entrevistas se tomaron apuntes sobre lo que resaltaban las enfermeras, y luego, al ir transcribiendo los audiocasetes, se fueron ordenando las ideas, según las preguntas establecidas. año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 56 la técnica utilizada para la recolecla la técnica utilizada para la recolección de la información fue la entrevista semiestructurada, flexible en la secuencia y en la redacción de las preguntas. se elaboró una guía, que permitió conocer las opiniones de las profesionales de enfermería que ejercen o ejercieron la profesión liberalmente, como fuentes primarias de información; para ello se diseñaron las entrevistas guía, que nacieron de una serie de preguntas originadas de los objetivos, los cuales correspondían a 30 preguntas; estas se clasificaron y agruparon, para que finalmente quedaran 10 preguntas, en las que se basaron las entrevistas; asimismo, se elaboraron dos esquemas de entrevistas para darle claridad y clasificación a las personas entrevistadas por las enfermeras que actualmente ejercen y las que lo realizaban en tiempo pasado; instrumentos que contienen diversos puntos, con los cuales se logró nutrir la investigación. luego de recogida la información inicial, se detectó la necesidad de ampliar cada entrevista, lo cual se logró mediante conversaciones telefónicas. todas estas fueron grabadas y luego transcritas para su análisis. los datos cualitativos fenomenológicos recolectados se analizaron a partir de la metodología descriptivo-analítica del contenido, que derivó unas categorías interpretativas, las cuales permitieron establecer la relación y significado que tiene el fenómeno estudiado. se realizó una interpretación textual y gráfica de los resultados de la investigación, que permite ampliar la visión de las categorías que se tuvieron en cuenta para el análisis; posteriormente se hizo un esquema explicativo, el cual surgió de la clasificación de las categorías, queriendo dar una visión esquemática para empezar la narrativa; y al realizar el escrito del análisis de la información, se enriqueció el comentario con la narrativa interpretativa de cada uno de los puntos estudiados; además, se tuvieron apartes demostrativos con las palabras textuales de las entrevistadas y, finalmente, el apoyo de publicaciones que complementan los análisis elaborados. en este capítulo se presentan, una a una, las preguntas de la entrevista que se va a analizar, con un esquema gráfico de cada una de ellas, que permite una visión amplia de la temática respectiva, para enseguida representar su agrupación esquemática, que aclara la clasificación de las categorías; finalmente, se presenta la narrativa del análisis interpretativo de las repuestas a las preguntas, acompañado de frases textuales de las entrevistadas, así como párrafos de artículos que ilustran lo expresado en las preguntas y sus respuestas. técnica de recolección de la información registro de la información análisis de los hallazgos 57 ejercicio liberal de la enfermera(o) en el área materno infantil conclusiones las conclusiones se presentan en dos niveles: inicialmente, las referentes a cada uno de los temas planteados en las preguntas directas de la encuesta, y luego las conclusiones de conjunto, teniendo en cuenta los objetivos de la investigación. con referencia a la pregunta sobre la motivación que tuvieron para ejercer la profesión de enfermería liberalmente, se encontró que tienen diversas motivaciones, de tipo emocional, profesional, personal, y la recibida por el medio que las rodea. el trabajo liberal es una alternativa laboral más agradable, y el hecho de poder asociarse con otras colegas las motiva aún más; buscan realizarse profesionalmente, y así lograr una autonomía desde el punto de vista de dirección, de toma de decisiones y de la misma elección de la población que van a atender, lo cual requiere conocimiento y experiencia; además, esto tiene como marco el sentido de propiedad, que las lleva a realizar un trabajo con excelencia y de alta calidad, y a preocuparse cada vez más por adquirir mejores conocimientos; por todo esto, ven la necesidad de continuar con estudios formales, para así lograr nuevos horizontes para su desarrollo y un crecimiento en su desempeño. y como deben mostrar su trabajo a la sociedad, lo cual requiere de mayor asesoramiento en salud, adquieren así mayor reconocimiento. además de esto, su trabajo es de autogestión, ya que pueden determinar su horario, los servicios y la remuneración. respecto de la pregunta sobre la época en la que iniciaron su trabajo, la población entrevistada dijo que comenzó en la década de los ochenta, y sobre esa base surgió la pregunta sobre la ley 100 de 1993 y la 266 de 1996. algunas han visto la ley 100 como una oportunidad de ofrecer paquetes de servicio a las e.p.s., para lo cual ha habido la necesidad de legalizar su desempeño liberal y modificar las tarifas; esto no ha sido del todo beneficioso, ya que hasta cierto punto se han visto limitadas financieramente. la ley 266 les parece que es una forma de unidad del gremio de enfermería. acerca de la pregunta sobre los factores que tuvieron en cuenta para ejercer la profesión liberalmente, se encontraron factores personales, profesionales, de planeación, logísticos y sociales. es necesario estar motivado, tener entusiasmo, reciprocidad y apoyo familiar, para lo cual resulta indispensable planear, con responsabilidad y entrega, teniendo en cuenta a quiénes van dirigidos los servicios y qué bases científicas se deben tener para ejercerlos. entre estas se encuentra la parte correspondiente a la legislación, y tener en cuenta que dicha planeación va a ser ejecutada por las mismas enfermeras. para esto, una gran mayoría de las entrevistadas consideraron necesario tener un sitio estratégico desde el cual desarrollar sus actividades. también debe tenerse en cuenta la parte financiera, pues mientras se empieza es un poco complicada, y realizar un buen despliegue publicitario, para darse a conocer. por último, es necesario saber cuál es el mercado al que le interesan los servicios. en relación con la pregunta sobre las personas que apoyaron el ejercicio liberal, se encontró que tuvieron apoyo de miembros del equipo de salud y de la misma sociedad. el hecho de hacer su trabajo independiente les brinda una gran oportunidad de disponer de su tiempo, organizar el desplazamiento y la parte económica resulta más llevadera; así mismo, el apoyo de profesionales de otras ramas ha brindado orientación, y han tenido remisión de pacientes; esta ayuda refuerza, pues cliente bien atendido llama más clientes; además, las familias de las enfermeras han sido un punto de partida, puesto que las han acompañado en el proceso, a partir del apoyo emocional. con referencia a la pregunta sobre las dificultades que han tenido en el desarrollo de su trabajo, las enfermeras manifestaron: personales, logísticas, económicas y profesionales. es necesario tener una identidad profesional clara, que se adquiere con destreza y experiencia. también resulta indispensable una planeación efectiva, la cual requiere de tiempo; esto se dificulta cuando las enfermeras deciden desempeñar su labor, pero no tienen conocimientos en administración y legislación, ni comodidades de transporte domiciliario. no olvidar que este estilo de trabajo requiere de una gran inversión, que a su debido tiempo dará rentabilidad; al principio se necesita de buenos créditos y paciencia, mientras se año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 58 empieza a producir; a esto se agrega la poca credibilidad que ante la sociedad tienen las enfermeras, pues se les cree solo cuando están respaldadas por un médico. en consecuencia, las enfermeras deben adquirir la destreza necesaria para dar a conocer sus conocimientos de forma clara y contundente, y así lograr la confianza de sus clientes. finalmente, a lo anterior se suman los celos profesionales, que existen en todos los gremios. respecto de la pregunta sobre el área materno-infantil, en la cual pusieron énfasis, se observó lo siguiente: niños. se encontró gran variedad de casos: atención domiciliaria para educar y realizar cuidado directo de pacientes en situaciones específicas, como estimulación temprana, cuidado de prematuros, de sometidos a colostomía; administración de medicamentos, vacunación, terapias físicas y respiratorias; puericultura, valoración de niños sanos; fabricación y venta de artículos de estimulación y creación de centros especializados en la formación de niños sanos. madres. educación a las madres y sus familias, en la preparación para la gestación; acompañamiento de parturientas y cuidado de mujeres con alteraciones de salud asociadas con la maternidad, así como preparación para una efectiva lactancia. las enfermeras comentan cómo al iniciar su trabajo lo hacían a domicilio, y poco a poco se han ido estableciendo en un lugar, donde ofrecen sus servicios y crecen cada día; también establecieron sus propios consultorios e incluso crearon fábricas, almacenes, centros de estimulación-formación y jardines. acerca de la pregunta sobre las estrategias de divulgación utilizadas, se encontró que realizan visitas persona a persona, tanto al cliente potencial como al referido para dar a conocer los diferentes servicios que ofrecen. también elaboran publicaciones y tarjetas de presentación, así como cartas. algunas realizan informes, los cuales entregan a los padres de los niños o a los médicos tratantes, y aprovechan la televisión para hacer pequeñas reuniones. con relación a la pregunta sobre la legalización de su ejercicio liberal, algunas al inicio no la tenían, pero con el aumento de su trabajo han tenido que formalizarla; la gran mayoría han tenido que hacerlo, para lograr la licencia de funcionamiento, pagar impuestos, poder pasar las cuentas de cobro, contratar empleados y hacer publicaciones. en referencia a la pregunta sobre la oportunidad de crecimiento y desarrollo, las enfermeras han encontrado que el ejercicio liberal las ha hecho ser más responsables, les ha dado la oportunidad de una mejor remuneración económica y les ha brindado la oportunidad de crecer en su autonomía, lo cual aumentó su seguridad y confianza. también han llegado a ser líderes de grupos interdisciplinarios, y han tenido la oportunidad de crecimiento intelectual, lo cual las ha llevado a sortear mejor la toma de decisiones. de igual manera, han trabajado por la satisfacción personal y la de los pacientes, y se han preocupado más por la calidad en sus servicios que por el mismo reconocimiento del gremio. el enfrentarse a esta modalidad les ha permitido aprender a planear su tiempo libre, así como a establecer la remuneración económica por los servicios prestados. acerca de la pregunta que trata de las satisfacciones recibidas con el trabajo independiente, tenemos: las que más enfatizaron las enfermeras fueron las personales, pues realizan su trabajo con gran motivación, con placer y gusto por la profesión; además, planean cada actividad y distribuyen de la mejor forma el tiempo y el dinero. lo anterior produce crecimiento intelectual y madurez profesional, y el logro de experiencia y seguridad en el cuidado de enfermería, todo enmarcado dentro de la satisfacción de los pacientes, que son los que al final se benefician de un buen trabajo, el cual lleva indirectamente a la divulgación de los servicios ofrecidos. con relación a la pregunta sobre las características que debe tener la enfermera que ejerce liberalmente, estas serían: fortaleza, interés, ternura, compromiso, honestidad, empeño; ser emprendedora, responsable, constante, segura, entusiasta, sagaz, inteligente y ordenada; además, debe tener expe59 ejercicio liberal de la enfermera(o) en el área materno infantil riencia y conocimiento, unas muy buenas relaciones interpersonales y un adecuado apoyo económico, pues al principio la situación financiera es determinante en el futuro de su empresa. respecto a la pregunta sobre los puntos positivos y negativos del ejercicio de la profesión liberalmente, tenemos: los positivos: el ejercicio liberal les brinda la oportunidad de mostrar su profesión; así logran autonomía e independencia personal y económica, y ello les crea la necesidad de seguir adquiriendo nuevos conocimientos cada día. los negativos: el tener pacientes requiere de responsabilidad, lo cual incluye implicaciones legales. al principio cuesta trabajo cobrar los honorarios, porque no han sido entrenadas en la parte financiera; además, si existe una buena demanda, es necesario saber calcular y ordenar el tiempo, para poder responder a todo. con referencia a la pregunta sobre los motivos de deserción del ejercicio liberal, no se debe olvidar que este tipo de trabajo requiere de tiempo y motivación, y en muchos casos pesó más el ofrecimiento de estabilidad económica y laboral en lo que les gustaba. conclusiones generales según los objetivos: con base en las opiniones de las encuestadas, las características que se encontraron en su actividad liberal fueron: área infantil: existió gran variedad, que va desde la visita domiciliaria para educar y realizar cuidados de puericultura y valoración del niño sano, hasta vacunación, terapia respiratoria, toma de muestras de laboratorio, administración de medicamentos y estimulación temprana, que ha sido lo tradicional. las enfermeras han innovado con el fomento de instituciones especializadas en la fabricación de elementos de estimulación temprana, de ropa infantil y de accesorios utilizados para estimular el crecimiento de los niños; además, con la asesoría de diferentes marcas han logrado una adecuada orientación física, biológica, psíquica y social de los niños, y han revolucionado el cuidado de los niños canguro y aquellos en situaciones especiales, como los sometidos a colostomía o que tienen malformaciones. área materna: las enfermeras preparan a las gestantes para la maternidad, y en su labor incluyen ejercicios, sesiones educativas y puericultura. también proporcionan asesoría sobre los diferentes aspectos que giran alrededor de la gestación, la maternidad y lo concerniente a tener un recién nacido, e innovan en la afirmación de la participación de los esposos, situación que utilizan como estrategia para ganar mayor población. asimismo, ofrecen acompañamiento en el momento del parto y después de él, servicio de control a domicilio en situaciones especiales, como hipertensión por la gestación u otras patologías, y realizan toma de muestras de laboratorio, administración de medicamentos, curaciones y controles prenatales. el papel que ha desempeñado la profesional de enfermería en el ejercicio liberal va enriqueciéndose con la toma de decisiones, sobre una base fuerte de conocimientos. gracias a la formación que ha tenido posee gran iniciativa, y busca prestar el cuidado de tal forma que le produzca placer; además, que sirva de respuesta a las necesidades sentidas por la comunidad y sea acorde con las nuevas exigencias de la ley colombiana. al tener la gerencia de su trabajo liberal en al área comercial y el liderazgo en la prestación de servicios a sus clientes, la mayoría de las instituciones creadas por las enfermeras se han convertido en fuente de empleo en las diferentes modalidades profesionales, de carácter técnico o empírico, y por eso ellas tienen consultorios, fábricas, almacenes, centros de estimulación, jardines o gimnasios, o realizan su trabajo a domicilio. la actividad de las enfermeras en el ámbito liberal es muy amplia, y puede variar desde las mismas asesorías, pasando por la consultoría y las visitas domiciliarias, hasta llegar al diseño, ejecución y evaluación de estudios de factibilidad, de proyectos, programas y protocolos, a cualquier nivel de atención en salud. año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 60 referencias bibliográficas abaúnza, myriam, y vega, yolanda. “perspectivas de la práctica del profesional de enfermería en el sistema de seguridad social en salud”, rev. avances, vol. xiii, p. 134-136, alberdi, rosamaría. “la identidad profesional de la enfermera”, españa, revista rol, n° 170, p. 39-40, 1993. bates, b. doctor and nurse. changing roles and relations, new england, p. 124-129, julio, 1970. campos, victoria. “¿en qué momento se perdió el objetivo profesional que define a las enfermeras?”, españa, rev. rol, n° 178, p. 46-50, 1993. cedeño, marlene; mera, rosalba, y rueda, beatriz. participación actual de la enfermera en las actividades comprendidas en el “papel ampliado de la enfermera”, año de 1985. creghton, h. law every nurse should know, filadelfia, pp. 74-75, 1981. de alma ata al año 2000. oms y la unicef, ginebra, 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funciones independientes ejecutadas por el personal de enfermería, presentado en el congreso nacional de enfermería en santo domingo, 22 de febrero, 1988. leddy, susan. “bases de la enfermería profesional”, j. nurs., ed. 21, nueva york, p. 45-46, 1989. kramer, s. reality shock. why nurses leavenursing?, st. louis, p. 159160, 1974. marinez, maría matilde; hernández tesoquida, isabel, y rodríguez velásquez, juana. “la enfermera mexicana: un estudio sociológico de su carrera y profesión”. revista inv. y educ. en enfermería, vol. vi, p. 11-20, marzo, 1988. ministerio de salud, ops/oms, anec, acofaen. estudio nacional de enfermería (ene), 1985-1987, bogotá, 1989. moore, e. j. “visiting nursing”, am. j. nurs., p. 17-21, octubre, 1990. nespral, cecilia. “tendencias que influyen en el futuro de la enfermería”, rev. rol de enfermería, n° 176, abril, 1993. national league for nursing. nursing data book, nueva york, p. 3-4, 1982. organización mundial de la salud. comité de expertos. el ejercicio 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del profesional de enfermería”, revista avances en enfermería, bogotá, juliodiciembre, 1995. velandia, ana luisa. “imagen social del personal de enfermería”, revista perspectivas salud enfermedad, diciembre, 1995. velandia, ana luisa. “tres campos de acción de la enfermería como profesional, como trabajadora y como ciudadana”, revista anec, 1985. velandia, ana luisa. futuro e identidad de la enfermería con base en el cuidado. una historia prospectiva del cuidado de enfermería en colombia. dimensiones del cuidado, bogotá, universidad nacional de colombia, 1ª. ed., pp 134-151, 1998. velandia, ana luisa. historia de la enfermería en colombia, ediciones u.n.c., pp. 121-178, 1995. 61 ejercicio liberal de la enfermera(o) en el área materno infantil 509 522 cuidado transcultural y estrategias.indd 509 esperanza begoña garcía-navarro1 estrella gualda2 cuidado transcultural y estrategias familiares ante la dependencia: el fenómeno de los cuidadores extranjeros 1 enfermera, profesora asociada, departamento enfermería, universidad de huelva. unidad de sueño, área hospitalaria juan ramón jiménez, huelva (españa). esperanza.garcia@denf.uhu.es 2 doctora en sociología. profesora titular, departamento de sociología y trabajo social, universidad de huelva (españa). estrella@uhu.es recibido: 7 de septiembre de 2013 enviado a pares: 22 de octubre de 2013 aceptado por pares: 12 de enero de 2014 aprobado: 10 de abril de 2014 doi: 10.5294/aqui.2014.14.4.6 para citar este artículo / to reference this article / para citar este artigo garcía-navarro be, gualda e. cuidado transcultural y estrategias familiares ante la dependencia: el fenómeno de los cuidadores extranjeros. aquichan. 2014; 14 (4): 509522. doi: 10.5294/aqui.2014.14.4.6 resumen introducción: cuando un cuidador procede de un país diferente al de la persona cuidada se presenta una contraposición de culturas y prácticas sociales. el concepto de cuidado transcultural de leininger hace eco de la diversidad cultural que supone esta contraposición y recomienda incorporarla en la práctica profesional, desarrollando cuidados que ella define como culturalmente competentes. objetivo: conocer qué tipo de estrategias desarrollan los cuidadores extranjeros a la hora de cuidar personas de diferente origen y cómo estas se integran en el contexto social, cultural e institucional de la sociedad receptora. materiales y métodos: método cualitativo, a través de entrevistas en profundidad a cuidadoras inmigrantes en la provincia de huelva, así como a personal especializado en los cuidados de pacientes en situación de dependencia. resultados: descripción de prácticas socioculturales que los cuidadores elaboran según su cultura y cómo intervienen en el ejercicio de los cuidados en la sociedad receptora. conclusiones: los cuidadores extranjeros desarrollan en ocasiones estrategias afines a sus propias creencias priorizándolas sobre las de la persona cuidada o las de la sociedad receptora, lo que genera choques culturales. se sugiere que los profesionales de enfermería deben identificarlas para poder intervenir, utilizando la formación y competencia cultural como herramientas para el cambio. palabras clave cuidadores extranjeros, dependencia, competencia cultural, inmigración, cuidados transculturales. (fuente: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 509-522 510 aquichan issn 1657-5997 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 509-522 transcultural care and family strategies to deal with dependency: the phenomenon of foreign caregivers abstract introduction: when a caregiver comes from a country other than that of the person being cared for there is a clash of cultures and social practices. leininger’s concept of transcultural care echoes the cultural diversity this contrast or opposition involves and recommends incorporating it into professional practice by developing what she defines as culturally competent care. purpose: the purpose of this study was to know what type of strategies foreign caregivers develop when caring for people of different origin and how these strategies are integrated into the social, cultural and institutional context of the recipient society. study materials and methods: a qualitative approach was used, based on in-depth interviews with immigrant caregivers in the province of huelva and with personnel specialized in dependent patient care. results: the study provides a description of the socio-cultural practices caregivers develop, according to their culture, and how those practices intervene in the exercise of care in the recipient society. conclusions: foreign caregivers sometimes develop strategies akin to their own beliefs, giving them priority over those of the care recipient or the recipient society. this can cause cultural clashes. nursing professionals must identify these clashes so as to be able to intervene, using training and cultural competency as tools for change. key words foreign caregivers, dependency, cultural competency, immigration, transcultural care. (source: decs, bireme). 511 cuidado transcultural y estrategias familiares ante la dependencia: el fenómeno de los cuidadores extranjeros l esperanza begoña garcía-navarro, estrella gualda cuidado transcultural e estratégias familiares ante a dependência: o fenômeno dos cuidadores estrangeiros resumo introdução: quando um cuidador vem de um país diferente ao da pessoa cuidada, apresenta-se uma contraposição de culturas e práticas sociais. o conceito de cuidado transcultural de leininger reitera a diversidade cultural que essa contraposição supõe e recomenda incorporá-la na prática profissional desenvolvendo cuidados que ela define como culturalmente competentes. objetivo: conhecer que tipo de estratégias desenvolvem os cuidadores estrangeiros na hora de cuidar de pessoas de diferente origem e como estas se integram no contexto social, cultural e institucional da sociedade receptora. materiais e métodos: método qualitativo, por meio de entrevistas em profundidade a cuidadores imigrantes em huelva (espanha), assim como a pessoal especializado nos cuidados de pacientes em situação de dependência. resultados: descrição de práticas socioculturais que os cuidadores elaboram segundo sua cultura e como intervêm no exercício dos cuidados na sociedade receptora. conclusões: os cuidadores estrangeiros desenvolvem em ocasiões estratégias afins a suas próprias crenças e priorizam-nas sobre as da pessoa cuidada ou as da sociedade receptora, o que gera choques culturais. sugere-se que os profissionais de enfermagem as identifiquem para poder intervir utilizando a formação e competência cultural como ferramentas para a mudança. palavras-chave cuidadores estrangeiros, dependência, competência cultural, imigração, cuidados transculturais. (fonte: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 509-522 512 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 introducción en el presente artículo se describen los resultados de un estudio en marcha sobre los cuidadores inmigrantes y sus estrategias de cuidado en áreas claves, de huelva y provincia (sur de españa), donde se brinda atención a pacientes en situación de dependencia en diferentes ámbitos de especialización: atención especializada en hospitales y atención de la unidad familiar en el hogar. una vez se caracteriza el área de estudio y se explican los objetivos, y el método y las técnicas empleadas, se describen algunas de las estrategias que las cuidadoras están desarrollando, y cómo estas tienen que ver con sus propias percepciones y experiencias de partida, y se integran en el contexto social, cultural e institucional de los cuidados a personas dependientes de la sociedad receptora. también nos aproximamos a las perspectivas que algunos profesionales tienen al respecto. este trabajo ha permitido identificar algunas diferencias y choques culturales que se producen en el desarrollo de los cuidados. usamos el término choque cultural en este trabajo para describir la ansiedad y los sentimientos (de sorpresa, desorientación, confusión, etc.) causados en un individuo por el contacto con un medio social totalmente distinto, como les ocurre en ocasiones a las cuidadoras extranjeras. la apreciación de diferencias culturales ha generado algunas situaciones que van más allá de lo que significa “cuidar”, lo que ha incidido en la salud del paciente y en cómo se gestionan las tareas que se realizan en el proceso de cuidado de los mayores dependientes. la pertinencia de este estudio radica en que describe realidades sociales y sanitarias cada vez más frecuentes en los hogares y en centros públicos sanitarios en españa, y particularmente en la provincia de huelva, sobre las que prioritariamente debería intervenirse. este trabajo sugiere pistas para mejorar la calidad de la atención que las cuidadoras extranjeras prestan a los dependientes, a partir de los conocimientos y aprendizajes generados en esta investigación. estas van unidas a una mejor comprensión del sistema de creencias, valores y prácticas culturales que tienen los sujetos de estudio, además de la identificación de su influencia sobre la acción de cuidar. estado de la cuestión sistemas de provisión de cuidados. el domicilio como protagonista los cuidados informales van en aumento en nuestro país y, más concretamente, en la región andaluza (1); es más, su papel resulta esencial, por un lado, porque completan las carencias que las redes institucionales ofrecen para la provisión de cuidados, y, por otro, porque las políticas sociales de los países desarrollados tienden a plantear “el envejecimiento en casa” como su objetivo prioritario, debiendo a su vez potenciar el sistema informal de cuidados (2-4). el interés por estudiar la repercusión de los cuidados de larga duración en los cuidadores y en las redes de apoyo informal es bastante reciente en la mayoría de los países. los estudios pioneros sobre la atención informal aparecieron en países anglosajones, centrándose en la problemática del núcleo familiar que los alberga y direccionándolos a las denominadas “crisis del estado de bienestar” (5). los estudios revisados (6-10) muestran diferentes enfoques, algunos se centran en las redes de atención al cuidador, además de describir los programas de intervención hacia el mismo (6). esta es una revisión sistemática que analiza la situación actual de los cuidados en nuestro país (españa) y reflexiona sobre el futuro de los mismos, debido a los cambios profundos que se están produciendo en las formas de vida de la familia. también se hace hincapié en las repercusiones físicas, psicológicas y sociales que tiene el hecho de cuidar para el cuidador principal, y en el proceso de atención a la familia que deberían desarrollar los sanitarios, concretamente los profesionales de enfermería. las familias siguen protagonizando el cuidado de la dependencia, dejando en un segundo plano las instituciones. un estudio realizado en madrid (7) demostró que solo uno de cada 20 pacientes diagnosticados en situación de dependencia se encontraba en una residencia, al igual que otro estudio (8) elaborado 15 años después. en los estudios revisados (6-10) se confirma que la prestación de servicios sociales a estas familias es prácticamente inexistente. las fuentes de apoyo al cuidado en el domicilio, externas al núcleo familiar, normalmente son de origen privado (9); otro de los estudios (10) afirma, tras una simulación de diferentes escenarios demográficos, que el envejecimiento de los cuidadores, más que el de los dependientes, provoca que la diferencia en la preferencia de atención domiciliaria respecto al salario del cuidador aumente de seis a quince puntos porcentuales, de ahí la necesidad de búsqueda de una figura que sea proveedor de cuidados, que acepte un salario mínimo, generándose así el nicho laboral de la cuidadora extranjera (10). 513 cuidado transcultural y estrategias familiares ante la dependencia: el fenómeno de los cuidadores extranjeros l esperanza begoña garcía-navarro, estrella gualda el protagonismo de la mujer como cuidadora: cuidadores extranjeros. cuidados transculturales el hecho de cuidar a una persona dependiente implica suplir aquellas necesidades que dicha persona no puede satisfacer por ella misma debido a su falta de independencia o autonomía (11). el cuidado se transmite de generación en generación, como práctica social y como herencia cultural. se enseña a través de la cultura, de las prácticas sociales y se aprende a través de la experiencia personal. al mismo tiempo, los cuidados no se producen en el vacío sino que tienen lugar en el contexto de sistemas y estructuras sanitarias y sociales que los terminan de configurar; una realidad aún latente es que el trabajo de cuidados, formales o informales, se sigue perfilando en femenino. mayoritariamente, son las mujeres las que continúan haciéndose cargo de la tarea del cuidado, relegando su autocuidado a un segundo plano, con la consiguiente repercusión que esto tiene para su salud física y psíquica, así como para sus proyectos personales, lo que plantea un gran reto para alcanzar una igualdad efectiva (12). esta difícil complementariedad familiar, genera estrategias domésticas para poder conciliar las necesidades personales con las obligaciones morales de los cuidadores, estrategias basadas en el mercado del cuidado, contratando para ello a los cuidadores extranjeros. cuando una cuidadora procede de otro país se ponen en contraposición las culturas y prácticas sociales del origen y el destino a la hora de cuidar. el concepto de cuidado transcultural (13) hace eco de la diversidad cultural que supone esta contraposición y recomienda incorporarla en su práctica profesional desarrollando cuidados que ella define como culturalmente competentes. otras teóricas, como la doctora campinha-bacote (14), incorporan otras dimensiones como los prejuicios, desarrollando aproximaciones que argumentan que antes de cuidar se debe crear una sensibilidad intercultural. en el ámbito de los estudios de género e inmigración, las migraciones femeninas son percibidas como fuerza de trabajo idónea para realizar las tareas vinculadas a la reproducción social, puesto que estas labores suelen ser actividades socialmente poco valoradas, escasamente cualificadas, asumidas como algo inherente a la condición femenina y, a menudo, realizadas desde la economía informal. en este sector, la mujer inmigrante se ha introducido en españa sin apenas competencia con las nacionales (especialmente como “cuidadoras” en el servicio doméstico interno). sin embargo, la competencia sí existe entre los mismos inmigrantes, produciendo un proceso de etnoestratificación sustentado en las preferencias de las familias empleadoras (15). algunos autores (10, 15, 16) argumentan que el perfil de las mujeres inmigrantes que se dedican al cuidado de personas en situación de dependencia varía en relación con el patrón descrito de cuidadoras formales, y esto se debe a las circunstancias personales que suelen rodear el contexto laboral y personal de este colectivo (16). contexto nacional hay varios fenómenos que acompañan la situación real de la dependencia en nuestro país y, más concretamente, en la provincia objeto de estudio, huelva. el primero de ellos es la transformación de los núcleos familiares de nuestra provincia, donde además de la disminución de la natalidad, la mujer se incorpora al trabajo. asimismo, las dificultades económicas en los hogares, la inversión en tiempo y dinero que genera el cuidado de otra persona, y el hecho de que las pensiones que suelen recibir los mayores no cubren ni la mitad de los gastos que supondrían sus cuidados, son características comunes. este mosaico de rasgos ha contribuido a que la situación del cuidado del mayor dependiente tenga hoy mucho que ver con la existencia de centros alternativos de cuidados a los mayores. las residencias de ancianos son la principal opción, pero cargan con un pesado lastre: la escasez de la oferta ante una demanda que no hace sino aumentar; en españa solo se dispone de 3,7 plazas en ellas (agrupando privadas y públicas) por cada cien personas mayores de 65 años, y la mayoría de las residencias, especialmente las de titularidad pública (son bastante más baratas), reciben al solicitante después de largas y desalentadoras listas de espera (17). los centros de día, por otra parte, constituyen una alternativa para atender a los mayores dependientes; pero en la actualidad, solo están registrados cerca de 1.700 de estos centros para personas mayores dependientes que cuentan con unas 40.000 plazas y que acogen al usuario durante el día (normalmente desde las 8 de la mañana hasta las 7 de la tarde), de lunes a viernes (17). estos recursos insuficientes instan a las familias andaluzas a la permanencia del paciente en su domicilio. este modelo de atención donde la familia, y concretamente la mujer, juega un papel tan importante en tanto cuidadora (1), tiene sin duda aspectos muy positivos para la persona demandante de cuidados, pero no podemos olvidar los efectos negativos y la sobrecarga para las cuidadoras familiares (18). los gerontólogos 514 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 hablan de un nivel de tolerancia para el cuidado informal, por el cual se transfieren responsabilidades a los cuidadores formales (19). la necesidad de contar con terceras personas para el cuidado de los mayores origina un gasto económico familiar adicional (ep2, enfermera gestora de casos, 2012). la existencia de personas de origen extranjero con posibilidades de realizar tareas de cuidado a mayores dependientes, que además pueden residir en el propio domicilio del mayor en calidad de “internas”, propicia una situación nueva que oculta, en parte, la limitación de los servicios de proximidad, como se sugiere en los estudios de cuidados a la dependencia e inmigración (16-20). contexto andaluz en el caso concreto de andalucía, el servicio andaluz de salud dispone de una red de servicios asistenciales integrada y organizada para garantizar la accesibilidad de la población y la equidad en la distribución de recursos. el primer nivel de atención es la atención primaria de salud, que integra la asistencia preventiva, curativa, rehabilitadora y la promoción de la salud de los ciudadanos. en el segundo nivel, de atención hospitalaria, se atiende a los pacientes que precisan de hospitalización. para el caso que nos ocupa, las cuidadoras, la atención a la dependencia se reestructura en la región tras la aprobación del decreto 137/72 de apoyo a las familias andaluzas, donde las cuidadoras familiares han pasado a convertirse en la población diana de la cartera de servicios del sistema sanitario público andaluz. para ello, se ponen en marcha diferentes medidas para la mejora de los cuidados en la atención domiciliaria, incluyendo la atención de las cuidadoras familiares, la prevención, el tratamiento y la adaptación de problemas de movilidad relacionados con el cuidado, la adaptación de los problemas que la discapacidad crea en el entorno y la atención a los problemas sociales vinculados a problemas de salud (21, 22). para ello se ha incorporado una nueva figura sanitaria con el fin de mejorar y ampliar la capacidad de resolución de los servicios, denominada enfermera gestora de casos (egc), cuya máxima responsabilidad es la asistencia y formación de las cuidadoras familiares. objetivos los principales objetivos de este trabajo son describir las tareas y los cuidados que realizan las personas que atienden a los mayores dependientes, así como la experiencia y los conocimientos que sobre estos tienen. igualmente, nos interesa focalizar la atención en las estrategias que desarrollan a la hora de cuidar a personas de diferente origen, y cómo estas se integran en el contexto social, cultural e institucional de los cuidados a dependientes de la sociedad receptora. en este marco, este artículo quiere identificar algunas de las percepciones que las cuidadoras y los cuidadores extranjeros tienen sobre la salud y la enfermedad, atendiendo a algunas diferencias culturales. se estudian estas percepciones y experiencias teniendo en cuenta el perfil sociodemográfico de los cuidadores entrevistados en nuestra área de estudio. materiales y métodos en este apartado se describe el diseño metodológico y técnico desarrollado hasta el momento, que se arraiga en un enfoque de pluralismo metodológico, acompañado de la triangulación de datos e informaciones (23-25), que enfatizan la necesidad de coherencia entre los métodos de investigación y el objeto de estudio. dada la diversidad de aspectos que queríamos observar, se han empleado diferentes estrategias y técnicas de investigación social. para abordar el estudio sobre la realidad del cuidado a pacientes en situación de dependencia que prestan las mujeres extranjeras, se han utilizado tres tipos de aproximaciones metodológicas que dan respuesta a los distintos objetivos que se acaban de exponer. fuentes secundarias se manejan aquí, además de las fuentes bibliográficas y administrativas que permiten describir someramente el entramado organizativo del sistema sociosanitario andaluz encaminado a la atención de la dependencia, estudios e investigaciones sobre la materia e instrumentos de evaluación existentes. en este caso, contamos tanto con aproximaciones cuantitativas como cualitativas. fuentes primarias nuestras fuentes primarias de análisis son de carácter cualitativo, habiéndose centrado el grueso del trabajo de campo en la obtención de datos por la vía de la entrevista en profundidad, realizada a diferentes personas que podríamos clasificar en dos tipos3: 3 se conservó el anonimato en las referencias a sus declaraciones o discursos a lo largo del texto. 515 cuidado transcultural y estrategias familiares ante la dependencia: el fenómeno de los cuidadores extranjeros l esperanza begoña garcía-navarro, estrella gualda • profesionales del sistema (público o privado) de todas las áreas de estudio en este subgrupo se llevaron a cabo entrevistas a personas que compondrían lo que podríamos llamar dos perfiles diferentes: tres enfermeros gestores de casos de las zonas estratégicas de estudio: huelva capital, huelva costa y huelva condado-campiña (mujer, 42 años; varones, 39 y 46 años respectivamente). el gerente de una empresa que contrata a cuidadoras extranjeras para desarrollar servicios en el hospital (varón, 38 años). • no profesionales se entrevistaron 16 informantes, cuidadoras y cuidadores extranjeros que dispensan atención directa a personas autóctonas dependientes. en esta fase de la investigación, todas las entrevistas desarrolladas hasta la fecha fueron realizadas a cuidadoras mujeres; no se identificaron cuidadores varones en nuestra área de estudio, fenómeno que se repite en investigaciones similares (3, 10, 16, 20, 21). el único varón entrevistado ocupaba el rol de gestor de empresa que subcontrataba a cuidadores extranjeros, como se ha especificado. el discurso y las experiencias obtenidas tras la realización de esta primera fase de entrevistas permiten aproximarse al fenómeno de los cuidados desde la perspectiva de las personas que están día a día a cargo de la gestión de la provisión de los cuidados, tanto públicos como privados, formales e informales, cuanto desde la perspectiva de las cuidadoras que llevan a cabo los mismos. para la selección de las personas entrevistadas, más que atender a criterios de muestreo representativo, que tenían poco sentido para esta investigación, se abordó un muestreo teórico con el objeto de acercarnos a personas que pudieran representar socialmente espacios discursivos diferentes respecto a la atención a dependientes, y las problemáticas derivadas de posibles choques interculturales. se intentó igualmente, conociendo por estudios previos las diferencias existentes en la provincia entre una migración más reciente y otra más consolidada, que entre los entrevistados profesionales se pudiera recoger la experiencia de enfermeros que atienden en zonas donde la migración es más reciente, y zonas donde es más antigua (almonte frente a punta umbría), sin olvidar la dualidad rural / urbano (almonte y punta umbría frente a huelva capital, por ejemplo). todo ello bajo la idea de que podrían identificarse realidades diferentes en lugares con más o menos experiencia migratoria en los servicios sociosanitarios para la atención a mayores en situación de dependencia. esto es, ¿la tendencia a emplear a cuidadoras inmigrantes varía según la migración sea más estable o no?, ¿la existencia de una migración más consolidada implica un aprendizaje intercultural que se traslada al ámbito de los cuidados, minimizando posibles choques interculturales? por otra parte, cabe indicar también que en esta fase de la investigación, dado lo anecdótico de los cuidados prestados por mujeres extranjeras en el área de la sierra de huelva, no se realizaron entrevistas a cuidadoras allí, concentrándose todas de momento en las áreas de la costa, el condado y la capital. otros detalles metodológicos para el desarrollo del trabajo de campo, de acuerdo con el perfil de las personas que iban a ser entrevistadas y el tipo de información que se pretendía recoger, se usaron diferentes instrumentos de recogida de la información o guiones cualitativos. en ellos se contemplaba un abanico diverso de temas por discutir, tales como: aspectos ligados al perfil migratorio, laboral o familiar, sus prácticas y experiencias en el cuidado, aspectos relacionados con los choques interculturales. para el caso de las entrevistas con profesionales, las preguntas recogidas en el guión eran algo diferentes, para reunir otras informaciones como la distribución de mujeres extranjeras en su zona, la provisión de cuidados formales en el área de estudio, la existencia de talleres de formación para cuidadoras, etc. el trabajo de campo se desarrolló entre los años 2011 y 2012; las entrevistas se llevaron a acabo algunas veces en el lugar de trabajo de las entrevistadas, y, otras, en los domicilios de residencia. en el caso de las cuidadoras, normalmente se celebraron en el domicilio donde prestaban los cuidados, ya que vivían en régimen interno y solo descansaban los domingos, además de ser un espacio donde se encontraban más tranquilas porque no abandonaban su lugar de trabajo. respecto a los enfermeros y otros profesionales entrevistados, las entrevistas se realizaron en un despacho cedido por la unidad de investigación del área hospitalaria juan ramón jiménez de huelva, por ser un lugar neutral para el entrevistado. 516 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 resultados diversidad sociocultural entre las cuidadoras uno de los primeros factores que salta a la luz en el discurso de profesionales del estudio y de cuidadores, es la existencia de diferentes estilos de vida sociosanitarios entre personas de diversa procedencia, distintos niveles formativos y diferentes experiencias laborales previas. así lo explicaba uno de nuestros entrevistados, gestor de una empresa que ofrece servicios de cuidados y que hace de intermediario entre las cuidadoras finalmente contratadas y las familias de las personas atendidas: las diferencias culturales son muchísimas, la cultura… ten en cuenta no sé si lo dices por el grado de instrucción, que eso es lo más variado, tengo enfermeras, tengo auxiliares, licenciadas en historia, tengo una abogada que trabaja conmigo, una chica que estudió odontología, un chaval que es administrador, un chaval que estudió teología, iba para cura y luego lo dejó, tengo chavales que han llegado a un nivel de instrucción de bachillerato, entonces se les nota la diferencia del nivel de instrucción… pero ninguno excepto las enfermeras están formados en cuidados (ep1. varón de perú, 38 años. gestor de una empresa que contrata a cuidadoras extranjeras). la cita anterior refleja claramente la diversidad interna existente entre las personas que proporcionan cuidados en la provincia de huelva. igualmente, hace palpable que las diferencias culturales no se atribuyen solo al país de origen sino también al nivel global de instrucción o formación alcanzada. el siguiente discurso es de una cuidadora con estudios universitarios en su país de origen, que nos refiere cómo influye el nivel de instrucción de ella y del paciente al que cuida en la comunicación interpersonal entre ambos y cómo esto se relaciona con la salud: “si los pacientes tienen un nivel más alto, te entiendes mucho mejor, entienden mejor a las personas, entienden mejor lo que dice el médico y todo lo demás. la persona que tiene menos instrucción entiende un poquito menos pero se va instruyendo para mejorar” (ec14. cuidadora rumana, 42 años). diferentes autores (25, 26) explican que dar formación aumenta la satisfacción de los cuidadores en un 96 % de los casos, 4 ec = entrevista a cuidadora. y que la consideran útil para mejorar la eficacia del cuidado en un 66 %. un ejemplo de ello es que aportan datos que definen como universitarias a un tercio de las informantes seleccionadas (informática y magisterio) en sus ámbitos de estudio, mientras que el resto tendrían estudios de bachiller y primarios, no adecuándose sus estudios al trabajo desarrollado en españa. en su país, ninguna de las cuidadoras cuidaba previamente a ancianos, dedicándose a tareas administrativas, agrarias, docentes o trabajando como operarias, entre otras tareas. cuando llegan a españa no tienen la posibilidad de realizar el trabajo que hacían en sus países de origen, lo que hace que muchas mujeres inmigrantes se dediquen al cuidado de ancianos. percepciones relativas a los conceptos de salud y enfermedad entre las cuidadoras y los cuidadores la literatura advierte que las nociones de salud y enfermedad varían de acuerdo con las coordenadas espacio-temporales y sociales de referencia de las personas. cada sociedad desarrolla conocimientos, prácticas e instituciones particulares a estos efectos, o lo que kleinman denomina como sistema de atención a la salud (27). este, desde su perspectiva, engloba todos los componentes presentes en una sociedad relacionados con la salud, incluyendo los conocimientos sobre los orígenes, las causas y los tratamientos de las enfermedades, las técnicas terapéuticas, sus practicantes, los papeles, patrones y agentes en acción en este “escenario”. a estos se suman las relaciones de poder y las instituciones dedicadas a la manutención o restauración del “estado de salud”. este sistema es amparado por esquemas de símbolos que se expresan a través de las prácticas, interacciones e instituciones; todos coinciden con la cultura general del grupo, que a su vez, sirve para definir, clasificar y explicar los fenómenos percibidos y catalogados como “enfermedad” (28). esta idea se ve reflejada en el discurso emergente de las entrevistas realizadas. diversas ideas aportadas por las informantes vinculan salud a la ausencia de enfermedad (y, por tanto, de tratamientos), mientras que otras aluden a nociones psicosociales y emocionales, cuando van más allá de los aspectos físicos. también encontramos que algunas cuidadoras se refieren a las vertientes física, mental y social de la salud. en este sentido, “tener salud” puede ser tanto no estar enfermo, como no estar triste, e incluso contar con apoyos de otras personas (traducido en términos de cariño, etc.), o simplemente sentirse entendida, com517 cuidado transcultural y estrategias familiares ante la dependencia: el fenómeno de los cuidadores extranjeros l esperanza begoña garcía-navarro, estrella gualda prendida e incluso, en algunos casos, la idea de la salud se asocia a una dimensión más social, unida al disfrute del ocio y tiempo libre. esta multiplicidad de significados atribuidos se aprecia en los discursos que siguen, a modo de ejemplo: salud, como su nombre lo indica, es… está la persona bien tanto interna como externamente, ¿no?, o sea en cuanto, también a lo ambiental todo, todo, o sea integral. para mí, más que todo influye mucho el cariño. […] porque una persona puede estar enferma y siempre y cuando se le brinda cariño, […] como que aminoran la enfermedad. claro, porque la persona además se siente útil, así tengan la enfermedad que tengan, se sienten queridas (ec2. cuidadora ecuatoriana, 34 años). para mí una persona con salud es aquella que no le duele nada, que tiene el corazón sano, la cabeza, que no toma pastillas. también que no esté triste (ec1. cuidadora rumana, 42 años). una persona vive mejor si no está triste. no es bueno que piense mucho en su enfermedad (ec4. cuidadora marroquí, 38 años). ¿la salud? ¿qué es la salud? ¿cómo es de importante? ¿lo importante?..., yo no sé, me parece tener a una persona que cuide a las personas mayores, es muy importante porque cuando hay una persona un poquito mayor y sola, eso no está bien (ec5. cuidadora boliviana, 35 años). ¿salud? salud, si la persona físicamente está buena eso y no hace falta médico. yo eso no lo sé qué es salud… no puedo… la salud es lo primero… no puedo. ¿qué importante? pues no sé qué contestar. es muy importante entender persona a otra, ¿sabe? querer a ella, es muy importante” (ec6. cuidadora rusa, 32 años). en las anteriores definiciones, transcritas literalmente, se observan las similitudes de las percepciones de las informantes a pesar de que procedan de países tan distintos como rumania, ecuador, marruecos, bolivia y rusia, con diferentes marcos culturales de referencia. no obstante, a pesar de las similitudes, la noción de salud es construida individualmente, en la medida en que cada persona desarrolla un concepto distinto en función de su biografía y de su cultura, así como de su relación con el sistema de salud y otros factores, como sugieren las citas anteriores. un estudio revisado (29) de corte cualitativo, desarrollado con familias, que explora las necesidades de salud de la población de chile, concluye que el concepto de salud surge de tres tipos de experiencias: la percepción de carencia económica, la enfermedad y la relación con su entorno social y familiar. en este último caso, la salud personal y la salud social están relacionadas. así, cuando en un hogar alguien se enferma, mantiene un nivel de discapacidad o necesita ingreso hospitalario, no solo se enferma el paciente, sino que el problema se extiende a la familia, ya que esta modifica su concepto de salud por la propia experiencia que está viviendo. en el caso de las cuidadoras extranjeras, la definición de salud, como se expresó en las citas anteriores, está asociada a la ausencia de enfermedad, aunque también aparecen los conceptos de cariño, soledad, sentirte cuidado o entendido por alguien; para ellas, la salud tiene que ver en gran medida con el hecho de estar bien emocionalmente. la elaboración de su discurso en algunos casos propone al estado emocional como eje principal de su salud. la importancia de estar bien emocionalmente es un factor subrayado en la literatura existente sobre la salud de los inmigrantes (26, 30-32), cuando se alude al síndrome de ulises o al estrés de traslado postraumático, cuya causa viene determinada por el duelo migratorio que lleva asociado un coste de salud mental, no solo por la añoranza de los suyos, sino por lo que conlleva el estar en otro país, en soledad, sin los suyos, con otro idioma, con la falta de integración. por eso, puede resultar normal encontrar en las cuidadoras una definición de salud que se acerque a estar bien emocionalmente, a la ausencia de problemas mentales. se trata de un síndrome exclusivo de las cuidadoras formales de origen extranjero, inherente al proceso de emigrar. según refiere una de las entrevistadas de origen rumano, en su país el sistema sanitario es parecido al nuestro, existen buenos hospitales, buenos profesionales, el gran problema es la falta de recursos para acceder a ellos. por eso, en su definición de salud señala que la salud tiene que ver con el dinero. los recursos que un país destina a la salud, y los resultados de estos pueden medirse mediante diversos indicadores (índices y valores numéricos). describir el nivel de salud de una población significa medir todos los aspectos que aporten información sobre cómo se distribuye el proceso salud-enfermedad entre sus habitantes. existe una gran cantidad de indicadores; los más utilizados son aquellos que muestran falta de salud de una población, como la mortalidad y morbilidad. según el informe de estadísticas sanitarias mundiales del año 2009, de la organización mundial de la salud (oms), rumania tiene una tasa de mortalidad infantil por neumonía del 25 %, siendo la de ucrania del 19 % y la de españa del 1 %, citando otros ejemplos que pueden servir de referencia. estos datos reflejan que, aunque tienen los materiales para definir el bacilo que provoca la neumonía, no existen los recursos necesarios para tratarla. 518 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 percepciones, experiencias y choques culturales en el proceso de “cuidar” el cuidado tiene una dimensión cultural muy importante inherente a la persona que lo presta. la dimensión simbólica de la percepción que se tiene sobre cuidar incluye los conocimientos, las percepciones y cogniciones utilizadas para definir, clasificar, percibir y explicar la enfermedad o los procesos que ella conlleva. en todas las sociedades hay marcos culturales que definen conceptos sobre lo que es el cuidado (28, 33, 34). dada la diversidad existente entre las personas que prestan cuidados y los múltiples tipos de cuidados por prestar, sería muy difícil crear un recetario que relatara cómo deben prestarse los cuidados atendiendo a los orígenes diversos de los cuidadores. otro de los factores que contribuye a esta dificultad es que pueden documentarse percepciones distintas según el país de origen de acuerdo con sus propias experiencias, relaciones, educación, etc. algunas de las percepciones que tienden a ser similares entre nuestras entrevistadas procedentes del mismo país son las asociadas a los sistemas sanitarios y políticos de su país de origen, si bien otros factores como el nivel de instrucción, o el área concreta de procedencia, entre otros, también contribuyen a la formación de estas percepciones (13, 35). choques culturales entre los sistemas sanitarios y estructuras de atención: desigualdad social y económica el sistema de atención a la salud es tanto un sistema cultural como un sistema social de salud. definimos este último como aquel que está compuesto por las instituciones relacionadas con la salud, la organización de papeles de los profesionales de la salud que en él participan, sus reglas de interacción, así como las relaciones de poder inherentes a este. a esta dimensión del sistema de atención a la salud también se le pueden atribuir (28) profesionales de la salud no reconocidos institucionalmente, ni por el sistema biomédico, tales como curanderos, brujos, hechiceros, meso-terapeutas, padres-de-santo, pastores. en el universo de cada grupo social, los especialistas tienen un papel específico que desempeñar frente al tratamiento de determinada enfermedad, y los pacientes tienen ciertas expectativas sobre cómo será llevado a cabo ese papel, qué enfermedades puede curar el especialista, así como una idea general acerca de los métodos terapéuticos que serán empleados (36). en este apartado se cumple uno de los objetivos planteados en el estudio: conocer cómo cuidan y cómo se cuida en los países de origen. a continuación vamos a describir algunas prácticas que se realizan en los países de los cuidadores para aproximarnos a la comprensión de sus comportamientos en nuestro país respecto a la salud: sí, a la medicina, a las cosas que hay aquí que no hay en mi país, las comodidades como la seguridad social que existe, porque nosotros no la tenemos así para todos, sino solamente para las personas mayores y para los recién nacidos menores de un año, y las personas mayores de 65 años para arriba también la tienen. pues esa es la diferencia en la medicina que yo veo acá que está muy bien. y otra diferencia que yo veo es la forma como viven, que trabajan todos también y en la casa siempre la mujer, todavía nosotras estamos acostumbradas a que el hombre nos mantenga y a estar en casa… (ec7. cuidadora colombiana, 36 años). lo que allá sí se practica es por ejemplo la medicina, la terapéutica, o sea con terapias por ejemplo de plantas medicinales y todo eso. aquí, aquí casi no lo hay. […] sí, aquí es menos y ¿qué otras cosas? sí, allá hay de todo. lo que pasa es que la falta de recursos es que es lo malo. claro por que allá todavía se piensa, no como aquí, allá todavía se tienen culturas, ¿no?, por ejemplo, los indios, nuestros indios, ellos se curan con sus poderes que ellos han adquirido (ec8. cuidadora perú, 34 años). pues las prácticas son más que nada lo que es la medicina alternativa o la medicina tradicional que son un poco el uso de hierbas, de ungüentos de animales, el uso de otro tipo de conocimientos empíricos que a veces va coordinado y de la mano en el desarrollo de la medicina. hay una obra muy importante en cuanto a este aspecto que es la medicina tradicional y lo que es la […] instructiva que es la medicina que se estudia en la universidad, la medicina tradicional tiene brujos, curanderos, hechiceros que cada uno tiene sus aspectos para poder curar a los usuarios de determinados pueblos, se da mucho esto en el perú, porque allí la seguridad social no es como aquí en españa gratuita, sino de una forma muy… este… ¿cómo te puedo explicar? de una forma costosa, o sea, que te cuesta, te cuesta una consulta, te cuesta una medicina (ep1. varón de perú, 38 años. gestor de una empresa que contrata a cuidadoras extranjeras). hay mucha gente que cree otra forma medicina, no sé como aquí en españa, pero en mi país sí. es medicina y medicina otra. eso ya como gente piense. los hospitales, los médicos… bueno, todo eso hay pero cuesta mucho ¿sabe? cuesta dinero. ¿entiende? pero hay todo mismo, pero necesitas dinero, y por eso todos 519 cuidado transcultural y estrategias familiares ante la dependencia: el fenómeno de los cuidadores extranjeros l esperanza begoña garcía-navarro, estrella gualda estamos por todos sitios del extranjero y tenemos que emigrar, ¿sabes?, estar sano cuesta mucho dinero… (ec1. cuidadora rumana, 42 años). se pone de relieve que una gran parte de las diferencias culturales en el hecho de cuidar se vincula, no solo con tradiciones, sino también con la situación socioeconómica de los países de origen, que contribuye a que se mantengan medicinas alternativas. en este sentido, cuidar y ser cuidado conecta tanto con la cultura como con la estructura social, y lo mismo ocurre con las prácticas que se desarrollan. desconocimiento del sistema de atención el inmigrante económico ve alterados todos los condicionantes de su salud de forma que se convierte en una persona vulnerable desde el punto de vista sanitario. a la llegada al país de acogida debe afrontar un duro y complejo proceso en el que influyen cantidad de factores relacionados directamente con el desconocimiento, déficit o ausencia de derechos, las condiciones laborales a menudo precarias, la carencia de apoyo social o familiar, el duelo migratorio, la dificultad para acceder a recursos preventivos, el desconocimiento del sistema sanitario local. el miedo, la desconfianza y la soledad son sentimientos que con frecuencia se presentan en la población que ha inmigrado y pueden relacionarse con la dificultad que presentan para acceder y utilizar los servicios de salud en un contexto de normalidad (37). en cierto modo, el desconocimiento mutuo es una de las causas de que el sistema de salud sea injusto. así, no puede existir equidad cuando tanto el que presta el servicio como el que lo recibe desconoce al “otro”, y no puede producirse el diálogo básico que todos sabemos imprescindible entre sanitario y enfermo (38). la información debe ser bidireccional para que se pueda llamar comunicación y es básica para que puedan proporcionarse buenos diagnósticos y buenos cuidados. el fenómeno del desconocimiento entre los autóctonos y el inmigrante, al igual que el desconocimiento del sistema sanitario por la brecha entre recursos sanitarios del país de origen del que cuida y del país del paciente cuidado, se observa también en nuestro estudio, tal y como se describe en los siguientes fragmentos de las entrevistas realizadas: sí, aquí cuando una persona mayor se pone enferma y llamáis al médico viene muy pronto, no hace falta que esté enferma del corazón (ec1. cuidadora rumana, 42 años). en mi país tardan mucho en venir; puede pasar más de una hora, aunque llamemos para algo urgente; no vienen rápido. a veces incluso dicen cosas como “no hay gasolina para el coche” o “tenemos muchos avisos” (ec3. cuidadora ucraniana, 38 años). las cuidadoras extranjeras, en general, tienen interiorizado el sistema sanitario y los cuidados que se realizan en su país de origen, por lo que tienden a reproducir elementos que son propios del funcionamiento de sus instituciones en las del país de acogida, ante el desconocimiento de su sistema y las barreras de accesibilidad al mismo. choques y diferencias interculturales en la prestación de cuidados y entre los sistemas sanitarios las personas de origen extranjero tienden a reproducir a veces en el país de llegada el sistema sanitario de origen como única estructura sanitaria interiorizada. esto puede provocar dificultades a la hora de afrontar un problema de salud, propio o de la persona a la que se cuida, cuando se es provisora de cuidados, como ocurre de hecho en el caso de las protagonistas de nuestro estudio. este choque o diferencias se ilustran claramente en los siguientes discursos: españa tiene uno de los mejores sistemas sanitarios del mundo en cuanto a prestaciones de servicios y no lo sabemos apreciar realmente porque en verdad ese aspecto de lo que es la sanidad gratuita y aquí en españa en cuanto a la atención médica a la prestación de servicios, respecto a las medicinas que tienes gratuitas para las personas mayores, que también tienes un 40 por ciento para las personas que estamos en activo, es una bendición y se sabe que aquí a españa vienen muchas personas de portugal para hacerse operaciones gratis y el tratamiento gratis para luego retornar a su país” (ep1. varón de perú, 38 años. gestor de una empresa que contrata a cuidadoras extranjeras). en el perú no, tienes que pagar su dinero y los recursos, allí hay mucha corrupción y la economía está muy mal organizada. es un desastre en cuanto a la atención en el campo de salud, a veces confundía la situación social de mi país con la de españa, porque el de españa desconocía totalmente y conocía el mío, entonces pues entraba en un dilema que no entendía uno de otro pero ya habiendo superado con los años y la experiencia pues sí, ahora sí (ep1. varón de perú, 38 años. gestor de una empresa que contrata a cuidadoras extranjeras). 520 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 diferencias lingüísticas y comunicativas: el papel del idioma y las formas de cuidar las barreras de comunicación originadas por el escaso o nulo conocimiento del idioma del lugar de acogida, la diferencia de códigos culturales y la carencia de competencias lingüísticoculturales dentro del sistema sanitario, constituyen dificultades importantes a las que se enfrentan las personas inmigrantes (39). en nuestra población de estudio, se identifica este fenómeno en el discurso de algunas entrevistadas: diferencia respecto a su país, la forma de comunicarse y relacionarse con la gente muchísima aquí el andaluz, el de huelva, vozarrón, gritan y las cosas claras y directas y entonces no es un trato más frío, más seco en cuanto a, claro, a la forma de ser de aquí pero nosotros, los iberoamericanos, somos más suaves, de hablar más tranquilo, más despacio, más cariñoso y eso muchas veces es el aspecto más importante en cuanto al cuidado de las personas mayores, que se ponen como niños y les gusta que los traten con cariño, no con cariño, sino con esa dulzura, la forma diferente de hablar y eso es el atractivo y lo que a veces gusta, y entonces, pues, el comunicarnos, no tenemos problemas más que nada por lo que es el idioma ya te he dicho (ec7. cuidadora colombiana, de 36 años). como se observa en la cita, tan importante puede resultar el manejo del idioma en algunos casos, como las costumbres a la hora de comunicarse con los demás. la cita revela claramente cómo hay una clara conciencia de que una forma de ser más abierta y expresiva puede ser un valor añadido en la prestación de cuidados a mayores. discusión y conclusiones las páginas anteriores han puesto de manifiesto los vínculos que existen entre la diversidad cultural, las percepciones respecto a la salud y la enfermedad, los choques culturales y las estrategias de cuidado que se desarrollan por parte de las cuidadoras y los cuidadores extranjeros que hemos entrevistado. enfermeras/ os y otros profesionales del cuidado, desde su perspectiva, son conscientes igualmente de algunas de estas relaciones, así como las familias. las distintas percepciones sobre la salud, y el conocimiento de prácticas socioculturales en el hecho de cuidar que traen del país de origen, y que contrastan con la del país de destino migratorio, son unas de las diferencias o choques culturales observados. ambos elementos —percepciones y conocimiento de prácticas heredadas del origen— tienen repercusión en algunas de las filosofías y los planteamientos que despliegan al cuidar en destino, así como en las estrategias concretas que desarrollan a la hora de cuidar a personas, y de relacionarse con las familias de los enfermos y las enfermas. también parecen estar repercutiendo en cómo las cuidadoras se integran en el contexto social, cultural e institucional de los cuidados a dependientes de la sociedad receptora. entre otros resultados destacables se encuentran la descripción de algunas prácticas socioculturales que las cuidadoras elaboran según su cultura, y cómo intervienen en el ejercicio de los cuidados llevados a cabo en destino. pero también se pone de relieve cómo la diversidad no es solo derivada del país o la zona de procedencia, sino de aspectos como el grado de formación, o las experiencias profesionales previas, el tipo de sistema sociosanitario y la familia en que se ha estado, etc. se sugiere, por tanto, la importancia de adoptar cuidados culturalmente competentes (13), adecuando para ello aquellos que prestan a la cultura del paciente al que cuidan; valorando, aceptando y respetando la diversidad. con la capacidad, el compromiso y la motivación para la introspección en la propia sensibilidad cultural del cuidador, y siendo conscientes de lo dinámica que es la cultura y cómo esto interviene en la relación y comunicación con el paciente (40). adaptarse para crear espacios en la diversidad de cada una de las personas que necesitan cuidados personalizados, ya que cada individuo es único y producto de sus experiencias, valores y creencias que han sido aprendidos y transmitidos de generación en generación. por ello, si los cuidadores desarrollan estrategias afines a sus propias creencias, sin tener en cuenta las de la persona cuidada, se generan choques culturales cuyos resultados son conductas inadecuadas que inciden en la salud del paciente, según se ha podido documentar en el trabajo de campo. no obstante, conviene insistir en la importancia que las prácticas culturales y otros condicionantes socioeconómicos tienen en los cuidados desarrollados. 521 cuidado transcultural y estrategias familiares ante la dependencia: el fenómeno de los cuidadores extranjeros l esperanza begoña garcía-navarro, estrella gualda referencias 1. gualda e, rodríguez i. huelva, dependencia y solidaridad en las redes familiares. sevilla: instituto de estadística de andalucía; 2008. 2. moya p, escribano f, pardo i. la participación en el mercado laboral de los cuidadores informales de personas mayores en españa. innovar: revistas de ciencias administrativas y sociales. 2012;22(43):55-66. 3. casado-mejía r, ruiz-arias e, solano-parés a. el cuidado familiar prestado por mujeres inmigrantes y su repercusión en la calidad del cuidado y en la salud. gaceta sanitaria. 2012;26(6):547-553. 4. abellán-garcía a, esparza c, díaz-pérez j. evolución y estructura de la población en situación de dependencia. 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2010. 39. cross terry l, et al. defining youth success using culturally appropriate community-based participatory research methods. best practices in mental health. 2011;7(1):94-114. 141 147 primeras paginas.indd 146 aquichan issn 1657-5997 año 13 vol. 13 nº 2 chía, colombia agosto 2013 editorial humanización del cuidado: una meta enraizada en la esencia de enfermería humanizing care: a goal rooted in the essence of nursing humanização do cuidado: uma meta enraizada na essência da enfermagem la humanización de la atención recuperó su esencia en la atención de los servicios de salud; ahora que tanto se habla de medición de los procesos de calidad institucional, este es un criterio fundamental. por ello es primordial expresarlo de manera clara en los principios filosóficos que orientan el quehacer institucional. humanización hace referencia al ser humano, que es todo aquello relativo o perteneciente al hombre y propio de él (1). los seres humanos se caracterizan porque son únicos y trascendentes, existen en relación con otros, están inmersos en un contexto familiar y social, con creencias y valores enraizados en la cultura. tienen capacidad de introspección y por ello una visión de la vida particular y única; su ser es más que un cuerpo físico, posee unas características personales y atributos que lo diferencian de los demás; su existencia adquiere sentido en la medida en que tiene una continuidad entre el pasado y el presente, y una proyección hacia el futuro (2). por ello, desde esta perspectiva humanizante, es fundamental reivindicar la importancia de la visión subjetiva de las personas en la toma de decisiones relacionadas con el tratamiento de los problemas de salud (3). para la enfermería, la humanización como referente de calidad está inmersa en su razón de ser. de hecho, los conceptos centrales del metaparadigma de la disciplina se refieren al ser humano, el cual comprende a los individuos, las familias y los grupos de la comunidad, sujetos del cuidado de enfermería (4). el ambiente se refiere a las personas significativas, al entorno físico donde se establece la relación de enfermería y a la percepción que tienen las personas acerca de este, basada en su conocimiento y sus experiencias previas. el concepto de salud da cuenta de los procesos de vivir y morir, y el de enfermería, de las acciones que desarrollan las enfermeras(os), junto con los seres humanos, para alcanzar las metas de salud propuestas (4). en torno a estos conceptos se ha consolidado el desarrollo científico de enfermería en modelos conceptuales y teorías que los describen desde una perspectiva humanista, para ampliar el conocimiento sobre el cuidado de la salud humana como fenómeno de interés de la disciplina. cody (5) define el cuidado como “una interacción reconocible y estructurada, a través de la cual las personas proveen y reciben asistencia, para atender sus necesidades básicas en la condición de salud en que se encuentran”. los modelos conceptuales y las teorías que describen estos conceptos —como los de roy, orem, leinninger, watson, newman, parse, peplau, king y levine, entre otros— constituyen el referente teórico que fundamenta la práctica profesional basada en la evidencia. en la medida en que se comprenden —desde la visión humanística que caracteriza nuestra razón de ser y nuestro quehacer— se garantiza la atención humanizada que demandan las personas y que requieren los servicios para alcanzar los estándares de calidad. una atención humanizada se caracteriza por el interés del personal de salud por identificar las necesidades particulares de las personas y su familia; por comprender el significado que tiene para ellas la situación que están viviendo, conocer sus experiencias anteriores, su cultura, sus creencias y valores. por esta razón es fundamental la comunicación permanente con el paciente. de igual manera, en la calidad de la atención al paciente son determinantes el verdadero interés que el profesional de en147 referencias 1. real academia española. diccionario de la lengua española, 2001. [visitado jul. 2013]. disponible en: http://www.rae.es 2. todres l, galvin kt, holloway m. the humanization of healthcare: a value framework for qualitative research. international journal of qualitative studies on health and well-being. 2009;4:68-77. 3. cuéllar z. la trascendencia del acto humano en la medicina como acto humano humanizante. pers.bioét. 2004;8:34-43. 4. fawcett j, de santo madeya s. contemporary nursing knowledge. analysis and evaluation of nursing models and theories. 3rd edition. philadelphia: f.a. davis; 2013. 5. cody w. philosophical and theoretical perspectives for advanced nursing practice. 4th edition. boston: jones and bartlett publishers; 2006. fermeía demuestra por ayudarlo a él y a su familia a encontrar sentido a la experiencia que está viviendo; el apoyo emocional y espiritual; el respeto por sus creencias y valores; el fomento de su autodeterminación para tomar decisiones informadas y libres frente a su condición de salud y de asumir la responsabilidad del cuidado de la misma. por lo anterior aquichan, a través de las propuestas de sus autores, presenta estrategias para promover la humanización del cuidado y ejercer el liderazgo en los servicios de enfermería, y permite la aproximación al contexto vivencial del otro, a fin de comprender la dimensión humana y social de las personas en la condición que están viviendo. los artículos destacan este aspecto en las personas que buscan protección por una condición de maltrato, en los padres de niños con cáncer que tratan de encontrar un significado positivo a la condición que están viviendo sus hijos, en las madres con hijos menores de un año que buscan afianzar sus vínculos afectivos y fortalecer la vivencia de la maternidad, y en hombres y mujeres con enfermedad crónica. del mismo modo, en los resultados de los estudios se plantea la importancia de desarrollar proyectos encaminados a promover estrategias de afrontamiento y adaptación de los familiares de pacientes en un estado crítico de salud, la trascendencia de identificar oportunamente las necesidades de las personas en condición de discapacidad para prevenir complicaciones y favorecer los procesos de recuperación y rehabilitación. esperamos que los lectores encuentren en nuestra publicación elementos que los ayuden a liderar una práctica humanizada del cuidado, en beneficio de las personas que reciben nuestro servicio y en el de los enfermeros y enfermeras de todo el mundo abanderados de esta causa. maría elisa moreno-fergusson profesora titular y decana facultad de enfermería y rehabilitación universidad de la sabana mariae.moreno@unisabana.edu.co primeras paginas.indd 5 editorial la familia como sujeto de cuidado the family as a care subject a família como sujeito de cuidado uno de los conceptos centrales del metaparadigma de enfermería es el de ser humano, que comprende al individuo, a la familia y a los grupos comunitarios y de otro tipo (1). la familia es una unidad que precisa ser reconocida y que está conformada por seres humanos y, como una unidad, necesita de cuidados de enfermería y de autocuidados. en este número de aquichan se publican algunos artículos que tienen relación con la familia desde diferentes perspectivas, por lo cual es importante destacar la importancia que tiene este fenómeno para la disciplina de enfermería. la familia puede ser considerada como un grupo de personas que están relacionadas entre sí por patrones o roles específicos y, por tanto, crea y mantiene una cultura común (2). el propósito del sistema familiar es transmitir cultura, esto es, perdurar y ajustarse a los cambios y mantener la congruencia con su ambiente (3). la cultura de la familia es la suma de todos los procesos familiares en un punto determinado en el tiempo; su estabilidad se mantiene a partir de la transmisión de patrones y valores estables de una generación a la siguiente. el crecimiento también es posible en el sistema familiar y se da a través de patrones culturales transformados, donde cada miembro de la familia obtiene nuevas ideas, realizaciones y conocimiento que van a influenciar a otros y a cambiar su sistema personal. es importante tener a la familia como una unidad, como un sistema en el cual cualquier alteración en alguno de sus miembros implica disfuncionalidad en su totalidad. la familia constituye un sistema en todo el sentido de la palabra, en tanto que está formada por un conjunto organizado de elementos que se relacionan e interactúan entre sí, de tal manera que cualquier acción, alteración o cambio en uno de ellos repercute en todos los demás (4). históricamente la enfermería se ha enfocado en los individuos y, en consecuencia, la familia ha pasado a ser un agregado, es decir, ha sido vista como un contexto y no como un sujeto de cuidado. pero en los últimos años la enfermería familiar ha tenido grandes avances y se ha logrado posicionar a la familia como un fenómeno focal en la disciplina (5). así, la familia puede ser vista como esa unidad de cuidado en la que se interviene a la persona, o como una totalidad. los profesionales de enfermería pueden optar por una u otra dependiendo del nivel de competencia que se tenga (6). los artículos que se publican en este número de la revista abordan algunos de los aspectos mencionados que son importantes para la salud familiar y determinan el rol de enfermería en el cuidado de esta como unidad: el impacto que tiene la hospitalización de un niño para los padres y la importancia del soporte social que brindan los familiares a los bebés hospitalizados; la esperanza como una experiencia que favorece el afrontamiento de los padres ante una enfermedad crónica como el cáncer en los hijos. y, finalmente, se presenta un artículo sobre las experiencias de los ancianos institucionalizados, quienes tienen que abandonar las costumbres y los patrones que traían de sus hogares a cambio de algunos beneficios, perdiéndose así el concepto de unidad familiar. cuidar desde un enfoque familiar implica incluir a la familia en el proceso de prestación de cuidados. es así como ella se con6 aquichan issn 1657-5997 año 13 vol. 13 nº 1 chía, colombia abril 2013 referencias 1. fawcett j. contemporary nursing knowledge. analysis and evaluation of nursing models and theories. 2 edition. philadelphia: fa davis company; 2005. 2. roy c. stabilizer and innovator control process. the roy adaptation model. 3 edition. new jersey: pearson; 2008. 3. fridemann m. the framework of systemic organization. a conceptual approach to families and nursing. newbury park: sage; 1995. 4. apolinar i, fernández m. familia: introducción al estudio de sus elementos. méxico d.f.: editores de textos mexicanos; 2008. 5. torres l, morales a. participación familiar en el cuidado del paciente crítico. recomendaciones de la sociedad andaluza de enfermería de cuidados críticos. tempus vitalis rev internacional para el cuidado del paciente crítico 2004;4(1):18-25. 6. leon am, knapp s. involving family systems in critical care nursing. dimensions of critical care nursing 2008;27(6):255-262. vierte en un estímulo favorable para la recuperación de la salud de alguno de sus miembros. el profesional de enfermería debe tener una preparación rigurosa para el trabajo con familias a fin de desarrollar en estas un sentimiento de unidad y promover la cooperación, el apoyo mutuo y la coordinación; propiciar algunas formas de adaptación a las diferentes situaciones a las que se deben enfrentar en el transcurso de su ciclo vital; ver a las familias como cuidadoras de sus propios miembros, e identificar el hogar como el lugar en el que viven el paciente y sus familiares. beatriz pérez giraldo directora programa de enfermería y rehabilitación universidad de la sabana beatriz.perez@unisabana.edu.co 91 96 primeras paginas.indd 95 editorial metodologías para la aplicación del conocimiento teórico de enfermería methods for applying theoretical nursing know-how metodologia para a aplicação do conhecimento teórico de enfermagem en editoriales anteriores me he referido a la importancia que tiene el desarrollo del conocimiento disciplinar para la enfermería y su aplicación en los diferentes ámbitos del ejercicio profesional (docencia, cuidado de la salud de las personas e investigación). este aspecto fundamental para el reconocimiento de enfermería como ciencia ha sido motivo de estudio por parte de los teóricos de la disciplina quienes, consecuentes con las exigencias y el perfeccionamiento de todas las ciencias se dieron a la tarea de definir y desarrollar modelos y teorías propios de enfermería. son modelos que pretenden describir, explicar y predecir los fenómenos de interés de la disciplina a fin de llegar a prescribir las intervenciones que se requieren para atender las necesidades de cuidado de las personas, de las familias y de grupos de la comunidad. en este proceso de desarrollo del conocimiento científico de enfermería se han tenido en cuenta los aportes de la filosofía a la ciencia, y la aplicación de distintas metodologías que tienen como propósito reducir la brecha entre la teoría y la práctica. según fawcett (1), la filosofía apunta al desarrollo del conocimiento y a comunicar aquello que es valioso y cierto para los miembros de una disciplina. en enfermería, las corrientes filosóficas que mayor dominio han ejercido son el positivismo, el pospositivismo, el paradigma interpretativo y el paradigma de la crítica teórica social (2), cuya influencia ha generado cambios positivos en la medida en que su estudio ha motivado a los profesionales a pensar sobre qué es enfermería, cómo quieren que sea su práctica y cómo deben desarrollar el conocimiento. con ello han visto la necesidad de establecer un equilibrio en la utilización de los métodos cualitativos y cuantitativos en el desarrollo de la investigación. los avances del conocimiento en enfermería han sido también resultado de la aplicación de metodologías que nos dan el know how para la construcción y validación del conocimiento con el propósito de comprender los fenómenos de enfermería en todas sus dimensiones y para “traducir” el conocimiento teórico en el mundo real de la práctica profesional. algunas de las más empleadas son el análisis de conceptos, la construcción y aplicación de teorías de rango medio, y la investigación que prueba teoría, entre otros. puede decirse que el análisis de conceptos es el primer paso para el desarrollo teórico de enfermería. en la práctica profesional, las enfermeras acuden a esos conceptos que trascienden los signos y los síntomas de una patología y que, de hecho, constituyen la esencia del cuidado porque reflejan las experiencias que viven las personas en una condición de salud determinada y, por ello, su comprensión determina el “tono humano” de la práctica (3). los conceptos son los elementos fundamentales de las teorías y el análisis de los mismos es esencial para identificar sus atributos y establecer parámetros de medición que favorezcan la práctica basada en la evidencia (4). la construcción de teorías de rango medio ha sido esencial para la aplicación de la teoría en la práctica. estas, a diferencia de los modelos conceptuales, se caracterizan porque se enfocan 96 aquichan issn 1657-5997 año 12 vol. 12 nº 2 chía, colombia agosto 2012 referencias 1. fawcett j. contemporary nursing knowledge. analysis and evaluation of nursing models and theories. 2nd edition. philadelphia: f.a. davis; 2005. 2. weaver k, olson j. understanding paradigms used for nursing research. journal of advanced nursing 2006, 53 (4); 459-469. 3. cutcliffe jr, mc kenna hp. the essential concepts of nursing. edinburgh: elsevier churchill livingstone; 2005. 4. walker lo, avant kc. strategies for theory construction in nursing. new jersey: prentice hall; 2005. en una dimensión particular de la realidad, tienen un número limitado de conceptos, y son de gran utilidad para comprender y estudiar los fenómenos derivados de la práctica. uno de los métodos que se emplean para desarrollar estas tesis es la derivación teórica, el cual consiste en construir un planteamiento teórico, a partir de otro ya descrito, que contiene elementos que favorecen la introspección y comprensión del fenómeno que se desea estudiar. este método es particularmente útil cuando la información disponible es escasa (4). por último, la investigación que prueba teoría es un proceso fundamental para la aplicación de la teoría en la práctica. este tipo de estudio utiliza modelos estadísticos para determinar la relación que tienen cada uno de los conceptos con el planteamiento teórico propuesto, y es fundamental a la hora de validar la aplicación de la teoría en situaciones determinadas, como lo reflejan los resultados de investigaciones adelantadas por diferentes profesionales de enfermería, cuyos artículos publicamos en esta edición de aquichan. en las páginas siguientes, diferentes autores latinoamericanos reflejan el interés y la firmeza por avanzar en el desarrollo del conocimiento en enfermería para facilitar la aplicación de la teoría en la práctica. maría elisa moreno-fergusson 57 68 analisis de concepto decision de cambio.indd 57 erick landeros-olvera1 raquel benavides2 keville frederickson3 maría del carmen martínez-reyes4 marisol celis-garcía5 análisis de concepto: “decisión de cambio” para mejorar las conductas de salud en el contexto de las enfermedades crónicas en adultos 1. doctor en ciencias de enfermería. presidente del colegio mexicano de licenciado en enfermería a.c. filial puebla. erick_landeross@hotmail.com 2. doctor en ciencias de enfermería. profesora de la facultad de enfermería de la uanl. rabenavi@gmail.com 3. doctorado en ciencias de enfermería. the city university of new york. keville.frederickson@lehman.cuny.edu 4. maestra en ciencias de enfermería. investigador, benemérita universidad autónoma de puebla (fe-buap). maria.dcmartinez@correo.buap.mx 5. estudiante de licenciatura, benemérita universidad autónoma de puebla (fe-buap). marisol.celis@correo.buap.mx recibido: 9 de febrero de 2012 aceptado: 25 de febrero de 2013 año 13 vol. 13 nº 1 chía, colombia abril 2013  57-68 resumen objetivo: a fin de contribuir con la clarificación y el desarrollo de conceptos útiles para la ciencia de enfermería en su práctica, este trabajo utilizó la metodología de rodgers con el fin de proporcionar una definición del concepto “decisión de cambio” (dc) para el mejoramiento de conductas de salud en el contexto de las enfermedades crónicas (obesidad, hipertensión arterial y diabetes). método: se realizó el análisis de evidencia empírica en bases de datos para identificar atributos, términos subrogados, antecedentes y consecuencias en relación con el concepto dc. de forma complementaria se aplicaron entrevistas semiestructuradas con codificación abierta. resultados: la decisión de cambio es definida, entonces, como el proceso de elección que requiere de intención y actitud para comprometerse con responsabilidad en el mejoramiento de la conducta de salud, de manera efectiva y permanente respecto de las condiciones sociales y emocionales a las que una persona es sometida ante la presencia de una enfermedad crónica y que requiere de manera impostergable el apoyo familiar y profesional de salud. conclusión: la decisión de cambio es un juicio de elección que requiere de voluntad permanente para cambiar las conductas de salud y resolver las posibles contingencias que pueda provocar una enfermedad crónica. palabras clave enfermería, salud, enfermedad crónica. (fuente: decs, bireme). 58 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 analyzing “decision to change” in order to improve health care behavior in adult chronic disease abstract objective: in order to clarify and develop useful concepts for nursing practice, this study used rodger’s methodology with the purpose of defining “decision to change” (dc) and thus improve health care behavior when dealing with chronic disease (obesity, hypertension, diabetes). method: empirical evidence found in databases was analyzed in order to determine the attributes, subrogated terms, background and consequences in the dc concept. to complement this, semi-structured open coded interviews were also applied. results: thus, the “decision to change” can de defined as electing an intention and an attitude to responsibly commit towards effectively and permanently improving behavior towards the social and emotional conditions surrounding a persona affected by chronic disease, who requires immediate support from family and health care providers. conclusion: decision to change is a deliberate election that requires permanent determination to change health care behavior and solve eventual contingencies resulting from chronic illness. key words nursing, health, chronic disease. (source: decs, bireme). análise de conceito: “decisão de mudança” para melhorar as condutas de saúde no contexto das doenças crônicas em adultos resumo objetivo: a fim de contribuir com a classificação e o desenvolvimento de conceitos úteis para a ciência de enfermagem no contexto de sua prática, este trabalho utilizou a metodologia de rodgers com o propósito de proporcionar uma definição do conceito “decisão de mudanças” (dm) para o melhoramento de condutas de saúde no contexto das doenças crônicas (obesidade, hipertensão arterial e diabetes). métodos: realizou-se a análise de evidência empírica com bases de dados para identificar atributos, termos substitutos, antecedentes e consequências com relação ao conceito dm. de forma complementar, aplicaram-se entrevistas semiestruturadas com codificação aberta. resultados: a dm é definida, então, como o processo de eleição que requer intenção e atitude para comprometer-se com responsabilidade no melhoramento da conduta de saúde, de maneira efetiva e permanente, com respeito às condições sociais e emocionais às quais uma pessoa é submetida na presença de doenças crônicas e que requer de maneira urgente o apoio familiar e profissional de saúde. conclusão: a dm é um julgamento de escolha que requer vontade permanente para mudar as condutas de saúde e resolver as possíveis contingências que possa provocar uma doença crônica. palavras-chave enfermagem, saúde, doença crônica. (fonte: decs, bireme). 59 análisis de concepto: “decisión de cambio” para mejorar las conductas de salud en el contexto de las enfermedades crónicas en adultos l erick landeros-olvera introducción el perfil epidemiológico en el continente americano señala que las enfermedades crónicas (ec) como la obesidad, la hipertensión arterial (hta) y la diabetes mellitus tipo 2 (dmt2) representan las principales causas de morbilidad y mortalidad; hoy en día constituyen epidemias en la población adulta, y han superado las fronteras socioeconómicas y aquejan por igual a ricos y a pobres (1). de acuerdo con las estadísticas, méxico es el segundo país con más casos de obesidad en el mundo (2), el sobrepeso en conjunto con la obesidad afectan al 70 % de toda la población entre los 30 y 60 años en ambos sexos (3), y el problema es aún mayor porque la obesidad es considerada un factor de riesgo directamente relacionado con otras enfermedades crónicas, por ejemplo, la cifra promedio de las personas que padecen hipertensión arterial más obesidad es del 77,5 %, y en personas con diabetes la cifra alcanza el 80 %; estos padecimientos causan 50 mil muertes al año (4-7). una vez que el padecimiento crónico es diagnosticado y los síntomas se hacen presentes, las personas contemplan con determinante decisión cambiar la forma de cuidar de su salud, pero ¿por qué lo hacen? ¿qué es lo que condiciona o propicia la decisión de cambio? hoy en día es claro que la dmt2, la hta y la obesidad son consecuencia de conductas que no favorecen la salud y que dependen a su vez de factores de riesgo no modificables como el sexo y la condición genética, en consecuencia, estos padecimientos solo pueden controlarse, no se curan. es por ello que entender el concepto “decisión de cambio” para mejorar conductas de salud en personas que ya tienen el padecimiento es primordial a fin de controlar la posible generación o exacerbación de síntomas que puedan desarrollar complicaciones. es imperativo comprender cómo es que se ha desarrollado este concepto en aquellos que han superado el problema y que mantienen bajo control las ec, es decir, aquellas personas que han conseguido mejorar sus conductas de salud reflejadas en el control de las cifras de hipertensión, la hiperglucemia y la reducción de peso. lo anterior, teóricamente, podría ser útil para la prevención, ofreciendo un soporte empírico para las investigaciones que traten el tema de enfermedades crónicas. de acuerdo con el estado del arte, el concepto de interés no tiene evidencia en el desarrollo de su aplicación en enfermería, ni ha sido del todo dinámico, no ha sido clarificado y no se ha utilizado desde un punto de vista pragmático en el contexto de enfermedades crónicas en adultos. el propósito de este trabajo es analizar y proporcionar una definición del concepto “decisión de cambio” para el mejoramiento de conductas de salud en el contexto de las ec en adultos, con el fin de obtener una comprensión clara para su utilidad en las intervenciones de enfermería en el contexto social, y que sirva para desarrollar instrumentos para la investigación dentro del primer nivel de atención para la salud utilizando la práctica basada en la evidencia (8). antecedentes tradicionalmente el concepto “decisión” se utilizaba en las ciencias matemáticas, económicas y en la estadística (9). desde la década de los setenta el concepto ha sido utilizado por los psicólogos en el ámbito del estrés como proceso de conducta en la toma de decisiones ante situaciones críticas (10). el diccionario de la lengua española (11) presenta dos definiciones para el concepto decisión: 1) determinación, resolución que se toma o se da en una cosa dudosa; 2) firmeza de carácter. la definición del oxford dictionary of american english (12) señala que es una conclusión o resolución para llegar a alcanzar acciones futuras, después de considerar un juicio firme de resolución. bajo estas premisas, el objetivo de utilizar el concepto “decisión de cambio” es para mejorar las conductas de salud con el interés particular que representan en la prevención y control de ec. este concepto tiene una serie de atributos que se identifican en diferentes contextos y denotan posturas filosóficas o disciplinares particulares relacionadas, pero su análisis finalmente resultará de una revisión exhaustiva de literatura y entrevistas que arrojen como resultado una definición útil del concepto. método el análisis de la literatura se realizó bajo la perspectiva de análisis de rodgers (13) e incluyó a las disciplinas de psicología, sociología y, preferentemente, enfermería y medicina. el periodo de búsqueda se realizó durante los años de 1997 a 2011. los idiomas de elección fueron el español y el inglés en las siguientes bases de datos: cuiden, cinahl, lilacs, medline y la base de datos de la universidad de austin, texas. la búsqueda se enfocó en los resúmenes y de estos se seleccionaron los artículos de interés, se utilizaron palabras clave y términos subrogados en la búsqueda de literatura como: resolver, solucionar, solventar, determinación, voluntad y disposición; adicionalmente, se buscó la palabra “cambio”. estos términos se determinaron con base en 60 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 el diccionario de la lengua española (11) y el oxford dictionary of american english (12). el muestreo se realizó por conveniencia encontrando en la literatura un total de 39 artículos relacionados con el concepto de interés, de los cuales fueron seleccionados 25 por la relación directa con la temática. de acuerdo con la disciplina se encontraron doce artículos de enfermería, nueve de medicina, dos de sociología y siete de psicología. resultados para el proceso de análisis del concepto de interés se expusieron sus atributos, el contexto donde se ha desarrollado, los antecedentes, las consecuencias, los términos subrogados y los relacionados. 1. los principales atributos fueron proceso y control, los cuales aparecieron repetidamente en varios de los artículos (1417). los autores señalan que algunos comportamientos son difíciles de modificar porque no son fácilmente controlables, requieren de un proceso que incluye mejorías, recaídas, frustración y resentimiento, que finalmente resultan en el control del comportamiento. para que este proceso sea exitoso y la conducta se pueda controlar, se requiere de algunos otros atributos como la responsabilidad (15) y el compromiso (18), los cuales deben ser compartidos, es decir, no solo deben recaer en el personal de salud, es necesario buscar la responsabilidad y el compromiso del paciente, y esto se logra cuando el personal de salud le otorga el poder (15), atributo que en la toma de decisiones incluye al autocuidado que resulta en el apego al tratamiento exitoso y efectivo a largo plazo. esta acción por parte del personal de salud involucra a los enfermos con el conocimiento de sus padecimientos, lo que resulta en un atributo más: la búsqueda (16), la cual ayuda a incrementar el conocimiento de nuevas alternativas de tratamiento e innovaciones en tecnología; la búsqueda llega a ser permanente e incita al paciente a valorar constantemente diversas opciones existentes a fin de decidir sobre la mejor alternativa para cuidarse (en pacientes con diabetes se ha demostrado que a menor conocimiento sobre la enfermedad, menor toma de decisión con respecto al tratamiento) (19). las personas con ec requieren enfrentar nuevos retos en la vida y vislumbrar los cambios de conducta como nuevas oportunidades. se precisa tomar riesgos que vinculen al paciente activamente en los comportamientos que promuevan la salud, para ello se requiere de otros atributos del concepto: el coraje (20) (carácter) y la actitud (21) que indiscutiblemente son fundamentales para lograr la "decisión de cambio" en la conducta de salud. finalmente, los atributos de autodirección y autodeterminación (14). el primero se refiere al deseo de progreso, apertura a la experiencia, sentimiento de libertad, espontaneidad, confianza en uno mismo para tomar decisiones con objetivos trazados, con dirección. con respecto a la autodeterminación en una persona que padece alguna enfermedad crónica, es una etapa donde el enfermo se hace dueño en alguna medida de su propia vida porque controla algunas de sus contingencias, como tomar en consideración el sentido de prevención para controlar síntomas de alarma ante una elevada presión arterial o una hiperglucemia y, en consecuencia, tomar acciones para no verse inmiscuido en esos problemas, por ejemplo: comer sano, hacer ejercicio, controlar su estrés, conservar el peso, entre otros. 2. el concepto se ha desarrollado en el contexto de diferentes disciplinas. con respecto a enfermería y medicina, este ha sido manejado de forma implícita al explicar la manera en que las personas pueden cambiar sus estilos de vida con respecto a las conductas que favorecen la salud, sin embargo, la mayoría de los artículos encontrados en la disciplina médica han demostrado ser aún muy puntuales desde el punto de vista biológico, es decir, se centran en los mecanismos de la enfermedad crónica, la epidemiología y el tratamiento, relacionados con los ámbitos del sistema de salud y servicios hospitalarios. por otra parte, en enfermería minoritariamente se centran en la atención personalizada, el cuidado de la familia con enfermos crónicos y la atención holística que requiere la comunidad. la psicología y la sociología han tratado de explicar las conductas y sus cambios a través de diversos modelos, estudiando a las personas con ec desde un punto de vista que apoya el tratamiento y el cuidado, porque incluyen el contexto de salud y sus determinantes sociales. los trabajos de sociología contienen metodología cualitativa, tratan de explicar la perspectiva de las enfermedades crónicas desde el punto de vista del enfermo (16, 22-26), lo que ha resultado en la evidencia de conocimiento sumamente valioso para la atención de estas enfermedades y la comprensión de quienes las padecen. 61 análisis de concepto: “decisión de cambio” para mejorar las conductas de salud en el contexto de las enfermedades crónicas en adultos l erick landeros-olvera 3. los antecedentes del concepto son variados, se enfocan en el proceso que experimenta un individuo para incorporar la "decisión de cambio". entre los más significativos se encuentra la afección familiar (17, 21, 27) cuando uno de sus miembros padece alguna enfermedad, y los cambios de roles (17, 27). dentro del grupo familiar, de acuerdo con la evidencia, los cónyuges son la primera fuente de cuidados para las personas que están casadas, y los hijos la segunda, sin embargo, se reconoce que las madres y las hijas ocupan el primer lugar como cuidadores primarios (17). por otro lado, el rol de cuidador no es asumido por las personas con enfermedades crónicas (autocuidado) dado que, a falta de síntomas que incapaciten su vida cotidiana, no requieren o no perciben la necesidad de obtener ayuda; las enfermedades como la hta y la dmt2 son comúnmente llamadas “silenciosas”, y mientras no causen dolor o incapacidad como la obesidad, las personas no se perciben enfermas (28). con estos antecedentes, el individuo implicado y su familia experimentan la difícil situación de decidir sobre la conveniencia de los tratamientos cuando se hace evidente que la salud ha sido afectada, porque antes no había sido necesario. en ese justo momento es cuando la estabilidad familiar empieza a dañarse, los roles empiezan a cambiar, las habilidades de los cuidadores adquieren un papel importante dado que comienzan a desarrollar destrezas específicas, y la economía es mucho más planificada máxime cuando el soporte principal de la familia es precisamente el que padece la enfermedad (29). otro antecedente son las presiones sociales (30). la adopción de nuevos patrones de conducta está influenciada por diversas formas de presión, por un lado, toda la mercadotecnia de la comida no nutritiva es anunciada en la televisión y la radio como principales medios masivos de comunicación, por otro, los aparadores de las tiendas muestran ropa de moda que únicamente las personas delgadas podrían usar, aunado a que el estereotipo del cuerpo humano mejor aceptado es el delgado, y en muchas de las situaciones de forma extrema, tal como se observa en las mujeres que se dedican al modelaje. ambas posturas son controversiales y son factores externos al individuo. socialmente la presión en las personas con obesidad es cruel, pues constantemente se les suele decir “gordo, obeso” y muchos otros sobrenombres que hieren susceptibilidades. considerando la relación que tiene la obesidad con la hta y la dmt2, la presión social incita a las personas a renunciar a ciertas satisfacciones (31) y a cambiar su forma actual de conducta como el comer sal, postres, grasa; por otro lado, no vestir lo que le gusta porque el sobrepeso los incita a adoptar patrones más sanos de comportamiento. la dieta y el ejercicio han sido las principales conductas con las que se han enfrentado las enfermedades crónicas en adultos (32), sin embargo, la deserción es muy alta porque no se llega a una fase de mantenimiento de las mismas a pesar de conocer los riesgos (33). dentro de los antecedentes más importantes se halló en algunos artículos la experiencia previa, al respecto existe una percepción de riesgo y beneficio (34). la percepción de beneficio es un antecedente común en las personas que han tratado de mantener conductas saludables y han experimentado sus bondades tanto físicas como mentales; por otro lado, el riesgo incluye a aquellos individuos que han tenido problemas con las manifestaciones de la enfermedad crónica dado que solo lo perciben cuando se está afectando gravemente su salud. así, tanto la percepción de riesgo como la de beneficio, a pesar de ser dos posturas opuestas son complementarias, y constituyen antecedentes fundamentales para iniciar y mantener conductas de ejercicio, buena alimentación, eliminar el consumo de tabaco y disminuir el estrés. cuando las personas deciden autocuidarse comúnmente se tiene el antecedente de haber reforzado su cambio de conducta a través de pláticas previas con el personal de salud (15, 18, 21, 23, 27, 31, 32), principalmente con las enfermeras y los psicólogos quienes motivan a la persona a decidirse por adoptar un nuevo estilo de vida. uno de los antecedentes más claros en la "decisión de cambio" es la pérdida de la función o habilidad para mantenerse en el trabajo (imposibilidad de trabajar) (16). cuando las personas sufren los estragos de una enfermedad que las incapacita no son las mismas y se vuelven dependientes de quienes las cuidan, esta situación provoca sentimientos de tristeza, dolor, llanto y llegan a la depresión por no poder controlar la enfermedad; finalmente, para los que toman la "decisión de cambio", la imposibilidad de trabajar los incita a adoptar nuevos estilos de vida a fin de recuperar la salud. esta situación se concatena con el antecedente de la motivación familiar (30), si la familia está bien organizada, muestra cohesión entre sus miembros y existe buena comunicación, la motivación para adoptar estilos de vida saludables es menos traumática. 62 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 4. entre las principales consecuencias se encuentra el cambio de conducta (17, 25, 27, 30, 31, 33, 34-36) que en realidad es la decisión esperada en la mayoría de las personas con enfermedades crónicas. sin embargo, este cambio de conducta para mantener hábitos saludables no es tan exitoso pues en muchas ocasiones es esporádico, un impulso de motivación limitada que no dura más de seis meses o no se adopta en más de dos años para considerarla como un éxito (37). un ejemplo muy conocido es cuando se decide dejar el cigarrillo, siempre existe la posibilidad de recaída y deserción o se retoma, pero finalmente se abandona (38). existen muchos casos exitosos, pero para lograr el soporte conductual se requiere del cambio de comportamiento de toda la familia (17, 20, 21, 27, 35) como consecuencia de la toma de decisiones en el cuidado de la salud. esto significa que las responsabilidades son compartidas (15), cada uno de los miembros de la familia deberá poner de su parte para cambiar sus conductas en beneficio de quien padece la enfermedad crónica, así en conjunto la familia empieza a des-aprender malos comportamientos (20) que afecten a la salud, lo cual no es una tarea fácil, pero es una de las consecuencias que dan mayor soporte a la "decisión de cambio" en el contexto de las enfermedades crónicas y que solo se logra con el tiempo y la perseverancia, no es un efecto inmediato. una de las consecuencias más deseadas por parte de los enfermos es no sentir los síntomas de la enfermedad; cuando se decide cambiar y se logra mantener la conducta, disminuyen las preocupaciones (15) porque se mantiene el control de las manifestaciones (16) y esto es consecuencia de la eficacia en la salud nutricional, el control del peso y la actividad física regular, que en conjunto provocan un sentimiento de satisfacción (39). no obstante, la mayoría de las personas que tienen éxito cuando han decidido cuidarse procuran mantener la expectativa (20) porque saben que la enfermedad crónica no se cura, y en cualquier momento podrían tener problemas de salud si abandonan su nuevo estilo de vida. 5. los términos subrogados para el concepto "decisión de cambio" fueron: juicio (17), relativo a una introspección del individuo que le permite valorar las ganancias potenciales frente a potenciales pérdidas; la "decisión de cambio" para mejorar las conductas de salud es un juicio permanente. elección (17), referente a una alternativa específica, cuando la decisión es procesada solo se puede obtener una parte de los resultados; si la decisión es determinante, conforme pasa el tiempo los nuevos hábitos son la única elección. control (14) sobre uno mismo; la "decisión de cambio" es considerada como un control en el sentido de recuperar la salud y regular su propio entorno. voluntad (21), para apegarse a un patrón de conducta que favorezca la salud se requiere de una actitud positiva a fin de seguir el cambio de comportamiento; decidir en un conflicto significa resolver (15) la ambivalencia que ayude a realizar efectivamente las acciones necesarias sobre las nuevas alternativas de cuidado, y seleccionar a priori las expectativas de resultado convenientes para la salud. estilos de vida (25), entendidos como una forma de vida que se basa en patrones de comportamiento identificables determinados por la interacción entre las características personales individuales, las interacciones sociales y las condiciones de vida socioeconómicas y ambientales. afrontamiento (22), que constituye un mecanismo cognitivo que puede intervenir en la adaptación a la enfermedad y facilitar el ajuste psicológico del paciente, lo que se ha relacionado con la adhesión al tratamiento. 6. los términos relacionados fueron: intención (30) de llevar a cabo distintas formas de conducta saludable; la intención parece determinada básicamente por la percepción del control sobre la conducta y el balance coste-beneficio de la misma (expectativa de control y de resultados). la intención es uno de los elementos que finalmente contribuyen a la iniciación y el mantenimiento del cambio de conducta. dilema (17) y conflicto (37) con respecto a las decisiones en los problemas de salud. estos términos son internos y requieren de solución; las personas con ec tiene la alternativa (36) de modificar su conducta para mantener o recuperar su salud, o continuar con los mismos hábitos que los hacen sentirse placenteros o que son una rutina muy arraigada que forma parte de lo cotidiano, pero que saben que finalmente los perjudica. por ejemplo, utilizar el automóvil para trasladarse a muy cortas distancias, mantenerse todo el día sentado en la oficina, acostarse por varias horas a ver el televisor con el control del mismo en la mano, tomar refresco todos los días a la hora de los alimentos o disfrutarlo con alimentos no nutritivos, fumarse un cigarrillo al amanecer antes de cualquier otra cosa, subir por el ascensor en vez de tomar las escaleras, bajarse del autobús lo más cerca posible a la oficina, etc. todo esto responde a un estilo de vida predeterminado, y cuando se manifiesta la enfermedad y causa problemas de incapacidad, es cuando cobra significado adoptar nuevos patrones de conducta (15, 18). 63 análisis de concepto: “decisión de cambio” para mejorar las conductas de salud en el contexto de las enfermedades crónicas en adultos l erick landeros-olvera la expresión cambio en el estilo de vida (21, 35, 39, 40) es a menudo relacionada con la "decisión de cambio" en el contexto de las enfermedades crónicas, allí se incluye el cambio en creencias, comportamientos como el alimentario, los hábitos para la prevención como el ejercicio, apego al tratamiento farmacológico, cambios en rutinas establecidas que incluyen las familiares para adoptar nuevos patrones de conducta y autocuidado (15, 28, 40, 41). si en la persona con ec existen dudas acerca de la decisión que va a tomar, o no conoce qué va a resultar si decide o no solucionar el conflicto con respecto a su cambio de conducta, siempre se mantiene la incertidumbre o la incapacidad de construir un significado ante la enfermedad. un término relacionado con la decisión de cambio es el compromiso (21), que representa responsabilidad activa por parte del paciente y de la entidad de salud que lo atiende. cuando una persona es diagnosticada con alguna enfermedad crónica, el compromiso es hacerse responsable de esta, no tanto con la salud, pues esta ya no existe, sino en cuanto a enfrentar nuevos retos en la vida (20). 7. hallazgos adicionales: se aplicaron entrevistas semiestructuradas a seis personas que padecen enfermedades crónicas y que han podido mantenerlas bajo control, con la finalidad de buscar los elementos relacionados que propiciaron la decisión de mejorar sus conductas de salud. el análisis de las entrevistas se realizó en un nivel de codificación abierta con el programa atlas.ti 5.2 (42) en cuatro categorías (figura 1). a continuación se explican y se muestran junto con algunas de sus expresiones. categoría familia. referida al grupo de personas que viven juntas y que comparten condiciones, opiniones, conductas de salud y estilos de vida en común. expresiones: …que pudieras cambiar la mentalidad de un gordo que lo que más le gusta es comer, porque es la idiosincrasia de la familia, creer que comer es la felicidad, que probamos de todo y podemos dar cátedra de las mejores dietas, aunque nunca las llevemos a cabo, que cuando nos enfermamos decimos "ahora sí", y es un día y al siguiente estamos comiendo, porque nos llena de felicidad comer, contéstame, ¿tú no eres feliz cuando ves a tu familia y comes lo que hace tu mamá? entonces, la familia también tiene que cambiar. ...mi familia igual tuvo que cambiar la comida, ahora todos pues, comemos sano, no tanta sal, aunque no les gustó al principio, ya se acostumbraron, ahora solo tomamos agua, no refrescos. categoría salud. referida a las condiciones físicas y orgánicas en las que se encuentra una persona con enfermedad crónica, con o sin manifestaciones del padecimiento. expresiones: …me dijeron que me podía infartar, y en ese momento tomé la decisión de no comer tanta grasa y controlar mi presión. …cuando tuve el susto (consecuencia de una hiperglicemia), fue cuando decidí cambiar mi vida, no se lo deseo a nadie, pero entendí que la salud es lo mejor que uno puede tener, y pues ahora me cuido. categoría actitud. referida a la postura cognitiva determinada por la creencia de poder realizar eficazmente las metas propuestas. expresiones: pensar que podía hacerlo, pensando positivamente, yo pesaba 123 kilos, por lo menos tenía que bajar 30 kilos; actualmente peso 76 kilos y mi diabetes no me causa problemas y puedo hacer todas mis cosas, sigo haciendo ejercicio. categoría acciones. referidas a las habilidades que una persona con enfermedad crónica realiza para cuidar de sí misma a través del cambio de su conducta o la regulación de su medioambiente. expresiones: ...cuando decidí bajar el azúcar, en primer lugar tenía que ponerme en manos de un profesional. ...ahora ya no me quedo en la sala viendo televisión, trato de hacer cosas, mantenerme ocupado; los fines de semana me levanto, pues, como si fuera a trabajar, para hacer algo en la casa, lo que sea, pintar, arreglar (reparar), no sé… definición resultante en las personas con ec la "decisión de cambio" se define como: el proceso de elección que requiere de intención y actitud para comprometerse con responsabilidad en el mejoramiento de la conducta de salud, de manera efectiva y permanente con respecto a las condiciones sociales y emocionales a las que una 64 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 persona es sometida ante la presencia de una enfermedad crónica, y que requiere de manera impostergable el apoyo familiar y profesional de salud. discusión el método de análisis de rodgers (13) contribuyó a comprender el concepto "decisión de cambio" para el mejoramiento de las conductas de salud que se configura alrededor de la presencia de enfermedades crónicas en adultos. la estructuración de la definición resultante puede contribuir a la propuesta de intervenciones efectivas contra la obesidad, la dmt2 y la hta, enfermedades que tienen un fuerte impacto económico y repercusiones familiares importantes (3, 29). en los artículos revisados diversos autores refieren que la toma de decisiones (o sus subrogados) requiere de un proceso dinámico, gradual, influido por el medioambiente y diferentes factores (30, 34, 35, 43). tal vez esto sea resultado de los conflictos que ocurren ante la presencia de una enfermedad crónica, las presiones sociales por la imagen corporal en el caso de la obesidad, el desgaste económico de la familia en el caso del tratamiento de la dmt2 y la hta, el impedimento para trabajar o no acudir a la escuela, todo lo cual implica situaciones personales de respuesta variada que, de acuerdo con los hallazgos, buscan el control de la situación a través del mejoramiento de la conducta de salud con la satisfacción de mantener sus actividades cotidianas normales, situaciones que corresponden a los resultados de la categoría actitud de los códigos vivos. un problema en particular se presenta con la obesidad dado que muchas personas no la perciben como una enfermedad porque no incapacita, no produce dolor o malestar (28), situación que es similar en las fases iniciales de la diabetes y la hipertensión por ser “enfermedades silenciosas”, y solo hasta que empieza el detrimento físico es cuando deciden mejorar sus conductas de salud (20, 21). esto es apoyado por los estudios de noone (34) ricciardi (44) lamond y thompson (45) davidson y knalf (46) quienes concuerdan en que para tomar la decisión de cambiar la conducta que mejore la salud tiene que haber como antecedente una percepción de riesgo o beneficio, situación que motivó a configurar la definición resultado de este trabajo en un sentido estrictamente preventivo. de acuerdo con gonzález schlenker (31) y fierro (14), mientras no haya conciencia de la magnitud del problema por parte de la población, y no se renuncie a ciertas satisfacciones para que los patrones de conducta nuevos den inicio, no se dará el proceso de decisión de cambio, lo que en este trabajo se confirma con la categoría de salud de los códigos vivos. en varios artículos se puntualiza que la decisión de cambio está influida por el asesoramiento y la información que brinda el personal profesional de salud (15, 18, 21, 23, 27, 35, 47), quienes ponderan a la educación en dieta y ejercicio como estrategia para mejorar los resultados de la adherencia al tratamiento. esta situación concuerda con la categoría de acción de los códigos vivos en los hallazgos adicionales, y se refleja en la definición resultado de este trabajo. para que una persona decida cambiar su conducta de salud es absolutamente necesario el apoyo familiar, los resultados que respaldan esta afirmación se identificaron en la categoría familia del código vivo y en las investigaciones de goldbaum (35), bermúdez et al. (30) seligman et al. (27), cazenave et al. (17) y lopategui (20). de acuerdo con los resultados de estas investigaciones, la intervención de la familia es definitiva en los padecimientos crónicos, pero implica la siguiente conjetura: comer sanamente, mejorar la actividad física y el ejercicio, dejar el tabaco, disminuir el estrés, acciones que teóricamente podrían implicar un cambio de conducta en todos los integrantes de la familia en apoyo al que padece la enfermedad crónica. bajo esta suposición es que la familia se incluyó en la definición resultado. es imperativo señalar que la búsqueda del concepto requirió de palabras subrogadas que se adaptaran a la idea que se buscaba; la mayoría de los artículos —tanto en español como en inglés— no la operaban como tal, no se presentaba como su objetivo principal de discusión excepto en el trabajo de campos y pérez (36) para obesidad en mujeres, y el trabajo de dewalt et al. (19) en adultos con dmt2. en solo tres artículos en inglés se presentó como concepto central de discusión para la toma de decisiones en salud (34, 44, 48) pero no de forma específica en el contexto de las ec. la carencia de la utilización del concepto denotó un nivel de abstracción muy elevado que requirió de la interpretación de los investigadores en el análisis de los subrogados y palabras relacionadas. sin embargo, consideramos que los factores identificados en cada artículo representan elementos primarios que han dado un primer soporte empírico a la definición. con respecto a los atributos de proceso, control, responsabilidad, compromiso, poder, búsqueda, coraje, actitud, autodirección 65 análisis de concepto: “decisión de cambio” para mejorar las conductas de salud en el contexto de las enfermedades crónicas en adultos l erick landeros-olvera y autodeterminación consideramos a la madurez personal un factor común en todos ellos, y que en muchas ocasiones, de acuerdo con nuestra experiencia en la clínica y en la comunidad, llega a establecerse después de que la persona ha experimentado alguna de las consecuencias de las conductas que no favorecen la salud y que exacerban los problemas específicos de las enfermedades crónicas, que van desde un desmayo por hipoglucemia, un dolor de cabeza por hta, amputación de miembros inferiores, accidente cerebrovascular, hasta un infarto al músculo cardiaco; luego entonces, como consecuencia, establecen la decisión de cambio y mejoran sus conductas de salud. por ello es que la definición resultado de este trabajo es en el sentido preventivo más que curativo. con la premisa clara de que la fuerza de la teoría que guía la disciplina está dada por la claridad de su conceptos (49), lo ideal sería su operacionalización, es decir, medirlos, aplicarlos en un nivel menos abstracto, más pragmático, como en una intervención de enfermería con un grupo piloto de personas con obesidad, dmt2 o hta, con el propósito de estimular el desarrollo gradual para el mejoramiento de la conducta de salud hasta conseguir el mantenimiento de la misma. en esta perspectiva, el empirismo puede ser un punto de partida para el análisis del concepto hasta su operacionalización. es obligatorio señalar que la forma en que se interpreta un concepto depende del contexto de cada disciplina y su uso de acuerdo con su propia perspectiva; según kuhn (50), esto responde al paradigma objeto de análisis, así la definición resultado de este trabajo puede ser utilizada desde un muy particular punto de vista de la nutriología, la psicología, la medicina, la antropología o de la propia enfermería. conclusión con respecto a los resultados arrojados podemos exponer que la decisión de cambio es un juicio de elección que requiere de voluntad permanente y tiempo para cambiar las conductas de salud y resolver las posibles contingencias que pueda provocar una enfermedad crónica, luego la decisión de cambio es un proceso interno que posee propiedades de predicción de conductas saludables en individuos con enfermedad crónica. el concepto “decisión de cambio” en adultos con obesidad, dmt2 e hta requiere principalmente de autocontrol, de un proceso para renunciar a ciertas satisfacciones, del apoyo de la familia y del personal de salud. el propósito de este trabajo de teorización fue cubierto, sin embargo, queda solo desarrollarlo y mostrar su utilidad para prevenir consecuencias de salud en personas que padecen enfermedades crónicas; puede ser utilizado por enfermería u otra disciplina científica desde una corriente pragmática. referencias 1. organización panamericana de la salud, naciones unidas, organización mundial de la salud. salud de las américas. washington; 2010. 2. organización mundial de la salud. obesidad y sobrepeso 2011. 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[consultado: 2010 enero 20] en www.msd.es 40. soriano s, arrioja m, tlalpan h. percepción del estado de salud y su influencia en las capacidades de autocuidado en las personas con síndrome coronario. revista mexicana de enfermería cardiológica 2005;13(1-2):25-30. 41. lenz er, pugh lc, milligan ra, gift a, suppe f. la teoría de rango medio de los síntomas desagradables: una actualización. adv nursing sciences 1997;3(19):14-27. 42. atlas.ti [en línea]. the knowledge workbench. demo, version win 5.2. 2007. [consultado: 2010 marzo 13] en www.atlasti.com 43. rodríguez g. factores psicosociales en el manejo de la diabetes tipo ii. vitae, 26. academia biomédica digital. facultad de medicina, universidad central de venezuela; 2006. 44. riccardi r. sedentarism: a concept analysis. nursing forum. proquest nursing & allied health source 2005;40(3):79-87. 45. lamond d, thompson c. intuition and analysis in decision making and choice. journal of nursing scholarship. fouth quarter 2000;32(4):411-414. 46. davidson m, knalf k. dimensional analysis of the concept of obesity. blackwell publishing; 2006. 47. núñez de vf. consentimiento educado vs. consentimiento informado. revista cubana de salud pública 2006;32(4). 48. rut a, withmann-price. exploring the subconcepts of the witmann-price theory of emancipated decision-making in women´s health care. journal of nursing scholar ship 2006;38(4):377-382. 49. cianlelli r, ferrer l. análisis de concepto, una estrategia para desarrollar conocimiento en enfermería. horizonte de enfermería 2001;12(1):46-52. 50. kuhn ts. la estructura de las revoluciones científicas. trad. carlos solís santos. méxico: fondo de cultura económica; 2007. 68 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 figura 1. categorías presentadas por las personas con enfermedades crónicas que decidieron mejorar su conducta de salud 322 335 valoracion de estrategias de afrontamiento.indd 322 aquichan issn 1657-5997 julián andrés barragán1 geraldine almanza-rodríguez2 valoración de estrategias de afrontamiento, a nivel ambulatorio, del dolor crónico en personas con cáncer3 1 enfermero. magíster en enfermería con énfasis en gerencia de servicios de salud y enfermería. docente asistente, universidad pedagógica y tecnológica de colombia, colombia. julian.barragan@uptc.edu.co 2 enfermera. universidad pedagógica y tecnológica de colombia, colombia. geraldine.almanza@uptc.edu.co 3 los autores agradecen a sara esther lizarazo, semillera del grupo de investigación, por la recolección de la información y la tabulación de datos. recibido: 25 de mayo de 2012 enviado a pares: 4 de junio de 2012 aceptado por pares: 29 de octubre de 2013 aprobado: 29 de octubre de 2013 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 322-335 para citar este artículo / to reference this article / para citar este artigo barragán, j. a., almanza rodríguez, g. (2013). valoración de estrategias de afrontamiento, a nivel ambulatorio, del dolor crónico en personas con cáncer. aquichan. vol. 13, no. 3, 322-335. resumen actualmente el dolor es conocido como un síntoma desagradable que nace de la interacción de la persona con su entorno y consigo misma, y es responsabilidad del profesional de enfermería evaluarlo a fin de establecer acciones concretas para su atención. objetivo: valorar las estrategias de afrontamiento del dolor crónico en personas con cáncer de forma multidimensional dentro de procesos físicos y emocionales. materiales y métodos: estudio descriptivo transversal; se aplicó la versión en español del cuestionario de afrontamiento del dolor crónico (cad) a una muestra de 117 personas con cáncer de diversa etiología, mayores de 18 años y sin alteración del estado mental, entre junio y octubre del 2010, los datos se procesaron el spss; se realizó validez facial y conceptual para colombia. resultados: la aplicación del cad permitió obtener puntuaciones de los factores que componen el cuestionario, así como la correlación con variables sociodemográficas; las personas utilizan estrategias adaptativas relacionadas con las categorías: esperanza (media de 5,1), autoinstrucciones (media de 4,33), distracción cognitiva (media de 4,9), es decir la confianza, la ayuda y la visión de un futuro sin dolor; se destacan como conductas desadaptativas la castrofización (media de 3,9) y fe y plegarias (media 5,23). conclusiones: el estudio permitió valorar conductas de afrontamiento adaptativas al dolor crónico de las dimensiones propuestas; sin embargo, persisten conductas de tipo desadaptativo al afrontamiento. palabras clave dolor crónico, neoplasias, percepción del dolor, evaluación, estrategias, enfermería. (fuente: decs, bireme). 323 valoración de estrategias de afrontamiento, a nivel ambulatorio, del dolor crónico en personas con cáncer l julián andrés barragán, geraldine almanza-rodríguez rating strategies at the outpatient level for coping with chronic pain in persons with cancer abstract pain is understood currently as an unpleasant symptom that arises from a person’s interaction with his/ her environment and with themselves, and it is the nurse’s responsibility to assess pain in the interest of instituting specific action to cope with it. objective: assess strategies for coping with chronic pain in persons with cancer in a multidimensional way, as part of physical and emotional processes. materials and methods: this is a cross-sectional, descriptive study. the spanishlanguage version of the chronic pain coping questionnaire (csq) was applied between june and october 2010 to a sample of 117 persons ages 18 and over who have cancer of diverse etiology and no alteration in their mental state. the data were processed through spss. face and conceptual validity for colombia was done. results: application of the csq produced scores for the factors included in the questionnaire and allowed for a correlation with socio-demographic variables. persons use coping strategies related to the categories of hope (mean of 5.1), self-instruction (mean of 4.33) and cognitive distraction (mean of 4.9); that is, confidence, support and vision of a future without pain. catastrophization (mean of 3.9) and faith and prayer (mean of 5. 23) stand out as behavior reflecting a certain inability to cope. conclusions: the study allowed for an evaluation of behavior to cope with chronic pain in the stated dimensions; however, behavior indicative of inability to cope persists. key words chronic pain, neoplasms, pain perception, evaluation, strategies, nursing. (source: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 322-335 324 aquichan issn 1657-5997 avaliação de estratégias de enfrentamento, no âmbito ambulatório, da dor crônica em pessoas com câncer resumo atualmente, a dor é conhecida como um sintoma desagradável que nasce da interação da pessoa com seu ambiente e consigo mesma, e é responsabilidade do profissional de enfermagem avaliá-la a fim de estabelecer ações concretas para seu atendimento. objetivo: avaliar as estratégias de enfrentamento da dor crônica em pessoas com câncer de forma multidimensional dentro de processos físicos e emocionais. materiais e métodos: estudo descritivo transversal; aplicou-se a versão em espanhol do questionário de enfrentamento da dor crônica (cad, com sua sigla em espanhol) a uma amostra de 117 pessoas com câncer de diversa etiologia, maiores de 18 anos e sem alteração do estado mental, entre junho e outubro de 2010; os dados se processaram o spss; realizou-se validade facial e conceitual para a colômbia. resultados: a aplicação do cad permitiu obter pontuações dos fatores que compõem o questionário, bem como a correlação com variáveis sociodemográficas; as pessoas utilizam estratégias adaptativas relacionadas com as categorias: esperança (média de 5,1), autoinstruções (média de 4,33), distração cognitiva (média de 4,9), isto é a confiança, a ajuda e a visão de um futuro sem dor; destacamse como condutas mal adaptativas a catastrofização (média de 3,9) e fé e preces (média 5,23). conclusões: o estudo permitiu avaliar condutas de enfrentamento adaptativas à dor crônica das dimensões propostas; contudo, persistem condutas de tipo mal adaptativo ao enfrentamento. palavras-chave dor crônica, neoplasias, percepção da dor, avaliação, estratégias, enfermagem. (fonte: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 322-335 325 valoración de estrategias de afrontamiento, a nivel ambulatorio, del dolor crónico en personas con cáncer l julián andrés barragán, geraldine almanza-rodríguez introducción la asociación internacional para el estudio del dolor (iasp, seattle, washington) define el dolor como una experiencia sensorial desagradable y emocional, que se asocia a una lesión actual o potencial de los tejidos o en función de dicha lesión (1, 2). el dolor por cáncer se clasifica como crónico y tiene características específicas como mayor duración y alteraciones psicológicas que condicionan la conducta de tipo doloroso (3); estas traen como consecuencia implicaciones a nivel psicosocial en la persona que padece el dolor de tipo oncológico y conducen a alteraciones en las relaciones sociales y en la manera como se convive con la enfermedad (4). el dolor asociado al cáncer evoluciona de una etapa aguda a crónica, interrumpe las actividades diarias de la persona que lo padece, y depende del estadio de la enfermedad y del grado de control que el individuo ejerza sobre el mismo (5, 6). en colombia el número de personas diagnosticadas con esta patología ha aumentado considerablemente; la tasa de mortalidad por neoplasias para el año 2010 fue de 73,1 por cada cien mil habitantes, siendo más común el cáncer de estómago y de vías digestivas con una tasa de 103,5 por cada cien mil habitantes (7). en el departamento de boyacá, el 14,2 % de la mortalidad reportada se asoció a muertes por cáncer de estómago con un 16,4 % en los hombres y cáncer de seno como la tercera causa en las mujeres (7). las personas que cursan con cáncer son diagnosticadas y tratadas en cuatro instituciones de salud del departamento por un grupo de profesionales que incluye a enfermeras para el cuidado; las instituciones que realizan abordaje a las personas con cáncer cuentan con el servicio de dolor y cuidados paliativos, y generalmente tratan el dolor como un síntoma, en cuya valoración se utiliza la escala analgésica del dolor (1). el dolor crónico presenta una duración entre tres y seis meses, y se asocia por lo general a una enfermedad permanente, su manifestación puede ser espontánea, intermitente o recurrente, y requiere manejo diario (8). los profesionales de enfermería deben realizar la valoración de la persona de forma holística e interdisciplinar, y establecer procesos investigativos para determinar si las personas con cáncer realizan estrategias de afrontamiento del dolor, los tipos de estrategias y su efectividad. el afrontamiento como concepto hace referencia a los “esfuerzos cognitivos y conductuales en constante cambio que sirven para manejar las demandas externas y/o internas y que son valoradas como excedentes o desbordantes de los recursos del individuo” (9). las estrategias como acciones concretas dependen de la evaluación primaria y secundaria, es decir, la situación y los recursos que tenga la persona para afrontarla determinan su condición como reto o amenaza para hacerle frente. cuando las estrategias constituyen una amenaza, la persona se torna ansiosa y con poca disposición al afrontamiento y, por tanto, menos tendente a realizar acciones eficaces (9, 10). los profesionales de enfermería valoran el dolor como una sensación desagradable e individual que responde a factores estresores internos o externos y cuyo tratamiento no solo obedece al manejo farmacológico. en este caso existe una afectación integral del ser humano, en cuyos sistemas, el conjunto de componentes organizados son más que la suma de sus partes y reaccionan e interactúan con otros sistemas del entorno (11). para roy, la persona es un sistema abierto y adaptativo que aplica un ciclo de retroacción de entrada, procesamiento y salida; esto indica que cada persona se adapta de acuerdo con los estímulos internos y externos que la rodean, y reacciona a los factores que generan estrés de forma particular, debido a que son cambiantes (12). las personas realizan procesos de afrontamiento que se modifican a medida que transcurre el diario vivir; en el desarrollo de esta adaptación, roy plantea que los sres humanos emplean gran cantidad de energía que podría ser canalizada hacia la recuperación de la enfermedad (12). la participación de enfermería inicia cuando la persona gasta más energía en el afrontamiento y deja muy poca energía disponible para el logro de las metas de supervivencia, crecimiento, reproducción y dominio. la enfermera (o) juega un papel importante en la atención de las personas debido a que puede ayudar a quienes padecen cáncer en el proceso de afrontamiento del dolor como parte de su proceso patológico y contribuir en el ahorro de energía para que sea empleada en la recuperación de la enfermedad (13). es importante fijar la meta de enfermería en ayudar a la persona con dolor crónico producido por cáncer a adaptarse y generar estrategias activas de afrontamiento que permitan una mejoría en la calidad de vida, así como con las implicaciones a nivel fisiológico y emocional que el dolor trae consigo (12). de igual forma, en el ámbito afectivo, el dolor de tipo oncológico aflige al ser humano en todas sus esferas y conlleva conduc326 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 tas de tipo suicida, convirtiéndose así en la enfermedad misma (13, 14). la complejidad de la conducta dolorosa en la persona con enfermedad terminal se asocia al concepto de dolor total (15). las personas que sufren dolor provocado por cáncer, en general, desarrollan y utilizan estrategias para afrontar, manejar o minimizar los efectos del dolor. estas estrategias pueden incluir conductas como el descanso, la aplicación de calor húmedo, cambios de postura, el ritmo de las actividades, o usar métodos de relajación; otras, sin embargo, abordan el afrontamiento del dolor y buscan cambiar la forma de pensar, como concentrarse en algo para distraerse, repetir autoafirmaciones, calmarse, practicar meditación o rezar, aspectos que contempla el modelo propuesto por lazarus y folkman (16). se observa que las personas que cursaron con cáncer utilizan estrategias útiles para aliviar el dolor, algunas son positivas como la distracción, ignorar el dolor o darse autoinstrucciones, otras son negativas como la catastrofización (17); las estrategias positivas les permiten mantenerse activas para manejar la angustia psicológica. estudios demuestran que las personas que viven el dolor como algo catastrófico tienen más probabilidades de experimentar niveles elevados del mismo, ansiedad y problemas que interfieren en sus actividades diarias (17, 18). existen instrumentos para la valoración del dolor como la escala análoga visual, la escala mcgill, el cuestionario breve, la escalas de distress del dolor, entre otros, que son aplicables al contexto colombiano, pero no evalúan las estrategias de afrontamiento que realizan las personas con cáncer. la mayoría de las escalas miden el dolor de forma unidimensional, lo que limita las intervenciones que el profesional de enfermería puede realizar para el cuidado de la persona. el cuestionario de estrategias de afrontamiento del dolor (cad) fue validado para españa en el 2004 por cano et al.; obtuvo un alfa de cronbach de 0,88 por lo cual es un instrumento fiable y válido para la población española en la valoración de afrontamiento del dolor en pacientes con migraña, cefalea tensional, dolores óseos y dolores musculares (17). los autores encontraron que quienes sufrían de cefalea tensional y dolor óseo realizaron un afrontamiento del dolor más adaptativo que quienes sufrían de las demás patologías, lo que conduce a concluir que la presencia de una lesión de tipo orgánico influye positivamente en la adaptación de la persona que padece la enfermedad (17). el abordaje de enfermería a las personas que sufren dolor crónico debe acometerse no solo desde los aspectos farmacológicos, sino a partir de intervenciones integrales que permitan a la persona que padece la enfermedad y a su familia adaptarse a la nueva situación y a los estilos de vida que trae como consecuencia el hecho de convivir con dolor ocasionado por cáncer (3, 19). en boyacá no se encontró evidencia de estudios publicados sobre el manejo del dolor o valoración de estrategias de afrontamiento en personas con cáncer o similares. investigaciones sobre el dolor en colombia evidencian resultados concretos respecto a la intervención integral de la persona para el manejo efectivo del dolor crónico, tales como el diagnóstico preciso, el abordaje de la calidad de vida y el reforzamiento de estrategias eficaces, fuera del tratamiento farmacológico convencional. estudios realizados acerca de estrategias de afrontamiento del dolor crónico concluyen que las personas son capaces de asumir la enfermedad como una experiencia enriquecedora, en cuyo caso conductas como la búsqueda de apoyo social, espiritualidad, solución de problemas y evitar del dolor, entre otras, aumentan la satisfacción con la vida (20-22), aun cuando el diagnóstico del cáncer genere un impacto catastrófico (23). si bien los tratamientos farmacológicos para el manejo del dolor resultan efectivos en el 80 % de los casos (24), se requieren intervenciones concretas para el afrontamiento y la capacidad de la persona para mejorar su calidad de vida. materiales y métodos se realizó un estudio descriptivo transversal, la muestra estuvo compuesta por 117 personas diagnosticadas con cáncer de diversa etiología que asistieron a citas de control o tratamiento en una institución especializada en el departamento de boyacá, durante el primer semestre del año 2010. se establecieron fases para el desarrollo de la investigación: en la primera fase se obtuvo la validez facial del instrumento (anexo 1) que consistió en la realización de una prueba piloto con 39 personas no incluidas en la muestra final que cumplieron con los criterios de inclusión planteados en el diseño metodológico y aceptaron participar en el estudio. las 39 personas se seleccionaron de acuerdo con el número de ítems de cad, previa autorización de los autores, con el fin de determinar dificultades en el lenguaje y la aplicación en personas que asistieron a consulta y tratamiento en una institución para el manejo de cáncer en tunja. una vez realizada la validez facial se dio paso a la segunda fase para la obtención de validez de contenido; se utilizó la meto327 valoración de estrategias de afrontamiento, a nivel ambulatorio, del dolor crónico en personas con cáncer l julián andrés barragán, geraldine almanza-rodríguez dología de lobiondo-wood, haber y cohen, mediante un panel de cinco expertos de reconocida trayectoria académica y experiencia en el abordaje del dolor, así como en la validación de instrumentos. esta validez tuvo en cuenta cuatro criterios: la definición del constructo por medir, la formulación de los ítems del cuestionario, el desarrollo de instrucciones para los expertos evaluadores y la validez del instrumento (25). se elaboró un instructivo que fue enviado a los evaluadores vía correo electrónico. la tercera fase consistió en la recolección de la información y su procesamiento en el programa estadístico spss® versión 10.0. se utilizaron estadísticos descriptivos y un análisis bivariado. la investigación estuvo enmarcada dentro de los principios éticos contemplados en la resolución 008430 de 1993 que establece normas científicas, técnicas y administrativas para la investigación en salud. este estudio se clasifica como investigación de mínimo riesgo. se contó con la aprobación del comité de ética de la institución y se respetó el principio de confidencialidad por medio de la utilización del consentimiento informado así como el de beneficencia, con la retroalimentación de los resultados en la institución y el respeto a las personas si en algún momento decidieran retirarse del estudio, aspectos contemplados en la ley 911 de 2004 (26). instrumento el cuestionario de estrategias de afrontamiento del dolor (cad), creado inicialmente por rosenstiel y keefe en 1983 (27), y posteriormente adaptado y modificado a una versión en español por rodríguez, cano y blanco en 2004, es un instrumento válido y confiable para evaluar las estrategias de afrontamiento del dolor crónico. tiene una varianza del 59,2 % y una consistencia interna entre 0,68 a 0,89 de los ocho factores que posee (17). el primer factor se denomina catastrofización con 6 items, el cual sugiere una ideación negativa y dramática del dolor, con consecuencias y dificultades para afrontarlo (28). el segundo factor, denominado conductas distractoras con 6 items, incluye actividades de ocio no mentales encaminadas a distraerse de la percepción dolorosa. el tercer factor, autoinstrucciones, con 5 ítems, se refiere a una serie de autoverbalizaciones dirigidas a afrontar con éxito el dolor. el cuarto factor sugiere comportamientos que pretenden eliminar la influencia del dolor en la vida diaria, este se denomina ignorar el dolor y contiene 6 ítems. el quinto factor, reinterpretar el dolor, revela la intención de transformar la percepción dolorosa para aliviar su impacto, contiene 7 ítems. el sexto factor, esperanza, con 3 ítems, establece la idea de que el dolor desaparecerá con el tiempo. el séptimo factor con 3 items, fe y plegarias, basa el afrontamiento en creencias y conductas religiosas. por último, el octavo factor, distracción cognitiva, con 3 items, se basa en actividades mentales de distracción que al mismo tiempo pretenden compensar el sufrimiento producido por el dolor (17). el instrumento consta de 39 ítems en total, evaluados en una escala de 0 a 6, siendo 0 correspondiente a nunca, 1 casi nunca, 2 pocas veces, 3 a veces, 4 muchas veces, 5 casi siempre, y 6 siempre. el instrumento original contempla como datos sociodemográficos: la edad, el nombre y la fecha de la valoración; con el fin de establecer relaciones entre estas variables se decidió agregar datos como género, estado civil, lugar de residencia y ocupación. el porcentaje de aceptabilidad fue del 100 % de las personas que conformaron la muestra. resultados se aplicaron en total 121 instrumentos, de los cuales 4 fueron descartados por diligenciamiento incompleto; todas las personas aceptaron su participación voluntaria en el estudio. el 64,1 % de los encuestados correspondió al género femenino, mientras que el 35,9 % fueron del género masculino. la media de edad fue de 58,03 años, siendo la población más representativa el grupo de edad correspondiente a los 56-64 años con un 19,6 %, y las personas entre los 74 y 82 años con un 15,3 %. respecto al estado civil, el 44,4 % de las personas participantes en la investigación estaban casadas, el 19,6 % eran solteras, el 18 % viudos, el 10,3 % vivían en unión libre, y el 7,7 % separados. se encontraron 28 diagnósticos diferentes de cáncer que se agruparon de forma cefalocaudal, como se muestra en la tabla 1, para un total de 10 grupos; se destaca la elevada incidencia de cáncer de seno, gástrico, de colon y de cuello uterino. si se tiene en cuenta la localización y el género, fueron las mujeres quienes más se vieron afectadas por la enfermedad. la validez facial dio como resultado la comprensión de todos los ítems del instrumento y su interpretación, por lo que no se introdujeron cambios en el lenguaje del mismo; cada persona utilizó en promedio 10 minutos para responder la totalidad del 328 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 cuestionario. para la validez de contenido se tuvieron en cuenta los criterios de pertinencia, relevancia, claridad y redacción con la fórmula de índice de validez de contenido (ivc) (29); la puntuación de los 39 ítems fue superior a 0,80, lo cual permite afirmar que el cad es un instrumento válido en cuanto a su apariencia y contenido en el contexto colombiano, y en la valoración de estrategias de afrontamiento del dolor asociado al cáncer. la prueba de confiabilidad a través del alpha de cronbach fue de 0,89, y con eliminación de ítems el valor se mantuvo entre 0,88 y 0,90, demostrando la confiabilidad del cad. la tabla 2 muestra los resultados por categorías; se encontró que los ítems correspondientes a catastrofización (cat) mostraron una media de 2,23, es decir, pocas veces. se resaltan los porcentajes obtenidos para nunca (21,1 %), a veces (21,3 %) y siempre (21,8 %), lo cual supone una menor proporción de quienes no realizan catastrofización y mayor para aquellos que tienden a hacerla o definitivamente la realizan. en la categoría conductas distractoras (cdi) se observa una media de 3,27 a veces, lo cual evidencia que acciones como “me pongo a cantar o tararear canciones mentalmente”, con una media de 1,6, no son realizadas en gran medida. por otro lado se observa que la media más alta para los ítems de esta categoría es para la afirmación “hago cosas que me gustan como ver televisión o escuchar la radio”, con una media de 4,21, debido a que culturalmente es más factible acceder a este tipo de recursos y a que son más asequibles. la categoría autoafirmación (aut) tuvo una media de 4,33 muchas veces con varianza de 2,43, lo cual indica la posibilidad de que las personas realicen afirmaciones positivas para tener control sobre el dolor. para la categoría ignorar el dolor (ido) la media fue de 4,11 con una varianza de 3,7, que indica la variedad en las respuestas de las personas encuestadas frente a esta categoría, pues se establece una conducta de tipo adaptativo que busca disminuir el dolor ignorándolo. la categoría reinterpretar el dolor (rdo) evalúa las estrategias que realizan las personas para alejarse de este; se observó una media de 4,13 muchas veces, con una varianza de 4,6. este dato indicó que no siempre se recurre a actividades simples como dormir, debido a la complejidad que representa convencerse a sí mismos de que el dolor está fuera de su cuerpo y que lo pueden alejar mentalmente. la categoría de esperanza (esp) evaluó pensamientos de las personas acerca de la creencia, en un futuro, respecto a la mejoría de la enfermedad. se obtuvo una media de 5,1, con una varianza de 2,88, que indica que la esperanza está casi siempre presente en las personas, que creen en un futuro con mejor calidad de vida. se resalta que esta categoría influye de manera positiva en el afrontamiento del dolor. la categoría fe y plegarias evidenció una media de 5,7 con una varianza de 0,9, la media más alta y la menor varianza en la medición de las categorías del instrumento, aspecto que indica que las personas encuestadas se aferran a la fe y a las conductas religiosas con el fin de mejorar su estado de salud. por último, la categoría distracción cognitiva (dic) evidenció una media de 4,9 muchas veces y una varianza de 3,0. de igual forma, se realizó un análisis de conglomerados con el objetivo de determinar la agrupación de puntuaciones de las categorías respecto a la variable género, la cual permitió diferenciar la asociación de puntuaciones bajas para los hombres en las conductas de afrontamiento desadaptativo (catastrofización, media de 3,96; fe y plegarias, media de 5,28) y menores en las de tipo adaptativo (especialmente ignorar el dolor, media de 2,39, y reinterpretar el dolor, media de 1,59). respecto a las mujeres, dentro de las conductas de afrontamiento desadaptativo están fe y plegarias tabla 1. descripción de los diagnósticos fuente: base de datos de la investigación spss v 10.0. diagnóstico descripción porcentaje cabeza y cuello cáncer cerebral, cara, tiroides, cuello y cáncer de nariz 11,10 tórax cáncer de pulmón y de seno 25,60 abdomen cáncer gástrico, hepático y de páncreas 15,40 colon cáncer colon 15,40 cuello uterino cáncer de cuello uterino 11,10 próstata cáncer de próstata 6,80 piel y tejidos blandos cáncer de piel, tejidos blandos, glioma de células gigantes. 4,30 vasos sanguíneos linfoma hodking, leucemia 3,40 metástasis metástasis 1,70 otros cáncer renal, de columna y de pierna 5,10 329 valoración de estrategias de afrontamiento, a nivel ambulatorio, del dolor crónico en personas con cáncer l julián andrés barragán, geraldine almanza-rodríguez con una media de 5,82, y mayor para las de tipo adaptativo como esperanza, media de 5,48, y distracción cognitiva, media de 2,28. el análisis de regresión, se realizó como prueba de predicción de las variables independientes edad, género, estado civil y ocupación, con las categorías del instrumento, para determinar su incidencia en el afrontamiento (tabla 3). no se encontraron relaciones estadísticamente significativas, en las pruebas de regresión realizadas (p > 0,005). categoría variable (%) nunca (%) casi nunca (%) pocas veces (%) a veces (%) muchas veces (%) casi siempre (%) siempre (%) m v media categoría cat el dolor es terrible y pienso que nunca me pondré mejor 26,50 12,00 11,10 20,50 5,10 7,70 17,10 2,57 4,73 2.23 cat creo que no puedo soportarlo más 19,70 9,40 11,10 21,40 10,30 8,50 19,70 2,97 4,51 cat pienso que no vale la pena vivir así 34,20 13,70 8,50 17,90 6,00 3,40 16,20 2,23 4,82 cat el dolor es horrible y siento que me desborda 12,00 11,10 6,80 26,50 7,70 8,50 27,40 3,42 4,33 cat creo que no puedo más 19,70 7,70 13,10 23,10 10,30 7,70 17,90 2,91 4,27 cat me paso el día preocupado pensando en si alguna vez acabará el dolor 14,50 9,40 5,10 18,80 10,30 9,40 32,50 3,59 4,83 cdi me pongo a cantar o a tararear canciones mentalmente 53 11,10 2,60 14,50 4,30 2,60 12 1,62 4,58 3.24 cdi hago cosas que me gustan como ver televisión o escuchar la radio 12,80 5,10 4,30 10,30 8,50 11,10 47,90 4,21 4,81 cdi realizo juegos o distracciones mentales para quitar el dolor de mi cabeza 41 9,40 4,30 17,10 4,30 6 17,90 2,24 5,48 cdi salgo de casa y hago algo, como ir al cine o ir de compras 23,10 4,30 2,60 13,70 8,50 16,20 31,60 3,56 5,59 cdi paseo mucho 25,60 10,30 6,00 12,00 3,40 7,70 35,00 3,21 6,29 cdi trato de estar con otras personas 6,00 5,10 4,30 7,70 4,30 9,40 63,20 4,8 3,68 aut veo el dolor como un desafío y no dejo que me moleste 12,80 7,70 7,70 25,60 9,40 9,40 27,40 3,49 4,27 2.43 aut me digo a mí mismo que no puedo permitir que el dolor interfiera con lo que tengo que hacer 12 7,70 3,40 17,90 6 14,50 38,50 3,96 4,64 aut me digo a mí mismo que puedo superar el dolor 7,70 3,40 5,10 12,80 5,10 11,10 54,70 4,56 3,89 aut no importa lo grande que sea el dolor, sé que puedo con él 7,70 2,60 6,00 12,80 10,30 11,10 49,60 4,47 3,73 aut me digo a mí mismo que debo ser fuerte y continuar a pesar del dolor 4,30 1,70 2,60 4,30 2,60 16,20 68,40 5,21 2,43 ido no presto atención al dolor 20,50 6 5,10 23,90 6,80 8,50 29,10 3,32 5,1 4.11 ido no pienso en el dolor 13,70 11,10 6 16,20 6,80 11,10 35 3,65 5,02 tabla 2. resultados por categorías cda: estrategias de afrontamiento del dolor en pacientes con cáncer 330 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 categoría variable (%) nunca (%) casi nunca (%) pocas veces (%) a veces (%) muchas veces (%) casi siempre (%) siempre (%) m v media categoría ido me pongo a hacer cosas como tareas domésticas o planear actividades 13,70 3,40 1,70 12,80 6,80 12,80 48,70 4,29 4,73 ido aunque me duela sigo con lo que estaba haciendo 8,50 5,10 1,70 6,00 7,70 15,40 55,60 4,68 3,91 ido continúo con lo que estaba haciendo como si no pasara nada 8,50 0,90 4,30 14,50 6,80 10,30 54,30 4,59 3,74 ido ignoro el dolor 10,30 3,40 6,80 16,20 7,70 12,00 43,60 4,18 4,25 rdo me acuesto 10,30 3,40 3,40 29,10 6,80 6,00 41,00 4,01 4,11 4.13 rdo me imagino que el dolor está fuera de mí 17,10 3,40 3,40 10,30 6,80 14,50 44,40 4,08 5,24 rdo hago como si no me doliera nada 11,10 6,00 6,00 13,70 6,80 9,40 47,00 4,15 4,68 rdo hago como si el dolor no fuera parte de mí 13,70 5,10 5,10 12,80 6,80 12,80 43,60 4,07 4,89 rdo me digo a mí mismo que no me duele 8,50 5,10 5,10 8,50 7,70 13,70 51,30 4,48 4,11 rdo trato de distanciarme del dolor, casi como si el dolor estuviera en otro cuerpo 12,00 6,80 3,40 12,80 8,50 11,10 45,30 4,14 4,74 rdo trato de no pensar en que el dolor está en mi cuerpo, como si estuviera fuera de mí 14,50 4,30 0,90 18,80 9,40 10,30 41,90 4,03 4,75 esp tengo confianza en que los médicos algún día me curarán el dolor 3,40 1,70 0,00 6,80 0,90 5,10 82,10 5,44 2,06 5.1 esp creo que algún día alguien me ayudará y el dolor desaparecerá 1,70 0,00 0,90 7,70 1,70 8,50 79,50 5,51 1,37 esp trato de imaginarme un futuro en el que me haya librado del dolor 10,30 2,60 5,10 8,50 6,00 6,80 60,70 4,61 4,33 fep rezo a dios para que no me dure más el dolor 0,90 0,00 1,70 4,30 3,40 1,70 88,00 5,67 1,02 5.7 fep rezo para que me pare el dolor 0,90 0,00 2,60 3,40 1,70 5,10 85,50 5,66 1,05 fep cuento con mi fe en dios 0,90 0,00 1,70 2,60 0,00 1,70 93,20 5,79 0,79 dic pienso en cosas que disfruto haciendo 7,70 4,30 3,40 7,70 4,30 17,10 55,60 4,7 3,76 4.9 dic recuerdo buenos momentos del pasado 6,80 0,90 3,40 6,80 9,40 13,70 59,00 4,88 3,12 dic pienso en personas con las que me gusta estar 2,60 2,60 1,70 6,00 4,30 13,70 69,20 5,25 2,14 fuente: base de datos de la investigación spss v 10.0. 331 valoración de estrategias de afrontamiento, a nivel ambulatorio, del dolor crónico en personas con cáncer l julián andrés barragán, geraldine almanza-rodríguez discusión la evaluación de las estrategias de afrontamiento del dolor permitió identificar las conductas que influyen en el abordaje y manejo del dolor que utilizan las personas con cáncer en boyacá. sobre las conductas de tipo adaptativo para el afrontamiento del dolor las personas utilizan más aquellas relacionadas con la categoría esperanza, es decir la confianza, la ayuda y la visión de un futuro sin dolor; este abordaje resulta importante para el personal de enfermería, puesto que el cuidado se debe orientar a la ayuda y el fortalecimiento de acciones que permitan a la persona confiar en sí misma y adaptarse al dolor. otras conductas asociadas al afrontamiento adaptativo en la muestra se relacionan con autoinstrucciones por medio de las cuales las personas son capaces mentalmente de darse afirmaciones para controlar el dolor. si bien este tipo de conductas psicológicas aporta elementos de autoayuda, es necesario el abordaje integral de la intervención clínica por parte de los profesionales de salud, que además incluya la reciprocidad para que la persona se involucre en su cuidado y sea capaz de aportar herramientas propias para sí mismo (3). son útiles conductas como la distracción cognitiva que constituyen estrategias de tipo adaptativo frente al dolor (17) y facilitan la realización de procesos mentales conducentes a la distracción y el olvido del mismo, disminución de la intensidad y menor duración de la experiencia dolorosa. la catastrofización resultó ser una de las estrategias utilizadas por las personas en el presente estudio y aquella que conduce a un afrontamiento desadaptativo e ineficaz; al igual que en los estudios de cano, soriano y soucase, se observa que cuando prevalece el uso de este tipo de conductas se prolonga la experiencia dolorosa y se limita la utilización de las estrategias adaptivas (17, 18, 21, 30, 31). se encontró que la categoría fe y plegarias representa un porcentaje significativo en la utilización de estrategias de afrontamiento, posiblemente asociada a la cultura boyacense y colombiana de religiosidad y su vínculo con aspectos espirituales; se resalta que el dolor asociado a enfermedades como el cáncer genera en las personas mayor temor a la muerte y es posible que exista una alta tendencia al uso de este tipo de estrategias. esta categoría es compleja de analizar debido a que se correlaciona con la catastrofización y, a su vez, con la categoría esperanza. las conductas de fe y plegarias han sido asumidas como desadaptativas en los estudios de validez y aplicación del cad en españa y en otras regiones donde ha sido aplicado. esta categoría ha sido descrita como desadaptativa para el afrontamiento del dolor (17, tabla 3. análisis de regresión múltiple: estrategias de afrontamiento al dolor en pacientes con cáncer variable dependiente: género variable independiente beta error típico coeficiente beta t p catastrofización 3,20 1,08 0.447 2,95 0,40 conductas distractoras 0,16 0,08 0,197 2,07 0,40 auto instrucciones -0,36 0,34 -0,115 -1,08 0,28 ignorar el dolor -0,18 0,10 -0,161 -1,73 0,08 reinterpretar el dolor -0,21 0,17 -0,127 -1,27 0,20 esperanza 6,82 0,06 0,107 1,13 0,26 fe y plegarias 2,1 0,29 0,007 0,07 0,94 distracción cognitiva -0,27 0,77 -0,137 -1,37 0,28 constante 4.59 1.56 3,94 0,01 r = 3.551 r cuadrado = 0.126 error = 1.483 f = 26.43 sign. = 0,020 fuente: base de datos investigación spss v 10.0. 332 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 18), relacionándose de forma directa con las conductas correspondientes a la categoría de catastrofización que en la puntuación del cuestionario (cad) obtuvieron el mayor puntaje en los ítems casi siempre y siempre. cabe resaltar que la categoría fe y plegarias se correlaciona negativamente con catastrofización y positivamente con esperanza (17). las estrategias de afrontamiento del dolor constituyen abordajes complementarios para el cuidado de enfermería que guían a los profesionales a reforzar acciones tendentes a mejorar la calidad de vida de las personas, e integran no solo aspectos físicos o fisiológicos para el manejo del dolor, sino elementos psicológicos y emocionales más allá de la terapia farmacológica (32). en el presente estudio, los hombres tienen tendencia al afrontamiento desadaptativo más que las mujeres, aspecto que difiere de los resultados obtenidos en la investigación de miró et al., donde las mujeres realizan mayor uso de la catastrofización que los hombres (30). es importante tener en cuenta el entorno de la persona, así como su edad y diagnóstico, aspectos que permitirán un mejor direccionamiento de las intervenciones y la pronta mejoría y disminución de la sensación dolorosa. conclusiones en las estrategias de afrontamiento del dolor se presentan variaciones en cuanto al modo de adaptación frente al dolor crónico ocasionado por el cáncer, siendo las categorías esperanza, autoinstrucciones, distracción cognitiva, castrofización y fe y plegarias las más utilizadas por las personas para hacerle frente. las variables sociodemográficas como edad, sexo, ocupación y diagnóstico no tienen relación, en el presente estudio, con la aparición de estrategias de afrontamiento adaptativas. se encontró mayor incidencia de cáncer en el sexo femenino; sin embargo, son las mujeres quienes realizan mayor cantidad de estrategias adaptativas que los hombres. los profesionales de enfermería están en capacidad de participar interdisciplinariamente en el diagnóstico, abordaje y cuidado integral de las personas que padecen dolor crónico a causa de enfermedades como el cáncer; los conocimientos y el dominio de los procesos de adaptación y afrontamiento en las personas resultan un manejo profesional que facilita la adopción de estrategias activas y eficaces en la población colombiana con este padecimiento. referencias 1. organización mundial de la salud. alivio del dolor y tratamiento paliativo en cáncer. informe de un comité de expertos. serie de informes técnicos, ginebra; 1990. 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[citado 2013 sep 10]. disponible en: http://sparta. javeriana.edu.co/psicologia/publicaciones/actualizarrevista/archivos/v3n209caracteristicas_espirituales.pdf 24. murillo m, alarcón a. tratamientos psicosomáticos en el paciente con cáncer. rev colomb psiquiatr [internet] [citado 2013 sep 09]. disponible en: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=s003474502006000500007 &lng=en 25. garcía mj, rodríguez f, carmona l. validación de cuestionarios. reumatol clín. 2009;5(4):171-177. 26. república de colombia. ley 911 de 2004 [internet] [citado 2012 abr 26]. disponible en: http://www.anec.org.co/index. php?option=com_content&view=article&id=70&itemid=91 27. rosenstiel ak, keefe fj. the use of coping strategies in chronic low back pain patients: relationship to patient characteristics and current adjustment. pain. 1983;17(1):33-44. 334 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 28. esteve r, lópez a, ramírez c. índices generales versus específicos en la evaluación del afrontamiento al dolor crónico. psicothema. 2004;16(3):421-8. 29. lamprea ja, gómez-restrepo c. validez en la evaluación de escalas. rev colomb psiquiatr. 2007;36:340-348. 30. miró e, diener fn, martínez mp et al. la fibromialgia en hombres y mujeres: comparación de los principales síntomas clínicos. psicothema. 2012;24(1):10-5. 31. soriano j, monsalve v. validación del cuestionario de afrontamiento al dolor crónico reducido (cad-r). rev soc esp dolor [internet]. 2004 nov [citado 2013 sep 10]; 11(7):27-34. disponible en: http://scielo.isciii.es/scielo.php?script=sci_ arttext&pid=s1134-80462004000700002&lng=es 32. grupo de estudio facultad de enfermería. análisis de los conceptos del modelo de adaptación de callista roy. aquichan [internet]. 2009 may 28 [citado 2012 mar 12]; 2(1). disponible en: http://aquichan.unisabana.edu.co/index.php/ aquichan/article/view/18/36 anexo 1 cuestionario de estrategias de afrontamiento del dolor (cad) rosenstiel y keefe, 1983. adaptado por rodríguez, cano y blanco (17) responda, marcando con una x en la casilla correspondiente, con qué frecuencia realiza las siguientes acciones cuando tiene dolor. utilice la siguiente escala: 0 = nunca, 1 = casi nunca, 2 = pocas veces, 3 = a veces, 4 = muchas veces, 5 = casi siempre, 6 = siempre esté seguro de responder a todas las frases y de que marca solo una casilla en cada una de ellas. no hay respuestas correctas ni incorrectas; solo se evalúa lo que usted hace en ese momento. nombre: edad: fecha: ocupación: estado civil: lugar de residencia: género: diagnóstico: 335 valoración de estrategias de afrontamiento, a nivel ambulatorio, del dolor crónico en personas con cáncer l julián andrés barragán, geraldine almanza-rodríguez 1 veo el dolor como un desafío y no dejo que me moleste 0 1 2 3 4 5 6 2 creo que no puedo más 0 1 2 3 4 5 6 3 me digo a mí mismo que no puedo permitir que el dolor interfiera con lo que tengo que hacer 0 1 2 3 4 5 6 4 me pongo a cantar o a tararear canciones mentalmente 0 1 2 3 4 5 6 5 no presto atención al dolor 0 1 2 3 4 5 6 6 hago cosas que me gustan como ver televisión o escuchar la radio 0 1 2 3 4 5 6 7 no pienso en el dolor 0 1 2 3 4 5 6 8 realizo juegos o distracciones mentales para quitar el dolor de mi cabeza 0 1 2 3 4 5 6 9 salgo de casa y hago algo, como ir al cine o ir de compras 0 1 2 3 4 5 6 10 me digo a mí mismo que puedo superar el dolor 0 1 2 3 4 5 6 11 paseo mucho 0 1 2 3 4 5 6 12 el dolor es terrible y pienso que nunca me pondré mejor 0 1 2 3 4 5 6 13 tengo confianza en que los médicos algún día me curarán el dolor 0 1 2 3 4 5 6 14 creo que algún día alguien me ayudará y el dolor desaparecerá 0 1 2 3 4 5 6 15 me imagino que el dolor esta fuera de mí 0 1 2 3 4 5 6 16 creo que no puedo soportarlo más 0 1 2 3 4 5 6 17 hago como si no me doliera nada 0 1 2 3 4 5 6 18 hago como si el dolor no fuera parte de mí 0 1 2 3 4 5 6 19 rezo a dios para que no me dure más el dolor 0 1 2 3 4 5 6 20 me pongo a hacer cosas como tareas domésticas o planear actividades 0 1 2 3 4 5 6 21 rezo para que me pare el dolor 0 1 2 3 4 5 6 22 me digo a mí mismo que no me duele 0 1 2 3 4 5 6 23 pienso que no vale la pena vivir así 0 1 2 3 4 5 6 24 aunque me duela sigo con lo que estaba haciendo 0 1 2 3 4 5 6 25 no importa lo grande que sea el dolor, sé que puedo con él 0 1 2 3 4 5 6 26 trato de imaginarme un futuro en el que me haya librado del dolor 0 1 2 3 4 5 6 27 me digo a mí mismo que debo ser fuerte y continuar a pesar del dolor 0 1 2 3 4 5 6 28 continúo con lo que estaba haciendo como si no pasara nada 0 1 2 3 4 5 6 29 ignoro el dolor 0 1 2 3 4 5 6 30 trato de distanciarme del dolor, casi como si el dolor estuviera en otro cuerpo 0 1 2 3 4 5 6 31 el dolor es horrible y siento que me desborda 0 1 2 3 4 5 6 32 me paso el día preocupado pensando en si alguna vez acabará el dolor 0 1 2 3 4 5 6 33 trato de no pensar en que el dolor está en mi cuerpo, como si estuviera fuera de mí 0 1 2 3 4 5 6 34 pienso en cosas que disfruto haciendo 0 1 2 3 4 5 6 35 trato de estar con otras personas 0 1 2 3 4 5 6 36 recuerdo buenos momentos del pasado 0 1 2 3 4 5 6 37 cuento con mi fe en dios 0 1 2 3 4 5 6 38 me acuesto 0 1 2 3 4 5 6 39 pienso en personas con las que me gusta estar 0 1 2 3 4 5 6 582 593 estudo das nao conformidades.indd 582 aquichan issn 1657-5997 helen cristiny teodoro couto ribeiro1 lismar isis campos2 bruna figueiredo manzo3 maria josé menezes brito4 marília alves5 estudo das não conformidades no trabalho da enfermagem: evidências relevantes para melhoria da qualidade hospitalar6 1 doutoranda da escola de enfermagem da universidade federal de minas gerais. enfermeira, coordenadora do núcleo de gestão da qualidade da secretaria de estado de saúde de minas gerais. belo horizonte (brasil). helen.cristiny@saude.mg.gov.br. 2 mestre pela faculdade de medicina da universidade federal de minas gerais. administradora hospitalar com atuação no hospital das clínicas da ufmg. belo horizonte (brasil). lismarisis@yahoo.com.br 3 doutora em enfermagem pela escola de enfermagem da universidade federal de minas gerais. professora adjunta do departamento de enfermagem materno infantil e saúde publica da escola de enfermagem da universidade federal de minas gerais. belo horizonte (brasil). brunaamancio@yahoo.com.br. 4 doutora em administração pela universidade federal de minas gerais. professora associada do departamento de enfermagem aplicada da universidade federal de minas gerais. vice-líder do núcleo de pesquisa administração em enfermagem. belo horizonte (brasil). brito@enf.ufmg.br 5 doutora em enfermagem pela universidade de são paulo. professora titular do departamento de enfermagem aplicada da universidade federal de minas gerais. líder do núcleo de pesquisa administração em enfermagem. belo horizonte (brasil). marilix@ufmg.br. 6 estudo extraído da dissertação “estudo de não conformidades no trabalho de enfermagem: evidências que interferem na qualidade de hospitais em minas gerais”, apresentada à escola de enfermagem da universidade federal de minas gerais (brasil) em 2011. recibido: 17 de diciembre de 2012 enviado a pares: 15 de marzo de 2013 aceptado por pares: 5 de septiembre de 2013 aprobado: 26 de noviembre de 2013 doi: 10.5294/aqui.2014.14.4.12 para citar este artículo / to reference this article / para citar este artigo couto-ribeiro hct, campos li, manzo bf, brito mjm, alves m. estudo das não conformidades no trabalho da enfermagem: evidências relevantes para melhoria da qualidade hospitalar. aquichan. 2014; 14l (4): 582-593. doi: 10.5294/aqui.2014.14.4.12 resumo objetivo: identificar as não conformidades relativas ao trabalho da enfermagem em hospitais de minas gerais, brasil. método: tratase de uma pesquisa quantitativa, de caráter descritivo. os dados foram coletados dos relatórios de diagnóstico organizacional realizado pelo sistema brasileiro de acreditação de 37 hospitais dos 45 avaliados em 2009 (amostra de 82,22 %). as não conformidades relativas ao trabalho da enfermagem foram classificadas em três grupos: cuidar/assistir; administrar/gerenciar e educar/pesquisar. resultados: os resultados deste estudo apontaram distanciamento entre o estabelecido pelo sistema brasileiro de acreditação e a prática da enfermagem. revelaram quesitos importantes a serem corrigidos para a segurança dos pacientes, organização dos hospitais e cumprimento da legislação brasileira vigente. no entanto, observou-se que as não conformidades relativas à enfermagem estão intrinsecamente ligadas ao trabalho dos demais profissionais de saúde. conclusões: a resolução das não conformidades identificadas não está na governabilidade exclusiva da equipe de enfermagem. é necessária uma mudança de cultura e a elaboração de uma política organizacional pelos dirigentes dos hospitais que assegure à equipe multiprofissional oportunidades de discussão das causas das não conformidades e elaboração de estratégias para promover a melhoria contínua da qualidade e segurança no cotidiano dos hospitais. palavras-chave serviço hospitalar de enfermagem, gestão de qualidade, qualidade da assistência à saúde, acreditação, hospitais. (fonte: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 582-593 583 estudo das não conformidades no trabalho da enfermagem: evidências relevantes para melhoria da qualidade hospitalar l helen cristiny teodoro couto-ribeiro, e outros. año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 582-593 estudio de las no conformidades en el trabajo de enfermería: evidencias relevantes para la mejora de la calidad hospitalaria resumen objetivo: identificar las no conformidades relativas al trabajo de la enfermería en hospitales de minas gerais (brasil). método: investigación cuantitativa, de carácter descriptivo. los datos se recolectaron de los informes de diagnóstico organizacional realizados por el sistema brasileño de acreditación de 37 hospitales de los 45 evaluados en 2009 (muestra de 82,22 %). las no conformidades relativas al trabajo de la enfermería se clasificaron en tres grupos: cuidar/asistir, administrar/dirigir y educar/investigar. resultados: los resultados de este estudio señalaron distanciamiento entre lo establecido por el sistema brasileño de acreditación y la práctica de enfermería. revelaron puntos importantes por corregirse para la seguridad de los pacientes, organización de los hospitales y cumplimiento de la legislación brasileña actual. sin embargo, se observó que las no conformidades relativas a la enfermería están intrínsecamente conectadas al trabajo de los demás profesionales de salud. conclusiones: la resolución de las no conformidades identificadas no está en la gobernabilidad exclusiva del equipo de enfermería. es necesario un cambio de cultura y la elaboración de una política organizacional por los dirigentes de los hospitales que le asegure al equipo multiprofesional oportunidades para promover la mejora permanente de la calidad y seguridad en la cotidianidad de los hospitales. palabras clave servicio hospitalario de enfermería, gestión de calidad, calidad de la asistencia a salud, acreditación, hospitales. (fuente: decs, bireme). 584 aquichan issn 1657-5997 a study of nonconformities in nursing work: evidence relevant to improving hospital quality abstract objective: the purpose of this study was to identify the nonconformities related to nursing work at hospitals in minas gerais (brazil). method: a quantitative, descriptive method was used. the data were collected from organizational diagnosis reports prepared by the brazilian accreditation system for 37 of the 45 hospitals evaluated in 2009 (sample of 82.22%). the nonconformities related to nursing work were classified into three groups: care/assistance, management/supervision, and education/research. results: the results of this study show there is a gap between the provisions of the brazilian accreditation system and nursing practice. they revealed important issues that should be corrected in the interest of patient safety, hospital organization, and compliance with current legislation in brazil. however, it was noted the nonconformities related to nursing work are intrinsically connected to the work of other health professionals. conclusions: resolving the nonconformities that were identified does not depend exclusively on the nursing team. a change in the hospital culture and the development of an organizational policy on the part of hospital managers are required to ensure the multi-professional team has opportunities to encourage continuous improvement in the quality and safety of the everyday, routine operation of hospitals. key words hospital nursing service, quality management, health care quality, accreditation, hospitals. (sources: mesh, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 582-593 585 estudo das não conformidades no trabalho da enfermagem: evidências relevantes para melhoria da qualidade hospitalar l helen cristiny teodoro couto-ribeiro, e outros. introdução dentre os pioneiros da avaliação da qualidade de hospitais encontra-se florence nightingale, precursora da enfermagem moderna. seu trabalho no hospital militar de scutari durante a guerra da crimeia (1854-1856) foi fundamental para mostrar o impacto da precariedade das condições sanitárias (falta de saneamento, ventilação, sujeira) na mortalidade dos soldados. após sua avaliação, ela mostrou estatisticamente que o indice de morte dos soldados era dez vezes maior por doenças decorrentes das condições estruturais do hospital do que aqueles causados por ferimento da guerra (1). após implantar medidas simples a taxa de óbito reduziu em dois terços do total de soldados (2). no entanto, foi somente no século seguinte a partir dos estudos do médico avedis donabedian é que a avaliação dos cuidados se desenvolveu de forma conceitual e metodológica e se difundiu para muitos países por meio do apoio da organização mundial de saúde (3). donabedian introduziu o modelo estrutura-processoresultado que passou a orientar a avaliação sistemática da qualidade do atendimento em saúde. estrutura foi concebida como o ambiente em que os serviços de saúde são prestados; processo foi descrito como as etapas envolvidas na prestação de serviços médicos, e os resultados são medidos por vários critérios – indicadores de saúde e satisfação dos pacientes, dentre outros – para analisar o cuidado (4). essa tríade tem orientado diversas metodologias de acreditação, que é um processo voluntário, de aprendizagem e melhoria contínua da qualidade que tem despertado grande interesse nos últimos anos como uma abordagem para aprimorar e manter a qualidade dos cuidados de saúde (5). o sistema brasileiro de acreditação (sba) – iniciado a partir de 1999, pela organização nacional de acreditação –, considerando as organizações de saúde um sistema complexo afirma que as estruturas, os processos e os resultados estão tão interligados que o funcionamento de um componente interfere no conjunto e no resultado final. assim, o sba é um método de consenso, racionalização, ordenação dos serviços de saúde e, principalmente, um processo permanente de educação dos profissionais. a avaliação é realizada in loco e transversal, de forma sistêmica permitindo analisar os processos de trabalho e as relações com os resultados, não se avaliando um setor ou processo isoladamente (6). o processo de avaliação do sba é realizado por instituições acreditadoras credenciadas (iac) pela organização nacional de acreditação (ona), as quais são de direito privado, com ou sem fins lucrativos. atualmente, existem seis iac/ona e há duas formas de avaliação, uma para a acreditação propriamente dita e outra com finalidade de diagnóstico organizacional. na primeira após o processo de avaliação, o serviço de saúde pode se encaixar em quatro situações, a saber: não acreditado; acreditado (nível 1, com certificado válido por dois anos); acreditado pleno (nível 2, com certificado válido também por dois anos); ou acreditado com excelência (nível 3, com certificado válido por três anos). a outra forma de avaliação – diagnóstico organizacional – não tem a finalidade de definir estes nivelamentos e sim de fornecer para os dirigentes um relatório da situação do serviço de saúde (6). para estas duas possibilidades de avaliação as instituições acreditadoras estabelecem equipes, compostas por, no mínimo, três profissionais, geralmente um médico, um enfermeiro e um profissional com experiência em gestão (sendo um deles o avaliadorlíder) que para coletarem os dados visitam todos os setores do serviço de saúde. para tanto, os avaliadores são acompanhados durante esta visita por profissionais do próprio serviço (de qualquer categoria profissional), os quais, geralmente, são gerentes ou supervisores de cada um dos setores visitados ou responsáveis designados pela direção para fornecerem as informações, as documentações e as evidências solicitadas pelos avaliadores. os avaliadores também podem solicitar estas informações ou evidências a qualquer profissional dos setores visitados de forma aleatória, não tendo um grupo específico de profissionais ou uma amostragem definida. os avaliadores baseiam sua avaliação em questões pré-estabelecidas nas normas técnicas específicas para cada atividade-fim dos serviços de saúde avaliados; das deliberações da ona e principalmente pelo manual brasileiro de acreditação (mba). o mba é discutido e validado pelas entidades fundadoras e associadas da ona. as instituições acreditadores, os avaliadores e os serviços de saúde também podem sugerir melhorias para o manual em cada nova edição por meio de consulta pública realizado pela ona. o mba é constituído de seções e subseções, as quais contêm padrões de qualidade que são interdependentes e devem ser integralmente atendidos pelos serviços (6). as informações, as documentações e as evidências levantadas durante o processo de avaliação são para análise do cumprimento destes padrões do manual. diante deste contexto brasileiro para melhoria da qualidade dos serviços de saúde, a secretaria de estado de saúde de minas gerais lançou, em 2008, um rol de ações para avaliar os hospi586 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 tais do programa de fortalecimento e melhoria da qualidade dos hospitais do sistema único de saúde de minas gerais/brasil. este programa visa desenvolver um parque hospitalar público capaz de operar com eficiência e prestar serviços de qualidade que atendam as necessidades da população e que se insiram em redes integrais de atenção à saúde. a secretaria de estado de saúde de minas gerais então assumiu, com o banco mundial, o compromisso de realizar nestes hospitais um processo de diagnóstico organizacional. este processo resultou em relatórios detalhado de cada hospital, proporcionando aos dirigentes informações dos pontos das não conformidades (nc) que precisam ser corrigidos. quando a instituição não atinge a determinados padrões, ou seja, um nível de qualidade adequate, acceptable ou optimal – neste caso os estabelecidos pela ona – há a ocorrência de nc (7). a ocorrência e a permanência de nc podem configurar cenários inseguros, ocasionando erros por parte dos profissionais, o que compromete sua própria segurança e, principalmente, a segurança dos pacientes (8). a temática avaliação de conformidades na saúde é pouco explorada, o que é evidenciado pela escassez de estudos na literatura científica. porém, a identificação das nc na saúde propicia a melhoria para a segurança do paciente, a qual é uma das dimensões de uma assistência com qualidade. a segurança do paciente é entendida como um conjunto de medidas e políticas que visam a redução, a um mínimo aceitável, do risco de ocorrência de dano desnecessário ao paciente relacionado com a assistência à saúde (9-11). neste sentido, a identificação de não conformidades é um sinal de alerta para que os profissionais discutam suas causas e elaborem estratégias para promover a melhoria contínua da estrutura e dos processos, para que a qualidade, a segurança e os resultados positivos sejam uma consequência inerente a todo esforço implementado (8). embora as não conformidades ocorram em um contexto que envolve diversos profissionais de saúde, optou-se neste estudo pela análise das não conformidades relativas ao trabalho de enfermagem. isso se justifica uma vez que esta categoria constitui o grupo mais crítico de profissionais para a evolução dos pacientes, pois permanece cerca de 90% do seu tempo cuidando dos pacientes (5), de forma ininterrupta nas 24 horas, sendo, portanto atores fundamentais para a qualidade dos processos assistenciais nos hospitais. assim, o objetivo desse estudo foi identificar as não conformidades relativas ao trabalho da enfermagem em hospitais do estado de minas gerais, brasil. métodos trata-se de estudo de abordagem quantitativa, de caráter descritivo com base na análise das não conformidades apresentadas nos relatórios da avaliação de diagnóstico organizacional de hospitais do programa de fortalecimento e melhoria da qualidade dos hospitais do sistema único de saúde de minas gerais, brasil. a amostra foi composta de 37 (82,22%) dos 45 hospitais avaliados em 2009. as avaliações de diagnóstico organizacional foram realizadas por equipe multiprofissional de avaliadores de uma instituição acreditadora credenciada pela organização nacional de acreditação (ona). para subsidiar a elaboração do relatório de diagnóstico organizacional os avaliadores, acompanhados por profissionais dos hospitais (geralmente coordenadores ou profissionais designados pela direção), visitaram todos os setores dos hospitais, coletando informações, documentos e evidências de cumprimento dos padrões estabelecidos pelo manual brasileiro de acreditação da ona. a versão 2006 do manual, vigente na época da avaliação, foi o instrumento orientador deste processo. o maior contingente dos 37 hospitais localizava-se na região ampliada de saúde (macrorregião) centro de minas gerais. do total, 10,81% correspondiam à esfera administrativa municipal, 8,11% a federal, 2,70% a estadual, 78,38% eram filantrópicos e 32,43% eram hospitais de ensino. a maioria (54,05%) eram referências para a população de sua região de saúde (microrregião), que é base territorial de planejamento da atenção secundária em saúde e 45,95% eram referências para a região ampliada de saúde (macrorregião), ou seja, base territorial de planejamento da atenção terciária. a maioria dos hospitais deste estudo (51,35%) tinham entre 101 a 200 leitos, seguidos do grupo de mais de 201 leitos (24,32%). a variável não conformidade foi coletada na seção organização profissional e subseção enfermagem do relatório de diagnóstico organizacional. as demais variáveis (número de profissionais de enfermagem e número total de profissionais de saúde relativas a 2009) foram coletadas no cadastro nacional de estabelecimentos de saúde. para a coleta, tratamento e análise dos dados foram adotados, respectivamentes, os softwares tabwin 3.6b, microsoft office excel® 2007 e data analysis and statistical software versão 11.1. 587 estudo das não conformidades no trabalho da enfermagem: evidências relevantes para melhoria da qualidade hospitalar l helen cristiny teodoro couto-ribeiro, e outros. foram estabelecidos três grupos para análise das não conformidades. grupo 1 não conformidades no processo de trabalho cuidar/assistir: relacionadas às atividades de cuidado direto e à organização da assistência. o grupo 2 não conformidades no processo de trabalho administrar/gerenciar: relacionadas a atividades associadas ao trabalho do enfermeiro na organização e gestão de recursos materiais e físicos e gestão de pessoas. o grupo 3 não conformidades ao processo de trabalho educar/ pesquisar: relacionadas às atividades educativas e de pesquisa. os limites entre esses grupos são tênues e variam na literatura de acordo com o foco das pesquisas e seus achados, os quais são decorrentes das várias formas de organização da enfermagem nos hospitais. elaborou-se um modelo de análise (figura 1) com a finalidade de classificar as não conformidades considerando o caráter integrado e multiprofissional do trabalho da enfermagem. figura 1. classificação das não conformidades do processo de trabalho da enfermagem 10,00% e outros 08 (oito) têm menos de 30,00% de pessoal de enfermagem. a média do percentual de enfermeiros em relação à equipe de enfermagem dos 37 hospitais pesquisados foi de 19,07%. a nc mais significativa do ponto de vista quantitativo no grupo 1cuidar/assistir foi “ausência de plano seguro multiprofissional de aplicação medicamentosa”, evidenciada em 89,19% dos hospitais. a tabela 1 apresentada a distribuição das nc evidenciadas nesse grupo. no grupo 2administrar/gerenciar, a nc mais significativa e que ocorreu em 100,00% dos hospitais foi “ausência de política de gerenciamento de riscos”, conforme tabela 2. a nc “ausência de definição de programa de treinamento para os colaboradores com foco nas não conformidades dos setores, com mensuração de sua eficácia e eficiência” foi a mais frequente no grupo 3educar/pesquisar, com evidência em 43,24% dos hospitais (tabela 3). discussão os hospitais estudados apresentaram características heterogêneas. há instituições de grande porte e que exercem atividade de ensino e hospitais de pequeno porte e sem atividade de ensino. o número de profissionais enfermeiros contraria as normas do conselho federal de enfermagem do brasil e o percentual da equipe de enfermagem não atinge o parâmetro que a literatura descreve ser de aproximadamente 60% do contingente de pessoal (12, 13). no grupo 1cuidar/assistir, as não conformidades (nc) revelaram quesitos importantes para a segurança dos pacientes e estão intrinsecamente ligados ao trabalho de outros profissionais. a nc mais expressiva, “ausência de plano seguro multiprofissional de aplicação medicamentosa”, merece destaque por envolver toda a equipe. os danos causados por eventos adversos a medicamentos ocorrem em todo o mundo, alguns estudos sugerem que eles respondem por um quarto de todos os erros médicos. nos estados unidos, austrália e frança, esse tipo de evento ocorre em aproximadamente 4% das internações hospitalares, resultando em óbito em cerca de 5%-10% das ocorrências. no reino unido, em 2001, mais de mil pessoas morreram por eventos adversos a medicamentos (14). dos 550 eventos adversos na assistência de enfermagem em uma uti de um hospital no brasil, 51,4% estavam relacionados à administração de medicamentos fonte: ribeiro (8). a pesquisa foi autorizada pelos 37 hospitais e aprovada no comitê de ética da universidade federal de minas gerais sob o parecer etic 0501.0.203.000-10. resultados a média dos profissionais de enfermagem em 2009, nos 37 hospitais estudados foi de 243,84. a média do percentual de profissionais de enfermagem em relação ao total de profissionais foi de 33,56%. em 03 (três) hospitais esse percentual foi abaixo de 588 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 tabela 1. distribuição das não conformidades (nc) relacionadas ao processo de trabalho de enfermagem cuidar/assistir nos 37 hospitais. belo horizonte/mg, 2011 tabela 2. distribuição das não conformidades (nc) relacionadas ao processo de trabalho de enfermagem administrar/gerenciar nos 37 hospitais. belo horizonte/mg, 2011 não conformidade (nc) n % ausência de plano seguro multiprofissional de aplicação medicamentosa 33 89,19 ausência de metodologia para o planejamento da assistência de enfermagem com base no risco evidenciado implantação da sae* 29 78,38 ausência de método para a estratificação de risco da totalidade dos pacientes admitidos na instituição 27 72,97 ausência de protocolo de transporte intra e extra hospitalar 21 56,76 ausência de controle de eventos assistenciais, com definição de ações de prevenção e controle de danos 17 45,95 ausência de metodologia segura para identificação da totalidade dos pacientes, com foco na segurança 16 43,24 ausência de plano multiprofissional de alta hospitalar 12 32,43 ausência de modelo assistencial claramente definido 6 16,22 ausência de implantação de gerenciamento de risco na sua totalidade, a partir da definição de erros e eventos adversos 6 16,22 outras† 4 10,81 fonte: relatórios de diagnóstico organizacional ona de hospitais de minas gerais/brasil (h1 a h37), 2009. * sae sistematização da assistência de enfermagem. † nc que foram evidenciadas em apenas 1 hospital cada uma. não conformidade (nc) n % ausência de política de gerenciamento de riscos 37 100,00 ausência de fluxo de atendimento às emergências nas diversas áreas assistenciais, contemplando profissionais, equipamentos e medicamentos 29 78,38 a política para garantia e melhoria do preenchimento de documentos e a identificação dos profissionais e pacientes nos prontuários deve ser reforçada 23 62,16 ausência de comissão de ética em enfermagem 19 51,35 ausência de método formal para o controle de materiais, medicações e equipamentos do carro de emergência e a ausência de checagem formal e diária do desfibrilador 19 51,35 ausência de metodologia para o dimensionamento de pessoas com base no perfil de complexidade da unidade, obtido através da ferramenta de estratificação de risco/dependência para as áreas críticas 17 45,95 ausência de indicadores básicos de apoio a gestão (absenteísmo e turnover, por exemplo) 15 40,54 ausência do regimento interno disponível do serviço 10 27,03 ausência de metodologia para o gerenciamento dos riscos identificados: queda, flebites, úlceras por pressão entre outros 9 24,32 ausência de método efetivo de controle, em conjunto com a farmácia e almoxarifado, do estoque de medicamentos, materiais médicos e equipamentos disponíveis nas unidades 6 16,22 os procedimentos de risco junto ao serviço de controle de infecção hospitalar devem ser validados 6 16,22 ausência de registro de responsabilidade técnica 6 16,22 ausência de método seguro para o controle de temperatura das geladeiras de medicamentos 3 8,11 a falta de cobertura de enfermeiro nas 24 horas com foco na legislação e gerenciamento de risco deve ser analisada criticamente 2 5,41 outras* 11 29,73 fonte: relatórios de diagnóstico organizacional ona de hospitais de minas gerais/brasil (h1 a h37), 2009. * nc que foram evidenciadas em apenas 1 hospital cada uma. 589 estudo das não conformidades no trabalho da enfermagem: evidências relevantes para melhoria da qualidade hospitalar l helen cristiny teodoro couto-ribeiro, e outros. tabela 3. distribuição das não conformidades (nc) relacionadas ao processo de trabalho de enfermagem educar/pesquisar nos 37 hospitais. belo horizonte/mg, 2011 fonte: relatórios de diagnóstico organizacional ona de hospitais de minas gerais/brasil (h1 a h37), 2009. não conformidade (nc) n % ausência de definição de programa de treinamento para os colaboradores com foco nas não conformidades dos setores, com mensuração de sua eficácia e eficiência 16 43,24 ausência de programa para a capacitação e envolvimento das lideranças para o gerenciamento efetivo de cada célula de negócio 8 21,62 ausência de programa de integração do novo colaborador com foco na capacitação e no desenvolvimento 3 8,11 ausência de programa formal de acompanhamento de estagiários 1 2,70 (15). sugere-se que 75% desses erros por medicamentos são evitáveis (14), mas a abordagem na saúde para a prevenção de erro é reativa, sendo, geralmente, descobertos apenas quando há incidente, efeito indesejável ou prejuízo para o paciente (16). assim, o plano multiprofissional de aplicação medicamentosa é uma estratégia que instrumentaliza a equipe de enfermagem e os demais membros da equipe multiprofissional na prevenção de erros relacionados a medicamentos (8). sendo fundamental que todos os hospitais estabeleçam políticas para garantir a segurança do sistema de medicação (14). outra nc que também se destaca por envolver a equipe multiprofissional é a “ausência de controle de eventos assistenciais, com definição de ações de prevenção e controle de danos”. em países desenvolvidos um em cada 10 pacientes é prejudicado ao receber cuidados hospitalares devido a erros, sendo que nos países em desenvolvimento a probabilidade é bem maior (17). há diversar formas de se realizar o controle dos eventos adversos, geralmente eles são dependentes da notificação dos profissionais de saúde, que pode ser realizado em sistema eletrônico ou em formulários preenchidos manualmente. a literatura mostra, no entanto, que há uma preocupação por parte dos profissionais com a questão do anonimato e que muitas vezes eles preferem formas não oficiais para comunicar algum evento assistencial que ocasionou dano ao paciente, como por exemplo, relato verbal, anotação no prontuário do paciente ou a descrição do ocorrido em treinamentos (18). assim, faz-se necessário implantar uma política hospitalar que aborde o erro como uma ocorrência sistêmica, decorrentes de falhas em vários processos, mudando, assim, a cultura de encontrar o culpado pelo ocorrido, motivando a notificação, discussão e resolução em equipe destes eventos indesejados. a nc “ausência de metodologia segura para identificação da totalidade dos pacientes, com foco na segurança” encontrada neste estudo, pode levar a erros de medicação, de transfusão de hemocomponentes, de exames de apoio diagnóstico, de realização de procedimentos em pacientes errados e de bebês entregues a famílias erradas (19), e também é de responsabilidade de toda a equipe. a identificação errada do paciente é uma causa-raiz de muitos erros, sendo que a joint commission nos eua listou a melhoria da identificação dos pacientes como a primeira das metas nacional de segurança do paciente apresentadas em 2003 (19) e a primeira das metas internacionais para segurança do paciente lançada em 2010 (20), sendo um requisito de acreditação. o programa nacional de segurança do paciente no brasil lançado em abril de 2013 também tem como primeira ação a melhoria da identificação dos pacientes (21). enfim, a mitigação e a solução de muitas nc deste grupo 1 não estão sob a governabilidade exclusiva da enfermagem. ademais, o sistema brasileiro de acreditação não visa responsabilizar determinada classe profissional ou setor, a metodologia focaliza o serviço ou processo como um todo. assim, é necessário que a alta direção promova constantemente educação permanente e grupos de discussão nas instituições hospitalares, dando oportunidade dos profissionais refletirem sobre as nc referentes ao processo em que está inserido à sua prática e, busquem viabilizar ações conjuntas para que as nc sejam totalmente solucionadas. no grupo 2administrar/gerenciar as nc revelam aspectos importantes para a organização dos hospitais e estão diretamente relacionadas ao cumprimento da legislação brasileira vigente. chama a atenção a nc “ausência de política de gerenciamento de 590 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 riscos” presente na totalidade dos hospitais. os riscos podem ser assistenciais, sanitários, ambientais, ocupacionais e de responsabilidade civil (6), os quais podem levar a erros e causar danos nos pacientes, por vezes, irreparáveis. os métodos utilizados para prevenção de erros na saúde têm-se baseado em treinamento e punição (desaprovação social). os erros são considerados como falhas de alguém, causadas por desatenção. contudo, estudiosos sobre erros e desempenho rejeitam este postulado, pois as causas de um erro humano costumam estar além do controle do indivíduo, sendo que os sistemas que dependem de desempenho livre de erros estão fadados ao fracasso (16). torna-se necessário então, que as organizações de saúde realizem a gestão dos riscos, que envolve os ciclos de prevenção, detecção e mitigação dos riscos (6). a gestão do risco deve estar integrada à filosofia da organização. a alta administração tem que apoiar a mudança de cultura e estabelecer uma política administrativa que tenha relação com os planos estratégicos, tático e operacional, além de um planejamento com o escopo a ser trabalhado e as diretrizes de classificação dos riscos (12). “a política para garantia e melhoria do preenchimento de documentos e a identificação dos profissionais e pacientes nos prontuários deve ser reforçada” foi uma nc constatada. a anotação em prontuários é uma atividade importante da enfermagem e demais profissionais quando está em pauta a qualidade dos serviços. o registro sobre a assistência ao paciente respalda, ética e legalmente, o profissional responsável, assim como o paciente. quando o registro é inadequado há comprometimento da segurança e da perspectiva de cuidado, além da dificuldade de mensurar os resultados da prática. a padronização das anotações e das evoluções de enfermagem é necessária para minimizar as falhas existentes no que se refere à linguagem formal, à exatidão, legibilidade, identificação e terminologia técnica (22). a nc “ausência de método formal para o controle de materiais, medicações e equipamentos do carro de emergência e a ausência de checagem formal e diária do desfibrilador” também foi evidenciada. corroborando pesquisas da literatura como um estudo brasileiro que teve por objetivo analisar a adequação dos carros de emergência à diretriz de apoio ao suporte avançado de vida em dois hospitais. constatou-se que nenhum carro de emergência avaliado apresentava o conjunto de materiais especificados na normatização brasileira. em nenhum deles foi encontrado tubo oro traqueal de todos os tamanhos. de todos os carros de emergência, os da unidade pediátrica eram os mais defasados em materiais e equipamentos. nenhum dos carros estava localizado em pontos adequados dos setores (23). enfim, os resultados do grupo 2 corroboram um documento do banco mundial que afirma que no brasil apesar de possuir um programa de acreditação bem desenhado, a apropriação dos seus princípios é limitada a um pequeno número de hospitais, geralmente, pertencentes à elite do setor e que é preciso expandir a acreditação para que os hospitais estejam motivados a monitorar e melhorar seus processos e resultados (24). assim, a alta direção dos hospitais participantes do estudo e demais hospitais devem viabilizar educação permanente para os profissionais, possibilitando um (re)pensar da sua prática gerencial, bem como, prover os recursos necessários no sentido de um trabalho conjunto da enfermagem, demais profissionais de saúde e alta direção para a mitigação e solução das nc encontradas (8). no grupo3ensinar/pesquisar, a nc “ausência de definição de programa de treinamento para os colaboradores com foco nas não conformidades dos setores, com mensuração de sua eficácia e eficiência” foi a mais frequente. este resultado reforça as ações realizadas pela secretaria de estado de saúde de minas gerais no brasil, no sentido de dar elementos para que os hospitais possam trabalhar para a melhoria contínua dos seus serviços. as nc diagnosticadas devem subsidiar a identificação de necessidades de treinamentos dos colaboradores. a “ausência de programa para a capacitação e envolvimento das lideranças para o gerenciamento efetivo de cada célula de negócio” é um aspecto importante para a melhoria ou não da qualidade. a liderança influencia diretamente a cultura de uma organização (5). há dois fatores que influenciam o sucesso da liderança. o primeiro é a autoridade, que inclui a capacidade de influenciar profissionais tanto para elogiar quanto para repreendê-los e o segundo é o carisma, que é a capacidade de persuadir, motivar, inspirar confiança e dar exemplo pessoal de compromisso para a melhoria da qualidade do atendimento (25). assim a liderança tem forte capacidade de redesenhar a cultura organizacional (5). os enfermeiros são agentes que influenciam diretamente a qualidade do serviço e esta qualidade depende significativamente do líder e da maneira que ele gerencia a equipe (26). em estudo desenvolvido em 14 hospitais certificados pela ona e pela joint commission international no brasil, a liderança foi a competência 591 estudo das não conformidades no trabalho da enfermagem: evidências relevantes para melhoria da qualidade hospitalar l helen cristiny teodoro couto-ribeiro, e outros. mais importante e mais presente nos gerentes de enfermagem, na visão dos seus superiores hierárquicos (27). os resultados de um estudo sobre a influência da liderança na qualidade do cuidado de enfermagem mostraram que o reconhecimento de seus liderados; a promoção do desenvolvimento da equipe de enfermagem; a comunicação; e a forma como os líderes inspiram e incentivam a inovação dos serviços realizados são importantes papéis do líder de enfermagem (26). o grupo 3 revela que a associação das metodologias e das práticas da educação não estão alinhados com o saber-fazer assistencial e gerencial da enfermagem. desde a formação dos profissionais não ocorre de forma integrada a teoria e a prática, sendo necessário (re)construir abordagens que consigam agregá-las no cotidiano de trabalho. neste sentido, a qualidade em saúde, pode ser vista como o produto de dois fatores: primeiro, a ciência e tecnologia de cuidados de saúde; e segundo, a aplicação dela na prática dos serviços de saúde. ou seja, a qualidade do atendimento realizado no cotidiano é o produto destes dois fatores: a ciência e a tecnologia em si (saber teórico) e sua aplicabilidade (prática). este produto é caracterizado por vários atributos, que incluem eficácia, efetividade, eficiência, otimização, aceitabilidade, legitimidade e equidade (25). a eficácia refere-se à habilidade da ciência e da tecnologia dos cuidados de saúde em produzir melhorias na saúde. a efetividade reflete o grau no qual melhorias possíveis nos cuidados de saúde são de fato atingíveis. a eficiência aponta a capacidade do serviço de reduzir o custo do cuidado sem diminuir as melhorias possíveis na saúde. a otimização consiste no equilíbrio das melhorias e dos seus custos. a aceitabilidade se refere à conformidade com os desejos e as expectativas dos pacientes e suas famílias. a legitimidade indica conformidade às preferências sociais expressas em princípios éticos, valores, normas, costumes, leis e regulamentos. a equidade determina a correta distribuição dos cuidados de saúde e seus benefícios entre a população. estes atributos, se tomados individualmente ou combinando-os de várias formas, constituem uma definição de qualidade. quando medidos de uma forma ou de outra, irão significar sua magnitude (25). assim, observou-se que as nc do grupo 3 estão ligadas diretamente à política de gestão e desenvolvimento de pessoas colocada em pratica pela instituição, sendo necessário assim, que os dirigentes hospitalares revisem essa política. diante deste contexto a redução e solução das nc relativas ao trabalho da enfermagem não estão na governabilidade exclusiva da equipe de enfermagem, tendo em vista o trabalho coletivo nos hospitais. a acreditação hospitalar para trazer melhorias para a qualidade da assistência exige trabalho com vistas à interdisciplinaridade e superação da fragmentação institucional da assistência, fazendo com que os profissionais se organizem para entender a lógica do cuidado integral e atingirem, consequentemente, a qualidade desejada. no entanto, em um estudo os autores concluíram que o impacto dos modelos de avaliação externa baseada em padrões varia de acordo com sua finalidade, normas, procedimentos e incentivos. os hospitais que apresentaram maiores níveis de segurança foram associados mais com a acreditação do que com a certificação pela international organization for standardization, mas ambos os sistemas foram significativamente melhores que nenhum processo de avaliação externa (28). porém, para que os programas de acreditação tenham maior impacto no sistema de saúde, necessariamente, devem envolver uma grande proporção de hospitais deste sistema (28), o que é um desafio no contexto brasileiro atual. conclusão os resultados do estudo apontam um distanciamento significativo entre o estabelecido pelo sistema brasileiro de acreditação e as evidências coletadas pelos avaliadores sobre a prática da enfermagem nos hospitais estudados. no entanto, o quantitativo de profissionais de enfermagem e enfermeiros destes foi baixo quando comparado com o previsto na literatura, o que pode justificar a ocorrência de muitas não conformidades. além disso, observou-se que estas não são problemas sob a governabilidade exclusiva da enfermagem, pelo contrário, envolvem toda a equipe multiprofissional. a avaliação de não conformidades deve ser trabalhada com foco na governança clínica, de forma multiprofissional e interdisciplinar, onde a gestão e a assistência se harmonizem e reflitam em uma política organizacional comprometida com a qualidade dos serviços prestados. constitui limite deste estudo o fato de os dados dos relatórios de diagnóstico organizacional referir-se a hospitais avaliados em 2009, não representando a totalidade ou uma amostra representativa dos hospitais do estado de minas gerais no brasil e também o fato de, por ser um estudo descritivo, não ter sido realizada 592 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 correlações entre as variáveis. para suprir esta limitação sugerese a realização de pesquisas focalizando maior número de hospitais e também que busquem as causas das não conformidades, contemplando o sistema hospitalar como um todo, uma vez que a ação conjunta de todos os profissionais é que assegura a qualidade e seguranças da assistência nos hospitais. referências 1. fee e, garofalo me. florence nightingale and the crimean war. am j public health. 2010;100(9):1591. 2. garofalo me, fee e. florence nightingale (1820-1910): feminism and hospital reform. am j public health. 2010;100(9):1588. 3. serapioni m. avaliação da qualidade em saúde. reflexões teórico-metodológicas para uma abordagem multidimensional. rev crítica ciênc soc. 2009;85:65-82. 4. rodkey gv, itani kmf. evaluation of healthcare quality: a tale of three giants. am j surg. 2009;198(suppl 5): s3-8. 5. awa ba, mazrooa aa, rayes o, hati te, devreux i, noury ka. benchmarking the post-accreditation patient safety culture at king abdulaziz university hospital. ann saudi med. 2014;32(2):143-150. 6. organização nacional de acreditação. manual das organizações prestadoras de serviços de saúde. coleção manual brasileiro de acreditação. brasília (brasil): organização nacional de acreditação; 2014. 7. donabedian a. criteria, norms and standards of quality: what do they mean? am j public health. 1981;71(4):409-12. 8. ribeiro hctc. estudo de não conformidades no trabalho de enfermagem: evidências que interferem na qualidade de hospitais em minas gerais [dissertação]. belo horizonte: escola de enfermagem, universidade federal de minas gerais; 2011. 9. institute of medicine. to err is human: building a safer health system. washington, dc: national academy press; 2000. 10. institute of medicine. crossing the quality cahsm: a new helth system for the 21 st century. whashington, dc: national academy press; 2001. 11. runcikman w, hibbert p, thompson r, schaaf tvd, sherman h, lewalle p. towards an international classification for patient safety: key concepts and terms. int j qual health care. 2009;21(1):18-26. 12. feldman lb, org. gestão de risco e segurança hospitalar. 2ª ed. são paulo: martinari; 2009. 13. kobayashi rm, silva abv, ayoub ac. gerenciando dificuldades para acreditação hospitalar em hospital cardiovascular. rene. 2010;11(4):19-28. 14. world health organization. patient safety workshop. learning from error [serial on-line] 2008 [cited 2011 set 4]. available from: url: http://www.who.int/patientsafety/ activities/technical/vincristine_learning-from-error.pdf. 15. beccaria lm, pereira ram, contrin lm, lobo sma, trajano dhl. eventos adversos na assistência de enfermagem em uma unidade de terapia intensiva. rev bras ter intensiva. 2009;21(3):276-82. 16. leape ll. error in medicine. jama. 1994;272(23):1851-57. 17. world health organization. 10 facts on patient safety [serial on-line] 2011. [cited 2011 sep 4]. available from: url: http://www.who.int/features/factfiles/patient_safety/patient_safety_facts/en/index1.html 18. lederman r, dreyfus s, matchan j, knott jc, milton sk. electronic error-reporting systems: a case study into the impact on nurse reporting of medical errors. nurs outlook. 2013;61(6):417-426. 19. world health organization. patient identification. patient safety solutions [serial on-line] 2007 may [cited 2011 set 4]; 1 (2). available from: url: http://www.who.int/patientsafety/solutions/patientsafety/ps-solution2.pdf 20. consórcio brasileiro de acreditação de sistemas e serviços de saúde (cba); joint commission international (jci). padrões de acreditação da joint commission international para hospitais. rio de janeiro (brasil): cba; 2010. 593 estudo das não conformidades no trabalho da enfermagem: evidências relevantes para melhoria da qualidade hospitalar l helen cristiny teodoro couto-ribeiro, e outros. 21. brasil. ministério da saúde. gabinete do ministro. portaria n. 529/2013. institui o programa nacional de segurança do paciente. diário oficial da união (brasil): 2013. 22. setz vg, d’innocenzo m. avaliação da qualidade dos registros de enfermagem no prontuário por meio da auditoria. acta paul enf. 2009;22(3):313-7. 23. lima sg, diniz lr, nunes filho eo, oliveira mf, oliveira jav, sá mpbo, et al. os carros de emergência e o suporte avançado de vida. rev soc bras clín méd. 2010;8(5):399-404. 24. la forgia gm, couttolenc bf. hospital performance in brazil: the search for excellence. são paulo: singular; 2009. 25. donabedian a. an introduction to quality assurance in health care. new york: oxford university press; 2003. 26. mendes l, fradique mdejjg. influence of leadership on quality nursing care. int j health care qual assur. 2014;27(5): 439-50. 27. furukawa p, cunha ick. profile and competencies of nurse managers at accredited hospitals. rev latino-am enfermagem. 2011;19(1):106-14. 28. shaw c, bruneau c, kutryba b, jongh g, suño r. towards hospital standardization in europe. int j qual health care. 2010;22(4):244-9. eye care interventions in critical/surgical patients in the prone position: scoping review article eye care interventions in critical/surgical patients in the prone position: scoping review intervenciones para el cuidado ocular en pacientes críticos/quirúrgicos en decúbito prono: revisión de alcance intervenções para a saúde ocular em pacientes críticos ou cirúrgicos em decúbito ventral: revisão de escopo 10.5294/aqui.2022.22.3.3 ana clara dantas 1 marília lopes costa 2 amanda barbosa da silva 3 bárbara ebilizarda coutinho borges 4 jéssica naiara de medeiros araújo 5 allyne fortes vitor 6 1 0000-0002-5634-7498 universidade federal do rio grande do norte, brazil anaclaradaantas@yahoo.com.br 2 0000-0002-5035-3627 universidade federal do rio grande do norte, brazil maariliia@hotmail.com 3 0000-0002-5410-7060 universidade federal do rio grande do norte, brazil amandab641@hotmail.com 4 0000-0001-6922-1475 universidade federal do rio grande do norte, brazil barbara_ebilizarda@hotmail.com 5 0000-0002-9115-3285 universidade federal do rio grande do norte, brazil jessicanaiara_rn@hotmail.com 6 0000-0002-4672-2303 universidade federal do rio grande do norte, brazil allynefortes@gmail.com received: 06/02/2022 sent to peers: 11/05/2022 accepted by peers: 17/07/2022 approved: 18/07/2022 theme: promotion and prevention. contribution to the discipline: the results of the present study highlight that interventions such as eye examination, the use of lubricants/specific ophthalmic solution, reverse trendelenburg positioning, and protection with adhesive tape reduce the risks for patients in the prone position. knowledge of these interventions is essential since ophthalmic care in critical/surgical patients in the prone position avoids complications, such as facial edema and pressure injuries on the face, thoracic region, and lower and upper limbs. the prone position is an adjunctive postural therapy commonly used to manage specific patients, especially during the covid-19 pandemic. para citar este artículo / to reference this article / para citar este artigo: dantas ac, lopes costa m, barbosa da silva a, coutinho borges be, de medeiros araújo jn, fortes vitor a. eye care interventions in critical/surgical patients in the prone position: scoping review. aquichan. 2022;22(3):e2233. doi: https://doi.org/10.5294/aqui.2022.22.3.3 abstract objectives: this study aimed to map evidence of eye care interventions in managing critical or surgical patients submitted to prone positions. materials and method: this scoping review was prepared according to the joanna briggs institute's methodology, following the prisma-scr criteria. a search was conducted from july to august 2020 in the scopus, web of science, science direct, pubmed central, cinahl, and cochrane databases. the following research question was delimited: "what are the strategies and interventions used for eye care in the management of critical patients or surgical patients submitted to the prone position?" the sample consisted of 24 studies after applying the inclusion and exclusion criteria. results: eye care interventions in managing critical/surgical patients submitted to the prone position were eye examination, use of lubricants/specific ophthalmic solution, reverse trendelenburg positioning, and protection with adhesive tape. conclusions: this review allowed the understanding of eye care for critical/surgical patients in a prone position. among the care presented, a large part is related to nursing since it is closer to patient care. the findings emphasize the need to implement patient safety policies with eye care as a priority. keywords (source decs): critical care; general surgery; nursing care; ocular health; prone position. resumen objetivos: el presente estudio tuvo como objetivo mapear la evidencia de las intervenciones de cuidado ocular en el manejo de pacientes críticos o quirúrgicos sometidos a decúbito prono. materiales y método: esta revisión de alcance se elaboró de acuerdo con la metodología del instituto joanna briggs y bajo los criterios de prisma-scr. se realizó una búsqueda entre julio y agosto de 2020 en las bases de datos scopus, web of science, science direct, pubmed central, cinahl y cochrane. además, se delimitó la siguiente pregunta de investigación: "¿cuáles son las estrategias e intervenciones utilizadas para el cuidado ocular en el manejo del paciente crítico o quirúrgico sometido al decúbito prono?". después de aplicar los criterios de inclusión y exclusión, la muestra quedó constituida por 24 estudios. resultados: las intervenciones oftalmológicas en el manejo de pacientes críticos/quirúrgicos sometidos a decúbito prono fueron examen oftalmológico, uso de lubricantes/solución oftálmica específica, posicionamiento de trendelenburg inverso y protección con cinta adhesiva. conclusiones: esta revisión permitió la comprensión del cuidado ocular de pacientes críticos/quirúrgicos en decúbito prono. entre los cuidados presentados, gran parte está relacionada con la enfermería, puesto que es más cercana al cuidado del paciente. los hallazgos enfatizan la necesidad de implementar políticas de seguridad del paciente con el cuidado ocular como prioridad. palabras clave (fuente decs): cuidados críticos; cirugía general; atención de enfermería; salud ocular; posición prona. resumo objetivos: o objetivo do presente estudo é mapear a evidência das intervenções de cuidado ocular na gestão de pacientes críticos ou cirúrgicos submetidos a decúbito ventral. materiais e método: esta revisão de escopo é elaborada de acordo com a metodologia do instituto joanna briggs e sob os critérios do prisma-scr. foi realizada uma busca entre julho e agosto de 2020 nas bases de dados scopus, web of science, science direct, pubmed central, cinahl e cochrane. além disso, foi delimitada a seguinte pergunta de pesquisa: quais as estratégias e intervenções utilizadas para a saúde ocular na gestão do paciente crítico ou cirúrgico submetido ao decúbito ventral? após aplicar os critérios de inclusão e exclusão, a amostra se constituiu de 24 estudos. resultados: as intervenções oftalmológicas na gestão de pacientes críticos ou cirúrgicos submetidos a decúbito ventral foram exame oftalmológico, uso de lubrificante/ solução oftálmica específica, posicionamento de trendelenburg reverso e proteção com fita adesiva. conclusões: esta revisão permite compreender a saúde ocular de pacientes críticos ou cirúrgicos em decúbito ventral. entre os cuidados apresentados, grande parte está relacionada com a enfermagem, visto que é mais próxima do cuidado do paciente. os achados enfatizam a necessidade de implementar políticas de segurança do paciente com relação ao cuidado dos olhos como prioridade. palavras-chave (fonte decs): cuidados críticos; cirurgia geral; cuidados de enfermagem; saúde ocular; decúbito ventral. introduction the prone position is a postural adjuvant therapy first presented in the literature in 1974. it is defined as a maneuver of rotation from a supine to a prone position, effective in managing specific patients(1). used in surgical procedures from ancient times to the present day, prone positioning allows better visualization and access to the particular location of the therapy, as in head, neck, and spine surgeries(1). in addition to surgical procedures, it has been observed in recent years that the prone position in patients with acute respiratory distress syndrome (ards) can improve oxygenation and reduce mortality(3-4). despite the benefits, the prone position is not without risks. it presents the possibility of complications, such as facial edema and pressure lesions in the face region, the thoracic region, and lower and upper limbs. among these complications, eye injuries are evident, including conjunctival edema and direct pressure on the orbit or eyeball(5). studies point out that the incidence of pressure injuries due to the prone position is more frequent when compared to patients in the supine position. one study confirmed that the risk of developing pressure injury in the prone position is 57.1 %, while the risk in the supine position is 42.5 °%. in addition, it demonstrated that lesions on the face and chest were the most prevalent(6). the prone position enhances contact between the patient's face and the pillow or cushion. corneal abrasions from tissue shear may occur if the eyelid is not entirely closed. in this way, the authors report the importance of eye protection so that the complete closure of the eyelid is possible, minimizing the risks of eye complications until the potential loss of vision(7). among complications, a large part is related to the management by the nursing team, given that nursing is closer to patient care. therefore, it is up to the nurse professionals to develop care plans to minimize the incidence of complications. it is known that care for critical and surgical patients is complex due to the required procedures. therefore, some care is overlooked by the teams, such as eye care. however, vision preservation must be prioritized, considering the eyes are critical sensory organs(8-9). some interventions are used for eye care in critically ill/surgical patients in the prone position, such as hydrocolloid patches, ointments, and lubricating eye drops. however, no studies were found in the literature that addressed the degree of recommendation of interventions for eye protection. despite the scale of the problem, eye care protocols are generally not encouraged, and documentation of this care is often deficient(10). in this context, the study is justified by the need to obtain scientific knowledge about possible eye care/interventions to be implement­ed in the care of patients in a prone position. there is a clear need for specific care protocols to manage complications and reduce patient risks. new studies on this topic add even more quality to health care since protocols for eye care are scarce(10). this study aimed to map evidence of interventions applied to eye care in managing critical or surgical patients submitted to the prone position. material and methods design it is a scoping review, prepared according to the methodological assumptions of the joanna briggs institute of 2020, following criteria defined by the checklist preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr)(11-12). the study in question was registered on the open science framework study platform and generated a sequential identifier from uniform resource locator(13). through the guidance of a research protocol, the five methodological steps were followed: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) mapping and extracting the results; and (5) making a narrative synthesis of the results(11). identifying the research question as a way of defining the guiding question of the review, the pcc mnemonic strategy was used, where p: population 'critical or surgical patients'; c: concept 'strategies and interventions for eye care', and c: context 'critical or surgical patients who need the prone position during care'. based on this strategy, the following research question was delimited: what strategies and interventions are used for eye care in managing critical or surgical patients submitted to the prone position? identifying relevant studies to identify relevant studies for the presented theme, a search was carried out from july to august 2020 on the following databases: scopus, web of science, science direct, pubmed central, cumulative index to nursing and allied health literature (cinahl), and cochrane. access for the search was supported by the federal university of rio grande do norte, via the federated academic community, through the coordination for the improvement of university education personnel. as a search strategy in the databases, the descriptors ordered in medical subject headings (mesh) were defined: "eye," "eye health," "nursing care," "critical care," "ocular care," "intensive care units," and "prone position." to identify other relevant studies, a search was performed on google® scholar using the keywords identified in the studies in the first phase of the search. crossings used the boolean operator and, as shown in table 1. table 1. search strategies used in each database. natal-rn, brazil, 2020 database crossing scopus all("eye health") and ("prone position") all("eye health") and ("prone position") and ("nursing care") all("eye") and ("prone position") and ("nursing care") all("eye health") and ("prone position") and ("critical care") all("eye") and ("prone position") and ("critical care") all("eye health") and ("prone position") and ("intensive care units") all("eye") and ("prone position") and ("intensive care units") all("eye") and ("prone position") web of science all=("eye health") and ("prone position") all=("eye health") and ("prone position") and ("nursing care") all=("eye") and ("prone position") and ("nursing care") all=("eye health") and ("prone position") and ("critical care") all=("eye") and ("prone position") and ("critical care") all=("eye health") and ("prone position") and ("intensive care units") all=("eye") and ("prone position") and ("intensive care units") all=("eye") and ("prone position") science direct title, abstract, keywords: "eye health" and "prone position" "eye health" and "prone position" and "nursing care" "eye" and "prone position" and "nursing care" "eye health" and "prone position" and "critical care" "eye" and "prone position" and "critical care" "eye health" and "prone position" and "intensive care units" "eye" and "prone position" and "intensive care units" "eye" and "prone position" pubmed central all fields: "eye health" and "prone position" "eye health" and "prone position" and "nursing care" "eye" and "prone position" and "nursing care" "eye health" and "prone position" and "critical care" "eye" and "prone position" and "critical care" "eye health" and "prone position" and "intensive care units" "eye" and "prone position" and "intensive care units" "eye" and "prone position" cinahl "eye health" and "prone position" "eye health" and "prone position" and "nursing care" "eye" and "prone position" and "nursing care" "eye health" and "prone position" and "critical care" "eye" and "prone position" and "critical care" "eye health" and "prone position" and "intensive care units" "eye" and "prone position" and "intensive care units" "eye" and "prone position" cochrane title, abstract, keywords: "eye health" and "prone position" "eye health" and "prone position" and "nursing care" "eye" and "prone position" and "nursing care" "eye health" and "prone position" and "critical care" "eye" and "prone position" and "critical care" "eye health" and "prone position" and "intensive care units" "eye" and "prone position" and "intensive care units" "eye" and "prone position" google® scholar "eye health" and "nursing care" and "prone position" eye health" and "critical care" and "prone position" eye health" and "intensive care units" and "prone position" "ocular care" and "prone position" "ocular care" and "intensive care units" and "prone position" source: own elaboration. a reverse search was performed using references identified in the selected articles to identify additional studies. this way, it is possible to capture articles relevant to the study that were not viewed in the databases. the reverse search allows for a broader sample, making it possible to understand more comprehensively the study process of a given research subject matter(11). the inclusion criteria used were studies that addressed evidence about eye care interventions in patients in a prone position, full-text articles in the databases, original articles, and review articles e articles available in english, portuguese, and spanish. regarding the year of publication, the studies were selected between 1999 and 2020. editorials, letters to the editor, abstracts, and articles that did not address the relevant topic within the scope of the review objective were excluded from the sample. identifying relevant studies the search process was carried out in pairs on different computers at the same time. at the end of each part of the search, the results were analyzed by dynamically reading the titles and abstracts, and subsequently, they were read in full by two reviewers independently. studies that did not meet the eligibility criteria were excluded, duplicates were counted only once, and divergences between reviewers were decided by consensus. the search stage in databases and google® scholar resulted in a total of 8,371 identified articles. after applying the inclusion and exclusion criteria, 23 were selected. in a similar search in references, one article was included. thus, 24 studies made up the final sample, according to the flowchart shown in figure 1. figure 1. flowchart of the literature search and article selection according to the prisma-scr guidelines. natal-rn, brazil, 2020. source: own elaboration. mapping the data data mapping and extraction were performed using an instrument prepared with the following items: title of the study, authors, year of publication, country, type of study, evidence level and degree of recommendation, source data, objective of the study, central interventions, and conclusions on eye care in the prone position. regarding the evidence level and the degree of recommendation, we decided to follow the oxford center for evidence-based medicine guidelines. thus, the classification of the evidence level followed the pattern that the lower the number, the higher the level. in addition, the degree of recommendation considers "a" as the highest recommendation and "d" as the lowest recommendation(14). summarizing and reporting results the results were presented descriptively in tables with the characterization and synthesis of the studies. results as for the characterization of the studies selected and analyzed in the review, the data were presented according to year, data source, and place of publication (table 2). table 2. characterization of studies according to year, data source, and country of publication (n = 24). natal-rn, brazil, 2020. variables n % year of publication 2016 ‖— ‖ 2020 10 41.6 2011 ‖— ‖ 2015 09 37.5 2004 02 8.3 2009 01 4.1 2006 01 4.1 1999 01 4.1 data source scopus 13 54.1 science direct 05 20.8 cinahl 02 8.3 web of science 01 4.1 pubmed central 01 4.1 google® scholar 01 4.1 parallel search 01 4.1 country of publication usa 13 54.1 united kingdom 04 16.6 turkey 02 8.3 australia 02 8.3 spain 01 4.1 france 01 4.1 singapore 01 4.1 source: own elaboration. studies that addressed the surgical patient were more frequent with 66.7 % (n = 16), followed by studies with critical patients 25.0 % (n = 6). only 8.3 °% (n = 2) addressed the two populations in the same study. after a complete analysis of the 24 studies selected for the scoping review, we could identify the title, authors, year, country of publication, type of study, evidence level, degree of recommendation, and interventions on eye care in critical or surgical patients in the prone position of the selected studies, as shown in table 3. table 3. identification of studies and eye care interventions in patients in the prone position. natal-rn, brazil, 2020 title authors (year) country of publication type of study/ evidence level /degree of recommendation* eye care interventions in patients in the prone position the prone position during surgery and its complications: a systematic review and evidence-based guidelines kwee et al. (2015)(15) australia systematic review/1a/a reverse trendelenburg; use of head restraints; mayfield headrest; monitoring eye position every 20 minutes with a mirror attached to the headrest; computer video streaming system to monitor the eye position throughout the process; preoperative ophthalmological examination systematic review and meta-analysis of prone position on intraocular pressure in adults undergoing surgery wilcklin (2020)(16) usa a systematic review and meta-analysis/1a/a preoperative eye exams; reverse trendelenburg from 5 to 10°; monitoring intraocular pressure; providing periodic changes in position or rest periods, and administering specific medications or anesthetics can help reduce the risk of eye damage the comparison of four different methods of perioperative eye protection under general anesthesia in prone position kocatürk et al. (2012)(17) turkey randomized clinical trial/1b/a the following eye protection methods were applied: hypafix® hypoallergenic adhesive tape, terramycine® antibiotic ointment, artificial tear gel containing viscotears® polyacrylic acid, and duratears ointment eye lubricant. there was no significant difference between groups regarding adhesive tapes. all methods are suitable for protecting against corneal injuries the effect of head rotation on intraocular pressure in prone position: a randomized trial deniz et al. (2012) (18) turkey randomized clinical trial/1b/a patients in a prone position with the head turned 45° sideways to the right side had significantly lower intraocular pressure than those in a prone position without head rotation clinical trial design effect of prone positioning on clinical outcomes in infants and children with acute respiratory distress syndrome curley et al. (2006) (19) usa randomized clinical trial/1b/a if the patient is receiving a paralytic pharmacological agent or if there is incomplete eyelid closure, eye protection is provided to prevent corneal abrasions the effect of body inclination during prone positioning on intraocular pressure in awake volunteers: a comparison of two operating tables ozcan et al. (2004) (20) usa clinical trial/1b/a the reverse trendelenburg position of 10° improves intraocular pressure in patients in the prone position comparison of medical adhesive tapes in patients at risk of facial skin trauma under anesthesia zeng et al. (2016) (21) singapore randomized controlled clinical trial/1b/a the use of silicone tapes 'removal type 3m™' for eyelids significantly reduces skin lesions compared to standard acrylate tapes effect of the degree of reverse trendelenburg position on intraocular pressure during prone spine surgery: a randomized controlled trial carey et al. (2014)(22) usa randomized controlled clinical trial/1b/a reverse trendelenburg positioning decreases intraocular pressure in patients in a prone position for spinal surgery effects of crystalloid versus colloid and the a-2 agonist brimonidine versus placebo on intraocular pressure during prone spine surgery farag et al. (2012) (23) usa randomized clinical trial/1b/a using 2 % brimonidine administered preoperatively helps reduce intraocular pressure during spine surgeries in the prone position pressure on the face while in the prone position: proneview™ versus prone positioner™ atwater et al. (2004)(24) usa clinical trial/1b/a proneviewtm produces a lower face surface pressure than the prone positionertm device, reducing the incidence of skin damage modified prone position using lateral brace attachments for cervico-dorsal spine surgeries kadam et al. (2013) (25) usa clinical trial/1b/a cervical tweezers with two cylindrical padded supports and two lateral supports were applied to a conventional operating table to stabilize the head and reduce eye and facial complications related to the pressure of the prone position care of the eye during anaesthesia and intensive care small et al. (2019) (8) united kingdom descriptive study/2c/b in critically ill patients, the eyes should be examined, relubricated, and closed with tape every four hours. the position must remain neutral or with the head higher than the heart. in surgical patients, head support (mayfield) is recommended eye protection in anaesthesia and intensive care keita et al. (2017) (26) france literature review/2c/b it is recommended that lubricants containing an aqueous solution in a single dose be used, such as methylcellulose or viscosogel, combined with occlusion of the eyelid using adhesive tapes. in addition, the use of appropriate head restraints (mayfield or specific cushion) and a slight inclination, such as the trendelenburg position, are advisable prone position of patients with covid-19 and acute respiratory distress syndrome makic (2020)(27) usa literature review/2c/b the patient's eyes should be lubricated and closed to protect against corneal injury artificial ventilation in the prone position gibson et al. (1999) (28) australia literature review/2c/b training on implications and complications of making the patient prone. regular eye care and protection from the pillow surface may be necessary to prevent abrasion of the cornea helmet continuous positive airway pressure and prone positioning: a proposal for an early management of covid-19 patients longhini et al. (2020)(29) spain literature review/2c/b continuous positive airway pressure during the prone position is more comfortable since it allows for constant and extended treatment and fewer complications related to the interface (that is, irritation in the eyes, gastric distension, and skin necrosis) eye care in the intensive care unit during the covid-19 pandemic sansome et al. (2020)(30) united kingdom literature review/2c/b daily eye examination; lubricating ointment every 4 hours; referral to ophthalmology when necessary; if there are concerns about damage to the cornea, further examination can be performed; before applying the lubricating ointment, the eye should be bathed in gauze soaked in saline and cleaned inside out ocular care and complications in the critically ill kam et al. (2011)(31) united kingdom literature review/2c/b adhesive tapes are recommended, as lagophthalmia is frequently checked or viscous lubricating drops are instilled often. patients should be referred to ophthalmologists if there is constant exposure current intraoperative devices to reduce visual loss after spine surgery urine et al. (2012) (32) usa literature review/2c/b the review showed the classic horseshoe-shaped headrest, the face mask with foam pad and transparent operating table, the opti-gard eye protector, the voss prone positioner, the roho neoprene cushion, the "float a dry," the proneview® helmet system, and the proneview® video camera monitoring system as new devices to prevent mechanical eye compression during surgical procedures in the prone position positioning patients for spine surgery: avoiding uncommon position related complications kamel et al. (2014) (33) usa literature review/2c/b evidence shows that the head must be in a neutral position on the head support structure to avoid direct pressure on the eye (proneview®'. proneview® allows for prone positioning without any pressure on facial structures. the extendable mirror allows frequent checking of facial structures in the prone position how to avoid perioperative visual loss following prone spinal surgery epstein (2016)(34) usa literature review/2c/b preventive measures such as routine use of an arterial line, intraoperative monitoring, 3-pin head support, and elevation of the head 10° from the horizontal decrease the risk of perioperative visual loss in spine surgeries performed in the prone position perioperative visual loss: what do we know, what can we do? roth (2009)(35) usa literature review/2c/b using foam headrests and a mirror to allow a direct view of patients' eyes during spinal surgery in a prone position prevents the loss of perioperative vision extendable mirrors to improve anesthesia provider comfort for eye and positioning checks in prone patients: a pilot study lin et al. (2020)(36) usa pilot study/2c/b the use of an extensible mirror is recommended for frequent eye checking and careful neck positioning strategies to prevent ischemic optic neuropathy following major spine surgery: a narrative review fandino (2017)(37) united kingdom narrative review/3a/b the review presented interventions such as keeping the head at the same level or higher than the heart and maintaining approximately 10° in the direction of reverse trendelenburg for spinal procedures in a prone position to improve the increase in intraocular pressure * evidence level: 1a, 1b, 1c (degree of recommendation a); 2a, 2b, 2c, 3a, 3b (degree of recommendation b); 4 (degree of recommendation c); and 5 (degree of recommendation d)(13) source: own elaboration. table 4 features the primary eye care interventions according to the population (critical and surgical patients). table 4. characterization of the primary interventions for eye care in patients in a prone position (n = 24). natal-rn, brazil, 2020 main interventions n %* eye examination critical patients 03 12.5 surgical patients 07 29.1 use of lubricants/specific ophthalmic solution critical patients 06 25.0 surgical patients 03 12.5 reverse trendelenburg positioning critical patients 01 4.1 surgical patients 07 29.1 protection with adhesive tape critical patients 05 20.8 surgical patients 03 12.5 adequate head support critical patients surgical patients 06 25.0 cleaning with saline solution critical patients 02 8.3 surgical patients head rotation at 45° critical patients surgical patients 01 4.1 professional training critical patients 01 4.1 surgical patients *the variable assumes multiple responses. source: own elaboration. regarding the central interventions for eye care in patients in the prone position, eye examination, the use of lubricants/specific ophthalmic solution, the reverse trendelenburg positioning, and the protection with adhesive tape stand out. discussion noteworthy are the scientific productions published in the last year, demonstrating the relevance of the theme today. next, the evidence identified will be addressed in two categories: eye care in critically ill patients and eye care in surgical patients. the study was limited by the low number of more specific recommendations, especially concerning ophthalmic care in critically ill patients. as corroborated by the study, there is a need for further studies in intensive care units to assess eye injury, including the follow-up of patients(38). eye care in critically ill patients in the prone position related to critical patients, it is known that the intervention of the prone position is an essential therapy for hypoxemic respiratory failure and ards, including for patients with covid-19 in the current context(27). concerning patients undergoing treatment for covid-19, they are more susceptible to eye complications due to prone positioning and the increased demand by the intensive care team(39-41). critically ill patients can be in the prone position for at least 16 hours a day to improve oxygenation. one study observed patients in the prone position for long periods who had bilateral funduscopic findings of optic disc edema and retinal hemorrhages, in addition to a substantial increase in intraocular pressure(42). however, prone position intervention in critically ill patients with breathing difficulties has often been discussed only in recent years. as a result, few published studies are related to critically ill patients. the study points out that despite our routine ophthalmic protocols, invasive mechanical ventilation applications predispose to corneal surface damage in patients in the intensive care unit(43-44). thus, knowledge of complementary protocols for eye care in critically ill patients is necessary. regarding eye care in patients with covid-19, the authors did not present any intervention other than those recommended in uncontaminated patients. because it is a recently discovered virus, further studies are needed to define care with lower infection risks(25,27,30). among the interventions, lubricants and eye protection with adhesive tape were the most frequent in the sample for critically ill patients, followed by eye examination and cleaning with saline. in general, in patients receiving an anesthetic pharmacological agent or with incomplete eyelid closure, the authors recommend that, before performing the prone positioning maneuver, the eyes should be cleaned with saline, preferably inside out in a single direction, applied lubricant drops, and protected with adhesive tapes(19,27). after performing the maneuver, it is recommended that the eyes be examined, relubricated, and closed with tape every four hours(8). regarding the eye examination, it is recommended that it be done daily. if there is a concern related to the damage, a deeper examination of the eyes can be performed with the application of drops of fluorescein and viewing the cornea through blue light, often found in ophthalmoscopes. patients who are constantly exposed should be referred to ophthalmologists(27,34). the study identified patients in the prone position who required treatment for eye diseases through detailed examinations, first with a handheld biomicroscope and direct ophthalmoscope for each patient. then, the eyes were dilated with 1 % tropicamide, and retinal and optic nerve examinations were performed with an ophthalmoscope(45). as for positioning during the prone position, patients should be kept in a neutral position or with the head higher than the heart level (reverse trendelenburg)(8). studies with critically ill patients did not address the degree of elevation for the reverse trendelenburg. concerning the devices used, a recent study showed that the prone position becomes more comfortable when using continuous positive airway pressure (cpap), as this approach develops fewer complications, such as eye irritation(30). it is also observed that the teams' training on the possible complications of the prone position is indispensable to managing patients adequately and preventing risks(35,46). the training of care professionals in handling patients in the prone position is less frequent; however, it is an intervention that must be considered. a clinical trial performed on patients with reduced or absent blink reflex after losing consciousness or using sedatives determined that implementing the eye care protocol could significantly reduce complications and eye problems(47). based on these data, developing protocols for eye care is essential. eye care in surgical patients in the prone position studies involving surgical patients in the prone position appear more frequently in the sample. due to the long surgery period, it is necessary to intervene so that new complications do not occur, prioritizing patient safety. in patients undergoing spinal surgery, for example, the prone position has a tenfold increased risk of eye injury compared to the supine and lateral positions(48). reverse trendelenburg positioning, eye examination, and adequate head support were the most addressed interventions among the studies. the reverse trendelenburg is used as a strat­egy to reduce intraocular pressure and, consequently, perioperative visual loss(21,24). the authors recommend that the head elevation should be 10°(16,33). as for eye examination, a preoperative ophthalmological examination is recommended to form an opinion about the 'patient's vision. as intraoperative interventions, some authors have addressed using an extensible mirror for frequent eye checking(32,34). one study showed eye position monitoring every 20 minutes with an attached mirror as a strategy. a computer video streaming system was implemented to monitor the eye position throughout the process, proving to be a practical technological innovation in health(15). concerning adequate head support, an effective strategy to reduce the risk of direct pressure on the eye involves using a three-pin mayfield head support, which fixes and holds the head during surgical procedures(8,24). another device used to reduce direct pressure is the proneviewtm protective helmet system with facial contour, which allows for prone positioning and reduces the incidence of facial damage. compared to the prone positionertm without facial contour, this system proved more effective(25,27-28,49). the use of tapes for eye protection and lubricants was less frequent in the sample. regarding the protection with adhesive tape, a study concluded that the use of silicone tapes with the removal of the type 3m for eyelids used in long surgeries significantly reduced skin lesions when compared with acrylate tapes, thus presenting itself as a strategy that can be considered for eye protection(24,27-28,50). in contrast, a study compared the effectiveness of four protection methods, involving the use of hypafix® hypoallergenic adhesive tape, terramycine® antibiotic ointment, artificial tear gel containing viscotears® polyacrylic acid, and duratears® ointment eye lubricant. it was concluded that there was no significant difference between the protection methods, showing that all the methods presented are suitable for protecting against corneal injuries(17,23,51). corroborating the findings of the review, a prospective study performed a trial with a foam-based facial protection method to cover bony prominences during spinal surgical procedures, decreasing the incidence of iatrogenic facial ulcers in surgery by reducing friction and shear force(52). some studies have addressed using a specific ophthalmic solution to lower intraocular pressure in surgical patients. in one of these studies, the authors recommended using 2 % brimonidine, which should be used preoperatively, for about one hour before anesthesia and every eight hours for 24 hours, helping reduce intraocular pressure in spine surgeries(25,53-54). only one study pointed to head rotation at 45° turned to the right as a technique for lowering intraocular pressure in patients placed in a prone position(18). conclusion among the findings of the selected studies, care was suggested using lubricants to prevent dry eyes and specific ophthalmic solutions to reduce intraocular pressure. it is also essential to associate the prone position with the reverse trendelenburg to minimize the risk of pressure in the face region and the proper headrest. the studies also propose recommendations on eye protection with adhesive tapes, frequent eye examination, cleaning with saline solution, and head rotation at 45° as essential precautions for preventing risks associated with eye health. more collaborative clinical studies on eye care are suggested in isolation, as a shortage of scientific evidence that addressed more specific recommendations was identified, especially in critically ill patients. conflicts of interest: there are no conflicts of interest to declare. references 1. dalmedico mm, salas d, oliveira am, baran 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peesay t, walsh ar, fernandez s, et al. facial pressure injuries from prone positioning in the covid-19 era. laryngoscope. 2021;131(7):2139-2142. doi: https://doi.org/10.1002/lary.29374 home copia de 100-102.pdf revista aquichan issn 1657-5997 año 7 vol. 7 nº 1 • chía, colombia abril 2007100 directrices para la enseñaza de enfermería en la educación superior año 7 vol. 7 nº 1 • chía, colombia abril 2007100 la asociación colombiana de facultades de enfermería 2006 (acofaen), lideró el proyecto que culminó con la publicación de libro: directrices para la enseñaza de enfermería en la educación superior, gracias al trabajo riguroso y comprometido de un importante grupo de docentes de distintas instituciones académicas del país. las integrantes de los comités y grupos, modelos y teorías, promoción de la salud, formación y participación política, ética y bioética, han plasmado en cada uno de los capítulos su valiosa formación académica y su experiencia profesional. estas temáticas atraviesan de manera transversal el plan de estudios, y a la vez son ejes integradores del currículo, presentes en los diferentes programas de enfermería a nivel nacional. la obra se constituye en una interesante y muy completa revisión de temas de actualidad, que indican la ruta que se debe seguir en la formación académica de nuestros estudiantes. el texto está pensado y escrito por docentes, para docentes y estudiantes de programas de pre y posgrado, enfermeras de servicio y otros profesionales que por la razón de ser de su disciplina requieren estos lineamientos. se resaltan, desde la conceptualización de enfermería como disciplina profesional, la importancia de la ética y la bioética en los programas de pre y posgrado, y la reflexión alrededor de la formación política de los estudiantes de enfermería. igualmente en el último capítulo, �promoción de la salud�, se destaca el contexto de la promoción de la salud, los retos, la situación social colombiana y las políticas internacionales, entre otros, además de una mirada a la legislación de la educación superior y la formación por competencias. maría clara quintero l. profesora asociada universidad de la sabana 336 346 the perception of nurses and doctors.indd 336 aquichan issn 1657-5997 pathmawathi subramanian1 nick allcock2 veronica james3 judith lathlean4 the perception of nurses and doctors on a care bundle guideline for management of pain in critical care 1. senior lecturer, department of nursing science, faculty of medicine, university of malaya, malaya. pathmawathi@um.edu.my 2. clinical academic professor of nursing, division of nursing and community health, glasgow caledonian university, united kingdom. nick.allcock@nottingham.ac.uk 3. professor nursing studies in the school of nursing and midwifery, university of nottingham, united kingdom. veronica.james@nottingham.ac.uk 4. professor of health research, university of southampton, faculty of health sciences, united kingdom. j.lathlean@soton.ac.uk recibido: 18 de abril de 2012 enviado a pares: 4 de septiembre de 2012 aceptado por pares: 29 de octubre de 2013 aprobado: 9 de noviembre de 2013 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 336-346 to reference this article / para citar este artículo / para citar este artigo subramanian, p., allock, n., james, j., lathlean, j. (2013). the perception of nurses and doctors on a care bundle guideline for management of pain in critical care. aquichan. vol. 13, no. 3, 336-346. abstract objective: the aim of this study was to explore nurses’ and doctors’ perception on using a care bundle as a guideline for the management of pain in critical care. despite the development of evidence-based guidelines and protocols on the management of pain in critical care, pain is still a major problem. the introduction of care bundles in critical care has improved the management of ventilated patients. a care bundle in pain management aims to reduce variations in practice. method: this study employed a qualitative prospective design using a semi-structured, in-depth interview of 23 nurses and doctors in a critical care unit. result: four main themes emerged: 1) suitability to the critical care setting; 2) applicability to the critical care setting; 3) ownership of the pain care bundle; and 4) necessity for current practice. the results showed a poor uptake by the healthcare professionals in managing acute pain among critically ill patients. conclusion: the study found that nurses and doctors did not perceive the pain care bundle as a useful tool for improving pain managment, with evidence pointing to a gap between pain management practice, as described by the care bundle, and actual practice. key words critical care, pain, pain management, nurses, perception, nursing. (source: decs, bireme). 337 the perception of nurses and doctors on a care bundle guideline for management of pain in critical care l pathmawathi subramanian, nick allcock, veronica james, judith lathlean percepción de enfermeras y médicos sobre el uso de un paquete de atención como una guía para el manejo del dolor en cuidados críticos resumen objetivo: el objetivo de este estudio fue explorar la percepción de las enfermeras y los médicos sobre el uso de un paquete de atención como una guía para el manejo del dolor en cuidados críticos. a pesar del desarrollo de guías y protocolos para el manejo del dolor en cuidados críticos, basados en la evidencia, el dolor sigue siendo un problema importante. la introducción de un paquete de atención para cuidados críticos ha mejorado el manejo de los pacientes ventilados. un paquete de atención en el manejo del dolor tiene como objetivo reducir las variaciones en la práctica. método: el estudio tiene un diseño prospectivo cualitativo desarrollado mediante una entrevista en profundidad y semi-estructurada de 23 enfermeros y médicos en una unidad de cuidado crítico. resultado: cuatro temas principales surgieron: 1 ) la adecuación al escenario de cuidado crítico, 2) la aplicabilidad al escenario de cuidado crítico, 3 ) la propiedad del paquete de atención al dolor, y 4) la necesidad en la práctica actual. los resultados mostraron una pobre aceptación del paquete por parte de los profesionales de la salud en el manejo de dolor agudo en los enfermos críticos. conclusión: el estudio encontró que las enfermeras y los médicos no percibieron el paquete de atención al dolor como una herramienta útil para mejorar el manejo del dolor, con pruebas que apuntan a una brecha entre la práctica del manejo del dolor, tal como se describe por el paquete de atención, y la práctica real. palabras clave cuidados críticos, dolor, manejo del dolor, enfermeras, percepción, enfermería. (fuente: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 336-346 338 aquichan issn 1657-5997 a percepção das enfermeiras e dos médicos sobre o uso de um pacote de atendimento como guia para lidar com a dor em cuidados críticos resumo objetivo: o objetivo deste estudo foi explorar a percepção das enfermeiras e dos médicos sobre o uso de um pacote de atendimento como guia para lidar com a dor em cuidados críticos. apesar do desenvolvimento de guias e protocolos para lidar com a dor em cuidados críticos, baseados na evidência, a dor continua sendo um problema importante. a introdução de um pacote de atendimento para cuidados críticos vem melhorando o tratamento dado a pacientes ventilados. um pacote de atendimento no tratamento da dor tem como objetivo reduzir as variações na prática. método: o estudo tem um desenho prospectivo qualitativo desenvolvido mediante uma entrevista em profundidade e semiestruturada de 23 enfermeiros e médicos em uma unidade de cuidado crítico. resultado: quatro temas principais surgiram: 1) a adequação ao cenário de cuidado crítico; 2) a aplicabilidade ao cenário de cuidado crítico; 3) a propriedade do pacote de atendimento à dor, e 4) a necessidade na prática atual. os resultados mostraram uma baixa aceitação do pacote por parte dos profissionais em saúde no tratamento da dor aguda nos doentes críticos. conclusão: o estudo constatou que as enfermeiras e os médicos não perceberam o pacote de atendimento à dor como uma ferramenta útil para melhorar o tratamento da dor, com provas que apontam a uma brecha entre a prática do tratamento da dor, tal como se descreve pelo pacote de atendimento, e a prática real. palavras-chave cuidados críticos, dor, manejo da dor, enfermeiras, percepção, enfermagem. (fonte: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 336-346 339 the perception of nurses and doctors on a care bundle guideline for management of pain in critical care l pathmawathi subramanian, nick allcock, veronica james, judith lathlean introduction various approaches have been used in health organizations to improve clinical outcomes (1), including clinical guidelines, protocols, practice policies, clinical policies, algorithms, standards and clinical pathways. (2) the development of the bundle concept is a new approach to ensure evidence-based practice to improve patient outcomes. (3) the concept of care bundles was developed in the united states in 2002. (4) a bundle is a collection of evidence-based interventions for the treatment of particular symptoms, which are used in combination. (5) a bundle is, therefore, a collection of three to five evidence-based interventions with components that, when performed together, should improve patient outcomes. ventilator, sepsis, renal and nutrition care bundles have been developed. the modernization agency identified three core components to distinguish the care bundle from clinical guidelines and protocols (table 1). following this, the national institute for clinical excellence initiated use of the care bundle in critical settings in 2002, by developing new bundles through local service improvement groups. (6,7) the anticipated benefits of the pain care bundle (pcb) were improved pain management, improved utilisation of existing pain services, and a reduction in delayed discharge due to pain management problems. the study was conducted in one adult critical care unit equipped with sixteen beds. the pcb components were developed to improve pain management practice, based on consensus ideas and expert opinion from the acute pain team. the components of the bundle also were based on a review of evidence from a range of sources, including the royal college of nursing, the scottish intercollegiate guidelines network, the department of health , the national health service, quality improvement scotland and the joint commission on accreditation of healthcare organisations. the pcb was divided into epidural (table 2) and non-epidural pcb (table 3). the epidural pcb has seven main components and is related to pain management for patients with epidural infusions, while the non-epidural pcb has five main elements. philosophical assumption of the study in understanding the impact of the pcb on the development of effective pain management practices, it is important to identify nurses’ and doctors’ perception of the tool and to understand how it influences their pain management practices. human beings involved in caring for others hold views or beliefs about the world, including what influences human behaviour and what constitutes quality of care. clarification of these beliefs can assist in understanding the relationship between ontological and epistemological issues. (8) the interpretive epistemology underlying this study provides valuable insights and exploration into human beings’ meaningful actions, based on their pain guideline experience. and how to understand this action rationally. interpretivist claim people’s experiences are basically context-bound, (9) and researchers must understand the socially-constructed nature of the world and value its impact on the research process. (10) in terms of its theoretical foundation, the study was based on the promoting action on research implementation in health services model (parihs). (11-13) this model stresses that successful implementation occurs when the evidence is robust, the context is conducive and receptive to change, and where the change process is facilitated efficiently. the study aim the aim of this study was to explore the factors that influence the uptake of a pcb among health care practitioners in a critical care setting. the primary focus of the study was to evaluate the usefulness and value of the pain care bundle in improving pain management. method this study utilized a qualitative design with an interpretive approach to explore health care providers’ perspectives on the context of the implementation of a pain care bundle and its influence on pain management setting the study was conducted in a large acute-care teaching hospital trust that provides a wide range of inpatient, outpatient, and day care services for a local population of more than half a million. the study was carried out in the adult critical care unit. it has an intensive care unit with seven beds, and a high dependency unit with ten beds. 340 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 participants a purposive sample of twenty three nurses and doctors participated in this study. this group was chosen to capture a rich description regarding their views on the pcb. fifteen critical care nurses and eight doctors who were involved with patient management in the critical care unit took part in the study. the doctors were the key practitioners in planning care and managing the patients in the critical care setting, while the nurses were involved directly in the provision of care to critically ill patients in the adult critical care unit. the opinions and perceptions of key personnel are important in exploring the internal problems of any organisation. (14) ethical consideration the protocol and its subsequent amendments were developed in accordance with the ethical conduct of the research study based on the declaration of helsinki on vulnerable groups. the study also complied with the requirements of the research governance framework for health and social care, (2005). formal ethical approval for the study was granted by the local research ethics committee and the trusts’ research and development department. all the participants were given information about the study and assured of the confidentiality of the information they provided, and written consent was obtained from each participant prior to being interviewed. data collection a semi-structured, in-depth interview was chosen to explore the views of nurses and doctors about implementation of the pcbs, inasmuch as semi-structured, in-depth, open-ended interviews can provide valuable insight into the nature of phenomenon in naturalistic inquiry. (14) data were collected over six months. the interview schedules provided prompt exploration the key issues related to the use of pcb and pain management practice. the interview guide was developed from key issues identified during the literature review (table 4). the questions addressed issues pertaining to management of pain, the current approach to pain management, the strengths and limitations of current approaches to pain management, using the care bundle, and the challenges encountered in managing pain. twenty three interviews were conducted with all participants consenting to the tape recording of their interviews. each interview lasted 45 to 60 minutes. data analysis a total of 23 interviews were transcribed verbatim. each interview was analysed using framework analysis, with the aid of the qsr nvivo 7 software program. framework analysis was chosen because it is geared explicitly towards generating policy and practice-orientated findings. (15) in this study, the data collection and analysis processes were interwoven from the beginning. the framework analysis approach has five (5) key stages, which are: 1. familiarization: familiarization involves listening to the interview recordings and re-reading the transcripts until the researcher is familiar with the data. 2. identifying a thematic framework: here, the coding scheme identifies the key issues, concepts, and themes related to views about the pcb. 3. indexing: in this case, the thematic framework was applied systematically to each transcript. any interconnection of themes or multiple indexes was applied through charting, mapping and interpreting the association between the themes. 4. charting: this involves rearranging the data according to the thematic content of each transcript and also by themes. sub-themes for each participant were summarized using spreadsheets. 5. mapping and interpretation: this is the final stage of looking at the associations between themes and codes. the key strategy involves the use of diagrams and tables to explore the relationship between the concepts and to define and illustrate the key concepts and the nature of the perceptions of the participants with regard to the pcb. four main themes were subsequently developed. during the study, a journal was kept in which the contents and the process of interaction were noted, so as to increase self-awareness. the journal guided the researcher in keeping track of the relationships and provided material from reflection. by detailing decisions taken in the research process, a clear audit trail can be established to enhance dependability, fittingness and conformability. 341 the perception of nurses and doctors on a care bundle guideline for management of pain in critical care l pathmawathi subramanian, nick allcock, veronica james, judith lathlean results participants the participants’ years of experience ranged from less than two (2) to more than 20, with the majority of participants having between two (2) and five (5) years of experience. fourteen respondents were female and nine were male (table 5). major themes four major themes were identified: suitability, applicability, ownership and necessity. the participants’ demographic details have been anonymised and changed to maintain confidentiality. suitability of the care bundle the majority of the participants felt the pcb was not a useful guideline for pain management practice in the critical care unit. it was suggested the pcb components have limited alternative interventions to guide pain management, especially when pain management was perceived as difficult: ‘... the pcb does not provide many alternatives (treatment). i think it is good for basic management, but for complex pain management or patients who cannot tolerate simple opiates, it is not suitable’ (doctor1). another participant noted the content of the pcb is very limited, since it states what the junior doctors and nurses should expect, rather than guiding an improvement in the patient’s care. the respondents also indicated that some of the components of the pcb were only useful initially, such as paracetamol before the consideration of opioids. most of the patients who were admitted to the critical care unit with acute pain following surgery were treated via an epidural catheter. accordingly, the pcb was seen to be of limited relevance: ‘… beyond pain scoring and paracetamol, giving analgesia and changing boluses, there is not awful a lot to do. i have to admit, there are not many interventions to carry out, whereas with the ventilator care bundle, there are a lot of aspects we have to deal with…’ (doctor2). the care bundle was, therefore, seen by the participants to be of limited use, since it was regarded as recommending basic care, while failing to offer adequate alternatives, should basic care prove to be inadequate. clinical leaders were not convinced that using the pcb improved pain management practices, since the scientific evidence was perceived as too limited to support practice. all good guidelines must embody the latest evidence-based practice to encourage consistent practice and to prevent clinical errors. (1) a study looking at why physicians do not follow clinical practice guidelines (16) suggested guidelines that do not indicate outcome measure may not work well in the clinical areas. the lack of clear, clinically measureable outcomes associated with pain management was seen as a limitation of the pain bundle. applicability to pain management fifteen participants, especially those involved with direct patient care, reported the pcb did not agree with the policy of the unit, which was developed within the trust by staff members of the pain management team. hence, there was a a perceived conflict between the unit’s policy and the pcb. the participants explained this by comparing the differences in analgesia recommended in the pcb and the critical care unit. ‘i agree all the components are evidence-based, but there is no evidence to support grouping them together like a bundle’ (nurse 1). ‘i don’t think the pcb addresses the needs of critically ill patients’ (nurse 2). the participants, especially the nurses, felt the pcb was not applicable to critical care, since there was no evidence to show the bundle could improve practice, and that pain management for critical care patients is often complex and should be based on the individual patient’s needs. ‘i agree all the components are evidence-based but there is no evidence to support grouping them together like a bundle’ (doctor 3). ‘for patients with significant morbidity to analgesia, particularly thoracic or upper gi (gastro intestinal), those who are at high risk of coughing, respiratory malfunction and breathing problems, we have a simple analgesia protocol, a complex analgesia protocol, and an almost separate epidural protocol. we are fairly free with how we mix and match. we have far more autonomy in our management plans. so, we don’t quite fit in with the rest of the hospital and the ward management. i don’t know if it fits in with 342 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 the pcb or not, but that is what we often do it here. we don’t have a fixed approach. we commonly use analgesia sedatives such as morphine, midazolam, propofol or alfentanyl for them’ (doctor 4). ownership of the care bundle the participants explained the pcb was developed as a generic pain protocol and was not tailored to the needs of specific groups of patients. since the pcb was developed by a regional network, it was created and intended to be applied to all the critical units in the region, and this was perceived as a weakness, making it less applicable to particular units: ‘... the care bundle was developed over the network to cover six or seven different intensive care units, to cover a wide group of patient populations, and i don’t think it is realistic to use in our unit, since we deal with a larger population and various types of cases’ (nurse 3). another participant gave similar examples; again, pointing out the pcb was perceived as an externally developed policy and, therefore, was not useful to this critical care unit, since every unit has its own organizational policies and procedures: ‘... the problem with these guidelines is because they came from the network and are not meant for one hospital; and, different hospitals here use different drugs such as alfentanil and remifentanil. we can’t put in specific guidelines, because each hospital has their own formula, different policy in purchasing and contracts. even though it is a good framework, it does not meet everybody’s needs’ (doctor 4). necessity for current practice according to the participants, some of the components were similar to the trusts’ current pain management guidelines. aspects of the recommendations in the bundle were seen as already being standard policy: for example, the use of paracetamol and opiates, and the components in the epidural care bundle. therefore, it was felt the pcb added little to the current policy and, hence, provided little new understanding of possible approaches. ‘... i have been practicing and it is not different from what we have been doing, it is actually recognized as good practice. i think we are good at it and don’t necessarily follow the pcb, because it is within the practice’ (nurse 4). the participants from all groups of professions felt that pain management is always handled well in the unit and there was no necessity for the introduction of a pain care bundle: ‘i would say pain (management) is pretty good, and we are always aware when pain is an issue for patients. we don’t need another pain guideline here.’ [in the unit]. (nurse 5). the participants shared similar views on the generally good quality of pain management, and they also felt their pain management practice is good, as explained below: ‘i think we are quite good at managing pain. the doctor, pain team and members of staff manage patients here well. we have more staff here and the doctors are more available compared to the [general] wards, and we have our consultant who knows what they are doing, and i think we are doing a good job here. we don’t use the bundle to manage pain; we don’t need it here’ (nurse 6). discussion this study set out to explore nurses’ and doctors’ perceptions on the introduction of a pcb to improve pain management in critical care. the findings highlight a number of issues with regard to development and implementation of the pcb, which have affected its introduction and acceptance in the critical care setting studied. the findings highlight the importance of considering the three factors that are identified in the parihs framework when designing a practice improvement approach. despite that fact that care bundles have been shown to improve practice (17) and bundles relating to a number of aspects of critical care have been introduced, not to mention the existence of evidence suggesting room for improvement in relation to pain management, apparently there are several local contextual factors that have adversely affected development and introduction of the care bundle. the participants in this study appear to perceive current pain management as being good and, therefore, do not see the need for a pcb. the pcb was developed on a regional basis and this seems to have led to a lack of ownership and perceived conflicts with the local policy. there was a perceived lack of flexibility and also a lack of advice for more complex pain management issues. interestingly, there also was a lack of perception of the benefit of combining interventions into a bundle in the field of pain and a perceived lack of evidence on which to base recommendations. 343 the perception of nurses and doctors on a care bundle guideline for management of pain in critical care l pathmawathi subramanian, nick allcock, veronica james, judith lathlean the nurses, in particular, wanted more guidance in advanced pain management. they needed guidance to assist their decisions beyond the administration of mild non-opiate analgesia and opiate analgesia, such as morphine. the lack of perceived benefit of the pcb over current policies also could have contributed to a perception that the pcb was not particularly useful in improving pain management. moreover, the respondents concluded the pcb would be more useful if it was clearer and provided the more precise information needed to act as a reliable tool in managing pain. when any guideline has been developed it needs to be appraised in terms of validity and reliability before being implemented. guidelines of questionable validity could adversely affect patient care, be ineffective, or a waste of resources. (18) a good guideline needs to be identified by appraising the criteria set by the relevant accreditation bodies, such as the national institute for health and clinical excellence (nice), and assessed by using tools such as the agree tool. however, developing the guideline is not in itself enough to ensure good implementation. as the pahris framework suggests, context and facilitation are also important. several aspects of the introduction of the pcb illustrated the difficulties that can be encountered, should these aspects not be adequately considered. implication for nursing practice prior to the completion of this study, there was no published research exploring the application and value of a pcb in the adult critical care population, using either qualitative or quantitative methodology. the findings suggest the development of a care bundle in pain management did not have a positive impact on self-reported pain management practices. while this study highlights the importance of considering all the factors identified in frameworks for introducing changes in practice, it also raises broader questions about the scope of the care bundle concept, which require further evaluation. this study also illustrates the benefit of a qualitative evaluation of pain management practices among nurses. qualitative evaluation was able to identify the percpetions of the health care staff introducing the pcb and key weaknesses in the implementation strategy, which may have been missed by quantitative evaluation of outcomes in, for example, an audit. this study was limited to one location and, therfore, can only provide limited insight. further evaluation of the potential benefits of the pcb are needed before any firm conclusions about the benefit of a pcb can be reached. conclusion and recommendations this study highlighted a number of difficulties associated with the introduction of a pcb in a critical care unit in the uk. although there were a number of aspects of the introduction of the pcb that might account for these difficulties, it also raises a question regarding the applicability of the care bundle concept. further research is needed to assess the implementation of care bundles before their potential impact on pain management can be evaluated. bibliographic references 1. mcmaster p, rogers d, kerr m, spencer a. getting guidelines to work in practice. archives of disease in childhood. 2007;92:104-106. 2. miller m, kearney n. guidelines for clinical practice: development, dissemination and implementation. international journal of nursing studies. 2004;41(813-821). 3. national health service modernisation agency. 10 high impact changes for service improvement and delivery: a guide for nhs leaders. 2004. 4. berenholtz s, dorman t, ngo k, provonost p. qualitative review of intensive care unit quality indicators. journal of critical care. 2002;17:12-15. 5. fulbrook p, mooney s. care bundles in critical care: a practical approach to evidence-based practice. nursing in critical care. 2003;8:249-255. 6. national institute for clinical excellence. principles for best practice in clinical audit. oxford. 2002. 344 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 7. national institute for clinical excellence. progress report on nhs evidence. special health authority;2008. 8. benton t, craib i. philosophy of social science: the philosophical foundations of social thought. 1st ed. new york: palgrave macmillan; 2001. 9. holloway i, wheeler s. qualitative research for nurses. 1st ed. london: blackwell science ltd; 1996. 10. denzin nk. the research act: a theoretical introduction to sociological methods. 3rd ed. englewood cliffs nj: prentice hall; 1989. 11. harvey a, rycroft-malone j, titchen a, kitson a, mccormack b, seers k. getting evidence into practice: the role and function of facilitation. journal of advanced nursing. 2002;37(6):577-588. 12. rogers e. diffusion of innovations. 4th ed. new york: free press; 1995. 13. rycroft-malone j, seers k, titchen a, harvey g, kitson a, mccormak b. what counts as evidence in evidence-based practice? journal of advanced nursing. 2004;3(1):81-90. 14. patton m. how to use qualitative methods in evaluation. 1st ed. london: sage publications; 2001. 15. green j, thorogood n. qualitative methods for health research. 1st ed. london: sage publications limited; 2004. 16. cabana m, rand c, powe n, et al. why don’t physicians follow clinical practice guidelines? a framework for improvement. journal of american medical association. 1999;282:1458-1465. 17. al-tawfiq ja, abed ms. decreasing ventilator-associated pneumonia in adult intensive care units using the institute for healthcare improvement bundle. american journal of infection control. 2010;38(7):552-556. 18. grol r, grimshaw j. from best evidence to best practice: effective implementation of change in patients’ care. the lancet. 2003;362:1225-1230. table 1: components of the bundle tables 1. all changes are necessary and sufficient. 2. all changes based on level 1 evidence (randomised, controlled trials) are accepted and well established. 3. all changes are straightforward, involving an all-ornothing approach. (modernisation agency, 2004). 345 the perception of nurses and doctors on a care bundle guideline for management of pain in critical care l pathmawathi subramanian, nick allcock, veronica james, judith lathlean table 2: epidural pain care bundle 1 drug solution: when epidural analgesia is used, a combined opiate or local anaesthetic mixture should be administered according to specified protocols. 2 administration: a single-dedicated infusion device and giving set should be used. these should be clearly distinguished from those used for other drug infusions. 3 observations: appropriate standardized observations in accordance with local guidelines should be carried out and documented while epidural analgesia is in progress. 4 alternative analgesia: prior to the discontinuation of epidural analgesia, appropriate alternative analgesia should be prescribed and administered. 5 discontinuation of epidural analgesia: epidural analgesia should be stopped only when clinically no longer indicated. 6 catheter removal: the timing of epidural catheter removal should follow local guidelines related to the timing and dose of prescribed thrombo-prophylaxis. 7 pain team referral: patients discharged with epidural analgesia should be referred to the hospital acute pain team. table 3: non-epidural pain care bundle 1 pain score: for all patients, the pain score at rest or in motion should be recorded regularly with other vital signs on the critical care chart, using standardized scoring tools. 2 paracetamol: paracetamol should be administered regularly for all patients, unless contraindicated. 3 opiates: strong opiate analgesia should be administered according to the local protocol for patients with moderate to severe pain, unless contraindicated. 4 pre-discharge pain management: hospital ward-based guidelines for pain management should be implemented and pain control should be achieved prior to critical care discharge. 5 pain team referral: patients with significant pain control problems within critical care should be referred to the appropriate specialist pain team. 346 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 table 4: interview guide table 5: characteristics of the participants • role of nurses and doctors in pain management in a critical care setting? • factors and issues led to the decision to develop the care bundle what were the drivers? • what were the perceived strenghts and limitations in current practice that led to the development of the bundle? • the development of the care bundle. • how was the development of the bundle organized? • who was involved? • how did the process go? • how were the bundles introduced? • was there any staff development activity? • how has it been used in practice? • what aspects of pain management have been influenced by the bundle? • how did the staff accept the introduction? • are there aspects of practice that have not been affected by the bundle and should be? • was the pain care bundle suitable and easy for the healthcare providers to use? • was the pain care bundle useful? gender n female 14 male 9 years of practice two years or less 2 2.1-5 years 13 5.1-10 years 4 10.1-20 years 2 more than 20 years 2 background area of practice nursing 15 doctors 8 contributions of advanced practice nursing to primary health care: a scoping review articles  contributions of advanced practice nursing to primary health care: a scoping review aportes de la enfermería de práctica avanzada a la atención primaria de salud: revisión de alcance contribuições das práticas avançadas de enfermagem na atenção primária à saúde: scoping review 10.5294/aqui.2023.23.1.5  joão cruz neto1 paula suene pereira dos santos2 célida juliana de oliveira3 kely vanessa leite gomes da silva4 joseph dimas de oliveira5 tahissa frota cavalcante6 1 0000-0002-0972-2988  universidade da integração internacional da lusofonia afro-brasileira, brazil joao.cruz@aluno.unilab.edu.br 2 0000-0001-6463-7316 universidade regional do cariri, brazil paulasuene.pereiradossantos@urca.br 3 0000-0002-8900-6833 universidade regional do cariri, brazil celida.oliveira@urca.br 4 0000-0001-5179-8962 universidade regional do cariri, brazil kely.silva@urca.br 5 0000-0001-8105-4286 universidade regional do cariri, brazil joseph.oliveira@urca.br 6 0000-0002-2594-2323 universidade da integração internacional da lusofonia afro-brasileira, brazil tahissa@unilab.edu.br theme: evidence-based practice. contributions to the subject: this study identifies advanced practice nursing as a healthcare model aiming to corroborate clinical practices. in light of the scientific developments and breakthroughs in the profession, the spread of advanced practice becomes a challenge for the nursing class based on the profession’s ethical, scientific, and political values. in this sense, it expands the discussion to the field of primary care to qualify and subsidize the measures provided at this level of care, in addition to being a starting point for new research on the subject. received: 27/07/2022 submitted to peers: 09/08/2022 accepted by peers: 25/11/2022 approved: 29/11/2022 para citar este artículo / to reference this article / para citar este artigo: cruz neto j, santos psp, oliveira cj, silva kvlg, oliveira jd, cavalcante tf. contributions of advanced practice nursing to primary health care: a scoping review. aquichan. 2023;23(1):e2315. doi: https://doi.org/10.5294/aqui.2023.23.1.5 abstract objective: to map the contributions and strategies to implement advanced practice nursing in primary health care. materials and methods: this scoping review was carried out following the guidelines of the joanna briggs institute in six databases, namely: lilacs, medline, wos, embase, cinahl, and scopus, in addition to a bibliographic repository. a total of 3,076 studies were found, from which 12 were selected. results: the contributions mentioned by the studies regarding advanced practice nursing were divided into three subcategories, as follows: care, educational or management, and preventive practices. they concern autonomy, specialized clinical skills, therapeutic counseling, and patient-centered interaction. some strategies to implement advanced practice are related to continuing education, practice management, self-care, and disease management. conclusions: there is a need to improve strategies for advanced practice nursing, especially in primary care, to address gaps in specialized care, the development of indicators, and therapeutic objectives. keywords (source: decs): nursing; nurse practitioners; advanced practice nursing; nursing specialties; primary health care. resumen objetivo: mapear los aportes y las estrategias para implementar la enfermería de práctica avanzada en la atención primaria de salud. materiales y método: se trata de una revisión de alcance, realizada conforme a las recomendaciones del instituto joanna briggs en seis bases de datos: lilacs, medline, wos, embase, cinahl y scopus, además de un repositorio bibliográfico. se encontraron 3076 estudios, de los cuales se seleccionaron 12. resultados: los aportes enumerados en los estudios respecto a la enfermería de práctica avanzada se dividieron en tres subcategorías: prácticas asistenciales, educativas o de gestión y preventivas, las cuales versan sobre la autonomía, las habilidades clínicas especializadas, el asesoramiento terapéutico y la interacción centrada en el paciente. algunas estrategias para implementar la práctica avanzada se relacionan con la educación continua, la gestión de la práctica, el autocuidado y la gestión de enfermedades. conclusiones: se observa la necesidad de perfeccionar estrategias direccionadas a la enfermería de práctica avanzada, en especial en el marco de la atención primaria, con el fin de cerrar brechas en atención especializada, formulación de indicadores y metas terapéuticas. palabras clave (fuente: decs): enfermería; profesionales de enfermería; enfermería de práctica avanzada; especialidades de enfermería; atención primaria de salud. resumo objetivo: mapear as contribuições e as estratégias para implementar as práticas avançadas de enfermagem na atenção primária a saúde. materiais e método: trata-se de uma scoping review, realizada conforme as recomendações do instituto joanna briggs, em seis bases de dados: lilacs, medline, wos, embase, cinahl e scopus, além de um repositório bibliográfico. foram encontrados 3076 estudos, dos quais 12 foram selecionados. resultados: as contribuições apontadas pelos estudos a respeito da prática avançada de enfermagem foram divididas em três subcategorias: práticas assistenciais, educativas ou de gestão e preventivas. elas versam sobre autonomia, habilidades clínicas especializadas, aconselhamento terapêutico e interação centrada no paciente. algumas estratégias para efetivar práticas avançadas relacionam-se à educação continuada, à gestão da clínica, ao autocuidado e ao manejo de doenças. conclusões: diante do exposto, observa-se a necessidade de aprimorar estratégias voltadas à prática avançada de enfermagem especialmente no âmbito da atenção primária com vistas a sanar lacunas para um atendimento especializado, formulação de indicadores e metas terapêuticas. palavras-chave: (fonte: decs): enfermagem; profissionais de enfermagem; prática avançada de enfermagem; especialidades de enfermagem; atenção primária à saúde. introduction advanced practice nursing (apn) comprises a perspective on expanding professional practice in the number of people and the fields of practice. this broad term encompasses several different professional profiles in nursing. however, two common possibilities are mentioned for apn: the clinical nurse specialist in the hospital setting: and the advanced practice nurse in primary care (1). apn emerged in the united states in the mid-1950s in the hospital setting with a swift spread to primary health care (phc) in several european countries. in 2016, strategies were implemented in latin america and the caribbean to increase access to primary care, with nurses holding apn competencies as its core figure. since 2015, nursing representatives from brazil have been trying to promote its implementation in the country (2). apn becomes a global issue as it becomes a world health organization priority promoted by the pan american health organization (paho). in this sense, apn is encouraged to mobilize decision-making professionals capable of providing services primarily to vulnerable populations, creating pan-american networks, instituting apn where it does not exist, and developing related phc models (2). when providing care in phc, nurses acquire advanced competencies that enable the implementation of care and professional autonomy. in developed countries, apn is synonymous with qualification for expanding clinical competencies through a master’s program, which allows the development of care models for healthcare users based on reliable scientific evidence (3, 4). these actions directly impact health services since they lead to improved care in contexts with a limited supply of professionals, favor care quality based on the follow-up and guidance of individuals with chronic conditions in phc or hospitals, and cost reduction. in addition, there is a reduction in health expenses stemming from chronic conditions followed by apn, which prevents complications and unnecessary hospitalizations (2-5). in the social protection models, phc is expanded and works as the gateway to the health system, organizing care in the healthcare network. it aims to outline strategies, structures, and working methods in nursing to nurture its practice, providing quality health care to service users and their families, as it is based on current scientific evidence (6, 7). the importance of phc and the role of nurses in these services are highlighted, as they provide healthcare services comprising a set of competencies that range from research, education, and care practice to management. in this sense, apn is considered an innovative instrument that improves health care, especially for the most vulnerable populations (4). the studies on apn have been gaining prominence in the international scene for representing a feasible strategy for public services, especially for agencies that promote research funding and professional qualification. the evidence on this theme already indicates that, in addition to identifying which activities are part of apn, it is necessary to recognize its contributions and practices that culturally and scientifically validate each competence (7). thus, the present study inquires about the inputs and strategies for implementing apn in phc. through a search in the literature and the open science framework (osf), a substantial gap was found regarding studies related to apn in phc, especially regarding which activities are considered contributions to the practice, thus providing indicators for the quality of professional nursing care. it is also emphasized that research can clarify the understanding of apn in the primary care setting (6). thus, the present study aimed to map the contributions and strategies to implement apn in phc. materials and methods this scoping review was carried out following the guidelines of the joanna briggs institute (8), which aims to describe and report the available evidence in the literature on a given theme. the following stages were adopted to conduct the study: identification of the guiding question; identification of relevant studies; study selection; data mapping; clustering, summarizing, and study reporting (8, 9). this study’s registration protocol can be found in the osf (10.17605/osf.io/k54vg). considering the methodological rigor to find answers to the theme, the acronym “population, concept, and context” (pcc) was used, where “population” stands for nurses, “concept” stands for apn, and “context” stands for primary care. the guiding question was established based on these definitions: what are the contributions and strategies to implement apn in phc? the search was carried out in the following scientific databases and a bibliographic repository of scientific and technical production: latin american and caribbean health sciences literature (lilacs), medical literature analysis and retrieval system online (medline) via ebsco information services, web of science (wos), embase via elsevier, cumulative index to nursing and allied health literature (cinahl), and scopus. regarding gray literature, the theses and dissertations catalog of the coordination for the improvement of higher level personnel (capes) was adopted, as recommended by the reviewer’s manual (8). the descriptors in health sciences (decs) were adopted for latin american databases or the medical subject headings (mesh) for databases in english. the queries in the databases were carried out between february and march 2021. the inclusion criteria were studies published in portuguese, english, and spanish with different methodological designs. there was no timeframe. the selected studies that addressed the present review’s guiding question were read in full, and the references were analyzed in search of additional studies for possible inclusion. the selection was made by reading the titles and abstracts, excluding opinion articles, annals, articles with unrelated themes, and those unavailable in full text. after reading, the studies were evaluated regarding irrelevant content. the mendeley® reference manager was used to assist in the study selection. duplicate studies were removed. the search strategy consisted of descriptors, as described in table 1. table 1. database search strategies for the research. brazil, 2021 databases search strategies medline [title/abstract] (nurse practitioners [mesh terms]) and (advanced practice nursing [mesh terms]) or (nursing specialties [mesh terms]) or (education, graduate [mesh terms]) and (primary health care [mesh terms]) or (family health strategy [mesh terms]) embase [title/abstract] (nurse practitioners) and (advanced practice nursing) or (nursing specialties) or (education, graduate) and (primary health care) or (family health strategy) scopus [title/abstract] (all (nurse and practitioners [mesh terms])  and all (advanced and practice and nursing or nursing and specialties or education, graduate [mesh terms]) and title-abs-key (primary and health and care or family and health and strategy [mesh terms])  wos mh (nurse practitioners [mesh terms]) and mh (advanced practice nursing [mesh terms] ) or mh (nursing specialties [mesh terms] ) or mh (education, graduate [mesh terms]) and mh (primary health care [mesh terms] ) or mh (family health strategy [mesh terms]) cinahl  (nurse practitioners [mesh terms]) and (advanced practice nursing [mesh terms]) or (nursing specialties [mesh terms] ) or (education, graduate [mesh terms]) and (primary health care [mesh terms]) or mh (family health strategy [mesh terms]) lilacs  [title/abstract] (profissionais de enfermagem) or (prática avançada de enfermagem) or (especialidades de enfermagem) or (educação de pós-graduação) and (atenção primária à saúde) or (estratégia saúde da família) source: prepared by the authors. the preferred reporting items for systematic reviews and metaanalyses extension for scoping reviews (prisma-scr [9]) checklist was used to ensure this study’s methodological quality. two independent researchers performed a paired review to ensure the relevance of the studies. the researchers read and selected the articles according to the inclusion criteria and compared the databases. however, in case of disagreements, studies were reviewed by a third researcher, including the studies with an agreement above 75 %. in addition, the form recommended by the joanna briggs institute (8) was used to guide the information synthesis in the data collection and the relevance of the recommendations. the extracted results corresponded to authors, design, country, year, journals, the category of nursing contributions, and conclusion. the findings were described in tables and figures and discussed narratively. for study selection and inclusion, the preferred reporting items for systematic reviews and meta-analyses (prisma [10]) were adopted to assist in the decision and selection process. after reading the studies in full-text, their references were reviewed to find potential studies not yet included. the studies were classified regarding the levels of evidence and recommendation according to the joanna briggs institute (11). according to resolution 510 of 2016, review studies do not require approval from the research ethics committee as there is no direct contact with human beings. however, it is the responsibility of this type of study to preserve the integrity and authorship of the documents used. results of the 3,076 studies evaluated, 12 were selected to comprise the final sample, of which four were from wos, four from embase, one from lilacs, one from medline, one from cinahl, and one from capes, as presented in figure 1. figure 1. flowchart of the search process according to prisma-scr. brazil, 2021 source: adapted from moher (10). the studies were published between 2001 and 2019, of which three were from the united states, two from brazil, and two from england, while china, the united kingdom, finland, switzerland, and scandinavia each had one study, as presented in table 2. table 2. categorization of the studies analyzed in the review, brazil, 2021 authors/year/ country design sample/time in the profession/ sex/age group objective contributions to apn le/lr barratt, thomas, 2019 (12) england case series, observational 30 patients sex: 24 female and six male participants age: 32 years old to analyze the use of different social interaction styles within professional nurses’ appointments regarding satisfaction, qualification, and duration of appointment time the nurse:    •    analyzes ofhcial and observational indexes;    •    plans, organizes, and coordinates technical/administrative meetings;    •    analyzes cases for home visits;    •    evaluates contraindications and advancements;    •    updates and refreshes the vaccination portfolio;    •    evaluates the results of requested and collected exams for breast and cervical cancers;    •    provides information, contraceptive methods, and condoms for reproductive planning and sexually transmitted infections/ aids;    •    performs childbirth without dystocia;    •    performs technical procedures such as probing, bowel cleansing, electrocardiography, oral rehydration therapy, endotracheal aspiration, osteomized patient care, and umbilical cauterization;    •    plans and coordinates the training and continuing education of community health agents;    •    plans and discusses protocols, guidelines, rules, and institutional referrals with the basic healthcare unit team and the nursing team;    •    provides systematized training for nurses;    •    plans, participates, and implements training and continuing education programs for nursing and healthcare professionals, and    •    prescribes medications 4c boman, glasberg, levymalmberg, fagerström, 2019 (13) scandinavia (sweden, norway, denmark, and the faroe islands) qualitative, semi-structured interviews 25 female nurses age: 47 to 65 years old education and training: 26.5 years to explore the viability of introducing geriatric nurses into phc in scandinavia the nurse:    •    provides dressing and wound care;    •    develops interpersonal skills;    •    manages people;    •    manages time;    •    has computer and negotiation skills;    •    manages finances;    •    provides auditing;    •    provides health education, particularly for patients with chronic health problems; refers patients, and    •    prescribes medications 4c josi, bianchi, 2019 (14) switzerland ethnography with semistructured interviews and non-participant observations 16 nurses time in the profession: 23.8 years sex: female age: 45 years old to explore the potential of new care models for nurse assistants and nurses in advanced practice and non-advanced practice the nurse:    •    identifies nurses with advanced competencies;    •    listens carefully, observes, and interprets patients’ signs of illness, and    •    understands patients’ health and needs 4 rewa, 2018 (15) brazil descriptive, exploratoryqualitative eight nurses education and training: four to 24 years sex: three male and five female participants age: 32 years old to develop a competency profile for apn in phc in the brazilian context the nurse:    •    conducts investigations;    •    provides self-care counseling and follow-up;    •    provides consultation on phytotherapy;    •    develops guidelines for oral antifungal and paracetamol use;    •    provides lifestyle counseling;    •    treats pressure injuries;    •    provides pregnancy counseling, and    •    develops guidelines for emollient use, self-care, and pain relief 4 nascimento et al., 2018 (16) brazil documental, exploratory, and qualitative research 62 documents to carry out a documentary study on the rules, guidelines, policies, and institutional support for nurses to prescribe medications and request tests regarding advanced practice in phc the nurse:    •    provides direct patient care;    •    leads;    •    plays alternative roles;    •    develops professional practices as a counselor/consultant;    •    manages chronic diseases;    •    evaluates family health needs and public health;    •    exercises administrative management, and    •    promotes research 4a swan, ferguson, chang, larson, smaldone, 2015 (17) the united states systematic literature review ten articles/10,911 participants age: 47 to 65 years old education and training: 26.5 years to conduct a systematic review of randomized controlled trials regarding the safety and effectiveness of primary care provided by advanced practice nurses and evaluate the potential of their deployment to assist in relieving primary care shortages the nurse improves the follow-up of elderly patients and enables the healthcare team to become competent regarding the needs of elderly patients 1a wisurhokkanen, glasberg, mäkelä, fagerström, 2014 (18) finland descriptive, exploratoryqualitative 24 nurses education and training: 22 years sex: female age: 35 to 59 years old to explore the experiences of advanced practice nurses in the context of nursing care and to describe the promoting or inhibiting factors for working with a complete apn scope the nurse:    •    provides safe and effective care;    •    promotes increased patient access to health care and increased patient satisfaction, and    •    fosters increased adherence to the proposed treatment and improved communication between healthcare professionals and patients 4a bonsall, cheater, 2008 (19) the united kingdom integrative literature review 88 articles to review and collect the evidence from studies that have evaluated the impact of nursing roles on advanced primary care the nurse schedules follow-up appointments with patients with chronic diseases and makes medication adjustments (according to the patient’s clinical symptoms) n/e* mao, anastasi, 2010 (20) the united states literature review ___ to discuss the etiology, clinical presentation, diagnosis, and management of endometriosis by advanced practice nurses in primary care the nurse prescribes medications and requests tests n/e* twin, thompson, lopez, lee, shiu, 2005 (21) china multiple case study 41 nurses to examine the determinants of the development of an apn model in primary care the nurse:    •    makes nursing care effective;    •    uses sanitary resources, and    •    uses physiological measurements (hemoglobin, blood pressure, lipid profile) 4 carnwell, daly, 2003 (22) england descriptivequalitative 31 nurses sex: male education and training: five years to explore the role of apn in primary care in the west midlands, uk, and how nurses have played their roles over time the nurse:    •    reduces pain and prevents infertility through patient-oriented health education;    •    informs and directs the use of nutritional and integrative therapies in treating endometriosis, and    •    educates and assists patients in optimizing therapeutic interventions to improve their quality of life 4 markle, 2001 (23) the united states literature review ___ to discuss the diagnosis and management of polycystic ovary syndrome by apn in primary care the nurse:    •    enables patients to fight against weight loss;    •    takes a holistic approach to stress management techniques;    •    guides on the importance of adherence to treatment regimens, and    •    reports changes in symptoms and schedules regular follow-up appointments n/e note. le: level of evidence; lr: level of recommendation; *n/e: no evidence. source: prepared by the authors. the studied population consisted of nurses, from eight to 41 people, and the time working in the profession ranged from four to 26.5 years. among the studies, exploratory and theoretical studies prevailed. the predominant sex in the studies was female, aged 26.5 to 59 years. the overall level of evidence in the studies was 4, and the study design was non-experimental, descriptive, and exploratory-qualitative. the nursing strategies consisted of education and clinical practice management (12), research (12), best clinical practice (12-19), autonomy (12-21), specialized clinical skills (13, 14, 20, 21), therapeutic counseling (15, 22), predominant verbal communication (15, 22, 23), health administration and management (16), disease management (16), advanced competence development (17), professional experience more closely to patients (17, 21), increased accessibility to professionals (19), more effective and efficient professional performance (17, 19), constant updates to provide information and care based on reliable scientific evidence (19), patient-centered interactions (12, 22, 23), and continuing education (12, 13, 22). figure 2 summarizes the 12 studies included in the scoping review according to the aspects of their scientific production. the concept used to identify apn is that of the international council of nursing, which highlights specialized scientific knowledge, clinical decisionmaking, reorganization of practices, and implementation of programs focused on care(12-21). data were categorized according to an adaptation for studies in primary care (24). the barriers indicate the social phenomena in which apn is embedded in phc, and the strategies denote the human, educational, translational, and managerial needs to make apn effective in phc. figure 2. synthesis of the studies included in the scoping review. brazil, 2021 source: prepared by the authors. discussion the nurse’s work is essential for managing or performing care, educational, and preventive practices (24). care practices in the context of primary care, nurses can perform managerial and care activities regarding vaccines; provide assistance and referrals to chronic and non-chronic patients; plan and coordinate technical-administrative meetings; train, supervise, and qualify the nursing team and community health agents; provide information, contraceptive methods, and condoms for reproductive planning and sexually transmitted infections/aids; diagnose the families’ needs in all stages of the life cycle, especially for pregnant and postpartum women in prenatal and postnatal follow-up; evaluate and treat dressings, and prescribe medications (12, 13, 15, 19, 20, 22, 23). training is a vital tool for implementing apn (25). according to paho, apn nurses should, among other competencies, have the following nine: clinical expertise, leadership, care experience (individual, group, or community), care and education in varied settings, applied research, interprofessional collaboration, ethical decision-making, advocacy, and technology (2). all of these activities can be observed in the present study. education becomes critical in nursing practice (26-29). nurses are essential in promoting direct care in phc since the work process reaches beyond direct care. these professionals must master knowledge, skills, and competencies that culminate in assistance management or care management (30, 31). thus, their work is also considered strategic and vital, especially concerning managing or implementing care, educational, and preventive practices at the primary care level (24). the present study found that nurses use their care experience and technical qualifications in phc to adjust treatment regimens, report changes in symptoms, and maintain regular follow-up appointments. among the various technical activities, the following stand out: probing, bowel lavage, electrocardiography, oral rehydration therapy, endotracheal aspiration, ostomized patient care, umbilical cauterization by prescription, and collection of oncotic cytology (12). continually adopting procedures needed to ensure patient safety, these techniques are supported by clinical care in health and essential clinical reasoning in advanced practices (12). currently, apn is established and present in more than 50 countries worldwide, with proven quality in the cost-effectiveness of the care provided compared to other healthcare professionals (32, 33). apn contributes directly to improving the quality of care, increasing health coverage, and decreasing healthcare costs (34, 35). educational or managerial practices the research on phc indicates the active participation of nurses in intersectoral management activities (12). they are included in broad discussions regarding health (16) by conducting, participating in, and applying research or other forms of knowledge production to qualify professional practice (12). in the professional and theoretical fields, advanced practice nurses differ in workload, leadership, and alternative roles (16). moreover, they plan and hold discussions with the basic health unit team and the nursing team regarding protocols, guidelines, rules, and institutional referrals in a systematized way (12). aligning the roles of advanced practice nurses with the health needs of patients and the population is critical to achieving improvements and efficiency in health care. the evaluations of apn roles focus on the effectiveness of attaining outcomes for patients, employees, and health systems (36, 37). therefore, this study has found that apn professionals stand out in patient care regarding leadership and user satisfaction (16, 18, 21). moreover, with the range of possible activities, the work of these professionals increases patient access to health care, provides education, and assists in optimizing therapeutic interventions to improve quality of life (18). in some countries, such as spain, apn excels in performing roles that integrate research, education, practical experience, and management with a high level of professional autonomy, developing specific competencies, such as advanced health assessment, decision-making, and reasoning in diagnosis, and planning, implementing and evaluating health programs, among other competencies (38-40). all of these qualities were found in the present study. concerning apn in the home care context, the possibility of prescribing medications also exists (30). thus, it is possible to provide nursing care by recommending or requesting tests and treatment under direct observation, streamlining, and enabling the adequate provision of care (32, 40). the present study demonstrates the contributions of prescriptive practice to phc that assists in the treatment of parasitoses or dermatitis, direct prenatal and postnatal care, the prevention of complications and improvement of clinical rates, the monitoring and prevention of sexually transmitted diseases and aids, and the treatment of cases of miliaria and ear aches (12, 18-20). in addition, the therapeutic resources presented in this study demonstrate in the prescription practice, essential interventions based on protocols in the treatment of scabies, pediculosis, intestinal parasitosis, seborrheic dermatitis, intertrigo, and impetigo, nicotine replacement therapy, and the development of guidelines that elucidate the form of use and therapeutic indications for patients using emollient, antibiotic, antifungal, and paracetamol medications (12, 13, 15, 19). therefore, nurses’ prescription of drugs (12, 13, 15, 19, 20, 22, 23) is a quality that indicates significant apn improvements in phc. apn stands out in the context of advanced practices since decisionmaking, leadership, and improved care planning are skills that underlie apn. the latter is responsible for mediating their ability to decide on care, as care management ultimately becomes the foundation of these practices (30, 41). preventive practices this study emphasizes ongoing and continuous work with pregnant and older women in phc in specific populations. the activities performed include the evaluation of physiological measurements (hemoglobin, blood pressure, lipid profile [21]). pregnancy counseling is provided (15) with a broad clinical and therapeutic evaluation, which promotes mother-baby safety (13). the review of test results and referrals for diagnosis or treatment of breast and cervical cancers in pregnant and non-pregnant women are also highlighted (12, 18). regarding the elderly, it enables team decision-making to acquire skills for monitoring and preventing comorbidities (17). therefore, this study unveils nurses’ managerial activities as an essential part of health problem prevention, especially the analysis of cases for home visits, mobilizing the necessary professionals (12), and the planning, organization, and coordination of technical-administrative meetings (12, 23) with the nursing team and the healthcare unit, and helps consolidate these professionals’ practices. advanced practice nurses in phc should develop skills, provide effective and efficient health care, be recognized for their leadership by the healthcare team and patients, and use science to guide their practice, thus integrating nursing knowledge with clinical experience (42-45). they assume essential roles in the health-disease process; therefore, their participation is vital for its successful implementation (3, 46). regarding the study findings, monitoring patients with chronic diseases, medication adjustments, safe and effective care demonstrated by increased patient satisfaction, and effective communication are some of the mentioned competencies that corroborate the categories (12, 13, 18-20). a systematic review (17) underlines the potential of apn actions, in which nurses’ perspective is sovereign on activities related to physiological measures, user satisfaction, and costs, suggesting increased safety and efficiency provided by these professionals. the level of user satisfaction and the safety of apn nurses’ practices were among the activities mentioned in the present study that contribute to the quality of care provided in phc. apn nurses have more time for their patients, with skilled and qualified practices, and closer contact with patients, benefiting them directly (47). in addition, their role has added value due to their competence in performing tasks such as advanced care planning, specialized patient care, or coordination with the social sector. the range of activities performed by these professionals is varied and vast, which implies an improvement in the quality of care as a result of the specialized care provided by them, resulting in the efficiency of care and the consequent increase in the level of satisfaction with the activities performed. among the activities performed by apn nurses, a study (48) carried out with family health strategy nurses found that in addition to the authority to diagnose, prescribe, test, and therapeutically treat individuals, evaluation, judgment, decision-making, and diagnostic reasoning skills are parts of apn, which corroborates the present study. the growing and increasingly complex health needs demand new professional profiles from healthcare professionals dedicated to the interactive practice and focused on collaboration with other healthcare professionals (15). thus, it is necessary to reflect upon the training process of advanced practice nurses as a potential alternative to overcome these barriers and meet the population’s healthcare needs. it is noteworthy that the contributions of apn are perpetuated in this scenario where nursing indicators are closely related to the systematization of care. diagnoses are essential to this process and culminate in health promotion strategies for specific or non-specific populations (49). this process is also noted when identifying the needs of the individuals receiving care (50). however, the implementation of apn faces some challenges, such as the lack of legal and regulatory frameworks that define the role of advanced practice nurses, the lack of clarity regarding the roles and attributions of advanced practice nurses, the lack of knowledge on apn itself, the medical professionals’ reluctance towards the expansion of nurses’ attributions, and the creation of the apn model in each country (51-54). therefore, nurses should demonstrate specialized practices and establish the “advanced” attribute as a landmark of their new attributions; otherwise, they will be subjected to taxative and devaluating constraints (53). it is noteworthy that the studies on this theme are still incipient, and articles with a moderate risk of bias were included, albeit having met the proposed objective. there was neither standardization of the diagnostic methods of the studies presented nor the risk of bias, as preconized in scoping reviews. conclusions the contributions that support apn in phc are autonomy, therapeutic counseling, verbal communication, specialized clinical skills, and patient-centered interaction. in turn, the strategies mapped emphasize continuing education, practice management, self-care, and disease management. in light of these findings, we emphasize the implementation of advanced practices in all contexts of health care and the consolidation of structures that enable nurses to work with autonomy and safety. finally, we encourage new studies to demonstrate the results of apn in phc based on cross-cultural evaluative processes and the emergence of indicators that measure the effectiveness of the contributions mentioned and their implications in healthcare promotion. conflicts of interest: none declared. references 1.   laurant m, van der biezen m, wijers n, watananirun k, kontopantelis e, van vught aj. nurses as substitutes for doctors in primary care (review). cochrane database syst rev [internet]. 2018;7:1-110. doi: https://doi.org/10.1002/14651858.cd001271.pub3 2.   world 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editorial improving quality in the dissemination of nursing science susan gennaro1 william fehder2 donaldson and crowley (1978), in their seminal discussion of the discipline of nursing, exhorted nursing to ensure we possess three attributes as a discipline. every discipline that gets its mandate from society, must have a unique body of knowledge, and must be autonomous. if society does not see a need for nursing, then nursing will not exist. many surveys in the u.s. (gallup, 2010) have shown nurses are currently well regarded as a profession and are trusted for honesty and ethics. however, to continue to have a societal mandate, nursing must provide important services to patients as they seek to improve their own health or the health of family members or while they strive to attain a peaceful death. these services must be based on nursing science. for too long, we have practiced nursing based either on tradition, what authority figures recommend, or on our own experience, rather than practice based on science. for example, many of the interventions we perform for women who are in labor are based on tradition and not on science, and these traditions have been slow to change. (gennaro, mayberry, kafulafula, 2007). what is more distressing, there are many interventions we should be performing and are not. in such case, although their benefits have been supported by excellent research (such as 1:1 nursing care in labor, or delayed pushing during second stage labor, or putting stocking caps on infants in incubators), these interventions have yet to be incorporated fully into nursing practice (gennaro, 2010). there is a long gap between the time research is produced and before it is established in practice. some studies in the united states show 30-45 per cent of patients are not getting the best treatment science has to offer and 20-25 per cent are actually receiving care that could hurt them. (mcglynn, 2003). therefore, it is imperative that nursing science be widely disseminated in a timely fashion. the third characteristic of a discipline is that it has autonomy. when it is not clear what nurses are able to do on their own, it becomes difficult for them to have an inde1 rn, d.s.n., faan. dean and professor, william f. connell school of nursing, boston college, m.a. editor of the journal of nursing scholarship. susan.gennaro@bc.edu 2 ph.d., crna, clinical associate professor , william f. connell school of nursing, boston college, m.a. william.fehder@bc.edu 235 pendent body of knowledge that guides nursing practice. therefore, it is very important nurses have organizations that develop nursing standards and help to legislate independent nursing practice. nursing is, by its very nature, interdisciplinary. so, although we need to understand how and when nurses can act independently and to define the scope of nursing practice, nursing care is provided in conjunction with many other disciplines contributing to patient outcomes. this is important, because it impacts the science that needs to be produced to support our care. much of the work that defines evidence based medicine has the advantage of often providing information for a solo practitioner working with a single patient. for example, to decide how best to treat a patient’s diabetes, the evidence does not need to take into account systems concerns or the practice of other health care providers. rather, evidence-based medicine can evaluate what works best in independent practice. evidence-based nursing is a little more complex, because nursing often occurs within a system and interacts with much more than just the patient (the family, community, etc.). so, nurses must disseminate research that is interdisciplinary and must do so in nursing and interdisciplinary journals that are available to all health practitioners. nurse researchers who successfully conduct significant and innovative studies are interested in ensuring their research is disseminated in the highest quality journals. nurse editors, who generally serve for three to five years in the position of editor before they feel they developed their expertise adequately, are very interested in producing the highest quality journals (freda, and kearney, 2005). nurse reviewers, who report spending an average of five hours on each review and who do this as a voluntary contribution to the discipline, also are interested in reviewing for the highest quality journals (kearney, baggs, broome, doughery, freda, 2008). quality, however, is not always easily defined. one common measure of quality is the impact factor that measures the number of times an article is cited by other authors and develops a ratio that compares citations with the number of citable articles published in a given period of time. there are ways to artificially manipulate the impact factor, such as demanding authors cite works from a particular journal. such tactics are not entirely ethical. another reason why impact factors might not adequately measure quality is that all citations are not captured in the process of developing the impact factor. there is systematic bias as to which journals are included in the citation process and which are not. although the number of nursing journals thompson reuters includes in its examination of impact factors has increased in the last few years, nursing remains underrepresented. (gennaro, 2010). similarly, a particular journal may have many citations to all its articles that are all counted in the numerator of the impact factor, but only a few articles meet the 236 aquichan issn 1657-5997 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 criteria to be classified as citable and are counted in the denominator, thereby, artificially raising the journal’s impact factor (jacso, 2001) certain journals have been shown to have a slow but steady accrual of citations over more than the preceding two years, which is typical of the slow rate of change in clinical practice. these journals might have a consistently lower impact factor when compared to journals with a large but brief citation accrual (vanclay, 2009). in nursing, a one-year picture might not truly capture the quality of work being produced, and a five-year look at impact might be a better measure of quality, as the article influence score might be. the article influence score and the five-year impact factor are both rankings produced by thompson reuters; they take time into account when defining the quality of a given piece of work (thomson reuters, 2010). systems that categorize the number of times a work is cited by other researchers certainly measure quality in terms of contribution to science, but do not provide information about the impact of a journal on practice. a better measure of quality for practicing nurses is to examine downloads. publishers are able to provide information about how many times a particular article has been downloaded. just because a nurse has downloaded a manuscript does not mean she has used the knowledge found in the article to change practice. however, downloads do provide information as to what nurses who are not writing for publication find to be of interest. unfortunately, there is no easy way for authors, editors, or reviewers to compare the number of downloads between journals to ascertain which journals are producing clinically relevant information. the length of time journals are indexed in major databases is another mark of quality. journals that are consistently indexed ensure researchers and practitioners have the ability to easily access knowledge they need. examining some of the more important databases is a good way to understand the quality of nursing science in a particular region of the world (mendoza-para, paravic-kijn, munoz-munoz,, barriga, jimenz-contreras (2009). production values of a particular journal also are tied to quality. because we wish to ensure science is translated into practice in a timely fashion, it is important to ensure studies are disseminated within an appropriate time frame. peer review takes time, but making sure all authors are able to hear decisions on their manuscripts within three months is quite possible, given the computerized manuscript management systems that are now in place for journals. these systems send out automated reminders to reviewers concerning reviews that are due, collate reviews for editors, and help editors to track tardy reviews and send out blinded copies of decisions, including a full set of reviews to authors and to reviewers. journals with good production values, savvy editors, and committed reviewers are aided in disseminating significant research by also having an involved editorial board to help set direction in terms of the kinds of manuscripts a journal is most interested in publishing. editorial boards in different journals have different functions, but an editorial board generally serves to provide some support and direction to the editor and helps to solicit excellent research for dissemination, as well as reviewers who are committed to providing timely, helpful, and constructive reviews. 237 quality journals also provide marketing services to make sure their most important articles are read by potential audiences. attending professional conferences and sharing recent copies of the journal is one common activity provided by publishers. other helpful activities are sending email alerts to potential readers about articles that might be of specific interest based on subject matter. editors can track which articles are most cited and most downloaded and can ensure other articles on these topics are sent to the authors of those articles, so important science is disseminated to interested parties as quickly as possible. finally, quality journals have a staff to ensure manuscripts that are submitted are copy edited and proofed carefully so references are correct, the language is clear, and mistakes are minimized. no matter how careful and diligent an editor is, it is quite impossible for the same person to copy edit and proof. familiarity with manuscripts makes it difficult to see mistakes. so, having staff to copy edit and proof is an important mark of quality. when an author is deciding to which journal he or she would like to submit, probably the most important factors that help to determine this selection are the mission of the journal and the databases in which a journal is indexed. clearly, the length of time it takes to hear from reviewers and the length of time prior to publication also concern authors. before submitting a manuscript, an author should ensure the journal is published on a regular basis with an adequate amount of copy. this is the most basic measure of quality. no author wants to send a manuscript to a journal that does not publish regularly and does not have a sufficient number of manuscripts. such journals are not widely read and do not meet the criteria to be included in the major indexes. questions about quality and barriers to disseminating the science needed for nursing practice are always rising. the current model of double-blinded peer review journals is not the only model for research dissemination and might not be the model of the future. some prestigious scientific journals, such as nature , have experimented with open online reviews in which readers are encouraged to comment on submitted manuscripts prior to acceptance for publication, if the authors agree to this process (greaves, 2006). open-access journals are currently another model of knowledge dissemination, although there are many questions as to which model produces the best quality dissemination. open-access journals are often quicker in terms of disseminating information, but might not always have the same level of quality as journals with double-blind reviews. one interesting model in open-access journals is that of biomed central (bmc), which publishes 220 journals on science, technology, and medicine. each of their journals has a unique, detailed peer-review policy, ranging from traditional anonymous peer review to signed reviews and databases of reviewers’ reports, authors’ responses and revisions, all linked to the published article (such as bmc nursing). since bmc journals are online, article publication can be rapid and efficient subsequent to peer-review and editor approval. many of these journals are tracked for the impact factor, and allow authors to retain certain intellectual property rights to re-use and redistribute their work (biomed central, 2011). no matter what the model of dissemination, there are several new tools editors are currently using to help ensure quality in research dissemination. questions about plagia238 aquichan issn 1657-5997 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 rism and self-plagiarism have long plagued the publishing world. ensuring the work being disseminated is the intellectual property of the author and has not been disseminated elsewhere is important. time is a resource, as are page limits. so, no matter what the method of dissemination, abusing this resource by publishing the same information verbatim in more than one venue (self-plagiarism) is not ethical. certainly, stealing the work of authors is even more abhorrent. computerized programs are a new tool to ensure the work being disseminated is not plagiarized. “crosscheck” is one example. it compares submitted manuscripts to other published work or works on the internet. with the use of authenticating software, editors are able to ensure originality, which is another indicator of quality. as editors, reviewers, and researchers all work to improve the quality of the research that is being disseminated, there are a few important things to remember. we are increasingly a global world. consequently, examining the research from different parts of the world before planning a research study is important. knowing the global state of the science is a vital first step in deciding what research needs to be done and will be important for the lives of as many people as possible. after all, research is hard to do, and all of us want to make the most meaningful contribution possible. in addition to understanding the state of the science from a global perspective, it is important to realize language is a barrier. although english is currently the language of science, not all of us can write in english as well as we speak or understand the language. however, there are many professionals to help edit manuscripts from authors who have english as a second language. researchers need to be able to produce significant research. reviewers need to be able to identify significant research, and editors need to be able to help that research be communicated as effectively as possible. nurse editors will continue to struggle with issues concerning language and how best to ensure information is disseminated in more than one language and in a way that ensures translation is appropriate. however, although the challenges to disseminating nursing research globally are easily identified, it is unthinkable that we, as a discipline, will not meet these challenges. today, more than ever before, the society to whom we answer is a global society and it gives us our mandate to function autonomously and to improve our body of knowledge, so the discipline of nursing can continue to improve the health of the world’s people. referencias 1. donaldson s, crowley. the discipline of nursing. nursing outlook 1978; 26: 113-120. 2. gallup. nurses top honesty and ethics list for 11th year; 2010. retrieved august 24, 2011. from http://www.gallup.com/poll/145043/nurses-tophonesty-ethics-list-11-year.aspx#1 3. gennaro s, mayberry l, kafulafula u. the evidence supporting nursing management of labor. jognn 2007; 36: 598-604. 4. gennaro s. implementing the evidence-based change in perinatal and neonatal nursing. journal of perinatal and neonatal nursing 2010; 24: 55-60. 5. mcglynn e et al. the quality of health care delivered to adults in the united states. new england journal of medicine 2003; 348: 2635-2645. 6. freda mc, kearney m. an international survey of nurse editors’roles and practices. journal of nursing scholarship 2005; 37: 87-94. 239 7. kearney m, baggs j, broome m, doughert m, freda m. experience, time investment, and motivators of nursing journal peer reviewers. journal of nursing scholarship 2008; 40: 395-400. 8. gennaro s. impact and scholarship. journal of nursing scholarship 2010; 42: 233. 9. jacso p. a deficiency in the algorithm for calculating the impact factor of scholarly journals: the journal impact factor. cortex 2001; 37: 590-594. 10. vanclay j. bias in the journal impact factor. scientometrics 2009; 78: 3-11. 11. thomson reuters. science essays. retrieved july 17, 2010. from http://thomsonreuters.com/products.services/science/free/essays/ 12. mendoza-parra s, paravic-klijn t, muñoz-muñoz am, barriga o, jiménez-contreras e. visibility of latin american research (1959-2005). journal of nursing scholarship 2009; 41: 54-63. 13. greaves s et al. nature’s trial of open peer review; 2006. retrieved august 26, 2011. from http:// www.nature.com/nature/peerreview/debate/nature05535.html 14. biomed central. what is biomed central. retrieved august 29, 2011. from http://www.biomedcentral. com/info/about/ 496 508 relacoes estabelecidas pelos profissionais.indd 496 aquichan issn 1657-5997 thamiza l. da rosa dos reis1 cristiane cardoso de paula2 tassiana potrich3 stela maris de mello padoin4 aline bin5 cintia flores mutti6 renata de moura bubadué7 relações estabelecidas pelos profi ssionais de enfermagem no cuidado às crianças com doença oncológica avançada 1 residente em enfermagem obstétrica do centro universitário franciscano. santa maria-rs (brasil). thamiza1@hotmail.com 2 doutora em enfermagem. professora adjunta do departamento de enfermagem da universidade federal de santa maria-rs (brasil). cris_depaula1@hotmail.com 3 mestranda do programa de pós-graduação em enfermagem da universidade federal de santa maria-rs (brasil). tassipotrich@yahoo.com.br 4 doutora em enfermagem. professora adjunta do departamento de enfermagem da universidade federal de santa maria-rs (brasil). stelamaris_padoin@hotmail.com 5 enfermeira assistencial do hospital universitário de santa maria-rs (brasil). linebin@gmail.com 6 mestre em enfermagem pela universidade federal de santa maria-rs (brasil). cfmutti@hotmail.com 7 mestranda do programa de pós-graduação da escola de enfermagem anna nery da universidade federal do rio de janeiro-rj (brasil). renatabubadue@gmail.com recibido: 20 de febrero de 2013 enviado a pares: 11 de agosto de 2013 aceptado por pares: 27 de junio de 2014 aprobado: 6 de octubre de 2014 doi: 10.5294/aqui.2014.14.4.5 para citar este artículo / to reference this article / para citar este artigo da rosa dos reis tl, cardoso de paula c, potrich t, padoin smm, bin a, flores mutti c, bubadué rm. relações estabelecidas pelos profissionais de enfermagem no cuidado às crianças com doença oncológica avançada. aquichan. 2014; 14(4): 496-508 doi: 10.5294/aqui.2014.14.4.5 resumo a assistência de enfermagem em oncologia pediátrica é complexa e envolve as diferentes etapas de cuidado, desde a prevenção, o diagnóstico, os tratamentos prolongados, até o cuidado paliativo. o objetivo deste estudo foi compreender as relações estabelecidas pelos profissionais da equipe de enfermagem no cuidado às crianças com doença oncológica avançada, sem possibilidades terapêuticas. estudo descritivo de abordagem qualitativa, desenvolvido por meio de análise de banco de dados com 15 entrevistas de uma pesquisa matricial realizada no interior do rio grande do sul, brasil. a análise de conteúdo das entrevistas resultou em tipos de relação: ao cuidar de crianças com doença oncológica avançada, o profissional de enfermagem estabelece uma relação consigo e com a equipe; ao cuidar, o profissional desenvolve uma relação com as crianças; e, ao cuidar, o profissional desenvolve uma relação com os familiares das crianças. essas relações refletem as dificuldades do cuidar diante do câncer, intensificadas por se tratar de crianças, uma vez que sua concepção dessa doença está associada ao sofrimento e à morte. palavras-chave saúde da criança, criança, neoplasias, cuidados paliativos, enfermagem. (fonte: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 496-508 497 relações estabelecidas pelos profissionais de enfermagem no cuidado às crianças com doença oncológica avançada l thamiza l. da rosa dos reis e outros. año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 496-508 relaciones establecidas por los profesionales de enfermería en el cuidado a los niños con enfermedad oncológica avanzada resumen la asistencia de enfermería en oncología pediátrica es compleja e involucra las diferentes etapas de cuidado, desde la prevención, el diagnóstico, los tratamientos prolongados, hasta el cuidado paliativo. el objetivo de este estudio fue comprender las relaciones establecidas por los profesionales del equipo de enfermería en el cuidado a los niños con enfermedad oncológica avanzada, sin posibilidades terapéuticas. estudio descriptivo de abordaje cualitativo, desarrollado por medio de análisis de banco de datos con 15 entrevistas de una investigación matricial realizada en el departamento de rio grande do sul (brasil). el análisis de contenido de las entrevistas resultó en tipos de relación que el profesional desarrolla al cuidar de niños con enfermedad oncológica avanzada: una relación consigo y con el equipo, una relación con los niños y una relación con los familiares de los niños. esas relaciones reflejan las dificultades del cuidar ante el cáncer, intensificadas por tratarse de niños, dado que su concepción de esa enfermedad está asociada al sufrimiento y a la muerte. palabras clave salud de los niños, niños, neoplasias, cuidados paliativos, enfermería. (fuente: decs, bireme). 498 aquichan issn 1657-5997 relationships established by nursing professionals when caring for children with advanced cancer abstract nursing care in pediatric oncology is complex and involves different stages of care that range from prevention, diagnosis and prolonged treatments to palliative care. the purpose of this study is to understand the relationships established by members of the nursing staff while providing care for children who have advanced cancer with no therapeutic possibilities. a descriptive study with a qualitative approach was developed through analysis of a database with 15 interviews from a matrix study carried out in the department of rio grande do sul (brazil). a content analysis of the interviews revealed the types of relationships the nursing professional develops while providing care to children with advanced cancer: a relationship with oneself and the nursing team, a relationship with the child, and a relationship with the child’s family. these relationships reflect the difficulties encountered when providing care to cancer patients. in the case of children, the difficulties become more intense, since their understanding of the disease is associated with suffering and death. key words children’s health, children, neoplasms, palliative care, nursing. (sources: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 496-508 499 relações estabelecidas pelos profissionais de enfermagem no cuidado às crianças com doença oncológica avançada l thamiza l. da rosa dos reis e outros. introdução a assistência em oncologia desenvolve-se pelo cuidado preventivo, curativo e paliativo. no que se refere à prevenção, a principal estratégia é a detecção precoce, pois permite um tratamento menos agressivo e mais efetivo (1, 2). o cuidado curativo envolve as fases de diagnóstico, tratamento e controle, e tem como objetivo aumentar as taxas de sobrevida, minimizar os efeitos tardios do tratamento e reintegrar a criança na sociedade com qualidade de vida (3). apesar do progresso tecnológico e do aumento dos índices de cura e sobrevida dessa população, em alguns casos, a criança pode apresentar recidivas durante o tratamento, o que pode levar ao descontrole da doença, não havendo mais possibilidades terapêuticas curativas (1). nesse sentido, surge o cuidado paliativo como uma abordagem que visa melhorar a qualidade de vida dos pacientes e de suas famílias que enfrentam problemas associados a doenças que põem em risco a vida. essa abordagem tornase possível por meio da prevenção e alívio do sofrimento, além de outros problemas de ordem física, psicossocial e espiritual (4). persiste, ainda, a dificuldade no uso da terminologia referente aos cuidados paliativos; possivelmente, como reflexo da ausência de oferta desses cuidados por parte da rede pública brasileira de assistência à saúde. recentemente, passou-se a usar a expressão “pacientes fora de possibilidades terapêuticas”, que permite englobar desde o tratamento dos pacientes em internação hospitalar até os atendidos em ambulatório para controle da sintomatologia (5). no brasil, o instrumento legal que institui os cuidados paliativos em oncologia é a política nacional de atenção oncológica: promoção, prevenção, diagnóstico, tratamento, reabilitação e cuidados paliativos (6), a qual estabelece as diretrizes para o atendimento em oncologia no país, e suas ações são orientadas por um modelo assistencial que deve organizar e articular recursos em diferentes níveis de atenção, para garantir acesso aos serviços e integralidade do cuidado (7). diante da complexidade da assistência em oncologia pediátrica, destaca-se a importância de uma equipe de saúde multiprofissional. a enfermagem, como integrante dessa equipe, está presente nas diferentes etapas de cuidado, desde a prevenção, o diagnóstico, os tratamentos prolongados, até o cuidado paliativo (8). este cuidado é potencializado ante o diagnóstico de câncer sem possibilidades terapêuticas. o enfermeiro se torna referência para o apoio à criança e ao adolescente, bem como à sua família para enfrentar a fase terminal e, consequentemente, a morte (4). são inúmeros os desafios para a equipe de saúde no que tange à inserção de programas de cuidados paliativos destinados a crianças com câncer (1). considerando-se as muitas facetas que permeiam o universo oncológico e pediátrico, é de grande relevância que o enfermeiro esteja seguro em suas práticas cotidianas e transcenda os limites técnicos ao cuidar da criança (9). diante disso, surgiram inquietações acerca do cuidado de enfermagem às crianças com câncer sem possibilidades terapêuticas. assim, tem-se como questão de pesquisa: quais as relações estabelecidas pelos profissionais de enfermagem no cuidado às crianças com doença oncológica avançada? e como objetivo do estudo: compreender as relações estabelecidas pelos profissionais da equipe de enfermagem no cuidado às crianças com doença oncológica avançada, sem possibilidades terapêuticas. materiais e método estudo descritivo de abordagem qualitativa, desenvolvido por meio de análise do banco de dados de entrevistas da pesquisa matricial: ser-profissional-de-enfermagem-que-cuida da criança que tem doença oncológica avançada que não responde mais aos tratamentos curativos (8, 10). este é um subprojeto da pesquisa matricial, a qual obteve aprovação pelo comitê de ética em pesquisa com seres humanos da universidade federal de santa maria, no estado do rio grande do sul (rs), brasil, sob o n. 0284.0.243.000-10, onde foram respeitados os preceitos éticos e legais conforme a resolução 196/1996 do conselho nacional de saúde. o banco de dados constitui-se de 15 entrevistas realizadas no período de dezembro de 2010 a março de 2011, com profissionais de enfermagem que desenvolviam ações de cuidado às crianças com doença oncológica avançada, cuja enfermidade não respondia mais aos tratamentos curativos. esses profissionais integravam as equipes do ambulatório de quimioterapia, centro de tratamento à criança e adolescente com câncer (ctcriac) e/ou da unidade de terapia intensiva pediátrica (utip) de um hospital público de ensino do interior do estado do rs. 500 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 as entrevistas foram codificadas com a letra e de “enfermagem”, seguida dos números de 1 a 15, e foram submetidas à análise de conteúdo temática no período de setembro a outubro de 2012. as fases de análise foram compostas por: pré-análise; exploração do material e tratamento dos resultados obtidos (11). na fase de pré-análise, foi realizada a leitura flutuante das entrevistas, a fim de se obter um maior contato com o conteúdo. na sequência, realizou-se a construção das categorias, a qual buscava expressões ou palavras significativas que respondessem à questão de pesquisa. foi desenvolvido o agrupamento por afinidade das ideias e feito um recorte das respostas à questão central; além disso, realizou-se codificação cromática dos achados e categorizaram-se conceitos gerais que orientaram a análise. por meio de leitura exaustiva, estabeleceram-se questionamentos teóricos para melhor identificar o sentido do conteúdo. durante a exploração do material, foram identificadas as ideias comuns refletidas nesses recortes, indicados como relevantes na pré-análise. cada entrevista foi lida e relida na íntegra, para confirmar que essas ideias estavam expressas ao longo das falas dos sujeitos. buscou-se, por meio das leituras, identificar a relação das categorias entre si, chegando aos aspectos comuns e inter-relacionados que proporcionaram a especificação dos conteúdos que emergiram e a construção da categoria teórica: relações estabelecidas pelos profissionais de enfermagem no cuidado às crianças com doença oncológica avançada. por fim, o tratamento e interpretação dos resultados, que permitiu colocar em destaque as informações obtidas em análise individual e geral das entrevistas, ao relacioná-las à produção teórica encontrada na literatura. resultados e discussão a análise de conteúdo das entrevistas resultou em três tipos de relação, , quais sejam: ao cuidar de crianças com doença oncológica avançada, o profissional de enfermagem estabelece uma relação consigo e com a equipe; ao cuidar, o profissional desenvolve uma relação com as crianças; e, ao cuidar, o profissional desenvolve uma relação com os familiares das crianças. ao cuidar de crianças com doença oncológica avançada, o profissional de enfermagem estabelece uma relação consigo e com a equipe o cuidado de crianças com doença oncológica avançada é complexo. tanto a criança com diagnóstico de câncer infantil quanto a sua família possuem necessidades físicas, psicológicas e sociais específicas. diante desse cuidado, são mobilizadas no profissional de enfermagem inúmeras percepções e sentimentos ante a doença oncológica pediátrica, tais como pesar, dor, sofrimento e angústia. os profissionais procuram superar esses sentimentos no cotidiano pessoal e assistencial; para tanto, buscam estratégias para separar a relação profissional da emocional. relatam também que aprendem a lidar com as situações de dor e se proteger do sofrimento gerado pelo cotidiano assistencial permeado pela angústia das famílias e pelas perdas das crianças. mas, às vezes, não conseguem, e, então, o cuidado os abala. [...] eu consegui separar direitinho isso, o profissional do emocional [...] consigo levar numa boa, não que a gente não se emocione, não se apegue, não é isso [...] mas eu procuro não lembrar lá fora [...] já aprendi bastante a separar, porque senão tu enlouquece junto! (e2) [...] é preciso estar bem preparado para trabalhar num lugar assim, tem que ter um emocional muito forte, [...] eu procuro, quando saio daqui, esquecer o trabalho, vejo o meu filho lá fora, vivo minha vida, [...] senão acho que a gente se sobrecarrega muito. (e3) [...] eu tento [pausa] ser mais profissional [pausa] a maioria das vezes, claro tem algumas exceções. (e5) [...] eu não levo para a minha vida pessoal, às vezes tu te emociona com algum familiar, mas eu procuro me distrair daquela emoção [pausa], pensar em outra coisa, pra não levar pra minha vida [pausa]. tenho conseguido. (e6) o cuidar em oncologia pediátrica é desafiador e gera um desgaste emocional do profissional, uma vez que essa doença é uma das que mais causam dor, sofrimento, medo, ansiedade e estresse, tanto para o paciente quanto para a família e para os profissionais que cuidam de tais crianças. a proximidade durante a rotina assistencial transfere à equipe de enfermagem a responsabilidade de realizar os cuidados à criança com câncer, o que fortalece o vínculo desta com a equipe e gera inúmeros sentimentos no momento em que a criança encontra sua finitude (12, 13). 501 relações estabelecidas pelos profissionais de enfermagem no cuidado às crianças com doença oncológica avançada l thamiza l. da rosa dos reis e outros. os profissionais que atuam nesta área, especialmente quando a criança é diagnosticada sem possibilidades terapêuticas, passam a utilizar estratégias de defesa na tentativa de se adaptarem à situação vivenciada, de maneira a reduzir seu caráter aversivo. diante da convivência com a criança nos momentos mais difíceis, o enfermeiro busca se afastar na tentativa de evitar o envolvimento emocional e esforça-se para limitar sua relação com a criança aos procedimentos técnicos e à rotina assistencial. de modo a separar a relação pessoal da profissional, buscando amenizar seu sofrimento e melhorar o processo de cuidar dos pacientes oncológicos pediátricos (12, 14). os profissionais de enfermagem relataram que tentavam não se envolver com as crianças em tratamento a fim de se proteger do sofrimento. com as experiências e o tempo de trabalho, buscavam cuidá-las sem desenvolver laços. entretanto, nem sempre é possível, existem as exceções das crianças com as quais eles se apegam e sentem mais. os profissionais expressam que esse envolvimento pode trazer sofrimento e sobrecarga emocional. [...] eu procuro não me apegar muito às crianças [...] eu tento não misturar muito as coisas. claro, tem crianças que tu te apega mais, tu sente mais, interage mais [pausa]. mas eu tento não entrar no particular de cada paciente [pausa], isso foi uma proteção minha, pra eu não sofrer tanto [...] não que eu não goste, mas se eu me apegar muito vai ser ruim pra mim [...] eu procuro não me envolver pra eu não sofrer. (e5) [...] eu me envolvo até certo ponto, até quando vejo que estou me abalando muito [...] eu procuro esquecer, porque senão enlouqueço. (e12) [...] eu sei que aquele cuidado, aquela quimio que ele está fazendo é paliativo, vou tentar fazer da melhor forma possível, para dar uma melhor qualidade na assistência e pra me proteger também, não me envolver emocionalmente [...] não que eu seja fria, mas dentro do quadro é aquilo ali que é possível fazer, então eu vou fazendo. (e14) [...] com o tempo a gente vai formando uma crosta em cima da gente, a gente chora sim, mas tem que saber que cada um tem o seu momento e que isso é muito dolorido e nós temos que passar. (e15) o cuidado de pacientes sem possibilidades terapêuticas leva o profissional de enfermagem a confrontar-se com a morte iminente e suas limitações ante a criança doente (12). dessa situação surge o aumento das fantasias e dos medos, o que leva os profissionais a agirem de forma defensiva ante a criança, autoprotegendo-se de presenciar o sofrimento. no entanto, são seres humanos e refletem seus próprios sentimentos naqueles que eles cuidam, o que torna inevitável não direcionar sentimentos no cuidado ao outro (4). ao exercer o cuidar, o profissional desvela uma conduta humana que lhe é própria no cuidado com o outro, desenvolve uma ação social que visa o conforto da criança por meio de uma relação de solidariedade (15). tal cenário torna evidente a necessidade de investimento em treinamento específico para atribuições a serem desenvolvidas nessa área, a fim de possibilitar que os profissionais se sintam amparados e seguros no desenvolvimento de suas ações e na avaliação dos próprios limites e do contexto onde estão inseridos (12, 14). nas falas dos profissionais de enfermagem, constata-se que, especialmente quando são mães, vivenciam um momento singular ao cuidar das crianças com doença oncológica avançada. nesse sentido, expressam que se relacionam de forma diferente com a criança a partir de suas vivências no cotidiano familiar. assim, consideram que há um envolvimento maior, pois se colocam no lugar das mães dessas crianças. mesmo tentando evitar, envolvem-se, apegam-se e imaginam que também poderiam estar vivenciando essa situação. nessa perspectiva, cuidar torna-se mais difícil e triste. [...] a parte mais difícil é a emocional, a gente que é mãe, também, tem vezes parece que se toca mais, se aproxima mais. (e1) [...] é difícil de tu lidar, tu tem que ter o emocional bem preparado, ainda mais eu que tenho filho, que vejo muitas crianças chegando, da idade dele, é difícil não comparar, não se sentir na pele daquelas mães. (e3) [...] criança em que a cura não é mais possível me deixa muito triste, ainda mais quando são adolescentes, já que eu tenho dois filhos adolescentes. então me dói pela mãe, pelo pai, eu me coloco no lugar [...], um sentimento de perda, e eu poderia estar perdendo um filho. (e5) [...] depois que a gente tem filho, a gente se envolve, não adianta. (e12) 502 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 [...] umas crianças a gente se apega mais [pausa], principalmente aqueles que são da idade da minha pequena [filha], parece que fico mais sensível. (e14) ao cuidar de crianças, as possibilidades de o profissional de enfermagem se envolver emocionalmente e desenvolver uma relação de afeto com o paciente são maiores. algumas vezes essa relação é intensa, o que gera sentimentos de empatia e apego ou então leva o profissional a projetar a situação como se fosse seu próprio filho (14). nessa situação, os sentimentos de perda e frustração podem ser potencializados e provocar o luto (16). no dia a dia profissional, o enfermeiro lança mão de suas vivências, ou seja, de sua bagagem de conhecimentos para agir de uma dada maneira. assim, muitas vezes, o profissional não consegue lidar com a morte e o morrer como uma possibilidade do fim do ciclo da vida. os profissionais nem sempre estão preparados para compartilhar esse momento tão difícil, o que demonstra que prestar assistência a crianças hospitalizadas em tratamento oncológico fora de possibilidade de cura atual é um processo de sofrimento e um misto de emoções para o profissional (15, 16). no entanto, as falas dos profissionais de enfermagem também mostram que eles encaram essa difícil vivência como uma forma de aprendizado. diante do sofrimento causado pelo câncer, o profissional compreende o cuidado como uma possibilidade de aprendizado, ou seja, a cada momento em que cuida da criança com doença oncológica avançada, vivencia novas lições de vida. expressam que, diante da força e esperança com que as crianças enfrentam a doença e a vontade que elas têm de viver e de superar essa situação, os profissionais passam a repensar sua vida pessoal, o que refletirá sobre suas prioridades e valores. [...] lá fora é uma vida de sonho, quando eu chego aqui eu tô na vida real, a cada dia aprendo uma nova lição. a gente acha que tem problema, quando chega aqui a gente aprende. (e1) [...] pode estar a 1, 20 ou 30 anos, vai estar sempre aprendendo. (e3) [...] a gente vê muita coisa boa também [...] tem aquelas que nos surpreendem e nos dão bastante força pra essas barras mais pesadas [...] fortalecem a gente. (e5) [...] é um aprendizado. apesar de toda a doença, de todo o problema, às vezes, eles estão cheio de petéquias nos lábios, vomitando, e eles estão rindo, brincando na cama [...] eles vivem tranquilos e se adaptam, brincam, dão risada até das carequinhas [...] pra gente é um aprendizado porque, às vezes, os teus problemas acabam se amenizando perto dos deles, [...] eles te dão uma lição de vida [...] tu aprende com eles. (e11) diante da perspectiva de amenizar o sofrimento do outro, o profissional de enfermagem tem a possibilidade de aprendizagem de conhecimentos que superam a ciência e envolvem os valores humanísticos da vida, que implicam desenvolvimento pessoal e humano. ao cuidar da criança com possibilidade de morte iminente, o profissional passa a refletir sobre a condição humana e a sua fragilidade, e percebe o quanto é impotente diante da morte. nesse contexto, sensações de limitações afloram, especialmente, quando percebe a inevitabilidade da finitude (17). os profissionais expressam a importância do reconhecimento da equipe para satisfação pessoal no cotidiano assistencial. as divergências do modo com que cada profissional compreende o cuidar da criança com doença oncológica avançada podem ser resolvidas quando o profissional conquista a confiança da equipe e consegue expor sua forma de pensar. [...] a gente só aprende com algum tempo de experiência. no início, não tem autonomia, o pessoal não confia muito em ti, porque tu é nova. agora, como eu já tenho um tempo de trabalho, os médicos, toda a equipe e os pacientes que vêm de longo tratamento já me conhecem, sabem como sou. fico mais segura, isso me tranquiliza bastante e eu tenho também a minha autonomia, eles cofiam em mim. (e2) [...] não é só o cuidado profissional, é fazer alguma coisa que faça a diferença [pausa], as minhas colegas dizem que eu mimo as crianças [sorrindo], mas é isso que me satisfaz. (e6) [...] a gente faz, faz, e parece que a gente não tem retorno [da equipe médica], não digo dos pacientes, porque eles são agradecidos por demais [...] no dia a dia, tem vezes que parece que a gente não é nada, sabe, tem muitas vezes que a gente fica tão desmotivada. (e7) nas relações interpessoais que se estabelecem na prática cotidiana do cuidar, o profissional se depara com a sua subjetivida503 relações estabelecidas pelos profissionais de enfermagem no cuidado às crianças com doença oncológica avançada l thamiza l. da rosa dos reis e outros. de e a do outro, o que envolve o entendimento do ser humano, de seus conflitos, de seus vínculos consigo mesmo e a interação com os demais membros da equipe. as relações que se estabelecem entre os profissionais de saúde se manifestam de acordo com o referencial de vida de cada membro da equipe. nos relacionamentos, cada um coloca um pouco de si, mostra seu modo de agir e influencia o outro de forma positiva ou negativa (18). no entanto, as relações profissionais modificam-se a cada momento e definem a maior ou menor abertura para a interação entre os profissionais. os problemas que surgem na realização do trabalho afetam as relações entre os integrantes das equipes, bem como entre eles e os usuários e familiares (19). assim, o reconhecimento por parte da equipe pode contribuir para estabelecer uma relação satisfatória consigo mesmo de modo a minimizar o desgaste emocional do profissional e, consequentemente, promover a qualificação da assistência prestada. ao cuidar, o profissional desenvolve uma relação com as crianças com doença oncológica avançada o longo período de hospitalização, tratamento e acompanhamento torna o convívio entre os profissionais de enfermagem e a criança inevitável. as frequentes hospitalizações possibilitam um relacionamento mais próximo com a criança e a família, compartilhando experiências boas e ruins. os profissionais expressaram que desse envolvimento emergem sentimentos, afetividades como: apego, afinidade, interação, vínculo e amizade. relatam que essa interação e o retorno que as crianças dão, por meio do carinho pelo profissional, são o maior estímulo e recompensa que eles poderiam receber. é uma relação de troca. [...] eu trato como se fossem da minha família [...] a gente faz parte da família deles, a gente adota eles como se fossem filhos [...] não tem coisa que pague eles virem te abraçar, te visitar [no hospital após a alta]. (e1) [...] tem crianças que você tem mais afinidade, que tu se apega mais [...] há anos estes pacientes fazem tratamento, no fim, a família deles é a gente [pausa], é com quem eles mais convivem. [...] tu não é frio o suficiente para ignorar isso [pausa], tu tem um sentimento por aquele paciente. (e2) [...] eu acho que a metade do tratamento é o carinho que tu dá, é a atenção. (e6) [...] tem algumas crianças que tu te apega um pouco mais [...] chorar junto, a gente chora. (e8) [...] a gente se apega muito aos pacientes aqui, são pacientes que iniciam o tratamento e ficam um longo tempo e a gente forma um vínculo de amizade. (e9) [...] é longo [o tratamento] e a gente se apega, eles ficam muito tempo com a gente. [...] tu trata bem, tu cuida, tu faz a tua parte, tem vários envolvimentos [...] eles são muito apegados na gente. (e10) [...] muitas vezes tu se apega porque eles ficam meses aqui com a gente, vão um mês para casa e quando tu vê já estão aqui de volta [...] eles gostam de ti, então tu te sente um pouco realizado porque tu trata com alegria eles, é uma troca. (e11) a relação entre o enfermeiro e a criança é que constitui o processo de cuidar, o qual integra técnica, intuição, comunicação, diálogo e sensibilidade (20). as falas convergem com a literatura, a qual descreve que a criação de vínculo entre o profissional de enfermagem e o paciente com câncer infantil torna-se inevitável pelo seu longo tempo de acompanhamento, pois a convivência com as crianças e seus familiares diz potencializa a construção de uma relação singular, pautada na confiança, na esperança e no respeito (4). o vínculo ocorre por meio dos atos de escutar, de dialogar, o que possibilita que a criança adquira confiança em quem a cuida. nesse sentido, o cuidado adquire dimensões significativas, em virtude das trocas e do compartilhar de emoções e sentimentos (13). ao falar do cuidado diário, os profissionais de enfermagem relataram suas concepções sobre cuidados paliativos de acordo com a sua experiência de trabalho, expressando que há investimento no tratamento enquanto há possibilidade de cura, mas, por vezes, os procedimentos não têm o resultado esperado, o câncer avança e a criança passa a receber somente cuidados paliativos. identificam-se nas falas dos profissionais valores fundamentais desse tipo de assistência, como conforto, controle da dor, humanidade e apoio à família. percebe-se ainda a preocupação em amenizar o sofrimento; para isso, os profissionais expressam que 504 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 fazem tudo o que podem para proporcionar melhor qualidade de vida e bem-estar à criança e sua família. para que não se sintam sozinhos, oferecem conforto, carinho, atenção, força e conversam para acalmá-los. [...] chega num momento que a quimioterapia não responde mais ao tratamento, daí entra em cuidados paliativos, que é o conforto geral ao paciente terminal [...] a gente tenta de tudo, acalma [...] tenta o máximo dar conforto. (e1) [...] paciente terminal a gente tenta fazer de tudo para amenizar um pouco aquele sofrimento. tenta passar para a família e para o paciente que eles não estão sozinhos, pra ele ter o maior conforto possível. (e2) [...] eu me sinto bem dando conforto pra eles, eu acho que não tem por que você deixar uma criança com dor, tu tem que fazer o possível, são os últimos momentos dele [...] (e3) [...] a gente dá o máximo que pode, tanto o que a gente tem de medicação para oferecer, quanto a gente estar ali junto, dar conforto [...]. (e8) [...] o investimento é feito até aonde realmente não dá mais [...] aquela coisa de não ter o que fazer é muito chocante, pesa muito [...] a gente procura não deixar o paciente com dor, dar conforto, dar o que a gente pode. o suporte que a gente [...] a arma que a gente tem é minimizar a dor. (e9) [...] a equipe de enfermagem que está sempre ali do lado, tu tem que tentar manter [pausa] é a qualidade de vida, de conforto. (e13) [...] eu tento proporcionar a essa criança que ela tenha menos sofrimento. às vezes nós somos limitados, principalmente quanto à dor, mas não ficamos quietas, chamamos a clínica da dor e quem o médico possa chamar para aliviar mais esse sofrimento [...] a gente tenta fazer com que esta pessoa tenha um sentido de vida realizado, o que eu posso fazer é proporcionar uma melhor qualidade de vida, melhores momentos de vida [...] (e15) a literatura afirma que processo terminal é a condição em que o paciente já não pode ser mais curado, mas sim cuidado (4). ao profissional de enfermagem cabe o desenvolvimento de uma assistência humanizada ao paciente que vivencia sua terminalidade, buscando, por meio de seu conhecimento, amenizar qualquer desconforto que a criança ou sua família apresente, por exemplo, a dor (21). na relação estabelecida com a criança, algumas vezes, o provimento do conforto facilita o despertar do sentimento de confiança e empatia pelo profissional. atualmente, o alívio da dor é visto como um direito humano básico que vai além da analgesia e deve ser acrescido de outras atitudes que permeiam a relação humana, como o contato físico e apoio psicológico, o que possibilita o processo de morrer com dignidade (17, 22, 23). a dificuldade de enfrentar a morte dessas crianças esteve presente na fala de diversos profissionais. cuidar da criança sem saber se amanhã ainda estará na unidade, vivenciando a situação em que a criança piora sua condição de saúde a cada dia e morre, gera um sentimento de perda. expressam sentimento de pesar, já que para muitos a morte da criança se configura como um episódio doloroso, que lhes causa desgaste emocional. referem que, quando a criança morre, toda a unidade fica de luto. [...] tem crianças que eu já me apeguei muito que já foram a óbito, isso sim a gente sente muito [...] a gente vai pra casa e pensa: será que esse paciente vai estar amanhã? e toda vez que morre um paciente a unidade toda fica em luto. (e2) [...] um dia você está conversando com ele [com a criança] e tu acha que ele não vai logo [morrer], e no outro dia tu vem e não está mais. (e5) os pacientes sempre emocionam a gente, a gente cuida, cuida, e depois morre [...] é bem estressante, a gente convive anos e anos com aquela criança e aí morre, é uma coisa parece que puxa a gente. (e7) [...] é difícil pra gente aceitar, mas a gente fica muito triste quando a gente sabe que não tem volta. (e9) [...] não dá para entrar em desespero, faz parte tu ficar triste, é uma perda. [...] é como perder um familiar, tu tem que aprender a conviver com isso, saber discernir entre o teu trabalho, as tuas limitações e as vontades de deus. (e11) o cuidado à criança com doença oncológica avançada é um desafio para o profissional de enfermagem (12). capacitado para 505 relações estabelecidas pelos profissionais de enfermagem no cuidado às crianças com doença oncológica avançada l thamiza l. da rosa dos reis e outros. o cuidado fundamentado na cura, este se sente compromissado com a vida, apontando o despreparo para conviver com a morte. ao presenciar a situação de terminalidade da criança, o profissional tende a se abalar emocionalmente diante da dificuldade de encarar o sofrimento da criança e sua família, com quem conviveu e se relacionou (16). isso gera um sentimento de perda, ou seja, o luto como resposta à separação. tanto para o profissional quanto para a família da criança, a morte no início do desenvolvimento humano pode ser caracterizada como um evento perturbador, um fato que contraria a expectativa de vida, uma inversão na ordem cronológica (17). ao cuidar das crianças, o profissional desenvolve uma relação com os familiares quando a criança é diagnosticada como fora de possibilidades terapêuticas, o emocional da família é abalado e expresso pelo choro, revolta e lamentações. esse sofrimento dos pais gera um sentimento de profundo pesar nos profissionais que integram a equipe de enfermagem. ao falar do cotidiano de cuidado, esse profissional expressa que é complicado, ele deseja amenizar o sofrimento e a dor, dar conforto para a criança e para a família, mas sofre quando a criança está em cuidado paliativo. a maneira que eles encontram de amenizar esse sofrimento é dar apoio à família por meio de palavras de conforto, de gestos de carinho ou, até mesmo, pela companhia. [...] gente apoia a família, [...] a gente faz parte da família deles. (e1) [...] a gente quer é amenizar um pouco aquele sofrimento, não que não vai deixar de acontecer, mas pelo menos a gente tenta passar para a família que ela não está sozinha [...] (e2) [...] não é só tu levar a medicação, é tu ouvir, dar atenção, dar carinho para um familiar [...] conversar com a mãe [...] tu também está cuidando do paciente, se tu der atenção para um familiar. (e6) [...] a gente costuma chamar pastor quando a família quer [...] tem famílias que se sentem bem confortáveis, cada um com a sua religião. a gente também tenta deixar a psicóloga bem próxima da família pra dar esse suporte neste momento. (e8) [...] a gente tem que dar força, alguém tem que dar, até porque muitas vezes elas estão sozinhas [as mães], não tem pai, não tem familiar em volta, porque a maioria é de outra cidade. [...] eu ficava ali do lado, conversava com a mãe, cansei de segurar na mão da criança e a mãe estar ali agarrada no meu ombro. [...] não tem o que falar nessas horas, a gente sabe, não tem o que se diga que conforte. às vezes, tu não precisa dizer nada, basta tu estar ali do lado, não deixar sozinha, não abandonar. (e13) [...] quando morre uma criança, ou quando uma criança está mal e a mãe está chorando, acho que ali tu tem que abraçar aquela mãe, tem que ter esse ombro amigo naquele momento [...] (e15) a família é de extrema importância na manutenção da saúde, na prevenção e no enfrentamento de doenças. no cuidado em oncologia pediátrica, a criança e a família são indissociáveis, portanto o cuidado de um implica o cuidado do outro (20). desse modo, o cuidado precisa ser integral, de forma a atender não somente às necessidades dos pequenos pacientes, como também as necessidades dos familiares que se encontram no ambiente hospitalar com a criança (24). nesse contexto, é a equipe de enfermagem que desenvolve o cuidado que vislumbra a melhora do estado emocional da família e, por conseguinte, da criança. com o intuito de atender às necessidades dos familiares, a equipe de enfermagem deve trabalhar em um espaço participativo, no qual se estreitem as relações, a respeito da autonomia das pessoas (25). para tanto, utiliza-se de estratégias como atitude de escuta das angústias, das incertezas e dos medos da família, bem com do diálogo. nos momentos de dor e sofrimento, em que as palavras podem ser insuficientes para o consolo, a presença e companhia, mesmo silenciosas, do profissional consolam e confortam a família (17). os profissionais de enfermagem precisam estar aptos para o auxílio e compreensão da criança e da família, o que favorece o entendimento da doença e promove a força da família diante do sofrimento de ter um filho com doença oncológica avançada (23). os profissionais devem informar às famílias sobre todas as condições da doença da criança. no entanto, é necessário fazê-lo considerando as necessidades particulares de cada família (26). o profissional expressa que, diante da iminente morte da criança, passa a vivenciar o sofrimento pela perda da criança e pela dor da família. ele se envolve com a família, mantém-se jun506 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 to, abraça e oferece apoio e consolo. esse momento é sofrido, muitas vezes ele se coloca no lugar dessa família, o que torna ainda mais difícil o cuidar. [...] a gente chora com uma mãe [...] fica sensível àquela situação, com os familiares [...] (e2) [...] a família se aproxima muito da gente e a gente se sente tão triste quanto a família, na verdade eles perdem e a gente também sente essa perda. (e8) [...] existe um vínculo de amizade com os pacientes e com os familiares [...] quando morre, a gente chora junto, a gente se envolve e fica triste de ver o familiar sofrendo. (e9) [...] a gente sofre, a gente chora, principalmente com aquela mãe que está ali do teu lado. (e15) no que tange ao cuidado integral à criança com doença oncológica avançada, a enfermagem deve identificar que a família precisa de cuidados para enfrentar aquele momento de tristeza. ao perceber a proximidade da morte da criança, a família recorre mais intensamente aos profissionais que a cercam, e é nesse momento que ela precisa de ajuda, compreensão e apoio (17). no entanto, para os profissionais de enfermagem, o sofrimento dos pais pela perda do filho gera um sentimento de profundo pesar. e, ao compartilhar o processo de morte, o enfermeiro investe todos os seus esforços para ajudar a família, ao participar do sofrimento vivenciado por ela. com o desejo de querer ajudar, tenta entender esse sofrimento e também demonstrar seus próprios sentimentos aos familiares. considerações finais esta pesquisa possibilitou compreender que as relações estabelecidas pelo profissional de enfermagem no desenvolvimento do cuidado à criança com doença oncológica avançada, fora de possibilidades terapêuticas, incluem aqueles com quem convive no cotidiano assistencial: a própria criança, os familiares, a equipe de saúde, além de si mesmo. essas relações refletem as dificuldades do cuidar diante do câncer, intensificadas por tratar-se de crianças, uma vez que sua concepção dessa doença está associada ao sofrimento e à morte. os profissionais de enfermagem vivenciam um desgaste emocional em consequência das relações de vínculo e afeto estabelecidas com a criança e sua família. diante da morte da criança, o profissional sofre e se depara com o sentimento de perda. a fim de se proteger, busca estratégias para não se envolver emocionalmente com a criança, entretanto, algumas vezes não conseguem evitar. diante dessas situações de doença oncológica avançada fora de possibilidades terapêuticas, os profissionais passam a desenvolver os cuidados paliativos como uma maneira de tornar a vivência do câncer infantil o menos sofrida possível, tanto para criança quanto para sua família. buscam proporcionar o conforto de várias maneiras, por meio de terapia medicamentosa, palavras de apoio, presença nos momentos difíceis, entre outras. ao lidar com a morte, o profissional se sensibiliza com a situação da criança e seus familiares. a proximidade da morte de uma criança é um momento de dor para a família e para aqueles com quem ela convive, pois, frequentemente, aceitar e compreender essa situação é difícil e doloroso. entretanto, ao amparar a família, o profissional se envolve e vivencia o sentimento de perda da criança, o que torna ainda mais difícil o cuidar, por gerar sofrimento. os resultados indicaram as relações estabelecidas nesse cuidar e suas implicações desde o cuidado paliativo até a morte da criança. assim, aponta-se a necessidade de implementar estratégias no serviço hospitalar de educação permanente para os profissionais, além de apoio para essas situações do cotidiano assistencial, a fim de minimizar sentimentos negativos e possibilitar um cuidado humanizado ao outro e a si. 507 relações estabelecidas pelos profissionais de enfermagem no cuidado às crianças com doença oncológica avançada l thamiza l. da rosa dos reis e outros. referências 1. mutti cf, paula cc, souto md. assistência à saúde da criança com câncer na produção científica brasileira. rev. bras. cancerol [on-line] 2010; 56(1): 71-83 2. ministério da saúde (brasil). instituto nacional de câncer. diagnóstico precoce do câncer na criança e no adolescente. 2ª ed. rio de janeiro; 2011. 3. camargo b, kurashima ay. cuidados paliativos e oncologia pediátrica: o cuidar além do curar. são paulo: lemar; 2007. 4. avanci bs et al. cuidados paliativos à criança oncológica na situação do viver/morrer: a ótica do cuidar em enfermagem. esc. anna nery 2009; 13(4): 708-16. 5. rabello cafg, rodrigues ph. a. saúde da família e cuidados paliativos infantis: ouvindo os familiares de crianças dependentes de tecnologia. ciênc. saúde coletiva [on-line]. 2010; 15(2): 379-88. 6. portaria n. 2.439/gm, de 8 de dezembro de 2005. institui a politica nacional de atenção oncológica: promoção, prevenção, diagnóstico, tratamento, reabilitação e cuidados paliativos, a ser implantada em todas as unidades federadas, respeitando as competências das três esferas de gestão. diário oficial [da república federativa do brasil]. brasília, df, n. 76, 9 dez. 2005. seção 1, p. 113. 7. chagas-moreira m, luzia lj, miranda da silva m, vincler da silva m, gomes-drunond f, félix da silva ma. estratégias de apoio de enfermagem na atenção à saúde de portadores de câncer: expectativas de moradores de uma comunidade brasileira. aquichán 2010; 10(2): 132-45. 8. mutti cf, padoin smm, paula cc. espacialidade do ser-profissional-de-enfermagem no mundo do cuidado à criança que tem câncer. esc. anna nery 2012; 16(3): 493-99. 9. amador dd, gomes ip, coutinho sed, costa tna, collet n. concepção dos enfermeiros acerca da capacitação no cuidado à criança com câncer. texto contexto – enferm. [on-line] 2011; 20(1): 94-101. 10. mutti cf, padoin, smm, paula cc. cuidado de enfermagem à criança com doença oncológica avançada: um olhar fenomenológico. cogitare enferm. 2011; 16(2): 369-70. 11. minayo mcs. o desafio do conhecimento: pesquisa qualitativa em saúde. 12 ed. são paulo: hucitec; 2010. 12. lages mgg, costa mao, lopes tr, amorim fcs, araujo neto ap, nascimento ird, costa cls. estratégias de enfrentamento de enfermeiros frente ao paciente oncológico pediátrico. rev. bras. cancerol 2011; 57(4): 503-10. 13. silva af, issi hb, motta mgc. a família da criança oncológica em cuidados paliativos: o olhar da equipe de enfermagem. cienc cuid saúde 2011; 10(4): 820-27. 14. alves m, scudeler d, luppi c, nitsche m, toso l. morte e morrer em unidade de terapia intensiva pediátrica: percepção dos profissionais de saúde. cogitare enfermagem [online]. 2012 jul/set; 17(3): 543-8. 15. monteiro acm, rodrigues bmrd, pacheco sta. o enfermeiro e o cuidar da criança com câncer sem possibilidade de cura atual. esc anna nery 2012; 16(4): 741-6. 16. rockembach jv, casarin st, siqueira hch. morte pediátrica no cotidiano de trabalho do enfermeiro: sentimentos e estratégias de enfrentamento. rev. rene [on-line]. fortaleza, 2010; 11(2): 63-71. 17. moro cr, almeida is, rodrigues bmrd, ribeiro ib. desvelando o processo de morrer na adolescência: a ótica da equipe de enfermagem. rev. rene [on-line]. fortaleza, 2010; 11(1): 48-57. 18. cunha, matos e, pires dep, campos gws. relações de trabalho em equipes interdisciplinares: contribuições para a constituição de novas formas de organização do trabalho em saúde. rev. bras. enferm. [on-line]. 2009; 62(6): 863-9. 19. peres crfb, caldas jal, silva rf, marin mjs. o agente comunitário de saúde frente ao processo de trabalho em equipe: facilidades e dificuldades. rev. esc. enferm. usp [on-line]. 2011; 45(4): 905-11. 20. diefenbach g, motta m. o cuidar em enfermagem: família e criança com dor oncológica. cogitare enfermagem [online]. 2012; 17(3): 458-63. 508 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 21. maranhão ta, melo bms, vieira ts, veloso amv, batista nnla. a humanização no cuidar da criança portadora de câncer: fatores limitantes e facilitadores. j. health sci. inst. 2011; 29(2): 106-9. 22. pinto m, crus m, cesariano c, pereira a, ribeiro r, beccaria l. o cuidado de enfermagem ao paciente de oncológico fora de possibilidade de cura: percepção de um grupo de profissionais. cogitare enferm. [on-line]. 2011; 16(4): 647-53. 23. waterkemper r, reibnitz ks. cuidados paliativos: a avaliação da dor na percepção de enfermeiras. rev gaúcha enferm [on-line]. porto alegre, 2010; 31(1): 84-91. 24. barbeiro fms. sentimentos evidenciados pelos pais e familiares frente ao diagnóstico de câncer na criança. rev. pesqui. cuid. fundam. 2013; 5(5): 162-72. 25. silva mm, moreira mc, leite jl, erdmann al. análise do cuidado de enfermagem e da participação dos familiares na atenção paliativa oncológica. texto contexto – enferm. [on-line]. 2012; 21(3): 658-66. 26. ângelo m, moreira pl, rodrigues lma. incertezas diante do câncer infantil: compreendendo as necessidades da mãe. esc anna nery. rio de janeiro, 2010; 14(2): 301-8. 275 zaider gloria triviño-vargas1 conductas promotoras de salud en estudiantes de una institución de educación superior 1 enfermera, phd. universidad del valle, colombia. ztrivino@correounivalle.edu.co recibido: 6 de enero de 2012 aceptado: 11 de septiembre de 2012 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 l 275-285 resumen objetivo: determinar factores predictores que influencian conductas promotoras de salud según modelo de enfermería pender en estudiantes de una institución de educación superior de cali, colombia. materiales y métodos: diseño descriptivo correlacional, con muestra de 384 estudiantes, aleatoria estratificada, con nivel de confianza de 95% (¬¬p ≤ 0,05), margen de error del 5%. las variables fueron la conducta promotora de salud y los factores biopsicosocioculturales. se aplicaron los instrumentos: escala estilo de vida promotor de salud ii para medir la variable dependiente, percepción de autoeficacia, percepción del estado de salud y variables sociodemográficas. resultados: el 50,1% de estudiantes obtuvo conductas promotoras de salud superiores a la media. las conductas fortalecidas en estudiantes por encima de la media fueron: crecimiento espiritual (61,7%), relaciones interpersonales (53,4%), responsabilidad en salud (50,5%); las deficitarias por debajo de la media, actividad física (46,7%), manejo del estrés (46%) y nutrición (49,6%). según modelo de regresión múltiple, los factores que predijeron mayor variabilidad en la conducta promotora de salud ii, fueron: percepción del estado de salud, autoeficacia y tipo de relación familiar en la vivienda (r2 = 11,6%, p < 0,05). conclusión: estos factores se consideraron con influencia baja sobre la conducta promotora de estudiantes, pero se recomendó tenerlos en cuenta en la promoción del cuidado de estudiantes. palabras clave educación, promoción de la salud, cuidado, estudiantes, enfermería (fuente: decs, bireme). health-promoting behavior among students at an institution of higher education abstract objective: this study was intended to determine the predictive factors that influence health-promoting behavior among students at an institution of higher education in cali (colombia), using the pender model. materials and methods: a descriptive, correlational design was used with a sample of 384 students who were selected at random. the confidence level is 95% (p ≤ .05) and the margin of 276 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 error, 5%. health-promoting behavior and bio-psycho-social-cultural factors were the variables. health-promoting lifestyle ii was the instrument applied to measure the dependent variable, perceived self-efficacy, perceived state of health and the socio-demographic variables. results: in all, 50.1% of the students in the sample showed above-average health-promoting behavior. the behavior reinforced in above-average students included spiritual growth (61.7%), interpersonal relations (53.4%) and responsibility in health (50.5%). the below-average behavior deficits were physical activity (46.7%), stress management (46%) and nutrition (49.6%). according to a multiple regression model, the factors that predicted greater variability in health-promoting behavior ii were, in order of importance, perceived state of health, self-efficacy and type of family relationship at home (r2 = 11.6%, p < 0,000). conclusion: these factors were regarded as having minimal impact on students’ health-promoting behavior. however, it is recommended they be taken into account when promoting student care. key words education, health promotion, care, students, nursing (source: decs, bireme). condutas promotoras de saúde em estudantes de uma instituição de educação superior resumo objetivo: determinar fatores preditores que influenciam condutas promotoras de saúde segundo modelo pender em estudantes de uma instituição educativa superior de cali. materiais e métodos: desenho descritivo correlacional, com amostra de 384 estudantes, aleatória estratificada, com nível de confiança de 95% (¬¬p ≤ 0,05), margem de erro de 5%. as variáveis foram a conduta promotora de saúde e os fatores biopsicossocioculturais. aplicaram-se os instrumentos: escala estilo de vida promotor de saúde ii para medir a variável dependente, percepção de autoeficácia, percepção do estado de saúde e variáveis sociodemográficas. resultados: 50,1% de estudantes obtiveram condutas promotoras de saúde superiores à média. as condutas fortalecidas em estudantes acima da média foram: crescimento espiritual (61,7%), relações interpessoais (53,4%), responsabilidade em saúde (50,5%); as deficitárias abaixo da média, atividade física (46,7%), administração do estresse (46%) e nutrição (49,6%). segundo o modelo de regressão múltipla, os fatores que predisseram maior variabilidade na conduta promotora de saúde ii foram: percepção do estado de saúde, autoeficácia e tipo de relação familiar na residência (r2 = 11,6%, p < 0,05). conclusão: estes fatores se consideraram com influência baixa sobre a conduta promotora de estudantes, mas se recomendou considerá-los na promoção do cuidado de estudantes. palavras-chave educação, promoção da saúde, cuidado, estudantes, enfermagem (fonte: decs, bireme). 277 predictores de conductas promotoras de salud en estudiantes de una institución educativa superior de cali 2007 l zaider gloria triviño-vargas introducción el propósito es acercarse más al estudiante universitario que realiza su proceso educativo para identificar las conductas promotoras de salud que realiza y proponer estrategias educativas que lo incentiven y motiven a mejorar patrones de salud y con ello su calidad de vida. de acuerdo con el modelo de pender, en este estudio se considera trabajar la promoción de la salud como primer enfoque. en síntesis, coherente con el modelo promotor de salud de pender (mps), los estudiantes pueden comprometerse e involucrarse en conductas promotoras de salud (cps) de las cuales ellos anticipen beneficios personales, se perciban competentes o autoeficaces y con conocimientos previos para ejecutarlas. puede considerarse que la promoción de la salud ha sido una preocupación constante en el ser humano. la primera conferencia internacional sobre la promoción de la salud reunida en ottawa el 21 de noviembre de 1986 emite la carta dirigida a la consecución del objetivo: salud para todos en el año 2000 (1). esta conferencia fue, ante todo, una respuesta a la creciente demanda de una nueva concepción de la salud pública en el mundo. las discusiones se centraron en las necesidades de los países industrializados y se tuvieron también en cuenta los problemas de las demás regiones. la conferencia tomó como punto de partida los progresos alcanzados como consecuencia de la declaración de alma de ata sobre la atención primaria, el documento “objetivos de la salud para todos” de la organización mundial de la salud (oms), y el debate sobre la acción intersectorial para la salud sostenido recientemente en la asamblea mundial de la salud. la oms, en 1986 (2), acoge la carta de ottawa que plantea cinco áreas fundamentales para la promoción de la salud: construcción de políticas públicas saludables, mejoramiento de los entornos o ambientes, fortalecimiento de la participación social, desarrollo de actitudes personales y reorientación de los servicios. de acuerdo con este planteamiento, un área fundamental de promoción de la salud, referida a los entornos y ambientes, se encuentra y encaja con la universidad como el ámbito donde viven la mayor parte de su tiempo los estudiantes. otra área fundamental está referida al desarrollo de actitudes personales, es aquí donde se necesita el compromiso del estudiante para que desarrolle comportamientos positivos en la promoción de su salud. las cps contribuyen a formar parte del estilo de vida de la población estudiantil, se consideran conductas promotoras de salud, de acuerdo con el planteamiento de la doctora pender en su escala estilo de vida promotor de salud ii: la actividad física, el manejo del estrés, la responsabilidad en salud, las relaciones interpersonales, la nutrición y el crecimiento espiritual (3). el ministerio de salud de chile, con la finalidad de detener los factores de riesgo y desarrollar conductas promotoras de salud de carácter biopsicosocial y ambiental, en el 2003 inició una reorientación de los servicios sanitarios hacia la promoción de la salud. la mayoría de los hábitos nocivos para la salud adquiridos durante la juventud no se traducen en morbimortalidad durante el periodo de la juventud masiva, sino muchos años después (4). el center for chronic disease prevention and health promotion mostró que el 73% de la población mundial no practica actividad física o deporte regularmente. se puede vivenciar una constante disminución de la práctica de actividad física debido a varios factores dentro de los cuales se encuentra la sistematización o automatización de los procesos productivos y de la vida cotidiana (5). en cuanto a alimentación saludable, pich (6) encontró que el 85% de los estudiantes universitarios no desayunan, lo que se constituye en un problema, ya que las respuestas fisiológicas del organismo como consecuencia de los niveles bajos de energía (glucosa) se traducen en disminución de los niveles de concentración y estado de alerta en el estudiante. otro factor importante es el consumo de comidas rápidas y de menor costo, frecuente en esta población. asimismo, uno de los términos más usados hoy en día es el de dieta, y la razón principal por la que esta se ha transformado casi en una moda es por el efecto que tiene en la imagen corporal, sin embargo, los estudiantes no miden las consecuencias que una dieta desequilibrada puede ocasionar; uno de cada cuatro adolescentes, ha hecho o ha intentado hacer dieta en alguna ocasión. en el ámbito universitario se presentan varios factores de riesgo para sufrir trastornos del comportamiento alimentario, tales como crisis depresivas, estrés y ansiedad, factores que disminuyen la calidad de vida y la capacidad de aprendizaje en el estudiante (7). en el 85% de los casos, la edad promedio de los inicios de los trastornos alimenticios se presenta entre los 13 y 20 años (8), edad en que se encuentran los jóvenes universitarios. 278 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 en latinoamérica la prevalencia de estrés es de hasta un 64,5% en estudiantes que presentan un mayor número de síntomas relacionados con el estrés de la población general (9). en caldas, colombia, debido al bajo nivel cultural, económico y educativo de la población, en lo que tiene que ver con la responsabilidad en salud se presenta el fenómeno de la automedicación, lo que trae consecuencias tales como el aumento de los costos y reacciones adversas secundarias generando también condiciones negativas en el bienestar o la calidad de vida (10). en cuanto a las relaciones interpersonales, un buen número de investigaciones basadas en entrevistas y observaciones de la vida académica de las estudiantes demuestran que las alumnas se sienten sumamente cohibidas y oprimidas por sus profesores (11). en colombia el 11% de los adultos menores de 24 años fuman, y 4% son exfumadores (12). se reporta también que el promedio de edad de inicio del consumo de alcohol corresponde a los 13 años (13). la organización panamericana de la salud (ops) (14), en la conferencia sanitaria panamericana, aclara que la promoción de la salud es concebida cada vez en mayor grado como la suma de las acciones de la población, los servicios de salud, las autoridades sanitarias y otros sectores sociales y productivos encaminados al desarrollo de mejores condiciones de salud individual y colectiva. en el sector educativo, las universidades pueden facilitar el desarrollo de mejores condiciones de salud de los estudiantes a través de estrategias en su malla curricular, con seminarios, talleres y dinámicas de incorporación de conductas promotoras de salud en sus estudiantes. hoy en día se reconoce que la aplicación activa de las estrategias de promoción de la salud es esencial para prevenir gran parte las enfermedades que siguen aquejando a las américas, así como para mantener una mente sana en un cuerpo sano. meda et al. (15) expresaron que la promoción de salud en el ámbito escolar constituye un valor agregado al de por sí ya extraordinario valor que tiene la escuela. se reconoce la importancia del estudio de los estilos de vida como un indicador de riesgo de diversas enfermedades o causas de muerte, ya que el estilo de vida representa un conjunto de conductas relacionadas con la salud, de valores y actitudes adoptadas por el sujeto en respuesta a su ambiente social, cultural y económico. en el transcurso de los años las personas van desarrollando ciertos estilos de vida que se van sistematizando como un proceso de aprendizaje por asimilación o imitación de modelos o patrones familiares de grupos. todo ello orienta las concepciones, los criterios y las decisiones de los individuos, su tiempo, energía física y psíquica, además de sus relaciones con otras esferas de su vida (16). este estudio propuso el modelo promotor de salud de pender (mps), una de las teorías de la disciplina de enfermería, como guía para su desarrollo. el mps integra constructos desde la teoría de expectativasvalores y la teoría del aprendizaje social (teoría cognitiva social), dentro de una perspectiva de enfermería. la teoría cognitiva social presenta un modelo de interacción de causalidad en el cual eventos ambientales, factores personales y conducta actúan como determinantes recíprocos de cada uno. en esta interacción de causalidad, las creencias propias formadas a través de autoobservación y pensamiento autorreflexivo influencian poderosamente el funcionamiento humano (17). la teoría de expectativas y valores se basa en la motivación humana de feather (18). de acuerdo con el modelo de expectativas y valores la conducta es racional y económica, no se desgasta; específicamente una persona se involucra en una acción y persiste en ella cuando el valor de la acción es positivo y personal, y cuando la información que posee le motiva a seguir un curso de acción que probablemente le traerá el resultado deseado. este estudio da importancia a la evaluación subjetiva que realizaron los estudiantes sobre sus conductas, para que ellos en su autonomía reconozcan la importancia de esta y se motiven hacia una conducta promotora de salud para su mejor calidad de vida. entre otros supuestos la teoría del modelo pender plantea que las personas tienen la capacidad de autoconciencia reflexiva incluyendo la valoración de sus propias competencias; los individuos buscan regular su propia conducta en forma activa; estos, en toda su complejidad biopsicosocial, interactúan con su ambiente progresivamente transformándolo y siendo transformados a través del tiempo, la reconfiguración autoiniciada de patrones interactivos persona-ambiente es esencial (17). 279 predictores de conductas promotoras de salud en estudiantes de una institución educativa superior de cali 2007 l zaider gloria triviño-vargas las propuestas teóricas del modelo de promoción de salud (mps) de pender son, entre otras: conductas previas y características heredadas o adquiridas influencian las creencias, los afectos y los surgimientos de conductas promotoras de salud; las personas se comprometen a involucrarse en conductas de las cuales ellas anticipan y derivan beneficios personalmente valorados; las barreras percibidas pueden impedir el compromiso con la acción, un mediador de la conducta, así como la conducta real; la percepción de competencia o autoeficacia para ejecutar una conducta dada incrementa la posibilidad de compromiso con la acción y actual realización de la conducta; una mayor percepción de autoeficacia resulta en menos barreras percibidas hacia una conducta específica de salud; el afecto positivo hacia la conducta resulta en una mayor autoeficacia percibida, la cual a su vez resulta en aumento de dicho afecto; cuando las emociones positivas o el afecto se asocian con una conducta, la probabilidad de compromiso y acción aumentan; es más posible que las personas se comprometan e involucren en conductas promotoras de salud cuando otros modelos significativos de conducta esperan que esta ocurra, y proveen asistencia y apoyo para facilitarla; familiares, pares y proveedores de cuidado son fuente importante de influencias interpersonales que pueden incrementar o decrecer el compromiso para involucrarse en conductas promotoras de salud; influencias situacionales en el ambiente externo pueden aumentar o decrecer el compromiso o la participación en conductas promotoras de salud; mientras mayor sea el compromiso con un plan específico de acción, hay mayor probabilidad de que las conductas promotoras de salud se mantengan a través del tiempo; el compromiso con un plan de acción tiene menos probabilidad de resultar en la conducta deseada en situaciones de emergencia como también cuando se presentan actividades más atractivas y preferidas sobre la conducta objetivo; las personas pueden modificar cogniciones, afectos y ambientes interpersonales y físicos a fin de crear incentivos para las acciones de salud. el propósito de este estudio fue determinar los factores que predicen conductas promotoras de salud de los estudiantes de una institución de nivel superior de cali 2007, según el modelo pender, identificando el perfil de estudiantes con cps suficientes y con déficit. materiales y métodos estudio descriptivo-correlacional, con una muestra constituida por 384 estudiantes registrados y matriculados financiera y académicamente en una institución de educación superior de cali, sede diurna. muestra probabilística con un nivel de confianza de 95% ( p ≤ 0,05) con margen de error del 5%. se realizó muestreo aleatorio estratificado por programas, en donde los tamaños de las submuestras son proporcionales a los tamaños de los estratos en la población de estudiantes de la modalidad diurna de la institución, así: económicas empresariales 322 (13%), ingeniería 124 (5%); derecho 297 (12%); comunicación 310 (12,5%); salud 1414 (57%), y educación 50 (2%). los criterios de inclusión fueron los estudiantes registrados y matriculados, según base de datos de la oficina de registro y control académico y financiero de la institución, sede diurna; los de exclusión fueron los estudiantes ingresados por transferencia de otras instituciones, aquellos que estuvieran realizando pasantías en el momento de aplicar la encuesta y aquellos que no firmaron o de quienes no se obtuvo el consentimiento informado por sus padres o tutores. los datos se obtuvieron a partir de la aplicación de los instrumentos: escala estilo de vida promotor de salud (evps ii) de pender (3), la cual ha sido validada en el contexto latinoamericano, presenta un alfa de cronbach de 0, 93, y su validez fue reportada por análisis factorial de componentes principales y ha sido utilizada en el contexto de mujeres caleñas por triviño, stiepovich y merino en el 2007 (19). la escala está estructurada por 52 ítems con opciones de respuesta tipo likert. la escala presenta seis subdimensiones: crecimiento espiritual, manejo del estrés, actividad física, relaciones interpersonales, nutrición y responsabilidad en salud, con esta se midió la variable dependiente (cps). las variables independientes fueron: biológicas (peso, edad y sexo), psicológicas (percepción de autoeficacia, estado de salud percibido), socioculturales (etnia, estado civil, estrato social, facultad, semestre, procedencia, tenencia de hijos y tipo de relación familiar en la vivienda). el estado de salud percibido de recker y wong (20) reporta un alfa de cronbach de 0,78 a 0,83, y percepción de autoeficacia; schwarzer y blaber (21) reportan un alfa de cronbach de 0,75 a 0,91 y validez de constructo; desde una perspectiva de enfermería, el elemento teórico del constructo del aprendizaje social, la motivación, es la base conceptual del mps de pender, constituido por factores personales biológicos, psicológicos y socioculturales que al interactuar con las características y las experiencias 280 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 individuales producen respuestas específicas de conducta y un resultado final en esta. la percepción del estado de salud permite medir la presencia de emociones positivas, felicidad, satisfacción, alegría y ausencia de emociones negativas como ansiedad, depresión y miedo; estas experiencias individuales también producen respuestas y resultados en la conducta de las personas; de otra parte, el mps de pender, la ubica en la dimensión psicológica del constructo teórico. el cuestionario estructurado con variables sociodemográficas fue elaborado por la autora de este estudio. el procedimiento de recolección de datos fue diligenciado por estudiantes de viii semestre de enfermería y medicina de la institución de educación superior de cali, debidamente preparados para ese efecto. para el procesamiento de datos se utilizó programa spss 15. en el procesamiento y la recolección de datos, una vez diseñado el instrumento, fueron sometidos a prueba piloto la cual se realizó con estudiantes de otra institución de nivel superior, lo que permitió realizar los respectivos ajustes al instrumento. para la recolección de la información se procedió a tomar los listados de alumnos matriculados de cada curso seleccionado, estos fueron numerados y se sacó de una bolsa el número correspondiente al estudiante seleccionado, si en el momento no se encontraba en el aula fue reemplazado por el número siguiente. de esta manera se obtuvo en cada curso el número de estudiantes establecido por facultad y semestres en la muestra total. luego se procedió a diligenciar las encuestas. se contó con el aval del comité de ética de la facultad de salud de la institución de educación superior. el análisis de los datos se planteó en términos de análisis descriptivo de las variables a partir de medidas de tendencia central y de variabilidad. para la determinación de los factores que permiten predecir las conductas promotoras de salud se utilizó el análisis multivariado para determinar los factores que influyen porcentualmente en la variabilidad de la conducta promotora de salud en los estudiantes. el análisis de regresión permitió observar, además, la variable con mayor capacidad predictiva, es decir, la que define mayor variabilidad; para el establecimiento del perfil de conductas promotoras de salud de los estudiantes de la institución de educación superior. resultados tabla 1. descriptivo de las subdimensiones de escala estilo de vida promotor de salud ii de pender en estudiantes de una institución educativa superior de cali, 2007 subdimension de la escala evps ii n m/m1 teórico empírico mínimo empírico máximo media desv. típ. < media ≥ media (%) crecimiento espiritual 384 9/36 25 36,00 33,7 2,4 38,3-61,7 manejo del estrés 383 8/32 17,00 32,00 25,9 2,8 54-46 actividad física 383 8/32 16,00 32,00 24,1 4,1 53,3-46,7 relaciones interpersonales 384 9/36 19,00 36,00 32,3 2,7 46,6-53,4 nutrición 383 9/36 18,00 36,00 28,3 3,4 50,4-49,6 responsabilidad en salud 384 9/36 19,00 36,00 29,3 3,7 49,5-50,5 cps 381 52/208 119 208 173,6 13,7 49,9-50,1 fuente: conductas promotoras de salud de los estudiantes de una institución educativa superior de cali, 2007. 1: m/m = máximo/mínimo. la tabla 1 presenta el análisis descriptivo de los puntajes alcanzados por los estudiantes en la conducta promotora de salud según subescalas, de la escala estilo de vida promotor de salud (evps ii) de pender. la escala que midió la conducta promotora de salud fue tipo likert, constituida por 52 ítems. cada ítem de esta escala permite calificaciones de 1 a 4 según grado de concordancia con la afirmación indicada, donde 1 es igual a nunca; 2 corresponde a algunas veces; 3 es frecuentemente y 4 siempre. como el total de preguntas en la escala es de 52, el puntaje total podría variar entre los valores de 52 a 208. la columna titulada m/m teórico muestra los valores mínimos y máximos teóricos posibles; mientras que las columnas de empírico mínimo y empírico máximo muestran los valores reales. el 61,7% de los estudiantes obtuvieron puntajes por encima de la media (33,6), esta subescala presenta un alto promedio en los estudiantes con la conducta de espiritualidad. 281 predictores de conductas promotoras de salud en estudiantes de una institución educativa superior de cali 2007 l zaider gloria triviño-vargas el 54% de los estudiantes obtuvieron puntajes por debajo de la media (25,89). los estudiantes presentaron un promedio bajo en su conducta de manejo del estrés. en la subescala de actividad física se observó alta variabilidad, el 53,3% de los estudiantes obtuvieron puntajes por debajo de la media (24,1). los estudiantes presentaron un promedio bajo en su conducta de actividad física. en cuanto a relaciones interpersonales se evidenció un promedio alto en esta conducta. en cuanto a la subescala de nutrición se observó alta variabilidad, el 50,4% de los estudiantes obtuvieron puntajes por debajo de la media (24,1). los estudiantes presentaron un promedio bajo en la conducta de nutrición. en cuanto a responsabilidad en salud, el 50,5% de los estudiantes obtuvieron puntajes por encima de la media (29,7), un promedio alto en su conducta de responsabilidad en salud. los valores alcanzados por los estudiantes en cuanto a las conductas promotoras de salud para la escala, con un n de 381, tuvieron un puntaje mínimo de 119 y un máximo de 208 puntos, de un teórico de 52/208. el promedio de escala observada fue de 173.57 puntos. la figura 1 presenta las subdimensiones de la escala estilo de vida promotor de salud (evps ii) de pender, donde se observa que la conducta con más alto puntaje fue la de crecimiento espiritual. figura 1. subdimensiones de la escala evps ii de pender la regresión bivariada relacionó la conducta promotora de salud con cada una de las variables del estudio encontrándose relaciones significativas en las siguientes: relación familiar en la vivienda (p = 0,032), percepción del estado de salud (p = 0,000), percepción de autoeficacia (p = 0,000) y consumo de tabaco (p = 0,008), indicando que estas variables entrarían en el análisis posterior, entre las no significativas están: estrato (p = 0,123), facultad (p = 0,339), semestre (p = 0,690), estado civil (p = 0,073), tenencia de hijos (p = 0,0944), trabajo (p = 0,727), consumo de bebidas alcohólicas (p = 0,522), sexo (p = 0,0315), edad (p = 0,927), peso (p = 0,984), tabla 2. análisis multivariado de predictores de la variable cps en estudiantes de una institución educativa superior de cali, 2007 predictores ss. total ss model gl r2 p percepción del estado de salud + percepción de autoeficacia + relación familiar en la vivienda 71,487.726 8265,714 3 0,116 0,000 fuente: conductas promotoras de salud de los estudiantes de una institución de educación superior de cali, 2007. al estimar el modelo de regresión se generó el modelo óptimo seleccionando como variables independientes aquellas que tuvieron la más alta correlación observada. en el análisis multivariado los predictores: percepción del estado de salud, percepción de autoeficacia y el tipo de relación familiar que se da en la vivienda de los estudiantes alcanzan el 11,6% de la explicación en la variabilidad de la conducta promotora de salud en los estudiantes. tabla 3. valores estimados de los parámetros del modelo de regresión próximos a la cps variables modelo coeficientes estandarizados t sig. beta b error típ. (constante) 20,710 0,000 percepción del estado de salud 0,216 4,408 0,000 autoeficacia 0,188 3,817 0,000 dummy_vivienda 1 0,161 3,319 0,001 fuente: conductas promotoras de salud de los estudiantes de una institución de educación superior de cali, 2007. 282 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 los coeficientes beta de percepción del estado de salud, percepción de autoeficacia y relación familiar en la vivienda del estudiante son significativos frente al valor cero; es decir, tienen capacidad de influenciar la variable dependiente, conducta promotora de salud. análisis y discusión en cuanto al perfil de los estudiantes de la institución educativa superior de cali, 2007, la mayor frecuencia de los estudiantes pertenece al estrato 3, con un 45,3%, coherente con lo reportado por el dane (22), donde la mayor proporción de la población de cali corresponde a este estrato. llama la atención que estratos altos aparecen en esta población de estudiantes, aunque en menor proporción; al respecto es necesario analizar que muchos de los estudiantes acceden a créditos educativos, los cuales permiten que los de estrato bajo y medio accedan a la educación superior en esta institución privada. la facultad de salud presenta el mayor número de estudiantes posiblemente debido a que tiene el mayor número de programas; esta característica no coincide con lo reportado por el diario el tiempo (23), donde se informa que los estudiantes tienen sus preferencias hacia las carreras de administración de empresas, mercadeo, economía y negocios internacionales. hay presencia de estudiantes de otras regiones del país, sobre todo del suroccidente, lo cual muestra que la institución tiene aceptación en el área del suroccidente del país. las tres cuartas partes de los estudiantes son solteros, lo que se observa como un factor protector para el desarrollo de sus actividades académicas. los estudiantes viven con sus padres, sin embargo, mencionaron que les gustaría tener la oportunidad de vivir aparte, teniendo más autonomía y decisiones, este hecho se presenta como una tendencia muy contemporánea y en aumento, reflejada en la convivencia con amigos en apartamentos o apartaestudios. el promedio de edad de los estudiantes es de 21 años, dato que corresponde a la etapa final de la adolescencia (24), acorde con lo reportado por huertas et al., donde el promedio de edad fue entre 17 y 21 años (25), lo cual permite analizar que los estudiantes son jóvenes y posiblemente esto permite que su rendimiento académico sea mejor y que ingresen temprano a la etapa productiva. no tienen hijos en un 93,2%, siendo igualmente un factor protector a nivel de sus responsabilidades personales y académicas. la mayor parte de ellos no trabaja y es lo ideal para lograr un rendimiento óptimo en su proceso de enseñanza-aprendizaje (26), sin embargo, el 11,5% sí trabaja (27). los estudiantes declaran consumir tres comidas diarias. en cuanto a la actividad física, más del 50% de los estudiantes no realizan dicha actividad, hallazgo que coincide con lo reportado en el estudio sobre actividad física en estudiantes universitarios (28, 29); los estudiantes de la institución de educación superior de cali declararon disminuir las actividades físicas por falta de tiempo, alta carga curricular o no les gusta. así también registran poca actividad recreativa en un 65,6%, este hallazgo posiblemente termina en un aprendizaje menos productivo y placentero. los estudiantes en mayor proporción (70,8%) consumen bebidas alcohólicas y en promedio iniciaron su consumo a los 16 años, porcentaje que está por encima del promedio de consumo en la población colombiana estudiada por martínez et al. (30). en cuanto al consumo de tabaco lo hacen en menor proporción, y aquellos que fuman iniciaron este hábito a los 16 años; este dato se corrobora con los hallazgos obtenidos por tafur et al. (12), lo cual no contribuye a una conducta promotora de salud. la mayor proporción de estudiantes tiene un sistema de seguridad social en salud. perfil de las conductas promotoras de salud en los estudiantes de la institución con relación a la conducta de crecimiento espiritual los estudiantes presentan una alta espiritualidad puesto que sienten que su vida tiene un propósito, creen en un ser superior sin importar la religiosidad; este hallazgo fue inesperado considerando que el reporte de los estudios publicados por gurucharri (31) y benjamins (32) menciona que las personas adultas tienen mejores conductas de espiritualidad mas no los adolescentes. los jóvenes poseen una alta conducta de espiritualidad, sentirse en paz consigo mismos produce tranquilidad; se somete a discusión ese nivel de espiritualidad en el sentido que el estudiante actual puede tener mayor autodeterminación y autorregulación como plantea el mps, con relación a estudiantes de otras épocas. en cuanto a la conducta de manejo del estrés el comportamiento reportado por los estudiantes fue bajo, dato que se corrobora con los estudios reportados por marty, lavín y figueroa (9); es muy posible, y se somete a discusión, el hecho de que los currículos muy cargados no son flexibles, el tiempo independiente de los estudiantes no se respeta, y los cursos electivos no son suficientes; estas situacio283 predictores de conductas promotoras de salud en estudiantes de una institución educativa superior de cali 2007 l zaider gloria triviño-vargas nes son barreras percibidas por los estudiantes de acuerdo con el mps, que sumadas a la baja actividad física poco facilitan las conductas promotoras de salud dentro del proceso enseñanzaaprendizaje, como la generación de estilos de vida saludables a futuro. se somete a discusión el que las directivas de las instituciones de educación superior deben revisar sus estructuras curriculares, respetar el estudio independiente de los estudiantes, apoyar acciones para minimizar el estrés a través de electivas de interés de los jóvenes, comprometiéndose con la implementación de instituciones con ambientes saludables de facto, como lo contempla la carta de ottawa en cuanto a los cinco determinantes para el mejoramiento de los entornos o ambientes saludables. el nivel de actividad física es bajo, hallazgo que coincide con lo reportado por otras investigaciones en estudiantes universitarios (28, 29). posiblemente los estudiantes no anticipan beneficios personales, no se perciban competentes o autoeficaces y presentan barreras percibidas para ejecutar la conducta de actividad física; también puede considerarse el hecho de que los estudiantes no se comprometen en esta conducta debido a los procesos de automatización, que actúan en el poco afecto percibido y como una barrera para que se produzca el resultado final en la conducta de actividad física. en cuanto a las relaciones interpersonales en los estudiantes la calificación fue alta, es decir, positiva; se evidencia que estos tienen pocos problemas en relacionarse, se discute que posiblemente este hallazgo neutralice las altas cargas de estrés encontradas. la conducta nutricional fue baja en sus promedios; este comportamiento es el esperado teniendo en cuenta que los estudiantes comen a deshoras, aunque reportan comer las tres raciones diarias. es discutible la situación económica la cual pesa en el consumo ideal de alimentos nutritivos. por otra parte, los estudiantes no tienen incorporada la conducta nutricional de combinar los alimentos de la pirámide alimenticia y consumen muchas comidas rápidas; la institución educativa podría proponer mayores espacios de comida nutritiva y asignaturas electivas al respecto. se somete a discusión que al incorporar estas acciones posiblemente se logre mejorar la percepción cognitiva de los estudiantes frente a mejor nutrición y se motive a lograr esta conducta. de acuerdo con el mps de pender los estudiantes se involucran en conductas de las cuales ellos anticipan beneficios personalmente valorados. el reporte de esta inadecuada conducta nutricional coincide con lo reportado, entre otros, por montero et al. (33). la conducta de responsabilidad en salud se mostró por encima del promedio, posiblemente por sus conocimientos en el área y el miedo a presentar problemas al respecto. este hallazgo es discutible porque aún existe un gran porcentaje (49,5%) de estudiantes que no presentan suficientes cps en responsabilidad; probablemente tienen los conocimientos pero no son autoeficaces para desarrollar la conducta de responsabilidad en salud o no presentan alta expectativa de interés en lograrla. en cuanto al análisis multivariado, los factores predictores que influyen en la variabilidad de la cps evidenciaron la percepción del estado de salud, la percepción de autoeficacia y el tipo de relación familiar en la vivienda. este hallazgo puede ser explicado por la capacidad que las personas tienen de autorregularse en su conducta como lo plantea pender; de otra forma, si los jóvenes se perciben sanos y tienen habilidad para valorar sus propias competencias, se posibilita que la percepción de salud y autoeficacia influencien en gran medida la conducta promotora de salud en los estudiantes. en cuanto a la percepción del estado de salud, este hallazgo coincide con lo reportado por triviño, stiepovich y merino (19) quienes en su estudio sobre conductas promotoras de salud encontraron como mayor predictor de la cps la percepción del estado de salud y la autoeficacia, aunque realizaron el estudio en una muestra diferente; la percepción del estado de salud para el presente estudio fue el predictor que produjo la mayor fuerza en la variabilidad de la cps. la variable tipo de relación familiar es un hallazgo nuevo y se discute que el hecho de vivir con la familia posiblemente es mejor debido al cuidado proporcionado al estudiante en la convivencia familiar, el amor en relación con sus hábitos nutricionales, las normas, los valores, el compromiso y la responsabilidad en su actitud. es importante analizar que entre estos factores predictores solo se obtuvo un porcentaje de explicación de la variable cps de 11,6% que, aunque se considera bajo, se debe tener en cuenta porque son factores predictores y todos son susceptibles de intervenir a nivel de los estudiantes, institución y familia. conclusiones los factores que predicen conductas promotoras de salud en los estudiantes son la percepción del estado de salud, la percepción de autoeficacia y el tipo de relación familiar en la vivienda, los cuales producen una variabilidad del 11,6% sobre la conducta promotora de salud; aunque esta variabilidad se consideró baja, 284 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 se recomienda tenerla en cuenta en la promoción de la salud y en el cuidado de los estudiantes. a nivel de los programas de instituciones de educación superior de cali se recomienda incluir en los respectivos diseños curriculares electivas sobre nutrición adecuada, manejo del estrés y manejo del tiempo libre, talleres sobre mantenimiento de autoeficacia, autoestima, autoconocimiento e importancia de la actividad física. asimismo, se sugiere revisar la malla curricular en cuanto al respeto por los espacios de tiempo independiente de los estudiantes para actividades diferentes a las curriculares. al programa de enfermería se le recomienda trabajar en la asignatura de promoción de la salud las dimensiones de pender como una opción para incorporar conductas promotoras de salud en los estudiantes y así potenciarlas en el colectivo hacia estilos de vida saludables. referencias 1. oms/ops. carta de ottawa [serial on line] 1986. [visitado 2008 jun. 24]. disponible en: www.cepis.opsoms.org/bvsdeps/fulltex/confl.pdf 2. organización mundial de la salud (oms). documentos de salud. declaración de alma ata. washington d.c.; 1978. 3. walker s, kerr mj, pender nj, sechrist kr. a spanish language version of the health-promoting lifestyle profile. nursing research 1990;39(5):268-273. 4. cid p, merino j, stiepovich j. factores biológicos y psicosociales predictores del estilo de vida promotor de salud. rev med chile 2006;134(12):1491-1499. 5. velásquez m, torres d, sánchez h. análisis psicológico de la actividad física en estudiantes de la universidad nacional. bogotá, colombia. rev. de salud pública 2006;8(2):1-16. 6. pich j. alimentación en adolescentes [serial on line] 2003. [consultado el 3 de septiembre de 2006]. disponible en: www.uib.es/servei/comunicacio/sc/projectes/arxiu/nousprojectes/aliment/alimentcast.pd 7. fandiño a, giraldo s, martínez c, aux p, espinosa r. factores asociados con los trastornos de la conducta alimentaria en estudiantes universitarios en cali, colombia. colomb med 2007;38(4):344-351. 8. behar r, gonzález t, rivera n. detección de actitudes y conductas predisponentes a trastornos alimentarios en estudiantes de enseñanza media de tres colegios particulares de viña del mar. chilena de nutrición 2007;34(3):1-14. 9. marty mc, lavin m, figueroa m. prevalencia de estrés en estudiantes del área de salud de la universidad de los andes. chilena de neuro-psiquiatría 2005;43(1):24-32. 10. buriticá o, giraldo am, franco d, cañas a, giraldo j. automedicación en estudiantes de la universidad de caldas. ciencias básicas de la salud 2002;1:7-14. 11. medina j. la pedagogía del cuidado: saberes y prácticas en la formación universitaria en enfermería. barcelona: laertes; 1999. 12. tafur la, ordóñez g, millán jc, varela jm, rebellón p. prevalencia de tabaquismo en estudiantes recién ingresados de la universidad santiago de cali. colom med 2006;37:126-132. 13. herrán f, ardila mf. consumo de alcohol, riesgo de alcoholismo, y alcoholismo en bucaramanga colombia. colom med 2002;28(1):1-4. 14. ops. promoción de la salud [serial on line] 1990 [consultado el 2 de septiembre de 2005]. disponible en: http://www. paho.org/spanish/d/ops98-02_ch05.pdf 15. meda r, moreno b, morales m, torres p, lara b, nava g. creencias de salud-enfermedad en estudiantes universitarios. educación y desarrollo 2004;3:31-37. 16. flórez l. cuestionario de estilo de vida promotor de la salud. boletín de la asociación colombiana de psicología de la salud 1994;3:16-22. 285 predictores de conductas promotoras de salud en estudiantes de una institución educativa superior de cali 2007 l zaider gloria triviño-vargas 17. pender n, murdaugh c, parson m. health promotion in nursing practice. 4 edition. new jersey: prentice; 2002. 18. feather nt. expectations and actions: expectancy-value models in psychology. hillsdale: lea; 1982. 19. triviño z, stiepovich j, merino j. factores predictores de conductas promotoras de salud en mujeres peri-postmenopáusicas de cali, colombia. colom med 2007;38(4):395-407. 20. recker gt, wong p. psychological and physical well-being in the elderly; the perceived will-being scale (pwb). canadian journal on aging 1984;3(1):23-32. 21. schwarzer r, babler. spanish adaptation of the general perceived self-efficacy. 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[consultado el 18 de marzo de 2009]. disponible en: www.onusida.org.co. 25. huertas ca, caro pd, vásquez am, vélez js. consumo cultural y uso del tiempo libre en estudiantes lasallistas. lasallista de investig 2008;5(2):36-47. 26. porto a, di grecia l. rendimiento en estudiantes universitarios y sus determinantes. universidad nacional de la plata: argentina. unlp; 2001. 27. revista la nación. estudian y trabajan cuatro de cada diez universitarios [serial on line] 2001 [consultado el 20 de marzo de 2008]. disponible en: www.lanacion.com.ar/nota.aspnota 28. martins mh, de castro ch, de santana g, oliveira s. estado nutricional, medidas antropométricas, nivel socioeconómico y actividad física en estudiantes brasileños. nutrición hospitalaria 2008;23(3):234-241. 29. lópez j, gonzález m, gutiérrez m. actividad física en estudiantes universitarios: prevalencia, características y tendencia. med int mex 2006;22(3):189-196. 30. martínez ja, amaya w, campillo h, díaz la, campo a. consumo diario de cigarrillo en adolecentes estudiantes; factores psicosociales relacionados con el género. latino-americana enfermagen 2008;16(5):37-52. 31. gurucharri mv. algunas reflexiones sobre la religiosidad de los jóvenes universitarios. sociedad y religión 2006;14(15):13-17. 32. benjamins rm. religious influences on preventive health care use in a nationally representative sample of middle-age women. journal of behavioral medicine 2006;29(1):1. 33. montero a, martin u, garcía a. evaluación de los hábitos alimentarios de una población de estudiantes universitarios en relación con sus conocimientos nutricionales. nutr hosp 2006;21(4):1-10. li ve d ex pe ri en ce s of n ur si ng p ro fe ss io na ls p ro vi di ng c ar e to c o v id -1 9 pa ti en ts 1 jack roberto silva fhon https://orcid.org /0000-0002-1880-4379 universidade de são paulo, brazil. betofhon@usp.br vilanice alves de araújo püschel https://orcid.org /0000-0001-6375-3876 universidade de são paulo, brazil. vilanice@usp.br larissa bertacchini de oliveira https://orcid.org /0000-0001-9509-4422 universidade de são paulo/instituto do coração, brazil. larissa.oliveira@hc.fm.usp.br jessica soares silva https://orcid.org /0000-0003-0699-968x universidade de são paulo, brazil. jessica.soares@hc.fm.usp.br rodrigo santana tolentino https://orcid.org /0000-0002-4400-4690 universidade de são paulo, brazil. rodrigo.tolentino@hc.fm.usp.br vinicius cardoso da silva https://orcid.org /0000-0001-8198-4539 universidade de são paulo, brazil. vinicius.cardoso.silva@usp.br luipa michele silva https://orcid.org /0000-0001-6147-9164 universidade federal de catalão, brazil. luipams@ufcat.edu.br fábio da costa carbogim https://orcid.org /0000-0003-2065-5998 universidade federal de juiz de fora, brazil. fabio.carbogim@ufjf.br article lived experiences of nursing professionals providing care to covid-19 patients received: 21/04/2022 sent to peers: 09/06/2022 approved by peers: 03/10/2022 accepted: 19/10/2022 doi: 10.5294/aqui.2022.22.4.7 para citar este artículo / to reference this article / para citar este artigo fhon jrs, püschel vaa, oliveira lb, silva js, tolentino rs, silva vc, silva lm, carbogim fc. the lived experiences of nursing professionals providing care to covid-19 patients. aquichan. 2022;22(4):e2247. doi: https://doi.org/10.5294/aqui.2022.22.4.7 https://orcid.org/0000-0002-1880-4379 https://orcid.org/0000-0001-6375-3876 mailto:vilanice%40usp.br%20?subject= https://orcid.org/0000-0001-9509-4422 mailto:larissa.oliveira%40hc.fm.usp.br%20?subject= https://orcid.org/0000-0003-0699-968x mailto:jessica.soares%40hc.fm.usp.br%20?subject= https://orcid.org/0000-0002-4400-4690 mailto:rodrigo.tolentino%40hc.fm.usp.br%20?subject= https://orcid.org/0000-0001-8198-4539 mailto:vinicius.cardoso.silva@usp.br https://orcid.org/0000-0001-6147-9164 mailto:luipams@ufcat.edu.br https://orcid.org/0000-0003-2065-5998 mailto:fabio.carbogim%40ufjf.br%20?subject= https://doi.org/10.5294/aqui.2022.22.4.7 https://doi.org/10.5294/aqui.2022.22.4.7 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2022.22.4.7&amp;domain=pdf&amp;date_stamp=2022-12-16 theme: care processes and practices contribution to the subject: this article contributes to the knowledge of how nurses have felt and experienced providing care to patients with covid-19, considering their limited preparation to face the pandemic and the fears that emerged during this entire process. in addition, this article highlights the importance of the continuous care process and the nursing practice itself, organized to provide care to this population. li ve d ex pe ri en ce s of n ur si ng p ro fe ss io na ls p ro vi di ng c ar e to c o v id -1 9 pa ti en ts 3 abstract objective: to analyze nursing professionals’ reports on their lived experience in the care provided to hospitalized patients with covid-19. materials and methods: this is an exploratory study using a qualitative analysis, which included twelve nurses and eight nursing technicians from a public hospital in brazil, conducted between december 2020 and february 2021. the inclusion criteria were professionals who provided care to covid-19 patients in emergency, intensive care, and inpatient units and who had at least one year of experience in the institution. the interviews were analyzed through content and similarity analysis that generated a similarity tree; the reinert method was used for thematic categories. results: most participants were female, with a mean age of 34.15 years and 4.85 years of experience. from the analysis, the words ‘patient,’ ‘to stay,’ and ‘to find’ were the most frequent, and for the categories, they were “nursing professionals’ feelings regarding the pandemic,” “the nurses’ role and work with the multi-professional team in the care provided to patients with covid-19,” “precautions with the care provided to patients with covid-19,” and “nursing professionals’ concern that their family members may become ill during the pandemic.” conclusions: the nursing staff is predominantly composed of females and, in their reports on the lived experience of providing care to patients with covid-19, they pointed out that concern and fear were prevalent, with the family being one of the protective factors to withstand the risks of working against something novel that may result in death. keywords (source: decs) coronavirus infections; covid-19; nursing; pandemics; life change events; qualitative research. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 47 4 resumen objetivo: analizar los relatos de profesionales de enfermería sobre la experiencia y vivencia en la asistencia brindada a los pacientes hospitalizados con covid-19. materiales y método: estudio exploratorio, con análisis cualitativo, en el que participaron 12 enfermeros y ocho técnicos de enfermería de un hospital público en brasil, realizado entre diciembre de 2020 y febrero de 2021. como criterio de inclusión estaban profesionales que brindaban asistencia a pacientes con covid-19, en unidades de emergencia, de terapia intensiva y de hospitalización y al menos un año de experiencia en la institución. el análisis de las entrevistas por el análisis de contenido y por el análisis de similitud que generó un árbol de similitud y se utilizó el método reinert para las categorías temáticas. resultados: la mayoría de los participantes fue mujer, con promedio de 34,15 años y experiencia de 4,85 años. de los análisis, las palabras “paciente”, “ficar” (“quedar”) y “achar” (“crer”) fueron las más frecuentes y las categorías “sentimientos de los profesionales de enfermería ante la pandemia”; “rol del enfermero y trabajo con el equipo multiprofesional en los cuidados al paciente con covid-19”; “cuidados en la atención al paciente con covid-19” y “preocupación de los profesionales de enfermería de que sus familiares se enfermaran durante la pandemia”. conclusiones: la enfermería es predominantemente constituida por mujeres y, en sus relatos sobre la experiencia y vivencia de cuidar a paciente con covid-19, señalaron que la preocupación y el miedo fueron predominantes, siendo la familia un de los factores protectores para soportar los riesgos de trabajar en contra algo nuevo y que puede culminar con la muerte. palabras clave (fuente: decs) infección por coronavirus; covid-19; enfermería; pandemia; acontecimientos que cambian la vida; investigación cualitativa. experiencias y vivencias de profesionales de enfermería en el cuidado a pacientes con covid-19 li ve d ex pe ri en ce s of n ur si ng p ro fe ss io na ls p ro vi di ng c ar e to c o v id -1 9 pa ti en ts 5 experiências e vivências de profissionais de enfermagem no cuidado a pacientes com covid-19 resumo objetivo: analisar os relatos de profissionais de enfermagem sobre a experiência e vivência na assistência prestada aos pacientes hospitalizados com covid-19. materiais e método: estudo exploratório, com análise qualitativa, do qual participaram 12 enfermeiros e oito técnicos de enfermagem de um hospital público no brasil, realizado entre dezembro de 2020 e fevereiro de 2021. como critério de inclusão estavam profissionais que prestavam assistência a pacientes com covid-19, em unidades de emergência, de terapia intensiva e de internação e pelo menos um ano de experiência na instituição. a análise das entrevistas pela análise de conteúdo e pela análise de similitude que gerou uma árvore de similitude e foi utilizado o método reinert para as categorias temáticas. resultados: a maioria dos participantes foi mulher, com média de 34,15 anos e experiência de 4,85 anos. das análises, as palavras “paciente”, “ficar” e “achar” foram as mais frequentes e as categorias “sentimentos dos profissionais de enfermagem ante a pandemia”; “papel do enfermeiro e trabalho com a equipe multiprofissional nos cuidados ao paciente com covid-19”; “cuidados no atendimento ao paciente com covid-19” e “preocupação dos profissionais de enfermagem de seus familiares adoecerem durante a pandemia”. conclusões: a enfermagem é predominantemente constituída por mulheres e, nos seus relatos sobre a experiência e a vivência de cuidar de paciente com covid-19, apontaram que a preocupação e o medo foram predominantes, sendo a família um dos fatores protetores para suportar os riscos de trabalhar contra algo novo e que pode culminar com a morte. palavras-chave (fonte decs) infecções por coronavírus; covid-19; enfermagem; pandemias; acontecimentos que mudam a vida; pesquisa qualitativa. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 47 6 introduction the pandemic caused by the coronavirus disease (covid-19), declared by the world health organization (who) on march 11th, 2020, has been a challenge for all countries due to the severe health, economic, and social crisis (1). of epidemiological importance, by february 11th, 2022, a total of 406,809,841 cases and 5,794,030 deaths have been confirmed worldwide. in brazil, a total of 27,135,550 cases and 636,338 deaths had been confirmed (2). nursing teams have been working on the front lines as responders to the pandemic since its inception, providing care to covid-19 patients daily, being exposed to contamination by the disease, as well as to the development of psychological changes due to the pressure suffered inside and outside healthcare organizations (3). the pandemic had a profound impact on nursing professionals due to the complexity of providing care to a novel and unknown disease, raising questions concerning nursing practices, the need to search for scientific evidence, and the need to promote continuous education and research (4). a study conducted in the uk highlighted nursing professionals found new ways of working, such as starting to work remotely, but were faced with infection/control risks and the impact on users during the pandemic. in addition, the need for support became evident for nursing professionals who provided care during the pandemic as they suffered mental health impacts manifested as anxiety, stress, panic, and communication issues (5). still, it is emphasized that the risk of infection and performance limitation is higher due to work overload (6). a brazilian study conducted with nurses who provided care to covid-19 patients in intensive care units (icu) showed that these professionals had to live with “situations that interfered with their physical and mental health, involving the fear of contamination, the severity of the patients’ conditions, the experience of witnessing co-workers become ill, and distancing from family members and patients” (7: 7). with the aim of understanding the nursing staff ’s experience at a public teaching hospital, which specializes in cardiology and is a reference hospital in brazil and latin america that started providing care to covid-19 patients, this study was developed to answer the following question: how have nursing professionals experienced the care provided to hospitalized covid-19 patients in a public teaching hospital in são paulo? thus, this study aimed to analyze the reports of nursing professionals concerning their lived experiences in the care provided to hospitalized covid-19 patients. materials and methods this is an exploratory study, which used qualitative analysis, carried out in a public teaching hospital that provides high complexity care li ve d ex pe ri en ce s of n ur si ng p ro fe ss io na ls p ro vi di ng c ar e to c o v id -1 9 pa ti en ts 7 to patients in the city of são paulo, brazil. the manuscript was conducted according to the consolidated criteria for reporting qualitative research (coreq [8]). the study was carried out at the instituto do coração (incor), hospital das clínicas da faculdade de medicina da universidade de são paulo, são paulo-sp, brazil, which, along with other institutes within the hospital complex, has been providing care to patients infected by sars-cov-2. at incor, there are 535 beds distributed among 13 care units; 168 belong to the highly complex icus. during the pandemic, 100 beds, including emergency, intensive care, and inpatient unit beds, were allocated for the care of covid-19 patients. the study was conducted with nurses and nursing technicians providing care to patients hospitalized for covid-19, who were selected according to the following inclusion criteria: professionals who provided care to covid-19 patients in emergency, intensive care, and inpatient units and had at least one year of experience in the institution. professionals who were on vacation or leave due to health problems were excluded. the first contact with the nursing professionals was carried out by phone; they were invited to participate in the study. the informed consent form (icf) was sent virtually, and a meeting time was scheduled for the interview. to comply with social distancing, the interviews were conducted in a remote format through the google meet platform. the interviews were carried out from december 2020 to february 2021, had an average duration of 40 minutes, were recorded with the participant’s permission, and stored for later transcription and analysis. for data collection, an instrument composed of two parts was used. the first part was comprised of sociodemographic data such as sex, age, religion, profession, education level, and time working in the institution. the second part was composed of the following guiding questions: “tell us about your lived experience providing care to covid-19 patients”; “what has it been like for you to provide care to covid-19 patients (confirmed or suspected)?”; “describe how you feel when providing care to covid-19 patients”; “what feelings did you experience or have you experienced?; have there been changes in your work routine following the covid-19 pandemic? if so, tell me about it”; “has the covid-19 pandemic interfered with your personal and family life? if so, tell me about it”; “how do you evaluate this moment for nursing?”; what is the role of nursing during this pandemic?”; “what was the greatest experience or lesson to be learned when experiencing care during the pandemic?”, and “what was it like to provide care to a well-known colleague admitted to the icu?”. the interviews were recorded and transcribed in full by the interviewer, and the content was validated by the study coordinaa q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 47 8 tion. during the validation process, some terms used by the professionals were standardized, respecting the participants’ speech and context, aiming to simplify the comparison during the analysis. the interviews were organized in a database and analyzed using the interface de r pour les analyses multidimensionnelles de textes et de questionnaires (ir amuteq) 0.6 alpha 3 software, brazilian version (9), with the use of the lexometric content analysis technique, as it is able to verify the frequency of word usage in a given text (10). the established themes were interpreted in light of the theoretical referential on covid-19, occupational health, and the role of nurses on the front line, grounded on several authors (3-7). similarity analysis was also used, which is based on graph theory, allowing the identification of uses between words and the relationship between them, shaping the structure of the text corpus. the figure formed was the maximum tree, where the ‘nodes’ can be identified based on the words with the highest frequencies. the creation of the figure had a frequency greater than 40 (9). furthermore, the text was submitted to the reinert method, which presents a descending hierarchical classification of the uses of terms in a specific segment with the objective of identifying co-occurrences of terms in the same segments, distributing texts in classes by proximity, and hierarchizing the relative presence of each term in the word classes created. through the software, it was possible to create the dendrogram, which displays the categories formed by grouping the words similar to each other. the categories are exemplified by the participants’ statements (p), according to the order in which the interview was conducted (from 1 to 20). the study was approved by the research ethics committee of the nursing school of the universidade de são paulo (legal opinion 4,072,114) and by the ethics committee for research project analysis of the hospital das clínicas, the medical school of the universidade de são paulo (legal opinion 4,249,921), in compliance with resolution 466/2012 of the conselho nacional de saúde, brazil. the icf was signed electronically. results a total of twenty nursing professionals participated in the study, twelve of them were nurses, and eight were nursing technicians. most were female (70 %), with a mean age of 34.15 years and a mean professional time of experience in the institution of 4.85 years. among the nurses, half had a lato sensu postgraduate qualification, and all had more than four years of experience in the profession working at incor. the nursing technicians had a greater variety of experience in terms of time working in the profession and experience in the institution, ranging from 1 to 20 years. li ve d ex pe ri en ce s of n ur si ng p ro fe ss io na ls p ro vi di ng c ar e to c o v id -1 9 pa ti en ts 9 the corpus composed of the 20 interviews was broken down into 1,169 text segments, which contained 63,493 uses, 2,893 analyzable forms, and 1,069 words that had a single use in the text, corresponding to 40.4 % of the analyzable forms and 1.84 % of the uses. in the lexical analysis of the texts, a dendrogram was generated to display the classes formed by the 1,785 (88.1 %) analyzable text segments (figure 3). thus, four classes emerged, which were categorized based on the theoretical framework, named as follows: “category 1 — nursing professionals’ feelings regarding the pandemic,” “category 2 — nursing professionals’ concern that their family members may become ill during the pandemic,” “category 3 — precautions with the care provided to patients with covid-19,” and “category 4 — the nurses’ role and work with the multi-professional team in the care provided to patients with covid-19.” figure 1. dendrogram with the categories formed from the synthesis of the participants’ statements. são paulo, 2021 * source: ir amuteq software. class 3 class 2 class 4 class 1 32 % 23,80 % 21,20 % 23 % icu patient floor bed covid receive suspected unit respiratory technician hospitalize nurse there on duty to go up morning after hospital march hospitalization period almost including month suspicion to arrive to wait interesting intubated team long afternoon sector nursing role flow to take care (of ) ppes assistance beyond hospital important to provide system to offer environment to organize to show nurse medicine psychologist training to engage field employee journal visibility present professional to train team respect mastering avoid direct class home mother to live son father god family child grace contract brother husband alone family member away attempt elderly stay difficult sir sir relative sad to chat turn suddenly to visit to drink leave spouse to talk to perform visit fear situation disease to find therefore to believe to feel to live no to recover nothing world to see person to think everything very to be exposed to appear anxiety pandemic feeling strong vaccine precaution to transmit something so cause to decrease a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 47 10 the four thematic categories, along with some of the participants’, statements are presented below. category 1. nursing professionals’ feelings regarding the pandemic in this category, the feelings that emerged, such as the fear of getting sick, uncertainty, anxiety, and insecurity, during the care provided to covid-19 patients were identified in the participants’ statements, with the appreciation of their own lives, according to the statements expressed below. so, we need to prepare ourselves somehow. i think even to limit the contact with me because from now on i can be a source of contamination [...] i think it is a feeling of uncertainty, a feeling of doubt, of anxiety from that situation. (p1) you feel fear, but, at the same time, you know that you have to face it head on, you have to fight, not give up at any moment [...] but i think that, in the beginning, it was much more difficult, only now i can face it differently. (p3) i think that what i’ll take with me is learning to appreciate life itself. i think that this is a life experience because it’s not easy. i think i realized a lot of what goes through the minds of patients who are admitted to the icu. (p9) it’s the television, colleagues, public transportation… you were already experiencing this fear, and it intensified when you were there, face to face, with the virus, with the affected patients. (p12) category 2. the nurses’ role and work with the multi-professional team in the care provided to patients with covid-19 with the spread of the pandemic, nursing alongside the multi professional team stood out for its work in the frontline providing care to covid-19 patients, strengthening and acquiring new knowledge and teamwork during care, as evidenced in the following statements. nowadays, i’m more knowledgeable about it because we already know the contamination risks. we have all the equipment, so i’m safer when providing care. (p4) so, the role of nursing is or was very important, both in raising awareness and in helping in the process of providing care to these patients so that the disease would not spread, that it would not contaminate more people, and for the cure itself. (p5) the great learning is teamwork, getting everybody together to be able to offer the best because, like it or not, the multi-professional team, both the nursing technicians and the nurses, as well as the nurses, physicians, and physios [physical therapists], are part of patient care. (p20) category 3. precautions with the care provided to patients with covid-19 with the onset of the pandemic, the work routine changed, and the care of covid-19 patients led to increased demands on nursing li ve d ex pe ri en ce s of n ur si ng p ro fe ss io na ls p ro vi di ng c ar e to c o v id -1 9 pa ti en ts 11 care with longer hospital stays, where practices had to be adapted to reduce contamination. these are patients that require prolonged hospitalization, and we have had patients staying with us for almost four months, so it is a long hospital stay, and we deal with all the complications resulting from this. (p1) the first patients started to be admitted to the unit, and it was still a matter of the staff adapting to this new situation. so there was a lot of dressing up and also fear of what could happen to us, the professionals. (p19) so, i had to learn a lot of things fast and at the same time. you could see patients developing complications quickly within a few days, 4 to 5 days, who needed to be intubated, and dialysis was turned on. sometimes an iabp [intra-aortic balloon pump] was needed, along with cardiac support. (p20) in addition to the change in work routines to provide care to covid-19 patients, nursing professionals had to deal with the lack of personal protective equipment (ppe), as the following statements demonstrate. we managed everything, from difficult intubations with the entire risk of the team becoming contaminated; we were all dressed up. in the beginning, it was a little difficult to dress up [with] all the necessary material. i think that was a difficult part, the dressing up and the lack of materials. (p4) as a nurse, i see that we are stagnating, of course. i see the coren’s performance there trying their best, auditing to check if there is ppe available, which i think is the minimum that hospitals have to offer us. (p7) category 4. nursing professionals’ concern that their family members may become ill during the pandemic in this category, the statements of the nursing professionals are presented regarding their concern about contaminating their own family members with the novel coronavirus and the different measures followed to reduce this risk. shoes no longer get into the house, and basically my routine now is like this: it’s work-home, home-work without my family, my friends, or going out to parties. (p13) in the beginning, there was a lot of talking, a lot of conversation, then we sort of isolated ourselves from the fake news, isolated ourselves from what was happening in the rest of the world, too, and to what was coming. (p14) to synthesize the content, the existing relationship between the words that led to the maximum tree was analyzed. in it, it is possible seeing three nodes, namely: patient, to stay, and to find, as shown in figure 2. the most referred words compose a tree with three nuclei and strong connections between them. the word ‘patient’ is in the first nucleus, the words ‘to stay’ are in the second, and the words ‘to find’ are in the third. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 47 12 figure 2. maximum tree composed of the interviews with the nursing professionals who have provided care to patients with covid-19. são paulo, brazil, 2021 source: ir amuteq software. the nucleus composed of the word ‘paciente’ (‘patient’) is surrounded by words that highlight the icu hospitalization process for covid-19, the severity of the disease, the nursing professionals’ concern over patients —being isolated, not having contact with family members— in addition to aspects related to starting the shift/dressing up and the care itself, highlighting the relationship with the team and patients, the feelings generated, the interaction established through verbal (talking, conversation) and non-verbal communication (seeing), and having to address death. in this nucleus, there are verbs that stand out, such as ‘chegar’ (‘to arrive’), ‘falar’ (‘to talk’), ‘dar’ (‘to give’), ‘ver’ (‘to see’), ‘olhar’ (‘to look’), ‘conversar’ (‘to have a conversation’), ‘voltar’ (‘to return’), ‘prestar’ (‘to provide’), ‘lidar’ (‘to deal’), ‘receber’ (‘to receive’), ‘tentar’ (‘to try’), ‘aprender’ (‘to learn’), ‘entender’ (‘to understand’), ‘evoluir’ (‘to evolve’), and ‘conseguir’ (‘to achieve’). li ve d ex pe ri en ce s of n ur si ng p ro fe ss io na ls p ro vi di ng c ar e to c o v id -1 9 pa ti en ts 13 the second node, which has as its nucleus the word ‘ficar’ (‘to stay’), is surrounded by words that highlight the nursing professionals’ concern with the isolated sick people and with contaminating their own family members, requiring them to leave home to stay isolated during the pandemic. furthermore, nursing professionals felt fear and insecurity when providing care to patients diagnosed with covid-19. the verbs that stood out the most in the ‘ficar’ (‘to stay’) nucleus were ‘passar’ (‘to spread’) (to the household), ‘contaminar’ (‘to contaminate’) (the team/feeling fear), ‘contar’ (‘to tell’), ‘internar’ (‘to hospitalize’), ‘entrar’ (‘to enter’) (the room), ‘sair’ (‘to leave’), ‘dispensar’ (‘to discharge’), ‘precisar’ (‘to need’), ‘conhecer’ (‘to know’), and ‘colocar no lugar’ (‘to set in place’). the other node had as its main nucleus the word ‘achar’ (‘to find’) and is surrounded by words related to beliefs (‘deus’, ‘graça’) [‘god’, ‘grace’], and worries (‘pegar’, ‘evitar’, ‘continuar’, ‘falta’) [‘to catch’, ‘to avoid’, ‘to continue’, ‘to lack’], in addition to situations desired by the professionals, such as having a moment with their families. it is also related to the need for new nursing professionals to provide continued care to covid-19 patients. in this nucleus, the verbs that stood out the most were ‘pegar’ (‘to take’), ‘acreditar’ (‘to believe’), ‘querer’ (‘to want’), and ‘continuar’ (‘to continue’). discussion the study participants were nursing professionals who had been working in the institution for more than four years and already had more experience when they started to provide care to people with a novel disease, namely covid-19. despite their experience in providing care, the daily difficulties faced by the professionals started emerging as they provided care to people with an unknown disease, leading to concern, fear, and caution to avoid their own contamination and that of their family members (6). the nurses and nursing technicians who were on the frontline of providing care to covid-19 patients lived through new experiences and feelings marked by fear and uncertainty, in addition to new challenges, meanings, and significance of being a nursing professional during a pandemic. in this scenario, the illness and death of nursing professionals due to covid-19 stand out, in addition to professional resignation. according to the observatório de enfermagem do conselho federal de enfermagem (nursing observatory of the federal council of nursing), since the onset of the pandemic, there have been 61,787 reported cases, 872 deaths, and a lethality rate of 2.46 %, reported up to february 11, 2022 (11), although, as of april 2021, a drop in deaths has been observed (12). the international council of nurses (icn) has recorded over 3,000 deaths of nurses worldwide, and in research conducted after one year of the pandemic, a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 47 14 increased numbers of nurses quitting the profession were reported due to heavy workloads, insufficient resources, burnout, and stress as factors that are driving this exodus. the who has confirmed the mass trauma experienced by healthcare professionals, highlighted by the icn in january 2021 (13). furthermore, in the face of instability in clinical cases and constant changes in the profile of patients admitted to hospital institutions, nursing professionals have emphasized the importance of social isolation and the adoption of non-pharmacological protective measures against covid-19. an analysis of news stories in three brazilian newspapers highlighted the importance of upholding protective measures against covid-19 (14). in addition, law 13,979/2020 highlights the importance of complying with social isolation or social distancing measures, compulsory testing, wearing masks, ventilating environments, washing hands, and using 70 % alcohol gel to fight coronavirus variants (15). in the statements, the concerns and fear of personal and family contamination become evident, as well as the increase in demands related to hospitalized patients and the availability of human resources necessary for nursing care. moreover, the professionals reported concern and fear for having experienced the illness of their colleagues since many of them got sick and had to receive care from professional colleagues. these aspects led to a variety of challenges related to mental health, especially burnout and fear, which deserve attention and support from hospital managers (16). in a study conducted with 120 nursing technicians in the first year of the pandemic, a prevalence of burnout syndrome was identified in 25.5 % of the professionals (17). another study conducted with nurses from 26 hospitals in madrid found that professionals faced communication difficulties with managers (21.2 %), emotional exhaustion (53.5 %), and difficulty in expressing their emotions (44.9 % [18]). at the personal and family levels, there are concerns regarding contamination, getting sick, and contaminating family members. this leads to the adoption of measures of social distancing, especially from home, and to increase biosafety, such as wearing protective clothing when starting the shift and the use of masks. regarding patients, the professionals expressed concern considering patients are isolated from their families, often in a serious condition, without contact with people who are close to them, which emphasizes the need for individualized care and a friendly conversation to externalize concerns and fears (18). a study conducted with 437 healthcare professionals, with the objective of identifying the prevalence of suspected and confirmed cases of covid-19, showed that 36 % of the participants reported presenting comorbidities, 21.1 % had symptoms that suggested covid-19, and 27 % had some type of test for the diagnosis of covid-19 (16). the transmissibility potential of the disease is high, especially in healthcare settings, posing a real threat to nursing professionals, making li ve d ex pe ri en ce s of n ur si ng p ro fe ss io na ls p ro vi di ng c ar e to c o v id -1 9 pa ti en ts 15 them more susceptible to infection (19). these findings corroborate the present study’s data since, in the tree and the categories, the professionals’ concerns and worries regarding caring for themselves and their own family members emerged. it is worth noting that, in the reports, the nursing care provided to people with covid-19 demands increased workloads, especially when they are in a severe condition. these aspects are in line with the existing connections between the words ‘paciente’ (‘patient’), ‘covid’, ‘grave’ (‘severe’), and ‘cuidado’ (‘care’). this indicates that contaminated patients require specialized care based on protocols that ensure the safety of professionals, but that, even following the routine, feelings such as fear, insecurity, and exposure of their families to contamination emerge, which have led several professionals to distance themselves from their homes. a study conducted in three belgian hospitals aimed to evaluate the nurse-patient relationship required by covid-19 patients and to identify the factors that influence nursing in this context (20). the study concluded that patients admitted to icus for covid-19 require longer nursing care than other medical conditions, requiring an average ratio of one nurse for each patient. in this sense, the pandemic increased the demand for professionals’ work to meet complex needs, generating work overload, exhaustion, and a high contamination risk for nursing professionals (21). in addition to the severity of the disease and the high technological apparatus required, especially in icus, which demand high workloads (22), the work in the pandemic setting has led professionals to experience physical exhaustion due to the long working hours and emotional fragility for experiencing severe cases that culminated on unexpected death, fear of their own contamination, and the risk of contaminating their family members with the virus (23). the pandemic led nursing teams to face new challenges (24), such as fear, concern, and the need for new knowledge regarding an unknown and threatening disease, which led nursing professionals to become ill in addition to affecting the provision of continuous and comprehensive care to hospitalized patients and the risk of suffering psychological alterations, such as anxiety, depression, insomnia, and stress (25). a study carried out with 643 frontline nurses in hospitals in wuhan, china, identified that one-third (33.4 %) of the participants reported that anxiety was associated with perceived stress, insomnia, frequency of night shifts per week, and level of fear of covid-19 (26). the pandemic also exposed the need for nursing teams to work based on technical and scientific competences, knowledge, skills, and emotional control over the practice, considering that providing care exposed the team to situations of risk, physical exhaustion, and negative emotional issues, responsibilities towards other people’s lives, in addition to facing fears and suffering (27). a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 47 16 when observing the maximum tree, another fact stands out in the study, the word ‘achar’ (‘to find’) has a connection with the word ‘paciente’ (‘patient’) and, around it, there are words such as ‘mundo’ (‘world’), ‘deus’ (‘god’), ‘familiar’ (‘family’), and ‘difícil’ (‘difficult’). these are words that highlight the situation lived by the professionals where they experienced difficult moments, which leads to the emergence of the spirituality dimension, with words related to beliefs, such as ‘deus’ (‘god’), and ‘graça’ (‘grace’). one of the potentials mentioned by healthcare professionals to provide continued patient care is to believe in a greater external power that, for some, may be god and, for others, means having a deep spirituality. nursing professionals are constantly with their patients, including in the active dying process, and, in this pandemic, have experienced this process more intensely, losing patients who could not have family or friends present due to visiting restrictions. the special need for spiritual self-care was identified (28). spirituality can encompass values, beliefs, and religions, in addition to providing meaning to life, connection with others, and life purpose, being a transcendental or metaphysical phenomenon that correlates with the purpose and meaning of life (29). in nursing care, the dimension of spiritual health and self-care is supported by studies that emphasize the importance of the therapeutic dimensions of spirituality (30). a study carried out with 200 healthcare professionals in malaysia identified that positive religious coping is vital in reducing anxiety and depression among healthcare professionals in the midst of a pandemic (31). furthermore, the multi-professional healthcare team has faced obstacles during the pandemic that negatively interfered with the work process, such as the absence of meetings and feedback, overlapping tasks, and work overload. however, it was strengthened by the knowledge exchange between different healthcare professionals in order to provide quality care (32). as a study limitation, it is emphasized that this research was carried out in a single institution, which may have generated a bias in the answers due to all participants being in the same environment. however, it is considered that the findings express the experience of nurses and nursing technicians in patient care during a pandemic, which can contribute to new investments in the training of professionals and nursing education to face future situations. the present study contributed to the understanding of the lived experiences of nursing professionals providing care to covid-19 patients, the challenges faced by them, and the concerns and fears that emerged, in addition to highlighting the importance and centrality of this professional category during the pandemic. in the nursing care provided, the work overload, the patient-centered care, the concern with the distance from the family, the fear of inli ve d ex pe ri en ce s of n ur si ng p ro fe ss io na ls p ro vi di ng c ar e to c o v id -1 9 pa ti en ts 17 fection, and the emotional overload were evident. moreover, the study raises aspects regarding nursing care to hospitalized covid-19 patients, allows these professionals to speak out, and opens perspectives for research and interventions on aspects that can affect the quality of care and the physical and mental health of the professionals. conclusions the lived experiences have different meanings for the professionals; while, for some, the covid-19 pandemic brought fear, uncertainties, and concerns, for others, the distance from loved ones and being away from their families can led to fragilities in patient care. these behaviors can be products of the historical, social, and cultural processes that the pandemic carries in its genesis and can be internalized by society and professionals in a misguided way since there were several divergences in addressing and dealing with the virus. in this study, it was found that the knowledge, behaviors, experiences, and feelings surrounding the care provided to hospitalized patients with covid-19 in a teaching hospital led to the emergence of four categories, namely: “nursing professionals’ feelings regarding the pandemic,” “the nurses’ role and work with the multi-professional team in the care provided to patients with covid-19,” “precautions with the care provided to patients with covid-19,” and “nursing professionals’ concern that their family members may become ill during the pandemic.” therefore, it is necessary to implement measures in all sectors of society, demystifying the experience that providing care to people with covid-19 generates fear of 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https://doi.org/10.1007/978-3-030-04420-6_1 https://doi.org/10.3390/healthcare9010079 https://doi.org/10.34117/bjdv7n4-044 121 125 primeras paginas.indd 124 aquichan issn 1657-5997 año 11 vol. 11 nº 2 chía, colombia agosto 2011 l 124-125 editorial es un hecho que, en el quehacer académico y científico, el tema de las redes de revistas se ha convertido en un asunto de primer orden por su contribución al desarrollo y la difusión de nuevos conocimientos, a la consolidación de investigadores, y al fortalecimiento de la tarea editorial científica. desde esta perspectiva, en los últimos meses la universidad de la sabana ha sido el escenario de observación sobre la función sustantiva de las revistas científicas. en dos eventos en los que participaron los doctores atilio bustos gonzález, investigador en scimago research group y director del sistema de bibliotecas de la universidad católica de valparaíso, chile, y susan gennaro, editora del journal of nursingscholarship, de la sociedad de honor sigma theta tau internacional y decana de la william f. connell school of nursing en boston college, editores, enfermeras e investigadores reflexionaron sobre el compromiso ético-científico que implica editar una revista, aspecto al cual nos hemos referido en los últimos editoriales de aquichan. en el análisis del tema, el capítulo de las redes de revistas de enfermería nacionales e internaciones salió a la palestra como estrategia clave que nos permita no solo incrementar la producción, sino elevar la calidad y el impacto de nuestras publicaciones. de esta manera, no solo contribuimos con la excelencia de maestrías y doctorados, sino que concretamos el desarrollo de la disciplina y nos volvemos consulta obligada por parte de los diseñadores de políticas públicas. así hablaremos de un real impacto en la sociedad. aunque nos falta mucho por hacer, la enfermería colombiana ha demostrado un fortalecimiento de los programas de posgrado que se refleja en el número de revistas científicas de alta calidad y, desde luego, en el contenido de las mismas. por ejemplo, hoy se encuentran clasificadas en el índice nacional publindex cinco de las nueve revistas de enfermería, y algunas facultades están iniciando el proceso de edición de otras nuevas publicaciones, siguiendo los parámetros establecidos por los sistemas de indexación y resumen internacionales. en este sentido, aquichan viene siguiendo las pautas internacionales, lo cual se evidencia en una mayor participación de investigadores reconocidos en colombia, en latinoamérica, estados unidos y españa. las redes de revistas científicas de enfermería: un medio para potenciar el conocimiento de la disciplina 125 editorial la meta es continuar mejorando la calidad de la revista con dos propósitos: uno, impulsar el desarrollo del conocimiento de enfermería incrementando la exigencia en la calidad de la producción científica que responda a la necesidades de los lectores y a las del cuidado de enfermería de las personas, familias y comunidades; y dos, responder a la necesidad de los científicos de enfermería de contar con una revista de alta calidad que les permita divulgar en el ámbito nacional e internacional los resultados de la investigación y de su aplicación en la práctica. el interés por alcanzar estos propósitos es compartido por los editores de las revistas colombianas y extranjeras, por ello en las conclusiones de la actividad académica en la que participó la doctora gennaro se reiteró en la consolidación de una red de editores de revistas de enfermería, que ya había sido propuesta en el 2008, cuando la universidad de la sabana organizó el primer encuentro de editores de enfermería en el que participó la doctora lynda harrison, profesora de la universidad de alabama y directora del centro colaborativo en enfermería internacional, de la organización panamericana de la salud (ops). a través de la red se pueden generar espacios de discusión y apoyo donde los editores tienen la oportunidad de compartir inquietudes y experiencias, analizar temas de actualidad, estrategias para mejorar los índices de citación y contar con bases de información de evaluadores. la fortaleza y grandeza de nuestra disciplina dependen en buena medida de la calidad de nuestras publicaciones científicas. por ello, invitamos a todas las personas interesadas en consolidar esta red de editores de revistas a comunicarse con nosotros. maría elisa moreno-fergusson editora mariae.moreno@unisabana.edu.co networks of scientific nursing journals: a way to empower knowledge of the discipline redes de revistas científicas de enfermagem: uma via para potencializar o conhecimento desta disciplina 1 flávia helena pereira1 danilo donizetti trevisan2 daniela santos lourenço3 juliana bastoni da silva4 maria helena de melo lima5 efeito de estratégias educativas na qualidade do sono de pessoas com diabetes: ensaio clínico randomizado 1 orcid.org/0000-0001-9331-7020. instituto federal de educação, ciência e tecnologia do sul de minas gerais, brasil. flavia.pereira@ifsuldeminas.edu.br 2 orcid.org/0000-0002-6998-9166. universidade federal de são joão del-rei, brasil. ddtrevisan@ufsj.edu.br 3 orcid.org/0000-0002-4176-300x. universidade federal de alfenas, brasil. daniela.maximo@unifal.edu.br 4 orcid.org/-0000-0002-6642-8910. universidade federal do tocantins, brasil. juliana.bastoni@uft.edu.br 5 orcid.org/0000-0001-6521-8324. universidade estadual de campinas, brasil. melolima@unicamp.br recebido: 10/01/2019 submetido: 06/03/2019 aceito por pares: 24/05/2019 aceito: 12/06/2019 doi: 10.5294/aqui.2019.19.3.2 para citar este artigo / para citar este artículo / to reference this article pereira fh, trevisan dd, santos d, da silva jb, lima mhdm . effect of educational strategies on the sleep quality of people with diabetes: randomized clinical trial. aquichan 2019; 19(3): e1932. doi: https://doi.org/10.5294/aqui.2019.19.3.2 resumo objetivo: avaliar o efeito de estratégias educativas sobre a qualidade do sono e sua relação com o estresse emocional associado com o diabetes em pessoas com dm2. materiais e método: ensaio clínico randomizado com dois grupos. o grupo 1 (g1, n = 45) recebeu orientações verbais e folhetos sobre estratégias de higiene do sono; o grupo 2 (g2, n = 46), orientações usuais das unidades de saúde sobre autocuidado com os pés. o sono foi avaliado pelo pittsburgh sleep quality inventory (psqi-br), e o estresse emocional, pelo diabetes distress scale (b-dds). utilizaram-se modelos lineares de efeitos mistos e modelo de regressão linear para as análises estatísticas. resultados: no final do seguimento, verificou-se melhora da qualidade do sono (p = 0,02) no g1. baixo escore de estresse emocional (p = 0,03), ser do sexo masculino (p = 0,02), pertencer ao g1 (p = 0,002) e idade (p = 0,04) contribuíram para melhor qualidade do sono. conclusão: orientações educativas sobre a higiene do sono em pacientes com dm2 foram efetivas na melhora da pontuação da qualidade do sono, mensurada pelo instrumento psqi-br, e do estresse emocional relacionado ao diabetes, avaliado pelo instrumento do b-dds. palavras-chave (fonte: decs) sono; higiene do sono; diabetes mellitus tipo 2; estresse psicológico; enfermagem. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1932 temática: cuidado crônico. contribuição para a disciplina: os achados deste estudo reforçam a importância de os profissionais de saúde conhecerem integralmente o paciente com diabetes mellitus tipo 2 (dm2), fazendo com que a abordagem e a avaliação do padrão do sono sejam parte da prática clínica, para que intervenções de higiene do sono sejam propostas de acordo com cada necessidade. além disso, ações de higiene do sono podem melhorar o estresse relacionado à doença e à qualidade de vida, o que reflete em atitudes positivas para o controle da doença. http://orcid.org/0000-0001-9331-7020 mailto:flavia.pereira@ifsuldeminas.edu.br http://orcid.org/0000-0002-6998-9166 mailto:ddtrevisan@ufsj.edu.br http://orcid.org/0000-0002-4176-300x mailto:daniela.maximo@unifal.edu.br mailto:juliana.bastoni@uft.edu.br http://orcid.org/0000-0001-6521-8324 mailto:melolima@unicamp.br https://doi.org/10.5294/aqui.2019.19.3.2 https://doi.org/10.5294/aqui.2019.19.3.2 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1932 efecto de estrategias educativas en la calidad del sueño en personas con diabetes: ensayo clínico aleatorizado resumen objetivo: evaluar el efecto de estrategias educativas en la calidad del sueño y su relación con el estrés emocional asociado con diabetes en personas con dm2. materiales y método: ensayo clínico aleatorizado con dos grupos. el grupo 1 (g1, n = 45) tuvo orientaciones verbales y folletos acerca de estrategias de higiene del sueño; el grupo 2 (g2, n = 46), orientaciones usuales de las unidades de salud sobre autocuidado con los pies. el sueño se evaluó por el pittsburgh sleep quality inventory (psqi-br), y el estrés emocional, por el diabetes distress scale (b-dds). se emplearon modelos lineales de efectos mixtos y modelo de regresión lineal para análisis estadísticas. resultados: al término del seguimiento, se encontró mejoría de la calidad del sueño (p = 0,02) en el g1. bajo índice de estrés emocional (p = 0,03), ser del sexo masculino (p = 0,02), pertenecer al g1 (p = 0,002) y edad (p = 0,04) contribuyeron a mejor calidad del sueño. conclusión: orientaciones educativas acerca de la higiene del sueño en pacientes con dm2 fueron efectivas en la mejoría de la puntuación de la calidad del sueño, mensurada por el instrumento psqi-br, y del estrés emocional relacionado con diabetes, evaluado por el instrumento del b-dds. palabras clave (fuente: decs) sueño; higiene del sueño; diabetes mellitus tipo 2; estrés psicológico; enfermería. 3 efeito de estratégias educativas na qualidade do sono de pessoas com diabetes: ensaio clínico randomizado l flávia helena pereira e outros effect of educational strategies on the sleep quality of people with diabetes: randomized clinical trial abstract objective: to evaluate the effect of educational strategies on sleep quality and its relation to diabetes-related distress and glycemic control in people with type 2 diabetes mellitus (dm2). materials and methods: randomized clinical trial involving two groups. group 1 (g1, n = 45) received verbal guidance and leaflets on sleep hygiene strategies and group 2 (g2, n = 46) received usual health care guidelines on self-care with the feet. sleep was assessed by the pittsburgh sleep quality inventory and diabetes-related distress by the diabetes distress scale. linear mixed-effects models and linear regression model were used for the statistical analysis. results: at the end of the follow-up, sleep quality improvement (p = 0.02) was verified in g1. low diabetes-related distress score (p = 0.03), being male (p = 0.02), belonging to g1 (p = 0.002), and age (p = 0.04) contributed to better sleep quality. conclusion: educational guidelines on sleep hygiene in patients with dm2 were effective in improving sleep quality, measured by the psqi instrument and emotional stress related to diabetes as assessed by the diabetes distress scale. keywords (source: decs) sleep; sleep hygiene; diabetes mellitus, type 2; stress, psychological; nursing. año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1932 4 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1932 aquichan issn 1657-5997 eissn 2027-5374 introdução a federação internacional de diabetes (idf) estimou, em 2017, que aproximadamente 425 milhões de pessoas viviam com diabetes mellitus (dm) no mundo. em 2045, esse número poderá ultrapassar 629 milhões de pessoas (1). naquele mesmo ano, aproximadamente 12,4 milhões de brasileiros adultos entre 20 e 79 anos conviviam com dm, o que levou o país a ser considerado o primeiro nas américas do sul e central, e o quarto em âmbito mundial com maior número de adultos com dm, considerando a população total (1). o diabetes mellitus tipo 2 (dm2) é o tipo mais prevalente dessa condição crônica. na literatura, a relação entre o dm2 e os distúrbios do sono é bem estabelecida (2-4). pessoas com essa condição crônica comumente apresentam alterações no padrão do sono, como dificuldade em iniciar e manter o sono, sonolência diurna e baixa qualidade do sono (5-8). estudo mostrou que 55 % das pessoas com dm2 apresentavam baixa qualidade do sono, de acordo com o pittsburgh sleep quality inventory (índice de qualidade do sono de pittsburgh — psqi) (9). a baixa qualidade do sono pode afetar o bem-estar físico e emocional, e contribuir negativamente no tratamento do dm2 (9). além disso, devido à condição complexa que o dm2 pode demandar, muitos pacientes podem enfrentar dificuldades na modificação do estilo de vida, o que envolve mudanças dos hábitos alimentares, realização de atividade física e adesão ao tratamento medicamentoso; desse modo, podem sofrer impactos psicológicos importantes, como o aumento dos níveis de estresse emocional relacionado ao diabetes. níveis elevados de estresse emocional relacionado ao diabetes são significativamente relacionados à má qualidade do sono e a maiores níveis de hemoglobina glicada (a1c) em diferentes cenários e tipos de estudo (9-11). algumas medidas não farmacológicas como intervenções que envolvem a terapia cognitivo-comportamental, a exposição à luz, a realização de atividade física, a higiene do sono e terapias de relaxamento são direcionadas para a melhora da qualidade do sono e podem contribuir para diminuir o estresse relacionado ao diabetes (12-16); em consequência, pode-se observar aumento do autocuidado para o manejo do dm. entretanto, a relação entre a qualidade do sono e o estresse relacionado ao diabetes ainda permanece estreita, sugerindo a necessidade de novos estudos para melhor elucidá-la. nesse sentido, o objetivo deste estudo foi avaliar o efeito de estratégias educativas baseadas na higiene do sono sobre a qualidade do sono e sua relação com o estresse emocional relacionado ao diabetes em pessoas com dm2. método desenho do estudo trata-se de um ensaio clínico randomizado, paralelo e composto por dois braços — grupo 1 (g1) e grupo 2 (g2). o estudo ocorreu em quatro unidades de estratégias de saúde da família (esfs) de um município do sul de minas gerais, brasil. o estudo foi conduzido entre setembro de 2015 e agosto de 2016, aprovado pelo comitê de ética em pesquisa local, com parecer favorável (1.183.930/2016), e registrado no registro brasileiro de ensaios clínicos (rebec, rbr-468wm2). o consolidated statement of reporting trials (consort) (17) foi seguido para a aleatorização, o cegamento, o seguimento e a análise dos dados. participantes participaram deste estudo pessoas com dm2, adultas e que realizam o tratamento dessa condição crônica nas unidades de esfs onde se realizou este estudo. foram incluídos os usuários que estavam em tratamento do dm2 há pelo menos seis meses, que possuíam baixa qualidade do sono (pontuação > 5 pontos), mensurada por meio do psqi (18) , que não faziam qualquer tratamento farmacológico ou não farmacológico que interferisse no sono e que tinham acesso telefônico (móvel ou fixo). foram excluídos os participantes que apresentaram comportamento cognitivo insuficiente, de acordo com as faixas de escolaridade, por meio do instrumento miniexame do estado mental (meem) (19), e os que eram trabalhadores noturnos. os critérios de descontinuidade foram: não comparecimento ou desistência em qualquer um dos encontros agendados e início de tratamento farmacológico/não farmacológico que interferisse no sono. tamanho da amostra o tamanho amostral foi estimado considerando a metodologia para o cálculo de amostra de acordo com o teste t de student não pareado a partir dos resultados observados em estudo prévio (20). assumiu-se um poder de 80 % e um nível de significância de 1,25 % nos cálculos amostrais. esse nível de significância foi determinado por meio da correção de bonferroni. após considerar 5 efeito de estratégias educativas na qualidade do sono de pessoas com diabetes: ensaio clínico randomizado l flávia helena pereira e outros uma taxa de perda de 20 %, a amostra foi composta, no mínimo, por 47 participantes em cada grupo. programa de intervenção o programa de intervenção foi composto por dois grupos, g1 e g2, monitorados ao longo de 90 dias por meio de quatro encontros presenciais: baseline (t0), 30 dias após t0 (t1), 60 dias após t0 (t2) e 90 dias após t0 (t3). houve também reforços telefônicos semanais até 60 dias de seguimento, totalizando quatro encontros presenciais e seis contatos telefônicos por grupo. em t 0 (baseline), realizou-se o primeiro encontro presencial com os participantes de ambos os grupos (g1 e g2) para explicar os objetivos do estudo e obter a concordância para participar da pesquisa. após aceitarem a participar do estudo, os participantes foram conduzidos para uma sala privativa da esf. em seguida, foram aplicados os instrumentos para a caracterização sociodemográfica e clínica, para a avaliação do estado cognitivo, para a mensuração da qualidade do sono e para o estresse emocional relacionado ao diabetes. os participantes que obtiveram escorem total do psqi > 5 pontos e estado cognitivo suficiente de acordo com o nível de escolaridade foram aleatorizados em ambos os grupos (g1 ou g2) e lhes foi entregue o pedido para a coleta de sangue para mensurar os níveis de a1c. os participantes do g1, em t0, receberam orientações educativas sobre higiene do sono baseadas nas diretrizes internacionais e nacionais de dm e sono (21, 22) vigentes na época do estudo. a higiene é considerada uma intervenção psicoeducacional, que consiste em ensinar a pessoa a evitar fatores externos ou ambientais que gerem efeitos adversos e nocivos ao sono (22). as sessões de orientação duraram de 30 a 40 minutos e foram conduzidas pessoalmente pelo pesquisador principal por meio de orientações verbais e de folhetos. as orientações realizadas envolveram aspectos para promover a melhora da qualidade do sono, tais como: manter o ambiente silencioso, escuro e com temperatura agradável para dormir; ir para a cama somente quando estiver sonolento; não ler, escrever, comer, assistir à televisão, falar ao telefone ou jogar cartas na cama; levantar-se caso tenha deitado e não tenha conseguido dormir em 20 minutos; utilizar técnicas de relaxamento como de respiração, concentração e alongamento antes de dormir; manter regularidade de horário de dormir; não se alimentar em grande quantidade antes de dormir, preferindo pequenas porções ou um lanche; não tomar café, chá preto ou mate, refrigerantes, chocolate ou bebida alcoólica de quatro a seis horas antes de ir dormir; não fumar pelo menos de quatro a seis horas antes de deitar; evitar longos repousos após o almoço (mais que uma hora) ou diminuir cochilos diurnos; evitar atividade física quatro horas ou menos antes de dormir; expor-se à luz solar diariamente por 40 minutos na primeira metade da manhã ou no final da tarde. esse período foi escolhido como medida para proteger dos possíveis danos solares na pele dos participantes. em t 1 e t 2 , os encontros foram destinados para reforçar as orientações educativas e esclarecer dúvidas dos participantes. isso aconteceu semanalmente por contato telefônico entre t0 e t1 e t1 e t2. para o g2, em t0, os participantes receberam orientações sobre os cuidados com os pés, focadas na higiene, na hidratação, no uso adequado de sapatos e meias apropriadas, e no corte de unhas (21). essa orientação foi proposta por se tratar de uma estratégia já implantada nas unidades onde ocorreu a coleta de dados e por não estar associada com a qualidade do sono. esse grupo também recebeu os reforços presenciais e contatos telefônicos nos mesmos moldes do g1, entretanto foram reforçadas as orientações de autocuidado com os pés. por fim, em t3, realizou-se novamente a mensuração das variáveis do estudo dos participantes de ambos os grupos (g1 e g2). nessa fase, um colaborador da pesquisa previamente capacitado realizou a coleta de dados. os participantes dos grupos g1 e g2 foram compostos por indivíduos das quatro unidades de esf. para evitar o contato entre os participantes de ambos os grupos, foram realizados os agendamentos dos encontros presenciais em horários intervalados, de forma que os participantes não se encontrassem na unidade de saúde. durante a coleta de dados, os participantes foram também orientados a não revelar o grupo ao qual pertenciam. coleta de dados as variáveis sociodemográficas e clínicas foram obtidas por meio de instrumento semiestruturado e subdividido em informações sociodemográficas: idade em anos completos, sexo, estado civil, escolaridade, ocupação, renda familiar mensal e com quem residia atualmente; clínicas: tempo de tratamento do dm2 em meses, comorbidades, medicamentos utilizados, realização de atividade física, uso de tabaco e consumo de bebidas alcoólicas 6 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1932 aquichan issn 1657-5997 eissn 2027-5374 também foram variáveis abordadas. realizaram-se também as mensurações antropométricas de peso, altura, índice de massa corporal (imc) e circunferência abdominal. para avaliar o funcionamento cognitivo geral, utilizou-se o meem (19, 23). o instrumento possui 11 itens com escore máximo de 30 pontos ajustados de acordo com o nível de escolaridade do indivíduo: analfabetos: meem > 20 pontos; escolaridade de 1-4 anos: meem > 25 pontos; escolaridade de 5-8 anos: meem > 26,5; escolaridade 9-11 anos: meem > 28; escolaridade superior a 11 anos: meem > 29 (24). a qualidade do sono foi mensurada por meio da versão brasileira do psqi (18). a consistência interna da versão brasileira (psqi-br), mensurada pelo coeficiente alfa de cronbach, foi de 0,73, o que indicou alto grau de consistência interna. esse instrumento avalia a qualidade do sono em relação ao último mês e tem como objetivo fornecer uma medida de qualidade de sono padronizada entre “bons dormidores” e “maus dormidores”. é composto por quatro questões abertas e seis questões semiabertas divididas em sete domínios: qualidade subjetiva, latência, duração, eficiência habitual e distúrbios do sono, uso de medicações para dormir e distúrbios durante o dia; a pontuação máxima é 21 pontos. escores superiores a cinco pontos indicam qualidade ruim no padrão do sono (18). o estresse emocional relacionado ao diabetes foi mensurado por meio da versão brasileira do diabetes distress scale (b-dds) (24). o instrumento é composto por 17 itens divididos em quatro domínios: carga emocional (5 itens); insegurança relacionada ao profissional de saúde (4 itens); estresse relacionado ao regime terapêutico (5 itens) e estresse nas relações interpessoais (3 itens). a escala utilizada é do tipo likert, que varia entre 1 (não é um problema) e 6 (é um problema muito importante) pontos. a soma das respostas dos quatro domínios divididos pelo número de itens gera um escore total que varia entre 1 e 6. valores menores que 2,0 indicam pouco ou nenhum estresse relacionado ao diabetes; valores entre 2,0 e 2,9 indicam estresse moderado relacionado ao diabetes, e maiores ou iguais a 3,0 indicam alto estresse relacionado ao diabetes (25). todos os dados, exceto os de caracterização dos participantes, foram coletados em t0 e t3; a mensuração da a1c foi realizada em até cinco dias após t0. o método utilizado para mensurar a a1c seguiu as recomendações do national glycohemoglobin standardizartion program (ngsp) e foi padronizado pelo ensaio de referência do diabetes control and complications trial (dcct) (26). a coleta de sangue pré-intervenção ocorreu no laboratório do município onde o estudo foi realizado, pela técnica de cromatografia líquida de alto performance. recrutamento, aleatorização, alocação e cegamento por meio de uma lista de pessoas cadastradas nas unidades de saúde, foram acessados os prontuários de cada um dos participantes elegíveis. em seguida, as pessoas foram convidadas individualmente, por via telefônica, para participarem do estudo. no dia programado, o entrevistador reforçou o convite e explicou os passos da pesquisa. um membro da equipe de pesquisa que não teve contato com os participantes preparou uma lista de sequência aleatória gerada pelo website www.randomization.com, que considerou o método por blocos de tamanho aleatório com 100 participantes. a lista aleatorizada foi numerada em sequência e selada individualmente em envelopes opacos, a fim de ocultá-los dos pesquisadores. preparou-se um número excedente ao cálculo da amostra devido a possíveis perdas durante a coleta de dados. no final do primeiro encontro (baseline), após a aplicação dos instrumentos de medidas, o pesquisador principal abriu, na sequência, cada envelope e alocou o participante em um dos grupos (g1 ou g2). no final do seguimento, um pesquisador colaborador que não estava em contato com os participantes do estudo realizou a coleta dos dados, a fim de evitar viés de coleta. análise dos dados foi utilizada estatística descritiva para caracterizar a amostra no baseline, teste t de student, teste não paramétrico de mann-whitney, teste de qui-quadrado. o teste de kolmogorov-smirnov foi utilizado para avaliar a normalidade das variáveis. para as comparações entre os grupos com relação às variáveis qualidade do sono e estresse emocional, mensuradas ao longo do tempo, foram propostos modelos lineares de efeitos mistos. para os casos em que os pressupostos do modelo não foram atendidos, aplicou-se a transformação box-cox na variável dependente. um modelo de regressão linear múltipla foi construído com o objetivo de avaliar a relação entre um conjunto de variáveis independentes (imc, estresse emocional, idade, tempo de tratamento, sexo, estado civil, pessoas com quem reside, renda familiar, atividade física e grupo) e a qualidade do sono. esse modelo foi ajustado pela medida da qualidade do sono na linha de base. foi informado 7 efeito de estratégias educativas na qualidade do sono de pessoas com diabetes: ensaio clínico randomizado l flávia helena pereira e outros o valor do coeficiente de explicação r2 para o modelo ajustado (27), que sugere a seguinte classificação do coeficiente de explicação r2 de 0,01 até 0,08 (fraco); 0,09 a 0,24 (moderado) e maior ou igual a 0,25 (forte). as análises foram realizadas por meio do software sas versão 9.4 e foi considerado um nível de significância de 5 %. resultados um total de 189 indivíduos apresentavam critérios de elegibilidade. destes, 87 não atenderam aos critérios de inclusão, e dois recusaram-se a participar do estudo. houve perdas ao longo do seguimento em ambos os grupos. cinco participantes foram descontinuados no g1 e quatro no g2 por iniciarem tratamento farmacológico que interferia no sono (figura 1). nenhum dos participantes relatou complicações ou quaisquer danos atribuídos à intervenção durante o programa do estudo. na tabela 1, são apresentadas as características sociodemográficas e clínicas dos participantes no baseline. a amostra teve predomínio de mulheres (57,14 %), com média de idade de 54,87 ± 6,96 anos. a maioria dos participantes (71,43 %) possuía de 1 a 8 anos de escolaridade. a média de a1c foi de 8,18 ± 2,07. com exceção do gênero e do autorrelato de atividade física, não houve diferenças significantes entre os grupos. figura 1. diagrama do fluxo dos partici pantes do estudo conforme consort (paraguaçu, minas gerais, brasil, 2016) fonte: elaboração própria. inclusão avaliados para elegibilidade (n = 189) excluídos (n = 89) não atenderam aos critérios de inclusão (n = 87) recusaram a participar (n = 2) randomizados (n = 100) alocados no grupo 1 (n = 50) receberam intervenções de medidas de higiene do sono e exposição à luz (n = 50) alocação alocados no grupo 2 (n = 50) receberam orientações sobre cuidados com os pés (n = 50) seguimento perda de seguimento (n = 5) intervenção descontinuada: iniciaram o uso de medicamentos para dormir ou que interferiam no sono perda de seguimento (n = 4) intervenção descontinuada: iniciaram o uso de medicamentos para dormir ou que interferiam no sono análise analisados (n = 45) analisados (n = 46) 8 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1932 aquichan issn 1657-5997 eissn 2027-5374 tabela 1. comparação dos dados sociodemográficos e clínicos entre as pessoas com dm2 do g1 e do g2 na linha de base (paraguaçu, minas gerais, brasil, 2016) características dos participantes total (n = 91) g1 (n = 45) g2 (n = 46) p-valor* idade (anos), média (dp †) 54,87 (6,96) 55,78 (7,40) 53,98 (6,45) 0,11 ‡ gênero (% feminino) 57,14 68,89 45,65 0,02§ estado civil (% casados) 58,24 53,33 63,04 0,34§ ocupação (%) não trabalham 62,64 71,11 54,35 trabalham 37,36 28,89 45,65 0,09§ renda mensal (%) <r$1.000,00 36,26 40,00 32,61 <r$1.000,00 63,74 60,00 67,39 0,46|| anos de escolaridade (%) nenhum 15,38 15,56 15,22 1-8 anos 71,43 73,33 69,56 9 ou mais 13,19 11,11 15,22 0,84|| atividade física autorrelatada (%) não 75,82 66,67 84,78 sim 24,18 33,33 15,22 0,04|| imc (kg/m2), média (dp†) 31,24 (5,69) 31,29 (6,07) 31,20 (5,35) 0,92|| tempo de tratamento do dm2 (anos), média (dp†) 7,32 (5,98) 6,59 (5,62) 8,03(6,30) 0,28|| condições clínicas associadas (n), (%) hipertensão arterial sistêmica 62,00 (68,13) 32,00 (71,11) 30,00 (65,22) 0,54§ dislipidemia 31,00 (34,07) 17,00 (37,78) 14,00 (30,43) 0,45§ a1c¶ %, média (dp†) 8,18 (2,07) 8,12 (1,92) 8,23 (2,22) 0,96|| * p-valor, † desvio-padrão, ‡ p-valor obtido por meio do teste t de student não pareado, § p-valor obtido por meio do teste qui-quadrado, || p-valor obtido por meio do teste de mann-whitney, ¶ hemoglobina glicada. fonte: elaboração própria. 9 efeito de estratégias educativas na qualidade do sono de pessoas com diabetes: ensaio clínico randomizado l flávia helena pereira e outros para comparar as variáveis de qualidade do sono e de estresse emocional relacionado ao diabetes (e seus domínios), utilizaram-se modelos lineares de efeitos mistos. nos pacientes incluídos no g1, os resultados evidenciaram que as estratégias de higiene do sono foram efetivas na redução do escore do psqi (p < 0,01), entretanto não foram capazes para caracterizar esses participantes como bons dormidores (escore de 5,02 no final do seguimento). constatou-se diminuição significante dos níveis de estresse emocional relacionado ao diabetes (p < 0,01), dos domínios insegurança relacionada ao profissional (p < 0,01) e estresse relacionado ao regime terapêutico (p < 0,01); desse modo, as estratégias de higiene do sono contribuíram para que os níveis de estresse emocional reduzissem de moderado (2,13 ± 1,10) para pouco ou nenhum estresse emocional (1,51 ± 0,51). por outro lado, no g2, também se constatou redução significante dos níveis de psqi (p < 0,01), estresse emocional relacionado ao diabetes (p < 0,01) bem como dos domínios carga emocional (p < 0,01) e estresse relacionado ao regime terapêutico (p < 0,01). evidenciou-se redução significantemente maior do escore de psqi entre os participantes do g1 comparados ao g2 (p < 0,02) no final do seguimento (tabela 2). tabela 2. comparações intra e entre grupos de acordo com as variáveis ao longo do tempo — linha de base e três meses após o seguimento (paraguaçu, minas gerais, brasil, 2016) variáveis grupo baseline média + dp 3º mês média + dp p-valor* psqi, média (dp‡) g1 9,84 (2,89) 5,02 (3,00) <0,01 g2 9,57 (2,83) 6,30 (3,50) <0,01 p-valor† 0,70 0,02 ----dds, média (dp‡) g1 2,13 (1,10) 1,51 (0,51) <0,01 g2 1,95 (0,91) 1,42 (0,58) <0,01 p-valor† 0,47 0,30 ----carga emocional, média (dp‡) g1 2,67 (1,45) 2,20 (1,07) 0,05 g2 2,42 (1,35) 1,83 (0,95) <0,01 p-valor† 0,37 0,13 ----insegurança relacionada ao profissional, média (dp‡) g1 1,82 (1,20) 1,17 (0,45) <0,01 g2 1,63 (1,14) 1,30 (0,80) 0,06 p-valor† 0,26 0,75 ----estresse relacionado ao regime terapêutico, média (dp‡) g1 2,17 (1,27) 1,30 (0,51) <0,01 g2 2,19 (1,34) 1,32 (0,72) <0,01 p-valor† 0,95 0,72 ----estresse nas relações interpessoais, média (dp‡) g1 1,58 (1,34) 1,17 (0,56) 0,08 g2 1,21 (0,57) 1,04 (0,17) 0,15 p-valor† 0,24 0,38 ----*p-valor intragrupo, †p-valor entre grupos, ‡ desvio-padrão. fonte: elaboração própria. 10 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1932 aquichan issn 1657-5997 eissn 2027-5374 na tabela 3, é apresentado um modelo de regressão linear múltipla construído com o objetivo de avaliar a relação entre um conjunto de variáveis independentes e a variável dependente (qualidade do sono). a qualidade do sono no final do seguimento esteve associada com as variáveis estresse emocional relacionado ao diabetes (p = 0,04), idade (p = 0,04), sexo (p = 0,01) e grupo (p < 0,01). o aumento de 1 ponto no escore do dds colaborou para o aumento de 1,22 pontos no escore do psqi; na variável idade, o acréscimo de 1 ano na idade implica média no aumento de 0,09 no escore do psqi; ser do gênero feminino acarretou aumento de 1,57 pontos no escore do psqi quando comparado aos indivíduos do sexo masculino e, finalmente, estar incluído no g1 colaborou para diminuição de 1,77 pontos no escore do psqi quando comparados ao g2. assim, o modelo foi capaz de explicar 32 % a variabilidade da variável dependente, sendo o coeficiente de correlação considerado forte, de acordo com cohen (27) (tabela 3). tabela 3. análise de regressão linear múltipla entre a qualidade do sono e as variáveis independentes (paraguaçu, minas gerais, brasil, 2016) * p-valor; † o modelo foi ajustado pela medida do psqi em t0, ‡ índice de qualidade do sono de pittsburgh, § índice de massa corpórea, || diabetes distress scale. fonte: elaboração própria. variável desfecho † variáveis independentes coeficiente intervalo de confiança 95 % p-valor* r² l. i. l. s. psqi‡ imc§ – t3 -0,06 -0,17 0,06 0,34 0,32 dds || t3 1,22 0,05 2,39 0,04 idade 0,09 0,01 0,17 0,04 tempo de tratamento -0,05 -0,15 0,06 0,36 sexo (ref = masculino) 1,57 0,29 2,86 0,01 estado civil (ref = sem companheiro) 0,55 -0,68 1,77 0,38 mora com (ref = com outra pessoa) 1,00 -1,07 3,06 0,34 renda familiar (ref = <r$1.000,00) 0,32 -0,90 1,54 0,60 grupo (ref = g2) -1,77 -2,98 -0,56 <0,01 atividade física autorrelatada (ref = não) -0,69 -2,09 0,72 0,33 11 efeito de estratégias educativas na qualidade do sono de pessoas com diabetes: ensaio clínico randomizado l flávia helena pereira e outros discussão neste estudo, avaliaram-se estratégias educativas para melhorar a qualidade do sono e a relação com estresse emocional associado com o diabetes. as reduções dos valores médios do escore do psqi e do dds foram estatisticamente significantes e descrevem melhora da qualidade do sono e dos níveis de estresse emocional nos participantes do g1, o que é corroborado por estudos prévios (28, 29). ensaio clínico randomizado que investigou os efeitos de um plano de cuidados não farmacológico, que incluía higiene do sono e orientações de autocuidado em pessoas com dm2, revelou resultados similares ao nosso estudo, com redução significante do escore da qualidade do sono (psqi de 9,05 para 4,79) no grupo que recebeu esse plano de cuidados após 75 dias de seguimento, entretanto não foram encontradas diferenças significantes entre os grupos estudados (29). paralelamente, outro estudo que utilizou medidas de higiene do sono em pessoas em hemodiálise também observou diferença estatística significante entre os grupos no final do seguimento na qualidade do sono com a redução da média do escore de psqi de 12,7 para 7,03 (30). neste estudo, quanto ao estresse emocional relacionado ao diabetes, os participantes incluídos no g1 apresentaram redução significante ao longo do seguimento. estudos apontam que existe associação entre o sono e o estresse relacionado ao diabetes, uma vez que o tempo reduzido de sono se refere a um aumento desse estresse, e esses fatores podem influenciar a qualidade de vida das pessoas com dm2 (31-33). à medida que foram realizadas orientações voltadas para a melhora do sono, também se pôde constatar redução nos níveis de estresse emocional relacionado ao diabetes. as variáveis pertencer ao g1, idade e sexo feminino também estiveram envoltas na qualidade do sono. estar incluído no g1 colaborou para uma redução significante de 1,86 pontos no escore de psqi quando comparados ao g2. por sua vez, ser do sexo feminino colaborou significantemente para a piora da qualidade do sono. esses resultados confirmam o que já tem sido descrito previamente, ou seja, a forte relação entre a baixa qualidade do sono e ser do sexo feminino (34, 35). a idade foi outra variável que também contribuiu para piorar a qualidade do sono, sendo que o acréscimo de um ano colaborou para a piora no escore do psqi, em média de 0,09. esse resultado vem ao encontro de um estudo realizado no brasil com uma amostra de 1.024 participantes, com idade entre 20 e 80 anos, em que se observou um aumento linear entre acordar após o início do sono e o envelhecimento. além disso, o tempo total de sono, a eficiência do sono e o sono de ondas lentas também apresentaram redução com o envelhecimento, o que apontou um fator negativo com o passar da idade. destaca-se que esses resultados não foram relacionados ao gênero (36). outro achado do estudo, embora não fosse esperado, foi o fato de o g2 apresentar melhora na pontuação da qualidade do sono. contudo, essa redução não foi suficiente para classificar os pacientes como “bons dormidores”. houve também redução dos níveis de estresse emocional relacionado ao diabetes. entretanto, esse grupo inicialmente foi classificado com pouco ou nenhum estresse relacionado ao diabetes. o fato de ambos os grupos terem recebido orientações focadas na melhoria do autocuidado, sejam elas orientações de higiene do sono, sejam cuidados com os pés, pode ter influenciado nesse achado. outra hipótese seria o contato entre os participantes do g1 e do g2, que pode ter contribuído para a troca do conhecimento das ações direcionadas para higiene do sono. desse modo, futuramente e como continuação deste estudo, seria importante investigar a efetividade dessas intervenções juntamente com um grupo controle “puro”, ou seja, baseado no tratamento usual recebido no serviço, campo do estudo. os pontos fortes deste estudo foram envolver estratégias educativas associadas a reforços telefônicos, além da realização do estudo em serviço de atenção primária, local onde a maioria das pessoas com dm2 é acompanhada, o que permite a replicação das estratégias deste estudo em outros serviços com o mesmo nível de complexidade. contudo, este estudo apresenta algumas limitações: a ausência de um instrumento de registro formal (diário do sono) para os participantes, a medida da qualidade do sono por instrumento subjetivo e o fato de não mensurar o quanto e a forma que os participantes aderiram à exposição solar; além disso, a ausência de controle sobre o fato de o dia estar nublado ou chuvoso, bem como a sazonalidade das estações do ano, o curto período de seguimento dos participantes e a possibilidade de contaminação do grupo controle (por se tratar de unidades com baixo número de usuários; troca de saberes entre os participantes, contato com informações fornecidas pela mídia ou mesmo por outros profissionais da área da saúde) também são limitações possíveis. 12 año 19 vol. 19 nº 3 chía, colombia agosto 2019 l e1932 aquichan issn 1657-5997 eissn 2027-5374 conclusão após 90 dias de seguimento, conclui-se, com este estudo, que a realização de estratégias educativas presenciais baseadas na higiene do sono (com orientações verbais e folhetos) combinadas com reforços telefônicos foram efetivas para melhorar a qualidade do sono em pacientes com dm2, mensurada pelo instrumento psqi-br, e do estresse emocional relacionado ao diabetes, avaliado pelo intrumento do b-dds. essas orientações educativas são estratégias de baixo custo e podem ser implementadas na prática clínica do enfermeiro junto ao paciente com dm2. conflito de interesses: nenhum 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https://doi.org/10.1002/oby.20259 36. moraes w, piovezan r, poyares d, bittencourt lr, santos-silva r, tufik s. effects of aging on sleep structure throughout adulthood: a population-based study. sleep med. 2014;15(4):401-9. doi: https://doi.org/10.1016/j.sleep.2013.11.791 https://doi.org/10.1016/j.psychres.2017.02.049 https://doi.org/10.1111/jocn.13051 https://doi.org/10.1002/oby.20259 https://doi.org/10.1016/j.sleep.2013.11.791 best practices in maternal and child health from the perspective of healthcare professionals articles  best practices in maternal and child health from the perspective of healthcare professionals buenas prácticas en salud maternoinfantil desde la perspectiva de los profesionales de la salud boas práticas em saúde materno-infantil na percepção de profissionais de saúde 10.5294/aqui.2023.23.1.2  tanise pereira santini1 elisa sampaio von muhlen2 mara regina caino teixeira marchiori3 cristina saling kruel4 dirce stein backes5 1 0000-0002-7040-2350 universidade franciscana, brazil. tanisesantini@hotmail.com 2 0000-0003-3188-6070 universidade franciscana, brazil. elisa.muhlen@ufn.edu.br 3 0000-0001-9412-7755 universidade franciscana, brazil. maramarc@ufn.edu.br 4 0000-0003-1996-7708 universidade franciscana, brazil. cristinakruel@prof.ufn.edu.br 5 0000-0001-9447-1126 universidade franciscana, brazil. backesdirce@ufn.edu.br theme: the promotion of health, well-being, and quality of life. contribution to the subject: the present qualitative study is related to promoting health, well-being, and quality of life. it aims to expand and improve best practices in maternal and child health in southern brazil from the perspective of healthcare professionals. this expansion and qualification process can be achieved through continuing education in health, hospitality, ambiance, improved access to pregnant and postpartum women, and especially the professional-user relationship. received: 06/03/2022 sent to peers: 08/06/2022 approved by peers: 24/10/2022 accepted: 03/11/2022 para citar este artículo / to reference this article / para citar este artigo: santini tp, marchiori mrct, kruel cs, muhlen esv, backes ds. best practices in maternal and child health from the perspective of healthcare professionals. aquichan. 2023;23(1):e2312. doi: https://doi.org/10.5294/aqui.2023.23.1.2 abstract objective: to understand healthcare professionals’ perception of best practices in maternal and child health. materials and methods: this qualitative exploratory-descriptive study was conducted between december 2020 and march 2021. the study corpus consisted of 23 healthcare professionals from southern brazil. data were collected using a semi-structured script and coded based on minayo’s thematic content analysis proposed. results: data analysis enabled the delimitation of two thematic categories: “best practices in maternal and child health: from idealization to accomplishment” and “strategies to qualify the maternal and child healthcare network.” conclusions: healthcare professionals recognize the relevance of best practices in maternal and child health, although this process must be expanded and consolidated. continuing education, hospitality, ambiance, improved access, and the professional-user connection stand out among the qualifying strategies. keywords (fonte: decs): nursing research; patient care team; continuing education; maternal and child health; health strategies. resumen objetivo: conocer la percepción de los profesionales de la salud acerca de las buenas prácticas en salud maternoinfantil. materiales y método: se trata de una investigación cualitativa, de carácter exploratorio-descriptivo, realizada entre diciembre de 2020 y marzo de 2021. el corpus del estudio se compuso de 23 profesionales de la salud del sur de brasil. se recolectaron los datos por medio de un guion semiestructurado y se codificaron con base en el análisis de contenido de minayo. resultados: el análisis de los datos posibilitó la delimitación de dos categorías temáticas: “buenas prácticas en salud maternoinfantil: de lo idealizado a lo realizado” y “estrategias calificadoras de la red de atención a la salud maternoinfantil”. conclusiones: los profesionales de la salud reconocen la relevancia de las buenas prácticas en salud maternoinfantil, aunque este proceso necesite de ampliación y consolidación en la práctica. se destacan, entre las estrategias calificadoras, la educación continua, la acogida, el ambiente, la mejora del acceso  y el vínculo profesional-usuario. palabras clave (fuente: decs): investigación en enfermería; grupo de atención al paciente; educación continua; salud maternoinfantil; estrategias de salud. resumo objetivo: conhecer a percepção de profissionais de saúde sobre as boas práticas em saúde materno-infantil. materiais e método: trata-se de uma pesquisa qualitativa, de caráter exploratório-descritivo, realizada entre dezembro de 2020 e março de 2021. o corpus do estudo foi composto de 23 profissionais de saúde do sul do brasil. os dados foram coletados por meio de um roteiro semiestruturado e codificados com base na análise de conteúdo temática proposta por minayo. resultados: a análise dos dados possibilitou a delimitação de duas categorias temáticas: “boas práticas em saúde materno-infantil: do idealizado ao realizado”; “estratégias qualificadoras da rede de atenção à saúde materno-infantil”. conclusões: os profissionais de saúde reconhecem a relevância das boas práticas em saúde materno-infantil, embora esse processo necessite ser ampliado e consolidado na prática. destacam-se, entre as estratégias qualificadoras, a educação permanente, o acolhimento, a ambiência, o acesso facilitado e o vínculo profissional-usuário. palavras-chave (fonte: decs): pesquisa em enfermagem; equipe de assistência ao paciente; educação continuada; saúde materno-infantil; estratégias de saúde. introduction with the creation of the brazilian unified health system (sistema único de saúde brasileiro sus), the national policy for comprehensive women’s healthcare (1) was established in 2004, followed by the stork network (rede cegonha) in 2021, which gradually promotes best obstetric practices and maternal and child health. among the various concepts that comprise the expression “best obstetric practices” is the singular reception of the pregnant woman in the healthcare service, in addition to emotional support, well-being, and pain relief, which are based on non-pharmacological methods (2). maternal and child health has been a recurrent subject both nationally and internationally. the world health organization has taken an important initiative, which aims, among others, to reduce maternal and newborn mortality through strategies that promote timely access to healthcare services for pregnant women. in this line, countries, in general, have made investigative and assistance efforts to identify the best scientific evidence in maternal and child health (3). following brazil’s example, cuba and the dominican republic, along with other countries, have invested in new management and intervention approaches to promote the comprehensive health of women and children. the objective is, under this scope, to prospect strategies that ensure family planning, qualified prenatal care in primary healthcare, vaccination coverage, and universal access for pregnant women and children (4,5). based on these developments, the best maternal and child health practices transcend mechanized interventions and enable comprehensive and integrative care. based on this initiative, best practices are open to more than just a professional subject or a single sector. they are configured as a healthcare network that expands and converges with diverse social sectors (6). studies confirm the importance of access and qualified information in prenatal care to empower pregnant women concerning their rights, thereby contributing to their greater autonomy and leading role during labor and delivery. the sustainable development goals, especially those related to reducing maternal, newborn, and infant mortality, can be achieved through collective and collegiate efforts among the various actors involved (7,8). it is noted that maternal and child health in brazil has undergone growing developments in its conception and (re)structuring to expand and improve the best multi-professional practices. still, there are gaps in prenatal care regarding healthcare, infrastructure, health education, and a deficit of qualified professionals (9). however, the question concerning healthcare professionals’ perspective of best practices in maternal and child health remains. in this sense, this study aimed to understand the perspective of healthcare professionals regarding best practices in maternal and child health. materials and methods this research is a qualitative, exploratory, and descriptive study. the data collection was carried out online between december 2020 and march 2021. the study corpus consisted of 23 healthcare professionals out of the 33 appointed by the 4th regional health department in rio grande do sul for their strategic role in the 33 cities covered by the 4th department. the objective of the regional health departments is to integrate the organization, planning, and execution of healthcare activities and services. notably, among the professionals appointed by the 4th regional health department, 40 % had just a college education. the others had specializations and master’s degrees in maternal and child health. however, they all work in management activities and maternal and child healthcare. based on the nominated individuals, we considered as an inclusion criterion being willing and available to participate voluntarily in the study and, as an exclusion criterion, to be healthcare professionals on leave of absence for a justified reason. the data collection instrument was a semi-structured google forms questionnaire sent by e-mail along with the informed consent form to the professionals who had previously volunteered to participate in the study. the questionnaire contained questions regarding best practices in maternal and child health and aspects of the maternal and child healthcare network, such as what they know about best practices in maternal and child health and how they encourage such practices; which aspects should be considered in the management of the maternal and child healthcare network, and how to qualify the access to the maternal and child healthcare network. minayo’s thematic content analysis technique was used for data analysis, which was systematized in three stages. the first stage, named “pre-analysis,” consisted of resuming the initial hypotheses and objectives to direct data deepening. the second stage consisted of exploring the material. the texts were analyzed systematically, generating the initial thematic categories. the third stage comprised the treatment of results, i.e., the inference, interpretation, and final delimitation of thematic categories (10). throughout the research process, the recommendations of resolution 466/2012 by the national health council (conselho nacional de saúde) (11) and the circular letter (ofício circular) 2/2021 regarding research in the online modality (12) were followed. the research ethics committee of the universidade franciscana approved the research project under legal opinion 4.253.922. to ensure anonymity, the participants’ statements were identified throughout the text with the letters “hp,” standing for healthcare professionals, followed by a number corresponding to the order of the statements: hp1… hp23. this study decided not to differentiate nurses from medical doctors, as it was understood that the stork network focuses on multi-professional practices. results of the 23 study participants, 19 are nurses, and four are medical doctors working in basic health units (unidades básicas de saúde ubs) and residents of the central region of rio grande do sul, southern brazil. the analyzed data allowed the delimitation of two thematic categories: “best practices in maternal and child health: strategies in providing care” and “strategies to qualify the maternal and child healthcare network.” best practices in maternal and child health: strategies in providing care it was evident that the interviewees recognized that best practices in maternal and child health consist of measures identified as the best practices to be adopted in the mother-baby binomial. the participants’ reports demonstrate that best practices are understood as strategies that provide safety, quality, protection, and humanization throughout the pregnancy-puerperal process. they also highlight that such methods are based on scientific evidence and aim to reduce maternal and neonatal mortality, as described: humanization in the care provided aiming to follow evidence-based practices and providing knowledge, safety, and comprehensive care. (hp1) dissemination of knowledge and improvement strategies for the clinical/therapeutic care provided to the mother-baby binomial. (hp2) these are practices based on scientific evidence to reduce maternal and infant mortality. (hp16) it was noted in the participants’ statements that the best practices in maternal and child health are introduced from family planning so that women can become familiar with and choose contraceptive methods based on their health and that of their families. the participants recognize that this previous programming enables the qualification of comprehensive healthcare. best practices include family planning, orientation on contraceptive methods use, and access to quality prenatal care. (hp9) family planning can qualify for healthcare. (hp12) welcoming them with active listening and providing access to contraceptive methods and pregnancy testing. (hp21) it was found in the participants’ statements that the best practices used in the daily routine of healthcare services are related to non-pharmacological methods for pain relief during labor, such as warm baths, the swiss ball, music therapy, and penumbra. some also mentioned the “golden hour,” which is considered the first hour of the newborn’s life and, in this sense, stressed the importance of breastfeeding, skin-to-skin contact, and timely clamping of the umbilical cord. i consider warm baths, walking, swiss ball, squatting, and skin-to-skin contact paramount. (hp3) non-pharmacological pain relief methods are essential, such as warm baths, swiss ball, ambulation, company, timely cord clamping, skin-to-skin contact, and breastfeeding within one hour of life. (hp5) i emphasize non-pharmacological methods of labor pain relief, reducing the number of episiotomies. (hp6) patient care provided by a multi-professional team, company, non-invasive practices for pain relief, and the golden hour. (hp17) free demand breastfeeding, encouraging breastfeeding and a good latch, and humanization. (hp18) in the participants’ understanding, healthcare professionals responsible for maternal and child healthcare should consider women’s empowerment, rights, and duties. they address the importance of the companion of choice throughout the pregnancypuerperal journey to allow the singularity and multidimensionality of care throughout the process. i understand that respecting women’s decisions is necessary to empower them regarding their delivery and puerperium. (hp1) access to quality and humanized prenatal care with the support of a companion throughout the process must be considered. (hp14) the right to a companion during childbirth. (hp23) the professionals must be receptive to clarifying women’s doubts, enabling decision-making, and empowering them as protagonists of their care. (hp22) the participants’ understanding of the best maternal and child health practices is summarized in humanized, integrative, and resolutive practices throughout the healthcare network. this qualification process, however, is gradual and must be carried out by each healthcare professional. strategies to qualify the maternal and child healthcare network strategies to qualify the maternal and child healthcare network have been increasingly promoted in brazil. in this line, the participants highlighted the promotion of continuing education as lifelong training. it is from spaces of integration and (re)signification of knowledge and practices among co-workers that the needs and demands of each service are discussed, as described by a participant: through continuing education in network services, dialogue, and knowledge sharing, we can identify the demands and (re)signify our practice. (hp22) the participants’ reports indicate that the qualification of the healthcare network is achieved through dialogical and constructivist processes mediated by continuing education. from this perspective, some participants highlighted the horizontality of interprofessional relationships and the permanent dialogue between the various actors of the healthcare network. we need to keep qualifying the interprofessional dialogue... the professionals’ continued training in an integrated set; it is something that would certainly lead to better quality care provided to pregnant and postpartum women. (hp13) meetings with the network professionals for dialogue and agreement on the initiatives to be developed. (hp19) the participants emphasize early admission of pregnant women to healthcare services to identify their needs and expand the support network. they underline, from this perspective, the relevance of prenatal care to promote early bonding and ensure a safe and continued pregnancy throughout the pregnancy-puerperal period, as noted in the following statements: i focus on prenatal care. active search, hospitality, and the follow-up of postpartum and puerperium. (hp7) to welcome women in the ubs with suspected pregnancy, providing all the care for the beginning of prenatal care, such as exams and orientations related to care and assistance. (hp9) performing a comparative survey of the number of puerperal women discharged from the hospital with the number of first puerperal and child health appointments. (hp10) qualifying the care provided to pregnant women, puerperal women, and children should be considered a priority to prevent maternal and infant morbidity and mortality. (hp11) for the participants, the bond between professionals and pregnant women is established through active and dialogical participation. this bond is, however, hindered by the high turnover of professionals in healthcare units. besides the bond, hospitality with active listening, ambiance, and expanded and resolutive care were mentioned. i always advocate hospitality with active listening, health education, screening pregnant women and their families, and establishing a professional-user bond. (hp7) try to keep professionals in primary care and encourage people to stay because turnover is high. (hp8) measures that encourage personnel to reduce turnover. (hp15) the qualifying strategies of the maternal and child healthcare network are configured in the participants’ conception of soft technologies, which are expanded and consolidated from the interprofessional relationships. in this sense, continuing education, hospitality, ambiance, active listening, early access, and the professional-user bond are strategies that, summarized in figure 1, prospectively contribute to the qualification of the maternal and child healthcare network. figure 1. strategies that qualify the maternal and child healthcare network source: own elaboration. discussion the study participants consider themselves responsible for developing the best maternal and child health practices and for resolute and quality care. studies corroborate these findings by mentioning that the staff is committed to implementing the best maternal and child health practices, which are guaranteed, especially by continuing education in health and lifelong training (13, 14). in this context, continuing education in health is understood as learning on the job, where learning and teaching are brought together in professional practices. thus, this learning process appreciates the professionals’ pre-existing knowledge coordinated with daily challenges to improve their knowledge (15). adopting best practices focused on the maternal and child healthcare network entails a daily and permanent process through the stimulation of reflective and self-evaluative processes that promote prospective self-criticism. the reflective process, defined by knowledge associated with actions, demanding actions that transcend the linearity of the daily routine, must be stimulated in the development of theoretical-practical knowledge. in addition, alternative therapies should be discussed and encouraged, among which ambiance, music therapy, and aromatherapy stand out (16, 17). the ambiance is a physical space of interpersonal relationships that provides hospitality and humane care. the national humanization policy considers ambiance as a welcoming, integrating, and aggregating environment for best practices that aim to improve the work process (18). for healthcare professionals, best maternal and child health practices are translated daily into relational-interprofessional and humanizing actions. in this sense, dialogic action-reflection-action is essential for redefinition practices and interprofessional conduct to ensure special and multidimensional care. studies (19, 20) emphasize, under this approach, the relevance of the co-responsible engagement of the various actors within the network to overcome hegemonic standards and enable horizontal and dialogical intervention processes. according to the study participants, the best practices in maternal and child health, especially those related to soft technologies, enable greater dynamism and interprofessionalism. in this relationship, soft technologies emerge as enhancers of professional interactions and associations, strengthened by bonding and hospitality (21). according to the participants, these technologies must be expanded to enable greater interactivity in the maternal and child healthcare network. a study (22) corroborates this idea by mentioning that interactive and associative processes favor an ambiance that aggregates and enhances the autonomy of the various actors involved. in this dialogic path, it is also necessary to consider the active participation of companions as an empowering and bonding strategy (23, 24). therefore, the need to strengthen interpersonal and interprofessional relationships from new theoretical and practical references emerges. a study indicates that professional qualification, from an interprofessional perspective, enables dialogical and associative breakthroughs between professionals, and pregnant and postpartum women, encouraging the development of best maternal and child health practices starting from prenatal care (25). the participants stressed the relevance of strategies associated with active listening, dialogue, and the professional-user bond, which can be expanded and strengthened by the mediation of continuing education in health. studies indicate that innovative approaches, that is, those that are dialogical and horizontalized, enable qualified and resolutive interventions in maternal and child health (26). in this context, continuing health education is enabled by developing spaces for critical-reflective approaches that induce the (re)significance of the professional daily existence and performance (27-30). this study’s participants mentioned other strategies related to hospitality and supportive ambiance. they emphasize, in this sense, the importance of the parturient’s companion of choice, so that she feels welcomed and supported in her needs, is autonomous, and becomes the protagonist of the decision-making process. a study in this line has shown that hospitality, birth companion, and ambiance are vital for the quality of care provided to the parturient (31, 32). the qualifying strategies of the maternal and child healthcare network mentioned by the participants are within reach of healthcare professionals. they can be promoted, for the most part, without substantial structural investments. a study, however, opposes this argument by mentioning that structural and interpersonal assets must be considered in the management processes to enable qualified healthcare (33). therefore, the importance of continuing education in health is emphasized, as it promotes the professionals’ qualification, contributing to improved care through hospitality, ambiance, and active listening. conclusions healthcare professionals acknowledge the relevance of best practices in maternal and child health, although this process needs to be expanded and consolidated. continuing education, hospitality, ambiance, communication, early access, and the professionaluser bond stand out among the qualifying strategies. it is concluded, in summary, that the promotion of best practices in maternal and child health is related to more significant and better investments in human resources and a welcoming and aggregating ambiance. therefore, the questions remain regarding how to qualify professional relationships and interactions to reassure the singularities of each user and what new theoretical-methodological approaches should be promoted to meet the unique health demands. study limitations this study’s limitation is related to the low adherence of medical professionals, considering the 14 medical doctors previously referred by the 4th regional health department. another restraint may be associated with the exhaustion experienced by healthcare professionals due to the multiple and growing activities stemming from the pandemic. conflicts of interest: none declared. references 1. brasil. ministério da saúde. política nacional de atenção integral à saúde da mulher: princípios e diretrizes. brasília-df; 2004. disponível em: 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https://doi.org/10.1371/journal.pone.0213511 home cerrar 20 31 vivir con cancer.indd 20 aquichan issn 1657-5997 paula jaman-mewes1 maría soledad rivera2 vivir con cáncer: una experiencia de cambios profundos provocados por la quimioterapia3 1 enfermera. magíster en enfermería clínica. pontificia universidad católica de chile, chile. pjaman@uc.cl 2 enfermera. doctora en filosofía de enfermería. profesora asociada, pontificia universidad católica de chile, chile. mriverma@uc.cl 3 extracto de la tesis de investigación cualitativa para optar por el título de magíster en enfermería clínica, escuela de enfermería, pontificia universidad católica de chile, santiago, chile. recibido: 5 de julio de 2012 enviado a pares: 25 de agosto de 2012 aceptado por pares: 12 de agosto de 2013 aprobado: 18 de noviembre de 2013 año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 20-31 para citar este artí culo / to reference this article / para citar este artigo jaman-mewes, p.; rivera, m. s. (2014). vivir con cáncer: una experiencia de cambios profundos provocados por la quimioterapia. aquichan. vol. 14, no. 1, 20-31. resumen objetivo: develar las experiencias de mujeres chilenas con cáncer en tratamiento con quimioterapia. materiales y método: estudio de investigación cualitativa fenomenológica según el pensamiento filosófico de martín heidegger. se entrevistaron en profundidad a 10 mujeres entre 45 y 64 años, con diferentes diagnósticos de cáncer en tratamiento con quimioterapia. el análisis se realizó basado en el método de streubert y carpenter, triangulando con un investigador experto. resultados: la experiencia de vivir con cáncer y con quimioterapia significa estar “viviendo con un tratamiento que provoca cambios profundos en la vida de las mujeres”, siendo esta una categoría comprensiva esencial del estudio que contiene cuatro unidades de significados: 1) cambios en todas las dimensiones del “ser” de las mujeres tanto a nivel corporal como emocional y espiritual; 2) cambios en el “ser-sí-misma”: antes y durante la quimioterapia; 3) cambios de “ser” en el mundo; 4) cambios en la familia. conclusiones: la comprensión en profundidad de lo vivido por las mujeres de este estudio confirma lo publicado en la literatura, y se constituye en un saber comprensivo que puede servir de guía para realizar cuidados de enfermería oncológicos humanos y personalizados basados en las necesidades de cada persona. palabras clave quimioterapia, salud de la mujer, neoplasias, oncología médica, enfermería (fuente: decs, bireme). 21 vivir con cáncer: una experiencia de cambios profundos provocados por la quimioterapia l paula jaman-mewes, maría soledad rivera año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 20-31 living with cancer: an experience of profound changes brought on by chemotherapy abstract objective: to show the experiences of chilean women with cancer who are undergoing chemotherapy. materials and methods: this is a phenomenological qualitative study developed pursuant to the philosophical thinking of martin heidegger. in-depth interviews were conducted with 10 women between 45 and 64 years of age who have been diagnosed with different types of cancer and are undergoing chemotherapy. the analysis was based on the streubert-carpenter method and triangulated by a practiced researcher. results: the experience of living with cancer and chemotherapy means "living with a treatment that causes profound changes in women’s lives," this being an essential, comprehensive category of the study that contains four units of meaning: 1) changes in all the dimensions of "being" a woman; that is, at the corporal, emotional and spiritual level, 2) changes in "being oneself" before and during chemotherapy, 3) changes to "being” in the world, and 4) changes in the family. conclusions: an in-depth understanding of the experiences of the women in this study confirms the reports in literature and constitutes a comprehensive body of knowledge that can serve as a guide to humane and tailored cancer nursing care based on each person’s needs. key words drug therapy, women’s health, neoplasms, medical oncology, nursing (source: decs, bireme). 22 aquichan issn 1657-5997 viver com câncer: uma experiência de mudanças profundas provocadas pela quimioterapia resumo objetivo: revelar as experiências de mulheres chilenas com câncer em tratamento com quimioterapia. materiais e método: estudo de pesquisa qualitativa fenomenológica segundo o pensamento filosófico de martín heidegger. entrevistaram-se em profundidade 10 mulheres entre 45 e 64 anos, com diferentes diagnósticos de câncer em tratamento com quimioterapia. a análise foi realizada com base no método de streubert e carpenter, e triangulada com um pesquisador especialista. resultados: a experiência de viver com câncer e com quimioterapia significa estar “vivendo com um tratamento que provoca mudanças profundas na vida das mulheres”, e esta é uma categoria compreensiva essencial do estudo que contém quatro unidades de significados: 1) mudanças em todas as dimensões do “ser” das mulheres, tanto corporal quanto emocional e espiritualmente; 2) mudanças no “ser-si-mesma”: antes e durante a quimioterapia; 3) mudanças de “ser” no mundo; 4) mudanças na família. conclusões: a compreensão em profundidade do vivido pelas mulheres deste estudo confirma o publicado na literatura e constitui-se em um saber compreensivo que pode servir de guia para realizar cuidados de enfermagem oncológicos humanos e personalizados baseados nas necessidades de cada pessoa. palavras-chave quimioterapia, saúde da mulher, neoplasias, oncologia, enfermagem (fonte: decs, bireme). año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 20-31 23 vivir con cáncer: una experiencia de cambios profundos provocados por la quimioterapia l paula jaman-mewes, maría soledad rivera introducción el cáncer es la principal causa de muerte a nivel mundial. para el 2008 se le atribuyeron 7,6 millones de defunciones ocurridas en todo el mundo (1). en chile, esta enfermedad constituye la segunda causa de muerte (2), y a pesar de que esta afecta a hombres y mujeres, las causas de enfermar son diferentes (1). las mujeres adultas medias, entre 45 y 64 años, son el grupo etario con mayor número de muertes por cáncer en chile, dado principalmente por neoplasias malignas de tipo ginecológico: de mama y cuello de útero, entre otros tipos (3). diversos estudios cuantitativos sobre cáncer y calidad de vida señalan que ser de género femenino, menor de 65 años y con la enfermedad activa constituyen factores de riesgo para desarrollar trastornos psicológicos y emocionales durante la enfermedad viéndose afectada la calidad de vida de la persona y de su familia (4-6). el diagnóstico y tratamiento de cáncer es un evento estresante en la vida de las mujeres, con consecuencias profundas que se manifiestan en todos los aspectos de la vida humana (7). la quimioterapia es uno de los tratamientos más usados en esta enfermedad. puede ser utilizada para curarla o para detenerla, aumentando la sobrevida del paciente, o para mejorar la calidad de vida de las personas. se conoce como un tratamiento intenso que produce múltiples efectos secundarios transitorios (8). a nivel internacional se han realizado estudios cualitativos que describen los diferentes cambios y efectos colaterales durante el tratamiento con quimioterapia, desde la perspectiva de quien los vive (9, 10), como también los significados de la esperanza y de los apoyos durante este difícil tratamiento (11). en chile no se encontraron investigaciones que exploren la experiencia de mujeres con cáncer que reciben tratamiento con quimioterapia. el gran número de personas con neoplasias malignas que requieren de tratamiento en diferentes centros oncológicos debe llevar a los profesionales de la salud a tomar una postura reflexiva en relación con la experiencia vivida de quienes portan la enfermedad y con los programas de cuidados que se realizan. a pesar de lo enseñado en las universidades y lo descrito en la evidencia científica en relación con proporcionar cuidados integrales a las personas, en las prácticas clínicas cotidianas se observa al equipo de enfermería centrado en sus acciones, en la manipulación y administración de medicamentos tóxicos como la quimioterapia, olvidando el “ser” biopsicosocial y espiritual de cada persona enferma. entonces, se necesita comprender a las mujeres en esta etapa de la vida para identificar los momentos críticos y las necesidades de cuidado de cada una de ellas. en consecuencia, el propósito de este estudio fue construir conocimiento comprensivo sobre la experiencia que viven mujeres chilenas con cáncer en tratamiento con quimioterapia, para mejorar la calidad de los cuidados de enfermería tornándolos humanos y personalizados. materiales y método el diseño de investigación utilizado se fundamenta en la metodología cualitativa de tipo fenomenológico según el pensamiento filosófico de martin heidegger (12). este método sistemático y riguroso permite describir las experiencias humanas tal como son vividas, y es el proceso de hacer manifiesto en la conciencia lo que normalmente está escondido en las experiencias y relaciones humanas (13, 14). desde la perspectiva de heidegger, el ser humano se concibe como el “dasein” o “ser ahí”, es decir, un ser en el mundo que se relaciona consigo mismo y con “otros” interrogándose en busca de su verdad (12). estas consideraciones permitieron el encuentro con las vivencias de las mujeres, comprendiéndolas en su existencia de “ser” consigo mismas, en el mundo con los otros y logrando captar la esencia del existir con cáncer y su tratamiento. el criterio de selección de las participantes fue portar la enfermedad en estudio y aceptar voluntariamente participar, previa firma de un consentimiento informado; por tanto, se trata de un muestreo intencionado. se invitó a mujeres entre 45 y 64 años, chilenas, con diferentes diagnósticos de cáncer, en tratamiento con quimioterapia —con al menos tres ciclos—, en un centro de cáncer de un hospital universitario en santiago de chile. el número de participantes se determinó aplicando el criterio de saturación de significados (13). en un periodo de ocho meses, desde octubre de 2010 a julio de 2011, se entrevistaron en profundidad a diez mujeres con un promedio de edad de 56,2 años. seis de ellas con diagnóstico de cáncer de mama, y las otras con cáncer de recto, páncreas, vía biliar y leucemia aguda linfoblástica. respecto al tratamiento, siete de ellas habían sido sometidas a cirugía, cinco habían terminado sus sesiones de radioterapia y todas se encontraban en trata24 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 miento con quimioterapia. todas las mujeres vivían acompañadas de familiares, ocho de ellas eran madres, la mayoría tenía dos hijos y tres eran abuelas; la mayoría de ellas tenía educación superior. antes de la enfermedad todas se desempeñaban en trabajos remunerados o en voluntariados. la técnica de recolección de información se realizó a través de entrevistas en profundidad de aproximadamente una hora, en un lugar y hora de acuerdo con la voluntad de la participante. estas fueron grabadas con el consentimiento de cada mujer. la pregunta que guió la entrevista fue: ¿podría compartirme cómo está siendo para usted la experiencia de vivir con cáncer? luego de cada entrevista el investigador transcribió textualmente los testimonios de las participantes, y posteriormente se sumergió en la información entregada triangulando con el otro investigador todo el proceso de análisis sugerido por streubert y carpenter (13). este proceso comprende varias etapas, comenzando con la descripción personal del fenómeno de interés; luego la reducción fenomenológica, en la que se registran en forma permanente las ideas, los conocimientos, las creencias, las emociones, los sentimientos, etc. que tiene el investigador, para acercarse al fenómeno lo más puro posible y que se revele tal cual es. posteriormente se realizaron las entrevistas una a una, se transcribieron textualmente y se realizó una primera lectura para obtener el sentido general de la experiencia, y una segunda lectura para descubrir las unidades de significado. posteriormente, se descubrieron las relaciones entre unidades de significado y se agruparon en categorías comprensivas mayores. la saturación de los significados se logró en la entrevista número siete; sin embargo, se hicieron tres entrevistas más para confirmar el fenómeno develado y junto al investigador experto se decidió dejar de entrevistar. finalmente, se realizó la descripción formal del fenómeno. para asegurar el rigor metodológico se aplicaron los criterios de guba (15). para obtener la credibilidad de los resultados se devolvió a algunas de las participantes la descripción del fenómeno construido a fin de verificar si se reconocían en este (member checking) y se obtuvo su aprobación. otro criterio de rigor aplicado fue la fidedignidad de las categorías develadas. para esto se fue triangulando el proceso de análisis de las entrevistas y de cada paso del estudio entre ambos investigadores, y las unidades de significados se fundamentaron en palabras textuales de las participantes. para alcanzar el criterio de confirmabilidad del estudio los investigadores dejaron una huella de todo el proceso de investigación que los condujo a los resultados para que otros investigadores puedan seguir la ruta de lo que se ha hecho. finalmente, se realizó una descripción detallada de las participantes y el lugar del estudio para la eventual transferencia de los resultados. este estudio contó con la aprobación del comité de ética de la escuela de enfermería de la pontificia universidad católica de chile en septiembre de 2010. todas las mujeres entrevistadas firmaron consentimiento informado previo a la entrevista. para resguardar el anonimato y la confidencialidad de la información, se les asignó un nombre ficticio a los testimonios. resultados para las mujeres entrevistadas, la experiencia de vivir con cáncer y estar sometidas a tratamiento con quimioterapia se devela como un periodo difícil y traumático que significa estar “viviendo con un tratamiento que provoca cambios profundos en su vida”, siendo esta una categoría comprensiva esencial del estudio. se llegó a esta categoría mediante la emergencia de cuatro unidades de significados interrelacionadas entre sí, como ocurre con cualquier experiencia humana. vivir con cáncer y con la quimioterapia significa vivir 1) cambios en todas las dimensiones del “ser” de las mujeres tanto a nivel corporal como emocional y espiritual; por otra parte, se producen 2) cambios de identidad: antes y durante la quimioterapia y también 3) cambios de “ser” en el mundo y en el estilo de vivir. en consecuencia, la experiencia de estar viviendo con cáncer y con el tratamiento 4) modifica su vida y la de toda la familia, quienes también deben reorganizar sus rutinas cotidianas. 1. cambios en todas las dimensiones del “ser” de las mujeres vivir con cáncer y con el tratamiento de quimioterapia provoca múltiples cambios y síntomas corporales, funcionales, emocionales y espirituales que sumergen a las mujeres en un nuevo estado de salud. a nivel corporal, las mujeres manifiestan periodos de malestar general, dolores en el cuerpo, náuseas, cansancio, pérdida de vitalidad, fuerza y energía, llevándolas a depender de sus familiares para realizar actividades de la vida cotidiana. además, a muchas de ellas la quimioterapia les produce falta de apetito, 25 vivir con cáncer: una experiencia de cambios profundos provocados por la quimioterapia l paula jaman-mewes, maría soledad rivera cambios de temperatura corporal, a algunas les produce dificultades para coordinar lo que piensan con lo que dicen. ¡la primera quimio fue terrible! […] ¡era toda una cosa nueva para mí! la quimio, todos los trastornos que traía, entonces, es como que uno se encuentra con un mundo nuevo. no es un simple dolor de cabeza, no es un simple dolor que te duelen las coyunturas, sino que son cosas como que se te están haciendo tira los huesos, entonces cuesta; […] cuando empecé con la quimio empecé con otros trastornos, me empezó a subir fiebre cuando me las ponía a las 24 horas era mujer muerta en la cama, así tirada, con náusea, me dolía […] igual como cuando uno tiene una gripe, pero eran como 10 gripes en mi cuerpo, dolor de huesos y todo (isabel, 56 años). mira lo más difícil ha sido las veces que me han hecho las quimio. físicamente, ¡porque ha sido terrible, terrible! […] y es como que uno recibiera suero no más, y una cuestión tapada en una bolsa negra, nada más. si es después, como al tercer día, eso que no puedes ni abrir los ojos. no sabría describirlo, es como si no tuvieras fuerza, ni energía, como que uno no tiene nada, ni ganas de comer, ni ganas de hablar, por mí que me dejaran dormir los otros cuatro, cinco días y que nadie me diera nada (sofía, 58 años). para bañarme era una lucha, me costaba estar en el agua, como que me empezaba a cansar el agua caliente, la tenía que entibiar, después me cansaba hasta para refregarme, lavarme la cabeza era todo un…, algo tan simple (isabel, 56 años). y lo otro, los hábitos de comer, no me da hambre en ninguna hora del día y si como, después me da asco. ¡la hora de la comida para mí es un suplicio! (lurdes, 54 años). por otra parte, dos de ellas tuvieron complicaciones principalmente por infecciones, teniendo que postergar sus ciclos llegando incluso una de ellas a internarse en el hospital: “bueno como te digo: ¡en la primera (quimio) fue como una bomba!, porque terminé muy grave […] tuve una neutropenia febril, tuve que volver a hospitalizarme por fiebre porque hice una infección grave” (marta, 52 años). respecto al cambio de la imagen corporal producto de la caída del cabello o la pérdida de una de sus mamas, pocas mujeres describieron sentirse afectadas: “a veces, cuando me miraba al espejo, yo decía: parezco cadáver, ¡horrible! […] con decirte que cuando me baño tiene que ser en la mañana o noche, pero no me veo al espejo” (maría, 64 años). la mayoría pudieron enfrentar los cambios de la imagen de su cuerpo con actitud positiva buscando formas alternativas como pelucas: entonces bueno, como te digo, por ejemplo qué importancia tiene que las uñas estén más oscuras, no tiene mucha importancia, ¡que tontera!, eso no me interesa, no me importa. sé que el pelo me va a crecer, se ha demorado pero ¡bueno!, me va a crecer […] porque yo me las arreglé, tengo mi peluquita (rebeca, 60 años). los cambios corporales se acompañan de cambios emocionales como ansiedad, miedos e incertidumbre por el tratamiento, las posibles complicaciones y la posibilidad de que el cáncer vuelva: el aspecto más difícil para mí es la incertidumbre, el no saber qué va a pasar, el no saber que con determinado tratamiento esto va a estar mucho mejor, tener que ir probando cosas para ver cómo está (fátima, 55 años). sé que a lo mejor, tal vez, tenga cura. ahora ese es mi miedo digamos, pero puede aparecer después. en diez años más, cinco años más, no sé (ana, 45 años). pero claro, son esos trámites y esa ansiedad de terminar pronto. […] y después es como esta sensación de que esto no se acabó, porque uno sabe que puede tener recidivas, uno sabe que puede tener recaída. ¡es una enfermedad con la que tienes que convivir y tienes que seguir viviendo! (marta, 52 años). además, vivir con cáncer y con el tratamiento de quimioterapia despierta en el “ser” emocional de la persona momentos de tristeza y soledad, como también cambios de ánimo y de carácter: de repente vienen como esas depresiones, que eso también es normal dentro de la quimio. es normal que uno sienta depresión […] que uno se sienta triste, sobre todo esos días bien así, helados, fríos, uno siente una tristeza (isabel, 56 años). estoy como sola, entonces como que falta poder hablarlo más, como ahora lo estamos hablando, poder decir, poder sacarlo, porque yo igual tengo que estar bien, no me puedo estar deprimiendo, no puedo estar llorando todo el día en la casa, o sea, ¡no me puedo permitir! (magdalena, 55 años). el “ser espiritual” de las mujeres adquiere una preponderancia especial. la enfermedad y el sufrimiento generan una necesidad de conectarse internamente consigo mismas y con su ser 26 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 superior, a quien se le hace responsable por la enfermedad, pero también se le reconoce el poder de la cura: señor usted me puso mi primera enfermedad grande que tengo, porque yo nunca había tenido una enfermedad, no sabía de hospitales, ni de remedios fuertes. entonces ¡un cáncer yo!, y me senté en mi pieza y dije: pero ¿por qué a mí?,¿qué he hecho mal?, ¿qué pasó? dije yo: señor usted me está mandando una prueba, pero me la mandó fuerte altiro, pero ¿sabe qué?, si usted me ayuda, ¡yo la voy a superar! porque yo no quiero dejar a mis hijos todavía, yo no quiero dejar a mi familia, a mis nietos… y ahí puse a todos los santitos, a san expedito […] y al padre pío! (magdalena, 55 años). 2. cambios en el “ser-sí-misma”: antes y durante la quimioterapia estar viviendo con cáncer y con quimioterapia significa un proceso de cambios a todo nivel y, sobre todo, en la percepción que tienen de sí mismas. reconocen que la enfermedad les proporciona oportunidad de reflexionar y tomar conciencia de su “ser” de mujer, que ahora ha cambiado. sienten un cambio de identidad, dejan de “ser” como fueron “antes”, es decir: ágiles, activas, trabajadoras, independientes, con el control de las cosas, y se pasa a una nueva forma de “ser” con cáncer. su dasein cambia, se recoge y reconocen que deben reestructurarse desde el encuentro consigo mismas: porque yo era bien ágil, hacía natación, hacía actividad física y ahora no hago nada […] yo era súper poderosa, súper todo, yo manejaba todas las cosas, tenía todo claro y ahora llegó un momento que no tenía nada claro, estaba así en la vida como un bebé digamos. es como cuando te decía al principio, es como encontrarme conmigo misma, ¿quién soy yo?, empezar como a estructurarse de nuevo, como a recogerse de nuevo, bueno y ver todo lo que pueda quedar para adelante y disfrutar lo que tengo ahora (fátima, 55 años). bueno, ¡yo no sé si voy a volver a ser la misma de antes!, yo ya no tengo la misma energía, me dicen que es por el tratamiento (lurdes, 54 años). 3. cambios de “ser” en el mundo y en el estilo de vivir la relación con el mundo, en consecuencia, se ve restringida a los ambientes de la propia casa y el centro de salud, produciéndose un aislamiento social principalmente en los meses de invierno, ya que las personas están vulnerables a los contagios por enfermedades: … estoy un poco aburrida, a la única persona que veo es a mi mamá, porque estuve con las defensas demasiado bajas, ¡cualquier cosa me pesco un resfriado!, ¡me ha prohibido todas las visitas hasta septiembre! (sofía 58 años). llevo seis meses estando en la casa con licencia […] me gusta estar en la casa también, no me ha bajado ninguna desesperación. me ha gustado compartir con mis hijos, y con mi marido (marta, 52 años). además, esta experiencia les está provocando un nuevo estilo de vivir, una nueva mirada de enfrentarse a la vida. se deja atrás la forma de vida acelerada que llevaban, los múltiples roles del “ser” de mujer; prolongados días de trabajo, las tareas de la casa, el cuidado hacia los padres e hijos, etc. la enfermedad y la quimioterapia las obliga a vivir con más calma y tranquilidad, aparecen nuevas prioridades y nuevas formas de disfrutar la vida: el significado es como un cambio de vida. porque yo antes no dedicaba el tiempo para mí. yo siempre fui para mis hijos, mi casa y también mucha labor social. y ahora no, yo voy a la clínica, vuelvo, me siento en el parque, disfruto de los pajaritos, disfruto del aire, de los árboles, del pasto, todo, todo lo que sea maravilloso y disfruto la felicidad de ver a mis nietos acá junto conmigo (magdalena, 55 años). yo siempre trabajando de sol a sol. [ahora] de repente decir: oye vamos a tomar un helado, o ir al supermercado […] son cosas súper domésticas, pero ¡cuándo!, siempre corriendo como loca para llegar antes de que cierren (marta, 52 años). 4. cambios en la familia la experiencia de vivir con cáncer y estar con quimioterapia no solo afecta a las personas que portan la enfermedad, sino que toda la familia también experimenta múltiples cambios. las mujeres vuelven a sus casas después de haber trabajado toda su vida, y la familia debe adaptarse a esta nueva realidad. de ser totalmente independientes, pasan a ser dependientes de al menos un familiar. este debe reorganizar su vida para cuidar a quien tiene la enfermedad. por último, junto a estos cambios, en la familia también se despiertan sentimientos y emociones al ver a su ser querido enfermo: 27 vivir con cáncer: una experiencia de cambios profundos provocados por la quimioterapia l paula jaman-mewes, maría soledad rivera por ejemplo, trae un trastorno completo en la familia. yo vivo con mi padre, entonces otra hermana tenía que irse en la semana. un hermano mío llegaba el día viernes en la noche a atendernos hasta el día domingo. porque mi papá tiene 88 años. entonces así lo hacíamos. y mi hermana la que anda conmigo ahora, ella se encargó siempre desde un principio de traerme, llevarme, acompañarme cuando estaba hospitalizada (miriam, 63 años). en la casa no me dejan hacer nada, que voy a tomar una cosa y me dicen deja eso ahí, ¡tú no puedes hacer eso! (lurdes, 54 años). de repente, no tenía ánimo, porque no podía ni siquiera levantarme, ¡nada!, yo dependía de mi mamá para todo (sofía, 58 años). discusión vivir con cáncer en tratamiento con quimioterapia afecta y modifica todas las dimensiones del “ser” de las mujeres de este estudio, en influye en su manera de relacionarse consigo mismas y con el mundo produciendo temporalmente un cambio en su vida. estos hallazgos concuerdan con la literatura cualitativa revisada a nivel internacional (16-20). es así como en un estudio colombiano sobre la experiencia de vida de mujeres con cáncer de mama que reciben quimioterapia se develaron cuatro categorías comprensivas, entre ellas los cambios en la corporalidad, en las emociones y los significados del tratamiento, coincidiendo en varios aspectos con los resultados de este estudio (18). así mismo, en un estudio publicado recientemente en brasil, realizado a diez mujeres portadoras de cáncer y sus respectivos familiares, también se describen los diferentes cambios que se producen durante el tratamiento y lo que significa tener que convivir con esta enfermedad, tanto para la persona enferma como para sus familias. se detallan aspectos de las dificultades de la quimioterapia, sus efectos colaterales, entre ellos la caída del cabello y la pérdida de las mamas como significados representativos de la belleza y sexualidad femenina. también se señalan cambios emocionales como tener que lidiar con miedos e inseguridades, y los sentimientos negativos por parte de los familiares. desde la perspectiva social se menciona el tener que dejar las actividades planificadas y tener que posponer los planes construidos. se muestra que la convivencia con el cáncer para una mujer implica una nueva rutina de vida (21). en estados unidos, por su parte, un estudio cualitativo realizado a mujeres con diferentes diagnósticos de cáncer destacó la interrelación de los cambios físicos, psicológicos y espirituales durante el tratamiento con quimioterapia. describen también cuatro paradojas relacionadas con la fortaleza física, la apariencia física, labilidad emocional y cuestionamiento espiritual vividos en este periodo (16). la experiencia de sentir dolor físico tanto después de la cirugía, como en el transcurso de los ciclos de quimioterapias, también ha sido descrita en otros estudios. en australia, varios autores, tras un estudio cualitativo, encontraron que sentir dolor y entumecimiento e insensibilidad en las extremidades ocurría en muchas mujeres en quimioterapia (22). otros señalan que unas de las dificultades enfrentadas por los pacientes con cáncer durante el tratamiento es “la experiencia de dolor físico”, y que esta puede llevar a situaciones de descontrol psíquico extremo, teniendo como consecuencia el intento de suicidio de una de sus participantes (20). sin embargo, llama la atención que la experiencia de dolor no aparece relevante en otros estudios, y los efectos del tratamiento más frecuentes descritos son fatiga, pérdida de energía, vómitos, náuseas, pérdida de apetito, pérdida de peso, entre otros (10, 18, 19, 22, 23), los cuales concuerdan con lo develado en este estudio. estos efectos producen en las mujeres incapacidades físicas para desarrollar actividades de la vida diaria provocando sentimientos que deprimen la calidad de vida (20). al respecto, den y fann sostienen que para las mujeres de su investigación “lo más difícil de tener cáncer fue haber sufrido los efectos de la quimioterapia” (20). por su parte, mitchell describe que después de la primera quimioterapia algunas de las participantes refirieron sentirse bien, con pensamientos positivos de que el tratamiento sería exitoso y con pocos efectos colaterales. sin embargo, las experiencias subsecuentes revelaron los efectos acumulativos del tratamiento viéndose deterioradas física y emocionalmente. sentirse sin ánimo fue siempre asociado a los efectos físicos de la quimioterapia, en particular el cansancio, el letargo y dormir poco (24). esto es apoyado por otro estudio realizado en noruega, el cual reveló que debido a las drogas las mujeres refieren sentirse totalmente exhaustas. describen el tratamiento cito-tóxico de diversas maneras, tales como: “estar tirada”, “indispuesta”, “deprimida”, “cansada” “triste”, “mal”, “quebrada”, “suficiente”, “agotada”, entre otros. los testimonios demostraron que en la medida que progresaba el tratamiento, el sufrimiento físico empeoraba (25). otro hallazgo del estudio fue la poca preocupación por la imagen corporal de las participantes en relación con la pérdida de cabello debido a la quimioterapia. esto coincide con oxlad et al., quienes develaron que el cambio de la apariencia física apareció en menor grado con respecto a otros efectos (10, 26). por 28 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 el contrario, en comparación con otras investigaciones a nivel mundial, la imagen corporal es un fenómeno central (18, 20, 2729). es así como en un estudio colombiano las mujeres reportaron verse afligidas por la caída del cabello afectando su autoimagen y sintiéndose avergonzadas (30). así mismo, en irán, lo que más les preocupaba a las mujeres con cáncer y en quimioterapia eran los cambios físicos y de su imagen (31). además, se señala que en investigaciones previas, las mujeres más jóvenes se ven más afectadas con la imagen corporal que las mujeres de más edad. los significados de la imagen corporal entonces son variables y altamente influidos por el contexto cultural. para la mayoría de las participantes, sentir miedo e incertidumbre durante el tratamiento fue lo más frecuentemente descrito. el miedo se expresó principalmente por las posibles complicaciones de la quimioterapia y frente a las recaídas. en relación con la incertidumbre, esta permanece latente en todas las mujeres. son múltiples las interrogantes que van formulando sobre los resultados del tratamiento, y si serán capaces de eliminar el cáncer de su cuerpo. estos hallazgos concuerdan con la literatura cualitativa a nivel mundial (7, 10, 17, 22, 23, 26, 29). en brasil, en el estudio realizado por siqueira et al., también se describe la incertidumbre y el miedo como parte del día a día de las personas que viven con cáncer (20). oxlad et al. afirmaron que después de terminado el primer tratamiento de cáncer de mama, las mujeres reportaron aprehensiones sobre el futuro manifestadas en los sentimientos de sentirse perdidas, vacías, asustadas y con miedo principalmente a la recurrencia (10). esto es apoyado por otros autores, quienes refirieron que el hecho de completar el tratamiento fue un aspecto difícil de tratar, particularmente porque no existe un test final que confirme que el cáncer no está (22). esto también es compartido por bertero y wilmoth, quienes describen que vivir con incertidumbre afecta el “ser individual” y la relación con “otros”. sin embargo, describen que la información y el apoyo aumentan la certeza y proporcionan confianza (7). todo lo antes mencionado concuerda con lo descrito por shaha et al. en la revisión de literatura sobre incertidumbre y cáncer en la que se señala que esta comienza y prevalece desde el periodo del diagnóstico, continúa durante el tratamiento y posteriormente se mantiene en la vida de las mujeres (32). siguiendo con lo develado por las participantes, algunos ciclos se acompañaban de momentos de tristeza y soledad. estas afirmaciones concuerdan con lo planteado por varios autores (18, 28, 33). según mitchell, el estado de ánimo de los participantes de su estudio cambiaba no solo de día a día, sino por horas. además, agrega sentimientos de ansiedad causados por dificultades cognitivas debido a la quimioterapia como pérdida de memoria, concentración, incapacidad de tomar decisiones, como también alteraciones psicomotoras y de destreza manual (24). respecto a los cambios de “ser-sí-misma”, halstead y hull describen que las mujeres se enfrentan a la realidad de no poder controlar sus vidas de la misma manera que lo hacían previo al diagnóstico, y deben renunciar al control de ciertos aspectos de su existencia (16). otros autores señalan que la enfermedad las motivó a realizar una introspección de lo que ellas eran antes de la enfermedad y lo que estaban haciendo con sus vidas (33). otro estudio, realizado en brasil, describe que la vida de las mujeres cambió debido a que ellas cambiaron internamente como consecuencia de la enfermedad. las mujeres refirieron no ser las mismas que fueron antes de tener cáncer (34). por otra parte, existen varias investigaciones en las que el cambio de identidad está vinculado con la pérdida de la imagen corporal, específicamente la caída del cabello y la pérdida de una mama (25, 26). todo lo mencionado conduce inevitablemente a que las mujeres vayan modificando su mundo, teniendo que dejar sus trabajos y pasar más tiempo en sus hogares. a este respecto, siqueira et al. sostienen que una de las dificultades de las consecuencias de vivir con cáncer es el hecho de que todas las actividades pasan a restringirse a los ambientes de la casa y el hospital, lo cual provoca que los participantes se sientan excluidos de la sociedad (20). otros autores señalan que, debido a la enfermedad, las mujeres comienzan a “vivir el momento”, reconocen que en su vida eran adictas al trabajo y comienzan a comprender que cada nuevo día es un regalo (19), lo que también se mostró en nuestro estudio. en una investigación realizada en suecia se describe que existen signos de salud dentro de la enfermedad identificados como: las mujeres comienzan a ir más lento por la vida, se centran en sí mismas, se mantienen con una mayor apertura en su medioambiente y cambian su perspectiva de vivir en relación con lo que realmente es importante en sus vidas (27). por último, el tratamiento con quimioterapia afecta la vida de toda la familia, lo que también es señalado por otros autores quienes reconocen al cáncer como una enfermedad familiar en donde las preocupaciones de los pacientes son compartidas por el cónyuge y otros miembros de la familia generándose diferentes ajustes y cambios de roles al interior de esta (24, 35, 36). 29 vivir con cáncer: una experiencia de cambios profundos provocados por la quimioterapia l paula jaman-mewes, maría soledad rivera conclusiones e implicancias para enfermería las experiencias vividas por mujeres chilenas con cáncer en tratamiento con quimioterapia se develaron como un proceso constante de múltiples cambios provocados en su “ser” íntimo, en relación con sí mismas y con su mundo vida, lo que se confirmó con otros estudios a nivel mundial. los resultados proporcionan un nuevo antecedente a las enfermeras oncológicas y a los profesionales de la salud, permitiendo comprenderlas con mayor profundidad. las mujeres participantes señalan que producto del cáncer y la quimioterapia sus vidas sufren múltiples cambios físicos, psicológicamente se sienten deprimidas y vulnerables, y socialmente dependientes de su familia y aisladas. no obstante, reconocen que también se les han presentado oportunidades para ser más felices y vivir de una manera más armónica, dando prioridad a sus necesidades como familia. tomar conciencia de lo complejo que es vivir con cáncer y bajo el efecto de las drogas oncológicas puede servir de guía para reforzar o reformular los cuidados de enfermería en los servicios oncológicos, tornándolos más comprensivos y personalizados. la creación de “momentos de cuidado transpersonal” (37), como señala jean watson, podría contribuir a formar vínculos entre enfermera, paciente y familia para disminuir la carga emocional de las mujeres. se sugieren acciones interpersonales como acompañarlas durante el proceso de enfermedad, identificar las necesidades de cuidado continuamente y permitir mayor confianza durante el tratamiento. todo servicio de oncología debe ofrecer a sus pacientes un buen manual de autocuidado que detalle la información, en forma clara, sobre los efectos colaterales del tratamiento y las formas de cuidarse, pues tener un apoyo concreto y disponible al cual recurrir puede prevenir complicaciones. las necesidades de información y educación han sido quizás las que han suscitado más intervenciones de enfermería mediante diversas estrategias educativas orientadas al autocuidado durante la quimioterapia. sin embargo, se requiere estar continuamente innovando en el proceso de cuidado. de acuerdo con joyce travelbee, este debe ser interpersonal, significativo y terapéutico, lo que incluye acompañamiento e intervenciones de apoyo grupal, de reflexión y también de apoyo a la familia. además, estar conscientes de las necesidades espirituales puede llevar a tener espacios para la oración, para la música suave durante el tratamiento, proveer libros, etc. debido a la tecnología existente, implementar un sistema de cuidados humanos por internet puede servir para permanecer en contacto con el equipo de enfermería, aclarar dudas y compartir experiencias. respecto a las limitaciones de este estudio, como los resultados develados son temporales y pueden ser transferidos solo a poblaciones con las mismas características de las entrevistadas, se sugiere seguir investigando y profundizando, estudiar otras etapas de la enfermedad, otras edades, incluir a hombres y también a familiares. también es necesario comprender la experiencia vivida por los profesionales y técnicos oncológicos; considerar sus necesidades de autocuidado, de capacitación y sus inquietudes acerca de cómo mejorar los cuidados. los equipos que trabajan con personas con cáncer están expuestos a situaciones de alto riesgo emocional y no deben descuidar su autocuidado. agradecimientos: a cada mujer con diagnóstico de cáncer que debe enfrentarse a un tratamiento tan intenso como la quimioterapia. en especial a las mujeres que contribuyeron con este estudio. 30 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 referencias 1. organización mundial de la salud. cáncer [internet]. 2012 [visitado 2012 abril 20]. disponible en: http://www.who.int/ mediacentre/factsheets/fs297/es/ 2. chile. ministerio de salud. departamento de estadísticas e información de salud. indicadores básicos de salud [internet]. 2008 [visitado 2012 abril 20]. disponible en: http://deis.cl/desi/indicadores/indi2008.pdf 3. chile. ministerio de salud. departamento de estadísticas e información de salud. mortalidad de mujeres de 45 a 64 años, según las principales causas específicas de defunción [internet]. 2006 [visitado 2012 abril 20]. disponible en: http://deis.minsal.cl/deis/salida06/causas06.asp?temp=45_64_muj.htm 4. rustoen t, moum t, wiklund i, hanestad b. quality of life in newly diagnosed cancer patient. journal of advanced nursing. 1999;29(2):490-498. 5. strong v, waters r, hibberd c, rush r, cargill a, storey d, et al. emotional distress in cancer patients: the edinburgh cancer centre symptom study. cancer nursing practice. 2007;96:868-874. 6. pascoe 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philadelphia: lippincott williams & wilkins; 2007. 14. lopez k, willis d. descriptive versus interpretative phenomenology: their contributions to nursing knowledge. qualitative health research. 14:(5):726-735. 15. lincoln y, guba e. establishing trustworthiness. en lincoln y, guba e. editors. naturalistic inquiry. california: beverly hills sage publications; 1985. p. 289-331. 16. halstead mt, hull m. struggling with paradoxes: the process of spiritual development in women with cancer. oncology nursing forum. 2001;28(10):1534-1544. 17. lafaurie m, barbosa d, gonzales j, jiménez d, moreno l, ramírez l, et al. mujeres en tratamiento de cáncer, acogidas por un albergue de apoyo: circunstancias y perspectivas de cuidado de enfermería. rev colmb enf. 2009;4(4). 18. parra c, garcía l, insuasty j. experiencias de vida en mujeres con cáncer de mama en quimioterapia. rev colomb psiquiat. 2011;40(1):65-84. 19. sadler-gerhardt c, reynolds c, britton p, kruse s. women breast cancer survivors: 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cáncer de seno: experiencias y significados. revista colombiana de enfermería. 2011;7(7):12-21. 31. taleghani f, yekta z, nasrabadi a. coping with breast cancer in newly diagnosed iranian women. journal of advanced nursing. 2006;54(3):265-272. 32. shaha m, cox c, talman k, kelly d. uncertainty in breast, prostate, and colorectal cancer: implications for supportive care. journal of nursing scholarship. 2008;40(1):60-60-7. 33. gonzález l, lengacher, c. coping with breast cancer: a qualitative analysis of reflective journals. issues in mental health nursing. 2007;28(5):489-510. 34. vargens o, bertero c. living with breast cancer: its effect on the life situation and the close relationship of women in brazil. cancer nursing. 2007;30(6):471-478. 35. fu m, xu b, liu y, haber j. ‘making the best of it’: chinese women’s experiences of adjusting to breast cancer diagnosis and treatment. journal of advanced nursing. 2008;63(2):155-165. 36. middleton j. yo (no) quiero tener cáncer. 3 ed. chile: grijalbo; 2008. 37. watson j. human caring science: a theory of nursing. 2 ed. united states of america: jones & bartlett learning; 2012. 241 encarnación maría zambrano-domínguez1 maría dolores guerra-martín2 formación del cuidador informal: relación con el tiempo de cuidado a personas dependientes mayores de 65 años 1 enfermera. hospital san juan de dios, españa. enkarni.zbr_8288@hotmail.com 2 docente de la facultad de enfermería, fisioterapia y podología de la universidad de sevilla, españa. guema@us.es recibido: 28 de noviembre de 2011 aceptado: 2 de noviembre de 2012 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 l 241-251 resumen objetivo: analizar la formación recibida de los/as cuidadores/as informales de personas dependientes mayores de 65 años en relación con el tiempo de cuidado, de la zona básica de salud (zbs) de los palacios y villafranca, de sevilla (españa) durante el periodo de octubre de 2010 a mayo de 2011. materiales y métodos: estudio de corte transversal, descriptivo y correlacional. muestra: 41 cuidadores/as. muestreo no probabilístico intencional. cuestionario de elaboración propia. análisis de datos mediante spss versión 18.0. resultados: un 58,5% de las personas cuidadoras no han recibido ningún tipo de formación. de los/as cuidadores/as que han recibido formación, esta ha sido mayoritariamente sobre los cuidados básicos que precisa la persona cuidada. la institución encargada de la formación en la mayoría de los casos ha sido la unidad de gestión clínica, y en cuanto a los profesionales, han sido sobre todo enfermeros/ as. el 50% de los/as cuidadores/as informales llevan como cuidador/a una media de 7,6 años. el promedio del tiempo dedicado diariamente al cuidado en horas es de 10,9 horas. discusión/conclusiones: los/as cuidadores/as informales de la muestra estudiada que llevan más años dedicados/as al cuidado de una persona dependiente mayor de 65 años son los/as que han recibido en mayor proporción algún tipo de formación. palabras clave atención de enfermería, asistencia a los ancianos, anciano frágil, servicios de salud para ancianos, controles informales de la sociedad (fuente: decs, bireme). 242 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 training of informal caregivers: relationship to the time spent caring for dependent seniors over age 65 abstract objective: to analyze the training received by informal caregivers of dependent seniors over age 65 compared to the time spent on care in the los palacios and villafranca basic health zone (bhz) in seville (spain) during the period from october 2010 to may 2011. materials and methods: a cross-sectional, descriptive, correlational study. sample: forty-one (41) caregivers. intentional non-probabilistic sampling. own-design questionnaire. data analysis using spss, version 18.0. results: a good portion of the caregivers in the sample (58.5%) have received no training whatsoever. as for those who have, it was mainly on the basic health care required by the person receiving care. in most cases, the institution responsible for training has been the clinical operations unit and, in terms of the professionals involved, most have been nurses. fifty percent (50%) of the informal caregivers have been working as such for an average of 7.6 years. the average time spent daily on care is 10.9 hours. discussion / conclusions: the informal caregivers in the sample who have spent more years caring for a dependent person over age 65 are those who have received, in greater proportion, some type of training. key words: nursing care, old age assistance, frail elderly, health services for the aged, informal social control (source: decs, bireme). formação do cuidador informal: relação com o tempo de cuidado de pessoas dependentes maiores de 65 anos resumo objetivo: analisar a formação recebida dos/as cuidadores/as informais de pessoas dependentes maiores de 65 anos com relação ao tempo de cuidado, da zona básica de saúde (zbs) de los palacios e villafranca, de sevilha (espanha) durante o período de outubro de 2010 a maio de 2011. materiais e métodos: estudo de corte transversal, descritivo e correlacional. amostra: 41 cuidadores/as. amostragem não probabilística intencional. questionário de elaboração próprio. análise de dados mediante spss versão 18.0. resultados: 58,5% das pessoas cuidadoras não receberam nenhum tipo de formação. dos/as cuidadores/as que receberam formação, esta foi maioritariamente sobre os cuidados básicos que a pessoa cuidada precisa. a instituição encarregada da formação, na maioria dos casos, foi a unidade de gestão clínica e, quanto aos profissionais, foram principalmente enfermeiros/as. 50% dos/as cuidadores/as informais têm como experiência em média 7,6 anos. a média do tempo dedicado diariamente ao cuidado em horas é de 10,9 horas. discussão/conclusões: os/as cuidadores/as informais da amostra estudada que têm mais anos dedicados/as ao cuidado de uma pessoa dependente maior de 65 anos são os/as que receberam em maior proporção algum tipo de formação. palavras-chave cuidados de enfermagem, assistência a idosos, idoso fragilizado, serviços de saúde para idosos, controles informais da sociedade (fonte: decs, bireme). 243 formación del cuidador informal: relación con el tiempo de cuidado a personas dependientes... l encarnación maría zambrano-domínguez, maría dolores guerra-martín introducción el aumento de la longevidad poblacional hace aumentar las tasas de dependencia en todos los países, siendo de especial interés la necesidad de asistencia y cuidados de larga duración. la prolongación de la vida de las personas mayores tendrá como consecuencia la figura de una persona mayor cuidando de otra que se encuentre en situación de dependencia, con lo cual el envejecimiento de los/as cuidadores/as también pasará a edades superiores. es por ello que cada día irá adquiriendo mayor relevancia la atención a los/as cuidadores/as (1). la prestación informal de cuidados se encuentra incluida dentro de un amplio abanico de actividades que ofrece el sistema social sobre el estado de salud. el/la cuidador/a informal se puede definir como la persona que presta cuidados a individuos no autónomos que se encuentran en situación de dependencia, que provienen del círculo familiar, vecinal, amigos u otras personas, y que no reciben remuneración económica por la función fundamental que realizan hacia la sociedad (2, 3). entre los/as cuidadores/ as informales hay algunos/as que dedican gran parte de su tiempo diario al cuidado de un/a familiar (4, 5). el consejo de europa, en una de sus recomendaciones, define la dependencia como “la necesidad de ayuda o asistencia importante para las actividades de la vida cotidiana”, y también, como el “estado en el que se encuentran las personas que por razones ligadas a la falta o la pérdida de autonomía física, psíquica o intelectual, tienen necesidad de asistencia y/o ayudas importantes a fin de realizar los actos corrientes de la vida diaria y, de modo particular, los referentes al cuidado personal” (6). una persona se encuentra en situación de dependencia cuando su autonomía personal está disminuida, es decir, no es capaz de realizar de forma independiente, sin la ayuda de otra persona, las actividades básicas de la vida diaria. la dependencia de una persona mayor vendrá determinada por diferentes causas y estas varían de un individuo a otro. las causas pueden ser debidas a “factores físicos (fragilidad física, problemas de movilidad, enfermedades, limitaciones sensoriales y consumo de fármacos), factores psicológicos (trastornos psicológicos) y factores contextuales” (7). todo proceso o cambio requiere de una formación para aumentar la eficacia de los/as cuidadores/as y corregir las deficiencias que se pueden generar en los/as mismos/as; al hablar de formación se hace referencia a la orientación, supervisión y valoración que los profesionales sanitarios, fundamentalmente enfermería, desempeñan con la educación sanitaria y con la educación para la salud (8). diversas investigaciones describen en el perfil del/la cuidador/a informal el nivel de estudios de los mismos, que generalmente responde a un nivel bajo (4, 9-12). principalmente, son los profesionales de enfermería que trabajan en el ámbito de la atención primaria los que deben proporcionar a los/as cuidadores/as informales la formación requerida (13-15) mediante acciones encaminadas a la promoción de la salud para prevenir o diagnosticar a tiempo dictámenes enfermeros como puede ser el riesgo o cansancio en el rol del/la cuidador/a (16). generalmente, los/as cuidadores/as informales no poseen la suficiente formación en cuanto a cuidados básicos generales (9, 17), ni de los procesos patológicos de las personas mayores a las que cuidan (18), siendo esta formación muy importante para asegurar una provisión de cuidados de calidad en tanto afecta a la salud de la persona cuidada y a la de ellos/as mismos. en el libro blanco de la dependencia se hace referencia a la formación de los/as cuidadores/as informales, donde se expone que la formación que estos deben recibir ha de estar organizada en función del grado de intervención y la proximidad de estos con la persona mayor en situación de dependencia (19). por ello, es necesario difundir programas de formación e información que incorporen buenas prácticas para poder proveer mejores cuidados (20, 21). en el artículo “the domicile care: the vision of the dependent person and the caregiver”, realizado por zem-mascarenhas y barros (9), plantearon como objetivo caracterizar a la persona en situación de dependencia que requiere cuidados en el hogar y a sus respectivos cuidadores/as. en relación con la formación señalan que el/la cuidador/a se siente inseguro, temeroso y atento en la realización de las numerosas actividades relacionadas con el cuidado, y que por lo general no recibe ningún tipo de preparación para ello (9). siguiendo la misma línea, en otro estudio burgos et al. (22), sobre la caracterización y el nivel de conocimiento del/la cuidador/a informal de usuarios con dependencia severa, exponen que la importancia del nivel de conocimiento de los/as cuidadores/as in244 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 formales radica en que las familias son las que prestan, en mayor medida, los cuidados que requieren las personas dependientes, siendo el/la cuidador/a informal el que satisface las necesidades que la persona cuidada no puede cubrir por sí misma. de la muestra analizada en este estudio se extrae que los/as cuidadores/as informales tienen un nivel de conocimiento bueno en un 40%, y que un 44% cursaron educación media. proponen que debe considerarse la realización de actividades educativas o capacitaciones de forma constante dirigidas a los/as cuidadores/as, ya que las actividades educativas son eficaces para la transmisión de conocimiento, optimizan el desempeño en los cuidados y mejoran la calidad de vida tanto de ellos como de la persona en situación de dependencia. por ello, la atención primaria en salud deberá abordar aquellas áreas deficientes a las cuales se enfrenta el/la cuidador/a informal, mejorando de esta forma la calidad de vida tanto de la persona dependiente como la del/la cuidador/a (22). en el artículo “interacción de enfermería y cuidadoras informales de personas dependientes”, realizado por delicado et al. (15), se afirma que son los profesionales de enfermería que trabajan en el ámbito de la atención primaria los que deben proporcionar conocimientos y formación a los/as cuidadores/ as informales sobre la enfermedad que padece la persona dependiente, la realización de la higiene, los cambios posturales, la preparación de dietas adecuadas, las medidas preventivas y de seguridad, entre otros, siendo estos profesionales de enfermería los que facilitan a los/as cuidadores/as informales la comunicación mediante la escucha activa, el acceso a los recursos para el cuidado de la persona dependiente y el apoyo a el/la cuidador/a. sin embargo, este artículo recoge que los/as enfermeros/as consideran que tienen una falta de formación para la realización de tareas de apoyo hacia la persona cuidadora (15). por esta razón surge la necesidad de conocer la formación que reciben los/as cuidadores/as informales de personas mayores dependientes de acuerdo con los cuidados que requieran estas personas, así como la institución y los profesionales que imparten la formación. materiales y métodos estudio de corte transversal, descriptivo y correlacional. se plantea la siguiente hipótesis relacional: la formación que han recibido los/as cuidadores/as informales es mayor en relación con el tiempo que llevan dedicándose al cuidado (23-25). la investigación se ha llevado a cabo en el periodo de octubre del año 2010 al mes de mayo del año 2011, en la unidad de gestión clínica3 nuestra señora de las nieves de la zona básica de salud (zbs) de los palacios y villafranca del distrito sevilla sur (españa). este es un centro de características urbanas que atiende a una población de 36.824 habitantes, de los cuales 3866 (10,5%) tienen una edad de 65 años o más. esta investigación cuenta con la aprobación del comité de ética e investigación sanitaria del distrito de atención primaria de salud sevilla sur (españa). para captar a los/as cuidadores/as informales de las personas mayores en situación de dependencia de la zona básica se han localizado las personas cuidadoras que se encuentran al cuidado de mayores en situación de dependencia incluidas en el programa de cuidadores/as “tarjeta más cuidados” de la unidad de gestión clínica, a través de los registros de atención primaria con la ayuda de las enfermera gestoras de casos. la población total de cuidadores/as de personas dependientes mayores de 65 años asciende a 488, de las cuales se han seleccionado mediante muestreo no probabilístico intencional a los/as 41 cuidadores/ as que iban a acudir al menos a dos de las reuniones de grupo con la enfermera gestora de casos, ya que interesaba a las investigadoras que el lugar para realizar la entrevista personal no fuera el hogar, a fin de que los/as cuidadores/as pudieran tener una mayor atención y disponibilidad; también para poderles administrar el mismo cuestionario dos veces por parte de las dos investigadoras (24, 25). como criterios de inclusión se establecieron los siguientes: el/la cuidador/a debe llevar al menos dos meses cuidando a la persona mayor para que les haya dado tiempo de recibir alguna formación relacionada con los cuidados que requieren estas personas dependientes; en el caso de que hubiera más de un/a cuidador/a informal, se elegiría aquel que llevase más tiempo dedicándose al cuidado diario de la persona cuidada; la aceptación de los/as cuidadores/as de participar en la investigación, y que asistieran como mínimo a dos reuniones de grupo con la enfermera gestora de casos. los/as cuidadores/as seleccionados/as tenían que dar previamente su consentimiento por escrito antes de la recogida de 3 las unidades de gestión clínica (ucg) son un diseño organizativo para la gestión de los centros sanitarios que fomenta la implicación de los/as profesionales sanitarios en la gestión de los mismos, refuerza la continuidad asistencial entre los niveles de atención sanitaria, mejora la organización del trabajo y aumenta la satisfacción de los/as pacientes. 245 formación del cuidador informal: relación con el tiempo de cuidado a personas dependientes... l encarnación maría zambrano-domínguez, maría dolores guerra-martín datos, y una de las investigadoras les pasaba un cuestionario de elaboración propia (anexo 1) en una de las reuniones, y en una reunión posterior la segunda investigadora les volvía a pasar el mismo cuestionario. se eligió como instrumento de recolección de datos el cuestionario, ya que con este se realiza “un proceso estructurado de recogida de información a través de una serie predeterminada de preguntas” (23). para la elaboración del cuestionario nos hemos basado en la revisión de la literatura (4, 1012, 26, 27), y para la validez de contenido (24, 25) se han tenido en cuenta las opiniones de dos profesoras universitarias de enfermería y de dos enfermeras y un médico de atención primaria. todos los datos que se recogen a partir del cuestionario han sido aportados por el/la cuidador/a informal mediante entrevistas personales (23-25). las variables que se han incluido son las siguientes: variables universales (edad, género, estado civil, situación laboral y nivel de estudios), variables independientes (parentesco/relación con la persona cuidada, tiempo que lleva de cuidador/a en general, tiempo que dedica diariamente al cuidado, institución y profesionales que imparten la formación), variable dependiente (formación recibida). el cuestionario consta de diecisiete preguntas, algunas de selección múltiple, y otras de formulación cerrada o abierta, de las cuales se han utilizado para este trabajo las nueve preguntas relacionadas con la temática tratada. para el cálculo de la confiabilidad del instrumento el procedimiento utilizado ha sido el de medida de estabilidad, por lo que el cuestionario ha sido administrado por las dos investigadoras a todos/as los/as integrantes de la muestra en dos reuniones distintas (25). se ha realizado un análisis exploratorio de los datos para identificar valores atípicos (26, 27), tanto para el total del grupo como para los diferentes subgrupos. para el análisis de los datos se ha utilizado el paquete estadístico spss versión 18.0. para caracterizar las variables de tipo cualitativo se han realizado tablas de distribución de frecuencias y porcentajes, y para las cuantitativas medidas de centralización y dispersión. en aquellas distribuciones que se muestran simétricas se ha calculado la media y la desviación típica. en aquellas distribuciones que se han mostrado asimétricas se ha determinado la mediana y el recorrido intercuartílico (p25, p75). en todas ellas se han calculado intervalos de confianza al 95%. para valorar la relación entre dos variables de tipo cualitativo se han realizado tablas de contingencia y se ha aplicado el test de chi-cuadrado o la probabilidad exacta de fischer (tablas 2*2 grupos pequeños). para valorar la relación entre dos variables de tipo cuantitativo se ha calculado el coeficiente de correlación de pearson o rho-spearman según criterio de aplicación. para analizar la relación entre una variable cualitativa dicotómica y una cuantitativa se ha realizado el test t de student una vez validados los requisitos de aleatoriedad, normalidad e igualdad de varianza. en el caso de no cumplirse el requisito de igualdad de varianza se el test t de student con la corrección de welch, y en caso de no cumplirse el requisito de normalidad, se ha realizado la prueba no paramétrica umann withney. el propósito de aplicar estadística inferencial es conocer la posible relación que puede existir entre la variable formación o capacitación recibida con el tiempo en años como cuidador/a en general, y el tiempo en horas que el/la cuidador/a dedica diariamente al cuidado de la persona dependiente mayor de 65 años. resultados la muestra se corresponde con un 8,40% (41 cuidadores/as) de la población total (488 cuidadores/as), teniendo un intervalo de confianza de 14,66 para un intervalo de confianza del 95%. en las dos mediciones de los cuestionarios (confiabilidad por test-retest) se han obtenido el 100% de respuestas iguales en todas las preguntas cerradas, y en las preguntas abiertas los resultados han sido también iguales (cambiando solo alguna denominación por otra de significado parecido o sinónimo), por lo que la confiabilidad del instrumento ha sido elevada (25). la edad de quienes se encuentran al cuidado de una persona mayor en situación de dependencia oscila entre 31 y 67 años. un 87,8% de los/as cuidadores/as son mujeres. del total de la muestra de cuidadores/as, 36 (87,8%) casos están casado/as. en cuanto a la actividad laboral de las personas cuidadoras, el 80,5% se encuentran desempleadas. en relación con el parentesco entre persona cuidadora-persona cuidada, 68,3% de los/as cuidadores/as son hijas/os. el 50% de los/as cuidadores/as informales llevan como cuidador/a en general 4 (2,5;10) o más años, siendo la media de 7,6 (7,7) años. el promedio del tiempo dedicado diariamente al cuidado en horas es de 10,9 (3,6), ic 95% (9,7-11,9) horas. con respecto al nivel de estudios de las personas cuidadoras, 16 (39%) de ellas no tienen ningún tipo de estudios, y el resto 246 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 tiene estudios donde se puede incluir la educación primaria4 16 (39%), secundaria5 3 (7,3%), bachillerato6 1 (2,4%), grado medio de formación profesional7 2 (4,9%) y licenciatura8 3 (7,3%). en cuanto a la formación recibida en relación con los cuidados que precisa la persona cuidada, 17 (41,5%) individuos cuidadores respondieron que sí han recibido algún tipo de acción formativa; en cuanto al tipo de capacitación, 16 (94,1%) la han recibido sobre los cuidados básicos generales que precisa la persona a la que cuidan. un 76,5% de las personas cuidadoras ha recibido adiestramiento en la unidad de gestión clínica y un 11,8% la ha recibido por parte de la ayuda domiciliaria, el resto de las personas cuidadoras ha recibido la formación en el hospital o por parte de la consejería de salud (cuidabús). el 100% de las sesiones formativas han sido impartidas por profesionales enfermeros/as, en los que se incluyen los enfermeros/as en general o de familia, o los/as enfermeros/as gestores/as de casos. de las 17 (41,5%) personas cuidadoras que han recibido algún tipo de formación, 7 (17,1%) de ellas la han recibido de dos tipos, siendo la segunda relacionada con los cuidados del cuidador, impartida por los profesionales enfermeros/as en la unidad de gestión clínica a 4 personas (57,1%), a 2 (28,6%) por la ayuda domiciliaria, y la restante por la consejería de salud (cuidabús). al hacer un análisis bivariado entre la variable formación recibida con las variables de tipo cuantitativo recogidas en el estudio referidas al/la cuidador/a informal, se obtienen los resultados que se detallan en la tabla 1. en la tabla 1 se observa que no se han encontrado diferencias estadísticamente significativa entre la edad (p = 0,646) y el tiem4 la educación primaria en españa tiene carácter obligatorio y gratuito. comprende tres ciclos de dos años cada uno, en total seis cursos académicos que se seguirán ordinariamente entre los seis y los doce años de edad. 5 la educación secundaria obligatoria (eso) es una etapa educativa obligatoria y gratuita en españa, que completa la educación básica. consta de cuatro cursos académicos que se realizarán ordinariamente entre los 12 y los 16 años de edad. 6 el bachillerato en españa tiene carácter voluntario, para acceder al mismo se requiere haber obtenido la eso. consta de dos cursos académicos que se realizan ordinariamente entre los 16 y 18 años de edad. 7 la formación profesional en españa son todos los estudios y aprendizajes encaminados a la inserción, reinserción y actualización laboral, cuyo objetivo principal es aumentar y adecuar el conocimiento y las habilidades de los actuales y futuros trabajadores a lo largo de toda la vida. al ciclo formativo de grado medio en españa se accede después de haber obtenido el título de eso o bien haciendo una prueba específica de acceso a grado medio para la que es necesario tener 17 años. 8 la licenciatura en españa es el título intermedio o final que se obtiene al terminar una carrera universitaria compuesta de dos ciclos (entre 4 y 6 años). tabla 1. relación de la variable formación recibida con otras variables de tipo cuantitativo referidas al/la cuidador/a informal fuente: elaboración propia. variable: formación recibida variables sí n = 17 x(d); ic95% no n = 24 x(d); ic95% nivel de significación (p<) edad 49,6 (5,4); (46,752,3) 48,4 (9,1); (44,552,2) p = 0,646 tiempo que lleva de cuidador/a en general 10,6 (8,1); (6,414,7) 5,5 (6,7); (2,68,3) p = 0,011 tiempo que dedica diariamente al cuidado 10,8 (3,8); (9,112,4) 10,9 (3,8); (9,3,12,5) p = 0,895 po dedicado diariamente al cuidado en horas (p = 0,895) entre los/as cuidadores/as que han recibido formación frente a los/ as cuidadores/as que no la han recibido. sin embargo, se detecta que los/as cuidadores/as que llevan más años dedicándose al cuidado de una persona dependiente mayor de 65 años son los que han recibido en un número elevado algún tipo de capacitación formativa con respecto a los/as cuidadores/as que llevan menos años cuidando a una persona mayor dependiente que son los/ as que no han recibido en su mayoría alguna actividad formativa. dado lo anterior se puede afirmar que las diferencias observadas entre los tiempos que lleva de cuidador/a en general en ambos grupos no son debidas al azar (p = 0,011). no se han encontrado diferencias estadísticamente significativas entre la variable formación recibida y sexo (p = 0,382) y nivel de estudios (p = 0,443), por lo que se puede afirmar que la variable formación recibida y las demás variables de tipo cualitativo son independientes (tabla 2). al analizar la edad de los/as cuidadores/as informales y el tiempo dedicado en años al cuidado en general, se detecta que no existe correlación estadísticamente significativa entre la edad de los/as cuidadores/as y el tiempo dedicado al cuidado (r = 0,079; p = 0,624) (figura 1). 247 formación del cuidador informal: relación con el tiempo de cuidado a personas dependientes... l encarnación maría zambrano-domínguez, maría dolores guerra-martín figura 1. relación de la edad de los/as cuidadores/as con el tiempo dedicado al cuidado en general, en años existen diferencias significativas (p = 0,012) entre el género y el tiempo que llevan cuidando a la persona mayor de 65 años, por cuanto las mujeres llevan en promedio 6,5 (3; 11,5) años y los hombres 1 (0; 3) año. discusión/conclusiones en relación con el perfil de la persona cuidadora que se encuentra al cuidado de un mayor en situación de dependencia en la zbs de los palacios y villafranca, se constata que en un porcentaje muy elevado las tareas de cuidado recaen en las mujeres, resultados que coinciden con otros estudios (4, 28, 29), donde los hombres aparecen en un escaso porcentaje como cuidadores. la edad media obtenida de los/as cuidadores/as del estudio es de 48,8 años, lo cual difiere de los resultados obtenidos en otros estudios donde se recoge que la edad de los/as cuidadores/as es más avanzada (4,10-12). con respecto al estado civil de los/as cuidadores/as informales, en su mayoría están casados/ as y se encuentran desempleados/as, resultados que coinciden con los obtenidos en otros estudios (4, 29, 30). en cuanto al parentesco de la persona cuidadora, el que aparece de forma más prevalente es el de las/os hijas/os, siendo estos datos concordantes con los obtenidos en otra investigación (4). el nivel de estudios de los/as cuidadores/as es escaso, ya que un porcentaje elevado no los tiene o no terminó los estudios primarios, datos que se reflejan también en otras investigaciones (912). sin embargo, los resultados no coinciden con los obtenidos en otra investigación, donde se recoge que las personas cuidadoras tienen un nivel de estudios primario (4), ni con otra donde un alto porcentaje de los/as cuidadores/as cursó educación media (22). más de la mitad de las personas entrevistadas no han recibido ninguna acción formativa, por lo que los resultados obtenidos en nuestro estudio concuerdan con los hallazgos de otra investigación (9). en la investigación llevada a cabo por burgos et al., el 60% de los/as cuidadores/as había participado en un programa de formación, y el 40% presentaba un nivel de conocimiento bueno (22). el tipo de formación que han recibido los/as cuidadores/ as está relacionado en su mayoría con los cuidados básicos generales que precisa la persona mayor dependiente cuidada coincidiendo con otros estudios (9, 26), seguida de una formación relacionada con la enfermedad de la persona a la que cuidan, resultados también concordantes con otros estudios (31, 32). tabla 2. relación entre la variable formación recibida y las variables sexo y nivel de estudios variable: formación recibida sexo/nivel de estudios han recibido formación n = 17 x (%) no han recibido formación n = 24 x (%) nivel de significación (p<) mujer 16 (44,4%) 20 (55,6%) p = 0,382 hombre 1 (20%) 4 (80%) con estudios 13 (76,5%) 15 (65,2%) p = 0,443 sin estudios 4 (23,5%) 8 (34,8%) fuente: elaboración propia. fuente: elaboración propia. ed ad c ui da do re s/ as tiempo dedicado al cuidado en años 248 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 las acciones formativas han sido impartidas mayoritariamente en la unidad de gestión clínica coincidiendo con delicado et al. (15), y en un porcentaje escaso por el cuidabús (33), siendo estas dos instituciones las responsables de la formación de los/ as cuidadores/as informales de personas mayores en situación de dependencia (22, 34). los profesionales que generalmente son responsables de la formación de los/as cuidadores/as son los/as enfermeros/as, resultado concordante con otras investigaciones (13-15, 34-36). respecto a las características de la persona responsable del cuidado nuestros resultados determinan que el promedio de años dedicado al cuidado es de 7,6, estos datos discrepan de los obtenidos en otra investigación donde el tiempo medio dedicado al cuidado en años es de 4,2 (30); sin embargo, se acerca a los resultados obtenidos en otros estudios (4, 11). en cuanto a las horas diarias dedicadas al cuidado hemos obtenido como resultado que el/la cuidador/a dedica un tiempo medio de 10,9 horas al día, siendo este dato similar a los obtenidos en las bibliografías consultadas (4, 11, 27). en la revisión de la literatura científica se observa una amplia oferta de cursos formativos para los/as cuidadores/as, sin embargo, en nuestro estudio los/as cuidadores/as refieren que no tienen tiempo para formarse. se evidencia la necesidad de replantear desde las instituciones sanitarias nuevas estrategias de abordaje para que los/as cuidadores/as puedan asistir a las sesiones de formación. tenemos que resaltar la necesidad de evaluar los programas formativos que ofrecen las distintas instituciones para conocer y valorar la efectividad y la eficiencia de los mismos. por último, debemos decir que se confirma la hipótesis planteada, ya que tanto los/as cuidadores/as que dedican más horas al día al cuidado de una persona mayor dependiente, como aquellos/as que llevan más años dedicándose al cuidado, han recibido mayor formación. referencias 1. doncel lv, gutiérrez t. las personas mayores y su situación de dependencia en españa: aspectos demográficos de la población mayor en españa [serial on line] 2006, 21-51 [consultado el 18 de enero de 2011]. disponible en: http://vlex. com/vid/aspectos-demograficos-poblacion-443009 2. wright k. the economics of informal care of the elderly. centre for health economics. new york: university of york; 1983. 3. villar f. discapacidad, dependencia y autonomía en la vejez. gerona: aresta; 2009. 4. velasco e. educación grupal a cuidadores. en: sánchez mb, gómez j, duarte g. editors. educación para la salud. madrid: fuden; 2008. pp. 367-82. 5. garcía mm, mateo i, gutiérrez p. cuidados y cuidadores en el sistema informal de salud. granada: escuela andaluza de salud pública; 1999. 6. consejo de europa recomendación r. (98) 9. del comité de ministros relativa a la dependencia [serial on line] 1998 [consultado el 21 de enero de 2011]. disponible en: http://www.imsersomayores.csic.es/documentacion/biblioteca/registro.htm?id=51023 7. sociedad española de geriatría y gerontología. ¿por qué una persona mayor es dependiente? [serial on line] 2011 [consultado el 21 de enero de 2011]. disponible en: http://www.segg.es/book/%c2%bfpor/que/una/persona/mayor/es/dependiente 8. martínez af. la dependencia, los cuidadores y la necesidad de formación. enfermería docente 2007;87:2-4. 9. zem-mascarenhas sh, barros ac. the domicile care: the vision of the dependent person and the caregiver. revista electrônica de enfermagem [serial on line] 2009;11(1):45-54. 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[consultado el 21 de febrero de 2011]. disponible en: http://0-www. index-f.com.fama.us.es/evidentia/n13/291articulo.php 13. ubiergo mc, regoyos s, vico v, reyes mv. el soporte de enfermería y la claudicación del cuidador informal. enfermería clínica 2005;15(4):199-205. 14. agulló ms. las enfermeras y la ley de dependencia en españa. index de enfermería 2006;52(53):7-9. 15. delicado mv, candel e, alfaro a, lópez m y garcía c. interacción de enfermería y cuidadoras informales de personas dependientes. atención primaria 2004;23(4):193-99. 16. herdman th. diagnósticos enfermeros: definiciones y clasificación, 2009-2011. barcelona: elsevier; 2010. 17. gil-garcía e, escudero-carretero m, prieto-rodríguez ma, frías-osuna a. vivencias, expectativas y demandas de cuidadoras informales de pacientes en procesos de enfermedad de larga duración. enfermería clínica 2007;15(4):220-6. 18. martín r, buenestado c, caballero ml, lora f. intervención educativa dirigida a cuidadores de personas mayores dependientes. atención primaria 2000;25(7):148-53. 19. libro blanco de la dependencia. cuidados de larga duración a cargo de la familia: el apoyo informal. capítulo 3. madrid: ministerio de trabajo y asuntos sociales; 2005. pp. 167-226. 20. red2red consultores. valoración económica de los cuidados a personas dependientes. zerbitzuan 45. revista de servicios sociales 2009;73(6):73-81. 21. red2red consultores. cuidados a personas dependientes prestados por mujeres: valoración económica. madrid: instituto de la mujer; 2008. 22. burgos p, figueroa v, fuentes m, quijada i, espinoza e. caracterización y nivel de conocimiento del cuidador informal de usuarios con dependencia severa adscrito al centro de salud violeta parra-chillán. theoria 2008;17(2):7-14. 23. argimon jm, jiménez j. métodos de investigación clínica y epidemiológica. madrid: elservier; 2004. 24. polit df, hungler bp. investigación científica en ciencias de la salud. 6 ed. méxico: mcgraw-hill interamericana; 2000. 25. hernández r, fernández-collado c, baptista p. metodología de la investigación, 4 ed. méxico: mcgraw-hill; 2006. 26. lozano a, martín m, ortiz m, quintero r, pérez e, pérez l. elaborar un programa educativo para los cuidadores de personas mayores que contemplen los cuidados de salud. sesiones para la salud 2004;21:3-7. 27. lópez mj, orueta r, gómez s, sánchez a, carmona j, alonso fj. el rol de cuidador de personas dependientes y sus repercusiones sobre su calidad de vida y su salud. revista clínica medicina familiar [serial on line] 2009;2(7): 332-39. [consultado el 20 de mayo de 2011]. disponible en: http://www.scamfyc.org/html/publicaciones.html 28. arriola mj, setién ml. cuidadores de ancianos dependientes. demandas y estrategias de apoyo. portularia 2004;4:327-338. 29. larrañaga i, martín u, bacigalupe a, begiristáin jm, valderrama mj, arregi b. impacto del cuidado informal en la salud y la calidad de vida de las personas cuidadoras: análisis de las desigualdades de género. gaceta sanitaria 2008; 22(5):443-50. 30. bódalo-lozano e. cambios en los estilos de vida de las cuidadoras de personas dependientes. portularia 2010;10(1):85-97. 31. gelmini g, morabito b, braidi g. educational and formative training reduce stress in the caregivers of demented patients. archives of gerontology geriatrics 2009;49(suppl 1):s119-24. 32. fernández m, garcía t. conceptual structure of the family caregivers of the dependent elderly’s tension. revista electrônica de enfermagen 2009;11(3):469-76. 33. consejería para la igualdad y bienestar social. cuidabús. el cuidado en el entorno familiar de personas en situación de dependencia [serial on line] 2010 [consultado el 27 de abril de 2011]. disponible en: https://www.juntadeandalucia. es/igualdadybienestarsocial/extranet/cuidabus/presentacion.php 34. decreto 137/2002 de 30 de abril. plan de apoyo a las familias andaluzas. consejería de salud [serial on line] 2002 may;4(52):7127-34. [consultado el 27 de abril de 2011]. disponible en: http://www.juntadeandalucia.es/servicioandaluzdesalud/principal/documentosacc.asp?pagina=ges_cal_palnapoyofam_4 250 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 35. dirección regional de desarrollo e innovación de cuidados. servicio andaluz de salud. manual de la gestión de casos en andalucía: enfermeras gestoras de casos en atención primaria. sevilla: dirección regional de desarrollo e innovación en cuidados [serial on line] 2007 [consultado el 18 de mayo de 2011]. disponible en: http://www.index-f.com/ lascasas/documentos/lc0245.pdf. 36. berjano e. dependencia y calidad de vida en las personas mayores. revista multidisciplinaria de gerontología 2005;15(3):144-54. anexo 1. cuestionario de recolección de datos del/la cuidador/a informal 1. género: 1. femenino 2. masculino 2. edad ____________ años. 3. estado civil: 1. soltero/a 2. casado/a 3. viudo/a 4. separado/a y/o divorciado/a 4. situación laboral: 1. empleado/a a tiempo parcial 2. empleado/a a tiempo completo 3. desempleado/a 4. jubilado/a (por edad o invalidez) 5. otros (especificar): 5. parentesco/relación con la persona cuidada: 1. hija/o 2. esposa/o o /compañera/o 3. nuera/yerno 4. madre/padre 5. sobrina/o 6. vecina/o 7. amiga/o 8. nieta/o 9. otros/as (especificar): 6. ¿dispone de alguna persona u otro recurso que le ayuda a cuidar? sí______ no______ 7. en caso afirmativo especifique cuál: ________________________________________________________________________________________________ ________________________________________________________________________________________________ 251 formación del cuidador informal: relación con el tiempo de cuidado a personas dependientes... l encarnación maría zambrano-domínguez, maría dolores guerra-martín 8. nivel de estudios: 1. no sabe leer ni escribir 2. sabe leer y escribir 3. sin estudios 4. primaria incompleta 5. primaria completa (hasta los 12 años egb) 6. secundaria incompleta 7. secundaria completa (hasta los 16 años eso, bup) 8. grado medio de formación profesional (fp). especificar: _____________________________________________________ 9. estudios de bachiller superior (hasta los 18 años cou) 10. grado superior de fp. especificar: ____________________________________________________________________ 11. diplomatura. especificar: ___________________________________________________________________________ 12. licenciatura. especificar: ___________________________________________________________________________ 13. dea o máster oficial. especificar: _____________________________________________________________________ 14. doctorado. especificar: ____________________________________________________________________________ 15. otros (especificar): _______________________________________________________________________________ 9. ¿ha recibido usted alguna vez formación sobre los cuidados que necesita la persona a la que cuida? sí_____ no_____ (pase a la pregunta 13) 10. formación recibida en relación con los cuidados que precisa la persona que cuida, institución y profesional/es que se la imparte/n: 11. tiempo que lleva de cuidador/a: menos de un año: _____ (señalar con una cruz) a partir de un año: _____ especificar cuántos años:_____________________ 12. tiempo que dedica al cuidado diariamente: _____________________ horas. 13. ¿cree usted necesario formarse (o seguir formándose) sobre el/los problemas o cuidados que necesita la persona que cuida? sí_____ no_____ 14. especifique por qué en ambos casos: ________________________________________________________________________________________________ ________________________________________________________________________________________________ 15. ¿tendría usted posibilidades de recibir formación? sí_____ no_____ 16. especifique por qué en ambos casos: ________________________________________________________________________________________________ ________________________________________________________________________________________________ formación institución profesional/es 69 80 el hijo ajeno.indd 69 melva patricia ocampo1 el hijo ajeno: vivencia de madres de niños prematuros hospitalizados 1 magíster en enfermería con énfasis en cuidado al niño. universidad del valle, cali, colombia. melvapa67@yahoo.com.mx recibido: 28 de febrero de 2012 aceptado: 18 de febrero de 2013 año 13 vol. 13 nº 1 chía, colombia abril 2013  69-80 resumen objetivo: analizar el nacimiento de un niño prematuro y su posterior hospitalización en la unidad de cuidado intensivo neonatal, el cual casi siempre toma por sorpresa a sus padres, quienes a partir de ese momento se ven inmersos en una serie de situaciones que nunca consideraron en sus vidas y que determinan la relación con su hijo y su capacidad de cuidarlo. método: para conocer las vivencias de las madres durante la gestación, el nacimiento y la hospitalización de su hijo prematuro se realizó un estudio fenomenológico con diez madres. resultados: los hallazgos muestran que las mujeres vivieron la gestación como una sorpresa de corta duración y final inesperado, percibieron a su hijo distante y ajeno, lo cual es diferente a lo que viven las madres de niños nacidos sanos y a término. las situaciones que las mujeres vivieron durante el nacimiento y la hospitalización de su hijo retardaron la apropiación del rol de madre cuidadora debido a las restricciones para estar a su lado en la ucin y participar de su cuidado. conclusión: estos hallazgos indican que es prioritario implantar estrategias institucionales de cuidado que propendan por la cercanía y el contacto madre-hijo como el cuidado canguro intrahospitalario. palabras clave relaciones madre-hijo, recién nacido, prematuro, cuidado del niño. (fuente: decs, bireme). 70 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 the alien child: the experience of mothers of hospitalized premature children abstract objective: analyze the birth of child born prematurely and hospitalized in a neo natal intensive care unit, which usually takes the child’s parents by surprise. from the moment of birth, parents find themselves facing a series of circumstances they had not previously considered in their lives and that determine their relationship as well as their ability to care for their child. method: a ten-mother case study was undertaken in order to become familiar with a mother’s experience during the pregnancy, birth and hospitalization of their premature children. results: findings reveal that contrary to mothers who deliver healthy full term babies, these mothers experience a surprisingly short and an abruptly ending pregnancy; they felt their child was distant and alien to them. because of the restrictions of the nicu, the circumstances surrounding the birth and hospitalization of their child delayed their appropriation of their role as a caring mother. conclusion: these findings reveal that implanting institutional care strategies that encourage closeness and mother-child contact such as intra-mural kangaroo care is paramount. key words mother-child relationships, newborn, premature, child care. (source: decs, bireme). o filho distante: vivência de mães de filhos prematuros hospitalizados resumo objetivo: realizar o nascimento de um filho prematuro e sua posterior hospitalização na unidade de tratamento intensivo (uti) neonatal, o que quase sempre pega os pais de surpresa, os quais, a partir deste momento, se veem envolvidos em uma série de situações que nunca consideraram em suas vidas e que determinam a relação com seu filho e sua capacidade de cuidá-lo. métodos: para conhecer as vivências das mães durante a gestação, o nascimento e a hospitalização de seu filho prematuro, realizou-se um estudo fenomenológico com dez mães. resultados: os resultados mostram que as mulheres viveram isso como uma surpresa de curta duração e final esperado, e assim elas perceberam seu filho distante, o que é diferente daquilo que vivem as mães de crianças nascidas saudavelmente. as situações que as mulheres viveram durante o nascimento e a hospitalização de seu filho retardaram a apropriação do papel de mãe cuidadora devido às restrições para estar ao seu lado na uti neonatal e participar de seu cuidado. conclusões: os resultados indicam que é prioritário implantar estratégias institucionais de cuidado que tendam pela proximidade e o contato mãe-filho como o método canguru intra-hospitalar. palavras-chave relações mãe-filho, recém-nascido, prematuro, cuidado da criança. (fonte: decs, bireme). 71 el hijo ajeno: vivencia de madres de niños prematuros hospitalizados l melva patricia ocampo introducción en general, las personas que esperan un hijo suponen que tanto la gestación como el parto tendrán un curso normal, por lo que casi nunca están preparadas para un nacimiento prematuro ni para la hospitalización de su hijo en una unidad de cuidado intensivo neonatal (ucin). estudios realizados en los últimos años han permitido conocer parte de lo que sucede al interior de las familias cuando un recién nacido requiere hospitalización, cómo vivencian el proceso, qué pasa con sus roles, cuáles son sus dudas, temores, fortalezas, expectativas, mayores esperanzas y alegrías (14). hay evidencia de que la separación durante la hospitalización rompe con la dinámica del cuidado parental y tiene consecuencias en todos los integrantes del grupo familiar (5, 6). por esto, es común que al momento de anunciar la salida del niño del hospital, los padres se sientan inseguros, desconfíen de sus posibilidades de cuidar exitosamente al bebé, y tengan temores reales e imaginados que surgen de las experiencias vividas en la ucin (7-9). se ha reportado que los padres a quienes se les permite el contacto temprano con el recién nacido prematuro hospitalizado y participan de su cuidado diario en la medida que la situación clínica lo permite, al momento de la salida del hospital expresan sentirse más seguros para ejercer su papel de cuidadores en casa. en nuestro contexto, la mayoría de las familias de los niños prematuros no reciben acompañamiento para afrontar el duelo ocasionado por el nacimiento y la hospitalización, y no están aún reorganizadas cuando el niño es dado de alta ni están preparadas para asumir los cambios que tendrán que implementar (5, 7-9). los miembros del equipo de salud y, en especial, los profesionales de enfermería de la ucin (3, 8, 9) deben reconocer y comprender la complejidad de las vivencias de los padres para que puedan dimensionar sus verdaderas necesidades y ofrecer acciones de cuidado que les proporcionen elementos adaptativos, que indudablemente van más allá de dar información sobre la enfermedad del bebé y los procedimientos realizados. poco a poco, la mirada del personal de salud se dirige a los padres de los niños hospitalizados en la ucin para reconocerles y darles el espacio que tienen por derecho propio al lado de sus hijos. no obstante, en nuestro país los padres se consideran visitantes de sus hijos hospitalizados y los horarios de visita solo permiten el ingreso por periodos de 30 a 60 minutos, dos veces al día. con el objetivo de describir las vivencias de las madres durante la gestación y hospitalización de su hijo prematuro se realizó un estudio fenomenológico interpretativo que mostró que las mujeres viven un proceso para convertirse en madres competentes en el cuidado de su bebé nacido antes de término. en este proceso se identifican varios momentos: 1) la gestación, que en general fue sorpresiva, corta e insuficiente para prepararse como madre; 2) ser la madre de un “hijo ajeno”, que pertenece a las personas calificadas para cuidarlo en la ucin, quienes de manera constante la excluyen y solo le permiten verlo durante breves espacios de tiempo; 3) recobrar al hijo al ser dado de alta y poder actuar como madre ante la familia, los vecinos y amigos. a partir del egreso del hijo del hospital, el proceso continúa al 4) asumir su cuidado en el hogar durante las 24 horas con mezcla de angustia, zozobra y entrega hasta llegar a sentir confianza en su papel de madre, al saber que puede ofrecerle a su hijo no solo su amor sino todos los cuidados que lo mantendrán alejado del hospital y le ayudarán a crecer como un niño normal. el objetivo de este artículo es presentar los resultados pertinentes a las vivencias de las madres durante la gestación y la hospitalización de su hijo. los hallazgos referentes a los otros momentos del proceso vivido por las madres serán objeto de otras publicaciones. método tipo de estudio. se utilizó la fenomenología interpretativa o hermenéutica basada en la filosofía de martin heidegger. la fenomenología interpretativa como método de investigación pretende “comprender las habilidades, prácticas y experiencias cotidianas y articular las similitudes y las diferencias en los significados, compromisos, prácticas, habilidades y experiencias de los seres humanos” (10). el mundo para heidegger no es único o universal, por el contrario, es diferente para cada ser humano según su cultura, tiempo, época histórica y la familia en que nace (10). la manera de “ser” y de “estar” en el mundo está guida por el significado que cada quien le atribuye a las cosas y situaciones en su mundo propio y particular. estos significados los va construyendo cada persona a partir de su cultura y apoyada en todas las formas de expresión de que dispone (11). muestra. estuvo conformada por 10 madres entre 18 y 37 años. con relación a la escolaridad de las participantes, una de las madres era analfabeta, seis tenían algún grado de educación secundaria, dos de nivel técnico y una de nivel profesional. cuatro de las diez mujeres vivían en unión libre con el padre de su hijo, 72 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 una era separada, dos eran solteras y vivían con familiares, dos estaban casadas y vivían con su pareja, y una era viuda. siete de las diez participantes trabajaban al momento de descubrirse embarazadas, sin embargo, para la fecha de las entrevistas solo una de ellas tenía vinculación laboral. las nueve restantes estaban dedicadas de tiempo completo al cuidado de su hijo y no sabían cuándo volverían a la actividad laboral. en cuanto a la gravidez, se encontró que para seis de las mujeres era el primer embarazo, tres eran grávidas por segunda vez, y una de ellas había estado embarazada tres veces. hubo dos mujeres con antecedentes de hijo prematuro. ninguna de las diez mujeres planeó ni buscó el embarazo; ocho asistieron a más de cuatro controles prenatales, una solo a uno y otra nunca asistió porque no sabía que estaba embarazada. el nacimiento de los niños se dio por cesárea en seis de los casos y en los demás por parto vaginal. la edad gestacional de los niños fluctuó entre 28 y 34 semanas y fue calculada por el test de ballard realizado al recién nacido durante las primeras 48 horas de vida en la ucin, para un promedio de 30,3 semanas. el peso al nacer fluctuó entre 670 y 1495 g, con un promedio de 1182 g. la hospitalización de los bebés fue en promedio de 34,2 días, siendo la más extensa de 75 días y la más corta de 16. todos los niños recibieron oxígeno complementario, cinco de ellos al 100 % y los otros cinco tuvieron máxima fio2 de 40 %; solo dos de ellos requirieron el uso de ventilación asistida, los ocho restantes necesitaron microcámara; a cuatro de los diez niños se les administró surfactante exógeno, uno necesitó cierre quirúrgico del ductus arterioso persistente, seis fueron politransfundidos y los diez recibieron fototerapia y nutrición parenteral total. la ucin donde los niños estaban hospitalizados está clasificada como nivel iii de complejidad, dispone de capacidad instalada para 46 niños recién nacidos, 12 de ellos críticamente enfermos y es centro de referencia del suroccidente colombiano. criterios de inclusión. ser madre de un recién nacido prematuro hospitalizado en una ucin al menos durante dos semanas; tener 18 o más años de edad; niño sin malformaciones congénitas mayores, ni presencia de estomas, ni dependencia de oxígeno que ameritaran cuidados especiales. antes de proceder a la recolección de la información se contactó a las madres de los niños prematuros hospitalizados en la ucin para verificar los criterios de inclusión, explicar las características del estudio e invitarlas a participar. todas aceptaron ser participantes, firmaron el consentimiento informado y recibieron una copia del mismo. recolección de la información. la información fue recolectada por la investigadora mediante dos entrevistas en profundidad con cada participante cuya duración fluctuó entre 45 y 90 minutos, y se grabaron en una grabadora digital. las entrevistas fueron transcritas por la investigadora hasta la quinta participante; a partir de ese momento este trabajo lo realizaron dos digitadores reconocidos por sus cualidades éticas. la investigadora revisó estas transcripciones para corroborar que correspondieran exactamente con la grabación. para proteger la identidad de las participantes se usaron nombres ficticios. cada entrevista se orientó con una guía temática, pero se permitió que las participantes hablaran siempre de manera libre y espontánea. al inicio de la segunda entrevista se hizo a cada participante una síntesis de lo obtenido en la primera, de manera que pudiera confirmar las interpretaciones, aclararlas, ampliarlas o corregirlas según fuera el caso. es de resaltar la disponibilidad y disposición de las madres para compartir sus vivencias; no hubo ninguna cancelación de las citas para las entrevistas ni demostraron premura por terminarlas. análisis o interpretación de la información. el análisis de la información se hizo en dos niveles y momentos: durante la recolección de la información, y después de verificar la transcripción literal de cada entrevista, la investigadora analizó el texto de la misma para iniciar la comprensión de las historias de las participantes y para identificar aspectos que debían completarse, profundizarse o confirmarse en la segunda entrevista. al terminar la recolección de la información se procedió con el análisis profundo de las entrevistas. para esto se leyó cuidadosamente el texto de las mismas y se escribió la historia de cada participante, la cual fue revisada y complementada. una vez escritas todas las historias, se buscaron similitudes, diferencias y patrones en las historias de las madres lo que permitió identificar los temas y subtemas para describir sus vivencias. para velar por el rigor metodológico durante el estudio se tuvieron en cuenta los criterios de credibilidad o validez interna y auditabilidad o confirmabilidad de guba y lincon (12). para evitar imprimirle un sesgo personal a la descripción de las vivencias de 73 el hijo ajeno: vivencia de madres de niños prematuros hospitalizados l melva patricia ocampo los entrevistados se realizó la inmersión en la información obtenida a través de las entrevistas e historias que contaron sobre el cuidado del bebé, buscando de manera consciente ceñirse a los datos allí registrados. la transferibilidad del estudio será determinada por los lectores de este artículo al juzgar y verificar si los resultados describen las vivencias de los padres que afrontan el nacimiento y la hospitalización de su hijo prematuro en una institución que tiene breves espacios de visita para los padres. aspectos éticos. el estudio fue aprobado por el comité institucional de revisión de ética humana de la facultad de salud de la universidad del valle, cali, colombia. resultados a continuación se describen los hallazgos que corresponden a las vivencias de las mujeres durante la gestación del bebé, su nacimiento prematuro y la hospitalización en una ucin. estos resultados muestran las primeras etapas del proceso que siguieron las mujeres para convertirse en madres competentes al cuidado de su hijo prematuro. los hallazgos sobre las demás etapas de este proceso se presentan en otras publicaciones. la gestación: una sorpresa de corta duración y final inesperado descubrir que estaban embarazadas fue una sorpresa para todas las mujeres del estudio; el embarazo no estaba incluido en su proyecto de vida a pesar de que todas tenían una vida sexual activa con un compañero único, bien fuera el novio o el compañero con quien convivían. solo una mujer, que era adolescente, tenía deseos de embarazarse pero aun así no lo había planeado ni hablado con su novio. así que descubrirse como mujeres gestantes las tomó por total sorpresa; la noticia del embarazo alteró sus vidas con sus compañeros o su familia nuclear pues ellos tampoco pensaban, ni esperaban ni deseaban un embarazo; algunos quedaron atónitos, otros lo rechazaron abiertamente como le sucedió a nubia, que por varios años se creyó estéril pues no había logrado embarazarse a pesar de nunca haber usado anticonceptivos. la noticia del embarazo fue tan sorpresiva para ella como para su compañero, quien además no lo celebró. la indiferencia de él y el rechazo predominaron en ese momento de la gestación que cursaba las 22 semanas. … a los diez minutos me dijo una doctora: "mamá felicitaciones"; le dije yo, ¿felicitaciones?, ¿por qué? me dijo ella, "usted está en embarazo". entonces yo me puse a llorar, no me gustó… no me cayó nada bien, entonces yo me puse a llorar y yo decía "¿por qué yo? ¿por qué me vino a pasar esto ahora?" yo no quería hijos. y yo era llore y llore y llore, así que cuando llegué a la casa mi sobrina me dice, "¿tía por qué llora?". le dije, "no mira que estoy en embarazo; ahora ese señor –compañero de los últimos cinco años– ¿que dirá?... otros familiares rechazaron pasivamente el embarazo y a la mujer lo cual se manifestaba en la falta de demostraciones de afecto con ella o con el bebé en gestación. solo una de las mujeres recibió total apoyo de su esposo, que se sintió muy contento con la posibilidad de que naciera su primer hijo. la manera como la mayoría de las mujeres vivieron la revelación de su estado de embarazo puede considerarse un sustrato pobre y limitado para que ellas iniciaran amorosamente el proceso de transformarse en madres. a pesar de esto, cada mujer enfrentó de la mejor manera posible la inesperada noticia de la gestación; algunas rechazaron inicialmente el embarazo; una de ellas pensó en interrumpirlo, pero pronto se resignó; otras dejaron que pasara el tiempo sin pensar en el presente ni en el futuro. el tiempo con el que contaron las mujeres para crecer en la aceptación del embarazo y la preparación para el cambio de rol que les imponía la vida tampoco fue suficiente pues no tuvieron las 38 o 40 semanas de la gestación normal sino entre 26 y 28 semanas. el caso de luisa, profesional y casada, fue particular pues la duración de este periodo se redujo a tres semanas. ella supo que estaba embarazada cuando fue atendida por sufrir un accidente de tránsito cuando ya tenía 23 semanas de gestación; hasta ese momento ella había presentado sangrado menstrual cada 28 días y no había experimentado ninguno de los síntomas de embarazo. tres semanas después de saber que estaba embarazada inició actividad uterina y dos días después nació su hija. la historia de nancy, de 23 años y casada, confirma lo que le sucedió a la mayoría de las mujeres del estudio respecto al descubrimiento del embarazo; ella no tuvo tiempo de cambiar su estilo de vida “de mujer joven, independiente y sana” que incluía tomar cerveza diariamente, transportarse en motocicleta a todas partes y salir de rumba desde el viernes cada semana. el único cambio fue inscribirse tempranamente en el control prenatal y tomar vitaminas prenatales distintas de las recomendadas en la eps. para 74 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 cuando tenía 25 semanas de gestación, los cambios comportamentales y los preparativos materiales que rutinariamente suceden a raíz del embarazo aún no tenían lugar, ella los pospuso pues no se percibía como mujer en proceso de convertirse en madre. … yo me la pasaba jugando billar pool, jugando minitejo, andando en la moto pa´rriba y pa´ bajo… la cervecita, porque no hubo trago más fuerte. pero sí la cervecita, porque harto que me ha gustado, entonces me iba a jugar billar pool y me tomaba 3 o 4 cervezas tampoco más […] y también los viajes en la moto, yo me fui con mi esposo hasta neiva y nos devolvimos en la moto cuando tenía casi cinco meses, yo decía el "embarazo no es una enfermedad y yo no soy floja", como a veces mi familia me decía. la situación económica de las mujeres también tuvo implicaciones en el proceso de prepararse para ser madres. solo una de ellas, que dependía económicamente de su esposo y contó con su apoyo una vez se conoció el embarazo, alcanzó a hacer preparativos como encargar la cama-cuna, comprar alguna ropa, muñecos y el toldillo para el bebé; el esposo pintó las paredes del cuarto que sería para la niña. esta pareja estuvo trabajando para acoger a su hija, se imaginaban cómo sería y se veían cuidándola en el futuro. esto no sucedió con las otras mujeres, cuya dependencia económica fue vivida como una limitante en su preparación para ser madre. por ejemplo, lina, que vivía en unión libre desde hacía tiempo y tenía un hijo de diez años, se encontró con la indiferencia de su compañero por lo que únicamente se inscribió y asistió al control prenatal y decidió dejar que el tiempo pasara y ver qué sucedía. su compañero no aportó dinero para su ropa de maternidad, ni para comprar ropa para la hija que estaba esperando. las tres mujeres adolescentes participantes en el estudio se declararon atónitas al saberse embarazadas; aunque una de ellas pensó en maniobras abortivas y alcanzó a tomar un brebaje casero, todas decidieron dar tempranamente la noticia a sus novios y núcleo familiar. a partir de este momento tuvieron que empezar a hacer modificaciones en sus vidas para las que no estaban preparadas, tales como dejar de salir con sus pares y pareja en las tardes y noches, y en uno de los casos irse de la casa. lidiar con esas situaciones cotidianas las abrumó y no pudieron dedicar tiempo y energía emocional a su preparación como madres, como le sucedió a aura, que al darle la noticia del embarazo a su madre tuvo que irse de la casa; luego, al decírselo a su novio, él le expresó que no iba a estar con ella ni iba a responder por el hijo. entones se fue a vivir transitoriamente con una tía y algunas semanas después se trasladó a la casa de un joven de su barrio que le dijo que estaba dispuesto a responder por ella y por el bebé que estaba esperando. el final de la gestación fue también inesperado para todas las mujeres porque ninguna de ellas imaginó que su hijo nacería antes de término; en general, no pensaban en el nacimiento del bebé cuando este sucedió. por eso cuando consultaron al servicio de salud por las molestias que sentían ninguna sospechó que había llegado el momento del nacimiento. las mujeres consultaron a la institución de salud por dolor de cabeza, gastritis, hinchazón, dolor tipo cólico, sospecha de infección o salida de líquido, pero ninguna de ellas estaba preparada para quedarse hospitalizada, tener una cesárea de urgencia o descubrir que el trabajo de parto estaba tan adelantado que no funcionarían los betabloqueadores y tendrían un parto prematuro. ni siquiera las mujeres que ya habían tenido hijos sospecharon que lo que les estaba sucediendo conduciría al nacimiento prematuro de su bebé. por consiguiente, cuando fueron a la consulta médica no llevaron la ropa ni los elementos necesarios para ella ni para su hijo. esperaban regresar a la casa con una fórmula médica que les aliviara los síntomas que presentaban. en consecuencia, lo que les estaba sucediendo y las decisiones de los médicos en el hospital las sorprendieron y las confundieron, como lo expresa nancy: …para nosotros fue muy duro porque cuando yo llegué al hospital yo pensaba que no... que me iban a decir que era una infección y ya, que me iba para la casa. no llevábamos nada, ni ropa, y yo me tuve que quedar toda sola… y… no, me dijeron que me tenían que hospitalizar porque la niña se me iba a venir antes de tiempo, tenía dos de dilatación, entonces me iban a aplicar una inyección para retenérmela, me aplicaron como dos… pero ¡no!, a las 10 y 40 de la mañana ya la bebé estaba naciendo. durante las primeras horas de la hospitalización las mujeres recibieron información específica sobre los riesgos en que estaba su hijo según la edad gestacional y las características de cada una; a todas les quedó claro que si el bebé nacía prematuramente tendría muchos riesgos. el temor fue el sentimiento que predominó en las mujeres antes y después del nacimiento de su niño por parto o por cesárea. tenían miedo de la muerte del hijo y de cuál sería su apariencia. la imposibilidad de ver y tocar aunque fuera brevemente a su hijo al nacer dejó en las mujeres una sensación de vacío; algunas lo pudieron ver, otras “medio lo vieron”, otras solo lo oyeron e 75 el hijo ajeno: vivencia de madres de niños prematuros hospitalizados l melva patricia ocampo incluso a algunas de ellas les dijeron que no se lo podían mostrar para evitarles el impacto. las vivencias de las mujeres alrededor del nacimiento pueden resumirse así: aun cuando estaban luchando con la aceptación de un embarazo no planeado en sus vidas y en las de su pareja y núcleo familiar, el final de la gestación las sorprendió llenas de temores y preocupaciones por la vida y el bienestar de un hijo que no alcanzaron a ver y del que fueron separadas forzadamente para ingresarlo a un lugar que ellas desconocían: la ucin. el hijo ajeno no estar ya embarazadas ni tener a su hijo a su lado cuando estaban en el servicio de puerperio o se iban para la casa originó en las madres un profundo vacío; ellas sintieron que el ser que habían dado a luz era un hijo que no les pertenecía sino a las personas que lo cuidaban en la ucin. estas personas tomaban decisiones sobre su cuidado, sabían qué hacer, cuándo hacerlo y cómo hacerlo. la madre solo era una visitante que debía respetar horarios y reglas para estar por treinta minutos con su hijo a quien ahora llamaban nn seguido del apellido materno. la necesidad de trasladar al bebé a la ucin impidió que las madres los vieran el tiempo suficiente para hacerse una imagen clara de él en el momento del nacimiento, por lo que ellas sintieron durante varios días que no conocían a sus hijos. … yo lo único que vi… "no, mamá, hay que llevarla a una incubadora", y vi que pasaron con la incubadora y a las dos horas me dijeron: "la bebé está bien, está en una incubadora, está en una unidad de cuidado intensivo porque hizo esto, lo otro". cuando yo fui me tocó preguntar cuál era. y había tres niños ahí, y yo… ¿cuál es? porque yo no la conocía. al mirar a su alrededor las mujeres veían compañeras de habitación con su hijo recién nacido y presenciaban todos los momentos de interacción entre ellos; veían y oían a los otros niños recién nacidos dormir, llorar y a sus madres alimentarlos, cambiarles de pañal, vestirlos; también veían a los padres que llegaban de visita, cuando los alzaban en sus brazos, los acariciaban y hablaban con ellos. ellas, en cambio, estaban sin su hijo, pensando en cómo sería y cómo estaría. solo una de las mujeres tenía experiencia previa con un hijo en la ucin, para las demás mujeres y el hombre participantes en el estudio la experiencia era nueva. durante las horas o los días que transcurrieron entre el nacimiento y el momento en que las madres pudieron ir hasta la ucin a ver a su hijo ellas tuvieron dudas sobre la supervivencia del bebé y gran curiosidad por saber cómo era. ellas no pudieron elaborar una imagen completa de su bebé. …ya me dijeron que podía irla a ver, pero fue al otro día. ese día pasé con la curiosidad de cómo estaba, de cómo era, si estaba completico y de lo chiquitico que decían que era y a la vez con temor porque yo decía "a qué horas me dicen"… dios… que algo pasó, porque uno se espera muchas cosas. la indicación médica de reposo absoluto impidió a algunas mujeres ver a su hijo durante varios días. entonces, el esposo o compañero, la mamá o la abuela asumieron un rol fundamental como apoyo para que las mujeres pudieran crear en sus mentes la imagen de su niño recién nacido mediante las descripciones que le hacían, las fotografías y los videos que le tomaban y le llevaban a la hora de la visita. una de las madres, que no contaba con un familiar que pudiera darle esa información, encontró en una enfermera el apoyo para saber cómo estaba su hija. … y yo decía, "bueno será que se me murió mi niña ¿qué pasó? ¿por qué no me dejan ir a verla?" pero el problema era que los médicos decían que yo era una bomba de tiempo, de una se me subía la presión entonces que no me podían desconectar del goteo y todo eso… mi esposo me llevaba muchas fotos de ella, fotos, videos de cómo ella lloraba allá... allá en la incubadora. cuando llegó el ansiado momento de conocer personalmente a su bebé, vino la gran sorpresa al descubrir el mundo desconocido donde estaba su hijo. lavarse las manos en un lavamanos que ni siquiera tenía llave para hacer salir el agua, usar jabón que olía a hospital y lavarse hasta los codos antes de entrar a ver a su hijo fue algo totalmente extraño para ellas; en este momento aún no sabían que este lavado de manos se convertiría en un hábito que muchas de ellas luego trasladarían a su hogar. después, entrar a la ucin y ver tantos niños prematuros fue sorprendente e impactante para ellas. al ver a su hijo por primera vez a través de las paredes de la incubadora las madres sintieron desencanto y preocupación pues les pareció demasiado pequeño, delgado, con la piel muy fina y las venas visibles, desencanto y preocupación que aumentaron cuando notaron los cables, las sondas y las venas canalizadas, además de los equipos que suponían como elementos que esta76 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 ban ayudando a su hijo, pero que no conocían ni sabían si le ocasionarían dolor. las madres ignoraban si podían tocarlo o si solo lo podían observar. … ese día nos tocó en silla de ruedas, cuando ya llegué aquí, que a lavarme las manos, yo ni podía, mi esposo fue el que me ayudó. yo ya la conocía por fotos y videos. yo creo que es el regalo más grande que dios me ha dado, pero triste, deprimente al momento de tener que verlos ahí tan chiquitos, tan indefensos, ahí con agujitas en las manos y tan chiquitico… conectada a esos aparatos, eso es muy duro para uno de mamá. con la ayuda del personal de enfermería empezaron a aprender cómo abrir la incubadora y algunas se atrevieron a tocar al bebé la primera vez que entraron a visitarlo; otras madres sintieron que no sabían cómo tocarlo, o que no debían hacerlo porque tal vez lo lastimarían o interferirían con el tratamiento que estaba recibiendo. durante esa primera visita la mayoría de las madres miraron larga y detalladamente al niño y le tocaron las manos, los pies o la cabeza; fue un contacto con miedo y suavidad, de corta duración porque estaban asustadas de hacerlo. algunas de ellas lloraron por la emoción de ver a su bebé y saber que estaba vivo, que era más grande de lo que les habían dicho, que había otros niños que parecían más enfermos que el suyo, de verlo frágil, pequeño y, sobre todo, por tener que irse y dejarlo ahí solo. ese primer día que yo fui la niña ya tenía seis días, yo la acariciaba, la acariciaba; la enfermera me dijo que si la quería cargar, yo sentía mucho miedo, mucho miedo porque tan chiquitica y así me la pasaron. yo me senté con ella en la silla y la cargué, la acariciaba, y ella ahí con esa sonrisa, con la naricita, y tan chiquitita porque ella era muy, muy pequeña, se le veían hasta las costillitas… 1100 gramos pesaba… yo lloraba. las madres no faltaban a las visitas autorizadas en la mañana y en la tarde; para ellas esos eran los minutos más esperados del día. yo ya me venía todos los días y todo el día yo estaba aquí con ella, mi tía me empacaba almuercito y yo iba y almorzaba allá en el parque, ahí en la zona verde y volvía y subía, y eso que igual a uno acá no lo dejan todo el tiempo sino que es por medias horitas. pero uno igual se sentía pues feliz de estar ahí con ella esa media horita, pero luego uno tenerse que ir para la casa, que… que usted está de dieta, pero cuál de dieta si no tengo mi hijo acá al lado. muchas veces uno con ese dolor en esa herida… igual uno saber que… que yo a veces con cuestiones de la presión, de la herida, igual yo me venía porque tenía que verla. en general, las madres percibieron que el personal de la ucin les instó a establecer contacto físico con el bebé, les mostraron cómo abrir la incubadora y tocarlo cada vez más; la idea de que lo podrían lastimar fue disminuyendo. cuando las madres pudieron tener al niño en sus brazos volvió el temor intenso de lastimarlo o desconectar o dañar algo que necesitara para estar bien. las madres no sabían cómo sacar al niño de la incubadora por sí mismas ni qué elementos de esta se le podían retirar para poderlo cargar, ni qué cosas podían tocar o mover en su entorno, por tanto, dependían del tiempo, la información y ayuda del personal de enfermería para tomar a su hijo en brazos. algunas enfermeras fueron muy colaboradoras y permitieron que las madres ganaran confianza para estar con su bebé a medida que pasaba el tiempo. las madres rápidamente identificaron a quienes les colaboraban, se aprendieron sus nombres, se sentían contentas y tranquilas cuando ellas llegaban a turno, y muy felices si a estas les tocaba cuidar a su hijo. si estas enfermeras llegaban al turno nocturno se ponían de acuerdo con ellas para llamarlas más tarde o en la madrugada para preguntarles si su hijo había ganado peso o si había tolerado la vía oral o, simplemente, para saber si estaba dormido. un aspecto central en el proceso de convertirse en madres fue comenzar a encariñarse con el hijo una vez se superó la fase del miedo y el desencanto iniciales. compartir treinta minutos durante las visitas de la mañana y de la tarde todos los días permitió que las madres empezaran a apegarse a su hijo aunque este era prestado por poco tiempo y con una serie de limitaciones que debían observar al estar en la ucin. yo salía de la casa a las seis y media de la mañana, llegaba aquí a las siete, traía para almorzar, plata para comerme algo y simplemente volvía a la casa a las siete de la noche. a uno empiezan a sacarlo… "se acabó la visita"… y uno insista e insista, y entre esa insistidera se le van a uno las seis, más veinte minutos que uno se queda pegado del vidrio, porque es eso lo que uno hace, lo sacan de la sala, pero uno se queda allí mirando a ver qué le van a hacer, por qué lo sacaron, lo irán a cambiar, es que yo vi que tenía el pañal sucio… entones uno se queda otra media hora allí, simplemente en la ventana, mirándolo desde la ventana y rezándolo y mirando cómo lo dejó, haber al otro día cómo lo va a encontrar. el ambiente de la ucin fue percibido por las madres como poco amigable. ellas no se sentían bienvenidas o acogidas mientras estaban de visita, incluso en ocasiones se sentían como intrusas. siempre que llegaban a la visita preguntaban cómo estaba el niño, si lo podían tocar o cambiarle el pañal, o sea, pedían permiso 77 el hijo ajeno: vivencia de madres de niños prematuros hospitalizados l melva patricia ocampo para compartir con su hijo. en ocasiones, algunas madres intentaron cambiar al niño de posición y las enfermeras lo impidieron indicando que estaba lábil o acababa de comer y podía vomitar, entonces las madres aprendieron que siempre era necesario preguntar antes de tocarlo y esto reforzó la idea, en la mayoría de ellas, que el niño era del personal de enfermería y no suyo. cuando la niña estaba en el hospital era de las enfermeras, del hospital, porque es que uno… si usted se arrima y no ha tenido la precaución de lavarse las manos es “no la toque”, lo primero. uno viene con la pañalera, de pronto le han regalado que la bomba, porque uno le trae como el sonajero. “no, es que no puede entrar eso”, y o sea, es que son muchas restricciones, es que “ella acabó de comer, no la puede cargar”, cosas como esas. y si uno llega y ¡no! es que está orinadita, “no pero todavía no le cambie el pañal porque hay que esperar que haga popó, como hay que pesarlo, no lo haga”. entonces es que uno simplemente lo limitan a que uno se quede con los brazos cruzados, y mire así de lejos, entonces uno no tiene esa libertad, pues sí, es mi hija, pero no la puede tocar, no la puede ver cuando yo quiera, porque hay un horario de visita. las madres reconocían que su bebé necesitaba estar hospitalizado para recibir atención especializada y poderse recuperar; tenían claro que era el personal de salud el que sabía qué le sucedía, cómo tratarlo para que recuperara la salud y disminuyeran las complicaciones; ellos tomaban todas las decisiones. las madres no tenían voz ni voto, no podían decidir ni opinar sobre ninguna conducta o situación con el niño pues no era de su dominio, pero tampoco podían intervenir en lo concerniente a la ropa para vestirlo, la posición para acostarlo, el momento para arrullarlo, hablarle, alimentarlo, ni para estar con él; pensaban que si el niño estuviera en casa ellas serían quienes tomarían las decisiones y quienes sabrían cómo cuidarlo. las madres sintieron que su bebé no era suyo y que lo que debían hacer para recuperarlo era aprender a cuidarlo, “ganar los méritos” que exigían en la ucin para tener la oportunidad de poseerlo y cuidarlo como su madre. a veces se sentían invisibles pues su presencia era ignorada durante la visita y a la hora de alimentar al bebé. también se sentían invisibles cuando no se enteraban que al niño le habían realizado una transfusión sanguínea u otro procedimiento y ellas habían estado todo el día en el hospital. las madres estaban ahí haciendo lo que les era permitido y querían ser tomadas en cuenta, querían tener un lugar al lado de su hijo para darle su calor, el amor de madre, al fin y al cabo ellas eran quienes iban a cuidarlo en casa después del alta de la ucin y por el resto de la vida. las madres percibían que al final de cada día debían irse a su casa y dejar al niño solo, con personas extrañas que no podían darle el amor que ella sentía y que necesitaba. estas se ponían en el lugar del bebé: imaginaban sentimientos, necesidades y dudas de su hijo, tenían la certeza de que estaría viviendo situaciones y procesos como soledad, aburrimiento, extrañeza por no tener a su madre siempre cerca para acompañarlo. “julio [el esposo], yo creo que yo le hago falta a la niña, la niña debe estar aburrida allá”, ¿si me entendés? entonces yo pensaba que lo que yo sentía mi hija lo estaba sintiendo, ¿me entendés? y yo decía, "mi niña debe estar aburrida" y para mí cuando llegaban las 7 de la noche… y me tenía que ir, era horrible, no veía la hora de que amaneciera para volvernos a encontrar; yo sabía que mi hija también tenía que estar muy aburrida, yo sé y yo creo que eso era lo que más me angustiaba a mí. discusión los hallazgos de este estudio sobre las vivencias de las madres durante la gestación, el nacimiento y la hospitalización de su hijo nacido prematuramente permiten comprender: a) que la gestación fue insuficiente como preparación para ser madre, y b) que la separación madre-hijo conduce a que ella se sienta vacía y perciba a su hijo distante, ajeno y desconocido. la gestación inesperada y corta, la falta de contacto visual y táctil y de participación de la madre en el cuidado del bebé durante la hospitalización sustentan y acrecientan esta percepción, lo que finalmente se traduce en dudas e inseguridad en su capacidad para cuidarlo. estos hallazgos son similares a los obtenidos por diversos autores que reportan la inhabilidad de las madres para establecer apropiadamente un vínculo afectivo con su hijo al no tener contacto con él después del nacimiento (1, 2, 7, 8, 13, 14). las limitantes identificadas por las madres en la ucin para desarrollar el rol de cuidadora de su hijo durante la hospitalización; el sentimiento de incapacidad para cuidarlo en casa al momento de ser dado de alta del hospital (5,1416), y las dudas e inquietudes sobre cómo aproximarse, realizar contacto y cuidar a su hijo (3, 8, 9, 14-17). los resultados de esta investigación hacen pensar que en la ucin donde estuvieron hospitalizados los bebés de las mujeres participantes es prioritario institucionalizar estrategias de cuidado que minimicen la separación madre-hijo. estas estrategias se fundamentan en el reconocimiento de la enorme importancia de la cercanía y el contacto constante madre-hijo desde el momento 78 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 del nacimiento, y en los conocimientos existentes sobre la crisis que representa para la mujer el nacimiento prematuro y la hospitalización de un hijo en la ucin. la estrategia del cuidado madre canguro o cuidado piel a piel que se inició en 1978 en bogotá (18) parece ser una alternativa apropiada para eliminar la separación padres-hijo y modificar la situación descrita por las madres participantes en el estudio y, por consiguiente, la vivida por otros padres en la ucin. el cuidado canguro ha demostrado que es posible y benéfico para mantener la díada madre-hijo en contacto permanente desde el nacimiento y durante la hospitalización a pesar de la prematurez del niño. el cuidado canguro aminora la crisis producida por el nacimiento anticipado y promueve el apego y el desarrollo del rol de cuidadores que tienen derecho a ejercer los padres (19). ruiz y charpak (19) consideran, además, que el contacto piel a piel ofrece las condiciones ideales para que los niños de bajo peso se fortalezcan y para que sus padres participen y se empoderen del cuidado de sus hijos contribuyendo al proceso de sanación de ambos, es decir, el cuidado canguro contrarresta lo expresado por lupton sobre los efectos de la separación forzada madre-hijo que hace que estas sientan que no son madres sino personas temerosas, supervisadas e incapaces al cuidar a su hijo (20). varias sociedades de pediatría en europa (21) y en latinoamérica, como la sociedad chilena (22) han iniciado el camino del cuidado humano a los niños prematuros. la iniciativa del hospital amigo del niño (ihan) (23), propiciada desde la década de los ochenta por la organización mundial de la salud (oms) y la unicef ha causado un impacto altamente positivo en las díadas madre-hijo atendidas en los servicios de puerperio y pediatría en términos de lactancia materna, apego, menor abandono y maltrato infantil, pero esta iniciativa aún no se ha hecho extensiva a las ucin, donde la díada es abruptamente separada y limitada en su proceso de apego y cuidado como lo describe viera (22). en el reino unido, en 1961 y luego en 1986, el parlamento europeo transmitió al consejo de europa, a la unicef y a la oms una resolución denominada carta europea de los derechos del niño hospitalizado (21). en esta carta se define el derecho del niño enfermo a estar acompañado de sus padres o sustitutos el mayor tiempo posible durante su permanencia en el hospital. además, se reconoce que los padres o sustitutos no son espectadores pasivos sino participantes activos del cuidado del niño. también, en el título i, artículo 44 de la constitución política de colombia (24), el estado reconoce entre los derechos fundamentales de los niños el derecho a “tener una familia y no ser separados de ella”. conclusión los resultados presentados indican que el contacto de la madre con su hijo nacido prematuramente, y la participación de ella en su cuidado durante la hospitalización, son aspectos fundamentales para llenar el vacío que ella siente respecto a su hijo, para conocerlo y sentirse confiada para ser madre cuidadora ante sí misma y ante los demás. el profesional de enfermería debe asumir el compromiso de liderar procesos de “cuidado humano” (25), ser la voz de los niños prematuros hospitalizados que necesitan, además de los cuidados especializados del equipo multidisciplinario, del amor y la dedicación de sus padres. el profesional de enfermería debe ser también la voz y el soporte particularmente de las madres para que ellas sientan a su hijo como propio, lo conozcan y tengan desde el momento del nacimiento la oportunidad de convertirse en madres cuidadoras competentes. las puertas de las ucin deben abrirse a las madres y los padres al menos durante doce horas al día, y el personal de enfermería debe acogerlos y apoyar su participación activa en el cuidado del hijo. el cuidado canguro intrahospitalario puede ser una alternativa eficiente para modificar positivamente las vivencias de las madres y los padres de bebés prematuros hospitalizados. si bien los hallazgos del presente estudio no se pueden generalizar, es muy razonable pensar que se reproducen en contextos similares en colombia y latinoamérica. 79 el hijo ajeno: vivencia de madres de niños prematuros hospitalizados l melva patricia ocampo referencias 1. desai pp, ng jb, bryant sg. care of children and families in the cicu: a focus on their developmental, psychosocial, and spiritual needs. crit care nurs q 2002;25(3):88-97. 2. fernández g, moraes m, malbares g. trabajo grupal con padres de niños internados en un cti neonatal y pediátrico. arch pediatr urug 2004;75(1):68-71. 3. sáenz 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university press of colorado; 2008. 170 183 coping and health problems.indd 170 aquichan issn 1657-5997 prangtip chayaput1 ketsarin utriyaprasit2 somsong bootcheewan3 orapan thosingha4 coping and health problems of caregivers of survivors with traumatic brain injury 1 phd. assistant professor, mahidol university, thailand. prangtip.cha@mahidol.ac.th 2 assistant professor dr., mahidol university, thailand. ketsarin.utr@mahidol.ac.th 3 mns. advanced practice nurse, ayutthaya hospital, thailand. s_bootcheewan@hotmail.com 4 dns. assistant professor, mahidol university, thailand. orapan.tho@mahidol.ac.th recibido: 2 de octubre de 2012 enviado a pares: 2 de octubre de 2012 aceptado por pares: 2 de septiembre de 2013 aprobado: 1 de noviembre de 2013 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 170-183 para citar este artículo / to reference this article / para citar este artigo chayaput p, utriyaprasit k, bootcheewan s, thosingha o. coping and health problems of caregivers of survivors with traumatic brain injury. aquichan 2014; 14(2): 170-183. abstract objectives: to evaluate coping and the health problems of caregivers at the time of survivor discharge and at one month after discharge and to determine correlations among personal data, coping and health problems of caregivers and disability of survivors. method: eighty-five dyads of survivors with traumatic brain injury and their caregivers were included. the instruments employed for data collection were the 27-item thai version of the coping and adaptation processing scale-short form, the health problem questionnaire for caregivers and the disability rating scale for survivors. the roy adaptation model was used as a conceptual framework for this study. pearson’s product moment correlation coefficient was employed for analysis. results: no statistical differences were found between coping and health problems among caregivers. the health problems most frequently reported by caregivers were headache on the day of discharge and no health problems after one month of caregiving engagement. the disability level and marital status of the caregivers were correlated negatively with coping (r = -.245, p = .024, r = -.220, p = .043, respectively). conclusions: the findings delineated that the caregivers remained able to handle the difficulties involved in caring for survivors at home with fewer health problems. married caregivers were likely to manage this burden better than other caregivers. key words brain injuries, caregivers, adaptation, psychological, patient discharge, survivors, nursing (source: decs, bireme). 171 coping and health problems of caregivers of survivors with traumatic brain injury l prangtip chayaput, ketsarin utriyaprasit, somsong bootcheewan, orapan thosingha año 14 vol. 14 nº 2 chía, colombia junio 2014 l 170-183 afrontamiento y problemas de salud en los cuidadores de sobrevivientes con lesiones traumáticas del cerebro resumen objetivos: evaluar el afrontamiento y los problemas de salud de los cuidadores en el momento en que el sobreviviente fue dado de alta y un mes después de que el sobreviviente fue dado de alta. además, determinar las correlaciones entre los datos de carácter personal, afrontamiento y los problemas de salud de los cuidadores y la incapacidad de los sobrevivientes. método: fueron incluidos en la investigación ochenta y cinco díadas de supervivientes con lesiones cerebrales traumáticas y sus cuidadores. los instrumentos utilizados para la recolección de datos fueron la versión tailandesa de la escala de medición del proceso de afrontamiento y adaptación – formato corto, con 27 ítems, el cuestionario de problemas de salud para los cuidadores y la clasificación de escala de discapacidad para los sobrevivientes. el modelo de adaptación de roy se utilizó como marco conceptual para este estudio. la correlación producto-momento de pearson se utilizó para el análisis. resultados: no se encontraron diferencias estadísticas entre los problemas de afrontamiento y de salud en los cuidadores. los problemas de salud reportados más frecuentemente por los cuidadores fueron dolor de cabeza en el día de alta y ningún problema de salud después de un mes de participación en el cuidado del sobreviviente. el nivel de la discapacidad de los sobrevivientes y el estado civil de los cuidadores se correlacionaron negativamente con el afrontamiento (r = 0,245 , p = 0,024, r = 0,220, p = 0,043, respectivamente). conclusiones: los resultados demuestran que los cuidadores permanecieron capaces de manejar las dificultades que implica el cuidado de los sobrevivientes en casa con menos problemas de salud. los cuidadores casados eran propensos a manejar esta carga mejor que otros cuidadores. palabras clave traumatismos encefálicos, cuidadores, adaptación psicológica, alta del paciente, sobrevivientes, enfermería (fuente: decs, bireme). 172 aquichan issn 1657-5997 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 170-183 adaptação e problemas de saúde cuidadores de sobreviventes com lesões cerebrais traumáticas resumo objetivos: avaliar a adaptação e os problemas de saúde dos cuidadores no momento em que o sobrevivente recebe alta e um mês depois disso, e determinar as correlações entre os dados de caráter pessoal, adaptação e os problemas de saúde dos cuidadores e a incapacidade dos sobreviventes. método: 85 díades de sobreviventes com lesões cerebrais traumáticas e seus cuidadores foram incluídos na pesquisa. os instrumentos utilizados para a coleta de dados foram a versão tailandesa da escala de medição do processo de enfretamento e adaptação – formatação curta, com 27 itens, o questionário de problemas de saúde para os cuidadores e a classificação de escala de deficiência para os sobreviventes. o modelo de adaptação de roy foi utilizado como marco conceitual para este estudo. a correlação produto-momento de pearson foi utilizada para a análise. resultados: não se constataram diferenças estatísticas entre os problemas de adaptação e de saúde nos cuidadores. os problemas de saúde relatados mais frequentemente pelos cuidadores foram dor de cabeça no dia da alta e nenhum problema de saúde depois de um mês de participação no cuidado do sobrevivente. o nível da deficiência dos sobreviventes e o estado civil dos cuidadores se correlacionaram negativamente com o afrontamento (r = 0,245 , p = 0,024 , r = 0,220 , p = 0,043 , respectivamente). conclusões: os resultados demonstram que os cuidadores permaneceram capazes de lidar com as dificuldades que implica o cuidado dos sobreviventes em casa com menos problemas de saúde. os cuidadores casados eram propensos a lidar com essa carga melhor que outros cuidadores. palavras-chave traumatismos encefálicos, cuidadores, adaptação psicológica, alta do paciente, sobreviventes, enfermagem (fonte: decs, bireme). 173 coping and health problems of caregivers of survivors with traumatic brain injury l prangtip chayaput, ketsarin utriyaprasit, somsong bootcheewan, orapan thosingha introduction the caregivers of disabled survivors with traumatic brain injury (tbi) are key persons in providing home-based care for those survivors. nevertheless, before survivors are discharged from hospital, caregivers are given discharge instructions and preparation to offer care as part of routine nursing intervention (1).the impact of long-term responsibilities in caring for disabled survivors after they return to their rural homes, with limited support from local resources, is discussed thoroughly (2). survivors with traumatic brain injury are dependent on caregivers in the early stage following discharge from hospital, because neurobehavioral and/or physical deficits remain present even at 6-12 months post-injury (3,4). the caregivers of these survivors play a major role in fulfilling the demanding mission of facilitating recovery and rehabilitation (1,5).if the caregivers are unable to deal with this difficult situation, feelings of heavy burden, stress, anxiety and depression can occur, thereby leading to a decline in the status of their health (6,7).the aforementioned conditions affect functioning and caregiving ability (8).in turn, ineffective caregiving or inability to accomplish caregiving tasks can impact the patient´s health status and disability rehabilitation (9). as in the evidence from the aforementioned literature, the coping and health problems of caregivers are related to the rehabilitation of disabled survivors with tbi. these factors can promote or inhibit survivor rehabilitation.at the same time, the caregiver’s health problems and ability to cope are categorized as a condition correlated with the disability of survivors with tbi during transition from the illness phase to the rehabilitation phase (10). several longitudinal follow-up studies (11-13) on survivors with tbi notea significant impact on caregiver roles.several associations between caregiver quality of life, health status and survivor recovery also are evident in the findings of these studies. however, an evaluation of the difficulty in providing care for survivors with tbi during the immediate rehabilitation phase after discharge from hospital has been recommended (1,3). not many studies have been done to describe conditions related to the disability of survivors during the early rehabilitation phase (3), especially at one month after survivors are discharged from hospital and during continued home-based care. following discharge from hospital, survivors continue to experience problems such as physical, cognitive and behavioral dysfunctions, which have both a personal and family impact (13,14).caregiver ability to cope with accepting survivors’ disability and re-adjusting to new roles is a crucial factor that influences the outcome of rehabilitation for survivors with tbi, as do the healthcare services and support required to help caregivers manage such problems in the long run (10,15). the healthcare resources available to thai survivors with tbi and their caregivers are unlike those in other countries where previously mentioned studies were conducted on the services and coverage offered. there are few studies on survivors with tbi and their caregivers in thailand in the early stage following discharge from the hospital. additionally, thai culture and support in the duty of caring for ill family members with tbi remain vastly different from the situation in western countries (1,5).thus, coping and the health problems of caregivers at the time of survivor discharge and at one month after discharge are examined in this study. enhancing the understanding of coping and health problems among thai caregivers in the early phase, with the support of increased evidence, can help to develop useful nursing interventions aimed at maximum restoration of caregivers’ health and the recovery of survivors with tbi. therefore, the objectives of this study were:1) to evaluate the differences between the coping and health problems of caregivers upon the discharge of survivors with tbi and at one month after discharge; and 2) to determine the correlations among age, marital status, income, previous caregiving experience, coping, health problems of caregivers and the disability level of survivors with tbi. conceptual framework according to the roy adaptation model (ram), individuals as adaptive bio-psychosocial systems deal with challenging or threatening situations in their daily lives in order to survive (16). changing environments or stressor persons perceived as posing difficulty act as stimuli. focal stimulus refers to a stressor with direct influence on behavioral outcomes. contextual stimuli are stressors that affect the focal stimulus, but also play a role in promoting behavioral responses (16-18). persons handle these stressors through cognator and regulator subsystems that function as an adaptive system to alleviate confronted stressors. a cognator subsystem is defined as a cognitive coping process, while a regulator subsystem is referred to 174 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 as an automatic physiological process to maintain body system integrity (16).persons perceive a threat or harmful stimulus that is provoked through a cognator, then moderate a regulator to stabilize the homeostasis of the body system (16,18). in this study, the caregivers of survivors with tbi are adaptive individuals who were reacting to changing environments (1,18) and struggling with stressful experiences in the unpredictability of life situations by adjusting to the new role of being caregivers after returning home with the survivors. thus, having a family member as a disabled survivor with tbi, i.e. the disability level of survivors, was a focal stimulus for the caregivers. the age, marital status, income and previous caregiving experience of the caregivers constituted the contextual stimuli. those factors contributed to effective or ineffective adjustment to the caregiving role through cognator and regulator subsystems. the abovementioned focal and contextual stimuli acted as inputs to manifestation of the caregivers’ adaptation through relations to behavioral responses. the caregivers reacted and articulated through adaptive modes. hence, the observed behavior; i.e. coping and health problems, pointed to the outcomes of the caregivers’ nursing efforts or the outputs of the human adaptive system with respect to the ram. if caregivers could adjust to their roles effectively, by completing essential daily living activities for survivors, the integrity of the caregivers’ health status and family functioning could be maintained. on the contrary, any impediments to coping and caregiving activities could lead to a disruption of health and family integrity (1,16,18). a diagram of the correlations between variables of interest to the caregivers in the present study with regard to the ram (16) is provided in figure 1.the conceptual-theoretical-empirical structure (19) of this study is outlined in figure 2. materials and methods participants the sample size was calculated through the use of power analysis (20).to examine the differences between two measures by a correlated t-test and relationships, a two-tailed test with a power of .80, an alpha of .05, and a moderate effect size of .50 was set (21).according to this calculation, the minimum number of required participants was 85. after the institutional review board for human subjects had granted approval, 85 caregivers and 85 survivors with tbi living in rural areas were enrolled in this study subsequent to their discharge from four tertiary hospitals in the central region of thailand. the caregivers of survivors with tbi who participated in the study were family members with no history of learning disability or psychiatric problems. they lived with the survivors and played a major role in taking care of them. the degree to which the survivors recruited for the study had to depend on the caregivers in daily living activities immediately after discharge from the hospitals was assessed using a barthel index of the activities of daily living (bi) (22).all eligible survivors showed dependency on their caregivers for at least four out of ten activities, with scores under 10 on the bi. all the participants were informed about the research objectives, methods, risks, benefits and ethical concerns with respect to confidentiality, anonymity and legal representation for granting permission for the incompetent survivors with tbi to take part in the study. each of them also completed an informed consent form in writing. data collection data were gathered using four instruments. personal data on the caregivers; i.e. data on age, gender, marital status, education, income, employment, previous caregiving experience and relationship with survivors, were collected. the age, gender, marital status, education and employment of survivors with tbi were then recorded. the researcher collected the data by conducting a follow-up assessment on the coping and health problems of caregivers, as well as the disability level of survivors with tbi on the day of discharge and at one month after discharge. the ability of caregivers to cope was examined using the 27-item thai version of the coping and adaptation processing scale-short form (23).data on health problems were gathered using the health record form developed by the researchers. the disability level of the survivors with tbi was evaluated with the disability rating scale (24,25). measurements thai version of the coping and adaptation processing scale-short form the 27-item thai version of the coping and adaptation processing scale-short form (tcaps-sf) was modified from the 47item thai version of the coping and adaptation processing scale 175 coping and health problems of caregivers of survivors with traumatic brain injury l prangtip chayaput, ketsarin utriyaprasit, somsong bootcheewan, orapan thosingha (tcaps), which was back-translated from the english version of roy’s coping and adaptation processing scale (caps) and validated (23). the caps was used to assess the coping strategy and based on the ram and roy’s nursing model of cognitive processing (26). the tcaps-sf contains four subscales with 51.6% of the total explained variance:1) resourceful and systematic (eight items); 2) physical and fixed (six items); 3) positive and knowing (seven items) and 4) alert processing (six items).most items denoted problem-solving coping strategies. each item particularized the coping strategies individuals used to deal with difficult episodes confronted while maintaining a balance between work and routine daily activities (1,23,26). the first subscale illustrates how individuals gather more information from any resource, think carefully step-by-step and develop strategies to overcome the problem at hand. the second subscale demonstrates how individuals react when faced with difficulty, e.g. overreaction, confusion and self-blame. the third subscale shows positive thinking and action toward solving problems. the last subscale represents how individuals take dynamic action to resolve problems (23). the tcaps-sf has good reliability (1,23). cronbach’s alpha coefficient for the total scale was 0.89 and ranged from 0.72 to 0.89 for each subscale (23).the following were used for the likert-type four-level rating scale: 1 = never; 2 = rarely; 3 = sometimes and 4 = always. the total scores on the tcaps-sf ranged from 27 to 108.higher scores for each item illustrate more frequent use of specified coping strategies; i.e. the higher the score for each subscale, the more frequent the described coping strategy used by the individual (23).in this study, cronbach’s alpha coefficients for the total scale and each subscale were .79, .73, .75, .70 and .70, respectively. health problem questionnaire the caregiver health problem questionnaire is a self-report checklist of possible health problems. it contains questions about what health problems caregivers faced at the time of survivor discharge from hospital and at one month after taking care of the survivor at home. the caregivers reported all health problems and rated the problems that concerned them the most. two clinical nursing experts and a neurosurgeon examined the content validity of the questionnaire, which yielded a score of .90. disability rating scale the 8-item disability rating scale (drs) was developed by rappaport et al. (24) to measure the disability levels of patients with tbi. the scores ranged from 0 to 29.the minimum score of zero indicated no disability. scores of seven to eleven illustrated moderately severe injury, and scores of 25 and above reflected an extreme vegetative state (24).the drs had exhibited excellent reliability and validity for assessing the level of functional disability in populations with tbi (15,24,25).the inter-rater correlation among survivors with tbi in this study was one. data analyses data analyses were conducted with a statistical computer package. the descriptive statistics used frequency, percentage, mean and standard deviation. a paired-samples t-test was performed to measure the differences between the coping and health problems of caregivers at the time of survivors’ discharge and at one month after returning home. the correlations among the variables, including the disability level of survivors with tbi, age, marital status, income, previous caregiving experience, and the coping and health problems of caregivers, were calculated using pearson’s product moment correlation coefficient. results personal data of caregivers and survivors with tbi as shown in table 1, the majority of the caregivers were married, employed, female and had primary educational achievements (grades 1-6). their ages ranged from 18 to 66, with the average being 40.85 years of age (sd 11.7).most of the relationships with survivors were parental, followed by spousal or partner relationships with no caregiving experience. the majority of the survivors with tbi were single, employed and male, and had high school educational achievements (grades 7-12). their ages ranged from 15 to 72, with the average being 29.59 years of age (sd 13).at one month after discharge, nearly all the survivors with tbi continued to show a dependency on caregivers for at least four out of ten activities on the bi. the bi scores were still under 10. 176 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 coping and health problems of caregivers the mean coping ratings at the time of discharge and at one month after discharge were 81.88 (sd 9.22) and 83.45 (sd 7.83), respectively. there were no statistical differences between the total mean scores for coping and health problems among caregivers, as shown in table 2. with regard to the analysis of each coping strategy used, the caregivers applied similar strategies both at discharge and after having taken care of the survivors for one month. at one month after discharge, the caregivers indicated an increase in the coping strategies used for all of the items. only one strategy was used significantly less; i.e. caregivers tended to blame themselves less for whatever difficulties they encountered after one month of performing caregiving tasks. table 3 illustrates the health problems mentioned most frequently by the caregivers; namely, headache, stress, no health problems, fatigue, backache and fever at the time of discharge. the health problems reported most often most at one month after discharge were no health problems, headache, fatigue, backache, stress and fever. disability level of survivors with tbi the disability levels of the survivors with tbi averaged 4.41 (sd .82) on the day of discharge and 3.48 (sd 1.59)at one month after discharge. there was only one negative correlation between coping and disability level at the time of discharge (r = -.245, p = .024), as shown in table 4.this study found no correlations among coping, health problems and disability level at one month after discharge, as illustrated in table 5. relationships among personal data, coping, health problems and disability level the correlations among age, marital status, income, previous caregiving experience, coping, caregiver health problems and the disability level of survivors were sought. only the marital status of caregivers was negatively related to the coping of caregivers (r = -.220, p = .043), as shown in table 5. furthermore, the married caregivers reported higher coping scores than the single, widowed and separated caregivers: 81.98 (sd 6.52), 81.34 (sd 9.84) on the day of discharge, and 83.72 (sd 6.88), 82.37 (sd 8.11) at one month after discharge. the married caregivers tended to make frequent use effective coping strategies after returning home. in other words, these findings suggest that married caregivers would be more likely to cope and to deal with the commitments involved in caring for disabled survivors effectively than single, widowed and separated caregivers. discussion as for the personal data of the survivors with tbi, their characteristics are similar to those noted in other studies done in thailand and western countries, with most of the survivors being young adult males (1,4,27).in thai culture, caregiving and household responsibilities are usually the duty of the females in the family. mothers, daughters, sisters and other female relatives are supposed to perform such tasks (1,28).thus, most of the caregivers in the present study were found to be females and parents of survivors. the survivors with tbi face major life-devastating impacts that distinguish them from healthy persons as they transition from the critically ill to the rehabilitation phase. hence, caregivers play an important role in helping them to go through the abovementioned processes (1,5,6,9-11,15).effective adjustment to these difficult consequences enables survivors to recover from disability, gain increased independence and improve their quality of life (27). in terms of the coping strategies used by caregivers, it was found that they seek more resources and cope more effectively at one month after discharge, as the disability level of survivors gradually decreased. to the extent that the survivors with tbi began to recover, the fatigue, distress, and burden caregivers felt seemed to be alleviated (9), thereby enhancing the caregivers’ satisfaction with their role. this study found the caregivers tended to blame themselves less after one month had passed. they were able to pursue caregiving roles effectively after feeling themselves able to facilitate the recovery of the survivors with tbi. for this reason, the ability of the caregiver to cope has direct impact on the survivor’s recovery (14). according to the ram (16,18), it appears the caregivers coped with taking care of the survivors at home by accepting and adjusting to their new role. subsequently, they were able to per177 coping and health problems of caregivers of survivors with traumatic brain injury l prangtip chayaput, ketsarin utriyaprasit, somsong bootcheewan, orapan thosingha form expected caregiving tasks and self-care with less dependency on others, eventually being able to return to work and to interact better with other members of society (18). they used more effective coping strategies by seeking resources, thinking carefully and being on the alert for new information about ways and means to care for the survivors effectively. according to the findings of this study, the married caregivers demonstrated adaptive behavior, reporting higher scores for coping and utilizing less emotional-solving coping strategies than single, widowed and separated caregivers. for caregivers and family members, functioning was related significantly to the survivors’ total scores for level of independence and disability (1,5,9).moreover, in families with healthy caregivers who suffered no depression or sense of burden due to the demands of caregiving, the survivors with tbi had statistically significant higher levels of recovery from disability than in those with unhealthy caregivers. caregiver health also resulted in good recovery of patients with tbi and enhanced survivor selfcare ability (7). how caregivers cope can adversely affect the status of their health (1,11,14,18).as for their health problems, emotional functioning, mental and physical health, many studies (29-32) clearly note correlations with the recovery outcomes of survivors with tbi in the rehabilitation phase. however, the caregivers in this study reported more problems with physical health than emotional functioning and mental health. this finding might be explained by the fact that thai culture offers social support from families, friends and other resources in the community immediately after a survivor with tbi returns home (1,4,5,28). consequently, the caregivers had taken advantage of all the obtainable support that was suitable for them (5).they might feel more positive and confident with less perceived role strain. nonetheless, the decline in physical health was mentioned because the caregivers had to juggle new roles. this study revealed that married caregivers deal with caregiving obligations better than single, widowed and separated caregivers. the findings also showed that most caregivers were parents and spouses. other studies note reciprocal results in that caregivers who were parents (1) and spouses (1,33) also perceived caregiving responsibilities as less burdensome than adult-child caregivers. they had less difficulty adjusting to caregivers’ lifestyles, because they accepted caregiving as a duty (1,5,28).in addition, the more the caregivers perceived the task as burdensome, the more likely they were to have mental health problems (14,31,33).several studies (31,32,34) also have shown an increase in levels of depression and anxiety among both parental and spousal caregivers following the discharge of survivors with tbi. the aforementioned factors affected the success of the transition from hospital to home and placed the caregivers at risk of poor health-related quality of life and mental health problems. the evidence-based findings in this study do not offer statistical support for correlations between coping and health problems at the time of discharge and at one month after discharge. however, the theoretical support from the ram continues to show the context in terms of how the caregivers coped with the disability levels of survivors with tbi and how the health problems of the caregivers changed after they became involved with caregiving responsibilities. conclusion in summary, the results explain how the caregivers of disabled persons with tbi were able to master the unexpected situations occurring in their lives during the acute rehabilitation phase at home. caregivers’ ability to cope with role adjustments in providing care for survivors with tbi was affected by several influential factors. the findings show caregivers were able to effectively handle the task of accompanying and caring for disabled survivors with tbi at home. the ram can be engaged to describe the correlations between coping and the health problems of caregivers, as well as the disability levels of survivors. however, further research to examine the proposed theoretical concepts is required. nursing interventions to help caregivers continue to cope effectively should be established and implemented to meet caregivers’ needs with accessible local resources. even if the caregivers coped well with fewer health problems at one month after discharge from hospital, they would have a longterm duty to care for survivors with tbi who might recover slowly. furthermore, most longitudinal studies have shown the long-term burdens involved in providing care for disabled survivors are correlated with the caregivers’ quality of life. for this reason, followup studies are essential to improving the quality of nursing care among thai caregivers and survivors with tbi. 178 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 acknowledgement this study was supported by the china medical board of new york, inc. mahidol university, faculty of nursing. it was presented during an oral session at the 10th annual conference of the roy adaptation association (raa), boston college, chestnut hill, massachusetts, usa. references 1. khiewchaum r, thosingha 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injury: a multicenter investigation. arch phys med rehabil 2012; 93(5): 842-8. 30. arango-lasprilla jc, nicholls e, villasenor cabrera t, drew a, jimenez-maldonado m, martinez-cortes ml. health-related quality of life in caregivers of individuals with traumatic brain injury from guadalajara, mexico. j rehabil med 2011; 43(11): 983-6. 31. ennis n, rosenbloom bn, canzian s, topolovec-vranic j. depression and anxiety in parent versus spouse caregivers of adult patients with traumatic brain injury: a systematic review. neuropsychol rehabil 2013; 23(1): 1-18. 32. nalder e, fleming j, foster m, cornwell p, shields c, khan a. identifying factors associated with perceived success in the transition from hospital to home after brain injury. j head trauma rehabil 2012; 27(2): 143-53. 33. conde-sala jl, garre-olmo j, turro-garriga o, vilalta-franch j, lopez-pousa s. differential features of burden between spouse and adult-child caregivers of patients with alzheimer’s disease: an exploratory comparative design. int j nurs stud 2010; 47(10): 1262-73. 34. turner b, fleming j, cornwell p, haines t, ownsworth t. profiling early outcomes during the transition from hospital to home after brain injury. brain inj 2009; 23(1): 51-60. 180 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 inputs controls outputs focal stimulus disability level of survivors with tbi contextual stimuli caregivers’ characteristics age marital status income previous caregiving experience coping processes cognator subsystem regulator subsystem caregivers’ behaviors coping health problems figure 1. diagram of correlations between variables of interest for caregivers relating to the ram in this study figure 2. conceptual-theoretical-empirical structure for the study on coping and health problems of caregivers of survivors with tbi conceptual model concepts theoretical concepts empirical research instruments focal stimulus disability level of survivors with tbi disability rating scale (drs) contextual stimuli caregivers’ characteristics • age • marital status • income • previous caregiving experience personal data record form coping thai version of coping and adaptation processing scale-short form (tcaps-sf) health problems health problems questionnaire adaptive modes 181 coping and health problems of caregivers of survivors with traumatic brain injury l prangtip chayaput, ketsarin utriyaprasit, somsong bootcheewan, orapan thosingha table 1. personal data of caregivers (n = 85) and survivors with tbi (n = 85) variable caregivers survivors with tbi n % n % gender male 11 12.9 76 89.4 female 74 87.1 9 10.6 marital status single 10 11.8 40 47.1 married 67 78.8 38 44.7 widowed/separated 8 9.4 7 8.2 religion buddhist 79 92.9 79 92.9 islam 5 5.9 5 5.9 catholic/protestant 1 1.2 1 1.2 education no education 5 5.9 1 1.2 grade 1-6 56 65.9 36 42.4 grade 7-12 17 20.0 39 45.8 2-year college 3 3.5 6 7.1 4-year college 4 4.7 3 3.5 employment unemployed 19 23.3 21 23.7 employed 66 76.7 64 76.3 caregiving experience yes 10 11.8 no 75 88.2 relationship to survivor spouse/partner 23 27.0 parent 45 52.9 daughter/son 5 5.9 sibling 11 13.0 other relatives 1 1.2 182 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 table 2. differences between coping and health problems of caregivers at the time of discharge and one month after discharge (n = 85) variable t df sig (2-tailed) coping at discharge vs. coping one month after discharge -1.929 84 .057 ns health problems at discharge vs. health problems one month after discharge 1.280 84 .204 ns table 3. health problems most concerned by caregivers (n = 85) ns = non-significant variable n % health problems at the time of survivors’ discharge headache 30 35.3 stress 27 31.7 no health problems 14 16.5 fatigue 8 9.4 backache 5 5.9 fever 1 1.2 health problems one after month discharge no health problems 35 41.3 headache 23 27.0 fatigue 8 9.4 backache 8 9.4 stress 7 8.2 fever 4 4.7 table 4. correlations among coping, health problems, age, marital status, previous caregiving experience of caregivers and disability level of survivors at the time of discharge (n = 85, 85) variable 1 2 3 4 5 6 1. coping 1 2. health problems -.089 1 3. age of caregivers -.020 .045 1 4. marital status of caregivers -.097 .170 .301 1 5. previous caregiving experience .017 -.086 .049 -.014 1 6. disability level -.245* -.054 .162 .209 -.050 1 * p < .05 183 coping and health problems of caregivers of survivors with traumatic brain injury l prangtip chayaput, ketsarin utriyaprasit, somsong bootcheewan, orapan thosingha table 5. correlations among coping, health problems, age, marital status, previous caregiving experience of caregivers and disability level of survivors at one month after discharge (n = 85, 85) variable 1 2 3 4 5 6 1. coping 1 2. health problems .021 1 3. age of caregivers -.002 .165 1 4. marital status of caregivers -.220*. .132 .301 1 5. previous caregiving experience .101 -.030 .049 -.014 1 6. disability level -.012 .198 .000 .024 -.089 1 * p < .05 1 7 primeras paginas.indd 5 editorial enfermería es una disciplina profesional, y por su naturaleza debe generar conocimiento que explique los fenómenos propios y que pueda aplicarse en los diversos contextos de la práctica. algunos de esos hechos —sino la mayoría— que interesan a los profesionales de enfermería deben ser conocidos a través del desarrollo de metodologías cuantitativas que requieren la aplicación rigurosa de técnicas de medición precisas, en un esfuerzo por limitar al máximo la posibilidad de error y por obtener así resultados reales, válidos, exactos, consistentes y generalizables (1, 2). si la técnica de medición seleccionada es incorrecta, el investigador entregará resultados errados, aspecto que afecta directamente la validez interna y externa del proceso investigativo (3, 4). la estructura sintáctica de la disciplina que postularon donaldson y crowley (5) incluye los aspectos metodológicos de la investigación científica dentro de los cuales cabe mencionar el uso de técnicas de medición que se adecuen empíricamente a los conceptos teóricos, y que cumplan con los más altos estándares que la ciencia exige, pues como ciencia, enfermería debe utilizar metodologías que garanticen la calidad y aplicabilidad de los hallazgos. en este sentido, la investigación cuantitativa mide y comprueba aspectos teóricos o hipótesis que pueden moverse desde la descripción hasta la predicción del cuidado de enfermería (6), y para ello se requiere la aplicación de métodos o indicadores empíricos, como por ejemplo, instrumentos de medición. así, la medición implica la asignación numérica o cuantificación de una cosa, objeto, situación, experimento o fenómeno siguiendo una regla o norma. uno de los componentes de la medición es medición de fenómenos de enfermería: el reto de la ydolgh]�\�frq¿delolgdg�hq�od�lqyhvwljdflyq�fxdqwlwdwlyd la instrumentación, definida como toda condición experimental o procedimiento usado para observar y medir atributos, cualidades o propiedades, constructos o conceptos completamente teóricos, que son imposibles de cuantificar de otra forma. la información obtenida a través de estos se denomina dato, y su función es proveer medidas objetivas de la teoría de la cual se derivan (2, 7, 8) . la comprobación de nuestros fenómenos de interés puede realizarse a partir de mediciones directas e indirectas. las directas hacen referencia a la cuantificación de elementos concretos y objetivos; el interés de evaluar la técnica de medición se centra en valorar su precisión en términos de exactitud y reproducibilidad, y se logra a partir de un proceso denominado calibración. habitualmente en enfermería, además de las mediciones directas, son muy importantes las mediciones indirectas dirigidas a valorar características o atributos de un concepto abstracto o complejo, allí el objetivo se dirige a indagar las características relacionadas con la validez y la confiabilidad (3, 2). toda técnica de medición exhibe cierto grado de error, entendido como la diferencia entre la medición obtenida y la medición real. el error aleatorio no tiene un patrón definido o dirección, se debe al azar y puede estar influenciado por factores como alteraciones en el procedimiento de aplicación, errores en el diligenciamiento, o en la captura de información en bases de datos, entre otros. por el contrario, los errores sistemáticos, son aquellos que se repiten bajo un patrón definido y constante; los investigadores dirigen gran parte sus esfuerzos a limitar su ocurrencia con el fin de afinar la técnica y prevenir la generación de conclusiones erradas (2). 0hdvxuhphqw�ri�1xuvlqj�3khqrphqd��7kh�&kdoohqjh�ri�$fklhylqj� wkh�9dolglw\�$qguholdelolw\�lq�4xdqwlwdwlyh�5hvhdufk 0hglomr�gh�ihq{phqrv�gh�hqihupdjhp��r�ghvd¿r�gh�dofdqodu� d�ydolgdgh�hd�frq¿delolgdgh�gd�shvtxlvd�txdqwlwdwlyd 6 aquichan issn 1657-5997 año 12 vol. 12 nº 1 chía, colombia abril 2012 la evaluación de las características de validez y confiabilidad de los instrumentos es una forma de demostrar la rigurosidad en el diseño o la elección de los mismos, y representa un desafío teniendo en cuenta la cantidad de técnicas de medición disponibles y la necesidad de generar nuevos indicadores empíricos para diferentes conceptos y constructos teóricos. seleccionar adecuadamente el instrumento de medición permitirá evaluar la adecuación empírica de este con la teoría y la adecuación pragmática de los resultados al contexto real (7). la confiabilidad se relaciona con la consistencia interna, coherencia, reproducibilidad, estabilidad y equivalencia de los resultados que dependen de la medición (9). indica que la aplicación repetida de un instrumento genera los mismos resultados en diferentes circunstancias, y expresa la proporción de error aleatorio inherente a la medición. un instrumento es confiable si la característica que mide en los sujetos es atribuible a diferencias verdaderas entre estos, y no a las características de la técnica o de quienes la administran. documenta el grado de estabilidad entre individuos, observadores y a través del tiempo (3). más que una característica per se del instrumento es una característica evaluable a partir de la muestra específica en la que se aplica, razón por la cual es fundamental evaluar la confiabilidad cada vez que se utilice el instrumento (2, 10). la confiabilidad puede referirse a diversos aspectos: congruencia de las mediciones en diferentes momentos de aplicación o a través del tiempo (estabilidad), congruencia de los ítems, consistencia de los resultados a partir de los ítems (consistencia interna), congruencia de los resultados en dos o más instrumentos o entre observadores (equivalencia) (3). la confiabilidad es necesaria pero insuficiente para establecer la validez de una técnica de medición, un instrumento que no es confiable probablemente es errático, inconsistente e inexacto (1, 2, 4). la validez indica la capacidad de un instrumento para medir lo que debe medir o cuán bien se refleja el constructo que se quiere estimar. aspecto que muestra si el resultado de la medición expresa con precisión la realidad y la proporción de error sistemático de la prueba. existen varios tipos de validez que deben ser demostrados a partir del refinamiento de la técnica de medición. la validez que implica la evaluación respecto a claridad, precisión del lenguaje y presunción de aquello que la técnica pretende medir (validez facial); la que indaga sobre la extensión en la cual el conjunto de ítems mide todas las dimensiones o características de un dominio teórico específico (validez de contenido) cuando se realiza la comparación de la técnica respecto a otras disponibles (criterioconcurrente), cuando se predicen futuros eventos a partir de los resultados que arroja la técnica (criterio-predictiva), o cuando se evalúa la capacidad para discriminar sujetos con la característica de aquellos que no la tienen (criterio-discriminante). finalmente, la validez de constructo se basa en la forma en que una prueba mide o captura un constructo teórico o rasgo. evalúa la relación entre la medida usada y la teoría en la cual se apoya (2, 4, 9, 10). además, es clave recordar la importancia de diseñar y validar instrumentos de enfermería teniendo en cuenta el contexto cultural específico, aspecto que va más allá de la mera traducción o adaptación lingüística. esto obedece a que el uso de palabras, frases o idiomas distintos al contexto en el que se desenvuelve la persona que responde puede aumentar el error sistemático de la prueba y afectar así la validez de la medición (2). cuando se revisa un reporte de resultados de investigación es fundamental indagar acerca del origen y las características psicométricas de las técnicas o herramientas de medición empleadas. utilizar instrumentos sin validez o confiabilidad lleva a que la medición de aspectos teóricos sea ineficaz y se obstaculice así el avance en el desarrollo teórico y de la práctica basada en la evidencia, pues se altera la correspondencia entre el resultado obtenido y la realidad estudiada. además, se considera que los instrumentos de medición son elementos críticos de la validez y confiabilidad general de la investigación porque aunque el problema, el propósito y los procedimientos de recolección y análisis de la información sean correctos, si el instrumento de medición tiene limitaciones o problemas inherentes, los resultados se vuelven limitados o cuestionables (4, 10, 11). en este número de aquichan se publican dos artículos relacionados con la validez y la confiabilidad de instrumentos utilizados para medir el cuidado de enfermería fundamentado en la teoría de jean watson y en la escala de comportamiento de autocuidado fundamentado en la teoría de dorothea orem. artículos como estos, que presentan la evaluación de características de precisión, validez y confiabilidad de los instrumentos, son fundamentales porque facilitan la aplicación de resultados a la práctica de enfermería. 7 estos escritos nos demuestran cómo el investigador tiene la responsabilidad de indagar acerca de las características psicométricas de los instrumentos seleccionados, y de hacer las pruebas que el rigor metodológico exija para el estudio particular. como tal, la medición y la instrumentación son elementos críticos para mejorar la investigación científica en enfermería. gloria carvajal-carrascal universidad de la sabana gloria.carvajal@unisabana.edu.co referencias bibliográficas 1 roberts p, priest h. reliability and validity in research. nursing standard 2006; 20 (44): 41-45. 2 burns n, grove s. medición y recogida de datos en investigación. investigación en enfermería. 3 edición. madrid: elsevier; 2004, p. 287-304. 3 houser j. precision, reliability and validity: essential elements of measurement in nursing research. scientific inquiry. journal for specialists in pediatric nursing 2008; 13 (4): 297-299. 4 lobiondo g, haber j. reliability and validity. nursing research: methods and critical appraisal for evidence – based practice. 6 edition. st louis missouri: mosby-elsevier; 2006, p. 335-356. 5 donaldson s, crowley d .the discipline of nursing. nursing outlook 1978; 26 (2): 113-120. 6 durán de villalobos m. enfermería. desarrollo teórico e investigativo. bogotá: unibiblos, universidad nacional de colombia; 1998. 7 fawcett j. contemporary nursing knowledge. analysis and evaluation of nursing models and theories. 2 edition. fa davis company; 2005. 8 bland jm, altman dg. validating scales and indexes. br med j 2002; 324: 606-607. 9 twycross a, shields l. validity and reliability – what is it all about? part 1 validity and quantitative studies. pediatric nursing 2004; 16 (9). 10 polit d, beck c. nursing research: principles and methods. 7 edition. philadelphia: lippincott, williams & wilkins; 2004. 11 malmgreen c. validating research instruments. national nursing staff development organization. nnsdo; 2005. 23 inna elida flórez-torres1 eliana herrera-alarcón2 estefany carpio-jiménez3 maría a. veccino-amador4 diana zambrano-barrios5 yoleidis reyes-narváez6 sandra torres-contreras7 afrontamiento y adaptación en pacientes egresados de unidades de cuidado intensivo 1 magíster en enfermería. docente, universidad de cartagena, facultad de enfermería. campus de zaragocilla, cartagena, colombia. iflorezt@unicartagena.edu.co 2 enfermera. universidad de cartagena. elianapha@hotmail.com 3 enfermera. universidad de cartagena. escarji@hotmail.com 4 enfermera. universidad de cartagena. mariaveccino@gmail.com 5 enfermera. universidad de cartagena. dicazaba@hotmail.com 6 enfermera. universidad de cartagena. yolereyesn@hotmail.com 7 enfermera. universidad de cartagena. sandrytorresc@hotmail.com recibido: 01 de noviembre de 2010 aceptado: 28 de marzo de 2011 resumen objetivo: describir la capacidad de afrontamiento y adaptación en pacientes egresados de unidades de cuidado intensivo de la ciudad de cartagena, colombia. método: estudio descriptivo, realizado en 171 pacientes egresados de unidades de cuidados intensivos durante el segundo semestre de 2009. se empleó la escala de medición del proceso de afrontamiento y adaptación de callista roy. para valorar los factores que miden las estrategias y los recursos de afrontamiento para la adaptación se utilizaron medidas de tendencia central y coeficiente de variación. resultados: el 50,3 % de los participantes fueron mujeres y 49,7 % hombres. la capacidad de afrontamiento y adaptación fue del 63,2 %, el 19,9 % presentó mediana capacidad. la baja capacidad reportó 1,2 %. por factores, el proceso de alerta presentó una mayor puntuación, con 46,2 %, en alta capacidad en las estrategias de afrontamiento, y en el procesamiento sistemático, el 45,0% se ubicó en muy alta capacidad en cuanto a los recursos utilizados para la adaptación. conclusión: los pacientes reflejaron un estilo de afrontamiento activo con estrategias centradas en el problema tanto cognitivas como comportamentales, percibiendo la situación como controlable. el modelo de roy permite a las enfermeras identificar en los pacientes estrategias adecuadas o inefectivas y orientar el cuidado. palabras clave afrontamiento, adaptación, unidad de cuidados intensivos. (fuente: decs). año 11 vol. 11 nº 1 chía, colombia abril 2011 l 23-39 24 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 coping and adaptation in patients discharged from intensive care units abstract objective: describe the capacity for coping and adaptation among patients released from intensive care units in the city of cartagena (colombia). method: a descriptive study of 171 patients who were released from intensive care units in the second half of 2009. callista roy’s coping and adaptation measurement scale was used. measures of the central tendency and coefficient of variation were employed to assess the factors that gauge coping strategies and resources for adaptation. results: 50.3% of the participants were women and 49.7% were men. the capacity to cope and adapt was in 63.2% of the patients studied, while 19.9% showed medium or average capacity, and 1.2% reported low capacity. by factors, the warning process scored highest, with 46.2% of the patients being quite capable in terms of their coping strategies. as for systematic processing, 45.0% showed extremely good capacity with respect to the resources used to adapt. conclusion: the patients in question displayed an active coping style with cognitive and behavioral strategies centered on the problem and with the situation being perceived as controllable. the roy model allows nurses to identify adequate or ineffective strategies in patients and to orient care accordingly. key words adaptation, intensive care units, nursing care, critical state, patients (source: decs). enfrentamento e adaptação em pacientes dados de alta de unidades de cuidados intensivos resumo objetivo: descrever o enfrentamento e a adaptação em pacientes que receberam alta da unidade de terapia intensiva na cidade de cartagena, colômbia. método: estudo descritivo em 171 pacientes que receberam alta da unidade de cuidados intensivos durante o segundo semestre de 2009. utilizou-se a escala de callista roy para medir o processo de enfrentamento e adaptação. para avaliar os fatores que medem as estratégias e os recursos de enfrentamento; para a adaptação se utilizaram medidas de tendência central e coeficiente de variação. resultados: 50,3% dos participantes eram mulheres e 49,7% homens. a capacidade de enfrentar e adaptar-se foi em 63,2% dos pacientes. o 19,9% mostrou capacidade média. o 1,2% apresentou baixa capacidade. pelos fatores, o processo de alerta alcançou maior pontuação (46,2%) com alta capacidade nas estratégias de enfrentamento e no processamento, o 45,0% se situou en muita alta 25 afrontamiento y adaptación en pacientes egresados de unidades de cuidado intensivo l inna elida flórez-torres, eliana herrera-alarcón, estefany carpio-jiménez et al. capacidade em termos de recursos utilizados para a adaptação. conclusão: os pacientes apresentaram um estilo ativo de enfrentamento com estratégias cognitivas e comportamentais focalizadas no problemas, percebendo a situação controlável. o modelo de roy permite as enfermeiras identificarem estratégias adequadas o inefeticazes nos pacientes e orientarem o cuidado. palavras-chave adaptação, cuidados intensivos, cuidados de enfermagem, pacientes criticamente enfermos. (fonte: decs). 26 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 introducción el aumento en la morbilidad por enfermedades crónicas, como enfermedad cardiovascular, diabetes mellitus, cáncer, y las enfermedades respiratorias, entre otras, sumado a condicionantes como los actuales estilos de vida poco saludables de la población, la persistencia de la tendencia al consumo de sustancias nocivas, la contaminación ambiental y el incumplimiento a largo plazo de los tratamientos para las enfermedades crónicas han contribuido al aumento de su incidencia, al riesgo de enfermar, a la presencia de complicaciones, a hospitalizaciones en unidades de cuidado intensivo (uci), incapacidad y a la muerte (1). las respuestas humanas observadas en los pacientes hospitalizados en una uci, relacionadas con el campo psicosocial, tienen que ver con la presencia real de factores de estrés vinculados con amenaza de muerte, pensamiento aterrador, trastornos del sueño, pérdida de control de su entorno personal y familiar, pérdida de autonomía, abandono de roles individuales, familiares y sociales, aislamiento familiar y social, temor a la discapacidad o miedo a los tratamientos invasivos (2, 3). estudios recientes han descrito el significado de la experiencia de estar hospitalizado en una unidad de cuidado intensivo (4, 5, 6). no obstante, las respuestas comportamentales de las personas hospitalizadas en una uci, a partir de un referente teórico de enfermería, no han sido lo suficientemente abordadas. las personas hospitalizadas en una uci están expuestas a un sinnúmero de estímulos que generan respuestas adaptativas o de afrontamiento. callista roy (7), define el afrontamiento como los esfuerzos comportamentales y cognitivos que realiza una persona para atender las demandas del ambiente, los cuales actúan como un todo para mantener sus procesos vitales y su integridad. en su modelo de adaptación, roy postula que el subsistema cognoscitivo es el proceso de afrontamiento principal de la persona, y se manifiesta en la conducta bajo la respuesta o modo fisiológico de autoconcepto, función de rol e interdependencia (8). se refiere al afrontamiento y a los procesos de adaptación como a un constructo multidimensional que representa las respuestas o modos fisiológico y psicosocial. como sistema posee niveles jerárquicos pues abarca procesos cognoscitivos tanto a nivel de entradas o estímulos, procesos internos o centrales, como de salidas o respuestas (9). los estímulos focales son aquellas situaciones o circunstancias que la persona debe confrontar en forma inmediata, tales como una enfermedad o un evento externo y para lo cual requiere consumo de energía; (10) en el caso de una persona en estado crítico, están representados en enfermedades que ponen en peligro su vida como las enfermedades cardiacas, respiratorias, descompensaciones metabólicas, estados agudos de enfermedades neoplásicas, renales, traumas múltiples, posoperatorios de cirugías complejas, entre otras. los contextuales están presentes en la situación, y aunque no son el centro de atención o de consumo de energía, influyen en la forma como la persona puede afrontar el eslos estímulos focales son aquellas situaciones o circunstancias que la persona debe confrontar en forma inmediata, tales como una enfermedad o un evento externo y para lo cual requiere consumo de energía. 27 afrontamiento y adaptación en pacientes egresados de unidades de cuidado intensivo l inna elida flórez-torres, eliana herrera-alarcón, estefany carpio-jiménez et al. timulo focal (10). en la hospitalización en una uci tales estímulos están representados en las características del servicio, el aislamiento, el riesgo de infección, la difícil y escasa comunicación, en lugares ocupados y equipados por numerosos instrumentos (11). los estímulos residuales son factores desconocidos que se encuentran en el ambiente, cuyos efectos no han sido confirmados. estos pueden ser una expectativa, un valor, una actitud o una creencia, producto de experiencias pasadas. en el momento en el que se conoce cómo están actuando en la situación se vuelven contextuales (10). en la situación del paciente en estado crítico estos estímulos se consideran factores que se encuentran en el ambiente, el cambio y la pérdida del rol anterior a la hospitalización, los sentimientos de pérdidas, de la independencia, modificación de valores y filosofía de la vida, lo cual se traduce en alteración del autoconcepto (12). la forma como el paciente hospitalizado en una uci se enfrenta a la situación va a depender de muchos factores que pueden ser resumidos en la evaluación cognitiva que los individuos realizan frente al evento. las estrategias comportamentales buscan controlar el estímulo o estresor en forma directa, actuando frente al problema que la persona considera es susceptible de modificar. pueden ser evasivas cuando la persona siente que no puede actuar ante el estímulo y lo rechaza en forma consciente o inconsciente (13). las estrategias afectivas hacen referencia a los intentos que realiza la persona para controlar las reacciones emocionales que el problema genera. se manifiestan con la expresión de sentimientos frente a sí mismo y a los demás. las cognitivas pueden ser de dos tipos: aquellas que buscan minimizar las consecuencias y el impacto de la situación negando su gravedad o ignorándola, y las que, por el contrario, se enfocan en la situación y se ocupan de ella. las personas intentan mantener el control de las situaciones percibidas como difíciles mediante la utilización de respuestas racionales, en donde están presentes estrategias comportamentales y cognitivas que permiten dar solución a la situación (13). la capacidad y las estrategias de afrontamiento hacen visibles las características personales relacionadas con los pensamientos, los sentimientos y las acciones individuales propias de un ser holístico quien, al utilizar los recursos de afrontamiento innatos y adquiridos, busca adaptarse a un ambiente cambiante (10). su identificación permite a las enfermeras identificar en los pacientes estrategias adecuadas o inefectivas y orientar el cuidado. el objetivo del estudio fue describir la capacidad de afrontamiento y adaptación en pacientes egresados de unidades de cuidado intensivo de la ciudad de cartagena, en 2009. método estudio descriptivo realizado en el segundo semestre de 2009. la población la conformaron pacientes egresados de cinco unidades de cuidados intensivos de la ciudad de cartagena; la muestra fue de 171 pacientes, seleccionados a través de un muestreo estratificado. se incluyeron adultos hospitalizados en sala general, egrela forma como el paciente hospitalizado en una uci se enfrenta a la situación va a depender de muchos factores que pueden ser resumidos en la evaluación cognitiva que los individuos realizan frente al evento. 28 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 sados de su primera estancia en uci, en condición de salud estable, que desearon participar voluntariamente y firmaron su consentimiento; se excluyeron aquellos en condición de salud estable, que recibían soporte ventilatorio, con alteraciones mentales y estados de inconciencia. las investigadoras diligenciaron los instrumentos. se empleó la escala de medición del proceso de afrontamiento y adaptación (caps) de callista roy, basada en una teoría de mediano rango sobre dicho proceso. consta de 47 reactivos, cinco dimensiones o factores, patrón de respuesta tipo liker, desde 1 = nunca, a 4 = siempre (13). el puntaje puede oscilar entre 47 a 188 puntos, a mayor puntaje significa un uso más consistente de estrategias de afrontamiento. con relación a los cinco factores, los tres primeros miden los comportamientos, las reacciones y los recursos de afrontamiento que utilizan las personas, y los dos últimos miden las estrategias empleadas para sobrellevar la situación. factor 1: recursivo y centrado (10 ítems). refleja los comportamientos personales y los recursos para expandir las entradas, ser creativo y buscar resultados. factor 2: reacciones físicas y enfocadas (14 ítems). resalta las reacciones físicas y la fase de entrada para el manejo de situaciones. factor 3: proceso de alerta (9 ítems). representa los comportamientos del yo personal y físico, y se enfoca en los tres niveles de procesamiento de la información: entradas, procesos centrales y salidas. factor 4: procesamiento sistemático (6 ítems). describe las estrategias personales y físicas para hacerse cargo de las situaciones y manejarlas metódicamente. factor 5: conocer y relacionar (8 ítems). describe las estrategias que utiliza la persona para recurrir a sí misma y a otros, usando la memoria y la imaginación. la confiabilidad del instrumento en su versión en español fue informada por gutiérrez et al., en el contexto colombiano, evaluada a través de la consistencia interna, presentando un alfa de cronbach de 0,88 (13). el análisis se condujo de acuerdo con la categorización realizada a la escala por gutiérrez y lópez (14), a nivel global y por factores: fuente: gutiérrez y lópez de mesa (14). grado de capacidad de factor 1 factor 2 factor 3 factor 4 factor 5 puntaje afrontamiento y adaptación global baja capacidad 11-19 13-23 9-16 6-11 8-14 47-82 mediana capacidad 20-28 24-33 17-23 12-15 15-20 83-118 alta capacidad 29-36 34-42 24-29 16-20 21-26 119-153 muy alta capacidad 37-44 43-52 30-36 21-24 27-32 154-188 análisis estadístico los datos se incorporaron en una matriz creada en microsoft excel y se procesaron en el programa estadístico para ciencias sociales (spss) versión 15.0, con el cual se generaron estadísticas descriptivas, medidas de tendencia central, y coeficiente de variación del puntaje obtenido por el grupo a nivel global y por factores. la investigación respetó los parámetros éticos para estudios con seres humanos contenidos en la resolución 008430 de 1993 del ministerio de salud de colombia, y del código de ética en enfermería; la clasificación fue de riesgo mínimo (15, 16). 29 afrontamiento y adaptación en pacientes egresados de unidades de cuidado intensivo l inna elida flórez-torres, eliana herrera-alarcón, estefany carpio-jiménez et al. resultados características de los participantes participaron 171 pacientes, con edades entre 18 y 88 años, y una media de 50,8 ic 95% (48,1-53,6); con relación al sexo, 50,3% fueron mujeres y 49,7% hombres; los estratos socioeconómicos predominantes fueron el 2 y 3 (41,5 y 29,8%, respectivamente) y en menor porcentaje el 6 (1,2%). la escolaridad estuvo representada por primaria incompleta en un 24,0%, primaria completa 20,5%, secundaria incompleta 18,7%, secundaria completa 16,4%, técnicos 7,0%, universitario completo 6,4% y universitario incompleto 2,9%. los participantes fueron casados en un 43,9%, solteros el 15,8%, en unión libre 24,6%, viudos 11,7% y separados 4,1%. la religión predominante fue la católica en un 70,8%. el 64,3% de los pacientes es de procedencia urbana, el 49,1% pertenece al régimen subsidiado, y un 46,8% al contributivo. el 45,0% se dedica al hogar, 25,0%, son empleados y en un 3,5%, estudiantes. del total de participantes, el 36,3% reportó alteraciones cardiovasculares, 13,5%, respiratorias, seguido de sepsis y complicaciones quirúrgicas con un 9,4% respectivamente, alteraciones neurológicas 5,8%; en igual porcentaje traumas, alteraciones gastrointestinales, estados de choque, alteraciones metabólicas con un 4,7%, hematooncológicas con 4,1%, y en menor porcentaje las alteraciones renales con 2,9%. capacidad de afrontamiento y adaptación los hallazgos a nivel global y por factores se presentan en la tabla 1 (ver anexo). el 63,2% de los participantes se ubicó en el nivel de alta capacidad, el 19,9% en el mediana, y la baja capacidad de afrontamiento y adaptación reportó 1,2% (ver anexo, gráfico 1). en el factor 1, recursivo y centrado, el 44,4% de los participantes presentó alta capacidad, el 31,6% muy alta capacidad, el 21,6% mediana y el 2,3% baja capacidad. el estar atento a cualquier cosa relacionada con la situación, estar dispuesto a modificar su vida radicalmente con tal de salir de la crisis, y obtener la mayor información posible para aumentar las opciones fueron los ítems que reportaron mejores resultados (63,7, 56,1 y 55,6 %, respectivamente). los hallazgos de esta dimensión se presentan en la tabla 2 (ver anexo). con relación al factor 2, reacciones físicas y enfocadas, el 40,9% presentó mediana capacidad de afrontamiento, el 32,2% alta capacidad, y el 19,9% baja capacidad. los ítems: al parecer me hago muchas ilusiones acerca de cómo resultarán las cosas, trato de hacer frente a la crisis desde el principio y solo puedo pensar en lo que me preocupa fueron los que mostraron una mayor proporción, con un mejor resultado (41,5, 39, 8% y 39,8%, respectivamente). los porcentajes obtenidos se presentan en la tabla 3. en cuanto al factor 3, proceso de alerta, el 46,2% presentó alta capacidad, el 25,7% muy alta capacidad, el 21,6% una mediana capacidad, y el 6,4% baja capacidad de afrontamiento. los ítems que mejor puntuaron fueron: poder seguir una gran cantidad de instrucciones a la vez (45%), poner los sentimientos a un lado y ser muy objetivo acerca de lo que sucede (43,3%), manejar la situación analizando rápidamente los detalles tal como ellos 30 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 sucedieron (43,3 %), obtener buenos resultados al manejar problemas complejos (35,7 %), y en menor proporción, nunca adoptan rápidamente nuevas capacidades cuando estas resuelven sus problemas (7 %) (ver anexo, tabla 4). en el factor 4, procesamiento sistemático, el 45% de los participantes se ubicó en muy alta capacidad, el 36,3% en alta capacidad, el 8,2% mediana capacidad, y el 10,5% baja capacidad de afrontamiento. la mayor proporción de participantes siempre llaman al problema por su nombre y tratan de verlo en su totalidad; analizan la situación como realmente es, y tratan de mantener equilibrio entre la actividad y el descanso (52, 48,5 y 45,6% respectivamente). un 7,6% nunca se toma el tiempo necesario y no actúa hasta no tener una buena comprensión de la situación. los hallazgos de este factor se presentan en la tabla 5 (ver anexo). con relación al factor 5, conocer y relacionar, el 43,3 % de los pacientes se encontró en la categoría alta capacidad, el 42,7 % en muy alta capacidad, en mediana capacidad de afrontamiento 14 %, ningún participante se ubicó en baja capacidad. los ítems: me siento bien al saber que estoy manejando el problema lo mejor que puedo, trato de recordar las estrategias o las soluciones que me han servido en el pasado, y recuerdo cosas que me ayudaron en otras situaciones, fueron los que revelaron mayor proporción de pacientes con un mejor resultado (61,4; 56,7 y 55,0%). los porcentajes obtenidos se presentan en la tabla 6 (ver anexo). discusión ante la enfermedad grave como estímulo estresante, donde se engloban cambios repentinos, inmediatos o impredecibles en el modo de vida, situaciones ambiguas, alteraciones que atentan contra la vida o que implican limitaciones, las personas desarrollan comportamientos y pensamientos conocidos como afrontamiento, para manejar la situación (17). los hallazgos señalan alta capacidad de afrontamiento y adaptación en los pacientes egresados de uci ante los estímulos focales, contextuales y residuales propios de la hospitalización, reflejando un estilo de afrontamiento centrado estrategias cognitivas que buscan encontrar significado al suceso, y solucionar directamente la situación. en los estímulos comportamentales la conducta estuvo dirigida a confrontar la realidad y manejar sus consecuencias, y en los emocionales reflejaron esfuerzos para controlar el estímulo estresor y mantener el equilibrio afectivo (14). este estudio ratifica los planteamientos de lazarus y folkman (17) sobre las estrategias identificadas en los participantes del estudio; los individuos emplean dos tipos generales de estrategias, las de resolución de problemas, directamente dirigidas a manejarlo o alterarlo, y las de regulación emocional, mediante métodos dirigidos a regular la respuesta emocional ante el problema. beltrán (4, 6) informa que la experiencia de adultos críticamente enfermos hospitalizados en uci significó una motivación para cambiar la forma de vivir y de pensar, permitió avanzar en el aprendizaje y en el crecimiento personal, y sirvió como base para tomar decisiones respecto a la vida futura. no obstante, sus planteamientos señalan respuestas que afectaron el modo fisiológico y el autoconcepto de los la experiencia de adultos críticamente enfermos hospitalizados en uci significó una motivación para cambiar la forma de vivir y de pensar, permitió avanzar en el aprendizaje y en el crecimiento personal. 31 afrontamiento y adaptación en pacientes egresados de unidades de cuidado intensivo l inna elida flórez-torres, eliana herrera-alarcón, estefany carpio-jiménez et al. participantes, al destacar los problemas y el sufrimiento físico y psicológico durante el tiempo que está presente la enfermedad y sus limitaciones para la vida de los pacientes. también altera el autoconcepto, por lo cual los pacientes no se reconocen a sí mismos, no reconocen su propio cuerpo. asimismo, una investigación guiada por el modelo de adaptación de callista roy, cuyo propósito fue conocer las repercusiones psicosociales de adolescentes hospitalizados en uci después del trasplante renal, y los mecanismos de adaptación utilizados en su nueva condición de vida, identificó respuestas inefectivas en el modo fisiológico como limitación física, en el modo de autoconcepto, sentimientos de vergüenza, miedo al rechazo e impotencia. sin embargo, los adolescentes pudieron afrontar de manera positiva tal situación y mejorar la adaptación a su nueva condición, lo que les permitió un tratamiento más eficaz y, consecuentemente, una mejor calidad de vida (18). contrario a los resultados del estudio, del barrio et al. (19) observaron que los pacientes de uci sometidos a trasplante hepático relatan su experiencia como negativa, debido a la limitación de movimiento que les causaban las vías invasivas, la idea de la alteración de su imagen corporal, la preocupación por la insatisfacción en las necesidades básicas, y el recuerdo de personas significativas. las respuestas emocionales ante el trasplante fueron muy diversas, desde el miedo, la ansiedad o el dolor producido por la separación de sus familias ante la posibilidad de la muerte, hasta un estado de tranquilidad y felicidad. livneh, citado por gutiérrez et al. (13), plantea que las estrategias afectivas hacen referencia a los intentos que realiza la persona para controlar las reacciones emocionales que el problema genera; estas se manifiestan a través de la expresión de sentimientos frente a sí misma y frente a otros, aceptando estos sentimientos o resignándose a permanecer en esa condición. la revisión teórica de vásquez et al. (20) respalda el empleo de múltiples estrategias para manejar una situación estresante; cada individuo tiene una propensión a utilizar una serie determinada de estrategias en situaciones diversas. esto es lo que se denomina estilo de afrontamiento; se han investigado de modo sistemático personas con tendencia evitadora o minimizadora, mientras otras tienden a utilizar un estilo más confrontativo (o vigilante), bien sea buscando información o tomando una acción directa ante cualquier problema. martínez et al. (21) identificaron en los pacientes hospitalizados en uci coronarias estrategias de afrontamiento pasivas como la negación, la evitación, el escape y la resignación como conformidad ante el sufrimiento. no obstante, la estancia de los pacientes no fue percibida como problemática, sino como algo necesario hacia la recuperación; dentro del discurso de los entrevistados se asoma la voluntad de realizar cambios positivos como dejar de fu mar, cambios en el estilo de vida y la dieta, y en general la supresión de factores de riesgo. la literatura respalda, sobre los estilos de afrontamiento, que ningún estilo es por sí mismo más efectivo que otro; así por ejemplo, el evitador es más útil para sucesos amenazantes a corto plazo, mientras que el estilo vigilante es más efectivo cuando existe un suceso amenazante que se repite o que persiste a lo los pacientes de uci sometidos a trasplante hepático relatan su experiencia como negativa, debido a la limitación de movimiento que les causaban las vías invasivas, la idea de la alteración de su imagen corporal, la preocupación por la insatisfacción en las necesidades básicas, y el recuerdo de personas significativas. 32 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 largo del tiempo. el estilo confrontativo es útil pues permite anticipar planes de acción ante riesgos futuros aunque genera mayor ansiedad (20). cuando se trata de problemas de salud las personas mayores tienden a utilizar un estilo de afrontamiento que confronta la situación, realizando más prácticas de promoción de la salud y prevención de la enfermedad, evitando hábitos nocivos y teniendo un estilo de afrontamiento más vigilante. gonzález encontró, en una investigación sobre calidad de vida y estrategias de afrontamiento ante problemas y enfermedades en ancianos, estrategias de afrontamiento orientadas al problema, las cuales se refieren a las conductas dirigidas a confrontar la realidad y el tener una reapreciación positiva, manejando sus consecuencias (22). se ha informado que el afrontamiento activo, centrado en la solución de problemas, junto a la posibilidad de contar con personas dispuestas a brindar escucha y afecto, han sido identificados como factores protectores contra el distrés emocional. siendo, por el contrario, las estrategias de evitación, los comportamientos pasivos y de desesperanza, junto con una actitud pasiva frente a la enfermedad y la ausencia de apoyo afectivo, los mejores predictores del distrés emocional (23). existen muchas estrategias posibles de afrontamiento que puede manejar un individuo. el uso de unas u otras en buena medida suele estar determinado por la naturaleza del estresor y las circunstancias en las que se produce (20). los estímulos que influyen en el proceso de afrontamiento y adaptación de las personas con enfermedades crónicas como la diabetes mellitus han sido objeto de estudio desde la perspectiva de roy; se destaca el bienestar espiritual como estímulo contextual positivo para afrontar las reacciones emocionales consecuentes con la evolución crónica e incapacidad física y social derivadas de la enfermedad (24). contrario a lo anterior, el estrés percibido como estímulo contextual tuvo un efecto negativo en las estrategias de afrontamiento y en la adaptación psicosocial en términos de autoconcepto, función del rol e interdependencia afectando las habilidades para la solución de problemas, juicio, emoción, búsqueda de resultados, creatividad y manejo de situaciones (25). conclusiones los hallazgos permiten reconocer que la investigación de enfermería basada en el conocimiento propio fortalece la autonomía de las enfermeras y contribuye a mejorar la calidad del cuidado ofrecido en los diferentes contextos. el modelo de callista roy muestra una visión particular de la práctica, sustentada en el estudio de los procesos de afrontamiento y adaptación, y facilita su aplicación en el cuidado del paciente hospitalizado en una uci. los participantes del estudio presentaron una alta capacidad de afrontamiento y adaptación, reflejando un estilo activo, con estrategias centradas en el problema, tanto cognitivas como comportamentales, con una percepción de la situación como controlable, y buscaron encontrar significado a la hospitalización en uci. el modelo de callista roy permite a las enfermeras avanzar en el desarrollo de la práctica disciplinar, y fortalecer la autonomía profesional a partir de su aplicación. la escala diseñada por roy permitió identificar las estrategias de afrontamiento el modelo de callista roy muestra una visión particular de la práctica, sustentada en el estudio de los procesos de afrontamiento y adaptación, y facilita su aplicación en el cuidado del paciente hospitalizado en una uci. 33 afrontamiento y adaptación en pacientes egresados de unidades de cuidado intensivo l inna elida flórez-torres, eliana herrera-alarcón, estefany carpio-jiménez et al. y adaptación en los participantes del estudio, y se constituye en un importante aporte para la validación de una teoría de mediano rango de enfermería, que fortalece la práctica profesional y el cuidado. la capacidad de afrontamiento y adaptación le permite al ser humano responder mediante comportamientos, pensamientos o emociones a eventos estresantes, como la enfermedad grave y la hospitalización en uci. es importante que las enfermeras conozcan e identifiquen estas respuestas a fin de promover la adaptación. en cuanto a limitaciones, son escasas las publicaciones basadas en la propuesta teórica de roy que permitan respaldar o contrastar los hallazgos del estudio. por la complejidad de algunos ítems que integran la escala, y las dificultades relacionadas con su comprensión, esta fue administrada a los participantes por las investigadoras, lo que sugiere la necesidad de continuar con el proceso de validación formal. se recomienda continuar la investigación que permita establecer la relación entre las diferentes variables sociodemográficas, el tipo de enfermedades de los pacientes y la capacidad de afrontamiento y adaptación. además, el diseño e implementación de planes de cuidados de enfermería orientados a identificar estrategias de afrontamiento, adecuadas o inefectivas, a fin de favorecer la adaptación de las personas hospitalizadas en uci. agradecimientos las autoras expresan sus agradecimientos al capítulo colombiano roy, universidad de la sabana, por su autorización para el empleo del instrumento. referencias bibliográficas 1. sánchez b. el cuidado de la salud de las personas que viven situaciones de enfermedad crónica en américa latina. actualiz enferm 2002; 5 (1): 13-16. 2. parra m, guáqueta sr. fundamentos para el cuidado de pacientes con infarto agudo cardiaco. universidad nacional de colombia; 2004. 3. parra m. problemas más frecuentes de los pacientes hospitalizados en las uci. en: enfermería cardiovascular. bogotá: distribuna; 2008. pp. 251-259. 4. beltrán oa. la enfermedad grave, una oportunidad. invest educ enferm 2008; 26 (1): 68-77. 5. beltrán oa. la práctica de enfermería en cuidado intensivo. aquichan 2008; (1): 50-63. 6. beltrán oa. la experiencia de estar hospitalizado en una unidad de cuidado intensivo. aquichan 2009; (1): 50-63. 7. chayaput p. development and psychometric evaluation of the thai version of the coping and adaptation processing scale. boston: boston college, william f. connell, graduate school of nursing. aat 3135960, 2004. pp. 22-27. 8. roy c, andrews h. the roy adaptation model. 2 ed. stanford, ct: appleton & lange; 1999. p. 31-48 9. lazcano m, salazar bc, gómez mc. validación del instrumento: afrontamiento y proceso de adaptación de roy en pacientes con diabetes mellitus tipo 2. aquichan 2008; 8 (1): 116-125. 10. veloza m, moreno me, crespo o, gutiérrez e. proceso de afrontamiento y adaptación. en: gutiérrez m. universidad de la sabana. adaptación y cuidado en el ser humano. una visión de enfermería. bogotá: el manual moderno; 2007. pp.13-25. 11. rincón f. el cuidado de la salud y de la vida en servicios de la salud altamente tecnificados. en: grupo de cuidado. cátedra manuel ancízar. cuidado de la vida. bogotá: unibiblos; 2007. pp.117-140. 12. rivera ln. el cuidado al paciente cardiovascular en situaciones que generan un gran sentimiento de pérdida, amenaza, temor o muerte. av eferm 2008; 26 (1): 124-133. 13. gutiérrez c, veloza m, moreno m, durán mm, lópez c, crespo o. validez y confiabilidad de la versión en español del instrumento escala de medición del proceso de afrontamiento y adaptación de callista roy. aquichán 2007; 7 (1): 54-63. 14. gutiérrez c, lópez c. escala de medición del proceso de afrontamiento y adaptación de callista roy: una propuesta metodológica para su interpretación; 2009. 34 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 15. ministerio de salud. resolución 008430 por la cual se establecen las normas académicas, técnicas y administrativas para la investigación en salud. santa fe de bogotá: ministerio de salud; 1993. 16. colombia. república de colombia, tribunal nacional ético de enfermería. ley 911 de 2004, octubre 5. por el cual se dictan disposiciones en materia de responsabilidad deontológica para el ejercicio de la profesión de enfermería en colombia; se establece el régimen disciplinario correspondiente y se dictan otras disposiciones. bogotá d. c., 2004. 17. lazarus rs, folkman s. estrés y procesos cognitivos. barcelona: ediciones martínez roca; 1986. 18. brandao de carvalho al, cavalcante guedes mv, venicios de oliveira m. adaptação psicossocial do adolescente pós-trasplante renal segundo a teoria de roy. invest educ enferm 2005; 23 (1): 68-77. 19. del barrio m, lacunza mm, armendáriz ac, margall ma, asiain mc. pacientes con trasplante hepático: su experiencia en cuidados intensivos. estudio fenomenológico. enferm intensiva 2001; 12 (3): 13545. en: http://www.seeiuc.com/revista/res1234.htm [fecha de consulta: junio de 2009]. 20. vázquez c, crespo m, ring jm. estrategias de afrontamiento. medición clínica en psiquiatría y psicología; 2003. cáp. 31, pp. 425-35. en:http:// www.psicosocial.net/index.php?option=com_doc man&task=docclick&itemid=52&bid=94&limitstart =0&limit=10 [fecha de consulta: junio de 2009]. 21. martínez a, rodríguez a, rodríguez c, rodríguez a. percepción de las estrategias de afrontamiento ante el estrés en pacientes ingresados en una unidad de coronarias. enferm cardio 2005; (34) 15-21. en http://www.enfermeriaencardiologia.com/revista/3401.pdf. consultado julio de 2008. [fecha de consulta: junio de 2009]. 22. gonzález al, padilla a. calidad de vida y estrategias de afrontamiento ante problemas y enfermedades en ancianos de ciudad de méxico univ. psychol 2006; 5 (3): 501-509. http://revistas.javeriana.edu. co/index.php/revpsycho/article/view/456/313 [fecha de consulta: junio de 2009].. 23. carrobles ja, remor e, rodríguez-alzamora l. afrontamiento, apoyo social percibido y distrés emocional en pacientes con infección por vih. psicothema 2003; 15 (3): 420-426. en: http://www. psicothema.com/pdf/1082.pdf [fecha de consulta: julio de 2009]. 24. zavala m del r. vázquez o, whetsell mv. bienestar espiritual y ansiedad en pacientes diabéticos. aquichan 2006; 6 (1): 8-21. 25. lazcano m, salazar bc. estrés percibido y adaptación en pacientes con diabetes mellitus tipo 2. aquichan 2007; 7 (1): 77-84. 35 afrontamiento y adaptación en pacientes egresados de unidades de cuidado intensivo l inna elida flórez-torres, eliana herrera-alarcón, estefany carpio-jiménez et al. tabla 1. niveles de afrontamiento y adaptación en pacientes egresados de uci fuente: datos del estudio. factor rangos promedio ic 95% coeficiente de variación (%) factor 1 11-44 32,3 (31,4 33,2) 17,9 factor 2 13-52 31,0 (29,9 32,1) 24,0 factor 3 9-36 26,0 (25,2 26,7) 20,2 factor 4 6-24 18,9 (18,2 19,5) 23,6 factor 5 8-32 25,7 (25,1 26,4) 17,1 global 47-188 133,8 (130,8 136,9) 15,2 grafico 1. capacidad de afrontamiento y adaptación por factores y global de los pacientes egresados de uci anexo 36 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 tabla 2. factor 1: recursivo y centrado fuente: datos del estudio. ítems nunca rara vez algunas veces siempre (%) (%) (%) (%) propongo una solución nueva para un problema nuevo. 5,3 17,0 28,7 49,1 obtengo la mayor información posible para aumentar mis opciones. 4,7 15,8 24,0 55,6 trato de que todo funcione a mi favor. 6,4 8,2 33,3 52,0 identifico cómo quiero que resulte la situación y luego miro cómo lo puedo lograr. 7,6 15,8 29,2 47,4 trato de redirigir mis sentimientos para enfocarlos constructivamente. 8,2 16,4 27,5 48,0 estoy atento a cualquier cosa relacionada con la situación. 3,5 8,2 24,6 63,7 trato de ser recursivo para enfrentar la situación. 3,5 10,5 31,6 54,4 con tal de salir de la crisis estoy dispuesto a modificar mi vida radicalmente. 12,3 9,9 21,6 56,1 trato de ser creativo y proponer nuevas soluciones. 7,0 18,7 22,8 51,5 desarrollo un plan con una serie de acciones para enfrentar la situación. 17,0 14,6 31,0 37,4 37 afrontamiento y adaptación en pacientes egresados de unidades de cuidado intensivo l inna elida flórez-torres, eliana herrera-alarcón, estefany carpio-jiménez et al. tabla 3. factor 2: físico y enfocado *todos los ítems inversos. ítems* nunca rara vez algunas veces siempre (%) (%) (%) (%) tengo dificultad para completar tareas o proyectos. 22,2 48,0 14,0 15,8 solo puedo pensar en lo que me preocupa. 39,8 26,9 21,6 11,7 encuentro la situación demasiado compleja, con más elementos de los que puedo manejar. 31,6 33,9 21,1 13,5 parece que actúo con lentitud sin razón aparente. 31,6 33,9 21,1 13,5 tiendo a reaccionar con exageración al comienzo. 25,7 34,5 18,7 21,1 tiendo a paralizarme y confundirme al menos por un tiempo. 31,0 32,7 17,5 18,7 encuentro difícil explicar cuál es el verdadero problema. 30,4 31,6 21,6 16,4 tiendo a culparme por cualquier dificultad que tenga. 31,6 31,0 17,5 19,9 por alguna razón no parezco beneficiarme de mis experiencias pasadas. 26,9 27,5 24,6 21,1 experimento cambios en la actividad física. 28,7 40,4 19,3 11,7 trato de hacer frente a la crisis desde el principio. 39,8 31,6 13,5 14,6 me doy cuenta que me estoy enfermando. 38,0 33,3 17,0 11,7 me rindo fácilmente. 20,5 25,1 21,6 32,7 al parecer me hago muchas ilusiones acerca de cómo resultarán las cosas. 41,5 30,4 12,9 15,2 38 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 tabla 4. factor 3: proceso de alerta *ítem inverso. ítems* nunca rara vez algunas veces siempre (%) (%) (%) (%) puedo seguir una gran cantidad de instrucciones a la vez. 14,6 12,3 28,1 45,0 *soy menos eficaz bajo estrés. 43,3 21,1 17,5 18,1 me siento alerta y activo durante el día. 11,2 14,7 31,2 42,9 pongo mis sentimientos a un lado y soy muy objetivo acerca de lo que sucede. 14,6 12,3 29,8 43,3 obtengo buenos resultados al manejar problemas complejos. 11,1 18,1 35,1 35,7 puedo desenvolverme mejor que la mayoría de la gente cuando tengo que ir a lugares desconocidos. 12,9 14,0 33,9 39,2 soy más eficaz bajo estrés. 21,1 12,9 35,7 30,4 manejo la situación analizando rápidamente los detalles tal como ellos sucedieron. 14,6 13,5 28,7 43,3 adopto rápidamente nuevas capacidades, cuando estas pueden resolver mi problema. 7,0 22,8 28,7 41,5 tabla 5. factor 4: procesamiento sistemático ítems nunca rara vez algunas veces siempre (%) (%) (%) (%) llamo al problema por su nombre y trato de verlo en su totalidad. 8,2 10,5 29,2 52,0 me tomo el tiempo necesario y no actúo hasta que no tengo una buena comprensión de la situación. 7,6 12,3 31,6 48,5 pienso en el problema sistemáticamente, paso a paso. 11,7 14,0 25,7 48,5 analizo la situación como realmente es. 8,2 16,4 26,9 48,5 trato de mantener el equilibrio entre la actividad y el descanso. 10,5 14,0 29,8 45,6 trato de aclarar cualquier tipo de duda antes de actuar. 15,8 12,9 23,4 48,0 39 afrontamiento y adaptación en pacientes egresados de unidades de cuidado intensivo l inna elida flórez-torres, eliana herrera-alarcón, estefany carpio-jiménez et al. tabla 6. factor 5: conocer y relacionar ítems nunca rara vez algunas veces siempre (%) (%) (%) (%) trato de recordar las estrategias o las soluciones que me han servido en el pasado. 1,8 11,1 30,4 56,7 me siento bien al saber que estoy manejando el problema lo mejor que puedo. 1,8 12,3 24,6 61,4 recuerdo cosas que me ayudaron en otras situaciones. 2,9 12,9 29,2 55,0 utilizo el humor para manejar la situación. 7,6 18,1 33,3 40,9 puedo relacionar lo que sucede con las experiencias pasadas o con los planes futuros. 4,7 15,2 33,3 46,8 aprendo de las soluciones que han funcionado para otros. 5,3 19,9 30,4 44,4 miro la situación positivamente como una oportunidad o desafío. 12,3 17,0 30,4 40,4 planteo diferentes soluciones aunque parezcan difíciles de alcanzar. 10,5 17,0 29,2 43,3 42 52 la enfermeria en colombia.indd 42 aquichan issn 1657-5997 edna margarita gómez-bustamante1 la enfermería en colombia: una mirada desde la sociología de las profesiones2 1 profesora asociada. facultad de enfermería. universidad de cartagena, cartagena, colombia. egomezb@unicartagena.edu.co 2 revisión y análisis producto de la construcción teórica de la propuesta de tesis doctoral “la profesión de enfermería: una mirada desde las enfermeras (os) del caribe colombiano”. doctorado en ciencias de la educación. rudecolombia. recibido: 23 de enero de 2012 aceptado: 20 de marzo de 2012 resumen objetivo: analizar el proceso de profesionalización de la enfermería en colombia a partir de la sociología de las profesiones; de igual manera, se expone una reflexión sobre el papel protagónico que deben asumir los currículos para fortalecer el ser y el quehacer de la profesión. método: se realizó una búsqueda electrónica y manual de la literatura que incluyó bases de datos, revistas, libros y tesis doctorales, direccionada por los descriptores profesiones, educación, enfermería y sociología. resultados: se revisaron solo estudios y textos en español e inglés; la información recolectada se organizó en las categorías profesión, profesionalización, profesionalización de la enfermería. conclusión: se muestra que el proceso de profesionalización de la enfermería evidencia adelantos importantes, pero está sujeto a tensiones y conflictos que derivan en la necesidad de asumir desde los programas de formación un rol protagónico que permita consolidar y fortalecer dicho proceso. palabras clave sociología, profesión, educación, enfermería (fuente: decs). nursing in colombia: a view from the sociology of professions abstract objective: the purpose of this study is to analyze the professionalization of nursing in colombia, based on the sociology of professions, and to reflect on the leading role curricula should assume to strengthen the “whys and wherefores” of the profession. method: an electronic and manual search of literature was conducted. it included databases, journals, books and doctoral dissertations, and was guided by several descriptors; namely, professions, education, nursing and sociology. results: only texts in spanish and english were reviewed. the information gathered was organized into the following categories: profession, professionalization and professionalization of nursing. conclusion: the study shows important headway has been made in the process to professionalize nursing. however, it is subject to tensions and conflicts that underscore the need to assume a leading role, beginning with training programs, in order to consolidate and strengthen that process. key words sociology, profession, education, nursing (source: decs). año 12 vol. 12 nº 1 chía, colombia abril 2012 l 42-52 43 la enfermería en colombia: una mirada desde la sociología de las profesiones l edna margarita gómez-bustamante a enfermagem na colômbia: um olhar a partir da sociologia das profissões resumo objetivo: analisar o processo de profissionalização da enfermagem na colômbia a partir da sociologia das profissões; da mesma maneira, apresenta-se uma reflexão sobre o papel principal que devem assumir os currículos para fortalecer o ser e o fazer da profissão. método: realizou-se uma busca eletrônica e manual da literatura que incluiu base de dados, revistas, livros e teses doutorais, direcionada pelos descritores profissões, educação, enfermagem e sociologia. resultados: revisaram-se somente estudos e textos em espanhol e inglês; a informação coletada se organizou nas categorias profissão, profissionalização, profissionalização da enfermagem. conclusão: mostra-se que o processo de profissionalização da enfermagem evidencia progressos importantes, mas está sujeito a tensões e conflitos que derivam na necessidade de assumir, a partir dos programas de formação, um papel protagonista que permita consolidar e fortalecer dito processo. palavras-chave sociologia, profissão, educação, enfermagem (fonte: decs). 44 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 método se llevó a cabo una revisión bibliográfica de publicaciones referenciadas en las bases de datos scielo, nursing consult, redalyc, pubmed; asmismo, se hizo una revisión manual que incluyó revistas, libros, tesis doctorales y conferencias debidamente publicadas en memorias de eventos científicos a nivel nacional e internacional, sin delimitar espacio y periodo de tiempo de publicación; es así como se revisaron textos clásicos de la sociología de las profesiones que datan del año 1906, hasta autores contemporáneos de las últimas décadas. para la búsqueda se utilizaron los siguientes descriptores y sus combinaciones: profesiones, educación, enfermería y sociología. se revisaron solo estudios y textos en español e inglés. se evaluaron 146 escritos, de los cuales 86 eran artículos de revisión, reflexión y productos de investigación científica; 14 eran informes de tesis doctoral y 46 capítulos de libros. la revisión exhaustiva proporcionó 54 publicaciones que cumplían los siguientes criterios inclusión: que abordaran el eje conceptual de la sociología de las profesiones y que dieran cuenta de lo que ha sido el proceso de profesionalización de la enfermería a nivel mundial, nacional y regional. todos los artículos que cumplieron los criterios de elegibilidad fueron sometidos a un análisis de contenido, buscando la correspondencia con el objetivo planteado. resultado se evaluaron en total 54 artículos que cumplieron con los criterios de búsqueda, estos artículos revisados se agruparon y organizaron en las siguientes categorías de discusión: aproximación al concepto de profesión, profesionalización, profesionalización de la enfermería. aproximación al concepto de profesión hoy día, el concepto de profesión surca un proceso de renovación y evolución a tal punto que las profesiones están intrínsecamente relacionadas con el contexto en el que surgen, situación que lleva a que adopten algunas de las características sociales de dicho contexto. en los estudios sobre evolución histórica de las profesiones aparecen diferentes posturas; por ejemplo, el pensamiento de spencer muestra claramente la concepción político-eclesiástica que lo permeó y establece su hacer ligado a la vocación; es decir, el ser profesional está relacionado con la introducción la sociología de las profesiones se considera un campo particular de la sociología que busca que los profesionales puedan ser considerados y analizados como un grupo en el seno de una sociedad. identifica las funciones que cumplen las profesiones dentro de un contexto social y establece las bases conceptuales y las categorías de análisis que direccionan su estudio (1). este campo del conocimiento posibilita el estudio de las profesiones como una manifestación peculiar de la diferenciación social y de la división del trabajo, que se desarrolló esencialmente a partir de la sociedad industrial (2). las teorías sociológicas como el funcionalismo estructural han sido parte importante para tratar de dar a las profesiones un papel claro dentro de la estructura social. la tradición funcionalista se enfocó hacia los mecanismos de cohesión social utilizados por durkheim, en donde se detalla la estructura o la organización social que indaga sobre las profesiones y el rol que desempeñan en el sistema social (3). el enfoque sociológico de las profesiones tiene como objetivos fundamentales analizar los fenómenos de socialización y de inclusión dentro de una determinada profesión, los procesos de asociación dentro de las categorías profesionales, los tipos de acción social que se generan con los roles profesionales, además de identificar y explicar los canales y modelos de movilidad social que una u otra profesión producen o incentivan (3). se considera la década de los setenta como el periodo en el que se establece plenamente la sociología de las profesiones como área dentro de la sociología, con objeto de estudio, metodología de indagación y cuerpo categorial propio (4). a partir de esta época se hace visible la realización de muchos estudios orientados a vislumbrar la razón de ser de ciertas profesiones en diversos contextos sociales e interprofesionales. desde la profesión de enfermería son escasos los estudios que se han realizado fundamentados en este enfoque, de ahí la necesidad urgente de analizar y discutir sobre la esencia de la profesión a partir del concierto social e interprofesional, para de esta forma contribuir a su proyección y posicionamiento. el presente artículo pretende reflexionar sobre el proceso de profesionalización de la enfermería en colombia a partir del eje conceptual de la sociología de las profesiones; de igual manera, se intentará reflexionar sobre el rol protagónico que deben asumir los currículos para fortalecer el ser y quehacer de la profesión. 45 la enfermería en colombia: una mirada desde la sociología de las profesiones l edna margarita gómez-bustamante voluntad de entrega y sufrimiento (5). en la misma línea de ideas, weber planteó que la profesión es concebida como aquello que el hombre ha de aceptar porque la providencia se lo asigna, algo a lo que tiene que allanarse, estableciéndose el trabajo profesional como misión, es decir, un medio por excelencia al servicio de dios (6). estas concepciones permanecieron y predominaron por mucho tiempo, y profesiones como la medicina, la enfermería, el derecho, la arquitectura, entre otras, fundamentaron su hacer basados en estas posturas. por su parte, parsons (7) estudia las profesiones como grupos sociales singulares; es decir, como comunidades autónomas y homogéneas, cuyos miembros se cohesionan a través de una identidad. esta postura planteó dos categorías de organización, una categoría por erudición y otra denominada liberal; esta clasificación aportó elementos importantes para la organización de las profesiones en la época moderna, y permitió diferenciar cuáles de ellas se denominan profesiones de consulta y cuáles de práctica social. las primeras profesiones liberales, como se sabe, concentraron sus esfuerzos en la reglamentación del orden en la sociedad (derecho) y la atención a la salud (medicina). a su vez, collins (8) las caracterizó de acuerdo al control y la jurisdicción exclusiva para practicar una habilidad o destreza en particular, para regular acceso y entrenamiento de nuevos miembros, y para juzgar si las habilidades y destrezas adquiridas se realizan de manera apropiada, es decir, son conjuntos ocupacionales formados por grupos altamente conscientes y autorregulados. el autor planteó la existencia de profesiones fuertes, determinadas por la capacidad del grupo profesional para validar la pericia o las competencias a causa de algunas propiedades intrínsecas de las funciones que desempeñan. este grupo de profesiones posee una alta aceptación pública, mayor prestigio y mejores ingresos debido a su alto desempeño autónomo y al control de su trabajo (9). para la década de los cincuenta, autores como goode se preocupan por diferenciar los rasgos distintivos entre las profesiones y las ocupaciones, estableciendo una serie de atributos que las delimitan: un cuerpo de conocimientos abstracto, una orientación de servicio y un entrenamiento especializado prolongado (10). aportaciones de freidson permiten analizar que las profesiones son organizaciones ocupacionales en las cuales prosperan ciertos esquemas mentales en virtud de su rol dominante en la sociedad; son capaces de transformar y crear la esencia de su propio trabajo, siendo la autonomía la característica más estratégica y apreciada (11). se consideran grupos únicos, caracterizados por ser una cultura con patrones de comportamientos distintos, que surgen y responden a las necesidades sociales (12, 13). en este sentido, las profesiones constituyen mediaciones entre las necesidades individuales y las funcionales, y contribuyen a la regulación y al control que posibilita el buen funcionamiento de la sociedad. desde la postura funcionalista de durkheim se contribuye a explicar que las profesiones actúan como fuerzas positivas en el progreso social, representan condición necesaria para el avance y consenso de la sociedad industrial, atendiendo a la ruptura de orden moral derivada de la fragmentación y la división del trabajo producto de este desarrollo (14). en la década de los noventa, autores como pacheco estudian las profesiones como estructuras sociales formalmente establecidas y legitimadas, no solo por su conjunto de normas y sistemas de organización social históricamente constituidas, sino por el sector social que las establece; de tal forma, que ellas surgen de la división del trabajo que aporta desde la organización del conocimiento la necesidad de crear ocupaciones en respuesta a esos contextos (15). en este orden de ideas, se puede decir que las necesidades sociales generan nuevas formas de institucionalización y crean tendencias de especialización del conocimiento cada vez más exigentes, que llevan a replantear y a evaluar a las profesiones ya conformadas para atender a un contexto pluralista y riguroso. autores contemporáneos como hernández comparten que el énfasis de las profesiones radica en la prestación de servicios para satisfacer las necesidades sociales, relaciona la denominación de profesión con el trabajo interdisciplinario e interinstitucional, lo que obliga cada vez más a reflexionar sobre sus fundamentos y a ampliar el marco de conocimientos previamente adquiridos, lo que lleva a los profesionales a discutir sobre el impacto y su actuación en el entorno social (16). lo anteriormente planteado permite precisar que el concepto de profesión es el resultado de la conjunción de factores históricos que afectan y determinan sus condiciones y características. las profesiones perduran en el tiempo en la medida de su respuesta y satisfacción a las necesidades reales de conocimiento del contexto donde evolucionan. 46 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 profesionalización la profesionalización es entendida como la serie de etapas y pautas necesarias que deben cumplir las ocupaciones en la búsqueda de un estatus profesional, y que correlativamente permiten o posibilitan la elevación del estatus de quienes la ejercen (2). para ello, cada ocupación construye procesos y traza caminos que dependen del contexto ideológico, económico, político, social y cultural en el que surge y evoluciona (17). al construir históricamente su propia perspectiva, las profesiones reformulan las experiencias de los legos resignificando la realidad social y originando una nueva; esta última es posible gracias a la posición autónoma que tales grupos logran adquirir en el transcurso de este proceso de reformulación. tal como lo afirma elliot, las profesiones representan retos y están inscritas en trayectorias históricas (18). a finales del siglo xix e inicios del xx la profesionalización se consolidó como proceso estructurador de la nueva sociedad industrial, aspectos como la expansión de los conocimientos técnicos, la explosión demográfica y el crecimiento de los centros urbanos de la época, contribuyeron a modificar la organización social existente, propiciando la creación de tareas profesionales especializadas (9, 19) que generaron la necesidad de maduración de los grupos ocupacionales. la revolución industrial supuso un impacto directo sobre el mercado de los servicios profesionales; los sistemas educativos y ocupacionales se adaptaron a las necesidades del conocimiento y al ejercicio económico del momento (20). la reforma aceleró el proceso de separación iglesia-estado y, paralelo a ello, ocurrió un cambio gradual en relación con el conocimiento apropiado al ejercicio profesional. el ideal profesional empieza a poner el énfasis en la figura del experto, que adquiere tal condición mediante el entrenamiento prolongado y la selección por méritos llevada a cabo no por el mercado, sino por el juicio de sus pares, factor este considerado como uno de los aspectos más característicos de las estrategias de profesionalización (21). asimismo, las diversas expresiones del ideal humanista sucumbieron ante la necesidad de regular y reglamentar las formas del ejercicio de las habilidades profesionales de tal manera que para poder realizar una profesión no solo se necesitó del conocimiento específico, sino que se buscó regular y legalizar lo escolar como única forma válida de tener acceso a este conocimiento (22), promoviéndose de esta manera la creación y organización de instituciones educativas que ofertaran programas de formación especializada. con relación a las ocupaciones wilensky (23) expresa una serie de características que estas deben cumplir de forma sucesiva para que se les reconozca como profesión: presentación de un grupo ocupacional en una actividad que exige dedicación exclusiva sobre un conjunto de problemas determinados. establecimiento de procedimientos de instrucción y selección, normalmente en instituciones especializadas (universidades), donde se formalizan las vías de acceso. constitución de una asociación profesional, normalmente de ámbito nacional. esta etapa establece y define su función ocupacional, además de instituir modelos y normas. sirve además para demarcar las relaciones con otros grupos, especialmente los competitivos. movimientos de la profesión en orden a obtener protección legal, concretada en el reconocimiento público y en el apoyo legal para controlar, en régimen de monopolio, su ejercicio, así como el acceso a ella. dotación de un código deontológico que, a nuestro juicio, realimenta el proceso. por su parte fernández, citando a moore y freidson, plantea algunas ideas centrales para definir una profesión, entre ellas destaca: ser una ocupación de tiempo integral, caracterizada por la presencia de profesionales en una organización que permite la mutua identificación de intereses, con adquisición de conocimientos formales y autónomos, que ofrezca un amplio servicio a los clientes y a la sociedad (24). de igual manera, cleaves expresa como condiciones indispensables el tener un conocimiento especializado, capacitación de alto nivel, control sobre el contenido de trabajo, organización, autorregulación, altruismo, espíritu de servicio a la comunidad y elevadas normas éticas (25). para el caso de la enfermería, se han tratado de establecer criterios internos de profesionalización que permiten reflexionar sobre las características de su surgimiento y evolución y, por consiguiente, el desarrollo de la profesión. laddy y pepper (26) plantean que las características para evaluar la profesión están dadas por: 47 la enfermería en colombia: una mirada desde la sociología de las profesiones l edna margarita gómez-bustamante las características intelectuales: compuestas por tres elementos, un conjunto de conocimientos en el que se fundamenta la práctica de la profesión, educación especializada para transmitir el conjunto de conocimientos y el empleo de los mismos en el pensamiento crítico y creativo. los elementos prácticos: están relacionados con las habilidades especializadas que son esenciales para el desempeño de una función profesional única. el servicio a la sociedad: exige integridad y responsabilidad en la práctica ética y un compromiso de toda la vida que implica no considerar a la enfermería como un trabajo, una manera de ganar el pan, sino como una profesión. autonomía; significa que los practicantes de una profesión controlan sus propias funciones en el ambiente de trabajo; implica independencia, disposición a correr riesgos y responsabilidad de los propios actos, así como autodeterminación y autorregulación. es importante resaltar que el aumento en el número de profesiones que reclaman reconocimiento es un hecho que necesita profundo análisis y seguimiento desde el enfoque externalista entendido este como la perspectiva que utiliza categorías desde la sociología para organizar, establecer e incluso arriesgar explicaciones sobre las transformaciones que le ocurren a las profesiones en momentos y contextos específicos (27). profesionalización de la enfermería como lo muestra philip, el proceso de profesionalización es el resultado de diversas variables que condicionan el desarrollo de una profesión. en el caso de enfermería, algunos factores como la feminización de los cuidados, el orden vocacional y religioso, los legados de subordinación a la profesión médica, entre otros, han generado ataduras que evitan que se apropie como una profesión liberal y autónoma (28, 29). durante miles de años los cuidados —eje central de la práctica de enfermería— no fueron propios de un oficio ni menos de una profesión determinada; estaban históricamente ligados a la mujer, asociados a las actividades de cuidar la vida y a preservar la especie (30). este vínculo entre la mujer y los cuidados ha sido históricamente asumido como algo natural y raramente cuestionado. los orígenes de esta vinculación, que son paralelos a la propia evolución de la enfermería, pueden ser entendidos mediante el análisis de los sistemas de relaciones socialmente establecidos entre naturaleza y cultura, ámbito doméstico y trabajo productivo/improductivo (31, 32), lo cual explica por qué la suposición de enfermería como arte innato a la mujer ha obstaculizado desde su origen el proceso de profesionalización; la sociedad crea imágenes y simbolismos que condicionan los distintos roles sociales que repercuten en el ser de una profesión, carga que interfiere de forma más o menos consciente en su desarrollo profesional (33, 34). el orden religioso fue otro factor importante en la evolución de la enfermería, pues los valores marcados por el cristianismo y la religiosidad evidenciaron una práctica de servicio al prójimo y de vocación personal que se ejercía más como caridad cristiana que como derecho ciudadano; el paciente era concebido como una persona hecha a imagen y semejanza de dios. se reforzó entonces un modelo vocacional al quehacer ocupacional (35, 36) que se reflejó en la posición y remuneración de las enfermeras en los diferentes escenarios de cuidado. otro factor que ha influido negativamente en la profesionalización de la enfermería fue la subordinación del conocimiento a la hegemonía de la práctica médica, por lo que desde siempre la medicina condicionó y delimitó la formación de esta profesión. la medicalización de la sociedad generó necesidades y demandas que hicieron que estos profesionales entrenaran mujeres servidoras, disciplinadas y con corazón sensible, es decir, agentes ejecutores e informadores dependientes del cuerpo médico, cuyo sentido de responsabilidad implicaba el cumplir actividades, pero evitando los juicios, los discernimientos y la crítica (37). por años el desarrollo científico de la medicina fue protagónico y dominó el campo de la salud, regulando la práctica sanitaria, al igual que la práctica de profesiones más débiles (2). fue en este contexto donde surgió la enfermería moderna, con florence nightingale, quien fundó el primer programa de formación, la nightingale training school for nurses, motivada por la importancia de la formación de una enfermera poseedora de conocimientos, pero manteniendo una conexión trascendental entre lo científico, lo religioso y lo vocacional. su objetivo era preparar enfermeras de hospitales para la atención de los enfermos pobres y más necesitados; de igual manera, extender su modelo a otros países, capacitando enfermeras que ayudaran a la formación de otras (38, 39). cada país ha tenido procesos de profesionalización diferentes que ha variado de acuerdo a las condiciones socioculturales y políticas donde la enfermería ha evolucionado (40). en colombia, la 48 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 enfermería da sus primeros pasos como profesión a inicios del siglo xx, con un programa de entrenamiento en cartagena gestado por el doctor rafael calvo, quien influenciado por corrientes extranjeras de formación se motiva a entrenar un grupo de mujeres que se encargaran de la atención en el área de obstetricia (41). posteriormente, en el año 1919, por decreto de la gobernación del departamento de bolívar, esta fue declarada como escuela oficial anexa a la facultad de medicina y ciencias naturales de la universidad de cartagena, reglamentándose los estudios y estableciéndose las condiciones para la admisión de las alumnas (42). esta experiencia de formación aportó al proceso de institucionalización de la enseñanza de enfermería en el ámbito universitario, superándose el empirismo del entrenamiento en instituciones asistenciales de salud (35). paso a paso la enfermería fue consolidándose, los programas pasaron de la hegemonía médica a ser dirigidos por enfermeras, y los currículos estructurados según el ser, saber y hacer de la profesión (cuerpo de conocimientos). en la década de los treinta nace la asociación nacional de enfermería (anec) como agremiación sindical y reguladora de la profesión (43). en 1976, con la promulgación del decreto 2184 que reglamentó la ley 87 de 1946, se hizo una actualización interesante de la legislación existente, especialmente en funciones y actividades que ampliaron el rol de la enfermera, los criterios de admisión, los perfiles de formación y el direccionamiento laboral (44). un aspecto de gran trascendencia en el proceso de profesionalización fue el despertar al desarrollo teórico de enfermería, promoviendo un marco conceptual propio que fundamentara la identidad profesional y disciplinar, y disminuyera la dependencia histórica con otras profesiones de la salud (45). a partir de la década de los cincuenta comienza un periodo de progreso investigador que se solapa con el inicio de un avance teórico que se enfatiza hacia los años setenta-ochenta (46), época de reconocimiento e identificación de una serie de conceptos centrales que fundamentaron el marco epistemológico de la disciplina profesional de la enfermería, aspectos importantes para su desarrollo y evolución (47). en la década de los setenta se hicieron muchos esfuerzos académicos, de soporte y de financiación de la investigación, además del reconocimiento de las publicaciones científicas, que constituyeron hechos fundamentales para el giro que dio la profesión, pero sobre todo para la mejor comprensión de la necesidad de la utilización de la teoría, y de la generación y validación de la misma para garantizar la autonomía de la práctica profesional (48). la década de los ochenta fue una época de cambios en los procesos de formación, se inicia una conversión paulatina de los programas de nivel tecnológico a programas de licenciatura, y a comienzos de los noventa todos los programas en funcionamiento eran de nivel universitario (44). de igual forma, para la misma década se empiezan a desarrollar las especializaciones, maestrías y posteriormente los doctorados, impulsando la investigación como eje necesario y articulador de formación de comunidad académica (39). la ley 266 de 1996 define la naturaleza y el propósito de la profesión, el ámbito del ejercicio y determina sus entes rectores de dirección, organización, acreditación y control, permitiéndose la autorregulación y autocontrol de la profesión (49). estos avances demuestran la consolidación de etapas importantes del proceso de profesionalización. sin embargo, la enfermería sigue siendo una profesión de baja constitución, con poco prestigio social, baja independencia y autodeterminación, poca apropiación de su acervo conceptual y poco compromiso por sus agremiaciones, situación esta que influye en su posicionamiento y proyección social (28); sin olvidar que la transformación de la enfermería en profesión es un proceso en construcción que demanda de esfuerzos permanentes, persistencia y compromiso (50). de acuerdo con lo anterior, existe una necesidad creciente de crear, desde los programas de formación, propuestas orientadas al fortalecimiento de cada una de las dimensiones que se consideren necesarias para incrementar el posicionamiento y el rol del enfermero en esta sociedad tan competitiva, exigente y segregadora. la educación como agente transformador de cosmovisiones ayuda a crear y a legitimar formas de conciencia que refuerzan o posibilitan las actitudes y las acciones frente al mundo, por tanto, debe ser el punto de partida para llevar a cabo cambios estructurales y de poder que faciliten el avance profesional (51). los programas de enfermería tienen el compromiso urgente de propender por estimular el fortalecimiento de la autonomía, la identidad, el estatus, el posicionamiento, la apropiación del cuerpo de conocimientos y de lucha por la defensa de las agremiaciones, como categorías importantes dentro del enfoque sociológico de las profesiones para consolidar, afianzar y proyectar el desarrollo profesional. 49 la enfermería en colombia: una mirada desde la sociología de las profesiones l edna margarita gómez-bustamante la autonomía, entendida como la capacidad para controlar las actividades profesionales en el ambiente de trabajo, implica independencia, responsabilidad de los propios actos y autorregulación de la organización social y económica del trabajo (52, 53). asimismo, la autonomía en la práctica, y la aplicación de un único cuerpo de conocimientos de la disciplina, y libertad para hacer juicios y tomar decisiones dentro del alcance profesional (52). el estatus o prestigio social está determinado por la utilidad y el reconocimiento público otorgados por el campo profesional (28). el prestigio debe ser proporcional a la labor social que enfermería presta, y sus profesionales deben ser valorados de manera importante e imprescindible en el equipo interprofesional, para ello es necesario construir o reafirmar el concepto de autopercepción profesional, es decir, el concepto que tiene un profesional de sí mismo y de su profesión (50). es necesario trabajar en los imaginarios y las representaciones sociales que los estudiantes y egresados tienen con relación a la profesión, pues la imagen social de la enfermería se ve matizada por una gama de circunstancias histórico-sociales que la estigmatizan e impiden construir y pronunciar a los profesionales su propio discurso, expresar sus ideas, reconstruirse como sujetos sociales y profesionales con deberes y derechos (54). es por ello que se debe promover la imagen que las enfermeras y los enfermeros deben proyectar en el campo de actuación e impulsar el fortalecimiento de las agremiaciones como organizaciones importantes que velan por el desarrollo y dinamismo del ejercicio profesional. consolidar y apropiar el cuerpo de conocimientos de enfermería es otro reto trascendental, teniendo en cuenta que la profesión que tiene tras ella un cuerpo de conocimientos sustancial y teórico está más capacitada para convencer a la sociedad de la necesidad de sus servicios y persuadirla de su derecho a hacerse responsable de ellos (11). el desarrollo de la disciplina profesional debe ser el sustento para el posicionamiento y la reivindicación de la enfermería como profesión (47). es importante resaltar que la educación en enfermería constituye la base esencial para edificar el desarrollo y progreso de la profesión. su desenvolvimiento, actualización e innovación reclaman transformaciones intensas que den respuesta a su proceso de fortalecimiento. por tanto, la formación debe garantizar la preparación de profesionales competentes que se identifiquen con su quehacer, con elevado autoconcepto profesional, que sean gestores de sus propios ambientes laborales y que trabajen en equipos interdisciplinarios de manera integrada y propositiva, de tal forma que la enfermería como profesión sea visible y adquiera el reconocimiento social e interprofesional tan necesario en este contexto exigente y competitivo. conclusión el desarrollo disciplinar de enfermería revela progreso y avances, según los criterios de profesionalización considerados por el enfoque sociológico de las profesiones. pero, es importante destacar que este no es un proceso lineal, es discontinuo, está sujeto a tensiones y conflictos de diversa naturaleza, lo cual implica el compromiso de los programas de formación para problematizar, analizar y discutir todas las variables que influyen en este proceso en la búsqueda de un mayor avance y desarrollo. 50 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 referencias bibliográficas 1. díaz-barriga a. las profesiones ante los nuevos retos. globalización, 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contemporánea. rev. española de investigación sociológica 1992; 59: 9-18. disponible en: www.reis.cis.es/reis (fecha de acceso: 24 de enero de 2011). 21. gonzález r. las profesiones. entre la vocación y el interés corporativo. fundamentos para su estudio histórico. madrid: editorial cratriel; 1999. 22. díaz-barriga a. la profesión y la elaboración de planes de estudio. puntos de articulación y problema de diseño. en: la profesión. su condición social e institucional. méxico: edición centros de estudio sobre la universidad; 1997. 51 la enfermería en colombia: una mirada desde la sociología de las profesiones l edna margarita gómez-bustamante 23. wilensky h. the professionalization of everyone. american journal of sociology 1964; 70: 137-58. 24. fernández j. elementos que consolidan al concepto de profesión. notas para su reflexión. rev. electrónica de investigación educativa 2001;3(1). disponible en: http://redie.uabc.mx/contenido/vol3no2 /contenido-fernandez.pdf (fecha de acceso: diciembre 2010). 25. cleaves p. las profesiones y el estado: el caso de méxico. méxico: el colegio de méxico; 1985. 26. leddy s, pepper jm. bases conceptuales de la enfermería profesional. washington: ops, lb lippincott; 1989. 27. velandia m. análisis de la periodización utilizada en historia de la enfermería. rev. investigación y educación en enfermería 2008; 26 (1): 36-48. 28. gómez c, munar c. albores de la enfermería profesional en colombia. temperamentvm 2009; 9: 1-12. disponible en http://www.index-f.com!temperamentum (fecha de acceso: julio de 2009). 29. cárdena l. la profesionalización de la enfermería en méxico. méxico: editores universidad autónoma de méxico; 2005. 30. colliere m. promover la vida. madrid: mcgraw-hill; 1993. 31. flórez p, sábado j. mujer y cuidados: la historia de una relación natural. rev. cultura de los cuidados 2003; 13: 1-6. disponible en: http://hdl.handle.net/10045/4815 32. martínez m, latapi p, hernández i, rodríguez j. sociología de una profesión “el caso de una profesión de enfermería”. 2 ed. méxico: centro de estudios educativos; 1993. 33. celma m, acuña v. influencia de la feminización de la enfermería en su desarrollo profesional. rev. antropología experimental 2009; 9: 119-36. 34. carrasco m, acosta m, márquez g, fernández j. antropología-enfermería perspectiva de género. rev. cultura de los cuidados 2005; 18: 52-9. 35. velandia a. historia de la enfermería en colombia. bogotá: editorial universidad nacional; 1995. 36. celma m. cultura organizacional y desarrollo profesional de las enfermeras. granada: editorial universidad de granada; 2007. 37. garcía c. reflexión del papel de la enfermería a lo largo de la historia. eglobal 2007;(11):1-5. disponible en: www. um.es/eglobal (fecha de acceso: octubre de 2010). 38. donahue mp. historia de la enfermería. madrid: harcourt, mosby company; 1985. 39. attewel a. florence nightingale (1820-1910). the quarterly review of comparative education 1998; 28 (1); 153-66. 40. gómez c. la profesionalización de la enfermería en colombia. en: el arte y la ciencia del cuidado. bogotá: universidad nacional de colombia; 2002. 41. ferreira y. desarrollo histórico de los estudios de enfermería en cartagena de indias. en: la cátedra historia de la universidad de cartagena. cartagena: editorial universitaria; 2003. 42. diario de la costa. escuela de enfermeras y parteras. enero 24 de 1919. 43. morales e. 75 años de participación social en la defensa del derecho a la salud y condiciones dignas y justas para el ejercicio profesional. publicación oficial de la asociación nacional de enfermeras de colombia; 2010; 27: 5-9. 44. velandia a. análisis prospectivo de la enfermería colombiana frente a las nuevas tendencias en salud y educación en américa latina. trabajo presentado en la reunión del grupo de consulta para desarrollar un plan de enfermería para 1998-2002. washington d.c.; 1997. disponible en: http://analuisa-velandia-mora-publicaciones.blogspot. com/2010/09/analisis-prospectivo-de-la-enfermeria.html 52 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 45. vásquez ml. desarrollo conceptual de la enfermería: evolución, tendencias y desafíos. avances de enfermería 2006; xxiv (1). 46. aimar a, videla n, torre m. tendencias y perspectivas de la ciencia de enfermería. enfermería global 2006; (9): 1-8. disponible en: www.um.es/global/ 47. durán de villalobos m. marco epistemológico de la enfermería. aquichan 2002; 2 (2): 7-18. 48. durán de villalobos m. teoría de enfermería ¿un camino de herradura? aquichan 2007; 7 (2): 161-173. 49. colombia. ministerio de educación. ley 266 de 1996 por la cual se reglamenta la profesión de enfermería en colombia y se dictan otras disposiciones. bogotá; 1966. 50. durán de villalobos m. el desarrollo del liderazgo y la educación en enfermería. educ med salud 1988; 22 (2): 48-62. 51. torres a. desarrollo de la autoestima profesional. investigación y educación en enfermería. antioquia 2006; 24 (2): 112-119. 52. cárdenas l. la autonomía o interdependencia profesional en enfermería. en: el mundo de las profesiones en el siglo xxi: perspectivas y enfoques. méxico: ediciones facultad de filosofía y letras, universidad autónoma de puebla; 2008. 53. tapp d, stansfield, stewat j. la autonomía en la práctica de enfermería. aquichan 2005; 5 (8): 114-27. 54. cuesta g. la construcción de identidad profesional. en: la dimensión social de la práctica de enfermería. medellín: ediciones universidad de antioquia; 1997. 62 76 aporte de enfermeria.indd 62 aquichan issn 1657-5997 lina maría vargas-escobar1 aporte de enfermería a la calidad de vida del cuidador familiar del paciente con alzheimer 1 m.sc. estudiante de doctorado en enfermería, universidad nacional de colombia. profesora ocasional, facultad de enfermería, universidad nacional de colombia. limvargases@unal.edu.co recibido: 2 de julio de 2011 aceptado: 5 de febrero de 2012 resumen objetivo: generar una reflexión acerca de las intervenciones de enfermería en la atención de los cuidadores de pacientes con enfermedad de alzheimer a partir de la revisión de la literatura que aborda los diferentes aspectos de la calidad de vida de esta población. método: se efectuó una revisión de la literatura científica y académica con 40 artículos publicados entre 2000 y 2011 en bases de datos (isi web of science, scielo, medline, pubmed, science direct y ovid) así como los resultados de google scholar. resultados: se evidencian los principales aspectos que integran la calidad de vida para el cuidador, especialmente en el ámbito subjetivo, representados en las dimensiones físicas, psicológicas, sociales y espirituales. conclusiones: la calidad de vida del cuidador familiar del paciente con alzheimer está dada por las condiciones objetivas y subjetivas que integran el concepto. enfermería tiene el potencial de participar no solo desde la práctica clínica y comunitaria, sino desde los roles en educación, investigación y política pública. palabras clave calidad de vida, cuidador, enfermedad de alzheimer, cuidado de enfermería (fuente: decs). nursing’s contribution to the quality of life of family caregivers of alzheimer patients abstract objective: the idea is to prompt reflection on nursing intervention in caring for the caregivers of patients with alzheimer’s disease, based on a literature review that addresses the different aspects of the quality of life enjoyed by this population. method: a review of scientific and academic literature was conducted, featuring 40 articles published between 2000 and 2011 in databases (isi web of scienaño 12 vol. 12 nº 1 chía, colombia abril 2012 l 62-76 63 aporte de enfermería a la calidad de vida del cuidador familiar del paciente con alzheimer l lina maría vargas-escobar ce, scielo, medline, pubmed, sciencedirect and ovid) and the results of google scholar. results: the review showed the chief physical, psychological, social and spiritual elements that contribute to the caregiver’s quality of life, particularly in the subjective realm. conclusions: the quality of life of a family caregiver of a patient with alzheimer’s disease is determined by the objective and subjective conditions that make up the concept. nursing has the potential to participate, not only from the standpoint of clinical and community practice, but also through roles in education, research and public policy. key words quality of life, caregiver, alzheimer’s disease, nursing care (source: decs). a contribuição da enfermagem para a qualidade de vida do cuidador familiar do paciente com alzheimer resumo objetivo: gerar uma reflexão sobre as intervenções da enfermagem no atendimento dos cuidadores de pacientes com alzheimer a partir da revisão da literatura que aborda os diferentes aspectos da qualidade de vida dessa população. método: efetuou-se uma revisão da literatura científica e acadêmica com 40 artigos publicados entre 2000 e 2011 em base de dados (isi web of science, scielo, medline, pubmed, science direct e ovid) assim como os resultados de google scholar. resultados: evidenciam-se os principais aspectos que integram a qualidade de vida para o cuidador, especialmente no âmbito subjetivo, representados nas dimensões físicas, psicológicas, sociais e espirituais. conclusões: a qualidade de vida do cuidador familiar do paciente com alzheimer se dá pelas condições objetivas e subjetivas que integram o conceito. a enfermagem tem o potencial de participar não só a partir da prática clínica e comunitária mas também a partir dos papéis em educação, pesquisa e política pública. palavras-chave qualidade de vida, cuidador, doença de alzheimer, cuidado de enfermagem (fonte: decs). 64 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 introducción las situaciones de enfermedad crónica representan desde hace algunos años un foco de interés para enfermería dado su carácter progresivo, incapacitante, irreversible, prolongado y único, que afecta la totalidad de la vida de las personas implicadas, y genera modificaciones en todas las dimensiones del ser humano, comprometiendo por tanto su calidad de vida y su salud (1). dentro de las situaciones de cronicidad se encuentran las derivadas de enfermedades neurodegenerativas, siendo una de las más comunes la demencia tipo alzheimer, la cual afecta el cerebro y origina un deterioro gradual y progresivo de las habilidades cognitivas e intelectuales de la memoria, la percepción del tiempo y el espacio, el lenguaje, el juicio y el pensamiento, secundario al daño neuronal irreversible producido (2). la duración media de la enfermedad oscila entre los 8-12 años, en un rango entre los 2-20 años, y es especialmente común en la población mayor de 65 años (3-4). de acuerdo al informe alzheimer’s disease international (adi) (2011), se calcula que 36 millones de personas en todo el mundo viven con demencia, encontrándose un aumento en su incidencia en los países de bajos y medianos ingresos (5). en colombia se ha estimado una prevalencia de demencia del 1,8 y 3,4% en grupos de pacientes mayores de 65 y 75 años (6). igualmente, de acuerdo con el estudio neuroepidemiológico nacional (epineuro), la prevalencia de demencia corresponde a 1,3% entre los mayores de 50 años, ascendiendo esta cifra a 3,04% en mayores de 70 años (7). debido a que esta enfermedad va deteriorando de forma progresiva todas las capacidades cognitivas e intelectuales de la persona, se produce una pérdida gradual de la capacidad de cuidar de sí mismo y de necesitar, con el paso del tiempo, de la ayuda de un cuidador familiar que pueda apoyarlo en la realización de aquellas actividades de la vida diaria necesarias para subsistir (4). esta situación, además de generar un estado de dependencia del enfermo de alzheimer hacia su cuidador familiar, produce a su vez una serie de consecuencias para la salud del cuidador producto del rol adquirido (8-9). a pesar del creciente interés en la literatura de la salud que aborda la situación de los cuidadores familiares de pacientes con alzheimer, es importante que enfermería reflexione en torno a la forma en que debe dirigir el cuidado, según los aspectos que resultan importantes para la calidad de vida de esta población. el propósito de este artículo es generar una reflexión acerca de las intervenciones de enfermería para el cuidado de los cuidadores de pacientes con enfermedad de alzheimer, a partir de la revisión de la literatura que aborda los diferentes aspectos de la calidad de vida de esta población. método se realizó una revisión de la literatura científica entre 2000 y 2011, en las bases datos isi web of science, scielo, medline, pubmed, science direct y ovid, así como de google scholar, relacionada con la calidad de vida del cuidador del paciente con alzheimer. los descriptores para esta revisión fueron: quality of life for caregivers, caregivers of persons with alzheimer’s disease, y subtemas como physical well-being, psychological well-being, social well-being and spiritual well-being, en su título, resumen o palabras clave. para la recolección y sistematización de la información se construyó una matriz con información general del artículo (título, año de publicación, autores, país de origen, enfoque metodológico, temas y subtemas) en excel de microsoft office versión 2007. antecedentes múltiples significados, opiniones, consensos y divergencias se han construido en torno al concepto de calidad de vida. los comienzos del concepto se remontan a finales del siglo xix y comienzos del xx, y hacían referencia a la posibilidad que tenían las personas de contar con las comodidades necesarias para la subsistencia. sin embargo, fue hasta la década de los sesenta que el término comienza a difundirse con gran interés en el conocimiento del bienestar humano y la preocupación de los efectos de la industrialización para las personas. surge entonces la necesidad de medir este impacto mediante indicadores objetivos que establecieran una medida entre los datos y hechos relacionados con el bienestar social de la población. posteriormente, en la década de los ochenta comienza a presentarse un gran proceso de diferenciación en lo referente a los indicadores sociales objetivos y al verdadero concepto y significado de calidad de vida, que comienza a definirse desde un carácter integrador, multidimensional y multidisciplinar, que hace referencia a condiciones tanto objetivas como subjetivas (10). 65 aporte de enfermería a la calidad de vida del cuidador familiar del paciente con alzheimer l lina maría vargas-escobar es a partir de estos inicios que disciplinas como medicina, psicología, economía, sociología, educación, enfermería, entre otras, han realizado importantes aportes en torno al concepto de calidad de vida con objetivos, metodologías y fundamentos propios de sus áreas específicas del conocimiento, proporcionando un carácter multifacético que permite abordar una gran variedad de ámbitos y contemplar al ser humano y al entorno que lo rodea (11). a continuación se presentan algunas definiciones en torno al concepto de calidad de vida. la organización mundial de la salud (oms) define la calidad de vida como la percepción individual de un ser humano, su posición en la vida y su cultura con relación a sus objetivos, metas y valores. […] integrando de una manera compleja la salud física de las personas y su propia percepción de su estado psicológico, su autonomía, sus relaciones sociales, sus creencias personales y su relación con los eventos del ambiente (12). coelho y amante, citados por giraldo (13), manifiestan que la calidad de vida es la condición de la existencia del ser humano referida a los modos de vivir en sociedad, esto es, dentro de los límites establecidos en cada momento histórico para vivir la cotidianidad, […] esta existencia también debe satisfacer las exigencias o demandas que la cotidianidad genera para las personas que integran la sociedad (13). vinaccia (14) manifiesta que la calidad de vida relacionada con la salud (cvrs), desde una perspectiva subjetiva, hace referencia a la valoración que realiza cada individuo en un momento o una situación determinada y con base en sus propios criterios, sobre su estado físico, emocional y social. expresa además que la calidad de vida como una valoración implica de parte del individuo una respuesta cognitiva seguida de una reacción emocional, reflejando en este proceso el grado de satisfacción personal en función del logro de las expectativas iniciales. velarde (11) establece que la calidad de vida “consiste en la sensación de bienestar que puede ser experimentada por las personas y que representa la suma de sensaciones subjetivas y personales (sentirse bien)”. según giraldo y franco (13), el concepto de calidad de vida está influenciado por las circunstancias de la persona y está determinado por factores tales como: las posibilidades educativas, los aspectos biológicos, psicológicos, culturales y sociales que cambian con el tiempo, lo que implica que una misma persona tiene diferentes conceptos de calidad de vida en momentos diferentes. con base en estas definiciones es posible establecer que el concepto de calidad de vida involucra una serie de aspectos propios de la persona (como el nivel educativo, aspectos biológicos, psicológicos y culturales), para desarrollarse en su propia vida, logrando así los mejores beneficios en el cumplimiento de logros, objetivos, expectativas, aspiraciones e intereses, lo que le permitirá adquirir bienestar y satisfacción personal en las actividades de la vida diaria, las relaciones sociales e interpersonales, el sistema económico y financiero, el sistema físico y del componente afectivo y psicológico (15, 16). lo anterior trae implícita una connotación subjetiva en la que prima la percepción de la satisfacción experimentada por la persona ante su vida; sin embargo, como se mencionó al comienzo, el concepto de calidad de vida también contempla un aspecto objetivo relacionado con las condiciones de las personas desde los indicadores sociales o epidemiológicos. esto se ha convertido en un tema de discusión entre los diferentes autores, especialmente en lo relacionado con la forma más adecuada de medir e interpretar este concepto. de esta manera, velandia (17) establece que el concepto de calidad de vida contiene un análisis teórico efectuado a partir de dos vertientes: una filosófica, que pretende situar ideológicamente el concepto, y una pragmática, que se interesa más en buscar los indicadores de la misma, por lo que la forma en que este concepto debe ser medido podría poseer diferentes posibilidades (17). obermeyer, citado por gonzález (18), manifiesta que el concepto de calidad de vida es una categoría que puede ser subdividida en diferentes niveles de particularidad hasta llegar al nivel del individuo, la calidad de vida “no se mide, sino se valora o estima a partir de la actividad humana, su contexto histórico, sus resultados y su percepción individual”. velandia (17) expresa que la calidad de vida “es aquella sensación subjetiva del bienestar psicosomático, autoestima, satisfacción personal y de adaptación al entorno resultado de la interacción de varios factores: salud, alimentación, vestido, vivienda, trabajo, educación, seguridad social, recreación y libertades humanas”. 66 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 en este sentido, los indicadores epidemiológicos tienen una importante función al tratar de medir u objetivizar sucesos colectivos o situaciones determinadas y, a la vez, poder evaluar su comportamiento en el tiempo. “los indicadores de salud son instrumentos de evaluación que pueden determinar directa o indirectamente modificaciones dando así una idea del estado de situación de una condición” (19). dentro de las medidas clásicas utilizadas por la epidemiología se encuentran indicadores tales como la morbilidad, mortalidad, la expectativa de vida, los años potenciales de vida perdidos, seguidos por otros como la situación nutricional, la cobertura de seguridad social, el acceso a la educación, el acceso a los servicios públicos, entre otros. estas medidas son contempladas por autores como fernández y hernández (20) en el establecimiento de políticas sanitarias así como en la determinación de las diferencias en salud entre la población, y por entidades como el departamento nacional de estadística (dane), que define la calidad de vida como un indicador: “la investigación que cuantifica y caracteriza las condiciones de vida de los pobres y los no pobres, comprendiendo así el fenómeno de la pobreza, al incluir las variables tan importantes, relacionadas con la vivienda, los servicios públicos y los miembros del hogar” (21). minayo, hartz y buss, citados por schwartzmann (22), señalan que el concepto de calidad de vida debe contemplar el área individual, independiente de que esta evaluación sea o no compartida por los demás, y tiene tres marcos de referencia que lo sustentan: histórico, en el que cada sociedad maneja parámetros diferentes de calidad de vida en momentos históricos distintos; cultural, donde cada pueblo tiene tradiciones culturales diferentes, a partir de las cuales se construyen los valores y las necesidades, y clase social a la que se pertenece, donde las expectativas que cada uno tiene respecto a su propia vida están relacionadas con la clase social a la que se pertenezca. este último aspecto merece una reflexión aparte que muestra que tanto los indicadores subjetivos (percepción), como los llamados “objetivos” (ingresos, empleo, oportunidades de acceso a la salud) son igualmente valiosos, dependiendo del objetivo de la evaluación (22). estas definiciones permiten establecer que tanto los indicadores sociales o epidemiológicos (medidas objetivas), como la percepción expresada por el individuo (medida subjetiva) son fundamentales a la hora de establecer el grado de salud de la población, su bienestar y su calidad de vida. se resalta además que en la actualidad es importante dejar el debate entre lo objetivo y subjetivo de forma tal que pueda otorgarse un mayor valor a las percepciones y los sentimientos que condicionan el bienestar físico, psíquico, social y espiritual de los individuos, que surgen a partir de su propios valores y creencias, su contexto cultural y su historia personal. en este sentido, el concepto de calidad de vida resulta de la combinación de aspectos objetivos y subjetivos incluyendo, además de las percepciones que tienen las personas de sus propias condiciones y el grado de satisfacción con el logro de sus aspiraciones personales, aquellas relacionadas con el desarrollo económico y social, el nivel de vida, las necesidades fundamentales de la persona, la desigualdad económica y social, el modo de vida y el nivel de salud. resultados la revisión de la literatura establece la definición del cuidador familiar del paciente con alzheimer, sus características principales y los aspectos relacionados con su calidad de vida, representados en las dimensiones físicas, psicológicas, sociales y espirituales de la persona. el cuidador familiar del paciente con alzheimer se define como la persona adulta, con vínculo de parentesco o cercanía, que asume la responsabilidad del cuidado de un ser querido que vive con esta enfermedad. el cuidador realiza, supervisa o apoya las actividades de la vida diaria del receptor del cuidado (23). según algera, citado por ruiz (24), dentro de las actividades que llevan a cabo los cuidadores se encuentran principalmente: los cuidados domésticos, los relacionados con las actividades de la vida diaria (también llamados cuidados físicos o cuidados personales), los cuidados sanitarios, las actividades de gestión y relación con los servicios sociosanitarios y los cuidados psicosociales. gómez (25) ha establecido que el cuidador del paciente de alzheimer debe desarrollar algunas características como: la fuerza física para movilizar al paciente, la disponibilidad, la capacidad de amor y los recursos necesarios para cubrir los gastos y medicamentos requeridos para brindar bienestar al familiar con demencia. por otro lado la familia, y en especial el cuidador familiar, debe adquirir habilidades y conocimientos para poder prestar la atención requerida por el paciente con alzheimer, de acuerdo no 67 aporte de enfermería a la calidad de vida del cuidador familiar del paciente con alzheimer l lina maría vargas-escobar solo con su nivel de independencia, sino con la condición patológica en la que se encuentra. esta habilidad incluye las dimensiones cognoscitiva y actitudinal, que son identificadas y medidas según los indicadores de conocimiento, valor y paciencia que propone ngozi o. nkongho. los planteamientos conceptuales de nkongho, citado por barrera et al.: “señalan que la habilidad de cuidado es el potencial de cuidado que tiene la persona adulta que incluye una dimensión cognoscitiva y actitudinal identificadas y medidas con indicadores de conocimiento, valor y paciencia” (26). lo anterior sugiere no solo la importancia que tiene para el paciente el recibir cuidados adecuados y acertados, sino para el cuidador familiar del paciente con alzheimer adquirir conocimientos y buena disposición para brindarlos. para el cuidador familiar la calidad de vida está relacionada con aspectos tales como: las ganancias del cuidado, la funcionalidad física, la habilidad de trabajar, el estado socioeconómico, la red de apoyo social, la autoestima, el humor, las tensiones, las cargas, el tiempo de cuidado, la felicidad, el valor y el significado de la vida, y la satisfacción con la vida y la cultura (4). igualmente, son considerados como indicadores de buena calidad de vida: la edad de los cuidadores, la salud física, el tener un propósito en la vida, el estado financiero, la red de soporte social, la independencia del paciente, el tiempo libre para la realización de sus propias actividades, la salud mental y espiritual del cuidador (4, 12). así como el bienestar proporcionado por los allegados, la satisfacción de las necesidades de su hijos y parientes más cercanos, el conquistar metas en el estudio y el trabajo, y cumplir satisfactoriamente con las obligaciones o responsabilidades adquiridas (13). de esta manera, la calidad de vida para el cuidador familiar del enfermo de alzheimer estaría representada por el impacto que le genera el cuidado de su familiar en términos de la disminución de oportunidades, sus secuelas o consecuencias, las políticas de salud que los representa, así como la percepción que tiene el cuidador sobre su propio bienestar. la calidad de vida, por tanto, es la valoración que el cuidador familiar realiza sobre su estado físico, psicológico, social y espiritual de acuerdo con la situación que vive en el rol de cuidador y en el proceso de cuidado (27). asimismo se ha establecido que el cuidador familiar, en el momento de iniciar el cuidado, no es consciente de las responsabilidades que asume, del impacto que va a tener sobre él, del tiempo que va a durar la situación, ni tampoco de la dedicación y energía progresiva que requerirá en la tarea de cuidado. esto se debe en gran parte al desconocimiento existente en la población general en torno a la enfermedad de alzheimer, y a la concepción de que muchos de los cambios del paciente se presentan como consecuencia del proceso de envejecimiento normal por el que pasa toda persona (28). adicionalmente, resultan relevantes los requerimientos propuestos por el cuidador familiar para el cuidado del paciente con alzheimer, que están relacionados con la necesidad de informarse sobre la enfermedad, y adquirir un mayor aprendizaje a través de la experiencia en aspectos como la organización de los recursos, las acciones de cuidado, el manejo del tiempo y la apropiación de su labor. lo anterior implica que los cuidadores deben ser capaces de superar dificultades y presiones, enfrentar el desconocimiento y el miedo al cuidado, aprender a afrontar los momentos difíciles que se generan producto de la conducta desordenada del enfermo, y de las situaciones propias del cuidado como la monotonía, el aislamiento y la falta de apoyo (29). ferrell et al. (30, 31, 32) expresan la calidad de vida de los cuidadores como un concepto multidimensional que abarca percepciones subjetivas de aspectos tanto positivos como negativos que caracterizan la vida. esta incluye cuatro dominios: el bienestar físico, el psicológico, el social y el espiritual de la persona. bienestar físico: es el mantenimiento de la funcionalidad que incluye la habilidad funcional, la salud física en general y síntomas tales como fatiga, apetito, dolor y cambios en el sueño. bienestar psicológico: incorpora el sentido de control en el enfrentamiento de una enfermedad desde felicidad, satisfacción, capacidad de concertación y recordación, utilidad, ansiedad, depresión y miedo. bienestar social: considera el reconocimiento de la persona con su enfermedad, sus relaciones y roles desde las situaciones de estrés familiar, aislamiento social, finanzas y función sexual. bienestar espiritual: considera aspectos de significado y propósito de la vida, la esperanza, la incertidumbre y la trascendencia. de acuerdo con lo anterior, y al revisar la literatura relacionada con las principales alteraciones que presentan los cuidadores familiares del paciente con alzheimer en el ejercicio del cuidado, es posible evidenciar que las cuatro dimensiones de calidad de 68 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 vida anteriormente descritas se han visto fuertemente comprometidas como se muestra a continuación: bienestar físico. en la literatura se han descrito las implicaciones físicas que tiene para el cuidador familiar la atención del enfermo crónico especialmente el de alzheimer. las principales alteraciones giran en torno a síntomas tales como gastritis, anemia, fatiga, insomnio, cefalea, dolores de espalda, desnutrición (13), , lumbalgias, dorsalgias y cervicalgias, artrosis, insuficiencia venosa crónica, algias musculares inespecíficas (33, 34), astenia, fatiga crónica, estrés, alteración del ciclo de sueño-vigilia, insomnio, deterioro en la función inmune, entre otras (14). adicionalmente, se ha referido que en muchos de los casos los cuidadores aumentan el consumo de alcohol, tabaco y fármacos (33, 35). gran parte de esta sintomatología se asocia al síndrome de burnout —o del cuidador quemado—, el cual consiste en un desgaste físico y emocional que experimenta la persona que convive y cuida a un enfermo crónico, producido por un estrés continuado que puede llevar al cuidador a agotarlo completamente (36). es de resaltar que en el caso de los pacientes con demencia tipo alzheimer, el deterioro funcional se presenta de forma progresiva, por lo cual la asistencia en las actividades de la vida diaria por parte del cuidador (como el baño, la deambulación, los cambios de posición, entre otros que demandan un gran esfuerzo físico), se van incrementando de menor a mayor grado, hasta el punto en que perciben que sus seres queridos son completamente dependientes de ellos (37). bienestar psicológico. esta es una de las dimensiones que más ha sido documentada entre los cuidadores familiares de enfermos de alzheimer. las modificaciones en el área psicológica se producen como consecuencia de las respuestas individuales de los pacientes, las familias, los amigos, la sociedad y del mismo cuidador frente al diagnóstico y al pronóstico de la enfermedad y a su propia calidad de vida. de esta forma pueden encontrarse matices diferentes entre los sentimientos de los cuidadores frente a su rol, tales como aceptación y satisfacción, o insatisfacción y contrariedad (38). la carga laboral, los intereses personales del enfermo de alzheimer, y las altas demandas de cuidados en fases avanzadas de la enfermedad llevan al cuidador a padecer alteraciones como baja autoestima —con la consecuente distorsión de la identidad personal—, depresión, ansiedad, tristeza, desesperanza, insatisfacción, soledad, angustia y falta de concentración (2, 36, 39). por otro lado, los cuidadores tienden a presentar una subvaloración de sus propios síntomas al compararlos con los de sus familiares a cargo, por lo que muchos de los que padecen pueden estar asociados a una patología que no ha sido diagnosticada (40). esto es relevante desde la dimensión psicológica en la medida en que la falta de conciencia de la presencia de los síntomas no les permite consultar a tiempo y, por tanto, tiende a agudizarse la problemática en el cuidador. esto no es extraño y, de hecho, se ha contemplado que para muchos cuidadores los conceptos de “cuidado familiar” y “cuidador familiar” resultan desconocidos (13). según rosness et al. (41), el aumento de sintomatología depresiva en los cuidadores se asoció con estar casado, tener hijos y cuidar a un paciente con demencia, lo que implica que además de los roles sociales y familiares que debe desempeñar el cuidador, las situaciones de dependencia de la persona con alzheimer son también generadoras de depresión. sin embargo, tal como lo menciona papastavrou et al. (42), la dependencia se vuelve secundaria para el cuidador ante situaciones como las alteraciones de conducta, los trastornos como la agresividad, el andar errante y la desorientación que son propios de los pacientes con alzheimer en algunas fases de la enfermedad. para canam y acorn, citados por giraldo (13), la calidad de vida desde la dimensión del bienestar psicológico está relacionada con la satisfacción que tiene la persona con su vida, sus metas alcanzadas y su felicidad, lo que está seriamente afectado en este grupo poblacional debido a que los intereses, las motivaciones y las expectativas por el proyecto de vida propio pasan a un segundo plano en la medida en que deben dedicar la mayor parte de su tiempo al cuidado de su familiar (13). asimismo, factores como la situación de dependencia del familiar en la realización de sus actividades, las tareas que debe realizar el cuidador, el tiempo de cuidado (que en una persona de alzheimer oscila entre 8 a 20 horas diarias y a una supervivencia de 8 a 14 años) (24), y el impacto negativo de estas actividades, influyen notablemente en el área psicológica del cuidador afectando su calidad de vida. otro aspecto fundamental se asocia a los sentimientos que genera la atención para el cuidador familiar. al respecto biurrun unzué, citado por roca (36), manifiesta que los cuidadores tienen sentimientos de culpabilidad por no atender convenientemente al 69 aporte de enfermería a la calidad de vida del cuidador familiar del paciente con alzheimer l lina maría vargas-escobar familiar, irritabilidad, preocupación por heredar la misma enfermedad, reacciones constantes de duelo por las pérdidas constantes que sufre su ser querido con la progresión de la enfermedad (de comunicación, del rol dentro de la familia, del reconocimiento cuando el paciente no se reconoce a sí mismo y a su cuidador, y finalmente del fallecimiento) (36). asimismo, el cuidador se somete a un desgaste afectivo prolongado relacionado con la evolución de la enfermedad, influyendo en este caso factores como el desconocimiento de la misma, la falta de la habilidad para el cuidado y el deterioro del paciente con el paso del tiempo (43-46). teniendo en cuenta lo anterior, es posible establecer que los principales síntomas psicológicos asociados a los cuidadores familiares son los referentes a depresiones reactivas y a trastornos de ansiedad que llevan al cuidador a padecer de estrés agudo, ansiedad y depresión, principalmente entre aquellos que cuidan a un enfermo con cuadros demenciales como el alzheimer. igualmente, la disminución de oportunidades de desarrollo personal y profesional, los temores generados ante el proceso evolutivo de la enfermedad y a la posibilidad de adquirirla en el futuro, generan en el cuidador alteraciones en su calidad de vida desde la dimensión psicológica. bienestar social. el soporte social es fundamental para lograr un adecuado afrontamiento de las situaciones y la superación de los obstáculos que puedan presentarse en el transcurso de la vida (22). sin embargo, para los cuidadores familiares de enfermos de alzheimer, el bienestar social es perturbador debido al tiempo de cuidado que deben dedicarle al paciente. según losada, citado por roca (36), los cuidadores de personas con deterioro cognitivo y funcional dedican en promedio 11 horas al cuidado de su familiar. no obstante, en el caso de los cuidadores de familiares de enfermos de alzheimer estos dedican entre 60 y 75 horas semanales, viviendo un promedio de 7 a 10 años después de iniciados los síntomas (36). este aspecto resulta relevante debido al poco tiempo que les queda para las actividades sociales, que como se mencionó al principio, son fundamentales para lograr un adecuado afrontamiento de la situación y de los obstáculos de la vida. la familia del enfermo de alzheimer experimenta fuertes repercusiones en su dinámica interna, llevando a posponer planes o proyectos a futuro (como en el hecho de tener o no hijos y casarse), discusiones y conflictos en la pareja, entre otros que son fundamentales para el desarrollo y la estructura de la familia (36). las relaciones de tipo marital pueden verse seriamente afectadas debido a que las parejas comienzan a experimentar pérdida de la compañía, problemas de comunicación y una gran carga en el cuidado, todo esto como consecuencia del progreso que tiene la enfermedad (47). un aspecto adicional se relaciona con la condición del ser querido al manifestar: “la persona que sufre, aunque ‘siente algo’ como dicen los cuidadores, no experimenta ni gusto, ni dicha; no habla, ni recuerda; pierde su individualidad y deja de ser el miembro conocido que una vez formó parte de esa familia” (48). la familia del enfermo y el cuidador también deben efectuar una organización del ambiente de cuidado con el fin de crear condiciones físicas y simbólicas que logren satisfacer las necesidades del paciente, con acciones orientadas a realizar arreglos domésticos del mobiliario y el espacio, y organizar el cuidado en cuanto lo que se debe hacer y en qué momento realizarlo (49). en este sentido, la alteración que se produce al interior de las familias y los hogares de los cuidadores está generando que exista cada vez un número más reducido de cuidadores familiares que estén dispuestos a asumir este rol y, por tanto, busquen la opción de delegar esta labor a hogares geriátricos u otras instituciones que puedan responsabilizarse de la atención y los cuidados que el enfermo de alzheimer necesita (50). lo expresado con respecto a la familia permite establecer la importancia que esta tiene para el cuidador y para el paciente como una red proveedora de apoyo (50). sin embargo, se hace manifiesto que los cuidadores familiares carecen de redes de apoyo formal que además de orientarlos en las actividades relacionadas con el cuidado directo de su familiar, les brinden la posibilidad de compartir con otros cuidadores su situación, su experiencia y sus necesidades en torno al cuidado y el rol que ejercen en la prestación del mismo. esto es importante si se tiene en cuenta que este tipo de apoyo les brinda mucho del ajuste social que necesitan y evita el aislamiento. con respecto a la actividad laboral del cuidador familiar, se presenta una tendencia al abandono del empleo, de responsabilidades y compromisos por el aumento de la carga doméstica y de cuidado que supone un enfermo crónico, especialmente en el caso de las mujeres (2, 36). sin embargo, un estudio encontró que en el 70 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 caso de los cuidadores familiares de pacientes con alzheimer de bogotá, colombia, la predisposición a la pérdida del empleo era mínima, y una de las explicaciones que lo justificaba eran los altos gastos generados en el cuidado del paciente (9). por tanto, la problemática laboral de los cuidadores pone de manifiesto un aspecto importante relacionado con los costos que genera para el cuidador familiar la enfermedad de alzheimer (51). en el actual sistema de salud colombiano, es la familia quien debe asumir el costo de gran parte de los tratamientos, diagnósticos y aquellos asociados al cuidado en casa, ya que el sistema en sí mismo no cubre la totalidad de los gastos económicos que implica una enfermedad neurodegenerativa. esto debido en gran parte a que no existe una política clara que proteja y reconozca a los cuidadores familiares de enfermos crónicos como sujetos importantes en la prestación de los cuidados (9). según croog et al. (52), el costo anual del paciente de alzheimer en la unión europea es de 28.198 euros (36.144 dólares), principalmente asociados con las categorías del cuidado informal y el costo de medicamentos. igualmente precisó que los costos de la enfermedad aumentan con el deterioro progresivo, estableciendo el siguiente costo medio anual: deterioro cognoscitivo leve, 14.956 euros (19.171 dólares), un deterioro cognoscitivo moderado de 25.562 euros (32.765 dólares) y para un deterioro severo de 41.669 euros (53.441 dólares) (52). un aspecto adicional relacionado con el bienestar social se asocia a las actividades de ocio, al tiempo libre y a la conformación y el mantenimiento de relaciones sociales. como ya se ha mencionado, los cuidadores familiares de enfermos de alzheimer dedican varias horas al día al cuidado de su ser querido, durante los siete días de la semana, quedándoles muy poco tiempo libre para su propio esparcimiento y el cultivo adecuado de las relaciones sociales; por lo que en general se produce un aislamiento progresivo causante de gran parte de la sintomatología psicológica que estos presentan. bienestar espiritual. el bienestar espiritual juega un papel fundamental en el manejo de las percepciones que establece el cuidador de sí mismo y de la situación de cuidado en la que se encuentra debido a que le proporciona cierto grado de crecimiento personal y de superación que le permite seguir motivado para mantenerse en el ejercicio del cuidado. es así como la espiritualidad por sí misma representa una gran variedad de ideas acerca de la vida y su propósito, brindando significados al ser, saber y hacer; un sistema básico para el bienestar humano que de una u otra forma motiva a las personas a moverse en la búsqueda y consecución de respuestas (53). este bienestar se relaciona con la fe, las creencias y los significados interiores de cada persona. en un estudio realizado a 150 cuidadores (71 afroamericanos, 77 caucásicos y 2 cuidadores más), se establecen diferencias importantes entre la percepción del bienestar espiritual y la carga del cuidador entre el grupo de afroamericanos y los caucásicos. asimismo, se establecen comportamientos espirituales como la oración en ambos grupos, y se demostró que los cuidadores del familiar con alzheimer terminal dependen del recurso espiritual de una forma importante (54). también se estableció que la espiritualidad es una medida significativa del mantenimiento de la salud y el bienestar (55). stolley, buckwalter y koenig, raby (55), informaron que los cuidadores de personas con alzheimer dependían de la oración y las actividades religiosas como forma de ayuda durante su experiencia y su rol en el cuidado. wykle y segal, citados por raby (55), revisaron las diferencias que existen en las demandas de cuidado de una persona con enfermedad demencial y se estableció que los cuidadores de raza negra utilizaban más las estrategias de la oración, la fe y la religión, en comparación con las personas de raza blanca, quienes prefieren utilizar ayuda de tipo profesional (55). un aspecto adicional relacionado con el bienestar espiritual es que brinda a los cuidadores la posibilidad de obtener estilos de vida más saludables gracias a que los que creen muestran un mayor interés en el cuidado de su propia salud. de esta manera koenig, citado por sánchez (56), establece que la espiritualidad de los creyentes pareciera protegerlos de las dolencias físicas producto de las tensiones de la vida, el estrés y la depresión, por lo cual experimentan una mejor salud y una vida más duradera en comparación con quienes no practican su fe, teniendo en cuenta que esta última es capaz de proveerlos del impulso interior y de la determinación para superar diversas situaciones, brindándoles además la capacidad de recuperarse emocionalmente (56). 71 aporte de enfermería a la calidad de vida del cuidador familiar del paciente con alzheimer l lina maría vargas-escobar de acuerdo con lo anterior, es posible establecer que la espiritualidad representa un área fundamental para los cuidadores que ven en ella la posibilidad de comprender y sobrellevar muchas de las situaciones y adversidades que se presentan en el cuidado cotidiano del enfermo de alzheimer en casa. los profesionales de enfermería han establecido que el cuidado de los seres humanos debe abordarse de forma total y holística teniendo como principio la interacción de la persona con su contexto; así, el bienestar espiritual abordado desde la perspectiva de calidad de vida permite el acercamiento a este abordaje. reflexión de las intervenciones de enfermería en la identificación que realiza enfermería de la calidad de vida de los cuidadores familiares de los pacientes con alzheimer, es importante considerar tanto los aspectos objetivos como subjetivos que la integran. con respecto a los aspectos objetivos, es importante que los gobiernos garanticen los recursos mínimos de educación, vivienda, servicios públicos domiciliarios y de seguridad social, que son de extrema importancia para toda la población y que, en este caso, son necesarios para el bienestar y la salud de pacientes y cuidadores que afrontan una situación de cronicidad como la demencia. lo anterior debe ser una prioridad para los profesionales de la salud incluyendo a enfermería en el campo de las políticas públicas en salud, así como para los profesionales en ejercicio de la práctica clínica o comunitaria, como parte de los recursos disponibles para brindar un cuidado de calidad al paciente y al cuidador mismo. como parte de los aspectos subjetivos, es importante recordar que el objeto de enfermería es la experiencia de salud de los seres humamos, y que durante el proceso de cuidado de enfermería en las situaciones de alzheimer, se está garantizando no solo el reconocimiento de la labor de cuidador, sino mejores condiciones de bienestar para este y para el paciente, recordando que en la medida en que el cuidador familiar se sienta bien, así mismo lo estará el paciente con alzheimer a su cuidado. la enfermedad de alzheimer es una de las condiciones de mayor impacto para la salud, no solo del paciente sino también para el bienestar físico, psicológico, social y espiritual del cuidador familiar, razón por la cual el cuidado de enfermería debe orientarse de manera integral y continua en cada situación, recordando que la percepción de la calidad de vida por parte del cuidador puede manifestarse de manera dinámica en el tiempo y conforme progresa la enfermedad y la situaciones de cuidado. en este sentido, las intervenciones de enfermería al cuidador familiar del paciente con alzheimer, específicas para la práctica, deben centrarse en cuatro áreas: la información y educación sobre la enfermedad de alzheimer, el cuidado del enfermo, los recursos de apoyo disponibles y el cuidado de sí mismo. en lo que respecta a la información y educación sobre la enfermedad de alzheimer, es importante que la enfermera(o) informe al cuidador familiar en qué consiste la enfermedad, cómo se va desarrollando durante las diferentes fases, la disponibilidad de los tratamientos y lo que debe esperar en relación con la enfermedad de su ser querido. esta área de intervención es importante para el cuidador ya que el tener un conocimiento real de la enfermedad le permitirá planificar su futuro, disminuir su ansiedad (secundaria a los cambios progresivos que se van generando en el paciente), se evitan las falsas expectativas o esperanzas (en relación con tratamientos curativos de la enfermedad) y, al mismo tiempo, permite que el cuidador sea capaz de reconocer los síntomas y los cambios producidos en las diferentes fases del alzheimer, con el fin de buscar el apoyo oportuno, así como participar en las consultas médicas de manera más activa siendo capaz de expresar sus dudas. en relación con el enfermo, el cuidador necesita fortalecer su habilidad de cuidado (conocimiento, valor y paciencia) a lo largo de la tarea que lleva a cabo (22). en este ámbito, es importante que el profesional de enfermería le indique al cuidador la mejor manera de llevar a cabo las actividades de la vida diaria (avd), a utilizar de forma óptima los recursos disponibles en el hogar para ofrecer el cuidado, a mantener la seguridad en el hogar en cada tarea, a manejar estratégicamente las conductas y los comportamientos del paciente (tales como agresividad, vagabundeo, alucinaciones, apatía, problemas de sueño o de comunicación), y a sobrellevar la falta de reconocimiento (por parte del paciente) de miembros de su familia y del propio cuidador que en muchos casos suele ser dolorosa para toda la familia. con respecto a la disponibilidad de recursos, es importante que el profesional de enfermería pueda orientar al cuidador fa72 año 12 vol. 12 nº 1 chía, colombia abril 2012 aquichan issn 1657-5997 miliar con información sobre centros día, servicios domiciliarios, programas de cuidadores, hogares o residencias de cuidado y asociaciones de pacientes que estén disponibles. en este punto es importante enfatizar que si la familia y el cuidador optan por alguno de estos servicios, debe mantenerse el contacto con él, seguir su evolución y sostener los vínculos familiares evitando el olvido de su ser querido. asimismo, es importante que el apoyo de enfermería desde este ámbito esté disponible también con estrategias como el uso de las tecnologías de la información y la comunicación (tic) que sirvan para acortar las distancias entre cuidadores familiares y profesionales de enfermería y, más aún, en situaciones demenciales como el alzheimer donde las oportunidades de dejar al paciente solo en casa pueden dificultarse para el cuidador (57). es importante el autocuidado. en este ámbito el profesional de enfermería debe centrarse en el reconocimiento por parte del cuidador de su nuevo rol y de las implicaciones tanto positivas como negativas que pueden generarse como consecuencia de esta labor, y la forma de abordarlas. la enfermera(o) debe dar a conocer al cuidador sus derechos, instarlo al reconocimiento de sus propias necesidades y de síntomas de dolor, tristeza, insomnio, cansancio o estrés de forma oportuna, apoyarlo en el establecimiento de estrategias de acción para la disminución de la sobrecarga física, psicológica y social, para lo cual una de las estrategias más efectivas consiste en el fortalecimiento de estilos de vida saludables en áreas nutricionales, de actividad física, de manejo del estrés, de asistencia médica y de soporte interpersonal para el mantenimiento de su salud. igualmente, es importante que el cuidador familiar sea capaz de delegar sus tareas de cuidado en otros miembros de la familia y que tenga tiempo para sí mismo, por lo cual se busca que, en la medida de lo posible, otros miembros de la familia también se informen y se capaciten en las tareas de cuidado de la persona con alzheimer. conclusiones las situaciones de cronicidad como las experimentadas con la enfermedad de alzheimer son de interés para enfermería en la medida en que comprometen todas las dimensiones del ser humano, su calidad de vida y su salud. la calidad de vida es considerada como un proceso dinámico y cambiante que incluye interacciones continuas entre el cuidador y su medioambiente. de acuerdo con este concepto, la calidad de vida del cuidador del paciente con alzheimer es el resultado de la interacción del tipo de enfermedad que se padece y de su evolución, de la personalidad del cuidador, el grado de cambio que inevitablemente se produce en su vida, el soporte social recibido y percibido, y la etapa de la vida en que se produce la enfermedad en el paciente. la calidad de vida del cuidador familiar del paciente con alzheimer está dada tanto por condiciones objetivas como subjetivas, en las que enfermería tiene el potencial de participar. el trabajo de cuidador es una experiencia de compromiso, de tiempo y de paciencia que demanda habilidades y cualidades que son fundamentales en la realización de las actividades de la vida diaria con el familiar. sin embargo, los familiares cuidadores se pueden ver expuestos a alteraciones en su propio bienestar y calidad de vida debido a los cambios que han debido efectuar en su propio estilo de vida como consecuencia de las largas e intensas jornadas de cuidado, situaciones de estrés, altos grados de dependencia funcional y el deterioro progresivo de la persona con alzheimer a quien se cuida (51). la enfermedad de alzheimer y los síndromes relacionados generan fuertes consecuencias sociales y humanas para el paciente y su familia. además de las problemáticas relacionadas con la memoria y la pérdida de autonomía, la familia y el cuidador deben soportar los síntomas conductuales y psicológicos de la demencia, la cual genera un importante costo humano y la ayuda formal a menudo resulta insuficiente (3). enfermería tiene un papel importante en el mejoramiento del bienestar físico, psicológico, social y espiritual del cuidador familiar del paciente con alzheimer no solo desde la práctica clínica y comunitaria, sino desde los roles en educación, investigación y política pública. recomendaciones la intervención de enfermería en el caso de los cuidadores familiares de pacientes con alzheimer debe dirigirse a los ámbitos de la práctica, la educación, la investigación en enfermería y la política pública. para la práctica, el cuidado de enfermería al cuidador familiar debe centrarse en cuatro áreas específicas: la información y edu73 aporte de enfermería a la calidad de vida del cuidador familiar del paciente con alzheimer l lina maría vargas-escobar cación sobre la enfermedad de alzheimer, el cuidado del enfermo, los recursos de apoyo disponibles y el cuidado de sí mismo. en la educación superior de enfermería es importante incluir núcleos temáticos que aborden de forma reflexiva la experiencia de vivir con una enfermedad crónica como el alzheimer, y la forma de abordar estas situaciones para el paciente y su cuidador. igualmente, deben generarse espacios de educación continuada que capaciten a los profesionales de enfermería en la temática y generen iniciativas de cambio en las instituciones con la creación y el fortalecimiento de programas en este aspecto. en la investigación es importante la exploración de aspectos propios del cuidado en el hogar del cuidador, la forma en que el cuidador aprende a cuidar, sus creencias en torno a las prácticas de cuidado y la forma en que cuida de sí mismo para lo cual serían útiles los abordajes de tipo cualitativo. igualmente, debe avanzarse en investigación que muestre los resultados de estrategias de intervención específicas para este grupo poblacional. en la política pública es importante que enfermería participe en la creación de una ley que brinde atención especial a las personas en condición de enfermedad crónica y a sus cuidadores familiares, en la cual se reconozcan sus derechos y se les dé el apoyo y la orientación necesarias para afrontar el cuidado. lo anterior considerando que gran parte de los costos y la asistencia de las personas con alzheimer y otras enfermedades crónicas es asumida en la actualidad por la familia. es necesario que en colombia se realice un diagnóstico real del impacto de enfermedades demenciales como el alzheimer con el fin de determinar su situación actual y los costos sociales y económicos que está generando. lo anterior, considerando que no existen registros unificados ni documentación actualizada que evidencie la magnitud de la enfermedad de alzheimer en el país. este análisis puede conducir a procesos de mejoramiento en la atención a pacientes y cuidadores familiares en todos los niveles de atención, en donde los recursos sean destinados para suplir las verdaderas necesidades de este grupo poblacional y generar de esta manera soluciones más reales y efectivas. referencias bibliográficas 1. barrera l, pinto n, sánchez b, carrillo g, chaparro l. el enfermo crónico y su cuidador familiar. en: cuidando a los cuidadores 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(2014). expectativas laborales y empleabilidad en enfermería y psicología. aquichan. vol. 14, no. 1, 67-78. resumen objetivo: describir la empleabilidad de los estudiantes de las carreras de enfermería y psicología respecto a la búsqueda, obtención y expectativas de un trabajo. materiales y métodos: estudio descriptivo, transversal, en estudiantes universitarios de la universidad autónoma del estado de morelos (uaem, cuernavaca, méxico), de las carreras de enfermería y psicología; el universo muestral fue de 1060 estudiantes, se obtuvo una muestra intencional de 297 estudiantes, 126 de enfermería y 171 de psicología; las variables estudiadas fueron: mercado de trabajo, futuro laboral, valoración de un empleo, aportación a la empresa u organización, perfil de trabajo ideal y variables sociodemográficas. se elaboró una encuesta para medir la variable dependiente. resultados: se observa un mayor predominio de mujeres (74,7 %); el 20,9 % de los graduados trabajan actualmente, de los cuales 18,1 % son psicólogos/as y 24,3 % enfermeros/as (71 % mujeres). en lo referente a la valoración de un empleo, aportación a la empresa u organización y perfil de trabajo ideal, los estudiantes de la carrera de enfermería muestran mejores puntajes que los de psicología. conclusión: la empleabilidad es un constructo complejo, la formación profesional debe valorar en qué medida su perfil de egreso permite satisfacer las demandas del mercado laboral, que está sujeto a condiciones precarias de empleo, factores culturales, habilidades mostradas y potencial del factor humano. palabras clave empleo, estudiantes del área de la salud, estudiantes de enfermería, psicología, educación profesional, enfermería (fuente: decs, bireme). 68 aquichan issn 1657-5997 año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 67-78 job prospects and employability in nursing and psychology abstract objective: describe the employability of students majoring in nursing and psychology with respect to their job expectations and success in finding work. materials and methods: this is a descriptive, cross-sectional study conducted among nursing and psychology students at the autonomous university of the state of morelos (uaem) in cuernavaca, mexico. the sampling universe was comprised of 1,060 students, and a purposive sample of 297 students was obtained: 126 who are majoring in nursing and 171 in psychology. the variables studied include the job market, employment future, job appreciation, contribution to the company or organization, ideal job profile and socio-demographic variables. a survey was developed to measure the dependent variable. results: a higher prevalence of women (74.7%) was observed; 20.9 % of the graduates are currently employed; 18.1% of those who are working are psychologists and 24.3% are nurses (71% women). as for job appreciation, contribution to the company or organization and ideal job profile, the students majoring in nursing had better scores than those majoring in psychology. conclusion: employability is a complex construct. professional training should assess to what extent the graduate’s profile coincides with the demands of the job market, which is subject to precarious employment conditions, cultural factors, demonstrated skills and the potential of the human factor. key words employment, students, health occupations, students, nursing, psychology, education, professional, nursing (source: decs, bireme). 69 expectativas laborales y empleabilidad en enfermería y psicología l francisco paz-rodríguez, norma betanzos-díaz, noemí uribe-barrera expectativas laborais e empregabilidade em enfermagem e psicologia resumo objetivo: descrever a empregabilidade dos estudantes dos cursos de enfermagem e psicologia a respeito da procura, obtenção e expectativas de trabalho. materiais e métodos: estudo descritivo, transversal, em estudantes universitários da universidade autônoma do estado de morelos (uaem, cuernavaca, méxico), dos cursos de enfermagem e psicologia. o universo da amostra foi de 1.060 estudantes; obteve-se uma amostra intencional de 297 estudantes, 126 de enfermagem e 171 de psicologia; as variáveis estudadas foram: mercado de trabalho, futuro laboral, valorização de um emprego, contribuição para a empresa ou organização, perfil de trabalho ideal e variáveis sociodemográficas. elaborou-se uma enquete para medir a variável dependente. resultados: observa-se um maior predomínio de mulheres (74,7 %); 20,9 % dos formados trabalham atualmente, dos quais 18,1% são psicólogos/as e 24,3 % enfermeiros/as (71 % mulheres). quanto à valorização de um emprego, contribuição para a empresa ou organização e perfil de trabalho ideal, os estudantes do curso de enfermagem mostram melhores pontuações do que os de psicologia. conclusão: a empregabilidade é um constructo complexo; a formação profissional deve valorizar em que medida seu perfil de egresso permite satisfazer as demandas do mercado laboral, que está sujeito a condições precárias de emprego, fatores culturais, habilidades mostradas e potencial do fator humano. palavras-chave emprego, estudantes de ciências da saúde, estudantes de enfermagem, psicologia, educação profissionalizante, enfermagem (fonte: decs, bireme). año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 67-78 70 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 introducción sin duda el trabajo es una actividad que aporta grandes beneficios a las personas entre los que se encuentran el darle estructura y sentido a la vida, estatus, prestigio, identidad personal y laboral, ganar dinero, mantener una dependencia económica, oportunidad de interacción social, estructura del tiempo, adquisición de habilidades y destrezas en el trabajo, socializar, transmitir normas, creencias y expectativas sociales, obtención de poder, control y disfrute de la actividad laboral (1). se trata de una relación dialéctica entre hombre y naturaleza, en la cual la transformación de uno redunda en la del otro, y viceversa. el trabajo también presupone la relación con otros hombres y puede ser comprendido como un esfuerzo colectivo, en el cual todos tendrían que participar (2). el tener un trabajo es la meta a la que todo estudiante de nivel universitario aspira, lo cual se ha vuelto uno de los aspectos más difíciles de alcanzar para una gran mayoría de jóvenes en muchos países del mundo. en 2012 hay en el mundo casi 75 millones de jóvenes desempleados, 4 millones más que en 2007, y más de 6 millones han abandonado la búsqueda de un puesto de trabajo. más de 200 millones de jóvenes están trabajando pero ganan menos de 2 dólares de los estados unidos por día. el empleo informal entre los jóvenes sigue ganando terreno (3). así, mientras en las escuelas y las universidades se forma a los jóvenes para desempeñarse en diversas disciplinas, el mercado de trabajo exige otras prioridades sobre las habilidades de los trabajadores que parecen no empatar entre sí. esta situación ha generado diversos problemas para los jóvenes, tales como una dependencia prolongada de su familia de origen, no contar con recursos propios, aplazamiento de su ingreso al mercado laboral, y dejar de lado proyectos personales (4). los jóvenes abandonan los hogares paternos a edades más avanzadas, ya que en muchas ocasiones la autonomía adulta se produce en grupos de edad en torno a los 40 años. en este contexto, el concepto de juventud ha evolucionado con la prolongación de este periodo, debido a la escasez de empleo y la ampliación del tiempo de formación (5). ante este panorama muchos de los jóvenes optan por aceptar ofertas de empleo muy por debajo de su formación profesional, vincularse a trabajos no acordes con su profesión o aceptar empleos precarios que pueden ser temporales, de tiempo parcial, trabajar por su cuenta o en la informalidad. trabajos todos estos que no cumplen con las expectativas de los jóvenes ni les permiten alcanzar una buena calidad de vida, ni su completa integración al mundo laboral. este sector de jóvenes desarrolla inseguridad hacia el futuro y pérdida de horizontes, no perciben en el futuro una meta en la cual pueden centrarse positivamente (6). igualmente, se presenta otro fenómeno como es la posescolarización, que lleva a los jóvenes a optar por estudiar maestrías y doctorados (7) que les permiten, en muchos casos, acceder a una beca que cubre sus necesidades económicas a corto plazo y postergan su inserción laboral para adquirir mayores habilidades y conocimientos. por otra parte, el mercado laboral marca una gran diferencia en la contratación de jóvenes dependiendo de la carrera profesional estudiada pues algunas son altamente demandadas por las organizaciones y, por ello, en ciertas carreras hay mayor probabilidad de formar parte de los desempleados. de acuerdo con el observatorio laboral de la secretaría del trabajo y previsión social (stps) de méxico, al segundo trimestre de 2012 el número de profesionales ocupados en el país era de 6,6 millones de personas. el porcentaje de mujeres profesionales ocupadas con respecto al total era de 42,4 %. las áreas donde las mujeres representan a más de la mitad del total de profesionales ocupados son: humanidades, educación, ciencias de la salud y artes. en las carreras con mayor demanda los egresados tienen más facilidades para conseguir empleo y mejores sueldos; sin embargo, esta es una ventaja aparente pues no se debe olvidar que se ha incrementado también el número de estudiantes en todas las profesiones y, por tanto, existe una fuerte competencia para todos los puestos vacantes. como ejemplo, la psicología y la enfermería ocupan el séptimo y doceavo lugar de 76 profesiones nacionales, en cuanto a ingreso promedio nacional ocupan los lugares 48 y 55. en ambas profesiones las mujeres se encuentran bien representadas pues son un 75,5 y 89 % de las profesionales ocupadas. el porcentaje de profesionales con trabajo no acorde con sus estudios es 49,9 y 13,6 % en estas carreras (8). 71 expectativas laborales y empleabilidad en enfermería y psicología l francisco paz-rodríguez, norma betanzos-díaz, noemí uribe-barrera un estudio realizado en universitarios españoles reporta que existe preocupación por el futuro laboral y que será difícil o muy difícil encontrar un buen trabajo donde se pueda desarrollar la actividad profesional relacionada con su formación. (9). cabría preguntarse si existen habilidades comunes para todas las profesiones que permitan a los estudiantes y egresados lograr una inserción al mercado de trabajo. sin duda son fundamentales los conocimientos que cada profesional adquirió en su formación universitaria pero también se debe contar con una serie de competencias y habilidades que hacen la diferencia entre contratar a un joven egresado sobre otros. con este fin, en esta investigación se diseñó un instrumento para medir la empleabilidad. se utilizó como base la investigación “compromiso laboral de los universitarios. diagnóstico comparativo 2008/2009”, la cual analizó el nivel de compromiso y las expectativas laborales en 3.006 universitarios españoles del último curso de carrera y recién titulados. desde el punto de vista de la psicología organizacional se buscó describir qué tan empleables se consideran los estudiantes de las carreras de psicología y enfermería en cuanto a la búsqueda, obtención y expectativas de un trabajo, respecto a las necesidades que les marca el mercado laboral. materiales y métodos participantes en este trabajo participaron estudiantes universitarios de la uaem, de las carreras de enfermería y psicología, el universo muestral fue de 1060 estudiantes, la muestra fue de 297 estudiantes universitarios (75 hombres y 222 mujeres); 57,6 % de los participantes pertenecían a la facultad de psicología y el 42,4 % a la facultad de enfermería. la media de edad de los participantes fue 22,21 (desviación típica dt = 3,64), con un rango de 18 a 49 años; el 48,5 % eran pasantes. instrumento a continuación se detallan las características de los cuestionarios y las propiedades psicométricas más relevantes de los instrumentos de evaluación. características sociodemográficas. se creó un formato que incluyó sexo, edad, año universitario que se cursa, estado civil, con quién vive, escolaridad de los padres y si tenía dependientes económicos. empleabilidad mercado de trabajo. se exploró si el estudiante contaba con trabajo, desde hacía cuánto tiempo, tipo de contrato, si recibía prestaciones y salario mensual. futuro laboral. se utilizaron tres reactivos referentes a la planeación de su futuro laboral: ¿piensas buscar un empleo? ¿te preocupa tu futuro laboral? ¿consideras urgente buscar trabajo?, con opciones de respuesta dicotómica cerrada (sí/no). dos reactivos referentes a la dificultad y probabilidad de trabajar en la profesión: ¿qué grado de dificultad crees que tendrías para encontrar un trabajo bien pagado? ¿en qué medida consideras probable que llegues a desarrollar una actividad profesional relacionada con tu profesión? medida tipo likert que va de “muy difícil” (1 punto) a “ninguna dificultad” (5 puntos), para el primer reactivo, y de “poco probable” (1 punto) a “estoy seguro” (4 puntos) en el segundo reactivo. finalmente, se preguntó qué harán una vez finalizados los estudios. valoración de un empleo y aportación a la empresa. el instrumento se centra en dos aspectos del trabajo; por un lado, lo que valora el profesional en una oferta de trabajo, se trata de afirmaciones relacionadas con la posibilidad de desarrollo, trabajo interesante, aprendizaje y formación, equilibrio entre la vida personal y profesional, buen ambiente de trabajo, promoción, buen sueldo, seguridad, horario cómodo, proyección, prestigio y cercanía al domicilio. consta de 13 reactivos tipo likert de 10 puntos. los valores obtenidos mediante el alpha de cronbach fueron de 0,844. por otro lado se analiza lo que aporta el profesional al trabajo, se trata de cuestiones como: ser capaz de orientar a los demás, prestar un servicio, innovar o experimentar, tener independencia / autonomía, alcanzar el éxito, sentir que aporto / ser útil, superarse constantemente / tener retos, conocer nuevas situaciones y experiencias, aceptación, integración con el grupo y tener buenas relaciones, aprendizaje, reconocimiento y prestigio por lo que se hace. se trata de 14 reactivos tipo likert de 10 puntos. los valores reportados mediante el alpha de cronbach fueron de 0,864. perfil del trabajo ideal. se trata de 14 preguntas relacionadas con lo que consideran un buen trabajo. se evalúa indicando “sí” o “no” según del grado de acuerdo con la afirmación. está conformado por situaciones como: trabajar en un puesto donde 72 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 tenga que dirigir a los demás en lugar de ser dirigido; que permita ejercer la profesión aunque el sueldo sea más bajo; estar en una empresa innovadora, creativa y en continuo cambio, aunque tenga poca seguridad laboral a futuro; un trabajo que permita viajar; que pueda realizarlo conjuntamente con otros; que le permita seguir estudiando; que pueda continuar y desarrollar la vida profesional; donde tenga responsabilidades y dé cuenta de lo que se hace; que deje tiempo libre aunque el sueldo no sea muy bueno. método y técnica estudio mediante encuesta, con el objetivo de describir las características de empleabilidad de los estudiantes de la uaem de las carreras de psicología y enfermería. se informó a los estudiantes la naturaleza de la investigación y se pidió su participación voluntaria. todos firmaron una carta de consentimiento informado. los cuestionarios se aplicaron en una sola sesión en las aulas de la uaem. el tiempo promedio para completar el cuestionario fue de 20 minutos, siempre fue administrado por psicólogos capacitados en la aplicación de este instrumento. posteriormente se procedió a calificar los cuestionarios y codificar en una base de datos los resultados de los mismos. análisis estadísticos para describir los datos sociodemográficos y de empleabilidad se calcularon frecuencias (f), porcentajes, medidas de tendencia central (media m) y dispersión (dt). la fiabilidad de los instrumentos se analizó a través del alpha de cronbach. el análisis estadístico se realizó por medio de comparaciones entre las carreras por medio de chi cuadrado y pruebas t de student. resultados características sociodemográficas en la tabla 1, al comparar las carreras por sexo, se observa un mayor predominio de mujeres. ambas carreras continúan siendo altamente feminizadas, de manera general observamos un 25,3 % de hombres y 74,7 % mujeres, con una edad promedio de 22,2 años (de 3,6), el 48,5 % son pasantes o graduados. en lo referente a su estado civil el 90,2 % son solteros; las madres de las psicólogas tienen una mayor educación que las madres de las enfermeras (11,1 vs. 9,7, t (288) = 2.830; p = 0,003), y sucede lo mismo con los padres (12,1 vs. 10,1, t (294) = 2.868; p = 0,001). en lo referente a los dependientes económicos las enfermeras muestran un mayor porcentaje de estos (14,3 vs. 6,4, x2 (1) = 5.078; p = 0,024). empleabilidad mercado de trabajo. del total de estudiantes encuestados un 20,9 % (62) trabajan actualmente, de los cuales 18,1 % (31) son psicólogas y 24,3 % (31) enfermeras, 71 % (44) mujeres. tienen una antigüedad desde 1 y hasta 132 meses (m 18; dt 24 meses). el 22,6 % tiene contrato de planta y el 54,8 % tiene horario fijo, un 83,9 % no recibe prestaciones, en el 62,9 % su trabajo no se relaciona con la profesión que estudian (58,1 % psicología y 67,7 % enfermería) y en el 79 % de los casos reciben menos de $3.000,00 pesos ($ 225,00 dólares) por esta labor. búsqueda de empleo. a la pregunta sobre si han buscado empleo en los últimos seis meses un 40,1 % (119) respondió afirmativamente, siendo 73,9 % (88) mujeres. en un 51,3 % (61) el trabajo buscado estaba relacionado a la carrera (58,1 % psicología y 67,7 % enfermería). al preguntar sobre si pensaban buscar algún empleo en los siguientes seis meses un 69,4 % respondió que sí. de estos, un 71,4 % lo buscarían relacionado con la carrera que estudiaban (62,3 % psicología y 82,6 % enfermería). futuro laboral. en lo referente a si les preocupa su futuro laboral solo el 8,1 % responde de forma negativa. el 56,9 % considera urgente buscar trabajo, un 30,3 % piensa que tendrá dificultad para encontrar un trabajo bien pagado, y el 60,6 % considera que es muy probable que encuentre un trabajo relacionado con su profesión. en cuanto a lo que harán una vez terminados los estudios; el 31,8 % buscará trabajo en el gobierno o sector público, el 20,6 % planea realizar una maestría o doctorado, un 19,9 % piensa buscar trabajo en la iniciativa privada, un 8,4 % trabajará por su cuenta o creará una empresa, el 8,4 % realizará otros estudios, un 5,4 % buscará prácticas en otro lugar, el 3,7 % viajará y un 1,7 % no piensa hacer nada. valoración de un empleo y aportación a la empresa u organización en la tabla 2 se muestran los puntajes de estudiantes hacia la valoración de un empleo, apreciándose diferencias en aspectos económicos entre los estudiantes de enfermería y psicología, específicamente en el sueldo (9,77 vs. 9,29, t (285) = 5.059; p 73 expectativas laborales y empleabilidad en enfermería y psicología l francisco paz-rodríguez, norma betanzos-díaz, noemí uribe-barrera = 0,001) y seguridad laboral (9,77 vs. 9,09, t (231) = 6.478; p = 0,001). también las hay relacionadas con las características de la empresa: prestigio (8,98 vs. 8,05, t (292) = 5.294; p = 0,001), ambiente (9,45 vs. 9,07, t (292) = 3.158; p = 0,002) y misión (9,02 vs. 7,99, t (293) = 5.640; p = 0,001). así como diferencias de carácter profesional: trabajo interesante (9,44 vs. 9,22, t (295) = 1.954; p = 0,052), desarrollo (9,42 vs. 9,05, t (283) = 2.852; p = 0,005) y promoción (9,17 vs. 8,84, t (247) = 2.079; p = 0,039). en la tabla 3 se reportan las diferencias entre enfermería y psicología sobre la aportación al trabajo. en cuestiones relacionadas con la orientación (9,17 vs. 8,70, t (295) = 3.321; p = 0,001), el servicio (9,56 vs. 8,89, t (289) = 5.394; p = 0,001), las buenas relaciones (9,22 vs. 8,65, t (268) = 3.338; p = 0,001), ver el trabajo como reto (9,71 vs. 9,39, t (232) = 2.902; p = 0,004) y el aprendizaje (9,74 vs. 9,49, t (294) = 2.921; p = 0,004), así como la integración al grupo (9,03 vs. 8,46, t (247) = 2.864; p = 0,005), aceptación (8,45 vs. 7,94, t (252) = 2.140; p = 0,033), prestigio (9,17 vs. 8,78, t (264) = 2.148; p = 0,033) y reconocimiento (8,69 vs. 8,20, t (242) = 2.062; p = 0,040). perfil del trabajo ideal en la tabla 4 se reporta lo que los estudiantes consideran un trabajo ideal, observamos diferencias entre enfermería y psicología en lo referente a trabajar donde puedan ejercer la profesión aunque el sueldo sea bajo (14,3 vs. 37,1, x2 (1) = 18.881; p = 0,001), se pueda continuar y desarrollar la profesión (58,7 vs. 97,1, x2 (1) = 68.782; p = 0,001), donde se tenga tiempo libre aunque el sueldo no sea bueno (13,5 vs. 42,1, x2 (1) = 28.301; p = 0,001), observando porcentajes más altos entre los psicólogos. por otra parte, situaciones de trabajo donde este se realice en equipo (92,9 vs. 77,2, x2 (1) = 13.137; p = 0,001), que haya responsabilidad y se dé cuenta de lo que se hace (89,7 vs. 78,9, x2 (1) = 6.069; p = 0,014), y que se permita seguir estudiando (97,6 vs. 91,2, x2 (1) = 5.205; p = 0,023), las enfermeras reportan los porcentajes más altos. análisis y discusión los resultados coinciden con los datos reportados por los universitarios españoles, los estudiantes se preocupan por su futuro laboral y consideran que le será difícil o muy difícil encontrar un buen trabajo donde pueda desarrollar la actividad profesional relacionada con su formación. aun cuando la evidencia no permite establecer la empleabilidad de este grupo de profesionales, se pudo observar que las condiciones de empleo que tienen no son las más adecuadas para asegurar las oportunidades de trabajo. en morelos, el 39,2 % de mujeres corresponde a población económicamente activa (pea), de estas el 46,3 % son profesionales. de acuerdo con la encuesta nacional de ocupación y empleo durante el 2010 un 17,7 % se desempeñaban como profesionales (9). como en el resto del país, el acceso al mercado laboral depende de factores culturales y económicos, así como de las características que asume la demanda de la mano de obra. aun cuando enfermería y psicología han tenido una demanda e incremento notable en su matrícula en los últimos años el déficit de empleos es notorio. a pesar de esto, la mayoría piensa buscar trabajo en los sectores público y privado, llama la atención que el 20 % buscará seguir estudiando una maestría o doctorado, presentándose el fenómeno de posescolarización (7). las diferencias observadas en la muestra estudiada, independientemente de sus variaciones, están relacionadas con situaciones como periodos de reproducción o de enfermedad, tener responsabilidades universitarias y laborales de manera simultánea, así como deficiencias pedagógicas como la detección de necesidades y demandas de la profesión (10). lo anterior ha dado como resultado que los egresados no cuenten con el “saber hacer” suficiente para resolver problemas en su área de competencia profesional (11). conclusiones la formación profesional de los estudiantes debe valorar en qué medida su perfil de egreso permite satisfacer las demandas del mercado laboral; sin embargo, es poca la investigación al respecto (12). se puede observar la consistencia en la formación y la función entre las profesiones, como realizar un trabajo interesante y gratificante que les haga sentirse útiles y que aportan a los demás, con aprendizaje y formación continuos, conocer nuevas situaciones y experiencias, integrarse en el grupo y conciliar la vida personal y profesional. los egresados prefieren un trabajo que les permita seguir estudiando, asumir responsabilidades, tomar decisiones y trabajar en equipo. les atraen las empresas innovadoras en las que deban ser creativos y puedan asumir retos, aunque sea a costa de una menor seguridad de futuro. están dispuestos a cobrar menos si a cambio pueden ejercer su profesión o tener más tiempo libre. más de la mitad 74 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 quiere trabajar en una empresa en la que pueda desarrollar toda su vida profesional. por otro lado, las habilidades para realizar funciones de liderazgo o de coordinación de equipos de trabajo, creación de empresas y el trabajo por cuenta propia obtienen puntuaciones más bajas. estas respuestas y las de los otros reactivos muestran que la actuación con responsabilidad está presente en la atención de los pacientes, en la seguridad de estos y en la toma de decisiones, lo que es acorde con el perfil del egresado establecido en el plan de estudio de las carreras estudiadas, donde los contenidos son más informativos que formativos, pues se centran en la adquisición de conocimientos y dejan en segundo plano el desarrollo de habilidades congruentes con el ejercicio profesional de los egresados (11). a diferencia de los universitarios españoles la movilidad no es uno de sus intereses, y la seguridad en el puesto de trabajo figura entre sus primeras prioridades. además, la posibilidad de mantener la retribución tiene, para los jóvenes, más importancia que el equilibrio entre la vida personal y profesional a la hora de valorar una oferta de trabajo, situación que se explica por las condiciones laborales que prevalecen actualmente en méxico, donde el mercado de trabajo profesional es reducido para la mayoría de las profesiones. aquí se considera la demanda real del mercado que hace énfasis en ciertas habilidades que debe mostrar el trabajador de acuerdo con aspectos de cierto sector y, por tanto, evidencia un déficit en capital humano. así, las necesidades de crecimiento en ciertos campos o actividades económicas llevan a afirmar que se emplea a los que son requeridos en las organizaciones de acuerdo con su perfil laboral y no necesariamente a los mejor preparados o más capacitados (13). sin embrago, existe una preocupación por elevar la calidad del desempeño de los egresados, no solo por lo valioso que ello resulta, sino también por las graves repercusiones que un mal desempeño tiene en un campo tan sensible como lo es la salud (14). por otro lado, es cada vez más frecuente que las empresas seleccionen a sus futuros empleados teniendo en cuenta su potencial más que sus conocimientos. aunque no cabe duda que una sólida preparación académica es indispensable para desarrollar adecuadamente la profesión, las habilidades y competencias desarrolladas por el estudiante influyen en su desarrollo profesional, pues comprende los aspectos que una persona enriquece o mejora con vistas a lograr objetivos, implica crecer como individuo y realizarse en su trabajo como una necesidad inherente al ser humano. se inicia en cada persona por su disposición a lograr metas y por la aceptación de responsabilidades que ello conlleva. estos datos evidencian que la empleabilidad es un constructo complejo, multidimensional, que tiene que ver con la obtención y el mantenimiento de un trabajo, y que depende de la decisión de buscar un empleo, de las características de la persona, el desarrollo de habilidades, la valoración de sus propias capacidades y del mercado laboral (15). referencias 1. salanova m, gracia fj, peiró jm. significado del trabajo y valores laborales. en: peiró jm, prieto f., directores. tratado de psicología del trabajo. volumen ii: aspectos psicosociales del trabajo. madrid: síntesis; 1996. 2. da rosa s, chalfin m, baasch d, soares j. sentidos y significados del trabajo: un análisis con base en diferentes perspectivas teórico-epistemológicas en psicología. univ psychol. 2011;10(1),175-188. 3. organización internacional del trabajo. la crisis del empleo juvenil: un llamado a la acción. resolución y conclusiones de la 101 reunión de la conferencia internacional del trabajo, ginebra [serial on line] 2012. [visitado 2013 mayo 17]. disponible en: www.ilo.org/wcmsp5/groups/public/---ed_norm/---relconf/documents/meetingdocument/ wcms_187080.pdf 4. pinochet cobos c, gerber-bicecci v. estrategias creativas y redes en las artes visuales. en: garcía-canclini n, castropozo m. cultura y desarrollo: una visión distinta desde los jóvenes. serie avances de investigación, 65. carolina; 2011. 5. martínez-rodríguez f. el proceso de inserción laboral: implicaciones educativas para la mejora de la empleabilidad. rev complut educ. 2009;20(2):455-471. 75 expectativas laborales y empleabilidad en enfermería y psicología l francisco paz-rodríguez, norma betanzos-díaz, noemí uribe-barrera 6. pérez-moreno a. los jóvenes y su participación educativa y laboral. méxico: universidad autónoma del estado de morelos; 2008. 7. moral-jiménez m. preparación para el trabajo de los jóvenes contemporáneos en una sociedad postindustrial: trabajo, educación y globalización. ese. 2007;13:171-194. 8. subsecretaría de empleo y productividad laboral, morelos. información laboral, abril 2013. morelos: secretaría del trabajo y prevención social; 2013. 9. fundación universidad-empresa. informe: compromiso laboral de los universitarios. diagnóstico comparativo 2008/2009. fundación universidad-empresa; 2010. p. 1-20. 10. nigenda g, ruiz ja, rosales y, bejarano r. personal de enfermería con licenciatura en méxico: valoración del desperdicio en su formación y en el mercado de trabajo. salud pública méx. 2006;48:22-29. 11. zanatta ce, yuren ct. la formación profesional del psicólogo en méxico: trayecto de la construcción de su identidad disciplinar. enseñanza e investigación en psicología. 2012;17(1):151-170. 12. cabrera r, hickman h, mares g. perfil profesional del psicólogo requerido por empleadores en entidades federativas con diferente nivel socioeconómico en méxico. enseñanza e investigación en psicología. 2010;15(2):257-271. 13. balseiro-almario cl, zárate-grajales ra, matus-miranda r, balan-gleaves c, sacristán-ruiz f, garcía-cardona m, et al. inserción laboral, desarrollo profesional y desempeño institucional de las (os) egresadas (os) del plan único de especialización en enfermería de la eneo-unam: una experiencia de doce años. enfermería universitaria. 2012;9(1):16-26. 14. rodríguez cuba. índice de empleabilidad de los jóvenes. serie avances de investigación 32. fundación carolina. cealsi; 2009. 15. rentería-pérez e, malvezzi s. empleabilidad, cambios y exigencias psicosociales en el trabajo. univ psychol. 2008;7(2):319-334. 76 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 tabla 1. características sociodemográficas de estudiantes universitarios de las carreras de enfermería y psicología de la uaem enfermería psicología total chi sig126 171 297 cuadrado n % n % n % sexo masculino 23 18,3 52 30,4 75 25,3 5,679 0,017 femenino 103 81,7 119 69,6 222 74,7 edad 22,16 3,49 22,24 3,76 22,21 3,64 0,191 0,848 grado de estudios 1-4 sem. 50 39,7 53 31,0 103 34,7 2,696 0,260 5-7 sem. 18 14,3 32 18,7 50 16,8 pasante 58 46,0 86 50,3 144 48,5 religión católica 81 64,3 80 46,8 161 54,2 23,347 0,001 otra1 24 19,0 18 10,5 42 14,1 ninguna 21 16,7 73 42,7 94 31,6 estado civil soltero(a) 108 85,7 160 93,6 268 90,2 8,991 0,029 casado(a) 8 6,3 9 5,3 17 5,7 divorciado 1 0,8 0 0,0 1 0,3 unión libre 9 7,1 2 1,2 11 3,7 vives con padres y hermanos 90 71,4 132 77,2 222 74,7 3,085 0,687 familiares 12 9,5 12 7,0 24 8,1 solo(a) 6 4,8 7 4,1 13 4,4 amigos 5 4,0 9 5,3 14 4,7 pareja e hijos 9 7,1 9 5,3 18 6,1 esposa/suegros 4 3,2 2 1,2 6 2,0 tiene hijos sí 18 14,3 11 6,4 29 9,8 5,078 0,024 no 108 85,7 160 93,6 268 90,2 cuántos (m;ds) 1,3 0,65 1,2 0,43 1,2 0,51 0,230 0,821 escolaridad madre (m;ds) 9,7 3,5 11,1 4,2 10,5 4,0 2,830 0,003 escolaridad padre (m;ds) 10,1 4,0 12,1 4,3 11,2 4,2 2,868 0,001 fuente: elaboración propia. 1. otra religión (testigo de jehová, cristiano, evangelista); b. prueba t de student; c. fisher test. 77 expectativas laborales y empleabilidad en enfermería y psicología l francisco paz-rodríguez, norma betanzos-díaz, noemí uribe-barrera tabla 2. situaciones que los estudiantes de las carreras de psicología y enfermería de la uaem valoran en una oferta de trabajo carrera enfermería psicología media desv. tip. media desv. tip. t sig. buen sueldo 9,77 0,609 9,29 1,010 5,059 0,001 seguridad en el puesto de trabajo 9,77 0,476 9,09 1,247 6,478 0,001 misión, valores y cultura de la empresa 9,02 1,386 7,99 1,734 5,640 0,001 prestigio de la empresa 8,98 1,359 8,05 1,662 5,294 0,001 buen ambiente de trabajo 9,45 0,960 9,07 1,120 3,158 0,002 posibilidad de desarrollo de la profesión 9,42 0,833 9,05 1,413 2,852 0,005 horario cómodo/vacaciones 9,15 1,272 8,73 1,430 2,666 0,008 cercanía al domicilio actual 8,02 2,128 7,37 2,049 2,633 0,009 posibilidades de aprendizaje y formación 9,33 1,144 9,04 1,183 2,130 0,034 posibilidades de promoción 9,17 1,465 8,84 1,273 2,078 0,039 proyección del trabajo desarrollado 8,91 1,529 8,56 1,329 2,068 0,040 trabajo interesante/gratificante 9,44 0,785 9,22 1,105 1,954 0,052 equilibrio entre la vida personal y profesional 9,40 1,020 9,17 1,376 1,634 0,103 tabla 3. aportación del profesional de la salud a un trabajo carrera enfermería psicología media desv. tip. media desv. tip. t sig. ser capaz de orientar a los demás 9,17 1,049 8,70 1,363 3,321 0,001 prestar un servicio a los demás 9,56 0,825 8,89 1,299 5,394 0,001 tener buenas relaciones con los demás 9,22 1,469 8,65 1,453 3,338 0,001 superarme constantemente/tener retos 9,71 1,005 9,39 0,800 2,902 0,004 aprender constantemente 9,74 0,635 9,49 0,822 2,921 0,004 integrarme en el grupo 9,03 1,789 8,46 1,558 2,864 0,005 sentirme aceptado por los demás 8,45 2,145 7,94 1,929 2,140 0,033 obtener prestigio en lo que hago 9,17 1,538 8,78 1,493 2,148 0,033 recibir admiración y reconocimiento 8,69 2,137 8,20 1,815 2,062 0,040 tener independencia/autonomía en mi trabajo 8,79 1,484 9,06 1,172 -1,708 0,089 alcanzar el éxito profesional 9,63 1,157 9,44 0,958 1,489 0,138 conocer nuevas situaciones y experiencias 9,49 1,115 9,35 0,878 1,177 0,240 sentir que aporto/sentirme útil 9,47 1,506 9,32 1,124 0,957 0,340 innovar o experimentar 9,02 1,196 8,96 1,214 0,458 0,647 78 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 tabla 4. perfil del trabajo ideal prefiero trabajar en una empresa donde: carrera chi cuadrado sig.enfermería psicología n % n % el trabajo haya de realizarse conjuntamente con otros empleados 117 77,2 132 92,9 13,137 0,001 pueda continuar y desarrollar mi vida profesional 74 58,7 166 97,1 68,782 0,001 me deje tiempo libre aunque el sueldo no sea muy bueno 17 13,5 72 42,1 28,301 0,001 me permita ejercer la profesión aunque el sueldo sea más bajo 18 14,3 63 37,1 18,881 0,001 tenga responsabilidad y dar cuenta de lo que se hace 113 89,7 135 78,9 6,069 0,014 me permita seguir estudiando 123 97,6 156 91,2 5,205 0,023 sea innovadora, creativa y, por tanto, tenga poca seguridad de un futuro 49 38,9 82 48,0 2,418 0,120 me permita viajar 100 79,4 122 71,3 2,416 0,172 tenga que dirigir a los demás en lugar de ser dirigido 72 57,1 93 54,4 0,223 0,637 473 484 validacion de un instrumento.indd 473 maría cecilia arechabala-mantuliz1 silvia cristina barrios-araya2 maría isabel catoni-salamanca3 eugenia eliana palma-castro4 yolanda ibacache celedón5 joanna andrea richards6 validación de un instrumento de medición de cuidados según dependencia y riesgo en pacientes en terapia de hemodiálisis crónica 1 enfermera. profesor titular, escuela de enfermería, pontificia universidad católica de chile. directora de la revista de la sociedad chilena de enfermería en diálisis y trasplante renal (senferdialt). marechab@uc.cl 2 enfermera. profesor asistente, escuela de enfermería, pontificia universidad católica. presidenta de la sociedad chilena de enfermería en diálisis y trasplante renal (senferdialt). sbarrios@uc.cl 3 enfermera-matrona. profesor titular, escuela de enfermería, pontificia universidad católica de chile. presidenta sociedad latinoamericana en enfermería nefrológica (slaen). mcatoni@uc.cl 4 enfermera. profesor asociado adjunto, escuela de enfermería, pontificia universidad católica de chile. miembro del comité editorial de la revista de la sociedad chilena de enfermería en diálisis y trasplante renal (senferdialt). epalma@med.puc.cl 5 enfermera. coordinadora clínica nacional diaverum chile. secretaria de la sociedad latinoamericana en enfermería nefrológica (slaen). yolanda.ibacache@diaverum.com 6 enfermera. enfermera integración / operaciones diaverum chile. secretaria de la sociedad chilena de enfermería en diálisis y trasplante renal (senferdialt). joanna.richards@diaverum.com recibido: 22 de noviembre de 2012 enviado a pares: 21 de enero de 2013 aceptado por pares: 14 de julio de 2013 aprobado: 11 de septiembre de 2013 doi: 10.5294/aqui.2014.14.4.3 para citar este artículo / to reference this article / para citar este artigo arechabala-mantuliz mc, barrios-araya sc, catoni-salamanca mi, palma-castro ee, ibacache-celedón y, richards j. validación de un instrumento de medición de cuidados según dependencia y riesgo en pacientes en terapia de hemodiálisis crónica. aquichan. 2014; 14 (4): 473-484. doi: 10.5294/aqui.2014.14.4.3 resumen los instrumentos de categorización de pacientes son útiles porque permiten asignar los profesionales y recursos materiales de acuerdo con el perfil real de los pacientes. el objetivo del presente estudio es adecuar y validar el instrumento “categorización de usuarios según dependencia y riesgo de cuidados” (cudyr) en hemodiálisis crónica (hdc). el instrumento para pacientes en hdc se denominó “cudyr-dial” y quedó constituido por dos subescalas y catorce ítems. la muestra estuvo conformada por 150 pacientes seleccionados en forma estratificada y al azar de cinco unidades de diálisis, a los que se les aplicó un total de 620 veces el cudyr-dial. se encontró que todos los ítems muestran correlaciones significativas (> 0,3) con el puntaje total obtenido en la escala, y que la confiabilidad de la escala se mantiene estable al ir eliminando uno a uno los ítems, fluctuando entre 0,86 y 0,87. la confiabilidad total del instrumento muestra un alfa de cronbach de 0,878. los usuarios en hdc presentan cuatro perfiles de dependencia (parcial a total) y riesgo (mediano a alto). se concluye que el instrumento cudyr-dial presenta una buena confiabilidad y constituye un aporte para la categorización de pacientes en hdc según dependencia y riesgo. palabras clave hemodiálisis, dependencia, riesgo, validación. (fuente: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 473-484 474 aquichan issn 1657-5997 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 473-484 validation of an instrument to measure care according to patient dependency and risk in chronic hemodialysis therapy abstract instruments to categorize patients are useful because they make it possible to allocate professionals and material resources according to the actual profile of the patient. the purpose of this study was to adapt and validate an instrument known as "categorizing users according to care dependency and risk” (cudyr) in chronic hemodialysis (chd). the instrument for patients in chd was called "cudyrdial" and was comprised of two subscales and fourteen items. the sample consisted of 150 patients from five dialysis units who were selected in a stratified manner, at random. the cudyr-dial instrument was applied to them a total of 620 times. all the items showed significant correlations (> 0.3) with the total score on the scale, and the reliability of the scale remained stable when the items were eliminated one by one, fluctuating between 0.86 and 0.87. the overall reliability of the instrument shows a cronbach’s alpha of 0.878. users in hdc fit four profiles in terms of dependency (partial to complete) and risk (medium to high). it was concluded the reliability of the cudyr-dial instrument is good and it represents a contribution to categorizing patients according hdc dependence and risk. key words hemodialysis, dependency, risk, validation. (source: decs, bireme). 475 validación de un instrumento de medición de cuidados según dependencia y riesgo en pacientes en terapia de hemodiálisis crónica l maría cecilia arechabala-mantuliz y otros validação de um instrumento de medição de cuidados segundo dependência e risco em pacientes em terapia de hemodiálise crônica resumo os instrumentos de categorização de pacientes são úteis porque permitem designar os profissionais e recursos materiais de acordo com o perfil real dos pacientes. o objetivo do presente estudo é adequar e validar o instrumento “categorização de usuários segundo dependência e risco de cuidados” (cudyr) em hemodiálise crônica (hdc). o instrumento para pacientes em hdc se denominou “cudyrdial” e ficou constituído por duas subescalas e quatorze itens. a amostra foi conformada por 150 pacientes selecionados em forma estratificada e aleatória de cinco unidades de diálise, aos quais foi aplicado um total de 620 vezes o cudyr-dial. constatou-se que todos os itens mostram correlações significativas (> 0,3) com a pontuação total obtida na escala, e que a confiabilidade da escala se mantém estável ao ir eliminando um a um os itens, flutuando entre 0,86 e 0,87. a confiabilidade total do instrumento mostra um alfa de cronbach de 0,878. os usuários em hdc apresentam quatro perfis de dependência (parcial a total) e risco (médio a alto). conclui-se que o instrumento cudyr-dial apresenta uma boa confiabilidade e constitui uma contribuição para a categorização de pacientes em hdc segundo dependência e risco. palavras-chave hemodiálise, dependência, risco, validação. (fonte: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 473-484 476 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 introducción la prevalencia de la enfermedad renal crónica terminal (erct) es mayor en las personas de la tercera edad, siendo diez veces más frecuente en los adultos mayores entre 65 y 75 años. para su tratamiento y control, las personas requieren de un procedimiento de sustitución renal (tsr) de por vida (1, 2). debido a la mayor esperanza de vida en muchos países, se ha incrementado la población mayor de 65 años que comienza con tsr cada año. de estos, el segmento que más ha aumentado es aquel de 75 años y más, los que en promedio tienen una sobrevida de 25 a 44 meses posterior al inicio de la terapia. lo anterior implica que en este grupo aumenta la dependencia funcional con el consecuente riesgo de hospitalización y la poca efectividad del tratamiento dialítico (3, 4, 2). en chile hay aproximadamente 14.070 pacientes en hemodiálisis crónica (hdc), que se dializan en 173 centros, con un promedio de 81,3 pacientes por centro (5). el 52 % de ellos tiene 61 años o más, y el 6 % es mayor de 81 años (5). asimismo, se sabe que en la medida que aumenta la edad se incrementa la comorbilidad, la que a su vez se asocia a mayor riesgo de muerte y dependencia (6). las características de los usuarios no solo tienen implicancias para ellos sino que también repercuten en los aspectos funcionales y estructurales de las unidades de hemodiálisis (uhd), específicamente en lo relacionado con el tipo y la frecuencia de cuidados que requieren los pacientes (1). como una forma de conciliar las características de los pacientes con la organización administrativa necesaria para dar respuesta a sus necesidades de cuidado, se han creado sistemas de clasificación de pacientes. estos son un elemento clave ya que permiten conocer el perfil de los usuarios, las necesidades de recursos humanos y materiales, la dinámica de la atención y los costos, de acuerdo con las características particulares de los pacientes y sus necesidades de cuidado (6). un estudio realizado por cobo et al. en el año 2008, cuyo objetivo era evaluar el grado de dependencia de los pacientes en hemodiálisis (hd) y analizar las necesidades de cuidado que requerían, mostró que el 50 % de ellos tenía algún grado de dependencia, y que alrededor del 70 % requería de cuidados de enfermería más especializados. estos se relacionaban principalmente con la presencia de catéteres venosos centrales y curaciones de úlceras, fístulas o heridas quirúrgicas (7). entre los instrumentos utilizados para evaluar la dependencia en pacientes en hdc se encuentra el test delta. este test consta de una escala principal que evalúa la dependencia total y dos subescalas que evalúan la dependencia física y psicológica respectivamente. en un estudio realizado por hernández et al. en el año 2007, en el cual aplicaron el test delta, se encontró que un 39 % de los pacientes tenía algún grado de dependencia que determinaba una mayor carga asistencial para las enfermeras (8). se han utilizado diversos instrumentos para evaluar el riesgo de los pacientes y la carga que esta condición implica en su cuidado. en unidades de cuidados críticos (uci) se ha utilizado el acute physiology and chronic health evaluation iii (apache) que permite predecir el riesgo de muerte de los pacientes (9), y el therapeutic interventions scoring system (tiss), que tiene como objetivo medir las cargas de trabajo de las enfermeras (10). sin embargo, en chile no se han desarrollado instrumentos que permitan medir dependencia y riesgo durante la sesión de hd en pacientes en hdc. el objetivo del presente estudio fue adaptar y validar el instrumento “cuidados según dependencia y riesgo (cudyr)” en pacientes en terapia de hdc. la validación de este instrumento constituye la primera etapa de la investigación titulada “dotación de personal de enfermería según dependencia y riesgo de los usuarios en unidades de hemodiálisis”, realizada en cinco centros de hemodiálisis en la ciudad de santiago (chile). materiales y métodos participantes si bien es cierto que en chile hay unidades de hemodiálisis a lo largo de todo el país, la mayoría de los pacientes se concentran en la ciudad de santiago o región metropolitana (rm) (5). por lo anterior, se seleccionaron uhd de esta región para realizar el presente estudio. la muestra estuvo conformada por 150 pacientes sometidos a hd. para la selección de la muestra se consideraron dos criterios. el primero, fue la zona geográfica dentro de la ciudad de santiago en donde se ubica la uhd, ya que esta se relaciona con 477 validación de un instrumento de medición de cuidados según dependencia y riesgo en pacientes en terapia de hemodiálisis crónica l maría cecilia arechabala-mantuliz y otros características socioeconómicas de los pacientes que acuden a ella; el segundo, fue el turno en el cual se dializaba el paciente, ya que este se relaciona con la capacidad para trabajar o estudiar de los usuarios. los dos criterios mencionados son relevantes al momento de evaluar el grado de dependencia de los pacientes en hdc. así, la rm se dividió en cinco zonas (oriente, poniente, sur, norte y centro) y se consideró una uhd por cada una de ellas. en cada unidad seleccionada se eligió en forma aleatoria el 30 % de los pacientes, estratificados por turno. a los pacientes seleccionados se les aplicó el mini mental de lobos (11) con el objeto de evaluar su capacidad de tomar decisiones en forma autónoma. a aquellos que obtuvieron un puntaje mayor a 19 puntos se les solicitó su participación voluntaria en el estudio, a través de un proceso que culminó con la firma del documento denominado consentimiento informado. en el caso de aquellos que obtuvieron un puntaje menor se solicitó el consentimiento a su representante legal, al que se le explicó el proyecto y se le solicitó la autorización para la inclusión del paciente en el estudio. en los casos en que el representante legal aceptó fue él quien firmó el consentimiento informado. el estudio fue aprobado por el comité de evaluación ético-científica del servicio de salud metropolitano sur oriente, específicamente del complejo asistencial dr. sotero del río, y por el comité de ética de la escuela de enfermería de la pontificia universidad católica de chile. instrumento el instrumento original, “cuidados según dependencia y riesgo (cudyr)” forma parte de un modelo de dotación de personal de enfermería desarrollado en el año 1995 en un hospital universitario de la ciudad de santiago. este permite clasificar a los usuarios según dependencia y riesgo, y, de acuerdo a esto, estimar las necesidades de asignación de personal de enfermería en un servicio de salud determinado (12). el instrumento está centrado en el cuidado del paciente y basado en los requisitos de autocuidado de dorothea orem (12). su objetivo es categorizar a los usuarios según dependencia y riesgo de acuerdo al cuidado que requieren, permitiendo de esta manera elaborar el perfil de atención de las unidades asistenciales a partir de la distribución porcentual de las diferentes categorías de pacientes. con esta información es posible realizar un cálculo de la carga de trabajo del personal de un servicio asistencial de acuerdo con las características de los usuarios que recibe (13). el cudyr está formado por dos escalas, una que mide dependencia y otra que mide riesgo. se entiende por dependencia de cuidados de enfermería al individuo que no puede valerse por sí mismo para satisfacer sus necesidades básicas durante una hospitalización o un procedimiento, y que requiere cuidados de enfermería universales. por otra parte, se entenderá por riesgo de cuidados de enfermería a un individuo en situación de desviación de salud, que requiere de cuidados de enfermería terapéuticos durante una hospitalización o un procedimiento (14). el grado de dependencia se identifica a través de la valoración de las demandas de autocuidado universal: prácticas de confort, alimentación y eliminación; y el nivel de riesgo se mide a través de los cuidados terapéuticos que los pacientes requieren en situación de desviación de salud: medición de parámetros clínicos, intervenciones profesionales multidisciplinarias y procedimientos de enfermería (13). cada uno de los ítems que forman las escalas es calificado con un puntaje que va de 0 a 3, donde un mayor puntaje indica una mayor dependencia o riesgo (13). una vez calculado el puntaje total de cada una de las escalas, estos se llevan a una tabla preestablecida que relaciona ambas variables: dependencia y riesgo. es así como la integración de ambas variables establece doce categorías de usuarios en las que se combinan el riesgo (máximo, alto, mediano y bajo), con el grado de dependencia (total, parcial, autosuficiencia) (tabla 1) (13). en el presente estudio, con el fin de validar el instrumento cudyr para pacientes en hdc, se realizaron los siguientes pasos: 1. adecuación del instrumento cudyr para pacientes en hdc, proceso que consideró tres etapas: a. selección de los ítems por incluir en el nuevo instrumento: con este fin se realizó un grupo focal con siete enfermeras especialistas en hd, con el objeto de identificar las condiciones y los cuidados que otorga el personal de en478 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 fermería en la atención de los pacientes durante la tsr, y determinar desde su experiencia cuáles implicaban dependencia y cuáles riesgo. posteriormente, se analizó esta información con uno de los autores del instrumento original, y se elaboró la versión adaptada del instrumento, el cual quedó constituido por: seis requisitos de autocuidado que implicaban dependencia y ocho cuidados que involucraban riesgo, es decir, un total de catorce ítems. si bien se mantuvo el número de ítems del instrumento original, se cambió uno de ellos (manejo de vía área por manejo de acceso vascular). b. adecuación del instrumento cudyr: con base en el listado de requisitos y cuidados se adecuó el instrumento cudyr original a pacientes sometidos a hdc, pasando a denominarse “cuidados según dependencia y riesgo en diálisis” (cudyr-dial) (tabla 2). c. asignación de puntajes y definición de puntos de corte: en conjunto con el autor del instrumento original se procedió a reasignar el puntaje a cada uno de los ítems (0 a 3 puntos), manteniendo el criterio de a mayor puntaje mayor riesgo o dependencia, según corresponda. para la clasificación general, según dependencia y riesgo de los pacientes, se utilizaron los puntos de cortes del instrumento original, manteniendo las categorías que combinaban la dependencia con el riesgo (13). 2. proceso de validación del cudyr-dial. a. en primer término, se realizó una aplicación piloto del instrumento a treinta pacientes sometidos a hd para verificar la comprensión de los ítems por parte de los profesionales en una ud no incluida en el estudio, cuyos usuarios tenían características similares a las de los que se incluirían en la investigación. además, uno de los investigadores aplicó el instrumento en diez de estos pacientes. lo anterior permitió incorporar algunas sugerencias para mejorar el entendimiento del instrumento por parte de los profesionales que lo aplicarían posteriormente. b. una vez estructurado el cudyr-dial definitivo, se dio inicio a su validación. para asegurar la calidad de este proceso se consideraron tres tipos de evaluaciones: intraobservador, interobservador y evaluación por experto. para lo anterior, las enfermeras de cada una de las uhd incluidas en el estudio aplicaron de tres a seis veces el instrumento a la totalidad de los pacientes de su uhd, durante un mes (evaluación intraobservador), registrando cada una de las mediciones y sacando finalmente un puntaje promedio en cada una de las dimensiones. con los promedios de dependencia y riesgo categorizaron a cada usuario en una de las doce categorías preestablecidas en el cudyr original. posteriormente, las enfermeras se rotaron en las distintas uhd del estudio y aplicaron el instrumento por una vez al 50 % de los pacientes seleccionados de otra uhd (evaluación interobservador), estableciendo nuevamente para cada uno de los pacientes una categoría de dependencia y riesgo. finalmente, una enfermera experta, externa a la investigación, aplicó el cudyr-dial por una vez al 100 % de los usuarios que participaron en el estudio (evaluación experto). las enfermeras que aplicaron el cudyr-dial en las diferentes etapas de su proceso de validación recibieron capacitación por parte del autor del instrumento original, con el fin de homogeneizar la aplicación del mismo. análisis estadístico los datos fueron analizados en el paquete estadístico para las ciencias sociales spss 18.0 (windows). se calcularon medidas de tendencia central para los datos sociodemográficos. en la validación del instrumento cudyrdial se realizó análisis factorial para determinar la estructura del instrumento y alfa de cronbach para determinar la consistencia interna. resultados características de los pacientes: un 55 % (81) de los usuarios en hd pertenecen al sexo masculino. respecto al nivel educacional, el 30 % (45) tenía educación básica, un 25,8 % (38) educación media, el 15,2 % (23) educación de nivel superior y un 29 % (43) no reporta nivel de instrucción. un 46 % (69) de los participantes era portador de diabetes mellitus y un 29 % (43) era hipertenso. un 9 % (13) de los usuarios presentaba cardiopatía asociada a su irct, y un 7 % (11) anemia e hiperparatiroidismo secundario. 479 validación de un instrumento de medición de cuidados según dependencia y riesgo en pacientes en terapia de hemodiálisis crónica l maría cecilia arechabala-mantuliz y otros el 89,4 % (134) se dializaba a través de una fístula arteriovenosa (fav), y un 9,3 % (14) por catéter venoso central (cvc). el 33 % (49) recibía durante su terapia de hd eritropoyetina y fierro endovenoso, un 10 % (15) calcio endovenoso, un 11 % (16) solo fierro y un 1,4 % (2) transfusiones de sangre/plasma. dentro de las limitaciones físicas, el 6 %(9) de los pacientes reportó ceguera y un 3 % (4) presentaba la amputación de al menos un miembro. posterior a la aplicación del cudyr-dial fue posible identificar cuatro categorías de usuarios según dependencia y riesgo medido: alto riesgo-dependencia parcial, alto riesgo-autosuficiencia parcial, mediano riesgo-dependencia parcial, y mediano riesgo-autosuficiencia parcial (tabla 3). para evaluar la concordancia entre los evaluadores se utilizó el estadístico de kappa (cohen), el cual mostró una concordancia leve a moderada para dependencia-riesgo: 0,279-0,415. comportamiento de los ítems el estudio del comportamiento de los ítems se realizó bajo la teoría clásica de la medición. en la tabla 4 es posible observar que los catorce ítems muestran correlaciones significativas (> 0,3) con el puntaje total obtenido en la escala. la confiabilidad de la escala se mantuvo estable al ir eliminando uno a uno los ítems, fluctuando entre 0,861 y 0,875. así, es posible inferir que el cudyr-dial presenta una buena confiabilidad, por lo que se decidió mantener los 14 ítems. la confiabilidad total del instrumento calculada a través del alfa de cronbach fue de 0,878. análisis factorial exploratorio y confirmatorio la construcción del cudyr original se basó en un modelo conceptual de dos factores, que se denominaron dependencia y riesgo (13). por lo anterior, se realizó un análisis factorial exploratorio para identificar los factores del modelo antes descrito, es decir, para identificar las variables latentes que subyacen a los ítems. el análisis exploratorio entregó cuatro factores con valores propios mayores a 1 que explicaban el 61,8 % de la varianza total (tabla 5). el primer factor corresponde exactamente a los ítems de dependencia del instrumento original y tiene una confiabilidad dada por el alfa de cronbach de 0,81. por otra parte, los ítems de riesgo se agrupan en tres factores diferentes. en el primero se reúnen los ítems “cuidados de piel y curaciones”, “presencia de elementos invasivos”, “intervenciones profesionales” y “manejo de accesos vasculares”, con un alfa de cronbach de 0,70. el segundo factor está formado por los ítems “administración de tratamiento farmacológico” y “cuidados en oxigenoterapia”, y el tercer factor por los ítems “balance hídrico” y “medición de signos vitales”. estos dos últimos factores tienen una baja confiabilidad (alfa de cronbach inferior a 0,20), lo que podría explicarse debido a que estos factores están compuestos solamente por dos ítems cada uno. si se fuerza el análisis factorial para obtener los dos factores hipotéticos de dependencia y riesgo, la distribución de los ítems es diferente a la propuesta planteada en el cudyr-dial. se observa que el primer factor se encuentra formado por la totalidad de los ítems de dependencia propuestos, más dos ítems de riesgo que corresponden a “administración de tratamiento farmacológico” y “cuidados en oxigenoterapia”, con un alfa de cronbach de 0,75. mientras que el segundo factor está compuesto por el resto de los ítems de riesgo, con un alfa de cronbach de 0,61. sin embargo, esta estructura de dos factores explica solo el 44,2 % de la varianza. discusión los resultados obtenidos a través de la aplicación del cudyrdial, 620 veces a 150 pacientes, permitió establecer que las personas sometidas a hdc presentan principalmente un perfil de mediano riesgo y autonomía parcial. esto es concordante con el estudio de cobo et al. en pacientes en hd a los que se les aplicó el test delta, encontrando que más del 50 % de ellos presentaba algún grado de dependencia (7). determinar la dependencia y el riesgo de los pacientes en hdc a través de un instrumento adaptado y validado como el cudyrdial es un aporte para el cuidado de enfermería en las uhd. esto concuerda con lo que muestra la literatura, donde se destaca la importancia de determinar el grado de autonomía de las personas sometidas a hd. lo anterior, debido a que esta es una patología cuya incidencia se relaciona con la edad, lo que sumado a la comorbilidad trae como resultado un número importante de usuarios con falta de autonomía, con repercusiones no solo en la 480 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 morbimortalidad, sino en aspectos funcionales y estructurales de las uhd, hecho que se corrobora en los estudios de kurella (2) y herlin (15). esto se traduce en que el personal de enfermería debe entregar cuidados no solo en relación con el procedimiento propiamente tal, sino además dar respuesta a una serie de necesidades, lo que supone un aumento en la carga de trabajo y en el tiempo que deben dedicar a la atención de cada uno de los pacientes a cargo (16-18). de hecho, los pacientes en hdc esperan encontrar profesionales de la salud competentes que los ayuden a enfrentar la pérdida de su independencia (15). conocer la dependencia y el riesgo de los pacientes en hd permite, por una parte, asignar la dotación de personal de acuerdo al perfil de dependencia y riesgo de los usuarios, modificándola según este varíe y, además, monitorizar durante el periodo de la diálisis aquellas condiciones o características de los usuarios que implican un riesgo. esto permite implementar medidas preventivas que eviten hospitalizaciones, o la aparición de complicaciones derivadas de la patología o tratamiento. es importante tener presente que la dependencia funcional es un buen predictor de hospitalización en personas de la tercera edad, grupo etario al que pertenece un porcentaje importante de los usuarios sometidos a hd (3, 4). desde el punto de vista de la gestión del cuidado, contar con un instrumento que categorice a los pacientes en hd según dependencia y riesgo permite manejar en forma dinámica, de acuerdo con las condiciones actuales de los usuarios, la dotación del equipo de enfermería dentro de las uhd, optimizando de esta manera el recurso humano y asegurando un cuidado de calidad (19). los sistemas de clasificación de usuarios son un elemento relevante para la gestión del cuidado, ya que permiten determinar el perfil asistencial de los pacientes, realizar distribución de los recursos humanos y materiales, reorientar el funcionamiento de las unidades asistenciales y, finalmente, determinar los costos de la atención de los usuarios (6). la clasificación de dependencia y riesgo de los usuarios del presente estudio está basada principalmente en el requerimiento de cuidados durante la hdc tales como: curación de heridas, administración de medicamentos o ciertas condiciones fisiopatológicas que implican un riesgo. esto es concordante con otros estudios que muestran que en las últimas tres décadas los pacientes sometidos a hdc tienen una mayor discapacidad, comorbilidad y dificultad para tener un buen acceso vascular. por lo anterior, las actividades que se realizan en una udh son cada vez más complejas, y los riesgos de un paciente que va a ser sometido a hd son diversos y de diferente importancia (20). las condiciones anteriormente descritas condicionan la presencia de un mayor número de pacientes que se dializan a través de cvc, los cuales requieren de medidas de prevención de infecciones y de curaciones, lo que incide en pacientes de mayor riesgo y, por ende, en una sobrecarga de trabajo del equipo de enfermería (8). conocer las condiciones particulares de los pacientes permite instalar medidas preventivas para controlar el riesgo de los usuarios y evitar la sobrecarga del equipo que realiza el procedimiento de diálisis, a fin de mantener la calidad de la atención de los usuarios. conclusiones fue posible adaptar el cudyr para utilizarlo como un instrumento de categorización de dependencia y riesgo en personas sometidas a hdc. a través de grupos focales con enfermeras expertas en hd, se identificaron los cuidados de enfermería que determinaban dependencia y riesgo. el nuevo instrumento se denominó cudyr-dial, y quedó conformado por 14 ítems, de los cuales seis indican dependencia y ocho riesgos. el total de ítems se distribuyó al realizar el análisis factorial en cuatro componentes, manteniéndose separados los ítems correspondientes a dependencia y riesgo, lo que mostró claramente dos constructos. el primero, denominado dependencia, formado por seis ítems, y el segundo, denominado riesgo, formado por tres subescalas con un total de ocho ítems. por lo anterior, se propone dividir la escala de riesgo en tres subescalas. la primera, denominada “procedimientos invasivos que requieren cuidados profesionales”, compuesta de cuatro ítems; una segunda, denominada “tratamientos complementarios a la hd”, conformada por dos ítems; y una tercera, denominada “monitorización durante la hd”, con dos ítems. al analizar las propiedades métricas del cudyr-dial se concluye que este tiene una buena validez y consistencia interna. su aplicación en las uhd permitiría categorizar a los pacientes según dependencia y riesgo de cuidados, lo que aportaría elementos cla481 validación de un instrumento de medición de cuidados según dependencia y riesgo en pacientes en terapia de hemodiálisis crónica l maría cecilia arechabala-mantuliz y otros ves para las decisiones actuales en relación con la organización del cuidado, optimización de recursos, como también las decisiones futuras de estimación de dotación de personal de enfermería. además, posibilitaría la comparación de presión asistencial al interior de la uhd facilitando la adecuada y oportuna distribución del personal según la carga asistencial identificada. limitaciones la categorización de pacientes según dependencia y riesgo con el instrumento cudyr-dial contó con el método de validación cruzada interna, que logró un grado de concordancia leve a moderado para dependencia y riesgo (kappa de cohen = 0,279-0,415). se justifica este resultado porque las mediciones fueron realizadas en diferentes momentos de la atención del paciente. agradecimientos agradecemos a los directivos y enfermeras de las uhd que participaron en el estudio. estudio financiado por la dirección de investigación de la escuela de enfermería de la pontificia universidad católica de chile, y por la sociedad chilena de enfermería en diálisis y trasplante renal (senferdialt). referencias 1. arenas md, álvarez-ude f, angoso m, berdud i, antolín a, lacueva j et al. valoración del grado de dependencia funcional de los pacientes en hemodiálisis (hd): estudio multicéntrico. nefrología. 2006;26(5):600-08. 2. kurella m, covinsky k, chertow g, yaffe k, landefeld s, mcculloch c. functional status of elderly adults before and after initiation of dialysis. n engl j med. 2009;361(16):1539-47. 3. cook wl, jassal sv. functional dependencies among the elderly on hemodialysis. kidney int. 2008;73:1289-1295 4. couchoud c, labeeuw m, moranne o, allot v, esnault v, frimat l et al. a clinical score predict 6-month prognosis in ederly patients starting dialysis for end-stage renal disease. nephrol dial transplant. 2009;24(5):1553-61. 5. poblete h. xxxi cuenta de hemodiálisis crónica (hdc) chile, 2011. 6. bjorklund de lima l, borges d, da costa s, rejane e. classification of patients according to the degree of dependence on nursing care and illness severity in a postanesthesia care unit. rev latino-am enfermagem. 2010;18(5):881-7. 7. cobo jl, pelayo r, sánchez ms, alonso r, menezo r, gándara m et al. repercusión del grado de dependencia de los pacientes en hemodiálisis sobre la carga de trabajo de enfermería. rev soc esp enferm nefrol. 2008;11(1):6-11. 8. hernández v, palacios g, rubio fj, porras g, rodríguez j, uguet m et al. evaluación del grado de dependencia de los pacientes en hemodiálisis mediante el test delta. comunicaciones xxxi congreso nacional de la sociedad española de enfermería nefrológica [internet] 2006 [citado 2012 jul 15]. disponible en: https://www.seden.org/publicaciones_articulodet.asp?idioma=&pg=publicaciones_revistadet.asp&buscar=&id=129&idarticulo=1796&datapageid=3&intinicio=1 9. moore ec, pilcher dv, bailey mj, cleland h, mcnamee j. a simple tool for mortality prediction in burns patients: apache iii score and ftsa. burns [internet]; 2010 [citado 2012 oct 10]. disponible en: www.elsevier.com/locate/burns 10. díaz a, beguistain a, fernández n. relación paciente-enfermería a través de la evaluación clínica del sistema therapeutic intervention scoring system (tiss) 28. revista uruguaya de enfermería [internet]. 2006; [citado 2011 may 15], 1-20. disponible en: http:www.fenf.edu.uy/rue/sitio/num2/2_art01_evaluacion.pdf. 11. vinyoles e, vila j, argimon jm, espinás j, abos t, limón e. concordance among mini-examen cognoscitivo and minimental state examination in cognitive impairment screening. atención primaria. 2000;30(1):5-13. 12. garcía ma. categorización de usuarios según dependencia y riesgo. hospital clínico. facultad de medicina. pontificia universidad católica de chile. rev horizonte. 2005;2:56-64. 13. garcía ma, castillo l. categorización de usuarios: una herramienta para evaluar las cargas de trabajo de enfermería. rev med chile [internet]. 2000; [citado 2012 oct 10], 128(2). disponible en: http://www.scielo.cl/scielo.php?pid=s003498872000000200007&script=sci_arttext 482 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 14. robles c, camus l, garcía a. modelo de asignación de personal de enfermería (mape) según dependencia y riesgo de cuidado y complejidad de tratamiento médico. informe final proyecto sa 06i20025. chile: fondo nacional de desarrollo e investigación en salud (fonis); s. f. 15. herlin c, wann-hansson ch. the experience of being 30-45 years of age and depending on haemodialysis treatment: a phenomenological study. scand j caring sci. 2010;24(4):693-9. 16. camps e, andreu l, codinachs m, claramunt l, pas m. valoración del grado de autonomía funcional de pacientes renales crónicos según índices de barthel, lawton y baremo de ley de dependencia. rev soc esp enferm nefrol. 2009;12(2):188-92. 17. reddy nc, korbet sm, wozniak ja, floramo sl, lewis ej. staff-assisted nursing home haemodialysis patient characteristics and outcome. nephrol dial transplant. 2007;22:1399-406. 18. mena m, cerdán e, pérez-seoane a, manrique j. asociación entre dependencia funcional y sintomatología afectivodepresiva en pacientes en programa de hemodiálisis. rev soc esp enferm nefrol. 2010;13:236-41. 19. peña p, lópez j, de la torre l, muelas f. cargas de trabajo en una unidad de nefrológica. comunicaciones xvii congreso nacional de la sociedad española de enfermería nefrológica; 1992. 20. matarán e, aguilar r, muñoz m. incidencia y tipo de efectos adversos durante el procedimiento de hemodiálisis. enferm nefrol. 2013;16:36-40. 483 validación de un instrumento de medición de cuidados según dependencia y riesgo en pacientes en terapia de hemodiálisis crónica l maría cecilia arechabala-mantuliz y otros tabla 1. categorías según dependencia y riesgo instrumento cudyr escala de dependencia dependencia total: 13 a 18 dependencia parcial: 7 a 12 autosuficiencia parcial: 0 a 6 escala de riesgo máximo riesgo: 19 a 24 alto riesgo: 12 a 18 mediano riesgo 6 a 11 bajo riesgo: 0 a 5 max riesgo dep total alto riesgo dep total med riesgo dep total bajo riesgo dep total max riesgo dep parcial alto riesgo dep parcial med riesgo dep parcial bajo riesgo dep parcial max riesgo aut parcial alto riesgo aut parcial med riesgo aut parcial bajo riesgo aut parcial a b c d 1 2 3 tabla 2. instrumento de categorización de usuarios por dependencia y riesgo (cudyr-dial) cuidados de enfermería que identifican dependencia cuidados en confort y bienestar cambio de ropa personal y sillón cuidados en confort y bienestar movilización y transporte cuidados en alimentación oral, enteral, parenteral cuidados en eliminación orina, deposición apoyo psicosocial y emocional apoyo recibido vigilancia alteración de conciencia, riesgo de caída cuidados de enfermería que identifican riesgo control diario de signos vitales más de dos en forma simultánea balance hídrico egresos/ingresos cuidados en oxigenoterapia traqueotomía, tubo endotraqueal, halo, máscara, sonda o bigotera manejo de accesos vasculares fístula arterio-venosa, injerto gorotex, catéter venoso central intervenciones profesionales procedimientos invasivos cuidados de piel y curaciones prevención de lesiones y curaciones administración de tratamiento farmacológico inyectable endovenoso y no endovenoso, y vías no invasivas presencia de elementos invasivos vías, catéteres, sondas, drenajes tabla 3. categorización según dependencia y riesgo de pacientes sometidos a hemodiálisis crónica con cudyr-dial categoría frecuencia porcentaje (%) alto riesgo-dependencia total 8 5,3 alto riesgo-autonomía parcial 24 15,9 mediano riesgo-dependencia parcial 2 1,3 mediano riesgo-autonomía parcial 117 77,48 total 151 99.98 484 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 tabla 4. análisis de ítems de “cuidados según dependencia y riesgo en hemodiálisis crónica, cudyr-dial” correlación ítems-test alfa de cronbach si el ítem cuidados en confort y bienestar ,555 0,869 cuidados de movilización y transporte ,699 0,861 cuidados de alimentación ,682 0,862 cuidados de eliminación ,709 0,861 apoyo psicosocial y emocional ,313 0,882 vigilancia ,591 0,868 cuidados de piel y curaciones ,597 0,868 presencia de elementos invasivos ,614 0,866 intervenciones profesionales ,337 0,881 manejo de accesos vasculares ,657 0,865 administración de tratamiento farmacológico ,336 0,878 cuidados de oxigenoterapia ,622 0,866 balance hídrico ,433 0,875 medición de signos vitales ,516 0,872 tabla 5. carga factorial de los ítems (rotación varimax), “cuidados según dependencia y riesgo en hemodiálisis crónica, cudyr-dial”. modelo de cuatro factores items factores categoría 1 2 3 4 cuidados en confort y bienestar 0,832 0,071 -0,046 0,150 dependencia cuidados de movilización y transporte 0,887 0,173 0,033 -0,029 dependencia cuidados de alimentación 0,665 -0,032 0,207 0,030 dependencia cuidados de eliminación 0,832 0,136 0,119 0,028 dependencia apoyo psicosocial y emocional 0,579 0,109 0,415 0,282 dependencia vigilancia 0,701 -0,007 -0,066 -0,134 dependencia cuidados de piel y curaciones -0,060 0,918 -0,084 0,031 riesgo presencia de elementos invasivos -0,006 0,825 -0,084 0,134 riesgo intervenciones profesionales 0,150 0,656 0,055 -0,066 riesgo manejo de accesos vasculares 0,181 0,622 0,235 0,008 riesgo administración de tratamiento farmacológico -0,059 -0,071 0,778 0,053 riesgo cuidados de oxigenoterapia 0,252 0,156 0,638 -0,207 riesgo balance hídrico 0,078 0,040 0,017 0,774 riesgo medición de signos vitales -0,012 0,019 -0,067 0,714 riesgo 158 172 la experiencia de ser cuidadora.indd 158 aquichan issn 1657-5997 gabriela aldana-gonzález1 liliana garcía-gómez2 la experiencia de ser cuidadora de un anciano con enfermedad crónica 1 magister en gerontología social; profesora de la universidad autónoma del estado de méxico, centro universitario ecatepec, méxico. gabriela_aldana@yahoo.com.mx 2 estudiante del doctorado en ciencias die-cinvestav; profesora de la universidad autónoma del estado de méxico, centro universitario ecatepec, méxico. pumitasep@yahoo.com.mx recibido: 12 de mayo de 2010 aceptado: 24 de mayo de 2011 resumen objetivo: conocer la construcción de la experiencia de ser cuidador de un anciano con enfermedad crónico-degenerativa en mujeres de san cristóbal ecatepec, méxico. método: investigación de corte cualitativo, con cuatro personas de sexo femenino todas ellas cuidadoras de ancianos con enfermedades crónico-degenerativas. se utilizó la entrevista a profundidad como técnica para la recolección de datos. los datos se analizaron a partir de ubicar categorías de análisis desde una orientación fenomenológica. la investigación se llevó a cabo en la ciudad de san cristóbal ecatepec, estado de méxico, méxico, entre marzo y junio del 2008. resultados: el rol de cuidador está asignado a las mujeres. la categoría que aquí se describe se refiere a la cotidianidad del cuidado. los discursos nos permiten develar el conflicto al que se enfrentan las cuidadoras: la responsabilidad moral del cuidado al adulto mayor y la necesidad de desarrollar un proyecto de vida autónomo. conclusiones: la experiencia de ser cuidadora se asume como una responsabilidad y un compromiso moral que tiene que cumplirse por encima del cuidado personal. tiene relación con la cultura mexicana respecto a la construcción de género y familia. palabras clave cuidadores, anciano, enfermedad crónica, entrevistas como asunto, investigación cualitativa. año 11 vol. 11 nº 2 chía, colombia agosto 2011 l 158-172 159 la experiencia de ser cuidadora de un anciano con enfermedad crónica en san cristóbal ecatepec, méxico l gabriela aldana-gonzález, liliana garcía-gómez the experience of being a caregiver for a chronically ill elderly person abstract objective: to understand how the experience of being a caregiver for an elderly person with a chronic degenerative disease evolves among women in san cristobal ecatepec, mexico. method: a qualitative study of four female caregivers who work with elderly patients with chronic degenerative diseases. in-depth interviews were used to collect the data, which were analyzed by establishing categories from a phenomenological standpoint. the research was conducted in mexico, specifically in the city of san cristobal ecatepec in the state of mexico, between march and june 2008. results: the role of caregiver is assigned to women. the category described in the study refers to daily care. the information from the interviews reveals the conflict facing these caregivers: the moral responsibility of providing care to an elderly patient and the need to develop a project for a life of their own. conclusions: the experience of being a caregiver is assumed as a moral responsibility and commitment to be met above and beyond any obligation for their own personal care. it is related to mexican culture with respect to the construction of gender and family. key words caregivers, elderly, chronic illness, interviews as a topic, qualitative research. a experiência de ser cuidadora de uma pessoa idosa com doença crônica resumo objetivo: experimentar a construção de ser cuidador de um idoso com doença degenerativa crônica em mulheres de san cristóbal ecatepec (méxico). método: pesquisa qualitativa com quatro pessoas do sexo feminino, cuidadoras de idosos com doenças degenerativas crônicas. nós usamos a entrevista em profundidade como técnica de coleta de dados. para analisar os dados, se aplicaram categorias fenomenológicas de análise. a pesquisa se realizou na cidade de san cristóbal ecatepec (estado de méxico) entre março e junho de 2008. resultados: o papel de cuidar é atribuído às mulheres. a categoria descrita refere-se ao cuidado diário. os discursos nos permitem descobrir o conflito enfrentado pelas cuidadoras: a responsabilidade moral de cuidar do idoso e a necessidade de desenvolver um projeto de vida independente. conclusões: a experiência de cuidar se assume como uma responsabilidade e um compromisso moral que tem prioridade sobre o cuidado pessoal. isto se moldura na forma de construir gênero e família na cultura mexicana. palavras-chave cuidadores, doença crônica, entrevistas como assunto, idoso, pesquisa qualitativa. 160 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 introducción el interés por el estudio del envejecimiento en la población se ha ido incrementando, pues las proyecciones demográficas mundiales no mienten: el mundo está envejeciendo. dada la inminente transición epidemiológica se ha hecho necesario profundizar en la investigación sobre el envejecimiento. las teorías del desarrollo hacen hincapié en describir y predecir los cambios que con el tiempo y con la edad se producen en el ser humano; así, en la vejez comienza a ser notorio un declive en sus capacidades físicas, ello ocurre en todos los seres vivos y es considerado normal. el deterioro es considerado como una desviación significativa del decremento de la media del grupo, se considera como anormal y está asociado a las patologías biológicas. cuando se manifiesta un deterioro permanente y progresivo en el ser humano se dice que se presentan las enfermedades crónico-degenerativas (1). en muchos casos, el ser un enfermo crónico implica ser un sujeto dependiente. esta es la condición en la que el individuo es incapaz de satisfacer sus propias necesidades y cuidar de sí mismo, por lo que es necesario confiar su cuidado a otras personas. dicho estado produce una dependencia progresiva e irreversible de tipo orgánico y social, pues el organismo empieza a perder sus habilidades, dificultándose el cumplimiento de los roles sociales y la capacidad de una interacción recíproca con los demás. la afrenta mayor para el enfermo es que nunca se vuelve a recuperar el estatus de persona sana (2). el 80% de las muertes provocadas por enfermedades crónicas se producen actualmente en países de bajos y medianos ingresos, donde afectan a hombres y mujeres casi en la misma proporción. las enfermedades crónicas acabaron con la vida de unos 35 millones de personas en el 2008, más del 60% de los 58 millones de defunciones que se produjeron en todo el mundo (3). la organización mundial de la salud (oms) (3) señala que las enfermedades crónicas tienen efectos devastadores para las personas, las familias y las comunidades, especialmente las poblaciones pobres, y constituyen un obstáculo cada vez mayor para el desarrollo económico. es más, las poblaciones vulnerables, como los pobres, tienen mayores probabilidades de contraer enfermedades crónicas, y las familias de bajos ingresos son más susceptibles de empobrecerse como consecuencia de ellas. los costos sociales asociados con las enfermedades crónicas son abrumadores. en méxico, la morbilidad crónico-degenerativa y sus consecuencias, en particular la dependencia, se han convertido en un determinante del peso social y económico de la enfermedad de la población envejecida (4). la obligación filial es la norma cultural por la cual se define que la familia es la responsable del cuidado de los ancianos, y se determina qué integrante de ésta es el que debe asumir directamente esa responsabilidad (5). los ancianos esperan que por esta 161 la experiencia de ser cuidadora de un anciano con enfermedad crónica en san cristóbal ecatepec, méxico l gabriela aldana-gonzález, liliana garcía-gómez obligación filial la familia, y en particular los hijos, los cuiden cuando lo necesiten. el cuidado es un tema vigente para la investigación social y antropológica. el envejecimiento y las enfermedades crónicas generan cada vez más discapacidades que afectan la autonomía y crean dependencia en la población adulta mayor (2). el cuidador es definido como “aquella persona que asiste o cuida a otra afectada por cualquier tipo de discapacidad, minusvalía o incapacidad que le dificulta o impide el desarrollo normal de sus actividades vitales o de sus relaciones sociales” (6). es así que el cuidador es una figura esencial para el apoyo y las ayudas de los ancianos con enfermedades crónicas. es importante señalar las particularidades de los diferentes tipos de cuidadores. estos se diferencian en dos grandes rubros: los cuidadores informales y los formales (7). los cuidadores formales se definen como aquellas personas capacitadas a través de cursos teórico-prácticos de formación para brindar atención preventiva, asistencial y educativa al anciano y a su núcleo familiar. su campo de acción cubre el hogar, el hospital, los clubes y los centros de jubilados, las residencias geriátricas y los servicios sanatoriales. el cuidador apoya al personal de enfermería y a equipos gerontológicos de trabajo (8). sin embargo, la formación de cuidadores es aún incipiente, con una falta de capacitación no solo entre los que cuidan, sino del personal que desde sus especialidades tiene interacción con los ancianos (médicos, psicólogos, abogados, enfermeros, etc.). a diferencia de los cuidadores formales, los informales no disponen de capacitación, no son remunerados por su tarea, y tienen un elevado grado de compromiso hacia la misma que se caracteriza por prodigar una atención sin límites de horario, dada la carga afectiva que tienen hacia la persona enferma. este cuidado lo otorgan principalmente familiares, aunque algunas veces participan amigos y vecinos (6, 7). de estos cuidadores resalta el “cuidador principal”, que por lo general es el cónyuge o el familiar femenino más cercano. los cuidadores principales o primarios son los que asumen la responsabilidad total del cuidado del enfermo. estas personas dedican una gran parte de su tiempo al cuidado del enfermo o de la persona que es dependiente y realizan estos cuidados de manera constante y por un tiempo prolongado. el cuidador secundario apoya de diferentes maneras al primario, aunque no tiene la responsabilidad total del cuidado (6, 9). el cuidador primario es un tipo de trabajador que dedica gran parte de su tiempo y energías al cuidado, y que adquiere conocimientos y habilidades en el desempeño del rol cuando lo asume. sus actividades son extensas y complejas (10). “la familia es la responsable por excelencia del cuidado de sus miembros dependientes en casi todo el mundo” (5). cuando la familia asume el rol de cuidadora se notan ciertas ventajas, puesto que generalmente existe mayor seguridad emocional, menos incomodidades y mayor intimidad, evitando así los problemas psicopatológicos de la institucionalización. también se pueden enumerar desventajas tales como el desconocimiento de una tarea que requiere especialización, la falta a diferencia de los cuidadores formales, los informales no disponen de capacitación, no son remunerados por su tarea, y tienen un elevado grado de compromiso hacia la misma que se caracteriza por prodigar una atención sin límites de horario, dada la carga afectiva que tienen hacia la persona enferma. 162 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 de equipo de apoyo, las instalaciones inadecuadas dentro del hogar para los cuidados, los problemas económicos y los conflictos familiares que derivan en la sobrecarga del cuidador principal (6, 7). el cuidado del anciano enfermo por parte de la familia se da en tres grandes rubros: apoyo en tareas domésticas tales como limpiar, lavar, cocinar, etc.; realizar actividades cotidianas fuera de la casa al salir de compras, acompañarlo al médico, a la calle, etc., y llevar a cabo los cuidados personales del adulto mayor enfermo como son asearse, vestirse y comer (9). dependiendo del nivel en que se atienda al anciano, se modifican las funciones de la familia en cuanto a su cuidado. así, las mayores ayudas tienen que ver con las relacionadas con el entorno social (ir de compras, hablar con profesionistas, hacer gestiones, salir a la calle), seguidas de las tareas domésticas y los cuidados personales y, por último, aquellas que implican alto grado de dependencia (caminar, cambiar pañales, asearse). es importante mencionar que, además del apoyo instrumental en estos tres niveles, los cuidadores le otorgan al adulto mayor una atención emocional escuchándolo, haciéndole compañía, buscando que “se encuentre bien”, que “esté a gusto”, que se sienta querido. todo este tipo de atenciones se incrementan en función de la dependencia que presenta el anciano enfermo, lo que repercute en la mayor cantidad de tiempo y esfuerzo que debe emplear el cuidador para su atención. históricamente, los cuidadores informales han sido la principal fuente de apoyo de los ancianos, la diferencia con las últimas décadas es el número de personas que desempeñan el rol de cuidador, la duración de los cuidados y las tareas que tiene que desempeñar. estos cambios tienen una relación directa con las características actuales de los adultos mayores, pues el aumento de la esperanza de vida y los avances de la medicina han propiciado que los cuidadores tengan que serlo durante una gran cantidad de tiempo (6). aunado a esto, los cambios sociales también impactan en el rol del cuidador. actualmente, la mujer se ha incorporado al ámbito laboral, se considera que la estabilidad de la familia nuclear se encuentra en crisis, existe una tendencia a la desaparición de la familia extensa y a la proliferación de núcleos familiares más pequeños (1 o 2 hijos), comienzan a aparecer nuevos modelos familiares, se genera la desaparición de las redes informales de las comunidades tradicionales (la figura del vecino solidario), se está presentando un aumento de la movilidad social y laboral, y la disminución del tamaño de las viviendas es evidente (9). estos cambios hacen que existan cada vez menos personas con posibilidad de cuidar a los ancianos enfermos, por lo que el cuidado recae sobre unos pocos o sobre una sola persona. se produce así una situación paradójica en la que se encuentra, por un lado, una demanda de apoyo cada vez mayor (más ancianos, más enfermedades crónico-degenerativas), y por otro lado, cada vez menos personas con disponibilidad de cuidar (menos personas en el hogar, las que hay tienen ocupaciones fuera) (9). este proceso de cambio en el que se encuentran actualmente las familias indica que en el futuro los ancianos y sus familias necesitarán de un apoyo de parte de la sociedad civil (7). en la presente investigación se buscó comprender la experiencia de ser cuidadora de un anciano que presentaba una enfermedad crónico-degenerativa. método el estudio es de orden fenomenológico, pues esta perspectiva hace énfasis en las experiencias subjetivas de la persona, tomando en cuenta sus ideas, sus vivencias y sus sentimientos. lo anterior captado desde el marco de referencias internas del ser humano que las experimenta. incluyó a cuatro mujeres adultas quienes vivieron la experiencia de ser cuidadoras principales e informales de un(a) anciano(a) con enfermedad crónica degenerativa por más de seis meses y fueran habitantes originarias de san cristóbal ecatepec, méxico, localidad que se considera en transición de rural a urbana. sus edades durante el cuidado oscilaron entre los 35 y 60 años. la selección de la muestra fue por conveniencia (11). todas ellas cuidaron a su madre o padre cuando enfermaron y fueron dependientes. se les solicitó su participación voluntaria para esta investigación, utilizando el consentimiento informado (12). la técnica utilizada para obtener la información fue la entrevista en profundidad (13). las entrevistas se realizaron en cada uno de los domicilios de las participantes en un espacio cómodo y privado. la duración aproximada de cada entrevista fue de una a tres horas, utilizando una o dos sesiones. las entrevistas culminaron cuando expresaron haber concluido su relato acerca de su experiencia. las entrevistas 163 la experiencia de ser cuidadora de un anciano con enfermedad crónica en san cristóbal ecatepec, méxico l gabriela aldana-gonzález, liliana garcía-gómez se grabaron y posteriormente se transcribieron para su análisis. se llevaron a cabo entre marzo y junio del 2008. el análisis de los datos se realizó de acuerdo con los principios postulados por ulin, robinson y tolley (14), quienes indican que el proceso comienza con leer y releer las transcripciones, buscando detectar los temas que surgen, así es que comenzamos a detectar los temas y a asignar rótulos a los fragmentos de texto que estos representaban. una vez codificados los textos buscamos integrar en detalle la información pertinente para cada categoría y, finalmente, la redujimos a puntos esenciales de las mismas. en cada uno de estos pasos se buscó el significado básico de los pensamientos, sentimientos y comportamientos descritos por los textos, esto es: se interpretaron los datos. por último, realizamos una interpretación global de los resultados del estudio explicando cómo al relacionarse las áreas temáticas exponemos la experiencia de ser cuidadora de un anciano con enfermedad crónico-degenerativa. como parte de la validación del análisis de resultados, las mujeres entrevistadas leyeron las transcripciones de las entrevistas y el análisis de las mismas, buscando reconocerse a través de estas. sus comentarios fueron tomados en cuenta para que el texto representara su voz y no solamente la de las investigadoras (15). se buscó guardar la confidencialidad y el anonimato de las entrevistadas, por lo que sus nombres fueron sustituidos por otros. resultados los resultados que se encontraron en este estudio permitieron determinar categorías de análisis que recuperan las características más significativas de esta experiencia reportadas por las entrevistadas, estas son: la cotidianidad del cuidado, el género y la elección del cuidador, la vida después del cuidado, las relaciones familiares y el cuidado, la salud de la cuidadora, y el futuro de las cuidadoras. estas temáticas fueron identificadas de forma reiterativa en las cuidadoras, y representan las perspectivas que tienen las informantes respecto a su experiencia expresadas desde sus propias palabras (16). el presente artículo se centra en describir la primera categoría mencionada en la experiencia de las cuidadoras: la cotidianidad del cuidado. se eligió esta categoría como esencial en este estudio, pues describir la vida cotidiana de estas personas permite develar los significados de ser cuidador en el conjunto de su mundo y de su entorno sociocultural. agnes heller (17) decía que la vida cotidiana era “el espejo de la historia”, también la definía “como el conjunto de actividades que caracterizan la reproducción de los hombres particulares, los cuales crean la posibilidad de la reproducción social […] es la forma real en que se viven los valores, creencias, aspiraciones y necesidades”. es así que la vida cotidiana refleja las vivencias diarias, repletas de significados, intereses y estrategias. por su parte, lefevbre comenta que la vida cotidiana “es reconocer y entender comportamientos, costumbres, proyección de necesidades, captar cambios a partir del uso de los espacios y tiempos concretos” (18). para esta investigación se retoma la mirada sociológica de la vida cotidiana, pues precisamente su objetivo es analizar si esta vida se construye en prácticas de para esta investigación se retoma la mirada sociológica de la vida cotidiana, pues precisamente su objetivo es analizar si esta vida se construye en prácticas de libertad y convicción propias o sí, por el contrario, se determina como una vida impuesta desde el exterior. 164 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 libertad y convicción propias o sí, por el contrario, se determina como una vida impuesta desde el exterior. el escuchar la cotidianidad de las cuidadoras favorece descubrir los elementos que determinaron las acciones del cuidado y los supuestos que subyacen a sus decisiones. la cotidianidad del cuidado diferentes estudios coinciden en que las familias que se encuentran al cuidado de ancianos presentan un desgaste físico y emocional constante que implica una cantidad de tiempo y esfuerzo dedicado al cuidado que se suma a las actividades diarias del cuidador. ello repercute en el desarrollo normal de las actividades laborales, privaciones al cónyuge, a los hijos y reducción de la vida social (6, 7, 19). la vida del cuidador primario se organiza en función del adulto mayor enfermo, buscando que las actividades de cuidado sean compatibles con las acciones de la vida cotidiana. cuando se cuida a mayores con enfermedades crónico-degenerativas, todo el horario de vida (laboral, familiar, ocio, etc.) se adapta en función del enfermo que se atiende (9). tal y como lo señalan diferentes investigaciones al respecto de la designación de los cuidadores (2, 20-24), encontramos en los discursos de las entrevistadas la confirmación de que es la mujer la encargada de asumir las actividades de cuidado en la salud/enfermedad, específicamente en el cuidado en el hogar de enfermos ancianos. en el caso de las entrevistadas, todas ellas hijas de la persona a quien debían cuidar, asumieron como obligación filial (5) el cuidar de sus padres, por lo que su cotidianidad se vio impactada por las modificaciones que debieron hacer para cumplir con el cuidado. yolanda relata cómo su vida se adaptó a ser cuidadora de su madre, particularmente cuando esta se volvió dependiente para realizar actividades de la vida diaria, como por ejemplo su aseo personal: a todo se acostumbra uno, yo la llevaba al baño. la sentaba, la volteaba, ya estaba el agua caliente, y luego la volteaba, porque ella no permitía que le lavara uno enfrente, ella solita. el domingo yo en la mañana la limpiaba, la paraba, ah porque hasta que no terminaba de hacer mi quehacer no la paraba… ella: “ya levántame, ya levántame”, “ahorita mamá, ahorita”, y ya la levantaba y al baño, la bañaba yo y a las 10 de la mañana ya estaba desayunando. y nos la llevamos bien, y ella últimamente ya no salía, ya la bañaba y la echaba a desayunar y le daba una vuelta, porque ella caminaba aquí en la casa, afuera no, entonces le daba una vuelta ahí al patio... ya la sentaba yo ahí en su sillón y me salía o la acostaba y ella solita se subía a la cama y se bajaba al sillón, y me salía a abrir el changarro y ya le daba sus vueltas y luego, ya como a las tres, me metía yo a calentar la comida y a darle de comer; le daba de comer y la llevaba a su cuarto o le daba otra vuelta o venía uno de mis hermanos a darle otra vuelta… entonces me salía a una vuelta al changarro o me iba a esas horas a aurrera… a las 7 cerraba y me ponía a guisar, y era cuando empezaba ella: “ya vente, ya vente”, porque le prendía la televisión y ya me ponía yo a guisar y “ya vente, ya vente”, y yo “ya mamá ahorita voy”. cuando se cuida a mayores con enfermedades crónicodegenerativas, todo el horario de vida (laboral, familiar, ocio, etc.) se adapta en función del enfermo que se atiende. 165 la experiencia de ser cuidadora de un anciano con enfermedad crónica en san cristóbal ecatepec, méxico l gabriela aldana-gonzález, liliana garcía-gómez al principio teníamos cada quien nuestra recámara, pero cuando ya se enfermó nos quedamos en el mismo cuarto. se da uno muchas mañas… qué iba a saber yo de cambiarle el pañal a una persona… la volteaba yo de lado y ya le limpiaba. yo siempre le compraba ropa a mi gusto, ella no me decía que no le gustaba, solo que no le comprara tanta ropa que no cabía en el clóset. pero, pues era mi vicio. ella y yo nada más (información obtenida en la primera entrevista realizada en el hogar de la cuidadora el 13 de marzo del 2008). en el discurso de yolanda se destaca el haber adaptado toda su rutina de vida en torno al cuidado de su madre, ajustando tiempos, actividades y afinidades con ella. el cuidado se volvió una rutina muy bien organizada, en la cual giró la vida de yolanda durante esos tres años. por su parte, marcela comenta respecto a su cotidianidad en esos dos años en que cuidó a su madre: en la casa gracias a dios que mi mamá sí se valía por sí misma, no fue necesario ni pañal, nada, iba al baño normal, no hubo ningún cuidado especial, ella salía a bañarse, se peinaba, iba al baño. pensábamos si se podía caer, pero no, ella era fuerte a pesar de la enfermedad, ella misma desayunaba, pera ya poco a poco iba perdiendo sus funciones biológicamente. por ejemplo: su café ya no lo agarraba bien. llegó un momento de comerse el pan con papel, pero eso fue de las últimas veces. mi mamá tenía que seguir el tratamiento, la oxigenaban, le daban el tratamiento y cuando se terminaba todo esto, recaía, y era llevarla otra vez… […] el doctor internista nos dijo que mi mamá podía durar un día, una semana o un año, pero trayéndola y llevándola, trayéndola y llevándola al hospital. para llevarla y traerla nos hacía el favor mis tíos o mi hermano. le gritábamos a las doce de la noche y ya nos llevaban. mi papá la cargaba. mi papá nos hizo el favor de cuidarla en la noche y yo en el día… al final de su enfermedad teníamos que cuidarle la comida, era una comida ya molida, si llevó una comida especial, eso fue como medio año. pues yo ahí estaba, sábados y domingos, pero a veces si se desesperaba uno, porque yo veía que ellos salían y yo ni salía, y bianca [hermana] también con su carácter se iba y me dejaba sola… no, si es una cosa muy difícil, hay que tenerle paciencia porque si no ya luego uno no lo aguanta (información obtenida en la segunda entrevista realizada a la cuidadora al atardecer en el parque cercano a su hogar el 28 de junio del 2008). en la cotidianidad del cuidado de marcela resalta el que ella considera “un favor” el que su padre cuidara por las noches a su mamá, así como el que sus tíos la llevaran en las noches al hospital. el favor, más que para la madre enferma es para la hija, pues ella es la que asume el cuidado principal, dado que se considera parte de las responsabilidades de las mujeres cuidadoras. esto tiene una relación directa con la construcción de género (20, 21) que lleva implícita la obligación filial de las mujeres para con sus padres (5). irene nos relata cómo era un día normal cuando cuidaba a su madre: pues yo llegaba temprano, hacía el quehacer de la casa, iba por el mandado, hacía la comida, veía a mi mamá, por que cuando le salió una llaga en la pierna el doctor nos dijo que teníamos que lavarle diario, y allí yo estaba lavándole con gasas y mi mamá sufría mucho pero ni modo, nos teníamos que aguantar. ella del dolor, yo de hacerla sufrir. pero era por su bien. luego cuando me ponía a lavar me llevaba a mi mamá junto a mí, al final mi mamá ya nada más quería estar junto a mí, andaba pegada conmigo y luego ni podía lavar ni hacer nada por estar con ella. luego pasaban las horas y no me podía ir por que tenía que terminar de atender a mi mamá, cambiarla, acostarla. mis hermanas llegaban hasta las nueve o diez de la noche ya que habían terminado de atender a sus casas, y yo llegaba a mi casa cansada a ver a mi esposo, a dormir con mis hijos. mi hijo darío estaba todo el día en casa de mi mamá, el desde bebé lo tuve ahí, ahí andaba gateando, con su andadera… y también coincidió que mi hija con mis nietos se fueron a vivir ahí. como era la casa materna, todos llegaban a comer, a ver a mi mamá… siempre había gente, pero yo era la encargada de todas las tareas de la casa (información obtenida en la segunda entrevista realizada a la cuidadora al atardecer en el parque cercano a su hogar el 28 de junio del 2008). las actividades diarias que realizaba irene eran el cuidado de su casa y la de su madre, la elaboración de la comida, el cuidado de la madre y de su hijo, la atención a las visitas, la atención de su esposo y de sus nietos. es una labor que refleja sobrecarga en su cotidianidad durante el periodo de cuidado de su madre (23, 25). 166 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 raquel comparte su día a día en el cuidado con su papá y su mamá: era un ir y venir con mi papá, al principio solo al médico y a la clínica, ya después era muy seguido, hasta que tuvimos que cuidarlo en su casa, levantarlo, bañarlo, cambiarlo, era muy difícil. yo me tenía que levantar bien temprano a dejar mis camisas blancas en jabón, pues mi marido siempre usó camisas blancas, y ya me decía mi marido: “córrele raquel que tu mamá ya no ha de poder cuidar a tu papá”, le pasaba un trapo a los pisos, medio arreglaba la casa y ya me iba yo corriendo. allá lavaba, hacía de comer, atendía a mi papá y luego regresaba en las noches atender mis camisas, a ver la casa, a mis hijas, a mi marido, a preparar las cosas para el otro día… es bien difícil cuidar dos casas (su voz se quiebra). yo tenía dos casas. mi papá se dejó cuidar muy bien, se tomaba todas las medicinas, todo se lo comía, yo digo que él amaba mucho la vida… pero sí es muy duro, a veces estábamos comiendo y de repente se ponía enfermo y a movernos, hablaba con mi hermana, que vamos a llevarlo al hospital, o al médico internista… a veces ya ni comíamos de la angustia, de la preocupación, si es tremendo, muy tremendo. era un batallar con mi madre, pues yo iba ayudar con mi papá y mi mamá me escondía la ropa sucia, me decía que era su responsabilidad lavarla, yo le explicaba que para eso iba yo a ayudarlos… a mi mamá le costó mucho trabajo aceptarlo pues era su casa, sus reglas. mi mamá siempre fue de un carácter muy fuerte, malhablada, nos decía las cosas directas, cuando ella se enfermó fue muy difícil cuidarla, se enojaba, no quería la comida sin sal, decía que era como si se tirara el dinero a la basura porque las medicinas ya no la hacían sentir mejor. con mi mamá fue mucho batallar, me despreciaba la comida, le tenía que rogar y explicar, ya cuando me enojaba mejor me salía y decía “dios mío ayúdame a tener tolerancia con mi madre” (información obtenida en la primera entrevista realizada a la cuidadora en la casa de la entrevistadora el 1 de abril del 2008). esta atención diaria y constante durante la mayoría del día hace que la vida solo se centre en el cuidado, dejando de lado actividades sociales, recreativas y personales. la rutina diaria de estar atento a la salud del otro genera desgaste, cansancio, el estrés es parte de la cotidianidad en el cuidado. perciben una sobrecarga en sus actividades diarias, el estar luchando por realizar lo mejor posible su papel de cuidadoras a pesar del cansancio crónico que viven. el trabajo de cuidador exige un esfuerzo permanente tanto físico como psicológico. este asume el papel buscando adaptarse a las rutinas del enfermo, es parte de su responsabilidad, de su compromiso, de su deber para con su madre o su padre. los estresores generados por el cuidado pueden ser representados por las demandas y las tareas que realiza el cuidador tanto por el adulto mayor enfermo, como por la propia situación de atención diaria que se genera (26). en esta cotidianidad rutinaria del cuidado las cuidadoras entrevistadas manifiestan como una necesidad el tener actividades de esparcimiento, sin embargo, el rol que asumen y que les depositan los demás como cuidadoras primarias es el que predomina en su vida diaria. parece que este compromiso filial de género se ve confrontado con las necesidades personales. los estresores generados por el cuidado pueden ser representados por las demandas y las tareas que realiza el cuidador tanto por el adulto mayor enfermo, como por la propia situación de atención diaria que se genera. 167 la experiencia de ser cuidadora de un anciano con enfermedad crónica en san cristóbal ecatepec, méxico l gabriela aldana-gonzález, liliana garcía-gómez la reducción del tiempo libre es una de las consecuencias más comunes del cuidado (26). esta información se desprende de las experiencias que se narran a continuación. nos cuenta yolanda: en una ocasión, fue cuando lo de la diabetes, me iba yo a ir a tecolutla, era mi santo, y se me hizo fácil, me fui, y les hacía yo de comer y les dejaba comida para que comieran todos y así estaban con mi mamá. que hice en irme y llegar a tecolutla y en la noche que me hablan por teléfono: ¡tú mamá se puso mal!, ¿dónde tienes papeles y dinero para el doctor? y se fueron, llegué aquí como a las tres de la tarde y mi mamá estaba internada, no sé si porque la dejé… no sé, y fue cuando se le declaró la diabetes, en esa ocasión sentí que era mi culpa (información recuperada en la primera entrevista realizada a la cuidadora en la sala de su casa al atardecer del 22 de mayo del 2008). respecto al uso del tiempo libre yolanda nos comparte: cuando eres cuidador te vuelves a ella, a ella (persona enferma) yo no salía ni al cine ni al teatro. nada más mi salida era ir a comprar mis cosas los domingos y a oír misa, y ya después ya me quedaba aquí. antes todo el tiempo estaba aquí pero por mi mamá, ahora nunca me encuentran, por eso digo: cuando quieran venir avísenme y los espero, de otra manera me salgo, al mercado o cualquier cosa (información recuperada en la primera entrevista realizada a la cuidadora en la sala de su casa al atardecer del 22 de mayo del 2008). marcela nos narra respecto al uso de su tiempo libre, cuando sus hermanos y sobrinos salían de paseo: yo veía que ellos salían y yo ni salía, y bianca [hermana] también con su carácter “no que yo me voy”. allá en donde paseaban se quedaban a dormir y yo aquí encerrada, yo tenía ganas de salir pero ni nos invitaban (información obtenida en la primera entrevista realizada el 3 de junio del 2008). irene nos relata la experiencia acerca de su tiempo libre: pues yo no tenía tiempo libre, cuando salíamos buscábamos llevarnos a mi mamá para que se distrajera. no podíamos dejar a mi mamá, ¿con quién se quedaba? yo de buscar una distracción era dentro de la propia casa de mi mamá, ahí me llevaba mis costuras de la máquina y me ponía a coser. algo que yo hacía para distraerme era el estar cambiando de posición los muebles de la casa de mi mamá, barriendo donde estaba sucio, limpiando lo que podía. yo no supe de distracciones cuando cuidé a mi mamá, pues era mi responsabilidad, además tenía que atender a mis hijos, ver a mi esposo ¿en qué tiempo? no había tiempo (información obtenida el 13 de marzo del 2008). respecto a su tiempo libre raquel nos comenta: yo los fines de semana soy maestra de manualidades en el parque de aragón. cuando me quedé a cuidar a mis padres, yo les dije a mis hermanos que yo estaría con ellos toda la semana, pero que los fines de semana eran míos, que me tenía que ir al parque, porque yo allá tengo muchos años y no quería perder mi lugar, además que es algo que me gusta mucho… los fines de semana se venía una hermana que vivía en toluca y cuidaba a mi papá; yo el lunes regresaba a la misma rutina. cuando yo me iba al parque sentía que agarraba fuerzas para seguir en mi labor de cuidar a mis padres (información obtenida el 1 de abril del 2008). la situación que reportan las entrevistadas coincide respecto a que los problemas sociales que mencionan los cuidadores con mayor frecuencia son la falta de tiempo libre, la soledad y el aislamiento (23). sus actividades se ven limitadas al cuidado del anciano, teniendo que reajustar su vida en torno a ellos. esto genera sentimientos de tristeza, desesperación, angustia, estrés, culpa. las decisiones personales se postergan, dependen de cumplir primero las necesidades del enfermo a quien se cuida. una de las características de los cuidadores es que se olvidan de sí mismos, no tomándose el tiempo libre que necesitan para descansar; abandonan las aficiones que tenían, dejan de comunicarse con los amigos, etc. es decir, acaban paralizados durante algunos años su proyecto de vida, dependiendo del tiempo del cuidado (27). las entrevistadas mencionan la necesidad de tener actividades de esparcimiento, pero después de sus “obligaciones” de cuidado. incluso parece que no se tiene derecho a una vida personal, a la diversión, pues permanece un sentimiento de culpa. se encuentran ante la decisión de luchar por su derecho de cuidarse a sí mismas, o resignarse a ser solo cuidadoras del anciano enfermo. se destaca la situación de raquel, que logra negociar con su familia los fines de 168 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 semana para sí misma, ello permite compartir la responsabilidad del cuidado, y tener actividades de esparcimiento personal, lo cual es un factor protector de la presencia de estrés en cuidadores de ancianos dependientes (9). sin embargo, las cuidadoras relegan a un segundo plano los aspectos de su propia persona. la cotidianidad del cuidado al otro rebasa la mirada hacia el cuidado personal. aunado a las dificultades para el uso del tiempo libre en actividades de esparcimiento es de resaltar que para lograr asumir el rol de cuidador, las labores se ven limitadas al entorno del hogar, no teniendo oportunidad de asumir un “trabajo formal” que les permita tener un momento de lejanía del cuidado. uno de los conflictos de los cuidadores son los problemas laborales (26). al respecto las entrevistadas comentan su situación laboral durante el cuidado de la anciana o el anciano enfermo. en el caso de yolanda, ella organizó su vida en torno al cuidado de su madre, como las dos eran jubiladas recibían una pensión quincenal. yolanda atendía una tienda de regalos en el mismo domicilio, lo cual le permitía “estar al tanto” de su mamá. ella nos relata los últimos meses de atención a su madre: antes de que se fuera mi mamá yo cerré el negocio, ella se puso mala en julio, entonces yo cerré mi changarro y me dediqué a mi mamá, ya en diciembre empecé a abrir en las tardes, pero mi mamá se volvió a enfermar, entonces ya no lo abrí (información obtenida en la segunda entrevista realizada a la cuidadora en la casa de la entrevistadora el 17 de junio del 2008). en el caso de marcela su situación económica era distinta, ella tenía un trabajo remunerado y compartía los gastos del hogar con su padre que estaba pensionado. sin embargo, al ser la cuidadora principal, ya no podía trabajar de manera formal, y empezó a sobrevivir de diferentes trabajos “extras” a su labor como cuidadora, ella nos narra que: cuando mi mamá estaba enferma yo le ayudaba a la señora hermelinda una vecina haciendo quehacer en su casa, cuando estaban porque luego se iba… de eso me ayudaba para comprar la comida, la leche de mi niño (información obtenida en la segunda entrevista realizada a la cuidadora en la cocina de su casa el 3 de junio del 2008). irene nos comenta que ella no trabajaba de manera formal, pues tenía que atender dos casas: pues yo trabajé en la general electric un tiempo en la maquila, ya después tuve mis hijos, mi mamá siempre me ayudó a cuidarlos. mi hermana y yo estudiamos alta costura y nos hacían encargos de ropa… cuando cuidaba a mi mamá todavía yo cosía, ahí con mi mamá cosíamos mi hermana y yo… yo cuidaba la casa, hacía la comida, veía a mi mamá y también cosía, era cosa de locos. después llegaba a mi casa en la noche a ver a mi marido, atender a mi hijo, por que aunque estaba conmigo todo el día yo lo descuidaba mucho, ahí andaba el pobre de mi hijo de un lado a otro conmigo. luego me retrasaba mucho en las entregas y empecé a perder clientes… ya después dejamos de coser (información obtenida el 13 de marzo del 2008). raquel coincide en que tenía que atender dos casas, sin embargo, la negociación a la que llegó con su hermana le permitía ir a trabajar los fines de semana como maestra de manualidades. aunque ella comenta que este trabajo era más como un esparcimiento personal, pues la remuneración económica que percibía era mínima. al respecto del trabajo nos comenta: en ese entonces estábamos en una situación económica muy difícil, aunque mi marido siempre ha sido muy trabajador, pues eran muchos los gastos de mi casa: la renta, la escuela de mis hijas. yo les dije a mis hermanos que yo en lo único que podía colaborar era en cuidar a mis padres, en hacer la limpieza, hacer de comer, porque en dinero nada. cuando hablé con mis hermanos de que yo me ofrecía a cuidar a mis padres, les pedí que ellos los vieran por los fines de semana porque yo quería continuar como maestra de cerámica, más que un trabajo es un esparcimiento (información obtenida en la segunda entrevista realizada a la cuidadora en la casa de la entrevistadora el 17 de junio del 2008). de los anteriores testimonios se desprende que el trabajo pasa a ser una opción secundaria en la rutina del cuidado diario del anciano. las cuidadoras trabajan de forma intermitente y buscan un trabajo que se ajuste a los horarios de cuidado, de no ser así, renuncian a su trabajo. esta acción es una de las características que presentan las cuidadoras y que se constituye en un factor de riesgo en cuanto a sobrecarga en el cuidado (20). existe una menor sobrecarga en el cuidador principal cuando este recibe el apoyo social de sus familiares allegados, vecinos, etc., mientras que los que no reciben apoyo social son más propensos a padecer depresión y a sentir angustia (28). 169 la experiencia de ser cuidadora de un anciano con enfermedad crónica en san cristóbal ecatepec, méxico l gabriela aldana-gonzález, liliana garcía-gómez este factor protector no se ve reflejado en las relaciones sociales y familiares de marcela, yolanda e irene, al contrario, la familia genera mayor tensión y ansiedad en ellas al exigirles el cuidado de sus padres. la vida de estas mujeres se centra en las acciones diarias del cuidado, sin tener claro cuándo podrán retomar su rutina personal pues esta implica un esfuerzo mayor a sus actividades diarias. así es como se asume el cuidado, con todas las limitaciones de la vida propia, por estar atendiendo al otro, y con la retribución emocional que implica este acto. en las cuidadoras entrevistadas los intereses, las motivaciones y las expectativas en su proyecto de vida pasan a un segundo plano, todo el tiempo lo dedican al cuidado del otro (29, 30). conclusiones en este trabajo se observó que la feminización como obligación filial (5) se refleja en que las entrevistadas asumen el papel de ser designadas como cuidadoras de los padres ancianos con una enfermedad crónico-degenerativa. también se evidencian las pocas o nulas ayudas que perciben las cuidadoras en sus actividades, pues se designa al cuidado como una obligación que deben cumplir, pareciendo una acción invisible, que debe realizarse, sin dar el crédito, el reconocimiento o las ayudas necesarias a la cuidadora principal (31, 32). estas características nos permiten ubicar a las cuidadoras como un grupo vulnerable a la sobrecarga, al estrés, a la exclusión, a la marginalidad y al olvido social. sin embargo, al hacer evidente la cotidianidad del cuidado se logró resignificar la obligación filial, pues develó las constantes contradicciones morales a las que se ven sometidas las cuidadoras. por una parte, la aceptación del rol de cuidadoras dado el compromiso filial, y por la otra, el rechazo a este papel al mostrar un deseo constante de tomar decisiones sobre su propia vida y añorar su autonomía, pues la presencia de sobrecarga y de estrés por el cuidado es evidente. se genera entonces una lucha interna en el rol de ser cuidadora entre el asumir el papel obligado designado por los otros, y el tomarlo como convicción propia, como reflejo diario del amor filial. aunque en sus acciones siempre reflejan este compromiso filial, en sus pensamientos y análisis personales manifiestan estar menos dispuestas a renunciar a su bienestar personal para dedicar su vida al cuidado. ello involucra un desgaste emocional y físico continuo. su cotidianidad se vuelve una pesada carga impuesta por los otros y asumida por ellas mismas. el papel designado por la sociedad lo reconstruyen como propio al resistirse a solo ser cuidadoras. ello refleja la redefinición del rol de género femenino de las cuidadoras en el siglo xxi: estar menos dispuestas a ser el único apoyo de los ancianos en condiciones de vulnerabilidad física (5). los cambios del perfil de las cuidadoras hacen necesario desarrollar alternativas para el apoyo a los ancianos enfermos y a las propias cuidadoras. los planteamientos de la gerontología son propositivos al respecto (oms). el envejecimiento activo, entendido como el proceso de aprovechar al máximo las oportunidades para tener un bienestar físico, psíquico y social durante toda el envejecimiento activo, entendido como el proceso de aprovechar al máximo las oportunidades para tener un bienestar físico, psíquico y social durante toda la vida, es la tarea principal a la que le apuesta la gerontología. 170 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 la vida, es la tarea principal a la que le apuesta la gerontología. su objetivo primordial es extender la calidad, la productividad y la esperanza de vida a edades avanzadas. el primer planteamiento que sostenemos es la importancia de mantener la independencia de los individuos. la salud es el medio que posibilita la independencia para envejecer activamente. en la medida en que los ancianos se mantengan activos y saludables por más tiempo, la intervención de los cuidadores se postergará. e incluso los propios cuidadores y cuidadoras llegarán saludables a la vejez. por ello señalamos que es necesaria la implementación de acciones de atención primaria que promuevan el envejecimiento activo dentro de la comunidad. actualmente existen propuestas al respecto (33). sin embargo, aun con el incremento del envejecimiento activo, el cuidado es una situación que no puede eludirse en su totalidad, por ello nuestro segundo planteamiento se dirige a subrayar la importancia del fortalecimiento de las redes sociales como una alternativa necesaria para que el cuidado de los ancianos sea compartido, y así disminuir la sobrecarga hacia los cuidadores. señalamos la necesidad de generar acciones que permitan fortalecer los vínculos intergeneracionales (34) como una manera también de promover estilos de vida saludables en las generaciones jóvenes y maduras, pues estos jóvenes son los futuros ancianos y en ellos deben reflejarse las premisas del envejecimiento activo, baste recordar las proyecciones poblacionales. para el 2050, en méxico se proyecta que el número de adultos mayores del país se cuadriplicará al pasar de 6,7 millones en 2000 a 36,5 millones en el 2050 (35). a través de este tipo de investigaciones, en donde se da voz a las protagonistas del cuidado, hacemos patente la necesidad de que se reconozca su papel, se valore, se remunere y se generen ayudas. y ayudas no solo de parte de las familias inmediatas sino también de tipo institucional, en donde se asuma el papel del estado como promotor de la salud comunitaria (36). el desarrollo de políticas públicas basadas en la voz de los protagonistas es necesario para que estas tengan éxito en la población. es indispensable que se diseñen políticas públicas de atención primaria que apoyen la función de las cuidadoras, que sean apropiadas a los sentires y necesidades expresadas desde la experiencia y la voz de los protagonistas, pues su éxito se identifica cuando estos las hacen suyas, las repiensan, las reconstruyen y ajustan a sus visiones personales de ver el conflicto. cuando esto se logra, se puede decir que las políticas llegarán a tener éxito (15). finalmente, identificamos a las metodologías cualitativas como un vehículo privilegiado para “dar voz”, enfatizar la propia experiencia y proponer nuevas vías de acceso al conocimiento de lo social, pues existe una urgente necesidad de aumentar el reconocimiento y la comprensión de las personas pertenecientes a grupos vulnerables a través de sistemas que practiquen el “arte de 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6 (1): 22-33. 37. barton l. emancipatory research and disabled people: some observations and questions. educational review 2005; 57 (3): 317-327. 549 559 efectividad de una intervencion.indd 549 emilio gonzález-jiménez1 gustavo raúl cañadas2 almudena lastra-caro3 guillermo arturo cañadas-de la fuente4 efectividad de una intervención educativa sobre nutrición y actividad física en una población de adolescentes. prevención de factores de riesgos endocrino-metabólicos y cardiovasculares 1 doctor por la universidad de granada, facultad de enfermería (campus de melilla). universidad de granada, melilla (españa). emigoji@ugr.es 2 doctor por la universidad de granada, facultad de ciencias de la educación, universidad de granada, granada (españa). gcanadas@ugr.es 3 enfermera, área de gestión sanitaria norte de almería, almería (españa). almudenalastra@hotmail.com 4 doctor por la uned, facultad de ciencias de la salud, departamento de enfermería, universidad de granada, granada (españa). gacf@ugr.es recibido: 6 de diciembre de 2012 enviado a pares: 17 de febrero de 2013 aceptado por pares: 18 de octubre de 2013 aprobado: 18 de noviembre de 2013 doi: 10.5294/aqui.2014.14.4.9 para citar este artículo / to reference this article / para citar este artigo gonzález-jiménez e, cañadas gr, lastra-caro a, cañadas-de la fuente ga. efectividad de una intervención educativa sobre nutrición y actividad física en una población de adolescentes. prevención de factores de riesgos endocrino-metabólicos y cardiovasculares. aquichan. 2014; 14(4): 549-559. doi: 10.5294/aqui.2014.14.4.9 resumen objetivo: verificar una mejora del estado nutricional y la adopción de hábitos alimentarios y de actividad física saludables en una población de estudiantes tras una intervención educativa en salud. materiales y métodos: población compuesta por 90 adolescentes entre 15 y 17 años de edad, 46 hombres (51,1 %) y 44 mujeres (48,9 %), pertenecientes a un centro educativo público de la ciudad de almería (españa). el estudio se realizó en tres fases. la primera fase contempló valoración del estado nutricional; la segunda, intervención educativa sobre alimentación saludable y actividad física; la tercera, evaluación de la eficacia de dicha intervención. resultados: estadísticamente hubo mejoría (p < 0,000) en el estado nutricional de los alumnos valorados con independencia de su sexo. respecto de la adopción de hábitos saludables, se observaron diferencias significativas en las puntuaciones del test kreceplus (p < 0,000), aunque no para la actividad física tras la intervención (p = 0,568). conclusiones: los resultados muestran la efectividad de los procedimientos aplicados en esta intervención para modificar hábitos alimentarios. con todo ello, la práctica de ejercicio físico continúa siendo una asignatura pendiente entre los adolescentes. palabras clave educación en enfermería, obesidad, adolescente, estado nutricional, actividad motora. (fuente: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 549-559 550 aquichan issn 1657-5997 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 549-559 effectiveness of an educational intervention on nutrition and physical activity in an adolescent population. prevention of endocrine-metabolic and cardiovascular risk factors abstract purpose: the purpose of this study was to verify an improvement in nutritional status and the adoption of healthy habits with respect to eating and physical activity in a population of students, following a health-education intervention. study materials and methods: the sample was comprised of 90 adolescents between 15 and 17 years of age; 46 are male (51.1%) and 44, female (48.9%). all of them are from a public school in the city of almeria (spain). the study was conducted in three phases. the first phase involved an assessment of nutritional status. the second was comprised of an educational intervention on healthy habits with respect to eating and physical activity, while the third focused on an assessment of the effectiveness of that intervention. results: statistically, there was an improvement (p <0.000) in the nutritional status of the students who were evaluated, regardless of their gender. as to the adoption of healthy habits, significant differences in the kreceplus test scores (p <0.000) were observed subsequent to the intervention, although not for physical activity (p = 0.568). conclusions: the results show the procedures applied in this intervention to modify dietary habits were effective. yet, physical exercise remains a pending issue among adolescents. key words nursing education, obesity, adolescent, nutritional status, motor activity. (source: decs, bireme). 551 efectividad de una intervención educativa sobre nutrición y actividad física en una población de adolescentes. l emilio gonzález-jiménez y otros efetividade de uma intervenção educativa sobre nutrição e atividade física numa população de adolescentes. prevenção de fatores de riscos endócrino-metabólicos e cardiovasculares resumo objetivo: verificar uma melhoria do estado nutricional e da adoção de hábitos alimentares e de atividade física saudáveis numa população de estudantes após uma intervenção educativa em saúde. materiais e métodos: população composta por 90 adolescentes entre 15 e 17 anos de idade, 46 homens (51,1 %) e 44 mulheres (48,9 %), pertencentes a um centro educacional público da cidade de almería (espanha). o estudo foi realizado em três fases. a primeira fase contemplou avaliação do estado nutricional; a segunda, intervenção educativa sobre alimentação saudável e atividade física; a terceira, avaliação da eficácia dessa intervenção. resultados: estatisticamente, houve melhoria (p < 0,000) no estado nutricional dos estudantes avaliados independentemente de seu sexo. a respeito da adoção de hábitos saudáveis, observaram-se diferenças significativas nas pontuações do teste kreceplus (p < 0,000), embora não para a atividade física após a intervenção (p = 0,568). conclusões: os resultados mostram a efetividade dos procedimentos aplicados nessa intervenção para modificar hábitos alimentares. com tudo isso, a prática de atividades físicas continua sendo uma matéria pendente entre os adolescentes. palavras-chave educação em enfermagem, obesidade, adolescente, estado nutricional, atividade motora. (fonte: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 549-559 552 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 introducción en la actualidad, la obesidad constituye el trastorno nutricional más prevalente entre la población infantil y adolescente (1). comparando los resultados obtenidos a partir de estudios realizados en la década de los ochenta y hasta la actualidad, se observa una tendencia al alza, lo que se traduce en que la tasa de sobrepeso y obesidad se ha triplicado entre los más jóvenes (2, 3). ello parece tener entre sus causas una mayor disponibilidad y acceso fácil a alimentos de alto contenido calórico y escaso poder nutricional, así como la adopción de estilos de vida sedentarios, especialmente en poblaciones urbanas (4). además, la existencia de un entorno familiar carente de hábitos alimentarios saludables complica aún más la situación. de acuerdo con gonzález (5), el modo de alimentarse, las preferencias y los rechazos hacia determinados alimentos se encuentran fuertemente condicionados por el contexto familiar durante la etapa infantil. por otra parte, el incremento de las tasas de obesidad infantil ha ocasionado el afloramiento de un importante número de patologías que hasta el momento eran propias de la edad adulta (6). trastornos endocrino-metabólicos como la dislipemia o resistencia insulínica, con el consiguiente riesgo de desarrollar diabetes mellitus tipo 2, y cardiovasculares como la hipertensión arterial o la aterosclerosis, son cada vez más frecuentes entre la población más joven de nuestro país (7-11). a la luz de todo ello, no cabe duda de que la obesidad representa un grave problema de salud entre los más jóvenes y una prioridad que se debe abordar a edades cada vez más precoces para prevenir los factores de riesgo mencionados (10, 11). en este sentido, su prevención ha de iniciarse desde la más temprana edad y tomando como base el sistema educativo, fomentando en este el desarrollo y la implantación de programas de educación nutricional (12, 13). hasta el momento, los estudios de intervención realizados sobre alimentación y actividad física en población escolar confirman no solo su efectividad sino además el deseo e interés que los mismos despiertan entre los alumnos y el propio profesorado de los centros en los que se desarrollan (14-16), aspecto este último de gran importancia para garantizar el avance y la adecuada evolución de la intervención en salud. en este sentido, estudios recientes confirman que una intervención educativa en salud por profesionales de enfermería, mediada por una educación nutricional y complementada con actividad física regular, mejora el estado nutricional entre los más jóvenes (17, 18). objetivos teniendo en cuenta lo anterior, los objetivos de este trabajo son: • verificar una mejoría en el estado nutricional (reducción de los valores del índice de masa corporal) de un grupo de 91 alumnos pertenecientes a un centro educativo público de la ciudad de almería. • verificar la adopción de hábitos alimentarios y de actividad física saludables tras el desarrollo de una intervención educativa en salud. materiales y métodos la población objeto de estudio estaba compuesta por 91 adolescentes de entre 15 y 17 años de edad, 46 chicos (51,1 %) y 44 chicas (48,9 %), pertenecientes a un centro educativo público de la ciudad de almería. como criterios de inclusión de la muestra fueron considerados candidatos a participar en el estudio todos aquellos chicos y chicas carentes de patología endocrina o física. además, fue necesario contar con la autorización, vía consentimiento informado, por parte de los padres o tutores. la experiencia se llevó a cabo durante el curso académico 2011-2012, abarcando el periodo de tiempo comprendido entre los meses de septiembre de 2011 hasta junio de 2012. el estudio se articuló en tres fases. una primera etapa, que comprende la segunda quincena del mes de septiembre. en ella se realizó una valoración del estado nutricional de todos los alumnos. mediante el uso de técnicas antropométricas se determinaron las variables peso, estatura e índice de masa corporal, según edad y sexo. se tomaron como referencia los estándares de cole et al. (19). una segunda fase del estudio comprendió los meses de octubre de 2011, hasta la primera quincena de junio de 2012, para un total de 8 meses y 2 semanas. en esta segunda fase tuvo lugar la intervención educativa sobre alimentación saludable y ejercicio físico. a nivel nutricional, se realizaron tres talleres educativos sobre hábitos y pautas de alimentación saludable. cada taller se realizó durante la primera semana correspondiente a los meses de octubre, enero y abril. a los talleres asistieron los alumnos en compañía de sus padres o tutores. en ellos, además de proporcionar principios para una alimentación equilibrada, se daba respuesta a dudas y curiosidades que alumnos y padres plateaban. en el ámbito de la actividad física, y previo acuerdo con el profesor de 553 efectividad de una intervención educativa sobre nutrición y actividad física en una población de adolescentes. l emilio gonzález-jiménez y otros educación física del centro, se establecieron una serie de juegos y actividades que los alumnos deberían realizar durante las clases de educación física, esto es, durante tres días a la semana. la última fase del estudio tuvo lugar durante las dos últimas semanas del mes de junio. en este periodo se llevó a cabo la evaluación de la eficacia de la intervención educativa desarrollada, en términos de mejora o no del estado nutricional de los alumnos y hábitos saludables adquiridos. a fin de valorar la mejoría del estado nutricional y los hábitos de nuestros estudiantes durante el periodo de la intervención educativa, se llevó a cabo un análisis de variables mediante comparación de medias relacionadas en las variables consideradas de interés. entre las variables seleccionadas tenemos: índice de masa corporal (imc), estatura, peso y puntuación en el test rápido de kreceplus. todas ellas fueron medidas antes y después de la experiencia, a excepción de la variable peso, la cual fue determinada en nueve momentos diferentes distribuidos de forma regular a lo largo de todo el periodo de tiempo de la intervención. para el análisis de los datos se utilizó el paquete estadístico spss versión 19 para windows. resultados los resultados obtenidos muestran, en líneas generales, una mejora por parte de los alumnos en su estado nutricional. respecto del índice de masa corporal, medido antes (m = 23,2; dt = 4,1) y después (m = 23; dt = 3,9), mediante la prueba t para muestras relacionadas, se obtiene una significación de 0,035. luego, las medias de los dos grupos se consideran diferentes, lo cual indica que se produce un descenso en el índice de masa corporal. en el caso de su estudio por sexos, se puede observar que en las chicas hay valores superiores (tabla 1 y figura 1). por otro lado, para el primer caso, las variables kreceplus y actividad física muestran una significación de 0,000, esto es, los valores en el test kreceplus aumentaron después de la intervención. por otro lado, para la actividad física no se encontraron diferencias estadísticamente significativas (0,568). al realizar este mismo estudio de forma independiente para chicos y para chicas, se observa que no existen diferencias significativas (tabla 2). en la figura 2, se muestran estas comparaciones de forma más ilustrativa. la variable peso muestra un descenso en sus valores, tanto al comienzo de la intervención como a su término (figura 3). los análisis de comparaciones de medias para los pesos consecutivos muestran diferencias en varios momentos, siendo durante la última fase cuando se acentúan más (tabla 3). discusión en la actualidad, el incremento de la prevalencia de sobrepeso y obesidad en el ámbito escolar representa un grave problema de salud pública (20). los resultados obtenidos en este estudio muestran cómo una intervención en salud en el ámbito educativo constituye una vía efectiva de abordaje para reducir los niveles de sobrepeso y obesidad entre los más jóvenes, además de sus futuras complicaciones endocrino-metabólicas y cardiovasculares (10, 11). considerando el sexo, los resultados confirman diferencias en la mejora del estado nutricional tras los nueve meses de intervención educativa. los chicos redujeron en mayor escala sus puntuaciones en el índice de masa corporal respecto al sexo femenino. de igual modo, la variable peso experimentó un progresivo descenso en ambos sexos, a medida que avanzaba el periodo de la intervención educativa. todo ello coincide con lo reportado por gonzález (21) en su estudio con una población de escolares de la provincia de granada, en donde concluía que los chicos mostraban una mayor adherencia al régimen de recomendaciones nutricionales establecidas durante la intervención nutricional. asimismo, de acuerdo con gonzález (22), las diferencias en composición corporal entre ambos sexos pueden suponer igualmente un factor influyente y por considerar en el ritmo de descenso de las puntuaciones del índice de masa corporal entre dicha población. en relación con la adopción de hábitos saludables tras la intervención, el test kreceplus puso de manifiesto una mejoría estadísticamente significativa en la adopción de hábitos de alimentación saludables. todos los alumnos pasaron de un nivel nutricional muy bajo antes de la intervención, hasta un nivel nutricional medio después de los nueve meses de intervención nutricional. al igual que en otros estudios (23, 24), los resultados alcanzados avalan la eficacia de los talleres desarrollados, así como una óptima adherencia a los mismos por parte de los alumnos. con relación a la práctica de actividad física, se puede observar que ni chicas ni chicos incrementaron el tiempo dedicado a la misma fuera del ámbito escolar. únicamente las chicas aumentaron levemente el periodo de tiempo diario dedicado a la actividad física. a la vista de los resultados alcanzados, y de acuerdo con lo planteado por estudios anteriores (25, 26), se observa la efecti554 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 vidad de los procedimientos aplicados en esta intervención para modificar los hábitos alimentarios. no obstante, la no adopción de niveles de actividad física más altos tras la intervención entre la muestra estudiada, determina la necesidad de seguir profundizando en esta cuestión, a partir del análisis de todos los factores potencialmente implicados, a fin de alcanzar el desarrollo de una vida más activa físicamente entre los más jóvenes, que contribuya a prevenir factores de riesgo que aumenten la incidencia y, por tanto, la prevalencia de complicaciones endocrino-metabólicas y cardiovasculares (10, 11). referencias 1. cáncer e, abilés v, abilés j, martínez ma, bretón i, peláez n, et al. técnicas mínimamente invasivas emergentes en el tratamiento de la obesidad. nutr hosp. 2012;27(4):1025-30. 2. gonzález-jiménez e, montero-alonso ma, schmidt-riovalle j, garcía-garcía cj, padez c. metabolic syndrome in spanish adolescents and its association with birth weight, breastfeeding duration, maternal smoking, and maternal obesity: a cross-sectional study. eur j nutr. 2014; 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2010. 22. gonzález jiménez e. body composition: assessment and clinical value. endocrinol nutr. 2013;60(2):69-75. 23. lloyd-richardson ee, jelalian e, sato af, hart cn, mehlenbeck r, wing rr. two-year follow-up of an adolescent behavioral weight control intervention. pediatrics. 2012;130(2):281-88. 24. jelalian e, lloyd-richardson ee, mehlenbeck rs, hart cn, flynn-o’brien k, kaplan j, neill m, wing rr. behavioral weight control treatment with supervised exercise or peer-enhanced adventure for overweight adolescents. j pediatr. 2010;157(6):923-28. 25. haynos af, o’donohue wt. universal childhood and adolescent obesity prevention programs: review and critical analysis. clin psychol rev. 2012;32(5):383-99. 26. friedrich rr, schuch i, wagner mb. effect of interventions on the body mass index of school-age students. rev saude publica. 2012;46(3):551-60. 556 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 figura 1. evolución en el tiempo de la variable imc según el sexo 557 efectividad de una intervención educativa sobre nutrición y actividad física en una población de adolescentes. l emilio gonzález-jiménez y otros figura 2. krece plus y actividad física antes y después de la intervención 558 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 figura 3. evolución de la variable peso durante la intervención según el sexo 559 efectividad de una intervención educativa sobre nutrición y actividad física en una población de adolescentes. l emilio gonzález-jiménez y otros tabla 1. índice de masa corporal antes y después de la intervención según el sexo sexo recuento porcentaje antes después sig. media varianza media varianza f 44 48,9 25,92 15,95 24,79 13,87 0,000 m 46 51,1 20,54 3,18 19,61 3,57 0,000 tabla 2. krece-plus y actividad física antes y después de la intervención según el sexo sexo recuento porcentaje antes después sig. media varianza media varianza krece-plus f 44 48,9 25,92 15,95 24,79 13,87 0,000 m 46 51,1 20,54 3,18 19,61 3,57 0,000 actividad física f 44 48,9 46,27 865,13 48,73 984,58 0,459 m 46 51,1 47,76 722,45 43 605,6 0,089 tabla 3. evolución del peso durante los nueve meses de intervención según el sexo momento sig.5 femenino masculino media varianza media varianza peso 1 0,114 75,9 186,86 56,79 73,15 peso 2 0,056 75,69 188,87 56,43 75,26 peso 3 0,014 75,48 186,84 56,32 74,32 peso 4 0,897 75,13 180,16 56,13 73,06 peso 5 0,000 75,15 181,47 56,07 75,38 peso 6 0,044 74,71 179,11 55,9 77,03 peso 7 0,000 74,42 182,03 55,49 75,45 peso 8 0,014 72,37 128,11 55,11 75,56 peso 9 71,33 108,91 54,49 75,45 5 comparaciones de los pesos consecutivos 169 182 modelo de resiliencia sexual.indd 169 lubia castillo-arcos1 raquel benavides-torres2 modelo de resiliencia sexual en el adolescente: teoría de rango medio 1 estudiante de doctorado en ciencias de enfermería, universidad autónoma de nuevo león, uanl. centro de investigación y desarrollo en ciencias de la salud, méxico. lubiacastilloa@gmail.com 2 phd. universidad autónoma de nuevo león, uanl, facultad de enfermería, centro de investigación y desarrollo en ciencias de la salud, méxico. rabenavi@gmail.com recibido: 17 de enero de 2012 aceptado: 25 de junio de 2012 resumen para el profesional de enfermería es indispensable contar con teorías propias que le ayuden a sustentar científicamente el cuidado, haciendo de esta forma una práctica disciplinar más autónoma y segura. el presente trabajo tuvo como objetivo generar una teoría de rango medio para dar explicación al fenómeno de la conducta sexual de riesgo en el adolescente. se utilizó el método de derivación teórica de fawcett para realizar la estructuración conceptual-teórica-empírica de la teoría propuesta. la revisión de la literatura permitió realizar la estructura del modelo de resiliencia sexual en el adolescente a partir de los conceptos y las proposiciones que integran los factores de riesgo, factores protectores y factor resultado que influyen en la resiliencia durante la etapa de desarrollo del adolescente. asimismo, el modelo contribuye al diseño de intervenciones psicoeducativas dirigidas a la prevención de conductas sexuales de riesgo para vih. palabras clave resiliencia psicológica, educación sexual, sociología médica. (fuente: decs, bireme). model of sexual resilience in the adolescent: middle range theory abstract it is indispensable for nursing professionals to have their own theories to help them scientifically support care, so as to make the practice of this discipline more autonomous and safer. the purpose of this study was to generate a middle range theory to explain the phenomenon of risky sexual behavior on the part of adolescents. fawcett’s theoretical derivation method was used to develop the conceptual-theoretical-empirical structure of the proposed theory. a literature review made it possible to structure the model of sexual resilience in adolescents based on the concepts and proposals that constitute the risk factors, the protective factors and the outcome factor influencing resilience during the period of adolescent development. the model also contributes to the design of psycho-educational interventions focused on preventing the sort of sexual conduct that poses a risk of contracting hiv. key words resilience, psychological, sex education, sociology, medical. (source: decs, bireme). año 12 vol. 12 nº 2 chía, colombia agosto 2012 l 169-182 170 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 modelo de resiliência sexual no adolescente: teoria de classe média resumo para o profissional de enfermagem, é indispensável contar com teorias próprias que o ajude a sustentar cientificamente o cuidado, o que permite ele realizar uma prática disciplinar mais autônoma e segura. o presente trabalho teve como objetivo gerar uma teoria de classe média para dar explicação ao fenômeno da conduta sexual de risco no adolescente. utilizou-se o método de derivação teórica de fawcett para realizar a estruturação conceitual-teórica-empírica da teoria proposta. a revisão da literatura permitiu realizar a estrutura do modelo de resiliência sexual no adolescente a partir dos conceitos e das proposições que integram os fatores de risco, fatores protetores e fator resultado, que influenciam na resiliência durante a etapa de desenvolvimento do adolescente. além disso, o modelo contribui para o desenho de intervenções psicoeducativas dirigidas à prevenção de condutas sexuais de risco para o hiv. palavras-chave resiliência psicológica, educação sexual, sociologia médica. (fonte: decs, bireme). 171 modelo de resiliencia sexual en el adolescente: teoría de rango medio l lubia castillo-arcos, raquel benavides-torres introducción el síndrome de inmunodeficiencia adquirida (sida) es la epidemia más extendida de la actualidad, que afecta principalmente a los adolescentes. se estima que en américa latina y el caribe existen más de 2,1 millones de personas que están viviendo con el virus de inmunodeficiencia humana (vih), de los cuales 740.000 son jóvenes entre los 15 y 24 años (1). el centro nacional para la prevención y control del sida (censida) (2) indica que el 48,6 % de los casos de sida se infectó en la adolescencia, y que el 99 % ocurrió por contacto sexual. asimismo, la evidencia científica reporta que disminuir el impacto de los factores de riesgo propicia las conductas sexuales saludables. chirinos (3) refiere que los adolescentes que no se perciben en riesgo no contemplan modificar las conductas sexuales riesgosas y consideran que la infección por vih les puede ocurrir a otros pero no a ellos; se creen invulnerables. es por esto que modificar tales conductas es sin duda un gran desafío. en este sentido, la resiliencia basada en prevención se dirige a fortalecer los factores protectores que posee el individuo y a disminuir los factores de riesgo (4) permitiendo de esta forma dar solución a problemas de salud que afectan de manera importante a los adolescentes. la resiliencia ha mostrado su efectividad en diversas intervenciones ya que promueve el proceso de superar los efectos negativos de la exposición al riesgo, el afrontamiento exitoso de las experiencias estresantes, y la evitación de las trayectorias negativas asociadas al riesgo (5, 6, 7). la organización de las naciones unidas para la educación, la ciencia y la cultura (8) estima que en el 2030 existirán más de 40 millones de adolescentes que se infectarán con el vih en todo el mundo. por esta razón, es necesario que los profesionales de la salud, especialmente los que realizan investigación en enfermería, continúen y redoblen esfuerzos enfocados a generar teorías de rango medio de prevención en vih/sida para reducir la incidencia de infecciones en adolescentes debido a que hasta el momento aún no existe una vacuna que proteja de contagiarse del vih, ni tratamiento que garantice la cura a esta enfermedad con consecuencias fatales (9). con base en lo anterior, las teorías de rango medio permiten instrumentalizar la práctica del cuidado y hacer que las intervenciones de enfermería se generen de acuerdo con una comprensión más operativa del fenómeno y den respuesta a las necesidades del sujeto de cuidado, en este caso al adolescente dentro del contexto de la conducta sexual de riesgo. en el presente trabajo se utilizó como base el modelo de resiliencia en adolescentes (mra) para entender la conducta sexual de estos, que a la vez permitió proponer la teoría de rango medio modelo de resiliencia sexual en el adolescente (mrsa). modelo de resiliencia en adolescentes el mra es uno de los primeros modelos teóricos desarrollados para el estudio de la resiliencia en los adolescentes, se generó para dar respuesta a cómo los adolescentes con cáncer se adaptan a las situaciones difíciles, y cómo los factores de protección que influyen en la salud positiva son susceptibles de mejorar. se fundamenta en dos perspectivas filosóficas: la etapa de desarrollo de la vida y los modelos basados en el significado. la primera perspectiva busca determinar la influencia histórica y contemporánea de la etapa de desarrollo de la persona, así como la respuesta del adolecente a la salud y la enfermedad. la segunda perspectiva filosófica se basa en los modelos de significado, esta hace referencia a los patrones, la experiencia y la percepción de la persona hacia la enfermedad. además de las perspectivas filosóficas el mra se desarrolló mediante el uso de la metodología mixta, lo que permitió una mejor comprensión de la resiliencia desde los enfoques cuantitativo y cualitativo (7). el mra (7) propone una representación integral del proceso y resultado de resiliencia durante la etapa de desarrollo de la adolescencia. además, este modelo permite su aplicación en intervenciones psicoeducativas para la prevención de las conductas sexuales de riesgo. de acuerdo con este modelo se describen los supuestos y la relación de los conceptos elegidos para dar explicación al fenómeno de interés. el modelo parte de los siguientes supuestos: 1) el cambio en una persona puede ser observado a través de las etapas de desarrollo desde la primera infancia hasta la edad adulta, este cambio se acentúa durante la adolescencia; 2) la adolescencia, vista como una etapa de desarrollo, abarca los cambios físicos de la pubertad, y su experiencia previa y durante la misma; 3) la persona posee recursos y fortalezas para gestionar con flexibilidad los factores de estrés para obtener resultados positivos; 4) los adolescentes tienen respuestas específicas a la salud y la enferme172 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 dad; 5) la familia y la sociedad son elementos importantes en la protección del adolescente. de acuerdo con esto, el modelo está integrado por conceptos que se clasifican en factores de riesgo, factores de protección y el factor resultado; a continuación se describen cada uno de estos factores. en el mra los factores de riesgo se dividen en riesgo relacionado con la enfermedad y riesgo individual. el primero considera los factores que producen una influencia negativa en la resiliencia; el segundo comprende el riesgo individual exacerbado por los problemas de salud y las estrategias de afrontamiento defensivo que son empleadas cuando las personas responden a los acontecimientos estresantes. entre los factores de protección están los de protección familiar, social e individual. los de protección familiar son componentes que se encuentran dentro y fuera de la familia, siendo una fuente importante de protección para el adolescente contra problemas psicosociales. los de protección social hacen referencia al apoyo que recibe la persona por parte de sus amigos y proveedores de salud. los de protección individual incluyen estrategias que proporcionan mayor capacidad de recuperación y permiten modificar los resultados adversos. por último, como factor de resultado se encuentra la resiliencia, que ha sido considerada como un proceso de identificación y desarrollo de recursos para manejar los factores de riesgo a fin de obtener resultados positivos. así, un adolescente posee factores de protección que lo ayudan a desarrollar capacidades resilientes que le favorecen para tener conductas saludables. rew y horner (10) agregan que el contexto sociocultural influye en las conductas de riesgo para la salud, por lo que factores socioculturales como la edad, el género y los roles de género, y la historia previa de enfermedades pueden potencializar o aminorar el riesgo para la salud. se realizó una derivación de conceptos del mra: riesgo relacionado con la enfermedad, riesgo individual, protección familiar, protección social, protección individual y resiliencia. se utilizó el método de derivación teórica de fawcett (11) empleando los cinco pasos propuestos por la autora a fin de desarrollar una teoría de rango medio que pueda ser utilizada para la prevención del vih en adolescentes. 1. identificación de los conceptos de interés de la teoría de rango medio: en el mra se identificaron los nombres de los conceptos de interés y sus respectivas dimensiones; incluye los factores de riesgo (riesgo relacionado con la enfermedad y riesgo individual), los factores de protección (familiar, social e individual) y el factor resultado (resiliencia). 2. clasificación de los conceptos de la teoría de rango medio: se utilizó la clasificación por variabilidad, representada por las variables del fenómeno por estudiar, las cuales conformaron los conceptos de los tres factores (protectores, riesgo y resultado). 3. identificación y clasificación de las preposiciones de la teoría de rango medio propuesta: en esta etapa se formalizó la estructura conceptual-teórica-empírica propuesta, la cual guío la investigación documental. 4. ordenamiento jerárquico de las preposiciones: se determinó a través del razonamiento deductivo, donde se considera que el desarrollo de los factores protectores en el adolescente contrarresta los factores de riesgo sexual. 5. construcción del diagrama: en esta última etapa se realizó el diagrama que integra la derivación realizada, conformada por el mra como teoría de origen, la puesta en marcha de la teoría de rango medio propuesta, y las escalas que medirán los conceptos de interés. a continuación se presenta esta derivación para los conceptos de factor de riesgo, factor de protección y factor resultado de la teoría de rango medio modelo de resiliencia sexual en el adolescente (figuras 1, 2, 3 y 4). riesgo relacionado con la etapa de la adolescencia haase (7) refiere que el riesgo relacionado con la enfermedad produce una influencia negativa en la resiliencia. en el presente estudio se considera que el riesgo no se relaciona con la enfermedad sino con los cambios propios de la etapa de la adolescencia que provocan incertidumbre. estos cambios son de tipo físico, psicológico y social. durante la adolescencia las capacidades física, sexual, imaginativa, intelectual y crítica funcionan con mayor intensidad que en cualquier otro momento de la vida. los cambios emocionales propios de esta etapa pueden hacer que el adolescente tienda a exagerarlo todo. el sentimiento infantil de un día de alegría y diversión se transforma en emociones y sentimientos nuevos, muchas veces confusos y entremezclados (12). en esta 173 modelo de resiliencia sexual en el adolescente: teoría de rango medio l lubia castillo-arcos, raquel benavides-torres etapa, los cambios que están ocurriendo significan el inicio de la madurez sexual, es un momento esperado por el adolescente que se caracteriza por incertidumbre debido al desconocimiento de lo que le ocurre y de lo que siente. en el mismo orden de ideas, andino (13) refiere que la adolescencia es un periodo de la vida que abarca la maduración biológica, psíquica y social. está caracterizada por cambios en el desarrollo físico, mental, emocional y social, por lo que el adolescente busca un equilibrio consigo mismo y con la sociedad. en esta etapa se observa ambivalencia, incertidumbre y contradicciones que hacen que esta etapa se convierta en un suceso estresante. lo anterior puede llevar al adolescente a tomar riesgos para experimentar nuevas sensaciones, formar una identidad y buscar independencia y aceptación de otros importantes. de acuerdo con esto se puede decir que es común que a esta edad el adolescente homologue la conducta de riesgo con una experiencia relevante que propicia su maduración. lo anterior produce un nivel elevado de incertidumbre en esta etapa debido a que la mayoría de los acontecimientos que lo aquejan son desconocidos. la incertidumbre es mayor cuando no posee información acerca de lo que le está sucediendo, no entiende la información que se le proporciona o cuando los eventos que le ocurren son extraños, desconocidos o inesperados (7). la incertidumbre en la adolescencia es provocada por los cambios físicos, el despertar sexual y por la imagen corporal. una de sus mayores preocupaciones se relaciona con el tiempo en que ocurrirán estos cambios ya que es común que se comparen con sus iguales y también les preocupa la imagen atractiva que desean tener. figueroa et al. (14) mencionan que la adolescencia es una etapa importante de constantes transformaciones en la cual se presentan cambios en la personalidad, se define la identidad y se realiza la elección de la pareja, lo que conlleva un riesgo y se explica en dos fases. la primera es una fase de crisis, en la que se estructura la personalidad y se presentan grandes conflictos emocionales; la segunda, en la cual el adolescente presenta inestabilidad emocional producida por los cambios propios del proceso de crecimiento y desarrollo que serán paulatinamente resueltos. por su parte, perter y valkenburg (15) refieren que en la medida en que los adolescentes no tienen claro sus creencias sexuales va en aumento la incertidumbre sexual. según esto, la incertidumbre representa un riesgo relacionado con la etapa de la adolescencia la cual ejerce una influencia negativa en la conducta sexual inmediata y futura. para el presente estudio, la incertidumbre sexual es el grado de desconocimiento del adolescente acerca de cómo debe reaccionar ante lo que le está aconteciendo y las nuevas sensaciones que experimenta, que le impiden tener claro sus creencias y valores sexuales. riesgo sexual haase (7) menciona que el riesgo relacionado con la enfermedad produce una influencia negativa en la resiliencia. en el presente estudio se considera que el riesgo sexual es exacerbado por los cambios psicológicos (invulnerabilidad) y los mecanismos de afrontamiento defensivo (evasivo, fatalista y emotivo) comunes de esta etapa de desarrollo, mismos que influyen en la conducta sexual del adolescente. durante la adolescencia, los cambios psicológicos afectan el contenido de los pensamientos por lo que su capacidad de abstracción causa que el adolescente vea la vida de manera fantasiosa, con pensamientos como “a mí nunca me va a pasar eso”. esta percepción de invulnerabilidad conlleva comportamientos sexuales riesgosos, como las relaciones sexuales sin protección, que los ponen en riesgo de embarazos no deseados y enfermedades de transmisión sexual (its)-vih/sida (12, 16). en este sentido, taylor-seehafer y rew (17) refieren que durante la adolescencia los procesos cognitivos se modifican significativamente. para predecir las consecuencias de las acciones, y para comprender el contexto social de los comportamientos, es necesario el desarrollo de la capacidad de razonar de manera abstracta. los adolescentes que están pensando en un nivel preoperacional pueden verse a sí mismos como invulnerables y tener una visión optimista de los riesgos; en este sentido, el adolescente considera que puede pasarle a otros, pero a él no. los cambios psicológicos de la pubertad y la menarquía son factores importantes que afectan el comportamiento de los adolescentes, de esta manera se sienten motivados a involucrarse en comportamientos sexuales de riesgo que incluyen la necesidad de pertenecer a un grupo, el deseo, la pasión y la curiosidad, así como la necesidad de desarrollar una identidad personal. para el presente estudio, la invulnerabilidad al vih es la percepción que posee el adolescente de no tener riesgo de infectarse con el vih. otro factor que exacerba el riesgo individual es el afrontamiento defensivo, que es muy común en los adolescentes; también se denomina de negación. este mecanismo se asocia a etapas de transición o crisis, con resultados menos positivos, que 174 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 son empleados con mayor frecuencia cuando una nueva situación de riesgo es identificada durante la adolescencia (7, 18). las estrategias de afrontamiento defensivo que afectan negativamente la capacidad de recuperación son etiquetadas como evasivas, fatalistas y emotivas (19, 20). reflejan en el adolescente la incapacidad de identificar los riesgos sexuales. uno de los tipos de afrontamiento defensivo más utilizado por los adolescentes es el evasivo, el cual impide que enfrente un problema o reflexione sobre él. los adolescentes buscan reducir el estrés emocional asociado a la situación sexual a través del uso de estrategias de afrontamiento defensivo, estas no permiten oponerse de manera asertiva a una relación sexual sin protección (21). para el presente estudio el afrontamiento defensivo al riesgo sexual es el empleo de estrategias de evasión, fatalistas y emotivas que le impiden al adolescente identificar el riesgo sexual y tomar decisiones seguras sobre su conducta sexual. protección familiar contra el riesgo sexual para haase (7), la protección familiar integra los componentes de protección que se encuentran dentro y fuera de la familia. en el caso del presente estudio se manejará como la protección familiar contra el riesgo sexual que se traduce en apoyo familiar para la conducta sexual segura (css). la protección de la familia es una fuente importante de apoyo contra problemas psicosociales para que el adolescente practique conductas sexuales seguras, ya que esta es culturalmente vista como apoyo (22). la red familiar se conforma de las personas íntimamente relacionadas en una familia nuclear. en situaciones de crisis y de riesgo los miembros de la familia dependen en gran medida de su red de apoyo. de acuerdo con haase (7), las familias resilientes son flexibles, coherentes, tienen un significado en la vida, se comunican y resuelven problemas con eficacia. diversos autores han sugerido que el apoyo familiar aumenta la resiliencia, la presencia de relaciones cálidas, protectoras y de apoyo en donde al menos uno de los padres actúa como protector (23, 24). en este sentido, marsiglia, nieri y rubin (25) refieren que el monitoreo de padres es un elemento clave para que el adolescente practique conductas sexuales saludables. asimismo, mencionan que en las familias donde existe una relación positiva entre padres e hijos, y se discuten temas relacionados con sexo seguro, el adolescente tiene menos posibilidades de verse involucrado en situaciones de riesgo sexual. el constante apoyo familiar representa un modo ininterrumpido de estímulo protector, así como el control efectivo ejercido por los padres. para el presente estudio se considerarán como apoyo familiar para la conducta sexual segura las relaciones afectivas de protección y cuidado que brindan los miembros de la familia para favorecer en el adolescente la práctica de conductas sexuales seguras. protección social contra el riesgo sexual el concepto de protección social contra el riesgo sexual, de acuerdo con el mra, es la medida en que los individuos perciben que sus necesidades de apoyo, información y retroalimentación son cumplidas por los amigos y el proveedor de salud. en este estudio se manejará dicho concepto, que incluirá el apoyo social para la conducta sexual segura. rosario et al. (26) definen apoyo social como la percepción que tiene el adolescente en relación con la ayuda proporcionada por otras personas, que puede ser emocional, de información o de asistencia. la protección social es uno de los recursos externos considerados de suma importancia por su efecto positivo en la salud. las personas que presentan mayor protección social tienen menos problemas físicos y psicológicos, y contrarrestan mejor el estrés. haase (7) menciona que el adolescente tiene la capacidad de mantener la relación entre sus pares, las relaciones escolares y las relaciones con las redes sociales para conseguir resultados positivos y reducir o evitar los resultados negativos. cardozo y alderete (27) refieren que el apoyo social es un factor protector relacionado con los recursos que posee el adolescente que le permite hacer frente a una amplia gama de adversidades. dentro de estos recursos se encuentran las personas del entorno en quienes el adolescente puede confiar, y que a su vez le establecen límites y le enseñan la forma de evitar los problemas. en este sentido, las personas significativas le instruyen la manera correcta de proceder, de desenvolverse solo, y le ayudan a enfrentar situaciones de peligro (18). para el presente estudio, el apoyo social para la conducta sexual segura es el soporte que el adolescente percibe de su pareja, amigos y proveedores de salud para practicar el sexo seguro. protección individual contra el riesgo sexual el mra de haase (7) refiere que la protección individual incluye los recursos que la persona utiliza para modificar los re175 modelo de resiliencia sexual en el adolescente: teoría de rango medio l lubia castillo-arcos, raquel benavides-torres sultados adversos y hacer que ocurra la resiliencia; a partir de este concepto se propone el de protección individual contra el riesgo sexual. rutter (28) refiere que los recursos son contextuales y varían de un individuo a otro; sin embargo, dependiendo de la situación de riesgo los recursos utilizados en cada individuo son diferentes de acuerdo con la circunstancia (29, 30). algunos investigadores refieren que la persona, al identificar el riesgo, utiliza los factores de protección internos para llegar a la recuperación (5, 31, 32). estos factores permiten amortiguar las consecuencias de los peligros e interrumpen la cadena causa y efecto bloqueando los resultados negativos. la experiencia previa del individuo con el riesgo o la situación estresante influye de manera directa en los recursos disponibles que emplea como protectores modificando la respuesta de la persona en un sentido más adaptativo que el esperable (31). por su parte, lázarus y folkman (33) consideran que ante situaciones de amenaza o de riesgo la persona utiliza estrategias positivas para manejarlas que se pueden orientar tanto al dominio de la situación, como para evitarla o minimizarla; estas se conocen como estrategias de afrontamiento positivo. taylor-seehafer y rew (17) refieren que los factores protectores que contribuyen a disminuir la conducta sexual de riesgo son: los conocimientos sobre sexualidad, la autoestima y la autoeficacia. de acuerdo con lo anterior, en la presente teoría de rango medio los factores protectores son considerados como amortiguadores del impacto de las conductas sexuales de riesgo para vih/sida, e incluyen el afrontamiento positivo del riesgo sexual, el conocimiento sobre vih/sida, la autoestima y la autoeficacia para la conducta sexual segura. a continuación se describen cada unos de estos factores. el afrontamiento positivo es una estrategia utilizada por la persona para eliminar, reducir o tolerar el estrés o el riesgo (26). lindqvist, carlsson y sjödén (20) mencionan que existen cinco estilos de afrontamiento que son empleados por la persona para enfrentar el estrés: 1) el optimista, se caracteriza por el mantenimiento de actitudes positivas acerca del problema; 2) el confrontativo, utiliza el enfrentamiento y la confrontación para solucionar los problemas; 3) el de apoyo, maneja los sistemas personales, profesionales o espirituales de enfrentamiento; 4) el autosuficiente, depende de la persona más que de otros para resolver el problema; y 5) el paliativo, incluye realizar otras actividades para sentirse mejor (19). los adolescentes pueden utilizar estos estilos de afrontamiento positivo para contrarrestar los efectos negativos del riesgo sexual y poder manejar con seguridad el estrés producido por los cambios de la adolescencia permitiéndole de esta manera tomar decisiones sobre sexo seguro. en el presente estudio el afrontamiento positivo del riesgo sexual es el empleo de las estrategias optimistas, confrontativas, de apoyo, autosuficiencia y paliativas que permiten que el adolescente evite conductas sexuales de riesgo. otro factor de protección personal es el conocimiento sobre vih/sida. bogart, cecil y pinkerton (34) consideran que los niveles moderados y altos de conocimiento que la persona posee sobre esta enfermedad le proporcionan un medio de protección para evitar conductas sexuales de riesgo ya que le permiten decidir la mejor forma de protegerse. es importante que la información sea variada y suficiente para que pueda tomar una decisión sobre su conducta sexual. por su parte, givaudan y pick (35) reportan que los adolescentes que no poseen los conocimientos necesarios sobre el vih/sida y sus formas de prevención tendrán menos probabilidades de utilizar un condón en la primera relación sexual en comparación con los adolescentes que tienen este conocimiento. de acuerdo con lo anterior, la educación para la prevención del vih/sida significa ofrecer al adolescente la oportunidad de que adquiera y desarrolle el conocimiento, las competencias y los valores sobre sexo seguro que le ayuden a retrasar el inicio de la actividad sexual y protejan a los sexualmente activos contra its y vih/sida (36). los conocimientos que adquiere el adolescente le ayudan a contrarrestar el riesgo sexual y le permiten a la vez tener la capacidad de identificar situaciones contextuales que lo ponen en peligro (37). para el presente estudio el conocimiento sobre vih/sida es la información que posee el adolescente sobre los métodos de trasmisión, protección y detección del vih/ sida que le permiten la toma de decisiones sobre conductas de sexo seguro. la autoestima también se considera un protector individual y se define como el grado en el que el adolescente se percibe de manera positiva o negativa (7). un adolescente con autoestima alta establece sentimientos de valor propio y desarrolla seguridad para hacer frente a situaciones de riesgo exitosamente (23). este concepto se fundamenta en la convicción de un sentimiento de valía personal en el que el individuo se cree competente para manejar su vida y funcionar adecuadamente dentro del ambiente familiar y social en el que se encuentra. en este sentido, la autoestima tiene dos componentes, un sentimiento de capacidad y estima personal, es decir, es la suma 176 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 de la confianza, la decisión y el respeto por sí mismo. refleja el juicio implícito que cada uno hace de su habilidad para enfrentar los desafíos de la vida al comprender y superar los problemas, el derecho a ser feliz, así como el defender sus intereses y necesidades (38). para el presente estudio la autoestima es la percepción positiva de valía personal que el adolescente posee que le permite hacer frente a situaciones de riesgo sexual. otro factor protector es la autoeficacia. según bandura (39), las personas que logran un control sobre los sucesos que perturban sus vidas y son capaces de tomar acciones futuras para evitar que vuelvan a suceder tienen un nivel elevado de autoeficacia. esta lucha por lograr el control de las situaciones es una alternativa para garantizar beneficios personales y sociales; por otro lado, cuando un individuo es incapaz de ejercer control se crea aprehensión, apatía o desesperación. la capacidad percibida de que se puede producir el resultado esperado proporciona incentivos para llevar a cabo la conducta en cuestión. ajzen (40) menciona que la autoeficacia se convierte en el medio por el cual la persona sigue sus metas y controla lo que es capaz de hacer. entonces, la autoeficacia se reconoce como un predictor del cambio de conducta y se define como la creencia que tiene una persona sobre su capacidad y esfuerzo necesario para ejecutar con habilidad una determinada tarea. en el presente estudio la autoeficacia para conducta sexual segura es la capacidad percibida por el adolescente sobre sus habilidades para negarse a practicar conductas sexuales de riesgo para vih/sida. resiliencia para haase (7), la resiliencia se define como un proceso de identificación y desarrollo de recursos para manejar los factores estresantes a fin de obtener resultados positivos —en este capítulo tomamos este concepto y lo adaptamos como resiliencia sexual en el adolescente—. asimismo, la resiliencia es entendida como la capacidad de rebote o de enfrentar con éxito una situación a pesar de la adversidad (23). algunos autores han investigado la resiliencia como un rasgo de la personalidad, mientras que en los últimos dos decenios esta ha sido redefinida como una dinámica y proceso modificable (24, 41, 42). este último enfoque permite el desarrollo de las intervenciones basadas en la resiliencia ya que la adversidad es el antecedente que desencadena este proceso y es justamente la que estimula el desarrollo de los recursos internos y la capacidad para enfrentar situaciones desfavorables de riesgo y estrés (5, 23). la perturbación que genera el cambio permite el aprendizaje del individuo para emplear sus cualidades resilientes. una revisión de la literatura nos muestra que es indispensable que el o la adolescente cuente con la capacidad cognitiva y social para interpretar la adversidad a fin de hacer frente al cambio (10, 43). fergus y zimmerman (41) consideran que la conducta sexual de los adolescentes representa un riesgo individual para contraer its-vih/sida, la cual puede ser compensada por recursos personales resilientes que le permitan evitarla. la resiliencia posibilita que el o la adolescente planee su futuro alejándose de situaciones de riesgo sexual. en este sentido la conducta sexual, según fergus y zimmerman (41), presupone un grado de coherencia entre pensamiento, sentimiento y acción, los cuales influyen en la toma de decisiones a nivel conductual de manera racional, utilizando la información disponible. lohman (44) refiere que la conducta sexual abarca las acciones que el adolescente decide realizar en situaciones sexuales en las que entorno y los estímulos recibidos juegan un papel relevante. gonçalves, castellá y carlotto (21) señalan que la conducta sexual se ve influenciada por diversos factores de riesgo, siendo imprescindible que el adolescente reciba educación sexual que le ayude a contrarrestar la influencia negativa del entorno y así evitar exponerse a situaciones de riesgo sexual. la resiliencia sexual en el adolescente favorece la práctica del sexo seguro a través de los factores de protección familiar, social e individual, y contrarresta los factores de riesgo sexual y los relacionados con esta etapa. visto de este modo, la resiliencia es un mecanismo que reduce el impacto del riesgo ya que el adolescente está en un constante estado de vulnerabilidad y los factores protección le permiten la toma de decisiones adecuadas ante situaciones de riesgo sexual (45). con base en la aplicación del sistema teórico empírico de fawcett (11), para el presente estudio se considera que la resiliencia sexual es el proceso mediante el cual el adolescente utiliza sus recursos protectores disponibles para contrarrestar los factores de riesgo sexual. lo anterior se verá reflejado en conductas como la abstinencia, el uso constante y correcto del condón, la monogamia, la búsqueda de orientación sobre its-vih/sida y la realización de la prueba de vih en quienes hayan tenido conductas de riesgo. 177 modelo de resiliencia sexual en el adolescente: teoría de rango medio l lubia castillo-arcos, raquel benavides-torres figura 1. estructura teórica-conceptual empírica del factor de riesgo teórica conceptual empírica riesgo relacionado con la enfermedad riesgo relacionado con la etapa de adolescencia. incertidumbre sexual. es el grado de desconocimiento del adolescente acerca de cómo debe reaccionar ante lo que le está aconteciendo y las nuevas sensaciones que experimenta, que le impiden tener claro sus creencias y valores sexuales. escala de incertidumbre sexual (16). riesgo individual riesgo sexual (rs) invulnerabilidad al vih. es la percepción que posee el adolescente de no tener riesgo de infectarse con el vih. escala de susceptibilidad percibida de una infección por vih (46). afrontamiento defensivo al rs. es el empleo de estrategias de evasión, fatalistas y emotivas que le impiden al adolescente identificar el riesgo sexual y tomar decisiones seguras sobre su conducta sexual. escala de afrontamiento jalowiec (20). figura 2. estructura teórica-conceptual empírica del factor protector teórica conceptual empírica protección familiar protección familiar contra el rs. apoyo familiar para la css. incluye las relaciones afectivas de protección y cuidado que brindan los miembros de la familia para favorecer en el adolescente la práctica de conductas sexuales seguras. escala de provisión social para sexo seguro (47, 48). protección social protección social contra el rs. apoyo social para la css. es el apoyo que el adolescente percibe de de su pareja, amigos y proveedores de salud para practicar el sexo seguro. escala de provisión social para sexo seguro (47,48). protección individual protección individual contra el rs. afrontamiento positivo al rs es el empleo de estrategias optimistas, confrontativas, de apoyo, autosuficiencia y paliativas que permiten que el adolescente evite conductas sexuales de riesgo. conocimientos sobre vih/sida es la información que posee el adolescente sobre los métodos de trasmisión, protección y detección del vih/sida que le permiten la toma de decisiones sobre css. autoestima. es la percepción positiva de valía personal del adolescente, que le permite hacer frente a situaciones de rs. autoeficacia para la css. es la capacidad percibida por el adolescente sobre sus habilidades para negarse a practicar conductas sexuales de riesgo para vih/sida. escala de afrontamiento jalowiec (20). cuestionario de conocimiento para embarazo, sida e its (49). escala de autoestima (50). escala de autoeficacia para la prevención del sida (51). 178 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 figura 3. estructura teórica conceptual empírica del factor resultado teórica conceptual empírica resiliencia resiliencia sexual en el adolescente. es el proceso mediante el cual el adolescente utiliza sus recursos protectores disponibles para contrarrestar los factores de riesgo sexual. escala de resiliencia para sexo seguro (48, 52) escala de conducta sexual (49). a partir de los conceptos previamente derivados se propone la teoría de rango medio modelo de resiliencia sexual en el adolescente. figura 4. esquema de relación de conceptos-modelo resiliencia sexual en el adolescente riesgo relacionado con la etapa de adolescencia. incertidumbre sexual. protección familiar al rs. apoyo familiar para la conducta sexual segura. protección social al rs. apoyo social para la conducta sexual segura. riesgo sexual (rs). invulnerabilidad al vih. afrontamiento defensivo al rs. protección individual al riesgo sexual afrontamiento positivo al rs. conocimientos sobre vih/sida. autoestima. autoeficacia para la conducta sexual segura. resiliencia sexual en el adolescente fa ct or es d e ri es go s ex ua l fa ct or es d e pr ot ec ci ón de l r ie sg o se xu al modelo de resiliencia sexual en el adolescente el modelo de resiliencia sexual en el adolescente parte de los siguientes supuestos: 1) en la adolescencia se acentúan los cambios; 2) la adolescencia es vista como una etapa de desarrollo que abarca cambios físicos, psicológicos y sociales; 3) el adolescente posee factores protectores de conductas sexuales de riesgo para hacer frente a los factores de riesgo sexual que le permiten obtener resultados positivos; 4) los adolescentes tienen respuestas específicas a la salud sexual y los riesgos sexuales; 5) la familia y la sociedad son elementos importantes en la protección del adolescente ante el riesgo sexual. el modelo está integrado por conceptos que se clasifican como factores de riesgo sexual, factores de protección de conductas sexuales de riesgo y el factor de resultado. a continuación se describen cada uno de estos y la relación entre ellos. 179 modelo de resiliencia sexual en el adolescente: teoría de rango medio l lubia castillo-arcos, raquel benavides-torres los factores de riesgo sexual están integrados por el riesgo relacionado con la etapa de adolescencia y el riesgo sexual. el riesgo relacionado con la adolescencia tiene que ver con los cambios propios de la etapa que le provocan incertidumbre al adolescente, lo cual se conecta positivamente con el riesgo sexual afectando en forma negativa la resiliencia sexual del adolescente. el riesgo sexual se empeora debido a la percepción de invulnerabilidad al vih y los mecanismos de afrontamiento defensivo (evasivos, fatalista y emotivo) que influyen de forma negativa en la protección individual y en la resiliencia sexual del adolescente. los factores de protección de conductas sexuales de riesgo están integrados por la protección familiar, la social y la individual. la protección familiar contra el riesgo sexual se considera como el apoyo familiar para la conducta sexual segura que amortigua los efectos de los riesgos sexuales y se relaciona positivamente con la protección social y la individual contra los riesgos mencionados. la protección social contra el riesgo sexual se refiere al grado en el que el adolescente percibe apoyo por parte de su pareja, amigos y proveedores de salud, se relaciona positivamente con la protección individual y la resiliencia sexual en el adolescente. la protección individual contra el riego sexual incluye el afrontamiento positivo, el conocimiento sobre vih/sida, la autoestima y la autoeficacia para conductas sexuales seguras que contrarrestan el impacto del riesgo para dicha enfermedad. en el factor de protección individual influye negativamente el riesgo sexual y positivamente la protección familiar y social; asimismo, se relaciona de manera directa con la resiliencia sexual en el adolescente. por último, el factor resultado es la resiliencia sexual en el adolescente que se considera como la capacidad de respuesta para evitar conductas sexuales de riesgo y prevenir el vih/sida. esta se da cuando los factores de protección son fortalecidos y estos a su vez contrarrestan los factores de riesgo sexual. cabe destacar que en este modelo el efecto de la intervención está moderado por la edad, el género y la experiencia sexual. conclusiones la generación de la teoría es un elemento indispensable en el fortalecimiento del conocimiento de la disciplina para dar sustento doctrinal a la práctica. es importante destacar que poseer un cuerpo de teorías que predigan, expliquen o controlen fenómenos de interés disciplinar le proporciona identidad a la profesión. en este sentido podemos decir que las teorías de rango medio se enfocan en fenómenos específicos y surgen de las necesidades observables de la práctica. la utilización de la derivación conceptual-teórica-empírica (11) es un método práctico para proponer teorías de rango medio, las cuales se integran por conceptos y proposiciones operacionalizados en forma sencilla y clara que permiten la aplicación en la práctica real del cuidado de enfermería. de esta manera, el método utilizado propuesto por fawcett fue apropiado para generar la teoría de rango medio mrsa, la cual se encamina al fortalecimiento del adolescente como persona responsable para prevenir la infección por vih al generarse en él un cambio de aprendizaje que lo lleva a emplear sus cualidades resilientes para interpretar y evitar la adversidad del riesgo sexual. asimismo, el mrsa ofrece un sustento teórico para realizar intervenciones con enfoque preventivo y de protección, que pueden tener un impacto positivo en los resultados a corto, mediano y largo plazo. por lo anterior, el desarrollo teórico es la tarea más importante que el profesional de enfermería enfrenta para el avance del conocimiento. así, el mrsa contribuye a la legitimización y autonomía de la disciplina al proporcionar bases científicas para comprender y dar respuesta al fenómeno de la conducta sexual de riesgo en el adolescente siendo, sin duda, una forma práctica y concreta de dar cuidado dentro del contexto de la prevención del vih/sida a través 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de graduação e pós-graduação em enfermagem da universidade federal do ceará. fortaleza, ceará, brasil. marligalvao@gmail.com. 3 doutor em enfermagem. professor do curso de graduação e pós-graduação em enfermagem da universidade federal do ceará. fortaleza, ceará, brasil. marcos@ufc.br. recibido: 9 de mayo de 2012 aceptado: 3 de octubre de 2012 resumo objetivo: objetivou-se analisar o conceito de adesão ao tratamento de crianças soropositivas ao hiv, expresso pela literatura da área de saúde, identificando seus atributos essenciais, antecedentes e consequentes. método: seguiu-se o método evolucionário de análise de conceito, proposto por rodgers, para avaliar 17 artigos que focalizaram a temática do estudo. resultados: como atributos essenciais identificados que caracterizam o conceito constaram: seguimento da prescrição médica pelo binômio criança-família, disponibilidade de formulações pediátricas, acompanhamento clínico-laboratorial regular, adequação de hábitos e compartilhamento de decisões entre cuidador e criança. conclusões: a partir dos elementos identificados, elaborou-se uma definição consensual, na qual adesão ao tratamento de crianças soropositivas é compreendida como um processo colaborativo, que vai além da ingestão de medicamentos, considerando-se o dinamismo, aspectos familiares, o cotidiano das crianças, os determinantes sociais, econômicos e estruturais que integram o fenômeno em estudo. os achados permitem uma compreensão mais abrangente do conceito e fornecem subsídios para a prestação de uma assistência integral, direcionada ao controle da doença e a uma melhor qualidade de vida. sugere-se a formação de grupos multiprofissionais dedicados a realização de trabalhos educativos sobre as dificuldades na adesão, promovendo um espaço para trocas de experiências e para o desenvolvimento de estratégias de enfrentamento. palavras-chave adesão à medicação, criança, hiv, síndrome de imunodeficiência adquirida, formação de conceito, emfermagen (fonte: decs, bireme). adherence to the treatment of children living with hiv: a conceptual analysis abstract objective: the objective was to analyze the concept of adherence to treatment of children living with hiv, expressed in the health literature, identifying its essential attributes, antecedents and consequences. method: the evolutionary method of concept analysis proposed by rodgers was followed to evaluate 17 articles that focused on the study theme. results: as essential attributes identified by año 12 vol. 12 nº 3 chía, colombia diciembre 2012 l 228-240 229 adesão ao tratamento de crianças soropositivas ao hiv: uma análise conceitual l eliane rolim de holanda, maria amelia de souza, viviane rolim de holanda y otros. characterizing the concept are included: following the prescription by the child-family binomial, availability of pediatric formulations, regular clinical and laboratory follow-up, habits adequacy and shared decision making between caregiver and child. conclusions: based on the identified elements, a consensual definition was elaborated, in which the treatment compliance by positive-hiv children is understood as a collaborative process, which goes beyond taking medications, considering the dynamism, family aspects, the daily lives of children, the social, economic and structural determinant that integrate the phenomenon under study. the findings allow a more comprehensive understanding of the concept and provide subsidies for the provision of comprehensive care, targeted to disease control and improved life quality. it is suggested the formation of multidisciplinary groups dedicated to conducting educational works about the difficulties in compliance, promoting a space for exchange of experiences and development of coping strategies. key words adherence to medication, child, hiv, acquired immunodeficiency syndrome, concept formation, nursing (source: decs, bireme). adherencia al tratamiento de niños que viven con el vih: un análisis conceptual resumen objetivo: analizar el concepto de la adherencia al tratamiento de los niños que viven con el vih, expresado en la literatura de la salud, haciendo la identificación de sus atributos esenciales, antecedentes y consecuencias. método: método evolutivo de análisis de concepto propuesto por rodgers para evaluar los 17 artículos que se centraron en el tema del estudio. resultados: identificado como atributos esenciales que caracterizan el concepto. a raíz de la prescripción por el binomio niño-familia, la disponibilidad de formulaciones pediátricas, acompañamiento clínico y de laboratorio regulares, adecuación de los hábitos y toma de decisiones compartida entre el cuidador y el niño. conclusiones: con base en los elementos identificados, se elaboró una definición consensuada en que se entiende la adherencia al tratamiento de los niños vih positivos como un proceso de colaboración que va más allá de tomar los medicamentos, teniendo en cuenta el dinamismo, los aspectos de la familia, la vida cotidiana de los niños, la parte social, económica y estructural del fenómeno en estudio. los hallazgos permiten una comprensión más amplia del concepto y ofrecer subsidios para la prestación de la atención integral dirigida a controlar la enfermedad y mejorar la calidad de vida. se sugiere la formación de grupos multidisciplinarios dedicados a la realización de trabajos educativos sobre las dificultades en el cumplimiento, la promoción de un espacio de intercambio de experiencias y el desarrollo de estrategias de afrontamiento. palabras clave adherencia a la medicación, niño, vih, síndrome de inmunodeficiencia adquirida, formación de conceptos, enfermería (fuente: decs, bireme). 230 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 introdução em 2011, a síndrome da imunodeficiência adquirida (aids) completou 30 anos. atualmente um grande número de crianças que foram expostas ao vírus da imunodeficiência humana (hiv) em decorrência da transmissão vertical, ocorrida durante a gestação, parto ou pelo aleitamento natural, tem atingido a adolescência e a idade adulta (1, 2). no brasil, a aids continua em patamares elevados. até junho de 2010, foram notificados 592.914 casos. na faixa etária de 0 a 19 anos de idade registraram-se 31.896 novos casos (3). esses resultados confirmam a atual situação da infecção, caracterizada pela heterossexualização, feminização e aumento da transmissão vertical, incluindo as crianças como um novo grupo populacional (3). nos países onde o acesso ao tratamento é garantido, observam-se melhorias nos indicadores de saúde e de desenvolvimento das crianças que convivem com o hiv, com redução acentuada da ocorrência de infecções oportunistas, diminuição das taxas de internações, redução da mortalidade e melhora da qualidade de vida (4). desta forma, a doença passou a ser considerada uma condição crônica. como tal, para ser controlada, é imprescindível que a criança receba adequadamente as doses dos medicamentos antirretrovirais (5). o uso irregular, doses insuficientes ou o não seguimento de rotinas podem aumentar o risco de falência virológica e resistência viral (6, 7). a adesão de crianças ao tratamento antirretroviral é um processo dinâmico, que difere do adulto e permanece como um desafio no qual múltiplos fatores estão envolvidos. tal processo requer melhor elucidação. no entanto, conforme aponta a literatura (6, 8, 9, 10), apesar da grande população pediátrica com hiv, a investigação em cuidados e tratamento neste cenário ainda é limitada, principalmente em face do pequeno recorte temporal da epidemia envolvendo crianças. são escassos os estudos sobre essa temática e os existentes foram conduzidos em países desenvolvidos. deste modo, há disparidades socioculturais, econômicas e de acesso aos serviços de saúde. ter coerência sobre os fundamentos inerentes ao tema representa uma questão primordial para melhorar a avaliação, a assistência e a pesquisa sobre adesão ao tratamento. assim, considera-se imperativo o conhecimento das características essenciais que configuram o conceito de adesão ao tratamento de crianças soropositivas ao hiv, no intuito de favorecer melhor entendimento dos diversos aspectos presentes em tal conceito. conceitos são representações cognitivas e abstratas da realidade perceptível, formados por experiências diretas ou indiretas (11). são construídos ao longo da história e trazem contribuições significativas à construção do conhecimento e as atividades de investigação científica (12). considerados símbolos do que acontece no mundo dos fenômenos reais e instrumentos de trabalho para pesquisadores e profissionais, é necessário esclarecê-los e defini-los na perspectiva de serem utilizados com mais coerência, entendimento do seu sentido e, assim, contribuírem para a melhoria da qualidade da assistência prestada (13). o método de análise de conceito tem sido usado para trazer o grau desejado de clareza de alguns conceitos de interesse em determinada área (14). trata-se de um exame cuidadoso e da descrição de uma palavra ou expressão que incentiva a comunicação e promove o entendimento do fenômeno em estudo (15). no início da década de 1980, surgiu uma abordagem para realização de análise conceitual denominada de método evolucionário (14). trata-se de uma técnica indutiva destinada a clarificar conceitos e reduzir problemas conceituais existentes. baseia-se na ideia de que os conceitos são dinâmicos e dependentes do contexto no qual estão inseridos, ao contrário de estáticos ou imutáveis. ilustra o desenvolvimento do conceito como um ciclo evolucionário, que continua através do tempo e dentro de um contexto particular, sendo composto por três aspectos importantes: o “significado”, o “uso” e a “aplicação” do conceito (14). o conceito adquire significado pelo seu uso e aplicação a cada situação no tempo, influenciado por fatores internos e externos que ampliam, refinam e caracterizam, adequadamente, esse conceito (16). o uso do conceito expressa a maneira pela qual é aplicado em situações apropriadas, manifestando atributos essenciais. por sua vez a aplicação revela-se quando um conceito está associado ao uso em particular e cuja compreensão difunde-se na interação social, reflete o conceito efetivado e identificado no contexto, que passa a ser continuamente refinado, incorporando outros significados. deste modo, a aplicação revela não somente o fortalecimento do conceito, mas suas limitações (14). 231 adesão ao tratamento de crianças soropositivas ao hiv: uma análise conceitual l eliane rolim de holanda, maria amelia de souza, viviane rolim de holanda y otros. investigações desta natureza são importantes para a descrição da estrutura de uma disciplina, sendo um dos métodos possíveis para construir o conhecimento de enfermagem, pois, à medida que os conceitos vão sendo desenvolvidos e validados, o conhecimento científico será construído (17). além disso, a análise conceitual torna-se necessária para ampliar o entendimento do conceito, considerando seu dinamismo e suas variações conforme o contexto em que ele é evidenciado, de modo a favorecer a elaboração de uma definição consensual do fenômeno que considere as vivências biológicas, psicossociais e culturais que o integram (18). esta pesquisa justifica-se pela necessidade de maior compreensão do conceito de adesão ao tratamento de crianças soropositivas ao hiv, diante das suas possíveis utilidades e sua adequada aplicação à realidade das práticas dos serviços de saúde brasileiros. justifica-se, ainda, pela possibilidade de apresentar as tendências das pesquisas desenvolvidas nessa temática e com isso contribuir para o direcionamento do corpo de conhecimentos em enfermagem. em face do exposto, este estudo teve como objetivo analisar o conceito de adesão ao tratamento de crianças soropositivas ao hiv, expresso pela literatura da área de saúde, identificando seus atributos essenciais, antecedentes e consequentes. método trata-se de um estudo de análise de conceito, norteado pelo modelo evolucionário, o qual inclui as seguintes etapas: 1) identificar o conceito de interesse e expressões associadas; 2) selecionar o cenário apropriado para coleta de dados; 3) coletar os dados; 4) analisar os dados identificando os atributos essenciais do conceito, seus antecedentes e consequentes; 5) identificar os termos substitutos, conceitos relacionados e caso modelo do conceito; 6) identificar hipóteses e implicações para outros estudos (14). o método evolucionário constitui-se em uma estratégia adequada para investigar, caracterizar e ilustrar determinado conceito de interesse, vislumbrando-se a possibilidade de contribuir com a prática, pesquisa e educação dos profissionais da saúde, principalmente os da enfermagem (16). nesta investigação, utilizaram-se as quatro primeiras etapas do método por entender que estas contemplam a análise da evolução do conceito de adesão ao tratamento de crianças soropositivas ao hiv, objeto deste estudo. diante do referencial adotado, para a identificação dos atributos essenciais de adesão ao tratamento de crianças soropositivas, trabalharam-se as seguintes questões preconizadas pelo modelo (14): como os autores definem o conceito? quais as características apontadas por eles? que ideias os autores discutem sobre o conceito de adesão ao tratamento de crianças soropositivas? os eventos antecedentes foram identificados pelas respostas às seguintes perguntas (14): que eventos contribuem para a iminência do conceito de adesão ao tratamento de crianças soropositivas? o que é necessário para que a criança desenvolva as características de adesão? e para identificação dos consequentes adotaram-se as seguintes indagações: o que aconteceu após a adesão ao tratamento de crianças soropositivas? o que se pretende atingir com a adesão ao tratamento? as buscas do material empírico foram realizadas no mês de outubro de 2011 por meio da rede biblioteca virtual em saúde (bvs) que segue como fonte de informação as bases de dados lilacs, medline, bdenf, ibecs, biblioteca cochrane e scielo. no intuito de abranger o maior número possível de publicações, realizou-se, ainda, busca na base de dados cinahl. para o levantamento dos artigos, utilizou-se a combinação dos descritores controlados, adotados pelos descritores em ciências da saúde (decs) e pelo medical subjetc headings (mesh), a saber: “adesão do paciente”, “criança”, “hiv” e “aids”, aplicados nas línguas portuguesa, inglesa e espanhola. durante a coleta e leitura inicial dos artigos, identificaram-se outros descritores utilizados para abordar a temática de adesão ao tratamento, como é o caso das variações: “recusa do paciente ao tratamento” e “cooperação do paciente”. deste modo, expandiu-se a busca ao se incluir tais termos. para a seleção dos estudos, estabeleceram-se os seguintes critérios de inclusão: publicações nas áreas médica e de enfermagem, disponibilizadas eletronicamente e na íntegra em português, inglês ou espanhol, contidas no recorte temporal de 2000 a 2011, que estudaram ou focalizaram a adesão ao tratamento entre crianças com hiv/aids. como critério de exclusão 232 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 estabeleceu-se os trabalhos fora da área de pediatria, porquanto o foco da pesquisa é a adesão ao tratamento entre crianças soropositivas ao hiv. excluíram-se os artigos que não guardavam relação com a temática mediante leitura minuciosa dos títulos e dos resumos. aqueles que suscitavam dúvidas quanto à sua relevância foram lidos na íntegra, a fim de incluí-los ou não no rol de artigos eleitos para estudo em profundidade. na busca inicial encontraram-se 247 publicações. após a aplicação dos devidos critérios, excluíram-se 230 artigos, pelos seguintes motivos: não estarem disponíveis eletronicamente, serem repetidos, não apresentarem elementos suficientes para a realização da análise de conceito, serem editoriais ou carta ao editor ou possuírem algum dos termos delimitados na busca, mas sem abordar o assunto, nem a população pediátrica alvo de interesse deste estudo. deste modo, a amostra final do estudo constituiu-se de 17 artigos. definidos os textos a serem utilizados, procedeu-se à leitura analítica na íntegra, lendo-os e relendo-os diversas vezes, com vistas à identificação dos trechos que correspondiam aos atributos essenciais, antecedentes e consequentes do conceito investigado. os resultados foram apresentados por meio da caracterização dos estudos e por categorias temáticas advindas da análise conceitual. como se trata de pesquisa realizada com dados de artigos de domínio público, sem envolvimento de seres humanos, não houve necessidade de apreciação de um comitê de ética em pesquisa. outrossim, registra-se o emprego ético dos conteúdos abstraídos. resultados considerando as características dos artigos que constituíram o universo de estudo, conforme aponta a tabela 1, verificou-se a predominância de trabalhos no período de 2007 a 2011, a demonstrar, assim, um incremento do interesse dos pesquisadores acerca da temática nos últimos quatro anos. houve predominância de artigos publicados na língua inglesa (58,8%), por ser no contexto dos países do hemisfério norte, de países desenvolvidos, onde se dá o maior número de publicações relativas ao assunto. quanto ao tipo de artigo, 15 (88,2%) eram originais e apenas 2 (11,8%) revisão de literatura. este resultado parece refletir o empenho dos profissionais de saúde em desenvolver e expandir seu corpo de conhecimento acerca das inserções concretas da infecção pelo hiv/aids em crianças. tal iniciativa fortalece a prática baseada em evidências por meio da utilização dos resultados de pesquisas para fundamentar suas decisões, ações e interações com os pacientes sob sua responsabilidade. tabela 1 – características dos artigos utilizados na análise do conceito fonte: elaboração própria, 2011. a categorização dos atributos, dos antecedentes e consequentes identificados na análise dos artigos está disposta na figura 1. discussão atributos do conceito adesão ao tratamento de crianças soropositivas os atributos são as palavras e/ou expressões usadas, com frequência, pelos autores para descrever as características do conceito. quanto mais claro for o conceito, quer dizer, a expressão dos seus atributos essenciais, maior será a compreensão entre aqueles que o utilizam (14). variáveis n % ano de publicação 2000 01 5,9 2007 03 17,6 2008 06 35,3 2009 04 23,5 2010 01 5,9 2011 02 11,8 idioma inglês 10 58,8 português 06 35,3 espanhol 01 5,9 tipo de arquivo original 15 88,2 revisão de literatura 02 11,8 total 17 100 233 adesão ao tratamento de crianças soropositivas ao hiv: uma análise conceitual l eliane rolim de holanda, maria amelia de souza, viviane rolim de holanda y otros. comumente a adesão foi quantificada como o percentual das doses tomadas como prescrito (19). no entanto, variáveis como frequência (número de doses por dia) quantidade (número de comprimidos por dose) e especificidade (condições de armazenamento de medicamentos) do regime muitas vezes são tratadas de forma diferente entre as pesquisas (20). quando comparada com pacientes adultos a adesão é mais complexa entre crianças em virtude de diversos fatores, entre estes: dependência de cuidadores, que podem ou não estar doentes e ser ou não pais da criança; excessivo número de doses e drogas; pobre palatabilidade das drogas; dificuldade de tomar os comprimidos e interferência com rotinas diárias (19, 21, 22). em corroboração a tais aspectos, o maior problema em crianças com infecção pelo hiv é o fato delas dependerem dos pais ou cuidadores para receberem seus medicamentos e do comportamento da própria criança em acatar as recomendações advindas da equipe de saúde (6, 10, 21). a adequação de hábitos torna-se primordial para favorecer a adesão, buscando associar a ingestão medicamentosa às atividades rotineiras executadas no dia a dia da criança. por exemplo, a interrupção na frequência à escola parece refletir a dificuldade da criança em adaptar sua realidade à ingestão dos medicamentos de forma confidencial por receio das reações negativas dos colegas que podem ostracizá-la (9, 10, 23). além disso, medicamentos antirretrovirais compartilham características que amplificam as dificuldades inerentes à adesão à medicação para crianças (24). a limitada disponibilidade de formulações pediátricas age como uma barreira adicional para o tratamento. embora as combinações medicamentosas fixas, conhecidas como “fixed drug combinations” (fdc), promovam melhor aderência e tendam a ter melhor custo-efetividade, a disponibilidade de antirretrovirais em formulações líquidas e com dosagem adequadas para pacientes pediátricos ainda são escassas (1, 25, 26). as formulações sólidas de antirretrovirais fornecidos pelo governo são principalmente pílulas, comprimidos, cápsulas ou comprimidos que crianças com menos de sete anos de idade são geralmente incapazes de engolir. na ausência de fdcs adaptados às crianças, os cuidadores trituram e dissolvem a medicação antes de oferecer a elas. logo, muitas crianças soropositivas têm que tomar cápsulas abertas, comprimidos esmagados ou grandes quantidades de antirretrovirais líquidos (26, 27). figura 1 – distribuição dos atributos essenciais, antecedentes e consequentes do conceito de adesão ao tratamento de crianças soropositivas segundo categorias fonte: elaboração própria, 2011. • seguimento da prescrição médica pelo binômio criança-família • disponibilidade de formulações pediátricas • acompanhamento clínico-laboratorial regular • adequação de hábitos • compartilhamento de decisões entre cuidador e criança • compreensão da criança sobre a terapia antirretroviral • cuidado centrado no binômio criança-família • comunicação adequada entre equipe de saúde, criança e família • estabelecimento de vínculo com a equipe de saúde • envolvimento do cuidador no tratamento • circunstâncias socioeconômicas favoráveis • escolaridade mínima do cuidador • apoio social e familiar • ingestão correta de medicamentos prescritos • redução da morbimortalidade por hiv/aids • mudança de curso da infecção de doença fatal para condição crônica • prevenção de infecções oportunistas • supressão dos níveis de carga viral • diminuição do risco de progressão da doença • prevenção da resistência viral • prolongamento da sobrevida da criança soropositiva • melhoria da qualidade de vida • interferência nas rotinas diárias a d es ã o a o t r a ta m en to d e c r ia n ç a s s o r o p o s it iv a s c o n s eq u en te s a n te c ed en te s a tr ib u to s na ausência de critérios universalmente aceitos entre os pesquisadores para o estabelecimento conceitual de adesão, o seguimento da prescrição médica pelo binômio criança-família foi retratado nos estudos como a concordância entre a prescrição médica e o comportamento adotado pela criança no tocante à ingestão dos medicamentos. 234 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 de modo geral, os esquemas pediátricos são complexos, envolvem vários medicamentos e xaropes que mudam frequentemente de acordo com o crescimento da criança e a disponibilidade de drogas. ademais, formulações inadequadas, os efeitos colaterais das drogas, o grande volume dos comprimidos, os horários de utilização e o sabor desagradável podem levar a baixa adesão em crianças, que por sua vez associa-se diretamente à falha do tratamento (27, 28). nesse sentido, diante da baixa palatilidade, podem-se criar estratégias capazes de mascarar o paladar do fármaco, tais como misturá-lo a sucos, leite ou outros líquidos do agrado da criança. outro determinante do sucesso da adesão é o acompanhamento clínico-laboratorial regular, ou seja, a assiduidade das crianças aos serviços de saúde para avaliações periódicas (29). a precariedade social a que está submetida a maioria das famílias que convive com o hiv/aids, seja pela baixa renda, baixa escolaridade, número excessivo de pessoas habitando no mesmo domicílio, entre outros, pode aumentar a vulnerabilidade dessas crianças às doenças próprias da infância, bem como o risco de atraso no crescimento e desenvolvimento. é preciso, pois, ampliar a ajuda e o seguimento dessas crianças expostas ao vírus considerando suas condições de vida (30). sobressai, também, o compartilhamento de decisões entre cuidador e criança, por ser fundamental para o estabelecimento de uma aliança de cumplicidade, onde as orientações medicamentosas devem ser compartilhadas para que ambos se sintam responsáveis pela administração da terapêutica implementada (1). a enfermagem exerce papel decisivo junto a esse binômio cuidador-criança, na manutenção da motivação, da comunicação e no repasse de informações de forma clara e simples com a finalidade de proporcionar-lhes melhor qualidade de vida. antecedentes do conceito adesão ao tratamento de crianças soropositivas entende-se por antecedentes as situações, eventos ou fenômenos que precedem o conceito de interesse. os antecedentes auxiliam na compreensão do contexto social no qual o conceito é geralmente utilizado, bem como favorecem seu refinamento (14). a compreensão da criança sobre seu diagnóstico pode motivála a aderir ao seu regime terapêutico, ajudando-a a criar autonomia e relações de confiança que facilitam a adesão. ao entender a infecção pelo hiv, ela passa a dar sentido à doença, relacionando-a com suas próprias experiências e à importância da necessidade de seguir a terapia preconizada (9, 10, 22, 23, 31). como consta em estudo, o cuidado centrado no binômio criança-família incentiva a coparticipação da família nas tomadas de decisão; inclui uma relação horizontal e compartilhada entre a equipe e a família; integra os diversos profissionais de saúde na promoção do cuidado; compreende o que é a família e como ela se define; oferece atividades recreativas e respeita as diferenças culturais (32). no entanto, o que se verifica na prática profissional é que esse tipo de abordagem ainda não está incorporado à filosofia assistencial dos sistemas de saúde pediátricos brasileiros. para a concretização dessa perspectiva, se requer modificações na estrutura organizacional e nas relações de trabalho dos profissionais, a fim de estabelecer os limites de cada um no processo terapêutico (33). é preciso perceber que, ao mesmo tempo em que se deve enxergar a família como parceira na promoção do cuidado, tornase indispensável compreendê-la, também, durante a prática profissional cotidiana, como objeto desse cuidado, em um processo de produção de relações e intervenções, para além do atendimento clínico (34). nesse sentido, a família não pode ser vista apenas como aquela que deve cumprir as determinações dos profissionais de saúde. precisa ter suas dúvidas esclarecidas e opinião considerada, além da participação incentivada no processo de cuidar. cabe ao enfermeiro ser um elemento facilitador no desenvolvimento de habilidades da família, ajudando-a a encontrar suas próprias soluções. ao conhecer a família, tem condições de avaliar, junto com ela, os recursos disponíveis capazes de fortalecer a adesão ao tratamento da criança soropositiva. a comunicação adequada e o estabelecimento de vínculo entre equipe de saúde, criança e família incluem o assessoramento às famílias em suas dúvidas, o apoio às suas iniciativas, a avaliação da sua vulnerabilidade e o estímulo ao empoderamento 235 adesão ao tratamento de crianças soropositivas ao hiv: uma análise conceitual l eliane rolim de holanda, maria amelia de souza, viviane rolim de holanda y otros. com vistas a se tornarem cada vez mais ativas na implementação de um cuidado terapêutico que atenda às demandas clínico-imunológica da criança soropositiva (31, 32, 35). conforme indicado em estudos, baixo nível de escolaridade dos cuidadores, condição de pauperização, ocultação do diagnóstico para a criança, vulnerabilidade social e rede social de apoio limitado são fatores que dificultam a adesão e o cuidado adequado às crianças com hiv (36, 37, 38). a identificação destes fatores pode orientar as equipes de saúde, a realizar intervenções capazes de maximizar a adesão entre as crianças por meio da ênfase no monitoramento daqueles cuidadores que apresentam tais características de risco descritas (39). além disso, a aids impõe modificações na vida da criança e sua família, que, em meio ao caos, buscam formas de adaptação e desenvolvem estratégias de enfrentamento diversas para o manejo de estressores (40). durante esse período, necessitam de suporte, e é essencial sentirem-se acolhidas por todos da equipe de saúde, a fim de garantir uma boa adesão aos controles e tratamento (41). entre crianças soropositivas, uma adequada adesão ao tratamento antirretroviral não depende exclusivamente delas, mas da adesão do cuidador, os quais nem sempre são seus pais biológicos (42). verifica-se na literatura que muitas famílias podem passar por processos de reorganização do núcleo familiar, quando um dos pais biológicos, ou ambos, vem a falecer em decorrência das complicações advindas da aids (43, 44). é possível que o impacto trazido por esse tipo de reorganização familiar gere situações concorrentes à adesão e contextos adversos ao uso dos medicamentos. os pais biológicos de crianças soropositivas também enfrentam dificuldades associadas com a sua própria doença e comorbidades. assim, estes podem estar fisicamente fatigados ou debilitados. nestes casos, o tratamento pode se tornar para estes uma lembrança de culpa sobre o seu papel na aquisição da infecção do filho, o que é mais um desafio para a adesão (45). por várias razões, ao se atribuir a responsabilidade de administração da terapia antirretroviral às próprias crianças, sem a supervisão dos pais ou responsáveis, torna-se praticamente improvável que elas completem o esquema com sucesso (23, 46). assim, estimular o envolvimento do cuidador no tratamento, tentando compreender o que o impede de realizar a tarefa de administração dos medicamentos à criança e o que o ajuda a ter sucesso, pode ser crucial para o desenvolvimento de intervenções passíveis de promover uma adesão eficaz (46). consequentes do conceito as consequências do conceito dizem respeito a eventos ou situações resultantes da sua utilização (14). a definição precisa das consequências será concretizada após a exploração do conceito em sua manifestação prática. os eventos consequentes são úteis para fornecer novas ideias às pesquisas, pois permitem investigação mais ampla de todas as facetas do conceito em estudo (15). nos documentos examinados identificaram-se eventos consequentes que estão discutidos tanto nas questões biológicas como nas sociais. como evidenciado, a ingestão correta de medicamentos prescritos e a adequada aderência da criança aos cuidados prescritos têm se mostrado efetivas para a redução da replicação do vírus hiv, suprimindo os níveis de carga viral e consequentemente levando à restauração imune (10, 19, 22). a melhoria do estado imunitário é clinicamente visível pela diminuição significativa de episódios de adoecimento (25). observa-se ainda a ocorrência da prevenção da resistência viral e de infecções oportunistas, redução da morbimortalidade, diminuição do risco de progressão da doença, prolongamento da sobrevida e melhora na qualidade de vida e saúde das crianças soropositivas. tudo isso propicia ganhos em seus processos de crescimento e desenvolvimento (8, 10, 21). no entanto, a adesão ao regime terapêutico requer interferência nas rotinas diárias da vida da criança e de sua família, com vistas à realização de atividades específicas que promovam e mantenham a saúde. essas atividades envolvem tomar as medicações prescritas regularmente, manter uma dieta adequada, automonitorar os sinais e sintomas da doença e submeter-se a avaliações de saúde periódicas (36, 47). a adesão de crianças soropositivas à terapia antirretroviral altamente ativa (haart) mudou o curso da aids de uma doença fatal para uma doença crônica (20). com o advento da haart, a 236 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 aquichan issn 1657-5997 sobrevida dessa população aumentou e, desta forma, a infecção pelo hiv passou a ser considerada uma condição crônica na infância, ou seja, “interfere no funcionamento do corpo da criança em longo prazo, requer assistência e seguimento por profissionais de saúde, limita, de alguma forma, suas atividades diárias e causa repercussões no seu processo de crescimento e desenvolvimento, afetando o cotidiano de todos os membros da família” (48: 21). nesse contexto, por se tratar de uma condição crônica constitui intensa fonte de ansiedade. para a criança, além do impacto direto nas funções biológicas, afeta-a as dimensões emocionais, psíquicas e sociais. é frequente o surgimento de sentimentos diversos, tais como: o temor do abandono, a interpretação da doença como um castigo, a insegurança em relação às suas possibilidades escolares, o receio das restrições impostas pela doença e o medo do que as outras crianças possam pensar em relação à sua doença (34, 49). para a família, também representa grande fonte de sofrimento psíquico, emocional e moral oriundo da presença objetiva da morte no seio familiar ou de um forte processo de culpabilização quando se pode identificar a pessoa responsável pela transmissão da doença (35). percebe-se, então, a importância de um processo de educação dialógica em saúde que considere as particularidades e limitações do binômio cuidador-criança e que construa soluções passíveis de superá-las. no modelo dialógico de educação em saúde, o indivíduo é reconhecido como um sujeito que traz consigo um saber prévio, que embora distinto do saber técnicocientífico não é deslegitimado pelos serviços. desta forma, todos, profissionais, criança e família, atuam como iguais, ainda que com papéis diferenciados (50). nesse âmbito, o enfermeiro desempenha papel relevante em decorrência da sua relação de proximidade com pacientes e familiares, bem como das suas competências profissionais para exercer a função de agente educador. considerações finais a análise conceitual propiciou uma compreensão mais abrangente do conceito de adesão ao tratamento de crianças soropositivas. elaborou-se uma definição consensual que vai além da ingestão de medicamentos, considerando-se o dinamismo, aspectos familiares, o cotidiano das crianças, os determinantes sociais, econômicos e estruturais que integram o fenômeno, por meio da identificação dos atributos, dos antecedentes e dos consequentes mais frequentemente associados ao mencionado conceito. os resultados obtidos evidenciam que adesão é um processo colaborativo que demanda seguimento da prescrição médica pelo binômio criança-família, disponibilidade de formulações pediátricas, acompanhamento clínico-laboratorial regular, adequação de hábitos, compartilhamento de decisões entre cuidador e criança. para tanto, faz-se necessário previamente à compreensão da criança sobre a terapia antirretroviral, um cuidado centrado no binômio criança-família, o estabelecimento de vínculo com a equipe de saúde, o envolvimento do cuidador no tratamento e apoio social e familiar. disto resultará a aceitação e a integração ao regime terapêutico no cotidiano das crianças em tratamento, pressupondo uma redução da morbimortalidade por hiv/aids, prevenção da resistência viral, diminuição das infecções oportunistas e mudança no curso da infecção de doença fatal para condição crônica. a partir deste entendimento, vislumbram-se novos caminhos no agir do enfermeiro, para que este possa planejar e exercer de modo mais eficaz sua assistência, uma vez que a organização do conhecimento sobre o conceito de adesão ao tratamento de crianças soropositivas favorece o entendimento de situações ligadas à sua prática. os resultados propiciaram também subsídios para elaboração futura de instrumentos a serem utilizados em trabalhos de pesquisa relacionados à temática, inclusive que sejam capazes de avaliar, em situações concretas assistenciais, os fatores associados à adesão aos antirretrovirais na infância. os elementos identificados nos artigos foram incorporados ao método evolucionário e se mostraram válidos para a compreensão do conceito estudado, auxiliando a prestação de uma assistência integral, o direcionamento de ações ao binômio criança-cuidador, o controle da doença e uma melhor qualidade de vida. conforme se percebeu, apesar da elevada parcela de crianças verticalmente expostas ao hiv na população brasileira, a investigação em cuidados e tratamento neste cenário ainda é limitada. portanto, é pertinente a recomendação de pesquisas de enfermagem nesta temática, subsidiando uma prática baseada em evidências. 237 adesão ao tratamento de crianças soropositivas ao hiv: uma análise conceitual l eliane rolim de holanda, maria amelia de souza, viviane rolim de holanda y otros. a adesão é um ato de caráter dinâmico a ser constantemente incentivado. profissionais de saúde, pacientes, sua rede familiar e social são corresponsáveis pelo sucesso ou possível falha no tratamento antirretroviral. os serviços de saúde são locais estratégicos de execução de intervenções no campo da adesão, entre as quais se incluem a disponibilidade de informação sobre a importância da adesão e a adequação do tratamento à rotina de vida da criança. diante do exposto, sugere-se, dentro das possibilidades de cada serviço, a formação de grupos de profissionais multidisciplinares dedicados a facilitar a adesão por parte das crianças e de seus cuidadores. também recomenda-se a realização de trabalhos educativos com os cuidadores voltados a promover a troca de experiências, melhorar o nível de conhecimento sobre o hiv/aids e auxiliar no desenvolvimento de estratégias de enfrentamento coerentes com suas realidades. referências 1. martins ss, martins tss. adesão ao tratamento antirretroviral: vivências de escolares. texto context-enferm 2011 mar; 20 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dos cuidadores.indd 188 paula cristina nogueira1 simone de godoy2 isabel amélia costa mendes3 daiane leite da roza4 conhecimento dos cuidadores de indivíduos com lesão medular sobre prevenção de úlcera por pressão 1 professora doutor da escola de enfermagem da universidade de são paulo, brasil. pcnogueira@usp.br 2 escola de enfermagem de ribeirão preto da universidade de são paulo (eerp-usp), centro colaborador da organização mundial da saúde para o desenvolvimento da pesquisa em enfermagem, brasil. sig@eerp.usp.br 3 escola de enfermagem de ribeirão preto da universidade de são paulo (eerp-usp), centro colaborador da organização mundial da saúde para o desenvolvimento da pesquisa em enfermagem, brasil. iamendes@usp.br 4 bacharela em estatística. doutoranda da faculdade de medicina de ribeirão preto da universidade de são paulo, brasil. daianeroza@usp.br recibido: 23 de julio de 2013 enviado a pares: 4 de agosto de 2013 aceptado por pares: 30 de noviembre de 2014 aprobado: 25 de enero de 2015 doi: 10.5294/aqui.2015.15.2.3 para citar este artículo / to reference this article / para citar este artigo nogueira pc, godoy s, mendes iac, roza dl. conhecimento dos cuidadores de indivíduos com lesão medular sobre prevenção de úlcera por pressão. aquichan. 2015; 15 (2): 188-199. doi: 10.5294/aqui.2015.15.2.3 resumo estudo descritivo exploratório que teve como objetivos identificar as características sociodemográficas das pessoas com lesão da medula espinhal (lme) e de seus cuidadores familiares e avaliar o conhecimento dos cuidadores sobre prevenção de úlcera por pressão (upp). participaram do estudo 47 pessoas com lme e 47 cuidadores que responderam a um teste de conhecimento sobre prevenção de upp. esse teste é composto por questões fechadas com opções de resposta: v = verdadeiro, f = falso e ns = não sei. para análise estatística dos dados, foi utilizado o proc ttest do software sas® 9. dos indivíduos com lme, 80,8% eram do sexo masculino, idade média de 41,6 anos e 57,5% tiveram lesão medular traumática. quanto aos cuidadores, 89,3% eram do sexo feminino, com média de idade de 44 anos, 76,6% casados. a porcentagem média de acertos no teste de conhecimento foi de 67,8% (dp = 14,8), o mínimo foi 14,3% e o máximo foi 88,5%, o que demonstrou conhecimento insuficiente relacionado com a prevenção de upp. a porcentagem de acertos no teste foi menor conforme o aumento da idade. a identificação dos déficits de conhecimento dos cuidadores sobre a temática permite ao enfermeiro realizar um planejamento de estratégias educativas para prevenção de upp. palavras-chave úlcera por pressão, traumatismos da medula espinhal, cuidadores, prevenção e controle, educação em enfermagem (fonte: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 188-199 189 conhecimento dos cuidadores de indivíduos com lesão medular sobre prevenção de úlcera por pressão l paula cristina nogueira y otros año 15 vol. 15 nº 2 chía, colombia junio 2015 l 188-199 conocimiento de los cuidadores de individuos con lesión medular acerca de la prevención de úlcera por presión resumen estudio descriptivo exploratorio que tuvo como objetivos identificar las características sociodemográficas de las personas con lesión de la medula espinal (lme) y de sus cuidadores familiares y evaluar el conocimiento de los cuidadores acerca de la prevención de úlcera por presión (upp). participaron en el estudio 47 personas con lme y 47 cuidadores quienes contestaron una prueba de conocimiento sobre prevención de upp. esta prueba está conformada por cuestiones cerradas, con opción de respuesta: v = verdadero, f = falso y ns = no sé. para análisis estadístico de los datos, se ha utilizado el proc ttest del software sas® 9. de los individuos con lme, el 80,8% era del sexo masculino, promedio de edad de 41,6 años, y el 57,5% tuvo lesión medular traumática. en cuanto a los cuidadores, el 89,3% era del sexo femenino, promedio de edad de 44 años, el 76,6% casado. el porcentaje promedio de respuestas correctas en la prueba de conocimiento fue del 67,8% (dp = 14,8), el mínimo fue el 14,3% y el máximo fue el 88,5%, lo que ha demostrado conocimiento insuficiente relacionado con la prevención de upp. el resultado de respuestas correctas en la prueba fue menor conforme al aumento de la edad. la identificación de los déficits de conocimiento de los cuidadores acerca de la temática le permite al enfermero realizar una planeación de estrategias educativas para prevención de upp. palabras clave úlcera por presión, traumatismos de la medula espinal, cuidadores, prevención y control, educación en enfermería (fuente: decs, bireme). 190 aquichan issn 1657-5997 knowledge on pressure ulcer prevention among caregivers of spinal cord injury patients abstract a descriptive exploratory study that aimed to identify sociodemographic characteristics of persons with spinal cord injury (sci) and of their family caregivers and to asses knowledge on pressure ulcer prevention among caregivers. participants were 47 persons with sci and 47 caregivers who completed a test of knowledge about prevention upp. this test consists of closed questions with answer options: v = true, f = false and ns = not know. for statistical analysis we used the proc ttest software sas ® 9. among individuals with sci, 80.8% were male, mean age of 41,6 years and 57,5% had traumatic sci. among caregivers, 89.3% were female with a mean age of 44 years, 76,6% were married. the mean percentage of correct answers on the knowledge test was 67,8% (sd = 14.8), the minimum was 14,3% and the maximum was 88,5%, demonstrating insufficient knowledge related to prevention upp. the percentage of correct answers on the test was lower with increasing age. the identification of deficits knowledge of caregivers on the theme allows nurses to conduct a planning educational strategies for the prevention of upp. keywords pressure ulcer; spinal cord injuries; caregivers; prevention & control; education, nursing (source: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 188-199 191 conhecimento dos cuidadores de indivíduos com lesão medular sobre prevenção de úlcera por pressão l paula cristina nogueira y otros introdução a lesão da medula espinhal (lme) resulta em sérias alterações das funções motoras, sensitivas e dos sistemas orgânicos. grandes modificações na vida do paciente, família e sociedade ocorrem em decorrência da gravidade da lesão (1, 2). considerando a etiologia, a lme pode ser dividida em duas categorias: as lesões traumáticas da medula espinhal (ltme) e as não traumáticas. dentre as causas das ltme, incluem-se os ferimentos por arma de fogo, acidentes automobilísticos, quedas e mergulhos (2, 3). as lesões não traumáticas geralmente resultam de patologias que comprometem a medula espinhal e podem ser classificadas em: congênitas (mielodisplasias), degenerativas, tumorais, infecciosas, doenças neurológicas, sistêmicas e vasculares (3). as pessoas com lme estão sujeitas a inúmeras complicações durante a fase aguda da lesão e também na fase de reabilitação. as complicações são frequentes causas de morbi/mortalidade e conduzem para um aumento das taxas de reospitalização e custo do cuidado, além da diminuição da qualidade de vida do indivíduo acometido e de seu cuidador familiar (1, 2). vários fatores, incluindo o nível neurológico e a extensão da lesão, a redução das habilidades funcionais e o tipo de complicação secundária à lesão, são apontados como aspectos que influenciam nas taxas de reospitalização. estas, quando repetidas, trazem grandes consequências para o indivíduo e seu cuidador familiar e também para a instituição de saúde que terá mais gastos com o tratamento (1, 2, 4). a úlcera por pressão (upp) é uma complicação secundária de grande incidência nas pessoas com lme, pois estas apresentam vários fatores de risco para o aparecimento dessas lesões. além do déficit de mobilidade e sensibilidade, há outros fatores intrínsecos e extrínsecos que devem ser considerados como risco. entre os fatores intrínsecos destacam-se: incontinência fecal ou urinária, umidade (transpiração e incontinência), ausência de mobilidade, cognição alterada, nutrição inadequada e idade. entre os fatores extrínsecos além da pressão, a fricção, cisalhamento e umidade (secagem insuficiente após banho) devem ser considerados (4, 5). a presença de upp traz grande impacto negativo para as atividades da vida diária (avd) e relacionamentos sociais dos indivíduos ao interromper ou atrasar, frequentemente, o processo de reabilitação e reintegração social (1, 6). e não somente o indivíduo sofrerá as consequências de uma ou mais upp, mas também o seu cuidador familiar, o qual se torna responsável pela realização cuidados o que inclui os curativos diários. a manutenção da integridade da pele e tecidos subjacentes para a prevenção da upp tem sido tradicionalmente uma responsabilidade da equipe de enfermagem embora outros profissionais da equipe de saúde necessitem estar envolvidos pela natureza multicausal do problema. portanto, cabe ao enfermeiro o preparo da díade paciente com lme e cuidador orientando-os sobre os cuidados no domicílio e enfatizando como prevenir as upp. objetivos identificar as características sociodemográficas das pessoas com lme e de seus cuidadores familiares e avaliar o conhecimento dos cuidadores sobre a prevenção de upp. materiais e métodos estudo descritivo-exploratório, quantitativo, realizado em um hospital universitário, de nível terciário, localizado em um município do interior do estado de são paulo, brasil. após a aprovação do comitê de ética e pesquisa (processo 1.425/2011), cuidadores de indivíduos com lme atendidos nos setores de ortopedia, neurologia, neurocirurgia, clínica cirúrgica e no centro de reabilitação do hospital foram convidados a participar da pesquisa mediante assinatura do termo de consentimento livre e esclarecido. quarenta e sete cuidadores participaram do estudo no período de março a agosto de 2012. para a coleta de dados, foram utilizados dois questionários: um para caracterização sociodemográfica da pessoa com lme e de seu cuidador, e outro para avaliar o conhecimento dos cuidadores sobre a prevenção de upp. este último é um teste de conhecimento que possui sua confiabilidade e validade relatadas na literatura (7, 8). no brasil, foi validado e utilizado em estudos anteriores com profissionais da equipe de enfermagem (9, 10). o teste é baseado nas recomendações propostas por diretrizes internacionais para prevenção de upp e é composto por questões em que o indivíduo deve escolher umas das opções de resposta: v = verdadeiro, f = falso e ns = não sei. fizemos uma adaptação semântica do teste utilizado nos estudos anteriores (9, 10) com profissionais de enfermagem, para avaliar o conhecimento de cuidadores de indivíduos com lme sobre a prevenção de upp, e foi validado por quatro enfermeiras/docentes 192 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 especialistas na área temática e por cinco cuidadores de indivíduos com lme. as sugestões indicadas que julgamos pertinentes foram acatadas e o teste adaptado com 35 questões foi aplicado aos cuidadores que aceitaram participar da pesquisa. os dados coletados foram analisados de forma quantitativa utilizando estatística descritiva. para os dados sociodemográficos, foi utilizado o cálculo da frequência e porcentagem. na análise dos dados do teste, consideramos as respostas marcadas como “não sei” como erro. a proporção dos erros e acertos de cada questão do teste foi realizada. o escore total do teste de conhecimento correspondeu à soma de todas as respostas corretas. as comparações entre as variáveis sociodemográficas de interesse e as porcentagens de acerto foram feitas utilizando o teste t-student, o qual consiste em comparar duas médias provenientes de amostras não pareadas. para a realização desse procedimento, foi utilizado o proc ttest do software sas ® 9 (11) e a análise de variância (anova) (12). essa metodologia baseia-se em particionar a variância total de uma determinada resposta (variável dependente) em duas: a primeira devido ao modelo de regressão (no caso, entre grupos) e a segunda devido aos resíduos (erros) (dentro dos grupos). quanto maior for a primeira em relação à segunda, maior é a evidência da diferença entre as médias dos grupos. esse modelo tem como pressuposto que seus resíduos tenham distribuição normal com média 0 e variância constante. quando esse pressuposto não foi atendido, foi aplicada uma transformação na variável resposta. esse procedimento foi realizado por meio do software sas® 9 (11), utilizando a proc glm. para as comparações, foram utilizados contrastes ortogonais baseados na distribuição t. o nível adotado de significância foi o descritivo (α) de 5% (p ≤ 0,05), os valores de p≤ 0,05 indicaram significância estatística entre os dados comparados. os erros e acertos foram classificados com base em estudo anterior (11), em: baixo (< 50%); regular (50 a 69,9%); médio (70 a 89,9%) e alto (≥ 90%), índices de acertos. resultados e discussão no que se refere às características sociodemográficas e clínicas das 47 pessoas com lme, 38 (80,8%) eram do sexo masculino, com idade média de 41,6 anos (dp=15,9). vinte e sete (57,5%) indivíduos tiveram ltme, como principais causas do trauma: acidente motociclístico – 7 (26,9%), quedas – 5 (19,2%), ferimento por arma de fogo – 4 (15,4%) e acidente automobilístico – 3 (11,5%). quanto às características dos 47 cuidadores, a maioria, 42 (89,3%), era do sexo feminino, com média de idade de 44 anos (dp=12,8), 36 (76,6%) casados, 26 (55,3%) com baixo nível de escolaridade e somente 20 (42,5%) tinham ocupação, como atividade laboral remunerada. quanto ao grau de parentesco, houve predomínio de 19 (40,4%) cuidadoras que eram esposas, seguido de 13 (27,6%) cuidadoras que eram mães dos indivíduos com lme. trinta e três (70,2%) entrevistas foram realizadas no centro de reabilitação do hospital e as demais foram feitas nos setores de internação: neurocirurgia, neurologia e ortopedia. as características sociodemográficas das pessoas com lme e de seus cuidadores encontradas neste estudo corroboram outras pesquisas realizadas com essa mesma população, nas quais destacam que a maioria dos indivíduos acometidos pela lesão medular é de adultos jovens, do sexo masculino, com predomínio de ltme causada por acidentes com veículos automotores, ferimento por arma de fogo ou quedas (1-3, 6,13). estudos apontam que os cuidadores desses indivíduos, na grande maioria, são do sexo feminino, mães e esposas, casadas, sem atividade laboral remunerada (1, 14). para avaliar a porcentagem de acertos no teste de conhecimento realizado pelos cuidadores, os 35 itens dele foram categorizados em avaliação e classificação da upp (7 itens) e medidas preventivas (28 itens). a porcentagem de acerto obtida pelos cuidadores de indivíduos com lme referente à avaliação e classificação da upp, do teste de conhecimento, é apresentada na tabela 1. observou-se que, em nenhum dos itens referentes à avaliação e classificação da upp, os cuidadores obtiveram 90% ou mais de acertos; em quatro itens (número 1, 9, 28 e 29), o índice de acertos ficou entre 70 e 89,9% e, em três itens (número 6, 18 e 33), abaixo de 70% de acertos, sendo que, em um desses itens (número 6), a porcentagem de acertos foi muito baixa (19,1%). na tabela 2 são apresentados os resultados referentes aos demais itens do teste sobre a prevenção da upp. identificou-se que, dos itens referentes à prevenção da upp do teste, em apenas 11 (39,2%) os participantes tiveram mais do que 90% de acertos, ou seja, apresentaram nível alto de conhecimento; em 7 (25%) itens o nível de conhecimento foi médio, entre 70 e 89,9% de acertos; em 2 (7,1%) foi regular, entre 50 e 69,9% de acertos e em 8 (28,6%) a porcentagem de acertos foi menor 193 conhecimento dos cuidadores de indivíduos com lesão medular sobre prevenção de úlcera por pressão l paula cristina nogueira y otros tabela 1. porcentagem de acertos dos participantes da pesquisa (n = 47) no teste de conhecimento, segundo os itens sobre a avaliação e classificação da upp (ribeirão preto, 2013) tabela 2. porcentagem de acertos dos participantes da pesquisa (n=47) no teste de conhecimento, segundo os itens sobre a prevenção da úlcera por pressão (ribeirão preto, 2013) fonte: elaboração própria. avaliação e classificação da úlcera por pressão n % 1 o estágio i (1) da úlcera por pressão é definido como avermelhamento de uma área localizada, sem a perda da pele, a qual, quando palpada, não apresenta embranquecimento visível ou a cor difere da área ao redor. (v) 37 78,7 6 uma úlcera por pressão em estágio iii (3) tem uma perda parcial de pele que envolve a epiderme (primeira camada da pele). (f) 9 19,1 9 as úlceras por pressão no estágio iv (4) apresentam perda total de pele com intensa destruição e podem atingir músculos e ossos. (v) 35 74,5 18 as úlceras por pressão no estágio ii (2) apresentam perda de todas as camadas da pele. (f) 19 40,4 28 uma região da pele com cicatriz de úlcera por pressão poderá ser lesada mais rapidamente do que a pele íntegra (sem cicatriz). (v) 35 74,5 29 uma bolha na região do calcanhar não deve ser motivo para preocupação. (f) 39 83 33 as úlceras por pressão em estágio ii podem ser extremamente doloridas, em decorrência da exposição das terminações nervosas que causam dor. (v) 29 61,7 avaliação e classificação da úlcera por pressão n % 2 os fatores de risco para o aparecimento da úlcera por pressão são: perda dos movimentos do corpo, perda da sensibilidade, incontinência (não consegue controlar a urina e/ou fezes) e má alimentação. (v) 34 72,3 3 todos os pacientes em risco para ter a úlcera por pressão devem ter a sua pele avaliada pelo menos uma vez por semana. (f) 12 25,5 4 o uso de água quente e sabonete pode ressecar a pele e aumentar o risco para aparecer a úlcera por pressão. (v) 19 40,4 5 é importante massagear as regiões das proeminências ósseas (que são as regiões em que os ossos ficam mais evidentes, por exemplo: cotovelos, calcanhar) se estiverem avermelhadas. (f) 10 21,2 7 todos os pacientes devem ser avaliados quanto ao risco para o desenvolvimento de úlcera por pressão todos os dias quando estiverem internados ou quando estiverem em suas casas. (v) 43 91,4 8 os cremes e alguns tipos de curativo como os curativos transparentes e curativos de hidrocoloide extrafino (tipo de curativo para proteger as proeminências ósseas) auxiliam na proteção da pele contra os efeitos da fricção (fricção é uma força mecânica de duas superfícies que se movem uma contra a outra e danifica a pele. pode ocorrer, por exemplo, quando o calcanhar fica esfregando no lençol). (v) 31 66 10 a alimentação adequada com verduras, frutas, carnes, grãos, deve ser mantida durante a hospitalização e no domicílio. (v) 43 91,4 194 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 fonte: elaboração própria. avaliação e classificação da úlcera por pressão n % 11 os pacientes que ficam restritos ao leito (acamados) devem ser reposicionados (mudados de posição) a cada três horas. (f) 11 23,4 12 uma escala com horários para mudar o paciente de posição deve ser utilizada para cada paciente com presença ou em risco para ter a úlcera por pressão. (v) 42 89,3 13 as luvas d’água ou de ar aliviam a pressão nos calcanhares. (f) 5 10,6 14 as almofadas tipo rodas d’água (que tem um buraco no meio) ou de ar ajudam a prevenir a úlcera por pressão. (f) 13 27,6 15 o paciente que não se movimenta sozinho deve ser mudado de posição a cada duas horas quando estiver sentado na cadeira. (f) 18 38,3 16 o paciente que tem movimentos e força nos braços e que pode mudar a posição do corpo sem ajuda deve ser orientado a realizar o alívio da pressão, a cada 15 minutos, enquanto estiver sentado na cadeira. (v) 38 80,8 17 o paciente que pode permanecer sentado na cadeira deve ter uma almofada no assento para proteção da região das proeminências ósseas. (v) 43 91,4 19 a pele do paciente em risco para úlcera por pressão deve permanecer limpa e livre de umidade. (v) 46 97,8 20 as medidas para prevenir novas lesões não necessitam ser adotadas continuamente quando o paciente já possui úlcera por pressão. (f) 41 87,2 21 lençóis dobrados ou forros na cama devem ser utilizados para transferir ou movimentar pacientes que não se movimentam sozinhos. (v) 40 85,1 22 a movimentação e a transferência de pacientes que não se movimentam sozinhos devem ser sempre realizadas por duas ou mais pessoas. (v) 46 97,8 23 no paciente que não se movimenta sozinho, o programa de reabilitação deve ser iniciado e incluir orientações sobre a prevenção e tratamento da úlcera por pressão. (v) 43 91,5 24 os pacientes e familiares devem ser orientados quanto às causas e fatores de risco para o desenvolvimento de úlcera por pressão. (v) 46 97,8 25 as regiões das proeminências ósseas podem ficar em contato direto uma com a outra (por exemplo: se o paciente estiver deitado de lado, ficaria com os joelhos em contato direto). (f) 33 70,2 26 todo paciente em risco para desenvolver úlcera por pressão deve usar um colchão que redistribua a pressão como, por exemplo, o colchão caixa de ovos, colchão de ar ou de água. (v) 43 91,5 27 a pele quando fica úmida por certo período, danifica-se mais facilmente. (v) 44 91,6 30 uma boa maneira de diminuir a pressão na região dos calcanhares é mantê-los elevados da cama. (v) 41 87,2 31 cisalhamento é a força que ocorre quando a pele adere a uma superfície e o corpo desliza. (v) 6 12,7 32 a fricção pode ocorrer ao movimentar o paciente sobre o leito. (v) 32 68 34 no paciente que não controla a urina ou fezes (que usa fraldas), a pele deve ser limpa toda vez que tiver urinado ou evacuado. (v) 46 97,8 35 o desenvolvimento de programas educacionais nos hospitais e serviços/postos de saúde pode reduzir o número de casos de pacientes com úlcera por pressão. (v) 44 93,6 195 conhecimento dos cuidadores de indivíduos com lesão medular sobre prevenção de úlcera por pressão l paula cristina nogueira y otros que 50%, o que demonstrou nível ruim de conhecimento sobre a prevenção de upp. ao considerar o teste como um todo (tabelas 1 e 2), a porcentagem média de acertos dos 47 cuidadores foi de 67,8% (dp = 14,8), o mínimo foi 14,3% e o máximo foi 88,5%, o que demonstrou que os cuidadores apresentaram nível de conhecimento sobre a prevenção de upp insuficiente. na tabela 3, apresentamos as comparações entre os escores de conhecimento dos cuidadores com as suas variáveis sociodemográficas. a porcentagem de acertos do teste ao comparar cuidadores do sexo feminino e masculino foi semelhante e, ao aplicar o teste t de student, não houve diferenças estatísticas (p = 0,65). ao comparar as faixas etárias, observamos que quanto maior idade, menor porcentagem de acertos no teste, o que evidencia diferenças estatísticas (p = 0,02 ao comparar a faixa etária 1 com a 3 e p = 0,03 ao comparar a faixa etária 2 com a 3 – teste anova). para as variáveis escolaridade e ocupação, as porcentagens de acertos também foram semelhantes e não houve evidências de diferenças estatísticas ao aplicar o teste t de student (p=0,54 na comparação da escolaridade e p=0,37 na comparação da ocupação). das 47 pessoas com lme deste estudo, 20 (42,5%) informaram apresentar upp no momento da coleta de dados, sendo que as regiões mais acometidas foram sacral, ísquios e calcâneos. essas regiões são onde as upp ocorrem com frequência, pois o indivíduo com lme apresenta déficit de mobilidade e sensibilidade e, com isso, pode permanecer por muitas horas nas posições dorsal ou sentada, sem realizar o alívio da pressão nas proeminências ósseas. por ser a pressão o principal fator causal da upp, deve-se considerar a sua intensidade e duração. a pressão média do sangue ao entrar nos capilares arteriais é de 32 mm/hg. quando o grau de compressão excede essa pressão capilar, ocorre a hipóxia celular e isquemia ocasionando dano tecidual e quebra da integridade da tabela 3. tabela de medidas descritivas das porcentagens de acertos no teste de conhecimento dos cuidadores de indivíduos com lesão medular segundo variáveis sociodemográficas (ribeirão preto, 2013) fonte: elaboração própria. porcentagem de acertos n média dp mínimo mediana máximo sexo feminino 42 68.16 14.49 14.29 65.71 88.57 masculino 5 65.14 10.77 48.57 71.43 88.57 faixa etária (anos) 1. 20 – 39 19 70.08 11.64 48.57 74.29 82.86 2. 40 – 59 23 68.94 12.58 45.71 71.43 88.57 3. ≥ 60 5 54.29 23.21 14.29 62.86 74.29 escolaridade ensino fundamental 26 66.70 15.40 14.29 71.43 88.57 ensino médio 21 69.25 12.48 45.71 71.43 85.71 ocupação atividade não remunerada 27 66.24 15.37 14.29 71.43 88.57 atividade remunerada 20 70.00 12.17 45.71 71.43 85.71 196 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 pele. os capilares da região sacral podem sofrer as consequências de uma pressão da interface entre o colchão e o corpo de 70 mm/ hg, na posição decúbito dorsal, e, quando sentado, a pressão na região isquiática pode chegar a 300 mm/hg (15). estudos nacionais e internacionais mostram que a prevalência e a incidência de upp permanecem altas nas pessoas com lme (5,13). essas lesões, dependendo da profundidade dos tecidos acometidos, podem trazer sérias complicações como ostiomielite, septicemia e até mesmo óbito, além de todas as demais repercussões biopsicossociais à pessoa com lme e seu cuidador familiar (1, 6). entretanto, as upp podem ser prevenidas com a adoção de medidas adequadas, educação dirigida às pessoas com lme e seu cuidador familiar, com estratégias que visem à continuidade do cuidado no domicílio. para que as upp possam ser prevenidas, é necessário conhecer os fatores de risco que esses indivíduos apresentam para o aparecimento dessas lesões. uma vez instalada, a upp, dependendo do estágio, requer avaliação constante, curativos diários e o processo de cicatrização é longo e oneroso, o que implica a restrição da pessoa e seu cuidador em participar de atividades sociais, de lazer, nas atividades esportivas, além de trazer sofrimento físico e emocional (4, 6). conforme o nível de profundidade da upp e de seu aspecto clínico, a pessoa terá hospitalizações frequentes. os custos com o tratamento de upp são significativamente maiores que os custos gerados com a adoção de medidas preventivas básicas; esse fato tem sido reportado em várias pesquisas (4, 16). nesse sentido, é necessário e extremamente importante incluir o cuidador no processo de cuidado à pessoa com lme desde a sua primeira internação, uma vez que é ele que dará continuidade à assistência no domicílio. cabem ao enfermeiro o planejamento, a execução e a avaliação de intervenções educativas para cuidadores domiciliários quanto às medidas preventivas adequadas para upp. pelos resultados obtidos no teste aplicado aos cuidadores, observamos que o nível de conhecimento destes foi ruim. quanto às questões relacionadas com a avaliação e classificação das upp, nenhuma obteve escore ≥ 90% de acerto. observou-se que a maioria dos cuidadores sabe que uma bolha na região do calcâneo deve ser um motivo de preocupação (83% de acertos) e sabe reconhecer os estágios i e iv das upp (78,7 e 74,5% de acertos), porém não sabe diferenciar as upp estágio ii e iii (40,4 e 19,1%). a respeito das medidas preventivas, as questões relacionadas com a higiene (questões 19, 27, 34), o uso de superfícies de suporte para alívio da pressão (questões 17 e 26) e a educação em saúde (7, 10, 22, 43, 46, 35) foram as que tiveram porcentagem de acerto ≥ 90%, ou seja, nessas questões, os cuidadores demonstraram um nível alto de conhecimento. os aspectos com menor acerto pelos cuidadores foram referentes ao uso luvas d’água ou de ar (10,6%), cisalhamento (12,7%), massagem nas proeminências ósseas avermelhadas (21,2%), frequência da mudança de decúbito (23,4%), frequência da avaliação/inspeção da pele (25,5%) e uso de rodas d’água (27,6%). no primeiro estudo em que foi desenvolvido esse teste e aplicado a 228 enfermeiros americanos, identificou-se uma porcentagem média de acertos de 71,7% e foi observado um conhecimento relativamente maior dos enfermeiros que haviam assistido a palestras ou lido artigos referentes à temática (7). no brasil, em estudo realizado com profissionais da equipe de enfermagem, para avaliar o conhecimento destes sobre a prevenção de upp, utilizando o mesmo teste de conhecimento, as pesquisadoras obtiveram como resultado que as questões com menor porcentagem de acertos foram referentes à massagem nas proeminências ósseas avermelhadas (21,2%), uso de almofadas tipo rodas d’água (35,2%), luvas d’água ou de ar (47,9%) e quanto ao período de tempo quando sentado (28%). os resultados demonstraram que tanto o conhecimento dos enfermeiros (média 79,4%) quanto o dos auxiliares/técnicos de enfermagem (média 73,6%) foram insuficientes. dos 136 enfermeiros que participaram da pesquisa, apenas 16 (11,8%) apresentaram uma porcentagem de acertos no teste ≥ 90% e, dos 250 auxiliares/técnicos, apenas 4 (16%) tiveram essa porcentagem de acertos (10). com base nos resultados desses estudos realizados com profissionais de enfermagem que utilizaram o mesmo teste, surgem alguns questionamentos: se os profissionais da enfermagem que prestam assistência direta aos pacientes apresentaram déficit de conhecimento, como orientarão e realizarão a educação dirigida aos pacientes e cuidadores? se ainda muitos fazem uso de luvas d´água sob o calcâneo, massagem nas áreas avermelhadas, uso de almofadas tipo roda d´água durante o período de internação do paciente, provavelmente, devem realizar 197 conhecimento dos cuidadores de indivíduos com lesão medular sobre prevenção de úlcera por pressão l paula cristina nogueira y otros orientações inadequadas à díade (paciente e cuidador) sobre a prevenção de upp. pelos resultados dos estudos nacionais e internacionais com os profissionais de enfermagem, observamos que há déficit no conhecimento destes sobre a prevenção de upp, mesmo com todas as evidências e avanço técnico-científico que existem hoje sobre a temática, como, por exemplo, as diretrizes disponíveis online e que fazem parte das recomendações para a prática segura (17-19), as escalas de avaliação de risco para o desenvolvimento de upp, traduzidas e validadas para o brasil, como a escala de braden (20), que auxilia o enfermeiro a identificar o risco do paciente e seus fatores associados para upp. o enfermeiro deve fazer uso desses recursos para planejar as medidas preventivas a serem adotadas para cada paciente e poder orientar não somente a equipe de enfermagem que presta assistência direta, mas também aos pacientes e cuidadores familiares. a utilização de diretrizes baseadas em evidências para assistência aos indivíduos em risco para o desenvolvimento de upp favorece o alcance de melhores resultados na assistência e contribuem para a adesão à prática clínica segura (21). no contexto atual que vivenciamos, em que a segurança do paciente, a humanização e qualidade dos cuidados são preceitos que têm sido amplamente discutidos e valorizados, a incidência alta de upp é apontada como um indicador negativo da qualidade da assistência em enfermagem. assim, é necessário que o enfermeiro utilize conhecimentos atualizados e use estratégias e princípios norteadores para o planejamento da assistência de modo a prevenir as upp e promover a qualidade da assistência, segurança do paciente e orientações adequadas ao cuidador que dará continuidade à assistência no domicílio. conclusão os resultados evidenciaram que, das 47 pessoas com lme, a maioria era do sexo masculino, idade média de 41,6 anos e com ltme. quanto aos 47 cuidadores, a maioria era do sexo feminino, com média de idade de 44 anos e casados. a porcentagem média de acertos no teste de conhecimento realizado pelos cuidadores demonstrou conhecimento insuficiente relacionado com a prevenção de upp. a porcentagem de acertos no teste foi menor conforme o aumento da idade, o que evidencia diferenças estatísticas (p ≤ 0,05). não houve evidências estatisticamente significantes entre a porcentagem de acertos no teste e o sexo, escolaridade e ocupação dos cuidadores. com os resultados obtidos neste estudo, os profissionais de enfermagem podem identificar quais as principais deficiências no conhecimento dos cuidadores e realizar o planejamento de estratégias educativas para prevenção de upp que visem à continuidade do cuidado seguro e de qualidade no domicílio. a manutenção da integridade da pele deve ser um dos objetivos da equipe de enfermagem que presta assistência à pessoa com lme e essa assistência deve ser embasada em evidências científicas. o uso apropriado das intervenções selecionadas trará um menor custo emocional e financeiro para o paciente, para o seu cuidador e para o sistema de saúde. 198 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 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[on-line]. 2013 [consultado em 1º dez 2014]; 18(2): 238-244. disponível em: http:// dx.doi.org/10.5380/ce.v18i2.26085 594 604 pensamiento critico en enfermeria.indd 594 aquichan issn 1657-5997 inmaculada minguez moreno1 josé siles2 pensamiento crítico en enfermería: de la racionalidad técnica a la práctica refl exiva 1 doctoranda, departamento de enfermería, universidad de alicante, zaragoza (españa). rodiles78@hotmail.com 2 catedrático, facultad de ciencias de la salud, universidad de alicante, zaragoza (españa). jose.siles@ua.es recibido: 22 de octubre de 2013 enviado a pares: 11 de abril de 2014 aceptado por pares: 29 de julio de 2014 aprobado: 29 de octubre de 2014 doi: 10.5294/aqui.2014.14.4.13 para citar este artículo / to reference this article / para citar este artigo moreno im, siles j. pensamiento crítico en enfermería: de la racionalidad técnica a la práctica reflexiva. aquichan. 2014; 14 (4): 594-604. doi: 10.5294/aqui.2014.14.4.13 resumen objetivos: identificar la evolución de la enfermería española desde la racionalidad técnica a la práctica reflexiva. mostrar evidencia respecto al pensamiento crítico y la práctica reflexiva identificando sus paralelismos con la enfermería sociocrítica. clarificar la influencia histórica de los paradigmas imperantes en españa durante la segunda mitad del siglo xx. materiales y métodos: se realizó una revisión temática descriptiva. se utilizaron fuentes primarias: compte, hume, bacon, habermas, foucault y horkheimer, y fuentes secundarias relacionadas con la profesión como: index, scielo. resultado: la evolución de la racionalidad técnica a la práctica reflexiva se produjo con los cambios de pensamiento dominantes en cada época. la práctica reflexiva y el pensamiento crítico se muestran necesarios para entender la enfermería sociocrítica. la situación histórica española determinó los cambios en la enfermería de este país. conclusiones: la evolución del pensamiento enfermero en españa siguió la evolución de los paradigmas de pensamiento dominantes. la práctica reflexiva y el pensamiento crítico descrito por habermas permiten la emancipación y, por extensión, la autonomía del paciente por la vía de la participación activa en la solución de sus problemas de salud. este proceso se origina con la toma de conciencia del papel que deben desempeñar el profesional y el ciudadano/paciente en la planificación de los cuidados de salud. tanto el perfil de la mujer fraguado por el franquismo, como la llegada de la democracia a españa, fueron determinantes para la evolución estudiada, el primero actuando como asfixiante y la segunda como motor. palabras clave paradigma positivista, paradigma sociocrítico, pensamiento crítico, práctica reflexiva, historia enfermería españa. (fuente: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 594-604 595 pensamiento crítico en enfermería: de la racionalidad técnica a la práctica reflexiva l inmaculada minguez-moreno, josé siles año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 594-604 critical thinking in nursing: from technical rationality to reflective practice abstract purpose: this is a multi-purpose study intended to identify how spanish nursing evolved from technical rationality to reflective practice and to show evidence of critical thinking and reflective practice by identifying their parallels with socio-critical nursing. another objective was to explain the historical influence of the paradigms prevailing in spain during the second half of the twentieth century. study materials and methods: a descriptive thematic review was conducted. compte, hume, bacon, habermas, foucault and horkheimer were the primary sources used, along with secondary sources related to the profession; namely, index and scielo. results: the evolution from technical rationality to reflective practice occurred with the changes in prevailing thought during each period. reflective practice and critical thinking are shown as being necessary to understanding socio-critical nursing. spain’s history determined the changes in nursing in that country. conclusions: the evolution of nursing thought in spain followed the changes in the dominant paradigms in spanish society. reflective practice and critical thinking, as described by habermas, allow for emancipation and, by extension, the patient’s autonomy, through active participation in solving their health problems. this process begins with an awareness of the role to be played by the nursing professional and the citizen/patient in planning health care. the profile of women set by the franco regime and the arrival of democracy in spain were decisive to this evolution. the former was stifling, while the latter was a driving force. key words positivist paradigm, socio-critical paradigm, critical thinking, reflective practice, nursing history, spain. (source: decs, bireme). 596 aquichan issn 1657-5997 pensamento crítico em enfermagem: da racionalidade técnica à prática reflexiva resumo objetivos: identificar a evolução da enfermagem espanhola desde a racionalidade técnica à prática reflexiva. mostrar evidência a respeito do pensamento crítico e da prática reflexiva identificando seus paralelismos com a enfermagem sociocrítica. esclarecer a influência histórica dos paradigmas imperantes na espanha durante a segunda metade do século xx. materiais e métodos: realizou-se uma revisão temática descritiva. utilizaram-se fontes primárias: compte, hume, bacon, habermas, foucault e horkheimer, além de fontes secundárias relacionadas com a profissão como: index, scielo. resultado: a evolução da racionalidade técnica à prática reflexiva foi produzida com as mudanças de pensamento dominantes em cada época. a prática reflexiva e o pensamento crítico se mostram necessários para entender a enfermagem sociocrítica. a situação histórica espanhola determinou as mudanças na enfermagem desse país. conclusões: a evolução do pensamento enfermeiro na espanha segue a evolução dos paradigmas de pensamento dominantes. a prática reflexiva e o pensamento crítico descrito por habermas permitem a emancipação e, por extensão, a autonomia do paciente pela via da participação ativa na solução de seus problemas de saúde. esse processo se origina com a conscientização do papel que o profissional e o cidadão/paciente devem desempenhar no planejamento dos cuidados de saúde. tanto o perfil da mulher, forjado pelo franquismo, quanto a chegada da democracia à espanha foram determinantes para a evolução estudada; o primeiro atuando como asfixiante e a segunda, como motor. palavras-chave paradigma positivista, paradigma sociocrítico, pensamento crítico, prática reflexiva, história enfermagem espanha. (fonte: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 594-604 597 pensamiento crítico en enfermería: de la racionalidad técnica a la práctica reflexiva l inmaculada minguez-moreno, josé siles introducción la ciencia, la política y la economía son algunos de los ámbitos donde en el último siglo y medio han podido contemplarse vertiginosos cambios de pensamiento comparado con siglos anteriores. hoy en día, ya nadie discute la veracidad de la teoría de kuhn (1) sobre la supremacía de un pensamiento o paradigma dominante en un momento histórico, así como su caída y el posterior renacimiento de otro pensamiento que se convierte en el dominante sustituyendo a su antecesor. esos cambios paradigmáticos implican maneras distintas de interpretar, entender y concebir el mundo. de la rigidez positivista al aperturismo sociocrítico han pasado apenas cien años. en esa evolución se han producido cambios en la manera de abordar y entender el mundo. esas variaciones en la interpretación de la realidad han ido renovando los enfoques de la ciencia en función de la concepción reinante. la enfermería, como parte de la ciencia, se ha visto inmersa en esos cambios, en los que el dominio y la caída de paradigmas de pensamiento han ido sucediéndose (2). el paradigma positivista suscitó la objetividad y la asepsia con la realidad en todos los ámbitos, incluido el de la salud. de ahí se evolucionó para llegar a la concepción actual (3). la intención principal de este artículo es conocer esa evolución desde la racionalidad técnica positivista a la práctica reflexiva en españa, en la segunda mitad del siglo xx. la práctica reflexiva implica el desarrollo de un pensamiento crítico, algo que constituye un tema prioritario en las líneas de investigación a nivel nacional e internacional. de manifiesto queda en el marco de la convergencia del espacio europeo de educación superior (bolonia) y para instituciones como la unesco y la organización mundial de la salud (oms), donde la participación ciudadana en los procesos de salud/enfermedad se sustenta en la reflexión y el pensamiento crítico. asimismo, resulta fundamental para la enfermería en general y para la función educativa y asistencial en particular. diversas investigaciones han demostrado la relación entre pensamiento crítico y culturas democráticas. el pensamiento crítico y la reflexión sobre los cuidados y autocuidados constituyen una línea de investigación fundamental en los países libres y democráticos (4). en este proceso reflexivo y crítico se pretende: • identificar los aspectos relevantes de la evolución de la enfermería desde la racionalidad técnica hasta la práctica reflexiva. • mostrar la evidencia disponible respecto al pensamiento crítico y la práctica reflexiva identificando sus concomitancias / paralelismos con la enfermería sociocrítica. • clarificar la influencia histórica de los paradigmas imperantes en españa durante la segunda mitad del siglo xx. materiales y métodos en la presente investigación se realiza un abordaje cualitativo sobre la evolución histórica de la enfermería en la segunda mitad del siglo xx en españa, desde una perspectiva sociocrítica. se realizó una revisión sistemática que cumple con la mayoría de los criterios establecidos para ser un artículo de revisión (5), siguiendo los estándares metodológicos pertinentes para este tipo de artículos, que se han fundamentado en los trabajos de revisión realizados por investigadores expertos en la materia (6, 7). para ello se utilizaron fuentes primarias para analizar tanto los rasgos generales de los paradigmas dominantes en la segunda mitad del siglo xx como la influencia de estos en la cultura enfermera. también se consultaron fuentes secundarias relacionadas con la profesión como index y scielo. los criterios para incluir los artículos fueron (8): artículo original, texto completo, el idioma —inglés o español— y las palabras clave: enfermería racional-tecnológica, enfermería sociocrítica, pensamiento crítico enfermero, españa. se excluyeron los artículos duplicados. la búsqueda arrojó inicialmente los siguientes datos: fuentes encontrados desestimados usados primarias 40 35 15 secundarias • index 447 427 20 • scielo 57 42 15 resumen de la búsqueda bibliográfica. uno de los problemas principales de la búsqueda fue la limitada bibliografía escrita sobre la evolución del pensamiento enfermero en españa. existe abundante documentación sobre la evolución del pensamiento enfermero internacional, pero no así sobre el nacional. 598 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 resultados positivismo y racionalidad técnica el positivismo ha sido, desde el siglo xix y hasta bien entrado el xx, el paradigma dominante en el pensamiento. también conocido como racionalista o empírico-analista, tras la revolución francesa se produjo una transformación en la visión del individuo y la sociedad atribuyendo la posibilidad, desconocida hasta entonces, del ser humano como objeto de estudio (9). el término positivismo fue usado por primera vez por compte, aunque determinados conceptos positivistas tienen su origen en autores como hume, saint simon o kant. esta corriente filosófica sostiene que el único conocimiento válido es el denominado “conocimiento científico”, entendiéndose por este el que surge del considerado único método validado para ello, el “método científico” (10), descrito por f. bacon. el de las ciencias físicas-naturales ha sido considerado el único método y modelo para poder manifestar la existencia del conocimiento científico hasta bien entrado el siglo xx. el positivismo redujo la racionalidad al conocimiento objetivo. bacon establece que el proceso de obtención del conocimiento científico ha de ser inductivo (de lo general a lo particular) con el fin de evitar generalidades precipitadas. de igual manera, la realidad es considerada una, con independencia de quien la estudia, y la relación entre los fenómenos es siempre causal. la observación y el experimento son los caminos considerados legítimos para la producción de conocimiento científico (11). el seguimiento exhaustivo de todo el proceso descrito permite generar resultados de forma experimental, lo que determinará si las hipótesis planteadas, en un inicio, se toman como verdaderas o no. este paradigma de pensamiento relega la razón a ser un instrumento mediador, convirtiéndola en la conocida razón instrumental positivista (12). este concepto de instrumentalización lo utiliza horkheimer (13) para definir aquella situación en la que la técnica no sirve como una herramienta de desarrollo para hombre, sino que lo subyuga (14). todo ello genera una corriente de pensamiento que de forma extensible define un concepto de salud y un tipo de profesional de enfermería concreto. la enfermería es una mera aplicadora de técnicas y el individuo un sujeto pasivo que recibe los cuidado: la enfermera es mera aplicadora de técnicas, subordinada a la figura del médico siendo su auxiliar. es mera manipuladora externa respecto al estado de salud y necesidades de la comunidad. el paciente es un receptor pasivo de procedimientos, tratamientos, y a lo sumo, consejos que son lanzados en forma estandarizada y unidireccional desde las instituciones. el concepto de salud es vacío y negativo, dado que se concibe como la ausencia de manifestaciones clínicas y su elaboración corresponde exclusivamente a las autoridades sanitarias. la enfermería desarrolla su conocimiento como su disciplina auxiliar de otras ciencias de las que depende para renovar sus conocimientos y técnicas (15). paradigma sociocrítico y pensamiento crítico a causa de la necesidad de reflexionar sobre la construcción de una sociedad desconocida hasta entonces, la burguesa, de la crisis de valores y de la relación entre ciencia y poder, surgen nuevas corrientes de pensamiento; y producto de una de ellas es el instituto de frankfurt en 1923, formado por pesadores alemanes con espíritu crítico. sus principales influencias: las teorías marxistas, la fenomenología y el psicoanálisis. algunos de sus pensadores más ilustres fueron horkheimer y adorno, así como habermas, wellmer, offe, negt y schmidt (16), exponentes más importantes de la denominada segunda generación. el instituto, posteriormente llamado escuela de frankfurt, pone de manifiesto el uso del concepto y la filosofía del pensamiento crítico en la era moderna. la defensa de pensamiento crítico y el paradigma sociocrítico pueden considerarse el sello de identidad de este instituto, que promocionó una evolución que permitiría el abandono del tradicionalismo y reduccionismo dominante por parte del positivismo (17). ese paradigma, el sociocrítico, como cualquier corriente de pensamiento, cuenta con una serie de características que distintos autores, como popkewitz, han estudiado y enumerado (18): • conocer la realidad como praxis (19). • unificar teoría y práctica. • elevar el conocimiento hacia la emancipación permitiendo así la liberación humana, conseguir la participación de todos los implicados, incluido el investigador. • establecer procesos de autorreflexión y toma de decisiones consensuadas. para kincheloe y mclaren (20), el paradigma sociocrítico establece que: 599 pensamiento crítico en enfermería: de la racionalidad técnica a la práctica reflexiva l inmaculada minguez-moreno, josé siles • todo pensamiento está condicionado por las relaciones sociales. • en el proceso de comunicación los conceptos de significantesignificado son variables. • los sucesos no pueden separase del dominio de los valores y la ideología. • el lenguaje es un vehículo de subjetividad consciente e inconsciente. • en todo grupo social existen grupos dominantes y dominados, esta relación se refuerza cuando la situación de sumisión es aceptada de forma natural. • no se debe obviar ninguna de las posibles facetas de la opresión; la opresión de razas, de clases, de género, etc., está normalmente alineada con las formas de investigación consolidadas. como cualquier corriente de pensamiento, no es algo estable, sino variable. desde su nacimiento, el paradigma sociocrítico no ha hecho más que absorber distintas aportaciones, evoluciones, etc.; tanto es así, que ha habido autores muy relevantes en su evolución de los que no se puede hablar del paradigma sociocrítico sin nombrarlos. es el caso de foucault. a pesar de la insistencia de determinados autores por instaurar a foucault como el reemplazo de la teoría sociocrítica, muchos son los puntos en común entre sus teorías y el paradigma sociocrítico. autores como mccarthy (21), entre otros, describen la existencia de nexos de unión con habermas, los cuales pueden ser considerados comunes en ambos autores, que definen los puntales de un modelo conceptual sociocrítico común: • la importancia de lo práctico sobre lo teórico, distanciándose así de la concepción positivista, donde lo práctico se reduce a técnica. • la negación de la existencia del sujeto cartesiano, con una concepción unicista de un sujeto aislado de la sociedad y aséptico a esta. • la crítica de la instrumentalización de la razón positivista. ambos autores señalan la necesidad de mantener una actitud crítica, principalmente sobre las epistemologías y metodologías productoras de conocimiento con el fin de evitar las tecnocracias y los modelos de dominación social producidos por la instrumentalización de la razón. para habermas, esa instrumentalización “hunde sus raíces epistemológicas en la simplificación de la práctica a técnica. esa simplificación surge producto de la aplicación del modelo positivista de las ciencias naturales a las sociales, eliminando así cualquier implicación de subjetividad o de particularidad y abandonando todo tipo de implicaciones éticas, sociales, ideológicas” (22). las diferencias existentes vienen dadas por las influencias de uno y otro autor. marx y hegel son las influencias principales para habermas mientras que nietzsche es la principal para foucault. como consecuencia de esa nueva corriente de pensamiento, del paradigma sociocrítico, surge una nueva forma de entender y comprender el mundo, adecuada a las características descritas previamente: el pensamiento crítico. su definición etimológica lo explica a la perfección. con dos raíces griegas, kriterion (normas) y kriticos (juicios exigentes), muestra de forma elocuente su significado: juicio elaborado sobre las normas más exigentes. el origen del pensamiento crítico hunde sus raíces en la dialéctica, la retórica y la lógica del pensamiento griego; dewey (1910) puede considerarse el primer autor que lo nombra en la edad moderna y lo define como: “la consideración activa, persistente y cuidadosa de una creencia o forma supuesta de conocimiento a la luz de los fundamentos que lo apoyan y de las conclusiones a las que atiende” (23). el concepto que posteriormente evolucionaría hasta el que hoy se conoce como pensamiento crítico lo hace de la mano del paradigma sociocrítico. para habermas, el pensamiento crítico puede concebirse de tres formas: como producto, como práctica o como praxis. esta última hace referencia al desarrollo de “una conciencia crítica, orientada a la emancipación y la autonomía de la persona y la comunidad, con el propósito del mejoramiento de la experiencia individual y social” (24). lo que en palabras de habermas se acerca al conocimiento emancipatorio. a lo largo de los siglos xx y xxi, otros autores han continuado distintas trazas del pensamiento crítico, en diversos ámbitos como la psicología o la pedagogía, principalmente. autores como: wundt y chaffee (2000) dressel y mayhew (1954), paul (1990, 1992) son algunos de ellos (25). en la enfermería, igual que en cualquier otro ámbito del conocimiento, el paradigma sociocrítico se hizo extensible. siles define una enfermería socio-crítica como: “el tipo de conocimiento es el propio de una enfermería social inmersa en un proceso dialéctico y subjetivo cuyo objetivo es la construcción de nuevas 600 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 realidades sociosanitarias” (26). en la enfermería española, el desarrollo del paradigma sociocrítico estuvo sujeto a los sucesos históricos (27): • por un lado, el feminismo llegó a españa de manos de los movimientos sociales a principios del siglo xx, quedándose silenciado hasta la llegada de la democracia (28). • esa época predemocrática, en la que la enfermería española era mayoritariamente femenina, estuvo perfilada por el concepto de mujer (29) que se tenía en la dictadura política existente, siguiendo la misma línea de kinder, küche, kirche alemana (niños, cocina, iglesia). • la dictadura provocó un estancamiento e, incluso, el retroceso en la salud pública impulsada desde la república (30). • la llegada de la democracia dio la madurez y el desarrollo para el cambio paradigmático ya que permitió el marco legal (31), formativo y estructural para que se produjera el paso desde el iluminismo a la crítica, canalizándose y materializándose el concepto de salud y el proceso de atención mundialmente extendido (32). como expresión de esta evolución y cambio del concepto en salud, surge dentro de la estructura sanitaria española la enfermería comunitaria propiamente (33). con la llegada del nuevo paradigma, el proceso de formación y adiestramiento (34) de la enfermería cambiaría para dar satisfacción a un concepto de salud. en él, cada uno de los ciudadanos es responsable de su propia salud y la enfermería pasa de adoptar un rol maternal y adoctrinante, a ser agente activo en salud. la enfermería ha sido el ámbito en el que más se ha investigado el pensamiento crítico. estudios realizados por white y por proffeto y mcgrath en el 2003, muestran la diferencia de la atención prestada entre las enfermeras que desarrollan un pensamiento crítico y las que no: “la toma de decisiones es la función clínica que diferencia al personal profesional de enfermería del personal técnico” (35). la llegada del pensamiento crítico a la enfermería se produjo impulsada principalmente por dos ideas (36): • la teoría crítica. • los estudios feministas en este ámbito. conceptos de práctica reflexiva y pensamiento crítico distintos autores han utilizado el término práctica reflexiva: james y clark, shön, habermas, freire, mezirow son algunos de ellos (37). el término puede ser analizado desde distintas perspectivas. dependiendo a qué característica del mismo se atienda, puede adquirir uno u otro enfoque. independientemente del enfoque, el contenido del término permanece estable, esto quiere decir que conceptualmente es igual para todos. cada uno de los autores arriba referenciados coincide en establecer distintos grados o planos de reflexión. existen dos modelos que se pueden considerar principales que abordan el término práctica reflexiva. uno es el encabezado por schön en 1986, russel y griffitis y tann, entre otros. este modelo establece que la práctica reflexiva como conocimiento tácito surge de la acción inmediata. este modelo recibe sus principales críticas por considerarse “monológico, individual y aislacionista más bien que dialógico y pragmático” (38), así como por obviar los contextos y por la dimisión de la práctica. el otro modelo es el descrito por habermas. en él, la reflexión recoge tres niveles siguiendo el mismo patrón utilizado en su teoría de los intereses constitutivos (24). contempla la práctica reflexiva paralela al conocimiento emancipatorio, y es un concepto muy relacionado con la autorreflexión del psicoanálisis freudiano. habermas describe cuatro etapas cuando habla de la práctica reflexiva. estas etapas van, desde la descripción e interpretación de la situación que se aborda, pasando por la búsqueda de los motivos que generan esa situación para poder llegar a modificarla, y, finalmente, evaluar la capacidad de modificarla. discusión el dominio total del paradigma positivista comenzó su caída en la última mitad del siglo xx. la evidencia de la limitación del modelo técnico que “presenta una visión inadecuada: estrecha, instrumental y rígida” (39), repleto de carencias y nada adecuado para el trabajo práctico (24), como es el caso del trabajo enfermero, llevó a cambios paradigmáticos impulsando nuevos conceptos científicos y el comienzo de nuevas formas de hacer ciencia (40). autores como schön o habermas, fueron algunos de los que modificaron la concepción establecida hasta entonces. la evolución desde la racionalidad técnica a la práctica reflexiva en la enfermería se produjo con los cambios paradigmáticos. el nacimiento de un paradigma científico formó nuevas escuelas de pensamiento 601 pensamiento crítico en enfermería: de la racionalidad técnica a la práctica reflexiva l inmaculada minguez-moreno, josé siles enfermeras influidas por las noveles corrientes, cambiando el concepto de ciencia vigente hasta entonces (41). esto lleva a la enfermería la concepción de un conocimiento científico desde la práctica, fruto de un razonamiento práctico. se busca una epistemología que cubra las necesidades reales de una enfermería en cambio, donde se estaba dando una revolución en la forma de entender la salud y la profesión (42). autoras como newman (43), fawcett (44) y meleis (45) son buena muestra de ello. esta revolución marcaría nuevos conceptos y nuevas formas de cuidar que se engloban dentro del nuevo paradigma y se muestra como enfermería sociocrítica. esto cambiaría el cómo y el para qué de la enfermería. a partir de ese momento se redefiniría su existencia orientándose hacia la práctica y apartándola del reduccionismo técnico para asignarle significado propio. este perfil enfermero se caracteriza por la creación de nuevas realidades sociales, la subjetividad de los procesos, así como por la autonomía del paciente, como exigencias para poder hablar de ella. todo esto no es posible sin el pensamiento crítico y la practica reflexiva, ya que: • el pensamiento crítico, tanto del paciente como de la enfermería, permite la libertad y la autonomía de ambos, para aplicar un concepto de salud positivo, donde el paciente es el único y último responsable de su salud, forma en la que la enfermería sociocrítica puede trabajar. • la práctica reflexiva permite, a través de la autorreflexión, la modificación de conductas. es, según habermas, una herramienta de emancipación. tanto uno como otro concepto son necesarios para poder acuñar el término sociocrítico. ese proceso evolutivo paradigmático se dio de forma diferente y más tardía en españa que en otros países (46). en el caso del pensamiento crítico se desarrolló de forma distinta a causa de la particular forma de desarrollo de los dos condicionantes expuestos previamente: el pensamiento crítico y el feminismo. por un lado, el feminismo que se había introducido en españa a principios de siglo. durante la república se vio reforzado pero la llegada de la dictadura franquista (47) hizo que se asfixiase por la promoción del régimen de un papel de mujer como esposa y madre, reforzado por principios religiosos y legales (48). al igual que con el feminismo, la dictadura también actuó como opresora para la introducción de los cambios paradigmáticos que estaban sucediendo (49). la llegada del pensamiento crítico está profundamente unida a la madurez y el desarrollo de la democracia (50). la reforma de la ley general de sanidad se puede señalar como punto de referencia a la hora de establecer la materialización de un cambio paradigmático profesional en la enfermería en españa (51). conclusiones • la evolución del pensamiento enfermero en españa siguió la evolución de los paradigmas de pensamiento dominantes en cada momento, pasando de una práctica basada en la racionalidad técnica, típica del paradigma positivista, a una práctica reflexiva guiada por el paradigma sociocrítico. • la práctica reflexiva y el pensamiento crítico descritos por habermas, permiten la emancipación y, por extensión, la autonomía del paciente por la vía de la participación activa en la solución de sus problemas de salud. este proceso se origina con la toma de conciencia del papel que deben desempeñar (profesional y ciudadano paciente) en la planificación de los cuidados de salud. • la toma de conciencia del rol participativo del paciente es inherente a la reflexión en la práctica y al desarrollo del pensamiento crítico, derivando todo este proceso en el marco científico profesional de la enfermería sociocrítica. • tanto el perfil de la mujer fraguado por el franquismo como la llegada de la democracia a españa fueron determinantes para la evolución estudiada, actuando el primero como asfixiante y la segunda como motor. 602 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 referencias 1. kuhn t. la estructura de las revoluciones científicas. madrid: paidos; 2005. 2. siles gonzález j. la eterna guerra de la identidad enfermera: un enfoque dialéctico y deconstruccionista. index enferm [revista 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cantero-gonzález m, hernández-conesa j, beneit-montesinos jv. formación e identidad enfermera en el franquismo. murcia: diego marín; 2011. 50. siles j, solano mc. sistemas políticos y perspectiva de la educación de enfermería en la transición española (del franquismo a la democracia). una contribución desde la historia de la enfermería. ridec. 2010;10(3):192-203. 51. mínguez i, siles j. crisis de identidad enfermera: origen y... ¿superación a través de la práctica reflexiva en el entorno comunitario? ridec. 2010;3(2):5-8. 1 -6 primeras paginas.indd 5 editorial la renovación del conocimiento y la práctica renewal of knowledge and practice a renovação do conhecimento e da prática al mirar las características de las disciplinas profesionales como enfermería, se anota que la práctica va acompañada por un sistema de conocimientos abstractos, de desarrollo dinámico, el cual para su producción y modificación requiere apoyarse en la práctica genérica que, en última instancia, pone de presente los fenómenos y problemas relevantes del conocimiento disciplinar. esta situación obliga a mantener un constante desarrollo y renovación del conocimiento que dé respuestas a las necesidades de cuidado de la sociedad, con participación de las enfermeras en ejercicio profesional, ya que es en la práctica en donde se genera y prueba la validez y calidad de las propuestas teóricas y de la ciencia de enfermería. en este orden de ideas, se plantean dos hechos significativos en relación con el conocimiento disciplinar: la jurisdicción y la subordinación. reed (1) plantea que andrew abbott (1988) al estudiar los sistemas profesionales sugiere que “el conocimiento abstracto es el elemento más importante del nivel de jurisdicción o control de la práctica”; dicho de otra forma, la autonomía de la misma. las profesiones manejan diversas estrategias para mantener ese nivel de jurisdicción o autonomía del conocimiento y sugiere que enfermería es un ejemplo de nivel bajo de esa jurisdicción y la llama subordinación. la práctica de enfermería, sin duda alguna, ha contribuido al bienestar de las personas y a la viabilidad de los sistemas de salud (2). sin embargo, su producción de conocimiento no es reconocida en la justa medida. las enfermeras/os se ven más como usuarias/os del conocimiento que como productoras/os del mismo. esta perspectiva, muchas veces, se refuerza en la práctica y en la docencia (3). como se pregunta j. fawcett (4), “¿cómo se pretende que enfermería sea tomada en cuenta cuando muy pocas de sus publicaciones apuntan seriamente a mostrar soluciones para el conocimiento disciplinar y la práctica?”. cuando se responden estas inquietudes surge la idea de la subordinación, la cual se explica esencialmente por las formas de educación, pero más importante es el hecho de la presencia del pensamiento abstracto y de la forma como se utilizan las teorías y la evidencia en la práctica. es decir, de la forma como se utiliza el conocimiento disciplinar en la práctica (5). la jurisdicción y la autonomía son difíciles de lograr sin el requisito del conocimiento y sin las habilidades para su construcción. por esta razón se propone el cambio de la idea de generación del conocimiento académico por la del conocimiento basado en la práctica. esta propuesta genera una transformación del “saber hacer” diario de la práctica de enfermería al “conocer de ese hacer” pero a través del conocimiento científico. el conocimiento científico, entonces, se convierte en el soporte central de la práctica diaria y ello requiere de un trabajo de doble vía, en donde la teoría y la evidencia se generen a partir de las necesidades de la práctica y, a su vez, se validen y prueben en la misma. si bien enfermería ha obtenido el conocimiento disciplinar siguiendo la ortodoxia científica (5), tal como lo muestra el énfasis que se genera con la idea inequívoca de la práctica basada en la evidencia, paralelamente, el desarrollo de ese conocimiento puede manejarse a partir de la idea del “conocimiento basado en 6 aquichan issn 1657-5997 año 14 vol. 14 nº 1 chía, colombia marzo 2014 la práctica”. pocas académicas han tratado de explicar la “ciencia basada en la práctica” y la “teoría derivada de la práctica”. de acuerdo con reed (6), dicoff y james (1968), diers (2004, 1985) doane, browne, reimer, mcleod y maclellan (2009), doane y varcoe (2005), kim (1993, 1999) son autores que han introducido la idea mencionada y son muy tenidos en cuenta por la comunidad de enfermería. naturalmente, la pregunta que surge de estos desafíos no se responde exclusivamente a partir de la epistemología clásica que trata de entender “qué es el conocimiento de enfermería”, sino de la apreciación poco tradicional de “cómo es que aquello que se llama conocimiento de enfermería se convierte en algo real”. la respuesta no se encontrará sino se hace el esfuerzo de convertir en un fenómeno único la producción y la aplicación del conocimiento, a partir de la nueva idea de la interacción entre la producción de la ciencia de enfermería y del cuidado de la misma, y en el reforzamiento de la práctica y la contextualización del conocimiento. en este orden de ideas, el manejo del conocimiento disciplinar es dinámico y tiende a identificar necesidades con enfoques empíricos, teóricos, éticos... que requieren de la participación de las enfermeras de las áreas clínicas porque es allí en donde surgen estos hechos de importancia para el conocimiento. en concordancia con lo anterior, aquichan tiene como misión divulgar el conocimiento de enfermería y su aplicación en los diferentes ámbitos de la práctica. por esta razón el comité editorial es estricto en su objetivo de que los artículos que se publiquen sean de enfermería y tengan relevancia para la disciplina, por su rigor y por su contribución al conocimiento y, por ende, a la práctica profesional. con el ánimo de atender la necesidad de actualización de los profesionales y de divulgación del conocimiento disciplinar, a partir de este año la revista se publicará cuatrimestralmente y se mantendrá la disponibilidad de consulta en texto completo en la plataforma virtual y en las bases de datos en donde se encuentra indexada. maría mercedes durán de villalobos profesora titular y emérita facultad de enfermería universidad nacional de colombia miembro del comité editorial de aquichan mmvillalobos@gmail.com referencias 1. reed p. the spiral path of nursing knowledge. en reed p, shearer, nb. nursing knowledge and theory innovation: advancing the science of practice. new york: springer publishing company; 2011. p. 18-19. 2. meleis ai. theoretical nursing: development and progress. 5th edition. philadelphia: lippincott williams & wilkins; 2005. p. 87-108. 3. reed p, laurence la. a paradigm for the production of practice based knowledge: philosophical and practical considerations. en reed p, shearer, nb. nursing knowledge and theory innovation: advancing the science of practice. new york: springer publishing company; 2011. p. 133-150. 4. fawcett j. editorial: but it is nursing research? western journal of nursing research. 2000;22(5);524-25. 5. durán de villalobos mm. la teoría, soporte de la ciencia y práctica de enfermería: tendencias. avances en enfermería. 2012;30(1):9-12. 6. reed p. the spiral path of nursing knowledge. en reed p, shearer, nb. nursing knowledge and theory innovation: advancing the science of practice. new york: springer publishing company; 2011. p. 21-22. co ns eq ue nc es o f t he c o v id -1 9 pa nd em ic o n ch ild d ev el op m en t: a n in te gr at iv e li te ra tu re r ev ie w 1 ana maría quezada-ugalde https://orcid.org /0000-0003-1855-6894 universidad de la laguna, spain ana.quezada.ugalde.16@ull.edu.es alfonso miguel garcía-hernández https://orcid.org /0000-0002-2838-8735 universidad de la laguna, spain almigar@ull.edu.es josé alfonso maya-barrios https://orcid.org /0000-0003-0474-4165 hospital general dr. manuel gea gonzález, mexico jamayab@hotmail.com alejandra auza-benavides https://orcid.org /0000-0002-7592-4625 hospital general dr. manuel gea gonzález, mexico alejandra.auza@yahoo.com article consequences of the covid-19 pandemic on child development: an integrative literature review received: 09/12/2022 sent to peers: 26/01/2023 accepted by peers: 29/05/2023 approved: 07/06/2023 doi: 10.5294/aqui.2023.23.3.2 to reference this article / para citar este artículo / para citar este artigo quezada-ugalde am, garcía-hernández am, maya-barrios ja, auza-benavides a. consequences of the covid-19 pandemic on child development: an integrative literature review. aquichán. 2023;23(3):e2332. doi: https://doi.org/10.5294/aqui.2023.23.3.2 https://orcid.org/0000-0003-1855-6894 mailto:ana.quezada.ugalde.16@ull.edu.es https://orcid.org/0000-0002-2838-8735 mailto:almigar@ull.edu.es https://orcid.org/0000-0003-0474-4165 mailto:jamayab@hotmail.com https://orcid.org/0000-0002-7592-4625 mailto:alejandra.auza@yahoo.com https://doi.org/10.5294/aqui.2023.23.3.2 https://doi.org/10.5294/aqui.2023.23.3.2 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2023.23.3.2&amp;domain=pdf&amp;date_stamp=2023-08-18 theme: health, well-being, and quality of life promotion contribution to the subject: this review offers an overview of the effects on child development in children aged less than 5 years old that were living with their parents during the covid-19 pandemic years, allowing evidencing the need to prioritize care for timely detection and assistance of neurodevelopmental changes. these tasks are action spaces where pediatric nursing and other disciplines linked to childcare should work jointly, as part of a surveillance system. co ns eq ue nc es o f t he c o v id -1 9 pa nd em ic o n ch ild d ev el op m en t: a n in te gr at iv e li te ra tu re r ev ie w 3 abstract introduction: the covid-19 pandemic reduced the possibilities of generating stimulating spaces for children’s development, as all the systems with which a child interacts during this phase were affected. objective: to identify the existing scientific evidence about the effects on child development in children aged less than 5 years old that were living with their parents while the social distancing measures adopted due to covid-19 were in force. method: an integrative review guided by the framework proposed by whittemore and knafl and the prisma statement, to consult the following databases: medline, sciencedirect, scopus and scielo, with a search performed in english using these descriptors: “child development,” “growth and development,” “parenting,” “teleworking,” “infant care,” “home nursing,” “social isolation,” “coronavirus infections,” and “covid-19.” the eligibility criteria were as follows: quantitative or qualitative studies that addressed the direct effects of the pandemic on children aged less than 5 years old; in turn, the exclusion criteria corresponded to articles with a population comprised of children with diagnosed developmental disorders or disabilities. results: a total of 17  articles were included, whose findings were classified into the following categories: exposure to risk stimuli, deprivation of stimuli, and exposure to protective stimuli. it is revealed that parental stress, absence of games and lower exposure to interactions that promote development are connected to changes in cognitive, emotional, and learning processing, in addition to exerting a negative impact on motor and language development. conclusion: the evidence suggests that social distancing can be the main cause for the onset of delays in child development, in its motor, language, cognitive, and socioemotional areas. keywords (source: decs) child development; covid-19; pediatric nursing; caregivers; environment; family. 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 2 resumen introducción: la pandemia por la covid-19 disminuyó las posibilidades de generar espacios estimulantes para el desarrollo de los niños, puesto que todos los sistemas con los que interactúa un niño en desarrollo se vieron impactados. objetivo: identificar la evidencia científica que hay sobre los efectos en el desarrollo infantil en menores de 5 años que convivieron con sus padres y madres durante las medidas de distanciamiento social tomadas por causa de la covid-19. método: revisión integrativa guiada por el marco propuesto por whittemore y knafl, y the prisma statement, para consultar las bases de datos: medline, sciencedirect, scopus y scielo, con una búsqueda realizada en inglés, utilizando los descriptores: “child development”, “growth and development”, “parenting”, “teleworking”, “infant care”, “home nursing”, “social isolation”, “coronavirus infections”, “covid-19”. los criterios de elegibilidad: estudios cuantitativos o cualitativos que abordaran los efectos directos de la pandemia en niños menores de 5 años; y de exclusión: artículos con población de niñez con trastornos del desarrollo diagnosticados o discapacidad. resultados: fueron incluidos 17 artículos, cuyos hallazgos se clasifican en las categorías: exposición a estímulos de riesgo, privación de estímulos y exposición a estímulos protectores. se revela que el estrés parental, la ausencia de juego y una menor exposición a interacciones promotoras del desarrollo se vinculan con alteraciones en el procesamiento cognitivo, emocional y de aprendizaje, y tuvieron un impacto negativo en el desarrollo motriz y del lenguaje. conclusión: la evidencia sugiere que el distanciamiento social puede ser la causa principal en la aparición de retrasos en el desarrollo infantil, en sus áreas: motriz, de lenguaje, cognitivo y socioemocional. palabras clave (fuente decs) desarrollo infantil; covid-19; enfermería pediátrica; cuidadores; ambiente; familia. consecuencias en el desarrollo infantil derivadas de la pandemia por covid-19: revisión integrativa de literatura co ns eq ue nc es o f t he c o v id -1 9 pa nd em ic o n ch ild d ev el op m en t: a n in te gr at iv e li te ra tu re r ev ie w 5 consequências no desenvolvimento infantil derivadas da pandemia de covid-19: revisão integrativa da literatura resumo introdução: a pandemia de covid-19 diminuiu as possibilidades de criar espaços estimulantes para o desenvolvimento das crianças, uma vez que todos os sistemas com os quais uma criança em desenvolvimento interage foram afetados. objetivo: identificar a evidência científica sobre os efeitos no desenvolvimento infantil das crianças com menos de 5  anos que viveram com os pais durante as medidas de distanciamento social adoptadas devido à pandemia de covid-19. método: revisão integrativa orientada pelo quadro proposto por whittemore e knafl, e the prisma statement, para consultar as seguintes bases de dados: medline, sciencedirect, scopus e scielo, com uma pesquisa efetuada em inglês, utilizando os descritores: “child development”, “growth and development”, “parenting”, “teleworking”, “infant care”, “home nursing”, “social isolation”, “coronavirus infections”, “covid-19”. critérios de elegibilidade: estudos quantitativos ou qualitativos que abordem os efeitos diretos da pandemia em crianças com menos de 5 anos de idade; e critérios de exclusão: artigos com uma população de crianças com distúrbios de desenvolvimento diagnosticados ou deficiência. resultados: foram incluídos 17 artigos, cujos resultados se enquadram nas categorias: exposição a estímulos de risco, privação de estímulos e exposição a estímulos protetores. verificou-se que o stress parental, a ausência de brincadeiras e a menor exposição a interações de apoio ao desenvolvimento estavam associados a alterações no processamento cognitivo, emocional e de aprendizagem, e tinham um impacto negativo no desenvolvimento motor e da linguagem. conclusão: os dados sugerem que o distanciamento social pode ser a principal causa de atrasos no desenvolvimento da criança nas áreas motora, linguística, cognitiva e socioemocional. palavras-chave (fuente: decs) desenvolvimento infantil; covid-19; enfermagem pediátrica; cuidadores; meio ambiente; família. 6 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 2 introduction child development encompasses a series of biological, physiological, and behavioral changes in children from the moment they are born, when they are fully dependent, until their adolescence, when they achieve certain autonomy (1, 2). the first five years of life, characterized by high brain plasticity (3, 4), are especially important for children to have timely promotion experiences and to interact with their environment, aiming to reach optimum levels of physical, cognitive, language, and social development (5, 6). ecological theory (7) confirms how the interactions between a person and their environment can significantly affect human development, it describes the ecological environment as a set of nested structures that extend beyond the immediate situation faced by an individual and which is comprised of four levels: a)  micro-system, defined as the inter-relations within the developing person’s closest environment (e.g., school, community, group of peers); b)  meso-system, which is the interconnection between the micro-systems: c)  exo-system, which includes the elements with which the developing person has no contact but that produce events affecting their immediate environment (e.g., parents’ workplaces, communication media); and d)  macro-system, which represents the culture and its subcultures, the social institutions, the health policy and the values (7, 8). in this regard, brain development results from the interaction between biological and environmental influences. in the first years of life, those interactions should be generated by the caregivers, who should motivate children to move and turn around, providing them objects to explore, reach, and play with; in addition, during this stage, children need love and affection and that their hunger, tiredness, sleep, sadness, or happiness signals are acknowledged (6, 9). in this sense, the father-/mother-child relationship becomes the center of the environment for children. the interactions between mothers and their newborns were carefully observed in a longitudinal study, finding that, when the caregiver intervenes confidently with the infant and constantly generates social interactions, the child’s functionality is protected and premature maturation of structures such as the amygdala and hippocampus is prevented  (which intervene in the memory and socioemotional relationships processes)  (10). in opposition, the absence of a bond with a caregiver due to abandonment situations, for example in institutionalized children (11), severely impairs neuronal circuits, which generates future developmental delays and behavioral deficits (12). during the years of the covid-19 pandemic, families faced demanding childcare situations. their routines were disrupted, as the parents had to work from their homes, take care of household chores, assist their children’s education and simultaneously meet the rest of their demands. all this produced an increase in the onset of parental co ns eq ue nc es o f t he c o v id -1 9 pa nd em ic o n ch ild d ev el op m en t: a n in te gr at iv e li te ra tu re r ev ie w 7 anxiety, depression, and stress, which in turn triggered negligent or punitive parenting situations and unfavorable environments for the progression of children’s cognitive, socioemotional, and communication skills (13-15). it can be asserted that the pandemic did not only cause physical ailments in people or communities (16); this phenomenon also reduced the possibilities of generating stimulating spaces for children’s development (17). in terms of the ecological theory, all systems with which developing children interact were affected (7). it is also known that experiencing adverse events in childhood (such as natural disasters, wars, confinement, or chronic stress) can impair children’s neurodevelopment  (18, 19). in this sense, the covid-19 pandemic equals a natural disaster  (20), and it is possible the impact generated on the child population is not yet tangible. however, this integrative review will allow conducting a search, critical assessment, and synthesis of the diverse available evidence (21), to know the effects on child development in children aged less than 5  years old that were living with their parents while the social distancing measures adopted were in force. the topic is of utmost importance for all health areas, especially for the nursing discipline, as there is an urgent need to devise care actions around young children, putting into practice continuous programs to evaluate development and instruct families on the care to be provided for optimum child development (1, 9). methodology an integrative review was conducted following the five-phase design proposed by whittemore and knafl: 1) identification of the problem; 2) search in the literature; 3) assessment of the information; 4) analysis of the information, and 5) presentation (22). in addition, to improve quality and transparency, the prisma statement guide extension was adopted as a reference (23). in the first phase, identification of the problem, it was determined that the review purpose would be to know the effects on child development in children aged less than 5 years old that were living with their parents while the social distancing measures adopted due to covid-19 were in force. for this reason, the research question was formulated according to the pico strategy (population, phenomenon of interest, and context) (24), where p: children aged less than 5 years old, i: effects on child development due to social distancing and the parents’ remote work; and co: during the covid-19 pandemic. this strategy allowed the formulation of the question: what were the effects of social distancing and the parents’ remote work during the covid-19 pandemic on the development of children aged less than 5 years old? 8 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 2 for the second stage, search in the literature, the following databases were chosen: medical literature analysis and retrieval system online  (medline), elsevier sciencedirect, elsevier scopus and scientific electronic library online (scielo). the search was independently and simultaneously conducted by two of the researchers in january and february 2022. given the novelty of the theme, the research was only carried out in english, using decs and mesh to select the descriptors: “child development,” “growth and development,” “parenting,” “teleworking,” “infant care,” “home nursing,” “social isolation,” “coronavirus infections,” and “covid-19.” these terms were combined one-to-one using the and and or boolean operators to generate algorithms (presented in table  1), and thus reach the maximum variability possible. likewise, organization, selection and identification of duplicates regarding the information was managed in the mendeley tool (25). table 1. search algorithms concept boolean operator concept boolean operator concept child development and /or parenting teleworking infant care home nursing social isolation and /or coronavirus infections child development parenting teleworking infant care home nursing social isolation covid-19 growth and development parenting teleworking infant care home nursing social isolation coronavirus infections growth and development parenting teleworking infant care home nursing social isolation covid-19 source: prepared by the authors. additionally, the eligibility criteria included quantitative studies (observational, correlational, experimental, and cohort) and qualitative studies (descriptive, phenomenological, case, and ethnographic studies) published in scientific journals and addressing the direct effects of the pandemic on the child population aged from 0 to 5  years old, even if the manuscripts included other age groups. the exclusion criterion was applied to articles corresponding to dissertations, monographs, editorials or letters to the editor, as well as to publications whose populations were comprised of children with diagnosed developmental disorders or disabilities. co ns eq ue nc es o f t he c o v id -1 9 pa nd em ic o n ch ild d ev el op m en t: a n in te gr at iv e li te ra tu re r ev ie w 9 employing this strategy, the two researchers who conducted the search initially identified 4486 documents. in addition, another researcher manually sought research studies in the references from those included. however, no publications were added with this strategy. the detailed information flow is presented in figure 1. the third phase, information assessment, was performed independently by three researchers. one of them assessed eligibility and discarded the documents that failed to meet the requirements established, whereas the other two researchers read the studies, evaluating their quality and pertinence regarding the phenomenon under study. any discrepancies were solved by consensus, with a fourth reviewer available in case no agreement was reached. for each study, the critical assessment tools proposed by the jbi (26) were considered, which include a checklist with the following answer options: yes, no, unclear, and does not apply. the level of evidence was established according to the recommendations set forth by the oxford university centre for evidence-based medicine (27). the data were extracted by two independent researchers who resorted to the data extraction tool proposed by the jbi (26) to summarize and organize them, materials with which an emptying matrix was prepared where the year, title, objective, design, population, main results, discussion, conclusions, limitations, and recommendations from each of the publications were detailed. consequently, visualization was eased, which served as the starting point for data interpretation. the next step consisted of coding, categorizing and summarizing the data to produce answers to the research question. this practice corresponds to the fourth phase: analysis of the information. a second matrix was designed to present the relevant information from each article included in the analysis (table 2), which was grouped according to the effects found in the child population. iteratively, the research team made comparisons between the groupings to identify patterns in common that allowed defining the categories organized for their presentation. in the fifth and last stage, the emerging categories are presented, and the results of this document are described. the bioethical principles applied to the context of an integrative review were met. authorship of the studies and publications included was respected at all times, and the materials acquired from indexed scientific journals. this paper has academic purposes, with the intention of knowing the current situation around child development and the actions that health professionals should take. 10 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 2 results the search process yielded a total of 4,486  documents; however, 4,451 articles were removed after applying the inclusion and exclusion criteria. the main reasons for this were document duplicity, not being research studies, not belonging to the knowledge area of interest or not answering the research question. once this stage was concluded, 35  productions were analyzed in their entirety and 18 of them were discarded because they were not connected to child development and, thus, failed to answer the research question; therefore, 17 scientific productions were included in this integrative review. figure 1 shows the flow to select the studies. figure 1. flowchart corresponding to the articles included in the study source: adapted from the prisma statement (23). identi�cation of studies through databases and records records or citations identi�ed in: ebsco/medline (n=97) scielo (n=8) science direct (n=3,844) scopus (n=537) records or citations removed before screening: duplicate records (n=40) records signaled as ineligible by automation tools (n=0) records removed after reading titles and abstracts (n=4,406) records or citations screened (n=40) publications sought for retrieval (n=40) publications assessed for eligibility (n=35) records or citations excluded (n=4,446) publications not retrieved (n=0) publications excluded after full reading (n=5) publications excluded: not meeting the eligibility criteria (n=18) total studies included in the review (n=17) id en ti �c at io n sc re en in g in cl u si o n when characterizing the studies according to their origin, most of them  (n=8) were developed in north american countries (united states, mexico and canada), followed by asia (n=5) (indonesia, japan, korea and china), the european continent (n=3) (spain, united kingdom and portugal) and, finally, south america (n=1) (brazil). co ns eq ue nc es o f t he c o v id -1 9 pa nd em ic o n ch ild d ev el op m en t: a n in te gr at iv e li te ra tu re r ev ie w 11 according to the knowledge areas, most of the studies are grounded on psychology, psychiatry or neuropsychology (n=7), followed by human development (n=3), children’s health (n=2) and parenthood and family support (n=1), as well as on academic disciplines such as nursing (n=1), public health (n=1), social work (n=1) and education sciences  (n=1). in addition, according to the methodology implemented, 15  articles following quantitative methods and 2 qualitative studies were included. table 2 presents a synthesis of the main elements from the studies that comprise the final sample of this review. table 2. characteristics of included studies according to the effects on the child population authors / year objective/problem design participants main results le* torres-gonzález c, galindo-aldana g, garcía-león ia , padilla-lópez l a , álvarez-núñez dn, espinozagutiérrez yi. / 2020 (18) to characterize the effects of voluntary social isolation due to covid-19 on socio-family behaviors at the personal level and on the children’s activities in the house. to determine the vulnerability predictors to undergo a negative isolation experience. descriptive and crosssectional 365 participants, adult parents of children aged between 1 and 12 years old. family well-being during isolation is a complex and multifactorial phenomenon, which also exerts specific effects on socio-family behaviors. in the child population, correlations were found between personal experience regarding isolation and changes in sleep quality, irritability, emotional control, hopes about the future, motivation, attention capability and problemsolving. 2c hails k a , petts r a , hostutler ca , simoni m, greene r, snider tc, et al. / 2021 (13) to determine whether the families’ covid-19-related anguish is associated with young children’s emotional/behavioral functioning through negative parenting and whether these relationships vary according to events undergone by parents who have faced adverse child experiences (aces)†. descriptive and crosssectional 267 parents of children aged from 1.5 to 5 years old. family anguish related to the pandemic was significantly associated with the increase in children’s emotional/behavioral problems. the parents that reported higher anguish levels were more prone to resorting to negative parenting practices (hostility, physical control and la x control), which in turn were associated with more emotional/behavioral problems in the children. 2c riany ye, morawska a . / 2021 (16) to develop and examine a model to explain how the factors identified in the literature are associated with children’s non-adaptation and skills during the pandemic. descriptive and crosssectional 354 mothers/ fathers with at least one child showing atypical development and aged from 2 to 10 years old. the families with psychosocial functioning problems perceived fewer positive family interactions and more non-adaptation in the children during the pandemic. therefore, the parents’ mental health problems derived from the pandemic affected everyday care activities, resulting in significant problems among the children (such as aggressiveness, conduct problems, and emotional/behavioral problems). 2c mochida s, sanada m, shao q, lee j, takaoka j, ando s, et al. / 2021 (20) research question: were there changes in children’s psychological and physical stress during the covid-19 pandemic and, if any, how did they manifest in children’s behaviors? descriptive and crosssectional 1,030 main caregivers of children aged between 1 and 6 years old (mean of 3.8). it was possible to identify that the mothers’ (main caregivers) schooling level and family income were related to lower stress signs in the children. there were also lower stress signs in the children that continued to attend daycare centers or kindergarten. warm or permissive parenting protects children from presenting more stress signs, whereas punitive parenting increases them in children. 2c waller r, powell t, rodriguez y, corbett n, perlstein s, white lk, et al. / 2021 (28) to examine the associations between exposure to covid-19, the parents’ concerns about the pandemic, strict and warm parenting practices and the children’s behavioral problems (cps)§ and insensitive-unemotional (cu) traits||. descriptive and crosssectional 303 children aged between 3 and 10 years old. afro-american and hispanic parents, as well as those earning lower monthly family incomes, reported greater exposure and concern in relation to covid-19. high levels of strict parenting were related to higher cp§ and cu|| traits in children, whereas lower levels of warm parenting are only linked to high cu|| traits. 2c 12 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 2 authors / year objective/problem design participants main results le* huang p, zhou f, guo y, yuan s, lin s, lu j, et al./ 2021 (29) to investigate the association between the coronavirus pandemic experience and neurodevelopment in children aged 6 months and 1 year old and to explore the differences in this association by birth order. cohort study 831 children (exposed group) and 5 ,223 children (unexposed group). in 2020, the pandemic experience was associated with a higher risk of delays in the fine motor skills and communication domains during the first year of life. the association between the pandemic experience and communication delays at one year of age was only found in first-born children, not in those born afterward. no associations were observed in any domain among the 6-month-old children. 2b diniz e, brandão t, monteiro l, veríssimo m. / 2021 ( 30) to examine the direct effects of marital adjustment on children’s behavior and to test if the parents’ self-efficacy mediated this association during home confinement due to covid-19. descriptive and crosssectional 163 children aged between 2 and 12 years old (mean of 6.09) and their caregivers (mothers and fathers). greater marital adjustment (the mutual process by which gratification is developed in a couple for achieving common objectives) was related to lesser aggressive behaviors in the children. the parents’ self-efficacy played a key role in explaining the association between marital adjustment and child development, contributing to increasing social competence and to reducing children’s aggressiveness and emotional withdrawal during this challenging situation. 2c fitriahadi e, priskila y, suryaningsih ek, satriyandari y, intarti wd. / 2021 ( 31) to perform a sociodemographic analysis of young children’s growth and development during the covid-19 pandemic in yogyakarta, indonesia. descriptive and crosssectional 30 young children and their parents. the sociodemographic data significantly linked to growth and development in children aged less than 5 years old were maternal schooling (**p=0.001) and family income (**p=0.000). it was determined that having higher education allows people to be more rational when handling life problems, resorting to more effective coping strategies. in addition, young children’s development is negatively affected when their parents fail to participate directly or stimulate them. the higher the maternal schooling level, the better the knowledge about the need to stimulate child development. 3 cardoso de sá cs, pombo a , luz c, rodrigues lp, cordovil r. / 2021 ( 32) to identify how brazilian families with children aged less than 13 years old faced social distancing during the covid-19 pandemic, mainly concerning the time devoted to physical and intellectual activities, games, activities in the open air and screen time. descriptive and crosssectional families of 816 children aged from 0 to 12 years old. the parents consider that the time children devote to practicing physical activities was reduced and that the time spent behind screens and in family activities was increased. differences between the genders were found for screen time (boys ††> girls) and for games with no physical activity (girls ††> boys); there were effects in all the categories analyzed according to the children’s age, with a trend towards an increase in the total time of sedentary lifestyle and a reduction in the time devoted to physical activity as age advanced. the increase in these activities favors the early onset of chronic diseases and changes in young children’s behaviors. 2c gibson ly, lockyer b, dickerson j, endacott c, bridges s, mceachan rrc, et al. / 2021 ( 33) to understand the experience and impact of the initial lockdown due to covid-19 in young families with children aged less than 4 years old. qualitative 903 participants, origins (n=400, australia) and born in bradford (n‡=503, united kingdom) cohorts. the most common concerns were as follows: a) financial and employment insecurity: b) health anxiety due to covid-19; c) children’s education and care; d) current and future impacts of covid-19 on society: e) child development and well-being; f ) mental health; and g) not seeing friends and family members. “positive” or enjoyable aspects were also reported, such as spending more time with the family, leading a calmer life and practicing more physical exercises. 3 jáuregui a , argumedo g, medina c, bonvecchioarenas a , romeromartínez m, okely ad. / 2021 ( 34) to investigate the correlations of the changes in the movement-related behaviors before and after the first stages of the confinement period due to covid-19 in a nationwide sample of infants and preschool children from mexico. descriptive and crosssectional 631 caregivers or parents of children aged from 1 to 5 years old. during the confinement period, only one out of three preschool children and infants met the physical activity recommendations and less than 4 %|||| complied with the screen time guidelines. the data showed that only 1.3 %|||| of the children included in this study met the movement recommendations during this period. 2c co ns eq ue nc es o f t he c o v id -1 9 pa nd em ic o n ch ild d ev el op m en t: a n in te gr at iv e li te ra tu re r ev ie w 13 authors / year objective/problem design participants main results le* baiden ph, labrenz ca , findley e. / 2021 ( 35) to examine the association between adherence to the social distancing measures and the feeling of concern/ anxiety in female caregivers of children aged from 0 to 5 years old. descriptive and crosssectional 358 mothers of children aged between 0 and 5 years old. the caregivers that strictly complied with social distancing were 1.86 times more likely to feel concerned/anxious (or a ¶¶=1.86, 95%||||ci***=1.07– 3.24). the caregivers that were upset for having to distance themselves from their activities of interest were 4.11 times more likely to feel concerned/anxious (or a ¶¶=4 ,11, 95 %||||ci***=2.32– 7.24). the stress, concern and anxiety experienced imposed problems in childcare. 2c lozano-blasco r, quilez-robres a , delgado-bujedo d, latorre-martínez mp. / 2021 ( 36) research questions: has the consumption of youtube channels targeted at early childhood increased during the covid-19 pandemic? what types of resources have been most used? has the consumption of educational content increased or, to the contrary, has playful content prevailed? longitudinal analysis of diverse social networks. the results not only indicate an increase in the use of youtube channels by children. social distancing increased the consumption of visual recreational content as a behavioral containment measure and reduced the promotion of traditional games. use and consumption of content through screens implies possible risks (with changes in the learning system among them), which may not only generate addiction but also subsequent problems with attention and memory. 2c russell bs, tomkunas aj, hutchison m, tambling rr, horton al. / 2022 (15) to examine the longitudinal impacts on the relationships between parents and children and the caregivers’ burden in the context of the parents’ reports on resilience, stress (both general and covid19-specific), depression and anxiety, as well as closeness and conflicts with their children. descriptive and crosssectional 271 parents, over 18 years old and with children aged less than 18 years old (between 0 and 5 , n‡=103). the parents’ depression symptoms are producing more challenging effects on their parenting experiences. the parents also reported higher perceived stress rates in the children. the unemployment rates affected the female gender more than the male gender during covid-19, and women reported worse mental health symptoms and care burdens at the beginning of the pandemic. 2c stienwandt s, cameron ee, soderstrom m, casar m, le c, roos le / 2022 (17) to examine how the home factors and the changes related to covid-19 increased or reduced the chances to take part in didactic activities to support development (“hands-on play”) and other similar ones (non-educational screen time) between parents and children. descriptive and crosssectional 708 parents, over 18 years old and with at least one child aged between 2 and 8 years old. the parents that meet the childcare needs and present lower parental stress levels reported more time devoted to hands-on play in all children’s age groups. the parents that meet the childcare needs and experienced higher parental stress levels reported more screen time among preschool children. 2c park j-h, park j-y, jin k-s / 2022 ( 37) to explore the effects of the covid-19 pandemic and the social distancing practices related to family life, the childcare burden on the parents and the children’s everyday life, during the initial stage of the pandemic in south korea. to evaluate the negative impact of the pandemic on parents’ and children’s stress levels. descriptive and crosssectional 288 adults, parents of at least one child aged between 1 and 12 years old. the time devoted to childcare by the main caregivers significantly increased during the pandemic. for children, the time devoted to screens (h¶=1.76) and to online interactions (h¶=0.95) was significantly increased, whereas the in-person interaction time (h¶=4.17) and the time devoted to learning (h¶=2.16) were significantly reduced. in addition, the parents’ and children’s stress levels were significantly increased during the pandemic. 2c snyder k, chaudhary p, pereira a , masuda k, niski j, dinkel d. / 2022 ( 38) to explore the perceptions of health workers, parents and childcare providers about the influence exerted by the pandemic on how they interacted with infants to promote physical activity, muscle strength and communication. qualitative 37 participants: parents (n‡=12), caregivers of children (n‡=12), health professionals (n‡=13). the caregivers identified concerns related to the following: limitations in social interactions (especially mask use, which affects communication), lack of access to peer modeling, fewer opportunities for physical exploration and the need for creative activities in various environments (e.g., §§, home/daycare centers), to promote child development during and after the pandemic. 3 *le = level of evidence from the oxford centre for evidence-based medicine; †aces = adverse child experiences; ‡n = absolute number; §cps = conduct problems; ||cu = callous unemotional; ¶h = hours; **p = non-arbitrary minimum significance level (p-value); ††> = greater than; §§e.g. = for example; ||||% = percentage; ¶¶or a = adjusted odds ratio; ***ci = confidence interval. source: prepared by the authors. 14 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 2 the analysis of the studies allows classifying the findings into three categories that present the effects suffered by the child population aged less than 5 years old and their caregivers throughout the pandemic, as well as the connection of such consequences with child development. the first category is exposure to risk stimuli, which responds to the increase in parental stress during the pandemic and to excessive screen use by children. the second category is called deprivation of stimuli and is related to the change in the families’ habits and to the absence of games, accompanied by increased sedentary lifestyles and even with parents resorting to punitive parenting practices. the last category, exposure to protective stimuli, alludes to the existence of opportunities during social distancing to preserve positive coexistence and closely track developmental milestones. discussion based on the question set out, it might be stated that the effects of social distancing and the parents’ remote work during the pandemic on the development of children aged less than 5 years old are related to the deprivation of stimuli that protect development and also to the continuous exposure to risk stimuli, to the detriment of opportunities to implement protective stimuli. in this sense, the findings of this integrative review would make it clear that the parents are a key component in children’s micro-systems (7, 39), especially in the age group between 0 and 5 years old. therefore, when the environment is so abruptly modified as it was during the pandemic, the bond between caregivers and their children can be impaired and, consequently, exert an impact on child development. the main effects will be presented according to the emerging categories. exposure to risk stimuli compellingly, the findings indicate how the pandemic years  (2020 and 2021) have represented a major challenge for families around the world, especially for those that raise very young children, as parents are expected to look after their safety, health, nutrition, leisure and rest. added to these responsibilities, they experienced circumstances such as increased workloads, job loss, lower social interaction and increased house chores (16, 29). all these changes in everyday life favor the onset of risk stimuli for children in full development. one of these risks would be high parental stress levels, which in turn hinders understanding the children’s needs and conditions and the possibility of positively responding to them. stress in caregivers is accompanied by other changes in mental health, such as anxiety, depression, frustration and irritability (16, 35). the studies describe that, in this panorama, co ns eq ue nc es o f t he c o v id -1 9 pa nd em ic o n ch ild d ev el op m en t: a n in te gr at iv e li te ra tu re r ev ie w 15 parenting practices are usually negative (punitive) and associated with emotional/behavioral problems in children, such as difficulties externalizing emotions  (12, 13, 37). for example, one of the studies sets forth that fewer experiences of gratifying interactions with parents (demonstrations of warmth and affection) imply fewer opportunities to imitate, practice or develop behaviors related to social connections, cooperation and affiliation with others (28). as a last element for this category, we should mention an important number of publications indicating the increased exposure to screens among children aged less than 5 years old (29, 32, 36, 37, 40, 41). according to the world health organization (40), children should not be exposed to electronic devices before the age of 2, whereas screens may be used for a maximum of one hour a day after that age. during the pandemic, parents resorted to electronic devices to mitigate the childcare burden  (37), the reason why these gadgets became the primary entertainment or distraction resource, even for more than 2.5 hours a day (29, 32, 36). use and consumption of contents through screens carries with it possible physical and intellectual risks, such as changes in cognitive processing and in learning the primarily expressive language, in addition to a reduction in some executive functions such as attention and memory (37, 41, 42). in a longitudinal study, it was verified that screen use during the pandemic was due to the need to mitigate the lack of activities in the open air and, consequently, the consumption of audiovisual materials was mainly focused on leisure and not on academic purposes (36). deprivation of stimuli during the pandemic years, it has been understood that parents were stressed and focused on meeting the household and work demands, the reason why they have found it difficult to generate interactive playful intervals (use of blocks, puzzles and imaginary role play, among others) with their children  (17). in addition, the evidence highlights that most of the population lives in apartments, which generally lack suitable spaces to practice physical activity. they live in overcrowded places in some cases and, given the restrictions imposed by the pandemic, it was not possible to access recreational parks (32, 34). regarding play, it is of vital importance to note that they are normal and expected behaviors for childhood, and it is indispensable that children enjoy constant playful periods (18). added to this, modeling is crucial for children’s learning; however, given the restrictions imposed by the pandemic, their recreational interaction was reduced, either with their parents or with other family members, and they had no contact with other children in most cases (31, 36). 16 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 2 therefore, increased sedentary lifestyles and the limited opportunities for games and physical exploration, as well as lack of access to modeling by groups of peers, suggest lesser participation in muscle strength and learning activities and scarce bonding (29, 32, 34, 37, 38). in terms of child development, we might be facing a negative impact on the motor, cognitive, language and socioemotional areas (42-44). in parallel, children’s everyday routines changed, as some of them ceased to attend educational centers and had their recreational activities suspended, which resulted in an increase in boredom and irritability levels. finally, until the usual balance of routines is resumed, the changes in the eating, sleep and rest habits may continue to be a reality in most homes (16, 34, 45, 46). to close this category, we again mention punitive parenting practices, as the evidence indicates that the combination of parental stress and children’s irritability sometimes results in the use of aggressive measures as a control resource. on the contrary, to ensure healthy emotional development, acceptance and negotiation in the face of children’s behaviors are recommended, with no severe punishments (1, 2, 13, 20, 30, 46-48). exposure to protective stimuli an aspect that has been highlighted by the research studies is the families’ socioeconomic level and how it influenced each household’s dynamics during social distancing. for example, the families with no financial difficulties reported “staying home” as a positive experience through which they spent quality time among all its members, devoted time to stimulate and/or educate their children, and carried out collaborative activities such as playing, eating, and doing the house chores (16). likewise, other positive elements were reported, such as the opportunity to lead a calmer life and, consequently, paying more attention to the developmental milestones gradually reached by young children (33, 48, 49). the importance of maintaining good quality interpersonal relationships to favor well-being and socioemotional skills in children stood out (30, 50). to conclude, it is to be mentioned that, between birth and the age of 5, children go through a critical time window to establish increasingly complex functions in the different developmental domains. finally, as already mentioned, optimum development depends on the stability of the interconnected systems that comprise the environment. consequently, the covid-19 pandemic years represented a drastic change for very young children’s micro-, meso-, exoand macro-systems, in addition to exerting negative impacts in at least one area of their development. this review has its limitations. despite the rigorous search strategy and the selection of articles, there is a prevalence of cross-sectional co ns eq ue nc es o f t he c o v id -1 9 pa nd em ic o n ch ild d ev el op m en t: a n in te gr at iv e li te ra tu re r ev ie w 17 surveys, which, due to their design characteristics, restrict extrapolation of the results and making causal inferences; however, the phenomenon under study forces research studies to follow such design. in addition, the studies were developed during the pandemic months, reason why access to the participants was via digital means, which reduced and exerted an impact on the possibility to recruit families that lacked electronic devices or internet connections. as a strength, it is noted that the review is focused on child development. although children’s physical and mental health is important for the nursing discipline, it becomes necessary to turn to look at the new generations’ development skills, as the nations’ potential and future productivity depend on them, as well as the elaboration and effective implementation of policies for child development. among the implications for nursing, as well as for those involved in child development would be the creation of family monitoring programs during the first years of the children’s life since, according to their training and due to the ability to implement care actions around growth, development and childcare, the professionals from the pediatric field are the ones with the ideal competencies for their implementation. these programs should be included in the development of surveillance systems that include the participation of different health professionals in all existing levels of healthcare, with pediatric nursing among them and in a central position. the findings of this study allow for generating hypotheses for future primary research studies that include broad sociodemographic diversity and assess child development through standardized instruments; in addition, from there, it becomes necessary to develop new secondary research studies that investigate the new family dynamics, the parenthood experiences and parental-child attachment, among other topics. conclusion the studies reveal the following as the main effects caused by the covid-19 pandemic: increased parental stress, changes in family habits, absence of games, and increased sedentary lifestyles, which in turn reduce the interactions that promote development in children aged less than 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brasil. dilenearaujo@uol.com.br 4 enfermeira. mestranda em enfermagem. membro pesquisador, universidade federal do ceará, brasil. samira_magalhaes@hotmail.com 5 enfermeira. membro pesquisador, universidade federal do ceará, brasil. adilinaromero@sarah.br 6 enfermeira. enfermeira, unidade básica de saúde dr. helio góis. membro pesquisador universidade federal do ceará, brasil. nupen@fortalnet.com.br 7 estudo desenvolvido pelo núcleo de pesquisa e extensão em enfermagem neurológica do departamento de enfermagem da faculdade de farmácia, odontologia e enfermagem da universidade federal do ceará nupen/denf/ffoe/ufc no âmbito do programa institucional de bolsa de iniciação cientifica pibic/cnpq/ufc. recibido: 16 de agosto de 2012 enviado a pares: 30 de agosto de 2012 aceptado por pares: 13 de agosto de 2013 aprobado: 10 de marzo de 2014 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 148-158 para citar este artículo / to reference this article / para citar este artigo figueiredo-carvalho zm, gomes-machado w, araújo-façanha dm, rocha-magalhães s, romero-rodrigues as, carvalho-e-brito am. avaliação da funcionalidade de pessoas com lesão medular para atividades da vida diária. aquichan 2014; 14(2): 148-158. resumo objetivo: aplicar o índice de barthel na avaliação de pessoas com lesão medular hospitalizadas e no domicilio, comparando as condições de funcionalidade no desenvolvimento das atividades da vida diária. material e método: estudo quantitativo, transversal, realizado com 62 pessoas, hospitalizadas e em domicílios. os dados foram coletados mediante aplicação de um formulário com as variáveis de interesse do estudo, no período de janeiro a maio de 2010. para a análise, utilizou-se o programa predictive analytics software, com provas de mann —whitney e kruskal— wallis. resultados: a idade média de 37,5 anos com desvio padrão de ± 13,74. nas atividades: banho 79% são dependentes; vestir-se 59%; o uso de toalete 91%; intestino 81% eram incontinentes; transferências 95% apresentaram incapacidade; atividade de mobilidade 94 % faziam com ajuda; utilização de escadas com cadeira de rodas nos hospitalizados 94,1% apresentaram incapacidade e, no domicílio, 78,5%. a análise da pontuação final de barthel obteve média de 48,4% com desvio padrão de ± 32,62. conclusões: existe significância acentuada sobre o grau de dependência entre hospitalizados em relação aos que se encontram em domicílio. palavras-chave atividades cotidianas, dependência, enfermagem, estudos de avaliação, funcionalidade, traumatismos da medula espinal (fonte: decs, bireme). 149 avaliação da funcionalidade de pessoas com lesão medular para atividades da vida diária l zuila maria de figueiredo-carvalho, winner gomes-machado y otros. año 14 vol. 14 nº 2 chía, colombia junio 2014 l 148-158 evaluación de la funcionalidad de las personas con lesión medular en las actividades de la vida diaria resumen objetivo: aplicar el índice de barthel en la evaluación de personas con lesión medular hospitalizada y en su domicilio, comparando las condiciones de funcionalidad en el desarrollo de las actividades de la vida diaria. material y método: estudio cuantitativo, transversal, realizado con 62 personas, hospitalizadas y en domicilios. los datos fueron recolectados mediante un formulario con las variables de interés del estudio, en enero a mayo de 2010. para su análisis, se utilizó el programa predictive analytics software, con pruebas de mann — whitney y kruskal — wallis. resultados: la edad media de 37,5 años con desvío patrón de ± 13,74. en las actividades: baño un 79 % son dependientes; vestirse, un 59 %; el uso de toielet, un 91 %; intestino, un 81 % eran incontinentes; transferencias, un 95 % presentaron incapacidad; actividad de movilidad, un 94 % hacían con ayuda; utilización de escaleras con silla de ruedas en los hospitalizados, un 94,1 % presentaron incapacidad y en el domicilio, un 78,5 %. el análisis de la puntuación final de barthel obtuvo media del 48,4 % con desvío patrón de ± 32,62. conclusiones: existe significancia acentuada en relación al grado de dependencia entre hospitalizados en relación a los que se encuentra en su domicilio. palabras clave actividades cotidianas, dependencia, enfermería, estudios de evaluación, funcionalidad, traumatismos de la médula espinal (fuente: decs, bireme). 150 aquichan issn 1657-5997 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 148-158 assessing the functionality of persons with spinal cord injury in daily living activities abstract objective: apply barthel’s index to an assessment of persons with spinal cord injury, hospitalized and at home, by comparing conditions of functionality in the performance of routine activities involved in daily living. material and methods: a quantitative, cross-sectional study was done with 62 persons, hospitalized and at home. the data were collected between january and may 2010 using a form with the variables of interest to the study. predictive analytics software was used with the mann whitney and kruskal wallis tests. results: the mean age was 37.5 with a standard deviation of ± 13.74. as for daily activities, 79% of the participants were dependent in bathing, 59% in dressing and 91% when using the toilet. eighty-one percent (81%) were bowel incontinent, 95% experienced disability in transference; 94% required assistance for activity involving mobility, and 94.1% of those hospitalized had disability in using stairs with a wheel chair as opposed to 78.5% at home. the analysis of the final barthel score yielded an average of 48.4% with a standard deviation of ± 32.62. conclusions: there is a marked significance with respect to the degree of dependence among hospitalized participants compared to those at home. key words activities of daily living, dependency, nursing, evaluation studies, functioning, spinal cord injuries (source: decs, bireme). 151 avaliação da funcionalidade de pessoas com lesão medular para atividades da vida diária l zuila maria de figueiredo-carvalho, winner gomes-machado y otros. introdução a lesão medular (lm) é uma síndrome neurológica incapacitante; caracteriza-se por uma agressão à medula espinhal que causa sua interrupção parcial ou total, o que pode ocasionar danos neurológicos e distúrbios neurovegetativos abaixo do nível da lesão com alterações nas funções motora, sensitiva e autônoma, bem como trazer repercussões nos sistemas cardiorrespiratório, gastrintestinal e geniturinário (1, 2, 3), além das questões relativas à incapacidade física que acarreta essa condição crônica. a situação de incapacidade determina uma variedade de mudanças tanto na vida da pessoa acometida quanto na dos seus familiares (4). dentre as principais causas de lm, destacam-se as externas, decorrentes do crescente aumento da violência e dos acidentes, principalmente os automobilísticos, quedas e mergulho em águas rasas, ferimentos por armas de fogo e agressão interpessoal (5, 6). os comprometimentos funcionais decorrentes da lm variam de um indivíduo para o outro, e os desempenhos nas habilidades das atividades da vida diária são fortemente prejudicados, o que predispõe a pessoa a um quadro de incapacidade funcional e provoca, assim, vários graus de dependência, principalmente no tocante à mobilização, aos cuidados de higiene, ao apoio na alimentação, à realização das atividades domésticas, dentre outros. as atividades da vida diária (avds) podem ser entendidas como atividades necessárias aos cuidados pessoais diários, à manutenção pessoal e à vida comunitária independente. abrangem ações de aspectos práticos e funcionais rotineiros que envolvem atividades nas quais as pessoas desempenham para si e para os outros. estão relacionadas com o interesse, necessidades e a autonomia, quando lhes é possível escolher e agir livremente, e, assim, melhorar sua qualidade de vida (7-9). na avaliação das avds são aplicadas escalas de avaliação de desempenho que medem de forma rápida, simples e quantificada a dependência do sujeito em atividades fundamentais e apontam ações terapêuticas que podem ser adotadas como tratamento (9). tais escalas permitem detectar as incapacidades funcionais que ele apresenta na realização de suas avds, avaliar os problemas e as prioridades, reconhecer, medir e reduzir os déficits, assim como planejar o tratamento, realizar o prognóstico e avaliar o desenvolvimento dos pacientes analisados, o que tem proporcionado muitos benefícios, principalmente em pacientes com necessidades especiais físicas ou mentais e em idosos (10). entre as várias escalas existentes, destaca-se o índice de barthel, elaborado em 1955 por mahoney e barthel (11), publicado pela primeira vez em 1965; é uma escala usada para medir as avds, criada para estabelecer o grau de dependência de pacientes cronicamente deficientes, em especial com distúrbios neuromusculares ou musculoesqueléticos, mas atualmente tem sido bastante aplicada a qualquer pessoa que apresente algum tipo de incapacidade funcional. este trabalho justifica-se pelo fato de serem poucas as pesquisas sobre avds nos portadores de lesão medular, principalmente no que se refere à aplicação do índice de barthel. após pesquisas em bases de dados nacionais e internacionais, foi encontrado um artigo cubano relacionado à temática, principalmente no que diz respeito a conhecimentos e a estratégias que podem ser desenvolvidos por meio dessas atividades (12). assim, este estudo torna-se relevante, pois vem ao encontro da promoção da saúde dos portadores de lesão medular, uma vez que esse instrumento pode orientar na identificação das necessidades concretas do paciente, no reconhecimento da prevenção de complicações, na ajuda ao paciente a adaptar-se a suas incapacidades e no direcionamento de programas de reabilitação; portanto, é mais um estudo que possivelmente fortalecerá a prática e a pesquisa na enfermagem neurológica brasileira, em especial, servirá de subsídio para a prática dos enfermeiros cearenses. com base no exposto, objetivou-se aplicar o índice de barthel na avaliação de pessoas com lm hospitalizadas e no domicílio comparando as condições de funcionalidade no desenvolvimento das avds. material e método trata-se de um estudo transversal, de caráter exploratório com abordagem quantitativa. a amostra foi composta de 62 pessoas, sendo 34 hospitalizadas, selecionadas por conveniência, conforme a internação em um hospital de referência em trauma do estado do ceará (brasil) e 28 no domicílio, cadastrados em um banco de dados existente no núcleo de pesquisa e extensão em enfermagem neurológica (nupen), constituído de 87 portadores de lm que atendessem aos critérios de inclusão do estudo. para os hospitalizados: terem sido submetidos à cirurgia; em domicílio: estarem com mais de seis meses de lesão, pois nesse período as pessoas já estão inseridas em uma fase de organização da 152 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 vida pessoal e adaptação à nova condição, isto é, ser portador de uma lesão assim busca alternativas para readaptação; não terem participado de programa de reabilitação, serem maiores de dezoito anos; serem residentes no município de fortaleza, por facilidade de deslocamento da pesquisadora, e aceitarem participar do estudo. a coleta dos dados realizou-se mediante a utilização de um formulário com as variáveis de interesse do estudo: dados de identificação do sujeito da pesquisa e perguntas de múltipla escolha autoexplicativas relacionadas ao desempenho das avds, baseadas no índice de barthel. o índice estuda dez itens das avds que envolvem a mobilidade e cuidados pessoais, bem como inclui: alimentação, higiene pessoal, bexiga (controle do esfíncter vesical), intestino, transferências cama-cadeira, mobilidade/marcha (uso de cadeira de rodas), uso de toalete (uso do sanitário), vestirse, banho e escadas (capacidade de subir e descer escadas). os itens banho e higiene pessoal são pontuados com 0 ou 5, deslocação e mobilidade/marcha com 0, 5, 10 ou 15, e os demais com 0, 5 ou 10. a pontuação total varia de 0 a 100, sendo que entre 0-20 = dependência total, 21-60 = dependência severa, 61-90 = dependência moderada, 91-99 = dependência fraca e 100 = independente (11, 13). os dados foram compilados no programa predictive analytics software, versão 18.0, um software aplicativo (programa de computador) do tipo científico, que tem por objetivo o desempenho de tarefas práticas, em geral conectadas ao processamento de dados (14); na análise, utilizaram-se as provas de mann —whitney e kruskal— wallis, cujos resultados estão apresentados em quadros e gráficos com frequência absoluta e relativa com o intuito de proferir uma análise panorâmica da distribuição do nível de dependência dos envolvidos. a análise foi fundamentada com base na literatura pertinente. os aspectos éticos na pesquisa estão de acordo com as exigências da resolução 196/1996 do conselho nacional de saúde, brasil (15), que estabelece as diretrizes e normas regulamentadoras de pesquisas que envolvem seres humanos. o projeto foi aprovado pelos comitês de ética do hospital e da universidade federal do ceará (ufc), sob os protocolos n. 150147/2009 e 0044/2010. todos os envolvidos assinaram o termo de consentimento livre e esclarecido (tcle) e, somente após consentimento por escrito ou impressão digital, ocorreu a coleta dos dados. resultados após análise estatística, foi verificado o somatório das pessoas com lm, no hospital e no domicílio. esses dados foram dispostos juntos porque não apresentaram significância estatística para comparação. quadro 1. distribuição dos pacientes com lm no hospital e no domicílio segundo os dados sociodemográficos e clínicos variáveis dados demográficos frequência % sexo masculino 53 85,50 feminino 9 14,50 escolaridade baixa escolaridade 37 59,70 média escolaridade 23 37,10 alta escolaridade 2 3,20 procedência capital 47 75,80 47 75,80 interior 15 24,20 15 24,20 ocupação com ocupação 30 48,38 sem ocupação 24 38,70 aposentado 8 12,90 dados clínicos causa da lesão perfuração por arma de fogo 24 38,70 queda 20 32,30 acidente automotivo 9 14,50 atropelamento 6 9,70 outros 3 4,80 american spinal cord injury association (asia) completa 53 85,50 incompleta 9 14,50 tempo de paraplegia menos de seis meses 32 51,60 mais de seis meses a dois anos 2 3,20 mais de dois anos a cinco anos 2 3,20 mais de cinco anos 26 41,90 153 avaliação da funcionalidade de pessoas com lesão medular para atividades da vida diária l zuila maria de figueiredo-carvalho, winner gomes-machado y otros. grupo hospital 34 54,80 domicílio 28 45,20 variáveis média desvio padrão idade 37,56 13,74 total da pontuação de barthel 48,39 32,62 fonte: elaboração própria, 2010. primeiramente, os resultados da escala de barthel são expostos separadamente para as pessoas com lm que estavam hospitalizados e os que estavam em domicílio, para, em seguida, analisar em que avds houve significância estatística para fazer comparação entre as atividades e o local em que se encontravam as pessoas com lm. discussão na aplicação do índice de barthel nas pessoas com lm, no âmbito hospitalar e domiciliar, com vista na avaliação e comparação das condições de funcionalidade para o desenvolvimento das avds, alguns aspectos são destacados: sexo e idade evidenciam a predominância para o sexo masculino 85,5% e uma média de idade de 37,56 anos. em muitos outros estudos é recorrente esse fato relacionado ao sexo masculino e à idade produtiva. no estudo de tuono (16), após análise de 21.000 prontuários referentes a internações por trauma de coluna no ano de 2000 a 2005, obteve que 68% dos pacientes eram do sexo masculino e a maioria, 40%, pertencia à faixa etária produtiva de 20 e 30 anos. entretanto, um estudo epidemiológico (17) sobre traumatismo da coluna vertebral mostrou que as causas de lm traumática diferem entre os sexos e que o sexo feminino está mais exposto aos acidentes automobilísticos e quedas, bem como que não ocorre caso de ferimento por arma de fogo, mergulho em águas rasas e agressões. quanto a classificação do nível da lesão em conformidade ao que preconiza a asia (18), nota-se uma prevalência de lesões completas 85,5%, aspecto também evidenciado no estudo de magalhães (19), o qual relata a influência da atividade física na sexualidade de indivíduos com lesão vértebro-medular, uma estatística convergente com a maioria, 61,8%, com lesão completa. a baixa escolaridade de 59,70% é encontrada, também, no estudo de venturi, decésaro e marcon (20) em pacientes com lm; estes apontam que 71,9% das pessoas tinham baixa escolaridade (ensino fundamental); 18,8%, ensino médio, e 3,1% com ensino superior. quanto à causa da lesão, obtiveram-se percentuais maiores para perfuração por arma de fogo 38,7 %, seguido pela queda 32,3%, acidente automotivo 14,5%, atropelamento 9,7% e outros 4,8%. corroborando com os resultados citados, observase na literatura a predominância para causa da lm a violência, que engloba os acidentes devido à perfuração por arma de fogo, queda e acidente automotivo, como cita koch (21) em seu estudo realizado com 502 pacientes. a maioria dos entrevistados estava no âmbito hospitalar, 54,8%, devido à facilidade de entrevistá-los. por sua vez, as pessoas com lm que se encontravam em domicílio representam a minoria, 45,2%, devido às dificuldades de encontrá-las. . uma vez que o estudo foi realizado em parte no hospital, é esperado que muitos dos entrevistados estivessem em fase aguda da lesão (51,6%). após aplicação do índice de barthel, foi possível identificar o nível de dependência em portadores de lm, conhecer os problemas relacionados ao desempenho das avds nesse público e correlacionar o grau de dependência entre as pessoas hospitalizadas e os que se encontram no domicílio. as pessoas que se encontravam no domicílio possuem maior grau de independência para a realização de suas avds. desse modo, destacam-se alguns aspectos preponderantes, tais como: os hospitalizados apresentam grande dependência (35%) em relação aos que estão no domicílio para a atividade banho; quanto ao fator vestir-se 20,96%; o uso do toalete 41,93%; para a atividade intestino, os hospitalizados apresentaram 30,64% (incontinência); a respeito da transferência cadeira-cama, os hospitalizados versam os no domicílio em 38,70% como incapazes e, no que tange à mobilização, há diferença de 40,32% como mobilizados. a problemática encontrada para a realização dessas atividades no ambiente hospitalar não está somente relacionada com as questões físicas do ambiente, as quais não estão dentro dos padrões exigidos pela secretaria nacional para a reabilitação e integração das pessoas com deficiência (22), mas também com a falta de instrumentos que auxiliem nas avds. para araújo (23), o uso de alguns equipamentos auxiliadores é fundamental, como por exemplo, uma calçadeira com cabo lon154 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 figura 1. escala de barthel — avds: banho e higiene fonte: elaboração própria, 2010. figura 2. escala de barthel — avds: vestir-se e uso do toalete fonte: elaboração própria, 2010. figura 3. escala de barthel — avds: intestino e sistema urinário fonte: elaboração própria, 2010. 155 avaliação da funcionalidade de pessoas com lesão medular para atividades da vida diária l zuila maria de figueiredo-carvalho, winner gomes-machado y otros. figura 4. escala de barthel — avds: escada e mobilidade fonte: elaboração própria, 2010. figura 5. escala de barthel — avds: transferência e alimentação fonte: elaboração própria, 2010. go, barras de apoio e muitos outros. ainda no estudo de riberto et al (24), obteve-se que, no início do programa de reabilitação, a questão vestir-se (24%) foi a tarefa na qual os pacientes apresentavam mais dependência. quanto à eliminação intestinal, a incontinência preponderante entre os hospitalizados está relacionada com o fato de ainda não estarem treinados para suas eliminações, fator que depende de tempo, aceitação e acostumar-se com reflexos que demonstrem que está na hora da eliminação. após análise separada das avds, que demonstraram maior dependência e independência conforme o local onde se encontravam as pessoas, obtém-se que, neste estudo, houve para a pontuação final de barthel uma média de 48,39% com desvio padrão de ± 32,62. o que significa que essas pessoas apresentavam em média de dependência fraca à dependência moderada para a realização de suas avds. infelizmente, não se encontraram estudos com a utilização da pontuação final da escala de barthel em pessoas com paraplegia e tetraplegia hospitalizadas para se fazer uma análise comparativa de resultados. a escala de barthel foi validada após sua aplicação, pela primeira vez, em doentes crônicos com problemas neuromusculares e osteomusculares hospitalizados. hoje, depois de 55 anos de sua criação e 45 anos de sua primeira publicação, ainda há uma escassez de artigos que relatem a utilização dessa escala no hospital, em especial com a temática estudada neste trabalho. constatou-se também que, embora a escala tenha sido validada no ambiente hospitalar, ela é aplicada na maioria das vezes com pessoas em fase de reabilitação, seja em clínicas especializadas ou no domicílio. 156 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 no estudo incapacidade funcional dos indivíduos adultos com lesão medular e sua associação com características sociodemográficas (25), os autores utilizaram o índice de barthel em 75 pessoas e encontraram os seguintes resultados: o alfa cronbach para o índice de barthel foi 0,807, e as atividades que foram mais difíceis de realizar foram: subir e descer escadas (92%) e caminhada (82,7%). a pontuação média do índice de barthel foi de 64 pontos. os testes de associação demonstraram valores com p> 0,05. ricardo (26), ao utilizar o índice de barthel para caracterizar o grau de dependência na admissão, no quinto dia de hospitalização, na alta e na consulta aproximadamente com dois meses após um acidente vascular encefálico (ave), aponta que, na admissão, 42% dos doentes eram dependentes totais. no quinto dia, o grau de dependência revelou que a percentagem de dependentes totais diminuiu par a 25,2%, o que denota uma evolução funcional dos doentes. na alta, verificou-se um aumento dos dependentes leves com 29,2% e os autônomos com 19,2% referente às avaliações anteriores, o que revela bons resultados. na consulta, cerca de dois meses após a alta, a avaliação do grau de dependência revelou que 31,5% dos doentes eram autônomos, 28,3% dependentes leves e os dependentes totais eram apenas 12,3%. o estudo realizado por scivoletto et al. (27), no qual utilizaram o índice de barthel para avaliar os resultados de um programa de reabilitação com pessoas com tetra e paraplegia, obtiveram-se os seguintes índices antes e após a lesão: as pessoas com asia — a progrediram de uma média de 16 pontos (dp: ± 12,4) para 50 pontos (dp: ± 26,7); as pessoas com asia — c progrediram de uma média de 24 pontos (dp: ± 18,1) para 57 pontos (dp: ± 31) e as pessoas com asia — d progrediram de uma média de 62 pontos (dp: ± 25,7) para 88 pontos (dp: ± 15,2). entende-se assim que o índice de barthel é um instrumento de avaliação funcional muito estudado e, portanto, uma escala sensível à mudança, que fornece um significativo prognóstico dos resultados de reabilitação ao se relacionar significativamente com outras medidas do estado do paciente. lamentavelmente, ainda são escassos os estudos nacionais com aplicação do índice de barthel a pessoas com lm. conclusões diante de tais resultados, conclui-se que existe uma significância acentuada no grau de dependência entre os portadores de lm traumática hospitalizados em relação àqueles que se encontram em domicílio. quanto à funcionalidade para o desenvolvimento das avds, após a aplicação do índice de barthel, no aspecto geral, este se manifestou de forma distinta nos grupos. os hospitalizados demonstraram maior dependência, enquanto os domiciliares demosnstraram maior independência. ao analisar cada categoria, ficou evidente que as atividades: higiene pessoal, intestinos, deslocação, mobilidade, uso do toalete, vestirse e banho apresentaram resultados divergentes; os hospitalizados mostraram uma maior dependência, enquanto os domiciliares, uma maior independência. apenas nas atividades alimentação, bexiga e escada, obtiveram-se resultados convergentes tanto para os hospitalizados quanto para os domiciliares, tanto os pacientes hospitalizados como em domicílios demonstraram independência para se alimentar, incontinência urinária e incapacidade para subir/descer escadas sem ajuda. o estudo realizado permitiu conhecer, por meio da utilização do índice de barthel, as limitações nas avds dessas pessoas, bem como as dificuldades enfrentadas por elas para a realização de suas avds. a identificação das condições de funcionalidade para o desenvolvimento das avds possibilitará a elaboração de um modelo de intervenções de enfermagem que vise à promoção da saúde e melhoria da qualidade de vida das pessoas com lm, bem como facilitar a melhoria da prática profissional de enfermeiros envolvidos no cuidado dessas pessoas. a experiência de elaborar este estudo significou conhecer mais claramente as condições de funcionalidade apresentadas pelas pessoas com lm, possibilitou uma reflexão sobre a problemática que essa condição crônica impõe à pessoa que a vivencia. mostrou, ainda, que, conhecendo o nível de dependência que vivem essas pessoas, o enfermeiro pode tentar minimizar suas limitações. finalmente, além de se constituir em uma oportunidade de ampliar e aprofundar a conceituação acerca da lm, propicia o crescimento e a autonomia do conhecimento e da prática de enfermagem. agradecimentos: a pró-reitoria de pesquisa e pós-graduação da universidade federal do ceará (ufc), ao conselho nacional 157 avaliação da funcionalidade de pessoas com lesão medular para atividades da vida diária l zuila maria de figueiredo-carvalho, winner gomes-machado y otros. de desenvolvimento tecnológico (cnpq) e à fundação cearense de apoio ao desenvolvimento científico e tecnológico (funcap), pelo apoio financeiro, em forma de bolsa de iniciação científica às estudantes do curso de graduação em enfermagem. referências 1. organização mundial de saúde. classificação internacional das deficiências, incapacidades e desvantagens (handicaps): um manual de classificação das consequências das doenças. lisboa, 2008. 2. moreno-fergusson me, maya rey mc. cuerpo y corporalidad en la paraplejia: significado de los cambios. av. enferm. 2012; xxx(1):82-94. 3. carvalho zm de f, mulet fvf, nuñez ajh,brito amc, gularte tm, mulet cs. el cuidado de enfermería en la percepción de los familiares de personas ingresadas con lesión medular. enfermería integral 2009; 85:30-5. 4. moreno fergusso me, rodríguez mc, gutiérrez duque m, yorladi ramírez l, pardo ob. ¿qué significa la discapacidad? aquichán 2006;6(1):78-91. disponible en: http://aquichan.unisabana.edu.co/index.php/aquichan/article/view/82/168 5. wyndaele m, wyndaele jj. incidence, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey? spinal cord. 2006; 44(9):523-9. 6. dawodu st. spinal cord injury: definition, epidemiology, pathophysiology. medicine j. 2008; 2(8). disponible en: <http:// www.emedicine.com/pmr/topic182.htm 7. cavalcante kmh. cuidado de enfermagem à pessoa com paraplegia fundamentado no modelo roper-logan-tierney. [dissertação mestrado]. fortaleza: departamento de enfermagem da faculdade de farmácia, odontologia e enfermagem da universidade federal do ceará; 2007. 215 p. 8. blanes l, lourenço l, carmagnani mis, ferreira lm. clinical and socio-demographic characteristics of persons with traumatic paraplegia living in são paulo, brazil. arq neuropsiquiatr. 2009; 67(2-b):388-90. 9. nishida ap, amorim mzm, inoue mme. a. índice de barthel e do estado funcional de pacientes pós acidente vascular cerebral em programa de fisioterapia. salusvita, bauru, 2004;23(3):467-77. disponible en: http://www.edusc.com.br/ colecoes/revistas/salusvita_pdf/3/artigo%2010%202004-3.pdf 10. araújo f, ribeiro jlp, oliveira a, pinto c. validação do índice de barthel numa amostra de idosos não institucionalizados. revista portuguesa de saúde pública 2007; 5(2): 59-66. disponible en: http://www.cdi.ensp.unl.pt/docbweb/ multimedia/rpsp2007-2/05.pdf 11. mahoney fi, barthel d. functional evaluation: the barthel index. maryland state med. j. 1965; 14:56-61. 12. paz lm, rodríguez mg, cossio jg, quinteiro ie. accionar de enfermería y aplicación del índice de barthel a pacientes lesionados medulares en la clínica raquimedular del ciren. medwave, la habana 2005;5(10). disponible en: http:// www.medwave.cl/enfermeria/2005/noviembre/1.act 13. ruzafa jc, moreno jd. valoración de la discapacidad física: el índice de barthel. rev esp salud pública 1997;71(2):12737. disponible en: http://www.scielosp.org/pdf/resp/v71n2/barthel.pdf 14. predictive analytics software, versão 18.0: statistical software. [s.i.]: spss inc., 2004. 15. brasil. ministério da saúde. conselho nacional de saúde. resolução n. 196/1996. 4(2):15-22, 1996. 16. tuono v l. traumas de coluna no brasil: análise das internações hospitalares. [dissertação de mestrado]. faculdade de saúde pública, universidade de são paulo, são paulo; 2008. 17. campos, mf et al. epidemiologia do traumatismo da coluna vertebral. rev. col. bras. cir. 2008;35(2):88-93. disponible en: http://www.scielo.br/pdf/rcbc/v35n2/05.pdf 18. american spinal injury association. classification of spinal cord injuries. disponible en: http://www.asia-spinalinjury.org/# 19. magalhães imb. influência da actividade física na sexualidade de indivíduos com lesão vértebro-medular. [dissertação de mestrado]. faculdade de ciência do deporto e de educação física da universidade do porto; 2005. 158 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 20. venturini da, decésaro mn, marcon ss. alterações e expectativas vivenciadas pelos indivíduos com lesão raquimedular e suas famílias. rev esc enferm usp 2007; 41(4):589-96. 21. koch alex, graells xavier soler i, zaninelli ed marcelo. epidemiologia de fraturas da coluna de acordo com o mecanismo de trauma: análise de 502 casos. coluna/columna 2007; 6(1):1-50. 22. secretaria nacional para a reabilitação e integração das pessoas com deficiência. disponible en: http://bvsms.saude. gov.br/ 23. araújo t. dificuldades nas atividades diárias. disponible en: http://www.institutofrisoli.com.br/progr05.htm 24. riberto m, pinto ppn, sakamoto h, battistella lr. independência funcional de pacientes com lesão medular. acta fisiátrica 2005;12(2):61-66. disponible en: http://www.actafisiatrica.org.br 25. coura as, frança isx, enders bc, barbosa ml, souza jrs.functional disability of adult individuals with spinal cord injury and its association with socio-demographic characteristics. rev.latino-am. enfermagem 2012; jan-fev.20(1):84-92. disponible en: www.eerp.usp.br/rlae 26. ricardo rmp. avaliação dos ganhos em saúde utilizando o índice de barthel, nos doentes com avc em fase aguda e após a alta, com intervenção de enfermagem de reabilitação. [dissertação de mestrado em enfermagem de reabilitação]. instituto politécnico de bragança; 2012. disponible en: https://bibliotecadigital.ipb.pt/bitstream/10198/7680/1/ avalia%c3%a7%c3%a3o%20dos%20ganhos%20em%20sa%c3%bade%20utilizando%20o%20%c3%8dndice%20de%20 barthel.pdf 27. scivoletto g., morganti b., cosentino, e., molinari, m. utility of delayed spinal cord injury rehabilitation: an italian study. neurol. sci. 2006; 27:86-90. disponible en: < http://springerlink.metapress.com/content/ev1275pp2167368t/ fulltext.pdf 92 103 politicas gerencia e inovacao.indd 92 aquichan issn 1657-5997 alacoque lorenzini erdmann1 josé luis guedes dos santos2 patrícia klock3 rafael marcelo soder4 grace teresinha marcon dal sasso5 rolf hermann erdmann6 políticas, gerência e inovação de grupos de pesquisa para a excelência em enfermagem 1. doutora em filosofia da enfermagem. professora titular do departamento de enfermagem e programa de pós-graduação em enfermagem (pen) da universidade federal de santa catarina (ufsc). alacoque@newsite.com.br 2. doutorando em enfermagem do pen da ufsc. bolsista da coordenação de aperfeiçoamento de pessoal de nível superior. joseenfermagem@gmail.com 3. doutoranda do pen da ufsc. bolsista do cnpq. patynurse@hotmail.com 4. doutorando em enfermagem do pen da ufsc. professor do curso de enfermagem da universidade federal da fronteira sul. rafaelsoder@hotmail.com 5. doutora em enfermagem. professora associado ii do departamento de enfermagem e pen da ufsc. grace@ccs.ufsc.br 6. doutor em engenharia de produção. professor associado iii do departamento de ciência da administração e programa de pós-graduação em administração da ufsc. erdmann@cse.ufsc.br recibido: 12 de junio de 2012 aceptado: 27 de febrero de 2013 año 13 vol. 13 nº 1 chía, colombia abril 2013  92-103 resumo objetivo: apontar pressupostos sobre políticas, gerência e inovação de grupos de pesquisa (gps) de excelência em enfermagem. método: estudo interpretativo, de dialogicidade e reflexividade, realizado com gestores/pesquisadores autores e atores desse processo. resultados: pressupostos para gps de excelência em enfermagem: possui políticas bem definidas e processo gerencial competente e inovador; promove a formação de novos pesquisadores altamente qualificados; produz conhecimentos avançados com infraestrutura física, pessoal, financeira, organizativa e logística adequadas; considera que a prática da produção de conhecimentos é um processo coletivo, dinâmico, contínuo e complementar; integra tecnologias da informação e comunicação na produção, consumo e disseminação do conhecimento. discussão: esses pressupostos podem potencializar as estruturas organizativas e operacionais dos gps visando a uma maior produtividade e impacto pela aplicação do conhecimento produzido. conclusões: a excelência do gp é fruto de políticas bem definidas, processo gerencial competente, inovador, dinâmico e efetivo, constituindo-se em referência de empreendedorismo e inovação em pesquisa. palavras-chave grupos de pesquisa, enfermagem, saúde, pesquisa em enfermagem. (fonte decs, bireme). 93 políticas, gerência e inovação de grupos de pesquisa para a excelência em enfermagem l alacoque lorenzini erdmann y otros políticas, gerencia e innovación de grupos de investigación para la excelencia en enfermería resumen objetivo: apuntar presupuestos sobre políticas, gerencia e innovación de grupos de investigación (gps, sigla en portugués) de excelencia en enfermería. método: estudio interpretativo, de dialogicidad y reflexión, realizado con gestores/investigadores autores y actores de este proceso. resultado: presupuestos para gps de excelencia en enfermería: cuenta con políticas bien definidas altamente calificados; produce conocimientos avanzados con infra-estructura física, personal, financiera, organizacional y logística adecuadas; considera que la práctica de la producción de conocimientos es un proceso colectivo, dinámico, continuo y complementario; integra tecnologías de la información y comunicación en la producción, consumo y diseminación del conocimiento. discusión: esos presupuestos pueden potencializar las estructuras organizativas y operacionales de los gps objetivando una mayor productividad e impacto por la aplicación del conocimiento producido. conclusiones: la excelencia del gp es fruto de políticas bien definidas, proceso gerencial competente, innovador, dinámico y efectivo, constituyéndose en referencia de emprendedorismo e innovación en investigación. palabras clave grupos de investigación, enfermería, salud, investigación en enfermería. (fuente decs, bireme). policies, management and innovation research groups for nursing excellence abstract purpose: to register policies, management and innovation motives for research groups on excellence in nursing (gps, acronym in portuguese). method: an interpretative study through dialogue and reflection, undertaken with managers/ researchers authors and actors in this process. result: budgets for gps on excellence in nursing; having well defined highly qualified policies; produces advanced knowledge with appropriate physical, personnel, financial, organizational and logistic infrastructure; believes that that knowledge production practice is a collective, dynamic, ongoing, and complementary process; it integrates ict in producing, consuming and disseminating knowledge. discussion: these motives can potential organizational and operational structures of the gp’s and aim towards greater production and impact through the knowledge produced. conclusion: excellence in gp results from well defined policies, a competent, innovating, dynamic and effective management process, thus becoming a reference for entrepreneurship and innovation in research. key words research groups, nursing, health, nursing research. (source: decs, bireme). 94 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 introdução a produção de conhecimentos na modalidade de pesquisa é desenvolvida por equipes de pesquisadores titulados ou em formação, organizados sob a designação de grupos de pesquisa (gps). o diretório dos gps no brasil, existente desde 1992 no conselho nacional de desenvolvimento científico e tecnológico (cnpq) – ministério da ciência, tecnologia e inovação (mcti), constitui-se em bases de dados com informações importantes sobre os gps em atividade no país (1). o cnpq se destina ao apoio e incentivo à ciência, tecnologia e inovação na formação e absorção de recursos humanos e financiamento de projetos de pesquisa que contribuem para o aumento da produção de conhecimento e geração de novas oportunidades de crescimento para o país. o gp congrega pesquisadores, organizados em torno de um ou dois líderes, dotados de experiência, destaque e liderança científica ou tecnológica; que realizam um trabalho profissional contínuo de atividades de pesquisa vinculadas a linhas de pesquisa e que compartilham instalações e equipamentos apropriados para essa finalidade (1). para a realização de pesquisa em grupos, núcleos, laboratórios, institutos ou centros, dentre outras denominações, quer em instituições de ensino, especialmente nas universidades e programas de pós-graduação, quer em empresas de produção de bens e serviços para a geração de novas tecnologias, é necessário ter infraestrutura com espaço/ambiente e equipamentos/ tecnologias adequada à produção de conhecimentos segundo as características de objetos de estudos e linhas de pesquisa dos gps. as pesquisas são produzidas em parcerias ou compartilhadas entre projetos e entre gps e sob a orientação de um ou mais docente pesquisador. a qualidade dos produtos de conclusão de curso de graduação, dissertações, teses, pesquisas de iniciação científica, dentre outras, reflete a qualidade dos laboratórios ou gps e respectivas tecnologias de investigação mais avançadas. entende-se que a excelência de um gp na enfermagem depende de políticas, gerência e inovação centradas no ter e fazer o que existe de melhor, do mais avançado, do mais qualificado, do diferente, do estar à frente dos demais, sendo referência pela competência em domínios dos mais avançados possíveis acompanhada da alta produtividade e distinção das pessoas ali integrantes. assim, questiona-se: nossos gps propiciam a excelência na produção de conhecimentos? são altamente produtivos? o que é necessário para um gp ser produtivo e propiciar a formação qualificada do graduando, mestrando ou doutorando? e, para a realização de experiências em pesquisa na modalidade de estágio de pós-doutorado? como é a prática de produção de conhecimentos em outras áreas? é importante investir em tecnologias avançadas de infraestrutura física, equipamentos e profissionais experts nos grupos/núcleos ou laboratórios ou institutos ou centros de pesquisa? como alcançar a excelência, tanto na qualidade da infraestrutura, políticas e inovação dos gps, quanto na dos resultados das pesquisas ou conhecimentos avançados produzidos neles? na área da enfermagem no brasil, os primeiros gps surgiram na década de 1970, e seu crescimento e forma de organização se expandiram, principalmente nas duas últimas décadas. conforme o último censo do diretório de grupos de pesquisa do cnpq de 2010, existem 27.523 gps cadastrados; destes, 4.573 são da grande área denominada ciências da saúde, da qual 482 grupos são de enfermagem, o que representa quase 10% do total da grande área e 1,8% do total geral, que inclui 76 áreas de conhecimentos (2). a criação e consolidação de gp na enfermagem vêm crescendo nos últimos anos, acompanhando a expansão dos programas de pós-graduação. atualmente, os programas e cursos de pós-graduação em enfermagem stricto sensu credenciados pela coordenação de aperfeiçoamento de pessoal de nível superior (capes), totalizam 58 programas com um total de 80 cursos, sendo 26 doutorados em enfermagem, 43 mestrados acadêmicos e mais 11 mestrados profissionais em enfermagem. o perfil de desempenho e produtividade qualificada desses programas é fruto das atividades de pesquisa ou produção de conhecimentos realizados, consequente aumento da criação e consolidação de novas linhas de pesquisa, crescimento das publicações de maior impacto, melhor qualificação na formação dos graduandos, mestres e doutores da área e fortalecimento dos gps rumo à excelência no desempenho. a modalidade de produção de conhecimentos em grupo agrega pessoas interessadas em aprender e fazer pesquisas, sob a coordenação de pesquisadores docentes, e envolve alunos e outros participantes como os profissionais de instituições da saúde. o desenvolvimento de gps é uma importante estratégia para o fortalecimento da enfermagem como ciência e profissão, exercendo uma prática profissional sustentada por uma contínua busca de novos conhecimentos. e a competência para cuidar, pesquisando, educando e gerenciando, vem sendo desenvolvida 95 políticas, gerência e inovação de grupos de pesquisa para a excelência em enfermagem l alacoque lorenzini erdmann y otros na formação e no exercício profissional do enfermeiro. a enfermagem necessita incrementar a produção de conhecimentos por meio da pesquisa para maior visibilidade, reconhecimento e consolidação da profissão como ciência, tecnologia e inovação. além disso, a competência investigativa é necessária para o desenvolvimento sociopolítico e tecnológico em saúde e primordial na formação, na prática e nos centros de investigação da área, bem como para a melhoria da saúde da população e avanço no desenvolvimento do país (3, 4). porém, ainda faz-se necessário avançar na compreensão do que é um gp para a área, quais são as suas principais características, bem como os critérios específicos para análise do mérito no seu credenciamento, hoje nas modalidades de emergentes e consolidados (3). no contexto acadêmico, de maneira geral, ainda são poucas as iniciativas, os estudos ou os modelos de gestão do conhecimento em gp que consideram as suas particularidades, a natureza da produção do conhecimento científico, a estrutura e o comportamento de comunidades científicas, além da própria cultura que envolve o ambiente acadêmico (5). diante do número de gps em enfermagem constituídos no brasil, seu crescimento ao longo dos anos e a importância das políticas, gerência e inovação deles para a qualificação de excelência, centram-se nossas interlocuções, neste estudo, na seguinte questão norteadora: que pressupostos podem ser apontados sobre políticas, gerência e inovação de gps de excelência em enfermagem? assim, teve-se como objetivo apontar alguns pressupostos sobre políticas, gerência e inovação de gps de excelência em enfermagem. método trata-se de um estudo interpretativo, de dialogicidade e reflexividade, realizado com gestores/pesquisadores autores e atores deste processo. o caráter reflexivo, de natureza interpretativa, toma o pesquisador como sendo ao mesmo tempo intérprete e autor, pois o conhecimento é inerente daquele que o produz. nesse sentido, a reflexão pode ser entendida como as próprias interpretações do pesquisador por meio de processos constantes de indução, dedução e abdução (6, 7). estudos reflexivos e de natureza interpretativa podem ter como etapas: 1) definição do tema e problema de pesquisa; 2) realização de uma revisão de literatura sobre o problema de investigação; 3) coleta de dados por meio de grupos focais entre os pesquisadores autores do estudo; 4) interpretação de primeiro nível, com organização e transcrição dos dados coletados; 5) interpretação de segundo nível, a qual consistiu na interpretação teórica da interpretação empírica anterior; 6) interpretação crítica de terceiro nível, em que os pressupostos teóricos usados no nível anterior foram interpretados à luz de circunstâncias políticas, ideológicas e culturais; 7) interpretação de quarto nível, na qual se busca a reflexão, crítica e síntese sobre todos os níveis anteriores com base no problema que suscitou a investigação (6, 7). os autores/atores deste estudo, mediante encontros programados, de outubro de 2011 a maio de 2012, exercitaram a reflexividade e dialogicidade, balizados pelas etapas anteriormente descritas, para o alcance do objetivo proposto. utilizou-se como processo de análise o constante exercício de indução, dedução e abdução sobre as informações, vivências, experiências ou práticas que apontavam ideias norteadoras como possíveis proposições de pressupostos sobre políticas, gerência e inovação de gps de excelência em enfermagem. considerando a metodologia adotada e o fato de os sujeitos do estudo serem seus próprios autores, não foi registrado o projeto em um comitê de ética, porém todos firmaram o consentimento informado e levaram em consideração os aspectos éticos de construção coletiva de conhecimentos. resultados e discussão os principais pressupostos sobre políticas, gerência e inovação de gps de excelência em enfermagem emergidos nas dinâmicas dialógicas e de reflexividade dos autores/atores deste estudo foram: um gp deve estar alicerçado em políticas bem definidas e com um processo gerencial competente e inovador; promover a formação dos novos pesquisadores em nível de excelência, com o aprofundamento teórico e domínio da prática do seu campo de saber; produzir conhecimentos avançados com infraestrutura física, pessoal, financeira, organizativa e logística adequadas; levar em consideração que a prática da produção de conhecimentos envolve um maior número de participantes num processo coletivo, dinâmico, contínuo e complementar; além de integrar as tecnologias da informação e comunicação na produção, consumo e disseminação do conhecimento. as principais ideias ou informações que sustentam estes pressupostos são descritas a seguir. 96 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 um gp de excelência deve estar alicerçado com um processo gerencial competente as políticas organizativas de um gp envolvem a definição da sua missão e visão, de normativas de funcionamento claras e precisas, estrutura logística e sistema de informação e comunicação em página web ou site, folders ou booklet, que possibilita o acesso e registro das atividades e interesses dos seus membros e da comunidade interessada. o ingresso de novos participantes com estratégias ou políticas definidas para recrutamento de novos integrantes, bem como as atividades realizadas pelos membros efetivos e mesmo o controle dos egressos devem ser regulados com políticas ou diretrizes claras e explícitas. os aspectos legais de participação, direitos e deveres ou compromissos destes, devem estar centrados numa filosofia instituinte de grupos, se possível explicitada em normativas cujos interesses refletem a competitividade construtiva e colaborativa em que todos ganham cooperativamente. o processo gerencial sustenta-se por um planejamento estratégico que assegure o alcance de metas e produtos, respeitando os diferentes integrantes do gp, seus níveis de formação e capacitação, e centra os esforços em potencializá-los para o domínio e liderança em pesquisa, cada um no seu nível de alcance ou de domínio, quer nos aspectos metodológicos quanto de conteúdo teórico-filosófico, aplicação prática ou aderência ao seu campo de atuação. trata-se de um processo gerencial avançado envolvendo a liderança de todos os seus integrantes, coordenação determinada e segura, e forte domínio sobre os aspectos relativos ao empreendedorismo em pesquisa. os gps se estruturam por equipes de pesquisadores sujeitos a uma coordenação e trabalhando alinhados a um ou vários projetos de pesquisa em comum. visto como um sistema de produção de pesquisa e de conhecimento os gps devem merecer planejamento, uma programação e respectivos controles. sua constituição e estrutura assemelham-se a um complexo de relações que produz resultados muitas vezes de forma irregular. seu funcionamento decorre do esforço intelectual que depende de inspiração e disciplina, nem sempre presentes em organizações deste tipo. no entanto, os resultados são esperados e projetados por órgãos de fomento à pesquisa, dirigidos aos programas de pósgraduação, o que deve, por consequência, refletir-se sobre os gps que os suportam. a programação de ações implica o estabelecimento de parâmetros ou de referências sobre o que se quer ou se deve fazer. um gp produz pesquisa e, como tal, esta produção deve ser convertida em produtos definidos e quantificados. portanto, as saídas esperadas são a publicação de artigos em periódicos, participação em eventos, elaboração de novos projetos de pesquisa, preparação de aulas e palestras, dentre outras atividades. a produtividade é, conceitualmente, uma relação entre o que se obtém e o que se investe. orientados por essa premissa, pensou-se relacionar o tempo posto à disposição de um estudante de pós-graduação e o tempo despendido; ao lado disto, evidencia-se a pontuação obtida no sistema qualis da capes. ambos os parâmetros são considerados individual e coletivamente. a formação em nível stricto sensu não é, no entanto, reduzível a parâmetros tão simples. doutores e mestres são pessoas hábeis a formar novos pesquisadores e devem ser capazes de fazer a prospecção de oportunidades, captar, elaborar e gerenciar projetos de pesquisa. e os esforços nessa direção devem ser relevados. a competência didática é outro ponto fundamental de sua formação, o que deve levar ao exercício docente, preparando e dando aulas. outros aspectos complementares também compõem a equação da programação e controle. sugere-se que a programação de atividades seja feita pelo pesquisador coordenador do gp e respectiva carga horária média semanal, considerando: 1) formação de recursos humanos em pesquisa número de créditos x conceito + qualificação no prazo + defesa no prazo; 2) publicações artigos em periódicos x qualis; artigos completos ou resumos em eventos científicos nacionais e internacionais; 3) projetos de pesquisa a órgãos de fomento; 4) preparação de aulas, palestras, seminários, dentre outros; 5) avaliação ou parecer de artigos; 6) participação de bancas de qualificação de mestrado e de doutorado; 7) participação de bancas de defesa de mestrado e de doutorado. é importante estabelecer coletivamente um sistema de controle que leve em consideração as diferentes realidades e, assim, ter-se o ponto de partida para o controle do desempenho do gp com mapa-programa, indicadores coletivos, acompanhamento individual, registros das atividades e respectivos produtos com 97 políticas, gerência e inovação de grupos de pesquisa para a excelência em enfermagem l alacoque lorenzini erdmann y otros indicadores de desempenho que propiciem o alcance de metas e consequente possibilidade de comprovar a excelência do gp. diante desta organização interna do gp, pode-se investir na busca de financiamento e gerência dos recursos financeiros, com espírito empreendedor para a geração de conhecimentos mais relevantes e contributivos para o avanço da ciência, tecnologia e inovação da área da enfermagem e saúde. ainda, é importante considerar o perfil do doutor em enfermagem que precisamos formar para o alcance da excelência e respectivas políticas de formação, conforme documento de área 2009 (triênio 2007-09) – área da enfermagem (8). os gps promovem a formação dos novos pesquisadores em nível de excelência os gps fornecem o suporte necessário de infraestrutura para as atividades de pesquisa dos enfermeiros, graduandos e pósgraduandos, a oportunidade de trabalho integrado e a possibilidade de incremento do potencial em pesquisa. o processo de construção de conhecimentos passa pela possibilidade de dispor de recursos humanos competentes no processo investigativo, no domínio dos diferentes métodos de investigação e das bases teórico-filosóficas que sustentam o saber da enfermagem (3). na formação das novas gerações de pesquisadores no ensino superior, é preciso desenvolver o saber pensar, pois “a universidade precisa garantir que os alunos aprendam a pesquisar e a aprender” (9), e os gps são um lócus privilegiado para que isso aconteça. a participação nos gps contribui para o desenvolvimento e aprimoramento das habilidades a serem desenvolvidas durante o processo de formação profissional no ensino superior, tais como: encontrar as informações necessárias, elaborar sínteses, construir reflexões, relações e aplicá-las em situações diversas de modo criativo (10). entre as atividades acadêmicas que o ensino superior propicia para que o acadêmico desenvolva o seu “espírito científico”, destaca-se a iniciação científica (ic), que se configura como a principal estratégia para formação de novos pesquisadores nos gps. a ic tem como finalidade introduzir o estudante no mundo da pesquisa científica, estimular novos talentos potenciais entre estudantes de graduação e contribuir para reduzir o tempo médio de titulação de mestres e doutores (10). no brasil, os programas de ic das universidades desenvolveram-se no bojo do fortalecimento da pesquisa e da pós-graduação, principalmente a partir dos anos 1980 e 1990, inspirados nos modelos de países que já tinham uma atividade científica institucionalizada, a exemplo dos estados unidos e da frança. o financiamento das atividades de ic está respaldado na lei da reforma universitária de 1968 (art. 2º da lei n. 5.540, de 28/11/1968), que determinou o princípio da “indissociabilidade ensino-pesquisa” como “norma disciplinadora do ensino superior”. mais tarde, essa associação foi incorporada na constituição de 1988 e, consequentemente, na nova lei de diretrizes e bases da educação nacional (lei n. 9.394, de 20/12/1996) (11). uma das principais vantagens da participação em gps para a formação de novos pesquisadores é o contato e a relação com colegas mais experientes e professores/orientadores. os gps são uma instância comum de compartilhamento do que os pesquisadores produzem e sabem com seus alunos, principalmente de pós-graduação. nessa circunstância específica, a do ensino e da orientação, é compartilhado, pois, não somente o conhecimento científico explícito (informação), mas também o conhecimento científico tácito e seus elementos, ou seja, a experiência, os modelos mentais e a vivência do orientador como pesquisador e como professor (12). estudos sobre a experiência de ser bolsista ic destacaram como benefícios uma melhor compreensão das atividades de pesquisa, dos métodos e instrumentos investigativos mediante acompanhamento de todas as etapas dos projetos, inclusive a divulgação dos resultados, ampliando a formação para o mestrado, pelo contato com outras pesquisas e interação com os pesquisadores. além disso, a remuneração da bolsa e flexibilidade de horário possibilitam a dedicação exclusiva dos estudantes às atividades da graduação (13, 14). apesar dessas potencialidades, alguns pontos relacionados à ic requerem reflexão. a bolsa é um incentivo aos alunos que demonstram potencial e vocação acadêmica, no entanto a ic deve ser o projeto básico de formação universitária para todos os alu98 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 nos (13). assim, cabe o questionamento: como as universidades e os gps podem se organizar/estruturar para que todos os estudantes tenham a oportunidade de atuarem ou pelo menos terem experiências semelhantes aos bolsistas ic? alguns aspectos ainda vêm sendo objeto de questionamentos: qual é a dedicação às atividades de pesquisa que os integrantes de um gp deve se comprometer? quais as políticas ou diretrizes curriculares dos programas de pós-graduação com relação à carga horária ou créditos em atividades de pesquisa que um aluno deve cumprir? se a formação em disciplinas teóricas envolve um terço da carga horária de formação de um aluno de pós-graduação stricto sensu, outro um terço deve ser destinado para o aprendizado em atividades de pesquisa e outro um terço para os estudos individuais ou independentes, como equalizar os cronograma de presença e atividades no gp? como essa carga horária deve ser visível e considerada no histórico do aluno? como regular ou normatizar o tempo destinado à participação dos alunos, bem como dos demais integrantes? como efetivar o compromisso de ser um membro integrante e participativo em um gp? como devem ser organizados os projetos de pesquisa dentro do gp: distribuição de competências, responsabilidades, vínculos...? estas e outras questões devem ser objeto da organização das atividades de formação dos novos pesquisadores em nível de excelência. a produção de conhecimento necessita infraestrutura física, financeira e logística considerando os esforços realizados pela área de enfermagem a fim de gerenciar as possibilidades de avanço no campo de conhecimento científico, é de suma importância valorizar aspectos como a infraestrutura necessária para viabilizar as metas almejadas. o processo de construção de conhecimentos passa pela possibilidade de dispor de recursos humanos competentes no processo investigativo, no domínio dos diferentes métodos de investigação e das bases teórico-filosóficas que sustentam o saber da enfermagem (15). os gps caracterizam-se cada vez mais como sendo responsáveis pela infraestrutura que viabilizam as atividades de pesquisa, quer na geração de novos conhecimentos pela contínua geração de novos projetos de pesquisa e sua implementação e orientação de trabalhos finais na formação de recursos humanos, quer nas atividades de ensino ao alimentar ou mesmo ministrar as disciplinas nas temáticas de domínio, e, ainda, promover eventos científicos bem como gerenciar os recursos financeiros dos projetos e bolsas financiadas, dentre outras atividades. nestes grupos, cuja identidade se assegura pelas linhas de pesquisa que dominam, as possibilidades de participação de alunos e profissionais, graduandos e pós-graduandos, enfermeiros docentes e assistenciais para a socialização de conhecimentos oriundos dos trabalhos desenvolvidos de forma integrada se abrem. todos esses fatores são viabilizados segundo a política organizativa fortemente centrada pela atuação, competência ou empenho do pesquisador líder do grupo. destaca-se também que os avanços e conscientização da necessidade de atingir novos patamares em pesquisa na área da enfermagem são viabilizados pela valorização do fomento para viabilização e incremento das pesquisas planejadas. neste contexto, cabe descrever que, para se atingir a excelência e a alta produtividade de um gp, é imprescindível que se tenha estrutura física adequada, amparada por tecnologia de ponta ou avançada ou o mais atualizada possível. além disso, é necessário que se ofereçam condições ambientais favoráveis à produtividade, ao mesmo tempo, com espaços que possibilitam o princípio da mobilidade dos pesquisadores, ou seja, que acolham pesquisadores externos e desloquem pesquisadores internos para interagirem com novas e diferentes tecnologias, com a pluralidade cultural e, em especial, com discussões sobre os novos caminhos para a enfermagem e a saúde no brasil, a partir da conectividade e inserção internacional que um gp de excelência deva constituir. nos estudos de leite (5), os entrevistados ressaltaram também a questão da infraestrutura como uma contrapartida da organização. de uma maneira geral, ao mencionarem infraestrutura, estavam se referindo a laboratórios, salas de reuniões, tecnologias, equipamentos, mais espaço físico e, de maneira não menos importante, infraestrutura humana. o financiamento da pesquisa, quando mencionado pelos entrevistados, não é de responsabilidade das universidades (5). a infraestrutura é uma questão importante no contexto das organizações no sentido de como influenciam a criação e o compartilhamento do conhecimento científico (5). 99 políticas, gerência e inovação de grupos de pesquisa para a excelência em enfermagem l alacoque lorenzini erdmann y otros a produção de conhecimento em gps organizados consolida diferentes modos de produção com diferentes tipos de estrutura, sendo alguns caracterizados como laboratórios mais fechados, de pesquisas clínicas, pesquisa experimental, desenvolvimento de produtos, testes ou experimentos com animais, dentre outros, os quais tendem a associar os laboratórios de pesquisa à pesquisa laboratorial. já os laboratórios mais abertos ou de campo, mais atrelados à pesquisa social com sujeitos inseridos na própria prática do cuidado, viabilizam as ditas pesquisas de campo na prática da enfermagem, o que dá origem a estudos que subsidiam os gps em suas atividades na medida em que seus objetivos são alcançados por aprofundamentos a partir da prática, explorando as subjetividades relacionadas às funções biológicas e intervenções sociais. portanto, são características estas que dependem da natureza do conhecimento e/ou objeto de estudo e processos metodológicos mais utilizados e sua inserção na realidade. o conhecimento se constrói coletivamente os atores da enfermagem vêm lançando novos olhares em sua atuação, diante da necessidade de fortalecer-se enquanto profissão e consolidar-se como ciência do cuidado de enfermagem ao ser humano em sua saúde. dessa forma, busca encontrar maneiras que sustentem e viabilizem esta prerrogativa, sendo a pesquisa essencial para seu avanço. a partir da pesquisa como construção coletiva, cada vez mais presente na prática profissional da enfermagem, seja qual for seu ramo de atuação, aproximam-se as diversas facetas de cuidado, diante da necessidade de criação de novos conhecimentos para a área e o aprimoramento dos saberes já utilizados. a pertinência e a profundidade do conhecimento na área da enfermagem, na sua amplitude e especificidade, é um constante avançar e retroceder entre o próprio/específico, o coletivo/interdisciplinar, as interfaces/aproximações, o que fortalece a identidade/disciplina enfermagem e sustentar novas configurações da prática profissional com possibilidades de novas características e competências profissionais (16). os projetos de pesquisa são estruturas propositivas de produção de conhecimentos por meio do processo investigativo e se viabilizam nos gps. a tendência atual é de produção integrada e em parcerias, e não mais de projetos isolados e realizados apenas um de cada vez. assim, o gp acaba sendo a forma de organização adequada para a realização de atividades coletivas ou compartilhadas de produção de conhecimentos (15). um gp constitui-se de atores com ações distintas e compartilhadas. o pesquisador líder de grupo é o personagem que detém a liderança acadêmica e intelectual naquele ambiente de pesquisa. normalmente, tem a responsabilidade de coordenação e planejamento dos trabalhos de pesquisa do grupo. sua função aglutina os esforços dos demais pesquisadores e aponta horizontes e novas áreas de atuação dos trabalhos. pesquisadores são os membros graduados ou pós-graduados da equipe de pesquisa e criativamente envolvidos com a realização de projetos e com a produção científica, tecnológica e artística do grupo. estagiários pós-doutores são considerados pesquisadores. os estudantes, bolsistas ou não de ic ou de pós-graduação, são os que participam ativamente das linhas de pesquisa desenvolvidas pelo grupo como parte de suas atividades discentes, sob a orientação de pesquisadores do grupo. outros integrantes como técnicos de laboratório no manuseio de equipamentos de experimentos ou bolsistas de apoio técnico, técnicos de informática e controle de banco de dados, estatísticos, tradutores de língua, bibliotecários, dentre outros, podem fazer parte da equipe de pesquisa na medida em que sua função se constitui no envolvimento com o processo de pesquisa e domínio de parte do conteúdo do conhecimento sobre o objeto estudado. a natureza da produção de conhecimentos nos gps centrados em áreas de conhecimentos, linhas de pesquisa, macroprojetos de pesquisa e respectivos projetos ou subprojetos derivados, projetos integrados, projetos em parcerias com projetos de outros gp, com especialistas em diferentes métodos de investigação, diferentes temáticas e campos de saber, constituem-se hoje em uma prática cada vez mais colaborativa, multi, inter e, se possível, transdisciplinar para o avanço da ciência e geração de novas tecnologias e sua aplicação prática ou inovação resultante de impactos imediatos na sociedade. além disso, a formação de equipes multidisciplinares para a realização de estudos colaborativos pode contribuir com a elaboração e publicação de artigos em revistas internacionais com maior impacto e repercussão científica (17). o conhecimento é, hoje, produto de uma construção coletiva, de novas políticas e formas de produção e de novos processos de controle, e que requer diretrizes e gerência com especificida100 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 des de domínio do que é esperado de desempenho de um gp. o planejamento e controle do sistema organizativo de um gp são fundamentais para o seu melhor desempenho. a cultura de produção de conhecimentos compartilhada, dialogada, que convive com diferentes atores e diferentes ações e competências, que utiliza diferentes instrumentos e processos, com gestão multiusuária de espaços/equipamentos/logísticas e normativas bem gerenciadas das atividades, converge para que gps sejam referência de domínio e especialidade de tecnologia de produção de conhecimentos avançados. isso pode propiciar a geração de produtos competitivos nacional e internacionalmente pela alta qualificação, importante e necessária para o trabalho do pesquisador bem como para a formação de pesquisadores altamente qualificados; além de abrir caminho para os intercâmbios e parcerias nacionais e internacionais pela mobilidade acadêmica e possibilidade de captação de recursos financeiros. a construção de conhecimentos coletivamente, integrando pesquisadores do próprio gp e de outros gps que possam congregar esforços para obter conhecimentos diferenciados e de relevância reconhecida, é uma prática de contínuo aprender e ensinar a exercitar este novo modo organizativo de produzir ciência no mundo acadêmico, nas nossas universidades. um gp de excelência deve ser inovador e integrar as tics o uso das tics tem sido uma prioridade em todas as áreas do conhecimento. particularmente, com relação aos gps, para o alcance da excelência, o seu uso se faz necessário tanto no processo de desenvolvimento do conhecimento quanto na produção, disseminação e consumo de informação. existem diferentes níveis de maturidade dentro dos gps para a utilização das tics. e, nesse sentido, entendemos que algumas estratégias são necessárias para que um grupo atinja o seu potencial máximo de produção do conhecimento com o apoio das tics (18, 19). mas qual seriam os resultados e o impacto em se investir nas tics para o alcance da excelência dos gp? inovar a partir das tics nos gps tornou-se também mais orientado ao mercado, está mais rápido, e intenso, mais intimamente ligado ao progresso científico e mais amplamente difundido por meio da economia. como resultado, as estratégias comerciais dos gps também mudaram, pois a gama de tecnologias necessária para a inovação tem se expandido e as tecnologias se tornaram mais complexas (20, 21). estes desenvolvimentos oferecem novas possibilidades para a produção, difusão e organização da informação no sentido de desenvolver parcerias com empresas, outros gps, escolas, indústrias e comunidades, e explorar novas oportunidades de mercado científico e tecnológico. este contexto também aumenta a importância da cooperação entre os participantes do grupo em diferentes campos do saber, a fim de reduzir os custos de incerteza, compartilhar o conhecimento e trazer produtos e serviços inovadores para o mercado (21). as instituições científicas são importantes para a difusão e a inovação da tecnologia. a atividade científica que se desenvolve nos gps é a fonte-chave para o conhecimento básico da inovação e, portanto, estas atividades devem fazer parte dos currículos tanto de graduação quanto de pós-graduação (21). apesar de ainda não termos pesquisas suficientes na área, entende-se ser importante nomear os principais aspectos positivos da aplicabilidade das tics nos gps, bem como apontar os principais desafios que estão por vir. dentre estes aspectos, podemos considerar (21): • a possibilidade de divulgar, armazenar, disseminar e organizar a informação das produções do grupo. nesse sentido, as tics seriam compreendidas como suporte ao desenvolvimento do conhecimento; • o desenvolvimento de sistemas de informação/sistemas de software, objetos de aprendizagem, tecnologias de cuidado e educação. aqui as tics seriam compreendidas como produtoras de conhecimento; • processamento de sinais e controle que realiza pesquisa de alto impacto teórico e algorítmico, o que leva a novos métodos e sistemas em duas áreas fundamentais: controle descentralizado e estimativa para grandes sistemas distribuídos (sistemas de grande escala), e do avanço de uma nova biologia, que é uma convergência de sistemas, sinais e ciências de computação com biomédica e ciências da vida; • imagens por computador, inclusive com estratégias de teleimersão combinando aspectos da realidade virtual com os da 101 políticas, gerência e inovação de grupos de pesquisa para a excelência em enfermagem l alacoque lorenzini erdmann y otros videoconferência. as principais abordagens estão explorando a geometria com visão múltipla, pesquisando novas técnicas, tais como otimização de gráfico na segmentação, técnicas de aprendizado de máquina para detectar e reconhecer objetos de interesse, bem como técnicas de reconhecimento estatístico de padrões para compreender as imagens e vídeos; • aprendizagem com suporte computacional está focada em algoritmos e tecnologias, desenvolve tecnologias que interpretam e dão sentido a dados em aplicações que abrangem a recuperação da informação, mineração de dados, interação humano-computador e processamento de linguagem computacional natural em qualquer momento e lugar; • a otimização visa proporcionar uma nova geração de sistemas de otimização para tomada de decisão em ambientes intensivo de dados e dinâmicos. os focos da pesquisa são o planejamento e o controle de complexos cybersistemas físicos, que incluem redes inteligentes, logística humanitária, cadeias multimodais de abastecimento, bem como a compreensão e a regulação de grandes sistemas biológicos e sociais. tópicos de pesquisa fundamentais incluem modelagem, hibridação, não linear de otimização, confiabilidade e escalabilidade, diagnóstico, previsão e simulação, escolha social computacional e computação pervasiva; • as redes visam melhorar a qualidade e a experiência dos usuários que acessam as informações e os serviços em ambientes de geração atual e futura da rede. o gp desenvolve novas teorias, modelos e métodos para maximizar o uso da infraestrutura disponível e fornecer a funcionalidade fundamental para novos serviços e aplicações também utilizando os recursos das telecomunicações. dessa forma, para que um gp com o suporte das tics e com o compromisso de desenvolvimento de novos atinja seus níveis de excelência, deve contar com a motivação positiva de seus integrantes para o contínuo aprendizado de forma engajada, com o desenvolvimento de pesquisas, divulgação dos resultados dos estudos e, sobretudo, comprometidos com o avanço do conhecimento para a sociedade. considerações finais para a formação de um grupo de pesquisa que idealize a excelência, é imprescindível que este se organize em torno de uma liderança exponencial com perfil organizativo e empreendedor, e que esta seja vinculada a uma instituição reconhecida pela indissociabilidade dos pilares universitários, ou seja, qualificada no ensino, na pesquisa e na extensão. o caminho para o desenvolvimento e consolidação de um gp de excelência, perpassa pelo contínuo e ascendente fortalecimento da produtividade qualificada dos pesquisadores; estes, por sua vez, são responsáveis pela materialização das bases fomentadoras científicas, por meio da construção de novos conhecimentos, mudanças paradigmáticas, indagações ao estado da arte e críticas difusas e/ou focais aos tradicionais e aos novos saberes. nesta perspectiva, para que um gp se consolide aproximandose da excelência e que seja altamente produtivo, alguns princípios fundamentais básicos devem ser seguidos como fios condutores de um grupo. dentre eles, constituir o grupo com pesquisadores comprometidos com produções qualificadas, as quais sirvam de alicerce para demais estudos. além disso, é fundamental que a constituição de um grupo seja organizativa e que transforme recurso humano e físico em produção qualificada, sustentada sempre pelo rigor científico. neste contexto, cabe colocar que, para se atingir a excelência e a alta produtividade de um grupo de pesquisa, são imprescindíveis que se tenham estrutura física de excelente qualidade, amparada por tecnologia avançada ou de ponta, e condições ambientais favoráveis à produtividade, ao mesmo tempo, com espaços que possibilitam o princípio da mobilidade dos pesquisadores. assim, destacamos como principais pressupostos que um gp de excelência deve estar alicerçado em políticas bem definidas e com um processo gerencial competente; promover a formação dos novos pesquisadores altamente qualificados, com o aprofundamento teórico e domínio da prática do seu campo de saber; produzir conhecimentos avançados com infraestrutura física, pessoal, financeira, política, organizativa e logística adequadas; finalmente, levar em consideração que a prática da produção de conhecimentos envolve um maior número de participantes num processo coletivo, dinâmico, contínuo e complementar. a necessidade de criação de novos gps na enfermagem é contínua e vital para alavancar cada vez mais a produção científica da área. o grande desafio é organizar e consolidar grupos de excelência altamente produtivos, envolvidos e comprometidos 102 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 referências 1. ministério da ciência, tecnologia e inovação (brasil). conselho nacional de desenvolvimento científico e tecnológico. diretório dos grupos de pesquisa no brasil. [serial online]. brasília, ministério da ciência, tecnologia e inovação; 2012 [atualizada em 16 de janeiro de 2012]. disponível em: http://dgp.cnpq.br/diretorioc/html/infogeral/index.html 2. ministério da ciência, tecnologia e inovação (brasil). conselho nacional de desenvolvimento científico e tecnológico. súmula estatística. [homepage na internet]. brasília, ministério da ciência, tecnologia e inovação; 2012 [atualizada em 16 de janeiro de 2012]. disponível em: http://dgp.cnpq.br/censos/sumula_estatistica/2010/grupos/index_grupo.htm 3. erdmann al, lanzoni gmm. características dos grupos de pesquisa da enfermagem brasileira certificados pelo cnpq de 2005 a 2007. esc anna nery rev enferm 2008; 12 (2): 316-22. 4. asner-self k. research on groups: writing your quantitative study so that jsgw will publish it; researchers, academics, and practitioners will use it; everyone will benefit; and good quality groups will proliferate. journal for specialists in group work 2009; 34(3): 195-201. 5. leite fcl, costa sms. gestão do conhecimento científico: proposta de um modelo conceitual com base em processos de comunicação científica. ci. inf. 2007; 36 (1): 92-107. 6. vergara sc. métodos de pesquisa em administração. 3ª ed. são paulo: atlas; 2008. 7. alvesson m, sköldberg k. reflexive methodology: new vistas for qualitative research. 2ª ed. london: sage publications; 2009. 8. ministério da educação (brasil). capes. avaliação. documento de área. [serial online] brasília, ministério da educação; 2012 [atualizada em 22 de abril de 2012]. disponível em: http://www.capes.gov.br/avaliacao/documentos-dearea-/3270 9. demo p. política científica e educacional na universidade. educação 2002; 25 (47): 07-21. 10. giordani em, henriques cm. oficinas de aquisição de habilidades básicas em pesquisa: alternativa à formação das novas gerações de pesquisadores. revista virtual p@rtes [serial online] 2009 nov. disponível em: www.partes.com.br/ educacao/oficinasdeaquisicao.asp. [acesso em 12 abril 2012] 11. massi l, linhares sq. estudos sobre iniciação científica no brasil: uma revisão. cadernos de pesquisa 2010; 40(139): 173-97. 12. leite fcl. o conhecimento científico tácito na dinâmica da pesquisa: alguns indícios. datagramazero 2007; 8 (3): 1-34. 13. gasque kcgd. o pensamento reflexivo na busca e no uso da informação na comunicação científica [tese]. brasília: universidade de brasília; 2008. 14. erdmann al, leite jl, nascimento kc, lanzoni gmm. vislumbrando o significado da iniciação científica a partir do graduando de enfermagem. esc. anna nery 2010; 14(1): 1-2. 15. erdmann al, lanzoni gmm. características dos grupos de pesquisa da enfermagem brasileira certificados pelo cnpq de 2005 a 2007. esc. anna nery 2008; 12(2): 316-22. 16. erdmann al. a necessidade de atingirmos novos patamares na pesquisa de enfermagem. acta paul enferm 2009; 22 (2): v-vi. com a qualidade na construção de novos saberes e tecnologias na consolidação da enfermagem como ciência. em suma: um gp deve produzir conhecimentos relevantes, ter alta produtividade com publicações altamente qualificadas, produzir impacto pela aplicação do conhecimento produzido, manter uma gerência atuante e empreendedora de novas tecnologias de investigação e do aprender a ser pesquisador para formar recursos humanos de excelência em pesquisa. 103 políticas, gerência e inovação de grupos de pesquisa para a excelência em enfermagem l alacoque lorenzini erdmann y otros 17. fernández-sola c, granero-molina j, hernández-padilla j, aguilera-manrique g. factor de impacto de revistas: ¿amenaza u oportunidad? aquichan 2011; 11 (3): 245-55. 18. eudaly k, schafer m, jessup s boyd j, glischinksi s, mcbridge a. (2009). the complete book of north american railroading. minneapolis: voyageur press; 2009. 19. o’sullivan d. framework for managing development in the networked organisations. journal of computers in industry 2002; 47 (1): 77-88. 20. chalkidou k, tunis s, lopert r, rochaix l, sawicki pt, nasser m, et ál. comparative effectiveness research and evidence-based health policy: experience from four countries. the milbank quarterly 2009; 87(2): 339-67. 21. siltala r. innovativity and cooperative learning in business life and teaching [dissertação]. turku: university of turku; 2010. 537 548 calidad de vida de adultos mayores.indd 537 estela melguizo-herrera1 sandra ayala-medrano2 maolis grau-coneo3 alexandra merchán-duitama4 tatiana montes-hernández5 catherine payares-martínez6 tatyana reyes-villadiego7 calidad de vida de adultos mayores en centros de protección social en cartagena (colombia) 1 doctora en enfermería. profesora titular, universidad de cartagena (colombia). esmelguizo@hotmail.com 2 enfermera, facultad de enfermería, universidad de cartagena (colombia). sanya301@hotmail.com 3 enfermera, facultad de enfermería, universidad de cartagena (colombia). magracoenf@hotmail.com 4 enfermera, facultad de enfermería, universidad de cartagena (colombia). merchanduit_88@hotmail.com 5 enfermera, facultad de enfermería, universidad de cartagena (colombia). tatypooh1@hotmail.com 6 enfermera, facultad de enfermería, universidad de cartagena (colombia). florecita2005_02@hotmail.com 7 enfermera, facultad de enfermería, universidad de cartagena (colombia). tatto_mh@hotmail.com recibido: 08 de noviembre de 2012 enviado a pares: 17 de enero de 2013 aceptado por pares: 21 de marzo de 2014 aprobado: 28 de marzo de 2014 doi: 10.5294/aqui.2014.14.4.8 para citar este artículo / to reference this article / para citar este artigo melguizo-herrera e, ayala-medrano s, grau-coneo m, merchán-duitama a, montes-hernández t, payares-martínez c, reyes-villadiego t. calidad de vida de adultos mayores en centros de protección social en cartagena (colombia). aquichan. 2014;14(3): 537-548. doi: 10.5294/aqui.2014.14.4.8 resumen objetivo: describir la calidad de vida relacionada con la salud de los adultos mayores residentes en centros de protección social en cartagena (colombia). materiales y métodos: estudio descriptivo. la población fueron 187 adultos mayores residentes en centros de protección social en cartagena. se aplicó el test de valoración mental (pfeiffer), una encuesta sociodemográfica y el “índice multicultural de calidad de vida”. se mantuvo la confidencialidad de la información, el anonimato de los participantes y se diligenció el consentimiento informado. resultados: el promedio de edad fue de 75 años (95 %), predominó el estado civil soltero (57,6 %), nivel educativo primaria (45,5 %), recibir medicamentos (80,3 %), realizar actividades físicas (54,5 %) y no realizar actividades productivas (37,9 %). la autopercepción de la calidad de vida relacionada con salud tiende a valores que pueden considerarse como buenos (7,6 %). conclusiones: las dimensiones que presentaron puntajes más altos fueron la plenitud espiritual y el autocuidado, y con menor puntaje el bienestar físico y el apoyo comunitario. esta información será útil para proponer políticas de salud y prácticas de cuidado para esta población. palabras clave calidad de vida, salud, adulto mayor. (fuente: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 537-548 538 aquichan issn 1657-5997 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 537-548 quality of life of senior citizens at social welfare centers in cartagena (colombia) abstract objective: describe the quality of life related to the health of senior residents at social welfare centers in cartagena (colombia). materials and methods: this is a descriptive study. the population was comprised of 187 seniors living at welfare centers in cartagena. the mental status test (pfeiffer), a socio-demographic survey and the multicultural quality of life index were applied. confidentiality of information was maintained, the participants remained anonymous, and informed consent was given. results: the mean age was 75 (95%). most of the participants are single (57.6%). some have a primary education (45.5%), are receiving medication (80.3%), engage in physical activity (54.5%) and carry out non-productive activities (37.9%). the self-perception of quality of life related to health tends towards values that can be considered good (7.6%). conclusions: the aspects with the highest scores were spiritual fulfillment and self-care; the lowest scores pertained to physical well-being and community support. the information will be useful to propose health care policies and practices for this segment of the population. key words quality of life, health, senior citizens. (source: decs, bireme). 539 calidad de vida de adultos mayores en centros de protección social en cartagena (colombia) l estela melguizo-herrera y otros qualidade de vida de idosos em centros de proteção social em cartagena (colombia) resumo objetivo: descrever a qualidade de vida relacionada com a saúde dos idosos residentes em centros de proteção social em cartagena (colômbia). materiais e métodos: estudo descritivo. a população foi constituída por 187 idosos residentes em centros de proteção social em cartagena. aplicou-se o teste de valorização mental (pfeiffer[rd1] ), uma enquete sociodemográfica, e o “índice multicultural de qualidade de vida”. manteve-se a confidencialidade da informação, o anonimato dos participantes e diligenciou-se o consentimento informado. resultados: a média de idade foi de 75 anos (95 %), predominou o estado civil solteiro (57,6 %), nível educativo primário (45,5 %), receber medicamentos (80,3 %), realizar atividades físicas (54,5 %) e não realizar atividades produtivas (37,9 %). a autopercepção da qualidade de vida relacionada com saúde tende a valores que podem ser considerados bons (7,6 %). conclusões: as dimensões que apresentaram pontuações mais altas foram a plenitude espiritual e o autocuidado, e com menor pontuação o bem-estar físico e o apoio comunitário. esta informação será útil para propor políticas de saúde e práticas de cuidado para esta população. palavras-chave qualidade de vida, saúde, idoso. (fonte: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 537-548 540 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 introducción la calidad de vida relacionada con la salud (cvrs) es “la percepción subjetiva influenciada por el estado de salud actual de la capacidad para realizar aquellas actividades importantes para el individuo” (1), la cual puede estar influenciada por factores objetivos o subjetivos y puede ser un indicador que complemente los índices de esperanza de vida y de uso de los servicios de salud de los adultos mayores. en este estudio, el adulto mayor es considerado como “aquella persona que cuenta con sesenta años o más” (2), según lo estipulado por la reglamentación vigente en el país. los aspectos objetivos que influencian la cvrs dependen del individuo (utilización y aprovechamiento de sus potenciales: intelectual, emocional y creador) y de las circunstancias externas (estructura socioeconómica, sociopsicológica, cultural y política) que interactúan con él. los aspectos subjetivos están dados por la satisfacción del individuo, el grado de realización de las aspiraciones personales y la percepción que se tenga de las condiciones globales de vida, lo que se traduce en sentimientos positivos o negativos (3). si se tiene en cuenta que la cvrs es un concepto individual y que de esta misma individualidad depende un envejecimiento exitoso, se podría afirmar que esta condición estará influenciada por aquellos factores con los que cuenta el adulto mayor a su alrededor, como por ejemplo: situaciones familiares, condiciones de salud, circunstancias económicas, entre otros. todos estos factores hacen parte de los cambios que presentan los adultos mayores quienes a su vez atraviesan por un proceso de deterioro en sus múltiples esferas, afectando de esta manera su cvrs. los adultos mayores son considerados un grupo en condición de vulnerabilidad debido al declive físico, psicológico y social que acompaña esta etapa de la vida, el cual es más evidente en aquellos que residen en centros de protección social. en colombia, los centros de protección social para el adulto mayor son “instituciones de protección destinadas al ofrecimiento de servicios de hospedaje, de bienestar social y cuidado integral de manera permanente o temporal a adultos mayores” (4). aunque algunos piensen que los centros de protección social son lugares de soledad y abandono, en realidad son sitios donde se favorece el contacto y las relaciones sociales. allí, los adultos mayores pueden desarrollar nuevas habilidades y destrezas físicas y sociales, y compartir con gente de su misma edad. para este estudio se tuvieron en cuenta los resultados de investigaciones (5) sobre la cvrs de los adultos mayores de la comuna 9 de cartagena y los factores asociados, reportando valores que pueden considerarse como una buena autopercepción y donde se resaltan el autocuidado, la plenitud espiritual y el funcionamiento interpersonal como las dimensiones de más alta puntuación. los factores sociodemográficos que se asociaron a la cvrs fueron el sexo, nivel de escolaridad, el estrato socioeconómico, la condición laboral y el número de personas en el hogar, siendo la condición laboral la que se asoció a mayor número de dimensiones. por otra parte, de acuerdo con los hallazgos de un estudio cualitativo realizado por vera (6), la cv para los adultos mayores “significa tener paz y tranquilidad, ser cuidado y protegido por la familia con dignidad, amor y respeto, y tener satisfechas como ser social sus necesidades de libre expresión, decisión, comunicación e información”. peterson (7) afirma que “la cvrs tiene que ver con la representación en la vida de los sentimientos, actitudes o la habilidad de experimentar satisfacción en un área de la vida que ha sido afectada por el proceso de una enfermedad o déficit de la salud”. según este autor, la cvrs se relaciona con aspectos físicos, psicológicos, socioeconómicos y espirituales, y resulta de una combinación de factores objetivos y subjetivos que interactúan con el individuo. entre los factores que afectan a la calidad de vida de los adultos mayores residentes en centros de protección social, en estudios realizados internacionalmente se encontró el estado civil, las actividades de la vida diaria y el empoderamiento de la atención percibida (8); tener hábitos de ejercicio físico, sentir satisfacción de vivir en el centro de protección social (9); cambios en el medioambiente físico (10), y estar en algún centro de protección social (11). en colombia, la calidad de vida de la población en general ha mejorado, según las conclusiones de estudios realizados en el país en los años 1997, 2003, 2008 y 2010, basados en la percepción de cada colombiano sobre su calidad de vida en condiciones de pobreza y desigualdad. dicho estudio mostró que cada vez son menos los colombianos que sienten que viven en condiciones de pobreza debido a que fueron muchos los que tuvieron acceso a bienes y servicios que consideran fundamentales (12). 541 calidad de vida de adultos mayores en centros de protección social en cartagena (colombia) l estela melguizo-herrera y otros estos estudios son alentadores en cuanto a la situación económica y se realizaron evaluando la parte subjetiva y objetiva, aunque el enfoque fue mucho más objetivo ya que se evaluó la capacidad de adquisición de elementos que satisfacen necesidades básicas, lo que animó a realizar el presente estudio para aproximarse a la subjetividad de la calidad de vida relacionada con salud de adultos mayores residentes en centros de protección social en cartagena. las definiciones de cvrs citadas dan cuenta de que este es un concepto dinámico que puede ser abordado desde lo subjetivo o lo objetivo, y es producto de una construcción social. las investigaciones citadas evidencian que la cvrs en adultos mayores residentes en centros de protección social tiende a variar según factores sociodemográficos, personales y del entorno, lo cual muestra la complejidad del fenómeno y la necesidad de abordarlo desde la investigación científica para favorecer su comprensión y así poder mejorar la cvrs de esta población. actualmente no se han encontrado estudios sobre cvrs de adultos mayores residentes en centros de protección social en colombia, lo cual evidencia un vacío en el conocimiento de esta población, que podría estar generando una atención en salud no acorde con las percepciones reales de los adultos mayores. el objetivo de este estudio fue describir la calidad de vida relacionada con salud de los adultos mayores residentes en centros de protección social en cartagena, considerando las dimensiones que la conforman y según características como la edad, el sexo, realización de actividades físicas y participación en actividades productivas. materiales y métodos se realizó un estudio con enfoque cuantitativo, de tipo descriptivo. la población y muestra del estudio estuvo conformada por todos los adultos mayores residentes en centros de protección social de la ciudad de cartagena, los cuales correspondieron a 187, según informe de la secretaría de participación y desarrollo social de cartagena. para participar en el estudio se tuvo en cuenta ser adulto mayor (de 60 años y más), residir en un centro de protección social, manifestar el deseo de participar y presentar dos o menos errores (valoración normal) en el test de valoración mental (pfeiffer) teniendo en cuenta el nivel educativo de los participantes. fueron excluidos 121 (64,7 %) adultos mayores de acuerdo con el resultado del test de valoración mental (pfeiffer). las investigadoras se encargaron de recolectar la información. las visitas se programaron teniendo en cuenta la disponibilidad de las investigadoras y de los adultos mayores residentes en los centros de protección social, durante los meses de marzo y abril de 2011. se obtuvo el listado de los adultos mayores pertenecientes a cada centro con el fin de llevar un control de la población. una vez que cada participante manifestó querer colaborar con en el estudio, se le solicitó firmar el consentimiento informado explicándole el objetivo de la encuesta. luego, a los adultos mayores que obtuvieron una puntuación normal en el test de valoración mental (pfeiffer) se les aplicó una encuesta sociodemográfica y personal. la información sociodemográfica contenía los datos de identificación, edad, sexo, estado civil, recursos económicos y nivel educativo. los datos personales indagaban sobre si recibían o no medicamentos, qué patologías padecían (las cuales fueron confirmadas con los cuidadores de los diferentes centros) y si participaban en actividades físicas y productivas. por último, se les aplicó el instrumento índice multicultural de calidad de vida (13), el cual mide la percepción de la cvrs en relación con las dimensiones de: bienestar físico, bienestar psicológico/emocional, autocuidado y funcionamiento independiente, funcionamiento ocupacional, funcionamiento interpersonal, apoyo social-emocional, apoyo comunitario y de servicios, plenitud personal, plenitud espiritual y percepción global de calidad de vida. para el diligenciamiento de este instrumento se solicitó a cada participante que indicara, según su nivel de salud actual, cuál era su percepción de calidad de vida marcando con una x uno de los diez puntos que aparecían en las escalas del instrumento (un valor de 10 era “excelente” y un valor de 1 equivalía a “mala”). es decir, la percepción de cada dimensión de la cvrs se valoró desde la percepción del nivel de salud que tenía cada participante. la escala ha sido validada en español, inglés, chino, coreano y portugués. ha sido aplicada en perú (14), argentina (15, 16) y cartagena, colombia (5, 17). estos estudios permitieron concluir que esta es una escala confiable, que posee buena consistencia interna (0,753), que es capaz de discriminar grupos en los que se presumen diferentes niveles de cvrs y, además, es de fácil aplicación. 542 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 dado que el autor del instrumento índice multicultural de calidad de vida no propone un punto de corte para categorizar el nivel de cvrs, las investigadoras establecieron para este estudio los siguientes valores, ya que consideraron que tres categorías de valoración permitirían evidenciar mejor el comportamiento del fenómeno de estudio: de 1 a 3 puntos corresponde a mala percepción de la cvrs; de 4 a 6 puntos corresponde a regular percepción de la cvrs; de 7 a 10 puntos corresponde a buena percepción de la cvrs. se consideraron los promedios del total de participantes y luego el promedio de cada centro por separado. de acuerdo con el parágrafo “a” del artículo 11 de la resolución 08430 del 4 de octubre 1993 del ministerio de salud pública de colombia, esta fue una “investigación sin riesgo” debido a que “no se plasma ninguna intervención o modificación intencionada de las variables biológicas, fisiológicas, psicológicas o sociales de los individuos que participaron en el estudio”, debido a que los instrumentos que se utilizaron son cuestionarios (18). en este estudio se mantuvo la privacidad y el anonimato de los participantes y se diligenció el consentimiento informado según lo establecido en los artículos 6, 15 y 16 de la resolución 08430 del 4 de octubre 1993 del ministerio de salud pública de colombia (18). también se consideraron los aspectos éticos contemplados en la declaración de helsinki (19) y en el código de ética de enfermería de colombia (ley 911 de 2004 del congreso de colombia) (20) evidenciados en la protección de la vida, la salud, la dignidad, la integridad, el derecho a la autodeterminación, la intimidad y la confidencialidad de la información de las personas que participaron en esta investigación, los cuales fueron considerados en el consentimiento informado. análisis de los datos: el software spss 17.0r permitió elaborar gráficos y figuras que facilitaron la descripción de los datos. se estimaron las medidas de tendencia central, estadísticos de dispersión y estadísticos de posición. resultados participaron 66 adultos mayores. el alfa de cronbach calculado para el instrumento en la presente investigación fue de 0,875. los adultos mayores que participaron en este estudio se caracterizaron por tener una edad promedio de 75 años (ic 95 %: 73,6-77,8): 38 (57,6 %) eran solteros; 30 (45,5 %) habían cursado estudios de primaria; 53 (80,3 %) recibían medicamentos; 36 (54,5 %) realizaban actividades físicas, y 41 (62,1 %) realizaban actividades productivas. en cuanto a las enfermedades que padecen los adultos mayores, la que obtuvo el mayor puntaje fue la hipertensión arterial con un 37,1 %, seguida de los problemas visuales con un 34 %. respecto a la percepción de calidad de vida relacionada con salud de los adultos mayores el mayor puntaje lo obtuvo la dimensión plenitud espiritual con un promedio de 9,0; seguido del autocuidado con un promedio de 8,2. las dimensiones con menor puntaje fueron el bienestar físico y el apoyo comunitario, con un promedio de 7,1 respectivamente (tabla 1). la tabla 2 ilustra sobre la percepción de calidad de vida relacionada con salud en los adultos mayores según el centro de protección social en que residen. los adultos mayores que evidenciaron mayores puntajes fueron los residentes de una mano amiga, con un promedio de 8,1, seguido de san pedro claver con un promedio de 8,0; los que obtuvieron una percepción más baja de cvrs fueron los residentes en dones de la misericordia con un promedio de 6,9, seguido de san josé con un promedio de 7,1. en la tabla 3 se aprecia que tanto hombres como mujeres destacan en cuanto a las puntuaciones obtenidas en su plenitud espiritual. sin embargo, difieren en que el puntaje más bajo lo reportaron los hombres en la dimensión de bienestar físico, mientras que las mujeres reportaron el menor promedio en la dimensión de apoyo comunitario. las dimensiones en que se presentó mayor diferencia entre hombres y mujeres fueron la plenitud personal y el bienestar psicológico/emocional, donde los hombres alcanzaron puntuaciones mayores que las mujeres. según la participación o no en actividades físicas llama la atención que la plenitud espiritual sigue siendo la dimensión en que los adultos mayores reportan mayores promedios. el apoyo comunitario fue la dimensión en que reportaron menor promedio aquellos que no participaban de actividades físicas programadas en los centros. es notorio que la dimensión de bienestar físico fue la que obtuvo menor promedio entre quienes sí participaban en actividades físicas (tabla 4). 543 calidad de vida de adultos mayores en centros de protección social en cartagena (colombia) l estela melguizo-herrera y otros tabla 1. promedio de las dimensiones de la calidad de vida relacionada con la salud de los participantes del estudio, cartagena, 2011 tabla 2. promedios de las dimensiones de calidad de vida relacionadas con la salud según centros de protección, cartagena, 2011 dimensiones promedio intervalo de confianza 95 % coeficiente de variación (%)lim inf lim sup bienestar físico 7,1 6,5 7,7 8,2 bienestar psicológico/emocional 7,7 7,2 8,2 7,1 autocuidado y funcionamiento independiente 8,2 7,8 8,7 5,8 funcionamiento ocupacional 7,7 7,2 8,3 7,4 funcionamiento interpersonal 7,5 6,8 8,1 8,5 apoyo social emocional 7,8 7,3 8,4 7,4 apoyo comunitario 7,1 6,4 7,8 9,7 plenitud personal 7,5 7,0 8,1 7,2 plenitud espiritual 9,0 8,6 9,4 4,7 percepción global de calidad de vida 8,0 7,5 8,6 6,5 fuente: encuestas aplicadas 2011. dimensiones la milagrosa dones de la misericordia san josé san pedro claver una mano amiga bienestar físico 7,2 7,5 6,7 7,1 7,5 bienestar psicológico/emocional 7,5 6,0 7,0 8,1 9,2 autocuidado y funcionamiento independiente 8,7 7,0 7,8 8,6 7,0 funcionamiento ocupacional 7,8 7,5 6,9 8,4 6,7 funcionamiento interpersonal 7,5 6,3 7,2 7,6 8,3 apoyo social emocional 8,6 6,5 7,1 8,0 7,5 apoyo comunitario y de servicio 7,9 5,3 5,8 7,3 7,7 plenitud personal 7,4 7,8 6,5 7,8 8,8 plenitud espiritual 8,8 8,3 8,5 9,4 9,3 percepción global calidad de vida 7,7 7,3 7,7 8,2 9,7 promedio total 7,9 6,9 7,1 8,0 8,1 fuente: encuestas aplicadas, 2011. 544 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 tabla 3. promedios de las dimensiones de calidad de vida relacionada con la salud según sexo, 2011 tabla 4. promedios de las dimensiones de calidad de vida relacionada con la salud según la realización de actividades físicas, 2011 dimensiones sexo femenino masculino bienestar físico 7,2 7,1 bienestar psicológico/emocional 7,2 8,1 autocuidado y funcionamiento independiente 8,0 8,4 funcionamiento ocupacional 7,4 8,0 funcionamiento interpersonal 7,0 7,8 apoyo social emocional 8,3 7,6 apoyo comunitario 6,8 7,3 plenitud personal 6,9 8,0 plenitud espiritual 8,7 9,2 percepción global calidad de vida 7,6 8,3 fuente: encuestas aplicadas, 2011. dimensiones realiza actividades físicas no sí bienestar físico 7,1 7,1 bienestar psicológico/emocional 8,0 7,4 autocuidado y funcionamiento independiente 7,9 8,5 funcionamiento ocupacional 7,4 8,1 funcionamiento interpersonal 7,3 7,6 apoyo social emocional 7,4 8,2 apoyo comunitario 6,8 7,3 plenitud personal 7,8 7,3 plenitud espiritual 9,4 8,7 percepción global calidad de vida 8,5 7,7 fuente: encuestas aplicadas, 2011. 545 calidad de vida de adultos mayores en centros de protección social en cartagena (colombia) l estela melguizo-herrera y otros discusión los adultos mayores que participaron en este estudio mostraron una buena percepción de su cvrs, lo que se reflejó principalmente en la plenitud espiritual, el autocuidado, el funcionamiento independiente y la percepción global de la calidad de vida. fue preocupante el bajo porcentaje de la población que pudo participar en esta investigación, luego de la aplicación del test de valoración mental. si bien es cierto que los adultos mayores internados presentan mayor declive de sus facultades físicas, mentales y limitaciones para su autocuidado, las investigadoras pudieron observar que muchos no aprobaron el test porque estaban desorientados en tiempo, lugar o en hechos cotidianos (como el nombre del presidente actual, nombre del presidente anterior y la dirección de residencia o el número de teléfono), pero eran capaces de realizar trabajo matemático seriado, recordar datos personales y ocuparse diariamente de su autocuidado. la anterior situación motivó a que el grupo de investigación “cuidado y vida”, de la facultad de enfermería de la universidad de cartagena, proyectara otras investigaciones sobre el funcionamiento cognitivo de esta población y su oportuna y apropiada estimulación. en cuanto a los altos promedios obtenidos en la dimensión de plenitud espiritual, se observa que son similares a los encontrados en la comuna 9 de la ciudad de cartagena (5), que muestra puntuaciones altas de dicha dimensión. a este respecto, algunos estudios señalan la dimensión espiritual de los adultos mayores como un recurso positivo para el cuidado de su salud (21-24) y para mejorar la calidad de vida (25). aunque otros estudios evidencian que los adultos mayores parecen no beneficiarse de su vida espiritual (26). dado que la plenitud espiritual es la dimensión con mayor promedio, podría ser un valioso recurso dentro del cuidado de la salud de los adultos mayores, dado que las prácticas religiosas o espirituales suelen ser económicas, están disponibles las 24 horas del día, favorecen la socialización y gozan de aceptación por parte de los adultos mayores. no obstante, hace falta evidencia científica al respecto. el autocuidado y el funcionamiento independiente fue otra dimensión que mostró promedios altos en la percepción de la cvrs, lo que concuerda con el estudio de murakami (27) realizado en brasil, el cual indica que a medida que aumenta la independencia funcional mejora la calidad de vida. los resultados anteriores están en concordancia con lo encontrado en el estudio de lobo (28), realizado en portugal, quien concluye que la calidad de vida de ancianos institucionalizados parece estar asociada a sus niveles de dependencia, estado mental y funcionalidad. de igual forma, el estudio realizado en rio de janeiro por ali cader (11) parece evidenciar que, una vez ingresan centros de protección social, los adultos mayores se vuelven más dependientes “repercutiendo en peor calidad de vida”. por otra parte, el estudio realizado por emel (9), en turquía, mostró que los adultos mayores residentes en centros de protección, que realizaban actividades de la vida diaria (bañarse, vestirse, usar el retrete, trasladarse, tener continencia y alimentarse) tenían mayor probabilidad de mostrar mejor autopercepción de calidad de vida relacionada con salud. aunque en el presente estudio no se midió la capacidad de realizar actividades de la vida diaria (funcionalidad), ni se analizó la relación de esta con la percepción de la cvrs, parece ser que las variables se comportan de forma similar a los otros estudios. favorecer el autocuidado y la autonomía de la población adulta mayor institucionalizada podría ser una labor liderada por enfermería, que cuenta con teorías y modelos que contemplan los distintos tipos de apoyo que se puede ofrecer según las condiciones específicas de cada persona. los hallazgos del presente estudio en relación con la dimensión del bienestar psicológico/emocional sugieren que los adultos mayores poseen una buena percepción de esta. a este respecto, un estudio realizado por torvik (29) en noruega mostró la relación negativa entre el dolor y el estado de ánimo, visto este último como una dimensión de la calidad de vida. esto invita a continuar profundizando sobre los factores asociados a la calidad de vida de los adultos mayores residentes en centros de protección social, y a tener en cuenta condiciones frecuentes en esta edad como son la presencia de dolor o de otras enfermedades. la dimensión de apoyo social obtuvo una puntuación que puede considerarse como una buena autopercepción por parte de los adultos mayores. el apoyo social, como dimensión de la calidad de vida, se encontró asociado positivamente al cuidado que recibían 546 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 los adultos mayores institucionalizados en noruega, según el estudio realizado por drageset (30). este hallazgo es llamativo, pues generalmente se piensa que los centros de protección social son lugares de soledad y abandono, como se había afirmado. el funcionamiento ocupacional de los adultos mayores sugiere una buena puntuación, es decir, tienen la capacidad de realizar tareas cotidianas, lo cual difiere de los resultados planteados en un estudio realizado en taiwan por yu-ching (8), que reflejó puntuaciones bajas ya que son incapaces de realizar actividades por sí mismos. en este mismo estudio se evidencia que los adultos mayores residentes en centros de protección social poseen un nivel medio en cuanto a la percepción de la calidad de vida. los participantes del presente estudio poseen una buena percepción general de esta dimensión. no se encontraron estudios que permitieran discutir los resultados de las dimensiones bienestar físico, funcionamiento interpersonal, apoyo comunitario y de servicios, plenitud personal y percepción global de la calidad de vida. así mismo, no se encontraron estudios para discutir los hallazgos referentes a cvrs según sexo y participación en actividades físicas. en general, todas las dimensiones evaluadas obtuvieron buenos resultados, lo que quizá indica una buena percepción de la cvrs de los adultos mayores que participaron en este estudio, a pesar de ser una población con bajo nivel de escolaridad, donde sus ingresos económicos son casi nulos. una limitante de este estudio fue que solo el 35,29 % de la población pudo participar debido a los resultados obtenidos en el test de valoración mental (pfeiffer), por tanto, las conclusiones son limitadas. otra restricción fue que se analizó la percepción de cvrs, pero no así la situación de salud de los participantes. se debe seguir investigando al respecto, ojalá con muestras representativas. conclusiones los participantes de este estudio presentaron valores que pueden considerarse como una buena percepción, resaltando la plenitud espiritual, el autocuidado, el funcionamiento independiente y la percepción global de calidad de vida. entre los adultos mayores de este estudio predominó el sexo masculino, estado civil soltero, nivel educativo primaria, sin recursos económicos, el consumir medicamentos, realizar actividades físicas y no realizar actividades productivas. de las dimensiones medidas en el estudio, las que arrojaron menor puntuación fueron el apoyo comunitario y el bienestar físico, lo que refleja quizá aquellos aspectos en que deben enfatizarse en los planes de cuidado para esta población. el centro que obtuvo mayor promedio de cvrs fue una mano amiga, seguido por san pedro claver. en el tercer lugar se encuentra la milagrosa, en cuarto lugar san josé y por último dones de la misericordia. 547 calidad de vida de adultos mayores en centros de protección social en cartagena (colombia) l estela melguizo-herrera y otros referencias 1. schwartzmann l. calidad de vida relacionada con la salud: aspectos conceptuales. ciencia y enfermería ix. 2003 [visitado 2010 mayo 2]; (2):9-21. disponible en htpp:www.promocionsalud.ucaldas.edu.co/downloads/revista%2012_2.pdf. 2. colombia. congreso de la república. ley 1276 de 2009, enero 5, a través de la cual se modifica la ley 687 del 15 de agosto de 2001 y se establecen nuevos criterios de atención integral del adulto mayor en los centros de vida. bogotá: el congreso; 2009. 3. botero e, pico m. calidad de vida relacionada con la salud en adultos mayores de 60 años: una aproximación teórica. hacia la promoción de la salud. 2007;12:11-24. 4. colombia. congreso de la republica. ley 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(2014). valores intervenientes no cuidado do enfermeiro ao cliente com hiv/aids. aquichan. vol. 14, no. 1, 32-40. resumo objetivo: o presente estudo teve por objetivos analisar valores intervenientes no cuidar, pelo enfermeiro, a clientes com hiv/aids. método: trata-se de pesquisa social, descritiva e exploratória, com abordagem qualitativa. os participantes/cenário foram 23 enfermeiros de três instituições de saúde do estado do rio de janeiro. a coleta de dados foi realizada de janeiro de 2010 a dezembro de 2012 por meio de entrevista semiestruturada com roteiro preestabelecido, gravado em fita magnética. o projeto de pesquisa foi submetido ao cep huap 279/09, com caae n. 980.0.000.258-09. resultados: do processo de categorização emergiram quatro categorias. os valores mais ressaltados foram: discriminação, respeito, igualdade e solidariedade. conclusão: conclui-se que cada membro da equipe de saúde deve se autoconhecer, o que implica a reflexão de seus valores, crenças e cultura afim de que estes não interfiram negativamente na realização de suas ações. assim, mediante o conhecimento de seus valores e reconhecimento de valores alheios, poder-se-á, numa maior dimensão, realizar uma assistência de melhor qualidade, que proporcione aos portadores de hiv, bem como aos clientes de quaisquer patologias, um cuidado digno dentro dos preceitos preconizados pela profissão. palavras-chave enfermagem, cuidado, hiv, síndrome de imunodeficiência adquirida, assistência ao paciente (fonte: decs, bireme). 33 valores intervenientes no cuidado do enfermeiro ao cliente com hiv/aids l fernanda de carvalho-dantas, claudia de carvalho-dantas año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 32-40 valores intervinientes en el cuidado del enfermero al cliente con vih/sida resumen objetivo: analizar los valores intervinientes en el cuidar, por el enfermero, a clientes con vih/sida. método: se trata de una investigación social, descriptiva y exploratoria, con abordaje cualitativo. los participantes/escenario fueron 23 enfermeros de tres instituciones de salud del departamento de rio de janeiro. la recolecta de datos se realizó de enero del 2010 a diciembre del 2012 por medio de entrevistas semiestructuradas con guion preestablecido, grabadas en cinta magnética. el proyecto de investigación se sometió al cep huap 279/09, con caae n. 980.0.000.258-09. resultados: del proceso de categorización emergieron cuatro categorías. los valores más destacados fueron: discriminación, respeto, igualdad y solidaridad. conclusión: cada miembro del equipo de salud debe autoconocerse, lo que implica la reflexión de sus valores, creencias y cultura con el fin de que estos no interfieran negativamente en la realización de sus acciones. así, mediante el conocimiento de sus valores y reconocimiento de valores ajenos, se podrá, en una mayor dimensión, realizar una asistencia de mejor calidad, que proporcione a los portadores de vih, así como a los clientes de cualquier patología, un cuidado digno dentro de los preceptos preconizados por la profesión. palabras clave enfermería, cuidado, vih, síndrome de inmunodeficiencia adquirida, atención al paciente (fuente: decs, bireme). 34 aquichan issn 1657-5997 values intervening in nursing care for clients with hiv / aids abstract objective: the study is designed to analyze the values involved in nursing care for clients with hiv / aids. method: this is social, descriptive and exploratory research with a qualitative approach. the participants/scenario included 23 nurses from three health institutions in the department of rio de janeiro. the data were collected between january 2010 and december 2012, through taperecorded, semi-structured interviews with a pre-established scrip. the research project was subjected to cep huap 279 /09, with caae n. 980.0.000.258-09. results: four categories emerged from the categorization process. discrimination, respect, equality and solidarity were the most important values. conclusion: each member of the health team must know themselves. this implies reflecting on one’s values, beliefs and culture to make sure they do not interfere adversely with the duties nurses perform. by understanding their own values and recognizing the values of others, nurses are able to supply better quality care in a larger dimension that provides hiv carriers and clients with any other pathology dignified attention consistent with the precepts advocated by the profession. key words nursing, care, hiv, acquired immunodeficiency syndrome, patient care (source: decs, bireme). año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 32-40 35 valores intervenientes no cuidado do enfermeiro ao cliente com hiv/aids l fernanda de carvalho-dantas, claudia de carvalho-dantas introdução a síndrome da imunodeficiência adquirida (aids, por sua sigla em inglês) surgiu no início da década de 1980 e, até junho de 2012, o brasil registrou 709.447 casos de aids. no ano de 2012, a taxa de incidência da doença chegou a 20,2 para cada 100 mil habitantes (1). a razão entre os sexos vem apresentando diminuição, já que antes, em 1989, os homens eram os mais acometidos (1:6). em 2012, último dado disponível, chegou a 1,9 caso em homens para cada 1 caso em mulheres (1). independentemente do sexo, a faixa etária habitual de notificação da aids é de 25 a 49 anos (1, 2). no tocante ao cenário internacional, dados de renomada agência da organização das nações unidas (onu) revelam que 1,6 milhões de pessoas morreram em decorrência da aids (3-5). apesar das estatísticas anteriormente citadas, verifica-se uma diminuição de casos do vírus da imunodeficiência humana (hiv, por sua sigla em inglês) em decorrência de esforços do mundo inteiro para cumprimento das metas do milênio, dentre as quais se encontra a morbidade em questão, cujo objetivo é a sua redução. embora se tenha observado a diminuição no cenário nacional e internacional, o número de casos existentes ainda é preocupante e demanda investimento. no ano de 2002 existiam us$ 3,8 bilhões para combater a doença. em 2012, foram investidos quase us$ 19 bilhões (4). vale ressaltar que o brasil aparece como o país com o maior orçamento nacional para o combate à doença entre os emergentes. por ano, são mais de us$ 745 milhões. outros países como a china, com uma população seis vezes maior, investem us$ 497 milhões, contra us$ 200 milhões na tailândia e us$ 262 milhões em botsuana (5). ante o exposto, esforços de todos os envolvidos (profissionais de saúde, portadores do hiv, governantes, sociedade em geral) devem ser mantidos e estimulados. no tocante aos profissionais de saúde, em especial, além de um atendimento de qualidade, cabem a eles a realização de pesquisas para cada vez mais corroborar com a qualidade de vida dos portadores. nesse sentido, a presente pesquisa teve por objeto de investigação os valores intervenientes no cuidado do profissional de enfermagem ao portador de hiv/aids. as autoras têm observado, no transcorrer de sua prática profissional, que membros da equipe de saúde não se encontram preparados para atender às especificidades da clientela em questão. acredita-se que muitos desses profissionais possuem arraigados preconceitos que, mesmo após décadas de informação sobre a aids, são exteriorizados por meio de gestos e comentários, conforme estudo realizado em 2011 com 110 portadores do hiv (6). destarte, busca-se, na presente pesquisa, conhecer os valores atribuídos à equipe ante a assistência ao portador de hiv/aids. na literatura científica existem diversas pesquisas publicadas sobre o hiv, por diversas categorias profissionais. por outro lado, ao buscar por trabalhos cujo foco tenha sido os fatores/valores intervenientes na assistência prestada pelo profissional ao portador de hiv, verifica-se a escassez. um dos poucos trabalhos (7), cujo objetivo foi identificar os dilemas éticos enfrentados pela equipe de enfermagem atuante no programa dst/ hiv/aids, concluiu que a temática é alicerçada no sigilo e no preconceito que a aids suscita. e, ainda, que a aids é um tema impactante para os próprios profissionais que atuam diretamente com o paciente, os familiares, a sociedade e a própria equipe. para eles, as autoras sugeriram a capacitação da equipe ante a bioética e o tema da aids, visando reflexões sobre os valores profissionais e o processo de trabalho da enfermagem ao paciente e família do programa de dst/aids, além de reflexões sobre a ética do cuidado, sobre os estigmas que rondam a aids e sobre os próprios preconceitos. isso posto, justifica-se a presente pesquisa devido à escassez de publicações sobre a conduta profissional da enfermagem com foco nos valores profissionais. outra justificava refere-se ao alto índice do hiv que ainda perdura no cenário nacional e internacional e, dessa forma, tem o intuito de contribuir com reflexões referentes à prática profissional no que tange aos valores intervenientes no cuidado de profissionais de enfermagem. nesse sentido, a presente pesquisa teve por objetivo analisar valores intervenientes no cuidar pelo enfermeiro a portadores do hiv/aids a fim de discutir as implicações desses valores para assistência de enfermagem. método trata-se de pesquisa qualitativa, de natureza descritivo-exploratória. os participantes da pesquisa foram enfermeiros que assistiram ou estavam assistindo portadores do hiv/aids. os critérios utilizados para seleção dos profissionais foram: aceite em participar do estudo; ser enfermeira(o); ter no mínimo dois anos de experiência profissional; estar ou ter assistido portadores do 36 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 hiv/aids. com o intuito de resguardar o anonimato, foi atribuído um pseudônimo a cada participante da seguinte forma: enfa x, em que enfa refere-se a uma forma contracta para enfermeira (tanto para os profissionais do sexo masculino quanto para o feminino) e x refere-se a um algarismo cardinal que representa a ordem de realização da entrevista. exemplo: enfa 2 significa que este participante foi entrevistado em segundo lugar. os cenários de coleta de dados da pesquisa foram três hospitais de grande porte localizados no estado do rio de janeiro. a preferência em desenvolver o estudo nessas instituições atribuise ao fato de estas desenvolverem trabalhos em parceria com o programa nacional de dst/aids, e de uma delas ser um centro de pesquisa em aids, além de ter despontado no início da epidemia na luta contra a síndrome em questão. a coleta de dados foi realizada durante o primeiro semestre de 2010 ao segundo semestre de 2012, mediante entrevista gravada em sistema digital. optou-se por esse método porque é por meio da entrevista que “o pesquisador busca obter informes contidos na fala dos atores sociais, se insere como meio de coleta dos fatos relatados pelos atores, enquanto sujeitos-objetos da pesquisa que vivenciam uma determinada realidade que está sendo focalizada” (8:57). o instrumento utilizado para realização da entrevista foi composto de duas partes. a primeira parte foi construída com variáveis para conhecer o perfil dos participantes quanto a: idade, sexo, tempo de experiência profissional, realização de cursos de atualização sobre hiv/aids, local de trabalho, cargo/função. a segunda parte foi composta por duas questões abertas: “o que é para você cuidar de um cliente com hiv” e “como você percebe o cuidado realizado pela equipe de enfermagem?”. após a coleta das entrevistas, elas foram prontamente transcritas e submetidas ao processo de categorização (8). o quantitativo de depoimentos foi determinado de acordo com o ponto de saturação teórica. esse é o ponto que, na visão do pesquisador, deve-se suspender a inclusão de novos participantes na pesquisa quando os dados coletados apresentam repetição e não acrescentam dados novos à coleta; portanto, a amostra é fechada (9). como forma de adquirir respaldo legal para realizar esta pesquisa e transitar pelas dependências da instituição, foi encaminhada ao comitê de ética em pesquisa, a fim de obter a devida autorização, por meio do protocolo cep huap 279/09, com caae n. 980.0.000.258-09. para cada sujeito, antes da realização da entrevista, foi fornecido um termo de consentimento, conforme preceitua as normatizações das pesquisas que envolvem seres humanos, de modo a resguardar o anonimato dos participantes e a divulgação dos dados coletados pelos pesquisadores. resultados dos 23 enfermeiros entrevistados, a maioria pertence ao sexo feminino (total de 16). com relação ao tempo de atuação profissional, sete possuem entre dois a nove anos; 10 possuem entre 10 a 19 anos; cinco possuem entre 20 a 29 anos e um possui entre 30 a 39 anos. quanto ao cargo ocupado, dois são chefes de serviços, um trabalha na educação permanente do hospital e a maioria (total de 20) é gerente de serviço. sobre os setores desses 20 enfermeiros, eles estão distribuídos da seguinte forma: oito em clínica médica, cinco em clínica cirúrgica, dois em enfermaria de gestante e cinco em ambulatório de dst/aids. referente à realização de cursos de atualização em doenças sexualmente transmissíveis, a maioria relatou ter participado (total de 13). categoria central: valores intervenientes no cuidar de clientes com hiv/aids a categoria central foi composta por quatro subcategorias, as quais serão apresentadas a seguir. conhecendo valores nesta subcategoria, foram identificados os seguintes valores, a partir dos depoimentos de enfermeiros: discriminação, solidariedade, respeito e igualdade. infelizmente, a sociedade ainda associa a aids a homossexualismo, prostituição, drogas, o que dificulta a aceitação desse cliente pela sociedade. e, mais infelizmente ainda é que, este fato é percebido não só entre pessoas da sociedade, mas também em alguns profissionais da própria equipe de saúde (enfa 1). teve até uma situação, uma vez na enfermaria, que uma menina estava passando álcool no braço todo, na mão toda, porque tocou na mão de um cliente com hiv. em pleno ano de 2011, quando eu vi aquela cena, eu falei assim: “não, eu acho que eu não estou acreditando, não é possível”. e era uma colega enfermeira, não era de curso técnico nem de auxiliar, e fazendo isso. ela, olhando 37 valores intervenientes no cuidado do enfermeiro ao cliente com hiv/aids l fernanda de carvalho-dantas, claudia de carvalho-dantas para mim, disse: “não, de repente, sei lá, pode ter alguma contaminação”. então, por mais que saibam, os preconceitos, as lendas que existem em nosso subconsciente ainda afloram muito na hora do cuidar de um cliente hiv (...) ainda se tem muita dúvida, muitas dúvidas mesmo (enfa 5). vejo que aqui os profissionais fazem o cuidado sem interesse, fazem e gostam do que fazem... poucos são aqueles que discriminam... pelo menos aqui... a equipe tem um objetivo em comum: proporcionar o melhor cuidado possível, apesar das dificuldades que temos em termos de recursos materiais e humanos... mas, pelo menos, tentamos ser solidários... damos o ombro quando o cliente quer chorar, principalmente o hiv onde percebo que a família o abandona e que, na maioria das vezes, quem passa a ser família é o próprio parceiro... (enfa 4). eu não vejo o paciente com hiv como um paciente diferente dos outros... é um paciente com uma patologia (aids) como outra qualquer (enfa 8). mas como hoje em dia a gente não tem como saber quem é hiv e quem não é, as precauções de início são as universais. então, a gente tem que ter o mesmo cuidado com hiv que a gente teria com qualquer outro, sabendo ou não que é hiv: cuidado com sangue, com secreção... (enfa 6). reconhecendo seus valores o reconhecimento dos valores pessoais por cada profissional é indispensável para o cuidado ao ser humano. verificou-se, em alguns discursos, a clareza por parte de alguns depoentes acerca da importância de cada pessoa refletir sobre seus atos/valores pessoais. no contexto hospitalar, em virtude da fragilidade que o cliente se encontra, o profissional deve reconhecer seus valores para que estes não interfiram negativamente na assistência a ser prestada. a enfermeira tem que saber seus limites, saber lidar com seus valores, suas crenças, buscar sempre a atualização de seus conhecimentos e atos (enfa 1). não tenho nada contra os novos sem prática, seja em tempo de serviço ou inserção em setor especializado... mas cada um deve se conhecer e por o pé apenas aonde sabe que vai alcançar... (enfa 7). respeitando valores alheios todo ser humano almeja o respeito e consideração dos demais membros que compartilham de seu ambiente de convívio. respeitar valores alheios consiste no aceite sem questionamentos da conduta do outro, desde que não esteja causando nenhum dano para outrem. o respeito é a base de tudo, principalmente quando se trata de uma doença com forte estigma social, embora estejamos em pleno século xxi (enfa 1). precisamos realizar um cuidado independente da religião do outro, opção sexual, nível social, cor sexo... percebo que muitos colegas julgam os outros e esquecem que também são passíveis de serem julgados... (enfa 19). trabalhando valores esta subcategoria agrupa depoimentos que apontam para a necessidade de o profissional, após reconhecer a necessidade de mudança, buscar pelo seu constante aprimoramento. o enfermeiro responsável pelo setor deve atentar para a forma como sua equipe desenvolve o cuidado para detectar possíveis condutas inapropriadas e intervir de imediato. devem ser feitos treinamentos que contemplem não apenas a parte técnica, mas também aspectos inerentes ao relacionamento interpessoal. antes de qualquer coisa, de qualquer escolha na vida, o profissional tem que se conhecer, saber de suas fraquezas, de seus pontos fortes, mas principalmente dos fracos para que possam ser trabalhados... e, aqui, vejo que as pessoas precisam trabalhar seus valores, seus conhecimentos sobre a aids (enfa 5). o enfermeiro, em especial, o responsável pelo plantão, tem que estar atento à forma como sua equipe presta o cuidado para, caso necessário, poder intervir de forma individualizada ou em grupo, quando perceber que se trata de uma demando do grupo como um todo (enfa 23). discussão o valor atribuído às ações cotidianas interfere na forma como o ser humano se relaciona com o mundo. o significado dado às ações define a forma como será desencadeada a ação huma38 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 na. todo ser humano, na tomada de decisão, age com base em significados que são construídos ao logo de sua vida pessoal e profissional, decorrentes das relações humanas. muitas dessas construções são feitas com base na moral, fortemente influenciada pelo meio que, em dadas situações, refletem o desejo deste, mas não da pessoa que o vivencia. conhecendo os valores é o primeiro passo para se caminhar em direção a uma assistência de qualidade com igualdade no cuidado ao portador do hiv. verifica-se, por meio dos discursos, que as pessoas precisam refletir sobre seus valores, reconhecê-los e respeitar os valores alheios. em estudo (10) que delineou um modelo de cuidado ao portador do hiv, verificou-se que um modelo de cuidado deve estar pautado em três pilares: no profissional, na patologia e no paciente. com relação ao pilar “profissional”, deve-se primar pela sua atualização e conhecimento de suas habilidades e competências perpassando por seus valores profissionais, visando ao oferecimento de uma assistência de qualidade. essa afirmativa tem subsídios na formação do enfermeiro e aponta para a necessidade de preparar as pessoas para as mudanças no mundo e no contexto de trabalho, ao procurar conciliar a necessidade de desenvolvimento pessoal e de grupo com a instituição e a sociedade. nessa linha de raciocínio, pesquisadores (11, 12) reforçam a necessidade de reafirmar a questão da educação como um compromisso para o crescimento pessoal e profissional, com o objetivo de melhorar a qualidade da prática profissional. defende-se que a competência profissional é um conceito educacional e político abrangente, um processo de articulação e mobilização gradual e contínua de conhecimentos gerais e específicos. complementa-se, ainda, que o conceito de competência profissional refere-se a um processo de habilidades teóricas e práticas, de atitudes e hábitos e de valores éticos, que permitem ao profissional a realização de seu trabalho de forma crítica, consciente e eficiente (13, 14). os valores que o profissional possui devem ser destituídos de preconceitos, não deixando que valores morais e éticos interfiram na assistência que desenvolve a cada dia, pois, ao não saber lidar com eles, tende a agir de modo que considera correto, ao ponto de considerar inválidas todas as posturas que são contraditórias àquilo que se pensa, inclusive em termos de ofensa/afronta pessoal. ao considerar que são os valores que movem nossa ação, se estes estiverem corrompidos por uma visão equivocada dos fatos, tenderão a constranger e a prejudicar, ao invés de estimular o relacionamento/interação do profissional da equipe de enfermagem com o cliente portador do hiv. vários foram os valores ressaltados pelos enfermeiros como fundamentais para a construção de um ambiente harmônico, que valorizam o relacionamento interpessoal. eles guiam nossa ação, nossos cuidados e, ao não estarmos cientes de nossos valores, torna-se difícil o exercício de uma assistência igualitária ao cliente. a esse respeito, destaca-se que: na assistência ao paciente, muitas vezes este tenta fazer suas escolhas ou tomar suas decisões, mas, por acharmos que podemos fazer melhores escolhas que ele e por sabermos o que é melhor para ele, na maioria das vezes ignoramos suas vontades, decisões, valores, história de vida e cultura (15:368). nessa linha de raciocínio, outros autores (16) defendem que os valores são fundamentos do agir profissional da enfermeira, os quais nem sempre são claramente identificados por tais profissionais. o profissional deve refletir sobre seus valores pessoais e identificar como eles interferem na assistência prestada. para todo profissional que desconhecer a influência de seus valores pessoais na conduta profissional, poderá ter seus atos distanciados dos fundamentos éticos, o que prejudicará a assistência ao paciente. isso se deve ao fato de os valores serem entendidos, também, como norteadores de julgamentos que levam em consideração as figura 1. valores intervenientes no cuidado 39 valores intervenientes no cuidado do enfermeiro ao cliente com hiv/aids l fernanda de carvalho-dantas, claudia de carvalho-dantas preferências do que é mais desejável para o indivíduo. tudo o que cerca o homem pode ser atribuído um valor e, diante disso, sempre assumirá uma escolha: aceitá-lo ou rejeitá-lo (17). por exemplo: o comportamento de um paciente, a forma de falar, a forma de se vestir, a sua opção sexual e/ou religiosa, dentre outros. se o profissional não refletir sobre seus valores, poderá, involuntariamente, aproximar-se ou realizar uma assistência de melhor qualidade para aqueles que guardarem proximidade com seus valores pessoais. é de extrema relevância refletir sobre como os atos têm sido concretizados e até que ponto as decisões têm sido tomadas de forma imparcial, uma vez que não é possível passar indiferente aos valores, os quais (17) não existem por si mesmos, pelo menos necessitam de um depositário no mundo. aparecem como meras qualidades desses depositários, no caso do estudo, enfermeiros. uma qualidade faz parte da própria existência do objeto ao passo que o valor refere-se ao sujeito em relação ao objeto, o que serve como norteador para a tomada de decisão (17). o sentimento da vida de um homem é dado pelos valores e, por meio deles, o homem vive plenamente a sua condição humana, sendo possível observar que o indivíduo exerce uma atitude axiológica diante de tudo que o cerca, sendo com isso capaz de julgar se alguma coisa é boa ou ruim, agradável ou desagradável, justa ou injusta (16). nesse contexto, o profissional que assiste o cliente portador de hiv depara-se com questões relacionadas à sexualidade, discriminação e preconceito e, dependendo do valor que atribuir a tais questões, tenderá a desenvolver uma assistência adequada ou inadequada em termos de qualidade. abordar as temáticas das doenças sexualmente transmissíveis implica invariavelmente deparar-se com a questão do exercício da sexualidade e dos valores sexuais de cada pessoa que, por sua vez, antecedem e fundamentam suas atitudes sexuais. tratase de um tema que está envolto de uma rede de subjetividade repleto de significações pessoais pelas quais se aprendem a realidade (18:37). com o objetivo de contribuir para uma assistência de melhor qualidade, cabe ao enfermeiro realizar capacitações de sua equipe, por meio da educação permanente, para o desenvolvimento de uma assistência de qualidade, em especial aos portadores do hiv que culturalmente têm enfrentado grandes desafios no âmbito dos serviços de saúde. conclusão verificou-se, por meio das categorias e subcategorias, que os valores mais ressaltados foram: discriminação, respeito, preconceito, sexualidade, vida, igualdade e solidariedade. no tocante ao discurso de enfermeiros, verifica-se que, para cuidar de alguém, se deve cuidar independentemente de patologia. os profissionais devem reconhecer os limites de seus valores e não permitir que estes conduzam para um cuidado discriminatório, que valoriza apenas os pacientes que tenham semelhança com seus valores. conclui-se que, cada membro da equipe de saúde deve se autoconhecer, o que implica a reflexão de seus valores, crenças e cultura a fim de que estes não interfiram negativamente na realização de suas ações. assim, mediante o conhecimento de seus valores e reconhecimento de valores alheios, poder-se-á, numa maior dimensão, realizar uma assistência de melhor qualidade, que proporcione aos portadores de hiv, bem como aos portadores de quaisquer patologias, um cuidado digno dentro dos preceitos preconizados pela profissão. 40 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 referências 1. brasil. ministério da saúde. secretária de vigilância saúde. programa nacional de dst e aids. boletim epidemiológico – aids e dst – ano ii. n. 1 até 26ª semana epidemiológica – dezembro de 2013. brasília (df): ministério da saúde; 2013. 2. oliveira gd, almeida as, nogueira mf, barreto ajr, nogueira ja, trigueiro drsg et al. health, life, and death for seropositives: subjective meanings of quality of life. j nurs ufpe 2012; 6(3): 530-9. 3. araújo tme, monteiro cfs, mesquita gv, alves elm, carvalho km, monteiro rm. risk factors for hiv infection in adolescents. rev. enferm. uerj 2012; 20(2): 242-7. 4. unaids. report of global aids epidemic [internet]. 2010 [citado 12 jun. 2013]. disponível em: url: http://www.viewer. zmags.com/showmag. php 5. unaids. estratégia do unaids/onusida 2011-2015: chegando a zero. [internet]. 2010 [citado 12 jun. 2013]. disponível em: url: http://www.unaids.org/en/media/unaids/contentassets/documents/unaidspublication/2010/jc2034_ unaids_strategy_pt.pdf 6. pereira k, amorim f, dantas fc, dantas cc. o cuidado de enfermagem sob a ótica do portador de hiv. rio de janeiro (rj): snct uff; 2011 . 7. soratto mt, zaccaron rc. ethical dilemmas faced by the nursing team in a std/hiv/aids program. rev centro universitário são camilo 2010; 4(3): 332-6. 8. minayo mcs. o desafio do conhecimento: pesquisa qualitativa em saúde. são paulo: hucitec; 2010. 9. fontanella bjb, luchesi bm, saidel mgb, ricas j, turato er, melo dg. amostragem em pesquisas qualitativas: proposta de procedimentos para constatar saturação teórica. cad saúde pública 2011; 27(2): 389-94. 10. leite jl, dantas fc, dantas cc, erdmann al, lima sbs, oliveira pb. delineando un modelo de cuidado a partir del análisis sistemático de la actividad diaria del enfermero en un hospital universitario de rio de janeiro. aquichan 2010; 10(2): 146-56. 11. paschol sp, mantovani mf, méier m j. percepção da educação permanente, continuada e em serviço para enfermeiros de um hospital de ensino. revista da escola enfermagem da usp 2007; 41(3): 478-84. 12. gryschesk alfpl, domingos jc, figueiredo crdl, nichiata lyi, osório, l.m. necessidades de qualificação da equipe de enfermagem para a assistência aos clientes portadores do hiv e da aids. revista da escola enfermagem da usp 2000; 34(3): 188-93. 13. peduzzi m, anselmi ml. o processo de trabalho de enfermagem: a cisão entre o planejamento e execução do cuidado. revista brasileira de enfermagem 2002; 55(4): 392-8. 14. ballester ar. eficacia terapéutica de un programa de intervención grupal cognitivo-comportamental para mejorar la adhesión al tratamiento y el estado emocional de pacientes con infección por vih/sida. psicothema: oviedo; 2003. 15. domingues tam, chaves ec. o conhecimento científico como valor no agir do enfermeiro. revista da escola enfermagem da usp 2007; 39 (3): 580-8. 16. domingues tam, chaves ec. os valores constitutivos do cuidar. acta. paul. enf. 2004; 17(4): 369-76. 17. frondizi r. ¿qué son los valores? introducción a la axiología. 6ª. ed. méxico: fondo de cultura económica; 1986. 18. wilhelm w. aprendendo com os líderes do passado. em: hesselbein f, godsmith m, beckhard r. o líder do futuro. são paulo (sp): futura; 1996. pp. 69-80. 387 395 como entender la experiencia.indd 387 paola carrasco-aldunate1 alejandra araya-gutiérrez2 carla loayza-godoy3 lilian ferrer-lagunas4 claudio trujillo-guarda5 ana fernández-sarmiento6 martín lasso-barreto7 carlos pérez-cortés8 cómo entender la experiencia de personas que viven con vih: implicaciones para la clínica y la investigación9 1 enfermera-matrona. magíster en ciencias de la educación. profesor asistente, pontificia universidad católica de chile, chile. dcarrasa@uc.cl 2 enfermera-matrona. phd. profesor asistente, pontificia universidad católica de chile, chile. aarayagu@uc.cl 3 enfermera. red de salud uc, pontificia universidad católica de chile, chile. cloayza@med.puc.cl 4 enfermera-matrona. phd. profesor asociado, pontificia universidad católica de chile, chile. lferrerl@uc.cl 5 alumno de enfermería. pontificia universidad católica de chile, chile. catrujillo@uc.cl 6 matrona. complejo asistencial dr. sótero del río, chile. amfernandez@ssmso.cl 7 médico. complejo asistencial dr. sótero del río, chile. zoalde@yahoo.com 8 médico departamento de enfermedades infecciosas. pontificia universidad católica de chile, chile. cape@med.puc.cl 9 unidad de infectología del centro de diagnóstico y tratamiento (cdt) del complejo asistencial dr. sótero del río (casr). proyecto financiado por la dirección de investigación escuela de enfermería pontificia universidad católica de chile, concurso interdisciplinario 2010 ciiem#201001. la organización que proporcionó el financiamiento no tuvo influencia en el diseño del estudio, ni en la recolección, el análisis o la interpretación de los datos, ni en la preparación, revisión o aprobación del manuscrito. recibido: 20 de julio de 2012 enviado a pares: 21 de agosto de 2012 aceptado por pares: 26 de agosto de 2013 aprobado: 27 de agosto de 2013 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 387-395 para citar este artículo / to reference this article / para citar este artigo carrasco-aldunate, p., araya-gutié rrez, a., loayza godoy, c., ferrer-lagunas, l., et al. (2013). cómo entender la experiencia de personas que viven con vih: implicaciones para la clínica y la investigación. (2013). aquichan. vol. 13, no. 3, 387-395. resumen objetivo: las personas que viven con una enfermedad crónica experimentan procesos complejos de transformación personal para adaptarse a su nueva condición de salud. el objetivo del artículo es develar el significado de vivir con vih en personas que fueron diagnosticadas en etapa de sida. materiales y métodos: estudio cualitativo descriptivo en el que se realizaron entrevistas en profundidad a 15 personas que viven con vih (pvvih) en etapa de sida, que se atienden en el sistema público de salud chileno. resultados: del análisis de contenido emergieron seis dimensiones del significado de vivir con la enfermedad: cambios personales posteriores al diagnóstico; apoyo social y acompañamiento, resignación a la adquisición del vih; percepción de discriminación / rechazo; revelación del diagnóstico; cuidar a otros de la adquisición del vih. conclusiones: los hallazgos orientan a los profesionales de la salud sobre 388 aquichan issn 1657-5997 las estrategias que se deben utilizar en la atención directa de las personas que viven con vih con el fin de otorgar un cuidado integral considerando el apoyo para el desarrollo de estrategias de autocuidado y la revelación del diagnóstico a su núcleo cercano, para reducir los costos psicosociales asociados a la enfermedad. palabras clave vih, síndrome de inmunodeficiencia adquirida, investigación, enfermería, chile. (fuente: decs, bireme). how to understand the experience of persons living with hiv: implications for clinical practice and research abstract objective: those who live with chronic disease undergo complex processes of personal transformation to adapt to their new health condition. the aim of this article is to show what it means to live with hiv for persons who have been diagnosed with aids. materials and methods: this is a descriptive qualitative study based on 15 people who are living with hiv/aids and being treated through the chilean public health system. results: the content analysis showed six dimensions of what it means to live with the disease: personal changes after the diagnosis, social support and accompaniment, being resigned to having contracted hiv, perceived discrimination / rejection, disclosure of the diagnosis, and protecting others from contracting hiv. conclusion: the findings can provide guidance to health professionals on the strategies that should be used in providing direct care to persons living with hiv. in this respect, the goal is to offer comprehensive care, taking into account support for the development of self-care strategies and disclosure of the diagnosis to the patient´s family and close friends, so as to reduce the psycho-social costs of the disease. key words hiv, acquired immunodeficiency syndrome, research, nursing, chile. (source: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 387-395 389 cómo entender la experiencia de personas que viven con vih: implicaciones para la clínica y la investigación l paola carrasco-aldunate y otros. como entender a experiência de pessoas que vivem com hiv: implicações para a clínica e para a pesquisa resumo objetivo: as pessoas que vivem com uma doença crônica experimentam processos complexos de transformação pessoal para se adaptar a sua nova condição de saúde. o objetivo deste artigo é revelar o significado de viver com hiv em pessoas que foram diagnosticadas em etapa de aids. materiais e métodos: estudo qualitativo descritivo no qual se realizaram entrevistas em profundidade com 15 pessoas que vivem com o hiv (pvhiv) em etapa de aids, que se atendem no sistema público de saúde chileno. resultados: da análise de conteúdo emergiram seis dimensões do significado de viver com a doença: mudanças pessoais posteriores ao diagnóstico; apoio social e acompanhamento, resignação à aquisição do hiv; percepção de discriminação ou rejeição; revelação do diagnóstico; cuidar a outros sobre a aquisição do hiv. conclusões: as descobertas orientam os profissionais da saúde sobre as estratégias que se devem utilizar no atendimento direto das pessoas que vivem com o hiv, com o objetivo de outorgar um cuidado integral que considere o apoio para o desenvolvimento de estratégias de autocuidado e a revelação do diagnóstico a seu núcleo de pessoas próximas, para reduzir os custos psicossociais associados à doença. palavras-chave hiv, síndrome de imunodeficiência adquirida, pesquisa, enfermagen, chile. (fonte: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 387-395 390 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 introducción actualmente en chile se estima que hay cerca de 50.000 personas que viven con el virus de la inmunodeficiencia humana (vih) y con el síndrome de inmunodeficiencia adquirida (sida) (1). el grupo de edad más afectado se encuentra entre los 20 y 49 años, siendo el género masculino el más prevalente (2). la vía de transmisión más frecuente es la sexual, con un predominio de hombres que tienen sexo con hombres (3). la mayoría de las personas que viven con vih (pvvih) residen en santiago y son atendidas por el sistema público de salud (2). en chile, la infección por vih es considerada una enfermedad crónica desde la aparición de la terapia antirretroviral (tarv), a la que las personas tienen acceso universal garantizado a través del plan ges del ministerio de salud chileno, evitando en la mayoría de casos la aparición de infecciones oportunistas y neoplasias asociadas. las pvvih experimentan procesos complejos de transformación personal al ser diagnosticadas y vivir con una enfermedad crónica. además, su condición de vivir con vih los lleva a una redefinición de su persona y de su vida mediante un proceso de aprendizaje sobre sí mismos y sobre la enfermedad (4). el significado que cada persona le otorgue a su condición de vih puede determinar indicadores de salud. el objetivo de este estudio es develar el significado de vivir con vih en un grupo de personas que fueron diagnosticadas con esta infección en etapa de sida, con el propósito de identificar algunos elementos de sus vivencias que permitan orientar la consejería y el acompañamiento, reducir los costos psicosociales asociados al hecho de ser una persona con vih y favorecer la adherencia a la terapia antirretroviral (tarv). materiales y métodos estudio cualitativo de tipo fenomenológico realizado con 15 pvvih en etapa de sida que son atendidos en la unidad de infectología de un hospital público del sector suroriente de santiago de chile, entre mayo y julio del año 2011. los criterios de inclusión fueron : ser usuario de la unidad de infectología, con diagnóstico confirmado de vih en etapa de sida, mayor de 18 años, no tener discapacidad mental, no haber estado hospitalizado el mes anterior a la entrevista y, en caso de ser mujer, no estar embarazada al momento de la recolección de datos. este centro de atención de pvvih es uno de los más grandes de la ciudad de santiago. el criterio para la selección de un centro de salud de la ciudad de santiago es que en este lugar existe un mayor número de pvvih que en otras regiones del país. más del 70 % de las personas infectadas por el virus vive en santiago (3). la recolección de datos se inició con un contacto verbal de invitación a participar del estudio dirigido a los usuarios que se encontraban en la sala de espera del centro de salud. esta invitación fue realizada por los coordinadores de terreno, miembros del equipo de salud tratante. una vez que aceptaban la invitación, los posibles participantes eran contactados por el equipo de investigación. solo los integrantes de este equipo, el cual no tiene ningún contacto clínico con los usuarios, realizaron el ingreso de participantes al proyecto. ningún profesional clínico del equipo tratante del centro ingresó usuarios a este estudio. posterior a la firma del consentimiento informado, enfermeras o enfermeras-matronas miembros del equipo de investigadores, entrenadas en la realización de entrevistas en profundidad, y quienes no conocían de antemano a los entrevistados, llevaron a cabo cada entrevista. se realizó una entrevista con una única pregunta abierta que guió el desarrollo de la misma: ¿cómo ha sido su experiencia de vivir con vih? durante el desarrollo de la conversación se fueron abordando las temáticas que los entrevistados iban señalando a modo de clarificar y esclarecer las expresiones, en un recorrido que evocó desde el momento del diagnóstico hasta el momento actual. durante la entrevista los usuarios señalaban hitos de su vivencia, los que finalmente fueron analizados e interpretados en dimensiones y significados en el análisis de las entrevistas, las cuales duraron en promedio 40 minutos, y fueron grabadas y transcritas de manera textual por personas entrenadas para esta actividad. una vez finalizada la entrevista se aplicó un cuestionario para medir variables demográficas y de la enfermedad. para el análisis de los datos del cuestionario se utilizaron medidas de tendencia central. para el análisis de datos de la entrevista se utilizó la técnica de análisis de contenido descrita por krippendorff (5). tres investigadores del equipo analizaron separadamente las transcripciones con la siguiente metodología: cada uno, de manera independiente, realizó una lectura inicial de los textos transcritos sin interpretación; luego una segunda lectura en que se identificaron los significados, implícitos o explícitos de cada pvvih entrevistado; después de identificar los significados se constru391 cómo entender la experiencia de personas que viven con vih: implicaciones para la clínica y la investigación l paola carrasco-aldunate y otros. yeron las dimensiones. en el análisis los investigadores llegaron a un consenso de las dimensiones y los significados encontrados después de que cada investigador planteó su propuesta de análisis. para asegurar la credibilidad de los análisis de datos y su validez descriptiva se utilizaron los criterios de creswell (6). con este objetivo, después de analizar las entrevistas en profundidad, se realizó el member check a los usuarios participantes y se les mencionaron las dimensiones y los significados encontrados para corroborar la validez de los datos obtenidos. se obtuvo la aceptación de los resultados. junto con esto, las dimensiones y los significados fueron respaldados por una descripción detallada de cada uno de los relatos, lo que permite establecer la utilidad y aplicabilidad de los resultados de este estudio. finalmente, las dimensiones y los significados fueron examinados por el investigador principal y tres investigadores quienes son expertos temáticos, clínicos y metodológicos. de esta manera se consideraron válidos los resultados obtenidos. resultados las pvvih entrevistadas presentan una mediana de 40 años (34 y 61 años). del total de participantes, 12 eran hombres y 11 de ellos habían completado la enseñanza media. seis de 15 tenían trabajo de tiempo completo y siete eran hombres que tenían sexo con hombres. la edad de diagnóstico del vih tiene una mediana de 31 años (24-57 años), el recuento de linfocitos cd4 con una mediana de 372 células/mm3 (79-1308 céls/mm3), al momento de la entrevista, y la carga viral al momento de la recolección de datos fue indetectables en 12 de los 15 entrevistados. del análisis de contenido de las entrevistas emergieron seis dimensiones que representan aspectos únicos del significado de vivir con vih (tabla 1). a continuación cada dimensión y significado es definido y ejemplificado por relatos que dan cuenta de ellas. la dimensión “cambios personales posteriores al diagnóstico” se refiere a las modificaciones implementadas después del diagnóstico de la enfermedad y que han sido efectuadas por las pvvih de manera voluntaria y con la convicción de que son necesarias para seguir con la vida. en esta dimensión se distinguen dos significados: adaptación a vivir con vih y sobreponerse al diagnóstico. significado 1: adaptación a vivir con vih se refiere a los cambios implementados después de conocer el diagnóstico en lo relativo a lo personal, sexual, a la terapia, alimentación, tabaco y alcohol. pvvih: “sí, súper conscientes y ser súper rigurosos con sus drogas y tomárselas todos los días y darse cuenta que esto no va de la mano ni con el alcohol ni con las drogas, que el cigarro también nos afecta, que hay que tener una buena alimentación…” . pvvih: “…las caricias, la conversación, el acto sexual, y todo salía bien pero a partir de que me diagnosticaron el vih y me dijeron que había que usar preservativos la cosa cambió, me cambió todo un mundo…”. significado 2: sobreponerse al diagnóstico se refiere al deseo de seguir viviendo, que la vida sigue su curso a pesar de tener el diagnóstico de vih. pvvih: “…he estado como le dije anteriormente con ánimo, pensando positivamente, saliendo adelante, estoy como más alegre, pensando en la vida más positiva…”. pvvih: “…yo quiero vivir, yo quiero estar bien para mis hijos, yo quiero verlos crecer, a mí me gusta la vida (ríe), me gusta verme bonita (ríe), me gusta verme bien…”. la dimensión “apoyo social y acompañamiento” se refiere al apoyo de las personas significativas, de su familia u otros que comparten su vida después de conocer el diagnóstico. pvvih: “…mi familia me apoyó harto, tuve el apoyo de mis papás, de mis hermanos, de… de toda mi familia…”. pvvih: “… fue mi mayor apoyo, mis hijos, mi esposa conmigo, mi familia; y en el hospital el apoyo lo tuve mucho, de todo el mundo…”. la dimensión “resignación a la adquisición del vih” tiene relación con el conformismo o la sumisión al diagnóstico de la enfermedad y sus consecuencias. pvvih: “… sí, al final, bueno, cometimos un error y estamos en esto y hay que tratar de seguir adelante nomás de la mejor forma posible…”. pvvih: “…cuando se me informó que padecía de vih sentí una pena sumamente grande, una impotencia sumamente grande, pero a la vez estaba súper tranquilo porque reconocí y asumí el error que yo había cometido en el no haberme cuidado…”. 392 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 la “percepción de discriminación o rechazo” es una dimensión que se refiere a la apreciación de alejamiento o separación por parte de las personas debido al diagnóstico. pvvih: “… me ha tocado ir a alguna institución o centro asistencial y he sentido como un poco de rechazo… la mujer que me sacó el examen de sangre fue como muy pesada conmigo… muy indiferente, y yo lo sentí…”. pvvih: “… un pequeño rechazo… porque yo me iba a operar de várices y le dije a cierto profesional de la salud… y yo le estiré la mano y no me dio la mano, entonces hay ciertos profesionales que sí rechazan esta enfermedad como que ellos mismos te discriminan, entre unos mismos… discrimina…”. la dimensión “revelación del diagnóstico” involucra a aquellos relatos que señalan la decisión de compartir o no con otros la información de su serología positiva. pvvih: “…tener que decírselo [sobrina] para mí fue fuerte… y igual para ella también… preferí yo decírselo de mis propios labios, y ahora igual… me siento como más aliviado en ese aspecto y más tranquilo…”. pvvih: “… bueno para mí personalmente es un tema que todavía lo estoy viendo, el hecho de informárselo a mi familia, no es tanto el contarles el hecho de que, lo que significa para ellos, eso me preocupa que va a ser a lo mejor un balde de agua fría, eso, eso me preocupa, todavía no se los he dicho…”. la dimensión “cuidar a otros de la adquisición del vih” involucra a aquellos relatos en que se señala la percepción de responsabilidad para evitar la transmisión del vih. pvvih: “…cuando conozco una persona… a la primera o segunda vez que nos vemos yo siempre digo lo que padezco, que soy portador y todo eso. entonces igual es importante informárselo a la otra persona para que esté consciente de si quiere seguir más adelante o llegar hasta ahí, es como lo justo para los dos…”. pvvih: “… y ahora me da miedo porque de repente por más que uno ponga cuidado igual corre el riesgo la persona si está sana, entonces es un peso, una responsabilidad muy grande que uno lleva…”. discusión los cambios personales producidos con posterioridad al diagnóstico muestran que desde el momento del diagnóstico las personas vivencian un impacto (7-9) que corresponde al inicio de las modificaciones que una enfermedad crónica implementa en su vida (8). los cambios experimentados en sus rutinas, decisiones y relaciones, así como el cambio en los estilos de vida se producen a consecuencia de la enfermedad (10, 11). con el pasar del tiempo, el impacto de la noticia (8, 12-14) se transforma en un sentimiento de valoración de la vida y cambio de los objetivos en la misma (15). este tipo de expresiones o conductas dan cuenta del proceso de incorporación de la condición de ser pvvih a la identidad de cada persona (16). en este estudio, las pvvih manifiestan que han experimentado cambios en diferentes esferas de su vida posterior al diagnóstico; sin embargo, y a pesar de los cambios, también expresan la intensión y el deseo de seguir viviendo. son diversas las razones de este deseo: motivaciones personales o por otras personas significativas. lo cierto es que manifiestan expresamente que la vida continúa y que quieren vivirla. el estigma social y la discriminación son aspectos que afectan tanto al individuo como a sus familias (15, 17, 18). una vez que se conoce el diagnóstico, la percepción de discriminación o rechazo es una expresión de la experiencia de vivir con vih; no obstante, por el contrario también expresan apoyo, en especial de su familia y cercanos. el apoyo social se describe como una estrategia para la disminución de la incertidumbre experimentada por la pvvih, ya que facilita el desarrollo de habilidades, permite asistir en la búsqueda de información y apoya la aceptación de sí mismo (19). los participantes expresan que una decisión que deben tomar es revelar (divulgar) el diagnóstico. la decisión de dar a conocer u ocultar su nueva condición es un aspecto que se ha encontrado en otros estudios (20). la divulgación del diagnóstico a alguna persona o familiar cercano existe dentro de los planes de acción de las pvvih (21). sin embargo, la literatura muestra que las personas deciden contar el diagnóstico primero a amigos antes que a la pareja o la familia (22). si bien no lo expresaron las pvvih entrevistadas en este estudio, investigaciones muestran que en la medida que se divulgue más, se produce un procesamiento del 393 cómo entender la experiencia de personas que viven con vih: implicaciones para la clínica y la investigación l paola carrasco-aldunate y otros. trauma originado por el diagnóstico que traería beneficios para la salud e inmunología de las pvvih (23). así también, se señala que en la medida que el diagnóstico se revela, el proceso de vivir con la enfermedad crónica permite avanzar a etapas posteriores para hacerlo parte de su identidad (16). la protección de otros para no contagiarlos es un aspecto que se destaca como un proceso reflexivo que se produce con el paso del tiempo (24). en esta investigación las motivaciones de las pvvih para prevenir la infección de otros apuntan a la responsabilidad que sienten hacia la pareja sexual actual así como a una eventual pareja, todo con el fin de evitarles daño físico y emocional. por otro lado, la planificación de un embarazo por la mujer evita poner en riesgo a los niños. las motivaciones coinciden con las encontradas en la literatura; sin embargo, no son expresadas con la connotación de la creencia que la transmisión del vih es igual a “asesinato” o la percepción de que los niños son “inocentes” (24). la resignación a tener la enfermedad y haberse contagiado se describe en personas adictas a drogas endovenosas (25). al respecto, las pvvih entrevistadas hacen referencia a su responsabilidad por no tomar precauciones para evitar el contagio por vía sexual. por lo anterior, este es un aspecto que se constituye en un hallazgo que puede ser objeto de futuras investigaciones. este estudio considera que los resultados obtenidos no son generalizables a toda la población chilena portadora de vih que es atendida en los servicios públicos de atención. sin embargo, este estudio se constituye en un punto de partida para conocer el significado que le otorgan las pvvih, en etapa de sida, a la enfermedad. conclusiones este es el primer estudio chileno que devela el significado de vivir con vih en un grupo de pvvih en etapa de sida. seis dimensiones explican esta experiencia y orientan a los profesionales de la salud sobre las estrategias que se deben utilizar para guiar los cuidados necesarios a lo largo de la enfermedad. las implicaciones clínicas radican en conocer el significado de la enfermedad a fin de incorporar los elementos develados en este estudio en la atención directa de pvvih otorgando un cuidado integral con el objeto de apoyar el desarrollo de estrategias que apunten a mejorar su autocuidado, la revelación del diagnóstico a su núcleo cercano y reducir los costos psicosociales asociados a la enfermedad. futuras investigaciones pueden orientarse a profundizar en los conceptos de discriminación y rechazo, situación que puede influir en la calidad de vida de las pvvih y llevar a explorar a las personas significativas para las pvvih, como una manera de conocer la vivencia que estas tienen del acompañamiento. finalmente, una sugerencia posible de implementar en la atención es la incorporación de un tercero significativo para el usuario como una estrategia de apoyo y acompañamiento al momento y después del diagnóstico, aspecto que está documentado por su rol positivo para la salud (8). agradecimientos a todos los usuarios del programa de infectología del complejo asistencial dr. sótero del río. 394 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 referencias 1. minsal. situación epidemiológica de vih/sida, chile 1984-2008. 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2008;12:244-5. 18. sandelowski m, lambe c, barroso j. stigma in hiv-positive women. j nurs scholarsh. 2004;36(2):122-8. 19. brashers de, neidig jl, goldsmith dj. social support and the management of uncertainty for people living with hiv or aids. health commun 2004;16(3):305-31. 20. petrak ja, doyle am, smith a, skinner c, hedge b. factors associated with self-disclosure of hiv serostatus to significant others. br j health psychol. 2001;6(pt1):69-79. 21. arthur g, nduba v, forsythe s, mutemi r, odhiambo j, gilks c. behaviour change in clients of health centre-based voluntary hiv counselling and testing services in kenya. sex transm infect. 2007;83:541-6. 395 cómo entender la experiencia de personas que viven con vih: implicaciones para la clínica y la investigación l paola carrasco-aldunate y otros. 22. serovich jm, esbensen aj, mason tl. disclosure of positive hiv serostatus by men who have sex with men to family and friends over time. aids patient care stds. 2007;21(7):492-500. 23. o’cleirigh c, ironson g, fletcher ma, schneiderman n. written emotional disclosure and processing of trauma are associated with protected health status and immunity in people living with hiv/aids. br j health psychol. 2008;13:81-4. 24. king r, lifshay j, nakayiwa s, katuntu d, lindkvist p, bunnell r. the virus stops with me: hiv-infected ugandans’ motivations in preventing hiv transmission. soc sci med. 2009;68(4):749-57. 25. mosack ke, abbott m, singer m, weeks mr, rohena l. if i didn’t have hiv, i’d be dead now: illness narratives of drug users living with hiv/aids. qual health res 2005;15:586-605. tabla 1. dimensiones y significados extraídos de los relatos de las pvvih (n = 15) dimensión significado cambios personales posteriores al diagnóstico adaptación a vivir con vih resiliencia y proyección de vida apoyo social y acompañamiento resignación a la adquisición del vih percepción de discriminación / rechazo revelación del diagnóstico cuidar a otros de la adquisición del vih se lf -c ar e re qu is it es f or p eo pl e w it h in te st in al o st om ie s: a s co pi ng r ev ie w 1 isabelle pereira da silva https://orcid.org /0000-0002-9865-2618 universidade federal do rio grande do norte, brazil. isabelle.silva.015@ufrn.edu.br iraktânia vitorino diniz https://orcid.org /0000-0002-0309-6007 universidade federal da paraíba, brazil. contato@iraktania.page julliana fernandes de sena https://orcid.org /0000-0002-8968-1521 universidade federal do rio grande do norte, brazil. julliana.sena.012@ufrn.br silvia kalyma paiva lucena https://orcid.org /0000-0002-1191-927x universidade federal do rio grande do norte, brazil. silvia.lucena@ufrn.br lorena brito do o’ https://orcid.org /0000-0002-8419-3457 universidade federal do rio grande do norte, brazil. lorena.o.702@ufrn.edu.br rodrigo assis neves dantas https://orcid.org /0000-0002-9309-2092 universidade federal do rio grande do norte, brazil. rodrigo.neves@ufrn.br isabelle katherinne fernandes costa https://orcid.org /0000-0002-1476-8702 universidade federal do rio grande do norte, brazil. isabelle.fernandes@ufrn.br artículo self-care requisites for people with intestinal ostomies: a scoping review* received: 17/10/2022 sent to peers: 20/01/2023 approved by peers: 16/03/2023 accepted: 23/03/2023 * this article derives from the master’s thesis “construction of mobile application prototype to assist in the self-care of people with an intestinal ostomy” of the graduate program in nursing of universidade federal do rio grande do norte, brazil. available at: https://repositorio.ufrn.br/jspui/handle/123456789/32394. this research was funded by the national council for scientific and technological development, public notice cnpq/ ms/sctie/decit 27/2019. doi: 10.5294/aqui.2023.23.2.5 para citar este artículo / to reference this article / para citar este artigo silva ip, diniz iv, sena jf, lucena skp, do o’ lb, dantas ran et al. self-care requisites for people with intestinal ostomies: a scoping review. aquichán. 2023;23(2):e2325. doi: https://doi.org/10.5294/aqui.2023.23.2.5 https://orcid.org/0000-0002-9865-2618 mailto:isabelle.silva.015@ufrn.edu.br https://orcid.org/0000-0002-0309-6007 mailto:contato@iraktania.page https://orcid.org/0000-0002-8968-1521 mailto:julliana.sena.012@ufrn.br https://orcid.org/0000-0002-1191-927x mailto:silvia.lucena@ufrn.br https://orcid.org/0000-0002-8419-3457 mailto:lorena.o.702@ufrn.edu.br https://orcid.org/0000-0002-9309-2092 mailto:rodrigo.neves@ufrn.br https://orcid.org/0000-0002-1476-8702 mailto:isabelle.fernandes@ufrn.br https://repositorio.ufrn.br/jspui/handle/123456789/32394 https://doi.org/10.5294/aqui.2023.23.2.5 https://doi.org/10.5294/aqui.2023.23.2.5 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2023.23.2.5&amp;domain=pdf&amp;date_stamp=2023-05-19 theme: promotion of health, well-being, and quality of life contribution to the discipline: self-care is an indispensable factor to all human beings and an object of health care. people with ostomies present new demands of self-care that require support to achieve the necessary skills and knowledge. in this sense, this study contributes to expanding the knowledge about the necessary requisites for the person with an ostomy, found in literature, which support the planning and assistance of health professionals, especially nursing, to this population in the process of health education. moreover, the review can provide the basis for new intervention studies in the area, improving the assistance to this population. se lf -c ar e re qu is it es f or p eo pl e w it h in te st in al o st om ie s: a s co pi ng r ev ie w 3 abstract self-care is one of the main factors altered in the life of a person with an ostomy. self-care requisites with nursing support are necessary. objectives: to map the self-care requisites for people with intestinal ostomies in their adaptive process, guided by orem’s theory. materials and methodology: a scoping review was conducted between may and june 2022, in which studies published from 2000 to 2022 were selected, based on orem’s self-care deficit nursing theory. the sources of evidence used were medical literature analysis and retrieval system online, cinahl, scopus, latin american and caribbean health sciences literature, nursing database, índice bibliográfico español en ciencias de la salud, web of science, scientific electronic library online, brazilian digital library of theses and dissertations, open access scientific repositories of portugal, theses canada, dart-europe e-theses portal, and national etd portal. studies presenting at least one requisite of self-care for people with intestinal ostomies, whether or not they addressed orem’s theory, and that were published in full were included. we followed the recommendations of the joanna briggs institute and the prisma international guide, registered in the open science framework (10.17605/osf.io/xrh5k). the following descriptors and search strategies were used: (ostomy or colostomy or ileostomy or stoma) and (self-care or self-management) and (adaptation or adjustment). results: the final sample was composed of 87 studies. in universal requisites, studies in the category “nutritional aspects” predominated, of which the most frequent was “eat regularly and follow a balanced diet” (23; 26.4%); in developmental requisites, the prevalent category was “stoma and peristomal skin care” and requisite “assess peristomal skin integrity” (27; 31.0%); in the health deviation requisites, the predominant category was “choice of collection equipment and adjuvant products” and the requisite “use hydrocolloid powder to absorb moisture in cases of dermatitis” (13; 14.9%). conclusions: the study contributes to guiding the assistance to the person with an ostomy, improving the self-care learning process. however, new intervention studies are still needed. keywords (source: decs) ostomy; self-care; nursing; health education; nursing models. 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 25 requisitos de autocuidado a personas con ostomías intestinales: revisión de alcance* resumen el autocuidado es uno de los principales factores en la vida de la persona con ostomía. requisitos de autocuidado con el soporte de la enfermería son necesarios. objetivos: mapear los requisitos de autocuidado a personas con ostomía intestinal en su proceso adaptativo, norteado por la teoría de orem. materiales y método: revisión de alcance llevada a cabo entre mayo y junio de 2022, en la que se seleccionaron estudios publicados de 2000 a 2022, desde el marco de la teoría de enfermería del déficit del autocuidado de orem. se emplearon como fuentes de evidencia medical literature analysis and retrieval system online, cinahl, scopus, literatura latinoamericana y del caribe en ciencias de la salud, base de datos en enfermería, índice bibliográfico español en ciencias de la salud, web of science, scientific electronic library online, biblioteca digital brasileira de teses e dissertações, repositório científico de acesso aberto de portugal, theses canada, dart-europe e-theses portal y national etd portal. se incluyeron estudios que presentaran al menos un requisito de autocuidado a personas con ostomías intestinales, que abordaran o no la teoría de orem y publicados en la íntegra. se siguieron las recomendaciones de joanna briggs institute y prisma international guide, con registro en la open science framework (10.17605/osf.io/ xrh5k). se emplearon los siguientes descriptores y estrategias de búsqueda: (ostomy or colostomy or ileostomy or stoma) and (self care or self-management) and (adaptation or adjustment). resultados: la muestra final fue de 87 estudios. en los requisitos universales, predominaron estudios en la categoría “aspectos nutricionales”, de los cuales el más frecuente fue “comer regularmente y seguir una dieta balanceada” (23; 26,4 %); en los requisitos de desarrollo, la categoría prevalente fue “cuidados con la ostomía y la piel periestomal” y el requisito, “evaluar la integridad de la piel periestomal” (27; 31,0 %); en los requisitos de desviación de la salud, la categoría predominante fue “selección del equipo recolector y los productos adyuvantes”, y el requisito, “usar polvo hidrocoloide para absorber la humidad en casos de dermatitis” (13; 14,9  %). conclusiones: el estudio aporta a la orientación de la atención a la persona con ostomía, lo que puede mejorar el proceso de aprendizaje del autocuidado. sin embargo, nuevos estudios de intervención aún son necesarios. palabras clave (fuente: decs) ostomía; autocuidado; enfermería; educación en salud; modelos de enfermería. * el artículo se deriva de la tesis de maestría “construción de protótipo de aplicación móbil para auxiliar en el autocuidado a personas con ostomías intestinales” en el marco del programa de postgrado en enfermería de la universidade federal do rio grande do norte, brasil. disponible en: https://repositorio.ufrn.br/jspui/handle/123456789/32394. la investigación fue auspiciada por el conselho nacional de desenvolvimento científico e tecnológico, edital cnpq/ms/sctie/decit 27/2019. https://repositorio.ufrn.br/jspui/handle/123456789/32394 se lf -c ar e re qu is it es f or p eo pl e w it h in te st in al o st om ie s: a s co pi ng r ev ie w 5 requisitos de autocuidado para pessoas com estomias intestinais: revisão de escopo* resumo o autocuidado é um dos principais fatores alterados na vida da pessoa com estomia. requisitos de autocuidado com o apoio da enfermagem são necessários. objetivos: mapear os requisitos de autocuidado para pessoas com estomia intestinal em seu processo adaptativo, norteado pela teoria de orem. materiais e método: revisão de escopo realizada entre maio e junho de 2022, na qual foram selecionados estudos publicados de 2000 a 2022, com base no referencial da teoria de enfermagem do déficit do autocuidado de orem. utilizaram-se como fontes de evidência medical literature analysis and retrieval system online, cinahl, scopus, literatura latino-americana e do caribe em ciências da saúde, base de dados em enfermagem, índice bibliográfico español en ciencias de la salud, web of science, scientific electronic library online, biblioteca digital brasileira de teses e dissertações, repositório científico de acesso aberto de portugal, theses canada, dart-europe e-theses portal e national etd portal. incluíram-se estudos que apresentassem pelo menos um requisito de autocuidado para pessoas com estomias intestinais, que abordassem ou não a teoria de orem e publicados na íntegra. seguiram-se as recomendações da joanna briggs institute e do prisma international guide, com registro na open science framework (10.17605/osf.io/xrh5k). usaram-se os seguintes descritores e estratégias de busca: (ostomy or colostomy or ileostomy or stoma) and (self care or self-management) and (adaptation or adjustment). resultados: a amostra final foi composta de 87 estudos. nos requisitos universais, predominaram estudos na categoria “aspectos nutricionais”, dos quais o mais frequente foi “comer regularmente e seguir uma dieta equilibrada” (23; 26,4 %); nos requisitos de desenvolvimento, a categoria prevalente foi “cuidados com a estomia e a pele periestomal” e o requisito, “avaliar a integridade da pele periestomal” (27; 31,0 %); nos requisitos de desvio de saúde, a categoria predominante foi “escolha do equipamento coletor e dos produtos adjuvantes”, e o requisito, “usar pó hidrocoloide para absorver a umidade em casos de dermatite” (13; 14,9  %). conclusões: o estudo contribui para nortear a assistência à pessoa com estomia, melhorando o processo de aprendizado do autocuidado. contudo, novos estudos de intervenção ainda são necessários. palavras-chave (fonte decs) estomia; autocuidado; enfermagem; educação em saúde; modelos de enfermagem. * este artigo é derivado da dissertação de mestrado “construção de protótipo de aplicativo móvel para auxiliar no autocuidado de pessoas com estomias intestinais” do programa de pós-graduação em enfermagem da universidade federal do rio grande do norte, brasil. disponível em: https://repositorio.ufrn.br/jspui/handle/123456789/32394 https://repositorio.ufrn.br/jspui/handle/123456789/32394 6 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 25 introduction intestinal ostomies consist of surgical openings to exteriorize a segment of the intestine to supply the needs of fecal elimination (1). the process of living with an ostomy has repercussions on biopsychosocial aspects and promotes changes and adaptations in people’s daily habits, self-care, and self-image (2). self-care is one of the main factors altered in the life of a person with an ostomy, due to the new demands of body care that permeate aspects such as body hygiene, stoma and peristomal skin, nutrition, sexuality, social relations, and psychological factors. insufficient self-care can lead to complications associated with the stoma and hinder the adaptive process (3). dorothea orem defines self-care as actions that people perform to maintain the functioning and well-being of the body, preserving organic development, health, and life. when there is an imbalance between the demands and the ability to perform these actions, there is a self-care deficit, a situation in which the nurse plays an important role in supporting the patient who has difficulties in self-care (4). people with ostomies experience deficits, especially during the initial period after surgery, related to the new skills required in the care of the ostomy and the collection equipment, as well as the psychological and social repercussions (5). these aspects derive from problems of acceptance and aversion to touch or care for the stoma, and from difficulties with the required skills and in the process of learning about self-care (3, 6). such factors need to be developed and directed by the nurse in the process of health education, in which the person with an ostomy, along with caregivers and family members, has a central and active role. for this, orem establishes essential actions for the provision of self-care, called “requisites”, which can be universal when they concern the maintenance of life, developmental when related to body changes or new events, and of health deviation when associated with pathologies or injuries (4). it is fundamental that people with ostomies develop these requisites in their learning process of self-care with the support of nursing, especially because the nurse has an important role in the performance of healthcare services for people with ostomies within the unified health system (sus, by its acronym in portuguese), participating in the comprehensive assistance to the population, as well as in the duties of organizing services (7). in this sense, this study is justified by the need to expand the knowledge of nurses about the requisites of self-care, aiming to improve the assistance provided, in addition to giving information that can support the development of technologies and educational methods for the self-care of this population. therefore, the objective of the se lf -c ar e re qu is it es f or p eo pl e w it h in te st in al o st om ie s: a s co pi ng r ev ie w 7 study is to map the self-care requisites for people with intestinal ostomies in their adaptive process, guided by orem’s theory. materials and methodology the study consists of a scoping review conducted from may to june 2022, based on the theoretical framework of orem’s selfcare deficit nursing theory (4), in which studies published from 2000 to 2022 were selected. we followed the protocol of the joanna briggs institute (jbi) reviewers’ manual: delimitation of the research question, surveys of studies in the literature, selection based on eligibility criteria, data analysis, synthesis, and presentation (8). for the structured presentation of results, the recommendations of the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr [9]) were followed. a search for protocols similar to this review was performed in april 2022 in the jbi clinical online network of evidence for care and therapeutics (connect+), database of abstracts of reviews of effects (dare), the cochrane library, and international prospective register of ongoing systematic reviews (prospero) data sources. it was found that there are no protocols similar to the purpose of this study. after that, a search protocol was created with the following items: objective, guiding question (mnemonic “population, concept, context — pcc”), inclusion and exclusion criteria, search strategy, data to be extracted from the studies, and form of presentation of results. the study protocol was registered on the open science framework (osf) platform under the doi: 10.17605/osf.io/xrh5k. the guiding question was elaborated from the mnemonic “pcc”, in which “p” indicates people with intestinal ostomies; “c”, selfcare requisites; “c”, adaptive process. in this way, the aim is to question what self-care requisites are necessary for people with ostomies in their adaptive process. the descriptors were selected in the indexed vocabulary of the medical subject headings (mesh) and descriptors in health sciences (decs); in addition, the keywords were searched in the studies available in the national library of medicine (pubmed) and the cumulative index to nursing & allied health literature (cinahl), according to the recommendations of the jbi. based on this, the following search strategy was elaborated: (ostomy or colostomy or ileostomy or stoma) and (self-care or self-management) and (adaptation or adjustment). the following data sources were used: medical literature analysis and retrieval system online (medline), cinahl, scopus, latin american and caribbean health sciences literature (lilacs, by 8 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 25 its acronym in portuguese), nursing database (bdenf, by its acronym in portuguese), índice bibliográfico español en ciencias de la salud (ibecs), web of science, and scientific electronic library online (scielo). regarding the gray literature sources, studies were sought in the brazilian digital library of theses and dissertations (bdtd, by its acronym in portuguese), the open access scientific repository of portugal (rcaap, by its acronym in portuguese), theses canada, the dart-europe e-theses portal, and the national etd portal. due to the specifications of the data sources, the search strategy was adapted to each of them, but we tried to keep it as similar as possible to the original strategy. table 1 presents the strategies used for each source. table 1. search strategies conducted in each data source. natal, rio grande do norte, brazil, 2022 search strategies source ti ostomy or ti colostomy or ti ileostomy or ti stoma and ti self care or ti selfmanagement and ti adaptation or ti adjustment medline ti ostomy or ti colostomy or ti ileostomy or ti stoma and ti self care or ti selfmanagement and ti adaptation or ti adjustment cinahl (title-abs-key (ostomy) or title-abs-key (colostomy) or title-abs-key (ileostomy) or title-abs-key (stoma) and title-abs-key (self and care) or title-abs-key (self and management) and title-abs-key (adaptation) or title-abs-key (adjustment)) scopus (tw:(ostomy)) or (tw:(colostomy)) or (tw:(ileostomy)) or (tw:(stoma)) and (tw:(self-care)) or (tw:(self-management)) and (tw:(adaptation)) or (tw:(adjustment)) lilacs (tw:(ostomy)) or (tw:(colostomy)) or (tw:(ileostomy)) or (tw:(stoma)) and (tw:(self-care)) or (tw:(self-management)) and (tw:(adaptation)) or (tw:(adjustment)) bdenf (tw:(ostomy)) or (tw:(colostomy)) or (tw:(ileostomy)) or (tw:(stoma)) and (tw:(self-care)) or (tw:(self-management)) and (tw:(adaptation)) or (tw:(adjustment)) ibecs (tw:(ostomy)) or (tw:(colostomy)) or (tw:(ileostomy)) or (tw:(stoma)) and (tw:(self-care)) or (tw:(self-management)) and (tw:(adaptation)) or (tw:(adjustment)) scielo (all fields: ostomy and all fields: self-care) bdtd ostomy or (colostomy or ileostomy or stoma) and self-care or (self-management) and adaptation or (adjustment) rcaap ostomy or colostomy or ileostomy or stoma and self-care or self-management and adaptation or adjustment theses canada ostomy or colostomy or ileostomy or stoma and self-care or self-management and adaptation or adjustment dart-europe e-theses portal ostomy or (colostomy or ileostomy or stoma) and self-care or (self-management) and adaptation or (adjustment) national etd portal source: elaborated by the authors. se lf -c ar e re qu is it es f or p eo pl e w it h in te st in al o st om ie s: a s co pi ng r ev ie w 9 the eligibility criteria included studies that presented at least one requisite of self-care (actions aimed at the provision of selfcare [4]) for people with intestinal ostomies, whether or not they addressed orem’s theory, and that were published in full online in the journals portal of the coordination for the improvement of higher education personnel (capes, by its acronym in portuguese). access to the portal was through the federated academic community (cafe, by its acronym in portuguese), a resource funded by the university where the study was conducted. duplicates, editorials, experience reports, opinion articles, and theoretical essays were excluded. the studies were initially selected based on the titles and abstracts, and after the initial sorting, they were read in full for the sample selection. the search was conducted by two researchers independently, and at the end, the selected texts were compared and read in their entirety. in case of disagreement, a third researcher delimited the study to be included. no software was used in the process of selection and analysis of the studies. the self-care requisites were grouped as proposed by orem (5): universal when they addressed basic activities of daily living for the functioning of the body, developmental when related to specialized actions of the universal requisites for changes in body development or new conditions or events, and health deviation for situations of diseases or injuries that require diagnostic, therapeutic or rehabilitative care actions. moreover, the requisites were subdivided into thematic categories based on the brazilian consensus on stomal therapy (10). the selected studies were identified by the letter “e”, from e1e83 (6, 11-96). the data extracted from the studies of the final sample (identification data, type of study, and recommendations for self-care) were tabulated in a microsoft excel spreadsheet, analyzed according to descriptive statistics, and presented in table format. results a total of 35,363 studies were identified in the databases and gray literature, of which 87 were selected to compose the sample, as detailed in the diagram of figure 1. of this total, 78 are articles, with eight dissertations and one thesis. regarding the characterization of the studies in the sample, it was found that most were from the cinahl database (52; 59.8%) and the british journal of nursing (18; 20.7%), published in the united kingdom (40; 46.0%) and carried out in the united kingdom (44; 50.6%). the publications occurred between 2000 and 2022, mostly in the years 2019 (9; 10.3%), 2013 (8; 9.2%), and 2014 (7; 8.0%), and were found to be predominantly literature reviews 10 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 25 studies identi�ed in databases n = 35,363 studies identi�ed in gray literature n = 270 total number of studies n = 35,633 total number of studies after application of �lters n = 17,935 filters: full text and abstract available excluded due to duplicity excluded for not meeting inclusion criteria n = 116 excluded for not answering the research question n = 51 pre-selected by title and abstract n = 286 total number of studies after exclusion due to duplicity n = 254 studies included in the sample n = 87 total number of studies after application of eligibility criteria n = 138 id en ti fi c a ti o n so r ti n g el ig ib il it y in c lu si o n (50; 57.5%). regarding self-care requisites, 78 requisites were identified, of which 19 were classified as universal, 41 as developmental, and 18 as health deviation. concerning the universal requisites, described in table 2, most studies were identified in the category “nutritional aspects”, of which the most frequent was “eating regularly and following a balanced diet”. in addition, within this category, the least frequent were “observe the effects of dietary changes on stool” (5; 5.7% [29, 36, 73, 78, 92]), “avoid consuming large amounts of fluid during or immediately before or after meals” (4; 4.6% [14, 22, 32, 34]), “avoid talking while eating” (3; 3.4% [56, 75, 78]), “avoid foods that may cause obstruction” (3; 3.4% [16, 21, 73]), “avoid foods that cause diarrhea” (3; 3.4% [14, 15, 52]), and “control foods that cause odor” (2; 2.3% [18, 78]). figure 1. diagram of study selection from data sources. natal, rio grande do norte, brazil, 2022 source: elaborated by the authors. se lf -c ar e re qu is it es f or p eo pl e w it h in te st in al o st om ie s: a s co pi ng r ev ie w 11 table 2. absolute and relative frequency of the universal requisites identified in the studies. natal, rio grande do norte, brazil, 2022 universal requisites studies n (%) nutritional aspects eat regularly and follow a balanced diet e2, e6, e12, e13, e15, e16, e17, e18, e19, e20, e23, e27, e29, e33, e40, e46, e48, e49, e67, e69, e71, e75, e84. 23 (26.4) maintain a good fluid intake e2, e4, e8, e9, e17, e19, e20, e24, e27, e33, e40, e46, e48, e49, e51, e56, e67, e69. 18 (20.7) avoid gas-producing foods e2, e12, e13, e15, e17, e51, e56, e63, e67, e69, e71, e80, e81, e82. 14 (16.1) masticate food thoroughly e2, e12, e17, e19, e27, e33, e37, e40, e46, e48, e56, e67, e69, e71. 14 (16.1) taste foods gradually e12, e17, e20, e23, e24, e27, e33, e40, e56, e69, e71. 11 (12.6) intestinal control watch for signs of change in the stool e5, e7, e37, e45, e53, e63, e86. 7 (8.0) physical activities perform moderate physical exercises to prevent constipation e19, e20, e39, e51. 4 (4.6) take walks to help stimulate bowel function and muscle tone e39, e40, e62. 3 (3.4) professional clinical advice should be sought before beginning any kind of exercise e39, e40. 2 (2.3) sexuality express concerns and doubts about sexual aspects and body image e66, e73, e75, e84. 4 (4.6) explore other comfortable positions for sexual activities e66, e73, e83. 3 (3.4) accept to adapt to changes and self-image after the ostomy e85, e87. 2 (2.3) discuss aspects that can improve self-image with health-care professionals e36. 1 (1.1) source: elaborated by the authors. as for the developmental requisites, described in table 3, the predominance of the category “stoma and peristomal skin care” and the requisite “assess peristomal skin integrity” were observed. in this category, the least frequent requisites were “keep the peristomal skin clean and dry” (4; 4.6% [43, 46, 67, 74]), “cut the peristomal skin hairs” (3; 3.4% [45, 79, 83]), “measure the length and width of irregular stomas” (2; 2.3% [45, 63]), and “expose the skin around the stoma to the sun” and “protect the stoma with moist gauze” (1; 1.1% [83]). 12 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 25 table 3. absolute and relative frequency of the developmental requisites identified in the studies. natal, rio grande do norte, brazil, 2022 developmental requisites studies n (%) stoma and peristomal skin care assess peristomal skin integrity e20, e26, e23, e25, e29, e32, e33, e35, e37, e38, e40, e43, e46, e47, e50, e52, e53, e54, e55, e56, e58, e67, e68, e69, e72, e76, e86. 27 (31.0) clean the peristomal skin with tap water and dry thoroughly e1, e9, e15, e17, e19, e21, e22, e25, e26, e29, e38, e40, e41, e56, e57, e58, e67, e69, e72, e76, e81, e82. 22 (25.3) check the normal appearance of the stoma e3, e4, e7, e9, e15, e17, e20, e24, e27, e29, e40, e41, e43, e46, e50, e52, e67, e72, e76, e77. 20 (23.0) assess the viability of the ostomy and its characteristics e7, e8, e25, e29, e35, e38, e50, e52, e55, e68, e72, e76. 12 (13.8) avoid the use of moisturizers on the peristomal skin e29, e41, e56, e58, e68, e69, e76. 7 (8.0) choice of collection equipment and supplies the opening of the base plate should be cut in the diameter of the stoma e1, e3, e7, e8, e13, e14, e17, e20, e24, e29, e38, e40, e41, e50, e58, e61, e68, e72, e76, e77. 20 (23.0) use products that act as a barrier to protect the peristomal skin e3, e8, e17, e19, e21, e24, e26, e32, e38, e44, e46, e47, e50, e57, e58, e65, e68, e69, e72. 19 (21.8) remove the collection bag carefully e1, e3, e15, e17, e21, e22, e25, e38, e57, e58, e67, e69, e72, e76, e77. 15 (17.2) measure the stoma to define the size of the collection bag cutout e15, e17, e23, e24, e25, e29, e38, e40, e56, e61, e67, e76, e77. 13 (14.9) empty the bag when it is 1/3 or even 1/2 full e1, e3, e7, e9, e17, e29, e33, e40, e56, e69, e72, e76. 12 (13.8) choice of collection equipment and supplies choose the collection equipment according to the needs, individual characteristics, and type of stoma e10, e11, e12, e22, e23, e37, e41, e52, e68, e69, e72, e76, e85. 13 (14.9) use products for stomas to fill skin folds and level the skin e3, e8, e19, e32, e38, e40, e41, e44, e50, e60, e72. 11 (12.6) use bags with activated charcoal filters for the neutralization of odor e12, e17, e51, e56, e67, e69, e71, e74, e77, e78. 10 (12.0) use a transparent collection bag when it is necessary to visualize the stoma e4, e7, e12, e41, e72, e77. 6 (6.9) use deodorant sprays in the bag to control odors e27, e44, e51, e56, e69, e71. 6 (6.9) nutritional aspects decrease fiber intake for people with ileostomies e2, e12, e24, e27, e31, e33, e43, e49. 8 (9.2) se lf -c ar e re qu is it es f or p eo pl e w it h in te st in al o st om ie s: a s co pi ng r ev ie w 13 developmental requisites studies n (%) maintain adequate fiber food and fluid intake for people with colostomies e24, e46, e48, e51, e63, e69. 6 (6.9) recognize symptoms of dehydration in people with ileostomies e2, e30, e59, e67. 4 (4.6) sexuality use alternative strategies such as underwear and belts to encourage intimacy e6, e37, e62, e66, e73, e75, e83. 7 (8.0) empty or replace the collection bag before intercourse e6, e64, e66, e73, e75. 5 (5.7) avoid foods that can cause gas or strong odors before intercourse e66, e75. 2 (2.3) clinical assistance express concerns or anxieties in conversations with health-care professionals e36, e37, e40, e64, e70, e73, e75, 6 (6.9) seek help from professionals to evaluate the possibility of using continence systems e6, e64, e75, 3 (3.4) social aspects participate in groups with other people with ostomies e23, e74, e86, e87. 4 (4.6) physical activities empty the collection bag before physical activities e67, e76. 2 (2.3) source: elaborated by the authors. in the category “care of the collection equipment and supplies”, it was observed that “assess peristomal skin integrity” was the most common requisite. the least frequent requisites were “carefully remove adhesive parts of the collection equipment” (10; 12.0% [25, 28, 40, 41, 43, 46, 50, 71, 75, 77]), “check for signs of leakage in the collection equipment” (9; 10.3% [20, 25, 27, 33, 43, 47, 60, 74, 79]), “adjust the opening of the collection equipment in the first weeks after surgery” (7; 8.0% [29, 45, 47, 51, 74, 79, 92]), “carefully place the collection equipment around the stoma” (6; 6.9 % [16, 24, 25, 73, 83, 84]), “take extra supplies and collection equipment when away from home” (6; 6.9% [6, 15, 75, 83, 86, 87]), “fix the collection equipment correctly from bottom to top on the peristomal skin” (6; 6.9% [11, 27, 33, 41, 83, 84]), “identify and perform the change of the collection equipment when the plate is saturated” (5; 5.7% [18, 44, 67, 75, 83]), “when changing the collection equipment, keep it pressed for a few seconds” (4; 4.6% [26, 41, 83, 84]), “apply the barrier cream in circular movements with the fingertip” (3; 3.4% [28, 51, 62]), and “monitor the adaptation to the collection equipment” (2; 2.3% [93, 95]). the category “choice of the collection equipment and supplies” had the most common requisite for choosing the collection equipment according to the needs, individual characteristics, 14 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 25 and type of stoma. and the requisite “patients along with the nurse select the appropriate collection equipment” was the least frequent (3; 3.4% [25, 54, 83]). table 4 presents the health deviation requisites, which had “choice of collection equipment and supplies” as the most frequent category, and the requisite “use hydrocolloid powder to absorb moisture in cases of dermatitis”. in this category, the least frequent requisites were “change the collection equipment in case of allergic dermatitis” (8; 9.2% [17, 21, 25, 46, 58, 58, 67, 71, 77]), “use barrier products and rings in the presence of granulomas” (6; 6.9% [25, 43, 58, 69, 71, 88]), and “use aloe vera may help in the management of peristomal complications” (1; 1.1% [30]). table 4. absolute and relative frequency of health deviation requisites identified in the studies. natal, rio grande do norte, brazil, 2022 health deviation requisites studies n (%) choice of collection equipment and supplies use hydrocolloid powder to absorb moisture in cases of dermatitis e8, e13, e19, e24, e26, e32, e41, e50, e57, e60, e65, e68, e69. 13 (14.9) managing contact dermatitis treatment using ostomy skin barriers e7, e20, e26, e37, e38, e40, e42, e50, e54, e61, e65, e69. 12 (13.8) use a bag with convex barrier rings in cases of retraction e7, e8, e16, e23, e34, e37, e53, e63, e65, e69, e72. 10 (12.0) manage the parastomal hernia with the use of a support belt, one-piece systems, and skin protection products e1, e5, e7, e20, e23, e46, e53, e63, e65, e69. 10 (12.0) identify and manage the underlying cause of stomal complications e23, e32, e38, e46, e53, e57, e61, e68, e69, e84, e85. 11 (12.6) stoma and peristomal skin care monitor the extent of necrosis, assessing the stoma and peristomal skin e4, e23, e37, e40, e65, e69. 6 (6.9) observe signs of ischemia when the stoma presents stenosis e4, e7, e20, e53, e63. 5 (5.7) observe signs of stoma obstruction in case of complications e5, e86. 2 (2.3) prevent stomal and peristomal complications e85, e86. 2 (2.3) demonstrate strategies for the resolution of stomal and peristomal complications e86. 1 (1.1) clinical assistance seek nursing professional help in case of stomal and peristomal complications e46, e52, e56, e67, e68, e72, e76, e86, e87. 9 (10.3) seek professional help when effluents are above normal volume e30, e56, e67, e86. 4 (4.6) se lf -c ar e re qu is it es f or p eo pl e w it h in te st in al o st om ie s: a s co pi ng r ev ie w 15 health deviation requisites studies n (%) nutritional aspects use oral rehydration in case of large losses of fecal content e59, e67. 2 (2.3) physical activities discontinue exercise in case of health problems e39. 1 (1.1) sexuality seek professional help to evaluate physiological problems related to sexual activities e6, e62, e64, e66, e73. 5 (5.7) source: elaborated by the authors. discussion it was observed that the studies mapped mainly requisites on aspects of care with the stoma and the peristomal skin, nutritional aspects, and the choice of collection equipment and supplies. moreover, most of the requisites were developmental, related to the changes that people with ostomies face both in body aspects and in activities of daily living. such findings indicate the need for professionals to emphasize these aspects in the process of health education. the universal requisites presented the nutritional aspects as the most frequent category, with requisites that addressed proper nutrition, fluid intake, and bowel control, including the observation of changes in the stool. orem establishes the provision of sufficient food for the needs of body integrity, as well as the care related to elimination needs as essential for self-care. this principle should be considered by nursing, which should support this process so that the individual can manage food choices and control excrement (4). given this need, it becomes essential to monitor the changes in eating habits that people with intestinal ostomies experience since nutrition influences bowel function and elimination, which can generate undesirable effects, such as the increase of flatus, associated with the stoma type (97, 98), resulting in poorer quality of life, since the loss of consumption of certain foods may deprive the pleasurable sensations associated with eating (99, 100). in this sense, it is necessary that, in this population’s assistance, the orientations about nutritional aspects are included, as well as the available strategies that can help the person in their autonomy, such as the practice of irrigation, if the individual meets the conditions required to perform it (98). furthermore, the joint work of nursing with the multi-professional team is highlighted, through the services of attention to the health of the person with an ostomy, which has, in the scope of sus, multi-professional 16 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 25 assistance that includes nutritionists to meet the needs of nutritional and dietary assessment (7). regarding the developmental requisites, the predominant category was “stoma and peristomal skin care”, with emphasis and more frequency on the requisite “assessment of peristomal skin integrity”, followed by the categories “care and choice of the collection equipment and supplies”, which presented requisites on the correct use and handling of this equipment and the choice of products for self-care. these results are related to the changes experienced and the new self-care needs, which require specific actions for the proper functioning of the ostomy and the protection against complications, in which the support of the nursing team is of fundamental importance. for this reason, the assessment of the peristomal skin integrity is one of the essential care after having an ostomy, to prevent complications associated with the use of the collection system and the contact of stool with the skin (25). the latest recommendations encourage nurses to enable the patient to assess their stoma and peristomal skin, so that they can actively participate in the care and identify changes for preventive care, with the support of health professionals (10). among the factors that can interfere with the integrity of the peristomal skin, the inadequate handling of collection equipment, effluent leakage, and the self-care deficit related to hygiene are highlighted (3). these difficulties occur mainly during the initial period after surgery, which generates feelings of anxiety and insecurity. therefore, adequate instruction about this care provides greater safety and satisfaction to this population, especially when performed by nurses with specialized knowledge in stomal therapy (101). regarding the requisites related to the collection equipment, we emphasize the importance of the choice of the collection equipment being made in a participative way between nurses and the population with an ostomy. in the context of the sus, the collection equipment and supplies are made available in the care services for people with ostomies free of charge, and when selected appropriately and periodically reassessed, they provide confidence and satisfaction to the person with an ostomy (102), besides contributing to the resolution of complications (7). the selection of the collection equipment follows the nurse’s prescription, which must be based on the individuality of each person, considering the aspects of the patient’s preference, type of ostomy, adaptation, peristomal skin, and characteristics of the person’s abdomen (10). as for the health deviation requisites, the main category referred to the choice of the collection equipment and supplies, in which the main requisite dealt with the use of hydrocolloid powder to absorb moisture in cases of dermatitis. this category, as well as that of stoma and peristomal skin care, indicated mainly the handling of stomal and peristomal complications, present in several studies. se lf -c ar e re qu is it es f or p eo pl e w it h in te st in al o st om ie s: a s co pi ng r ev ie w 17 complications, besides negatively impacting the adaptation of people with ostomies, cause costly expenses for health services. thus, the population can benefit from more emphasis on preventive education rather than only receiving curative treatment (103). several products are available to assist in the prevention and treatment of stomal and peristomal complications, such as barrier films, adhesive removers, pastes, and powders with actives that protect or assist in the healing of lesions. it is necessary to assess not only the lesion but also the person with an ostomy as a whole, given the impact that this complication can cause in their lives, to then designate a specific conduct for each situation (104). regarding the categories of physical activities, sexuality, and social aspects present in the requisites, this review highlights the scarcity of research on these topics. this can be explained because, in self-care, the emphasis is notoriously on practical skills related to ostomy care, along with the peristomal skin and the collection equipment. however, the repercussions of an ostomy transcend the physiological changes and alter how the person sees him or herself and how he or she relates to other people as a result (105). according to orem, health deviation requisites also encompass the need to accept self-image modifications arising from treatments, health conditions, or illness (4). thus, a multidimensional nursing approach that focuses, in addition to physical changes, on emotional, sexual, and social aspects is imperative to assist in the self-care of this population. it is also noteworthy that self-care involves not only the practical care with the ostomy and the collection equipment, but also the psychological, physical, and environmental needs (4). thus, sensitivity and knowledge of nursing are crucial to identifying the main needs of this population, in an individualized and holistic way, to provide the demands of self-care. some strategies and educational technologies are being produced and have shown positive effects on health education, which can support nursing care to the person with an ostomy for the provision of self-care (106). considering the requisites identified in this study, it is expected to assist in the planning of interventions for the self-care of this population, as well as in new studies for the advancement of knowledge in the area. as a limitation, this review presents the mapping of the requisites identified in different types of studies without assessing the degree of evidence and indication for clinical practice. more studies are needed to understand these requisites based on the experiences of people with ostomies and evidence-based research, using orem’s theory to support nursing care for this population. 18 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 25 conclusions this study presented the main self-care requisites mapped in the literature and guided by orem’s theory. the universal requisites mainly addressed nutritional aspects; for the developmental requisites, the stoma and peristomal skin care predominated; as for the main health deviation requisites, they dealt with the choice of the collection equipment and supplies in case of complications. few studies addressed the categories “physical activities”, “sexuality”, and “social aspects.” therefore, the requisites identified in this study can guide nursing care to the person with an ostomy, improving the assistance provided and the process of learning self-care. furthermore, the study contributes to the advancement of nursing as a science by presenting the mapping of evidence based on a nursing theory. new intervention studies and the development of technologies based on the results of this review are suggested. conflict of interest: non to declare references 1. united ostomy associations of america. new ostomy patient guide [internet]. united states 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/10.12968/ gasn.2017.15.7.25 105. meira ifa , silva fr, sousa ar, carvalho ess, rosa dos, pereira á . repercussions of intestinal ostomy on male sexuality: an integrative review. rev bras enferm [internet]. 2020;73(6):e20190245. doi: https://doi.org /10.1590/00347167-2019-0245 106. wang qq, zhao j, huo xr, wu l, yang lf, li jy, wang j. effects of a home care mobile app on the outcomes of discharged patients with a stoma: a randomised controlled trial. j clin nurs [internet]. 2018;27(19-20):3592-602. doi: https://doi. org /10.1111/jocn.14515 http://www.bdtd.uerj.br/tde_busca/arquivo.php?codarquivo=5200 http://www.bdtd.uerj.br/tde_busca/arquivo.php?codarquivo=5200 https://doi.org/10.12968/bjon.2005.14.sup4.19738 https://doi.org/10.31011/reaid-2022-v.96-n.37-art.1274 https://doi.org/10.31011/reaid-2022-v.96-n.37-art.1274 https://doi.org/10.1111/jan.14691 https://doi.org/10.5294/aqui.2022.22.1.2 https://doi.org/10.5294/aqui.2022.22.1.2 https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s1132-12962020000200018&lng=es https://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s1132-12962020000200018&lng=es https://doi.org/10.4314/ejhs.v31i5.11 https://doi.org/10.1590/1980-265x-tce-2018-0156 https://doi.org/10.1590/1980-265x-tce-2018-0156 https://doi.org/10.1016/j.jcol.2020.07.003 https://doi.org/10.1016/j.jcol.2020.07.003 https://doi.org/10.1007/s11764-020-00940-5 https://doi.org/10.1590/1518-8345.2059.2961 https://doi.org/10.33448/rsd-v10i10.18681 https://doi.org/10.33448/rsd-v10i10.18681 http://www.ncbi.nlm.nih.gov/pubmed/28570245 http://www.ncbi.nlm.nih.gov/pubmed/28570245 https://doi.org/10.12968/gasn.2017.15.7.25 https://doi.org/10.12968/gasn.2017.15.7.25 https://doi.org/10.1590/0034-7167-2019-0245 https://doi.org/10.1590/0034-7167-2019-0245 https://doi.org/10.1111/jocn.14515 https://doi.org/10.1111/jocn.14515 94 aquichan issn 1657-5997 paola vernaza-pinzón1 gabriel álvarez-bravo2 producción científica latinoamericana de fisioterapia / kinesiología 1 fisioterapeuta, especialista en entornos virtuales de aprendizaje. docente titular, universidad del cauca, facultad de ciencias de la salud, departamento de fisioterapia, popayán, colombia. pvernaza@unicauca.edu.co, acostavernaza@gmail.com 2 estudiante de x semestre del programa de fisioterapia. universidad del cauca, popayán, colombia. galvarez@unicauca.edu.co recibido: 23 de abril de 2010 aceptado: 28 de marzo de 2011 resumen objetivo: caracterizar la producción latinoamericana de literatura científica sobre fisioterapia / kinesiología entre los años 2000 y 2007. método: se realizó un estudio descriptivo retrospectivo a 1700 artículos en el área de fisioterapia / kinesiología publicados en las bases de datos de scielo y lillacs. las variables estudiadas fueron: frecuencia documental, número de documentos encontrados, producción científica por país, producción científica por cada descriptor sobre fisioterapia / kinesiología, número de autores, filiación institucional, tipo de publicación, idioma, tipo de estudio y número de referencias bibliográficas. resultados: la tendencia de producción científica por país refleja que brasil lidera con el 70,1 % la producción científica de la fisioterapia / kinesiología en latinoamérica, seguido de chile con el 13,4 %, colombia y venezuela con el 6 %, argentina con el 3,4 %, y con menos del 1 % de representatividad en producción se encuentran cuba y perú. conclusiones: a pesar de que los estudios bibliométricos en una sola área del conocimiento no resuelven las necesidades de medida de la actividad científica, dan claridad y orientan el trabajo investigativo. conocer las investigaciones de la fisioterapia / kinesiología en la región permitirá a los académicos generar una política de investigación latinoamericana que redunde en el beneficio de la profesión, de las comunidades y del contexto. palabras clave fisioterapia, terapia física, bibliometría, investigación, américa latina (fuente: decs). latin american scientific output in physical therapy/kinesiology abstract objective: characterize the output of scientific literature in latin america between 2000 and 2007 with respect to physical therapy/ kinesiology. method: the authors conducted a retrospective study of 1,700 articles on physical therapy/kinesiology published in the scielo and lillacs databases. the variables studied were: document frequency, number of documents found, scientific output per country, scientific output for each describer with respect to physical therapy/kinesiology, number of authors, institutional affiliation, type of publication, language, type of study, and number of works listed in the bibliography. results: the trend in scientific output per country shows brazil leads in latin america, with 70.1 % of the scientific output on physical therapy/kinesiology, followed by chile with 13.4 %, colombia año 11 vol. 11 nº 1 chía, colombia abril 2011 l 94-107 95 producción científica latinoamericana de fisioterapia / kinesiología l paola vernaza-pinzón, gabriel álvarez-bravo and venezuela with 6 %, argentina with 3.4 %, and cuba and peru with less than 1 % of the output. conclusions: although bibliometric studies in only one field of knowledge do not resolve the need to measure scientific activity, they provide clarity and guide research work. knowing what studies on physical therapy/kinesiology have been done in the region will enable academics to generate a latin american research policy that is of benefit to the profession, the community and the context. key words physiotherapy, physical therapy, bibliometrics, research, latin america (source: decs). produção científica latino-americana de fisioterapia e cinesiologia resumo objetivo: caracterizar a produção latino-americana da literatura científica sobre fisioterapia e cinesiologia entre 2000 e 2007. método: realizou-se um estudo retrospectivo de 1700 artigos na área de fisioterapia/cinesiologia publicado em scielo e lillacs. as variáveis estudadas foram freqüência documental, número de documentos encontrados, produção científica por país, produção científica por cada descritor sobre fisioterapia/cinesiologia, número de autores, filiação institucional, tipo de publicação, idioma, tipo de estudo, número de referências. resultados: a tendência da produção científica por país mostra que o brasil lidera (70,1 %) a produção científica de fisioterapia/cinesiologia na américa latina, seguido pelo chile (13,4 %), colômbia e venezuela (6 %), argentina (3,4 %). cuba e peru apresentam 1 % da produção. conclusões: embora os estudos bibliométricos em uma área do conhecimento não satisfaz as necessidades de medição da atividade científica, dão clareza e orientam o trabalho de pesquisa. conhecer as investigações da fisioterapia/cinesiologia na região permitirá aos estudiosos gerar uma política de pesquisa na américa latina que beneficie à profissão, as comunidades e ao contexto. palavras-chave fisioterapia, terapia física, a bibliometria, pesquisa, américa latina (fonte: decs). 96 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 introducción la bibliometría es una parte de la cienciometría que aplica métodos matemáticos y estadísticos a toda la literatura de carácter científico y a los autores que la producen, con el objetivo de estudiar y analizar la actividad científica (1); para ello se ayuda de leyes bibliométricas basadas en el comportamiento estadístico regular que a lo largo del tiempo han mostrado los diferentes elementos que forman parte de la ciencia. los instrumentos utilizados para medir los aspectos de este fenómeno social son los indicadores bibliométricos, medidas que proporcionan información sobre los resultados de la actividad científica en cualquiera de sus áreas de conocimiento. los indicadores bibliométricos son datos estadísticos deducidos de las distintas características de las publicaciones científicas, que proporcionan información cuantitativa y objetiva sobre los resultados del proceso investigador: cantidad, estabilidad y visibilidad internacional de los investigadores y de los grupos de investigación. de esta manera, el análisis y la evaluación de la información y el conocimiento resultantes de la actividad científica son elementos imprescindibles para todos los programas de investigación y desarrollo que se implementan en una sociedad, y es allí donde la ciencia de la información brinda una ayuda inestimable al desarrollar técnicas e instrumentos para medir la producción de conocimiento y su transformación en bienes (2). en latinoamérica, la investigación tuvo que esperar varias décadas para que se generalizara su institucionalización y se profesionalizara la actividad científica. actualmente, la formación de investigadores está bien jerarquizada y organizada. no obstante, para ser buen investigador se requiere aprender a ver el mundo de manera diferente, formular preguntas inteligentes para que mediante una estrategia se intente su solución, es decir, el investigador debe ser creativo, además de contar con los instrumentos metodológicos para cumplir con su cometido. el estudio más representativo sobre bibliometría en américa latina es el reportado por licea de arenas y colaboradores (3), quienes mostraron que 31 países o unidades territoriales estuvieron representados en las bases de datos; brasil fue el país con el mayor número de artículos indizados (53,6%), seguido por méxico, cuba y colombia. veinticinco autores de cuatro países fueron los más productivos según las bases de datos utilizadas, a saber: brasil (17 autores), méxico (5 autores), chile (1 autor), colombia (1 autor) y cuba (1 autor), dichos autores participaron en 234 artículos, de los cuales 59 (25 %) fueron en coautoría. de la relación de autores con mayor número de artículos en las bases de datos utilizadas para construir los datos empíricos es posible advertir que algunos de ellos han sido impulsores del desarrollo de la ciencia y la tecnología en la región, bien sea en su calidad de formadores de recursos humanos o como practicantes de la profesión. los cinco primeros autores de la lista acumularon el 34,2 % del total de publicaciones de los autores más productivos; según las fuentes utilizadas, el predominio de la autoría individual (76 % del total de artículos) nos lleva a pensar que todavía la bibliotecología y la ciencia de la información de américa latina tienen un largo trecho que recorrer. la coautoría en otras áreas del conocimiento ha demostrado que el trabajo grupal no sólo contribuye a la consolidación de las disciplinas sino también a la formación de recursos humanos. el análisis y la evaluación de la información y el conocimiento resultantes de la actividad científica son elementos imprescindibles para todos los programas de investigación y desarrollo que se implementan en una sociedad. 97 producción científica latinoamericana de fisioterapia / kinesiología l paola vernaza-pinzón, gabriel álvarez-bravo hoy en día, el profesional de la información tiene que desarrollar nuevas capacidades de productividad al disponer de herramientas novedosas, dada la existencia de nuevos procesos y productos de la industria del conocimiento que establecen nuevos perfiles de trabajo profesional antes desconocidos e impensados. asimismo, debe concentrarse no sólo en la información estructurada y las fuentes formales de la misma, sino también en aquella no estructurada, suelta, informal o efímera, para impedir que tenga una comprensión artificial de lo que constituye un bien en información. de esta manera, los egresados universitarios de la región deben caracterizarse por demostrar una formación científica, una capacidad de adaptación al sistema económico actual, contar con habilidades empresariales para la venta de sus servicios y las destrezas que está demandando la sociedad. la formación científica será esencial para que los profesionales de américa latina adapten y adopten conocimiento y generen los productos de sus investigaciones científicas para la acción disciplinar. respecto a las mediciones bibliométricas latinoamericanas en ciencias de la salud, solo se encontró el estudio de macías-chapula (4), el cual presenta los resultados de un análisis bibliográfico de la producción científica sobre salud pública en la región de américa latina y el caribe. los estudios bibliométricos en américa latina por disciplinas del conocimiento continúan siendo escasos, y el no contar con referencias de dichos estudios para la fisioterapia en américa latina justificó el desarrollo de la investigación, con el objetivo de caracterizar la producción investigativa de la fisioterapia / kinesiología en la región sur de la world confederation for physical therapy (wcpt) durante el periodo 2000-2007, pues se pretende documentar a la comunidad científica de la confederación latinoamericana de fisioterapia y kinesiología (clafk), del centro latinoamericano de desarrollo de la fisioterapia y la kinesiología (cladefk), y de la wcpt sobre el estado de la investigación en estas disciplinas, su presente y su futuro, con el propósito de responder a las necesidades de la comunidad, además de clasificar por medio de indicadores bibliométricos la calidad de las investigaciones a fin de que se tomen decisiones y adopten políticas en cuanto a la generación de nuevo conocimiento. teniendo en cuenta la región en la cual se enmarca el presente estudio, se trabajó con dos bases de datos: scieloscientific electronic library online (biblioteca científica electrónica en línea) como modelo para la publicación electrónica cooperativa de revistas científicas en internet, y lilacs coordinada por bireme (centro latinoamericano y del caribe de información en ciencias de la salud), a la que los diferentes países comprendidos en el entorno geográfico latinoamericano contribuyen con el envío de registros bibliográficos. estas bases de datos han sido especialmente desarrolladas para responder a las necesidades de la comunicación científica en los países en desarrollo, particularmente de américa latina. método se realizó un estudio descriptivo longitudinal retrospectivo de los resultados obtenidos en el análisis bibliométrico de la producción investigativa en fisioterapia / kinesiología en américa latina durante el periodo 2000-2007. los datos se obturespecto a las mediciones bibliométricas latinoamericanas en ciencias de la salud, solo se encontró el estudio de macíaschapula, el cual presenta los resultados de un análisis bibliográfico de la producción científica sobre salud pública 98 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 vieron de la consulta directa y online de las bases de datos bibliográficas scielo y lilacs. el universo estuvo conformado por 12.305 artículos (correspondiente a 2.664 artículos obtenidos de la base de datos scielo y 9.641 artículos de la base de datos de lilacs). antes de iniciar la búsqueda documental se listaron, tal como se observa en el cuadro 1 (ver anexo), los descriptores mesh3 y desc4, herramientas utilizadas para la búsqueda documental. en el cuadro 2 (ver anexo) se describe la estructura jerárquica de los descriptores mesh utilizada para realizar una búsqueda más analítica de las publicaciones científicas en fisioterapia / kinesiología. teniendo claros los descriptores de búsqueda, y dando cumplimiento a los siguientes criterios, fueron seleccionados para el estudio 2.810 artículos. criterios de inclusión: 1) artículos que dentro de sus key words incluyeran la palabra de búsqueda mesh-decs. 2) artículos publicados en revistas de américa latina. 3) artículos escritos por diferentes profesionales que incluyeran la palabra de búsqueda mesh-decs y que aportaran a la fisioterapia / kinesiología. como criterios de exclusión se tuvieron en cuenta: 1) artículos que no permitieran el acceso electrónico. 2) artículos cuya página había caducado y cuyo host no existía. 3) las cartas al editor. las variables que se tuvieron en cuenta para el presente estudio fueron: frecuencia documental, número de documentos encontrados, producción científica por país, producción científica por cada descriptor sobre fisioterapia, número de autores por publicación especificada por país, filiación institucional, idioma, tipo de estudio, y número de referencias bibliográficas. una vez obtenido el total de documentos por base bibliográfica, se eliminaron los artículos redundantes entre las bases de datos ingresando finalmente al estudio 1.700 artículos de los cuales el 72,4 % fueron depurados de la base de datos de scielo y el 27,6 % de la base de datos de lilacs. cada uno de los documentos revisados se categorizó, de acuerdo con su afinidad temática, en 15 áreas de conocimiento, algunas de las cuales han sido definidas dentro de las políticas mundiales de la wcpt (5): actividad física, fundamentación del movimiento corporal humano, cardiovascular, rehabilitación basada en la comunidad, educación, salud pública, metabólico, infecciones, neurología, obstetricia, oncología, renal, respiratorio, osteomuscular y salud mental. entre tanto, la metodología del artículo se clasificó en: descriptivo y ensayo clínico. respecto a la filiación institucional se tomaron como centros de referencia universidades, grupos de investigación e instituciones, y datos extraídos de la información de los autores. para el procesamiento y análisis estadístico de la información se construyó una base de datos en el programa excel, información que fue analizada en el paquete estadístico spss.14. las variables cualitativas se expresaron en frecuencias y proporciones, y a las variables cuantitativas se les aplicó estadística de tendencia central. los resultados fueron presentados en tablas y gráficos de tendencia. resultados analizadas las bases de datos scielo y lilacs se revela la tendencia creciente en la producción científica de la fisioterapia / 3 medical subject headings: descriptor en inglés para búsqueda. 4 descriptor en ciencias de la salud. descriptor en español para efectuar la búsqueda en castellano (español) y en portugués. kinesiología en latinoamérica, 2000-2007 (ver anexo, gráfica 1). la tendencia de producción científica por país refleja que brasil lidera con el 70,1 % la producción científica de la fisioterapia / kinesiología en latinoamérica, seguido de chile con el 13,4 %, colombia y venezuela con el 6%, argentina con el 3,4 % y con menos del 1 % de representatividad en producción se encuentran cuba y perú. no reportan producción científica en las bases de datos analizadas los países de bolivia, ecuador, paraguay y uruguay. en la gráfica 2 (ver anexo) se revela la tendencia creciente de la producción científica por cada país, observándose cómo brasil repunta desde el 2003 con un crecimiento exponencial. con referencia a la producción científica por descriptor el estudio arrojó 56 descriptores de los cuales los que más se referencian en la producción investigativa son: exercise, relaxation, hyperthermia, massage, walking y homeopathy, mientras que los descriptores que menos se referencian son: modalidades de terapia física, terapia física, exercise movement techniques, motion therapy, continuous passive, diathermy y kinesiology applied. los cinco descriptores de mayor referenciación por país se pueden observar en la tabla 1 (ver anexo). es importante destacar que cada país utilizó con mayor frecuencia un número de descriptores dentro de sus palabras clave de búsqueda, es así como argentina utilizó 10 descriptores, chile 21, brasil 48, venezuela 15, colombia 19, cuba 2 y perú 1. en cuanto a los temas de producción científica más predominantes por país se encontró que para argentina predomina la siguiente jerarquización: rehabilitación basada en la comunidad, seguida por cardiovascular, salud pública, fundamentación del movimiento corporal 99 producción científica latinoamericana de fisioterapia / kinesiología l paola vernaza-pinzón, gabriel álvarez-bravo humano y educación; en chile predomina la publicación de artículos en temas de rehabilitación basada en la comunidad, respiratorio, educación, salud pública y metabólico; brasil se destaca con su producción científica en rehabilitación basada en la comunidad, fundamentación del movimiento corporal humano, actividad física, cardiovascular y metabólico; la producción científica en venezuela tiene que ver con la rehabilitación basada en la comunidad, educación, ciencias básicas, infecciones y metabólico; colombia destaca su producción en temas como rehabilitación basada en la comunidad, cardiovascular, fundamentación del movimiento corporal humano, actividad física y educación; respecto a las publicaciones científicas cubanas los temas de mayor publicación son rehabilitación basada en la comunidad, educación y respiratorio; mientras que en perú la publicación se ha centrado en el tema metabólico. respecto al número de autores, el mínimo referenciado por publicación fue de 1, el máximo fue de 19, la media fue de 3,57 con una desviación estándar de ± 2,29. el país que más autores referenció en una publicación fue chile con 19, seguido de venezuela con 17, brasil con 14 y colombia con 13; argentina, cuba y perú referenciaron menos de 10 autores por publicación. las revistas escogidas para publicaciones por cada país en orden de frecuencia fueron: revista brasilera de medicina del deporte, con periodicidad bimensual (rev bras med esporte); revista médica de chile de publicación mensual; revista de medicina de buenos aires (argentina), con seis publicaciones al año; gaceta médica de caracas (venezuela), de publicación trimestral, y revista de salud pública de la universidad nacional de colombia, con publicación trimestral. del total de publicaciones, el 38,0 % son generadas regularmente desde universidades y centros hospitalarios. el mínimo número de instituciones que respaldan a los autores en su publicación es 1, el máximo 14; la media es de 2,73 con una desviación estándar de ± 2,07; las instituciones que mayor productividad reportan son: universidad federal de são paulo (brasil), universidad de chile, universidad de buenos aires (argentina), pontificia universidad católica de chile, universidad federal do rio grande do sul (porto alegre-brasil), universidad federal de santa catarina (brasil), universidad estadual de campinas (brasil), universidad del estado de zulia (venezuela) y la universidad del rosario (colombia). respecto a la representatividad de los grupos de investigación en las publicaciones se pudo apreciar que el 96,5 % de estas no están siendo soportadas por grupos de investigación, sólo argentina, brasil, chile y colombia representan el 3,5 % del total de publicaciones que refieren respaldo de grupos de investigación. en cuanto a los temas de publicación de los grupos de investigación, los resultados del estudio arrojan los siguientes: rehabilitación basada en la comunidad, actividad física y cardiovascular. de acuerdo con el tipo de estudio es de anotar que las investigaciones descriptivas tienen una participación del 77,7 % y las investigaciones tipo ensayo clínico registran una participación del 22,2 %. venezuela y perú son los únicos países que no reportan investigaciones con metodología experimental, los otros países presentan una relación de 4:1 respecto a las investigaciones descriptivas frente a los ensayos clínicos. en cuanto a las áreas temáticas y el tipo de estudio, el 17,68 % de los estudios descriptivos se realizan en el área de rehabilitación basada en la comunidad, mientras que el 3,82 % de los estudios experimentacolombia destaca su producción en temas como rehabilitación basada en la comunidad, cardiovascular, fundamentación del movimiento corporal humano, actividad física y educación. 100 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 les se realizan en las áreas básicas que se fundamentan en movimiento corporal humano. la temática del tipo de investigación puede apreciarse en la tabla 2. respecto al idioma del descriptor, las publicaciones utilizan descriptores en inglés en un 71,9 % y en español en 27,0 %. la frecuencia del idioma del descriptor por país se presenta en la gráfica 3. ahora bien, respecto al idioma, el 57 % de las publicaciones se hacen en portugués, entendiendo que el país latinoamericano de mayor producción es brasil. el estudio también arrojó que brasil, chile, colombia y venezuela presentaron publicaciones en español, inglés y portugués, mientras que argentina solo refiere publicaciones en español e inglés, y cuba y perú solamente registraron sus publicaciones en español tal como se observa en la gráfica 4. ahora bien, respecto a las áreas temáticas por idioma, en la tabla 3 se aprecia que en español son más frecuentes las publicaciones en rehabilitación basada en la comunidad, en inglés son frecuentes las publicaciones en rehabilitación basada en comunidad seguidas del área temática de cardiovascular y actividad física, mientras que en portugués son frecuentes las publicaciones en rehabilitación basada en comunidad, fundamentación del movimiento corporal y actividad física. la fisioterapia / kinesiología se encuentra en un permanente desarrollo, que la convierte en una disciplina dinámica con participación interdisciplinar en diferentes grupos de conocimiento como medicina, enfermería, antropología, psicología, biología e ingeniería electrónica. a partir de la categorización temática se pudieron establecer las áreas de mayor producción investigativa en orden de frecuencia: rehabilitación basada en la comunidad, fundamentación del movimiento corporal humano, cardiovascular, actividad física, respiratorio, metabólico, educación, neurología, osteomuscular, salud mental, salud pública, oncología, obstetricia, infecciones y renal. las áreas de investigación específicas para cada país se encuentran en la tabla 4 (ver anexo), en la que se vislumbra el perfil de investigación para américa latina convirtiendo en una fortaleza la investigación en rehabilitación basada en la comunidad. acerca del número de referencias citadas, el mínimo fue de 6 y el máximo fue de 294; el promedio de referencias en el total de publicaciones fue de 29,9 con una moda de 30 y una desviación estándar de ±21,96. lastimosamente, nuestro estudio no clasificó cualitativamente la variable referencia bibliográfica, de haberlo realizado hubiese sido posible cuantificar el porcentaje de revistas referenciadas frente a otro tipo de publicación. discusión el hecho de realizar un análisis bibliométrico de la fisioterapia / kinesiología en américa latina permite dar a conocer a la comunidad científica la situación de la investigación en esta área, entregando la posibilidad de comparar las diferentes situaciones de desarrollo científico entre países, pero es importante reconocer que los estudios bibliométricos cuentan con limitaciones (6, 7, 8) como la variedad de formas con que los nombres son indizados (9), y la utilización de descriptores de referencia sin aporte a la fisioterapia a pesar de estar dentro de la jerarquización de la disciplina, siendo un aspecto que hace engorrosa la búsqueda documental. pero no hay duda que, a pesar de las objeciones que se pueden y se deben hacer, los indicadores bibliométricos facilitan la comprensión de la actividad investigadora de un área o disciplina del conocimiento (10). la fisioterapia / kinesiología se encuentra en un permanente desarrollo, que la convierte en una disciplina dinámica con participación interdisciplinar en diferentes grupos de conocimiento como medicina, enfermería, antropología, psicología, biología e ingeniería electrónica. 101 producción científica latinoamericana de fisioterapia / kinesiología l paola vernaza-pinzón, gabriel álvarez-bravo los resultados del análisis bibliométrico de la fisioterapia / kinesiología en el periodo estudio, permiten apreciar el incremento de la producción documental de la disciplina año a año, producción abanderada por brasil, país que deja apreciar su fortaleza investigativa frente a los otros países latinoamericanos. a pesar de ello, difiere de la visibilidad internacional, pues la revista médica de chile, escogida para la divulgación del conocimiento de la fisioterapia / kinesiología, en el 2007 se ubicó dentro del scimago rank (sjr) en el puesto 2.406, mientras que la revista brasilera de medicina esporte quedó en el puesto 3.814, dentro de las publicaciones científicas reconocidas por el scopus en el área de la medicina (11). en cuanto a la producción científica por descriptor, el estudio arroja importantes datos respecto a que dentro de la organización jerárquica de los descriptores para la búsqueda documental en fisioterapia / kinesiología se encontraron 86 de estos, y latinoamérica utiliza 56 convirtiéndose en un resultado importante de referencia para la búsqueda bibliográfica, lo que permitirá a muchos investigadores centrar sus esfuerzos de búsqueda hacia los descriptores más utilizados (12); sin embargo, el estudio de varela y colaboradores revela que el número total de palabras clave utilizadas en el estudio del análisis temático y metodológico de la investigación en la revista española de fisioterapia fue de 585 con una media de 3,05 y una desviación típica de 1,76 (13). en lo referente al número de autores, predominan los artículos firmados por un solo autor. este indicador, según lópez (14), presenta una correlación positiva con indicadores económicos de apoyo a la actividad científica, lo que permite apreciar que aún es pobre la ayuda que se da a la investigación en fisioterapia / kinesiología. lastimosamente, por la inadecuada indización de autores no se pudo consolidar la información referida a los autores más productivos por país y área, haciendo difícil la consolidación de productividad de los mismos. el estudio arroja que los principales generadores de conocimiento son las universidades y los centros hospitalarios, similar a lo reportado en el estudio de productividad de los fisioterapeutas españoles en el período 1991-1999 a través del análisis bibliométrico de la revista fisioterapia (15). son pocos los investigadores que reportan su filiación a grupos de investigación o centros de excelencia cuando es en ellos donde se soporta de manera organizada y autónoma la conformación de una masa crítica dinámica y comprometida en la producción de nuevo conocimiento (16). es importante anotar que a pesar de que la fisioterapia / kinesiología es una disciplina joven, existe el compromiso de generar nuevo conocimiento encontrando una participación significativa de publicaciones de estudios descriptivos, y a pesar de contar actualmente con una baja formación en maestrías y doctorados (17), se aprecia la incursión en metodologías de tipo experimental que de alguna manera deben incorporar esfuerzos a nivel latinoamericano para generar políticas de desarrollo científico en la fundamentación disciplinar. los idiomas que predominaron fueron portugués, español e inglés, similar a lo reportado en el estudio de gamboa y colaboradores (18), observando que la contribución de las publicaciones al inglés es la más baja. el presente estudio permitió definir el perfil de investigación latinoamericano de la fisioterapia / kinesiología durante el periodo 2000-2007, encontrando que la rehabilitación basada en la comunidad es común a los países de latinoamérica, ello implica la necesidad urgente de plantear políticas de investigación conjuntas a través de estudios multicéntricos regionales que hagan posible el planteamiento de estrategias de desarrollo comunitario para la rehabilitación, la igualdad de oportunidades, la reducción de la pobreza y la integración social de todas las personas con discapacidad. la publicación de los resultados de investigación en el ámbito de la fisioterapia / kinesiología es un compromiso que los profesionales docentes-investigadores de la disciplina están obligados a cumplir. a pesar de que los estudios bibliométricos en una sola área del conocimiento no pueden resolver todas las necesidades de medida de la actividad científica, son necesarios para aportar objetividad a la actividad investigativa (18, 19). conocer las investigaciones de la fisioterapia / kinesiología en la región permitirá a los académicos generar una política de investigación latinoamericana que redunde en el crecimiento de la profesión, de las comunidades y del contexto. agradecimientos los autores desean expresar su gratitud al profesor jerónimo londoño, al doctor javier sanz por sus valiosos aportes durante el proceso de jerarquización de los descriptores, a los estudiantes auxiliares de investigación edgar jácome, luisa fernanda bolaños y joaquín guillermo gonzález. 102 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 referencias bibliográficas 1. ríos gómez c, herrero solana v. latin american scientific production and world-wide science: a bibliographic overview (1989-2003). revista interamericana de bibliotecología 2005; 28 (1): 43-61. 2. arencibia jr, de moya anegón f. la evaluación de la investigación científica: una aproximación teórica desde la cienciometría. acimed 2008; 17 (4) [revista en la internet]. [citado el 9 de marzo del 2011]. disponible en: http://scielo.sld. cu/scielo.php?script=sci_arttext&pid=s10249435008000400004&ing=es. 3. licea de arenas j, valles j, arévalo g, cervantes c. visión bibliométrica de la investigación en bibliotecología y ciencia de la información de américa latina y el caribe. revista española de documentación científica 2000; 23 (1): 45-53. 4. macías-chapula, césar a. hacia un modelo de comunicación en salud pública en américa latina y el caribe. rev panam salud pública 2005; 18 (6): 427-38. 5. martínez-gonzález m, gómez-conesa a. estudio bibliométrico de la revista iberoamericana de fisioterapia y kinesiología (1998-2002). rev iberoam fisioter kinesiol 2003; 6 (1): 58-71. 6. bordons m, fernández mt, gómez i. advantages and limitations in the use of impact factor measures for the assessmente of research, performance in a peripheral country. scientometrics 2000; 53 (2): 195-196. 7. sancho r. misjudments and shortcomings in the measurement of scientific activities in less developed countries. scientometrics 1992; 23 (1): 221.233. 8. dávila m, guzmán r, macareno h, piñeres d, de la rosa d, caballero c. bibliometría: conceptos y utilidades para el estudio médico y la formación profesional. salud uninorte 2009; 25 (2): 319-330. 9. hernon p, metoyer-duran ch. literature reviews and inaccurate referencing: an exploratory study of academic librarians. coll & res libr 1992; 53: 499-512. 10. camps d. limitaciones de los indicadores bibliométricos en la evaluación de la actividad científica biomédica. colomb med 2008; 39 (1): 74-79. 11. scimago. sjr scimago journal & country rank 2007; retrieved april 17, 2010, available from url: http://www.scimagojr.com [fecha de consulta: mayo 9 de 2010]. 12. pinillo a, cadeño r. el mesh: una herramienta clave para la búsqueda de información en las bases de datos medline. acimed, revista cubana de los profesionales de la información y la comunicación en salud 2005; 13 (2). 13. varela a, montilla b, medina i, mirapeix b, massò âvila c, bernabeu c, saez d. análisis temático y metodológico de la investigación en la revista fisioterapia (1991-1999). revista fisioterapia 2007; 29: 13-25. 14. lópez jm, terrada ml. los indicadores bibliométricos y la evaluación de la actividad médico-científica. los indicadores de producción, circulación y dispersión, consumo de la información y repercusión. med clin 1992; 98: 142-8. 15. massò a, bernabéu b, medina i, mirapeix b. productividad de los fisioterapeutas españoles en el periodo 1991-1999 a través del análisis bibliométrico de la revista fisioterapia. revista fisioterapia 2000; 22: 2-11. 16. carvajal de pabón, lm. los grupos de investigación. vitae, medellín 2009; 16 (2): 181-182. 17. conclusiones mesa de salud pública. ii encuentro latinoamericano de académicos en fisioterapia y kinesiología. 3, 4, 5 de junio. bogotá; 2009. disponible en: http://www.clafk.net/docs/relatoria_mesa_ salud_publica.pdf. [citado el 23 de enero de 2010]. 18. alonso jo, reyna fr. compilación de datos bibliométricos regionales usando las bases de datos clase y periódica. rev interam bibliot 2005; 28 (1). 19. centro de ciencias humanas y sociales. el análisis bibliométrico de la producción española en ciencias sociales y humanas. ¿contamos con las fuentes necesarias? revista española de documentación científica 2010; 33 (1): 145-161. 103 producción científica latinoamericana de fisioterapia / kinesiología l paola vernaza-pinzón, gabriel álvarez-bravo cuadro 1. descriptores de búsqueda para fisioterapia / kinesiología mesh desc= español desc= portuguez physical therapy modalities modalidades de terapia física modalidades de fisioterapia physical therapy department, servicio de fisioterapia serviço hospitalar hospital en hospital de fisioterapia physical therapy (specialty) terapia física (especialidad) fisioterapia (especialidade) exercise movement técnicas por movimiento técnicas de exercício techniques de ejercicio e de movimento postoperative care cuidados posoperatorios cuidados pós-operatórios complementary therapies terapias complementarias terapias complementares anexo cuadro 2. estructura jerárquica de los descriptores para la búsqueda de publicaciones científicas en fisioterapia / kinesiología physical therapy modalities exercise movement complementary therapies techniques balneology: ammotherapy, baths, mud therapy, breathing exercises acupuncture therapy + anthroposophy steam bath electric stimulation therapy: electroacupuncture, dance therapy holistic health transcutaneous, electric nerve stimulation exercise therapy, motion therapy, continuous passive, drainage, postural homeopathy muscle stretching exercises hydrotherapy exercise, exercise therapy medicine, traditional: medicine, african traditional, medicine, arabic +medicine, ayurvedic, medicine, kampo, medicine,oriental traditional + shamanism hyperthermia, induced ammotherapy muscle stretching exercises mind-body and relaxation techniques: aromatherapy, biofeedback (psychology) diathermy +steam bath breathing exercises, hypnosis + imagery (psychotherapy), laughter therapy, meditation, mental healing, mind-body, relations (metaphysics), psychophysiology, relaxation, relaxation techniques, tai ji, therapeutic touch, yoga musculoskeletal manipulations: relaxation kinesiology, applied manipulation, chiropractic, manipulation, osteopathic manipulation, spinal massage + relaxation techniques. manipulation, spinal + massage + myofunctional therapy relaxation techniques relaxation techniques naturopathy, organotherapy, tissue therapy, phytotherapy, aromatherapy, eclecticism, historical, reflexotherapy, rejuvenation, sensory art therapies, acoustic stimulation, aromatherapy, art therapy, color therapy, dance therapy, music therapy, play therapy, psychodrama + spiritual therapies, faith healing, homeopathy, magic, medicine, african traditional, meditation, mental healing, occultism, radiesthesia, shamanism, therapeutic touch, witchcraft, yoga. tai ji walking yoga 104 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 gráfica 1. tendencia de la producción científica de la fisioterapia / kinesiología publicada en las bases de datos scielo y lilacs en américa latina, 2000-2007 gráfica 2. tendencia por país de la producción científica de la fisioterapia / kinesiología publicada en las bases de datos scielo y lilacs en américa latina, 2000-2007 porcentaje frecuencia argentina brasil chile colombia cuba perú venezuela 105 producción científica latinoamericana de fisioterapia / kinesiología l paola vernaza-pinzón, gabriel álvarez-bravo gráfica 3. frecuencia del idioma del descriptor por país en la producción científica de la fisioterapia / kinesiología publicada en las bases de datos scielo y lilacs en américa latina, 2000-2007 gráfica 4. frecuencia del idioma de publicación en la producción científica de la fisioterapia / kinesiología publicada en las bases de datos scielo y lilacs en américa latina, 2000-2007 inglés español ´ ´ ´ 106 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 tabla 1. descriptores de búsqueda mesh, decs de mayor referenciación por país publicados en las bases de datos scielo y lilacs en américa latina, 2000-2007 tabla 2. áreas temáticas según metodología del artículo en el estudio bibliométrico de la fisioterapia / kinesiología publicadas en las bases de datos scielo y lilacs en américa latina, 2000-2007. descriptores de mayor frecuencia por país (total descriptores 56) argentina (10) chile (21) brasil (48) venezuela (15) colombia (19) cuba (2) perú (1) excercise excercise excercise excercise relaxation physical therapy terapias complementarias relaxation walking relaxation relaxation tai ji terapias complementarias walking relaxation walking walking yoga homeopathy terapia fisica massage baths relaxation techniques meditation massage homeopathy massage terapia física estudios descriptivos estudios tipo ensayo clínico áreas temáticas n % n % actividad física 79 4,79 62 3,64 fundamentación del movimiento corporal humano 123 7,46 65 3,82 cardiovascular 90 5,41 62 3,64 rehabilitación basada en la comunidad 294 17,68 37 2,17 educación 118 7,09 9 0,59 salud pública 56 3,36 10 0,58 metabólico 102 6,13 26 1,52 infecciones 23 1,38 4 0,23 neurología 98 5,89 16 0,94 obstetricia 25 1,50 8 0,47 oncología 41 2,46 6 0,35 renal 12 0,72 1 0,05 respiratorio 100 6,01 29 1,70 salud mental 60 3,60 12 0,70 osteomuscular 61 3,66 31 1,82 total 1282 77,1 378 22,23 107 producción científica latinoamericana de fisioterapia / kinesiología l paola vernaza-pinzón, gabriel álvarez-bravo tabla 3. áreas temáticas según idioma del artículo en el estudio bibliométrico de la fisioterapia / kinesiología publicada en las bases de datos scielo y lilacs en américa latina, 2000-2007. tabla 4. áreas temáticas de mayor referenciación por país en el estudio bibliométrico de la fisioterapia / kinesiología en américa latina, 2000-2007 español inglés portugués áreas temáticas n % n % n % actividad física 9 0,52 23 1,35 109 6,41 fundamentación del movimiento corporal humano 41 2,41 37 2,17 110 6,47 cardiovascular 42 2,47 26 1,52 82 4,82 rehabilitación basada en la comunidad 155 9,11 30 1,76 180 10,58 educación 51 3,0 6 0,35 69 4,05 salud pública 27 1,58 6 0,35 42 2,47 metabólico 34 2,0 11 0,64 83 4,88 infecciones 14 0,82 4 0,23 11 0,64 neurología 19 1,11 21 1,23 68 4,0 obstetricia 10 0,58 5 0,29 18 1,05 oncología 25 1,47 5 0,29 22 1,29 renal 5 0,29 4 0,23 4 0,23 respiratorio 38 2,23 18 1,05 73 4,29 salud mental 24 1,41 3 0,17 44 2,58 osteomuscular 16 0,94 22 1,29 54 3,17 total 510 30 221 13 969 57 áreas temáticas por país argentina chile brasil venezuela colombia cuba perú rehabilitación basada en la comunidad cardiovascular salud pública fundamentación educación rehabilitación basada en la comunidad respiratorio educación salud pública metabólico rehabilitación basada en la comunidad fundamentación acividad física cardiobascular metabólico rehabilitación basada en comunidad educación ciencias básicas infecciones metabólico rehabilitación basada en comunidad cardiovascular fundamentación actividad física educación rehabilitación basada en la comunidad educación respiratorio metabólico 159 172 capacidad de afrontamiento y adaptacion.indd 159 vivian fernanda jiménez-ocampo1 lina shirley zapata-gutiérrez2 leticia díaz-suárez3 capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en una unidad de cuidado intensivo 1. enfermera. magíster en enfermería. coordinadora de unidades estratégicas de desarrollo, clínica universidad de la sabana, chía, colombia. vivianjo@clinicaunisabana.edu.co 2. enfermera. magíster en enfermería. unidad de cuidados intensivos, clínica colombia, colombia. linaszg@gmail.com 3. enfermera. magíster en educación. directora de tesis. lettyds@gmail.com recibido: 9 de julio de 2012 enviado a pares: 22 de julio de 2012 aceptado por pares: 13 de mayo de 2013 aprobado: 17 de mayo de 2012 año 13 vol. 13 nº 2 chía, colombia agosto 2013  159-172 para citar este artículo / to reference this article / para citar este artigo jiménez ocampo, v. f., zapata gutiérrez, l. s., díaz suárez, l. (2013). capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en una unidad de cuidado intensivo. aquichan. vol. 13, no. 2, 159-172. resumen objetivo: identificar la capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo de la clínica universidad de la sabana, en chía, colombia. materiales y métodos: estudio de tipo cuantitativo descriptivo desarrollado en el segundo semestre del 2010, que incluyó 61 familiares. para la recolección de la información se utilizó el instrumento escala de medición del proceso de afrontamiento y adaptación de callista roy. para el análisis de datos se utilizaron medidas de tendencia central, test estadísticos de mann-whitney y kruskal-wallis. los rangos de edad de los participantes oscilaron entre 18 y 65 años, con una participación mayoritaria del género femenino (67,2 %) sobre el masculino (32,8 %). resultados: se consideró que la capacidad de afrontamiento y adaptación fue alta al obtener un puntaje del 85,2 % y baja con puntaje del 14,8 %. se observó que en una gama de estrategias de afrontamiento y adaptación las utilizadas con mayor frecuencia por los familiares fueron: las de factor físico y enfocado (factor 2, relacionado con bajo afrontamiento), y factores combinados recursivo y centrado (factores 1 y 3, relacionados con alta capacidad de afrontamiento). conclusiones: las estrategias de afrontamiento utilizadas por los familiares fueron las dirigidas a la solución del problema, caracterizándose por hacer frente a la situación desde un principio, planeando actividades dirigidas a modificar la conducta y desarrollar objetivos específicos que contribuyan con la solución del mismo. palabras clave relaciones familiares, adaptación, cuidados intensivos, enfermería. (fuente: decs, bireme). 160 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 ability to cope and adapt in relatives of adult patients hospitalized at an intensive care unit abstract objective: the study identifies the ability of relatives of adult patients in the intensive care unit at clínica universidad de la sabana, in chía, colombia, to cope and adapt. materials and methods: this was a quantitative descriptive research initiative developed during the second half of 2010. it included 61 family members. callista roy’s coping and adaptation process scale was used to collect the data, which was analyzed with measures of central tendency and mann-whitney and kruskal-wallis statistical tests. the age of the participants ranged from 18 to 65 years, with the majority being females (67.2 %) as opposed to male (32.8 %). results: in terms of the capacity to cope and adapt, 85.2 % scored high and 14.8 % scored low. it was found that, within a range of strategies for coping and adapting, those used most frequently by family members were the physical and focused factor (factor 2, associated with a limited ability to cope), and the recursive and centered factors combined (factors 1 and 3, associated with a high ability to cope). conclusions: the coping strategies used by family members were aimed at solving the problem and were distinguished by dealing with the situation from the beginning, planning activities to change behavior, and pursuing specific objectives that contribute to a solution. keywords family relations, adaptation, intensive care, nursing. (source: decs, bireme). 161 capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en una unidad de cuidado intensivo l vivian fernanda jiménez-ocampo y otros. capacidade de enfrentamento e adaptação dos familiares do paciente idoso hospitalizado em uma unidade de tratamento intensivo resumo objetivo: identificar a capacidade de enfrentamento e adaptação dos familiares do paciente idoso hospitalizado na unidade de tratamento intensivo da clínica universidad de la sabana, em chía (colômbia). materiais e métodos: estudo de tipo quantitativo descritivo desenvolvido no segundo semestre de 2010, que incluiu 61 familiares. para a coleta da informação, utilizou-se o instrumento escala de medição do processo de enfrentamento e adaptação de callista roy. para a análise dos dados, utilizaram-se medidas de tendência central, teste estatísticos de mann-whitney e kruskal-wallis. a faixa etária dos participantes oscilou entre 18 e 65 anos, com uma participação maioritária do gênero feminino (67,2 %) contra 32,8 % do masculino. resultados: considerou-se que a capacidade de enfrentamento e adaptação foi alta ao obter uma pontuação de 85,2 % e baixa com pontuação de 14,8 %. observou-se que, em uma série de estratégias de enfrentamento e adaptação, as utilizadas com maior frequência pelos familiares foram: as de fator físico e enfocado (fator 2, relacionado com baixo enfrentamento) e fatores combinados recursivo e centrado (fatores 1 e 3, relacionados com alta capacidade de enfrentamento). conclusões: as estratégias de enfrentamento utilizadas pelos familiares foram as dirigidas à solução do problema e se caracterizavam por enfrentar a situação desde um princípio, ao planejar atividades direcionadas a modificar a conduta e desenvolver objetivos específicos que contribuíssem com a solução deste. palavras-chave relações familiares, adaptação, terapia intensiva, enfermagem. (decs, bireme). 162 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 introducción el objetivo de las unidades de cuidado intensivo es brindar atención al paciente en estado crítico o grave de salud. la persona en este estado presenta alteraciones vitales de uno o más órganos que ponen en peligro su vida e ingresa a la unidad de cuidado intensivo adultos (uci) para ser sometido a monitoreo continuo, reanimación, mantenimiento de signos vitales, tratamiento definitivo, recibir cuidados de enfermería específicos dada su situación de salud y lograr de esta forma su recuperación (1-4). sin embargo, este paciente cursa con una situación que involucra procesos fisiológicos diversos que pueden tener resultados definitivos (incluyendo la muerte) por lo que al mismo tiempo deriva en cambios en el estado psicológico de las familias y cambia el ambiente social. esto supone una situación de crisis, un acontecimiento estresante que produce un impacto en la vida del paciente, con efectos en los familiares e inestabilidad en su dinámica emocional, observando en ellos estrés, ansiedad, preocupación, irritabilidad, culpa, frustración, depresión e incertidumbre que se traducen en un constante deseo de información clara y concreta de su paciente (5-8). molter desarrolló un estudio donde identificó 45 necesidades específicas de los familiares del enfermo crítico después de un proceso de enfermedad de uno de sus miembros, necesidades que hacen referencia a aspectos de información, ayuda, atención de calidad, bienestar, horarios flexibles de visita, aspectos de entorno, etc., llegando a la conclusión de que es enfermería quien cubre mejor la mayoría de estas necesidades (9). las familias de los pacientes hos pitalizados en una unidad de cuidado intensivo requieren cuidados, atención e información opor tuna. con frecuencia se les observa en las salas de espera con manifestaciones de diferente índole de acuerdo con el contexto de sus vivencias y necesidades. es conocido por cualquiera, aun por aquellos no familiarizados con las unidades de cuidado intensivo, que las primeras visitas pueden ser alarmantes; crean angustia, expectativas con relación a la cantidad de dispositivos de monitoreo, equipos de mantenimiento de la vida y controles ambientales necesarios para garan tizar un cuidado con calidad (10). el afrontamiento del individuo y sus familiares al impacto de la hospitalización en la uci como un fenómeno no predecible genera desorganización y caos inicial (es un cambio brusco y desequilibrante) en el que el asesoramiento de los profesionales de enfermería y su actuación son primordiales. esto ha demostrado ser útil para la evolución del paciente, y contribuye al mantenimiento de la salud del núcleo familiar en unos momentos donde su permanente equilibrio es crucial (11). el concepto de afrontamiento ha tenido una evolución conceptual y metodológica fruto de los diferentes enfoques que se han utilizado para su estudio. la descripción de la naturaleza y las características del afrontamiento, así como su definición conceptual y operativa, han variado dependiendo de la perspectiva desde la que se ha abordado su estudio y del campo de aplicación en el que se han realizado las investigaciones. lazarus y folkman definen el afrontamiento como un proceso cognitivo y conductual constantemente cambiante que se desarrolla para manejar las demandas específicas externas o internas, que son evaluadas como desbordantes de los recursos del individuo. es un subconjunto de actividades adaptativas que implican esfuerzo y que no incluyen todo aquello que hacemos con relación al entorno (12). al mismo tiempo, desde la perspectiva de enfermería, la adaptación se define como el ajuste que realiza el organismo a los cambios ambientales, según lo menciona pitel, basado en la premisa que existe y se tiene que identificar un mecanismo de control y un regulador fisiológico que explica por qué el organismo mantiene un ambiente interno constante (13). peplau afirma sobre la adaptación que el comportamiento de la persona es moldeado por momentos en el campo interpersonal para lograr la integración armoniosa del comportamiento con otros estímulos en los diversos campos psicosociales; con esto introduce la perspectiva de que una mala adaptación lleva a la aparición de los estados de enfermedad, motivo por el cual la enfermera debe conocer y comprender el proceso normal de adaptación para identificar lo anormal desde su origen y así brindar un mejor cuidado (14). el afrontamiento y la adaptación son conceptos muy importantes para la calidad de vida de un individuo porque son fenómenos dinámicos en los cuales se realizan procesos de integración entre este y el entorno, que generan estilos y estrategias para afrontar una situación. el fenómeno de afrontamiento presenta diversas conceptualizaciones debido a su enfoque en varias disciplinas, pero los mayores desarrollos conceptuales se han abordado fundamentalmente desde la perspectiva de enfermería a partir del modelo de adaptación de callista roy (15). 163 capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en una unidad de cuidado intensivo l vivian fernanda jiménez-ocampo y otros. roy redefine el proceso de afrontamiento y adaptación como los patrones innatos y adquiridos de las formas de manejar y responder al ambiente cambiante en las situaciones de la vida diaria y los periodos críticos mediante comportamientos directamente enfocados a alcanzar el dominio, la supervivencia, el crecimiento y la trascendencia (16). los procesos adquiridos de afrontamiento se desarrollan a través de estrategias como el aprendizaje, donde las experiencias a lo largo de la vida contribuyen a responder de forma habitual a un estímulo particular del entorno. del mismo modo, los patrones adquiridos están determinados por el subsistema cognitivo y se relacionan en la conciencia, y gracias al procesamiento de la información la persona interactúa y otorga un significado a los estímulos ambientales internos y externos. a partir de estos dos subsistemas el individuo interpreta en forma particular los estímulos generando un estilo para afrontar la situación y unas estrategias, que pueden ser adaptativas o inefectivas, que se manifiestan en los cuatro modos de adaptación (17). el estudio tuvo como objetivo la identificación del nivel de capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo como herramienta para profundizar en el abordaje de intervención de los pacientes y sus familias. materiales y métodos el estudio fue de tipo cuantitativo descriptivo transversal, realizado en el segundo semestre del 2010. se aplicó la escala de medición del proceso de afrontamiento y adaptación de callista roy, que mide la capacidad de afrontamiento y adaptación de los individuos en condiciones de salud y enfermedad, basada en su teoría de mediano rango. se obtuvo una muestra de familiares de pacientes hospitalizados en la unidad de cuidado intensivo de la clínica universidad de la sabana en chía, colombia. el tamaño de la muestra fue calculado mediante la expresión usual para poblaciones infinitas cuando el objetivo central lleva latente la estimación del promedio poblacional. con una participación de 61 familiares, se logró superar el punto de corte con una desviación estándar del total de la escala en la muestra de 14,52 puntos, asumiendo un error máximo de 3 puntos de la escala del caps, y un intervalo de confianza del 95 %. los criterios de inclusión que se tuvieron en cuenta en el proceso de recolección de la información fueron los siguientes: • familiar del paciente que ingrese a la unidad de cuidados intensivos adultos de la clínica universidad de la sabana con un grado de consanguinidad directa (papá, mamá e hijos) o según grado de afinidad (esposo, esposa o compañero (a) permanente). • familiar mayor de edad y menor de 70 años. para el desarrollo de la investigación se tuvieron en cuenta los siguientes aspectos éticos: respeto a las políticas y normas institucionales; consentimiento informado; respeto a la autonomía, la privacidad y la confidencialidad; confiabilidad y fidelidad con la información que brindó el familiar. además, se ponderaron y respetaron los aspectos culturales, los valores y las creencias (18). la validez de la escala de medición del proceso de afrontamiento y adaptación (caps) de roy se fundamenta en diversos estudios que han determinado la confiabilidad de la misma en sus versiones en inglés, tailandés y español (19-21), siendo la versión en español validada por la facultad de enfermería de la universidad de la sabana, en donde se determinó la validez facial y la confiabilidad (consistencia interna y estabilidad, presentando un alfa de cronbach de 0,088), con el fin de evaluar su comportamiento y dominio (22). la escala está conformada por 47 ítems agrupados en cinco factores, con una calificación likert de cuatro puntos, que varía desde 1 = nunca, hasta 4 = siempre; cada ítem es una frase corta acerca de cómo una persona responde cuando experimenta una crisis o un evento difícil. el puntaje total puede oscilar entre 47 a 188 puntos. los individuos con un puntaje entre 117-188 poseen una alta capacidad de afrontamiento y adaptación, interpretada como mayor frecuencia en el uso de las estrategias de afrontamiento. los individuos con un puntaje entre 47-116 poseen una baja capacidad de afrontamiento y adaptación, interpretada como poca frecuencia en el uso de las estrategias de afrontamiento. con relación a los cinco factores propuestos por roy, los tres primeros miden los comportamientos, las reacciones y los recursos de afrontamiento que utilizan las personas, y los dos últimos miden las estrategias empleadas para sobrellevar la situación, a saber (23): 164 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 factor uno: recursivo y centrado (10 ítems). este factor refleja comportamientos de la utilización del yo y de los recursos que se concentran para expandir las entradas del sistema cognitivo de la información, considerando actitudes respecto a la solución de problemas como el ser creativo y buscar resultados. factor dos: reacciones físicas y enfocadas (14 ítems). resaltan las reacciones físicas y la fase de entrada para el manejo de situaciones. factor tres: proceso de alerta (9 ítems). representa los comportamientos del yo personal respecto a las características de cada persona como las expectativas, los valores, las virtudes y las metas, y los comportamientos del yo físico haciendo referencias a aspecto físicos, funcionalidad, salud y estado de enfermedad, compuesto por las sensaciones corporales y la imagen corporal. este factor se enfoca en los tres niveles de procesamiento de la información: entradas, procesos centrales y salidas. factor cuatro: procesamiento sistemático (6 ítems). describe las estrategias personales y físicas para hacerse cargo de las situaciones y manejarlas metódicamente. factor cinco: conocer y relacionar (8 ítems). describe las estrategias que utiliza la persona para recurrir a sí misma y a otros usando la memoria y la imaginación. en cuanto a la forma de puntuación de la escala roy indica que el puntaje total de cada estrategia lo conforma la suma de los puntajes obtenidos en cada uno de los ítems. para obtener el puntaje total de la escala se suman los puntajes totales obtenidos en cada factor, el rango de puntaje para los 47 ítems va de 47 a 188. a su vez, para dar una puntuación total a la escala, es necesario tener en cuenta que existen ítems con puntajes inversos. la propuesta utilizada para clasificar a los sujetos de la muestra con relación a la capacidad de afrontamiento y adaptación fue la desarrollada por gonzález, quien según el puntaje obtenido por el sujeto lo asigna a una categoría de alta o baja capacidad (tabla 1). análisis estadístico se realizó una comparación entre la capacidad de afrontamiento y adaptación y las variables sociodemográficas para analizar si el puntaje total dado por la escala difería entre el género, los grupos de edad, la escolaridad y el grado de consanguinidadafinidad. para el análisis se tomó como recurso de comparación los test estadísticos de mann-whitney y de kruskal-wallis (24). la información recolectada se ingresó en una base de datos construida en el programa excel versión 2007, para el análisis estadístico correspondiente. resultados variables sociodemográficas participaron 61 familiares, 32,8 % hombres y 67,2 % mujeres, se encontró que el 44,2 % de los participantes estaban en el rango de 18 a 40 años. con respecto al nivel educativo, la mitad de los participantes tienen estudios técnicos (39,3 %), seguido por estudios de secundaria (29,5 %), universitarios (23 %) y primarios (8,2 %). respecto al grado de consanguinidad-afinidad, los participantes indicaron con mayor frecuencia ser hijo/a(s) (4 %) y esposo(a) (33 %) (gráfica 1). se realizó el cálculo de la capacidad de proceso de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo encontrando: alta capacidad de afrontamiento y adaptación (85,2 %), y baja capacidad de afrontamiento y adaptación (14,8 %) (gráfica 2). para identificar y analizar las estrategias de afrontamiento y adaptación utilizadas con mayor frecuencia se realizó un análisis de los cinco factores (tabla 2). descriptivamente, los familiares con baja capacidad de afrontamiento y adaptación utilizaron el factor físico y enfocado (factor 2); por otro lado, los familiares con alta capacidad de afrontamiento y adaptación utilizaron las combinaciones de los factores: recursivo y centrado, y proceso de alerta (factores 1, 3). posteriormente, para analizar las reacciones y los comportamientos utilizados con mayor frecuencia en los factores mencionados se analizaron cada uno los ítems de los factores en donde se obtuvo baja y alta capacidad de afrontamiento, es decir los factores 2, 1 y 3 respectivamente. los participantes con baja capacidad de afrontamiento utilizaron las reacciones de afrontamiento físico y enfocado, factor 2 (tabla 3), que se caracterizaron por identificar su dificultad para 165 capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en una unidad de cuidado intensivo l vivian fernanda jiménez-ocampo y otros. expresar el verdadero problema cuando lo enfrentan, dificultad para completar tareas, actividades o proyectos; en ocasiones reaccionan con exageración, tienden a paralizarse y a confundirse por un rato, y no utilizan sus experiencias pasadas para enfrentar la situación. los participantes con alta capacidad de afrontamiento y adaptación presentaron la combinación de los factores 1 y 3, recursivo y centrado con proceso de alerta, respectivamente. se observa que el comportamiento adoptado está enfocado en la solución del problema y la atención está dirigida a la situación, a la que hacen frente desde un principio; asimismo, sus actividades están dirigidas a modificar su conducta basados en la planificación y el desarrollo de objetivos específicos que ayuden a la solución del problema (tablas 4 y 5). con el fin de conocer las estrategias de afrontamiento más usadas por los participantes se analizaron los ítems con mayor puntaje de los factores 4 y 5, procesamiento sistemático y conociendo y relacionando, respectivamente, en donde se observa que las estrategias utilizadas con mayor frecuencia están dirigidas al análisis detallado y sistemático de la situación, estas estrategias son: llaman al problema por su nombre y tratan de verlo en su totalidad, piensan en todo el problema paso a paso, tratan de aclarar las dudas antes de actuar. también se observa que recurren con mayor frecuencia a la imaginación para la solución del problema presentándose preferencia por: relatar lo que sucede con sus experiencias pasadas o planes futuros; mirar la situación positivamente como una oportunidad/desafió; sentirse bien de saber que está manejando el problema lo mejor que puede y se plantean muchas ideas como soluciones posibles a la situación, aunque parezcan difíciles de alcanzar (tablas 6 y 7). el estudio de comparación entre la capacidad de afrontamiento y adaptación y las variables sociodemográficas (género, grupos de edad, escolaridad y grado de consanguinidad-afinidad) mostró que no existe diferencia significativa entre estas (gráficas 3-6). discusión los resultados encontrados con respecto a la capacidad de afrontamiento y adaptación de los familiares ante la situación de crisis como es la de tener un familiar hospitalizado 85,2 % mostraron una alta capacidad de afrontamiento y adaptación y un 14,8 % una baja capacidad de afrontamiento y adaptación. los familiares con baja capacidad utilizaron las reacciones: físico y enfocado, respondiendo que presentan dificultad para completar tareas, encuentran el problema demasiado complejo y les es difícil explicar cuál es el verdadero problema. una posible explicación para este resultado se puede encontrar en el concepto que indica que cuando un evento estresante es percibido como fuera del control personal, las personas tienden a utilizar estrategias de afrontamiento enfocadas en la emoción como primera opción de respuesta a las demandas que provienen de tal evento estresante (25, 26). dentro de los comportamientos más frecuente adoptadas por los familiares con alta capacidad de afrontamiento se encontró que presentaron la combinación de los factores 1 y 3, recursivo y centrado con proceso de alerta, respectivamente, respondiendo con mayor frecuencia a la categoría de siempre en los siguientes ítems: reúnen la mayor cantidad de información posible para aumentar las opciones a fin de solucionar el problema, están atentos a cualquier cosa relacionada con la situación, hacen frente a las situaciones desde el principio y desarrollan un plan con una serie de acciones para enfrentar la situación. la utilización de estas estrategias de afrontamiento se puede relacionar con lo descrito por moos cuando menciona que en el afrontamiento cognitivo se recurre a la planeación, se ensayan mentalmente una serie de acciones por seguir, analizándose sus consecuencias, y se acepta la realidad del evento estresante tratando de cambiarlo para obtener efectos positivos (27). los resultados de la alta capacidad de afrontamiento reflejada en los familiares ante la hospitalización de un ser querido en la unidad de cuidado intensivo ratifican lo descrito por roy con relación al procesamiento de la información; cuando el individuo se enfrenta a un problema se construyen nuevos conocimientos a través de los recuerdos y las experiencias nuevas, lo cual le permite desarrollar nuevas capacidades o destrezas para la solución de problemas (15). con relación a las estrategias de afrontamiento y adaptación de los factores 4 y 5: procesamiento sistemático, y conociendo y relacionando, más utilizadas por los familiares, se observó que respondieron con mayor frecuencia a la categoría de siempre en los siguientes ítems: llaman al problema por su nombre y tratan de verlo en su totalidad, piensan en todo el problema paso a paso, tratan de aclarar las dudas antes de actuar. también se observa que recurren con mayor frecuencia a la imaginación para la solución del problema, encontrando relevancia en los siguientes 166 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 ítems: pueden relatar lo que sucede con sus experiencias pasadas o planes futuros, miran la situación positivamente como una oportunidad/desafío, se sienten bien de saber que están manejando el problema lo mejor que pueden y se plantean muchas ideas como soluciones posibles a la situación, aunque parezcan difíciles de alcanzar. los resultados de la alta capacidad de afrontamiento reflejada en los familiares ante la hospitalización de un ser querido en la unidad de cuidado intensivo ratifican lo descrito por roy con relación al procesamiento de la información: cuando el individuo se enfrenta a un problema se construyen nuevos conocimientos a través de los recuerdos y las experiencias nuevas, lo cual le permite desarrollar nuevas capacidades o destrezas para la solución de problemas (15). livneh describe que la persona utiliza tres tipos de estrategias de afrontamiento: comportamentales, efectivas y cognitivas; si se observa a la luz de los resultados, se identifican estas estrategias en los familiares de los pacientes, y se refuerza la interpretación del afrontamiento como un proceso en donde la interacción permanente individuo-ambiente desencadena múltiples estrategias según situaciones particulares. la capacidad y las estrategias de afrontamiento hacen visibles las características personales relacionadas con los pensamientos, los sentimientos y las acciones individuales propias de un ser holístico quien, al utilizar los recursos de afrontamiento innatos y adquiridos busca adaptarse a un ambiente cambiante (28). conclusiones • los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo presentaron una alta capacidad de afrontamiento y adaptación, observándose con mayor frecuencia el uso de estrategias dirigidas a la solución del problema, caracterizadas por hacer frente a la situación desde un principio, planear actividades dirigidas a modificar la conducta y el desarrollo de objetivos específicos que contribuyan con la solución del problema. • los comportamientos de uso más frecuente por los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo que obtuvieron alta capacidad de afrontamiento fueron los enfocados en lo recursivo y centrado (factor 1) y proceso de alerta (factor 3). en donde se observa que el comportamiento adoptado está enfocado en la solución del problema, atención dirigida a la situación y hacer frente a la situación desde un principio; las actividades están dirigidas a modificar su conducta basándose en la planificación y el desarrollo de objetivos específicos que ayuden a la solución del problema. • las reacciones físicas de afrontamiento y la fase de entrada para el manejo de situaciones (factor 2) fueron las de uso más frecuente en los familiares que tuvieron baja capacidad de afrontamiento y adaptación, identificándose su dificultad para expresar el verdadero problema cuando lo enfrentan; dificultad para completar tareas, actividades o proyectos; reaccionan con exageración; tienden a paralizarse y a confundirse por un rato, y no utilizan sus experiencias pasadas para enfrentar la situación. • no se encontraron diferencias estadísticamente significativas entre la capacidad de afrontamiento y adaptación de los familiares y las variables sociodemográficas de género, grupos de edad, escolaridad y grado de consanguinidad-afinidad. • el cuidado de enfermería no solo involucra la atención dirigida a solucionar las respuestas orgánicas del ser humano. es importante que el enfermero brinde un cuidado holístico con base en el conocimiento y la comprensión del subsistema cognitivo, ya que le permite identificar respuestas en cada individuo que potencialicen su proceso de adaptación. • la aplicación de teorías de mediano rango, como lo es la teoría de adaptación de roy, contribuye al desarrollo del conocimiento disciplinar y, por ende, a mejorar las intervenciones de cuidado de los individuos en sus procesos de salud-enfermedad. recomendaciones existen pocas investigaciones en relación con las intervenciones de las familias de pacientes críticos, y muy pocas sobre cómo mejorar su adaptación. una estrategia para reforzar este bajo afrontamiento obtenido en el factor 2 es continuar haciendo partícipe a la familia en el cuidado del paciente como una medida de apoyo para promover su adaptación y la satisfacción de sus necesidades. para el enriquecimiento de la disciplina profesional es importante continuar investigando en este campo, potencializando en los familiares las estrategias empleadas para el afrontamiento y la adaptación durante el proceso de hospitalización de su ser 167 capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en una unidad de cuidado intensivo l vivian fernanda jiménez-ocampo y otros. querido en la uci y, a partir de estas, plantear intervenciones de cuidado que aseguren la completa adaptación. en términos de las limitaciones del estudio cabe destacar que la semántica del instrumento es compleja y los ítems que lo conforman son extensos, lo que representó dificultad en la comprensión de las preguntas por parte de los familiares. se recomienda realizar una revisión de la escala de medición del proceso de afrontamiento y adaptación (caps) fundamentada en la investigación. referencias 1. gómez p. el ingreso en la unidad de cuidados intensivos, la repercusión en el familiar del paciente. boletín de psicología. 2006;87:61-87. 2. bernat r. vivencias de los familiares del enfermo ingresado en la unidad de cuidados intensivos. estudio cuantitativo. españa: enfermería clínica; 1999. pp. 19-27. 3. oliva et al. impacto de los familiares del paciente crítico ante una acogida protocolizada. españa: enfermería intensiva; 2003. pp. 49-60. 4. gutiérrez b et al. experiencias, percepciones y necesidades en la uci. revisión sistemática de estudios cualitativos. españa: enfermería global; 2008. 5. bond e et al. needs of family members of patients with sereve traumatic brain injury: implications for evidence-based practice. columbia: critical care nurse, american association of critical care nurses; 2003. pp. 63-72. 6. nelson d, plost g. registered nurses as family care specialists in the intensive care unit. usa: critical care nurse; 2009. pp. 46-52. 7. santana k. necesidades de familiares de pacientes em unidades de terapia intensiva: analisis comparativo entre hospital público y privado. rev latino-am enfermagem. 2007;15. 8. díaz n, díaz a. una experiencia sobre las vivencias de los familiares de pacientes críticos. nure investigación. 2004;10. 9. lautrette a et al. a communication strategy and brochure for relatives of patients dying in the icu. n engl j med. 2007;356(5):469-478. 10. torres l, morales a. participación de familiar en el cuidado del paciente crítico. recomendaciones de la sociedad andaluza de enfermería de cuidados críticos. revista internacional para el cuidado del paciente critico; 2004. 11. singer p, martin d, kelner m. quality end-of-life care. patients´ perspectives. jama. 1999;281(2):163-168. 12. lazarus r, folkman s. estrés y procesos cognitivos. barcelona: martínez roca; 1986. 13. pitel m. physiological adaptation in man. nursing science. 1963:263-271. 14. peplau he. interpersonal relations and the process of adaptation. nursing science. 1963:272-279. 15. veloza m, moreno me, crespo o, gutiérrez e. proceso de afrontamiento y adaptación. en gutiérrez m. universidad de la sabana. adaptación y cuidado en el ser humano. una visión de enfermería. bogotá: el manual moderno; 2007. pp. 13-25. 16. roy c. the roy adaptation model. 3 ed. new jersey: pearson; 2009. 17. gonzález y. evaluación de la eficacia del cuidado como intervención terapéutica: un programa educativo con enfoque cognitivo con un grupo de apoyo de soporte emocional para mantener y fortalecer la capacidad de proceso de afrontamiento cognitivo y la adaptación en personas que padecen cardiopatía isquémica a partir del modelo de adaptación y la teoría de proceso de afrontamiento y adaptación de callista roy [tesis doctoral]. bogotá: universidad nacional de colombia; 2007. 18. ministerio de salud. resolución 008430 por la cual se establecen las normas académicas, técnicas y administrativas para la investigación en salud. santa fe de bogotá: ministerio de salud; 1993. 168 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 19. roy c, prangtip ch. coping and adaptation processing scale english and thai versions. roy adaptation association bulletin. 2004;6(2):4-6. 20. chayaput p. development and psychometric evaluation of the thai version of the coping and adaptation processing scale. boston college, william f. connell, graduate school of nursing. 2004; p. 22-27. 21. chayaput p. psiychometric properties of the thai version of the coping and adaptation processing scale. roy adaptation association bulletin. 2005;8(1):6. 22. gutiérrez c, veloza m, moreno m, durán mm, lópez c, crespo o. validez y confiabilidad de la versión en español del instrumento escala de medición del proceso de afrontamiento y adaptación de callista roy. aquichán. 2007;7(1):54-63. 23. roy c. coping and adaptation processing scale: development and testing (en prensa); 2004. 24. ruis f, varon f. bioestadística. españa: thonson editores; 2005. 25. evans p. stress and coping. en pitts m, phillips k (eds.). the psychology of health. an introduction london: routledge; 1993. pp. 31-45. 26. miller s, summerton j, brody ds. styles of coping with threat: implications for health. journal of personality and social psychology. 1988;54(1):142-148. 27. moos rh, schaefer ja. coping resources and processes: current concepts and measures. en goldberger l, shlomo b. (eds.). handbook of stress. theoretical and clinical aspects; 1993. pp. 234-257. 28. livneh h. psychosocial adaptation to chronic illness and desability: a conceptual framework. bulletin. 2001;44(3):151-161. gráfica 1. variables sociodemográficas fuente: datos obtenidos mediante aplicación de caps a los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo de la clínica universitaria teletón. gráfica 2. capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo fuente: datos obtenidos mediante aplicación de caps a los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo de la clínica universidad de la sabana. 169 capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en una unidad de cuidado intensivo l vivian fernanda jiménez-ocampo y otros. gráfica 3. comportamiento descriptivo de la variable género comparado con la capacidad de afrontamiento y adaptación gráfica 4. capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en la unidad de cuidados intensivos correlacionado con la edad gráfica 5. capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en la unidad de cuidados intensivos correlacionado con el grado de consanguinidad-afinidad gráfica 6. capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en la unidad de cuidados intensivos correlacionado con la escolaridad fuente: datos obtenidos mediante aplicación de caps a los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo de la clínica universidad de la sabana. fuente: datos obtenidos mediante aplicación de caps a los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo de la clínica universitaria teletón. fuente: datos obtenidos mediante aplicación de caps a los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo de la clínica universidad de la sabana. fuente: datos obtenidos mediante aplicación de caps a los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo de la clínica universidad de la sabana. 170 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 estrategias de afrontamiento puntuación categorías de la capacidad del proceso de afrontamiento y adaptación baja capacidad alta capacidad recursivo y centrado factor 1 11-44 11-27 28-44 físico y enfocado factor 2 13-52 13-32 33-52 proceso de alerta factor 3 9-36 9-22 23-36 procesamiento sistemático factor 4 6-24 6-18 19-24 conociendo y relacionando factor 5 8-32 8-24 25-32 escala total 47-188 47-117 118-188 clasificación bajo fr (%) alto fr (%) factor 1 2 3 59 97 factor 2 55 90 6 10 factor 3 12 20 49 80 factor 4 24 39 37 61 factor 5 31 51 30 49 total 9 15 52 85 ítems nunca (%) rara vez (%) algunas veces (%) siempre (%) 5. cuando estoy preocupado tengo dificultad para completar tareas, actividades o proyectos. 8 30 23 39* 8. solo puedo pensar en lo que me preocupa. 1,6 11,4 42 45* 13. encuentro el problema o crisis demasiado complejo, con más elementos de los que yo puedo manejar. 0 13 59* 28 35. por alguna razón no saco beneficio de mis experiencias pasadas. 11,5 32,5 44* 12 47. al parecer me hago muchas ilusiones acerca de cómo resultarán las cosas. 0 5 26 69* 15. parece que soy más lenta para actuar sin razón aparente. 1,5 11,5 46 41 20. tiendo a reaccionar con exageración al comienzo. 21 34,5 34,5* 10 23. cuando se me presenta un problema tiendo a paralizarme y a confundirme por un rato. 1,5 27 52,5* 19 24. encuentro difícil explicar cuál es el verdadero problema. 14 17 64* 5 33. tiendo a culparme por cualquier dificultad que tenga. 23 8 57 12 39. experimento cambios en la actividad física. 33 57 10 0 43. esta situación me está enfermando. 5 9 49 37 45. me rindo fácilmente. 69 23 5 3 tabla 1. categorización de la capacidad de proceso de afrontamiento y adaptación según gonzález (17) tabla 2. estrategias de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo fuente: datos obtenidos mediante aplicación de caps a los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo de la clínica universidad de la sabana. tabla 3. análisis de los ítems del factor 2 fuente: datos obtenidos mediante aplicación de caps a los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo de la clínica universitaria teletón. 171 capacidad de afrontamiento y adaptación de los familiares del paciente adulto hospitalizado en una unidad de cuidado intensivo l vivian fernanda jiménez-ocampo y otros. tabla 4. análisis de los ítems del factor 1 fuente: datos obtenidos mediante aplicación de caps a los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo de la clínica universidad de la sabana. ítems nunca rara vez (%) algunas veces (%) siempre (%) 4. reúno la mayor cantidad de información posible para aumentar mis opciones a fin de solucionar el problema. 1,5 8,5 39 51* 7. trato de hacer que todo funcione en mi favor. 8 11,5 46 34,5 19. estoy atento a cualquier cosa relacionada con la situación. 0 1,5 24,5 74* 26. trato de obtener más recursos para enfrentar la situación. 0 8 54 38 42. tiendo a hacer frente a las situaciones desde el principio. 0 6,5 37,5 56* 10. identifico cómo quiero que resulte la situación, luego miro cómo lo puedo lograr. 1,5 5 41 52,5* 46. desarrollo un plan con una serie de acciones para enfrentar la situación. 1,5 10 29,5 59* 2. propongo una solución nueva para una situación nueva. 0 26 49 25 34. trato de ser creativo y proponer nuevas soluciones. 3 11,5 39,5 46 16. me empeño en redirigir mis sentimientos para reenfocarlos constructivamente. 3 11 46 40 29. con tal de salir del problema o situación estoy dispuesto a cambiar mi vida radicalmente. 0 21 53 26 ítems nunca rara vez (%) algunas veces (%) siempre (%) 1. puedo seguir una gran cantidad de instrucciones a la vez, incluso en una crisis o con un problema. 5 10 70* 15 44. adopto rápidamente un nuevo recurso cuando este puede resolver mi problema o situación. 1,5 16,5 59 23 18. cuando dejo mis sentimientos a un lado soy muy objetivo acerca de lo que sucede. 3 15 54 28 40. manejo la situación analizando rápidamente los detalles tal como sucedieron. 0 24,5 26,5 49* 11. soy menos efectivo bajo estrés. 10 29 33 28 17. cuando estoy en una crisis o con un problema me siento alerta y activo durante todo el día. 1,5 38 36 24,5 25. obtengo buenos resultados al manejar problemas complejos o complicados. 0 20 60 20 27. puedo desenvolverme mejor que la mayoría de las personas cuando tengo que ir a lugares desconocidos. 3 10 70 17 31. soy más efectivo bajo estrés. 31 15 38 16 tabla 5. análisis de los ítems del factor 3 fuente: datos obtenidos mediante aplicación de caps a los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo de la clínica universidad de la sabana. 172 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 ítems nunca rara vez (%) algunas veces (%) siempre (%) 3. llamo al problema por su nombre y trato de verlo en su totalidad. 0 6,5 31 62,5 12. me tomo el tiempo necesario y no actúo hasta que tenga una buena comprensión de la situación. 1,5 18 52,5 28 14. pienso en todo el problema paso a paso. 1,5 21 34,5 43 22. analizo la situación y la miro como realmente es. 3 28 29,5 39,5 41. trato de aclarar las dudas antes de actuar. 0 6,5 29,5 64 30. trato de mantener el equilibrio entre mis actividades y el descanso. 0 15 67 18 ítems nunca rara vez (%) algunas veces (%) siempre (%) 36. aprendo de las soluciones que han funcionado para otros. 0 11 74 15 6. trato de recordar las estrategias o soluciones que me han servido en el pasado. 6 20 61 13 21. recuerdo cosas que me ayudaron en otras situaciones. 0 21 52 27 32. puedo relatar lo que sucede con mis experiencias pasadas o planes futuros. 3 16 35 46 37. miro la situación positivamente como una oportunidad / desafío. 0 16 30 54 9. me siento bien de saber que estoy manejando el problema lo mejor que puedo. 0 8 49 43 28. utilizo el sentido del humor para manejar la situación. 13 56 28 3 38. me planteo muchas ideas como soluciones posibles a la situación, aunque parezcan difíciles de alcanzar. 0 16 43 41 tabla 6. análisis de los ítems del factor 4 tabla 7. análisis de los ítems del factor 5 fuente: datos obtenidos mediante aplicación de caps a los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo de la clínica universitaria teletón. fuente: datos obtenidos mediante aplicación de caps a los familiares del paciente adulto hospitalizado en la unidad de cuidado intensivo de la clínica universitaria teletón. fa m ily c ar e fo r d ep en de nt o ld er p eo pl e at h om e: a c om pa ra ti ve s tu dy b et w ee n br az il an d co lo m bi a 1 luis fernando penagos-cubillos https://orcid.org /0000-0002-2902-9400 universidad nacional de colombia, colombia. lfpenagosc@unal.edu.co maria do livramento fortes figueiredo https://orcid.org /0000-0003-4938-2807 universidade federal do piauí, brazil. liff@ufpi.edu.br maria antonieta rubio tyrrell https://orcid.org /0000-0002-1885-6865 universidade federal do rio de janeiro, brazil. tyrrell@eean.ufrj.br ana maria ribeiro dos santos https://orcid.org /0000-0002-5825-5335 universidade federal do piauí, brazil. anasantos@ufpi.edu.br mauriely paiva de alcântara e silva https://orcid.org /0000-0002-2667-1596 universidade de são paulo, brazil. maurielypaiva@usp.br sonia patrícia carreño moreno https://orcid.org /0000-0002-2163-0787 universidad nacional de colombia, colombia. spcarrenom@unal.edu.co artículo family care for dependent older people at home: a comparative study between brazil and colombia received: 11/01/2022 sent to peers: 05/03/2022 approved by peers: 13/06/2022 accepted: 13/06/2022 doi: 10.5294/aqui.2023.23.2.7 para citar este artículo / to reference this article / para citar este artigo penagos-cubillos lf, fortes m do l, rubio ma, ribeiro dos santos am, paiva de alcântara m, carreño sp. family care for dependent older people at home: a comparative study between brazil and colombia. aquichan. 2023;23(2):e2327. doi: https://doi.org/10.5294/aqui.2023.23.2.7 * this article stems from the master’s thesis entitled: “cuidado familiar a pessoas idosas idosas dependentes no domicilio: estudo comparativo brasil/colômbia” (family care for dependent elderly people at home: a comparative study between brazil/colombia), presented to the nursing graduate program at the universidade federal do piauí, brazil. https://orcid.org/0000-0002-2902-9400 mailto:lfpenagosc@unal.edu.co https://orcid.org/0000-0003-4938-2807 mailto:liff@ufpi.edu.br https://orcid.org/0000-0002-1885-6865 mailto:tyrrell@eean.ufrj.br https://orcid.org/0000-0002-5825-5335 mailto:anasantos@ufpi.edu.br https://orcid.org/0000-0002-2667-1596 mailto:maurielypaiva@usp.br https://orcid.org/0000-0002-2163-0787 mailto:spcarrenom@unal.edu.co https://doi.org/10.5294/aqui.2023.23.2.7 https://doi.org/10.5294/aqui.2023.23.2.7 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2023.23.2.7&amp;domain=pdf&amp;date_stamp=2023-05-23 theme: promotion and prevention. contributions to the subject: the present study provides evidence of the socio-demographic profile and the care situation of dependent older adults and their family caregivers using an innovative methodology for comparative studies between two countries, which has become increasingly prevalent in recent decades in the field of health sciences. fa m ily c ar e fo r d ep en de nt o ld er p eo pl e at h om e: a c om pa ra ti ve s tu dy b et w ee n br az il an d co lo m bi a 3 abstract objective: to analyze the socio-demographic profile and caregiving situation of dependent older adults and their family caregivers in brazil and colombia. method: this mixed comparative and exploratory study follows the comparative study stages proposed by bereday, namely: description, interpretation, juxtaposition, and comparison. a semi-structured interview was used. national and international ethical principles were followed in the study, with the ethics committee’s approval in each country. results: a total of 250 participants were interviewed: 52 dependent older adults in brazil and 56 in colombia, along with 70 family caregivers in brazil and 72 in colombia. a total of 68.5 % of the elderly and 83.8 % of the caregivers were women. twelve categories were created based on the participants’ statements, six in the dependent older people and six in the caregivers. conclusion: women and daughters were the primary family caregivers, and the catholic religion was prevalent in both countries. regarding the caregiving situation in both countries, it stands out that dependent older people and family caregivers feel the presence of a superior being assisting them in overcoming the challenges of caregiving activities. keywords (source: decs) aged; aging; caregivers; geriatric nursing; comparative study. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3. n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 27 4 resumen objetivo: analizar el perfil sociodemográfico y la situación de cuidado de los adultos mayores dependientes y sus cuidadores familiares en brasil y colombia. método: investigación comparativa mixta y de tipo exploratorio, la cual sigue las fases de estudios comparativos propuestos por bereday: descripción, interpretación, yuxtaposición y comparación. se utilizó una entrevista semiestructurada. se tuvieron en cuenta los principios éticos nacionales e internacionales dentro del estudio, con la aprobación de cada comité de ética en cada país. resultados: fueron entrevistados 250 participantes: 52 adultos mayores dependientes en brasil y 56 en colombia, y 70 cuidadores familiares en brasil y 72 en colombia. el 68,5 % de los adultos mayores y el 83,8  % de los cuidadores eran mujeres. se construyeron doce categorías a partir del discurso de los participantes, seis en los adultos mayores dependientes y seis en los cuidadores. conclusión: hubo predominio de las mujeres e hijas como la mayoría de las cuidadoras familiares, así como la religión católica como la más prevalente en ambos países. respecto a la situación de cuidado, en ambos países destaca que los adultos mayores dependientes y los cuidadores familiares sienten la presencia de un ser superior ayudándolos a superar los desafíos en las actividades de cuidado. palabras clave (fuente: decs) anciano; envejecimiento; cuidadores; enfermería geriátrica; estudio comparativo. cuidado familiar de adultos mayores dependientes en el hogar: un estudio comparativo entre brasil y colombia * este artículo se deriva de la tesis de maestría titulada: “cuidado familiar a pessoas idosas dependentes no domicilio: estudo comparativo brasil/colômbia”, presentada al programa de posgrado en enfermería de la universidade federal do piauí, brasil. fa m ily c ar e fo r d ep en de nt o ld er p eo pl e at h om e: a c om pa ra ti ve s tu dy b et w ee n br az il an d co lo m bi a 5 cuidado familiar de idosos dependentes no domicílio: um estudo comparativo entre brasil e colômbia resumo objetivo: analisar o perfil sociodemográfico e a situação de cuidado dos idosos dependentes e seus cuidadores familiares no brasil e na colômbia. materiais e método: pesquisa comparativa mista e de tipo exploratório, a qual segue as fases de estudos comparativos propostos por bereday: descrição, interpretação, justaposição e comparação. foi utilizada entrevista semiestrutura. foram considerados os princípios éticos nacionais e internacionais para o estudo, com a aprovação de cada comitê de ética dos referidos países. resultados: foram entrevistados 250 participantes, dos quais 52 idosos dependentes no brasil e 56 na colômbia, e 70 cuidadores familiares no brasil e 72 na colômbia. 68,5 % dos idosos e 83,8 % dos cuidadores eram mulheres. foram construídas 12 categorias a partir do discurso dos participantes, seis nos idosos dependentes e seis nos cuidadores. conclusões: houve predomínio das mulheres e filhas como cuidadoras familiares, bem como a religião católica como a mais prevalente em ambos os países. a respeito da situação de cuidado, nos dois países, destaca-se que os idosos dependentes e os cuidadores familiares sentem a presença de um ser superior que os ajuda a superar os desafios das atividades de cuidado. palavras-chave (fonte: decs) idoso; envelhecimento; cuidadores; enfermagem geriátrica; estudo comparativo. * este artigo é derivado da tese de mestrado intitulada “cuidado familiar a pessoas idosas dependentes no domicilio: estudo comparativo brasil/colômbia”, submetida ao programa de pós-graduação em enfermagem da universidade federal do piauí, brasil. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3. n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 27 6 introduction aging is a gradual and irreversible change in an individual’s structure and function, which occurs due to the passage of time at the psychobiological level. it is considered a process, and old age is viewed as a stage of the human life cycle. thus, it is related to a heterogeneous transition that depends on how individuals organize their lives, which may be based on historical and cultural circumstances, the incidence of diseases, and the interaction between genetic and environmental factors (1). in colombia and brazil, an older adult is considered to be someone who is sixty or older (2). in both countries, the caregivers are people who may or may not be family members and care for the ill dependent older person as part of their paid or unpaid daily activities. the caregiver’s objective is to assist the elderly in their activities, such as feeding, personal hygiene, daily medications, accompanying them to health services, and other actions required daily (3-4). this global phenomenon has increased significantly recently, from 770 million people aged 60 or older to 900 million in 2015. in 2020, it was estimated that this number would reach one billion; by 2050, it will come two billion, of which 80 % will be in countries with medium and low per capita income (5-6). in brazil, 19.2 million people aged 65 or older were registered in 2018, and in 2060 this number is estimated to reach 58.2 million older adults (7). in colombia, there are estimated to be 6.8 million older adults in 2020, projected to double by 2050 (8). this demographic transition, similar to an exponential curve growth, means that families are faced with providing care for dependent older people and caregivers who often assume this role without adequate preparation, assistance, or social support, which affects both their quality of life as caregivers, as well as that of the elderly (9). due to the importance of dependent older adults and their family caregivers in this study, the main objective is to analyze the socio demographic profile and the caregiving situation of dependent older people and their family caregivers in brazil and colombia. materials and methods this mixed comparative study of the exploratory type based on bereday’s (1964) guidelines complies with the four stages of description, interpretation, juxtaposition, and comparison. in addition, it includes two countries, covering the similarities and differences between the sociocultural and political organizations within brazil and colombia, particularly dependent older adults and their family caregivers (10). fa m ily c ar e fo r d ep en de nt o ld er p eo pl e at h om e: a c om pa ra ti ve s tu dy b et w ee n br az il an d co lo m bi a 7 the study was conducted according to the guidelines: consolidated criteria for reporting qualitative research (coreq) (11) and strengthening the reporting of observational studies in epidemiology (strobe) (12). a semi-structured interview was used to guide the collection of information, which included questions regarding socio-demographic data, the older people’s ability to perform daily activities, and open-ended questions regarding their cognitive, mental/emotional, and social dependence. the researchers did not know the participants before the study. once contact was established between researchers and interviewees, training was provided to the researchers, and the study’s objective was shared with them. in brazil, seven cities that were included in the estratégia saúde da família (family health strategy), a primary healthcare program, were the research sites for convenience. these cities were teresina, brasilia, belo horizonte, manaus, fortaleza, and rio de janeiro, which were part of the national multicenter research by cecilia minayo entitled: “situational study of dependent older adults living with their families” to propose a care policy and support to caregivers. the author approved the use of data for research purposes. in colombia, data collection by convenience was carried out through the cuidando a cuidadores (caring for caregivers) program, thanks to a nursing professional who is a member and leader of this program. in both areas, prior authorization was granted by the respective ethics committee. families whose elderly lived in old homes or lived alone were excluded. all dependent older adults and family caregivers living in the same household who agreed to participate voluntarily in the study were included. in both countries, data collection was conducted at the participants’ homes, where only the participant and the researcher were present. in brazil, data collection was carried out between september and november 2019, and in colombia, between february and april 2020, with an average interview duration of forty minutes. repeated interviews were not conducted. verbatim transcriptions of the audio-recorded interviews were made to support the results and interpretations presented (content analysis). leading questions were avoided to prevent bias, and during information interpretation and analysis, researchers maintained neutrality in indicating the commonality of responses and holistically examining representation. the qualitative analysis software atlas.ti and the programs excel and spss version 22 were used for quantitative analysis. due to the covid-19 pandemic between 2020 and 2021, it was impossible to return transcripts to participants after coding and have feedback on the results. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3. n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 27 8 according to bereday’s model (13), description represents the detailed narration of a discourse; interpretation determines the meaning of a text with certainty, juxtaposition incorporates the initial confrontation of data, and, finally, comparison represents the simultaneous analysis of the variables of the different places included. atlas.ti, a qualitative data analysis program, was used to create a total of 66 codes that were included in categories, subsequently analyzed and compared between the two countries. results a total of 250 participants were interviewed in the two countries. of these, 52 dependent older adults and 70 family caregivers were interviewed in brazil, and 56 dependent older people and 72 family caregivers in colombia. table 1 presents the participants’ sex and age. the number of participants who voluntarily decided not to be included in the study was not recorded. table 1. sex and age of the older adults and family caregivers in brazil and colombia sex older people in brazil older people in colombia total of older people n % n % n % female 35 67.3 39 69.6 74 68.5 male 17 32.7 17 30.4 34 31.5 total 52 100 56 100 108 100 sex caregivers in brazil caregivers in colombia total caregivers n % n % n % female 57 81.4 62 86.1 119 83.8 male 13 18.6 10 13.9 23 16.2 total 70 100 72 100 142 100 age brazil colombia p-value mean sd mean sd older people 79.35 9.1 73.82 9.01 0.002** family caregivers 55.6 12.2 40.2 14.5 0.01* * p < 0.05, ** p < 0.01 source: own elaboration it is evident that, in both countries, the female sex is prevalent among the elderly and the family caregivers, as out of the total number of participants, 250 people, 193 were women (77.2 %). the age of the elderly and family caregivers in the two countries showed a statistically significant difference, 5.53 and 15.4 years, respectively, being higher in the brazilian participants. a variety of ethnicities are present in both countries (asian, caucasian, african, mixed, hispanic); the most prevalent in brazil is caucasian among older adults (40.4 %) and mixed among family caregivers (35.7 %). in colombia, the most pervasive ethnicity identified fa m ily c ar e fo r d ep en de nt o ld er p eo pl e at h om e: a c om pa ra ti ve s tu dy b et w ee n br az il an d co lo m bi a 9 by the participants, both among older people and family caregivers, was mixed (48.2 % and 59.7 %, respectively) (p < 0.05, p < 0.01). when family caregivers were asked about the relationship with the dependent older adult, most participants in both countries responded that they were their children (57.14 % in brazil and 52.78 % in colombia). however, the second most frequent response in brazil was the spouse (24.29 %), and in colombia, the granddaughter (18.06 %) (p < 0.01). regarding marital status, it was evident that most dependent older people were widowed (44.2 %), followed by married people (38.5 %), while the opposite was true in colombia (married 30.4 % and widowed 28.6 %) (p < 0.05). religion-wise, catholicism was the predominant religion in brazil and colombia; however, in colombia, it was more prevalent with 91.1 % of the participants (p < 0.05). similarly, regarding education, the percentage of people who reported having completed primary education was higher in colombia (28.57 %) (p < 0.05). within the physical and structural adaptations of the household, 91.1 % of the dependent older adults in colombia reported having some modification, compared to 59.6 % of the older people in brazil (p < 0.01). finally, 53.6 % of dependent older adults in colombia stated having some leisure activity, while in brazil, this rate was 9.6 % (p < 0.01). regarding the qualitative data from the interviews, a complete reading of the interviews of all participants was carried out, whose common statements were identified with a code, which was later grouped into the final categories by similar attributes. from the dependent older adults’ statements in brazil, five categories emerged, namely: i am a burden, i want to be autonomous, i am no longer who i was before, i accomplished my mission, and i am okay with god. in colombia, six categories emerged: i do not feel useful, i want to be autonomous, i am not who i was before, i accomplished my mission, i am okay with god, and my role in my family (shown in table 2). the categories developed based on the statements of dependent older people in brazil and colombia are described below. i am a burden (identified in brazil): when faced with a situation of physical, emotional, and social dependence, in addition to aging and the onset of diseases that hinder their ability to carry out daily activities, older adults feel that they are no longer productive and begin to feel useless and as a burden. i do not feel useful (identified in colombia): it expresses sadness for having to receive assistance from another person (the family caregiver) in their daily activities due to their dependence situation. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3. n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 27 10 table 2. categories of the participants’ statements brazil colombia older people 1) i am a burden 2) i want to be autonomous 3) i am no longer who i was before 4) i accomplished my mission 5) i am okay with god 1) i am a burden 2) i want to be autonomous 3) i am no longer who i was before 4) i accomplished my mission 5) i am okay with god 6) my role in my family family caregivers 1) how i became a caregiver 2) the burden of caregiving on me 3) changes in our lives 4) i have support 5) i have god’s help 6) my challenges as a caregiver source: own elaboration i want to be autonomous: the expression of a wish to carry out daily activities that they performed before they became dependent, such as bathing, preparing food, or undergoing treatment. however, due to their condition, they cannot do them on their own. i am no longer who i was before: older adults often remember the activities they performed when they were independent; however, although they would like to perform them again, the people in their context (to a greater extent, their family) prevent them from completing them due to their condition and the possibility of adverse events. older people may engage in a denial process. i accomplished my mission: when they feel they have achieved their mission throughout life. it refers to the fact that while they were independent, they did the most out of their health and family. currently, the older adults accept their condition, given their limitations, and do what they can with joy and accept what they cannot do with resilience. i am okay with god: it is the transformation of their pain and dependence situation. they establish a relationship with a higher being who helps them accept themselves, leave their worries and hardships with this higher being, and receive a sense of inner peace in return. my role in my family (identified in colombia): it represents the perception of usefulness as family members of the older adults who, aware of their dependence and limitations, participate in the decisions regarding their care, family decisions, or home adaptations, which gives them a feeling of usefulness and family unity. the categories developed based on the family caregivers’ statements in brazil and colombia were the following: how i became a caregiver, the burden of caregiving on me, changes in our lives, i have support, i have god’s help, and my challenges as a caregiver. table 2 presents the description of these categories, as well as the statements of some interviewees. fa m ily c ar e fo r d ep en de nt o ld er p eo pl e at h om e: a c om pa ra ti ve s tu dy b et w ee n br az il an d co lo m bi a 11 how i became a caregiver: this includes the meanings that cause a person to become a caregiver. it also refers to the internal and external motivations or conditions that led the person to make this decision, including reasons of time and past experiences with the dependent older person. the burden of caregiving on me: this represents the responsibility of being with the dependent older person in their daily activities. often, these tasks become so excessive that they impact the caregiver’s life. they can also be influenced by internal or external personal factors or stressful situations, to the point of having difficulties in carrying out one’s activities, which result in having to carry them out with concerns. changes in our lives: some significant changes occur in the lives of family caregivers as they become the ones who provide care the most to the dependent elderly; also, changes in the lives of the elderly occur and are perceived by family caregivers as their health situation is critical to the caregivers. i have support: secondary to the caregiving situation, help or support appears, which may be material or intangible, is perceived by the family caregivers in their daily activities related to the care provided to the elderly and helps them to avoid or reduce the care burden. i have god’s help: some caregivers perceive their situation as being helped by a higher being (god), who helps them to be resilient and leave their concerns and problems with that being; in return, they receive a sense of inner peace. likewise, the feelings of spiritual support in the lives of older adults perceived and described by caregivers are also noted. my challenges as a caregiver: this represents all the challenges perceived, consciously or unconsciously, by family caregivers as a consequence of the caregiving situation, and new methods are identified to assist in maintaining this relationship as a healthy one. discussion a prevalence of the female sex is found among dependent older adults and family caregivers both in brazil and colombia, which can be attributed to the life expectancy at birth at the national level, which is higher in women in both countries (13). this result is similar to other studies, where older people and family caregivers are primarily female (14-17). regarding the age of the dependent older adults, the studies vary between an average of 69.3 years and 75.5 years, ranging from 60 to 96 years (14,16-17). regarding family caregivers’ age, an average of 43.1 years was identified among family caregivers in colombia (18). however, studies conducted in different regions a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3. n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 27 12 of brazil found that the average age of family caregivers is over 50 years (19-22), similar to what was found in the present study. the ethnicity most reported by older adults in brazil was caucasian, which differs from what was found in the study, as 76.9 % of older people reported themselves as mixed. although mixed was the most reported ethnicity in colombia, it represented only 48.2 % (22). at the national level, the instituto brasileiro de geografia e estatística ibge (statistics and geography brazilian institute) stated that 46.7 % of the brazilian population declared themselves mixed, being the most prevalent ethnicity in brazil, followed by the caucasian ethnicity, which is contrary to what was found in the present study (23). in colombia, according to the departamento administrativo nacional de estadísticas dane (national administrative department of statistics), the most prevalent ethnicity in the population is mixed, which is similar to what was found in the present study (8). regarding the family caregivers, the prevalent ethnicity in both countries was mixed, consistent with national studies conducted by ibge (23) and dane (8). likewise, a study carried out in the state of ceará, brazil, showed that 76.9 % of family caregivers identified themselves as mixed (22). concerning the relationship of the family caregivers with the dependent older people, a study conducted in canada found that children represent 56.2 % of the caregivers, followed by spouses (35.4 %) (24), which is consistent with what was found in brazil. however, it differs from the results obtained in colombia, which may be attributed to the life expectancy in canada, which is higher than that of brazil and colombia; living longer, couples age together and take care of their spouses (13). for marital status, in brazil, the older adults reported that 44.2 % of them were widowed, and 38.5 % were married, which is consistent with the study results, where 38.5 % of the older people were married. the same percentage were widowed (22). nonetheless, it differs from the results among older adults in colombia, who reported a higher rate of being married (30.4 %) and then widowed (28.6 %), which may be related to the average age of the participants (older in brazil). it is noted that the prevalent religion in both countries is catholic, which is consistent with what was found by (22), who indicates that 76.9 % of the dependent older people in his study considered themselves catholics, which may be attributed to the fact that both in brazil (23) and colombia (8), the prevalent religion is catholic. among the physical and structural household adaptations, the present study showed a higher percentage of affirmative responses from older adults in colombia than those in brazil (91.1 % versus 59.6 %). however, the high prevalence of these adaptations may be fa m ily c ar e fo r d ep en de nt o ld er p eo pl e at h om e: a c om pa ra ti ve s tu dy b et w ee n br az il an d co lo m bi a 13 associated with an increase in the perception of the functional capabilities of the dependent older people themselves, impacting confidence and quality of life in other areas (25). regarding leisure activities and free time, in brazil, 9.6 % of the older people stated that they engage in them, compared to 53.6 % in colombia, which may be explained by the participants’ average age, which is lower in colombia. in the categories i am a burden, i want to be autonomous, and i am no longer who i was before, it was found that most of the older adults were female, with women tending to be more dependent regarding daily activities when compared to men (26). in the category i accomplished my mission, a code is referred to as partner (bond), representing the affective bonding that exists mainly when the caregiver is also the spouse. in both countries, almost a quarter of the dependent older people reported being cared for by their spouses, which may be attributed to the emergence of statements corresponding to establishing a bond. it may represent a protective factor associated with the burden experienced by the older people when the social interaction is positive, as evidenced in the statements of the dependent older adults interviewed (17). in addition, the category i am okay with god is identified as one with a high prevalence due to the high number of people who practice a religion. there are discourses in which dependent older adults express themselves calmly in stressful situations, including death. in this way, they identify spirituality as a support for the dependent older adult (27). the last category described for older people, particularly identified in the colombian participants’ interviews, corresponds to the category entitled my role in my family. the study in canada addressed the participation of dependent older people and found that 93 % of them reported assuming an active or collaborative role in the decision-making process (24). these results are consistent with the present study, which may be attributed to the type and complexity of the older adults’ dependence and their ability to communicate with their families. regarding family caregivers, the first category, entitled how i became a caregiver, is filled with motivations that encompass personal and external situations. in a study conducted in iran, an attempt was made to determine why caregivers assume this role, identifying four psychosocial motivation categories (28). the first was related to moral reasons, similar to the statements from brazil and colombia participants. the second concerned religious or spiritual reasons. the third was related to financial a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3. n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 27 14 reasons. in the present study, caregivers were identified as lacking the financial means to hire a formal caregiver. finally, immoral reasons are related to taking revenge on or stealing from the dependent older person, which is not associated with what was found in the present study in brazil and colombia. in the second category, the burden of caregiving on me, similarities are evident with the findings of a study that identifies that caring for the elderly can create a burden, especially when the caregiver experiences stress and lacks adequate social support to help them, according to the level of dependence of the elderly (17). in the category entitled changes in our lives, in the interviews, the transformation of the household for the elderly is evident, representing changes in the physical environment. it is related to the findings of a study that concluded that the adaptations in the household might be associated with an increase in the perception of functional capacity by the elderly themselves when performing an activity independently that they were only able to perform with the caregiver’s assistance (25). the i have support category represents the support the family caregiver receives and is perceived by the caregiver. thus, an interaction between both parties must exist for decisions regarding tasks and care, influencing the situation of the elderly (24). the fifth category, i have god’s help, presents statements that may be attributed to the religious and spiritual prevalence of both countries (brazil and colombia), which is partially consistent with a study where religiosity represents support for receiving emotional strength and continuing to care for the dependent elderly (28). in the last category, my challenges as a caregiver, the family caregivers consider their limitations and those of the dependent elderly to provide the best care. what stands out is the importance of community health professionals in outlining a care plan for the binomial dependent elderly and family caregiver (including family), the elderly who leads the household as far as possible, and the situation of being dependent (17, 29). conclusion the present study analyzed the socio-demographic profile and the caregiving situation of dependent older adults and their family caregivers in brazil and colombia through a methodologically innovative mixed-approach study. it found a complex socio-demographic profile of the participants, with a prevalence of wives and daughters of the elderly as the majority of family caregivers and a preponderance of the catholic religion. the caregiving situation is evident within the categories generated from the participants’ statements, as dependent older people feel fa m ily c ar e fo r d ep en de nt o ld er p eo pl e at h om e: a c om pa ra ti ve s tu dy b et w ee n br az il an d co lo m bi a 15 as if they are a burden, they do not feel helpful or the same as they were before; also, they expressed the desire to be autonomous and to have accomplished their mission in life, as they feel at peace with a superior being. in addition, it was evident in the colombian statements that the elderly people referred to their role in their families. regarding family caregivers, the caregiving situation is centered on why they became caregivers, how caregiving impacts their lives, how different changes develop, the different types of human and material support that occur during caregiving, the help they perceive from a superior being in providing their services to the older adults, and, finally, the challenges that the caregivers perceive in caregiving activities. however, due to the magnitude of the number of interviews, it was impossible to address all aspects completely. considering that four research subjects are presented with similar elements, they are entirely different in other parts. likewise, after data collection, it was challenging to provide feedback on the transcription and the results to the participants due to the covid-19 pandemic and the quarantine measures adopted at the national level. conflict of interest: none declared. funding one of the authors received a grant from the organización de los estados americanos (american states organization) and the grupo coimbra de universidades brasileiras (coimbra group of brazilian universities) oas-gcub for conducting the research. references 1. rishworth a , elliott sj. global environmental change in an aging world: the role of space, place and scale. soc sci med. 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https://doi.org/10.4067/s0717-95532018000100217 https://doi.org/10.1590/0034-7167-2018-0111 https://doi.org/10.1590/0034-7167-2018-0111 https://www.ibge.gov.br/estatisticas/sociais/educacao/9127-pesquisa-nacional-por-amostra-de-domicilios.html?=&t=o-que-e https://www.ibge.gov.br/estatisticas/sociais/educacao/9127-pesquisa-nacional-por-amostra-de-domicilios.html?=&t=o-que-e https://www.ibge.gov.br/estatisticas/sociais/educacao/9127-pesquisa-nacional-por-amostra-de-domicilios.html?=&t=o-que-e https://doi.org/10.1080/08952841.2019.1686325 https://doi.org/10.1080/08952841.2019.1686325 184 195 comunicacion equipo enfermeria pacientes.indd 184 aquichan issn 1657-5997 noelia pilar rojas1 claudia raquel bustamante-troncoso2 angelina dois-castellón3 comunicación entre equipo de enfermería y pacientes con ventilación mecánica invasiva en una unidad de paciente crítico 1 enfermera-matrona. especialista en cuidados críticos del adulto. profesora asistente, pontificia universidad católica de chile, chile. nprojas@uc.cl 2 enfermera-matrona. magíster en enfermería. profesora asistente, pontificia universidad católica de chile, chile. cqbustam@uc.cl 3 enfermera-matrona, magíster en psicologí a de la salud. profesora asociada, pontificia universidad cató lica de chile, chile. adois@uc.cl recibido: 2013-03-10 enviado a pares: 2013-04-19 aceptado por pares: 2014-03-18 aprobado: 2014-04-11 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 184-195 para citar este artículo / to reference this article / para citar este artigo rojas np, bustamante-troncoso cr, dois-castellón a. comunicación entre equipo de enfermería y pacientes con ventilación mecánica invasiva en una unidad de paciente crítico. aquichan 2014; 14(2): 184-195. resumen la comunicación se basa en la utilización de herramientas e involucra la interacción recíproca de dos interlocutores. en las unidades de cuidados intensivo (uci), la aplicación de ventilación mecánica invasiva (vmi), genera condiciones especiales en el paciente que dificultan su comunicación. la ausencia de comunicación entre el equipo de enfermería (ee) y los pacientes con vmi es atribuida a múltiples barreras y produce efectos negativos que afectan la recuperación y el bienestar. objetivo: conocer las características de la comunicación con pacientes con vmi que aplica elementos de la teoría fundada para el proceso de análisis y utilizó como técnica de recolección de datos grupos focales de enfermeras y técnicos de enfermería que realizan cuidado directo a pacientes con vmi en una uci. método: investigación de diseño cualitativo, orientada por la teoría fundada, para el análisis y la asociación de conceptos, que utilizó grupos focales como técnica de recolección de la información. resultados: si bien los hallazgos permiten describir las principales características de la comunicación con estos pacientes identificando los medios y las formas utilizados por el ee para hacerlo, los momentos en que ocurre la comunicación, los beneficios y las barreras percibidas por el grupo de participantes, no se llega a establecer una categoría central con las estructuras y definiciones del proceso dentro de la misma, para lo que se requerirían nuevas investigaciones. conclusión: a partir de estos hallazgos se espera contribuir al cuerpo de conocimientos de la disciplina de enfermería y fortalecer la gestión del cuidado que realiza el ee en las uci. palabras clave enfermería, cuidados intensivos, comunicación, cuidados críticos, pacientes (fuente: decs, bireme). 185 comunicación entre equipo de enfermería y pacientes con ventilación mecánica invasiva en una unidad de paciente crítico l noelia pilar rojas y otros. año 14 vol. 14 nº 2 chía, colombia junio 2014 l 184-195 communication between the nursing team and patients on invasive mechanical ventilation in an intensive care unit abstract communication, in this case, is based on the use of tools and involves reciprocal interaction between two parties. the use of mechanical ventilation in intensive care units generates patient-specific conditions that impede communication. a lack of communication between the nursing team and mechanically-ventilated patients is attributed to a variety of barriers and produces negative effects that can have an impact on the patient’s recovery and comfort. objective: the study was conducted to become familiar with the characteristics of communication between mechanically-ventilated patients and the nursing team. method: the elements of the grounded theory method were applied to the analytical process, and focus groups of nurses and nursing technicians who provide care directly to mechanically-ventilated patients in an icu were used to gather the data. results: the findings provide a description of the main features of communication with these patients by identifying the ways and means of communicating used by the nursing team, the moments when communication occurs, and the benefits and barriers perceived by the participant group. however, it was not possible to establish a central category with the structures and definitions of the process within it, which will require new research. conclusion: the findings are expected to contribute to the body of nursing knowledge and to help reinforce the management of care provided by icu nursing teams. key words nursing, intensive care, communication, critical care, patients (source: decs, bireme). 186 aquichan issn 1657-5997 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 184-195 comunicação entre equipe de enfermagem e pacientes com ventilação mecânica invasiva em uma unidade de paciente crítico resumo a comunicação se baseia na utilização de ferramentas e envolve a interação recíproca de dois interlocutores. nas unidades de tratamento intensivo (uti), a aplicação de ventilação mecânica invasiva (vmi), gera condições especiais no paciente que dificultam sua comunicação. a ausência de comunicação entre a equipe de enfermagem (ee) e os pacientes com vmi é atribuída a múltiplas barreiras e produz efeitos negativos que afetam a recuperação e o bem-estar. objetivo: conhecer as características da comunicação com pacientes com vmi que aplica elementos da teoria fundada para o processo de análise e que utilizou como técnica de coleta de dados grupos focais de enfermeiras e técnicos de enfermagem que realizam cuidado direto a pacientes com vmi em uma uti. método: projeto de pesquisa qualitativa, orientada pela teoria fundamentada, para a análise e associação de conceitos, que utilizou grupos focais como técnica de coleta de dados. resultados: embora as constatações permitam descrever as principais características da comunicação com esses pacientes, ao identificar os meios e as formas utilizados pela ee para fazer isso, os momentos em que ocorre a comunicação, os benefícios e as barreiras percebidas pelo grupo de participantes, não se chega a estabelecer uma categoria central com as estruturas e definições do processo dentro desta, para o qual se requereriam novas pesquisas. a partir dessas constatações, espera-se contribuir ao corpo de conhecimentos da disciplina de enfermagem e fortalecer a gestão do cuidado que realiza a ee nas uti. palavras-chave enfermagem, terapia intensiva, comunicação, cuidados críticos, pacientes (fonte: decs, bireme). 187 comunicación entre equipo de enfermería y pacientes con ventilación mecánica invasiva en una unidad de paciente crítico l noelia pilar rojas y otros. introducción desde sus comienzos y a lo largo de todo el proceso de vida el habla y la comunicación forman parte importante de la expresión del ser humano, al permitirle manifestar sus necesidades y deseos, darse a conocer y relacionarse con el mundo que lo rodea (1). la comunicación, entendida como un proceso de envío y recepción de mensajes, se basa en la utilización de herramientas de comunicación verbal y no verbal (2), involucra la interacción recíproca de dos interlocutores (3) y requiere de feedback para ser efectiva (4). en el contexto sanitario, la comunicación se ha convertido en una herramienta fundamental porque permite a los pacientes expresar sus necesidades al equipo de salud. sin embargo, y con frecuencia, los individuos pueden encontrarse en situaciones bajo las cuales están imposibilitados para comunicarse, ya sea temporal o permanentemente (5). la mayor parte de estas ocasiones están directamente relacionadas con el estado de salud, y retardan la recuperación de los pacientes, en vista de la relación existente entre comunicación efectiva y buena práctica sanitaria (3). en una uci se convive con la gravedad de los individuos hospitalizados, el sufrimiento de sus familiares y la vivencia constante de la vida y de la muerte (6). en este contexto, los pacientes que requieren apoyo ventilatorio señalan que los problemas de comunicación vividos son desde moderados a extremadamente molestos. no poder hablar debido a la presencia de un dispositivo en la boca puede convertirse en una experiencia aterradora (7). un factor adicional de interferencia es el uso de sedantes, los cuales se utilizan para favorecer la adaptación del paciente a la ventilación (8). del mismo modo, el uso de contenciones físicas, frecuentes y necesarias en este grupo de pacientes, también se ha relacionado con menores grados de comunicación (8), dado que se imponen como una barrera física entre el paciente y quien lo cuida. de acuerdo con beltrán, “la relación enfermero-paciente involucra variados contactos físicos en la realización de procedimientos, la interpretación de gestos, movimientos y posiciones con las cuales los pacientes sometidos a ventilación mecánica comunican sus emociones, sentimientos y percepciones, debido a que no pueden expresarlos por medio del lenguaje hablado” (9). sin embargo, la incorporación de la comunicación con el paciente con vmi, como parte de los cuidados habituales que debe recibir, se ve influenciada por múltiples factores, algunos de ellos relacionados directamente con los conocimientos que el ee tenga respecto al impacto de esta variable en el estado de salud de los pacientes (6). en la medida en que este beneficio no sea conocido por el ee, la comunicación no será integrada consistentemente a la práctica diaria de manera que técnicos de enfermería y enfermeras continuarán acercándose a los estos pacientes solo para realizar actividades administrativas o funcionales (7). la ausencia de comunicación entre el ee y los pacientes tiene efectos negativos. en particular, estos últimos han reportado sentimientos de ira, miedo, inquietud, pérdida de control, despersonalización, frustración y ansiedad (5, 8). del mismo modo, el desánimo que en ocasiones presentan producto de las dificultades en la comunicación condiciona una menor interacción con la familia y sus cuidadores (10). considerando que cuando el ee tiene dificultades para entender el mensaje que el paciente ventilado quiere transmitir se pierde la claridad y el resultado puede ser incierto (6), sumado a los resultados de investigaciones que señalan una integración inconsistente de estrategias de comunicación con pacientes ventilados (11), surge la pregunta: ¿cuáles son las principales características de la comunicación entre el ee y los pacientes en vmi en una uci?, teniendo como objetivo: “conocer las principales características de la comunicación entre el ee y los pacientes en vmi en una uci". materiales y métodos investigación de diseño cualitativo, orientada por la teoría fundada, para el análisis y la asociación de conceptos, que utilizó grupos focales como técnica de recolección de la información. para la conformación de los grupos se trabajó con una muestra intencionada de participantes conformada por enfermeras y técnicos en enfermería pertenecientes al ee de la uci de un hospital clínico (hc) de la región metropolitana. se crearon cuatro grupos focales, dos con enfermeras(os) y dos con técnicos en enfermería, entre junio y julio del año 2011, logrando la participación de 19 personas que realizan cuidados directos a pacientes con vmi. previo a cada sesión de grupo focal los participantes completaron el proceso de consentimiento informado, y una encuesta que recogía datos demográficos. los grupos focales fueron guiados por un profesional no perteneciente al 188 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 grupo de investigadores. para el análisis de los datos se utilizaron las transcripciones verbatim de cada sesión de grupos focales. se aplicó la técnica de análisis comparativo constante de los datos, lo que permitió identificar patrones y descubrir las relaciones entre las ideas y los conceptos. de este proceso participaron tres investigadoras, una de ellas en su calidad de asesora metodológica y dos con experiencia previa en la metodología. a modo de síntesis del proceso, se siguieron los siguientes pasos (12): 1. agrupar los datos en dimensiones similares. 2. dar un nombre a las dimensiones, transformándolas en categorías. 3. disponer los patrones en relación unos con otros. respecto a los datos obtenidos de la aplicación del cuestionario “caracterización equipo de enfermería”, estos fueron subidos a una base de datos construida en excel (programa microsoft office). durante la investigación se procuró mantener los criterios de rigor de credibilidad, auditabilidad y transferibilidad de guba y lincoln citados por castillo y vásquez (13). la investigación contó con la evaluación y aprobación del comité de ética de la escuela de enfermería de la pontificia universidad católica de chile y del comité de ética del hospital clínico de la misma institución. características de los participantes. la muestra estuvo constituida por 9 enfermeras(os) y 10 técnicos de nivel superior en enfermería. el promedio de edad fue de 31 años y el tiempo de experiencia laboral en uci varió entre los 6 meses hasta los 30 años. todos los participantes trabajan por turnos, teniendo un promedio de 3 pacientes a su cargo en cada jornada de trabajo. características de la comunicación entre el ee y pacientes con vmi. completar la codificación abierta de la investigación permitió describir el proceso de comunicación entre el ee y los pacientes con vmi. este proceso presenta características que le son particulares y que se derivan tanto de la condición clínica del paciente como del tipo de trabajo que realiza el ee en la uci. en este sentido, los elementos claves son el trabajo en uci y la comunicación, los que a su vez tienen dimensiones (características del trabajo en uci, características de la familia del paciente en uci, condiciones clínicas del paciente, tipo de cuidado y técnicas de comunicación) que se comportan como barreras o como facilitadores de la comunicación. en esta etapa de la investigación se determinaron algunas relaciones incipientes entre las dimensiones. todo lo anterior se esquematiza en la figura 1. resultados beneficios de la comunicación los participantes de los grupos focales estiman que el poder comunicarse con los pacientes con vmi tiene efectos positivos tales como: • favorece su independencia y autonomía: el paciente pasa de un estado de dependencia total a ser una persona que deja la unidad en una condición totalmente distinta habiendo recuperado parte de su independencia. • mejora los resultados clínicos: este corresponde a uno de los principales logros de la comunicación. de acuerdo con los participantes del estudio aquel paciente que logra comunicar sus necesidades mejora progresivamente su condición clínica acelerando el proceso de recuperación. "porque vemos que el paciente avanza, hasta pueden conversar y ser más autónomos cada día" (g1, 121)*. • desarrolla un mayor nivel de confianza con el ee: el contacto diario con un grupo de técnicos y profesionales le permite el paciente desarrollar un mayor nivel de confianza, a través de la voz reconoce a quienes lo cuidan y en quienes confía. "facilita la confianza. fortalecen el vínculo... reconocen la voz" (g1 119). • mejora los resultados clínicos: este corresponde a uno de los principales logros de la comunicación. de acuerdo con los participantes del estudio, aquel paciente que logra comunicar sus necesidades mejora progresivamente su condición clínica acelerando el proceso de recuperación. factores favorables de la comunicación entre el ee y los pacientes con vmi para poder observar los beneficios de la comunicación se deben tener en consideración aquellos factores que la favorecen los * las letras corresponde al grupo focal y el número que acompaña a la letra corresponde al párrafo de la transcripción donde aparece la aseveración. 189 comunicación entre equipo de enfermería y pacientes con ventilación mecánica invasiva en una unidad de paciente crítico l noelia pilar rojas y otros. cuales, de acuerdo al análisis de los grupos focales, pueden ser categorizados en: • mantener a los pacientes informados respecto de los cuidados que les son realizados, y de las técnicas y los procedimientos a las que pueden ser sometidos, reduciendo significativamente su incomodidad y ansiedad, y favoreciendo la seguridad y bienestar. avisándoles con palabras simples lo que les vamos a hacer, me ha tocado que hay pacientes que están sedados y que cuando les digo por ejemplo sra. rosita le voy a poner el termómetro, la paciente me hace un gesto de aprobación.ç hablarles, “don juanito, lo voy a controlar y le voy a administrar sus antibióticos”, aunque el paciente esté sedado (a – 126). figura 1. codificación axial: factores relacionados con la comunicación entre equipo de enfermería y pacientes en ventilación mecánica invasiva 190 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 • mostar disposición a escuchar: el paciente reconoce en quien lo cuida la disposición a escucharlo, a intentar comprenderlo y satisfacer sus necesidades. "lo escucho... lo escucho e intento comprender lo que quiere…" (b134). • empatía: la empatía se reconoce como un atributo especial de quienes forman el ee ya que en la medida en que quienes cuidan a los pacientes con vmi se ponen en su lugar podrán acercarse a identificar sus necesidades. "y la disposición y la empatía de querer comunicarse. por ejemplo, hay que ser empática, pensar, si yo estuviese en esta situación qué querría y entonces le pregunto: ¿quiere ver a su familia?" (a-91). • tono de voz suave: se debe además hablar cerca del oído, y lentamente favoreciendo de este modo la comprensión en los pacientes. se debe evitar gritarlos ya que esto los altera e incomoda. "con tono parejo, acercándose al oído... que se entienda […] ee asustan; si usted levanta el tono de voz se asusta el paciente" (b 171). • la proximidad física al momento de intentar comprender lo que el paciente necesita es interpretada también como señal de interés por comunicarse. • disponibilidad de tiempo programado dentro de la jornada y como parte del plan de cuidados que los pacientes con vmi requieren. "se debe evaluar a cada paciente... pero para eso hay que dedicarle tiempo, aunque sea un poquito en la mañana, otro poquito en la tarde" (b 140). • estado de alerta: representa la condición clínica que más influye en la posibilidad de éxito de los intentos de comunicación. • uso correcto de las herramientas de comunicación: estas constituyen el medio a través del cual el ee intenta acercarse a los pacientes con vmi y poder reconocer sus necesidades. a continuación se presentan algunas herramientas que los participantes señalaron como de uso más frecuente: medios o formas utilizados por el ee para comunicarse con pacientes con vmi. debido a que las formas comunes de comunicación no son aplicables, los medios que el ee utiliza para comunicarse con estos pacientes constituyen un elemento esencial, entre ellas se encuentran: • los movimientos de cabeza de aseveración o rechazo, el solicitar al paciente abrir y cerrar la mano y el parpadeo. estas formas de comunicación son utilizadas por el ee particularmente con pacientes cuyo estado de conciencia permite la comprensión de las indicaciones y de las preguntas que se les realizan... "nosotros tratamos de hacerlo sobre todo cuando revisamos a los pacientes... les decimos: "don juan, si me escucha apriéteme la mano"… se comunican con los ojos" (a 90). • el uso de preguntas simples que permiten al ee consultar al paciente por aspectos específicos relacionados con la sintomatología derivada del estado de salud y las múltiples terapias. el paciente es interrogado en torno a síntomas como dolor, calor, frío, necesidad de cambiar de posición o ver a la familia. "les preguntamos cosas puntuales como si tiene frío, calor, dolor... por ejemplo, le preguntamos si le duele la cabeza o si quiere ver a alguien de su familia" (c 105). • láminas con el abecedario y con imágenes de necesidades frecuentes en los pacientes hospitalizados como: sed, frío, calor, dolor, encendido/apagado de luz, exceso de ruido, temor, etc. "a mí me ha funcionado más la lámina de letras que la de imágenes. tenemos las tablitas con el abecedario, y ahí al paciente le contenemos la manito y va formando con su dedo una palabra…" (b 74). • el lápiz y el papel han demostrado ser las herramientas de mayor utilidad aun cuando represente un mayor grado de dificultad para el paciente tomar el lápiz y escribir. "... es más fácil para mí pasarle un lápiz para que me escriba, me ha pasado que aun estando ventilados si se les pasa una hoja y un lápiz escriben" (b 105). si bien en las unidades el ee cuenta con estas herramientas para poder intentar comunicarse con el paciente con vmi, el éxi191 comunicación entre equipo de enfermería y pacientes con ventilación mecánica invasiva en una unidad de paciente crítico l noelia pilar rojas y otros. to en la utilización de las mismas está determinado por factores relacionados con las características propias de las herramientas, con el ee y con el paciente en vmi. características de las herramientas. particularmente, la disponibilidad en la unidad y su adecuación a la realidad local son factores relevantes, dado que en ocasiones las herramientas con las que se cuenta se encuentran en otro idioma, o bien en el caso de las láminas de imágenes estas no contienen figuras representativas de las necesidades de los pacientes o bien no son comprendidas por este debido a que se encuentran en otro idioma o no corresponden a la realidad local. "claro, a veces en la imagen no sale todo lo que el paciente quiere expresar. hay algunas que están en inglés" (b 119). en el último tiempo, y de la mano del desarrollo tecnológico, algunos centros han incorporado al cuidado de pacientes con vmi dispositivos a través de los cuales ellos tienen la posibilidad de comunicarse con quienes les cuidan. el éxito de las experiencias internacionales es conocido por el ee. "se comunicaba a través de un computador... tenía un programa en el computador que transcribía lo que escribía a palabras que se oían" (c 224). asociadas al ee: los factores relacionados con el ee son el haber recibido entrenamiento previo en el uso de las herramientas disponibles y la disposición que técnicos y profesionales muestren por utilizarlas. esta disposición a su vez está determinada por la importancia que el ee le atribuye a la comunicación con pacientes con vmi, por las experiencias previas y por el tiempo disponible para utilizarlas. si bien las unidades cuentan con herramientas como láminas de imágenes, a menudo el ee no recibe el entrenamiento necesario para utilizarlas lo cual influye en la disposición del personal para su uso y, por tanto, en la posibilidad de que los pacientes puedan intentar comunicarse. experiencias anteriores no favorables con el uso de alguna de las herramientas son determinantes en la decisión de enfermeras/ técnicos para destinar tiempo a volver utilizarlas e intentar comunicarse con el paciente. "... son muy pocas las oportunidades en que he podido sacarle provecho a las láminas…" (c 119). asociadas al paciente: los factores relacionados con el paciente son el estado de conciencia, la presencia de contenciones en las extremidades, la movilidad física y el interés que este muestre para intentar expresar sus necesidades. es frecuente que los pacientes con vmi permanezcan contenidos en sus extremidades superiores debido al riesgo de autorretiro del ventilador mecánico o de otros dispositivos, esto limita la movilidad física y, por tanto, la posibilidad de usar de forma correcta algunas de las herramientas de comunicación. sumado a ello, el estado de conciencia variable por efecto de drogas y sedantes dificulta las posibilidades de que el paciente exprese su necesidades. algunas herramientas de comunicación requieren un mayor control de los movimientos, particularmente de la motricidad fina, tal es el caso de las herramientas de lápiz y papel, y las láminas de letras e imágenes en las que es necesario que el paciente pueda señalar la letra o imagen correspondiente. "el paciente parece que quiere escribir y finalmente no escribe nada o no se entiende nada porque no tiene la motricidad suficiente como para poder expresarse" (c 121). los factores antes mencionados se presentan como determinantes del nivel de aplicación de las herramientas por el ee cuando se realizan intentos de comunicación. la percepción de los participantes del estudio es que existe en la actualidad una subutilización de las mismas debido a la multiplicidad de factores que se presentan cuando se cuidan pacientes con vmi. momentos durante los cuales el ee se comunica con el paciente con vmi el análisis de los grupos focales permitió identificar algunos momentos específicos durante los cuales el ee intenta comunicarse con el paciente con vmi. particularmente, los participantes señalaron que durante el momento en que conocen por primea vez al paciente o tienen el primer contacto con este se intenta establecer algún tipo de comunicación con la idea de poder tener una impresión general de la condición clínica. en esta instancia el ee evalúa la posibilidad de comunicación con el paciente considerando el nivel de conciencia, las terapias que recibe y el plan terapéutico. "... buenos días don juan, estamos en la entrega de turno, trate de decirme si siente dolor" (a 113). 192 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 otro momento es aquel durante el retiro del ventilador mecánico, los pacientes espontáneamente intentan comunicarse debido en parte a los menores niveles de sedación y a la necesidad que tienen de hacerse entender. "personalmente, la decisión para comunicarme con un paciente intubado va a estar relacionada con el ir cortando la sedación e ir despertándolo... y mejor si el paciente despierta tranquilo" (c 34). otras instancias favorecedoras de la comunicación se presentan en la rutina diaria: al inicio de la jornada de turno, y en los momentos de cuidado directo, particularmente durante el aseo y confort de los pacientes. "nosotras lo tratamos de hacer sobre todo cuando revisamos a los pacientes: “don juan, lo vamos a bañar, ¿me escucha?”. muchas veces en la visita en la mañana le preguntamos "¿cómo se siente, como está?" (a 90). barreras que dificultan la posibilidad de comunicarse con pacientes con vmi los intentos de comunicación se ven afectados por la existencia de múltiples barreras, las cuales se derivan principalmente de: • factores mecánicos: aquellos relacionados con la presencia de una vía aérea artificial, en particular la presencia del tubo oro-traqueal (tot), y las contenciones de extremidades superiores que limitan los movimientos y son frecuentes en los pacientes en vmi. "el tubo que está en la boca no permite que el paciente gesticule... entonces no se puede comunicar" (a 84). • condición clínica: esta representa una de las barreras más significativas para poder establecer algún grado de comunicación. en pacientes con niveles mayores de sedación y en aquellos desorientados los medios de comunicación habituales son poco aplicables, siendo en el caso de los pacientes desorientados el tiempo un factor determinante ya que con frecuencia el personal requiere de un lapso mayor para intentar comprender lo que necesitan. … a los pacientes desorientados ¿cómo los hago entender? (a-98) es a veces posible comunicarse con pacientes que están ventilados y responden a través de gestos o de movimientos de cabeza de “sí” y “no”, pero con los pacientes ventilados, que están además desorientados, es casi imposible comunicarse porque no logras saber lo que quieren, lo que les pasa, lo que les duele, o lo que no quieren (c-16). la posibilidad de contar con instrumentos que permiten valorar de forma objetiva el nivel de sedación y ajustar las dosis de sedantes tiene un impacto positivo en el interés del ee para comunicarse con los pacientes con vmi ya que la aplicación sistemática de las escalas de sedación orienta al ee hacia el momento más adecuado para realizar intentos de comunicación con los pacientes. además, para la aplicación de dichas escalas se requiere que el ee interactúe con el paciente e intente obtener respuesta. probablemente también un facilitador sea el que contemos con escalas de sedación y ahora tengamos los pacientes relativamente despiertos, diferente a como los teníamos antes que de verdad, en general estaban todos más dormidos siendo más difícil comunicarse (c-198). • nivel de sobrecarga laboral: las barreras para la comunicación también se derivan del nivel de carga laboral que el ee tenga. la percepción de altos niveles de sobrecarga reduce el interés de técnicos y profesionales por destinar tiempo en su jornada de trabajo para intentar comunicarse con un paciente con vmi. la multiplicidad de tareas y las demandas de cuidado que suponen los pacientes críticos disminuyen la probabilidad de contar con tiempo especial para interactuar con estos pacientes. y el tiempo dedicado va a depender de la condición en la que se encuentre el paciente, porque hay pacientes tan graves... que requieren de mucho más tiempo para hacerse entender, en ocasiones toda la mañana (c 176). • la falta de habilidades, así como el desinterés del ee determinan que la comunicación sea relegada a un tercer lugar dentro de la planificación de los cuidados de enfermería para este tipo de pacientes. "en ocasiones no hay interés, o no saben cómo comunicarse. porque no es vital, al menos en nuestra área, por eso a veces se deja en un plano secundario" (c 220). sin embargo, el desconocimiento de técnicas de comunicación no verbales ha llevado a desarrollar estrategias individuales y a manifestar su interés por adquirir nuevas habilidades en comunicación no verbal. 193 comunicación entre equipo de enfermería y pacientes con ventilación mecánica invasiva en una unidad de paciente crítico l noelia pilar rojas y otros. sí, porque a nosotros nadie nos enseña cómo comunicarnos con un paciente intubado sino que va un poco por sentido común, de mirar a los ojos, de tratar de entablar una comunicación con él y ahí uno va casi experimentando si le resulta el tema de la mano, si se comunica, no se comunica, si mira, si no mira, si abre los ojos. podría ser un elemento a trabajar el desarrollo de habilidades para comunicarse con alguien que no lo puede hacer directamente. finalmente, la imposibilidad para comunicarse se transforma en una experiencia negativa durante el proceso de hospitalización, el paciente pierde también el interés debido a que los esfuerzos por expresar sus necesidades nos son comprendidos ni atendidos, lo que genera actitudes de desgano, falta de motivación y frustración. el proceso de recuperación se ve afectado y, por tanto, la posibilidad de retiro del ventilador mecánico se ve retrasada. "me ha pasado a mí varias veces que ellos tratan de comunicarse y como a veces no les logramos entender, ellos reaccionan señalando... ya déjelo" (c 70). "pero el problema es que se angustian y se frustran cuando no se les entiende" (b 76). debido a los importantes efectos negativos que la falta de comunicación genera en el paciente con vmi es que es relevante que el ee permanezca atento a las oportunidades de poder conocer y satisfacer sus demandas de cuidado. la comunicación entre ee y paciente afianza el vínculo de confianza, se profundiza en su conocimiento y en la posibilidad de apoyarlos de la mejor forma en el difícil proceso de recuperación. discusión los hallazgos generales muestran que el equipo de enfermería, aun cuando reconoce la importancia de la comunicación con los pacientes con ventilación mecánica, no tiene incorporada en su práctica diaria la aplicación de estrategias específicas de comunicación, lo que coincide con lo planteado por coyer (11), quien señala que la comunicación no ha sido consistentemente bien integrada al cuidado de enfermería. para beltrán, las barreras en la comunicación con pacientes con vmi son múltiples, siendo tarea del ee desarrollar habilidades para captar el real significado de los mensajes debido a que estos son la base para la detección y para la toma de decisiones (9). si bien el grupo en estudio identifica los beneficios de la comunicación para pacientes con vmi, estos se circunscriben a dos elementos: por una parte, a favorecer su independencia y autonomía y, por otra, a afianzar el vínculo de confianza. la literatura señala que, desde la perspectiva del paciente, existen un sinnúmero de beneficios secundarios a la comunicación, entre los que destaca la posibilidad para el ee de acompañar al paciente a sobrellevar una experiencia que se vuelve incómoda y aterradora (14). las oportunidades de comunicación se presentan particularmente en instancias de cuidados más directos tales como el baño, el control de signos vitales y la administración de medicamentos. es significativa la evaluación inicial que el ee realiza al inicio de cada turno, así como cuando el paciente está iniciando el proceso de desconexión de la ventilación mecánica. en estos momentos la valoración de la posibilidad de comunicación resulta clave a fin de identificar los cuidados más adecuados para la condición clínica del paciente. al respecto, patak (5) señala que los equipos de enfermería que realizan cuidados directos a pacientes deben estar atentos a sus necesidades con el objetivo de otorgar cuidados seguros, efectivos y acordes con las necesidades particulares de cada paciente. las principales formas o medios de comunicación identificadas por el ee coinciden con las encontradas en la literatura: solicitar al paciente que apriete la mano o que cierre los ojos si la respuesta es afirmativa frente a preguntas simples, o el ofrecer lápiz y papel para escribir (14). sin embargo, la sola existencia de dichas herramientas no asegura la comunicación dado que determinadas condiciones relacionadas con el estado del paciente con vmi reducen la posibilidad de comunicación, entre ellas la sedación y el uso de contenciones, las cuales también han sido identificadas por otros autores (8). así mismo, magnus y turkington (10), y coyer (11) señalan como motivos por los cuales las enfermeras no se comunican con pacientes con ventilación mecánica la dificultad de estas para leer los labios y, particularmente, la falta de tiempo para tratar de entender lo que los pacientes necesitan; esta última barrera también fue identificada por el ee estudiado haciendo énfasis en la dificultad de disponer de tiempo para poder intentar comunicarse con los pacientes con vmi (15). otra barrera señalada en la literatura y que coincide con los resultados de la investigación es la falta de habilidades o entre194 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 namiento en técnicas de comunicación no verbal en el ee (10), lo que reduce su posibilidad de establecer estrategias de comunicación. este aspecto se relaciona con lo planteado por johnson (16), quien señala la importancia de que, particularmente las enfermeras, adquirieran conocimientos en aspectos psicosociales del cuidado del paciente con ventilación mecánica, dentro de los cuales se encontraba la comunicación como medio de transmisión de necesidades. de acuerdo con magnus y turkington (10), el conocimiento por parte del ee del impacto que la comunicación tiene en el proceso de recuperación de la enfermedad, en particular en pacientes con vmi, evitaría la realización de cuidados basados en presunciones acerca de las necesidades de los pacientes (8), lo cual es reforzado por el ee. limitaciones una limitación de este estudio es que no se llegó a establecer una categoría central única y se ha optado por dejar para una etapa siguiente la profundización en la codificación axial y selectiva final, que permitiría sustentar una teoría fundada en los datos respecto a la comunicación entre el equipo de enfermería y los pacientes con vmi. para esta etapa de la investigación el objetivo planteado y logrado fue describir el proceso y, por tanto, no avanzar hacia un análisis interpretativo del mismo. conclusiones finalmente, los hallazgos de este estudio constituyen una oportunidad para continuar la línea de investigación en torno a esta temática. un punto importante por considerar desde la perspectiva de los participantes es la necesidad de formación continua y la posibilidad de brindar espacios para la reflexión acerca de la práctica. esta sensibilización para la autorreflexión tiene efectos positivos para lo que posteriormente se aplica en la práctica, además promueve la cohesión grupal y la autoconfianza (17). tal como señalan autores que han abordado el tema de la comunicación con pacientes con vmi desde distintas perspectivas, un primer paso para otorgar los mejores cuidados de enfermería requiere de la disposición del ee para valorar las necesidades del paciente, las que sin duda son múltiples. la necesidad de expresarse y de ser comprendido es tanto o más importante que cualquier otra dado que le permite al paciente expresarse y comunicar cómo vive cada experiencia. referencias 1. carrol sm. silent, slow lifeworld: the communication experience of nonvocal ventilated patients. qual health res. 2007;17(9):1165-1177. 2. mccabe c. nurse-patient communication: an exploration of patients’ experiences. j clin nurs. 2004;13:41-49. 3. finke hm, light j, kitko l. a systematic review of the effectiveness of nurse communication with patients with complex communication needs with a focus on the use of augmentative and alternative communication. j clin nurs. 2008; 17:2102-2115. 4. happ mb. interpretation of nonvocal behavior and the meaning of voicelessness in critical care. soc science med. 2000;1247-1255. 5. patak l, gawlinski a, fung i, doering l, berg j. patients’ reports of health care practitioner interventions that are related to communication during mechanical ventilation. heart lung. 2004;33(5):308-21. 6. trevisan j, do carmo ml, garanhani ml. sentimentos de prazer entre enfermeiros de unidades de terapia intensiva. cienc enferm. 2009;15(3):45-53. 7. rotondi aj, chelluri l, sirio c, mendelsohn a, schulz r, belle s, et al. patient`s recollection of stressful experiences while receiving prolonged mechanical ventilation in an intensive care unit. critical care medicine. 2002;30(4):746-752. 8. happ mb, tuite p, dobbin k, divirgilio-thomas d, kitutu j. communication ability, method, and content among nonspeaking nonsurviving patients treated with mechanical ventilation in the intensive care unit. am j crit care. 2004;13(3):210-218. 9. beltrán-salazar o. la práctica de enfermería en cuidados intensivo. aquichan. 2008;8(1):50-63. 195 comunicación entre equipo de enfermería y pacientes con ventilación mecánica invasiva en una unidad de paciente crítico l noelia pilar rojas y otros. 10. magnus vs, turkington l. communication interaction in icu-patient and staff experiences and perceptions. intensive crit care nurs. 2006;22:167-180. 11. coyer fm, wheeler mk, wetzig sm, couchman ba. nursing care of the mechanically ventilated patient: what does the evidence say? part two. intensive crit care nurs. 2007;23:71-80. 12. krueger r, casey am. focus groups a practical guide for applied research. in: planning the focus group study, 4nd ed. california: sage publications; 2009. p. 17-33. 13. castillo e, vásquez ml. el rigor metodológico en la investigación cualitativa. revista colombia médica. 2003;34(3):64-167. 14. patak l .communication boards in critical care: patient´s views. appl nurs res. 2006;19(4):182-190. 15. henao am. hacerse entender: la experiencia de pacientes sometidos a ventilación mecánica sin efectos de sedación. invest educ enferm. 2008;26(2):236-242. 16. johnson p. long-term mechanical ventilation in a critical care unit: existing in an uneveryday world. journal of advanced nursing. 2006;53(5):551-558. 17. ordahi lfb, padilha mics, souza lna. communication between nursing staff and clients unable to communicate verbally. rev latino-am enfermagem. 2007;15(5):965-972. 216 225 acolhimento na percepcao dos enfermeiros.indd 216 aquichan issn 1657-5997 maria de lourdes da silva marques-ferreira1 rosana maria do vale barreira-penques2 maria josé sanches-marin3 acolhimento na percepção dos enfermeiros da atenção primária à saúde 1 enfermeira. professora, universidade estatal paulista, brasil. malusa@fmb.unesp.br 2 enfermeira. mestre, universidade estatal paulista, brasil. rosanabp@unilins.edu.br 3 enfermeira. professora, faculdade de medicina de marília, brasil. marnadia@terra.com.br recibido: 11 de abril de 2013 enviado a pares: 23 de mayo de 2013 aprobado por pares: 29 de octubre de 2013 aceptado: 11 de noviembre de 2013 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 216-225 para citar este artículo / to reference this article / para citar este artigo marques-ferreira ml, barreira-penques rm, sanches-marin mj. acolhimento na percepção dos enfermeiros da atenção primária à saúde. aquichan 2014; 14(2): 216-225. resumo objetivo: o presente estudo propõe-se a compreender a percepção de enfermeiros que atuam na atenção primária à saúde sobre o acolhimento. método: pesquisa qualitativa realizada a partir de entrevistas com 21 enfermeiros de oito municípios do interior paulista. a análise dos dados pautou-se na vertente fenomenológica, modalidade estrutura do fenômeno. resultados: revelou-se que a compreensão dos enfermeiros sobre acolhimento, em alguns momentos, se aproxima dos princípios e diretrizes do sus. por outro lado, manifestam dificuldades com a estrutura, organização e gestão dos serviços de saúde, além de expressarem ações e crenças que se aproximam do modelo tradicional de cuidado. conclusões: diante dos resultados, constata-se a união de esforços dos diferentes atores envolvidos no processo. palavras-chave acolhimento, atenção primária à saúde, sistemas de saúde, enfermagem, enfermeiros (fonte: decs, bireme). 217 acolhimento na percepção dos enfermeiros da atenção primária à saúde l maria de lourdes da silva marques-ferreira e outros. año 14 vol. 14 nº 2 chía, colombia junio 2014 l 216-225 acogida en la percepción de los enfermeros de la atención primaria a la salud resumen objetivo: el presente estudio se propone comprender la percepción de la acogida de los enfermeros que actúan en la atención primaria a la salud. método: es una investigación cualitativa realizada con entrevistas con 21 enfermeros de ocho municipios del interior del estado de são paulo. el análisis de los datos se fundamentó en la vertiente fenomenológica, modalidad estructura del fenómeno. resultados: se reveló que la comprensión de los enfermeros sobre la acogida, en algunos momentos, se aproxima de los principios y directrices del sistema único de salud (sus). conclusiones: por otro lado, esos profesionales manifiestan dificultades con la estructura, organización y gestión de los servicios de salud y expresan acciones y creencias que se acercan al modelo tradicional de cuidado. para la concreción de la acogida necesitan unir sus esfuerzos de los diferentes atores involucrados. palabras clave acogimiento, atención primaria de salud, sistemas de salud, enfermeira, enfermeros (fuente: decs, bireme). 218 aquichan issn 1657-5997 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 216-225 acceptance in the perception of nurses involved in primary health care abstract objective: this paper is intended to explore how nurses working in primary health care perceive acceptance. method: it is based on a qualitative study conducted through interviews with 21 nurses from eight municipalities in the state of são paulo. a phenomenological approach was used in data analysis. results: it was found that nurses’ understanding of acceptance, at certain points in time, comes close to the principles and guidelines of the unified health system (sus). conclusions: nursing professionals manifest difficulties with the structure, organization and management of health services and express actions and beliefs related to the traditional model of care. the various stakeholders need to join forces if acceptance is to be achieved. key words user embracement, primary health care, health system, nursing, nurses, male (source: decs, bireme). 219 acolhimento na percepção dos enfermeiros da atenção primária à saúde l maria de lourdes da silva marques-ferreira e outros. introdução historicamente, o modelo de atenção à saúde no brasil foi marcado pela assistência médica curativa e individual e pela compreensão de saúde como ausência de doença, pautada nos princípios do modelo flexneriano e, portanto, na fragmentação do cuidado. o sistema único de saúde (sus), instituído em 1988 propõe o rompimento com esse paradigma, uma vez que o mesmo não responde às necessidades de saúde da população (1). na proposição do sus, definiu-se um conceito ampliado de saúde que considera os diferentes determinantes e condicionantes do processo de saúde-doença e que a atenção à saúde deve seguir os princípios da universalidade do acesso, integralidade da assistência, equidade, descentralização, hierarquização e participação social (2), com ênfase na atenção primária à saúde. a atenção primária é definida pelo ministério da saúde (ms) como “ações de caráter individual ou coletivo, desenvolvidas no primeiro nível de atenção dos sistemas de serviços, voltadas para a promoção da saúde, prevenção dos agravos, tratamento e reabilitação” (3). na lógica da hierarquização do sistema de saúde, a atenção primária se constitui na porta de entrada para todas as novas necessidades, além de integrar a atenção fornecida em outros níveis de atenção à saúde. é nela que se proporciona a otimização de recursos, tanto básicos quanto especializados, e que mantêm o vínculo e a responsabilização pelas necessidades de saúde das pessoas, das famílias e da comunidade (4). diante de tais pressupostos, observam-se incontestáveis avanços, porém, ainda são muitos os desafios e debates necessários nessa construção que demanda infindáveis enfrentamentos. o ms vem propondo direcionamentos que, embora não representem garantias de operacionalização no cotidiano dos serviços, se constituem em disparadores de reflexões e decisões em prol de nova forma de pensar e agir na atenção à saúde. neste cenário surge, em 2003, a política nacional de humanização da atenção e gestão do sus — humaniza sus (pnh)17,20 e, nessa direção, o acolhimento passa a ser considerado uma diretriz de grande relevância (5). considerado como uma ação técnico-assistencial, o acolhimento pressupõe a mudança da relação profissional-usuário e sua rede social através de parâmetros técnicos, éticos, humanitários e de solidariedade, em que se reconhece o usuário como sujeito e participante ativo no processo de produção da saúde (6). o acolhimento implica, portanto, atitudes de amparo e hospitalidade, que favorecem a construção de uma relação de confiança e compromissos dos usuários com as equipes e os serviços, e contribui, assim, para a legitimação do sistema público de saúde (7). passa a ser uma estratégia fundamental, que consiste na reorganização do processo de trabalho de maneira a atender a todos que procuram os serviços de saúde, que fortalece o princípio da universalidade e a busca da integralidade e da equidade. tem como eixo estimular e promover reflexões e ações de humanização dos serviços de saúde, fundamentadas na ética e na cidadania (8). esse acolhimento também desempenha papel fundamental na dinâmica organizacional, o que resulta em encaminhamentos, deslocamentos, que passam por tomada de decisões num encontro pautado pelas disposições “morais” e “cognitivas”. trata-se rigorosamente de técnica de conversa, diálogo orientado pela busca de maior “ciência” das necessidades do usuário, bem como das possibilidades e dos modos de satisfazê-las (9). nessa perspectiva, considera-se que o acolhimento tem que avançar no sentido de sair das relações rotineiras de trabalho (assistencialismo) meramente burocrático para incorporar-se no sistema de atendimento como forma facilitadora na promoção do bemestar físico, mental e social do usuário do sistema público de saúde (10, 11). no entanto, se observa que o acolhimento tem assumido diferentes formatos e vieses que dificultam sua efetivação, propõe-se como objetivo para o presente estudo compreender a compreensão de enfermeiros da atenção básica sobre acolhimento. método trata-se de estudo de natureza pesquisa qualitativa, na qual se utiliza o método fenomenológico, modalidade estrutura do fenômeno situado, cuja essencialidade refere-se à compreensão abrangente e profunda dos dados obtidos (12). a pesquisa fenomenológica propõe o “ir à coisa mesma”, ou seja, àqueles que possuem experiência do fenômeno interrogado em seu mundo-vida, e por isto, podem falar sobre ele (13). busca-se, dessa forma, essa essência, a partir da percepção dos enfermeiros que atuam na atenção primária à saúde sobre acolhimento. 220 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 o estudo foi realizado de fevereiro de 2010 a dezembro de 2011, sendo a coleta dos dados realizada no período de agosto a novembro de 2010. a pesquisa abrangeu os municípios cafelândia, getulina, guaiçara, pongaí, promissão, sabino, uru e lins, pertencentes à direção regional de saúde (drs – vi) com sede no município de bauru/sp. totalizaram oito municípios localizados na região noroeste do estado de são paulo, que juntos constitui em uma população de 160.000 habitantes (14). a rede básica de saúde, para os municípios em estudo, compõe-se de 30 unidades de atenção primária à saúde, sendo sete na modalidade da estratégia de saúde da família, 23 tradicionais, e destas, 10 incorporam o programa de agente comunitário de saúde (pacs). a escolha dos municípios justifica-se por ser área de atuação da pesquisadora que buscou na investigação resposta de suas inquietações sobre o acolhimento. a atenção primária à saúde possui uma equipe multidisciplinar, mas o interesse deste estudo refere-se particularmente ao atendimento prestado pelos enfermeiros, uma vez que, além de acolher em sua assistência, tem sob sua responsabilidade toda a equipe de enfermagem. a coleta de dados foi realizada por um questionário que contemplou dados pessoais e relativos à função exercida, tempo de atuação, especialização na área e características da unidade. a entrevista semiestruturada foi estratégia utilizada para coletar os depoimentos dos enfermeiros que se encerraram quando houve a repetição dos conteúdos das descrições, o que indicou o fenômeno desvelado. assim, o número da amostra constituiu-se de 21 enfermeiros e teve, como questão norteadora: para você, o que é acolhimento em saúde? o projeto de pesquisa foi aprovado pelo comitê de ética em pesquisa com seres humanos da faculdade de medicina de marília, protocolo n. 238/10. para a realização da entrevista, esclareceu-se aos participantes o objetivo do estudo e estes assinaram o termo de consentimento livre e esclarecido. os depoimentos foram enumerados de acordo com a ordem de realização das entrevistas. para a análise dos dados, inicialmente foram realizadas repetidas leituras atentiva dos discursos, a fim de, apreender o sentido do todo e, na sequência, identificaram-se as unidades de significado, para caminhar em direção à intersubjetividade, chegar à descrição das evidências da experiência vivida do sujeito, e destacar os dados significativos para a compreensão do fenômeno pesquisado (15). a extração da essencialidade da percepção do conhecimento sobre acolhimento e a identificação das unidades de significados levaram a uma redução na busca da “percepção de acolhimento para os enfermeiros”, nos dados constituídos, ao partir da interrogação do pesquisador. após, estabeleceu-se a redução fenomenológica, cujas expressões cotidianas dos sujeitos da pesquisa foram transformadas na linguagem do pesquisador (16). em seguida, foi realizada a etapa de compreensão ou interpretação, que se iniciou pela análise ideográfica que se refere à individualidade de cada discurso, de forma a evidenciar a estrutura do fenômeno situado: ser enfermeiro e sua percepção sobre acolhimento dos pacientes atendidos. na busca das unidades de significados, os discursos foram agrupados de acordo com categoria comum, com objetivo de organizar as articulações do discurso conforme as várias significações sobre acolhimento (16). após, procedeu-se a análise nomotética, que se constitui da análise geral dos discursos na qual se buscou a generalidade para apreender os aspectos mais comuns dos depoimentos. assim, inicialmente foram agrupados os temas que emergiram das unidades de significados interpretadas por meio da redução fenomenológica (16). resultados dentre os 21 enfermeiros entrevistados, a maioria é do sexo feminino, com idade entre 20 e 45 anos, sendo que 11 eram casados, nove solteiros e dois divorciados. os enfermeiros entrevistados atuam em unidades básicas tradicionais com ou sem o pacs e, também, em unidades de saúde da família (usf). a maioria ocupa função gerencial ou são responsáveis técnicos do serviço de enfermagem e coordenação do pacs. a maioria ocupa função gerencial ou é responsável técnico do serviço de enfermagem e coordenação do pacs. o tempo de atuação dos enfermeiros na atenção básica varia de dois a 20 anos. a maioria deles possui especialização nas áreas de uti, urgência e emergência, enfermagem do trabalho e obstetrícia. no processamento dos dados emergiram três categorias temáticas que, ao serem consideradas as convergências, divergên221 acolhimento na percepção dos enfermeiros da atenção primária à saúde l maria de lourdes da silva marques-ferreira e outros. cias e idiossincrasias, revelam a percepção dos enfermeiros que vivenciam o modelo de atenção básica sobre acolhimento. o acolhimento como instrumento para acompanhamento da implementação da pnh na atenção primária à saúde a pnh enquanto uma política do sus tem o acolhimento como instrumento para acompanhamento da implementação e responsabilização pelas necessidades dos usuários. o acolhimento nas unidades de saúde favorece a construção de uma relação de confiança e compromisso dos usuários com as equipes e os serviços, o que contribui para a legitimação do sistema público de saúde essencial da e para a população. os princípios revelados incluem integralidade, universalidade, acesso, resolubilidade, política nacional de humanização (pnh) e responsabilização pelas necessidades dos usuários, conforme se destaca na falas seguintes: “porque um paciente entra no atendimento, a gente acolhe esse paciente como um todo. (...) em questões sociais, de saúde, que é de fundamental importância para nós, a questão preventiva.” (dep. vi); “assim, [...] por mais que você tenha direito a tudo, sus é pra todos, no momento não está funcionando assim...” (dep. ix); “acolher é resolver as necessidades dos pacientes. quando se atende bem o paciente e se resolve as suas necessidades, se realizam ações humanizadas”. (dep. xiii); “acolhimento pra mim é atender a todos que procuram a unidade, é ter facilidade de acesso, se não tiver como atender às necessidades dos usuários, não se tem acolhimento”. (dep. viii); “acolhimento pra mim faz parte do programa de humanização...”. (dep. x); “o acolhimento acontece a partir do momento em que a gente acaba escutando esse paciente, atendendo de forma humanizada, resolvendo o seu problema, ou que ele resolva da melhor forma possível”. (dep. iv); “me responsabilizar de uma forma ou de outra. a partir do momento que ela entrou aqui. na verdade, eu tenho que corresponsabilizar, é eu e ela”. (dep xiii). a relação da organização e gestão com o acolhimento nos serviços de saúde nesta categoria, os enfermeiros identificam a falta de recursos humanos e materiais, dificuldades diante da organização do processo de trabalho dos profissionais, além da necessidade de capacitação e desenvolvimento da educação permanente entre os profissionais e, ainda, a falta de aproximação dos gestores no processo de atenção à saúde das unidades. tais aspectos evidenciam-se nos trechos seguintes: “na minha realidade aqui na unidade, o que eu enxergo é que o quadro de funcionários é bem diminuído. e acaba sobrecarregando. e na parte de acolhimento fica devendo muito” (dep. ii); “as condições para fazer um acolhimento decente com o seu valor e tudo, aí eu acho que precisa melhorar o recurso físico. (dep. iii); “os enfermeiros acabam sobrecarregados, porque você tem farmacêutico, tem dentista, mas tudo cai nas costas do enfermeiro dentro da unidade, inclusive tentar fazer um bom acolhimento”. (dep. xiii); “como eu vejo o acolhimento... não é do jeito que eu acho que é certo, mas não depende só da gente, depende de outras pessoas, de nossos superiores, de hierarquia, se você pede uma coisa, passa para outro departamento e para outro”. (dep. ix); “a minha percepção é que o acolhimento ainda está deixando muito a desejar... só os cursos básicos não dão resultados práticos, não são suficientes para melhorar a assistência”. (dep. i). a desconstrução do sentido do acolhimento nesta categoria se observa que os enfermeiros revelam uma percepção de acolhimento que se aproxima do modelo tradicional de atenção primária à saúde. tradicionalmente, a percepção de acolhimento se restringe à atitude voluntária de bondade e favor oferecidos por alguns profissionais; recepção administrativa e ambiente confortável; e, ainda, ação de triagem (administrativa, de enfermagem ou médica) com seleção daqueles que serão atendidos pelo serviço naquele momento: “acolhimento para mim é a pessoa chegar à recepção, ser bem acolhida. ser recepcionista é ter um calor humano, para poder atender bem em todos os locais dentro da unidade”. (dep. i); “a gente tem um acolhimento bom. aqui é assim: a pessoa chega e a consulta é agendada na janela. não tem nada de senha, a pessoa chega aqui no fichário. o paciente quer passar com tal médico. a pessoa procura fazer uma triagem, encaixar com aquele médico”. (dep. xii). discussões no desvelamento da percepção sobre acolhimento, no que se refere à ferramenta para se atingir os princípios do sus, os enfermeiros estabeleceram relação com o princípio da integralidade, ao apontar para uma visão abrangente das pessoas e levar, em consideração o nível de complexidade presente em cada uma delas (17). além disso, acrescenta-se a perspectiva de um atendimento que ultrapassa o cuidado à doença. 222 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 nessa dimensão, a integralidade se apresenta contrária às ações fragmentadas, que privilegiam a especialização e segmentação e que reduzem o paciente ao aparelho (ou sistema biológico) e toma como referencial a medicina integral e a incorporação de ações de promoção, prevenção, ações curativas e de reabilitação (6). embora o princípio da universalidade também tenha sido considerado no depoimento dos enfermeiros, há o reconhecimento de dificuldades para sua aplicabilidade. de acordo com o princípio da universalidade, todas as pessoas possuem direito ao acesso às ações e aos serviços de saúde, o que antes era assegurado somente às pessoas que tinham previdência social e rede privada (18). no reconhecimento da dificuldade de se atender ao princípio da universalidade na atenção básica, os enfermeiros revelaram perceber que o acolhimento contribui para o acesso ao serviço de saúde, uma vez que o sus garante ao cidadão o direito de acesso à saúde, contemplando, desde ações assistenciais em todos os níveis de complexidade, até atividades inseridas nos âmbitos da prevenção de doenças e de promoção da saúde. o princípio da resolubilidade definido como “eficiência na capacidade de resolução das ações e serviços de saúde por meio de assistência integral, contínua e de boa qualidade” (19), foi considerado na fala dos enfermeiros. o atendimento à saúde precisa ter resolubilidade, pois a solução de problemas de saúde e de cuidado apresentados pelos usuários é essencial para a humanização da assistência (20). a percepção dos enfermeiros sobre acolhimento também revela a integração com os pressupostos da pnh. o acolhimento enquanto diretriz da pnh, representa o aspecto mais evidente, especialmente na atenção básica à saúde, pela influência que exerce no acesso dos usuários ao sistema de saúde e nas mudanças no processo de trabalho, com a finalidade de atender a todas as pessoas que procuram o serviço de saúde (7, 8). os enfermeiros associam a humanização da atenção à saúde ao acolhimento-diálogo, que diz respeito a um tipo de norma geral de comunicação entre todos os elementos que compõem a rede. assim, não se trata necessariamente de uma atividade em particular, mas de um conteúdo de qualquer assistência. portanto, a rede de conversações seria, o espaço coletivo composto de vários e distintos locais de conversa interligadas. a escuta no atendimento não deve desprezar nenhum aspecto das queixas, pois escutar é ajudar o usuário a refazer os motivos que ocasionaram o adoecimento, bem como correlações que são estabelecidas entre os sentimentos e sua vida (20). alguns conceitos que contribuem para a formação de um corpo de conhecimento necessário às ações de saúde pautadas em uma nova lógica também foram aspectos relatados pelos enfermeiros. nesse sentido, destaca-se, a relação entre responsabilização e acolhimento, condição que os enfermeiros incorporam nos depoimentos, conforme segue. diante de tal compreensão, o acolhimento é representado como um encontro entre os sujeitos, que permite, uma relação de compromisso e ajuda — “é eu e ela”. assume-se, assim, uma forma de cuidado que considera as necessidades da pessoa, num encontro que ultrapassa a dimensão sintomática que motivou o usuário a procurar o serviço de saúde. acrescenta-se que as ações de não responsabilização tendem a enxergar os problemas do usuário apenas sob o prisma da dimensão biológica, não estendida às demais. foca-se em direção única, o que deixa os profissionais da equipe distantes da assistência ao usuário (21). no que se refere à relação da organização e gestão com o acolhimento dos serviços de saúde, os enfermeiros destacam a insuficiência na quantidade de profissionais para atender às necessidades dos serviços. reconhecidamente, quando o acolhimento se estrutura como uma recepção melhorada aparentemente, a dificuldade para os trabalhadores aumenta. eles têm que atender a todos e têm de ouvi-los. essa escuta — por mais que seja meramente ouvir o que o outro diz, a “escuta qualificada”, traz implicação e responsabilidade para o trabalhador (22). o acolhimento é mais do que escuta, pois pressupõe identificação de problemas e intervenções resolutivas, ampliação da capacidade da equipe de saúde em responder às demandas dos usuários, redução da centralidade das consultas médicas e utilização do potencial dos demais profissionais (10). isso, porém, cria novas demandas e necessidades de intervenções, e foge das ações normativas do cotidiano dos serviços. é importante considerar, então, que o dimensionamento de pessoal interfere diretamente na eficácia e qualidade da assistência à saúde e, por outro lado, pode gerar conflitos entre os profissionais com sérias consequências às instituições de saúde (23). a 223 acolhimento na percepção dos enfermeiros da atenção primária à saúde l maria de lourdes da silva marques-ferreira e outros. falta de condições adequadas para o desenvolvimento do trabalho também é fator de estresse profissional, além de levar ao conformismo e à acomodação com relação às deficiências do sistema. acrescenta-se que é preciso garantir condições adequadas de trabalho, uma vez que a estrutura de um serviço se traduz em condição essencial para o seu desenvolvimento, embora não garanta a qualidade do processo assistencial. a dificuldade ante a organização do processo de trabalho dos profissionais revela que, ainda que ocupem o mesmo espaço físico, exercem as atividades de forma isolada e operam em lógicas diferenciadas. no acolhimento, por não ser uma atividade específica de uma determinada profissão, todos os profissionais precisam estar comprometidos e capacitados para receber a população com ações acolhedoras. a qualidade dos serviços e cuidado em saúde depende da articulação complexa do processo de trabalho da equipe multidisciplinar com as condições de infraestrutura, serviços e sistema de saúde com a gestão que exerce papel importante nessa articulação (24). ainda se identifica, na percepção dos enfermeiros, que para avançar é preciso o desenvolvimento de educação permanente (ep), a qual é considerada como uma ferramenta que busca uma reflexão crítica sobre as práticas de serviço. convém ressaltar que só a prática educativa aplicada ao trabalho possibilita transformações nas relações, processos de trabalho, condutas, atitudes, profissionais, assim como na equipe (25). ao se referir à categoria da desconstrução do sentido do acolhimento, salienta-se que no campo da saúde, há duas compreensões de acolhimento identificadas. uma delas é que acolhimento se mostra em um espaço como ambiente repleto de conforto. a outra identifica o acolhimento como triagem e encaminhamento de serviços (26). quando o acolhimento é compreendido como sinônimo da realização da triagem, consulta agendada, encaminhamentos e normas de acesso, isso pode perpetuar a exclusão dos usuários, o que dificulta o processo terapêutico, o vínculo e a corresponsabilização (27). ao se contrapor à percepção dos enfermeiros, o acolhimento não é um espaço ou um local, mas uma postura ética, não pressupõe hora ou profissionais específicos para fazê-lo, implica compartilhamento de saberes, angústias e invenções, ao tomar para si a responsabilidade de “abrigar e agasalhar” as pessoas em suas demandas, com responsabilidade e resolubilidade sinalizada pelo caso em questão. desse modo, o que diferencia acolhimento de triagem é que ele não constitui uma etapa do processo, mas sim tipo diferenciado de ação que deve ocorrer em todos os locais e momentos do serviço de saúde. para que o acolhimento seja uma diretriz operacional é necessário mudança na forma de fazer saúde (28). outro aspecto que necessita de superação é a visão afetuosa atribuída ao acolhimento que, embora necessária, muitas vezes não se apresenta como forma de resolução da necessidade. o profissional precisa incrementar o atendimento com interrogações que levam à compreensão das necessidades expressas e veladas pelo contexto de vida e pelo próprio entendimento das possibilidades do sistema de saúde. conclusão no percurso da compreensão da percepção dos enfermeiros da região de lins, estado de são paulo, constata-se que o acolhimento está relacionado aos princípios e conceitos que direcionam a construção de um modelo de atenção pautado no sus. ao fazerem essa relação, revela-se que os profissionais de enfermagem compreendem que o acolhimento envolve a integralidade, universalidade e humanização da atenção, além da responsabilização pelas necessidades dos usuários, do trabalho em equipe e da escuta ampliada, como elementos essenciais nesta construção. por outro lado, embora os enfermeiros reconheçam os aspectos conceituais do acolhimento, há indicativos de que o modelo tradicional de cuidado também continua permeando as ações e as crenças arraigadas pela tradição. desvelou-se também que a falta de investimento na contratação e qualificação dos profissionais, bem como a falta de adequação da estrutura física e de participação efetiva dos gestores dificultam a adequada implementação do acolhimento. o estudo indica a necessidade de inserção de abordagens teóricas e práticas sobre o acolhimento no cotidiano dos enfermeiros, para que sejam elementos essenciais na realização de uma prática humanizada e integral. é preciso a conscientização de que não 224 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 basta ser tecnicamente capaz, mas, sobretudo ser humanamente eficiente, pois é por meio das ações do profissional que decorre boa ou má assistência. é por meio do acolhimento que as relações de trabalho em saúde podem ser refletidas e repensadas. referências 1. brasil. ministério da saúde; oms. opas. políticas de recursos humanos em saúde: seminário internacional. brasília, 2002. 2. buss pm. promoção da saúde e qualidade de vida. cienc saúde coletiva 2000; 5: 163-77. 3. almeida c, macinko j. validação de metodologia de avaliação rápida das características organizacionais e desempenho dos serviços de atenção básica do sus em nível local. brasília: organização pan-americana de saúde; 2006. 4. starfield b. atenção primária: equilíbrio entre necessidades de saúde, serviços e tecnologia. brasília: ministério da saúde; 2002. 5. brasil. ministério da saúde. secretaria de atenção à saúde. núcleo técnico da política nacional de humanização. acolhimento nas práticas de produção de saúde. ministério da saúde. brasília: ministério da saúde; 2006. 6. brasil. ministério da 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(orgs.). construção da integralidade: cotidiano, saberes e práticas em saúde. rio de janeiro: instituto de medicina social, universidade do estado do rio de janeiro/abrasco; 2003.p. 49-61. 23. kurcgant p et ál. gerenciamento em enfermagem. rio de janeiro. guanabara koogam, 2005. 24. solla jjsp. acolhimento no sistema municipal de saúde. rev bras saúde matern infant; 2005; 5(4): 493-503. 25. carotta f, kawamura d, salazar j. educação permanente em saúde: uma estratégia de gestão para pensar, refletir e construir práticas educativas e processos de trabalho. saúde soc. 2009, 18(supl1): 48-51. 26. camelo shh, angerami els, silva em, mishima sm. acolhimento à clientela: estudo em unidades básicas de saúde no município de ribeirão preto. rev latino-am enfermagem 2000; 8(4): 30-7. 27. bertussi, oliveira, lima. a unidade básica no contexto do sistema de saúde. em: andrade sm, soares da, junior lc. (orgs.). bases da saúde coletiva. londrina: abrasco; 2001. 28. benevides r, passos e. humanização na saúde: um novo modismo? interface (botucatu) 2005; 9 (17): 398-406. 364 387 soporte social con herramienta.indd 364 aquichan issn 1657-5997 juan carlos díaz-álvarez1 maribel pinilla-alarcón2 daniel gonzalo eslava-albarracín3 martha patricia padilla-velasco4 soporte social con herramienta edumática para cuidadores familiares de personas con enfermedad crónica5 1 enfermero. doctor en educación. candidato a doctor en bioética. profesor asistente. pontificia universidad javeriana, bogotá, colombia. j.diaza@javeriana.edu.co 2 enfermera. magíster en política social. profesor asistente. pontificia universidad javeriana, bogotá, colombia. mpinilla@javeriana.edu.co 3 enfermero. doctor en salud pública. posdoctorado en drogas. profesor asociado, director oficina posgrados. pontificia universidad javeriana, bogotá, colombia. dgeslava@javeriana.edu.co 4 enfermera. coordinadora de programas preventivos, javesalud ips, bogotá, colombia. especialista en epidemiologia. mpadilla@javesalud.com.co 5 investigación que hace parte del estudio multicentrico “soporte social con tecnología de la información y la comunicación (tic) para cuidadores familiares de personas con enfermedad crónica en américa latina”, liderado por el grupo de cuidado al paciente crónico y su familia, de la universidad nacional de colombia. recibido: 19 de abril de 2013 enviado a pares: 29 de abril de 2013 aceptado por pares: 19 de marzo de 2014 aprobado: 19 de marzo de 2014 doi: 10.5294/aqui.2014.14.3.8 para citar este artículo / to reference this article / para citar este artigo díaz-álvarez jc, pinilla-alarcón m, eslava-albarracín dg, padilla-velasco mp. soporte social con herramienta edumática para cuidadores familiares de personas con enfermedad crónica. aquichan. 2014;14(3): 364-387.doi: 10.5294/aqui.2014.14.3.8 resumen objetivo: medir la efectividad de la intervención del soporte social mediante el uso de una herramienta edumática (cd rom interactivo) y el seguimiento telefónico dirigido a cuidadores de personas con hipertensión arterial. materiales y métodos: estudio analítico cuasiexperimental en 110 cuidadores familiares realizado en 2012; se utilizó el instrumento “inventario de soporte social en enfermedad crónica” propuesto por hilbert, integrado por cinco categorías. los datos se expresaron mediante estadística descriptiva, las comparaciones entre puntajes obtenidos en la primera y segunda medición se hicieron con la prueba de signos con rangos de wilcoxon. resultados: se encontró diferencia estadísticamente significativa entre los valores iniciales medianos del puntaje y los valores finales medianos para la dimensión de interacción social (p = 0,002), con un incremento en su puntaje. las demás dimensiones medidas (interacción personal, guía, retroalimentación) no sufrieron cambios en ambas mediciones. la dimensión apoyo tangible no fue evaluada por razones éticas. palabras clave cuidadores, apoyo social, enfermedad crónica, enfermería. (fuente: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 364-387 365 soporte social con herramienta edumática para cuidadores familiares de personas con enfermedad crónica. l juan carlos díaz-álvarez y otros. año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 364-387 social support through edumatic for family caregivers of chronically ill persons abstract objective: measure the effectiveness of social support intervention through edumatic (an interactive cd rom) and telephone followup focused on caregivers of persons with hypertension. methods: this quasi-experimental research study of 110 family caregivers was completed in 2012. hilbert’s "inventory of social support in chronic illness" was used. it consists of five categories. the data were expressed through descriptive statistics. comparisons between scores on the first and second measurements were done with the wilcoxon signed-rank test. results: a statistically significant difference was found between the initial mean values of the score and the final mean values for the social interaction dimension (p = 0.002), with an increase in its score. the other dimensions that were gauged (personal interaction, guidance, feedback) showed no change in either measurement. the dimension of tangible support was not evaluated for ethical reasons. key words caregivers, social support, chronic illness, nursing. (source: decs, bireme). 366 aquichan issn 1657-5997 suporte social com ferramenta edumática para cuidadores familiares de pessoas com doença crônica resumo objetivo: medir a efetividade da intervenção do suporte social mediante o uso de ferramenta edumática (cd rom interativo) e o seguimento telefônico dirigido a cuidadores de pessoas com hipertensão arterial. materiais e métodos: estudo analítico quase experimental em 110 cuidadores familiares realizado em 2012; utilizou-se o instrumento “inventário de suporte social em doença crônica”, proposto por hilbert, integrado por cinco categorias. os dados se expressaram mediante estatística descritiva; as comparações entre pontuações obtidas na primeira e segunda medição foram feitas com a prova de sinais com teste wilcoxon. resultados: constatou-se diferença estatisticamente significativa entre os valores iniciais medianos da pontuação e os valores finais medianos para a dimensão de interação social (p = 0,002), com um aumento em sua pontuação. as demais dimensões medidas (interação pessoal, guia, retroalimentação) não sofreram mudanças em ambas as medições. a dimensão apoio tangível não foi avaliada por razões éticas. palavras-chave cuidadores, apoio social, doença crônica, enfermagem. (fonte: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 364-387 367 soporte social con herramienta edumática para cuidadores familiares de personas con enfermedad crónica. l juan carlos díaz-álvarez y otros. introducción la “declaración del milenio” de las naciones unidas en 2012 (resolución 55/02 del pnud) puso en la agenda internacional el asunto de la inequidad y la pobreza, y planteó como objetivo el direccionamiento de políticas en países miembros para disminuir la desigualdad, la inequidad y atender problemas prioritarios. este escenario coincidió en colombia para el sector salud con la propuesta de revitalizar la estrategia de atención primaria en salud (aps), la cual vincula a los pacientes a la red de apoyo familiar y social para que sea posible vivir en comunidad y disminuir la demanda de servicios hospitalarios (1-3). esta estrategia, impulsada por la organización panamericana de la salud (ops) y la organización mundial de la salud (oms), permitió introducir la noción de determinantes sociales de la salud, y volvió sobre el concepto de atención primaria recuperando postulados de universalidad y cumplimiento de derechos, reconociendo la historicidad y la relatividad de saberes disciplinarios que posibilitan un abordaje complejo y no unilateral o lineal. esto introduce la defensa de valores, principios y elementos esenciales a todo sistema de salud (4, 5); valores como el derecho a la salud, la solidaridad y la equidad. principios como dar respuesta a necesidades de la población, orientación hacia la calidad, responsabilidad y rendición de cuentas de los gobiernos, justicia social, sustentabilidad, participación e intersectorialidad, y aporta al acceso, la cobertura universal, la atención integral e integrada, el énfasis en la promoción y la prevención, la orientación familiar y comunitaria, los mecanismos de participación activa, la organización y la gestión óptimas, políticas y programas pro-equidad, primer contacto, recursos humanos apropiados y acciones intersectoriales. al respecto, la ops considera que: la evidencia internacional sugirió que los sistemas de salud organizados con base en una fuerte orientación de la aps alcanzaban mejores y más equitativos resultados de salud, eran más eficientes, tenían costos más bajos de atención y lograban una satisfacción más alta del usuario comparada con la de aquellos sistemas que tienen una débil orientación de la aps. la reorientación de los sistemas de salud con un enfoque de la aps demandaba reajustar los servicios de salud hacia la promoción y la prevención —ajuste que debía ser conseguido por medio de la asignación de funciones apropiadas a cada nivel de gobierno; de la integración de los servicios de salud pública y de atención personal; del desarrollo de una orientación hacia las familias y las comunidades; y de la creación de un marco institucional que incentive la mejoría de la calidad de los servicios— (6). la aps denota el desarrollo de un nivel de asistencia con enfoque global de suministro de servicios. en países con ingresos medios y altos se entiende como un primer nivel asistencial, mientras que en países con bajos ingresos y acceso difícil a los servicios de salud, esta es considerada como una estrategia de todo el sistema (7). bogotá, desde 2005, adoptó la aps basada en la integralidad de la atención según las necesidades humanas, como forma de organización de los servicios de salud en diferentes niveles, articulando acciones individuales y colectivas para responder a necesidades poblacionales. el enfoque enfatiza en la equidad social, la corresponsabilidad, los sectores público y privado, la solidaridad y la participación social como concepto amplio de salud. pretende orientar y articular esfuerzos del sector salud con otros sectores sociales para que las intervenciones que se desarrollen en la comunidad den respuesta integral a problemas y necesidades de la población, logrando enfrentar los determinantes sociales de la inequidad en salud (8). con la ley 1438 de 2011, mediante la cual se reforma el sistema general de seguridad social en salud (sgss) en colombia, se establece que la estrategia de atención primaria en salud es un marco obligatorio, disponiendo en su artículo 12 su constitución por los servicios de salud, la acción entre los sectores y la participación social, comunitaria y ciudadana. como estrategia: permite la atención integral e integrada, desde la salud pública, la promoción de la salud, la prevención de la enfermedad, el diagnóstico, el tratamiento, la rehabilitación del paciente en todos los niveles de complejidad a fin de garantizar un mayor nivel de bienestar en los usuarios, sin perjuicio de las competencias legales de cada uno de los actores del sistema general de seguridad social en salud (9). la situación actual del sgss no permite evidenciar la implementación de esta estrategia. tal como lo manifiesta iván darío gonzález (10) en el primer foro internacional de cuidado primario ambulatorio, los pronósticos no son los más halagadores porque: existen programas de promoción y prevención, campañas de vacunación, pero de ahí en adelante no se visualiza con claridad un modelo de atención primaria en salud que integre y articule las actividades preventivas y las resolutivas, con el fin de ofrecer una atención verdaderamente centrada en las necesidades de la población colombiana (10). se continúa centrado en la enferme368 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 dad, con poco desarrollo de programas ambulatorios e incentivos para el recurso humano: la mayoría de los modelos de atención se centra en la enfermedad y no en personas con condiciones clínicas y situaciones de vida particulares […], seguimos creando “clubes de hipertensión”, “programas de diabetes” pero adolecemos de un modelo de atención primaria cuyo centro sean las personas, sujetos principales de cualquier sistema de salud […], en los temas de cuidado primario de salud en el nivel ambulatorio no existen políticas ni incentivos para formar, retener y ofrecer un entrenamiento continuado a los profesionales de las distintas disciplinas que se requieren (10). aunque se ha trabajado con estrategias extramurales, aún existe largo camino por recorrer. según gonzález, “la actual estructura de la red de atención y la ausencia de modelos de atención extramural no facilitan el cumplimiento de las tareas de cuidado primario ambulatorio” (10), las personas que requieren atención en este nivel tienen situaciones clínicas crónicas, requieren servicios hospitalarios, de consulta externa y ambulatorios, lo que implica algunos periodos de diversa duración sobre los cuales quedan sin acompañamiento del sistema de salud. este sistema centra su atención en costos y beneficios económicos sometiendo las personas a procesos que desconocen el rol del cuidador; aunque existe apropiación de tecnologías de la información y la comunicación a nivel hospitalario, se hace indispensable conectar las personas, posibilitar la construcción de redes de apoyo entre cuidadores, el sistema de salud, médicos, enfermeras y pacientes. por otro lado, la oms ha catalogado a las enfermedades crónicas no transmisibles como un conjunto de padecimientos de larga duración y progresión lenta, entre los que incluye enfermedades cardiovasculares, hipertensión arterial, infartos, cáncer, enfermedades respiratorias, diabetes, entre otras, las cuales responden por un alto porcentaje de defunciones en el mundo. la hipertensión arterial se constituye, además, en un factor de riesgo importante para la presentación de problemas en salud cardiovascular y renal, puesto que puede acompañarse de hiperglicemia, hiperlipidemia, problemas de sobrepeso y obesidad, inactividad física y otros factores relacionados con hábitos de vida poco saludables. en el sistema de salud colombiano, el cuidador familiar asume una carga importante en el cuidado, para la cual el sistema no ofrece un apoyo efectivo, e incluso, no le hace seguimiento. algunas instituciones prestadoras de salud (ips) utilizan la educación informal tradicional y las charlas educativas como soporte para informar al enfermo y a su familia sobre su condición en general. tradicionalmente, la mujer cumple diversos roles a nivel intrafamiliar, laboral y social. pero en el hogar se encarga del cuidado de sus hijos y de los miembros enfermos de su familia. algunos estudios muestran su compromiso y su sobrecarga cuando no encuentran apoyo entre los miembros de su propio núcleo familiar (11-14). el grupo académico de cuidado al paciente crónico de la facultad de enfermería de la universidad nacional de colombia ha realizado serios esfuerzos para construir una red de cuidado a cuidadores de pacientes con enfermedad crónica. estos esfuerzos han dado fruto y desde el concepto de trabajo en red el grupo ha sistematizado numerosas acciones tendentes a ofrecer un apoyo de tipo social (15). según ardila et al. (16), las tecnologías de la información y comunicación (tic) aplicadas como soporte social en cuidadores familiares de personas con enfermedad crónica tienen un efecto protector que facilita el vínculo afectivo. entre las tic más utilizadas se reconocen el teléfono y uso de la internet. el apoyo social con tic es un método práctico que facilita acceso a los cuidadores sin importar la distancia geográfica, permite el empoderamiento, mejora estrategias de cuidado. el punto crítico está en la falta de acceso a tales tecnologías. varios estudios han mostrado el soporte social a cuidadores familiares de personas con enfermedad crónica; romero et al., evidencia un incremento en la satisfacción con el apoyo percibido de tipo emocional (17); flórez et al, al utilizar la web y la radio, muestra efectividad en el soporte social (18). los desarrollos biotecnológicos han permitido a las personas superar la sobrevida y la incidencia de enfermedades crónicas —incluida la hipertensión— que generan discapacidad. vivir con enfermedad crónica es requerir de atención y cuidados que en gran parte se cubren en el hogar por la red familiar inmediata, la calidad de vida se afecta por la cronicidad e influye en la capacidad funcional y la independencia del enfermo. el curso o la trayectoria de la enfermedad crónica cambia con el tiempo, los síntomas aumentan o disminuyen y el estado fisiológico se modifica (19). se observa que el soporte social es influyente en la experiencia del cuidado y en cuidadores familiares, en procesos interactivos entre individuos, mediante vínculos de amistad e información, recibiendo apoyo emocional, material o afectivo que brindan solución a situaciones cotidianas (20). el apoyo social como concepto 369 soporte social con herramienta edumática para cuidadores familiares de personas con enfermedad crónica. l juan carlos díaz-álvarez y otros. se reporta en la literatura reciente; se reconoce a las enfermeras como parte de un sistema de apoyo para el paciente y su cuidador familiar, porque su función educativa desde el ingreso hospitalario hasta su alta, incluso en el domicilio, se constituye en labor importante (21). en países demócratas la educación se está limitando a la difusión del conocimiento en plataformas que tienden a ser deficientes estructuralmente; en consecuencia, el desarrollo requiere cambios radicales para promover el acceso a los individuos y evitar la exclusión, elementos promovidos por consenso en el modelo neoliberal de la educación. la enfermería colombiana reconoce como importante fomentar habilidades de cuidado en los cuidadores familiares de personas con enfermedad crónica; incrementar el conocimiento en estos respecto al manejo y la prevención de complicaciones puede influir en la toma de decisiones y en la adopción de estilos de vida favorables para la salud física y mental del enfermo crónico y su familia (22-25). el presente estudio tiene como objetivo la medición de la efectividad de una intervención educativa para el soporte social mediante el uso de una herramienta edumática (cd rom interactivo) y el seguimiento telefónico, dirigido a cuidadores de personas con hipertensión arterial. materiales y métodos investigación analítica cuasiexperimental realizada en el año 2012 a 110 cuidadores seleccionados en cinco sedes de una institución prestadora de salud en bogotá según los siguientes criterios: cuidadores familiares de pacientes hipertensos que se encontraban en control ambulatorio de hipertensión arterial en la ips estudiada, que no participaban en programas de intervención para enfermedades crónicas, mayores de 18 años, que tenían acceso a un computador con lector de cd o dvd, que se vincularon al estudio mediante su consentimiento informado tanto verbal como escrito, y cuyo lugar de residencia fue bogotá d.c. instrumentos utilizados para obtener datos sociodemográficos y caracterizar al grupo de estudio se utilizó la encuesta de caracterización de cuidadores familiares de personas con enfermedad crónica elaborada por el grupo de cuidado de la universidad nacional de colombia (26), esta consta de ítems que indagan aspectos como el género, la edad, la relación de la edad con el cuidador, la edad del paciente, la escolaridad, el estado civil, la ocupación, el estrato social, el tiempo percibido en la relación de cuidado y el tipo de cuidador. para medir el soporte social se empleó el instrumento inventario de soporte social en enfermedad crónica (issec) de hilbert (21), constituido por cinco subescalas: a) interacción personal (apoyo de tipo emocional requerido para el afrontamiento adecuado en diversas situaciones de enfermedad crónica. ítems 1 a 10); b) guía (ayuda que percibe el cuidador con educación e información. ítems 11 a 17 y 30 a 36); c) retroalimentación (apoyo a las acciones. ítems 18 a 21, 37, 38); d) ayuda tangible (apoyo material y en las tareas físicas y labores desempeñadas por el cuidador. ítems 21 a 24); e) interacción social (apoyo para permitir que los cuidadores rescaten sus relaciones con otros grupos, familias e instituciones que respondan a sus necesidades. ítems 25 a 29). cada ítem se califica mediante una escala tipo likert que va de 1 (insatisfecho) hasta 6 (muy satisfecho). la puntuación máxima fue de 228, a mayor puntaje mayor apoyo social brindado por la persona nombrada como la más importante por el cuidador. para el presente estudio, por razones éticas, no se utilizaron los ítems que corresponden a la subescala ayuda tangible, pues no se pretendía ofrecer ayuda económica alguna, por lo que el máximo de puntuación fue de 204. la confiabilidad del instrumento utilizado, medido con el alfa de cronbach por subescalas, fue: interacción personal 0,93; guía 0,95; retroalimentación 0,89; interacción social 0,88 (19). el instrumento ha sido utilizado en población colombiana en la investigación multicéntrica “soporte social con tecnología de la información y la comunicación (tic) para cuidadores familiares de personas con enfermedad crónica en américa latina” (27) liderado por enfermeras docentes de la universidad nacional de colombia. el instrumento de hilbert permite determinar la efectividad del soporte social brindado mediante las tecnologías de la información y la comunicación a cuidadores familiares de personas con enfermedad crónica. este estudio tuvo como objetivo medir la efectividad de la intervención del soporte social mediante el uso de una herramienta edumática (cd rom interactivo) y seguimiento telefónico, dirigido a cuidadores de personas con hipertensión arterial. 370 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 previo a la intervención se aplicó la primera medición con el instrumento de hilbert, evaluándose el apoyo percibido por los cuidadores familiares de estas personas. el grupo recibió la intervención luego de asistir a una consulta médica de control donde se le entregó un cd rom interactivo con instrucciones escritas para su uso. en esta sesión, en algunas sedes de la ips de estudio, se pudo además demostrar y manipular el cd en un computador portátil en la sala de sesiones educativas. durante dos meses se realizaron seguimientos telefónicos a los cuidadores familiares, en los que se les preguntaba sobre la frecuencia en el uso de la herramienta edumática entregada y se ofrecía información según necesidades. pasado este tiempo se les contactó y se aplicó la segunda medición con el instrumento de hilbert. la investigación cumplió parámetros éticos contemplados en la resolución 8430 de 1993 del ministerio de salud colombiano (28), se consideró sin riesgo y fue aprobada por el comité de investigación y ética de la facultad de enfermería de la pontificia universidad javeriana y por el comité de ética de la ips a la cual pertenecían los cuidadores. la información fue obtenida por los investigadores previo conocimiento de los cuidadores familiares sobre el propósito del estudio, su participación fue voluntaria y se ratificó con la firma del consentimiento informado. con el fin de mantener el anonimato de los participantes los formularios fueron codificados. la primera intervención contó con la participación de 133 cuidadores familiares. la segunda medición se realizó a 110 cuidadores familiares, los demás no se tuvieron en cuenta como consecuencia de retiro voluntario, imposibilidad de ubicación telefónica, cambio de residencia, incumplimiento en la revisión de los contenidos del cd rom y muerte de un participante. los contenidos del cd rom interactivo fueron elaborados por los investigadores con representantes de la ips donde se llevaría a cabo la investigación. este consta de cinco apartados denominados: “debes aprender, puedes cuidar, debes hacer, debes saber y para saber más”. cada apartado tiene los conceptos de actividad física, alimentación diaria y saludable, manejo de medicamentos, hábitos de vida y salud mental. estos elementos se desarrollan con una simple teorización que incluye conocimientos anatómicos y funcionales del aparato circulatorio, apoyada con películas sobre la enfermedad crónica, videos para el control de la hipertensión, artículos de conocimiento público, pósteres educativos y campañas de salud recopiladas de eventos nacionales e internacionales para evitar los factores de riesgo de la hipertensión. la sección denominada para saber más contiene videos, foros y películas que tratan desde múltiples ópticas la enfermedad crónica, especialmente en adultos. las características de los cuidadores y su relación con el cuidado se condensaron para su interpretación en una tabla con frecuencia y porcentaje; las dimensiones de la escala de hilbert se consolidaron en una tabla interpretada por mediana, rango intercuartílico y valor p. los datos se analizaron en el programa estadístico stata, versión 12. las comparaciones entre puntajes obtenidos en la primera y segunda medición se hicieron con la prueba de suma de rangos de wilcoxon. para el análisis y la interpretación de los resultados los datos se presentan en tablas distribuidas por cada dimensión del instrumento de hilbert, allí se especifica el número y el porcentaje de personas que no modificaron su satisfacción fuera positiva o negativa en la segunda medición. frente a este aparece el porcentaje de cambio en la satisfacción por incremento o decremento de esta. resultados características de los cuidadores y relación de cuidado en la tabla 1 se consolidan las características sociodemográficas y la relación de cuidado de los cuidadores, allí se observa que el 79,09 % de los cuidadores son mujeres y el 20,9 % son hombres. por rangos de edad predominaron cuidadores entre los 41 y 60 años (52,73 %), seguidos por los que tienen más de 61 años (30 %), solo el 17,27 % tienen menos de 40 años. el promedio de edad del cuidador fue de 52,5 años, y el del familiar con enfermedad crónica fue de 72,72 años. en cuanto a su escolaridad, el 35,46 % tienen estudios de secundaria; el 52,73 % son casados y el 35,45 % realizan labores en el hogar. en cuanto al estrato socioeconómico la mayoría se ubica en el estrato 3 (38,18 %), seguido de los estratos 4 (32,73 %) y 2 (26,36 %). la mayoría (80 %) informa que lleva más de 3 años en su labor de cuidado, el 45,45 % considera que dedica las 24 horas a cuidar a su familiar. 371 soporte social con herramienta edumática para cuidadores familiares de personas con enfermedad crónica. l juan carlos díaz-álvarez y otros. el 54,55 % son cuidadores únicos y el 35,46 % cuida además a otros familiares; el 35,45 % cuida a sus hijos, el 21,82 % a sus esposos (as) y el 16,36 % a sus padres; solo el 1,82 cuida a su abuelo (a), el 22,73 % cuida a alguien diferente a su núcleo familiar principal, ya sea cuñados, tías, primos, entre otros. al preguntarles sobre el apoyo familiar, el 30,91 % percibe que no tienen ningún tipo de apoyo de la familia. tabla 1. características de los cuidadores y relación de cuidado característica frecuencia porcentaje género masculino 23 20,91 femenino 87 79,09 rango de edad 19-40 años 19 17,27 41-60 años 58 52,73 61-y más años 33 30,00 grado de escolaridad primaria incompleta 4 3,64 primaria completa 15 13,64 bachillerato incompleto 16 14,55 bachillerato completo 23 20,91 técnico 17 15,45 universidad incompleta 8 7,27 universidad completa 27 24,55 estado civil soltero (a) 30 27,27 casado (a) 58 52,73 separado (a) 7 6,36 viudo (a) 5 4,55 unión libre 10 9,09 ocupación del cuidador hogar 39 35,45 empleado (a) 22 20,00 trabajo independiente 21 19,09 estudiante 3 2,73 desempleado 2 1,82 pensionado 23 20,91 característica frecuencia porcentaje estrato socioeconómico estrato 1 3 2,73 estrato 2 29 26,36 estrato 3 42 38,18 estrato 4 36 32,73 experiencia de cuidado desde hace 6 meses 6 5,45 menos de hace 18 meses 8 7,27 llevo hasta 3 años 8 7,27 llevo más de 3 años 88 80,00 horas dedicadas al cuidado menos de 6 horas 33 30,0 entre 7 y 12 horas 19 17,27 entre 13 y 23 horas 8 7,27 24 horas 50 45,45 cuidador único sí 60 54,55 no 50 45,45 cuidado a otros familiares sí 39 35,46 no 71 64,54 relación con el familiar esposo (a) 24 21,82 madre / padre 18 16,36 hijo (a) 39 35,45 abuelo (a) 2 1,82 amigo (a) 2 1,82 otro 25 22,73 apoyo familiar sí 76 69,09 no 34 30,91 promedio de edad del cuidador 52,5 años del familiar hipertenso 72,72 años fuente: datos del estudio. efectividad de la intervención del soporte social a cuidadores en la tabla 2 se concretan los puntajes por mediana y rango intercuartílico de cada dimensión estudiada, de acuerdo con las mediciones previa y posterior; allí se observa que solo se encontró diferencia estadísticamente significativa entre los valores iniciales medianos del puntaje y los valores finales medianos para 372 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 la dimensión de interacción social (p = 0,002), con un incremento en su puntaje. tabla 2. distribución de las dimensiones de la escala de hilbert seguido de dice que estoy bien como estoy [16]. en la medición posterior a la intervención, el ítem de mayor satisfacción fue me consuela cuando estoy molesto [11], los ítems 5, 6, 7, no presentaron diferencia entre las dos mediciones. llama la atención que en esta dimensión la mayoría de ítems presentó una importante disminución en la segunda medición. la mayor insatisfacción se observó en el ítem 5 con una frecuencia de respuesta de 24 previo a la intervención, tras lo cual disminuyó a una frecuencia de 15. para una mayor comprensión del comportamiento de cada uno de los ítems en la dimensión interacciones personales se presenta la tabla 4, en ella se puede verificar que un número y porcentaje determinado de participantes mantuvieron igual opinión y calificaron de la misma forma ambas mediciones; en la segunda columna se encuentran aquellas personas que en la segunda medición disminuyeron su percepción y calificaron negativamente. en la tercera columna están relacionadas las personas que en la segunda medición incrementaron su puntaje de acuerdo con su percepción y calificaron positivamente. así mismo existe un porcentaje de cambio, esto corresponde a las personas que al comparar el puntaje obtenido en la primera medición, incrementaron o disminuyeron su calificación en la segunda. para el ítem 1 (dicen que estoy bien como estoy), el 52,7 % mantuvo igual opinión y calificó ambas mediciones de la misma manera. el 47,3 % varió su opinión, de tal forma que el 28,2 % puntuó negativamente este ítem, en tanto que el 19,1 % lo hizo positivamente. ajustando el porcentaje y teniendo como referencia el número de participantes que modificaron su apreciación y puntuaron tanto positiva como negativamente en la segunda medición —que para el caso corresponde a 52 participantes—, entonces el 40,4 % (21 participantes) mejoró su percepción e incrementó su puntuación al calificar en la segunda medición, en tanto que el 59,6 % (31 participantes) calificó negativamente. según lo anterior, y siguiendo el mismo esquema de análisis para el resto de ítems, se puede evidenciar que el comportamiento en el porcentaje de cambio para los que incrementaron su apreciación y mejoraron la puntuación en la segunda medición corresponde, en su orden, al ítem 9 (66,7 %), ítem 5 (61,4 %), ítem 2 (54,7 %). el menor porcentaje de cambio fue referido al ítem 1 (40,4 %). el comportamiento del porcentaje de cambio para las personas que en la segunda medición calificaron negativamente correspondió a: ítem 1 (59,6 %), ítem 6 (57,4 %), ítem 4 (56,5 %). dimensión evaluación mediana rango intercuartílico p interacción personal antes 45,0 18,0 0,4615 después 45,0 15,0 guía antes 67,5 25,0 0,8964 después 66,5 18,0 retroalimentación antes 24,0 10,0 0,1072 después 24,0 7,0 interacción social antes 17,5 17,0 0,0020 después 21,0 12,0 fuente: datos del estudio. categorías del soporte social a los cuidadores dimensión interacciones personales en la dimensión interacciones personales (ver resultados para esta dimensión en la tabla 2), los cuidadores puntuaron una mediana de 45 antes y después de la intervención, con un rango intercuartílico de 18 para la primera medición y de 15 para la segunda con p = 0,4615. de acuerdo con la frecuencia reportada para satisfecho (tabla 3), la mayoría de aspectos relacionados con esta dimensión en la medición previa mostraron satisfacción en los ítems: dice que estoy bien como estoy [60], está disponible para escuchar cuando yo quiero hablarle [59], me hace saber que puedo contar con él si necesito ayuda [57]. en la medición posterior se destacan por orden de frecuencia e incremento en su puntaje los siguientes ítems: me conforta mostrándome algo de afecto físico [51], permite que yo vaya donde ella (el) cuando me siento deprimido [47], el resto de ítems en la segunda medición mostró un decremento en la calificación por parte de los participantes. de acuerdo con la frecuencia para muy satisfecho, en la primera medición la mayor satisfacción se presenta en el ítem: me hace saber que puedo contar con él si necesito ayuda [19], 373 soporte social con herramienta edumática para cuidadores familiares de personas con enfermedad crónica. l juan carlos díaz-álvarez y otros. ítems evaluación insatisfecho algo insatisfecho parcialmente satisfecho algo satisfecho satisfecho muy satisfecho 1. dice que estoy bien como estoy antes 7 6 8 13 60 16 después 8 6 8 26 51 11 2. me confortan mostrándome algo de afecto físico antes 12 9 9 18 49 13 después 11 6 7 25 51 10 3. me hace saber que puedo contar con él si necesito ayuda antes 10 7 9 8 57 19 después 9 3 9 27 45 17 4. expresa interés y preocupación por mi bienestar antes 9 6 13 15 51 16 después 10 4 11 33 38 14 5. me dice que se siente muy cercano a mí antes 24 10 10 15 40 11 después 15 2 10 30 42 11 6. está disponible para escuchar cuando yo quiero hablarle antes 10 8 12 6 59 15 después 11 6 12 25 41 15 7. disfruta escuchando lo que yo pienso antes 17 9 8 15 49 12 después 13 6 11 24 44 12 8. me consuela cuando estoy molesta antes 19 8 10 14 50 9 después 13 8 12 24 42 11 9. permite que yo vaya donde ella cuando me siento deprimido antes 24 4 20 17 35 10 después 11 7 19 20 47 6 10. me acepta totalmente incluyendo lo mejor o peor de mí antes 13 7 12 11 54 13 después 7 6 20 19 47 11 tabla 3. distribución por frecuencia de respuesta de la dimensión interacciones personales fuente: datos del estudio. los ítems de la dimensión interacciones personales que presentaron en la segunda medición un incremento en la insatisfacción porque disminuyeron su percepción y calificaron en la segunda medición con puntajes inferiores fueron: ítem 1 (59,6 %), ítem 3 (53,7 %), ítem 4 (56,5 %), ítem 6 (57,4 %), ello podría señalar que las personas consideran que no les informan que están bien como están; no se les hace saber que pueden contar con el sistema si necesitan ayuda; no expresan interés y preocupación por el bienestar del cuidador, y no se encuentran disponibles para escuchar cuando el cuidador quiere hablar. los ítems de la dimensión interacciones personales que presentaron en la segunda medición un incremento en la satisfacción porque aumentaron su percepción y calificaron en la segunda medición con puntajes superiores fueron: ítem 2 (54,7 %), ítem 5 (61,4 %), ítem 9 (66,7 %) e ítems 7 y 8 con un 54,4 % respectivamente; esto podría significar que a los cuidadores se les conforta mostrándoles afecto físico; les informan que se sienten muy cercanos a ellos, permiten que ellos se dirijan a consultar al personal de enfermería cuando se sienten deprimidos, y el sistema les consuela cuando están molestos y los escuchan. dimensión guía en la dimensión guía (ver resultados para esta dimensión en la tabla 2) los cuidadores puntuaron una mediana de 67,5 antes y 66,5 después de la intervención con un rango intercuartílico de 25 para la primera medición y de 18 para la segunda, con p = 0,8964. la distribución de la frecuencia de respuesta (ver tabla 5) tendió hacia la satisfacción en todos los ítems. se destaca satisfacción en la medición previa por orden de frecuencia en los 374 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 tabla 4. distribución por frecuencia, porcentaje y porcentaje de cambio del nivel de satisfacción obtenida en la segunda medición. dimensión interacciones personales ítems personas que mantuvieron igual opinión en ambas mediciones personas que disminuyeron su percepción en la segunda medición personas que incrementaron su percepción en la segunda medición no. % % cambio no. % % cambio no. % % cambio 1. dicen que estoy bien como estoy 58 52,7 0,0 31 28,2 59,6 21 19,1 40,4 2. me confortan mostrándome algo de afecto físico 57 51,8 0,0 24 21,8 45,3 29 26,4 54,7 3. me hace saber que puedo contar con él si necesito ayuda 56 50,9 0,0 29 26,4 53,7 25 22,7 46,3 4. expresa interés y preocupación por mi bienestar 48 43,6 0,0 35 31,8 56,5 27 24,5 43,5 5. me dice que se siente muy cercano a mí 40 36,4 0,0 27 24,5 38,6 43 39,1 61,4 6. está disponible para escuchar cuando yo quiero hablarle 49 44,5 0,0 35 31,8 57,4 26 23,6 42,6 7. disfruta escuchando lo que yo pienso 42 38,2 0,0 31 28,2 45,6 37 33,6 54,4 8. me consuela cuando estoy molesta 42 38,2 0,0 31 28,2 45,6 37 33,6 54,4 9. permite que yo vaya donde ella cuando me siento deprimido 44 40,0 0,0 22 20,0 33,3 44 40,0 66,7 10. me acepta totalmente incluyendo lo mejor o peor de mí 52 47,3 0,0 29 26,3 50,0 29 26,3 50,0 fuente: datos del estudio. tabla 5. distribución por frecuencia de respuesta de la dimensión guía ítems evaluación insatisfecho algo insatisfecho parcialmente satisfecho algo satisfecho satisfecho muy satisfecho 11. me dejó claro lo que se esperaba de mí antes 14 6 9 12 51 18 después 7 5 14 23 49 12 12. me orientó sobre cómo tenía que hacer ciertas cosas antes 7 6 7 5 62 23 después 5 3 11 24 57 10 13. me dio información para ayudarme a entender la situación en que me encontraba antes 10 4 9 6 64 17 después 6 1 11 29 55 8 14. me dijo cómo buscar asistencia antes 12 6 7 4 63 18 después 5 5 10 28 54 8 15. me dijo qué esperar en una situación que está a punto de ocurrir antes 17 8 8 9 56 12 después 8 6 10 28 48 10 16. me enseñó cómo hacer algo (en una situación) antes 13 5 6 12 57 17 después 5 6 11 25 52 11 17. me habló sobre un problema para ayudar a resolverlo antes 18 9 9 9 50 15 después 10 7 11 23 50 9 30. compartía información conmigo sobre las recomendaciones que hacia el equipo de salud antes 17 7 10 9 54 13 después 8 5 14 22 54 7 375 soporte social con herramienta edumática para cuidadores familiares de personas con enfermedad crónica. l juan carlos díaz-álvarez y otros. ítems: me dio información para ayudarme a entender la situación en que me encontraba [64], me dijo cómo buscar asistencia [63], me orientó sobre cómo tenía que hacer ciertas cosas [62], me enseñó a llevar a cabo las recomendaciones dadas por el equipo de salud [60]. en la segunda medición luego de la intervención los ítems con mayor registro en frecuencia fueron: habló conmigo acerca de los problemas que he estado teniendo con las recomendaciones del equipo de salud [59], me dijo a quién debo buscar para que me asista cuando tengo problemas con las recomendaciones del equipo de salud [53]. salvo los ítems 17 y 30, que no modificaron en ninguna de las dos mediciones, el resto de ítems disminuyó en la segunda medición. respecto a los diferentes niveles de insatisfacción se evidencia que esta disminuyó en la segunda medición luego de la intervención, comparada con la medición inicial. en la tabla 6 se evidencia el número y porcentaje de los participantes que no cambiaron de opinión en ambas mediciones, seguidos de las personas que en la segunda medición disminuyeron su percepción y calificaron negativamente, y las que incrementaron el puntaje de acuerdo con su percepción calificando positivamente. de acuerdo al porcentaje de cambio se puede afirmar lo siguiente: los ítems que fueron calificados por los participantes y que incrementaron el puntaje en la segunda medición son: 15, 17, 30, 32 a 36. por el contrario, los ítems que en la segunda medición disminuyeron el puntaje fueron: 11 a 14, 16, 31. dimensión retroalimentación en la dimensión retroalimentación (ver resultados para esta dimensión en la tabla 2) los cuidadores puntuaron una mediana de 24 en ambas mediciones, con un rango intercuartílico de 10 para la primera medición y 7 para la segunda medición, con p = 0,1072. al igual que en las dimensiones anteriores, la frecuencia de respuesta tendió hacia la satisfacción en ambas mediciones. la mayor insatisfacción se presentó en el ítem: me ayudó a entender por qué no hago algo bien, con 21 respuestas; sin embargo, en la segunda medición este bajó a 11 respuestas (tabla 7). en cuanto a la satisfacción, en la medición inicial 60 cuidadores consideraron que con ellos se revisa si han seguido los consejos que se dan, y 59 cuidadores puntuaron que revisan si han seguido las recomendaciones que consideran importantes. en la segunda medición, 57 cuidadores reconocen que se hacen comentarios favorables cuando ejecutan recomendaciones del equipo de salud, lo cual incrementó en 6 puntos ítems evaluación insatisfecho algo insatisfecho parcialmente satisfecho algo satisfecho satisfecho muy satisfecho 31. me ayudó a comprender mi enfermedad antes 10 7 11 8 57 17 después 6 4 15 21 55 9 32. me dijo a quién debo buscar para que me asista cuando tengo problemas con las recomendaciones del equipo de salud antes 13 7 11 11 51 17 después 8 4 11 23 53 11 33. me dijo qué tan útiles eran las recomendaciones del equipo de salud para evitar complicaciones antes 19 5 6 8 57 15 después 8 5 10 20 55 12 34. me enseñó cómo llevar a cabo las recomendaciones dadas por el equipo de salud antes 17 8 7 6 60 12 después 7 6 12 16 57 12 35. habló conmigo acerca de los problemas que he estado teniendo con las recomendaciones del equipo de salud antes 21 4 8 14 50 13 después 9 4 10 19 59 9 36. me motivó a tener un cuidado de mí mismo antes 15 3 10 12 57 13 después 7 5 9 21 54 14 fuente: datos del estudio. 376 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 tabla 6. distribución por frecuencia, porcentaje y porcentaje de cambio del nivel de satisfacción obtenido en la segunda medición. dimensión interacciones guía ítems personas que mantuvieron igual opinión en ambas mediciones personas que disminuyeron su percepción en la segunda medición personas que incrementaron su percepción en la segunda medición no. % % cambio no. % % cambio no. % % cambio 11. me dejó claro lo que esperaba de mí 49 44,5 0,0 32 29,1 52,5 29 26,4 47,5 12. me orientó sobre cómo tenía que hacer ciertas cosas 52 47,3 0,0 40 36,4 68,0 18 16,4 31,0 13. me dio información para ayudarme a entender la situación en la que me encontraba 57 51,8 0,0 32 29,1 60,4 21 19,1 39,6 14. me dijo cómo buscar asistencia 53 48,2 0,0 32 29,1 56,1 25 22,7 43,9 15. me dijo qué esperar en una situación que está a punto de ocurrir 51 46,6 0,0 25 22,7 42,4 34 30,9 57,6 16. me enseñó cómo hacer algo en una situación 55 50,0 0,0 28 25,5 50,9 27 24,5 49,1 17. me habló sobre un problema para ayudar a resolverlo 50 45,5 0,0 27 24,5 45,0 33 30,0 55,0 30. compartía información conmigo sobre las recomendaciones que hacía el equipo de salud 46 41,8 0,0 31 28,2 48,4 33 30,0 51,6 31. me ayudó a comprender mi enfermedad 45 40,9 0,0 36 32,7 55,4 29 26,4 44,6 32. me dijo a quién debo buscar para que me asista cuando tengo problemas con las recomendaciones del equipo de salud 52 47,3 0,0 26 23,6 44,8 32 29,1 55,2 33. me dijo qué tan útiles eran las recomendaciones del equipo de salud para evitar complicaciones 57 51,8 0,0 23 20,9 43,4 30 27,3 56,6 34. me enseñó cómo llevar a cabo las recomendaciones dadas por el equipo de salud 59 53,9 0,0 20 18,2 39,2 31 28,2 60,8 35. habló conmigo acerca de los problemas que he estado teniendo con las recomendaciones del equipo de salud 56 50,9 0,0 20 18,2 37,0 34 30,9 63,0 36. me motivó a tener un cuidado de mí mismo 50 45,5 0,0 28 25,5 46,7 32 29,1 53,3 fuente: datos del estudio. respecto a la medición inicial. el ítem 20 no presentó ninguna modificación en ambas mediciones, en tanto que los ítems 18, 19 y 37 presentaron disminución en la frecuencia de respuesta en la segunda medición, después de la intervención, comparada la medición inicial. según el porcentaje de cambio en la opinión de los cuidadores en la segunda medición, se pudo identificar que el ítem que presentó mayor disminución en el puntaje fue el número 18, en tanto que los restantes (ítems 19, 20, 37 y 38) incrementaron el puntaje (tabla 8). dimensión interacción social en la dimensión interacción social (ver resultados para esta dimensión en la tabla 2) los cuidadores puntuaron una mediana de 17,5 en la primera medición y 21 en la segunda, con un rango intercuartílico de 17 para la primera medición y 12 para la segunda, con p = 0,0020. 377 soporte social con herramienta edumática para cuidadores familiares de personas con enfermedad crónica. l juan carlos díaz-álvarez y otros. tabla 7. distribución por frecuencia de respuesta de la dimensión retroalimentación tabla 8. distribución por frecuencia, porcentaje y porcentaje de cambio del nivel de satisfacción obtenido en la segunda medición. dimensión retroalimentación ítems evaluación insatisfecho algo insatisfecho parcialmente satisfecho algo satisfecho satisfecho muy satisfecho 18. revisa conmigo si he seguido los consejos que me dan antes 13 9 8 5 60 15 después 8 6 15 20 52 9 19. me ayudó a entender por qué no hago algo bien antes 21 7 8 10 56 8 después 11 5 14 19 54 7 20. me retroalimenta acerca de cómo estoy sin decirme si está bien o no antes 18 5 10 15 54 8 después 8 4 16 20 54 8 37. revisan si he seguido las recomendaciones que considero importantes antes 15 5 6 10 59 15 después 7 3 14 17 55 14 38. hace comentarios favorables cuando ejecuto recomendaciones del equipo de salud antes 17 4 11 11 51 16 después 5 6 14 16 57 12 fuente: datos del estudio. fuente: datos del estudio. ítems personas que mantuvieron igual opinión en ambas mediciones personas que disminuyeron su percepción en la segunda medición personas que incrementaron su percepción en la segunda medición no. % % cambio no. % % cambio no. % % cambio 18. revisa conmigo si he seguido los consejos que me dan 59 53,6 0,0 29 26, 4 56,9 22 20,0 43,1 19. me ayudó a entender por qué no hago algo bien 57 51,8 0,0 23 20,9 43,4 30 27,3 56,6 20, me retroalimenta acerca de cómo estoy sin decirme si está bien o no 56 50,9 0,0 22 20,0 40,7 32 29,1 59,3 37. revisan si he seguido las recomendaciones que considero importantes 57 51,8 0,0 26 23.6 49,1 27 24,5 50,9 38. hace comentarios favorables cuando ejecuto recomendaciones del equipo de salud 52 47,3 0,0 25 22,7 43,1 33 30,0 56,9 en cada uno de los ítems de la dimensión interacción social (tabla 9) se puede determinar un incremento en las calificaciones para satisfecho y algo satisfecho comparando los puntajes obtenidos antes y después de la intervención; la insatisfacción disminuyó en la segunda medición en todos los ítems. llama la atención que la calificación muy satisfecho presentó un comportamiento diferente e inverso, puesto que el puntaje obtenido antes es superior al obtenido después de la intervención. en la medición inicial se presentó satisfacción en el ítem: me hace bromas o chistes para darme ánimo, con una frecuencia de respuesta de 37, el cual presenta un incremento de 7 puntos en la 378 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 segunda medición. tras la intervención en la segunda medición 49 cuidadores refieren que se les ofrecen alternativas de distracción y recreación que al comparar con la frecuencia de respuesta de la medición inicial, incrementó en 14 puntos. de la misma forma se presentó un incremento de 10 puntos en la segunda medición en el ítem puedo contar con él o ella para distraerme de las preocupaciones. en la tabla 10 se consolida la distribución de la frecuencia de respuesta de acuerdo al nivel de satisfacción —comparadas la primera y segunda medición— de cada uno de los ítems que constituyen la dimensión interacción social. en ella se puede observar que para el ítem 25, me ofrecen alternativas de distracción y recreación, de las 39 personas que en la primera medición marcaron insatisfacción, en la segunda medición 12 continuaron insatisfechos, 7 algo insatisfechos, 4 parcialmente satisfechos, 7 algo satisfechos, 8 satisfechos y 1 muy satisfecho. de la misma forma, de los 12 cuidadores que en la primera medición marcaron muy satisfechos, en la segunda medición 1 continuó insatisfecho, 3 algo satisfechos, 4 satisfechos y 4 muy satisfechos. en este mismo ítem se puede identificar que en la primera medición 39 marcaron insatisfacción, 11 dijeron estar algo insatisfechos, 6 parcialmente satisfechos, 7 estar algo satisfechos, 35 satisfechos y 12 muy satisfechos. respecto a la segunda medición se pudo determinar que 16 continuaron con insatisfacción, 12 se sentían algo insatisfechos, 9 consideraron estar parcialmente satisfechos, 15 algo satisfechos, 49 refirieron sentirse satisfechos y 9 continuaban muy satisfechos. como se puede ver en la tabla 10, para el ítem 25 en la medición inicial 35 personas se sentían satisfechas y en la segunda medición se incrementó la cifra a 49. por su parte, en la primera medición 12 personas estaban muy satisfechas, en tanto que tal cifra disminuyó para la segunda medición y quedó en 9. teniendo en cuenta en su orden la distribución por frecuencia de la primera medición, comparada esta con la distribución por frecuencia de la segunda medición, se puede observar que para el ítem analizado, de 39 insatisfechos se pasó a 16, de 11 algo insatisfechos se pasó a 12, de 6 parcialmente satisfechos se incrementó a 9, de 35 satisfechos se pasó a 49 y de 12 satisfechos se pasó a 9. para el ítem 26, hablan conmigo sobre algunos de mis intereses, al comparar las frecuencias de respuestas de la primera medición con la segunda se pudo determinar que de los 36 cuidadores que inicialmente estaban insatisfechos, 18 continuaron estándolo; de los 11 que inicialmente estaban algo insatisfechos, se pasó a 12; así mismo, de los 6 que inicialmente estaban parcialmente satisfechos se pasó a 11, de 13 que estaban algo satisfechos en la segunda medición se incrementaron a 19, 35 estaban satisfechos y se incrementaron a 43, y de los 9 que estaban muy satisfechos, en este rango quedaron solo 7. tabla 9. distribución por frecuencia de respuesta de la dimensión interacción social ítems evaluación insatisfecho algo insatisfecho parcialmente satisfecho algo satisfecho satisfecho muy satisfecho 25. me ofrece alternativas de distracción y recreación antes 39 11 6 7 35 12 después 16 12 9 15 49 9 26. habla conmigo sobre algunos de mis intereses antes 36 11 6 13 35 9 después 18 12 11 19 43 7 27. me hace bromas o chistes para darme ánimo antes 34 6 10 13 37 10 después 18 13 7 20 44 8 28. comparte conmigo algún interés antes 34 8 7 19 32 10 después 20 8 10 20 44 8 29. puedo contar con él o ella para distraerme de las preocupaciones antes 32 7 11 14 35 11 después 19 7 11 20 45 8 fuente: datos del estudio. 379 soporte social con herramienta edumática para cuidadores familiares de personas con enfermedad crónica. l juan carlos díaz-álvarez y otros. tabla 10. comparación distribución por frecuencia del nivel de satisfacción, mediciones previa y posterior de los ítems en la dimensión interacción social ítem 25. me ofrecen alternativas de distracción y recreación primera medición segunda medición insatisfecho algo insatisfecho parcialmente satisfecho algo satisfecho satisfecho muy satisfecho total insatisfecho 12 7 4 7 8 1 39 algo insatisfecho 1 3 2 1 4 0 11 parcialmente satisfecho 0 1 1 2 2 0 6 algo satisfecho 1 1 1 0 4 0 7 satisfecho 1 0 1 2 27 4 35 muy satisfecho 1 0 0 3 4 4 12 total 16 12 9 15 49 9 110 ítem 26. hablan conmigo sobre algunos de mis intereses primera medición segunda medición insatisfecho algo insatisfecho parcialmente satisfecho algo satisfecho satisfecho muy satisfecho total insatisfecho 12 6 4 8 5 1 36 algo insatisfecho 2 4 1 2 1 1 11 parcialmente satisfecho 0 1 3 2 0 0 6 algo satisfecho 1 0 0 2 10 0 13 satisfecho 2 1 2 4 23 3 35 muy satisfecho 1 0 1 1 4 2 9 total 18 12 11 19 43 7 110 ítem 27. me hacen bromas o chistes para darme ánimos primera medición segunda medición insatisfecho algo insatisfecho parcialmente satisfecho algo satisfecho satisfecho muy satisfecho total insatisfecho 12 6 0 10 5 1 34 algo insatisfecho 1 1 1 2 1 0 6 parcialmente satisfecho 1 4 2 0 3 0 10 algo satisfecho 0 1 0 4 7 1 13 satisfecho 3 1 3 3 25 2 37 muy satisfecho 1 0 1 1 3 4 10 total 18 13 7 20 44 8 110 380 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 ítem 28. comparten conmigo algún interés primera medición segunda medición insatisfecho algo insatisfecho parcialmente satisfecho algo satisfecho satisfecho muy satisfecho total insatisfecho 14 3 3 9 4 1 34 algo insatisfecho 1 2 3 0 0 2 8 parcialmente satisfecho 1 1 1 2 2 0 7 algo satisfecho 1 1 0 5 12 0 19 satisfecho 2 1 2 3 23 1 32 muy satisfecho 1 0 1 1 3 4 10 total 20 8 10 20 44 8 110 ítem 29. puedo contar con ellos para distraerme de las preocupaciones primera medición segunda medición insatisfecho algo insatisfecho parcialmente satisfecho algo satisfecho satisfecho muy satisfecho total insatisfecho 12 2 4 7 5 2 32 algo insatisfecho 3 2 0 1 1 0 7 parcialmente satisfecho 1 1 4 3 2 0 11 algo satisfecho 0 0 0 3 11 0 14 satisfecho 2 2 3 4 22 2 35 muy satisfecho 1 0 0 2 4 4 11 total 19 7 11 20 45 8 110 fuente: datos del estudio. para el ítem 27, me hacen bromas o chistes para darme ánimo, inicialmente 34 cuidadores estaban insatisfechos y solo 18 continuaron insatisfechos para la segunda medición. de 37 que estaban satisfechos, se pasó a 44. comportamiento similar ocurrió en el resto de los ítems de la dimensión interacción social. en la tabla 11 se encuentra la distribución por frecuencia, porcentaje y porcentaje de cambio del nivel de satisfacción obtenida en la segunda medición; en la dimensión interacción social se puede verificar que en todos los ítems en la segunda medición se presentó un incremento porcentual significativo en la percepción de las personas una vez utilizada la herramienta edumática, la lectura de estas corresponde a lo siguiente: el 42,7 % de los participantes mantuvo la misma opinión y calificó igual su satisfacción en ambas mediciones. por el contrario, el 57,3 % cambió su opinión y calificó diferente su satisfacción en la segunda medición; de ellos, el 15,5 % disminuyó su satisfacción, en tanto que el 41,8 % la incrementó. tomando como referencia el porcentaje de cambio, es decir, respecto al número de personas que cambiaron su opinión, el 27 % disminuyó su satisfacción, en tanto que el 73 % la incrementó y calificó mejor el ítem relacionado con ofrecimiento de alternativas de distracción y recreación, ello significa que la satisfacción incrementó y los participantes consideran que se les ofrecen alternativas de distracción y recreación. los ítems 26 a 29 presentaron comportamiento similar. respecto al porcentaje de cambio, el 31,3 % disminuyó su percepción de satisfacción, y el 68,8 % la incrementó al considerar que se habla con el participante sobre alguno de sus intereses; de la misma forma, el 62,9 % incrementó su satisfacción al considerar que se les hacen bromas o chistes para animarlos; el 68,9 % considera que se comparte con ellos algún interés, y el 63,5 % refiere que pueden contar con ellos para distraerse de las preocupaciones. 381 soporte social con herramienta edumática para cuidadores familiares de personas con enfermedad crónica. l juan carlos díaz-álvarez y otros. tabla 11. distribución por frecuencia, porcentaje y porcentaje de cambio del nivel de satisfacción obtenido en la segunda medición. dimensión interacción social ítems personas que mantuvieron igual opinión en ambas mediciones personas que disminuyeron su percepción en la segunda medición personas que incrementaron su percepción en la segunda medición no. % % cambio no. % % cambio no. % % cambio 25. me ofrecen alternativas de distracción y recreación. 47 42,7 0,0 17 15,5 27,0 46 41,8 73,0 26. hablan conmigo sobre algunos de mis intereses 46 41,8 0,0 20 18,2 31,3 44 40,0 68,8 27. me hacen bromas o chistes para darme ánimos 48 43,6 0,0 23 20,9 37,1 39 35,5 62,9 28. comparten conmigo algún interés 49 44,5 0,0 19 17,3 31,1 42 38,2 68,9 29. puedo contar con ellos para distraerme de las preocupaciones 47 42,7 0,0 23 20,9 36,5 40 36,4 63,5 fuente: datos del estudio. discusión esta investigación determinó la presencia de 79,0 % de cuidadores femeninos, predominó el rango de edad entre los 41 y 60 años, seguido por un 30 % que tienen más de 61 años. la mayoría de cuidadores son hijos, esposos y padres, pero en una proporción importante (22,7 %) también cuidan a otros familiares. el 54,5 % son cuidadores únicos que tienen a su cargo el cuidado de otros familiares, y un 30,9 % no recibe ningún tipo de apoyo familiar. la mayoría de cuidadores tienen vínculo con sus esposos o parejas, pues el 52,7 % son casados y el 9,0 % conviven en unión libre; solo una tercera parte de los cuidadores percibe que no tienen ningún tipo de apoyo familiar. algunos estudios (29-33) muestran la participación de la mujer en el cuidado de sus familiares y de personas con enfermedad crónica. tradicionalmente, la mujer cumple diversos roles a nivel intrafamiliar, laboral y social. en su hogar se encarga del cuidado de sus hijos y de los miembros enfermos de su familia. otros estudios evidencian su compromiso y sobrecarga cuando no encuentra apoyo entre los miembros de su núcleo familiar (1114). aunque el presente estudio no pretendía medir la sobrecarga percibida por el cuidador, es interesante encontrar que la manifestaron, lo cual puede relacionarse con factores como el asumir varios roles diferentes al cuidado; el permanecer en el hogar la mayor parte de tiempo (el 35,45 % ejecutan labores en el hogar, el 20,9 % son pensionados, el 54,5 % son únicos responsables del cuidado, el 35,4 % además cuidan a otros familiares; el 24,5 % asume el cuidado entre 7 y 23 horas al día, en tanto que el 45,4 % lo asume las 24 horas del día). al comparar estos datos con estudios sobre habilidades de cuidado (34-38) se establecieron similitudes en relación con las características sociodemográficas y con algunos elementos de sobrecarga percibida, pues la mayoría de cuidadores de estos estudios eran mujeres entre los 36 y 59 años, cuidadores únicos; quienes ejercen labores de cuidado permanecen en el hogar, desarrollan esta actividad sin apoyo de otro familiar, la mayoría ha cuidado por más de tres años y perciben cuidar las 24 horas. respecto a las dimensiones del instrumento de soporte social de hilbert se pudo determinar que las de interacción personal, guía y retroalimentación no sufrieron cambios mayores en las dos mediciones. en la dimensión interacción social se observaron cambios significativos en la medición posterior tras la intervención en relación con los siguientes aspectos: “me ofrece alternativas de distracción y recreación”, “puedo contar con él o ella para distraerme de las preocupaciones”, “comparten conmigo algún interés”, “me hace bromas o chistes para darme ánimo”, “hablan conmigo sobre algunos de mis intereses”. 382 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 de acuerdo con hilbert, la dimensión interacción social permite verificar la forma como las personas se involucran en interacciones sociales por diversión y relajación; en la medición presentó un mayor incremento en cada ítem luego de utilizar la herramienta edumática seleccionada (cd rom interactivo); es posible que su contenido haya generado relajación y diversión pues en su estructura existían varias películas internacionalmente reconocidas sobre el manejo de la hipertensión y de la cronicidad, al igual que interactividad en los contenidos, lo cual pudo repercutir en esta percepción de satisfacción. igualmente, los participantes del estudio reconocen que la ips donde se ejecutó la investigación los tuvo en cuenta para entregarles un instrumento de consulta que favorecía la autonomía en la revisión de contenidos, ya que en su estructura estos elementos estaban pedagógica y didácticamente incorporados de acuerdo con necesidades respecto al conocimiento del cuidado, que un cuidador familiar debe saber y saber hacer para incrementar su satisfacción en el cuidado y en el soporte social ofrecido permitiendo la toma posterior de algunas decisiones que impactan el cuidado y el autocuidado. a pesar de la estructura de la herramienta edumática, los cuidadores familiares no percibieron que con ella se les diera consejo, información o instrucción, ni mucho menos consejería tradicional, ni apreciaron que el cd rom les brindara retroalimentación, ya que se espera un diálogo continuo con el personal de salud en el momento de la consulta y no mediante un instrumento. es probable que tal percepción también esté relacionada con el bajo número de veces que la herramienta fue consultada, lo cual se evidenció en el seguimiento telefónico ofrecido, donde se reforzaba su uso. de acuerdo con las dimensiones del instrumento de hilbert, la consejería tradicional no directiva, tal como escuchar y mostrar estimación, cuidado y comprensión, puede estar incorporada en las consultas médicas y en los seguimientos a las personas con enfermedad crónica; sin embargo, en colombia puede estar limitada al cumplimiento de estándares relacionadas con el tiempo de atención y la rotación de las mismas. el ofrecimiento de consejo y guía está íntimamente relacionado con el manejo de complicaciones y con seguir instrucciones médicas, que se ofrecen en forma escrita y quedan consignadas en la historia clínica, sobre las cuales se hace una breve explicación de acuerdo al tiempo de consulta ofrecido. por su parte, la retroalimentación respecto a los comportamientos, pensamientos o sentimientos generalmente se realiza en las consultas de control y seguimiento, pero aún no se ha incorporado un seguimiento telefónico significativo que permita verificar tales cambios. se considera que la educación ofrecida por el equipo de salud en el momento de la consulta está basada en aspectos físicos y poco en los emocionales. los resultados reflejan el efecto producido en la dimensión de interacción social, con un incremento significativo en la medición posterior a una intervención con una herramienta edumática interactiva, lo que permitió a los cuidadores involucrarse en interacciones para la relajación y la diversión. es probable que los cuidadores, al enfrentarse a los contenidos programados en el cd rom, reflexionaran sobre el cuidado a su familiar, e incluso sobre el autocuidado en algunos contextos de desarrollo, e implementaran cambios en sus rutinas de vida con resultados más satisfactorios. aunque no era objeto de este estudio medir la satisfacción de los cuidadores con la herramienta utilizada, se pudo identificar que esta permitió generar alternativas de recreación, colaboró parcialmente en el manejo de la ansiedad e incrementó el conocimiento, lo que puede explicar en parte los resultados en la dimensión de interacción social. la evaluación del soporte social de acuerdo con las categorías propuestas por hilbert para esta investigación mostró un comportamiento similar en ambas mediciones (pre y posintervención), para las dimensiones interacciones personales, guía y retroalimentación, con resultados más significativos en la dimensión de interacción social. los cuidadores de manera general sienten satisfacción con: a) la consejería tradicional no directiva como escuchar y mostrar estimación, comprensión y cuidado por el otro; b) con el ofrecimiento de información; c) con la retroalimentación de su comportamiento, sentimientos, pensamientos y cuidado. pero concluyeron que luego de la intervención con la herramienta edumática seleccionada (cd rom interactivo) y con el seguimiento telefónico incrementaron significativamente su satisfacción en cada uno de los ítems contenidos en la dimensión interacción social. en los ítems de la dimensión interacción social para calificaciones de satisfecho y algo satisfecho los puntajes obtenidos posteriores a la intervención se incrementaron, comparados con los puntajes en la primera medición. por su parte, la calificación de insatisfacción disminuyó. por el contrario, la calificación de muy 383 soporte social con herramienta edumática para cuidadores familiares de personas con enfermedad crónica. l juan carlos díaz-álvarez y otros. satisfecho presentó un comportamiento inverso obteniendo calificaciones superiores en la primera valoración comparadas con la valoración posterior a la intervención. el incremento de estas calificaciones (satisfecho y algo satisfecho, y la disminución en la insatisfacción de los cuidadores) puede ser explicado como efecto de la intervención con la herramienta edumática seleccionada y por el seguimiento telefónico que se ofreció a los cuidadores; se desconoce cuáles fueron los aspectos específicos de los contenidos temáticos que causaron la disposición de los puntajes en la segunda medición. en la medición inicial el ítem que presentaba mejor satisfacción fue “me hacen bromas o chistes para darme ánimo”, los otros presentaron un comportamiento similar respecto a su calificación; el ítem con menor puntaje fue “comparten conmigo algún interés”. en la medición final el ítem con mayor puntaje luego de la intervención fue “me ofrecen alternativas de distracción y recreación”, seguido de “puedo contar con él o ella para distraerme de las preocupaciones”, los dos presentaron puntajes similares; el ítem con menor puntaje en esta dimensión fue “habla conmigo sobre algunos de mis intereses”. el seguimiento telefónico y el uso de la herramienta seleccionada pueden explicar tal comportamiento, pues los niveles de satisfacción se incrementaron en cada uno de los ítems de la dimensión interacción social, convirtiéndose el cd rom interactivo en una oportunidad para ofrecer distracción y recreación de acuerdo con los contenidos del mismo y como consecuencia de su uso a libre demanda. algunos estudios (39, 40) señalan que los cuidadores familiares de personas con enfermedad crónica muestran satisfacción con la atención en salud proporcionada por las ips respecto a capacidad técnico-científica del personal médico y de enfermería; sin embargo, también existe insatisfacción relacionada con la oportunidad en la atención (41). actualmente, en el sistema de salud colombiano el tiempo ofrecido por el personal médico y de enfermería durante la atención del enfermo y de su familia en las consultas de control está limitado por protocolos de manejo y cumplimiento de estándares de atención; no obstante, se comparte poco respecto a intereses y singularidades de las necesidades sociales y emocionales de los usuarios, lo que afecta la satisfacción de los mismos. al parecer esta situación se ha perpetuado en el tiempo, ya que en un ensayo publicado sobre cuidadores de pacientes con enfermedad mental en el 2004 se reportó que cuando los cuidadores y los pacientes llegan a cualquier actividad como terapias, consultas o controles: se encuentran con personas que están de afán y no les dedican el tiempo que ellos esperan, además si el paciente está mal o tiene algún problema con el tratamiento, lo regañan y los tratan como culpables de esa situación […], los familiares cuidadores se sienten ignorados al no ser tenidos en cuenta por el equipo de salud y por las personas que prestan cuidados a los enfermos; y concluyen que sus necesidades y su bienestar no son importantes para el personal de salud (42). según lo anterior, los cuidadores familiares tienen necesidades de asesoramiento sobre la enfermedad, sobre intervenciones concretas frente a síntomas específicos, requieren comunicación verbal para aprobación previa en la ejecución de cuidados cotidianos, y también destacan la importancia de suplir necesidades propias y aquellas relacionadas con la distracción y el tiempo libre (43). el soporte social brindado a cuidadores con la herramienta edumática utilizada en esta investigación ofreció información general pero suficiente sobre la enfermedad y su manejo, y reforzó necesidades educativas para promover el cuidado y la toma de decisiones individuales sobre el cuidador y el familiar cuidado, de acuerdo con los tiempos disponibles para la revisión de los contenidos. también proporcionó diversión y relajación satisfaciendo las necesidades de distracción y manejo del tiempo libre, lo que incrementó como consecuencia la satisfacción en los ítems contenidos en la escala de hilbert para la dimensión de interacción social. un estudio publicado en el año 2008, titulado “interactive digital education asid in breast reconstruccion” (44), realizado en 133 mujeres asistentes a un instituto oncológico en texas, estados unidos, señaló que fueron asistidas mediante ayuda digital interactiva (cd rom) para informar detalladamente las técnicas de reconstrucción mamaria en pacientes oncológicos. mostró que la educación ofrecida fue exitosa porque informó acerca de la reconstrucción quirúrgica de la mama, y les permitió elegir la técnica más apropiada, lo que significó que la disposición de la información y el uso que de ella hicieron permitió tomar decisiones acordes a sus propias necesidades en salud. al comparar los resultados de esta investigación con dos estudios realizados en cartagena con cuidadores familiares de personas con enfermedad crónica y que utilizaron la escala de hilbert, 384 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 se identifican diferencias en las dimensiones que reportaron cambios significativos, pues en una de ellas la dimensión guía fue la mejor evaluada mediante el soporte social apoyado por la radio y la internet (17), mientras que en el segundo estudio la mayor satisfacción fue reportada en la dimensión de interacción personal y guía con el apoyo de la red familiar (16). el soporte social con cualquier herramienta de las tic ofrece satisfacción en las diferentes dimensiones incorporadas en la escala de hilbert. posiblemente, las características de los cuidadores respecto a su ámbito de desarrollo el contexto social y las diferentes particularidades regionales podrían ser factores que intervienen en la percepción; no obstante, estos aspectos deben seguirse profundizando para determinar la herramienta que genere mayores satisfacciones e impacto en los cuidadores y en el actual sistema de salud. el soporte social aporta positivamente a la vida de los individuos y redunda en el mejoramiento de su calidad de vida, reduce sentimientos asociados a la exclusión o el aislamiento e incrementa el bienestar mediante la promoción de la salud (45, 46); es una base para afrontar situaciones que afectan el normal desempeño de los individuos, y se considera una ayuda para que el cuidador afronte mejor la experiencia de cuidar (17, 47). conclusiones respecto al soporte social a cuidadores de personas con enfermedad crónica en una ips en bogotá, los resultados evidencian que los cuidadores presentan satisfacción en todas las dimensiones de la escala de hilbert, con un incremento significativo en la dimensión de interacción social, luego de utilizar como herramienta de soporte social un cd rom interactivo, acompañado de un seguimiento telefónico. la medición posterior a la intervención, en la dimensión interacción social, mostró un porcentaje de cambio en la opinión de los participantes respecto a su satisfacción, de tal forma que el 73 % incrementó su complacencia al reconocer que se le ofrecen alternativas de distracción y recreación, el 68,9 % y el 68,8 % respectivamente consideraron que comparten algunos intereses y hablan con los cuidadores al respecto; el 63,5 % consideró que puede contar con el sistema para distraerse de sus preocupaciones, en tanto que el menor porcentaje de cambio se presentó con un 62,9 % en el ítem relacionado con hacer bromas o chistes para ofrecer ánimo. el estudio aporta elementos importantes para enfermería respecto a la medición del soporte social, y permite identificar la herramienta cd rom como una opción estratégica para la promoción de la salud y la prevención de la enfermedad, que pueda ser incorporada en el sistema de salud colombiano y que requerirá evaluaciones posteriores respecto a las singularidades de su efectividad. la educación es utilizada por enfermería como un atributo para promocionar la salud y prevenir complicaciones en la relación del cuidado entre el cuidador familiar y la persona con enfermedad crónica, es la enfermera quien puede diseñar contenidos en herramientas edumáticas que utilizan plataformas tecnológicas de comunicación para impactar en el cuidado y ofrecer soporte social. recomendaciones de acuerdo con los resultados se sugiere realizar estudios posteriores en este grupo de cuidadores sobre los factores que generan sobrecarga e identificar y evaluar propuestas de intervención de enfermería en este sentido. es importante profundizar en la herramienta edumática seleccionada (cd rom interactivo) para verificar, a partir de evaluaciones de los cuidadores, las características de este y la información que deberá contener para soportar mejor el cuidado. se hace indispensable verificar la efectividad de esta herramienta en diferentes contextos de desarrollo. limitaciones del estudio la investigación, por razones éticas, no ofreció a los cuidadores incentivos económicos, lo que no permitió evaluar la subescala de apoyo tangible, la cual es una de las dimensiones del instrumento de hilbert. sin embargo, el resto de dimensiones del instrumento conservó inalterada su consistencia interna y a estas se les realizaron dos mediciones, una antes de la intervención y otra después de la misma con la herramienta edumática seleccionada. el estudio incorporó 110 cuidadores de un total de 133 que participaron en la primera medición; el resto, por varias razones, no logró aplicar para la segunda medición. 385 soporte social con herramienta edumática para cuidadores familiares de personas con enfermedad crónica. l juan carlos díaz-álvarez y otros. agradecimientos los autores de este estudio agradecen a todos los cuidadores participantes por permitir interactuar con ellos. igualmente, ofrecemos nuestros sinceros agradecimientos al grupo de cuidado al paciente crónico y a la red latinoamericana para el cuidado al paciente crónico, liderados por la universidad nacional de colombia, por su maravilloso empeño en fortalecer el cuidado, y especialmente por permitir nuestra participación como uno de los integrantes nodales en este estudio multicéntrico. también agradecemos a la vicerrectoría académica, a la facultad de enfermería de la pontificia universidad javeriana y a javesalud ips donde se realizó el estudio, pues su contribución fue significativa para el logro de los objetivos propuestos. referencias 1. echeverri g, otálora n. guía para la planeación del componente de salud mental en los planes territoriales de salud. bogotá d.c.: ministerio de la protección social; 2005 [visitado 2013 feb. 21]. disponible en: http://www.consultorsalud.com/biblioteca/documentos/2009/guia%20para%20la%20planeacion%20del%20componente%20de%20salud%20 mental%20en%20los%20planes%20territoriales%20de%20salud.pdf 2. franco a. atención primaria en salud (aps): ¿de regreso al pasado? en: ponencia, 6º. congreso internacional de salud pública, facultad nacional de salud pública. medellín: centro de convenciones plaza mayor. junio 11 al 13 de 2009. 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26(2): 212222. disponible en: http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=s0120-55522010000200005&lng=es. 39. villavicencio-chávez c, ferrer benages n, hernández gutiérrez ma, terrade bosch j, garberi vila i, gonzález soria c. satisfacción de los cuidadores principales con el programa de atención domiciliaria equipo de soporte del instituto de atención geriátrica y sociosanitaria. med paliat. 2012;19(3):105-112. 40. orozco b, henao lh, londoño ol. nivel de satisfacción del usuario en el servicio de consulta externa del hospital departamental san josé de marulanda, caldas ese. universidad católica de manizales; 2011. 41. sotto mayor m, ribeiro o, paúl c. percepción de la satisfacción de cuidadores de personas con demencia y de cuidadores de personas con avc. rev latino-am enfermagem. 2009;17(5). 42. torres am. vivencias de los cuidadores de enfermos mentales. rev investigación en enfermería: imagen y desarrollo. 2004;6(1-2):20-25. 43. moreno moreno ja, arango-lasprilla jc, rogers h. necesidades familiares y su relación con las características psicosociales que presentan los cuidadores de personas con demencia. psicología desde el caribe. universidad del norte. 2010(26):1-35. 44. heller l, parker pa, youssef a, miller j. interactive digital education aid in breast reconstruction. department of plastic surgery and department of behavioral science, university of texas. plastic and reconstructive surgery; 2008. 45. guzmán j, huenchuan s, montes de oca v. redes de apoyo social de las personas mayores. marco conceptual. ponencia presentada en el simposio viejos y viejas. participación, ciudadanía e inclusión social. 51 congreso internacional de americanistas. santiago de chile, 14 al 18 de julio de 2003. 46. palacio j, madariaga c. psicología social aplicada y análisis de redes sociales (ars). en: palacio j (comp.). psicología social: teoría y práctica. barranquilla: ediciones uninorte; 2006. 47. ávila-toscano jh. redes sociales, generación de apoyo social ante la pobreza y calidad de vida. revista iberoamericana de psicología: ciencia y tecnología. 20092(2):65-73. 09. asociacišn roy 61 actualidad 61 a facultad de enfermería recibió los documentos que la acreditan como miembro oficial de la roy adaptation association (raa). esta asociación es presidida por la doctora callista roy, autora del modelo conceptual de adaptación, que constituye el marco de referencia para las asignaturas de enfermería de la facultad. la asociación se inició en 1991, cuando un grupo de enfermeras investigadoras presentaron los resultados de los proyectos que habían desarrollado individualmente, aplicando el modelo de adaptación, en la reunión del consejo de investigadores de enfermería, celebrada en los ángeles. en este encuentro, y en otros que tuvieron posteriormente, establecieron la necesidad de analizar estos estudios de manera conjunta, para lograr una mayor profundización acerca de las relaciones teóricas y empíricas del modelo, de tal manera que la asociación se conformó definitivamente en 1994. como miembro de la raa, la facultad participa de manera activa en la elaboración y socialización de investigaciones sobre enfermería y acerca de la aplicación y adaptación del modelo a nuestro medio; en el desarrollo de conocimientos sobre la disciplina de enfermería, tiene la posibilidad de compartir experiencias con grupos académicos de las diferentes universidades y organizaciones afiliadas y a la vez puede promover intercambios entre expertos de las distintas entidades que hacen parte de la asociación. para la facultad, la obtención de la membresía de la raa es un reconocimiento a la calidad de su programa académico y a su proyección en el ámbito nacional e internacional. 216 225 que significa la esperanza.indd 216 aquichan issn 1657-5997 tania catalina chinchilla-salcedo1 ¿qué signifi ca la esperanza en padres de hijos con cáncer? 1 enfermera. magíster en enfermería. profesora, universidad de la sabana, chía, colombia. tania.chinchilla@unisabana.edu.co recibido: 10 de febrero de 2012 enviado a pares: 12 de abril de 2012 aceptado por pares: 26 de mayo de 2013 aprobado: 27 de mayo de 2013 año 13 vol. 13 nº 2 chía, colombia agosto 2013  216-225 resumen objetivo: describir el concepto de la esperanza que tienen los padres de niños entre 0 y 15 años de edad con diagnóstico de cáncer. método: investigación cualitativa de tipo descriptivo exploratorio; la información se recolectó en cuatro ciudades de colombia, a través de entrevistas semiestructuradas a once padres de niños con diagnóstico de cáncer. resultados: se identificaron doce categorías que describen las experiencias de los padres y cómo estas los llevan vivir y a describir la esperanza como virtud y estado de ánimo. conclusiones: la esperanza termina siendo el eje fundamental que mueve la vida de los padres; las experiencias alrededor del cáncer de sus hijos transforman el significado de la enfermedad y de su propias vidas, en las cuales se redescubren estrategias y mecanismos positivos de afrontamiento. palabras clave teoría de enfermería, relaciones padres-hijo, neoplasias, enfermería. (fuente: decs, bireme). what hope means to parents of children with cancer? abstract objective: describe the concept of hope in parents of children between 0 and 15 years of age who have been diagnosed with cancer. method: the information for this descriptive exploratory qualitative study was collected in four colombian cities, through semi-structured interviews with eleven parents of children diagnosed with cancer. results: twelve categories were identified that describe not only the parents’ experiences and how they help them to cope, but also depict hope as a virtue and a frame of mind. conclusions: hope ends up being the cornerstone that changes parents’ lives. the experience with their children’s cancer transforms the meaning of illness and the significance of their own lives, helping them to rediscover positive strategies and coping mechanisms. key words nursing theory, parent-child relations, neoplasms, nursing. (source: decs, bireme). para citar este artículo / to reference this article / para citar este artigo chinchilla salcedo, t. (2013). ¿qué significa la esperanza en padres de hijos con cáncer? aquichan. vol. 13, no. 2, 216-225. 217 ¿qué significa la esperanza en padres de hijos con cáncer? l tania catalina chinchilla-salcedo o que significa a esperança em pais de filhos com câncer? resumo objetivo: descrever o conceito da esperança que os pais de crianças entre 0 e 15 anos de idade com diagnóstico de câncer têm. método: pesquisa qualitativa de tipo descritivo exploratório; a informação foi coletada em quatro cidades da colômbia por meio de entrevistas semiestruturadas a onze pais de crianças com diagnóstico de câncer. resultados: identificaram-se doze categorias que descrevem as experiências dos pais e como estas os levam a viver e a descrever a esperança como virtude e estado de ânimo. conclusões: a esperança acaba sendo o eixo fundamental que move a vida dos pais; as experiências em torno do câncer de seus filhos transformam o significado da doença e de suas próprias vidas, nas quais se redescobrem estratégias e mecanismos positivos de enfrentamento. palavras-chave teoria de enfermagem, relações pais-filho, neoplasias, enfermagem. (fonte: decs, bireme). 218 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 introducción el cáncer es una enfermedad crónica que amenaza la vida, simboliza lo desconocido y lo peligroso, el sufrimiento, el dolor, la culpa, el caos y la ansiedad (1). de acuerdo con la organización mundial de la salud (oms), anualmente mueren 7,6 millones de personas por cáncer y se estima un aumento de 13.1 millones de muertes para el 2030. (2). el cáncer en colombia ha aumentado en los últimos años. de acuerdo con el reporte del dane se presentan anualmente 32.316 casos en hombres y 38.571 en mujeres (3). en menores de edad la incidencia del cáncer es más alta día a día, en ellos la pirámide es inversa —de 1 caso en 6000 al año— comparándola con otros tipos de patologías que afectan a la población infantil. de acuerdo con el reporte del dane, de las 18.400 muertes en menores de 15 años ocurridas entre el 2002 y el 2006, 828 ocurrieron por cáncer y de estas, 372 correspondieron a leucemias de diferentes tipos (4). cada año se registran 1.200 casos de menores con cáncer y el 3 % de estos fallecen (5). esto se debe a múltiples factores relacionados con la enfermedad y a otros, entre los cuales se destacan el bajo nivel sociocultural de los pacientes, la demora en la atención y en los procesos de autorización de servicios y procedimientos por parte de las entidades prestadoras de salud, y la ausencia de médicos especializados (6). un aspecto que vale la pena resaltar es que de los niños que reciben tratamiento, el 30 % lo abandonan, y una de las causas es que los padres lo suspenden cuando evidencian alguna mejoría en los síntomas, lo cual ocasiona un efecto contraproducente para su estado de salud (6). para la familia es difícil afrontar esta situación; según castillo y chelsa (1), cuando un hijo es diagnosticado con cáncer la familia, en especial padres y hermanos, tienen dificultad para comprender que el niño está enfermo y que se va a enfrentar al sufrimiento. por ello, los padres viven una serie de situaciones que les dificultan enfrentar el dolor y el inminente quebrantamiento de la salud, algunos de ellos optan por el aislamiento físico y emocional tanto para el paciente como para su familia (7). asumir la enfermedad es un proceso que lleva tiempo y que está relacionado con la fortaleza y la esperanza por parte de cada uno de los miembros de la familia. los padres se aferran a ellas porque los motivan a buscar mecanismos que les permitan entender el proceso de la enfermedad y su tratamiento (8). asimismo, los ayudan a afrontar de una manera más adecuada la enfermedad, el dolor y el contexto, durante el proceso de diagnóstico y tratamiento (9). morse y penrod (10) afirman que la esperanza es una respuesta útil ante la amenaza de la enfermedad, le da sentido a la búsqueda de ayudas internas y externas para poder comprenderla, por ello se convierte en un eje central del cuidado de enfermería (10). adicionalmente, cutcliffe y herth (9), y morse y doberneck (11) afirman que la esperanza minimiza los pensamientos negativos, lleva a compartir las experiencias con otras personas que están viviendo la misma situación con quienes se fortalecen las relaciones y se evita el aislamiento, permite dar un cuidado multidimensional y promueve la inclusión de nuevas estrategias que fortalecen el cuidado de enfermería. dada la importancia que tiene este concepto para la disciplina de enfermería, el propósito del estudio fue describir el concepto de esperanza en los padres de niños entre 0 y 15 años de edad con diagnóstico de cáncer. método se realizó un estudio cualitativo interpretativo, de tipo descriptivo exploratorio, método que permite describir la esperanza de los padres frente a un hijo con cáncer, y el ambiente y las situaciones que se dan alrededor de esta situación. los participantes del estudio fueron once padres (siete mujeres y cuatro hombres) de niños entre 0 y 15 años con diagnóstico de cáncer, quienes se ubicaron con la estrategia de bola de nieve, procedentes de bogotá, bucaramanga, barrancabermeja y santa rosa de bolívar, en colombia. las entrevistas se realizaron en el lugar que los participantes seleccionaron, ocho en la casa y cuatro en el lugar de trabajo. la recolección de la información se llevó a cabo por medio de entrevistas semiestructuradas y diarios de campo. la entrevista combina preguntas cerradas (o estructuradas) y abiertas, donde el entrevistado tiene la posibilidad de discurrir el tema propuesto sin respuesta o condiciones prefijadas por el investigador (11). en el diario de campo se registró la información relacionada con el ambiente de la entrevista, las expresiones no verbales y las emociones de los participantes durante los encuentros (12). las entrevistas fueron grabadas de manera digital y luego se transcribieron textualmente. es importante mencionar que el muestreo 219 ¿qué significa la esperanza en padres de hijos con cáncer? l tania catalina chinchilla-salcedo en esta investigación fue teórico, hasta lograr la saturación de la información. el proceso de recolección y análisis de la información se realizó simultáneamente. una vez transcritas textualmente las entrevistas se inició con cada una de ellas el proceso de codificación, seleccionando las expresiones significativas que reflejaban la esperanza de los participantes. estas expresiones (códigos sustantivos) se resaltaron con colores y se enumeraron, así como también el folio y el número del reglón donde aparecía cada una de ellas. posteriormente, los códigos sustantivos se agruparon por afinidad y se colocó al frente de cada descriptor el código nominal correspondiente a cada relato. después de un proceso relacionado de agrupación y comparación del material de análisis y el marco teórico de la investigación se identificaron doce categorías emergentes y se realizó la interpretación teórica de la información (13). las categorías se definieron según las expresiones dadas por los participantes, y así se obtuvieron ideas generales para construir la explicación del fenómeno de la esperanza de los padres de niños con cáncer. en cuanto a los aspectos éticos, en el desarrollo de la investigación se tuvieron en cuenta las recomendaciones previstas por la dirección de investigación de la universidad de la sabana, las cuales se fundamentan en la declaración de helsinsky de la asociación médica mundial (14); la resolución 008430 de 1993, del ministerio de salud de colombia, por la cual se establecieron las normas científicas, técnicas y administrativas para la investigación en salud (15); y el código deontológico de enfermería en colombia (ley 911 de 2004) (16). esta investigación estuvo sujeta a la verdad y a la fidelidad, de manera que se cumplían los principios establecidos y adquiridos con los padres en la investigación. es importante mencionar que se solicitó la firma del consentimiento informado, en el que se solicitó a los padres la aprobación de la realización y grabación de las entrevistas. para garantizar la privacidad de los participantes, a cada uno se le asignó un número como medio para identificarlo. resultados el proceso de análisis de la información permitió identificar doce categorías que reflejan las experiencias que viven los padres de los niños con cáncer: dificultad para aceptar la realidad del diagnóstico, no aceptación de la enfermedad, dificultad para enfrentar la enfermedad, sentimientos negativos frente a la enfermedad, desesperanza, falta de apoyo, esperanza, aceptar la enfermedad, interactuar con la enfermedad, sentimientos positivos frente a la enfermedad, sistemas de apoyo, reconocer valores espirituales. a continuación se describen cada una de ellas. dificultad para aceptar la realidad del diagnóstico ella me dijo [la doctora] que la niña tenía un tumor pues eso fue terrible para mí… me la mandaron para acá y acá más a fondo me concretaron que sí, que la niña tenía cáncer, de por sí pues ¡terrible! pero igualmente pasaron tres meses que yo tenía de estar en el hospital con la niña y los tíos y mi esposo me llamaban que, qué era lo que tenía la niña… pero nunca tuve el valor de decírselos a ellos, la verdad no me sentía capaz de decirles a ellos (8.1.1.3-11) (17). esta categoría representa la duda, el dolor y la incertidumbre que se generan en los padres al conocer el diagnóstico de cáncer en sus hijos. una vez conocen el diagnóstico se despiertan sentimientos de desconcierto, puesto que los padres relacionan la enfermedad con un riesgo inminente de muerte al recordar situaciones en las cuales amigos, familiares o allegados han tenido esta enfermedad y han fallecido a causa de ella. asimismo, la visualizan con un tratamiento que causa fuertes dolores y cargas, y que al final no termina en buenos resultados, por lo que les falta valor para contarlo a sus familiares y amigos, por ser un momento de incertidumbre y dolor. no aceptación de la enfermedad primero que todo yo tenía miedo de que el diagnóstico fuera lupus, porque al ser esposa de médico pues uno como que tiene más referentes ¡no!..., según los síntomas que está presentando mi hija yo decía "no, que sea artritis, pero lupus no" (4.1.1-4) (17). esta categoría representa la negación, inconformidad y no aceptación de la enfermedad por parte de los padres ante la noticia devastadora del diagnóstico de cáncer en los niños, la cual va acompañada de sentimientos de rabia y frustración que muchas veces llevan al abandono del tratamiento o al abandono del niño por parte de uno de los padres al conocer la situación. para los padres es muy difícil aceptar que su hijo tenga cáncer y por eso constantemente se preguntan por qué a ellos y por 220 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 qué dios lo permite. muchos afirmaron que por ser una situación tan difícil de manejar, les costaba entenderla y aceptarla. dificultad para enfrentar la enfermedad y ahorita acostumbrarnos a convivir con la enfermedad y a tratar de hacerle la vida lo más normal posible… no se puede hacer lo mismo, no pueden salir a los mismos parques de diversión (con la hermana) pues tratamos de hacer la vida normal pero al igual esto lleva muchos cuidados, entonces el cambio es brusco (agacha la cabeza, cara de tristeza), bastante brusco (2.1.1.12-20) (17). esta categoría refleja el conflicto que viven los padres de niños con cáncer durante el proceso de la enfermedad en sus hijos por la falta de experiencia para manejarla, las crisis, las recaídas, el tratamiento y las complicaciones que genera la enfermedad en la cotidianidad de la vida familiar, y la dificultad para hacerla parte de sus vidas, creando así experiencias negativas. sentimientos negativos frente a la enfermedad "pesimismo, miedo, incertidumbre, desesperanza, frustración. rabia, inconformidad…, temor, ansiedad, inquietud, o sea, como que uno entiende que hay cosas que definitivamente se salen de las manos" (4.1.1.33-36) (17). esta categoría representa todas aquellas expresiones negativas tales como la ansiedad, la tristeza, la angustia, el temor, la desilusión, la impotencia y el estrés que se generan a causa del diagnóstico y del proceso de la enfermedad del cáncer en los niños, lo que conlleva sentimientos de rabia, desesperación y frustración. durante el proceso de la enfermedad los padres de niños con cáncer atraviesan por diferentes situaciones, muchas de la cuales causan en ellos conflictos que ocasionan y generan sentimientos negativos que no solo afectan al niño, sino a toda la familia, tanto a nivel emocional como personal, ocasionando dificultad para comprender y aceptar la enfermedad. desesperanza "cuando comencé con mi hija pensé que ella hasta ahí llegaba, que ya no era más, que no iba a luchar más, o sea sentí que todo se me venía encima" (5.1.2.34-35) (17). la desesperanza implica el desaliento y la duda que se generan en los padres ante las experiencias negativas de la enfermedad o ante la enfermedad misma en sus hijos y trae como consecuencia sentimientos de tristeza, soledad y desesperación. los padres con desesperanza tienen dificultad para comprender y aceptar la enfermedad, las opciones de recuperación se ven limitadas y la persona es incapaz de transmitir alegría y sentimientos positivos a aquellas personas que se encuentran a su alrededor. falta de apoyo yo con él [el papá] nunca más volví a hablar, yo tenía otro niño y él se lo llevó. y en muy malas palabras me dijo: "yo me llevo el alentado y quédense ustedes dos que al fin y al cabo son enfermos" (7.1.3.123-125) (17). la falta de apoyo abarca la ausencia, el abandono y la falta de soporte afectivo, económico, social y por parte de los familiares y profesionales de la salud durante el proceso de la enfermedad. a raíz de la enfermedad del niño, algunos familiares o amigos tienden a alejarse de la situación, muchas veces por miedo y otras simplemente porque les cuesta comprenderla; sin embargo, esta falta de apoyo no solo se da en la familia o los amigos, aquí también juega un papel importante la ayuda que prestan los profesionales de la salud, el personal administrativo de las instituciones y hasta el profesorado y las directivas de un colegio, ya que todas estas personas intervienen de una manera u otra en el cuidado del niño. aceptar la enfermedad yo pienso que a modo muy personal hemos pasado por tres etapas, yo creo que la primera fue asimilar la noticia, entre comillas ya la tenemos asimilada, ahorita… cumplimos un año del diagnóstico, en medio de todo creo que intentamos un mes tratando de asimilar la noticia y de acostumbrarnos a una nueva vida, porque esto le cambia la vida a uno totalmente [agacha la cabeza y se pone la mano en ella] (2.1.1.2-7) (17). esta categoría implica enfrentar, reconocer y aprender a convivir con la enfermedad del cáncer en el niño, de modo que permita a los padres acostumbrarse al nuevo estilo de vida aprendiendo a ser fuertes y a prepararse para las diferentes situaciones que se puedan llegar a vivir durante el proceso de la enfermedad. 221 ¿qué significa la esperanza en padres de hijos con cáncer? l tania catalina chinchilla-salcedo el proceso de aceptar la enfermedad y habituarse a ella es difícil, a veces se logra con el tiempo, cuando aprenden a conocerla y a manejarla. los padres siguen luchando y buscando mecanismos que favorezcan la recuperación de sus hijos o el mantenimiento de sus vidas. por otra parte, habituarse a la enfermedad llevó a los padres a continuar con sus vidas, muchos de ellos mencionaron que vieron la necesidad de no centrar toda su atención en el niño enfermo, porque tenían que atender a sus otros hijos y continuar con las labores y los compromisos previos. interactuar con la enfermedad cómo enfrentar la situación, cómo te explicara… no es que sea como un problema, todo el mundo lo ve desde allá como un problema y no es un problema. lo que pasa es que hay que saber interactuar con la enfermedad. al igual es que los seres humanos somos animales de costumbre, uno se tiene que acostumbrar que lo que pasa; es que como tú antes llegabas y no te lavabas las manos seguidas, comías normal. ahora todo eso es lo que nos cambia, simplemente es acostumbrarse uno a las cosas… algunas cosas pueden ser difíciles otras son normales, cambiar un hábito de vida simplemente y pues es bueno para todos… inclusive para toda la familia (2.1.2.84-93) (17). esta categoría hace referencia a la habilidad por parte de los padres para aprender de la enfermedad, de los aspectos negativos y positivos de esta, de modo que aprendan a convivir con ella y logren recuperar o transformar los hábitos y las rutinas, es decir, su cotidianidad. a medida que los padres van aceptando la enfermedad se acostumbran y aprenden también a interactuar con ella, a manejarla, adquieren nuevos hábitos y rutinas para toda la familia en las que incorporan cuidados como el lavado de las manos, modificaciones en la dieta y se vuelven “enfermeros” para sus hijos. esta interacción con la enfermedad también les permite buscar actividades que los llevan a relajarse y a distraerse ante la situación que están viviendo. sentimientos positivos frente a la enfermedad para nosotros es un ejemplo para seguir; una niña que le aplican una droga y que se va a sentir muy mal, y que de pronto va a vomitar y de pronto quiere quedarse acostada, y se levante común y corriente. maría, ese es nuestro ejemplo de vida. no le gusta faltar al colegio, ella es feliz y eso nos fortalece a nosotros dos (3.1.1.231-236) (17). los sentimientos positivos frente a la enfermedad son todas aquellas emociones y expresiones de cariño, amor, tranquilidad, felicidad y lucha que se dan durante el proceso de la enfermedad y que facilitan la aceptación y la comprensión de la misma, de una manera más positiva. para los padres es muy importante expresar los sentimientos de amor a sus hijos. los participantes de este estudio afirmaron que la enfermedad había creado un lazo tan estrecho entre padres e hijos que sentían que por ellos debían seguir luchando. asimismo, algunos padres expresaron que el ver a sus hijos felices y motivados los ayudaba a ellos a continuar con sus vidas. durante la experiencia con la enfermedad, madres y padres tuvieron algunos momentos de euforia y felicidad en los que reconocieron sentirse muy esperanzadas(os) y contentos cada vez que obtenían un logro importante en el tratamiento del niño(a), como por ejemplo, terminar una fase del mismo, obtener buenos resultados en las pruebas de laboratorio, escuchar decir al oncólogo que su hijo(a) iba muy bien y ver la mejoría en la salud de su propio(a) hijo(a) y la de los demás niños(as). sistemas de apoyo los amigos del colegio ¡divinos!… eso eran llamadas, tarjetas, el tío la llamaba todas la noches desde miami, él es pastor, un tipazo, la llamaba y se ponía a hablar con ella y en la noche no, no… espectacular; amigas siempre ahí apoyando, acompañando… quizá no es tanto lo que se le hable a la persona sino estar ahí al lado, incondicional ¡no! (4.1.4.138-142) (17). los sistemas de apoyo tienen que ver con la ayuda, la comprensión y la presencia que brindan los amigos, familiares o el personal de salud durante el proceso de la enfermedad, de modo que facilitan la aceptación y la interacción con la enfermedad del cáncer en el niño. para los participantes, el cariño y la compañía que recibían de los amigos y familiares les brindaban la fortaleza para seguir adelante. algunos manifestaron que las amistades se hicieron más estrechas y esto facilitó el proceso de la enfermedad, ya que sentían su presencia y reconocían en ellos un apoyo constante e incondicional que les daba una voz de aliento para continuar adelante con sus vidas. 222 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 reconocer valores espirituales hay que estar muy fortalecido permitiéndose llorar, permitiéndose sentir dolor. yo creo que cuando uno permite el sentimiento y se lo entrega a dios, dios tendrá unas respuestas como las que yo tuve, "vamos a salir adelante, vamos a poder; yo estoy contigo, no te dejo sola". eso sentía de dios y de la virgen (4.1.2.67-71) (17). esta categoría hace referencia a conocer y aceptar los valores espirituales como un medio para fortalecer el alma y el espíritu durante el proceso de la enfermedad. los participantes manifestaron confiar y entregar su dolor a dios y sentir la necesidad de pedirle por sus hijos y por ellos mismos. la creencia en un ser superior les ayuda a encontrar un significado a la enfermedad y a la vida en esta situación, y despierta sentimientos de gratitud por el hijo que tienen y la alegría que ha traído a sus vidas. la fe es un mecanismo para mantener pensamientos positivos, e inspira la esperanza por parte de los padres hacia sus hijos y de los hijos hacia sus padres. esperanza esperanza al principio es una mezcla entre el miedo a perder a alguien a quien se ama y la fe en que todo saldrá bien. la esperanza frente a alguien amado enfermo es algo íntimo, emocional y que cada persona maneja según sus creencias y sus influencias. a mí la fortaleza en dios me da esperanza, a veces me dan ganas de llorar (1.1.1.10-13) (17). la esperanza es una experiencia humana, multidimensional, es una mezcla entre el temor y la fe en que todo saldrá bien. permite a los padres ver oportunidades a través del camino difícil de la enfermedad. los motiva a persistir en el esfuerzo de buscar alternativas de solución a la situación, y a la búsqueda del bienestar. cada vez que los padres pasan por momentos de angustia y desconsuelo ante la enfermedad, ven la necesidad al mismo tiempo de luchar por sus hijos y buscar un camino que facilite su recuperación. los padres retroalimentan su esperanza con el apoyo de los amigos y familiares, con la fortaleza de sus hijos y la certeza que estos tienen de ser capaces de salir adelante con la enfermedad. la esperanza permite el planteamiento de nuevas metas que redefinan el futuro y le den un significado más positivo a la enfermedad y a la vida misma, a fin de obtener la fortaleza que requieren para continuar. discusión el siguiente mapa (gráfica 1) muestra las experiencias y las etapas que los padres vivencian durante el transcurso de la enfermedad de sus hijos, y cómo cada una de ellas es un mecanismo o estrategia desde las experiencias que les permiten llegar a la esperanza y hacerla parte de sus vidas. fuente: chinchilla (17). el análisis de las categorías encontradas en este estudio muestra las experiencias que viven los padres de niños con diagnóstico de cáncer, y la importancia que adquiere la esperanza durante el proceso para poder enfrentar la enfermedad de sus hijos. el impacto emocional de un diagnóstico de cáncer se agrava por la carga de la enfermedad y los efectos secundarios del tratamiento (8). a los padres les cuesta aceptar la enfermedad y simplemente la niegan, por tanto la repuesta de estos y de cada uno de los miembros de la familia siempre se verá influenciada por la visión que la sociedad da al cáncer como aquel riesgo inminente de muerte, que implica un tratamiento que muchas veces causa fuertes dolores y cargas que al final no terminan en buenos resultados (6). durante el análisis de las entrevistas se observó que cuando se les confirma la realidad del diagnóstico de cáncer en sus hijos los padres sienten morirse, sienten que el mundo se les ha venido encima, ese no creer en nadie, y esa sensación de adormecimiento, ellos usan palabras como “choqueado” o totalmente sorprendido (7). kilicarslan-toruner y akgun-citak declararon que el impacto psicológico del cáncer infantil en los padres y los niños causa síntomas postraumáticos de estrés, depresión y ansiedad (8). el ver 223 ¿qué significa la esperanza en padres de hijos con cáncer? l tania catalina chinchilla-salcedo a su hijo enfermo llenó a los padres de sentimientos de angustia, dolor, impotencia y desesperanza, y generó en ellos síntomas de estrés y ansiedad; pero fueron estos sentimientos los que permitieron generar mecanismos para afrontar la enfermedad y llenarse de esperanza. es por ello que la esperanza se convierte en un factor importante que permite a los pacientes y sus familias ajustarse personalmente a las situaciones de pérdida, incertidumbre y sufrimiento (18). miller ha descrito la esperanza como un fenómeno humano que está acompañado por emociones y experiencias (19). durante el análisis de las categorías se observó cómo todas aquellas emociones y experiencias que los padres viven durante el proceso de la enfermedad de sus hijos los conducen a la esperanza, ya que son ellas las que les permiten redefinir sus metas en la vida y afrontar las situaciones por las cuales están pasando. mcclement y chochinou, durante el proceso de la exploración del concepto de la esperanza, describen dos atributos de la esperanza entre los que se destacan: enfocarse en el futuro y redefinir el futuro, a través de estos atributos la esperanza se define como un estado de energía mental que envuelve sensaciones de incertidumbre que están caracterizadas por una expectativa cognoscitivamente práctica, donde una meta o un resultado futuro positivo es posible. la esperanza, por tanto, es un constructo multidimensional que produce bienestar cuando se presentan los diferentes cambios de la vida; por tanto, la esperanza salva a la persona de la agonía y de la desesperación (20). kirk et al. observaron también la importancia de la esperanza en la comunicación, ya que ellas permiten dar y escuchar mensajes alentadores que incluyen la posibilidad de un milagro (21). durante el análisis de las entrevistas se observó la importancia del apoyo, la comunicación y la escucha como estrategias, por medio de las cuales los padres podían hablar sobre lo que les estaba sucediendo y, de esta manera, disminuir el estrés y la ansiedad por la situación y generar esperanza. igualmente, cabe notar que morse y penrod, en uno de sus estudios, encontraron que en pacientes con enfermedades crónicas la esperanza se centró en buscar pequeñas metas que les permitieran lograr un mejor estilo de vida de manera que tuvieran algo de independencia y lograran adaptarse a su nueva situación (10). por ello cabe resaltar que, una vez los padres han aceptado la enfermedad de sus hijos y comienzan a interactuar con ella, ven la importancia de redefinir unas nuevas metas para sus vidas y las de sus hijos, de modo que estas acciones los lleven a tener esperanza y así generar estrategias que disminuyan el estrés y los lleven a fortalecer la esperanza en lo que está por venir. miller (19) publicó de un modelo de esperanza basado en estrategias que la inspiren. en dicho modelo hace énfasis en maximizar las experiencias de la rutina diaria que pueden ser especialmente útiles al final de la vida, tales como la vivienda, el sabor de la comida hecha por los seres queridos, disfrutar de la calidez de un rayo de sol, mirar a través del cristal y observar el cielo azul, escuchar música, y la lectura de libros que pueden reforzar la belleza del momento (19). por otra parte, durante el análisis de las entrevistas se observó el papel fundamental que juegan los hijos durante el proceso de la enfermedad, ya que son ellos quienes terminan siendo inspiradores de esperanza para sus padres y, de este modo, de los padres a sus hijos. es allí donde comienza a vislumbrarse la esperanza como una experiencia multidimensional que les permite poco a poco aceptar la enfermedad e interactuar con ella de manera que puedan aprender de la misma y así redefinir el futuro y plantearse unas metas nuevas. inspirar esperanza requiere la presencia de otro ser humano que demuestre una incondicional aceptación, tolerancia y entendimiento de la enfermedad (20, 21). gracias a la esperanza los padres comienzan a ver la necesidad de aprender y conocer sobre la enfermedad. en una familia con un niño con enfermedad crónica los padres, al ser los cuidadores primarios (22), están obligados a convertirse en el centro que brinda atención, y lograr una madurez para mantener la esperanza y darle un nuevo significado a sus vidas y las de sus hijos. por otra parte, los padres vieron la importancia de compartir al máximo cada momento con sus hijos, de manera que, a pesar del cansancio o el sueño siempre estuvieran allí para ellos; una de las madres comentó que cuando se iba para la casa a descansar no veía la hora de regresar al hospital para cuidar y estar con su hija. para los padres son esenciales los valores espirituales tales como la fe, la confianza en dios y el apoyo de amigos, familiares, enfermeros y personal de la salud, que se constituyen en elementos clave que llevan a la esperanza y permiten mantenerla y ser 224 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 inspiradores de la misma. “inspirar esperanza involucra la presencia de otro ser humano que demuestre una aceptación incondicional, tolerancia y entendimiento” (9). los sueños se extienden hacia el futuro y se relacionan con verlos estudiar, casarse y tener hijos (23). mantener la esperanza como un estado incluye el tener una conexión con la familia, los amigos y cuidadores, luchar continuamente para dejar de lado los pensamientos negativos y conservar el espíritu vivo (23). conclusiones • la esperanza tiene un significado fundamental en la vida de los padres, es la luz que guía sus caminos y les permite seguir adelante dándole un significado más positivo a sus vidas y a la enfermedad; asimismo, los hijos se convierten en motivadores de esperanza. • esta investigación reconoce la importancia de la esperanza en los procesos de cuidado de enfermería y en todas aquellas áreas y profesiones en las que se trabaje con situaciones similares; además, hace un aporte significativo al permitir conocer las experiencias y las estrategias que los padres utilizan para enfrentar la enfermedad a través de la esperanza. • esta investigación hace un aporte a la salud mental al conocer los mecanismos que los padres utilizan para afrontar la enfermedad y las dificultades que en ocasiones les impiden continuar con sus vidas. recomendaciones • la esperanza se convierte en aquella herramienta fundamental en el proceso de cuidado de enfermería, que permite dar a conocer las experiencias que los padres de niños o pacientes han tenido durante el proceso de la enfermedad, y de este modo generar estrategias y mecanismos que motiven e inspiren este sentimiento. • es importante que las nuevas investigaciones vayan encaminadas a generar estrategias e intervenciones de cuidado en enfermería que inspiren y midan la esperanza en los pacientes y sus familias. • se recomienda aplicar estos conocimientos en la docencia, de manera que enriquezcan las asignaturas de cuidado y las líneas de cuidado de investigación en enfermería. • a través de situaciones de enfermería se deben discutir estrategias de cuidado basadas en la esperanza. • se recomienda trabajar el concepto de la esperanza en la práctica de enfermería, de modo que se generen diagnósticos acordes a las necesidades de los pacientes. • es necesario investigar estrategias que ayuden a inspirar esperanza en los padres y en los pacientes, no solo en el contexto del cáncer. • se exhorta a seguir estudiando e investigando la descripción del concepto de esperanza en enfermería, en otras áreas, poblaciones o situaciones que permitan con el tiempo construir una teoría de rango medio. referencias 1. castillo e, chesla c. viviendo con el cáncer de un(a) hijo(a). colombia médica 2003;34(3):155-163. 2. ferlay j, shin hr, bray f, forman d, mathers c and parkin dm. globocan 2008 v2.0, cancer incidence and mortality worldwide: iarc cancerbase no. 10 [internet]. lyon, france: international agency for research on cancer; 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c, gray b. parents dilemma: decisions concerning end-of-life care for their child. j pediatr health care 2012;26(1):29-39. 23. kylma j, juvakka t. hope in adolescents with cancer. eur oncol nurs 2009;13(3):193-199. learning needs and educational strategies for adult patients in the preoperative period of myocardial revascularization: scoping review article learning needs and educational strategies for adult patients in the preoperative period of myocardial revascularization: scoping review* necesidades de aprendizaje y estrategias educativas para pacientes adultos en preoperatorio de revascularización miocárdica: scoping review** necessidades de aprendizagem e estratégias educacionais para pacientes adultos no pré-operatório de revascularização do miocárdio: scoping review*** 10.5294/aqui.2022.22.3.7 alcides viana de lima neto 1 breno wagner araújo cosme da silva 2 vivianne lima de melo 3 josé adailton da silva 4 isabelle katherinne fernandes costa 5 1 0000-0001-6191-9465 universidade federal do rio grande do norte, brazil alcides.viana.066@ufrn.edu.br 2 0000-0001-7240-4408 universidade federal do rio grande do norte, brazil breno.araujo.072@ufrn.edu.br 3 0000-0002-6792-3462 universidade federal do rio grande do norte, brazil vivia1999@ufrn.edu.br 4 0000-0002-6037-7649 universidade federal do rio grande do norte, brazil adailton.silva@ufrn.br 5 0000-0002-1476-8702 universidade federal do rio grande do norte, brazil isabelle.fernandes@ufrn.br received: 25/08/2021 sent to peers: 24/01/2022 approved by peers: 10/03/2022 accepted: 15/03/2022 * this article derives from the dissertation entitled "mobile app para auxilio en la educación del paciente en el preoperatorio de revascularización miocárdica" submitted to the nursing graduate program at the federal university of rio grande do norte, brazil. ** artículo derivado de la tesis de doctorado titulada "mobile app para auxilio en la educación del paciente en el preoperatorio de revascularización miocárdica", presentada al programa de posgrado en enfermería de la universidade federal do rio grande do norte, brasil. *** este artigo é derivado da tese de doutorado intitulada "mobile app para auxílio na educação do paciente no pré-operatório de revascularização do miocárdio", submetida ao programa de pós-graduação em enfermagem da universidade federal do rio grande do norte, brasil. theme: evidence-based practice. contribution for the discipline: the present study may help the nursing and/or health team in planning and implementing health orientation and education programs for adult patients who will undergo coronary artery bypass graft surgery based on scientific evidence. in this way, better clinical results can be achieved after surgical intervention. para citar este artículo / to reference this article / para citar este artigo : lima neto av, silva bwac, melo vl, silva ja, costa ikf. learning needs and educational strategies for adult patients in the preoperative period of myocardial revascularization: scoping review. aquichan. 2022:22(3):e2237. doi: https://doi.org/10.5294/aqui.2022.22.3.7 abstract objective: to identify and map learning needs and educational strategies for adult patients in the preoperative period of myocardial revascularization. materials and method: scoping review conducted between march and april 2021 in national and international databases to identify records published in scientific journals and gray literature, without period. results: the selected sample consisted of 35 records, composed mostly of articles (32; 91.42 %) published from 1990 to 2021. the learning needs of patients before surgery were categorized into cardiovascular system and coronary artery disease; procedures and routines before, during, and after surgery. in addition, several educational strategies implemented in the studies were identified. conclusions: the learning needs identified can contribute to planning and implementing patient-centered educational strategies before surgery. keywords (source decs): preoperative period; patient education; myocardial revascularization; patient care team; nursing. resumen objetivo: identificar y mapear las necesidades de aprendizaje y estrategias educativas para pacientes adultos en el preoperatorio de revascularización miocárdica. materiales y método: scoping review realizada entre marzo y abril de 2021 en bases de datos nacionales e internacionales para identificar registros publicados en periódicos científicos y en la literatura gris, sin recorte temporal. resultados: la muestra se conformó de 35 registros, de los cuales 32 fueron artículos (91,42 °%) publicados entre 1990 y 2021. las necesidades de aprendizaje de los pacientes antes de la cirugía se categorizaron en sistema cardiovascular y enfermedad de las arterias coronarias; cuidados, procedimientos y rutinas antes, durante y después de la cirugía. además, se identificaron diversas estrategias educativas implementadas en los diferentes contextos de los estudios. conclusiones: las necesidades de aprendizaje identificadas pueden aportar a la planeación e implementación de estrategias educativas enfocadas en el paciente antes de la realización de la cirugía. palabras clave (fuente decs): periodo preoperatorio; educación del paciente; revascularización miocárdica; grupo de atención al paciente; enfermería. resumo objetivo: identificar e mapear as necessidades de aprendizagem e estratégias educacionais para pacientes adultos no pré-operatório de revascularização do miocárdio. materiais e método: scoping review realizada entre março e abril de 2021, em bases de dados nacionais e internacionais para identificar registros publicados em periódicos científicos e na literatura cinzenta, sem recorte temporal. resultados: a amostra selecionada foi de 35 registros, compostos, em sua maioria, de artigos (32; 91,42 °%), publicados de 1990 a 2021. as necessidades de aprendizagem dos pacientes antes da cirurgia foram categorizadas em sistema cardiovascular e doença arterial coronariana; cuidados, procedimentos e rotinas antes, durante e após a cirurgia. além disso, identificaram-se diversas estratégias educacionais implementadas nos diferentes contextos dos estudos. conclusões: as necessidades de aprendizagem identificadas podem contribuir para o planejamento e a implementação de estratégias educacionais centradas no paciente antes da realização da cirurgia. palavras-chave (fonte decs): período pré-operatório; educação do paciente; revascularização miocárdica; equipe de saúde; enfermagem. introduction cardiovascular diseases (cvd) are the leading cause of death worldwide, with an estimated 17.9 million lives each year. they represent a group of diseases of the heart and blood vessels that include coronary artery disease (cad) and other conditions (1). cad is caused by the accumulation of plaques formed by deposits of cholesterol and other substances on the walls of the coronary arteries, which provide blood to the heart and other parts of the body. this accumulation causes the interior of the arteries to narrow over time, which can partially or totally block blood flow (2). therefore, the identification of individuals at higher risk for developing diseases such as cad and the guarantee of appropriate treatment can avoid consequences such as premature deaths. therefore, access to essential medicines and health technologies is important (3). thus, among the treatments for this condition is myocardial revascularization surgery (mrs), also known as "saphenous bridge" or "breast". it is performed when drug and other alternatives are not sufficient to restore coronary blood supply, and enables proven long-term survival benefits (3,4). however, mrs can be considered a stressful event for patients due to physical factors, such as pain, and psychological factors such as anxiety, fear, and depression. this can be caused by thoughts of uncertainty about survival, the risks of complications, the environment of the intensive care unit (icu), in addition to concerns about the postoperative care process and the resumption of routine activities. therefore, the physical and mental well-being of the individual can be impaired and negatively influence the outcome of treatment and the evolution of the postoperative period (5). therefore, identifying the patient's learning needs about surgery and how he/she faces and deals with the preoperative period is an important aspect for the multidisciplinary team that assists him/her to identify risk factors. it can be done through educational activities, in which the health professional must also understand the patient's previous knowledge and follow the appropriate orientations, according to their particularities and using an accessible language. this can create and strengthen the bond, contribute to better clinical results, and reduce hospitalization time, care-related infections, and other postoperative complications (6). thus, educational interventions with resources such as images, audio and video are important facilitating tools for the multidisciplinary team. they can contribute to a better understanding of patients about their health condition and the procedures and conducts adopted in the pretransand postoperative phases of surgery, and help establish a relationship of trust and learning between the patient and the professional (5). thus, prior to the elaboration of the research protocol on this theme, a search was conducted in national and international databases. no similar study was found, which justifies the realization of this scoping review. therefore, the objective is to identify and map learning needs and educational strategies for adult patients in the preoperative period of mrs. materials and method this scoping review followed the reference proposed by the joanna briggs institute (jbi), which allows mapping the main concepts, clarifying research areas, and identifying knowledge gaps (7). for formulating the research question, the mnemonic strategy population, concept, and context were used. with this, the following were defined: population (p) — adult patients; concept (c) — learning needs and educational strategies; context (c) — preoperative care for mrs in hospitals. thus, based on these definitions, the guiding question was outlined: what learning needs and educational strategies are used preoperatively for adult patients of mrs in hospitals? for conducting the study, a protocol entitled "learning needs and educational strategies for adult patients in the preoperative period of mrs": was prepared, according to jbi recommendations. this protocol is registered and available for consultation on the open science framework (osf), through the digital object identifier system (doi): 10.17605/osf. io/2pbem, which can be accessed at: https://osf.io/2pbem/. initially, through random keywords related to the theme, a search was conducted to build a bank of terms. at this stage, we consulted the basis of the descriptors in health sciences (decs) and identified the terms in portuguese for each item of the mnemonic: p — "paciente"; c — "aprendizagem e estratégias"; c — "cuidados pré-operatórios", "unidades de terapia intensiva", "enfermarias", "unidades de cuidados coronarianos". in addition to the decs platform, the search was conducted at the cumulative index to nursing and allied health literature (cinahl) and the national library of medicine (pubmed) databases to identify the medical subject headings (mesh): p — "patient"; "patients"; "client"; "clients"; c — "patient education"; "health education"; "education"; "educational activities"; c — "preoperative period"; "perioperative care"; "myocardial revascularization"; "internal mammary artery implantation"; "coronary artery bypass"; "coronary artery surgery"; "hospital"; "intensive care unit"; "coronary care units"; "inpatients"; "hospitalization". as eligibility criteria, texts available in full, in any language, without time limits and addressing learning needs and/or educational strategies for adult patients in the preoperative period of mrs were adopted. opinion articles and texts not available in full were excluded. subsequently, with the terms, searches were conducted in pairs of scientific production, according to the eligibility criteria in march and april 2021 in the databases pubmed, cinahl, web of science, scopus, latin american and caribbean health sciences literature (lilacs), the cochrane library, and embase. the restricted databases were accessed through a resource of the federated academic community, available to students, professors, and other public workers of brazilian institutions. the grey literature consulted were the catalogue of theses and dissertations of the coordenação de aperfeiçoamento de pessoal de nível superior, the dart-europe e-theses portal, electronic theses online service, the repositório científico de acesso aberto de portugal, the national library of australia (trove), the national etd portal, the education resources information center, and theses canada. the search strategy with the mesh was used in an adapted way, according to the specific fields in each database and boolean operators: "patient" or "client" and "patient education" or "health education" or "learning needs" or "learning" or "active learning" or "educational needs assessment" and "preoperative period" or "perioperative care" and "myocardial revascularization" or "internal mammary artery implantation" or "coronary artery bypass graft surgery" or "coronary artery surgery" and "hospital" or "intensive care unit" or "coronary care units" or "inpatients" or "hospitalization". first, the titles and abstracts of the documents retrieved were read to fill out a location spreadsheet. next, these documents were analyzed in full for inclusion in the review, according to the criteria of eligibility and extraction of the data in a spreadsheet in the microsoft excel® software to create a database. the following variables were analyzed by simple descriptive statistics: type of document (article, thesis, dissertation, or other); year of publication; journal or higher education institution (heis); country of origin; language in which it was published; type of study; approach; level of evidence according to jbi classification (8); sample/participants; person responsible for the implementation of educational strategies; unit where it was implemented; period of the educational strategy; duration of the intervention; age; gender, and educational level of the participants. regarding the learning needs and educational strategies used, methods and resources, a thematic categorization was carried out. the results are made available descriptively, as charts and tables. results from the searches performed, 305,361 records were identified in the databases, of which 35 studies were included in the final sample. this process is illustrated in figure 1. figure 1. prisma flowchart of the scoping review. natal, rio grande do norte, brazil, 2021 source: own elaboration following jbi recommendations (7). the selected sample (n = 35) consists of 32 articles (91.42 %), a doctoral dissertation (2.86 %), a master's thesis (2.86 %), and an academic project (2.86 %). it has records from 1990 to 2021, whose year with the highest number was 2019, with four studies (11.43 %). the predominant countries were the united states and germany, with five studies each (14.29 %), and the most frequent language was english, with 31 records (88.57 %). regarding methodological characterization, 16 randomized clinical trials (45.70 %), 28 quantitative studies (80 %) and 16 clinical trials belonging to evidence level 1c (45.70 %) stood out. table 1 presents the detailed characterization of the studies according to journal or heis, year of publication, design of the study-approach-level of evidence and country of origin. table 1. detailed characterization of the studies analyzed according to journal or hei, year of publication, study design-approach-level of evidence and country of origin. natal, rio grande do norte, brazil, 2021 study journal or hei year study design-approach-level of evidence country of origin a1 (9) social science & medicine 1990 prospective-quantitative-3e united states of america a2 (10) journal of advanced nursing 1990 experimental-quantitative-2c united states of america a3 (11) annals of behavioral medicine 1998 experimental-quantitative-2c united states of america a4 (12) annals of internal medicine 2000 randomized clinical trial-quantitative-1c canada a5 (13) patient education and counseling 2001 narrative-qualitative review-we* united kingdom a6 (14) european heart journal 2002 randomized clinical trial-quantitative-1c united kingdom a7 (15) international association for the study of pain 2004 randomized clinical trial-quantitative-1c canada a8 (16) journal of cardiac, thoracic and vascular surgery 2005 methodological-quantitative-we* germany a9 (17) journal of cardiovascular nursing 2006 narrative-qualitative review-we* united states of america a10 (18) schmerz 2006 randomized clinical trial-quantitative-1c germany a11 (19) patient education and counseling 2007 randomized clinical trial-quantitative-1c norway a12 (20) rehabilitation 2008 longitudinal-quantitative study3e germany a13 (21) thoracic cardiovascular surgery 2009 cross-sectional-quantitative study-3e germany a14 (22) international journal of nursing terminologies and classifications 2010 cross-sectional-quantitative study-3e brazil a15 (23) pakistan journal of medical sciences 2010 quasi-experimental-quantitativestudy-2c turkey a16 (24) journal of cardiovascular nursing 2012 randomized clinical trial-quantitative-1c china a17 (25) the international journal of psychiatry in medicine 2013 retrospective-quantitative study-3e south korea a18 (26) european journal of cardiovascular nursing 2014 integrative-mixed-we review* canada a19 (27) british association of critical care nurses 2014 randomized clinical trial-quantitative-1c iran a20 (28) turkish journal of thoracic and cardiovascular surgery 2014 randomized clinical trial-quantitative-1c turkey a21 (29) european journal of cardiovascular nursing 2015 randomized clinical trial-quantitative-1c denmark a22 (30) bmj open 2016 randomized clinical trial-quantitative-1c china a23 (6) journal of clinical nursing 2017 critical literature review-qualitative-we* united kingdom a24 (31) kardiologia polska 2018 exploratory-qualitative-3e poland a25 (32) critical care nursing 2018 randomized clinical trial-quantitative-1c iran a26 (33) nursing critical care 2019 qualitative-4d case study uninformed a27 (34) arya atherosclerosis 2019 randomized clinical trial-quantitative-1c iran a28 (3) patient education and counseling 2019 randomized clinical trial-quantitative-1c iran a29 (35) journal of rehabilitation medicine 2019 randomized clinical trial-quantitative-1c denmark a30 (36) current cardiology reports 2020 narrative-qualitative review-se* germany a31 (4) complementary therapies in clinical practice 2020 randomized clinical trial-quantitative-1c india a32 (5) bmj quality & safety 2021 randomized clinical trial-quantitative-1c china d1 (37) university of kwazulu natal 2002 cross-sectional-quantitative study-3e united arab emirates t1 (38) universidade de são paulo 2007 methodological-quantitative-we* brazil p1 (39) university of maryland school of nursing 2017 methodological-quantitative-we* united states of america *we: without level of evidence according to jbi classification. source: own elaboration. the identified records that came from research with humans showed a sample variation from 1 to 745 individuals, with mean ages from 54.9 to 68.3 years, mostly men, with different levels of schooling, in the preoperative period of mrs. figure 2 presents the learning needs of patients before mrs identified, categorized into cardiovascular system and coronary artery disease; care, procedures, and routines before surgery; procedure and care during surgery; procedures and routines after surgery. figure 2. learning needs of adult patients in the preoperative period of myocardial revascularization. natal, rio grande do norte, brazil, 2021 source: own elaboration. regarding the educational strategies used, it was noticed that the majority, 21 (60 %), were performed in the patient's own ward; two studies (5.71 %) also reported having used an exclusive room for patient education; one (2.86 %) performed in wards and outpatient spaces; one (2.86 %) in wards and cardiac rehabilitation room; one (2.86 %) in the counselling room; one (2.86 %) in coronary units, and six (17.14 %) did not report the place of implementation of educational actions. as for those responsible for implementing the strategies, the participation of nurses was identified in 27 records (77.14 %); in 12 (34.29 %) the physician and seven (20 %) mentioned the health team, but did not specify which professionals. in addition, five (14.29 %) reported the involvement of psychologists; five (14.29 %) of physical therapists; three (8.57 %) did not report; two (5.71 %) of patients — peer education; two (5.71 %) of the nutritionist; one (2.86 %) of a occupational therapist; one (2.86 %) of the pharmacist; one (2.86 %) of the anesthesia technician, and one (2.86 %) of the social worker. educational interventions were implemented in certain situations early in hospitalization and/or with frequencies from one to 14 days before surgery. the duration of the activity ranged from five minutes to four hours. figure 3 presents the resources and educational strategies used divided into two categories: resources and strategies. figure 3. educational resources and strategies for patients in the preoperative period of mrs. natal, rio grande do norte, brazil, 2021 source: own elaboration. discussion most of the records that are part of the sample of this study are articles made available in english. the countries that produced the most were the united states and germany. this corroborates the idea of the important number of studies in these countries, which make them references to world science. it is also emphasized the need for the conduct of studies on the subject in all continents since cvd affects many individuals worldwide, which requires, in several situations, surgical treatment (40-45). regarding methodological quality, randomized clinical trials with a quantitative approach were highlighted. this type of study represents a high level of evidence, which can be used for decision-making and the foundation of clinical practice in cardiology by professionals who provide direct care to patients (46-48). the study sample showed a variation of age groups, with an average age greater than 54 years. this is in agreement with the fact that aging is one of the main risk factors for cad, which usually occurs in men over 55 years of age and women over 45 (34, 49-51). it was also identified in the records the predominance of men with cvd, which agrees with the epidemiology of cardiovascular diseases. the male gender is placed as a risk factor for cvd, and a higher incidence and prevalence is perceived in this group, with an important mortality (52-54). regarding the learning needs of patients in the preoperative period of mrs, the first category represents the cardiovascular system and cad with topics related to the physiology of the heart and the disease itself. thus, it agrees with the importance of the guidance provided by the multidisciplinary team to the patient on this theme since they can contribute to a better treatment + during the hospitalization period, as evidenced in international studies (4, 31, 55-57). the second category highlighted some care, procedures, and routines before surgery. in this category, reference is made to the knowledge about the hospitalization process, including the characteristics, routines, and the team involved in care. it is relevant to provide detailed information since, in several situations, it is a new context for the individual who will undergo surgery (5, 58, 59). moreover, the preparation of the patient can prolong the hospitalization time because it involves care such as the performance of several tests to better understand the profile of patients, the guarantee of the correct surgical indication, and the aid in the establishment of individual risk scores. they are important and contribute to better knowledge of each patient's case (60-62). fasting and trichotomy are also necessary for the procedure. this concerns the removal of hair in the chest, close to the radial arteries and the saphenous vein to prepare the skin of the area in which incisions will be made, according to the routines established by each service. currently, it has been recommended to perform it no more than two hours before surgery, with a specific electrical device, because it helps in infection control, a theme that was also identified in this category (63, 64). in addition, the studies cited the importance of an approach to the medications used by the patient and the administration of drugs to reduce anxiety and facilitate sleep on the eve and one hour before surgery. the drug strategy associated with psychological counseling and nursing interventions contribute to reduce the anxiety, fear, anger, and stress that can affect individuals (65, 66). this was highlighted in research conducted in china (hong kong) and germany as important to minimize the psychological mechanisms mentioned above, which can be caused by uncertainties about survival, the risk of complications, the process of illness, and the insertion of the individual in the hospital environment (5, 36). the third category comprises the procedure and care during surgery. it was related to the instruction about the proper name of the surgery, which can be rvm or saphenous or breast bridge; in addition, how it is performed and some characteristics, such as extra-corporeal circulation, complications, results, risks, prognosis, and survival rate (67, 68). it is noteworthy that the previous items should be part of the scope of preoperative orientations since the patient needs to be aware of the interventions that will be performed during the surgery (36). additionally, in the same category, the importance of information on anesthesia and post-anesthetic recovery was highlighted. in this case, the patient needs to understand that mrs requires general anesthesia, induced exclusively with intravenous drugs or a combination of inhalation agents, known as volatile agents, used during the procedure (69-71). care, procedures, and routines after surgery represented the fourth category. it includes topics related to routines and important care that need to be adopted by patients and that directly influence postoperative recovery, as well as maintaining good health and quality of life. topics such as the postoperative environment of the icu and the invasive devices used also need to be addressed since, in the vast majority of situations, they are not known and will be part of the patient's context, especially in the first hours after leaving the operating room (33, 72, 73). with regard to the experience of pain, it is known to be present since incisions are made in the thorax (sternotomy), the saphenous vein region (saphenectomy), and the places where the monitoring lines and invasive devices are inserted, such as the endotracheal tube and the thoracic tube (5, 33, 74). in this case, the individual needs to be guided on measures to relieve pain, which can be through intravenous or oral medications, usually opioids and anti-inflammatory drugs (75, 76). additionally, events such as nausea and delirium can also happen. the first, ratified in a study conducted in denmark with 310 patients, highlighted the importance of administering drugs for control (35). delirium, which can occur postoperatively in the icu, related to cognitive decline, was investigated in a recent meta-analysis that revealed prevalence in 43 % of patients up to four days, which remains high (39 %) up to one month after mrs (77). topics such as wound care, communication, recovery, physical and pulmonary rehabilitation, nutrition and weight control, and correct use of prescribed medications were also highlighted and should be part of the scope of guidance provided to patients. the preceding aims to improve the proposed treatment and the results with surgical intervention (3, 4, 33, 35). educational resources and strategies used by several professionals in the hospital environment were also identified, especially in the wards, to provide information to patients about their status, preoperative care, surgical intervention, and post-operative context. nurses, physicians, psychologists, and physiotherapists were responsible for the implementation of these actions (5, 35, 36). it is considered that, in the educational process implemented, several resources can be used to favor the learning of patients (5). the use of drawings, educational booklets with texts and images, videos, slides, audio tapes, interactive software, questionnaires, and other types of illustrations stood out as educational resources for training patients. it is known that, with the evolution of knowledge and the development of learning resources, new technologies were incorporated into this process. they help provide valid and accurate information that impacts patient education. from this, the patient will understand how actions influence their treatment and may be actively involved in their care (78). regarding educational strategies, they were implemented through verbal education, short courses, guided tours, meeting with teams and other patients, and demonstrations about surgery and care. all the resources and educational strategies identified in this review have their importance depending on the context in which they are employed and how they are used. these findings corroborate a randomized clinical trial conducted in iran, which did not show significant differences in preoperative education through the implementation of verbal orientations or other resources, but reinforced that preoperative training has benefits for the patient, such as reduced anxiety (79). limitations in the preparation of this review were the small number of data bases due to the recent restrictions in the portal made available for consultation by brazilian researchers; the inclusion of many studies with more than ten years of publication; the restricted number of languages in the records; the absence of critical analysis of the methodological quality of the studies. however, because it is a scope review, some of these limitations may be considered because it is not necessary to include extensive literature on the subject. the critical-methodological analysis of the studies is also dispensed with. conclusions the study identified that patients have several learning needs that should be considered by health professionals in planning and implementing the guidelines and care before myocardial revascularization surgery. they are related to the cardiovascular system and coronary artery disease itself; care, procedures, and routines before, during, and after surgery. therefore, the interprofessional team should implement, through various strategies, according to the available resources, educational activities that favor patient-centered teaching about their disease and the therapeutic plan to be implemented. among the strategies, conventional education can be considered through verbal orientations, courses, guided tours, meetings with staff and patients, and demonstrations about surgery and care. from this, it is possible to achieve a better patient's support to the conducts and guide the actions so that satisfactory clinical results are accomplished in the various stages of mrs surgery. based on the findings of this review, it is expected that professionals act in a way that is directed to implement educational activities based on the needs identified. in addition, we suggest conducting further studies to identify learning needs and educational strategies of patients who will undergo other types of surgeries, including different cardiac surgeries. conflict of interests: none declared. references 1. world health organization (who). cardiovascular diseases (cvds); 2017. available from: https://www.who.int/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds) 2. centers for disease control and prevention (cdc). coronary artery disease (cad); 2019. available from: https://www.cdc.gov/heartdisease/coronary_ad.htm 3. golaghaie f, esmaeili-kalantari s, sarzaeem m, rafiei f. adherence to lifestyle changes after coronary artery bypass graft: outcome of preoperative peer education. patient educ couns. 2019;102(12):2231-7. doi: https://doi.org/10.1016/j.pec.2019.07.019 4. chandrababu r, nayak bs, pai vb, n r, george ls, devi 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doi: https://doi.org/10.21675/2357-707x.2020.v11.n4.3277 79. amini k, alihossaini z, ghahremani z. randomized clinical trial comparison of the effect of verbal education and education booklet on preoperative anxiety. j perianesth nurs. 2019;34(2):289-96. doi: https://doi.org/10.1016/j.jopan.2018.06.101 home 10. reseœas (62 a 64) esta obra se refiere a la salud pública en las américas. muestra el contexto en el cual se percibe y se practica la salud pública, y expone el grado en que se cumplen las funciones esenciales para promover y preservar la salud de los colectivos; analiza la necesidad de fortalecer el ejercicio de la salud pública en las regiones, a la luz de las reformas planteadas por el sector salud y que se han concentrado en cambios estructurales, financieros y de organización. habla de los orígenes de la salud pública y los escenarios actuales, y hace un recuento histórico de cómo el hombre siempre ha buscado preservar la vida acudiendo a diferentes medios, como la comunicación con dioses o la magia, pero también muestra cómo el hombre ha evolucionado en sus conocimientos, hasta encontrar modelos nuevos para tener salud y preservar la vida como fin último. hace nuevos planteamientos sobre los conceptos de salud pública, refiriéndose a la particularidad de las personas y a las nuevas circunstancias a las que se ven enfrentadas, incluyendo a todas las personas que conforman el núcleo que debe fortalecer la salud pública. contempla las prácticas sociales como la expresión de valores, costumbres, creencias y normas adquiridas por las personas o grupos sociales, y muestra cómo las actuaciones realizadas con fines concretos, como el mejorar la salud de la población, son funciones específicas de la salud pública. se refiere a las intervenciones destinadas a mejorar la práctica de la salud pública, manejadas con una visión de conjunto e integralidad según las estrategias de acción, que nos deben llevar a una medición más acertada y real del desempeño y cumplimiento de las funciones en la salud pública; también pone de manifiesto la importancia de la evaluación del desempeño de los sistemas sociales, y especialmente de la salud, a través de instrumentos de medición con indicadores que faciliten medir el desempeño. finalmente, muestra los resultados de la medición de las funciones en las américas por regiones, contemplando a los estados unidos de américa, y presenta la forma de fortalecer con acciones las instituciones de salud, en lo que se refiere a la salud pública, teniendo en cuenta financiamiento, gastos, desarrollo de la fuerza de trabajo y la cooperación internacional. el texto está dirigido a todos los profesionales de la salud interesados en la salud pública, así como a los estudiantes de pregrado, ya que los orienta sobre la importancia de las funciones en la salud de los individuos y los colectivos. organización panamericana de la salud (ops), organización mundial de la salud (oms). 2002. blanca cecilia venegas bustos profesora asistente la salud pública en las américas nuevos conceptos, análisis del desempeño y bases para la acción 62 reseñas 63 esta segunda edición del manual de salud escolar está dirigida a todas las enfermeras, a los profesionales del área de la salud, a los profesores y padres de familia que de una u otra forma trabajan con niños, escolares y adolescentes. es una rápida referencia acerca de los principales aspectos relacionados con la infancia, ya que permite el acceso a información sobre el crecimiento y el desarrollo, problemas de salud y aspectos psicosociales actuales, que son comunes en la población infantil mundial. se involucran hallazgos actuales con relación a tecnologías diagnósticas de punta, hallazgos en fisiología –especialmente a nivel cerebral– y en genética, y nuevos desafíos para el siglo xxi, tales como problemas ergonómicos (por la utilización de morrales, computadores…), problemas sociales (pandillas...) y mentales (desórdenes bipolares, obsesivos, depresivos…), terrorismo. y se enfatiza la importancia de la promoción de las conductas saludables y la prevención de violencia y el abuso de sustancias psicoactivas, la intervención en desastres y los primeros auxilios. provee guías de cuidado –con la información necesaria para planear un adecuado cuidado de la salud–, las cuales se pueden ampliar y complementar en las diferentes referencias y direcciones web que se brindan al final de cada capítulo. en este libro, conviene resaltar que se cuenta con un capítulo (9) en el cual se pone énfasis en el cuidado del niño con necesidades especiales. en la actualidad, cuantos más niños y adultos jóvenes con discapacidades se integren a la vida comunitaria y social de forma temprana, mejor calidad de vida tendrán; por ello, desde el nacimiento, y en especial en las etapas preescolar y escolar, deben ofrecerse las condiciones óptimas para lograr su adaptación al medio. en este capítulo se incluyen procedimientos de cuidado especializados, según las necesidades de estos niños, las cuales requieren de diferentes modalidades de tratamiento y asistencia, que involucran la participación de un equipo interdisciplinario. el grupo de cuidado de la universidad nacional de colombia viene trabajando de manera permanente en la conceptualización de la esencia de la profesión, el cuidado, con un importante y valioso recorrido. el grupo ha logrado plasmar en los anteriores volúmenes (dimensiones del cuidado, 1998, y cuidado y práctica de enfermería, 2000) los resultados de este trabajo de reflexión colectiva, surgido de la experiencia de la práctica y del quehacer académico. este tercer libro, el arte y la ciencia del cuidado, 2003, se constituye en una interesante y muy valiosa recopilación de experiencias y abordajes del cuidado, con la participación de enfermeras de servicio y docentes de distintas unidades académicas del país, quienes han logrado consolidar una clara línea de investigación, fortalecida con el aporte de pares académicos nacionales e internacionales, en la estructuración y desarrollo de nuevos proyectos. en esta publicación se destaca, en el primer capítulo, la relevancia de la utilización de modelos conceptuales, y la vigencia de la aplicación de teorías de rango medio. la obra nos lleva por un interesante camino, donde temas como currículo y cuidado, cuidado en los procesos de enseñanza y aprendizaje, humanización, cotidianidad y ética, junto con la espiritualidad, discapacidad, cuidado neonatal y materno, cuidado y cuidadores y liderazgo, entre otros, aportan una interesante y valiosa recopilación de experiencias y abordajes, que enriquecerán sin duda la academia y la asistencia. el capítulo v resalta los aportes y los avances de la investigación, y señala su importancia en la búsqueda de respuestas, soluciones y alternativas a los problemas actuales derivados de la práctica de la enfermería. grupo de cuidado, facultad de enfermería, universidad nacional de colombia, editorial: unibiblos u.n. 2002. keeta destefano lewis, bonnie j. bear. editorial: saunders, segunda edición, 2002. maría clara quintero laverde profesora asociada manual of school health el arte y la ciencia del cuidado ángela hernández posada profesora asistente revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 64 pediatric nursing caring for children and their families ángela hernández posada profesora asistente nicki l. potts, barbara l. mandleco. editorial: delmar. thomson learning, 2002 este libro se constituye en un texto para estudiantes de pregrado que inician su acercamiento al cuidado de la salud del niño, con una visión holística centrada en la familia. se parte del análisis de la enfermería pediátrica en una sociedad cambiante, y se incluyen estándares de cuidado, aspectos ético-legales del ejercicio profesional, el niño en la familia, la enfermería en el contexto comunitario, el hogar y la escuela, para dar una visión acerca de los aspectos normales y las alteraciones en cada una de las funciones, tanto fisiológicas como psicosociales. provee lecturas orientadas y un acercamiento visual y atractivo, que ayuda a comprender y retener una gran cantidad de información acerca del cuidado del niño y su familia. este aspecto sigue siendo un gran desafío para el siglo xxi, puesto que muchos niños y sus familias continúan sintiendo el impacto de la pobreza, el abuso de las drogas, el abuso físico, emocional y sexual, y la violencia. todo esto sobreagregado al problema de la violencia y del terrorismo actual. a través de este texto se han incorporado resultados recientes de investigaciones basadas en la evidencia y la práctica, lo cual contribuye a dar un aporte al conocimiento en cada tópico. otro aspecto que se debe resaltar es la orientación que se da en cada capítulo, sobre las competencias que se espera que el estudiante logre, y el planteamiento de situaciones de tal manera que orienten el pensamiento crítico y reflexivo. el libro puede complementarse con un texto guía para el docente, un texto guía para el estudiante y un cd-rom tutorial, en el cual se describen, paso a paso, los procedimientos básicos para el cuidado del niño, que servirán de orientación para el estudiante. cuenta también con recursos en línea para la actualización de los temas, y presenta una amplia relación de direcciones en la web, además de las referencias bibliográficas al final de cada capítulo. 138 147 individual and group education.indd 138 aquichan issn 1657-5997 elif ünsal-avdal1 burcu arkan2 individual and group education in diabetes and outcomes 1 phd. asistant professor, izmir katip çelebi university, turkey. 2 lecturer. uludag university, turkey. recibido: 17 de julio de 2013 enviado a pares: 26 de agosto de 2013 aceptado por pares: 10 de enero de 2014 aprobado: 10 de abril de 2014 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 138-147 to reference this article / para citar este artí culo / para citar este artigo ünsal-avdal e, arkan b. individual and group education in diabetes and outcomes. aquichan 2014; 14(2): 138-147. abstract aim: the purpose of the present study in this context was to review the effect two different types of diabetes education being implemented in an actual setting had on the outcome of care (levels of knowledge, self-care agency, a1c, bmi). methods: research was carried out as a correlational and descriptive study. the sample was comprised of 391 persons. the data were collected through diabetic assesment forms, diabetes knowledge assessment forms, the self-care agency scale and a1c and bmi assessment forms. results: the results indicated the type of educational technique was able to affect levels of knowledge by 77%, self-care agency by 76%, a1c levels by 78% and the bmi by 75%. conclusions: the delivery of individual and group diabetes education, together, is perceived to be a better method of ensuring an individual’s effective self-management. key words education, diabetes mellitus, body mass index, self care, nursing (source: decs, bireme). 139 individual and group education in diabetes and outcomes l elif ünsal-avdal, burcu arkan año 14 vol. 14 nº 2 chía, colombia junio 2014 l 138-147 educación individual y grupal sobre la diabetes y sus resultados resumen objetivo: el propósito del presente estudio fue examinar los efectos de las dos técnicas de educación diabética que se estaban implementando en un entorno real sobre los resultados de la atención (los niveles de conocimiento, el manejo del auto cuidado, a1c , bmi). métodos: la investigación se llevó a cabo como un estudio correlacional y descriptivo. el muestreo fue compuesto por 391 personas. los datos se seleccionaron mediante formularios de evaluación diabética, formularios de evaluación de los conocimientos diabéticos, la escala de agencia de autocuidado y formularios de evaluación de a1c y bmi. resultados: los resultados indicaron que la modalidad de la técnica educativa fue capaz de afectar a los niveles de conocimiento en un 77 %, a la agencia de autocuidado en un 76 % , a los niveles de a1c en un 78 % y al índice de masa corporal en un 75 %. conclusión: se ve que una combinación de educación diabética individual y grupal es un mejor método para asegurar la autogestión eficaz de un individuo. palabras clave educación, diabetes mellitus, índice de masa corporal, autocuidado, enfermería (fuente: decs, bireme). 140 aquichan issn 1657-5997 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 138-147 educação individual e grupal sobre a diabete e os resultados resumo objetivo: o propósito do presente estudo foi examinar os efeitos das duas técnicas de educação diabética que estavam sendo implementadas em um ambiente real sobre os resultados do atendimento (os níveis de conhecimento, o manejo do autocuidado, a1c, bmi). métodos: a pesquisa foi realizada como um estudo correlacional e descritivo. a amostra foi composta por 391 pessoas. os dados foram selecionados mediante formulários de avaliação diabética, formulários de avaliação dos conhecimentos diabéticos, a escala de agência de autocuidado e formulários de avaliação de a1c e bmi. resultados: os resultados indicaram que a modalidade da técnica educativa foi capaz de afetar os níveis de conhecimento em 77%, a agência de autocuidado em 76%, os níveis de a1c em 78% e o índice de massa corporal em 75%. conclusão: vê-se que uma combinação de educação diabética individual e grupal é o melhor método para garantir a autogestão eficaz de um indivíduo. palavras-chave educaçao, diabetes mellitus, índice de massa corporal, autocuidado, enfermagem (fonte: decs, bireme). 141 individual and group education in diabetes and outcomes l elif ünsal-avdal, burcu arkan introduction diabetes is a disease that is becoming increasingly more prevalent (international diabetes federation, 2012; international diabetes federation, 2011). in 2002, there were approximately 171.2 million diabetics around the world and this figure is expected to double by 2030 (wild, roglic, gren & et al., 2004; international diabetes federation, 2011). because of its acute and chronic complications, diabetes is a high-cost disease, but the emergence of complications can be reduced through effective metabolic control (international diabetes federation, 2012; american diabates association, 2012). self-care refers to actions and attitudes that contribute to the maintenance of well-being and personal health and promote human development (american diabates association, 2012). diabetes self-care is essential to effective metabolic control. self-care agency is a human aptitude that involves “the ability for engaging in self-care. self-management has become a popular term for behavioral interventions, as well as for healthful behavior (american diabates association,2012). self-management education is necessary to ensure diabetes self-care (american diabates association, 2012; funnell,brown, childs & et.al., 2007). diabetes self-management serves to enable the patient to make educated decisions and otherwise supports effective self-care behavior and problem-solving. it also encourages active cooperation with the health team to improve clinical results, general health and quality of life (bilir & çağdaş, 2004). how education is delivered is important to ensuring its effectiveness. in an article, bilir refers to one of the leaders in adult education, eduard christian lindeman, who claims educational technique rather than content is of more importance (medicare program, 2012). diabetes self-management education is delivered as a program for individual education or as group education. both techniques are patient-focused. in individual education, there is one-on-one contact with the individual who has diabetes, and interaction with the specialist is intense. in group education, individuals with diabetes mellitus share their experiences and problems with one another and a problemsolving approach is implemented more effectively (bilir & çağdaş, 2004; funnell,brown, childs & et.al., 2007; american diabates association, 2012). the group technique delivers education simultaneously to greater numbers of individuals with diabetes mellitus. according to the criteria established by the international health care finance group, the number of participants in group education is defined as no less than two (2) and 20 at the most. it also saysone group education session is the equivalent of ten individual education sessions (rickheim, weaver, flader & et al., 2002). for this reason, group education is more cost-effective (norris, engelgau, narayan, 2001; zrebiec, 2003). many studies have been conducted on diabetes education techniques. however, their results differ and the most effective education methodology has yet to be defined. most of the research in this field consists of experimental, randomized controlled studies. the results of a study that defines an actual implementation setting may be useful to the evaluation of other results. background this is especially true for the management of chronic conditions. diabetes self-management education is delivered as a program for individual education or as group education. today, the tendency toward group education has increased due to its costeffectiveness. according to the literature, results attained subsequent to individual and group education have been measured and compared and meta-analysis and reviews have been conducted in this context (norris, lau, smith & et al., 2002; mensing & norris, 2003; mannucci, pala & rotella, 2005; deakin, mcshane, cade & et al., 2005; uttech, 2006; kulzer hermanns, reinecker & et al., 2007; jarvinen, juurinen, alvarsson & et al., 2007; funnell, brown, childs et.al., 2007; international diabetes federation, 2011). in 2001, norris et al. performed a systematic review of randomized control trials and compared the results of individual and group education (norris, lau & smith, 2002). their studies revealed the teaching of lifestyles and skills was effective in both individual and group education. they also showed the methodology used in some group work was weak, and the recommendation was that more research should be conducted in this area. norris et al. worked on the same subject again in 2002, conducting a meta-analysis of studies on the effectiveness of diabetes education that were published during 1980-1999 (mensing & norris, 2003). the results of their meta-analysis showed there was no significant difference between the effects of group and individual education on glycemic control. in 2003, mensing and norris reviewed the work that had been done in 1985-1996 on the effectiveness and implementation of group education (deakin, mcshane, cade & et al., 2005). the results of mensing and norris’s (2003) review indicated quality literature on the effectiveness of individual versus group 142 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 education was inadequate. they stated the characteristics of both the patient and the educator could affect results, the best format for education had yet to be defined, and both methods had advantages and disadvantages. again, the recommendation was that more quality studies should be carried out in this area. deakin et al. (2005), in their 2005 meta-analysis , found group education was effective in improving knowledge levels, fasting blood glucose levels, a1c, blood pressure and drug dependency in patients with type 2 diabetes mellitus (mannucci, pala & rotella, 2005). other studies also have displayed differing results. the research results reported by mannuchi et al. showed a statistically significant improvement in alc levels and quality of life in individuals with type 1 diabetes who had received interactive group education, compared to patients who had experienced no group interaction (kulzer, hermanns, reinecker & et al., 2007). kulzer also found group education to be more effective than individual education (uttech, 2006). on the other hand, uttech found, in his thesis, that group education had no effect on self-sufficiency, while jarvinen et al. reported similar effects on glycemic control and treatment satisfaction through individual and group education in patients with type 2 diabetes mellitus who were just starting an insulin regime (jarvinen, juurinen, alvarsson & et al., 2007; international diabetes federation, 2011). the purpose of the present study, in this context, was to review the effects two different types of diabetes education being implemented in an actual setting had on the results of care (levels of knowledge, self-care agency, a1c, bmi). material and methods design this descriptive study was conducted at the endocrinology polyclinics of two university hospitals in izmir, turkey. participants and setting this study was conducted at the endocrinology polyclinics of two university hospitals in izmir, turkey. both polyclinics work from 8:00 a.m. to 5:00 p.m., four days a week, and individuals with diabetes are invited for a checkup and diabetes education every three months. the polyclinics are furnished with diabetes education centers managed by diabetes nurses. newly diagnosed patients with diabetes mellitus are referred to diabetes nurses. the nurses carry out individual education sessions in accordance with adult education principles and ada (2012) criteria, so as to ensure the self-management of individuals with diabetes. in addition, group education sessions are planned and implemented every wednesday. individual education is repeated two to three times, depending on the patient’s needs , and the patient is encouraged to participate in the group sessions on wednesdays. group education takes place with about 15-20 patients, although this number is sometimes higher. in the group sessions, specialists (nurses, doctors, dieticians) impart diabetes education answer patients’ questions, share experiences and formulate plans for the next group session. however, in spite of this guidance, some patients attend group or individual sessions only sporadically. no more than approximately one third of the patients regularly attend both individual and group education sessions. the sample for the research included 391 persons between the ages of 19 and 65 who went to the polyclinics (department of a hospital at which outpatients are treated) for routine checkups during the period from january to june 2010, who had been diagnosed with diabetes at least six months before, who consented to volunteering for the study and who had received diabetes education previously. since patients usually come to the polyclinics for a checkup every three months, the data collection period for both hospitals was defined as three months for each hospital. data collection this study featured one-time data collection and post-assessment. the data were collected by the researchers during a face-to-face interview in the waiting room, before the patient was called in to see the doctor. the a1c value is average blood glucose control for the past three (3) months; the bmi value is current. the diabetic’s a1c and bmi values were obtained from the medical files. measures the data for the research were collected using diabetic assesment forms, diabetes knowledge assessment forms, the self-care agency scale and a1c and bmi assessment forms. the diabetes 143 individual and group education in diabetes and outcomes l elif ünsal-avdal, burcu arkan knowledge assessment form was created by the researchers on the basis of the relevant literature (american association of clinical endocrinologists guideline, 2012; international diabetes federation, 2012). the form was prepared separately for individuals with type 1 and type 2 diabetes mellitus, and contained questions to assess knowledge about diabetes in general, nutrition, exercise, treatment and monitoring. the high total points recorded in the diabetes knowledge assessment form showed the individual with diabetes mellitus has adequate knowledge concerning the disease. the cronbach alpha coefficient defining reliability of the responses to the questions and homogeneity within the items was found to be 0.88. the self-care agency scale developed by kearney and fleisher is made up of 43 items (kearney & fleisher, 1979). it was adapted to the turkish population by nahcıvan in 1993 (nahcivan,1993); the items were reduced to 35, with the kuder-richardson 20 reliability coefficient calculated as 0.92 (nahcivan,1993). pınar, too, worked on the validity and reliability of the scale for chronic diseases in 1996 and item 7 was extracted as a result, because its correlational value was found to be inadequate. the scale was implemented on the basis of 34 items; its cronbach alpha coefficient was calculated as 0.89 (national institute for clinical excellence, 2012). in the present study, the 34-item scale was used and the cronbach alpha reliability coefficient was found to be 0.97. a high level of total points on the self-care agency scale indicates the individual with diabetes mellitus is adequately able to act independently in self-management. analysis in this correlational and descriptive study, the spss 16.00 statical programme was used and the chi-square test was applied to determine whether there were differences between the three groups in terms of descriptive characteristics. variance analysis was used to assess the effect of the mode of diabetes education on the level of knowledge, self-care agency, a1c and bmi. tukey’s hsd test was applied to determine which variable was responsible for the effect. the degree to which the variables influenced the results was evaluated through multiple regression analysis. the reliability interval used in the evaluation of the results was 95%. there was no difference in the outcomes according to the different types of diabetes. ethical considerations the consent form was approved and official written permission was obtained for the study from the dokuz eylül university ethics committees and the aegean university hospital ethics committees. the patients who agreed to participate after being informed by the researchers of the purpose and methodology of the study were given a consent form to sign and asked to respond to the questions in the questionnaire. results the corelational, descriptive characteristics of the study population comprising the sample; namely, age, gender, diabetes type, education, duration of diabetes (years) and the type of diabetes education the patient had received, are summarized in table 1. out of the 391 diabetics in the sample, it was found that 140 (35.8%) had received individual education, 51 (13.04%) had received group education and 200 (51.1%) had attended both individual and group education sessions. these results show us that increasing a patient’s educational level also increases his/ her commitment to diabetes education. the descriptive characteristics of these subjects did not differ significantly according to the three types of education (p>0.05). the study population’s diabetes knowledge, a1c, bmi and self-care agency values are shown in table 2, according to the type of education received. the values for level of knowledge, a1c, bmi and self-care agency differed according to the type of education received. this difference proved to be be statistically significant (p=0.021, knowledge; p=0.000, self care agency, a1c and bmi). using the turkish hsd test, it was found the difference stemmed from the group sessions;those receiving group education had lower values for knowledge and self-care agency,a1c and bmi compared to the other two groups. the degree to which education type influences knowledge, a1c, bmi and self-care agency is shown in table 3. the multiple regression analysis carried out to determine the degree of influence demonstratedthe method of education was able to affect the level of knowledge by 77%, self-care agency by 76%, a1c by 78% and bmi by 75% (r2: 0.77, r2 :0.76, r2 : 0.78, r2 : 0.75). discussion this study showed the patients who received group education had lower values for diabetes knowledge, a1c, bmi and self-care 144 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 table 1. distribution of the patients’ descriptive characteristics, by diabetes education type (n:391) characteristic individual (n=140) group (n=51) individual+group (n=200) significance (p) n % n % n % age 30-40 39 27.9 11 21.6 40 20.0 0.113 >.05 41-50 29 20.7 13 25.5 48 24.0 51-60 52 37.1 15 29.4 79 39.5 61 and ↑ 20 14.3 12 23.5 33 16.5 gender female 75 53.6 26 51.0 101 50.5 0.221 >.05 male 65 46.4 25 49.0 99 49.5 diabetes type type 1 dm 65 46.4 22 43.1 90 45.0 0.213 >.05 type 2 dm 75 53.6 29 56.9 110 55.0 education illiterate 11 7.9 4 7.9 13 6.5 0.321 >.05 literate 29 20.7 5 9.8 27 13.5 elementary 20 14.3 5 9.8 20 10.0 middle 22 15.7 10 19.6 44 22.0 school high school 23 16.4 10 9.6 47 23.5 0.311 >.05 college 35 25.0 17 33.3 49 24.5 duration of diabetes 1-5 years 20 14.4 6 11.7 46 23.0 0.301 >.05 6-10 years 42 30.0 18 35.3 50 25.0 11-15 years 23 16.4 10 19.6 42 21.0 16-20 years 31 22.1 8 15.7 35 17.5 21 years and ↑ 24 17.1 9 17.7 27 13.5 agency than the other two groups, while the patients who had received both individual and group education had the highest values. in other words, it can be said that group education alone was inadequate and individual education by itself was also less effective than both individual and group education combined. in studies where the type of education was analyzed in the literature, two outcomes were reported. either the effects of individual and group education on final results have been found to be similar, or group education has been determined as being comparatively more effective. in three back-to-back reviews, it was 145 individual and group education in diabetes and outcomes l elif ünsal-avdal, burcu arkan table 2. influence of diabetes education type on outcomes (n: 391) table 3. degree of influence of diabetes education type on outcomes (n:391) individual (n:140) − x ± ss group (n:51) − x ± ss individual+group (n:200) − x ± ss p knowledge 70.9±10.2 63±9.4 77.4±11.2 < 0.021 self-care agency 101.4± 5.4 85.8±3.7 101.6±4.1 < 0.000 a1c 6.3±0.3 7.8±0.3 6.1± 0.3 < 0.000 bmi 26.4±1.9 29.0±2.5 25.9±3.2 < 0.000 knowledge self-care a1c bmi p r2 p r2 p r2 p r2 individual .004 .002 .000 .001 group .000 0.77 .001 0.76 .001 0.78 .012 0.75 individual+group .000 .001 .002 .003 stated that both individual and group education were effective in teaching lifestyle changes and skills and in ensuring glycemic control, but that each method has its own advantages and disadvantages (norris, lau, smith & et al., 2002; mensing & norris, 2003; funnell, brown, childs& et.al., 2007). in one review, group education was found to be more effective (mannucci, pala & rotella, 2005). in addition to these reviews, studies conducted in later years also show group education is either more effective compared to an individual approach or the effects of individual and group sessions on results are similar (uttech, 2006; kulzer, hermanns, reinecker & et al., 2007; international diabetes federation, 2012). however, the result obtained in our study is different from the literature and is to the disadvantage of group education. our study determined group education was less effective than individual education in improving the outcome for individuals with diabetes. only uttech’s study refers to a result that is similar to ours. uttech stated group education has no influence on self-adequacy (jarvinen, juurinen, alvarsson & et al., 2007). the reason for this may be the difference in research methodologies. all the studies comparing the effects of diabetes education methods on outcomes are experimental and most focus on the effectiveness of group education versus individual education. among these studies, ours is the only one that is not experimental. the study carried out in this case took place at two centers where both individual and group education were being delivered to patients in an effort to develop self-management skills in persons with diabetes. group education at these centers sometimes involved groups of more than 20 patients. this may have been a factor in reducing the effectiveness of group education. however, our study showedthe effectiveness of both individual and group education was decidedly more pronounced compared to individual or group educationby itself. this leads one to think that individual and group education support and complement each other. the fact that the patient in an individual session is able to express him/herself more freely, understand better what the health professional is teaching and reach an effective outcome may lead to an awareness at the individual level that facilitates a more effective response in group education. at the same time, the theory of adult learning should not be overlooked (baumgartner, lee, birden & et al., 2003). according 146 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 to that theory, an adult learns whenthere is a need to learn, problem-solving is more important than content, every individual’s style of learning is different, and planning and evaluation must be carried out effectively (american association of clinical endocrinologists guideline, 2012). the theory suggests that perhaps patients should be given a choice of more than one learning environment to meet their learning needs. the continuity of education is also an important factor in bringing about changes in knowledge and behavior (pınar,1999; national institute for clinical excellence, 2012). in our study, we were not able to learn how many individual and group sessions each patient had attended. were this possible, the fact that diabetic patients receiving both individual and group education had better outcomes could have been tied to their having attended a greater number of individual or group sessions. not being able to clarify this point was a weakness in our study. however, the data collected are supported by the guide published by the national institute for clinical excellence, in which it is emphasized that a combination of individual and group education has a positive effect on patient results (baumgartner, lee, birden & et al.,2003). the ada 2012 guidebook also supports this view (american diabates association, 2012). conclusion at the end of this study, it was established that individual or group education was not sufficient, by itself, to improve the outcome for a person with diabetes. according to the research results, the recommendation might be to have every patient diagnosed with diabetes attend individual and group education sessions. nurses can use both individual and group education to get the best results at clinics. it might be appropriate to conduct studies on education methods, outcomes and cost at the place of implementation, while continuing with experimental studies relevance to clinical practice: diabetes education is effective when it comes to improving clinical outcomes, at least in the shortterm. individual and group diabetes education is a guide for diabetes nurses at clincs. this education could make it easier for nurses in clinical situations to follow-up on patients with diabetes. limitations of the study: one limitation obeys the fact that dataon the patients who were excluded from the sample could not be reviewed due to a lack of information in their files. conflict of interest the authors stated no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. references 1. american association of clinical endocrinologists guideline (aace, 2012). (access: 25.03.2013). available at: http:// www.aace.com 2. american diabates association (ada,2012). standarts of medical care in diabetes. http://www.diabetes org (access: 25.03.2013). 3. baumgartner lm, lee my, birden s, et al. (2003). adult learning theory: a primer information series, center on education and training for employment. ohio stateuniversity. eric publications. (access: 25.03.2013). available at: http:// www. cete.org/acve/docs/theory.pdf 4. bilir m, & çağdaş y. (2004). yetişkin eğitimi liderlerinden eduard christian lindeman yaşamı, eğitim görüşü ve hizmetleri. ankara university. journal of faculty of educational sciences, 37: 15-25. (in turkish). 5. deakin t, mcshane c, cade je, et al. (2005). group based self-management education in adults with type 2 diabetes mellitus (review). cochrane database systematic review, 2. 6. funnell mm, brown tl, childs bp, haas lb, hosey gm, jensen b, maryniuk m, peyrot m, piette jd, reader d, siminerio lm, weinger k, & weiss ma. (2007). national standards for diabetes self-management education. diabetes care, 30: 1630–1637. 147 individual and group education in diabetes and outcomes l elif ünsal-avdal, burcu arkan 7. international diabetes federation (idf, 2012). clinical guidelines task force. global gudeline for type 2 diabetes. brussels: international diabetes federation. (access: 25.03.2013). available at: http://www.idf.org/webdata/docs/idf%20 ggt2d.pdf 8. international diabetes federation diabetes atlas. (2011). global estimates of the prevalence of diabetes for 2011 and 2030. diabetes res clin prac, dec; 94(3):311-21. 9. jarvinen hy, juurinen l, alvarsson m, et al. (2007).initiate insulin by aggressive titration and education (initiate): a randomized study to compare initiation of insulin combination therapy in type 2 diabetic patients individually and in groups. diabetes care, 30: 1364-1369. 10. kearney by, & fleisher bj. (1979). development of an instrument to measure exercise of self-care agency. res. nurs health, 22: 25-34. 11. kulzer b, hermanns n, reinecker h, et al. (2007). effects of self-management training in type 2 diabetes: a randomized, prospective trial. diabetic medicine, 24: 415-423. 12. mannucci e, pala l, & rotella cm. (2005). long-term interactive group education for type 1 diabetic patients. acta diabetologia, 42: 1–6. 13. medicare program. (2012). health care finance administration, rules and regulations. federal register, 65: 83129–83154. 14. mensing cr, & norris sl. (2003). group education in diabetes: effectiveness and implementation. diabetes spectrum,16: 96-103. 15. nahcivan n. (1993). sağlıklı gençlerde özbakım gücü ve aile ortamının etkileri. doctorate thesis, i̇stanbul üniversitesi, 64-66. (in turkish). 16. national institute for clinical excellence (nice, 2012). guidance on the use of patienteducation models for diabetes. (access: 25.03.2013). available at: http://www.formulary.cht.nhs.uk/guidelines/nice/060_pt_ed_diabetes.htm 17. norris sl, engelgau mm, narayan kmv. (2001). effectiveness of self-management training in type 2 diabetes: a systematic review of randomized control trials. diabetes care, 24: 561–587. 18. norris sl, lau j, smith sj, et al. (2002). self-management education for adults with type 2 diabetes: a meta-analysis of the effect on glycemic control. diabetes care, 25: 11591171. 19. pınar r. (1999). diabetes mellituslu hastalarda özbakım gücü ve özbakım gücünü etkileyen sosyodemografik faktörlerin incelenmesi. türk diyabet yıllığı,11: 1248-2579. (in turkish). 20. rickheim pl, weaver tw, flader jl, et al.(2002). assessment of group versus individual diabetes education. diabetes care, 25: 269–274. 21. uttech cj. (2006) (counseler: edelstein, jan). survey of diabetes self-efficacy for individuals newly diagnosed with type two diabetes before and after empowerment group education. marian college of fond du lac, aat 1440799.68. (access: 25.03.2013). available at: http://proquest.umi.com/pqdweb 22. wild s, roglic g, gren a, et al. (2004). global prevalence of diabetes estimates for the year 2000 and projections for 2030. diabetes care, 27: 1047-1053. 23. zrebiec j. (2003). tips for running a successful group. diabetes spectrum, 16:108–110. 433 441 consecuencias de una muerte materna.indd 433 doris rodríguez-leal1 josé verdú2 consecuencias de una muerte materna en la familia 1 doctora en salud pública. universidad del tolima, colombia. drodigu@ut.edu.co 2 doctor en salud pública. universidad de alicante, españa. pepe.verdu@ua.es recibido: 22 de agosto de 2012 enviado a pares: 22 de octubre de 2012 aceptado por pares: 27 de agosto de 2013 aprobado: 27 de agosto de 2013 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 433-441 para citar este artículo / to reference this article / para citar este artigo rodrí guez-leal, d., verdú , j. (2013). consecuencias de una muerte materna en la familia. aquichan. vol. 13, no. 3, 433-441. resumen objetivo: identificar y analizar las publicaciones que traten sobre las repercusiones o consecuencias de una muerte materna en la familia. método: revisión sistemática de publicaciones de investigaciones cualitativas y cuantitativas en revistas indexadas de bases de datos biomédicas en los idiomas inglés, portugués y español. resultados: de las siete publicaciones incluidas tres usan metodología cualitativa, dos cuantitativa y dos cualicuantitativa, con procedencias de los continentes europeo y americano. en el total de los artículos revisados participaron 439 familias de mujeres fallecidas y se realizaron dos reconstrucciones históricas a partir de los registros familiares de dos poblaciones. las consecuencias de una muerte materna son de tal dimensión que repercuten durante mucho tiempo, tanto en la familia como en la comunidad misma. al analizar los hallazgos encontramos problemas en común como son: el duelo, la supervivencia de los hijos, la reconstitución de los hogares. conclusiones: aunque son escasos los trabajos que identifican y cuantifican las consecuencias familiares de una muerte materna y su análisis se restringe a algunos estudios cualitativos, estas producen un impacto negativo en la estructura y dinámica familiar, así como el aumento en la morbi-mortalidad infantil. palabras clave mortalidad materna, familia, relaciones familiares, pesar, enfermería. (fuente decs, bireme). consequences of maternal death in the family abstract objective: identify and analyze publications that deal with the implications or consequences of maternal death in the family. method: a systematic review of qualitative and quantitative research published in journals indexed by biomedical databases in english, portuguese and spanish. results: three of the seven publications included in the study use a qualitative method, two rely on a quantitative method, and two feature a quali-quantitative method, with provenances on the european and american continents. in total, 439 families of deceased women participated in the articles that were reviewed, and two historical reconstructions were done on the basis 434 aquichan issn 1657-5997 of family records of two populations. the dimensions of the consequences of maternal death are such that the impact on both the family and in the community lasts for a long time. in analyzing the findings, the authors found common problems such as grief, the survival of children and reconstruction of the household. conclusions: although not many studies have been done to identify and quantify the family consequences of maternal death and their analysis is restricted to a few qualitative studies, these consequences have a negative impact on family structure and dynamics, and contribute to an increase in child morbidity and mortality. key words maternal mortality, family, family relations, grief, nursing. (source: decs, bireme). consequências de uma morte materna na família resumo objetivo: identificar e analisar as publicações que tratam das repercussões ou consequências de uma morte materna na família. metodologia: revisão sistemática de publicações de pesquisas qualitativas e quantitativas em revistas indexadas de bases de dados biomédicas nos idiomas inglês, português e espanhol. resultados: das sete publicações incluídas, três usam metodologia qualitativa, duas quantitativa e duas qualiquantitativa, com procedências dos continentes europeu e americano. no total dos artigos revisados, participaram 439 famílias de mulheres falecidas e realizaram-se duas reconstruções históricas a partir dos registros familiares de duas populações. as consequências de uma morte materna são de tal dimensão que repercutem durante muito tempo tanto na família quanto na comunidade em si. ao analisar as descobertas, encontramos problemas em comum como: o luto, a sobrevivência dos filhos, a reconstituição dos lares. conclusões: embora sejam escassos os trabalhos que identificam e quantificam as consequências familiares de uma morte materna e sua análise se restrinja a alguns estudos qualitativos, estas produzem um impacto negativo na estrutura e dinâmica familiar, bem como o aumento na morbimortalidade infantil. palavras-chave mortalidade materna, família, relações familiares, pesar, enfermagen. (fonte: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 433-441 435 consecuencias de una muerte materna en la familia l doris rodríguez-leal, josé verdú introducción a pesar de ser la maternidad uno de los acontecimientos más importantes en la vida de la mujer, se considera uno de los más riesgosos, si las condiciones sanitarias y sociales de apoyo relacionadas con la gestación, el parto y el puerperio no son las apropiadas. anualmente en el mundo por lo menos 20 millones de mujeres presentan complicaciones agudas durante la gestación, de las cuales 529.000 terminan en muertes maternas (1) asociadas al embarazo, parto y puerperio. una muerte materna es el producto final de la correlación de múltiples factores interactuantes; por tal razón, la mortalidad materna es considerada un indicador sensible para describir la calidad de los servicios de salud de las regiones y localidades. mientras la mortalidad infantil y las tasas de fertilidad han disminuido en décadas recientes, y la expectativa de vida al nacer se ha incrementado, la mortalidad materna en los países en vía de desarrollo no ha mostrado mayor reducción en el mismo periodo de tiempo (2), con altos índices de mortalidad materna en las regiones menos desarrolladas como áfrica, seguida de asia, latinoamérica y, por último, las regiones desarrolladas (3). aunque la mayoría de muertes maternas ocurre en países en desarrollo, esto no significa que solo las mujeres de estos países sufren complicaciones médicas durante o después del embarazo (4). cada muerte materno-fetal constituye un problema de salud pública y social que se agrava en nuestro contexto por la carencia de oportunidades, la desigualdad económica, educativa, legal o familiar de la mujer y, dentro del componente asistencial, el acceso, la oportunidad y la calidad de los servicios de salud (5). la prevención de las muertes maternas se reconoce actualmente como prioridad internacional y muchos países se han comprometido a mejorar y ampliar los servicios de salud materna. la conferencia internacional sobre la población y el desarrollo (1994) y la cuarta conferencia mundial sobre la mujer (1995) establecieron la reducción de la mortalidad materna en 50 % para el año 2000 como objetivo principal y reafirmaron la importancia de monitorear el progreso. más recientemente, las naciones unidas, en la cumbre del milenio (2000), instaron a la comunidad internacional a reducir la mortalidad materna en 75 % para el año 2015, frente a los niveles de 1990. para américa latina y el caribe, la 26ª conferencia sanitaria panamericana adoptó una meta a mediano plazo para reducir la mortalidad materna a menos de 100 defunciones maternas por 100.000 nacidos vivos (6). los objetivos de desarrollo del milenio (odm) han dado a la salud materna un lugar central, por consiguiente, las altas metas acordadas por los jefes de los estados miembros en 2000 ofrecen la oportunidad para renovar y redoblar los esfuerzos por mejorar la salud de la madre y el recién nacido (7). la décima revisión de la clasificación internacional de enfermedades (cie-10) (8) define la defunción materna como la muerte de una mujer mientras está embarazada o dentro de los 42 días siguientes a la terminación del embarazo, independientemente de la duración y el sitio de la gestación, debida a cualquier causa relacionada con o agravada por el embarazo mismo o su atención, pero no por causas accidentales o incidentales. las defunciones maternas pueden subdividirse en dos grupos: las defunciones obstétricas directas y las obstétricas indirectas. entre las principales causas directas de la muerte materna se encuentran las hemorragias graves, los abortos en condiciones inadecuadas, las infecciones, la eclampsia y el parto obstruido. las causas indirectas incluyen anemia, paludismo, enfermedades coronarias y vih. las complicaciones durante el embarazo son la principal causa de muerte en las mujeres de 15 a 19 años de edad (9). la muerte de una mujer y el deterioro de su salud tienen consecuencias graves para el bienestar de la familia y la comunidad. todo esto teniendo en cuenta que se encuentra no solo en edad reproductiva, sino que además está en edad productiva, son las creadoras de la nueva vida y las que cuidan de la vida diaria, ayudan a la formación y educación de sus hijos, laboran dentro y fuera de sus viviendas y se constituyen en muchos casos en la columna vertebral de sus hogares. la familia constituye para el individuo fuente de amor, satisfacción, bienestar y apoyo, pero también se puede convertir en fuente de insatisfacción, malestar, estrés y enfermedad. las alteraciones de la vida familiar pueden provocar variación emocional, desequilibrio y descompensación del estado de salud. la vivencia de problemas familiares precipita respuestas de estrés, entre las cuales se encuentra el inicio de enfermedades crónicas o alteraciones de estas (10). materiales y métodos se realizó una revisión sistemática de la literatura científica que tuvo como pregunta de investigación: ¿cuál es el impacto familiar de una muerte materna? año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 433-441 436 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 como estrategia de búsqueda primaria se utilizaron los descriptores de los tesauros de las bases de datos —descriptores en ciencias de la salud (decs) en las bases de datos iberoamericanas y medical subject headings (mesh) en las bases de datos en inglés—. por tanto, las bases de datos biomédicas consultadas fueron: medline (a través de pubmed), cochrane, lilacs, ibecs y cuiden, durante los meses de febrero a abril de 2010. no se acotó por año de publicación. solo se tuvieron en cuenta los artículos que hacían referencia a humanos. se usaron los siguientes descriptores: “mortalidad materna” (maternal mortality) y “familia” (family) unidos entre sí mediante matemática boleana “and”, quedando como ecuación final: “maternal mortality”[major]and“family”[major]. la búsqueda incluyó las publicaciones de investigaciones cualitativas y cuantitativas en revistas indexadas de bases de datos en inglés, portugués y español. se incluyeron investigaciones originales, sin tener en cuenta el tipo de diseño, cuyos resultados mostraran el impacto o las consecuencias de una muerte materna en la familia. se excluyeron artículos cuyos resultados no hicieran referencia a la pregunta, así como las revisiones y aquellos artículos que no contenían abstract o eran resúmenes de congresos. como estrategia de búsqueda secundaria se revisaron las referencias contenidas en los artículos seleccionados y si se encontraban artículos relevantes que no estaban contenidos dentro de la búsqueda inicial, eran incluidos en la lista de estudios para revisión. no se realizó búsqueda de literatura gris. la selección de datos de los estudios escogidos se llevó a cabo mediante una tabla ad hoc en la que se registró la información más importante como: autor, año, país, objetivo general, diseño metodológico, resultados y conclusiones. luego se eliminaron aquellos artículos repetidos. posteriormente, dos investigadores en forma independiente revisaron los títulos y resúmenes para seleccionar aquellos que cumplían con los criterios de elegibilidad propuestos. las publicaciones seleccionadas fueron revisadas a texto completo, verificándose nuevamente si cumplían con los criterios de selección. finalmente se analizó el impacto o las consecuencias a nivel familiar de una muerte materna, donde se describen los resultados y principales conclusiones de cada uno de los estudios incluidos. resultados los resultados de la búsqueda se encuentran reflejados en la figura 1. figura 1. flujograma de la revisión sistemática de las siete publicaciones incluidas, tres usan metodología cualitativa, dos cuantitativa y dos cuali-cuantitativa, procedentes de europa y america, lo que indica la utilidad de investigar en la temática. dichos estudios fueron realizados por médicos y enfermeras, lo que permite ampliar el abordaje de estos y realizar una intervención interdisciplinaria. en el total de los artículos revisados participaron 439 familias de las mujeres fallecidas y se realizaron dos reconstrucciones históricas a partir de los registros familiares de dos poblaciones. a pesar del reducido número de artículos encontrados, la mayoría de estos estudios confirman y evidencian la grave realidad relacionada con la accesibilidad cultural y física a la atención de salud en la mujer embarazada, agravada en algunos casos por la 437 consecuencias de una muerte materna en la familia l doris rodríguez-leal, josé verdú calidad deficiente del cuidado prenatal de las mujeres que llegan a ser atendidas, lo que incrementa la probabilidad de la morbimortalidad de dichas mujeres y las consecuencias sobre sus hijos. en cuanto a los resultados de los estudios, pelloso y guarino (11) consideran que a pesar del tiempo transcurrido desde la muerte de la mujer, los sentimientos por parte de los viudos siguen siendo los mismos: dolor, soledad, falta, reflejados en el llanto, la desesperación y la angustia en el momento de la entrevista. para las familias, el dolor de la pérdida viene cargado de sentimientos de confusión y de la constatación de la desigualdad y el abandono de la atención. se sienten dejados de lado, incomprendidos e impotentes ante la injusticia. sus palabras reflejan una falta de humanismo por parte de las instituciones de salud; asimismo, sienten dudas acerca de la formación de los profesionales de salud, reconociendo que dichos profesionales tienen que estar preparados para dar una atención eficaz y humana a la gestante. en el estudio de azevedo et al. (12) se señala que la muerte de una joven mujer en el parto o poco después es trágica para todos: familia, profesionales de la salud y la sociedad. la pérdida relativa es irremediable, sobre todo cuando la supervivencia de los niños está relacionada con la de la madre. la muerte de una joven madre produce alteración en la estructura y la dinámica familiar; la familia debe impedir la desintegración debido a una muerte prematura y evitable. dicha muerte genera, también, una pérdida económica para su familia porque la mujer es un miembro activo en el esquema de producción y financiero familiar. en el estudio realizado por reyes et al. (13) concluyeron que el 58 % de las mujeres que fallecieron tenían una capacidad de respuesta a emergencias limitada (regular o inadecuada), en función de la capacidad de las mujeres para reconocer, aceptar y tomar acciones ante una urgencia. en cuanto a las repercusiones familiares, los integrantes de las familias que cambiaron de actividades con mayor frecuencia fueron los hijos de la mujer que falleció, de igual manera las repercusiones afectivas se observaron en ellos. los padres o suegros de la mujer fueron las personas que se ocuparon del hogar y de los niños con mayor frecuencia, esto evidentemente altera la dinámica de su familia original por cambios en los integrantes, en los roles y en la capacidad económica. el estudio realizado por ramírez et al. (14) concluye que además de la fragmentación de la familia, la mortalidad materna produjo impacto físico, psicológico, espiritual y social mayor en los 50 huérfanos. respecto a la migración de las familias de las fallecidas es evidente la evolución de la familia nuclear hacia la familia extendida. dicha población está en una franca desventaja porque la madre era el eje del hogar y su muerte biológica se convierte en una muerte social y de la familia, pues se pierde la integración familiar. en el estudio de willführ (15) el impacto sobre la supervivencia de los niños dependía del sexo y del momento de la infancia en que su padre o su madre habían muerto. la supervivencia inmediata de los niños se vio afectada por la pérdida materna; asimismo, se ha comprobado que las hijas que perdieron a sus padres antes de cumplir un año tienen mayor mortalidad durante su juventud; la edad de muerte de las hijas también se redujo si tuvieran que vivir con una madrastra durante la primera infancia. el estudio realizado por pavard et al. (16) considera que el aumento de la mortalidad infantil se explica principalmente por la pérdida de la atención materna debido a que la mayoría de las muertes de niños se produjeron después de la muerte de la madre. cuanto más pequeño sea el niño cuando su madre murió, más alto es el riesgo de que él/ella muera debido a que la lactancia materna es un factor determinante en la supervivencia infantil. este mayor riesgo de mortalidad para los niños huérfanos de madre sigue siendo significativo durante la infancia y los primeros años de la adolescencia. la hipótesis principal que explica este fenómeno es la pérdida de la atención de salud por parte de la madre. de la misma manera, la degradación de las condiciones del hogar tras la muerte de la madre puede conducir a una falta de atención médica que aumenta la mortalidad de los niños. herrera et al. (17) consideran que la evaluación de la muerte materna dentro del grupo doméstico permitió comprender que el problema no termina con las consecuencias inmediatas del deceso y de los factores que contribuyeron a él, sino que se extiende hasta las complejas secuelas emocionales de la pérdida de la hija, la esposa y la madre, y persiste en el curso del tiempo con efectos tan devastadores como la muerte del recién nacido y un futuro incierto para los hijos huérfanos. la contribución de la madre al desarrollo económico y social de los hijos se verá truncada y se irá reduciendo a lo largo del tiempo, de tal forma que los inte438 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 grantes de la comunidad tendrán que establecer estrategias para apoyar al grupo doméstico desintegrado, entre ellas buscar nueva pareja para el viudo, adoptar a los huérfanos y, a menudo, ceder para ellos sus escasos alimentos. discusión y conclusiones las consecuencias de una muerte materna son de tal dimensión que repercuten durante mucho tiempo, tanto en la familia como en la comunidad misma. generalmente la muerte materna afecta a toda la familia y produce un impacto negativo en la estructura y dinámica familiar, con severas consecuencias futuras, de manera particular en el bienestar de los niños que se quedan sin madre, lo cual se traduce en un incremento en la morbi-mortalidad infantil, deserción escolar, adquisición de nuevos roles y un futuro incierto en algunos casos para los hijos huérfanos. en el aspecto comunitario se reflejan problemas como la desintegración familiar y la fusión con una nueva familia, lo que puede afectar la situación económica de esta, así como las repercusiones económicas cuando la mujer era el único o más importante sostén familiar, además del papel que cumplen las abuelas, hermanas o hijas como madres sustitutas en la adquisición y el desarrollo de este nuevo rol. ante la ausencia de un familiar por muerte se presenta una situación dolorosa y real de sufrimiento y desconsuelo. estas pérdidas traen una serie de síntomas físicos, emocionales, comportamentales y cognitivos. se pueden generar sentimientos contradictorios: por un lado se vive el dolor por la ausencia del familiar fallecido, y por otro, la alegría por la presencia de un nuevo miembro. la familia vive una situación de duelo ante la muerte de alguien que trae y cuida la vida, considerada como una muerte trágica y prematura, por lo que la espera de recibir a un nuevo miembro es sustituida por una pérdida. todos esperan en casa a un nuevo miembro: el bebé, y nunca se imaginan que llegue a casa el bebé sin su madre o, en algunos casos, no llegue ninguno. al analizar los hallazgos encontramos problemas en común como son: el duelo, la supervivencia de los hijos y la reconstitución de los hogares. en lo relacionado con el duelo se puede evidenciar la forma de asumirlo por parte de los adultos y los niños: los viudos sienten desesperanza, tristeza e impotencia; los niños por su parte somatizan dichos sentimientos, donde predominan los síntomas de ansiedad y las alteraciones del humor (18). todos estos factores estresantes pueden originar igualmente manifestaciones emocionales como tristeza, llanto, desesperanza, impotencia, rabia y culpa, además de la desadaptación a nivel social y laboral (11, 12, 14, 19-21). según herrera et al. (17) los niños, además de vivir la pérdida de la madre, enfrentan en algunos casos la separación de su padre y hermanos. de igual manera, los tipos de actitud característicos en los adolescentes frente a la muerte son de miedo y aceptación de acercamiento, evidenciado en el artículo de álvarez-ramírez (22). por su parte, la supervivencia del niño está estrechamente relacionada con el momento, el espaciamiento y el número de nacimientos, y con la salud reproductiva de las madres. la pobreza, la malnutrición, la disminución de la lactancia materna y la insuficiencia o falta de servicios de saneamiento y salud están asociados a la alta mortalidad de lactantes y niños pequeños debido a que una de las necesidades básicas del niño es la presencia de una figura materna que lo alimente, proteja e instruya; lo anterior concuerda con lo señalado por willführ (15) y pavard et al. (16). igualmente, se considera que la supervivencia del recién nacido y de los otros niños se reduce grandemente con la defunción de la madre (23). asimismo, la supervivencia de los hijos está asociada a la reconstitución de los hogares, ya que generalmente son los abuelos quienes asumen el cuidado de estos, como señalan reyes et al. (13). muchos de los estudios realizados (24-35) hacen análisis epidemiológicos parciales centrados especialmente en causas y factores asociados con la ocurrencia del evento, subestimación de casos y evaluación de programas para la reducción de estos. por su parte, la organización mundial de la salud (oms) y la organización panamericana de la salud (ops) han implementado políticas y estrategias para contrarrestar la morbi-mortalidad materna y perinatal (36-42), y estas a su vez han sido adoptadas por los diferentes países, siendo apoyadas por dichos organismos. a pesar de lo anterior, y de que el tema socialmente no es muy importante debido a que se han visibilizado problemas en grupos más vulnerables como son el aborto y el vih/sida (43-48), se debe promover la realización de investigaciones que permitan tomar decisiones respecto al diseño de servicios de salud que garanticen la continuidad de la asistencia en el embarazo y reduzcan 439 consecuencias de una muerte materna en la familia l doris rodríguez-leal, josé verdú los riesgos asociados, ofreciendo una oportuna y óptima atención en las etapas de: preconcepción, gestación, parto y puerperio. también es necesario fortalecer la vigilancia epidemiológica del evento “muerte materna”, entendida como un proceso regular y continuo de observación e investigación. de igual manera, fortalecer el “control prenatal” con el fin de lograr la meta de reducir la morbi-mortalidad materna estableciendo parámetros mínimos que garanticen una atención con calidad y con racionalidad científica para el desarrollo de las actividades, los procedimientos y las intervenciones durante el control prenatal (49) por parte de todos los profesionales de salud garantizando el acceso de las mujeres embarazadas a los servicios de salud. y por último reconocer, cómo los determinantes sociales y culturales influyen en la toma de decisiones de la mujer embarazada y su entorno, lo que determina su conducta respecto al cuidado prenatal y, por consiguiente, el desenlace del embarazo (50). finalmente, podemos considerar que son escasos los trabajos que identifican y cuantifican las consecuencias familiares y comunitarias de una muerte materna y su análisis se restringe a algunos estudios cualitativos; tampoco se han evaluado las formas de compensación destinadas a las familias y comunidades afectadas. a pesar de esto se debe determinar si estas familias asumen situaciones de pérdida y duelo ellas solas porque cuentan con sistemas de apoyo que compensan parcialmente la pérdida o ayudan en el proceso de afrontamiento, resolución del duelo y reorganización de sus vidas, por lo cual puede ser innecesario que el estado medie con acciones, programas o políticas destinadas a la intervención familiar. sin embargo, se puede considerar realizar un seguimiento a las familias de las mujeres que han fallecido por muerte materna con el fin de brindar asesoría familiar y legal cuando han quedado hijos menores de 18 años. como estrategia institucional se debe realizar educación continuada para todo el personal asistencial que suministra atención directa a las embarazadas y parturientas, con el fin de lograr una actualización permanente y una atención eficiente. asimismo, sería importante que los profesionales de enfermería investigaran sobre esta temática y que dichas investigaciones estén enfocadas hacia la metodología cualitativa, teniendo en cuenta el contacto directo que tienen con las gestantes, las parturientas y sus familias. agradecimientos los autores expresan su gratitud a la profesora patricia elena dueñas granados, por las observaciones realizadas en el presente artículo. referencias 1. world health organization. maternal mortality in 2000: estimates developed by who, unicef, and unfpa. geneva: world health organization; 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(fuente: decs, bireme). 105 adecuación semántica de la escala de cuidado profesional (cps) l maría neyfeth posada-morales, carmen helena ruiz semantic adaptation for spanish version of the scale of professional care (spc) abstract objective: to forward how semantics are adapted for the spanish version of dr. kristen swanson (cps) 2.000’s scale of professional care. method: using the pre-test or field survey technique, a methodological study with a quantitative approach was undertaken to explore the clarity and comprehension of the statement for each item in the scale and how they are measured from the perspective of pregnant women. the sample was represented by 60 pregnant women to whom the spanish version of the scale was applied; additionally, it was represented by 50 more pregnant women to whom the semantically adapted scale was applied. results: only 3 of the items in the scale (1, 7, 14) attained a 100 % or close to 100 % clarity and understanding rate; as a result, these statements did not require semantic adaptation. semantic adaptation was necessary in items with clarity and understanding rates between 60 and 80 %; the items attaining less than 60 % in understanding and clarity rates, underwent a process of radical semantic adaptation; this means linguistic signs (words) were changed completely in order to make them more understandable and clear but without affecting their conceptual equivalence or interpretability. conclusion: to conclude, in any semantic adaptation process many items can vary to make the wording clearer and more understandable, but researchers must have the ability to make these changes while ensuring that contents are faithfully reproduced (conceptual equivalency) and easily interpreted. in semantic adaptation processes for a scale, it is necessary to determine how acceptable the wording and changes are; this will ensure that the adaptation will not become a semantic barrier that can lead to interpretation mistakes. key words semantics, prenatal care, nursing care, cross-cultural comparison. (source: decs, bireme). 106 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 adequação semântica da escala de cuidado profissional (cps) resumo objetivo: desenvolver a adequação semântica na escala de cuidado profissional da doutora kristen swanson (cps, sigla em inglês) 2.000, versão em espanhol. método: realizou-se um estudo metodológico com abordagem quantitativa, utilizando a técnica de pré-teste ou sondagem em uma prova de campo, com o objetivo de explorar a clareza e compreensão do enunciado de cada item da escala e as opções de medida, sob a perspectiva das gestantes. a amostra foi representada por sessenta gestantes nas quais aplicaram a primeira versão em espanhol da escala, e cinquenta gestantes mais nas quais aplicaram a escala adaptada semanticamente. resultados: somente três dos itens da escala (1, 47, 14) atingiram uma porcentagem de claridade e compreensão de 100 % ou próximo a este, pelo qual seus enunciados, sem necessidade de ajuste semântico. realizou-se adequação semântica nos itens com porcentagem de clareza e compreensão entre 60 e 80 %, no entanto o enunciado não se modificou completamente dado que se determinou que, para torná-lo mais compreensível e claro, necessitava-se que fosse ajustado ao mesmo processo de gestação, lugar ou contexto personalizando, assim, o enunciado. pelo contrário, os itens que atingiram porcentagens de compreensão e clareza abaixo de 60 % sofreram um processo de adequação semântica radical, isto é, os signos linguísticos (palavras) foram mudados em sua totalidade para torná-los mais compreensíveis e claros, mas sem afetar sua equivalência conceitual e interpretação. conclusão: em todo processo de adequação semântica muitos itens podem sofrer modificações no enunciado para torná-lo mais claro e compreensível, mas o pesquisador deve ter a capacidade de fazer isso conservando a fidelidade da reprodução do conteúdo (equivalência conceitual) e a interpretação. nos processos de adequação semântica de uma escala, é necessário determinar a aceitação em termos de clareza e compreensão, tanto do enunciado do item quanto da opção de medida, para que não se convertam em uma barreira semântica que possa levar a interpretações errôneas na aplicação. palavras-chave semântica, cuidados de enfermagem, cuidado pré-natal, comparação transcultural. (fonte: decs, bireme). 107 adecuación semántica de la escala de cuidado profesional (cps) l maría neyfeth posada-morales, carmen helena ruiz introducción en la búsqueda de un instrumento válido que evaluara directamente el cuidado ofrecido por la enfermera durante el control prenatal se encontró la escala de cuidado profesional (cps caring professional scale) elaborada por la doctora kristen swanson en el año 2000 (1), la cual fue diseñada para ser utilizada en diferentes contextos donde se establecieran relaciones de cuidado. la escala original se encuentra en inglés, razón por la cual fue necesario desarrollar un proceso denominado adaptación transcultural (2-5) que incluye dos aspectos importantes: primero, la traducción y retrotraducción del idioma original al idioma local y viceversa, en donde intervienen expertos bilingües (6-10), los cuales están encargados de elaborar la primera versión en español de la escala y verificar la equivalencia conceptual (este proceso fue obra del grupo de investigación de cuidado materno perinatal de la universidad nacional de colombia). en segundo lugar, y con el fin de que no se presentaran sesgos culturales debidos al idioma que pudieran invalidar su aplicación o los resultados, esta versión fue aplicada a la población de estudio, en donde se exploró la aceptabilidad de cada uno de los ítems de la escala y de las opciones de respuesta en términos de claridad y comprensión —lo que se denomina adecuación semántica—, tema que llama la atención y se convierte en el objetivo principal de este proyecto. siguiendo las recomendaciones dadas por alberto arribas (11) se realizó una prueba de campo donde participó un grupo de sesenta gestantes de bajo riesgo, con escolaridad hasta octavo grado, que asistieron a control prenatal en el hospital santa mónica, de dosquebradas (risaralda), en el periodo mayo-junio de 2011, y posteriormente en agosto del mismo año. una vez cumplidos los aspectos éticos reglamentarios en todo estudio investigativo con seres humanos, el investigador diligenció las respuestas emitidas por las gestantes que contemplaban aspectos sociodemográficos, claridad y comprensión de cada uno de los ítems, y medidas de respuesta, dificultades y razones de estas, así como la reformulación del ítem en sus propias palabras (parafraseo) (12). obtenidos los datos, y una vez realizado el análisis respectivo de estos, se elaboró una nueva versión en español de la escala de cuidado profesional de la doctora swanson adaptada semánticamente desde la perspectiva de las gestantes, la cual permitió realizar una adecuación de los ítems que no fueron claros y comprensibles teniendo en cuenta el parafraseo, la significancia del ítem, el significado a la luz del diccionario de la lengua española, el proceso de traducción y retraducción de la escala, los conceptos de la teoría y las competencias cognitivas, afectivas y técnicas de la enfermera. considerando la necesidad de determinar si esta nueva versión en español era lo suficientemente clara y comprensible para la población objeto de estudio, y teniendo en cuenta que para muchos autores como arribas este proceso mejoraba la adecuación semántica de los ítems, se aplicó de nuevo la escala ya adaptada semánticamente a un grupo de gestantes (50) que cumplían los mismos criterios de inclusión, hallando resultados muy similares en lo relacionado con los aspectos sociodemográficos y observándose porcentajes de comprensión y claridad del 100 % en 14 de los 15 ítems que contiene la escala. problema necesidad de contar con un instrumento en español que permita desde la perspectiva de las gestante evaluar el cuidado que ofrecen las enfermeras durante el control prenatal. objetivos objetivo general. desarrollar la adecuación semántica de la escala de cuidado profesional de la doctora kristen swanson (cps) 2.000, versión en español. objetivos específicos explorar la aceptabilidad del enunciado de cada ítem de la escala de cuidado profesional de la doctora kristen swanson (cps) versión en español, en sus características gramaticales y semánticas, hecho que representa la comprensión de las gestantes participantes en el estudio. explorar desde la perspectiva de las gestantes la diversidad de opciones de medida para responder a los ítems de la escala de cuidado profesional de la doctora kristen swanson (cps). definición de los principales conceptos adaptación transcultural: proceso que tiene como objetivo lograr una equivalencia de significados entre la cultura en la que se desarrolló el cuestionario o la escala y aquella en 108 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 la que se va a aplicar. de esta forma se obtendrá un instrumento adaptado equivalente al original, que permitirá la medición de un fenómeno similar en diferentes culturas (13). adecuación semántica: capacidad de saber escoger los signos lingüísticos más apropiados entre toda la variedad que ofrece un idioma o lengua, utilizando un lenguaje local propicio al contexto, pero que a la vez cumpla con ciertas normas y principios que lo regulan, ya que al adecuarlo a un nuevo idioma, por ejemplo, se puede afectar la gramática, la sintaxis y el léxico semántico. su finalidad, entonces, siempre será que el signo lingüístico comunique el significado que quiere darse a entender y no otro, es decir, que tenga interpretabilidad o aceptabilidad semántica (14, 15). método se realizó un estudio metodológico con abordaje cuantitativo utilizando en una prueba de campo la técnica de pretesteo o sondeo con el fin de explorar la claridad y comprensión del enunciado de cada ítem de la escala y las opciones de medida desde la perspectiva de las gestantes (16). el muestreo intencional y no probabilístico contó con una muestra de sesenta gestantes a las cuales se les aplicó la primera versión en español de la escala, y cincuenta gestantes más a las cuales se les aplicó la escala adaptada semánticamente una vez se analizaron los primeros resultados. se incluyeron gestantes adolescentes o adultas de bajo riesgo que asistieron al control prenatal con enfermería en el hospital santa mónica de dosquebradas, las cuales debían haber aprobado hasta octavo grado de escolaridad, razón por la cual se excluyeron las gestantes con discapacidad cognitiva diagnosticada y aquellas con alto nivel educativo. se tuvieron en cuenta los principios éticos relacionados con el respeto a la dignidad humana, beneficencia, justicia y diversidad cultural, los lineamientos de la resolución 008430 (17), y las recomendaciones del council for international organizations of medical sciences (cioms) para la investigación biomédica en seres humanos (18, 19). resultados y análisis de los datos aplicación de la primera escala versión en español 1. aspectos sociodemográficos. los datos sociodemográficos más relevantes para este estudio se relacionaron con la escolaridad y la edad como se evidencia en el anexo 1. era importante resaltar que científicamente existían diferencias cognitivas entre las personas de baja escolaridad y las que no lo eran, en el sentido de que las primeras tienen menos capacidad de entender el significado de un lenguaje comprensivo, complejo o abstracto que las segundas (20), lo que implicaba en este caso que si los ítems de la escala de cuidado profesional eran claros y comprensibles para las gestantes de baja escolaridad, lo serían para las de mayor grado de escolaridad. asimismo, algunos autores consideran que la edad se asocia con la capacidad de comprensión del lenguaje abstracto, entre menos edad más reducido es este proceso (21). como lo muestra la figura 1, solo 3 de los ítems (1, 7, 14) alcanzaron un porcentaje de claridad y comprensión del 100 % o cercano a este, por lo cual sus enunciados no se modificaron, es decir, no requirieron adecuación semántica. a los ítems con porcentajes de claridad y comprensión entre el 60 y el 80 % fue necesario realizarles adecuación semántica; sin embargo, los enunciados no se modificaron completamente dado que se determinó que para hacerlos más comprensibles y claros requerían ser ajustados al mismo proceso de gestación, lugar o contexto, personalizando el enunciado por ejemplo, el ítem ¿tuvo una actitud positiva con usted?, en este caso se hace referencia a la enfermera, por tanto, el término “enfermera” debe aparecer (lo que personaliza la pregunta), igualmente debe contextualizarse en un escenario propio de la atención a la gestante, en este caso sería durante el “control prenatal”, términos que también deben hacer parte de la pregunta. por el contrario, los ítems que alcanzaron porcentajes de comprensión y claridad por debajo del 60 % sufrieron un proceso de adecuación semántica radical, es decir, que los signos lingüísticos (palabras) fueron cambiados en su totalidad para hacerlos más comprensibles y claros pero sin afectar su equivalencia conceptual e interpretabilidad. 2. aceptabilidad de la opción de medida de los ítems. como lo sugiere arribas (11, 22), era necesario explorar la aceptabilidad, interpretabilidad y equivalencia semántica de las opciones de respuesta para verificar si estas eran también claras y consistentes con la pregunta o el ítem. por tanto, las gestantes tuvieron la oportunidad de seleccionar la opción de medida que les parecía más adecuada y clara para contestar el ítem (entre 109 adecuación semántica de la escala de cuidado profesional (cps) l maría neyfeth posada-morales, carmen helena ruiz cuatro opciones), hallándose que la medida de respuesta dicotómica (sí o no) fue la escogida por ellas al considerar que es fácil de entender y comprender; por el contrario, la opción de respuesta que tuvo mayor confusión fue precisamente la presentada en la escala original de la doctora swanson (anexo 2). 3. aplicación de la escala versión en español adaptada semánticamente al nuevo grupo de gestantes. como se señaló, la escala adaptada semánticamente fue aplicada de nuevo a un grupo de cincuenta gestantes que cumplían con los mismos criterios de inclusión, con el fin de establecer si los ítems y la opción de medida propuestos en la versión en español tenían la claridad y comprensión esperada. los datos arrojaron los siguientes resultados: existen similitudes en los datos sociodemográficos, en donde son relevantes la escolaridad y la edad. una vez se exploró la aceptabilidad de cada uno de los ítems de la escala adaptada semánticamente se observó en la gráfica una claridad y comprensión del 100 % de 14 de los 15 ítems; solo el ítem no. 2 propuesto alcanzó una claridad del 76 % pues las gestantes continuaron manifestando que la palabra “optimista” no era clara, no la entendían, pero la interpretación de la pregunta en sus propias palabras logró una comprensión del 100 % (figura 2). en cuanto a la aceptabilidad de la opción de respuesta las gestantes consideraron muy clara y de fácil comprensión contestar los 15 ítems de la escala en la forma dicotómica propuesta. escala para utilizar el instrumento y realizarle la respectiva adaptación semántica se contó con la autorización de la autora de la escala (23). en el anexo 3 se muestran los enunciados de la escala que se aplicó y aquellos propuestos después del análisis. es importante anotar que la escala versión en español que surgió desde la perspectiva de las gestantes conservó los 15 ítems que tiene la escala original y que se encuentran agrupados en dos subescalas denominadas “sanador compasivo” y “sanador competente”, sin embargo, no conservó la opción de medida original por las razones antes mencionadas. sanador compasivo: se refiere al comportamiento del profesional de enfermería que en la práctica del cuidado de la salud de los seres humanos establece una relación afectuosa y de confianza (24). consta de 7 ítems: reconfortante, positiva, escucha atentamente, atenta a sus sentimientos, visiblemente afectada por su experiencia, capaz de ofrecer esperanza y respetuosa. sanador competente: se refiere al comportamiento del profesional de enfermería con responsabilidad, compromiso, pericia e idoneidad para ejercer la práctica del cuidado de la salud de los seres humanos (24). costa de 7 ítems: informativa, clínicamente competente, personal, apoyo, técnicamente hábil, cuidado y centrada en el paciente. las dos subescalas son las que se relacionan con los procesos de cuidado derivados de la teoría de mediano rango de la doctora swanson —teoría del cuidado informado para el bienestar de otros— (25), las cuales agrupan el comportamiento de enfermería en su práctica de cuidado. la primera subescala se orienta a la parte cognitiva/afectiva y la segunda a la parte cognitiva del saber/hacer (anexo 4). por último se muestra la escala semánticamente adecuada, desde la perspectiva de las gestantes (anexo 5). conclusiones en los procesos de adecuación semántica de una escala se requiere determinar la aceptabilidad en términos de claridad y comprensión, tanto del enunciado del ítem como de la opción de medida, para que no se conviertan en una barrera semántica que pueda llevar a interpretaciones erróneas en la aplicación. en todo proceso de adecuación semántica muchos ítems pueden sufrir modificaciones en el enunciado para hacerlo más claro y comprensible, sin embargo, el investigador debe tener la capacidad de hacerlo conservando la fidelidad de la reproducción del contenido (equivalencia conceptual) y la misma interpretabilidad. en los procesos de adecuación semántica se requiere articular los datos obtenidos en el parafraseo que designa la significancia del ítem, el significado del enunciado a la luz del diccionario de la rae, el proceso de traducción y retraducción de la escala (adaptación transcultural) y las competencias cognitivas y afectivas de la enfermera. 110 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 recomendaciones la versión en español de la escala, planteada desde la perspectiva de las gestantes, debe ser aplicada en varios contextos donde se establezcan relaciones de cuidado con el fin de perfeccionar el proceso de adecuación semántica. la escala requiere de pruebas psicométricas de validez y confiabilidad hasta conseguir la aceptación y la confianza para la comunidad científica de enfermería. referencias 1. swanson k. desarrollo empírico de una teoría de cuidado de rango medio. nursing research 1991;40(3):161-166. 2. fernández l et al. actualizaciones secot: cirugía ortopédica y traumatología. vol. 4. barcelona: elservier; 2003. p. 10. 3. sánchez r et al. adaptación transcultural de dos escalas para medir la calidad de vida en pacientes con cáncer en colombia: eortc qlq-c30 y qlq-br23. revista colombiana de cancerología 2009;13(4):205-212. 4. aguilar b, blanquez c, rubio e. adaptación transcultural del cuestionario de medida de calidad de vida (qolie_ad_48) en adolescentes epilépticos. revista psiquis 2002;23(6):226-237. 5. peiro s, palencia e. adaptación transcultural del cuestionario. the portrait values cuestionare (p: v: q) iv versión basada en el modelo de hrqol instruments. revista de valores universidad de carabobo 2009;1(11):9-17. 6. serra-sutton v, herdman m. metodología de adaptación transcultural de instrumentos de medida de la calidad de vida relacionada con la salud. informatiu aatm 2001 (24). 7. álvarez f et al. adaptación transcultural y validación preliminar de la versión española del kidney disease questionnaire (cuestionario de la enfermedad renal). revista de nefrología 1997;17(6):486-496. 8. curvelo e, cardoso de sousa rm. adaptación transcultural del instrumento family needs questionnaire. revista latino americana de enfermagem 2009;17 (4):541-547. 9. ordóñez cp. validación lingüística y psicométrica (adaptación cultural) del cuestionario dermatológico de calidad de vida en niños, en pacientes con dermatitis atópica. tesis de maestría en epidemiología. pontificia universidad javeriana, noviembre 2009. 10. rengel c. necesidad de la adaptación transcultural en las herramientas de valoración enfermeras. revista index de enfermería 2011;20(1-2):130-131. 11. arribas a. adaptación transcultural de instrumentos. guía para el proceso de validación de instrumentos tipo encuesta. revista científica de la ambb 2006;16(3):4. 12. bach c, freixa j, suárez m. equivalencia conceptual y reformulación parafrástica en terminología. actas vii simposio iberoamericano de terminología. lisboa; 2004. pp. 14-17. 13. pons r, escriba v. la versión castellana de la escala “the nursing stress scale”. proceso de adaptación transcultural. rev esp salud publica 1998;72(6):529-538. 14. álvarez a. escribir en español: la creación del texto escrito, composición y uso de modelos del texto. españa: nobel; 2005. p. 51. 15. vidal gu. taller de lectura y redacción ii: con enfoque en competencias. méxico; 2010. 16. berra s et al. adaptación transcultural del cuestionario kidscreen para medir calidad de vida relacionada con la salud: en la población argentina de 8 a 18 años. revista archivos argentinos de pediatría 2009;107(4):307-314. 17. república de colombia. ministerio de salud. resolución 008430 (octubre 4 1993). capítulos ii, iii, iv y v. 18. división salud y desarrollo humano. ops/oms. normas éticas de cioms para investigación biomédica. bioética informa 2001;18(2). 111 adecuación semántica de la escala de cuidado profesional (cps) l maría neyfeth posada-morales, carmen helena ruiz 19. normas éticas de cioms para la investigación biomédica. revista médica 2001;129(6):695. 20. matalinares m et al. lenguaje comprensivo y memoria auditiva inmediata en estudiantes de 5º y 6º grado de primaria de zona rural y urbana de lima. revista de investigación en psicología 2007;10(2):71-83. 21. matute e et al. influencia de la edad en la ejecución de las tareas relacionadas con el lenguaje en escolares. revista neuropsicología, neuropsiquiatría y neurociencias 2010;10(2):9-21. 22. arribas m. diseño y validación de cuestionarios. revista matronas profesión 2004;5(17):23-29. 23. acosta a, neusa m, brito e. adaptación transcultural de instrumentos utilizados en salud ocupacional. revista panamericana de salud pública 2002;11(2). 24. grupo de investigación materno perinatal. universidad nacional de colombia. programa de enfermería. bogotá; 2011. 25. swanson k. la enfermería como el cuidado informado para el bienestar de los demás (traducción elaborada con fines académicos). bogotá: universidad nacional de colombia; 2000. 112 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 figura 1 . aceptabilidad de cada uno de los ítems de la escala de cuidado profesional (cps) primera versión en español fuente: base de datos prueba de campo. figura 2 . aceptabilidad de cada uno de los ítems de la escala de cuidado profesional (cps) versión en español: adaptada semánticamente desde la perspectiva de las gestantes fuente: base de datos prueba de campo. 113 adecuación semántica de la escala de cuidado profesional (cps) l maría neyfeth posada-morales, carmen helena ruiz anexo 1. datos sociodemográficos fuente: base de datos prueba de campo. distribución de las gestantes objeto del estudio según datos sociodemográficos aspectos sociodemográficos intervalo porcentaje escolaridad (grados) ninguno 1,66 primero 0% segundo 3,33 tercero 1,66 cuarto 5 quinto 21,66 sexto 18,33 séptimo 21,66 octavo 26,66 edad (años) 10 a 14 3,33 15 a 19 36,66 0 a 24 33,33 25 a 40 26,66 procedencia urbana 87 rural 13 ocupación ninguno 2 ama de casa 78 estudiante 18 otros 2 estado civil soltera 30 unión libre 62 casada 8 otros 0 114 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 anexo 2. opciones de respuesta fuente: base de datos prueba de campo. opción de respuesta ítems forma no.1 forma no.2 forma no.3 forma no.4 % % % % ítem 1 71,67 12,66 6,67 0 ítem 2 60 26,67 13,33 0 ítem 3 63,67 21,66 11,67 0 ítem 4 75 18,33 6,67 0 ítem 5 53,33 23,34 23,33 0 ítem 6 60 18,33 21,67 0 ítem 7 61,67 23,33 15 0 ítem 8 63,33 21,67 15 0 ítem 9 51,67 26,66 21,67 0 ítem 10 51,67 23,33 25 0 ítem 11 55 23,33 21,67 0 ítem 12 55 20 25 0 ítem 13 53,33 25 21,67 0 ítem 14 55 23,33 21,67 0 ítem 15 66,67 21,66 11,67 0 opción de respuesta 1 opción de respuesta 2 opción de respuesta 3 opción de respuesta 4 sí ___ no__ nunca ____ algunas veces ___ siempre ____ siempre ___ la mayoría de veces ___ algunas veces sí, algunas veces no _____ nunca ____ sí definitivamente ___ en su mayoría ___ mitad y mitad ___ ocasionalmente ___ no, para nada ___ 115 adecuación semántica de la escala de cuidado profesional (cps) l maría neyfeth posada-morales, carmen helena ruiz anexo 3. adecuación semántica de los ítems escala aplicada escala propuesta sanador compasivo sanador compasivo 1. ¿la enfermera la hizo sentir bien? 1. ¿la enfermera la hizo sentir bien? 2. ¿tuvo una actitud positiva con usted? 2. ¿la enfermera se mostró optimista con la evolución de su embarazo? 3. ¿sintió que la enfermera escuchó sus necesidades? 3. ¿la enfermera la escuchó con atención? 4. ¿la enfermera estuvo atenta a sus sentimientos? 4. ¿la enfermera le permitió expresar sus sentimientos? 5. ¿sintió que la enfermera se preocupó por su situación? 5. ¿la enfermera demostró preocupación por lo que le sucede a usted? 6. ¿la enfermera le dio confianza para salir adelante? 6. ¿la enfermera la estimuló para que siga adelante? 7. ¿la enfermera fue respetuosa con usted? 7. ¿la enfermera fue respetuosa con usted? 8. ¿cree usted que la enfermera escuchó sus necesidades? 8. ¿la enfermera comprendió sus dolencias y preocupaciones sanador competente sanador competente 9. ¿le pareció que la enfermera sabía cómo cuidarla? 9. ¿la enfermera demostró que estaba preparada para hacer su trabajo? 10. ¿se sintió apoyada por la enfermera? 10. ¿la enfermera le brindó ayuda y colaboración? 11. ¿le pareció que la enfermera sabía hacer los procedimientos con usted? 11. ¿la enfermera le realizó correctamente el control prenatal? 12. ¿la enfermera estuvo pendiente de usted? 12. ¿la enfermera estuvo al cuidado de usted durante el control prenatal? 13. ¿le brindó información clara? 13. ¿la enfermera le explicó en forma clara las indicaciones por seguir? 14. ¿sintió que la enfermera fue amable con usted? 14. ¿la enfermera fue amable con usted? 15. ¿la enfermera la hizo sentir importante? 15. ¿la enfermera la trató como persona? 116 año 13 vol. 13 nº 1 chía, colombia abril 2013 aquichan issn 1657-5997 anexo 4 universidad nacional de colombia. facultad de enfermería. grupo de investigación cuidado materno perinatal escala de cuidado profesional swanson 2000 propuesta por: lucy muñoz de rodríguez y carmen helena ruiz de cárdenas, 28 de julio de 2010. revisado por el grupo de investigación, agosto 2 de 2010 adaptado de: viviana ayala, carlos arturo nieto, lucy muñoz. cuidado de enfermería a la mujer histerectomizada y su pareja. trabajo de asignatura modalidades de cuidado ii. programa maestría en enfermería, universidad de la sabana, chía, 2001 inglés español propuesta de pregunta la enfermera: proceso de cuidado conforting reconfortante ¿la hizo sentir bien? hacer para positive positivo ¿tuvo una actitud positiva con ud.? mantener la fe informative informativo ¿le brindó información clara? permitir clinically competent clínicamente competente ¿le pareció que la enfermera sabía cómo cuidarla? hacer para comprensive comprensivo ¿cree usted que la enfermera comprendió sus necesidades? estar con personal personal ¿la enfermera la hizo sentir importante? conocer caring cuidado ¿sintió que la enfermera fue amable con usted? estar con supportive apoyo ¿se sintió apoyada por la enfermera? permitir an attentive listener escucha atentamente ¿sintió que la enfermera escuchó sus necesidades? estar con centered on you centrada en usted ¿la enfermera estuvo pendiente de usted? conocer technically skilled técnicamente hábil ¿le pareció que la enfermera sabía hacer los procedimientos con ud.? hacer para aware of your feelings atenta a sus sentimientos ¿la enfermera estuvo atenta a sus sentimientos estar con visibly touched by your experience visiblemente afectada por su experiencia ¿sintió que la enfermera se preocupó por su situación? estar con able to offer you hope capaz de ofrecer esperanza ¿la enfermera le dio confianza para salir adelante? mantener la fe respectful of you respetuosa con usted ¿la enfermera fue respetuosa con usted? hacer para 117 adecuación semántica de la escala de cuidado profesional (cps) l maría neyfeth posada-morales, carmen helena ruiz anexo 5 propuesta escala del cuidado profesional versión en español 2011 (original en inglés doctora kristen swanson) en la siguiente escala usted puede evaluar la clase de atención que recibió de parte de la enfermera profesional que le realizó el control prenatal. para ello se recomienda que en cada una de las preguntas encierre en un círculo el número que usted considere se acerca más a lo que usted percibió, de la siguiente forma: 1 = sí 2 = no actividad evaluada en enfermería sí no sanador compasivo 1. ¿la enfermera la hizo sentir bien? 1 2 2. ¿la enfermera se mostró optimista con la evolución de su embarazo? 1 2 3. ¿la enfermera la escuchó con atención? 1 2 4. ¿la enfermera le permitió expresar sus sentimientos? 1 2 5. ¿la enfermera demostró preocupación por lo que le sucede a usted? 1 2 6. ¿la enfermera la estimuló para que siga adelante? 1 2 7. ¿la enfermera fue respetuosa con usted? 1 2 8. ¿la enfermera comprendió sus dolencias y preocupaciones 1 2 sanador competente 9. ¿la enfermera demostró que estaba preparada para hacer su trabajo? 1 2 10. ¿la enfermera le brindó ayuda y colaboración? 1 2 11. ¿la enfermera le realizó correctamente el control prenatal? 1 2 12. ¿la enfermera estuvo al cuidado de usted durante el control prenatal? 1 2 13. ¿la enfermera le explicó en forma clara las indicaciones por seguir? 1 2 14. ¿la enfermera fue amable con usted? 1 2 15. ¿la enfermera la trató como persona? 1 2 196 206 calidad asistencia enfermeria prenatal.indd 196 aquichan issn 1657-5997 maria aparecida vasconcelos-moura1 giuliana fernandes e-silva2 cláudia santos3 vivianne mendes de araújo-silva4 la calidad de asistencia de enfermería en el periodo prenatal desde la perspectiva de la mujer embarazada 1 enfermera. profesora doctora asociada iv, escuela de enfermería anna nery de la universidad federal de río de janeiro, brasil. maparecidavas@yahoo.com.br 2 enfermera. miembro del núcleo de pesquisa en salud de la mujer (nupesm), brasil. giulianafernandes@hotmail.com 3 enfermera. profesora doctora adjunto iv, universidad federal de río de janeiro. investigadora y miembro del núcleo de pesquisa en salud de la mujer (nupesm). claudiasantos.ufrj@gmail.com 4 enfermera. investigadora y miembro del núcleo de pesquisa en salud de la mujer (nupesm). viviannenfe@gmail.com recibido: 16 de agosto de 2012 enviado a pares: 30 de agosto de 2012 aceptado por pares: 13 de agosto de 2013 aprobado: 10 de marzo de 2014 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 196-206 para citar este artículo / to reference this article / para citar este artigo vasconcelos-moura ma, fernandes e-silva g, santos c, mendes de araújo-silva v. la calidad de asistencia de enfermería en el periodo prenatal desde la perspectiva de la mujer embarazada. aquichan 2014; 14(2): 196-206. resumen introducción: la calidad de la atención a la embarazada exige acogimiento, escucha, envolvimiento y compromiso, además de la resolución de problemas o disponibilidad de recursos tecnológicos e infraestructura. objetivo: describir la visión de las embarazadas acerca de la calidad de la asistencia de enfermería en el periodo prenatal e identificar las expectativas y necesidades de las mujeres en esa perspectiva. materiales y métodos: investigación cualitativa, exploratoria, realizada en el hospital de rio de janeiro, brasil. participaron veinte embarazadas. se utilizó la entrevista abierta e individual; el referencial metodológico fue el análisis del contenido de bardin. la investigación fue aprobada por el comité de ética, los sujetos fueron las mujeres embarazadas en su mayoría casadas y con la enseñanza media completa. resultados: como resultados satisfactorios emergieron aquellos referentes por la atención recibida por parte de los enfermeros en el prenatal, mientras la insatisfacción se dio por la infraestructura, los recursos materiales y la falta de una unidad materna para la atención del parto. conclusiones: la visión de las madres frente a la atención prestada en el prenatal fue positiva en cuanto a sus expectativas y necesidades. la calidad de la asistencia está centrada en la interacción de los profesionales de enfermería durante los momentos de verdad donde las embarazadas entran en contacto con la atención, desde la admisión hasta el alta. palabras clave enfermería, salud de la mujer, salud, mujeres embarazadas (fuente: decs, bireme). 197 la calidad de asistencia de enfermería en el periodo prenatal desde la perspectiva de la mujer embarazada l maria aparecida vasconcelos-moura y otros. año 14 vol. 14 nº 2 chía, colombia junio 2014 l 196-206 the quality of prenatal period nursing care from the perspective of pregnant women abstract introduction: the quality care provided to pregnant women requires acceptance and protection, listening, involvement and commitment, as well as solving problems or having technological resources and infrastructure available. objective: the purpose of this study is to describe how pregnant women feel about the quality of prenatal nursing care and to identify women’s expectations and needs in that regard. materials and methods: this is a qualitative, exploratory study conducted at the rio de janeiro hospital in brazil. twenty pregnant women took part. the technique featured individual open interviews. bardin’s content analysis was the methodological reference. the research was approved by the ethics committee and the subjects were mostly married women with a high school education. results: the results demonstrate satisfaction with the prenatal nursing care provided, but dissatisfaction with the infrastructure, material resources and the lack of birthing services. conclusions: the mothers had a positive view of the prenatal care being provided in terms of its meeting their expectations and needs. the quality of that care is centered on the interaction that exists among nursing professionals during the moments of truth when pregnant women are in contact with the assistance provided by nurses, from admission to discharge. key words nursing, women health, health, pregnant women (source: decs, bireme). 198 aquichan issn 1657-5997 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 196-206 a qualidade de assistência de enfermagem no período pré-natal na perspectiva da mulher gestante resumo introdução: a qualidade do atendimento à gestante exige acolhimento, escuta, envolvimento e compromisso, além da resolução de problemas ou a disponibilidade de recursos tecnológicos e infraestrutura. objetivo: descrever a visão das gestantes sobre a qualidade da assistência de enfermagem no pré-natal e identificar as expectativas e necessidades das mulheres nessa perspectiva. materiais e métodos: pesquisa qualitativa, exploratória, realizada no hospital rio de janeiro (brasil) e aprovada pelo comitê de ética. participaram 20 gestantes, em sua maioria casada e com ensino médio completo. a técnica foi entrevista aberta, individual e o referencial metodológico foi a análise de conteúdo de bardin. resultados: como resultados satisfatórios estão os referentes ao atendimento recebido pelos enfermeiros no pré-natal; enquanto a insatisfação se deu pela infraestrutura, recursos materiais e a falta da maternidade para acolhimento ao parto. conclusões: concluímos que a visão da clientela ao atendimento prestado no pré-natal teve suas expectativas e necessidades atendidas. a qualidade da assistência está focada na interação dos profissionais de enfermagem durante os momentos de verdade nos quais as gestantes entram em contato com o atendimento, desde a admissão até a alta, e avaliaram o serviço prestado. palavras-chave enfermagem, saúde da mulher, saúde, gestantes (fonte: decs, bireme). 199 la calidad de asistencia de enfermería en el periodo prenatal desde la perspectiva de la mujer embarazada l maria aparecida vasconcelos-moura y otros. introducción la calidad de la atención en salud es condición esencial para que las acciones se traduzcan en la resolución de los problemas identificados, la satisfacción de los individuos asistidos, el reconocimiento y las reivindicaciones de sus derechos, y la promoción del autocuidado (1). específicamente, la atención prenatal de calidad y humanizada es fundamental para la salud materna y neonatal. la atención a la mujer embarazada debe incluir acciones de prevención y promoción de la salud, además del diagnóstico y tratamiento de los problemas que pueden ocurrir en este periodo. aunque en las últimas décadas la cobertura de atención prenatal haya aumentado, garantizar su calidad es el mayor desafío. esa mejoría de la calidad se refiere a un cambio sensible en la actitud de los profesionales de la salud y a la eficiencia y presteza de los servicios (2). de esta forma se hace importante analizar la calidad a partir de las usuarias que reciben el servicio de los profesionales que las atienden en el sistema único de salud (sus). a partir del análisis de las condiciones en las cuales viven y la manera como mueren las mujeres, se puede evaluar el grado de desarrollo de una determinada sociedad. razones de mortalidad materna (rmm) elevadas son indicativas de precarias condiciones socioeconómicas, bajo grado de información y escolaridad, dinámicas familiares en las cuales la violencia está presente y, sobre todo, dificultades de acceso a servicios de salud de buena calidad. la salud de la mujer ha sido una temática en discusión a lo largo de varias décadas. los programas de salud pública contemplan las acciones que serán ejecutadas por los profesionales involucrados con la asistencia a la salud de la mujer, valorando el modo intervencionista, medicalizado e institucionalizado de tratar o cuidar de la salud (3). actualmente, las enfermeras en los hospitales y demás instituciones de la salud se están encontrando con situaciones en las que es necesario más apoyo para la realización de actividades diarias relativas al cuidado de la embarazada. en esa perspectiva, algunos estudios (4) señalan que muchas instituciones poseen pocos enfermeros especializados esperando que estos coordinen la prestación de cuidados, hagan evaluaciones, diagnósticos profesionales y tomen las decisiones clínicas, prescriban la terapia y, en caso de ser necesario, cambien, aconsejen y orienten a los clientes. observamos que esta realidad se vuelve un problema para las enfermeras que enfrentan el cuotidiano e sus prácticas de trabajo, pues debido a la grande demanda, tanto la calidad de la asistencia como la seguridad casi siempre se ven perjudicadas. la implementación de la consulta de enfermería a las gestantes tiene también como finalidades la reducción de la morbimortalidad materna e infantil, el aumento de la cobertura en los servicios prenatales, el incentivo a la lactancia, el aumento de la cobertura de vacunas y la gestión del servicio de salud a las mujeres, garantizando el acceso, la acogida, equidad y resolutividad. el diálogo franco, la sensibilidad y la capacidad de percepción de quien acompaña el prenatal son condiciones básicas para que el saber en salud sea puesto a disposición de la mujer (5). de este modo, la participación del profesional de enfermería en la atención a la gestante viabiliza un intercambio de saberes e informaciones que promueven el autocuidado; ese diálogo enfermera-cliente ayuda a definir metas y los objetivos propuestos, buscando la mejoría de la calidad de la asistencia a la salud de la mujer. para este estudio delineamos los siguientes objetivos: describir la visión de las embarazadas sobre la calidad de la asistencia de enfermería en el prenatal e identificar las expectativas y necesidades de las mujeres en esta perspectiva. este estudio puede contribuir a la calidad de la asistencia a la salud de la mujer durante el acompañamiento de su embarazo y aportar conocimientos a los profesionales de enfermería aumentando los patrones de asistencia en el prenatal para satisfacción de esas clientes. método la investigación es cualitativa y exploratoria, trabaja con el universo de significados, motivos, aspiraciones, creencias, valores y actitudes, y profundiza en el mundo de los significados de las acciones y relaciones humanas (6). el marco conceptual teórico (7) busca la base y las perspectivas significativas en el concepto de momento de verdad. este momento se define como cualquier episodio en el cual la cliente entra en contacto con la organización o los servicios y recibe una impresión del atendimiento, principalmente cuando hay interacción entre clientes y profesionales, formando el momento de verdad en su opinión sobre la calidad de los servicios prestados en el prenatal. 200 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 el escenario para recolectar los datos el hospital escola são francisco de assis (hesfa), debido a que el prenatal de este hospital posee un equipo de enfermeros que atiende las consultas de las gestantes de bajo riesgo, y cuando es necesaria una consulta médica, la gestante es remitida para acompañamiento en otra unidad de referencia. el hesfa, como unidad de enseñanza, asistencia, investigación y extensión, integra el complejo hospitalario de la universidad federal de rio de janeiro con la misión de atender con calidad las demandas específicas de la atención básica de salud (abs) y de los programas de salud de la familia (psf), dentro de una perspectiva multidisciplinaria e integrada; desarrolla otras acciones relacionadas con su función como institución universitaria insertada en la red de asistencia pública de salud del municipio y del estado de rio de janeiro, brasil. en la investigación participaron gestantes inscritas en el servicio de atención prenatal de un hospital-escuela del municipio de rio de janeiro, con un total de veinte gestantes que asistían al control prenatal en la consulta de enfermería. como criterio de inclusión de las participantes se estableció que estas deberían ser gestantes, atendidas en el prenatal del hesfa, poseer más de dieciocho años y aceptar participar en la investigación. las declaraciones fueron grabadas en mp3, transcritas y archivadas por un término de cinco años cuando serán incineradas. la recolección de los datos fue realizada por las estudiantes de la maestría durante los meses de junio y julio de 2010, y el número de entrevistadas fue determinado por la saturación de los datos, cuando se verificó la repetición de información. la técnica para la recolección de datos fue la entrevista abierta e individual, garantizando la confidencialidad, el anonimato y la solicitud de firma del consentimiento libre e informado (tcle). inicialmente fueron recolectados datos relativos a la caracterización de las participantes, y posteriormente se aplicó el cuestionario para responder los objetivos de la investigación. con el fin de preservar el anonimato, las participantes fueron identificadas con la letra e (entrevistada), seguida de un número, en secuencia de 1 a 20, respetando el orden de realización de las entrevistas. el estudio recibió aprobación del comité de ética y pesquisa (cep) de la escuela de enfermería anna nery y del hospital escuela são francisco de assis de la universidad federal de rio de janeiro, bajo el protocolo n°41/10, según prevé la resolución 196/96, en cuanto a los aspectos éticos. el análisis de los resultados siguió las directrices del análisis de contenido (8) compuesto por: preanálisis, fase de organización y sistematización de las ideas iniciales; exploración del material, que consistió en operaciones de codificación del material obtenido; tratamiento de los resultados, inferencia e interpretación, en esta etapa los resultados fueron tratados de manera que fuesen significativos y válidos. en síntesis, el análisis de contenido buscó identificar las ideas convergentes, agrupar y categorizar las informaciones con el fin de dar respuesta al objetivo de la investigación. inicialmente se realizó la organización y lectura del material recolectado en el campo empírico de la investigación, enseguida se hicieron sucesivas lecturas, visando la exploración y la construcción de categorías empíricas por convergencia de ideas. por último, los resultados fueron analizados, interpretados y discutidos con base en la literatura que aborda la temática. resultados y discusión las participantes se encontraban en una franja de edad entre los 18 y 39 años. se observó una predominancia de mujeres adultas con 13 embarazadas (de 25 a 39 años) y 7 mujeres jóvenes (18 a 23 años). a partir de los resultados obtenidos constatamos que hay una mayor comprensión entre esas embarazadas en cuanto a la necesidad de la búsqueda de asistencia al prenatal, lo que coincide con los preceptos del ministerio de la salud sobre la importancia del acompañamiento de la atención a la madre y el bebé durante el embarazo. verificamos que trece de las embarazadas entrevistadas, representando la mayoría, tienen educación media completa, lo que puede ser considerado un grado elevado de instrucción para la realidad brasileña pues, de acuerdo con los estudios (9), hasta 65,21 % de la población femenina de la región metropolitana de rio de janeiro sobrepasa los ocho años de escolaridad; en este sentido, 60 % de las embarazadas entrevistadas se encuentran en este grupo social. este nivel de escolaridad se muestra pertinente para la comprensión de la participación femenina en el mercado de trabajo, una vez que existe una relación entre escolaridad y acceso a oportunidades y estabilidad en el mercado de trabajo. en cuanto a la situación conyugal, 15 de las entrevistadas (75 %) declararon estar en relación estable, viviendo con el compañero o marido, y solamente 5 eran solteras (25 %). aunque la constitución federal de brasil reconoce la unión libre, socialmente esta todavía es objeto de posiciones tanto conser201 la calidad de asistencia de enfermería en el periodo prenatal desde la perspectiva de la mujer embarazada l maria aparecida vasconcelos-moura y otros. vadoras como tolerantes, influenciadas por los diferentes contextos y factores sociales, tales como clase social, edad y género (10). considerando la variable lugar de residencia observamos que la mayoría de las embarazadas no vivía en el área del hospital-escuela y provenían de otros municipios, desde donde se desplazaban para hacer el control prenatal en esta institución de referencia de atención básica a la salud en el sistema único de salud. en el desarrollo de un proceso es importante contar con un equipo de recepción bien entrenado y consciente del trabajo integrado, receptivo y con buen trato, a fin de poder obtener la adhesión de las embarazadas que buscan el servicio y ofrecerles atención de mejor calidad (11). las siguientes categorías buscan la comprensión de la visión de las participantes del estudio sobre los resultados que emergieron en los momentos de verdad, y las expectativas y necesidades de la asistencia en el prenatal desde una perspectiva de la calidad de la atención. categoría 1. visión de las embarazadas acerca de la calidad de la asistencia en la consulta de enfermería en el prenatal un modelo de asistencia está determinado por una racionalidad que indica la acción, las prácticas o los procesos de trabajo en salud (12). por tanto, dicho modelo también produce valores, reglas, procedimientos, rituales, una cultura que se expresa en los saberes y en sus prácticas, es decir, el modo de producción de cuidados (13). la calidad es algo individual, donde cada uno, de acuerdo con su propia percepción y cultura, tendrá una representación distinta de su significado, esto es, su propio concepto acerca del servicio de salud recibido. la calidad de la asistencia de enfermería es, por tanto, influenciada por diversos factores, sea por los profesionales de la salud o por los servicios ofrecidos. la cualificación de la atención prenatal, del parto y el puerperio debe propender por garantizar una buena condición de salud tanto para la mujer como para el recién nacido, así como por posibilitar a la mujer una experiencia de vida gratificante en este periodo. en este contexto es necesario que los profesionales involucrados en el proceso asistencial estén conscientes de la importancia de su actuación y de la necesidad de combinar el conocimiento técnico específico con el compromiso con un resultado satisfactorio en la atención, teniendo en cuenta el significado de este resultado para cada gestante. la consulta prenatal, para muchas mujeres, constituye la única que tienen para verificar su estado de salud; se debe considerar también como una oportunidad para que el sistema pueda actuar integralmente en la promoción y, eventualmente, en la recuperación de su salud (2). los testimonios nos permitieron conocer la visión de las embarazadas en relación con la atención, el respeto, el escuchar y la atención que expresan las necesidades mínimas que el equipo de servicios puede ofrecer a las clientes, y que son fundamentales para la calidad de atención prestada, conforme se señala en los testimonios que siguen: ¡óptimo! desde el primer día fui bien orientada en el prenatal. cuando llegué yo no sabía cómo moverme aquí, y el chico de la puerta me trajo hasta aquí. fui bien acogida, me gustó (e18: 38 años, embarazada v). ¡muy bueno, excelente! mucho mejor que en las unidades de salud. yo estaba haciendo prenatal en la unidad de salud. ¡dios! ¡aquí es mucho mejor, muy bien atendida, es diferente por eso! (e6: 19 años, embarazada i). yo creo que es de buena calidad la atención aquí, son enfermeras, ¿verdad? entonces, ellas son muy atenciosas. me atienden como quiero, me está gustando (e8: 19 años, embarazada i). según la organización mundial de salud (oms) existen elementos que repercuten directamente en la calidad de la asistencia: un alto grado de competencia del profesional, minimización de los riesgos, alto grado de satisfacción de los pacientes y un efecto favorable en la salud de la paciente asistida (14). por tanto, es durante el cambio de informaciones y el diálogo que la enfermera puede detectar indicios de situaciones o necesidades específicas, así como programar orientaciones de acuerdo con las expectativas individuales, a fin de aumentar la calidad de la asistencia ofertada. todas las embarazadas que participaron en este estudio se refirieron a la asistencia prenatal de la institución como satisfactoria, principalmente por el hecho de ser bien atendidas en las consultas: 202 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 lo que más me gustó fue la atención. aquí los profesionales son más educados, ¿entiendes? son más atentos. antes, en el hospital que fui, el médico ni siquiera me miraba. de ahí que desistí, como no fui bien atendida, no regresé. yo no quiero ser “mimada”, pero creo que se debe tener respeto, un poco más de atención. a veces la persona tiene algún problema y ellos ni siquiera lo sabrán. aquí es diferente (e20: 35 años, embarazada iv). me gustó la atención que él dispensa, el enfermero explica todo lo que está haciendo, me dice qué está ocurriendo con mi cuerpo y no había eso en mis otros embarazos, iba el día programado, el médico me consultaba, me decía que estaba todo bien y se acababa. el enfermero explica todos los detalles del embarazo, es completamente distinto de los médicos. las dudas que yo tenía ya fueron aclaradas (e18: 38 años, embarazada v). el paciente es el punto de partida para que exista calidad en la atención. uno debe escucharlo y cuestionarlo acerca de la asistencia prestada para que las informaciones sean procesadas y desarrolladas a fin de perfeccionar la atención en los servicios y obtener la satisfacción de la gestante (7). frente a la dimensión estructural de la institución escenario de la investigación es importante destacar que para alcanzar la calidad de la asistencia se hace necesario invertir en los profesionales de la salud. esos aspectos que serán considerados se refieren al cuantitativo de recursos humanos, a la jornada de trabajo, a la cualificación de sus profesionales y de los servicios ofrecidos, a la motivación en el trabajo, al sueldo y al estrés al cual están expuestos (15). en la visión de las embarazadas y como resultado de una asistencia de calidad percibimos que ellas consideran la atención de los enfermeros como más dedicada, más minuciosa, con respeto y preocupación para aclarar las dudas. ellas sienten la diferencia en relación con la atención del médico debido a la forma sucinta con la cual este conduce la consulta, y resaltan la carencia que sienten cuando el médico no las escucha. la percepción de la calidad en la atención del prenatal expresada por las embarazadas también nos mostró las dificultades del servicio respecto al mantenimiento y la oferta de asistencia de calidad, como se pudo percibir en los testimonios: soy bien atendida. lo malo es que no encaminan directamente para tener el bebé, a la maternidad. eso estaría maravilloso… lo que me preocupa es llegar a 41, 42 semanas de embarazo y que no hayan hecho el parto. es que aquí no tienen maternidad, solo atienden el prenatal en ambulatorio (e14: 29 años, embarazada i). creo que sí, que el servicio siempre puede mejorar. si el profesional se siente bien, en un ambiente adecuado […] el que ve desde afuera no piensa que las cosas funcionen tan bien y que aquí hay varios servicios. (e4: 27 años, embarazada i). se hace importante reformar [el hospital], para ser una tarjeta postal. y ampliar para una maternidad, ya que se hace aquí el prenatal, podría haber la maternidad. un profesional complementando el servicio del otro. la embarazada iría directamente, creo que facilitaría bastante. creo que tener una persona auxiliando, para ayudar a coger el prontuario, sábanas... esas cosas, el servicio sería más rápido. agilizaría la buena atención (e 19: 35 años, embarazada ii). la asistencia algunas veces puede verse perjudicada por la falta de material, recursos humanos e infraestructura para proporcionar un examen completo y de calidad que atienda a las particularidades de una consulta prenatal. la falta de la maternidad en el hospital-escuela para la atención del parto y el nacimiento del bebé es otra gran preocupación que persiste en todas las embarazadas atendidas, pues realizar el prenatal en esta institución no asegura a la embarazada que, cuando llegue el momento del parto, tendrá acceso y será bien atendida en otro hospital. conforme a los testimonios de las embarazadas existen factores desfavorables a la calidad en el prenatal ofertado en la institución, entre ellos está el hecho de que el servicio no dispone de una maternidad para partos y también la fragilidad en las remisiones a otros servicios de la red de salud, que no garantizan el acceso a las maternidades por ocasión del parto. con relación a esta problemática, el acompañamiento prenatal y la falta de maternidad para la realización del parto llevan a la quiebra de asistencia, pues la mayoría de las veces la embarazada recibe asistencia en una unidad hospitalaria con la cual no tiene familiaridad, y tampoco está cercana a los profesionales, desconociendo totalmente el equipo (16). no cabe duda de que tal alejamiento contribuye a aumentar el nivel de ansiedad y preocupación de la mujer durante el embarazo. otro indicador desfavorable a la calidad en el prenatal de la institución, citado por las embarazadas, se refiere a la estructura 203 la calidad de asistencia de enfermería en el periodo prenatal desde la perspectiva de la mujer embarazada l maria aparecida vasconcelos-moura y otros. del servicio, que incluye la falta de material, equipamientos y estructura física apropiada para la atención. esa realidad, a pesar de ser común en varias instituciones públicas de salud, necesita ser evaluada y modificada cuando se busca la calidad en los servicios. entre los elementos esenciales para alcanzar los principios de humanización y calidad figuran la capacitación técnica de los profesionales de la salud y funcionarios de los servicios contenidos en las acciones de salud para el uso de la tecnología adecuada; el acogimiento humanizado y las prácticas educativas al usuario y la comunidad; el acogimiento amigable en todos los niveles de asistencia, con la solución de los problemas, garantizando la autonomía en los procesos decisorios en todos los momentos de la atención (11). el hecho de que la mayoría de las embarazadas sean oriundas de otros municipios, principalmente porque no encuentran atención adecuada en sus municipios, o cuando la encuentran no la consideran satisfactoria o no consiguen una vacante, demuestra la importancia de esa institución como referencia para ese tipo de atención en el sistema público de salud. otra variable relevante en la caracterización de las embarazadas fue el alto nivel de escolaridad de la mayoría, lo que contribuye a facilitar la comunicación y la comprensión de las orientaciones durante la consulta del prenatal. existen implicaciones negativas importantes para la salud materna en el hecho de que la embarazada no encuentre servicios de salud disponibles y de calidad próximos a su lugar de residencia. las historias de las mujeres en la búsqueda de los servicios de salud expresan discriminación, frustraciones y violaciones de los derechos, y aparecen como fuente de tensión y malestar físico e psíquico. por esta razón, la humanización y la calidad de la atención a la mujer implican la promoción, el reconocimiento y respeto de los derechos humanos dentro de un marco ético que garantice la salud integral y su bienestar (1). el momento de verdad expresado por las embarazadas indicó un servicio prenatal que las tiene en cuenta, principalmente en cuanto a la calidad en la consulta de enfermería, incluyendo el acogimiento, la atención y el servicio ofrecido. verificamos que todos en la organización, desde el más alto ejecutivo hasta el funcionario de base necesitan de orientación para comprender y realmente apreciar las cosas desde el punto de vista y de los sentimientos de la cliente (17). esta situación nos muestra la importancia de la atención cuando la gestante llega al servicio, pues es ahí donde empieza el primer momento de verdad en el cual la cliente inicia su observación sobre la atención y despierta su evaluación o análisis, pudiendo señalar su percepción sobre la asistencia prestada en los diferentes momentos. para cada momento de verdad en los diferentes servicios recibidos identificamos las experiencias que las gestantes consideran satisfactorias o insatisfactorias. de este modo, podemos planificar y analizar el momento de servicio como un todo e identificar las características globales que debemos administrar para ofrecer una experiencia de calidad (7). respecto a la visión de las gestantes en cuanto a la calidad del servicio prestado en el prenatal concordamos con la afirmativa, allí el manual (5) describe que: una atención prenatal y puerperal calificada y humanizada ocurre a partir de la incorporación de conductas acogedoras y sin intervenciones innecesarias; del fácil acceso a servicios de salud de calidad, con acciones que integren todos los niveles de la atención: promoción, prevención y asistencia a la salud de la gestante y del recién nacido. la consulta de enfermería en la asistencia a la embrazada fue citada como un indicador importante de la calidad en el servicio de prenatal. en esta consulta puede ocurrir la participación activa de la gestante a través de la interacción con el profesional enfermero(a), en la que ambos intercambian saberes e informaciones con miras a la promoción del autocuidado (5). en esa perspectiva, es a través de esta consulta que la enfermera y la embarazada encuentran un momento para el diálogo en el que pueden definir metas y objetivos para alcanzar, entre ellos la mejora de la calidad en la atención a la salud del binomio madre-hijo. igualmente, la valoración del trabajo en equipo y la satisfacción de todos los actores implicados en el cuidado, teniendo en cuenta que la mejora continua de la calidad asistencial debe ser considerada por los enfermeros como un proceso dinámico y exhaustivo de identificación de los factores intervinientes en el proceso de trabajo del equipo de enfermería (18). categoría 2. expectativas y necesidades de la asistencia a las embarazadas en el prenatal la investigación sobre las expectativas y necesidades de las embarazadas busca entender cuáles son los pensamientos y sen204 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 timientos en relación con el servicio producido en el momento en el cual entra en contacto con el mismo. lo que piensa la embarazada o lo que espera encontrar al llegar al servicio, y después de la primera atención, sus experiencias acerca de cómo fue atendida. lo que determina la calidad de la prestación del servicio será la comparación o impresión que la mujer describe de su expectativa y de sus necesidades de atención con aquella que fue prestada por los profesionales de la salud. para las embarazadas las expectativas en la asistencia variaban entre conseguir atención en el prenatal; ser bien asistidas; tener atención más completa, personal y única; y que fuesen examinadas por los profesionales de la salud con respeto, dignidad y calidad, hecho poco común en muchas instituciones de salud pública, conforme los testimonios: me quedé en la expectativa si conseguiría, porque la peor cosa que hay hoy en día es conseguir un [lugar para acompañamiento] prenatal. vivo en la ilha do governador, y mira dónde vine parar… en la ciudad busqué en todos lados en la ilha y no conseguí nada, ni en puesto y tampoco en el hospital. felizmente conseguí y me están atendiendo mucho mejor de lo que esperaba (e10: 23 años, embarazada ii). atiende [a las expectativas] todo. el enfermero explica todo. generalmente en otro hospital ellos [médicos] solo nos pesan, miden la tensión y solo, solo es diferente si la embarazada está con algún problema, de ahí sí que ellos nos dan más atención. aquí no, ellas [enfermeras] hacen de todo, examen en la barriga, del corazón del bebé, tensión y explican cada cosa que hacen y orientan [sobre los cuidados de la madre y del bebé] (e20: 35 años, embarazada iv). el embarazo no es una enfermedad, aunque ocurran numerosos cambios en el cuerpo y en el estado emocional y psicológico de la mujer, asociados al contexto socioeconómico y cultural en el cual esta se encuentra insertada. todos estos cambios hacen de este un momento único en la vida de la mujer, y cada una vive este proceso de embarazo de forma diferente, con todos sus tabús, miedos, angustias y fantasías, que deben ser valoradas por los profesionales de salud. en un prenatal de buena calidad esos aspectos son tenidos en cuenta y se implementan acciones concretas en el sentido de integrar la asistencia ofrecida (19). la atención prenatal, en general, envuelve procedimientos simples; en las consultas el profesional debe preparar a la gestante para el parto, ayudando a disminuir su ansiedad e inseguridad, así como el miedo al parto, al dolor, a que el bebé nazca con problemas, entre otros (2). en las declaraciones se percibe que las expectativas de las gestantes en relación con la atención recibida fueron resueltas y demostraron estar satisfechas, lo que evidencia la calidad de la atención por parte de los enfermeros, considerando las experiencias en otras instituciones de salud donde fueron atendidas. se hace esencial que los profesionales de la salud ofrezcan una atención integrada, con buena recepción y acogimiento en la consulta, que sea de calidad y satisfactoria. respecto a la enfermera, verificamos que todas las embarazadas señalan la calidad de la atención y expresan que fueron muy bien atendidas, mejor que en los demás lugares, atendiendo a sus expectativas, como podemos constatar a través de los testimonios que siguen: excelente [la atención], no hay de qué quejarse. atendió a mis expectativas, antes yo no sabía. ahora, gracias a dios, estoy bastante bien atendida, las personas son unos amores (e10: 23 años, embarazada ii). normal [la atención], como en los otros embarazos, pero aquí la atención está mejor. mis prenatales nunca fueron bien hechos como lo están haciendo acá. yo creía que sería como los otros, algo rápido, que el médico no te mira, escribe el nombre y te dice adiós (e20: 35 años, embarazada iv). es importante que cada profesional se sienta responsable por la asistencia en los diferentes momentos de verdad y servicios que reciben las gestantes, y que se preocupe por actuar de tal manera que esta vuelva al servicio. esto sucederá cuando la mayoría de los profesionales asuma el compromiso de poner a la mujer en primer lugar y se esmere en brindar una atención de calidad (7). en relación con las expectativas de la atención recibida durante las consultas percibimos, a través de los testimonios, que las embarazadas quedaron satisfechas y evidenciaron la diferencia de atención de los profesionales en este hospital comparada con las experiencias en otras instituciones. 205 la calidad de asistencia de enfermería en el periodo prenatal desde la perspectiva de la mujer embarazada l maria aparecida vasconcelos-moura y otros. conclusión los hallazgos de este estudio nos permitieron delinear el perfil de las embarazadas atendidas, cuyas características fueron mujeres jóvenes entre 18 y 39 años, casadas y la mayoría con un alto nivel de escolaridad, no residentes en el área de salud donde se localiza la institución, siendo oriundas de otros municipio de rio de janeiro, brasil. estas gestantes buscaron el servicio a través de amigas que realizaron el prenatal en la institución y consideraron satisfactoria la atención. en relación con la visión de las gestantes en cuanto a la atención prestada en el prenatal, todas las entrevistadas refirieron tener sus expectativas y necesidades bien atendidas. la calidad de la asistencia prestada está centrada, esencialmente, en la interacción con los profesionales de enfermería durante los momentos de verdad por los cuales entran en contacto con el servicio del hospital-escuela, caracterizado por una atención calificada, digna y respetuosa, poco encontrada en las instituciones públicas de salud en brasil. ellas tienen conocimiento sobre sus derechos y se declaran satisfechas simplemente por conseguir la atención. observamos que las gestantes entrevistadas presentaron puntos positivos y negativos, siendo satisfactorios los aspectos referentes a la atención y acogida recibida por los profesionales de salud en el prenatal. las gestantes se sienten seguras cuando las enfermeras prestan la consulta con acogida, escucha y orientación, aclarando dudas sobre la importancia del prenatal, las fases de la gestación y del autocuidado, y brindando conocimientos sobre este nuevo momento de la llegada de una nueva vida. afirmaron sentir una gran diferencia en el servicio prestado por los enfermeros, enfatizando la satisfacción de la calidad de la asistencia a través de la atención en el prenatal, con mucho cuidado y respeto. la insatisfacción de algunas gestantes entrevistadas se dio en relación con la infraestructura del ambiente, los recursos materiales específicos de la atención en la consulta prenatal, y la preocupación por la falta de maternidad en aquel hospital para asistir el parto. tal situación contribuye a la inseguridad materna respecto a los riesgos maternos y perinatales, y a la atención al parto. mejorar la calidad de la asistencia a la embarazada en el prenatal significa mejorar la propia capacidad de atención, reconocer y comunicar problemas relacionados con otros servicios, y realizar evaluaciones seguidas en los servicios que desarrollan estas actividades. es posibilitar la construcción de una cultura que hace de la excelencia del servicio prestado una misión reconocida por todos los miembros de la organización, incluso sus administradores, para hacer de la calidad del mismo la clave de funcionamiento de la institución de salud. referencias 1. ministério da saúde (br). política nacional de atenção integral à saúde da mulher: princípios e diretrizes. secretaria de atenção à saúde. brasília; 2007. 2. mininsterio de la saúde (br). manual técnico do pré-natal e puerpério. secretaria de estado da saúde de são paulo; 2010. 3. duarte sjh. representação social da gestante residente no marabá a respeito do pré-natal. [dissertação]. campo grande: universidade federal mato grosso do sul; 2006. 4. potter pa, perry ag. fundamentos de enfermagem. rio de janeiro: elsevier; 2005. 5. ministério da saúde (br). pré-natal e puerpério: atenção qualificada e humanizada. manual técnico. brasília; 2005. 6. minayo mcs. desafio do conhecimento: pesquisa qualitativa em saúde. são paulo: hucitec; 2007. 7. albrecht k. revolução nos serviços: como as empresas podem revolucionar a maneira de tratar os seus clientes. 3 ed. são paulo: pioneira; 1992. 8. bardin l. análise de conteúdo. 3 ed. lisboa: edições 70; 2009. 9. santos as, lovisi g, legay l, abelha l. prevalência de transtornos mentais nas tentativas de suicídio em um hospital de emergência no rio de janeiro. cad saúde pública. 2009;25(9):2064-74. 206 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 10. ministério da saúde (br). adendo especial novo código civil. lei n. 10.406, de 10 de janeiro de 2002. 53 ed. são paulo: saraiva; 2002. 11. meira mlf. a qualidade da assistência à gestante na testagem para o hiv no cta: uma contribuição da enfermagem. 2007. [dissertação]. rio de janeiro: escola de enfermagem anna nery, universidade federal do rio de janeiro; 2007. 12. paim js. modelos de atenção e vigilância de saúde. in: rouquayrol mz. epidemiologia & saúde. 6 ed. rio de janeiro: medsi; 2003. 13. pereira alf, moura mav. modelos assistenciais na atenção obstétrica e neonatal no sus, na perspectiva da humanização do parto e nascimento. proenf: saúde materna e neonatal. programa de atualização em enfermagem; abenfo. 2010;1:39-62. 14. oliveira fmcsn, ferreira ec, rufino na, santos ssm. educação permanente e qualidade da assistência à saúde: aprendizagem significativa no trabalho da enfermagem. aquichán. 2011;11(1):48-65,. 15. farias snp. qualidade de vida no trabalho: um enfoque para enfermagem em centro municipal de saúde. [tese]. rio de janeiro: escola de enfermagem anna nery, universidade federal do rio de janeiro; 2004. 16. lima yms. consulta de enfermagem pré-natal: a qualidade centrada na satisfação da cliente. [dissertação]. rio de janeiro: escola de enfermagem anna nery, universidade federal do rio de janeiro; 2003. 17. albrecht k, bradford lj. serviços com qualidade: a vantagem competitiva, como entender e identificar as necessidades de seus clientes. são paulo: makron books; 1992. 18. gabriel cs, gabriel ab, bernardes a, rocha flr, miasso ai. qualidade na assistência de enfermagem hospitalar: visão de alunos de graduação. rev gaúcha enferm. 2010;31(3):534. 19. barbosa ma. avaliação da assistência pré-natal de baixo risco no município de francisco morato. [dissertação]. são paulo: universidade de guarulhos; 2007. 07. cuidando al ad..(52 a 58) revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 52 resumen el propósito del artículo es describir, desde el ámbito universitario, la experiencia en la aplicación de la teoría del déficit de autocuidado (tdac) con la población adulta y anciana. se explican los procesos y resultados desde la preparación docente, la conformación de la asignatura, hasta el desarrollo de la experiencia práctica en el ámbito hospitalario y de la vida cotidiana. la experiencia muestra la adecuación de la tdac para abordar el cuidado de esta población y la necesidad de desarrollar otros estudios al respecto. palabras clave: teoría, teoría del déficit del autocuidado, adulto, anciano. abstract the purpose of the article is to describe from a university point of view, the experience in the application of self care deficit theory (scdt) with adults and the aged. the processes and results are explained, from teachers preparation, organization of the subject, to the development of practice experience at the hospital and at daily life. the experience shows the application of the scdt to give care to that population and the necessity to develop other studies. key words: theory, self care deficit theory, self care, adult, aged. alba lucero lópez díaz m.sc., ph.d. profesora-investigadora, departamento de enfermería, universidad de ciencias aplicadas y ambientales, udca. profesora, facultad de enfermería, universidad nacional de colombia, un. * este estudio nutre el proyecto de investigación “modelos y teorías de enfermería aplicados al pei de la universidad de ciencias aplicadas y ambientales, udca”. cuidando al adulto y al anciano 53 ¿por qué trabajar con teorías de enfermería en américa latina? la importancia de las teorías, modelos o marcos conceptuales de enfermería es bien documentada en la literatura internacional. ellas posibilitan estructura, organización del conocimiento de enfermería, la provisión de un significado sistemático, y explican, predicen e influyen la práctica de enfermería (2, 5, 6, 11). el uso de los modelos teóricos permite la racionalidad, reduce la intuición, genera delimitación del saber profesional y disciplinar. contribuye a proyectar el quehacer más allá de la técnica, de las rutinas y la tradición. fomenta un cuerpo de conocimientos sistemático, consistente con la ciencia (5). el escaso uso de los modelos teóricos y teorías de enfermería en américa latina es documentado por orrego et al. (9), quienes al analizar la producción científica en los coloquios panamericanos de enfermería, entre 1989 y 1998, observan que ningún trabajo presentado en los eventos usa como referente las teorías de enfermería. no ocurre lo mismo a nivel mundial. según kim (4), al analizar el panorama de la investigación en el mundo entre 1988 y 1992, encontró que el 51,8% de los grupos basan su investigación en una o varias teorías de enfermería. en colombia, la discusión sobre la pertinencia o no de adoptar una teoría de enfermería aún es vigente en el espacio académico. las posiciones se encuentran entre quienes opinan que una teoría encasilla el conocimiento de enfermería, en detrimento de la pluralidad, y los que señalan los modelos y teorías como productos de la realidad norteamericana, que difiere de nuestro contexto sociocultural. hay quienes opinan que la teoría pertenece al mundo de lo abstracto y contribuye poco a la práctica. es probable que para américa latina, en particular, el asunto teórico se encuentre en una fase de comprensión, donde se busca tener claridad sobre el objeto de la teoría para la disciplina y la práctica. de cualquier forma, desde la academia y la literatura se aconseja el pluralismo, como hecho necesario para abordar los fenómenos complejos de enfermería (1). el pluralismo, desde nuestra perspectiva, deberá ser asumido como la posibilidad de tomar una, dos o varias teoristas para explicar los fenómenos que se están abordando. de ninguna forma es la invitación a una moratoria en el uso de las teorías. para el educador, el investigador o el practicante, deberá ser claro que cada modelo o teoría va a generar estándares para la práctica de enfermería, ciertos propósitos que deberán ser alcanzados y algunos problemas clínicos que tendrán que considerarse. la teoría va a identificar los ámbitos donde la práctica puede aplicarse, y las características de los receptores del cuidado. establece los procesos y tecnologías que serán utilizados, incluyendo los parámetros para evaluación de los pacientes, el lenguaje para sus problemas, las tipologías de intervención y los criterios de evaluación de los resultados de esta (3). cabe señalar que avanzar en el uso de algún modelo teórico es entrar en el desafío de establecer el vínculo de la teoría/práctica, de la comprensión y sistematización de los fenómenos de el uso de los modelos teóricos permite la racionalidad, reduce la intuición, genera delimitación del saber profesional y disciplinar. contribuye a proyectar el quehacer más allá de la técnica, de las rutinas y de la tradición revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 54 interés, de generar un pensamiento crítico, del uso de un lenguaje propio y la motivación para generar, por qué no, nuevas teorías. ¿por qué elegimos la teoría del déficit del autocuidado? escoger una teoría para la docencia, la investigación y la práctica puede responder a procesos subjetivos y objetivos, de igual importancia en ambos casos (7). los criterios objetivos para evaluar una teoría reflejan el nivel de sofisticación del conocimiento, la adecuación de la teoría, los criterios externos e intrínsecos, la posibilidad de comprobación y los criterios de aceptación (1, 7, 12). los procesos subjetivos se refieren a las decisiones basadas en la congruencia o incongruencia de los presupuestos teóricos con los nuestros o los del programa educativo institucional (pei), a un escaso convencimiento de la experiencia efectiva del teórico, o simplemente al profesional de enfermería, que trabajó con un teórico y continúa utilizando su teoría. en la udca existe preocupación sobre la teoría más apropiada para su plan curricular, y viene desarrollando un trabajo investigativo, en cuya revisión bibliográfica fue evidente el alto porcentaje de reportes donde se mencionaba el uso de la teoría del déficit del autocuidado (tdac). encontrar tan significativa proporción de trabajos, además dirigidos a adultos y ancianos, nos dio un indicador objetivo de que la tdac contaba con una amplia divulgación profesional, con oportunidad de verificación y aceptación de la teoría en diferentes ámbitos. a esto se sumó, como criterio subjetivo, mi experiencia en el manejo de la teoría durante los estudios de postgrado. sin ser la teoría elegida para la carrera, decidimos emprender un ejercicio de aplicación, para conocer sus ventajas, desventajas y aplicabilidad en nuestro ámbito, y así determinar su posterior pertinencia para el pei. con estas razones, se organizó la asignatura de cuidado de enfermería al adulto y al anciano, desde la perspectiva teórica de orem. esta experiencia será la comentada en esta presentación, de la siguiente manera: un primer bloque, donde comentaremos de manera breve los principales conceptos y relaciones teóricas de la tdac, y un segundo bloque, constituido por cinco partes que sintetizan nuestra experiencia con la tdac. ¿en qué consiste la tdac? la tdac es el producto de un esfuerzo sistemático de más de 50 años de su autora, dorothea elizabeth orem, y su grupo, hoy constituido en la “international orem society for nursing science and scholarship”. publican periódicamente el international orem society newsletter y realizan conferencias bienales de la teoría del déficit del autocuidado. la última versión de la teoría se encuentra disponible en una edición de la editorial mosby: nursing: concepts of practice (8). la de orem es una teoría general, constituida por tres teorías: teoría del autocuidado (tac), teoría del déficit del autocuidado (tdac) y teoría de los sistemas de enfermería (tse). la tac tiene algunos conceptos clave para su comprensión. el autocuidado (ac) es el conjunto de acciones intencionales que realiza la persona para controlar factores internos o externos, que pueden comprometer su vida y su desarrollo posterior. las personas deben alcanzar algunos objetivos cuando se ocupan de su ac, los cuales se denominan como requisitos de autocuidado (rac), y son de tres tipos: requisitos universales, requisitos de desarrollo y requisitos ante el desvío de la salud. los primeros permiten el mantenimiento de la estructura y el funcionamiento humano, comunes a todos los individuos. los segundos se refieren a las condiciones de maduración y a los nuevos eventos cabe señalar que avanzar en el uso de algún modelo teórico es entrar en el desafío de establecer el vínculo de la teoría/práctica, de la comprensión y sistematización de los fenómenos de interés. cuidando al adulto y al anciano 55 en el ciclo vital. ejemplos de ellos pueden ser la adaptación a un nuevo trabajo, a la muerte de un ser significativo, a los cambios físicos. los últimos son los que se presentan cuando hay enfermedad o lesión, y deben mantenerse bajo tratamiento. orem parte de la premisa de que todo individuo está en capacidad de satisfacer su ac. lo explica mejor con el concepto de agencia de autocuidado (agac), que son las capacidades y el poder de la persona para cuidar de sí misma. quien posee esa agencia se denomina el agente de autocuidado (agt-ac), es decir, uno mismo. cuando las acciones de ac las debe realizar otra persona, se llama agente de cuidado al dependiente (agt-cd), y si son cuidados especializados, realizados por una persona con formación en enfermería, se denomina agente de cuidado terapéutico (agtct). otro concepto de gran importancia son los factores condicionantes básicos (fscb): edad, sexo, momento del ciclo vital, estado de salud, disponibilidad de recursos, nivel educativo, sistema familiar, orientación sociocultural. según orem, los fscb vienen a afectar la capacidad de ac del individuo, la cantidad o el tipo de ac requerido. la tdac describe y explica lo que la enfermería es y puede ser, una vez que orienta hacia cuándo hay necesidad de la enfermera. el déficit de autocuidado (dac) explica la relación entre las capacidades y el poder del individuo (ag-ac) para alcanzar los objetivos del ac (los r-ac). entonces, el dac no se refiere a una limitación específica, sino establece la relación entre lo que el individuo es capaz y la necesidad que posee. instalado el dac, se deben realizar acciones profesionales de enfermería durante algún tiempo para compensarlo; a esto orem lo llama demanda terapéutica de autocuidado (dtac). cuando existe el dac, el profesional de enfermería puede compensarlo por medio del sistema de enfermería (se), que puede ser: totalmente compensatorio, parcialmente compensatorio y de apoyo educativo. el tipo de sistema dice del grado de participación del individuo para ejecutar su ac, regular o rechazar el cuidado terapéutico. una persona o grupo puede pasar de un se a otro en cualquier circunstancia, o puede activar varios sistemas al mismo tiempo. ¿cuál fue el sendero recorrido en la aplicación de la tdac? tenemos la idea de que describir sistemáticamente nuestra experiencia, durante el segundo semestre de 2001 (ii/01) y el primer semestre de 2002 (i/02), podrá retroalimentarnos y ofrecer caminos a esfuerzos similares. es interesante y alentador observar la madurez adquirida entre la primera experiencia y la segunda. seguramente una tercera será mucho mejor. los diferentes momentos durante la aplicación de la tdac en la asignatura de cuidado de enfermería al adulto y al anciano, se denominan de acuerdo con la acción principal que se realiza: preparación del cuerpo docente, elaboración del programa, preparación y ejecución del componente teórico, preparación y ejecución del componente práctico y evaluación de la aplicación de la tdac en la asignatura. preparación del cuerpo docente es entendible que buena parte de los logros y dificultades para aplicar una teoría está en la preparación del cuerpo docente. serán los docentes los encargados de ofrecer la coherencia entre docencia, investigación y práctica inicialmente procedimos a la lectura, análisis y comprensión de la teoría de orem. fue importante contar con matebuena parte de los logros y dificultades para aplicar una teoría está en la preparación del cuerpo docente. serán los docentes los encargados de ofrecer la coherencia entre docencia, investigación y práctica. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 56 rial en español, la realización de varias sesiones de discusión grupal, la comprensión y análisis de los conceptos por medio de ejemplos prácticos. cuando hubo confusión en la interpretación de conceptos, el libro original fue el mayor auxiliador. por esto, es recomendable tener acceso al material original y a la versión más reciente de la teoría. igualmente, se sugiere la lectura de investigaciones que usen el modelo teórico, sin discriminar el sujeto de atención o el énfasis. elaboración del programa de la asignatura para elaborar el programa fue necesario deconstruir el lenguaje tradicional y el abordaje de los sujetos por patrones, patologías o sistemas alterados, y la división de lo biológico, psicológico y social. también se requirió incorporar desde el programa los conceptos clave de la teoría e integrar en los r-ac los aspectos bio-psico-sociales del adulto y el anciano. el programa quedó organizado en tres partes: la primera aborda generalidades, como los perfiles epidemiológicos del adulto y el anciano, y las políticas de salud para estos grupos etarios. la segunda estudia el cuidado de enfermería desde la perspectiva teórica de orem. analiza y valora los cambios de las personas adultas, de acuerdo con los r-ac universales y ante el desarrollo. se da a conocer el sistema de enfermería geronto-geriátrico y en el ambiente quirúrgico. en la última parte se abordan los desvíos de la salud de los adultos y los ancianos, de acuerdo con los r-ac. un ejemplo de esta organización es: conocer y planear la atención de enfermería al adulto y al anciano ante el desvío de la salud, relacionado con el requisito universal de mantenimiento del aporte suficiente de aire. las temáticas abordadas son: señales y síntomas de problemas respiratorios, evaluación diagnóstica de la función respiratoria, cuidados de enfermería al adulto y al anciano portador de problemas del tracto respiratorio superior, etc. preparación y ejecución del componente teórico en las primeras seis semanas, el estudiante tiene la oportunidad de acceder a los contenidos generales de la asignatura, que posteriormente profundizará en el componente práctico. en el ii/01, el profesor debió invertir tres veces más en la preparación de clase, debido a la nueva organización por r-ac, a la necesidad de adoptar el lenguaje conceptual de orem, a la búsqueda del desarrollo temático coherente con el modelo y al diseño de estrategias pedagógicas que facilitaran la comprensión de la temática. en el i/02 se recuperó la normalidad en la preparación de la clase. fue necesario crear un instrumento de valoración de enfermería, que permitiera tener los indicadores empíricos de la tdac. cuatro versiones del instrumento se obtuvieron durante el año transcurrido, y la quinta se utilizó en el segundo semestre de 2002. la versión final permite evaluar la ag-ac del adulto o el anciano, y la detección de la presencia o ausencia del dac. el instrumento está diseñado para profesionales y estudiantes de semestres avanzados, que conozcan el lenguaje clínico y dominen las técnicas de entrevista. para el i/02 se comenzó a estimular el conocimiento y el uso del instrumento desde el componente teórico, porque favorece la comprensión y el manejo práctico de la tdac. el proceso de enfermería se utiliza en su fase de valoración, de acuerdo con los r-ac, y la base es el instrumento. en la fase diagnóstica se optó por mantener el lenguaje de la nanda, a pesar de que orem cuenta con una propuesta de diagnósticos (10). la planeación inicialmente se discriminaba por el sistema de enfermería que sería activado, pero encontramos que esto complica la elaboración escrita del proceso de enfermería. se optó porque el estudiante justifique oralmente el tipo de sistema y escriba la ejecución, como se hace tradicionalmente. preparación y ejecución del componente práctico la experiencia práctica fue realizada durante doce semanas, en los ámbitos institucional y extramural. en el primero el estudiante permanece seis semanas con personas adultas y ancianas, ubicadas en los servicios de medicina interna y del área quirúrgica. en el ámbito extramural trabajan con ancianos que poseen alguna dificultad para salir del hogar, por medio de un programa de visita docuidando al adulto y al anciano 57 miciliaria, y con los ancianos reunidos en clubes de la tercera edad, con programas educativos. en el ámbito institucional, la implementación de la teoría se efectuó con estudios de caso. era necesaria la elaboración del instrumento y su respectivo proceso de enfermería. cotidianamente, el estudiante se estimulaba para que elaborara mentalmente el proceso de enfermería y realizara las anotaciones de acuerdo con el lenguaje de orem. sin embargo, es una actividad que se ve restringida por las rutinas de los servicios. nuevas estrategias deberán ser diseñadas. en la práctica con los clubes de ancianos, las estudiantes planearon y desarrollaron dos programas educativos, que se elaboraron evaluando los dac grupales, para poder realizar un trabajo acorde con las necesidades sentidas. el primer programa, desarrollado en el ii/01, buscó promover el ac de las personas ancianas, frente a los r-ac de tipo universal y ante el desvío de la salud. es decir, se trabajó sobre el reconocimiento de cambios propios en la vejez, el conocimiento sobre el control de las patologías referidas y el autocuidado con los regímenes terapéuticos. el segundo programa, desarrollado en el i/02, buscó promover el ac de los ancianos, frente a los r-ac de promoción de la normalidad y los r-ac para el desarrollo. se abordaron estrategias para el manejo de conflictos en las relaciones familiares, la mejora de la autoestima, los derechos de la persona de la tercera edad, el rescate de la autonomía y la independencia. el programa de visita domiciliaria buscaba organizar, con el adulto mayor y el agt-cd, un sistema de apoyo educativo y parcialmente compensatorio, para facilitar y promover el ac del adulto mayor discapacitado. inició con cuatro personas ancianas, en el ii/02; fue necesario hacer planes de cuidado para dos agtcd, por encontrarse cansancio en el desempeño del rol de cuidador. los dac más frecuentemente encontrados en los planes corresponden a los r-ac ante el desvío de la salud y universales, como el de prevención de peligros para la vida, la funcionalidad y el bienestar, el mantenimiento del equilibrio entre soledad e interacción social, la promoción de la normalidad, los cuidados asociados con la eliminación y la excreción, y el mantenimiento del equilibrio entre actividad y reposo. se ejecutaron entre catorce y dieciocho visitas domiciliarias, en un período de doce semanas. se observó que los adultos mayores y sus cuidadores alcanzaron mayores niveles de autocuidado, y potencializaron sus capacidades y conocimientos para cuidarse. evaluación de la aplicación de la tdac la evaluación se realiza tanto en la docencia, como en la práctica, la investigación y la difusión de resultados. en la docencia, la tdac permitió una nueva organización curricular y de pensamiento, tanto para docentes como para estudiantes. posibilitó un nuevo lenguaje y nuevas perspectivas para abordar el cuidado de los adultos y los ancianos en diferentes ámbitos. en el proceso de enseñanza/aprendizaje, al estudiante se le permite generar un proceso cognitivo organizado y secuencial. el reto es mantener a los docentes preparados en el uso de la tdac, tanto en el componente teórico como práctico, para poder conservar la coherencia entre teoría/práctica. mantener esa anhelada coherencia es responsabilidad institucional y del grupo docente participante del desarrollo curricular. institucional, porque necesitará propiciar la capacitación de todos los docentes involucrados en la asignatura, y generar espacios para la instrucción de los docentes nuevos. además, promover la formación continuada en los avances teóricos, por medio de la participación en eventos, la vinculación a las asociaciones y redes, y la adquisición de libros y revistas específicas. la responsabilidad del grupo docente tiene que ver con el compromiso de hacer uso de las posibilidades institucionales, la constante indagación, la sistematización de los hallazgos y la formulación de propuestas que mantengan la coherencia teórico/práctica/investigativa. el lenguaje de la teoría deberá ser reforzado por los docentes en los diferentes ámbitos; este es un esfuerzo permanente, ya que existe la tendencia del docente a utilizar su anterior vocabulario. en la práctica, la tdac contribuye al desarrollo del pensamiento crítico del estudiante y la correlación de hallazgos, y refuerza la justificación teórica para la implementación del plan de cuidado. la aplicación del instrumento y del proceso de enfermería facilita el abordaje de la revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 58 teoría en la práctica, y posibilita que el profesor y el estudiante detecten las necesidades particulares de aprendizaje. individualiza las necesidades y las acciones profesionales que van a ser ejecutadas con los agentes de autocuidado, sean grupos o sujetos. da soporte teórico al quehacer de enfermería y genera actitudes de autonomía y seguridad en el estudiante. posibilita generar una imagen social de independencia. la experiencia con la tdac señala la viabilidad de su aplicación en los contextos de la práctica propuestos para esta asignatura. sería interesante promover nuevas estrategias metodológicas en el ámbito de la práctica institucional, que refuercen el uso de la tdac. se necesita hacer cada vez más esfuerzos, para que tanto profesores como estudiantes usen el lenguaje teórico, sin mezclarlo con otros abordajes. en la investigación, a pesar de no llevarse un proceso investigativo formal en este período, los diferentes pasos de implementación del modelo pueden considerarse pequeños estudios descriptivo-exploratorios, con un alto componente de observación, medición y corrección para poder presentar estos resultados. es conveniente comenzar a elaborar proyectos formales, que puedan arrojar nuevos hallazgos sobre el uso de la tdac en la docencia, la asistencia y la práctica. igualmente, sería importante determinar correlaciones más refinadas de presupuestos y conceptos teóricos, con aspectos del cuidado del adulto y el anciano en sus diferentes ámbitos. podría explorarse la posibilidad de desarrollar proyectos de investigación, con el apoyo financiero de la international orem society. la divulgación ha sido un esfuerzo deliberado, porque la entendemos como una forma de obligar a sistematizar los esfuerzos, hallazgos y análisis en la implementación de la teoría. permite construir un grupo de experiencias en latinoamérica, quizá para llegar a aportar a emprendimientos similares. además, favorece el debate con los pares académicos. referencias bibliográficas 1. durán, m. m. de. enfermería: desarrollo teórico e investigativo, ed. universidad nacional, bogotá, 181 p., 1998. 2. fawcett, j. “the state of nursing science: hallmarks of the 20th and 21st centuries”, nursing science quarterly, vol. 12, no. 4, pp. 311-318, 1999. 3. fawcett, j. “conceptual models and nursing practice: the reciprocal relationship”, journal of advanced nursing, vol. 17, pp. 224-228, 1992. 4. kim, m. i. “nursing research: a worldwide picture”, revista da escola de enfermagem, vol. 26, número especial, pp. 7-22, 1992. 5. mckenna, g. “unique theory is it essential in the development of a science of nursing?”, nurse education today, vol. 13, pp. 121-127, 1993. 6. meleis, a. j. la relación entre la teoría, la práctica y la investigación con la calidad del cuidado de enfermería. memorias de las ponencias centrales y paneles. vii coloquio panamericano de investigación en enfermería, 9 al 12 de octubre de 2000, bogotá, colombia, pp. 86-94, 2000. 7. meleis, a. j. theoretical nursing: development and progress, ed. j. b. lippincott (philadelphia), cap. 7, 1985. 8. orem, d. e. nursing: concepts of practice, ed. mosby year book co. (st. louis), 6ª ed., 2001. 9. orrego, s.; castrillón, m. c.; nájera, r. m.; salazar, m. o. estado del arte de la investigación presentada en los coloquios panamericanos de investigación en enfermería: 1988-1998, url: http://www.r-e-a-l.org/consuelo, 2000. 10. ostiguín, r. m.; velázquez, s. m. teoría general del déficit de autocuidado: guía básica ilustrada, ed. el manual moderno (méxico), 68 p., 2001. 11. ray, m. “complexity and nursing science”, nursing science quarterly, vol.11, no. 3, pp. 91-93, 1998. 12. stevenes, b. nursing theory: analysis, application, evaluation, ed. little brown and company (boston/toronto), cap. 1, 1984. cuidando al adulto y al anciano 59 09 20 diferencias de genero en la percepcion.indd 9 sonia betzabeth ticona benavente1 erika maria santos monteiro2 ana lucia siqueira costa3 diferencias de género en la percepción de estrés y estrategias de afrontamiento en pacientes con cáncer colorrectal que reciben quimioterapia 1 universidad de são paulo. brasil. sonibenavente@usp.br 2 ac camargo cancer center. brasil. erikammsantos@gmail.com 3 universidad de são paulo. brasil. anascosta@usp.br recibido: 03 de marzo de 2013 enviado a pares: 12 de mayo de 2013 aceptado por pares: 12 de diciembre de 2014 aprobado: 19 enero de 2015 doi: 10.5294/aqui.2015.15.1.2 para citar este artículo / to reference this article / para citar este artigo ticona benavente sb, santos monteiro em, siqueira costa al. diferencias de género en la percepción de estrés y estrategias de afrontamiento en pacientes con cáncer colorrectal que reciben quimioterapia. aquichan. 2015;15(1):9-20. doi: 10.5294/aqui.2015.15.1.2 resumen objetivo: verificar si existen diferencias de género en la percepción de estrés y estrategias de afrontamiento; identificar las estrategias de afrontamiento y las variables clínicas y sociodemográficas que influyen sobre el estrés de pacientes con cáncer colorrectal en quimioterapia. materiales y métodos: estudio transversal con abordaje cuantitativo. conformaron la muestra 100 pacientes, 47 mujeres y 53 hombres, de la unidad ambulatoria de quimioterapia del ac camargo cancer center, brasil. se utilizó la escala de estrés percibido (pss-10) e inventario de estrategias de coping. el análisis estadístico fue mediante el test-t, correlación de pearson y regresión linear con 95 % de intervalo de confianza. resultados: las mujeres tuvieron más altos niveles de estrés (p = 0,029), y no hubo diferencia de género en las estrategias de afrontamiento. adicionalmente, identificamos influencia positiva al estrés percibido en pacientes comprometidos con otras enfermedades (β = 3,50, p = 0,00), género femenino (β = 3,15, p = 0,04), viudos (β = 9,19, p = 0,00), tratamiento con fluorouracil (β = 6,36, p = 0,00), que usan estrategias de dominio del afrontamiento (β = 0,70, p = 0,00), aceptación de responsabilidad (β = 0,45, p = 0,01) y estadio del tumor iii (β = 4,03, p = 0,05). conclusiones: el equipo de enfermería oncológica, por estar en estrecho y prolongado contacto con los pacientes, debe considerar el género y las características clínicas y sociodemográficas de cada paciente durante su cuidado. palabras clave estrés psicológico, adaptación psicológica, neoplasias, pacientes, identidad de género, neoplasias colorrectales (fuente: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 9-20 10 aquichan issn 1657-5997 año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 9-20 gender differences in perceived stress and coping strategies among colorectal cancer patients receiving chemotherapy abstract purpose: the purpose of the study was to verify whether or not there are gender differences in the perception of stress and in coping strategies. it also was designed to identify coping strategies and clinical and socio-demographic variables that influence colorectal cancer patient stress in chemotherapy. materials and methods: this is a cross-sectional study with a quantitative approach. the sample was comprised of 100 patients: 47 women and 53 men, from the outpatient chemotherapy unit at the ac camargo cancer center in brazil. the perceived stress scale (pss-10) and the coping strategies inventory were used. statistical analysis was done using the t-test, pearson correlation and linear regression with 95 % confidence interval. findings: women had higher stress levels (p = 0.029), and there was no gender difference in coping strategies. in addition, a positive influence on perceived stress was identified in patients compromised by other diseases (β = 3.50, p = 0.00), females (β = 3.15, p = 0.04), widowers (β = 9, 19, p = 0.00), treatment with fluorouracil (β = 6.36, p = 0.00), patients using coping strategies (β = 0.70, p = 0.00), acceptance of responsibility (β = 0.45, p = 0.01) and stage iii tumor (β = 4.03, p = 0.05). conclusions: because the oncology nursing team is in close and prolonged contact with patients, it should take into account each patient’s gender and clinical and socio-demographic characteristics when providing care. keywords psychological stress, psychological adjustment, neoplasias, patients, gender identity, colorectal neoplasms (source: mesh, bireme). 11 diferencias de género en la percepción de estrés y estrategias de afrontamiento en pacientes con cáncer... l sonia betzabeth ticona benavente y otros diferenças de gênero na percepção de estresse e estratégias de enfrentamento em pacientes com câncer colorretal que fazem quimioterapia resumo objetivo: verificar se existem diferenças de gênero na percepção de estresse e estratégias de enfretamento; identificar as estratégias de enfrentamento e as variáveis clínicas e sociodemográficas que influenciam no estresse de pacientes com câncer colorretal em quimioterapia. materiais e métodos: estudo transversal com abordagem quantitativa. a amostra está formada por 100 pacientes (47 mulheres e 53 homens), da unidade ambulatória de quimioterapia do ac camargo cancer center, brasil. utilizaram-se escala de estresse percebido (pss-10) e inventário de estratégias de coping. a análise estatística se deu mediante o teste-t, correlação de pearson e regressão linear com 95 % de intervalo de confiança. resultados: as mulheres tiveram mais altos níveis de estresse (p = 0,029) e não houve diferença de gênero nas estratégias de enfrentamento. além disso, identificamos influência positiva no estresse percebido em pacientes comprometidos com outras doenças (β = 3,50, p = 0,00), gênero feminino (β = 3,15, p = 0,04), viúvos (β = 9,19, p = 0,00), tratamento com fluorouracil (β = 6,36, p = 0,00), que usam estratégias de domínio do enfrentamento (β = 0,70, p = 0,00), aceitação de responsabilidade (β = 0,45, p = 0,01) e estágio do tumor iii (β = 4,03, p = 0,05). conclusões: a equipe de enfermagem oncológica, por estar em contato direto e prolongado com os pacientes, deve considerar o gênero e as características clínicas e sociodemográficas de cada paciente durante seu cuidado. palavras-chave estresse psicológico, adaptação psicológica, neoplasia, pacientes, identidade de gênero, neoplasias colorretais (fonte: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 9-20 12 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 introducción el cáncer es una de las principales causas de muerte en el mundo; según la organización mundial de la salud (oms), en 2012 hubo 14,1 millones de casos nuevos de cáncer a nivel mundial, 8,2 millones de muertes y 32,6 millones de individuos con hasta cinco años de prevalencia (1). se observa que la mayoría de los casos nuevos fueron en la regiones de áfrica, asia, centroamérica y sudamérica, representando el 60 % (1). el cáncer colorrectal representa el 9,7 % de los casos nuevos de todos los tipos de cáncer, siendo el tercero más frecuente en el mundo entre hombres y mujeres (2). en brasil, el cáncer colorrectal es el tercer tipo de cáncer más frecuente entre hombres y mujeres, sin considerar los tumores de piel no melanoma (3). de acuerdo con las estimaciones del instituto nacional del cáncer josé alencar gomes da silva (inca) para 2014, esta enfermedad representará el 5,0 % (15.070) de casos nuevos entre hombres, y 6,4 % (17.530) en mujeres. adicionalmente, el estado de são paulo tiene uno de los índices más altos de este tipo de cáncer, donde en 2014 fueron estimados 11.560 casos nuevos (3). en este sentido, la ciudad de são paulo, con sus características metropolitanas en constante actividad, favorece que las personas adquieran hábitos alimenticios nocivos para la salud (4), como consumo de carnes grasas, alcohol, alimentos bajos en fibras, vida sedentaria, descanso reducido y estrés laboral, hábitos que contribuyen con el surgimiento y desarrollo de esta enfermedad. la presente investigación está basada en el modelo interaccionista del estrés de folkman y lazarus que explora la relación del individuo con el ambiente (5). los autores indican que el estrés surge a partir de una serie de fenómenos subjetivos que el individuo experimenta cuando las exigencias de un evento superan sus recursos de adaptación y ponen en peligro su bienestar personal. una vez que un evento es percibido como estresante se inicia el proceso del uso de estrategias de afrontamiento, definidas como las acciones o los recursos personales que tienen como objetivo de afrontar demandas internas o externas. asimismo, las estrategias de afrontamiento al estrés —también llamadas estrategias de coping— se agrupan en dos grandes áreas: el problema, que se refiere a acciones orientadas a resolver el evento estresor alterándolo directamente; y la emoción, que se refiere a las acciones dirigidas a regular la respuesta emocional para disminuir los aspectos negativos del estrés (5). el cáncer, más allá de ser definido como un conjunto de más de cien enfermedades, es sinónimo de una patología devastadora que genera un enorme sufrimiento. estudios muestran que una enfermedad crónica con la magnitud del cáncer, está relacionada con diversos estresores como los emocionales (6), físicos, sociales, existenciales (7) y financieros (8), ocasionando cambios significativos en el estilo de vida del individuo (6), y en su calidad de vida (7). lo anterior se observa particularmente en el cáncer colorrectal, ya que debido a la localización del tumor existe la posibilidad terapéutica de desvío del tracto intestinal originando una colostomía, lo que contribuye a preocupaciones sobre el cuidado con la dieta, restricciones al escoger la vestimenta, el cuidado con la bolsa colectora y su autocuidado (9), así como cambios en las actividades sociales, sexuales y diarias, lo que provoca un comportamiento de aislamiento (7), vivencias que pueden contribuir a la percepción del estrés. la literatura verifica la presencia del estrés psicológico en la experiencia de todo paciente oncológico. en ese sentido, una investigación afirma que durante todo el tratamiento de la enfermedad, el individuo experimenta diferentes situaciones de estrés, no solo en el momento de la confirmación del diagnóstico sino también antes del tratamiento antineoplásico, y, especialmente, entre pacientes que reciben quimioterapia (10, 11), por ser este un tratamiento sistémico y agresivo debido a los efectos secundarios. adicionalmente, la literatura muestra que la percepción de estrés varía entre hombres y mujeres; así, la presencia de un estresor en particular puede tener un fuerte efecto en mujeres pero no en hombres. un estudio realizado en sobrevivientes de melanoma identificó que las mujeres presentan más estrés que los hombres (12). otra investigación, al comparar la percepción de estrés entre hombres y mujeres, en una muestra de 400 pacientes con cáncer colorrectal, verificó altos niveles de estrés en el género femenino (13). de igual forma, las diferencias de género en relación con la preferencia de uso de estrategias de afrontamiento se muestran relevantes. un estudio en sobrevivientes de melanoma encontró que las mujeres utilizan con menor frecuencia la evaluación cognitiva para escoger las estrategias de afrontamiento y se orientan más al apoyo social, al contrario de los hombres, que prefieren estrategias orientadas a la resolución de problemas (12). otro 13 diferencias de género en la percepción de estrés y estrategias de afrontamiento en pacientes con cáncer... l sonia betzabeth ticona benavente y otros estudio en pacientes con cáncer colorrectal identificó que las mujeres se muestran más dispuestas a discutir sobre sus preocupaciones que los hombres (14). en consecuencia, deberían ser consideradas las diferencias de género en la percepción del estrés y en la utilización de las estrategias de afrontamiento. en una revisión de la literatura se analizaron las diferencias de género en la percepción de estrés en individuos saludables (15) y en pacientes con enfermedades crónicas, como el trastorno por estrés postraumático (16), cáncer (12, 14) y enfermedad pulmonar obstructiva (17). la necesidad de realizar esta investigación surgió porque se identificó una escasez de estudios que consideren las diferencias de género en la percepción de estrés y estrategias de afrontamiento en pacientes oncológicos y, en menor número, estudios dirigidos a pacientes con cáncer colorrectal. adicionalmente, debido a la importancia de estudiar al paciente como un individuo, se identificaron estudios que analizan el género basados en enfermedades que lo caracterizan, como el cáncer de mama o el cáncer ginecológico en mujeres, y el cáncer de próstata en hombres, inhibiendo la comparación entre géneros. este estudio pretende encontrar resultados relevantes de manera que el entendimiento sobre las diferencias de género en la percepción de estrés y estrategias de afrontamiento entre pacientes con cáncer colorrectal que reciben quimioterapia sea ampliado, con la propuesta de que las diferencias e individualidades sean consideradas e incorporadas en la evaluación y definición del abordaje del paciente por el equipo de enfermería oncológica y otros profesionales que hacen parte del equipo de salud. objetivos el presente estudio tiene como objetivos: 1) analizar las diferencias de género en la percepción de estrés y el uso de estrategias de afrontamiento de pacientes con cáncer colorrectal que reciben quimioterapia; 2) investigar si el género, las estrategias de afrontamiento y las variables sociodemográficas están asociadas con la intensidad del estrés entre estos pacientes, 3) evaluar la confiabilidad de los instrumentos utilizados. materiales y métodos este es un estudio transversal, con enfoque cuantitativo. el proyecto fue sometido al comité de ética e investigación de la escuela de enfermería de la universidad de são paulo (proceso número 1055/2011) y al comité de ética e investigación del centro de cáncer antonio cándido camargo en el estado de são paulo (proceso número 1601/11), el cual fue aprobado por ambas instituciones. la muestra fue seleccionada de la unidad ambulatoria de quimioterapia del ac camargo cancer center, localizado en são paulo (brasil). los datos fueron colectados entre diciembre de 2011 y febrero de 2012. se escogieron los pacientes con cáncer que cumplían con los siguientes criterios de inclusión: 1) diagnosticados con cáncer de colon o de recto, 2) que estuvieran recibiendo quimioterapia, 3) mayores de 21 años de edad, y 4) sin limitación cognitiva aparente que pueda comprometer su participación. de esta forma, la muestra estuvo compuesta por 100 pacientes con cáncer colorrectal, 47 mujeres y 53 hombres. la enfermera investigadora abordó a los participantes durante el tratamiento en la unidad ambulatoria de quimioterapia a través de una invitación formal e individual. se informó a los participantes sobre la investigación, los objetivos, la relevancia y el contenido del formulario de consentimiento informado. no se ofreció ninguna remuneración. los pacientes manifestaron su consentimiento a participar en la investigación mediante la firma de este formulario. después de esto, se dio inicio a la recolección de datos. para estandarizar la recolección de dados, la investigadora leyó cada instrucción del cuestionario y registró las respuestas expresadas por los pacientes. la secuencia en la que fueron aplicados los instrumentos fue, primero, el cuestionario sociodemográfico, seguido por la escala de estrés percibido (pss-10), y finalmente el inventario de estrategias de afrontamiento, versión brasileña, la aplicación de los instrumentos duró entre 40-50 minutos. escala de estrés percibido (pss-10) la pss-10 fue originalmente desarrollada en estados unidos por cohen, kamarck y mermelstein con el fin de medir el grado en el cual las situaciones de la vida son percibidas como estresantes. fue traducida y validada en brasil por reis, hino y añez, con un coeficiente de alfa de cronbach de 0,87 (18). este instrumento está compuesto de diez preguntas con opciones de respuesta que varían de “nunca” a “siempre”, en una escala tipo likert de 1 a 5. las preguntas evalúan situaciones estresantes relativas al mes anterior al día de la entrevista, por ejemplo, ¿con qué frecuencia usted se siente incapaz de controlar las cosas importantes en 14 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 su vida? ¿con qué frecuencia usted se siente capaz de controlar las irritaciones en su vida? después de seguir las instrucciones del instrumento para consolidar los resultados, la suma total de las respuestas puede variar de 0 a 40; un índice más alto indica que el individuo tiene más estrés. en esta investigación, el alfa de cronbach fue 0,81. inventario de estrategias de afrontamiento el inventario de estrategias de afrontamiento fue originalmente desarrollado en estados unidos por folkman y lazarus con el objetivo de consolidar pensamientos y acciones que las personas usan para lidiar con las demandas internas y externas de un evento estresante específico. en brasil, fue traducido y validado por savóia, santana y mejías, obteniendo valores de consistencia interna entre 0,42 y 0,68 (19). este instrumento tiene respuestas de tipo likert y está compuesto de 46 estrategias, con puntuación de 0 a 3, agrupadas en ocho factores descritos en el manual del instrumento: afrontamiento, intento de modificar la situación, incluso mostrando hostilidad y tomando riesgos, con 6 estrategias que varían de 0 a 18; planificación, pensar y desarrollar estrategias para solucionar el problema, con 4 estrategias, que varían de 0 a 12; distanciamiento, intentos cognitivos de desapegarse de la situación, intentando minimizar su significancia, con 7 estrategias, con una variación de 0 a 21; autocontrol, buscar diversos tipos de apoyo, como información, ayuda efectiva y emocional, con 5 estrategias, que varían de 0 a 15; búsqueda de apoyo social, acudir a otras personas como amigos, familiares, etc., para buscar ayuda, o información, comprensión y apoyo emocional, con 6 estrategias, variando de 0 a 18; aceptación de responsabilidad, reconocer la participación propia en el problema, y, a la vez, intentar arreglar las cosas, con 7 estrategias, con una variación de 0 a 21; escapeevitación, huir del problema con pensamiento y comportamiento positivos, con 2 estrategias, variando de 0 a 6; revaluación positiva, focalizada en el crecimiento personal para crear un significado positivo de la situación, con 9 estrategias, que varían de 0 a 27. en esta investigación el coeficiente de alfa de cronbach total fue de 0,75 y la variación por factor fue de 0,20 a 0,73. análisis estadístico las variables cualitativas fueron descritas por medio de medidas de frecuencias relativas y absolutas, y para las variables cuantitativas fueron usadas medidas de dispersión y tendencia central. la percepción de estrés y las estrategias de afrontamiento entre géneros fueron comparadas utilizando el test-t. por último, se elaboró un modelo para predecir la puntuación de estrés, utilizando como predictores las estrategias de afrontamiento, el género y otras variables clínicas y sociodemográficas. para las variables cuantitativas adoptamos un modelo de regresión lineal múltiple, así como los dominios de coping afrontamiento, aceptación de responsabilidad y revaluación positiva, y el ciclo de quimioterapia. las variables cualitativas fueron representadas con valores de 0 y 1 para los géneros masculino y femenino respectivamente; valores del 0 al 3 en el estado civil, y de 0 y 1 para el lugar de nacimiento; en el caso de las drogas se adoptó 0 y 1 para indicar la ausencia o presencia, respectivamente; para educación, con valores de 0 a 2, representando primaria, secundaria y superior, respectivamente; estadio del tumor con el intervalo de 0 a 2, para estadios ii, iii y iv respectivamente. la consistencia interna del pss-10 y el inventario de estrategias de afrontamiento, versión brasileña, fueron evaluados con el alfa de cronbach. para todo el análisis estadístico se utilizó el intervalo de confianza bilateral de 95 % y nivel de significancia estadística p menor o igual a 0,05. el procesamiento de los datos fue realizado mediante el software estadístico r, versión 3,0. resultados características sociodemográficas y clínicas del total de 100 pacientes, 47 % fueron mujeres y 53 % hombres; el 86 % de ellos tenía entre 40 y 79 años (promedio = 56,4 años, ds = 13,8), y 42 % con nivel de educación superior (tabla 1). en relación con las características clínicas, el tipo predominante de cáncer fue el de colon, con 66 %; en este grupo, el 50 % de los pacientes tuvieron tumores en estadio iv, y 54 % presentaron metástasis. percepción de estrés la tabla 2 muestra que el valor promedio del estrés fue de 12,1 puntos, con valor máximo de 36. una diferencia estadísticamente significativa fue identificada en la percepción de estrés entre hombres y mujeres (p = 0,029), con valores mayores para las mujeres. 15 diferencias de género en la percepción de estrés y estrategias de afrontamiento en pacientes con cáncer... l sonia betzabeth ticona benavente y otros tabla 1. distribución de individuos de acuerdo con las características sociodemográficas y clínicas (n = 100) total n % características sociodemográficas sexo femenino 47 47,0 masculino 53 53,0 edad (años) 20-39 12 12,0 40-59 44 44,0 60-79 42 42,0 80 o más 2 2,0 estado civil casado 69 69,0 separado 7 7,0 soltero 15 15,0 viudo 9 9,0 educación analfabeto 1 1,0 primaria 25 25,0 secundaria 32 32,0 superior 42 42,0 características clínicas diagnóstico médico cáncer de colon 66 66,0 cáncer de recto 34 34,0 estadio del tumor ii 13 13,0 iii 37 37,0 iv 50 50,0 metástasis no 46 46,0 sí 54 54,0 datos presentados en frecuencias absolutas (n) y relativas (%). estrategias de afrontamiento la tabla 3 muestra que a pesar de que los hombres tienen valores medios más altos en las estrategias de afrontamiento que las mujeres, no hay diferencia estadísticamente significativa (p = 0,57). percepción de estrés, estrategias de afrontamiento y otras variables los resultados de la tabla 4 revelan el mejor modelo para esa muestra, con r2 = 0,538 y r2 ajustado = 0,421, con p < 0,0001. así, las siguientes variables tienen contribución positiva para la variación del estrés: utilización de estrategias de los dominios afrontamiento y aceptación de responsabilidad, sexo femenino, estadio del tumor iii, tratamiento con fluorouracil y tener otra enfermedad. discusión esta investigación exploró las diferencias de género en la percepción de estrés y el uso de estrategias de afrontamiento en pacientes con cáncer colorrectal que reciben quimioterapia. corroborando resultados de otras investigaciones, encontramos que las mujeres presentaron niveles más altos de estrés que los hombres; en diferentes países se obtuvieron resultados semejantes, tanto para el cáncer como para otras enfermedades: en holanda, pacientes con cáncer colorrectal (13); en israel, para sobrevivientes de melanoma (12), y en corea, en pacientes con enfermedad pulmonar obstructiva crónica (17). vale la pena notar que se encontró un puntaje medio de percepción de estrés de 12,1, esta es una puntuación baja comparada con una población de ancianos que utilizaron el mismo instrumento en la versión brasileña, teniendo como puntuación 15,1 (20). otro estudio realizado por el autor de la escala en estados unidos con individuos saludables encontró puntuaciones de estrés entre 15,5 y 16,1 (21). en otra investigación desarrollada con pacientes en el periodo de preparación precolonoscópica, utilizando el mismo instrumento, se obtuvo puntuación media de 22,2 para el estrés (22). en una revisión de la literatura para buscar el motivo de este valor bajo, se encontró un estudio longitudinal el cual reporta que el nivel de estrés puede variar a lo largo del curso del tratamiento; 16 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 tabla 3. diferencia de medias de dominios de estrategias de afrontamiento por género tabla 2. distribución de pacientes según el género y la percepción de estrés género n min max media desv. estánd. mediana 1º cuartil 3º cuartil cia 95 % valor pb femenino 47 0 36 13,8 8,144 14 8 18,5 11,4-16 0,029masculino 53 0 30 10,5 6,621 9 6 14 8,7-12 total 100 0 36 12,1 7,524 11,5 6 16 10,6-14 a intervalo de confianza. b test t. media hombres media mujeres 95 % cia valor t valor pb afrontamiento 5,00 5,87 -1,95 – 0,21 -1,59 0,11 distanciamiento 8,60 9,46 -2,14 – 0,41 -1,33 0,18 autocontrol 8,41 7,65 -0,13 – 1,65 1,67 0,09 búsqueda de apoyo social 13,81 12,95 -0,39 – 2,10 1,35 0,17 aceptación de la responsabilidad 8,50 9,12 -2,12 – 0,88 -0,81 0,41 escape-evitación 4,05 3,65 -0,31 – 1,10 1,11 0,26 planificación 9,94 9,17 -0,04 – 1,59 1,86 0,06 revaluación positiva 19,64 18,57 -0,98 – 3,12 1,03 0,30 coping total 77,98 76,48 -3,71 – 6,69 0,56 0,57 a intervalo de confianza. b test t. así, un estudio encontró que los pacientes experimentaron altos niveles de estrés inmediatamente después del diagnóstico (13); no obstante, seis y doce meses después del mismo, los niveles de estrés se redujeron (13, 23). adicionalmente, la literatura muestra que la disminución de los niveles de estrés está asociada a diversos factores, como recibir consejos, resultados positivos de la quimioterapia o mejor aceptación del diagnóstico y el tratamiento (24). en relación con el uso de estrategias de afrontamiento, no se encontró diferencia estadísticamente significativa entre hombres y mujeres. este resultado sugiere que el uso de estrategias de afrontamiento no depende del género en el grupo de pacientes de esta investigación. sin embargo, este no es un resultado concluyente, pues se encontraron resultados divergentes en una revisión sistemática (25). en este estudio se identificaron predictores potenciales que pueden aumentar la percepción de estrés, tales como las estrategias del dominio afrontamiento, en que los pacientes intentan modificar su situación; y el dominio aceptación de responsabilidad, en el que los pacientes se sienten culpables por su enfermedad. este resultado indica que existen estrategias no adecuadas para afrontar enfermedades de gran impacto, como el cáncer. en este sentido, se puede afirmar que el uso de las estrategias que se encuadran dentro de estos dominios contribuye con el aumento del nivel de estrés. por otro lado, encontramos que el uso de estrategias del dominio revaluación positiva, en el que los pacientes se enfocan en el crecimiento personal, dándole un significado positivo a su situación, contribuye a la disminución de la percepción de estrés. 17 diferencias de género en la percepción de estrés y estrategias de afrontamiento en pacientes con cáncer... l sonia betzabeth ticona benavente y otros tabla 4. coeficientes del modelo de regresión lineal múltiple para el estrés, comparando estrategias de afrontamiento, género y otras variables variable β error estándar t-valor p-valor intercepto 10,08 7,67 1,31 0,19 dominios de coping afrontamiento 0,70 0,24 2,94 0,00 aceptación de la responsabilidad 0,45 0,17 2,59 0,01 revaluación positiva -0,35 0,13 -2,70 0,00 género masculino referencia femenino 3,15 1,55 2,02 0,04 estado civil separado referencia casado 4,81 2,69 1,78 0,07 soltero 0,91 2,74 0,33 0,73 viudo 9,19 3,30 2,77 0,00 educación primaria referencia secundaria -3,04 1,62 -1,87 0,06 superior 0,70 1,59 0,44 0,66 lugar de nacimiento estado de são paulo referencia otros estados -4,37 1,61 -2,71 0,00 estadio del tumor ii referencia iii 4,03 2,06 1,95 0,05 iv 3,29 2,28 1,44 0,15 drogas quimioterápicas avastin no referencia sí -1,88 1,57 -1,19 0,23 xeloda no referencia sí 7,94 4,99 1,59 0,11 fluorouracil no referencia sí 6,36 2,38 2,67 0,00 ciclo de quimioterapiaa -0,44 0,15 -2,80 0,00 18 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 este resultado permite precisar que así como existen estrategias que aumentan los niveles de estrés, hay otras que los disminuyen, hecho que puede contribuir a la experiencia del paciente con cáncer en la quimioterapia. el profesional de enfermería debería considerar dentro de la práctica clínica este resultado para incentivar en los pacientes el uso de estrategias que sean contempladas dentro de este dominio. así, un estudio afirma que los pacientes con cáncer necesitan adaptarse a los cambios relacionados con las limitaciones de capacidad funcional, implicaciones médicas y reacciones psicológicas (26) para afrontar de forma efectiva todo el proceso de la enfermedad y el tratamiento. otro predictor potencial del nivel de estrés identificado en esta investigación es el estado civil, donde la viudez aumenta los niveles de percepción de estrés. este resultado sugiere la importancia del apoyo social proveniente de la pareja a lo largo del proceso de la enfermedad. otra investigación resalta el beneficio relacionado con el apoyo social proveniente del cónyuge (27). finalmente, encontramos otros predictores potenciales como el estadio del tumor iii, el tratamiento con fluorouracil y tener otras enfermedades; se considera que estas variables deben ser estudiadas en el futuro. en relación con la presencia de comorbilidad como factor predictor del estrés, la literatura apoya este resultado; así, un estudio conducido en 118 pacientes recientemente diagnosticados con cáncer de pulmón obtuvo resultados similares (9). conclusión en conclusión, nuestros resultados amplían el conocimiento sobre la percepción de estrés bajo la perspectiva del género, concluyendo que las mujeres perciben mayores niveles de estrés. en relación con el afrontamiento del estrés, no se verificó la diferencia de género en el uso de estrategias para afrontarlo; sin embargo, se identificó la influencia de algunos factores que contribuyen al aumento del nivel de estrés así como a su reducción, y se observó la posible intervención de otros factores que modifican la percepción del estrés de los pacientes con cáncer colorrectal en tratamiento con quimioterapia. sin duda, son necesarios más estudios para entender mejor estas diferencias considerando el contexto sociocultural, ya que este estudio provee resultados recientes sobre diferencias de género en un contexto brasileño. finalmente, el profesional de enfermería oncológica, por ser el que interactúa de forma más estrecha y prolongada con los pacientes, debería considerar e incorporar en sus intervenciones clínicas las diferencias de género de cada individuo en la percepción de estrés psicológico relacionado con la enfermedad y el tratamiento con quimioterapia, a fin de ofrecer un cuidado holístico durante el proceso de salud-enfermedad. así, estos resultados también favorecen la creación e implementación de programas de intervención con el objetivo de apoyar emocionalmente a los pacientes con cáncer colorrectal. variable β error estándar t-valor p-valor metástasis no referencia sí 2,69 1,63 1,64 0,10 historia familiar no referencia sí 2,08 1,47 1,41 0,16 otras enfermedadesb no referencia sí 3,50 1,31 2,66 0,00 a se refiere al ciclo de quimioterapia en el que se encuentra el paciente en el día de la entrevista. b señala si el paciente presenta otras enfermedades además del cáncer, entre ellas hipertensión, diabetes, enfermedad cardiovascular, artritis, etc. 19 diferencias de género en la percepción de estrés y estrategias de afrontamiento en pacientes con cáncer... l sonia betzabeth ticona benavente y otros referencias 1. international agency for research on cancer (iarc). globocan 2012: estimated cancer incidence, mortality and prevalence worldwide in 2012, cancer facts stats: cancer [internet]; 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(citado 2013 ene 10). disponível em: http:// globocan.iarc.fr/pages/fact_sheets_population.aspx 3. instituto nacional do câncer, estimativa 2014. incidência do câncer no brasil. rio de janeiro: inca; 2013. 4. de melo mm, nunes lc, leite icg. relação entre fatores alimentares e antropomêtricos e neoplasias do trato gastrointestinal: investigações conduzidas no brasil. revista brasileira de cancerologia. 2012;58(1):85-95. 5. lazarus s, folkman r. stress, appraisal and coping. new york: springer; 1984. 6. hopman p, rijken m. illness perceptions of cancer patients: relationships with illness characteristics and coping. psychooncology. 2014. 7. sun v, grant m, mcmullen ck, altschuler a, mohler mj, hornbrook mc, et al. surviving colorectal cancer: long-term, persistent ostomy-specific concerns and adaptations. j wound ostomy continence nurs. 2013;40(1):61-72. 8. van hoose l, black ll, doty k, sabata d, twumasi-ankrah p, taylor s, johnson r. an analysis of the distress thermometer problem list and distress in patients with cancer. support care cancer. 2014. 9. sharpe l, patel d, clarke s. the relationship between body image disturbance and distress in colorectal cancer patients with and without stomas. j psychosom res. 2011;70:395-402. 10. brant jm, beck sl, dudley wn, cobb p, pepper g, miaskowski c. symptom trajectories during chemotherapy in outpatients with lung cancer colorectal cancer, or lymphoma. eur j oncol nurs. 2011;15(5):470-7. 11. pereira mg, figueiredo ap, fincham fd. anxiety, depression, traumatic stress and quality of life in colorectal cancer after different treatments: a study with portuguese patients and their partners. ejon. 2012;16:227-232. 12. hamama-raz y. does psychological adjustment of melanoma survivors differs between genders? psychooncology. 2012;21(3):255-263. 13. landsbergen km, prins jb, brunner hg, van duijvendijk p, nagengast fm, van krieken jh, et al. psychological distress in newly diagnosed colorectal cancer patients following microsatellite instability testing for lynch syndrome on the pathologist’s initiative. familial cancer. 2012;11:259-267. 14. grant m, mcmullen ck, altschuler a, mohler mj, hornbrook mc, herrinton lj, wendel cs, baldwin cm, krouse rs. gender differences in quality of life among long-term colorectal cancer survivors with ostomies. oncol nurs forum. 2011;38(5):587-96. 15. lipinska-grobelny a. effects of gender role on personal resources and coping with stress. int j occup med environ health. 2011;24(1):18-28. 16. felmingham kl, bryant ra. gender differences in the maintenance of response to cognitive behavior therapy for posttraumatic stress disorder. j consult clin psychol. 2012;80(2):196-200. 17. kim j, kim k. gender differences in health-related quality of life of korean patients with chronic obstructive lung disease. public health nurs. 2014;23. 18. reis rs, hino aaf, añez crr. perceived stress scale: realiability and validity study in brazil. j health psychol. 2010;15(1):107-114. 19. savóia mg, santana, pr, mejias np. adaptação do inventário estratégias de coping de folkman e lazarus para o portugués. psicol usp. 1996;7(1/2):183-201. 20. luft cb, sanches so, mazo gz, andrade a. brazilian version of the perceived stress scale: translation and validation for the elderly. rev saúde pública. 2007;41(4):606-15. 20 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 21. cohen s, janicki-deverts d. who’s stressed? distributions of psychological stress in the united states in probability samples from 1983, 2006, and 2009. j appl soc psychol. 2012;42(6):1320-34. 22. antonietti cc. percepção do estresse e estilo de coping dos pacientes no periodo pré-procedimento colonoscópico [tesis]. são paulo: escola de enfermagem, universidade de são paulo; 2012. 23. hyphantisa t, paikaa v, almyroudia a, kampletsasb eo, pavlidisb n. personality variables as predictors of early nonmetastatic colorectal cancer patients’ psychological distress and health-related quality of life: a one-year prospective study. journal of psychosomatic research. 2011;70(5):411-421. 24. singh h, kaur k, banipal rp, singh s, bala r. quality of life in cancer patients undergoing chemotherapy in a tertiary care center in malwa region of punjab. indian j palliat care. 2014;20(2):116-22. 25. robles pg, brooks d, goldstein r, salbach n, mathur s. gender-associated differences in pulmonary rehabilitation outcomes in people with chronic obstructive pulmonary disease: a systematic review. journal of cardiopulmonary rehabilitation and prevention. 2014;34(2):87-97. 26. antoni mh. psychosocial intervention effects on adaptation, disease course and biobehavioral processes in cancer. brain, behavior, and immunity. 2013;30(15):s88–s98. 27. duggleby w, bally j, cooper d, doell h, thomas r. engaging hope: the experiences of male spouses of women with breast cancer. oncol nurs forum. 2012;39(4):400-406. 159 169 proceso adaptacion mujeres con lesion medular.indd 159 maría ángeles alcedo-rodríguez1 lara garcía-carenas2 yolanda fontanil-gómez3 benito arias-martínez4 antonio león aguado-díaz5 proceso de adaptación en mujeres con lesión medular: relaciones entre variables psicológicas y sociodemográfi cas 1 doctora en psicología. profesora titular, universidad de oviedo, españa. malcedo@uniovi.es 2 doctora en psicología. directora, centro de atención integral, españa. infocai@aspaym-asturias.es 3 doctora en psicología. profesora titular, universidad de oviedo, españa. fontanil@uniovi.es 4 doctor en psicología. profesor titular, universidad de oviedo, españa. barias@psi.uva.es 5 doctor en psicología. profesor titular, universidad de oviedo, españa. aaguado@uniovi.es recibido: 28 de mayo de 2012 enviado a pares: 22 de julio de 2012 aceptado por pares: 28 de febrero de 2014 aprobado: 19 de marzo de 2014 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 159-169 para citar este artículo / to reference this article / para citar este artigo alcedo-rodríguez ma, garcía-carenas l, fontanil-gómez y, arias-martínez b, aguado díaz al. proceso de adaptación en mujeres con lesión medular: relaciones entre variables psicológicas y sociodemográficas. aquichan 2014; 14(2): 159-169. resumen objetivo: conocer el funcionamiento psicológico de 44 mujeres con lm en el proceso de adaptación a la lesión; en concreto, las estrategias de afrontamiento, la motivación y ansiedad de ejecución, el neuroticismo-extraversión, la depresión y su posible relación con variables sociodemográficas. método: se trata de un estudio con estrategia correlacional y diseño de evaluación transversal. el proceso de selección ha sido realizado a través de centros sanitarios y de asociaciones de personas con discapacidad. participaron un total de 44 mujeres con lm, residentes en su mayoría en el principado de asturias (54,5 %) y en euskadi (40,9 %), aunque también contamos con una pequeña representación de mujeres procedentes de valladolid (4,5 %). resultados: las diferencias significativas halladas nos muestran puntuaciones más elevadas en la escala de depresión en mujeres casadas y con menor nivel educativo. los datos de este estudio reflejan la existencia de procesos individualizados de adaptación con un funcionamiento bastante aleatorio respecto a las variables sociodemográficas y, por tanto, apoyan los postulados del modelo de diferencias individuales en el proceso de adaptación a la lm. conclusión: se sugiere que los procesos terapéuticos deben ser sensibles a la aparición de sentimientos de desesperanza y depresión en las mujeres con lm. palabras clave salud de la mujer, mujer, lesión medular, adaptación, enfermería (fuente: decs, bireme). 160 aquichan issn 1657-5997 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 159-169 adaptation process in women with spinal cord injury: the relationship between psychological and sociodemographic variables abstract objective: the primary objective of this research is to examine the psychological reaction of 44 women with sci during their process of adaptation to spinal cord injury, specifically with regard to coping strategies, motivation, performance anxiety, neuroticism, extraversion, depression and the possible relationship between these variables and others of a socio-demographic nature. method: this is a correlational study with cross design strategy and evaluation. the selection process was carried out through health centers and associations of people with disabilities. a total of 44 women with lm participated, mostly resident in principality of asturias (54.5%) and basque country (40.9%), although they have a small representation of women from valladolid (4.5 %). results: the significant differences that were found show the highest scores on the depression scale pertain to women who are married and have less schooling. moreover, the data from the study reflect the existence of individualized processes of adaptation with highly random functioning in terms of the sociodemographic variables, thereby supporting the assumptions on the model of individual differences in the process of adaptation to spinal cord injury. conclusion: they also suggest therapeutic processes must be sensitive to the appearance of feelings of hopelessness and depression in women with spinal cord injury. key words women’s health, women, spinal cord injury, adaptation, nursing (source: decs, biereme). 161 proceso de adaptación en mujeres con lesión medular: relaciones entre variables psicológicas y sociodemográficas l maría ángeles alcedo-rodríguez, lara garcía-carenas y otros. año 14 vol. 14 nº 2 chía, colombia junio 2014 l 159-169 processo de adaptação em mulheres com lesão medular: relações entre variáveis psicológicas e sociodemográficas resumo objetivo: conhecer o funcionamento psicológico de 44 mulheres com lm no processo de adaptação à lesão; em concreto, as estratégias para enfrentar a doença, a motivação e a ansiedade de execução, o neuroticismo-extraversão, a depressão e a sua possível relação com variáveis sociodemográficas. método: este é um estudo correlacional com a estratégia de design da cruz e avaliação. o processo de seleção foi realizado por meio de centros de saúde e associações de pessoas com deficiência. um total de 44 mulheres com lm, a maioria residente no principado das astúrias (54,5%) e país basco (40,9%), embora tenham uma pequena representação das mulheres de valladolid (4,5 %). resultados: as diferenças significativas encontradas nos mostram pontuações mais elevadas na escala de depressão em mulheres casadas e com menor nível educativo. os dados deste estudo refletem a existência de processos individualizados de adaptação com um funcionamento bastante aleatório a respeito das variáveis sociodemográficas. conclusão: apoiam as premissas do modelo de diferenças individuais no processo de adaptação à lm. palavras-chave saúde da mulher, mulher, lesão medular, adaptação, enfermagem (fonte: decs, bireme). 162 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 introducción en el año 2003 phil klebine (1) señalaba que gracias a los esfuerzos de investigación desarrollados desde la década de los sesenta sobre la lesión medular (lm) cualquier persona que sufra esta enfermedad será probable que viva una vida más larga y saludable debido a los avances en los tratamientos médicos que se han obtenido de dichas investigaciones. en su revisión centrada en el número y tipo de publicaciones sobre el tema concluía que, aunque bastantes investigaciones incluían hombres y mujeres como sujetos de estudio, era necesario que se realizaran estudios específicos de género para mejorar los conocimientos sobre temas de salud y bienestar que impactan de forma diferente en hombres y mujeres. en los países industrializados las mujeres representan cerca del 20 % de los casos nuevos de lm cada año, aunque de hecho constituyen un 25 a 30 % de los casos debido a su mayor longevidad. ahora bien, ¿están las mujeres suficientemente representadas en la investigación sobre lm? con base en estas cifras lo esperable es que el 25 % de los artículos o publicaciones refieran información sobre mujeres con lesión medular y el 75 % reseñen datos sobre varones con lm. sin embargo, la realidad es bien distinta; solo un 1 % de los estudios publicados en la década de los setenta desarrollaban temas sobre la población de mujeres con lm (1). la década de los noventa supone un incremento de la investigación sobre mujeres hasta llegar al 5 %, y este porcentaje permanecía estable en los primeros años del siglo xxi. la revisión elaborada por hirschberg, weiss y zafonte (2) confirma esta tendencia a incluir en los estudios sobre lm tanto a hombres como a mujeres, pero aún así es mucho lo que queda por conocer respecto a las diferencias de género. esto nos sumerge en una cierta indefensión incluso cuando utilizamos modernas técnicas de análisis de datos para intentar aclarar el campo. así, un metaanálisis llevado a cabo por farace, wayne y alves (3) sobre un tema tan estudiado como son las secuelas del daño cerebral no llega a conclusiones firmes ya que están limitadas por el hecho de que solo un pequeño porcentaje de las publicaciones analizadas describen bien diferenciados sus resultados según el género. para resumir, a pesar del hecho de que las mujeres representan más de la cuarta parte de las personas con lesión medular, solo el 5 % de los artículos incluyen información sobre temas relevantes para este género. nos encontramos, por tanto, en un campo en el que se necesitan mayores esfuerzos investigadores. centrándonos ya en los estudios que tienen en cuenta las posibles diferencias entre hombres y mujeres con lm, los temas más estudiados tienen que ver con la sexualidad y la reproducción y son muy pocos los artículos dedicados a la evaluación específica de variables psicológicas en la mujer con lm (4), y prácticamente inexistentes los que evalúan su relación con variables sociodemográficas, donde muchos de los resultados que aparecen son variados y contradictorios entre sí. de hecho, los antecedentes de nuestro trabajo se basan sobre todo en estudios que muestran los datos sociodemográficos tan solo como parte obligada de la descripción de la muestra, y la mayor parte de nuestras referencias comparativas han tenido que ser rastreadas en estas tablas descriptivas. así pues, y ante la escasa trayectoria investigadora respecto de esta temática, nuestro interés se ha centrado en el análisis de las relaciones entre variables sociodemográficas (edad, nivel educativo y ocupacional, y estado civil) y las variables psicológicas más citadas en la bibliografía especializada como determinantes del proceso de adaptación a la lm (depresión, ansiedad, motivación, extraversión-neuroticismo y afrontamiento) (4, 5). los referentes de nuestro trabajo se encuentran tanto en estudios que relacionan variables demográficas y psicológicas en muestras compuestas por hombres y mujeres (6-11), como en aquellos otros centrados de forma específica en mujeres con lesión medular, como los realizados por el equipo de margaret nosek en el center for research on women with disabilities (crowd) (12-15) o los trabajos de kalpakjian et al. (8, 16). en función de esta bibliografía previa, el objetivo general de este trabajo es conocer el funcionamiento psicológico de las mujeres con lm en su proceso de adaptación a la lesión. en concreto, las estrategias de afrontamiento, la motivación y ansiedad de ejecución, el neuroticismo-extraversión, la depresión y su posible relación con variables sociodemográficas. se trata de profundizar en el tema de la perspectiva de género en la discapacidad, campo de investigación con poca trayectoria investigadora, al tiempo que aportar apoyo empírico al modelo de las diferencias individuales sobre el proceso de adaptación a la lm, frente al modelo de las etapas, para así poder establecer programas adaptados a las necesidades específicas de cada persona con lm, de forma que brinden una buena eficacia terapéutica. el modelo de las diferencias individuales postula que el proceso de adaptación a la lm no es único ni homogéneo para todos los sujetos y que no sigue una secuencia determinada de fases o etapas. también se afirma que no 163 proceso de adaptación en mujeres con lesión medular: relaciones entre variables psicológicas y sociodemográficas l maría ángeles alcedo-rodríguez, lara garcía-carenas y otros. existe una personalidad única de la persona con lm y que no hay correlación entre la gravedad de la discapacidad y el desajuste psicológico (17-20). desde este modelo se hace especial hincapié en la importancia de las variables psicológicas en el proceso de adaptación y la individualidad de dicho proceso. con base en estos supuestos la hipótesis de partida de nuestro trabajo plantea la existencia de diferencias individuales en cada una de las escalas psicológicas analizadas. esta hipótesis principal se ha subdividido en cuatro subhipótesis en función de las cuatro variables sociodemográficas analizadas. la primera subhipótesis plantea que existirán diferencias significativas en función de la edad en las puntuaciones obtenidas en las cinco escalas psicológicas (h1). la segunda postula la existencia de diferencias significativas entre el nivel cultural y las puntuaciones obtenidas en las citadas escalas psicológicas (h2). la tercera asume diferencias significativas entre el estado civil y las puntuaciones obtenidas en las cinco escalas psicológicas en este grupo de mujeres con lm (h3). por último, la cuarta subhipótesis propone la existencia de diferencias en función de la ocupación que presenten estas mujeres (h4). método participantes en el presente estudio han participado un total de 44 mujeres con lm, residentes en su mayoría en el principado de asturias (54,5 %) y en euskadi (40,9 %), aunque también contamos con una pequeña representación de mujeres procedentes de valladolid (4,5 %). las mujeres participantes tenían una edad media de 38,11 años (de = 12,25). el rango de edad estaba entre los 18 y los 71 años. en cuanto al tipo de lesión, existía un predominio de lesiones completas en 29 mujeres (65,9 %), de las cuales 24 presentaban paraplejia y 5 tetraplejia. de las 15 mujeres con lesiones incompletas (34,1 %), en 11 casos se trataba de paraparesias y en los 4 restantes tetraparesias. respecto a la etiología, las más frecuentes eran lesiones sobrevenidas, en concreto los accidentes de tráfico (40,9 %), seguidas de aquellas causadas por enfermedad (29,5 %); el resto de casos se agrupa en otro tipo de accidentes, p. e., domésticos, deportivos (20,5 %) y de etiología desconocida (9,1 %). la variables sociodemográficas se distribuyeron en nuestra muestra de la siguiente forma: en lo que atañe al estado civil, en su mayoría eran solteras (56,8 %), y el resto se repartían entre casadas (22,7), separadas (11,4 %), viudas (6,8 %), y una mujer que vivía en pareja. si atendemos al nivel cultural, existía una sobrerrepresentación de mujeres con estudios de nivel primario (52,3 %), y solo 10 mujeres presentaban un nivel cultural medio (22,7 %); el resto de las 11 mujeres con lm habían alcanzado estudios universitarios, en concreto, ocho tituladas superiores (18,2 %) y tres diplomadas (6,8 %). por último, la variable ocupación recogía como grupo más numeroso el de pensionistas (27,3 %), seguido del de amas de casa (20,4 %), mujeres que se encontraban laboralmente activas (15,9 %), estudiantes (13,6 %) y, por último, desempleadas (11,4 %) y jubiladas (11,4 %). diseño y procedimiento se trata de un estudio con estrategia correlacional y diseño de evaluación transversal. el proceso de selección ha sido realizado a través de centros sanitarios y de asociaciones de personas con discapacidad. el estudio de campo se ha llevado a cabo en tres provincias españolas: asturias, vizcaya y valladolid, y forma parte de un proyecto de investigación más amplio que se desarrolla entre los años 2009 y 2011. el proceso de evaluación fue realizado individualmente y la duración media aproximada del diligenciamiento de los instrumentos de evaluación ha sido de cuatro horas repartidas en varias sesiones. los criterios fijados como requisitos para formar parte de la muestra han sido los siguientes: personas con lm crónica con al menos un año de evolución, que hubieran finalizado la rehabilitación médico-funcional, y con variabilidad en etiología, tipo y nivel de la lm, que no hubieran presentado problemas de salud mental previos a la aparición de la lesión y sin diagnóstico de daño cerebral o traumatismo craneoencefálico. instrumentos de medida se ha utilizado como instrumento de evaluación la escala multidimensional de evaluación de personas con lesión medular (emelm) (5, 21, 22). esta escala permite una evaluación bastante exhaustiva de las características clínicas, psicológicas y sociodemográficas de las personas con lm. la escala también recoge una serie de cuestionarios que permiten evaluar variables determinantes en el proceso de adapatación a la lm. estos cuestionarios son los siguientes: 1. cuestionario e-n de extraversión y neuroticismo, adaptación a personas con lm del mismo cuestionario de pelechano (23). 164 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 2. cuestionario mae de motivación y ansiedad de ejecución, adaptación del cuestionario de pelechano (24). 3. cuestionario de estrategias de afrontamiento actuales, adaptación a personas con lm del instrumento construido por pelechano para evaluar el afrontamiento en otros enfermos físicos y crónicos (25, 26). 4. cuestionario de rememoración de estrategias de afrontamiento, adaptación a lm del instrumento de pelechano para otros enfermos físicos y crónicos (25, 26). 5. inventario de depresión de beck, adaptación a lm del clásico instrumento en su adaptación española de conde, esteban y useros (27). se ha comprobado la adecuación de las escalas psicológicas en nuestra muestra de lm, aún sabiendo que dichos cuestionarios son instrumentos de probada fiabilidad en otras muestras de población. para ello hemos utilizado el alfa de cronbach, un indicador de la consistencia interna de los tests. respecto de los cuestionarios de estrategias de afrontamiento actuales y rememoración de estrategias de afrontamiento, presentan alfas de cronbach de 0.903 y 0.924, respectivamente. ambos son índices muy aceptables de consistencia interna. por su parte, el cuetionario mae de motivación y ansiedad de ejecución con un alfa de 0.822 y el inventario de depresión de beck con un alfa de 0.813, son también indicadores de buena consistencia interna. por último, el cuestionario e-n de extraversión y neuroticismo presenta un alfa de 0.737, representando el índice de consistencia interna más bajo. análisis de datos para el contraste de las cuatro hipótesis se han llevado a cabo dos procedimientos de análisis diferentes: la prueba de kruskalwallis que resulta el equivalente no paramétrico del anova, y la u de mann-whitney, el equivalente no paramétrico de la prueba t de student para comparar medias de dos muestras independientes. las técnicas de análisis de datos se han realizado bajo el programa estadístico para las ciencias sociales spss v.15.0. resultados la primera subhipótesis planteaba que existirían diferencias significativas en función de la edad en las puntuaciones obtenidas en las cinco escalas psicológicas (h 1 ). para su contraste se ha utilizado la prueba de kruskal-wallis, previa recodificación de la variable edad en tres categorías o niveles: mujeres con lm menores de 30 años, otro grupo con rango de edad entre los 30 y los 36 años y, finalmente, mujeres mayores de 36 años. en la figura 1 se observa la distribución de la muestra, donde apreciamos cómo la altura de la caja, que representa la amplitud intercuartil, recoge a los sujetos comprendidos entre el percentil 25 y 75. en su distribución encontramos tres casos extremos (36, 82 y 124) cuya edad está muy alejada del resto por el límite superior (figura 1). figura 1. gráfico de cajas de la variable edad 80 60 40 20 0 0 124 0 82 0 36 edad los resultados obtenidos (tabla 1) permiten afirmar que en la muestra analizada no existen diferencias significativas en función de la edad en ninguna de las cinco escalas psicológicas. dicho de otra forma, parece que la edad no guarda relación con las variables psicológicas de depresión, ansiedad, motivación, extraversión-neuroticismo y afrontamiento, evaluadas por los cuestionarios diligenciados por las mujeres del grupo con lm estudiado. tabla 1. estadísticos de contraste en función de la edad total e total n total mae total afra total afrm total beck chi cuadrado 0,497 3,244 1,637 0,104 0,390 0,938 gl 2 2 2 2 2 2 sig. asintót. 0,780 0,198 0,441 0,949 0,823 0,626 165 proceso de adaptación en mujeres con lesión medular: relaciones entre variables psicológicas y sociodemográficas l maría ángeles alcedo-rodríguez, lara garcía-carenas y otros. la segunda subhipótesis postulaba la existencia de diferencias significativas entre el nivel cultural y las puntuaciones obtenidas en las cinco escalas psicológicas (h 2 ). para su contraste se ha aplicado la prueba u de mann-whitney, y se ha procedido a la recodificación de la variable nivel cultural, que originalmente contaba con cuatro categorías (esto es, primarios, medios, diplomados y superiores), en dos grupos (estudios primarios frente a estudios medios y superiores) dada la desigual productividad de las categorías y la mayor concentración (> 50 %) en estudios primarios. los resultados (tabla 2) indican que las puntuaciones que las mujeres con lm obtienen en extraversión-neuroticismo, motivación y ansiedad de ejecución, y estrategias de afrontamiento actual y rememorado son independientes de que hayan cursado estudios primarios o medios/superiores. por el contrario, sí aparecen diferencias estadísticamente significativas en el inventario de depresión de beck (u = 127.500, p < 0,05). las mujeres con estudios primarios presentan unos rangos promedio superiores en depresión (24,70) frente a aquellas con niveles de estudios más altos, es decir, medios/superiores (16,71). tabla 2. estadísticos de contraste en función del nivel cultural que son más propensas a presentar comportamientos depresivos las mujeres de nuestra muestra, que están casadas, en contra de lo que en un principio podría esperarse debido al apoyo que presumiblemente ejercería la pareja. tabla 3. estadísticos de contraste en función del estado civil total e total n total mae total afra total afrm total beck u de mannwhitney 165.500 189.500 162.000 163.000 196.500 127.500 w de wilcoxon 441.500 399.500 352.000 373.000 406.500 317.500 z -1,578 -0,989 -1,232 -1,227 -0,592 -2,136 sig. asintót. (bilateral) 0,115 0,323 0,218 0,220 0,554 0,033 la tercera subhipótesis asumía diferencias significativas entre el estado civil y las puntuaciones obtenidas en las cinco escalas psicológicas en este grupo de mujeres con lm (h 3 ). dicha variable contaba originalmente con cinco categorías: soltera, casada, en pareja, separada y viuda. como las dos primeras (soltera y casada) eran las que contaban con un mayor porcentaje de casos (soltera, n = 25; casada, n = 10) decidimos realizar el análisis exclusivamente con ellas. una vez que contamos con una variable con dos categorías, estamos en condiciones de aplicar la prueba de contraste u de mann-whitney. los resultados solo muestran diferencias significativas (tabla 3) entre el inventario de depresión de beck y el estado civil (u = 32.500, p < 0,05). las mujeres solteras presentan unos rangos promedios (11,71) inferiores a las casadas (18,36). estos datos ponen de manifiesto total e total n total mae total afra total afrm total beck u de mannwhitney 58.500 40.000 37.000 50.000 51.000 32.500 w de wilcoxon 248.500 230.000 208.000 240.000 72.000 222.500 z -0,465 -1,537 -1,579 -0,447 -0,382 -1,973 sig.asintót. (bilateral) 0,642 0,124 0,114 0,655 0,703 0,049 sig.exacta (unilateral) 0,651 0,135 0,125 0,687 0,733 0,048 por último, la cuarta subhipótesis planteaba la existencia de diferencias en función de la ocupación que presentan estas mujeres (h4). para contrastar dicha hipótesis se ha utilizado un análisis de varianza no paramétrico a través de la prueba de kruskal-wallis. se procedió, en primer lugar, a recodificar la variable que contaba originalmente con seis categorías: estudiante, ama de casa, empleada, desempleada, jubilada y pensionista. por un lado, se agruparon aquellos casos que no reciben salario remunerado: estudiante, ama de casa y desempleada. por otro, aquellos que no se encuentran activos profesionalmente: pensionistas y jubiladas. la variable ocupación queda finalmente recodificada en tres categorías o niveles: estudiante y ama de casa, empleada y jubilada. en la tabla 4 se observa que la prueba de kruskal-wallis no ha encontrado diferencias significativas en ninguna de las cinco escalas psicológicas analizadas en función de la ocupación. tabla 4. estadísticos de contraste en función de la ocupación total e total n total mae total afra total afrm total beck chi cuadrado 1,382 0,138 0,080 3,079 3.557 0,723 gl 2 2 2 2 2 2 sig. asintót. 0,501 0,934 0.961 0,215 0,169 0,697 en definitiva, del total de las cuatro subhipótesis planteadas hemos confirmado parcialmente dos de ellas y rechazado otras dos. han sido refutadas la subhipótesis (h1) edad en la aplica166 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 ción de la prueba, y la subhipótesis (h4), ocupación, puesto que en ninguna de ella hemos encontrado diferencias estadísticamente significativas con respecto a las cinco escalas psicológicas. por el contrario, las subhipótesis h2 y h3 se ratifican parcialmente ya que aparece asociación entre nivel educativo y estado civil con la variable depresión. discusión y conclusiones el objetivo central de este trabajo ha sido estudiar el funcionamiento psicológico de las mujeres con lm, en concreto, las estrategias de afrontamiento, la motivación y la ansiedad de ejecución, el neuroticismo-extraversión y la depresión, y su posible relación con variables sociodemográficas. los resultados apoyan la variabilidad en el funcionamiento psicológico, si bien con algunas restricciones que se pueden resumir detallando que: i) las mujeres con menor nivel cultural tienen más dificultades para enfrentarse a la situación de discapacidad y sienten mayores niveles de desesperanza y depresión; ii) las mujeres casadas presentan puntuaciones más elevadas en la escala de depresión que las solteras. respecto a las relaciones entre la edad de las mujeres de nuestra muestra y su funcionamiento psicológico parece que la edad no implica una distribución no aleatoria del mismo. aun así, si analizamos detenidamente los resultados se observa que son las mujeres entre 30 y 36 años las que puntúan más alto en neuroticismo y depresión. con estos resultados podemos inferir que es este grupo al que más le ha costado afrontar la nueva situación, se sienten tristes y no son capaces de poner en marcha estrategias de control personal. en cuanto al grupo más joven (menores de 30 años) podemos observar que tienen muy pocas estrategias de afrontamiento, tanto actuales como rememoradas, pero sus puntuaciones en depresión son muy bajas. es decir, aunque todavía no han sido capaces de desarrollar estrategias de afrontamiento, probablemente debido a su menor edad, esto no les hace sentirse frustradas ni deprimidas ante su nueva situación. por último, las mujeres mayores (más de 36 años) representan el grupo con puntuaciones más homogéneas en todas las escalas psicológicas. podemos inferir que debido a su mayor edad han sabido asumir la situación y desarrollar estrategias de afrontamiento adecuadas para superarla y adaptarse con éxito. en la revisión de la literatura que relaciona la variable edad con procesos psicológicos hemos encontrado escasos antecedentes que obtienen, además, resultados contradictorios. así, en el estudio de cook (28) son las mujeres de más edad las que puntúan más alto en las escalas de neuroticismo. sin embargo, las respuestas en depresión y ansiedad no presentan ninguna asociación significativa con ningún grupo de edad. con resultados opuestos, laatsch y shahani (29) encuentran que las personas con discapacidad física más jóvenes presentan niveles más altos en ansiedad, hostilidad y paranoia. el trabajo de hughes et al. (13) examina el nivel de depresión en 64 mujeres con lm, encontrando que un 59,4 % de la muestra presenta problemas depresivos pero no aparece asociación entre edad y depresión. está claro que la relación entre edad y funcionamiento psicológico necesita mayores esfuerzos de investigación si queremos aclarar la dirección que deben seguir nuestros apoyos terapéuticos hacia este colectivo de mujeres con lm. por otro lado, la asociación entre funcionamiento psicológico y nivel cultural de las mujeres con lm muestra diferencias significativas respecto al nivel de depresión. nuestros datos señalan que las mujeres con pocos estudios presentan rangos promedios más altos en la escala de depresión. estos resultados apuntan, como ya anticipamos, a que estas mujeres con menor nivel cultural tienen más dificultades para enfrentarse a la nueva situación y sienten mayores niveles de desesperanza y depresión. por otra parte, los resultados encontrados en nuestra investigación en el inventario de depresión de beck van en la línea del trabajo de elfstrom, kreuter, ryden, persson y sullivan (30) que concluye que las personas con lm con niveles educativos superiores presentan niveles bajos en depresión. esta asociación del mayor nivel educativo con menores niveles de depresión ha sido un resultado reiterado en los trabajos del equipo de margaret nosek en el crowd (13-15). en este sentido, nuestra investigación confirma la tendencia de las investigaciones precedentes y dado que, como resume el equipo de nosek, las mujeres con discapacidad presentan mayor riesgo de sufrir el impacto de la depresión —muy relacionado con el hecho de ser mujer y tener discapacidad, ya que ello supone una doble desventaja que a su vez conlleva mayor discriminación—, se requiere que los programas de apoyo a mujeres con lm sean más accesibles cuando estas han tenido menor desarrollo educativo y oportunidades de formación. respecto a la relación entre nivel ocupacional y funcionamiento psicológico, la revisión de ottomanelli y lind (31) encuentra 60 167 proceso de adaptación en mujeres con lesión medular: relaciones entre variables psicológicas y sociodemográficas l maría ángeles alcedo-rodríguez, lara garcía-carenas y otros. artículos que incluyen referencias al nivel laboral en individuos con lm; de ellos, una escasa representación recoge datos sobre variables psicológicas y son menos aún los que hacen análisis específicos en mujeres con lm. trabajos como el de schreuer et al. (9) centran sus objetivos en estudiar la sintomatología depresiva en una muestra de varones y mujeres con lm. una de las variables evaluadas fue el nivel de ocupación, pero las diferencias encontradas no fueron significativas. de forma indirecta, pero ya con una muestra de mujeres, el equipo de margaret nosek en el crowd (13) obtuvo resultados opuestos al encontrar menores niveles de depresión en mujeres con lm con mayores niveles económicos. nuestros resultados no apoyan esta vez los del crowd, ya que no encontramos diferencias significativas, pero creemos que puede deberse a que codifican esta variable de forma dicotómica entre empleada y no empleada, mientras que en nuestro estudio dividimos la muestra en tres grupos. pero el antecedente más directo de nuestra investigación lo tenemos en los trabajos de chapin y holbert (32, 33), que no encuentran diferencias respecto al nivel ocupacional previo a la lesión pero sí respecto al posterior tras el acceso a cursos formativos de inserción laboral una vez adquirida la lesión. señalan que las personas que han recibido una adecuada rehabilitación para el empleo muestran menos sentimientos de tristeza y depresión, lo que enfatiza la importancia de realizar intervenciones para la inclusión laboral en el proceso de rehabilitación de las mujeres con lm. por último, nuestro estudio evalúa la asociación entre estatus marital y funcionamiento psicológico, y encuentra diferencias significativas que muestran puntuaciones más elevadas en la escala de depresión en las mujeres casadas. en la misma línea de nuestros resultados, bombardier et al. (6) y kalpakjian y albright (8) encuentran niveles de depresión más bajos en personas que están solteras y más altos en aquellas que están casadas, viudas, divorciadas o separadas. es más, parece que las mujeres con lm, divorciadas, tienen más probabilidades de desarrollar mayor depresión. en cuanto a las parejas sentimentales, aquellas que se mantienen desde antes de la lesión se sienten más comprometidas y atadas, y llegan a considerar a sus parejas como cargas más pesadas, que los matrimonios que se forman después de aparecer la lesión. en líneas generales podría afirmarse que la aparición de una lm no obstaculiza y cambia solo la vida de la mujer con lm sino también la de sus compañeros sentimentales. hace unos años el equipo de schopp publicó un trabajo que puede considerarse el anverso de nuestra línea actual de investigación. su trabajo se centraba en el estudio de las variables del rol masculino tradicional en relación con el ajuste a la lm (34), y concluía que ciertos aspectos de ese rol masculino, como la habilidad para modular las emociones fuertes, pueden ser adaptativos en el proceso de rehabilitación, mientras que otros, como el estilo interpersonal dominante, pueden ser una barrera para el mismo. tanto este trabajo como los anteriores desarrollados por nuestro equipo (4, 22, 35) nos impulsan a seguir investigando cómo el género en sus distintos aspectos puede actuar como promotor de procesos adaptativos o desadaptativos. es necesario completar el panorama observando cómo los roles de género se imbrican con otras variables que hacen que la vida cotidiana de las mujeres con lm contenga más tristezas y desaliento del deseado. la implementación de programas de rehabilitación adecuados a las necesidades de estas mujeres requiere de estudios que aborden de forma específica su proceso de ajuste a la situación de discapacidad. en este sentido, y con las limitaciones que se derivan del hecho de trabajar con muestras de tamaño reducido, surge este estudio, que 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clínicas y psicológicas y su implicación en el proceso de adaptación a la lesión medular. universitas psychologica 2010;(9):315-330. fa lls s uf fe re d by h os pi ta liz ed a du lt pa ti en ts : s up po rt to t he n ur si ng t ea m a s th e se co nd v ic ti m 1 deise vacario de quadros https://orcid.org /0000-0001-6442-2649 universidade federal do rio grande do sul, brazil dquadros@hcpa.edu.br ana maria müller de magalhães https://orcid.org /0000-0003-0691-7306 universidade federal do rio grande do sul, brazil eduarda boufleuer https://orcid.org /0000-0003-1745-3391 universidade federal do rio grande do sul, brazil juliana petri tavares https://orcid.org /0000-0003-4121-645x universidade federal do rio grande do sul, brazil ricardo de souza kuchenbecker https://orcid.org /0000-0002-4707-3683 universidade federal do rio grande do sul, brazil daiane dal pai https://orcid.org /0000-0002-6761-0415 universidade federal do rio grande do sul, brazil artículo falls suffered by hospitalized adult patients: support to the nursing team as the second victim* received: 07/02/2022 sent to peers: 23/05/2022 approved by peers: 12/09/2022 accepted: 13/09/2022 doi: 10.5294/aqui.2022.22.4.6 para citar este artículo / to reference this article / para citar este artigo quadros dv, magalhães amm, boufleuer e, tavares jp, kuchenbecker rs, dal pai d. falls suffered by hospitalized adult patients: support to the nursing team as the second victim. aquichan. 2022;22(4):e2246. doi: https://doi.org/10.5294/aqui.2022.22.4.6 * article extracted from the master’s thesis: “modelado de proceso en caída de pacientes adultos hospitalizados y la perspectiva del trabajador de enfermería como segunda víctima”, presented to the graduate nursing program of the universidade federal do rio grande do sul, in 2020. https://orcid.org/0000-0001-6442-2649 mailto:dquadros@hcpa.edu.br https://orcid.org/0000-0003-0691-7306 https://orcid.org/0000-0003-1745-3391 https://orcid.org/0000-0003-4121-645x https://orcid.org/0000-0002-4707-3683 https://orcid.org/0000-0002-6761-0415 https://doi.org/10.5294/aqui.2022.22.4.6 https://doi.org/10.5294/aqui.2022.22.4.6 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2022.22.4.6&amp;domain=pdf&amp;date_stamp=2022-10-25 subject: promotion and prevention contributions to the subject: in this study, aspects of the relevance of providing support to the nursing team involved as the second victim of adverse events in the hospital context are contemplated, which raise the need for the development of structured institutional programs that promote early support, actively provided to the team. in addition, the discussion in academia during nursing training programs constitutes another possible contribution of the study, as there is a close relationship between attentive and welcoming leadership and the strengthening of the bond between the members of the nursing team in the work environments. fa lls s uf fe re d by h os pi ta liz ed a du lt pa ti en ts : s up po rt to t he n ur si ng t ea m a s th e se co nd v ic ti m 3 abstract objective: to describe the support received by the second victim in falls suffered by hospitalized adult patients from the nursing team’s perspective. materials and methods: this is an exploratory and descriptive study with a qualitative approach, conducted in a large general hospital in the southern region of brazil. data collection was carried out through semi-structured interviews with 21 nursing professionals (seven nurses and fourteen nursing technicians) selected by random sampling, who worked in the inpatient units where falls occurred with a level of harm ranging from moderate to severe during march and may of 2020. the data were submitted to content analysis from july to august of the same year. results: on the one hand, from the nursing team’s perspective, support for the second victim was considered incipient by the hospital institution. on the other, participants highlighted the support received by their families and peers in the work environment. the study followed the guidelines of the consolidated criteria for reporting qualitative research (coreq) . conclusions: an institutional flow of support for the second victim needs to be formalized to mitigate the repercussions on staff. keywords (fonte: decs) nursing; fall accidents; occupational health; patient safety; safety management. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 46 4 resumen objetivo: describir el soporte recibido por la segunda víctima en las caídas de pacientes adultos hospitalizados desde la perspectiva del equipo de enfermería. materiales y método: estudio exploratorio y descriptivo, con enfoque cualitativo, realizado en hospital general de gran tamaño en la región sur de brasil. se realizó la recolección de dados por medio de entrevista semiestructurada con 21 trabajadores de enfermería (siete enfermeros y 14 técnicos de enfermería) seleccionados por muestra aleatoria y que trabajaban en las unidades de hospitalización en que ocurrieron caídas con grado de daño comprendido de moderado a grave, de marzo a mayo de 2020. se sometieron los datos al análisis de contenido, de julio a agosto de dicho año. resultados: por una parte, desde la percepción del equipo de enfermería, el soporte a la segunda víctima se consideró incipiente por la institución hospitalaria. por otra, los participantes destacan el apoyo recibido por sus familiares y pares en el entorno laboral. el estudio siguió las directrices del consolidated criteria for reporting qualitative research (coreq). conclusiones: hay necesidad de formalizar un flujo institucional de soporte a la segunda víctima con el fin de mitigar las implicaciones a los trabajadores. palabras clave (fuente: decs) enfermería; accidentes por caída; salud del trabajador; seguridad del paciente; gestión de la seguridad. caidas de pacientes adultos hospitalizados: soporte al equipo de enfermería como segunda víctima* * artículo derivado de la tesis de maestría “modelado de proceso en caída de pacientes adultos hospitalizados y la perspectiva del trabajador de enfermería como segunda víctima”, presentada al programa de posgrado en enfermería, de la universidade federal do rio grande do sul, en 2020. fa lls s uf fe re d by h os pi ta liz ed a du lt pa ti en ts : s up po rt to t he n ur si ng t ea m a s th e se co nd v ic ti m 5 quedas de pacientes adultos hospitalizados: suporte à equipe de enfermagem como segunda vítima* resumo objetivo: descrever o suporte recebido pela segunda vítima nas quedas de pacientes adultos hospitalizados sob a perspectiva da equipe de enfermagem. materiais e método: estudo exploratório e descritivo, de abordagem qualitativa, realizado em hospital geral de grande porte na região sul do brasil. a coleta de dados foi realizada por meio de entrevista semiestruturada com 21 trabalhadores de enfermagem (sete enfermeiros e 14 técnicos de enfermagem) selecionados por amostragem aleatória e que trabalhavam nas unidades de internação em que aconteceram quedas com grau de dano compreendido de moderado a grave, de março a maio de 2020. os dados foram submetidos à análise de conteúdo, de julho a agosto do mesmo ano. resultados: por um lado, na percepção da equipe de enfermagem, o suporte à segunda vítima foi considerado incipiente pela instituição hospitalar. por outro, os participantes destacam o apoio recebido pelos seus familiares e por pares no ambiente de trabalho. o estudo seguiu as diretrizes do consolidated criteria for reporting qualitative research (coreq). conclusões: há necessidade de formalizar um fluxo institucional de suporte à segunda vítima a fim de mitigar as repercussões sobre os trabalhadores. palavras-chave (fonte: decs) enfermagem; acidentes por quedas; saúde do trabalhador; segurança do paciente; gestão da segurança. * artigo extraído da dissertação de mestrado “modelagem de processo em quedas de pacientes adultos hospitalizados e a perspectiva do trabalhador de enfermagem como segunda vítima”, apresentada ao programa de pós-graduação em enfermagem, da universidade federal do rio grande do sul, em 2020. a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 46 6 introduction the classification of incidents and adverse events related to patient safety by the world health organization (who) in the late 1990s revealed a pressing need for improvement in the quality and management of care processes and health services. patient safety is an issue related to care practices with the objective of reducing adverse events and unsafe actions that put patients’ health at risk (1). among the identified events, which compromise patient safety, are falls in the hospital environment (2). the who defines ‘fall’ as the unintentional displacement of the body to a level below the initial position, without the possibility of timely correction, compromising stability, adding a variety of associated factors (3, 4). falls cause injuries in almost half of the patients who are affected by this event, which may, in the most severe cases, lead to death (2). in addition, a fall can generate psychological impact by the fear of the patient falling again, which influences the risk of future falls (5), in addition to negatively interfering with the patient’s functional capacity and mobility (6), which can increase the length of hospital stay and care costs, generating anxiety in the nursing team and producing repercussions on the institution’s credibility, in addition to legal consequences (7, 8). nursing teams who are directly involved in the care of a patient who has fallen experience feelings such as guilt, distress, and helplessness. these feelings stem from a self-judgment that leads to devaluation by patients, who are instructed on fall prevention care and do not adhere to the measures, and from the understanding that falls are a reflection of a work process that is solely the responsibility of the nursing team (9), when, in fact, it should be the reason for multiprofessional care, considering that it is an event that requires a multimodal approach. this happens because the implementation of collaborative practices results in better outcomes for patients and safer care, based on the promotion of trust relationships between healthcare teams (10) and, consequently, on the promotion of healthcare staff safety. institutions that fail to emphasize work processes related to healthcare and to promote a safety culture in the workplace lead their staff to be more susceptible to feelings of guilt due to patient falls. moreover, this type of event can have repercussions on the institution’s image (11), consisting of a challenge for nursing leaders to ensure the quality of care and patient safety (12). an organization that recognizes its susceptibility to errors is more likely to implement safety processes while supporting those that become instances of such imperfection (13). although an adverse event with a severe outcome and even death causes suffering to patients and their families, they are the first victims of this process, but not the only ones. the staff involved, directly or indirectly, also suffers and is considered the second potential fa lls s uf fe re d by h os pi ta liz ed a du lt pa ti en ts : s up po rt to t he n ur si ng t ea m a s th e se co nd v ic ti m 7 victim; moreover, the impact caused to the caregivers involved — regardless of sex, age, and professional category— can leave permanent marks on most individuals. therefore, any team member who is providing care to a patient who is a victim of harm resulting from care may suffer impacts from this, with repercussions on their private or professional lives, and is therefore considered a “second victim” of the event. this expression emerged in the literature for the first time in 2000, in an editorial of the british medical journal, concerning the impact on healthcare staff involved in an error or when they feel responsible for the adverse event and the unexpected injuries caused to the patient (14). second victims may experience negative feelings resulting from patient outcomes, which may vary depending on the support provided to healthcare staff. this support, although essential, is not usually widespread and frequent, but it is an effective measure to mitigate the symptoms that often affect the second victim (13, 15-17). in light of this scenario, this study’s objective was to describe the support second victims received in falls suffered by hospitalized adult patients from the nursing team’s perspective. materials and methods this was an exploratory and descriptive study with a qualitative approach supported by content analysis. the study was carried out in a large general hospital in the southern region of brazil, in a reference hospital for high complexity cases, with an installed capacity of 843 beds. the study followed the consolidated criteria for reporting qualitative research (coreq) guidelines. data collection was carried out from march to may 2020 through semi-structured interviews with the nursing team members (nurses and nursing technicians), who were selected via random sampling (simple draw) based on the following inclusion criteria: to work as a nurse or nursing technician in one of the five inpatient units and to be working at the time of the study on a work schedule, in the respective shift where the falls occurred. the exclusion criteria considered were being a member of the nursing team with less than one year of experience in the institution, being on vacation or leave of any kind, in addition to those working under a temporary contract during the data collection period. the five inpatient units listed for the nursing team interviews were among those where fall events had occurred, classified with moderate to severe harm, from july 2018 to july 2019, totaling 12 falls. the participants were drawn in the presence of the unit manager for each shift where a fall had occurred; one nurse and two nursing technicians were drawn. one staff member declined the invitation to participate in the study, and another was una q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 46 8 able to participate due to problems in the unit. after they accepted, the informed consent form was presented, describing the study objectives, the research area of interest, the opportunities for care practice, as well as the possibility of withdrawing, if desired, and the researcher’s credentials. a sample of 21 nursing team members answered the interview, which was defined by information saturation, i.e., the interviews were terminated when repeated information about the study’s theme was found. the sample consisted of a total population of 153 nursing team members working in the shifts of the five inpatient units where the falls occurred. the interview script was developed by the researchers based on the literature on which the study was based. first, a pilot test was conducted with a nursing technician belonging to a unit not included in the study, which allowed adjusting the script in order to meet the study objective. initially, institutional data related to the frequency and classification of safety incidents related to falls in the last year were contextualized to the nursing team. subsequently, the participant was invited to talk about a patient fall that happened under their or a colleague’s responsibility, describing the repercussions of the occurrence and how the approach was carried out with the staff member involved in that incident. the interview was conducted in person by the main researcher, who has a master’s degree, during the participants’ work shifts, at a previously scheduled time, in a reserved room at the workplace of the study participant, with an average duration of 35 minutes, with audio recording and subsequent transcription. immediately after the interviews, field notes were taken to prevent information loss. the researcher worked at the study’s focus institution, was acquainted with most participants, had experience in conducting group interviews in event analysis, and periodically met with the other researchers to share information. when the researcher and the participant had not previously met, the moment of the draw and the invitation to participate in the study was the first interaction between them. it was clarified to the staff invited to answer the interview that participation was voluntary and that they could quit at any time without harm to or interference with their care attributions or work relationship. this information was also included in the informed consent form handed out to the study participants. the data were submitted to content analysis, applying the steps of pre-analysis, material exploration, treatment of results, inference, and interpretation, without using any software (18). the codes “nur” for nurses and “nt” for nursing technicians were used, in addition to the numbers referring to the order in which the interviews were conducted, with the objective of ensuring the participants’ anonymity. the original statements of the research participants were preserved in order to respect the internal and original vision of the thoughts fa lls s uf fe re d by h os pi ta liz ed a du lt pa ti en ts : s up po rt to t he n ur si ng t ea m a s th e se co nd v ic ti m 9 and feelings of the researched group. the researcher’s perspective contemplated the interpretations based on the literature and on the inferences expressed in the discussion of the data with the objective of furthering knowledge. this study complies with resolution 466 of 2012, issued by the national health council. it is a project approved by the research ethics committee of the institution and complies with all ethical precepts. results seven nurses and fourteen nursing technicians participated in the study. among the nurses, all were female, aged between 30 and 52 years. their time working as nurses ranged from 8 to 27 years, and their time of employment at the researched institution ranged from 7 to 20 years. regarding the nursing technicians, five were male, and nine were female, aged between 36 and 65 years, their time working as nursing technicians ranged from 7 to 34 years, and their time working at the researched institution ranged from 1 to 29 years. the support received in the instances of involvement with a fall event was described by the nursing team based on individual aspects (“individual support” category) and institutional aspects (“institutional support” category). individual support when nursing team members were asked about the support they received in a situation where a hospitalized patient suffered a fall, responses varied, ranging from receiving support from a close colleague, from the immediate manager, or from one of their family members. [...] i receive support from colleagues first because they go through the same circumstances because of the shift nurse’s point of view, but nurses already understand things in a more managerial way, while technicians are more practical. (nt1) we tell our immediate bosses, but there is no support. (nur1) according to the interviewees, this support is provided by the proximity of previously established relationships, a possible dialogue space between the different members of the work teams, by colleagues who offer to listen and welcome the feelings arising from the experiences related to the patient’s fall. with my colleagues... just talking like this is already a relief. whether it’s over a cup of coffee or when you’re sitting at the computer typing, it’s already a relief; you can get it out, and it seems to give you some peace of mind. (nt9) but then you get closer to your colleague, you support them because you see that they are a little shaken, as i said [...] “but how come so-and-so fell down if they were fine just now,” but then they say, “it happens,” you see, there’s nothing you can do. (nt10) a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 46 10 another aspect mentioned as desirable by the staff was to receive immediate support from their colleagues when an adverse event occurs with a patient under their care. however, they report that this is not always the case, either because the family bond is able to meet this demand in a more welcoming way or because the work environment sometimes does not allow this listening moment, given the exhausting routine and situations that may involve the denial of feelings related to the experience of the incident. i think that mostly from my family, from the people that i have affection for out of here, [it is in this environment] that i will report that a negative situation happened with a patient. (nur7) [...] the unit itself does not give you this space. [...], you arrive already working, asking [...] there is no way to say you want to sit down to have a conversation with the nurse for 10 minutes. [...] she has five, six assistants, [...] to coordinate and over 15, 16 patients [...] she may even want to, but while she is talking to me, another one comes. (nt10) the nursing team members also reported that immediate support from a colleague with whom they have an affinity bond promotes effective welcoming and reduces the feeling of judgment for being involved in an incident. institutional support when questioned about the institutional support received, the nursing team members demonstrated not having found this support or that they understood that it had to be requested. there is no support like that, i think it is very much in our heads, [...] the other day i was with the researcher [...] she even cried and felt responsible for this. but i think that there is no support. we make practical and rational referrals and i keep working because the demand is very high and we can’t stop to think. (nur5) totally upset [...] feeling down. that would be the case of... that kind of follow-up we would have to have with someone who was not from the unit. (nt10) [...] there is some support, but for the feelings, there’s nobody. i looked for some support to find out what happened [...], but not for my feelings. (nur4) even though interviewees listed institutional support exists, they did not perceive it as efficient, requesting that it could be actively provided. they ask for structured institutional support provided by someone outside the unit who could address their feelings in the field of mental health. [...] requesting support, reporting that i went through a certain situation, that’s how i felt, i think i would receive the appropriate support. but i would have to look for that [...] there’s no way to know what’s happening here, [...] unless it was a constant program or a follow-up. (nur7) i believe that it exists, but it’s not culturally used. i understand that the oms [occupational medicine service] provides an occupational psychologist, i don’t know if there’s an open schedule. [...] some of us seek care outside. anyway, these things end up coming up in our own therapies. i think that the hospital has it, we culturally don’t adhere to it or maybe come across it that way, as explicit that this resource exists to fa lls s uf fe re d by h os pi ta liz ed a du lt pa ti en ts : s up po rt to t he n ur si ng t ea m a s th e se co nd v ic ti m 11 be used in this context, you know? because, if you think about the managerial aspect of things, what reaches us is the demand, is the indicator, is the answer that there is a problem. (nur6) today [...] it would be this follow-up with a psychologist, this counseling with the doctor or with someone who comes to talk to us. without asking for it, it happened automatically because when we do something wrong with the medication we are automatically called, we are charged. [...] because we are interested [...] when, in reality, there should be interest from the institution to tell us. (nt10) the nursing team members understand that the welcoming can be structured in a better way and proposed in a continuous way. in addition, they understand that the support should be of interest to the institution in order to invest in the nursing team. i think that in the first place the institution should give me some support within the occupational medicine service, psychology [...] they could provide this support and offer me a follow-up and i think that it’s also up to the person because sometimes employees don’t feel comfortable to report something within the psychology and occupational medicine environment, i see that many people seek it. (nur3) [...] i didn’t look for it because i thought it wouldn’t be effective since it takes so long to receive care down there that i didn’t even try [...] other times that we needed it for illnesses, for more serious things, you stay there for hours waiting and sometimes they don’t take it seriously. [...] i think that in a case like this they won’t even take it seriously. i think, honestly, that the oms doesn’t give us the welcoming that it should [...] they keep waiting, waiting, waiting. i don’t have time to wait. we have no support for this. (nt12) the statements reveal that there is an identification of the need for institutional support and the consolidation of an approach for the welcoming of the staff, which possibly requires dedicated personnel for this purpose. [...] the staff works a lot and needs more care. we need this care as much as they [the patients] do, so that they are well taken care of, we have to be well taken care of by the institution. (nt11) [...] i don’t know if everyone would accept a follow-up, would want to talk, to open up to the psychologist. [...] i already had the notion of talking to a psychologist about other things and it didn’t help me at all, it didn’t solve anything. (nt6) the previous speech also displays some disbelief regarding the effectiveness of the existing service, restating the need for investment and improvement in this aspect. in turn, staff members who are involved as the second victim of adverse events recognize that the institutional approach represents a way to value and invest in their emotional safety. discussion the falls suffered by patients represent not only frequent incidents in healthcare but are also the source of feelings of guilt among the nursing team members involved, amid other negative feelings typically experienced in second victim situations. these facts are evidenced in the statements when nursing team members identify the need to share with a close colleague or family a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 46 12 members the feelings experienced by having a patient who has suffered a fall during the work schedule, which is a way of seeking support. from this perspective, it is necessary to provide greater support to the nursing team (13, 19). the psychological impact of becoming a second victim is directly related to the severity of an event. a study with healthcare staff from 93 hospitals in belgium showed that the impact of a death is the greatest among nurses, whereas, with severe harm, it is the greatest among medical professionals. according to the researchers, the justification lies in the nature of the profession and ultimate responsibility towards the patient (20). the second victim phenomenon occurs widely and more frequently in places with patients who require more care and with the occurrence of death. however, patients who suffered severe injuries, where the care provided had a direct impact on the outcome of these patients, led to feelings of guilt, a fact that demonstrates the importance of structuring programs that support second victims (9, 20). it is not uncommon that, in circumstances where the harm to the patient stands out, the nursing team needs to deal individually with the emotional repercussions of the event. these circumstances are validated by previous situations where the staff member needed the occupational medicine service and could not identify the organizational support. nursing is a profession strongly rooted in the outcome of success, disregarding the fallibility inherent in complex processes, and it holds a strong sense of responsibility, a quality that, in addition to harm reduction, influences the impact of the occurrence (20). the constant focus on outcomes intensifies the attention to adverse events and identifies opportunities for improvement, retrospectively analyzing practice scenarios, implementing improvement plans, and focusing on the continuing education of the staff who provide care. although all these factors are relevant, it is necessary to monitor work environments (21) and identify the repercussion of adverse events for staff in order to influence the organizational safety culture, indicating the importance of discussing when something unexpected happens, both from the perspective of the work process and of welcoming staff, aiming to create a sense of purpose. becoming a second victim can be equated to post-traumatic syndromes, considering the range of feelings encompassed, with about 50 % of healthcare professionals having experience feelings that caused them to doubt their ability to work and feel a profound responsibility regarding the negative repercussions on the patient’s future life, which is in line with the interviewees’ statements (13, 16). fa lls s uf fe re d by h os pi ta liz ed a du lt pa ti en ts : s up po rt to t he n ur si ng t ea m a s th e se co nd v ic ti m 13 among the feelings experienced by the second victim are guilt stemming from the harm done to the patient, fear for the loss of reputation, and distress over the charge of uncleared or unaddressed situations are all part of the second victim’s experiences (9, 20, 22). the reduction of psychological impact requires active and planned strategies well beyond any individual capacity for resilience and support-seeking, although the latter is important. the failure to clearly identify institutional support or the ineffectiveness of occupational care are important reports concerning support as a way to appreciate both the staff members and the patients. the support provided and organizational cultures with clear guidelines allow feelings like these to be at least mitigated (20). strategies such as avoidance are described in the literature and may become common among nurses, as the focus on tasks and emotions are also reported as second victim coping alternatives (23). strategies such as these lead to an environment of dissatisfaction among staff members and deconstruct trusting relationships among peers (16). in this sense, institutional support, both to provide the staff with protagonism for this action and to support them, is the key to these measures (13, 15). feelings and behaviors of avoidance and denial related to incidents, despite when they are likely to be classified as defense mechanisms, hinder the investigation of more effective possibilities for coping with situations that cause psychic suffering. these situations can occur in the absence of formal institutional support, allowing the emergence of feelings of disrespect and depreciation of staff members, in addition to the preservation of second victim feelings (24). appropriate coping strategies have positive repercussions when they elicit proactive actions and behaviors that are beneficial to patients, but it is necessary to identify that inappropriate strategies can weaken the provider-patient therapeutic bond, reflected by more aggressive or defensive behavior from the healthcare staff (25), representing a warning for hospital institutions and an important reason for the implementation of structured support with an early, scaled, and continuous approach. considering that, after an incident, the staff member feels the need to talk about it to be relieved from the work schedule and to feel supported by colleagues and the institution, it is essential to train representatives of the care and management teams who can be implemented through attentive leadership and qualified listening. for this, the level of organizational support to leaders is crucial so that they can identify programs and projects that support second victims (15, 20, 26). institutional support is paramount to mitigate the impacts of the second victim’s experience, and the immediate response constia q u ic h a n | ei ss n 2 02 753 74 | a ñ o 22 v o l. 2 2 n º 4 ch ía , c o lo m bi a o ct u br ed ic ie m br e 20 22 | e 22 46 14 tutes a form of welcoming. awareness of an adverse event assists the development of individual coping strategies and support for peers going through similar situations. therefore, avenues of support for second victims must be available, visible, and accessible; sharing the staff experiences allows restitution in the work team and enables the restoration of integrity (13, 15) since the emotional disruption of participating in an adverse event can alter professional relationships and the type of support received, which influences the emotional responses (27). the creation of a support program for second victims called resilience in stressful events (rise) at the johns hopkins university hospital (united states) proved to be beneficial for the institution, structuring the support of the healthcare team after the occurrence of a stressful event related to patients. other programs with a similar purpose have been created, such as the “mitigating impact in second victims” (mise) , with a virtual support format, which aims to train frontline staff and managers to assist members of the healthcare team involved in events with repercussions for second victims. in this line, the university of missouri (united states), with the for you program, has shown that only 10 % of second victims need specialized mental health support, which demonstrates the importance of immediate welcoming and of qualified listening to peers in the work environment (17, 26, 28, 29). moreover, it is noteworthy that the support provided to the second victim by the institution can help prevent new instances of the event, as it is an investment in the staff members, not exempting them from liability, considering the repercussions of the harm. likewise, it is important to identify the experiences of nursing team members as second victims in healthcare institutions in order to propose measures and support programs appropriate and possible to be carried out (30), immediately, in the medium and long terms for reducing the emotional stress and promoting individual and systemic resilience (25). finally, this is a small-scale study, where the results are sensitive to the context applied, which may characterize a study limitation, as well as the researcher’s previous knowledge of the study participants. however, this methodology can be replicated, which allows for alternatives to be identified for planning support for staff members as a way of valuing and investing in workplace relationships. as far as nursing is concerned, the identification of people who are willing and have a welcoming and empathetic profile in the healthcare units is a relevant possibility to be implemented, as a form of immediate support, based on previously built relationships and an initial step in the approach to the second victim. in addition, the discussion in academia during training constitutes another possible contribution of the present study, as there is a close relationship between attentive leadership and the promotion of a welcoming environment. fa lls s uf fe re d by h os pi ta liz ed a du lt pa ti en ts : s up po rt to t he n ur si ng t ea m a s th e se co nd v ic ti m 15 conclusions the present study identified the perceptions of the nursing team regarding the relevance of individual support, whether from peers in the work environment or family members in the private context or in situations that predispose second victims among nursing team members. the incipiency of institutional support and the need to talk openly about the situations experienced by second victims, even if in fear of the repercussions, is necessary to mitigate the feelings of the staff involved in care failures, to appreciate the nursing team, and to promote humanized care for the members of the healthcare teams. the support to the nursing team enables contributing to the promotion of an institutional culture of safety that allows learning, strengthening trust relationships, and promoting the team members’ well-being as a way to provide care in the search for qualification in the work environment, represented by the managerial challenge translated by the relevance of falls in the international context. the level of investment in healthcare staff 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(2014). rito católico e imagem da enfermeira (1957). aquichan. vol. 14, no. 1, 109-118. resumo objetivo: analisar a imagem da enfermeira na ritualística de missa de formatura, da primeira turma da escola de enfermagem de ribeirão preto da universidade de são paulo (usp) em 1957. métodos: o texto imagético foi analisado à luz de pierre bourdieu e da literatura sobre rito, moda, linguagem corporal, história do brasil e da enfermagem. resultados: foram localizadas duas imagens no acervo histórico institucional que atendiam os critérios de inclusão. o rito de missa de formatura deu-se em 21 de dezembro de 1957, às 8h30 da manhã intitulada “missa solene em ação de graças, na capela sagrado coração de jesus, da santa casa de misericórdia de ribeirão preto”. conclusão: os signos instituídos no rito de missa de formatura foram o uniforme, a touca, a demarcação com tecido claro do espaço entre as formandas e o público, o que constituiu um espaço de distinção social. soma-se, ainda, a hexis corporal que transparece seriedade e pureza, e colabora para a constituição da nova imagem da enfermeira diplomada em ribeirão preto. as contribuições deste estudo dão-se na ampliação das discussões sobre a construção da imagem da enfermeira, identidade profissional e influência católica na formação do enfermeiro. palavras-chave história da enfermagem, comportamento ritualístico, enfermagem, escolas de enfermagem, simbolismo (fonte: decs, bireme). 110 aquichan issn 1657-5997 año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 109-118 misa católica e imagen de la enfermera (1957) resumen objetivo: analizar la imagen de la enfermera en el ritual de misa de graduación de la primera clase de la escuela de enfermería de ribeirão preto de la universidad de são paulo (usp) en 1957. método: las imágenes fueron analizadas a la luz de pierre bourdieu y de la literatura sobre rito, moda, lenguaje corporal, historia de brasil y de la enfermería. resultados: han sido ubicadas dos imágenes en la colección histórica institucional que respondían a los criterios de inclusión. el rito de misa de graduación fue celebrado el 21 de diciembre del 1957 a las 8:30 de la mañana, titulado “misa solemne en acción de gracias, en la capela sagrado coração de jesus, de la santa casa de misericórdia de ribeirão preto”. conclusión: los signos instituidos en el rito de misa de graduación fueron el uniforme, la toca, la demarcación con tela clara del espacio entre graduandas y público, lo que constituye espacio de distinción social. además, la héxis corporal revela seriedad y pureza, y colabora hacia la constitución de la nueva imagen de la enfermera diplomada en ribeirão preto. este estudio contribuye con la ampliación de las discusiones sobre la construcción de la imagen de la enfermera, identidad profesional e influencia católica en la formación del enfermero. palabras clave historia de la enfermeira, conducta cerimonial, enfermería, escuelas de enfermeira, simbolismo (fuente: decs, bireme). 111 rito católico e imagem da enfermeira (1957) l maria fernanda simiele, luciana barizon-luchesi, fernando porto, tatiana oliveira-sousa, emiliane silva-santiago, simone aguiar catholic mass and the nurse’s image (1957) abstract objective: the purpose of the study is to analyze the nurse’s image during the commencement mass for the first graduating class of the ribeirão preto school of nursing at the university of são paulo (usp) in 1957. methods: the images were analyzed in light of the thinking of pierre bourdieu and the literature on rites, fashion, body language, the history of brazil and the history of nursing. results: two images that meet the criteria for inclusion were found in the institution’s historical collection. the graduation mass was celebrated on december 21, 1957 at 8:30 a.m. and was entitled the solemn mass of thanksgiving in the chapel of the sacred heart of jesus at the ribeirão preto holy house of mercy. conclusion: the signs instituted in the graduation mass include the uniform, the cap and the space between the graduates and the public, which was marked with clear fabric and denotes an area of social distinction. in addition, the corporal héxis reveals seriousness and purity, and helps to establish the new image of the graduate nurse in ribeirão preto. this study serves to broaden the discussion on construction of the nurse’s image, professional identity and the catholic influence in nursing education. key words history of nursing, ceremonial behavior, nursing, schools, nursing, symbolism (source: decs, bireme). año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 109-118 112 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 introdução o objeto de análise do estudo é a imagem das enfermeiras na ritualística da missa católica, que antecedeu o rito de formatura, da primeira turma da escola de enfermagem de ribeirão preto, da universidade de são paulo (eerp-usp), em 1957. no estado de são paulo, a fundação rockefeller teve papel importante no processo de criação das escolas de enfermagem da usp. com o objetivo de colaborar na estruturação da escola de enfermagem da universidade de são paulo (ee-usp), criada anexa à faculdade de medicina (fm-usp), em 1942, a referida fundação ofereceu seis bolsas de estudo (quatro efetivamente utilizadas) para graduação em enfermagem, no exterior, de educadoras sanitárias (1). entre as bolsistas estava glete de alcântara, que se graduou em enfermagem geral e enfermagem de saúde pública junto à faculty of nursing (atual lawrence s. bloomberg), da university of toronto (1944). em 1951, recebeu o título master of arts pelo teacher’s college, columbia university, e licenciou-se em ciências sociais na usp em 1952 (2). em 26 de dezembro de 1951, sob a lei estadual 1.467, foi aprovada a estrutura didático-administrativa da faculdade de medicina, na cidade de ribeirão preto (fmrp-usp), e, no artigo 13, criada, em anexo, a eerp-usp, que deveria seguir o modelo da ee-usp e manter cursos de enfermagem e de auxiliar de enfermagem (3). em 1952, o prof. dr. zeferino vaz, designado como diretor da fmrp-usp, convidou a prof.ª glete de alcântara para instalar e dirigir a eerp-usp, após indicação do prof. paulo césar de azevedo antunes, então diretor da faculdade de higiene e saúde pública da usp, conforme consta em ata da 312ª sessão do conselho universitário da usp, de 5 de março de 1952. contudo, somente em agosto de 1953 foram iniciadas, efetivamente, as atividades da eerp-usp. a figura da enfermeira diplomada era pouco conhecida no cenário sociocultural de ribeirão preto e praticamente inexistente. portanto, a instituição desse profissional provavelmente representou grande desafio à sua diretora, que necessitava, para o recrutamento de estudantes, se fazer ver e se fazer crer nesse espaço social (4). nessa perspectiva, após quatro anos de formação no curso de enfermagem, teria chegado o momento de apresentar à sociedade de ribeirão preto as primeiras enfermeiras oriundas da eerpusp, apresentação feita de forma acadêmica, por meio do rito de imposição de grau, ocorrendo antes uma missa. entende-se, para o presente estudo, que ambos compuseram o rito de formatura. o rito acadêmico de formatura é composto de microrrituais, dentre eles: a entrada dos formandos, chamada nominal, acendimento e passagem da lâmpada (símbolo da profissão), juramento, imposição de grau de bacharelado em enfermagem, homenagens e discursos. nesse sentido, já foi relatado na literatura a ritualística, bem como outros ritos que, direta e/ou indiretamente, envolvem a religião católica (5), o que despertou interesse como objeto de análise, em virtude da possível sacralização da profissão. dito de outra maneira, há indício de que essa ritualística possa ter influenciado o mecanismo de construção da imagem da enfermeira brasileira que, na voz corrente, às vezes é conhecida como o anjo de branco. o presente estudo teve como objetivo analisar a imagem da enfermeira na ritualística de missa de formatura, que antecedeu o rito de imposição de grau de enfermeira, da primeira turma da eerp-usp. as contribuições deste estudo para o avanço da área da enfermagem dão-se no sentido de ampliar as discussões sobre a construção da imagem da enfermeira e da identidade profissional. ademais, é uma possibilidade de se investigar o nexus que a religião católica, na década de 1950, teve na enfermagem, em especial, nessa escola. método trata-se de estudo histórico sob a perspectiva da micro-história, que parte do olhar microscópico ao manejar níveis de escala diferentes da mesma forma que na abordagem multiscópica, na produção das formas e das relações sociais (6). a análise do objeto proposto teve o marco temporal referente a 21 de dezembro de 1957, dia da realização da missa de formatura. para tanto, analisou-se fotografias de uma coleção do mesmo ano, pertencente ao centro de memória da eerp-usp, totalizando 53 fotos, das quais 28 são sobre a formatura da primeira turma de enfermeiras. mediante o critério de inclusão de análise (presença das formandas na ritualística católica), foram selecionadas duas fotos que possuem a referência: “serviço fotográfico e encadernação foto miyasaka – ribeirão preto”, cujo fotógrafo responsável era tony miyasaka. 113 rito católico e imagem da enfermeira (1957) l maria fernanda simiele, luciana barizon-luchesi, fernando porto, tatiana oliveira-sousa, emiliane silva-santiago, simone aguiar para a análise do texto fotográfico, teve-se como base a matriz de análise, ajustada para o texto fotográfico com os seguintes itens: 1) dados de identificação (local do acervo, ano de impressão); 2) dados para o plano de expressão (crédito, relação texto/imagem, legenda, resumo do texto, tipo de foto, formato, plano, sentido); 3) dados para o plano de conteúdo (local e pessoas retratadas, tema, atributos pessoais/paisagem) e 4) dados complementares (5). para triangulação das fontes, além das fotografias, foram usados documentos, entrevistas coletadas junto ao estudo origens da eerp-usp, sob a ótica de glete de alcântara, atas, livros e teses referentes ao assunto. a interpretação dos dados foi norteada pelas noções teóricas de pierre bourdieu, principalmente a de rito institucional e hexis corporal, articulado a autores sobre rito, moda, linguagem corporal, história do brasil e da enfermagem. ressalta-se que a palavra “rito” deriva de ritus, que significa ordem prescrita. sua etimologia remete ao sentido de ordem seja do cosmos, relações deuses/homens ou homens/homens. no campo religioso, os termos “cerimonial” e “ritual” se entrelaçam. o termo “cerimônia” originalmente refere-se a ritos cívicos e solenes, ou seja, de origem profana (7). o rito ou ritual refere-se a uma série de atos formais que possuem dimensão simbólica, com recorte espaço/tempo próprio, linguagens, signos e objetos próprios, cuja interpretação constitui um bem comum de um grupo (7), pode também ser entendido como um rito de instituição, quando consagra uma ordem estabelecida, ao levar aqueles que são transformados nesse ato a se comportarem da mesma forma como a representação do real se mostra (8). a linguagem do corpo também foi referencial para análise por meio da hexis corporal, entendida como postura corporal, aquela que pode determinar as relações do mundo social que representam as expressões ética e estética de determinada condição social (8). a moda foi entendida pelos trajes das formandas, pois a roupa constitui vocabulário e gramática próprios. a linguagem da moda, de acordo com o contexto cultural, não inclui apenas as vestimentas, mas também os acessórios, joias, decoração do corpo e maquiagem (9). estes foram articulados ao contexto brasileiro e à história da enfermagem brasileira. o estudo foi aprovado pelo comitê de ética em pesquisa (cep/eerp-usp), em 2011 (1.299/2011), com previsão de uso de entrevistas do estudo origens da eerp-usp, sob a ótica de glete de alcântara (cep/eerp-usp/0970/2008). houve autorização, para uso das imagens, dos indivíduos fotografados, do fotógrafo ou de seus herdeiros e da instituição. resultados e discussão a primeira turma de formandas da eerp-usp foi constituída por cinco ingressantes em agosto de 1953 e cinco ingressantes em fevereiro de 1954, com rito de formatura em 21 de dezembro de 1957. a programação referida no convite de formatura consta que, às 8h30 da manhã, houve a “missa solene em ação de graças, na capela sagrado coração de jesus, da santa casa de misericórdia de ribeirão preto”, e, às 20h30, “colação de grau no salão nobre da associação comercial e industrial de ribeirão preto” (acirp). destaca-se que, na década de 1920, eram fortes os laços de apoio entre estado e igreja. na década de 1950, sob as normativas dos dispositivos legais, o ensino religioso era matéria constituinte nas escolas públicas primárias, secundárias, com participação facultativa do estudante. nessa perspectiva, 95% dos brasileiros, na década de 1940, declaravam-se católicos apostólicos romanos, com predomínio de adeptos do gênero feminino. o analfabetismo era de 56,8% (maiores de 10 anos); entre as mulheres, o índice era de 61,9% (10). apesar de o ensino religioso não ser obrigatório, era predominante sua influência no cenário brasileiro. nesse sentido, infere-se que não deve ter ocorrido ao acaso a ritualista da missa como bênção às formandas, uma vez que estas, provavelmente, foram influenciadas para seguirem a doutrina católica. a missa católica, como rito, tem o poder de transmitir uma tradição, cuja articulação envolve comportamentos de repetição, o que provoca sua compreensão dos fatos de forma compartilhada (7). deduz-se que a missa católica possa ter sido uma atitude arbitrária pelas responsáveis institucionais, pois não cabe aqui afirmar que todas fossem católicas. por outro lado, o rito pode ser entendido como forma de cortesia acadêmica, em virtude de parte do estágio das alunas ter sido realizado junto à santa casa de misericórdia, o que contribuiria para reforçar os laços institucionais. sobre a missa, como parte integrante do ritual de formatura, tem-se registro, até o momento, que esta ocorre desde 1925, 114 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 quando da formatura da turma pioneira da escola de enfermeiras do departamento nacional de saúde pública (eednsp), atual escola de enfermagem anna nery-ufrj (eean). foi realizada na matriz da candelária, no rio de janeiro (5), o que deixa transparecer ter sido incorporada como rito para as formandas que se estende até os dias atuais em muitas instituições. o ato de registrar em fotografias momentos como a ritualística leva a se pensar na preservação da memória que o tempo é capaz de afastar, deixando lembranças distantes, ou até mesmo de apagá-las dos sujeitos que participaram. nesse sentido, os ritos da enfermagem podem ser destacados em sua função de demonstrar, de forma homogênea, uma imagem respeitável que, intrinsicamente, dava visibilidade e promoção de status à profissão (11). a figura 1 refere-se à missa de colação de grau; as cores, em tons cinza, deixam transparecer ser flagrante, de composição grupal de homens e mulheres, no formato geométrico retangular e cenário natural interno. o texto imagético apresenta-se em plano geral e central, que possibilita a visão panorâmica de um dos lados da igreja no sentido horizontal. figura 1. missa de formatura da 1ª turma de formandas da eerp-usp, 1957 trajam uniforme (da esquerda para a direita, são: libânia meirelles, maria anna cerchiaro, emília luigia saporiti, odette apparecida de carvalho bocchi e carmem sílvia monteiro de barros martinelli) e outras dezenove pessoas, aproximadamente, de pé. destaca-se que, ao lado esquerdo, ao fundo, encontra-se uma freira, podendo-se inferir ser uma das irmãs apóstolas do sagrado coração de jesus, em virtude dos estágios realizados pelas formandas junto à santa casa de misericórdia, o que se depreendeu de sua presença representar homenagem e/ou materialização dos laços institucionais. observa-se que as formandas trajam toucas de cor clara, aparentemente de modelo idêntico, pouco se pode inferir sobre o tamanho/penteado/corte dos cabelos em virtude da hexis corporal e posicionamento da touca. elas apresentam vestidos claros, compridos, provavelmente abaixo da altura do joelho, com mangas na altura do ponto médio do braço. por outro lado, não se observa uniformidade na modelagem do uniforme. da esquerda para a direita, a 1ª, 2ª e 4ª formandas retratadas apresentam modelagem semelhante de uniforme: vestidos claros, com uma pequena gola na altura do pescoço, com diferenciação na gola da 1ª em relação às demais, com botões da cintura para cima, que acompanham a linha esternal anatômica e decote. as 3ª e 5ª formandas, da esquerda para a direita, usam modelos distintos de uniforme em relação às demais: apresentam vestidos claros, compridos, completamente fechados, com uma pequena gola, que lembram desenho oriental e com, aparentemente, quatro botões, próximo à linha hemiclavicular esquerda. o vestido em referência trata-se de uniforme na cor branca, foi usado como possível traje de gala e na vida profissional. o uniforme trata-se da extrema imposição do outro sobre a forma de vestir. ao trajá-lo, o indivíduo abdica de sua autonomia e está, de certa forma, sob censura. esse traje, por outro lado, tem o poder de conferir confiança e dignidade, podendo ser um mecanismo de representação simbólica e identificação de um determinado grupo social, com sua respectiva posição hierárquica (9). no excerto de três entrevistas, foi identificado o rigor disciplinar para o comportamento, a distinção entre o uniforme da estudante e da enfermeira e cuidados com excesso de adornos: fonte: centro de memória da eerp-usp. código mf149. o local retratado trata-se da capela da santa casa de misericórdia de ribeirão preto, dado triangulado com o convite de formatura e entrevistas. a imagem apresenta cinco formandas que 115 rito católico e imagem da enfermeira (1957) l maria fernanda simiele, luciana barizon-luchesi, fernando porto, tatiana oliveira-sousa, emiliane silva-santiago, simone aguiar [...] o uniforme da escola... a gente usava aquele uniforme cinza, quando era estagiária. somente depois de formada é que passa a usar branco. depois o uniforme era vestido branco e a touca [...] (formanda 1). [...] então a gente tinha uma disciplina em tudo, o cabelo não podia ficar esvoaçando, o uniforme não podia ficar acima do joelho, nós tínhamos calçados de cor exata, meia... era a disciplina, vamos dizer (formanda 2). [...] primeiro a questão da aparência, a aparência física com relação à roupa, o cuidado com os cabelos, evitar pinturas exageradas, não uso de joias, por motivos óbvios, com relação à contaminação, mas, também, não combinava com o uniforme, não se usava joias, apenas o relógio e o cabelo sempre preso e, no começo, ainda havia o uso da touca que era ainda tradicional, a gente tinha que prender os cabelos e usar uma redinha (formanda 3)1. a cor branca representa a pureza, usada por cientistas e profissionais de saúde, pessoas direta ou indiretamente ligadas à assistência dos enfermos, por se tratar de cor que não ameaça e transmite ideia de confiabilidade para a realização dos cuidados (12), como também mencionado em outros estudos (5, 13). ademais, duas formandas aparentam usar adereços no braço esquerdo (relógio de pulso). em estudo sobre a imagem pública da enfermeira-parteira, na imprensa, ao analisar os ritos institucionais do hospital maternidade pró-matre do rio de janeiro (1928-1931), identificou-se, dentre as representações objetais da enfermeira, o relógio de pulso, que teve o significado de prosperidade em virtude do uso no pós-guerra (1914-1918) (13). depreende-se, no caso das formandas retratadas na figura 1, que, possivelmente, tenha ocorrido a incorporação simbólica dessa representação no decorrer dos tempos, uma vez que o relógio parece compor o uniforme da enfermeira em virtude do uso, de forma completar, nas atividades dos cuidados prestados, por exemplo, para a mensuração do pulso, respiração e controle de gotejamento. o cenário interno da fotografia é destinado ao culto religioso católico, adornado por quatro vitrais: dois na lateral esquerda e, ao fundo, observa-se outros dois vitrais e um candelabro aceso. o banco, à frente das formandas, apresenta um tecido na cor clara, diferentemente dos demais presentes e dois objetos, o que deixa transparecer serem livros, que podem ser, pela quantidade de páginas, exemplares da bíblia católica. as formandas apresentam-se com hexis corporal de mãos entrelaçados na altura da cintura ou quadris. quando as mãos não possuem nada para segurar, o entrelaçar de mãos pode ser tomado como posição que busca conforto e calma, típica em situações em que há exposição do indivíduo (14). nessa situação, as formandas encontram-se na primeira fileira, com tecido que demarca distinção entre elas e o público, o que as deixa em situação de evidência. há indícios de que a eerp-usp sofria influência da disciplina, ensino e, em especial, do aspecto da religiosidade, adotados na faculty of nursing (atual lawrence s. bloomberg), da university of toronto (fn-ut), reforçada pela liderança de glete de alcântara, oriunda dessa escola e diretora da eerp-usp de 1953 a 1971 (15). no período em que glete de alcântara foi estudante, o cotidiano, na fn-ut, iniciava-se às 6h55, na sala de estar, onde uma das professoras ficava responsável pelas orações. as refeições eram circunstanciadas por pompa e rituais específicos a serem seguidos. minutos antes das 18h30, soava o primeiro sinal, que determinava a reunião das estudantes do hall de entrada do refeitório; na sequência, o segundo sinal demarcava a entrada das docentes e diretora no refeitório; por último, as alunas poderiam adentrar. quando todos estavam posicionados, a diretora iniciava a oração de agradecimento da refeição, cuja finalização autorizava todos a se sentarem. quando todos terminavam o jantar as docentes saíam do recinto e, somente após a saída das professoras, as alunas eram autorizadas a deixar o refeitório (2). as crenças religiosas eram respeitadas, uma vez que a religião católica era minoria no canadá, mesmo assim, as refeições eram programadas para atender as demandas, como o oferecimento de peixe na sexta-feira e quarta-feira da quaresma (2). ao se articular o aspecto religioso disciplinar da fn-ut com a ritualística católica de missa, na formatura das formandas da eerp-usp, pode-se inferir a influência da religiosidade advinda da américa do norte, como forma de se sacralizar a profissão e as enfermeiras para o ato do cuidar. a figura 2 apresenta as mesmas características da figura 1 em relação ao local, cor da imagem, composição grupal, formato geométrico, cenário e plano fotográfico. a figura 2 apresenta cinco formandas, trajando uniforme, além de aproximadamente 26 pessoas sentadas e duas de pé. as formandas, da esquerda para a direita, são: vilma aquino, ge116 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 raldina pásseri, lydia ferreira, luzia apparecida urbano e zaíra benedini. assim como na figura 1, observa-se o uso de toucas de cor clara, aparentemente de modelo idêntico, aparentam ter os cabelos curtos ou presos, vestidos de tom claro, comprimento do vestido/ uniforme semelhantes, sem uniformidade nas modelagens. da esquerda para a direita, na figura 2, a 1ª e a 2ª formandas usam modelagem de uniforme equivalente à das 3ª e 5ª formandas da figura 1. igualmente na figura 2, a 3ª, 4ª e 5ª formandas apresentam modelagem equivalente à das 1ª, 2ª e 4ª formandas da figura 1. a 1ª formanda, à esquerda, figura 2, ostenta óculos escuros e, ao seu lado, a formanda utiliza óculos claros, possivelmente corretivos da acuidade visual. nessa perspectiva, o uso de óculos em tom escuro remete à seguinte entrevista: [...] aqui é a capela da santa casa [...]. [...]essa foto da missa de formatura batia muito sol (formanda1)8, provavelmente o uso do óculos em tom escuro deu-se em virtude da claridade excessiva da manhã ensolarada, durante o rito institucional. 8 fonte das entrevistas: laboratório de estudos em história da enfermagem (laeshe). coleção pioneiras: conjunto de entrevistas transcritas com egressas da turmas de 1957 a 1961. ribeirão preto; escola de enfermagem de ribeirão preto, da universidade de são paulo: 2005-2011. as figuras 1 e 2 se apresentam no mesmo cenário, com foco diferenciado pela lente da máquina fotográfica, com vitrais em temas religiosos e com ornamentos em tecido claro, o que distingue as formandas do público presente. destaca-se que a segunda fotografia, pela sequência ritualística, pode também ser a primeira. dito de outra maneira, a ordenação das fotografias não foi considerada, por se entender como objeto de análise a imagem da enfermeira e não o movimento da ritualística católica. na figura 2, identificam-se homens em traje social (terno), característica, à época, que exigia rigor na vestimenta, quando se tratava de um rito institucional. apesar de, em décadas anteriores, este também ter sido identificado em outros estudos (5). nesse sentido, quanto mais oficial uma situação é retratada maior o poder de legitimidade de uma expressão dominante, que também pode determinar regras rigorosas, como trajes em situações oficiais, que são acatadas, independentemente do constrangimento que causam, mas que corroboram e intensificam a legitimidade da expressão (8). a hexis corporal das formandas, em especial da figura 1, de mãos juntas, pode denotar confinamento simbólico da mesma maneira com a posição de pernas cruzadas, mãos entrelaçadas sobre as coxas, dito na voz corrente, no colo. nesse sentido, o confinamento simbólico, ao ser decodificado, pode significar recato e pureza (16). ademais, os rituais são os limites das situações de imposição, pois, por meio de uma competência técnica, pode se exercer uma competência social, que legitima e autoriza o discurso do locutor legítimo (8). depreende-se, dessa hexis corporal contextualizada no rito, o sentido de respeito, principalmente por estar diante de imagens santificadas. esse comportamento coaduna com a investidura de enfermeiras, ao serem consagradas com uma nova identidade, não mais poderiam adotar a postura de alunas, pois o rito impõe simbolicamente a obrigatoriedade de se apropriar do que se espera ser enfermeira, sua nova identidade, daquele momento em diante. ao mesmo tempo, essa identidade está atrelada à hexis corporal própria da classe, assim como o uso de signos exteriores ao corpo. nesse caso, podem-se incluir as medalhas, uniformes, insígnias e mesmo os signos incorporados, como postura, maneira de falar, o que demarca o espaço desses agentes no campo social (8). figura 2. missa de formatura da 1ª turma de formandas da eerp-usp, 1957 fonte: centro de memória da eerp-usp. código mf148. 117 rito católico e imagem da enfermeira (1957) l maria fernanda simiele, luciana barizon-luchesi, fernando porto, tatiana oliveira-sousa, emiliane silva-santiago, simone aguiar a touca, na década de 1920, na eednsp, esteve associada ao valor simbólico na profissão, que, ao mesmo tempo, identificava a enfermeira e a distinguia dentre as escolas à época, ao conferir obrigações e privilégios, sempre repousada sobre cabelos presos (11). no canadá, até os anos 1970, uma enfermeira poderia ser reconhecida pelo uso da touca. o primeiro modelo foi a nun’s coif, utilizada pelas ordens religiosas que fundaram hospitais em quebec e montreal (século xvii). tinha-se como objetivos, em relação às primeiras cuidadoras laicas, a manutenção do cabelo limpo e arrumado, posteriormente o uniforme foi amplamente adotado, pois perceberam que isso agregava status para o hospital ou escola (17). um dos rituais na formação canadense era o capping ceremony, no qual a estudante de enfermagem, por meio de exame, mediante aprovação, recebia sua primeira touca. no rito de formatura, a graduanda recebia outro modelo de touca, com uma listra preta, a tradicional blackcap band. nas primeiras décadas do século xx, as toucas canadenses se tornaram estilizadas e com forte função simbólica (17). não foi observada a utilização do friso nas toucas das primeiras turmas da eerp-usp. entretanto, a listra ou friso escuro é identificado na cerimônia de formatura da eednsp, em 1925. sua apresentação refere-se ao momento de graduação, que passou a compor, assim como as canadenses, um símbolo de distinção entre a aluna e a enfermeira diplomada. dessa forma, passa a constituir, também, capital simbólico, construído durante a graduação, que visava manter o poder exclusivo de “enunciação da imagem da enfermeira brasileira” (5). o ritual passa a ser incorporado e transmitido por gerações dentro de determinados grupos sociais, cujas práticas possuem ordenação definida. dito de outra maneira, o rito é constituído de certos gestos, palavras e objetos e os presentes acreditam em algo que o transcende (7). a missa, como ritual, é o momento de garantia da reprodução do reconhecimento da linguagem predominante, a religiosa, pois o ambiente, gestos e palavras devem ser cridos e obedecidos com o objetivo de garantir sua legitimidade. nesse caso, o sacerdote tem o poder instituído de falar e comportar-se em nome de um grupo (8). mediante o exposto, observa-se que, em ambas as figuras analisadas, os olhares das formandas se dirigem para o altar, local onde provavelmente estava a figura do sacerdote. além disso, esse comportamento denota estado de concentração e respeito, requisito para a legitimidade desse tipo de rito. a recuperação dos significados dos ritos, emblemas e hexis corporal, para se remontar a história da enfermagem, é uma das possibilidades de se evidenciar o efeito simbólico das tradições inventadas, que permite desvelar as relações de poder no campo da saúde. conclusão vários rituais foram incorporados com o objetivo de contribuir para a formação da identidade da enfermeira e instituir o poder da categoria no espaço da saúde. para tanto, os signos incorporados pela eerp-usp, na tentativa de se fazer ver e de se fazer crer no rito de missa de formatura, foram o uso do uniforme e da touca, a delimitação do espaço entre as formandas e o público (tecido claro), o que demarca a distinção destas e do público ouvinte que, com uma postura de seriedade e recato, demonstrado em posições de repouso das mãos sobre o corpo, pode ter significado a necessidade de transparecer seriedade e pureza. observa-se também a presença de um grande público, o que significa que o evento teve ampla adesão social, provavelmente de familiares e outras autoridades, corroborando o processo de legitimação do rito de passagem da aluna para enfermeira diplomada. as determinações referentes ao traje, provavelmente estivessem restritas à cor, comprimento da saia, mangas, tecido ou modelagens gerais, o que possibilitou que as formandas expressassem sua individualidade na determinação das golas e decote (presença ou não). neste artigo reconhece-se a possibilidade de algumas lacunas que merecem investimento intelectual de pesquisadores seja da enfermagem e/ou das ciências sociais, com o objetivo de se ampliar os horizontes e o avanço na construção do conhecimento a ser aplicado na profissão. por fim, o presente estudo tende a dar continuidade sobre a temática rito de imposição de grau, no qual as enfermeiras não mais trajam seus uniformes, mas, sim, trajes talares. agradecimentos: agradecemos à escola de enfermagem de ribeirão preto-usp a disponibilização do acervo para pesquisa e autorização para publicação das fontes. 118 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 referências 1. carvalho ac. escola de enfermagem da universidade de são paulo: resumo histórico, 1942-1980. rev esc enferm usp 1980; 14 (supl): 1-271. 2. pinheiro mrs. formação profissional. in: angerami els, pelá ntr. glete de alcântara: vida e obra. são paulo: revista dos tribunais; 1976. p. 3-18. 3. angerami els. 40 years. the conquest of maturity. rev lat am enfermagem 1993; 1 (2): 5-20. 4. bourdieu p. o poder simbólico. rio de janeiro: bertrand brasil; 2005. 5. porto f, santos tcf. a enfermeira brasileira na mira do clique fotográfico (1919-1925). in: porto f, amorim wm, organizadores. história da enfermagem brasileira: lutas, ritos e emblemas. rio de janeiro: águia dourada; 2007. p. 24-188. 6. revel j, organizador. jogos de escalas: a experiência da microanálise. rio de janeiro: fundação getúlio vargas (fgv); 1998. p. 7-14. 7. segalen m. ritos e rituais contemporâneos. rio de janeiro: fgv; 2002. 8. bourdieu p. economia das trocas linguísticas: o que falar quer dizer. são paulo: edusp; 1998. 9. lurie a. a linguagem das roupas. rio de janeiro: rocco; 1997. 10. ibge. tendências demográficas: uma análise da população com base nos resultados dos censos demográficos de 1940 e 2000. [internet]. ministério do planejamento, orçamento e gestão; 2000 [acesso 21 fev. 2012]. disponível em: http:// www.ibge.gov.br/home /estatistica/ populacao/tendencia_demografica/analise_populacao/1940_2000/analise_populacao.pdf 11. santos tcf. significado dos emblemas e rituais na formação da identidade da enfermeira brasileira: uma reflexão após oitenta anos. esc anna nery rev enferm 2004; 8 (1): 81-6. 12. fischer-mirkin t. o código do vestir: os significados ocultos da roupa feminina. rio de janeiro: rocco; 2001. 13. fonseca ef. a imagem pública da enfermeira-parteira do hospital maternidade pró-matre do rio de janeiro no período de 1928-1931: (des)construção de uma identidade profissional. [dissertação]. rio de janeiro: escola de enfermagem alfredo pinto da universidade federal do estado do rio de janeiro, 2011. 14. guglielmi a. a linguagem secreta do corpo: a comunicação não verbal. trad. denise jardim duarte. 3ª. ed. petropólis (rj): vozes; 2011. 15. luchesi lb, vanin jc, costa jr ml. a criação e estruturação do ensino da escola de enfermagem de ribeirão preto usp de 1951 a 1971. r pesq cuid fundam. (on-line) 2010; 2 (supl.): 336-8. 16. bourdieu p. a dominação masculina. rio de janeiro: bertrand brasil; 2009. 17. bates c. the nurse’s cap: symbol of a profession. in: bates c, dodd d, rousseau n, organizadores. on all frontiers: four centuries of canadian nursing. quebec: university of ottawa and canadian museum of civilization corporation; 2005. p. 7. 529 540 revisao integrativa as praticas.indd 529 virginia faria damásio dutra1 rosane mara pontes oliveira2 revisão integrativa: as práticas territoriais de cuidado em saúde mental 1 professora. universidade federal do rio de janeiro, brasil. virginia.damasio@gmail.com 2 doutora em enfermagem. universidade federal do rio de janeiro, brasil. romapope@gmail.com recibido: 12 de noviembre de 2013 enviado a evaluadores: 21 de abril de 2014 aceptado por evaluadores: 14 de agosto de 2015 aprobado: 07 de septiembre de 2015 doi: 10.5294/aqui.2015.15.4.8 para citar este artículo / to reference this article / para citar este artigo dutra, vfd. & oliveira, rmp. revisão integrativa: as práticas territoriais de cuidado em saúde mental. aquichan. 2015; 15 (4): 529-540. doi: 10.5294/aqui.2015.15.4.8 resumo objetivos: identificar abordagens e elementos das práticas territoriais dos profissionais da saúde mental e discutir as práticas territoriais na perspectiva do trabalho da enfermagem psiquiátrica. método: revisão de literatura integrativa de estudos científicos publicados no período entre 2001 a 2011 na biblioteca virtual da saúde, a base de dados lilacs, utilizando as expressões saúde mental e território, em setembro de 2012. a pesquisa foi guiada pela pergunta: como acontecem as práticas de cuidados territoriais no campo da saúde mental? utilizou-se da análise temática para compreender e sistematizar os dados. resultados: nos 52 estudos analisados, evidencia-se que, no território, acontecem articulações e negociações de diversas naturezas, numa teia de construção de cuidados de saúde mental, principalmente fomentadas pelos centros de atenção psicossocial e atenção básica. conclusão: apropria-se de conceitos, como: rede, articulação, integralidade, acessibilidade, responsabilização, promoção de saúde mental, acolhimento, vínculo, itinerância, estratégia grupal, grupos educativos, profissional de referência, entre outros orientadores da emancipação dos cidadãos. palavras-chave saúde mental, enfermagem psiquiátrica, cuidados de enfermagem (fonte: decs, bireme). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 529-540 530 aquichan issn 1657-5997 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 529-540 revisión integradora: las prácticas territoriales de cuidado en salud mental resumen objetivos: identificar abordajes y elementos de las prácticas territoriales de los profesionales de la salud mental y discutir las prácticas territoriales en la perspectiva del trabajo de enfermería psiquiátrica. método: revisión integradora de estudios científicos publicados entre 2001 y 2011 en la biblioteca virtual de la salud, la base de datos lilacs, empleando las expresiones salud mental y territorio, en septiembre de 2012. la investigación se orientó por la pregunta: ¿cómo ocurren las prácticas de cuidados territoriales en el campo de la salud mental? se utilizó el análisis temático para comprender y sistematizar los datos. resultados: en los 52 estudios analizados, se encuentra que, en el territorio, ocurren articulaciones y negociaciones de diversas naturalezas, sobre todo fomentadas por los centros de atención psicosocial y atención básica. conclusión: se apropia de conceptos, como red, articulación, acogida, vínculo, itinerancia, estrategia grupal, grupos educativos, profesional de referencia, entre otros orientadores de la emancipación de los ciudadanos. palabras clave salud mental, enfermería psiquiátrica, cuidados de enfermería (fuente: decs, bireme). 531 revisão integrativa: as práticas territoriais de cuidado em saúde mental l virginia faria damásio dutra, rosane mara pontes oliveira an integrative review: territorial practices in mental health care abstract objectives: identify approaches and elements in the territorial practices of mental health professionals and discuss those practices from the standpoint of work in the field of psychiatric nursing. method: the research is based on an integrative review of scientific studies published between 2001 and 2011 in the virtual health library and the lilacs database, using the terms mental health and territory. conducted in september 2012, it was guided by the question: how do territorial practices occur in the field of mental health care? thematic analysis was used to understand and process the data. results: in the 52 studies analyzed, it was found that different types of networking and negotiations occur in the field, promoted largely by centers for psychosocial and primary care. conclusion: concepts such as network, networking, response, link, roaming, group strategy, educational groups and reference professional are appropriated, among other guidelines to citizens’ emancipation. keywords mental health, psychiatric nursing, nursing care (source: decs, birime). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 529-540 532 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 introdução a reforma psiquiátrica brasileira acontece em processo dinâmico e paralelo nos campos dos conceituais, técnico-assistencial, políticos, jurídicos, social e cultural. nesse processo de transformação, adotam-se conceitos, estratégias e princípios. entre eles, saúde, saúde mental e território. saúde é a resultante das condições de alimentação, habitação, educação, renda, meio ambiente, trabalho, transporte, emprego, lazer, liberdade, acesso e posse da terra e acesso a serviços de saúde. esse conceito passa a ser discutido como o conceito ampliado de saúde, como eixo fundamental para a construção do modo de atenção em saúde mental. enquanto para a organização mundial da saúde (oms), os conceitos de saúde e saúde mental abrangem, entre outras coisas, o bem-estar subjetivo, a autoeficácia percebida, a autonomia, a competência, a dependência intergeracional e a autorrealização do potencial intelectual e emocional da pessoa. numa perspectiva transcultural, é impossível definir saúde mental de uma forma completa. porém, de um modo geral, a saúde mental é percebida como mais do que a ausência de perturbações mentais (1). por sua vez, território é a designação não apenas de uma área geográfica, mas também das pessoas, das instituições, das redes e dos cenários nos quais se dá na vida comunitária (2). assim, trabalhar no território significa utilizar todos os componentes, saberes e forças concretas da comunidade, a qual propõe soluções, apresenta demandas e que pode construir objetivos comuns. as práticas territoriais envolvem os saberes e as potencialidades dos recursos da comunidade, da construção coletiva de soluções, das trocas entre as pessoas e a ideia de cuidado. dessa maneira, o conceito de território funciona como organizador da rede de atenção à saúde mental e orienta as ações de todos os seus equipamentos (2). considerando esses três conceitos, a saúde mental de uma pessoa se constrói e se reconstrói nas relações estabelecidas com o meio onde se vive. essa trama de interações sociais, na qual a pessoa se estabelece enquanto vive, é chamada de rede ou trama social. o espaço físico e simbólico onde a trama acontece é chamado de território. dessa maneira, num mesmo território, estão emaranhadas várias redes e, entre elas, a rede de serviços de saúde e a rede de saúde mental; além destas, as demais redes comunitárias, de trabalho, apoio e vizinhança. no entanto, a enfermagem psiquiátrica, que teve sua gênese no hospital psiquiátrico, encontra-se imersa nas transformações das suas práticas, sustentada pela transição paradigmática. nesse sentido, o “bom cuidado” da enfermagem psiquiátrica transformou-se com as demandas da política de saúde do brasil e foi necessário incluir outros elementos, entre eles, o território. nesse contexto, estabeleceu-se como pergunta de pesquisa: como acontecem as práticas de cuidados territoriais no campo da saúde mental? e, como objetivos: identificar abordagens e elementos das práticas territoriais dos profissionais da saúde mental e discutir as práticas territoriais na perspectiva do trabalho da enfermagem psiquiátrica. método em setembro de 2012, realizou-se revisão integrativa (3) de estudos científicos publicados no período entre 2001 e 2011 na biblioteca virtual da saúde, a base de dados lilacs, na qual foram utilizadas as expressões saúde mental e território. a base se justifica pelas particularidades do campo psicossocial no brasil e na américa latina, enquanto os estudos da américa do norte, europa e do oriente utilizam de outras abordagens e apresentam realidades distintas. o período, pós-lei 10.216, representa a concretização e a efetivação de uma política discutida e construída a partir da reforma sanitária e psiquiátrica. as etapas da revisão integrativa da literatura estão alicerçadas numa estrutura de trabalho definida por um protocolo previamente elaborado, as quais foram adotadas visando manter o rigor científico, a saber: 1) seleção da pergunta de pesquisa; 2) definição dos critérios de inclusão de estudos e seleção da amostra; 3) representação dos estudos selecionados em formato de tabelas, que representassem todas as características em comum; 4) análise crítica dos achados, que identificasse diferenças e conflitos; 5) interpretação dos resultados; 6) relatório claro sobre a evidência encontrada. os critérios para a inclusão dos artigos foram: texto completo disponível on-line, publicados no período de 2001 a 2011, que contivesse no assunto saúde mental e território/comunidade/grupos sociais. foram incluídas todas as categoriais de publicações. critério de exclusão: repetidos, editoriais, reflexão e fuga do objetivo. a busca resultou em 63 artigos e, destes, 11 artigos foram excluídos por terem sido publicados no período de 1980 a 2000. 533 revisão integrativa: as práticas territoriais de cuidado em saúde mental l virginia faria damásio dutra, rosane mara pontes oliveira dos 52, procedeu-se à leitura minuciosa de cada resumo e, em seguida, do artigo na íntegra. nessa etapa, foram excluídas 19 publicações por suas temáticas serem divergentes do nosso objetivo, tais como: dificuldades dos profissionais, psicanálise, população indígena, enfoque em doenças, perfil epidemiológico, deficiência física e hospital psiquiátrico. das 33 publicações analisadas, todas optaram pela abordagem qualitativa, sendo 24 artigos e 9 teses ou dissertações. quanto ao tipo de estudos: 10 declaram ser descritivos exploratórios; 5 avaliativos; 4 bibliográficos; 3 etnográficos; 5 outros e 6 não deixam claro o tipo do estudo (3). optou-se por análise temática (4). para sistematizar a análise dos estudos, foi utilizado um quadro com título, autores, fontes, objetivos, tema principal, resumo, principais resultados e observações importantes. posteriormente, foram realizadas síntese dos núcleos temáticos, categorização e descrição dos resultados. resultados o material analisado resultou em três categorias temáticas: o conceito de território na construção do campo psicossocial; atenção básica e saúde mental imersas no mesmo território; a integralidade e a invenção de estratégias para promoção de saúde mental. essas categorias serão descritas a seguir. o conceito de território na construção do campo psicossocial o conceito de campo psicossocial surge da busca de uma nova psiquiatria quando a clássica não mais era eficiente para atender às demandas atuais. na verdade, as críticas ao hospital psiquiátrico surgem com o nascimento do próprio hospital e foram muitas as tentativas de reformá-lo, o que levou à discussão pela humanização do atendimento, superação do conceito de doença mental como incapacidade e cidadania dos que sofrem psiquicamente. assim, afirmaram-se a ruptura com a psiquiatria hegemônica (afinada com a biologia, com a normatividade e a instituição) e a abertura para o modo psicossocial (voltado às respostas localmente construídas e que investe na pessoa). a nova psiquiatria rompe com o conceito de comunidade e enreda-se pelo conceito de território (5). a partir da década de 1990, a política pública do campo da saúde mental trazia no seu bojo propostas inovadoras e estratégias de cuidados aos que sofrem psiquicamente. a estratégia principal, a criação de centros de atenção psicossocial (caps), expandiu pelo brasil como objetivo de prestar atendimento ambulatorial personalizado aos portadores de transtornos mentais graves, gerenciar a rede de saúde mental, promover saúde mental da comunidade, promover a inserção social e a cidadania, entre outros. o caps preconiza a interdisciplinaridade e a orientação territorial (5). no contexto político da redemocratização do país e nas lutas pela revisão dos marcos conceituais, das formas de atenção e de financiamento das ações de saúde mental, surge o caps luis da rocha cerqueira e, juntamente com os núcleos de atenção psicossocial (naps), inaugurados a partir de 1989, em santos, constituem-se em referência obrigatória para a implantação de serviços substitutivos ao manicômio em nosso país (7). nesse sentido, os caps são considerados dispositivos estratégicos para cuidados em saúde mental que se configuram simbólica e numericamente. esses dispositivos trazem consigo uma aproximação entre a saúde coletiva e a saúde mental e ainda, a necessidade da constituição de um campo interdisciplinar de saberes e práticas (6). assim, configuram-se as práticas de cuidados territoriais por meio da junção de ações, serviços e articulações entre pessoas e setores. desse modo, as práticas sustentam-se na demanda dos usuários ou do território com vistas à produção de saúde ou, no mínimo, à busca de maneiras de minimizar o problema vivenciado pelo usuário. a mudança do conceito de saúde mental abandona a assistência centrada na doença e adota o enfoque na produção de saúde, no resgate da cidadania e na participação social. assim, ampliaram-se os espaços terapêuticos para o território e passou-se a buscar a desinstitucionalização e a reabilitação psicossocial. as ações terapêuticas ocorrem nas inter-relações entre subjetividade, gestão dos processos de trabalho e clínica. o cuidado, nessa perspectiva, exige dos conhecimentos técnicos e do comprometimento sociopolítico habilidade em lidar com a diferença e responsabilidade com a vida de cada pessoa que o busca, além de motivação profissional e valorização do seu trabalho (7). a solidez está alicerçada no questionamento, na reflexão e, sobretudo, nas relações interpessoais dialógicas. essas características articulam-se com o compartilhamento das ideias da reforma psiquiátrica e com uma prática cotidiana crítica, reflexiva e criativa (7). 534 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 a constituição do cuidado territorial envolve uma trama de relações, desde as interpessoais, as interinstitucionais até as intersetoriais. portanto, a constituição de uma rede de atenção deve levar em consideração não somente as unidades de saúde, mas também uma rede comunitária mediada por canais de comunicação entre seus constituintes, numa relação de parceria na construção de bem-estar. no entanto, essa rede tem, em instituições de parceria intersetorial (igrejas, escolas e justiça), importantes pontos de produção de cuidado. em outras palavras, parcerias intra e interinstitucionais necessárias segundo as demandas do usuário ou grupo (8). a partir de uma investigação (8) sobre a construção da rede a partir das famílias de portadores de transtorno mental em desinstitucionalização, observou-se a dificuldade em formar redes sociais fortalecidas e destacou-se o predomínio de laços fracos. os usuários, quando estão fora do hospital, acabam ficando restritos ao ambiente doméstico, sem ter oportunidade de expandir os laços de amizade e sem desenvolver habilidades sociais. na relação com vizinhos ou pessoas do mesmo bairro, há, ao mesmo tempo, disposição para ajuda, mas também medo de reações agressivas e receio de mais crises. para este estudo, o fortalecimento do usuário e da família no território faz necessária a construção de estratégias pelos serviços de saúde que os encorajem, os auxilie, os oriente e, principalmente, faça a ponte entre os recursos do território. a parir dessa construção, as relações de aversão pelo estigma ou o medo das crises vão abrindo espaços para solidariedade e trocas sociais mais efetivas. a proposta de serviços substitutivos aconteceu no complexo processo de desconstrução de saberes, instituições, valores e cultura. assim, esses serviços comunitários tornam-se substitutivos ao hospital e, a partir deles, propõe-se a invenção de uma nova realidade que possibilite a criação de novos diálogos com a complexidade da existência-sofrimento, de itinerários de exercício de direitos e de um novo lugar social para a experiência da loucura (9). a lógica do território privilegia a organização dos serviços, mas há um amplo campo a ser discutido e analisado quando o foco se volta para os aspectos sociológicos da experiência dos usuários. isso significa que os profissionais e serviços investem para compreender as relações e as vivências que os sujeitos sociais estabelecem em seu território a fim de que os níveis de saúde aumentem (10). entende-se por território a base do trabalho, local de residência, espaço de trocas materiais e subjetivas, sobre as quais ele influi. é no território que se inscreve uma identidade social, uma prática social, a construção histórica e a identidade coletiva dos sujeitos sociais. assim, a identidade de cada ator social está relacionada com a maneira em que ele estabelece relações dentro do território (10). estas, por sua vez, refletem certamente um dos fatores que problematizam o universo cultural, simbólico e estético desses sujeitos (10). nesse sentido, à medida que vivem, buscam satisfazer suas necessidades, fazem trocas e escrevem suas histórias e, consequentemente, a história do território. nesse contexto, a pessoa é percebida como um ser social repleto de significações construídas ao longo da vida. entre os princípios do campo psicossocial trazidos nos artigos analisados, incluem: desinstitucionalização, interdisciplinaridade (6, 5) responsabilização, participação social, suporte social (11), itinerância, articulação, integralidade (12), protagonismo das pessoas cuidadas (13). há um apelo pela responsabilização no cenário contemporâneo da reforma psiquiátrica que a dimensiona como a tomada de responsabilidade do serviço pelo território, o aumento da responsabilidade do profissional pelo processo de trabalho e a possibilidade de o sujeito advir como responsável por sua própria condição (11). para tanto, na “diretriz governamental de tomada de responsabilidade dos serviços pelo território, ocorre uma mudança da lógica de demanda e oferta de atendimento” (10:149). os profissionais dos caps representam um mediador com usuários, familiares, rede social, instituições, recursos sociais, instâncias de direitos que visam fortalecer os usuários para aumentarem sua autonomia e potencial de interação no território. ou seja, o profissional, o que inclui o enfermeiro, reúne as estratégias necessárias na negociação para cada necessidade apresentada. as mediações negociadas visam ajudar os usuários a se fortalecerem socialmente, encontrarem os recursos/suportes sociais do território, compreenderem o processo democrático, aumentarem sua autonomia e construírem novos modos de viver naquele território. os profissionais se referem a todos que compõem a equipe multiprofissional do caps, inclusive o enfermeiro. o trabalho no território acontece a partir da proposta terapêutica construída pelo terapeuta de referência juntamente com o usuário e a equipe 535 revisão integrativa: as práticas territoriais de cuidado em saúde mental l virginia faria damásio dutra, rosane mara pontes oliveira (por vezes, envolvem outros sujeitos sociais). nessa perspectiva, a enfermagem adota os preceitos terapêuticos próprios da profissão e a abordagem psicossocial, filosofia dos serviços determinada pela política de saúde mental do brasil. para atender à mudança da proposta hospitalocêntrica para a proposta psicossocial, foi necessário ocupar-se daqueles que se encontravam internos: a desinstitucionalização. o processo complexo de reconstrução de identidade, história de vida e estrutura social para viver na sociedade, acontece da mesma forma, resgatam-se fragmentos de subjetividade e reconstroemse outras possibilidades de vida. para dar respostas a tantos problemas para a complexidade da vida dos usuários, o campo psicossocial apropriou-se de várias disciplinas: sociologia, geografia, psicologia, biologia, antropologia entre outras. quando estas estão representadas numa reunião de equipe, por exemplo, pratica-se a interdisciplinaridade e os elementos da prática, por sua vez, são construídos a partir das demandas dos sujeitos e do território (5). para a complexidade da saúde mental, os espaços em que se atende se constroem na dinâmica dos espaços em que se vive: moradia, rua, espaços comuns, instituições, caps e todo o território. surgem elementos tecnológicos, tais como: articulação, cartografia e itinerância. na rede, as articulações são nós da trama, ou seja, negociações estabelecidas por serviços, profissionais, usuários e recursos do território. a itinerância (12) é um modo de operacionalizar o cuidado no território e faz considerar o problema da percepção do movimento. esse conceito de práticas de cuidado se decompõe em três elementos: 1) o movimento realizado no ato de ir ao encontro do usuário; 2) os movimentos que os trabalhadores produzem ao acompanhar o usuário no processo de construir seu pertencimento a um território; 3) o movimento de desestabilização que a invenção de novos caminhos produz no pensamento e no real social. os autores adotam o conceito de agenciamento por ajudar a pensar o movimento dos usuários na construção ou ampliação de seus territórios existenciais e no modo pelo qual o desejo, como força em estado bruto, territorializa-se. as práticas territoriais são parte do objetivo maior da política de saúde no brasil: a produção de saúde. entre as estratégias de cuidado territorial, estão: acolhimento, escuta, vínculo, visita domiciliar, discussão de casos, consultas, grupos terapêuticos (13), busca ativa no território (12), cuidado ampliado, encontro, inclusão social (14). atenção básica e saúde mental: imersas no mesmo território na década de 1990, após a consolidação da política de saúde no brasil adotou-se a estratégia saúde da família (esf) para a mudança do enfoque curativista para a promoção da saúde. portanto, “é uma estratégia de reorientação do modelo assistencial da atenção básica, operacionalizada mediante a implantação de equipes multiprofissionais em unidades básicas de saúde. as equipes são responsáveis pelo acompanhamento de um número definido de famílias, localizadas numa área geográfica delimitada e atuam com ações de promoção da saúde, prevenção, recuperação, reabilitação de doenças e agravos mais frequentes, e na manutenção da saúde desta comunidade” (15). a esf e a rede de saúde mental são estratégias da política pública que trazem o conceito de território no bojo da construção teórica e prática. além dos princípios e diretrizes do sistema único de saúde (sus), têm em comum uma concepção de cuidado personalizado, com enfoque na subjetividade e nas necessidades múltiplas e complexas do cidadão atendido no contexto onde vive. para tal, sustentam o direito à saúde de todo o cidadão, a acessibilidade à rede de saúde, a participação em todas as decisões dos serviços e trabalham em equipe multiprofissional, que considera os múltiplos saberes e disciplinas. um estudo (16), que teve como objetivo relatar uma experiência de parceria entre um caps de três equipes da esf, utilizou-se como estratégias as reuniões de equipe (nas quais há capacitação, discussão de casos), o acolhimento e a elaboração de projetos terapêuticos, além de visitas domiciliares. os resultados apontam que o trabalho conjunto enriquece ainda mais a prática e possibilita uma rede maior de cuidados no território. portanto, fez-se necessário criar novas propostas e iniciativas inovadoras à medida que estabelecia a interação com os casos e o território. nesse contexto, apresentam-se duas questões quanto à saúde mental na atenção básica: assistência às pessoas com sofrimento psíquico grave ou persistente e a promoção de saúde mental das pessoas que transitam no território. na literatura analisada, muito se fala das estratégias para atender os usuários do serviço especializado de saúde mental e alguns estudos chegam a justificar a necessidade de tais estratégias pela ineficiência do serviço especializado em saúde mental. no entanto, ambas as estratégias da rede foram idealizadas com recursos materiais, 536 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 humanos e afetivos para a reconstrução das relações cotidianas e do bem-estar. portanto, não se trata de uma ou outra, mas de fortalecer a rede de cuidados e criar oportunidades de subjetivação e transformação do seu nível de saúde (17). as ações de atenção e promoção à saúde mental na atenção básica envolvem acolhimento, escuta, vínculo, visita domiciliar, discussão de casos, consulta médica e grupos terapêuticos (13). e, ainda, projeto coletivo de cuidados ampliados voltados para prevenção, promoção e proteção da saúde mental no território (18), apoio institucional, estratégias de atenção especializada combinadas com atenção básica (19), além de arranjos diferenciados em que o profissional atua como facilitador segundo as necessidades apresentadas. essas estratégias têm em comum a valorização do indivíduo em sofrimento psíquico como protagonista de sua existência e consideram sua subjetividade, sua história e seus projetos de vida. uma intervenção de apoio matricial (20), por meio de reuniões, discussão de casos e visitas domiciliares entre a equipe de saúde mental e atenção básica, possibilitou: 1) a construção coletiva de saberes em saúde mental; 2) o espaço de escuta aos agentes comunitários de saúde; 3) a construção de redes no território e 4) o favorecimento do exercício da cidadania e da autonomia dos sujeitos. nessa experiência, destacou-se o processo dinâmico e cotidiano de construção e reconstrução de conceitos e modos de fazer/relacionar no território. entendeu-se que os projetos terapêuticos se constroem de maneira integrada num processo de corresponsabilização e, ao final, percebeu-se que ampliou o conceito que se tinha de saúde. dessa forma, favorecem-se as relações em redes e valoriza-se a solidariedade. a parceria entre caps e esf enriquece a prática e possibilita uma rede maior de cuidados no território. criar novas propostas e iniciativas inovadoras, segundo as necessidades das pessoas atendidas, concretiza a produção de saúde e desenvolvimento social da comunidade. portanto, “transitar pelo território subjetivo das pessoas e modificá-lo é também formar relações de confiança e vínculo, cuidado, disponibilidade, afetividade” (16:1490). os princípios da responsabilização e lógica do território (15) colocam a atenção básica e saúde mental, imersas no mesmo território, num diálogo permanente e numa construção conjunta de estratégias produtoras de saúde. a enfermagem, por exemplo, traz da sua profissão o cuidado na sua essência, com a amplitude do bem-estar subjetivo, a autoeficácia e a autonomia das pessoas e da comunidade. além disso, somam-se à prática de enfermagem os preceitos psicossociais ligados à promoção de saúde no território, o “empoderamento” de pessoas, a mediação da autonomia, o fortalecimento de laços sociais, entre outras. a integralidade: a invenção de estratégias para promoção de saúde mental o processo da reforma psiquiátrica brasileira ocorre concomitante ao da reforma sanitária; ambos resultam em leis para garantir a integralidade, acesso universal à saúde, equidade, participação social, além de assegurarem os direitos dos portadores de transtornos mentais. para cumprir com tais princípios, as esferas governamentais adotaram medidas para reorganização dos espaços de produção da saúde, bem como adoção de novos conceitos e práticas que atendessem ao “utópico” conceito de saúde. no município de cascavel-pr (21), por exemplo, para a assistência ao portador de transtorno mental, foram implantados ambulatório especializado, serviço de urgência, caps para adultos, crianças e usuários de álcool e drogas, todos estruturados com suporte assistencial às unidades básicas de saúde. assim, faz-se necessário ampliar as antigas grandes estruturas hospitalares ou ambulatoriais da saúde e atenção à saúde mental para a construção de unidades/modos de atendimentos territoriais a fim de garantir acesso, respostas reais às demandas e produção de saúde. entre as estratégias adotadas atualmente, envolver o domicílio, seja em visitas seja em assistência específica, tem permitido alçar posições mais integrais na assistência à saúde. desse modo, no campo da atenção psicossocial, o cuidado é orientado para o território e preocupa-se com o cotidiano e a inserção na sociedade. segundo um estudo que avalia o cuidado do portador de transtorno mental no domicílio pela família, “o cuidado se organiza nas dimensões psicossocial, clínica e afetiva, possibilitando a construção de um cuidado ampliado a integral. as facilidades do cuidado envolvem o cuidar em casa, cuidado clínico e os apoios à família, amigos, igreja, a esf, grupo evolução, escuta e fé. foram consideradas dificuldades a sobrecarga, as interferências e o preconceito” (22:10). utilizando-se da itinerância e da cartografia como um modo de operacionalizar o cuidado no território, a noção de território 537 revisão integrativa: as práticas territoriais de cuidado em saúde mental l virginia faria damásio dutra, rosane mara pontes oliveira se tornou um princípio organizador dos processos de trabalho nas políticas de atenção básica e saúde mental. ambos os conceitos traduzem-se em movimento, dinamismos e produção de relações nos contextos existenciais dos cidadãos que são alvos da saúde. assim, é possível explorar a potência política do movimento e transformar o território dos usuários num laboratório de invenção de vida. aspirando a integralidade, o cuidado deve ser contextualizado ao modo de vida dos usuários e deslocar a tônica da demanda para as reais necessidades de saúde, de modo a estabelecer como objeto de intervenção um sujeito em sofrimento no seu contexto de vida. a saúde integra o conjunto de capacidades que facilita o desenvolvimento do ser humano nas diferentes facetas, o que inclui a qualidade de vida e acesso aos serviços de saúde. o princípio da integralidade coloca a enfermagem psiquiátrica como produtora de saúde, ou seja, conduz as práticas para o território e adota outras tecnologias para o cuidado. com isso, pratica-se: acolhimento, vínculo, articulações, intersetorialidade, negociações, diálogos etc. discussões e algumas considerações os resultados fazem referência a dois conflitos: o psiquiatra no caps e os modelos adotados pelos profissionais no ato do cuidado. os psiquiatras, geralmente formados nos grandes hospitais, encontram no território o imaginário social do tratamento farmacológico como forma de lidar com os problemas mentais. a sociedade também traz contradições acerca da figura do psiquiatra, ora espera respostas da psiquiatria clássica, ora a valorização enquanto ser humano-psíquico-social. no segundo conflito, os profissionais no campo psicossocial têm como principal elemento ele próprio; no entanto, “identifica-se a coexistência de três modelos de cuidado nesse caps: o modelo biomédico humanizado, o psicossocial com ênfase na instituição e o psicossocial com ênfase no território” (7:188). assim, a construção de práticas territoriais (para fora do caps) acontece juntamente com os processos de transformação propostos pela reforma psiquiátrica, permeados por conflitos e tensões vislumbradas principalmente no campo ideológico. desde os primórdios da enfermagem, defende-se apostar no poder vital para a pessoa se reconstruir e a relação terapêutica como forma de ajudar o outro a alcançar níveis melhores de saúde. no entanto, na conteporaniedade, a enfermagem soma a isso os desafios de reunir a essência da enfermagem, dos constructos da reforma psiquiatrica e do sus. considerando os resultados das publicações analisadas, observa-se que o território é apontado na implantação da proposta psicossocial, o que é evidenciado pelas temáticas apresentadas: as ideias de território e rede na construção do campo psicossocial; a relação entre atenção básica e saúde mental, que visa ao cuidado ampliado aos cidadãos; a abordagem da integralidade e a promoção de saúde mental nas práticas realizadas no território. no entanto, as práticas territoriais na perspectiva do trabalho da enfermagem psiquiátrica não foram tratadas diretamente já que elas são abordadas pela construção filosófica das equipes multiprofissionais ligadas aos serviços de saúde mental. entende-se que a lógica do território está em franca construção, na qual enfermeiros, profissionais de saúde e gestores têm atuado. as publicações apontam dois eixos das práticas territoriais: o cuidado territorial de saúde mental ao cidadão atendido pela atenção básica em parceria dos serviços especializados de saúde mental e o cuidado ampliado e territorial pelos caps aos usuários com sofrimento psíquico grave, com vista à emancipação. no primeiro eixo —a atenção à saúde mental de todos os cidadãos, realizada pela atenção básica—, apontam-se resultados, tais como: • espaços voltados à saúde mental no contexto da atenção básica contribuirão para a efetivação de práticas e construção de novos saberes para a produção de saúde e vida no território existencial dos sujeitos (23); • as unidades básicas possuem estratégias semelhantes no atendimento de saúde mental à população e estruturam, a partir do acolhimento, o fluxo do usuário nos serviços. as estratégias utilizadas são: reuniões de equipe, nas quais há capacitação, discussão de casos, acolhimento e elaboração de projetos terapêuticos, além de visitas domiciliares conjuntas (13); • o trabalho conjunto entre esf e caps enriquece ainda mais a prática e possibilita uma rede maior de cuidados no território (13); • os registros em prontuário podem constituir os atores e instâncias sociais citados como envolvidos no campo da saúde mental enredando-os na malha administrativa construída como rede de suporte social (11); 538 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 • o apoio matricial proporciona a construção coletiva de saberes em saúde mental, de cuidado aos agentes comunitários de saúde e fomenta a construção de redes do cotidiano estimulando a articulação entre saúde mental e saúde da família de forma a favorecer o exercício da cidadania e a autonomia dos sujeitos sobre sua própria saúde (20). • rede e território são conceitos fundamentais para o entendimento do lugar e articulações dos caps e isso se aplica também à sua relação com a rede de atenção básica de saúde (11); • os profissionais das equipes de atenção básica necessitam de retaguarda assistencial e orientações técnicas de equipes especializadas em saúde mental para a realização de ações de saúde mental no território (apoio matricial) (24). no segundo eixo —o cuidado territorial aos usuários com sofrimento psíquico grave—, evidenciam-se resultados, tais como: • o cuidado territórial está na intersecção da clínica especializada e os contextos das práticas relacionadas com a vida dos usuários (13); • as práticas itinerantes passaram a ter uma importância estratégica na desinstitucionalização das práticas e na construção da integralidade do cuidado (12); • a abordagem grupal favorece o fortalecimento dos vículos e dos laços de confiança entre profissionais e usuários, o que proporcionou a reconstrução das relações sociais (13); as atividades comunitárias, coordenadas pelos caps, permitem a ampliação das relaçoes sociais; • o “técnico de referência” toma por responsabilidade o processo de negociação, divisão e delegação de encargos pelo cuidado em saúde mental, entre profissionais, familiares, usuários e membros da comunidade (11); • o engajamento, o vínculo e a implicação do profissional de referência são técnicas cujas funções terapêuticas e administrativas são articuladas (11); • as relações interpessoais e interações sociais são compreendidas como a base do existir humano e antecedem as técnicas terapêuticas inscrevendo-se na dimensão cidadã e política do cuidado (7); • mudanças significativas têm acontecido no campo da saúde mental quanto ao conceito de saúde mental e a assistência centrada na doença tem sido substituída pelo enfoque na promoção da saúde, no resgate da cidadania e na participação social (25); • percebe-se que familiares e vizinhos de pacientes psiquiátricos têm sido instigados a participarem da política pública, principalmente no lugar de suporte social, considerados parceiros (11). portanto, as abordagens e os elementos da prática territorial, propostas nas publicações analisadas, abarcam os elementos diversos do campo psicossocial: estratégias, princípios, ação dos profissionais, recursos territoriais, cidadania, emancipação dos sujeitos etc. as práticas territoriais trazem como único imperativo a valorização do usuário como ser social, cidadão, autônomo, único, capaz de elevar seus níveis de saúde. para tal, as práticas devem acontecer de dentro para fora dos serviços, ou seja, no território onde os usuários vivem. o modus operandi dessa proposta é a relação; assim, pode-se dizer que o profissional ocupase permanentemente da negociação com pessoas ou recursos do território. nessa perspectiva, a enfermagem psiquiátrica investe na valorização do contexto em que os usuários vivem, nas suas interações sociais significativas, nos recursos territoriais necessários à emancipação e na autonomia dos usuários (17, 24). o grande desafio para a enfermagem, tanto nos caps quanto nas esf, é romper com as práticas historicamente hospitalocêntrica pautadas em procedimentos técnicos, fragmentados e autoritários centrados na “doença”. as práticas territoriais ligadas aos serviços de saúde mental comunitária, segundo as publicações analisadas após 2001, investem no conceito ampliado de saúde como eixo fundamental para a construção do modo de atenção em saúde mental. para isso, a enfermagem psiquiátrica se reinventou no cuidado em espaços onde os sujeitos cuidados vivem e se reinventou no trabalho em equipe multiprofissional, mas sem perder a essência: o cuidado. as publicações de autoria de enfermeiras também analisam as práticas territoriais para saúde mental, realizadas pela equipe. nenhuma publicação analisou a prática da enfermagem no território, no contexto da saúde mental. no entanto, o conceito de território assume esse papel central na transformação no que se refere à “loucura” visto que é o trabalho no campo social que possibilita a inclusão e o resgate da cidadania das pessoas com sofrimento psíquico. é por meio do 539 revisão integrativa: as práticas territoriais de cuidado em saúde mental l virginia faria damásio dutra, rosane mara pontes oliveira território, entendido como um conjunto de forças sociais, produzidas por mecanismos de inclusão e exclusão, com possibilidade de acionamento ou reformulação, que essa transformação cultural acontece. assim, as ações territoriais dos profissionais de saúde mental vislumbram a produção de saúde mental e ativação de recursos escondidos no território. referências 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(dissertação) rio de janeiro: instituto de medicina social/universidade do estado do rio de janeiro; 2009. 22. lavall e. família e o cuidado de saúde mental no domicílio: estudo avaliativo. (dissertação) porto alegre: escola de enfermagem universidade federal do rio grande do sul; 2010. 23. antonacci mh, pinho lb. saúde mental na atenção básica: uma abordagem convergente assistencial. rev. gaúcha enferm. 2011; 32(1): 136-42. 24. mielke fb, olchowsky a. saúde mental na estratégia saúde da família: a avaliação de apoio matricial. rev. bras. enferm. 2010; 63(6): 900-7. 25. almeida dt, trevisan ér. estratégias de intervenção da terapia ocupacional em consonância com as transformações da assistência em saúde mental no brasil. interface (botucatu). 2011; 15(36): 299-308. 388 402 empatia en estudiantes de enfermeria.indd 388 aquichan issn 1657-5997 víctor patricio díaz-narváez1 gina muñoz-gámbaro2 nancy duarte-gómez3 maría cristina reyes-martínez4 sara elvira caro5 aracelis calzadilla-núñez6 luz marina alonso-palacio7 empatía en estudiantes de enfermería de la universidad mayor, sede temuco, ix región, chile 1 dr. cs. biol. phd. profesor investigador. universidad san sebastián, santiago, chile. investigador asociado. universidad autónoma de chile. chile. victor.diaz@uss.cl; vpdiaz@tie.cl 2 enfermera universitaria. magíster en pedagogía universitaria y educación superior. directora escuela de enfermería, universidad mayor, sede temuco, temuco, chile. gina.muñoz@umayor.cl 3 psicóloga. doctor of psichology. directora, escuela de psicología, universidad mayor. sede temuco, temuco, chile. nancy.duarte@umayor.cl 4 enfermera universitaria. magíster en pedagogía universitaria y educación superior. profesora. universidad mayor. sede temuco, temuco, chile. maria.reyesm@umayor.cl 5 enfermera universitaria. magíster en educación y docencia universitaria y en desarrollo familiar. profesora, universidad del norte, barranquilla, colombia. scaro@uninorte.edu.co 6 médico. especialista en psiquiatría infantil y del adolescente. hospital félix bulnes cerda, servicio de salud metropolitano occidente, santiago, chile. araceliscalza@gmail. 7 economista. magíster en salud pública y en demografía. profesora, universidad del norte, barranquilla, colombia. lmalonso@uninorte.edu.co recibido: 28 de diciembre de 2013 enviado a pares: 31 de enero de 2014 aceptado por pares: 20 de marzo de 2014 aprobado: 20 de marzo de 2014 doi: 10.5294/aqui.2014.14.3.9 para citar este artículo / to reference this article / para citar este artigo díaz-narváez vp, muñoz-gámbaro g, duarte-gómez n, reyes-martínez mc, caro se, calzadilla-núñez a, et.al. empatía en estudiantes de enfermería de la universidad mayor, sede temuco, ix región, chile. aquichan. 2014;14(3): 388-402. doi: 10.5294/aqui.2014.14.3.9 resumen objetivo: estimar la orientación empática y el comportamiento de la estructura del constructo empatía en los estudiantes de enfermería de la universidad mayor, sede temuco (chile). materiales y métodos: se aplicó la escala de empatía médica de jefferson en la versión en español para estudiantes, validada culturalmente mediante criterio de jueces. se estimó confiabilidad interna mediante la prueba alfa de cronbach y aditividad de tukey. las medias de las sumatorias de los datos de los sujetos fueron comparadas mediante anova bifactorial y prueba de duncan. se emplearon las pruebas de adecuación muestral. los componentes fueron estimados por medio de una prueba factorial de componentes principales con rotación varimax. resultados: la escala mostró confiabilidad. existen diferencias de orientación empática entre los cursos, pero no en el género; se observaron seis componentes. conclusiones: los estudiantes de enfermería se caracterizan por tener niveles de empatía relativamente altos, los cuales no difieren entre los géneros y existe una tendencia a su aumento a medida que los cursos avanzan. palabras clave estudiantes de enfermería, empatía, enfermería. (fuente: decs, bierme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 388-402 389 empatía en estudiantes de enfermería de la universidad mayor, sede temuco, ix región, chile l víctor patricio díaz narváez y otros. año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 388-402 empathy in nursing students at the universidad mayor, temuco campus, ix region, chile abstract objective: estimate the empathic orientation and behavior of the structure of the empathy construct in nursing students at the universidad mayor, temuco campus (chile). materials and methods: the spanish version of the jefferson scale of physician empathy for students was applied. it is culturally validated through criteria for judges. internal reliability was estimated using cronbach’s alpha test and tukey’s additivity test. the averages of the summations of the data on the participants were compared through a two-way anova and duncan’s test. sampling adequacy tests were conducted. the components were estimated through a factor analysis of the principal components with varimax rotation. results: the scale showed reliability. there are differences in empathic orientation among the courses, but not in terms of gender; six components were observed. conclusions: nursing students are characterized by having relatively high levels of empathy, which did not differ between genders, and there is a tendency for empathy to increase as the courses progress. key words nursing students, empathy, nursing. (source: decs, bireme). 390 aquichan issn 1657-5997 empatia em estudantes de enfermagem da universidad mayor, sede temuco, ix região, chile resumo objetivo: estimar a orientação empática e o comportamento da estrutura do construto empatia nos estudantes de enfermagem da universidad mayor, sede temuco (chile). materiais e métodos: aplicou-se a escala de empatia médica de jefferson na versão em espanhol para estudantes, validada culturalmente mediante critério de juízes. estimou-se confiabilidade interna por meio da prova alfa de cronbach e aditividade de tukey. as médias das somatórias dos dados dos sujeitos foram comparadas mediante anova bifatorial e a prova de duncan. empregaram-se as provas de adequação amostral. os componentes foram estimados por uma prova fatorial de componentes principais com rotação varimax. resultados: a escala mostrou confiabilidade. existem diferenças de orientação empática entre os cursos, mas não no gênero; observaram-se seis componentes. conclusões: os estudantes de enfermagem se caracterizam por ter níveis de empatia relativamente altos, os quais não diferem entre os gêneros e existe uma tendência a seu aumento à medida que os cursos avançam. palavras-chave estudantes de enfermagem, empatia, enfermagem. (fonte: decs, bierme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 388-402 391 empatía en estudiantes de enfermería de la universidad mayor, sede temuco, ix región, chile l víctor patricio díaz narváez y otros. introducción la interrelación entre el paciente y los profesionales de la salud constituye un elemento determinante en el cuidado que se brinda a las personas. sin embargo, el desarrollo tecnológico ha llevado a que se presente un distanciamiento en la interacción, lo cual genera la percepción de que dichos profesionales se han “desligado” de la atención del mismo (3). la empatía podría constituirse en un factor que puede contribuir positivamente a “reconstruir” la relación entre ambos. sin embargo, este constructo, en su dimensión práctica, requiere una compleja forma de deducción psicológica en la que la observación, la memoria, el conocimiento y el razonamiento se combinan para producir una idea de los pensamientos y sentimientos de otros (4). en última instancia, el concepto de empatía está relacionado con la habilidad para entender las experiencias y los sentimientos de otra persona, en combinación con la capacidad de comunicar este entendimiento a los demás (2). hojat et al. (5) plantean que la empatía se han asociado atributos que son importantes en la práctica del personal de salud tales como: el comportamiento prosocial, el respeto, las actitudes positivas hacia las personas mayores, el razonamiento moral, la ausencia de malas prácticas, la habilidad para recabar la historia clínica y la ejecución del examen físico, la satisfacción del paciente y de los profesionales, la mejor relación terapéutica y los buenos resultados clínicos. en otra dimensión se ha plantado la necesidad de estudiar la empatía e introducirla en la formación de éstos. (6). uno de los instrumentos más empleados para medir la empatía es la escala de empatía médica de jefferson (eemj), la cual es consistente con la estructura multidimensional que posee este concepto (7) y la define sobre la base de tres factores: a) toma de perspectiva, b) atención con compasión y c) habilidad para “ponerse en los zapatos del paciente” (2). se ha estudiado la empatía en estudiantes de medicina, odontología y enfermería en diferentes países (8-18). sin embargo, en américa latina son pocos y se remiten esencialmente a los estudiantes de kinesiología, medicina y odontología (19-29). los autores del presente trabajo no han hallado en la literatura de nuestra región (américa latina) estudios que midan el nivel de orientación empática y la estructura de los componentes o factores de este constructo en los estudiantes de enfermería y solo han podido encontrar algunos trabajos que intentan estudiar aspectos relacionados con este concepto (30-32). dado que la empatía está asociada a un conjunto de atributos que favorecen la relación entre paciente y profesional de la salud, resulta imprescindible realizar estudios de la orientación empática que poseen los estudiantes de enfermería en particular, y de los graduados, en general. el objeto del presente trabajo es estimar los niveles de orientación empática y explorar la estructura factorial que tiene este constructo en los estudiantes de enfermería de la universidad mayor, sede de temuco, ix región, chile. materiales y métodos este trabajo es de tipo exploratorio, no experimental, descriptivo, de corte transversal y ex post facto causa-efecto, regido bioéticamente por las normas de helsinski. la población estudiada está compuesta por los estudiantes pertenecientes a los cursos primero a quinto año de la carrera de enfermería de la universidad mayor, sede temuco, chile (n = 403). de esta población se obtuvieron las siguientes muestras estratificadas por curso: primer año, 64; segundo año, 59; tercer año, 73; cuarto año, 52 y quinto año, 29. la recolección de datos se realizó en dos días 14 y 15 de julio de 2013. como los estudiantes podían realizar visitas a diferentes áreas clínicas, tenían clases en lugares diferentes, además de las inasistencias a clases, entre otras circunstancias, no fue posible aplicar la escala a todos los alumnos. a los que faltaron, por las razones señaladas, no se les aplicó la escala en una segunda oportunidad con el objeto de evitar una posible contaminación en las respuestas. todos, en el momento de la aplicación, estaban cursando el término del primer semestre de cada curso (primer año a finales de primer semestre; segundo año a finales del tercer semestre y así sucesivamente). a los participantes se les aplicó la escala de empatía médica de jefferson (eemj) en la versión en español para estudiantes de medicina (versión s), validada en méxico y chile (2, 29), en salas de clases o salas de áreas clínicas, en una única medición anónima y confidencial, mediante operador neutral. antes de ser aplicada la eemj fue sometida a criterio de jueces (comité conformado por tres académicos relevantes en la profesión de enfermería o relacionados con la misma) con el objeto de verificar la validez cultural y de contenido (2). con el objeto de comprobar la comprensión de los estudiantes de la escala adaptada culturalmente (prueba piloto), se escogió una muestra al azar de 35 sujetos y se les aplicaron dos escalas: eemj (comprensión) y el cuestionario de medida de la empatía 392 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 emocional (qmee) (validez convergente). no existieron criterios de exclusión, pues el objeto era evaluar la variable de interés a la mayor cantidad de estudiantes. en el caso de que existieran datos perdidos por fila (sujetos) se sustituyó por la mediana del elemento (pregunta, reactivo, ítem) correspondiente y tal proceso se realizó en cinco sujetos y en cinco elementos diferentes. los datos primeramente fueron sometidos a la prueba de alfa de cronbach (confiabilidad mediante consistencia interna) (33-35) y alfa de cronbach basada en los elementos tipificados. posteriormente, se estimaron la media y la varianza de la escala si se eliminaba el elemento, la correlación elemento-total corregida, la correlación múltiple al cuadrado (coeficiente de determinación) y el alfa de cronbach si se eliminaba el elemento. adicionalmente se aplicó la prueba de no aditividad de tukey (36) con el objeto de verificar la presencia de independencia entre los elementos de la escala. se estimó el t2 de hotelling con el fin de verificar si existen diferencias entre las medias de los elementos de la escala (37). para evaluar la validez de convergencia se estimó la correlación entre los resultados de la escalas eemj y qmee, en la muestra piloto antes descrita, mediante el coeficiente de correlación de spearman (r s ); se empleó este coeficiente debido a que los datos de ambas escalas no se distribuyeron en forma normal. el qmee se caracteriza por tener buenas propiedades psicométricas en cuanto a fiabilidad y validez. las sumatorias del puntaje de los datos primarios obtenidos en la escala antes referida fueron sometidos inicialmente a la prueba de normalidad de shapiro-wilk en los dos factores estudiados (curso y género) (38). también fueron expuestos a la prueba de homocedasticidad de levene (igualdad de varianzas) (39). se estimaron los estadígrafos descriptivos; media aritmética y desviación típica de estas sumatorias en todos los factores y sus niveles correspondientes (incluyendo los datos atípicos). la comparación de las medias dentro de los niveles de los factores principales estudiados se realizó mediante un modelo lineal general univariado (anova) bifactorial modelo iii, con interacciones de primer orden y una prueba de comparación múltiple de duncan para datos desbalanceados, aplicada a aquellos factores que el modelo mostrara como significativos. además, se evaluó la potencia observada (1 β) y el tamaño del efecto mediante el estadígrafo eta cuadrado (η2) en todos los casos (40). los estadígrafos estimados se dibujaron en un gráfico aritmético simple, histogramas y diagramas de caja (incluyendo datos atípicos). posteriormente, los mismos datos fueron sometidos a las pruebas de adecuación muestral de kmo y de esfericidad de bartlett (41-43) con el objeto de comparar los coeficientes de correlación de pearson con los coeficientes de correlación parcial para determinar si la correlación entre cada par puede ser explicada por el resto de las correlaciones y para verificar si la matriz de correlaciones es una matriz de identidad y, por tanto, comprobar si existen correlaciones entre los elementos estudiados respectivamente. la dimensionalidad de los 20 elementos se evaluó mediante un análisis factorial de componentes principales y con rotación varimax (ortogonal) (44). la magnitud del autovalor empleado fue de 1,0 y se consideraron todos los coeficientes de los elementos a aquellos que tuvieron un valor de carga de 0,30 o mayor. cuando alguna pregunta cargó a más de un factor se escogió la carga más alta de todas. los datos fueron procesados mediante el programa estadístico spss 20.0. el nivel de significación utilizado fue de α ≤ 0,05 y β ≤ 0,05 en todos los casos. resultados los estudiantes manifestaron una correcta comprensión de los contenidos de la escala eemj y del qmee. el valor del alfa de cronbach general fue de 0,793, lo cual indica que existe evidencia de que la consistencia interna puede ser caracterizada como buena y el valor de este estadígrafo, basado en elementos tipificados, resultó parecido al no tipificado (0,827), todo lo cual muestra que las varianzas son similares entre los elementos. los valores de la correlación elemento-total corregida, del coeficiente de determinación de la escala y del alfa de cronbach, cuando se eliminó un elemento, fluctuaron entre 0,178-0,590; 0,139-0,571 y 0,773-0,801 respectivamente, lo cual indica que todos los elementos están aportando algún grado de explicación del constructo estudiado. la prueba de no aditividad de tukey resultó altamente significativa (p < 0,005), lo cual significa que no se cumple el principio de aditividad entre los elementos y es un indicador de que la muestra empleada no es lo suficientemente grande para eliminar el efecto no aditivo. la prueba muestra que la potencia requerida debe ser de 1,44 para eliminar este efecto. el estadígrafo f = 69,84 de la prueba t2 de hotelling fue altamente significativo (p < 0,001), lo cual demuestra que las medias de los elementos se distribuyen de manera diferente. todo lo anterior muestra que la escala es confiable pero que arrastra falta de aditividad, lo cual exigirá discutir los resultados con cierta cautela. el valor observado del coeficiente de correlación de spearman (r(s) = 0,41) fue muy significativo (p < 0,01). el valor muestra que existe validez 393 empatía en estudiantes de enfermería de la universidad mayor, sede temuco, ix región, chile l víctor patricio díaz narváez y otros. convergente aceptable, toda vez que el qmee está correlacionado positivamente con los test de empatía cognitiva y afectiva (teca) y con el índice de reactividad interpersonal (iri), que son escalas que miden la empatía con niveles altos de consistencia interna (0,84; 0,86 y 0,74 respectivamente). en la tabla 1 se presentan las medias de las sumatorias de los datos observados en todos los elementos en cada sujeto analizado por curso y género, con su correspondiente desviación estándar. en las figuras 1 y 2 se muestran las medias por curso y género (considerando los datos atípicos). en la tabla 2 se presentan los resultados del anova bifactorial. se observó que el modelo fue altamente significativo (p < 0,0005), lo cual indica que los coeficientes de los factores estudiados son diferentes del valor 0,0. de los factores estudiados solo resultó altamente significativo (p < 0,0005) el curso, lo cual indica que existen diferencias entre las medias respectivas. sin embargo, el estadígrafo η2 = 0,088 indica que las diferencias encontradas entre los cursos es pequeña. la potencia fue de 0,99 lo que demuestra que existen pocas probabilidades de cometer el error de tipo ii. en la tabla 3 (figura 3) se muestra la estimación de las medias por curso (sin considerar el género) y en la tabla 4 se presentan los resultados de la prueba de comparación múltiple de medias de duncan. se observaron tres grupos claramente diferenciados: el primer grupo está formado por la media del primer curso, el cual difiere significativamente (p < 0,05) de las medias del segundo grupo el cual está conformado por las medias del cuarto y segundo año y no existen diferencias significativas entre estos (p > 0,05); finalmente, el tercer grupo está conformado por el quinto y el tercer año, los cuales difieren significativamente del cuarto año (p < 0,05), pero no del segundo (p > 0,05). como consecuencia, se aprecia que el tercer y quinto año tienen los valores de orientación empática más altos entre los cursos estudiados y el primer año los valores más bajos. los resultados de la estimación del estadígrafo kmo fuero de 0,830; este se sitúa entre la clasificación de buena (0,80) y excelente (0,90) y la prueba de esfericidad de bartlett fue altamente significativa (χ2 = 1398,11; p < 0,0005), indicando que no estamos en presencia de una matriz de identidad, lo que demuestra que el análisis factorial de componentes principales puede ser aplicado. se han extraído seis factores de la escala aplicada (figura 4) para un total de 59,173 % de varianza explicada por estos. el resto de la varianza (40,827 %) se distribuye en forma relativamente homogénea en los demás componentes estimados. en la tabla 5 se muestran los resultados de todos los componentes o factores resultantes con autovalores mayores que 1,0 y de la carga que tiene cada una de las preguntas. se observaron seis factores (se esperaban solo tres) donde “la toma de perspectiva” se distribuyó en los factores 2, 3 y 6. el “cuidado con compasión” cargó a los factores 1 y 4. finalmente, dos preguntas asociadas a “ponerse en los zapatos del paciente” cargaron al factor 5 y una al factor 4. en general es posible señalar que cada uno de los conceptos esenciales de la empatía, se asocia a factores bien definidos, aunque algunas de las preguntas puedan situarse en diferentes factores. discusión no existen uno o varios puntos de corte científicamente establecidos en el instrumento empleado; por tanto, no es posible clasificar los valores de los niveles de orientación empática. sin embargo, los resultados de estos niveles en los estudiantes examinados en este trabajo son relativamente altos por el hecho de que las medias observadas en todos los factores analizados, son relativamente cercanas al máximo valor posible que pueda ser observado (140). estos valores no se pudieron comparar con estudiantes de enfermería de otras universidades en américa latina porque no existen en la literatura científica estudios de este tipo realizados, al menos, con el mismo instrumento. en chile se han llevado a cabo estudios de esta variable en estudiantes de kinesiología (19) y odontología (25, 29). en las investigaciones realizadas en estudiantes de kinesiología de la universidad de chile y universidad mayor y de odontología de la universidad finis terrae solo se examinaron tres años, la comparación de los resultados del presente trabajo sería posible con los estudiantes de odontología de la universidad de concepción (25). en todos los estudios señalados se observan dos tendencias comunes en general: a) los niveles de la variable estudiada aumentan desde los cursos inferiores a los superiores (salvo cierta “anomalía relativa” en cuarto año de enfermería en el presente estudio) y b) que el género femenino tiende a tener valores de orientación empática superiores en relación con los hombres; sin embargo, en los resultados observados en el presente trabajo, esas diferencias no se expresan desde el punto de vista estadístico y, aún más, en algunos cursos la media de los hombres supera la de las mujeres. las diferencias de empatía entre géneros (9) han sido estudiadas y fundamentadas en algunos trabajos. retuerto (45) concluye que las mujeres “puntúan significativamente 394 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 más que los varones en fantasía, preocupación empática y malestar personal” y, por tanto, en futuros trabajos hay que establecer si la “ausencia” de diferencias estadísticas encontradas en este trabajo es una situación particular en la carrera estudiada o se manifiesta del mismo modo en otras escuelas de enfermería de chile. aunque existen investigaciones en estudiantes de odontología y medicina en otros países, no se realizaron comparaciones, toda vez que se ha mostrado que existen factores sociales y culturales que pueden incidir en el comportamiento de la variable en estudio (46). los altos niveles de orientación empática en general y la tendencia al aumento de estos valores en la medida que aumenta el curso podrían ser explicados, en parte, por la estructura del currículum (pénsum) de esta carrera. esta estructura se caracteriza no solo por una adecuada preparación clínica que proporciona la madurez necesaria para enfrentar con éxito la relación con el paciente, sino también porque proporciona las habilidades interpersonales suficientes para abordar las diversas situaciones clínicas con un enfoque integral de atención a los pacientes. la existencia de este enfoque (biopsicosocial) (21, 28, 46) en el pénsum está basada en el reconocimiento de la importancia que ocupan los factores sociales y psicológicos en la génesis, el desarrollo y la resolución de una patología y del rol que juega la profesión de enfermería en los procesos señalados, incluyendo en estos a la prevención de las patologías. estos resultados no son consistentes con el concepto que en la medida que un estudiante entra en contacto con los pacientes se irá produciendo un “adormecimiento emocional”, como se plantea en algunos trabajos (47-51). el hecho de que en el presente estudio las mujeres en general, puntearan valores absolutos superiores a los hombres, aunque no existieran diferencias estadísticas, coincide con algunos resultados declarados en la literatura en los cuales se muestra la existencia de mayor empatía en mujeres que estudian carreras del área de la salud (49-52). sin embargo, existen trabajos que muestran resultados diferentes y en contradicción con el trabajo actual (53, 54). en general, los resultados de cómo la orientación empática se comporta entre los cursos y entre los géneros constituyen aspectos aún en discusión precisamente por el carácter contradictorio de los mismos, por la falta de estudios de cohortes y la imposibilidad ética de realizar estudios de panel, debido a la discusión de si la empatía puede ser “aprendida” (21, 27, 50, 51, 53) a la largo de la formación escolar y universitaria e incluso, por las diferencias de la orientación empática encontradas dentro de un mismo país y entre países (46). como consecuencia se requiere hoy desarrollar investigación exploratoria y descriptiva con el objeto de acumular mayor información al respecto. el alto nivel de empatía observado en los estudiantes de enfermería en el presente trabajo en los factores estructurales de este concepto —toma de perspectiva, cuidado con compasión y ponerse en los zapatos del paciente— se explicaría por el alto nivel de motivación y compromiso de los estudiantes de enfermería en la atención del dolor humano y cuidado de los pacientes. esto indicaría que la empatía se transforma en un precursor de cuidado genuino, más que en un mero sentimiento. yu y kirk (54) señalan que la empatía, como constructo, es un atributo predominantemente cognitivo, más que emocional, que involucraría entender más que sentir lo que los pacientes experimentan. es decir, la necesidad de entender el dolor del paciente y ser capaz de entregar el apoyo adecuado y comunicarlo a través de la relación paciente-enfermera o paciente-enfermero. sin embargo, el pénsum de la carrera contribuiría, además, a desarrollar los componentes restantes de este constructo. la capacidad de entender o comprender el dolor del otro se relaciona con factores motivacionales, elementos clave para estudiar enfermería y para el ejercicio de la misma. no obstante, se ha planteado que este constructo parece depender mucho de otros factores que operan en su estructuración (46). se sugiere, para un futuro estudio, ampliar la muestra a otras universidades del país y que otros aspectos de la relación enfermera-paciente sean explorados, para así tener una visión más amplia y mejor comprensión de este tipo de relación. aunque pareciera no haber fundamento para decir si la empatía es una dimensión de la personalidad, una emoción experimentada o una habilidad observable, sí se sabe que involucra la habilidad de comunicar la comprensión del mundo del paciente. por estas razones se sigue estudiando y, a pesar de que existe amplia información en la literatura que investiga la empatía, se considera a esta como un constructo clave como facilitador importante en las relaciones paciente-profesional del área salud (55-57), entre otros muchos complejos procesos involucrados en ella. el presente trabajo tiene restricciones. la presencia de no aditividad y los tamaños de muestra en cada curso y por cada género pueden ser dos factores que podrían explicar la estructura encontrada en el estudio e induce a la cautela en la discusión realizada, todo lo cual requiere que futuras investigaciones consideren estos aspectos para sus propias discusiones ya que los tamaños de las muestras, en cada institución, no pueden ser aumentados arbitrariamente. la conclusión de este trabajo se puede sintetizar señalando que las tres dimensiones que constituyen el constructo en estudio 395 empatía en estudiantes de enfermería de la universidad mayor, sede temuco, ix región, chile l víctor patricio díaz narváez y otros. tienen altos valores, todo lo cual quiere decir que los niveles de empatía de los estudiantes de enfermería de la universidad mayor, sede temuco, son relativamente altos. las mujeres poseen niveles de empatía superiores a los hombres en términos de valores absolutos, pero no estadísticos, y estos niveles en general se elevan en la medida en que los estudiantes se sitúan en cursos superiores. tabla 1. resultado de la estimación de las medias de las sumatorias de los datos observados en cada uno de los 20 elementos estudiados por curso y género curso género media desviación típica n primer año mujer 111,37 15,013 46 hombre 111,94 13,760 18 total 111,53 14,566 64 segundo año mujer 119,81 11,548 43 hombre 118,50 15,397 16 total 119,46 12,578 59 tercer año mujer 123,59 8,218 66 hombre 125,86 4,598 7 total 123,81 7,949 73 cuarto año mujer 118,53 14,011 47 hombre 112,00 5,339 5 total 117,90 13,530 52 quinto año mujer 123,08 12,208 24 hombre 123,40 9,762 5 total 123,14 11,664 29 total mujer 119,28 12,838 226 hombre 117,04 13,245 51 total 118,87 12,919 277 396 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 figura 1. medias de las sumatorias de los datos de todos los elementos de cada sujeto analizado en cada curso estudiado figura 2. medias de las sumatorias de los datos de todos los elementos de cada sujeto analizado en cada género 397 empatía en estudiantes de enfermería de la universidad mayor, sede temuco, ix región, chile l víctor patricio díaz narváez y otros. tabla 2. resultado del anova bifactorial, modelo iii origen suma de cuadrados tipo iii gl media cuadrática f sig. eta al cuadrado parcial potencia observada modelo 3919870,279 10 391987,028 2617,317 0,0001 0,990 1,000 curso 3850,846 4 962,712 6,428 0,0001 0,088 0,990 género 28,033 1 28,033 ,187 0,6661 0,001 0,072 curso género 238,192 4 59,548 ,398 0,8101 0,006 0,142 error 39987,721 267 149,767 total 3959858,000 277 tabla 3. resultados de la estimación de las medias de los cursos curso media error típ. intervalo de confianza 95 % límite inferior límite superior primer año 111,657 1,701 108,308 115,006 segundo año 119,157 1,792 115,629 122,685 tercer año 124,724 2,432 119,935 129,513 cuarto año 115,266 2,878 109,599 120,933 quinto año 123,242 3,008 117,319 129,164 tabla 4. resultados de la aplicación de la prueba de comparación múltiple de medias de duncan curso n subconjunto 1 2 3 primer año 64 111,53 cuarto año 52 117,90 segundo año 59 119,46 119,46 quinto año 29 123,14 tercer año 73 123,81 sig. 1,000 ,526 ,094 398 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 figura 3. medias de los cursos en cada uno de los géneros estudiados figura 4. gráfico de sedimentación con el número de componentes extraídos a partir del autovalor 1,0 399 empatía en estudiantes de enfermería de la universidad mayor, sede temuco, ix región, chile l víctor patricio díaz narváez y otros. tabla 5. componentes resultantes y cargas en cada uno de ellos preguntas del eemj componentes resultantes y cargas en cada uno de ellos 1 2 3 4 5 6 pregunta 1 0,563 pregunta 2 0,709 pregunta 3 0,788 pregunta 4 0,849 pregunta 5 0,379 pregunta 6 0,792 pregunta 7 0,696 pregunta 8 0,692 pregunta 9 0,574 pregunta 10 0,729 pregunta 11 0,535 pregunta 12 0,608 pregunta 13 0,471 pregunta 14 0,541 pregunta 15 0,411 pregunta 16 0,660 pregunta 17 0,876 pregunta 18 0,687 pregunta 19 0,640 pregunta 20 0,837 cuidado con compasión: preguntas 1, 7, 8, 11, 12, 14 y 19. toma de perspectiva: preguntas 2, 4, 5, 9, 10, 13, 15, 16, 17 y 20. “ponerse en los zapatos del otro”: preguntas 3, 6 y 18. 400 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 referencias 1. hojat m, louis dz, maxwell k, markham f, wender r, gonnella js. patient perceptions of physician empathy, satisfaction with physician, 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(16 a 20) año 3 nº 3 • bogotá, colombia octubre 2003 16 resumen el desarrollo de las teorías de enfermería ha cambiado irreversiblemente el desarrollo de la ciencia de la enfermería. la teoría ha contribuido no solo a definir las competencias profesionales, sino también al desarrollo de su cuerpo de conocimientos, los cuales reflejan lo que es específico de la profesión: su enfoque en la persona, su comportamiento y el significado de sus experiencias, considerados de manera holística. por lo tanto, las transacciones biopsicosocioculturales y espirituales del ser humano son centrales a la disciplina de la enfermería. este trabajo presenta una visión de la enfermería que analiza los conceptos fundamentales de ser humano, salud-enfermedad, entorno y enfermería. el desarrollo teórico también ha ayudado al entendimiento y aceptación de la complejidad de la enfermería y la inevitabilidad de sus múltiples teorías. el pluralismo paradigmático del desarrollo de la disciplina refleja la diversidad de su enfoque, la persona, la diversidad de sus interacciones en la salud y en la enfermedad, y la diversidad de las intervenciones de enfermería. palabras clave: ser humano, enfermería, salud, enfermedad y teorías. abstract the development of nursing theories has changed the development of nursing science. the theory has contributed not only to define professional competencies, but also to the development of knowledge, which reflects specific aspects of the profession: its focus on the person, its behavior and the meaning of its experiences, considered in a holistic way. in consequence, the bio psycho socio cultural and spiritual transactions of the human being are the center of nursing discipline. this work presents a nursing view, analyzing main concepts of the human being, health-disease, environment and nursing. the theoretical development helped also to the comprehension and acceptation of nursing and its multiple theories. the paradigmatic pluralism of the development of the discipline shows the diversity of its focus, the person, different interactions in health and disease and different nursing interventions. key words: human being, nursery, health, pathology and theories. adelaida zabalegui yárnoz r.n., ph.d., directora de la facultad de enfermería, universidad internacional de cataluña. barcelona, españa el rol del profesional en enfermería 17 a naturaleza del ser humano consiste en un grupo de rasgos dinámicos que unen a los seres humanos de todos los tiempos. el ser humano está constantemente en proceso de autocreación, y su último objetivo es el describir y entender el mundo que le rodea y, al mismo tiempo, hacerlo más sensible a los ideales de la persona, utilizando su característica específica: la racionalidad. las acciones del ser humano son responsables en el sentido de que él elige intencionadamente entre las diversas opciones. por otra parte, la persona está en constante interacción con su entorno y con otras personas para conseguir su objetivo. el ser humano actúa con base en su experiencia, manifestando sus capacidades de funcionar efectiva y eficazmente, afrontar y adaptarse a la vida. cada persona tiene su propia “realidad”, basada en sus experiencias. cada uno interpreta y le da su propio significado a la realidad, con una relación de interdependencia entre las experiencias vividas. para maslow (4), cada persona tiene una jerarquía de necesidades que debe ser satisfecha, y el poder para cambiar el mundo de acuerdo con sus intereses. el estudio histórico de la evolución de la naturaleza humana nos da la perspectiva necesaria para poner en contexto y enfocar los problemas asociados a la existencia del ser humano. es obvia la necesidad de conocer nuestra propia historia, nuestra evolución cultural, social, política y económica, la evolución de las acciones, costumbres y creencias del ser humano, y las teorías filosóficas que han moldeado las relaciones entre los seres humanos. el entender las causas de los cambios en el pasado nos capacitará para afrontar mejor los retos del presente y para que nuestra contribución al bienestar de las generaciones futuras sea más eficaz. si analizamos la historia, podemos identificar diferentes conceptos de salud. por ejemplo, para las teóricas de la enfermería, como orem (1971), la salud se define como un estado dinámico de integridad de la estructura y función. roy (10) enfatiza la necesidad de la continua adaptación a los estresores del entorno interno o externo. newman (7) contempla la salud como una conciencia en expansión. watson (11) define la salud como la congruencia entre la autopercepción y la vida diaria de la persona. la capacidad de realizar funciones independientes es la visión del concepto de salud para virginia henderson (2). para la organización mundial de la salud (12), por otra parte, este concepto se define como un estado de completo bienestar físico, mental y social, y no solamente la ausencia de enfermedad. la autora ve la salud como un estilo de vida dinámico satisfactorio, que incluye una adaptación al entorno satisfactoria y un estado de libertad de las alteraciones fisiológicas, psicológicas o de comportamiento que entendemos como molestas o perturbadoras. la salud nunca es completa o absoluta, pero representa un objetivo deseado. la obtención de este objetivo es el eje de las intervenciones de enfermería para prevenir la pérdida, promover o restaurar la autonomía de las personas desde el estado de restricción que representa la enfermedad. en general, el concepto de enfermedad se define como una limitación concreta del ser humano, pero que varía dependiendo de los valores personales, que están influenciados por las características del individuo y de su entorno. las la persona está en constante interacción con su entorno y con otras personas para conseguir su objetivo. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 18 personas, con sus antecedentes característicos, ven la enfermedad y la salud de diferentes maneras y, consecuentemente, existe una variabilidad de comportamientos en sus acciones hacia la salud. las características individuales, como edad, género, origen étnico, antecedentes genéticos, nivel intelectual y motivación, valores éticos y socioculturales, que varían entre personas y a lo largo del tiempo, han demostrado su influencia en las respuestas fisiológicas y en el comportamiento humano hacia la adaptación al entorno. se reconoce tanto la influencia genética como la del entorno, en relación con el comportamiento humano (5). los factores del entorno, que influencian la manera como las personas perciben y centran sus acciones en relación con la salud, los podemos clasificar en tres grupos: el entorno físico, los patrones culturales y los patrones sociales. estos factores han sido agrupados de diferentes maneras, dependiendo del interés específico de la autora, así como desde el punto de vista de la relación enfermero-cliente o de los principios del sistema de salud pública. el entorno físico incluye las variables físicas, químicas y biológicas que influencian la salud humana. el entorno deseable proporciona una gran variedad de estímulos compatibles, que son necesarios para el desarrollo mental y físico. además, también provee lo indispensable para satisfacer las necesidades básicas o fundamentales, como agua, alimentos, etc. los peligros potenciales de las actividades humanas, como desechos, contaminación o destrucción de materiales tóxicos de labores industriales, como asbestos, monóxido de carbono o derrames de petróleo, son el principal centro de atención, ya que están claramente identificados como factores negativos relacionados con la exposición a toxicidad (6). entre los patrones culturales encontramos la religión, la organización familiar, el lenguaje, el uso de medicamentos, el cuidado de los niños y de los ancianos, los hábitos alimentarios, etc. dentro de estos patrones podemos identificar una amplia variedad de conceptos, que tienen significado saludable para unos, mientras que no es así para otros. los patrones sociales, como el nivel de educación, el estatus socioeconómico, el empleo y los patrones de relación entre las personas, influencian significativamente la accesibilidad al cuidado de la salud y la capacidad de tomar decisiones informadas. en algunos de los patrones culturales o sociales se han podido identificar factores de riesgo para enfermedades específicas. por ejemplo, el estrés, la obesidad, la falta de ejercicio físico y el consumo de tabaco se han relacionado con las enfermedades cardiovasculares. a pesar de que el abandono de estos hábitos requiere cambios lentos de conducta, y en algunos casos son muy difíciles al enfrentarse a los valores específicos de grupos sociales determinados, los resultados de la actividad de enfermería son muy satisfactorios y generan mejoras significativas en los niveles de salud de la población. el papel de los valores grupales y personales en el entendimiento de la salud y la enfermedad es un tema central en la práctica del cuidado de la salud. la enfermería, al igual que otras profesiones de la salud, debe asegurarse de que se consideran justamente los valores de cada persona y que no se abuse de sus derechos y privilegios. los valores definen la salud-enfermedad y establecen funciones sociales, como la de paciente o enfermera, y además interconectan estas funciones con las expectativas estructuradas, como los derechos y las obligaciones. ¿cuál es la función del profesional en enfermería en el sistema actual de cuidado de la salud? ¿y cuál debe ser el ámbito de la intervención en nuestra interacción con el cliente y su entorno? el consejo internacional de enfermería, como la más antigua organización profesional internacional, ha clasificado las funciones fundamentales de la enfermería en cuatro áreas: promover la salud, prevenir la enfermedad, restaurar la salud y aliviar el sufrimiento. esta organización apolítica reúne personas de diferentes países, con un interés profesional y un propósito común de desarrollo de la enfermería a nivel internacional (3). la enfermería se ha autoidentificado como una profesión humanista, que se adhiere a una filosofía básica centrada los factores del entorno han sido agrupados de diferentes maneras, dependiendo del interés específico de la autora, así como del punto de vista de la relación enfermera-cliente o de los principios del sistema de salud pública. ¿cuál es la función del profesional en enfermería en el sistema actual de cuidado de la salud? ¿y cuál debe ser el ámbito de la intervención en nuestra interacción con el cliente y su entorno? el rol del profesional en enfermería 19 en el ser humano y su interacción con el entorno, donde la persona elige, se autodetermina y es un ser activo. el objetivo de la enfermería debe ser, esencialmente, para el beneficio del paciente, y su trabajo debe estar centrado en él. desde el punto de vista de la autora, las intervenciones de enfermería se pueden clasificar principalmente en cuatro categorías, que afrontan las demandas del cliente: 1) cuidado; 2) competencia; 3) servicios de información y asistencia jurídica, y 4) conexión. el objetivo del cuidado debe ser promover el proceso de aprendizaje que permita al paciente ser activo en su rehabilitación o promoción de su propia salud, mediante cambios en sus hábitos o transformando las condiciones ambientales que le afectan. la función de la enfermera, como cuidadora, implica la participación activa en la promoción, mantenimiento y recuperación de la salud, mediante medidas preventivas para evitar la aparición de la enfermedad, su progresión o prevenir secuelas asegurando la continuidad del cuidado. esta cuidadora debe estar abierta a las percepciones y preocupaciones del paciente y su familia, ser moralmente responsable, estar dedicada como profesional y permanecer dispuesta para escuchar, dialogar y responder en situaciones holísticas complejas. además, debe estar basada en la evidencia empírica existente. el profesional en enfermería competente es aquel que utiliza sus conocimientos, habilidades y actitudes para emitir juicios clínicos, solucionar problemas y realizar tareas costo-eficaces. la función de la enfermería, al igual que la de otras profesiones de la salud, debe incluir la información y educación del cliente sobre la salud, para que él pueda elegir entre las diversas opciones posibles, una vez considerados los distintos riesgos y beneficios de cada alternativa. esta función de educación se está convirtiendo en prioritaria, ya que la tendencia del cuidado de la salud se centra en el cliente, como centro de la atención y como persona que toma la decisión del tratamiento y el tipo de cuidado que se va a realizar. además, el profesional en enfermería debe ser la conexión o unión entre los profesionales de la salud, el paciente y su familia. esta función tiene por objetivo la integración de los esfuerzos y la prevención de la fragmentación de los servicios de salud asociada a la especialización. es la enfermera quien crea relaciones, mediante el reconocimiento mutuo enfermera-paciente, conociendo sus percepciones y necesidades, y negociando el cuidado para alcanzar los objetivos propuestos en el plan de cuidados holísticos. como v. henderson (2) dijo, la enfermera debe conocer qué es lo que el enfermo necesita. debemos colaborar con nuestros pacientes en la identificación de sus necesidades (físicas, mentales, emocionales, socioculturales y espirituales) y en el desarrollo de soluciones. la enfermería, desde su comienzo, ha reconocido la importancia de la intervención familiar en el cuidado del paciente para promover la salud. esta necesidad de intervención debe expandirse a otros grupos, comunidades, organizaciones, colegios, etc. para alcanzar el equilibrio entre la persona y el entorno, debemos reconocer la importancia de los sistemas de apoyo social y los aspectos holísticos del cuidado físico, social, económico, político, espiritual y cultural. la enfermería debe participar en la búsqueda de medios para lograr la potenciación de la salud comunitaria. actualmente, las enfermedades predominantes son principalmente alteraciones debilitantes crónicas, en donde la promoción de la salud y la prevención de la enfermedad se reconocen como estrategias efectivas. se puede decir que la mayor parte de las muertes son el resultado de enfermedades coronarias, cáncer e infartos cerebrales. así, la enfermería debe intentar anticiparse a las situaciones que surgen y prevenir aquellas que dan lugar a riesgos para la salud. para alcanzar los objetivos anteriormente mencionados, la enfermera debe: • conocer qué es lo mejor para el paciente. • responder a las necesidades del paciente. • ser técnicamente competente, científicamente conocedora, prácticamente responsable y emocionalmente capaz de afrontar las situaciones de crisis en el cuidado de la salud. • ser competente en habilidades de comunicación y tener la capacidad de explicar la fundamentación empírica y filosófica de sus acciones en relación con el cuidado del paciente. • ser capaz de controlar las situaciones del paciente, con actividades y con el manejo de sus propias emociones. • reconocer que en cualquier momento una persona puede necesitar ayuda de otra. la enfermera(o) puede requerir ayuda para el mantenimiento o desarrollo de habilidades, para el autoconocimiento o la comprensión de otros. • potenciar la dignidad y el valor de las personas. • enfatizar y apoyar la contribución revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 20 del paciente y la familia al cuidado y a la adaptación. cuando la enfermería surge como profesión, en el siglo xix, florence nightingale (1859) (8) procuró no solo establecerla con unos fundamentos firmes sobre conocimientos científicos, sino también identificar e insistir sobre el comportamiento ético de la enfermería. posteriormente, en 1980, la asociación americana de enfermería define la función independiente de la profesión como el diagnóstico y tratamiento de las respuestas humanas a problemas de salud reales o potenciales. a medida que comenzamos el siglo xxi, surgen preguntas sobre la dirección hacia donde la profesión se mueve. en este nuevo contexto, la investigación de enfermería es necesaria para ser profesionales competentes dentro de la compleja realidad del sistema actual de cuidado de la salud. esta complejidad deriva del envejecimiento de la población, la disminución de las estancias hospitalarias, con un aumento del grado de gravedad de los pacientes ingresados, el progreso de la tecnología y los cambios sociales en el ámbito familiar. el análisis de la función de la enfermera en la planificación, realización y evaluación de la investigación, la divulgación de resultados y la aplicación en la práctica, proporcionan las bases para entender el rápido crecimiento de la investigación de enfermería en el cuidado del paciente oncológico. creemos que es importante definir la enfermería como una ciencia, en el sentido de adquisición de conocimientos mediante la observación y la experimentación, y la práctica basada en la evidencia científica. asimismo, la enfermería es un arte y una filosofía, compatibles con la visión científica. en la actualidad, el modelo de cuidado es fundamentalmente biomédico, centrado en la enfermedad, y deja poco espacio para las dimensiones sociales, psicológicas, culturales y espirituales de la salud. la enorme inversión existente y prevista en tecnología, para el diagnóstico y tratamiento de las enfermedades, favorece la tendencia hacia un cuidado impersonal y mecánico. el cambio necesario debe enfatizar el análisis de los valores sociales, culturales y personales de los seres humanos, y la función que ellos desempeñan en el análisis de la salud, como variables determinantes de intervenciones preventivas y terapéuticas. por otra parte, en el desarrollo de nuestra función como enfermeros, existen aspectos relacionados con la teoría y la práctica, que resultan problemáticos y necesitan ser solucionados; estos son la separación crónica de la teoría y la práctica, y la realidad frente al ideal de la enfermería. por lo tanto, debemos hacer un esfuerzo por alcanzar un objetivo importante: la práctica y la teoría de la enfermería deben unificarse y ambas fundamentarse firmemente en la realidad, en la evidencia científica y en el desarrollo de la humanidad. bibliografía 1. american nurses association. nursing: a social policy statement, kansas city, mo, autor, 1980. 2. henderson, v. the nature of nursing, new york, mcmillan, 1955. 3. kelly, l. y., & joel, l. a. dimensions of professional nursing, 8thed., new york, mcgraw-hill, 1999. 4. maslow, a. h. motivation and personality, 2nd ed., new york, harper & row, 1970. 5. mcgue, m. “nature-nurture and intelligence”, nature, 340: 507508,1989. 6. miller, a., & miller, m. options for health and health care, new york, john willey and sons, 1981. 7. newman, m. a. “theory for nursing practice”, nursing science quarterly, 7 (4): 153-157, 1994. 8. nightingale, f. n. notes on nursing: what it is and what it is not?, philadelphia, j. b. lippincott (documento original publicado en 1859),1992. 9. orem, d. e. modelo de orem: conceptos de enfermería en la práctica, 4ª ed., barcelona, masson-salvat, 1993. 10. roy, c., y andrews, a. the roy adaptation model, 2nd ed., stamford, ct, appleton & lange, 1999. 11. watson, j. nursing: the philosophy and science of caring, boulder, co, university press, 1985. 12. world health organization. constitution of the world health organization, chronicles of who, 1: 1-2, 1947. 40 aquichan issn 1657-5997 maría guadalupe moreno-monsiváis1 maría guadalupe interial-guzmán2 paz francisco sauceda-flores3 leticia vázquez-arreola4 julia teresa lópez-españa5 satisfacción de las madres con la atención a sus hijos hospitalizados 1 doctora en filosofía. magíster en enfermería. maestra de tiempo completo, universidad autónoma de nuevo león, facultad de enfermería. méxico. mgmoreno@hotmail.com 2 magíster en ciencias de enfermería. maestra de tiempo completo, universidad autónoma de nuevo león, facultad de enfermería. mginterial@hotmail.com 3 magíster en enfermería. maestro de tiempo completo, universidad autónoma de nuevo león, facultad de enfermería. psauceda2@hotmail.com 4 magíster en administración. maestra de tiempo completo, universidad autónoma de nuevo león, facultad de enfermería. levazque@hotmail.com 5 magíster en enfermería. maestra de tiempo completo, universidad autónoma de nuevo león. facultad de enfermería. july0521@hotmail.com recibido: 09 de octubre de 2010 aceptado: 10 de febrero de 2011 resumen el objetivo del estudio fue determinar los factores que se relacionan con la satisfacción de la madre con la atención que recibe su hijo hospitalizado. la muestra: 127 madres de niños hospitalizados en una institución pública de monterrey, n.l., méxico. estudio descriptivo correlacional. se utilizó el cuestionario de satisfacción del familiar pediátrico. el manejo del dolor fue un factor importante para la satisfacción de las madres participantes. la satisfacción de la madre con el servicio de hospitalización se asoció con la satisfacción con la atención de enfermería (rs = 0,458; p= 0,0001). la edad del hijo, el número de hospitalizaciones previas y la percepción de su estado de salud no fueron factores significativos para la satisfacción de las madres. es importante que el servicio de hospitalización y la atención de enfermería respondan a las expectativas de los familiares de estos pacientes. palabras clave atención, hospitalización, satisfacción del paciente, enfermería. (fuente: decs). maternal satisfaction with care provided to hospitalized children abstract the study was designed to identify the factors associated with a mother’s satisfaction with the care her child receives during hospitalization. the sample included 127 mothers of children who were patients at a public hospital in monterrey, n.l., méxico. the study was correlational and descriptive. a family pediatric satisfaction questionnaire was used. pain management was an important factor in the satisfaction of participating mothers. the mother’s satisfaction with inpatient services was associated with nursing care and assistance año 11 vol. 11 nº 1 chía, colombia abril 2011 l 40-47 41 satisfacción de las madres con la atención a sus hijos hospitalizados l maría guadalupe moreno-monsiváis, maría guadalupe interial-guzmán, paz francisco sauceda-flores et al. (rs = 0,458; p= 0,0001). the child’s age, the number of prior hospitalizations, and the perception of the child’s state of health were not significant factors with respect to maternal satisfaction. it also is important for inpatient services and nursing care to respond to the expectations of the pediatric patient’s family. key words care, hospitalization, patient’s satisfaction, nursing (source: decs). satisfação das mães com o cuidado à criança hospitalizada resumo o objetivo deste estudo foi determinar os fatores relacionados à satisfação materna com os cuidados ao seu filho internado em um hospital. a amostra constou de 127 mães de crianças internadas em uma instituição pública de monterrey, nl (méxico), aplicando uma pesquisa descritiva correlacional. foi utilizado o questionário de satisfação da família do paciente pediátrico. o manejo da dor é um fator importante para a satisfação das mães participantes. a satisfação maternal com o atendimento hospitalar foi associada à satisfação com os cuidados de enfermagem (rs = 0,458; p = 0,0001). a idade da criança, o número de hospitalizações e a percepção do estado de saúde não foram fatores significativos para a satisfação das mães. é importante que o serviço de internamento e os cuidados de enfermagem satisfaçam às expectativas da família do paciente. palavras-chave atendimento, internação, satisfação do paciente, enfermagem. (fonte: decs). 42 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 introducción actualmente, en los sistemas de salud, la satisfacción del paciente es considerada un indicador de calidad y un resultado clave para medir el cuidado. en méxico, el programa nacional de salud (pns) 2007-2012 establece como estrategia para lograr la calidad de los servicios implantar el sistema integral de calidad en salud (sicalidad) en el sistema nacional de salud, el cual tiene como componentes fundamentales otorgar servicios efectivos y seguros, que respondan a las expectativas de los usuarios y medir de manera regular la satisfacción del paciente (1). lo señalado también aplica a los servicios de salud dirigidos a la población pediátrica, que es un grupo prioritario de atención. los padres representan la voz del niño en el sistema, por consiguiente, representan la visión del paciente. ante este rol que desempeñan los padres, es relevante conocer su opinión respecto a la atención proporcionada a sus hijos (2). es importante identificar la satisfacción de los padres respecto a la atención que reciben sus hijos por el personal de salud, entre los que destaca el personal de enfermería por ser el que tiene mayor tiempo de contacto directo con los pacientes durante su hospitalización. determinar la satisfacción del familiar y los factores asociados constituye un área de oportunidad para mejorar la atención que se proporciona a este grupo específico. la evidencia empírica permitirá diseñar y desarrollar intervenciones de enfermería efectivas orientadas a incrementar la satisfacción. la satisfacción del paciente es considerado un indicador confiable y válido de la calidad del cuidado ya sea medido a través de la percepción del paciente o de los padres de la población pediátrica; esta se define como un indicador de calidad que refleja la opinión en relación con dos aspectos prioritarios: el servicio de hospitalización y la atención recibida durante la estancia hospitalaria. esta percepción se basa en la congruencia o acuerdo entre las expectativas del familiar del paciente pediátrico y la percepción de la experiencia. también puede considerarse que la satisfacción es una condición previa para el cuidado de calidad, donde se asume que una persona satisfecha cooperará más y demostrará una mayor conformidad a un tratamiento y, por consiguiente, regresará a solicitar atención nuevamente (3, 4). la revisión de literatura en torno a esta temática se ha centrado en medir la satisfacción desde el punto de vista del usuario directo de la atención. existen pocos estudios enfocados en medir la satisfacción en el paciente pediátrico a través de la percepción de sus padres; estos se han llevado a cabo en áreas de neonatal, emergencias, hospitalización y cuidado ambulatorio (2, 5 11). sin embargo, la principal crítica en relación con estos estudios, es que la satisfacción se ha medido con instrumentos diseñados para identificar el punto de vista del paciente, es decir, no se han utilizado instrumentos específicos que permitan conocerla desde el punto de vista de los padres del paciente pediátrico (12 16). los resultados de estos estudios señalan algunos factores importantes que se asocian con la satisfacción, entre estos se encuentran los relacionados con el trato, la inforla satisfacción del paciente es considerado un indicador confiable y válido de la calidad del cuidado ya sea medido a través de la percepción del paciente o de los padres de la población pediátrica. 43 satisfacción de las madres con la atención a sus hijos hospitalizados l maría guadalupe moreno-monsiváis, maría guadalupe interial-guzmán, paz francisco sauceda-flores et al. mación, la competencia del personal y el tiempo de espera, aspectos comunes a los reportados por pacientes hospitalizados; sin embargo, en estos estudios se incluyen algunos otros factores importantes para los padres como son: el servicio de hospitalización donde se considera el ambiente hospitalario respecto a lo adecuado de las instalaciones para este grupo de pacientes, y el proceso de ingreso al hospital. se han reportado, además, diferencias en la satisfacción de los padres respecto a la percepción del manejo del dolor en sus hijos (7). algunas características personales como la edad de los hijos, la experiencia de los padres con hospitalizaciones previas y la percepción respecto al estado de salud de sus hijos se han asociado con la satisfacción (2, 5, 7). en consideración a que los resultados de un estudio piloto reportaron que la madre es el familiar que permanece la mayor parte del tiempo de hospitalización junto al paciente pediátrico, el propósito del presente estudio fue determinar a través de un instrumento específico para medir la satisfacción del familiar pediátrico, la satisfacción de la madre con la atención que recibe su hijo hospitalizado y su asociación con la edad del niño, el número de hospitalizaciones previas, la percepción del estado de salud y del servicio de hospitalización, además de explorar diferencias en la satisfacción respecto a la percepción del manejo del dolor. materiales y métodos el estudio fue de tipo descriptivo correlacional (17). la población se conformó por las madres de los menores hospitalizados en el área de pediatría de una institución de salud pública de tercer nivel que reciben atención por personal de enfermería profesional. los pacientes hospitalizados en esta área se ubican en el grupo de edad de 0 a 15 años, con una edad mínima de 61 días de vida (dos meses). por ser una unidad de tercer nivel, los pacientes pediátricos ingresan por múltiples padecimientos crónicos correspondientes a las especialidades de gastroenterología, nefrología, neurología médica, neurocirugía, endocrinología, inmunología, infectología y medicina interna pediátrica. el tipo de muestreo fue probabilístico sistemático de uno en dos con inicio aleatorio, se entrevistó a las madres de pacientes pediátricos con un mínimo de 72 horas de hospitalización en el servicio de pediatría. el cálculo del tamaño de la muestra se determinó con el paquete estadístico nquery 2.0, mediante el análisis de correlación; se consideró un nivel de significancia de 0,05, una potencia de 0,85 y una correlación de 0,40, dando un total de 127 madres. para seleccionar a las madres participantes, primero se solicitó un listado de los pacientes pediátricos hospitalizados en el servicio de pediatría, se verificó cuáles tenían mínimo 72 horas de hospitalización, se seleccionó en forma aleatoria al primer paciente, y posteriormente de uno en dos hasta completar el tamaño de la muestra estimada. se acudió al área asignada a cada uno de ellos y sus madres se abordaron en un horario y situación conveniente (no en horario de comida, sin presencia de dolor en el niño, sin visitas de otros familiares y sin la presencia de personal médico o de enfermería), se les solicitó su participación voluntaria, se procedió a explicar el objetivo del estudio y se les informó que el cuestionario sería aplicado de forma anónima y confidencial. la satisfacción es una condición previa para el cuidado de calidad, donde se asume que una persona satisfecha cooperará más y demostrará una mayor conformidad a un tratamiento y, por consiguiente, regresará a solicitar atención nuevamente. 44 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 a las madres que aceptaron participar se les pidió que firmaran el consentimiento informado. posteriormente, se condujeron a un lugar privado dentro del área de pediatría; en los casos en que la madre no pudiera dejar solo a su hijo se entrevistó junto a la cama o cuna del niño, pero se cuidó que no hubiera personal de enfermería presente en el momento de la entrevista. primero se aplicó una cédula de datos personales que incluyó información relacionada con características individuales del paciente pediátrico y de la madre; respecto al hijo se consideró la edad y el número de hospitalizaciones previas en los dos últimos años. en cuanto a la madre se preguntó acerca de la edad, escolaridad, percepción del estado de salud de su hijo y del manejo del dolor. las opciones de respuesta estuvieron disponibles en escala continua –edad, escolaridad y hospitalizaciones previas–, ordinal –estado de salud del hijo–, y dicotómica –presencia de dolor y tratamiento adecuado para el manejo del mismo–. enseguida se aplicó el cuestionario de satisfacción del familiar pediátrico (pfsq) (18) que consta de 18 reactivos divididos en dos subescalas, la primera está integrada por 6 reactivos que miden la satisfacción con el servicio de hospitalización (incluye aspectos como procedimiento de admisión, higiene de las instalaciones y mobiliario, ruido, etc.), la segunda consta de 12 reactivos que miden la satisfacción con la atención de enfermería (se incluye trato, amabilidad, conocimiento y habilidad del personal de enfermería, continuidad del cuidado, información del estado de salud e involucramiento de la madre en el cuidado). la escala de medición para el total de reactivos es tipo likert con opciones de respuesta de 1, totalmente en desacuerdo, a 5, totalmente de acuerdo. el valor mínimo de la escala fue de 18 puntos y el máximo de 90, estos puntajes fueron transformados a un índice global de satisfacción con valores de 0 a 100, donde a mayor puntaje mayor satisfacción. la confiabilidad del instrumento a través del alpha de cronbach ha reportado valores que oscilan entre 0,83 a 0,89. para el presente estudio se obtuvo un valor de 0,84. el estudio se realizó con estricto apego a lo dispuesto en la ley general de salud en materia de investigación para la salud (19). se respetó específicamente la dignidad y la protección de los derechos de los participantes, la participación voluntaria y la libertad de retirarse en el momento en que lo desearan. se contó con el consentimiento informado y por escrito de las madres, las cuales se consideran las representantes legales de los niños, para esto se les explicó en forma clara en qué consistía el estudio y cuál sería su participación. se utilizó estadística descriptiva para señalar las características del paciente pediátrico y de las madres, la prueba de kolmogorov-smirnov (d) para determinar la distribución de los datos, así como análisis no paramétrico de correlación de spearman (rs) para identificar la relación entre la satisfacción de la madre con la edad del hijo, número de hospitalizaciones previas, percepción del estado de salud y servicios de hospitalización. adicionalmente, se determinó la diferencia en la satisfacción respecto a la percepción del manejo del dolor mediante la prueba de kruskal wallis y la u de mann whitnney. resultados la edad promedio de los hijos hospitalizados se ubicó en los seis años (de = 4,44), y se reportaron en promedio tres hospitalizaciones previas (de = 2,24). en cuanto a la madre, su edad promedio fue de 29 años (de= 6,28). el resto de la información relacionada con las características individuales del paciente pediátrico y de las madres se reporta en la tabla 1 (ver anexo). respecto a la distribución de los datos solo la edad de la madre presentó distribución normal (d= 1,24, p= 0,09). con relación a la percepción de la madre acerca del estado de salud del hijo se encontraron porcentajes semejantes entre quienes perciben a su hijo como muy enfermo y en las que lo perciben enfermo (ver anexo, figura 1). al cuestionar a las madres acerca de la presencia de dolor en sus hijos durante su estancia hospitalaria, el 82,4 % señaló que sí presentó dolor en algún momento de su hospitalización. en lo referente al adecuado del manejo del dolor, el 51,9 % respondió que sí fue un manejo adecuado, el 34.6 % señaló que no y el resto no pudo determinar si fue adecuado o no. en la tabla 2 (ver anexo) se observa que la satisfacción de las madres fue mayor con el servicio de hospitalización respecto a la atención proporcionada por el personal de enfermería. los datos no reportaron distribución normal. el análisis de correlación se realizó a través de estadística no paramétrica. el coeficiente de correlación de spearman reportó que la satisfacción de la madre con la atención de enfermería se asocia a la satisfacción con el servicio de hospitalización (rs = 0,458; p = 0,0001). la satisfacción de la madre no se asoció con la edad, el número de hospitalizaciones previas y la percepción del estado de salud de su hijo. 45 satisfacción de las madres con la atención a sus hijos hospitalizados l maría guadalupe moreno-monsiváis, maría guadalupe interial-guzmán, paz francisco sauceda-flores et al. la prueba de kruskal wallis mostró que existe diferencia en la satisfacción de las madres respecto a la percepción del manejo del dolor de sus hijos (chi2 = 5,61; p = ,04). para determinar la diferencia dentro de los grupos se aplicó la prueba u de mann whitnney, la cual reportó mayor satisfacción en las madres que percibieron un adecuado manejo del dolor (u = 1180,50; p = ,03). discusión la satisfacción de la madre no se asoció con la edad ni con el número de hospitalizaciones previas, así como tampoco con la percepción del estado de salud de su hijo. este resultado difiere de lo reportado por britt y arentz (4) y halfon et ál. (10) quienes encontraron que estos aspectos son factores significativos en la satisfacción de los padres. el resultado en relación con la edad pudiera atribuirse a que los pacientes pediátricos presentaban algún tipo de padecimiento crónico, por lo que independientemente de su edad, lo relevante para las madres es la atención que reciben respecto a sus demandas relacionadas con la patología. en cuanto al número de hospitalizaciones previas, el resultado pudiera deberse a que en el presente estudio la mayoría de las madres tenía experiencia previa por los reingresos continuos de sus hijos debido a los padecimientos de tipo crónico. en cuanto a la percepción del estado de salud de su hijo, autores como britt y arentz (4), halfon et ál. (10) y tucker y kelley (16), señalan que las madres reportan mayor insatisfacción cuando perciben a sus hijos muy enfermos. la no asociación en el presente estudio pudiera explicarse debido a la escasa variabilidad entre las madres que percibieron a su hijo muy enfermo y las que lo percibieron enfermo. es importante señalar como limitación del presente estudio que la percepción del estado de salud se concentró en enfermo o muy enfermo, debido a que los pacientes presentaban padecimientos crónicos, cuyo manejo requería de varias hospitalizaciones. en este grupo poblacional las madres tienden a ver estos dos estados de salud como habituales; por tanto, para futuros estudios se sugiere incluir pacientes pediátricos con diagnósticos médicos que permitan ampliar las categorías de la percepción del estado de salud de manera que se pueda identificar si es un factor que influye en la satisfacción de la madre con la atención de su hijo hospitalizado. la satisfacción de la madre con la atención de enfermería se asocia con su complacencia con el servicio de hospitalización, este resultado concuerda con los hallazgos de britt y arentz (4), y conner y nelson (6). en la satisfacción de la madre ambos aspectos son importantes de considerar. respecto al servicio de hospitalización, las instalaciones y el proceso de ingreso hospitalario son aspectos importantes para el familiar, y fueron calificados más alto respecto a la atención de enfermería. este hallazgo es relevante y debe ser considerado por los administradores de enfermería de las instituciones de salud. se requiere que se implementen estrategias dirigidas a mejorar aspectos como trato, conocimiento y habilidad del personal de enfermería, y la continuidad del cuidado, así como el involucramiento de la familia en la atención. la satisfacción es mayor en las madres que perciben que sus hijos han recibido un adecuado manejo del dolor, este resultado concuerda con lo reportado por britt y arnetz, (4), conner y nelson (6). este factor se considera relevante para el personal de enfermería porque enfatiza que la satisfacción de la madre está asociada con la satisfacción de necesidades de su hijo, en este caso, es importante que enfermería ponga especial atención en la valoración de la presencia, intensidad y manejo del dolor de los pacientes pediátricos. conclusiones los resultados del presente estudio contribuyen al conocimiento de la satisfacción de la madre con la atención que recibe su hijo hospitalizado y exploran su relación con algunos factores identificados en la literatura como relevantes. los factores que se relacionan con la satisfacción de la madre con la atención que recibe su hijo hospitalizado son la percepción de un adecuado manejo del dolor y la satisfacción con el servicio de hospitalización. en cuanto a la satisfacción con la atención de enfermería los resultados sugieren la necesidad de desarrollar estrategias orientadas a mejorar la calidad del cuidado de enfermería en los pacientes pediátricos. respecto al manejo del dolor, aspecto relevante para la satisfacción de las madres, es importante que las intervenciones de enfermería contribuyan a un adecuado manejo, por tanto, el personal de enfermería debe participar activamente en la valoración, el manejo y la documentación del dolor del paciente pediátrico. con relación al servicio de hospitalización es esencial que todas las instituciones de salud dispongan del equipo y mobiliario necesarios y acordes con la edad del paciente pediátrico, así como también revisen el proceso de admisión y busquen optimizarlo. es recomendable que los modelos de atención hospitalaria dirigidos al paciente pediátrico incluyan los aspectos señalados para mejorar la satisfacción con la atención que se proporciona a este grupo prioritario de atención. 46 año 11 vol. 11 nº 1 chía, colombia abril 2011 aquichan issn 1657-5997 referencias bibliográficas 1. programa nacional de salud [pns] (2007-2012). informe oficial méxico. portal.salud.gob.mx/descargas/pdf/pnscap1.pdf [fecha de consulta: octubre 2009]. 2. flores y, vázquez s, cerda r. satisfacción materna con el cuidado de la enfermera materno infantil en campeche, méxico. rev latino-am enfermagen 2009; 17 (5). disponible en: www.eerp.ursp.br/rlae [fecha de consulta: marzo de 2010]. 3. serrano r. la anatomía de la satisfacción del paciente. salud pública de méxico 2008; 50 (2): 162-172. 4. britt m, arentz j. quality of pediatric care, application and validation of an instrument for measuring parent satisfaction with hospital care. journal for quality health care 2001; 13 (1): 33-43. 5. velázquez r, flores j, picallos m, acosta e. calidad asistencial percibida por los padres en una unidad de preescolares y hemato-oncología pediátrica. index de enfermería 2010; 19 (1). http://scielo.isciii.es/scielo.php?pid=s113212962010000100007&script=sci_arttext [fecha de consulta: abril de 2010]. 6. conner j, nelson e. neonatal intensive care: satisfaction measured from a parent’s perspective. pediatric nursing 1999; 103 (1): 336-339. 7. castillo e, chesla c, echeverry g, tascón e, charry m, chicangana j et ál. satisfacción de los familiares cuidadores con la atención en salud dada a adultos y niños con cáncer. colombia médica 2005; 36 (3): 43-49. disponible en: http://www.bioline.org.br/ pdf?rc05051 [fecha de consulta: junio de 2010]. 8. fornaris m, castillo m, rodríguez a, arias z, acosta y. evaluación de la satisfacción de los usuarios con la atención estomatológica al menor de 19 años. medisan 2006; 10 (2). disponible en: http://bvs. sld.cu/revistas/san/vol10_2_06/san05206.pdf [fecha de consulta: junio de 2010]. 9. colunga c, lópez m, aguayo g, canales j. calidad de atención y satisfacción del usuario con cita previa en medicina familiar de guadalajara. revista cubana de salud pública 2007; 33 (3). disponible en: http:// bvs.sld.cu/revistas/spu/vol33_3_07/spu12307.htm [fecha de consulta: julio de 2010]. 10. nathan dm, clark ta, wardesn cr, magnusson ar, jerris r h. patient satisfaction in the emergency department a survey of pediatric. patient and their parents. acad emerg med 2002; 9 (12): 1379-1388. 11. halfon n, inkelas m, mistry r, olson l. satisfaction with health care for young children. pediatrics 2004; 113: 1965-1972. 12. ortiz r, muñoz j, torres e. satisfacción de los usuarios de 15 hospitales de hidalgo méxico. revista española de salud pública 2004; 78 (4): 527-537. 13. gómez c, guillamont j, pastor j, novelli a, corvella x. evaluación de la satisfacción de los pacientes ingresados en una unidad de corta estancia de urgencias. emergencias 2005; 17: 12-16. 14. velásquez l, ruiz n, trejo a, sotelo j. la satisfacción de los usuarios en relación a la atención en el instituto nacional de neurología y neurocirugía. arch neurocien (mex) 2006; 11 (3): 183-190. 15. seclén j, darras ch. satisfacción de usuarios de los servicios de salud: factores sociodemográficos y de accesibilidad asociados. perú, 2000. anales facultad de medicina 2005; 66 (2): 127-141. 16. tucker, kelley a. the influence of patient sociodemographic characteristics on patient satisfaction. military medicine 2000; 165 (1): 72-76. 17. polit d, hungler b. investigación científica en ciencias de la salud. méxico: mc graw-hill interamericana; 1999. 18. bragadóttir h, reed d. evaluation pediatric family satisfaction questionnaire. pediatric nursing 2002; 28 (5): 475-484. 19. secretaría de salubridad y asistencia. reglamento de la ley general de salud en materia de investigación para la salud. méxico: porrúa; 1987. 47 satisfacción de las madres con la atención a sus hijos hospitalizados l maría guadalupe moreno-monsiváis, maría guadalupe interial-guzmán, paz francisco sauceda-flores et al. tabla 1. características individuales del paciente pediátrico y de la madre fuente: pfsq n = 127 características media mdn de valor mínimo máximo edad del hijo 6,60 7,00 4,44 0,05 15,00 número de hospitalizaciones previas 3,50 3,00 2,24 1,00 10,00 edad de la madre 29,43 29,00 6,28 17,00 42,00 escolaridad de la madre 8,85 9,00 2,06 3,00 15,00 tabla 2. satisfacción del familiar del paciente pediátrico fuente: pfsq n = 127 satisfacción media mdn de valor mínimo máximo servicio de hospitalización 84,62 85,41 7,73 60,42 100,00 atención de enfermería 72,44 75,00 7,66 45,83 91,67 satisfacción global 80,56 81,94 6,92 56,94 94,44 figura 1. percepción de la madre acerca del estado de salud del hijo anexo 274 286 percepcion del apoyo social.indd 274 aquichan issn 1657-5997 olga marina vega-angarita1 percepción del apoyo social funcional en cuidadores familiares de enfermos crónicos 1 magíster en enfermería con énfasis en cuidado al paciente crónico. profesora asociada, universidad francisco de paula santander, cúcuta, colombia. omvega23@hotmail.com. recibido: 10 de mayo de 2011 aceptado: 7 de octubre de 2011 resumen objetivo: describir la percepción del apoyo social funcional en cuidadores familiares de enfermos crónicos en san josé de cúcuta, colombia. método: estudio cuantitativo, descriptivo de corte transversal, con aplicación de dos instrumentos: caracterización de los cuidadores y el cuestionario de apoyo social funcional de duke-unc. participaron 179 cuidadores de personas con enfermedades crónicas, no institucionalizados. resultados: la mayoría de los cuidadores (54,7%) tienen una percepción inadecuada frente al apoyo social funcional global brindado por su entorno más cercano; el 45,3% expresa lo contrario. sobre la dimensión del apoyo confidencial el mayor porcentaje de los participantes (53,6%) tiene una percepción inadecuada, mientras que el 46,4% considera que es la mejor; con un comportamiento similar en la dimensión afectiva se encontró que el 51,4% de los cuidadores tiene una percepción inadecuada, y el 48,6% la describen como adecuada. conclusiones: los resultados reportados en las dimensiones sugieren la necesidad de que enfermería fortalezca la integración de los cuidadores en los sistemas formales e informales para que, a través de ellos, los sujetos perciban mayor apoyo de su ambiente social, facilitando así los procesos de afrontamiento y adaptación a las demandas que le plantea su nueva realidad. palabras clave enfermedad crónica, cuidadores, apoyo social (fuente: decs, bireme). family caregivers of chronically ill patients: perception of functional social support abstract objective: the purpose of this study was to describe the family caregivers of chronically ill perception of functional social support. method: it is a quantitative, descriptive study developed with two instruments: characterization of caregivers and the duke-unc functional social questionnaire. the sample included 179 caregivers of non-institutionalized patients who were suffering from chronic diseases and being treated at a general hospital in colombia. once the information was collected, a descriptive analysis was conducted to identify año 11 vol. 11 nº 3 chía, colombia diciembre 2011 l 274-286 275 percepción del apoyo social funcional en cuidadores familiares de enfermos crónicos l olga marina vega-angarita the essential variables in the study. results: most of the caregivers (54.7%) perceived the overall functional social support provided by the immediate environment as being inadequate; 45.3% expressed the opposite. as to confidential support, the largest percentage of participants (53.6%) perceived it as inadequate; 46.4% felt it was excellent. similarly, in terms of the affective dimension, 51.4% of the caregivers perceived it as inadequate, while 48.6% described it as adequate. conclusions: the results reported for the various dimensions suggest the need to reinforce the extent to which caregivers are integrated into formal and informal systems, so as to give them a sense of added support from the social environment, thereby facilitating the process of coping and adapting to the demands posed by their new situation. key words chronic illness, caregivers, social support (source: mesh, bireme). percepção do apoio social funcional em cuidadores familiares de doentes crônicos resumo objetivo: identificar a percepção do apoio social funcional em cuidadores familiares de doentes crônicos em san josé de cúcuta, colômbia. método: estudo quantitativo, descritivo de corte transversal, com aplicação de dois instrumentos: caracterização dos cuidadores, e o questionário de apoio social funcional de duke-unc. a muestra foi de 179 cuidadores de pessoas com doenças crônicas, não institucionalizados. resultados: a maioria dos cuidadores (54,7%) tem uma percepção inadequada sobre o apoio social funcional global oferecido por seu ambiente mais próximo; 45,3% expressam o contrário. sobre a dimensão do apoio confidencial, a maior porcentagem dos participantes (53,6%) tem uma percepção inadequada, enquanto 46,4% consideram que é melhor. com um comportamento similar na dimensão afetiva, 51,4% dos cuidadores têm uma percepção inadequada e 48,6% a descrevem como adequada. conclusões: os resultados relatados nas dimensões demonstram a necessidade que da enfermeira deve fortalecer a integração dos cuidadores nos sistemas formais e informais, para que, por meio deles, os sujeitos percebam maior apoio de seu ambiente social, facilitando assim os processos de afrontamento e adaptação às demandas que a sua nova realidade impõe. palavras-chave doença crônica, cuidadores, apoio social (fonte: decs, bireme). 276 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 introducción los avances en la ciencia y en la medicina han tenido un fuerte impacto en los patrones demográficos de la población mundial reflejándose en el descenso de la natalidad, la disminución de la mortalidad en edades avanzadas, y la elevada expectativa de vida, principales características de nuestra actual y futura sociedad. el cambio en el perfil demográfico ha dado lugar al envejecimiento de la población con mayor prevalencia de las patologías crónicas que generan gran consumo y utilización de los servicios de salud (1). su presencia, además de la disposición genética y la edad, está relacionada con factores de riesgo asociados a estilos de vida, hábitos y costumbres como la mala nutrición, inactividad física, tabaquismo y el consumo de alcohol; otros factores son los niveles altos de colesterol, el sobrepeso y la obesidad. en los sistemas de salud este tipo de enfermedad está ejerciendo presión debido a los altos costos que representa la carga de morbilidad generada por la complejidad de la tecnología médica para su diagnóstico y tratamiento (2), en países desarrollados suponen el 75% del gasto sanitario y el 80% del gasto farmacéutico (3). ante ello, la capacidad de ofrecer cuidados en el sistema informal (no profesionalizado de ayuda mutua y reciprocidad prestado por familiares, amigos y vecinos sin retribución económica) es aprovechado por las instituciones de salud para reducir costos (4). según la organización mundial de la salud (oms) (5), del total de 58 millones de defunciones previstas para 2005 por todas las causas, se estima que 35 millones corresponderán a enfermedades crónicas, lo que supone el doble del número de defunciones correspondiente al conjunto de todas las enfermedades infecciosas. en las últimas décadas, y siguiendo la tendencia mundial, en colombia se han observado dos importantes sucesos, la transición demográfica y la epidemiológica, que han producido cambios considerables en el perfil de ocurrencia de las enfermedades (2). del total de muertes registradas en el país durante 1990 al 2005 la mortalidad por enfermedades crónicas se incrementó pasando del 59 al 62,6% (6). en la actualidad, las enfermedades crónicas no transmisibles se constituyen en un problema de salud pública que produce mayor carga de padecimiento, generando un aumento imparable en el número de personas que requieren cuidados de larga duración y de la necesidad de asistencia desde los sistemas informales, siendo la familia y los cuidadores proveedores directos de atención. la enfermedad golpea al enfermo y su familia y, ante ella, la perspectiva cambia, la percepción del tiempo se altera y la consideración de lo que es prioritario, importante o no varía totalmente (7). la presencia de un enfermo crónico en el hogar provoca en la familia una reasignación de roles y tareas entre sus diversos miembros para tratar de cubrir o compensar sus funciones. las formas en que los cuidadores afrontan las demandas de cuidado dependen de lo estresante de la situación, de la etapa de la enfermedad en que se encuentra el receptor según la organización mundial de la salud, del total de 58 millones de defunciones previstas para 2005 por todas las causas, se estima que 35 millones corresponderán a enfermedades crónicas, lo que supone el doble del número de defunciones correspondiente al conjunto de todas las enfermedades infecciosas. 277 percepción del apoyo social funcional en cuidadores familiares de enfermos crónicos l olga marina vega-angarita de cuidado (8), y de la percepción de apoyo de las fuentes cercanas a él. el apoyo brindado para adaptarse a una enfermedad crónica puede provenir bien de un entorno natural (familiares y amigos), o bien de profesionales sanitarios o grupos de apoyo formales (9). en el cuidador, las personas disponibles para ayudarle y la percepción de esa disponibilidad son fundamentales en el rol asumido. algunas investigaciones (10), (11) han sugerido que el apoyo social reduce las consecuencias negativas de los acontecimientos estresantes que se producen en el cuidado de enfermos crónicos. otros estudios han destacado la existencia de una relación significativa entre el apoyo social percibido y la menor carga subjetiva de cuidadores informales (12). se ha sugerido también que la vulnerabilidad de los cuidadores en su rol, y la institucionalización del enfermo están relacionadas con la escasez de ayuda recibida y la clara percepción de la inexistencia de tales ayudas (13). el término apoyo social funcional fue definido por wethington y kessler (14) como la percepción hipotética que tiene una persona sobre los recursos sociales disponibles para ser asesorada y ayudada en caso de necesitarlo. se refiere a una dimensión de carácter subjetivo que establece el cuidador como resultado de su relación con el entorno más cercano, sobre la percepción de la posibilidad de contar con ayuda en caso de necesitarla, tanto para realizar actividades de la vida cotidiana como para resolver situaciones de emergencia. por su efecto en la generación de carga, la subjetividad en el cuidado familiar se está convirtiendo en un asunto cada vez más relevante y de interés en el estudio del peso del cuidado (15). el apoyo afectivo se entiende como un tipo de soporte en el cual el individuo, a través de la comunicación, satisface necesidades emocionales y de afiliación (compartiendo sus sentimientos, sintiéndose querido, valorado y aceptado por los demás). cuando las personas consideran que otro les ofrece soporte se dedican a buscarlo y a mantener una relación interpersonal que lo facilite y lo fomente (16). el apoyo confidencial representa la posibilidad de contar con personas a quien poder referirles problemas, situaciones conflictivas o asuntos que requieran comprensión y ayuda. en el contexto nacional no son muchas las investigaciones disponibles que exploren la percepción del cuidador acerca de la disponibilidad de personas capaces de ofrecer ayuda en las dificultades, de ahí la pertinencia de llevar a cabo dicho estudio para tratar de aportar evidencia científica al tema. conocer la percepción del apoyo social funcional que tiene el cuidador permite identificar los aspectos negativos que estos experimentan en el cuidado a largo plazo de una enfermedad crónica, planteando la necesidad de que enfermería asuma un papel protagónico en la implementación de programas asistenciales y educativos que preparen y habiliten a los cuidadores en el trabajo que su nueva realidad les plantea, y en el mejoramiento de la calidad de vida no solo de los familiares bajo su responsabilidad sino también de sí mismos. el presente estudio tiene como objetivo describir la percepción del apoyo social funcional en cuidadores familiares de enfermos crónicos en san josé de cúcuta. el término apoyo social funcional fue definido por wethington y kessler como la percepción hipotética que tiene una persona sobre los recursos sociales disponibles para ser asesorada y ayudada en caso de necesitarlo. 278 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 método se efectuó un estudio descriptivo, de tipo transversal, con abordaje cuantitativo que incluyo a 179 cuidadores familiares de enfermos crónicos asistentes a tres unidades básicas prestadoras de servicios: la libertad, puente barco y comuneros de la ese imsalud en el municipio de san josé de cúcuta, colombia, entidades de primer nivel de atención con las que el programa de enfermería de la universidad francisco de paula santander tiene establecido convenio docente asistencial. los participantes fueron elegibles mediante un muestreo no probabilístico por conveniencia tomando como base los siguientes criterios de inclusión: cuidadores mayores de 18 años y que aceptaran la participación voluntaria en el estudio. la recolección de los datos se realizó en el periodo comprendido entre el 1 de septiembre al 30 de diciembre del año 2010. atendiendo los parámetros definidos en la resolución 008430 (17) y el código de ética de enfermería (18), la incorporación de los participantes se hizo después de la explicación precisa sobre los alcances y objetivos de la investigación, los datos fueron obtenidos previo consentimiento informado, se respetó en todo momento el derecho a la confidencialidad y el anonimato en los participantes, se contó con el permiso de las directivas de las instituciones sedes mediante la aprobación del protocolo del estudio por parte del comité de ética. en la medición del perfil de los cuidadores se utilizó el instrumento de caracterización de cuidadores (19) diseñado por el grupo de cuidado al paciente crónico y su familia de la facultad de enfermería de la universidad nacional de colombia, que mediante preguntas cerradas explora aspectos sociodemográficos y características de cuidado. igualmente, se utilizó el cuestionario de apoyo social funcional de duke-unc (functional social support questionnaire) (20, 21), instrumento sencillo y breve formado por 11 ítems, puntuados en un gradiente de frecuencia en escala tipo likert que va desde 1, “mucho menos de lo que deseo”, a 5, “tanto como deseo”; la puntuación obtenida es un reflejo del apoyo percibido, a menor puntuación, menor apoyo. se compone de dos dimensiones: la confidencial, que representa la opinión del cuidador sobre la posibilidad de contar con personas para comunicarse problemas íntimos o de cualquier otra índole así como situaciones conflictivas que requieren de la comprensión y ayuda, se explora a través de 7 preguntas, las puntuaciones mínimas y máximas de esta dimensión oscilan entre 7 y 35, se considera apoyo confidencial adecuado si se obtienen 21 puntos o más. la afectiva, evaluada mediante 4 preguntas, supone la demostración de amor, cariño y empatía, así como la disponibilidad de las personas para proporcionar esas expresiones de afecto, las puntuaciones de esta dimensión oscilan entre 4 y 20, y se considera apoyo afectivo adecuado si se obtienen 12 o más puntos (22). el rango de puntuación del apoyo funcional global oscila entre 11 y 55 puntos, una calificación igual o por encima de 32 indica una percepción adecuada de esta dimensión. se ha investigado la validez de concepto y la validez de constructo. la consistencia interna se ha estudiado obteniéndose un valor alfa de crombach de 0,90 para el total de la escala, y de 0,88 y 0,79 para las escalas de apoyo confidencial y afectivo, los ítems con mayor variabilidad de respuesta fueron el “tener la posibilidad de hablar con alguien de los problemas en el trabajo o en la casa” y “tener la posibilidad de hablar con alguien de los problemas económicos”. 279 percepción del apoyo social funcional en cuidadores familiares de enfermos crónicos l olga marina vega-angarita respectivamente (23). dicho instrumento ha sido validado en españa tanto en población general (24) como en personas con vih positivo (25). se conoce de pocos estudios sobre la utilización del cuestionario en la población colombiana (26). análisis estadístico se utilizó el programa microsoft excel para la sistematización y revisión de los datos recogidos, y el programa estadístico spss versión 16.0 para el análisis descriptivo de la información. presentación de resultados los resultados que se presentan a continuación corresponden al análisis descriptivo sobre el perfil de los cuidadores familiares a través de las variables estudiadas. como se observa en la tabla 1, el rol de cuidador es desempeñado en la mayoría de los casos por mujeres (78,8%), solo el 21,2% de los cuidadores son hombres. el 70,4% son personas entre 36 y 59 años de edad. sobre la relación de edad del binomio cuidador-cuidado se pudo determinar que la persona cuidada supera la edad del cuidador. el grado de escolaridad en la mayoría de los casos es bajo; el 18,3% de los cuidadores solo tiene estudios en primaria de manera completa o incompleta (25,6%). la mayoría de los cuidadores son personas casadas (47,6%) con relación estable; el 24,4% son solteros. la ocupación de mayor representatividad es el cuidado del hogar (53,7%). un porcentaje reducido (8,5%) son empleadas temporales en alguna empresa, o se desempeña laboralmente de manera independiente en el 26,8% de los casos. el 59,8% de los cuidadores pertenece a los estratos dos y uno en el 30,5% indicando que el nivel socioeconómico es bajo en la mayoría de los casos. el 67,6% viene desempeñándose como único cuidador del familiar enfermo; el 32,4% ha recibido apoyo de otros familiares o personas cercanas. el 72,1% de los cuidadores lleva más de 3 años desempeñando el rol de cuidador; el 67% de los cuidadores dedica entre 7 y 12 horas al cuidado de su familiar; el 17,9% se podría decir que dedica prácticamente todo el día al cuidado de su familiar. la mayoría de los cuidadores tienen una relación de consanguinidad de primera línea siendo estos hijos(as) en el 64,2%, mientras que en el 14,5% de los casos son padres. en cuanto al diagnóstico, la enfermedad crónica más frecuente en el grupo de receptores de cuidado es la hipertensión arterial (77,7%), seguida por la diabetes mellitus (10,6%), entidades clínicas que pueden limitar gradualmente las capacidades funcionales de quienes la padecen, dificultando desde la realización de actividades diarias relacionadas con el cuidado personal hasta las de tipo instrumental. frente al apoyo confidencial se logró determinar que el 53,6% de los cuidadores lo perciben como inadecuado, mientras que un 46,4% considera que el apoyo confidencial es el mejor (gráfico 1). en el análisis específico de los elementos de esta categoría el ítem donde se evidencia menor puntuación (inferior a 21) es el que hace referencia a “las visitas por parte de familiares y amigos”, donde el 44,1% de los cuidadores percibe que dichas visiel “recibir amor y afecto” fue el ítem con menor variabilidad de respuesta y mayor puntuación promedio, el 47,5% de los cuidadores perciben recibir afecto y amor de los familiares y allegados tanto como lo desean. 280 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 tas ocurren mucho menos de lo que ellos desean. los ítems con mayor variabilidad de respuesta fueron el “tener la posibilidad de hablar con alguien de los problemas en el trabajo o en la casa” y “tener la posibilidad de hablar con alguien de los problemas económicos” (coeficiente de variación = 56,5%). los ítems con menor variabilidad de respuesta fueron el “recibir ayuda en asuntos relacionados con la casa” y el “recibir consejos útiles cuando ocurre algún acontecimiento importante en la vida”. el 51,4% de los cuidadores perciben un apoyo afectivo inadecuado mientras que un 48,6% lo describen como adecuado (gráfico 2). curiosamente, el apoyo afectivo adecuado resulta ser más frecuente en los cuidadores hombres, observándose una diferencia estadísticamente significativa (p<=0,001). sobre el análisis particular de los elementos de esta categoría, el “recibir elogios y reconocimientos cuando hacen bien su trabajo” y el “contar con personas que se preocupan por lo que les sucede”, fueron los ítems con menor puntuación (inferior a 12); cuantitativamente el 44,7 y el 43,8% respectivamente de los cuidadores refieren que dichos elogios son recibidos muy pocas veces o mucho menos de lo que ellos esperan. en el estudio, el 35% de los cuidadores informaron que los familiares a su cargo requerían de su atención para movilizarse, vestirse y bañarse, actividades que por lo general pasan desapercibidas. el “recibir ayuda cuando están enfermos en la cama” fue la situación que presentó mayor variabilidad de respuesta (coeficiente de variación = 56,5%). el “recibir amor y afecto” fue el ítem con menor variabilidad de respuesta y mayor puntuación promedio, el 47,5% de los cuidadores perciben recibir afecto y amor de los familiares y allegados tanto como lo desean. de manera general, que se pudo identificar que apenas el 45,3% de los cuidadores tiene una percepción adecuada frente al apoyo social funcional global brindado. el 54,7% obtuvo una puntuación inferior a 32, lo cual indica que el apoyo social funcional global brindado a sus familiares es inadecuado (gráfico 3). discusión los estudios sobre esta temática son limitados en el contexto colombiano y latinoamericano, lo que impide hacer un contraste de la presente investigación con otras similares, y plantea la necesidad de nuevos aportes al respecto. las características sociodemográficas de los participantes de esta investigación coinciden con las señaladas en la mayoría de los estudios realizados dentro y fuera del contexto nortesantandereano (27, 28, 29, 30). el mayor peso porcentual de los cuidadores familiares corresponde al sexo femenino (78,8%), datos similares reportaron sánchez, pinto y barrera (31) en el estudio sobre caracterización de cuidadores en américa latina, en el que ratifican que, por lo general, la responsabilidad de ser cuidador recae en las mujeres, hasta tal punto que ocho de cada diez personas que cuidan de un familiar son de este género. ante este perfil, las investigadoras plantean que “son las mujeres quienes suministran con mayor frecuencia los cuidados de atención personal y los instrumentales, y están más implicadas en las de manera general, que se pudo identificar que apenas el 45,3% de los cuidadores tiene una percepción adecuada frente al apoyo social funcional global brindado. 281 percepción del apoyo social funcional en cuidadores familiares de enfermos crónicos l olga marina vega-angarita tareas de acompañamiento y vigilancia. asumen los cuidados más pesados, cotidianos y que exigen mayor dedicación”. sobre la relación de edad del binomio cuidador-cuidado es posible determinar que la persona cuidada supera la edad del cuidador, lo cual guarda relación con el parentesco entre ellos: hijos(as) en el 64,2% de los participantes. lo reportado corresponde con lo encontrado en el estudio “caracterización de cuidadores familiares en américa latina” (31), donde los hallazgos señalan que en la mayoría de los casos los cuidadores son menores que la persona cuidada. lo anterior supone en el cuidador la atención de personas mayores cuya enfermedad genera alteraciones que van desde lo físico hasta lo emocional, con pérdida de la independencia que a veces se prolonga por años. ante esta situación, la vida del cuidador se organiza en función del enfermo y los cuidados tienen que hacerse compatibles con las actividades de la vida cotidiana; las largas e intensas jornadas de cuidado acaban por producir situaciones estresantes en las que son evidentes los altos grados de dependencia; además, como lo relata vargas escobar (32), la sobrecarga de trabajo, las restricciones sociales, las limitaciones en el uso del tiempo libre y de la propia intimidad terminan por generar en el cuidador sentimientos de soledad, incomprensión e incertidumbre hacia el futuro. dado que la mayoría de los cuidadores son mujeres que superan los 36 años de edad y tienen bajo nivel educativo, la ocupación de mayor representatividad es la doméstica (53,7%). un porcentaje reducido (8,5%) son empleadas temporales en alguna empresa, o se desempeñan laboralmente de manera independiente en el 26,8%. lo encontrado en el estudio guarda correspondencia con las características de sexo y nivel educativo anteriormente descritas, y explica en alguna medida la condición socioeconómica reportada en los cuidadores participantes (estratos 1 y 2). como lo refieren barrera, ortiz y sánchez (2010) (31) en su trabajo, “en las personas que permanecen en el hogar las rutinas no se rompen y el cansancio se hace muchas veces más notorio aunque tienen más tiempo disponible”. el cuidador que trabaja independientemente puede estar más tiempo en su casa y tener más momentos de contacto con la persona a quien cuida, contrario a un empleado, quien dispone de tiempos muy medidos. sobre la historia de cuidado de los participantes en el estudio se muestra que el 72,1% de ellos hace más de tres años son responsables directos de su familiar, con un número de 7 a 12 horas dedicadas al cuidado (67,0%). lo reportado es referido por la literatura (33) donde muestra que la cantidad y el tipo de ayuda varía en función del grado y de la causa que haya determinado dependencia de la persona cuidada. la mayoría de los cuidadores tienen una relación de consanguinidad de primera línea siendo estos hijos(as) en el 64,2%, mientras que en el 14,5% de los casos son padres. esto corrobora lo citado por algunos autores (31) que sostienen que la experiencia de cuidado varía en función del parentesco y la relación entre la persona cuidada. barrera, en su reciente libro, plantea: cuando el cuidado es de hijos a padre, en especial ancianos representa un fuerte impacto emocional. es percatarse la sobrecarga de trabajo, las restricciones sociales, las limitaciones en el uso del tiempo libre y de la propia intimidad terminan por generar en el cuidador sentimientos de soledad, incomprensión e incertidumbre hacia el futuro. 282 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 de que ya sus papás no pueden valerse por sí mismos, y asumir una inversión de roles, pues de hijo se pasa ser padre del afectado al tenerle que prestar toda una serie de ayudas y atenciones. decidir dónde, cuándo y cómo invertir los esfuerzos y la energía es difícil, sobre todo cuando las demandas de ayuda de las personas a quienes se cuida son elevadas. en el estudio, las afecciones médicas que comúnmente condujeron a la necesidad de un cuidador fueron las enfermedades cardiovasculares y metabólicas, siendo la hipertensión arterial y la diabetes mellitus las principales causas de morbilidad en la región nortesantandereana. estos datos son concordantes con estudios nacionales (33) que indican que estas patologías se encuentran inmersas dentro del grupo de las enfermedades crónicas, las cuales son la principal causa de muerte en colombia y demandan una carga creciente de servicios. según un estudio (33), la hipertensión arterial y la diabetes son enfermedades que aumentan con la edad; por lo general, su inicio tiene lugar entre los 30 y 55 años. estas dos enfermedades, además, se caracterizan por compartir varios factores involucrados en su génesis —tales como los genéticos y ambientales—, y ser multifactoriales. el instrumento de duke-unc pone de relieve que la mayoría de los cuidadores (54,7%) perciben el apoyo funcional global que reciben del entorno como inadecuado, indicando que existe de forma significativa mayor sensación de apoyo limitado en el grupo de cuidadores. los resultados obtenidos en esta dimensión respaldan el argumento de que la vulnerabilidad de los cuidadores está relacionada con la escasez de ayuda recibida y la clara percepción de la inexistencia de la misma. la percepción de apoyo social es quizá la variable moduladora más importante para el cuidador familiar, ya que es una fuente importante de ayuda al momento de hacer frente a las situaciones que les son propias (34). en el dominio de apoyo confidencial, el 53,6% de los cuidadores perciben que disponen de inadecuado apoyo social mientras que un 46,4% consideran lo contrario. esto guarda correspondencia con lo planteado por la literatura en la que se establece que los cuidadores que tienen vínculo con los miembros de la familia o grupos de apoyo con quienes pueden y van a discutir sus problemas se enfrentan mejor a las situaciones vitales estresantes que los que carecen de él (35). por lo que resulta necesario que los profesionales de enfermería evalúen la percepción del apoyo social funcional que tienen estos cuidadores para prevenir el aislamiento social y las consecuencias emocionales negativas de este. respecto a la percepción del apoyo socioafectivo, el 51,4% de los cuidadores lo aprecian como inadecuado, mientras que un 48,6% lo describen como adecuado. otros trabajos han reportado hallazgos similares, tal es el caso del estudio tendiente a identificar las necesidades de apoyo que tienen los cuidadores de personas en situación de discapacidad por parte de las redes sociales, en el que fonseca (2009) (36) señala que los cuidadores expresan la necesidad de que sus familiares les presten atención y les den el merecido reconocimiento, pues se sienten frustrados al saber que su entorno más cercano no valora el esfuerzo físico, decidir dónde, cuándo y cómo invertir los esfuerzos y la energía es difícil, sobre todo cuando las demandas de ayuda de las personas a quienes se cuida son elevadas. 283 percepción del apoyo social funcional en cuidadores familiares de enfermos crónicos l olga marina vega-angarita mental y espiritual por ellos realizado, actividades complejas de supervisión y vigilancia que implican grandes dosis de tiempo y esfuerzo haciendo que se olviden de sus propios intereses. a partir de la revisión de la literatura (37) se puede señalar que en los cuidadores la percepción de elogios, aprobación y reconocimiento de su labor por parte del entorno (familiar, social, sanitario) produce resultados deseables en el desahogo de la tensión emocional, en el cambio de actitudes, aumento de la autoestima y modos de conducta en la remisión de la sobrecarga. el reconocimiento de la labor que realizan los cuidadores familiares es una fuente de satisfacción, de fortaleza y de estabilidad psicológica referencias 1. organización mundial de la salud. prevención de la enfermedades crónicas una inversión vital. nueva york: oms; 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[fecha de consulta: 5 de agosto de 2010]. 9. jaureguizar, j, espina a. estrés, apoyo social y familia. enfermedad física crónica y familia. 1 ed. madrid: libros en red; 2005. 10. abaunza m, acosta s, álzate ml, amaya p, barbosa g, barrera l et al. la investigación y el cuidado en américa latina. en pinto n (comp.). comprender la situación de cronicidad que viven nuestros pacientes. bogotá: unibiblios; 2005. 11. schwarz ka, roberts b. el apoyo social y la tensión de los cuidadores familiares de adultos mayores. nursing practice in action 2000; 14 (2): 77-90. 12. leturia, fj et al. valoración de las personas mayores: evaluar para conocer, conocer para intervenir. madrid: editores caritas española; 2001. 13. de los reyes mc. construyendo el concepto cuidador de ancianos. foro de investigación: envejecimiento de la población en el mercosur. iv reunión de antropologia do mercosul. noviembre de 2001. curitiba, brasil. 14. wethington e, kessler rc. perceived support, received support, and adjustment to stressful life events. journal of health and social behavior 1996; 27: 78-89. 15. cuesta c. el cuidado familiar: una revisión crítica. investigación y educación en enfermería 2009; xxvii: 96-102. 16. pinto n. cuidar en el hogar a personas con enfermedad crónica, su familia y cuidador. bogotá: faque les da seguridad y control teniendo un papel central en el manejo del estrés. las redes informales de apoyo, que incluyen las familias y las amistades, no solo constituyen uno de los principales recursos en los cuidadores que acuden en busca de ayuda sino que, comparadas con los servicios profesionales de ayuda también han demostrado su efectividad. 284 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 cultad de enfermería, universidad nacional de colombia; 2010. 17. colombia. ministerio de la protección social. resolución 8430 de 1993, 4 de octubre, por la cual se establecen las normas científico técnicas y administrativas para la investigación en salud. bogotá: el ministerio; 1993. 18. república de colombia. tribunal nacional ético de enfermería. ley 911 de 2004, octubre 5 por la cual se dictan disposiciones en materia de responsabilidad deontológica para el ejercicio de la profesión de enfermería en colombia. bogotá; 2004. 19. grupo de cuidado al paciente crónico. instrumento caracterización de los cuidadores. universidad nacional de colombia; 1996 (patente en curso). 20. bellón sa, delgado a, luna s, lardelli p. validez y fiabilidad del cuestionario de apoyo social funcional duke-unc-11. atención primaria 1996; 18: 153-163. 21. broadhead we, gehlbach sh, de gruy fw, kaplan bh. the duke-unk functional social support cuestionnaire. measurement of social support in family medicine patients. med care 1988; 26: 709. 22. vinaccia s et al. calidad de vida y apoyo social percibido en pacientes con diagnóstico de tuberculosis pulmonar. en anales de psicología 2007; 23 (2): 245-252. 23. de la revilla l, bailón e, de dios j et al. validación de una escala de apoyo social funcional para su uso en la consulta del médico de familia. atención primaria 1994); 9: 688. 24. bellón ja, delgado a, de dios j, lardelli p. validez y fiabilidad del cuestionario de apoyo social funcional duke-unc-11. aten primaria 1996; 18: 17-31. 25. de la revilla l, marcos b, castro ja, aybar r, marín i, mingorance i. percepción de salud apoyo social y función familiar en vih positivo. aten primaria 1994; 13: 21-6. 26. alvarado be, zunzunegui mv, delisle h. validación de escalas de seguridad alimentaria y de apoyo social en una población afrocolombiana: aplicación en el estudio de prevalencia del estado nutricional en niños de 6 a 18 meses. cad saúde pública [serial on the internet]. 2005 june; 21 (3): 724-736. disponible en: http://www.scielosp. 27. vega, om. habilidad del cuidado de los cuidadores primarios de adultos discapacitados por enfermedad cerebrovascular del norte de santander. san josé de cúcuta, 2005. tesis de maestría. enfermería. universidad nacional de colombia-universidad francisco de paula santander. 28. gonzález ds. habilidad del cuidado de cuidadores familiares de personas en situación crónica de enfermedad por diabetes mellitus. san josé de cúcuta; 2005. tesis de maestría. enfermería. universidad nacional de colombia, universidad francisco de paula santander. 29. estévez ep, rueda j. grado de preparación para el cuidado en casa de cuidadores familiares de adultos en situación de enfermedad crónica discapacitante neurovascular de la ese hospital universitario erasmo meoz. san josé de cúcuta, 2006. trabajo de grado. enfermería. universidad francisco de paula santander. 30. montalvo a, romero e, flórez ie. percepción de la calidad de vida de cuidadores de niños con cardiopatía congénita. cartagena, colombia. invest educ enferm 2011; 29 (1): 9-18. 31. barrera l, pinto n, sánchez b. caracterización de cuidadores familiares en américa latina. cuidando a los cuidadores familiares de personas con enfermedad crónica. bogotá: facultad de enfermería, universidad nacional de colombia; 2010. 32. vargas-escobar lm. marco para el cuidado de la salud en situaciones de enfermedad crónica. investigación en enfermería: imagen y desarrollo 2010; 12: 79-94. 33. fuentes n, ojeda aa. soporte y red social en el adulto maduro con hipertensión arterial y/o diabetes mellitus tipo ii en riesgo de insuficiencia renal. granada: biblioteca lascasas; 2007. disponible en: http://www.index-f.com/lascasas/documentos/ lc0261.php 34. house js, landis kr, umberson d. social relationships and health. science; 1998. p. 540-5. 35. espinosa mc, clerencia m, serrano m, alastuey c, mesa p, perlado f. apoyo social, demencia y cuidador. revista española de geriatría y gerontología 1996; 31 (1): 31-35. 36. fonseca km. necesidades de apoyo que tienen los cuidadores de personas en situación de discapacidad por parte de las redes sociales institucionales de la localidad de fontibón, 2009. trabajo de grado. bogotá: facultad de enfermería, pontificia.universidad javeriana. 37. calvete e. apoyo social y síntomas psicológicos en ancianos institucionalizados. revista española de geriatría y gerontología, 29 (2): 73-78. 285 percepción del apoyo social funcional en cuidadores familiares de enfermos crónicos l olga marina vega-angarita tabla 1. características sociodemográficas de los cuidadores (n =179) fuente: instrumento de caracterización de cuidadores. característica frecuencia porcentaje sexo masculino 38 21,2 femenino 141 78,8 edad del cuidador (años) 18-35 40 22,3 36-59 126 70,4 >60 13 7,3 nivel educativo ninguna 20 11,0 primaria incompleta 46 25,6 primaria completa 33 18,3 bachillerato incompleto 46 25,6 bachillerato completo 30 17,1 técnico o más 4 2,4 estado civil soltero 44 24,4 casado 85 47,6 unión libre 33 18,3 separado 6 3,7 viudo(a) 11 6,1 ocupación del cuidador hogar 96 53,7 trabajo independiente 47 26,8 empleado 15 8,5 estudiante 0 0,0 desempleado 13 7,3 estrato socioeconómico estrato 1 54 30,5 estrato 2 107 59,8 estrato 3 18 9,8 único cuidador sí 121 67,6 no 58 32,4 experiencia como cuidador (meses) 0 a 6 15 8,4 7 a 18 17 9,5 19 a 36 18 10,1 37 o más 129 72,1 286 año 11 vol. 11 nº 3 chía, colombia diciembre 2011 aquichan issn 1657-5997 anexo apoyo social funcional estimado cuidador: la presente encuesta tiene como propósito la medición de la percepción del apoyo social en términos de la disponibilidad de amigos y familiares ante situaciones particulares por usted experimentadas en el cuidado de su familiar. no deje preguntas sin responder. instrucciones: a continuación se presenta una serie de preguntas. elija para cada una la respuesta que mejor se ajuste a su situación según los siguientes criterios: 1. mucho menos de los que deseo; 2. menos de lo que deseo; 3. ni mucho ni poco; 4. casi como deseo; 5. tanto como deseo. 1. recibo visitas de mis amigos y familiares. 2. recibo ayuda en asuntos relacionados con mi casa. 3. recibo elogios y reconocimientos cuando hago bien mi trabajo. 4. cuento con personas que se preocupan por lo que me sucede. 5. recibo amor y afecto. 6. tengo la posibilidad de hablar con alguien de mis problemas en el trabajo o en la casa. 7. tengo la posibilidad de hablar con alguien de mis problemas personales y familiares. 8. tengo la posibilidad de hablar con alguien de mis problemas económicos. 9. recibo invitaciones para distraerme y salir con otras personas. 10. recibo consejos útiles cuando me ocurre algún acontecimiento importante en mi vida. 11. recibo ayuda cuando estoy enfermo en cama. pregunta 1 2 3 4 5 283 295 terapia de compresion tratamiento de ulceras.indd 283 júlia teixeira nicolosi1 silvana cereijido altran2 jéssica piro barragam3 viviane fernandes de carvalho4 césar issac5 terapias compressivas no tratamento de úlcera venosa: estudo bibliométrico 1 enfermeira, mestre de enfermagem pela universidade guarulhos, doutoranda da faculdade de medicina (universidade de são paulo), pesquisadora do laboratório de cultura celular e cicatrização lim 04 (faculdade de medicina da universidade de são paulo), docente do departamento de saúde pela universidade nove de julho (são paulo), são paulo, brasil. juliatnicolosi@yahoo.com.br 2 bióloga, mestre em ciências pela universidade de são paulo, doutoranda da faculdade de medicina (universidade de são paulo), biologista no laboratório de cultura celular e cicatrização lim 04 (faculdade de medicina da universidade de são paulo), são paulo, brasil. silaltran@yahoo.com.br 3 enfermeira, especialista em enfermagem clínica e cirúrgica pela universidade federal de são paulo, pesquisadora do laboratório de cultura celular e cicatrização lim 04 (faculdade de medicina da universidade de são paulo), são paulo, brasil. jessica.barragam@gmail.com 4 enfermeira, doutora em ciências da saúde pela disciplina de cirurgia plástica da faculdade de medicina da universidade de são paulo, vice-coordenadora do programa de mestrado em enfermagem universidade guarulhos, são paulo, brasil. vivianefcarvalho@usp.br 5 médico, doutor em ciências pela faculdade de medicina da universidade de são paulo, médico responsável pelo laboratório de cultura celular e cicatrização lim 04-f (faculdade de medicina da universidade de são paulo), orientador do programa de pósgraduação da faculdade de medicina da universidade de são paulo, são paulo, brasil. cesaris@plastica.fm.usp.br recibido: 27 de febrero de 2014 enviado a pares: 25 de abril de 2014 aceptado por pares: 14 de noviembre de 2014 aprobado: 25 de marzo de 2015 doi: 10.5294/aqui.2015.15.2.11 para citar este artículo / to reference this article / para citar este artigo nicolasi jt, altran sc, barragam jp, de carvalho vf, isaac c. terapias compressivas no tratamento de úlcera venosa: estudo bibliométrico. aquichan. 2015; 15 (2): 283-295. doi: 10.5294/aqui.2015.15.2.11 resumo introdução: úlceras de origem venosas são lesões cutâneas que geralmente acometem o terço inferior das pernas. o tratamento dessas feridas é dinâmico e depende da evolução das fases da reparação tecidual. esse tratamento inclui métodos clínicos e cirúrgicos, sendo a terapia compressiva o método não cirúrgico mais frequentemente utilizado. dentre as terapias compressivas, destacam-se as bandagens inelásticas e elásticas, meias elásticas e pressão pneumática intermitente. objetivo: o presente estudo pretendeu identificar o perfil da produção científica nacional e internacional que descrevesse terapia compressiva e úlcera venosa classificando-o de acordo com: cronologia de publicação, procedência, periódicos em que estão publicadas, avaliação do “qualis” — coordenação de aperfeiçoamento de pessoal de nível superior (capes), distribuição da abordagem metodológica, análise do conteúdo das publicações e comparar, quando possível, os dados apresentados nessa revisão. método: estudo bibliométrico realizado nas bases de dados medline, lilacs e cinahl no qual se utilizaram os descritores “varicose ulcer/therapy”, “compression bandages”, “wound healing” e o operador booleano and entre os anos de 2009 a 2013. resultados: foram selecionados 47 artigos; a maioria publicada em 2012 (n = 12; 25,53%), nos estados unidos (n=14; 29,78%) e reino unido (n=14; 29,78%), em revistas de especialidade vascular (n=19; 40,42%), com avaliações a2 (n=13; 27,65%) e b1 (n=13; 27,65%). a maior parte da metodologia utilizada nos estudos selecionados era tipo “estudos clínicos” (n= 30; 63,82%). dentre os estudos clínicos e metanálises, apenas 30% (n= 14) apresentavam como objetivo principal avaliação da terapia compressiva e pretenderam estudar comparativamente eficácia de bandagens elásticas, inelásticas, meias elásticas, pressão pneumática intermitente e ausência de terapia compressiva no tratamento de úlceras venosas. conclusão: há preocupação da comunidade científica com a busca do tratamento eficaz para as úlceras venosas, porém a distribuição mundial de publicações é desigual. evidenciou-se que a terapia compressiva não é o objeto principal na maioria dos trabalhos selecionados, o que leva ao interesse em terapias adjuvantes ou complementares a essa. ficou evidente a necessidade da terapia compressiva, porém não há consenso sobre qual pressão deva ser año 15 vol. 15 nº 2 chía, colombia junio 2015 l 283-295 284 aquichan issn 1657-5997 año 15 vol. 15 nº 2 chía, colombia junio 2015 l 283-295 utilizada para se obter melhores resultados na cicatrização; portanto, são necessários mais estudos que avaliem as interferências das diversas pressões sobre o processo de reparo tecidual. também há carência de estudos que comprovem a ação da pressão pneumática intermitente com associações ou não de bandagens elásticas. palavras-chave úlcera varicosa, dispositivos de compressão pneumática intermitente, meias de compressão, bandagens compressivas, cicatrização (fonte: decs, bireme). terapias compresivas en el tratamiento de úlcera venosa: estudio bibliométrico resumen introducción: úlceras de origen venosas son lesiones cutáneas que generalmente acometen el tercio inferior de las piernas. el tratamiento de estas heridas es dinámico y depende de la evolución de las fases de la reparación del tejido. este tratamiento incluye métodos clínicos y quirúrgicos, y la terapia compresiva es el método no quirúrgico más utilizado. entre las terapias compresivas, se destacan los vendajes inelásticos y elásticos, medias elásticas y presión neumática intermitente. objetivo: este estudio buscó identificar el perfil de la producción científica nacional e internacional que describiera la terapia compresiva y la úlcera venosa para clasificarla de acuerdo con: cronología de publicación, procedencia, periódicos en que están publicadas, evaluación del “qualis” — coordinación de perfeccionamiento de personal de nivel superior (capes), distribución del abordaje metodológico, análisis del contenido de las publicaciones y comparar, cuando fuera posible, los datos presentados en esta revisión. método: estudio bibliométrico realizado en las bases de datos medline, lilacs y cinahl en el que se utilizaron los descriptores “varicose ulcer/therapy”, “compression bandages”, “wound healing” y el operador booleano and entre los años de 2009 a 2013. resultados: se seleccionaron 47 artículos; la mayoría de ellos publicados en 2012 (n = 12; 25,53%), en estados unidos (n=14; 29,78%) y reino unido (n=14; 29,78%), en revistas de especialidad vascular (n=19; 40,42%), con evaluaciones a2 (n=13; 27,65%) y b1 (n=13; 27,65%). la parte más grande de la metodología utilizada en los estudios seleccionados fue tipo “estudios clínicos” (n= 30; 63,82%). entre los estudios clínicos y metanálisis, apenas 30% (n= 14) presentaban como objetivo principal evaluación de la terapia compresiva y estudiaban comparativamente eficacia de vendajes elásticos, inelásticos, medias elásticas, presión neumática intermitente y ausencia de terapia compresiva en el tratamiento de úlceras venosas. conclusión: hay preocupación de la comunidad científica sobre la búsqueda del tratamiento eficaz para las úlceras venosas; sin embargo, la distribución mundial de publicaciones es desigual. se evidenció que la terapia compresiva no es el objeto principal en la mayoría de los trabajos seleccionados, lo que lleva al interés en terapias adyuvantes o complementarias a esta. quedó evidente la necesidad de la terapia compresiva, pero no hay consenso sobre cuál presión deba ser utilizada para obtener mejores resultados en la cicatrización; por lo tanto, son necesarios más estudios que evalúen las interferencias de las diversas presiones sobre el proceso de reparación del tejido. también hay carencia de estudios que comprueben la acción de la presión neumática intermitente con asociaciones o no de vendajes elásticos. palabras clave úlcera varicosa, dispositivos de compresión neumática intermitente, medias de compresión, vendajes compresivos, cicatrización (fuente: decs, bireme). 285 terapias compressivas no tratamento de úlcera venosa: estudo bibliométrico l júlia teixeira nicolosi e outros compressive therapy in the treatment of venous ulcers: bibliometric study abstract introduction: venous ulcers are skin lesions, which usually affect the lower third of the legs. the treatment of these wounds is dynamic and depends on the tissue repair process. clinical and surgical procedures are included among those therapies, and the therapeutic compressive most often used non-surgical method. inelastic and elastic bandages, elastic stockings and intermittent pneumatic pressure are the most common compressive therapy used. objective: this study aimed to identify the national and international scientific literature profile describing compression therapy and venous ulcers and classify that profile according to: chronology of publication, country, periodicals that are published review of ‘qualis’ capes, distribution of the methodological approach, analysis of the publications content and compare, where possible, the data presented. method: bibliometric study conducted in the medline, lilacs and cinahl databases using the keywords “varicose ulcer / therapy”, “compression bandages”, “wound healing” and boleyn word and between the years 2009-2013. results: 47 articles were selected, the major part was published in 2012 (n = 12, 25.53 %), the united states (n = 14, 29.78 %) and the united kingdom (n = 14, 29.78%), in vascular surgery specialized magazines (n = 19, 40.42%), qualis a2 (n = 13, 27.65 %) and b1 (n = 13, 27.65 %). much of the methodology used in the selected studies was “clinical studies” type (n = 30, 63.82 %). only 30 % ( n = 14 ) had as main objective assessment of compressive therapy and intended study compared the effectiveness of elastic bandages, inelastic, elastic stockings , intermittent pneumatic pressure and absence compression therapy for the treatment of venous ulcers. conclusions: there is a concern, in the scientific community, about the research for effective treatment for venous ulcers. however, the worldwide distribution of publications is uneven. it was evident that compression therapy is not the main object in the majority of selected studies emerging interest in adjuvant or complementary to such therapies. it is evident the compressive therapy need, but there is no consensus on which pressure should be used for best results in healing and more studies must be performed to evaluate the interference of different pressures levels on the tissue repair process . there is also a lack of studies demonstrating the action of intermittent pneumatic pressure or not associations with elastic bandages keywords varicose ulcer, intermittent pneumatic compression devices, stockings, compression, compression bandages, wound healing (source: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 283-295 286 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 introdução úlceras crônicas em membros inferiores possuem etiologias diversas das quais se destacam: venosa, arterial, traumática, infecciosa e diabética (1,2). dentre estas, a de origem venosa acomete 1% da população mundial e corresponde a 75% de todas as úlceras crônicas (3). a cronicidade da úlcera venosa causa, ao paciente, dor e disfunção física, e o afasta de suas atividades diárias, o que gera impacto socioeconômico significativo. estimase que, nos estados unidos, sejam gastos, para cada paciente, aproximadamente 30 mil dólares por ano (4). entre os pacientes mais predispostos a desenvolver insuficiência e hipertensão venosa estão aqueles com histórico familiar de úlcera venosa, histórico de varizes e/ou cirurgia ou escleroterapia para varizes, flebite ou trombose venosa profunda, traumas (exemplo, fratura), ocupação sedentária, gênero (mais comum em mulheres), múltiplas gestações e obesidade (5). anatomicamente, o sistema venoso dos membros inferiores é formado pelas veias profundas, superficiais e perfurantes que comunicam as duas primeiras. o sangue é direcionado dos membros inferiores para o coração com a ajuda da contração dos músculos da perna. para permitir o fluxo unidirecional por essa rede venosa, há presença de válvulas bicúspides. com a queda da pressão no sistema arterial profundo, as válvulas fecham o que evita refluxo e aumenta a pressão no sistema venoso superficial. com o relaxamento da musculatura da perna, há esvaziamento do sistema venoso profundo e, consequentemente, queda da pressão, o que promove abertura das válvulas e direciona o fluxo de sangue do sistema superficial ao profundo (6-8). a patologia venosa surge quando a pressão venosa aumenta em decorrência do prejuízo do retorno do sangue. isso pode ser resultado de incompetência valvular, obstrução venosa, disfunção dos músculos da perna ou combinações desses fatores (7-8). diversas teorias tentam explicar a formação da úlcera venosa, porém todas são unânimes em considerar que há fibrinólise defeituosa, deposição excessiva de fibrina, dano capilar e hipertensão venosa (9-11). essas falhas no processo de reparo tecidual levam à cronicidade dessa lesão. várias terapias vêm sendo adotadas no tratamento dessas úlceras, porém há um consenso na literatura da eficácia de terapias compressivas que visa minimizar a hipertensão venosa, melhorar macrocirculação e microcirculação e promover cicatrização (2, 12,13). os métodos disponíveis de compressão são ataduras compressivas, meias elásticas e compressão pneumática (12). a pressão aplicada no membro (compressão) pode ser classificada em leve (<20 mmhg), moderada (≥20–40mmhg), forte (≥40–60mmhg) e muito forte (>60mmhg); a pressão recomendada para tratamento de úlceras venosas é ≥40mmhg, com restrições para pacientes portadores de insuficiência arterial, neuropatias e problemas cardíacos (13). dentre as ataduras compressivas, existem ataduras elásticas e inelásticas; cada tipo possui vantagens e desvantagens; portanto, há necessidade de compreender seu funcionamento para melhor indicação (13). a mais tradicional atadura inelástica é a bota de unna, que é constituída por atadura impregnada com óxido de zinco e forma um molde semissólido que realiza a compressão externa. outro exemplo de ataduras inelásticas é a short-strech. ataduras inelásticas apresentam a desvantagem de oferecer baixa pressão quando o paciente está em repouso (12,13). ataduras elásticas, se comparadas às inelásticas, proporcionam maior estiramento e menor variação de pressão entre a contração e o repouso muscular (12). destacam-se as ataduras multicamadas (três ou quatro camadas) (13). outra terapia que pode ser adotada em pacientes que têm dificuldade em se cuidar é o uso de meias elásticas. porém, por não serem absorventes, não são recomendadas para pacientes que possuam úlceras grandes e exsudativas (13). outra opção terapêutica é a compressão pneumática intermitente que consiste em câmaras de ar que, graças a uma bomba elétrica, ao serem insufladas e desinsufladas, proporcionam picos de pressão que simulam a ação do músculo (por exemplo, compressor scd express kendall®). seus benefícios podem ser potencializados quando associado às ataduras compressivas e é indicado para pacientes com redução da imobilidade ou fraqueza da musculatura da perna (13). devido à importância da terapia compressiva no tratamento das úlceras venosas, faz-se necessário investigar a produção científica com finalidade de responder ao seguinte questionamento: qual o perfil da pesquisa de terapia compressiva para o tratamento de úlceras venosas que descreva terapia compressiva e úlcera 287 terapias compressivas no tratamento de úlcera venosa: estudo bibliométrico l júlia teixeira nicolosi e outros venosa classificando de acordo com: cronologia de publicação, procedência, periódicos em que estão publicadas, avaliação do “qualis”, proposta pela coordenação de aperfeiçoamento de pessoal de nível superior (capes), distribuição da abordagem metodológica, análise do conteúdo das publicações e comparar, quando possível, os dados apresentados nessa revisão. método trata-se de pesquisa bibliométrica realizada nas bases de dados medline, lilacs e cinahl (cumulative index to nursing and allied health literature) em que se utilizaram os descritores “varicose ulcer/therapy”, “compression bandages”, “wound healing” e o “operador and” foram considerados artigos com até cinco anos de publicação em língua inglesa e portuguesa; foram excluídos os artigos que não apresentavam resumo e que não estavam publicados nas línguas referidas anteriormente. após leitura, foi realizada a categorização da produção científica na qual se utilizou o programa microsoft excel. os dados foram distribuídos entre os seguintes itens: ano de publicação, país de origem do estudo, periódico, qualis do periódico publicado, metodologia do estudo realizada e tipo de tratamento compressivo utilizado. no brasil, a maior parte de produção científica é gerada por pesquisadores ligados aos programas de pós-graduação (ppg), que, por sua vez, são subordinados à capes, do ministério da educação. a capes criou o qualis com a finalidade de aferir a qualidade dos artigos e de outros tipos de produção, a partir da análise da qualidade periódicos científicos e, assim, medir a produção científica dos programas de pós-graduação dentro de 46 áreas. portanto, a avaliação qualis contribui e interfere nas notas atribuídas aos ppgs no país (conceito mínimo de 3 e máximo de 7) e pretende avaliar a qualidade de produção intelectual de cada área (14). o qualis periódico foi dividido em oito estratos: a1 (o mais elevado), a2, b1, b2, b3, b4, c (peso zero) (14). dentre os trabalhos que adotaram ensaio clínico e metanálise como método, foi realizada a categorização dos artigos com a finalidade de comparar os resultados obtidos. resultados inicialmente foram encontrados na base de dados medline 85 artigos. destes, foram descartados os que não se adequavam aos critérios de inclusão, sendo então selecionados nessa base de dados 47 artigos. na base de dados lilacs, nenhum artigo foi encontrado; enquanto na bases de dados cinahl, foram encontrados três artigos, sendo dois deles com mais de cinco anos de publicação e o outro também encontrado na base de dados medline. portanto, foram selecionados neste estudo 47 artigos que se encontravam de acordo com os critérios de inclusão. no período de 2009 a 2013, houve homogenia na quantidade de publicações sobre o tema, com destaque para o ano de 2012 com o maior número de publicações (12 publicações), cuja distribuição é: 2009 (n= 9; 19,1%), 2010 (n= 9; 19,1%), 2011 (n= 8; 17,02%), 2012 (n= 12; 25,53%) e 2013 (n= 9; 19,14%) (figura 1). figura 1. distribuição da produção científica da base de dados medline na qual se utilizaram os descritores “varicose ulcer/therapy”, “compression bandages”, “wound healing” entre 2009-2013, de acordo com o ano de publicação, em que se identifica maior percentual de estudos no ano de 2012 quando analisada a origem mundial das publicações, há importante centralização de publicações nos estados unidos (n= 14; 29,78%) e reino unido (n= 14; 29,78%), conforme indicado na figura 2. 288 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 figura 2. distribuição da produção científica da base de dados medline na qual se utilizaram os descritores “varicose ulcer/therapy”, “compression bandages”, “wound healing” entre 2009-2013, de acordo com a origem, em que se identifica maior percentual de estudos nos estados unidos e reino unido figura 3. distribuição da porcentagem da produção científica da base de dados medline na qual se utilizaram os descritores “varicose ulcer/therapy”, “compression bandages”, “wound healing” entre 2009-2013, segundo o periódico publicado, em que se identifica maior percentual no journal vascular surgery e no journal of wound care 289 terapias compressivas no tratamento de úlcera venosa: estudo bibliométrico l júlia teixeira nicolosi e outros dentre os periódicos que mais publicaram o tema abordado, destacam-se o journal vascular surgery (n= 8; 17,02%), seguido do journal of wound care (n= 6; 12,76%), the british journal of nursing (n= 4; 8,51%) e o annals of vascular surgery (n= 4; 8,51%), com predomínio (n= 19; 40,42%) de publicações em periódicos da especialidade de cirurgia ou clínica vascular. dentre os periódicos que publicaram artigos referentes ao tema estudado, podemos avaliar a sua distribuição segundo a classificação qualis demonstrada na figura 4, além de constatar que a maioria dos artigos foram publicados em periódicos classificados pela capes de a2 (n= 13; 27,65%) e b1 (n=13; 27,65%). figura 4. distribuição da porcentagem da produção científica da base de dados medline na qual se utilizaram os descritores “varicose ulcer/therapy”, “compression bandages”, “wound healing” entre 2009-2013, segundo a classificação qualis, em que se identifica maior percentual de artigos publicados em periódicos a2 e b1 figura 5. distribuição do percentual do tipo de metodologia utilizada nas produções científicas da base de dados medline na qual se utilizaram os descritores “varicose ulcer/therapy”, “compression bandages”, “wound healing”, publicadas entre 2009-2013, em que se identifica maior percentual de estudos clínicos a distribuição da abordagem metodológica realizada para as publicações pode ser observada na figura 5, com destaque para as pesquisas de estudos clínicos (n= 30; 63,82%). dentre os estudos clínicos e metanálises, foram avaliados os trabalhos quanto à utilização da terapia compressiva (n=47), sendo classificado como sim, quando no objetivo do estudo estava a avaliação da terapia compressiva (n= 14; 30%) e não, quando o objetivo principal não era a análise dos efeitos de tal terapia (n= 19; 40,42%) (figura 6). figura 6. distribuição do percentual da utilização da terapia compressiva como objetivo principal do estudo nos estudos clínicos e metanálises da base de dados medline na qual se utilizaram os descritores “varicose ulcer/therapy”, “compression bandages”, “wound healing”, publicadas entre 2009-2013, em que se identifica maior percentual de estudos cujo objetivo principal não era analisar a terapia compressiva análise do conteúdo das publicações dentre os 15 periódicos que estudaram a terapia compressiva, 12 são estudos clínicos (tabela 1) e três são metanálise (tabela 2). 290 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 tabela 1. estudos clínicos que objetivavam avaliar a terapia compressiva para tratamento de úlcera venosa na qual se utilizaram os descritores “varicose ulcer/therapy”, “compression bandages”, “wound healing” disponíveis na base de dados medline entre 2009-2013 título produto utilizado/ n. de pacientes tempo de estudo resultado 1. is it time to re-appraise the role of compression in non-healing venous leg ulcers? (15) 257 sem terapia compressiva e 257 com terapia compressiva (meias elásticas, bandagem elástica curta, multicamada). 6 meses a taxa de cicatrização foi maior no grupo sem terapia compressiva (68% versus 47%). 2. evaluating the effectiveness of the customized unna boot when treating patients with venous ulcers (16) 32 utilizando bota de unna e 11 com curativo com colagenase e gaze. 2 meses a bota de unna acelera a cicatrização, porém após três meses o curativo com colagenase e gaze também parece ser efetivo. 3. randomized clinical trial of three-layer tubular bandaging system for venous leg ulcers (17) 23 pacientes com atadura compressiva de três camadas e 22 com atadura compressiva inelástica. 3 meses não houve diferença entre os dois grupos. 4. randomized controlled trial comparing treatment outcome of two compression bandaging systems and standard care without compression in patients with venous leg ulcers (18) 90 pacientes com bandagem compressiva de quatro camadas, 95 com bandagem compressiva inelástica e 91 sem tratamento compressivo. 6 meses maior redução da lesão e da dor no grupo com compressão do que no grupo sem. grupo com bandagem inelástica apresentou mais rápida cicatrização que o de quatro camadas. 5. the impact of providing product funding for compression bandaging and medical footwear on compression use, wound healing and quality of life (19) 54 pacientes que recebiam ajuda financeira e utilizaram bandagem de quatro camadas e 62 pacientes sem ajuda utilizaram vários tipos de terapêutica compressiva. 3 meses não houve diferença significativa a respeito da taxa e do tempo de cicatrização do grupo com e sem ajuda financeira. 6. efficacy of a two-component compression system for the therapy of venous leg ulcers (20) 136 pacientes todos com bandagem de compressão de duas camadas. 12 meses redução da lesão 2,9 +/5,5 cm por mês; 90,4% cicatrizaram em 12 meses. 7. the influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy (21) meias elásticas de alta compressão (grupo a= 42), ataduras compressivas multicamadas com uma camada de bandagem elástica (grupo b= 46) e ataduras compressivas elásticas multicamadas com duas camadas elásticas (grupo c= 43). 26 semanas maior cicatrização no grupo c (74% versus 67% grupo b e 25% grupo a). chance de cicatrização é menor nos grupos a e b. 8. randomised clinical trial of foam sclerotherapy for patients with a venous leg ulcer (22) 18 pacientes para escleroterapia + bandagem elástica de quatro camadas e 22 com bandagem de quatro camadas. 24 semanas escleroterapia associada à bandagem elástica de quatro camadas pode acelerar a cicatrização. 9. comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers (23) 28 utilizaram meia elástica e 27 com bandagem de três camadas. 6 meses sem diferença de tempo cicatrização entre as duas formas de compressão. 10. guideline concordant venous ulcer care predicts healing in a tertiary care veterans affairs medical center (24) 155 utilizaram bandagem de multicamadas comparados com a população geral portadora de úlcera venosa. 5 anos média de cicatrização mais rápida que a população geral (18,1 versus 36 semanas). 11. inflammatory cytokine levels in chronic venous insufficiency ulcer tissue before and after compression therapy (25) 30 pernas tratadas com bandagem de quatro camadas e três camadas. 4 semanas o uso da terapia compressiva promove decréscimo da maioria das citocinas pró-inflamatórias e aumento das proteínas antiinflamatórias. 291 terapias compressivas no tratamento de úlcera venosa: estudo bibliométrico l júlia teixeira nicolosi e outros tabela 2. metanálises que objetivavam avaliar a terapia compressiva para tratamento de úlcera venosa na qual se utilizaram os descritores “varicose ulcer/therapy”, “compression bandages”, “wound healing” disponíveis na base de dados medline entre 2009-2013 título objetivo do estudo n. de estudos analisados resultado 1. compression for venous leg ulcers (26) revisão de ensaios clínicos controlados randomizados que avalia a cicatrização com bandagem compressiva e meia elástica. 48 estudos, 59 comparações e 4.321 participantes no total. compressão ajuda na cicatrização se comparada sem compressão. multicomponentes são mais efetivos que monocomponente. bandagens elásticas são mais efetivas que as inelásticas. bandagens de duas camadas são mais efetivas que as de quatro camadas. bandagens de quatro camadas são mais efetivas que as inelásticas. meias de alta compressão são melhores que as inelásticas. 2. intermittent pneumatic compression for treating venous leg ulcers (27) determinar se a pressão pneumática intermitente auxilia na cicatrização de úlceras venosas e na qualidade de vida relatada de pacientes com úlcera venosa. 7 ensaios clínicos randomizados controlados, 367 pacientes. a pressão pneumática intermitente pode aumentar a cicatrização se comparada à nenhuma compressão. não é claro o quanto colabora para o tratamento complementar as bandagens ou se pode ser utilizada como único tratamento. 3. in search of optimal compression therapy for venous leg ulcers: a meta-analysis of studies comparing diverse [corrected] bandages with specifically designed stockings (28) comparar sistemas de compressão por meias e bandagens. 8 ensaios clínicos randomizados controlados, 692 pacientes. proporção da cicatrização foi maior com meia elástica que bandagens (62,7% versus 46,6%) e tempo médio de cicatrização foi de três semanas a menos com meia elástica. variação de pressão (31-35 mmhg = meia elástica e 27-49 mmhg bandagens). nenhum estudo demonstrou a bandagem ser melhor do que meia elástica. melhora da dor com uso das meias elásticas. discussão o ano de 2012 se destacou pelo maior número de publicações (25,53%); de modo geral, esses trabalhos envolveram a comparação entre meias e diferentes tipos de bandagens compressivas (17,18,26), o tratamento combinado da terapêutica compressiva com ablação endovenosa em pacientes com quadro grave (29), tratamento sistêmico com a ingestão de ácido acetil salicílico (30) e tratamentos tópicos com a utilização de dois curativos distintos (31,32). em suma, não identificamos um evento especial ou inovador relacionado com a terapia compressiva que merecesse destaque ou que justificasse o maior número de publicações nesse ano; portanto consideramos o maior número de publicações no ano de 2012 um acontecimento casual. apesar de a úlcera venosa ter incidência mundial de 1% e repercutir negativamente no cotidiano dos pacientes, não houve homogenia distribuição mundial das publicações sobre o tema o que demonstra a necessidade de mais esforços para o estudo do tratamento dessa ferida. a concentração de artigos sobre compressão e úlcera venosa proveniente dos estados unidos e reino unido reflete os dados divulgados por paraje et al. (33), que demonstraram a desigual distribuição das publicações na área de saúde a qual concentra 90% das publicações em apenas 20 países, sendo os estados unidos o responsável por mais de um terço das publicações mundiais. esses autores justificam tal desigualdade pela existência de políticas governamentais de apoio à pesquisa nesses países. outro fator relevante foi o maior número de publicações em periódicos destinados à especialidade de cirurgia ou clínica vascular, o que já era esperado tendo em vista que tanto a fisiopatologia da úlcera venosa quanto parte dos mecanismos necessários para sua cicatrização estão intimamente associados a essa espe292 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 cialidade médica; porém, existem publicações desenvolvidas em áreas como de cirurgia plástica, dermatologia e enfermagem que reforçam o interesse multidisciplinar sobre o tema. dentre esses periódicos, a maioria possui classificação qualis a2 e b1, o que evidencia a busca pela qualidade da produção intelectual sobre o tema. tal qualidade pode ser confirmada pois a maioria dos estudos selecionados são estudos clínicos inéditos e metanálise (70,21%), o que demonstra maiores graus de evidência clínica (34). entretanto, apesar de haver maior percentual de estudos clínicos, nem todos os trabalhos encontrados focaram a terapia compressiva como alvo principal; em parte deles, essa foi usada simplesmente como controle dos ensaios ou como agente adjuvante a fim de que outras avaliações, relacionadas ou não com a eficácia da terapia compressiva, fossem feitas. ainda assim, esses trabalhos oferecem informações importantes sobre o processo de cicatrização das úlceras venosas e seus prognósticos, e abrem caminho para novas possibilidades terapêuticas tópicas que incluem: pomada de óxido de prata (35), aplicação de oxigênio (two2) (36), cola de fibrina povoada com fibroblastos neonatais irradiados e queratinóciotos (37), alginato de cálcio associado à vulnamin® (glicina, lisina, leucina, ácido hialurônico e prolina) (31) e novas formulações que proporcionem uma barreira protetora às feridas (32). del rio sola et al. (30) avaliam a ingestão diária de aspirina® como fator adjuvante à terapia compressiva, referindo menor tempo de cicatrização nos portadores de úlceras que fizeram ingestão do medicamento. a identificação de fatores desfavoráveis para cicatrização de úlceras venosas foi pauta de alguns estudos; de modo geral, esses fatores são: duração da úlcera (37,38), tamanho inicial (30), presença de doença arterial (39), local (37), idade (30,37), raça (37) e presença de diferentes populações de bactérias mostraram pouca relevância para a evolução da ferida (30,40). quanto ao gênero, houve controversa entre autores; para alguns, o gênero do paciente não interfere na cicatrização (30, 37). no entanto, finlayson k et al. (41) consideraram o gênero masculino como um fator de risco estatisticamente significante para a recorrência de úlceras venosas cicatrizadas. a realização de procedimentos minimamente invasivos como ablação térmica endovenosa e escleroterapia por espuma associados à terapia compressiva, está apenas começando a ser discutida como tratamento para doenças venosas não complicadas, mas essa associação já mostrou ser eficaz na diminuição do tempo necessário para a cicatrização (42). analisando os artigos em que a terapia compressiva é o principal tratamento para úlceras venosas (30%), comprova-se que a presença de compressão é eficiente nesse tratamento (16,18,20,24,25,26). entretanto, no estudo de guest et al. (15), não foi encontrada diferença na taxa de cicatrização entre o grupo que utilizava diversas formas de compressão e o grupo sem compressão. o autor justifica o resultado contrário aos demais pois o estudo foi realizado em amostra heterogênea (o que inclui portadores de patologias arterial), teve duração de seis meses e alguns pacientes receberam antibiótico tópico e outros sistêmicos não sendo avaliada a interferência desse antibiótico na cicatrização. em referência ao tempo de utilização, luz et al. (16) compararam a compressão inelástica e ausência de compressão o que demonstrou que a compressão acelera a cicatrização até o terceiro mês de uso, não havendo diferenças no processo de cicatrização após esse período, o que confirma o benefício da compressão inelástica para a cicatrização. quando comparado os diversos tipos de compressão, houve controvérsia a respeito da eficiência das bandagens elásticas e inelásticas. no estudo de weller et al. (17), foi demonstrado não haver diferença na cicatrização dos grupos (bandagens elásticas e inelásticas); já no artigo publicado por wong et al. (18), houve melhor resultado no grupo que utilizou bandagens inelásticas em relação à multicamadas. contrariando os autores anteriormente citados, o’meara et al. (26), em metanálise, demonstram que multicomponentes são mais efetivos que apenas um componente, bandagens elásticas são mais efetivas que inelásticas, bandagens de duas camadas são mais efetivas que as de quatro camadas e bandagens de quatro camadas são mais efetivas que as inelásticas. quanto à comparação da eficiência das meias elásticas e das bandagens compressivas multicamadas (21,23), foi comprovado que houve uma melhora da cicatrização com duas camadas elásticas em relação à meia (21) e igual tempo de cicatrização entre meia elástica e bandagem elástica de três camadas (23). já na metanálise de amsler et al. (28), foi demonstrada eficiência da meia elástica a respeito do tempo e da ocorrência da cicatrização, não foi apresentado nenhum estudo que demonstrasse 293 terapias compressivas no tratamento de úlcera venosa: estudo bibliométrico l júlia teixeira nicolosi e outros que bandagem seja melhor que meia elástica; o’meara et al. (26) referiram que meias de alta compressão são melhores que as bandagens inelásticas. o único trabalho que estudou pressão pneumática intermitente foi aquele desenvolvido por nelson et al. (27), no qual se demonstrou que pressão pneumática intermitente pode aumentar a cicatrização se comparada à nenhuma compressão; porém, ainda não é conhecido o “quanto” essa forma de compressão pode colaborar no tratamento associado às bandagens ou ser utilizado como tratamento único. beidler et al. (25) foram os únicos a demonstrar interferência da compressão nas citocinas inflamatórias e, assim, colaborar para o processo de reparo tecidual; contudo, não mostraram se houve diferença entre os pacientes que utilizaram as bandagens de três camadas e de quatro camadas, o que deixa ainda essa lacuna ao nosso conhecimento científico sobre o tema. conclusão o resultado deste estudo aponta constante preocupação da comunidade científica com relação à busca do tratamento eficaz para as úlceras venosas. apesar disso, há uma carência de publicações no mundo sobre o tema. na américa latina, apesar de haver alta incidência de pacientes com úlcera venosa, foi encontrada somente duas publicações sobre o tema. quando analisados os objetivos dos estudos, evidencia-se que a terapia compressiva não é o principal objeto na maioria dos trabalhos selecionados. por outro lado, as boas qualificações (qualis) dos periódicos publicados apontam a seriedade com que o assunto vem sendo tratado na comunidade acadêmica. com relação ao tratamento da úlcera venosa, fica evidente a necessidade de terapia compressiva, porém não há consenso sobre qual pressão deve ser utilizada. mais estudos que avaliem as interferências das diversas pressões sobre o processo de reparo tecidual são necessários. também há carência de estudos que comprovem a ação da pressão pneumática intermitente com associações ou não de bandagens elásticas. o profissional de enfermagem, na maioria das vezes, é o responsável pela aplicação, manutenção e avaliação dessas terapias compressivas. com a finalidade de se obter uma melhor resposta terapêutica, questões como a ação das diversas pressões, da pressão pneumática e das bandagens elásticas no processo de reparo tecidual da úlcera venosa ainda precisam ser aprofundadas. apesar de haver publicações em revistas destinadas à enfermagem, se faz necessária a implementação de esforços desses profissionais que visem à pesquisa sobre o tema. referências 1. bergqvist d, lindholm c, nelzén o. chronic leg ulcers: the impact of venous disease. j vas surg 1999;29(4):752-5. 2. burton cs. venous ulceration. clinical materials 1991;8(3-4):203-8. 3. fowkes fg, evans cj, lee aj. prevalence and risk factors of chronic venous insufficiency. angiology 2001;52 suppl 1:s5-15. 4. o’donnell jr tf, lau j. a systematic review of randomized controlled trials of wound dressings for chronic venous ulcer. j vas surg 2006;44(5):1118-25. 5. lay-flurrie k. venous leg ulceration and graduated compression. br j nurs 2011;20(15):s4, s6-8. 6. angle n, bergan jj. chronic venous ulcer. bmj 1997;314(7086):1019-23. 7. bergan jj, schmid-schönbein gw, smith pdc, nicolaides an, boisseau mr, eklof b. chronic venous disease. n engl j med 2006;355(5):488-98. 8. eberhardt rt, raffetto jd. chronic venous insufficiency. circulation 2005;111(18):2398-409. 294 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 9. browse nl, burnand kg. the cause of venous ulceration. lancet 1982;2(8292):243-5. 10. coleridge smith pd, thomas p, scurr jh, dormandy ja. causes of venous ulceration: a new hypothesis. br med j (clin res ed) 1988;296(6638):1726-7. 11. falanga v, eaglstein wh. the “trap” hypothesis of venous ulceration. lancet 1993;341(8851):1006-8. 12. abbade lp, lastoria s. venous ulcer: epidemiology, physiopathology, diagnosis and treatment. int j dermatol 2005;44(6):449-56. 13. world union of wound healing societies (wuwhs). principles of best practices: compression in venous leg ulcers. a concensus document. londres: mep ltd; 2008. 14. coordenação de aperfeiçoamento de pessoal de nível superior (capes). qualis periódico [on-line]. brasília, brasil; 2006. [consultado 21 fev. 2014] disponível em: http://www.capes.gov.br/avaliacao/qualis 15. guest jf, charles h, cutting kf. is it time to re-appraise the role of compression in non-healing venous leg ulcers? j wound care 2013;22(9):453-60. 16. luz bs, araujo cs, atzingen da, mendonca ar, mesquita filho m, medeiros ml. evaluating the effectiveness of the customized unna boot when treating patients with venous ulcers. an bras dermatol 2013;88(1):41-9. 17. weller cd, evans sm, staples mp, aldons p, mcneil jj. randomized clinical trial of three-layer tubular bandaging system for venous leg ulcers. wound repair regen 2012;20(6):822-9. 18. wong ik, andriessen a, lee dt, et al. randomized controlled trial comparing treatment outcome of two compression bandaging systems and standard care without compression in patients with venous leg ulcers. j vasc surg 2012;55(5):1376-85. 19. kapp s, miller c, elder k. the impact of providing product funding for compression bandaging and medical footwear on compression use, wound healing and quality of life. int wound j 2012;9(5):494-504. 20. escaleira r, cardoso m, rego j, macedo p, midoes a. efficacy of a two-component compression system for the therapy of venous leg ulcers. j wound care 2010;19(3):104-9. 21. milic dj, zivic ss, bogdanovic dc, et al. the influence of different sub-bandage pressure values on venous leg ulcers healing when treated with compression therapy. j vasc surg 2010;51(3):655-61. 22. o’hare jl, earnshaw jj. randomised clinical trial of foam sclerotherapy for patients with a venous leg ulcer. eur j vasc endovasc surg 2010;39(4):495-9. 23. brizzio e, amsler f, lun b, blattler w. comparison of low-strength compression stockings with bandages for the treatment of recalcitrant venous ulcers. j vasc surg 2010;51(2):410-6. 24. olson jm, raugi gj, nguyen vq, yu o, reiber ge. guideline concordant venous ulcer care predicts healing in a tertiary care veterans affairs medical center. wound repair regen 2009;17(5):666-70. 25. beidler sk, douillet cd, berndt df, keagy ba, rich pb, marston wa. inflammatory cytokine levels in chronic venous insufficiency ulcer tissue before and after compression therapy. j vasc surg 2009;49(4):1013-20. 26. o’meara s, cullum n, nelson ea, dumville jc. compression for venous leg ulcers. cochrane database syst rev 2012;11:cd000265. 27. nelson ea, mani r, thomas k, vowden k. intermittent pneumatic compression for treating venous leg ulcers. cochrane database syst rev 2011(2):cd001899. 28. amsler f, willenberg t, blattler w. in search of optimal compression therapy for venous leg ulcers: a meta-analysis of studies comparing diverse [corrected] bandages with specifically designed stockings. j vasc surg 2009;50(3):668-74. 29. harlander-locke m, lawrence p, jimenez jc, rigberg d, derubertis b, gelabert h. combined treatment with compression therapy and ablation of incompetent superficial and perforating veins reduces ulcer recurrence in patients with ceap 5 venous disease. j vasc surg 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et al. silver oxide ointment wound dressing in venous ulcerations: home, selfmanagement. panminerva med 2011;53(3 suppl 1):29-33. 36. tawfick wa, sultan s. technical and clinical outcome of topical wound oxygen in comparison to conventional compression dressings in the management of refractory nonhealing venous ulcers. vasc endovascular surg 2013;47(1):30-7. 37. lantis jc, 2nd, marston wa, farber a, et al. the influence of patient and wound variables on healing of venous leg ulcers in a randomized controlled trial of growth-arrested allogeneic keratinocytes and fibroblasts. j vasc surg 2013;58(2):433-9. 38. hjerppe a, saarinen jp, venermo ma, huhtala hs, vaalasti a. prolonged healing of venous leg ulcers: the role of venous reflux, ulcer characteristics and mobility. j wound care 2010;19(11):474, 476, 478 passim. 39. neequaye sk, douglas ad, hofman d, et al. the difficult venous ulcer: case series of 177 ulcers referred for vascular surgical opinion following failure of conservative management. angiology 2009;60(4):492-5. 40. moore k, hall v, paull a, et al. surface bacteriology of venous leg ulcers and healing outcome. j clin pathol 2010;63(9):830-4. 41. finlayson k, edwards h, courtney m. relationships between preventive activities, psychosocial factors and recurrence of venous leg ulcers: a prospective study. j adv nurs 2011;67(10):2180-90. 42. alden pb, lips em, zimmerman kp, et al. chronic venous ulcer: minimally invasive treatment of superficial axial and perforator vein reflux speeds healing and reduces recurrence. ann vasc surg 2013;27(1):75-83. 122 133 recuperacion adiccion al alcohol.indd 122 aquichan issn 1657-5997 año 12 vol. 12 nº 2 chía, colombia agosto 2012 l 122-133 luz patricia díaz-heredia1 alba idaly muñoz-sánchez2 maría mercedes durán-de villalobos3 recuperación de la adicción al alcohol: una transformación para promover la salud4 1 candidata a doctor en enfermería. universidad nacional de colombia, colombia. lpdiazh@unal.edu.co 2 doctor en enfermería. universidad nacional de colombia, colombia. aimunozs@unal.edu.co 3 doctor en enfermería. universidad nacional de colombia, colombia. mmvillalobos@gmail.com 4 producto de la asignatura seminario de investigación iv del programa de doctorado en enfermería de la universidad nacional de colombia. recibido: 27 de enero de 2012 aceptado: 17 de abril de 2012 resumen se presenta una metasíntesis cuyo objetivo es establecer las características del proceso de recuperación en las personas que tienen adicción al alcohol. la metodología metasintética se fundamenta en la integración e interpretación de los hallazgos de algunos estudios cualitativos que permiten reconocer elementos sustanciales en la creación de nuevas interpretaciones en el fenómeno de recuperación de la adicción al alcohol. para ubicar las fuentes se realizó una búsqueda en las bases de datos ovid, medline, cinalh, psych info, lilacs y scielo, que comprendió el periodo 1988 a 2008, y en el que se ubicaron once artículos mediante las palabras clave: abuso de alcohol, adicción, dependencia, recuperación, experiencia e investigación cualitativa; de estos únicamente seis cumplieron con los criterios de calidad para ser incluidos en la metasíntesis. los hallazgos permiten señalar que la recuperación es concebida como una trasformación con movimiento ascendente, conceptualización que implica reconocer la potencialidad de los aspectos positivos de las personas, alcanzar la madurez psicológica y espiritual, y lograr la paz y la libertad para actuar. en conclusión, este proceso de transformación inmerso en la recuperación debe ser reconocido por el profesional de enfermería para establecer, entre ese otro y ella, una fructífera interacción que permita el desarrollo del cuidado. palabras clave alcoholismo, delirium por abstinencia alcohólica, salud. (fuente: decs, bireme). recovering from alcohol addiction: a transformation to promote health abstract a meta-synthesis is presented to determine the features of the recovery process in persons who are addicted to alcohol. the metasynthesis method is founded on the integration and interpretation of findings from certain qualitative studies that shed light on substantial elements in the creation of new interpretations of the phenomenon of recovery from alcoholism. a search of the ovid, medline, cinalh, 123 recuperación de la adicción al alcohol... l luz patricia díaz-heredia, alba idaly muñoz-sánchez, maría mercedes durán-de villalobos psychinfo, lilacs and scielo databases, covering the period from 1988 to 2008, was conducted to locate these sources and eleven (11) articles were found using the key words: alcohol abuse, addiction, dependency, recovery, experience and qualitative research. only six of these words met the quality criteria to be included in the meta-synthesis. the findings indicate recovery is perceived as a transformation with an upward movement, a notion that implies recognizing the potential of a person’s positive aspects, achieving psychological and spiritual maturity, and acquiring the peace and freedom to act. in conclusion, nursing professionals must recognize this process of transformation immersed in the recovery process, so as to establish fruitful interaction between themselves and the other person that allows care to develop. key words alcoholism, alcohol withdrawal delirium, health. (source: decs, bireme). recuperação do vício no álcool: uma transformação para promover a saúde resumo este artigo apresenta metassíntese, cujo objetivo é estabelecer as características do processo de recuperação nas pessoas que são viciadas no álcool. a metodologia metassintética se fundamenta na integração e interpretação dos descobrimentos de alguns estudos qualitativos que permitem reconhecer elementos substanciais na criação de novas interpretações no fenômeno de recuperação do vício no álcool. para localizar as fontes, realizou-se uma busca nas bases de dados ovid, medline, cinalh, psych info, lilacs e scielo, que compreendeu o período de 1988 a 2008, na qual se localizaram onze artigos a partir das palavras-chave: abuso de álcool, vício, dependência, recuperação, experiência e pesquisa qualitativa; destes onze, unicamente seis cumpriam os critérios de qualidade para serem incluídos na metassíntese. os descobrimentos indicam que a recuperação é concebida como uma transformação com movimento ascendente, conceptualização que implica reconhecer a potencialidade dos aspectos positivos das pessoas, atingir a maturidade psicológica e espiritual, bem como a paz e a liberdade para agir. em conclusão, esse processo de transformação imerso na recuperação deve ser reconhecido pelo profissional de enfermagem para estabelecer, entre este outro e ela, uma frutífera interação que permita o desenvolvimento do cuidado. palavras-chave alcoolismo, delirium por abstinência de álcool, saúde. (fonte: decs, bireme). 124 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 introducción la problemática de la adicción al alcohol en el mundo, sus impactos negativos y los aspectos relacionados con su tratamiento y rehabilitación, en especial en los últimos veinte años, han motivado a los investigadores a desarrollar propuestas de indagación desde perspectivas tanto cuantitativas como cualitativas. la ciencia de enfermería proclama porque una sola visión no permite comprender en su totalidad la realidad que constituye el recuperarse. las investigaciones que se fundamentan en el paradigma interpretativo en relación con el fenómeno en el que se centra este estudio son numerosas en la disciplina, y están motivadas por el interés de conocer los aspectos que se desarrollan al interior del ser humano que vive la experiencia de recuperarse cuando se tiene una adicción al alcohol. para generar evidencia científica sólida en cuanto al proceso que vivencia la persona cuando se recupera de la adicción al alcohol, es necesario el adelanto de estrategias y metodologías que permitan desarrollar la síntesis de los resultados de las investigaciones realizadas desde la perspectiva del paradigma interpretativo, esta es la tendencia actual en las ciencias de la salud (1), y con ello se busca el análisis y la crítica del conocimiento producido a fin de guiar la práctica, decantar los asuntos esenciales, y señalar acciones claras y sustentadas. una de las metodologías utilizadas es la metasíntesis, que tiene sus orígenes en la metaetnografía y en el paradigma interpretativo; esta metodología cuenta con procedimientos y lineamientos propios para su implementación (2). la metasíntesis ha permitido proveer una alternativa a los métodos agresivos de síntesis y un acercamiento a la inducción e interpretación; de igual manera, admite desarrollar el traslado de los resultados de un estudio a otro motivando a los investigadores a entender y transferir ideas, conceptos y metáforas entre los estudios, a crear una nueva forma de ver fenómenos que han sido estudiados desde esta perspectiva paradigmática, dado que se centra en lo interpretativo como eje central y su objetivo es hallar nuevos razonamientos a los resultados de otros estudios cualitativos. las investigaciones cualitativas desarrolladas por enfermería y otras disciplinas durante los últimos veinte años en relación con el fenómeno de recuperación a la adicción al alcohol han producido un variado espectro de resultados que vale la pena consolidar y reinterpretar a través de la metasíntesis. la temática es de actualidad debido a que la adicción al alcohol es una de las condiciones que mayor porcentaje de muertes produce en el mundo, según la organización mundial de la salud (oms), en el año 2011 existían a nivel mundial dos y medio millones de muertes en personas que consumían de manera adictiva el alcohol. globalmente, 6,2% de las muertes en hombres son atribuidas al consumo abusivo de alcohol y 1,1% en las mujeres (3). para la región de las américas, el consumo de alcohol causó en el año 2002, 1,8 millones de muertes (3,2%) del total de decesos, y 58,3 millones (4%) del total de años de vida saludables perdidos (avisa) (4). la ingesta abusiva de alcohol es la primera causa de morbilidad en los países en desarrollo, y la tercera en los países desarrollados (5). específicamente en colombia, es importante resaltar que las tasas de consumo según estudios desarrollados en los últimos diez años señalan que la ingesta de alcohol alguna vez en la vida se ha mantenido cercana al 90%, aunque ha tendido a un descenso leve en los últimos años, este valor se incrementa en la población universitaria. para la ciudad de bogotá en el año 2009, en un estudio desarrollado con una muestra amplia (6617 personas), la prevalencia de vida fue de 88%, los que consumieron en el último mes fueron 36%, en tanto que los que presentaron consumo riesgoso y de dependencia representaron el 11% (6). el consumo de alcohol está relacionado con más de 60 condiciones negativas y lesivas, que van desde las que son el resultado de un consumo excesivo durante el embarazo y que afecta al feto (7), a lesiones intencionales y no intencionales como caídas y accidentes de tránsito, y la asociación epidemiológica con el cáncer en diversos órganos. las intervenciones de tratamiento llevadas a cabo por los diferentes profesionales del área de la salud y de las ciencias sociales con personas que tienen problemas de adicción (8) hasta hace poco tiempo se han orientado a la desintoxicación, el planteamiento de estrategias para alcanzar la abstinencia o el consumo moderado y evitar las recaídas, pero la recuperación desde la perspectiva que se evidencia en este documento no ha sido incluida de manera frecuente en los objetivos de los diferentes tratamientos. la recuperación de las situaciones de afección mental, dentro de las que se incluye la adicción al alcohol, es comúnmente referida como un proceso en el cual la persona se encuentra con la vida mediante un afrontamiento positivo como una experiencia de restauración del sentido de sí mismo y del propósito vital (9). la idea de recuperación necesita de la participación del usuario 125 recuperación de la adicción al alcohol... l luz patricia díaz-heredia, alba idaly muñoz-sánchez, maría mercedes durán-de villalobos o paciente en el sentido que debe despertar y renovarse con esperanza para encontrar lo mejor de sí mismo, a fin de dejar de consumir de manera adictiva el alcohol. las orientaciones actuales que buscan el desarrollo de la salud mental y se encuentran fundamentadas en la recuperación están ganando terreno, es así como en el año 2005, los servicios de salud mental en los estados unidos se centraron en el cambio hacia un modelo basado en la familia y el consumidor dando prioridad a la recuperación, esta orientación lleva a cambiar la percepción tanto de los profesionales como de las personas en general respecto a que los problemas mentales son incurables. el modelo de la recuperación se constituye en un nuevo paradigma, un punto de partida, una filosofía que se origina en los requerimientos de los pacientes, la investigación empírica y la historia, y está centrado en la esperanza, el autocontrol y la oportunidad. los aspectos esenciales descritos para lograrla están fundamentados en buscar la autodirección centrada en el paciente que permite el empoderamiento, es holística, no es un proceso lineal, está basada en las fortalezas de la persona, se apoya en el soporte de pares, busca el respeto y aboga por los derechos del paciente promoviendo la responsabilidad y la esperanza (9, 10, 11). método la metodología de la metasíntesis se fundamenta en la metaetnografía (12), esta permite las interpretaciones sustantivas y da la posibilidad de analizar los textos (13) y crear nuevas interpretaciones en el proceso (12, 13, 14, 15). los seis pasos presentados por noblit y hare (1988) para desarrollar una metasíntesis son: 1) determinar la necesidad de la metasíntesis; 2) buscar las investigaciones cualitativas en bases de datos y en la literatura en general que tengan su eje central en el tema de estudio; 3) realizar una lectura continua y a profundidad de estas para determinar las metáforas, los temas y las categorías centrales de la investigación; 4) hacer comparaciones de manera recíproca o por refutación para establecer cómo se relacionan los estudios; 5) trasladar los resultados de un estudio a otro; 6) establecer las nuevas interpretaciones que constituyen la estructura básica de la metasíntesis; 7) presentar la metasíntesis (tabla 1). a continuación se presentan las fases a partir de lo propuesto por noblit y hare (16). la primera fase de este trabajo hizo posible establecer como prioridad para el desarrollo de la metasíntesis la temática de la recuperación a la adicción al alcohol por considerar que la aclaración de las características del proceso permitiría el establecimiento de las estrategias de cuidado de enfermería para alcanzarla, además porque no existe en la literatura reciente un estudio similar. tabla 1. método de metasíntesis de noblit y hare (1988) fase 1. inicio del proceso. se establece el área de interés y la necesidad de la metasíntesis. fase 2. decidir lo que es relevante. se desarrolla una búsqueda en la literatura con unos criterios claros. fase 3. leer los artículos. se realiza lectura y relectura de los artículos, con el fin de encontrar las metáforas interpretativas en cada uno. fase 4. determinar la relación de los estudios. los estudios son puestos de manera conjunta para buscar las relaciones entre ellos, mediante la comparación recíproca y la comparación por refutación. fase 5. trasladar los estudios uno dentro de otro. las metáforas y los temas son comparados en tanto que se conservan las metáforas centrales intactas. fase 6. sintetizar las traslaciones. en esta fase el investigador sintetiza las partes para crear el todo. fase 7. expresar la síntesis. se realiza la escritura de la síntesis. método de noblit y hare fuente: tomado de coffman (14). para dar continuidad a la metasíntesis se procedió a realizar una búsqueda exhaustiva en las bases de datos ovid, medline, cinalh, psych info, lilacs y scielo, en las que se ubicaron once artículos que incluían el periodo 1984 y 2009, con las palabras clave abuso de alcohol, adicción, recuperación, experiencia e investigación cualitativa. es importante señalar que en la literatura de habla hispana no fue posible ubicar estudios que se refirieran al proceso de recuperación de la adicción al alcohol. de los once artículos ubicados solo seis entraron en la metasíntesis (tabla 2) porque al realizar la revisión de estos a partir de los criterios ofrecidos por tong y salsbury (17) que incluyen, entre otros, la presentación de la experiencia y características del grupo investigador, el objetivo y la ubicación geográfica del estudio, la claridad en el diseño del estudio y el tipo de muestra del mismo, solo seis los cumplieron. 126 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 tabla 2. criterios de calidad de los estudios incluidos en la metasíntesis autor /año objetivo ubicación geográfica diseño y metodología muestra banonis 1988 desarrollar una estados unidos fenomenológico 3 mujeres descripción estructural de la experiencia de recuperarse. wing 1991 formular un modelo estados unidos etnografía y teoría 43 hombres y mujeres teórico de la progresión fundamentada natural de la recuperación en los datos de los alcohólicos. wing 1995 describir el proceso estados unidos teoría fundamentada 30 hombres y mujeres interno de la experiencia en los datos de trascender la negación durante la recuperación. bowden 1998 descubrir los aspectos estados unidos fenomenología 8 hombres y mujeres internos del cambio en las personas que viven sin consumir alcohol. wrigth 2003 explorar los elementos estados unidos fenomenología 15 mujeres esenciales de la experiencia espiritual en mujeres en recuperación de adicción. masters 2006 examinar la experiencia estados unidos teoría fundamentada 12 mujeres del proceso de adicción en los datos y recuperación de mujeres con adicción al alcohol. los artículos incluidos fueron elaborados por enfermeras, y aunque en los estudios iniciales se habían encontrado otras disciplinas, no fue posible incluirlos porque carecían de información relevante como la especificación del diseño, el tipo de muestreo, el proceso de análisis desarrollado. el total de pacientes involucrados en los seis estudios fue de 133. las metodologías desarrolladas incluyeron fenomenología (n:2), etnografía y fenomenología (n:1), teoría fundamentada en los datos (n:2), investigación descriptiva cualitativa (n:1) (tabla 2) la tercera fase se basa en la lectura de los documentos buscando identificar las metáforas interpretativas, los temas y las categorías centrales encontradas en los estudios (tabla 3). 127 recuperación de la adicción al alcohol... l luz patricia díaz-heredia, alba idaly muñoz-sánchez, maría mercedes durán-de villalobos tabla 3. metáforas interpretativas, temas, categorías y conceptos centrales de los estudios incluidos en la metasíntesis estudio banonis 1988 wing 1991 wing 1995 bowden 1998 wright 2003 masters et al. 2006 metáforas interpretativas la recuperación es experimentada como una forma de vivir en libertad. el alcoholismo es una enfermedad de negación. la recuperación es como un viaje mitológico. el alcoholismo es como una tierra de sombras. la recuperación es como una batalla de demonios internos de deseo y antojo. la ausencia de espiritualidad fue experimentada como abandono. la espiritualidad en la recuperación fue experimentada como reconexión. la recuperación es un “proceso de reconexión”. temas categorías elección de vida. llegar a ser. negación. dependencia. cambio de comportamiento. planeación de la vida. reacción a los eventos críticos. rol de desafiliación. anticipación ambigua. afiliación de pares. aceptación. viviendo en las sombras. partida. iniciación. regreso. reconexión con dios y con los otros. la espiritualidad fue experimentada como una trasformación. la espiritualidad, un experimento de maduración y logro de una nueva vida. estado de balance y conexión. hacerse adicto y tener conexiones poco saludables. desconexión del alcohol y de las drogas. recuperación, el proceso de reconectarse. conceptos trascender la negación. negación. motivación punitiva. amor propio. trascender la negación. tierra de sombras. el mundo de la recuperación. espiritualidad. maduración. sin conexión. reconectada. 128 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 las fases cuatro y cinco implicaron la comparación recíproca y por refutación de los hallazgos de los estudios y el establecimiento de las relaciones entre las categorías, los temas y conceptos derivados a fin de completar una nueva visión del fenómeno, es decir, una reinterpretación nueva de los hallazgos de los estudios cualitativos incluidos en la metasíntesis. las fases seis y siete evidenciaron la construcción de las cinco categorías, así: proceso de cambio y trasformación, movimiento ascendente, conexión consigo mismo y con los demás, madurez espiritual y psicológica, y alcanzar paz y libertad. la nueva síntesis se presenta en la tabla 4. tabla 4. reinterpretación derivada de la comparación de los conceptos, temas y categorías de los estudios incluidos en la metasíntesis conceptos, temas y categorías presentes en los diferentes estudios respecto a la recuperación reinterpretación banonis 1988 un proceso de cambio que conduce a la libertad, la libre elección y el crecimiento. se logra la iluminación de una vida restringida y limitada por el alcohol. la recuperación es un proceso de convertirse, para abriese a otros. se genera un crecimiento en todos los aspectos de la vida, se da confianza en las propias habilidades. al encontrarse libre de la estimulación de alcohol, la persona abriga sentimientos de espontaneidad, honestidad. wing 1991 se involucran cambios mayores en el comportamiento. se parte de la negación del problema del alcoholismo, no se ve la realidad. se conecta con otros cuando puede hacer planes de vida que incluyen a la familia y a los otros. se es capaz de tomar decisiones maduras e independientes, a partir de lo mejor para todos los involucrados. wing 1995 el trascender la negación es un proceso que lleva a la aceptación de la identidad del alcohólico. se trasciende la negación, hasta llegar a la aceptación, con el desarrollo de la percepción de la realidad. se dan las conexiones a través de la afiliación con pares. se aceptan las responsabilidades y se desarrolla una percepción exacta de la vida. bowden 1998 es un ascenso que conlleva un crecimiento espiritual. se sale de la tierra de sombras (alcoholismo) para llegar al mundo de la sobriedad. las conexiones en la recuperación son a nivel interno e intrapersonales. la trasformación del carácter y de las vidas de los informantes permite una mente abierta. las decisiones se realizan de manera intuitiva combinadas con la razón. las estrategias asociadas a la recuperación llevan al descubrimiento de la libertad, la confianza y la paz. wright 2003 un viaje que lleva a un despertar espiritual. la ausencia de espiritualidad es considerada como la oscuridad, la recuperación ilumina la vida. la recuperación como reconexión con los otros y consigo mismo. la madurez está referida como trasformación y como integración de todo lo aprendido. la madurez espiritual como libertad, que libera de lo pasado y da posibilidades para el futuro. masters et al. 2006 la recuperación es un proceso gradual de restructuración de sus vidas, para establecer conexiones y relaciones saludables. la adicción genera conexiones con el mundo que crean sentimientos oscuros como baja autoestima, inestabilidad emocional y financiera. la recuperación es crear conexiones con la comunidad, los otros e interiormente. es aprender a vivir y enfrentar la vida sin químicos. características de la recuperación como trasformación ascendente trasformación. cambio ó renovación. eje central de la recuperación. movimiento ascendente característica o atributo del proceso de recuperación del consumo abusivo. conexión. es un requisito para que se dé la transformación. madurez espiritual y psicológica. estado al que se llega después de recuperarse. libertad y paz. fin último del proceso de recuperación. 129 recuperación de la adicción al alcohol... l luz patricia díaz-heredia, alba idaly muñoz-sánchez, maría mercedes durán-de villalobos resultados proceso de cambio y transformación la recuperación de la persona que ha tenido problemas de adicción al alcohol es descrita como un proceso de trasformación o cambio que implica la innovación, la renovación profunda de todos los ámbitos de la persona, incluso hasta llegar a sentirse otro, se involucran todos los aspectos de la vida, una de las participantes lo expresa así: “perdí peso, casi 33 kilos, me sentía bien, dormía mejor y me sentí joven de nuevo” (18). el cambio se realiza de manera intencional, aunque inicialmente no siempre es producto de la voluntad propia, puesto que la negación está presente en el comienzo de la trasformación; la recuperación se logra cuando se percibe el cambio como algo deseable y se supera la negación. “admito que inicialmente vine a tratarme porque deseaba hacer feliz a mi esposa. yo planeaba estar sobrio por un corto periodo de tiempo, y luego volver a consumir. ahora realmente deseo estar sobrio” (19). la transformación se realiza gradualmente, desde el interior del ser hacia el exterior, lo que genera cambios de sentimientos, emociones y comportamientos que implica nuevas formas para enfrentar las situaciones estresantes de la vida y los malos momentos. la transformación conduce a otras maneras de ver las propias actuaciones y las de los demás, se elimina el resentimiento, la culpabilidad y, en general, lo negativo que pueda ser fuente de frustración y motivos para el consumo de alcohol. “… mis objetivos son los de expresar mis sentimientos, ser honesto con mis sentimientos, dejar ir los resentimientos, confiar en las personas, y lo más importante no tomar” (20, 21). al generarse el cambio se retoman actividades, relaciones y situaciones que dan una nueva oportunidad a la persona que ha realizado la transformación. el cambio no se da de manera espontánea, hay que trabajar momento a momento para alcanzar la recuperación y el establecimiento de relaciones interpersonales positivas. “mi esposo y yo volvimos […] pude volver a estar con mi familia, yo eliminé todas esas cosas negativas y ahora estamos más cercanos, ellos me escuchan, son capaces de conectarse con lo que siento” (22) p.179. movimiento ascendente la recuperación se caracteriza porque lleva al individuo a través del movimiento ascendente desde la oscuridad, la soledad, el aislamiento, la culpabilidad y, en general, los aspectos negativos de sí mismo hacia la luz, la iluminación, hacia todo aquello que es considerado positivo y enriquecedor; como lo enuncia newman, el movimiento es la condición natural de la vida, es la expresión de la conciencia y permite conocer el mundo, a nosotros mismos y a los demás (21, 23). los aspectos que restringen a la persona y la hacen sentir en una tierra de sombras en la que nada es lo que parece, el alcohol y las drogas que parecen ser los salvadores no lo son; por el contrario, evitan ver la realidad, que al no percibirla en su real dimensión, toma características tenebrosas. la única forma de enfrentar la realidad es aturdiendo los sentidos y los sentimientos. la connotación de oscuridad está relatada en los estudios como dolor, pena, malestar; este asunto es muy importante para los participantes y fue referido de maneras muy alegóricas. es como el efecto de rip van winkle (cuento anglosajón en donde un hombre se duerme al lado de un árbol y se despierta veinte años después.) "tú te despiertas a la realidad del mundo” (24). “la semana pasada estaba sentado en mi apartamento y me sentía sin esperanza, indefenso. pensaba en el suicidio, no podía continuar viviendo de esa manera” (20). “había algo que faltaba pero yo no sabía qué era. era como si estuviera buscando algo. yo tuve que pasar por todos esos malos momentos para hallarlo. se me mostró la luz porque yo estaba en la sombra” (22). el movimiento ascendente puede llevarlo a otros lugares del conocimiento de sí mismo que ni siquiera sabía que existían, sus potencialidades, así como las formas eficaces de llegar a enfrentar la vida, aspecto que es muy relevante para lograr una recuperación bien cimentada. el no contar con metas en la vida, el vivir sin un norte siendo el único el consumo, hacen muy difícil trascurrir por el mundo, un participante lo refirió así: “puede que no sepas el propósito para el mañana, pero tú sabes el propósito del ayer y no quieres nunca más volver a vivir en esa forma otra vez” (22). la recuperación es sinónimo de iluminación, aclaración, orientación, por lo que en este caso está referida como un bien deseable, que se espera permita lograr los propósitos en la vida, ampliar los límites personales, liberarse de las ataduras que conlleva la adicción al alcohol. el movimiento, como señala newman, es reflejo de la conciencia (23). la conciencia referida como el ser mismo en constante movimiento y con tendencia a niveles mayo130 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 res de energía. el movimiento ascendente permite el desarrollo de la espiritualidad, la madurez, la salud y todos los aspectos positivos del ser humano. conexión consigo mismo y los demás la conexión como parte del proceso de recuperación está presente cuando la persona ha logrado el autoconocimiento de sus aspectos positivos y negativos, y puede abrirse a los demás y reconectarse. el objetivo de esta reconexión es sanar las heridas que se pudieron haber causado por la conducta adictiva, las agresiones, los malos tratos y todo lo nocivo. las conexiones se desarrollan entre pares, familiares y, en general, con toda la comunidad, la recuperación permite ver las necesidades del otro, puesto que cuando se es dependiente del alcohol ese él el centro del mundo, el consumir es su objetivo principal, por lo que la soledad es una acompañante común del alcohólico, si bien toma en algunos casos para lograr conectarse con los otros desde un punto de vista superficial, el alcohol le impide establecer relaciones profundas y saludables o mantener las relaciones existentes. uno de los participantes lo refirió así: “yo abandone a mi familia, no me sentía feliz. este periodo ha sido el más triste de mi vida, me sentía sola…” (22). “… ellos me escuchan [refiriéndose a la familia], son capaces de conectarse con lo que siento” (22). al crear conexiones se pueden establecer planes de vida hacia el futuro, las metas están relacionadas con los demás y consigo mismo, esto permite encontrar sentido en la vida. en la recuperación, la oportunidad de participar en grupos de autoayuda —como alcohólicos anónimos— y en actividades comunitarias fortalece la conexión consigo mismo y con los demás, y da un nuevo sentido a lo que se es y se hace. “yo me involucre totalmente en la comunidad de aa” (24). al lograr la conexión consigo mismo se es capaz de crear lazos con los demás, al ver al interior de sí mismo se reconocen los ajustes y los cambios que deben desarrollarse, no es un proceso fácil ni que se dé espontáneamente, debe ser elaborado de manera minuciosa y con fortaleza. madurez espiritual y psicológica el reconocimiento de las potencialidades, fortalezas y debilidades genera cambios en la manera de afrontar la vida, se adquiere madurez, sobriedad y, en general, bienestar psicosocial y espiritual. se integran los aprendizajes y se toman las decisiones con procesos mentales claros y bien sustentados en la intuición y la razón. la madurez hace que se adquieran las responsabilidades en todos los aspectos de la vida, se admite que no se necesita del alcohol para sustentarse, las percepciones son reales y se afrontan con las herramientas que se han desarrollado durante el proceso de recuperación y que han sido el fruto de haber conocido el lado oscuro de sí mismo. no hay que negar que esa parte de sí mismos exista, lo que hay que hacer es aprovechar los aprendizajes para llegar a disfrutar de la vida con sus momentos tristes y alegres, pero sin dejarse llevar por los sentimientos negativos que subyacen en el interior. uno de los participantes asimiló esta nueva habilidad con el conducir una motocicleta: “comencé montando la motocicleta de una manera muy tambaleante, después pude hacerlo mejor. en dos semanas, por supuesto lucía como un completo corredor, esto es un gran empujón para la autoestima” (24). la madurez espiritual es muy importante en el proceso de recuperación, en algunos casos está asociada al reconocimiento de dios, en otros es vista como la aceptación de la energía que está presente en el universo y dentro de sí, es la fuerza que lo mueve a ser mejor persona. se encuentra que el ser humano con adicción transfiere su problemática interna a la ausencia de dios, es decir, a un locus de control externo, él no es el culpable de los problemas, es que dios falló, así lo refiere una participante: “había momentos cuando yo logré estar sobrio que el sentido de presencia (de dios) fue real. él estaba sentado en la silla junto a mí en mi automóvil, o detrás en la motocicleta. tú tienes que experimentarlo para comprenderme, sino no puedes describirlo” (24); “en algún punto o sentía que dios me había fallado, no sé exactamente cuándo” (22). como se señaló, el problema de la dependencia al alcohol reside dentro de la persona, no fuera de ella. sin embargo, la conexión con dios o el ser superior o la energía interior es fundamental en el logro de la recuperación, la persona sin ningún apoyo difícilmente puede llegar a recuperarse. “cuando usaba sustancias, yo no veía. estaba ciega. cuando empecé a no usarlas pude ver a dios, comencé a verlo” (22). en este tema el sentido de la vida cobra gran importancia, el propósito es mucho más que lograr el éxito, el dinero o la fama, es referido como el saber lo que se hace, por qué se hace y a 131 recuperación de la adicción al alcohol... l luz patricia díaz-heredia, alba idaly muñoz-sánchez, maría mercedes durán-de villalobos dónde conduce; es mirar el futuro y saber dónde se desea estar. al referirse a la madurez se está involucrando el movimiento ascendente que se ha referido como recuperación, este movimiento le permite desarrollarse y crecer para lograr la madurez en todos los campos de la vida, como lo comenta newman; cuando el movimiento cesa, es la indicación de que la vida se ha ido (23). alcanzar paz y libertad la recuperación le permite a la persona ser libre, actuar sin la influencia del alcohol es como aprender a caminar nuevamente pudiendo de manera consciente dirigirse hacia donde se desea. recuperarse del alcoholismo es estar en paz consigo mismo y con los demás, los sentimientos que lo ataban y lo hacían sentir culpabilidad ya no existen: “la madurez espiritual es libertad, tú solo lo sabes. es liberarse de una carga. la mente en paz” (22). la honestidad es un aspecto central en el logro de la libertad y la paz, es liberador no tener que esconder las acciones y los sentimientos, el ingerir alcohol ya no es la forma de tapar o escapar a los problemas. las posibilidades se amplían y aunque se necesite estar en abstinencia del alcohol, esta no se ve como una coartación de la libertad, por el contrario, se es libre de elegir el no consumo como una alternativa que lleva a la plenitud y el bienestar. la paz interior es deseable porque permite lograr la serenidad, que es considerada como una de las cualidades que lleva a los seres humanos a disminuir el estrés y a promover la salud en general. discusión a partir de las nuevas interpretaciones y la construcción desarrollada mediante la metasíntesis, y en concordancia con el objetivo de establecer las características del proceso de recuperación en las personas con adicción al alcohol, se ha podido establecer que este es complejo y profundo e implica la recuperación como un proceso de trasformación. la metodología de metasíntesis utilizada para condensar los hallazgos de las investigaciones cualitativas, es una fortaleza para el desarrollo teórico de la enfermería (25) debido a que ofrece oportunidades para crear nuevas conexiones y establecer propuestas de cuidado desde posturas teóricas innovadoras sobre temas que ya habían sido estudiados anteriormente, como es el caso de la recuperación en procesos de adicción a sustancias psicoactivas como el alcohol (26). la recuperación, concebida como una trasformación y una construcción personal (27) con movimiento ascendente, trae implícita la potencialidad de los aspectos positivos de las personas que se encuentran en esta situación, no enfatiza en los aspectos negativos, por el contrario, resalta lo que debe ser promovido o destacado requiriendo de las profesionales de enfermería la posibilidad de tener una visión unitaria trasformativa (21) en sus interacciones de cuidado; esta manera de percibir el mundo les permitirá, tanto al sujeto de cuidado como a quien lo brinda, enfrentar y comprender lo que realmente significa el proceso de la recuperación. desde otra perspectiva, es posible que no se logre la recuperación como es descrita aquí, pero cuando la trasformación es completa e involucra todos los aspectos de la vida (9, 10) permite la rehabilitación de la personas; este proceso requiere en el profesional de enfermería el desarrollo de habilidades para comprender lo que está sucediéndole interiormente a quien se está recuperando o desea recuperarse, es decir, que sea capaz de establecer una relación terapéutica que permita tanto el crecimiento del otro como su propio crecimiento. para el profesional de enfermería es importante reconocer en la persona recuperada, o en aquella que está en el proceso de recuperación de la adicción al alcohol, que ella ha tenido o tiene que vivir un largo proceso de trasformación interna que va en ascenso hacia niveles más altos de energía y bienestar; su papel se centra en afianzar lo conseguido y motivar a la persona para que llegue a la paz interior y la libertad. si aún la persona no ha iniciado el movimiento hacia la recuperación es procedente que, de manera conjunta, identifiquen los motivos que impiden la transformación, por ejemplo, la negación de la situación, la frustración, la soledad, la desesperanza, es decir, se deben explorar todos los aspectos que hacen que se mantengan en la adicción, este reconocimiento permite comenzar la recuperación como trasformación ascendente. futuras investigaciones con la metodología de metasíntesis u otras que sean procedentes deberán estar orientadas a establecer intervenciones de 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[revista en internet]. 2010; 23(1): 73-79. disponible en: http://www.scielo. br/scielo.php?script=sci_arttext&pid=s010321002010000100012&lng=en. doi: 10.1590/s0103-21002010000100012 [consultado en febrero 20 2011]. 31. salazar ám, martínez ac. un sobrevuelo por teorías donde la interacción enfermera-paciente es el núcleo del cuidado. avances en enfermería 2008; xxvi (2):107-115. 32. picard c. creative movement and transformation to choreography: a mode of research presentation. nurs sci q 2008;21:112-114. 33. picard c, jones d. giving voice to what we know: margaret newman’s theory of health as expanding consciousness in practice, research, and education. sudbury: jones and barlett publishers; 2005. 485 495 resistencia frente a la enfermedad.indd 485 cleotilde garcía-reza1 rita alvirde-vara2 martha landeros-lópez3 gloria solano-solano4 maría elizabeth medina-castro5 resistencia frente a la enfermedad: relato de un cuerpo dañado por la diabetes 1 phd en enfermería. profesora líder del cuerpo académico de enfermería y cuidado a la salud, perfil promep, facultad de enfermería y obstetricia, universidad autónoma del estado de méxico (uaem), toluca (méxico). cgarc0506@yahoo.com.mx. 2 m.sp facultad de enfermería y obstetricia, universidad autónoma del estado de méxico, toluca (méxico). ritalvir@hotmail.com. 3 phd en enfermería. profesora-investigadora, perfil promep, facultad de enfermería, universidad autónoma de san luis potosí (uaslp), san luis potosí (méxico). landeroart@hotmail.com 4 profesora en enfermería, perfil promep. integrante del cuerpo académico de psicología. línea de investigación comunitaria, universidad autónoma del estado de hidalgo, hidalgo (méxico). glorias_42@yahoo.com.mx 5 profesora, facultad de enfermería y obstetricia, universidad michoacana de san nicolás de hidalgo, michoacán (méxico). medinacastro@hotmail.com recibido: 25 de febrero de 2013 enviado a pares: 11 de abril de 2013 aceptado por pares: 25 de agosto de 2013 aprobado: 2 de septiembre de 2013 doi: 10.5294/aqui.2014.14.4.4 para citar este artículo / to reference this article / para citar este artigo garcía-reza c, alvirde-vara r, landeros-lópez m, solano-solano g, medina-castro me. resistencia frente a la enfermedad: relato de un cuerpo dañado por la diabetes. aquichan. 2014; 14 (4): 485-495. doi: 10.5294/aqui.2014.14.4.4 resumen objetivo: comprender el punto de vista acerca de la enfermedad de personas con diabetes mellitus tipo 2 en moradores de una comunidad del estado de méxico. materiales y métodos: estudio con una aproximación etnográfica que sustentó el análisis de los datos. la investigación se realizó en un centro de atención primaria de salud, participaron ocho personas que asistieron al consultorio de enfermería durante el periodo comprendido entre diciembre de 2009 y julio de 2010. se respetaron los aspectos éticos propios de la investigación. resultados: al escuchar las voces de los pacientes que viven con diabetes lograrmos introducirnos en el mundo de la enfermedad mediante sus relatos. conclusiones: la aproximación etnográfica permite comprender el sentido que le dan los pacientes con diabetes mellitus tipo 2 a su enfermedad, desde las creencias y los hábitos. tal como ellos lo relatan, con su experiencia logran resistir la persistencia de la enfermedad. palabras clave diabetes, enfermería, cuidado, cuerpo, enfermedad. (fuente: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 485-495 486 aquichan issn 1657-5997 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 485-495 resistance to disease: the story of a body damaged by diabetes abstract purpose: the purpose of this study was to understand how persons with type 2 diabetes mellitus who reside in a community in the state of mexico view their illness. study materials and methods: an ethnographic approach was used to support the data analysis. the study was conducted at a primary health care center. it involved eight people who came to the clinic for nursing consultation during the period between december 2009 and july 2010. the ethical aspects particular to the research were respected. results: listening to patients who live with diabetes enabled the authors to enter the world of this disease through their stories. conclusions: an ethnographic approach made it possible to understand the meaning patients with type 2 diabetes mellitus give to their illness, from the standpoint of beliefs and habits. as they described it, their experience enables them to resist the persistence of the disease. key words diabetes, nursing, care, body, disease. (source: decs, bireme). 487 resistencia frente a la enfermedad: relato de un cuerpo dañado por la diabetes l cleotilde garcía-reza y otros. resistência ante a doença: relato de um corpo prejudicado pela diabete resumo objetivo: compreender o ponto de vista sobre a doença de pessoas com diabete mellitus tipo 2 em moradores de uma comunidade do estado do méxico. materiais e métodos: estudo com uma aproximação etnográfica que sustentou a análise dos dados. a pesquisa foi realizada num centro de atendimento primário de saúde; participaram oito pessoas que estiveram no consultório de enfermagem durante o período compreendido entre dezembro de 2009 e julho de 2010. foram respeitados os aspectos éticos próprios da pesquisa. resultados: ao escutar as vozes dos pacientes que vivem com diabete, conseguimos entrar no mundo dessa doença mediante seus relatos. conclusões: a aproximação etnográfica permite compreender o sentido que os pacientes com diabete mellitus tipo 2 dão a sua doença, a partir de suas crenças e hábitos. tal como eles relatam, com sua experiência conseguem resistir a persistência da doença. palavras-chave diabete, enfermagem, cuidado, corpo, doença. (fonte: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 485-495 488 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 introducción la diabetes mellitus tipo 2 es un problema de salud pública a nivel mundial; actualmente, existe un estimado de 382 millones sobre todo en países en vías de desarrollo (1). en méxico, desde hace décadas, la diabetes ocupa los primeros lugares de morbilidad, y, por sus complicaciones severas, constituye la principal causa de discapacidad y muerte (2, 3). un sinnúmero de factores participan en las causas de la diabetes: herencia, alimentación, cultura, estilo de vida, lugar en el que se habita, ocupación, edad. desde esta óptica, para quienes la padecen inicia una experiencia que va más allá de la enfermedad, la cual envuelve un cuerpo lastimado (3), enfermo, que genera un significado en la construcción subjetiva frente a los trastornos de las personas que viven con diabetes a partir de la percepción cultural de estos actores sociales (4). cada individuo que vive con esta enfermedad aplica su cuidado según sus costumbres y creencias, de donde emergen las decisiones relacionadas con sus saberes tradicionales que, articulados con los de enfermería, crean alianzas para llegar a descubrir los puntos de vista émicos de estos pacientes. leininger (5) propone una dimensión transcultural, conocida por el enfoque cualitativo, que constituye una alternativa con un toque humanístico al cuidado de enfermería desde la perspectiva cultural de las personas con diabetes; esta adquiere un especial valor para estudiar los significados a partir de este paradigma metodológico, a fin de abordar este tipo de fenómenos de gran relevancia en la vida de las personas con diabetes mellitus tipo 2 (6). la aportación de esta teoría es crear un cuidado, a partir de la dimensión cultural, para respetar las creencias y prácticas curativas tradicionales fuertemente arraigadas en su sistema émico, relativas al cuidado (5, 7). considerando esta dimensión cultural (5) , el profesional de enfermería está ante los más grandes retos dirigidos a intensificar el cuidado para reducir la progresión de la enfermedad (8). el presente estudio se respalda en la teoría de madeleine leininger de la diversidad y universalidad del cuidado cultural, relacionada con el tratamiento de los pacientes con diabetes mellitus tipo 2. desde la cosmovisión cultural, el cuidado implica comprender que este es inseparable; sin él, la persona pierde su estructura, sentido, y muere. la teoría del cuidado cultural de leninger (5), llamada teoría de la diversidad y universalidad del cuidado, centraliza su estudio en el análisis de las culturas relacionadas con las conductas de cuidado de enfermería (9), sobre creencias y patrones de conducta acerca de la enfermedad. sus aspectos centrales enuncian que el cuidado esencial desde los valores, las creencias y las prácticas para el desarrollo de los seres humanos, influyen en los cuidados como unidad esencial para la curación, el bienestar y la conservación de las personas con diabetes y su cultura (10). las prácticas culturales de cuidado son diversas, por tanto, los cuidados de estas personas pueden predecir el bienestar o la salud de los individuos, las familias o los grupos, lo que al fin determina las visiones émicas (punto de vista del participante), o lo oculto de las personas, tal como lo creen y llevan a cabo. según leninger (5), este referente permite proporcionar cuidados coherentes con las necesidades y las realidades de las personas que viven con diabetes. desde este referente, el cuidado es un conjunto de fenómenos relacionados con la atención y las conductas hacia otros individuos con necesidades reales, para atenuar o mejorar su contexto; en este caso, las personas que viven con diabetes. el profesional de enfermería destaca su participación en la consulta, a partir de su rol educativo hacia las personas con diabetes; al respecto, cada vez más se vuelve significativa su participación en equipos multidisciplinarios (9) para liderar las estrategias educativas de promoción del cuidado de la salud. la teoría de leininger fortalece a las enfermeras a fin de que puedan descubrir cuidados específicos para este grupo de pacientes y proporcionar un cuidado culturalmente propicio que se adapte al modo de vida de las personas con esta condición de salud (10). teniendo en cuenta que al conocer las vivencias relacionadas con la enfermedad se puede obtener una interesante contribución para el cuidado sensible, ya que cada día requiere de un cuidado más coherente a las necesidades del paciente, planteamos el siguiente objetivo: comprender el punto de vista de la enfermedad en personas con diabetes mellitus tipo 2, moradores de una comunidad del estado de méxico. materiales y métodos se realizó un estudio cualitativo, con una aproximación etnográfica, en un centro de salud de estado de méxico, donde se congrega un grupo de educación permanente para personas que viven con diabetes mellitus; este grupo es dirigido por la consulta de enfermería. 489 resistencia frente a la enfermedad: relato de un cuerpo dañado por la diabetes l cleotilde garcía-reza y otros. el grupo de estudio lo formaron ocho personas con diagnóstico médico de diabetes mellitus tipo 2, cuatro mujeres y cuatro hombres registrados en ese centro de atención. los requisitos para la selección de los participantes fueron: hombres y mujeres mayores de 18 años con diabetes mellitus tipo 2, con tratamiento farmacológico, que asistieron a la consulta de enfermería en los últimos seis meses, sin problemas de comunicación ni mentales para proporcionar información en las entrevistas. para obtener la información fue necesario introducirse en la comunidad de santa cruz, en la que se ha trabajado desde el 2008 a la fecha; se realizaron visitas domiciliarias para la búsqueda de los informantes clave, que fueron escogidos por su vivencia con la enfermedad. siguiendo el método propuesto, se procedió a trabajar con una persona, programando las entrevistas, de acuerdo con la fecha y hora señaladas por los participantes; posteriormente, se realizó la entrevista etnográfica, con una duración aproximada de 20 horas por informante, hasta conseguir la saturación de los datos, de acuerdo con la secuencia temática. cabe señalar que aun teniendo citas programadas con los pacientes, estas fueron canceladas con los siguientes argumentos: olvido, encontrarse hospitalizados o estar fuera de la comunidad. asimismo, se les pidió llenar un formato de consentimiento libre e informado, y la autorización para grabar las entrevistas, a fin de realizarlas paulatinamente de acuerdo con el programa de visitas familiares. los entrevistados fueron identificados con la letra s, seguido por un número de acuerdo con el orden de las entrevistas. el estudio se desarrolló entre los meses de diciembre de 2009 a julio de 2010. el estudio se ajustó a lo señalado por el reglamento de la ley general de salud de méxico en materia de investigación (11), y cumple con los aspectos éticos de la investigación, según lo dispuesto en el reglamento de la ley general de salud en materia de investigación para la salud en su artículo 14, inciso vii; así como el artículo 17, inciso ii, considerando la investigación de riesgo mínimo para los participantes. como estrategia analítica empleada para trabajar con los datos se usó el análisis de contenido, a fin de indagar de forma reflexiva los temas culturales desde la perspectiva de los informantes con diabetes mellitus tipo 2; las entrevistas fueron transcritas en forma manual, después de leer y releer los relatos; el análisis siguió un proceso inductivo, lo que permitió identificar las categorías y los temas que surgieron de los relatos de las entrevistas. desde un sistema de codificación y categorización de los datos, se identificaron cinco temas centrales, entre ellos: el grupo como aprendizaje y transformación, el cual se presenta a continuación. con el objeto de realizar una mejor interpretación del contenido de las grabaciones, estas se escucharon varias veces para mantener el sentido del discurso de los informantes, logrando así una transcripción literal; para dar una lectura fluida se subrayaron las frases o respuestas culturales de cada pregunta. como estrategia de anonimato, cada persona entrevistada se identificó con un código de números consecutivos y se identificaron las frases subrayadas para agruparlas en textos de manera inmediata, preparándolas para el análisis bajo el tema central: resistencia frente a la insistencia de una enfermedad traicionera. los segmentos utilizados para el análisis estuvieron representados por párrafos de los cuales consideramos unidades de análisis solo aquellos que contuvieron información relevante para los objetivos del estudio. luego se aplicó el análisis taxonómico que permitió organizar las categorías de acuerdo con sus relaciones de significado. se estudiaron solo tres dominios seleccionados para saber cómo los informantes combinan los distintos segmentos culturales para descubrir ideas y pautas a fin de delimitar temas para lograr una visión general y holística de la cultura con significados integrados a un modelo general. a partir de las unidades se procedió al establecimiento de categorías y a la codificación de las mismas. las categorías detectadas fueron incorporadas a las entrevistas subsecuentes, con el fin de explorar su creencia sobre las mismas, de esta forma los temas culturales son unidades de pensamiento. resultados y discusión es relevante destacar las características sociodemográficas de los pacientes con diabetes mellitus tipo 2: participaron cuatro mujeres y cuatro hombres con edad promedio de ±55 años; cuatro comerciantes, tres mujeres dedicadas al hogar y un artesano. entre los entrevistados predomina la religión católica (siete personas), y una de ellas se identificó como cristiana; respecto al estado civil, seis refirieron estar casados, uno divorciado y una viuda. conforme a los ingresos económicos, los hombres tienen mayores ingresos que las mujeres: 300 / 200 dólares mensuales (tabla). 490 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 a partir de la lectura de los discursos, en este grupo de hombres y mujeres se procede a la codificación inductiva; se buscó la similitud de las experiencias, actividad enmarcada en un análisis descriptivo. a la luz de los datos, desde la perspectiva émic se evidencia el tema central: la resistencia de la enfermedad. resistencia frente a la insistencia de una enfermedad “traicionera” la persistencia de la diabetes es una experiencia que no puede evitarse (5), es vivida desde la raíz más profunda del ser social dentro de su entorno en el diario acontecer de las personas con diabetes, buscando resistir la enfermedad, lo que no siempre se consigue (12). …para mí es muy triste porque esta enfermedad insiste e insiste, ya no se cura, hay días en que me dan ganas de huir, la diabetes es muy mala, a veces uno se siente bien, a veces no quisiera vivir, solo me digo desde mis adentros: resiste, resiste (s2). …yo no le doy importancia a la diabetes, pero ella insiste, está presente en todo momento, es una enfermedad traicionera, me puede dar un coma diabético, ya no puedo salir de esto, por eso me digo siempre con coraje: resiste, resiste, no me traiciones (s8). …es una enfermedad difícil y traicionera porque hoy estás bien y mañana quién sabe, también piensas, piensas y me pregunto porqué te dio, qué pasó, cuándo empezó, cómo pasó (s6). …es una enfermedad muy fea que no se puede aceptar porque es algo que me perturba, y tienes que vivir toda la vida con ella, es muy canija y traicionera porque a veces estamos bien y a veces estamos mal, no sé hasta cuándo pueda resistir (s7). durante las entrevistas, al tiempo que los actores sociales narraban estas experiencias a partir del fenómeno vivido, se podía percibir la presencia de la enfermedad, su trascendencia de manera significativa en las emociones de las personas que la vivían (4, 9). la diabetes mellitus se visualiza como “resistente ante los cambios de hoy para el mañana”, donde día a día hay que vivirla, pero también resistirla; depende de emociones y cambios en los estados de ánimo que van desde tristezas, preocupaciones, desesperación, miedo, llanto, llegando al límite de “ya no querer vivir”. su presencia cambia la vida, estas personas la señalan como una enfermedad “traicionera” y “muy mala”. la experiencia de cada persona es única, pero las emociones emergen y afectan directamente su estabilidad física y emocional, cuyo impacto es evidente durante todo el proceso de la enfermedad, desde el diagnóstico hasta la misma muerte que se espera y que desespera a quien la vive día a día (13, 14). la visión de la enfermedad reconoce los desafíos que enfrenta el profesional de enfermería cuando la persona que vive esta experiencia solicita un cuidado en los escenarios de su contexto cultural (4); es indispensable descubrir y documentar el mundo del paciente, desde donde se centra la experiencia de vivir con la enfermedad, es decir, su cosmovisión se construye con la experiencia cotidiana de su entorno social, que conecta la existencia humana tabla. perfil sociodemográfico de los pacientes con dm tipo 2 de santiago tianguistenco, abril 2011 participantes y código sexo edad ocupación religión estado civil ingreso mensual dólares (s1) f 28 hogar católica casada 100 (s29) m 32 comerciante católica casado 300 (s39) m 55 artesano católica separado 200 (s4) m 56 comerciante católica casado 200 (s5) f 56 comerciante católica casada 150 (s6) m 57 comerciante cristiana casado 500 (s79) f 60 hogar católica casada 150 (s8) f 65 hogar católica viuda 100 491 resistencia frente a la enfermedad: relato de un cuerpo dañado por la diabetes l cleotilde garcía-reza y otros. con el verdadero origen del cuidar, que al estar influido por la cultura, puede protegerla ante la amenaza de un agente externo durante la prolongada convivencia con la enfermedad (15, 16). la culpa, el otro lado de la enfermedad muchos de los síntomas de la enfermedad guardan relación con la aparición del sentimiento de culpa debido a las creencias respecto al origen de la misma, lo que muchas veces aleja la oportunidad de perdón (17). sin embargo, quedarse en este juego destructivo de la culpa es totalmente insano para el alma; las personas que viven con diabetes deben darse un tiempo para meditar y no seguir con la culpa, tal como se muestra en los siguientes relatos: …es mi culpa porque no me cuidé, yo pienso que me dio por descuido, por tomar tantas y tantas cubas, el tequila, el pulmón, y también por tomar mucho refresco (s1). …a mí me dio por enojona, por afligirme y ponerme a pensar cómo cambiar el mundo, también por los sustos o corajes y comer alimentos dañinos como aguacate, carne y esto hace mucho mal, es mi culpa, siempre lo diré hasta el cansancio, es mi culpa, es mi culpa (s2). …cuando mi esposa se fue, la enfermedad surgió de repente, me abandonó, y vino el susto, sorpresas por eso me dio, se me derrumbó todo, llegó para quedarse esta mala enfermedad que daña mi cuerpo, lo lesiona más y más (s3). …yo pienso que me dio la enfermedad porque estaba muy gordo, por eso me dio, también por los corajes, sustos y por la mala alimentación que uno tiene, por eso, que lamentable es todo, todo ni modo, eso me abate y me asusta (s8). en la totalidad de respuestas, la enfermedad está relacionada con un susto o por corajes. algunos por el sobrepeso, los malos hábitos de alimentación, el estrés o las emociones capaces de desencadenarla; se debe destacar que en este estudio existe un arraigo cultural del “susto” y las emociones por acontecimientos de la vida diaria: “sobresalto” y “corajes”. las percepciones que los grupos sociales construyen sirven para comprender y explicar la realidad de los eventos de la vida; cada persona se respalda en las culpas, que le otorgan alternativas para entender y comprender la realidad cultural de su enfermedad (3, 13). la culpa, como una carga de ansiedad y angustia, encubre el reflejo real del pensamiento de estos personajes, quienes muchas veces esconden la frustración y la contradicción de ideas, piensan que podrían haberlo hecho mejor. la teoría de leininger ayuda a vislumbrar que la enfermera requiere brindar un cuidado holístico para proporcionar un cuidado cultural y religioso congruente para este grupo de personas dueñas de sus percepciones desde donde la enfermedad actúa en su cuerpo (16, 18). medicamentos no, los tés te salvan los largos periodos que conllevan estos tratamientos acentúan la dificultad en el trato con los pacientes, lo que muchas veces origina su abandono; ellos buscan continuamente la medicina alternativa considerada de fácil acceso. al respecto, la organización mundial de la salud (oms) reconoce que la población tiende a buscar la curación de su enfermedad a través de prácticas de medicina tradicional. esta afirmación se manifiesta en los siguientes relatos: …tomo el wereque porque me da hambre, siento que me hace bien, me lo tomo más cuando no me da hambre o me duele la cabeza, después siento relajado el cuerpo, lo hiervo en un vaso de agua y le coloco el wereque, lo dejo toda la noche y al otro día me lo tomo en ayunas, es muy amargoso (s2). …sí, yo tomo el té de nopal con cáscaras de tomates y una rebanada de calabaza, se hierve en un litro de agua y lo tomo tibio por la mañana, me lo recomendó la vecina y a veces uno con tal de que uno se sienta bien se toma uno lo que sea (s4). …yo tomo el té de la “tronadora”, el “chancar” “diente de león”, lo tomo como agua de tiempo tres veces a la semana, después de que me lo tomo se te refresca el estómago y me siento bien, es barato (s5). …sí, me tomo un licuado de nopal con piña, una cucharada de avena, la mitad de una manzana y un xoconostle, lo leí, ese fue el que me gustó más, me lo tomo una semana sí, y una no, después de que me tomo el licuado se quita el malestar de cansancio y dolor de mis piernas (s6). en cuanto al uso de la medicina tradicional entre los pacientes entrevistados, se destaca el consumo de infusiones de plantas y de té; las plantas más utilizadas son el wereque, la tronadora y el diente de león. otra práctica curativa es el consumo de jugo de nopal y de limón; generalmente lo hacen por recomendaciones 492 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 de familiares o conocidos, considerándolas como una alternativa por parte del paciente (18, 19). el impacto sobre el consumo de té es interpretado como de bienestar: “me refresca el estómago”, “me quita el cansancio”, “me dan ganas de hacer cosas”, “me corta el azúcar”. se percibe que estas prácticas curativas brindan una mejoría inmediata después de su consumo, son relevantes para adoptar acciones y decisiones sobre cuidados coherentes con los modos de vida. sin lugar a dudas, esto refleja la idiosincrasia de los pacientes ante la enfermedad; para ellos constituye una alternativa en el cuidado de su salud (12, 18). se puede percibir que las prácticas curativas pueden ser la máxima expresión de luz. desde la óptica de leininger (5), el individuo enfermo busca de manera incesante la medicina alternativa; a partir su visión emic percibe esta acción como una práctica significativa, fundamental, trascendente, para alcanzar un encuentro de expresiones prácticas que le dan sentido al cuidado de enfermería, influidas por el lenguaje, la religión, los factores económicos, la educación, los valores y las creencias culturales. es evidente su punto de partida sobre sus percepciones y experiencias relacionadas con el automanejo de su enfermedad; sin embargo, no relatan aspectos negativos de la medicina alternativa, ellos la aceptan sin ningún temor por sus beneficios en otros amigos y familiares. al respecto, leininger invita a la reflexión a fin de establecer un diálogo para construir un cuidado de la salud y la vida de estas personas con diabetes mellitus tipo 2 (17, 20). un hálito de vida, el aumento de la glucosa “apaga” mi vida otro elemento por destacar en las narrativas de los pacientes con diabetes es el momento de decidir qué acciones llevar a cabo cuando el aumento de la glucosa está presente, esto trae consigo buscar un “hálito de vida” lo antes posible. …aumenta mi azúcar, dolor de cabeza, apaga mi cuerpo, me siento borracha, no tengo fuerzas, me siento cansada, y me sorprende una vez más la enfermedad (s2). …la enfermedad es fea, yo reconozco cuando está alta la azúcar, me da sueño, no tengo ganas de hacer nada, estoy muy decaído, pero mi familia me alienta, me da ánimos para salir adelante, voy al centro de salud, y la enfermera me da un aliento de vida (s1). …cuando sube el azúcar, algo anda mal, me da sueño, no puedo hacer nada y me digo no voy a comer nunca más; pan, refresco, azúcar, chocolates, tortillas, carne; el médico me manda los estudios y está alta la glucosa, me pongo dos semanas a dieta me controlo, pero luego me da por comer de todo (s3). …puedo reconocer mi azúcar alta, se reseca la boca y muy amargosa, me hormiguea mucho la cara y siento mucha desesperación, se irrita uno fácilmente, es ahí cuando se apaga mi vida, siento que es lo último de mi vida (s4). ante la presencia de la enfermedad, se afligen al sentir claramente las alteraciones que produce; la reconocen, pero no siempre exteriorizan su padecer, situación que se debe considerar con fundamento en la experiencia cultural del padecimiento, que permite atender la voz de los actores que cotidianamente conviven con la enfermedad y sus consecuencias; al escuchar esas voces es probable que el profesional de enfermería comprenda e intérprete los conflictos (10, 21), en ocasiones hasta tragedias, que rodean al enfermo, el cual se ve abrumado por problemas y dificultades, dada su condición social, que se agregan a las necesidades y exigencias que le impone la experiencia de padecer una enfermedad crónica (2, 22). desde esta perspectiva de la etnoenfermería, constituye un desafío del hacer de la disciplina mantener un puente de comunicación entre las creencias de las personas y el conocimiento científico, entre las creencias y los mitos construidos alrededor del cuidado que protege y fortalece la vida de las personas con diabetes mellitus tipo 2, para su sobrevivencia y para mantener estas prácticas tradicionales (16, 20). el olvido, una amenaza de muerte la diabetes mellitus tipo 2 impacta a la persona enferma, sobre todo cuando se asocia a complicaciones que limitan su vida cotidiana por los tratamientos, su relación con el número de medicamentos utilizados, los efectos adversos y las enfermedades asociadas, así como los mitos y las creencias construidos que van a la par (5, 13). la dificultad que conlleva el vivir con la enfermedad, impide reconocer los beneficios de los medicamentos, lo que produce un efecto “paralizante” (22, 23). …frecuentemente olvido tomar la pastilla, pero lo recuerdo cuando mi cuerpo siente la amenaza de muerte; sí, eso, una amenaza de muerte, me recuerda el olvido mayúsculo, y llego 493 resistencia frente a la enfermedad: relato de un cuerpo dañado por la diabetes l cleotilde garcía-reza y otros. al hospital, el doctor pregunta tomó el medicamento, entonces, pienso: se va a enojar y mejor le digo: sí, sí, sí (s1). …a mí me dicen tome su medicina antes de desayunar y antes de comer, en ocasiones no me tomo el medicamento, por ejemplo hoy se me olvidó, no me la tomé, hay semanas que lo tomo diario, una vez lo dejé de tomar seis meses, yo me sentía bien pero una vez me dio un mareo y no veía nada, entonces me morí, si eso fue, una amenaza de muerte (s3). …yo me tomo el medicamento por la mañana antes de desayunar y antes de comer, la doctora me dice que debo de tomar el medicamento, porque después uno sufre, casi por lo regular no se me olvida pero a veces sí se me olvida, es importante tomarse el medicamento para mantener el nivel de la azúcar, ya que con cualquier cosa se sube (s6). …yo me tomo las pastillas en los horarios que él me da, me lo tomo después del medicamento, yo a veces he dejado de tomar el medicamento porque se me olvida, a veces porque son muchas pastillas, es cuando me llego a sentir muy mal, cuando yo voy a consulta, yo no le digo a la enfermera porque me da pena, siento feo decirlo, y es por eso que no le digo todo, la verdad no los tomo siempre, se me olvida (s7). se destaca en estas entrevistas que la mayor parte de los pacientes consideran importante el consumo del medicamento por los beneficios que tienen sobre los niveles de glucosa; además, existen estrategias implementadas por ellos para la ingesta de sus fármacos cuando tienen que salir o viajar, algunos realizan modificaciones en cuanto al horario y la dosis porque consideran que son “muchas pastillas”; algunos expresan que solo se lo toman cuando se sienten mal. otras limitaciones en relación con el consumo de los medicamentos es que no los toman cuando presentan otras enfermedades como “gripe”, “yo no me tomo nada, lo suspendo porque son muchas pastillas”. los pacientes no expresan estas conductas cuando acuden a consulta por pena a ser “criticados y hasta regañados”. ante estos relatos, el modelo leininger (5) permite una comprensión analítica subjetiva del grupo intercultural. en méxico tenemos una cosmovisión abierta, donde la persona con diabetes mellitus tipo 2 se debate entre el aporte de sus costumbres y las recomendaciones del médico. la competencia cultural de los profesionales de la salud debe centrarse en la capacidad para fomentar una comunicación respetuosa y eficaz de acuerdo con las múltiples identidades de los participantes, tolerante y de diálogo, constatando que la diversidad puede ser fuente de riqueza, ya que abre su visión para orientar el cuidado paliativo hacia las medicinas orientales y populares, con esa concepción científica que valida el discurso y sus resultados (17 ,16). en el presente siglo, las terapias alternativas le han dado sentido a los elementos de la teoría de leininger (5), pues buscan un punto de encuentro entre el cuidado cultural y los saberes de actores sociales dentro de su propia cosmovisión del mundo (13, 24), para fortalecer esos actos de cuidado significativos, y no rechazarlos por no comprender su cosmovisión de la salud, la enfermedad, la vida, el sufrimiento y la muerte. esto permite entender el pensamiento del individuo e identificar situaciones que abren propuestas de cuidado acordes a las necesidades de grupos de personas que viven con diabetes mellitus tipo 2, y que no son tenidas en cuenta a partir de su contexto (18, 25). conclusiones el enfoque cualitativo permitió aproximarnos a la realidad cultural de la muestra de estudio en la cotidianidad de la enfermedad, desde su visión emic, apoyada siempre en la experiencia relatada por estas personas, lo difícil que es para ellas vivir con la enfermedad, y, sobre todo, aceptar el tratamiento concomitante que requiere grandes voluntades para aprender a vivir con los múltiples cambios émicos de vida. una creencia que lesiona su cuerpo es la culpa por la alimentación. las personas relataron no seguir las recomendaciones alimenticias, esta conducta no es contada en la consulta, por temor a ser reprendidos. sin lugar a dudas, el papel de la educación debe ser para negociar los cuidados, sin separar sus creencias; por el contrario, el paciente debe ser escuchado para que externalice lo que está viviendo, para ayudarlo a vivir con las limitaciones. estos sucesos son motivo de reflexión al otorgar los cuidados de enfermería, considerando sus valores y creencias para reestructurar la atención desde su cosmovisión con el fin de negociar una alianza entre este tipo de usuario y el profesional de enfermería a fin de lograr un mejor control de su enfermedad y reducir las lesiones potenciales. el hecho de modificar el cuidado permite reflexionar acerca de las tareas que se deben emprender, acrecentar la formación teórica, resolver dudas, detectar resistencias y hacer frente a los 494 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 sentimientos de satisfacción o insatisfacción de los usuarios. a través del relato, las personas con diabetes confieren valor a su padecimiento, mediado por sus experiencias, emociones, creencias y valores culturales. es recomendable enfocar estrategias de intervención a través de la promoción de la salud en la consulta de enfermería contextualizada pero, sobre todo, individualizada. referencias 1. international diabetes federation (idf). diabetes atlas [internet]. brussels, belgium: idf; 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9(2):980-86. disponible en: http://www.redalyc.org/articulo.oa?id=50711454003. 13. conrand pk. antropología cultural espejo de la humanidad. méxico: mcgraw-hill; 2002. 14. lundberg pc, thrakul s. type 2 diabetes: how do thai buddhist people with diabetes practise self-management? j adv nurs [internet]. 2012 [citado 2013 ene 22]; 68:550-558. disponible en: http://onlinelibrary.wiley.com/doi/10.1111/ j.1365-2648.2011.05756.x/pdf 15. moreno a. enfermedad, cuerpo y corporeidad: una mirada antropológica. revista gac med méx 2010;(146)2:156. 16. gonzález gn, tinoco gam, benhumea gle. salud mental y emociones en pacientes con enfermedades crónico-degenerativas. un acercamiento a la diabetes mellitus tipo 2. espacios públicos [internet]. 2011 [citado 2012 jun 11]; 14258279. disponible en: http://www.redalyc.org/src/inicio/artpdfred.jsp?icve=67621319013 495 resistencia frente a la enfermedad: relato de un cuerpo dañado por la diabetes l cleotilde garcía-reza y otros. 17. ledón ll. impacto psicosocial de la diabetes mellitus, experiencias, significados y respuestas a la enfermedad. rev cubana endocrinol [internet]. 2012 [citado 2012 sep 11]; 23(1):76-97. disponible en: http://scielo.sld.cu/scielo. php?script. 18. vásquez ml. el cuidado desde la perspectiva transcultural: una necesidad en un mundo cambiante. invest educ enferm. 2002;19:48-54. 19. muñoz de rl, vásquez ml. mirando el cuidado cultural desde la óptica de leininger. colomb med [internet]. 2007 [citado 2013 ene 11]; (38)4,sup2:98-104. disponible en: www.scielo.org.co/pdf/cm/v38n4s2/v38n4s2a11.pdf 20. ledón ll. el desafío de vivir con enfermedades endocrinas: algunas anotaciones para la atención en salud. rev cubana endocrinol [internet]. 2008 [citado 2013 ene 26]. disponible en: http://scielo.sld.cu/scielo.php?script=sci_ arttext&pid=s1561-29532008000 21. almaguer gja, vargas v. interculturalidad en la atención a la salud en las poblaciones indígenas. en almaguer gja, mas oj, compiladores. interculturalidad en salud. experiencias y aportes para el fortalecimiento de los servicios de salud. méxico: unam-secretaría de salud; 2009. 22. lin cc, anderson rm, hagerty bm, lee bo. diabetes self-management experience: a focus group study of taiwanese patients with type 2 diabetes. j clin nurs. 2008;17(5a):34-42. 23. campo gn, portillo mc. patients´ selfmanagement of type 2 diabetes: a narrative review. anales sis san navarra [internet]. 2013 [citado 2012 ago 26]; 36(3):489-504. disponible en: http://scielo.isciii.es/scielo.php?script=sci_ arttext&pid=s113724. peres ds, santos ma, zanetti ml, ferronato aa. difficulties of diabetic patients in the illness control: feelings and behaviors. rev latino-am. enfermagem [internet]. 2007 [citado 2012 dic 11]; (15)6:1105-1112. disponible en: http scielo. br/pdf/rlae/v07.pdf. 25. torres ltm, sandoval dm, pando mm. blood and sugar: social representations of diabetes mellitus by chronic patients in guadalajara, mexico. cad. saúde pública [internet]. 2005 [cited 2012 sep 02]; 21(1):101-110. disponible en: http:// www.scielosp.org/scielo.php?script=sci_arttext&pid=s0102 141 153 la vinculacion etico-juridica.indd 141 paulina milos h.1 ana i. larraín s.2 la vinculación ético-jurídica entre la gestión del cuidado y la gestión de riesgos en el contexto de la seguridad del paciente 1 directora magíster en derecho de la salud, universidad de los andes, santiago, chile. pmilos@uandes.cl 2 directora de estudios, universidad de los andes, santiago, chile. recibido: 22 de diciembre de 2013 enviado a pares: 18 de febrero de 2014 aceptado por pares: 17 de noviembre de 2014 aprobado: 19 diciembre de 2014 doi: 10.5294/aqui.2015.15.1.13 para citar este artículo / to reference this article / para citar este artigo milos p, larraín ai. la vinculación ético-jurídica entre la gestión del cuidado y la gestión de riesgos en el contexto de la seguridad del paciente. aquichan. 2015;15(1):141-153. doi: 10.5294/aqui.2015.15.1.13 resumen el fomento de un entorno seguro es una función esencial de las enfermeras, que ocupa cada vez más un lugar central en la gestión del cuidado. el propósito de este artículo es develar la existencia de una relación ético-jurídica entre la gestión del cuidado y la gestión de riesgos, en el contexto de la seguridad del paciente. método: bajo un criterio ético-jurídico se reflexiona sobre la atención de enfermería y la seguridad del paciente. resultados: se demuestra una vinculación de carácter ético-jurídico entre la gestión del cuidado y la gestión de riesgos. se define a qué orden pertenece dicha vinculación y cómo se integra a la gestión del cuidado. por último, se propone la supervisión por riesgos. conclusiones: al demostrar la vinculación ética y jurídica existente entre la gestión del cuidado y la gestión de riesgos, la seguridad del paciente se levanta, para las enfermeras y la enfermería, como un imperativo moral y profesional. palabras clave gestión del cuidado, gestión de riesgos, seguridad del paciente, legislación como asunto, liderazgo en enfermería. (fuente: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 141-153 142 aquichan issn 1657-5997 año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 141-153 the ethical-legal link between care management and risk management in the context of patient safety abstract promoting a safe environment is an essential function of nursing and occupies an increasingly central role in care management. the purpose of this article is to show the existence of an ethical-legal relationship between care management and risk management in the context of patient safety. method: the article reflects on nursing care and patient safety from an ethical-legal standpoint. findings: an ethical-legal link between care management and risk management is demonstrated. the order of that relationship and how it fits in with care management are defined, and risk supervision is proposed. conclusions: demonstrating the ethical and legal relationship between care management and risk management enhances patient safety as a moral and professional imperative for nurses and nursing. keywords care management, risk management, patient ethics, legislation, nursing leadership (source: decs, bireme). 143 la vinculación ético-jurídica entre la gestión del cuidado y la gestión de riesgos en el contexto de la seguridad del paciente l paulina milos h., ana i. larraín s. a vinculação ético-jurídica entre a gestão do cuidado e a gestão de riscos no contexto da segurança do paciente resumo o fomento de um ambiente seguro é uma função essencial dos enfermeiros e ocupa cada vez mais um lugar central na gestão do cuidado. nesse sentido, o propósito deste artigo é evidenciar a existência de uma relação ético-jurídica entre a gestão do cuidado e a gestão de riscos no contexto da segurança do paciente. método: sob um critério ético-jurídico, reflete-se sobre o atendimento de enfermagem e a segurança do paciente. resultados: demonstra-se uma vinculação de caráter ético-jurídico entre a gestão do cuidado e a gestão de riscos. define-se a que ordem pertence essa vinculação e como se integra à gestão do cuidado. por último, propõe-se a supervisão por riscos. conclusões: ao demonstrar a vinculação ética e jurídica existente entre a gestão do cuidado e a gestão de riscos, a segurança do paciente se torna, para os enfermeiros e para a enfermagem, um imperativo moral e profissional. palavras-chave gestão do cuidado, gestão de riscos, segurança do paciente, legislação como assunto, liderança em enfermagem (fonte: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 141-153 144 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 planteamiento las políticas públicas centradas en la dignidad de la persona, la atención en salud basada en la evidencia científica, el paso de la incertidumbre al concepto de riesgo en cuanto probabilidad de ocurrencia de un daño y, por tanto, posible de gestionar, así como la mejora en la percepción y valoración de la seguridad asistencial han hecho hoy ―aun cuando no se trata de un fenómeno nuevo― que la seguridad del paciente, y la consecuente gestión de riesgos, se alcen como un imperativo en la prestación de servicios de enfermería, un reto para la formación profesional de pre y posgrado, y en una promisoria y fecunda área de investigación. la enfermera, de un modo universal —sociológica o jurídicamente— es la depositaria de la gestión del cuidado, entendida esta como la aplicación de un juicio profesional en la planificación, organización y control de la provisión de cuidados: directos, oportunos, seguros, integrales, continuos y personalizados, en el contexto de la atención en salud (1). el concepto de un cuidado seguro, que encierra la gestión del cuidado, es precisado por el consejo internacional de enfermeras (cie) que declara, entre otros, que el fomento de un entorno seguro es una función esencial de las enfermeras. la afirmación del cie encuentra fundamento, por una parte, en la naturaleza del quehacer de la enfermera, la que favorece una relación continua con el paciente y con el equipo de enfermería, en la que se gesta un liderazgo favorable a la construcción de una cultura de cuidados seguros (2), y por otra, en la circunstancia de que la enfermera y su equipo constituyen el grupo profesional más numeroso en los establecimientos de salud, con presencia transversal y continua, el que bajo la estructura del situs de enfermería (3) puede contribuir de un modo eficiente y eficaz a gestionar los riesgos en los diferentes niveles de la atención en salud. en chile, la ley 20.584 sobre derechos y deberes de las personas vinculados a su atención en salud (4), en su artículo 4 trata la seguridad del paciente, aspecto de las prestaciones sanitarias que hasta la fecha se regía por la moral y la ética profesional e institucional3 (5). desde una óptica proactiva, esta disposición 3 artículo 4º. toda persona tiene derecho a que, en el marco de la atención de salud que se le brinda, los miembros del equipo de salud y los prestadores institucionales cumplan las normas vigentes en el país, y con los protocolos establecidos, en materia de seguridad del paciente y calidad de la atención de salud, referentes a materias tales como infecciones legal motiva a preguntarse: ¿cuál es la vinculación existente entre la gestión del cuidado y la gestión de riesgos?, ¿a qué orden pertenece esta vinculación?, ¿cómo se integra la gestión de riesgos a la función gestión del cuidado? marco conceptual si bien la atención en salud tiene como meta la obtención de un beneficio para la persona, diversos estudios han demostrado que un 10 % de los pacientes que ingresan al sistema de atención cerrada sufrirá un incidente con consecuencia de daño (6), hecho que también se observa en la atención abierta, aunque con un menor número de efectos no deseados (7). el daño a que nos referimos es aquel que no es consecuencia de una enfermedad o lesión subyacente (8), sino de errores en la atención, los que en su mayoría responden como causa principal a defectos en los sistemas y procesos y no a conductas individuales (9). el daño incidental o evento adverso (ea) puede tener consecuencias deletéreas para los pacientes, las que pueden afectar tanto su dignidad, integridad física y psíquica, e incluso su vida, como también aquellos aspectos propios de una buena vida como son la pérdida de agrados o amenidades, que suponen un daño extrapatrimonial (10). lo anterior, sin descontar las pérdidas económicas y de capacidades que pueden llegar a comprometer un proyecto de vida. los costos asociados a este tipo de ea, como la pérdida de imagen, competitividad y prestigio, también se hacen extensivos a las instituciones de salud (11). la gestión de riesgos en la atención en salud la incertidumbre es desconocer el grado de probabilidad con que ocurrirá un hecho. acarrea variabilidad de la práctica clínica, la que en algunos casos puede constituirse en un factor de riesgo importante. el riesgo, en cambio, es la contingencia o proximidad de un daño, cuya ocurrencia es conocida. el riesgo es un evento que puede, o habría podido desencadenar un efecto no deseado o intrahospitalarias, identificación y accidentabilidad de los pacientes, errores en la atención de salud y, en general, todos aquellos eventos adversos evitables según las prácticas comúnmente aceptadas. adicionalmente, toda persona o quien la represente tiene derecho a ser informada acerca de la ocurrencia de un evento adverso, independientemente de la magnitud de los daños que aquel haya ocasionado. las normas y protocolos a que se refiere el inciso primero serán aprobados por resolución del ministro de salud, publicada en el diario oficial, y deberán ser permanentemente revisados y actualizados de acuerdo con la evidencia científica disponible (ley 20.584). 145 la vinculación ético-jurídica entre la gestión del cuidado y la gestión de riesgos en el contexto de la seguridad del paciente l paulina milos h., ana i. larraín s. comprometer la seguridad. en el ámbito sanitario se entiende por riesgo la probabilidad de ocurrencia de un evento adverso dentro del sistema de atención de salud o un factor que incremente tal probabilidad (12). en la actualidad se puede cuantificar el riesgo y ponderar los beneficios y, por tanto, sobre la base de evidencia científica, es posible decidir una intervención de manera prudente. en situaciones razonablemente riesgosas, sobre las cuales existe incertidumbre, se podrá decidir conforme al principio de precaución (13). el riesgo, por su condición de ser conocido y su probabilidad de ocurrencia, se puede gestionar. así, la gestión de riesgos se concibe como una estrategia tendente a reducir los riesgos hospitalarios (14) y también como un proceso que fundamenta la toma de decisiones en salud al proporcionar un mejor conocimiento de los riesgos y sus consecuencias (15). la seguridad del paciente: un imperativo de la atención en salud en este contexto surge el concepto “seguridad del paciente” entendido como la estructura, los procesos, los instrumentos y las metodologías basadas en evidencia científica, cuya finalidad es coordinar esfuerzos para disminuir el riesgo de sufrir un daño prevenible en el proceso de atención de salud o de atenuar sus consecuencias (8). la seguridad, en todo caso, no se concibe tan solo como una seguridad física, sino que concierne a la persona en una concepción integral. tampoco está referida exclusivamente al estricto cumplimiento de normas, comprende además la capacidad de anticipación, la evaluación de los riesgos y el hacerse cargo de sus efectos. la seguridad del paciente se alcanza, entre otros, mediante la gestión de riesgos. la enfermería y la seguridad del paciente la historia de la enfermería se identifica con la seguridad del paciente la profesión enfermera, en cuanto promotora de la seguridad del paciente, se confunde e identifica con sus raíces. nightingale documentó visionariamente en su “diagrama de área polar” las condiciones no seguras en los hospitales. también demostró con resultados que las enfermeras formadas sistemáticamente podían hacer más seguro el entorno de los pacientes bajo cuidados (16)4. posteriormente, en los años cincuenta del siglo xx fueron las enfermeras las que iniciaron los reportes de incidencias para ayudar a identificar los riesgos, contribuyendo así a la iniciación de la gestión de riesgos hospitalaria (17). las anteriores contribuciones han hecho que las enfermeras sean reconocidas como la clave de la calidad y seguridad en los hospitales (18), y líderes positivos como promotores y educadores de una cultura de la seguridad (19). lo que, en las últimas décadas, ha sido refrendado por estudios que señalan a las enfermeras como una variable crítica en la identificación de los factores de riesgo tanto potenciales como reales en la atención de los pacientes. de igual forma, ha quedado demostrado el impacto de la formación y dotación de enfermeras en los índices de morbimortalidad, estadía hospitalaria y en la satisfacción de los pacientes (20, 21). en chile, un primer estudio institucional del sector público señala que en enfermería se aprecia preocupación por la prevención de accidentes y un fuerte compromiso por la seguridad (22). de hecho, se ha constatado que las enfermeras se capacitan en temas sobre seguridad de la atención en mayor proporción que otros grupos profesionales (23). en general, los profesionales se capacitan influidos por el clima de seguridad, la seguridad de los pacientes, el tipo de institución, y también por la disciplina profesional de que se trate (24). el aporte de las enfermeras a la seguridad del paciente y la gestión de riesgos institucional la seguridad del paciente es un desafío del equipo de salud desde que el control de los riesgos y la consecuente reducción de ea requirió de un abordaje organizacional e interdisciplinar. en este contexto, los profesionales de enfermería se encuentran en una situación estratégica debido a que la posición que ocupan les 4 el artículo hace referencia a los aportes de florence nightingale a la organización de los hospitales y a la formación de enfermeras. los gráficos se encuentran en: nightingale f. notes on matters affecting the health efficiency and hospital administration of the british army founded chiefly on the experience of the late war. presented by request to the secretary of state for war. londres: harrison & sons; 1858. 146 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 permite obtener y compartir información con el paciente y los diversos profesionales de la salud. el aporte de las enfermeras y su equipo impacta positivamente en la seguridad (25) y también en la contención de los ea (26). en este tenor, el ministerio de salud y consumo español (2009) da cuenta que las enfermeras: i) coordinan y crean un entorno en el cual se pueden implantar nuevos protocolos multidisciplinarios, además de influenciar en su adherencia; ii) mantienen un mayor contacto con los pacientes; iii) tienen un vasto conocimiento de la realidad de la calidad de la atención y, iv) son una importante fuente de proposición de iniciativas de mejora. sobre estas observaciones establece como una buena práctica “la ampliación de las responsabilidades de las enfermeras en la gestión de la calidad y de los riesgos”. en igual sentido, teniendo en consideración la cooperación específica de las enfermeras a la gestión de riesgos en la atención en salud, algunos autores han concluido que una “cultura centrada en las enfermeras” permite reducir los riesgos y mejorar la calidad (27). las condicionantes de la seguridad del paciente en la atención de enfermería la necesidad de seguridad y la prescripción enfermera la prescripción de cuidados de enfermería tiene como fundamento la satisfacción de las necesidades sociales de la persona enferma, entre otras la necesidad de seguridad. la necesidad de seguridad, vista aisladamente, tiene relación con la estabilidad, la independencia, la protección de los peligros ambientales y la ausencia de miedo y ansiedad (28). también se ha vinculado con la necesidad de una estructura, unos límites, un orden, una ley, entre otras (29). en su dimensión integral la seguridad, en cambio, comprende todo aquello que cause menoscabo a la persona en una concepción integral. siguiendo esta línea es ilustrativo conocer las respuestas de los pacientes vertidas en un reciente estudio ante la pregunta ¿cuáles son las variables que importan para sentirse satisfechos? los usuarios, sin distinción, afirmaron su mayor aprecio por “la calidez humana del personal, que permita sentirse apoyado y que atenúe el sentimiento de desprotección propia de la vulnerabilidad que experimenta cuando se hospitaliza” (6). es importante, entonces, fomentar la práctica de indagar ex ante las preferencias, los deseos, las necesidades espirituales y las expectativas de los pacientes sobre tratamientos y procedimientos, a modo de contribuir a aminorar la sensación de inseguridad que los acompaña (30). hasta aquí podríamos precisar que es de la esencia de los servicios de la enfermera: la provisión de un entorno seguro, el otorgar cuidados humanizados, basados en la evidencia científica, y que los pacientes perciban en la atención confianza y seguridad. la atención de enfermería es eminentemente de equipo la atención de enfermería es un servicio eminentemente de equipo. que esta sea segura depende de cada una de las acciones que la comprenden, desde aquellas relativas al cuidado básico hasta las involucradas en un procedimiento de tecnología avanzada. en la práctica, el quehacer de la enfermera se multiplica a través del equipo de enfermería (3). a este equipo se suma un valioso aliado: los estudiantes, quienes por su cercanía al paciente juegan un rol importante en la humanización y seguridad de la atención (31). la actuación colectiva trae aparejada para la enfermera, en su calidad de gestora de los cuidados y jefe del equipo, el imperativo de ejercer un liderazgo orientado tanto al servicio de la persona (6) y a la incorporación de la evidencia científica (32, 33), como a supervisar y asumir ciertas y determinadas responsabilidades ligadas al mando o autoridad (3). al efecto proponemos un nuevo concepto de supervisión: la “supervisión por riesgos”. esta va más allá del cumplimiento de normas, tiene un carácter preventivo y lo que pretende es evitar el daño mediante una revisión focalizada que evalúe la gestión efectuada sobre los riesgos identificados. se trata de detectar la vulnerabilidad del servicio, en especial ante situaciones adversas. este tipo de supervisión encuentra su fundamento en la dignidad de la persona y el en el uso eficiente de los recursos de supervisión, e implica desarrollar modelos de evaluación de riesgos por parte del supervisor; intervenciones focalizadas, oportunas y flexibles; evaluar el riesgo in situ, su gestión y corrección en el día a día5. 5 las autoras han recogido el concepto “supervisión por riesgo” del sistema bancario, que a partir del comité de basilea (1997) introduce un nuevo enfoque sobre la base del principio 147 la vinculación ético-jurídica entre la gestión del cuidado y la gestión de riesgos en el contexto de la seguridad del paciente l paulina milos h., ana i. larraín s. la enfermera y su equipo comparten la vocación de “cuidar” llevando a cabo, en dimensiones diferentes, trabajos, servicios y cuidados, con un mismo fin: el cuidado del paciente. en este contexto, la enfermera deberá desarrollar capacidades que permitan que en el equipo se genere identidad, pertenencia, adherencia, cohesión y compromiso; una verdadera “pirámide de servicio” donde cada cual aporta lo suyo como una parte del todo. también, con el fin de asegurar servicios humanizados y seguros, deberá establecer canales de comunicación efectivos que favorezcan la transversalidad de los valores humanos y profesionales que el grupo comparte. la participación de los pacientes: la calidad de la información la participación de los pacientes en la seguridad de la atención ha sido reconocida como una estrategia, tanto en la gestión de los riesgos de su propia atención como en la creación de sistemas de prestación de asistencia más seguros (34-36). las enfermeras cuentan con experiencia en la incorporación de pacientes y familias al autocuidado. lo que se pretende ahora es introducir al paciente en la cultura de la seguridad como un agente más en la atención en salud. un reciente estudio muestra cómo influye en la seguridad el conocimiento de los tratamientos por parte de los pacientes hospitalizados. demuestra que la información actúa como una suerte de filtro ante posibles errores de medicación y es clave para la mejora de la seguridad asistencial (37). cabe tener presente que en chile la ley 20.584, en su artículo 11, establece que “toda persona tendrá derecho a recibir, por parte del médico tratante, una vez finalizada su hospitalización, un informe legible que, a lo menos, deberá contener: a) la identificación de la persona y del profesional que actuó como tratante principal; b) el periodo de tratamiento; c) una información comprensible acerca del diagnóstico de ingreso y de alta, con sus respectivas fechas, y los resultados más relevantes de exámenes y procedimientos efectuados que sean pertinentes al diagnóstico e indicaciones a seguir, y d) una lista de los medicamentos y dosis suministrados durante el tratamiento y de aquellos prescritos en la receta médica”. a propósito de la exigencia de un informe hosbásico “la supervisión bancaria efectiva requiere que sea evaluado el perfil de riesgo de los bancos individuales y que los recursos de supervisión sean asignados en consecuencia”. supervisory guidance on dealing with weak banks report of the task force on dealing with weak banks [internet]. march 2002 [visitado 2012 noviembre 5]. disponible en: http://www.bis.org/publ/bcbs88.pdf pitalario, nos parece importante que en dicho informe se agregue lo pertinente a los cuidados de enfermería, comprendidos en ellos la gestión de riesgos y la seguridad del paciente en el hogar. las variables críticas para una real y activa participación de los pacientes son dos: escuchar las lecciones aprendidas por ellos como consecuencia de un tratamiento y la calidad de la información que se les entregue para prevenir daños. sin embargo, rara vez existen canales efectivos para recoger los aportes de los pacientes, en especial los relativos a un ea. por lo general, ante un ea se levanta un “muro de silencio” y cesa toda interacción productiva. es frecuente que las preocupaciones de los usuarios se perciban como amenazas de litigio o anécdotas sin base científica, y no como un posible aporte (38). de otra parte, habrá que recoger la experiencia extranjera acerca de la eficacia de instrumentos tales como el informe médico del alta, en cuanto sea comprensible para el paciente, tanto en el lenguaje como en la claridad de contenidos (39). una información de mala calidad puede generar inseguridad y con ello inhibir al paciente impidiéndole reconocer las anomalías en su persona o en la organización. la vinculación ético-jurídica entre la gestión del cuidado, la seguridad del paciente y la gestión de riesgos el acto de cuidar y la seguridad del paciente el aporte de las enfermeras a la seguridad del paciente emana precisamente de la esencia de la profesión, que es el cuidar. cuidado y seguridad se funden en el acto enfermero. el cuidar y la seguridad se relacionan estrechamente con la vulnerabilidad y la confianza de las personas, y ambas actividades se despliegan a través de acciones que se dirigen a proteger, mantener y conservar la vida de un modo integral. de ahí que la obligación de seguridad que recae sobre los profesionales y establecimientos de salud se ha denominado también “obligación de cuidados” (40). el cie, conforme a la naturaleza de la profesión, mantiene entre sus prioridades la identificación y reducción riesgos y errores, con el propósito de mejorar la seguridad y la calidad del cuidado 148 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 en salud (41). en la misma línea, la norma chilena que dispone una estructura para ejercer la función “gestión del cuidado” establece que en el desempeño de la función se requerirán conocimientos sobre dirección, gestión, trabajo en equipo e investigación, a fin de garantizar la calidad, seguridad, eficacia y eficiencia, la continuidad y coordinación entre los niveles, los cuidados y, en general, el bienestar de los pacientes (1). la relación enfermera-paciente crea un vínculo ético-jurídico la relación enfermera-paciente, en términos generales, crea un vínculo ético-jurídico que genera una obligación principal, cual es la prestación diligente de los servicios propios de la enfermera. en forma complementaria a esta obligación, surgen las obligaciones de previsibilidad y evitabilidad del daño. estas obligaciones accesorias son independientes en cuanto a que son exigibles aunque la obligación principal se haya cumplido. se podría decir que la intervención de la enfermera se despliega en dos planos: uno prestacional y otro de protección. el deber de prestación manda a hacer o no hacer algo a lo que uno se ha comprometido. en cambio, el deber de protección nace con el fin de no afectar el patrimonio, la integridad física ni psíquica, la salud, ni ningún otro derecho con ocasión de la ejecución de la prestación debida (42). aun cumplido el acto, la acción o la actividad profesional existe la obligación de prever los posibles daños y de evitarlos si a pesar de las medidas de prevención estos ocurren. a modo de ejemplo: la técnica diagnóstica conocida como “prueba de esfuerzo” tiene un riesgo de 1/10.000 de presentar un paro cardio-respiratorio durante el procedimiento. medidas de prevención: anamnesis dirigida a detectar síndrome coronario en evolución; control previo: electrocardiograma, presión arterial, frecuencia cardiaca; consultar sobre tratamiento con medicamentos (en especial betabloqueadores), otros. medidas de evitabilidad: carro de paro en condiciones de uso, personal entrenado en rcp, aplicar rcp en caso necesario, contacto previo con uti para el traslado eventual de un paciente, otros. la vinculación ético-jurídica entre la gestión del cuidado y la seguridad del paciente, y la consecuente gestión de riesgos la función “gestión del cuidado”, tanto en su fase abstracta ―gestión― como en su fase concreta ―cuidado―, se relaciona respectivamente con la previsibilidad y la evitabilidad del daño, en cuanto obligaciones accesorias de la prestación de servicios de enfermería. también se vincula con “las medidas de mejora” (8), en cuanto acciones “basadas en el aprendizaje” dirigidas a prevenir un futuro daño. primera fase: gestión la primera fase en la “gestión del cuidado” es intelectual, de carácter abstracto y corresponde a la gestión que, en nuestro caso, es un proceso en el que se definen prioridades y se toman decisiones sobre cuidados de enfermería. al involucrar valores intrínsecos tales como la vida, la integridad física y psíquica y la intimidad, y valores instrumentales como la eficiencia, la eficacia y la rentabilidad, hace que esta no sea una tarea neutra, ni exenta de tensiones que, como parte de su misión la enfermera habrá de resolver de un modo prudente (43), haciendo primar el interés del paciente por sobre los propios intereses, los de las instituciones de salud o los del estado. la fase de gestión se relaciona con el pensar, con el saber, con la moral personal y el ethos profesional; es básicamente valorativa. es en este momento cuando surge el deber de cuidado interno, que es el que obliga tanto a advertir los riesgos (el peligro) que encierra la intervención que se pretende como a ponderar los efectos adversos que pueden acarrear las decisiones que se toman. el deber de cuidado interno hace referencia también a la conciencia de las propias limitaciones y capacidades antes de emprender las acciones de cuidado. es en la fase de gestión que entendemos inserta la obligación de previsibilidad. en la prevención del daño la enfermera deberá incorporar, conforme a la disciplina de enfermería, la mejor evidencia científica disponible ―sobre riesgos relacionados con la atención en salud en general, la enfermedad y los cuidados de enfermería en particular— y los recursos con que se cuenta. sobre la base de estos y otros antecedentes se decidirán las medidas preventivas inmediatas y mediatas, las acciones de información y 149 la vinculación ético-jurídica entre la gestión del cuidado y la gestión de riesgos en el contexto de la seguridad del paciente l paulina milos h., ana i. larraín s. educación al paciente, las de orientación y capacitación del personal, las de supervisión general y supervisión por riesgos, y otras que conforme a las particulares características del paciente permitan prevenir el daño de un modo integral. como se aprecia, la fase de gestión hace alusión a la previsibilidad individual, lo que obliga a valorar el riesgo y adecuar la conducta y los medios a dicho peligro para evitar el resultado. en esta fase se deberá entonces evaluar el riesgo específico del paciente en razón de su edad, sexo, patologías, antecedentes, así como el riesgo inherente al ámbito y los procesos de atención en el que este se encuentra, a fin de garantizar las barreras de seguridad que requiera. asimismo, se deberá decidir para el caso concreto cuáles actividades de cuidado son encargables (delegables) y cuáles no (25); como también establecer, conforme a la “supervisión por riesgos”, un orden de prelación e intensidad en el control del paciente bajo cuidado. en esta primera fase queda incluido el deber informar sobre los riesgos del tratamiento o la intervención propuestos y la obtención del consentimiento o el rechazo a las propuestas de cuidado. el informar sobre los riesgos a los pacientes no solo pretende el ejercicio de su autonomía, con la aceptación o el rechazo, también tiene el efecto de involucrarlo en su cuidado (44)6 y de comprometerlo con su seguridad (45), todos aspectos que incidirán en la gestión del cuidado. esta fase culmina con la “prescripción de cuidados de enfermería” para el caso concreto. segunda fase: cuidado la segunda fase, que corresponde al cuidado, se sustenta en la prescripción enfermera hecha en la fase anterior. esta fase es de carácter concreto y se relaciona principalmente con el hacer: comprende un componente humano y un componente técnico, e involucra un deber de cuidado externo que consiste en actuar de acuerdo con el peligro conocido, esto es, adecuar la conducta a la situación peligrosa advertida, con el fin de evitar la producción del resultado previsto. también significa la abstención de la realización de acciones peligrosas más allá de lo razonable y socialmente permitido (46)7. esta fase implica una intervención que potencial6 el autor vincula el deber de información con el deber de consejo. 7 cualquier contacto social entraña un riesgo, incluso cuando todos los intervinientes actúan de buena fe, de ahí surge el concepto de riesgo permitido, el que entre otras concepciones se entiende como el resultado de un tipo de actividad adecuada socialmente. mente puede ―para bien o para mal― cambiar el curso natural de los procesos. en ella, más allá de la prestación del servicio, en caso de que un riesgo, previsto o no, en la etapa anterior se concrete, surge un deber de cuidado externo que activará la obligación de evitabilidad, que comporta desplegar todas las acciones posibles dirigidas a evitar que el daño se consume o a reducirlo, si no fuera posible evitarlo. así, a la enfermera se le puede pedir que prevea el riesgo y que, en su caso, mitigue los daños (47). tercera fase: de mejora por último se suma una tercera fase, que involucra a las dos anteriores, que es aquella en que, de ser necesario, se reparará o compensará el daño ocasionado, se informará al paciente y se implementarán medidas de mejora. en caso de un incidente, con o sin resultado de daño, se deberán tomar medidas dirigidas: i) al paciente: posterior tratamiento clínico de una lesión, información sobre el evento adverso, presentación de disculpas, entre otros, y ii) a la organización: reunión informativa con el personal comunicando lo ocurrido, revisión de procedimientos, modificación de procedimientos y rutinas de ser necesario, gestión de reclamaciones (8). esta última fase, por una parte, retroalimenta a la etapa de gestión y, por otra, exige a los prestadores de los cuidados directos dar cuenta sobre los incidentes que hubieren sobrevenido durante su intervención (4). si a pesar de los esfuerzos por prevenir y evitar el daño, este se concreta, surge el deber ético y, en chile, el imperativo legal de informar al paciente sobre la ocurrencia de un daño no deseado ni vinculado directamente con la enfermedad y su tratamiento. el paciente tiene derecho, por una parte, a saber qué ha pasado y, por otra, a reclamar apoyo, ayuda y reparación del daño causado (48). se sabe que informar sobre los errores beneficia a los pacientes: les permite buscar soluciones de forma precoz y apropiada, pudiendo prevenir daños futuros; bajar la ansiedad al conocer las causas de lo ocurrido y participar de forma activa en la toma de decisiones. por otra parte, ofrece la oportunidad de compensar las pérdidas y mejorar la relación asistencial (48). frente al deber de informar un ea se han descrito las siguientes respuestas: i) no cumplirlo y ocultar la información, ii) manejar la información con grupos de pares, iii) comunicarla al paciente conforme a las normas internas de la institución, iv) notificarla a las autoridades sanitarias. se ha reportado que los profesionales, 150 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 en su mayoría, evitan comunicar al paciente la ocurrencia de un ea, señalando no encontrarse preparados para afrontar estas situaciones (49). las causas de no informar se han relacionado con el desconocimiento; la falta de habilidad para hacerlo; el miedo a perder la confianza, la reputación, los privilegios, el estatus profesional e incluso la licencia para ejercer; el sentimiento de desprotección o el temor a acciones legales (48). en chile, la disposición legal contenida en el artículo 4 de la ley 20.584 establece que “toda persona o quien la represente tiene derecho a ser informada acerca de la ocurrencia de un evento adverso, independientemente de la magnitud de los daños que aquel haya ocasionado” (4). dada la reciente publicación de la ley, la autoridad ha definido que será el director del establecimiento quien informará al paciente o su representante (50). sin embargo, teniendo en consideración la presencia de daño para el paciente, queda aún sin definir: qué informar y cómo informar, y de qué modo la garantía constitucional de no autoincriminación se aplica en esta situación. consideraciones finales los estudios sobre ea en los diferentes niveles de atención coinciden en señalar que un elevado número de pacientes sufren daño o fallecen como consecuencia de una atención sanitaria no segura. en este contexto se ha valorado la posición estratégica de la enfermera y su equipo en el control de los riesgos que conlleva tanto la atención de enfermería como la atención en salud. la atención de enfermería tiene sus propios riesgos, que son frecuentes pero controlables. al quedar demostrada en este estudio la vinculación ética y jurídica existente entre la “gestión del cuidado” y la “gestión de riesgos”, la seguridad del paciente y la gestión de riesgos se levantan, para las enfermeras y la enfermería, como un imperativo moral y profesional: en la asistencia el trabajo de la enfermera, que se desarrolla a través de actuaciones en equipo, caracterizado por un actuar jerárquico, implica supervisar las acciones que emanan del acto enfermero. de cara a la evidencia científica y la escasez de enfermeras se propone la supervisión por riesgos ya que permite mejorar la eficiencia y eficacia en el control de los riesgos, como también propender a la configuración de una pirámide de servicios fundada en el deber de protección de los pacientes; en el deber de velar por los recursos, tanto personales como institucionales, y en la mejora continua de la calidad de la atención y la profesión. se espera que los supervisores valoren la gestión de riesgos, aporten información sobre los riesgos observados, contribuyan a la cultura de la calidad y seguridad, y colaboren eficazmente con el gestor de riesgos, la unidad de calidad y la alta dirección del establecimiento. teniendo en cuenta que la supervisión por riesgos es una propuesta, de ser usada se recomienda elaborar un plan piloto validado por la institución a fin de evaluar su seguridad, eficiencia y eficacia, y comunicar sus resultados. es oportuno recordar que el legislador chileno, junto a la “gestión del cuidado” deposita en las enfermeras “el deber de velar por la mejor administración de los recursos de asistencia para el paciente”. la “gestión del cuidado” se impregna así de la ciencia de la administración y del deber ético de velar por los recursos. aspecto relevante del quehacer de la enfermera, que se conjuga al momento de gestionar y de ejecutar acciones de cuidado, en especial ante el imperativo de gestionar el riesgo de daños asociados a dichos recursos. por último, en este ámbito cabe a las enfermeras ser promotoras de la participación de los pacientes en su propio cuidado. ello en reconocimiento de su razón, como parte de su dignidad, y del legítimo interés que los pacientes tienen por su salud como también por los resultados positivos observados cuando se involucra a estos y sus familias en su propia seguridad. en la formación las entidades formadoras deberán asegurar que las mallas curriculares contemplen aquellos contenidos y competencias necesarias para que las enfermeras asuman desde la disciplina, y con propiedad, la “gestión de riesgos” y la “seguridad del paciente”, en tanto deberes éticos y obligaciones jurídicas que integran la “gestión del cuidado”. asimismo, como se ha sugerido en la literatura, es recomendable incorporar la gestión de riesgos y la seguridad del paciente en la formación teórica y práctica de alumnos. en la investigación8 las enfermeras deberán promover investigación que les permita, por una parte, identificar y describir los problemas de segu8 propuestas elaboradas sobre la base del curso on-line “introducción a la investigación en seguridad del paciente”. organización mundial de la salud (oms) y universidad de zaragoza, junio, 2012. disponible en: http://www.who.int/patientsafety/research/curso_virtual/es/index.html 151 la vinculación ético-jurídica entre la gestión del cuidado y la gestión de riesgos en el contexto de la seguridad del paciente l paulina milos h., ana i. larraín s. ridad propios de enfermería y, por otra, desarrollar y evaluar las soluciones planteadas conforme a los entornos de trabajo. será necesario, en cada lugar, estimar la magnitud y las características del riesgo que entrañan los servicios de la enfermera, conocer los factores que contribuyen a la aparición de ea, evaluar el impacto de los resultados adversos en el sistema de salud e identificar soluciones efectivas, factibles y sostenibles para lograr una atención segura, desde el ámbito de la enfermería. por último, a la luz de recientes estudios internacionales que miden el impacto de la atención de enfermería sobre la seguridad de los pacientes, se podrá evaluar el estado de la seguridad del paciente en chile. referencias 1. ministerio de salud (chile). comisión de legislación de enfermería 1995-1997. definición recogida en la norma 19, técnica administrativa. ministerio de salud [internet]. 2007 [visitado 2012 noviembre 1]. disponible en: http://juridico1. minsal.cl/resolucion_1127_07.doc 2. gómez o, soto a, arenas a, garzón j, gonzález a, mateus é. una mirada actual de la cultura de seguridad del paciente. av enferm. 2011;29(2):363-74. 3. milos p, larrain ai, simonetti m. categorización de servicios de enfermería: propuesta para asegurar una atención de calidad en tiempos de escasez de enfermeras. cienc enferm. 2009;15(1):17-24. 4. ley 20.584 de 13 de abril de 2012. regula los derechos y deberes que tienen las personas en relación con acciones vinculadas a su atención en salud [internet]. [visitado 2012 noviembre 1]. disponible en: http://www.leychile.cl/ navegar?idnorma=1039348 5. ministerio de salud (chile). subsecretaría de redes asistenciales. establece protocolos y normas sobre seguridad del paciente y calidad de la atención para ser aplicados por los prestadores institucionales públicos y privados (protocolo 0001). [internet]. [visitado 2012 diciembre 1]. disponible en: http://www.minsal.gob.cl/portal/url/item/ccb9752d3583b124e040010164010e01.pdf 6. pezoa m. superintendencia de salud: ¿qué elementos de la atención son, desde la perspectiva del usuario, los que más contribuyen a que se sienta satisfecho? [internet]. enero 2012 [visitado 2012 noviembre 1]. disponible en: http://www. minsal.gob.cl/portal/docs/1/5709760.pdf 7. ministerio de sanidad y consumo (españa). estudio apeas. estudio sobre la seguridad de los pacientes en atención primaria de salud [internet]. 2008 [visitado 2012 noviembre 2]. disponible en: http://www.msc.es/organizacion/sns/ plancalidadsns/docs/libroapeas.pdf 8. world health organization. más que palabras: marco conceptual de la clasificación internacional para la seguridad del paciente. informe técnico definitivo [internet]. enero de 2009 [visitado 2012 noviembre 2]. disponible en: http://www. who.int/patientsafety/implementation/icps/icps_full_report_es.pdf 9. martínez fj, ruiz jm, editores. manual de gestión de riesgos sanitarios. madrid: díaz de santos; 2001. p. 53-67. 10. barrientos m. del daño moral al daño extrapatrimonial: la superación del pretium doloris. revista chilena de derecho. 2008;35(1):85-106. 11. arango lj. importancia de los costos de la calidad y no calidad en las empresas de salud como herramienta de gestión para la competitividad. rev esc adm neg 2009;67:75-94. 12. ruiz jm. riesgo, incertidumbre y error en la práctica sanitaria. en: martínez fj, ruiz jm, editores. manual de gestión de riesgos sanitarios. madrid: díaz de santos; 2001. p. 1-24. 13. sánchez e. el principio de precaución: implicaciones para la salud pública. gac sanit. 2002;16(5):371-73. 14. ministerio de sanidad y consumo (españa). benchmarking de buenas prácticas en la gestión de riesgos y políticas de reordenación del gobierno clínico en el ámbito hospitalario. madrid: ministerio de sanidad y consumo [internet]. 2008 [visitado 2012 noviembre 2]. p. 33. disponible en: http://www.msc.es/organizacion/sns/plancalidadsns/docs/benchmarkinggestionriesgosgobiernoclinico.pdf 152 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 15. australian / new zealand standard, as/nzs 4360:1995. en: martínez fj, ruiz jm, editores. manual de gestión de riesgos sanitarios. madrid: díaz de santos; 2001. p. 59. 16. atewell a. florence nightingale 1821-1910. perspectivas: revista trimestral de educación comparada. 1998;28(1):173-189. 17. baptista jl. experiencias internacionales en gestión de riesgos sanitarios. en: martínez fj, ruiz jm, editores. manual de gestión de riesgos sanitarios. madrid: díaz de santos; 2001. pp. 226-228. 18. mason d. transforming health care for patient safety: nurses’ moral imperative to lead. en: hughes rg, editor. patient safety and quality: an evidence-based handbook for nurses. rockville (md): agency for healthcare research and quality (us); 2008. 19. sammer c, james b. patient safety culture: the nursing unit leader’s role. ojin: the online journal of issues in nursing [internet]. 2011 [visitado 2012 noviembre 4]. 16 (3). disponible en: http://www.nursingworld.org/mainmenucategories/anamarketplace/anaperiodicals/ojin/tableofcontents/vol-16-2011/no3-sept-2011/patient-safety-cultureand-nursing-unit-leader.html 20. needleman j, buerhaus p, mattke s, stewart m, zelevinsky k. nurse-staffing levels and the quality of care in hospitals. n engl j med. 2002;346:1715-1722. 21. tourangeau ae, doran dm, mcgillis l, o’brien-pallas ll, pringle d, tu jv et al. impact of hospital nursing care on 30-day mortality for acute medical patients. j ad nur. 2007;57(1):32-44. 22. superintendencia de salud (chile). usuarios del sistema de salud quieren más calidez en el trato e información que se entienda a la hora de ser atendidos por los médicos. [internet]. [visitado 2012 noviembre 4]. disponible en: http:// www.supersalud.gob.cl/568/w3-article-7393.html 23. muñoz-castro fj, valverde-gambero e, villanueva-guerrero l, mudarra-aceituno mj, vázquez-vázquez m, almuedopaz, a. evolución de la formación continuada acreditada tras la puesta en marcha de la estrategia para la seguridad del paciente. rev calidad asistencial. 2012;27(5):262-69. 24. singer sj, gaba dm, falwell a, lin s, hayes j, baker l. patient safety climate in 92 us hospitals: differences by work area and discipline. med care. 2009;47:23-31. 25. gómez ai, espinosa af. dilemas éticos frente a la seguridad del paciente. cuidar es pensar. aquichán. 2006;6(1):54-67. 26. ministerio de sanidad y política social (españa). la seguridad en los cuidados de los pacientes hospitalizados. proyecto séneca. madrid: ministerio de sanidad y política social [internet]. 2010 [visitado 2012 noviembre 4]. disponible en: http://www.mspsi.gob.es/organizacion/sns/plancalidadsns/pdf/proyectoseneca.pdf 27. ministerio de sanidad y política social (españa). estándares de calidad de cuidados para la seguridad del paciente en los hospitales del sns. proyecto séneca: informe técnico 2008 [internet]. madrid: ministerio de sanidad y política social. 2009 [visitado 2012 noviembre 4]. disponible en: http://www.msc.es/organizacion/sns/plancalidadsns/docs/ seneca.pdf 28. henderson v. principios básicos de los cuidados enfermería. ginebra: consejo internacional de enfermeras; 1971. 29. villarreal e. seguridad de los pacientes. un compromiso de todos para un cuidado de calidad. salud uninorte. 2007;23(1):112-19. 30. gómez o, arenas w, gonzález l, garzón j, mateus e, soto a. cultura de seguridad del paciente por personal de enfermería en bogotá. cienc enferm. 2011;17(3):97-111. 31. milos p, larraín ai, simonetti m. humanidad y seguridad en la atención de pacientes: guía de buenas prácticas para docentes y alumnos. santiago de chile: mediterráneo; 2010. 32. rodríguez v, paravic t. enfermería basada en la evidencia y gestión del cuidado. enferm glob. 2011;10(24):246-53. 33. pedro-gómez j, morales-asencio jm, sesé a, bennasar m, artigues g, perelló c. entorno de práctica de los profesionales de enfermería y competencia para la incorporación de la evidencia a las decisiones: situación en las islas baleares. gac sanit. 2011;25(3):191-97. 153 la vinculación ético-jurídica entre la gestión del cuidado y la gestión de riesgos en el contexto de la seguridad del paciente l paulina milos h., ana i. larraín s. 34. ministerio de salud y consumo (españa). estrategia en seguridad del paciente: recomendaciones del taller de expertos celebrado el 8 y 9 de febrero de 2005. [internet]. [visitado 2012 noviembre 5]. disponible en: http://www.msc.es/organizacion/sns/plancalidadsns/pdf/excelencia/opsc_sp1.pdf 35. organización mundial de la salud. 59ª asamblea mundial de la salud, punto 11.16 del orden del día provisional. la seguridad del paciente. [internet]. [visitado 2012 noviembre 5]. disponible en: http://apps.who.int/gb/ebwha/pdf_files/ wha59/a59_22-sp.pdf 36. organización mundial de la salud. pacientes en defensa de su seguridad. [internet]. [visitado 2012 noviembre 5]. disponible en: http://www.who.int/patientsafety/patients_for_patient/statement/es/index.html 37. santos-pérez mi, garcía-rodicio s, abajo del álamo c. conocimiento de los tratamientos en pacientes hospitalarios: herramienta necesaria para la seguridad asistencial. rev calidad asistencial. 2012;27(5):270-74. 38. lópez m, director. tratado de responsabilidad médica. responsabilidad civil, penal y hospitalaria. santiago de chile: legis; 2007. p. 483. 39. jiménez-puente a, lara-blanquer a, benítez-parejo n, garcía-díaz ma, garcía-alegría j. claridad de las recomendaciones al paciente en el informe de alta hospitalaria. rev calidad asistencial. 2012;27(5):283-7. 40. guajardo b. aspectos de la responsabilidad civil médica. doctrina y jurisprudencia. 2ª ed. santiago de chile: librotecnia; 2005. p. 75. 41. consejo internacional de enfermería (cie). declaración de posición del cie: seguridad de los pacientes. [internet]. [visitado 2012 noviembre 6]. disponible en: http://www.patienttalk.info/pspatientsafesp.htm 42. cabanillas a. introducción al estudio del deber de protección en el derecho de obligaciones. homenaje a luis rojo. santander: servicio de publicaciones de la universidad de cantabria; 2002. p.175. 43. gracia d. la ética en las instituciones sanitarias: entre la lógica asistencial y la lógica gerencial. en: ética profesional y ética institucional: entre la colaboración y el conflicto. cuadernos de la fundació víctor grífols i lucas. [internet]. [visitado 2012 noviembre 6]. disponible en: http://www.fundaciogrifols.org/polymitaimages/public/fundacio/publicacions/pdf/cuaderno28.pdf 44. acosta v. la responsabilidad civil médica. santiago de chile: jurídica de chile; 1990. p. 251. 45. de lorenzo l, montero r. responsabilidad legal del profesional sanitario. madrid: asociación española de derecho sanitario; 2000. 46. mir s. derecho penal: parte general. 8ª ed. barcelona: reppertor; 2009. p. 522-23. 47. barrientos m. la obligación de seguridad en la subcontratación laboral: previsibilidad del hecho y del daño. revista chilena de derecho. 2012;39(1):77-111. 48. lorda s. ética y seguridad de los pacientes. humanitas, humanidades médicas. 2005;8:145-60. 49. iglesias-alonso f, tejero-gonzález jm, torijano-casalengua ml, mira jj. elementos básicos de una cultura de seguridad clínica (carta al director). rev calidad asistencial. 2012;27(5):295-7. 50. ministerio de salud (chile). subsecretaría de redes asistenciales. normas sobre seguridad del paciente y calidad de la atención respecto de: reporte de eventos adversos y evento centinela (protocolo 0002) [internet]. [visitado 2012 diciembre 1]. disponible en: http://www.minsal.gob.cl/portal/url/item/ccba4463ab346131e040010164016a11.pdf 05. elcuidado de enfermer™a ok año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 24 resumen en el presente artículo se pretende motivar a los profesionales de enfermería para que retomen la familia como un paciente o cliente que necesita de cuidados de enfermería y de autocuidados. la enfermera(o) es la(el) llamada(o) a brindar cuidados de promoción de la salud y prevención de la enfermedad, de tal manera que descubra en cada una de las familias las potencialidades y fortalezas para que ayuden a mantener la adaptación en ellas. palabras clave enfermería, familia, cuidado, salud familiar, sistema. abstract this article pretends to motivate nursing professionals to consider the family as a patient or client needing nursing and self-care. the nurse is the one who gives health promotion and disease prevention care, to discover in each family the potentialities and strength to maintain adaptation. key words nursing, family, care, family health, system. beatriz pérez giraldo profesora asistente facultad de enfermería • universidad de la sabana 25 el cuidado en enfermería en familia: un reto para el siglo xxi n el presente artículo se pretende motivar a los profesionales de enfermería para que retomen la familia como un paciente legítimo y como una entidad que puede en sí misma necesitar de cuidados de enfermería y de autocuidados. entre las muchas definiciones de familia, una dice que es un grupo de personas que viven bajo un mismo techo, comparten creencias y costumbres y tienen como finalidad el bien ser y el bienestar de cada uno de sus miembros. para friedman, “la familia está compuesta de personas unidas por lazos matrimoniales, sanguíneos o de adopción. los miembros de la familia usualmente viven juntos, interactúan y se comunican con cada rol que tengan, bien sea esposa, esposo, madre, padre, hijo, hija, hermano, hermana. la familia comparte una cultura común”(1). “la familia está constituida por un grupo de individuos, hombres, mujeres, adolescentes y niños, cuyos rangos de edades pueden extenderse dos o más generaciones. las relaciones dentro de la familia son más intensas que en cualquier grupo de la sociedad. la familia normalmente posee una larga historia colectiva. su vida es un continuo flujo del distante pasado, del presente y del futuro. la familia tiene ciertas características que la distinguen: comparte un lenguaje, una clase social, un hogar, un ingreso económico; tiene funciones de satisfacer las necesidades afectivas y económicas de sus miembros, la satisfacción sexual de la pareja y la procreación y crianza de los hijos”(2). con el paso del tiempo, la familia ha pasado de ser considerada como constituida por marido, mujer e hijos a ser aceptada como un grupo de individuos con edades diferentes y pertenecientes a varias generaciones, donde se cumplen funciones afectivas, económicas y se tienen comportamientos propios. es importante tener a la familia como una unidad, como un sistema, en el cual cualquier alteración en alguno de sus miembros implica disfuncionalidad en la totalidad, mas no como la sumatoria de sus partes. “la familia constituye un sistema en todo el sentido de la palabra, en tanto que está formada por un conjunto organizado de elementos que se relacionan e interactúan entre sí, de tal manera que cualquier acción, alteración o cambio en uno de ellos repercute en todos los demás, y viceversa”(3). cuando aparece cualquier enfermedad en la familia, la unidad es afectada en su totalidad, es un proceso colectivo que afecta a cada uno de sus miembros. el cuidado familiar, según wright y leahey, “puede ser conceptualizado en dos direcciones: en la primera está el enfoque del individuo en el contexto de la familia, donde aquel es la figura y esta es el fundamento, y en la segunda –que enfoca a ambos, el individuo y la familia–, los sistemas de cuidado familiar pueden ser conceptualizados como enfoque sobre la familia completa como la unidad de cuidado”(4). las enfermeras(os) debemos optar por una de las dos posiciones, no porque una tenga mayor valor que la otra, sino por la que se adapte al nivel de competencia del profesional de enfermería. cuidar desde un enfoque familiar implica incluir a la familia en el proceso de prestación de cuidados. es así como ella se convierte en un estímulo favorable para la recuperación de la salud de alguno de sus miembros. surgen entonces algunas definiciones, como la de “salud familiar, que se refiere tanto al estado de salud de los integrantes de la familia como a la efectividad o funcionalidad de la familia como unidad”(5). horwitz dice que la salud familiar es el resultado de la interacción de sus componentes: a) salud física y psicológica de cada “sueño que algún día las enfermeras del mundo irán a los domicilios a cuidar y a curar a las personas que sufren y no tienen suficiente atención. pero eso tal vez sea para el año 2000”. florence nightingale (1820-1910) año 2 nº 2 • bogotá, colombia octubre 2002 revista aquichan issn 1657-5997 26 integrante de la familia y manejo de los problemas familiares. b) calidad de las relaciones interpersonales entre los miembros de la familia. c) características socio-económicas, demográficas y culturales de cada familia, que condicionan el tipo de problema que la familia enfrenta y resuelve durante su ciclo. desde esta perspectiva, el profesional de enfermería debe tener una preparación rigurosa para el trabajo con familias y desarrollar en estas un sentimiento de unidad y promover la cooperación, el apoyo mutuo y la coordinación; propiciar algunas formas de adaptación a las diferentes situaciones a las que se deben enfrentar en el transcurso de su ciclo vital familiar; ver a las familias como cuidadoras de sus propios miembros, e identificar el hogar como el lugar en que viven el paciente y sus familiares y amoldarse a ellos. este trabajo implica una gran responsabilidad, compromiso, sentido común, creatividad, continuidad en la atención, cuidado integral y trabajo interdisciplinario. según zerwekh (6), “establecer relaciones interpersonales durante las visitas domiciliarias de enfermería es la base para influir efectivamente en el comportamiento de salud y ayudar a que la gente se haga cargo de sus propias vidas”. al desarrollar estas clases de uniones se fortalecen las relaciones de cuidado, que llevan a mejorar estilos de vida y, por ende, la salud de la familia. se necesita de enfermeras(os) que tengan una visión amplia del cuidado, que se salgan de las rutinas hospitalarias y del esquema de que todo lo saben y que el paciente y la familia son seres pasivos de atención. en este abordaje familiar pueden surgir muchas dificultades, como la inseguridad al presentarse situaciones que no están previstas, el riesgo de atracos y asaltos, tener sustos, las posibilidades de accidentes, soportar las inclemencias del tiempo, todo lo cual “impone una tensión a la enfermera, especialmente en los primeros encuentros. cuando todavía no conoce al paciente y a la familia, o cuando los procesos son complicados, los riesgos son muchos o las expectativas puestas por la familia en la enfermera son desproporcionadas”(7). el cuidar a la familia se convierte en un reto profesional, ya que nos salimos de los esquemas del cuidado, bien sea en hospitales o centros de salud, en donde la situación familiar muy poco se vislumbra a plena luz. la atención domiciliaria será el futuro de gran parte de la profesión, siempre y cuando como enfermeras nos demos a conocer con una atención de calidad y logremos que reconozcan nuestro lugar fundamental en el sistema de salud. con la ley 100, de 1993, se le da un reconocimiento a la familia como la unidad básica que tiene como papel importante la conservación de la salud de sus miembros. cada individuo de la familia tiene la responsabilidad de cuidarse y utilizar los recursos de la familia y del ambiente para conservar la salud o recuperarla. en esta ley se aclara que la presencia de la salud o la enfermedad en la familia es producto de factores económicos, biológicos, sociales, culturales, ambientales y relacionados con los servicios de salud (multicausalidad). por lo tanto, se hace necesario que el profesional de enfermería tenga en cuenta esa conjunción de factores que actúan simultáneamente para mantener la salud de la familia. además, esta debe ser abordada por muchos profesionales de la salud así como de otras áreas, en un trabajo interdisciplinario que busque solucionar los problemas. es de suma importancia la participación de los profesionales de enfermería en el ámbito de la salud familiar, pues estos son los llamados a brindar cuidados de promoción de la salud y prevención de la enfermedad. hallando las potencialidades internas de la familia se busca reorientar su utilización o la identificación de los recursos externos que se encaminen a solucionarles sus necesidades. cuando abordamos la familia en procesos preventivos, promocionales y de rehabilitación, estamos brindando cuidados de enfermería y estamos dando cumplimiento al sueño de florence nightingale. bibliografía 1. friedman, m. family nursing. theory and assessment. introduction to the family, the united states of america, appleton century crofts, 338, 1981. 2. amaya de peña, p. familias de ancianos y escolares del sector de la estrella, ciudad bolívar (fase diagnóstica), bogotá, universidad nacional de colombia, facultad de enfermería, 12, 1992. 3. goldenberg, d. s. “la familia, un paciente olvidado”, revista rol de enfermería, 223: 25-30, 1997. 4. lorraine, m. w. and leahey, m. “trends nursing of families”, journal of advances nursing, 15: 148-154, 1990. 5. amaya de peña, p. memorias del primer congreso colombiano de salud familiar, cafam, bogotá, 454, 1987. 6. zerwekh, joyce v. making the connection during home visits: narratives of expert nurses, vol. 1, n° 1, 1997. 7. anton nardiz, m. las enfermeras, entre el desafío y la rutina. la enfermera domiciliaria, bocángel, madrid, díaz santos, 139, 1998. 247 260 carga del cuidado de la enfermedad.indd 247 beatriz sánchez-herrera1 gloria mabel carrillo-gonzález2 lucy barrera-ortiz3 lorena chaparro-díaz4 carga del cuidado de la enfermedad crónica no transmisible 1. enfermera. magíster en enfermería. profesora titular, universidad nacional de colombia, colombia. cbsanchezh@unal.edu.co 2. enfermera. magíster en enfermería. profesora asistente, universidad nacional de colombia, colombia. gmcarrillog@unal.edu.co 3. enfermera. magíster en enfermería. profesora titular, universidad nacional de colombia, colombia. lbarrerao@unal.edu.co 4. enfermera. doctora en enfermería. profesora asistente, universidad nacional de colombia, colombia. olchaparrod@unal.edu.co recibido: 6 de julio de 2012 enviado a pares: 25 de agosto de 2012 aceptado por pares: 6 de junio de 2013 aprobado: 6 de junio de 2013 año 13 vol. 13 nº 2 chía, colombia agosto 2013  247-260 para citar este artículo / to reference this article / para citar este artigo sánchez herrera, b., carrillo gonzález, g. m., barrera ortiz, l., chaparro díaz, l. (2013). carga del cuidado de la enfermedad crónica no transmisible. aquichan. vol. 13, no. 2, 247-260. resumen objetivo: analizar los diferentes enfoques para abordar la carga del cuidado en la enfermedad crónica no transmisible (ecnt). materiales y métodos: con base en una revisión de literatura en las bases de datos: cinahl, ovid, scielo, medline y psychoinfo, bajo los descriptores carga, impacto, costos, en combinación con enfermedad crónica y cuidado, con su respectiva traducción al inglés, se identificaron y analizaron los elementos estudiados como carga del cuidado de la ecnt. resultados: la carga del cuidado en la ecnt es un constructo multidimensional que incluye la perspectiva epidemiológica (relación con la frecuencia y valoración de consecuencias en años de vida y pérdidas funcionales), la económica (impacto sobre consumo, ahorro, oferta de mano de obra, productividad y acumulación de capital humano) y la social (factores de desgaste, estrés, impacto familiar, limitación social y aspectos positivos de la experiencia), con múltiples interrelaciones entre sí. conclusión: se requiere una mirada integral para examinar la carga del cuidado en la ecnt que incluya a los actores sociales afectados: pacientes, cuidadores familiares, familias, profesionales e instituciones de salud. palabras clave enfermedad crónica, cuidadores, costo de enfermedad, enfermería. (fuente: decs, bireme). 248 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 the burden of care in instances of chronic non-communicable disease abstract objective: the purpose of this study is to analyze different approaches to addressing the burden of care in instances of chronic noncommunicable disease (cncd). materials and methods: it is based on a review of the literature in several databases (cinahl, ovid, scielo, medline and psychoinfo). the descriptors, in english, were burden, impact and costs combined with chronic disease and care, and the elements studied were identified and analyzed as burden of care in cncd. results: the burden of care in cdcd is a multidimensional construct that includes the epidemiological perspective (in relation to frequency and assessment of consequences on years of life and functional losses), the economic angle (impact on consumption, savings, labor supply, productivity and human capital accumulation) and the social mind-set (factors involving wear and tear, stress, family impact, social limitations and positive aspects of the experience), with multiple relationships between them. conclusion: examining the burden of care in instances of cncd requires a comprehensive approach that includes the affected stakeholders; namely, patients, family caregivers, families, health professionals and health care institutions. key words chronic disease, caregivers, cost of illness, nursing. (source: decs, bireme). carga do cuidado da doença crônica não transmissível resumo objetivo: analisar os diferentes enfoques para abordar a carga do cuidado na doença crônica não transmissível (dcnt). materiais e métodos: com base em uma revisão de literatura nas bases de dados cinahl, ovid, scielo, medline e psychoinfo, sob os descritores carga, impacto, custos, em combinação com doença crônica e cuidado, com sua respectiva tradução para o inglês, identificaram-se e analisaram-se os elementos estudados como carga do cuidado da dcnt. resultados: a carga do cuidado na dcnt é um construto multidimensional que inclui a perspectiva epidemiológica (relação com a frequência e valoração de consequências em anos de vidas e perdas funcionais), a econômica (impacto sobre consumo, poupança, oferta de mão de obra, produtividade e acumulação de capital humano) e a social (fatores de desgaste, estresse, impacto familiar, limitação social e aspectos positivos da experiência), com múltiplas inter-relações entre si. conclusão: requer-se um olhar integral para examinar a carga do cuidado na dcnt que inclua os atores sociais afetados: pacientes, cuidadores familiares, família, profissionais e instituições de saúde. palavras-chave doença crónica, cuidadores, efeitos psicossociais da doença, enfermagem. (fonte: decs, bireme). 249 carga del cuidado de la enfermedad crónica no transmisible l beatriz sánchez-herrera, gloria mabel carrillo-gonzález, lucy barrera-ortiz, lorena chaparro-díaz introducción el problema de la ecnt ha tenido tal incremento en todo el mundo, que la asamblea general de las naciones unidas del 19 y 20 de septiembre de 2011 en nueva york, se dedicó a su análisis buscando concertar un compromiso que ubique la atención internacional sobre la situación de la enfermedad crónica y darle a este tema un lugar prioritario en la agenda de desarrollo internacional (1). abegunde et al. estudiaron la carga de la ecnt, en especial cardiovascular, cáncer, pulmonar y diabetes, en relación con la pérdida de crecimiento económico asociada a esta. analizaron información en 23 países de ingresos bajo y medio, entre ellos brasil, argentina, méxico y colombia, que en conjunto incluyeron cerca del 80 % del total de la carga de la mortalidad por enfermedad crónica de los países en desarrollo. en dichos países, para 2005, estas dolencias eran responsables del 50 % de la carga de la mortalidad. en 15 de estos 23 países las tasas de mortalidad estandarizadas eran 54 % más altas para los hombres y 86 % para las mujeres que las correspondientes en países desarrollados. los autores señalan que si no se hace nada para disminuir el riesgo de las ecnt, un estimado de us$84 billones de producción económica se perderá por enfermedades cardiocerebrovasculares y diabetes, solamente en esos 23 países entre los años 2006 al 2015. macinko et al. ratifican lo anterior al indicar que en américa latina y el caribe la acelerada transición demográfica y epidemiológica de la región se caracteriza por mayor prevalencia de ecnt; en particular las enfermedades cardiovasculares, los infartos y el cáncer, son hoy la principal causa de morbilidad y mortalidad en américa latina y el caribe, dado que representan el 68 % de las muertes y el 60 % de los años de vida ajustados en función de la discapacidad en la región. mientras en 2008 el bid reportaba 72 % de muertes por ecnt como proporción del total de fallecimientos, para el 2030 en el grupo de todas las edades se espera tener un incremento de 81 % de muertes asociadas a estas. de igual forma se observa un aumento en los problemas de salud mental, como es el caso de la depresión (1). en colombia, el incremento de la ecnt se vive en medio de un sistema general de seguridad social en salud (sgsss) frágil (2, 3), con ausencia de propuestas concretas para el manejo integral de las personas con ecnt y sus familias. el sgsss colombiano no reconoce a los cuidadores familiares como parte integral del mismo, y no ha generado mecanismos sólidos para apoyar a las familias frente a la creciente responsabilidad de cuidar a sus enfermos, como consecuencia de la búsqueda de disminución de costos de institucionalización por parte de las empresas promotoras de salud (eps), y son muy pocos, casi inexistentes, los servicios integrales que requiere el tratamiento y manejo de las personas con ecnt (4). tampoco se conocen planes institucionales que aborden el tema del cuidado seguro frente a las personas con estas enfermedades, ni planes o programas de incentivos para la formación de profesionales de la salud en este campo. poco se pregunta por el costo de oportunidad en la prevención de la ecnt en términos de los años de vida productivos perdidos (avpp), en sufrimiento y discapacidad para los pacientes, y en compromiso y desgaste psicológico, económico y social de los cuidadores familiares, las familias, los profesionales e instituciones de salud y del sistema mismo a largo plazo. en el país se reciben a diario denuncias sobre el sgsss que han obligado incluso a replantearlo totalmente (5). esta situación afecta a la población y vulnera sus derechos, en especial los de las personas con enfermedades crónicas, quienes tienen mayor dependencia del sistema. vale la pena señalar que a pesar del reconocimiento de la ecnt como un problema de salud pública, dentro del sgsss no hay claridad sobre los deberes y derechos de las personas enfermas, sus cuidadores o las familias, ni tampoco sobre los procesos que deben orientar a los profesionales ni a las instituciones de salud frente al cuidado de las personas con ecnt. en tal sentido, para aliviar la carga del cuidado de la ecnt se hace necesario comprender qué tipo de enfermedades se presentan, cuál es su dinámica, quiénes son las personas e instituciones involucradas, cuáles y cómo son los procesos necesarios para el cuidado de su salud y con qué apoyos cuentan. con esta información se podrá generar una línea de base que permita medir el avance sobre el tema en el país para aliviar la verdadera carga de la ecnt. dicho diagnóstico debe incluir, entre otros, los gastos físicos, psicológicos, sociales, económicos y financieros que caracterizan la presencia de la enfermedad crónica, incluyendo en el análisis a todos los actores e instancias involucrados. agudelo et al., con el fin de priorizar el tipo de investigación en salud que requiere el país, adelantaron un ejercicio con métodos recomendados en el ámbito internacional, como la matriz com250 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 binada propuesta por el foro mundial para la investigación en salud. con este acercamiento metodológico diseñaron y aplicaron un procedimiento para ponderar y ordenar, de manera cualitativa y cuantitativa, las problemáticas de investigación en salud, a partir del cual los representantes de comunidades científicas trabajaron para identificar la investigación requerida en el país. sus resultados señalan que colombia debe priorizar la investigación sobre las enfermedades crónicas (6). por otro lado, se deduce la necesidad de formación y capacitación del recurso humano en salud para asumir el reto del cuidado durante la cronicidad no solo en la actualidad sino en el que se proyecta para los próximos años, incluyendo el reto de generar planes o programas que incentiven la cualificación en esta área. la carga del cuidado de la salud en la ecnt es parte de los estudios necesarios y urgentes ya que comprenderla y aliviarla puede llegar a fortalecer al sgsss. el constructo “carga del cuidado de la ecnt”, o carga de la ecnt, representa un fenómeno no tangible, que no puede ser directamente observable o demostrable pero sí inferible. a pesar de que su esclarecimiento ha sido difícil y controvertido, se tienen avances importantes a nivel mundial logrados a través de procesos de categorización y medición de la carga del cuidado o carga de la ecnt, que incluyen entre otros la percepción, la conducta o el impacto que esta carga genera. el objetivo del presente trabajo es revisar qué significa y cómo se ha medido la carga de la ecnt para desarrollar con base en los avances disponibles una propuesta acorde al contexto colombiano. materiales y métodos con base en una revisión sistemática de la literatura que incluyó un periodo de 35 años, fueron identificados y analizados los elementos estudiados como parte del constructo “carga del cuidado de la ecnt”. se incluyeron artículos que estudiaron el contexto, la medición del fenómeno y las diversas formas de categorizarlo o abordarlo. de 158 documentos encontrados se seleccionaron los 80 que cumplieron criterios de inclusión y se analizaron a través de una matriz en la que se consideró la procedencia del documento, los objetivos, la metodología, los resultados y las conclusiones. dentro del trabajo se consideraron aspectos éticos propios de la revisión documental como la honradez en el trabajo científico, el respeto por los datos observados, sin deformarlos en beneficio de nada ni nadie, el respeto por las autorías mediante la citación exacta y la verificación sobre el interés del fenómeno estudiado para la comunidad científica y la sociedad en general. el comité de ética institucional dio aval al proyecto en el que se desarrolló la presente revisión5. se revisó con expertos en el tema y se encontró que el estudio atiende la política ambiental institucional6. resultados significado del contexto en el cuidado de la ecnt aunque las ecnt no se presentan en un segmento exclusivo de la población, es de particular relevancia el impacto que tienen sobre la población pobre, dada la mayor prevalencia de factores de riesgo, el menor acceso a servicios de detección y tratamiento, así como su menor capacidad para hacer frente a las consecuencias financieras que la ecnt genera (7, 8). algunas familias pobres reportan el gasto de todos sus ahorros con un episodio de exacerbación de la enfermedad (9). samb et al. establecen que los sistemas de salud de las naciones de bajo y mediano recurso necesitan fortalecimiento para asumir el reto de la ecnt a través de cada uno de los seis componentes clave de sus sistemas de salud: 1) financiación en salud, 2) gobernabilidad, 3) fuerza de trabajo, 4) información en salud, 5) productos médicos y 6) tecnologías y suministro de servicios de salud. los autores señalan cómo los esfuerzos en estos países han tendido a enfocarse en una enfermedad y en sus causas de forma fragmentada y vertical cuando la evidencia señala que para enfrentarse a la ecnt el enfoque debe ser multifactorial y transversal. para ellos, atender de manera adecuada los requerimientos de la ecnt fortalece los sistemas de salud para que puedan generar los múltiples servicios requeridos. es así como se considera que la forma en que se atienda la ecnt es un test decisivo para conocer el grado de fortaleza de un sistema de salud (10). un sistema de salud es vulnerable cuando su estructura es compleja, tiene gran número de actores involucrados, un flujo de 5 la revisión hace parte del proyecto “programa para disminuir la carga de la enfermedad crónica en colombia”. convocatoria 537 colciencias. 2012 6 concepto revisado bajo criterios del acuerdo 016 de 2011d el consejo superior universitario de la universidad nacional de colombia por el cual se establece la política ambiental institucional. 251 carga del cuidado de la enfermedad crónica no transmisible l beatriz sánchez-herrera, gloria mabel carrillo-gonzález, lucy barrera-ortiz, lorena chaparro-díaz recursos importante, información débil, los ciudadanos no tienen claros sus derechos y deberes frente al aseguramiento o la prestación del servicio, hay poco desarrollo de los sistemas de control y vigilancia al interior de cada organización y escaso desarrollo del sistema de control externo para el nivel público y el privado, los procesos y productos están mal definidos, falta seguimiento y control de los procesos y procedimientos, se carece de lineamientos para los funcionarios encargados de tomar las decisiones sobre gastos, hay dispersión normativa, se requieren una gran cantidad de trámites y no hay una revisión sistemática de resultados (11, 12). las características del sgsss colombiano lo hacen altamente vulnerable a la corrupción y a la mala atención de los usuarios, en especial de aquellos que, como las personas que viven con una ecnt, tienen alto nivel de interacción con el mismo. revisar los avances en la prestación de servicios del sgsss en respuesta a las necesidades de las personas e instituciones que viven el impacto de la ecnt, o la forma como las organizaciones atienden de manera específica estas situaciones podría generar un parámetro estratégico para evaluar de manera objetiva el funcionamiento del sgsss como un todo. sin embargo, no se encontraron encuestas o reportes sobre la carga de la enfermedad crónica para las instituciones colombianas, ni una mirada integral al sistema para valorar la carga de la ecnt y su cuidado. significado de la carga del cuidado o carga de la ecnt. formas de medición carga significa trabajo, dificultad, peso, desgaste, energía necesaria para algo. cuando se habla de la carga de la ecnt o de la carga del cuidado de la ecnt, se hace referencia al esfuerzo adicional que implica satisfacer las necesidades de las personas con enfermedad crónica, de sus cuidadores familiares y profesionales, de las instituciones y del sgsss y la sociedad en general. son varios los intentos por definir y medir la carga de la ecnt. algunos revisan el impacto epidemiológico, otros el económico, otros la carga objetiva y subjetiva para los pacientes y sus cuidadores, generalmente los familiares y muy pocos señalan aspectos positivos que se suman a esta carga del cuidado de la ecnt (tabla 1). impacto epidemiológico de la carga del cuidado en la ecnt desde la dimensión epidemiológica, lópez et al. (13) y la organización mundial de la salud (oms) indican que la carga de la ecnt se relaciona con la medida de las pérdidas de salud ocasionadas por las consecuencias mortales y no mortales de las ecnt y lesiones en una población. la carga atribuible a las ecnt depende, por un lado, de su frecuencia (incidencia, prevalencia y mortalidad) y, por otro, de la valoración de sus consecuencias mortales (pérdida de años de vida) y no mortales (pérdidas funcionales y de bienestar). esta dimensión incluye indicadores tales como años de vida ajustados por discapacidad (avisas), años de vida con discapacidad (avd), años de vida perdidos por muerte prematura (apmp), relación apmp/avd, esperanza de vida saludable (evisas) y calidad de vida percibida. el enfoque epidemiológico aborda especialmente al receptor del cuidado (paciente), siendo limitada desde esta perspectiva la determinación del impacto real y la carga asociada al cuidado de la ecnt, así como el alcance de las propuestas generadas en cada uno de los actores involucrados, especialmente el cuidador familiar, la familia, los profesionales del área de la salud y las instituciones que prestan los servicios. impacto económico de la carga del cuidado en la ecnt en relación con el impacto económico de la carga del cuidado en la ecnt, suhrcke et al. señalan con preocupación que las encuestas de hogar más comunes utilizadas por los investigadores no incluyen siempre un análisis de los riesgos de enfermedad crónica. se requieren mejores valoraciones y explicación de la distribución de la ecnt según el estatus socioeconómico, en especial en países de bajo y mediano ingreso. las encuestas deben medir el impacto de la microeconomía de la enfermedad crónica y riesgos relacionados en especial en bases de datos para análisis longitudinales. determinar el impacto macroeconómico en los países de mediano ingreso es un reto al tener que desenglobar los factores para comprender el crecimiento económico. la intervención de los gobiernos para prevenir la ecnt al examinar fallas de mercado potenciales debe ser mayor de lo que es actualmente. a pesar de la evidencia en costo-efectividad debe haber una mejor revisión de los aspectos económicos de la ecnt en los países en desarrollo. señalan los autores que entre las consecuencias económicas derivadas de las ecnt también se cuentan el impacto negativo sobre el consumo, el ahorro, la oferta de mano de obra, la productividad y la acumulación de capital humano (8). barceló et al. (14), con el objetivo de medir la carga económica asociada a la diabetes mellitus en américa latina y el caribe, 252 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 carga del cuidado en la enfermedad crónica no transmisible (ecnt) constructo multidimensional dimensión epidemiológica frecuencia incidencia prevalencia mortalidad valoración de sus consecuencias mortales: pérdida de años de vida no mortales: pérdidas funcionales y de bienestar dimensión económica costo-efectividad de los servicios costos directos costos indirectos impacto negativo consumo ahorro oferta de mano de obra productividad acumulación de capital humano. dimensión social: persona con ecnt cuidador familiar, familia estrés, culpa y afrontamiento del cuidador ante la ecnt de la persona a quien cuida implicaciones para la familia: en la funcionalidad de la misma (económica, social y personal) factores de desgaste variables físicas, comportamentales o cognitivas de los pacientes y fase de la enfermedad escenarios del cuidado autopercepción de carga del cuidado en el cuidador grado de preparación que tienen los cuidadores para asumir el rol costos del cuidado (consecuencias adversas reales o potenciales) costo económico costos sobre la salud física costos sobre la salud emocional restricciones sociales y personales inversión de valor en el dar cuidado aspectos positivos de la experiencia de cuidado satisfacción, reconocimiento, crecimiento, desarrollo, aprendizaje, trascendencia, vínculo con la persona cuidada. tabla 1. significado de la carga del cuidado en la enfermedad crónica fuente: elaboración propia a partir de la revisión de la literatura. estimaron los costos directos (medicamentos, hospitalización, consultas, manejo de complicaciones) e indirectos de la enfermedad (el abordaje de capital humano fue utilizado para calcular los costos indirectos e incluyó pérdidas de ingresos debidos a la muerte prematura y la discapacidad atribuida a la diabetes). se calculó un incremento del 3 % por compensación a futuro. estos autores concluyen que la diabetes, al igual que otras ecnt, impone una carga económica importante a los individuos y a la sociedad como un todo. kraft et al. estudiaron la carga económica de la demencia en personas residentes en su casa o en instituciones en suiza. los 253 carga del cuidado de la enfermedad crónica no transmisible l beatriz sánchez-herrera, gloria mabel carrillo-gonzález, lucy barrera-ortiz, lorena chaparro-díaz costos se estimaron con base en estadísticas nacionales, revisión de pares y análisis de expertos. reportan que los costos de las personas con demencia severa que viven en el hogar son cinco veces mayores que los de la demencia leve. los costos más altos se asociaron al cuidado (15). impacto social: la persona con enfermedad crónica, la familia y el cuidador familiar la literatura reporta más de cincuenta instrumentos de medición aplicables a pacientes y a cuidadores, en su mayor parte familiares, para mirar la carga del cuidado en situaciones genéricas y específicas, aspectos negativos y positivos, factores de desgaste y de construcción. en este sentido, se identifican unas subdimensiones con las que se asocia el significado de la carga del cuidado: 1. estrés y afrontamiento del cuidador ante la ecnt de la persona a quien cuida. cuidar a personas con ecnt es un evento estresor en el que se reúnen varias condiciones interrelacionadas que traen consigo repercusiones para el cuidador familiar. al respecto, algunos autores consideran abordar la carga como una reacción del cuidador, en respuesta a la situación de estrés, resultado de la experiencia de asumir el cuidado de una persona con ecnt. greene et al. midieron la carga a partir de las reacciones negativas y consecuencias del estrés personal del cuidador de una persona anciana con demencia que vive en la comunidad (16). pearlin et al., con base en el modelo conceptual del estrés de cuidadores del personas con enfermedad de alzheimer, identificaron los estresores primarios (el estado cognitivo, el comportamiento problemático, la sobrecarga, la deprivación de relaciones) y secundarios (conflicto familiar y laboral del cuidador, estado socioeconómico y recursos, pérdida de libertad en el rol, pérdida del propio ser, competencia del dar cuidado, y ganancia personal) que se generan en la experiencia de ser cuidador (17, 18). kaufer y su grupo midieron el estrés negativo psicológico de los cuidadores en relación con diez síntomas neuropsiquiátricos que se presentan en la enfermedad de alzheimer (19). cohen et al. (20) y cole (21) plantean el autorreporte sobre el estrés percibido a partir de la experiencia como una herramienta fundamental para medir la carga en el cuidador. derogatis (22, 23) diseñó un perfil para determinar el estrés psicológico del cuidador, en el que incorporó el modelo de interacción de lazarus y folkman en una estructura multidimensional. en seattle, vitaliano y su grupo proponen una herramienta de monitoreo para identificar las experiencias de estrés negativo (distrés) del cuidador en una forma ágil, revisando la carga objetiva (prevalencia de los eventos potenciales de estrés del cuidador de la experiencia) y subjetiva (experiencia de distrés por la ocurrencia de dichos eventos) (24). gerritsen y van der ende desarrollaron una escala para medir el estrés relacionado con el cuidado de personas ancianas enfermas. se incluye una evaluación negativa de la relación entre el dador y el receptor del cuidado y las consecuencias personales como medida subjetiva del impacto del cuidado (25). matsuda (26) buscó medir qué tan estresante es el cuidado para los cuidadores japoneses. kinney y stephens (27) proponen medir los problemas del cuidado que enfrentan los cuidadores en la vida diaria para conocer los estresores diarios de quienes cuidan a personas con demencia. 2. factores de desgaste. son todos aquellos aspectos susceptibles de evaluar tanto en el paciente como en cuidador, que pueden incidir en la carga del cuidado. variables físicas, comportamentales o cognitivas de los pacientes y fase de la enfermedad. al respecto, steven zarit construyó la entrevista de carga “burden interview” para evaluar la carga del cuidado en la clínica o en la comunidad. la construcción se desarrolló con base en la experiencia clínica con cuidadores y se clasificó en cinco categorías: salud, bienestar psicológico, finanzas, vida social y relación con la persona enferma (28-31). zarit et al. (32-34) han abordado también los problemas de las personas con alzheimer y la reacción de sus cuidadores. teri et al. (34) determinaron cómo los problemas relacionados con la memoria, síntomas de depresión y comportamiento disruptivo de los pacientes generan cierto tipo de reacción del cuidador frente a ellos. montorio et al. (35) indican que el cuidador tiene una peor percepción de su relación interpersonal con la persona cuidada y un mayor rechazo hacia ella cuando esta manifiesta problemas de conducta en un grado importante,a la vez que sesiente más incompetente, cuando la persona receptora de cuidados ha perdido 254 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 una parte importante de sus habilidades básicas para manejarse en la vida diaria. caserta et al. (36) determinaron la naturaleza multidimensional de la carga del cuidado. sus hallazgos reportan que la dependencia de tiempo se asocia a la disfunción del paciente y al compromiso con el cuidado. la carga emocional se asocia a la satisfacción al cuidar; la carga por desarrollo al nivel de depresión y a la satisfacción con el cuidado; sin embargo, la salud física se asocia más con la depresión y con el número de días de enfermedad del paciente. miyashita et al. (37) determinaron la valoración del tiempo de dependencia del paciente en relación con las cargas emocionales, existenciales y físicas identificadas en el cuidador. fredman y daly (38) proponen abordar el fenómeno de la carga en la díada cuidado-paciente revisando las actividades básicas cotidianas e instrumentales, así como la funcionalidad de los receptores del cuidado. escenarios del cuidado. el contexto/ambiente en el que se brinda la atención puede incidir directamente en la percepción de la carga del cuidado. al respecto, robinson (39) propone medir el índice de carga del cuidado en el cuidador en instituciones hospitalarias en aspectos como el sueño, el tiempo requerido, el esfuerzo físico, el confinamiento, los ajustes familiares, el cambio de planes, la demanda de tiempo, los ajustes emocionales, los ajustes en el trabajo, el comportamiento disruptivo, el cambio incómodo, la carga económica y la sensación de desbordamiento. covinsky (40), con base en un estudio realizado en cinco hospitales de tercer nivel de estados unidos, señala que las familias de las personas más enfermas experimentan mayor carga del cuidado y financiera. autopercepción de carga del cuidado en el cuidador. la estimación y el reconocimiento que el cuidador tiene en relación con la experiencia son definitivos para mediar la carga del cuidado en medio del contexto y la enfermedad. carey et al. (41), en un estudio con 49 cuidadores de pacientes en quimioterapia, y simmons (42) en uno de carga con 106 pacientes en tratamiento activo con cáncer frente a los cuidadores, sugieren y señalan la relevancia de este aspecto respecto al bienestar psicosocial y la calidad de vida global del cuidador. wells y jorm (43) plantean la importancia de incluir la culpa y la frustración del cuidador como indicadores que pueden incidir en la carga del cuidado. bindoff et al. (44), en un estudio sobre el nivel de bienestar de los cuidadores de personas con demencia, señalan que hay un menor bienestar, medido entre otras escalas con la de culpa, respecto a aquellos casos en que se cuida a personas con discapacidad mental. grado de preparación que tienen los cuidadores para asumir el rol. los conocimientos, la información y el reconocimiento de experiencias previas se consideran factores que inciden de forma directa en la carga del cuidado que presenta el cuidador. zeiss et al. (45) proponen la autoeficacia como un indicador de preparación del cuidador, la cual se refiere a autocuidado y la eficacia para resolver problemas. archbold et al. (46) desarrollaron el inventario de dar cuidado familiar con el fin de mirar las relaciones y el grado de preparación para el cuidado en cuidadores de ancianos dependientes (fortalezas y dificultades). 3. implicaciones de la carga del cuidado en la familia. la carga del cuidado se reconoce tanto en el cuidador principal como en el grupo familiar en la medida en que se identifica una alteración en la funcionalidad familiar e impacto en las esferas económicas, sociales y personales. epstein et al. (47, 48) recomiendan incluir la valoración familiar a través del mecanismo de mcmaster para abordar los aspectos de solución de problemas, comunicación, roles, respuestas afectivas, control del comportamiento y funcionalidad general. mccubbin et al. (49) proponen abordar el índice de resistencia del grupo familiar. a su vez carey et al. (50), en un estudio exploratorio con 49 cuidadores familiares de pacientes en quimioterapia, describieron las áreas y dificultades asociadas al cuidado familiar para predecir el ánimo de los cuidadores. frost et al. (51), con el propósito de examinar la relación entre la resistencia, la comunicación y el soporte en familias de niños con ecnt, entrevistaron a 108 padres que vivían esta situación y encontraron relación positiva entre la resistencia, el ingreso y el soporte. poulshock y deimling (52) revisaron el impacto social del cuidado con 614 familias que cuidaban a sus ancianos y reportaron algunos factores que reflejan la carga en el funcionamiento familiar: el cuidado, los cambios negativos en cuidador y receptor del cuidado y las relaciones o restricciones en las actividades del cuidador. 255 carga del cuidado de la enfermedad crónica no transmisible l beatriz sánchez-herrera, gloria mabel carrillo-gonzález, lucy barrera-ortiz, lorena chaparro-díaz bass y bowman (53) recomiendan la valoración familiar, a través del índice del dar cuidado, que incluye la estimación de las dificultades del cuidado, las consecuencias negativas del dar cuidado para el cuidador y para la familia. moos (54) propone abordar el clima familiar tal como el mismo es percibido por sus integrantes. 4. costos del cuidado. kosberg y cairl (55) plantean que el costo incluye la evaluación de las consecuencias adversas reales o potenciales que se presentan en los cuidadores. estas consecuencias corresponden al costo económico y a los costos sobre la salud física y emocional, las restricciones sociales y personales y la inversión de valor en el dar cuidado. oberst et al. (56) asocian la carga del cuidado con las demandas de energía para las tareas de cuidado que ejerce el cuidador, tales como los tratamientos, la atención personal, la asistencia con la movilidad, el apoyo emocional, el monitoreo y reporte, el manejo de finanzas con los costos de la enfermedad y el manejo de problemas de comportamiento. given y su grupo reconocen las reacciones de cuidadores de ancianos enfermos a partir de la estima del cuidador, la falta de soporte familiar, el impacto en las finanzas, en el horario y en la salud (57). stommel et al. (58) y gupta (59) proponen abordar la carga del cuidado a partir del impacto y las reacciones frente a la experiencia de ser cuidador: finanzas, horario de trabajo y salud física. strawbridge y wallhagen (60) señalan en qué medida los cuidadores de personas con ecnt perciben cambios como resultado del cuidado visto como un problema. stull (61) propone comprender la carga del cuidado de los cuidadores de personas ancianas a través de la respuesta subjetiva del cuidador a los problemas físicos, sociales, financieros, de tiempo, de relaciones interpersonales y de manipulación de la persona cuidada. davis et al. (62) midieron el tiempo gastado en las actividades de cuidado de personas con enfermedad de alzheimer diariamente, y a partir de ello definieron el costo económico de dicho cuidado. england y roberts (63), con hijos adultos de personas con trastornos neurológicos, determinaron desgaste psicosocial, físico e instrumental, el despertar emocional y el estrés negativo por la discrepancia en las metas establecidas. 5. aspectos positivos del cuidado. se refiere a aquellos factores de bienestar, impacto positivo, crecimiento y transformación que se generan a partir de la experiencia de ser cuidador. lawton et al. (64) determinaron dentro de la valoración de la carga subjetiva la inclusión de la satisfacción con el cuidado. hughes y caliandro (65), por su parte, exploraron la maestría o competencia para el cuidado definida como una habilidad que se desarrolla y se constituye en aspecto positivo de la experiencia. esta competencia se ha indagado en cuidadores de niños con síndrome de inmunodeficiencia, en cuidadores de pacientes dependientes de ventilador en el hogar (66) y cuidadores de adultos con trauma cerebral en un centro de rehabilitación y en el hogar (67). farran et al. (68) desarrollaron un cuestionario para valorar la experiencia de cuidar a personas con demencia teniendo en cuenta los aspectos positivos del dar cuidado: encontrarle sentido a la experiencia en el día a día y reconocer los atributos religiosos, filosóficos y espirituales asociados. refieren que el análisis de estos factores permite comprender la relación cercana entre las dificultades y los aspectos positivos de dar cuidado y reconocer las fortalezas de los cuidadores. kenney y stephens (69) plantean que en cada acción de cuidado puede haber problemas o estresores pero también hay algunas satisfacciones que enseñan y alientan al cuidador. motenko, en un estudio con mujeres cuidadoras de sus esposos con demencia, encontró que la frustración con el cuidado se asociaba más al estrés y la gratificación al bienestar. en particular, la experiencia fue más llevadera para las mujeres que percibieron mayor cercanía que para las que reportaron mayor cambio. la frustración frente al cuidado, más que la cantidad del mismo, se asoció con el nivel de bienestar (70). given (71) examinó cómo los pacientes de una unidad de quimioterapia ambulatoria mantenían su salud física y mental y el tipo de reacciones de sus cuidadores. sus hallazgos señalan que la depresión de los pacientes se asoció más a la sintomatología que a la pérdida de movilidad. el optimismo de los cuidadores fue un buen predictor de su salud mental y capacidad de reacción. stull et al. (72) revisaron aspectos positivos y negativos del cuidado. para ello generaron la herramienta de revisión de la carga que mira las necesidades del receptor del cuidado, el bienestar del cuidador, la carga sobre este y los resultados positivos del cuidado del anciano que vive en la comunidad. 256 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 suguhara et al. (73) estudiaron cómo cambia el bienestar psicológico de los cuidadores japoneses con el tiempo encontrando que con el paso de los días aumentan la depresión y el agobio emocional. schofield (74) y su grupo determinaron el bienestar general de la experiencia y la actividad social de la misma al comparar cuidadores con no cuidadores. la experiencia de cuidado familiar incluyó la satisfacción con el cuidado, el afecto positivo y negativo, el soporte social y la sobrecarga. picot et al. (75), con una muestra de 83 mujeres cuidadoras afroamericanas y 256 cuidadores y cuidadoras elegidos al azar entre afroamericanos y blancos, identificaron consecuencias positivas del cuidado. ferrari et al. (76) midieron la experiencia emocional —que puede ser de satisfacción o estrés— de personas que siendo trabajadores o voluntarios dan soporte social a personas con síndrome de inmunodeficiencia adquirida en fase sida. orbell et al. (77) proponen abordar aspectos positivos y negativos del cuidado de una persona anciana reconociendo aspectos tales como problemas o satisfacciones en el trabajo de cuidar, disgustos en las relaciones y satisfacción con el estilo de vida del cuidado. denney (78) y chou et al. (79) revisaron la eficiencia del cuidado suministrado, las demandas del mismo, la autoeficacia al cuidar y las estrategias de afrontamiento. vernooij-dassen et al. (80) propusieron medir el sentido de competencia o capacidad para el cuidado del cuidador de personas con demencia en aspectos que incluyen la satisfacción con el receptor del cuidado, satisfacción con la propia capacidad de cuidar y consecuencias de ser cuidador en la vida personal de quien cuida. conclusiones la carga del cuidado en la ecnt es un constructo multidimensional que incluye las perspectivas epidemiológica, económica y social, con múltiples interrelaciones entre sí. en colombia es necesario abordar el problema desde un punto de vista integral para revisar la carga del cuidado en la ecnt que considere de manera conjunta a los diferentes actores involucrados y afectados por la situación: personas que cursan con la enfermedad, cuidadores familiares, profesionales del área de la salud y las instituciones prestadoras de servicios de salud, entre otros. el alivio de la carga del cuidado de la ecnt a partir de medir el impacto y la efectividad de las intervenciones que se propongan, debe hacerse con base en indicadores que hayan sido mundialmente valorados pero que se ajusten al referente nacional y local, y que permitan construir y validar modelos de atención integral para responder a los retos del país. referencias 1. macinko j, dourado i, guanais fc. enfermedades crónicas, atención primaria y desempeño de los sistemas de salud: diagnóstico, herramientas e intervenciones. banco interamericano de desarrollo, 2011. 2. flórez m. informe global sobre corrupción 2006, riesgos de corrupción en el sector salud en colombia. transparencia por colombia. bogotá; 2006. 3. vargas s. principales acciones de la cgr en torno a la vigilancia de los recursos de la salud. bogotá: contraloría general de la república; 2006. 4. barrera l, pinto n, sánchez b. hacia la construcción de un modelo de cuidado de cuidadores de personas con enfermedad crónica. actualizaciones en enfermería. 2008;2(11):23-29. 5. colombia. consejo de estado. sentencia t-760 de 2008, protección del derecho a la salud. 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persoon jmg, felling aja. predictors of sense of competence in caregivers of demented persons. social science and medicine. 1996;43(1):41-49. tr ea tm en t n on -a dh er en ce o r a ba nd on m en t a m on g a do le sc en ts a nd y ou ng in di vi du al s li vi ng w it h h iv /a id s: a s co pi ng r ev ie w 1 camila moraes garollo piran https://orcid.org /0000-0002-9111-9992 universidade estadual de maringá, brazil. pg403637@uem.br lorhana gouveia magalhães https://orcid.org /0000-0003-3000-5446 universidade estadual de maringá, brazil. pg403646@uem.br bianca machado cruz shibukawa https://orcid.org /0000-0002-7739-7881 universidade estadual de maringá, brazil. bianca.shibukawa@ufms.br gabrieli patrício rissi https://orcid.org /0000-0002-1702-4004 universidade estadual de maringá, brazil. gabrieli.rissi@docentes.unicesumar.edu.br maria de fátima garcia lopes merino https://orcid.org /0000-0001-6483-7625 universidade estadual de maringá, brazil. mfglmerino2@uem.br marcela demitto furtado https://orcid.org /0000-0003-1427-4478 universidade estadual de maringá, brazil. mdfurtado@uem.br artículo treatment non-adherence or abandonment among adolescents and young individuals living with hiv/aids: a scoping review received: 21/08/2022 sent to peers: 07/10/2022 approved by peers: 25/01/2023 accepted: 14/02/2023 doi: 10.5294/aqui.2023.23.2.2 to reference this article / para citar este artigo / para citar este artículo piran cmg, magalhães lg, shibukawa bmc, rissi gp, merino mfgl, furtado md. treatment non-adherence or abandonment among adolescents and young individuals living with hiv/aids: a scoping review. aquichán. 2023;23(1):e2322. doi: https://doi.org/10.5294/aqui.2023.23.2.2 * this article derives from the master’s dissertation: predictors for antiretroviral therapy abandonment among adolescents and young individuals living with hiv/aids, submitted to the graduate program in nursing of universidade estadual de maringá, paraná, brazil. this paper was carried out with the support of the coordination for the improvement of higher education personnel (coordenação de aperfeiçoamento de pessoal de nível superior, capes), brazil: funding code 001. msc scholarship granted to camila moraes garollo piran. https://orcid.org/0000-0002-9111-9992 mailto:pg403637@uem.br https://orcid.org/0000-0003-3000-5446 mailto:pg403646@uem.br https://orcid.org/0000-0002-7739-7881 mailto:bianca.shibukawa@ufms.br https://orcid.org/0000-0002-1702-4004 mailto:gabrieli.rissi@docentes.unicesumar.edu.br https://orcid.org/0000-0001-6483-7625 mailto:mfglmerino2@uem.br https://orcid.org/0000-0003-1427-4478 mailto:mdfurtado@uem.br https://doi.org/10.5294/aqui.2023.23.2.2 https://doi.org/10.5294/aqui.2023.23.2.2 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2023.23.2.2&amp;domain=pdf&amp;date_stamp=2023-04-10 subject: care processes and practices. contribution to the subject: this scoping review allowed for identifying and mapping the scientific literature on the reasons for treatment non-adherence or abandonment among adolescents and young individuals living with hiv/aids. the study may assist health professionals because it offers reflections and subsidies, through updated literature, about the realities experienced by adolescents and young people who abandon treatment. thus, understanding the outcome of treatment discontinuation will contribute to developing care actions through strategies for adherence to the treatment to reduce the problems resulting from hiv/aids among adolescents and young individuals. tr ea tm en t n on -a dh er en ce o r a ba nd on m en t a m on g a do le sc en ts a nd y ou ng in di vi du al s li vi ng w it h h iv /a id s: a s co pi ng r ev ie w 3 abstract objective: to identify and map the scientific literature on the reasons for treatment non-adherence or abandonment among adolescents and young individuals living with hiv/aids. materials and method: a scoping review using the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) strategy for the presentation of data referring to the reasons for treatment non-adherence or abandonment among adolescents and young people living with hiv/aids. seven information sources were used to search for the articles, namely: medline via pubmed, web of science, lilacs, cinahl, bdenf, scopus, and embase, without a time frame and with the following search strategy: “patient dropouts” or “abandonment” or “lack of medication adherence” and “adolescent” or “young adult” and “acquired immunodeficiency syndrome” or “hiv” and “antiretroviral therapy highly active” or “medication adherence.” results: eight articles were included in the study, contemplating the reasons for treatment non-adherence or abandonment, which were related to access to health services, sociodemographic, structural, psychosocial and behavioral conditions, and factors associated with the disease or the medication. conclusions: the findings of this study evidenced how vulnerable adolescents and young people are to the issues inherent to hiv/aids treatment and that several reasons can influence its non-adherence or abandonment. keywords (fonte: decs) patient dropouts; adolescent; young adult; hiv; aids; acquired immunodeficiency syndrome. 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 22 no adherencia o desistencia del tratamiento entre adolescentes y jóvenes viviendo con vih/sida: scoping review* resumen objetivo: identificar y mapear la literatura científica del área acerca de los motivos para la no adherencia o desistencia del tratamiento entre adolescentes y jóvenes que viven con vih/sida. materiales y método: revisión de alcance con el empleo de la estrategia preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) para presentar datos referentes a los motivos de la no adherencia o desistencia del tratamiento entre adolescentes y jóvenes que viven con vih/sida. para la búsqueda de artículos, se utilizaron siete fuentes de información: medline via pubmed, web of science, lilacs, cinahl, bdenf, scopus y embase, sin limitación temporal, con la estrategia de búsqueda “patient dropouts” or “abandonment” or “lack of adherence to medication” and “adolescent” or “young adult” and “acquired immunodeficiency syndrome” or “hiv” and “antiretroviral therapy highly active” or “medication adherence”. resultados: se incluyeron ocho artículos en el estudio que contemplaban los motivos para la no adherencia o desistencia del tratamiento, los que estaban relacionados al acceso al servicio de salud, a condiciones sociodemográficas, estructurales, psicosociales y comportamentales, y a los factores asociados con la enfermedad o medicamentos. conclusiones: los hallazgos del estudio evidencian como son vulnerables los adolescentes y jóvenes a las cuestiones inherentes al tratamiento del vih/sida y que varios son los motivos que pueden influir la no adherencia o desistencia del tratamiento. palabras clave (fuente: decs) pacientes desertores de tratamiento; adolescente; adulto joven; vih; sida; síndrome de inmunodeficiencia adquirida. * este artículo deriva de la tesis de maestría de título factores que predicen el abandono de la terapia antirretroviral entre adolescentes y jóvenes que viven con vih/sida, presentada ante el programa de postgrado en enfermería de la universidad estatal de maringá, paraná, brasil. el presente trabajo de investigación fue realizado con el apoyo de la coordinación para el perfeccionamiento de personal de nivel superior (capes), brasil, con código de financiación 001. beca de maestría concedida a camila moraes garollo piran. tr ea tm en t n on -a dh er en ce o r a ba nd on m en t a m on g a do le sc en ts a nd y ou ng in di vi du al s li vi ng w it h h iv /a id s: a s co pi ng r ev ie w 5 não adesão ao tratamento ou abandono deste entre adolescentes e jovens vivendo com hiv/aids: scoping review* resumo objetivo: identificar e mapear a literatura científica da área acerca dos motivos da não adesão ao tratamento ou do abandono deste entre adolescentes e jovens que vivem com hiv/aids. materiais e método: revisão de escopo com uso da estratégia preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr) para a apresentação de dados referentes aos motivos da não adesão ao tratamento ou do abandono deste entre adolescentes e jovens que vivem com hiv/aids. para a busca dos artigos, utilizaram-se de sete fontes de informação: medline via pubmed, web of science, lilacs, cinahl, bdenf, scopus e embase, sem recorte temporal, com a estratégia de busca “patient dropouts” or “abandonment” or “lack of adherence to medication” and “adolescent” or “young adult” and “acquired immunodeficiency syndrome” or “hiv” and “antiretroviral therapy highly active” or “medication adherence”. resultados: foram incluídos oito artigos no estudo que contemplavam os motivos da não adesão ao tratamento ou do abandono deste, os quais estavam relacionados ao acesso ao serviço de saúde, às condições sociodemográficas, estruturais, psicossociais e comportamentais, e aos fatores associados à doença ou à medicação. conclusões: os achados deste estudo evidenciaram o quanto os adolescentes e os jovens são vulneráveis às questões inerentes ao tratamento do hiv/aids e que vários motivos podem influenciar a não adesão a este ou seu abandono. palavras-chave (fonte decs) pacientes desistentes do tratamento; adolescente; adulto jovem; hiv; aids; síndrome de imunodeficiência adquirida. * este artigo é derivado da dissertação de mestrado intitulada preditores para o abandono da terapia antirretroviral entre adolescentes e jovens vivendo com hiv/aids, submetida ao programa de pós-graduação em enfermagem da universidade estadual de maringá, paraná, brasil. o presente trabalho foi realizado com o apoio da coordenação de aperfeiçoamento de pessoal de nível superior (capes), brasil, com código de financiamento 001. bolsa de mestrado concedida a camila moraes garollo piran. 6 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 22 introduction the acquired immunodeficiency syndrome (aids) caused by the human immunodeficiency virus (hiv) has represented an extremely relevant global public health problem for over three decades. in 2020, nearly 37.7 million people were living with hiv in the world, of which 73 % had access to the treatment, and 16.18 % were unaware of the diagnosis. during the same period, 680,000 people died due to aids worldwide (1). an increasing incidence of hiv/aids is globally noticeable in adolescence —which encompasses the age group from 10 to 19 years old— and in youth —between 20 and 24 years old (2). in brazil, among adolescents and young people, mainly males, the number of new hiv cases increased gradually between 2010 and 2020, with a 29 % increase in the age group from 15 to 19 years old and 20.2 % between 20 and 24 years old, whose main transmission route was sexual (3). this situation can reflect the health risk behavior among this population segment, such as precocity for sexual life initiation, resistance to condom use, concurrent partners, and use of licit and illicit drugs (4). even with advances in the treatment of the disease, generating health benefits and better quality of life for people living with hiv/ aids, it is known that one of the health professionals’ most significant challenges is non-adherence to the antiretroviral therapy (art) among adolescents and young people (5). with the emergence of art, hiv/aids presents a new clinical and epidemiological profile and is now considered a chronic condition. it is believed that, with the correct use of this therapy, among other actions, it will be possible to achieve the goals stipulated by the joint united nations program on hiv/aids for the end of the epidemic worldwide by 2030. among the goals were identifying 90 % of the people living with the virus, treating 90 % of the individuals diagnosed with hiv, and achieving viral suppression in 90 % of the people on art (6). it is noted that treatment non-adherence or abandonment is defined as the patients interrupting the intake of antiretroviral drugs, as well as the absence of follow-up in the outpatient service (team guidance, examinations, and consultations [7]). even with many studies focused on the hiv/aids theme, it is clear that the reasons associated with art discontinuation and non-adherence or its abandonment by adolescents and young people are not entirely known (8), which represents a challenge for health professionals. based on this context, it is believed that all the information presented in this study may assist managers and health professionals in developing strategies that improve adherence to art in this population group. thus, the objective of this study was to identify and map the scientific literature on the reasons for treatment non-adherence tr ea tm en t n on -a dh er en ce o r a ba nd on m en t a m on g a do le sc en ts a nd y ou ng in di vi du al s li vi ng w it h h iv /a id s: a s co pi ng r ev ie w 7 or abandonment among adolescents and young individuals living with hiv/aids. materials and method this is a scoping review based on the recommendations set forth by the joanna briggs institute (jbi), intended to structure, explore, expand, and clarify the central information that may support a given research field (9). the option of conducting a scoping review was considered because it provides elucidation of the main concepts, definitions, characteristics, or related factors present in the literature and the gaps in knowledge about the theme under study (10). for elaborating the review question (9), “what are the scientific literature contents on the reasons for treatment non-adherence or abandonment among adolescents and young people living with hiv/aids?” the “pcc” acronym (p: population, c: concept, and c: context) was used, where p refers to adolescents and young people (from 10 to 24 years old); c to reasons for abandoning treatment; and c to people living with hiv/aids. the bibliographic survey was in charge of two researchers who worked independently from december 2021 to january 2022, following all three stages proposed by the scoping review. it was also defined that, in case of any divergence between both reviewers, a third one would be called upon. however, there was no disagreement between the researchers. the eligibility criteria corresponded to primary studies, editorials or books and guidelines that covered the theme of treatment non-adherence or abandonment among adolescents and young people living with hiv/aids and which answered the review question. in addition, no limitation regarding language or publication date was established, considering the scarcity of studies related to the theme. in the first stage, a limited database search was performed to identify the keywords and descriptors used later. the second stage contemplated more encompassing research for the other databases included in the study, resorting to all the descriptors identified in the previously selected studies. the third stage consisted of searching the references of the chosen articles. the jbi instrument (9) was used for data collection, which included the following items: title of the study, year of publication, author(s), study objective, methodological design, and main findings. initially, the search was performed with the “hiv,” “acquired immunodeficiency syndrome,” “adolescent,” “young adult,” “abandonment,” and “antiretroviral therapy highly” descriptors in the medical literature analysis and retrieval system online (medline) via pubmed and web of science databases. subsequently, the search for the literatura latino-americana e 8 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 22 do caribe em ciências da saúde (lilacs), cumulative index to nursing and allied health literature (cinahl), base de dados de enfermagem (bdenf ), scopus and embase information sources was expanded, totaling seven sources, also known as “health databases,” with access by means of the capes journals portal, through remote access via the federated academic community. it is noted that each study’s titles, abstracts, and respective descriptors were analyzed in all stages. the researchers read in full the articles that answered the review question, which had their references examined, thus ending the third step. to conduct the search strategy, descriptors controlled by the descriptors health sciences (descritores em ciências da saúde, decs) tool were used for the database in portuguese and by the medical subject headings (mesh) for english, in addition to the non-controlled descriptors. according to the access specificities in the databases selected, the controlled and uncontrolled descriptors were crossed, using the and and or boolean operators, creating the search strategy used in all databases: “patient dropouts” or “abandonment” or “lack of medication adherence” and “adolescent” or “young adult” and “acquired immunodeficiency syndrome” or “hiv” and “antiretroviral therapy highly active” or “medication adherence.” after a complete reading to evaluate the eligibility criteria, four articles that met the assumptions of this study were listed. subsequently, their references were verified, and another four articles from the analysis of these references were listed, thus, reaching a final sample of eight that met the inclusion criteria of this study. a flowchart was prepared, which used the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prisma-scr [11]) tool as a basis to ease visualization of the methodological path and selection of the studies, as shown in figure 1. the study was developed following the guidelines established by resolution 466/2012 of the national health council/ministry of health and approved by the standing committee on ethics in research involving human beings under opinion no. 5,202,623 (certificate of presentation of ethical appraisal 52331221.3.0000.0104), as it is part of a more extensive study referring to a master’s thesis. results the search strategy identified 519 publications. after excluding 167 duplicates and 336 due to eligibility criteria, only 16 studies were read in full for the eligibility assessment; of these, six were excluded for not reporting reasons for non-adherence or abandonment, and six evaluated another age group. thus, four publications were included in the complete reading phase. after reading references of the articles listed for the final sample, another eight studies were included in this scoping review. tr ea tm en t n on -a dh er en ce o r a ba nd on m en t a m on g a do le sc en ts a nd y ou ng in di vi du al s li vi ng w it h h iv /a id s: a s co pi ng r ev ie w 9 table 1 allows seeing the articles (a) included according to the general characteristics: author/year, title, information source (is), which indicates where the study was made available, locus, and language. the results of this review evidenced that the articles included were developed in botswana (12), the united kingdom (13), malawi (14), kenya (15), ghana (16), cameroon (17), and cape city (7), and published in the english language between 2013 and 2021. figure 1. prisma-scr flowchart corresponding to identification and selection of the articles included in the scoping review by means of the information sources. maringá, paraná, brazil, 2022 source: prepared by the authors. studies identi�ed in the information sources: pubmed (n = 205), web of science (n = 62), lilacs (n = 4), cinahl (n = 12), bdenf (n = 0), scopus (n = 43), embase (n = 193) total studies identi�ed (n = 519) reading of titles and abstracts (n = 352) studies read in full for the eligibility assessment (n =16) studies included after applying the eligibility criteria (n = 4) studies included after analyzing the references (n = 4) articles included (n = 8) studies excluded due to duplicity (n = 167) articles excluded for not meeting the inclusion criteria (n = 336) studies excluded (n = 12) no reasons reported (n = 6) other age group (n = 6) id en ti � ca ti o n se le ct io n el ig ib ili ty in cl u si o n table 1. presentation of the studies included in the review according to identification, year, author, information source, locus, language, and level of evidence. maringá, paraná, brazil, 2022 id author/year title is locus language a1 (12) ndiaye m, nyasulu p, nguyen h, lowenthal ed, gross r, mills ej, nachega jb/2013 risk factors for suboptimal antiretroviral therapy adherence in hiv-infected adolescents in gaborone, botswana: a pilot cross-sectional study reference of the articles listed botswana english 10 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 22 id author/year title is locus language a2 (13) hawkins a, evangeli m, sturgeon k, le prevost m, judd a/2016 episodic medication adherence in adolescents and young adults with perinatally acquired hiv: a within-participants approach pubmed the united kingdom english a3 (14) kim mh, mazenga ac, yu x, ahmed s, paul me, kazembe pn et al./2017 high self-reported nonadherence to antiretroviral therapy amongst adolescents living with hiv in malawi: barriers and associated factors web of science malawi english a4 (15) gaitho d, kumar m, wamalwa d, wambua gn, nduati r/2018 understanding mental health difficulties and associated psychosocial outcomes in adolescents in the hiv clinic at kenyatta national hospital, kenya cinahl kenya english a5 (16) anokye-kumatia ab, enimil a, afriyie dk, tetteh r, mensah nk, amo aa et al./2019 highly active antiretroviral therapy adherence among perinatally infected hiv adolescents at a teaching hospital in ghana. web of science ghana english a6 (17) ketchaji a, assah f, fokam j, tanue ea, monebenimp f, ngowe mn/2019 predictors of non-adherence to antiretroviral therapy among adolescents living with hiv in the centre region of cameroon reference of the articles listed cameroon english a7 (5) van wyk be, davids/2019 challenges to hiv treatment adherence amongst adolescents in a low socio-economic setting in cape town reference of the articles listed cape city english a8 (18) lantche mw, fokam j, cheudjui ajn, tchatchueng jbm, noumsi tsj, ateba fn et al./2021 factors associated with nonadherence to antiretroviral therapy among hiv-infected adolescents aged 15-19 years: a snapshot from the mother and child center in yaounde, cameroon reference of the articles listed cameroon english source: prepared by the authors. table 2 presents the characteristics of the articles selected for this review according to identification, method, and main results about the reasons for art non-adherence or abandonment among adolescents and young people. tr ea tm en t n on -a dh er en ce o r a ba nd on m en t a m on g a do le sc en ts a nd y ou ng in di vi du al s li vi ng w it h h iv /a id s: a s co pi ng r ev ie w 11 table 2. distribution of the articles selected according to identification, method and main results on the reasons for art non-adherence or abandonment among adolescents and young individuals. maringá, paraná, brazil, 2022 id method reasons for treatment non-adherence or abandonment a1 (12) a cross-sectional study conducted with 82 adolescents living with hiv. belonging to the male gender. forgetfulness in art use. a2 (13) a cohort study conducted with 29 adolescents and young adults living with hiv in the united kingdom. failure to maintain a routine during the weekends (from friday to sunday). staying out of the house for extended periods of time. reduced self-confidence and behavioral inabilities for art self-suggestion and self-administration. difficulty incorporating art into the daily routines and managing possible undesirable effects that interfere with continuous adherence. a3 (14) a cross-sectional study conducted with 519 adolescents living with hiv due to vertical transmission in malawi. forgetfulness in art use. geographical accessibility. feeling stigmatized due to their condition or being victims of bullying due to medication use. witnessing or suffering domestic violence. alcohol consumption. perception of ineffective treatment. presence of side effects. manifestation of depression symptoms. sensation of overload in terms of the care demands. hospitalizations. non-attendance to clinical appointments to access the medication in the last six months. other everyday demands interfere with the care routine. a4 (15) a cross-sectional study conducted with 270 adolescents living with hiv and treated in a comprehensive care clinic at the kenya national hospital, in nairobi. manifestation of depression symptoms. a5 (16) a cross-sectional study conducted in a university hospital from ghana with 106 adolescents aged from 10 to 20 years old. forgetfulness of art use. access impossibility to refill medications. a6 (17) a cross-sectional study conducted with 401 adolescents who underwent antiretroviral therapy in 13 health units from the cameroon central region. vertical transmission of the virus. medication dispensing is the same service as for adults. geographical accessibility. being on art for more than 12 months and an unsuppressed viral load. inconvenient appointments. hiv status disclosure before the 10-year time frame. stopping the treatment on time. presence of side effects. not participating in actions that promote counseling and awareness raising. being single. 12 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 22 id method reasons for treatment non-adherence or abandonment a7 (5) this was an exploratory and qualitative study conducted through four focus group discussions with 15 adolescents monitored at a primary healthcare clinic in a low socioeconomic urban environment from cape town and followed-up with eight structured interviews with two adolescents from each focus group. difficulty attending the appointments for being students. lack of financial support interfering with access to the health service. feeling stigmatized by the family due to their diagnosis. difficulty adapting to the health unit’s routine. fear of involuntarily disclosing their serological status. differentiated treatment and verbal abuse on the part of the health professionals in relation to the patients that missed the appointments. extremely strict art-associated treatment routine. a8 (18) a cross-sectional study conducted with 191 adolescents living with hiv monitored in yaoundé reference pediatric center. low monthly income. antiretroviral therapy time was less than five years. source: prepared by the authors. discussion given the findings of the survey performed, it was noticed that there were no published studies on treatment non-adherence or abandonment with adolescents and young people living with hiv/ aids as their population. even without defining any time frame for data collection, it was possible to identify and map only eight articles that discussed the reasons for treatment non-adherence or abandonment among adolescents and young people living with hiv/aids. in the studies included in the synoptic chart, it was noticed that the geographical distance between the home and the health service, the need to travel to have an appointment, the commute time and waiting for the consultation and acquisition of the antiretrovirals were reasons for treatment non-adherence or abandonment (5, 14, 16). geographical accessibility to health services is characterized by the possibility of the subject going to the service in search of a solution for their problem. however, easing access is directly associated with the days the care can be offered and the prospect of establishing alternative times for the patient with the possibility of unscheduled care and logistics to reach the reference locus (18, 19). the patient’s commute time to the specialized health service often exceeds hours. thus, people living in more distant places may face accessibility challenges, as difficulties moving to access treatment aimed at hiv/aids —crucial to achieving total suppression— compromises adherence to the treatment in adolescents and young people, exerting adverse impacts on the lives of those with morbidity and mortality factors (8, 20, 21). thus, centralization of specialized care and lack of integration with other healthcare levels, especially primary care, are considered negative factors for developing stratetr ea tm en t n on -a dh er en ce o r a ba nd on m en t a m on g a do le sc en ts a nd y ou ng in di vi du al s li vi ng w it h h iv /a id s: a s co pi ng r ev ie w 13 gies and preventing and promoting actions in people living with hiv/aids, especially adolescents and young individuals (20). some sociodemographic conditions, such as being male and single, socioeconomic factors and school status proved to be associated with difficulty adhering to the treatment among adolescents and young people with hiv/aids (5, 12, 17). the influence of biological sexual distinction, especially being male, of seeking health services less or oftentimes abandoning follow-up is due to cultural issues and access difficulties and, also, for being a period of the individual’s life characterized by the exploration of feelings that are experienced over time. however, the biological sexual distinction has implications for gender issues (sexual identity, sexual orientation, etc.) that must be considered to assist in adherence to the treatment. thus, it becomes indispensable that these young people are encouraged to stick to the treatment and, when seeking health services, feel welcomed by the health professionals (22). in addition to that, regarding sexual orientation, men who have sex with men aged from 15 to 24 years old are at a higher risk of hiv infection when compared to young heterosexual and older men (23). this is even more so when associated with factors of greater vulnerability, such as lack of access to information on health education and preventive strategies for unprotected sex, pre-exposure prophylaxis and sex with multiple partners without an hiv testing history (24, 25). marital status has influenced the follow-up of the treatment of patients with hiv/aids, in which single people are more likely to abandon treatment when compared to those who have partners. this data can be justified by the fact that individuals with partners receive more support and are more motivated by them to avoid transmission of the virus. in addition, it can be related to the need to achieve viral suppression have children without them being at risk of hiv infection (26). socioeconomic differences are widespread in developing countries. reductions in social inequalities are a challenge for public policies, mainly in places experiencing an economic, political, or social crisis (27). the increase in new hiv infections and changes in the funding landscape cause the global health community to accelerate the development of early hiv diagnosis to complement existing hiv prevention measures (28). in addition, the absence of financial support negatively implies family dynamics and hinders adherence even more when low socioeconomic status is related to lower schooling levels and understanding of the real importance of the treatment. thus, it becomes necessary to follow the equality principle based on developing care strategies to monitor all young people in the specialized service (27, 29). 14 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 22 the factors related to the presence of adolescents or young people in school environments, such as their commitment to studying and the professors’ attitudes regarding possible absences of these students, may hinder attendance in outpatient consultations and art adherence (7). however, secrecy and confidentiality about the hiv diagnosis have been an ethical foundation that ensures the preservation of the person’s integrity, especially of people living with hiv/ aids, due to the social stigma faced due to the diagnosis (30). the complexity of living with hiv/aids in adolescence and youth has been triggered by changes in everyday life imposed by the chronic condition, fostering feelings and behaviors that interfere with social, personal, and family relationships. therefore, health education actions and strategies aimed at this problem are urgently needed to alleviate the social stigma and prejudice imposed by society (8). it is important there is a collaboration between managers, health professionals and the community for accurate information about hiv/aids to be disseminated to society and for this to contribute to a better understanding of this condition (31, 32). one of the existing strategies to safely contribute knowledge is using mobile apps and social marketing based on reliable and safe scientific evidence, but that can be taken to the lay community. thus, increasing the knowledge related to hiv/aids may reduce stigma and prejudice (33). the studies pointed out that some adolescents and young people did not regularly attend their medical appointments and did not pick up the medications as recommended. this lack of attitude reflects the reality of many young people, as the search for autonomy, active social life and educational and financial responsibilities compete with involvement in hiv care. the stigma faced by adolescents and young people living with hiv/ aids, both in the family and society, was listed as a reason for non-adherence to the treatment. the exclusion from the family for being people living with hiv, the presence of violence at home, the fear of involuntary disclosure about their serological status, non-welcoming by the professionals due to absences in previously scheduled appointments and non-withdrawal of medications are recurrent justifications for young people to abandon treatment (5, 14). the importance attributed to stigma is closely linked to the dimensions that impact the health and well-being of this population group. in addition to that, feelings of shame or guilt about living with the infection (internalized stigma) and that person’s mood state (depression) significantly impact their health. thus, there is a relationship between stigma and self-rated health, mediated by internalized stigma and depression, which consequently affect the decision to continue or not the treatment and to maintain or abandon art. it is noted that the discrimination and stigma experienced by people living with hiv/aids, especially adolescents and young people, cause problems with their mental health. the overlap of different tr ea tm en t n on -a dh er en ce o r a ba nd on m en t a m on g a do le sc en ts a nd y ou ng in di vi du al s li vi ng w it h h iv /a id s: a s co pi ng r ev ie w 15 stigmas they experience triggers certain exacerbation of sensitivity, which contributes to negative results for their health, leading these individuals not to seek the specialized health service and not to adhere to the treatment (34). domestic violence is among the causes that negatively affect patients’ adherence to treatment. some adolescents and young people experience violence among members of their own families. in addition to that, domestic violence is an indicator of suffering, in which drug administration is not a priority. thus, young people who experience violence may suffer emotionally to the point of showing depressive signs, which increases the chance of interrupting the hiv/aids treatment (35). despite the difference between both age groups (4), adolescents and young people share the same risk characteristics for violence, such as vulnerability related to changes in cognitive, physical, social, emotional and sexual development (36). another point that deserves attention is the fact that adolescents and young people are reprimanded negatively by health professionals when they miss appointments or do not pick up the medications. thus, these individuals do not feel welcomed by the health service and are intimidated to continue the monitoring program (37). it should be noted that there are many symbolic constructions around hiv/aids that reflect how health professionals have been developing strategies for everyday life and their experiences with the care of people living with the infection. therefore, it raises the importance of strengthening permanent education actions among health professionals to broaden the reflection on the management of patients and their treatment in specialized services, ensuring improvements in the care actions (36) and, consequently, reducing abandonment and strengthening adherence to treatment and monitoring. gender issues that interfere with adherence to the treatment reflect historically evidenced situations in which ethnic and racial minorities, sexual minorities and low-income individuals experience worse health results and social conditions, which lead to negative results for their health (37). in addition to that, depressive symptoms, alcohol use, changing routines, forgetting to take the medication, and frequent hospitalizations are common reports among adolescents and young people who abandon the treatment (5, 12, 14, 16). the effect of depression and the sensation of being overwhelmed reflect on health, implying harm to the person. mild and moderate depression were present in 31.5 % and 21.3 % of the patients diagnosed with hiv/aids, respectively. this shows that hiv/aids can affect mental health and may even hinder 16 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 22 treatment adherence, consequently increasing the progression of infection (38). alcohol use is also pointed out in most studies as the main factor contributing to the risk of non-adherence to follow-up among adolescents and young people living with hiv/aids who interrupt the treatment to consume the substance (39). many participants did not regularly use antiretrovirals more than once a month due to forgetting to take the medication. this factor corresponds to one of the leading causes of non-adherence. in addition to that, during the weekends, getting out of the routine and being away from home also ease forgetfulness about using the antiretrovirals (12, 13). it is noteworthy that prejudice has collaborated to non-adherence, becoming a social problem. family support for treatment is considered of great value, as it improves adherence to the antiretrovirals in a relevant way. however, eventually revealing the diagnosis to family or friends can lead to negative outcomes and non-acceptance. for this reason, people frequently find it difficult to share their diagnosis due to the prejudice against people living with hiv and using antiretrovirals, directly interfering with adherence and making their adherence to secrecy less embarrassing (39). even so, one of the reasons for hospitalization among adolescents and young people can be related to untreated hiv/aids, which consequently increases the cases of repeated infections. the age group between 10 and 24 has the highest follow-up loss rates and worst virological results (40). it is essential to highlight that, in addition to demographic and clinical factors, socioeconomic disadvantages, social circumstances, mental health disorders and adverse lifestyles are also factors for hospitalization (41). it was noticed that art abandonment could be related to the infection itself and to the medications, such as the fact that the adolescents and young people were infected by vertical transmission, the absence of clinical consultation in the last six months, taking the medication in the same service with an adult, antiretroviral therapy time being less than five years, low self-efficacy in treatment, the treatment routine, and the presence of side effects (5, 13, 17). vertical transmission only appeared in one study as a predictor for treatment non-adherence or abandonment. this reason can be due to the follow-up carried out in specialized pediatric clinics since the discovery of the virus, generally at birth, when the child is stimulated to collaborate with the treatment and made aware of the importance of the therapy for its total growth and development (42). however, even in this context, there are results in which vertical transmission is seen in non-adherence to the therapy (17). this condition can be related to postponing the diagnosis by parents or letr ea tm en t n on -a dh er en ce o r a ba nd on m en t a m on g a do le sc en ts a nd y ou ng in di vi du al s li vi ng w it h h iv /a id s: a s co pi ng r ev ie w 17 gal guardians, as around 20 % of adolescents ignore their health condition and frequently discover it at conflicting moments and are full of insecurities while being educated on good sexual practices (42). discovery of the diagnosis of a stigmatizing disease such as hiv can provoke feelings of fear and revolt, especially in adolescents, who experience biopsychosocial changes, a fact that can lead to non-adherence to the treatment. the fact that vertical transmission is a factor for treatment abandonment reinforces that the adolescent and young population is vulnerable regarding hiv/aids; therefore, specialized care needs to be attentive to successfully ensure the transition from pediatric to adult care (43). it has been noticed that the profiles of the patient’s conditions and treatment patterns seem to vary according to transmission mode; thus, identification of hiv disease progression and the determinants of access to treatment among adolescents and young people can assist in understanding the outcome in adherence or abandonment (44). among the healthcare factors for young people, taking medication in the same service as adults and not being regularly advised by health professionals reflect non-adherence to treatment; this suggests that specialized care professionals are attentive to the patient’s needs and preferences to ensure adherence (45). also, considering medication, some patients are more sensitive to the drugs and, consequently, are at a higher risk of negative treatment results, which can be explained by the side effects and intentional non-adherence. such fact has impacted general adherence to art and in the hiv viral load (46). the absence of hiv/aids follow-up clinical consultations, that is, lack of monitoring and clinical treatment, has been a predictor of abandonment, which suggests the strengthening of the active search for missing patients at the beginning of the follow-up period to reduce morbidity, re-engage them in hiv/aids care and improve their maintenance and adherence to the service. the extended duration of the treatment has also contributed to non-adherence. thus, it becomes necessary for health professionals to (re)think and (re)devise actions and strategies to optimize adherence to art to keep patients engaged in their hiv/ aids treatment (47). the use of highly active art has been essential in managing viral replication, where adherence to the therapy is fundamental for such control. external and individual factors in relation to the patient influence treatment adherence and abandonment. in environments where resources are limited, approximately three-quarters of the adolescents may not adhere to art, in addition to late diagnoses that may reflect in adherence (17). 18 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 22 a study conducted in india shows that nearly 20 % of the patients had hiv symptoms for more than six months, which indicates the absence of hiv screening practices, consequently causing delays in diagnosis and art initiation. in addition to that, some patients delay going to the antiretroviral delivery service; such context can be due to the absence of adequate communication with the patients or to the service’s unavailability, resulting in faster progression and a worse evolution of the disease (44). the low self-efficacy and the rigid treatment routine for adolescents and young people reflect non-adherence. part of hiv/aids care and management has involved changes in the treatment with an art regimen with possible failures for another class of antiretrovirals. however, it is known that these regime changes are fundamental to achieving and maintaining virological suppression without compromising future treatment options (45). a study conducted in south korea identified that second-generation antiretroviral medications or single-pill regimens presented lower toxicity and viral resistance rates, contributing to better medication adherence and viral suppression effect. as patients living with hiv/ aids have a longer life expectancy, it becomes increasingly essential to manage medication adherence (48). given this context, health professionals, especially nurses, should evaluate adherence in various aspects, ensuring and respecting the individuality and vulnerabilities of people in specialized healthcare services. the knowledge about the existing influences regarding non-adherence to art allows nursing professionals to establish care directed to people diagnosed with hiv/aids to improve their quality of life and promote care continuity and adherence to art through comprehensive care (49). it is known health professionals are aware that adolescents and young people living with hiv/aids have specific health needs unique to the age group and should be treated through services aimed at this population segment and guided by scientific information (50, 51). despite the limitation demonstrated by the small number of studies included in the sample, they were relevant to the reflection on treatment abandonment among adolescents and young people living with hiv/aids. additionally, all the information in this study may help not only health professionals within the service but also undergraduate students and society interested in comprehensive healthcare in key or minority population groups. conclusions the findings of this study evidenced how vulnerable adolescents and young people are to the issues inherent to the treatment even more when living with hiv/aids and that several reasons can influence adherence or abandonment. tr ea tm en t n on -a dh er en ce o r a ba nd on m en t a m on g a do le sc en ts a nd y ou ng in di vi du al s li vi ng w it h h iv /a id s: a s co pi ng r ev ie w 19 the research contributes to the health professionals’ practice because it offers subsidies to understand the realities experienced by the individuals who abandon treatment. furthermore, the study’s findings show the need to conduct further research on non-adherence to art or its abandonment, both with those living with hiv/aids and with health professionals, to understand the phenomenon of hiv/aids treatment abandonment. conflict of interests: none declared. references 1. joint united nations program hiv/aids. informative summary. global hiv statistics. 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hiv in ethiopia be improved? healthcare professionals’ perspectives. compr child adolesc nurs. 2021;110. doi: https://doi.org /10.1080/24694193.2021.1914774 51. mammbona a a , mavhandu-mudzusi ah. enrolled nurses’ experiences of caring for patients living with hiv in a south african rural hospital. int nurs rev. 2019;66(1):139-46. doi: https://doi. org /10.1111/inr.12480 https://doi.org/10.1590/0034-7167-2021-0019 https://doi.org/10.1080/24694193.2021.1914774 https://doi.org/10.1111/inr.12480 https://doi.org/10.1111/inr.12480 396 406 validacion inicial de un instrumento.indd 396 aquichan issn 1657-5997 claudia bustamante1 claudia alcayaga2 j. carola pérez3 solange campos4 validación inicial de un instrumento de análisis del apoyo a la toma de decisiones para el manejo de enfermedades crónicas 1 enfermera-matrona. magíster en enfermería. profesora asistente, pontificia universidad católica de chile, chile. cqbustam@uc.cl 2 enfermera-matrona. magíster en psicología. profesora asistente adjunta, pontificia universidad católica de chile, chile. caalcaya@uc.cl 3 psicóloga. doctora en psicología. profesora, universidad del desarrollo, chile. janetperez@udd.cl 4 enfermera-matrona. magíster en psicología. profesora asociada, pontificia universidad católica de chile, chile. scamposr@uc.cl recibido: 29 noviembre 2012 enviado a pares: 7 de febrero de 2013 aceptado por pares: 1 de octubre de 2013 aprobado: 18 de octubre de 2013 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 396-406 para citar este artículo / to reference this article / para citar este artigo bustamante, c., alcayaga, c., pérez, j. c., campos, s. (2013). validación inicial de un instrumento de análisis del apoyo a la toma de decisiones para el manejo de enfermedades crónicas. aquichan. vol. 13, no. 3, 396-406. resumen introducción: el apoyo a la toma de decisiones en salud facilita el automanejo de personas con enfermedades crónicas (ec). objetivo: validar la versión en español del dsat-cdm: herramienta de análisis del apoyo en las decisiones para el manejo de ec, desarrollada por stacey (2006). materiales y métodos: estudio descriptivo que aplica un proceso sistemático que considera, entre otros: traducción-contratraducción, desarrollo de escenarios de simulación, entrenamiento de evaluadores, entrenamiento pacientes simulados y capacitación para participantes. muestra: 15 profesionales y 2 jueces, obteniéndose 60 dsat-cdm versión español aplicado (pre y pos capacitación). resultados: el instrumento presentó confiabilidad aceptable en la aplicación entre-jueces y detectó la mejora en la calidad del apoyo a la toma de decisiones en los profesionales. sin embargo, no se obtuvieron resultados que aportaran a la validez de criterio concurrente. conclusiones: este estudio es la primera evaluación del dsat-cdm en idioma español, el resultado principal indica que se detecta un cambio en el desempeño de profesionales para apoyar el proceso de toma de decisiones de sus pacientes y, a pesar estos hallazgos favorables, es necesario seguir evaluando el instrumento. palabras clave estudios de validación, toma de decisiones, enfermedades crónicas, autocuidado, capacitación, enfermería. (fuente: decs, bireme). 397 validación inicial de un instrumento de análisis del apoyo a la toma de decisiones para el manejo de enfermedades crónicas l claudia bustamante, claudia alcayaga y otros. initial validation of an analytical tool to support decision-making on chronic illness management abstract introduction: support for decision-making in health facilitates self-management by persons with chronic illness (ci). objective: validate the spanishlanguage version of dsat cdm: an analytical tool developed by stacey (2006) to support decision-making on ci management. materials and methods: this descriptive study applies a systematic process that considers a number of aspects, such as translation – back-translation, simulation scenario development, training evaluators, simulated patient training and training for participants. sample: 15 professionals and two judges, obtaining 60 dsat cdm with the applied spanish version (pre and post training). results: the instrument showed acceptable reliability in application among judges and found improvement in the quality of decision-making support on the part of professionals. however, no results were obtained that contribute to concurrent criterion validity. conclusions: this study is the first assessment of dsat – cdm in spanish. the main result indicates a change is detected in the performance of professionals to support the decision-making process of their patients. yet, despite this favorable finding, further evaluation of the instrument is necessary. key words validation studies, decision making, chronic disease, self care, training, nursing. (source: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 396-406 398 aquichan issn 1657-5997 validação inicial de um instrumento de análise do apoio na tomada de decisões para o manejo de doenças crônicas resumo introdução: o apoio na tomada de decisões em saúde facilita o automanejo de pessoas com doenças crônicas (ec em espanhol). objetivo: validar a versão em espanhol do dsta-cdm: ferramenta de análise do apoio nas decisões para o manejo de ec, desenvolvida por stacey (2006). materiais e métodos: estudo descritivo que aplica um processo sistemático que considera, entre outros: tradução-contratradução, desenvolvimento de cenários de simulação, treinamento de avaliadores, treinamento de pacientes simulados e capacitação para participantes. amostra: 15 profissionais e 2 juízes, com obtenção de 60 dsat-cdm versão espanhol aplicado (pré e pós capacitação). resultados: o instrumento apresentou confiabilidade aceitável na aplicação entre juízes e detectou a melhoria na qualidade do apoio na tomada de decisões nos profissionais. contudo, não se obtiveram resultados que contribuíssem para a validade de critério concorrente. conclusões: este estudo é a primeira avaliação do dsat-cdm em espanhol; o resultado principal indica que se detecta uma mudança no desempenho de profissionais para apoiar o processo de tomada de decisões de seus pacientes e, apesar dessas descobertas favoráveis, é necessário continuar avaliando o instrumento. palavras-chave estudos de validação, tomada de decisões, doenças crônicas, autocuidado, capacitação, enfermagem. (fonte: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 396-406 399 validación inicial de un instrumento de análisis del apoyo a la toma de decisiones para el manejo de enfermedades crónicas l claudia bustamante, claudia alcayaga y otros. introducción la comunidad científica ha reconocido que el enfoque tradicional de atención en salud, con énfasis biomédico, no ofrece el apoyo que necesitan las personas para modificar sus conductas de salud y afrontar con éxito las enfermedades crónicas (ec) (1). para que el paciente logre un automanejo efectivo y adquiera habilidades de autocuidado, los profesionales deben cambiar su foco de intervención desde una educación didáctica, hacia el acompañamiento y apoyo a los usuarios (2). estrategias de intervención participativas, como la toma de decisiones compartidas entre profesionales de la salud y pacientes, han demostrado ser efectivas en mejorar el cuidado de estos últimos (3); de hecho, este enfoque ha sido promovido como un modelo ético ideal de interacción con los usuarios (4). apoyar a las personas para que tomen mejores decisiones sobre el cuidado de la salud es una tarea de alta complejidad para los equipos de esta área (5). este proceso involucra: identificar las necesidades específicas de apoyo del usuario, ajustar las intervenciones de acuerdo con ellas y evaluar el apoyo entregado (6). en este contexto, la habilidad del profesional resulta crucial para el logro de mejores resultados en salud, en especial para enfrentar el desafío de encontrar una base común entre las prioridades clínicas (desde la perspectiva del profesional) y las personales (del usuario) a fin de lograr los cambios (7). es posible adquirir estas habilidades y entrenarlas; sin embargo, este proceso se dificulta, entre otros factores, por no contar con instrumentos válidos y confiables para medir el desempeño de los profesionales en la adquisición de esta habilidad (8). el presente estudio da cuenta del proceso inicial de validación de la versión en español del instrumento dsat-cdm: decision support analysis tool for chronic disease management, desarrollado por stacey en el año 2006, que es un instrumento que permite valorar la calidad del apoyo en la toma de decisiones que entregan profesionales de la salud en intervenciones con personas con ec. el dsat-cdm es un instrumento observacional que evalúa el apoyo a la toma de decisiones y las habilidades comunicacionales de los profesionales de la salud, en el contexto de intervenciones para personas con ec. fue desarrollado y publicado originalmente por pierrette guimond (9, 10). posteriormente, stacey desarrolla el dsat-10 y el dsat chronic disease management (dsat-cdm), instrumento para evaluar la calidad del apoyo en la toma de decisiones entregado a personas con ec que estén tomando determinaciones acerca de las prioridades para manejar su enfermedad (9), basada en su trabajo con el bc nurseline del ministerio de salud de british columbia, canadá. el presente estudio es el primer paso para contar con una herramienta en español que permita evaluar la adquisición de la habilidad de los profesionales para apoyar la toma de decisiones en salud de las personas. de esta manera, se espera contribuir a que estas tomen mejores decisiones en salud e incrementen su automanejo. materiales y métodos procedimientos la preparación de los materiales y la recolección de los datos de los participantes se realizó entre julio del 2008 y marzo del 2009. la muestra estuvo conformada por 15 profesionales de la salud. las participantes desarrollaron 30 interacciones telefónicas. la duración de las llamadas tuvo una media de 6,5 minutos en la medición basal (ds 2.93) y 8,2 minutos en la medición final (ds 2.30). el estudio de validación consideró: a) la adaptación cultural y de lenguaje del instrumento original al idioma español, considerando los procesos de traducción, contra-traducción y adaptación del lenguaje (11); b) el estudio de concordancia y confiabilidad, y c) el estudio de validez. 1. adaptación cultural y de lenguaje del instrumento: al tratarse de un instrumento en un idioma distinto al lenguaje materno de los usuarios, es importante considerar que la traducción tiene como objetivo lograr equivalencia tanto conceptual como de los ítemes, semántica, operacional y de medida entre la versión original y la traducida (12). para ello una enfermera chilena bilingüe tradujo el dsat-cdm original en inglés al idioma español. esta versión fue analizada por tres expertas en el marco conceptual de la toma de decisiones, una de ellas bilingüe, que verificaron la coherencia de los conceptos traducidos con el marco conceptual de referencia. esta primera versión en español fue traducida al inglés por una enfermera estudiante bilingüe de posgrado cuya lengua materna es el inglés, con el objetivo de verificar la concordancia entre la versión modificada y la versión original del dsat-cdm. esta versión del dsat-cdm fue revi400 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 sada por la autora del instrumento original y por la experta y creadora del marco conceptual de la toma de decisiones (annette o`connor) en que se enmarca este instrumento, quienes verificaron que la versión traducida mantenía el sentido del instrumento original. además, se realizaron ajustes en algunos ítemes considerando la última información del uso del dsat-cdm en canadá. al finalizar este proceso se obtuvo la versión en español del instrumento que consta de 16 ítemes agrupados en 3 áreas y que considera 2 puntajes subtotales respetando el mismo formato que el original. 2. estudio de concordancia y confiabilidad: al tratarse de un instrumento observacional fue necesario contar con evaluadores entrenados en su aplicación y establecer el nivel de acuerdo que había entre ellos. el panel de evaluadores se conformó con tres docentes de carreras de la salud con formación y experiencia en toma de decisiones en salud. las evaluadoras fueron convocadas a una sesión para revisión en conjunto del instrumento, en esta se acordaron los criterios para la calificación de cada uno de los ítemes, luego el grupo escuchó una interacción simulada enfermera-paciente, se aplicó el dsat-cdm en forma individual y se realizó un análisis en conjunto de los resultados con el fin de verificar la aplicación de los criterios acordados. para finalizar estre proceso, a cada juez se le entregaron tres audios de interacciones y se les solicitó aplicar el dsat-cdm y devolver los resultados. para la siguiente etapa del proceso se seleccionó la dupla de evaluadores que presentaron el nivel de acuerdo más alto (kappa 0,60 , p < 0,001) y que realizaron la siguiente etapa de aplicación del instrumento. 3. estudio de la validez: se evaluó la validez del instrumento desde dos perspectivas. en primer lugar, se estableció la capacidad del dsat-cdm versión español de dar cuenta de las diferencias intraindividuales en el desempeño de profesionales, previo y posterior a una capacitación en apoyo a la toma de decisiones de personas con ec y habilidades de entrevista motivacional. este análisis indica la sensibilidad de la prueba al cambio en la calidad del apoyo a la toma de decisiones entregado. en segundo lugar, se determinó la validez concurrente de la prueba. para ello se establecieron correlaciones entre los puntajes de la prueba dsat-cdm versión español con el nivel de conocimientos sobre el marco conceptual de toma de decisiones y el nivel de conocimientos de respuesta empática. para evaluar la capacidad del dsat-cdm de detectar un cambio en el desempeño de profesionales con entrenamiento en apoyo a la toma de decisiones en salud de personas con ec se realizó una capacitación de seis horas al grupo de profesionales que conformaron la muestra, que incluyó el marco de referencia de apoyo a la toma de decisiones y el ejercicio de habilidades de entrevista motivacional en el contexto de contactos con personas con ec. como parte de los contenidos se incluyó la revisión del dsat-cdm y su aplicación, y se entregó material escrito de apoyo. para medir las habilidades de toma de decisiones de los profesionales se realizó una medición basal (previa a la asistencia al taller de capacitacion) y una final. en la evaluación pre y poscapacitación cada participante tuvo un contacto telefónico con un paciente simulado. a pesar de la denominación de simulado, el factor clave para su uso es la estandarización del desempeño, entendido como un sujeto sano o un paciente que ha sido entrenado para representar con exactitud y consistentemente un caso particular (13). para este estudio se prepararon tres personas como pacientes simulados: una enfermera con experiencia en el manejo de ec, formación de posgrado y entrenamiento en habilidades de entrevista motivacional, y dos personas jubiladas, un hombre y una mujer de 66 años, ambos profesionales, portadores de ec y con controles al día en un centro de atención primaria. los escenarios de simulación utilizados fueron adaptados del material original desarrollado por la doctora stacey. cada una de las interacciones entre los profesionales de la muesta y los pacientes simulados (pre y postaller de capacitación) fueron grabadas y codificadas para mantener el anonimato del profesional. luego los evaluadores (binomino de jueces) aplicaron el dsat-cdm a las grabaciones. para la evaluación final (postaller), además de sostener un nuevo contacto telefónico con un paciente simulado, cada participante contestó un test de conocimientos sobre contenidos del marco conceptual de la toma de decisiones y de respuesta empática. todos los participantes aceptaron hacer parte de la investigación consintiendo en sus condiciones y firmaron un acta de consentimiento informado. el estudio fue evaluado y aprobado por el comité de ética de la escuela de enfermería. 401 validación inicial de un instrumento de análisis del apoyo a la toma de decisiones para el manejo de enfermedades crónicas l claudia bustamante, claudia alcayaga y otros. instrumentos • dsat-cdm: este instrumento evalúa los elementos involucrados en la toma de decisiones en salud de una persona con ec agrupados en tres áreas: a) el estado de la toma de decisión, b) las necesidades para la toma de decisión (conocimiento, prioridades, otras personas involucradas) y c) las necesidades para implementarla, junto con algunas habilidades de la entrevista motivacional. consta de 16 ítemes, para cada uno de ellos el evaluador debe indicar si se encuentra o no presente durante la interacción profesionalusuario. la escala entrega un puntaje total (puntaje máximo 16 puntos) y 2 subtotales: el primero corresponde a la suma de las tres áreas (puntaje máximo 14 puntos) y el segundo subtotal corresponde a la evaluación general de la interacción (puntaje máximo 2 puntos). • test de conocimentos: este instrumento fue diseñado para el presente estudio e incluye ítemes de selección simple y múltiple. stacey aportó ocho ítemes que evalúan los aspectos de toma de decisiones abordados durante la capacitación (definición de toma de decisiones, conflicto para la toma de decisiones, intervención de apoyo a la toma de decisiones). además incluye tres ítemes sobre respuesta empática aportados por urrutia. el puntaje máximo que se puede obtener corresponde a 15 puntos. análisis de los datos para evaluar la concordancia en cada uno de los ítemes del instrumento se utilizó kappa, y la medición de la confiabilidad en cada una de las mediciones (pre y pos) se realizó con el indice de correlación intra-clase (icc). para determinar la capacidad del dsat-cdm de detectar el cambio en el desempeño de los profesionales para apoyar la toma de decisiones —entrenados frente a no entrenados— se utilizó una prueba de diferencia de medianas para muestras relacionadas (test de wilcoxon). adicionalmente, se establecieron correlaciones entre la prueba de conocimientos sobre toma de decisiones y respuesta empática y los puntajes dsat-cdm posintervención a través de la prueba rho de spearman, utilizando el software estadístico spss versión 15. resultados se reclutaron 17 profesionales de la salud provenientes de programas de posgrado (postítulo y magíster) de una escuela de enfermería que participaron en el taller de capacitación en apoyo a la toma de decisiones en salud de seis horas de duración. quince de ellos participaron del entrenamiento y completaron la medición inicial y final. la edad promedio de los participantes fue de 27 años, todas mujeres. la profesión de las participantes fue mayoritariamente enfermera (73 %), y participaron además dos nutricionistas y una odontóloga. acuerdo y confiabilidad del dsat-cdm versión español. se estimó la concordancia entre-jueces ítem por ítem a través del índice kappa en la medición basal y final. el nivel de acuerdo entrejueces fue heterogéneo, con valores k = 0,22 a k = 1,0 (tabla 1). los ítemes en que los jueces presentaron mejor acuerdo fueron los 3, 10 y 12 en ambas mediciones (basal y final). en aquellos ítemes que presentaron mayor desacuerdo en ambas mediciones (1, 2, 6, 11, 13 y 14) se solicitó a los evaluadores realizar una conciliación de sus diferencias en los siguientes ítemes: estado de la toma de decisión: • escucha, entiende o valora la incertidumbre. • escucha entiende o valora la percepción acerca de la etapa de manejo. necesidades para la toma de decisiones: • interviene en las prioridades. necesidades para la implementación: • identifica los obstáculos. • estimula la verbalización. • utiliza la escucha activa. el objetivo de la conciliación de los observadores fue contar con puntajes de las escalas del instrumento para evaluar su confiabilidad. la confiabilidad de la escala total (16 ítemes) en la medición basal fue de un icc de 0,926 (ic 95 %: 0,779-0,975, p < 0,001). adicionalmente, en la sub-escala que corresponde a la evaluación de los estados de la toma de decisión, necesidades para la toma de decisiones y necesidades para la implementación (14 ítemes) el icc fue de 0,936 (ic 95 %: 0,808-0,978, p < 0,001) y en la eva402 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 luación general de la interacción (2 ítemes) este alcanza un valor de 0,741 (ic 95 %: 0,228-0,913, p < 0,01). en la medición final la confiabilidad fue de icc 0,968 para la escala total (16 ítemes, ic 95 %: 0,905-0,939, p < 0,01), de 0,974 (14 ítemes, ic 95 %: 0,921-0,991, p < 0,001) y 0,803 (2 ítemes, ic 95 %: 0,413-0,934, p < 0,01) en cada una de las respectivas subescalas. sensibilidad al cambio del dsat-cdm versión español pre y poscapacitación. el puntaje promedio obtenido de la calidad del apoyo a la toma de decisiones en la medición basal fue de 4,13 puntos (ds 2.13). en la medición final, el puntaje promedio de la calidad del apoyo a la toma de decisiones fue 9,2 puntos (ds 3,2). para contrastar las diferencias en las medianas de la calidad del apoyo a la toma de decisiones, entre las mediciones pre y posentrenamiento, se utilizó la prueba de rangos signados de wilcoxon. los resultados indicaron que se presenta una diferencia estadísticamente significativa (z = -3.409, p < 0,001) en dichas medianas entre ambos momentos, siendo el nivel medio de la calidad del apoyo a la toma de decisiones mayor en el momento posintervención. esto indica que la prueba es capaz de dar cuenta de cambio en el nivel de apoyo a la toma de decisiones en ec de los participantes pre y postaller de capacitación. de esta manera se confirma la hipótesis referida a que el dsat-cdm versión en español es capaz de detectar la mejora en la calidad del apoyo a la toma de decisiones entregado por profesionales de la salud que participan de un programa de capacitación. respecto al desempeño de las participantes en cada uno los ítemes (tabla 2), los resultados indican que hubo variación entre la medición basal y final, es decir, pre y poscapacitación. la diferencia de mayor magnitud se presentó en los ítemes de “fortalecimiento de la autoeficacia”, “valoración de las prioridades” e “intervención en las prioridades”, “valoración de la motivación” y “utilización apropiada del tiempo”. en el único ítem en que disminuyó el desempeño fue en la “valoración de otras personas involucradas en el manejo” de la patología. se observó que en la medición basal las intervenciones de apoyo se concentraron más en el área estado de la toma de decisión, específicamente en la dimensión de valoración de las necesidades para la toma de decisión, a excepción del “conocimiento de la enfermedad” en que las profesionales también realizaron intervención (específicamente de entrega de información). relación del dsat-cdm versión español con prueba conocimientos en toma de decisiones. el promedio de puntaje en la evaluación del conocimiento de toma de decisiones fue 8,06 (ds 1,4) de un máximo posible de 11 puntos. el promedio en el puntaje de evaluación de conocimiento de respuesta empática fue 2,8 (ds 1,6) de un máximo posible de 4 puntos. las correlaciones entre la prueba de conocimientos y el puntaje dsat-cdm indican que el desempeño de los profesionales en la interacción con un paciente se relaciona en forma estadísticamente significativa con el nivel de conocimientos de respuesta empática (rsp = 0,534, p 0,041). es decir, en los profesionales que presentan mayor grado de apoyo a la toma de decisiones se asocia a un mayor nivel de conocimientos en la respuesta empática. en cambio, no se presentó una correlación significativa entre el apoyo a la toma de decisiones y el nivel de conocimientos de la misma (rsp = 0,063, p 0,823). discusión esta primera versión en idioma español del dsat-cdm se obtiene a partir de un proceso riguroso de traducción, contratraducción (back translation) y adaptación de su contenido, velando por mantener su coherencia con el instrumento original (14). el principal resultado del estudio indica que el instrumento fue capaz de detectar los cambios en las habilidades de apoyo a la toma de decisiones por parte de profesionales de la salud, que fueron capacitados o entrenados para desarrollar dicha habilidad. en la medición basal, las intervenciones de apoyo de los profesionales se concentraron más en el área estado de la toma de decisión y específicamente en el ítem de valoración de las necesidades para la toma de decisión, a excepción del “conocimiento de la enfermedad” en que las profesionales, además de valoración, también realizaron entrega de información. resultados similares se obtuvieron con el dsat y el dsat-10 (9, 10). guimond et al. (10) señalan que este resultado se relaciona con la formación tradicional de los profesionales de la salud, en un paradigma de comunicación interpersonal en el que prevalece la entrega de información, por tanto, en escenarios de evaluación los profesionales (especialmente previo a participar del taller de capacitación) tienden a replicar el modelo de práctica con el que están familiarizados y con el que se sienten confortables. adicionalmente, en este tipo de interacción, desde la perspectiva de los usuarios, los profesio403 validación inicial de un instrumento de análisis del apoyo a la toma de decisiones para el manejo de enfermedades crónicas l claudia bustamante, claudia alcayaga y otros. ítem dsat-cdm versión español medición inicial medición final nº nombre del ítem coeficiente kappa error típico p coeficiente kappa error típico p 1 estado de la toma de decisión: incertidumbre 0,022 0,026 0,685 0,091 0,091 0,398 2 estado de la toma de decisión: percepción etapa de manejo 0,062 0,208 0,756 -0,125 0,112 0,464 3 necesidades para la toma de decisión: conocimiento/escucha 0,602 0,204 0,019 0,865 0,129 0,001 4 necesidades para la toma de decisión: conocimiento/interviene 0,602 0,204 0,019 -0,053 0,249 0,833 5 necesidades para la toma de decisión: prioridades/escucha -0,154 0,76 0,551 0,651 0,221 0,011 6 necesidades para la toma de decisión: prioridades/interviene -0,071 0,050 0,782 0,455 0,224 0,067 7 necesidades para la toma de decisión: otras personas involucradas/escucha * 10,0 0,000 0,000 8 necesidades para la toma de decisión: otras personas involucradas/interviene * 0,762 0,223 0,002 9 necesidades para la implementación: motivación 0,634 0,329 0,008 0,444 0,236 0,085 10 necesidades para la implementación: autoeficacia 1.0 0,000 0,000 1.0 0,000 0,000 11 necesidades para la implementación: obstáculos/escucha 0,167 0,257 0,519 0,455 0,224 0,067 12 necesidades para la implementación: obstáculos/interviene 0,526 0,237 0,039 0,471 0,232 0,032 13 necesidades para la implementación: verbalización 0,000 0,224 1.0 -0,119 0,102 0,533 14 necesidades para la implementación: escucha activa -0,125 0,112 0,464 0,118 0,115 0,333 15 evaluación general de la interacción: diálogo * 0,857 0,137 0,001 16 evaluación general de la interacción: tiempo 0,483 0,190 0,029 * tabla 2. media de los puntajes por ítem en las mediciones basal y final tabla 1. acuerdo entre jueces por ítem en las mediciones basal y final * no pudo ser estimado por la proporción de ceros en los datos. se repite el porcentaje de acuerdo. ítem puntaje basal puntaje final diferencia final-inicial nº nombre del ítem media ds media ds z p 1 estado de la toma de decisión: incertidumbre 0,07 0,26 0,63 0,35 -0,298 0,003 2 estado de la toma de decisión: percepción etapa de manejo 0,6 0,47 0,73 0,46 -0,97 0,33 3 necesidades para la toma de decisión: conocimiento/escucha 0,5 0,46 0,57 0,50 -0,359 0,72 4 necesidades para la toma de decisión: conocimiento/interviene 0,5 0,46 0,53 0,35 -0,302 0,76 5 necesidades para la toma de decisión: prioridades/escucha 0,2 0,37 0,73 0,42 -,2.805 0,005 6 necesidades para la toma de decisión: prioridades/interviene 0,0 0 0,53 0,52 -,2.828 0,005 7 necesidades para la toma de decisión: otras personas involucradas/escucha 0,1 0,21 0,33 0,49 -1.734 0,083 8 necesidades para la toma de decisión: otras personas involucradas/interviene 0,03 0,13 0,17 0,36 -1.300 0,194 9 necesidades para la implementación: motivación 0,1 0,28 0,60 0,43 -2.425 0,015 10 necesidades para la implementación: autoeficacia 0,27 0,46 0,80 0,41 -2.530 0,011 11 necesidades para la implementación: obstáculos/escucha 0,27 0,46 0,33 0,49 -0,447 0,655 12 necesidades para la implementación: obstáculos/interviene 0,30 0,41 0,23 0,37 -0,520 0,603 13 necesidades para la implementación: verbalización 0,33 0,49 0,73 0,45 -1.732 0,083 14 necesidades para la implementación: escucha activa 0,27 0,46 0,73 0,46 -2.646 0,008 15 evaluación general de la interacción: diálogo 0,20 0,25 0,63 0,48 -2.425 0,015 16 evaluación general de la interacción: tiempo 0,40 0,43 0,90 0,21 -2.743 0,006 404 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 nales no ofrecen oportunidades para participar en el proceso de toma de decisiones, aun cuando ellos quisieran hacerlo en forma activa (15). en la medición poscapacitación las participantes mejoraron sus puntajes en el área de necesidades para la implementación, ello habría sido facilitado por la aplicación de algunas microhabilidades de la entrevista motivacional (motivación, autoeficacia, escucha activa), ejercitadas durante la capacitación. miller y rollnick (16) describen, como una de las características del aprendizaje de la entrevista motivacional, que siempre se produce una retroalimentación inmediata a los profesionales en capacitación respecto a cómo incorporan las habilidades. el instrumento no solo fue capaz de detectar cambios en las habilidades, sino que se relacionó positivamente con conocimientos en la respuesta empática, pero no así con los conocimientos teóricos involucrados en el proceso de toma de decisiones. esto podría estar relacionado con el conocimiento previo de los profesionales de la salud con el concepto de empatía. tradicionalmente, alrededor de este concepto se ha centrado la enseñanza de habilidades de comunicación (17), es un constructo común en la cultura de la formación profesional de las participantes. por otra parte, el marco conceptual de la toma de decisiones en salud es menos conocido; de hecho, solo cinco personas del grupo reconocieron haber tenido formación previa al respecto. la empatía, además, es reconocida por los propios usuarios como un facilitador de su participación en el proceso de toma de decisiones en salud (15). los resultados de la correlación entre el nivel de conocimientos y el desempeño en el dsat-cdm versión español deben ser mirados con la limitación de que las pruebas de conocimiento verbalizado describen el “cómo” se ejecutaría la actividad, lo que no permite asegurar que la persona evaluada sea capaz de ejecutar lo que relata (18). si bien el nivel de conocimientos sobre toma de decisiones de las participantes es adecuado, esto no se asoció con la incorporación de la conducta en la intervención. dado que se trata de una herramienta de uso observacional, el acuerdo entre jueces resulta esencial para evaluar la confiabilidad del dsat-cdm, la que se considera como adecuada. el acuerdo entre jueces por ítemes fue notoriamente mayor en las llamadas de la medición final frente a la medición basal, resultados que son concordantes con lo reportado en el estudio del dsat-10 de stacey et al. los ítemes que presentaron más dificultad de acuerdo con el icc están relacionados con evaluación de habilidades comunicacionales generales. la dificultad para el acuerdo entre los jueces en la medición precapacitación puede deberse a que durante esta observación el criterio de evaluación no estuvo explícitamente presente, por esto los evaluadores tuvieron dificultad en identificarlo, lo que genera desacuerdo entre ellos. en la experiencia de stacey et al. también se observó este comportamiento en los evaluadores (9). resulta importante destacar que si bien hubo bajo acuerdo entre jueces, no se presentó “no acuerdo” entre ellos. por otra parte, dadas las características del instrumento, en que los jueces solo pueden evaluar como presente o no cada ítem evaluado, es decir, solo dos alternativas de respuesta, sumado a la baja presencia de la característica evaluada en la medición basal (o alta prevalencia en la medición final), es que se obtienen bajos valores kappa (19). finalmente, es importante resaltar que los profesionales de la salud deben ser formados en las habilidades que les permitan apoyar a los pacientes y sus familias en la toma de decisiones en salud, lo que puede ser fomentado a través de intervenciones dirigidas específicamente a enfermeras, pero también debe estar incorporado en las instituciones donde se forman y en las cuales se desempeñan estos profesionales (20). las limitaciones del estudio para interpretar estos resultados son: • las características de la muestra. se trata de un grupo selecto, altamente motivado, que logra la adquisición de habilidades a partir de una intervención única. • la complejidad de la aplicación del instrumento de acuerdo con la opinión de los jueces y conforme a la variabilidad de los índices kappa. luego de terminadas sus evaluaciones, los jueces consideraron que las principales dificultades en la aplicación del dsat-cdm versión español fueron poder distinguir cuándo una intervención es intencional o planificada o solo aparece en el diálogo de forma incidental, lo cual fue más notorio en la medición basal. otro aspecto complejo fue evaluar solo la presencia o ausencia de un apoyo, sin considerar su nivel de calidad. para mejorar el instrumento se propone profundizar la especificación de los criterios por aplicar por los jueces, para la asig405 validación inicial de un instrumento de análisis del apoyo a la toma de decisiones para el manejo de enfermedades crónicas l claudia bustamante, claudia alcayaga y otros. nación de cada uno de los puntajes (valor 0, valor 1). además, con el objetivo de favorecer la reproducibilidad del instrumento, se debería considerar en el entrenamiento de los evaluadores una metodología más intensiva que la utilizada en el presente estudio, reforzando especialmente las definiciones de cada ítem para que sean aún más específicos y observables, además de considerar que los evaluadores puedan comparar su desempeño con evaluaciones de expertos o estándar de oro. además, es necesario establecer su validez concurrente, para lo cual se requiere contar con instrumentos validados a fin de evaluar entrevista motivacional, los que al momento del estudio no estaban disponibles. el principal resultado de este estudio indica que esta versión del dsat-cdm, tiene la capacidad de detectar un cambio en el desempeño de profesionales para apoyar el proceso de toma de decisiones de sus pacientes. conclusiones este estudio es la primera evaluación del dsat-cdm en idioma español, y por tanto su primera aplicación por jueces en profesionales chilenas para evaluar intervenciones telefónicas con pacientes con ec. los resultados obtenidos permiten confirmar dos de las tres hipótesis planteadas por el estudio como indicadores de validación: el dsat-cdm versión en español presentó confiabilidad adecuada (icc) y detectó la mejora en la calidad del apoyo a la toma de decisiones entregado por profesionales de la salud que participaron de un programa de capacitación. por otra parte, los resultados respecto de la validez de criterio concurrente no son concluyentes. dados estos resultados, se considera que este estudio corresponde a un proceso inicial de validación del dsat-cdm versión en español, y que se debería continuar buscando evidencia respecto de la validez de constructo y la validez concurrente que complementen los resultados obtenidos, incorporando las sugerencias que han surgido de este análisis. para una futura versión del dsat-cdm versión en español se sugiere incorporar indicadores que den cuenta de grados en la aplicación de habilidades de apoyo a la toma de decisiones, pues la sola presencia o ausencia de la habilidad no refleja necesariamente la calidad del apoyo. además, se enfatiza en la importancia de un entrenamiento similar para los jueces que lo aplicarán. consideraciones finales y agradecimientos: el presente estudio fue realizado como tesis para optar al grado de magíster en enfermería. especiales agradecimientos a ilta lange y mila urrutia, profesoras titulares de la pontificia universidad católica de chile, por su contribución al desarrollo de esta investigación. se contó además con la asesoría experta de la doctora dawn stacey de la university of ottawa. referencias 1. téllez a. atención primaria: factor clave en la reforma al sistema de salud. santiago: pontificia universidad católica vicerrectoría de comunicaciones y asuntos públicos; 2006. 2. wagner eh, austin bt, davis c, hindmarsh m, schaefer j, bonomi a. improving chronic illness care: translating evidence into action. health aff. 2001;20(6):64-78. 3. marshall m, bibby j. supporting patients to make the best decisions. bmj [internet] 2011 apr [cited 2012 oct 15]; 342: d2117. disponible en: http://www.bmj.com/content/342/bmj.d2117 4. saba gw, wong st, schillinger d, fernández a, somkin cp, wilson cc, grumbach k. shared decision making and the experience of partnership in primary care. ann fam med. 2006;4(1):54-62. 5. glanz k, rimer kb, viswanath k. health behavior and health education: theory, research, and practice. 4 ed. san francisco: wiley; 2008. 6. o´connor am, jacobsen mj, editores. conflicto decisional: valorando y apoyando a las usuarias que tienen dificultad para tomar decisiones que afectan su salud. santiago: pontificia universidad católica de chile; 2004. 406 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 7. o`connor am, legaré f, stacey d. risk communication in practice: the contribution of decision aids. bmj. 2008;327(7417):736-40. 8. gonzález-ortega y. instrumento de cuidado de comportamiento profesional: validez y confiabilidad. aquichan. 2008;8(2):170-182. 9. stacey d, taljaard m, drake er, o`connor am. audit and feedback using the brief decision support analysis tool (dsat-10) to evaluate nurse-standarized patient encounters. patient educ couns. 2008;73(3):519-25. 10. guimond p, bunn h, o`connor am, jacobsen mj, tait vk, drake er, et al. validation of a tool to assess health practitioner`s decision support and communication skills. patient educ couns. 2003;50(3):235-45. 11. guillermin f, bombardier c, beaton d. cross-cultural adaptation of health-related quality of life measures: literature review and proposed guidelines. j clin epidemiol. 1993;46(12):1417-32. 12. streiner dl, norman gr. basic concepts. en streiner dl, norman gr, health measurement scales: a practical guide to their development and use. 4 ed. oxford: oxford university press; 2008. 13. beullens j, rethans jj, goedhuys j, buntinx f. the use of standardized patients in research in general practice. family practice. 1996;14(1):58-62. 14. sánchez r, echeverri j. validación de escalas de medición en salud. rev salud pública. 2004;6(3):1-14. 15. ruiz r, peralta l, pérula la, olloqui j, carrión t, sobrino a, et al. opiniones y percepciones de los pacientes sobre su participación en la toma de decisiones en las consultas de medicina familiar. aten primaria. 2012;44(1):5-10. 16. miller wr, rollnick s. motivational interviewing: preparing people for change. 2 ed. new york: the guilford press; 2002. 17. walker r, moore p, cazenave a. entrenamiento en habilidades de comunicación a través del análisis del diálogo médico-paciente en forma de guión escrito. camillianum. 2001;(2):321-329. 18. ahumada p. principios y procedimientos de evaluación educacional. valparaíso: ediciones universitarias de valparaíso; 1983. 19. gwet k. handbook of inter-rater reliability: the definitive guide to measuring the extent of agreement among multiple raters. 3 ed. llc: advanced analytics; 2012. 20. stacey d, murray ma, légaré f, sandy d, menard p, o`connor a. decision coaching to support shared decision making: a framework, evidence, and implications for nursing practice, education, and policy. worldviews evid based nurs. 2008;5(1):25-35. 134 143 enfermedad cronica y sufrimiento.indd 134 aquichan issn 1657-5997 año 12 vol. 12 nº 2 chía, colombia agosto 2012 l 134-143 amparo montalvo-prieto1 boris cabrera-nanclares2 sandra quiñones-arrieta3 enfermedad crónica y sufrimiento: revisión de literatura 1 magíster en enfermería. universidad de cartagena, colombia. amontalvop1@unicartagena.edu.co 2 estudiantes semillero de investigación, grupo cuidado a las personas. universidad de cartagena, colombia. bcabreran@unicartagena.edu.co 3 estudiantes semillero de investigación, grupo cuidado a las personas. universidad de cartagena, colombia. squinoneza@unicartagena.edu.co recibido: 07 de marzo de 2012 aceptado: 25 de mayo de 2012 resumen con el propósito de conocer los desarrollos que la enfermería ha alcanzado acerca del cuidado de pacientes con enfermedad crónica, de sus familiares, y su sufrimiento, así como los instrumentos propuestos para medirlo, se realizó una revisión de la literatura a partir de los descriptores: sufrimiento, instrumentos, enfermos crónicos, enfermería (circunscrito a la persona con enfermedad crónica que sufre), y las escalas que se utilizan para evaluarlo. la búsqueda se hizo en las bases de datos scielo, nursing consult, redalyc, dialnet, ebscohost; se revisaron un total de 116 artículos de los cuales se seleccionaron 40 que trataban la cronicidad y su afectación emocional en las personas, el sufrimiento, el cuidado de enfermería y los instrumentos utilizados para medirlo. los resultados de la búsqueda evidenciaron los escasos estudios que enfermería ha realizado sobre el tema, aunque destacan la importancia que tiene para la disciplina comprender el sufrimiento de las personas en condición de cronicidad, porque permite asumir en el cuidado la totalidad del ser humano, con un trato digno y humanizado, y fortalecer a través de la investigación el cuidado del paciente con sufrimiento tanto físico como emocional. palabras clave enfermedad crónica, dolor, manejo del dolor. (fuente: decs, bireme). chronic illness and suffering: a literature review abstract a literature review was conducted for an insight into the progress nursing has made with respect to the care of chronically ill patients, their families and their suffering, as well as the instruments proposed to measure it. the review was based on several descriptors; namely, suffering, instruments, chronically ill, nursing (limited to the chronically ill person who is suffering), and the scale used to evaluate it. the scielo, nursingconsult, redalyc, dialnet, and ebscohost databases were searched, and a total of 116 articles were reviewed. out of that group, 40 articles dealing with chronicity and its emotional impact on persons, suffering, nursing care and the instruments used 135 enfermedad crónica y sufrimiento: revisión de literatura l amparo montalvo-prieto, boris cabrera-nanclares, sandra quiñones-arrieta to measure it were selected. the results of the search show the limited amount of research nursing has done on this topic, although they do underscore how important it is for the discipline to understand the suffering of patients in a chronic condition, so as to provide comprehensive care for the person as a whole, with dignified and humanized treatment, and to reinforce, through research, the care given to patients with physical and emotional suffering. key words chronic disease, pain, pain management. (source: decs, bireme). doença crônica e sofrimento: revisão de literatura resumo com o propósito de conhecer o desenvolvimento que a enfermagem tem obtido sobre o cuidado de pacientes com doença crônica, seus familiares e seu sofrimento, bem como os instrumentos propostos para medi-lo, realizou-se uma revisão da literatura a partir dos descritores: sofrimento, instrumentos, doentes crônicos, enfermagem (limitada à pessoa com doença crônica que sofre), e as escalas que utilizam para avaliá-lo. a busca se realizou nas bases de dados scielo, nursing consult, redalyc, dialnet, ebscohost; revisaram-se um total de 116 artigos dos quais se selecionaram 40 a respeito da cronicidade e dos instrumentos utilizados para medi-la. os resultados da busca evidenciaram os escassos estudos que a enfermagem tem realizado sobre o tema, muito embora destaquem a importância que tem para a disciplina compreender o sofrimento das pessoas em condições de cronicidade porque isso permite assumir, no cuidado, a totalidade do ser humano, com um tratamento digno e humanizado, e fortalecer, por meio da pesquisa, o cuidado do paciente com sofrimento tanto físico quanto emocional. palavras-chave doença crônica, dor, manejo da dor. (fonte: decs, bireme). 136 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 introducción las enfermedades crónicas no transmisibles (ecnt) son actualmente la principal causa de muerte en el mundo; ocasionan el doble de las defunciones ocasionadas por las enfermedades infecciosas, las complicaciones del parto y la desnutrición combinadas. por varias décadas, las enfermedades crónicas habían sido la causa principal de defunción en canadá y los estados unidos. hoy en día ellas son también la primera causa de mortalidad en américa latina y el caribe, ya que provocan dos de cada tres defunciones en la región, según datos de la organización panamericana de la salud (ops) (1). las ecnt aumentan a medida que la población envejece y los factores subyacentes se generalizan más. según las tendencias actuales, se prevee que las defunciones por causa de las enfermedades crónicas aumentarán 17% en los próximos ocho años. sumado a lo anterior, se observa que las enfermedades crónicas perjudican las economías y la productividad de la fuerza laboral. se calcula que el costo actual de la diabetes en américa latina y el caribe es de 85 mil millones de dólares al año. algunos países del caribe están perdiendo entre 5 y 8% de su producto interno bruto (pib) debido a la diabetes y la hipertensión (2). las enfermedades crónicas han alcanzado proporciones epidémicas con múltiples consecuencias para la salud y la vida de las personas, como son: discapacidad, años de vida productivos perdidos y, pérdidas de vidas humanas, además, muchas se inician en edades tempranas. el costo social es incalculable y representan una problemática ética hasta ahora no abordada. consumen un porcentaje alto de los presupuestos nacionales al aumentar la demanda de servicios de cuidado en los sistemas de salud, que en ocasiones superan su capacidad de respuesta (3). vivir con una enfermedad crónica discapacitante es la experiencia de padecer un trastorno orgánico y funcional que provoca alteraciones en las funciones o estructuras corporales y algún grado de limitación en la actividad de la persona (4). investigaciones centradas en el estudio de individuos con situaciones vitales crónicas, cónyuges cuidadores de personas con una enfermedad mental y padres de niños con retraso mental, reportan la presencia de una pena recurrente, las manifestaciones de las personas en estas situaciones son descritas como una reacción psicológica denominada duelo disfuncional (5, 6). la presencia de estos sentimientos es una constante durante la vida de las personas con trastornos disfuncionales, sus cuidadores familiares y aquellos que han perdido un ser querido (7). la angustia, el miedo, el resentimiento, la depresión, la intolerancia, la insatisfacción, son producto de manejar mal nuestras cargas emocionales (8), por ser las enfermedades crónicas trastornos mórbidos de origen multicausal, de carácter permanente, que provocan en las personas que la padecen y en sus familias modificaciones en el estilo de vida y en la dinámica familiar (9). eakes (10) considera que los profesionales sanitarios y las personas en general tienen una deficiente preparación para tratar a individuos que hacen frente a enfermedades, a la muerte, y a las reacciones de pesar experimentadas en respuesta a situaciones de pérdida. ante la necesidad de obtener información acerca del cuidado que enfermería brinda a estas personas, se inicia una revisión teórica que incluyó búsqueda de literatura científica de la disciplina sobre el tema, en el contexto de la cronicidad y sus escalas de valoración. esta búsqueda permitió reflexionar acerca de los aspectos referentes al sufrimiento, revisar los instrumentos utilizados para su medición, y establecer las tendencias investigativas acerca del tema. a partir de esta reflexión se plantea la necesidad de generar propuestas o estándares de cuidado que contribuyan a cualificar la práctica. por lo anteriormente expuesto, la presente revisión de literatura aportará elementos conceptuales y metodológicos a los profesionales de enfermería e investigadores y, a su vez, invita a la reflexión en torno a la necesidad de abordajes holísticos y una práctica de enfermería humanizada. método a partir de los descriptores enfermedad crónica, sufrimiento y calidad de vida, se realizó una revisión de las publicaciones de las bases de datos scielo, nursing consult, redalyc, dialnet, ebscohost y publicaciones oficiales de organismos estatales, así como una revisión manual que incluyó revistas, libros, tesis y conferencias publicadas en memorias de eventos científicos de las dos últimas décadas. fueron seleccionados un total de 116 artículos. de estos se escogieron 40 que cumplían con los criterios de cronicidad como tema central, sufrimiento como efecto emocional, cuidado de enfermería e instrumentos utilizados para medirlo. a 137 enfermedad crónica y sufrimiento: revisión de literatura l amparo montalvo-prieto, boris cabrera-nanclares, sandra quiñones-arrieta los documentos escogidos se les hizo una revisión final, donde se identificó cómo se abordaba el tema de acuerdo con las palabras clave y el objetivo planteado. enfermedad crónica la enfermedad crónica se define como un trastorno orgánico funcional que obliga a la modificación de los estilos de vida de una persona y que tiende a persistir a lo largo de su vida. frente a la etiología no hay mayor claridad, hay una serie de factores que en conjunto dan pie a la enfermedad; entre estos se encuentran el ambiente, los estilos de vida y los hábitos, la herencia, los niveles de estrés, la calidad de vida y la presencia de una enfermedad persistente que puede pasar a ser crónica (11). las enfermedades crónicas son prolongadas, su pronóstico es incierto, algunas son de carácter intermitente o episódico. quienes las padecen han de aprender a vivir con los síntomas así como con los efectos secundarios de los procedimientos médicos (12), estas condiciones conducen a que se establezca un vínculo de parentesco y afectivo importante, central en la relación de cuidado, la cual es una una fuente de sufrimiento emocional (13) y físico que acompaña a la persona que padece la enfermedad y a su familia. la mayor parte de las manifestaciones de las enfermedades crónicas son graves y constituyen una amenaza para la vida; representan también un problema significativo para la medicina y la psicología de la salud, ya que no solo afectan a la persona que padece la enfermedad, sino también a los familiares y amigos (14). la presencia de enfermedades crónicas dificulta el crecimiento económico y reduce el potencial de desarrollo de los países (15), estas no tienen un grupo de edad determinado y afectan a sistemas y órganos. se prevé que para los próximos 10 años las defunciones por enfermedades crónicas aumentarán un 17 %. eso significa que de los 64 millones de personas que fallecerán en 2015, 41 millones lo harán a causa de enfermedades crónicas (15). los trastornos mentales, el virus de la inmunodeficiencia humana/síndrome de inmunodeficiencia adquirida (vih/sida) y la tuberculosis representaron el 54 % de la carga mundial de todas las enfermedades en el 2001 y sobrepasarán el 65 % en el 2020 (16). las discapacidades visuales y la ceguera, los defectos de audición y la sordera, las enfermedades bucodentales y los trastornos genéticos son otras afecciones crónicas que representan una porción sustancial de la carga mundial de morbilidad (17). las enfermedades crónicas se han identificado en la niñez como un problema de salud a nivel mundial, algunos autores documentan que en los países desarrollados, entre un 5 y un 10% de niños que no han cumplido los 18 años tienen situaciones de este tipo, y muchos pueden llegar a tener una expectativa de vida más elevada si tienen al alcance la tecnología moderna (17, 18). en esta etapa la cronicidad les genera a los niños y sus familias retos más complejos que aquellos impuestos por las tareas normales del desarrollo (19). en la fase inicial o de impacto, la respuesta es muy emocional y se caracteriza por el choque o sorpresa, la incredulidad y a veces la negación. casi siempre después de esta etapa se pueden presentar diferentes tipos de reacciones que influirán en la respuesta final al problema (19). por su parte, en la población adulta la cronicidad se ha identificado como un problema grave tanto en los países desarrollados como en aquellos en vía de desarrollo (3). las enfermedades crónicas están aumentando a una tasa acelerada a medida que la población envejece, y los factores subyacentes se generalizan más (1). la cronicidad en los adultos compite con las metas y los sueños que caracterizan esta etapa de la vida (18), y presenta respuestas diferentes en cada caso (20). en colombia, la situación de las ecnt guarda correspondencia con la situación mundial (21, 22), y es un problema de salud pública con mayor relevancia para el país. son la primera causa de morbimortalidad y representan una alta carga de enfermedad y discapacidad tanto a nivel nacional como regional (23). para bishop (24), el cuidar al paciente con enfermedad crónica desde el sufrimiento es de gran importancia, destaca que cuidar es la esencia de enfermería y su práctica se mejora con la aplicación del conocimiento científico, es a partir de este conocimiento que se cualifica el cuidado de enfermería. el sufrimiento es definido como un estado que se presenta cuando es percibida una situación de destrucción inminente por la persona, y continúa hasta que la amenaza de destrucción o hasta que la integridad del individuo pueda ser restablecida de alguna manera (25). wiklund (26) mira el sufrimiento como una lucha entre caos y control, donde la persona está constantemente tratando de tomar control sobre las situaciones que están sucediendo. padecer una enfermedad implica una carga de sentimientos como frustración e incertidumbre porque la enfermedad arrebata al paciente de su cotidianidad, de su contexto y de sus prácticas 138 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 culturales, y lo confina en una sala de hospital donde todo es diferente pero a la vez rutinario, y donde se ve sometido a una serie de intervenciones, medicaciones, procedimientos, exámenes y dietas que le pueden ocasionar ansiedad y rechazo (27). la enfermedad se manifiesta a través de un lenguaje que hay que saber interpretar, y que el cuerpo expresa para dar a entender que algo no funciona en la conciencia del sujeto. esta interpretación otorga al individuo la total responsabilidad de aquello que le ocurre, lo verdaderamente valioso es que existe la reformulación de un problema y un enfoque que tiene en cuenta aspectos no exclusivamente biológicos (28). es ante la presencia de enfermedades cuando el ser humano se encuentra en una crisis en muchos planos de su vida, en ese momento se da cuenta que no conocía muchos de sus estados emocionales, mentales y físicos que lo llevan a actuar de diferentes maneras, sin poder controlar las situaciones en muchos casos (29). los pacientes que no son informados sienten un mayor sufrimiento físico y psicosocial, y hablan de un nivel inferior de calidad de vida que los que son informados según su voluntad (30). estos procesos de enfermedad que vive la persona le ocasionan cambios en su estilo de vida, y necesidades de apoyo. en cuanto a la atención en salud, el excesivo énfasis en los aspectos tecnológicos, y el deterioro en la comunicación del equipo de salud-paciente, ha ido quitándole a la relación de ayuda profesional la calidad relacional que fuese otrora soporte social para el paciente y fuente de gratificación y reconocimiento para el profesional de la salud (31). el cuidado se ha orientado muchas veces hacia lo técnico, distanciándose de los valores morales y políticos que forman parte de su trabajo cotidiano (32), los profesionales de la salud con frecuencia se centran en la atención al paciente y a menudo pasan por alto el sufrimiento del cuidador, desatendiendo sus necesidades físicas y emocionales (33). para cuidar se debe considerar a la persona como un ser holístico, ya que no se puede hablar de salud física y mental como dos entidades diferenciadas (32), por tanto, la comprensión de esta circunstancia contribuye para que el cuidado, de la misma manera que busca resolver problemas en el cuerpo, también sirva para que las emociones y las respuestas de los pacientes estén acordes con las necesidades y los problemas por resolver. es por esto que las expresiones favorecidas por la enfermedad y el tratamiento, como temor y sufrimiento, pueden llevar al rechazo de prácticas de cuidado; conocer estas condiciones hace posible que puedan ser intervenidas en forma oportuna (27). es cada vez más frecuente la presencia de dificultades por el uso indiscriminado de complicados procedimientos tecnológicos para el diagnóstico y el tratamiento de la enfermedad, a nivel biomédico exclusivamente, los cuales han representado un salto cualitativo a nivel de la supervivencia en enfermedades antes rápidamente mortales, pero han dejado de lado, en muchas ocasiones, la aproximación más holística al cuidado de la salud, donde no solo se busque combatir la enfermedad sino promover el bienestar (32). mejía (34) expresa que los pacientes de su estudio establecieron relaciones sociales situacionales con las enfermeras que los cuidaban; revelaron sus sentimientos y pensamientos íntimos, y entregaron sus sufrimientos a las enfermeras porque creyeron en ellas y confiaron en que les podían ayudar. la depresión, reacción emocional muy frecuente en los enfermos crónicos al inicio de su enfermedad, ha sido estudiada por ford (35), quien estableció que los síntomas depresivos se relacionan estrechamente con el estadio de la enfermedad y con el apoyo social. la enfermedad en general, y el cáncer en particular (especialmente cuando se encuentra en fases avanzadas), podrán afectar de diferentes modos a la persona y sus dimensiones, teniendo en cuenta que usualmente la amenaza a la integridad personal es global, y cuando se afecta una dimensión comúnmente se afectan otras de ellas (36). con relación a estas manifestaciones emocionales, zhao (37) encontró en las mujeres con cáncer de mama mayores niveles de depresión y ansiedad, así como un afrontamiento más negativo del mismo. los trastornos de sufrimiento que las aquejan incluyen frecuentemente ansiedad, insomnio, vergüenza, sentimientos de inutilidad y subvaloración personal (38). aunque se tenga una imagen del enfermo crónico como estable y sin grandes cambios, en realidad su vida está repleta de momentos intensos que sacuden la larga enfermedad. los empeoramientos, el dolor y otros síntomas físicos, la dependencia, la soledad, el duelo de lo perdido, las dificultades económicas, los fracasos de los tratamientos y el miedo al futuro son solo algunos de los eventos que causan, en el paciente crónico, una gran carga emocional (49). la enfermedad misma, y muchas de las intervenciones incluidas en el tratamiento causan dolor, incomodidad, sufrimiento físico y psicológico y todo esto lleva, en un intento por preservar la integridad, a una deficiente aceptación e incluso rechazo hacia la vivencia de una experiencia compleja como es la de estar enfermo (27). el escaso manejo del tema para cuidar a estas personas, el temor y el sufrimiento ante la realidad que vive el paciente, 139 enfermedad crónica y sufrimiento: revisión de literatura l amparo montalvo-prieto, boris cabrera-nanclares, sandra quiñones-arrieta pueden llevar al rechazo de prácticas de cuidado; conocer estos aspectos contribuye a que enfermería asuma un cuidado integral, pero con cierta frecuencia los profesionales de la salud no están preparados académica ni espiritualmente para dialogar sobre los interrogantes existenciales (14). en esta medida, para el profesional es importante desarrollar habilidades que le permitan reconocer en cuál estado de sufrimiento se encuentra el enfermo; el cuidado debería estar basado en las señales dadas por el paciente que está sufriendo. las enfermeras necesitan reconocer y diferenciar entre el endurecimiento y la liberación emocional de los estados de sufrimiento (6). sufrimiento torralba (40) considera que todo en el ser humano es vulnerable, no solo su naturaleza somática, sino todas y cada una de sus dimensiones fundamentales. es vulnerable físicamente porque está sujeto a la enfermedad, al dolor y a la decrepitud, y se hace evidente cuando el ser humano ejerce su facultad de pensar. es en esos momentos cuando se da cuenta de que su ser no es absoluto, sino finito y limitado. la persona enferma vive especialmente el carácter vulnerable de la condición humana. el sufrimiento fue inicialmente definido por cassell (41) como un malestar generado por la amenaza inminente, percibida o actual, a la integridad o la continuidad existencial de la persona. el sufrimiento, por tanto, es una experiencia que abarca la totalidad de los aspectos que componen la existencia de una persona, y se manifiesta de manera individual teniendo en cuenta que es una experiencia subjetiva vivenciada solo por quien lo padece. para algunos autores (41, 42) el sufrimiento es un complejo estado afectivo, cognitivo y negativo que se caracteriza por la sensación de amenaza a la integridad, un sentimiento de impotencia para hacer frente a dicha amenaza, y por el agotamiento de los recursos personales que permiten enfrentarla. como se mencionó, el sufrimiento puede ser causado por múltiples factores, entre ellos físicos, psicológicos, socioculturales, espirituales y existenciales. los diferentes componentes del sufrimiento tienden a tener un efecto aditivo, a pesar de que pueden ser independientes uno del otro. es común encontrar que la persistencia de alguna de las causas del sufrimiento genere o exacerbe otros aspectos del sufrimiento total en el paciente y su familia. kissane (43) ha descrito el síndrome de desmoralización como la desesperanza, la pérdida de sentido de vida, las actitudes pesimistas, la indefensión, la sensación de entrampamiento, entre otros. se ha encontrado que algunos de los asuntos que contribuyen al sufrimiento existencial son la pérdida de la autonomía, la baja autoestima y la desesperanza, así como problemas referidos a la dignidad y la autoimagen, el aislamiento social, la falta de acceso a recursos y apoyo, la culpa, la pobre salud espiritual y la falta de sentido (44, 45). aunque la sociedad occidental medicalizada dolor y sufrimiento suelen utilizarse como términos sinónimos, en realidad no lo son. el sufrimiento puede tener su origen en el dolor físico pero también se puede sufrir sin dolor. a veces, el dolor puede soportarse bien sin sufrimiento, y otras, la supresión del dolor tisular, paradójicamente, incrementa el sufrimiento de origen psicosocial (46). morse (47) plantea que la respuesta del individuo ante una situación amenazante se caracteriza por dos estados, uno de endurecimiento y denominado por ella sufrimiento emocional. en este estado la persona comprende que su futuro está irrevocablemente alterado. el sufrimiento forma parte entonces de un proceso, un “trabajo” tedioso que la persona debe hacer (48). sin embargo, el sufrimiento no es solo la experiencia de un individuo aislado sino una experiencia vivida en el seno de la sociedad, conectada al ethos de una cultura y la forma como el individuo lo comunica a la sociedad (49). esto quiere decir que el sufrimiento de una persona está mediado o condicionado por sus características sociales y culturales (50), por lo cual enfermería, desde su relación de cuidado, debe orientar al paciente a aumentar su armonía dentro de la mente, el cuerpo y el alma para generar procesos de conocimiento de sí mismo que ayuden a lograr cambios en su estilo de vida. la intervención de cuidado requiere de herramientas que le permitan dimensionar el sufrimiento en la persona que cuida, a partir de los niveles de medición que permitan establecer una intervención adecuada y oportuna a la situación del paciente. escalas para medir el sufrimiento el dolor físico se informa, se refiere, se mide y se evalúa a través de numerosos instrumentos que posibilitan el manejo de la persona que lo presenta, las escalas utilizadas permiten valorar su intensidad (51). para valorar el sufrimiento bayés (52) propuso una escala conformada por dos preguntas. en la primera pregunta 140 año 12 vol. 12 nº 2 chía, colombia agosto 2012 aquichan issn 1657-5997 hay una valoración subjetiva acerca de cómo se le hizo el tiempo durante la etapa del sufrimiento, y en la segunda pregunta se pide una aclaración acerca de la respuesta dada. karnofsky (53), a su vez, estableció una escala que permite conocer la capacidad del paciente para poder realizar actividades cotidianas. se considera una herramienta para utilizar en cualquier tipo de patologías que se puede utilizar como predictor independiente de mortalidad. el perfil de salud de nottingham (nottingham health profile nhp) (54) fue diseñado en gran bretaña para medir la percepción de salud y para evaluar en qué forma se ven afectadas las actividades cotidianas por los problemas de salud. sus autores lo consideran útil para la valoración de las intervenciones médicas o sociales, como medida de comparaciones entre grupos. es un cuestionario autoadministrado que evalúa diferentes dimensiones de la salud como energía, dolor, movilidad física, reacciones emocionales, sueño y aislamiento social, y otro componente que evalúa la existencia de limitaciones, a causa de la situación de salud, en aspectos como trabajo, tareas domésticas; vida social, familiar y sexual, aficiones y tiempo libre. la escala de sufrimiento es un instrumento propuesto por el programa argentino de medicina paliativa-fundación femeba (pamp-ff), organización no gubernamental, con la misión de promover el desarrollo del cuidado paliativo en argentina (55). el instrumento permite de manera gráfica (en una escala de 0 a 10) la valoración del sufrimiento en tres niveles (sin sufrimiento, sufrimiento moderado y máximo sufrimiento) a través de la evaluación de las posibles causas de este referidas a los aspectos de condición del paciente, problemas familiares, prácticos, emocionales y preocupación religiosa/espiritual. esta escala fue utilizada en un estudio donde se cuantificó el nivel de sufrimiento por medio de la escala del termómetro emocional en cuidadores de pacientes (56). conclusión implicaciones para enfermería este reto acerca de cuidar al ser humano desde su totalidad le plantea a la disciplina de enfermería la búsqueda de nuevas propuestas de intervención, la investigación se constituye en una herramienta básica en la consecución de esos propósitos, y son las unidades formadoras de enfermería las responsables de generar en sus estudiantes el compromiso de cuidar desde el acompañamiento a la persona para el logro de un equilibrio a pesar de su malestar, de comprender y aceptar que este puede recibir o rechazar el cuidado, a pesar de su condición física. la enfermedad se equipara a un lenguaje que hay que saber interpretar, es un lenguaje que el cuerpo expresa para dar a entender que algo no funciona en la conciencia del sujeto, y enfermería es responsable de identificar y dar una propuesta ante esta situación de la persona. con el fin de cuidar al paciente que sufre es importante que para su valoración se utilicen escalas claras y precisas. esta circunstancia ha conducido al surgimiento de nuevos estilos de vida, a modificaciones en los comportamientos cotidianos generados por el incremento de los padecimientos crónico-degenerativos, y a cuestionar el sufrimiento como un sentimiento que se vive a consecuencia de estas situaciones; asimismo, lleva a preguntarse cuál es la calidad de vida que se tiene. es por esto que tener en cuenta la valoración del sufrimiento emocional del paciente ante una enfermedad proporciona elementos 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confl icto armado en colombia: los aportes de la experiencia campesina para un cuidado creativo2 1 enfermera. magíster en educación y desarrollo comunitario. doctora en salud mental comunitaria. profesora asociada, facultad de enfermería, universidad de antioquia, medellín (colombia). beatriz.arias@udea.edu.co 2 este artículo aborda uno de los resultados de la tesis doctoral titulada violencia, resistencia y subjetividad. destejer y tejer la salud mental. estudio de caso, municipio de san francisco, oriente antioqueño, colombia, 2011-2012. este proyecto no recibió financiación, ni subvención distinta a la derivada de la comisión de estudios concedida por la universidad de antioquia y el apoyo logístico de la asociación campesina de antioquia (aca). recibido: 26 de octubre de 2013 enviado a pares: 20 de noviembre de 2013 aceptado por pares: 30 de noviembre de 2014 aprobado: 03 de febrero de 2015 doi: 10.5294/aqui.2015.15.2.8 para citar este artículo / to reference this article / para citar este artigo arias-lópez be. vida cotidiana y conflicto armado en colombia: los aportes de la experiencia campesina para un cuidado creativo. aquichan. 2015; 15 (2): 239-252. doi: 10.5294/aqui.2015.15.2.8 resumen objetivo: describir la manera como el conflicto armado prolongado se instaló y modificó la vida cotidiana de un grupo de familias campesinas y cómo los eventos de violencia política son percibidos y articulados en las relaciones familiares y vecinales y en las trayectorias de vida personal. materiales y métodos: estudio de caso en san francisco, oriente antioqueño (colombia), que combinó elementos del método etnográfico y biográfico. resultados: la cotidianidad campesina, escenario de reproducción personal y social, se va configurando entre la habituación que produce un conflicto armado prolongado y lo sorpresivo que impone su dinámica, de tal manera que las personas deben reinventar cotidianamente su vida. el sufrimiento aparece en función de los significados particulares que se asignan a los eventos, más que a las generalizaciones de la cronología oficial del conflicto. conclusión: la transformación de la vida cotidiana campesina se configura en el devenir de formas endógenas de enfrentar lo ajeno, lo nuevo y lo desconocido para darle un lugar, resignificar la experiencia y seguir construyendo la vida en interacción con otros, en un proceso de reinvención permanente de tiempos, espacios y relaciones microsociales por parte de los sujetos, que constituyen elementos centrales para generar cuidados de la salud mental creativos y singulares. palabras clave cuidados de enfermería, salud mental, guerra, acontecimientos que cambian la vida, población rural (fuente: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 239-252 240 aquichan issn 1657-5997 año 15 vol. 15 nº 2 chía, colombia junio 2015 l 239-252 daily life and armed conflict in colombia: contributions to creative care based on the peasant experience abstract objective: describe how the prolonged armed conflict came about and changed daily life for a group of peasant families and how events involving political violence are perceived and tied in with relations between family members and neighbors and with the course of personal life. materials and methods:this is a case study done in san francisco, in eastern antioquia (colombia). it combines elements of the ethnographic and biographical method. findings: everyday peasant life, the scenario for personal and social reproduction, is shaped by the accustomedness that comes with a prolonged armed conflict and the surprises imposed by its dynamics, which means people must reinvent their lives on a daily basis. suffering is more a function of the particular meaning assigned to events, than generalizations of the official chronology of the conflict. conclusion: the change in everyday peasant life is influencedby endogenous ways of dealing with what is foreign, new and unknown, so as to give it a place, to assign new meaning to the experience, and to continue to build a life in interaction with others. this is a process to permanently reinvent time, space and micro-social relations on the part of those concerned, whoare crucial to generating creative and unique mental health care. keywords nursing care, mental health, life-changing events, rural population (source: decs, bireme). 241 vida cotidiana y conflicto armado en colombia: los aportes de la experiencia campesina para un cuidado creativo l beatriz elena arias-lópez vida cotidiana e conflito armado na colômbia: contribuições da experiência camponesa para o cuidado criativo resumo objetivo: descrever a maneira como o conflito armado prolongado foi instalado e modificou a vida cotidiana de um grupo de famílias camponesas e como os eventos de violência política são percebidos e articulados nas relações familiares e entre vizinhos e nas trajetórias de vida pessoal. materiais e métodos: estudo de caso em san francisco, leste da antioquia (colômbia), que combinou elementos do método etnográfico e biográfico. resultados: a cotidianidade camponesa, cenário de reprodução pessoal e social, vai sendo configurada entre a habituação que produz um conflito armado prolongado e o surpreendente que impõe sua dinâmica, de tal maneira que as pessoas devem reinventar cotidianamente sua vida. o sofrimento aparece em função dos significados particulares que designam aos eventos, mais do que às generalizações da cronologia oficial do conflito. conclusão: a transformação da vida cotidiana camponesa se configura no devir de formas endógenas de enfrentar o alheio, o novo e o desconhecido para dar-lhe um lugar, ressignificar a experiência e continuar construindo a vida em interações com outros, num processo de reinvenção permanente de tempos, espaços e relações microssociais por parte dos sujeitos que constituem elementos centrais para gerar cuidados da saúde mental criativos e singulares. palavras-chave cuidados de enfermagem, saúde mental, acontecimentos que mudam a vida, população rural (fonte: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 239-252 242 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 introducción los desafíos de cuidar la vida y la salud mental en un país inmerso en un conflicto armado prolongado, ad portas de un posible escenario de posconflicto, son múltiples. una vía para afrontarlos se encuentra en la investigación, máxime si esta incorpora y explora los sentidos y significados que las personas construyen desde sus vivencias y experiencias, pues es allí donde se encuentran las respuestas más potentes para sus procesos de recuperación. teniendo en cuenta que el cuidado de la vida es el centro de orientación teórica y práctica de la enfermería, el propósito de este artículo es mostrar la manera como el acercamiento a la vida cotidiana constituye una fuente fructífera para hacer del cuidado un acto singular y creativo, especialmente en contextos de alta incertidumbre, tomando como referente una investigación realizada en un ámbito campesino y rural colombiano, reconocido hoy como el que mayores afectaciones ha tenido por efecto del conflicto armado, aunado a una alta cuota de indiferencia institucional y ciudadana (1). la investigación en mención, realizada con comunidades campesinas del municipio de san francisco, oriente antioqueño, entre los años 2011-2013, partió de la pregunta general por los efectos del conflicto armado prolongado sobre la salud mental de la población, a mediano y largo plazo, y se focalizó en un objetivo específico dirigido a indagar por la vida cotidiana de estas comunidades: la(s) manera(s) como los campesinos experimentaron y perciben los eventos de violencia política repetida; la(s) forma(s) como los han articulado a su vida; los significados que les asignan; las prácticas y los conocimientos que han perfilado a partir de dicha experiencia, y las relaciones familiares y vecinales que han ido construyendo. el municipio de san francisco, es una localidad campesina ubicada en la zona de bosques del oriente antioqueño, cuyos últimos cuarenta años de historia se han caracterizado por la presencia de actores armados como guerrillas y paramilitares, además de ser un territorio con cultivos familiares de coca documentados desde los años ochenta,3 y desarrollo de programas y proyectos relacionados con el acuerdo bilateral entre colombia y estados unidos, conocido como plan colombia. la población campesina y 3 según la oficina de las naciones unidas para el control de la drogas y el delito (unodc), el número de hectáreas de coca cultivadas en san francisco creció de 27 en el año 2005, a 139 en el año 2010, organizadas en su gran mayoría como cultivos familiares menores de 3 hectáreas. disponible en: https://www.unodc.org/colombia/. el territorio de san francisco, se han consolidado a través de un proceso histórico complejo relacionado con el problema agrario en colombia, cuyo modelo signó a sus pobladores a ocupar dos lugares marginales: el del colono campesino inmerso en un ciclo inacabado de apertura de nuevas tierras y despojo, o el de jornalero, trabajador agrícola sin las mínimas garantías laborales, dedicado a la producción de alimentos baratos, sin acceso a la tierra (2). estas características, entre otras, constituyeron elementos importantes para focalizar la atención sobre la vida cotidiana campesina, ya que allí confluyen no solamente los efectos del conflicto armado, sino una trayectoria histórica de exclusión y sufrimiento. ahora bien, la vida cotidiana es un tema de vieja data, que ha ocupado el interés de importantes autores de la filosofía y las ciencias sociales como agnes heller, veena das y michael de certau, y sin duda ha estado ligada intrínsecamente al desarrollo teórico y práctico de la enfermería. heller (3) define la vida cotidiana como el conjunto de actividades diversas que le permiten al hombre ordinario reproducirse a sí mismo y su función dentro de la sociedad, a la vez que garantiza las condiciones para que la sociedad también pueda hacerlo. mediante el despliegue de actos reiterativos y repetitivos se instaura una especie de naturalización y normalización, que permite establecer lo que se considera legítimo, verdadero, real y necesario para garantizar la continuidad propia, la del grupo social y, de alguna manera, definir lo que se constituye como el orden mismo. de ahí que heller afirme que “para la mayoría de los hombres la vida cotidiana es la vida” (3) y, por tanto, constituya el espacio de las relaciones, actividades y fuente de conocimiento para conducirse en el mundo. venna das (4) da continuidad a la pregunta de heller por la manera como los seres humanos habitamos el mundo pero, sobre todo, a la particularidad de un mundo devastado, donde la incertidumbre, la duda y el escepticismo se incorporan en las relaciones cotidianas. para ella, la violencia que se experimenta no solo en el cuerpo, sino también en el contexto, produce una fragilidad que se traduce en desconfianza y miedo, cuya recuperación solo se logra a través de las tareas diarias de sobrevivir y hacer habitable el mundo cotidiano, profundamente integradas a formas complejas de agencia y responsabilidad moral. michel de certeau (5) amplía esta perspectiva, en la medida en que identifica la vida cotidiana como fuente de potencial agenciamiento para las personas. para este autor, si bien la característica principal de la vida cotidiana es la repetición, simultáneamente es un espacio de potenciales 243 vida cotidiana y conflicto armado en colombia: los aportes de la experiencia campesina para un cuidado creativo l beatriz elena arias-lópez prácticas de innovación y cambio, donde es posible desplegar la capacidad para gestionar la propia vida (6). heller, das y de certau proporcionan argumentos para superar las limitaciones de algunas teorías explicativas de pretensión universalista, como aquellas procedentes de los modelos biomédicos convencionales, especialmente sensibles en el campo de la salud mental y, adicionalmente, permiten un acercamiento a la “experiencia de los sufrientes” (7), complementando las explicaciones macroestructurales de fenómenos como la violencia política. esta perspectiva traza caminos importantes para el cuidado de enfermería, toda vez que no solo reconoce el valor de la experiencia vivida, sino además comparte preocupaciones éticas comunes en torno a la dignidad y el reconocimiento del sujeto que sufre-sujeto del cuidado, como un productor social y cultural. los debates contemporáneos en la enfermería son enfáticos en reclamar una mayor politización de la disciplina y la profesión, y la generación de un conocimiento crítico, movilizado por la justicia y los derechos (8, 9). el desafío es construir un cuidado de enfermería que se articule a la experiencia vivida por los sujetos, al reconocimiento de vivencias únicas y singulares (10, 11), considerando el repertorio de recursos endógenos de los propios sujetos y comunidades, situados al margen de sistemas técnicos, especializados o institucionales (12). esto es, abrir los sentidos a percibir aquello que se expresa “en pequeños gestos, en un universo de detalles aparentemente sin importancia” (13), a lo que nos invita esta exploración etnográfica y biográfica de la vida cotidiana campesina. materiales y métodos la investigación se enmarcó en la perspectiva de la investigación cualitativa, más específicamente del diseño de los estudios de caso, cuya pretensión fundamental es el acercamiento a una experiencia de vida concreta (14). se eligió el municipio de san francisco, oriente antioqueño (colombia), más específicamente, un área geográfica menor compuesta por las veredas san isidro y la esperanza, localizadas en zona rural. en la investigación se combinaron elementos del método biográfico y del método etnográfico. se construyeron veinte relatos de vida,4 siguiendo la modalidad de relatos de vida cruzados (17), es decir, relatos convergentes en una temática común y una mirada múltiple sobre 4 la diferencia con las historias de vida es que estas se asocian al interés particular en un personaje de la historia y en el rastreo detallado de su trayectoria, que supone la complementación de otras fuentes de información adicional como cartas, diarios, etc. (15, 16). un mismo objeto, ubicados en una formación social de pequeña extensión. estos relatos se construyeron a partir de entrevistas en profundidad, realizadas en un promedio de tres encuentros con cada participante con un intervalo promedio de un mes. el muestreo fue intencional, lo que significó seleccionar casos ricos en información en relación con las preguntas y los objetivos planteados (18), aprovechando la estrategia de bola de nieve. los criterios de inclusión acercaron adultos de ambos sexos, que habían vivido durante toda su vida en el municipio de san francisco o en municipios con una historia similar, asegurando un conocimiento exhaustivo y rutinario de su ámbito de vida. adicionalmente, fueron personas que deseaban contar su historia y disponían de tiempo para hacerlo. teniendo en cuenta que ningún relato tiene pretensión de exhaustividad y que obedece a procesos selectivos, que organizan la experiencia, reafirmando algunos elementos, rechazando otros o incluso silenciándolos, se combinaron los enfoques biográfico y etnográfico, con el fin de recuperar la observación de aquello que no pudo ponerse en palabras. es así como se realizó el trabajo de campo etnográfico y la observación participante (19), por un periodo aproximado de 18 meses, alrededor de las rutinas cotidianas familiares: la preparación de alimentos, las actividades de ocio, las visitas entre vecinos, la actividad escolar de los menores, el cuidado de la huerta y las gallinas, las conversaciones, los recorridos entre veredas o hacia la cabecera municipal, entre otras. igualmente, los encuentros vecinales alrededor de actividades agrícolas como sembrar, limpiar y cosechar, en reuniones comunitarias de tipo organizativo, festividades y mercados campesinos. la gran riqueza de estas actividades fue el acercamiento a los procesos de reinvención de lo cotidiano, no desde lo extraordinario, sino desde lo rutinario y quizás “insignificante”. como estrategias complementarias de triangulación se realizó una revisión de prensa regional y nacional para la búsqueda de eventos de violencia política en la localidad entre 1989 y 2012. igualmente, se realizó una encuesta exploratoria, mediante visita domiciliaria, con el 60 % (35 grupos) de las familias habitantes de las veredas; 2 entrevistas semiestructuradas a líderes locales y 2 grupos focales (40 personas). la finalización del trabajo de campo se definió bajo el criterio de saturación (20). para la tabulación y el análisis de las encuestas familiares se utilizó el software spss, versión 17.0 y el software atlas ti, versión 6.2 para los datos cualitativos. se privilegió un análisis de tipo comprehensivo, identificando acontecimientos centrales y 244 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 su significado en la vida de las personas, al igual que un análisis temático orientado por los objetivos de la investigación (21). se mantuvo la revisión teórica durante el proceso, orientada por los hallazgos emergentes. de acuerdo con la resolución 8430 de 1993 del ministerio de salud de colombia, se consideró una investigación de riesgo mínimo, avalada por el comité de ética para la investigación de la facultad de enfermería de la universidad de antioquia (medellín, colombia), y por las juntas de acción comunal de las veredas san isidro y la esperanza. se concertó con el hospital local, ese san francisco de asís, el establecimiento de protocolos y el flujo de remisión de personas, los cuales no se requirieron. el proceso se condujo bajo el principio de acción sin daño (22), evitando al máximo todo riesgo sobre la integridad y la privacidad de los participantes (23). con todos se diligenció el consentimiento informado por escrito, bajo la figura de un seudónimo, estrategia prevista para el resguardo del anonimato, dadas las condiciones de seguridad y de conflicto en la localidad. las entrevistas se manejaron a través de dichos seudónimos y se analizaron utilizando códigos alfanuméricos.5 en las encuestas se obviaron igualmente datos de identificación. las entrevistas fueron grabadas con el consentimiento de los entrevistados y se resguardaron bajo estricta vigilancia y seguridad, lo que incluyó la transcripción total por parte de la investigadora. atendiendo al principio de reciprocidad, todas las transcripciones fueron devueltas a cada uno de los participantes (24) en forma parcial y, posteriormente, en una compilación total, lo cual les permitió realizar cambios y poner límites al uso de la información cuando lo consideraron pertinente. resultados como producto de la exploración biográfica y etnográfica se logró construir una descripción de los principales aspectos relacionados con la vida cotidiana de los campesinos que participaron en la investigación, que permite no solo identificar un contexto local situado y particular, sino mostrar la manera como dicha cotidianidad se teje en la convivencia con los distintos grupos armados y la dinámica misma del conflicto, en una tensión permanente entre lo habitual y lo sorpresivo, instalando la incertidumbre como 5 como se verá en el apartado de resultados, los códigos utilizados identifican con la letra e, la obtención del relato a través de entrevista individual, un número correspondiente al consecutivo de la misma, una letra en mayúscula correspondiente a la inicial del seudónimo y, al final, la letra m o h, según sea mujer u hombre. cuando los testimonios se obtuvieron a través de grupo focal, se identifican con las letras gf y un número consecutivo que identifica el grupo del cual proviene la información. elemento central de las transformaciones de sus tiempos, espacios y relaciones microsociales. generalidades de la vida cotidiana campesina como muchas otras localidades colombianas, san francisco es un territorio construido históricamente sobre la base del despojo y la exclusión. aislamiento, precariedad y marginalidad, pasados y recientes, se asocian a unos modelos de desarrollo que desvalorizan al campesino, y le asignan un lugar subsidiario como “peón de brega”, “jornalero” y “proveedor de alimentos baratos” (2). la población de este municipio es heredera de un histórico conflicto por la tierra, con repetidas situaciones de expulsión y desplazamiento forzado desde finales del siglo xix (25), producto de las primeras oleadas colonizadoras antioqueñas, la violencia bipartidista de los años cincuenta, las transformaciones derivadas de su cercanía a grandes proyectos económicos en los años sesenta y setenta, cultivos de coca, disputas territoriales entre guerrillas y, posteriormente, incursión paramilitar. el potencial estratégico y económico de su territorio, involucró a sus habitantes en la disputa entre grupos armados y los obligó a encarar una grave crisis de violación de sus derechos humanos: enfrentamientos, masacres y muertes selectivas afectaron a la población civil campesina que quedó en muchos casos en situación de confinamiento. las cifras de homicidios, desplazamiento y el uso de minas antipersonal, expresan la intensificación del conflicto armado en su jurisdicción, provocando el abandono de sus veredas, muchas de las cuales permanecen solas, después de diez años del desplazamiento forzado de sus habitantes.6 las veredas san isidro y la esperanza son dos asentamiento rurales, distantes una hora y media a pie de la cabecera municipal, sin acceso a agua potable y alcantarillado, con una disposición de aguas residuales a través de pozos sépticos. el sitio de referencia más cercano para la atención institucional de salud es el hospital público, ubicado en la cabecera municipal. en cuanto a recursos de salud tradicionales, cuentan con un par de sobanderos óseos y una partera tradicional, quien además posee conocimientos de 6 según datos de la personería municipal, entre 2003 y 2007, se desplazaron un total de 4335 personas, equivalente al 70 % del total de habitantes del municipio reportados en el censo poblacional del año 2005, superando con creces el promedio nacional. de las 41 veredas que conforman el área rural del municipio, 14 se encuentran deshabitadas a causa de estas presiones (26). el municipio de san francisco ocupa el segundo lugar, después del municipio de san carlos, con 109 víctimas de accidentes con mina antipersonal, ocurridos entre 2001 y 2012 (27). 245 vida cotidiana y conflicto armado en colombia: los aportes de la experiencia campesina para un cuidado creativo l beatriz elena arias-lópez herbolaria. sus viviendas están construidas en su gran mayoría (86 %) con materiales adecuados y debidamente terminadas. en los sistemas de propiedad, se encuentra la diversidad propia de las lógicas informales sobre predios de la ruralidad colombiana, donde se ponen en juego los llamados “contratos de palabra” o las ocupaciones de hecho, las cuales se asimilan a propiedad sobre los predios, aunque no se cuente con los títulos legalizados. el 50 % se identifican como propietarios de la vivienda y el terreno, y el 11 % de la vivienda solamente. el 39 % restante corresponde a ocupantes en préstamo. desde sus orígenes, los lazos parentales estuvieron presentes en el modelo de poblamiento de estas veredas, a partir de matrimonios y compadrazgos que afianzaron los vínculos entre las familias y que se siguen expresando en algunos apellidos, sellando la pertenencia territorial a una u otra vereda en el municipio (28). las relaciones de parentesco y afinidad han ido tejiendo una serie de lealtades familiares y vecinales, que sirven de soporte para las actividades cotidianas de reproducción social. la ocupación principal que genera la provisión de ingresos es básicamente la de pequeños propietarios de parcelas para autoconsumo, con trabajo directo de tipo familiar, en el que participan todos sus miembros, sin distinción de edad ni de sexo. esta forma de trabajo no genera excedentes ni cantidades significativas para la comercialización. la otra forma de trabajo, que opera complementariamente, es la de jornal, en la cual no hay relación de propiedad con la tierra, ni control sobre los medios de producción, y en el que se obtiene un ingreso variable en cantidad y frecuencia, de acuerdo con los ciclos de cosecha de los productos agrícolas.7 en ambos casos, se despliega un proceso tradicional artesanal con una precaria tecnificación, donde básicamente la fuerza de trabajo constituye la principal herramienta, lo que hace que el trabajo ocupe la totalidad del tiempo cotidiano, con muy poca disponibilidad de tiempo libre o de ocio. estas dinámicas de reproducción económica conducen a que la vida laboral y la vida doméstica se superpongan, a que los espacios de morada y de trabajo se conecten tanto para los hombres como para las mujeres; a pesar de los roles tradicionalmente diferenciados entre actividades públicas masculinas y 7 el trabajo al jornal consiste en obtener una retribución correspondiente a un día de trabajo. en el 2011 este jornal oscilaba entre quince y veinte mil pesos colombianos por día (entre ocho y once dólares). para contrastar, el valor del transporte a la vereda, por ejemplo, costaba cerca de un dólar para el transporte público, que solo funciona el día domingo, o cinco dólares, cuando se acude a un servicio privado. actividades privadas femeninas. la localización del trabajo dentro del perímetro de la vivienda o del escenario próximo de la vereda, la implicación en él de todos los miembros de la familia campesina y su doble papel en relación con la reproducción económica y familiar, son elementos constitutivos de su cotidianidad. la familia campesina, sobre todo la extensa, es decir la que integra miembros de diferentes generaciones y grados de parentesco, sigue ocupando un lugar fundamental en la inserción e integración de sus miembros a la vida social y, a la vez, a la dinámica económica, involucrándolos en tareas diferenciales de cuidado y subsistencia. la cotidianidad campesina transcurre fundamentalmente en dos espacios: el trabajadero y el vividero, el corte de trabajo y la casa. residir y trabajar (29) envuelven los movimientos, las trayectorias y las relaciones cotidianas de la mayoría de sus grupos familiares. trabajar implica no solo desplegar una actividad que “permite el devenir histórico y cultural” de su organización social, sino emprender una acción que opera como eje organizador del resto de actividades cotidianas (3). residir significa establecerse en el espacio, desplegando para ello múltiples actividades de apropiación y producción del mismo, hasta conseguir convertirlo en un vividero, término que adjetiva su valoración como lugar de disfrute, seguridad, certidumbre y bienestar. en este caso, el referente de vividero es la vereda como tal, ya que el tardío proceso administrativo de municipalización —que solo se dio hasta 1986— hizo que sus habitantes construyeran un sentido de certeza en el territorio más próximo, en tanto la figura municipal se ha ido incorporando muy lentamente a dicho referente (28). en cuanto al ámbito de lo público, la vida cotidiana campesina se despliega en tres escenarios: la escuela, la acción comunal y los caminos (y las carreteras). para los habitantes existe una estrecha relación entre vereda, acción comunal y escuela (28), ya que en la mayoría la organización de la acción comunal respondió en sus inicios a la necesidad de un espacio educativo para los niños y las niñas, considerando que dicha respuesta debía ser emprendida por las propias comunidades, dada la desconexión con espacios de decisión institucional. en esta experiencia empieza a configurarse para estas comunidades una idea de lo público ligada a sus propias relaciones vecinales, por fuera de los espacios instituciones gubernamentales o estatales. actualmente, cada vereda cuenta con una escuela de básica primaria, con un cupo de aproximadamente 25 niños, mientras la educación secundaria y técnica sigue siendo un proyecto inestable sujeto a los 246 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 vaivenes de las políticas y los presupuestos locales y regionales.8 el bajo nivel educativo y la deserción escolar, se ven incrementados además por las condiciones del trabajo agrícola tradicional, que requieren incorporar tempranamente a los miembros de la familia y, como se verá más adelante, como un efecto importante del conflicto armado. la escuela, más allá de sus funciones de centro educativo, adquiere otra relevancia para estas comunidades: su valor reside en que se constituye en referente de encuentro social, complementando la cotidianidad del residir/trabajar, ya mencionado. de este modo, la escuela es el lugar de reunión de la junta de acción comunal veredal y los grupos organizados a su alrededor; es el punto de encuentro para celebraciones y festividades comunitarias, es el sitio de la vereda dispuesto para la acogida de visitantes externos, es el lugar donde se realizan actividades de ocio y recreación, pues es el único lugar que cuenta con un espacio deportivo. el resto de encuentros cotidianos acontecen en el cruce de caminos y trochas veredales. convivir con grupos armados: entre lo habitual y lo sorpresivo “apenas estaba empezando a ir a la escuela, a hacer la o y el 1, y me tocó ver los primeros guerrillos”, recuerda alberto, campesino de 42 años. esta afirmación ilustra la permanencia de la guerrilla en el territorio de san francisco desde finales de la década de los setenta, especialmente del ejército de liberación nacional (eln). solo hasta 1998, ingresan las fuerzas armadas revolucionarias de colombia (farc) y empiezan a disputar algunas franjas de territorio. antes de que llegara la guerrilla y, aún con su presencia, hasta más o menos los años 1995-1998, las veredas la esperanza y san isidro son percibidas como espacios de tranquilidad por los campesinos. la disputa territorial entre el eln y las farc marca un momento importante de sufrimiento con el incremento de presiones y contradicciones, que se amplifican con el ingreso de las autodefensas campesinas del magdalena medio (acmm), finalizando el siglo y la operación marcial en el año 2003. la instalación de la guerrilla del eln en el territorio por varios años, provocó en los pobladores una suerte de acostumbramiento y naturalización, para quienes no era extraña la presencia de 8 la oferta de educación básica secundaria sigue concentrada en la cabecera municipal. solo hasta finales de la década de los noventa se incorpora una modalidad de aprendizaje tutorial para la población del campo, operado por una institución privada de orientación religiosa. grupos armados, si se tiene en cuenta la impronta que dejó la violencia de los años cincuenta en la zona.9 la relación con esta guerrilla discurrió a través de un lento proceso de seducción y convencimiento de las comunidades para compartir su ideología. la mediación en la resolución de problemas locales vecinales, reemplazando las labores policiales, generó credibilidad y confianza. estos años son, por tanto, identificados como de normalidad y tranquilidad, no hay grandes zozobras, ni riesgos ni sobresaltos en la vida cotidiana, como se ilustra en esta afirmación: “ni le quitaban nada a las malas a uno, ni le decían a uno venga váyase con nosotros. cuando eso era una vida muy tranquila” (e6lm). las familias campesinas recibían a los miembros del grupo guerrillero, bajo la misma lógica de relación que tenían con sus vecinos y familiares, fuertemente marcada por preceptos de la religiosidad católica tales como dar de beber al sediento, dar de comer al hambriento y dar posada al peregrino, por lo cual, actividades como compartir la comida y el techo, o algunos ratos de conversación, hicieron parte de la cotidianidad de este particular encuentro. el entrecruzamiento con las redes de parentesco hizo parte de la convivencia cotidiana con la guerrilla, dinamizada a partir de diversas estrategias que van generando el acercamiento: encuentros, juegos compartidos, visitas familiares, establecimiento de noviazgos y amistades, reuniones comunitarias, entre otras. estas situaciones vividas en el mediano y largo plazo, desbordan las categorías clásicas con las que se ha venido analizando la violencia política que, como lo afirman bolívar y nieto (30), ponen en cuestión la visión estereotipada que ubica a los actores armados como externos o extraños a las sociedades locales y a las comunidades como subversivas. por otro lado, el acento en lo afectivo, lo emocional y lo sentimental en el establecimiento de relaciones entre población campesina y actores armados, plantea interrogantes frente a la definición de lo político y al lugar que ocupan dichos nexos en la política. la violencia política, como elemento transversal a la vida cotidiana, permite considerar como elementos políticos aquellos de orden pragmático como los que hemos descrito, donde las lógicas de poder operan en el terreno de las motivaciones personales, más que en el de las decisiones racionales. razones menos nobles, como diría kalyvas (31), hacen parte de este repertorio y cuestionan, desde la perspectiva local, la idea de que las organizaciones armadas operen bajo una lógica 9 en la historia colombiana algunos analistas señalan la existencia de un continuo de guerras desde el siglo xix hasta el presente. en este recorrido, el periodo nombrado como la violencia cursa entre 1946 y 1964, y se caracteriza por el enfrentamiento bipartidista entre liberales y conservadores, que culminó con el pacto conocido como el frente nacional y cuyo efecto sobre las zonas campesinas fue devastador. 247 vida cotidiana y conflicto armado en colombia: los aportes de la experiencia campesina para un cuidado creativo l beatriz elena arias-lópez de cálculo y control total sobre sus miembros, cuyos intereses y preferencias pueden no ser ni racionales, conforme a una elección ideológica, ni mucho menos coherentes. esto se torna más claro después de 1998, cuando se producen las primeras incursiones de los paramilitares. los pobladores empiezan a incorporar el sentido de riesgo, debido al parentesco o a la amistad con los miembros del eln. empieza a darse así un distanciamiento entre algunos grupos familiares en las veredas, a romperse los lazos vecinales y a predominar la desconfianza en el ambiente social. los paramilitares imponen nuevas reglas, que alteran el curso de la vida cotidiana de las familias campesinas: sus consumos, su movilidad, sus conversaciones, sus horarios, sus rutinas. se buscaba el aniquilamiento de la guerrilla a través del control de la población campesina, estigmatizada como guerrillera o colaboradora. cualquier comportamiento era entonces sospechoso: “si llevaba más mercado de lo normal es que estaba llevando mercado pa la guerrilla, si llevaba botas pantaneras era guerrillero o le estaba cargando a la guerrilla, si llevaba una pipeta, porque cambio la leña por gas, entonces se la llevaba a la guerrilla” (e5dh). la irrupción abrupta y sorpresiva de los paramilitares en la vida cotidiana campesina constituyó un sinsentido, “sus normas” eran incomprensibles, lograban que cualquier palabra, gesto o comportamiento convirtiera al campesino en guerrillero. implicaba establecer nuevas formas de entendimiento, incorporando sus lógicas y controles a la vida cotidiana. una situación común en san francisco fue que muchos de los que hicieron parte del grupo guerrillero, luego ingresaron como informantes y miembros de los paramilitares. cuando otros grupos armados entraron en disputa por el territorio, la vida adquirió connotaciones de tristeza, miedo, desesperación y angustia. cualquier opinión o acción implicaba un riesgo que tocaba el límite entre la vida y la muerte. en general, las personas se sentían observadas y vigiladas: “si pensábamos malo y si no pensábamos, también” (e10rm). la presión de los distintos grupos armados, las muertes, intimidaciones y amenazas modificaron las relaciones vecinales, la cohesión y el sentido de comunidad. el cruce de redes de parentesco con los grupos armados acrecentó la vulnerabilidad, aunque en algunos casos operara como factor de protección. paradójicamente, esta situación, al no ser predecible, aumentaba la percepción de estar viviendo en un mundo caótico e incierto, lo cual rompía la predictibilidad y naturalización propia de la cotidianidad. la instalación de la incertidumbre se ha señalado que la vida cotidiana es eminentemente práctica, cuyas acciones pueden predecirse, pues hacen parte de lo conocido, evidente y repetitivo. la repetición es la que elimina cualquier asomo de sorpresa, haciendo posible que tengamos un sentido de seguridad en el mundo que habitamos. por el contrario, cuando ocurren eventos que no logran tener un espacio en el mundo de significados propios y compartidos con los otros, estos eventos, carentes de significado, interrumpen lo cotidiano. en la experiencia de estas comunidades, eventos como el desplazamiento forzado, los accidentes e incidentes con minas antipersonal y la operación marcial constituyeron experiencias excepcionales. de las 36 familias encuestadas, 34 han tenido de uno a tres eventos de desplazamiento forzado en su trayectoria vital, cuya frecuencia se incrementó a partir del año 2000, siendo el periodo 2003-2004 el que registra el mayor número, caracterizado por desplazamientos masivos, cuyo resultado fue el abandono intempestivo de casi la mitad de la zona rural del municipio: “nos daban plazo de 5 o 10 minutos y si a los 5 o 10 minutos volvían y estábamos, nos mataban. entonces mucha gentecita se fue así con el mero capillaito,10 rodando por ahí, dejando los campos” (gf1). las familias no solo debieron adaptarse a la pérdida de su espacio vital, social y cultural, a la pérdida de bienes materiales y simbólicos, de referentes de vida, sino que además llegaron a competir por la subsistencia con los habitantes de la cabecera municipal. sin embargo, pese a sus dificultades, esta experiencia fue menos intensa que la del desplazamiento hacia ciudades grandes: “es mala la comparación, pero en medellín estábamos peores que animales” (e8mm). referentes de vida desconocidos y ajenos, acrecentaban la sensación de dolor y sufrimiento: “no aguantamos tanto sufrimiento, tanta tristeza, tanto dolor, tanta cosa que nos tocó vivir por allá, que uno no estaba acostumbrado. uno enseñado a estar en el campo. uno en la ciudad no sabe qué hacer” (e9mm). en cuanto a las minas antipersonal y armas trampa, se relata que estas empezaron a sembrarse entre finales de los años noventa y principios del dos mil. según los relatos de los campesinos, tanto la guerrilla como el ejército utilizaron esta estrategia de guerra. el encierro y el confinamiento, el uso de caminos alternos para poder salir de las veredas, la experiencia de haber visto o escuchado la explosión accidental, los daños en las 10 “capillaito” es una palabra que expresa “lo que tenía puesto, la mera ropita”. 248 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 viviendas, los muertos y los heridos, la precaución sobre los sitios que reconocían como minados, los incidentes con sus animales son, entre otros, parte importante de los relatos. la operación marcial fue un operativo militar emprendido por las fuerzas militares del estado en marzo del 2003, con el objetivo de atacar los frentes 9 y 47 de las farc y carlos alirio buitrago y bernardo lópez arroyabe del eln. esta operación marca un momento muy importante en la vida de los campesinos del municipio de san francisco, y constituye una memoria de arrasamiento: “como cuando se desboca una feria de ganado, se llevaban en sus cachos lo que fuera” (e5dh). los pobladores lo recuerdan como un momento de transformación violenta, que volvió vulnerable a toda una población, en razón del tiempo de convivencia con los grupos guerrilleros, especialmente con el eln. según sus relatos, las fuerzas militares intentaron recuperar unos territorios que consideraban perdidos para la soberanía del estado, sin miramientos sobre la población civil. en los relatos se mencionan asesinatos en situación de indefensión, “los cuerpos amontonados de a dos o tres, iban subiendo por los caminos en bestias, tapados con un plástico” (e9mm). aparte de las detenciones arbitrarias, los señalamientos y las falsas acusaciones, los campesinos mencionan cómo fueron comunes en esta época los saqueos y robos tanto a las viviendas como a las escuelas, abandonadas durante los desplazamientos provocados por los enfrentamientos y bombardeos. en los caminos, los campesinos eran sometidos a humillaciones y golpizas, algunas escuelas fueron bombardeadas y los maestros señalados como colaboradores de la guerrilla. en otras veredas las familias fueron obligadas a encerrarse en sus casas, tomadas como escudo en medio de los enfrentamientos. transformación de espacios, tiempos y relaciones cotidianas las implicaciones de la violencia política sobre la salud y el bienestar han sido documentadas por investigadores de diversos conflictos en el mundo (32-35). se encuentra un cierto acuerdo en calificar los conflictos armados como catástrofes sociales, marcadas por la destrucción de la infraestructura política, económica, sociocultural y de los cuidados de salud, sumada a la inhabilidad de la población afectada para ser económicamente autosuficiente (36-38). en este caso, en correspondencia con las formas de vida campesina relacionadas con la dupla trabajadero/vividero, la mayoría de las transformaciones se volcaron al interior de la vida veredal, esto es la vida familiar, pero también se extendieron hacia el afuera próximo, representado en los espacios de trabajo y encuentro cotidiano como la escuela, la carretera y la cabecera municipal. como se ha señalado, la relación inicial con los grupos armados, más que una imposición, es relatada como una relación de solidaridad, producto de maneras campesinas tradicionales de intercambio, ayuda y acogida. desde esta perspectiva, los campesinos afirman que para ellos era imposible ocupar un terreno neutral en el conflicto armado y complejizan el concepto de ser colaborador. además de los diversos actores armados, también llegan nuevos pobladores procedentes de veredas alejadas o municipios vecinos, con lo cual, rápidamente, se presenta un cambio de vecindario que exige reconfigurar las relaciones sociales y comunitarias, en medio del miedo persistente y la desconfianza. los frágiles cambios en la “identidad” asignada de guerrilleros a informantes y de informantes a paramilitares provocan un sentido de incertidumbre e inseguridad frente a los otros: “la gente de las comunidades ya no es la misma […] la confianza ya no viene a ser como la misma […] así hayan otras personas que igual sean amables, no va ser lo mismo. no son las personas con quienes uno estudió, con los que se levantó” (gf1). en el periodo más álgido del conflicto armado, entre el 2001 y el 2005, la estructura familiar se modificó como resultado de la muerte, desaparición o reclutamiento de sus miembros, pero igualmente por la separación voluntaria, emprendida con el fin de garantizar la protección, sobre todo de los más jóvenes. el trabajo también fue sensiblemente transformado, la dinámica y la forma de realizar el trabajo agrícola cambió drásticamente y la producción agrícola disminuyó en forma considerable. hoy, la incertidumbre para emprender nuevos proyectos agrícolas y el miedo siguen latentes. la escuela fue centro de ocupación y permanencia por parte de los distintos actores armados. guerrilla, paramilitares y ejército hicieron uso de las instalaciones escolares: “la escuela la cogieron de parche todos los grupos armados […] incluso por ahí tenemos fotos de eso, donde están eln, farc-ep, auc. quiere decir que los cuatro grupos estuvieron ahí y cogieron la escuela como la casa de ellos” (e13oh). en relación con el afuera próximo de la vida cotidiana, la carretera, lugar de transición entre ese afuera y el espacio interior de la vereda, se vio fuertemente afectada. la carretera evoca una red simbólica, construida a través del recorrido compartido, de la conversación con el vecino, red de noticias y rumores: “paso de los campesinos en muchos momentos de alegría, en muchos momentos de tranquilidad pero también en muchos momentos de 249 vida cotidiana y conflicto armado en colombia: los aportes de la experiencia campesina para un cuidado creativo l beatriz elena arias-lópez tristeza” (e5dh). la carretera evoca el sufrimiento de otros, que fácilmente se torna en un sufrimiento autorreferencial: semejantes, anónimos o conocidos, civiles campesinos o foráneos, los que fueron detenidos arbitrariamente, los secuestrados, los desplazados. la incertidumbre ocupa y llena este espacio en su totalidad, “algo malo podía pasar o se podía encontrar” (e9mm). los enfrentamientos se volvieron frecuentes entre guerrilla, ejército y paramilitares; transitar la carretera era como ocupar entonces un “campo de batalla”. la siembra de minas y armas trampa en caminos y montes, acrecentaba los riesgos. los actores armados controlaban la movilidad y la compra de víveres y alimentos en la cabecera municipal. el recorrido que en otros momentos significó espacio de encuentro y tránsito compartido con los vecinos, se tornó en lugar de confrontación, en riesgo, en espacio de peligrosidad, miedo, rabia e impotencia; en incertidumbre, en interrogatorio y requisa, en desconfianza, señalamiento y humillación. en esta dinámica, la muerte aparece como el culmen en la transformación del sentido de la carretera: lugares específicos donde muchas personas fueron asesinadas, o donde los cadáveres eran depositados, en un ritual de terror que se repetía especialmente los fines de semana, cuando las comunidades debían acudir al pueblo a abastecerse de víveres: “¡cuando eso había una violencia mija! lo único que uno hacía era pasar por encima de los muertos en la carretera, la carretera era como el punto más estratégico para matar la gente. mataban desde la punta de la carretera hasta la llegada al pueblo” (e2sm). “en la carretera queda la historia plasmada” (e13oh). conclusión. vida cotidiana fuente para un cuidado creativo de la salud mental a manera de cierre, se presentan dos balances diferenciados pero sin lugar a dudas convergentes. de un lado, el referido al objetivo específico que buscaba indagar por la vida cotidiana campesina en un contexto de violencia prolongada y, de otro, su contribución en la perspectiva de un cuidado creativo de la salud mental. en el primer aspecto, se puede concluir que la experiencia descrita muestra los contrastes, las tensiones, los vaivenes y las tonalidades de una vivencia que de ninguna manera podría considerarse homogénea. el tránsito de lo habitual a lo sorpresivo, nos muestra que el sufrimiento derivado de la violencia política se experimenta en función del significado de las pérdidas y la modificación de lo cotidiano, más que por las cronologías oficiales, y que dicha dinámica es apropiada mediante una temporalidad subjetiva, que hace parte del matiz particular con el cual la experiencia es incorporada a los sentidos y significados de la vida práctica campesina. en este nivel, tiempo, espacio y relaciones microsociales, se tornan en elementos centrales para comprender la transformación de la vida cotidiana (29), en la cual se producen y reinventan permanentemente nuevas explicaciones y apropiaciones. rupturas, fragmentaciones, brechas y abismos toman el lugar de la confianza con el mundo y con los otros, instalando la misma pregunta que se hiciera das en sus estudios sobre la partición de la india y pakistán: “¿qué hacer para seguir viviendo en el lugar de la devastación?” (4). la investigación nos muestra que las comunidades campesinas responden esta pregunta en la medida en que enfrentan y transforman lo ajeno, lo nuevo y lo desconocido para darle un lugar, recrearlo y seguir construyendo su vida con otros. en segundo lugar, podríamos afirmar que los datos etnográficos y las narrativas relacionadas con la vida cotidiana, se constituyen en fuentes imprescindibles si queremos emprender acciones de cuidado más creativas, que no solo reconozcan la singularidad de la experiencia, sino que además incorporen su complejidad. los cuidados estandarizados y prediseñados, deben ceder su lugar a un cuidado que se inventa en función de las experiencias vividas y el tiempo subjetivo, lo que no significa asumirlo como restringido a un individuo, pues, la subjetividad supone siempre la relación con otros sujetos, que se construyen social e históricamente (39-40). el acercamiento a esta experiencia de sufrimiento enseña que la tensión entre lo habitual y lo sorpresivo en el discurrir de la vida cotidiana, impuso a las personas el reto permanente de aprender a vivir, integrando la incertidumbre, el caos y la contradicción. reconocer los saberes y recursos endógenos con los cuales estas comunidades han afrontado su sufrimiento, y articular una dosis de incertidumbre a nuestras propias prácticas, son elementos no solo de un cuidado más creativo, sino de un cuidado que se ocupa de la dignidad de las personas, en la medida en que reconoce su sufrimiento pero también su capacidad de agencia y su lugar activo en los procesos de recuperación de la vida cotidiana interrumpida. como afirma magdalena (11): “la situación de cuidado enfermero [se coconstruye] a partir de la valoración de las percepciones y sentimientos de las personas; de las múltiples y azarosas relaciones en el contexto y en la historia personal, familiar y comunitaria; de las habilidades y potencialidades de la persona y de sus relaciones de apoyo”. 250 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 en este sentido, las herramientas metodológicas derivadas del enfoque psicosocial (41), afines a la experiencia presentada, pueden nutrir el cuidado de enfermería, ya que desde ellas se asigna un lugar central a las situaciones de la cotidianidad que inundan las narrativas, incluso en mayor proporción que las directamente relacionadas con la experiencia violenta (22, 42). el aporte más importante de este enfoque es su pretensión explícita de no homogeneizar a las personas, ni a las situaciones, reconociendo el diferencial de cada experiencia (43), estableciendo un escenario privilegiado para la preservación y recuperación de la dignidad que, como afirma meleis (44), constituye el horizonte de las relaciones de cuidado. en conclusión, el caso presentado nos invita a construir prácticas de cuidado de la salud mental que reconozcan la capacidad de las personas para tramitar los conflictos y el sufrimiento que emerge de la interacción social, atendiendo el sentido y significado de dicho sufrimiento. no hay comprensión posible del sufrimiento, sino a partir de la historia del sujeto y de la manera como esta es tejida y significada por él mismo, evitando su fragmentación o aislamiento de la cultura y el mundo social que habita (45). el horizonte de la dignidad también alude a la apuesta por un cuidado que no condiciona, sino que provoca ejercicios libertarios, en la medida en que se compromete e involucra a estas personas en el conocimiento detallado de su propia experiencia, generando redes de sufrientes que reconocen en su experiencia común una fuente de recuperación cotidiana. en síntesis, un cuidado que recupera y reinventa la cotidianidad rural: para mí la vida cotidiana en el campo es estar con la familia, estar tranquilo sabiendo que ahí estoy y me siento seguro de que ese es mi lugar en la vida, trabajando y teniendo cerca de mí todo lo que quiera y pueda tener […] 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https://orcid.org /0000-0001-5468-2674 universidade federal da paraíba, brazil paulylima1@gmail.com greicy kelly gouveia dias bittencourt https://orcid.org /0000-0001-5287-8171 universidade federal da paraíba, brazil greicykel@gmail.com wynne pereira nogueira https://orcid.org /0000-0002-7492-7939 universidade federal da paraíba, brazil wynne.nogueira@academico.ufpb.br thainá karoline costa dias https://orcid.org /0000-0002-7265-1350 universidade federal da paraíba, brazil thainakaroline@gmail.com janislei soares dantas https://orcid.org /0000-0003-2632-7733 universidade federal da paraíba, brazil janisleisd@gmail.com mariana albernaz pinheiro de carvalho https://orcid.org /0000-0002-2911-324x universidade federal de campina grande, brazil mariana.albernaz@professor.ufcg.edu.br article main self-care deficits found in elderly people with diabetic foot ulcer: an integrative review recebido: 23/01/2023 submetido a pares: 14/03/2023 aceito por pares: 29/05/2023 aprovado: 11/07/2023 doi: 10.5294/aqui.2023.23.3.6 para citar este artículo / to reference this article / para citar este artigo lima pc, bittencourt gkgd, nogueira wp, dias tkc, dantas js, carvalho map. main self-care deficits found in elderly people with diabetic foot ulcer: an integrative review. aquichan. 2023;23(3):e2336. doi: https://doi.org/10.5294/aqui.2023.23.3.6 https://orcid.org/0000-0001-5468-2674 mailto:paulylima1@gmail.com https://orcid.org/0000-0001-5287-8171 mailto:greicykel@gmail.com https://orcid.org/0000-0002-7492-7939 mailto:wynne.nogueira@academico.ufpb.br https://orcid.org/0000-0002-7265-1350 mailto:thainakaroline@gmail.com https://orcid.org/0000-0003-2632-7733 mailto:janisleisd@gmail.com https://orcid.org/0000-0002-2911-324x mailto:mariana.albernaz@professor.ufcg.edu.br https://doi.org/10.5294/aqui.2023.23.3.6 https://doi.org/10.5294/aqui.2023.23.3.6 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2023.23.3.6&amp;domain=pdf&amp;date_stamp=2023-08-18 theme: health promotion, well-being, and quality of life contributions to the discipline: this study contributes to the identification and categorization of the most common self-care deficits in elderly people and the scientific evidence generated provides a foundation for conducting new studies on the theme, as well as assisting in decision-making by nurses to adopt measures that contribute to the self-care of this population group, in addition to guiding this population regarding the necessary care. furthermore, it contributes to training and qualifying the healthcare team in order to emphasize the need for self-care awareness. m ai n se lf -c ar e d efi ci ts f ou nd in e ld er ly p eo pl e w it h d ia be ti c fo ot u lc er : a n in te gr at iv e re vi ew 3 abstract introduction: the increase in the incidence of diabetes mellitus has led to public health consequences. several individuals with diabetes lose sensitivity and may present foot deformities, resulting in diabetic foot. knowing about self-care deficits can allow for planning healthcare in the management of diabetic foot and improve the patient’s quality of life. objective: to identify, from the scientific literature, the main selfcare deficits present in elderly people with diabetic foot ulcers, based on orem’s self-care deficit theory. materials and methods: this is an integrative review study. the search for studies was performed in january 2022, using the descriptors “diabetic foot”, “self-care,” and “aged.” the following virtual library and databases were used: bvs, lilacs, medline and bdenf via pubmed. the adaptation of the prisma flowchart was used. a synthesis of the articles was performed with the description of the main results and self-care deficits according to orem’s self-care theory. results: socioeconomic conditions, skin characteristics, activities, leisure and rest, diet, neurological conditions, and lack of knowledge about the need for therapeutic support and treatment were the main factors related to self-care deficits. conclusion: the scientific evidence generated provides a foundation for carrying out new studies on the theme, as well as assisting in decision-making by nurses to adopt measures that assist in the self-care of this population group, in addition to guiding this population regarding the necessary care. keywords (source: decs) diabetic foot; nursing; aged; diabetes mellitus; disease prevention. 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 6 principales déficits de autocuidado encontrados en ancianos con úlcera de pie diabético: una revisión integradora resumen introducción: el aumento de la incidencia de la diabetes mellitus ha tenido consecuencias para la salud pública. muchos individuos con diabetes pierden sensibilidad y pueden desarrollar deformidades en los pies, dando lugar al pie diabético. conocer los déficits de autocuidado puede permitir la planificación de la asistencia sanitaria en el manejo del pie diabético y mejorar la calidad de vida del paciente. objetivo: identificar, desde la literatura, los principales déficits de autocuidado presentes en adultos mayores con úlceras de pie diabético, con base en la teoría del déficit de autocuidado de orem. materiales y método: se trata de una revisión integradora. la búsqueda de estudios se realizó en enero de 2022, utilizando los descriptores “pie diabético”, “autocuidado” y “anciano”. se utilizaron las siguientes bases de datos y bibliotecas virtuales: bvs, lilacs, medline y bdenf a través de pubmed. se utilizó la adaptación del diagrama de flujo prisma. se realizó una síntesis de los artículos con la descripción de los principales resultados y déficits de autocuidado según la teoría de autocuidado de orem. resultados: condiciones socioeconómicas, características de la piel, actividades, ocio y descanso, alimentación, condiciones neurológicas y desconocimiento de la necesidad de apoyo terapéutico y tratamiento fueron las principales situaciones relacionadas a los déficits de autocuidado. conclusiones: se destaca la importancia de la educación sanitaria, el manejo terapéutico, los cuidados individualizados y el uso de una herramienta de consultas de enfermería para apoyar la prevención del pie diabético y mejorar la calidad de vida de los ancianos. palabras clave (fuente: decs) pie diabético; enfermería; ancianos; diabetes mellitus; prevención de enfermedades. m ai n se lf -c ar e d efi ci ts f ou nd in e ld er ly p eo pl e w it h d ia be ti c fo ot u lc er : a n in te gr at iv e re vi ew 5 resumo introdução: o aumento da incidência do diabetes mellitus vem acarretando consequências à saúde pública. muitos indivíduos com diabetes perdem a sensibilidade e podem desenvolver deformidades nos pés, ocasionando o pé diabético. conhecer os déficits de autocuidado pode permitir o planejamento da assistência à saúde no manejo do pé diabético e melhorar a qualidade de vida do paciente. objetivo: identificar, a partir da literatura científica, os principais déficits de autocuidado presentes em idosos com úlceras de pé diabético, fundamentando na teoria do déficit de autocuidado de orem. materiais e método: trata-se de um estudo do tipo revisão integrativa. a busca dos estudos ocorreu em janeiro de 2022, a partir dos descritores “pé diabético”, “autocuidado” e “idoso”. utilizaram-se as bases de dados e biblioteca virtual: bvs, lilacs, medline e bdenf por meio da pubmed. a adaptação do fluxograma prisma foi utilizada. uma síntese dos artigos foi realizada com a descrição dos principais resultados e déficits de autocuidado conforme a teoria de autocuidado de orem. resultados: condições socioeconômicas, características da pele, atividades, lazer e repouso, alimentação, condições neurológicas e falta de conhecimento sobre a necessidade de suporte terapêutico e de tratamento foram as principais situações relacionadas aos déficits de autocuidado. conclusão: a evidência científica gerada serve como base para realizar novos estudos sobre a temática, assim como auxilia na tomada de decisões por parte do enfermeiro para adotar medidas que auxiliem no autocuidado desse grupo populacional, além de orientar essa população quanto aos cuidados necessários. palavras-chave (fonte decs) pé diabético; enfermagem; idoso; diabetes mellitus; prevenção de doenças. principais déficits de autocuidado encontrados em idosos com úlcera de pé diabético: uma revisão integrativa 6 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 6 introduction the exponential and fast increase in the incidence of diabetes mellitus (dm) has led to consequences for public health, due to the severity of the sequelae caused by the disease. several individuals with diabetes lose sensitivity and may present foot deformities, which lead to “diabetic foot,” defined as the infection, ulceration, and/or destruction of deep tissues associated with neurological abnormalities and varying degrees of peripheral vascular disease in lower limbs. this represents a significant health and economic problem, particularly if it results in amputation and prolonged hospitalization, rehabilitation, as well as loss of productivity and impact on the individual’s quality of life (1). in addition, elderly people with dm are twice more likely to suffer from dementia. cognitive dysfunction hinders the performance of self-care tasks for patients, such as the management of capillary blood glucose, the administration of insulin doses, and the adoption of an adequate diet. in addition, brain aging, osteoarticular problems, and the presence of cataracts associated with diabetic retinopathy can negatively impact self-care activities and add to the incidence of diabetic foot in this population (2). in this context and since it is a profession directly related to care, nursing provides self-care teaching, which is a relevant strategy to address the problems related to the disease process and consequent reduction of disabilities caused by diabetic foot syndrome, since the educational interventions employed by nurses stimulate individuals to act in the promotion of their own health (2). this category has been responsible for endeavoring all efforts and strategies for the relief of suffering, during and after the disease, and playing a pioneering role in the development of know-how competence, performing effective care and safe clinical management. as a science, the profession went through distinct moments and gathered strength from florence nightingale’s care theories, which placed the profession in a new paradigm, as a holder of not only technical but also scientific knowledge, in which nursing knowhow intensifies the need for formal, organized, and scientific education with the consolidation of the administrative, managerial, and intellectual roles (3). nursing theories can be described as a set of interrelated concepts, definitions, or premises that present a systematic approach to observing, describing, or predicting phenomena/events to explain or propose the correlations between them (4). they provide a basis for the foundation of care as they guide the development of the systematization of nursing care (snc) and the application of the nursing process (np) based on patient-centered premises and foundations and on nursing as a promoter of comprehensive and holistic care, which provides an essential basis for autonomous, resolutive practice based on scientific evidence (5). m ai n se lf -c ar e d efi ci ts f ou nd in e ld er ly p eo pl e w it h d ia be ti c fo ot u lc er : a n in te gr at iv e re vi ew 7 orem’s theory is one of the theoretical constructs that have inspired brazilian nursing practice the most (2). orem’s general theory of self-care consists of three interrelated theoretical constructs: the theory of self-care, the theory of self-care deficit, and the theory of nursing systems, highlighting the importance of patient commitment to self-care (6). within the scope of this theory, nursing practices directed to individuals are intended to enable them to be fully or partially capable of providing care for themselves or their dependents (7). since elderly people are the age group with the highest prevalence of dm and the most vulnerable to the onset of sequelae, there was interest in searching the current literature about the problems found in this population with diabetic foot ulcer (dfu) to identify their self-care deficits, focusing on orem’s self-care theory, based on the following guiding question: what are the factors related to self-care deficits of elderly people with dfu? this is an extremely relevant study given the scarcity of other reviews on this issue. it is hoped that it will contribute to the production of new studies on this subject, as well as to the improvement of the care provided by nurses to this population. considering the above, the objective was to identify, from the scientific literature, the main self-care deficits present in elderly people with dfu, based on orem’s self-care deficit theory. materials and methods this is a bibliographic, descriptive, integrative literature review study, which provides the retrieval and systematic summarization of a given theme and leads to practice based on scientific knowledge. the steps proposed in the literature (8) were followed: 1. identification of the theme and selection of the hypothesis or research question for the development of the integrative review; 2. establishment of criteria for the inclusion and exclusion of studies/sampling or literature search; 3. definition of the information to be extracted from the selected studies/categorization of studies; 4. evaluation of studies to be included; 5. interpretation of results; 6. presentation of the review/synthesis of knowledge. the study was conducted based on the following question: what are the factors related to self-care deficits of elderly people with dfu? the study selection for analysis was performed in january 2022. for the literature search, the health sciences descriptors (decs) and the medical subject headings (mesh) were selected. the search strategy selected was “pé diabético” and “autocuidado” and “idoso” and the descriptors in english “diabetic foot” and “self-care” and “aged”. the descriptor “enfermagem” (nursing) was excluded, as it greatly limited the number of articles found. the following databases indexed in the virtual health library (bvs) were used: latin american and caribbean health sciences 8 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 6 literature (lilacs), medical literature analysis and retrieval system online (medline), through the public publisher medline database (pubmed) and nursing database (bdenf ). initially, 424 articles were found, using the following filters: scientific articles (original), published between 2011 and 2021, available in full text online and in portuguese, english, and spanish. as inclusion criteria, studies addressing the following descriptors in the abstract were selected: “pé diabético,” “autocuidado,” and “idoso,” that had an absolute number of elderly people in their sample (aged 60 years or above) and were original articles (cross-sectional, case-control, cohort, clinical trials). the exclusion criteria were defined as titles that did not correspond to the guiding question, review articles, theses, dissertations, monographs, books, book chapters, manuals, commentaries, opinion articles, and non-scientific production. then, the articles were refined by verifying the titles and keywords, and those that mentioned at least two of the descriptors defined in the pre-established criteria were selected. after the search, all identified articles were loaded into the endnote basic reference manager and then into the rayyan software; duplicates were removed, and the review steps were performed (9-10). in the first step, 424 articles were identified, 179 were excluded due to being duplicates, with 245 remaining, of which 4 were found in bdenf, 21 in lilacs, 102 in medline, and 118 in pubmed. the studies pre-selected in step 1 were restored in full and evaluated in step 2. all those that failed to meet the inclusion criteria were excluded, and the reasons were registered. after reading the titles and abstracts, 101 studies were excluded for being duplicates, with 144 remaining, of which 104 were excluded for not meeting the inclusion criteria such as mean age, ineligible methodological design, and not addressing the researched theme, and only one article was excluded for not being found in full. thus, the present review was composed of 37 studies. the flow diagram of the preferred reporting items for systematic reviews and meta-analysis (prisma [11]) was used to report the search and selection process of the studies (figure 1). the data obtained were grouped and presented in tables, with information regarding the articles and the self-care deficits found, for a clearer display of the studies included in the integrative review. the findings were summarized to identify the central theme addressed in each analyzed study. for the discussion of the results found, the findings of the studies regarding the adaptive problems experienced by elderly people were integrated. results in the database search step, 245 studies that addressed the theme of self-care in elderly people with diabetic foot were found. those were analyzed according to the methodological steps. of these, 101 were selected for full reading, thus the sample of this review was composed of 37 studies. m ai n se lf -c ar e d efi ci ts f ou nd in e ld er ly p eo pl e w it h d ia be ti c fo ot u lc er : a n in te gr at iv e re vi ew 9 in the �rst step, 424 articles were identi�ed. duplicate entries removed (n = 179). selected entries (n =245). excluded at the 2nd screening (n=101). reports evaluated for eligibility (n = 39). inclusion criteria: studies published in the format of a scienti�c article (original); available in full text; published between 2012 and 2022, presenting two descriptors in the abstract: diabetic foot, self-care, and aged. exclusion criteria: titles that did not correspond to the guiding question, review articles, theses, dissertations, monographs, books, book chapters, annals, commentaries, opinion articles, and non-scienti�c production. studies included in the review after reading the title and abstract (n = 38). id en ti �c at io n sc re en in g in cl u d ed table 1 presents an overview of the articles analyzed. they were published from 2012 to 2022, with a prevalence of articles published in 2014 and 2020, with 7 (18.9 %) published each year. regarding nationality, the country with the highest prevalence of articles on the theme was brazil, with a total of 7 (18.9 %). the analysis of the studies that composed the review sample allowed identifying a variety of research methods, with descriptive and cross-sectional exploratory methods being used the most (level of evidence vi). only two articles were randomized studies with level ii evidence. the level of evidence of 29 (78.4 %) of the articles from the sample of this integrative review was classified as weak (grade 6), except for those with clinical trials, with studies a2 and a14 being classified as level ii evidence, and a26 and a38 as level iii (table 1). figure 1. descriptor flowchart of the results obtained from the search strategy, according to the prisma strategy. source: adaptation of the prisma flowchart. table 1. articles disposition according to title, year, country, level of evidence, and methodological design. joão pessoa, paraíba, brazil, 2022 article year and country level of evidence methodological design a1 autocuidado de los pies en pacientes diabéticos (12) 2020 cuba vi cross-sectional descriptive study a2 relationships of health literacy to self-care behaviors in people with diabetes aged 60 and above: empowerment as a mediator (13) 2018 korea vi cross-sectional exploratory design 10 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 6 article year and country level of evidence methodological design a3 the effects of self-efficacy enhancing program on foot self-care behaviour of older adults with diabetes: a randomised controlled trial in elderly care facility, peninsular malaysia (14) 2018 malaysia ii randomized controlled trial a4 diabetic foot disease, self-care and clinical monitoring in adults with type 2 diabetes: the alberta’s caring for diabetes (abcd) cohort study (15) 2015 canada iv prospective cohort study a5 evaluation of diabetic foot screening in primary care (16) 2014 spain vi multicenter, cross-sectional epidemiological study a6 capacidades y actividades en el autocuidado del paciente con pie diabético (17) 2014 peru vi quantitative, descriptive cross-sectional study a7 association between foot care knowledge and practices among african americans with type 2 diabetes: an exploratory pilot study (18) 2019 the united states vi exploratory field study a8 the role of foot self-care behavior on developing foot ulcers in diabetic patients with peripheral neuropathy: a prospective study (19) 2014 taiwan vi prospective longitudinal study a9 impact of action cues, self-efficacy and perceived barriers on daily foot exam practice in type 2 diabetes mellitus patients with peripheral neuropathy (20) 2012 taiwan vi cross-sectional study a10 relation between causes of hospitalization and self-care in older adults with diabetes mellitus (21) 2020 chile vi descriptive study with a quantitative approach a11 a cohort study of diabetic patients and diabetic foot ulceration patients in china (22) 2015 china iv cohort study a12 foot care education among patients with diabetes mellitus in china: a cross-sectional study (23) 2020 china vi quantitative crosssectional study a13 an investigation of diabetes knowledge levels between newly diagnosed type 2 diabetes patients in galway, ireland and new york, usa: a crosssectional study (24) 2016 ireland vi cross-sectional study a14 efeito do grupo operativo no ensino do autocuidado com os pés de diabéticos: ensaio clínico randomizado (25) 2020 brazil ii randomized clinical trial a15 development, validation and psychometric analysis of the diabetic foot self-care questionnaire of the university of malaga, spain (dfsq-uma) (26) 2015 spain vi cross-sectional validation study a16 actividades de prevención y factores de riesgo en diabetes mellitus y pie diabético (27) 2014 colombia vi cross-sectional descriptive study a17 knowledge, attitudes and practices for the prevention of diabetic foot (28) 2014 brazil vi cross-sectional study a18 quality of life in diabetic foot ulcer: associated factors and the impact of anxiety/depression and adherence to self-care (29) 2020 greece vi cross-sectional study m ai n se lf -c ar e d efi ci ts f ou nd in e ld er ly p eo pl e w it h d ia be ti c fo ot u lc er : a n in te gr at iv e re vi ew 11 article year and country level of evidence methodological design a19 conhecimentos e práticas para a prevenção do pé diabético (30) 2019 colombia vi descriptive cross-sectional study a20 conocimientos sobre factores de riesgos y medidas de autocuidado en pacientes con diabetes mellitus tipo 2 con úlcera neuropática (31) 2021 cuba vi descriptive cross-sectional study a21 differences in foot self-care and lifestyle between men and women with diabetes mellitus (32) 2016 brazil vi cross-sectional study a22 locus de controle da saúde, imagem corporal e autoimagem em indivíduos diabéticos com pés ulcerados (33) 2017 brazil vi descriptive, analytical controlled study a23 foot self-care behavior and its predictors in diabetic patients in indonesia (34) 2020 indonesia vi cross-sectional study a24 a self-efficacy education programme on foot self-care behaviour among older patients with diabetes in a public long-term care institution, malaysia: a quasi-experimental pilot study (35) 2017 malaysia iii pre-experimental and post-quasi-experimental study a25 importance of factors determining the low health-related quality of life in people presenting with a diabetic foot ulcer: the eurodiale study (36) 2013 europe (10 countries) vi cross-sectional study a26 promoção da saúde de pessoas com diabetes mellitus no cuidado educativo preventivo do pédiabético (37) 2016 brazil vi mixed-method study a27 quality of foot care among patients with diabetes: a study using a polish version of the diabetes foot disease and foot care questionnaire (38) 2020 the united states vi cross-sectional study a28 illness beliefs predict self-care behaviours in patients with diabetic foot ulcers: a prospective study (39) 2014 the united kingdom vi prospective cohort study a29 the investigation of demographic characteristics and the health-related quality of life in patients with diabetic foot ulcers at first presentation (40) 2012 china iv cross-sectional study a30 people with diabetes foot complications do not recall their foot education: a cohort study (41) 2018 australia iv prospective cohort study a31 self-efficacy of foot care behaviour of elderly patients with diabetes (42) 2017 malásia vi cross-sectional study a32 avaliação do pé nos portadores de diabetes mellitus (43) 2021 brazil vi cross-sectional study with a quantitative approach a33 factors associated with foot ulcer selfmanagement behaviours among hospitalised patients with diabetes (44) 2019 taiwan iv cross-sectional study 12 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 6 article year and country level of evidence methodological design a34 evaluation of knowledge levels about diabetes foot care and self-care activities in diabetic individuals (45) 2021 turkey vi descriptive study a35 the influence of beliefs about health and illness on foot care in ugandan persons with diabetic foot ulcers (46) 2013 uganda vi exploratory study with a consecutive sample a36 effect of intensive nursing education on the prevention of diabetic foot ulceration among patients with high-risk diabetic foot: a follow-up analysis (47) 2014 china iii non-controlled experimental study a37 factors associated with foot ulceration of people with diabetes mellitus living in rural areas (48) 2017 brazil vi cross-sectional study source: prepared by the authors. in table 2, to clarify the presentation and organization of the articles’ outcomes, a summary is presented, describing the main results and self-care deficits found according to orem’s self-care theory. regarding the universal requirements, 69 deficits were found, of which 15 were related to socioeconomic conditions, 26 to skin conditions, 8 to activities, leisure, and rest, 5 to nutrition, 10 to neurological conditions, and 5 to neurological condition deficits. regarding incidence requirements, 5 deficits were found; on the other hand, regarding those on health deviations, 102 were evidenced, of which 72 were deficits in knowledge of self-care measures for feet and injuries, 24 about knowledge about the need for therapeutic support and treatment, and 6 about health status. table 2. relationship of self-care deficits of universal self-care, incidence, and health deviation requirements in elderly people found in the literature, joão pessoa, paraíba, brazil, 2022 self-care requirements self-care deficits universal requirements socioeconomic conditions (12-15, 17-23, 28, 30, 31-36, 38, 39, 41, 42, 44-47) age, advanced age, elderly people living in care institutions, family history of dm, poor body hygiene practices, low level of education, insufficient knowledge, family support, previous foot care behaviors, poor financial situation, employment, being a person with lower purchasing power, medical history. skin conditions (15-20, 29, 30, 32, 33, 36, 44-47) decreased vascular dilation and permeability, thickening of capillary basement membrane, ulcer, blisters, cuts, poor tissue perfusion, presence of edema, irregular thermoregulation, anhidrosis, skin fissures, corns and calluses, nail infection, skin lesion, involuted nail plates and dermatitis, ingrown toenails, sublingual lesion, interdigital maceration, reduction in lower limb perfusion, ulcer size, risk of limb ischemia, infection, peripheral arterial disease, and polyneuropathy. activities, leisure, and rest (13, 17, 34, 35, 47) sedentary lifestyle, physical exercise, inadequate activities, poor quality of life, reduced mobility, pain, discomfort, and inability to walk unassisted. m ai n se lf -c ar e d efi ci ts f ou nd in e ld er ly p eo pl e w it h d ia be ti c fo ot u lc er : a n in te gr at iv e re vi ew 13 self-care requirements self-care deficits nutrition (13, 17, 28, 35) poor nutrition, diet, lower dietary control, obesity, and patients without diabetic education. neurological condition (15-18, 28-30, 32, 34-36, 40, 47) impaired memory and learning, impaired attention, significantly lower levels of self-esteem, self-image, and locus of health control compared to diabetic patients without ulceration, beliefs about symptoms associated with ulceration, barrier belief, stress due to ulcer, diabetes distress, and/or depressive symptoms. social interaction (22, 29, 34-37, 41, 45, 47) few information exchanges, few listening spaces, social isolation due to smell and reduced mobility due to ulcers and no family collaboration. development requirements development requirements (15-20, 22, 23, 25, 27, 28, 32, 36, 37, 43-48) history of neuropathy, history of peripheral arterial disease, foot care behavior, health described as the and/or absence of disease and pain. health deviation requirements knowledge about selfcare measures for feet and injuries (12-25, 28-33, 35-39, 4248) misinformation, poor foot self-care habits, duration of diabetes, hypertension, hyperlipidemia, hyperglycemia, sustained hyperglycemia, high cholesterol, high-density lipoprotein, insulin level, decreased hdl, poor dietary habits, comorbid diseases, hba1c level >7 %, elevated c-reactive protein concentration, being current smokers, duration of foot ulcer, comorbid diseases, peripheral obstructive arterial disease, vascular disease, altered ankle-brachial index, absence of peripheral pulses, amputation, nephropathy, diabetic foot, high-risk foot, lower extremity complications, dysesthesias, intermittent claudication, neuropathy, vasculopathy, retinopathy, foot deformities, poor foot care, cutting own nails, not performing water temperature test before putting on feet, applying moisturizing lotion, purposefully wearing larger shoe sizes, not checking inside own shoes, hindrance to finding recommended footwear, inadequate dexterity and selfcare skills, ulcers, foot examinations by physicians, failure to perform foot examination, failure to question about dysesthesias, intermittent claudication, inadequate patient daily self-care, failure to check feet inside shoes, failure to perform interdigital drying, foot lubrication, no self-monitoring, inadequate nail clipping, failure to wear socks, therapeutic footwear, lack of knowledge of how to perform hygiene and what to observe in the feet, failure to perform care such as washing, drying, moisturizing, and massaging together, depression associated with age over 50 years, depressive symptoms associated with recurrence of ulcers, depression during the first ulcer associated with increased mortality, low frequency of drying of interdigital spaces, no periodic evaluation of the feet, habit of walking barefoot, unsatisfactory hygiene and inadequate nail cutting, lack of scalding the feet, inadequate footwear (slippers or sandals), omission in diabetes education, absence of inspection of the soles of the feet with a mirror, beliefs about the symptoms associated with ulceration. 14 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 6 self-care requirements self-care deficits knowledge about the need for therapeutic support and treatment (13, 15-23, 28-40, 42-44, 46-48) low and medium levels of knowledge about self-care, no measurement of the ankle-brachial index, no palpation of peripheral pulses, patients without diabetes education, no foot examination, difficulty with insulin treatment, increased number of hospitalizations, increased self-care scale score, diabetes decompensation, self-monitoring of blood glucose, poor glycemic control, nursing care, podiatrist appointment last year, no monitoring of blood glucose level, insufficient self-management of the ulcer, not performing laboratory tests for lipid profile at the recommended frequency, poor preventive activities by medical doctors and not providing education on foot self-care, unaware of correct nail cutting, willingness to perform self-care, their understanding of ulceration and their perceived personal control over ulceration, diabetic foot ulcers were already in poor condition at the first time patients had an appointment with the clinic. health status (15, 17-23, 28-30, 32, 36-37, 43, 45, 48) clinical presentations of diabetes, failure to perform daily foot examination, decompensation of diabetes, impaired vascular condition, previous amputations. source: prepared by the authors. discussion elderly people with diabetes and self-care in the prevention of foot injuries the results presented indicate a prevalence of the elderly population group considering the other age groups, given that the present review aimed to identify self-care deficits in this group. elderly people with diabetes have a shorter life expectancy and are particularly burdened by foot diseases that can lead to amputation and other disabilities in addition to physical and psychological suffering. in malaysia, it was reported that 55.3 % of patients with diabetes experience diabetic foot problems and 38.3 % of them were among the elderly (35). people with diabetes need to adopt regular foot self-care behaviors to prevent and delay potential complications, such as avoiding skin dryness, damage between the toes and calluses on the feet that can reduce blood circulation and lead to early occurrence of trauma and complications. however, several factors in the elderly population can have an impact, including physical limitations, health status, as well as cognitive and psychosocial aspects. thus, the aging of the world population and the exponential sharp increase of elderly diabetics make dfu a challenge for health professionals (14). the study conducted in 2017 on the self-care behavior of diabetic elderly people reported that the adoption of foot care can help mitigate problems in these body segments by 49-85 % (14). analysis of respondents through a set of validated questionnaires showed that participants were aware of the importance of foot care for the prevention of complications, but the professional and skin care subscales received only moderate scores. the same study pointed out m ai n se lf -c ar e d efi ci ts f ou nd in e ld er ly p eo pl e w it h d ia be ti c fo ot u lc er : a n in te gr at iv e re vi ew 15 that only a limited number of elderly people with diabetes seek medical advice when they experience the onset of the disease; most only seek professional assistance for treatment when the disease becomes severe. adherence to self-care behavior is considered low in people with diabetes, so the underlying determinants need to be identified (49). in a study conducted in cuba, misinformation on foot selfcare measures prevailed (84.3 %), with higher percentages in the 61-70 years group (100 %) versus 65 % in the 50-60 years group. most patients qualified as having poor foot self-care habits (86.6 %). it was noted by the researchers that in the 61-70 age group, this category rose to 96 %; however, in the 50-60 age group, 5 patients had good and regular habits (2 and 3 representing 10 % and 15 %, respectively). the variable “foot self-care” showed a prevalence of patients with poor evaluation (82.1 % [12]). dfu can be reduced through adequate guidance on podiatric care, as early identification of tissue at risk of ulceration can enable appropriate preventive care, thus reducing the incidence of foot ulceration. such results were shown in a study that evidenced a substantial decrease in the incidence of dfu, in which 185 patients with diabetes at high risk for foot disease received intensive nursing education and, after two years of follow-up, the incidence of dfu was significantly reduced. more ulcers were healed, and fewer surgical procedures were required in patients who were monitored (47). however, the rates of foot examinations and prevention activities carried out by health professionals are low. according to the literature, only 14 % of respondents have ever received guidance on foot care and only 26 % have had their feet examined by a professional (43). in a colombian study, diabetic foot prevention activities performed by medical doctors were found to be precarious, as 59.5 % of patients reported not having received guidance on foot self-care. only 106 (40.5 %) reported having received guidance on foot self-care. similarly, 57.1 % of patients reported that the outpatient medical doctor had not examined their feet, i.e., in the last year, only 42.9 % of patients had had their feet examined. similarly, 68.3 % were not asked about dysesthesia and intermittent claudication in 74.8 % of the total group of patients surveyed (27). this reality contrasts with what is recommended by the international diabetic foot group guidelines, which highlight the cost-effectiveness of prevention activities to reduce the prevalence of ulcers and amputations. it has been shown that patients at high risk of diabetic foot injuries need timely diagnosis and education for appropriate diabetes self-care behaviors and foot self-examination. in light of the above, every clinician providing care to a patient with dm should question them regarding risk factors for diabetic foot (dysesthesias, intermittent claudication, ulceration, and amputation), perform a primary foot examination (inspection, protective tenderness with the semmes wein16 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 6 stein monofilament, vibration with a 128 hz tuning fork), and screen them for peripheral vascular disease (50). orem’s theory and its self-care requirements it should be noted that nursing theories are used as a basis to substantiate care and are considered a relevant strategy to aid in the educational interventions employed by nurses and consequently reduce the disabilities caused by diabetic foot syndrome and stimulate patients to act in the promotion of their health as they guide the development of the snc and implementation of the np. orem’s theory is one of the theoretical constructs that have inspired brazilian nursing practice the most (2). among its three interrelated theoretical constructs, there are the self-care theory and the universal, development, and health deviation requirements. self-care deficits of universal requirements the articles that presented universal deficits point out that elderly people were less confident in protecting and checking their feet daily for any abnormality such as redness, cuts, blisters, and dry skin. the barriers to performing these tasks may be explained by geriatric conditions such as visual impairment and other medical conditions that limit the ability to adequately inspect and protect the feet. the highest self-care subscale scores in this study were for footwear, hygiene, and safety. this finding is supported by previous research showing that self-efficacy is significantly associated with foot self-care behavior of elderly people with diabetes (12). a study (17) performed with 60 patients hospitalized for diabetic foot used the questionnaire on capacities and self-care activities of patients with diabetic foot as an instrument, which highlighted that, when it came to foot care, 58.3 % had an inadequate level; 50 % of users had lesions, that is, calluses, fungal infections, and bad odor. this is due to their poor condition and the use of cloth, plastic, and leather sandals, the latter being traditionally used. in the primary health care system of a city in the countryside of são paulo, a study was performed to evaluate the feet of individuals with dm (43), it was found that 94 % of the respondents had no lesions on their feet; in the sensitivity test, 88 % had preserved sensitivity and 77 % had preserved pedic pulse, showing that, in both tests, a percentage of patients already present alterations in the exams, allowing timely guidance to be provided. thus, the effect of intensive nursing education on the prevention of dfu in patients at high risk for diabetic foot is not only possible but m ai n se lf -c ar e d efi ci ts f ou nd in e ld er ly p eo pl e w it h d ia be ti c fo ot u lc er : a n in te gr at iv e re vi ew 17 also highly beneficial for the patient, so that they can have their feet inspected regularly. at the end of the follow-up, the onset of dfu was prevented and the participants were educated about sensory neuropathy, which leads to a deficit or loss of the skin’s self-protection mechanism (47). motor neuropathy alters the plantar pressure load, and autonomic neuropathy reduces the perspiration of the foot skin, making the skin dry and easily damaged or cracked. visual inspection of the skin for signs of dryness is often vital to prevent skin integrity cracking. checking the skin will provide an early warning of impending problems and such inspections should be encouraged and guided by healthcare professionals in their care (47). self-care deficits of development requirements regarding development deficits, the literature shows that 50.4 % of patients have mobility problems, 28.2 % have self-care problems, and 47.6 % have regular activities problems (51). in addition to finding a significant association between adherence to foot care and mobility problems, self-care, and regular activities (p < 0.05). a significant association was also found between lack of adherence to exercise and poor mobility, self-care, regular activities, pain, and anxiety (p < 0.05). non-adherence to diet was associated with poor mobility (p < 0.05). in this study, patients who had a non-adherence index also had lower quality of life. according to descriptive results in one study (29), 42.1 % of the elderly participants suffered from some other disease other than diabetes, 26.3 % were current smokers and 30.8 % were alcoholics. ulcers are associated with an increased risk of all-cause mortality, fatal myocardial infarction, and fatal stroke. these patients have insulin resistance, central obesity, dyslipidemia, and hypertension. the finding that 26.3 % of participants were current smokers needs to be carefully considered due to the vasoconstrictive effects of nicotine on late or non-healing ulcers and the increased risk of diabetic foot amputation. when analyzing the self-care and social support variable, it was possible to note that patients who live alone, who live with their partner, and with their family presented a higher percentage in the partially adequate self-care category: 2 (50 %), 4 (44.4 %), and 10 (55.6 %), respectively; and 3 (33.3 %) of those who live with a partner presented adequate self-care (21). regarding the level of education, it is worth noting that participants with higher education, when compared to those with secondary education, obtained significantly higher foot care behavior scores than those with low education. thus, it emphasizes that less educated people tend to be less knowledgeable about health, lead18 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 3 ch ía , c o lo m bi a j u li o -s ep ti em br e 20 23 | e2 33 6 ing to unhealthy behaviors compared to those with higher levels of education (34). it was also possible to note that patients with dfu are more likely to have depression and anxiety compared to those without foot complications, while patients with dm are twice more likely to have anxiety and depression when compared to the general population. anxiety is associated with dm duration (< 10 years), comorbid conditions, and hba1c level > 7 %, while depression is associated with patients’ age (< 50 years), being female, being a current smoker, foot ulcer duration, and comorbid conditions. depressive symptoms are associated with ulcer recurrence in dm patients aged 60 years old. depression at the first ulcer occurrence is associated with a 2-fold increase in mortality within 5 years and an increased amputation rate (29). self-care deficits of health deviation requirements regarding health deviation deficits, the mean number of years since diagnosis of the participants studied was 17.1 (sd = 12.6). in the group with less than 11 years since diagnosis, the category “partially adequate self-care” prevailed (n = 6; 37.5 %); but in the group with 11 to 20 years, the category “no self-care capacity” was more frequent (n = 3.5 %). in people with more than 20 years since diagnosis, there was still a higher percentage of “partially adequate self-care”. the category that presented the highest percentage was “partially adequate self-care” in all groups, with 5 (71.4 %) in the group with 21 to 30 years, but in the group with 10 to 20 years, there were 2 (40 %) that presented the category “self-care deficit” (21). in this same study, when evaluating the relationship between selfcare and hospitalization in elderly people, it was found that the main cause of hospitalization of elderly diabetics was due to diabetic foot, followed by patients with metabolic decompensation (21). it was found that 51.7 % of patients with diabetes received foot care education from a nurse, 80 % knew the negative effect of diabetes on the feet, 69.2 % had no foot problems after diagnosis, 40 % attended a health care institution in case of any foot problem, 76.7 % performed leg and foot gymnastics, 63 % performed leg and foot gymnastics regularly daily, and 30.8 % performed foot examination daily (45). the aforementioned study also found that patients’ knowledge about diabetic foot and diabetes self-care behaviors increased significantly as the duration of diabetes increased, but they failed to convert this knowledge into foot-care behaviors. this result suggests that the patients included in the study had difficulty converting their knowledge into behaviors due to their older mean age (45). therefore, when evaluating the effect of the operating group in teaching foot self-care for the prevention of diabetic foot, with the participation of 209 people with diabetes, several aspects were m ai n se lf -c ar e d efi ci ts f ou nd in e ld er ly p eo pl e w it h d ia be ti c fo ot u lc er : a n in te gr at iv e re vi ew 19 considered in the intensive nursing teaching. dry and cracked foot skin was addressed and patients were instructed to wash their feet correctly, including care for adequate water temperature and how to keep the feet dry. in addition, patients were advised on the choice of adequate shoes and socks and their awareness of self-protection was improved. therefore, patients were encouraged to perform an inspection of their feet and consequently to practice daily self-care (6). conclusions the findings of the selected studies evidenced that participants had a low level of knowledge on the theme, in addition to limitations to self-care in elderly people, who are affected by the long-term complications of diabetes. in addition, the progression of the disease associated with gaps in communication and guidance from health professionals could be noted in the studies that had a large number of participants who stated that they had never received foot care guidelines, which resulted in serious consequences in the onset and healing of dfu. it should be stated to patients that adequate foot care in diabetes is essential to prevent the occurrence of wounds. in this sense, orem’s self-care theory proved to be compatible with the study, enabling the identification and classification of the main self-care deficits and their categorization, which can ease care and improve the self-care perspective. therefore, the importance of carrying out the present study is highlighted, which contributes to the identification and categorization of the most common self-care deficits in elderly people. the scientific evidence hereby produced provides a basis for further studies on the theme, in addition to assisting nurses in decision-making to adopt measures that 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colombia. cvargasporras@yahoo.com, carvarpo@uis.edu.co received: 22 june 2014 sent for peer review: 25 august 2014 accepted by peers: 9 february 2015 approved: 11 march 2015 doi: 10.5294/aqui.2015.15.2.2 para citar este artículo / to reference this article / para citar este artigo orozco-vargas lc, villamizar-carvajal b, vargas-porras c. impaired parenting in primiparous mothers: clinical validation through rasch analysis. aquichan. 2015; 15 (2): 176-187. doi: 10.5294/aqui.2015.15.2.2 abstract introduction: a valid instrument is needed to establish a nursing diagnosis of impaired parenting and to conduct interventions. objective: the purpose of this study is to validate the nursing diagnosis of impaired parenting using rasch analysis with primiparous mothers up to24 years of age, during the first year of child rearing, and to compare the results of the clinical validation of that diagnosis using rasch analysis and fehring’s method to clinically validatenursing diagnosis. method: this was a cross-sectional study based on rasch analysis, pursuant to messick’s construct validity guidelines. results: twenty-seven items representing 18 parenting-defining characteristics showed content, structural, substantive and generalized validity. conclusion: clinically validating nursing diagnosis using rasch analysis makes it possible to establish dimensional diagnoses with construct validity. keywords mothers, parenting, validation studies, nursing diagnosis (source: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 176-187 177 impaired parenting in primiparous mothers: clinical validation through rasch analysis l luis carlos orozco-vargas and others año 15 vol. 15 nº 2 chía, colombia junio 2015 l 176-187 deterioro parental (00056) en madres primíparas: validación clínica a través del análisis de rasch resumen introducción. es necesario un instrumento válido que permita establecer el diagnóstico de enfermería deterioro parental (00056), y poder realizar intervenciones. objetivos. -validar el diagnóstico de enfermería “deterioro parental” mediante análisis rasch en madres primíparas hasta los 24 años de edad, durante el primer año de crianza. -comparar resultados de la validación clínica del diagnóstico entre el análisis rasch y el método fehring de validación clínica. métodos. estudio corte transversal. análisis rasch, según lineamientos de validación de constructo según messick. resultados. veintisiete ítems que representan 18 características definitorias mostraron validez de contenido, estructural, sustantiva y generalización. conclusión. validar clínicamente diagnósticos de enfermería mediante análisis rasch, permite establecer diagnósticos dimensionales con validez de constructo. palabras clave madres, crianza del niño, estudios de validación, diagnóstico de enfermería (fuente: decs, bireme). deficiência na criação em mães primigestas: validação clínica por meio da análise de rasch resumo introdução: é necessário um instrumento válido para ser capaz de estabelecer um diagnóstico de enfermagem da maternidade com deficiência e realizar intervenções. objetivo: o objetivo do presente estudo é validar o diagnóstico da enfermagem na criação deficiente por meio da análise de rasch em primigestas de até 24 anos de idade durante o primeiro ano da criação e para comparar os resultados da validação clínica desse diagnóstico usando a análise de rasch e o método proposto por fehring para a validação clínica do diagnóstico de enfermagem. método: realizou-se um estudo transversal com base na análise de rasch de acordo com as diretrizes de construto de messick. resultados: vinte e sete itens, que representam 18 características definidoras dos pais, mostraram uma validade de conteúdo, estrutural, substantiva e geral. conclusão: validar clinicamente diagnósticos de enfermagem por meio da análise de rasch permite o estabelecimento de diagnósticos dimensionais com validade de construto. palavras-chave mães, criação dos filhos, estudos de validação, diagnóstico de enfermagem (fonte: decs, bireme). 178 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 introduction adoption of the maternal role, according to ramona mercer, (1) is “an interactive process of continual evolution whereby the mother senses a bond developing between her and her child, acquires skills to provide the care associated with her role, and experiences pleasure and gratification in that role.” mercer’s theory (2) has four phases that occur during the first year of motherhood: a physical recovery phase that goes from birth to the end of the first month, a consecutive phase that goes from the second to the fifth month after birth, a disorganization phase between the sixth and eighth month, and, finally, a reorganization phase that starts in the eighth month and remains ongoing by the time the child is a year old. according to the results of the series of demographic and health surveys applied in colombia, the incidence of teen pregnancies in 2010 was 19.5%. this figure is evidence of a severe problem, considering that pregnancies during adolescence and young adulthood (15 to 24 years of age, according to the united nations) are generally neither planned nor desired, and have a negative impact on the physical and mental state of these young women for their adoption of motherhood. (3) after the child is born the mother faces a series of tasks when taking care of her child, while experiencing at the same time a range of hormonal and biological changes related to stages of increased psychological vulnerability, coupled with the changes particular to young women’s lives. (4) young primiparous mothers living with their parents (5) evidence the lowest levels of adoption of the maternal role. this is due, in part, to overprotection by the parents, which prevents these mothers from carrying out the activities needed for appropriate adoption of the maternal role, thus creating an uncertain future for the “mother-child” relationship and formation of the family nucleus. an impaired maternal role can affect child development, resulting in a higher frequency of abuse, infectious diseases, non-compliance with appropriate immunization schemes, and a decrease in exclusive breastfeeding. these aspects may even influence child mortality during the first year of life. (6) studies (7, 8, 9) in psychology and nursing have been conducted to measure parental competency, (10) parental efficacy, (11, 12) and perceptions about motherhood.(13) moreover, based on standardized language, nursing has proposed diagnoses of the parental role from the standpoint of both risk and well-being, such as risk of impaired parenting (00057), readiness to enhance the parental role (00164) conflict with the parental role (00064) and impaired parenting(00056). this last diagnosis: impaired parenting (00056: nanda, 20092011) (14), approved in 1978 and reviewed most recently in 1998, does not appear in the literature and lacks evidence. our review of the scientific literature yielded one study conducted in 2005 to determine the factors associated with impaired parenting. (15) taking into account that nurses can carry out interventions that favor adoption of the maternal role, a valid instrument is needed for them to establish these diagnoses and to plan and conduct interventions for this vulnerable group, thereby favoring maternal and child health and wellbeing. the methods currently used to validate nursing diagnoses are based on the four models proposed by fehring.(16) the one most commonly used is the expert content validation model; the least commonly used is the clinical validation model. however, fehring’s models do not allow for the diagnosis-defining construct to be validated. validation of a unidimensional construct to obtain a dimensional nursing diagnosis that may easily become a categorical diagnosis is possible only with the methodology proposed by rasch. (17) when the items on a questionnaire, in our case diagnosisdefining characteristics, fit the rasch model, a common interval level measure is obtained for both the items and the individuals. more than 20 papers published in nursing journals between 1985 and 2012 have recommended the use of rasch analysis to validate different constructs used in nursing. (28) taking the foregoing into account, this study focuses on validation of the nursing diagnosis of “impaired parenting” using rasch analysis in primiparous mothers 24 years of age and younger, during the first year of child rearing. objectives validate the nursing diagnosis of “impaired parenting” using rasch analysis in primiparous mothers 24 years of age and younger, during the first year of child rearing. 179 impaired parenting in primiparous mothers: clinical validation through rasch analysis l luis carlos orozco-vargas and others compare the results of clinical validation of the diagnosis using rasch analysis and the results using fehring’s clinical validation method. methods study design. a cross-sectional study was conducted. the inclusion criteria were: being a primiparous mother of a term newborn with no health issues, being 24 years of age or younger, and being in the first year of child rearing. the exclusion criteria were: communication impairment, mental abnormalities, and use of psychoactive substances. the study population included primiparous mothers, 24 years of age and younger, who were in their first year of child rearing and resided in the urban area of bucaramanga (santander). sample: the sample was composed of 301 mothers who met all the inclusion criteria and gave their informed consent. instrument: the study employed part of an instrument used previously, where the operational definitions of the diagnosis-defining characteristics were validated by six expert nurses (15). it is composed of 28 dichotomous items representing the 19 parenting-defining characteristics of the nursing diagnosis of “impaired parenting” (00056), as defined by nanda (2009-2011). three of those items are to be completed based on observations made by the researcher; the others are to be completed based on responses given by the mothers. the primary outcome was the inability of the primary caretaker to create, maintain, or regain an environment that promotes the child’s optimum growth and development .the variables (items) were 18 parenting-defining characteristics (table 1). additional variables were taken into account, such as the mother’s age, the age of the child, and the mother’s socioeconomic status and occupation. data collection procedure: all the study subjects, who gave their informed consent to participate, were from a third-level hospital. the database was created and doubly digitized into epi info 6.04d software to compare the data with the validate subprogram. the data were reviewed using the stata v10 program, followed by rasch analysis using winsteps (19) for the items used to assess the nursing diagnosis-defining characteristics. analysis: rasch analysis was used. its basic equation for dichotomous items states that a positive response for an item depends on both the ability of the individual and the difficulty of the item. its mathematical expression is: ln(p/1-p)=bn-di. with certain modifications in the equation, the model can be used with items rated as ordinals, such as likert scales. the rasch model is a probabilistic form of the conjoint measurement (20) that turns ordinal observations into interval measures; i.e., logits, which are the natural logarithm of the odds of a positive response. they can be transformed into scales that are easier for the user to comprehend, such as 0 to 100 scales. the model fit employs two statistics: the infit and the outfit, which are expressed both as mean-squares and as z values. the unidimensionality of the construct is obtained with an analysis of the principal components of the residuals resulting from a comparison between the expected and observed values. the marginal values obtained from the data matrix are used to calculate the difficulty of the items and the ability of the individuals, because these statistics are sufficient for estimating them. accordingly, the difficulty of the items and the ability of the individuals can being obtained independent of one another and in the same logit scale. unlike factor analysis and item-response theory, when one uses the rasch methodology the question is not: what model fits my data? but does my data fit the rasch model? (21, 22, 23) messick’s construct validation guidelines, (24) structured into the rasch methodology by wolfe smith, (25) were followed for this study. the aspects mentioned by messick concerning validity are presented as follows. substantive validity: consistency should be >40% (measures imply categories and categories imply measures).the study subjects’ standardized outfit should be within ±3z. content validity: the outfit mean square (mnsq) of the items should be between 0.5 and 1.5. these are the most productive limits to obtain the measure 25.31; the ideal value is 1. the correlation between items and measures should be >0.3, although for criterion measurements it may be any positive value. (26) structural validity: analysis of the principal components of the residuals is done to establish unidimensionality. these components should not show any specific pattern; the variance explained by the measures preferably should be>50% and the variance explained by the first contrast, <5.0%. in eigen values, the first contrast should be below two, and the loading ideally should be between -0.4 and +0.4. generalization validity: the separation (s) between individuals and items should be above 0.7, and the invariance should be demonstrated by the absence of differential functioning of the items (dif) when their measures are compared between mothers ≤19 years and ≥20 years of age, and the measures of the items between the individuals rated high and low in the original scale and any 180 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 other variable that is deemed relevant. the value to determine a uniform dif is a difference of more than 0.5 between the two groups in absolute values and with a p-value <0.05. multiple comparisons preferably should be made using the benjamini-hochberg technique. (27) fehring-rasch comparison: assuming perfect reproducibility of the presence of the nursing diagnosis-defining characteristics, their prevalence was used as the fehring clinical validity index, and a correlation analysis was conducted with spearman’s rho, drawing a histogram with the measures obtained using rasch analysis for the items. ethical aspects: colombian resolution 008430 on healthrelated research and research-related aspects of law 911 was taken into account. the study was approved by the ethics committee and was rated as risk-free research. findings the sample included 301 mothers. their mean age was 19 (in a range of 13-24).the mean age of their children was 6 months (in a range of 0.2-12).they came from socioeconomic brackets 1 (29%), 2 (52%) and 3 (19%).the most common occupation was housewife (87%). substantive validity: the consistency of the ratings was high, with the lowest value being 40%. only 0.9% (3 in 301) of the individuals exhibited a standardized oufit<-3 or >3. content validity: item adjustment (oufit mnsq) was between 1.32 and 0.57. all the item correlations measured were positive (table 2). structural validity: the analysis of the residuals with principal components showed the measures account for 9.8 eigen values, which represent 27%. the first contrast represents 2.6 eigen values. the load balancing graph failed to exhibit any clustering, and most values are between ± 0.5. generalization validity: separation is 1.30 for individuals and 5.84 for items. the separation of the individuals would allow for the formation of two strata. the “interaction deficit” item exhibited differential functioning when the sample was divided into two age groups: ≤19 years and ≥20 years. for younger mothers, this item exhibited a -0.75 difficulty, whereas it was 0.74 for mothers age 19 and older, thus resulting in a dif of -1.49 with p=0.0007 using mantel-hanzel, and p=0.00003 using welch’s test. benjamini-hochberg’s critical value was p=0.00089. this item was removed. the wright map showed the scale formed by the items is between -2.77 and +3.24 logits. the mothers obtained measures between -3.97 and +0.88; eight mothers with rates -5.26 were removed, as they were believed to pertain to a 2.7% floor phenomenon (figure1). fehring-rasch comparison: spearman’s rho was -1.0, and figure 2 shows there would be no primary nursing diagnosis-defining characteristics and only three of them would be secondary, should the validation be carried out using fehring´s method. discussion nanda mentions 24 parenting-defining characteristics that have not changed in the last three editions. five of these parenting-defining characteristics were not included in this study; namely, “child abandonment and child abuse,” as it is difficult to measure in a single interview; “inconsistent behavior management,” because it is contained in the parenting-defining characteristic of “inconsistent care:” “poor parent-child interaction” and “parent-child interaction deficit,” as these are contained in the parenting-defining characteristic of “mother-child interaction deficit,” which was evaluated. all of the 18 characteristics studied are parenting-defined. those pertaining to the infant/child were not taken into account, because most are a consequence of the “impaired parenting” nursing diagnosis. therefore, having clinically validated diagnoses strengthens scientific evidence for their use. if, moreover, there is a dimensional diagnosis, the study of that particular diagnosis and its associated factors is facilitated. the results of the aspects mentioned by messick; namely, substantive, content, structural, and generalization validities, are highly adequate. notwithstanding the above, the generalization validity of the items needs to be empirically confirmed with mothers 24 years of age and older who are multiparous and from different countries. there is no explanation for the finding concerning differential functioning with respect to the “impaired mother-child interaction” item, and no publications were found on this particular subject. the structural aspect showed the measures only account for a 27% variance, somewhat below the recommended figure; however, one has to recognize that there is no consensus on this aspect. 181 impaired parenting in primiparous mothers: clinical validation through rasch analysis l luis carlos orozco-vargas and others this is the first clinical validation study of the “impaired parenting” (00056) nursing diagnosis to establish construct validity measures using rasch analysis. it demonstrates that 27 items pertaining to 18 parenting-defining characteristics fit the rasch model and, therefore, are linear unidimensional interval measurements of the nursing diagnosis. several other nursing diagnosis validation studies using rasch analysis have been conducted in colombia: “caregiver role strain” (00061), (28) “risk to other-directed violence” (00138),(18) and “anxiety” (00146) (29). as with this study, they yielded results that are contrary to fehring’s analysis. finally, the reader is urged to continue validating nursing diagnoses using rasch analysis, which allows for dimensional diagnoses with construct validity. for a more detailed explanation of the rasch measurement model, the reader may consult and cite two references (30, 31): the journal of nursing measurement and the international journal of nursing studies. references 1. mercer r. becoming a mother versus maternal role attainment. journal of nursing scholarships, 2004; 36(3): 226-232. 2. mercer r. first-time motherhood: experiences from teens to forties. springer. new york, 1986; 299-314. 3. 3. observatorio asuntos de género. seguimiento a la política social del gobierno e indicadores poblacionales, con enfoque de género. salud sexual y reproductiva. bogotá, 2011. 4. farkas-klein ch. escala de evaluación parental (eep): desarrollo, propiedades psicométricas y aplicaciones. univ. psychol. bogotá, 2008; 7(2): 457-467. 5. garrido m, marchán m. adopción del rol materno en madres adolescentes primerizas según grupo de convivencia. rev. psicol. trujillo. perú, 2011; 13(1): 11-28. 6. ruiz y, cárdenas mh. lactancia materna encaje perfecto en la aceptación del rol materno en la adolescente embarazada. biblioteca lascasas, 2009; 5(6). available from http://www.indexf.com/lascasas/documentos/lc0495.php 7. porter cl, hsu hc. first-time mothers’ perceptions of efficacy during the transition to motherhood: links to infant temperament. journal of family psychology, 2003; 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38 (supl 2): 79-88. 16. fehring r. methods to validate nursing diagnoses. heart & lung, 1987;16 (5): 625-629. 182 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 17. rasch g. probabilistic models for some intelligence and attainment tests. copenhagen: danmarks paedogogiske institut; reprint, with foreword and afterword by b. d. wright. chicago: universitv of chicago press, 1980. 18. pinilla e, orozco lc, camargo fa, berrío ja, medina lx. bullying en adolescentes escolarizados: validación del diagnóstico de enfermería ‘riesgo de violencia dirigida a otros’. hacia la promoción de la salud, 2012; 45-58. 19. linacre jm. winsteps® rasch measurement computer program. version 3.73 chicago: winsteps.com, 2010. 20. fisher wp, wright bd. introduction to probabilistic conjoint measurement theory and applications, international journal of educational research, 1994; 21(6): 559–568. 21. smith ev, smith rm. introduction to rasch measurement: theory, models, and applications. maple grove, mn: jam press, 2004. 22. bezruczko n. rasch measurement in health sciences. maple grove, mn: jam press, 2005. 23. bond tg, fox cm. applying the rasch model: fundamental measurement in the human sciences. 2nd ed. lawrence erlbaum associates, publishers, 2007. 24. messick s. validity of psychological assessment. validation of inferences from person´s responses and performances as scientific inquiry into score meaning. american psychologist, 1995; 50(9): 741-749. 25. wolfe ew, smith ev, instrument development tools and activities for measure validation using rasch models: part i and part ii -instrument development tools. in smith ev, smith rm, editors. rasch measurement: advanced and specialized applications. maple grove: jam press, 2007; 202-290. 26. frisbie da. measurement 101: some fundamentals revisited. educational measurement: issues and practice. fall, 2005; 21-28. 27. thissen d, steinberg l, kuang d. quick and easy implementation of the benjamini-hochberg procedure for controlling the false positive rate in multiple comparisons. journal of educational and behavioral statistics, 2002; 27(1): 7783. 28. orozco lc. diagnósticos, rasch y algo más. memorias del congreso. speaking the same language: an international initiative for nursing diagnosis. sao paulo. brasil, 2011. 29. orozco lc. métodos para validação de diagnósticos de enfermagem modelo rasch. in: nanda internacional inc. pronanda: programa de atualização em diagnóstico de enfermagem. porto alegre: artmed panamericana, 2013. 30. smith ev, conrad km, chang k, piazza j. an introduction to rasch measurement for scale development and person assessment. journal of nursing measurement, 2002; 10(3): 189-206. 31. hagquist c, bruce m, gustavsson jp. using the rasch model in nursing research: an introduction and illustrative example. international journal of nursing studies, 2009, 46: 380–393. 183 impaired parenting in primiparous mothers: clinical validation through rasch analysis l luis carlos orozco-vargas and others table 1. defining characteristics (dc) and their operational definitions (od) of the “parenting: impaired” nursing diagnosis defining characteristics item # dc: inadequate attachment od: the mother expresses emotional bond alteration, for example the inability to play with her child. 18 dc: little cuddling od: lack of expression of the mother’s affection manifested in caresses, kisses, hugs, words, and actions. 14,15,16,17 dc: maternal-child interaction deficit od: the mother has no initiative to contact his child and ignores or avoids communication with him. 19 dc: negative statements about child od: the mother shows bad feelings toward the child. 13 dc: reports frustration of role inadequacy od: the mother expressed disappointment of what she hoped to be in her role as a mother 1 dc: child neglect od: child neglect is observed by the child not being vaccinated, not being served his/her physical or emotional needs, or lack of response to child's signals. 28 dc: frequently punitive od: the mother expresses physical measures of repression to correct misconduct of the child, by frequently hitting him or her. 21 dc: hostility to child od: the mother manifests aggressive feelings toward her child in the form of emotional violence, as is upset by everything the child does. 20 dc: rejection of child od: the mother avoids being with the child and attending to his/her care. 22 dc: inadequate child health maintenance od: the mother does not provide the necessary child care for a good health such as immunizations, breastfeeding, and attending growth and development support programs. 8,9,10 dc: reports inability to control child od: the mother states that the child cannot be controlled; the child does not follow instructions. 3 dc: inappropriate child care arrangements od: the mother states that caring for her child does not give her any pleasure. 7 dc: inappropriate caretaking skills od: the mother does not acquire the skills to provide appropriate care to the child, such as feeding, bathing and dressing, or soothing a crying child. 4,5,6 184 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 defining characteristics item # dc: inappropriate stimulation (visual, tactile, auditory) od: the mother does not perform actions that promote her child’s proper auditory, tactile and visual development. 23,24,25 dc: inconsistent and incoherent care od: the care provided by the mother is not commensurate to the child's needs. 26,27 dc: unsafe home environment od: the mother states that the place where the child lives or the surrounding him/her can endanger safety, for example stairs, slippery floors, balconies without railings, electric outlets easily accessible to children, among others. 12 dc: inflexibility in meeting the needs of the child od: the mother expresses that she is unable to cope with the changes that arise in meeting the child's needs, such as giving the child a bath at a time that is not the regular time. 11 dc: statements of inability to meet child´s needs od: the mother verbalizes that she cannot respond to the needs of the child, for example, she does not know why the child cries. 2 source: authors. 185 impaired parenting in primiparous mothers: clinical validation through rasch analysis l luis carlos orozco-vargas and others table 2. measurement items and values, oufit mnsw, item-measure correlation number item measure (se) outfit mnsq item-measure correlation 13 negative statements about child 3.24 (0.58) 1.25 0.04 8 inadequate child health maintenance (vaccination) 2.52 (0.42) 0.98 0.13 22 rejection of child 1.39 (0.26) 0.94 0.18 7 inappropriate child care arrangements 1.32 (0.25) 0.71 0.23 18 inadequate attachment 1.04 (0.23) 0.82 0.25 4 inappropriate caretaking skills, feeding 0.64(0.20) 0.84 0.29 27 inconsistent care 0.64 (0.20) 0.64 0.38 1 reports frustration or role inadequacy 0.53 (0.19) 0.78 0.32 24 inappropriate stimulation (tactile) 0.53(0.19) 0.57 0.43 5 inappropriate caretaking skills (bathing, dressing) 0.36 (0.18) 0.72 0.36 9 inadequate child health maintenance (breastfeeding) 0.30 (0.18) 1.04 0.24 23 inappropriate stimulation (auditory) 0.23 (0.17) 0.61 0.46 14 little cuddling (caresses) 0.20 (0.17) 0.93 0.32 15 little cuddling( kisses) 0.01 (0.16) 0.75 0.39 25 inappropriate stimulation (visual) -0.04 (0.16) 0.70 0.45 28 child neglect -0.10 (0.16) 0.89 0.37 16 little cuddling (words) -0.36(0.15) 1.01 0.32 26 incoherent care -0.36(0.15) 1.21 0.28 21 frequently punitive -0.38 (0.15) 0.80 0.42 10 inadequate child health maintenance (control) -0.45 (0.15) 0.97 0.33 17 little cuddling (hugs) -0.57 (0.14) 0.98 0.34 20 hostility to child -1.14 (0.13) 1.05 0.34 6 inappropriate caretaking skills (soothing) -1.27 (0.13) 1.12 0.37 11 inflexibility in meeting needs of child -1.27(0.13) 1.32 0.21 2 statements of inability to meet child´s needs -2.05 (0.13) 1.15 0.36 3 reports inability to control child -2.19 (0.13) 0.96 0.46 12 unsafe home environment -2.77 (0.14) 1.24 0.34 source: authors. 186 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 figure 1. wright map for rasch analysis: difficulty item/attributes individuals 187 impaired parenting in primiparous mothers: clinical validation through rasch analysis l luis carlos orozco-vargas and others figure 2. comparison of rasch measures and fehring clinical diagnostic validity (cdv) 173 186 relacion carga laboral de enfermería.indd 173 elizabeth romero-massa1 johana patricia lorduy-bolívar2 carmen pájaro-melgar3 carolina andrea pérez-duque4 relación entre la carga laboral de enfermería y la gravedad del paciente en unidades de cuidado intensivo de adultos 1 magíster en salud cardiovascular; docente asociada de la universidad de cartagena, cartagena, colombia. eromerom@unicartagena.edu.co. 2 enfermera, universidad de cartagena, cartagena, colombia. 3 enfermera, universidad de cartagena, cartagena, colombia. 4 enfermera, universidad de cartagena, cartagena, colombia. recibido: 15 de julio de 2010 aceptado: 10 de marzo de 2011 resumen objetivo: determinar la relación entre la demanda de carga laboral de enfermería y la gravedad del paciente en unidades de cuidados intensivos de adultos en la ciudad de cartagena, en el mes de julio de 2008. método: investigación de corte longitudinal. muestra de 42 pacientes, se obtuvieron registros tiss-28 y registros apache ii. se realizó el cálculo de media aritmética, desviación estándar y proporciones, así como el cálculo del coeficiente de correlación de pearson. resultados: participaron 42 pacientes; la media para la edad fue 58,2 años (ic 95% 52,1-64,4). el 51,3% fueron mujeres. se obtuvieron 42 calificaciones del apache ii al ingreso de los pacientes a la uci con un promedio de 28,9, de los cuales el 66,7% (28) tienen un mal pronóstico, y 188 calificaciones de tiss-28, con un promedio de 28,7 (ic 95% 25,7-31,7). el promedio de tiss de egreso fue de 25,7 (ic 95% 22,4-28,9) por paciente. el 61,9% de los pacientes perteneció a la clase iii. la razón enfermera/paciente clase iv fue de 0,57 inferior a 1:1(1). se encontró una asociación entre el apache ii y tiss-28 de 0,55 (0,501-0,75) y un coeficiente de determinación de 0,38 (p<0,05). conclusiones: existe una moderada correlación entre el tiss-28 y el apache ii dejando ver sobrecarga de trabajo de enfermería en las uci, lo que repercute en la atención directa al paciente crítico. palabras clave cuidados intensivos, carga de trabajo, índice de severidad de la enfermedad, enfermería. año 11 vol. 11 nº 2 chía, colombia agosto 2011 l 173-186 174 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 relationship between the nursing workload and the severity of the patient’s condition in adult intensive care units abstract objective: to determine the relationship between the demands of the nursing workload and the severity of the patient’s condition in adult intensive care units in the city of cartagena during july 2008. methodo: this is a longitudinal study with a sample comprised of 42 patients. tiss-28 (therapeutic intervention scoring system) and apache ii (acute physiology and chronic health evaluation) records were obtained. arithmetic average, standard deviation and proportions were calculated, as was the pearson correlation coefficient. results: in this study involving a total of 42 patients, the average age was 58.2 years (ic 95% 52.1-64.4), and 51.3 percent of the patients in the sample were women. forty-two (42) apache ii evaluations were obtained when the patients were admitted to the icu, with an average of 28.9, and 66.7 percent if the patients (28) have a poor prognosis. there were 188 tiss-28 scores, with an average of 28.7 (ic 95% 25.7 31.7) per patient. the average tiss upon release from the icu was 25.7 (95% ci 22.4 to 28.9) per patient. in all, 61.9 per cent of the patients were class iii. the nurse/ class iv patient ratio was 0.57 less than 1:1. the study found a relationship of 0.55 between apache ii and tiss-28. (0.501-0.75) and a coefficient of determination equal to 0.38 (p<0.05). conclusions: there is a moderate correlation between tiss-28 and apache ii that shows an overload of nursing work in intensive care units. this has repercussions on the direct care provided to critical patients. key words intensive care, workload, severity of illness index, nursing. 175 relación entre la carga laboral de enfermería y la gravedad del paciente en unidades de cuidado intensivo... l elizabeth romero-massa, johana patricia lorduy-bolívar et al. relação entre carga de trabalho de enfermagem e estado grave do paciente em unidades de cuidados intensivos para adultos resumo objetivo: determinar a relação entre a demanda por carga de trabalho de enfermagem e estado grave do paciente em unidades de cuidados intensivos para adultos na cidade de cartagena em julho de 2008. método: pesquisa longitudinal. amostra de 42 pacientes. lograram-se registros tiss-28 e apache ii. calculou-se a média aritmética, o desvio padrão e proporções, o cálculo do coeficiente de correlação de pearson. resultados: 42 pacientes participaram. a idade média foi de 58,2 anos (ic 95%, 52,1-64,4). o 51,3% eram mulheres. na uci obtiveram-se 42 registros de apache ii na admissão dos pacientes, com uma média de 28,9 no qual 66,7% (28) têm um mau prognóstico, e 188 do tiss-28 registros com uma média de 28,7 (ic 95%, 25,7-31,7). o tiss médio de saída foi de 25,7 (ic 95%, 22,4-28,9) por paciente. o 61,9% dos pacientes pertenciam à classe iii. a relação enfermeira/paciente foi 0,57 de classe iv, menos de 1:1 (1). entre apache ii e tiss-28 achou-se uma relação de 0,55 (0,501-0,75) e um coeficiente de determinação de 0,38 (p < 0,05). conclusões: existe correlação moderada entre o tiss-28 e ii apache, que mostra sobrecarga de trabalho de enfermagem nas uci. esta situação influência no atendimento direto de pacientes críticos. palavras-chave cuidados intensivos, carga de trabalho, índice de gravidade de doença, enfermagem. 176 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 introducción el profesional de enfermería juega un papel muy importante en las unidades de cuidado intensivo (uci) para garantizar la calidad en la atención de los pacientes. uno de los factores que inciden en esta calidad es la escasez del recurso humano de enfermería, por lo que se incrementa la carga de trabajo del personal presente. la atención del paciente crítico se ha convertido en un recurso sanitario convencional e imprescindible para dar cobertura a la alta frecuencia de procesos cardiovasculares y traumatismos, y a la alta demanda de atención urgente (1). determinar las cargas de trabajo, calcular el personal y la asignación de pacientes en la unidad de cuidado intensivo, apoyado en un método cuantitativo validado en otros contextos, se constituye en una herramienta para la gestión del cuidado y del servicio de enfermería. lo anterior permite hacer una aproximación objetiva al volumen de trabajo y el rendimiento real que el equipo de enfermería puede alcanzar para brindar cuidado ajustado a las necesidades de las personas hospitalizadas, de acuerdo con la gravedad de su problema de salud y con los recursos humanos y tecnológicos con los que se cuenta. de esta manera, se interviene directamente en la calidad del cuidado y en la satisfacción que el equipo de enfermería pueda experimentar (2). en el caso específico de la atención al paciente grave se han propuesto varios modelos de predicción de mortalidad (epec, mbc, apache i, ii, iii; glasgow, tiss, saps ii, mpm ii, mpmo, nems, nas, omega, pnr y otros), que establecen sus pronósticos de forma dinámica durante el curso de la evolución clínica y, aunque no existe un consenso mundial sobre cuál es el más efectivo, los autores coinciden en que “los modelos de pronósticos” ayudan a concentrar los esfuerzos en aquellos pacientes cuya probabilidad de beneficio sea mayor o tengan una recuperación con el menor número de secuelas posibles. adicionalmente, permiten comparar el funcionamiento adecuado de las uci, evaluar el empleo de nuevas tecnologías, así como el análisis comparativo de las terapéuticas protocolizadas con el fin de decidir cuándo deben limitarse o suspenderse las mismas (3). desde los inicios de la década de los setenta los investigadores han tratado de idear sistemas capaces de medir en forma objetiva, reproducible, fiable y sensible las actividades del personal dedicado a la atención de pacientes. los primeros esfuerzos corresponden al equipo dirigido por cullen y civetta en 1974 (4), quienes crearon y desarrollaron el sistema de puntuación therapeutic intervention scoring system (tiss) destinado a medir esfuerzo asistencial de enfermería, su complejidad, su valoración y el elevado período de tiempo que requería su cumplimiento en los pacientes críticos (5). el tiss-28 es un método para medir la intensidad de la carga de trabajo y establecer la relación enfermera-paciente adecuada. de acuerdo con las variables diagnósticas y terapéuticas brindadas al paciente puede medir: la gravedad de la enfermedad, el uso de las camas relacionado con la ocupación y gravedad de los pacientes, las necesidades de capacitación y dotación tecnológica del servicio, correlacionar el diagnóstico médico y el puntaje del tiss obtenido, y calcular algunos de los costos de la atención en unidades de cuidado intensivo (4, 6). la atención del paciente crítico se ha convertido en un recurso sanitario convencional e imprescindible para dar cobertura a la alta frecuencia de procesos cardiovasculares y traumatismos, y a la alta demanda de atención urgente. 177 relación entre la carga laboral de enfermería y la gravedad del paciente en unidades de cuidado intensivo... l elizabeth romero-massa, johana patricia lorduy-bolívar et al. el tiss se utilizó hasta la aparición del sistema appache como indicador de gravedad. desde su publicación en 1985, el apache ii (acute physiology and chronic health evaluation) ha sido uno de los sistemas más empleados para clasificar grupos de pacientes sobre la base de severidad de la enfermedad, la cual define la probabilidad de mortalidad. facilita el pronóstico de los pacientes graves ingresados en cuidados intensivos, a pesar de que se ha empleado utilizando las peores variables clínicas y de laboratorio después del ingreso (7). diferentes estudios han demostrado que existe relación entre el índice de gravedad apache ii con el esfuerzo terapéutico medido en la escala tiss (8), estos sistemas permiten seleccionar a los pacientes que deben ingresar a las uci y predecir la ocurrencia de mortalidad del paciente en estado crítico, por lo que es importante que se apliquen en todo tipo de unidades de cuidados intensivos, ya que son confiables y reproducibles en todo el mundo (9). varios investigadores han mostrado interés en el tema de la medición de la carga laboral y el cálculo de personal de enfermería utilizando los sistemas tiss28 y apache; díaz et al. (10) realizan la división por clases del tiss-28, observando faltantes de enfermeras en un promedio de 2,6 (33%) para atender un promedio de 9,9 pacientes de los cuales 3,8 correspondieron a pacientes clase iv y 6,0 a clase iii. el índice de gravedad estudiado a través del appache ii muestra que la población estudiada presenta valores elevados. los anteriores autores encuentran que la relación enfermera-paciente necesaria a nivel operativo, de acuerdo con la división por clases de pacientes estudiada, difiere de las planificadas en este servicio. existe un déficit de recursos humanos de enfermeros en relación con el trabajo real que se genera. cada unidad de enfermería soporta una media de 0,33 pacientes más de lo que sería operativo. las cargas de trabajo guardan relación directa con la severidad de la enfermedad medida por appache ii, y con el número de intervenciones terapéuticas medidas por el score de intervenciones terapéuticas (tiss-28) (10). la investigación de rodríguez et al. (11), que determina el índice enfermerapaciente a través del sistema de evaluación clínica en unidades de cuidados intensivos (tiss-28), obtuvo puntuaciones de 36 o más, lo que se traduce en complejidad de los cuidados de enfermería requeridos, ameritando la asignación de una enfermera por cada paciente, la cual fue modificándose; para el tercer día la relación cambió del 1:2 o 1:3 y los días de estancia no rebasaron los 5, con una significancia estadística de <0,001. las investigaciones en diferentes países no solo han generado un impacto para el personal de enfermería, pues sin duda la aplicación de estos sistemas de medición plantea beneficios para el usuario en cuanto a disminución de morbilidad, mortalidad, menor estadía en uci, lo que tendrá un impacto en los costos de las hospitalizaciones. ello implica una mejor planificación de los recursos humanos, la carga laboral y la asignación del personal; todos estos aspectos están relacionados con una gestión del cuidado (12). por último, ante la escasez de investigaciones en colombia sobre este tema, con la realización de este estudio se buscó determinar la relación entre la carga laboral de enfermería y la gravedad del existe un déficit de recursos humanos de enfermeros en relación con el trabajo real que se genera. cada unidad de enfermería soporta una media de 0,33 pacientes más de lo que sería operativo. 178 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 paciente en unidades de cuidados intensivos de adultos en la ciudad de cartagena, colombia, en el mes de julio de 2008. método estudio longitudinal, con una población constituida por 106 pacientes que ingresaron a tres unidades polivalentes de cuidado intensivo en la ciudad de cartagena; se excluyeron del estudio aquellos enfermos hospitalizados en la unidad por menos de 24 horas, y aquellos en los que no se consiguió la información completa. la muestra la constituyeron 42 pacientes mayores de 18 años que firmaron el consentimiento de participación voluntaria. se consignaron variables sociodemográficas. las enfermeras de las unidades de cuidados intensivos reportaron una formación académica homogénea dado que no se encontraron especialistas. la recolección de los datos se realizó mediante la aplicación del índice de gravedad medido por appache ii, y la severidad de intervenciones terapéuticas medidas por tiss-28. durante un mes calendario fue aplicado el tiss-28 diariamente en las horas de la mañana por enfermeras egresadas del pregrado de enfermería previamente capacitadas que laboraban en cada uci, teniendo en cuenta las intervenciones realizadas al paciente durante su estancia hospitalaria, y el apache ii fue aplicado por el personal médico al ingreso del paciente. el número de integrantes del equipo de enfermería asignados en 24 horas en las uci estudiadas fue de seis enfermeras: dos profesionales por turno, en dos turnos de seis horas y uno de doce horas. para establecer la relación enfermera-paciente esperada o adecuada en las uci, concebida como número de enfermeros en relación con el número de pacientes, estos últimos se clasificaron de acuerdo con el puntaje diario de tiss-28 de cada paciente en cuatro clases: i, ii, iii y iv. los enfermos clase i, con menos de 10 puntos, no requieren terapia intensiva o solo necesitan observación, y una razón enfermera-paciente 1:4 (0,25) es satisfactoria. los clase ii, o enfermos con 10-19 puntos, son pacientes en observación que pueden ser manejados con una razón 1:4 (0,25) por una enfermera especialista y una enfermera general. los enfermos clase iii estables, con 20-39 puntos, pueden ser atendidos junto con un enfermo clase ii en una razón 1:2 (0,5); de estar inestables pueden requerir una razón 1:1. finalmente, los enfermos clase iv, con 40 o más puntos, requieren una razón 1:1 (1) o 2:1 (2) (13). instrumentos el sistema simplificado de calificación de la intervención terapéutica (tiss-28), traducido por miranda (8), es una herramienta administrativa y de enfermería que permite fácil y rápidamente obtener datos comparativos que pueden emplearse con fines de manejo hospitalario, de personal humano y de recursos materiales. en europa se desarrolló y validó una versión simplificada, el tiss-28, en 22 uci alemanas con 1.820 pares válidos de registros de tiss-76 y tiss-28. los autores concluyen que el tiss-28 puede reemplazar a la versión original en la práctica clínica de la terapia intensiva (8). este formato tipo encuesta consta de siete apartados tipo likert, cada uno de ellos con varias actividades a las cuales se les asigna un puntaje (de 1 a 8: a mayor complejidad mayor puntaje) de acuerdo con la complejidad de la intervención terapéutica el sistema simplificado de calificación de la intervención terapéutica (tiss-28), traducido por miranda, es una herramienta administrativa y de enfermería que permite fácil y rápidamente obtener datos comparativos que pueden emplearse con fines de manejo hospitalario, de personal humano y de recursos materiales. 179 relación entre la carga laboral de enfermería y la gravedad del paciente en unidades de cuidado intensivo... l elizabeth romero-massa, johana patricia lorduy-bolívar et al. aplicada por el personal de enfermería; se realiza una sumatoria total de las actividades realizadas. el puntaje final del tiss-28 varía de un mínimo de cero a un máximo de 76 puntos (8). para el uso del tiss-28 se mantuvieron los siguientes lineamientos generales: a. los datos debían recabarse todos los días a la misma hora, por la mañana y por el mismo observador. b. se verificó si cada rubro del tiss-28 se había realizado en las 24 horas previas. c. se realizó un tiss-28 del turno previo cuando el enfermo egresó de la uci. d. el puntaje del tiss-28 debía disminuir conforme el enfermo mejorara y viceversa. si ocurrieran situaciones incongruentes debían buscarse errores en la captura o interpretación de la información. e. muchas intervenciones debían estar relacionadas y podían excluirse automáticamente, como ocurrió en el caso del manejo de la ventilación mecánica y cuando se evaluaba soporte de oxígeno. f. se verificó que los responsables de la recolección de la información estuvieran capacitados en cuidado crítico para que tuvieran un mejor juicio en la aplicación del sistema (8). acute physiology and chronic health evaluation (apache). en el año 1981 se comienza a trabajar a nivel mundial con índices pronósticos para determinar la severidad de la enfermedad. knaus describió el sistema como un índice pronóstico de gravedad, y demostró su efectividad predictiva en la supervivencia de este tipo de pacientes (14). posteriormente, el propio knaus (14) perfeccionó el sistema apache reduciendo el número de variables (apache ii), generalizándose su uso en la mayor parte de los servicios de medicina intensiva, como índice pronóstico de gravedad de la persona hospitalizada. la estructura del apache ii comprende la evaluación de 12 variables agudas, la edad según intervalos, los antecedentes del paciente y la causa de ingreso a uci. los peores valores del aps en las primeras 24 horas desde la admisión a uci son considerados para establecer los puntos del mismo. no se hacen ajustes posteriores al curso clínico del paciente (14). su puntuación varía de 0 a 71, se distribuye en los tres componentes: 1) amplitud de la alteración de 12 medidas fisiológicas (aps); 2) edad; 3) enfermedad crónica; a cada variable se le asigna un valor que va del 0 al 4 (15). el componente denominado chronic health evaluation califica la edad y el estado de salud previo. si existe inmunocompromiso, insuficiencia hepática, cardiaca, renal o respiratoria, y es sometido a un procedimiento quirúrgico programado, deberán sumarse 2 puntos al total, se asigna una puntuación (0-6) (a mayor edad mayor puntaje), pero si es sometido a un procedimiento de urgencias, deberán sumarse 5 puntos. al final se realiza la sumatoria de a+b+c, lo cual indica que a mayor puntaje mayor mortalidad esperada del paciente crítico (15). las puntuaciones se interpretan así: de 0 a 14 puntos buen pronóstico; de 15 a 24, riesgo1 elevado, y >25 muy alto riesgo, mal pronóstico. aunque la puntuación máxima posible del sistema apache ii es 180 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 71, apenas existe supervivencia sobrepasando los 55 puntos. el apache ii ha sido validado ampliamente y es usado en todo el mundo (15). de acuerdo con la resolución 008430 de 1993 del ministerio de salud de colombia, esta se consideró como una investigación sin riesgo, puesto que se emplearon métodos de estudio documental, y no se realizaron intervenciones o modificaciones de las variables fisiológicas, biológicas, psicológicas o sociales de los individuos que participaron en el estudio. se cumplió con todos los compromisos adquiridos con las instituciones y las personas participantes en torno al uso de la información con fines académicos. esta investigación fue aprobada por el comité de ética de la universidad de cartagena, y salvaguardó los principios éticos de beneficencia, justicia y respeto. los datos fueron analizados en el paquete estadístico para las ciencias sociales spss 15.0 (windows). para los datos categóricos se establecieron frecuencias y porcentajes, y para los datos cuantitativos se hallaron promedios y desviación estándar. a fin de encontrar asociaciones se realizó el cálculo del coeficiente de correlación de pearson considerando un nivel de significancia a un valor de p< 0,05. resultados inicialmente se incluyeron 49 pacientes, pero por traslado a otros servicios salieron 7 y quedaron 42. de los 42 pacientes que conformaron la muestra del estudio, 9 (21,4%) fueron de la uci 1, 18 (42,9%) de la uci 2, y 15 (35,7%) de la uci 3. el 51,3% eran mujeres, la edad promedio fue de 58,2 años (ic 95% 52,164,4). veinte pacientes (47,6%) provenían de otras instituciones; 13 (31%) entraron por urgencias, 7 (16,7%) por cirugía y 2 (4,8%) de servicios de hospitalización. los diagnósticos de ingreso a las uci fueron: enfermedad cardiovascular (30%), sepsis (8%), encefalopatías (14%), enfermedades respiratorias (14%), trastornos metabólicos (14%), trastornos hematológicos (6%), otras causas (14%). la estancia hospitalaria fue de 4,1 días (ic 95% 3,3-4,9 días) (tabla 1). en lo que concierne al apache ii en cuanto al ingreso de los pacientes a la uci, el puntaje promedio fue de 28,9 (ic 95% 25,5-32,4), de los cuales el 66,7% tenían un mal pronóstico y el 19% riesgo elevado (tabla 2). en total se realizaron 188 calificaciones de tiss, con un promedio de 28,7 por paciente (ic 95% 25,7-31,7), el mayor porcentaje de pacientes; el promedio de tiss de egreso fue de 25,7 (ic 95% 22,4-28,9) por paciente; 61,9% perteneció a la clase iii, le sigue en su orden la clase ii con el 21% (tabla 2). el promedio de tiss de egreso fue de 25,7 (ic 95% 22,4-28,9) por paciente. en cuanto a la relación enfermera/ paciente los resultados fueron discriminados según categoría de tiss-28. la razón encontrada para los pacientes clase ii fue de 0,44, superior a la norma que indica que enfermos con 10-19 puntos pueden ser manejados a una razón enfermera/ paciente de 1:4 (0,25) por una especialista y una general. en los pacientes clase iii la razón observada (0,15) fue inferior a la normatividad en la cual los enfermos clase iii estables, con 20-39 puntos, pueden ser atendidos junto con un enfermo clase ii en una razón 1:2 (0,5). de igual modo, la razón enfermera / paciente en la 181 relación entre la carga laboral de enfermería y la gravedad del paciente en unidades de cuidado intensivo... l elizabeth romero-massa, johana patricia lorduy-bolívar et al. clase iv fue de 0,57, la cual es inferior a la normatividad en la que pacientes con 40 o más puntos requieren una razón 1:1 (1) o 2:1 (2) (tabla 4). en el análisis bivariado se encontró una correlación directa moderada entre el apache ii y tiss-28 con un coeficiente de correlación de pearson de 0,55 (0,5010,75), y un coeficiente de determinación de 0,38 (p<0,05) (tabla 3). discusión la edad promedio del grupo fue de 58,2 años, estos datos son similares a los informados por sánchez y carrillo (13, 16), quienes encontraron la edad promedio de los pacientes en 56,9 y 58,6 años respectivamente; en este estudio hubo predominio del sexo femenino. contrario a estos hallazgos, cervantes del ángel (17) encuentra en su estudio mayoría de hombres (52,7%). los pacientes objeto del presente estudio provenían en de urgencias (31%), de cirugía (16,7%) y de servicios de hospitalización (4,8%); cervantes hizo hallazgos similares en su estudio en el que la población provino predominantemente de urgencias (58,3%), quirófano (35,7%) y hospitalización (6,0%) (17). lo anterior guarda concordancia con los diagnósticos de ingreso a las uci, en los que cervantes encontró en mayor grado la coronariopatía, le siguen en importancia la sepsis y los trastornos metabólicos (17). el índice de gravedad medido al ingreso a la unidad de cuidado intensivo a través del apache ii muestra que la población estudiada presentó valores elevados de gravedad con un promedio de 28,9, un gran porcentaje (66,7%) de los pacientes del presente estudio presentó puntuaciones altas en el apache ii, clasificados en el grupo de mal pronóstico. dato similar se presenta en el estudio de freitas (18), el puntaje apache ii en las primeras 24 horas, y la tasa de mortalidad real fueron elevados (58,2%), predominando en pacientes que presentaron puntaje apache ii de más de 20. recientemente se demostró que en pacientes con puntaje apache ii superior a 18 puntos la mortalidad es significativamente mayor comparados con aquellos que presentan valores menores (19). respecto a eso, la mayor demanda de atención de estos pacientes frente al ofrecimiento de un cuidado de mayor calidad —lo cual puede ser establecido con una mayor dedicación de tiempo por enfermería— puede ser un factor determinante en la reducción de la mortalidad. los estudios de cervantes del ángel y santos y carrillo mostraron promedios de apache inferiores con valores de 11,5, 11,6 y de 12,91 respectivamente (17, 20, 16). las calificaciones de tiss-28 fueron al inicio de 28,7 puntos. estos datos concuerdan con el estudio de sánchez et al., en el cual el valor medio de tiss-28 fue 26,5 + 8,5 (5-61) con una mediana de 25 puntos (13), al igual que santos, con un promedio de 27,2 (20). rodríguez observó, con base en la evaluación tiss-28, que todos los pacientes a su ingreso presentaron puntuaciones de 36 o más, lo que traduce la complejidad de los cuidados de enfermería requeridos, ameritando la asignación de una enfermera para cada paciente (11), la presente investigación muestra que los pacientes, de acuerdo con el puntaje diario de tiss-28, pertenecen en su mayoría (61,9%) a la clase iii (entre 20 a 39 puntos). lo anterior guarda similitud el índice de gravedad medido al ingreso a la unidad de cuidado intensivo a través del apache ii muestra que la población estudiada presentó valores elevados de gravedad con un promedio de 28,9. 182 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 con los resultados encontrados por díaz (10) en los que, de un promedio de 9,9 pacientes, el 6,0 correspondieron a pacientes clase iii y 3,8 a pacientes clase i. en su estudio, carrillo (16) encontró iguales promedios en pacientes clases iii y iv: 32,1% fueron clase iii (20-39 puntos) y 32,1% fueron clase iv (≥ 40 puntos). esto requiere de las enfermeras mayor compromiso para el cuidado, a mayor gravedad mayores actividades terapéuticas aumentando la carga operativa diaria en este servicio (5). las calificaciones de tiss-28 fueron al inicio de 28,7 puntos, y el promedio de tiss de egreso fue de 25,7 (ic 95% 22,428,9) por paciente. al respecto, matud (21) considera que los índices de clasificación de gravedad pueden ser útiles para los diversos grados de cuidado; analizar el tipo y la cantidad de recursos necesarios para asistir a los pacientes de acuerdo con el nivel de gravedad ha sido un mecanismo ampliamente utilizado en las uci. la relación enfermera/paciente en el grupo de personas de clases iii y iv fue de 0,15, inferior a la normatividad vigente que establece una razón de 1:2 (0,5). díaz (10) informa hallazgos similares encontrando una relación enfermera paciente con valores menores a 1:1 en toda la muestra (con una media de 0,81), faltando un 24% de integrantes del equipo de enfermería para alcanzar esta relación. al respecto, matud señala que determinar la mayor o menor necesidad de asistencia en enfermería, además de una buena clasificación, es de mucha utilidad para una aplicación más efectiva y racional de la terapéutica y probablemente para disminución de ingresos innecesarios, reduciendo costos y morbilidad, entre otros. es importante tener en cuenta que los servicios de enfermería se deben basar en la premisa de que los pacientes son individuos con diferentes necesidades de cuidado, los cuales varían día a día (21). el promedio de estancia hospitalaria informado en este estudio fue de 4,1 días; similar a estos resultados, rodríguez observa en el grupo de intervención —que consistió en asignarles a las enfermeras el número de pacientes de acuerdo con el puntaje obtenido— que los días de estancia no pasaron de 5, mientras que en el grupo control el 46% tuvo 5 o más días de estancia. esta diferencia fue estadísticamente significativa para una p<0,001 (11). la asignación enfermero-paciente según complejidad de los procedimientos de enfermería requeridos, evaluados por tiss-28, disminuye los días estancia de los pacientes en la unidad de cuidado crítico (10). reyes (22), en contraposición, reporta en su estudio estancias mayores a 6 días, siendo conveniente revisar diariamente las condiciones clínicas del enfermo para identificar el momento en que ya no puede recibir más beneficio durante la hospitalización, si ha alcanzado la homeostasis y el apoyo terapéutico es mínimo o el enfermo está tan deteriorado que intervenciones adicionales no harán más que prolongar su agonía. en el presente estudio se obtuvo una correlación directa moderada entre el apache ii y tiss-28. teniendo en cuenta la correlación directa encontrada entre la gravedad del paciente, definida por el puntaje obtenido con el apache ii, y la demanda de atención o esfuerzo de enfermería requerido, definida por el tiss-28, díaz encuentra el apache ii a las 24 horas de ingreso de los pacientes a la uci en un los sistemas de clasificación constituyen un punto de partida a la hora de distribuir cargas de trabajo en el ámbito de enfermería, parecen ser el mejor mecanismo para cuantificar los cuidados del área a un mismo grupo de pacientes que consumen igual cantidad de recursos. 183 relación entre la carga laboral de enfermería y la gravedad del paciente en unidades de cuidado intensivo... l elizabeth romero-massa, johana patricia lorduy-bolívar et al. promedio de 19,72, lo que se correlaciona con puntos tiss altos y días de internación prolongados. el valor de la media de puntos tiss manejados por enfermería en el cuidado del paciente crítico del centro de tratamiento intensivo (cti) del hospital de clínicas de uruguay, es de 39,7 puntos tiss, siendo superior a los puntos tiss manejables por un enfermero, cuyo valor es de 36,94 puntos tiss (10). se concluye que existe una moderada correlación entre la gravedad de los pacientes y los índices de esfuerzo terapéutico de enfermería requeridos (tiss-28 y el apache ii) dejando ver sobrecarga de trabajo de enfermería en las uci, dada por un promedio de enfermeras para la atención de pacientes en clase ii y iii inferior al ideal. los sistemas de clasificación constituyen un punto de partida a la hora de distribuir cargas de trabajo en el ámbito de enfermería, y parecen ser el mejor mecanismo para cuantificar los cuidados del área a un mismo grupo de pacientes que consumen igual cantidad de recursos; la asignación de enfermería acorde con necesidades reales y concretas de cada unidad de cuidado intensivo es una herramienta útil para la gestión de recursos que permitirá actuaciones científico-tecnológicas requeridas para un grupo de pacientes altamente complejos, lo que se traduce en menos complicaciones, menos secuelas, mejor calidad de vida y menos mortalidad. una limitación del estudio consistió en que los datos registrados en la aplicación de apache ii solo al ingreso del paciente a la uci, continuando con la aplicación del tiss-28 hasta el egreso del mismo, presentan un posible sesgo, lo que pudo subestimar la carga de trabajo en relación con la condición clínica de los pacientes, pues no se incluyeron todas las calificaciones de su gravedad. 184 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 referencias bibliográficas 1. moreno m. evaluación de la carga de trabajo de enfermería en uci; propuesta de un modelo informático. bol hosp viña del mar; dic. 2004. 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evaluación clínica (tiss28) rev enferm imss 2002; 10 (2): 73-78. 12. miranda r, nap r, rijk a, schaufell w, lapichino g. nursing activities score. critic care med 2003: 31 (2); 374-82. 13. sánchez l, reyes m, ector m, gonzález a, magdaleno m, gonzales m. validación del sistema simplificado de calificación de la intervención terapéutica (tiss-28) en población mexicana. estudio multicéntrico. rev mex de med critica 2000; 14 (6):191-196. 14. knaus wa, draper ea, wagner dp et al. apache ii. a severity of disease classification. crit care med 1985; 13 (10): 818-29. 15. civetta jm, hudson-civetta ja, kirton o, aragon c, salas c. further appraisal of apache ii limitations and potential. surg gynecol obstet 1992; 175: 195-203. 16. carrillo r, ramírez f, contreras n, gonzález a. clasificación de la intervención terapéutica (tiss-28) en la unidad de terapia intensiva de la fundación clínica médicasur. rev de la asoc mex de medicina crítica 2007; 21 (4): 245-265. 17. cervantes m, sánchez l, vergara r, ortiz j, ávila l, zenteno f. uso de recursos y su correlación con la gravedad de la enfermedad en la terapia intensiva. revista de la asociación mexicana de medicina crítica y terapia intensiva 2007; 21 (4): 165-169. 18. freitas e, perfil y gravedad de los pacientes de las unidades de terapia intensiva: aplicación prospectiva del puntaje apache ii. rev latino-am enfermagem 2010: 18 (3). 19. couto do, feijo car, aguiar sm, meneses fa. characteristics of patients with systemic lupus erythematosus admitted to the intensive care unit in a brazilian teaching hospital. rev bras ter intensiva 2008; 20 (3): 249-53. 20. santos c, sánchez n. enfermería en anestesia-reanimación-terapia del dolor. murcia, octubre del 2004. 21. matud mc, cos mj, díaz-prieto a, mayoral jm. la medida del nivel de cuidado de los pacientes de uci. comparación de métodos prn, tiss y apache. revista enfermería clínica 1992; 2 (2): 43-50. 22. reyes s, llerena m, martínez n, vignier d, fernández m. evaluación de la calidad en la atención al grave con el sistema pronóstico tiss-28, en la uci del hmc dr. carlos j. finlay. rev cub med int emerg 2008; 7 (1): 987-1001. 185 relación entre la carga laboral de enfermería y la gravedad del paciente en unidades de cuidado intensivo... l elizabeth romero-massa, johana patricia lorduy-bolívar et al. tabla 1. características sociodemográficas de los pacientes de estudio según uci variables uci 1 uci 2 uci 3 total (%) (%) (%) (%) sexo femenino 44 50 60 51,3 masculino 56 50 40 48,7 edad < 44 años 19 27 34 26,7 45-54 años 25 6 7 12,7 55-64 años 31 22 13 22,0 65-74 años 6 17 13 12,0 > 75 años 37 28 33 32,7 promedio 60, 31 56,72 57,87 57,2 desv. estándar 17,22 21,24 23,45 20,6 procedencia remitido 68 61 27 52,0 cirugía 19 0 33 17,3 hospitalización 13 0 0 4,3 urgencias 0 39 40 26,3 dx. ingreso enf. cardiovascular 25 25 44 31,3 sepsis 7 10 4 7,0 encefalopatías 25 10 9 14,7 enf. respiratorias 4 24 17 15,0 trastorno metabólico 14 21 4 13,0 trastorno hematológico 11 3 0 4,7 otros 14 7 22 14,3 estancia hospitalaria < 3 días 43 39 80 54,0 4-9 días 38 44 20 34,0 > 10 días 19 17 0 12,0 fuente: cálculos del autor. 186 año 11 vol. 11 nº 2 chía, colombia agosto 2011 aquichan issn 1657-5997 tabla 2. distribución porcentual de pacientes según apache ii y tiss-28 inicial clasificación apache ii n° (%) buen pronóstico 6 14,3 mal pronóstico 28 66,7 riesgo elevado 8 19,0 clasificación tiss-28 inicial n° (%) clase ii 9 21,4 clase iii 26 61,9 clase iv 7 16,7 total 42 100,0 fuente: cálculos del autor. tabla 3. promedio de los puntajes obtenidos con el apache y el tiss-28 inicial. correlación de pearson en cada una de las uci uci promedio de apache promedio de tiss-28 r inicial uci 1 13,2 21,0 0,28 uci 2 29,3 33,8 0,18 uci 3 37,9 36,6 0,47 total 28,9 32,1 0,55 fuente: cálculos del autor. tabla 4. razón enfermera/paciente establecida frente a razón enfermera/paciente encontrada, según tipo de paciente tiss-8 tiss-8 no. razón no. de razón inicial pacientes establecida enfermeras encontrada (durante 24 horas) clase ii 9 0,25 4 0,44 clase iii 26 0,5 4 0,15 clase iv 7 1 4 0,57 fuente: cálculos del autor. 363 372 efecto de un plan educativo.indd 363 diana marcela achury-saldaña1 sandra mónica rodríguez2 luisa fernanda achury-beltrán3 martha patricia padilla-velasco4 jenny marcela leuro-umaña5 maría angélica martínez6 jenny astrid soto-rodríguez7 yarisselle almonacid-lever8 ángela maría sosa9 liliana enith camargo-becerra10 efecto de un plan educativo en la capacidad de agencia de autocuidado del paciente con hipertensión arterial en una institución de segundo nivel11 1 enfermera. magíster en enfermería con énfasis en salud cardiovascular. profesor asociada, pontificia universidad javeriana (investigador principal), colombia. dachury@javeriana.edu.co 2 enfermera. magíster en política social. profesor instructor, pontificia universidad javeriana (investigador principal), colombia. smrodriguez@javeriana.edu.co 3 especialista en enfermería en cuidado crítico, pontificia universidad javeriana. profesor instructor, pontificia universidad javeriana (investigador principal). achuryl@javeriana.edu.co. 4 enfermera. supervisora prevención y promoción, colombia. mpadilla@javesalud.com.co 5 enfermera. departamento prevención y promoción javesalud (colaborador), colombia. jennyro16@yahoo.es 6 enfermera. departamento prevención y promoción, javesalud (colaborador), colombia. angelicamartinez1409@hotmail.com 7 enfermera. departamento prevención y promoción javesalud (colaborador), colombia. jennyro16@yahoo.es 8 enfermera. departamento prevención y promoción javesalud (colaborador), colombia. yarisselle@gmail.com 9 especialista en administración en salud. coordinadora de programas preventivos, javesalud (colaborador), colombia. amsosa@hotmail.com 10 enfermera. departamento prevención y promoción javesalud, colombia. lcamargo@javesalud.com.co 11 este artículo es el resultado de la segunda fase de un estudio perteneciente a la línea de investigación cuidado integral a las personas con enfermedades cardiovasculares del grupo conceptualización y práctica de la facultad de enfermería de la pontificia universidad javeriana. recibido: 23 de mayo de 2012 enviado a pares: 6 de febrero de 2013 aceptado por pares: 30 de septiembre de 2013 aprobado: 30 de septiembre de 2013 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 363-372 para citar este artí culo / to reference this article / para citar este artigo achury-saldaña, d., rodríguez, s. m., achury-beltrán, l. f., padilla-velasco, m. p., et al. (2013). efecto de un plan educativo en la capacidad de agencia de autocuidado del paciente con hipertensión arterial en una institución de segundo nivel. aquichan. vol. 13, no. 3, 363-372. resumen objetivo: el propósito de este estudio fue determinar el efecto de un plan educativo en la capacidad de agencia de autocuidado del paciente hipertenso en una institución de segundo nivel. materiales y métodos: se realizó un estudio de intervención pre y postest, con la participación de 83 pacientes con diagnóstico de hipertensión arterial, a quienes se les aplicó el instrumento “evaluación de la capacidad de agencia de autocuidado en el paciente hipertenso” al inicio del estudio y tres meses posteriores a la implementación del plan educativo. resultados: el plan educativo mejoró tanto la capacidad de agencia de autocuidado global como sus rangos, encontrando significancia estadística con un valor de probabilidad menor de 0,002 y de 0,0001 respectivamente. conclusiones: las intervenciones educativas estructuradas a partir de la identificación de las necesidades individuales de información, en conjunto con el empoderamiento del indivi364 aquichan issn 1657-5997 duo y el seguimiento por parte del profesional de enfermería, permiten alcanzar conductas permanentes de autocuidado que facilitan el autoconocimiento, la modificación del comportamiento así como la adquisición de conocimientos y habilidades. palabras clave hipertensión, autocuidado, educación, enfermería, pacientes. (fuente decs, bireme). effect of an educational plan on the self-care management capacity of hypertensive patients at a second-tier institution abstract objective: the purpose of this study was to determine the effect of an educational plan on the capacity of hypertensive patients at a second-tier institution to manage self-care. materials and methods: a pre -and post-intervention test was conducted with the participation of 83 patients who had been diagnosed with hypertension. an instrument entitled “assessment of self-care management capacity among hypertensive patients” was applied to this group at the beginning of the study and three months after implementation of the educational plan. results: the educational plan improved self-care management capacity overall and in the different ranges, showing a statistical significance with a probability value under 0.002 and 0.0001, respectively. conclusions: structured educational interventions based on identified individual needs, coupled with individual empowerment and monitoring done by nursing professionals, made it possible to achieve permanent behavior with respect to self-care, facilitating self-knowledge and changes in behavior patterns, in addition to the acquisition of skills and know-how. key words hypertension, self-care, education, nursing, patients. (source: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 363-372 365 efecto de un plan educativo en la capacidad de agencia de autocuidado del paciente con hipertensión arterial... l diana marcela achury-saldaña y otros. efeito de um programa educativo na capacidade de agência de autocuidado do paciente com hipertensão arterial em uma instituição segundo nível resumo objetivo: o propósito deste artigo foi determinar o efeito de um programa educativo na capacidade de agência de autocuidado do paciente hipertenso em uma instituição de segundo nível. materiais e métodos: realizou-se um estudo de intervenção pré e pós-teste, com a participação de 83 pacientes com diagnóstico de hipertensão arterial, aos quais se aplicou o instrumento “avaliação da capacidade de agência de autocuidado no paciente hipertenso” ao início do estudo e três meses posteriores à implementação do programa educativo. resultados: o programa educativo melhorou tanto a capacidade de agência de autocuidado global quanto suas faixas, constatando significância estatística com um valor de probabilidade menor de 0,002 e de 0,0001, respectivamente. conclusões: as intervenções educativas estruturadas a partir da identificação das necessidades individuais de informação, em conjunto com o empoderamento do indivíduo e o seguimento por parte do profissional de enfermagem, permitem atingir condutas permanentes de autocuidado que facilitam o autoconhecimento, a modificação do comportamento, bem como a aquisição de conhecimentos e habilidades. palavras-chave hipertensão, autocuidado, educação, enfermagem, pacientes. (fonte: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 363-372 366 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 introducción la hipertensión arterial se ha convertido en un problema de salud pública a nivel mundial, se estima que causa 7,6 millones de muertes prematuras (13,5 % del total) y pérdidas por 92 millones de dólares (6 % del total) de años de vida saludables (avisa) (1). según la encuesta nacional de demografía y salud (2), y los indicadores básicos de salud del 2010 (3), las enfermedades hipertensivas se constituyen como la cuarta causa de muerte en personas mayores de 65 años con predominio en mujeres. el manejo y control de esta enfermedad se encuentra como prioridad en los objetivos sanitarios de la organización mundial de la salud (oms), por este motivo el autocuidado se convierte en el principal elemento terapéutico de adecuado control de la enfermedad; sin embargo, alrededor del 53 % de la población hipertensa tiene un importante déficit en el autocuidado (4), convirtiéndose en la principal causa de reingresos hospitalarios y alteración de la calidad de vida en el paciente. algunas teóricas de enfermería, como dorothea orem, proponen que para que el paciente logre el autocuidado debe desarrollar una habilidad humana llamada “capacidad de agencia de autocuidado”, definida como el desarrollo de la compleja capacidad que permite a los adultos y adolescentes discernir los factores que deben ser controlados o tratados para regular su propio funcionamiento y desarrollo, y así decidir lo que puede y debería hacerse con respecto a la regulación para exponer los componentes de su demanda de autocuidado terapéutico y, finalmente, para realizar las actividades de cuidado determinadas a fin de cumplir sus requisitos de autocuidado a lo largo del tiempo (5). debido a lo anterior se ha buscado el desarrollo de una serie de estrategias orientadas a la prevención, el manejo y la minimización de complicaciones, en donde la educación es un componente esencial del cuidado de enfermería orientado hacia la promoción, la conservación y el restablecimiento de la salud. una de las herramientas es el plan educativo, un método de enseñanza por medio del cual se transmite información que responde a las necesidades individuales para generar un cambio de comportamiento que permita alcanzar objetivos terapéuticos, mejorar y mantener la calidad de vida, impedir las complicaciones y muertes conservando la autonomía y el empoderamiento del paciente (6). muchas investigaciones fortalecen esta definición, dentro de las cuales cabe resaltar dos estudios: el primero mostró que con el paso de los años el porcentaje de recursos que el sistema de salud invierte en los pacientes con entidades crónicas es mayor, llegando a ser hasta el 76 % de los recursos destinados a un 46 % de la población que busca servicios de salud (7). esto ha llevado a buscar estrategias para disminuir los costos sin alterar la calidad de los servicios prestados, dichas estrategias están centradas en la educación del paciente y su familia. un segundo estudio controlado y aleatorizado evaluó la importancia de una intervención educativa por parte de enfermería en el paciente con enfermedades crónicas y su familia, demostrando disminución en la mortalidad, en el número de reingresos y una disminución en los costos de manejo de los pacientes sometidos a la intervención (8). desde hace casi dos décadas se ha entendido la educación como la concepción de conocimiento y transmisión de información convirtiéndose en un sistema de educación pasiva y no participativa, este concepto ha generado que los profesionales de la salud generalicen y reduzcan las estrategias educativas únicamente al concepto de educación en salud sin importar el ámbito en el que se desarrolle o si existe o no la enfermedad; de ahí que el impacto de las intervenciones no haya sido tan efectivo y sigamos evidenciando un incremento en la incidencia y prevalencia de estas enfermedades. con lo anterior, el concepto y el direccionamiento de la educación no se puede reducir únicamente a la transmisión de información sino que, por el contrario, debe centrar su atención en la generación de habilidades y actitudes que produzcan el cambio de comportamiento necesario para alcanzar los objetivos terapéuticos a través de la potenciación del autocuidado y de la autonomía de la persona así como el refuerzo a largo plazo (9). vista así la necesidad de aplicación de algunas teorías de enfermería que permitan mejorar el cuidado al paciente con hipertensión arterial, dorotea orem plantea algunos elementos que debe tener en cuenta el profesional de enfermería en la elaboración de planes educativos, aplicando la teoría de sistema de apoyo educativo, en donde se destaca que la persona con hipertensión arterial se convierte en el sujeto de cuidado que necesita de asistencia para tomar una decisión, modificar un comportamiento o adquirir conocimiento y habilidad (10). este sistema permite desarrollar el cuidado centrado de tres formas: 367 efecto de un plan educativo en la capacidad de agencia de autocuidado del paciente con hipertensión arterial... l diana marcela achury-saldaña y otros. 1. ayuda a la familia a desarrollarse a sí misma como una unidad. 2. promueve el desarrollo de las capacidades del agente de cuidado. 3. favorece la observación y el análisis de las interrelaciones de las demandas terapéuticas entre los miembros de la familia, y los asiste en el planeamiento y la satisfacción de estas demandas, utilizando sus propios recursos. con este sistema de apoyo educativo la enfermera debe promover en el paciente la capacidad de conocer, analizar, deducir y actuar ante su enfermedad para reforzar sus conocimientos en el manejo del tratamiento farmacológico y no farmacológico. por otra parte, al revisar la literatura internacional y nacional se encuentran muy pocos estudios que evalúen el efecto de intervenciones educativas en el paciente con hipertensión arterial; adicionalmente, los pocos estudios encontrados muestran algunas limitaciones relacionadas con el tipo de diseño utilizado y el tamaño de la muestra; por esta razón el grupo de investigación se planteó la pregunta: ¿cuál es el efecto de un plan educativo en la capacidad de agencia de autocuidado del paciente con hipertensión arterial en una institución de segundo nivel durante el periodo comprendido de 2010-2011? materiales y métodos se realizó un estudio de intervención pre y postest con un único grupo de 83 pacientes hipertensos, siendo estos el mismo control. los pacientes asistieron a consulta ambulatoria en una institución de segundo nivel durante el periodo comprendido 2010-2011, en el cual se evaluó el efecto de un plan educativo para establecer la capacidad de agencia de autocuidado al inicio y transcurridos tres meses de la implementación del plan educativo. se utilizó un muestreo no probabilístico para la obtención de la muestra. procedimiento para la recolección de datos se utilizó el instrumento “evaluación de la capacidad de agencia de autocuidado en el paciente hipertenso” (11), el cual fue incluido en el software de la historia clínica de la institución de segundo nivel y aplicado durante la consulta de enfermería, previa autorización de la institución de salud y firma del consentimiento informado por cada participante. la duración de la aplicación del instrumento a cada uno de los participantes fue de aproximadamente 15-20 minutos y, posteriormente, el software determinaba de inmediato los niveles de capacidad de agencia de autocuidado en que se encontraba el paciente y permitía al profesional de enfermería identificar las necesidades educativas específicas de cada uno de los individuos. la aplicación del plan educativo requirió de la elaboración de una cartilla denominada cuida tu vida, que contenía las recomendaciones de autocuidado para el manejo de la enfermedad, la cual permitió entregar educación de forma verbal y escrita al paciente, promoviendo el autoestudio con el propósito de lograr su empoderamiento. para la elaboración de estas recomendaciones se tomó como referencia el vii consenso de hipertensión arterial de la joint commition y contó con la revisión de expertos de diferentes especialidades (nutrición, medicina, fisioterapia, psicología, enfermería). tres meses después de la intervención se realizó seguimiento al paciente y se aplicó nuevamente el instrumento. la información recolectada fue analizada con el programa spss versión 19.0, con el fin de determinar la diferencia de puntajes entre el pretest y el postest. se emplearon tres pruebas estadísticas: la t pareada como prueba paramétrica, la prueba signada de wilcoxon y el test de mcnemar como pruebas no paramétricas. los mecanismos de control de la calidad de la información que se tuvieron en cuenta fueron los siguientes: a) capacitación de las enfermeras que participaron en la aplicación del instrumento y el plan educativo, b) prueba piloto. instrumento el instrumento de aplicación fue elaborado por achury et al., cuenta con un grado de validez y confiabilidad de 0,75 (11) y está constituido por 17 ítems que determinan la capacidad global de agencia de autocuidado mediante una escala sumativa de tipo likert que consta de 5 opciones de respuesta en donde 1 es nunca, 2 es casi nunca, 3 es a veces, 4 es casi siempre y 5 es siempre, lo cual permite determinar el rango para evaluar grado de capacidad de agencia de autocuidado (tabla 1). 368 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 tabla 1. rangos ponderales para evaluar nivel de capacidad de agencia de autocuidado los resultados del estudio mostraron que predominó entre los participantes el sexo femenino con un 74,7 %, la ocupación de jubilación con un 51,8 %, seguido del hogar con un 33,8 %, la formación de bachillerato con un 62,6 %, seguido de la primaria con un 24,1 % y la red de apoyo familiar con un 52 %. 2. análisis global de la capacidad de agencia de autocuidado de los pacientes con hipertensión arterial pre y posintervención educativa (tabla3). el análisis de los resultados del estudio en términos del cambio de la capacidad de agencia de autocuidado global de los pacientes hipertensos posintervención se realizó mediante la aplicación de la t pareada como prueba paramétrica y la prueba signada de wilcoxon como no paramétrica. tabla 3. análisis global de la capacidad de agencia de autocuidado de los pacientes con hipertensión arterial pre y posintervención educativa fuente: instrumento evaluación capacidad agencia de autocuidado en el paciente hipertenso. resultados 1. descripción de variables sociodemográficas en los pacientes con hipertensión arterial (tabla 2). tabla 2. descripción de variables sociodemográficas en los pacientes con hipertensión arterial puntaje capacidad de agencia de autocuidado 17-28 baja 29-56 media 57-85 alta sexo frecuencia porcentaje femenino 62 74,7 masculino 21 25,3 ocupación frecuencia porcentaje jubilado 43 51,8 hogar 28 33,8 empleado 4 6,8 independiente 8 9,6 escolaridad frecuencia porcentaje primaria 20 24,1 bachillerato 38 62,6 universitario 14 14,5 ninguna 11 13,2 red de apoyo frecuencia porcentaje familia 44 53 grupo religioso 14 16,9 grupo hospitalario 15 18,1 ninguno 11 13,2 fuente: resultados del estudio. muestra n = 83 media desviación estándar valor p preintervención 51,72 8,68 posintervención 56,35 8,12 < 0,00233 fuente: resultados del estudio. los resultados encontrados indican que el plan educativo mejoró la capacidad de agencia de autocuidado encontrando significancia estadística ya que el valor de probabilidad fue menor de 0,002, este resultado se reconfirmó con la prueba de rango signado de wilcoxon. 3. descripción del efecto del plan educativo en los rangos de capacidad de agencia de autocuidado. tabla 4. cambio de rango en la capacidad de agencia de autocuidado rango preintervención rango posintervención muestra (n = 83) medio alto medio 59 44 15 alto 24 0 24 fuente: resultados del estudio. 369 efecto de un plan educativo en la capacidad de agencia de autocuidado del paciente con hipertensión arterial... l diana marcela achury-saldaña y otros. el plan educativo generó un cambio significativo en los rangos de capacidad de agencia de autocuidado (p de 0,0001), puesto que en los resultados preintervención se observó que 59 pacientes tenían un autocuidado medio y 24 un autocuidado alto; posterior a la intervención educativa de los 59 pacientes que se encontraban en rango medio 15 pasaron a rango alto y 44 continuaron en el mismo rango, de la misma forma que se mantuvieron los 24 pacientes que se encontraban inicialmente en rango alto (tabla 4). 4. ítems que mostraron un cambio en la capacidad de agencia de autocuidado posterior a la aplicación del plan educativo. con el propósito de conocer los aspectos que permiten orientar un cuidado de enfermería que promueva y fortalezca la capacidad de agencia de autocuidado en los pacientes con hipertensión arterial, la tabla 5 presenta el comportamiento de los ítems que mostraron un cambio estadísticamente significativo posterior a la aplicación del plan educativo. tabla 5. ítems que mostraron un cambio en la capacidad de agencia de autocuidado posterior a la aplicación del plan educativo en la tabla 5 se puede observar que el plan educativo produjo un cambio estadísticamente significativo en 15 de los 17 ítems del instrumento, evidenciando mejoría de los aspectos relacionados con el autocuidado; sin embargo, los ítems 16 y 17 no mostraron ningún cambio. discusión los pacientes incluidos en el estudio corresponden en su mayoría al sexo femenino, datos que concuerdan con los indicadores de salud del 2010 (3), en donde se evidencia claramente que las enfermedades hipertensivas predominan en este sexo, situación de género relevante para el profesional de enfermería en el direccionamiento que realiza a las intervenciones que hacen parte de los planes educativos impartidos a la población en general, ya que históricamente la mujer ha adoptado un rol relevante como cuidadora de otros, lo cual ha generado en ella bajos conceptos de autonomía, autoconcepto y autoestima, aspectos que influyen de forma importante en la manera de asumir su autocuidado (12). asimismo, gran parte de los participantes se dedicaban al hogar o se encontraban jubilados, su red de apoyo era la familia y la escolaridad en su mayoría era de secundaria o primaria, resultados que coinciden con otros estudios realizados (13, 14). estas variables se correlacionan con investigaciones (13, 15-18) en donde se ha evidenciado que pueden convertirse en factores que tienden a favorecer un incremento en la capacidad de agencia de autocuidado en la medida que un nivel alto de escolaridad permite desarrollar más fácilmente actividades que promuevan un mejor autocuidado, y la red de apoyo se convierte en el principal elemento de motivación para el paciente en el manejo de la enfermedad; de la misma manera, el hogar y la jubilación podrían generar mayor tiempo de dedicación para ejercer las actividades de autocuidado puesto que sus responsabilidades laborales son menores y cuenta con más tiempo para sí mismo. se observó que posterior a la intervención educativa realizada en la consulta de enfermería se presentó un cambio estadísticamente significativo en la capacidad global y en los rangos de agencia de autocuidado (medio-alto); es importante resaltar que aunque algunos pacientes se mantuvieron en los rangos medio y alto tanto en el pre como en el postest, aun manteniéndose en el mismo rango se evidenciaron incrementos en la puntuación posintervención. este resultado comprueba la importancia de utilizar la educación orientada a satisfacer las necesidades individuales, ítems p 1 cuando duermo 6-8 horas diarias me siento descansado. 0,0109 2 invierto tiempo en mi cuidado. 0,000002 3 considero importante realizar ejercicio. 0,0028 4 busco información y orientación sobre el manejo de mi enfermedad. 0,0000000006 5 considero que conozco cómo actúan y las reacciones desfavorables de los medicamentos. 0,00000000003 6 solicito información necesaria para la correcta administración de los medicamentos nuevos. 0,0003 7 considero que la cantidad máxima de sal que puedo utilizar para todo el día son dos cucharaditas. 0,000004 8 reemplazo mi tratamiento por terapias alternativas. 0,0094 9 considero que el profesional de enfermería me escucha y aclara mis inquietudes. 0,0002 10 conozco las complicaciones derivadas de la enfermedad. 0,0000003 11 camino diariamente como mínimo 30 minutos. 0,0005 12 realizo cambios para mantener la salud y manejar adecuadamente la enfermedad. 0,0001 13 realizo cambios en mi dieta para mantener un peso adecuado 0,000006 14 evalúo si el manejo de mi enfermedad permite garantizar mi bienestar y el de mi familia 0,000002 15 consumo en mi dieta comidas ricas en verduras, frutas, fibra y baja en grasas 0,000006 fuente: resultados del estudio. 370 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 así como a desarrollar habilidades y actitudes que produzcan un cambio de comportamiento suficiente para alcanzar los objetivos terapéuticos (19). adicionalmente, el seguimiento se convierte en una herramienta complementaria a la intervención educativa, la cual debe realizarse de forma continua y no solo a corto sino a mediano y largo plazo para fomentar el mantenimiento en los cambios de la capacidad de agencia de autocuidado (14); estas dos herramientas permiten promover la adaptación de la enfermedad y el empoderamiento en el paciente. estos resultados concuerdan con los datos de algunos estudios en donde la consulta de enfermería es una modalidad de atención que permite dar educación, punto esencial en el quehacer profesional y, además, hacer el acompañamiento que permita reforzar el autocuidado en los pacientes (14). de la misma forma, los resultados obtenidos por fernández (20) en su estudio demuestran que la aplicación de una intervención educativa estructurada mejora la agencia de autocuidado de los pacientes con hipertensión arterial y con ello el pronóstico de la enfermedad. cabe destacar que 15 de los 17 ítems del instrumento mostraron una mejoría estadísticamente significativa posintervención; sin embargo, los ítems que revelaron mayor significancia estadística estuvieron relacionados con la búsqueda de información y orientación sobre la enfermedad, el conocimiento de los mecanismos de acción y efectos secundarios de los medicamentos, así como la toma correcta de los mismos, el uso adecuado de la cantidad de sal y el conocimiento de las complicaciones derivadas de la enfermedad, aspectos que se consideran indispensables en el manejo y control de los pacientes hipertensos. la búsqueda de la información le permite al paciente conocer y manejar su enfermedad y desempeñar un papel activo en su autocuidado, logrando la adherencia al tratamiento farmacológico y no farmacológico (21, 22), de forma que el conocimiento del tratamiento farmacológico se constituye en una directriz que permite mejorar la calidad de vida, reducir complicaciones y la progresión de la enfermedad (23). lograr que el paciente use adecuadamente la sal en su dieta es indicador de una apropiada información y comprensión, puesto que los estudios han mostrado que una de las mayores dificultades en el manejo de la hipertensión arterial es el uso adecuado de sal, debido a que una reducción de sodio puede disminuir 3,9 mm/hg la presión sistólica y 1,9 mm/hg la presión diastólica (13). por otra parte, se encontró que los ítems que no mostraron ningún cambio estuvieron relacionados con el acceso a los controles, las consultas y los medicamentos, así como con el desarrollo de la vida sexual. el ítem 16 relacionado con el acceso a las consultas, los controles y la adquisición de medicamentos no mostró un cambio posterior a la intervención educativa, probablemente porque la educación no es suficiente, puesto que este ítem se convierte en un aspecto derivado del funcionamiento de las ips y del actual sistema de salud, de forma que si las directivas no desarrollan estrategias que permitan dar solución oportuna generarán desmotivación para el paciente lo cual repercutiría de forma negativa en su autocuidado. la literatura evidencia que estas dificultades se convierten en factores que pueden comprometer el autocuidado y la adherencia que tienen los pacientes al tratamiento, pues el adecuado control de la hipertensión arterial depende de la disponibilidad de medicamentos que se tengan y los ajustes realizados a la medicación y al resto de conductas no farmacológicas que como parte del tratamiento se promueven en los controles médicos, lo cual finalmente tiene un impacto positivo en la reducción de las complicaciones cardiovasculares que como consecuencia de la hipertensión arterial se puedan producir (24). el ítem 17 que indagó sobre las dificultades en el desarrollo de la vida sexual tampoco mostró ningún cambio, de manera que algunos pacientes preintervención referían que su enfermedad podría estar generando dificultades en su sexualidad. es probable que este aspecto, fundamental en el ser humano, no pueda ser abordado y explorado de una forma tan fácil como otros aspectos del manejo en la hipertensión arterial, y una intervención educativa no alcanza a dar solución a los problemas de disfunción sexual que podrían estar presentado los pacientes. algunos estudios confirman este hallazgo destacando que es un aspecto inexplorado todavía y que genera incomodidad en los pacientes encuestados; sin embargo, es una situación que no se debe descuidar pues los estudios demuestran importantes tasas de incidencia y prevalencia de dificultades en la vida sexual en la población hipertensa (25-27). conclusiones las variables sociodemográficas que mostraron una mayor frecuencia fueron el género femenino, la jubilación, los estudios secundarios o técnicos y la red de apoyo familiar. 371 efecto de un plan educativo en la capacidad de agencia de autocuidado del paciente con hipertensión arterial... l diana marcela achury-saldaña y otros. el plan educativo generó un cambio estadísticamente significativo en la capacidad de agencia de autocuidado global de los pacientes con hipertensión arterial, así como en los cambios del rango de autocuidado. el plan educativo generó un cambio estadísticamente significativo en los ítems del 1-15 del instrumento, destacando aquellos relacionados con la búsqueda de la información sobre la enfermedad, el conocimiento de los medicamentos y el consumo de sal. los ítems que no mostraron cambio con la aplicación del plan estuvieron relacionados con el acceso a las consultas y la sexualidad. una intervención educativa estructurada y orientada específicamente a las necesidades individuales del paciente con hipertensión arterial, en conjunto con el autoestudio, la motivación y el empoderamiento del paciente, así como con un adecuado seguimiento por parte del profesional de enfermería, consigue una mejoría en la capacidad de agencia de autocuidado y, con ello, en la calidad de vida, disminución de las complicaciones y de los reingresos hospitalarios. recomendaciones implementar en la práctica profesional instrumentos que se conviertan en herramientas que direccionen las acciones de enfermería y sean un insumo para el desarrollo de investigación. realizar estudios de investigación con muestras más amplias, seguimientos a largo plazo y diseños de tipo experimental que permitan determinar la persistencia de los cambios generados por el plan educativo. los ítems que no generaron cambio estadísticamente significativo requieren de mayor investigación. agradecimientos a javesalud, doctor iván gonzález ortiz, doctor carlos tobar, enfermera ángela sosa, enfermera marta padilla, y a todo su grupo, por su apoyo permanente en el desarrollo del estudio y por permitir el acercamiento a los 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3 enfermeira. universidade federal do ceará, brasil. jessica_lc14@msn.com 4 enfermeira. universidade federal do ceará, brasil. lalah_zinha3@hotmail.com 5 doutorado em enfermagem. universidade federal do ceará, brasil. anakelve@hotmail.com 6 doutorado em enfermagem. universidade federal do ceará, brasil. escolpaz@yahoo.com.br recibido: 10 de febrero de 2014 enviado a pares: 23 de marzo de 2014 aceptado por pares: 16 de septiembre de 2015 aprobado: 23 de septiembre de 2015 doi: 10.5294/aqui.2015.15.4.3 para citar este artículo / to reference this article / para citar este artigo moraes jlm, machado carrion pm, carneiro jl, beserra ra, castro ak, ferreira moura er. conhecimento de puérperas acerca do método anticoncepcional da lactação com amenorreia. aquichan. 2015; 15 (4): 475-485. doi: 10.5294/aqui.2015.15.4.3 resumo objetivo: verificar o conhecimento de puérperas acerca do método anticoncepcional da lactação com amenorreia (lam). materiais e métodos: pesquisa transversal, realizada com 278 puérperas internadas em alojamento conjunto de maternidade de referência de fortaleza, ceará, nordeste do brasil, de fevereiro a maio de 2012. resultados: identificou-se que 131 (47,1 %) haviam ouvido falar sobre a lam e, destas, 58 (44,3 %) declararam conhecê-la antes da gravidez e 56 (42,7 %) no pré-natal; 94 (71,6 %) puérperas desacreditavam na sua eficácia e 100 (76,3 %) desconheciam os critérios para uso seguro. a fonte de informações sobre o método para 43 (32,8 %) puérperas foi amigos, familiares ou conhecidos, ou seja, de modo informal, e 71 (54,1 %) não foram orientadas por profissionais da saúde. conclusões: lacunas no conhecimento de puérperas geram baixo uso e uso incorreto da lam; também se destaca o elevado percentual de puérperas sem orientações por parte de profissionais da saúde. palavras-chave lactação, amenorreia, conhecimento, obstetrícia, gravidez (fonte: decs, bireme). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 475-485 476 aquichan issn 1657-5997 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 475-485 conocimiento de puérperas acerca del método de amenorrea de la lactancia como recurso anticonceptivo resumen objetivo: verificar el nivel de conocimiento de puérperas acerca del método de amenorrea de la lactancia (mela) como recurso anticonceptivo. materiales y método: investigación transversal realizada con 278 puérperas internadas en una maternidad de referencia de fortaleza (ceará, noreste de brasil), de febrero a mayo del 2012. resultados: se encontró que 131 (47,1 %) habían oído sobre el mela y, de ellas, 58 (44,3 %) declararon conocerlo antes del embarazo y 56 (42,7 %) en el prenatal; 94 (71,6 %) puérperas no creen en su eficacia y 100 (76,3 %) desconocían los criterios para uso seguro. la fuente de informaciones acerca del método para 43 (32,8 %) puérperas fue amigos, familiares o conocidos, es decir, de modo informal, y 71 (54,1 %) no recibieron orientación de profesionales de la salud. conclusiones: vacíos en el conocimiento de puérperas generan bajo uso y uso incorrecto del mela; igualmente se destaca el elevado porcentaje de puérperas sin orientación por parte de profesionales de la salud. palabras clave lactancia, amenorrea, conocimiento, obstetricia, embarazo (fuente: decs, bireme). 477 conhecimento de puérperas acerca do método anticoncepcional da lactação com amenorreia l jamile lopes de moraes moraes y otros knowledge of lactational amenorrhea as a contraceptive method abstract objective: verify what new mothers know about lactational amenorrhea (lam) as a method of contraception. materials and method: this is a transversal study conducted between february and may 2012 with 278 postpartum patients at a maternity unit in fortaleza (ceara, northeastern brazil). results: it was found that 131 (47.1%) of the women had heard about lam, including 58 (44.3%) who stated they knew about it before pregnancy and 56 (42.7%) who learned of it during the prenatal stage; 94 (71.6%) do not believe it is effective and 100 (76.3%) were unaware of the criteria for using it safely. forty-three (32.8%) of the postpartum women in the sample learned about lam from, relatives or acquaintances; that is, informally, and 71 (54.1%) stated they had received no guidance on lam from health professionals. conclusions: gaps in what mothers know have led to limited use and misuse of lam. the study also brings to light the high percentage of postpartum patients who lack guidance from health professionals. keywords lactation amenorrhea, knowledge, obstetrics, pregnancy (source: decs, bireme). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 475-485 478 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 introdução é de consenso mundial que os profissionais de saúde devem incentivar o aleitamento materno exclusivo (ame) nos primeiros seis meses pós-parto. nesse contexto, eles são os responsáveis por apresentar os benefícios da amamentação para a mãe e/ou família e orientá-la quanto ao uso do método da lactação com amenorreia (lam). por ser um método natural de inibição da fertilidade que estimula o ame, pode ser utilizado isoladamente ou associado com outro método anticoncepcional (mac) que não interfira na amamentação (1). a lam é um mac com 98% de eficácia, desde que seguidos corretamente os critérios de amenorreia pós-parto, criança com idade de até seis meses e amamentação materna integral ou quase integral (2). apesar dos benefícios da lam e de sua eficácia equiparada a de outros macs mais eficazes e amplamente utilizados, o método ainda tem pouca aceitação por parte das mulheres devido ao ceticismo relacionado com sua baixa eficácia (3). essa realidade pode estar associada com a falta de conhecimento por parte das mulheres no que se refere à lam como mac e seu uso correto. estudo realizado nas enfermarias de ginecologia e obstetrícia do hospital de clínicas da universidade federal do triângulo mineiro (brasil) com 358 puérperas apontou que apenas 0,3 % das mulheres tinha intenção em utilizar a lam como mac (4). em contrapartida, pesquisa realizada em níger (áfrica ocidental), com 673 mulheres, evidenciou o uso da lam como principal método de contracepção por 52 % da amostra, porém apenas 21 % das mulheres usavam a lam corretamente (5). pesquisa realizada em fortaleza (ceará, nordeste do brasil), na qual foram ouvidos 137 enfermeiros da estratégia saúde da família (esf), evidenciou que a maior parte das mulheres aceita parcialmente a lam, uma vez que, ao final do aconselhamento, solicitam um mac complementar, inseguras com a sua eficácia (3). esses achados reforçam a necessidade de abordar essa lacuna de conhecimento visto que, se usado corretamente, a lam pode ser uma ferramenta valiosa de planejamento familiar, particularmente em países em desenvolvimento (5). considerando que o uso da lam traz benefícios à saúde materna e infantil e que a puérpera deve dispor de conhecimento satisfatório para utilizá-la corretamente, decidiu-se pela realização da presente pesquisa de modo a responder ao questionamento: o que puérperas de um alojamento conjunto de maternidade de referência sabem sobre a lam? referencial teórico visando dar sustentação teórica à pesquisa, utilizou-se a teoria de interação social do psicólogo russo lev seminovitch vygotsky, também chamada de construtivismo. essa teoria defende que a interação social pode ser entendida como a troca de informação entre pelo menos duas pessoas, na qual deve ocorrer a reciprocidade entre os envolvidos (6). vygotsky acredita que os indivíduos nascem dotados de funções psicológicas elementares nas quais a interação social é o canal que as transformam em funções psicológicas superiores. de acordo com essa concepção teórica, a interação social é tida como uma forma de troca de informações em que os participantes devem apresentar níveis cognitivos semelhantes que visem facilitar o processo de ensino-aprendizagem (6). materiais e método estudo transversal, desenvolvido em alojamento conjunto de maternidade de referência do sistema público de saúde de fortaleza (ceará, nordeste do brasil). a população foi constituída por puérperas internadas no referido alojamento conjunto de fevereiro a maio de 2012. a coleta de dados foi realizada em 60 dias, cuja população estimada de passar no serviço nesse número de dias foi de 1.000 puérperas já que foi considerada uma média de 500 partos/mês nessa maternidade, conforme dados da própria instituição. a amostra foi calculada aplicando-se a fórmula para cálculos com populações finitas, com intervalo de confiança de 95 %, erro máximo permitido de 0,05 e uma prevalência do fenômeno de 50 %, o que totaliza 278 puérperas. foram excluídas as mulheres que não se apresentavam aptas a responder à entrevista devido a complicações do parto. a coleta de dados foi realizada três vezes por semana (conveniência) por meio de formulário que continha 23 questões, as quais abrangiam aspectos demográficos, socioeconômicos, obstétricos e de conhecimento das puérperas sobre a lam. 479 conhecimento de puérperas acerca do método anticoncepcional da lactação com amenorreia l jamile lopes de moraes moraes y otros os dados coletados foram armazenados no programa statistical package for the social sciences (spss) versão 17.0 e foram calculadas as frequências absolutas e relativas, medidas de tendência central e desvio padrão. em seguida, os dados foram tabelados e analisados com base na literatura pertinente. o projeto de pesquisa foi submetido ao comitê de ética da maternidade que sediou o estudo e aprovado conforme o protocolo n. 113/2011. as participantes assinaram o termo de consentimento livre e esclarecido (tcle) e tiveram a privacidade respeitada. obedeceu-se às recomendações da resolução 466/2012 do conselho nacional de saúde do ministério da saúde, que trata de pesquisa com seres humanos (7). resultados observando a tabela 1, constata-se que, no tocante à idade das puérperas, constata-se um número considerável de adolescentes. a maior parte das mulheres era casada ou vivia em união consensual. o grupo pesquisado como um todo apresentou baixa renda, em que a maioria possuía renda familiar de um a dois salários-mínimos. no que tange à escolaridade, houve prevalência de um a oito anos de estudo. houve predomínio de mulheres que desempenhavam atividades fora do lar e a maioria das puérperas declarou religiões católica e protestante. a tabela 2 demonstra que houve predomínio de primigestas e de primíparas no grupo pesquisado. no tocante à assistência pré-natal, mais da metade das participantes realizou seis ou mais consultas. das que realizaram pré-natal, observou-se que pouco mais da metade não recebeu orientações sobre amamentação e grande parcela das puérperas teve o enfermeiro presente em seu pré-natal. essa assistência foi realizada em serviço público, em serviço privado e em ambos; no entanto, predominou-se o serviço público enquanto esf-ubs. a tabela 3 mostra que um pouco menos da metade das puérperas entrevistadas, 131 (47,1 %), possuía algum conhecimento sobre a lam e, destas, a maioria a considerava ineficaz. observou-se um baixo percentual de puérperas que conheciam a lam e souberam citar um ou dois dos três critérios para sua utilização; o critério mais conhecido foi amamentação integral tabela 1. distribuição do número de puérperas segundo características demográficas e socioeconômicas (alojamento conjunto de maternidade de referência de fortaleza, fev.maio, 2012) variáveis (n=278) n. % idade (anos) = 23,97 anos; dp= 6,67 12 a 19 80 28,8 20 a 34 175 62,9 35 a 47 23 8,3 procedência capital 195 70,1 interior 83 29,9 condição de união união consensual 134 48,2 solteira 77 27,7 casada 65 23,4 viúva 2 0,7 renda familiar (salário-mínimo*) até 1 47 16,9 1 a 2 199 71,6 > 2 32 11,5 ocupação do lar 138 49,6 fora do lar 140 50,4 anos de estudos nenhum 2 0,7 1 a 8 142 51,1 9 a 15 134 48,2 religião católica 167 60,1 protestante 78 28,1 agnóstica 28 10,1 outra 5 1,7 *salário-mínimo durante o estudo era r$622,00/ usd$155.88. fonte: elaboração própria. 480 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 tabela 2. distribuição do número de puérperas segundo características obstétricas e assistência recebida no pré-natal (alojamento conjunto de maternidade de referência de fortaleza, fev.-maio, 2012) tabela 3. distribuição do número de puérperas segundo o conhecimento acerca da lam (alojamento conjunto de maternidade de referência de fortaleza, fev.-maio, 2012) variáveis n. % número de gestações (n=278) = 2,03; dp = 1,51 1 142 51,1 2 a 3 101 36,3 4 ou mais 35 12,6 número de partos (n=278) = 1,38; dp = 1,36 1 159 57,2 2 a 3 85 30,6 4 ou mais 34 12,2 número de consultas de pré-natal (n=278) = 5,76; dp =2,77 nenhuma consulta 8 2,9 1 a 5 consultas 118 42,4 6 consultas ou mais 152 54,7 recebeu orientação sobre amamentação (n=270) sim 131 48,5 não 139 51,5 profissional que realizou o pré-natal (n=270) enfermeiro e médico 142 52,6 médico 79 29,3 enfermeiro 49 18,1 serviço de realização do pré-natal (n=270) unidade básica de saúde (ubs) 196 72,6 maternidade pública 34 12,6 serviço privado 17 6,3 ubs e maternidade pública 15 5,5 ubs e serviço privado 5 1,8 outra 3 1,1 fonte: elaboração própria. fonte: elaboração própria. variáveis n. % ter ouvido falar sobre o efeito contraceptivo da amamentação (n=278) sim 131 47,1 não 147 52,9 conhecimento sobre a eficácia da lam (n=131) não é eficaz 94 71,6 é eficaz 23 17,6 a eficácia varia de acordo com a mulher 7 5,4 não soube responder 7 5,4 conhecimento sobre os critérios para o uso eficaz da lam (n=131) não soube responder 100 76,3 amamentação integral/quase integral 12 9,2 o bebê ter até 6 meses 10 7,6 a menstruação não ter retornado 5 3,8 o bebê ter até 6 meses e amamentação integral/quase integral 3 2,3 amamentação integral/quase integral e a menstruação não ter retornado 1 0,8 ou quase integral. apenas 3 (2,3 %) mulheres citaram até seis meses de pós-parto com a amamentação integral ou quase integral e nenhuma citou o critério amenorreia. grande parte das puérperas que afirmaram ter ouvido falar na lam não soube informar nenhum dos três critérios para seu uso consistente. de acordo com a tabela 4, verifica-se que os períodos mais prevalentes de aquisição de informação foram antes de engravidar e durante o pré-natal, e a principal fonte desse conhecimento foi a informal, que correspondeu a 32,8 % (43 entrevistadas), principalmente por meio de alguém que já havia utilizado o método. grande parcela das participantes não foi orientada a respeito desse mac por profissionais da saúde. 481 conhecimento de puérperas acerca do método anticoncepcional da lactação com amenorreia l jamile lopes de moraes moraes y otros mento artificial satisfatório, uma vez que este imprime elevado custo financeiro para a família. assim, a promoção do ame deve estar associada com a promoção da lam. segundo pesquisa realizada em viçosa (minas gerais, brasil), são fatores associados com o abandono do ame nos primeiros meses de vida do bebê: sintomas depressivos, parto traumático, menor escolaridade materna, falta da casa própria, retorno ao trabalho, não ter sido orientada sobre aleitamento materno no período pós-parto, reação negativa da mãe para a notícia da gravidez e não receber ajuda nos cuidados com o bebê de seu parceiro. além disso, demonstrou que, ao serem incentivadas e orientadas de acordo com os princípios éticos de modo a amamentar exclusivamente seus bebês até o sexto mês, a taxa de abandono foi reduzida (10). a puérperas em estudo apresentaram, em sua maioria, baixa escolaridade. esses resultados são importantes para se perceber a dinâmica mais adequada de oferecer informações sobre a lam conforme o público receptor. a baixa escolaridade pode comprometer o entendimento a respeito de hábitos saudáveis, o que pode gerar efeitos negativos sobre os cuidados com a família. baixas condições socioeconômicas e de escolaridade devem ser levadas em consideração ao avaliar o conhecimento sobre a lam, pois influenciam o acesso e a capacidade de decodificação das informações sobre a obtenção e também o uso dos macs de forma consistente (11). pesquisa desenvolvida em pernambuco (nordeste do brasil) verificou que os anos de estudo formal da mãe, a realização de assistência pré-natal e o tipo de parto evidenciaram associação estatisticamente significativa com o prolongamento do ame para quatro e mais meses de idade, além da renda per capita igual ou acima de 0,5 salário-mínimo, a orientação sobre o aleitamento materno no pré-natal estão associados favoravelmente com o ame (12). é essencial ao profissional da saúde estabelecer uma comunicação acessível ao paciente sem subestimar seus conhecimentos e experiências acumuladas. também é importante validar se as clientes entenderam o que lhes foi explicado. vale ressaltar que o momento do pré-natal é ideal para realizar essas orientações e, muitas vezes, percebe-se que o profissional perde essa oportunidade de estimular a prática, e uma gestante que possui alto potencial de fazer o ame acaba abandonando por não ter conhecimento e ter sido pouco motivada. tabela 4. distribuição do número de puérperas segundo o momento de aquisição do conhecimento acerca da lam e fonte de aquisição (alojamento conjunto de maternidade de referência de fortaleza fev.-maio, 2012) fonte: elaboração própria. variáveis (n=131) n. % momento antes de engravidar 58 44,3 durante o pré-natal 56 42,7 no pós-parto 17 13,0 fonte amigos, familiares ou conhecidos 43 32,8 enfermeiro 32 24,4 médico 23 17,6 alguém que já utilizou o método 22 16,8 outro profissional da saúde 5 3,8 mídia 4 3,1 escola 2 1,5 discussão a amostra do estudo foi composta de quantidade significativa de puérperas adolescentes. esse achado é relevante por se tratar de um público que exige uma interação interpessoal diferenciada durante o aconselhamento voltado à lam, com um acolhimento específico por parte do profissional, com linguagem direcionada e informações atrativas, sem julgamentos e sem discriminação. além disso, esse grupo apresenta gravidez mais frequente no primeiro ano pós-parto quando comparadas a mulheres adultas (8). sendo a maioria casada ou em união consensual, é fundamental o envolvimento do parceiro no aconselhamento sobre a lam, pois, por vezes, são estes que determinam o mac a ser usado pela mulher e influenciam, portanto, de modo positivo ou negativo no aleitamento materno. estudo realizado em caxias (maranhão, nordeste do brasil) observou uma maior prevalência do aleitamento materno (am) entre as mulheres casadas (9). observou-se que as mulheres com renda familiar reduzida devem priorizar o ame, tanto pela sua superioridade nutricional para a criança quanto pela impossibilidade de instalar um aleita482 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 houve grande prevalência de mulheres que desempenhavam atividades fora do lar, fato que pode diminuir a adesão aa lam visto que os horários a serem cumpridos nas jornadas de trabalho podem dificultar a prática do ame, além de algumas instituições adotarem a licença-maternidade de apenas quatro meses. teoricamente, as religiões declaradas (católica e protestante) defendem a prática de métodos naturais de planejamento familiar pelas fiéis. assim, grande parte das puérperas seguidoras das respectivas religiões tem na lam uma opção contraceptiva aceita e recomendada. o perfil das puérperas pesquisadas corrobora com estudo realizado com 323 mulheres em um alojamento conjunto ao identificar predominância de mulheres na faixa etária de 20 a 29 anos 174 (53,9 %), no qual 270 (83,6 %) viviam com seus parceiros em união consensual com predomínio de participantes pertencentes à classe econômica c, classe desfavorecida economicamente (13). as primigestas e primíparas, mais prevalentes no grupo pesquisado, representam um grupo de risco para a interrupção do aleitamento materno devido à inexperiência, o que exige dos profissionais da saúde que intervenham de modo mais eficaz. mais da metade das participantes realizou seis ou mais consultas e uma pequena parcela das mulheres não realizou nenhuma consulta. sabe-se que a organização mundial da saúde (oms) preconiza que a gestante realize no mínimo seis consultas durante o período gestacional e que sua primeira consulta deve ser realizada até a 12ª semana de gestação (14). esses resultados se assemelham aos achados de pesquisa realizada em cuiabá (centro-oeste do brasil), na qual se constatou que 149 (48,9 %) mulheres receberam orientações sobre aleitamento materno nas consultas médicas, de enfermagem e/ou nas visitas domiciliares do agente comunitário de saúde (acs) (15). a realização do atendimento pré-natal foi predominante na esf. o serviço público parece favorecer o acesso das gestantes às informações sobre o período gravídico puerperal e, em particular, sobre o aleitamento materno, em detrimento dos serviços privados. nestes, a assistência é desempenhada, em geral, exclusivamente pelo médico, o que pode levar, em algumas vezes, a um baixo enfoque no componente educativo. um estudo realizado com puérperas do rio grande do sul (brasil) verificou que aproximadamente 99 % das parturientes realizaram ao menos uma consulta de pré-natal, porém menos da metade dessas mulheres (49 %) relatou lembrar-se de ter recebido algum tipo de informação acerca de aleitamento materno e/ ou alimentação complementar durante as consultas de pré-natal. esse fato mostrou-se bastante importante, pois as mães que foram orientadas pretenderam amamentar mais tempo do que as que não foram; essa diferença foi estatisticamente significativa (p < 0,001) (16). ter realizado o pré-natal deveria favorecer o acesso das gestantes às informações sobre o aleitamento materno e a lam uma vez que o enfermeiro se destaca na função de educador enquanto profissional da esf e visa promover estilos de vida saudáveis atuando como agente de mudanças capaz de interagir e intervir na sociedade, impulsionado pela transformação pessoal, profissional e social. pouco menos da metade das puérperas possuía algum conhecimento sobre a lam, porém, em sua maioria, a consideraram ineficaz. estudo realizado com o objetivo de avaliar o uso da lam por enfermeiras atuantes na esf verificou que apenas 19,6 % das entrevistadas afirmaram ter adotado a lam, motivadas por sua praticidade e benefícios; entre as que não a adotaram, a principal razão citada foi a não confiança no método, resultado considerado negativo, pois a falta de confiança para a prática pessoal pode influenciar negativamente na prática profissional (3). pesquisa realizada com alunos da graduação de medicina e de enfermagem do rio de janeiro, brasil, constatou que 41 % sabiam do efeito contraceptivo da amamentação nos primeiros seis meses após o parto e, ainda, que 43 % não acreditavam na eficácia do método; somente 6 % da amostra confiava no método (17). pequena parcela das puérperas que conheciam a lam soube citar um ou dois dos três critérios para sua utilização e nenhuma citou o critério amenorreia, que corresponde ao principal indicador de infertilidade. grande parte das puérperas que afirmaram ter ouvido falar na lam não soube informar nenhum dos três critérios para seu uso consistente, o que demonstra desconhecimento para praticar o método. estudo descritivo, realizado nas enfermarias de ginecologia e obstetrícia do hospital de clínicas em minas gerais, demonstrou a falta de confiança de puérperas no uso da lam, ao associar esse método com o uso da minipílula (4). o uso correto da lam só é possível quando se associa o conhecimento com a confiança no 483 conhecimento de puérperas acerca do método anticoncepcional da lactação com amenorreia l jamile lopes de moraes moraes y otros mac; ambas as orientações são de responsabilidade do profissional de saúde. uma pesquisa realizada em 45 países entre 1998 e 2011 com o objetivo de analisar o uso correto desse método contraceptivo revelou que somente 26% dos usuários que usam a lam cumprem os critérios para a prática correta (18). a lam é um dos métodos mais seguros e apropriados às mulheres no pós-parto, pois, além da eficácia de 98%, não acarreta malefício ao bebê, estimula a ame e, consequentemente, auxilia para sua melhor nutrição e desenvolvimento (1). assim, a crença de que o método não é eficaz é incorreto e deve ser combatida por parte dos profissionais que promovem a lam. acreditar que a amamentação exerce ação de anticoncepção sem conhecer e atentar-se aos critérios de utilização do método pode levar a puérpera a uma gravidez não planejada e fortalecer o mito de que a lam é de baixa eficácia. em pesquisa concluída na turquia, onde a lam é amplamente utilizada, avaliaram-se os fatores que contribuem para o sucesso ou falha do método: 34 % das 188 puérperas entrevistadas afirmaram estar fazendo uso do método; no entanto, apenas 17,2 % da amostra estava cumprindo os três critérios para seu uso correto. dentre elas, 43,8 % haviam menstruado e 70,3% iniciado a introdução de alimentação complementar ao bebê. observou-se, ao final do estudo, uma taxa de gravidez de 32,8% entre as puérperas que faziam o uso da lam (19). esse estudo evidencia o risco corrido pelas mulheres que utilizam a amamentação como método de anticoncepção sem a correta orientação dos critérios. as mulheres entrevistadas que receberam alguma informação sobre a lam a obtiveram predominantemente antes de engravidar e durante o pré-natal, momentos estratégicos, pois as mulheres estão ávidas por conhecimentos relacionados com o exercício da maternidade e a sua saúde reprodutiva. a principal fonte de conhecimento foi a informal, em especial por alguém que já havia utilizado o método. portanto, nota-se que o efeito contraceptivo do aleitamento é bastante difundido no círculo social das puérperas pesquisadas. sabe-se, no entanto, que o conhecimento adquirido dessa forma é passível de falhas. o método contraceptivo iniciado no pós-parto depende de uma série de fatores, o que inclui histórico médico, fatores anatômicos e hormonais, a preferência do paciente, e se a mulher está ou não amamentando. independentemente do método eleito, ele deve ser orientado por um profissional da saúde (20). antes da gravidez, a discussão pode ser feita nas consultas de planejamento familiar (pf) com o enfermeiro ou médico, por meio de orientação individual ou grupal, o que possibilita a troca de experiências com mulheres que possivelmente tenham ouvido falar sobre o método, esclarece as dúvidas e desfaz os mitos. durante o pré-natal, a mulher está mais interessada em adquirir conhecimentos que influenciem na saúde e no cuidado do bebê; portanto, é o momento ideal para promover o ame e orientar quanto aos macs recomendados, como a lam, para a puérpera que irá amamentar. ao longo das consultas, deve-se investigar a vivência, as experiências, as crenças e as atitudes da gestante a respeito do aleitamento, pois, quando estabelecida a confiança entre paciente e profissional, é possível iniciar as orientações sobre a importância do ame a fim de proporcionar informações concisas e clarificar os questionamentos existentes. durante o pós-parto, as mulheres têm interesse em usar métodos contraceptivos, pois desejam evitar uma nova gravidez. a informação quanto ao mac deve ser bem orientada sobre esse período específico e deve-se atentar para as modificações anatômicas e fisiológicas no organismo da mulher. além disso, é importante destacar sua interface com a amamentação, que deve ser promovida e incentivada, bem como evitar o uso de métodos que comprometam o sucesso desse evento (4). esse período também corresponde ao momento em que há um maior recebimento de orientações informais sobre a amamentação de amigos e familiares, em especial para as primíparas. assim, tradições e crenças populares são repassadas à gestante e à puérpera e, se esta não for orientada por um profissional de saúde, as chances de acreditar em informações errôneas são elevadas. no puerpério imediato, é importante que o enfermeiro esteja próximo às puérperas, auxilie-as nas primeiras mamadas e observe como está sendo a pega da mama, para que o aleitamento materno seja iniciado o mais precoce possível. nesse momento, é importante iniciar as orientações em pf, para que essas mulheres saiam da maternidade bem informadas acerca da lam. os primeiros dias do pós-parto são cruciais para o sucesso do aleitamento, pois é nesse período que a lactação se estabelece e se inicia um processo de intenso aprendizado e adaptação da mãe a respeito do recém-nascido (rn). o profissional pode prestar assistência por meio de visitas domiciliares após a alta hospitalar ou ainda durante as consultas de revisão de parto e de puericultura. 484 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 dessa forma, deve-se desenvolver habilidades para identificar as crenças de cada lactante, assim como quais delas podem ou precisam ser mantidas, modificadas, reestruturadas ou ressignificadas. saber sobre o conhecimento prévio da mulher, seja ele intelectual ou cultural, favorecerá a adesão desta às recomendações oferecidas. além disso, o profissional deve reconhecer que o ame requer esforços da mãe visto que as dificuldades estão acima do desejo de introduzir outros alimentos antes dos seis meses e que momentos de crise interferem na autoconfiança da mulher em amamentar; portanto, o profissional deve auxiliá-la principalmente nesses momentos (21). grande parcela das participantes não foi orientada por profissionais da saúde e, quando a orientação ocorreu, a sua qualidade era de baixo impacto, fato preocupante demonstrado no baixo percentual das que conhecem a eficácia e os critérios de uso da lam. estudo revelou que a principal fonte de orientação dos macs após o parto é do profissional médico, relatado pela maioria das mulheres, 294 (86,5 %); 4 (1,2 %) citaram o enfermeiro; 14 (4,1 %) não sabiam quem iriam procurar para receber orientações e 8 (2,4 %) referiram que não procurariam por ninguém (4). com isso, percebe-se a importância de capacitar os profissionais que atuam em pf para promover a lam de forma adequada. essa qualificação pode ser iniciada ainda na graduação, ao serem apresentados os benefícios da amamentação, ou ao tratar-se do ensino em pf, em especial no pós-parto. para que as puérperas atinjam um nível de conhecimento satisfatório a ponto de se sentirem encorajadas para utilizar o método, é essencial que os profissionais conheçam, acreditem e promovam a lam em todas as oportunidades pertinentes e estejam preparados para lidar com as dúvidas que possam surgir. conclusão os resultados obtidos de déficit no conhecimento de puérperas acerca da lam parecem ser influenciados por mitos arraigados na própria comunidade, em especial relacionados com a eficácia e os critérios de utilização do método, uma vez que amigos ou familiares foi a principal fonte de informação desse grupo. percebe-se, ainda, que são elevadas as oportunidades perdidas pelas equipes de saúde para informar as mulheres quanto à lam, quando no pré-natal, por exemplo, menos de metade das puérperas foi orientada sobre esse método. sugere-se, para estudos futuros, a elaboração de uma proposta de intervenção para ser inserida na assistência em pf, com foco principal durante o ciclo gravídico-puerperal, que objetive ampliar a promoção da lam, junto aos enfermeiros da esf, para atingir melhorias no conhecimento e na adesão das puérperas a respeito desse mac. teve-se como limitação do estudo a investigação escassa no que se refere aos conhecimentos subjetivos das mulheres acerca da lam e também à realização de desenho metodológico qualitativo. referências 1. ministério da saúde (br). secretaria de atenção à saúde. departamento de atenção básica. saúde sexual e reprodutiva. brasília (df); 2013. 2. panzetta s. lactational amenorrhoea method contraception: improving knowledge. community pract. 2011 out.; 84(10): 35-7. 3. moura erf, freitas gl, pinheiro akb, machado mmt, silva rm, lopes mvo. lactação com amenorreia: experiência de enfermeiros e a promoção dessa opção contraceptiva. rev. esc. enferm. usp [on-line]. 2011 mar. [acesso em 23 abril 2013]. 45(1). disponível em: http://www.scielo.br. 4. parreira bdm, silva sr, miranz mas. intention of use of contraceptive methods among puerperal women of a university hospital. rev rene. 2011 jan.-mar.; 12(1):150-7. 5. sipsma hl, bradley eh, chen pg. lactational amenorrhea method as a contraceptive strategy in niger. maternal and child health journal. 2013 maio; 17(4): 654-60. 485 conhecimento de puérperas acerca do método anticoncepcional da lactação com amenorreia l jamile lopes de moraes moraes y otros 6. werlang rb, schneider rs, silveira fl. uma experiência de ensino de física de fluídos com o uso de novas tecnologias no contexto de uma escola técnica. rev. bras. ensino fís. [on-line]. 2008 [acesso em 10 dez. 2013]; 30(1). disponível em: http://www.scielo.br. 7. ministério da saúde (br). conselho nacional de saúde. resolução n. 466, de 12 de dezembro de 2012. brasília; 2012. 8. figueroa rbg, hernández lmm, ricalde rl, hernández a garcía. anticoncepción y lactancia. espaciamiento de los embarazos. conceptos actuales. ginecol obstet mex. 2014; 82: 389-93. 9. campos fkl, gomes rns, landim lasr, gomes vts, gomes ms, lago ec. prevalence and factors related to the exclusive breastfeeding. r. interd. 2015 abril-jun.; 8(2): 109-18. 10. machado mcm, assis kf, oliveira fcc, ribeiro aq, araújo rma, cury af et al. determinants of the exclusive breastfeeding abandonment: psychosocial factors. rev. saúde pública [internet]. 2014 dez. [acesso em 15 set. 2015]; 48(6): 985-94. 11. peixoto cr, freitas lv, teles lmr, campos fc, paula pf, damasceno akc. o pré-natal na atenção primária: o ponto de partida para reorganização da assistência obstétrica. rev. enferm. uerj. 2011 abril-jun.; 19(2): 286-91. 12. caminha mfc, azevedo ptacc, sampaio bb, acioly vmc, belo mpm, lira pic de et al. aleitamento materno em crianças de 0 a 59 meses no estado de pernambuco, brasil, segundo o peso ao nascer. ciênc. saúde coletiva [internet]. 2014 jul.; 19(7): 2021-32. 13. leite fm, barbosa tko, mota js, nascimento lcn, amorim mhc, primo cc. perfil socioeconômico e obstétrico de puérperas assistidas em uma maternidade filantrópica. cogitare enferm. 2013 abril-jun.; 18(2):344-50. 14. ministério da saúde (br). secretaria de atenção à saúde. departamento de atenção básica. atenção ao pré-natal de baixo risco. brasília (df); 2012. 15. barbosa ln, santos nc, moraes mam, rizzardi sd, corrêa ec. prevalencia de prácticas educativas sobre amamantamiento materno exclusiva (ame) en cuiabá-mt. esc. anna nery. 2015 jan./mar.; 19(1): 147-53. 16. machado akf, elert vw, pretto adb, pastore ca. intenção de amamentar e de introdução de alimentação complementar de puérperas de um hospital-escola do sul do brasil. ciênc. saúde coletiva [internet]. 2014 jul. [acesso em 15 set. 2015]; 19(7): 1983-9. 17. pinto elg, gouvêa adn, lopes alf, leite hc, lucas br. método contraceptivo da lactação e amenorreia (lam): conhecimento de alunos de graduação. resumos de trabalhos apresentados no 10° congresso internacional da rede unida; rio de janeiro (rj), brasil. 6-9 de maio de 2012. 18. fabic ms, choi y. assessing the quality of data regarding use of the lactational amenorrhea method. stud fam plann. 2013 jun.; 44(2):205-21. 19. turk r, terzioglu f, eroglu k. the use of lactational amenorrhea as a method of family planning in eastern turkey and influential factors. j. midwifery womens health. 2010 jan.-fev.; 55(1):1-7. 20. sober s, schreiber ca. postpartum contraception. clin obstet gynecol. 2014 dez.; 57(4): 763-76. 21. campos ams, chaoul co, carmona ev, higa r, vale in. exclusive breastfeeding practices reported by mothers and the introduction of additional liquids. rev. latino-am. enfermagem. 2015 mar.-abril; 23(2):283-90. 03. caracteriz. flias (21 a 31) resumen este trabajo pertenece a la línea de investigación “salud familiar, enfermería familiar”, de la universidad nacional de colombia. describe las características de los factores de riesgo y grado de salud familiar de las familias con adolescentes gestantes de los municipios de chía, cajicá y cota. es un estudio descriptivo, transversal, con abordaje cuantitativo. se utilizaron dos instrumentos de salud familiar: “riesgo familiar total 7-70” y el “isf ges 19”, elaborados y probados en familias colombianas de estratos 1 y 2, cuya autora es pilar amaya de peña (1992-1998). de las 66 familias estudiadas, se encontraron riesgos que afectan la salud familiar, así: 62% en alto riesgo, 36% en riesgo medio y 2% en riesgo bajo. las prácticas y los servicios de salud se incluyen dentro de las subcategorías de mayor riesgo. el estudio también aporta información sobre el grado de salud familiar, es decir, el nivel en que las familias se encuentran saludables y satisfechas con lo que la familia es y hace para mantener las metas de crecimiento, estabilidad y cohesión comportamental. se concluye que de las familias estudiadas, las del área rural tienen mayores riesgos para la salud que las que viven en la zona urbana. las familias estudiadas no tienen el conocimiento ni la práctica de la promoción de la salud y la prevención de la enfermedad. estos hallazgos exigen a la enfermería y demás trabajadores de la salud iniciar acciones contundentes que aseguren una prestación de servicios de salud, para disminuir el riesgo familiar total y mejorar el grado de salud familiar, teniendo en cuenta a las familias de las adolescentes gestantes y previendo con ellas acciones de prevención de la enfermedad y promoción de la salud. palabras clave: riesgo familiar total, salud familiar, familia con adolescente gestante, enfermería familiar. abstract this study on family nursing with emphasis on family run within the research of the universidad nacional de colombia. it describes the characteristics, risks factors and degree of family health faced by families with pregnant adolescents in little towns of cundinamarca (chía, cajicá and cota). it is a descriptive study that follows a transversal and quantitative methodology. two different instruments on family nursing were used: “total family risk 7-70” and “isf ges 19” which haven been made and tested by dr. pilar amaya de peña (19921998) with colombian urban families from low social status. from the 66 families studied, it was found that a 62% of families faced high risk of affected family health, 36% faced a medium high risk and 2% faced low risks. the high risk categories comprise health practice and services. it also revealed information on the degree of family health and family satisfaction with respect to what the family is and what they do to achieve their goals related to growth, stability and behavior. it was concluded that from the studied families, those who lived in rural areas run higher risk with respect to health than families living in urban areas. the families studied do not have the knowledge and practice to prevent sicknesses and the promote health within the family. these findings demand from nursing and other health professionals to offer health services to those families with pregnant adolescents in order to decrease the family health risks and promote the family health level by promoting actions to prevent sicknesses and assure healthy measures. keys words: family risk, family health, adolescent pregnant families and family nursing. 21 beatriz pérez giraldo especialista en educación y asesoría familiar. magíster en enfermería, con énfasis en salud familiar. docente de la facultad de enfermería, universidad de la sabana. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 22 introducción el riesgo en salud es una característica averiguable de una persona o grupo de personas, que se conoce como asociada con la probabilidad de desarrollar un proceso mórbido o estar especialmente afectados de manera adversa. el grado de salud familiar hace referencia a lo que la familia es y la satisfacción que tenga. partiendo de estos conceptos, se quiere caracterizar el riesgo y el grado de salud de un grupo de familias con adolescentes gestantes. el presente trabajo está basado en las teorías de riesgo y de organización sistémica de marie louise friedemann; además, utiliza los instrumentos de riesgo familiar total (rft 7-70) y de salud familiar y gestación (isf ges 19), diseñados, implementados y probados por la doctora pilar amaya de peña. este estudio es útil para la enfermería familiar, porque aporta información específica para el cuidado de enfermería con las personas y familias, enfrentadas a diversos factores de riesgo, como: riesgos por grupo de edad, riesgos biológico-familiares, riesgos de medio ambiente y riesgos de servicios de salud y familia. también aporta información sobre el grado de salud familiar en la escala de acuerdo y satisfacción, con lo que la familia es y la satisfacción que tenga. los resultados exigen a la enfermería y otros trabajadores de la salud iniciar acciones que aseguren una prestación de servicios de salud tendientes a disminuir riesgos y mejorar el grado de salud familiar, teniendo en cuenta a las familias de gestantes adolescentes. a través del trabajo se presentan, uno a uno, los componentes de la investigación, y se definen aspectos del marco de referencia, del marco conceptual, del marco metodológico, de los resultados, conclusiones y recomendaciones que se derivan del estudio. área problemática en la actualidad, el embarazo en la adolescencia se ve como uno de los problemas más sentidos en latinoamérica, ya que se aprecia un aumento sostenido en su incidencia, frente a lo cual no se ha desarrollado mayor conocimiento y, por lo tanto, tampoco existen estrategias importantes para prevenirlo y atenderlo. según la oms-ops: “colombia ha experimentado una mayor disminución de los nacimientos en el grupo de adolescentes, comparado con la tasa general total, y presenta la paradoja de que aunque la importancia relativa del grupo es menor (18% en 1973 y 16% en 1986), el número total de nacidos de madres adolescentes ha aumentado, porque la población adolescente es mayor. en colombia un 68% de los egresos hospitalarios entre los 12 y 18 años de edad y el 25% de las consultas ambulatorias de las mujeres de 16 a 18 años son por causa materna”1. estadísticas colombianas, proporcionadas por el entonces ministerio de salud (minsalud), muestran que el embarazo y los eventos relacionados con él ocupan el primer lugar como causas de consulta externa, las cinco primeras causas de egresos 1. silber, tomás y colab. manual de medicina de la adolescencia: embarazo en la adolescencia. oms/ops, washington, 1992, p. 474. el riesgo en salud consiste en la probabilidad de desarrollar un proceso mórbido o verse afectados de manera adversa. el grado de salud familiar hace referencia a lo que la familia es y a la satisfacción que tenga. caracterización de las familias con adolescentes gestantes 23 hospitalarios y seis de las ocho primeras causas de los mismos, en la población femenina entre los 15 y los 19 años. asimismo, es la segunda causa de egreso hospitalario en mujeres entre 10 y 14 años, lo cual manifiesta claramente la gravedad de la problemática referida2. en colombia, según la encuesta de demografía y salud (2000), el 15% de las adolescentes ya han sido madres y el 4% están en el embarazo de su primer hijo, para un total de 19% que han estado en embarazo o ya han tenido partos, en comparación con el 17% en la encuesta de 1995, en la cual se encontró que una de cada cinco adolescentes ha estado alguna vez embarazada. si se toma en cuenta que, a nivel mundial, el incremento absoluto de los adolescentes entre los 10 y los 19 años será de 27% en los próximos 35 años, que el 86% del total corresponderá a países en vías de desarrollo y que la vida sexual de los adolescentes es cada vez más activa y precoz, bien puede asegurarse que el fenómeno social referido resulta altamente complicado y peligroso3. según un reciente estudio sobre “la dinámica social”, del centro de investigaciones de la universidad externado de colombia, entre el 10 y el 15% de los 125 millones de niños que nacen anualmente en el mundo son hijos de madres adolescentes menores de 20 años. desde el punto de vista social, la adolescente se ve enfrentada al rechazo social, de su familia, de su círculo de amigos, de su pareja, y en el peor de los casos se tiene que ir de la casa. su proyecto de vida se ve afectado, pues la presencia de un hijo le exige salir a trabajar y abandonar sus estudios, para empezar su papel de madre. la presión social contra la adolescente embarazada desencadena consecuencias psicológicas para ella. con frecuencia la joven que no estaba preparada para ser madre, tiende a rechazar la idea de tener un bebé. por esta razón, el 44,4% de las adolescentes han abortado en colombia4. según tanaka y siqueira, “el riesgo del embarazo en la adolescente es alto, y sucede en todos los niveles sociales, presentando, por otro lado, mayores riesgos en los niveles sociales de escasos recursos socioeconómicos, en los que esta carencia dificulta el acceso a las informaciones y a la asistencia adecuada”5. la situación anterior se observa en chía, cajicá y cota, municipios del departamento de cundinamarca, donde se ha venido incrementando el número de embarazos en adolescentes. según estadísticas hospitalarias, se presentan un promedio de siete a ocho embarazos nuevos al mes en el hospital san antonio, de chía, y de dos a tres en el hospital jorge cavelier, del municipio de cajicá. las familias de las adolescentes gestantes del presente estudio pertenecen a los estratos 1 y 2, situación esta que puede llevar a muchos riesgos y dificultar el manejo de las situaciones familiares, y específicamente la situación del embarazo en la adolescencia. la crisis económica de la mayoría de las familias y la falta de comunicación asertiva, entre otros, pueden constituir factores de riesgo familiar, que llevan a afectar tanto el desarrollo gestacional como el de la propia familia. justificación la ley 100, de diciembre de 1993, presenta cambios en los conceptos relacionados con la prestación de los servicios, entre ellos: la universalidad, la solidaridad, la eficiencia y la integralidad, que implican la cobertura a la familia como elemento importante para su cumplimiento. esta cobertura familiar obedece al reconocimiento de que esta unidad básica tiene un papel importante en la conservación de la salud o en el deterioro de la misma. cada individuo de la familia tiene la responsabilidad de cuidarse y utilizar los recursos de la familia y del ambiente para conservar la salud o recuperarla. se parte del concepto de integralidad, que considera a las personas como seres vivos biosicosocioculturales y espirituales, que interactúan con la familia, la sociedad y el entorno en el cual viven. la integralidad incluye el promover, el mantener, el 2. mendieta cruz, néstor. familia de adolescente embarazada. estructura y dinámica. bogotá, 1996, p. 18. 3. klein, r. “programas de intervención para adolescentes”. en: la psicología en el ámbito perinatal. inper, méxico, 1998, p. 488. 4. wetember, lucy. embarazo precoz y aborto del adolescente en colombia, 1999, p. 28. 5. tanaka y siqueira. en: montes y valverde, maría marlene. un modelo fundamentado en el amor para la asistencia de la adolescente embarazada. edit. xyz, cali, 1999, p. 27. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 24 recuperar y el rehabilitar, cuando se ha perdido la salud. la ley 100 ha sido fundamentada bajo el esquema de promoción de la salud y prevención de la enfermedad; por tal motivo, está sustentada en un modelo capaz de conocer y evaluar los riesgos para la salud, con mecanismos suficientes para atenderlos efectivamente. dentro de esta misma ley se aclara que la presencia de la salud o la enfermedad en la familia es producida por muchos factores (multicausalidad), bien sea económicos, biológicos, sociales, culturales, ambientales y de servicios de salud; por lo tanto, se hace necesario que el profesional de la salud tenga en cuenta esa conjunción de factores que actúan simultáneamente sobre las familias, para mantener la salud de estas. un factor de riesgo puede estar asociado con múltiples patologías, y una patología puede estar relacionada con múltiples factores de riesgo. por ejemplo, es así como el tabaquismo se asocia con la incidencia de varios tipos de neoplasmas, y también algunas enfermedades perinatales se relacionan con el tabaquismo de la mujer en embarazo. la desnutrición proteicocalórica es el resultado de la presencia reiterativa o crónica de enfermedades infecciosas y de un insuficiente consumo de alimentos energéticos y proteicos. esta condición, a su vez, puede ser el resultado de la pobreza, de deficientes condiciones sanitarias, de hábitos inadecuados y de la falta de acceso apropiado a los servicios de salud (pinstrup-anderse y col., 1993). si se mejoran las condiciones de vida, se disminuye la carga de enfermedad6. la constitución política colombiana, en el artículo 42, señala a la familia como una institución social básica. se conforma por niveles naturales o jurídicos, por la decisión libre de un hombre y una mujer de contraer matrimonio o por la voluntad responsable de conformarla. el estado y la sociedad garantizan la protección integral de la familia. las relaciones familiares se basan en la igualdad de derechos y deberes de la pareja y en el respeto recíproco entre todos sus integrantes. la ley 266 de 1996, de la enfermería, aclara los principios de la práctica de la profesión, entre los que se encuentran el de integralidad, que orienta el proceso de cuidado de enfermería a la persona, la familia y la comunidad, con una visión unitaria para atender sus dimensiones físicas y espirituales. otros principios, como la individualidad, la dialogicidad, la calidad y la continuidad, son importantes para brindar un cuidado de enfermería de buena calidad. los principios anteriores van de la mano con los que plantea la ley 100, con el principio de integralidad que corresponde a la familia. por lo tanto, es importante tener en cuenta a la familia, en este caso a las familias de las adolescentes gestantes, para identificar los factores de riesgo o los factores protectores, que en un determinado momento se deben tener en cuenta para aprovecharlos y mejorar la situación de las familias. por estas razones, se hace necesario caracterizar las familias desde el enfoque de riesgo familiar, y grado de salud de la familia, con el fin de identificar los condicionantes que hacen que la familia tenga riesgos o no. este estudio, de familias con adolescentes embarazadas, pretende colaborar en la identificación de factores de riesgo y grado de salud familiar, que hacen que en el sistema familiar, y en los subsistemas, se desarrollen situaciones de salud positivas o negativas, como también identificar los elementos protectores para el mantenimiento de la salud. 6. ministerio de salud. la reforma a la seguridad social en salud. tomo i. “antecedentes y resultados”. editorial carrera séptima ltda., santafé de bogotá, 1994, p. 107. este estudio pretende colaborar con la identificación de factores de riesgo y grado de salud que hacen que, en el sistema familiar y en los subsistemas, se desarrollen situaciones positivas o negativas, como también identificar los elementos protectores para el mantenimiento de la salud. caracterización de las familias con adolescentes gestantes 25 es importante conocer los factores de riesgo y el grado de salud familiar presentes en las familias de las adolescentes, con el fin de lograr desarrollar acciones y programas preventivos, dirigidos a modificar aquellos que puedan comprometer de manera negativa su salud. la presente investigación aportará a la profesión de enfermería la identificación de riesgos de salud de las familias y el grado de salud familiar de estas, con el fin de orientar su cuidado, que le permita al profesional diseñar programas encaminados a mejorar estilos de vida y, por consiguiente, calidad de vida. por otra parte, genera un aporte en la aplicación de un modelo conceptual en un proceso investigativo, que sin duda enriquecerá la profesión. problema ¿cuáles son las características de los factores de riesgo familiar total y grado de salud familiar de las familias con adolescentes gestantes de los municipios de chía, cajicá y cota? objetivo general caracterizar el enfoque de riesgo familiar total y el grado de salud familiar de las familias con adolescentes gestantes de los municipios de chía, cajicá y cota. objetivos específicos • identificar las edades y el número de gestaciones de las adolescentes gestantes del estudio. • identificar la estructura, la tipología y el ciclo familiar de las familias con adolescentes gestantes. • identificar la percepción de riesgo, salud y enfermedad de las familias con adolescentes gestantes. •identificar enfermedades de carácter familiar de las familias con adolescentes gestantes. • identificar instituciones de apoyo familiar de las familias con adolescentes gestantes. • identificar riesgos por grupos de edad y salud individual de las familias con adolescentes gestantes. • identificar factores de riesgo familiar específicamente biológicos familiares, del medio ambiente y servicios de salud de las familias con adolescentes gestantes. • identificar el grado de salud familiar de las familias con adolescentes gestantes. • identificar el comportamiento del riesgo familiar y el grado de salud familiar de cada municipio: cajicá, chía y cota. definición de conceptos este aparte conceptualiza: caracterización de la familia con enfoque de riesgo y grado de salud familiar, familia, salud familiar y familia con adolescente gestante, conceptos que se consideran válidos para sustentar teóricamente el estudio. • caracterización de la familia. desde el enfoque de riesgo, se describe en función de parámetros de estructura: tipología (familia nuclear, familia nuclear modificada, familia nuclear reconstruida, familia extensa, familia extensa modificada, familia atípica), ciclo vital familiar (formación de la pareja, crianza de los hijos, familia con preescolar, familia con adolescente, revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 26 familia con adultos, familia en edad media, familia anciana, familia multicíclica), composición (número de personas, promedio de edad, sexo) y riesgos individuales y familiares; y en términos del grado de salud familiar (sinónimo de organización, dinámica, funcionamiento), que incluye lo que la familia habitualmente es y el grado de satisfacción al respecto; se determina por la medición de las dimensiones de mantenimiento, cohesión, cambio e individuación7. • riesgo. pilar amaya de peña (2000) cita a backet, davies y petros barvazain, 1984, quienes se refieren al riesgo como al incremento en la probabilidad de consecuencias adversas, por la presencia de una o más características o factores. estos mismos autores definen el factor de riesgo como “cualquier característica o circunstancia averiguable (comprobable, confirmable) de una persona o un grupo de personas, que se conocen como asociadas con la posibilidad de desarrollar o están especialmente afectadas de manera adversa a un proceso mórbido”8. • riesgo familiar total. probabilidad de consecuencias adversas individuales o familiares (enfermedad, desorganización o disfunción), debido a la presencia de algunas características detectadas en el momento de la valoración (amaya de peña, p., y herrera, a. n., en prensa). estas características incluyen aspectos de tipo biológico-demográficos (composición, morbilidad, mortalidad), físicos, ambientales, socioeconómicos, psicoafectivos, prácticas de salud y servicios de salud. además, incluye la trayectoria de los miembros de la familia (pilar amaya de peña (1992, 1998 y 2000) cita a clemen-stone, eigsti y mcguire, 1991). desde este punto de vista, una familia con menor riesgo será aquella que mediante sus prácticas cotidianas y apoyo de los servicios de salud mantiene controlados los riesgos individuales y familiares, utilizando medidas de promoción y prevención9. • familia. es una unidad con estructura y organización, que interactúa con su ambiente. la familia es un sistema con subsistemas interpersonales de parejas y unidades mayores, definidas por enlaces emocionales y responsabilidades comunes. la familia está conformada por todas las personas que llevan funciones familiares y están emocionalmente conectadas al individuo. la familia se define como todas las personas que un individuo considera su familia10. • grado de salud familiar. dimensiones del proceso (comportamientos y estrategias familiares): la familia inmersa en el sistema social está transmitiendo cultura, suministra necesidades físicas de seguridad, procreación, enseña destrezas sociales a sus miembros y promueve propósitos para la vida. la familia satisface las necesidades de sus miembros mediante el control de su ambiente y guía los procesos familiares con aceptación colectiva y comportamientos y estrategias que ayudan a regular las condiciones terrenales de espacio, tiempo, energía y materia11. los propósitos del sistema familiar se alcanzan con comportamientos que caen en tres grupos: crecimiento familiar (morfogénesis), estabilidad familiar (homeostasis) y cohesión comportamental, los cuales son definidos por pilar amaya de peña12. a. crecimiento familiar. refleja el ajuste de la familia en el proceso de acomodación a las necesidades cambiantes de sus miembros. b. estabilidad familiar. refleja la tradición y los patrones de comportamientos comunes enraizados en los valores básicos y creencias culturales que proveen a la familia un sentido de pertenencia y seguridad. c. cohesión comportamental. involucra los procesos de cambio requeridos por la familia en su organización y procesos de ajuste en su trayectoria de valores. • familia con adolescente gestante. familia con mujer menor de 20 años de edad en gestación. 7. amaya de peña, pilar. riesgo familiar total 7-70 y el isf gen 25. referentes teóricos-conceptuales y análisis de la información. santafé de bogotá, universidad nacional de colombia, 1992, 1998 y 2000, p. 8. 8. ibíd., p. 3. 9. ibíd., p. 1 y 2. 10. friedemann, marie louise. the famework of systemic organization a conceptual approach to families and nursing thousand oaks: age 1995, p. 11. 11. ibíd., p. 14. 12. amaya de peña, pilar. measuring family health perceptions of poor pregnant women in bogotá, colombia, universidad nacional de colombia, u. de wayne. dib, bogotá, 1998. caracterización de las familias con adolescentes gestantes 27 metodología se utilizó una metodología cuantitativa de tipo descriptivo transversal. se valoraron 66 familias que tenían una adolescente embarazada. estas se caracterizan con enfoque de riesgo familiar total y grado de salud familiar. se utilizaron dos instrumentos de salud familiar: “riesgo familiar total 7-70” y el “isf ges 19”, elaborados y probados con familias urbanas colombianas por pilar amaya de peña (1992-1998). la captación de las familias se realizó en forma aleatoria, en los municipios de cota, chía y cajicá. la información de las familias se recogió en la casa o en el centro de atención en salud, durante una hora. en la recolección de la información participó una persona del municipio de cajicá, la cual fue entrenada por la investigadora. la información recolectada, a través de los instrumentos rft 7-70 y el isf ges 19, fue codificada y procesada en el paquete estadístico “spss”. como guía de análisis se utilizó la orientación dada por pilar amaya de peña (1992, 1998 y 2000), teniendo en cuenta las categorías y subcategorías del rft 7-70, como también la estructura del isf ges 19, y sus grupos con los correspondientes ítems. para el desarrollo del proyecto se tuvo presente el permiso de las instituciones donde se llevó a cabo el estudio. a las gestantes adolescentes se les solicitó autorización voluntaria, se les informó sobre los fines del estudio y se leyó y firmó el consentimiento informado; de igual forma, a la autora de los instrumentos utilizados se le solicitó el respectivo permiso. resultados los resultados muestran que las 66 familias estudiadas tienen un promedio de cuatro a cinco personas, donde la distribución por sexo (masculino y femenino) es de uno a dos hombres y de dos a tres mujeres por familia. esta distribución muestra que en algunos hogares predomina la mujer como cabeza de familia, característica que ha venido en aumento en las familias de américa latina. según ramírez (1995), diversos estudios han concluido que los hogares con jefe mujer constituyen las familias más pobres, y que estas mujeres tienen además un menor nivel educacional. el rango de edad que prima es de 12 a 18 años. el tipo de familia que prevalece es la nuclear, con 48,5%, seguida de las atípicas, nucleares modificadas y nucleares reconstruidas, con un 39,3%, hecho este significativo, puesto que representa tipos de familias que por su conformación generan conflictos y pueden llevar a la disfuncionalidad. el ciclo familiar predominante es en formación, con un 24,2%; le sigue el de adolescente, con un 22,7%, lo que corrobora que en su mayoría son familias con integrantes jóvenes, que según duvall están sufriendo unos cambios y necesitan la aceptación de ambos cónyuges, tanto a nivel emocional como cultural y sexual. este tipo de familia se está enfrentando al embarazo, lo cual puede afectar notablemente su relación y llevar a consecuencias para ambos, como el fracaso matrimonial, no alcanzar determinados logros educativos, y algunos efectos sobre el nivel socioeconómico y el posible hijo. p. amaya de peña y a. n. herrera (en prensa) afirman que existen características de tipo biológico-demográfico (composición, morbilidad y mortalidad), factores de medio ambiente (ambiente socioeconómico, ambiente físico de vivienda y vecindario, ambiente psicoafectivo familiar, los estilos de vida y las prácticas de salud) y características o factores dados por la prestación de los servicios, como también la trayectoria de los miembros de la familia como unidad, lo cual determina el riesgo familiar total (rft). la información arrojada por el instrumento “rft 7-70” (amaya de peña p., 1992 1998) describe las puntuaciones de riesgo familiar de la muestra por subcategorías. teniendo en cuenta la calificación de las subcategorías del instrumento, se encontró que el riesgo es alto si puntúa por encima de 3, medio si puntúa entre 3 y 2 y bajo si es menor de 2. los resultados describen los riesgos de las 66 familias por subcategorías, de la siguiente manera (ver tabla a continuación): revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 28 el cuadro presenta el promedio de puntuación de riesgo familiar. registra desde el más alto y en forma descendente las subcategorías: se encuentran en alto riesgo las prácticas de salud y los servicios de salud y familia. en riesgo medio se hallan el ambiente socioeconómico, el ambiente psicoafectivo, la composición familiar, el riesgo por grupo de edad y el ambiente físico de vivienda y vecindario, y por último, en bajo riesgo están la morbilidad, el estilo de vida y la mortalidad en la familia. estos riesgos, analizados en forma global, brindan la pauta para dirigir acciones de promoción y prevención específicas para este grupo de familias. el instrumento “isf ges 19” arrojó los siguientes resultados: la escala de acuerdo, que demuestra lo que la familia es, se presenta de la siguiente manera: si las familias puntúan entre 68100, son altamente saludables; si están entre 67-50, son familias saludables, y de 49 y menos, son familias poco saludables (amaya de peña p., 1998). se encontró un promedio de 54,1%, que indica que estas familias son saludables, resultado que llama la atención al relacionarlo con el 62% de las familias con alto riesgo de salud, lo que quiere decir que no se perciben como familias en riesgo y, por lo tanto, dicen estar saludables. la escala de satisfacción, que demuestra la satisfacción con lo que la familia es, puntúa así: entre 68-100, familias altamente saludables; entre 67-50, familias saludables, y 49 y menos, familias poco o nada saludables (amaya de peña p., 1998). en las 66 familias el promedio, equivalente a 51,1%, significa que se encuentran satisfechas con lo que la familia es y hace, en cada grupo de la escala de satisfacción. resultados del 7-70 por subcategorías subcategoría promedio desviación máximo mínimo estándar prácticas de salud 4,36 1,25 7 2 servicios de salud y familia 3,38 1,61 7 0 ambiente socioeconómico 2,98 1,52 6 0 ambiente psicoafectivo familiar 2,65 1,69 7 0 composición familiar 2,64 1,30 5 1 riesgo por grupo de edad 2,62 1,60 5 1 ambiente físico de vivienda y vecindario 2,02 1,26 6 0 morbilidad de la familia 1,76 1,56 5 0 estilo de vida familiar 1,59 1,02 4 0 mortalidad de la familia 0,14 0,43 2 0 caracterización de las familias con adolescentes gestantes 29 conclusiones este estudio refleja: en primer lugar la tipología familiar, el ciclo familiar y la composición familiar que predominan en las familias de este estudio; las implicaciones en la dinámica familiar ya fueron descritas en párrafos anteriores; es importante resaltar que el 62% de las familias estudiadas tienen un alto riesgo de salud, lo que exige por parte de los profesionales de enfermería y el resto del equipo de salud, emprender acciones de prevención y promoción de la salud en diferentes modalidades, como el autocuidado individual y familiar. en la investigación se halló que de las 66 familias encuestadas, 52 viven en el sector rural y 14 en el urbano. comparando los resultados de la investigación, se encuentra que un 62% de las familias se hallan en alto riesgo de salud, circunstancia que llevaría a concluir que en el sector rural existe menos protección y más riesgo para las familias que en el urbano. evidentemente, los riesgos del sector rural son mayores que los del urbano: el deterioro ambiental, la carencia de servicios públicos y la falta de agua potable para el consumo humano aumentan el riesgo de las familias de dicho sector. la investigación permite que identificados los riesgos familiares totales a los que están expuestas las familias encuestadas, el profesional de enfermería y el equipo de salud cuenten con datos precisos y cifras claras para implementar planes de atención y cuidados para las familias, enfocados a las acciones de promoción y prevención. la adolescente percibe que su familia es saludable, apreciación esta que va acorde con su pensamiento y grado de madurez. para la adolescente, la problemática en torno a la salud de su familia es irrelevante, ya que considera que otros temas son de mayor importancia. de la investigación se desprende que las familias, no obstante estar afiliadas a la seguridad social, no conocen las bondades de la ley 100, bien porque las instituciones no efectúan una divulgación suficiente para que ellas hagan uso de los servicios, o porque las familias no se interesan en averiguar y enterarse de los servicios a que tienen derecho. de conformidad con los instrumentos de percepción del grado familiar y la escala de acuerdo, se encontró que en los municipios de cajicá y chía las familias son saludables, con un promedio de 54 y 52,3%, respectivamente, mientras en el municipio de cota se hallaron familias poco saludables, que corresponden a un promedio de 46,09%. en cuanto a la escala de satisfacción, se encontró que las familias de cajicá y chía se sienten satisfechas, con un promedio de 53,84 y 50,96%, respectivamente, en tanto que para el municipio de cota se encontraron familias poco satisfechas, que corresponden a un promedio de 44,09%. los índices anteriores muestran que las familias correspondientes al municipio de cota se hallan insatisfechas y son poco saludables; sin embargo, el resultado es contrario en los municipios de cajicá y chía, ya que la investigación halló que estas familias son saludables y se sienten satisfechas. se desprende de la investigación que los municipios con mayor riesgo familiar total son los de cajicá y cota, pues para ambas poblaciones se hallaron 24 y 7 familias, respectivamente, con alto riesgo; este hecho demuestra un estado socioeconómico deprimente, circunstancia que es diferente en el municipio de chía, a pesar de que todas las familias se hallan dentro de los estratos 1 y 2. el tener un modelo teórico en el abordaje de las familias facilitó el trabajo con ellas, ya que se contaba con una guía en el direccionamiento de los objetivos del proyecto. recomendaciones la investigación con este grupo de familias permite plantear las siguientes recomendaciones: • socializar los resultados de la presente investigación en las instituciones en las que se realizó la aplicación de los instrumentos, con las autoridades locales de cada uno de los municipios y con la facultad de enfermería de la universidad de la sabana, a fin de dar a conocer los resultados, que sirvan de revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 30 referencia en la toma de decisiones de las políticas sociales y de salud de cada municipio, y permitan una aproximación a la planificación de los recursos institucionales y comunitarios, así como la intervención de la facultad en el diseño de programas de apoyo específico para las familias con adolescentes gestantes con riesgo. • crear estrategias de divulgación en las instituciones de salud, las cuales sean efectivas y objetivas, con el fin de que los usuarios se informen de los servicios que ofrecen dichas instituciones, y de esta manera utilicen los programas de promoción y prevención, encaminados a mejorar los estilos de vida. • dinamizar los equipos interdisciplinarios de las diferentes instituciones de salud, para que conocida y analizada la información recogida de las 66 familias valoradas, se inicien acciones específicas que contribuyan a minimizar o controlar los factores de riesgo identificados, que en prioridad son: prácticas de salud y servicios de salud. • estimular la continuidad de la presente investigación, con el fin de explorar y relacionar diversos aspectos, como las prácticas de salud de la familia con el nivel educativo de la misma, el ambiente psicoafectivo familiar con el tipo de familia, el grado de salud familiar con los factores de riesgo presentes en la familia. la investigación con este grupo de familias permite plantear las siguientes recomendaciones: • socializar los resultados • crear estrategias de divulgación en las instituciones de salud • dinamizar los equipos interdisciplinarios de las diferentes instituciones de salud • estimular la continuidad de la presente investigación caracterización de las familias con adolescentes gestantes 31 bibliografía amaya de peña, pilar. aspectos psicométricos. instrumentos e instructivos. pruebas ipsf-gg rtf 7-70. santafé de bogotá, universidad nacional de colombia, facultad de enfermería, 2000. _______ . riesgo familiar total 7-70 y el isf gen 25. referentes teóricos-conceptuales y análisis de la información. facultad de enfermería, universidad nacional de colombia, agosto de 2000. _______ . instrumentos de salud familiar isf gen 25-isf ges 19. manual del usuario. agosto de 2000. _______ . measuring family health perception of poor pregnancy women in bogotá, colombia. universidad nacional de colombia y wayne state university. _______ . familias de ancianos y escolares del sector de la estrella, ciudad bolívar (fase diagnóstica). bogotá, universidad nacional de colombia, facultad de enfermería, 1992. _______ . salud familiar y enfermería. memorias del primer congreso colombiano de salud familiar. caja de compensación familiar cafam, bogotá, octubre, 1987. _______ . “seguimiento familiar en el área de perinatología: el recién nacido no es exclusivamente de la madre”. en: avances, vol. vi, no. 1, enerojunio, 1988. asociación salud con prevención. sexualidad en la adolescencia. editorial presencia ltda., 1993. b. kozier, et al. marcos para el estudio de la familia. conceptos y temas en la práctica de enfermería. méxico, mcgraw-hill, 1992. babativa, luz maría. el adolescente y la sexualidad, un espacio de reflexión para el adulto. 1999. boletín salud sexual y reproductiva en adolescentes. 1996. de la revilla, luis. conceptos e instrumentos de la atención familiar. barcelona, doyma, 1994. echeverri de ferrufino, ligia. cuadernos de familia i. universidad de caldas, facultad de desarrollo familiar, manizales, 1987. family care international. boletín de circulación nacional, no. 2, marzo de 1998. friedemann, marie louise. the fomework of systemic organization a conceptual approach to families and nursing thousand oaks: age 1995. gonzález, electra. adolescente embarazada. aspectos sociales. centro de medicina reproductiva del adolescente, unicef, chile, 1993. gutiérrez de pineda, virginia. familia y cultura en colombia. departamento de sociología, universidad nacional de colombia, bogotá, tercer mundo editores, 1961. hamel, patricia. familia y embarazo en la adolescencia. estrategia para la atención psicosocial de la joven embarazada. servicio nacional de la mujer, chile, 1994. kano florian, maría esther. “el proceso de enfrentar un embarazo en la adolescencia: ajustando la identidad. el contexto del embarazo en la adolescencia”. en: investigación y educación en enfermería, vol. xvii, no. 1, marzo, 1999. klein, r. la psicología en el ámbito perinatal. inper, méxico, 1988. lópez herrera, harold. consideraciones acerca de la relación entre familia y atención en salud. memorias del primer foro salud y cultura para el siglo xxi: hacia nuevos paradigmas desde los saberes. universidad simón bolívar, barranquilla, 2001. marti, gloria; canut, maría teresa. “enfermería psico-social: factores de riesgo y familias en crisis”. serie manuales modernos, salvat editores s.a. mejía, diego, y otros. salud familiar. iss, ascofame, bogotá, 1990. mendieta cruz, néstor. familia de la adolescente embarazada. estructura y dinámica. rasgos y color ltda., santafé de bogotá, 1996. ministerio de salud. la reforma a la seguridad social en salud. tomo 1: “antecedentes y resultados”. edit. carrera séptima, ltda., santafé de bogotá, 1994. montes valverde, maría marlene. un modelo fundamentado en el amor para la asistencia y el cuidado de las adolescentes embarazadas. editorial xyz, cali, colombia, 1999. portafolio. el diario de la economía y negocios. año 9, no. 1284. bogotá, 8 de febrero, 2001. presidencia de la república. consejería para la política social. icbf, unicef. las familias de hoy en colombia. tomo i. santafé de bogotá, formato, 1994. ramírez, valeria. cambios en la familia y en los roles de la mujer: nuevos roles de la mujer en la familia. santiago de chile. no ha sido sometido a revisión de editorial. 1995. rodríguez galvis, et. al. riesgo familiar: tecnología apropiada para intervención en salud con enfoque biosicosocial. memorias del 2º congreso colombiano de salud familiar, medellín, corporación social para el desarrollo integral familiar. ruiz puyana, carmen elisa. mantenimiento de la salud. taller para la aplicación de salud familiar en el valle, universidad del valle, facultad de salud, departamento de salud familiar, cali, 1990. silva gómez, edelmira, et al. influencia del medio ambiente en la organización familiar. universidad santo tomás de aquino, bogotá, 1975. silber, j. tomás, y colaboradores. manual de medicina de la adolescencia. oms/ops, 1992. wetember, lucy. embarazo precoz y aborto de la adolescente en colombia. 1999. 01. dim. espiritual (6-9) revista aquichan issn 1657-5997 año 4 nº 4 6-9 bogotá, colombia octubre 2004 6 resumen la enfermería reconoce como algo esencial abordar a los usuarios de manera totalitaria, para lo cual se hace necesario un mayor conocimiento sobre la dimensión espiritual del cuidado. el artículo presenta las reflexiones, avances y proyecciones que en este sentido tiene el grupo académico de cuidado al paciente crónico y su familia, de la facultad de enfermería de la universidad nacional de colombia, en donde se evidencia la importancia de la persona como un ser espiritual. para ello, parte de señalar las áreas de trabajo prioritario en el campo, hace un recuento de los motivos para trabajar la espiritualidad y las dificultades y logros en el estudio de este tema, puntualiza cuáles son sus contenidos fundamentales, establece la relación de la espiritualidad con el cuidado de la salud y su pertinencia en las situaciones de cronicidad y muerte. en relación con el cuidado, la espiritualidad es vista como un elemento de crecimiento en tiempos difíciles. por último, se invita al lector al estudio y profundización de la dimensión espiritual del cuidado, como parte de un reto para asumir la totalidad del ser humano. palabras clave espiritualidad, cuidado espiritual, cuidado crónico, totalidad. abstract part of the nursing discipline’s nature it the importance of looking at human beings in a totalitarian way. in order to do this it is necessary to have knowledge about the spiritual dimension of caring. this paper includes some reflections, advances and projections that in such direction have been developed by the academic group of patient and family’s chronic care at the school of nursing in the universidad nacional de colombia. in the group’s work it is clear that the human being is important as a spiritual being. the paper contain the main areas of work in the spiritual care, the justification for working in the field, difficulties and results that have been obtain while doing such work, it clarifies the core topics in the field, the established relationship between health care and spirituality, and addresses its pertinence in situations of chronic and death care. spirituality in its relationship to care is seen as a growth element among hard times. at the end it invites the reader to study and learn in the topic of spiritual care as a way to deal with the issue of total human care. key words spirituality, spiritual care, chronic care, totality. * profesora asociada, facultad de enfermería, universidad nacional de colombia icgbsh@elsitio.net.co beatriz sánchez herrera* recibido: el 15 de marzo de 2004 aprobado: el 14 de abril de 2004 dimensión espiritual del cuidado 7 esde hace varios años se adelantan algunos trabajos de investigación por parte del grupo académico de cuidado al paciente crónico y su familia, de la facultad de enfermería de la universidad nacional de colombia, sobre la temática del cuidado, de la experiencia de la salud humana en situaciones de cronicidad y muerte, en las cuales se hace evidente la importancia de la persona como un ser espiritual. durante este tiempo se han podido identificar algunas necesidades prioritarias para la asistencia a estos sujetos y a sus cuidadores familiares, y la importancia de desarrollar en cada uno de ellos sus habilidades de cuidado. a través de esta experiencia se ha evidenciado que cuando el trabajo de enfermería está basado en lineamientos conceptuales propios, logra sus propósitos y fortalece el cuidado a las personas. las prioridades en este trabajo han sido apoyar a quienes requieren de cambios en el estilo de vida, aliviar el sufrimiento de los que tienen dolor, limitación y mutilación, acompañar y respaldar a quienes viven situaciones que generan gran sentimiento de pérdida, temor o amenaza de muerte, y ser red efectiva de apoyo de aquellos que tienen alterada la capacidad de socializar. los resultados han permitido en algunos casos interpretar, ante niveles decisorios, la importancia de ofertar nuevos servicios y de cualificar los actuales, para mejorar la calidad de vida de las personas que afrontan situaciones de enfermedad crónica. en el curso del tiempo han surgido reflexiones sobre la forma como se debe orientar la práctica de la enfermería, las esperanzas y expectativas que nos alientan a unos y otros en estas vivencias, las fortalezas y debilidades que tiene cada profesional y las formas de abordar cada situación, disyuntivas que no terminan de ser resueltas. se ve con preocupación que, en la práctica, los principios del cuidado holístico no siempre se reflejan, y se percibe lejanía en las respuestas apropiadas para quienes buscan asistencia cálida y humanizada en instituciones de salud, con crecientes expectativas de costo-beneficio y tendencias a la sistematización y la tecnología complejas. estas reflexiones son el marco donde se ha iniciado la búsqueda del potencial espiritual de cada persona. la espiritualidad, vista como una posible fortaleza, es una dimensión de la cual solo se es consciente en algunos casos. esta exploración busca lo más valioso de cada persona, frente a tantas inquietudes que van quedando día a día sin respuesta. en las situaciones de enfermedad crónica, el cuidado de enfermería dirigido a la persona total busca cuidar la experiencia de la salud humana tal como ella se presenta, y las metas de la enfermería se encaminan a la vida y no a la enfermedad. es la persona integral, interactuando con su ambiente, desarrollándose en su contexto, como un ser único, evolutivo y trascendente, lo que interesa a la enfermería. el estudio de la espiritualidad es una pequeña parte de esa totalidad, que con frecuencia se olvida. en parte podría dejarse de lado, por el nivel de complejidad que lo caracteriza. la naturaleza intangible y variable de la espiritualidad, la variedad de formas en que se experimenta entre las diferentes personas y en los distintos momentos, las múltiples formas de expresión que tiene, a través del cuerpo, el pensamiento, los sentimientos, los juicios y la creatividad, y su relación con los aspectos no materiales de la vida, explican en parte esta percepción. la espiritualidad agrupa las ideas filosóficas acerca de la vida y su propósito, y tiene el poder de dar forma y significado al ser, saber y hacer, que se puede reconocer como un impulso unificador, si la espiritualidad tiene importancia terapéutica en pacientes que experimentan crisis o en quienes viven en situaciones de enfermedad, esta temática debe incluirse en los currículos de los programas, en la asistencia y en nuevas investigaciones, con el fin de cualificar la práctica con integración de la dimensión espiritual del cuidado. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 8 un sistema de guía interno básico para el bienestar humano, que motiva para escoger las relaciones y búsquedas necesarias. la espiritualidad no es prerrogativa de los creyentes, pues puede estar desvinculada de la religión y no ser expresada como una práctica religiosa. es decir, que como componente de la salud siempre está presente y se relaciona con la esencia de la vida. bajo el lema de hacer visible lo invisible, se ha señalado que la unión entre la espiritualidad y la salud es innegable. la evidencia deja ver con claridad que las prácticas espirituales, y en especial las que se realizan dentro del marco de una cultura religiosa organizada, se asocian con mejores estados de salud, menor depresión, mejores hábitos y menor mortalidad1, 2, 3, 4. se ha señalado, además, que no basta con decir que se tiene una creencia o práctica religiosa, sino que esta debe tener un rol importante en la vida de la persona, para que la relación evidenciada esté presente. con base en la revisión desarrollada para el estudio, se dice que los creyentes tienen más salud y pueden disfrutar de una vida más prolongada. al parecer, esas afirmaciones surgen porque la gente que observa una vida religiosa consecuente posee un estilo de vida más saludable que los no creyentes, y los que creen se interesan por acceder a un diagnóstico precoz de sus enfermedades, es decir, demuestran más interés por el cuidado de su salud, procurando la mejor atención médica que pueden hallar y siendo más cumplidores de las indicaciones profesionales. de otra parte, su interés por el estado de la salud de los demás se relaciona con la fe que practican, en donde como miembros de una iglesia fraterna prodigan entre sí apoyo personal y ánimo mutuo. la proyección espiritual de los creyentes pareciera protegerlos de las dolencias físicas provocadas por las tensiones de la vida moderna, el estrés y la depresión. ello les permite gozar de mayor salud y una vida más prolongada que los demás que no practican su fe5. a pesar de la gran evidencia que asocia la religiosidad con la salud, ella no significa que la religión y la fe sean la fuente de la salud y de la vida. los creyentes también experimentan el progresivo deterioro, debilitamiento, limitaciones y dificultades de todos los demás, pero se ha demostrado que no los sufren del mismo modo, pues la fe les brinda a muchos creyentes el impulso interior y la determinación necesaria para superar las inevitables dolencias físicas, proveyéndoles una adecuada capacidad de recuperación emocional. para muchas personas en situación de enfermedad crónica y cercanía a la muerte, la espiritualidad es un elemento esencial para disfrutar la vida y hacerla productiva. son varios los motivos para que la espiritualidad, vivida de manera religiosa, sea útil en la salud; entre ellos, se ha reconocido que la oración o la meditación generan un estado de paz interna que ayuda a la recuperación, y el tener pensamiento positivo es terapéutico. de otra parte, los grupos religiosos dan soporte social, y varias religiones rechazan hábitos no saludables. más aún, el sentido de la disciplina y la esperanza, propios de las culturas religiosas, se han podido asociar con mejor acatamiento de los regímenes prescritos6. para muchos que viven situaciones de cronicidad y muerte, donde la incertidumbre impera, tener la confianza en un ser superior, o en la fuerza de una relación con ellos mismos o con otros, apoya la recuperación. para otros, contar con dios, un poder o fuerza superior o un grupo de personas cercanas como aliados, en quienes descansa parte de la pesada carga que constituye la enfermedad, con la confianza de que las cosas suceden con algún propósito, aunque el mismo no sea claro de momento, alivia de manera importante. a pesar de ello, al preguntar a muchos profesionales del área de la salud si han podido ayudar a un paciente de manera espiritual, se obtienen respuestas negativas o evasivas, que reflejan en ambos casos desconocimiento y desconcierto. al parecer, falta mucha comprensión de la gran herramienta que es la espiritualidad, y lo que ella constituye para ayudar a una persona que vive situaciones de enfermedad o crisis. quizá muchas de las personas entrevistadas sí han podido ayudar a las demás de manera espiritual, pero no son conscientes de haberlo hecho. esa es la diferencia que los estudios de la facultad de enfermería pretenden evidenciar: no se trata de dar una ayuda espontánea, sino un buen cuidado, uno que refleje una 1. ross, linda. nurses perception of spiritual care, avebury, sydney, 1997, pp. 5-23. 2. coyle, j. “spirituality and health: towards a framework for exploring the relationship between spirituality and health”, journal of advanced nursing, 37 (6): 589-597, 2002. 3. koenig, harold. spirituality in patient care: why, how, when, and what, london, templeton foundation press, 2002. 4. “spiritual coping strategies: a review of the nursing research literature”, journal of advanced nursing, 34 (6): 833-841, jun. 2001. 5. koenig, harold. “an 83-year-old woman with chronic illness and strong religious beliefs”, jama, 288 (4): 487-493, jul. 24/31, 2002. 6. koenig, harold. op. cit. ...para admitir que un profesional cuida y valora a una persona, se debe partir de que él mismo sea formado y valorado como persona y esté en la capacidad de asumir el reto de la totalidad. dimensión espiritual del cuidado 9 conciencia expandida, con intención para actuar, para buscar y generar un espacio de crecimiento humano mutuo entre el profesional y el usuario, a través de la relación entre ellos. es decir, para admitir que un profesional cuida y valora a una persona, se debe partir de que él mismo sea formado y valorado como persona y esté en la capacidad de asumir el reto de la totalidad. al profundizar en este conocimiento y ver la espiritualidad de manera amplia, se hace evidente que dentro de la experiencia de vivir en situaciones de enfermedad, además de las grandes dificultades existen espacios de crecimiento, a través de redimensionar la vida y de ayudar a otros. la persona que vive con la enfermedad puede desesperar o trascender con su experiencia, aceptar la ayuda o rechazarla, vivir en armonía interna, a pesar de su malestar físico, o puede desesperar, aunque su pronóstico sea bueno. esta experiencia, tanto para la persona implicada en forma directa como para sus cuidadores, puede constituir un camino de fortalecimiento, de empoderamiento, e incrementar la autoestima; en estos casos, el cuidado puede convertirse en una fuerza sanadora espiritual para las partes. los estudios de la facultad de enfermería de la universidad nacional de colombia admiten que el conocimiento empírico puede contradecir lo espiritual y jamás podrán responder a todas las preguntas. sin embargo, a pesar del conflicto entre lo espiritual y lo científico, es decir, entre lo verificable y lo intuible, estos estudios han enseñado a reconocer indicadores de las necesidades espirituales, a identificar la salud espiritual, a indicar límites y terrenos comunes entre las diferentes profesiones que se vinculan al área de la salud, en donde los pastores, capellanes y otros orientadores espirituales deben estar presentes, y, por supuesto, a encontrar formas de ayudar y de transmitir el conocimiento del cuidado, concebido de una forma holística. con base en los hallazgos de estas investigaciones, se ha podido clarificar la ambigüedad de la relación entre el concepto espiritualidad y religión; se ha señalado que el tema no solo implica asuntos positivos, sino que exige una formación que trascienda el abordaje mecanicista de solución de problemas y busque una relación más simétrica entre el cuidador y el cuidado, que no enfatice en lo individualista y respete la totalidad del ser. la mirada a más de trescientas personas, entre aquellas que viven con dolor, limitación y mutilación, con pronóstico de muerte inminente; en quienes tienen un síndrome de inmunodeficiencia adquirida; en los que su vida está dispuesta alrededor del cuidado de un familiar enfermo, y en quienes saben que deben modificar el estilo de vida para mejorar su pronóstico, comparándolas a casi todas con grupos de personas similares en situación de no enfermedad7, todo sumado a estudios anteriores realizados por el mismo grupo8, 9, ha permitido concluir, en casi todos los casos, que el nivel de bienestar espiritual encontrado es alto, pero es mayor en la dimensión religiosa que en la existencial, y que para quienes viven en situaciones de enfermedad crónica o terminal, o para los que se encuentran cerca de estas personas, el bienestar espiritual puede significar un factor de crecimiento personal, un aspecto de trascendencia que los acerca a muchas respuestas, necesarias para dar sentido a la vida, la cotidianidad, el dolor y el sufrimiento humano. se espera continuar aportando, desde esta perspectiva, a la construcción del cuidado de las personas en situación de enfermedad crónica y terminal, y al de sus familiares, respetando el bienestar espiritual como un potencial para el mismo. crear salud en la experiencia de enfermedad crónica o terminal demanda un foco unitario, que supere la dicotomía entre salud y enfermedad, y acepte que estas son la expresión de una misma dimensión, que solo tiene sentido dentro de la totalidad del ser humano10. si la espiritualidad tiene importancia terapéutica en pacientes que experimentan crisis o en quienes viven en situaciones de enfermedad, esta temática debe incluirse en los currículos de los programas, en la asistencia y en nuevas investigaciones, con el fin de cualificar la práctica con integración de la dimensión espiritual del cuidado. el cuidado de quienes viven con enfermedad, o sufren a consecuencia de ella, debe priorizar aspectos espirituales, donde se logren espacios de reconciliación con dios, un ser o fuerza superior, compañía de los demás y reflexión de la propia vida, como parte fundamental de la experiencia de la salud. 7. sánchez, beatriz. dimensión espiritual del cuidado de enfermería en situaciones de cronicidad y muerte, bogotá, 2004 (en prensa). 8. pinto, natividad. comparación del empleo de dos escalas de bienestar espiritual en cuidadores familiares de niños con enfermedad crónica. trabajo de promoción a profesora asociada, facultad de enfermería, universidad nacional de colombia, 2002. 9. barrera, lucy, y pinto, natividad. comparación entre el bienestar espiritual y la habilidad de cuidado de los cuidadores de niños en situación de enfermedad crónica, facultad de enfermería, universidad nacional de colombia, 2002. 10. newman, margaret. salud como conciencia expandida, 2a. ed., nln, 1994, pp. 1-14. la espiritualidad no es prerrogativa de los creyentes, pues puede estar desvinculada de la religión y no ser expresada como una práctica religiosa. es decir, que como componente de la salud siempre está presente y se relaciona con la esencia de la vida. 206 215 apoyo social formal.indd 206 aquichan issn 1657-5997 sofía berlanga-fernández1 rosa m. pérez-cañaveras2 m. flores vizcaya-moreno3 rosa tarrés-cansado4 apoyo social formal a un grupo de madres con hijos menores de un año5 1. máster en ciencias de la enfermería. centro de atención primaria de salud amadeo torner, instituto catalán de la salud, barcelona, españa. sbf10@hotmail.es 2. doctora en antropología biológica y de la salud. profesora titular, universidad de alicante, alicante, españa. rm.perez@ua.es 3. doctora en antropología biológica y de la salud. profesora titular, universidad de alicante, alicante, españa. flores.vizcaya@ua.es 4. psicóloga clínica. área de servicios sociales, ayuntamiento hospitalet del llobregat, barcelona, españa. rmtarres@l-h.es 5. los resultados de este trabajo han sido presentados parcialmente en el iii simposio iberoamericano de historia de la enfermería, xii congreso nacional, vii internacional de historia de la enfermería y vii jornadas internacionales de cultura con los cuidados. este trabajo ha sido parcialmente financiado por el colegio de enfermería de barcelona y forma parte del proyecto pr5326-11. recibido: 24 de febrero de 2012 enviado a pares: 21 de agosto de 2012 aceptado por pares: 9 de mayo de 2013 aprobado: 12 de mayo de 2013 año 13 vol. 13 nº 2 chía, colombia agosto 2013  206-215 resumen objetivo: este trabajo pretende analizar el apoyo social formal a un grupo de madres con hijos menores de un año. método: estudio cualitativo, descriptivo interpretativo, en el cual participaron diez mujeres en un grupo focal que se reunió en siete ocasiones. resultados: a partir del análisis de contenido de las dinámicas grupales se detecta que el apoyo formal informativo es el más frecuente y resulta difícil separarlo del emocional. los profesionales, a través del apoyo informativo, tratan temas relacionados con la promoción de la salud y prevención de la enfermedad y acompañan a las madres en este rol. conclusión: para las madres el apoyo formal brindado por el personal de enfermería es positivo y percibido como un refuerzo en su vivencia de la maternidad, y debe estar enmarcado en un contexto cultural. palabras clave salud materno-infantil, investigación cualitativa, atención primaria de salud, atención de enfermería, enfermería. (fuente: decs, bireme). formal social support for a group of mothers with children under age one abstract objective: formal social support for a group of mothers with children under age one is analyzed in this research. method: a qualitative, descriptive study of an interpretive nature was conducted in which ten women participated in a focus group that met on seven occasions. results: a content analysis of the group’s dynamics showed formal informative support is the most common and is difficult to para citar este artículo / to reference this article / para citar este artigo berlanga fernández, s., pérez cañaveras, r., vizcaya moreno, m., tarrés cansado, r. (2013). apoyo social formal a un grupo de madres con hijos menores de un año. aquichan. vol. 13, no. 2, 206-215. 207 apoyo social formal a un grupo de madres con hijos menores de un año l sofía berlanga-fernández, rosa m. pérez-cañaveras, m. flores vizcaya-moreno, rosa tarrés-cansado separate from emotional support. through informative support, professionals address issues related to health promotion and disease prevention, and accompany mothers in this capacity. conclusion: for mothers, the formal support provided by members of the nursing staff is positive and perceived as a reinforcement of their experience with motherhood, and should be framed in a cultural context. key words maternal and child health, qualitative research, primary health care, nursing care, nusing. (source: decs, bireme). apoio social formal a um grupo de mães com filhos menores de um ano resumo objetivo: este trabalho pretende analisar o apoio social formal a um grupo de mães com filhos menores de um ano. método: estudo qualitativo, descritivo interpretativo, do qual participaram dez mulheres em um grupo focal que se reuniu em sete ocasiões. resultados: a partir da análise de conteúdo das dinâmicas grupais, detecta-se que o apoio formal informativo é o mais frequente e resulta difícil separá-lo do emocional. os profissionais, por meio do apoio informativo, tratam temas relacionados com a promoção da saúde e prevenção da doença, e acompanham as mães neste papel. conclusão: para as mães, o apoio formal oferecido pelo pessoal de enfermagem é positivo e percebido como um reforço em sua vivência da maternidade e deve estar situado em um contexto cultural. palavras-chave saúde materna e infantil, pesquisa qualitativa, cuidados de saúde primários, cuidados de enfermagem, enfermagem. (fonte: decs, bireme). 208 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 introducción el apoyo social es un “constructo multidimensional con diferentes aspectos estructurales y funcionales” (1). consta de cinco dimensiones definidas en la investigación previa: la dirección del apoyo, la disposición o accesibilidad a él, la descripción o su evaluación, el contenido del mismo y, por último, las redes que lo componen (1). las redes de apoyo, constituidas por proveedores, fuentes y relaciones íntimas (2), pueden dividirse en informales, siendo un ejemplo de estas la familia y los amigos, y formales donde encontraríamos a las enfermeras (3). los profesionales de enfermería, a través de su apoyo formal, pueden ofrecer distintos tipos de soporte, por ejemplo el apoyo social emocional, en el que la persona cuenta con relaciones en las que confía, comparte y comunica problemas o preocupaciones, sintiéndose querida y comprendida. a través del apoyo social informativo su consejo puede proporcionar una orientación y guía ayudando y acompañando al individuo en la resolución de sus problemas o situaciones. mediante el apoyo instrumental o físico la enfermera ofrecerá una ayuda directa. y por último, con el apoyo de valoración o evaluativo informará a las personas sobre la manera de llevar su rol utilizando comentarios y refuerzos de conductas y actitudes (1, 4). estos tipos de apoyo: emocional, informativo, instrumental y evaluativo constituyen la dimensión del apoyo según su contenido, y pueden ser ofrecidos por las enfermeras acompañando a las madres en su experiencia ante el nacimiento de un hijo. esta experiencia implica nuevos roles y relaciones que deben desarrollarse o redefinirse (5, 6). aunque su vivencia es particular (6, 7), suele ser sentida como estresante y solitaria, viéndose agravada por el aislamiento y la presión social que le acompaña (8). el apoyo social que las madres reciban mejorará el vínculo afectivo entre ella y su hijo y reducirá la tensión creada (6). este apoyo social puede tener su origen en las intervenciones comunitarias y grupales que realizan los profesionales de enfermería, las cuales ocupan un lugar privilegiado al tener un reconocido valor como fuente de salud (4). la evaluación del apoyo recibido a través de ellas requiere de distintos instrumentos, los cuales analizan diferentes aspectos de este constructo (1). pero son escasos los trabajos que evalúan el apoyo desde el punto de vista del proveedor (1). con este trabajo se desea conocer qué tipo de apoyo proporcionan los profesionales a través de las dinámicas grupales a madres con hijos menores de un año, para ello se pretende analizar el apoyo formal en una dinámica grupal de estas características desde la perspectiva profesional, es decir, valorando las intervenciones realizadas por la enfermera y la psicóloga en el transcurso de las sesiones grupales. materiales y métodos este estudio con diseño cualitativo permite el abordaje de la realidad desde la experiencia vivida por las madres, aproximándonos a la mirada emic de la maternidad tal y como se manifiesta, identificando los significados culturales atribuidos a la salud y describiendo el fenómeno (9). con tal fin la investigadora principal, como observadora participante, se incluyó en el campo de estudio colaborando en un grupo de madres con hijos menores de doce meses por un periodo de dos meses y medio, es decir, en el transcurso de siete sesiones de carácter semanal, en el centro de atención primaria de salud amadeo torner de barcelona (españa). en cada sesión, con una duración de dos horas y media, participaron diez madres con sus bebés menores de un año. este mismo grupo de madres es el que acudía semanalmente a cada una de las sesiones conducida por una psicóloga clínica. las participantes fueron elegidas por sus enfermeras referentes para participar en el grupo. se priorizaron las madres primerizas, las que presentaban tristeza o depresión posparto y aquellas que manifestaban la necesidad de compartir sus experiencias con un grupo. el número máximo de asistentes era de diez. para poder ser incluidas en el grupo las madres debían comprometerse en asistir a las sesiones y no podían presentar dificultad idiomática en la comunicación. la investigadora principal —en este caso la enfermera— participaba en todas las sesiones del grupo, observando lo que pasaba, escuchando lo que se decía y preguntando cosas in situ, eso significa que se efectuaron en el mismo lugar donde las personas vivían el fenómeno de interés (10). en este sentido de interacción se conjugaba el concepto del otro con el de la observadora, lo que permitió la aproximación a la realidad (11), pero también a la experiencia en la que la enfermera estaba inmersa (12). 209 apoyo social formal a un grupo de madres con hijos menores de un año l sofía berlanga-fernández, rosa m. pérez-cañaveras, m. flores vizcaya-moreno, rosa tarrés-cansado a través del grupo focal se pretendía comprender la idea, es decir, el tipo de apoyo que los profesionales aportaban. en nuestro caso, la fuente de datos la constituían las situaciones naturales que se producían en el grupo, y que la investigadora principal recogía permitiendo la interrelación e influencia mutua entre investigador y sujeto (11, 13). por tanto, la técnica utilizada para la recolección de datos fue la observación participante, expresión utilizada para designar la investigación que implica la interacción social entre investigador e informantes (14). para llevar a cabo esta investigación fue necesario crear contextos de interacción entre la enfermera y el grupo de madres que permitiera la comunicación espontánea de todos los participantes. cuando se estableció el vínculo de confianza esperado, la información fluyó, lo que permitió construir los datos de interés para el propósito de esta investigación. durante las sesiones del grupo focal el instrumento utilizado para la recolección de datos de manera sistemática y no intrusiva fue un diario de campo empleado por la investigadora principal. en este diario se registraban las conversaciones que se producían, así como las anotaciones para la investigación, siendo estas más amplias, analíticas e interpretativas que una simple enumeración de los sucesos. este recurso permitió consultar de nuevo un hecho producido en su propio momento de ocurrencia (15). el diario ha sido analizado minuciosamente sin la utilización de programas informáticos específicos. los textos resultantes de este proceso fueron analizados manualmente en su estructura (análisis de contenido latente) y contenido (análisis de contenido manifiesto) mediante el método “etapa a etapa” (stage-by-stage) ideado por burnard (16), según los siguientes pasos: a) etiquetado de los datos y creación del índice de datos, b) categorización del contenido de los datos en las categorías principales, c) formulación de una lista de categorías, códigos y subcódigos. las categorías identificadas atendían a las dimensiones del apoyo social: la dirección del apoyo, la disposición o accesibilidad a él, la descripción o su evaluación, el contenido del mismo y, por último, las redes que lo componen. posteriormente se profundizó en el análisis de las dos últimas categorías. de la primera se incluyeron como códigos: el apoyo informativo, emocional, instrumental y evaluativo. de la segunda, se analizó el código: red de apoyo social formal, es decir, el apoyo que como profesionales proporcionan la enfermera y la psicóloga que participan en el grupo. a partir de la intersección entre el código apoyo social y formal y los códigos apoyo informativo, emocional, instrumental y evaluativo, se identificaron una serie de subcódigos relacionados con aspectos más biomédicos, es decir, de promoción de la salud y prevención de la enfermedad, y otros tantos relacionados con los factores que ramona mercer describe en su teoría del rol maternal: convertirse en madre, factores que tal y como ella indica pueden influir de manera directa o indirecta sobre el rol maternalconvertirse en madre (2). una vez realizado el análisis del diario de campo, y con el objetivo de ofrecer rigor a la información obtenida, tanto la metodología —es decir, las categorizaciones y codificaciones identificadas— como los resultados fueron revisados, discutidos y contrastados con la psicóloga clínica que participó en el taller. ante diferencias de interpretación, y con el objetivo de resolverlas, se consultó con tres enfermeras con experiencia en la conducción de grupos focales similares. se debe señalar que previo al inicio de la investigación este proyecto fue presentado al comité de ética de investigación clínica del idiap jordi gol y gurina que emitió el certificado pertinente. también se pidió conformidad a las madres para tomar notas de campo y en todo el proceso los datos fueron registrados y analizados sin comprometer la identidad de las participantes. además, se informó de la importancia de este trabajo para poder analizar el apoyo que los profesionales implicados prestaban a las madres. resultados a partir de los análisis de los datos se identificaron los códigos relativos al tipo de apoyo social formal (informativo, evaluativo, emocional e instrumental), y su relación con los proveedores del apoyo (enfermera y psicóloga), y los subcódigos adopción del nuevo rol, y promoción de la salud y prevención de la enfermedad. la muestra estaba constituida por 10 madres entre 25 y 36 años de edad. de ellas el 80 % eran madres primerizas y el 20 % tenían dos hijos. el 80 % tenían pareja y el 20 % no. la asistencia 210 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 a las sesiones fue elevada, encontrando en todas las sesiones entre 9 y 10 participantes. en todos los casos la inclusión al grupo fue realizada por la enfermera referente del niño. en relación con el contenido del taller encontramos los siguientes resultados. en primer lugar, el apoyo formal informativo se produce en 209 ocasiones (98,1 %), seguido del evaluativo en 3 (1,3 %) y del emocional e instrumental en 1 (0,3 %) cada uno (figura 1). figura 1. tipos de apoyo social formal a (madre). el viernes le ponen las vacunas y eso me angustia, sobre todo por las reacciones. no hace cacas desde hace tres días. se la ve más intranquila y nerviosa y como no habla no sé lo que le pasa. enfermera. habla del ritmo en las deposiciones. también explica las vacunas y los efectos adversos: “es importante que participéis en el acto vacunal, hablando a vuestro bebé, cogiéndolo… y pensando que lo que le estáis haciendo es algo bueno”. en segundo lugar, según el proveedor encontramos que: la enfermera realiza el apoyo social informativo en 66 ocasiones (30,8 %), el evaluativo e instrumental en 1 (0,5 %) cada una. la psicóloga realiza el apoyo social informativo en 143 ocasiones (66,8 %), el evaluativo en 2 (0,9 %) y el emocional en 1 (0,5 %) (figura 2). figura 2. tipos de apoyo social formal según proveedor atendiendo al apoyo informativo, cuando la madre tiene dudas pregunta y comparte sus problemas. el profesional, a través de la información que facilita, proporciona orientación y guía acompañando a la madre en la resolución de sus preocupaciones. en ese momento la ansiedad, inseguridad o angustia que a la madre le pueda producir una situación queda disminuida. por tanto, el profesional aporta apoyo informativo que complementa y refuerza con un especial apoyo emocional: e (madre). a o le gusta dormir y solo llora si tiene sueño. toma el biberón. he tenido un posparto muy malo con muchas hemorragias. le dejé de dar el pecho. las cosas no eran como yo pensaba. lo malo es que no te explican bien lo que comporta la lactancia. enfermera. explica lo que es una vivencia positiva o negativa de la lactancia. las vivencias además son particulares. también comenta que la lactancia es dura al principio y que hay niños que lo ponen más fácil que otros. el apoyo proporcionado por ambas profesionales a través de sus intervenciones en el transcurso del taller se complementa para abordar a la persona en todas sus dimensiones: biológica, psicológica y social. psicóloga. explica que las situaciones difíciles son las que nos hacen enriquecer. un primer hijo es “un plato fuerte”. es un momento de crisis personal. el primer año de vida es un año para toda la vida. el ejemplo está en el peso, al año el peso… enfermera. lo triplica. psicóloga. lo mismo con la talla. ¿cuántos centímetros tenía vuestro hijo al nacer? las madres responden. enfermera. orienta sobre las medidas. 211 apoyo social formal a un grupo de madres con hijos menores de un año l sofía berlanga-fernández, rosa m. pérez-cañaveras, m. flores vizcaya-moreno, rosa tarrés-cansado en esta línea, desde situaciones concretas, como puede ser la alimentación, puede abarcarse no solo la dimensión biológica de la nutrición, sino los aspectos comunicativos y emocionales que envuelven el acto de comer: enfermera. habla de la comida, los alimentos que se incorporan según la edad del bebé y de la importancia de todos los momentos relacionados con la comida. psicóloga. informa que el comer es también un momento de relación. madre. pues para el bebé el comer es un momento de irritabilidad. psicóloga. explica que los bebés no tienen sensación de hambre. ellos tienen una sensación de malestar que se calma cuando la madre le alcanza un objeto a la boca: el pezón, y necesita que la madre se acerque y le diga: “¡necesitas comer!“, y es la madre la que sabe qué necesita comer. es un momento donde la madre le está dando un significado a lo que le pasa a su bebé. es importante el factor emocional y relacional: el niño no es un tubo digestivo. cuando alimentamos a un niño no es solo de leche, también es un momento de buena relación. este abordaje permite que a través del apoyo social informativo se traten temas relacionados con aspectos de la promoción de la salud y prevención de la enfermedad y acompañen a las madres en este nuevo rol, subcódigos detectados en el análisis de los contenidos del taller, los cuales están ordenados por frecuencias absolutas de mayor a menor aparición. respecto al subcódigo adopción del nuevo rol (tabla 1), este se divide en 23 ítems: señales de los lactantes, unión, adopción del rol maternal, ansiedad, tensión debida al rol, autoconcepto, estrés, padre, relación padre-madre, apoyo social, actitudes respecto a la crianza, estrés, características del niño, funcionamiento de la familia, identidad materna, estrés en el cuidado del niño, flexibilidad, culpabilidad-vergüenza, estrés vital, autoestima, gratificaciónsatisfacción, temperamento del niño y percepción de la experiencia del nacimiento. respecto al subcódigo promoción de la salud y prevención de la enfermedad (tabla 2), este se divide en 21 ítems: desarrollo psicomotor y físico, alimentación, descanso, consejos posturales, llanto, utilización del chupete, prevención de accidentes, vacunas, hiperestimulación, masaje, cólicos, cuidados de la piel, mosquitos, mucosidad, vómitos, ola de calor, deposiciones, higiene-esterilización, actividad acuática, televisión y sexualidad. tabla 2. frecuencia de los ítems relacionados con la promoción de la salud y prevención de la enfermedad tabla 1. frecuencia de los ítems relacionados con la adopción del nuevo rol 212 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 no obstante, se debe resaltar la complejidad en catalogar las distintas intervenciones, dado que una sola aportación puede incluir diferentes subcódigos: psicóloga. explica la importancia de estar acompañada en la medida de lo posible. alguien los puede ayudar en determinados momentos. todo lo que va pasando a nuestro alrededor es importante para poder pensar. un niño llora y se inquieta mucho, a la madre le entra de todo: palpitaciones, sudores, vergüenza… una ayuda va bien. la crianza en soledad es dura. en este sentido, esta intervención expresa un apoyo social informativo en el que la psicóloga explica la importancia de tener una ayuda, los sentimientos de ansiedad, inseguridad y vergüenza que provoca el llanto de un bebé en determinadas situaciones, la dificultad o tensión que siente una madre cuando debe afrontar la obligación de rol maternal, situaciones que pueden verse afectadas por la dificultad de interpretar las señales que su bebé le está enviando o por una vivencia maternal en solitario. aunque esta codificación resulte difícil, se puede observar que la información más frecuente es la relacionada con la adopción de un nuevo rol seguida de la promoción de la salud y prevención de la enfermedad. en relación con el rol, las profesiones orientan a las madres sobre las respuestas que les provocan las señales que sus hijos emiten, así como las acciones que pueden fomentar la unión con sus bebés: madre. yo en esta semana he observado que mi bebé se ha descubierto los pies, se los lleva a la boca y se enfada. psicóloga. ¿por qué creéis que se los lleva a la boca? madre. ¿por qué necesita descubrir las cosas? psicóloga. informa que eso es cierto. reconoce el mundo a través de la boca. madre. se trata de un niño dormilón, comilón y tranquilo. duerme muy bien por la noche. lo despierto por las tomas. le doy el biberón porque no puedo darle el pecho. psicóloga. hace reflexionar: sin importar lo que optéis las madres sobre el alimento escogido para el bebé, lo importante es el contacto, que os huelan. los bebés necesitan estar cuerpo a cuerpo. pero, ¿qué hacen los bebés cuando nos los ponemos encima? madre. buscan la postura. enfermera. habla de las posturas al dormir y de los ritmos de sueño y alimentación por las noches. también comenta la importancia del contacto piel a piel. además, en el transcurso de las sesiones surgen temas como la ansiedad, la tensión debida al rol o el autoconcepto, entre otros. desde el subcódigo promoción de la salud y prevención de la enfermedad, aparecen conceptos como el desarrollo psicomotor y físico del bebé, así como la alimentación, el descanso y el llanto. psicóloga. informa que a los dos meses debemos incorporarlos un poquito porque empiezan a ver mejor. enfermera. comenta que se debe respetar la evolución y maduración del bebé y no forzar los movimientos. madre. tengo dudas sobre dónde debe dormir el bebé. mi pareja y yo estamos de acuerdo en ponerlo en la cama y te encuentras en todo momento cuestionada y yo pienso en hacer lo que creo que sea más consecuente. tampoco se cuánto tiempo ha de estar en el pecho. estoy hecha un lío. psicóloga. informa que lo que la madre dice está muy bien. siempre se tienen dudas. lo importante es hablarlo y pensarlo. estas preocupaciones son convenientes. cada uno va encontrando su manera de hacer. al principio uno tiene que ir inventando horarios. después los niños se tendrán que adaptar a unas rutinas pero poco a poco. pero, ¿por qué el niño tiene todo el día el pecho en la boca? madres. por contacto, por seguridad, porque es relajante y se tranquiliza… para finalizar, todas las intervenciones son percibidas por las madres como un apoyo positivo y un refuerzo en su vivencia de la maternidad. madre. el curso ha sido muy enriquecedor. 213 apoyo social formal a un grupo de madres con hijos menores de un año l sofía berlanga-fernández, rosa m. pérez-cañaveras, m. flores vizcaya-moreno, rosa tarrés-cansado madre. lo recomiendo a otras madres. he podido compartir cosas y he encontrado apoyo. madre. el grupo muy bien. pienso que es necesario este tipo de actividad en que unas madres y otras se relacionan. discusión atendiendo al objetivo del estudio comentaremos los resultados más llamativos, poniéndolos en relación con los resultados de otros trabajos previos. en primer lugar, se analizará el apoyo social como aquel que pretende facilitar la transición de las mujeres hacia la maternidad, procurando un bienestar tanto de la madre como de su hijo (17). para procurar ese bienestar, tanto los profesionales participantes en nuestro estudio como los profesionales de estudios previos, desde la red social formal (17), han proporcionado apoyo informativo, emocional, instrumental y evaluativo, coincidiendo en que el informativo es el más prevalente. se ha sugerido que el apoyo informativo es el que permite a las madres adaptarse a la maternidad con facilidad y confianza (17). pero se fusiona a menudo al apoyo emocional, de tal manera que resulta difícil separarlos (6), lo cual se ha podido constatar también en los resultados obtenidos. ambos tipos de apoyo, ofrecidos tanto en esta como en otras experiencias (18, 19), pueden detectarse a través de las distintas intervenciones que tanto la enfermera como la psicóloga han proporcionado a partir de las preguntas formuladas por las participantes en el transcurso del taller. al respecto, tanto en este estudio como en investigaciones previas (6) se ha evidenciado que las madres buscan en las redes formales: apoyo informativo y emocional, y no tanto instrumental o físico. respecto al apoyo instrumental o físico, en el que profesionales ofrecen una ayuda directa, apenas fue proporcionado por la psicóloga y la enfermera en el transcurso de las sesiones. en cambio, sí pudo observarse cómo, de manera espontánea, unas madres se ayudaban a otras, por ejemplo, a preparar los biberones, así como a calmar o entretener al bebé de otras mamás. para finalizar el análisis del apoyo según su contenido, debemos hacer referencia al apoyo evaluativo. en relación con este, aunque otros estudios revelan la importancia que la enfermería tiene en proporcionar este tipo de soporte (17), ambas profesionales no suelen decir a la madre que están realizando ni bien ni mal determinadas acciones, en su defecto, ofrecen información al respecto para que sea ella misma la que analice su propia acción. de esta manera pueden observarse los distintos enfoques de crianza de los hijos sin crear las tensiones que pueden detectarse en otros grupos (19) y los profesionales. así, la orientación y el acompañamiento a las madres en la vivencia de su maternidad les permitirá reflexionar sobre el mejor enfoque, sin cuestionar las decisiones que van tomando, pero sí analizando los pros y los contras de las mismas. este análisis permitirá desarrollar la confianza y la sensación de capacidad de la madre, sugerida en otras experiencias (17). en este sentido, tanto la psicóloga como la enfermera mejorarán la calidad percibida por las madres proporcionando un apoyo formal que permita mejorar el afrontamiento de la maternidad, apoyo sugerido como estrategia de prevención y afrontamiento de los problemas emocionales en el posparto (12). este apoyo también ha sido considerado prioritario, según otros estudios, en proveedores de salud (10). por tanto, queremos hacer énfasis en que a través de esta dinámica grupal se ofrece a las madres un apoyo formal que resulta necesario durante el puerperio y en el desarrollo infantil enfrentándose al reto de desarrollar elementos que hagan énfasis en la información, la educación y la promoción de la salud, tal y como se observa en otros estudios (20). pero también observamos que se enfatizan aspectos relacionados con la prevención de la enfermedad y con situaciones derivadas de la adopción del nuevo rol (7). de esta manera, el soporte dado por las enfermeras y el grupo de apoyo es importante. sin este soporte, y sin una comunicación eficiente en el mismo, las mujeres, en este momento de su vida, pueden experimentar impotencia, así como menor autoconfianza y autoestima (6). es por este motivo que las madres requieren de la comprensión de la complejidad de los procesos que vive la familia por parte de las enfermeras, las cuales pueden ofrecer un cuidado “cultural, sensitivo, congruente y competente” (21), el cual se ha visto reflejado en el desarrollo de este taller, en el que se ha logrado recrear una situación de simbiosis entre lo biológico, lo psicológico y lo social. desde una perspectiva antropológica podríamos explicar que en ese escenario de interacción la psicóloga ejerce el rol de conductora del taller, siendo la enfermera la observadora participante. 214 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 entre las limitaciones metodológicas del presente estudio encontramos, tal y como se ha mencionado con anterioridad, las relacionadas con la complejidad en catalogar las distintas intervenciones, dado que una sola aportación puede estar incluida en diferentes categorías. además, todas estas aportaciones corresponden al análisis de una determinada dinámica grupal, en la cual las profesionales ofrecen apoyo social formal a un grupo de madres con hijos menores de un año. sería interesante evaluar si los resultados obtenidos de este estudio son similares a los desarrollados en otros grupos, ya sean de la misma o de diferente temática, analizando las intervenciones de enfermería como proveedoras de apoyo social formal. también sugerimos la evaluación de la percepción que las madres tienen en relación al apoyo social recibido por parte de enfermería, ya que no todos los estudios son coincidentes en sus resultados (7, 11, 22). conclusión se debe seguir estudiando y analizando el apoyo social formal y las actuaciones de la enfermera, a través de su rol autónomo y colaborador con otros profesionales, en relación con el acompañamiento a las madres en las dinámicas grupales y en su experiencia maternal. agradecimientos se reconoce la ayuda brindada por el colegio de enfermería de barcelona para el desarrollo de esta investigación concediendo a este proyecto una financiación parcial en el marco de ayudas a proyectos de investigación pr 5326-11. referencias 1. terol mc, lópez s, neipp mc, rodríguez j, pastor ma, martín-aragón m. apoyo social e instrumentos de evaluación: revisión y clasificación. anuario de psicología. 2004;35(1):23-45. 2. marrimer a, raile m. modelos y teorías en enfermería. 7 ed. madrid: elsevier; 2011. 3. leahy p. social support for first-time mothers. an irish study. mcn am j matern child nurs. 2007;32(6):368-74. 4. lópez i, menéndez s, lorence b, jiménez l, hidalgo mv, sánchez j. evaluación del apoyo social mediante la escala assis: descripción y resultados en una muestra de madres en situación de riesgo psicosocial. intervención psicosocial. 2007;16(3):323-337. 5. stern d. el nacimiento de una madre. barcelona: paidós ibérica; 1999. 6. nyström k, öhrling k. parenthood experiences during the child’s first year: literature review. j adv nurs. 2004;46(3):319-330. 7. wilkins c. a qualitative study exploring the support needs of first-time mothers on their journey towards intuitive parenting. midwifery. 2006;22:169-180. 8. alger i. la transformación de la maternidad en la sociedad española 1975-2005. otra visión sociológica. fundación centro de estudios andaluces 2006. [visitado ago. 2011]. disponible en: http://dialnet.unirioja.es/servlet/articulo?codigo=2133098 9. campos p, barbosa ma, fernandes g. the study of the phenomenology as one way of access for the improvement of the nursing assistance. cultura de los cuidados. 2011;29:9-15. 10. landeros e, morales mc, martínez mc. una aproximación al cuidado de enfermería desde el enfoque etnográfico. índex de enfermería. 2010;19(2-3):187-190. 11. jiménez v, hurtado i. apoyo educativo de enfermería en cuidados maternales de las adolescentes primíparas. desarrollo científ enferm. 2007;15(2):66-68. 12. de la cuesta b. estrategias cualitativas más usadas en el campo de la salud. nure investigación 2006. [visitado feb. 2012]; 26, nov-dic. disponible en: http://www.nureinvestigacion.es/ficheros_administrador/f_metodologica/ fmetod_25.pdf 215 apoyo social formal a un grupo de madres con hijos menores de un año l sofía berlanga-fernández, rosa m. pérez-cañaveras, m. flores vizcaya-moreno, rosa tarrés-cansado 13. de la cuesta c. el investigador como instrumento flexible de la indagación. international journal of qualitative methods, 2003. [visitado feb. 2012]; 2(4). disponible en: http://www.ualberta.ca/~iiqm/backissues/2_4/pdf/delacuesta.pdf 14. taylor sj, bogdan r. introducción a los métodos cualitativos de investigación. buenos aires: paidós; 1990. 15. prochnow a, dos santos jl, de lima sb, leite j. la etnografía utilizada en una investigación en enfermería: a construcción de una “descripción densa”. index de enfermería. 2009;18(1):47-51. 16. burnard p. a method of analysing interview transcripts in qualitative research. nurse education today. 1991;11,461-466. 17. leahy p. first-time mothers: social support and confidence in infant care. jan. 2005;50(5):479-488. 18. mcleod a, baker d, black m. investigating the nature of formal social support provision for young mothers in a city in the northwest of england. health and social care in the comumunity. 2006;14:453-464. 19. hall w, irvine v. e-communication among mothers of infants and toodlers in a community-based cohort: a content analysis. jan. 2008;65(1):175-183. 20. maroto-navarro g, garcía-calvente mm, mateo-rodríguez i. el reto de la maternidad en españa: dificultades sociales y sanitarias. gac. sanit. [en internet]. [visitado ene. 2012]. disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s0213-91112004000500004&lng=es 21. carnaval ge, jaramillo cd, rosero dh, valencia mg. la teoría de las transiciones y la salud de la mujer en el embarazo y en el postparto. aquichan, 2007. [visitado ene. 2012]; 7(1): 8-24. disponible en: http://aquichan.unisabana.edu.co/ index.php/aquichan/article/download/94/192 22. marten v, heckler hc, coelho s, de lima l. redes de apoyo utilizadas por la familia cuando el niño nace com necesidades especiales. evidentia. 2011 [visitado ene. 2012]; 8(36). disponible en: http:// www.index-f.com/evidentia/n36/ ev7235.php 336 350 la experiencia del padre durante.indd 336 aquichan issn 1657-5997 erika melania cañas-lopera1 yanira astrid rodríguez-holguín2 la experiencia del padre durante la hospitalización de su hijo recién nacido pretérmino extremo 1 magíster en enfermería con énfasis en cuidado materno perinatal. enfermera asistencial, unidad de recién nacidos, clínica palermo, bogotá, colombia. melis142@hotmail.com 2 magíster en enfermería con énfasis en cuidado materno perinatal. profesor catedrático asociado, universidad nacional de colombia. coordinadora de educación continuada, hospital militar central. bogotá, colombia. yanyrar@hotmail.com recibido: 07 de diciembre de 2012 enviado a pares: 11 de febrero de 2013 aceptado por pares: 03 de julio de 2014 aprobado: 03 de julio de 2014 doi: 10.5294/aqui.2014.14.3.6 para citar este artículo / to reference this article / para citar este artigo cañas-lopera em, rodríguez-holguín ya. la experiencia del padre durante la hospitalización de su hijo recién nacido pretérmino extremo. aquichan. 2014; 14 (3): 336-350. doi: 10.5294/aqui.2014.14.3.6 resumen objetivo: identificar el significado que le asigna el padre a la hospitalización de su hijo recién nacido pretérmino extremo. materiales y métodos: estudio cualitativo, con la metodología de etnoenfermería, realizado en bogotá, en el que participaron ocho padres. los datos fueron analizados teniendo en cuenta las cuatro fases para el análisis de la información según leininger. resultados y discusión: a la luz de la teoría del sol naciente de leininger surgen dos temas y siete patrones contrastados. primer tema: “la hospitalización del recién nacido pretérmino extremo: cambios en la estructura social y cultural del padre”, con cinco patrones. segundo tema: “unidad de cuidado intensivo neonatal: primer hogar para el recién nacido pretérmino extremo”, con dos patrones. conclusiones: para los padres la hospitalización del hijo representa un cambio en su vida, donde el eje central son su hijo y su pareja; esto genera modificaciones en la estructura social y cultural, con el propósito de afianzar la relación de pareja, el bienestar de la familia y compartir la situación que están viviendo. palabras clave padre, prematuro, relaciones padre-hijo, cuidado intensivo neonatal, enfermería neonatal, atención de enfermería, cultura. (fuente: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 336-350 337 la experiencia del padre durante la hospitalización de su hijo recién nacido pretérmino extremo l erika melania cañas lopera y otro. año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 336-350 the experience of fathers during the hospitalization of a preterm newborn abstract objective: identify what hospitalization of an extremely preterm newborn means to the father. materials and methods: this qualitative study, based on an ethnonursing methodology, was conducted in bogota. eight parents took part. the data were analyzed according to the leininger four-phase method for analysis. results and discussion: two topics and seven contrasting patterns emerged in light of leininger’s sunrise model. first topic: "hospitalization of extreme preterm infants: changes in the father’s social and cultural structure," with five patterns. second topic: "neonatal intensive care unit: first home for extremely preterm infants," with two patterns. conclusions: the hospitalization of a child is a life-changing event for the father, with the focus being on his child and his partner. this generates changes in the social and cultural structure, so as to strengthen the relationship with the partner, the well-being of the family and to share the situation they are going through. key words father, premature, parent-child relationships, neonatal intensive care, neonatal nursing, nursing care, culture (source: decs, bireme). 338 aquichan issn 1657-5997 a experiência do pai durante a hospitalização do seu filho recémnascido prematuro extremo resumo objetivo: identificar o significado que o pai dá à hospitalização de seu filho recém-nascido prematuro extremo. materiais e métodos: estudo qualitativo, com a metodologia de etnoenfermagem, realizado em bogotá, do qual participaram oito pais. os dados foram analisados considerando as quatro fases para a análise da informação segundo leininger. resultados e discussão: à luz da teoria do sol nascente de leininger, surgem dois temas e sete padrões constrastados. primeiro tema: “a hospitalização do recém-nascido prematuro extremo: mudanças na estrutura social e cultural do pai”, com cinco padrões. segundo tema: “unidade de tratamento intensivo neonatal: primeiro lar para o recém-nascido prematuro extremo”, com dois padrões. conclusões: para os pais, a hospitalização do filho representa uma mudança em sua vida, em que o eixo central são seu filho e sua companheiro; isso gera modificações na estrutura social e cultural, com o propósito de consolidar a relação do casal, o bem-estar da família e compartilhar a situação que está vivendo. palavras-chave pai, prematuro, relações pai-filho, tratamento intensivo neonatal, enfermagem neonatal, atendimento de enfermagem, cultura (fonte: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 336-350 339 la experiencia del padre durante la hospitalización de su hijo recién nacido pretérmino extremo l erika melania cañas lopera y otro. introducción dentro de la práctica profesional en las unidades de cuidado intensivo neonatal (ucin) se evidencia un impacto en la familia frente al nacimiento de un neonato pretérmino extremo (neonato con edad gestacional entre 24-30 semanas y peso inferior a 1.500 g), en especial para el padre, quien es la primera persona que se enfrent a a la hospitalización de su hijo; en muchos casos es la única fuente de comunicación que tiene la madre acerca de la situación de su hijo, cuando ella debe quedarse hospitalizada en la unidad de cuidado intensivo (uci), y para el neonato es, casi siempre, el único vínculo afectivo conocido hasta el momento, además de la madre. en la revisión realizada los estudios referentes al padre incluyen padre y madre o solamente la madre, estudios específicos dirigidos a los padres son pocos: “el cuidado y el convivir con el hijo prematuro: la experiencia del padre”, de rizatto (1), de lo que se concluye que es necesario insertar una mirada masculina como elemento importante en la construcción de un modelo de atención y gestión en las unidades neonatales, centrado en el control del riesgo de lazos emocionales entre padres e hijos, que están en peligro de ser afectados, relacionado con el periodo de hospitalización, las rutinas impuestas por la institución y el estado clínico de la madre y el niño. “involucrar a padres en la unidad de cuidado intensivo neonatal tomando los obstáculos para el bebé”, de nagorski (2), arroja una serie de perspectivas del padre, diferentes a las planteadas por la madre, como la confianza que necesita en el personal asistencial, barreras como las características físicas de la unidad, el desarrollo tecnológico de la misma y limitaciones sociales. existen dificultades del padre para acudir continuamente a las ucin, debidas en parte a que deben continuar con su trabajo para solventar económicamente a la familia, aspecto que es analizado en el estudio “la primacía del trabajo y la paternidad en prematuros: resultado de un estudio fenomenológico interpretativo”, de pohlman (3), que arrojó como resultado la primacía del trabajo del padre con un sentido de fervor, con el fin de proveer financieramente a sus familias, en parte, porque en el ámbito laboral los padres se sienten expertos, en lugar de sentirse novatos, como cuando asisten a la ucin. el padre que se enfrenta a la hospitalización de su hijo recién nacido pretérmino extremo llega a la ucin acompañado de una carga de preocupaciones relacionadas con el estado de salud de la madre y del hijo esperado, con una imagen ideal de recién nacido, para enfrentarse a una serie de impactos relacionados con el funcionamiento de las ucin, las características de su hijo, el bajo peso, alteraciones patológicas que requieren una intervención y abordaje por parte del equipo médico pero, en especial del personal, de enfermería, siendo este último quien en definitiva es la primera persona con la que se relaciona el padre en la unidad. la presente investigación aporta al significado social, disciplinar, teórico y práctico de la profesión de enfermería y las acciones e intervenciones requeridas por este profesional en la ucin, y permite el desarrollo del conocimiento de las necesidades de cuidado que tiene el padre como primer contacto del neonato pretérmino extremo, a fin de anticipar situaciones que requieran de apoyo e interacción inmediata del profesional motivándolo a dar solución a problemáticas surgidas en esta temática, basádo en la aplicación del conocimiento que emerge de investigación de enfermería. dentro del significado social aporta al cuidado integral y humanizado del neonato, pues vincula al padre al proceso de hospitalización del recién nacido pretérmino extremo y permite ver el cambio de roles inesperado que significa para el padre este evento; aporta de manera significativa a las políticas del fondo internacional de emergencia de las naciones unidas para los niños (unicef) para la integración del padre en el proceso de nacimiento y hospitalización de los hijos dentro del marco de la estrategia de las instituciones amigas de la mujer y la infancia (iami) (4), cuya finalidad en última instancia es garantizar a los niños y las niñas de colombia el mejor comienzo posible para sus vidas y el involucramiento responsable de los hombres a lo largo de la gestación, el nacimiento y la crianza de los hijos. teniendo en cuenta los planteamientos anteriores, el objetivo del presente estudio fue identificar el significado que le asigna el padre a la hospitalización de su hijo recién nacido pretérmino extremo en la ucin. materiales y métodos la presente investigación se realizó a partir de un abordaje cualitativo con la metodología de la etnoenfermería, a fin de identificar el significado que le asigna el padre a la hospitalización de su hijo recién nacido pretérmino extremo en la ucin, por medio de una descripción profunda y completa de eventos, situaciones mentales, interacciones, actitudes, creencias y emociones de los padres (5); se tuvo en cuenta la unidad de análisis de los significados (5), que son las categorías lingüísticas para referirse a 340 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 la vida social tales como definiciones, ideología o estereotipos, para ir más allá de la conducta, a partir de describir, interpretar y justificar; en este caso se tuvieron en cuenta las creencias, los valores y las ideologías del padre frente a la hospitalización de su hijo, para que sobre la base de este conocimiento la enfermera pueda brindarle a los padres un cuidado humanizado, integral y oportuno en la práctica profesional. la etnoenfermería es un método de investigación riguroso, científico e inductivo que surge de enfermería para enfermería y prepara al profesional con una sensibilidad susceptible a las necesidades de las personas, por medio de una clasificación sistemática de las creencias, los valores y las prácticas que se aplican en la asistencia de la disciplina, según los conocimientos teóricos o subjetivos que tiene el padre, a través de manifestaciones emicas (interior) expresadas por el lenguaje, las experiencias, las convicciones y el sistema de valores sobre el significado que le asigna a la hospitalización de su hijo recién nacido pretérmino extremo en la ucin (6), accediendo al descubrimiento de cuidados fundados y basados en los padres, empleando datos centrados en los informantes (padres) y no en las convicciones o prácticas éticas (conocimiento general, visión externa) del investigador. los temas y patrones obtenidos se contrastaron a la luz del modelo del sol naciente de madeleine leininger, y permitieron identificar factores de la estructura social que pueden ser más dominantes en unos padres que en otros (religión, parentesco, tecnología y economía); cada componente fue estudiado a profundidad para identificar aspectos del cuidado y entender el significado que le da el padre a la hospitalización de su hijo recién nacido pretérmino extremo en la ucin. como técnicas de recolección de la información se utilizaron: la observación-participación-reflexión (opr), diario de campo, entrevista abierta y a profundidad, y grabación. participantes y muestra: padres de neonatos pretérmino extremo hospitalizados en la ucin de una institución de salud de tercer nivel, con los siguientes criterios de inclusión: padres de recién nacidos pretérmino extremo hospitalizados en la unidad de recién nacidos (urn), padre que participa activamente durante la hospitalización de su hijo (que responde por la hospitalización de su hijo, que visita continuamente a su hijo o según su disponibilidad de tiempo), y padre que convive con la madre del bebé. los padres seleccionados fueron denominados informantes clave (tabla 1) (7), según la etnoenfermería son las personas que han sido escogidas a propósito por ser más conocedores sobre el dominio de la investigación. tabla 1. caracterización de los informantes clave fuente: tomado de erika melania cañas lopera, investigadora. padre estrato social religión padre que participa activamente en la hospitalización de su hijo datos del recién nacido peso edad gestacional tiempo de estancia en urn 1. camilo 4 cree en dios sí 775g 27 semanas 75 días 2. sebastián 3 católico sí 1410g 840g 30 semanas (gemelar) 46 días 3. andrés 5 católico sí 520g 27 semanas 76 días 4. mauricio 4 católico sí 780g 29 semanas 49 días 5. alberto 2 cristiano sí 500g 26.5 semanas 35 días 6. sergio 3 cree en dios sí 1304g 30.5 semanas 68 días 7. martín 4 católico sí 945g 29 semanas 49 días 8. antonio 2 mormón si 1220g 29 semanas 56 días 341 la experiencia del padre durante la hospitalización de su hijo recién nacido pretérmino extremo l erika melania cañas lopera y otro. la información se obtuvo a partir de 21 entrevistas realizadas a 8 padres participantes en el estudio. la muestra se dio por saturación de la información, teniendo en cuenta los criterios de muestreo según sandoval (8): pertinencia, adecuación, conveniencia, oportunidad y disponibilidad. consideraciones éticas: en esta investigación se tuvieron en cuenta los principios éticos básicos de la investigación contemplados por el consejo de organizaciones internacionales de las ciencias medicas (cioms) (9), como son: el respeto a la autonomía, la beneficencia y no maleficencia, la justicia, la veracidad, la fidelidad y la reciprocidad (10). a los padres se les informó sobre el estudio explicando los objetivos de la investigación, los riesgos, los beneficios, el tipo de información requerida y la posibilidad de publicación de resultados; posterior a la solicitud de su participación voluntaria, previo consentimiento informado, se programaron las entrevistas en horario diferente a la visita de su hijo en la urn. se contó con la aprobación del comité de ética de la institución donde se realizó la investigación. se consideró una investigación de riesgo mínimo. análisis de la información: el análisis se realizó teniendo en cuenta las cuatro fases para el estudio de los datos cualitativos en etnoenfermería según leininger (11), para lograr un análisis propio de la investigación cualitativa centrado en los criterios de validez y confiabilidad como son: credibilidad, confirmabilidad, significado en su contexto, patrones recurrentes, saturación y transferencia. la asociación de los datos se realizó a la luz del modelo del sol naciente, lo cual permitió una relación de la teoría con los hallazgos encontrados y, a partir de ellos, tener un conocimiento de enfermería basado en la teoría. primera fase. recolección, descripción y documentación de datos en bruto: la recolección de información de los informantes clave se inició por medio de entrevistas abiertas y a profundidad. para cada uno de los padres se utilizó un seudónimo y se realizó la transcripción exacta de las entrevistas, diario de campo y memos, resaltando expresiones del padre y tonos de voz, lo que permitió iniciar un análisis etnográfico (12) que es la búsqueda de frases y sus relaciones, identificando cómo son conceptualizadas por los padres, y los símbolos entendidos como cualquier evento u objeto que refiera a algo manifestado durante la entrevista con el padre como es: tono de voz elevado, movimiento de manos, silencios, los cuales se escribieron como notas de campo y memos al lado de cada respuesta del padre. se inició la señalización, por medio de colores, de las unidades de análisis (13) —líneas con unidades de significados importantes para el análisis— y los descriptores —que son los sentimientos manifestados por el padre que se relacionan con el objetivo del estudio—. se estableció un método de codificación para cada informante que se denominó caso, y a cada entrevista se le asignó un dígito según el número de entrevistas realizadas a cada padre; en la transcripción de cada entrevista se enumeraron los párrafos y se constituyeron en paquetes de información por cada informante; ejemplo: c2e1p1. segunda fase. identificación y categorización de los descriptores y componentes: se continuó con el análisis de cada una de las unidades de análisis identificadas y se procedió a realizar la asociación por color según la información analizada en la etapa anterior, se reunió cada unidad de análisis del mismo color y se continuó la codificación, esta última entendida como el proceso de identificar palabras, frases, temas o conceptos dentro de los datos de manera tal que los patrones subyacentes puedan ser identificados y analizados (14). se volvieron a leer los datos y se hicieron comentarios al margen observando todo aquello que era sobresaliente; se ubicaron dentro de una matriz de análisis con los siguientes datos: código numérico, descriptores, código sustantivo y memo, que permitieron descubrir las relaciones entre los datos recolectados y el fenómeno estudiado. en esta fase se seleccionaron todos los descriptores que apuntaban a un código sustantivo identificado en la entrevista y se agruparon. tercera fase. análisis contextual y de patrones: se retomó toda la información identificada en cada padre y se verificó la saturación de información a nivel individual, se realizó un cuadro acumulativo y comparativo de los códigos sustantivos identificados en cada uno de ellos con el fin de determinar los más representativos, el número de veces que se repetían y los códigos nuevos o únicos que requerían saturación con los siguientes participantes. cuarta fase. temas centrales, hallazgos de investigación, formulación teórica y recomendaciones: en esta fase se buscó abstraer y confirmar los temas principales, se extrajeron dos temas centrales con siete patrones que aportan al significado que le da el padre a la hospitalización de su hijo recién nacido pretérmino extremo en la ucin. 342 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 resultados el significado que le asigna el padre a la hospitalización de su hijo recién nacido pretérmino extremo en la ucin está enmarcado en dos temas centrales: “la hospitalización del recién nacido pretérmino extremo: cambios en la estructura social y cultural del padre” y “ucin: primer hogar para el recién nacido pretérmino extremo”, conformados por cinco y dos patrones respectivamente, relacionados con la dimensión de la estructura social y cultural, cuidado genérico y profesional del modelo del sol naciente de madeleine leininger (figura 1). el análisis de cada patrón a la luz del modelo del sol naciente con los factores de la estructura social permitió identificar en el padre universalidad y cierta diversidad acerca del significado que le asigna a la hospitalización de su hijo, aspectos que van a repercutir en los actos de cuidado brindados por él y la percepción que tenga de los ofrecidos por el profesional de enfermería. el padre reconoce que la ucin es el primer hogar para el recién nacido pretérmino extremo, ya que es el primer lugar al que él llega y que es inminentemente necesario por su condición de salud, por tanto, le da la connotación de hogar porque es un ambiente lleno de cariño, afecto, armonía para él y su hijo, en un marco de alta tensión, tecnología y procedimientos que buscan el bienestar del recién nacido pretérmino. este es un tema en el cual se ve reflejada la influencia de los factores tecnológicos dentro de la estructura social y cultural del modelo del sol naciente, por los cuidados genéricos y profesionales que permiten preservar o mantener, negociar o acomodar y restructurar o generar cambios en el cuidado cultural ofrecido al recién nacido por parte del padre. tema 1. la hospitalización del recién nacido pretérmino extremo: cambios en la estructura social y cultural del padre la hospitalización del recién nacido pretérmino extremo genera en el padre cambios en la estructura social y cultural, esta dimensión proporciona factores amplios, comprensivos y especiales que influencian las expresiones de cuidado y el significado que le asigna el padre a la hospitalización de su hijo; los cambios surgen en los siguientes factores: religiosos, espirituales y filosóficos; sociales y de parentesco; educativos; económicos, políticos y legales; valores culturales, creencias y estilos de vida; factores que influyen directamente en la salud y bienestar del recién nacido pretérmino extremo y permiten identificar el cuidado genérico figura 1. significado que le asigna el padre a la hospitalización de su hijo recién nacido pretérmino extremo contrastado con el modelo del sol naciente fuente: tomado de erika melania cañas lopera, investigadora. 343 la experiencia del padre durante la hospitalización de su hijo recién nacido pretérmino extremo l erika melania cañas lopera y otro. que ofrece el padre a su hijo, y que se ve orientado y fortalecido gracias al cuidado profesional de enfermería dentro de la urn, identificando cinco patrones recurrentes: pasaba yo por la virgencita del primer piso, me dio una tranquilidad en el momento que yo pasé por ahí, me dio una tranquilidad que yo no puedo expresar en palabras, el corazón se me infló, no sé, bueno, sentí una tranquilidad inexplicable y lo que vi fue que mi señora y mi bebé van a estar bien. 1. “aferro a las creencias religiosas y cambios en la forma de ver la vida”. en el enfoque del sol naciente se evidencia la influencia que tienen en el bienestar de las personas los factores filosóficos, espirituales y religiosos para afrontar cada situación de saludenfermedad. el fervor en dios y en la virgen hace sentir al padre positivo y tranquilo, cambiando incluso su forma de ver la vida. este patrón se relaciona con los resultados del estudio de rizatto (1), “el cuidado y el convivir con el hijo prematuro: la experiencia del padre” en la categoría de religiosidad, entendida esta como la búsqueda de la fuerza para cruzar el sufrimiento, independientemente del hecho de que los hombres tengan una religión, crean en el poder divino y en el llamado de dios, para sostener el camino de la vida (1). los resultados del patrón de la presente investigación amplían el concepto de religiosidad planteado en el artículo anterior, dado que esta se evidencia en los padres como la fuerza, el apoyo y el soporte frente a la actual situación que están viviendo. la espiritualidad —creencia en dios y fe en un ser superior— identificada en el presente estudio se relaciona con los resultados obtenidos en la investigación “vivencias de los padres de niños hospitalizados en la unidad de recién nacidos de dos instituciones de salud de la ciudad de bogotá” (15), la cual mostró cómo los padres se aferran a su fe en el todopoderoso que los ayuda a sobreponerse ante la situación y, al igual que en la presente investigación, uno de los padres hace referencia a la capacidad limitada del acto médico ante la enfermedad, y cómo las acciones de cuidado de su hijo están no solo en los médicos, las enfermeras, los medicamentos, sino también en dios, señalando en los dos estudios que la esperanza de recuperar a su hijo está en las manos de dios. 2. “los lazos y las relaciones con: recién nacido, la pareja, familia y amigos”. estos factores le dan un significado a la hospitalización del neonato y generan unas relaciones sólidas y de reciprocidad con el recién nacido, la pareja y la familia, además de un apoyo espiritual y económico. contrario a la relación que se genera con los amigos que se enfoca en compartir reuniones, deportes o comunicarse a partir de llamadas telefónicas, aspectos que no se pueden continuar en esta etapa de la vida del padre dada la primacía que él da a su esposa e hijo. siente algo muy grande, como que está protegiendo la vida de uno, algo que es de uno, siente uno que le está dando protección. yo que pienso de ella, primero pienso que es una dura, es admirable, siempre ha sido una mujer con un carácter y un empeño muy firme y con una serenidad que a veces yo no tengo, entonces primero siempre le digo mis sentimientos de admiración y de respeto porque nunca ha desfallecido. mucho apoyo de mi mamá y mi papá, ellos la quieren harto y ha tocado dejar a nataly con ellos y le han dado el tetero y han estado ahí y atentos, sí ellos también. totalmente, o sea la verdad rutina con amigos cero, llamadas telefónicas no cero, alguna reunión nada absolutamente nada, totalmente dedicados. el análisis y patrón planteado se relacionan con el estudio de rizatto (1) dentro de la categoría “convertirse en un padre”, donde la percepción de la responsabilidad y el nuevo estilo de vida traen cambios en la vida de las personas y la sociedad, aspectos identificados en el presente estudio como cambios en la vida social del padre con prioridad de la madre y el hijo, mayor apoyo y acercamiento de la familia y cambios en las relaciones y actividades realizadas con los amigos por la primacía del cuidado de la madre y el hijo. dentro del estudio de perin (16) “la formación del apego padres/recién nacido pretérmino y/o de bajo peso en el método madre canguro: una contribución de la enfermería”, se contempla dentro de la primera categoría, “el curso que se vivía antes de venir a la unidad neonatal”, una subcategoría llamada: “mirar, tocar, sentir al bebé que nace”, que confirma la interacción del padre como tiempo para sentir una pertenencia, conocerse y transmitir seguridad al recién nacido, aspecto que se identificó en este estudio, así como la necesidad del padre de ver, tocar y sentir a su bebé y, de esta manera, entablar lazos y relaciones paternales con su hijo. la quinta categoría planteada “la oportu344 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 nidad de aprender en el papel de madre, padre e hijo” en la cual se incluye “colocarse al niño”, es decir, el contacto del cuerpo como ayuda para superar la sensación de que la crianza es fácil, ofrece la oportunidad de realizar un contacto piel a piel con su bebé percibiendo que el cuerpo y sus movimientos son aliados importantes para el intercambio de sentimientos entre padre e hijo, resultados que se relacionan con el patrón planteado de los lazos y las relaciones con el recién nacido donde el padre manifiesta su alegría y satisfacción al iniciar la técnica canguro pues siente que está contribuyendo con su bebé con el amor, la protección y el apoyo, lo que le da una mayor satisfacción de ser padre dada su contribución al proceso de hospitalización de su hijo. se evidencia la preocupación de la mayoría de los padres por saber cómo está su pareja, ya que ella también se ve enfrentada a una situación compleja de salud-enfermedad; este hecho fortalece su relación. estos resultados se relacionan con los arrojados en la investigación de arenas lagos et al. (15), donde se describe que la hospitalización de un recién nacido es un evento que moviliza no solo a los padres, sino también emociones relacionadas con las expectativas ante la vida o el peligro de perder la misma por las condiciones en que se encuentra el recién nacido. la familia se constituye en su sistema primario de apoyo aportando acompañamiento, solidaridad y ayuda económica, permitiendo el fortalecimiento de los lazos afectivos existentes. la hospitalización del hijo se constituye en un hecho que les permitió a los padres afianzar y fortalecer los lazos existentes como parte de su vida afectiva. dentro de los lazos y las relaciones con el recién nacido dos padres manifestaron frustración por no llegar a tener un recién nacido a término, resultado que se relaciona con el obtenido en el estudio de arenas lagos et al. (15), en el cual se plantea que los padres siempre esperan el nacimiento de un hijo sano y perfecto, imagen que ha sido elaborada durante la gestación, siendo muy extraño que contemplen la posibilidad de hospitalizar a su recién nacido. 3. “la hospitalización: un aprendizaje y curso intensivo del cuidado del recién nacido pretérmino extremo”. la necesidad del padre por saber y entender las situaciones por las que pasa su hijo (cómo cuidarlo, sacarle los gases, sentarlo y ayudar mientras lo amamantan) se ve favorecida por el conocimiento ético del personal de enfermería de la urn, que es de gran valor para ayudar al padre en el período de hospitalización, aspecto apoyado por el factor educativo que dentro de la dimensión estructural, cultural y social se ve fortalecido gracias a la orientación que el padre recibe acerca de las prácticas de cuidado que puede realizar a su hijo, lo cual le permite entender su situación y contribuir con su desarrollo por medio de las diferentes actividades dentro de la urn (técnica canguro, estímulos: voz, música, tacto). volvemos a lo de un rato, el curso psicoprofiláctico a nivel doctorado, claro he aprendido mucho, he aprendido en 3 niveles, digamos un nivel técnico de bueno cuáles son las condiciones que debe estar la niña, cómo hacer y esto y lo otro. he aprendido cosas que podría uno llamar como dogmáticas entonces en lo que tiene que ver con el estado de salud y qué cosa influye con cuál, por ejemplo, este medicamento sirven para hacer esto o aquello, hemos detectado esto. y el tercer nivel, es un nivel que podríamos llamar ético, en el que he aprendido lo que significa el respeto de los otros, entre cada uno y entre el grupo. el patrón descrito se enfoca en el aprendizaje que el padre necesita, y adquiere poco a poco durante la hospitalización, acerca de los cuidados de un recién nacido pretérmino extremo y la forma como él puede contribuir en el proceso de hospitalización de su hijo, patrón que se relaciona con la categoría planteada en el estudio de perin (16), “la oportunidad de aprender en el papel de madre, padre e hijo”, en la cual los padres conocen su responsabilidad y sus tareas, pero a menudo se ven ensombrecidos por el temor de no ser capaces de cuidar a su hijo porque es algo completamente diferente a lo esperado y planeado, y con la subcategoría de “la responsabilidad de la atención directa de los niños” en la cual se observa que el papel desempeñado por los padres durante todo el periodo después del parto es una prueba para entender las distintas fases por las cuales pasa el recién nacido pretérmino, aquí es cuando el padre entra en el ambiente de la unidad neonatal, se relaciona con su niño con expresiones orales, facies de amor, afecto y brindándole atención según las orientaciones y la asesoría ofrecida por el equipo de salud. dentro de las consideraciones de enfermería planteadas en el estudio de nagorski (2) están “la confianza y comprensión”, así como la educación y la comunicación en la participación del cuidado y el fomento de la relación padre-hijo, buscando oportunidades para una participación activa del padre. en la presente investigación se ve reflejada la necesidad de educación y aprendizaje del padre en cuanto al cuidado de su hijo, teniendo en cuenta las orientaciones dadas por el equipo de salud, con mayor relevancia del personal de enfermería que es quien comparte las veinticuatro horas con su hijo. 345 la experiencia del padre durante la hospitalización de su hijo recién nacido pretérmino extremo l erika melania cañas lopera y otro. según el estudio de pohlman (3) se identifica un subtema planteado como “de expertos a principiantes”, referente a la ignorancia que tienen los padres frente al cuidado y comportamiento en una ucin, y la experiencia y las habilidades con las que cuentan en su trabajo que es donde se sienten más a gusto por el conocimiento que tienen (3), contrario a lo que se observa en esta investigación, pues el padre evidencia que busca momentos y oportunidades de aprendizaje para aportarle algo a su hijo, por ello involucrarlos tempranamente en la técnica canguro es una estrategia que los prepara para el cuidado del prematuro, se sienten útiles y les da confianza para sentir que están aportando al cuidado de sus hijos. las necesidades de cuidado identificadas en este patrón son: horarios más asequibles para los padres —“unidad de puertas abiertas”— y un espacio más tranquilo dentro de la urn, propuestas que se relacionan con los resultados del estudio de perin (16) en la categoría tres: “la participación activa todos los días de los padres”, en la cual se involucra a los padres en el medio neonatal, con las subcategorías de: “tener la libertad de ir y venir en el medioambiente neonatal”, con la flexibilidad de los horarios libres de obstáculos y la de tener al oportunidad de estar cerca de los niños el tiempo completo ayudando a entender sus necesidades y su progreso. el estudio de arenas lagos et al. (15) plantea como resultado dos componentes: “la visita de los padres al niño y las experiencias de aprendizaje durante la hospitalización del recién nacido”, en los cuales los padres consideran el tiempo de visita como corto e insuficiente y piensan que lo mejor para los hijos es estar continuamente junto a ellos, y el aprendizaje relacionado con los cuidados que se deben procurar al niño, dos componentes que se relacionan con los resultados obtenidos en esta investigación, es decir, la necesidad de cuidado de los padres identificada como un horario más asequible en la urn y la percepción del padre de mantener un aprendizaje intensivo, que coincide con lo manifestado por uno de los padres del presente estudio: “un curso psicoprofiláctico a nivel de doctorado” (c4e2p43). la preparación y el aprendizaje de los padres, categorías identificadas en el presente estudio, se relacionan con el manejo del neonato, sus cuidados, la alimentación y el plan canguro; el personal de enfermería ha permitido este conocimiento a los padres, resultado que se relaciona con la categoría cinco, “los padres aprenden de las enfermeras”, planteada en el estudio de guerra (17), en la cual se expone que el cuidado de los hijos lo aprende el padre directamente de la enfermera, siendo una enseñanza fundamental y con retroalimentación continua. 4. “organización del padre frente a la responsabilidad laboral y económica”. en la dimensión estructural cultural y social el bienestar de las personas se ve influenciado por factores políticos y legales —en este caso la licencia de paternidad, vacaciones, permisos y disponibilidad de tiempo del padre en el trabajo para organizar los momentos en que está con su hijo—, y factores económicos como lo es responder al trabajo para mantener el sustento de toda la familia, lo que genera una relación directa entre la situación económica y la posibilidad de dedicar tiempo para estar con su hijo durante la hospitalización. “se ha dado ese manejo del tiempo, lo de la ley maría que también es buena, creo que se puede hasta ir mejorando mucho más, como supuestamente se maneja en europa que es hasta un año acá son 3 meses, acá son 14 semanas allá un año, pero bueno digamos que se han hecho cambios que ayudan en esa parte”. “sí claro porque se nos ha generado bastante incremento en los costos pero pues realmente tenemos el apoyo de amigos y familiares y pues cuando le toca a uno cambiar sus hábitos, mientras pasa el rato de crisis” dentro del estudio de pohlman (3), frente a la primacía del trabajo y la paternidad en prematuros no se contemplan los beneficios otorgados al padre por la ley, como licencias y permisos, lo que sí se evidencia en la presente investigación. en el estudio de pohlman, en el tema “la primacía del trabajo en las vidas de los padres”, se genera un subtema, “malabares en el trabajo y el mundo exterior”, entendido como el balance que deben tener los padres frente al trabajo y su tiempo con el bebé, gestionando un espacio para su hijo, aspecto que toman con mucha seriedad y compromiso; sin embargo, frente a la hospitalización de su hijo sienten que aportan más desde el trabajo, por el desconocimiento de la urn. lo anterior contrasta con la presente investigación, pues el padre prioriza el tiempo que desea compartir con su hijo y esposa, utilizando al máximo los beneficios laborales otorgados; además, se resalta la importancia del factor económico, la prioridad del padre por visitar a su hijo en la urn, por estar en contacto con él, logrando así un equilibrio que le permite comprender que a pesar de ser la urn un mundo desconocido, puede aprender e involucrarse en este nuevo ambiente sin sentirse extraño o incómodo. 346 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 5. “una nueva percepción de la vida a partir de la hospitalización del recién nacido pretérmino extremo”. dentro de la estructura del sol naciente, los factores culturales y las creencias se relacionan con los sentimientos que percibe el padre frente a la hospitalización de su hijo, los cuales en un primer momento son muy divergentes y confusos, pero logra darles un orden y posteriormente tener claridad en ello. “han sido cambios pero la idea es ver al bebé, entonces es tratar de organizar las cosas, para poner a cada uno su tiempo”. “pasando una cosa cuando nos vamos, nos vamos como recargados, con una sonrisa de idiotas felices ahí y llamar los abuelitos y contarles que esto y que lo otro y que hizo esta mueca y la otra.” los resultados de este patrón se relacionan en parte con el estudio de rizatto (1) en la categoría de “el nacimiento: un viaje de acontecimientos no previstos”, donde se muestran una serie de cambios en el padre relacionados con el nacimiento repentino del bebé y la ruptura del sueño, de tener un hijo en el momento apropiado, lo que genera una percepción diferente de la vida con la paternidad, aspectos destacados en este patrón por cambios en el estilo y la percepción de la vida, la forma de pensar y preservar valores, las cuales aporten a la formación y el mantenimiento del hogar. todos los cambios en el estilo de vida que generan el nacimiento y la hospitalización del recién nacido pretérmino extremo se ven relacionados en el estudio “la formación del apego padres/recién nacido pretérmino y/o de bajo peso en el método madre canguro: una contribución de la enfermería (16), el cual en la primera categoría, “el curso que se vivía antes de venir a la unidad neonatal”, describe el mayor apego que se genera con la pareja, una preocupación mutua por el recién nacido pretérmino y posteriormente una preparación para enfrentar la hospitalización. esto asegura lo evidenciado en la presente investigación, donde se observa que el padre sufre una serie de cambios que lo llevan a tener una nueva percepción de la vida en aspectos como la vida misma, la muerte, la calma ante los altibajos en la recuperación del recién nacido pretérmino extremo, las expectativas frente a lo que vendrá; el preservar valores como el amor, la armonía y la paz, y sentimientos de alegría frente a cada pequeño avance de su hijo. en el estudio “vivencias de los padres de niños hospitalizados en la unidad de recién nacidos de dos instituciones de salud de la ciudad de bogotá (15)” se contempla el componente: “el conocimiento acerca de la hospitalización”, que normalmente simboliza alegría, celebración y expectativas, aspectos que se relacionan con los códigos sustantivos que conforman el patrón descrito en esta investigación: alegría, expectativas que llevan al padre a generar una nueva percepción de la vida y dejar a flote una serie de sentimientos como el amor y la paciencia, que le permiten una mejor adaptación frente a la hospitalización de su hijo. tema 2. ucin: primer hogar para el recién nacido pretérmino extremo el padre reconoce que la ucin es el primer hogar para el recién nacido pretérmino extremo, ya que es el primer lugar al que él llega y es necesario por su condición de salud; le da la connotación de hogar porque es un ambiente lleno de cariño, afecto, armonía para él y su hijo, en un marco de alta tensión, tecnología y procedimientos, que buscan el bienestar del recién nacido pretérmino, identificando dos patrones recurrentes: 1. “el equipo de salud es un salvavidas para el neonato y una bendición para los papás”. es evidente la relación que debe existir entre los cuidados genéricos y los profesionales, a estos últimos el padre les hace un mayor reconocimiento por el predominio de factores tecnológicos y humanos que él observa en su estancia en la urn, lo cual favorece la confianza frente a los cuidados que se le dan al neonato, generando tranquilidad y seguridad frente a la hospitalización de su hijo. pero siempre me he encontrado con una atención muy cálida, muy cercana, todos estamos pasando por esto y existe el espíritu de solidaridad, pero no una solidaridad en la tristeza que es una cosa que es muy importante, es una solidaridad en la alegría, una cosa muy bonita que continuamente hay sonrisas hay un ambiente chévere por muy complicada que sea una situación no hay un estado de solemnidad. eh, no pues son otras mamás, son unas mamás que tienen acá 24 horas, mientras que uno está con ellos por ahí 5 horas, dos horas y media en la mañana dos horas y media en la tarde. en el estudio de rizatto (1), dentro de las categorías se plantea la confianza y el respeto por el trabajo de los profesionales de la salud; los padres expresaron su confianza en el equipo de profesionales y el cuidado de la salud destacando actitudes como cordialidad, comunicación, información oportuna y hospitalidad. 347 la experiencia del padre durante la hospitalización de su hijo recién nacido pretérmino extremo l erika melania cañas lopera y otro. lo mismo ocurre en el estudio de perin (16), que dentro de la categoría “la atención y el equipo de atención neonatal plantea dos subcategorías denominadas “la asistencia y el cuidado del equipo de salud genera seguridad en los padres”, donde se expone que la atención al neonato no es una obligación o una mera técnica, es un trato humano acompañado de un gesto de calidez, una voz suave y el intercambio de información entre el personal y los padres, donde se señala la necesidad que tienen estos últimos de saber todos los pasos de la hospitalización. tales categorías y subcategorías se relacionan con los hallazgos del presente estudio, en el cual los padres manifiestan su confianza en los profesionales que atienden a su hijo y destacan su trato humano y cordial para el paciente y la familia, así como la información oportuna. el patrón propuesto se relaciona con un componente planteado en el estudio de arenas et al. (15): “su relación con el equipo de salud” como la figura que posee el conocimiento especializado y la experiencia que le permite dar un cuidado acorde con las necesidades de su hijos, en especial la enfermera, que es vista como la persona que favorece el contacto con su hijo, quien con sus conductas maternales, ante la ausencia de la madre, se convierte en una figura digna de admiración y agradecimiento por su labor y entrega en el cuidado del neonato; estos aspectos se relacionan con los hallazgos encontrados en el presente estudio, donde la confianza que los padres tienen en el equipo de salud está enmarcada en la atención brindada por las enfermeras, quienes llegan a ser unas mamás para sus hijos, entregando todo y brindando una atención las veinticuatro horas del día, destacando el trato humano, la disposición, la atención y confianza en dios que tiene el equipo de salud y en gran medida la enfermera. 2. “la urn, un camino necesario en la vida del recién nacido pretérmino extremo”. la influencia que tienen los factores tecnológicos dentro del significado que le da el padre a la hospitalización de su hijo en la urn se ve fortalecida por el conocimiento profesional que evidencia en el manejo del neonato y la edad gestacional de su hijo, reconociendo que la urn es una etapa esencial en el proceso de recuperación de su hijo, aspecto que se puede ver afectado por las creencias y la visión del mundo que se tenga frente a la hospitalización y el tamaño del neonato. que era lo mejor para ellas sí, que por lo pequeña, por lo prematura. mejor es que esté aquí que le están haciendo los cuidados adecuados, que no está sufriendo, que él está evolucionando para que se le formen y maduren los pulmones y todo el sistema de defensas y todo. según el estudio de perin (16), uno de los obstáculos que complican la formación del apego son los “equipos, las acciones del personal y una aproximación frustrante padre-madre”, estímulos que surgen de los dispositivos, de la especialización de las unidades y la atención asistencial, actitudes profesionales que en ocasiones están lejos de los padres. en relación con el presente estudio se evidencia el impacto que tiene el padre frente a este tipo de procedimientos, que pueden generar angustia y ser un obstáculo en la relación padre e hijo, pero se ve favorecido por el apoyo del profesional de enfermería. en el estudio de nagorski (2) también se plantean los obstáculos en la unidad de cuidado intensivo neonatal relacionados con la tecnología y el entorno físico, aspectos planteados en el presente estudio, pero que gracias a la orientación del profesional de enfermería y la integración temprana del padre al ambiente neonatal, él logra percibirlos como un “camino necesario en la vida del recién nacido pretérmino extremo. recomendaciones e implicaciones para enfermería el modelo del sol naciente de madeleine leininger y el método de la etnoenfermería son de gran ayuda en investigaciones que busquen el sentir de las personas, creencias y puntos de vista, por eso se recomienda realizar otros trabajos de investigación con aplicación del modelo y el método, con el fin de favorecer visiones de enfermería que aporten no solo al profesional sino al cuidado ofrecido al paciente y su familia de acuerdo con sus necesidades. tema 1. la hospitalización del recién nacido pretérmino extremo: cambios en la estructura social y cultural del padre patrón 1. aferro a las creencias religiosas y cambios en la forma de ver la vida: en las ucin se debe propiciar la libertad de culto como un derecho fundamental de la persona favoreciendo las creencias y los sentimientos de cada uno. patrón 2. lazos y relaciones con el recién nacido, la pareja, la familia y los amigos: en casos especiales como madre soltera, 348 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 adolescentes, patologías complejas de la madre o fallecimiento, es pertinente permitir el ingreso de una persona significativa para el neonato que sirva de apoyo a la madre o padre, con el fin de favorecer la adaptación al proceso de hospitalización y facilitar en el padre la adaptación al cuidado que debe ofrecer a su hijo dentro de la unidad, así como continuar con la atención humanizada y la participación activa temprana del padre en la técnica canguro favoreciendo el contacto piel a piel con el neonato. patrón 3. la hospitalización, un aprendizaje y curso intensivo de cuidado del recién nacido pretérmino extremo: es importante plantear posibles necesidades de cuidado a partir de los resultados de la presente investigación, que permitan preservar, negociar o reestructurar acciones con el fin de mejorar la atención prestada en la urn. los aspectos que se pueden ver satisfechos mediante la educación de los padres en las ucin son las ayudas educativas (folletos, cartillas) con la información pertinente (recomendaciones de ingreso, desarrollo de un recién nacido pretérmino extremo, cuidados y recomendaciones para el egreso, signos de alarma) para que el padre se involucre en el cuidado de su hijo con mayor seguridad. el profesional de enfermería debe generar espacios para hablar con los padres, pero no de una manera solícita, sino como una acción de cuidado, y de esta forma hacer una aproximación de los padres al medio de la urn. patrón 4. organización del padre frente a la responsabilidad laboral y económica: se deben realizar estudios de investigación que permitan ampliar la relación entre la importancia que le asigna el padre a su trabajo y las responsabilidades generadas a partir de la hospitalización de su hijo, con el fin de aclarar aspectos encontrados en el presente estudio, pues se observó que a pesar de la responsabilidad económica que tiene el padre, él organiza su tiempo y actividades con el fin de mantener el cumplimiento de sus responsabilidades como padre y las visitas de su hijo en la urn. patrón 5. una nueva percepción de la vida a partir de la hospitalización del recién nacido pretérmino extremo: para evidenciar el reconocimiento que el profesional de enfermería tiene acerca de la importancia del compromiso de los padres frente al cuidado de su hijo en la unidad, es necesario diligenciar el nombre del padre en los documentos de identificación del neonato dentro de la urn, como lo es el formato de identificación del recién nacido, historia clínica y boleta de egreso, y que el personal de enfermería se dirija a los padres con equidad de género. tema 2. ucin: primer hogar para el recién nacido pretérmino extremo patrón 1. el equipo de salud, un salvavidas para el neonato y una bendición para los papás: el trabajo realizado por el profesional de enfermería es de alta calidad científica, humana y práctica, y debe ser reconocida por los padres, esto se logra si al ingreso de estos a la urn, o en cada turno, se realiza una presentación del personal y se manifiesta la disponibilidad para el cuidado. se debe promover por parte del profesional de enfermería la comunicación terapéutica para asistir al padre y a las familias durante el proceso de hospitalización del neonato. patrón 2. la urn, un camino necesario en la vida del recién nacido pretérmino extremo: la enfermera debe considerar como prioridad orientar al padre respecto a los medios invasivos y los equipos con los que cuenta su hijo, con el fin de facilitar el vínculo, permitiendo que los padres reconozcan la importancia de la tecnología en el entorno de la unidad, pero vista desde un ambiente agradable y cordial, que permite posibilidades de contacto con el recién nacido pretérmino extremo. se debe contemplar la posibilidad de permitir horarios de visita más amplios en las unidades con el fin de ir haciendo cada día las unidades más amigables para los padres y que se pueda ofrecer un cuidado centrado en la familia. en necesario favorecer la vinculación temprana con otros padres que hayan tenido bebés en circunstancias similares fomentando la terapia de grupo o grupos focales que permitan compartir experiencias y de esta manera promover la adaptación del padre al proceso de hospitalización de su hijo (18). conclusiones culturalmente el padre se ha visto como una persona poco importante en la crianza y participación en el cuidado de un prematuro, aspectos que descansan exclusivamente en la madre; sin embargo, con la experiencia de asumir la responsabilidad de participar en el cuidado de su hijo prematuro hospitalizado descubre que entre él y su hijo existe un vínculo filial que los une y que no puede ser reemplazado por otro miembro de la familia. el padre reconoce la fortaleza del vínculo entre madre e hijo, pero descubre que en esta diada existe un espacio para él y se convierte en una triada. el significado que le asigna el padre a la hospitalización de su hijo recién nacido pretérmino extremo está enmarcado por dos temas centrales surgidos de la presente investigación que se relacionan con las tareas psicológicas (19) que deben llevar a cabo 349 la experiencia del padre durante la hospitalización de su hijo recién nacido pretérmino extremo l erika melania cañas lopera y otro. los padres para superar la crisis de haber procreado un producto prematuro extremo como son: preparación para la posible pérdida del hijo, adaptación al entorno de la unidad de cuidado intensivo y reanudar la interacción con el hijo una vez se ha superado el peligro de la pérdida. la hospitalización del recién nacido pretérmino extremo significa para el padre un cambio en su vida, donde el eje central son su hijo y su pareja, lo cual genera una serie de modificaciones en la estructura social (factores religiosos, espirituales, filosóficos, sociales y de parentesco, educación, económicos, políticos y legales y tecnológicos) y cultural en la cual se ha desenvuelto hasta ese momento, en busca de un bienestar para su familia afianzando más la relación con su pareja, deseando compartir con ella la situación que están viviendo. referencias 1. rizatto dm, tsunechiro ma. cuidar e o conviver com o filho prematuro: a experiência do pai. revista latino-americana de enfermagem. 2006;14:93-101. 2. nagorski a. engaging fathers in the nicu. taking down the barriers to the baby. j perinatal neonatal nurs. 2008;22:302-5. 3. pohlman s. the primacy of work and fathering preterm infants: findings from an interpretive phenomenological study. advances in neonatal care. 2005;5:204-16. 4. instituto de programas interdisciplinarios en atención primaria en salud, fondo de las naciones unidas para la infancia (unicef). iniciativa instituciones amigas de la mujer y la infancia en el marco de los derechos. venezuela; 2007. p. 1-17. 5. hernández r, fernández c, baptista p. recolección de los datos. en: método de la investigación. 3 ed. méxico: macgraw hill-interamericana; 2003. pp. 344-491 6. alice z et al. cuidados culturales: teoría de la diversidad y la universalidad. en: modelos y teorías en enfermería. 4 ed. madrid: harcourt brace; 2008;439-462. 7. leininger m, macfarland m. culture care diversity and universality: a world wide nursing theory. 2 ed. new york: jones and bartiett publishers; 2006. 8. sandoval c. programa de especialización en teorías, métodos y técnicas de investigación social. investigación cualitativa. bogotá: instituto colombiano para el fomento de la educación superior (icfes); 2002. p. 120-1-136-7. 9. consejo de organizaciones internacionales de las ciencias médicas (cioms) organización mundial de la salud (oms). pautas éticas internacionales para la investigación biomédica en seres humanos. ginebra; 2002. 10. fry s, johnstone mj. ética en la práctica de enfermería. 3 ed. méxico: manual moderno; 2010. p. 22-6. 11. leininger m. teoría de la universalidad y diversidad del cuidado cultural y evolución del método de la etnoenfermería. en: transcultural nursing many cultures one world. 3 ed. new york: mcgraw hill interamericana; 2002. p. 92-7. 12. spradley j. la entrevista etnográfica. orlando: hartcourt brace javanovich collage publeshers; 1979. 13. hernández r, fernández c, baptista p. análisis cualitativo de datos. en: método de la investigación. 3 ed. méxico: mcgraw hill interamericana; 2003. p. 579-622. 14. mayan m. una introducción a los métodos cualitativos. iztapalapa: qual institute press. international institute for qualitative methodology; 2001. 15. arenas jl, delgado cy, eslava dg. vivencias de los padres de niños hospitalizados en la unidad de recién nacidos de dos instituciones de salud de la ciudad de bogotá. en: actualizaciones en enfermería. bogotá: fundación santafé; 2005. p. 1-5. 350 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 16. perin g, monticelli ma. formação do apego pais/recém-nascido pré-termo e/ou de baixo peso no método mãe-canguru: uma contribuição da enfermagem. texto de contexto de enfermagem. 2007;16(4): 626-35. 17. guerra jc, ruiz ch. interpretación del cuidado de enfermería neonatal desde las experiencias y vivencias de los padres. revista avances en enfermería. 2008;26(2). 18. houska c. cuidados de enfermería. en: ventilación asistida neonatal. bogotá: distribuna; 2005. p. 168-9. 19. kenner c, amlung s. crisis familiares. en: deacon j, neill p. cuidados intensivos de enfermería en neonatos. 2 ed. méxico: mcgraw-hill; 2001. p. 717-33. 197 205 necessidades assistenciais.indd 197 letícia becker-vieira1 stela maris de mello-padoin2 ivis emília de oliveira-souza3 cristiane cardoso de paula4 marlene gomes-terra5 necessidades assistenciais de mulheres que denunciam na delegacia de polícia a vivência da violência6 1. enfermeira. doutoranda de enfermagem. vice-líder, universidade federal de santa maria, ufsm, santa maria, brasil. lebvieira@hotmail.com 2. enfermeira. doutora em enfermagem. docente, universidade federal de santa maria, santa maria, brasil. stelamaris_padoin@hotmail.com 3. enfermeira. doutora em enfermagem. titular de enfermagem obstétrica, escola de enfermagem anna nery, rio de janeiro, brasil. ivis@superig.com.br 4. enfermeira. doutora em enfermagem. docente, universidade federal de santa maria, santa maria, brasil. cris_depaula1@hotmail.com 5. enfermeira. doutora em enfermagem. docente, universidade federal de santa maria. santa maria, brasil. martesm@terra.com.br 6. texto inédito elaborado a partir da dissertação: “perspectivas de mulheres que denunciam o vivido da violência: cuidado de enfermagem à luz de schütz”, aprovada pelo programa de pós-graduação em enfermagem da universidade federal de santa maria –ufsm– santa maria (rs), brasil. bolsa da coordenação de aperfeiçoamento de pessoal de nível superior (capes). recibido: 8 de noviembre de 2012 enviado a pares: 20 de enero de 2013 aceptado por pares: 17 de junio de 2013 aprobado: 17 de junio de 2013 año 13 vol. 13 nº 2 chía, colombia agosto 2013  197-205 resumo devido aos impactos da violência na vida das mulheres, o estado, o setor saúde e a sociedade civil a entendem como uma ação que anula os direitos humanos e consideram esta problemática importante no campo da pesquisa. objetivo: apreender as necessidades assistenciais da mulher que denuncia, na delegacia de polícia, o vivido em situação de violência. método: estudo na abordagem qualitativa pautado no referencial teórico-metodológico da fenomenologia social de alfred schütz. desenvolvido em delegacias de um município do sul do brasil mediante entrevista fenomenológica com 13 mulheres. resultados: a intencionalidade da mulher para a ação de denunciar expressa as expectativas que remetem às necessidades assistenciais de justiça, de ajuda institucional e de proteção sua e dos filhos. conclusão: a denúncia está relacionada às demandas institucionais e sociais, bem como sinaliza a importância de vislumbrar esta clientela na sua dimensão humana e social no mundo da vida. palavras-chave saúde da mulher, violência contra a mulher, determinação de necessidades de cuidados de saúde, enfermagem. (fonte: decs, bireme). para citar este artículo / to reference this article / para citar este artigo becker vieira, l., maris de mello padoin, s., de oliveira sousa, i. e., cardoso de paula, c., gomes terra, m. (2013). necessidades assistenciais de mulheres que denunciam na delegacia de polícia a vivência da violência. aquichan. vol. 13, no. 2, 197-205. 198 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 necesidades de asistencia de las mujeres que denuncian en comisaría de policía la violencia vivida resumen debido al impacto de la violencia en la vida de las mujeres, el estado, el sector de la salud y la sociedad civil la entienden como una acción que niega los derechos humanos y la consideran una cuestión importante en la investigación. objetivo: comprender las necesidades de asistencia de la mujer que revela, en una comisaría de policía, la situación de violencia vivida. método: estudio de enfoque cualitativo guiado por el marco teórico y metodológico de la fenomenología social de alfred schütz. se llevó a cabo en comisarías de policía de una ciudad en el sur de brasil a través de entrevistas fenomenológicas con 13 mujeres. resultados: la intención de la mujer para denunciar la violencia que se vive expresa la esperanza que se refiere a las necesidades asistenciales de justicia, de ayuda institucional y de protección para ella y para su hijo(s). conclusión: la denuncia está relacionada a las demandas institucionales y sociales, lo que indica la importancia de entrever a las afectadas en su dimensión humana y social en el mundo. palabras clave salud de la mujer, violencia contra la mujer, evaluación de necesidades, enfermería. (fuente: decs, bireme). assistance needs of women who report incidents of personal violence to the police abstract violence has a serious impact on women’s lives and, for that reason, it is understood by the state, the health sector and civil society as an act that denies human rights and is an important issue in research. objective: the purpose of this study is to understand the assistance needs of women who report incidents of personal violence to the police. method: it is a qualitative study guided by the theoretical and methodological framework of the social phenomenology of alfred schütz. it was conducted at police stations in a city in southern brazil through phenomenological interviews with 13 women. results: women’s intention in denouncing incidents of violence perpetrated against them is an expression of hope with respect to their need for legal aid, institutional assistance and protection for themselves and their children. conclusion: the complaint is related to institutional and social demands, which indicates the importance of viewing the victims in light of their human and social dimension. keywords women’s health, violence against women, needs assessment, nursing. (source: decs, bireme). 199 necessidades assistenciais de mulheres que denunciam na delegacia de polícia a vivência da violência l letícia becker-vieira y otros. introdução em âmbito mundial, foi nos anos de 1990 que, oficialmente, o setor de saúde passou a compreender a violência como um dos fatores geradores de adoecimento e no campo da pesquisa é notória a participação acadêmica para dar maior visibilidade ao fenômeno, bem como evidência científica. tal valorização decorreu do impacto que provoca na vida das pessoas, das famílias e da sociedade, devido às lesões físicas, psíquicas e morais, que implicam demanda de atenção e cuidados dos serviços médico -hospitalares (1). já a violência contra as mulheres adquiriu, nas últimas décadas do século xx, um caráter público a partir de reivindicações de movimentos sociais e de mulheres que começaram a denunciar as situações de violência vividas dentro dos lares. até então possuía um caráter privado, sendo exercida e resolvida entre a mulher e o companheiro, e naturalizada pela sociedade. ao ganhar visibilidade e comprovar seus impactos sociais, econômicos e de saúde, passaram a ser exigidas, nas agendas governamentais, ações de combate e prevenção da violência em âmbito mundial (2). essas ações surgem na forma de movimentos por parte da sociedade civil e do estado, como convenções, conferências, e em políticas públicas e legislação, que tratam a violência como uma infração legal e uma ação que anula os direitos humanos do segmento feminino. no entanto, muitas mulheres, em seu mundo da vida cotidiana, ainda convivem e se relacionam com companheiros agressivos, ora em uma atitude de naturalização de tais situações imposta culturalmente pela sociedade, ora buscando meios para romper com o ciclo da violência (3). o relatório mundial sobre violência e saúde, elaborado pela organização mundial de saúde, refere que a forma mais prevalente de violência contra mulheres é aquela praticada pelo seu parceiro íntimo no espaço privado, ainda que não se restrinja ao espaço doméstico. as taxas de ocorrência dessa violência variam entre 15% e 52% de mulheres que experimentaram algum tipo de violência cometida pelo companheiro (4). para a organização pan-americana de saúde, estima-se que, entre 20% e 60% das mulheres na américa, encontrem-se em situação de violência (5). a realidade brasileira revela que uma em cada cinco mulheres considera já ter sofrido alguma vez algum tipo de violência por parte de algum homem, conhecido ou desconhecido. estudo de base populacional mediu a ocorrência de violência contra as mulheres no país. nessa investigação revelou-se que 43% das mulheres declararam ter sofrido violência praticada por um homem na vida; um terço admitiu ter sofrido alguma forma de violência física; 13%, sexual, e 27%, psicológica (6). aponta-se como responsabilidade do estado apoiar as mulheres em situação de violência, criando condições específicas de atendimento, encaminhando-as para cuidados efetivos. estes devem partir de uma atenção multidisciplinar e da conjunção de setores da sociedade, a fim de prestar o atendimento integral e humanizado que contemple estratégias voltadas para as suas necessidades sociais e de saúde. além disso, ao visar a respostas adequadas às demandas femininas, uma importante estratégia consiste em dar voz às mulheres que acessam os serviços sociais e de saúde. com base em seus conhecimentos, valores e vivências que traduzam as necessidades de atenção e assistência, quando buscam por apoio e suporte (7). mulheres que vivenciam situações de violência nas suas variáveis mais graves de agressão são mais propensas a buscar ajuda através de meios formais e informais. deve-se garantir que os prestadores de serviços profissionais, bem como membros da comunidade em geral estejam preparados e equipados para explorar questões de segurança e proteção às mulheres, buscando promover a sua saúde e bem-estar (8). dentre os documentos fundamentais e voltados para o atendimento, tem-se no brasil um instrumento legal e essencial para proteção da mulher e prevenção da violência, a lei 11.340 – conhecida como lei maria da penha. esse dispositivo cria mecanismos para coibir a violência doméstica e familiar contra as mulheres ao definir a violência como uma infração legal, e representa um importante marco de efetivação da política pública para as mulheres (9). a violência contra as mulheres, concebida como uma questão legal, jurídica, social e de saúde, impõe desafios na sua implementação, e traz à tona a discussão de um problema iminente. para dar conta destas questões, a lei prevê medidas, nos seus art. 9 e 29, “da assistência à mulher em situação de violência” e “da equipe de atendimento multidisciplinar”, respectivamente. de acordo com o texto legal, a equipe deve “ser integrada por profissionais especializados nas áreas psicossocial, jurídica e de saúde”, e visar, assim, a ações articuladas de proteção e assistência (9). 200 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 no entanto, não se pode perder de vista que a trajetória da mulher, na tentativa de ruptura do ciclo da violência, é ambivalente e irregular e não se restringe ao compasso institucional; concretiza-se na construção da cidadania feminina em conformidade com suas necessidades e decisões (10). desse modo, reconhece-se que as razões que levam as mulheres a denunciarem o companheiro desse relacionamento permeado de violência envolve a preocupação com os filhos e o medo de serem mortas (3). nessa perspectiva, a temática implica reconhecer que assumir uma atitude de enfrentamento da violência exige das mulheres não só coragem como também a renúncia a um projeto de vida em família – na conjugalidade e no modelo idealizado de mulher. ao mesmo tempo, implica a necessidade de buscar a garantia de sobrevivência e o apoio institucional como policial, jurídico, assistencial e de saúde, os quais muitas das vezes podem representar a busca de proteção de sua própria vida (11). diante da intencionalidade da ação (12) de denunciar a violência, é de extrema importância a atenção à saúde dessas mulheres, de modo que a ação profissional atenda as demandas clínicas e sociais, a partir das necessidades assistenciais que emergem do mundo da vida dessa clientela (3). essas necessidades assumem importância social, visto que trazem à tona a questão da violência no campo das relações humanas (13). portanto, como integrante da equipe multiprofissional, cabe ao enfermeiro e sua equipe desenvolver o processo de cuidado, desde o diagnóstico de enfermagem advindo da situação de violência até o acompanhamento das demandas e do desfecho da denúncia na vida da mulher e sua família. nesse sentido, as inquietações quanto ao tema violência contra as mulheres são frutos de vivências e discussões junto a profissionais de saúde de um hospital universitário do sul do brasil, com vistas a construir coletivamente uma rede assistencial que permita às mulheres uma assistência qualificada (14). desse modo, a questão orientadora desta investigação foi: quais as necessidades assistenciais de mulheres que denunciam a situação de violência? o estudo objetivou, em uma perspectiva sociofenomenológica, apreender as necessidades assistenciais da mulher que denuncia, na delegacia de polícia, o vivido em situação de violência. método o estudo constituiu-se de uma investigação na abordagem qualitativa, fundamentada na fenomenologia social de alfred schütz. o campo de pensamento de schütz é marcado por uma sociologia da ação, sustentada na compreensão da vida social e do conjunto de ações sociais. analisaram-se fatores fundamentais determinantes do comportamento do indivíduo no mundo da vida, de modo que sua ação é vista como um processo fundamentado em funções de motivação, razões e objetivos, guiados por antecipações na forma de planejamento e projeções (13). os critérios de inclusão foram mulheres na faixa etária de 18 a 59 anos, que realizaram o registro da violência na delegacia de polícia para a mulher (dppm) e delegacia de polícia de pronto atendimento (dppa) de um município do interior do rio grande do sul (rs), brasil. as entrevistas foram desenvolvidas nessas instituições em sala que possibilitasse privacidade, disponibilizada pelo serviço. a pesquisadora abordou as mulheres na sala de espera do atendimento, onde realizou o convite para participar da pesquisa após a denúncia da violência. a seleção das mulheres deu-se de forma aleatória, mediante a aceitação. a produção dos dados aconteceu entre março e abril de 2010. as entrevistas transcorreram com tempo médio de 22 minutos e tiveram por diretriz um roteiro que contemplava a situação biográfica da entrevistada e a questão orientadora: o que você tem em vista quando realiza a denúncia da violência? a entrevista fenomenológica oportunizou o relato de suas vivências no que se refere ao tema da questão e desvelou a intencionalidade de sua ação. para schütz, a pessoa explicita seu “motivo para”, sua intencionalidade, por meio da comunicação (13). essa intencionalidade envolve a expressão de significados que indicam perspectivas, necessidades, demandas e projetos de vida. assim, a fenomenologia social de alfred schütz propõe que, em toda ação que o sujeito estabelece, existe um sentido intencional que busca atender suas expectativas, suas necessidades (15). contudo, esse sentido e significado somente o próprio indivíduo pode desvelar (13). as mulheres do estudo, ao denunciarem o vivido da violência, têm expectativas que remetem às suas necessidades assistenciais, que estão relacionadas com seu mundo da vida. a captação destas requer admitir um conceito de necessidades que transcenda o cunho clínico ou biológico e que articule as demandas sociais. 201 necessidades assistenciais de mulheres que denunciam na delegacia de polícia a vivência da violência l letícia becker-vieira y otros. assim, saber escutar o que o sujeito tem a dizer, compreender e significar as necessidades a partir do seu vivido é fundamental nas práticas de saúde (16). a etapa de campo foi concluída diante da suficiência de significados, comuns na intencionalidade da ação das mulheres ou, ainda, a suficiência do conteúdo dos “motivos para”, expresso nas falas das entrevistadas, em convergência ao objetivo proposto no estudo (17). para a análise foram desenvolvidos os seguintes passos (15, 18): escuta do conteúdo gravado nas entrevistas; transcrição; leitura do texto na íntegra; agrupamento das falas por afinidade (ideias comuns); captação dos “motivos para” que respondiam à pergunta da pesquisa (categorias concretas do vivido); releitura do texto na íntegra, a fim de identificação das relações das categorias entre si, chegando ao típico da ação. a interpretação dos significados expressos nas categorias concretas do vivido fundamentou-se nas concepções teóricas da fenomenologia social de alfred schütz (13). o estudo seguiu os princípios éticos determinados na resolução 196/1996 do conselho nacional de saúde e foi aprovado no comitê de ética em pesquisa da universidade federal de santa maria (rs), sob o número do processo 23081.015518/2009-66. para preservar o anonimato das participantes, foram utilizados nomes fictícios de flores escolhidos pelas próprias mulheres. resultados foram entrevistadas 13 mulheres entre 18 e 49 anos. o número de filhos variou de um a oito, com uma média de 2,38 filhos. quanto à situação civil, quatro declararam estar casadas e nove moravam com o companheiro. dez referiram trabalhar, duas não trabalhar, e uma identificou-se como sendo dona de casa. a escolaridade apontou oito mulheres com ensino médio incompleto, uma com o ensino médio completo, três com ensino superior incompleto, e outra com ensino superior completo. na situação biográfica, com relação à violência, relataram ter realizado entre uma a cinco denúncias do companheiro na delegacia de polícia respaldadas na lei 11.340/2006 (9). a análise das falas das entrevistadas, representadas neste espaço pelo discurso de algumas mulheres, tendo por referência o significado do “motivo para” da ação, permitiu apreender suas intencionalidades e apontar necessidades assistenciais relacionadas a seguir. justiça e proteção legal eu espero que haja justiça, pra eu pelo menos ter um pouco de paz! por isso que eu estou aqui! eu não vou deixar impune, eu quero tocar pra frente! eu quero que a justiça seja feita! [...] existem leis, agora tem a maria da penha! eu peço que todas as mulheres que sejam agredidas, até verbalmente, que denunciem! que sejam fortes, que elas não vão ser desamparadas! como eu não tô sendo agora! (girassol) eu espero que tenha uma providência, ou que eu saia de casa, ou arrumem um jeito dele sair! assim, com nós dois dentro de casa, não dá mais! eu espero que tenha providência! (violeta) eu espero que alguma coisa seja feita dessa vez! ele tem que pagar! eu espero que dessa vez prendam ele, que ele pare, que ele leve assim, nem que seja um susto para aprender que não é assim as coisas! (rosa) a intencionalidade das mulheres ao denunciar a violência vivida focaliza-se em sua necessidade de justiça e de proteção com o cumprimento da lei. apreende-se sua expectativa com relação ao companheiro e que este seja punido e/ou preso pelos seus atos agressivos. no que diz respeito à lei, expressam a relevância de cumprimento desta e, por vezes, exprimem incertezas quanto seu desfecho. ajuda institucional na resolutividade da sua demanda espero que dessa vez eu não ouça a mesma coisa que eu ouvi aqui, que eu tô doente! eu tô doente, eu sei que estou! mas eu espero não ouvir isso hoje! eu espero hoje sair daqui com ao menos: nós vamos te ajudar a viver melhor! (gérbera). vou pedir pra falar com o juiz, com o advogado; vou pedir pra falar com o mundo e ninguém faz nada? já falei com o promotor! já falei na delegacia da mulher! eu não acredito então nessa maria da penha [...] não acontece nada! (rosa). eu já o denunciei uma vez, mas eu não sei o que deu, porque o processo nem chegou lá em casa, e, daí, assim eu parei de denunciar, porque ele [companheiro] sabia que não ia da em nada, né! (violeta). 202 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 eu queria muito ajuda! que acontecesse que a justiça, o juiz desse um afastamento dele de casa, isso ia melhorar muito a nossa [a dos filhos também] vida, ia facilitar tudo! (girassol). as mulheres do estudo que realizam a denúncia da violência expressam a expectativa de que os profissionais que prestam atendimento ajudem nas demandas por elas trazidas, com vistas a haver resolutividade do processo de afastamento do companheiro de suas vidas. proteção dos filhos ele vivia dizendo isso, que ia se matar, se eu não quisesse viver com ele, só que eu não sei até que ponto ali, numa hora pra outra, ele podia se virar contra mim, e se ele tirasse a minha vida, eu não ia poder criar o meu filho! eu não ia poder ver meu filho crescer! [...] então eu fugi porque eu queria ver meu filho crescer; se ele quisesse tirar a vida dele, problema é dele, eu quero viver pra criar o meu filho! então, o que me motivou na verdade foi isso. foi meu filho. (crisântemo). porque ele ameaçou a minha filha, de pegar ela! eu não me preocupo comigo, eu me preocupo com ela. eu me preocupo que ele faça algo pra ela! pra mim não, porque, ele me matando, só vai acabar tudo! [...] me preocupo com ela! (onze-horas). isso eu digo pra eles [filhos], o que o pai de vocês faz comigo eu não quero que vocês façam isso com as esposas! não quero isso pras minhas noras! (tulipa). as falas das mulheres revelam que o projeto intencional de realizar a denúncia da violência vivida está associado à necessidade de proteger, criar e cuidar de seus filhos livre da violência. exprimem a preocupação com as repercussões que essa situação possa gerar na vida e saúde dos filhos, bem como a preocupação com a reprodução da violência. discussão a análise permitiu apreender que a mulher em situação de violência, ao realizar a denúncia do companheiro em uma delegacia de polícia, concebe como necessidades assistenciais a justiça e a proteção legal, a ajuda institucional e a proteção dos filhos. tais expectativas estão relacionadas às demandas institucionais e sociais, e sinalizam a importância de vislumbrar essa clientela na sua dimensão humana e social no mundo da vida. as falas das mulheres que realizam a ação de denunciar confluíram para a construção do “motivo para”: necessidade de justiça e de proteção legal. ao se referirem às expectativas com relação à denúncia, expressam o desejo de que ela seja conduzida até o final, apesar de, muitas vezes, serem questionadas por pessoas da sua rede sobre o prosseguimento, se terão capacidade emocional e condições financeiras de seguir com o processo. tais expectativas da mulher surgem do seu vivido no cotidiano e do seu interesse, ou seja, aquilo que está à mão do sujeito social, sendo este eminentemente prático. trata-se, portanto, de uma instância prioritária dentro de um sistema maior de interesses inter-relacionados, que determinará o que será pensado e projetado, e que levará a uma ação. nessa situação, e de acordo com schütz, este sistema não é homogêneo, pois pode mudar de acordo com o papel desempenhado pelo sujeito em diferentes âmbitos do mundo social. também não é constante, porque pode adquirir maior ou menor prioridade entre o agora e o agora que acabou de passar (13). a intenção das mulheres ao denunciarem envolve a expectativa e aponta para a necessidade de proteção por meio da justiça legal. elas expressam a relevância de acreditar na justiça, esperam providências com relação à sua situação. reconhecem a lei maria da penha (7) como um instrumento mediador de justiça e esperam do serviço policial e judiciário a proteção e a ajuda de que necessitam. entretanto, apontam as incertezas e dúvidas no que diz respeito aos desfechos legais e desafios a serem superados no acolhimento institucional. segundo schütz, a dúvida se refere a uma certeza empírica já vivenciada, que se torna questionável (13). nesse sentido, as mulheres questionam a efetivação da lei por já terem vivenciado situações em que nada foi feito. pode acontecer por diferentes interpretações da legislação ou por desqualificação da violência pela instituição policial ou jurídica (7, 19). as mulheres relatam, ainda, que a medida protetiva não foi respeitada pelo companheiro e que as situações de violência após a denúncia se tornaram mais frequentes. esse fato leva muitas mulheres a realizarem a denúncia várias vezes, o que evidencia a falta de resolutividade nas demandas assistenciais delas. ao analisar o projeto almejado pela mulher ao realizar a denúncia, vislumbram-se as expectativas com relação ao cumprimento da lei de forma efetiva. na corrente de pensamento de schütz, o in203 necessidades assistenciais de mulheres que denunciam na delegacia de polícia a vivência da violência l letícia becker-vieira y otros. tercâmbio de pontos de vista e o acordo prático dos sistemas de escolhas constituem a tese geral da reciprocidade de perspectivas (13). desse modo, tem-se a tese geral que pressupõe objetivos em comum, a intersubjetividade e a comunicação entre o profissional que atende e a mulher que denuncia situações de violência. a reciprocidade de perspectivas compreende a apreensão de objetos e seus aspectos conhecidos pela mulher e potencialmente conhecidos pelo profissional, como um conhecimento de todos (13). nessa linha de pensamento, a mulher em situação de violência toma certa atitude e espera que o profissional envolvido no apoio institucional responda de uma determinada forma. ela age na expectativa de que o outro reaja motivado por causa da sua ação. a partir da interação, pode-se alcançar o projeto intencional e intersubjetivo para resolutividade das necessidades assistenciais das mulheres e que estão relacionadas com seu mundo da vida. ao confluir para a necessidade de ajuda institucional e resolutividade da sua demanda, demonstra-se que as mulheres acabam estabelecendo graus de familiaridade e de anonimato (13). nessa investigação, o afastamento do companheiro significa uma relação de anonimato. quanto mais anônima for a relação, mais afastada estará a unicidade e a individualidade. buscam no acolhimento institucional relações de familiaridade para enfrentamento da violência. a relação de familiaridade é vivida sob a forma do “nós” e permite a apreensão do outro como único em sua individualidade (3, 13). entretanto, ao se reportarem em especial à delegacia, apontam a incerteza quanto à resolutividade da lei e da proteção. o que remete para a falta de intercâmbio de pontos de vista entre as mulheres e os profissionais, o déficit de comunicação entre os envolvidos e os desencontros assistenciais no apoio institucional. na maioria das vezes, são priorizadas as necessidades preestabelecidas pelo olhar profissional (7, 14, 19). assim, são divergentes aos princípios de humanização, integralidade, cidadania e cuidado, inscritos nas políticas públicas sociais e de saúde brasileiras. dessa forma, faz-se necessário reconhecer a situação de violência e abordá-la com responsabilidade, como uma das maneiras de assegurar à mulher o direito de ser cuidada, de viver sem violência, de garantir sua cidadania e preservar sua saúde (20). as necessidades assistenciais expressas pelas mulheres do estudo em tela contemplam as ações de combate, assistência e garantia dos direitos das mulheres conforme determinado na política nacional de enfrentamento à violência contra as mulheres (21). no que se refere ao combate à violência, as mulheres expressaram a expectativa com relação ao estabelecimento e cumprimento de normas penais que garantam a punição e a responsabilização dos agressores/autores. no que tange à assistência, exprimem sua expectativa em receber um atendimento humanizado e qualificado. no que diz respeito aos direitos humanos das mulheres, estar protegida e proteger os filhos. ao denunciar o vivido da violência, o “motivo para” das mulheres diz respeito à intenção de proteção dos filhos. o projeto intencional da denúncia está associado à necessidade de proteger, criar e cuidar de seus filhos livre da violência por eles presenciada. a experiência do mundo social acontece em um mundo cotidiano, onde as nossas ações e intenções indicam um mundo subjetivo. esse mundo cotidiano representa o mundo de todos nós, espaço que nossas comunicações e relacionamentos ocorrem. diz respeito a tudo o que está a minha volta, onde estão os meus contemporâneos, antecessores e sucessores (13). os contemporâneos dividem a região do espaço e tempo. neste estudo, o contemporâneo das mulheres são seus companheiros, com os quais estabelecem uma relação face a face, de orientação para tudo o que envolve o seu mundo da vida social. os antecessores são aqueles cujas ações podem ter influência sobre a vida das mulheres, pois já vivenciou no passado, mas sobre as quais elas não podem atuar, como a situação da violência perpetuada o seu mundo da vida social. nesse mundo há também aqueles que as mulheres podem exercer certa influência, os sucessores. os filhos são seus sucessores e o fato de vivenciarem a violência entre a mãe e o pai ou padrasto as leva a denunciar. e elas expressam que isso foi determinante na sua decisão de afastar-se do companheiro, por meio do registro de ocorrência. desse modo, pela ação da denúncia, exercem a influência sobre seus filhos no sentido de mantê-los longe de um relacionamento imerso em discussões, agressões e humilhações. desejam que estes tenham boa índole e que não reproduzam essa violência com suas futuras namoradas, e, no caso das filhas, que estas não se permitam e não aceitem relacionar-se com homens com perfil agressor. 204 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 conclusão o estudo desvelou uma faceta da intencionalidade das mulheres que denunciam o vivido da violência em uma delegacia, qual seja: suas necessidades assistenciais no contexto da violência. conclui-se que, para apreender os motivos que levam à denúncia, requer compreender as relações que elas estabelecem com o companheiro, os filhos, os familiares, ou com os profissionais que atendem esta clientela. ao considerar o mundo social desta mulher, destaca-se a possibilidade de reconstrução dos sentidos de sua vida livre de agressões por meio da justiça, da proteção legal e da ajuda institucional. essa ressignificação passa a ter relevância no seu viver e relacionar-se ao incluir aí a busca pela satisfação de suas necessidades e o rompimento com um vivido em violência. viver/ conviver em uma relação livre de violência é um direito universal. para concretizar esse direito, é fundamental ter como ponto de partida a mulher, seu entendimento de viver sem violência e suas necessidades assistenciais. a percepção social de que a violência contra as mulheres é um problema da maior gravidade aponta para o reconhecimento de sua existência e das sérias consequências que a atingem – o envolvimento dos filhos na relação agressiva. portanto, enfrentar o fenômeno da violência não se restringe à assistência apenas à mulher, mas também aos filhos que necessitam de proteção e assistência, mediada por uma atenção diferenciada desde o acolhimento institucional até os desdobramentos da ação profissional, seja esta policial, judicial ou de saúde. ao considerar os serviços de saúde como parte de uma rede de atendimento às mulheres em situação de violência e os profissionais como corresponsáveis nesse processo, vislumbra-se que a aproximação do contexto vivencial do outro possibilita promover espaços de diálogo, de escuta diante de relações mais familiares e menos anônimas, em consonância com suas necessidades assistenciais. enfatiza-se o reconhecimento da ação profissional junto à mulher em situação de violência, em especial a ação do enfermeiro como um processo interativo, e que este precisa ser vivido e compartilhado, possuir um significado para quem o realiza (enfermeiro), e para aquela que o recebe (mulher). deve-se considerar que a interação transcende a adscrição a um serviço, significa estabelecer e fortalecer uma relação de familiaridade em um encontro subjetivo que almeje a resolutividade de suas necessidades e demandas; além disso, que permita estratégias de empoderamento das mulheres, promova o acesso à justiça e o resgate como sujeito de direitos. ressalta-se também a urgência de estudos que focalizem as ações assistenciais dos profissionais que atendem essa clientela, no intuito de desenvolver um cuidado voltado às necessidades das mulheres. recomenda-se a ampliação de estudos na temática com outras abordagens metodológicas. referências 1. minayo mcs.the difficult and slow inclusion of violence on the health sector agenda. cad saúde públ 2004 mai/jun; 20(3):646-7. 2. jong lc, sadala mla, tanaka acda. desistindo da denúncia ao agressor: relato de mulheres vítimas de violência doméstica. rev esc enferm usp 2008; 42(4):744-51. 3. vieira lb, padoin smm, souza ieo, paula cc. perspectivas para o cuidado de enfermagem às mulheres que denunciam o vivido da violência. esc anna nery rev enferm 2011; 15(4):677-84. 4. world health organization. who multi-country study on women’s health and domestic violence against women.geneva; 2005. 5. alemán m, vernaz d, tilli g, mazur v, sammartino br, marconi a, pannia k. detección de violencia basada en género. análisis de situación del sistema de atención primaria de salud en la ciudad de buenos aires. rev argent salud pública 2010; 1(5):22-7. 205 necessidades assistenciais de mulheres que denunciam na delegacia de polícia a vivência da violência l letícia becker-vieira y otros. 6. schraiber lb, d’oliveira afpl, frança-junior i, diniz s, portella ap, ludermir ab, valença o, couto mt. prevalência da violência contra a mulher por parceiro íntimo em regiões do brasil. rev. saúde pública 2007; 41(5):797-807. 7. santi ln, nakano ams, lettiere a. percepção de mulheres em situação de violência sobre o suporte e apoio recebido em seu contexto social. texto contexto enferm 2010; 19(3):417-24. 8. barrett bj, st. pierre m. variations in women’s help seeking in response to intimate partner violence: findings from a canadian population-based study. violence against women 2011; 17(1):47-70. 9. brasil. secretaria especial de políticas para as mulheres. lei maria da penha lei 11.340 de 7 de agosto de 2006 – coíbe a violência doméstica e familiar contra a mulher. brasília (df): spm; 2006. 10. pougy lg. desafios políticos em tempos de lei maria da penha. rev katálisys 2010; 13(1):76-85. 11. diniz nmf, lopes rlm, rodrigues ad, freitas ds. women who were burned by their husbands or partners. acta paul enferm 2007; 20(3):321-5. 12. souto cmrm, braga vab. vivências da vida conjugal: posicionamento das mulheres. rev bras enferm 2009; 62(5):670-4. 13. helmut w. sobre fenomenologia e relações sociais – alfred schütz. rio de janeiro: vozes, 2012. 14. vieira lb, padoin smm, landerdahl mc. a percepção de profissionais da saúde de um hospital sobre a violência contra as mulheres. rev gaúcha enferm 2009; 30(4):609-16. 15. lima ca, tocantins fr. healthcare needs of the aged: perspectives for nursing. rev bras enferm 2009; 62(3):367-73. 16. campos cms, mishima sm. necessidades de saúde pela voz da sociedade civil e do estado. cad saúde públ 2005; 21(4):1260-8. 17. paula cc, cabral ie, souza ieo, padoin smm. movimento analítico hermenêutico heideggeriano: possibilidade metodológica para a pesquisa em enfermagem. acta paul enferm 2012; 25(6):984-9. 18. rossi cs, rodrigues bmrd. characteristics of actions of professionals nurses regarding the care provided by family members of hospitalized children. acta paul enferm 2010; 23(5):640-5. 19. afifi ze, al-muhaideb ns, hadish nf, ismail fi, al-qeamy fm. domestic violence and its impact on married women’s health in eastern saudi arabia. saudi med j 2011; 32(6):612-20. 20. labronici lm, ferraz mir, trigueiro th, fegadoli d. profile of the violence committed against women assisted at pousada de maria lodging. rev esc enferm usp 2010; 44(1): 124-31. 21. brasil. presidência da república. secretaria especial de políticas para as mulheres. política nacional de enfrentamento à violência contra a mulher. brasília (df): spm: 2008. 7 19 efecto de los factores.indd 7 mireya gricelia galindo-martínez1 laura rico-herrera2 nicolás padilla-raygoza3 efecto de los factores socioculturales en la capacidad de autocuidado del paciente hospitalizado con diabetes tipo 2 1 magíster en ciencias de enfermería. hospital general tecomán, méxico. bryangabriel_29@hotmail.com 2 doctora en salud pública. universidad de guanajuato, méxico. laurarico.seade@gmail.com 3 doctor en ciencias, epidemiología. universidad de guanajuato, méxico. raygosan@ugto.mx recibido: 5 de agosto de 2013 enviado a pares: 4 de septiembre de 2013 aceptado por pares: 2 de noviembre de 2013 aprobado: 2 de noviembre de 2013 año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 7-19 para citar este artículo / to reference this article / para citar este artigo galindo-martínez, m. g.; rico-herrera, l.; padilla-raygoza, n. (2014). efecto de los factores socioculturales en la capacidad de autocuidado del paciente hospitalizado con diabetes tipo 2. aquichan. vol. 14, no. 1, 7-19. resumen introducción: la diabetes tipo 2 es considerada como un problema de salud pública por su creciente prevalencia e incidencia. objetivo: describir el efecto de los factores socioculturales en la capacidad de autocuidado del paciente hospitalizado con diabetes tipo 2 en el hospital general de tecomán, colima, méxico. método: estudio transversal, observacional. se trabajó con 68 pacientes hospitalizados con diabetes tipo 2; se utilizó un instrumento que midió el efecto de los factores socioculturales en la capacidad de autocuidado. el análisis de datos se realizó con razón de momios, intervalos de confianza al 95 % y fracción atribuible en expuestos. resultados: los factores socioculturales tuvieron un leve efecto positivo en la capacidad de autocuidado (rm = 1,10; ic 95 %: 0,26-4,74) en pacientes hospitalizados con diabetes tipo 2. conclusiones: los factores socioculturales: experiencias vitales, experiencias laborales, religión, costumbres y tradiciones, prácticas curativas y ritos, señalados en la teoría general del déficit de autocuidado, muestran un efecto positivo sobre la capacidad de autocuidado de las personas con diabetes tipo 2. palabras clave diabetes mellitus tipo 2, autocuidado, atención al paciente, salud pública, enfermería (fuente: decs, bireme). 8 aquichan issn 1657-5997 año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 7-19 the effect of socio-cultural factors on the self-care capacity of hospitalized patients with type 2 diabetes abstract introduction: type 2 diabetes is considered a public health problem because of its increasing prevalence and incidence. objective: the purpose of this research is to describe the effect of socio-cultural factors on the self-care capacity of patients with type 2 diabetes who are hospitalized at the tecomán general hospital in colima, mexico. method: this is a cross-sectional, observational study of 68 hospitalized patients with type 2 diabetes. an instrument to measure the effect of socio-cultural factors on the capacity for self-care was used. data analysis was conducted with the odds ratio method, confidence intervals at 95 % and attributable fraction in exposures. results: socio-cultural factors had a slight positive effect on the capacity for self-care among hospitalized patients with type 2 diabetes (rm = 1.10, 95 % ci, 0.26 to 4.74). conclusions: the socio-cultural factors outlined in the general self-care deficit theory; namely, life experiences, work experiences, religion, customs and traditions, healing practices and rituals, were shown to have a positive effect on the self-care capacity of people with type 2 diabetes. key words diabetes mellitus, type 2, self-care, patient care, public health, nursing (source: decs, bireme). 9 efecto de los factores socioculturales en la capacidad de autocuidado del paciente hospitalizado con diabetes tipo 2 l mireya gricelia galindo-martínez y otros. efeito dos fatores socioculturais na capacidade de autocuidado do paciente hospitalizado com diabete tipo 2 resumo introdução: a diabete tipo 2 é considerada um problema de saúde pública por sua crescente prevalência e incidência. objetivo: descrever o efeito dos fatores socioculturais na capacidade de autocuidado do paciente hospitalizado com diabete tipo 2 no hospital general de tecomán, colima, méxico. método: estudo transversal, observacional. trabalhou-se com 68 pacientes hospitalizados com diabete tipo 2; utilizou-se um instrumento que mediu o efeito dos fatores socioculturais na capacidade de autocuidado. a análise de dados foi realizada com razão de chances, intervalos de confiança de 95 % e fração atribuível em expostos. resultados: os fatores socioculturais tiveram um leve efeito positivo na capacidade de autocuidado (rm = 1,10; ic 95 %: 0,26-4,74) em pacientes hospitalizados com diabete tipo 2. conclusões: os fatores socioculturais, como experiências vitais, experiências laborais, religião, costumes e tradições, práticas curativas e rituais, indicados na teoria geral do déficit de autocuidado, mostram um efeito positivo sobre a capacidade de autocuidado das pessoas com diabete tipo 2. palavras-chave diabetes mellitus tipo 2, autocuidado, assistência ao paciente, saúde pública, enfermagem (fonte: decs, bireme). año 14 vol. 14 nº 1 chía, colombia marzo 2014 l 7-19 10 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 introducción la organización mundial de la salud (oms) estima que la diabetes afecta a 200 millones de personas en el mundo, muchas de ellas en países en desarrollo (1). en méxico se considera que hay 400.000 nuevos casos al año y ocasiona 60.000 muertes anuales, siendo la primera causa de mortalidad (2). de acuerdo con la encuesta nacional de salud y nutrición en méxico 2006 (ensanut), la prevalencia de diabetes se incrementó en 14 % (3), esperando que para el año 2025 existan 12,6 millones de personas con diabetes en el país (4). la tasa de mortalidad por diabetes se incrementó hasta el 70,8 % en el 2008, según el sistema nacional de información en salud (sinais) (5). en el estado de colima, la diabetes tipo 2 es la segunda causa de mortalidad con una tasa de 74,2 por cada 100.000 habitantes (6). los pacientes con diabetes tipo 2 requieren un control basado en un régimen de autocuidado que favorezca el manejo y monitoreo de la enfermedad, donde el individuo debe participar activamente, por lo que debe tener los conocimientos, las habilidades y las motivaciones para poder desempeñar su autocuidado con el fin de promover, mantener y conservar la salud y el bienestar. la oms plantea que el 95 % del tratamiento del paciente diabético recae directamente en él (7). la teoría de déficit de autocuidado de dorotea orem tiene tres subteorías relacionadas entre sí, cuyo objetivo principal es que el agente de autocuidado lleve a cabo y mantenga acciones para conservar la salud y la vida (8). el autocuidado es una acción aprendida por una persona en su contexto sociocultural, que se inicia de manera voluntaria a fin de mantener la vida, la salud y el bienestar (8). el desempeño descansa en el conocimiento, las habilidades y las motivaciones desarrolladas y ejercitadas específicamente para el autocuidado (9). orem señala que hay factores condicionantes básicos (fcb) que influyen en las capacidades del individuo para realizar el autocuidado (10), y los clasifica en cuatro grupos: los descriptivos, el patrón de vida, el sistema y estado de salud, y el estado del desarrollo; los factores socioculturales (fsc) forman parte de los descriptivos, concebidos como un sistema complejo e interrelacionado del ambiente social y del sistema de las creencias de las personas y los recursos disponibles (11). según orem, los factores socioculturales afectan a las demandas de autocuidado de los individuos limitando los medios para satisfacerlas (12). a partir de lo anterior surge la siguiente pregunta: ¿cuál es el efecto de los fsc en la capacidad de autocuidado de pacientes hospitalizados con diabetes tipo 2 en el hospital general de tecomán, colima, méxico? la hipótesis de trabajo es que los factores socioculturales tienen un efecto positivo en la capacidad de autocuidado de pacientes hospitalizados con diabetes tipo 2 en el hospital general de tecomán. materiales y métodos tipo de estudio transversal observacional, realizado en el hospital general de tecomán, de la secretaría de salud del estado de colima en méxico, durante el año 2012. el universo estuvo compuesto por pacientes con diagnóstico de diabetes tipo 2 hospitalizados en el hospital general de tecomán, colima. tamaño de muestra. se invitó a participar a 73 pacientes de los cuales aceptaron 68 (93,15 %). se esperaba que el 50 % tuvieran capacidad de autocuidado (cac) alta y factores socioculturales (fsc) adecuados, y que el 15 % tuvieran cac alto y fsc inadecuados (10); el tamaño mínimo de muestra fue de 32 sujetos con fsc adecuados y 32 con fsc inadecuados, con 95 % de precisión y 80 % de poder (epiinfo 3.5.1, 2008, cdc, atlanta, ga, eua). selección de los participantes criterios de inclusión. pacientes adultos de ambos géneros, con diagnóstico de diabetes tipo 2 hospitalizados en el hospital general de tecomán, que hubieran aceptado participar con la firma del consentimiento informado, con un tiempo mínimo de un año desde su diagnóstico de diabetes tipo 2, criterios de exclusión. pacientes con diabetes gestacional, diabetes tipo 1, pacientes con deterioro neurológico, estado crítico de salud o que no aceptaran participar en el estudio. medición de variables. se recogieron datos acerca de la edad, el género, la religión, la escolaridad, la ocupación, el ingreso mensual, el estado civil y el sistema que utiliza para la atención en salud. 11 efecto de los factores socioculturales en la capacidad de autocuidado del paciente hospitalizado con diabetes tipo 2 l mireya gricelia galindo-martínez y otros. factores sociocultulares. es el sistema múltiple, complejo e interrelacionado del ambiente social y del sistema de creencias espirituales de la persona; el nivel de educación, la ocupación que desempeña, las experiencias laborales o las experiencias vitales afectan directa o indirectamente la agencia de autocuidado (13). se midió como adecuado (76 a 152 puntos) o inadecuado (0 a 75 puntos). tiene las dimensiones: experiencias laborales, experiencias vitales, religión, costumbres y tradiciones y prácticas curativas o ritos. se midió con el instrumento “cuestionario para identificar el efecto de los factores socioculturales en la capacidad de autocuidado en pacientes con diabetes tipo 2”, basado en el cuestionario diseñado por jiménez “factores socioculturales que influyen en el patrón de vida del adulto maduro con obesidad” (14); este cuestionario está constituido por 38 ítems que contienen las experiencias laborales, vitales, religión, costumbres y tradiciones, prácticas curativas o ritos, con respuestas en escala tipo likert —nunca (0), casi nunca (1), pocas veces (2), casi siempre (3), siempre (4)—, con un alfa de cronbach de 0,74 de confiabilidad. capacidad de autocuidado. son las habilidades desarrolladas por la agencia de autocuidado de las personas para realizar de manera efectiva, dentro del marco temporal adecuado, la investigación, el juicio, la toma de decisiones y las operaciones reguladoras o de tratamiento necesarias para mantener su funcionamiento y desarrollo dentro de las normas compatibles con la vida, la salud y el bienestar (8). se calificó como alta capacidad de autocuidado (79 a 124 puntos) y baja capacidad de autocuidado (33 a 78 puntos). tiene tres dimensiones: conocimientos (satisfactorios 21 a 40 puntos y no satisfactorios 0 a 20 puntos); habilidades (suficiente 21 a 40 puntos, insuficiente 0 a 20 puntos); motivaciones (adecuada 23 a 44 puntos e inadecuada 0 a 22 puntos). se midió con el “cuestionario para identificar el efecto de los factores socioculturales en la capacidad de autocuidado en pacientes con diabetes tipo 2”, con un alfa de cronbach de 0,74 de confiabilidad basado en el cuestionario de flores “escala para determinar la capacidad de autocuidado de los pacientes con diabetes tipo 2” (13); consta de 31 ítems, 10 valoran conocimientos, 10 las habilidades y 11 las motivaciones; las respuestas son escala tipo likert —nunca (0), casi nunca (1), pocas veces (2), casi siempre (3) y siempre (4)—. procedimientos del estudio inicialmente se revisaron las hojas de movimiento diario de pacientes que se encontraban hospitalizados en los servicios de medicina interna, cirugía general y urgencias del hospital general de tecomán, para identificar aquellos que tenían el diagnóstico de diabetes tipo 2 y que cumplieran con los criterios de elegibilidad; posteriormente se les invitó a participar en el estudio, se les explicaron los objetivos, el manejo confidencial de los datos y en qué consistía su participación, también se les explicó que su participación era voluntaria. después de responder preguntas se les solicitó la firma del consentimiento informado para proceder a la recolección de datos. posteriormente se continuó con la aplicación del instrumento a través de la técnica de entrevista la cual tuvo una duración de 40 minutos. análisis estadístico. se utilizó una base de datos de stata 10.0® (stata corporation, college station, tx, eua). para las variables sociodemográficas se utilizó estadística descriptiva con medidas de tendencia central y dispersión para las variables cuantitativas, y frecuencias y porcentaje para las categóricas. se calculó razón de momios (rm) e intervalos de confianza al 95 % (ic 95 %) para medir el efecto de los fsc en la cac; a fin de conocer el impacto de los fsc sobre la cac se calculó la fracción atribuible en expuestos (fae). para demostrar la asociación entre fsc y cac se calculó chi cuadrado y valor de p. para demostrar significancia estadística de los resultados el valor de p se fijó en 0,05. resultados la muestra estuvo integrada por 68 pacientes con diabetes tipo 2 con un rango de edad de 43 a 70 años, con media de 57,5 y desviación estándar de 7,58. las características sociodemográficas de los sujetos participantes se muestran en el cuadro 1. en el cuadro 2 se observa la tabulación entre los factores socioculturales y la capacidad de autocuidado. no se encontró asociación estadísticamente significativa entre las variables (p > 0,05). las experiencias laborales como dimensión de factores socioculturales se tabularon con capacidad de autocuidado, encontrando que no hay asociación estadísticamente significativa, aunque los que reportaron experiencias laborales inadecuadas tuvieron casi dos y media veces más probabilidad de tener capacidad de autocuidado baja (cuadro 3). las experiencias vitales se reportaron muy semejantes entre los que tuvieron capacidad de autocuidado baja o adecuada, y 12 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 no se encontraron diferencias significativas (p > 0,05); lo mismo aconteció para las dimensiones de religión y prácticas curativas y ritos (cuadro 3); solo se encontró una asociación estadísticamente significativa para la dimensión de costumbres y tradiciones (p < 0,05); los pacientes con capacidad de autocuidado bajo tuvieron 17 veces mayor probabilidad de tener costumbres y tradiciones inadecuadas que los sujetos con capacidad de autocuidado alta; se tiene un 95 % de confianza en que la verdadera razón de momios en la población está entre 1,43 a 202,50; hay un efecto positivo de las costumbres y tradiciones inadecuadas sobre la capacidad de autocuidado y, de acuerdo con la fracción atribuible en expuestos, el 94 % de los pacientes que tuvieron capacidad de autocuidado baja se hubieran evitado si las costumbres y tradiciones hubieran sido adecuadas (cuadro 3). ninguna de las dimensiones de los fsc mostró una asociación significativa con los conocimientos de la capacidad de autocuidado (cuadro 4). las costumbres y tradiciones como parte de los fsc muestran una fuerte asociación estadísticamente significativa con habilidades de la capacidad de autocuidado (p < 0,05 y rm 80,0); la fracción atribuible en expuestos indica que el 98,75 % de los pacientes con habilidades insuficientes se hubieran evitado si las costumbres y tradiciones hubieran sido adecuadas (cuadro 5). el resto de dimensiones de los fsc no mostró relación significativa con las habilidades de la capacidad de autocuidado. las dimensiones de fsc y motivación para la capacidad de autocuidado muestran que las costumbres y tradiciones tienen una asociación estadísticamente significativa con la motivación (p < 0,05), y que los que tuvieron motivación inadecuada tenían una probabilidad 8 veces mayor de tener costumbres y tradiciones inadecuadas; el 87 % de los casos con motivación inadecuada se hubieran evitado si las costumbres y tradiciones fueran apropiadas (cuadro 6). discusión debido a que la muestra fue seleccionada por conveniencia los resultados no se pueden generalizar para la población de donde se obtuvieron los sujetos en estudio; además, existía el potencial de sesgos. se pretendió estudiar al total del universo que fue de 73 pacientes hospitalizados que cumplían con los criterios de inclusión, pero solo aceptaron participar 68 (93 %). con respecto a las variables de los factores socioculturales en la capacidad de autocuidado no hubo asociación estadística, lo cual puede deberse al tamaño de muestra pequeño. cabe resaltar que en una de las dimensiones correspondientes al factor sociocultural de costumbres y tradiciones, los pacientes con capacidad de autocuidado baja tuvieron 17 veces mayor probabilidad de tener costumbres y tradiciones inadecuadas que los sujetos con capacidad de autocuidado alta; hay una fuerte asociación estadística significativa entre costumbres y tradiciones con capacidad de autocuidado (p = 0,002), y existe un impacto en estas variables, ya que el porcentaje de los pacientes que tuvieron capacidad de autocuidado baja (94 %) se hubiera podido modificar si las costumbres y tradiciones fueran adecuadas (cuadro 3). romero (15) en su estudio ratifica que la capacidad de autocuidado de la persona con diabetes tipo 2 está vinculada a múltiples factores que merecen la atención de los profesionales de la salud en lo que se refiere a la proposición de programas de educación. los hallazgos obtenidos en su estudio contribuyen a la comprensión de los factores sociales y culturales como dimensiones importantes del autocuidado. orem refiere en su teoría que las orientaciones socioculturales influyen en las demandas de autocuidado terapéutico de los individuos, en gran parte limitando los requisitos del mismo y los medios para satisfacerlos, que serán aceptados como componentes constituyentes de las demandas de autocuidado terapéutico de las personas (16). es importante identificar los conocimientos de los elementos culturales interiorizados en las personas con diabetes tipo 2 y por los miembros del grupo social al que pertenecen en su autoconcepto y sistema de valores, y de esta forma partir de lo conocido y aceptado por ellos para el cumplimiento de las medidas de autocuidado a fin de favorecer o direccionar dichas acciones. por otro lado, en la tabulación de la dimensión del factor sociocultural costumbres y tradiciones con conocimientos de la capacidad de autocuidado se obtuvo una probabilidad de 0,08; los pacientes que reportaron conocimientos no satisfactorios tuvieron siete y media veces más probabilidad de tener costumbres y tradiciones inadecuadas comparados con los que tenían conocimientos satisfactorios. aunque no hubo asociación estadística entre las variables de conocimientos y costumbres y tradiciones (p = 0,08), se observa que existe un impacto, ya que el porcentaje de los pacientes que tenían conocimientos no satisfactorios (86 %) se hubiera podido modificar si las costumbres y tradiciones fueran adecuadas (cuadro 4). la adquisición de conocimientos para el autocuidado está influida por el nivel de madurez, conocimientos, experiencias 13 efecto de los factores socioculturales en la capacidad de autocuidado del paciente hospitalizado con diabetes tipo 2 l mireya gricelia galindo-martínez y otros. de vida, hábitos de pensamiento y condiciones ambientales de la persona, por lo que se debe iniciar con la toma de decisiones sobre las acciones que se van a llevar a cabo, lo que requiere de esfuerzo y perseverancia para lograr los objetivos fijados, pero para ello la persona necesita de conocimientos específicos y habilidades precisas, además de motivación para iniciar y continuar con su autocuidado (9). los pacientes que tuvieron habilidades insuficientes presentaron 80 veces más probabilidad de tener costumbres y tradiciones inadecuadas que aquellos que reportaron habilidades suficientes. además, hay una fuerte asociación estadística entre las variables habilidades y costumbres y tradiciones (p = 0,00001). el porcentaje de los pacientes que tuvieron habilidades insuficientes (98,75 %) se hubiera podido modificar si las costumbres y tradiciones hubieran sido adecuadas (cuadro 5). las costumbres y tradiciones demostraron una importante asociación estadísticamente significativa con la motivación de la capacidad de autocuidado (p < 0,05), y los que reportaron motivación inadecuada tuvieron casi ocho veces mayor probabilidad de costumbres y tradiciones inadecuadas que los sujetos que reportaron motivación adecuada; además, el porcentaje de los pacientes que reportaron habilidad inadecuada (87 %) se hubiera podido modificar si las costumbres y tradiciones hubieran sido adecuadas (cuadro 6). un estudio realizado por flores (13) demostró que el conocimiento de la enfermedad influye significativamente en las habilidades y motivaciones en el autocuidado de los pacientes con diabetes tipo 2. orem refiere que el ocuparse del autocuidado requiere de habilidades para autorregularse en un entorno estable o cambiante, y dichas habilidades van a estar condicionadas por las orientaciones socioculturales, la edad y los recursos disponibles (16); con estos resultados se confirma que las habilidades son una parte indispensable en las capacidades de autocuidado de los pacientes con diabetes tipo 2. se observa que las dimensiones de experiencias laborales, religión, prácticas curativas y ritos no mostraron asociación significativa con la capacidad de autocuidado ni con sus dimensiones (conocimientos, habilidades y motivaciones). esto se puede deber al tamaño de muestra pequeño, ya que este se recalculó con los resultados obtenidos, siendo de 42 integrantes con factores socioculturales adecuados y 42 con factores socioculturales inadecuados (stata 10.0® college station, tx, eua). conclusión con los resultados obtenidos se concluye que de las dimensiones de los factores socioculturales, las costumbres y tradiciones muestran un impacto sobre la capacidad de autocuidado en las personas hospitalizadas con diabetes tipo 2. estos resultados permiten tener evidencia en la identificación de factores socioculturales que tienen efecto sobre la capacidad de autocuidado de los pacientes con diabetes tipo 2, lo cual nos permitirá diseñar estrategias de intervención para tratar de modificar las costumbres y tradiciones de la población estudiada. en este rubro, el profesional de enfermería, al identificar los factores socioculturales que inciden en la capacidad de autocuidado, estará en condiciones de proporcionar una atención de enfermería efectiva garantizando con esto una atención holística, homogénea, con calidad, equidad y eficiencia desde un punto de vista intercultural, pero sobre todo con un enfoque particular hacia el mantenimiento de un sistema de apoyo educativo de enfermería y de acuerdo con lo estipulado con dorothea e. orem que establece que las enfermeras se caracterizan por su capacidad de aplicar sus conocimientos y habilidades en una variedad de situaciones y ser un agente transmisor de dichos conocimientos. 14 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 referencias 1. garcía h, meaney e, vargas g, escalante m, aldrete j. revisión actual de los conocimientos sobre la absorción intestinal de carbohidratos y su relación con la prevención del riesgo cardiovascular. medicina interna de méxico. 2011;27(3):270-9. 2. subsecretaría de prevención y promoción de la salud. secretaría de salud. programa de acción específico diabetes mellitus 2007-2012. méxico, d.f. secretaría de salud. 2008 [visitado 2013 julio 15]. disponible en: http://www.spps. gob.mx/diabetes-mellitus 3. garcía-alcalá h, meaney-mendiolea e, vargas-ayala g, escalante pulido m. revisión actual de los conocimientos sobre la absorción intestinal de carbohidratos y su relación con la prevención del riesgo cardiovascular. rev medicina interna méxico. 2011;27(3):270-80. 4. sistema nacional de información en salud. principales causas de mortalidad general por entidad federativa. 2008 [visitado 2011 agosto 16]. disponible en: http://sinais.salud.gob.mx/mortalidad/ 5. sistema automático de egresos hospitalarios (saeh). principales causas de mortalidad y morbilidad hospital general tecomán; 2010. 6. inegi. estadísticas a propósito del día mundial de la diabetes. 2010 [visitado 2011 agosto 8]. disponible en: http:// www.inegi.org.mx/inegi/contenidos/espanol/prensa/apropositom.asp?s=inegi&c=2773&ep=46 7. organización mundial de la salud. día mundial de la diabetes. 2010 [visitado 2013 julio 30]. disponible en: http:// www.worlddiabetesday.org/es 8. francisco c, benavente ma, ferrer e. el modelo teórico de dorothea e. orem. 2 ed. barcelona: harcourt; 2000. p. 317-47. 9. dennis cm. self-care deficit theory of nursing: concepts and applications. st. louis: mosby; 1997. 10. estrella j. factores socioculturales que influyen en la capacidad de autocuidado de la mujer embarazada. [tesis de maestría]. celaya, guanajuato, facultad de enfermería y obstetricia de celaya/universidad de guanajuato; 2007. pp. 15-25. 11. fernández a, manrique f. agencia de autocuidado y factores básicos condicionantes en adultos mayores. av enferm. 2011 [visitado 2013 julio 19]. 29(1): 22 pantallas. disponible en http://www.sci.unal.edu.co/scielo.php?script=sci_ arttext&pid=s0121-45002011000100004&lng=es&nrm=iso 12. organización panamericana de salud. fortalecimiento del autocuidado como estrategia de la atención primaria en salud: la contribución de las instituciones de salud en américa latina. santiago: organización panamericana de la salud. 2006 [visitado 2011 agosto 30]. disponible en: http://www7.uc.cl/enfermeria/html/noticias/precongreso/19447fortalecimiento%20autocuidado%20ops%20mayo%202006.pdf 13. flores s. influencia del conocimiento de la enfermedad en las habilidades y motivaciones en el autocuidado de los pacientes con diabetes mellitus tipo 2. desarrollo cientific enferm. 2006;14(9):357-361. 14. jiménez r. factores socioculturales que influyen en el patrón de vida del adulto maduro con obesidad. [tesis de maestría]. facultad de enfermería y obstetricia de celaya/universidad de guanajuato; 2010. p. 23-35. 15. romero i, dos santos m, aparecida t, zanetti m. autocuidado de personas con diabetes mellitus atendidas en un servicio de urgencia en méxico. rev latino-am enfermagem. 2010;18(6):1-9. 16. savannah ga. modelo de orem. conceptos de enfermería en la práctica. barcelona: ediciones científicas y técnicas, masson; 1993. p. 154. 15 efecto de los factores socioculturales en la capacidad de autocuidado del paciente hospitalizado con diabetes tipo 2 l mireya gricelia galindo-martínez y otros. cuadro 1. características sociodemográficas cualitativas de los participantes, hospital general tecomán, colima, méxico 2012 (n = 68) variable n porcentaje género masculino 21 30,88 femenino 47 69,12 estado civil soltero(a) 2 2,94 casado(a) 38 55,88 viudo(a) 12 17,65 divorciado 4 5,88 unión libre 12 17,65 escolaridad ninguna 11 16 primaria incompleta 29 43 primaria 14 20 secundaria 14 21 religión católica 51 75 protestante 2 3 evangélica 2 3 testigos de jehová 3 4 ninguna 2 3 otra 8 12 ingreso económico menos de 1500 13 19 1500-3000 8 12 3000-6000 5 7 sin percepción de ingresos 42 62 fuente: cuestionarios del estudio. 16 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 cuadro 2. tabulación de factores socioculturales y capacidad de autocuidado, hospital general tecomán, colima, méxico 2012 (n = 68) factores socioculturales capacidad de autocuidado total n x2 valor de p rm (ic 95%) fae (%) baja n (%) alta n (%) inadecuados 3 25,00 9 75.00 12 adecuados 13 23,21 43 76,79 56 total 16 52 68 0,02 0,89 1,10 (0,26 a 4,74) 9,09 rm: razón de momios. fae: fracción atribuible en expuestos. ic 95 %: intervalo de confianza al 95 %. fuente: cuestionario para identificar el efecto de los factores socioculturales en la capacidad de autocuidado en pacientes con diabetes tipo 2 y escala para determinar la capacidad de autocuidado de los pacientes con diabetes tipo 2. cuadro 3. tabulaciones de las dimensiones de factores socioculturales y capacidad de autocuidado, hospital general tecomán, colima, méxico 2012 (n = 68) dimensiones de factores socioculturales capacidad de autocuidado total n x2 valor de p rm (ic 95%) fae (%) baja n (%) alta n (%) experiencias laborales inadecuado 9 (33,33) 18 (66,67) 27 2,36 0,12 2,43 (0,75 a 7,83) 58,84 adecuado 7 (17,07) 34 (82,93) 41 experiencias vitales inadecuado 8 (22,22) 28 (77,78) 36 0,07 0,79 0,86 (0,28 a 2,65) 16,28 adecuado 8 (25,00) 24 (75,00) 32 religión inadecuado 8 (30,77) 28(69,23) 36 1,23 0,27 1,89 (0,60 a 5,98) 47,09 adecuado 8 (19,05) 24(80,95) 32 costumbres y tradiciones inadecuado 4 (80,00) 1 (20,00) 5 9,56 0,002 17,00 (1,43 a 202,50) 94,12 adecuado 12 (19,05) 51 (80,95) 63 prácticas curativas y ritos inadecuado 2 (25,00) 6 (75,00) 8 0,01 0,92 1,10 (0,20 a 6,12) 9,09 adecuado 14 (23,33) 46 (76,67) 60 rm: razón de momios. fae: fracción atribuible en expuestos. ic 95 %: intervalo de confianza al 95 %. fuente: cuestionario para identificar el efecto de los factores socioculturales en la capacidad de autocuidado en pacientes con diabetes tipo 2 y escala para determinar la capacidad de autocuidado de los pacientes con diabetes tipo 2. 17 efecto de los factores socioculturales en la capacidad de autocuidado del paciente hospitalizado con diabetes tipo 2 l mireya gricelia galindo-martínez y otros. dimensiones de factores socioculturales conocimiento total n x2 valor de p rm (ic 95%) fae (%) no satisfactorio n (%) satisfactorio n (%) experiencias laborales inadecuado 1 (3,70) 26 (96,30) 27 0,05 0,82 0,75 (0,06 a 8,87) 33,33 adecuado 2 (4,88) 39 (95,12) 41 experiencias vitales inadecuado 1 (2,78) 35 (97,22) 36 0,48 0,49 0,43 (0,04 a 5,10) 100 adecuado 2 (6,25) 30 (93,75) 32 religión inadecuado 2 (7,69) 24 (92,31) 26 1,06 0,30 3,42 (0,28 a 41,24) 70,76 adecuado 1 (2,38) 41 (97,62) 42 costumbres y tradiciones inadecuado 1 (20,00) 4 (80,00) 5 3,06 0,08 7,63 (0,52 a 111,93 86,89 adecuado 2 (3,17) 61 (96,83) 63 prácticas curativas y ritos inadecuado 0 (0,00) 8 (100,00) 8 0,53 0,47 2,05 (0,29 a 14,73) 51,22 adecuado 3 (5,00) 57 (95,00) 60 cuadro 4. tabulación de dimensiones de factores socioculturales con conocimiento, hospital general tecomán, colima, méxico 2012 (n = 68) rm: razón de momios. fae: fracción atribuible en expuestos. ic 95 %: intervalo de confianza al 95 %. fuente: cuestionario para identificar el efecto de los factores socioculturales en la capacidad de autocuidado en pacientes con diabetes tipo 2 y escala para determinar la capacidad de autocuidado de los pacientes con diabetes tipo 2. 18 año 14 vol. 14 nº 1 chía, colombia marzo 2014 aquichan issn 1657-5997 cuadro 5. tabulación de dimensiones de factores socioculturales y habilidad de autocuidado, hospital general tecomán, colima, méxico 2012 (n = 68) dimensiones de factores socioculturales habilidad total n x2 valor de p rm (ic 95%) fae (%) insuficiente n (%) suficiente n (%) experiencias laborales inadecuado 3 (11,11) 24 (88,89) 27 0,03 0,9 1,16 (0,23 a 5,70) 13.79 adecuado 4 (9,76) 37 (90,24) 41 experiencias vitales inadecuado 3 (8,33) 33 (91,67) 36 0,31 0,58 0,64 (0,13 a 3,14) 56.25 adecuado 4 (12,50) 28 (87,50) 32 religión inadecuado 3 (11,54) 23 (88,46) 26 0,07 0,79 1,24 (0,25 a 6,12) 19.35 adecuado 4 (9,52) 38 (90,48) 42 costumbres y tradiciones inadecuado 4 (80,00) 1 (20,00) 5 27,28 0,00001 80,00 (6,70 a 954,52) 98.75 adecuado 3 (4,76) 60 (95,24) 63 prácticas curativas y ritos inadecuado 1 (12,50) 7 (87,50) 8 0,05 0,83 1,29 (0,13 a 12,52) 22.48 adecuado 6 (10,00) 54 (90,00) 60 rm: razón de momios. fae: fracción atribuible en expuestos. ic 95 %: intervalo de confianza al 95 %. fuente: cuestionario para identificar el efecto de los factores socioculturales en la capacidad de autocuidado en pacientes con diabetes tipo 2 y escala para determinar la capacidad de autocuidado de los pacientes con diabetes tipo 2. 19 efecto de los factores socioculturales en la capacidad de autocuidado del paciente hospitalizado con diabetes tipo 2 l mireya gricelia galindo-martínez y otros. cuadro 6. tabulación de dimensiones de factores socioculturales y motivación para el autocuidado, hospital general tecomán, colima, méxico 2012 (n = 68) dimensiones de factores socioculturales motivación total n x2 valor de p rm (ic 95%) fae (%) inadecuada n (%) adecuada n (%) experiencias laborales inadecuado 7 (25,93) 20 (74,07) 27 1,32 0,25 2,04 (0,59 a 7,07) 50,98 adecuado 6 (14,63) 35 (85,37) 41 experiencias vitales inadecuado 5 (13,89) 31 (86,11) 36 1,33 0,25 0,41 (0,14 a 1,71) 100,00 adecuado 8 (25,00) 24 (75,00) 32 religión inadecuado 7 (26,92) 19 (73,08) 26 1,63 0,21 2,21 (0,63 a 7,70) 54,75 adecuado 6 (14,29) 36 (85,71) 42 costumbres y tradiciones inadecuado 3 (60,00) 2 (40,00) 5 5,75 0,02 7,95 (1,06 a 59,64) 87,42 adecuado 10 (15,87) 53 (84,13) 63 prácticas curativas y ritos inadecuado 1 (12,50) 7 (87,50) 8 0,25 0,62 0,57 (0,06 a 5,20) 75,44 adecuado 12 (20,00) 48 (80,00) 60 rm: razón de momios. fae: fracción atribuible en expuestos. ic 95 %: intervalo de confianza al 95 %. fuente: cuestionario para identificar el efecto de los factores socioculturales en la capacidad de autocuidado en pacientes con diabetes tipo 2 y escala para determinar la capacidad de autocuidado de los pacientes con diabetes tipo 2. 186 196 conductas criticas para experimentar.indd 186 aquichan issn 1657-5997 rodrigo javier yáñez-gallardo1 sandra valenzuela-suazo2 conductas críticas para experimentar confi anza en el liderazgo en enfermería en un hospital de alta complejidad 1. psicólogo. magister en investigación social y desarrollo. universidad de concepción, chile. ryanez@udec.cl 2. enfermera. doctora en enfermería. universidad de concepción, chile. svalenzu@udec.cl recibido: 12 de junio de 2012 enviado a pares: 24 de septiembre de 2012 aceptado por pares: 11 de abril de 2013 aprobado: 6 de mayo de 2013 año 13 vol. 13 nº 2 chía, colombia agosto 2013  186-196 resumen objetivo: esta investigación tiene por objetivo identificar el tipo de conductas de las jefaturas de enfermería más frecuentemente relacionadas con experimentar confianza hacia ellas según los funcionarios de la salud y determinar con cuál dimensión de la confiabilidad está más relacionada. método: la investigación fue de índole cualitativa y participaron 90 funcionarios de un hospital público de alta complejidad en chile; un 26,7 % eran enfermeras(os) y un 73,3 % técnicos paramédicos. se utilizó la técnica de incidentes críticos para la recolección de datos. se llevó a cabo un análisis fenomenológico interpretativo de las entrevistas semiestructuradas obteniéndose 66 incidentes críticos. en la entrevista se solicitó que describieran un incidente específico, significativo, que hubieran experimentado con su jefatura de enfermería. resultados: se identificaron cuatro categorías: ayuda instrumental ante problemas, apoyo emocional, apoyo y defensa ante ataques y apoyo al empoderamiento. se encontró que todas las categorías corresponden a la dimensión benevolencia de la percepción de confiabilidad del líder. conclusión: experimentar confianza en la jefatura se facilita cuando las enfermeras jefes ejercen un liderazgo que establece una confianza basada en un vínculo emocional positivo con los funcionarios, demostrando una preocupación cuando ellos enfrentan dificultades, tanto laborales como familiares, prestándoles entonces ayuda o apoyo emocional o profesional. palabras clave enfermería, confianza, liderazgo, instituciones de salud. (fuente: decs, bireme). para citar este artículo / to reference this article / para citar este artigo yáñez gallardo, r. j., valenzuela suazo, s. (2013). conductas críticas para experimentar confianza en el liderazgo en enfermería en un hospital de alta complejidad. aquichan. vol. 13, no. 2, 186-196. 187 conductas críticas para experimentar confianza en el liderazgo en enfermería en un hospital de alta complejidad l rodrigo javier yáñez-gallardo, sandra valenzuela-suazo behavior critical to trust in nursing leadership at a highly complex hospital abstract objective: this study was designed to identify the types of behavior displayed by head nurses that most often inspire trust among health workers and to determine what aspects of that behavior are most related to trust. methods: the research was qualitative and involved 90 staff members at a highly complex public hospital in chile: 26.7% were nurses and 73.3% were paramedic technicians. the critical incident technique was used to collect the data. an interpretative phenomenological analysis of semi-structured interviews yielded 66 critical incidents. those interviewed were asked to describe a specific, meaningful incident they had experienced with their head nurses. results: four categories were identified: instrumental help with problems, emotional support, support and defense against attacks, and support for empowerment. all the categories correspond to the benevolent aspect of the perception of trust in head nurses. conclusion: trust in nursing leadership is facilitated when head nurses lead in a way that fosters trust based on a positive emotional bond with staff members. this is accomplished by demonstrating concern when staff members face difficulties, both at work and at home, and by providing emotional or professional support and assistance. key words nursing, trust, leadership, health facilities. (source: decs, bireme). condutas críticas para experimentar confiança na liderança em enfermagem em um hospital de alta complexidade resumo objetivo: esta pesquisa tem como objetivo identificar o tipo de condutas das chefias de enfermagem mais frequentemente relacionadas com experimentar confiança a elas segundo os funcionários da saúde e determinar com qual dimensão da confiabilidade está mais relacionada. materiais e métodos: pesquisa qualitativa da qual participaram 90 funcionários de um hospital público de alta complexidade no chile; 26,7% eram enfermeiros(as) e 73,3%, técnicos paramédicos. utilizou-se a técnica de incidentes críticos para a coleta de dados. realizou-se uma análise fenomenológica interpretativa das entrevistas semiestruturas e se obtiveram 66 incidentes críticos. na entrevista, solicitou-se que descrevessem um incidente específico, significativo, que tivessem experimentado com sua chefia de enfermagem. resultados: identificaram-se quatro categorias: ajuda instrumental diante de problemas; apoio emocional; apoio e defesa diante de ataques e apoio ao empoderamento. constatou-se que todas as categorias correspondem à dimensão benevolência da percepção de confiabilidade do líder. conclusão: experimentar confiança na chefia se facilita quando as enfermeiras-chefe exercem uma liderança que estabelece uma confiança baseada em um vínculo emocional positivo com os funcionários, ao demonstrar uma preocupação quando eles enfrentam dificuldades, tanto laborais quanto familiares, e ao lhes oferecer ajuda ou apoio emocional ou profissional. palavras-chave enfermagem, confiança, liderança, instituições de saúde. (fonte: decs, bireme). 188 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 introducción ejercer liderazgo en enfermería en los servicios de salud es un trabajo muy complejo. por una parte, implica prestar un diligente cuidado a los pacientes (1) y, por otra, se debe gerenciar un equipo de salud que funciona con alto grado de interdependencia entre todos los integrantes, más aún si se considera que en muchos países se están implementando reformas en la gestión de la salud que fomentan la gestión participativa (2). en este contexto, las(os) enfermeras(os) jefes deben ser ejemplo para los funcionarios, deben proponer cambios, elaborar proyectos y tomar decisiones importantes; asimismo, es crucial que los funcionarios les crean y, más aún, las(os) apoyen. dado que la credibilidad, la adhesión a las instrucciones dadas y la cooperación voluntaria dependen en gran medida de la confianza en la jefatura, se sostendrá en este trabajo que el éxito en el rol de líder en enfermería depende, en gran parte, de la confianza de sus funcionarios. de hecho, las investigaciones avalan que la confianza en el jefe está estrechamente vinculada a un buen funcionamiento de los servicios de salud y, más aún, indirectamente influye en la relación enfermera(o)/paciente (3). se debe comprender que todo funcionario se siente vulnerable porque las jefaturas tienen sustancial poder para asignarles recursos, delegar funciones y ofrecer oportunidades de promoción (4). si los funcionarios tienen confianza en su jefatura disminuye el sentimiento de vulnerabilidad, se facilita significativamente la comunicación; es más factible que se atrevan a plantear un problema laboral o personal; a su vez, ellos podrán sentirse seguros ante una promesa de su jefatura y de la imparcialidad de sus evaluaciones. incluso, investigaciones muestran que dicha confianza aumenta la satisfacción laboral de los trabajadores (4, 5). sin embargo, para los funcionarios la decisión de confiar es riesgosa, siempre está latente la posibilidad de que las promesas no se cumplan. el temor a ser engañados o el hecho de que se haya producido una erosión de la confianza por situaciones pasadas puede inhibir significativamente la credibilidad y, con ello, la disposición hacia el trabajo colaborativo en su servicio. pese a la relevancia del estudio de la confianza en la jefatura existen escasas investigaciones que describan cuáles son las conductas de la jefatura vinculadas al desarrollo de la confianza interpersonal (6). aún más, son escasos los estudios en el contexto de enfermeras jefes de hospital, y los existentes se han centrado en la relación enfermera/o-paciente (3, 7). específicamente, las investigaciones sobre confianza en la jefatura se han circunscrito a la identificación de las dimensiones o los atributos generales que influyen en la confiabilidad de las jefaturas (8). por tanto, esta investigación se centra en la relación entre la conducta de la jefatura de enfermería y la confianza de los funcionarios en ella, más específicamente en: a) identificar las principales categorías de conductas de la jefatura de enfermería asociadas a experimentar confianza en los funcionarios de la salud, y b) determinar cuáles de las dimensiones de la percepción de confiabilidad en el jefe pueden favorecer más frecuentemente al desarrollo de la confianza con los funcionarios de la salud. confianza y confiabilidad en el líder a partir de las definiciones de confianza interpersonal existentes (3, 4, 6, 9) se podría definir la confianza en la jefatura como un proceso dinámico en el tiempo en el que los funcionarios de la salud llegan a tomar decisiones que impliquen creer o sentir que la jefatura actuará favorablemente hacia ellos sin tener certeza al respecto, y sin existir oportunidad de conocer o controlar la manera como realmente actuará la jefatura, optando el funcionario por correr el riesgo. la definición planteada realza el componente cognitivo de la confianza, sin embargo, se debe tener en consideración que la decisión de confiar involucra un componente afectivo, dado que también implica regulación emocional y la existencia de un vínculo afectivo con la jefatura (10, 11). si bien pueden existir varios factores que influyen en la confianza en la jefatura, una variable con significativa influencia es la percepción de confiabilidad de quien se confía, es decir, la evaluación de que la jefatura posee cualidades personales que ameritan poder confiar en ella (4), la cual corresponde a una evaluación construida, especialmente, a partir de las conductas que se muestra en las relaciones sociales. es un concepto complejo, multidimensional, en el que aún no existe acuerdo en el número total de variables involucradas, pero sobre las que existe mayor consenso son las dimensiones de capacidad, integridad y benevolencia del líder (8, 12, 13). las dos primeras relacionadas con la confianza basada en la cognición, es decir, juicios sobre si la otra persona cumplirá sus expectativas dada su capacidad o integridad; en cambio la última, la benevolencia, se relaciona con la confianza basada en el afecto, con experimentar un vínculo a partir de sentimientos positivos hacia el otro (10). cabe destacar que este último tipo de confiabilidad es la que tiene mayor impacto en 189 conductas críticas para experimentar confianza en el liderazgo en enfermería en un hospital de alta complejidad l rodrigo javier yáñez-gallardo, sandra valenzuela-suazo que los trabajadores presenten un alto desempeño, disposición a la cooperación y una alta satisfacción y compromiso laboral (11). sucintamente, las tres principales dimensiones de la confiabilidad se pueden definir en los siguientes términos (8, 14): la dimensión capacidad implicaría creer que el jefe tiene las habilidades y la capacidad que le permiten alcanzar logros dentro de un dominio específico. un ejemplo sería poseer dominio en alguna área técnica determinada; sin embargo, se acepta que en una área diferente puede tener una capacidad limitada y, por ende, puede no ser confiable en ese dominio. la dimensión integridad involucra creer que un(a) jefe de enfermería se adhiere a un conjunto de principios éticos que el funcionario encuentra importantes. ejemplos de conductas serían: no mostrar favoritismo por empleados, ser imparcial en asignar beneficios o ser sincero (15). la dimensión benevolencia consiste en creer que la jefatura desea hacer el bien al funcionario dejando de lado los motivos de beneficio personal, mostrándose amistoso, preocupado y servicial con los funcionarios (4, 15). se podría plantear la existencia de un paralelo entre el cuidado que la jefatura de enfermería presta a los pacientes (16) y la ayuda que debe brindar a sus funcionarios. investigaciones han encontrado que cada una de las tres dimensiones no aportan de igual forma al desarrollo y erosión de la confianza en la jefatura (8), y que dependen del referente hacia el que se tiene confianza (4). por una parte, una investigación a partir de la técnica delphi con funcionarios de salud encontró que la dimensión integridad era lo más importante para experimentar confianza en la jefatura (15). otro estudio encontró que la benevolencia y la integridad eran significativamente más importantes que la habilidad cuando se confiaba en el supervisor (4). por último, utilizándose la técnica de incidentes críticos se encontró que la confianza en la jefatura dependía fundamentalmente de la benevolencia (8). como los autores ya han planteado (14), la relevancia de la benevolencia para desarrollar confianza se funda en que los funcionarios inician una relación con la jefatura con la expectativa a priori de que posee un cierto nivel de capacidad e integridad, basados en la creencia de que la organización escoge jefaturas que demuestran capacidad en el dominio de su rol y tienen un alto sentido de integridad (8). esta expectativa se puede comprender a partir del hecho de que la relación jefatura-trabajador ocurre dentro de las instituciones en las que los empleados suelen mostrar niveles adecuados de confianza institucional. por tanto, un jefe que demuestra conductas que reafirman su integridad o capacidad puede no inspirar un nivel particularmente alto de confianza, actuaría solo de acuerdo a lo esperado para su rol. los comportamientos del líder que reflejen integridad y capacidad pueden percibirse como los más básicos requisitos que los trabajadores esperarían de un jefe. por ello, investigaciones muestran que estas dos dimensiones tienen un impacto significativo en erosionar la confianza más que en desarrollarla (8). por otro lado, investigaciones han encontrado que la benevolencia juega un papel más central que la integridad y la capacidad del jefe en el desarrollo de la confianza (8). la benevolencia no es una conducta que esté adscrita al rol de jefatura y el hecho de mostrarla es percibido por los funcionarios como reflejo de una actitud especialmente positiva hacia ellos, considerando que la jefatura con su comportamiento va más allá de lo esperado para su rol, generando así un vínculo personal con fuertes componentes emocionales (8). interesante es constatar que una investigación corrobora en gran medida lo anteriormente dicho pero en el contexto de la confianza de los pacientes con sus cuidadores, es decir, encontró que el desarrollo de la confianza se vinculaba a la percepción de que los cuidadores estaban preocupados de sus necesidades, que mostraban interés en cuidarlos adecuadamente, que los escuchaban; en cambio, la pérdida de la confianza se vinculaba fundamentalmente a la falta de competencia del cuidador por cometer errores o cubrirlos (17). materiales y métodos se escogió un diseño de investigación cualitativo y se utilizó la técnica de incidentes críticos para la recolección de datos optando por un enfoque fenomenológico para la realización de las entrevistas semiestructuradas y su adaptación para el análisis de los datos (18). esto es, a través de un proceso de entrevista se buscó captar los procesos de pensamiento, marcos de referencia y afectos sobre los incidentes que tienen un significado relevante para los participantes (18). en este trabajo, un principio fue circunscribirse a la interpretación que los entrevistados daban a las conductas de su jefatura en los incidentes de confianza. la técnica de incidentes críticos es una herramienta que fácilmente se adapta a una investigación cualitativa que intente comprender la experiencia de vida de las participantes en su trabajo. ella ha sido muy utilizada en enfermería porque es particularmente útil para identificar y comprender conductas claves que se pre190 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 sentan en el trabajo, y ello es justamente lo que la diferencia de otras técnicas (19). en esencia, se les solicita a los participantes recordar incidentes específicos significativos aportando una descripción detallada de las acciones de los involucrados en la situación y de los efectos del incidente. el objetivo es lograr describir en forma precisa los hechos considerando los contextos personal y social presentes en la situación, de este modo se puede comprender la situación y las conductas de los involucrados. por tanto, si bien se obtiene información cuantitativa sobre la frecuencia de conductas relevantes de las personas en su trabajo, no implica sacrificar los significados, la especificidad y la validez. para muchos teóricos la técnica desde sus orígenes ha asumido una perspectiva fenomenológica, es decir, entender los incidentes desde la perspectiva del entrevistado considerando que es él quien describe la manera en que se produjeron las situaciones en su trabajo (19). la investigación se realizó en un hospital público de alta complejidad, donde se lleva a cabo formación clínica e investigación universitaria, con alrededor de 2500 funcionarios, en la tercera ciudad más grande de chile. la recolección de datos se inició en septiembre del 2009, extendiéndose hasta diciembre del 2010. participantes participaron 90 funcionarios de un hospital de alta complejidad, un 26,7 % fueron enfermeras(os), un 73,3 % técnicos de enfermería. se escogieron dichos profesionales porque son los subalternos de enfermeras(os) jefes en los hospitales. los participantes pertenecían a 9 servicios clínicos diferentes. el método de selección fue a través de un muestreo accidental, de acuerdo con la disponibilidad de tiempo de los funcionarios en el momento en que los encuestadores se presentaron en los servicios clínicos. se consideraron como criterios de inclusión: que los funcionarios fueran enfermeras(o) o técnicos paramédicos; pertenecer al servicio clínico de un hospital y tener por lo menos un año de antigüedad en dicho servicio. de esta manera se garantizó que los participantes tuvieran una relación de dependencia con algún jefe y un conocimiento de las relaciones interpersonales de confianza con las jefaturas de enfermería. consideraciones éticas el proyecto de investigación fue aprobado por el comité de ética en investigación de la universidad de concepción. la recolección de datos se realizó con la autorización de las jefaturas del hospital, asegurándoles el retorno de los resultados. se les entregó a los participantes una carta de consentimiento libre e informado que debieron firmar previo a la entrevista. se les garantizó el anonimato y la confidencialidad de sus respuestas, además, se les solicitó un mínimo de datos personales. instrumento se construyó una entrevista semiestructurada para obtener incidentes críticos (19). en las instrucciones se solicitó que pensaran en una jefatura directa y que evocaran un incidente significativo que hubiera originado confianza y otro que hubiera generado desconfianza hacia su jefatura. el presente artículo presentará exclusivamente el análisis de las respuestas a una pregunta: “¿puede usted describirme una situación que haya vivido en su trabajo en el último tiempo y que haya significado para usted experimentar alto grado de confianza en su jefe directo?”. la segunda pregunta, la cual no se analiza en el trabajo, consultaba por un incidente de desconfianza. después se realizaron preguntas para profundizar más en esta experiencia, específicamente los comportamientos de la jefatura que generaron el incidente crítico. procedimiento de recolección de datos los entrevistadores fueron estudiantes de enfermería y psicología y recibieron una preparación para la utilización de la técnica de incidentes críticos y de contención emocional si fuese necesario. la instrucción incluyó la entrega de material escrito, análisis de casos de entrevistas y asesoría en el manejo del estado emocional de los entrevistados. las entrevistas se realizaron en el lugar de trabajo de los funcionarios resguardando para ellos un espacio que garantizara la privacidad, y tuvieron una duración aproximada de 20 a 25 minutos dado que los entrevistadores escribían las respuestas en papel. posteriormente las entrevistas fueron transcritas a un computador. análisis del contenido de los incidentes la sistematización de los datos estuvo a cargo de los autores de esta investigación. de las 90 entrevistas, 12 entrevistados no nombraron incidentes de confianza, de modo que se procedió a transcribir literalmente los relatos de 78 incidentes (además de las anotaciones pertinentes). una primera lectura determinó si su contenido era completamente pertinente, así se descartaron 191 conductas críticas para experimentar confianza en el liderazgo en enfermería en un hospital de alta complejidad l rodrigo javier yáñez-gallardo, sandra valenzuela-suazo 12 incidentes por no cumplir los requerimientos para ser incluidos (descripciones vagas o incidentes no vinculados a fortalecer la confianza con su jefatura), quedando finalmente 66 incidentes críticos para analizar. se siguió una propuesta fenomenológica para el análisis de los datos (20). el proceso de codificación tuvo tres etapas. en la primera se identificaron las unidades de significado general y posteriormente las relevantes para el tema: conductas de las jefaturas. luego se categorizaron las conductas presentadas por la jefatura ante eventos de confianza descritos por los entrevistados (obtención de subcategorías), ello implicó la lectura recurrente de las narraciones realizando comparaciones entre ellas, y el investigador —intentando abandonar sus preconceptos— se abocó a partir de un análisis comprensivo a que las categorías emergieran de los patrones comunes encontrados. esto fue realizado por uno de los investigadores y, posteriormente, un segundo investigador evaluó de forma independiente, realizándose una discusión de las diferencias encontradas hasta lograr un consenso. posteriormente se calcularon las frecuencias de mención de cada tipo de conducta encontrada y se procedió a la elaboración de una tabla de frecuencias. en una segunda etapa el objetivo fue agrupar las subcategorías que tenían un contenido compartido entre ellas, obteniéndose de este modo categorías más amplias. este procedimiento implicó que ambos investigadores en forma independiente construyeran agrupaciones, se discutieran las diferencias encontradas y se lograra un consenso. posteriormente se calcularon las frecuencias de mención de cada categoría y se procedió a la elaboración de un cuadro con los resultados. en la tercera etapa se determinó a qué dimensión de la confiabilidad estaban relacionadas las categorías encontradas. el marco teórico de burke et al. (7) sirvió como marco de referencia; sin embargo, no se circunscribió estrictamente a este, incorporando también los planteamientos de risting (9) y mayer et al. (12). en este caso, en primera instancia un investigador realizó el proceso de comparación entre las categorías emergentes y las dimensiones de la confiabilidad para lograr establecer cuáles compartían significado; luego, en forma independiente, el segundo investigador revisó la comparación del primer investigador, discutiéndose las diferencias encontradas llegando finalmente a un consenso. resultados se obtuvieron 66 incidentes críticos de confianza con jefaturas de enfermería de las entrevistas a 90 funcionarios. del análisis de contenido emergieron cinco categorías de conductas que favorecen la confianza en la jefatura de enfermería. de cada una de las categorías se pudieron obtener varias subcategorías, lo cual muestra que existen variadas formas que permiten desarrollar la confianza en las jefaturas (cuadro 1). la categoría que obtuvo mayor mención fue “ayuda instrumental ante problemas”, y la mayoría de las situaciones aluden a que la jefatura dio un permiso administrativo especial al funcionario, por ejemplo, permiso para poder asistir a la graduación de un hijo, al funeral de un ser querido, al matrimonio de una persona cercana. la segunda categoría con más alta mención fue “apoyo emocional” y se refiere a que la jefatura mostró compasión, una conducta empática ante el sufrimiento del funcionario por un problema familiar o un error en el trabajo y, en estos casos, la jefatura entregó palabras de comprensión y gestos de afecto dada la situación que estaba viviendo el subalterno. el tercer lugar fue compartido por dos categorías: “apoyo y defensa ante ataques”, esta tiene en parte elementos de la primera y segunda categorías descritas, ya que incluye ayuda y apoyo emocional pero se circunscribe a situaciones donde los funcionarios experimentaron violencia psicológica o física en el trabajo, y recibieron apoyo y protección por su jefatura. la otra categoría fue “apoyo al empoderamiento” y consistió en que la jefatura expresó confianza en la capacidad profesional del funcionario dándole la oportunidad para realizar una tarea compleja. la quinta categoría tuvo una muy baja frecuencia de mención y fue “buena comunicación”. discusión dada la complejidad que presenta la gestión de personas en hospitales se ha sostenido que es crítico un liderazgo en enfermería que contemple como un aspecto fundamental cultivar relaciones interpersonales de confianza con sus funcionarios. por ello, esta investigación tuvo dos objetivos, por una parte, identificar el tipo de conductas críticas más frecuentemente mencionadas con percibir confianza interpersonal en la jefatura de enfermería y, por otra, establecer qué dimensiones de la confiabilidad son representativas en dichas conductas. 192 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 cuadro 1. frecuencia y porcentaje de las categorías y subcategorías de conductas que desarrollan confianza en la jefatura de enfermería categoría subcategoría frec. % 1. ayuda instrumental ante problemas me dio un permiso administrativo especial para resolver un asunto familiar importante. 13 le solicité que no me cambiara de servicio y no me cambió. 2 facilitó mi contratación en el hospital. 2 ayudó a un familiar mío. 1 me seleccionó para que asistiera a una capacitación. 1 me ayudó económicamente. 1 me ayudó a resolver un problema con un paciente. 1 facilitó la fecha de vacaciones dada mi situación especial. 1 22 30,3 2. apoyo emocional ante un problema familiar (enfermedad padres, pareja, hijo) me apoyó y me tranquilizó. 7 ante un error o problema en el trabajo no me criticó negativamente, me aconsejó. 5 ante un problema personal, me dio consejo. 2 ante un problema me dio aliento y me dijo: “tú eres capaz”. 1 estaba atenta a la fecha de mi cumpleaños y me saludó y así era con todos. 1 tuvo el gesto de hacer un reconocimiento público de mi buen desempeño. 1 me dio el espacio para que yo me pudiera desahogar. 1 18 25,8 3. apoyo al empoderamiento me pidió que me hiciera cargo de un procedimiento complejo. 6 ante una situación especial optó por dejarme a mí a cargo del turno. 4 me pidió que me hiciera cargo de un paciente complicado. 1 me pidió que enseñara a alumnos en práctica. 1 me pidió que yo informara a los médicos. 1 13 19,7 4. apoyo y defensa ante ataques ante las acusaciones en mi contra me escuchó y creyó en mí. 4 corriendo un riesgo, creyó en mí y me defendió. 3 me defendió ante un paciente y luego me acompañó. 2 no le creyó al médico y después me dijo que era buena enfermera. 1 se acercó a mí para decirme que me apoyaba. 1 para cubrirme dijo que yo había encontrado el instrumento médico y fue ella. 1 no creyó los rumores que dijeron sobre mí. 1 13 19,7 5. buena comunicación me preguntó qué pensaba ante un problema. 1 dio más información de la imprescindible. 1 2 4,5 total: 66 100 193 conductas críticas para experimentar confianza en el liderazgo en enfermería en un hospital de alta complejidad l rodrigo javier yáñez-gallardo, sandra valenzuela-suazo en general, los resultados obtenidos muestran que las jefaturas de enfermería realizan una amplia gama de conductas que pueden impactar significativamente en que sus trabajadores confíen en ellas. la categoría que recibió mayor mención fue “ayuda instrumental ante problemas”. cabe destacar que la subcategoría dar permiso administrativo especial por un problema familiar obtuvo el más alto porcentaje de mención si se compara con las restantes subcategorías y ello estaría mostrando dos cosas importantes: uno, que los funcionarios en casos críticos esperan que sus jefaturas no apliquen rígidamente las reglas de su centro de salud y sean flexibles, mostrando una consideración individual ante las necesidades de los funcionarios. dos, estos problemas familiares son manifestación del conflicto latente trabajo/familia que viven muchos funcionarios de la salud y si las jefaturas esperan fortalecer la confianza interpersonal deben estar atentas a informarse detalladamente sobre estas situaciones personales que viven los funcionarios, ya que algunas de ellas tienen un profundo significado emocional y, en tales casos, se debe ser empáticos, compasivos y dispuestos a ayudar a sus funcionarios y, si no es posible, apoyarlos emocionalmente. si bien la bibliografía menciona que las jefaturas deben prestar ayuda a los funcionarios para mostrar benevolencia (13), es interesante constatar que los autores orientan esta ayuda hacia su trabajo en los servicios y no a resolver problemas familiares, como se ha obtenido en esta investigación. la categoría que obtuvo un segundo lugar en frecuencia de mención fue “apoyo emocional” y se asocia con que la jefatura de enfermería muestre afecto y comprensión o escuche y aconseje cuando los funcionarios tienen un problema familiares o profesional importante. de acuerdo a nuestros resultados, al parecer es en los momentos críticos, especialmente problemas familiares y errores en el trabajo, cuando los funcionarios valoran de manera significativa la contención y el apoyo emocional de su jefatura y ello los lleva a evaluar si esta es realmente de confianza. esta segunda categoría tiene estrecha relación con un nuevo enfoque del liderazgo, el llamado servicial, el cual considera entre sus elementos más importantes que el liderazgo en enfermería se debe concebir como servir a aquellos que sirven a otros (21, 22). este enfoque es coherente con el desarrollo de la confianza en la jefatura porque esta debe mostrar un real interés por el trabajador y su bienestar, fundamentalmente porque el trabajador se sienta realmente apoyado por su jefe (6, 21). es decir, existe un esfuerzo auténtico por crear relaciones interpersonales sanas con sus funcionarios (23). de este modo, un tipo de conducta central del líder que favorecería la benevolencia sería que las jefaturas se preocupen por proporcionar apoyo emocional a los funcionarios; este apoyo no sería un aspecto “opcional” del quehacer de la jefatura de enfermería sino un aspecto imprescindible (21), considerando el hecho de que los trabajadores de la salud tienen una alta carga emocional en su trabajo (15). en síntesis, así como los investigadores (1) enfatizan lo central que es en el profesional de enfermería el cuidado del paciente, con respecto al liderazgo en enfermería se debería señalar la importancia del apoyo hacia los funcionarios. por tanto, se puede afirmar que la categoría “apoyo emocional” se relaciona con investigaciones (21-23) que muestran que el liderazgo en enfermería debería implicar ser empáticos, compasivos y protectores, mostrando un interés real por los funcionarios como personas, incluso trascendiendo lo estrictamente laboral. por último, dos categorías obtuvieron igual porcentaje de mención. por una parte, “apoyo y defensa ante ataques”, que emergió de la presente investigación, no está presente en la revisión bibliográfica; se trataría de una situación extrema de menoscabo que experimentan los funcionarios, una situación de maltrato donde el trabajador está muy vulnerable. la respuesta asertiva de protección de la jefatura daría al trabajador el sentimiento de seguridad en el cual se sustenta la confianza. cabe destacar que las tres categorías previamente citadas tienen en común que se trata de situaciones personales o laborales difíciles para los funcionarios y obtuvieron ayuda o apoyo emocional de parte de su jefatura. ello mostraría que puede ser cierto el dicho que sostiene, “es en situaciones difíciles cuando las personas se dan cuenta que tienen un amigo”; aplicado al contexto laboral es en estas circunstancias cuando los trabajadores se dan cuenta si su jefatura tiene una real preocupación hacia ellos. la otra categoría que comparte el tercer lugar, “apoyo al empoderamiento”, difiere de las tres anteriores porque, en este caso, el trabajador se siente sorprendido por recibir de su jefatura una fuerte demostración de confianza en su capacidad de realizar un buen trabajo y se le asigna una tarea de responsabilidad. si bien este resultado es confirmado por otra investigación (3) difiere de ella porque los incidentes de empoderamiento obtenidos en este estudio fueron hechos puntuales experimentados más como un gesto de reconocimiento, de halago por ser un trabajador capaz, y no tanto como una práctica frecuente de la jefatura orientada a fomentar la autodirección de los funcionarios. 194 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 es interesante constatar que hay investigadores (3) que sostienen que un tipo de conducta central para la benevolencia es empoderar a los trabajadores delegando responsabilidad en tareas relevantes, ya que así se alienta la autodirección, el desarrollo profesional y la autonomía. vinculado a esto último, también se favorece el empoderamiento cuando la jefatura hace participar en la toma de decisiones y valora las opiniones de los trabajadores (13). al analizar las cuatro principales categorías encontradas y relacionarlas con las dimensiones de la confiabilidad propuestas por la literatura sobre confianza se encontró que todas están estrechamente vinculadas a la dimensión benevolencia, es decir, a alguna forma de conductas de apoyo y cuidado del trabajador por parte de la jefatura. estos resultados entregan un fuerte apoyo a investigaciones anteriores (4, 8) que indican que las dimensiones de la confiabilidad no son igualmente importantes para desarrollar confianza en la jefatura, y que la percepción de benevolencia es determinante para que la jefatura de enfermería logre ganarse la confianza de sus funcionarios. además, estos resultados corroboran la importancia de la dimensión emocional sobre la cognitiva para desarrollar la confianza interpersonal con la jefatura (10, 11). se estima que un aporte de esta investigación es haber profundizado en el significado de la actitud benevolente de la jefatura, dado que los investigadores se limitan a referirse a conceptos generales tales como preocuparse por el bienestar del trabajador, sin describir conductas específicas. estos resultados muestran que dicha preocupación por los trabajadores en la práctica se refiere a atender sus dificultades en el plano personal y laboral, debiendo presentar las jefaturas de enfermería inteligencia emocional, es decir, un escucha activa, empatía y, sobre todo, la actitud de compasión ante los problemas y sufrimientos de sus funcionarios. tres implicaciones prácticas se pueden extraer de los resultados obtenidos. primero, las jefaturas de enfermería deben tomar conciencia de la existencia de una asimetría de poder en sus relaciones con los funcionarios y deben darse cuenta de la condición de vulnerabilidad en la que estos se encuentran y que, por ende, es una necesidad fundamental confiar en sus jefes para sentirse seguros y poder enfrentar las incertidumbres inherentes a su trabajo sin temor. debe asumir que no es suficiente que las jefaturas de enfermería sean competentes en su labor técnica y muestren un comportamiento consistente y justo, para desarrollar relaciones interpersonales de confianza con los funcionarios es necesario que las jefaturas desarrollen un liderazgo servicial (21) mostrando una actitud de benevolencia hacia los funcionarios (3). segundo, las jefaturas deberían analizar las categorías y subcategorías de conductas que fueron más frecuentemente mencionadas en este estudio como críticas y deberían estar atentas a su presencia en sus servicios, a fin de actuar de manera oportuna en forma benevolente. la benevolencia implica para las jefaturas dedicar tiempo para preocuparse de conocer más a sus colaboradores como personas y cultivar un vínculo positivo con ellos, de modo que exista una comunicación franca y poder mostrar conductas de apoyo emocional, ayuda y empoderamiento acordes a la situación personal de cada uno de ellos. tercero, existe una responsabilidad de la institución de salud de crear un contexto de apoyo organizacional hacia sus funcionarios fomentando un clima ético organizacional que valore desarrollar relaciones interpersonales de confianza en los servicios, condiciones para empoderar a los funcionarios desarrollando sus capacidades y, por último, fomentando un estilo de liderazgo servicial en las jefaturas (21). para lo anterior, se debería promover periódicamente la realización de talleres de capacitación orientados a fortalecer habilidades socioemocionales de las jefaturas de enfermería, tales como las vinculadas a la inteligencia emocional. sin duda, lo señalado requiere que desde la formación de enfermería se aprenda a ser sensibles a sus relaciones interpersonales en el trabajo y a cultivar relaciones de confianza. por tanto, los docentes de enfermería tienen la responsabilidad de asegurarse de que las(os) estudiantes asuman actitudes de liderazgo servicial con disposición para establecer un vínculo emocional positivo que facilite mostrar gestos de benevolencia. la principal limitación de esta investigación fue que la muestra utilizada es representativa solamente de un hospital y, por ende, los resultados podrían solo estar reflejando la realidad particular de dicho centro de salud. por ello, se sugiere que futuras investigaciones se repliquen en otros hospitales. también se sugiere replicar esta investigación utilizando otras técnicas de recolección de datos, tales como entrevistas en profundidad y grupos de discusión. conclusión un factor importante para un buen ambiente de trabajo en los servicios de salud es que las jefaturas logren establecer relaciones interpersonales de confianza con los funcionarios. a través de la técnica de incidentes críticos fue posible obtener aquellas situaciones que pueden ser claves para fortalecer fuertemente la 195 conductas críticas para experimentar confianza en el liderazgo en enfermería en un hospital de alta complejidad l rodrigo javier yáñez-gallardo, sandra valenzuela-suazo confianza en la jefatura. los resultados muestran que se puede utilizar el dicho, “es en los momentos importantes cuando uno se da cuenta quiénes son realmente tus amigos”, ya que los funcionarios describieron diferentes tipos de situaciones laborales en que ellos tuvieron un problema o una necesidad importante y, en forma oportuna, y en algunos casos sorpresiva para ellos, recibieron de su jefatura de enfermería una ayuda concreta o un apoyo emocional o profesional. en estos casos, se estima, se estaría ante una jefatura que ejerce un nuevo modelo de liderazgo, uno que asume dentro de sus roles la actitud de servicio, no solo hacia los pacientes, sino también hacia sus trabajadores. por último, esta investigación ratificó otros estudios que sostienen que los trabajadores valoran más la benevolencia, una confianza basada en el afecto, que una basada en lo cognitivo, como sería centrarse en la percepción de la capacidad técnica o la integridad para experimentar alta confianza en las jefaturas. referencias 1. quintero mt, gómez m. el cuidado de enfermería significa ayuda. 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[visitado mar. 2012]. disponible en: http://pedagogia.fcep.urv.cat/revistaut/ revistes/juny10/article07.pdf 21. neill m, saunders n. servant leadership. enhancing quality of care and staff satisfaction. j nurs adm. 2008;38(9):395-400. 22. waterman h. principles of “servant leadership” and how they can enhance practice. nurs manag. 2011;17(9):24-26. 23. joseph e, winston b. a correlation of servant leadership, leader trust, and organizational trust. leadership & organization development journal. 2005;26(1):6-22. 219 227 la historia familiar y la conducta.indd 219 nora angélica armendáriz-garcía1 jessica belem almanza-lópez2 maría teresa de jesús alonso-castillo3 nora nelly oliva-rodríguez4 maría magdalena alonso-castillo5 manuel antonio lópez-cisneros6 la historia familiar y la conducta de consumo de alcohol como factor sociocultural en el adolescente. perspectiva de enfermería 1 doctora en ciencias de enfermería, profesor de tiempo completo de la facultad de enfermería, universidad autónoma de nuevo león, méxico. nordariz@hotmail.com 2 maestra en ciencias de enfermería, enfermera comunitaria, secretaria de salud. jesica18@hotmail.com 3 doctora en bioética, profesor de tiempo completo de la facultad de enfermería, universidad autónoma de nuevo león, méxico. talonso@hotmail.com 4 doctora en bioética, profesor de tiempo completo de la facultad de enfermería, universidad autónoma de nuevo león, méxico. norisnelly@gmail.com 5 doctora en filosofía con especialidad en psicología. profesora de tiempo completo de la facultad de enfermería, universidad autónoma de nuevo león, méxico. magdalena_alonso@hotmail.com. 6 doctor en ciencias de enfermería, profesor de tiempo completo del des ciencias de la salud, universidad autónoma del carmen, campeche, méxico. mlcisneros@hotmail.com recibido: 15 de septiembre de 2014 enviado a pares: 23 de octubre de 2014 aceptado por pares: 05 de marzo de 2015 aprobado: 08 de abril de 2015 doi: 10.5294/aqui.2015.15.2.6 para citar este artículo / to reference this article / para citar este artigo armendáriz-garcía na. et al. la historia familiar y la conducta de consumo de alcohol como factor sociocultural en el adolescente. perspectiva de enfermería. aquichan. 2015;15(2):219-227. doi: 10.5294/aqui.2015.15.2.6 resumen los adolescentes con mayor probabilidad de presentar la conducta de consumo de alcohol son los que están sometidos a diferentes factores de riesgo, los cuales pueden ser personales; dentro de estos factores se encuentra la historia familiar de consumo de alcohol (hfca). objetivo: establecer las diferencias y la relación entre el factor personal sociocultural a través de la hfca y la conducta no saludable de consumo de alcohol en adolescentes de preparatoria del estado de nuevo león. materiales y métodos: estudio descriptivo correlacional, la población estuvo conformada por 743 adolescentes de preparatoria, la muestra fue de 240, con un poder del 90 %. muestreo aleatorio estratificado con asignación proporcional al tamaño del estrato. dentro de cada estrato se empleó muestreo aleatorio por conglomerados unietápicos. los instrumentos empleados fueron el inventario de hfca y el cuestionario de identificación de los trastornos debidos al consumo de alcohol. resultados: los adolescentes con hfca positiva fueron quienes presentaron mayores prevalencias de conducta no saludable (consumo de alcohol); asimismo, el tipo de consumo de alcohol dependiente y dañino presentó esta misma año 15 vol. 15 nº 2 chía, colombia junio 2015 l 219-227 220 aquichan issn 1657-5997 año 15 vol. 15 nº 2 chía, colombia junio 2015 l 219-227 tendencia observándose diferencias estadísticamente significativas (p < 0,05). cuando se analiza la conducta de consumo de alcohol en los adolescentes se identificó una relación positiva y significativa (rs = 0,196, p < 0,01), lo que indica que a mayor consumo de alcohol por parte de los padres, se presenta un mayor consumo por parte del hijo adolescente. palabras clave consumo de alcohol, estudiantes, familia (fuente: decs, bireme). alcohol consumption: family history and behavior as a sociocultural factor during adolescence. a nursing perspective abstract adolescents are more likely to consume alcohol if they have a family history of alcohol consumption (fhac). objective: identify the differences and association between fhac, as a personal sociocultural factor, and unhealthy drinking behavior on the part of high school students in nuevo leon (mexico). materials and methods: this is a descriptive-correlational study focused on a population of 743 adolescent students; the sample included 240, with 90% power.stratified random sampling was used, with allocation proportional to the size of the stratum. random sampling within each stratum was done through single-stage cluster sampling.the fhac inventory and the alcohol use disorders identification questionnaire were the instruments used. findings: a higher prevalence of unhealthy behavior (alcohol consumption) was found among the adolescents with a positive fhac. the same trend was found with respect to dependent and harmful alcohol consumption, andstatistically significant differences were observed (p <0.05). a positive and significant correlation (rs = 0.196, p <0.01) was identified when analyzing alcohol consumption, which indicatesincreased alcohol consumption by parents raises the likelihood of increased consumption by their adolescent children. keywords alcohol consumption, adolescents, family (source: decs, bireme). 221 la historia familiar y la conducta de consumo de alcohol como factor sociocultural en el adolescente. perspectiva de enfermería l nora angélica armendáriz-garcía y otros a história familiar e a conduta de consumo de álcool como fator sociocultural no adolescente. perspectiva de enfermagem resumo os adolescentes com maior probabilidade de consumirem bebidas alcoólicas são aqueles em cujos fatores de risco se conta a história familiar de consumo de álcool (hfca). objetivo: estabelecer as diferenças e a relação entre o fator pessoal sociocultural por meio da hfca e a conduta não saudável de consumo de álcool em adolescentes de pré-vestibular do estado de nuevo león (méxico). materiais e métodos: estudo descritivo correlacional, com uma população composta por 743 adolescentes de pré-vestibular; a amostra foi de 240, com um poder de 90%. amostra aleatória estratificada com designação proporcional ao tamanho do estrato. dentro de cada estrato, empregou-se amostra aleatória por conglomerados unietápicos. os instrumentos empregados foram o inventário de hfca e o questionário de identificação dos transtornos devido ao consumo de álcool. resultados: os adolescentes com hfca positiva foram os que apresentaram maiores prevalências de conduta não saudável (consumo de álcool); além disso, o tipo de consumo de álcool dependente e prejudicial apresentou essa mesma tendência e observaram-se diferenças estatisticamente significativas (p < 0,05). quando a conduta de consumo de álcool nos adolescentes foi analisada, identificou-se uma relação positiva e significativa (rs = 0,196, p < 0,01), o que indica que, quanto maior o consumo de álcool por parte dos pais, um maior consumo se apresenta por parte do filho adolescente. palavras-chave consumo de álcool, estudantes, família (fonte: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 219-227 222 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 introducción el consumo de alcohol en los adolescentes es un problema social que tiene alta prevalencia en este grupo vulnerable, el cual puede causar serias consecuencias fisiológicas, emocionales, familiares y sociales en la salud del adolescente (1). en la perspectiva de enfermería, se reconoce que esta problemática debe abordarse desde la niñez, fomentando conductas promotoras de la salud donde se debe incluir a la familia, con el objetivo de lograr la implementación de estilos saludables. nola j. pender (2), a través de su modelo de promoción de la salud (mps), sustenta que algunos factores personales (biológicos, psicológicos y psicosociales) son determinantes en la conducta promotora de salud. este modelo expone que las características y las experiencias individuales, así como los conocimientos y afectos específicos de la conducta, llevan al individuo a participar o no en comportamientos de salud. asimismo, establece que los procesos cognitivos son importantes en el cambio de conducta, ya que incorporan aspectos del aprendizaje cognitivo, donde se reconoce que las influencias personales negativas pueden provocar un resultado conductual no saludable, sin necesidad de una evaluación de beneficios o barreras sobre la realización de dicha conducta, ya que esta puede ser aprendida y puede considerarse inofensiva o normal debido a que es frecuentemente practicada en su contexto. este mps es aplicable en múltiples conductas realizadas por las personas, sin embargo, no se ha identificado evidencia científica que muestre la aplicación del modelo de promoción de la salud en el fenómeno de consumo de alcohol en familias y adolescentes. en el presente estudio se pretende identificar si este modelo puede explicar la conducta de consumo de alcohol en los adolescentes de familias con historia familiar de consumo de alcohol (hfca), ya que según este modelo, la conducta de consumo de alcohol puede estar influida por diversos factores personales. esta conducta se considera no saludable. desde el modelo de promoción de la salud se puede entender que los factores personales socioculturales que experimentan los adolescentes están ligados a la influencia social de desarrollar una conducta saludable o no saludable (por ejemplo, consumo de alcohol), esto debido al aprendizaje conductual que se origina en la familia, lo cual puede favorecer la imitación de la conducta sobre todo en esta etapa donde el adolescente aprende y desarrolla estilos de vida. la literatura muestra que los factores personales socioculturales son importantes para que se desarrolle o no una conducta promotora de salud (3). al respecto, se ha observado que quienes tienen mayor probabilidad de consumo alcohol son aquellos expuestos a diferentes factores de riesgo socioculturales, dentro de los cuales se encuentra el consumo de alcohol por parte de personas significativas como amigos y familiares. se ha documentado que esta práctica puede guiar de forma significativa la conducta de consumo de los adolescentes, sobre todo si los padres muestran actitud positiva ante el mismo frente a sus hijos (4, 5). esto se debe posiblemente a que los padres tienen un rol único en la formación de conductas saludables o no saludables en sus hijos. la influencia social y los hábitos de los padres se reproducen por medio de la socialización y el ejemplo, lo que constituye la base en la formación de las actitudes, la personalidad, el autoconcepto, los valores y las conductas de sus hijos. se ha documentado que cuando los padres son consumidores de alcohol es probable que los hijos reproduzcan las mismas conductas de consumo e incluso igualando los patrones de consumo de los padres; sin embargo, esta relación no ha sido concluyente en todos los casos (6, 7). se considera relevante abordar esta problemática en virtud de que se reconoce que el abuso del consumo de alcohol ocupa el tercer lugar entre los factores de riesgo de la carga mundial de morbilidad. en cuanto a la mortalidad, se reporta que causa 2,5 millones de muertes anuales; asimismo, 320.000 jóvenes de entre 15 y 29 años de edad mueren por causas relacionadas con el consumo de alcohol, lo que representa un 9 % de las defunciones en ese grupo etario (8). en méxico, en la población adolescente se incrementó el consumo de alcohol de manera significativa del año 2008 al 2011 en los tres tipos de prevalencias. de tal manera que el consumo de alcohol alguna vez en la vida pasó de 35,6 a 42,9 %, la prevalencia de consumo en el último año de 25,7 a 30,0 % y en el último mes la prevalencia se incrementó de 7,1 a 14,5 %. esta misma tendencia se observó en los hombres y en las mujeres, especialmente en el consumo de alcohol en el último mes, ya que se incrementó en los varones de 11,5 a 17,4 % y en las mujeres de 2,7 a 11,6 %. además, se observó que del 2002 al 2011, el índice de adolescentes 223 la historia familiar y la conducta de consumo de alcohol como factor sociocultural en el adolescente. perspectiva de enfermería l nora angélica armendáriz-garcía y otros que consumen alcohol a diario se mantuvo estable, el consumo consuetudinario disminuyó y el índice de consumo dependiente registró un incremento significativo, que pasó de 2,1 a 4,1%, mientras que de 2008 a 2011 el consumo alto se mantuvo igual, y el consuetudinario disminuyó de 2,2 a 1% (9). adicionalmente, en la norma oficial mexicana (nom 028) se destaca que cualquier cantidad de consumo durante esta etapa de la vida es nociva para la salud, por lo que se considera a los adolescentes como un grupo vulnerable (10). desde la perspectiva de enfermería, hasta el momento existen escasos estudios que aborden el consumo de alcohol en los adolescentes como una conducta no saludable debido a factores personales socioculturales como la hfca por parte de los padres, por lo cual resulta relevante identificar la asociación entre estas variables (11). la enfermería, como profesión del cuidado de las personas, las familias y los colectivos, tiene dentro de sus funciones la promoción de la salud, la detección de riesgos de forma temprana y la prevención del primer contacto con sustancias adictivas como el alcohol en los adolescentes. al respecto, el consejo internacional de enfermería establece que la enfermera, en tanto profesional de salud, tiene como función crucial brindar cuidados enfocados en la prevención y la reducción del abuso de sustancias mediante la promoción de estilos de vida sanos, dotando a los jóvenes de las capacidades necesarias para afrontar los factores de riesgo que puedan favorecer el inicio de consumo de estas sustancias psicoactivas (12). con la finalidad de cumplir con las funciones señaladas, se requiere que la disciplina de enfermería valide y amplíe el conocimiento existente e incluso descubra nueva evidencia que pueda fortalecer su práctica y lograr así encaminar intervenciones enfocadas a los adolescentes, sus familias y colectivos, e incluso puede realizar propuestas de políticas de salud encaminadas a la prevención del consumo de drogas. por lo anteriormente expuesto, y con la información obtenida del presente estudio, se pretende en un futuro diseñar y aplicar intervenciones de promoción de la salud y preventivas para lograr reducir la demanda de consumo de esta sustancia, con enfoque en los adolescentes y los padres de familia. por tanto, el propósito del estudio fue establecer las diferencias y la relación que existe entre la hfca como factor personal sociocultural y el consumo de alcohol como conducta no saludable en los estudiantes de una preparatoria del estado de nuevo león. materiales y métodos el diseño del estudio fue descriptivo correlacional. la población estuvo conformada por 743 estudiantes de preparatoria de ambos sexos de una institución pública del estado de nuevo león. el muestreo fue aleatorio estratificado por conglomerado uniétapico, con asignación proporcional al tamaño de cada uno de los tres estratos (semestre), donde los conglomerados fueron los grupos. la muestra fue calculada por medio del paquete estadístico n´query advisor versión 4; se estableció un nivel de significancia del 95 %, con un poder estadístico del 90 %; asimismo, se fijó un efecto del diseño de 1,25 y una tasa de no respuesta del 5 %, obteniéndose así una muestra de 240 estudiantes. para la recolección de los datos se utilizó el inventario de historia familiar de consumo de alcohol (ihfca) y el cuestionario de identificación de desórdenes por uso de alcohol (audit). el inventario de historia familiar de consumo de alcohol (13) evalúa la presencia de consumo de alcohol de los padres. consta de 6 ítems con puntajes de cero a seis, si la respuesta es cero se considera historia familiar negativa, y mayor de uno se considera una historia familiar positiva al consumo de alcohol. este cuestionario reportó un alfa de cronbach de 0,79 en población universitaria en méxico (14), en el presente estudio se presentó un coeficiente de confiabilidad de 0,80. para evaluar el consumo de alcohol en los estudiantes universitarios se empleó el cuestionario de identificación de los trastornos debidos al consumo de alcohol (audit, por sus siglas en inglés) (14), desarrollado por la organización mundial de la salud (oms), como un método para examinar el consumo de alcohol en atención primaria. este instrumento ha sido empleado en mujeres y adultos, mostrando una consistencia interna aceptable, con alfa de cronbach de 0,89-0,93 (15, 16). el audit consta de 10 preguntas sobre el tipo de consumo de alcohol reciente. cada pregunta tiene de tres a cinco posibles respuestas. cada respuesta tiene un valor numérico que va de cero hasta dos o cuatro puntos. la sumatoria de los puntos de cada respuesta establece un puntaje mínimo de cero y un máximo posible de 40 puntos. la clasificación del consumo se realizó sumando el total de reactivos y los puntos de corte son de 0 a 3 puntos, lo que se consideró consumo sensato; de 4 a 7 puntos sugiere el inicio de 224 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 problemas con el consumo (dependiente) y de 8 a 40 puntos se consideró que existe un riesgo elevado de consumo de alcohol (perjudicial). procedimientos del estudio para la implementación del presente estudio se requirió la aprobación de la comisión de investigación y la comisión de ética de la facultad de enfermería de la universidad autónoma de nuevo león con número de registro de faen-d-807. se solicitó autorización por escrito a la autoridad de la preparatoria pública donde se llevó a cabo el presente estudio. la selección de los grupos participantes por semestre fue aleatoria. a los participantes se les entregó un consentimiento informado para padres con el objetivo de que estos autorizaran o negaran la participación de su hijo (a) en el estudio, y un asentimiento para el adolescente a fin de que el participante firmara en caso de desear formar parte del estudio. para la aplicación de los instrumentos se consideró que no existieran distractores en el aula donde se aplicaron los cuestionarios, en todo momento se consideraron los aspectos relativos a la ley general de salud en materia de investigación. análisis de los datos para el análisis de los datos se utilizó el paquete estadístico spss versión 17.0 para windows. se empleó estadística descriptiva e inferencial no paramétrica debido a que los datos no presentaron distribución normal. para establecer las diferencias entre el consumo de alcohol de los padres y el consumo de alcohol de sus hijos adolescentes se utilizó la prueba u de mann-whitney y x2 de pearson, y para conocer la relación del consumo de alcohol de los padres y de sus hijos adolescentes se empleó el coeficiente de correlación de spearman. resultados respecto a las características sociodemográficas de los participantes se identificó que el 77,1 % presenta una edad entre 15 y 16 años de edad, el género que predominó fue el femenino (55,4 %), el 42,5 % pertenecían al primer semestre, seguido por el tercer semestre (38,3 %) y posteriormente por el quinto semestre (19,2 %). la edad de inicio en el consumo de alcohol reporta una media de 14,8 años (de = 0,84). respecto a la presencia de consumo de alcohol por parte de los padres se observó que el mayor porcentaje de estos adolescentes no tiene padres que presenten hfca (56,7 %); sin embargo, el 43,3 % de los adolescentes tienen padres con hfca. referente a la prevalencia del consumo de alcohol en los adolescentes se identificó que el consumo alguna vez en la vida fue de 66,7 % (ic 95 %: 61-73), el consumo en el último año fue 48,3 % (ic 95 %: 42-55), el consumo en el último mes fue de 22,5 % (ic 95 %: 17-28), y, por último, el consumo en la última semana fue de 8,8 % (ic 95 %: 5-12). asimismo, se identificó el predominio del consumo sensato de alcohol en los adolescentes con un 74,1 %, seguido del consumo dañino o perjudicial con 14,7 %, y, por último, se observó en menor proporción el consumo de tipo dependiente con 11,2 %. respecto a los adolescentes que presentaron una conducta saludable de no consumo de alcohol se identificaron aquellos que no tenían el factor personal sociocultural hfca positiva (59,6 frente a 41,3 %). se observó mayor prevalencia de consumo de alcohol alguna vez en la vida (u = 5223,50; p = 0,020), en el último año (u = 5750,50; p = 0,007) y en el último mes (u = 3521,00, p = 0,001) en los adolescentes que presentaron el factor personal sociocultural hfca positiva; sin embargo, en la última semana no se encontró diferencia estadísticamente significativa (p = 0,084). respecto al consumo de alcohol sensato, fue mayor en quienes presentaban hfca positiva (41,3 %), a diferencia de quienes no presentan esta hfca. asimismo, se identificó un porcentaje más alto de consumo de alcohol perjudicial en los adolescentes que presentaron hfca positiva (9,6 %), en comparación con quienes presentaron hfca negativa (2,2 %); esta misma tendencia se identificó en los adolescentes que consumen alcohol de manera dañina (7,6 % frente a 6,6 %), siendo estas diferencias estadísticamente significativas (p = 0,010; x2 = 11,40). respecto al factor personal sociocultural hfca positiva no se encontró relación con la cantidad de consumo de los adolescentes que presentan la conducta saludable de no consumo de alcohol. sin embargo, cuando se analiza el consumo de alcohol incluyendo a los adolescentes que presentan y no presentan esta conducta saludable, se identificó una relación positiva y significativa (rs = 0,196; p < 0,01), lo que significa que a mayor consumo de alcohol por parte de los padres se presenta mayor consumo de alcohol en sus hijos adolescentes. 225 la historia familiar y la conducta de consumo de alcohol como factor sociocultural en el adolescente. perspectiva de enfermería l nora angélica armendáriz-garcía y otros discusión respecto a la hfca positiva de los padres de los adolescentes de preparatoria como factor personal sociocultural, se observó que un poco menos de la mitad de los estudiantes contaba con este factor personal sociocultural; no obstante, la proporción de adolescentes que presentan este factor es muy similar y esta información coincide con lo reportado por lema, varela, duarte y bonilla (17) quienes encontraron que en la mayoría de los integrantes de la familia ninguno bebe en exceso con frecuencia (55 %), mientras que un 24 % lo hace frecuentemente y en menor proporción dos o más de los familiares beben en exceso con frecuencia. como se observó, la presencia de la hfca positiva como factor personal sociocultural puede deberse a que esta conducta de consumo se encuentra muy arraigada en la población mexicana, lo que puede favorecer que los miembros de la familia, sobre todo los jefes del hogar, sean los que comúnmente muestran esta conducta que está permitida socialmente y es considerada un vehículo de interacción en grupos sociales y laborales (18). en cuanto a la presencia del factor personal sociocultural de hfca y la conducta no saludable del consumo de alcohol de hijos adolescentes, se identificó que aquellos que exhiben esta conducta no saludable presentan mayor consumo de alcohol en los padres, a diferencia de aquellos que no presentan este consumo alguna vez en la vida, como en el último año y en el último mes; sin embargo, en la última semana no se encontraron diferencias. esta información coincide con lo reportado por otros autores (3, 18), donde se identificó en general que una importante proporción de jóvenes que tienen familiares que beben en exceso, llegan a presentar un patrón de consumo de dependencia y dañino. de la misma manera, los jóvenes que tienen por lo menos un familiar que bebe en exceso con frecuencia, tienden a iniciar más temprano el consumo de alcohol (19, 20). lo anterior puede explicarse desde la perspectiva del modelo de promoción de pender, el cual indica que algunos factores personales (biológicos, psicológicos y socioculturales) son determinantes en la conducta del individuo para participar o no en comportamientos de salud. en este caso, el factor personal sociocultural es la hfca positiva en los adolescentes, que ejerce en ellos un rol importante en la formación de conductas como el consumo de alcohol; en este sentido, la influencia y los hábitos de los padres se reproducen en los hijos por socialización y ejemplo, es por ello que en la familia es donde se inician y se aprenden hábitos y conductas que pueden influir en el estado de salud de sus integrantes (21). respecto a la relación entre la hfca positiva y la conducta no saludable (consumo de alcohol de sus hijos adolescentes), no se observó relación significativa. esto puede explicarse tal vez porque podrían tener más peso otros factores personales socioculturales aparte de la hfca, que se encuentran más ligados al desarrollo de esta conducta en esta etapa de la vida, como el consumo de alcohol por parte de los hermanos o del mejor amigo, ya que la presión social para consumir resulta dominante en los adolescentes que tienen una fuerte necesidad de ser aceptados y de obtener reconocimiento social ante un grupo, aunado con la etapa de desarrollo que experimentan que se caracteriza por las transiciones y la vulnerabilidad (18). no obstante, se observó una relación positiva y significativa al realizar la correlación entre consumo y no consumo de alcohol por los hijos adolescentes, y la presencia hfca positiva, observándose que el no presentar consumo de alcohol por parte de los padres de familia se relaciona con el no consumo o escaso consumo de alcohol en los adolescentes. esto puede deberse a que los padres de familia de los hijos adolescentes están ejerciendo en ellos un modelo de rol positivo que se convierte en un factor protector ante el consumo de alcohol, y posiblemente este comportamiento protector puede estar influyendo en mejorar o mantener un estilo de vida saludable que contribuirá al mantenimiento de conductas saludables en la etapa de adultez. conclusiones e implicancias para enfermería con base en lo reportado respecto a la conducta no saludable de consumo de alcohol, se observó que los adolescentes presentan mayor prevalencia de consumo alguna vez en la vida, seguido por el consumo en el último año y en el último mes y, en menor proporción, en la última semana. en cuanto al tipo de consumo de alcohol predominó el sensato, seguido del dañino o perjudicial y posteriormente el dependiente. en relación con la presencia del factor personal sociocultural de hfca por parte de los padres se identificó que un poco menos de la mitad de los adolescentes lo presentan. 226 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 aunado a esto, se observó que los adolescentes que tienen el factor personal sociocultural hfca positiva con puntajes altos, fueron quienes presentaron mayor consumo de alcohol en cuanto a la prevalencia alguna vez en la vida, en el último año y el último mes, mientras que para el consumo de alcohol en la última semana no se encontró diferencia significativa respecto a los adolescentes que cuentan con hfca positiva y negativa. asimismo, cuando se analiza la conducta de consumo de alcohol incluyendo a los adolescentes que practican y no esta conducta no saludable, se identificó una relación positiva y significativa con la presencia del factor personal sociocultural hfca y la conducta no saludable de consumo de alcohol por parte del adolescente, lo que indica que la hfca negativa se relaciona con el no consumo de alcohol. la información obtenida en este estudio debe ser dirigida hacia el diseño y la aplicación de intervenciones de enfermería enfocadas a los padres de familia, que los oriente sobre el efecto negativo que ejerce el factor personal sociocultural la hfca en sus hijos que aún no han tenido contacto con esta sustancia, y en los adolescentes que ya han consumido esta sustancia puede favorecer el mantenimiento de esta conducta. asimismo, estas intervenciones deben brindar estrategias enfocadas a los cambios de conductas y promoción de estilos de vida saludables. referencias 1. consejo nacional contra las adicciones. prevención de adicciones [internet] [visitado 2014 dic 20]. disponible en: http://www.conadic.salud.gob.mx/interior/cirt_alcohol.html 2. pender nj, murdaugh cl, parsonsma. health promotion in nursing practice. prentice hall; 2010. 3. hawkins jd, catalano rf, miller jf. risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: implications for substance 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time of drinking onset and family history of alcohol problems in alcohol and drug use behaviors in argentinean college students. alcohol and alcoholism. 2014;49(2):128-37. 21. reimuller a, hussong a, ennett st. the influence of alcohol-specific communication on adolescent alcohol use and alcohol-related consequences. prev sci. 2001;12(4):389-400. 339 350 violencia fisica por parceiro.indd 339 jenny karol gomes sato sgobero1 lorenna viccentine coutinho monteschio2 robsmeire calvo melo zurita3 rosana rosseto de oliveira4 thais aidar de freitas mathias5 violência física por parceiro íntimo na gestação: prevalência e alguns fatores associados 1 enfermeira. mestre em enfermagem. secretaria municipal de saúde. jenny-sato@hotmail.com 2 enfermeira. mestre em enfermagem. hospital universitário regional de maringá. brasil. helorenn@hotmail.com 3 enfermeira. doutoranda. programa de pós-graduação em enfermagem da universidade estadual de maringá (uem), maringá. brasil. secretaria municipal de saúde. robszurita@bol.com.br 4 enfermeira. doutoranda. programa de pós-graduação em enfermagem da uem, maringá. brasil. rosanarosseto@gmail.com 5 enfermeira. doutora em saúde pública. professora titular do departamento de enfermagem e do programa de pós-graduação em enfermagem da uem, maringá. brasil. tafmathias@uem.br recibido: 07 de octubre de 2014 enviado a evaluadores: 15 de noviembre de 2014 aceptado por evaluadores: 20 de abril de 2015 aprobado: 21 de abril de 2015 doi: 10.5294/aqui.2015.15.3.3 para citar este artículo / to reference this article / para citar este artigo sgobero jkgs, monteschio lvc, zurita rcm, oliveira rr, mathias taf. violência física por parceiro íntimo na gestação: prevalência e alguns fatores associados. aquichan. 2015; 15(3): 339-350. doi: 10.5294/aqui.2015.15.3.3 resumo identificar alguns fatores associados com a violência física por parceiro íntimo na gestação. estudo transversal, com 358 puérperas residentes no município de maringá (paraná), atendidas pelo sistema único de saúde, em que foi utilizado o instrumento world health organization violence against women. a análise de associação foi realizada por meio do odds ratio or. a prevalência da violência física por parceiro íntimo na gestação foi de 7,5%, sendo maior entre as multigestas (89%; or = 6,3; p<0,001). houve associação significativa da violência física por parceiro íntimo na gestação com não ter religião (or = 3,1; p = 0,008), ter fumado na gestação (or = 2,7, p = 0,025) e ter filhos de outro parceiro (or = 3,4; p = 0,011). com relação às características do companheiro, houve associação com o companheiro não ter trabalhado durante a gestação (or = 8,2; p<0,001) e uso de drogas ilícitas (or = 3,1, p = 0,031). os profissionais de saúde que atendem no pré-natal devem investigar possíveis ocorrências de violência física na gestação, principalmente em mulheres multigestas, e oferecer atenção multidisciplinar extensiva à família, do planejamento familiar ao cuidado psicossocial. palavras-chave violência contra a mulher, gestação, saúde da mulher, maus-tratos conjugais, violência doméstica (fonte: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 339-350 340 aquichan issn 1657-5997 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 339-350 violencia física por el compañero íntimo en el embarazo: prevalencias y algunos factores asociados resumen identificar algunos factores asociados a la violencia física por compañero íntimo en el embarazo. estudio trasversal con 358 puérperas habitantes del municipio de maringá (paraná, brasil), atendidas por el sistema único de salud, en el que se utilizó el instrumento world health organization violence against women. el análisis de asociación se realizó por medio del odds ratio (or). la prevalencia de la violencia física por compañero íntimo en el embarazo fue de 7,5 %, siendo mayor entre las multigestas (89 %; or = 6,3; p<0,001). hubo asociación significativa de la violencia física por compañero íntimo en el embarazo con no tener religión (or = 3,1; p = 0,008), haber fumado en el embarazo (or = 2,7, p = 0,025) y haber tenido hijo de otra pareja (or = 3,4; p = 0,011). en relación con las características de la pareja, hubo asociación con el no haber trabajado durante el embarazo or = 8,2; p<0,001) y el uso de drogas ilícitas (or = 3,1, p = 0,031). los profesionales de salud que atienden en el prenatal deben investigar posibles ocurrencias de violencia física en el embarazo, sobre todo en mujeres multigestas, y ofrecer atención multidisciplinaria extensiva a la familia, desde la planeación hasta el cuidado psicosocial. palabras clave violencia en contra de la mujer, embarazo, salud de la mujer, maltratos conyugales, violencia doméstica (fuente: decs, bireme). 341 violência física por parceiro íntimo na gestação: prevalência e alguns fatores associados l jenny karol gomes sato sgobero e outros intimate partner violence perpetrated during pregnancy: prevalence and several associated factors abstract the purpose of this research was to identify some of the factors associated with intimate partner violence perpetrated during pregnancy. this is a cross-sectional study of 358 puerperae residing in the city of maringa (parana, brazil), who were being served by the unified health system. the world health organization violence against women instrument was used. an association analysis was performed using the odds ratio (or). the prevalence of intimate partner physical violence during pregnancy was 7.5%, being higher among women who have had multiple pregnancies (89%; or = 6.3; p < 0.001). a significant association was found between intimate partner physical violence during pregnancy and lack of religion (or = 3.1; p = 0.008), smoking during pregnancy (or = 2.7, p = 0.025) and having had a child with another partner (or = 3.4; p = 0.011). as for the characteristics of the couple, there was an association with the male partner not having worked during the pregnancy (or = 8.2; p <0.001) and with the use of illicit drugs (or = 3.1, p = 0.031). health professionals who provide prenatal care should investigate possible instances of physical violence during pregnancy, especially among women who have had multiple pregnancies, and offer extensive multidisciplinary care for the family, ranging from planning to psychosocial assistance. keywords violence against women, pregnancy, women’s health, spousal abuse, domestic violence (source: mesh, nlm). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 339-350 342 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 introdução a gestação é um período em que as mulheres enfrentam muitas mudanças, podendo ser uma fase vulnerável quanto às condições psicológicas, de autonomia e algumas vezes financeira, possibilitando uma predisposição à violência ou ao seu agravamento (1). tem sido relatado que o maior perpetrador de violência contra mulher é o seu parceiro íntimo (2, 3), como expressão da dominação masculina representada por indicadores como o ciúme doentio, o controle e o isolamento da mulher de seu ambiente social (4). a maioria dos países apresenta prevalências de violência física cometidas por parceiro íntimo na gestação entre 2% e 13,5%, com maior predomínio nos países da áfrica e da américa latina (5). o menor índice encontrado foi de 2% em países como a austrália, dinamarca, camboja e filipinas e os maiores foram de 10,6% na colômbia, 11,1% na nicarágua e 13,5% na uganda (5). as mulheres que sofrem violência física na gestação geralmente apresentam escolaridade e renda familiar baixa, referem não ter apoio paterno durante a gestação, e frequentemente iniciam o pré-natal tardiamente (6). as complicações da violência para a saúde da mulher vão desde a depressão, vícios nocivos como o uso de álcool, de tabaco e de drogas ilícitas, até o baixo peso ao nascimento, prematuridade e desfechos fatais para a mãe e o feto (6). apesar de a literatura demonstrar como a violência atinge negativamente a gestação para a saúde da mãe e do concepto, ainda existe uma invisibilidade social desse fenômeno (7) que pode ser minimizada com a realização de estudos sobre esse tema. identificar a ocorrência de episódios de violência, as características das mulheres na gestação e de seus companheiros são possíveis abordagens que podem contribuir para elaboração de uma assistência mais adequada (8). a análise da violência contribui para legitimar esse agravo como um problema para a área da saúde pública, e necessita ser abordado tanto como tema de pesquisa como na assistência (9), a fim de suprir a lacuna existente no conhecimento envolvendo a violência física por parceiro íntimo durante a gestação. assim, foi objetivo deste estudo identificar os fatores associados à violência física por parceiro íntimo na gestação, em um município de médio porte da região sul do brasil. materiais e métodos trata-se de um estudo transversal com puérperas residentes em maringá, paraná, internadas em unidade de alojamento conjunto de dois hospitais de referência do sistema único de saúde —sus—. a amostra foi calculada considerando os 2.178 partos financiados pelo sus em residentes no município no ano de 2011, com um nível de confiança de 95% e margem de erro de 4%. a amostra foi composta por 358 puérperas, já considerados 10% para possíveis perdas. como não foram identificados estudos na região ou no estado do paraná sobre violência à mulher na gestação, a prevalência estimada de 20% foi fundamentada em estudo realizado na cidade do rio de janeiro (6) que avaliou a violência física por parceiro íntimo durante a gestação como fator de risco para a má qualidade da assistência pré-natal. a participação de puérperas nesta pesquisa foi voluntária e foram incluídas puérperas em qualquer idade, com conceptos acima de 500g, que estivessem internadas em unidade de alojamento conjunto e em condições físicas e mentais para responder ao questionário. o período de coleta de dados ocorreu de 21 de dezembro de 2012 a 6 de abril de 2013 por meio de entrevista às puérperas. a variável dependente foi a ocorrência de violência física por parceiro íntimo —vfpi— durante a gestação atual ou em gestações anteriores investigadas por meio da seguinte pergunta às mulheres: “houve alguma ocasião na vida em que você foi agredida fisicamente por seu companheiro quando estava grávida?”. foi utilizado o questionário world health organization violence against women —who vaw—, instrumento multidimensional de pesquisa validado no brasil (10), sendo acrescentadas outras perguntas também pertinentes ao tema de estudo. as variáveis selecionadas como possíveis fatores associados à violência física durante a gestação contemplaram características socioeconômicas, hábitos da mãe, antecedentes obstétricos e reprodutivos, e características e hábitos do companheiro atual. as variáveis socioeconômicas pesquisadas foram: idade (10 a 19 anos, 20 a 34 anos e > 35 anos), escolaridade (1 a 4 anos de estudo, 5 a 8 anos de estudo, 9 a 11 anos de estudo e > 12 anos de estudo), ter companheiro (sim ou não), ocupação (do lar/ 343 violência física por parceiro íntimo na gestação: prevalência e alguns fatores associados l jenny karol gomes sato sgobero e outros estudante, carteira assinada, autônoma), raça/cor (preta/parda, branca/amarela) e renda familiar (<3 salários-mínimos e > 3 salários-mínimos). com relação às variáveis dos hábitos da mãe foram questionadas: religião (católica, evangélica, outra e nenhuma), ingesta de bebida alcoólica na gestação, tabagismo na gestação e uso de drogas (todas dicotomizadas em sim ou não). os antecedentes obstétricos e reprodutivos analisados no estudo tiveram as seguintes variáveis dicotomizadas (sim ou não): óbito fetal, aborto, filho prematuro, filho com baixo peso ao nascimento, recusa do uso de camisinha, filho de outro pai. a variável idade da primeira relação sexual foi categorizada em <16 anos e ≥16 anos, e a paridade em multigesta e primigesta. foram investigadas também características e hábitos do companheiro atual. as variáveis foram: idade (10 a 19 anos, 20 a 34 anos e ≥35 anos), escolaridade (1 a 4 anos de estudo, 5 a 8 anos de estudo, 9 a 11 anos de estudo e ≥12 anos de estudo), frequência da ingesta de bebida alcoólica (todos ou quase todos os dias, 1 vez na semana, 1 ou duas vezes ao mês, nunca). as variáveis trabalho na gestação, desejava a gestação atual da parceira e uso de drogas foram dicotomizadas em sim e não. os dados foram tabulados e organizados em planilha eletrônica do programa excel versão 2007, com dupla digitação independente. após a verificação de erros e inconsistências, os dados foram analisados por meio de técnicas de estatística descritiva utilizando o software statística 7. para o teste qui-quadrado foi utilizado o software epi info 7, considerando α=5%. foi utilizado o odds ratio —or— para mensurar a magnitude da associação entre as variáveis e seu respectivo intervalo de confiança —ic—. a coleta de dados foi realizada por duas enfermeiras capacitadas previamente. foi realizado estudo piloto prévio e observadas todas as recomendações éticas e de segurança para a realização de estudos que abordam a violência doméstica contra a mulher (11). as entrevistas foram realizadas em uma sala dos hospitais reservada para esse fim, com o objetivo de garantir privacidade à mulher, com duração média da entrevista de aproximadamente 40 minutos. após a entrevista, foi entregue a todas as puérperas um folheto com os locais de referência no município para assistência em situações de violência, constando o nome das instituições, endereços e telefones, seguido de orientações complementares. o estudo foi aprovado pelo comitê de ética em pesquisa envolvendo seres humanos da universidade estadual de maringá, sob o parecer 170.704/2012. todas as participantes assinaram o termo de consentimento livre e esclarecido, cumprindo os requisitos da resolução 466/2012 do conselho nacional de saúde. resultados das 358 puérperas entrevistadas 27 (7,5%) relataram algum episódio de violência física por parceiro íntimo durante a gestação. houve associação significativa da violência física na gestação com relato de ser multigesta, não ter religião e ter fumado durante a gestação (or = 6,3; p=0,001; or = 3,1; p = 0,008; or = 2,7, p = 0,025; respectivamente) (tabela 1). verificou-se que das 27 mulheres que relataram violência física durante a gestação, 89% eram multigestas (or = 6,3; p < 0,001). assim, a partir dessa constatação, e considerando as diferenças entre multigestas e primigestas quanto ao seu perfil e desfechos maternos e perinatais (12), a análise da tabela 2 foi realizada considerando o grupo de mulheres que já tinham pelo menos uma gestação anterior. para a análise da tabela 3 considerou-se somente as mulheres que relataram a presença de companheiro, independentemente da paridade. a tabela 2 mostra que para as mulheres multigestas a vfpi na gestação esteve associada com o fato de a mulher ter um ou mais filhos de outro companheiro que não o atual (or = 3,4; p = 0,011). ressalta-se ainda que a violência física foi mais frequente para alguns desfechos indicativos de risco obstétrico, tais como o óbito fetal, aborto e filhos anteriores nascidos com baixo peso, como também o início da atividade sexual antes dos 16 anos de idade e a recusa do uso de camisinha pelo parceiro. quanto às características do companheiro, houve associação da violência física durante a gestação com o fato de o companheiro não ter trabalhado durante a gestação (or = 8,2; p < 0,001) e ter usado ou usar drogas ilícitas (or = 3,1, p = 0,031) (tabela 3). 344 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 tabela 1. violência física na gestação segundo características socioeconômicas, hábitos maternos e paridade. maringá, pr, brasil, 2012-2013 violência na gestação sim (n=27) não (n=331) características n % n % or ic p* idade 0,704 10 a 19 3 4,4 65 95,6 0,8 0,1-4,9 20 a 34 22 8,7 232 91,3 1,6 0,4-7,2 ≥35 2 5,6 34 94,4 escolaridade 0,160 1 a 4 anos 2 15,4 11 84,6 4,4 0,3-53,4 5 a 8 anos 12 9,8 110 90,2 2,6 0,3-21,1 9 a 11 anos 12 6,1 186 93,9 1,5 0,2-12,4 ≥12 anos 1 4,0 24 96,0 companheiro 0,954 sim 24 7,6 293 92,4 1 0,29-3,61 não 3 7,3 38 92,7 ocupação 0,912 do lar/estudante 11 7,8 130 92,2 1 0,3-3,3 carteira assinada 4 7,8 47 92,2 autônoma 12 7,2 154 92,8 0,9 0,3-2,3 raça/cor 0,749 preta/parda 14 8,0 161 92,0 1,1 0,5-2,5 branca/amarela 13 7,1 170 92,9 renda** 0,180 < 3 salários 22 8,8 229 91,2 2 0,7-5,3 ≥ 3 salários 5 4,7 102 95,3 religião 0,008 católica 6 4,2 136 95,8 evangélica 11 8,3 122 91,7 2 0,7-5,7 outras 1 11,1 8 88,9 2,8 0,3-26,4 nenhuma 9 12,2 65 87,8 3,1 1,1-9,2 tabagismo 0,025 sim 8 17,4 38 82,6 2,7 1,1-6,5 não 19 6,1 293 93,9 345 violência física por parceiro íntimo na gestação: prevalência e alguns fatores associados l jenny karol gomes sato sgobero e outros tabela 2. violência física na gestação em multigestas segundo antecedentes obstétricos e reprodutivos. maringá-pr, brasil, 2012-2013 *teste qui-quadrado. a significância estatística foi fixada em p≤0,05. **renda familiar baseada em no salario-mínimo no brasil em 01/01/2013: r$678,00. violência na gestação sim (n=27) não (n=331) características n % n % or ic p* ingesta de bebida alcoólica 0,0 0,628 sim 3 5,9 48 94,1 0,7 0,2-2,5 não 24 7,8 283 92,2 uso de drogas 0,385 sim 2 13,3 13 86,7 2 0,4-9,1 não 25 7,3 318 92,7 paridade 0,001 multigesta 24 11,5 185 88,5 6,3 1,9-21,4 primigesta 3 2,0 146 98,0 violência na gestação sim (n=24) não (n=185) n % n % total or ic p * óbito fetal 0,130 sim 3 25,0 9 75,0 12 2,8 0,7-11,1 não 21 10,7 176 89,3 197 aborto 0,595 sim 8 13,3 52 86,7 60 1,3 0,5-3,2 não 16 10,7 133 89,3 149 filhos prematuros 0,494 sim 1 6,3 15 93,7 16 0,5 0,1-3,9 não 23 11,9 170 88,1 193 filhos baixo peso 0,562 sim 2 16,7 10 83,3 12 1,6 0,3-7,7 não 22 11,2 175 88,8 197 idade da primeira relação sexual 0,599 <16 12 12,8 82 87,2 94 1,3 0,5-2,9 ≥16 12 10,4 103 89,6 115 346 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 tabela 3. violência física na gestação em multigestas segundo características e hábitos do companheiro. maringá-pr, brasil, 2012-2013 violência na gestação sim (n=24) não (n=185) n % n % total or ic p * recusa uso de camisinha** 0,503 sim 6 15,4 33 84,6 39 1,4 0,5-4,0 não 13 11,3 102 88,7 115 filhos de outro pai*** 0,011 sim 16 17,8 74 82,2 90 3,4 1,3-9,2 não 6 5,9 95 94,1 101 *teste qui-quadrado. a significância estatística foi fixada em p≤0,05. **cinco mulheres não quiseram informar sobre a aceitação do uso de camisinha pelo parceiro. *** duas mulheres não quiseram informar sobre a existência de filhos de outro pai. violência na gestação sim (n=24) não (n=293) n % n % total or ic p * idade 0,936 10 a 19 20 100,0 20 20 a 34 19 8,0 218 92,0 237 1,0 0,3-2,7 ≥35 5 8,3 55 91,7 60 escolaridade 0,634 1 a 4 anos 5 a 8 anos 8 6,6 113 93,4 121 0,7 0,1-3,4 9 a 11 anos 14 8,2 157 91,8 171 0,8 0,2-4,0 ≥12 anos 2 9,5 19 90,5 21 trabalho na gestação 0,001 não 3 37,5 5 62,5 8 8,2 1,8-36,8 sim 21 6,8 288 93,2 309 desejava esta gestação 0,353 não 11 10,1 99 90,8 109 1,5 0,63-3,5 sim 13 6,3 194 94,2 206 347 violência física por parceiro íntimo na gestação: prevalência e alguns fatores associados l jenny karol gomes sato sgobero e outros discussão a prevalência de violência física na gestação encontrada neste estudo foi de 7,5%, valor semelhante aos resultados descritos em pesquisa realizada com puérperas em uma maternidade no abc paulista, estado de são paulo com prevalência de 7,6% para gestantes e puérperas em duas maternidades públicas municipais (13). menor prevalência foi encontrada em estudo com gestantes em atendimento de consultas de pré-natal na rede pública de saúde em campinas, são paulo, com 5,7% (14). por outro lado, a prevalência de 7,5% deste estudo foi inferior à verificada na cidade do rio de janeiro (20%) (6), resultado de estudo realizado em três hospitais públicos daquele município. essa diferença na prevalência de violência física na gestação, entre as mulheres residentes em maringá e no município do rio de janeiro, mostra, em primeiro lugar, a necessidade de que estudos desta natureza sejam realizados em diferentes regiões e municípios do país, pois as condições de vida, de acesso a serviços públicos e as condições socioeconômicas diferenciadas influenciam nesses resultados. por outro lado, é importante considerar que essas diferenças podem estar associadas a características da região relativas a investimentos em políticas públicas de incentivo às denúncias, maior disponibilidade de serviços de referência às mulheres e suas famílias, investimentos em campanhas de divulgação que possibilitem maior visibilidade desse agravo, e também mudança de valores e a conscientização por parte da mulher, acerca de seus direitos. esses fatores podem propiciar melhoria nas notificações dos casos e das formas de monitoramento de tal tipo de evento, acentuando as diferenças observadas nas prevalências de violência física na gestação. destaca-se ainda que esse diferencial nas prevalências de violência física na gestação pode refletir o uso de diferentes instrumentos de pesquisa para identificação dos casos, além de contextos historicamente construídos por ideologias que legitimam e classificam homens e mulheres com papéis sociais desiguais e com relações assimétricas de dominação masculina (15). esses fatores devem ser considerados quando os resultados das pesquisas são comparados entre si. assim, enfatiza-se que os profissionais de saúde devem estar cientes da real situação desse agravo no seu município para melhor orientar suas ações junto à comunidade em geral, e no atendimento ao pré-natal em particular. considerando que a violência raramente inicia-se durante a gestação, já que com frequência configura-se um padrão regular e sistemático de relacionamento do casal, é fundamental que o tema seja abordado desde a primeira consulta de pré-natal nos serviços de saúde, buscando-se identificar as famílias que vivenciaram conflitos conjugais, mesmo antes da atual gestação. da mesma forma, identificar situações de violência deveria fazer parte da rotina de internação e atendimentos das maternidades, especialmente quanto às gestantes que iniciaram tardiamente e/ ou tiveram um número reduzido de consultas pré-natais (6). *teste qui-quadrado. a significância estatística foi fixada em p≤0,05. violência na gestação sim (n=24) não (n=293) n % n % total or ic p * ingesta de bebida alcoólica 0,169 todos/quase todos os dias 2 8,0 23 92,0 25 0,8 0,2-3,8 uma vez na semana 6 5,4 105 94,6 111 0,5 0,2-1,4 uma ou duas vezes no mês 4 6,8 55 93,2 59 0,7 0,2-2,2 nunca 12 9,9 110 90,2 122 uso de drogas 0,031 sim 5 17,9 23 82,1 28 3,1 1,1-9,0 não 19 6,6 270 93,4 289 348 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 ao interpretar os resultados aqui apresentados devem-se considerar ainda as dificuldades em abordar o tema da violência por parceiro íntimo. existe a possibilidade de graus variados de constrangimento da mulher ao assumir ter sido vítima de alguma violência, fato que depende tanto da sua percepção do que seja a violência, quanto da coragem de confirmar algo que para ela pode ser humilhante e embaraçoso. assim, é possível que todos esses fatores contribuam para a variabilidade das prevalências em diferentes cenários socioculturais e municípios diversos. a religião foi um fator com associação significativa à ocorrência de violência física na gestação. as mulheres que relataram ter alguma religião apresentaram menor prevalência de vfpi na gestação do que as mulheres que disseram não ter religião, associação importante que deve ser considerada e melhor explorada em futuras pesquisas. é necessário ponderar, entretanto que a religião constitui uma variável de interpretação difícil por envolver dogmas religiosos que interferem no relato da violência. assumir não ter religião pode ser tabu na sociedade cristã, e assumir ser vítima de violência também pode ter esse caráter. tal fato deve ser considerado como possível dificuldade da mulher que relata ter religião admitir a ocorrência de violência pelo parceiro. a violência física mostrou associação com o tabagismo da mulher durante a gestação, o que pode ter algumas interpretações como uma possível perda da autoestima que leva a mulher a adquirir comportamentos de risco, como o hábito de fumar para aliviar o estresse e o sofrimento causados pela violência (16), assim como a convivência com parceiros tabagistas exercendo uma importante influência quanto a não cessação do hábito durante a gestação (17). lembrando que as associações aqui encontradas não podem ser consideradas uma relação de causa e efeito, devido o delineamento do estudo. o fato de a violência física ser mais frequente em mulheres multigestas, resultado encontrado no presente estudo, concorda com outros autores (18). considera-se que as mulheres com mais filhos são mais suscetíveis à violência supondo que um maior número de filhos pode aumentar o estresse na família. indo mais adiante pode acontecer que essas mulheres que sofrem violência física também são vitimas de outras formas de violência gerando uma situação de submissão, que por sua vez levaria a um menor poder de negociação no cotidiano como, por exemplo, na relação sexual e quanto ao uso de meios contraceptivos o que as deixam mais suscetíveis à gravidez tornando-as mães de vários filhos (19). a associação da violência física na gestação e filhos de outro parceiro encontrada neste estudo, também foi relatada em um estudo realizado no méxico, o qual faz referência à violência no período gestacional como um padrão mais grave de violência, que além de comprometer a saúde da mulher, pode comprometer futuramente também a infância, quando a violência passa a ser exercida por seu parceiro também em seus filhos (19). com relação às características do companheiro, a vfpi na gestação foi mais frequente quando este estava desempregado durante a gestação. o fato de estar sem renda pode resultar na percepção do companheiro de que a esposa é financeiramente independente ou que pode se tornar chefe de família aumentando a chance de episódios de violências, incluindo a violência física (20). outro resultado deste estudo foi a associação da violência física e o uso de drogas pelo parceiro, corroborando com achados de outros estudos (14, 21). na cidade de campinas, no estado de são paulo, foi descrito o uso de drogas pelo companheiro como fator preditivo para violência (14). recentemente, na cidade de pelotas, estado do rio grande do sul, um estudo apontou que o uso de drogas lícitas ou ilícitas no meio familiar pode gerar conflitos e resultar em atos de violência (21). este estudo apresenta dados úteis para orientar as iniciativas dos gestores e de profissionais da saúde visando à melhoria da qualidade da atenção a mulher durante a gestação. entretanto, é importante ressaltar algumas limitações, principalmente aquelas decorrentes da dificuldade de abordagem do tema, pois a prevalência de violência física durante a gestação foi estimada tendo como fonte o relato da mulher. considera-se que essa resposta envolve fatores culturais e emocionais podendo ser enfrentada com dificuldade, possibilitando a algumas mulheres omitirem a ocorrência desse agravo. finalmente, mesmo considerando que um estudo do tipo transversal como o presente não tem poder de estabelecer relação de causalidade da violência com as variáveis analisadas, a complexidade e a importância da violência como um problema de saúde pública presente na comunidade remetem à necessidade de se conhecer os fatores envolvidos com fins de legitimar esse agravo no âmbito da atenção à saúde. embora tenha sido observado aumento da produção científica sobre a violência nos últimos anos, ainda existem lacunas do conhecimento, sendo necessário investigar outros contextos desse 349 violência física por parceiro íntimo na gestação: prevalência e alguns fatores associados l jenny karol gomes sato sgobero e outros agravo como, por exemplo, aspectos psicológicos das gestantes vítimas de violência, experiências positivas de redes de apoio às mulheres e seus companheiros, e a efetividade dos serviços de saúde no cuidado e assistência às vítimas. conhecer os fatores que se associam à ocorrência da violência física permite instrumentalizar os profissionais da saúde, especialmente o enfermeiro, a identificar essas características na mulher e sua família priorizando um atendimento mais próximo, com equipe multiprofissional e abordagem interdisciplinar, a fim de elaborar uma assistência direcionada e específica para encaminhamentos necessários no sentido de proteger a mulher, seus filhos e sua família. sugere-se que o agravo da violência seja considerado e incorporado definitivamente aos serviços para que seja investigado pelos profissionais de saúde na rotina do atendimento à mulher "em geral" e durante o pré-natal em, particular. referências 1. makayoto la, omolo j, kamweya am, harder vs, mutai j. prevalence and associated factors of intimate partner violence among pregnant women attending kisumo district hospital, kenya. matern child health j. 2013;17:441-47. 2. world health organization. understanding and addressing violence against women: intimate partner violence. 2012. [cited 2015 apr 17]. disponível em: http://apps.who.int/iris/bitstream/10665/77432/1/who_rhr_12.36_eng.pdf?ua=1 3. miranda mpm, paula cs, bordin ia. violência conjugal física contra a mulher na vida: prevalência e impacto imediato na saúde, trabalho e família. rev panam salud publica. 2010;27(4):300-8. 4. gama is, bezerra filho jg, silva jg, vieira lje, parente eo. fatores associados à violência física denunciada por mulheres. j health biol sci. 2014;2(4):168-75 5. drevies km, kishor s, johnson h, stöckl h, bacchus lj, garcia-moreno c, et al. intimate partner violence during pregnancy: analysis of prevalence data from 19 countries. reproductive health matters. 2010;18(36):158–70. 6. moraes cl, arana fdn, reichenheim me. violência física entre parceiros íntimos na gestação como fator de risco para a má qualidade do pré-natal. rev saúde pública. 2010;44(4):667-76. 7. lettiere a, nakano ams. domestic violence: possibilities and limitations in coping. rev latino-am enfermagem. 2011;19(6):1421-28. 8. jahanfar s, howard lm, medley n. interventions for preventing or reducing domestic violence against pregnant women. cochrane. 2014;11(9414). 9. aragão as, ferriani mgc, vendruscollo ts, souza sl, gomes r. primary care nurses’ approach to cases of violence against children. rev latino-am enfermagem. 2013; 21(n.spe):172-9. 10. schraiber lb, latorre mrdo, frança jri, segri nj, d’oliveira afpl. validade do instrumento who vaw study para estimar violência de gênero contra mulher. rev saúde pública. 2010;44(4):658-66. 11. organización mundial de la salud. programa mundial sobre pruebas científicas para las políticas de salud. dando prioridad a las mujeres: recomendaciones éticas y de seguridad para la investigación sobre la violencia contra las mujeres. suiza; 1999. 12. schimel ms, bromiker r, hammerman c, chertman l, ioscovich a, granovsky-grisary s, et al. the effects of maternal age and parity on maternal and neonatal outcome. arch gynecol obstet. 2015;291:793-98. 13. puccia mir. violência por parceiro íntimo e morbidade materna grave [tese de doutorado]. ribeirão preto (sp): escola de enfermagem de ribeirão preto da universidade de são paulo; 2012.141 p. 14. audi caf, segall-corrêa am, santiago sm, andrade mgg, pèrez-escamila r. violência doméstica na gravidez: prevalência e fatores associados. rev saúde pública. 2008;42(5):877-85. 15. labronici lm, ferraz mir, trigueiro th, fegadoli d. perfil da violência contra mulheres atendidas na pousada de maria. rev esc enferm usp. 2010;44(1):126-33. 350 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 16. dahmer ts, gabatz rib, vieira lb, padoin smm. violência no contexto das relações familiares: implicações na saúde e vida das mulheres. cienc cuid saúde. 2012;11(3):497-505. 17. motta gcp, echer ic, lucena af. factors associated with smoking in pregnancy. rev latino-am enfermagem. 2010;18(4):809-15. 18. santos, as, lovisi gm, valente ccb, legay l, abelha l. et al. violência doméstica durante a gestação: um estudo descritivo em uma unidade básica de saúde no rio de janeiro. cad saúde colet. 2010;18(4):483-93. 19. castro r, ruiz a. prevalencia y severidad de la violencia contra mujeres embarazadas, méxico. rev saúde pública. 2004;38(1):62-70. 20. vieira em, perdona gsc, santos, ma. fatores associados à violência física por parceiro íntimo em usuárias de serviços de saúde. rev saúde pública. 2011;45(4):730-37. 21. bes tm, lopes far, morgan gj, ribeiro ms, duarte wr. relação da violência intrafamiliar e o uso abusivo de álcool ou entorpecentes na cidade de pelotas, rs. revista da amrigs. 2013;57(1):9-13. 148 158 validacion indice de satisfaccion.indd 148 aquichan issn 1657-5997 maría amparo de jesús kantún-marín1 josé moral de la rubia2 marco vinicio gómez-meza3 bertha cecilia salazar-gonzález4 validación del índice de satisfacción con la vida en la tercera edad 1. doctora en ciencias de enfermería, universidad autónoma del carmen, méxico. m_kantun@hotmail.com 2. doctor en psicología, universidad autónoma de nuevo león, méxico. jose_moral@hotmail.com 3. phd. doctor en estadística, universidad autónoma de nuevo león, méxico. marco.gomezmz@uanl.mx 4. doctora en enfermería, universidad autónoma de nuevo león, méxico. bceci195@hotmail.com recibido: 23 de julio de 2012 enviado a pares: 23 de julio de 2012 aceptado por pares: 13 de mayo de 2013 aprobado: 17 de mayo de 2013 año 13 vol. 13 nº 2 chía, colombia agosto 2013  148-158 resumen objetivos: estudiar la estructura factorial del life satisfaction index for the third age, short form (lsita-sf), su consistencia interna, la validez de contenido y de constructo, y la validez divergente y convergente. este índice se propone como uno de los indicadores subjetivos del envejecimiento exitoso, que a su vez representa el modo de autoconcepto del modelo de adaptación de roy y se contrasta con una medición breve de sintomatología depresiva (cesd-7 por sus siglas en inglés) y con la dimensión de salud física del sf-12. el cesd-7 representó un estímulo contextual y el sf-12 representó el modo fisiológico. materiales y métodos: estudio realizado en méxico, en donde a una muestra no probabilística de 255 participantes voluntarios de 60 a 100 años se le aplicaron las escalas lsita-sf, cesd-7 y sf12. tres expertos evaluaron su validez de contenido. se calculó la consistencia interna mediante el alfa de cronbach, el análisis factorial exploratorio por componentes principales y rotación varimax, el análisis factorial confirmatorio por máxima verosimilitud, y para la validez divergente y convergente se usaron coeficientes de correlación de spearman. resultados: la validación de contenido fue adecuada. el modelo con mejor ajuste fue el de 3 factores correlacionados (x2[41, n = 255] = 77,30, p = 0,001; gfi = 0,96; agfi = 0,935 y rmsea = 0,059 [ic 90% = 0,038-0,079]) al que se eliminó un reactivo. la consistencia interna fue = 0,80. la correlación entre lsita-sf y cesd7 fue de rs = -0,38; el coeficiente de correlación entre lsita-sf y sf-12 fue de rs = 0,32. conclusión: la escala lsita con 11 reactivos muestra confiabilidad y validez incipiente. es recomendable continuar su validación para su uso en países hispanoparlantes. palabras clave estudios de validación, anciano, satisfacción personal, envejecimiento, enfermería. (fuente: decs, bireme). validation of the life satisfaction index for the third age abstract objectives: study the factor structure of life satisfaction index for the third age, short form (lsita-sf), its internal consistency, content validity, and to contrast its divergent validity. this index is proposed as a subjective indicator of successful aging roy adaptation model, self concept mode. it is contrasted to a brief measurement of depression (cesd-7) that served as contextual stimuli in a major study. materials and methods: the lsita-sf scale and the (cesd-7) were applied to a non-probabilistic sample of 255 mexican volunteers para citar este artículo / to reference this article / para citar este artigo kantún marín, m. a., moral de la rubia, j., gómez meza, m. v., salazar gonzález, b. c. (2013). validación del indice de satisfacción con la vida en la tercera edad. aquichan. vol. 13, no. 2, 148-158. 149 validación del índice de satisfacción con la vida en la tercera edad l maría amparo de jesús kantún-marín, josé moral de la rubia y otros. from 60 to 100 years old. the content validity was evaluated by three experts. the internal consistency was calculated by the cronbach’s alpha coefficient, the factor analysis by principal component analysis and varimax rotation, the confirmatory factor analysis by maximum likelihood and the divergent validity by the spearman correlation coefficient. results: the content validity was adequate. a three correlated factors model showed the best fit (x2 [41, n = 255] = 77.30, p = 0,001, gfi = 0,96, agfi = 0,935, and rmsea = 0,059), one item was deleted. internal consistency was ( = 0,80). the correlation between lsita-sf11 and cesd-7 was moderate (rs = -0,38); and between lsita-11 and physical health measured by five items of sf-12 was (rs = 0,32). conclusion: the 11-items lsita scale shows preliminary good properties of reliability and validity in mexican elderly people. we suggest its study for further validation in mexico and other spanish speaking countries. key words validation studies, aged, personal satisfaction, aging, nursing. (source: decs, bireme). validação do índice de satisfação com a vida na terceira idade resumo objetivos: estudar a estrutura fatorial do life satisfaction index for the third age, short form (lsita-sf), sua consistência interna, a validade de conteúdo e de construto, e a validade divergente e convergente. este índice se propõe como um dos indicadores subjetivos do envelhecimento bem-sucedido que, por sua vez, representa o modo de auto-conceito do modelo de adaptação de roy e se contrasta com uma medição breve de sintomatologia depressiva (cesd-7 por suas siglas em inglês) e com a dimensão de saúde física do sf-12. o cesd-7 representou um estímulo contextual e o sf-12 representou o modo fisiológico. materiais e métodos: estudo no méxico, onde a uma amostra não probabilística de 255 participantes voluntários de 60 a 100 anos foram aplicadas as escalas lsita-sf, cesd-7 e sf-12. três especialistas avaliaram sua validade de conteúdo. calculou-se a consistência interna mediante o alfa de cronbach, a análise fatorial exploratório por componentes principais e rotação varimax, a análise fatorial confirmatória por máxima verossimilitude, e para a validade divergente e convergente se usaram coeficientes de correlação de spearman. resultados: a validação de conteúdo foi adequada. o modelo com melhor ajuste foi o de 3 fatores correlacionados (x2[41, n = 255] = 77,30, p = 0,001; gfi = 0,96; agfi = 0,935 e rmsea = 0,059 [ic 90% = 0,038-0,079]) ao que se eliminou um reativo. a consistência interna foi = 0,80. a correlação entre lsita-sf e cesd-7 foi de rs = -0,38; o coeficiente de correlação entre lsita-sf e sf-12 foi de rs = 0,32. conclusão: a escala lsita com 11 reativos mostra confiabilidade e validade incipiente. é recomendável continuar sua validação para seu uso em países hispanofalantes. palavras-chave estudos de validação, idoso, satisfação pessoal, envelhecimento, enfermagem. (fonte: decs, bireme). 150 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 introducción la población de adultos mayores aumenta cada año en todo el mundo. el sistema de estadísticas sanitarias mundiales de la organización mundial de la salud (1) reportó que en el año 2008 las personas mayores de 60 años representaban el 11 % de la población total; en méxico la población de adultos mayores era del 9 % del total de su población. la tasa de crecimiento anual está entre el 2 y el 5 % (2), con un estimado de 13’664.349 de personas de 60 años y mayores para el 2020 (3). el envejecimiento es un proceso individual del ciclo vital que afecta en alguna medida a todos los seres vivos; suele ir aparejado a cambios físicos tanto en la apariencia personal como en el funcionamiento de todos los órganos y sistemas (4). es en esta etapa de la vida en la que se observa disminución de las capacidades físicas e ingresos económicos (5) y se incrementa la pérdida de los seres queridos (6, 7); todas estas condiciones implican problemas de salud y su consecuente manejo. los estudiosos del envejecimiento tratan de responder a la heterogeneidad de esta condición y de entender cómo a pesar de que el envejecimiento es reflejo de la biología de cada quien y de los eventos de la vida, algunos adultos mayores mantienen y consolidan su nivel de independencia frente a retos mayores de la mente, del cuerpo y del espíritu (4). a ello algunos teóricos le llamarían resiliencia (8), gerotrascendencia (9) o envejecimiento exitoso (10). en ese sentido, el envejecimiento exitoso ha sido definido desde diferentes perspectivas; según flood (10) es la percepción favorable del individuo ante la acumulación de cambios fisiológicos y alteraciones funcionales asociadas al paso del tiempo mientras se experimenta conexión espiritual y sentido de propósito y significado de vida y, por tanto, se va adaptando. esta autora propone que el envejecimiento es un proceso de adaptación que va de lo simple a lo complejo. de acuerdo con roy, en la adaptación la persona usa conscientemente su libertad para crear su integración humana y ambiental, afirmación que es congruente con harris (4). a lo largo del ciclo vital se generan expectativas sobre el envejecimiento, y finalmente la persona, al alcanzar la etapa de adulto mayor, hace un balance de sus logros, ganancias y pérdidas, es decir, llega a un juicio sobre su vida, mismo que depende, en gran parte, de las comparaciones que hace entre las circunstancias de su vida y un estándar que considera adecuado (5). cada persona, de acuerdo a su juicio, define si está satisfecha o no. la satisfacción con la vida en la tercera edad puede definirse como un juicio positivo sobre qué tan a gusto se encuentra ante el envejecimiento, lo que de alguna manera refleja su bienestar (6). el autoconcepto para roy se divide en el yo físico y el yo personal, definido como la valoración de las características propias, expectativas, valores y valía (7). la apreciación de las características propias supone un juicio de valor y la satisfacción con la vida también contempla juicio sobre los propios logros en función de expectativas, autoconcepto y valía, razón por la que los autores de este estudio consideraron que el instrumento que mide la satisfacción con la vida en la tercera edad podría reflejar el yo personal del autoconcepto de roy. el logro de la satisfacción con la vida es un componente psicológico que tiene alta relación con la salud y la mortalidad (8). el riesgo de morir prematuramente por cualquier causa o padecer algún problema de salud es mayor en personas insatisfechas. las dificultades para realizar actividades de la vida diaria fuera del hogar que implican esfuerzo físico afectan el sentido que se tiene sobre la satisfacción con la vida. por el contrario, mejores condiciones sociodemográficas, como mayor escolaridad, tener vivienda propia y convivir con otras personas, se relacionan con la satisfacción con la vida (9). el cuidado de las personas mayores plantea retos importantes a los profesionales del área social en general y de la salud en particular. el proceso de envejecimiento no es una enfermedad; sin embargo, es la etapa de la vida en la cual se marcan diferencias en el estado de salud en relación con la población más joven. el hecho de que un factor como la satisfacción tenga influencia significativa en la salud de este grupo de población implica que deben utilizarse instrumentos fiables para medirlo. uno de los instrumentos de reciente utilización en la investigación de la satisfacción de adultos mayores es el life satisfaction index for the third age (lsita) de barrett y murk (10) con 35 reactivos. estos autores recientemente han desarrollado una versión abreviada de 12 reactivos (lsita-sf) (11), con propiedades psicométricas aceptables, con la ventaja de ser más rápida en su administración, lo cual es importante dentro de esta población. los autores aclaran que la escala abreviada a 12 reactivos (lsita-sf) mide el constructo de satisfacción con la vida en forma general —es decir unidimensional—, y su consistencia interna fue alta ( = 0,90); también señalan que se correlacionó con 151 validación del índice de satisfacción con la vida en la tercera edad l maría amparo de jesús kantún-marín, josé moral de la rubia y otros. otras dos escalas de satisfacción así como con la versión original, aunque no proporcionan datos estadísticos (11). la evaluación de la satisfacción de la vida con una escala breve (12 reactivos) y de fácil comprensión es de gran utilidad en enfermería ya que permite acceder de forma práctica y rápida a un aspecto de la subjetividad importante para la adaptación al envejecimiento. si bien la salud y funcionalidad no garantizan una perspectiva positiva de satisfacción con la vida, puntajes bajos pueden asociarse a problemas de salud que se enfrentarían mejor con una actitud positiva (12). para probar las propiedades psicométricas existen diversos métodos entre los que se encuentran el análisis de factores y contrastación con escalas opuestas (validez divergente) así como con escalas de depresión. la presente investigación tuvo como propósito traducir y validar en méxico la escala lsita-sf a fin de que sea utilizada en investigación. antes de aplicarla se recurrió a la validez de contenido por tres expertos. los objetivos fueron: estudiar la estructura factorial, determinar la consistencia interna y probar su validez divergente con depresión así como la validez convergente con la dimensión de salud física del sf-12. los tres instrumentos utilizados en este estudio representan tres de las variables del modelo de roy (7); el instrumento que mide síntomas depresivos evalúa uno de los estímulos contextuales, la dimensión de salud física del sf-12 (creencias de la propia salud y funcionamiento) representa el modo físico, y el de satisfacción con la vida representa el modo de autoconcepto. debe mencionarse que este trabajo se deriva de un estudio mayor sobre envejecimiento exitoso que comprende más variables (2 estímulos focales, 2 contextuales, 3 procesos de afrontamiento y 3 modos adaptativos). se anticipó que el análisis factorial confirmatorio del lsitasf arrojaría una estructura unidimensional, consistencia interna alta, distribución asimétrica negativa (con sesgo hacia valores altos o de satisfacción), equivalencia de medianas entre los sexos, y correlación negativa con depresión y positiva con salud física. materiales y métodos participantes y procedimiento de muestreo el índice de satisfacción con la vida de la tercera edadversión breve (lsita-sf) (11), el índice de síntomas depresivos (cesd-7) (13), y cinco reactivos que corresponden a la salud física del sf-12 fueron aplicados a 130 adultos mayores (censo) que acuden a programas de los sistemas para el desarrollo integral de la familia (dif), y 125 personas reclutadas en la consulta externa de los servicios médicos de la universidad autónoma de nuevo león, en monterrey, méxico (n = 255). los criterios de inclusión fueron: tener 60 o más años y saber leer y escribir. como criterios de exclusión se fijaron: mostrar evidencias de demencia o psicosis y necesitar apoyo o aparatos mecánicos para deambular (ya que se evalúo la actividad física a través de los pasos diarios empleando un podómetro de cintura). la aplicación de los instrumentos fue en forma de entrevista realizada por cuatro asistentes de investigación entrenados, entre enero y marzo de 2012. se solicitó el consentimiento informado a los participantes y se garantizó la confidencialidad de los datos, siguiendo las especificaciones del reglamento de la ley general de salud en materia de investigación para la salud (14). esta investigación fue aprobada por el comité de ética e investigación de la facultad de enfermería y unidad de servicios médicos de la universidad autónoma de nuevo león, y por las autoridades de los centros de desarrollo integral de la familia a donde acuden los adultos mayores. una vez explicados los objetivos y el estudio los participantes que reunían los criterios de inclusión y aceptaban participar firmaron el consentimiento informado. instrumentos la escala lsita-sf de 12 reactivos mide la satisfacción general de la persona con la vida. las opciones de respuestas van de 1 a 6, donde 6 = totalmente en desacuerdo, hasta 1 = totalmente de acuerdo. los valores de los reactivos 2, 4, 5 y 6 se invierten: 1 = totalmente en desacuerdo, a 6 = totalmente de acuerdo. el puntaje posible oscila entre 12 y 72 puntos. mayor puntaje indica mayor satisfacción con la vida. la escala lsita-sf se tradujo del inglés al español por el método de traducción pragmática y estética-poética (15). el texto fue enviado a tres expertos en geronto-geriatría para evaluar su validez de contenido (16). cada reactivo se valoraba mediante una escala likert con una calificación de 5 puntos correspondientes a: 1 = nada relacionado, 2 = no relacionado, 3 = no seguro de su relación, los reactivos requieren más revisión, 4 = relacionado, pero es necesario realizar pequeñas modificaciones, y 5 = totalmente relacionado, no requiere modificaciones. se siguió la propuesta de barraza (17); los reactivos con puntuaciones de 4 a 4,4 reflejan una validez aceptable, los reactivos con puntuaciones de 4,5 a 5 una validez fuerte, y los reactivos por debajo de 4 quedan en duda. 152 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 la escala de síntomas depresivos (cesd-7) (13) consta de 7 reactivos tipo likert con cuatro opciones de respuesta (de 0 a 3). una mayor puntuación refleja mayor presencia e intensidad de síntomas depresivos. la consistencia interna de sus 7 reactivos es alta ( de cronbach de 0,82 a 0,85) en adultos de 18 a 80 años (13). se usó la dimensión de salud física del cuestionario de salud sf-12, reducido por ware, kosinski y séller (18) del cuestionario de salud sf-36 del health institute, new england medical center, de boston massachussets, elaborado por stewart, hays y ware (19). los 12 reactivos explicaron más del 90 % de la varianza (18), contiene dos reactivos de cada una de las siguientes áreas: función física, rol físico, rol emocional, salud mental; y un reactivo de dolor corporal, vitalidad, función social y salud general. los reactivos aplicados corresponden a la función física, rol físico y dolor corporal; se valora si su salud actual le limita para realizar algunas actividades físicas, si ha dejado de llevar a cabo tareas cotidianas y si el dolor le ha limitado para dichas tareas durante las últimas cuatro semanas. el cuestionario ha sido validado en cataluña y aplicado en población mexicana (20); en este último estudio se obtuvo un coeficiente de consistencia interna alfa de cronbach de 0,80. los reactivos 1 y 2 miden la función física, las opciones de respuestas son de 3 puntos que van desde 1 que significa si me limita mucho hasta 3 no me limita; los reactivos 3 y 4 miden el rol físico y las respuestas son dicotómicas: 1 = sí y 2 = no, y el reactivo 5 mide el dolor corporal, con puntuaciones que van de 1 a 5 puntos, donde 1 = nada y 5 = demasiado. las puntuaciones del reactivo 5 se registran inversamente a fin de que los reactivos guarden el mismo sentido. puntuaciones altas significan menor limitación o mejor salud física percibida. enseguida los puntajes se transforman a un índice de 0 a 100 puntos (17). los puntajes de todos los instrumentos aplicados fueron transformados a índices (0-100 puntos). análisis estadísticos para la consistencia interna (alfa de cronbach) se consideraron valores altos aquellos mayores o iguales a 0,70; adecuados entre 0,69 y 0,60, y bajos por debajo de 0,60 (21). el instrumento fue analizado por dos técnicas de reducción de factores: análisis factorial exploratorio y confirmatorio. estas técnicas agrupan en un factor los reactivos que tienen una alta correlación entre sí, mientras que colocan en otro(s) factor(es) a aquellos reactivos que tiene una baja correlación con el primer factor. los reactivos con alta correlación entre sí sugieren que miden el mismo constructo, razón por lo que se consideran formas de validación. el análisis exploratorio procede cuando el investigador no cuenta con teoría o datos en relación con el número de factores de un determinado instrumento. por el contrario, el análisis confirmatorio es pertinente cuando con base en una investigación previa o teoría se anticipa el nombre y número de factores. se empleó análisis de componentes principales como método de extracción de factores del análisis exploratorio. los componentes se extrajeron de la matriz de correlaciones. para el número de componentes se consideró el criterio de kaiser o número de autovalores de la matriz de correlación mayores a 1 (22). los componentes se interpretaron desde la matriz de configuraciones tras realizar una rotación de la matriz factorial por el método varimax (23). para facilitar la lectura de las matrices de configuración se ordenaron los reactivos de acuerdo con el factor donde presentaron la mayor carga y de más a menos peso. el análisis factorial confirmatorio se realizó por máxima verosimilitud. se contemplaron nueve índices de ajuste: tres básicos —función de discrepancia (fd), prueba chi-cuadrado (x2) y cociente entre el estadístico chi-cuadrado y sus grados de libertad (x2/gl)—; dos poblacionales de no centralidad —parámetro de no centralidad poblacional (pncp) y residuo cuadrático medio de aproximación (rmsea) de steiger-lind—; además cuatro índices comparativos —índice de bondad de ajuste (gfi) de jöreskog y sörbom y su modalidad corregida (agfi) y los índices normado (nfi) y comparativo (cfi) de ajuste bentler-bonnet—. se adoptaron los siguientes valores como indicadores de buen ajuste para los índices: p de x2 ≥ 0,05; fd y x2/gl ≤ 2; pncp ≤ 1; rmsea ≤ 0,05; gfi y cfi ≥ 0,95, y agfi y nfi ≥ 0,90; y como valores adecuados: p de x2 ≥ 0,01; fd y x2/gl ≤ 3; pncp ≤ 2; rmsea ≤ 0,08; gfi y cfi ≥ 0,85, y agfi y nfi ≥ 0,80 (24). finalmente, la validez divergente y convergente se calculó por coeficientes de correlación de spearman. los cálculos se hicieron con spss16 (25) y amos16 (26). resultados descripción de la muestra del total de los participantes el 82,70 % (n = 211) fueron mujeres y 17,30 % (n = 44) hombres. la edad varió de 60 a 100 años con una media de 69,27 (de = 6,51). el 48,6 % (n = 124) de los participantes refirieron estar casados, 37,6 % (n = 96) viudos, 153 validación del índice de satisfacción con la vida en la tercera edad l maría amparo de jesús kantún-marín, josé moral de la rubia y otros. 7,5 % (n = 9) solteros, 3,9 % (n = 10) divorciados y 2,4 % (n = 6) separados. en cuanto a ocupación, 10,80 % (n = 27) señaló laborar actualmente, 22,70 % (n = 58) ser jubilado y 66,70 % (n = 170) dedicarse al hogar. el 89,40 % (n = 228) mencionó tomar uno o más medicamentos y 10,60 % (n = 27) ninguno. el 92,90 % (n = 237) indicó tener uno o más problemas de salud y 7,10 % (n = 18) ninguno. validez de contenido y consistencia interna de lsita-sf los 12 reactivos del lsita obtuvieron una media de validez de contenido (opinión de expertos) de 4,29. todos los reactivos obtuvieron calificación aceptable (de 4 a 4,4 puntos) a excepción del reactivo 7 que se refiere a “espero ocurran cosas interesantes y agradables en el futuro” que obtuvo una calificación de 3,5. según barraza (17) este valor no refleja validez aceptable. como se esperaba, la consistencia interna de los 12 reactivos mediante el coeficiente alfa de cronbach fue de 0,79, considerado bueno. al eliminar el reactivo 7 sube a 0,80. estructura dimensional y consistencia interna de los factores un primer análisis de extracción de factores con componentes principales con rotación varimax reveló 4 factores con eigenvalores o raíces características arriba de 1. sin embargo, el cuarto factor contribuyó con 8,57 % de la varianza, considerado bajo, razón por la que se lleva a cabo un segundo análisis sin el reactivo 7 y se forzó a tres factores. los once reactivos cargaron en alguno de los factores por encima de 0,480 (tabla 1). los tres factores explicaron el 59,05 % de la varianza total; el primer factor explicó el 35,49 %, el segundo el 13,61 % y el tercero el 9,94 % aproximándose a 10, razón por la que se decide dejarlo. el primer factor agrupó los reactivos 8, 9, 10, 11 y 12 que por su contenido se interpretó y denominó realización. el segundo factor agrupó los reactivos 1, 2, 3 y 6, de los cuales dos (2, 6) se relacionan con vida triste y aburrida y los otros dos con felicidad; en virtud de los valores de los reactivos negativos se invierten a fin de guardar un sentido positivo, a este factor se le denominó felicidad. finalmente, el tercer factor agrupó los reactivos 4 y 5 y se le denominó monotonía. el análisis confirmatorio con tres factores correlacionados (ic 90 % = 0,038-0,079) contiene al 0,05 anticipado como criterio de buen ajuste para la rmsea. sus valores fueron (x2[41, n = 255] = 77,30, p = 0,001; gfi = 0,96; agfi = 0,935 y rmsea = 0,059) (figura 1). el modelo por máxima verosimilitud mostró al reactivo lsita4 del factor denominado monotonía con valor de 1 por lo que se corrió de nuevo recurriendo al modelo por distribución asintóticamente libre que no requiere del supuesto de distribución normal (27-29) (figura 2). se observa que el coeficiente mejora a 0,71. reactivos f1 f2 f3 9. mi vida como adulto mayor es genial 0,794 10. todo es simplemente extraordinario en esta etapa de mi vida 0,722 8. las cosas que hago actualmente son tan interesantes como siempre 0,705 12. me gusta todo lo que hago en esta etapa de mi vida 0,686 11. cuando miro hacia el pasado me siento bien satisfecho(a) 0,662 6. las cosas que hago ahora son aburridas o monótonas* 0,730 3. me siento tan feliz como cuando era joven 0,708 1. a medida que envejezco las cosas parecen mejor de lo que pensé 0,698 2. ser adulto mayor es la etapa más triste de mi vida* 0,482 5. mi vida podría ser más feliz de lo que es ahora 0,853 4. disfrutaría más mi vida si no fuera tan aburrida 0,781 autovalores 3,90 1,49 1,09 varianza explicada % 35,49 13,61 9,94 varianza acumulada % 35,49 49,10 59,05 tabla 1. ponderación de factores con 11 reactivos método de extracción: análisis de componentes principales método de rotación: varimax con normalización kaiser la rotación convergió en 5 iteraciones * los valores de los reactivos negativos fueron revertidos 154 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 descripción de la distribución de lsita-11 y sus tres factores y diferencias por sexos con los 11 reactivos seleccionados, la media obtenida en la satisfacción con la vida fue de 77,51 (de = 15,73, rango 27,27100), esta media se considera alta. las varianzas y medias de la puntuación total y los tres factores de lsita-11 fueron estadísticamente equivalentes entre mujeres y hombres (tabla 3). validez divergente y convergente al extraer los factores de los 7 reactivos de la escala cesd-7 por componentes principales se definió un único componente por el criterio de kaiser que explicó el 56,98% de la varianza total. los reactivos tuvieron cargas de 0,85 a 0,56. la consistencia interna de los mismos fue alta ( = 0,75). las correlaciones entre la puntuación del lsita-11 (con tres factores) y la de cesd-7 fueron negativas, variando de -0,22 a -0,38 (tabla 4). esto significa que entre más síntomas de depresión es menor la satisfacción con la vida. en torno a validez convergente se observaron correlaciones significativas entre la puntuación de la dimensión física (5 reactivos) del sf-12 y la escala de lsita11 total, así como dos de los factores, el de realización y el de felicidad, mismas que fueron de rs 0,26 a 0,37; el factor monotonía (2 reactivos) solo mostró tendencia (rs = 0,11, p = 0,06). a mejor salud física percibida por el adulto mayor satisfacción con la vida (tabla 4). discusión en la presente muestra de adultos mayores mexicanos un reactivo de la escala lsita-sf presentó problemas de definición factorial, por lo que se optó por su eliminación (reactivo 7). con los 11 reactivos restantes se logró mejorar la consistencia interna a 0,80, considerada buena aunque menor a la observada en el estudio estadounidense de 0,91 (11). un valor de consistencia interna mayor o igual a 0,90 suele ser indicador de unidimensionalidad; por el contrario, las escalas multidimensionales suelen tener valores algo menores y próximos a 0,80 (21). en el caso figura 1. modelo estandarizado con tres factores por máxima verosimilitud figura 2. modelo estimado por distribución asintóticamente libre 155 validación del índice de satisfacción con la vida en la tercera edad l maría amparo de jesús kantún-marín, josé moral de la rubia y otros. escalas no. reactivos x mdn de valor mínimo valor máximo zk-s alpha de cronbach lsita total 11 77,51 80 15,73 27 100 0,096** 0,80 realización 5 85,58 88 16,97 0 100 0,198** 0,79 felicidad 4 78,86 85 20,85 5 100 0,180 0,69 monotonía 2 54,62 60 30,87 0 100 0,143** 0,60 cesd-7 7 29,63 24 20,25 0 95 0,221** 0,75 sf-12 5 76,71 80 25,59 0 100 0,207** 0,80 tabla 2. datos descriptivos, distribución de variables de las escalas y coeficiente alpha de cronbach ** p < 0,001 lsita-11 sexo mujeres hombres (n = 211) (n = 44) m de mdn m de mdn u de mann-whitney valor de p total 77,54 15,83 80 77,35 15,39 80 4605,00 0,934 felicidad 78,97 20,88 85 78,40 20,95 85 4506,50 0,759 realización 85,74 17,38 88 84,81 15,00 88 4231,00 0,344 monotonía 54,21 30,94 50 56,59 30,79 60 4459,50 0,679 tabla 3. diferencia de medianas de la puntuación total y los tres factores de lsita-11 por sexo lsita reactivos cesd-7 valor de p sf-12 valor de p lsita-11 (11) 1-12 -0,38 0,001 0,32 0,001 realización (5) 8-12 -0,28 0,001 0,26 0,001 felicidad (4) 1,2,3,6 -0,38 0,001 0,37 0,001 monotonía (2) 4,5 -0,22 0,001 0,11 0,066 tabla 4. coeficientes de correlación de spearman entre escalas n = 255 del presente estudio la consistencia interna correspondió a una escala multidimensional confirmada por el análisis factorial. los autores de la escala sugieren unidimensionalidad, sin embargo, no lo han validado. el modelo que presentó mejor ajuste es el de tres factores correlacionados. esta propuesta de tres dimensiones correlacionadas, si bien es incipiente y requiere de otras confirmaciones, puede ayudar en enfermería para explorar los matices de felicidad y realización personal, aspectos muy importantes en el envejecimiento. los reactivos que conforman el factor denominado vida realizada se refieren a que si su vida actual es interesante, le gusta lo que hace y está satisfecho(a) ello presupone que mantiene interés en lo que le rodea y en lo que hace, en ese sentido roy defiende la valía y significado en la vida como supuestos filosóficos de la persona. las media obtenida y el sesgo hacia los valores altos en la escala de satisfacción con la vida sugieren que los adultos mayores están satisfechos. se puede afirmar que, tanto hombres como mujeres están satisfechos con sus vidas. esto puede reflejar el estilo de vida mexicano más abocado a la relación familiar frente al mayor individualismo anglosajón; asimismo, la mayor tendencia al humor y al gusto por el baile y las reuniones, lo que probablemente per156 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 mita sacar más gusto y satisfacción a la vida, especialmente en la tercera y cuarta edad del ciclo vital (30). las medias fueron equivalentes entre ambos sexos, lo que concuerda con los estudios del grupo de barrett (10, 11) y otros investigadores (31-33) en los que se emplean escalas. no obstante, existen investigaciones que reportan mayor satisfacción en hombres (34-38) que en mujeres. la correlación fue moderada e inversa con depresión, al ser satisfacción con la vida y depresión conceptos claramente divergentes, lo que proporciona evidencias de validez de constructo a la escala. las tendencias depresivas son mayores en las mujeres que en los hombres, especialmente en la edad fértil (39), lo que puede explicar que la diferencia en satisfacción con la vida nunca se incline hacia el sexo femenino. aparte estarían las explicaciones sociológicas de desigualdad en el poder tanto dentro como fuera del hogar (40). las correlaciones positivas entre la satisfacción con la vida y la dimensión de salud física confirma que aquellos adultos mayores que se perciben más satisfechos también consideran que su salud física está mejor. esto agrega validez al instrumento. como limitaciones del estudio debe señalarse que, al basarse en una muestra no probabilística, los resultados constituyen hipótesis para futuras investigaciones con escalas de autorreporte en adultos mayores que acuden a consulta externa de servicios sanitarios y adultos mayores que acuden a servicios de recreación y ocio, los cuales no tienen impedimentos para caminar ni requieren de apoyo para esta actividad. conclusión se concluye que este cuestionario muestra propiedades psicométricas en términos de confiabilidad y validez adecuada aunque incipiente, lo que permitirá su utilización con cautela en las personas mayores de 60 o más años. se recomienda el uso del modelo de tres factores correlacionados (felicidad, realización y monotonía) con 11 reactivos en méxico y continuar su estudio en otros países hispanoparlantes. referencias 1. organización mundial de la salud. estadísticas sanitarias mundiales; 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[visitado jun. 2012]. disponible en: http://digital.library.unt.edu/ark:/67531/metadc3910/ 40. lópez-sánchez o. cuando las bajas son más altas: la depresión en personas adultas. género y salud en cifras. 2008;6(2):4-16. 67 82 validez y confiabilidad del instrumento.indd 67 erika marcela mateus-galeano1 viviana marycel céspedes-cuevas2 validez y confi abilidad del instrumento “medición de la autoefi cacia percibida en apnea del sueño” semsa. versión en español 1 fundación neumológica colombiana, colombia. emmateusg@unal.edu.co 2 universidad nacional de colombia, colombia. vmcespedesc@unal.edu.co recibido: 07 de julio de 2014 enviado a pares: 21 de agosto de 2014 aceptado por pares: 07 de octubre de 2015 aprobado: 30 de noviembre de 2015 doi: 10.5294/aqui.2016.16.1.8 para citar este artículo / to reference this article / para citar este artigo mateus-galeano em, céspedes-cuevas vm. validez y confiabilidad del instrumento “medición de la autoeficacia percibida en apnea del sueño” semsa. versión en español. aquichan. 2016;16(1):67-82. doi: 10.5294/aqui.2016.16.1.8 resumen objetivo: determinar la validez y la consistencia interna del instrumento “medición de la autoeficacia percibida en apnea del sueño” semsa, versión en español, diseñado por weaver et al. materiales y métodos: estudio de tipo descriptivo metodológico; se determinó la validez facial y de contenido con panel de expertos y un literato bilingüe. la muestra de la validez de constructo y consistencia interna fue de 151 pacientes con síndrome de apnea hipopnea del sueño que usaron el tratamiento de presión positiva continua en la vía aérea (cpap). resultados: la validez facial mostró un índice de aceptabilidad superior en las tres categorías evaluadas. en la validez de contenido, 23 ítems alcanzaron un nivel de aceptabilidad satisfactorio y los 4 ítems restantes fueron susceptibles de modificación. en la validez de constructo, el análisis factorial exploratorio determinó tres factores con una varianza total explicada de 52,2 %. la consistencia interna por el alfa de cronbach fue 0,90 para la escala total y para cada dimensión mayor de 0,84. discusión: la varianza total explicada comparándola con el estudio original fue mayor y el alfa de cronbach fue similar tanto en la escala total como dimensional. conclusión: el instrumento self efficacy measure sleep apnea, válido y homogéneo en el contexto urbano colombiano, es una herramienta relevante y objetiva acerca de las perspectivas del paciente con síndrome de apnea hipopnea del sueño sobre los riesgos asociados, el beneficio del tratamiento y el cumplimiento en el uso de presión positiva (cpap), a pesar de las barreras percibidas. palabras clave síndrome de apnea del sueño; autoeficacia; validez; confiabilidad (fuente: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 67-82 68 aquichan issn 1657-5997 año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 67-82 validity and reliability of the spanish version of the “self-efficacy measure for sleep apnea” (semsa) abstract objective: determine the validity and internal consistency of the spanish version of the "self-efficacy measure for sleep apnea (semsa) designed by weaver et al. materials and methods: this is a descriptive methodological study that determined facial and content validity with a panel of experts and a bilingual scholar. the construct validity and internal consistency sample was comprised of 151 patients with sleep apneahypopnea syndrome who were using continuous positive airway pressure (cpap) as treatment. results: facial validity showed a higher rate of acceptability in all three categories evaluated. as for content validity, 23 items had a satisfactory level of acceptability and the remaining four were subject to change. exploratory factor analysis of construct validity identified three factors with 52.2% total variance explained. internal consistency using cronbach’s alpha test was 0.90 for the total scale and 0.84 for each major dimension. discussion: total variance explained was higher compared to the original study, and cronbach’s alpha was similar in both the total and dimensional scale. conclusion: the self-efficacy measure for sleep apnea valid and homogeneous in the colombian urban context is an important and objective tool to gauge the prospects for patients with sleep apnea-hypopnea syndrome compared to the associated risks, the benefit of the treatment and compliance in the use of positive pressure (cpap), despite the perceived barriers. keywords sleep apnea syndrome; self-efficacy; validity; reliability (source: decs, bireme). 69 validez y confiabilidad del instrumento “medición de la autoeficacia percibida en apnea del sueño” semsa. versión en español l erika marcela mateus-galeano y otro validade e confiabilidade do instrumento “medição da autoeficácia percebida em apneia do sono” — semsa. versão em espanhol resumo objetivo: determinar a validade e a consistência interna do instrumento “medição da autoeficácia percebida em apneia do sono” — semsa, versão em espanhol, desenhado por weaver et al. materiais e métodos: estudo de tipo descritivo metodológico; determinou-se a validade facial e de conteúdo com painel de especialistas e um literato bilíngue. a amostra da validade de construto e consistência interna foi de 151 pacientes com síndrome de apneia-hipopneia do sono que usaram o tratamento de pressão positiva contínua nas vias aéreas (cpap, por sua sigla em inglês). resultados: a validade facial mostrou um índice de aceitabilidade superior nas 13 categorias avaliadas. na validade de conteúdo, 23 itens atingiram um nível de aceitabilidade satisfatório e os quatro itens restantes foram suscetíveis de modificação. na validade de construto, a análise fatorial exploratória determinou três fatores com uma variável total explicada de 52,2 %. a consistência interna pelo alfa de cronbach foi 0,90 para a escala total e para cada dimensão maior de 0,84%. discussão: a variável total explicada comparando-a com o estudo original foi maior e o alfa de cronbach foi similar tanto na escala total quanto na dimensional. conclusão: o instrumento self efficacy measure sleep apnea, válido e homogêneo no contexto urbano colombiano, é uma ferramenta relevante e objetiva sobre as perspectivas do paciente com síndrome de apneia-hipopneia do sono sobre os riscos associados, o benefício do tratamento e o cumprimento no uso do cpap, apesar das barreiras percebidas. palavras-chave síndrome da apneia do sono; autoeficácia; validade; confiabilidade (fonte: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 67-82 70 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 introducción el síndrome de apnea hipopnea del sueño (sahs), al ser un cuadro caracterizado por disminución de oxigenación sanguínea y retención de co2, resultado de la obstrucción de la vía aérea superior durante el sueño, conlleva trastornos a nivel neurológico, cognitivo y cardiorrespiratorio (1-3), aumentando los despertares entresueño, lo que produce un sueño no reparador (4-6). dentro del tratamiento del sahs se encuentra la presión positiva continua de aire en la vía aérea (cpap), que impide el colapso durante el sueño; esta presión se transmite provocando un incremento en el calibre de la vía aérea superior (7). el tratamiento tiene como objetivo resolver los signos y síntomas de la enfermedad, normalizar la calidad de sueño, disminuir el índice de apnea-hipopnea por hora (iah/h), reducir las consecuencias de enfermedades concomitantes y disminuir la desaturación de oxígeno (8). además, se ha evidenciado que contribuye a mejorar la calidad de vida debido al buen desarrollo de las actividades de la vida diaria y, en el área de salud pública, al disminuir los costos directos e indirectos que esta enfermedad genera. a partir de la teoría de la autoeficacia de bandura (9), se ha analizado la forma de entender e influir en el cambio de comportamiento y de varios tipos de conductas, incluyendo factores tales como el conocimiento, las habilidades, las capacidades, las creencias, las actitudes y el apoyo social, con el fin de promover el cumplimiento del tratamiento del sahs, desde el enfoque cognitivo, con la motivación del paciente por seguir una conducta de salud adecuada. la teoría de la autoeficacia, desarrollada inicialmente por la psicología social, ha recibido suficiente soporte empírico por parte de enfermería, buscando la meta disciplinar de ayudar a los sujetos de cuidado a ser independientes en el manejo de su salud, identificando los temores y las experiencias del paciente hacia el reconocimiento de sí mismo como sujeto activo de su cuidado. en la teoría de la autoeficacia, albert bandura (10) plantea el concepto de autoeficacia percibida, en el cual la motivación humana y la conducta están reguladas por el pensamiento, y donde se involucran tres tipos de expectativas: la percepción de la situación y de los riesgos, las expectativas de resultado y la autoeficacia percibida, referida como “la creencia que tiene una persona de poseer las capacidades para desempeñar las acciones necesarias que le permitan obtener los resultados deseados” (11). aplicándolo a los pacientes que usan el cpap, si estos tienen mayor autoeficacia pueden superar y afrontar las barreras que no les permiten cumplir con el tratamiento instaurado, ocupando un papel decisivo al evaluar la capacidad que el paciente tiene de seguir determinadas acciones. este estudio metodológico surge de la necesidad de un instrumento en español para medir la autoeficacia percibida, específicamente en el área de trastornos respiratorios del sueño, proporcionando a la comunidad de enfermería un aporte para la medición en apnea del sueño, en primer lugar, porque esta entidad es aún subdiagnosticada y poco conocida en el país por parte de la disciplina; en segundo lugar, por la relación que existe entre la autoeficacia y la importancia de las capacidades cognitivas de las personas en el mantenimiento, la evaluación y el cumplimiento de los tratamientos instaurados y, en tercer lugar, por las enormes ventajas de disponer de un instrumento válido y confiable que permita medir la autoeficacia percibida en el tratamiento de cpap en pacientes con síndrome de apnea obstructiva del sueño, al robustecer intervenciones que conlleven una mejor calidad de vida y prevención de complicaciones cardiorrespiratorias futuras relacionadas con este síndrome. objetivo determinar la validez y confiabilidad del instrumento “medición de la autoeficacia percibida en apnea del sueño” semsa (perceived self-efficacy measure for sleep apnea), versión en español. materiales y métodos para el desarrollo de la investigación se empleó un diseño metodológico cuantitativo utilizado para generar y evaluar las propiedades psicométricas y la adaptación de un instrumento, garantizando rigurosidad, calidad y éxito en el proceso de investigación (12, 13). las fases con las que se lograron los objetivos específicos propuestos fueron: selección del instrumento, traducción, fase de validez facial, fase de validez de contenido, retrotraducción y adaptación del instrumento, prueba piloto, fase de validez de constructo y prueba de consistencia interna. para cada una de ellas se precisan a continuación los aspectos metodológicos específicos para tener en cuenta, tal como se detalla en la figura 1. 71 validez y confiabilidad del instrumento “medición de la autoeficacia percibida en apnea del sueño” semsa. versión en español l erika marcela mateus-galeano y otro figura 1. fases de validación del instrumento semsa lacionados con los posibles resultados generales derivados del uso del cpap, como la disminución del ronquido, el aumento de la atención y la disminución de la somnolencia diurna. la autoeficacia percibida es la percepción del paciente al contar con los medios para utilizar el cpap de manera efectiva, bajo un amplio rango de circunstancias. se evalúa la voluntad de adoptar el tratamiento de cpap mediante 9 ítems, solicitándole al paciente que clasifique, en una escala de 4 puntos tipo likert (para nada cierto muy cierto), cada uno de los enunciados relacionados con su confianza en el uso del tratamiento a pesar de ciertos desafíos como viajar, la perturbación del sueño del compañero(a) de cama, la congestión nasal y la dificultad con la máscara. el instrumento semsa en su versión original cuenta con validez de contenido, de constructo y fiabilidad test-retest. la significación estadística se fijó en p < 0,05, y el porcentaje de varianza total entre los 30 ítems, explica una solución de 3 factores del 48,6 %. el alfa de cronbach se empleó para reportar la consistencia interna, dando como resultado del instrumento total 0,92, con correlaciones ítem total que oscilan entre 0,26 y 0,66. el alfa de cronbach para cada una de las tres subescalas fue mayor a 0,85, por lo cual los autores, basados en los criterios de nunnally y berstein (14) (α = 0,70), afirman que el semsa mide el mismo constructo y que los ítems están altamente correlacionados. fuente: mateus, erika. estudio de validez y confiabilidad del instrumento semsa. versión en español, 2013. selección del instrumento se seleccionó el semsa (self-efficacy measure for sleep apnea) por ser un instrumento completo que evalúa la autoeficacia percibida de la persona con síndrome de apnea hipopnea del sueño. las bases conceptuales para el desarrollo de este instrumento se sustentaron en la teoría social cognitiva de bandura (11), la cual sostiene la hipótesis de que los pacientes con mejor percepción de autoeficacia, mayores expectativas de resultados para la cpap y mayor nivel de conocimiento, serán más compatibles con el tratamiento de cpap. las respuestas se clasifican en una escala likert de 1 a 4, donde puntuaciones más altas indican mayor autoeficacia percibida, mayor percepción de riesgo y mayores expectativas de resultados con el tratamiento, respectivamente. la percepción del riesgo se mide mediante 8 ítems que evalúan la apreciación del grado de amenaza que la apnea del sueño sin tratar puede tener sobre un resultado negativo. se plantea por los riesgos que se han asociado al síndrome, como la morbilidad cardiovascular, somnolencia diurna, accidentes de tránsito, disminución del desempeño en las actividades realizadas, entre otros. las expectativas de resultado se refieren a la percepción de que el uso del tratamiento de cpap tendrá consecuencias positivas en la vida del paciente. se mide mediante 10 ítems re72 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 proceso de traducción y revisión de las traducciones oficiales se seleccionaron cuatro traductores oficiales a fin de contar con la versión más cercana al instrumento original en cuanto a gramática, contexto y constructo de autoeficacia. dos traductores oficiales realizaron las primeras traducciones del instrumento y, a partir de allí, empezó el proceso de verificación y revisión, en el que participaron seis expertos y un literato, quienes hicieron parte del equipo revisor para elegir la traducción más acorde. este proceso se hizo de manera simultánea con las fases de validez facial y de contenido, y con el equipo de revisión para explorar la redacción, el fraseo (comprensión, pertinencia y precisión) y el contenido de cada uno de los ítems, tanto desde la estructura gramatical como contextual de los pacientes. para establecer la validez facial se aplicaron dos métodos, el primero corresponde a un panel de seis expertos, que evaluaron el instrumento considerando tres criterios de calificación: claridad, precisión y comprensión para los 27 ítems del instrumento. la comprensión es definida como el entendimiento que existe al leer un ítem; la claridad es el tipo de lenguaje empleado y la forma de redacción del mismo; la precisión se refiere a si está expresado en un lenguaje conciso y exacto que evite ambigüedades. además, como recomienda hunt (15), se incluyeron personas legas para comprobar el lenguaje apropiado del instrumento. el segundo método corresponde a la verificación de fraseo, con 35 sujetos que no hicieron parte del estudio principal ni de la prueba piloto, cuya función fue evaluar el instrumento en su totalidad, determinando su comprensión, claridad y redacción. en el proceso de validez de contenido, los expertos evaluaron si las preguntas del instrumento representaban de manera adecuada el universo del contenido, eligiendo los ítems según tres categorías: esencial, útil pero no esencial y no necesario, con el fin de comprobar si cada ítem representa la adecuación a la muestra de contenido que se mide evaluando para cada uno si es esencial, útil pero no esencial o no necesario para la escala total. este proceso se realizó con cuatro expertos en apnea del sueño, autoeficacia y enfermería. a partir de los datos arrojados en la fase de revisión, de validez facial (con expertos y pacientes) y validez de contenido, los ítems se sometieron a revisión por un literato bilingüe, en aras de seleccionar la traducción más pertinente y continuar con el proceso. retrotraducción o traducción inversa la retrotraducción estuvo encaminada a desarrollar el proceso en términos del trabajo de contraste facial y de contenido necesario (16). la versión preliminar se envió a dos traductores oficiales que realizaron la traducción inversa o retrotraducción con el fin de consolidarla en una sola versión, después de la verificación por parte del autor y literato bilingüe para garantizar la adecuación contextual. posteriormente se realizó la prueba piloto, cuya importancia estuvo dada por la determinación del error muestral para el estudio principal en términos de la desviación estándar y la verificación de continuidad de los procedimientos de recolección de información por seguir, tales como búsqueda y contacto con los pacientes, diligenciamiento del instrumento y revisión de la calidad de la información obtenida. se calculó el tiempo de diligenciamiento del instrumento, así como la calidad de la información suministrada, con el fin de evitar pérdida de información. el tamaño de la muestra se obtuvo en función de la fracción de desviación estándar que se aceptó como error de aproximación para el análisis. a partir de un error muestral tipo ii, correspondiente a 0,18 —considerado como aceptable—, se calculó una muestra para la prueba piloto de 81 personas que cumplían con los criterios de inclusión. para la validez de constructo y consistencia interna se utilizó un muestreo intencional con el fin de que la muestra de pacientes seleccionados fuera representativa. el cálculo del tamaño muestral del estudio principal se determinó a partir de la desviación estándar obtenida en la prueba piloto, considerada como error muestral para el estudio principal (17). el error a partir de la desviación estándar del estudio piloto fue de 0,089, tomándose para fines de este estudio un error tipo ii de 0,1, cuyo valor teórico se considera óptimo. a partir de este dato empírico, se calculó una muestra para el estudio principal correspondiente a 151 personas. plan de análisis de datos en la figura 2 se detallan los procedimientos analíticos considerados en la presente investigación. los resultados de la validez facial fueron analizados mediante el índice de kappa de fleiss (18), donde valores cercanos a 1 corresponden a 100 % de acuerdo entre observadores, determinan73 validez y confiabilidad del instrumento “medición de la autoeficacia percibida en apnea del sueño” semsa. versión en español l erika marcela mateus-galeano y otro do como satisfactorios los aspectos de comprensión, precisión y claridad. como mencionan landis y koch (19), tradicionalmente se ha reconocido una fuente importante de error de medida en la variabilidad entre observadores. para efectos de este estudio, se consideraron como satisfactorios aquellos ítems que obtuvieran valores comprendidos entre 0,61 y 0,80, niveles que se reconocen como un acuerdo sustancial aceptable, mientras que los valores iguales o superiores a 0,81 se consideraron con grado de aceptabilidad superior. para validar el contenido del instrumento se tuvo en cuenta también el juicio de expertos. como menciona tristán, citando a lawshe (20), el modelo para dictaminar la validez de contenido consiste en organizar un panel de evaluación de contenido integrado por expertos en el área, que analicen el conjunto de ítems para comprobar si representan de manera adecuada el universo del contenido. el análisis de validez de contenido en la presente investigación se soporta en el modelo de lawshe modificado (21, 22). los cuatro expertos evaluaron las tres categorías con base en la pertinencia y relevancia del instrumento, emitiendo su opinión en tres categorías correspondientes a esencial, útil pero no esencial y no necesario. una vez que los panelistas dieron su opinión respecto a cada ítem en las tres categorías, se determinó el número de coincidencias de “esencial” esperando que se tuvieran acuerdos de más del 50 % entre los jueces, para considerar que el ítem tiene un cierto grado de validez de contenido (22). el mínimo aceptable para la cvr corresponde a 0,5823. al respecto tristán (22) manifiesta que el modelo de lawshe modificado tiene la ventaja de que la cvr’ es constante e independientemente del número de panelistas, resolviendo los desacuerdos existentes con relación al efecto de tamaño y la interpretación de los acuerdos relativos a la validez de contenido. los ítems no aceptables fueron revisados, corregidos y sometidos a un nuevo dictamen del grupo revisor junto con el literato y la investigadora para definir su validez. en la fase de verificación del constructo, se realizó un análisis factorial exploratorio (23, 24). según nunnally (14), el análisis factorial brinda útil evidencia circunstancial de las medidas que pretenden tener una alta validez. este método se desarrolló mediante una fase llamada extracción de factores, que consiste en condensar las variables de la matriz de datos en un número más reducido de factores o dimensiones fundamentales. seguido de esto, se rotaron los factores buscando una estructura más simple e interpretable. antes de iniciar el proceso de factorización, es indispensable realizar la comprobación de las condiciones necesarias para empezar un proceso de análisis de factores, varios figura 2. procedimientos analíticos. validez y confiabilidad del instrumento semsa fuente: mateus, erika. estudio de validez y confiabilidad del instrumento semsa. versión en español, 2013. 74 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 contrastes que pueden hacerse para evaluar si la extracción de estos en su conjunto es significativa (25). se interpreta que cuanto más cerca de 1 tenga el valor obtenido del test kmo, más alta es la relación entre las variables. si kmo ≥ 0,9 significa que el test es muy bueno; notable sería para kmo ≥ 0,8; mediano para kmo ≥ 0,7; bajo para kmo ≥ 0,6 y muy bajo para kmo < 0,5. el análisis factorial exploratorio de los componentes fue realizado con el paquete estadístico spss versión 19, el método de extracción utilizado fue el análisis de componentes principales y el método de rotación varimax con normalización de kaiser. las cargas factoriales aceptables para la investigación estuvieron definidas con un valor mayor a 0,3 que pesara en cada factor. la confiabilidad para este estudio se orientó a medir la consistencia interna, entendida como el grado en que un instrumento mide la correlación de los ítems de una escala (25). se considera que un instrumento tiene congruencia interna cuando todas las dimensiones que lo integran miden una misma característica. para la presente investigación se aceptaron puntos de corte según criterios de valderas et al. (26) quienes para la evaluación de la consistencia interna han propuesto como estándares mínimos apropiados valores de alfa de cronbach comprendidos entre 0,70 y 0,90. para el análisis de datos del estudio se utilizó el paquete estadístico spss versión 19. el presente estudio se enmarcó dentro de las disposiciones vigentes para la protección de los sujetos humanos que participan en investigación contenidas en el capítulo i, artículo 6 numeral g, y artículos 14 y 15, y en capítulo ii, artículo 18 de la resolución 8430 de 1993, del ministerio de salud (27). de igual forma, se tuvo en cuenta la ley 911 de 2004 (28), capítulo iv, artículos 29, 30 y 34, que establece la responsabilidad deontológica en los procesos de investigación en que el profesional de enfermería participa. resultados la versión final del instrumento es el resultado de la revisión por parte de los cuatro traductores oficiales, los seis expertos revisores de las traducciones, los seis expertos revisores de validez facial, los 35 pacientes que evaluaron el fraseo, los cuatro expertos revisores de validez de contenido y el literato bilingüe, quienes afinaron la concordancia de los ítems con la adecuación gramatical, la comprensibilidad y claridad, con el fin de lograr la equivalencia de los términos y la contextualización y adaptación transcultural de la prueba. validez facial en la validez facial respecto al criterio de comprensión se obtuvo un puntaje de 1, siendo perfecto acuerdo. en la categoría de claridad se obtuvo un acuerdo sustancial, específicamente en las preguntas 3b, 4b, 5b que corresponden a la dimensión de expectativas de resultado, en las cuales los expertos refirieron que debería cambiarse el tiempo verbal de los ítems. por ejemplo: “si yo uso cpap mi desempeño laboral mejora”; en este caso, con ayuda del lingüista, se decidió que como la dimensión debe avizorar que en un futuro, usando el tratamiento con cpap, la calidad de vida va a mejorar, el ítem debe redactarse en tiempo futuro, “si yo uso cpap, entonces mi desempeño laboral mejorará”. asimismo, la concordancia entre los expertos se vio afectada ya que refieren que la pregunta 3b no es clara al estar redactada en forma negativa, generando confusiones entre los participantes. en las preguntas relacionadas con la autoeficacia percibida, los expertos manifiestan que el término claustrofobia puede no ser conocido en la población colombiana. de igual forma, los expertos recomiendan que se usen en las frases pronombres para aclarar qué le ocurre al paciente, por ejemplo, utilizaría cpap incluso si se me congestionara la nariz, si me molestara, si le molestara el sueño a mi compañero de cama. en relación con la precisión de la escala, el índice de aceptabilidad mediante kappa de fleiss determinó un valor de 0,95, lo que corresponde a un acuerdo casi perfecto. solo un experto hace la aclaración de que las preguntas 7a y 8a, específicas en la probabilidad de deprimirse o de tener problemas con el desempeño sexual, son poco precisas porque no discriminan el hecho de que los problemas de depresión o de desempeño sexual tengan una causa diferente a la apnea del sueño. lo anterior considerando que no se excluyen las personas que sufren desórdenes diferentes a la apnea del sueño y que pueden generar depresión, refiriendo un experto que estas preguntas no son tan precisas debido a que las situaciones que evalúan pueden ser influenciadas por otras condiciones de salud. lo anterior indicó que era necesario revisar estos ítems desde la parte lingüística y literaria antes de desarrollar la prueba piloto. la validez facial realizada con los pacientes fue desarrollada con personas que no hicieron parte del estudio principal, ni de la prueba piloto, pero que sí cumplían con los criterios de inclusión. 75 validez y confiabilidad del instrumento “medición de la autoeficacia percibida en apnea del sueño” semsa. versión en español l erika marcela mateus-galeano y otro la evaluación del instrumento en su totalidad se realizó con 35 personas quienes evaluaron la comprensión y claridad de los 27 ítems del instrumento. en esta fase se evidenciaron aportes al fraseo, los cuales fueron incorporados. el 66 % de los pacientes escogieron la traducción 1 en la dimensión de percepción del riesgo, manifestando que la palabra adecuada es “posibilidades”, pues se entendía más que “probabilidades”. en las demás dimensiones no hubo términos en conflicto. el 13 % de los pacientes refirió que en la pregunta 2a: “mis posibilidades de quedarme dormido mientras conduzco comparadas con personas de mi misma edad y sexo que no tienen apnea del sueño son”, debería ser menos específica pues no todas las personas conducen automóvil. el 26 % de los pacientes realizaron observaciones a la pregunta 4a: “mis posibilidades de tener concentración difícil, comparadas con personas de mi misma edad y sexo que no tienen apnea del sueño son”, considerando en términos generales que la redacción quedaría mejor, “mis posibilidades de tener dificultades de concentración...”. una sola persona manifiesta que el instrumento no debería contener temas sexuales; sin embargo, como la afectación en el área sexual se describe ampliamente, no se consideró pertinente descartar los ítems relacionados. en esta fase se tuvo en cuenta lo que bandura sugiere en su guía para realizar escalas de autoeficacia (29), donde expresa que los ítems de eficacia deben reflejar con precisión el constructo. y como la autoeficacia hace referencia a la capacidad percibida, los ítems deberían estar redactados en términos de “puedo hacer”, en lugar de “lo haré”. por eso, en el presente instrumento “yo usaría cpap” es un juicio de capacidad, contrario a si estuviera redactado “utilizaría el cpap”, ya que sería una declaración de intención. por lo anterior, se incorpora el ajuste respectivo a la intencionalidad. validez de contenido para la validez de contenido se tuvo en cuenta el juicio de expertos o panel de evaluación; el análisis se soportó a partir del modelo de lawshe modificado (20, 21). en este análisis se encontró que en cuanto a la utilidad de cada ítem del instrumento semsa, de la escala total (27 ítems), 23 ítems alcanzaron un nivel de aceptabilidad satisfactorio. de la primera dimensión, percepción del riesgo, 5 ítems de 8 lograron una puntuación de 1 que equivale al 100 % de concordancia; por su parte, 1 ítem tuvo una puntuación de 0,75, la cual es satisfactoria, y solo 2 tuvieron un índice de aceptabilidad menor a 0,58. los ítems con niveles no aceptables y susceptibles de modificación corresponden a 2a: “mis posibilidades de quedarme dormido mientras conduzco comparadas con personas de mi misma edad y sexo que no tienen apnea del sueño son”, en el cual los evaluadores manifiestan que en el contexto colombiano es poco frecuente que las personas conduzcan automóvil, a diferencia del contexto del instrumento original donde la mayoría de personas manejan vehículos. al igual que los pacientes, manifiestan que no debería ser tan específico al manejo de vehículos sino de máquinas en general. la otra pregunta es la 7a: “mis posibilidades de deprimirme comparadas con personas de mi misma edad y sexo que no tienen apnea del sueño son”, en la cual se expone que la pregunta no es clara por la diversidad en las causas de depresión, lo que puede generar confusiones de contenido. en lo referente a la dimensión expectativas de resultados, se identificó que 2 ítems obtuvieron un índice de aceptabilidad menor a 0,56, es decir debieron ser evaluados nuevamente. las preguntas fueron la 3b: “si yo no uso cpap, estaré menos alerta durante el día”, y la 10b: “si yo uso cpap, mi deseo y desempeño sexual mejorarán”. al respecto, los jueces indican que preguntas como la 3b, al estar redactadas de forma negativa, generan confusiones en los pacientes, lo cual se ve reflejado en la evaluación cualitativa a la prueba de validez facial hecha con los pacientes, quienes afirmaban no comprender las preguntas 3b y 6b, las únicas redactadas en forma negativa. por esta razón, se analizó con el lingüista la posibilidad de cambiar la redacción de los ítems sin afectar el sentido de los mismos. a pesar de que la pregunta 6b tuvo un nivel de concordancia aceptable, se encontraba redactada negativamente, siendo susceptible de modificación. con respecto al ítem 10b, los expertos manifestaron que dentro de la población objeto pueden existir personas que no tengan pareja o una vida sexual activa, por lo que la pregunta no es útil para el instrumento según su juicio. en la dimensión autoeficacia percibida, la cvr de 1 estuvo presente en 4 preguntas del cuestionario siendo esenciales para el instrumento, mientras que las 5 restantes obtuvieron cvr’ de 0,75, siendo satisfactorias. esta dimensión fue la que tuvo mayor aceptabilidad de los jueces, siendo totalmente aceptable y fundamental para el instrumento. 76 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 a partir de los cambios efectuados con los resultados de los dos tipos de validez, se ajustó el instrumento de aplicación. en la tabla 1 se encuentran los principales cambios de redacción efectuados. el ítem 10b, aunque no estaba redactado en forma negativa, ni tuvo problemas en el fraseo, puntuó el ivc bajo; los expertos lo calificaron como útil pero no esencial, dado que para las personas sigue siento tabú hablar directamente del tema sexual. este ítem no cambió, porque si bien es cierto que tenemos población anciana con sahs, también lo es que su incidencia en adultos y adultos jóvenes es alta, así no tengan pareja sexual estable, sí puede haber influencia en su deseo y desempeño sexual. a continuación, para describir y contextualizar la población seleccionada, se presentan las características sociodemográficas de los 151 pacientes que respondieron el instrumento semsa. estos fueron en un 54,30 % de género masculino (n = 82) y el 45,70 % restantes de género femenino (n = 69). el 36,40 % de los participantes son profesionales (n = 50), y el 50,99 % (n = 77) no lo son, y un 12,58 % (n = 18) restante son pensionados. la edad promedio de quienes respondieron fue de 66 años ± 5, con edades comprendidas entre los 40 y 90 años. la severidad del síndrome de apnea hipoapnea del sueño está medida con un iah promedio entre los pacientes de 48,59/h, el mayor iah entre los participantes fue 112/h y el menor 19/h. la presión de cpap promedio entre los participantes fue de 11 cmh20 ± 5, la presión mayor de cpap fue de 19 cmh2o y la menor de 5 cmh20. validez de constructo se utilizó la prueba de adecuación muestral de kaiser-meierolkin (30), la cual relaciona los coeficientes de correlación observados entre las variables. en la presente investigación, el kmo = 0,863 comprueba la adecuación general de la matriz, lo que indica que se puede proseguir con la realización de un análisis de factores. los resultados del análisis factorial y la rotación varimax mostraron que el 52,2 % de la varianza total está contenida en tres factores; conforme a lo descrito por cea, citado por barón díaz, (31) se recomienda un valor de 30 % en las escalas del área social. el resultante en esta verificación estadística se considera como valor adecuado, pues con solo el primer componente se cumple el porcentaje de varianza de 30 %; sin embargo, se puede ver que aunque el segundo y tercer componente no representan cargas factoriales de varianza, se evidencia que el porcentaje de varianza acumulada en el tercer componente es de 52,2 %, por lo que es valioso su aporte al constructo en el proceso de verificación factorial. los ítems que se ajustan mejor, debido a su carga en cada uno de los factores, están descritos en la tabla 2. solo el ítem 10, correspondiente a la dimensión expectativa de resultado, no cumplió con el requisito de carga factorial, lo que puede estar relacionado con el hecho de haberla modificado en términos de validez de contenido al no estar contextualizatabla 1. cambios en la redacción de ítems después de la validez facial y de contenido. fuente: mateus, erika. estudio de validez y confiabilidad del instrumento semsa. versión en español, 2013. número del ítem antes después 2a mis probabilidades de quedarme dormido mientras conduzco comparadas con personas de mi misma edad y sexo que no tienen apnea del sueño son mis probabilidades de quedarme dormido mientras realizo mis actividades cotidianas en comparación con personas de mi misma edad y sexo que no tienen apnea del sueño son 7a mis probabilidades de deprimirme comparadas con personas de mi misma edad y sexo que no tienen apnea del sueño son mis probabilidades de sentirme deprimido en comparación con personas de mi misma edad y sexo que no tienen apnea del sueño son 3b si yo no uso cpap, estaré menos alerta durante el día si yo uso cpap, voy a estar más alerta durante el día 6b si yo no uso cpap, incrementaré mis posibilidades de tener un ataque cardiaco si yo uso cpap, voy a disminuir mis posibilidades de sufrir un ataque cardiaco 77 validez y confiabilidad del instrumento “medición de la autoeficacia percibida en apnea del sueño” semsa. versión en español l erika marcela mateus-galeano y otro tabla 2. agrupación de factores y cargas factoriales. fuente: mateus, erika. elaboración propia a partir de los resultados en spss, estudio de validez y confiabilidad del instrumento semsa. versión en español, 2013. componente 1 2 3 riesgo 1 0,056 0,066 0,688 riesgo 2 0,144 0,026 0,776 riesgo 3 0,020 0,077 0,717 riesgo 4 0,107 -0,033 0,795 riesgo 5 0,082 0,050 0,728 riesgo 6 0,158 ,046 0,738 riesgo 7 0,182 0,191 0,485 riesgo 8 0,318 -0,142 0,441 expectativa 1 0,443 0,166 0,247 expectativa 2 0,133 0,331 0,270 expectativa 3 0,678 0,305 0,204 expectativa 4 0,830 0,251 0,143 expectativa 5 0,805 0,175 0,054 expectativa 6 0,568 0,214 0,217 expectativa 7 0,550 0,152 0,073 expectativa 8 0,784 0,172 0,025 expectativa 9 0,846 0,227 0,051 expectativa 10 0,685 0,128 0,236 autoeficacia 1 0,156 0,671 0,196 autoeficacia 2 0,186 0,649 0,176 autoeficacia 3 0,418 0,572 0,064 autoeficacia 4 0,215 0,748 -0,036 autoeficacia 5 0,153 0,696 -0,029 autoeficacia 6 0,165 0,813 -0,035 autoeficacia 7 0,114 0,748 -0,015 autoeficacia 8 0,130 0,726 0,006 autoeficacia 9 0,220 0,624 0,082 da en este país, pues estaba diseñada para indagar sobre la percepción del paciente relativa al uso de la terapia cpap y su relación con menores riesgos de accidentes de tránsito mientras conduce. esta pregunta fue susceptible de modificación ya que en el contexto colombiano no todas las personas conducen, por lo cual la somnolencia diurna excesiva se valoró al manejar cualquier tipo de maquinaria (máquina plana, utensilios de cocina, entre otros). la verificación de la consistencia interna (32) se realizó con la muestra de 151 sujetos. se encontró una consistencia interna con un coeficiente alfa de cronbach = 0,905, valor estadísticamente significativo si se considera que la escala tiene un buen grado de homogeneidad para la escala en general. en la dimensión percepción del riesgo, la consistencia interna fue de 0,844, para expectativas de resultados de 0,876 y para autoeficacia percibida de 0,888, lo que evidencia óptimo grado de homogeneidad a nivel de la escala total y de cada una de sus dimensiones. discusión obtener un instrumento válido, confiable y adaptado al idioma español y la cultura colombiana de la ciudad de bogotá, se convierte en un punto de partida para medir la autoeficacia percibida en el tratamiento de cpap en pacientes con sahs, fortaleciendo la creación de líneas de intervención e investigación que lleven a una mejor calidad de vida y prevención de comorbilidades cardiorrespiratorias futuras relacionadas con este síndrome. a partir de la comparación de las teorías de enfermería que retoman el concepto de autoeficacia, se contempla el modelo de promoción de la salud de nola j. pender (33), que identifica en el individuo los factores cognitivos que suelen ser modificados por las características situacionales, personales e interpersonales, lo que da como resultado la participación en conductas favorecedoras de salud. por otra parte, la teoría de autoeficacia de bárbara resnick (34, 35) sostiene que las creencias de eficacia influyen en el comportamiento, el nivel de motivación, los patrones de pensamiento y las reacciones emocionales en respuesta a cualquier situación. sostiene además que el cambio de comportamiento puede estar relacionado o no con los resultados esperados, sin especificar la percepción de los pacientes en cuanto al riesgo de no llevar a cabo la conducta deseada. 78 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 en los pacientes con síndrome de apnea hipoapnea del sueño se ve reflejado que sus esperanzas de cumplir con el tratamiento cpap, esperando beneficios para su calidad de vida y para controlar las comorbilidades del síndrome, se convierten en un factor importante en la motivación para el uso adecuado del mismo. esta teoría, al tener influencia por la teoría de albert bandura, busca que las fuentes de información influyan en la autoeficacia, siendo necesario utilizar escalas de medición de la teoría que evalúen el dominio y los aspectos para los cuales se desea aplicar. como mencionan sawyer et al. (36), a medida que la disciplina de enfermería avanza hacia la comprobación de la eficacia de las intervenciones de promoción de la adherencia de cpap, la efectividad de dichas estrategias debe ser examinada en términos de utilidad clínica, de aceptación del paciente, de la relación costobeneficio y de la utilización de los recursos, pues estas habilidades para evaluar las capacidades cognitivas de las personas se han reconocido como un estándar de cuidado en el tratamiento de pacientes con apnea del sueño (37) e influyen en los factores determinantes y en las decisiones del paciente de aceptarlo o no. la autoeficacia percibida es útil en enfermería para modificar las conductas de riesgo. al evaluar la autoeficacia se puede predecir la intención del sujeto de cuidado de adquirir conductas de salud y prevenir conductas de riesgo facilitando la predicción de la intención de desarrollar diversas tareas y las posibilidades de éxito en los tratamientos. debido a la escasez de conocimiento disciplinar en instrumentos de medición, fueron necesarios procesos de adaptación transcultural, afinación semántica, validez facial, de contenido y de constructo, así como el análisis de la consistencia interna del instrumento semsa. en el proceso de validez facial se pudieron determinar aportes importantes en la comprensibilidad y el fraseo por parte de los expertos y los pacientes, siendo relevante el contexto en los ítems por evaluar. en la fase de validez de contenido se comprobó que los ítems fueron representativos, oportunos y pertinentes a través del ivc modificado. en la validez de constructo el instrumento debía demostrar que los ítems representaban los tres componentes principales de la teoría de autoeficacia de albert bandura (9). a partir de una muestra de 151 pacientes con sahs que estuvieran en tratamiento con cpap, se pudieron confirmar los postulados de la teoría, mediante la técnica de análisis factorial exploratorio utilizando el modelo de extracción de factores y de rotación varimax. de esta forma, se puso a prueba el concepto mayor de la teoría, comprobándose empíricamente sus postulados. por otra parte, el instrumento se respaldó en el atributo de objetividad en cada uno de los procesos desarrollados, tal es el caso de la revisión de calidad de las traducciones, la evaluación de fraseo, la verificación del contenido y de la adecuación teórica del instrumento. se mantuvo el rigor al contar con la participación de 4 traductores oficiales, 35 pacientes con criterios de inclusión, 16 expertos en trastornos respiratorios del sueño, autoeficacia y enfermería, y el apoyo constante de un literato bilingüe, quienes con guías objetivas de calificación concreta, analizaron objetivamente cada uno de los ítems del instrumento para a partir de estas revisiones, derivar las modificaciones pertinentes a fin de mejorar la comprensión y contextualización. los resultados del presente proceso de validación fueron similares a los del estudio original, obteniéndose un instrumento válido con congruencia interna que mantiene el constructo y soporte teórico original, autoadministrado, fácil de aplicar y con los atributos necesarios para identificar la autoeficacia percibida en los pacientes con sahs al poder analizar la capacidad de cumplimiento de los propósitos instaurados en la terapia con presión positiva continua en la vía aérea (cpap). comparándolo con el estudio original, versión inglés, la varianza total explicada obtenida fue mayor considerando que los 3 factores obtuvieron el 52,2 % en comparación con el estudio de terry weaver el cual explicó el 48,6 %. de igual forma, la consistencia interna obtenida fue de 0,905, y al compararla con el estudio original versión inglés igual 0,92 resulta equiparable el resultado. en la tabla 3 se describe la comparación de la varianza explicada entre las dimensiones del instrumento semsa original y la versión traducida y adaptada de esta investigación. tabla 3. varianza total explicada del instrumento semsa versión original y versión colombiana fuente: elaboración propia. estudio de validez y confiabilidad del instrumento semsa. versión en español, 2013 y versión original. varianza total explicada versión original versión español. colombia varianza explicada (%) 48,6 52,2 significación estadística p < 0,05 = 0,05 79 validez y confiabilidad del instrumento “medición de la autoeficacia percibida en apnea del sueño” semsa. versión en español l erika marcela mateus-galeano y otro tabla 4. alfa de cronbach de las dimensiones del instrumento semsa versión original y versión colombiana fuente: elaboración propia. estudio de validez y confiabilidad del instrumento semsa. versión en español, 2013 y versión original. factor alfa de cronbach del instrumento. versión original alfa de cronbach del instrumento semsa. versión español. colombia factor 1: percepción del riesgo (8 ítems) 0,85 0,844 factor 2: expectativas del resultado (10 ítems) 0,85 0,8760 factor 3: autoeficacia del tratamiento (9 ítems) 0,89 0,888 en la tabla 4 se describe la comparación del alfa de cronbach entre las dimensiones del instrumento semsa original y las de la versión traducida y adaptada de esta investigación. basados en estos resultados, se puede concluir que la confiabilidad del cuestionario en las diferentes dimensiones se comportó de manera similar a la versión original, lo que significa que a pesar de las variantes de contexto, los ítems no dejaron de correlacionarse, ni de medir el mismo constructo. como señalan cortina (38) y hebson (39), si los ítems de la escala o instrumento miden el mismo constructo deben mostrar altas correlación y homogeneidad, lo que se evalúa con el coeficiente de consistencia interna. cortada de kohan (40) afirma que para que los tests estén al servicio de la investigación es necesario establecer una relación estrecha entre las teorías cognitiva y psicométrica, y considerar la evaluación del estudio como una medición de las destrezas y aptitudes esenciales de los sujetos evaluados. lo anterior responde a la adecuación pragmática en la comprobación de la teoría que menciona fawcett (41). la significancia social de la teoría psicométrica se muestra a partir del uso del conocimiento existente y al llenar un vacío de investigación en el cuidado de enfermería en los trastornos respiratorios del sueño. la significancia teórica se evidencia en la presente investigación a través del reporte de hallazgos que demuestran el método utilizado como aporte a la teoría psicométrica en la práctica de la disciplina de enfermería. a partir del proceso simultáneo de revisión de las traducciones oficiales, la validez facial con los pacientes, la participación de expertos en el fraseo, la validez de contenido y la participación constante del literato-lingüista, se logra una versión del semsa con equivalencia semántica, conceptual y contextual, adaptada a la población urbana colombiana. conclusiones la presente investigación se convierte en el punto de partida para la medición específica de la percepción del riesgo del síndrome de apnea hipopnea del sueño, las expectativas de resultado en el tratamiento con cpap y la percepción de la capacidad para seguir el tratamiento ante un número importante de barreras percibidas. este instrumento es genérico y en futuras aplicaciones en investigación se proporcionará una perspectiva acerca de las opiniones de los pacientes con apnea del sueño. las propiedades psicométricas del instrumento semsa indican que es una medida válida y confiable. la validez facial se obtuvo a través de un puntaje de concordancia entre los expertos que evaluaron la claridad, comprensión y precisión del instrumento. el puntaje que se obtuvo en la validez con los pacientes fue de 0,8, que es un acuerdo casi perfecto, pero la relevancia de la validez con los pacientes radicó en la importancia de las observaciones cualitativas para la adaptación cultural del instrumento, indicando que el fraseo se adecuaría al contexto al que se aplicara la escala. la validez de contenido arrojó resultados satisfactorios; así, mediante el ivc modificado la cvr’ estuvo entre 0,75 y 1 en la mayoría de ítems (23 ítems), los 4 ítems restantes que fueron susceptibles de modificación, se caracterizaron por la redacción en forma negativa, los cuales necesitaban mejora en el contexto colombiano, todo con el fin de demostrar su pertinencia y relevancia. la validez de constructo obtenida con el análisis factorial exploratorio permitió agrupar los ítems en tres factores que explican el 52,2 % de la varianza, con lo que se probó que las dimensiones 80 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 se correlacionaban con el constructo inicial. a partir de los resultados de la validez de constructo se puso a prueba el concepto mayor de la teoría de autoeficacia de albert bandura, comprobándose empíricamente los postulados. el alfa de cronbach obtenido fue 0,90 para la escala total y dimensional por encima de 0,84 en la dimensión percepción del riesgo; el puntaje de la dimensión de expectativas de resultados fue de 0,87 y de la dimensión autoeficacia percibida de 0,888. a partir del proceso simultáneo de revisión de las traducciones oficiales, la validez facial con los pacientes, la participación de expertos en el fraseo, la validez de contenido y la participación constante del literato-lingüista se logra una versión del semsa con equivalencia semántica, conceptual y contextual adaptada a la población urbana colombiana, cumpliendo con los atributos de la medición. de acuerdo con lo anterior, se concluye que la versión colombiana del instrumento “medición de la autoeficacia percibida para la apnea del sueño” semsa, es válida y homogénea para la medición de la autoeficacia en pacientes con sahs que inician el tratamiento con cpap, y quienes podrían estar en riesgo potencial al no adherirse, lo que la hace una herramienta relevante para conseguir medidas objetivas acerca de las perspectivas del paciente sobre los riesgos asociados al sahs, el beneficio del tratamiento con cpap para su calidad de vida y la prevención de comorbilidades. desde el punto de vista teórico-disciplinar, un aporte importante de la presente investigación es el manejo del constructo de autoeficacia percibida con el fin de fortalecer el conocimiento derivado de las teorías en enfermería que manejan esta área del conocimiento. la motivación humana y la conducta se regulan por el pensamiento y están involucradas con las expectativas para obtener los resultados deseados, parte de aquí la importancia de generar instrumentos de medida que sean específicos en esta área del conocimiento disciplinar para facilitar la evaluación objetiva de las percepciones y el grado de optimismo en los cursos de acción a fin de cumplir con las metas establecidas y, en este caso, el tratamiento instaurado, en un área subdiagnosticada como es la apnea del sueño en población adulta. se puede concluir, asimismo, que investigación y práctica juntas constituyen la mejor alianza para el liderazgo y empoderamiento de la disciplina de enfermería en el campo de los trastornos del sueño a nivel institucional, y de impacto para la región y el país. el surgimiento de esta línea investigativa a partir de los avances del conocimiento, consolida los cimientos a fin de que futuros estudios en el área favorezca las alianzas necesarias para el desarrollo de investigación aplicada y traslacional con impacto en la práctica. referencias 1. redline ss, yenokyan g, gottlieb dj, shahar e, o’connor gt, resnick he, punjabi nm, et al. obstructive sleep apnea–hypopnea and incident stroke: the sleep heart health study. am j respir crit care med [internet]. 2010 [citado 2015 oct 07]; 182(2):269–277. disponible en: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2913239/pdf/ajrccm1822269.pdf 2. mokhlesi b, finn la, hagen ew, young t, hla km, van cauter e, peppard pe. obstructive sleep apnea during rem sleep and hypertension. results of the 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resaltar algunos aspectos importantes acerca del origen de la ética del cuidado, para de esta manera poder entender el cuidado de enfermería, a la luz de los valores y principios éticos que emergen de su disciplina. se resaltan aquellas responsabilidades, derechos, valores y principios éticos en la relación paciente-enfermera, durante las diversas etapas del proceso de enfermería, al igual que en todos aquellos momentos de contacto directo al ingreso a un centro asistencial, y a la salida de él. todo lo anterior nos lleva a finalizar nuestra revisión en un análisis que pretende fortalecer los aspectos éticos en la atención de salud y el cuidado de enfermería al individuo. palabras clave ética del cuidado, valores y principios éticos, etapas del proceso de enfermería, cuidado de enfermería, atención en salud, políticas y recursos. abstract this bibliographic review pretends to emphasize some important aspects about the origin of care ethics, to understand nursing care, under the orientation of values and ethic principles originated in its discipline. those responsibilities, rights, values and ethical principles in patient nurse relation are stated, during different steps of the nursing process, as in all direct contact situations at the admittance and discharge from a hospital. the above, takes us to end our review in an analysis which pretends to strength ethic aspects in health and nursing care. key words care ethics, values and ethical principles, steps in nursing process, nursing care, health care, sanitary politics and resources. alejandra alvarado garcía* recibido: 30 de marzo de 2004 aprobado: 5 de mayo de 2004 la ética del cuidado 31 ¿qué significa la ética del cuidado? para definirla es preciso revisar el significado de cuidar. “cuidar es, por tanto, mantener la vida asegurando la satisfacción de un conjunto de necesidades indispensables para la vida, pero que son diversas en su manifestación”1. cuidar es “encargarse de la protección, el bienestar o mantenimiento de algo o de alguien”2. por otra parte, el cuidado ético involucra la interacción y el contacto moral entre dos personas, en el que media una solicitud, en el que hay unión entre las personas, como parte de la relación humana. de lo anterior podemos deducir que la ética del cuidado es la disciplina que se ocupa de las acciones responsables y de las relaciones morales entre las personas, motivadas por una solicitud, y que tienen como fin último lograr el cuidado de sus semejantes o el suyo propio. la ética del cuidado se basa en la comprensión del mundo como una red de relaciones en la que nos sentimos inmersos, y de donde surge un reconocimiento de la responsabilidad hacia los otros. para ella, el compromiso hacia los demás se entiende como una acción en forma de ayuda. una persona tiene el deber de ayudar a los demás; si vemos una necesidad, nos sentimos obligadas a procurar que se resuelva. la ética del cuidado tiene que ver con situaciones reales, tan reales como las necesidades ajenas, el deseo de evitar el daño, la circunstancia de ser responsable de otro, tener que proteger, atender a alguien. la moralidad como compromiso deriva precisamente de la certeza de que el bienestar, e incluso la supervivencia, requieren algo más que autonomía y justicia: el reconocimiento y cumplimiento de derechos y deberes. ¿ cómo se origina y se desarrolla la ética del cuidado? se origina a partir de las investigaciones en psicología para describir el desarrollo moral de las personas. se inicia con los trabajos de jean piaget (1932) y lawrence kohlberg (1981-1984), quienes en sus estudios para describir el proceso y las etapas del desarrollo moral excluyeron inicialmente a las mujeres, y concluyeron que ellas tenían menos desarrollo moral que los hombres . puesto que ellas poseen mayor sensibilidad hacia los otros, son capaces de cambiar las reglas; sus juicios se enfocan más hacia la responsabilidad, y la moralidad se basa en el cuidado del otro. por el contrario, los hombres poseen un juicio autónomo y sus decisiones son claras; son individualistas y su moral se basa en los derechos de los individuos3. en 1982, carol gilligan refuta esa conclusión, a partir de los resultados que obtuvo en tres estudios realizados con mujeres: en el primero exploró la identidad y el desarrollo moral en los primeros años del adulto, el pensamiento acerca de la moral y la toma de decisiones, y en los otros grupos estudió la relación entre la experiencia, el pensamiento y el papel del conflicto en el desarrollo. las conclusiones de gilligan ponen de manifiesto que el desarrollo moral de las mujeres es diferente al de los hombres, pero igualmente valioso. señala que ellas, en vez de aplicar principios éticos abstractos a cuestiones morales, de conformidad con las teorías tradicionales, emplean estrategias diferentes en la toma de decisiones. la mujer entiende los problemas morales en términos de conflicto de responsabilidades. su juicio moral sigue una secuencia, en la cual primero se trata de la sobrevivencia, luego de la benevolencia y por último de la comprensión reflexiva del cuidado para la resolución de conflictos. a partir de la teoría de gilligan, en 1984 la filósofa noddings combinó el reconocimiento de la ética con perspectivas sobre el desarrollo moral de la mujer, y centró sus ideas en el valor de los cuidados y la actitud solícita, que encontramos desde el momento del nacimiento, cuando somos totalmente dependientes del cuidado de los demás. estos estudios marcan el desarrollo de la ética del cuidado. en cuanto a la evolución de la conceptualización del cuidado, se puede observar que se inicia en las apreciaciones de las diferencias entre hombres y mujeres, que se han establecido muy bien prácticamente desde la creación. desde allí ya se observa que la mujer y el hombre piensan y actúan diferente moralmente, se aprecia cómo en las culturas antiguas el hombre es símbolo de poder, de violencia, de fuerza, de muerte, mientras que la mujer simboliza la piedad, el cuidado, la sensibilidad ante el dolor. en lo que a la atención en salud se refiere, en el medioevo y en la modernidad el hombre presta atención al juicio justo, y la visión femenina al cuidado del enfermo. en otras palabras, el papel del médico y su moralidad, encauzados a la función curativa, se opusieron a la tarea del cuidado, propio de las enfermeras, y justificaron esos roles profesionales en la concepción de los géneros masculino y femenino, en los cuales se asignaban a la mujer 1. francoise colliére, marie. promover la vida, mcgraw-hill interamericana, madrid, 1993, p. 8. 2. fry, sara. la ética en la práctica de la enfermería. guía para la toma de decisiones éticas, ginebra, consejo internacional de enfermeras, 1994, p.37. 3. grupo de cuidado. “avances conceptuales del grupo de cuidado”, facultad de enfermería, universidad nacional de colombia, 1997. en: dimensiones del cuidado, p. 77 4. gilligan, carol. la moral y la teoría. psicología del desarrollo femenino, méxico, fondo de cultura económica, 1985, p. 35. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 32 las labores de alimentación, vestido y cuidado. en la posmodernidad, la propuesta de la ética del cuidado ha suscitado un gran interés, y muchos teóricos insisten que en lugar de replantear radicalmente la teoría moral, la teoría ética contemporánea debería tratar de establecer un equilibrio entre los enfoques orientados a los principios y a la ética del cuidado. algunos teóricos de enfermería han incluido el cuidado como un valor central en las dimensiones éticas de la práctica de la profesión. gadow, en 1985, afirma que el valor de los cuidados apoya una ética de enfermería dirigida a proteger y promover la dignidad humana de los pacientes que reciben atención en salud. watson, en 1985, sugiere que los cuidados constituyen el fundamento de la ciencia humana en la enfermería. esta disciplina tiene como eje central el cuidado, entendido este como el gran interés de proteger, promover la vida y la dignidad, y se basa en satisfacer las necesidades del otro, generando así grandes sentimientos de bienestar, tanto para quien recibe los cuidados como para quien los brinda. ¿cuál fue la contribución de piaget, kohlberg y gilligan a la ética del cuidado? realmente, los primeros estudios de piaget sobre el desarrollo moral poco tienen que ver con conceptualizaciones éticas. la preocupación de él se basa más en “el criterio moral en el niño”, se dirige más a comprender el desarrollo de nociones particulares, como la mentira, el manejo y origen de las reglas, el castigo, etc., sin que se exigiera una comprensión clara de los problemas morales. piaget entiende la justicia como el manejo de reglas sociales y el simple acto de transformación de estas por consenso social. estas “capacidades” cognitivas corresponderían con lo que kohlberg presenta como propio de un razonamiento convencional. para la teoría estructural de piaget y kohlberg es irrelevante contemplar las diferencias en el desarrollo debidas a variaciones culturales, sociales, educativas o de género; de igual modo, consideran la justicia como el eje central de la moralidad. kohlberg manifiesta que el desarrollo moral implica un proceso jerárquico de seis etapas, guiado por un sistema racionalista, donde prima la justicia como base fundamental de su teoría, la cual es procedimentalista; es decir, no se puede decir que algo es bueno en general, solo que la decisión se ha tomado, siguiendo o no las normas. el problema no radica en si los resultados son justos, sino en que se cumplan los procedimientos. para la ética de la justicia es necesario partir de las personas como entes separados, independientes, lo cual supone una concepción del individuo como previo a las relaciones sociales, que comprende el mundo como una red de relaciones, en las que se inserta el yo, y surge un reconocimiento de las responsabilidades hacia los demás. gilligan propone la ética del cuidado como la responsabilidad social, desde la que se plantea la búsqueda del bienestar de las personas, de aquellas que habrían de ser afectadas por las decisiones morales, las cuales tienen consecuencias para la vida, para el futuro de las próximas generaciones; hace una propuesta por una segunda voz, “que aboga por las diferencias, por el reconocimiento de historias particulares, por el cuidado y el deseo de bienestar del otro, por la benevolencia como matriz de las relaciones sociales y del juicio ético”. en su teoría, gilligan reclama por esa segunda voz, esa voz que grita más allá de las fronteras de un grupo, o de un género, una voz que clama por un espacio, donde el “otro” deba ser reconocido en su particularidad…4(cuadro 1). no obstante, para la ética del cuidado la responsabilidad hacia los demás se entiende como una acción en forma de ayuda. una persona tiene el deber de ayudar a los demás, de tal modo que no puede plantearse ni la omisión. si vemos una necesidad, nos sentimos obligados a procurar que se resuelva; sin embargo, esto se basa en la comprensión del mundo como una red de relaciones, en la que nos sentimos insertos. así, surge un reconocimiento de la responsabilidad hacia los otros. “cuidar es, por tanto, mantener la vida asegurando la satisfacción de un conjunto de necesidades indispensables para la vida, pero que son diversas en su manifestación”1 la ética del cuidado 33 la enfermera, como cualquier otra persona, es un ser moral que debe estar continuamente en una reflexión ética, la cual le permita revaluar sus compromisos con el cuidado de la vida en cualquiera de las etapas del ciclo vital. como primera medida, el mayor compromiso es el de defender la vida en sí misma, reconociéndole a cada persona su dignidad, su individualidad, intimidad, autonomía, capacidad de autorregularse, entre otros factores, siempre aplicando los principios y valores morales durante la elaboración del proceso de atención que debe brindar. en el cuadro 2 se mencionan algunos de ellos. cuadro 1. diferencias entre la ética del cuidado propuesta por kohlberg y gilligan ¿cuáles son los valores y principios éticos que fundamentan la relación enfermera-paciente-familia en las diferentes etapas del proceso de enfermería? el mayor compromiso de la enfermera es el de defender la vida en sí misma, reconociéndole a cada persona su dignidad... kohlberg 1. entendimiento egocéntrico de la imparcialidad, basado en la necesidad individual (podríamos decir que es no tener en cuenta a los demás). 2. concepto de la justicia anclado en las convenciones propuestas del acuerdo social (basarse en las normas sociales; por ejemplo, en lo que es legal o no). 3. entendimiento de los principios de la justicia: igualdad y reciprocidad (se entiende que puede no coincidir lo justo y lo legal. lo que se hace es aplicar por sí mismo los principios de la justicia). gilligan 1. atención al yo para asegurar la supervivencia (también es mirar solo por sí mismo). 2. entendimiento de la conexión entre el yo y los otros, mediante el concepto de responsabilidad. lo bueno es la atención a los demás (por lo tanto, posponerse a sí misma). 3. la responsabilidad del cuidado incluye a la vez al yo y a los otros. hay que hacer equilibrios entre el poder y el cuidado de sí mismo, por una parte, y el cuidado a los demás, por la otra. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 34 cuadro 2. valores y principios éticos involucrados en las etapas del proceso de atención de enfermería proceso de enfermería valores principios éticos 1. valoración • respeto a la persona y a su • autonomía (consentimiento dignidad humana. informado). • empatía, simpatía, afecto, para • beneficencia. lograr un trato digno y respetuoso. • integralidad. • honestidad, para no crear falsas expectativas. • veracidad. • diálogo, escucha activa. • fidelidad. • responsabilidad. • respeto por la vida humana. • seguridad: propiciar un ambiente • confiabilidad. cómodo, privado, seguro e íntimo. • abogacía • participación activa de la persona, • solicitud: comportamientos la familia y los cuidadores. en el momento oportuno. • privacidad. 2. diagnóstico • objetividad, para escribir los • veracidad, siempre en busca de diagnósticos sin emitir juicios de valor. afirmar la verdad. • claridad, para evitar • integralidad, para involucrar todas interpretaciones erradas. las respuestas humanas. • oportunidad, para evitar la negligencia por demoras injustificadas. • no maleficencia. • amor y afecto, para lograr un trato • beneficencia (estos dos para evitar humano, respetuoso y digno. los riesgos, el daño y asegurar el bienestar). • responsabilidad, clave para • autonomía. delimitar el campo de enfermería y para encauzar el plan de cuidado. • individualidad, porque cada ser humano es único, y como tal • competitividad, para lograr una debe ser respetado y comprendido. adecuada interpretación y prescribir adecuadamente. • confiabilidad. la ética del cuidado 35 proceso de enfermería valores principios éticos 3. planeación del cuidado • participación de la persona y la • beneficencia. familia en la elaboración del compromiso. • autonomía. • objetividad, para medir • cooperación entre todo capacidades y limitaciones. el equipo de salud. • diálogo. • oportunidad, para alcanzar los objetivos. • claridad, para reflejar lo que la persona y su familia expresarán. • continuidad, para brindar apoyo durante todo el proceso de • responsabilidad en el cumplimiento recuperación. de las promesas y compromisos. • tolerancia, para vencer los • independencia, porque debe ser obstáculos con paciencia. una meta por lograr, en la medida de lo posible, por el paciente, • autonomía en la toma de expresada en los planes de cuidado. decisiones, previo consentimiento informado. • fidelidad, expresada en la continuidad y el apoyo incondicional. • integralidad, vista holísticamente. 4. ejecución • responsabilidad. • cooperación. • objetividad. • integralidad. • seguridad. • continuidad. • calidez. • beneficencia. • privacidad. • no maleficencia. • amor y afecto. • justicia. • individualidad. • veracidad. • dialogismo. 5. evaluación • autorregulación. • responsabilidad. • compromiso. • continuidad. • responsabilidad, para asumir fallas • veracidad. por parte del paciente y el equipo de salud. • autonomía. • honestidad en el proceso y en la • beneficencia. comunicación de resultados. • libertad, para que el paciente y la familia expresen sus juicios y opiniones. • individualidad en el momento de evaluar los logros del paciente y de la enfermera. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 36 como se observa en el cuadro 2, se identifican algunos de los principios éticos y valores morales que predominan durante el proceso de atención de enfermería para cualquier paciente: en primera instancia, lidera la autonomía como derecho mismo del individuo de determinar sus propias acciones, de acuerdo con los planes que ha escogido, respetando sus convicciones y, por ende, sus decisiones. todo lo anterior antes del consentimiento informado. de igual manera, prevalece el principio de beneficencia, que significa evitar el daño y promover el bienestar de la persona. con la reflexión anterior no se quiere demeritar ninguno de los principios éticos, tan solo realizar un breve análisis de los que más sobresalieron para la autora durante la descripción del proceso de atención de enfermería. otro aspecto que se debe resaltar es la capacidad de autorregulación de cualquier individuo, puesto que esto lo hace ser único, irrepetible y capaz de escoger su propio bienestar. en el cuadro 3 se esquematizan algunos valores y principios éticos, los derechos y responsabilidades que se deben tener en cuenta durante los diferentes momentos de la atención en salud de la persona, desde su admisión en un centro asistencial hasta la salida de él. cuadro 3. valores y principios éticos, derechos y responsabilidades en los diferentes momentos de atención en salud momentos de atención en salud valores y principios éticos, derechos y responsabilidades ingreso valores: respeto, equidad, obligatoriedad, bienestar, amor, afecto, eficiencia. principios: veracidad, dialogismo, individualidad, beneficencia. derechos: atención, información, buen trato, accesibilidad. responsabilidades: seguridad, organización, cooperación. central de citas valores: honestidad, equidad, igualdad, buen trato, respeto, intimidad, amor, efectividad. principios: justicia, calidad, autonomía, integralidad, confiabilidad, veracidad, solidaridad, continuidad. derechos: atención oportuna, no discriminación, igualdad, gratitud, libre escogencia. responsabilidades: oportunidad, seguridad, protección, intimidad, protección de los derechos. entrevista de enfermería valores: igualdad, buen trato, competitividad, responsabilidad, participación, afecto, empatía, eficiencia. principios: integralidad, individualidad, veracidad, calidad, autonomía, privacidad, fidelidad, continuidad. derechos: oportunidad, información, consentimiento informado, libertad de expresión, participación, comunicación. la ética del cuidado 37 ¿cómo podríamos los profesionales de enfermería fortalecer los aspectos éticos en la atención de salud y en el cuidado? la profesión de enfermería, desde su origen, ha tenido la misión de velar por la calidad de las relaciones entre enfermera-paciente-familia y el personal de salud. desde este punto de vista, el profesional de enfermería tiene la obligación de capacitarse, para adquirir los conocimientos y habilidades que le permitan discutir o apoyar procesos relacionados con la práctica ética de las profesiones de salud. por lo tanto, la responsabilidad de la enfermera, en el desarrollo de los aspectos éticos en la atención en salud, va más allá del nivel individual, trasciende al ámbito interdisciplinario y busca siempre el bienestar del paciente, aboga por los derechos de las personas a quienes cuida, para asegurar que sus necesidades sean atendidas en forma eficiente y humanizada. por todo lo anterior, la autora está convencida de que los programas de formación en enfermería deben momentos de atención en salud valores y principios éticos, derechos y responsabilidades entrevista de enfermería responsabilidades: atención integral, oportuna, de calidad y humanizada; educación en salud; acogida al paciente, información, seguridad, protección, comodidad. atención médica valores: respeto, comprensión, equidad, responsabilidad, competitividad, participación, amor, eficiencia, bienestar. principios: autonomía, beneficencia, veracidad, fidelidad, confiabilidad, individualidad, integralidad, solidaridad, privacidad, justicia, calidad, dialogismo, continuidad. derechos: atención humanizada, oportuna y de calidad, información, consentimiento informado, libertad de expresión, respeto al silencio y a la comunicación, igualdad, abogacía. responsabilidades: información, educación, garantía de calidad, prevención de riesgos, seguridad, comodidad. egreso valores: veracidad, honestidad, respeto, eficiencia, bienestar. principios: solidaridad, beneficencia, autonomía, justicia, continuidad. derechos: veeduría, continuidad de la atención, libre escogencia, información, suministro de medicamentos y otros recursos. responsabilidades: satisfacción del usuario, información, continuidad, canalización para la continuidad del tratamiento. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 38 5. bankowski, z. foro mundial de la salud. la ética y los valores humanos en las políticas sanitarias, vol. 17, 1996, p. 153. enseñar, como herramienta fundamental de su currículo, la asignatura de ética y bioética, en la cual se brinden conceptos que permitan al profesional sentirse seguro, competente, con argumentos que sustenten las decisiones frente a los dilemas éticos y la toma de decisiones a los que se enfrenta cotidianamente. de igual modo, conviene promover el diálogo interdisciplinario con los pacientes y los demás grupos de profesionales, con base en los valores y principios éticos. durante la enseñanza se deben abrir espacios que permitan integrar la ética y la bioética en la práctica, de manera que el alumno adquiera habilidad en el razonamiento ético, a la vez que desarrolle sus habilidades de razonamiento clínico y experticia práctica. con ello, el profesional de enfermería estará en condiciones de participar activamente en los diferentes comités: de ética en enfermería, de ética hospitalaria, bioéticos clínicos asistenciales y de investigación, para aprender a considerar la dimensión ética del cuidado. también se requiere que el profesional de enfermería, en su cotidianeidad, siempre ponga en práctica sus principios éticos, junto con sus valores, actuando con ejemplo, impartiendo educación a quienes lo rodean, divulgando el análisis de la ética en las organizaciones donde labora, entre sus colegas y superiores, involucrando todos estos aspectos en la elaboración de planes de cuidado. ¿qué valores, derechos y principios éticos se deben atender en las políticas y en la organización del sistema de salud, en la discusión y en la utilización de los recursos disponibles? después de analizar los conceptos y argumentos de los principios éticos y los valores, la conclusión a la que se puede llegar es que estos constituyen la fuerza moral indispensable para garantizar una atención de calidad en salud y basada en el cuidado. en todos los procesos relacionados con la salud deben estar concebidos e implícitos los principios éticos, porque en todos ellos el objetivo es la salud y el bienestar del ser humano. los valores, por su parte, nos dan el soporte suficiente para que en la convivencia con nuestros semejantes y con la naturaleza podamos alcanzar la felicidad. los derechos son el camino para conseguir el bienestar, la solución a las necesidades básicas y fundamentales del ser humano, en la sociedad y en el mundo que habita. “la política sanitaria de una nación, de una comunidad o de una institución es su estrategia para controlar y optimizar la utilización social de sus conocimientos y recursos médicos”5. en las políticas de salud se deben tener en cuenta las creencias y compromisos de un determinado pueblo, pues de no ser así, no se basan en la realidad, ni en las necesidades de una nación; por lo tanto, esas políticas no tienen fundamento real y no son acordes con las necesidades de las personas. contar no solamente con la participación del sector salud, sino de otras disciplinas, las cuales ayudan a explicar mejor esas creencias y valores del pueblo, que son reales y hacen parte de la medicina tradicional. para atender la situación de salud en nuestro país, es importante tener en cuenta los principios éticos que rigen actualmente, en la ley 100 de 1993: • eficiencia: es la mejor utilización de los recursos administrativos, técnicos y financieros disponibles. • universalidad: garantía para que todas las personas tengan acceso a la salud. • solidaridad: práctica mutua de ayuda entre el sector. • integralidad: la cobertura de todas las contingencias que afectan la salud, condiciones de vida de toda la población. • unidad: articulación entre las políticas e instituciones para alcanzar los fines. • participación: intervención de la comunidad, a través de los beneficiarios de la seguridad social. la ética del cuidado 39 estos principios éticos, que rigen en el servicio público de seguridad social, son planteamientos positivos de la ley 100, frente a la cobertura total de los servicios y ante la comunidad colombiana. también está el régimen subsidiado, como herramienta fundamental para garantizar el servicio a todos aquellos individuos que no tienen acceso a un servicio de salud, por sus condiciones de pobreza absoluta. sin embargo, estas normas en la práctica no siempre se llevan a cabo, pues las malas administraciones y las burocracias han hecho que no tengan el impacto adecuado. además, los recursos en salud han disminuido o no son suficientes para atender las demandas. el derecho al que deben apuntar las políticas de salud y el sistema sanitario es el de salud para todos, pues toda persona tiene derecho a la protección de la vida y a la salud6. esto se pretendía con la ley 100, pero las metas no se cumplieron para el 2000. hay una carencia absoluta para este logro, puesto que la infraestructura del país no estaba preparada para estas nuevas políticas, que se perfilaban como las mejores para sacar al país de la crisis sanitaria por la que estaba atravesando. así, la salud se convirtió en un negocio, y el estado no asume su responsabilidad, sino que la transfiere al sector privado. estos aspectos no son favorables para la población, en cuanto a la atención y cuidado que debería recibir, pues por la forma como se está actuando se observa que no se da espacio para los principios de equidad, justicia, beneficencia, solidaridad y servicios con calidad humana. una enfermera que se compromete con la atención indaga y busca soluciones a corto plazo, teniendo como base la ética del cuidado, a fin de establecer el puente de conciliación entre las políticas actuales y el servicio que presta, para hacer de este un servicio digno para la comunidad sujeta al cuidado. distribución y utilización de recursos: valores: veracidad, pertinencia, responsabilidad, equidad, solidaridad, respeto, conciliación, sensibilidad, cultura. derechos: veeduría, participación, gratitud, no discriminación, oportunidad, suficiencia. principios: justicia, universalidad, beneficencia, no maleficencia, calidad, autonomía, integralidad, confiabilidad. políticas de salud: valores: equidad, solidaridad, conciliación, sensibilidad, cultura, comprensión, competitividad, continuidad. derechos: participación, información y educación en ética y valores, no discriminación. principios: dialogicidad, integralidad, justicia, universalidad, veracidad, beneficencia, no maleficencia, confiabilidad. organización del sistema de salud: valores: honestidad, responsabilidad, sensibilidad, cultura, competitividad, solidaridad, continuidad. derechos: oportunidad, calidad, suficiencia, cobertura, gratitud, accesibilidad, eficacia y eficiencia, oportunidad. principios: beneficencia, no maleficencia, integralidad, justicia, confiabilidad, autonomía. bibliografía 1. bankowski, zbioniew. “ética y salud”, salud mundial, abril, 1989, pp. 2-5. 2. fry, sara. la ética en la práctica de la enfermería, capítulos 2, 3 y 4, ginebra, suiza, cie, 1995. 3. garzón, nelly. “la ética del cuidado de enfermería”, dimensiones del cuidado, bogotá, colombia, universidad nacional de colombia, facultad de enfermería, unibiblos, 1998, pp. 76-82. 4. gracia, diego. bioética clínica, capítulos 1 y 2, santafé de bogotá, editorial el búho ltda., 1998. 5. grupo de cuidado, facultad de enfermería, universidad nacional de colombia. dimensiones del cuidado, santafé de bogotá, unibiblos, 1998. 6. martin, jean. ética y servicios de salud: el debate continúa, foro mundial de la salud, vol. 17, 1996, pp. 432-441. 7. tealdi, juan carlos. fundamentos de una ética del cuidado (material no publicado), escuela latinoamericana de bioética, gonnet, argentina, 1992. 6. lemos, carlos. constitución política de colombia, 1991, 18a. ed., bogotá, panamericana, p. 68. 261 269 enfermagem no pre natal.indd 261 neusa brittes feliciano1 vania marta pradebon2 suzinara soares de lima3 enfermagem no pré-natal de baixo risco na estratégia saúde da família 1. enfermeira. especializanda em saúde coletiva: ênfase na saúde da família uri/campus santiago-rs, brasil. neusabfeliciano@yahoo.com.br 2. enfermeira. mestre em enfermagem. docente, universidade regional integrada do alto uruguai e das missões-uri/campus santiago, brasil. vmprade@yahoo.com.br 3. doctora en enfermería. profesora adjunta, universidade federal de santa maria, santa maria, brasil. suzibslima@yahoo.com.br recibido: 16 de enero de 2013 enviado a pares: 22 de enero de 2013 aceptado por pares: 8 de mayo de 2013 aprobado: 10 de mayo de 2013 año 13 vol. 13 nº 2 chía, colombia agosto 2013  261-269 para citar este artículo / to reference this article / para citar este artigo brittes feliciano, n., pradebon, vania m., soares de lima, s. (2013). enfermagem no pré-natal de baixo risco na estratégia saúde da família. aquichan. vol. 13, no. 2, 261-269. resumo objetivo: descrever a experiência das mulheres grávidas no atendimento pré-natal e de baixo risco na consulta de enfermagem, residentes na área de cobertura da estratégia de saúde da família, em uma cidade do rio grande do sul (brasil), por meio da interação e do fortalecimento do vínculo das mulheres gestantes com o serviço. método: pesquisa qualitativa, na qual se desenvolveram atividades como: visitas domiciliárias às mulheres grávidas, educação em saúde sobre o período gestacional, cuidado com o recém-nascido e organização de um grupo de gestantes. resultados: neste experimento, demonstra-se que a inclusão de um serviço de saúde em uma comunidade realiza-se somente mediante a formação de vínculos, nos quais a união com as pessoas não fortalece unicamente a autonomia dos beneficiários, mas também toda a equipe de saúde. conclusão: as vivências com a equipe e com a população ampliaram a visão sobre a importância do enfermeiro, no que se refere à gerência dos serviços de saúde e à promoção de ações educativas e de cuidado da saúde das mulheres no ciclo gravídico puerperal. palavras-chaves enfermagem, cuidado pré-natal, saúde da família, gravidez, brasil. (fonte: decs, bireme). 262 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 enfermería en el periodo prenatal de bajo riesgo en la estrategia salud de la familia resumen objetivo: describir la experiencia de las mujeres embarazadas en la atención prenatal y de bajo riesgo, en la consulta de enfermería, residentes en el área de cobertura de la estrategia de salud de la familia, en una ciudad de rio grande do sul, brasil, por medio de la interacción y el fortalecimiento del vínculo de las mujeres gestantes con el servicio. método: investigación cualitativa, en la que se desarrollaron actividades como: visitas domiciliarias a las mujeres embarazadas, educación en salud sobre el periodo gestacional, cuidado con el recién nacido y organización de un grupo de embarazadas. resultados: en este experimento se demuestra que la inclusión de un servicio de salud en una comunidad se realiza solo mediante la formación de enlaces, en donde la unión con la gente consiguientemente no fortalece únicamente la autonomía de los beneficiarios, sino también a todo el equipo de salud. conclusión: las vivencias con el equipo y con la población ampliaron la visión acerca de la importancia del enfermero, en lo referente a la gerencia de los servicios de salud y a la promoción de acciones educativas y de cuidado a la salud de las mujeres en el ciclo gravídico puerperal. palabras clave enfermería, atención prenatal, salud de la familia, embarazo, brasil. (fuente: decs, bireme). nursing during the low-risk prenatal period as part of a family health strategy abstract objective: the purpose of the study is to describe the experience of pregnant women residing in a city of rio grande do sul (brazil) who received low-risk prenatal care as part of a nursing initiative to deploy a family health strategy based on interaction and strengthening the bond between pregnant women and the service. method: it is a qualitative initiative designed to develop activities involving home visits to pregnant women, health education on the gestational period, newborn care, and the organization of a pregnant women’s group. results: this experiment demonstrates that including a health service in a community is accomplished only by forming bonds in which the connection with people strengthens not only the autonomy of the beneficiaries, but also the entire health team. conclusion: the experiences with the team and the population expanded the view on the importance of nurses in managing health care services and in promoting educational and health-care actions for women in the pregnancy-puerperium cycle. key words nursing, prenatal care, family health, pregnancy, brazil. (fonte: decs, bireme). 263 enfermagem no pré-natal de baixo risco na estratégia saúde da família l neusa brittes feliciano, vania marta pradebon, suzinara soares de lima introdução no campo da saúde, tem-se dado ênfase à saúde da família para aprimorar cada vez mais a prevenção de agravos, a manutenção e a promoção da saúde. com relação à saúde da mulher, novas políticas, programas, estratégias e ações têm sido utilizadas para facilitar a obtenção de resultados positivos atinentes ao cuidado e à manutenção da sua saúde integral. nesse enfoque, no brasil, a saúde da mulher foi incorporada às políticas nacionais de saúde nas primeiras décadas do século xx, limitada, naquele período, somente às demandas relativas à gravidez e ao parto (1). no que tange ao processo de gestação, ele é considerado um período normal do ciclo vital feminino. porém, impõe à mulher modificações no seu organismo, como: aumento das suas necessidades nutricionais; alterações físicas, metabólicas, emocionais, as quais têm repercussões sobre o crescimento, desenvolvimento e o nascimento do feto, bem como na saúde mental da futura mãe (2). o programa de humanização ao parto e nascimento (phpn), no brasil, instituiu um elenco mínimo de ações que devem ser concretizadas, nos serviços de saúde no que se refere ao ciclo gravídico-puerperal, tais como: “seis consultas de pré-natal e a consulta de puerpério” (3, p. 32). a humanização e a qualidade da atenção em saúde são condições essenciais para que estas ações se traduzam na resolução dos problemas identificados neste período, na satisfação das usuárias, no fortalecimento da capacidade das mulheres identificarem suas demandas, no reconhecimento e reivindicação de seus direitos e na promoção do autocuidado. neste contexto, o enfermeiro ganha centralidade na política nacional de atenção básica (4)2 ao ter definidas como competências suas várias ações, dentre elas: realizar assistência integral que inclui ações de promoção e proteção da saúde, prevenção de agravos, diagnóstico, tratamento, reabilitação e manutenção da saúde de indivíduos e famílias na unidade de saúde da família (usf)3, em todas as fases do desenvolvimento humano; realizar 2 a atenção básica caracteriza-se por um conjunto de ações de saúde, no âmbito individual e coletivo, que abrangem a promoção e a proteção da saúde, a prevenção de agravos, o diagnóstico, o tratamento, a reabilitação e a manutenção da saúde. é desenvolvida por meio do exercício de práticas gerenciais e sanitárias democráticas e participativas, sob a forma de trabalho em equipe, dirigidas a populações de territórios bem delimitados, pelas quais assume a responsabilidade sanitária, considerando a dinamicidade existente no território em que vivem essas populações. [...]. orienta-se pelos princípios da universalidade, da acessibilidade e da coordenação do cuidado, do vínculo e continuidade, da integralidade, da responsabilização, da humanização, da equidade e da participação social (4, p. 3). 3 em 1994, a equipe de saúde mínima de uma usf, no brasil, era constituída por: um médico, consulta de enfermagem; planejar, gerenciar, coordenar e avaliar as ações desenvolvidas pelos agentes comunitários de saúde (acs); gerenciar serviços de saúde, coordenar programas governamentais nas diferentes esferas (federal, estadual, municipal), dentre outras. a consulta de enfermagem, no pré-natal de baixo risco, visa minimizar dúvidas e anseios para que a mulher tenha uma gestação saudável, pois além das informações técnicas, almeja-se o vínculo entre o enfermeiro do programa saúde da família (psf)4 e a usuária, bem como seu grupo familiar. o objetivo deste é relatar o acompanhamento ao pré-natal de baixo risco e a consulta de enfermagem, em uma unidade saúde da família brasileira localizada na região centro-oeste do rio grande do sul, visando um processo gravídico saudável. a estratégia saúde da família e a atenção à saúde da mulher o psf foi instituído, em 1994 no brasil, com o objetivo de mudar o antigo sistema de atenção existente à saúde familiar (5), e tem como principal objetivo contribuir para a reorientação do modelo assistencial. o processo de implantação das esfs é visto como uma forma de agregar aliados na reorganização da atenção básica, ao se reconhecer a necessidade de modificação das práticas de saúde, assim como a renovação dos vínculos de compromisso e de corresponsabilização entre esses serviços e a população (6). o acolhimento e o vínculo são modos de operar os processos de trabalho em saúde de forma a atender a todos que procuram os serviços de saúde. ouvir solicitações e assumir uma postura capaz de acolher, escutar e pactuar respostas mais adequadas aos usuários (7) e que estejam dentro das possibilidades do serviço de resolver ou realizar os encaminhamentos pertinentes, fazem parte deste processo. nesse contexto, o pré-natal de baixo risco representa uma nova dinâmica de atuação, na atenção básica, pois milhares de um enfermeiro, dois técnicos de enfermagem e por cinco ou seis agentes comunitários de saúde, para uma população de até 4.000 pessoas. posteriormente, o dentista e o auxiliar de consultório dentário (acd) passaram a integrar a equipe básica da usf. 4 neste trabalho, apesar das distinções conceituais existentes, foram usados, indistintamente, os termos programa saúde da família (psf), unidade de saúde da família (usf) e estratégia saúde da família (esf), com prevalência do primeiro. tal escolha decorre da dificuldade das pessoas da comunidade local em substituir a sigla psf em favor da esf. 264 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 mulheres morrem a cada ano no mundo, segundo a organização mundial da saúde (oms), devido a causas relacionadas com gravidez, parto, aborto e baixa qualidade dos serviços de saúde, visto que todas as mulheres grávidas correm riscos de sofrer complicações imprevisíveis, que requerem o cuidado de profissionais de saúde (8). com base no exposto, a captação (9) das gestantes deve ser precoce, ou seja, a primeira consulta de pré-natal precisa ser realizada até os 120 dias iniciais da gestação; que a mulher realize, no mínimo, seis consultas de pré-natal, as quais podem ser médicas ou de enfermagem; que ocorram, no serviço de referência, ações educativas com a gestante e seus familiares; estímulo ao parto normal e que sejam solicitados exames laboratoriais, no transcurso da sua gestação. também é importante a atenção à mulher e ao recém-nascido, na primeira semana após o parto, com realização das ações preconizadas na “primeira semana saúde integral”, pela agenda de compromisso para a redução da mortalidade infantil do ministério da saúde (10), e da “consulta puerperal, até o 42º dia pós-parto” (9, p. 11). nessa lógica, a visita domiciliária à mulher grávida é um instrumento de intervenção – utilizado pelos integrantes das equipes de saúde, para conhecer as condições de vida e saúde das famílias sob sua responsabilidade (11) – fundamental à esf, pois identifica suas características sociais e epidemiológicas, seus problemas de saúde e suscetibilidade aos agravos de saúde, o que permite o reconhecimento dos recursos que a família dispõe. outra estratégia de grande importância e resolutividade, nessa linha de ação, é a consulta de enfermagem à mulher-gestante, porque oportuniza tratar o indivíduo num contexto geral e, assim, é possível analisar seus aspectos físicos, psíquicos e sociais (12). ainda, a consulta de enfermagem é uma ocasião para o diálogo, quando enfermeiro e gestante podem definir metas e objetivos a serem atingidos, dentre eles, ações educativas à mulher que está em processo gravídico, bem como o acompanhamento do desenvolvimento da gravidez (13). na anamnese da mulher-grávida, abordam-se aspectos epidemiológicos, além dos antecedentes familiares, pessoais, ginecológicos, obstétricos e a situação da gravidez atual, escuta atenta e resolutiva das dúvidas e ansiedades da mulher (9). método o município da esf do relato localiza-se na região centro-oeste do rio grande do sul, brasil, com cerca de 49 mil habitantes e tem, como base econômica, a pecuária. no campo da saúde, em 2008, havia seis unidades de esf, sendo a última inaugurada em fevereiro de 2007, a qual se subdivide em seis microáreas e abrange um total de 1.236 famílias e 3.689 pessoas. nesta nova esf, desenvolveu-se este relato de experiência, no período de outubro a novembro de 2007 e de fevereiro a maio de 2008. destaca-se que os princípios éticos e legais foram respeitados conforme a resolução do conselho nacional de saúde/brasil – 196/1996(14), ou seja, as mulheres-gestantes, residentes na área de abrangência da esf participavam das atividades de educação em saúde e/ou de cuidado mediante sua aquiescência e assinatura do termo de consentimento livre e esclarecido. destarte, a proposta para o trabalho foi viabilizada em quatro momentos: 1º – na reunião da equipe de saúde foi exposto o objetivo da prática, bem como definido o modo de abordar e/ou de captar as mulheres na fase inicial da gestação, como preconiza o phpn; 2º – visitas domiciliares, junto com o acs de cada microárea, onde existiam mulheres com gestação confirmada, ou com suspeita de gravidez; divulgação do acompanhamento ao pré-natal de baixo risco que estava iniciando nesta esf5; 3º – distribuição de convites, nos domicílios, às mulheres-grávidas, com o fim de participarem de uma reunião, a qual objetivava a aproximação dessas mulheres com a esf; 4º – efetivação da consulta de enfermagem para o acompanhamento de pré-natal de baixo risco, nesta esf. foi realizada a confecção de um instrumento (apêndice a) que atendesse as necessidades do serviço e para sistematizar a consulta de enfermagem, com os registros do histórico, anamnese e planejamento das ações educativas e ou de cuidado às mulheresgestantes. cabe mencionar, também, que ocorreram consultas de enfermagem no domicílio para aquelas que não aceitaram comparecer à unidade de saúde; essas consultas visavam ao acompanhamento de enfermagem ao pré-natal de baixo risco a todas as mulheres-gestantes da esf. 5 nas outras cinco esfs do município, o acompanhamento ao pré-natal de baixo risco já estava consolidado, faltando, portanto, efetivar esse serviço nesta esf –que havia sido inaugurada em fevereiro de 2007– porque as mulheres-grávidas, residentes no bairro, continuavam buscando atendimento distante do seu domicílio, apesar de tê-lo disponível próximo dele, o que contrariava a lógica da esf. 265 enfermagem no pré-natal de baixo risco na estratégia saúde da família l neusa brittes feliciano, vania marta pradebon, suzinara soares de lima a aproximação das mulheresgrávidas à esf foram realizadas 30 visitas domiciliares durante toda prática assistencial, encontrando-se resistência por parte de várias mulheres-grávidas em procurar a unidade. nessas visitas, observou-se a falta de vínculo e de credibilidade nas ações de saúde propostas pela equipe de saúde desta esf à mulher-grávida. fato que causava estranheza à equipe, uma vez que no município existiam consulta médica, de enfermagem e outras ações direcionadas a esse segmento social, no centro materno-infantil e nas demais esfs. assim, conseguiu-se reunir três mulheres-gestantes, quase no final do segundo semestre de 2007, em dois encontros denominados “grupo de gestantes”, que foram realizados quinzenalmente, em um clube, próximo à unidade, pela manhã, com duração de uma hora. na oportunidade, foi combinada a realização de outros encontros nesse mesmo local. ressalta-se que, nesse período, a média era de dez mulheres-gestantes cadastradas, nas seis microáreas desta esf. embora a esf priorize ações de promoção e recuperação da saúde do indivíduo e de sua família, na perspectiva de efetivar uma nova dinâmica de trabalho, prestando assistência integral e qualificada à população (15), ficou evidente o quão difícil é a conquista do público para esse processo de trabalho. no entanto, insistia-se na formação do grupo de gestantes, pois é neste ambiente dinâmico que a promoção da saúde integral-individualcoletiva das gestantes pode ser realizada pelas interações e compartilhamento entre sujeitos com vivências/experiências comuns. participar do grupo permite que a mulher-gestante seja multiplicadora de conhecimentos (16), e isso se torna uma estratégia importante à promoção da gestação saudável e, por consequência, do parto e puerpério. no primeiro semestre de 2008, foram realizados mais cinco encontros com as gestantes e deu-se continuidade à proposta do semestre anterior. contudo, o primeiro encontro de 2008 teve adesão de somente duas mulheres-grávidas, que se mostraram bastante interessadas e ativas, como evidencia a fala: “com o médico, se a gente não pergunta, ele não diz nada. aqui a gente fica sabendo um monte de coisas novas...” (g2). pode-se observar que as gestantes ficam mais à vontade com os enfermeiros. e, no final do encontro, agendou-se a consulta de enfermagem para as duas participantes com essa metodologia de ação em todos os encontros seguintes. no segundo encontro, compareceram quatro gestantes e foi discutida a questão da “amamentação”, quando se abordou a maneira correta de o recém-nascido ser colocado no seio da mãe e os benefícios para ela e o bebê com a prática do aleitamento materno exclusivo. sobre isso, houve manifestações, como: “eu quero dar mamar pro meu filho. com meu outro filho, não sabia que podia preparar meu seio antes de ele nascer...” (g3). e, assim, paulatinamente, o quantitativo de mulheres-grávidas aumentava a cada encontro, mas ainda persistia a insegurança (da equipe) de que o interesse pelo grupo de gestantes e pela consulta de enfermagem, por parte das mulheres, fosse mais uma vez temporário. por isso, as mulheres-gestantes que não compareciam ao encontro anterior, eram revisitadas e ratificado o convite verbalmente, ou enviado convite impresso distribuído pelos acss. no quinto e último encontro, compareceram oito gestantes e abordou-se o tema: “cuidados com o recém-nascido”; quando houve declarações: “nunca cuidei de nenhuma criança... tenho medo de não saber como fazer ou fazer algo errado...” (g6). observa-se a necessidade de abordar estas temáticas, no intuito de facilitar e tranquilizar a mãe no cuidado ao seu filho. nos grupos há também a troca de experiências, o que faz com que as mães tenham mais segurança quanto às condutas ao recém-nascido. quanto à efetivação/implantação das consultas de enfermagem, nesta esf, elas foram agendadas quando se realizava o grupo de gestantes, ao término dos encontros. depois da realização das primeiras consultas de enfermagem, houve amento da demanda e do interesse em retornar à consulta, surpreendendo a equipe, pois as próprias mulheres-gestantes solicitavam agendamento para outras consultas. então, realizou-se cerca de dez consultas, entre os meses de abril e maio de 2008, ou seja, uma consulta mensal para cada mulher-grávida. com os grupos de gestantes, houve a aproximação das gestantes com a esf, o que possibilitou que houvesse o vínculo destas com a unidade de saúde, o que permitiu que o papel do enfermeiro de educador fosse colocado em prática, uma vez que 266 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 os encontros tiveram como objetivo de orientar as ações das gestantes neste ciclo. é fundamental a adoção de uma assistência de pré-natal de qualidade, pois estreita os laços de confiança com a equipe e, consequentemente, a acessibilidade aos serviços de saúde prestados à gestante, o que é fundamental à consecução das ações de saúde para este grupo. considerações finais no desenvolvimento desta prática, vivenciaram-se diretamente as dificuldades/limitações, como também as possibilidades desse modelo de assistência à saúde, preconizado pelo ministério da saúde do brasil, que repercute no processo de trabalho da equipe de saúde, especialmente, no do enfermeiro que atua na esf. também se observou que o processo de criação de vínculo entre o usuário e a equipe de saúde da esf constrói-se com a articulação de compromissos assumidos durante as intervenções dos profissionais de saúde, que podem ser educativas, cuidativas, informativas, terapêuticas, dentre outras. nesta experiência, parece estar/ficar demonstrado que a inserção de um serviço de saúde, em uma comunidade, concretizase somente quando há formação de vínculo, responsabilização, aproximação das pessoas com consequente valorização de sua autonomia, acolhimento, não só pelo recepcionista da unidade, mas também de toda equipe de saúde. prova disso é a grande resistência oferecida pelas mulheres-grávidas, devido à baixa credibilidade das gestantes nesse trabalho e falta de vínculo, quando a equipe da esf ofertou o acompanhamento ao pré-natal de baixo risco. no entanto, todos os esforços devem ser despendidos para garantir a plena participação da mulher-gestante nas atividades desenvolvidas pela unidade de saúde (17). assim, para alcançar os aspectos pontuados, às vezes, é necessário utilizar outras estratégias além da visita domiciliária, a qual é um importante instrumento no processo de trabalho da saúde coletiva, especialmente na modalidade da esf, como a formação de grupos de sujeitos com interesses comuns, realização de consulta de enfermagem na unidade ou no domicílio da mulher. assim, nesta esf, as ações dirigidas para o acompanhamento ao pré-natal de baixo risco a mulheres-grávidas, com a formação de grupo e consulta de enfermagem concretizaram-se somente após seis meses de incansáveis tentativas, de reinícios e, por este motivo, foi um trabalho árduo e desgastante, porém extremamente gratificante o que comprova que é possível ser-saberfazer enfermagem de um modo diverso do tradicional, ou seja, centrado nas necessidades dos usuários e não nas das equipes de saúde. ratifica-se a importância da atenção qualificada durante o pré-natal e a relevância da consulta de enfermagem para a concretização dessas ações, mas, especialmente, desvelando o valor do processo de formação de vínculo, neste caso, das mulheres-grávidas com a unidade esf. referências bibliográficas 1. brasil. ministério da saúde. política nacional de atenção integral à saúde da mulher: princípios e diretrizes. brasília: ministério da saúde; 2007. 2. melson ka, jaffe ms, amlung s. enfermagem materno-infantil: planos de cuidados. rio de janeiro: reichmann e affonso; 2002. 3. brasil. ministério da saúde. programa de humanização do parto: humanização no pré-natal e nascimento. brasília: ministério da saúde; 2002. 4. brasil. ministério da saúde. portaria n. 648: aprova a política nacional de atenção básica, de 28 de março de 2006. brasília: ministério da saúde; 2006a. 5. figueiredo nma de. ensinando a cuidar em saúde pública. são caetano do sul: yendis; 2005. 6. gaíva mam, silva amn. o processo de implantação do programa saúde da família no estado de mato grosso, brasil: perspectiva de atores sociais da gestão estadual. cogitare enferm 2008 out-dez; 13 (4): 576-84. 7. gomes mcpa, pinheiro r. acolhimento e vínculo: práticas de integralidade na gestão do cuidado em saúde em grandes centros urbanos. comunic, saúde, educ 2005 mar; 9 (17): 287-301. 267 enfermagem no pré-natal de baixo risco na estratégia saúde da família l neusa brittes feliciano, vania marta pradebon, suzinara soares de lima 8. costa ema, carbone mh. saúde da família: uma abordagem interdisciplinar. rio de janeiro: rubio; 2004. 9. brasil. ministério da saúde. pré-natal e puerpério: atenção qualificada e humanizada. brasília: ministério da saúde; 2006b. 10. brasil. ministério da saúde. agenda de compromissos para a saúde integral da criança e redução da mortalidade infantil. secretaria de atenção à saúde. departamento de ações programáticas estratégicas. brasília: ministério da saúde; 2004. 11. takahashi rf, oliveira mac. a visita domiciliar no contexto do psf. instituto para o desenvolvimento de saúde. universidade de são paulo: ministério da saúde; 2001. 12. martinelli m, camargo sb, pulga j, fraporti l, moretto efs, tagliari m. consulta de enfermagem no programa de saúde da família, na visão do enfermeiro. rev téc-cient enferm 2004; 2 (11): 209-16. 13. silva mg da. a consulta de enfermagem no contexto da comunicação interpessoal: a percepção do cliente. rev. latinoam. enfermagem 1998; 6 (1): 27-31. 14. brasil. ministério da saúde. resolução n. 196/1996: pesquisa em seres humanos. brasília: ministério da saúde; 1996. 15. mattei da. o enfermeiro na equipe de saúde da família. rev téc-cient enferm 2005; 3 (11): 308-17. 16. delfino mrr, patrício zm, martins as, silvério mr. o processo de cuidar participante com um grupo de gestantes: repercussões na saúde integral individual-coletiva. ciência e saúde coletiva 2004; 9 (4):1.057-66. 17. brasil. ministério da saúde. parto, aborto e puerpério: assistência humanizada à mulher. brasília: ministério da saúde; 2001. 268 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 anexo 1 apêndice a – instrumento para registro consulta de enfermagem à gestante identificação institucional: _______________________________________________________________________________ nome: ______________________________________________________________________________________________ data de nascimento: ______/______/_________ idade: ___________________________________________ estado civil: _____________________________ ocupação: ________________________________________ endereço: ___________________________________________________________________________________________ bairro: _____________________________________________________________________________________________ n. phpn: ____________________________________________________________________________________________ dum: ______/______/_________ aspectos de saúde gesta: _______________ para: _______________ n. de pn: _______________ n. de pc: _______________ idade e sexo dos filhos: _________________________________________________________________________________ grupo sanguíneo: ____________________________ fator rh: _________________________________________ amamentação: ( ) não ( ) sim quanto tempo? _____________________________________ peso dos filhos ao nascer: _______________________________________________________________________________ fez pré-natal? ( ) sim ( ) não ( ) nesta gestação ( ) nas anteriores ( ) em algumas ( ) n. de consultas: ( ) de 1 a 3 ( ) de 4 a 6 ( ) mais de 6 a gravidez foi planejada? ( ) sim ( ) não utilizava métodos contraceptivos antes da gestação? ( ) sim ( ) não pratica exercícios físicos? é fumante? exames gestacionais realizados ht / hb vdrl equ glicemia jejum toxoplasmose anti-hiv 1ª dose data: ____/____/_____ vacina antitetânica 2ª dose data: ____/____/_____ 3ª dose data: ____/____/_____ reforço data: ____/____/_____ 269 enfermagem no pré-natal de baixo risco na estratégia saúde da família l neusa brittes feliciano, vania marta pradebon, suzinara soares de lima acompanhamento de pré-natal data ig peso pa au bcf sinais e sintomas / ig (por trimestre) 1º 2º 3º náusea vômito pirose vertigem obstipação intestinal hemorroidas leucorreia aumento de secreção vaginal polaciúria disúria dificuldade para respirar mastalgia lombalgia cefaleia varizes edema sangramento gengival observações/orientações/intervenções: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ elaborado por: neusa brittes feliciano, acadêmica do ix semestre do curso de graduação em enfermagem uri – campus santiago, sob a orientação da profª. vania marta pradebon e supervisão de paula a. de bitencourt, enfermeira esf são vicente/itu – 2008. 01 08 primeras paginas.indd 6 aquichan issn 1657-5997 año 15 vol. 15 nº 1 chía, colombia marzo 2015 editorial la investigación en enfermería y la colaboración interprofesional nursing research and interprofessional collaboration $�shvtxlvd�hp�hqihupdjhp�h�d�froderudomr�lqwhusur¿vvlrqdo doi: 10.5294/aqui.2015.15.1.1 la colaboración interprofesional para satisfacer las necesidades del paciente fue un elemento identificado hace más de un siglo y, a pesar de ser considerada como un componente esencial de la asistencia sanitaria de alta calidad, la falta de comunicación y de trabajo en equipo sigue siendo una barrera para ofrecer los servicios con calidad y seguridad (1). el informe del institute of medicine (2003) titulado “errar es humano: la construcción de un sistema de atención de salud más seguro”, postula que mejorar la colaboración interprofesional es fundamental, dada la complejidad de las necesidades de salud de los pacientes y la gama de profesionales del área dentro y entre organizaciones (2). en este sentido, si bien sigue siendo vigente el legado de florence nightingale, quien en el siglo xix afirmaba que el rol de enfermería era asistir a la persona en el proceso de reparación natural, es importante considerar que el avance de la ciencia y la tecnología han hecho que el cuidado sea más complejo y ya no baste solo con asistir a la persona, sino que además es necesario implementar nuevas formas de apoyo y de cuidado. en el pasado, el lugar para brindar cuidados fue trasladado a las instituciones, con la creación del hospital, la clínica u otros sitios diseñados concretamente para proporcionar servicios de salud, por proveedores específicos, a determinadas personas, con condiciones o inquietudes puntuales. en la actualidad, los 1 profesora asociada, escuela de enfermería, universidad industrial de santander, bucaramanga (colombia). beatriz@uis.edu.co beatriz villamizar-carvajal1 grandes cambios en la tecnología y la información, las expectativas del consumidor, la demografía, la economía de la salud y la acción política están revolucionando la forma en que se proporciona el cuidado. estos cambios están dando un vuelco a las nociones convencionales sobre el sitio de atención y han abierto nuevas oportunidades y desafíos para la investigación en enfermería; es así como la increíble expansión de equipos móviles celulares puede ayudar en la creación de lugares de cuidado, que se extienden desde los sitios tradicionales, hasta el lugar donde se vive, donde quiera que se encuentre. de la misma forma, la interconexión tecnológica inteligente, que genera a los proveedores de cuidado de la salud (3) apoyo terapéutico en las unidades de cuidados crónicos, en los hogares y en el campo, está cambiando rápidamente la forma en que se realizan las evaluaciones y las decisiones de tratamiento (4, 5). el aumento de las oportunidades de financiación requiere nuevos conocimientos para entender el funcionamiento en los diversos lugares de cuidados, buscando dar respuesta a quién, dónde y cuándo se prestan los mismos. de ahí que se deba mirar la investigación como una estrategia que le permita a enfermería identificar nuevas formas de cuidado y ampliar el cuerpo del conocimiento de la profesión. este editorial tiene por objetivo presentar una mirada sobre la práctica de la investigación en enfermería actual y repensar el 7 enfoque de la producción científica de la disciplina, considerando que el cuidado de la persona está en continua evolución, y que las oportunidades de desempeño profesional abarcan diferentes ámbitos —clínico, comunitario, académico y gubernamental— a nivel nacional e internacional. dentro de esos ámbitos se podría pensar que la investigación que tiene más impacto en la persona y en la sociedad es la que indaga los aspectos relacionados con las enfermedades emergentes, la seguridad en la atención y, en general, las intervenciones de enfermería que mejoran la recuperación y el bienestar del ser humano. desde este supuesto, se pueden establecer unos desafíos de investigación para la profesión. a pesar de que las publicaciones de enfermería han ido en aumento en américa latina, la visibilidad en comparación con la producción global no es muy fuerte aún (6), por diversos motivos: debilidades en la formación, carencia de recursos, escasos grupos de enfermeras dedicadas a la investigación y entornos poco facilitadores en las instituciones prestadoras de servicios de salud (7). es posible que a la falta de disponibilidad de tiempo para la formación, se sumen otros problemas como la falta de apoyo de las instituciones (8). otro aspecto muy importante por considerar, es que la fuerza de trabajo en enfermería está canalizada hacia la asistencia hospitalaria, dejando poco lugar para la formación investigativa y la aplicación de la evidencia científica en la misma. aunado a esto, se observa que los sistemas de salud no son suficientes para cubrir los servicios que requiere la población, lo que resulta en una desigualdad internacionalmente reconocida (9). estos y muchos otros factores pueden limitar el recurso humano para el desarrollo investigativo. entonces, para superar dichos obstáculos, es importante seguir formándose en investigación y apostándole a los programas de posgrado disciplinares o multidisciplinares, como un camino posible y necesario en la carrera del investigador, en las diferentes líneas de estudio. es preciso, además, conseguir recursos vinculándose a grupos o centros de investigación de universidades, fundaciones y de instituciones nacionales e internacionales que estén dispuestas a apoyar las diferentes iniciativas de investigación. vale la pena indagar por las ofertas que se dan en las instituciones para realizar intercambios, pasantías y becas de posgrado. por último, se debe buscar trabajar en proyectos multicéntricos, para intercambiar ideas, medir respuestas humanas en diversas culturas, y publicar y difundir los resultados a fin de contribuir al cuerpo del conocimiento de la profesión y de la ciencia. si no se publica, el resto de profesionales no se podrán beneficiar para llegar al mismo plano de las demás ciencias. otra alternativa para superar el reto es formar equipos de trabajo en la práctica de investigación. el equipo hace que fluyan las ideas, es la fuerza que moviliza y pone a funcionar un proyecto. el trabajo en equipo promueve el intercambio de saberes, habilidades y crecimiento personal y profesional. para seguir repensando la investigación en enfermería y vislumbrar su horizonte, se debe mirar hacia dónde vamos, tomando conciencia del punto de partida. frenk et al. muestran el ambiente de desigualdad en el acceso al avance científico y tecnológico dentro del marco de cambios transicionales bruscos, con un desequilibrio entre las competencias laborales y la falta de liderazgo de los sistemas de salud (10). este punto de partida conlleva analizar el momento que vive la práctica de enfermería en general y, por supuesto, la investigación, dentro de ese ambiente de transiciones. los retos para el desarrollo de la investigación se ven abocados al contexto global, por lo cual se debe buscar promoverla e intercambiarla para que se dé un giro a la situación actual. por otra parte, indagar las situaciones de posibles cambios es urgente, y hacerlo en común unión con pares de la misma disciplina y otras organizaciones, tanto académicas como de la sociedad en general, es una buena solución. se deben buscar las oportunidades que requieren nuevos aprendizajes a fin de aclarar el camino. la investigación bien elaborada permite proponer las estructuras para la toma de decisiones, no solo clínicas, sino también estratégicas y políticas. desarrollar propuestas, argumentos para el campo clínico, estratégico y político es el camino indicado para la investigación en enfermería; y cuando esas propuestas y fundamentos estén ausentes, habrá que seguir en la búsqueda. los cambios se dan con el esfuerzo y la voluntad colectiva de construir un mundo mejor. para concluir, este editorial convoca a fortalecer la perspectiva de una enfermería empoderada en su saber científico, presente en los ámbitos de decisión más importantes y centrada en el bienestar humano. 8 aquichan issn 1657-5997 año 15 vol. 15 nº 1 chía, colombia marzo 2015 los temas incluyen, pero no se limitan, al uso de dispositivos y tecnologías de la información en el punto de atención, problemas de seguridad del paciente, diseño y evaluación de entornos “inteligentes” en el continuum salud-enfermedad, y la investigación sobre el aprendizaje de los sistemas de salud. los hallazgos de la investigación de la comunicación y la toma de decisiones en entornos de atención de punto de apoyo tecnológico emergente serán bienvenidos. es importante fortalecer el yo profesional para apuntarle al abordaje de los obstáculos como retos y no como dificultades, con el objetivo de seguir generando el cambio, sostenido por la fuerza científica del talento humano. esta fuerza facilitará el ser investigador y activará los líderes que están esperando oportunidades para aportar y crecer al ritmo de otros y ser parte de la recreación del conocimiento. referencias 1. gardner sf, chamberlin gd, heestand de, stowe cd. interdisciplinary didactic instruction at academic health centers in the united states: attitudes and barriers. advances in health science education: theory and practice. 2002;7:179-190. 2. the institute of medicine. to err is human. 2003. disponible en: http://www.iom.edu 3. van heerden a, tomlinson m, swartz l. point of care in your pocket: a research agenda for the field of m-health. bulletin of the world health organization. 2012;90:393-394. doi: 10.2471/ blt.11.099788. 4. bier ff, schumacher s. integration in bioanalysis: technologies for point-of-care testing. advances in biochemical engineering-biotechnology. 2013;133:1-14. doi: 10.1007/10_2012_164. 5. walia k. point of care investigations in pediatric care to improve health care in rural areas. indian journal of pediatrics. 2013;80:576-584. doi: 10.1007/s12098-013-1016-9. 6. mendoza-parra s, paravic-klijn t, munoz-munoz am, barriga oa, jimenez-contreras e. visibility of latin american nursing research (1959-2005). journal of nursing scholarship. 2009;41(1):54-63. 7. harrison l, hernández ar, cianelli r, rivera ms, urrutia m. perspectives of latin american nursing professors and leaders about research competencies needed by nurses with different levels of academic preparation. international journal of nursing education scholarship. 2005;2. 8. dowling da, savrin c, graham gc. writing for publication: perspectives of graduate nursing students and doctorally prepared faculty. the journal of nursing education. 2013;52(7):371-5. 9. reveiz l, chapman e, flórez ce, torres r. prioridades de investigación en políticas y sistemas de salud centradas en los recursos humanos en salud. revista panamericana de salud pública. 2013;34(5):295-303. 10. frenk j, chen l, bhutta za, cohen j, crisp n, evans t, et al. health professionals for a new century: transforming education to strengthen health systems in an interdependent world. lancet. 2010;376(9756):1923-58. 403 412 processo de trabalho em reabilitacao.indd 403 soraia dornelles schoeller1 luana maria bento2 jorge lorenzetti3 ana carolina klein4 denise pires5 processo de trabalho em reabilitação: a perspectiva do trabalhador e do usuário 1 enfermeira, doutora em enfermagem universidade federal de santa catarina (ufsc), brasil. soraia.dornelles@ufsc.br 2 enfermeira, mestranda em enfermagem na ufsc, brasil. luhbento@gmail.com 3 enfermeiro, doutor em enfermagem pela ufsc, brasil. jorgelorenzetti@hotmail.com 4 enfermeira na prefeitura municipal de schroeder (santa catarina), brasil. anacarolinaklein@hotmail.com 5 enfermeira, doutora em enfermagem pela ufsc, brasil. piresdp@yahoo.com recibido: 22 de mayo de 2015 enviado a evaluadores: 24 de mayo de 2015 aceptado por evaluadores: 23 de julio de 2015 aprobado: 28 de julio de 2015 doi: 10.5294/aqui.2015.15.3.8 para citar este artículo / to reference this article / para citar este artigo schoeller sd. bento l. lorenzetti j. klein ac. pires d. processo de trabalho em reabilitação: a perspectiva do trabalhador e do usuário. aquichan. 2015;15(3):403-412. doi: 10.5294/aqui.2015.15.3.8 resumo a prevalência das deficiências físicas constitui-se grave problema de saúde nas sociedades contemporâneas, o que demanda um processo longo de cuidados com ênfase na reabilitação. este é um estudo de caso com abordagem qualitativa realizado em um centro de reabilitação de referência estadual, o qual envolveu 10 usuários e 22 trabalhadores com o objetivo de analisar o processo de trabalho em reabilitação. foram coletados dados por meio de entrevistas com usuários e trabalhadores, observação sistemática e análise documental de prontuários. emergiram quatro categorias temáticas: usuários com lesão medular atendidos no centro de reabilitação; equipe profissional que atua junto às pessoas com lesão medular; aspectos do processo de trabalho que favorecem a reabilitação; aspectos do processo de trabalho que a dificultam. neste, destacaram-se déficits nos instrumentos de trabalho; nos aspectos que facilitam a reabilitação, destacou-se o trabalho em equipe humanizado. conclui-se que o trabalho multiprofissional facilita o processo de reabilitação, o que traz benefícios aos usuários, e que o trabalho de enfermagem é parte essencial desse processo. palavras-chave gestão em saúde, humanização da assistência, reabilitação, cuidados de enfermagem, medula espinhal (fonte: desc, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 403-412 404 aquichan issn 1657-5997 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 403-412 proceso de trabajo en rehabilitación: la perspectiva del trabajador y el usuario resumen la prevalencia de discapacidades físicas se constituye en un problema de salud en las sociedades contemporáneas, lo que demanda un proceso largo de cuidados con énfasis en la rehabilitación. este es un estudio de caso con abordaje cualitativo realizado en un centro de rehabilitación de referencia distrital, con 10 usuarios y 22 trabajadores, a fin de analizar el proceso de trabajo en rehabilitación. se recolectaron datos por medio de entrevistas a usuarios y trabajadores, observación sistemática y análisis documental de historias clínicas. emergieron cuatro categorías temáticas: usuarios con lesión medular atendidos en el centro de rehabilitación; equipo profesional que actúa junto a las personas con lesión medular; aspectos del proceso de trabajo que favorecen la rehabilitación; aspectos del proceso de trabajo que la dificultan. en esta última, se destacaron los déficits en los instrumentos de trabajos; en los que facilitan la rehabilitación, se destacó el trabajo humanizado en equipo. se concluye que el trabajo multiprofesional facilita el proceso de rehabilitación, lo que trae beneficios a los usuarios, y que el trabajo de enfermería es parte esencial de este proceso. palabras clave gestión en salud, humanización de la asistencia, rehabilitación, cuidados de enfermería, médula espinal (fuente: decs, bireme). 405 processo de trabalho em reabilitação: a perspectiva do trabalhador e do usuário l soraia dornelles schoeller e outros the working process during rehabilitation: from the standpoint of the worker and the user abstract the prevalence of physical disabilities is a serious health problem in contemporary societies and one that requires a long process of care with an emphasis on rehabilitation. this is a case study with a qualitative approach. it was conducted at a district rehabilitation center with 10 users and 22 workers to analyze the working process during rehabilitation. the data were collected through interviews with users and workers, systematic observation, and documentary analysis of medical records. four subject categories emerged: users with spinal cord injury who were being treated at the rehabilitation center; the professional team that works with persons who have spinal cord injuries; aspects of the working process that favor rehabilitation; and aspects of the working process that hamper rehabilitation. as for the latter, shortcomings in the instruments for rehabilitation work and in those facilitating rehabilitation were noted, and the humanized work of the team was highlighted. it was concluded that multidisciplinary work by professionals facilitates the rehabilitation process, which means benefits for users, and nursing work is an essential part of this process. keywords health management, humanizing care, rehabilitation, nursing care, spinal cord (source: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 403-412 406 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 introdução a lesão medular constitui-se grave problema de saúde na atualidade, especialmente devido ao aumento da violência urbana, evidenciado nos óbitos do capítulo das causas externas —acidentes e violências—, que inclui acidentes de trânsito, quedas, ferimentos por arma de fogo e arma branca, afogamentos, suicídio, agressões, dentre outras (1). no brasil, em 2010, ocorreram 143.256 óbitos por causas externas, 4.086 em santa catarina; destes, 52,96% entre 15 a 39 anos. dos 143.256 óbitos por essas causas ocorridos em 2010 no brasil, 50.380 foram em vias públicas, o que confirma os acidentes de trânsito como os grandes responsáveis por essas mortes (2). porém, a maior parcela das vítimas de acidentes sobrevive e requer atenção prolongada dos serviços de saúde. no brasil, na última década, para cada óbito em acidente de trânsito, houve 13 feridos (3). as vítimas não fatais são a face oculta das causas externas no brasil. em que condições de saúde sobrevivem essas pessoas aos eventos traumáticos dos quais são vítimas? não se dispõe de informações seguras sequer para afirmar que parcela dessas vítimas adquire graves incapacidades físicas e dependerá, por conseguinte, da assistência de serviços de saúde para o resto de suas vidas (3). parte dessas vítimas apresentará alguma necessidade especial: alterações em suas formas e/ou funções físicas e/ou mentais. a deficiência física relaciona-se com a perda ou anormalidade de estrutura ou função do corpo (4). a magnitude do tema deficiência versus cuidado em saúde é inversamente proporcional à relevância com que o assunto é tratado. os cursos de graduação na área da saúde, particularmente o de enfermagem, não evidenciam disciplinas voltadas ao tema reabilitação (5). a pouca relevância da temática na formação na área da saúde pode resultar em profissionais não preparados para desenvolver um processo de trabalho necessário à reabilitação das pessoas com deficiência. processo de trabalho diz respeito à ação transformadora, que no caso da saúde é desenvolvida, predominantemente, por equipes e envolve trabalho profissional (6-7). este engloba: 1) objetos de trabalho — são objetos a serem transformados, que podem ser matérias-primas, materiais já previamente elaborados ou, ainda, certos estados ou condições pessoais ou sociais; 2) meios de trabalho ou instrumento — máquinas, ferramentas ou equipamentos em geral e também conhecimentos; 3) força de trabalho — é composta pelos trabalhadores, responsáveis por transformarem objetos para se atingir fins previamente estabelecidos; 4) finalidade — visa satisfazer as necessidades e expectativas de seres humanos no seu contexto social e histórico. a análise do processo de trabalho nos serviços de saúde possibilita a identificação de pontos críticos e a elaboração de estratégias de intervenção que contribuem para uma abordagem mais eficaz e integral no sentido do proposto pelo sistema único de saúde (sus) e pela política nacional de humanização da atenção e da gestão (pnh) vigente no brasil. essa política propõe mudanças no sus que expandam os laços de solidariedade e corresponsabilidade na gestão, no cuidado e na formação de profissionais (8). a questão norteadora da pesquisa foi: como acontece o processo de trabalho em reabilitação em um centro de referência estadual? a partir das três perspectivas acima descritas —deficiência, processo de trabalho e humanização—, este estudo teve por objetivo analisar o processo de trabalho em um centro de reabilitação de referência estadual. metodologia utilizou-se como método o estudo de caso, com abordagem qualitativa, com dados coletados de outubro a dezembro de 2012, em um centro de referência em reabilitação para o estado de santa catarina (sul do brasil). os dados foram coletados por meio de entrevistas semiestruturadas com profissionais e usuários, observação sistemática do processo de trabalho e análise documental dos prontuários dos usuários entrevistados. trabalhou-se com triangulação de dados coletados a fim de possibilitar uma análise em maior profundidade sobre o processo de trabalho em reabilitação. participaram desta investigação 22 trabalhadores da equipe de saúde e 10 usuários com lesão medular do programa de reabilitação do centro de referência. os trabalhadores participantes foram aqueles envolvidos no programa de reabilitação da pessoa com lesão medular, independentemente do nível de formação/ categoria profissional. não participaram da pesquisa os que não 407 processo de trabalho em reabilitação: a perspectiva do trabalhador e do usuário l soraia dornelles schoeller e outros estavam presentes no centro durante a realização das entrevistas. em categorias com mais de um profissional, participou o mais antigo no serviço. os trabalhadores foram identificados pela letra “t”, seguida da ordem das entrevistas. os usuários foram pessoas com lesão medular do programa de reabilitação. a amostra deu-se por conveniência e incluiu apenas os usuários residentes no município de florianópolis, inseridos no programa no momento da pesquisa, com mais de 16 anos. estes foram convidados a participar do estudo pós-consulta de enfermagem. para manter o anonimato, foram identificados pela letra “u”, seguida da ordem em que foram entrevistados. para a entrevista dos trabalhadores, foi utilizado um roteiro que continha perguntas sobre idade, sexo, escolaridade, profissão, ocupação, estado civil, religião, formação, trabalho no centro, além de questionamentos sobre sua participação no processo de trabalho em reabilitação. com os usuários, foi utilizado um roteiro que continha perguntas sobre idade, sexo, escolaridade, profissão, ocupação, rendimento mensal, estado civil, religião, causa da lesão, data da lesão, fase do programa de reabilitação e contribuição do processo de trabalho e dos profissionais para sua reabilitação. os prontuários dos usuários participantes do estudo foram averiguados a fim de se coletar anotações e interação dos profissionais envolvidos no cuidado, organização do prontuário, encaminhamentos, letra legível e informações duplicadas. esses dados permitiram constatar a interação entre os diversos trabalhadores envolvidos no processo de trabalho em reabilitação e sua articulação com a política de humanização vigente no país. na observação sistemática do processo de trabalho, o foco esteve nas reuniões de equipe, nas consultas (profissionais de nível superior), além do trabalho realizado pelos profissionais que contribuem indiretamente para o processo de reabilitação — serviços gerais e marcenaria. os dados foram analisados segundo a análise temática que segue: categorização, inferência, descrição e interpretação (9). o estudo foi submetido ao comitê de ética da universidade federal de santa catarina, aprovado pelo parecer número 128.520, em 22/10/2012; portanto, são respeitados todos os requisitos éticos para pesquisa com seres humanos. este estudo é parte de outro financiado pela fundação de amparo à pesquisa de santa catarina (fapesc), intitulado o cuidado em saúde ao deficiente físico em santa catarina — realidade e desafios. resultados e discussão os resultados são apresentados na sequência das categorias temáticas: usuários com lesão medular atendidos no centro de reabilitação; equipe profissional que atua junto às pessoas com lesão medular; aspectos do processo de trabalho que favorecem a reabilitação; aspectos do processo de trabalho que a dificultam. usuários com lesão medular atendidos no centro de reabilitação foram entrevistados dez usuários participantes do programa, todos do sexo masculino e com idade entre 16 e 42 anos. sete são casados e três solteiros. seis possuem ensino fundamental incompleto, um ensino fundamental completo, um ensino médio incompleto, um ensino médio completo e um ensino superior incompleto. as profissões foram: colhedor de frutas, pintor, segurança, pedreiro, motorista de caminhão, mecânico, comerciante, caldeirista, inspetor de sinistro e um sem trabalho. quanto à religiosidade: seis são católicos, dois evangélicos, um umbandista e um sem religião. sobre a etiologia da lesão, quatro foram causadas por arma de fogo (duas balas perdidas, uma briga e um acidente de trabalho); duas, quedas; duas, acidente de moto; uma, acidente de carro e uma, anestesia raquimedular. aqui se evidenciou que o trauma foi a principal causa de lesão medular e que é consequência da violência urbana, como já visto em outro trabalho (10). o tempo de lesão variou de seis meses a nove anos. quanto ao nível da lesão, variou de tetraplegia (nível c5) à paraplegia baixa (nível l5). dois não souberam informar. equipe profissional que atua junto às pessoas com lesão medular dos 22 trabalhadores entrevistados, seis atuam na área administrativa. destes, um acrescenta às responsabilidades administrativas —gerência— o atendimento direto aos usuários 408 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 devido à demanda aumentada e à falta de profissionais; 16 trabalham diretamente no cuidado, mas não somente daqueles com lesão medular. o tempo de trabalho no centro variou de um mês a 31 anos. somente dois trabalham há menos de dois anos; dez trabalham entre três a dez anos e dez trabalham há mais de dez anos. destes, todos cursaram o ensino médio completo; 14 são graduados, dentre os quais, seis mestres e um doutor. nove concluíram cursos e atualizações em áreas que os auxiliam no processo de trabalho em reabilitação. quatro já trabalharam em outras instituições de reabilitação. os demais estão há, pelo menos, dois anos na instituição. segundo a organização mundial da saúde (oms), normalmente os profissionais de saúde não têm conhecimentos nem habilidades adequados para o atendimento às condições associadas com a deficiência (4). entretanto, a pesquisa evidenciou que os profissionais dessa equipe têm experiência e capacitação formal para o trabalho em reabilitação. aspectos do processo de trabalho que favorecem a reabilitação o processo de trabalho é regido pela finalidade; a partir dela, o trabalho é planejado (6). como finalidade do processo de trabalho aqui investigado, tem-se a reabilitação do usuário, de forma a possibilitar/contribuir para sua independência. a reabilitação ocorre com o trabalho multidisciplinar, evidenciado no centro de reabilitação. o acesso se dá com consulta na medicina física e reabilitação. a partir daí, são estipulados objetivos e são dados encaminhamentos para as diversas profissões e especialidades (fisioterapia, enfermagem, neurologia, cardiologia, ortopedia, nutrição, fonoaudiologia, serviço social, psicologia e educação física) de acordo com a necessidade de cada usuário. durante o programa, são feitas reuniões semanais da equipe multidisciplinar a fim de serem debatidos os casos mais relevantes, casos em que os objetivos estipulados não estão sendo alcançados. são discutidas as razões pelas quais não se alcançaram os objetivos e também as diversas profissões especificam o que fizeram e o que poderiam estar fazendo para mudar a situação. juntas propõem um planejamento estratégico para alcançá-los, no qual a participação do usuário é considerada. o alcance dos objetivos avalia o trabalho da equipe multidisciplinar e do usuário, e evidencia se o trabalho está indo ao encontro do que se planejou. o relatório mundial sobre deficiência evidenciou que outros profissionais, além do médico, são responsáveis pela reabilitação — a terapia, que restabelece e compensa a perda de funcionalidade em todas as áreas de vida da pessoa. de acordo com o relatório, “equipes multidisciplinares podem trazer muitos benefícios à reabilitação dos pacientes” (4:121). ainda, devem atuar de forma interdisciplinar ao considerar o objeto de trabalho de forma ampliada e participante no processo de reabilitação. são inerentes ao processo de trabalho em reabilitação o olhar e a intervenção das diversas profissões sobre a pessoa que necessita da intervenção. reabilitação abrange “aspectos educacionais, sociais e terapêuticos” (11:2.265). algumas medidas terapêuticas podem ser seguidas nas instituições de reabilitação, dentre elas o treinamento, exercícios e estratégias de compensação, educação, apoio e aconselhamento, além de modificações no ambiente: “as medidas de reabilitação visam às funções e estruturas corporais, atividades e participação, fatores ambientais e pessoais. elas contribuem para que a pessoa atinja e mantenha a funcionalidade ideal na interação com seu ambiente, utilizando os resultados abrangentes” (4:99). a enfermagem tem contribuição fundamental no processo de reabilitação. isso porque é a profissão que tem a integralidade do sujeito como fundamento do próprio cuidado e volta-se para a realização de atividades que objetivam o autocuidado na vida diária. ao iniciar a reabilitação no centro, os usuários entrevistados consideraram como principal objetivo a ser atingido a recuperação da atividade motora. entretanto, no decorrer do processo, ampliaram essa ideia e acrescentaram outros aspectos mais importantes como vestir-se sozinho e mudar de decúbito, tarefas simples que deveriam ser feitas sem auxílio. por fim, perceberam que o objetivo principal do processo de reabilitação é a conquista de independência para as atividades da vida diária, como se observa no depoimento de um participante. voltar a andar, mas depois percebi que me transferir da cadeira, me vestir sozinho é bom também. é o termo de reabilitação, né? claro que se pudesse voltar a andar também era bom, né! (uvii). no processo de trabalho, “a atividade do homem opera uma transformação, subordinada a um determinado fim, no objeto sobre que atua por meio do instrumental de trabalho” (12:3). no 409 processo de trabalho em reabilitação: a perspectiva do trabalhador e do usuário l soraia dornelles schoeller e outros centro de reabilitação, o usuário caracteriza-se como objeto do processo de trabalho, é aquele que precisa ser transformado para que se alcance a finalidade. estudo atesta que “todo processo de trabalho se realiza em algum objeto, sobre o qual se exerce ação transformadora, com o uso de meios e em condições determinadas” (6:23). entretanto, na saúde, o objeto de trabalho é o usuário, um ser humano, da mesma natureza de quem realiza o trabalho (7). nesse sentido, o trabalho em saúde implica relações; para atingir a finalidade do trabalho, depende da participação ativa de quem é o “objeto de trabalho”, em especial no caso do processo de reabilitação. quanto ao meio de trabalho, “é uma coisa ou um complexo de coisas, que o trabalhador insere entre si mesmo e o objeto de trabalho e lhe serve para dirigir sua atividade sobre esse objeto” (12:2). são artefatos utilizados pelos trabalhadores no processo de trabalho para a transformação do objeto. tais instrumentos podem ser tanto máquinas quanto ferramentas, equipamentos em geral. abarcam conhecimentos, protocolos e tecnologias disponíveis para o trabalho (6-7). a maquinaria e os equipamentos disponíveis no centro incluem: computadores, telefones, equipamentos específicos para a realização de sessões de fisioterapia, estrutura física dos consultórios e da instituição adaptada à pessoa com deficiência; material de alto custo para atendimento especializado (toxina botulínica, coberturas para feridas); materiais auxiliares, o que inclui as cadeiras de roda, de banho, órteses, próteses, sapatos ortopédicos e demais aparatos ofertados pela instituição por meio do programa órteses, próteses e meios auxiliares de locomoção (opmal). os trabalhadores do centro de reabilitação utilizam os instrumentos de trabalho já mencionados. nos casos de desnutrição se faz a orientação nutricional para o próprio paciente ou familiar, utilizando ou não suplementos nutricionais, fornecidos pela instituição, quando necessário. [...] nos casos de úlcera por pressão, também, orientação nutricional e suplemento caso necessário (tv). temos uma pequena parcela de usuários com lesão medular. são pessoas que têm doença neuromuscular, que utilizam um aparelho para auxílio na respiração, chamado bipap-synchrony (tvi). no que diz respeito a como o trabalho é desenvolvido e ao trabalho em equipe, 14 dos profissionais entrevistados mencionaram que sempre compartilham informações sobre o cuidado prestado ao usuário com outros profissionais do centro; dois, às vezes, compartilham, e três discutem nas reuniões de equipe. foram observadas trocas de informações intersetoriais, além das reuniões semanais de estudos de caso para discussão multidisciplinar. um número menor de trabalhadores (seis) afirmou ver o usuário na sua integralidade e quatro mencionaram a importância do tratamento e prevenção de comorbidades desencadeadas pela lesão. também foi registrada a importância do trabalho burocrático e administrativo para o bom resultado da reabilitação. acho que isso é fundamental, pois é a partir dessa integração que podemos ter um trabalho transdisciplinar e mais eficaz. temos poucos espaços, mas nestes, temos trocas muito importantes entre as áreas. principalmente na neuroadulto. temos reunião administrativa às terças-feiras e reunião técnica às quintas-feiras. nesses momentos, temos uma troca que possibilita a linguagem única e mais integrada (txxi). dada a complexidade do processo de reabilitação, não há uma profissão que, sozinha, detenha a totalidade do trabalho e realize todas as ações necessárias. nesse processo, a articulação dos diversos profissionais envolvidos é tão ou mais importante do que a ação individual. a reabilitação “é uma diversidade de técnicas e condutas em diálogo – ... [na qual] cada profissional terá que se haver com os trabalhos realizados por colegas de outras áreas” (11:2.264). o trabalho em equipe é importante ferramenta no atendimento ao usuário, pois o considera na sua integralidade. a troca de informações entre os profissionais e entre estes e o usuário é instrumento facilitador do processo de trabalho desenvolvido para a reabilitação do usuário com lesão medular. as características de trabalho em equipe, da abordagem interdisciplinar e da integralidade vêm ao encontro da proposta do ministério da saúde de humanização e clínica ampliada. a clínica ampliada e compartilhada é uma racionalidade que articula e inclui diversos olhares no cuidado aos usuários de modo a respeitar suas singularidades. envolve discussão em equipes interdisciplinares com a participação dos usuários (13). a instituição pesquisada realiza suas atividades contemplando os diversos olhares ao usuário, conforme se demonstra nos depoimentos a seguir. 410 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 trabalho com o médico, fisioterapeuta e nutricionista... depende das necessidades do paciente (tiii). converso com médico fisiatra, psicólogo, enfermeiro, nutricionista, assistente social, fisioterapia… educador físico. qualquer paciente que eu atenda e que seja atendido por outro profissional do centro de reabilitação, eu entro em contato com o profissional para trocar informações a respeito do paciente (tv). todos os usuários entrevistados mencionaram diversos profissionais como importantes no processo de reabilitação. isso evidencia duas questões: há comunicação entre os profissionais e os usuários, e o trabalho multiprofissional realmente acontece. enfermagem, fisioterapia, médico fisiatra, fonoaudiólogo, assistente social e nutricionista (ui). enfermagem [...] profissionais de fisioterapia [...] porque são os profissionais que mais temos convivência. mas a atenção de todos os profissionais é válida (uix). o cuidado em reabilitação exige a comunicação estreita entre os profissionais envolvidos no processo e entre estes e os usuários (14). as reuniões de equipe contam com a participação de todas as profissões do centro de reabilitação: médico cardiologista, educador físico, equipe de enfermagem, médico fisiatra, fisioterapeuta, médico neurologista, médico ortopedista, nutricionista, fonoaudiólogo, assistente social e psicólogo. nessas reuniões, que são semanais, são discutidos o ingresso e a alta dos usuários no programa de reabilitação, as condutas terapêuticas necessárias e realizadas, além de estudos de casos de usuários. sim, em reuniões semanais sobre os pacientes, estudo de caso (txxi). geralmente os problemas são levados para o estudo de caso, e praticamente 90% dos problemas são resolvidos (tiii). a melhora da qualidade de vida do usuário é ressaltada como contribuição importante por quatro trabalhadores. um deles relata que auxilia na reabilitação por meio da avaliação da condição social do usuário, e dois relataram contribuir mediante o suporte emocional. isso vem ao encontro do relatório mundial sobre deficiência, que assume qualidade de vida como abrangente e “que incorpora de forma complexa a saúde física, o estado psicológico, o nível de independência, as relações sociais, as crenças pessoais das pessoas e a relação com os fatores ambientais que as afetam” (4:315). o acolhimento é uma das diretrizes da política de humanização do sus, com o qual se busca construir o compromisso coletivo dos trabalhadores do sus para que as relações com o usuário sejam mais estreitas e de confiança, que é a base para o cuidado (15). no centro de reabilitação, todos os profissionais demonstraram preocupação em acolher o usuário. no entanto, a enfermagem foi citada pelos entrevistados como a que mais acolhe dentre as profissões da saúde. as enfermeiras são as que mais me ajudaram... são as que mais me atendem (uvi). o enfermeiro, no processo de cuidar, ampara o usuário, sistematiza quais são as ações de saúde necessárias para o cuidado e identifica suas demandas; além disso, favorece a comunicação entre todos os profissionais de saúde (16). isso é inerente ao cuidado de enfermagem. aspectos do processo de trabalho que dificultam a reabilitação estudo internacional evidencia as diferenças entre os diversos serviços de reabilitação voltados à pessoa com lesão medular (17). esta também é uma realidade do brasil, posto que as diferentes instituições públicas ou privadas se organizam de forma específica. porém, o planejamento em saúde é obrigatório para as instituições públicas e “será indutor de políticas para a iniciativa privada” (18). contudo, não é o que acontece no centro de reabilitação já que o planejamento não envolve todas áreas e não há uma reunião de planejamento anual e/ou mensal com todos os setores. o setor de enfermagem destaca-se no planejamento. não segue nenhum protocolo, mas planeja parte de suas atividades: faz a escala de trabalho dos funcionários do setor; realiza o pedido de materiais e medicamentos; controla a distribuição dos medicamentos por meio de um arquivo do excel criado para facilitar a visualização dos medicamentos disponíveis e agenda seus atendimentos previamente pela agenda do google criada pelo setor para organizar seus atendimentos. 411 processo de trabalho em reabilitação: a perspectiva do trabalhador e do usuário l soraia dornelles schoeller e outros outros aspectos que dificultam a reabilitação foram: déficits nos instrumentos de trabalho —não disponibilização do prontuário eletrônico, identificado pelos profissionais— e área física inadequada para o acesso dentro do centro, identificado pelos usuários. um fator dificultador é não ter prontuário eletrônico, que já existe na rede dos hospitais do estado e que ainda não chegou aqui o sistema, mas não é por falta de solicitação (tix). no que se refere ao acesso interno, muitos dos pacientes tetraplégicos, por não terem os movimentos finos das mãos, não conseguem abrir as portas do ambulatório de enfermagem, pois as maçanetas são de giro. somente pela falta da adaptação dentro do centro (ui). considerações finais a lesão medular e as deficiências físicas têm forte relação com o aumento da violência urbana e constituem-se em problema de saúde pública. no entanto, sua importância não se traduz em ações efetivas voltadas ao conhecimento e ao enfrentamento desse problema. na análise do processo de trabalho em saúde no centro de reabilitação estudado, identificou-se, como facilitador do processo de reabilitação, o trabalho em equipe, desenvolvido com trocas interdisciplinares, na perspectiva dos diversos olhares profissionais, e com o envolvimento de trabalhadores e usuários. isso foi reconhecido pelos usuários, objeto de trabalho em saúde. quanto aos aspectos que dificultam a reabilitação, profissionais e usuários identificaram déficits nos instrumentos de trabalho. importante destacar que a enfermagem é peça-chave no processo de trabalho em reabilitação e é destacada pelos usuários como a que tem mais contato com ele. este estudo contribui para a qualificação do cuidado em enfermagem voltado às pessoas com deficiência, o que evidencia que o processo de trabalho em reabilitação é, por um lado, multiprofissional e, por outro, tem como um dos profissionais mais importantes o enfermeiro. considerando-se os resultados obtidos e a escassez de estudos que abordam esta temática, recomenda-se a realização de novas pesquisas sob o olhar da teoria do processo de trabalho, o que contribuirá para um melhor entendimento da assistência a pessoas com deficiência. referências 1. ministério da saúde do brasil. política nacional de redução da morbimortalidade por acidentes e violências. brasília (df): ms; 2001. 2. ministério da saúde do brasil. datasus. óbitos por causas externas — brasil. 2010 [consultado 19 ago. 2012]. disponível em: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sim/cnv/ext10uf.def. 3. rede sarah de hospitais de reabilitação (brasil). mapa da morbidade por causas externas: apresentação [on-line]. [consultado 19 ago. 2012]. disponível em: http://www.sarah.br/educacao-e-prevencao/estatisticas/ 4. world health organization. world report on disability; 2011 [consultado em 19 ago. 2012] disponível em: http://www. who.int/disabilities/world_report/2011/en/ 5. schoeller sd, bitencourt rn, leopardi mt, pires dp, zanini mtb. mudanças na vida de pessoas com lesão medular adquirida. rev. eletr. enf. [internet] 2012 jan/mar; 14(1):95-103 [consultado em 19 ago. 2012]. disponível em: http://www. revistas.ufg.br/index.php/fen/article/view/12453 6. faria hp, werneck maf, santos ma, teixeira pf. núcleo de educação em saúde coletiva da faculdade de medicina/ufmg (nescon). processo de trabalho em saúde. 2ª ed. belo horizonte (mg): coopmed; 2009. 7. pires d. reestruturação produtiva e trabalho em saúde no brasil. 2ª ed. são paulo: annablume/cntss; 2008. 8. ministério da saúde do brasil. secretaria de atenção à saúde. cadernos humanizasus: formação e intervenção. brasília (df): ms; 2010. 412 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 9. minayo mcs (org.). pesquisa social: teoria, método e criatividade. 28ª ed. petrópolis (rj): vozes; 2009. 10. schoeller sd, borges amf, brigno p, kuhnen ae. know for care: characteristics of the people with spinal cord injury treated at a rehabilitation center. rev pesq: cuid. fundam. [on-line] 2012 jul.-set. [consultado 26 nov. 2012]; 4(3): 2.598-3.004. disponível em: http://www.seer.unirio.br/index.php/cuidadofundamental/article/view/1829. 11. de martini andré. reabilitação, ética e técnica. ciênc. saúde coletiva [internet]. 2011 abril [consultado 27 jul. 2015]; 16(4): 2.263-69. disponível em: http://www.scielosp.org/scielo.php?script=sci_arttext&pid=s141381232011000400025&lng=en. http://dx.doi.org/10.1590/s1413-81232011000400025. 12. marx k. o capital. coimbra (pt): sarl; 1974 [consultado 10 nov. 2012]. disponível em: http://www.marxists.org/portugues/marx/1867/ocapital-v1/index.htm. 13. ministério da saúde do brasil. secretaria de atenção à saúde. política nacional de humanização da atenção e gestão do sus: clínica ampliada e compartilhada. brasília (df): ms; 2009. 14. torres a, kunishige n, morimoto d, hanzawa t, ebesu m, fernandez j, nohara l, sanagustin e. & borg s. shared governance: a way to improve the care in an inpatient rehabilitation facility. rehabilitation nursing 2015; 40:69-73. doi: 10.1002/rnj.143 15. ministério da saúde do brasil. acolhimento nas práticas de produção de saúde. 2ª ed. brasília: editora ms; 2010 [consultado 26 nov. 2012]. disponível em: http://bvsms.saude.gov.br/bvs/publicacoes/acolhimento_praticas_producao_saude.pdf 16. backes ds. vislumbrando o cuidado de enfermagem como prática social empreendedora [tese]. florianópolis (sc): universidade federal de santa catarina, programa de pós-graduação em enfermagem; 2008. 17. new pw, townson a, scivoletto g, post mw, eriks-hoogland i, gupta a, smith e, reeves rk, gill za. international comparison of the organisation of rehabilitation services and systems of care for patients with spinal cord injury. spinal cord. 2013 jan.; 51(1):33-9. 18. brasil. decreto 7.508, de 28 de junho de 2011 — regulamenta a lei 8.080, de 19 de setembro de 1990, para dispor sobre a organização do sistema único de saúde — sus, o planejamento da saúde, a assistência à saúde e a articulação interfederativa, e dá outras providências [consultado 19 maio 2013]. disponível em: http://www.planalto.gov.br/ccivil_03/_ato2011-2014/2011/decreto/d7508.htm 03. caracteriz. flias (21 a 31) resumen este trabajo pertenece a la línea de investigación “salud familiar, enfermería familiar”, de la universidad nacional de colombia. describe las características de los factores de riesgo y grado de salud familiar de las familias con adolescentes gestantes de los municipios de chía, cajicá y cota. es un estudio descriptivo, transversal, con abordaje cuantitativo. se utilizaron dos instrumentos de salud familiar: “riesgo familiar total 7-70” y el “isf ges 19”, elaborados y probados en familias colombianas de estratos 1 y 2, cuya autora es pilar amaya de peña (1992-1998). de las 66 familias estudiadas, se encontraron riesgos que afectan la salud familiar, así: 62% en alto riesgo, 36% en riesgo medio y 2% en riesgo bajo. las prácticas y los servicios de salud se incluyen dentro de las subcategorías de mayor riesgo. el estudio también aporta información sobre el grado de salud familiar, es decir, el nivel en que las familias se encuentran saludables y satisfechas con lo que la familia es y hace para mantener las metas de crecimiento, estabilidad y cohesión comportamental. se concluye que de las familias estudiadas, las del área rural tienen mayores riesgos para la salud que las que viven en la zona urbana. las familias estudiadas no tienen el conocimiento ni la práctica de la promoción de la salud y la prevención de la enfermedad. estos hallazgos exigen a la enfermería y demás trabajadores de la salud iniciar acciones contundentes que aseguren una prestación de servicios de salud, para disminuir el riesgo familiar total y mejorar el grado de salud familiar, teniendo en cuenta a las familias de las adolescentes gestantes y previendo con ellas acciones de prevención de la enfermedad y promoción de la salud. palabras clave: riesgo familiar total, salud familiar, familia con adolescente gestante, enfermería familiar. abstract this study on family nursing with emphasis on family run within the research of the universidad nacional de colombia. it describes the characteristics, risks factors and degree of family health faced by families with pregnant adolescents in little towns of cundinamarca (chía, cajicá and cota). it is a descriptive study that follows a transversal and quantitative methodology. two different instruments on family nursing were used: “total family risk 7-70” and “isf ges 19” which haven been made and tested by dr. pilar amaya de peña (19921998) with colombian urban families from low social status. from the 66 families studied, it was found that a 62% of families faced high risk of affected family health, 36% faced a medium high risk and 2% faced low risks. the high risk categories comprise health practice and services. it also revealed information on the degree of family health and family satisfaction with respect to what the family is and what they do to achieve their goals related to growth, stability and behavior. it was concluded that from the studied families, those who lived in rural areas run higher risk with respect to health than families living in urban areas. the families studied do not have the knowledge and practice to prevent sicknesses and the promote health within the family. these findings demand from nursing and other health professionals to offer health services to those families with pregnant adolescents in order to decrease the family health risks and promote the family health level by promoting actions to prevent sicknesses and assure healthy measures. keys words: family risk, family health, adolescent pregnant families and family nursing. 21 beatriz pérez giraldo especialista en educación y asesoría familiar. magíster en enfermería, con énfasis en salud familiar. docente de la facultad de enfermería, universidad de la sabana. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 22 introducción el riesgo en salud es una característica averiguable de una persona o grupo de personas, que se conoce como asociada con la probabilidad de desarrollar un proceso mórbido o estar especialmente afectados de manera adversa. el grado de salud familiar hace referencia a lo que la familia es y la satisfacción que tenga. partiendo de estos conceptos, se quiere caracterizar el riesgo y el grado de salud de un grupo de familias con adolescentes gestantes. el presente trabajo está basado en las teorías de riesgo y de organización sistémica de marie louise friedemann; además, utiliza los instrumentos de riesgo familiar total (rft 7-70) y de salud familiar y gestación (isf ges 19), diseñados, implementados y probados por la doctora pilar amaya de peña. este estudio es útil para la enfermería familiar, porque aporta información específica para el cuidado de enfermería con las personas y familias, enfrentadas a diversos factores de riesgo, como: riesgos por grupo de edad, riesgos biológico-familiares, riesgos de medio ambiente y riesgos de servicios de salud y familia. también aporta información sobre el grado de salud familiar en la escala de acuerdo y satisfacción, con lo que la familia es y la satisfacción que tenga. los resultados exigen a la enfermería y otros trabajadores de la salud iniciar acciones que aseguren una prestación de servicios de salud tendientes a disminuir riesgos y mejorar el grado de salud familiar, teniendo en cuenta a las familias de gestantes adolescentes. a través del trabajo se presentan, uno a uno, los componentes de la investigación, y se definen aspectos del marco de referencia, del marco conceptual, del marco metodológico, de los resultados, conclusiones y recomendaciones que se derivan del estudio. área problemática en la actualidad, el embarazo en la adolescencia se ve como uno de los problemas más sentidos en latinoamérica, ya que se aprecia un aumento sostenido en su incidencia, frente a lo cual no se ha desarrollado mayor conocimiento y, por lo tanto, tampoco existen estrategias importantes para prevenirlo y atenderlo. según la oms-ops: “colombia ha experimentado una mayor disminución de los nacimientos en el grupo de adolescentes, comparado con la tasa general total, y presenta la paradoja de que aunque la importancia relativa del grupo es menor (18% en 1973 y 16% en 1986), el número total de nacidos de madres adolescentes ha aumentado, porque la población adolescente es mayor. en colombia un 68% de los egresos hospitalarios entre los 12 y 18 años de edad y el 25% de las consultas ambulatorias de las mujeres de 16 a 18 años son por causa materna”1. estadísticas colombianas, proporcionadas por el entonces ministerio de salud (minsalud), muestran que el embarazo y los eventos relacionados con él ocupan el primer lugar como causas de consulta externa, las cinco primeras causas de egresos 1. silber, tomás y colab. manual de medicina de la adolescencia: embarazo en la adolescencia. oms/ops, washington, 1992, p. 474. el riesgo en salud consiste en la probabilidad de desarrollar un proceso mórbido o verse afectados de manera adversa. el grado de salud familiar hace referencia a lo que la familia es y a la satisfacción que tenga. caracterización de las familias con adolescentes gestantes 23 hospitalarios y seis de las ocho primeras causas de los mismos, en la población femenina entre los 15 y los 19 años. asimismo, es la segunda causa de egreso hospitalario en mujeres entre 10 y 14 años, lo cual manifiesta claramente la gravedad de la problemática referida2. en colombia, según la encuesta de demografía y salud (2000), el 15% de las adolescentes ya han sido madres y el 4% están en el embarazo de su primer hijo, para un total de 19% que han estado en embarazo o ya han tenido partos, en comparación con el 17% en la encuesta de 1995, en la cual se encontró que una de cada cinco adolescentes ha estado alguna vez embarazada. si se toma en cuenta que, a nivel mundial, el incremento absoluto de los adolescentes entre los 10 y los 19 años será de 27% en los próximos 35 años, que el 86% del total corresponderá a países en vías de desarrollo y que la vida sexual de los adolescentes es cada vez más activa y precoz, bien puede asegurarse que el fenómeno social referido resulta altamente complicado y peligroso3. según un reciente estudio sobre “la dinámica social”, del centro de investigaciones de la universidad externado de colombia, entre el 10 y el 15% de los 125 millones de niños que nacen anualmente en el mundo son hijos de madres adolescentes menores de 20 años. desde el punto de vista social, la adolescente se ve enfrentada al rechazo social, de su familia, de su círculo de amigos, de su pareja, y en el peor de los casos se tiene que ir de la casa. su proyecto de vida se ve afectado, pues la presencia de un hijo le exige salir a trabajar y abandonar sus estudios, para empezar su papel de madre. la presión social contra la adolescente embarazada desencadena consecuencias psicológicas para ella. con frecuencia la joven que no estaba preparada para ser madre, tiende a rechazar la idea de tener un bebé. por esta razón, el 44,4% de las adolescentes han abortado en colombia4. según tanaka y siqueira, “el riesgo del embarazo en la adolescente es alto, y sucede en todos los niveles sociales, presentando, por otro lado, mayores riesgos en los niveles sociales de escasos recursos socioeconómicos, en los que esta carencia dificulta el acceso a las informaciones y a la asistencia adecuada”5. la situación anterior se observa en chía, cajicá y cota, municipios del departamento de cundinamarca, donde se ha venido incrementando el número de embarazos en adolescentes. según estadísticas hospitalarias, se presentan un promedio de siete a ocho embarazos nuevos al mes en el hospital san antonio, de chía, y de dos a tres en el hospital jorge cavelier, del municipio de cajicá. las familias de las adolescentes gestantes del presente estudio pertenecen a los estratos 1 y 2, situación esta que puede llevar a muchos riesgos y dificultar el manejo de las situaciones familiares, y específicamente la situación del embarazo en la adolescencia. la crisis económica de la mayoría de las familias y la falta de comunicación asertiva, entre otros, pueden constituir factores de riesgo familiar, que llevan a afectar tanto el desarrollo gestacional como el de la propia familia. justificación la ley 100, de diciembre de 1993, presenta cambios en los conceptos relacionados con la prestación de los servicios, entre ellos: la universalidad, la solidaridad, la eficiencia y la integralidad, que implican la cobertura a la familia como elemento importante para su cumplimiento. esta cobertura familiar obedece al reconocimiento de que esta unidad básica tiene un papel importante en la conservación de la salud o en el deterioro de la misma. cada individuo de la familia tiene la responsabilidad de cuidarse y utilizar los recursos de la familia y del ambiente para conservar la salud o recuperarla. se parte del concepto de integralidad, que considera a las personas como seres vivos biosicosocioculturales y espirituales, que interactúan con la familia, la sociedad y el entorno en el cual viven. la integralidad incluye el promover, el mantener, el 2. mendieta cruz, néstor. familia de adolescente embarazada. estructura y dinámica. bogotá, 1996, p. 18. 3. klein, r. “programas de intervención para adolescentes”. en: la psicología en el ámbito perinatal. inper, méxico, 1998, p. 488. 4. wetember, lucy. embarazo precoz y aborto del adolescente en colombia, 1999, p. 28. 5. tanaka y siqueira. en: montes y valverde, maría marlene. un modelo fundamentado en el amor para la asistencia de la adolescente embarazada. edit. xyz, cali, 1999, p. 27. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 24 recuperar y el rehabilitar, cuando se ha perdido la salud. la ley 100 ha sido fundamentada bajo el esquema de promoción de la salud y prevención de la enfermedad; por tal motivo, está sustentada en un modelo capaz de conocer y evaluar los riesgos para la salud, con mecanismos suficientes para atenderlos efectivamente. dentro de esta misma ley se aclara que la presencia de la salud o la enfermedad en la familia es producida por muchos factores (multicausalidad), bien sea económicos, biológicos, sociales, culturales, ambientales y de servicios de salud; por lo tanto, se hace necesario que el profesional de la salud tenga en cuenta esa conjunción de factores que actúan simultáneamente sobre las familias, para mantener la salud de estas. un factor de riesgo puede estar asociado con múltiples patologías, y una patología puede estar relacionada con múltiples factores de riesgo. por ejemplo, es así como el tabaquismo se asocia con la incidencia de varios tipos de neoplasmas, y también algunas enfermedades perinatales se relacionan con el tabaquismo de la mujer en embarazo. la desnutrición proteicocalórica es el resultado de la presencia reiterativa o crónica de enfermedades infecciosas y de un insuficiente consumo de alimentos energéticos y proteicos. esta condición, a su vez, puede ser el resultado de la pobreza, de deficientes condiciones sanitarias, de hábitos inadecuados y de la falta de acceso apropiado a los servicios de salud (pinstrup-anderse y col., 1993). si se mejoran las condiciones de vida, se disminuye la carga de enfermedad6. la constitución política colombiana, en el artículo 42, señala a la familia como una institución social básica. se conforma por niveles naturales o jurídicos, por la decisión libre de un hombre y una mujer de contraer matrimonio o por la voluntad responsable de conformarla. el estado y la sociedad garantizan la protección integral de la familia. las relaciones familiares se basan en la igualdad de derechos y deberes de la pareja y en el respeto recíproco entre todos sus integrantes. la ley 266 de 1996, de la enfermería, aclara los principios de la práctica de la profesión, entre los que se encuentran el de integralidad, que orienta el proceso de cuidado de enfermería a la persona, la familia y la comunidad, con una visión unitaria para atender sus dimensiones físicas y espirituales. otros principios, como la individualidad, la dialogicidad, la calidad y la continuidad, son importantes para brindar un cuidado de enfermería de buena calidad. los principios anteriores van de la mano con los que plantea la ley 100, con el principio de integralidad que corresponde a la familia. por lo tanto, es importante tener en cuenta a la familia, en este caso a las familias de las adolescentes gestantes, para identificar los factores de riesgo o los factores protectores, que en un determinado momento se deben tener en cuenta para aprovecharlos y mejorar la situación de las familias. por estas razones, se hace necesario caracterizar las familias desde el enfoque de riesgo familiar, y grado de salud de la familia, con el fin de identificar los condicionantes que hacen que la familia tenga riesgos o no. este estudio, de familias con adolescentes embarazadas, pretende colaborar en la identificación de factores de riesgo y grado de salud familiar, que hacen que en el sistema familiar, y en los subsistemas, se desarrollen situaciones de salud positivas o negativas, como también identificar los elementos protectores para el mantenimiento de la salud. 6. ministerio de salud. la reforma a la seguridad social en salud. tomo i. “antecedentes y resultados”. editorial carrera séptima ltda., santafé de bogotá, 1994, p. 107. este estudio pretende colaborar con la identificación de factores de riesgo y grado de salud que hacen que, en el sistema familiar y en los subsistemas, se desarrollen situaciones positivas o negativas, como también identificar los elementos protectores para el mantenimiento de la salud. caracterización de las familias con adolescentes gestantes 25 es importante conocer los factores de riesgo y el grado de salud familiar presentes en las familias de las adolescentes, con el fin de lograr desarrollar acciones y programas preventivos, dirigidos a modificar aquellos que puedan comprometer de manera negativa su salud. la presente investigación aportará a la profesión de enfermería la identificación de riesgos de salud de las familias y el grado de salud familiar de estas, con el fin de orientar su cuidado, que le permita al profesional diseñar programas encaminados a mejorar estilos de vida y, por consiguiente, calidad de vida. por otra parte, genera un aporte en la aplicación de un modelo conceptual en un proceso investigativo, que sin duda enriquecerá la profesión. problema ¿cuáles son las características de los factores de riesgo familiar total y grado de salud familiar de las familias con adolescentes gestantes de los municipios de chía, cajicá y cota? objetivo general caracterizar el enfoque de riesgo familiar total y el grado de salud familiar de las familias con adolescentes gestantes de los municipios de chía, cajicá y cota. objetivos específicos • identificar las edades y el número de gestaciones de las adolescentes gestantes del estudio. • identificar la estructura, la tipología y el ciclo familiar de las familias con adolescentes gestantes. • identificar la percepción de riesgo, salud y enfermedad de las familias con adolescentes gestantes. •identificar enfermedades de carácter familiar de las familias con adolescentes gestantes. • identificar instituciones de apoyo familiar de las familias con adolescentes gestantes. • identificar riesgos por grupos de edad y salud individual de las familias con adolescentes gestantes. • identificar factores de riesgo familiar específicamente biológicos familiares, del medio ambiente y servicios de salud de las familias con adolescentes gestantes. • identificar el grado de salud familiar de las familias con adolescentes gestantes. • identificar el comportamiento del riesgo familiar y el grado de salud familiar de cada municipio: cajicá, chía y cota. definición de conceptos este aparte conceptualiza: caracterización de la familia con enfoque de riesgo y grado de salud familiar, familia, salud familiar y familia con adolescente gestante, conceptos que se consideran válidos para sustentar teóricamente el estudio. • caracterización de la familia. desde el enfoque de riesgo, se describe en función de parámetros de estructura: tipología (familia nuclear, familia nuclear modificada, familia nuclear reconstruida, familia extensa, familia extensa modificada, familia atípica), ciclo vital familiar (formación de la pareja, crianza de los hijos, familia con preescolar, familia con adolescente, revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 26 familia con adultos, familia en edad media, familia anciana, familia multicíclica), composición (número de personas, promedio de edad, sexo) y riesgos individuales y familiares; y en términos del grado de salud familiar (sinónimo de organización, dinámica, funcionamiento), que incluye lo que la familia habitualmente es y el grado de satisfacción al respecto; se determina por la medición de las dimensiones de mantenimiento, cohesión, cambio e individuación7. • riesgo. pilar amaya de peña (2000) cita a backet, davies y petros barvazain, 1984, quienes se refieren al riesgo como al incremento en la probabilidad de consecuencias adversas, por la presencia de una o más características o factores. estos mismos autores definen el factor de riesgo como “cualquier característica o circunstancia averiguable (comprobable, confirmable) de una persona o un grupo de personas, que se conocen como asociadas con la posibilidad de desarrollar o están especialmente afectadas de manera adversa a un proceso mórbido”8. • riesgo familiar total. probabilidad de consecuencias adversas individuales o familiares (enfermedad, desorganización o disfunción), debido a la presencia de algunas características detectadas en el momento de la valoración (amaya de peña, p., y herrera, a. n., en prensa). estas características incluyen aspectos de tipo biológico-demográficos (composición, morbilidad, mortalidad), físicos, ambientales, socioeconómicos, psicoafectivos, prácticas de salud y servicios de salud. además, incluye la trayectoria de los miembros de la familia (pilar amaya de peña (1992, 1998 y 2000) cita a clemen-stone, eigsti y mcguire, 1991). desde este punto de vista, una familia con menor riesgo será aquella que mediante sus prácticas cotidianas y apoyo de los servicios de salud mantiene controlados los riesgos individuales y familiares, utilizando medidas de promoción y prevención9. • familia. es una unidad con estructura y organización, que interactúa con su ambiente. la familia es un sistema con subsistemas interpersonales de parejas y unidades mayores, definidas por enlaces emocionales y responsabilidades comunes. la familia está conformada por todas las personas que llevan funciones familiares y están emocionalmente conectadas al individuo. la familia se define como todas las personas que un individuo considera su familia10. • grado de salud familiar. dimensiones del proceso (comportamientos y estrategias familiares): la familia inmersa en el sistema social está transmitiendo cultura, suministra necesidades físicas de seguridad, procreación, enseña destrezas sociales a sus miembros y promueve propósitos para la vida. la familia satisface las necesidades de sus miembros mediante el control de su ambiente y guía los procesos familiares con aceptación colectiva y comportamientos y estrategias que ayudan a regular las condiciones terrenales de espacio, tiempo, energía y materia11. los propósitos del sistema familiar se alcanzan con comportamientos que caen en tres grupos: crecimiento familiar (morfogénesis), estabilidad familiar (homeostasis) y cohesión comportamental, los cuales son definidos por pilar amaya de peña12. a. crecimiento familiar. refleja el ajuste de la familia en el proceso de acomodación a las necesidades cambiantes de sus miembros. b. estabilidad familiar. refleja la tradición y los patrones de comportamientos comunes enraizados en los valores básicos y creencias culturales que proveen a la familia un sentido de pertenencia y seguridad. c. cohesión comportamental. involucra los procesos de cambio requeridos por la familia en su organización y procesos de ajuste en su trayectoria de valores. • familia con adolescente gestante. familia con mujer menor de 20 años de edad en gestación. 7. amaya de peña, pilar. riesgo familiar total 7-70 y el isf gen 25. referentes teóricos-conceptuales y análisis de la información. santafé de bogotá, universidad nacional de colombia, 1992, 1998 y 2000, p. 8. 8. ibíd., p. 3. 9. ibíd., p. 1 y 2. 10. friedemann, marie louise. the famework of systemic organization a conceptual approach to families and nursing thousand oaks: age 1995, p. 11. 11. ibíd., p. 14. 12. amaya de peña, pilar. measuring family health perceptions of poor pregnant women in bogotá, colombia, universidad nacional de colombia, u. de wayne. dib, bogotá, 1998. caracterización de las familias con adolescentes gestantes 27 metodología se utilizó una metodología cuantitativa de tipo descriptivo transversal. se valoraron 66 familias que tenían una adolescente embarazada. estas se caracterizan con enfoque de riesgo familiar total y grado de salud familiar. se utilizaron dos instrumentos de salud familiar: “riesgo familiar total 7-70” y el “isf ges 19”, elaborados y probados con familias urbanas colombianas por pilar amaya de peña (1992-1998). la captación de las familias se realizó en forma aleatoria, en los municipios de cota, chía y cajicá. la información de las familias se recogió en la casa o en el centro de atención en salud, durante una hora. en la recolección de la información participó una persona del municipio de cajicá, la cual fue entrenada por la investigadora. la información recolectada, a través de los instrumentos rft 7-70 y el isf ges 19, fue codificada y procesada en el paquete estadístico “spss”. como guía de análisis se utilizó la orientación dada por pilar amaya de peña (1992, 1998 y 2000), teniendo en cuenta las categorías y subcategorías del rft 7-70, como también la estructura del isf ges 19, y sus grupos con los correspondientes ítems. para el desarrollo del proyecto se tuvo presente el permiso de las instituciones donde se llevó a cabo el estudio. a las gestantes adolescentes se les solicitó autorización voluntaria, se les informó sobre los fines del estudio y se leyó y firmó el consentimiento informado; de igual forma, a la autora de los instrumentos utilizados se le solicitó el respectivo permiso. resultados los resultados muestran que las 66 familias estudiadas tienen un promedio de cuatro a cinco personas, donde la distribución por sexo (masculino y femenino) es de uno a dos hombres y de dos a tres mujeres por familia. esta distribución muestra que en algunos hogares predomina la mujer como cabeza de familia, característica que ha venido en aumento en las familias de américa latina. según ramírez (1995), diversos estudios han concluido que los hogares con jefe mujer constituyen las familias más pobres, y que estas mujeres tienen además un menor nivel educacional. el rango de edad que prima es de 12 a 18 años. el tipo de familia que prevalece es la nuclear, con 48,5%, seguida de las atípicas, nucleares modificadas y nucleares reconstruidas, con un 39,3%, hecho este significativo, puesto que representa tipos de familias que por su conformación generan conflictos y pueden llevar a la disfuncionalidad. el ciclo familiar predominante es en formación, con un 24,2%; le sigue el de adolescente, con un 22,7%, lo que corrobora que en su mayoría son familias con integrantes jóvenes, que según duvall están sufriendo unos cambios y necesitan la aceptación de ambos cónyuges, tanto a nivel emocional como cultural y sexual. este tipo de familia se está enfrentando al embarazo, lo cual puede afectar notablemente su relación y llevar a consecuencias para ambos, como el fracaso matrimonial, no alcanzar determinados logros educativos, y algunos efectos sobre el nivel socioeconómico y el posible hijo. p. amaya de peña y a. n. herrera (en prensa) afirman que existen características de tipo biológico-demográfico (composición, morbilidad y mortalidad), factores de medio ambiente (ambiente socioeconómico, ambiente físico de vivienda y vecindario, ambiente psicoafectivo familiar, los estilos de vida y las prácticas de salud) y características o factores dados por la prestación de los servicios, como también la trayectoria de los miembros de la familia como unidad, lo cual determina el riesgo familiar total (rft). la información arrojada por el instrumento “rft 7-70” (amaya de peña p., 1992 1998) describe las puntuaciones de riesgo familiar de la muestra por subcategorías. teniendo en cuenta la calificación de las subcategorías del instrumento, se encontró que el riesgo es alto si puntúa por encima de 3, medio si puntúa entre 3 y 2 y bajo si es menor de 2. los resultados describen los riesgos de las 66 familias por subcategorías, de la siguiente manera (ver tabla a continuación): revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 28 el cuadro presenta el promedio de puntuación de riesgo familiar. registra desde el más alto y en forma descendente las subcategorías: se encuentran en alto riesgo las prácticas de salud y los servicios de salud y familia. en riesgo medio se hallan el ambiente socioeconómico, el ambiente psicoafectivo, la composición familiar, el riesgo por grupo de edad y el ambiente físico de vivienda y vecindario, y por último, en bajo riesgo están la morbilidad, el estilo de vida y la mortalidad en la familia. estos riesgos, analizados en forma global, brindan la pauta para dirigir acciones de promoción y prevención específicas para este grupo de familias. el instrumento “isf ges 19” arrojó los siguientes resultados: la escala de acuerdo, que demuestra lo que la familia es, se presenta de la siguiente manera: si las familias puntúan entre 68100, son altamente saludables; si están entre 67-50, son familias saludables, y de 49 y menos, son familias poco saludables (amaya de peña p., 1998). se encontró un promedio de 54,1%, que indica que estas familias son saludables, resultado que llama la atención al relacionarlo con el 62% de las familias con alto riesgo de salud, lo que quiere decir que no se perciben como familias en riesgo y, por lo tanto, dicen estar saludables. la escala de satisfacción, que demuestra la satisfacción con lo que la familia es, puntúa así: entre 68-100, familias altamente saludables; entre 67-50, familias saludables, y 49 y menos, familias poco o nada saludables (amaya de peña p., 1998). en las 66 familias el promedio, equivalente a 51,1%, significa que se encuentran satisfechas con lo que la familia es y hace, en cada grupo de la escala de satisfacción. resultados del 7-70 por subcategorías subcategoría promedio desviación máximo mínimo estándar prácticas de salud 4,36 1,25 7 2 servicios de salud y familia 3,38 1,61 7 0 ambiente socioeconómico 2,98 1,52 6 0 ambiente psicoafectivo familiar 2,65 1,69 7 0 composición familiar 2,64 1,30 5 1 riesgo por grupo de edad 2,62 1,60 5 1 ambiente físico de vivienda y vecindario 2,02 1,26 6 0 morbilidad de la familia 1,76 1,56 5 0 estilo de vida familiar 1,59 1,02 4 0 mortalidad de la familia 0,14 0,43 2 0 caracterización de las familias con adolescentes gestantes 29 conclusiones este estudio refleja: en primer lugar la tipología familiar, el ciclo familiar y la composición familiar que predominan en las familias de este estudio; las implicaciones en la dinámica familiar ya fueron descritas en párrafos anteriores; es importante resaltar que el 62% de las familias estudiadas tienen un alto riesgo de salud, lo que exige por parte de los profesionales de enfermería y el resto del equipo de salud, emprender acciones de prevención y promoción de la salud en diferentes modalidades, como el autocuidado individual y familiar. en la investigación se halló que de las 66 familias encuestadas, 52 viven en el sector rural y 14 en el urbano. comparando los resultados de la investigación, se encuentra que un 62% de las familias se hallan en alto riesgo de salud, circunstancia que llevaría a concluir que en el sector rural existe menos protección y más riesgo para las familias que en el urbano. evidentemente, los riesgos del sector rural son mayores que los del urbano: el deterioro ambiental, la carencia de servicios públicos y la falta de agua potable para el consumo humano aumentan el riesgo de las familias de dicho sector. la investigación permite que identificados los riesgos familiares totales a los que están expuestas las familias encuestadas, el profesional de enfermería y el equipo de salud cuenten con datos precisos y cifras claras para implementar planes de atención y cuidados para las familias, enfocados a las acciones de promoción y prevención. la adolescente percibe que su familia es saludable, apreciación esta que va acorde con su pensamiento y grado de madurez. para la adolescente, la problemática en torno a la salud de su familia es irrelevante, ya que considera que otros temas son de mayor importancia. de la investigación se desprende que las familias, no obstante estar afiliadas a la seguridad social, no conocen las bondades de la ley 100, bien porque las instituciones no efectúan una divulgación suficiente para que ellas hagan uso de los servicios, o porque las familias no se interesan en averiguar y enterarse de los servicios a que tienen derecho. de conformidad con los instrumentos de percepción del grado familiar y la escala de acuerdo, se encontró que en los municipios de cajicá y chía las familias son saludables, con un promedio de 54 y 52,3%, respectivamente, mientras en el municipio de cota se hallaron familias poco saludables, que corresponden a un promedio de 46,09%. en cuanto a la escala de satisfacción, se encontró que las familias de cajicá y chía se sienten satisfechas, con un promedio de 53,84 y 50,96%, respectivamente, en tanto que para el municipio de cota se encontraron familias poco satisfechas, que corresponden a un promedio de 44,09%. los índices anteriores muestran que las familias correspondientes al municipio de cota se hallan insatisfechas y son poco saludables; sin embargo, el resultado es contrario en los municipios de cajicá y chía, ya que la investigación halló que estas familias son saludables y se sienten satisfechas. se desprende de la investigación que los municipios con mayor riesgo familiar total son los de cajicá y cota, pues para ambas poblaciones se hallaron 24 y 7 familias, respectivamente, con alto riesgo; este hecho demuestra un estado socioeconómico deprimente, circunstancia que es diferente en el municipio de chía, a pesar de que todas las familias se hallan dentro de los estratos 1 y 2. el tener un modelo teórico en el abordaje de las familias facilitó el trabajo con ellas, ya que se contaba con una guía en el direccionamiento de los objetivos del proyecto. recomendaciones la investigación con este grupo de familias permite plantear las siguientes recomendaciones: • socializar los resultados de la presente investigación en las instituciones en las que se realizó la aplicación de los instrumentos, con las autoridades locales de cada uno de los municipios y con la facultad de enfermería de la universidad de la sabana, a fin de dar a conocer los resultados, que sirvan de revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 30 referencia en la toma de decisiones de las políticas sociales y de salud de cada municipio, y permitan una aproximación a la planificación de los recursos institucionales y comunitarios, así como la intervención de la facultad en el diseño de programas de apoyo específico para las familias con adolescentes gestantes con riesgo. • crear estrategias de divulgación en las instituciones de salud, las cuales sean efectivas y objetivas, con el fin de que los usuarios se informen de los servicios que ofrecen dichas instituciones, y de esta manera utilicen los programas de promoción y prevención, encaminados a mejorar los estilos de vida. • dinamizar los equipos interdisciplinarios de las diferentes instituciones de salud, para que conocida y analizada la información recogida de las 66 familias valoradas, se inicien acciones específicas que contribuyan a minimizar o controlar los factores de riesgo identificados, que en prioridad son: prácticas de salud y servicios de salud. • estimular la continuidad de la presente investigación, con el fin de explorar y relacionar diversos aspectos, como las prácticas de salud de la familia con el nivel educativo de la misma, el ambiente psicoafectivo familiar con el tipo de familia, el grado de salud familiar con los factores de riesgo presentes en la familia. la investigación con este grupo de familias permite plantear las siguientes recomendaciones: • socializar los resultados • crear estrategias de divulgación en las instituciones de salud • dinamizar los equipos interdisciplinarios de las diferentes instituciones de salud • estimular la continuidad de la presente investigación caracterización de las familias con adolescentes gestantes 31 bibliografía amaya de peña, pilar. aspectos psicométricos. instrumentos e instructivos. pruebas ipsf-gg rtf 7-70. santafé de bogotá, universidad nacional de colombia, facultad de enfermería, 2000. _______ . riesgo familiar total 7-70 y el isf gen 25. referentes teóricos-conceptuales y análisis de la información. facultad de enfermería, universidad nacional de colombia, agosto de 2000. _______ . instrumentos de salud familiar isf gen 25-isf ges 19. manual del usuario. agosto de 2000. _______ . measuring family health perception of poor pregnancy women in bogotá, colombia. universidad nacional de colombia y wayne state university. _______ . familias de ancianos y 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(48 a 51) revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 48 resumen el artículo presenta algunas concepciones del ser humano en relación con el cuidado de enfermería. a partir de la organización de la vida se establecen relaciones, interacciones del ser humano, sus límites y posibilidades para el cuidado con la vida, con lo cotidiano y con la naturaleza. resalta la importancia y el compromiso en la construcción colectiva del ser ciudadano. palabras clave: ser humano, cuidado de la vida, relaciones, civilización humana. abstract the article presents some concepts of human being in relation with nursing care. from life organization, relations are established, interactions of human being, its limits and possibilities for life care, with daily life and with nature. it points out the importance and engagement in collective construction of the person. key words: human being, life care, relations, human civilization. alacoque lorenzini erdmann profesora titular de la universidad federal de santa catarina y doctora en filosofía de enfermería, pen/ufsc (brasil). luiz antonio bettinelli profesor titular de la universidad de passo fundo y doctor en enfermería, pen/ufsc (brasil). el ser humano y sus posibilidades de construcción desde el cuidado 49 a preocupación por la comprensión del ser humano se evidencia en todos los campos del conocimiento en el transcurrir de la historia. sus múltiples dimensiones posibilitan focalizar espacios, momentos, encuentros, condiciones y expresiones singulares, que permiten reafirmar su unidad, aparentemente imperfecta, ininteligible, imposible de ser comprendida por él mismo, ante el misterio de la naturaleza humana. así, parece que por la evolución del ser humano a través de los tiempos, se pueden referir algunas nociones, que dicen más de la estética del ser, presente en los ambientes naturales de la vida de los seres de este planeta, sintiendo, representando lo que se muestra o se caracteriza como ser humano. para morin (1), el ser humano “se define como trinidad: individuo, sociedad y especie”. es un ser “metativo, que a partir de sus aptitudes organizadoras y cognitivas crea nuevas formas de vida psíquica, espiritual y social”. es como homo complexus, es bipolarizado entre demens y sapiens, estando sapiens en demens y demens en sapiens, uno conteniendo al otro, antagónicos y complementarios, sin fronteras nítidas. tejen sus vidas entre lo utilitario, lo prosaico y lo lúdico, lo estético y lo poético, existiendo realmente. viven lo paradójico de la riqueza, de la libertad, de la felicidad, de la infelicidad, soportando la realidad en la tentativa de superar las incertidumbres y eliminar las angustias. el ser humano se define de modo bipolarizado en yin yang, siempre con la presencia de la afectividad: sapiens/demens; faber/ludens/imaginarius; economi/cus/consumans/esthetics; prosaicus/poeticus. también para morin (1) (p. 156), “el sobrevivir para vivir toma un sentido cuando vivir significa vivir poéticamente. vivir poéticamente significa vivir intensamente la vida, vivir de amor, vivir de comunión, vivir de comunidad, vivir de juego, vivir de estética, vivir de conocimiento, vivir de afectividad y de racionalidad, vivir asumiendo plenamente el destino de homo sapiens-demens, vivir insiriéndose en la finalidad trinitaria... (que dejó de imponerse por sí misma en nuestra civilización)”. pues el ser humano es el centro de la conciencia en la y por la sociedad, puede abrazar el mundo por la comprensión... puede construir una sociedad de alta complejidad, que comporta la autonomía individual y el civismo. en el vivir la vida, el ser humano ejercita variadas formas de relaciones o asociaciones afectivas, sociales o de trabajo, y cuidando de sí mismo y del otro o de las condiciones del vivir. el cuidado, ejercido por medio de los procesos de relación, interactivos y asociativos, está presente en la vida humana, en su proceso vital, en las condiciones naturales y sociales desde la concepción, nacimiento, crecimiento, envejecimiento, muerte y trascendencia. en este proceso de vida humana, el proceso del ser sano, enfermo y curado, pasa por los potenciales humanos y por los el cuidado, ejercido por medio de los procesos de relación, interactivos y asociativos, está presente en la vida humana, en su proceso vital, en las condiciones naturales y sociales desde la concepción, nacimiento, crecimiento, envejecimiento, muerte y trascendencia revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 50 riesgos relativos a que los individuos están expuestos en sus condiciones sociales y naturales de la vida. el proceso de vivir se traduce en sistemas de cuidado con diversas posibilidades de aplicación y en múltiples y variadas funciones o finalidades, pensando en ocasiones más sustantivamente, como científico, técnico, ético, estético y político, y en otras más empíricamente, haciendo parte de la vida y de la naturaleza. de este modo, el cuidado es necesario para el mantenimiento de las especies, como forma de enfrentamiento de las circunstancias a que están expuestas, substancial a la organización de cualquier sociedad, participando posiblemente de la constitución de la noósfera, de la vida de las ideas. la vida, o el proceso de vivir, es un continuo proceso de cuidado mutuo y simultáneo de sí mismo, de los otros, por los otros, de las formas vivas (seres vivos) y de los seres inanimados (mundo material físico). el ser humano transita en espacios y oportunidades de relaciones, vivenciando el cuidado en orden de su potencial y fuerza para demarcar, y utiliza de este espacio el derecho, la dependencia e interdependencia, la pertenencia y la privacidad. es a partir del ser humano, con él, en él y para él, que los movimientos y ondulaciones del vivir suceden y se muestran significativos como organización de la vida. todo ser humano busca el cuidado por la necesidad de sobrevivir y se cuidará según los valores de la vida establecidos y el amor propio, dependiendo igualmente de la voluntad de otras personas para su sobrevivencia. el cuidado parece ser la respuesta a las necesidades manifestadas o percibidas, siendo en ocasiones necesidades creadas o provocadas por diversos factores. el acto o acción de cuidar puede ser aprendido, des-aprendido, reaprendido, a pesar de ser único y particular, único y singular. las creencias y prácticas po-pulares y los cuidados profesionales muchas veces no se excluyen, aunque los espacios para los cuidados más complejos, técnicamente personalizados, son más reservados y se dan en ambientes propios. la actividad de cuidar surge de la creatividad humana, de la sensibilidad frente a los cambios con el otro y de las condiciones naturales de la capacidad del hombre de crear nuevas situaciones; de ejecutar una actividad humana con su estilo o modo de ser y hacer y de interactuar, y de su propia forma de presentar o representar el resultado de su actividad. es una actitud familiar con su propia vida, sus sentimientos y relaciones con seres de la naturaleza, que marca su originalidad porque consigue suscitar emociones y sentimientos en el ser humano, a veces agradables o confortables y en ocasiones agresivos, dolorosos, invasivos y desconfortables. la salud pasa por los movimientos u ondulaciones del vivir en los límites de las sensaciones, confort y desconfort, en la esperanza de nuevos momentos, en la posibilidad de estar en una situación y de prepararse para otra, y de sentir energía para superar los conflictos y exigencias del medio. lo saludable está en la posibilidad de estar vivo, de tener vitalidad y de ser feliz, animados en el vivir los altibajos en un vaivén de alegrías y tristezas, en la armonía regulada por la intersección de la vida y de la muerte. vivir la salud es vivir el amor, el placer, en la armonía conflictiva. es el querer vivir, querer evolucionar pleno de deseos y voluntades, cultivando los sueños y las esperanzas de crear, enfrentando los desafíos. la vida, o el proceso de vivir, es un continuo proceso de cuidado mutuo y simultáneo de sí mismo, de los otros, por los otros, de las formas vivas (seres vivos) y de los seres inanimados (mundo material físico). el ser humano y sus posibilidades de construcción desde el cuidado 51 el vivir las diferencias en el sistema de cuidados posibilita los procesos de relación. en esta relación se evidencia la negociación y el trueque, para llegar a la plenitud, donde el poder es conferido por los procesos de integración y diferenciación. estos no implican necesariamente el facilitar uno o sacrificar el otro, y sí pueden multiplicar ganancias y crecimiento mutuos, explorando el mundo de la incertidumbre y posibilidades, buscando sintonía con la heterogeneidad e integrando la diversidad. son cambios no siempre lógicos, racionales y conscientes, y sí rodeados de afectividad, emoción, empatía, intuición y otros elementos que forman la red de relaciones, en un juego de voluntades, aproximaciones y distanciamientos, promoviendo, alimentando las decisiones y el control. vivir la vida es conseguir intercalar lo prosaico con lo poético, los momentos de solidaridad orgánica y los momentos de solidaridad mecánica, ya que lo técnico o mecánico no puede ser dejado de lado; es vivir el bienestar de las cosas simples de nuestra cotidianidad, a pesar de exponerse a sucesos, tensiones y riesgos, los cuales son mutantes, imprevisibles y plenos de significados para la persona humana. el mundo propio de cada ser humano se llena por los cambios de energías de los diversos espacios o ambientes y por las relaciones de afecto en el estar con las personas, siendo solidario con el otro, ayudando a superar lo que se presenta como monótono y sofocante. las relaciones solidarias del cuidado, de la intuición, la razón y la lógica, dinamizan el arte de los procesos interactivos, por interacciones de relaciones múltiples inagotables, cuyos límites ultrapasan la finalidad objetiva que hace posible vivir la vida de manera saludable. en este orden de ideas se muestran las sensaciones vividas por las personas, su sensibilidad, la búsqueda del equilibrio como un modo de cuidar de sí mismo y del otro. de ser cuidado por los otros y de estar en este planeta sintiéndose integrante y perteneciente del mismo, en sus múltiples formas, conviviendo con y para el otro y en otros espacios. los actores sociales... ciudadanos de este planeta: son personas que tienen una historia de vida... son sensibles a lo que es bueno, importante, necesario, adecuado y agradable, y a lo que es monótono, sofocante o incómodo, a lo que es dado con amor, seguridad y responsabilidad. son seres humanos, personas que agradan y desagradan, actúan, reaccionan e interactúan, se aproximan y se distancian, se articulan, se asocian, dividen, negocian, interdependen, se ayudan, se diferencian, exploran como consumidores y son explorados, intercambian y se integran, que aprenden, desaprenden y reaprenden, sufren, lloran y reclaman, que se entregan, se reirguen, sueñan y sonríen, que estimulan, que aman y confortan, que esperan siempre recibir lo mejor, y estar libres de riesgos, que confían en la evolución humana, en las relaciones solidarias, en el respeto a lo que les pertenece, a lo que es del otro y a lo que es posible de ser compartido, en aquello que también puede ser suyo, en los múltiples límites del pertenecimiento, en los múltiples potenciales interiores, en la protección de la madre naturaleza, en la fe en las fuerzas divinas, en el querer vivir en una sociedad más justa, solidaria, sintiendo el cariño, el calor humano,... el sueño de una vida humana planetaria en una sociedad más civilizada. según los estudios de bettinelli (3), nosotros enfermeros demostramos conciencia solidaria en las relaciones de cuidado, haciendo emerger el sentido de la vida. por lo tanto, somos constructores de paz, cuidamos de la vida, cuidamos del ser humano... y reconocemos la importancia de la sensibilidad humana, indispensable para la construcción de una sociedad humanitaria. el mundo propio de cada ser humano se llena por los cambios de energías de los diversos espacios o ambientes y por las relaciones de afecto en el estar con las personas, siendo solidario con el otro, ayudando a superar lo que se presenta como monótono y sofocante. referencias bibliográficas 1. morin, edgar. el método 5: la humanidad de la humanidad (trad. de joemir machado da silva), porto alegre: sulina, 2002, 312 p. 2. erdmann, alacoque lorenzini. sistema de cuidados de enfermería, pelotas: universitária/ufpel, 1996, 138 p. (serie de tésis de enfermería/pen/ufsc, 01). 3. bettinelli, luiz antonio. la solidaridad en el cuidado: dimensión y sentido de la vida, florianópolis: ufsc/pen, 2002, 204 p. (tésis em enfemería, 41). 07. personas discap (60-65). revista aquichan issn 1657-5997 año 4 nº 4 60-65 bogotá, colombia octubre 2004 60 resumen el presente artículo se dirige no solo a los profesionales del área de la salud, sino a todas las personas interesadas en el mejoramiento de la calidad de vida de las personas con discapacidad, mediante la explicación de la diferencia entre los conceptos de discapacidad y minusvalía, y con argumentos que permiten el cambio de mentalidad hacia los individuos que la presentan. palabras clave: calidad de vida, bienestar social, vida autónoma, discapacidad, minusvalía, barreras, accesibilidad, enfermería en rehabilitación. abstract this article is written not only for health professionals, but for everyone interested in the improvement of life quality of handicapped people, explaining the difference between handicapped and impairment, with arguments allowing change of ideas, about people who have these problems. key words life quality, social welfare, autonomous life, handicapped, impairment, barriers, accessibility, rehabilitation nursing. * enfermera. especialista y magíster en evaluación educativa. profesora asistente, facultad de enfermería, universidad de la sabana, colombia. angela.hernandez@unisabana.edu.co ángela hernández posada* recibido: el 29 de abril de 2004 aprobado: el 9 de junio de 2004 las personas con discapacidad 61 uesto que la esencia del quehacer de la enfermería es el cuidado holístico de los seres humanos, entre los cuales cabe destacar aquellos con algún tipo de discapacidad, la meta de la profesión se orienta a asistir a estas personas (niños, adultos, ancianos), sus familias y cuidadores, para que se adapten de la manera más óptima y obtengan el mayor provecho de todas sus capacidades, no solo aprendiendo a manejar la discapacidad y logrando el grado más alto de independencia posible, estilos de vida saludables y la prevención de problemas secundarios, sino facilitando su integración al medio social en el cual se desenvuelven y el mejoramiento de su calidad de vida. según la oms, la discapacidad se define como: “toda reducción total o parcial de la capacidad para realizar una actividad compleja o integrada, representada en tareas, aptitudes y conductas”. esta reducción de la capacidad puede ser considerada como una deficiencia cognitiva, auditiva, visual, de habla y lenguaje, motora y de destreza, o asociada a la edad. en la actualidad, el término discapacidad no se considera como sinónimo de minusvalía o minusválido; este término tiene una connotación sociocultural, en la cual se considera que las personas, por su limitación, son incapaces de valerse por sí mismas; por lo tanto, se vuelven una carga para su familia y la sociedad. nacer con una discapacidad o adquirirla no debe convertirse en una limitante, que impida el desarrollo y la utilización de las potencialidades de una persona. esto suele ocurrir dentro de la sociedad, que desconoce que los seres humanos discapacitados también tienen derechos, como todos los demás, y los relega a un segundo plano. además, como han sido desconocidos y aislados de los demás grupos, y conforman sectores muy reducidos, carecen de poder social, político y económico. ahora bien, como las personas con discapacidad constituyen un grupo minoritario dentro de la sociedad, la mayoría de naciones no cuentan con una legislación que apoye su integración, derechos y deberes, como parte de la sociedad actual; esto hace que su calidad de vida y su bienestar se vean menoscabados, y que haya falta de comprensión, apoyo y oportunidades. por lo anterior, es importante aclarar los conceptos acerca de calidad de vida y bienestar social de una persona, los cuales abarcan no solo los aspectos materiales y económicos, que todo ser humano requiere para satisfacer sus necesidades básicas de supervivencia, sino también aquellos personales, físicos, emocionales y sociales. el bienestar social se puede definir como un valor cuya finalidad es que todos los miembros de la sociedad dispongan de los medios precisos para satisfacer aquellas demandas aceptadas como necesidades. y en cuanto a la calidad de vida, se podría decir que es: • la satisfacción experimentada por la persona con dichas condiciones vitales. • la combinación de las condiciones de vida y la satisfacción personal, ponderadas por la escala de valores, aspiraciones y expectativas personales. el concepto sobre calidad de vida comenzó a popularizarse en la década de los 60, hasta convertirse hoy en una noción utilizada en ámbitos muy diversos, como la salud física y mental, la educación, la economía, la política y el mundo de los servicios en general. la calidad de vida incluye aspectos vitales, tales como los físicos, fisiológicos y psicosociales (emocionales, espirituales, de revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 62 roles, de interdependencia, de autoestima). el hombre es un ser social ante todo, que necesita de los demás para sobrevivir, crecer, desarrollarse, alcanzar una adecuada autoestima e interdependencia, y desempeñar diferentes roles dentro de una sociedad cada vez más compleja y cambiante. todas las personas, sin distingo de raza, creencias o religión, tienen el derecho de vivir con dignidad y calidad. en especial aquellas con una discapacidad para realizar determinadas actividades, sin importar que la causa sea genética o adquirida. cabe resaltar que desde 1958 se está promulgando la readaptación profesional y el empleo de las personas con discapacidades, como está escrito en la historia, en los siguientes tratados: convenio sobre la readaptación profesional y empleo de personas inválidas, oit, 1958; declaración de los derechos del niño, onu, 1969; declaración de los derechos del retrasado mental, onu, 1975; declaración de los impedidos, onu, 1975; convenio sobre los derechos del niño, onu, 1989; normas uniformes sobre la igualdad de oportunidades para las personas con discapacidad, onu, 1993. declaraciones y convenios han sido el resultado de largos procesos, que han terminado con la adopción de disposiciones “obligatorias” para los estados miembros de las naciones unidas o del sistema interamericano. ellas se han convertido en tratados, en los cuales los estados expresan la voluntad y el compromiso de aplicarlas, pero su ejecución no se ha logrado del todo. cabe anotar que en latinoamérica, colombia es país pionero en tener una legislación en este campo, a partir de los años 70, cuando se comienzan a articular los derechos de las personas con limitaciones a los planes de acción definidos por las naciones unidas. desde entonces, el gobierno nacional se comprometió, en conjunto con los entes pertinentes, a dar respuestas a esa población. algunos decretos y resoluciones del gobierno colombiano han tratado de dar respuesta a dichos planes: • decreto 2358 de 1981, por el cual se creó el sistema nacional de rehabilitación. este no logró desarrollar los objetivos para los cuales fue creado, aunque identificó acciones que fortalecieron algunos sectores en el tema. • resolución 08321 de 1983, del ministerio de salud, sobre protección a sordos y conservación de la audición, de la salud y el bienestar de las personas, por causa de la producción y emisión de ruido. • resolución 14861 de 1985, del ministerio de salud, sobre protección, salud, seguridad y bienestar de las personas en el ambiente y en especial de los minusválidos. • ley 12 de 1987, que estableció requisitos de la construcción y del espacio público, para la eliminación de barreras arquitectónicas y posibilitar el acceso de las personas con discapacidades. • decreto 2737 de 1989, código del menor. en su título séptimo desarrolla lo pertinente al menor con deficiencia física, mental y sensorial, y crea el comité nacional para la protección del menor deficiente. asigna funciones y define responsabilidades sobre programas de protección y tratamiento, de educación especial y rehabilitación para los menores deficientes. sin embargo, la década de los 80 finaliza con el abandono de la población con discapacidad desde el ámbito gubernamentodas las personas, sin distingo de raza, creencias o religión, tienen el derecho de vivir con dignidad y calidad. en especial aquellas con una discapacidad para realizar determinadas actividades, sin importar que la causa sea genética o adquirida. las personas con discapacidad 63 tal, institucional y sectorial, y deja los anteriores actos administrativos como letra muerta, que no se aplicó ni se reglamentó. con el decreto 2164 de 1992 se crea, en el ministerio de salud, la división de servicios de rehabilitación, que tenía entre otras funciones la de promover, organizar y desarrollar el sistema nacional de rehabilitación. posteriormente se expide la ley 100 de 1993, en la cual se incluye el proceso de rehabilitación dentro del sistema de salud. en 1999, en colombia, los grupos focales convocados por la secretaría distrital de salud de bogotá y la alcaldía mayor participaron en el análisis de la situación de la discapacidad, y plantearon, entre otras, la siguiente definición para discapacidad: “la discapacidad se puede definir como la pérdida o disminución de una habilidad humana habitual o normal, que dificulta a través del tiempo su desempeño en una sociedad y su realización personal. se dice que dificulta, pero no que impide”1. el análisis resultante de estos grupos contribuyó al planteamiento de los lineamientos para la atención en salud de las personas con limitaciones en bogotá y el plan nacional para personas con discapacidad, en el cual se definen los lineamientos para la asistencia integral de la población con discapacidad, dentro del marco del plan del gobierno actual. hoy existe el plan distrital de discapacidad 2001-2005. aunque se han registrado avances, especialmente a nivel educativo, con respecto a los niños con limitaciones auditivas (educación bilingüe: comunicación total, solo señas, o verbo tonal total, señas y voz), hasta la fecha es poco lo que se ha aplicado en cuanto a las demás limitaciones, teniendo en cuenta que la población colombiana con discapacidad oscila entre el 10 y el 15%, cifras que no son diferentes a las que se manejan en países similares al nuestro. lo dramático es que cerca del 30% de esta población se encuentra por debajo de las líneas de pobreza y miseria, lo cual hace aún más difícil lograr el mejoramiento de su calidad de vida, si no se destinan recursos especiales y se crean empleos para que puedan obtener recursos para su subsistencia. para alcanzar una adecuada calidad de vida de las personas con discapacidad, además de destinar recursos y desarrollar programas específicos, se debe permitir ante todo la autonomía de ellas, lo cual hace indispensable la puesta en práctica de los siguientes derechos: • vida autónoma. • elección y autodeterminación. • participación y responsabilidad. • solidaridad, antes que compasión. al hablar de vida autónoma, no se trata de que la persona con discapacidad viva sola, sino que tenga las posibilidades de elegir, trabajar, relacionarse con los demás, amar y ser amada, y tener una vida privada, con participación en todos los ámbitos de la sociedad; ante todo, que pueda tomar sus propias decisiones. la persona que enfrenta alguna discapacidad, inicialmente no es consciente de sus propias potencialidades, en especial si se trata de un adulto, que llevaba una vida sin limitación de sus capacidades. él está ante una situación difícil de aceptar, y le cuesta más trabajo y tiempo enfrentar su nueva realidad. por ello, necesita el apoyo y la orientación de los demás, para la aceptación de sí mismo, el conocimiento y autodescubrimiento de sus capacidades, logros y alcances, y se le debe respetar la posibilidad de elección. en cambio, cuando un niño nace con una discapacidad se adapta con mayor facilidad y naturalidad, ya que convive con 1. secretaría distrital de salud de bogotá, d.c., dirección de salud pública. lineamientos de atención en salud para personas con discapacidad en bogotá, d.c. julio 2002, p. 30. “la discapacidad se puede definir como la pérdida o disminución de una habilidad humana habitual o normal, que dificulta a través del tiempo su desempeño en una sociedad y su realización personal. se dice que dificulta, pero no que impide”. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 64 ella desde su nacimiento. en el transcurso de su desarrollo aprende a utilizar sus potencialidades y capacidades, y llega a relacionarse con los demás. cuando un niño o un adulto con discapacidad puede elegir entre distintas opciones, como alimentación, recreación, actividades de formación y trabajo, vivienda, va adquiriendo autonomía y decisión, lo cual le permite buscar una forma de vida acorde con sus expectativas reales, y asumir las consecuencias de sus actos sin invadir el espacio de otros, ni ser invadido en el suyo. otro aspecto para resaltar es el de la solidaridad, que se expresa en la unión de las personas hacia un fin común y en la responsabilidad recíproca individual consigo mismo y con los demás. la solidaridad se ve reflejada en las actividades que realiza un individuo para mejorar las condiciones de vida, a partir de la toma de conciencia ante las situaciones que afectan a los individuos, sus necesidades, al descubrir las causas que afectan una situación y, ante todo, al reconocer la dignidad de la persona. desconocer los aspectos anteriormente mencionados crea parte de las barreras que dificultan e impiden una vida autónoma, entre las cuales cabe también mencionar la negación ante la discapacidad, el sentimiento de vergüenza, los prejuicios, la falta de apoyo, la indiferencia y huida ante una persona discapacitada, la generalización acerca de que si se tiene una discapacidad, esta afecta y limita a la persona en todo, y la falta de accesibilidad, entendida esta última como una característica básica del entorno construido, para permitir llegar, entrar y salir de lugares, edificios, parques, usar objetos, equipos y herramientas. para eliminar las barreras que dificultan la autonomía de las personas con discapacidad, se debe integrarlas en todos los niveles, en procesos de reflexión y toma de decisiones, a nivel político, social, económico, de planeación (urbanística, arquitectónica, de diseño industrial) y recreativo, favoreciendo la participación y el acceso de animales adiestrados para ayudar en actividades específicas (perros de asistencia), desmitificando la incapacidad y eliminando el sensacionalismo y las exageraciones. esto puede lograrse de diversas formas, mediante campañas de información a través de los medios de comunicación masiva, que difundan una imagen adecuada e integradora e insistan en la riqueza que existe en la diferencia y la diversidad en una sociedad; con la creación de centros de ayuda, asesoramiento y formación, y el reordenamiento de los servicios. todo esto permitirá ir evolucionando del mantenimiento y la dependencia hacia la participación activa y el fomento de la vida autónoma y la productividad. también se hace necesario modificar y adaptar los entornos inmediatos, las viviendas, las edificaciones y los parques, utilizando ayudas técnicas al alcance de todos los niveles sociales, con el apoyo indispensable del estado, desde el punto de vista legislativo, urbanístico y divulgativo, y la vinculación del sector empresarial y privado para obtener mayores y más rápidos recursos. además, se deben promulgar leyes y legislaciones que autoricen el acceso y la permanencia de los perros de asistencia, debidamente adiestrados, en transportes y edificios, lugares públicos, etc., como ayudas esenciales para las personas con discapacidades y no como animales perturbadores, que pongan en riesgo al usuario y a la demás población. sin embargo, el cambio de mentalidad no debe ser solo dentro de la sociedad. es necesario que las personas con discapacidades afronten su realidad, enfrenten los cambios de vida que requieren para adaptarse, se formen y reciban apoyo, y que sus familias y cuidadores sean a su vez un apoyo para ellos, manteniendo un diálogo permanente en este proceso de adaptación otro aspecto para resaltar es el de la solidaridad, que se expresa en la unión de las personas hacia un fin común y en la responsabilidad recíproca individual consigo mismo y con los demás. las personas con discapacidad 65 es donde los diferentes profesionales de la salud y de otras áreas deben actuar interdisciplinariamente. entre todos ellos, el profesional de enfermería tiene un papel preponderante, el cual se está retomando en la actualidad, puesto que no se le ha dado la relevancia que tiene. las enfermeras que se desempeñan en la rehabilitación y el cuidado de las personas con limitaciones deben adquirir conocimientos, experiencia y experticia, para enseñar a las comunidades y grupos acerca de las discapacidades, los estilos de vida saludables, los derechos y deberes, las necesidades de las personas que las tienen y las diferentes maneras para apoyarlas en su crecimiento y desarrollo personal, laboral y social. así se va logrando sensibilizar a la comunidad, para que las personas con alguna discapacidad se vayan involucrando en los servicios de atención en salud y en todos los procesos de la vida cotidiana, social, laboral y política, como usuarios y clientes y no como víctimas. las organizaciones que reúnen a las personas con determinada discapacidad también tienen un papel importante, ya que deben difundir información positiva, que llegue al público en general a través de los medios de comunicación masiva, en los cuales se logre una imagen integrada. conviene insistir en la riqueza de la diferencia y la diversidad, no en lo que le falta a la persona o no puede hacer, sino en lo que tiene y es capaz de hacer. finalmente, se puede concluir que a medida que esto se vaya logrando, se podrá evaluar si se está mejorando la calidad de vida de los discapacitados. esta evaluación se convierte en una herramienta que puede superar los modelos médicos, psicométricos e incluso sociales, ya que lejos de evaluar a quien tiene una discapacidad, se brinda un modo de descubrir el potencial de cada persona, que puede cualificarse a través de los siguientes indicadores: • experiencia de las propias capacidades. • presencia y participación en la comunidad. • respeto. • rol que desempeña dentro de una comunidad. para finalizar, no olvidar la siguiente frase: cuando te encuentres una persona con discapacidad, no te fijes en lo que le falta; mírala a los ojos, y descubrirás lo que es y sus potencialidades para llegar a hacer. bibliografía american academy of pediatrics. guidelines for pediatric home health care, aap, usa, elk grove, 2002. concepto europeo de accesibilidad, imserso-ceapat, madrid, 2000. de la rosa, raúl. el lugar y la vida, barcelona, rba, 1998. ekberg, jan. un paso adelante: diseño para todos (proyecto include), documentos ceapat: imserso-ceapat, madrid, 2000. hale, glorya, et al. the source book for the disabled, paddington press, ltda., 1990. meleski, debra d. “families with chronically ill children”, american journal of nursing, vol. 102, nº 5, may 2002. restrepo arbeláez, ricardo. rehabilitación en salud, ed. universidad de antioquia, 1995. secretaría de salud de bogotá, d.c. plan distrital de discapacidad 20012005, secretaría de salud, alcaldía mayor de bogotá, d.c., 2001. secretaría de salud de bogotá, d.c. lineamientos de atención en salud para las personas con discapacidad en bogotá, d.c., secretaría de salud, alcaldía mayor de bogotá, d.c., 2001. valenzuela, josé c. las discapacidades en el protocolo, madrid, ed. protocolo, 2001. venolia, carol. casas que curan, barcelona, martínez roca, 1995. 240 255 formacion licenciado en enfermeria.indd 240 carolina elena luengo-martínez1 olivia sanhueza-alvarado2 formación del licenciado en enfermería en américa latina 1 universidad del bio bio. chile. caroluengo@gmail.com 2 universidad de concepción. chile. osanhueza@udec.cl recibido: 6 noviembre de 2014 enviado a pares: 21 de enero de 2015 aceptado por pares: 5 de noviembre de 2015 aprobado: 31 enero 2016 doi: 10.5294/aqui.2016.16.2.11 para citar este artículo / to reference this article / para citar este artigo luengo martínez ce, sanhueza alvarado o. formación del licenciado en enfermería en américa latina. aquichan. 2016; 16(2): 240-255. doi: 10.5294/aqui.2016.16.2.11 resumen antecedentes: actualmente, américa latina requiere profesionales en enfermería cuyo perfil de egreso pueda responder a los cambios que ha traído consigo la globalización. se sabe que la formación del licenciado en enfermería es disímil en los países de américa latina e, incluso, al interior de estos. objetivo: describir la formación del licenciado en enfermería en américa latina en términos de plan de estudio, reglamentación u organismos regulatorios, tiempo, requisitos de egreso y perfil del licenciado. materiales y método: revisión bibliográfica de las páginas web de universidades latinoamericanas que forman licenciados en enfermería; los criterios de inclusión fueron: ranking de universidades del país (cuando existía), universidades con página web actualizada y disponibilidad de la información. conclusión: se constata la heterogeneidad en la formación del licenciado en enfermería en américa latina, que puede ser un factor de debilitamiento para la disciplina así como para la profesión. se sugiere un consenso sobre una formación curricular común en la región, que apunte a un perfil profesional apropiado, que proporcione la capacidad de enfrentar y satisfacer las necesidades que traen consigo los desafíos de nuestro tiempo. palabras clave américa latina, enfermería, educación, currículo, escuelas de enfermería (fuente: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 240-255 241 formación del licenciado en enfermería en américa latina l carolina elena luengo-martínez y otro año 16 vol. 16 nº 2 chía, colombia junio 2016 l 240-255 training for a bachelor´s degree in nursing in latin america abstract background: latin america currently requires nursing professionals whose profile upon graduation responds to the changes brought about by globalization. it is a known fact that training for a bachelor’s degree in nursing is not the same throughout latin america and is even different within these countries. objective: the study was designed to describe the training provided for a bachelor’s degree in nursing in latin america with respect to curriculum, regulations or governing bodies, time, graduation requirements and the profile of those who hold a degree of this type. materials and method: a bibliographic review of the websites of latin american universities that offer a bachelor’s degree in nursing was done. the criteria for inclusion were the following: the university’s ranking within the country (when ranking exists); universities with updated website, and availability of information. conclusion: the training provided for a bachelor’s degree in nursing in latin america was found to be heterogeneous. this might be a factor that weakens the discipline and the profession. it is suggested that a consensus be reached on a common curriculum for the region, specifically one that aims for an appropriate professional profile that provides the ability to cope and to satisfy the needs occasioned by the challenges posed in today’s world. keywords latin america, nursing, education, curriculum, nursing schools (source: decs, bireme). 242 aquichan issn 1657-5997 formação do licenciado em enfermagem na américa latina resumo antecedentes: atualmente, a américa latina exige profissionais em enfermagem cujo perfil de formando possa responder às mudanças que trouxe consigo a globalização. sabe-se que a formação do licenciado em enfermagem é diferenciada nos países latino-americanos e, inclusive, no interior destes. objetivo: descrever a formação do licenciado em enfermagem na américa latina em termos de plano de estudo, regulamentação ou organismos regulatórios, tempo, requisitos de ingresso e perfil do licenciado. materiais e métodos: revisão bibliográfica das páginas web de universidades latino-americanas que possuem licenciatura em enfermagem; os critérios de inclusão foram: ranking de universidades do país (quando existia); universidades com página web atualizada e disponibilidade de informação. conclusão: constata-se a heterogeneidade na formação do licenciado em enfermagem na américa latina que pode ser um fator de debilidade para a disciplina bem como para a profissão. sugere-se um consenso profissional sobre uma formação curricular comum na região que aponte a um perfil profissional apropriado, que proporcione a capacidade de enfrentar e de satisfazer as necessidades que os desafios do nosso tempo apresentam. palavras-chave américa latina, enfermagem, educação, currículo, escolas de enfermagem (fonte: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 240-255 243 formación del licenciado en enfermería en américa latina l carolina elena luengo-martínez y otro introducción los cambiantes escenarios económicos, políticos, culturales y ambientales producto del progreso tecnológico, de las comunicaciones; el aumento de la conectividad internacional, de los índices demográficos, las transiciones epidemiológicas, entre otros, han influido en la salud de la población (1) generando necesidades y demandas nuevas hacia las profesiones, las cuales deben adaptarse a estos cambios, incluso anticiparse a ellos (2). el cuidado, esencia de la disciplina de enfermería, constituye “un verdadero reto” en un mundo globalizado (3); en ese sentido, los establecimientos de educación superior deben adaptar sus planes curriculares para poder hacer frente a los nuevos cambios que se avistarán. enfermería, gracias a una producción ascendente de conocimientos, ha evolucionado como disciplina, lo que le ha permitido estructurar un cuerpo de conocimientos propios (4), sin cuya existencia el desarrollo disciplinar se vería estancado (5). los puntos anteriores han sido reconocidos y promovidos en la estructura curricular de enfermería en américa latina, formando profesionales con el grado de licenciado, los cuales presentan diversas competencias, como la de investigación, donde desarrollan el pensamiento crítico que les permite realizar juicios y tomar decisiones fundadas; competencias en el ámbito asistencial, que los facultan para dar cuidado integral al individuo, la familia y la comunidad, con un enfoque humanista; también se destaca la formación de competencias en el ámbito de la gestión, la administración, la educación y la ética (2). sin embargo, y a pesar de los adelantos y la globalización, aún la formación del licenciado es disímil en los países de américa latina, e incluso al interior de los mismos. las causas pueden ser de diversa índole: sociocultural, política, económica, ya que cada país ostenta un desarrollo económico y cultural diverso, con necesidades específicas y realidades únicas, siendo necesario reconocer también la responsabilidad que les corresponde a los propios enfermeros docentes, que forman a los futuros profesionales. por otro lado, esta heterogeneidad también puede deberse a que la formación universitaria de la enfermera es un proceso que se ha desarrollado en “diferentes épocas” (6); lo cierto es que en la estructura de los países existen diversos niveles de formación profesional para satisfacer esas necesidades. cualquiera sea el origen, esta heterogeneidad puede ser un factor que impide a la disciplina su crecimiento y desarrollo, así como también a la profesión, y produce en esta última área una diferenciación de las funciones de cada uno de los niveles de enfermería, así como en las responsabilidades de cada cual frente a los cuidados otorgados. se reitera así lo expresado por carvalho, quien señalaba que lo realmente importante es formar con un perfil profesional adecuado, que sea capaz de enfrentar y satisfacer las necesidades que traen consigo los desafíos de nuestro tiempo (7). la educación profesional y la preparación de los recursos humanos para el campo laboral y para la vida es y será un asunto en constante “cuestión”, quizás más en el campo de la salud, donde los cambios son periódicos y la satisfacción de los problemas de salud va más allá del ámbito de acción de esta. la presente revisión tiene como objetivo describir la formación del licenciado en enfermería en américa latina en términos de: estructura del plan de estudio, reglamentación u organismos regulatorios, tiempo y requisitos de egreso, y perfil del licenciado, de acuerdo con la información disponible de cada país, con el propósito de lograr una visión general de la formación de licenciado en enfermería en américa latina. se espera que esta revisión, por un lado, contribuya a ampliar el conocimiento de la realidad en la formación de profesionales de enfermería con grado de licenciado en las distintas regiones de américa latina y, por otro, que promueva un análisis regional con miras a aunar criterios referentes a una estructura curricular común. materiales y método se trata de una revisión bibliográfica, cuyos datos se obtuvieron de las páginas web de las asociaciones de enfermería, asociaciones de facultades o escuelas de enfermería y colegios profesionales de cada país, ministerios de educación y de salud, normativas legales vigentes, diarios oficiales y organización panamericana de la salud (ops); así mismo, de las propias universidades, utilizando como criterios de selección: universidades que formaran licenciados en enfermería, ranking de las universidades de un país (cuando este dato existía), universidades con página web actualizada al año 2014 y la disponibilidad de información que presentaran en sus páginas web. se revisaron 86 páginas web, y, de acuerdo con los criterios de selección, se consideraron 62 de ellas. se utilizó el navegador google chrome donde se usaron los descriptores: “licenciado en enfermería”, “grado de licenciado”. esta investigación consideró dentro de sus aspectos éticos la declaración de singapur sobre la integridad en la investigación 244 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 (8), y para cada etapa de este estudio los siete requisitos éticos de e. emanuel (9) y los principios bioéticos de beneficencia y no maleficencia (10). además, se realizó una entrevista estructurada a enfermeras de costa rica, méxico, perú y ecuador con residencia en chile, seleccionadas intencionalmente. las preguntas estuvieron orientadas a conocer la formación del profesional de enfermería en sus países, la existencia del grado de licenciado y los requisitos para su obtención. las respuestas se registraron en notas de campo y, posteriormente, se agruparon las respuestas con base en categorías apriorísticas, surgidas de la revisión previa de las páginas web correspondientes a: estructura del plan de estudio, reglamentación u organismos regulatorios, tiempo y requisitos de egreso y perfil del licenciado, lo cual permitió verificar la información obtenida de las páginas web y una mayor comprensión de la misma. desarrollo en el último siglo, el avance de la enfermería como profesión y disciplina en américa latina se ha incrementado de la mano de los avances científico-tecnológicos, y los cambios económicos, sociales y políticos que vive la sociedad actual, permitiendo con ello su fortalecimiento. otros factores que han contribuido a esto son el reconocimiento del rol crucial que cumple el enfermero(a) en la salud de las poblaciones, “factor esencial de la atención de salud” (11) y, secundariamente, el “proceso de profesionalización de la enfermería en los países de américa latina y del caribe”. este último se ha caracterizado por la transformación de la educación de la enfermera(o) desde un estilo técnico desarrollado en hospitales del siglo pasado hasta la modalidad universitaria, renovación de los reglamentos, regulación de la educación y la práctica, y la aparición de cada vez más establecimientos de carácter privado (12). los inicios de la enfermería en américa latina se remontan a la época precolombina con los curanderos y, posterior a 1900, adquiere un enfoque sanitario, bajo el alero de las congregaciones religiosas. en este momento nacen las primeras escuelas de enfermería en argentina, cuba, chile, méxico y uruguay. la segunda guerra mundial intensifica el surgimiento de un mayor número de escuelas. las condiciones socioeconómicas y culturales particulares le van dando a cada país sus características particulares, las que inciden en el desarrollo heterogéneo que han tenido (13, 14). la situación actual de la enfermería en américa latina, que representa un 50 a 60 % de la fuerza laboral del sistema de salud, según nájera y castrillón, puede verse desde tres focos diferentes pero relacionados entre sí: posición de la enfermería en el mercado laboral, en términos del desarrollo del recurso humano; estrategias de planificación de este recurso humano en los distintos países de la región, y formación de enfermería en cada uno de los países (14); este último tema se abordará más ampliamente en este ensayo desde la perspectiva de la obtención del grado de licenciado en enfermería en américa latina. el término américa latina se utiliza la mayoría de las veces para representar al conjunto de países de américa continental y el caribe, cuyos habitantes hablan el español o el portugués, correspondientes a 19 países: argentina, bolivia, brasil, colombia, costa rica, cuba, chile, ecuador, el salvador, guatemala, honduras, méxico, nicaragua, panamá, paraguay, perú, república dominicana, uruguay y venezuela (15). al revisar el marco histórico de la profesión, oguisso menciona que “su quehacer se ha orientado al ámbito asistencial con énfasis en lo curativo, donde se han considerado aspectos administrativos, organizativos y de evaluación de servicios”. y que asociado a las transiciones epidemiológicas y demográficas de la población y la introducción de las reformas de salud en américa latina, ya en los años 80, la enfermería “enfoca su actividad a otros campos, principalmente a la atención primaria y al trabajo comunitario” (12). más adelante, la formación de los profesionales de enfermería se desarrolla en paralelo con la de disciplina científica, como profesión transdisciplinaria del campo de las ciencias sociales y de la salud, en la cual va clarificando su objeto de estudio e intervención como el “cuidado humano”, asociado al desarrollo, la protección y recuperación de la salud, lo que beneficia al “sujeto humano como ser cultural, a la familia, a los grupos, a las comunidades y a la sociedad como unidades de análisis y cuidado” (16). además, este cuidado de enfermería, descrito como “único y universal”, debe garantizar los principios de equidad, oportunidad y calidad de la atención (17). lo expuesto implica una formación de profesionales inserta en el cambio de paradigma sanitario, de biomédico a la producción social de salud, y a los nuevos conceptos de salud integral y salud global. la educación, por ende, cumple un rol preponderante, al formar profesionales capaces de hacerse cargo de estos cambios paradigmáticos y, a la vez, formar un “sujeto ético”, aquel sujeto social que posee una autonomía que le permite establecer juicios de valor y ser capaz de asumirlos (18). como queda evidenciado, la formación del profesional de enfermería es compleja, ya que debe poseer y adquirir conocimientos y habilidades que le permitan desempeñarse con calidad, eficiencia y efectividad en “la 245 formación del licenciado en enfermería en américa latina l carolina elena luengo-martínez y otro promoción, prevención, diagnóstico, curación y rehabilitación de pacientes” (19), no solo de aquellos aquejados por enfermedades, tanto físicas como psicológicas. de esta manera, la formación de este recurso humano debe “anticiparse a los requerimientos de la sociedad, formando un profesional con una visión amplia e intersectorial” (20). por otro lado, el profesional de enfermería debe ser capaz de contribuir al desarrollo desde una base científica, con el fin de entregar cuidados seguros y de calidad, basados en la mejor evidencia disponible. para ello, su formación debe proporcionarles competencias en investigación, que en el ámbito de enfermería implicarían: …la capacidad de la enfermera(o) asistencial de demostrar las aptitudes, los conocimientos y las destrezas necesarias para generar, validar y clarificar los conocimientos que permitan encontrar y dar solución a los problemas de la práctica de enfermería, mejorar la calidad del cuidado y, al mismo tiempo, la calidad de vida de las personas involucradas (2). lo anterior se plasma en los currículos a través del perfil de egreso, que permite responder a todos estos cambios. el perfil de egreso se entiende como el “conjunto de cualidades y características que de acuerdo a los conocimientos, habilidades, aptitudes y valores le permiten a una persona asumir las actitudes y competencias requeridas en una responsabilidad definida” (20); también, como la “imagen contextualizada de la profesión en un momento y lugar, que orienta la determinación de los objetivos curriculares, sirve de referencia para la valoración de la calidad de la formación y para la elaboración de clasificadores de cargo” (21). de esta forma se converge en el grado de “licenciado” que, según la rae, es la “persona que ha obtenido en una facultad el grado que la habilita para ejercerla” (22). usualmente es un título que se obtiene al terminar una carrera universitaria de entre 4 y 6 años (2). las licenciaturas se desarrollan en torno a un área del saber y, generalmente, en muchas universidades sus estudios deben culminar con un trabajo que, de acuerdo con el país investigado en latinoamérica, puede adquirir diferentes nombres: tesis, trabajo final de grado, trabajo final integrador, proyecto de fin de carrera, entre otros. los estudios conducentes al grado de licenciado comprenden (23) todos los aspectos esenciales de un área de conocimiento o disciplina determinada que, como se mencionó, permiten desarrollar en el estudiante ciertas capacidades que le posibilitan progresar en aspectos específicos de ciertas áreas o disciplinas, desarrollando competencias en el manejo conceptual y metodológico básico en su área de formación, capacidad para interpretar críticamente, analizar y aplicar conocimientos en la solución de problemas; capacidad para gestionar y comunicar información y conocimientos de manera autónoma, para trabajar en equipo y redes, para comprender y actuar teniendo en cuenta lo propio del país y su interdependencia con el mundo globalizado, y para investigar y trabajar interdisciplinariamente en esa área del conocimiento. en chile, y en la gran mayoría de los países de américa latina, les corresponde solo a las universidades la potestad de otorgar grados académicos, en especial de licenciado, magíster y doctor. en chile, para obtener el título profesional, es requisito haber obtenido el grado de licenciado previamente (24); además, en este país, una carrera de cuatro años de duración debe cumplir con 240 créditos y una de cinco años, que es el caso de las licenciaturas, debe cumplir con 300 créditos; el número de horas para un año académico de trabajo efectivo oscila entre 1.440 y 1.900 (25). un estudio realizado en nueve facultades y escuelas de enfermería de países latinoamericanos pertenecientes a la asociación latinoamericana de escuelas y facultades de enfermería (aladefe), denominado “innovación en la formación del licenciado en enfermería” (2), describe que el perfil del licenciado “se orienta hacia un profesional generalista, capacitado para la asistencia integral del individuo, familia y comunidad, la gestión y administración, investigación y educación” (2). por otro lado, una característica que distingue al profesional de enfermería con carácter de licenciado, del técnico o auxiliar de enfermería, es la capacidad de usar el razonamiento científico en el análisis de problemas de su marco disciplinar (26). así, como se expuso, la formación de los profesionales de enfermería en las distintas regiones de américa latina no es homogénea, es producto de un proceso que se desarrolló en “diferentes épocas”, como afirma caligiore (6), y que se estructura con base en diversos “niveles de formación”, los cuales no solo varían entre países, sino además al interior de un mismo país. generalmente existen tres o más categorías de personal, y se carece muchas veces de límites claros en las acciones que desarrollan en el campo ocupacional (14). esta heterogeneidad entraña poca claridad en la delimitación de funciones, interfiere en el costoeficacia del cuidado de enfermería y es probablemente una de las causas del deterioro en el posicionamiento y la imagen social del grupo profesionales. resulta interesante entonces conocer la realidad de la obtención del grado de licenciado en enfermería en américa latina y, de eso modo, contribuir a una mejor comprensión de la propia formación. 246 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 resultados en términos generales, los planes de estudio presentan asignaturas de formación básica, profesional y complementarias u optativas, las cuales son impartidas en ciclos de formación, con un primer, segundo y tercer ciclo; en países con salidas intermedias de carácter técnico solo se cumplen los dos primeros ciclos, ya que el tercero involucra las áreas temáticas distintivas del licenciado en enfermería que corresponden, en la mayoría de los países, a gestión-administración, docencia, aspectos ético-legales e investigación, pero con horas y número de créditos diferentes. tabla 2. reglamentación u organismos regulatorios países niveles de formación colombia, chile, ecuador, panamá, uruguay enfermero profesional licenciado en enfermería técnico nivel superior auxiliar de enfermería bolivia, argentina, costa rica, el salvador, guatemala, honduras, paraguay, perú, república dominicana, venezuela licenciado enfermería enfermeros, enfermero nivel técnico superior, enfermero nivel medio universitario, bachiller o diplomada en enfermería, enfermeras con grado de tecnóloga o técnica auxiliares de enfermería, auxiliar comunitario, técnico medio en enfermería brasil, cuba licenciado en enfermería enfermero técnico, enfermero básico, técnicos medios técnico en enfermería auxiliar enfermería puerto rico enfermera especialista enfermera generalista enfermera asociada enfermera practica licenciada en enfermería méxico enfermera especialista licenciada en enfermería enfermera técnica especializada enfermera técnica enfermera profesional países reglamentos colombia, chile, ecuador, panamá, uruguay, república dominicana, venezuela, bolivia, argentina, costa rica, el salvador, guatemala, honduras, paraguay, perú, brasil, cuba, puerto rico, méxico y nicaragua ley educación superior, código sanitario, ministerio salud, ministerio educación, decretos supremos, junta educación, ministerio educación y cultura colombia asociación de enfermeras colombia, perú asociación facultades o escuelas enfermería cuba, paraguay, república dominicana dirección nacional general enfermería el salvador dirección de servicios de enfermería costa rica, guatemala, honduras puerto rico, perú colegio de enfermeras méxico, panamá comisión permanente de enfermería/ comité nacional enfermería fuente: elaboración propia (2798). referente al perfil de egreso al momento de la revisión todos los países estudiados, a excepción de honduras (64), tienen declarado un perfil de egreso que difiere según el establecimiento de educación superior, siendo bastante heterogéneos; sin embargo, se rescatan términos comunes en algunos de ellos: formación humanística, ética, calidad humana, formación en investigación, prevención, promoción, fuente: elaboración propia (27-98). tabla 1. niveles de formación de enfermería en los países de américa latina países niveles de formación nicaragua enfermera con maestría enfermera con licenciatura enfermera especialista o con posbásico enfermera profesional o general enfermera básica o técnico medio técnica quirúrgica auxiliar de enfermería 247 formación del licenciado en enfermería en américa latina l carolina elena luengo-martínez y otro discusión la formación en enfermería está marcada por distintos niveles, en general se establecen tres: profesional, salida intermedia técnica o básico y auxiliar de enfermería. países como colombia, chile, ecuador y uruguay solo presentan dos niveles en la formación —profesional y técnico—, y otros como méxico, nicaragua y puerto rico tienen entre cuatro y seis niveles. como postula durán de villalobos hoy en día, y lo hizo rogers hace ya veinte años, es justamente la “naturaleza, profundidad y utilización” que se hace del conocimiento lo que diferencia el nivel técnico del profesional y condiciona la práctica de enfermería (5). citando el ejemplo de durán de villalobos, un auxiliar y una enfermera cuidan pero es la naturaleza, profundidad y expresión del conocimiento de cuidar lo que hace una práctica diferenciada (5). entonces, el problema surge cuando no se vislumbra la distinción en las actuaciones de una y otra, esto puede enfatizarse cuando existen muchas “figuras de enfermería”, como es el caso de países como méxico, nicaragua y puerto rico, que hacen una gran diferenciación en la formación del personal de enfermería, existiendo hasta siete niveles de formación. surge entonces la pregunta: ¿puede ser esto adecuado? desde una perspectiva docente-asistencial se considera que no, ya que muchas veces es difícil distinguir y visibilizar los cuidados de enfermería y diferenciar nuestra labor del resto de las profesiones de salud, por lo que esta fragmentación puede confundir las funciones e interferir en el cuidado propiamente tal, al ser entregado tan fragmentado como el número de personas que lo proporciona, lo que causando un posible detrimento de la propia imagen ante la sociedad, y, más aún, de la visión holística del individuo. la mayoría de las universidades tiene un plan curricular que considera el desarrollo de asignaturas fundamentales donde se imparten conocimientos de las ciencias básicas e introductorios y fundantes de la disciplina; en años más avanzados se imparten asignaturas a nivel profesional, en las cuales se desarrollan conocimientos, habilidades y actitudes relacionadas con la función y el rol profesional y, finalmente, durante todo el periodo tienen asignaturas complementarias o electivas que pueden ser de temas profesionales o de otras áreas como culturales, deportivas. la formación curricular de un licenciado se diferencia de la formación de nivel técnico por el desarrollo de las áreas de metodología de la investigación, gestión y administración, y temas éticos. se destaca que algunas universidades entregan formación de inglés o de idiomas autóctonos como el quechua. tabla 3. duración de los estudios del licenciado países tiempo estudio república dominicana, ecuador méxico, paraguay puerto rico 4 años / 8 semestres argentina, brasil, colombia, cuba, salvador, nicaragua, uruguay, panamá 4 a 5 años / 8-10 semestres bolivia, chile, guatemala, honduras, perú, venezuela, costa rica 5 años / 10 semestres fuente: elaboración propia (27-98). tabla 4. requisitos de egreso para licenciatura países requisitos de egreso uruguay, venezuela, nicaragua, república dominicana, costa rica, chile, el salvador, perú trabajo especial grado, tesis, trabajo investigación, memoria de grado y práctica universitaria supervisada, servicio comunitario, internado argentina, brasil, colombia, guatemala, panamá, puerto rico trabajo grado, tesis, trabajo final investigación, trabajo monográfico bolivia trabajo monográfico, trabajo investigación o internado profesional ecuador, honduras, méxico, paraguay servicio salud rural, práctica cuba examen estatal fuente: elaboración propia (27-98). recuperación, rehabilitación, liderazgo, responsabilidad legal, reflexión, trabajo inter y multidisciplinario, toma de decisiones, aplicación de juicio crítico, servicio integral, calidad y seguridad, planificación, ejecución y evaluación del cuidado. cabe señalar que argentina presenta un perfil del licenciado declarado por la asociación de escuelas universitarias de enfermería de la república argentina (aeuera) válido para todas las universidades que imparten la carrera (31). 248 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 la mayoría de los países tienen una clara legislación referente al ejercicio profesional y la formación universitaria del profesional de enfermería. se destaca que en países como colombia y el salvador existan además otros organismos que regulan el ejercicio profesional como asociaciones nacionales de enfermeros o juntas de vigilancia de enfermería. referente a los colegios profesionales, la mayoría no requiere de una colegiatura de carácter obligatorio, pero existen países como guatemala, ecuador, puerto rico, costa rica, honduras y perú en los que, para ejercer la profesión, se debe estar registrado en un colegio de enfermeras, es decir que la colegiatura es obligatoria y los colegios tienen el rol de velar por el ejercicio profesional. es válido que la regulación del ejercicio de enfermería esté implementada en los países de américa latina y que existan, además de las leyes gubernamentales, organismos específicos que regulen el ejercicio profesional ya que resulta trascendente para proteger a las personas de los daños causados por una mala práctica a causa de una mala formación. la calidad y seguridad del usuario deben ser prioritarias en el ejercicio de la profesión. se destaca el rol que cumple el colegio de enfermeras en países como costa rica, guatemala u honduras, al velar por el ejercicio profesional, al ejercer un rol de supervisión y fiscalización de los servicios de enfermería; es por eso que la colegiatura es obligatoria. si esto fuera una norma para todos los países de américa latina habría probablemente mayor regulación y el colegio tendría una relevancia que permitiría la potenciación de la profesión a favor no solo de los intereses de sus miembros, sino de la población a la que van dirigidos los cuidados de enfermería. al considerar esta formación profesional, resulta prioritario que las universidades transiten por procesos de acreditación para asegurar una formación de calidad. los tiempos de estudio varían de un país a otro, incluso entre universidades del mismo país, pero en términos generales un licenciado en enfermería estudia de cuatro a cinco años. referente a este tema debería existir un consenso, pues esto facilitaría la movilidad estudiantil al interior del país y entre países ya que el entorno internacional crea la necesidad de homologar títulos y facilita el movimiento de profesionales (99); esta es una realidad tan palpable que en países como perú y puerto rico la migración de enfermeras se ha convertido en un problema. esta diferencia de años surge porque en algunos países se estudia un bachillerato que es el equivalente a las ciencias básicas de primer año, luego ingresan a una carrera profesional elegida y culminan los cuatro años restantes; desde esa panorámica, y con el requisito de bachiller, la formación de cuatro o cinco años vendría siendo lo mismo para aquellos países con esa modalidad. lo importante es que independientemente del tiempo de duración, se incluyan asignaturas que permitan una formación profesional adecuada incorporando la teoría pero también la práctica, con el número de horas adecuadas, con modalidades educativas innovadoras. se trae a colación lo anterior, porque el surgimiento de las universidades privadas y la escasez de profesionales de enfermería han llevado a las instituciones a estructurar programas que carecen del nivel de calidad que se exige para un licenciado, existiendo demasiadas asimetrías de conocimiento. como se mencionó, es común a todos los países estudiados que tengan un requisito para la obtención del grado, que puede ser un trabajo final que deben presentar y defender, o una experiencia práctica, la cual en su mayoría dura mínimo seis meses y abarca al área hospitalaria y comunitaria o ambos requisitos. a pesar de que no hay un criterio común en la formación del licenciado, hay cierto consenso en lo que se debe incluir en su educación, siendo la investigación un tema básico que incorporan todos los planes de estudio analizados, lo cual se ve reflejado en que como requisito de egreso se debe realizar un trabajo final de investigación en la gran mayoría de ellos el cual adopta diferentes nombres según la universidad. esto es altamente positivo ya que la investigación determina el desarrollo como ciencia y disciplina. por lo mismo, la investigación en enfermería ha adquirido una importancia creciente en las esferas nacionales e internacionales, y américa latina no es una excepción. existe una mayor conciencia de la relación entre investigación y ejercicio profesional, ya que permite otorgar una atención segura y de calidad al usuario, basada en la mejor evidencia disponible. otro aspecto en común es la formación del licenciado en administración y gestión; es reconocido que el profesional de enfermería lidera el equipo de enfermería y le corresponde planificar, organizar, dirigir, controlar y evaluar procesos y servicios de prestación sanitaria. se da importancia a la función administrativa, ya que en la medida en que el profesional de enfermería se empodere de su rol gestor, podrá participar más ampliamente en los círculos donde se tomen decisiones que atañen a la profesión e inciden en las políticas de salud de las poblaciones. finalmente, otro aspecto que destaca en el currículo es la formación ética de los licenciados. la “ética del cuidado”, según alvarado, es la que “se ocupa de las acciones responsables y de 249 formación del licenciado en enfermería en américa latina l carolina elena luengo-martínez y otro las relaciones morales entre las personas, motivadas por una solicitud, y que tienen como fin último lograr el cuidado de sus semejantes o el suyo propio” (100), esto cobra una vital importancia hoy en día, como lo exponen ángel et al. (101), ya que, con los avances tecnológicos, todo parece “ser solucionado a partir de la ciencia y tecnología”, con “retrocesos en materia de posturas éticas”. por esto se hace tan necesaria la formación ética desde el currículo, ya que el futuro profesional de enfermería debe tener valores y principios éticos que guíen su actuar, con convicción y posicionamiento de hacer el bien siempre a la persona vulnerable a través del cuidado, asumir valores vivenciales de la profesión con principios éticos que regulen y guíen su conducta profesional en los contextos donde se desempeña y evitar el error premeditado o las omisiones que conducen a la rutina. la mayoría de las universidades donde se imparte la licenciatura tienen declarado un perfil que en general, y en concordancia con el trabajo de behn, jara y najera, se orienta hacia un “profesional generalista, capacitado para la asistencia integral del individuo, familia y comunidad, la gestión y administración, investigación y educación” (2), con formación en liderazgo y valores éticos. capaz de aplicar el pensamiento crítico y emitir juicios con fundamento y así tomar decisiones en distintas áreas de la disciplina. finalmente se debe señalar que el perfil declarado por las universidades es disímil, pero todos se orientan a la formación de un profesional con habilidades en investigación, gestión y educación, con capacidad de pensamiento reflexivo, juicio crítico y que presente valores y principios éticos, todo esto para la asistencia integral del individuo, la familia y la comunidad, que es lo que se necesita para afrontar los cambios producidos en las últimas décadas en materia de globalización y de reforma de los estados en temas de salud. la labor de formación de un profesional de alto nivel es compleja ya que debe estar dotado de un sólido sistema de conocimientos y de habilidades para poder trabajar con elevada calidad y eficiencia en la promoción, prevención, diagnóstico, curación y rehabilitación de pacientes, en lo que influyen muchos factores, entre ellos la preparación docente (21). de esto se desprende la siguiente pregunta: ¿realmente las universidades están logrando formar un licenciado con estas competencias? este panorama heterogéneo en la formación de licenciados en enfermería puede traer consigo riesgos, amenazas y oportunidades para cada país en particular y para la enfermería en general. el hecho de que países como méxico, nicaragua y puerto rico presenten más de tres niveles en la estructuración del personal y otorguen salidas intermedias de niveles técnicos puede llevar a que se quieran formar solo enfermeros (as) de carácter técnico que en general tienen un menor costo porque son menos años de estudio, lo que implicaría menores costos de contratación, potenciando de esta manera solo la función asistencial de la profesión, la aplicación de técnicas y procedimientos como objetivo esencial del cuidado, acercándose más al modelo biomédico. la enfermera(o) profesional debería ser una sola, con habilidades y competencias que la habiliten para hacerse cargo de gestionar los cuidados de manera eficiente, efectiva y eficaz, para responder a la satisfacción de las necesidades de cuidado que demanda la población. al considerar el “situs de enfermería”, la profesión genera diversas ocupaciones u oficios (102); es necesario contar con personal auxiliar de enfermería en el cual encargar actividades considerando, claro está, criterios de asignación y límites de los servicios de enfermería, pero debe ser este profesional el que debe poseer los conocimientos necesarios del situ, es él quien debe asegurar su eficiencia (102). consideraciones finales por tanto, y considerando todos los aspectos señalados, debe existir solo una “figura de enfermería”, la enfermera licenciada, como única responsable de la gestión del cuidado. la formación actual del profesional de enfermería podría ser, en parte, la responsable del deterioro de su imagen en la sociedad ya que la comunidad no logra distinguir bien cuál es la enfermera(o) del técnico, el auxiliar, etc. más aún, son identificados como iguales, lo que constituye un riesgo y amenaza para la seguridad del paciente porque recibe atenciones demasiado fragmentadas en las cuales no está clara la responsabilidad final, deteriorando la calidad del cuidado. otro aspecto que se torna en riesgo y amenaza es la opción de algunos países en los cuales, para el obtener el grado de licenciado, se puede optar por hacer una tesis o un internado, lo que podría no ser adecuado porque una de las principales competencias de un licenciado es la investigación, como lo han expuesto behn, jara y najera (2); es esta competencia la que hace crecer como disciplina y ciencia. sin embargo, también es cierto que hace falta obtener evidencias de los logros obtenidos en los distintos países en relación con posicionamiento y liderazgo. finalmente, vale la pena analizar con detenimiento lo que ocurre en países como colombia y el salvador donde, además de 250 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 las leyes emanadas en cada país, existe otros organismos que regulan el ejercicio profesional, y en países como guatemala, ecuador y puerto rico, donde la colegiatura es obligatoria y los colegios tienen el rol de velar por el ejercicio profesional. mientras mayor regulación exista, más es la calidad y seguridad en la atención que se le entrega a la comunidad. en cuanto a los planes de estudio, la inclusión de asignaturas como administración, y el fortalecimiento de la asignatura de ética en todos los países de américa latina apuntan a las nuevas competencias que debe tener un licenciado en enfermería al tener que entregar cuidados humanizados y éticos y velar por la administración de recursos humanos y materiales. lo expuesto tal vez amerite adoptar una formación básica a nivel de latinoamérica para el licenciado en enfermería. referencias 1. mcmichael a. globalization, climate change and human health 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http://www.scielo.cl/scielo.php?script=sci_arttext&pid=s0717-95532009000100003&lng=es 351 363 validacion de escala para medir habilidad.indd 351 jenny paola blanco-sánchez1 validación de una escala para medir la habilidad de cuidado de cuidadores 1 enfermera. magíster en enfermería con énfasis en cuidado al paciente crónico. universidad nacional de colombia, bogotá, colombia. jpblancos@unal.edu.co recibido: 18 de julio de 2013 enviado a pares: 02 de agosto de 2013 aceptado por pares: 28 de marzo de 2014 aprobación: 28 de marzo de 2014 doi: 10.5294/aqui.2014.14.3.7 para citar este artículo / to reference this article / para citar este artigo blanco-sánchez j.p. validación de una escala para medir la habilidad de cuidado de cuidadores. aquichan; 2014. 14 (3): 351-363. doi: 10.5294/aqui.2014.14.3.7 resumen objetivo: determinar la validez facial y de contenido de una propuesta de modificación semántica de la escala para medir habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica creada por barrera. materiales y métodos: diseño de tipo metodológico realizado en tres fases: adecuación semántica, determinación del grado de comprensibilidad y validez facial y de contenido de la propuesta de modificación de la escala. resultados: en la adecuación semántica se revisaron uno a uno los ítems a partir de la discusión de los términos utilizados en su formulación inicial. para el grado de comprensibilidad se aplicaron 385 formatos diseñados por la investigadora; se encontraron cinco ítems con comprensibilidad baja y diez con comprensibilidad media, que recibieron cambios a la luz de la teoría y de las observaciones de los sujetos. la validez facial y de contenido se estableció mediante el método de panel de expertos utilizando el índice de concordancia de kappa de fleiss; para la primera se encontró que la mayoría de los ítems fueron aceptados, y para la segunda se concluyó que la escala modificada semánticamente mide la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica. palabras clave estudios de validación, validez, cuidadores familiares, habilidad, enfermedad crónica. (fuente: decs). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 351-363 352 aquichan issn 1657-5997 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 351-363 validation of a scale to measure the care-giving ability of caregivers abstract objective: determine the face validity and content validity of a proposed semantic modification in the scale created by barrera to measure the care-giving ability of family members who care for chronically ill persons. materials and methods: the study featured a methodological design and was conducted in three phases: semantic adequacy, determining the degree of comprehensibility, and face validity and content validity of the proposed amendment to the scale. results: the items were checked one by one to determine semantic adequacy, based on discussion of the terms used in the scale formulated initially. three hundred eighty-five (385) formats designed by the researcher were applied to determine the degree of comprehensibility. in all, five items were found with low comprehensibility and ten with medium comprehensibility; they were subject to changes in light of theory and the observations made by the subjects. face validity and content validity were determined by a panel of experts, using fleiss’s kappa coefficient of concordance. as for face validity, it was found that most of the items were accepted; in terms of content validity, it was concluded the semantically modified scale measures the care-giving ability of family members who care for persons with chronic illnesses. key words validation studies, validity, family caregivers, ability, chronic illness. (source: decs). 353 validación de una escala para medir la habilidad de cuidado de cuidadores l jenny paola blanco-sánchez validação de uma escala para medir a habilidade de cuidado de cuidadores resumo objetivo: determinar a validade facial e de conteúdo de uma proposta de modificação semântica da escala para medir habilidade de cuidado de cuidadores familiares de pessoas com doença crônica criada por barrera. materiais e métodos: desenho de tipo metodológico, realizado em três fases: adequação semântica, determinação do grau de compreensibilidade e validade facial e de conteúdo da proposta de modificação da escala. resultados: na adequação semântica, item por item foram revisados a partir da discussão dos termos utilizados em sua formulação inicial. para a graduação de compreensibilidade, aplicaram-se 385 formulários desenhados pela pesquisadora; foram encontrados cinco itens com compreensibilidade baixa e 10 com compreensibilidade média, que receberam mudanças à luz da teoria e das observações dos sujeitos. a validade fácil e de conteúdo se estabeleceu por meio do método de painel de especialistas que utilizava o índice de concordância de kappa de fleiss; para a segunda, concluiu-se que a escala modificada semanticamente mede a habilidade de cuidado de cuidadores familiares de pessoas com doença crônica. palavras-chave estudos de validação, validação, cuidados familiares, habilidade, doença crônica. (fonte: decs). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 351-363 354 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 introducción este estudio se enmarca dentro de la línea de investigación de habilidad de cuidado, del grupo de investigación cuidado al paciente crónico de la facultad de enfermería de la universidad nacional de colombia. el trabajo se desarrolla para determinar la validez facial y de contenido de una propuesta de modificación semántica de la escala de medición creada por lucy barrera ortiz, la cual busca medir el fenómeno de habilidad de cuidado en cuidadores familiares de personas con enfermedad crónica en el contexto colombiano. la propuesta de investigación surge de la necesidad de contar con un instrumento desarrollado para el contexto colombiano y latinoamericano que sea válido, confiable, funcional, eficaz y comprensible, que permita generar conocimientos de la realidad de los cuidadores familiares de personas con enfermedad crónica, y que fundamente propuestas orientadoras de la práctica a los profesionales de la salud; describe la importancia de investigar el fenómeno para contar con un instrumento de medición apropiado y confiable al contexto sociocultural colombiano y latinoamericano. un desafío permanente en la disciplina de enfermería se orienta a generar conocimiento a través de la investigación con el fin de enriquecerla teóricamente para construir su práctica y lograr el objetivo disciplinar de dar cuidado. “los fundamentos de enfermería como profesión sustentan conocimientos filosóficos, éticos y biopsicosociales como soporte al desarrollo de la misma. las actividades de docencia, asistencia e investigación en enfermería representan los escenarios para la construcción de conocimiento, siguiendo caminos que le faciliten dicha construcción” (1). así pues, la construcción del conocimiento desde la investigación se enmarca en los diferentes paradigmas investigativos que se diferencian por su concepción del mundo, por su perspectiva científica y por la relación entre el sujeto (investigador) y el objeto (fenómeno de estudio), construyendo “herramientas útiles para el abordaje de los diferentes fenómenos y su contribución al desarrollo de la ciencia” (1). en síntesis, la investigación en enfermería busca explicar “los fenómenos que existen y que influyen en las interacciones del cuidado, para apoyar intervenciones favorables a la vida misma” (1). en colombia se evidencia un claro problema en relación con la medición de fenómenos de enfermería, pues en esta comunidad científica se han venido utilizando permanentemente instrumentos de medición de norteamérica y otros países, los cuales han sido traducidos al español y validados en nuestro medio. sin embargo, son instrumentos construidos de acuerdo con necesidades y características socioculturales y económicas diferentes a las de nuestra región. este hecho llama la atención de los profesionales de enfermería sobre la necesidad de construir instrumentos confiables, más apropiados a nuestro medio, que permitan la medición de fenómenos identificados desde la disciplina tales como la habilidad de cuidado de los cuidadores familiares de personas en situación de enfermedad crónica, y que permitan identificar elementos para crear intervenciones de enfermería o interdisciplinarias aterrizadas a las características socioculturales de nuestra población y sus necesidades. teniendo claro lo mencionado anteriormente, el grupo de cuidado al paciente crónico de la universidad nacional de colombia, desde hace aproximadamente diez años ha liderado estudios en el país y en latinoamérica relacionados con aspectos del reconocimiento de la habilidad de cuidado de los cuidadores familiares, a través del instrumento propuesto por nkongho, quien con base en un estudio fenomenológico desarrolló el inventario de habilidad de cuidado (cai, por su sigla en inglés: caring ability inventory) (2), el cual cuantifica el grado de habilidad de cuidado que tienen los cuidadores familiares de personas con enfermedad crónica. este instrumento permite medir, analizar y comprender la habilidad de cuidado de estas personas especialmente en el campo de las relaciones humanas, al identificar las áreas de debilidad y fortaleza en tres dimensiones: conocimiento, valor y paciencia (2). para su aplicación en colombia, en el año 2005 corredor (3) realizó la traducción de dicho instrumento al español a fin de determinar su confiabilidad en un contexto de habla hispana y halló pocas diferencias en cuanto a la habilidad de cuidado entre las personas que participaron en el estudio original y las que participaron en el realizado por ella, lo que demostró la consistencia interna del instrumento traducido al español. a partir de la validación del instrumento mencionado se realizaron múltiples investigaciones con el interés de explorar la habilidad de cuidado de cuidadores familiares de personas en situación de enfermedad crónica en diversos escenarios y en diferentes situaciones de cronicidad, las cuales concluyen en que un alto porcentaje de cuidadores no presentaron un nivel óptimo de habilidad de cuidado (4-13). conscientes de la necesidad de apoyar a los cuidadores familiares de personas con enfermedad crónica, el grupo de cuidado 355 validación de una escala para medir la habilidad de cuidado de cuidadores l jenny paola blanco-sánchez al paciente crónico creó el programa cuidando a cuidadores® el cual, con su implementación y evaluación en diferentes países de latinoamérica, determinó que el instrumento que se venía utilizado en las investigaciones realizadas para describir el fenómeno no lograba identificar todas las necesidades que presentaban los cuidadores en contextos latinoamericanos en torno a su habilidad de cuidado, hallazgo respaldado por investigaciones como la de montalvo (14), díaz y rojas (15) y morales (16). de esta manera, en el 2008 lucy barrera ortiz diseña la escala “habilidad de cuidado de los cuidadores familiares de personas con enfermedad crónica”, en la que define tres dimensiones de la habilidad de cuidado: comprensión, relación y modificación de la vida, realizando pruebas de validez de criterio, validez de contenido y dando inicio al proceso de medición de la confiabilidad de la escala; sin embargo, recomienda ampliar la muestra para determinar su confiabilidad con una mayor precisión (17). investigaciones metodológicas posteriores de piratoba (18), vergara (19) y barón (20) permiten consolidar una base de datos de 894 cuidadores y determinar la confiabilidad con un alpha cronbach para el instrumento de 0,77 y por dimensiones, así: comprensión arroja un alfa cronbach de 0,64; relación de 0,76 y modificación de la vida de 0,54. para que una herramienta sea considerada confiable se debe obtener un nivel de 0,70 cuando el instrumento está recién desarrollado (21). sin embargo, al realizar un análisis semántico de los ítems de la escala mencionada se encuentran frases que podían no ser entendidas por personas con bajos niveles socioeconómicos y de escolaridad. si bien en el proceso inicial de la construcción de la escala se realizó una prueba de validez de contenido con expertos en el área, no se llevó a cabo ningún tipo de pruebas que garantizaran la correcta comprensión de los ítems de la escala por parte de personas de diferentes niveles socioeconómicos y de escolaridad, y en diversos ámbitos culturales. es en este último punto en el que se centra la presente investigación, con el ánimo de brindar un aporte al desarrollo del conocimiento de enfermería para llegar al planteamiento de indicadores empíricos confiables, comprensibles, eficaces y funcionales que permitan medir las necesidades identificadas en los sujetos de cuidado y determinar la situación real de los cuidadores familiares de personas en situación de cronicidad en colombia y latinoamérica. este objetivo lleva al planteamiento de intervenciones que de una u otra forma contribuyan al logro de la meta de la disciplina que es el bienestar de las personas que se cuidan, que en este caso son los cuidadores familiares; además, los hallazgos generados con el instrumento se constituirán en los referentes para fortalecer el área de conocimiento del cuidado al paciente crónico y a su familia, y posteriormente generar políticas públicas que permitan contribuir al bienestar de esta población. teniendo en cuenta lo anterior, el objetivo del presente estudio fue determinar la validez facial y de contenido de una propuesta de modificación de la escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica. para el presente estudio se tuvieron en cuenta los siguientes conceptos: habilidad de cuidado de los cuidadores familiares: de acuerdo con la conceptualización realizada por la autora del instrumento la habilidad de cuidado se define como la capacidad que tiene el cuidador en su experiencia de cuidado del familiar con enfermedad crónica para establecer la relación, la comprensión y la modificación de la vida (17). comprensibilidad: mide la comprensión de los diferentes ítems que se evalúan en relación con la habilidad de cuidado, la cual será validada a través de la validez facial y de contenido. validez facial: hace referencia a la relevancia de los ítems de la prueba, a la evaluación de su claridad y la comprensión del lenguaje que se utiliza para la redacción de cada uno de estos, es decir, evalúa uno a uno todos los ítems (22). validez de contenido: “consiste en que los ítems de un instrumento de medición sean relevantes y representativos del constructo para un propósito evaluativo particular” (23). método se realiza un estudio metodológico, con abordaje cuantitativo, que permite determinar el grado de comprensibilidad de cada uno de los ítems del instrumento y posteriormente la validez facial y de contenido de una propuesta de modificación de la escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica, este proceso se lleva a cabo a través de tres fases determinadas por la investigadora con la asesoría de un experto en estadística: fase 1. adecuación semántica. en esta fase se revisan uno a uno los ítems de la escala discutiendo cada uno de los términos utilizados en su formulación inicial, se cotejan con su significado en el diccionario de la lengua española y se pregunta a grupos 356 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 de personas de diferentes niveles educativos la mejor manera de plantearlos, todo esto teniendo en cuenta el concepto del atributo al cual pertenece el ítem en evaluación; es una metodología ajustada a la que propone pasquali (24). fase 2. determinación del grado de comprensibilidad. en esta fase se elaboró un formato con una escala de respuesta relacionada con la comprensión de cada ítem y se definió una muestra de 385 personas, lo que determinó un nivel de confianza del 95% y un error del 5%. dicha muestra estuvo conformada por personas de diferentes niveles de escolaridad y socioeconómicos de la ciudad de bogotá, algunos municipios aledaños y estudiantes de pregrado de la facultad de enfermería de las tres primeras matrículas. es importante tener en cuenta que el objetivo de la presente investigación era medir el grado de comprensión del instrumento y no el fenómeno de habilidad de cuidado, por lo cual para efectos de la muestra se incluyeron personas cuidadoras y no cuidadores, que supieran leer y escribir, mayores de 18 años, con procedencia cultural colombiana, de diferentes niveles de escolaridad y socioeconómicos. la comprensibilidad de cada ítem se midió porcentualmente, se adoptó como comprensibilidad admisible de cada ítem un porcentaje superior al 95%, en cuyo caso el ítem en consideración no requirió modificación alguna. los ítems con comprensibilidad inferior al 95% y mayor al 90% fueron examinados semánticamente y recibieron cambios menores a la luz de las observaciones de los sujetos. los ítems con comprensibilidad inferior al 90% fueron examinados a la luz de la conceptualización teórica del constructo, de su estructura semántica y de las observaciones de los sujetos para generar cambios sustanciales en los mismos. fase 3. validez facial y de contenido de la propuesta de modificación de la escala. teniendo en cuenta los resultados de la fase 2, se da paso a un proceso de validación facial y de contenido que se desarrolló mediante el método de panel de expertos, quienes evaluaron los ítems en su claridad (validez facial) (22), y para la validez de contenido evaluaron la coherencia, suficiencia, relevancia (23) y la esencialidad de los ítems; este proceso se llevó a cabo de acuerdo con lo recomendado por escobar y cuervo (23). se seleccionaros diez expertos teniendo en cuenta formación académica, experiencia y reconocimiento en la comunidad, de los cuales nueve fueron enfermeras, dos de ellas con formación de doctorado en enfermería, tres magíster con amplia experiencia en la investigación del fenómeno de estudio de la presente investigación, una magíster con experiencia en el diseño y la validación de instrumentos de medición para enfermería, tres doctoras en enfermería en proceso de formación quienes han profundizado en este fenómeno, y finalmente un psicólogo magíster en educación y docencia, con experiencia en psicología clínica, medición y evaluación psicológica-psicometría. para determinar el grado de acuerdo entre los jueces respecto a las categorías evaluadas para validez facial y de contenido se utilizó el índice de concordancia kappa de fleiss (25), definido como un estadístico de concordancia entre observadores que corrige el azar; al ser una probabilidad toma su valor en el intervalo [0-1] (26), en la presente investigación se consideró aceptable cuando los índices kappa fueron mayores 0,61, los cuales representan una fuerza de concordancia entre expertos buena y muy buena. la investigación contó con el aval del comité de ética de la facultad de enfermería, con el permiso de la autora del instrumento y del consejo de facultad de la facultad de enfermería para la recolección de parte de la muestra. el estudio se inscribe en el marco legal vigente relacionado con la ética de las investigaciones con seres humanos en colombia (resolución 8430 del 4 de octubre de 1993) y tiene en cuenta los principios éticos relacionados con el respeto a la dignidad humana y a sus derechos, sus valores, cultura, creencias, intimidad y autonomía. resultados primera fase: adecuación semántica en esta primera fase se realizó una revisión concienzuda de cada uno de los ítems del instrumento basándose en el concepto de las dimensiones y subdimensiones que plantea la autora; se encontraron varios ítems que no responden a la escala de respuesta, frases redactadas en presente que pueden sesgar las respuestas de los cuidadores respecto a su habilidad de cuidado, términos que podían no ser claros para las personas objeto de investigación, ítems que no se ajustan al concepto de las subdimensiones en las que se encuentran. por otra parte, los conceptos de las dimensiones no son excluyentes, por lo cual se presentan ítems que pueden pertenecer a otras dimensiones. este análisis permitió proponer modificaciones semánticas a la escala de habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica y dar paso a la siguiente fase del estudio. 357 validación de una escala para medir la habilidad de cuidado de cuidadores l jenny paola blanco-sánchez segunda fase: determinación del grado de comprensibilidad en esta fase del estudio se aplicó el formato diseñado para tal fin a 393 sujetos que cumplieron con los criterios de inclusión, de los cuales 8 diligenciaron de manera incorrecta el formulario, por lo cual se descartaron, quedando un total de 385 formatos aplicados para determinar el grado de comprensibilidad de la propuesta de modificación semántica del instrumento de barrera. en la tabla 1 se muestra la edad de los participantes, en la que se evidencia que el 61% de la población que participó se encuentra entre los 18 y 27 años, y el 39% de la muestra corresponde a una población variada distribuida en diferentes grupos de edad. la tabla 1 también muestra la variabilidad del nivel educativo en la muestra, se observa que el 35% de la población encuestada no cuenta con ningún tipo de formación superior, el 47% tiene estudios en formación técnica, tecnóloga o universitario incompleto y solo un 18% ha concluido sus estudios universitarios o cuenta con algún tipo de formación posgradual. de esta manera es indiscutible que se contó con una muestra diversa en los niveles de escolaridad y socioeconómico, lo que da mayor fiabilidad a los resultados del estudio. tabla 1. descripción demográfica (edad y escolaridad) en la figura 1 se muestra el porcentaje de comprensión de cada uno de los ítems de la propuesta de modificación de la escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica, se identificaron 10 ítems con comprensibilidad inferior al 95% y mayor al 90%, estos fueron examinados semánticamente y recibieron cambios menores a la luz de las observaciones de los sujetos. los cambios realizados se presentan en la tabla 2; se identifican cinco ítems con comprensibilidad inferior al 90%, los cuales fueron examinados a la luz de la conceptualización teórica del constructo, de su estructura semántica y de las observaciones de los sujetos para generar cambios sustanciales en los mismos, los cambios realizados en estos ítems se presentan en la tabla 3. figura 1. perfil de la comprensibilidad de la escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica fuente: datos de la investigación. tercera fase: validez facial y de contenido una vez determinada la comprensibilidad de los ítems presentados se procedió a realizar la validez facial y de contenido de la propuesta de modificación de la escala para medir la habilidad de cuidado de cuidadores de personas con enfermedad crónica, en esta fase se utilizó un formato creado por la autora para tal fin. validez facial sobre la base de lo planteado por herrans (22), la validez aparente o facial evalúa la claridad y comprensión de los ítems de una escala de medición teniendo en cuenta que en la segunda fase del presente estudio se evaluó la comprensión de cada uno de los ítems de la propuesta de modificación de la escala; en el panel de porcentaje edad de la población (años) 18-27 61 28-37 16 38-47 12 48-57 7 58 y más 4 nivel de escolaridad primaria incompleta 1 primaria 3 bachillerato 27 bachillerato incompleto 4 técnico 16 tecnólogo 4 universitario incompleto 27 universitario 13 posgrado 5 fuente: datos de la investigación. 358 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 tabla 2. análisis de los ítems con comprensibilidad inferior al 95% y mayor al 90% fuente: datos de la investigación. tabla 3. análisis de los ítems con comprensibilidad inferior al 90% ítem ítem evaluado propuesta de ítem 3 me ha producido temor el cuidado de mi familiar enfermo me ha producido temor atender a mi familiar enfermo 4 he podido resolver las situaciones de cuidado de mi familiar sin miedo a equivocarme he podido tomar decisiones sobre el cuidado de mi familiar sin miedo a equivocarme 9 he visto útiles los momentos de encuentro con otros cuidadores he utilizado las experiencias de otros cuidadores para mejorar el cuidado de mi familiar 11 me siento fuerte para continuar respondiendo por el cuidado de mi familiar me siento capaz de continuar respondiendo por el cuidado de mi familiar 19 he sido capaz de ausentarme de mi familiar sin sentir cargo de conciencia he sido capaz de ausentarme de mi familiar enfermo, sin sentir angustia por no estar con él 23 he decidido vivir momentos más importantes para mí, que cuidar a mi familiar enfermo he sentido que lo único importante en mi vida es cuidar a mi familiar 29 he usado la información que me han dado o lo que he aprendido con mi experiencia para cuidar a mi familiar enfermo he aplicado los conocimientos adquiridos para cuidar a mi familiar enfermo 31 me ha (sic) quedado claras las recomendaciones y los tratamientos médicos que le han ordenado a mi familiar me han quedado claras las recomendaciones y los tratamientos médicos que le han ordenado a mi familiar 36 he organizado la ayuda que me ofrecen otras personas para cuidar a mi familiar he organizado los cuidados que requiere mi familiar, con el apoyo de otras personas. 55 he sentido que mi vida a (sic) cambiado para mejorar con la experiencia del cuidado de mi familiar he sentido que mi vida ha cambiado positivamente gracias a la experiencia del cuidado de mi familiar ítem ítem evaluado propuesta de ítem 2 me ha molestado la manera como se comporta mi familiar enfermo me ha causado molestias la manera como se porta mi familiar enfermo en su situación 5 me he preocupado por no responder como lo espera mi familiar enfermo me he preocupado por cuidar a mi familiar enfermo como él lo necesita 37 he podido distribuir las ayudas que me ofrecen otras personas, cuando tengo que realizar otras actividades he podido organizar y realizar mis actividades personales cuando recibo ayuda de otras personas para cuidar a mi familiar 39 he tenido claro qué camino seguir en mi vida cuando pienso en la muerte de familiar enfermo o cuando no esté a mi cuidado he tenido claro qué hacer con mi vida cuando pienso en la muerte de mi familiar enfermo o cuando no esté a mi cuidado 51 las tareas de mis personas cercanas han cambiado por cuidar a mi familiar las actividades de personas cercanas a mí han cambiado para cuidar a mi familiar fuente: datos de la investigación. 359 validación de una escala para medir la habilidad de cuidado de cuidadores l jenny paola blanco-sánchez expertos se realizó la evaluación de la claridad de los mismos. de esta manera se determinó una fuerza de concordancia entre los expertos de débil y moderada (k = < 0,61) para 12 de los 55 ítems, y una fuerza de concordancia entre los expertos de buena y muy buena (k = > 0,61) para 33 de los 55 ítems. aquellos que no superan el rango aceptable para el presente estudio se considera que requieren una nueva revisión en cuanto su redacción con el fin de afinar su sintáctica y semántica, propendiendo por un mayor acuerdo entre jueces, lo que determinaría mayor validez facial para cada uno de ellos. el valor global de kappa de fleiss para la categoría claridad evaluada en el panel de expertos es k = 0,78, lo que demuestra una fuerza de concordancia buena entre los expertos, por lo cual se puede afirmar que el instrumento para medir la habilidad de cuidado de cuidadores de personas con enfermedad crónica propuesto por barrera y modificado semánticamente en el presente estudio cuenta con validez facial, pues los expertos concuerdan en afirmar que gran parte de los ítems son claros y parecen medir lo que pretenden medir. validez de contenido las categorías coherencia, relevancia, esencialidad y suficiencia permitieron determinar la validez de contenido de la propuesta de modificación semántica de la escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica. la categoría coherencia evaluó si el ítem tiene relación lógica con la dimensión o indicador que está midiendo; la relevancia determinó si el ítem es esencial o importante, es decir, si debe ser incluido en el instrumento, y para corroborar esta categoría se integró la esencialidad, donde los jueces determinaron si el ítem es indispensable para interpretar el fenómeno de estudio y, por tanto, es fundamental que se incluya en el instrumento y, finalmente, la categoría suficiencia evaluó si los ítems que pertenecen a una misma dimensión bastan para obtener la medición de esta. para la categoría coherencia se determinó una fuerza de concordancia entre los expertos de débil y moderada (k = < 0,61) para 21 de los 55 ítems, lo que indica que los jueces no están de acuerdo en afirmar que estos ítems tienen relación lógica con la dimensión que están midiendo; para la categoría relevancia se determinó una fuerza de concordancia entre los expertos de débil y moderada para 21 de los 55 ítems, lo que indica que los jueces no están de acuerdo en afirmar que estos ítems son esenciales o importantes, y para la categoría esencialidad se determinó una fuerza de concordancia entre los expertos de débil y moderada para 23 de los 55, lo que indica que los jueces no están de acuerdo en afirmar que el ítem es indispensable para interpretar el fenómeno de estudio. llaman la atención 12 ítems con una fuerza de concordancia débil y moderada (k = < 0,61) en coherencia, relevancia y esencialidad; además, seis de estos doce coinciden en que tampoco cumplen el criterio de aceptabilidad en la categoría claridad, por lo cual se plantea la importancia de revisarlos para clarificar su relación con la subdimensión en la que están planteados, así como su importancia para ser incluidos en el instrumento y que permitan medir el fenómeno de habilidad de cuidado que se pretende medir con esta escala. la figura 2 muestra la relación entre los índices de concordancia kappa de fleiss globales para las tres categorías evaluadas, estos hallazgos permiten determinar que las evaluaciones de los jueces son homogéneas para la valoración de los ítems en estas tres categorías, lo que establece que el contenido del instrumento construido es consistente teóricamente y válido para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica; sin embargo, es importante revisar los ítems mencionados anteriormente y que no alcanzaron los valores aceptables en el presente estudio, con el fin de propender por ítems más pertinentes y adecuados para medir dicho constructo. figura 2. concordancia entre expertos: coherencia, relevancia, esencialidad fuente: datos de la investigación. en cuanto a la categoría suficiencia la figura 3 muestra una representación de los kappa de fleiss globales para cada dimensión de la escala evaluada, en ellos es evidente que ningu360 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 na alcanza el índice aceptable para el presente estudio (k = < 0,61). estos resultados pueden obedecer a que los ítems que se plantean en cada subdimensión no son lo suficientemente claros, coherentes y relevantes como para que sean capaces de medir la dimensión de la que hacen parte, además de que requieren una reorganización en las subdimensiones que los representan. los kappa de fleiss globales que se muestran en el figura 3 permiten determinar que existe bajo acuerdo entre los jueces en esta categoría, lo que advierte que los ítems planteados no bastan para obtener la medición de cada una de las dimensiones de la escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica propuesta por barrera y modificada semánticamente en el presente estudio; no obstante, sería recomendable revisar las observaciones planteadas por los jueces pues existen ítems que, según ellos, se podrían fusionar, reorganizar e incluso plantear algunos enmarcados en contenidos que ellos mismos proponen. figura 3. suficiencia de ítem global de la escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica la medición de la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica. figura 4. resultados para las categorías evaluadas en la validez facial y de contenido fuente: datos de la investigación. en la figura 4 se muestran los resultados de los kappa de fleiss globales para las categorías evaluadas en el panel de expertos, tanto para validez facial como de contenido, donde es evidente que si bien los jueces muestran una buena fuerza de concordancia en las categorías claridad, coherencia, relevancia y esencialidad, existe una moderada fuerza de concordancia en la suficiencia por lo cual, como se planteó anteriormente, se sugiere revisar a la luz de las sugerencias planteadas por los jueces, con lo que se mejoraría aún más la consistencia teórica y la validez de fuente: datos de la investigación. análisis cualitativo finalmente se hace un análisis cualitativo de las observaciones realizadas por los jueces para cada uno de los ítems, dichas sugerencias se centran en la posibilidad de fusionar ítems con el fin de hacer la escala más corta, revisar las definiciones de las subdimensiones pues algunas no son claras para poder definir la pertinencia y coherencia de los ítems en cada una de ellas y reorganizarlos, puesto que algunos se enmarcan en otras dimensiones diferentes a aquellas en las que se encuentran planteados, realizan algunas observaciones en cuanto a redacción y sugieren acoger algunos ítems necesarios para medir cabalmente el constructo. estudios similares se han desarrollado para determinar la fiabilidad de instrumentos (26-30) en los que se evaluó la validez de contenido de instrumentos y escalas de medición mediante el método de panel de expertos utilizando el índice de concordancia kappa de fleiss, estos estudios determinaron instrumentos válidos a fin de medir las variables para las que fueron diseñados; los autores de dichas investigaciones sugieren adoptar las propuestas realizadas por los jueces con el fin de mejorar el grado de 361 validación de una escala para medir la habilidad de cuidado de cuidadores l jenny paola blanco-sánchez concordancia dado que encontraron los primeros índices kappa bajos lo que los obligó a realizar modificaciones y ajustes a las categorías en repetidas ocasiones hasta llegar al último y definitivo, que alcanza valores aceptables. en la disciplina de enfermería no se han adelantado estudios de validez de instrumentos de medición de fenómenos similares donde se utilice el índice de kappa de fleiss como método estadístico para determinar la concordancia entre jueces. en colombia se han desarrollado estudios de comprensibilidad y adecuación semántica de instrumentos de medida de fenómenos de interés para la disciplina (31-33), con el desarrollo de estas investigaciones se obtuvieron instrumentos válidos para la población en la cual se pretende indagar el fenómeno de interés para cada una de ellas. estas autoras también coinciden en resaltar la importancia de este proceso dentro de la investigación metodológica con el fin de contar con instrumentos claros y comprensibles para la población objeto de medición del fenómeno de estudio. conclusiones las teorías psicométricas dan a conocer el proceso de validación de instrumentos de medición; sin embargo, no muestran la relevancia, la importancia y la minuciosidad con la que se deben diseñar y validar inicialmente las escalas de medición, pues estos primeros pasos son determinantes para contar con instrumentos válidos y comprensibles para la población donde pretendemos medir el fenómeno de estudio. determinar la comprensión de los ítems de una escala de medición se convierte en un paso primordial antes de iniciar cualquier proceso de validación de instrumentos de medida, lo que garantiza que se cuenta con una herramienta que es fácilmente comprendida por población de diferentes edades, niveles socioculturales y educativos, características que generalmente están presentes en los sujetos en los que se miden los fenómenos de enfermería. la escala para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica diseñada por barrera —y modificada semánticamente en el presente estudio— cuenta con validez facial, pues de acuerdo con los resultados de la presente investigación el instrumento mide lo que se pretende. el contenido de la escala es consistente teóricamente y válido para medir la habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica; sin embargo, es importante revisar los ítems que no alcanzaron los valores aceptables para el presente estudio, con el fin de propender por otros más pertinentes y adecuados para medir dicho constructo. se establece la contribución con el proceso psicométrico del instrumento creado para el contexto colombiano como un aporte para la investigación en enfermería, lo cual permitirá la utilización de este instrumento en otras investigaciones en cuidadores de personas con enfermedad crónica. recomendaciones revisar la pertinencia de las sugerencias de los jueces e implementarlas en la escala permitirá contar con un instrumento quizá más corto y que incluya dimensiones, subdimensiones o ítems que no han sido incluidos en la escala propuesta inicialmente por barrera. revisar las definiciones de cada una de las dimensiones y subdimensiones y plantearlas de una manera más clara permitirá determinar la pertinencia y precisión de los ítems en cada una de ellas y que estos cumplan con el criterio de simplicidad expresando una única idea referente a la dimensión que se esté midiendo. continuar con el proceso para consolidar y completar la validación de la escala mediante la realización de pruebas de validez de criterio, validez de constructo, validez de escala y pruebas de confiabilidad (consistencia interna y estabilidad) permitirá contar con una escala sólida, rigurosa y estable que se pueda utilizar en todas las áreas del cuidado donde son protagonistas las personas que cuidan a su familiar con enfermedad crónica. finalizar el proceso de validación y confiabilidad de la escala para medir la habilidad de cuidado permitirá, desde la asistencia, identificar las necesidades reales de los cuidadores, y a través de la generalización de los resultados se podrán generar propuestas de intervención efectivas para apoyar a los cuidadores familiares de personas con enfermedad crónica. el desarrollo de estrategias de intervención para cuidadores familiares de personas con enfermedad crónica, generadas a partir de resultados de investigación en los que se utilicen 362 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 instrumentos claros, válidos y confiables en el contexto colombiano, permitirá la generación de políticas públicas para esta población, lo que redundará en el mejoramiento de la calidad de vida de los mismos y la posible reducción de costos a las entidades pertenecientes al sistema de salud generados por la carga que acarrea la enfermedad crónica en las familias. agradecimientos a la dirección de investigación de la universidad nacional de colombia, sede bogotá, por el apoyo económico para la realización de esta investigación, favorecida mediante la convocatoria “apoyo de la dib a tesis de investigación en posgrados”, quinto corte, código hermes 15236. referencias 1. triviño z, sanhueza o. paradigmas de investigación en enfermería. cienc enferm. 2005;11(1):17-24. 2. nkongho n. the caring ability inventory. in: stricklan ol, waltz cf. 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familiares de personas con enfermedad crónica. documento archivo grupo cuidado al paciente crónico. facultad de enfermería, universidad nacional de colombia; 2008. 18. piratoba bn. confiabilidad del instrumento para medir la “habilidad de cuidado de cuidadores familiares de personas con enfermedad crónica” en cuidadores de personas mayores de la localidad de usaquén, bogotá, d. c. tesis para optar por el título de magíster en enfermería. bogotá: universidad nacional de colombia; 2011. 19. vergara m. confiabilidad del instrumento “habilidad de cuidado de los cuidadores familiares de personas con enfermedad crónica”. montería, 2010. tesis para optar por el título de magíster en enfermería. córdoba: universidad nacional de colombia; 2011. 20. barón l. confiabilidad del instrumento “habilidad de cuidado de cuidadores familiares de personas que viven una situación de enfermedad crónica”. tesis para optar por el título de magíster en enfermería. bogotá: universidad nacional de colombia; 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[visitado 2013 apr 10]. disponible en: http://es.scribd.com/doc/129399486/validacinyconfiabilidadtesisdoctoral 29. rivas t, gonzález mj, delgado m. descripción y propiedades psicométricas del test de evaluación del rendimiento académico (tera). interam j psychol. 2010;44(2):279-290. 30. lópez-cabañas m. sistemas de registro en los servicios sociales comunitarios: validación de las categorías y fiabilización de un instrumento de datos sobre los usuarios [serial on-line]. tesis doctoral. universidad complutense de madrid. facultad de psicología; 1995. [visitado 2013 apr 10]. disponible en: http://biblioteca.ucm.es/tesis/19911996/s/4/ s4008401.pdf 31. cepeda ap. validez y confiabilidad del psncqq, cuestionario que mide la satisfacción del paciente con la calidad del cuidado de enfermería. tesis para optar por el título de magíster en enfermería. bogotá: universidad nacional de colombia; 2012. 32. posada mn. adaptación transcultural de la escala de cuidado profesional (cps): adecuación semántica. tesis para optar por el título de magíster en enfermería. bogotá: universidad nacional de colombia; 2011. 33. arcos d. validez y confiabilidad del instrumento calidad de vida, versión familiar en español. tesis para optar por el título de magíster en enfermería. bogotá: universidad nacional de colombia; 2010. 05. feminist narrative(40-49) revista aquichan issn 1657-5997 año 4 nº 4 40-49 bogotá, colombia octubre 2004 40 running head: feminist narrative interpretations funding: national institute of nursing research grant k07 nr00037 abstract an affinity for narrative is shared by researchers across a broad range of disciplines. narrative inquiry is an option for nurse researchers who are interested in using qualitative methods to explore experiences with nursing, health and illness. in this paper, we discuss the methodological and epistemological challenges, tensions and opportunities we encountered in the process of developing feminist narrative interpretations, an approach to narrative inquiry grounded in both nursing and feminist perspectives. key words: feminist research, narrative, narrative interpretation, nursing research, qualitative research methods resumen la afinidad por la narrativa la comparten los investigadores de muchas disciplinas. los estudios sobre narrativa son una opción para las enfermeras investigadoras interesadas en utilizar métodos cualitativos, para analizar sus experiencias en enfermería, salud y enfermedad. en este trabajo discutimos los retos metológicos y epistemológicos, las tensiones y oportunidades que hemos encontrado en el proceso para desarrollar interpretaciones de una narrativa feminista, y la aproximación de los estudios de narrativa, basados tanto en perspectivas feministas como en enfermería. palabras clave: investigación feminista, narrativa, narrativa interpretativa, investigación en enfermería, métodos de investigación cualitativa * ph.d., rn associate professor college of nursing and women’s studies program university of south carolina columbia, sc corresponding author information: office phones: 803 –777-0410; 803 -777-8423 e-mail: deanne.messias@sc.edu ** ph.d., cnm, faan professor emeritus school of nursing university of california san francisco, san francisco, ca deanne k. hilfinger messias* jeanne f. dejoseph** recibido: el 4 de marzo de 2004 aprobado: el 29 de abril de 2004 feminist narrative interpretations 41 torytelling is at once an ancient human tradition and a postmodern art. at the beginning of the last century virginia woolf reflected the spirit of postmodern literary criticism when she pronounced the death of storytelling and the familiar features of plot, character, and narrative, because “real life was too complex and elusive to be captured in a conventional story” (buford, 1996, p. 11). in contrast, at the beginning of the twenty-first century there is evidence of increasing interest in storytelling across diverse disciplines, including nursing and other health professions. commenting on this renewed attention to the narrative nature of human beings, buford suggested that: implicit in the extraordinary revival of storytelling is the possibility that we need stories – that they are a fundamental unit of knowledge, the foundation of memory, essential to the way we make sense of our lives…we have returned to narratives – in many fields of knowledge – because it is impossible to live without them.” (p. 12) despite the ubiquitous nature and renewed scholarly interest in narratives and stories, there is little agreement about what constitutes either. among researchers who engage in narrative inquiry, there are also definitional and methodological differences. accordingly, researchers from different disciplinary perspectives have constructed multiple approaches to the analysis and interpretation of narratives. through both our nursing and feminist connections, we discovered an affinity for narrative and began to explore the possibilities of narrative within our research interests in the areas of women’s health, work, and transitions (messias, 2001; 2002; messias & dejoseph, 2002a; 2002b). in the process, we drew on our previous experiences with other methods of qualitative analysis (lincoln & guba, 1985; strauss & corbin, 1998) and on the work of other narrative analysts (bell, 1988; labov, 1972; riessman, 1993; stevens, 1995). at the same time, we struggled to find methodological approaches that fit our philosophical and disciplinary perspectives. although we were clear about our nursing and feminist bearings, we constantly challenged ourselves to incorporate these multiple perspectives and standpoints into the research processes. the approach we developed is characterized by the co-creation, re-presentation, and interpretation of women’s stories and informed by the multiple perspectives of nursing, feminism, and qualitative/naturalistic research methods we bring to our research. we consider this approach a form of feminist narrative interpretations. the purpose of this paper is to discuss our responses to the various methodological and epistemological challenges, tensions, and opportunities we have encountered as we explored and developed our approach to feminist narrative interpretations. we begin with a brief discussion of the connections and challenges to narrative research posed by both nursing and feminist perspectives, then proceed with a more detailed description of how we addressed these challenges. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 42 narrative: nursing and feminist connections and challenges nursing “is no stranger to narrative; it has always been a part of how we have explored the shared world of our patients” (vezeau, 1993, p. 213). patients and clients often use stories to inform nurses about their experiences with health and illness. storytelling helps patients to find meaning in their experiences, gives them the opportunity to reconstruct their lives, and can promote health and healing (bartol, 1989; sandelowski, 1994). by listening to patients tell their stories, nurses gain an insight and understanding of the human experience with illness that is different from the knowledge of illness conveyed through decontextualized abstract labels or disengaged, analytical reasoning (benner, tanner, & chesla, 1996). nurses not only listen to patients’ stories, they also are storytellers. in communicating with each other about their experiences with patients, their families, and other health care professionals, nurses commonly use stories. they also incorporate storytelling into health education and in helping patients and families explore ways to identify and cope with illnesses. we were attracted to a narrative approach to research because searching for and sharing stories was a natural extension of our clinical nursing practice. feminism supports diversity in extending the methods of the qualitative traditions. experimentation with different forms and texts is one way feminists have found to express more fully the insights arising from transformations in research practice (devault, 1990). although there is no definitive, singular feminist research method, there are certain features that characterize research processes as feminist (bloom, 1998; devault, 1990; hall & stevens, 1991; harding, 1987; reinharz, 1992). feminist methodologies allow for more interpersonal and reciprocal relationships between researchers and the individuals whose lives and experiences constitute the focus of the research (bloom, 1998; lawless, 1991; 1993). these are similar to the relationships that nurses strive to develop with their patients and clients. the context for this paper is our qualitative research exploring women’s work during pregnancy. because we were interested in exploring women’s work during pregnancy within multiple contexts, the women we invited to participate were situated in different contexts across multiple continua of weeks of pregnancy, age, race, education, national origin, partnered status, and current employment, economic and living circumstances. rather than impose our definition of women’s work during pregnancy, we simply asked participants to define work and to share their perceptions and experiences concerning work during pregnancy. we interviewed 29 women at all stages of pregnancy and with diverse ethnic, socioeconomic, cultural, and demographic characteristics. (three of the interviews were conducted with the women and their male partners, interjecting other dimensions into the research dialogues.) we anticipated, and found, that these women defined, conceptualized, experienced, and interpreted work differently, and in diverse personal and social contexts and environments. staying open to the possibility of “uncovering” or “discovering” diversity in women’s experiences with work during pregnancy was a key underlying assumption of the study. the recognition of diversities among women, (e.g. age, economic status, sexual orientation, reproductive status, social position or status, health status, race, ethnicity, political, and religious persuasion) is another of the generally accepted characteristics or criteria of feminist research (reinharz, 1992). much of the mainstream research in all disciplines (including nursing) has been blind to such diversities among women. we agree with anderson (1985) that sound feminist analysis must entail an understanding of race, class, and gender, and other axes of inequality, as researchers seek both the commonalities and the differences across women's experiences. however, narrative researchers differ in the extent to which they include and consider the larger social context in which narratives are embedded (riessman, 1993). at one end of the spectrum, conversation analysts limit their focus to what participants say and do in a particular interaction. we situate ourselves more closely with other feminist narrative analysts such as the personal narratives group (1989), in making a conscious effort to consider how race, class, gender, sexuality, ability, feminist narrative interpretations 43 immigration status, and other contexts of diversity and inequality surface in research participants’ multilayered daily life experiences, their telling of their stories, and the multiple contexts within which these stories may be represented and interpreted. like other feminist researchers who embrace interpersonal and reciprocal relationships with those they study, we were challenged by “concerns about ethics, reflexivity, emotions, positionality, polyvocality, collaboration, identification with participants, intersubjectivity, and our own authority as interpreters” (bloom, 1998, p. 2). some of the tensions we had encountered in other qualitative approaches led us to experiment with different forms of narrative analysis, which we found posed other challenges as well as opportunities. heeding sandelowski’s (1991) forewarnings, as nurse scholars engaged in exploring narrative inquiry, we understood the need to address the ambiguous nature of truth, the metaphoric nature of language in communicating a putatively objective reality, the temporality and liminality of human beings’ interpretations of their lives, the historical and sociocultural constraints against which individuals labor to impart information about themselves to other individuals, who, in turn, labor to listen. (p. 161) in addition to grappling with issues of ownership, truth, temporality, and the social and environmental issues surrounding the creation and interpretation of stories within nursing research, underlying our ongoing collaborative efforts to develop this feminist narrative interpretative approach were several questions we felt compelled to attempt to answer: how does this approach to narrative reflect both nursing and feminist perspectives? what is our “working definition” of story? what is the position of the researcher in the co-creation of women’s stories? how useful are narrative analysis techniques in feminist narrative interpretations? what are possible forums and formats for adequately and ethically re-presenting these cocreated stories? in the remainder of this paper we discuss how we have responded to these tensions, challenges, and opportunities in developing our approach to feminist narrative interpretations. developing a working definition of story in colloquial usage, “story” can mean fantasy, truth, lie, or almost anything in between. the terms story and narrative are frequently used interchangeably and there are no definitive definitions of either (poirier & ayres, 1997; polkinghorne, 1988). therefore, one of our main challenges has been to develop a working definition for “story” within the context of feminist narrative interpretations. how we defined “story” was a key to the way we approached both the collection and interpretation of qualitative data. in developing our working definition, we dealt with the processes of eliciting stories in the context of research, the structure and function of stories, and the gendered nature of narratives. some qualitative researchers and narrative analysts ask participants to construct a story in response to a specific research question; others elicit the telling of a person’s life story (benner, tanner, & chesla, 1996; bloom, 1998; lawless, 1991; 1993). we felt that because each individual can have their own unique definition of “story,” requesting a research participant to “tell a story” could miss some of the richness of their experiences around particular topics. bell (1988) suggested that within an indepth interview, “people spontaneously tell stories to tie together significant events and important relationships in their lives, and to ‘make sense’ of their experiences” (p. 10). therefore, rather than asking for specific stories, we encouraged participants to talk about their work during pregnancy in whatever way they chose. the conversations that occurred in the course of research interviews were the direct result of shared moments and experiences that occurred between a storyteller and listener-researcher-interpreter. because we found their experiences were more naturally expressed and more clearly understood during guided conversations, we moved from a more traditional interview format to a style that resembles more a “conversation” (riessman, 1992, p. 58). we found that having a focused conversation allowed for a free flow of thoughts and encouraged participants to participate more fully in the research by offering their own interpretations of their life experiences and contexts. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 44 in both our research and our nursing practice, we have come to view women’s stories as representations of their experiences. we approach stories as interpretations of experience, reinterpreted with each telling-hearing-reading. therefore, we were not comfortable with the notion of story as an “accurate” or “true” account of what “really” happened. in each co-created research conversation a woman can only share what is “real” and “true” for her at that very moment. that reality can be shaped by, for example, her physical feelings, the weather, what she had for breakfast, how she reacts to the researcher, what she perceives the researcher wants to know, or any number of other environmental or contextual factors. likewise, the researcher may be affected by similar factors. these resulting research narratives are conversations bounded by the context (i.e., persons, place, time, interactions, and imbued meanings) of the research interview. we view stories as socially constructed tapestries that weave together unique threads of personal, relational, and cultural realities, perceptions, and experiences, in the process of facilitating the creation of fluid meaning (bruner, 1986; riessman, 1989; richardson, 1990). as other narrative analysts (poirier & ayres, 1997; lawless, 1993) have noted, people do not necessarily tell their stories in chronological or thematic order within the narrative texts of research conversations. within the narrative texts transcribed from our research conversations, only rarely have we identified a temporal sequence of plots or found stories that were plainly bounded or had clear indications of a beginning, middle, and end (riessman, 1993). therefore, a definition based on the expectation that stories told within the context of research interviews necessarily have a pre-existing structure was not appropriate for feminist narrative interpretations. engaging in this research process from a feminist perspective presented us with the challenge of recognizing and rupturing of our pre-conceived notions of story and narrative. although feminist scholars have embraced narrative forms and inquiry, they have not done so uncritically. smith (1987) and de lauretis (1987) both expressed misgivings about autobiographical narrative forms based on their association with patriarchal culture. other feminist scholars have proposed that because stories are gendered, the structure, style, form, and content of women’s stories need to be considered differently from those of men. a major hurdle is recognition of the distinct characteristics of women’s stories. lawless (1993) suggested women’s difficulties in identifying and constructing their own stories as women’s stories stemmed from the application of male constructs to women’s stories, noting the critical need for models and scripts that would fit the wholeness and complexity of women’s lives as they experience them. as one of the participants in lawless’s study of women clergy noted, “we don’t know what a woman’s story sounds like because we’ve never heard one…we can’t even tell them” (p. 79). another woman reflected a similar state of unknowing, but welcomed the challenge and opportunity to explore her own gendered stories: “i must say, i don’t know what a woman’s story sounds like…i’m sitting here saying i can’t believe i told my story that way. on the other hand, i’m glad i was asked to” (p. 57). one of the ways in which we have attempted to create the opportunity for women’s stories to surface in our research is not anticipating or imposing a pre-conceived structure or form on the stories women tell us. for the purpose of our research, we have come to identify stories as the unfolding of a description of a particular woman’s experiences around a focused topic of the research (e.g. her health, pregnancy, work, employment, or migration). each story is a dynamic representation of a particular woman's experiences around a focused topic as identified and interpreted by both the woman and the researchers. these stories unfold within the original narrative of the research conversation, but not necessarily in any particular order or format. the focus of these stories may be events, relationships, emotions, or environments. some stories are more “factual” accounts, others more personal reflections. throughout the research interviews there are also fragments of stories, some of which are unfinished, others which serve as support or corroboration. the stories that provide us insight into our research interests and questions exist within the various contexts of each particular woman’s experience, the researchers’ research context, and the shared context of the research interview. this contextual definition takes into consideration the temporal and transitory feminist narrative interpretations 45 nature of stories created in the process of our research. the co-creation and interpretation of stories: the interconnectedness of researchers and research participants as reinharz (1992) noted, there is a broad continuum of the degree of feminist researcher involvement in the lives of the people they study. feminist narrative interpretation shares with other qualitative and interpretative research the assumption of intersubjectivity between researcher and participant and the mutual creation of data. we agree with olesen’s (1994) notion that the women who participate in research are actually doing research in their daily lives, as they construct the meanings of the experiences that later become the data that researchers interpret. this approach is also based on the premise that storytelling is a mutual process (bruner, 1986, griffin, 1994). we approach each research interview opportunity as a challenge to create an interpersonal environment of respect, shared information, openness, and clarity of communication. we also assume that each study participant has experiences concerning the focused area of interest, viz. work during pregnancy, and thus, has stories of interest to us in our research endeavors. however, we acknowledge that the women we interviewed may not have considered or conceptualized their experiences either as “work” or as “stories” that they would tell others or that others would want to hear. we also recognize that some participants may be more willing or comfortable in telling their stories, and that we might perceive them as “better” storytellers. similarly, some women may be more at ease with the interviewer as “listener” than others. in any case, the quality and substance of the data produced at the moment of each researcher-participant interaction is dependent on the interpersonal quality of that interaction, as well as the participant’s perceived value of the experience and its retelling. mutuality refers to the efforts taken to identify and reduce the power inequalities among researchers and participants (hall & stevens, 1991). in creating spaces for women’s stories through our research, we have found that we are inviting anticipated, as well as unanticipated, disclosures (e.g. regarding sexuality, race, immigration status, physical or emotional health, and personal and family relationships). disclosure is a quality of researcher engagement related to mutuality and trust, and refers to the authentic revelation of the marginalized identities and experiences of research participants, in ways that are understandable to the research audience (meleis, 1996). our approach to the interactions and “data” produced by researchers and research participants reflects our ontological and epistemological standpoints (guba & lincoln, 1994). our ontological position is that realities are multiple, multilayered, and fluid; as such, they are constantly shaped by perceptions and contexts that include, but are not limited to, gender, class, culture, race, politics, and economics. our epistemological stance is based on the premise that the relationships between knower and what is to be known are subjective and interactive. we recognize that our values, as well as those of the women we interviewed, inevitably influence the inquiry. therefore, the resultant knowledge (e.g. the “findings” of the research) is mediated by and inextricably intertwined with the interactions between and among the investigators and the women who participate in the study. in essence, ontology and epistemology are fused. a story is not the work of the storyteller only, but requires that there be a listener or reader, unless it is to remain an “untold” story. audience is crucial to the story and influences how stories are told; it is, therefore, a key element in narrative research. for example, the story a woman tells an investigator in the context of a research interview will not necessarily be the same story that she would tell her best friend, a prospective employer, or a relative. when stories are co-created in the process of research, the initial audience consists of the actual investigator(s). however, by giving her consent and participating in a research interview, the study participant agrees to her stories about a focused research question being shared with a broader audience (e.g. other women, researchers, nurses, health professionals and the general public). although we recognize the potential value in taking qualitative data “back” to research participants, we have opted to revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 46 take the stories from our research “forward” to these other audiences. challenges and opportunities in narrative analysis, interpretation, and representation as we developed our approach, we found feminist narrative interpretations well suited to collaboration. other methodological challenges and opportunities we experienced included sorting through and critiquing the appropriateness and fit of various narrative analysis techniques and experimenting with diverse forms and venues for presenting the results of our research. interpretation as a collaborative effort. although the process is more complex, having more than one interpreter involved in the research process broadens the dialogue and enriches the process and the products. as co-interpreters, we often initially review the research texts independently, then meet together to direct our focus to the stories. this collaborative process of identifying and locating stories contained in each interview text occurs not only in interaction with the texts but also as a result of the dialogue between interpreters/researchers. when we meet, we share with each other the stories we noticed or created, and compare how story lines are similar or different within each participant’s narrative and across several participants’ narratives. we periodically return to the interview transcripts to refine the stories we have already identified and to locate other stories. while each story can stand alone, we also look for connections or contrasts between stories within each narrative and across groups of narratives. together, we then examine ways in which these stories expand or challenge our current understanding of the phenomenon of interest. in developing our “findings,” we challenge ourselves and each other to bring multiple perspectives to our interpretations. this process of co-creation recognizes the active, participatory relationship between and among researchers. each time we revisit the data individually or together, the possibility exists for the discovery of new stories or new interpretations of stories previously identified. sorting out techniques of narrative analysis. another methodological challenge was to determine the usefulness of narrative analysis techniques for feminist narrative interpretations. similar to other approaches to narrative analysis, searching for story lines is key to our interpretive approach. some narrative researchers analyze one story within an interview, others look for and analyze sequences of stories. bell (1998) extended story analysis by considering how sequences of stories can provide insight into personal experience. this process involves reducing the interview data to a core or skeleton narrative, then restoring a complete version of the stories. in the process, the storyteller becomes the analyst and the stories are told in the third person (bell, 1998). other approaches to narrative inquiry include withinand across-case identification of common or prime story lines (bottorff, johnson, irwin & ratner, 2000) or types of stories (ayres, 2000). we differ from those narrative analysts who define stories in terms of structural elements such as orientation, episode, coda, abstract, evaluation, and/or resolution. our approach to analysis and interpretation began to flow from our working definition of story as unfolding around a focused topic. not surprisingly, because we did not define story in terms of structure, we chose not to adopt analytic approaches that focused on structural forms or components of narratives. however, for some of our initial analyses, we did experiment with a more structural approach, based on labov’s (1972) functional categories, but found such techniques to be reductionistic in both process and results. like others who have used narrative analysis in health research, we concluded the use of certain structural narrative analysis techniques contributed little in terms of illuminating our understanding of the stories (crepeau, 2000). we decided these structural analytic techniques were analogous to diagramming sentences: although they may be useful to narrative researchers in the process of identifying the structure or function of stories, they contribute little to furthering understanding of the underlying meanings. similarly, some qualitative and narrative analysts reduce and decontextualize the stories that participants tell through coding and categorizing schemes. feminist narrative interpretations 47 rather than override the women’s experiences with our own codes and categories, we strove to preserve the saliency of women’s own words in the presentation of their stories. as listeners/interpreters, co-storytellers, in the processes of cocreating and re-presenting these stories, we identify the story lines and weave together the stories that we have identified as providing insight to our research questions. in the process, we actually may introduce some elements of structure (e.g. order of presentation) into these stories. for example, in re-presenting stories in written form, we occasionally “edit out” certain repetitive aspects of oral speech (e.g. um, like, you know) and also impose conventions of written speech, such as punctuation. the construction of composite narratives is another approach to narrative analysis (stevens, 1995; stevens, hall, & meleis, 1992). one of the advantages of such an approach is that the researcher does not have to worry about confidentiality or identity disclosure in a composite story, because there is no “real person” behind the story. although we have not adopted the composite narrative approach, we did experiment with synthesizing the various stories contained in an interview narrative into one integrated “core narrative” for individual participants. however, the resulting synthesis often proved too long and unwieldy. one of the ways in which we have addressed this challenge is to identify several story lines within each participant’s narrative, recognizing that there often are connections and overlap within these story lines, because they are part of women’s “larger”life stories. representing results. the challenge of large texts is one that is not unfamiliar to qualitative researchers in general, across disciplines and methodological persuasions. the intent of our approach to stories is to display the results of our interpretive research processes in a form that more closely reflects the participants whose stories the research is intended to present. sometimes we weave the cocreated stories and narrative interpretations together, alternating stories and interpretations. different stories or different storytellers may lend themselves to different forms of re-presentation. by re-presenting both the co-created stories (which preserve individual women’s words) and our interpretations of the contexts and meanings of those stories, we allow other audiences the opportunity to follow, challenge, or extend our interpretive weavings. in representing women’s stories, maintaining a balance between the voices of researchers and participants is an ongoing challenge in feminist narrative interpretations. the ways we choose to re-present women’s stories involve complex issues of “ownership.” we specifically want to privilege the women who shared their experiences and perspectives with us in the course of our research, rather than totally privileging our “overwriting” of their words and expressions. at the same time, we need to acknowledge our role and active engagement in the co-creation and interpretation of these stories, and the re-presentation of these stories to other nurses, researchers, and women, in furthering women’s health and well-being. another challenge is not to privilege one type or format of story over another. the choices of whose stories to “move forward” and re-present to other audiences has implications in terms of our role as feminist researchers with an obligation to combat the social and interpersonal structures that perpetuate the oppression of women. inherent in the process of women researching other women is the danger of reproducing existing structures of inequality and power (patai, 1988). we have had the occasion to re-tell participants’ stories in several different formats and forums. these include the more conventional format for research, in which we re-presented individual women’s stories within published research reports. however, we have also re-presented women’s stories orally at research conferences, in classroom presentations, and as case studies for health care providers. from both our personal perspectives and our observations of the reactions of our audiences, telling stories has been a meaningful and effective way to re-present the results of our research. summary and conclusions virginia wolff had a point in contending that life is complex. an illustration of revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 48 that complexity is the way health issues are embedded in the multiple contexts of women’s lives and work. we believe that stories can help nurse researchers make sense of and interpret the meaning of women’s health and illness related experiences. in this paper we have described and illustrated an approach to research that incorporates both nursing and feminist perspectives in the co-creation, representation and interpretation of stories. feminist narrative interpretation is a complex and dynamic research process that involves asking, listening, reading, looking for, identifying, locating, co-creating, re-presenting, and interpreting stories. these interpretive processes begin with development of the research project and continue with guided research conversations around a focused topic, viz. the research question(s). our approach to women’s stories is predicated on several underlying assumptions. we situate ourselves in the position of listener/conversationalist/interpreter to collect our research narratives. we define stories in terms of the interpretive interaction of researcher(s) and narratives, not in terms of form or structure – a distinction from other forms of narrative analysis. each story is a dynamic, unfolding representation of a particular woman’s experiences. how a story unfolds is a function of the interaction of the past and present experiences, perspectives, interests, and perceptions of both the narrators and the listeners. the resulting co-created stories are reproduced and re-presented in other moments and other forms through the researchers’ analyses, synthesis, and interpretations. like other methodological standpoints, feminist narrative interpretation is, “by definition, partial, incomplete, and historically contingent” (riessman, 1993, p. 70). research approaches such as feminist narrative interpretations both confirm and expand the applications of stories in nursing practice and research. boykin and schoenhofer (1991) suggested that stories are valuable as an approach for illuminating “the uniqueness, subtlety and depth of nursing knowledge” (p. 245) generated through nursing practice. the opportunity to witness, interpret, and represent other women’s stories certainly is a privilege. through research that furthers the sharing of cocreated and re-presented stories, nurses may also find knowledge, inspiration, and guidance for the transformation of nursing practice. references ayres, l. 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"storytelling: a practitioner's tool." mcn: american journal of maternal child nursing 18(4), 193-196. 373 386 un enfoque cualitativo a las barreras.indd 373 grever maría ávila-sansores1 patricia gómez-aguilar2 antonio vicente yam-sosa3 gloria vega-argote4 brenda eugenia franco-corona5 un enfoque cualitativo a las barreras de adherencia terapéutica en enfermos crónicos de guanajuato, méxico 1 enfermera. maestro en ciencias de enfermería. universidad de guanajuato, méxico. greavila@ugto.mx 2. doctor en enfermería fundamental. universidad autónoma de yucatán, méxico. patricia.gomez@uady.mx 3. magíster en ciencias de enfermería. universidad autónoma de yucatán, méxico. yamsosa@uady.mx 4. magíster en ciencias de enfermería. profesor de tiempo completo, universidad de guanajuato, méxico. gloria-vega-argote@ugto.mx 5. doctor en enfermería fundamental. universidad de guanajuato, méxico. francobe@ugto.mx recibido: 19 de marzo de 2013 enviado a pares: 30 de abril de 2013 aceptado por pares: 19 de septiembre de 2013 aprobado: 1 de octubre de 2013 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 373-386 para citar este artículo / to reference this article / para citar este artigo ávila sansores, g. m., gómez-aguilar, p., yam-sosa, a. v., vega-argote, g., franco-corona, b. e. (2013). un enfoque cualitativo a las barreras de adherencia terapéutica en enfermos crónicos de guanajuato, méxico. aquichan. vol. 13, no. 3, 373-386. resumen introducción: el perfil epidemiológico en méxico está dominado por enfermedades crónico-degenerativas y lesiones, estas a su vez están asociadas a las condiciones de vida actual. la ops y la oms aconsejan el estudio de barreras que impiden la atención de calidad. objetivo: explorar la percepción de las barreras personales y sociales hacia el tratamiento de personas con estados crónicos: diabetes e hipertensión. materiales y métodos: estudio cualitativo, con un componente descriptivo. la muestra estuvo conformada por diabéticos e hipertensos de colonias marginales. muestreo de tipo intencional. la recolección de la información se realizó por medio de entrevistas semiestructuradas y audio-grabadas. se trabajó con 3 grupos focales de 3 personas por grupo. un 77 % casado, 77 % analfabeta, 77 % labores del hogar, 56 % diabéticos tipo 2,22 % hipertensos, 22 % diabéticos con hipertensión. las barreras percibidas encontradas fueron: creencias relacionadas con el tratamiento, falta de conocimientos y habilidades para la dieta, descontento con la dieta, falta de apoyo familiar, dificultades económicas, falta de conocimientos sobre la medicación, indiferencia hacia el ejercicio, desconfianza y temor a los estudios de laboratorio. discusión y conclusión: para rosentock, en tanto que las claves para la acción incitan a las actividades preventivas para la salud, las barreras percibidas indican los caminos para la acción. es necesario superar barreras y ayudar al enfermo crónico a convivir con la enfermedad. palabras clave diabetes mellitus, hipertensión, cumplimiento de la medicación, enfermería. (fuente decs, bireme). 374 aquichan issn 1657-5997 a qualitative approach to barriers to adherence to therapy among the chronically ill in guanajuato, mexico abstract introduction: the epidemiological profile in mexico is dominated by chronic degenerative diseases and injuries. these, in turn, are associated with current living conditions. paho and who recommend the study of barriers to quality care. objective: the purpose of this research was to explore the perception of personal and social barriers to treatment for persons with chronic illnesses; namely, diabetes and hypertension. materials and methods: this is a qualitative study with a descriptive component. the sample was comprised of diabetics and hypertensive persons from low-income neighborhoods. intentional sampling was used. the data were collected through semistructured interviews that were audio-recorded. work was done with three focus groups of three people each: 77 % were married, 77 % were illiterate, 77 % were homemakers, 56 % had type ii diabetes, 22 % were hypertensive and 22 % were diabetics with hypertension. the perceived barriers revealed by the study include treatment-related beliefs, lack of knowledge and skill to pursue the recommended diet, dissatisfaction with the diet, lack of family support, economic hardship, lack of knowledge about the medication, indifference to exercise, and distrust and fear of laboratory exams. conclusion: for rosentock, whereas the keys to action encourage preventive activities with respect to health, the perceived barriers signal the path to action. barriers must be overcome and the chronically ill must receive help to live with their conditions. key words diabetes mellitus, diabetes, hypertension, medication adherence, nursing. (source: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 373-386 375 un enfoque cualitativo a las barreras de adherencia terapéutica en enfermos crónicos de guanajuato, méxico l grever maría ávila-sansores y otros. um enfoque qualitativo nas barreiras de adesão terapêutica em doentes crônicos de guanajuato, méxico resumo introdução: o perfil epidemiológico no méxico está dominado por doenças crônico-degenerativas e lesões, estas, por sua vez, estão associadas às condições de vida atual. a ops e a oms aconselham o estudo de barreiras que impedem o atendimento de qualidade. objetivo: explorar a percepção das barreiras pessoais e sociais ao tratamento de pessoas com estados crônicos: diabete e hipertensão. materiais e métodos: estudo qualitativo, com um componente descritivo. a amostra esteve conformada por diabéticos e hipertensos de colônias marginais. amostragem de tipo intencional. a coleta da informação se realizou por meio de entrevistas semiestruturadas e audiogravadas. trabalhou-se com 3 grupos focais de 3 pessoas por grupo. 77% casados, 77% analfabetas, 77% labores do lar, 56% diabéticos tipo 2, 22% hipertensos, 22% diabéticos com hipertensão. as barreiras percebidas encontradas foram: crenças relacionadas com o tratamento, falta de conhecimentos e habilidades para a dieta, descontentamento com a dieta, falta de apoio familiar, dificuldades econômicas, falta de conhecimentos sobre a medicação, indiferença ao exercício, desconfiança e receio dos estudos de laboratório. conclusão: para rosentock, enquanto as chaves para a ação incitam as atividades preventivas para a saúde, as barreiras percebidas indicam os caminhos para a ação. é necessário superar barreiras e ajudar o doente crônico a conviver com a doença. palavras-chave diabetes mellitus, hipertensão, adesão à medicação, enfermagen. (fonte: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 373-386 376 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 introducción de acuerdo con la organización mundial de la salud (oms) las enfermedades crónicas son padecimientos de larga duración y, por lo general, de progresión lenta, como la diabetes, las enfermedades cardiovasculares incluida la hipertensión, el cáncer, las enfermedades respiratorias crónicas, el vih-sida, la depresión y las discapacidades físicas. las enfermedades crónicas no transmisibles (ecnt), particularmente las cardiovasculares, la hipertensión, la diabetes y la enfermedad renal crónica han desplazado a las enfermedades transmisibles en todo el mundo, ocupan los primeros lugares de afectación y representan un problema prioritario para la salud pública (1). se espera que las muertes provocadas por ecnt incrementen en un 15 % a nivel global entre el 2010 y el 2020. en países de ingresos medios y bajos se espera que un 29 % de las muertes ocurran en personas de alrededor de 60 años de edad en comparación con los países de ingresos altos donde se espera solo un 13 %. las ecnt matan a más de 36 millones de personas cada año y cerca del 80 % de las muertes se concentran en los países de ingresos bajos y medios (2). entre los factores que causan y hacen que aumenten las ecnt se encuentran una dieta poco saludable, sedentarismo o poca actividad física, tabaquismo, abuso de alcohol, los que se pueden considerar como factores de riesgo modificables relacionados con el comportamiento de las personas; los factores como la edad, el género y la herencia se identifican como no modificables; y los factores de riesgo como la hipertensión, hiperglicemia (prediabetes, diabetes), hipercolesterolemia, sobrepeso y la obesidad se consideran de tipo biológico. también son de relevancia factores como la condición socioeconómica (pobreza), ambientales (contaminación), urbanización (acceso a productos y servicios) y cultura (prácticas y valores). sin embargo, a pesar de la abundante evidencia, algunos responsables políticos aún fallan respecto a considerar a las ecnt como una prioridad global o nacional, hay un incompleto entendimiento y errores persistentes que impiden la acción, especialmente en los sectores que no son de la salud en donde no se aprecia bien la influencia de las políticas públicas relacionadas con el tabaco, la nutrición, la actividad física y el uso nocivo del alcohol, que son de vital importancia para la reducción de comportamientos y factores de riesgo que se relacionan con las ecnt (2). el perfil epidemiológico que hoy caracteriza a méxico está dominado por enfermedades crónico-degenerativas y lesiones, estas a su vez se encuentran asociadas a condiciones de vida actual de la propia sociedad, así como a las capacidades de las personas para tomar decisiones en favor de la salud propia y de los suyos. los tres tipos de enfermedades que concentran más de 33 % de las muertes en mujeres y más de 26 % de las muertes en hombres son: la diabetes mellitus, las enfermedades isquémicas del corazón y las enfermedades cerebro-vasculares (3). la ops y la oms, en su reunión del 47° consejo directivo celebrado en washington, d.c., en 2006, de acuerdo con la estrategia regional y el plan de acción para un enfoque integrado sobre la prevención y el control de las enfermedades crónicas, señalan que se requieren medidas urgentes para prevenir y reducir la carga de las enfermedades crónicas y los factores de riesgo relacionados. en dicha estrategia también se aconseja llevar a cabo estudios sobre las barreras que impiden la atención de calidad y la satisfacción de los usuarios con los servicios de enfermedades crónicas para conocer más a fondo las cuestiones y las medidas correctivas necesarias para mejorar la atención (4). el modelo de creencias en salud (mcs) plantea la dimensión de las barreras percibidas como obstáculos para la ejecución de conductas saludables. enfatiza que para que el paciente se adhiera al tratamiento necesita percibirse a sí mismo como susceptible ante las complicaciones médicas que a su vez conllevan consecuencias graves y negativas para su vida y funcionamiento social. propone que a través de intervenciones educativas se reduzcan la percepción de barreras, se maximicen los beneficios y se enfaticen las señales para la acción (5). en el caso de los pacientes con diabetes mellitus entre algunas barreras que pueden interferir en el control glicémico se encuentran ciertos pensamientos erróneos como, por ejemplo, que por no presentar síntomas no se considere que la enfermedad es de seria importancia, o el no querer tomarse las tabletas puesto que no se sienten enfermos, o incluso que las complicaciones solo les ocurren a las personas que se administran insulina (6). en un estudio, montiel et al. señalan que la severidad percibida de la enfermedad de pacientes diabéticos se basan en tres elementos: el nivel de incapacidad resultante, el tratamiento recibido y la autopercepción de “sano” en comparación con otros. dicha incapacidad es más impactante cuando afecta la 377 un enfoque cualitativo a las barreras de adherencia terapéutica en enfermos crónicos de guanajuato, méxico l grever maría ávila-sansores y otros. movilidad y la agudeza visual. respecto al tratamiento le dan mayor importancia a la medicación, la actividad física es considerada como buena para el bienestar físico al igual que seguir la dieta; sin embargo, les resulta difícil adherirse al tratamiento debido a diferentes barreras tanto internas como externas. entre las barreras internas se encuentran que su manera habitual de comer no puede ser modificada, y es difícil dejar de disfrutar sus comidas favoritas, las que han consumido toda su vida, y los alimentos recomendados no les parecen apetecibles a su paladar. por otro lado, la alimentación implica un gasto extra y doble trabajo para la persona con diabetes, ya que necesitan preparar alimentos para la familia y los correspondientes a propia dieta. sobre la actividad física las principales barreras son las rutinas y la atención a otros miembros de la familia, también perciben limitantes en la capacidad física. para el cuidado de los pies y las manos se requiere de un alto costo, la medición de los niveles de glucosa se ve obstaculizada por el limitado acceso al centro de salud y falta de recursos económicos para la compra del glucómetro; además, el medicamento no siempre es provisto por el servicio de salud (7). onwudiwe et al., en un estudio realizado en 2011, exploró las percepciones de barreras para el autocuidado de pacientes diabéticos; se señala que es necesario identificar las barreras que presente el paciente y encontrar estrategias para superarlas. el estudio fue llevado a cabo por medio de grupos focales en los que participaron 31 pacientes afroamericanos; entre los resultados más importantes destacan que a pesar de que los pacientes conocen la técnica de punción capilar no les gusta medírsela pues les duele la punzada en el dedo, desconocen sus metas de control glicémico y, generalmente, acuden a otros medios para informarse pues no reciben una información adecuada para su cuidado por parte del médico. se señala también que la información proporcionada en su centro de salud es buena y muy útil aunque algunas veces es muy confusa. en lo que respecta a la medicación, los pacientes que no han recibido una intervención educativa identifican sus medicamentos por el color y el tamaño de sus pastillas, en el caso de quienes sí los han recibido los identifican por medio del nombre impreso en el embase de su medicamento. también se observó que los pacientes acuden a su médico principalmente solo cuando hay una emergencia. por tanto, la habilidad de los pacientes para manejar su diabetes es un punto crítico pues la adherencia al régimen terapéutico es esencial para la prevención o el retraso de la aparición de complicaciones al igual que para obtener mejores resultados en el control (8). soriano et al., en un estudio realizado en población hipertensa, refieren que los pacientes asimilan el concepto de hipertensión solo por haber presentado presión alta, no conocen la medicación que toman y ante la falta de la misma en el caps (centro de salud) dejan de tomarla. los pacientes activos reconocen el riesgo de no contar con su medicación y la buscan activamente generando circuitos alternativos en otros caps u otras instituciones y, en última instancia, la compran. por último, se concluye que existe un bajo grado de control de la hipertensión, aun cuando la medicación prescrita al paciente fuera adecuada, ya que hay diversas barreras para acceder al tratamiento y una tendencia a beneficiar a una minoría, por lo que aumenta la desigualdad dentro de la población más vulnerable (9). schmidt et al. señalan que algunos pacientes hipertensos no conocen los riesgos potenciales de mantener valores de tensión elevados, al igual que desconocen el valor adecuado. los pacientes suponen que el olvido de tomar su medicamento no implica ningún problema, pero sí sienten temor de que dicha medicación pueda interactuar con otros tratamientos; además, subestiman la enfermedad y manifiestan un conflicto con las medidas indicadas para su cuidado y el estilo de vida que llevan. principalmente con respecto al peso les es difícil alcanzar su meta, pican entre comidas y en las relaciones sociales no respetan la dieta. sobre el ejercicio remarcan la escasez de tiempo y dificultad para llevarlo acabo debido a patologías asociadas. por tanto, los hipertensos no son conscientes de su enfermedad y dejan el control exclusivamente en manos del médico dado que no perciben la gravedad de las potenciales complicaciones (10). un estudio de tipo cualitativo realizado en méxico por mercado y hernández en 2007, sobre las enfermedades crónicas, encontró que desde la perspectiva de los sujetos enfermos estos identifican tres enfermedades crónicas importantes: la diabetes, la hipertensión y la artritis; también hacen referencia a tales condiciones a través de un conjunto de temas ordenados jerárquicamente: manifestaciones orgánicas, trastornos emocionales, tratamiento y manejo de su enfermedad. la causa por la cual aparecieron sus padecimientos crónicos la atribuyeron principalmente a una influencia divina; de igual forma los pacientes perciben sus relaciones sociales como insatisfactorias (11). por tanto, ante un padecimiento crónico la persona puede enfrentarse a retos que impliquen superar barreras para alcanzar el control de la enfermedad, al igual que una adecuada adherencia 378 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 terapéutica, que a su vez garantizan la prevención o el retraso de las complicaciones y una mejor calidad de vida. dado lo anterior, en el presente estudio se propone explorar las barreras hacia el tratamiento de personas con diabetes e hipertensión, de manera que se provea de elementos que permitan favorecer intervenciones más eficaces con miras a la adherencia terapéutica y el control de la enfermedad. materiales y métodos el objetivo de la investigación fue explorar la percepción de las barreras personales y sociales hacia el tratamiento de personas con estados crónicos: diabetes e hipertensión. el estudio fue de tipo cualitativo, con un componente descriptivo y con la utilización de la técnica de grupo focal. sobre la selección del área y los informantes el estudio fue realizado en colonias marginales de irapuato, gto. los informantes fueron diabéticos tipo 2 e hipertensos, de nivel socioeconómico medio bajo y bajo, sin complicaciones (irc, pie diabético, retinopatía, cardiopatía). el muestreo fue de tipo intencional que pretende seleccionar a los informantes según las necesidades detectadas. respecto a los procedimientos llevados a cabo, en primera instancia se realizó la solicitud de autorización necesaria para la colecta de la información y entrevista con las autoridades correspondientes para primer contacto e información de objetivos de la investigación. posteriormente se invitó a las personas con diabetes, hipertensión o que tuvieran diagnóstico de ambas, que cumplieran con los requisitos de inclusión (adultos con diagnóstico confirmado, mayores de 18 años de edad, sin complicaciones: nefropatías, retinopatías, pie diabético; sin alteraciones mentales: psicosis, demencias), para participar en la investigación. las personas que aceptaron participar en el estudio firmaron el consentimiento informado, posteriormente se formaron tres grupos focales de tres personas, y se pactó la cita de la entrevista. durante la entrevista a los grupos se contó con una guía de cuatro preguntas detonadoras relacionadas con las barreras de adherencia, basada en la guía de montiel et al., que utilizó como marco de referencia el mcs (7). la guía abordó puntos relacionados con las dificultades que le impiden a la persona enferma seguir las recomendaciones para el control de la enfermedad, percepción de autoeficacia, de susceptibilidad de padecer complicaciones y de severidad de la enfermedad. todas las sesiones fueron audiograbadas en un espacio adecuado para la acústica, para un total de una sesión de aproximadamente dos horas para cada grupo focal; cabe señalar que se guardó la identidad de los participantes pues ellos mismos solicitaron que sus nombres no fueran revelados, por lo que a cada uno se le asignó un seudónimo, y únicamente el investigador responsable conoce el registro de los nombres reales. posterior a la colecta de la información se realizó la transcripción de las entrevistas de cada grupo focal con apoyo del programa express scribe pro v 5.48; y a partir del análisis de contenido de las sesiones transcritas se establecieron las categorías de forma manual. análisis de datos: sobre el proceso de análisis de contenido (12), al realizar la revisión del material audiograbado y transcrito se identificaron expresiones significativas que presentaron el mayor poder descriptivo, seguido de la identificación de categorías, subcategorías y códigos que posteriormente fueron interpretados. en cuanto a los aspectos ético-legales se contó con la aprobación y colaboración para realizar la investigación de un centro comunitario que brinda apoyo a colonias urbano-marginales en pobreza extrema en la ciudad de irapuato; cabe señalar que el presente proyecto es parte de uno mayor denominado “impacto de un programa para favorecer adherencia terapéutica de diabéticos tipo 2” financiado por la dirección de apoyo a la investigación y al posgrado (daip) de la universidad de guanajuato. se respetaron la dignidad y los derechos humanos de cada persona, acorde con la declaración de helsinki; el principal propósito de esta investigación fue para mejorar los procedimientos preventivos y terapéuticos de salud. la investigación se apegó a lo dispuesto en el reglamento de la ley general de salud mexicana en materia de investigación en su título segundo a fin de asegurar el respeto a la dignidad de los sujetos y la protección de sus derechos y bienestar (13). resultados se trabajó con tres grupos focales, cada uno de tres personas pertenecientes a colonias urbano-marginales en extrema pobreza de la ciudad de irapuato en guanajuato, méxico. el primer grupo lo conformó un total de dos mujeres hipertensas de 42 y 52 años de edad, y una mujer con diabetes e hipertensión de 60 años; el segundo grupo lo conformaron tres mujeres diabéticas de 42, 51 y 52 años; el tercer grupo estuvo conformado por dos varones, uno de 53 años, con diabetes, y otro de 67 años con diabetes e 379 un enfoque cualitativo a las barreras de adherencia terapéutica en enfermos crónicos de guanajuato, méxico l grever maría ávila-sansores y otros. informantes estado civil escolaridad ocupación religión diagnóstico/ tiempo diagnóstico flor: femenina, 42 años (grupo 1) casada secundaria labores del hogar y comerciante católica **hta/5 años rosa: femenina, 60 años (grupo 1) casada analfabeta labores del hogar católica *dmt2/ 2 años **hta violeta: femenina, 52 años (grupo 1) casada, analfabeta labores del hogar católica **hta/2 años margarita: femenina, 52 años (grupo 2) separada analfabeta labores del hogar católica *dmt2/3 meses azucena: femenina, 42 años (grupo 2) unión libre analfabeta labores del hogar testigo de jehová *dmt2/1 mes azalea: femenina, 51 años (grupo 2) casada analfabeta labores del hogar testigo de jehová *dmt2/12 años helecho: masculino, 53 años (grupo 3) casado preparatoria comerciante católico *dmt2/1 mes musgo: masculino, 67 años (grupo 3) casado analfabeta, pensionado y con negocio familiar católico *dmt2/9 años **hta begonia: femenina 57 años (grupo 3) casada analfabeta labores del hogar católica *dmt2/5 años cuadro 1. descripción sociodemográfica de grupos focales irapuato, guanajuato, méxico, 2012 fuente: ficha de entrevista sociodemográfica; n = 9 *dmt2 = diabetes mellitus tipo 2 **hta = hipertensión arterial. hipertensión, y una mujer de 57 años con diabetes. en el cuadro 1 se observa la descripción sociodemográfica, los nombres de los informantes se han sustituido para mantener su privacidad. con base en el análisis basado en el mcs se estructuraron las categorías: susceptibilidad percibida, severidad percibida, claves para la acción y barreras percibidas. en primer lugar, se define como susceptibilidad percibida la percepción subjetiva del riesgo de desarrollar una enfermedad, la aceptación de un diagnóstico, que a su vez se ve influenciada por sobrestimar o subestimar dicha condición (14-16). de acuerdo con el análisis respecto a esta dimensión existe una negación ante un diagnóstico de enfermedad crónica; la persona, dado que no experimenta sintomatología, se siente bien y hay menos probabilidad de que tenga una adherencia a su tratamiento tanto farmacológico como no farmacológico. además, tienden a subestimar el padecimiento crónico en la medida que padezcan de otras patologías que limiten de forma inmediata su funcionalidad física pero, de manera contradictoria aceptan que pueden vivir con una mejor calidad si se cuidan (cuadro 2). la categoría severidad percibida es definida como la percepción subjetiva de la gravedad de la enfermedad y las consecuencias por no darle un tratamiento adecuado (14-16). sobre la percepción de la severidad de la enfermedad los participantes comentan que la adquieren por un susto y por herencia, y miden los riesgos de acuerdo con las experiencias de personas cercanas a ellos pero no todos se sienten vulnerables a las complicaciones crónicas, en tanto a los que experimentan una severidad de complicaciones mayor les preocupa una posible repercusión en su rol como aportador económico a la familia. en cuanto a la severidad según los efectos físicos experimentan complicaciones agudas de hipotensión o hipoglucemia —sin embargo, no las identifican como tales—; también refieren insomnio. otros aspectos interesantes 380 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 están relacionados con los efectos experimentados en la sexualidad como disminución del libido y el miedo a la muerte (cuadro 3). al analizar la categoría de claves para la acción, definida como el impulso del individuo para realizar determinadas conductas que favorezcan su salud o el control de la enfermedad (14), se encontró que para que la persona pueda emprender comportamientos que la inclinen hacia la adherencia terapéutica necesita experimentar síntomas relacionados con la enfermedad crónica, entre los que refieren boca dulce, mareo, malestar en los pies; sin embargo, cuando las personas experimentan mejoría o desaparece la sintomatología abandonan el tratamiento indicado. además, es común la automedicación acorde con la sintomatología experimentada y, en ocasiones, sustituyen la medicación por otros tipos de medicina alternativa como el consumo de tés medicinales o licuados. para otros, el tomarse las pastillas de manera adecuada resulta de gran importancia, ya que les permite no tener que exponerse mensualmente a los estudios de laboratorio, de manera que dichos estudios son más espaciados en tiempo. por tanto, los enfermos crónicos no le dan importancia al tratamiento indicado por el profesional de salud (medicación, dieta y ejercicio) como medio de control de la enfermedad crónica (cuadro 4). cuadro 2. categoría “susceptibilidad percibida” irapuato, guanajuato, méxico, 2012 azucena: “no me he metido mucho en la cabeza que tengo diabetes; más bien hay otras enfermedades que tengo más graves, son las que me afectan, a mí el diabetes mmm… si me dijeran tienes cáncer, tienes esto otro, me quedo con el diabetis, siento que las personas viven a gusto sabiéndose cuidar”. begonia: “dicen que yo tengo diabetes, pero yo ni creo que yo lo tenga, pus yo como que a mi yo no, yo no andu mal, pos si a veces me siento cansada pos es del mismo quihacer porque yo tengo quihacer en mi casa”. rosa: “yo también soy de presión alta, y yo ya llevo tiempo también; atendiéndome pero ¡ya!, de que ya me atendí y, este ya llevo cuatro años, sí había veces que ya no le hacía mucho caso a... a la medicina, yo creía que pus, yo decía ¡me siento bien!, pero no, llegó el momento en que yo me sentía más mala”. fuente: guía de preguntas para grupo focal. cuadro 3. categoría “severidad percibida” irapuato, guanajuato, méxico, 2012 fuente: guía de preguntas para grupo focal. subcategorías enfermedad begonia: “mi, mi azúcar a mí, la que me dio fue de un susto, pero también tengo un hermano diabético, él le heredó de un tío mío”. helecho: “eh realmente esta enfermedad es… pos ataca, y compañeros que he visto por ahí, que están ciegos oh… también les han mochado un miembro a veces o sea los dedos o los pies”. “la diabetis es una enfermedad silenciosa, que ya cuando despiertas es porque ya le van a mochar un…, veda, o ya no va a poder trabajar, o ya va a estar incapacitado en su casa”. físicos azucena: “hay días que me siento muy bien y otros que me siento pos muy cansada, como muy flojerosa”. “también lo que se me quita mucho es el sueño”. musgo: “no… sí me da mucha hambre y sabe qué, hasta veo así medio borroso, empiezo a ver borroso, la vista se me empieza a borrar del hambre que traigo ya, desesperado”. rosa: “yo no puedo comer cosas grasosas porque luego me hincho también de la cara… sentí que ora en la mañana amanecí hinchada”. sexuales azalea: “lo pior que me ha pasado ah…, pues aquí somos mujeres fue… no tener nada con mi esposo, así como que todo me molesta, es lo más, […] o sea como que siria qué sentido tiene la vida y para mí así me he sentido”. emocionales (miedo a la muerte) azalea: “eh… y me veo más delgada y digo me voy a morir, ya me voy”. musgo: “entonces ¡hay veces que ando, que caigo, y que no caigo! pero yo le hecho ganas, pos digo pos no me voy a desanimar porque si me voy a desanimar pos me voy a sentar a pensar en lo que traigo, pos a la mejor me voy más pronto, no y pos ¡hay que echarle ganas!” 381 un enfoque cualitativo a las barreras de adherencia terapéutica en enfermos crónicos de guanajuato, méxico l grever maría ávila-sansores y otros. en lo que respecta a la categoría de barreras percibidas, esta es definida como aspectos negativos o situaciones que interfieren con la conducta de salud o tratamiento adecuado ante una enfermedad ya presente debido a que puede ser doloroso, costoso, desagradable o experimentar emociones como el miedo (14). en el presente estudio sobre las barreras percibidas para la adherencia a los comportamientos necesarios de dieta, ejercicio y medicación para el control de la enfermedad crónica se encontraron las siguientes categorías: creencias relacionadas con el tratamiento, falta de conocimientos-habilidades para la dieta, descontento con la dieta, falta de apoyo familiar, económicas, falta de conocimientos sobre la medicación, indiferencia hacia el ejercicio, desconfianza y temor a los estudios de laboratorio (14, 15). sobre las barreras presentes en cuanto a la dieta las personas con estados crónicos la señalan como restrictiva, también mencionan que han tenido una dieta “mala” desde la infancia, y que un cambio de la misma sería adecuado; sin embargo, no lo realizan. manifiestan una falta palpable de conocimientos en cuanto a la alimentación y forma de prepararlos; refieren que la dieta para diabéticos es la ingesta de verduras principalmente, pero no identifican claramente las frutas y las porciones adecuadas para su consumo. además, existe un descontento con la dieta debido a que para algunas personas no es agradable el consumo de verduras, y la limitación del consumo de tortillas resulta de gran problema, pues representa un pilar importante en la alimentación diaria de las familias mexicanas. por otra parte, la economía significa una barrera dado que las personas refieren que por tener una familia numerosa les es difícil comprar los alimentos, y consumen lo que consiguen de acuerdo a sus posibilidades, sin considerar las recomendaciones del profesional de salud. en muchos de los casos la familia no está dispuesta a consumir los alimentos con las restricciones indicadas para la persona con enfermedad crónica, por ejemplo, la limitación de consumo de sal y azúcar; tampoco consideran una alternativa de alimentos adecuados para la persona con enfermedad crónica durante fiestas o eventos sociales, lo que refleja una falta de apoyo familiar en la adaptación de la dieta. sobre la medicación persiste la creencia de que el medicamento ocasiona la ceguera y no identifican el descontrol de la enfermedad como causa primordial. manifiestan una falta de conocimientos en cuanto a dosis y efectos, y demeritan su importancia; practican la automedicación según experimenten los síntomas de la enfermedad, y a menudo utilizan bebidas o infusiones como sustituto. consideran el ejercicio como un hábito bueno para ayudarles a afrontar la enfermedad, pero frecuentemente presentan indiferencia e ideas erróneas al confundir ejercicio con actividades de la vida cotidiana. por tanto, este no forma una parte integral del tratamiento y la persona no se encuentra adherida a una rutina de ejercicio. en lo que respecta a los estudios de laboratorio, los informantes presentan una desconfianza sobre la veracidad de los cuadro 4. categoría “claves para la acción” irapuato, guanajuato, méxico, 2012 ejercicio begonia: “yo me siento cuando yo la traigo alta, siento la boca dulce entonces es cuando yo hago mis ejercicios, y andali hago”. medicación azalea: “yo siento que es la de la azúcar, sí, que si tomo tres o sea una en la mañana, una a medio día y una en la nochi; y a vecis yo sola le corto, nomas una, pues… una y una”. begonia: “yo nomas sí, las de la azúcar me tomo porque, porque es que me las tengo que tomar, por lo mismo de que no quiero que se me suba y no quiero que me vayan a sacar sangre cada mes por eso”. flor: “ya iba y le platicaba a la dotora, le digo: dotora, pos yo me siento mal; me dice: es que usted no se toma la medicina como es; bueno pus yo tuve que decirle que… que no, porque yo sabía que ya ella sí… sí sabía de que yo no me la tomaba (riendo y suspira), entonces este, pus ya fui con un control más o menos”. dieta azalea: “a vecis me cuido de unas comidas como que contengan grasa, a vecis si me descompaso un ratito, o sea que a vecis yo sola como me sienta le bajo o le entro”. begonia: “que se me sube pero este así ya sé que tengo que caminar y me…, me hago un licuado de…, de avena y ya, me controlo”. fuente: guía de preguntas para grupo focal. 382 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 resultados puesto que perciben una demanda importante que puede inducir a confusiones de tipo administrativo o de manejo; otro aspecto es el temor que manifiestan debido a la cantidad de sangre extraída y a la posible detección de otro tipo de complicaciones (cuadro 5). discusión el mcs plantea que para ejecutar una acción la persona con la enfermedad crónica necesita creer en una serie de afirmaciones: primero, una óptima susceptibilidad y severidad percibida, es decir, que la enfermedad puede afectar su vida de manera importante; segundo, que el llevar a cabo determinadas acciones como seguir la dieta, realizar ejercicio, medicación según indicaciones pueden reducir la amenaza percibida y, a su vez, le pueden proporcionar un apoyo para superar las barreras percibidas (17). este modelo afirma que la susceptibilidad juega un papel importante pues se relaciona con la motivación para seguir el tratamiento; sugiere que cuanto mayor sea esta susceptibilidad es más probable que la persona lleve a cabo las conductas preventivas para controlar la enfermedad crónica (14-16). para esta población en particular, la adherencia terapéutica es deficiente hacia dichas conductas debido a la baja susceptibilidad percibida, manifestacuadro 5. categoría “barreras percibidas” irapuato, guanajuato, méxico, 2012 fuente: guía de preguntas para grupo focal. subcategorías creencias relacionadas con el tratamiento musgo: “que dicen que a veces la enfermedad no es la que mata sino la dieta, eso es lo que dice mucha gente”. violeta: “uno era de rancho…¡¿pos cuál alimentación?! ninguna alimentación buena, ni nada”. “las pastillas que me están dando a lo mejor me están afectando la vista porque… les digo que a veces veo así, como muy borroso, como si viera mucho humo y me dicen que es por la medicina”. flor: “muchas veces traemos una alimentación desde pequeños que no es apta para nosotros y que ahora con el medicamento que nos dan no los aceptamos porque nuestro cuerpo está débil”. falta de conocimientos y habilidades para la dieta helecho: “pos al último no le entiende uno ni, ni como está la cosa de la dieta; uno hay más o menos se va midiendo”. margarita: “no puede comer uno que… manzanas, que sandía, que melón, que el mango, le digo pues entoncis ¿qué fruta vamos a comer?” flor: “nos dicen come verduras, come frutas, como esto, come aquello, pero no nos enseñan a prepararlos”. begonia: “o sea nunca nos dicen qué es lo que no debe comer uno, no más no coman tanta grasa pero ¡¿qué es lo que tengo que comer, qué es lo de verduras, qué es lo de frutas?!”. descontento con la dieta margarita: “mmm ¡ay! porque es que la verdura casi no me gusta (ríe)”. helecho: “la ponen muy estricta y pos le digo que la dotora me dio una tortilla al yo comerme de 40; eso de ¡bájele a la tortilla! ese ha sido el de…ese ha sido el problema”. falta de apoyo familiar azalea: “ni pues, no quieren las verduras, no quieren la fruta, no la quieren. yo sí trato de comerme una frutita aunque sea una más”. flor: “no, quierin… no quieren dejar menos de sal, menos de azúcar”. begonia: “que hay fiestas, que carnitas y…, y refrescos y pos ahí no hay agua, necesito salir a comprarla pero pos no, ¿cómo?, tenía que tomar refresco”. económicas flor: “se pone una a comprar todo lo que nos dice el dotor pos, es un dineral y no nos alcanza”. “sí, porque estamos pasando por un tiempo pos, que el salario es muy bajo y este y… somos una familia grande, y pos por lo tanto no podemos a todos este, darles de lo mejorcito, ¡vamos! y pues tenemos que recurrir a cosas más económicas, quizás, que nos hacen más daño, pero más económicas.” margarita: “a veces lo que hacemos mejor, compramos lo que los demás van a comer porque ya no nos alcanza, ya nomás serán, unas calabacitas”. begonia: “yo tengo que comer lo que haiga, no, no voy a estar pus, pos que hora no pude comprar las verduras, no, yo tengo que comer aunque sea frijoles”. falta de conocimientos sobre la medicación azalea: “este, ¡ay! no quiero tomarlos, me aburren, me arde el estómago a veces mejor me hago un tecito”. “pues de vez en cuando me tomo las pastillas pero eh…, no espéreme son las del seguro una chiquita y una grande. pero no, no me las tomo constante, me hago un tecito, me hago un licuadito de nopal con apio, perejil”. violeta: “me empecé a sentir como mareada, como cuando me la tomaba [hipotensor oral], como si la casa diera vuelta conmigo, y ya después fui con la dotora y me dijo que le bajara a dos”. indiferencia hacia el ejercicio rosa: “qué le diré… pos nomás voy a caminar a veces en las mañanas”. flor: “ah… pero es que camino por las actividades que tengo, no es en sí, no le doy tiempo a que dijéramos en media hora, no”. violeta: “yo voy a los ejercicios los días sábados”. azucena: “no hago ninguna actividad más que namas el puro quehacer”. desconfianza y temor a los estudios de laboratorio helecho: “en el hospital hay mucha confusión de que, que ya que llegan por montonis, hay allí personas en análisis pos llevan muestras, cada quien lleva su muestra hay veces que allí la revuelven y las confunden”. azalea: “o sea que como que soy muy nerviosa y digo ¡ah!… ya no quero saber de qué estoy más enferma así yo sola mmm, soy muy… ¿qué será? negativa”. begonia: “cada mes por mes análisis cada… ¡me van a dejar sin sangre y luego van a querer ponerme de otra, le digo”. 383 un enfoque cualitativo a las barreras de adherencia terapéutica en enfermos crónicos de guanajuato, méxico l grever maría ávila-sansores y otros. da por la negación del diagnóstico, o le restan importancia dado que se sienten “bien” puesto que no siempre experimentan sintomatología que les limite o interrumpa sus actividades de la vida diaria. garcía señala que ante una enfermedad que durará toda la vida se provoca cierto grado de frustración en la persona, por lo que es probable que experimente una percepción emocional negativa. en este sentido se requiere concientizar a la persona de los riesgos que puede correr de no controlar su enfermedad, pero a su vez es necesario empoderarlo sobre su capacidad para hacerle frente, pues si no se logra un cambio de comportamiento se puede generar una respuesta desadaptativa ante dicho padecimiento crónico (18). respecto a la severidad percibida del padecimiento crónico, la preocupación principal es la discapacidad, sobre todo cuando la persona afectada es el principal aportador económico de la familia. otro aspecto es que las personas experimentan complicaciones agudas de la enfermedad pero no perciben su importancia puesto que no las identifican como tal; conocen acerca de las complicaciones crónicas de acuerdo con las experiencias vividas de personas cercanas o amigos, por tanto, perciben como ajena una amenaza directa a complicaciones que a su vez puede repercutir en una pobre adherencia terapéutica. acosta et al., en un estudio sobre conocimientos, creencias y prácticas en pacientes hipertensos relacionados con su adherencia terapéutica, encontraron que más de la mitad de la población estudiada no realiza buenas prácticas de salud, también señalan que para cambiar esta situación se deben buscar estrategias para incorporar en ellos una percepción de amenaza sobre su salud por la sola presencia de la enfermedad, a fin de que se sientan vulnerables por las complicaciones que les puede ocasionar, pero al mismo tiempo que puedan percibir los beneficios que recibirán si siguen el tratamiento indicado (19). así las cosas en ambos casos, sea diabetes o hipertensión, se requiere de un trabajo educativo arduo. otro punto importante que se señala es la falta de intimidad con la pareja, situación que con frecuencia presentan las personas con enfermedades crónicas; en este aspecto pueden influir factores tanto físicos como psicológicos. los factores físicos incluyen los derivados de la propia enfermedad y las terapias empleadas, y entre los factores psicológicos pueden aparecer problemas de autoestima, de ansiedad, y sobre todo de depresión asociada a la propia enfermedad (20). la severidad percibida y la susceptibilidad proveen la energía para actuar, y los beneficios percibidos las rutas que se deben seguir para la adherencia terapéutica; para esta población en específico no son claros los beneficios para cada dimensión del tratamiento que se requiere y, por tanto, las intervenciones dirigidas deberá enfatizar en primera instancia un enfoque psicosocial, que aborde el apoyo para la aceptación del diagnóstico, estrategias de apoyo social y sensibilización de la importancia del tratamiento de manera integral (15). de acuerdo con el modelo de creencias las señales o claves para la acción son desencadenantes del comportamiento. para esta población, al igual que lo reportado por montiel et al., la experiencia relacionada con los síntomas de descontrol de la enfermedad reflejan los detonantes para que los enfermos crónicos retomen el tratamiento e inicien un esfuerzo para la adherencia terapéutica (7). en este sentido cabe poner a mesa de discusión si el miedo a las complicaciones es el único motivante para alcanzar determinada adherencia o si, muy probablemente, existe otro tipo de motivaciones o claves para la acción no reflejadas en este estudio que serán de importancia explorar. para rosentock, en tanto que las claves para la acción incitan a las actividades preventivas para la salud, las barreras percibidas indican los caminos para la acción (14-15); de esta forma se observaron en primera instancia barreras relacionadas con creencias sobre el tratamiento. las creencias, de acuerdo con el mcs, deben fortalecer al individuo para afrontar el padecimiento; sin embargo para este estudio, al igual que los resultados obtenidos por lópez et al., se observó que implican una barrera que no permite que puedan adherirse al tratamiento de manera adecuada ya que erróneamente le atribuyen complicaciones propias de la enfermedad. y de acuerdo con la percepción de síntomas de la enfermedad crónica, como se mencionó, es como seguirán o no un tratamiento (21). por tanto, la primera barrera implica para el profesional de salud la concientización del paciente sobre la enfermedad, la aceptación de la misma y la identificación de creencias que ponen en riesgo su calidad de vida. la siguiente barrera de gran peso se relaciona con la dimensión de alimentación, que refleja la mayor problemática para las personas con enfermedad crónica, al igual que en otros estudios, por la situación económica, la falta de habilidades para la preparación de la dieta, pero además por la percepción de una dieta limitante y por falta de conocimientos (7, 22, 23). 384 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 de esta forma descuidan un pilar importante para el tratamiento y control de su enfermedad debido a que para el paciente diabético la dieta debe ser variada, con suficiente consumo de verduras y frutas, hidratos de carbono complejos y fibra, y con restricciones en el consumo de grasas, con el objetivo de mantener concentraciones adecuadas de glucosa en la sangre y disminuir los niveles de lípidos; pero además, para el paciente hipertenso dicha dieta debe garantizar una adecuada ingestión de potasio, magnesio y calcio (24, 25). es de relevancia remarcar que al momento de proponer una intervención esta no solamente se centre en el aspecto de los conocimientos, ya que esto no necesariamente implica que el paciente presente una mejor adherencia (26); las intervenciones deben contemplar además las creencias, causalidades, experiencias de los síntomas y preocupaciones relacionadas con la enfermedad y el tratamiento de las personas que las padecen (23). la palpable falta de conocimientos sobre la medicación (21, 23) induce a la automedicación y, en ocasiones, a la sustitución de la misma por medicina alternativa, acorde con la sintomatología experimentada. de esta manera, la falta de conocimientos, los conocimientos erróneos, o algunas creencias y actitudes sobre la medicación pueden reducir el grado de adherencia terapéutica; como consecuencia, la intervención del profesional de salud debe fortalecer la información necesaria sobre la enfermedad, los efectos secundarios de la medicación, los beneficios de los medicamentos sobre el control de la enfermedad, además de estrategias para incorporar la percepción de amenaza y vulnerabilidad de complicaciones de no cumplir con el tratamiento (27, 28). otro punto importante por considerar será el nivel de educación de las personas para que el material didáctico sea el adecuado puesto que, específicamente para esta población de guanajuato, un gran porcentaje no sabe leer ni escribir. respecto al ejercicio, al igual que lo encontrado por lópez et al., para las personas con enfermedad crónica no representa una parte importante en el tratamiento de la misma, y muy comúnmente lo confunden con las actividades de la vida cotidiana, lo que las expone a un posible descontrol de la enfermedad. por tanto, la intervención debe plantearse primero en términos de concientización sobre los beneficios del ejercicio para el control de la enfermedad, seguido de un plan o rutina previo a los exámenes necesarios y las recomendaciones antes de iniciarlos, situación que no es especificada en un consultorio médico (28). gómez et al. señalan que el ejercicio regular es un medio de prevención y rehabilitación para las enfermedades crónicas degenerativas, y resulta de gran importancia buscar estrategias que garanticen que los sujetos puedan permanecer activos por el resto de la vida, considerando que los beneficios del ejercicio solo perdurarán con la continuidad de la práctica. por otro lado, la práctica de los mismos también tiene riesgos que deberían ser considerados (29). la desconfianza hacia los servicios de salud, específicamente los estudios de laboratorio para evaluar los parámetros de control, representa un problema grave, ya que la persona enferma podría no estar dispuesta a aceptar una recomendación hasta que no perciba que esa acción es factible y eficaz. la exploración de las barreras de las personas con enfermedades crónicas abre una ventana de oportunidades para implementar nuevas estrategias que innoven las intervenciones dirigidas a esta población blanco. es de vital importancia diseñar e implementar intervenciones que favorezcan la adherencia terapéutica, ya que esta garantiza la calidad de vida de los pacientes, pero para poder alcanzarla es necesario superar estas barreras, y enseñar al enfermo crónico a convivir con la enfermedad. con los resultados de este estudio también se observó que no solo la falta de conocimientos implica una barrera para la persona, sino que también actúan de manera importante las esferas psicosocial y emocional. conclusión para favorecer una óptima adherencia terapéutica en las personas con estados crónicos, particularmente con diabetes e hipertensión, es necesario diseñar y evaluar intervenciones enmarcadas en el mcs que incrementen la susceptibilidad y severidad percibida de la enfermedad, pero a su vez hacer conciencia en la capacidad de la persona enferma para afrontar la situación, y como profesionales de la salud proveer de las herramientas necesarias para lograrlo; para esto las barreras percibidas nos señalan los caminos para la acción y, en el caso de los enfermos de guanajuato, las intervenciones deben contemplar las creencias, causalidades, preocupaciones de las personas (económicas, educativas, laborales, sociales y familiares). además, las barreras de adherencia marcan señalan retos por superar para los profesionales de la salud junto con los enfermos crónicos, pues ante la 385 un enfoque cualitativo a las barreras de adherencia terapéutica en enfermos crónicos de guanajuato, méxico l grever maría ávila-sansores y otros. diversidad de las mismas el profesional de enfermería tiene la responsabilidad de fomentar la creación de grupos autogestivos, capaces de ir en la búsqueda de su propio cuidado (económico, social, de salud) y no solo limitarse al área de conocimiento relacionado con la enfermedad (no menos importante); de esta forma se pueden esperar intervenciones de gran impacto en la adherencia de los enfermos crónicos. agradecimientos a la dirección de apoyo a la investigación y al posgrado (daip) de la universidad de guanajuato, de igual manera a todas las personas con diabetes de las colonias participantes que nos concedieron su tiempo y al equipo de trabajo del centro comunitario san gabriel. referencias 1. organización panamericana de la salud [internet]. enfermedades crónicas: prevención y control en las américas. c2008 [citado 2012 sep 12]. disponible en: http://www.paho.org/spanish/ad/dpc/nc/cronic-2008-2-3.pdf 2. world health organization. global status report on noncommunicable diseases 2010. switzerland: world health organizaction; 2011. 3. secretaría de salud. programa nacional de salud 2007-2012 [internet]. 2007 [citado 2012 nov 10]. disponible en: http:// portal.salud.gob.mx/contenidos/programa_nacional/programa_07.html 4. organización panamericana de la salud, organización mundial de la salud. 47° consejo directivo y 58a sesión del comité regional, estrategia regional y plan de acción para un enfoque integrado sobre la prevención y el control de las enfermedades crónicas, incluyendo el 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sodium restrictions and health beliefs regarding these restrictions in irish patients receiving haemodialysis for end-stage renal disease. journal of clinical nursing. 2011;20:331-340. 23. marshall ij, wolfe cd, mckevitt c. lay perspectives on hypertension and drug adherence: systematic review of qualitative research. bmj 2012;345:e3953 doi: 10.1136/bmj.e3953. 24. secretaría de salud. norma oficial mexicana, nom-015-ssa2-1994, para la prevención, tratamiento y control de la diabetes mellitus [internet]. 2012 [citado 2012 jun 10]. disponible en: http://www.salud.gob.mx/unidades/cdi/nom/ m015ssa24.html 25. secretaría de salud. norma oficial mexicana, nom-030-ssa2-1999, para la prevención, tratamiento y control de la hipertensión arterial [internet]. 2012 [citado 2012 jun 18]. disponible en: http://www.salud.gob.mx/unidades/cdi/ 26. troncoso c, sotomayor m, ruiz f, zúñiga c. interpretación de los conocimientos que influyen en la adherencia a la dietoterapia en adultos mayores con diabetes tipo 2 de una comuna rural. rev chil nutr [internet]. 2008 [citado 2013 feb 28]; 35(4):421-426. disponible en: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=s071775182008000500004&lng=es. doi: 10.4067/s0717-75182008000500004. 27. acosta m, debs g, de la noval r, dueñas a. conocimientos, creencias y prácticas en pacientes hipertensos, relacionados con su adherencia terapéutica. rev cubana enfermer [internet]. 2005 [citado 2013 mar 01]; 21(3):1-1. disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=s0864-03192005000300008&lng=es. 28. lópez-amador kh, ocampo p. creencias sobre su enfermedad, hábitos de alimentación, actividad física y tratamiento en un grupo de diabéticos mexicanos. archivos en medicina familiar. 2007;9(2):80-86. 29. gómez r, monteiro h, cossio ma, fama d, zanesco a. physical exercise and its prescription in patients with chronic degenerative diseases. rev peru med exp salud pública. 2010;27(3):379-386. 211 editorial teorías de cuidado de la disciplina de enfermería theories on nursing care teorias de cuidado da disciplina de enfermagem la revista aquichan tiene como propósito que los lectores encuentren en los resultados de las investigaciones conocimientos de la disciplina de enfermería y rutas para su aplicación en la práctica, lo cual esperamos se cumpla con esta nueva edición. si partimos de las premisas de la práctica del cuidado de las personas (1) y de que la base teórica de la disciplina es el fundamento de la investigación, la enfermería como profesión debe propender por el desarrollo, la divulgación y la práctica del nuevo conocimiento, por lo cual fawcett plantea que la meta última de la investigación es traducir sus resultados en actividades prácticas útiles (2). de acuerdo con fawcett (3), la investigación es un proceso de desarrollo de teorías, y tanto las teorías de mediano rango —que se caracterizan por ser concretas y específicas— como los productos de investigación son recursos valiosos para la práctica del cuidado, cuyo principal objetivo es el impacto favorable en la salud de las personas, en los servicios de salud y en la utilidad del cuidado de enfermería. la aplicación de las teorías y de los resultados de investigación a la práctica requiere, en primer lugar, del convencimiento por parte de los profesionales de enfermería de la utilidad de las mismas y de los beneficios de los resultados para la salud de las personas, la calidad del cuidado en las instituciones y el reconocimiento de la disciplina. ejemplos de su aplicación son las propuestas de gestión del cuidado, que llevan implícita la planeación, ejecución y evaluación de la práctica del cuidado de enfermería que se ofrece a las personas (individuo, familias y grupos de la comunidad), de acuerdo con sus necesidades y experiencias de salud, enfermedad y muerte. según meleis (4) “la gestión de los cuidados de enfermería se ejerce no solamente con los recursos que ofrecen las teorías de la administración, sino también con las relaciones y concepciones propias de la disciplina de enfermería”, lo cual nos lleva a indagar en ¿cuáles recursos de la administración y de la disciplina profesional de enfermería se apoyará la enfermera o el enfermero para gestionar el cuidado de enfermería? históricamente la profesión ha estado direccionada por la administración, pero la utilización de los recursos disciplinares de enfermería es más reciente y empieza a tomar fuerza con los modelos conceptuales, las teorías de mediano rango, y con los nuevos conocimientos fruto de la investigación. solo por mencionar algunas experiencias concretas de la aplicación de teorías de mediano rango en el cuidado de seres humanos se enuncian las siguientes situaciones: requerimiento de cuidado para el afrontamiento de personas ante situaciones de salud, enfermedad o muerte; requerimiento de cuidado para el bienestar de las personas, y requerimiento de confort de pacientes sometidos a procedimientos de enfermería como el baño en cama. por ejemplo, en el requerimiento de cuidado para el afrontamiento de personas ante situaciones de salud, enfermedad o muerte, la teoría de afrontamiento y adaptación de roy (5) resulta de capital importancia, o mejor, es la teoría que hace ver y sentir 212 aquichan issn 1657-5997 año 12 vol. 12 nº 3 chía, colombia diciembre 2012 referencias 1. morse j. exploring the theoretical basis of nursing using advanced techniques of concept analysis. advances in nursing science 1995;17(3):31 a-46. 2. fawcett j, garity j. evaluation of the utility of the theory of practice. in: evaluating research for evidence-based nursing practice. philadelphia; davis company; 2009. pp. 255-271. 3. fawcett j, garity j. research and evidence-based nursing practice. in: evaluating research for evidence-based nursing practice. philadelphia: davis company; 2009. pp. 3-20. 4. meleis i. theoretical nursing: development & progress. 3 edition. philadelphia: lippincott; 1997. 5. roy c. research based on the roy adaptation model: last 25 years. nursing science quarterly 2011;24(4):312-320. 6. swanson km. nursing as informed caring for the well-being of others. image: the journal of nursing scholarship 1993;25(4):352-357. 7. kolcaba k. a theory of holistic comfort for nursing. journal of advanced nursing 1994;19:1178-1184. la disciplina de enfermería como la ciencia del cuidado, la cual cada día se acerca más al ser humano en toda su dimensión. en el requerimiento de cuidado para el bienestar de las personas la teoría de cuidado para el bienestar de kristen swanson habla de cinco procesos: conocer, mantener la fe, estar con, hacer por y posibilitar; procesos que al ser aplicados en la práctica permiten brindar cuidado para el bienestar (6). respecto al requerimiento de comodidad de pacientes sometidos a procedimientos de enfermería, como por ejemplo el baño en cama, kolcaba ofrece la teoría del confort que guía la atención de enfermería con intervenciones para atender las necesidades de comodidad de las personas desde lo físico, psicoespiritual, social y ambiental (7). finalmente, la invitación es a continuar desarrollando conocimiento disciplinar que contribuya a la salud de las personas y que justifique la asignación de recursos humanos para el cuidado de los individuos en sus procesos de salud, enfermedad y muerte. lucy muñoz de rodríguez magíster en enfermería. profesora asociada, facultad de enfermería, universidad nacional de colombia. lucymdero@yahoo.com 251 260 undergraduate nursing students.indd 251 nurcan ertuğ1 hatice önal2 undergraduate nursing students’ research activities and utilization: a turkish sample 1 phd, assist. prof. turgut özal university, turkey. ertugnurcan@gmail.com 2 bsn, lecturer. niğde university school of health, niğde, turkey. hatonal@hotmail.com recibido: 9 de julio de 2013 enviado a pares: 3 de septiembre de 2013 aprobado por pares: 14 de enero de 2014 aceptado: 25 de abril de 2014 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 251-260 to reference this article / para citar este artigo / para citar este artí culo ertuğ n, önal h. undergraduate nursing students’ research activities and utilization: a turkish sample. aquichan. 2014; 14(2): 251-260. abstract objective: the aim of this study was determine undergraduate nursing students’ research activities and utilization. method: a descriptive design was used in the study. this study conducted with undergraduate nursing students at the two universities in turkey during the spring term of 2012. the population consisted of 216 participants. the data were collected through a questionnaire developed by the author based on literature. the percentage, chi-square and fisher’s exact tests were used to evaluate the collected data. results: approximately half of the students (49,5%) knew how to reach scientific publications but none of the students followed or read scientific publications. only a few students (4,2%) had participated in a scientific research activity. it was found that 87,0% of the students did not utilize the research findings in clinical practice. of 216 students, 34,4% did not know how to utilize the research findings. conclusions: the majority of the students did not utilize the research findings in clinical practice. insufficient knowledge about research utilization was the most prominent reason for not utilizing research findings by students. it is suggested that students should be encouraged and supported to utilize research findings and conduct research. key words nursing, students, nursing research, research utilization, evidence-based practice, turkey (source: decs, bireme). 252 aquichan issn 1657-5997 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 251-260 actividades investigativas y la utilización de los resultados de la investigación por estudiantes de enfermería a nivel pregrado: una muestra de turquía resumen objetivo: el objetivo de este estudio fue determinar las actividades de investigación y la utilización de los resultados de la investigación por parte los estudiantes de enfermería de pregrado. método: un diseño descriptivo fue utilizado en el estudio que se desarrolló con estudiantes de pregrado de enfermería en dos universidades en turquía durante el semestre de primavera de 2012. la población estuvo conformada por 216 participantes. los datos fueron recolectados a través de un cuestionario elaborado por el autor en base a la literatura. las pruebas de porcentaje, chi-cuadrado y la prueba exacta de fisher fueron utilizados para evaluar los datos recogidos. resultados: aproximadamente la mitad de los estudiantes (49,5 %) sabían cómo acceder a las publicaciones científicas, pero ninguno de los estudiantes siguen o leen publicaciones científicas. solo unos pocos estudiantes (4,2 %) habían participado en una actividad de investigación científica. se encontró que el 87,0 % de los estudiantes no utilizan los resultados de la investigación en la práctica clínica. de 216 estudiantes, el 34,4 % no sabe cómo utilizar los resultados de la investigación científica. conclusiones: la mayoría de los estudiantes no utilizan los resultados de la investigación en la práctica clínica. falta de conocimiento sobre el uso de la investigación fue la razón más importante para que los estudiantes no utilizaran los resultados de la investigación. se sugiere que los estudiantes deben ser alentados y apoyados para utilizar los resultados de investigación y realizar investigaciones. palabras clave enfermería, estudiantes, investigación en enfermería, práctica clínica basada en la evidencia, turquía (fuente: decs, bireme). 253 undergraduate nursing students’ research activities and utilization: a turkish sample l nurcan ertuğ, hatice önal año 14 vol. 14 nº 2 chía, colombia junio 2014 l 251-260 atividades investigativas e a utilização dos resultados da pesquisa por estudantes de enfermagem na graduação: uma amostra da turquia resumo objetivo: determinar as atividades de pesquisa e a utilização dos resultados da pesquisa por parte dos estudantes de enfermagem de graduação. método: foi utilizado um desenho descritivo no estudo que se desenvolveu com estudantes de graduação de enfermagem nas duas universidades na turquia durante o semestre de primavera de 2012. a população esteve conformada por 216 participantes. os dados foram coletados por meio de um questionário elaborado pelo autor com base na literatura. as provas de porcentagem, chi-quadrado e a prova exata de fisher foram utilizados para avaliar os dados coletados. resultados: aproximadamente a metade dos estudantes (49,5%) sabia como aceder às publicações científicas, mas nenhum dos estudantes segue ou lê publicações científicas. somente uns poucos estudantes (4,2%) participaram de uma atividade de pesquisa científica. constatou-se que 87% dos estudantes não utilizam os resultados da pesquisa na prática clínica. de 216 estudantes, 34,4% não sabem como utilizar os resultados da pesquisa científica na prática clínica. conclusão: falta de conhecimento sobre a utilização da pesquisa foi a razão mais importante para que os estudantes não utilizassem os resultados da pesquisa. sugere-se que os estudantes sejam motivados a utilizar os resultados de pesquisa, bem como a realizá-la. palavras-chave enfermagem, estudantes, pesquisa em enfermagem, prática clínica baseada em evidências, turquia (fonte: decs, bireme). 254 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 introduction it is now widely recognized the world over that evidencebased practice (ebp) is key to delivering the highest quality of healthcare and ensuring the best patient outcomes. ebp involves using the best evidence to make patient-care decisions, and such evidence typically comes from research conducted by nurses and other healthcare professionals. it would seem a foregone conclusion that effective nursing practice is based on the best possible, rigorously tested evidence. yet, it is only in the past two decades that an emphasis on evidence as a basis for practice has reached the forefront of the professional nursing (1-3). the terms research utilization and ebp are sometimes used synonymously. although there is overlap between the two concepts, they are distinct. research utilization, the narrower of the two terms, is the use of findings from a study or set of studies in a practical application that is unrelated to the original research. ebp is the more general term and encompasses research utilization. evidence is constituted of more than the findings of research; the term research in research utilization denotes only the research findings (usually scientific). the utilization of research knowledge is regarded as a prominent feature of ebp. nurses, physicians, pharmacists, and other healthcare professionals seek answers to numerous clinical questions on a daily basis. an evidenced-based approach to care allows healthcare providers to access the best evidence to answer these questions in a timely fashion and to translate that evidence into clinical practice to improve patient care and outcomes (1, 3-5). nursing research is a systemic process of inquiry that uses rigorous guidelines to produce unbiased, trustworthy answers to questions about nursing practice. nurses use research to generate new knowledge or to validate and refine existing knowledge that directly or indirectly influences nursing practice. research ensures practices are based on evidence, rather than eloquence or tradition. without research, nursing practice would be based on tradition, authority, trial and error, personal experiences, intuition, and borrowed evidence (2, 6). there are numerous studies about nurses’ research activities and utilization, both in turkey (7-9) and other countries (10-13). in these studies, it has been determined that nurses have not utilized research results enough. the barriers to that utilization generally include lack of institutional support, lack of time to read research reports, inability to understand research reports, and insufficient research knowledge. research utilization is crucial to preparing the next generation of nurses, since they are expected to conduct new research, to stay abreast of research, to read and to use existing research to improve their ability to solve problems, to process information at a scientific level and to make decisions independently in clinical settings. therefore, nursing students need to be well prepared in relation to nursing research, and the education of nursing students is a key element in improved utilization of nursing research in clinical practice (14). the course “research in nursing” is mandatory in junior or senior year in the nursing baccalaureate curricula in turkey. yet, baccalaureate students, after completing a research course, are not prepared to critique research studies skillfully or to determine their potential use in professional practice. the faculty in baccalaureate nursing programs must incorporate nursing research throughout the curriculum. a single course on research process is no assurance that even the best and brightest students will be prepared to perform the investigative functions of a nurse with a baccalaureate degree in nursing (15). previous research studies recommend nursing research courses and concepts be introduced into the nursing curriculum as early as possible, since research courses and concepts improve nursing students’ positive attitudes toward nursing research (16, 17). the nursing curriculum in turkey includes a nursing research course. however, most of the nurses are unaware of the research that has been done and do not make use of research results in everyday practice. conducting and using research are regarded as an additional burden and task by nurses in turkey. moreover, nurses who conduct and use research are discriminated against by others. students have to fall in step with others after they become nurses, so as to avoid discrimination. studies on the use of research by turkish nurses show that 35–55% of nurses feel incapable of evaluating the quality of the research and 29–77% are unaware of the research that does exist (7, 18-20). however, presumably nurses should have acquired some research awareness and ability to evaluate research findings during the course of their training. although students’ research activities and research utilization skills are important, few studies have been done on this particular topic. thus, it is hoped that providing an insight into nursing students’ research activities and research utilization will help to restructure the nursing education curriculum and contribute to the development of effective strategies for research utilization. 255 undergraduate nursing students’ research activities and utilization: a turkish sample l nurcan ertuğ, hatice önal the aim of this study was to identify turkish undergraduate nursing students’ research activities and research utilization. materials and method a descriptive design was used in the study. the sample was recruited from undergraduate nursing students at the two universities in turkey. one of them is a private university; the other is public. the target population consisted of undergraduate nursing students who are in their sophomore, junior or senior years. sampling was not done, since we wanted to reach the entire target population, which consisted of 302 nursing students during the spring term of 2012. the questionnaire was distributed to 302 students, and 216 questionnaires were returned (a response rate of 71%). freshman students with no clinical experience were excluded. this study sought answers to the following questions: 1) do nursing students participate in research activities? 2) do nursing students read scientific publications? 3) do nursing students utilize research findings in clinical practice? 4) what are the barriers to nursing students using research in clinical practice? the data were collected by means of a questionnaire developed for this study on the basis of the literature (21, 22) . the questionnaire was pilot tested with ten nursing students and then revised based on the findings of the pilot study. the content validity of the questionnaire was evaluated by two experts. the items in question are: nursing students’ research activities, the utilization of research findings during clinical studies, barriers to research utilization, request to conduct research, reading scientific articles, and participation in scientific activities. the questionnaires were given to students immediately after any lesson and then collected. the study was approved by the research ethics committee of a university in turkey. the data were collected subsequent to approval of the study by the ethics committee. written permission for the study was obtained from the heads of the institutions in question. the students were informed about the purpose of the study and confidentiality was guaranteed. participation was voluntary and could be terminated at any point in time. in order to ensure anonymity, no identification was done at an individual level. prior to data collection, informed consent was obtained from all the participants. the data were analyzed using the statistical package for the social sciences (spss), version 16.0 (spss inc., chicago, il, usa). statistical significance was defined as p < 0.05. chi-square and fisher’s exact tests were used to evaluate differences between the variables. results the students were in the 19–33 age group and the average age was 21.5 years (sd = 1.75). most of the students were from the public university (59.3%), and there was no difference between the public university and the private university in terms of homogeneity (p > 0.05). female students accounted for 82.4% of the total group. the participation in scientific/research activities and research utilization by nursing students is shown in table 1. a relationship was found to exist between research education and conducting research (x2 = 10.582, p = 0.002) (table 2). nine students had participated in a research activity in the past, and 88.88% of them had completed a research course. the students who had taken a research course conducted more research than the others. no significant differences were observed between conducting research and research utilization (p = 1.000), participation in scientific activities (p = 0.093), and knowing how to access scientific publications (p = 1,000). as illustrated in table 3, no significant differences were found between research utilization and students’ educational year (p = 0.669), having a research course (p = 0,834), knowing how to access scientific publications (p = 0.094), foreign language level (p = 0,895), and participation in scientific activities (p = 0,934). the students had not utilized research findings for several reasons; namely, inadequate knowledge about research utilization (34.04%), not being allowed to do so by nurses (28.7%), inability to read articles in a foreign language (25%), never having read a research article (16.48%), and research results are not practical (11.7%). when nursing students were asked what they expected from their instructors concerning research utilization in their clini256 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 cal practice, they responded as follows: 23.9% expected to be taught research utilization, 18.2% wanted guidance to conduct research, 16.9% wanted sufficient resources in the library, and 15.9% wanted to be taught how to evaluate research articles. moreover, 11.9% students pointed out that nurses must utilize research findings. discussion the aim of this study was to investigate undergraduate nursing students’ research activities and research utilization. although the vast majority of the students (84.3%) were willing to participate in research studies, only 4.2% had conducted a research study by that point in time. it was assumed students are not supported or encouraged sufficiently by lecturers in relation to conducting research. björkström et al. (22) found a large number of students did not regard nursing lecturers as a resource for nursing development. the vast majority of the students (87%) were found not to have utilized research findings in clinical practice. this result parallels that of a previous study on research utilization (23). heikkila (23) found research utilization was fair or poor among most nurses and nursing students, and students’ research utilization skills seemed to depend on the amount of instruction. on the other hand, mattila et al. (5) and björkström et al. (22) found most students (72% and 78,1%, respectively) utilized research results in nursing practice. we recommend students be supported to conduct new research, to stay abreast of research, and to read and use existing research done by lecturers so as to improve research utilization among students. insufficient knowledge about research utilization was found to be the most prominent reason for not utilizing research findings. lecturers and curriculum are the most important factors regarding insufficient knowledge about research utilization on the part of nurses and nursing student. it is believed lecturers should not only instruct students, but also emphasize the importance of research utilization in nursing research courses and during other courses as well. nurses’ knowledge of research and attitudes towards it are of great importance, given their influence on students’ attitudes and behavior (24). most of the students (73.1%) stated nurses do not use research findings in their work. out of the 216 students, 19 (11.94%) indicated nurses should utilize research findings, because they are role models for nursing students. nurses’ behavior was shown to have an influence on students. therefore, research awareness should be encouraged among nurses as well. approximately half the students (49.5%) knew how to access scientific publications, but none of them followed or read scientific publications. previous studies found the number of students reading scientific articles to be quite small. in a study by björkström et al. (22), 24.5% of the students were non-readers. mattila et al. (5) found 25–36% of the students had read no scientific nursing journal whatsoever. it seems students have yet to comprehend fully the importance of research and research utilization, and lecturers do not encourage students to read articles. it was found that students who had taken a research course in the past conducted more research than others. considering that students learn research methods during a research course, this result is not surprising. however, students’ participation in research studies is very limited and this issue needs to be examined further. it is expected that students conducting research should utilize their research findings. however, no statistically significant relationship was found between conducting research and utilization of research findings. this may be due to students’ ignorance about how to utilize research findings, since research utilization requires different and special skills. conclusions the results of this study show the majority of the students did not participate in research activities and did not utilize research findings in clinical practice. none of the students followed or read scientific publications. the findings also indicate that insufficient knowledge about research utilization was the most prominent reason for students not utilizing research findings. the findings of this study could have consequences for nursing lecturers and institutions. the nursing curriculum must emphasize research utilization and ensure it is taught. in this respect, collaboration between clinical nurses and nursing lecturers on utilization of research findings is crucial. recommendations for practice it is recommended students receive support and encouragement to utilize research findings, conduct research, and follow the 257 undergraduate nursing students’ research activities and utilization: a turkish sample l nurcan ertuğ, hatice önal scientific publications recommended by their lecturers. the nursing curriculum might need to be restructured to emphasize the importance of research utilization and the utilization of research findings in courses. moreover, appropriate training must be imparted to nurses about research utilization, because students generally take nurses as examples in clinical practice. limitations of the study the students at two selected schools might not represent the population of all students in turkey. the small sample size might jeopardize generalization of the results. we suggest expanding the research by using a larger sample. references 1. melnyk bm, fineout-overholt e. evidence-based practice in nursing and healthcare. 2nd ed. philadelphia: lippincott williams & wilkins; 2011. 2. houser j. nursing research: reading, ssing, and reating evidence. 2nd ed. massachusetts: jones & bartlett learning; 2012. 3. polit df, beck ct. nursing research: generating and assessing evidence for nursing practice. 9th ed. philadelphia: lippincott williams & wilkins; 2012. 4. estabrooks ca. the conceptual structure of research utilization. res nurs health 1999;22(3):203-16. 5. mattila l-r, koivisto v, haggman-laitila a. evaluation of learning outcomes in a research process and the utilization of research knowledge from the viewpoint of nursing students. nurse educ today 2005;25:487-95. 6. schmidt na, brown jm. evidence-based practice for nurses. 2nd ed. sudbury, massachusetts: jones & bartlett learning; 2012. 7. uysal a, temel ab, ardahan m, ozkahraman s. barriers to research utilisation among nurses in turkey. j clin nurs 2010;19(23-24):3443-52. 8. alp-yılmaz f, tel h. determination of the nurses’ views of the research and the use of research results in practical field. journal of anatolia nursing and health sciences. 2010;13(1):15-23. 9. özdemir l, akdemir n. turkish nurses’ utilization of research evidence in clinical practice and influencing factors. int nurs rev 2009;56(3):319-25. 10. chau jpc, lopez v, thompson dr. a survey of hong kong nurses’ perceptions of barriers to and facilitators of research utilization. res nurs health 2008;31(6):640-9. 11. estabrooks ca, kenny dj, adewale aj, cummings gg, mallidou aa. a comparison of research utilization among nurses working in canadian civilian and united states army healthcare settings. res nurs health 2007;30(3):282-96. 12. mehrdad n, salsali m, kazemnejad a. the spectrum of barriers to and facilitators of research utilization in iranian nursing. j clin nurs 2008;17(6):2194-202. 13. ofi b, sowunmi l, edet d, anarado n. professional nurses’ opinion on research and research utilization for promoting quality nursing care in selected teaching hospitals in nigeria. int j nurs pract 2008;14(3):243-55. 14. halabi j, hamdan-mansour a. attitudes of jordanian nursing students towards nursing research. j res nurs 2012;17(4):363-73. 15. radjenovic d, chally p. research utilization by undergraduate students. nurse educ 1998; 23(2):26-9. 16. owens p, kelly j. student nurses’ attitudes toward nursing research. nurse educ 1998; 23(5):20, 9. 17. whitmeyer-hitchcock b, murphy e. a triad of research roles: experiential learning in an undergraduate research course. j nurs educ 1999;38(3):120-7. 18. kocaman g, seren s, lash aa, kurt s, bengu n, yurumezoglu ha. barriers to research utilisation by staff nurses in a university hospital. j clin nurs 2010;19(13-14):1908-18. 258 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 19. yava a, tosun n, çiçek h, yavan t, terakye g, hatipoğlu s. nurses’ perceptions of the barriers to and the facilitators of research utilization in turkey. appl nurs res 2009;22(3):166-75. 20. yava a, çiçek h, tosun n, yanmış n, koyuncu a, güler a, et al. kardiyoloji ve kalp damar cerrahisi hemsirelerinin arastirma sonuclarini kullanmalarini etkileyen faktörler (factors influencing use of research results by cardiology and cardiovascular surgery nurses). anatolian journal of clinical investigation. 2008;2(4):160-6. 21. funk s, champagne m, wiese r, tornquist e. barriers: the barriers to research utilization scale. appl nurs res 1991;4(1):39-45. 22. björkström me, johansson is, hamrin ekf, athlin ee. swedish nursing students’ attitudes to and awareness of research and development within nursing. j adv nurs 2003;41(4):393-402. 23. heikkilä a. ammattikorkeakoulusta valmistuvien hoitotyön opiskelijoiden tutkitun tiedon käyttö [doctoral thesis]. turku: university of turku; 2005. 24. kajermo kn, nordström g, krusebrant a, björvell h. perceptions of research utilization: comparisons between health care professionals, nursing students and a reference group of nurse clinicians. j adv nurs 2000;341(1):99-109. 259 undergraduate nursing students’ research activities and utilization: a turkish sample l nurcan ertuğ, hatice önal tables table 1. participation in scientific/research activities and research utilization by nursing students participation in scientific/research activities and research utilization n % research education yes 81 37.50 no 135 62.50 participation in scientific activities yes 171 79.20 no 45 20.80 knows how to access scientific publications yes 107 49.50 no 109 50.50 follows scientific publications yes 0 0 no 100 100.0 participation in research activities yes 9 4.20 no 207 95.80 wants to participate in research activities yes 182 84.30 no 34 15.70 foreign language level good-level 29 13.50 mid-level 80 37.00 poor-level 107 49.50 students’ research utilization in clinical practice yes 28 13.00 no 188 87.00 nurses’ research utilization in clinical practice yes 58 26.90 no 158 73.10 total 216 100.00 260 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 table 2. comparison between some of the students’ characterictics and conducting research some characteristics of students conducting research test yes no n % n % x2 p research education yes 8 9.9 73 90.1 10,582 0.002* no 1 0.7 134 99.3 research utilization yes 1 3.6 27 96.4 0,029 1.000* no 8 4.3 180 95.7 participation in scientific activities yes 5 2.9 166 97.1 3,174 0.093* no 4 8.9 41 91.1 knows how to access scientific publications yes 7 6.5 100 93.5 2.996 1.000* no 2 1.8 107 98.2 table 3. comparison between some of the students’ characteristics and research utilization some characteristics of students research utilization test yes no n % n % x2 p educational year sophomore 8 10.5 68 89.5 0.803 0.669junior 11 15.5 60 84.5 senior 9 13.0 60 87.0 research course yes 11 13.6 70 86.4 0.044 0.834 no 17 12.6 118 87.4 knows how to access scientific publications yes 18 16.8 89 83.2 2.799 0.094 no 10 9.2 99 90.8 foreign language level good-level 3 10.3 26 89.7 0.221 0.895mid-level 11 13.8 69 86.2 poor-level 14 13.1 93 86.9 participation in scientific activities yes 22 12.9 149 87.1 0.007 0.934 no 6 13.3 39 86.7 382 391 aplicacao do mapa conceitual.indd 382 diana paula de souza rego pinto carvalho1 allyne fortes vitor2 elizabeth barichello3 rosana lúcia alves de villar4 viviane euzébia pereira-santos5 marcos antonio ferreira-junior6 aplicação do mapa conceitual: resultados com diferentes métodos de ensino-aprendizagem7 1 orcid.org/0000-0001-9485-5015. universidade federal de pelotas, brasil. diana-rego@hotmail.com 2 orcid.org/ 0000-0002-4672-2303. universidade federal do rio grande do norte (ufrn), brasil. allynefortes@yahoo.com.br 3 orcid.org/0000-0001-7764-032x. universidade federal do triângulo mineiro (uftm), brasil. elizabeth.barichello@enfermagem.uftm.edu.br 4 orcid.org/0000-0002-8393-2561. universidade federal do rio grande do norte (ufrn), brasil. rosanaalvesrn@gmail.com 5 universidade federal do rio grande do norte (ufrn), brasil. vivianeepsantos@gmail.com 6 universidade federal do rio grande do norte (ufrn), brasil. marcosjunior@ufrnet.br 7 artigo extraído da dissertação de mestrado da primeira autora, intitulada: “a formação de conceitos no ensino de graduação em enfermagem à luz da teoria da aprendizagem significativa”. recibido: 31 de marzo de 2014 enviado a pares: 4 de mayo de 2014 aceptado por pares: 29 de mayo de 2016 aprobado: 31 de mayo de 2016 doi: 10.5294/aqui.2016.16.3.9 para citar este artículo / to reference this article / para citar este artigo de souza rego pinto carvalho dp, fortes vitor a, barichello e, alves de villar rl, pereira-santos ve, ferreira-junior ma. aplicação do mapa conceitual: resultados com diferentes métodos de ensino-aprendizagem. aquichan. 2016; 16(3): 382-391. doi: 10.5294/aqui.2016.16.3.9 resumo objetivo: analisar o resultado de uma intervenção de ensino aliada ao método tradicional para o desenvolvimento do conceito de complicações de pós-operatório mediato da ferida cirúrgica como proposta para uso nos cursos de graduação em enfermagem. método: estudo do tipo quase-experimental com análise qualitativa, aplicado por meio de uma intervenção de ensino em estudantes do curso de graduação em enfermagem. a coleta de dados ocorreu em duas etapas, e os estudantes foram divididos de forma aleatória para compor os subgrupos i e ii. para viabilizar a coleta de dados, os estudantes elaboraram mapas conceituais (mc) com auxílio do software cmap tools®. os dados foram analisados por meio da técnica de análise de conteúdo, com a identificação de 12 subcategorias. resultados: o subgrupo ii demonstrou resultados positivos em relação ao subgrupo i, uma vez que a associação dos dois métodos de ensino com o uso da técnica de mc conseguiu promover a capacidade de articulação dos conhecimentos prévios com os conceitos desenvolvidos. conclusão: constatou-se que a associação da intervenção de ensino com embasamento teórico na teoria da aprendizagem significativa somada ao método tradicional e o uso da técnica de mc estimulam um bom desempenho do estudante no processo de ensino-aprendizagem. palabras-chave educação em enfermagem; aprendizagem; enfermagem; ensino (fonte: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 382-391 383 aplicação do mapa conceitual: resultados com diferentes métodos de ensino-aprendizagem l diana paula de souza rego pinto carvalho e outros año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 382-391 aplicación de mapa conceptual: resultados con diferentes métodos de enseñanza y aprendizaje resumen objetivo: analizar el resultado de una intervención de enseñanza aliada a un método tradicional para el desarrollo del concepto de complicaciones de la herida quirúrgica postoperatoria para uso en el pregrado en enfermería. método: estudio de análisis cualitativo casi-experimental, aplicado por medio de una intervención de enseñanza en los estudiantes de enfermería de pregrado. la recolección de datos se dio en dos etapas, y los estudiantes fueron divididos al azar en los subgrupos i y ii. para facilitar la recopilación de datos, los estudiantes desarrollaron mapas conceptuales con la ayuda de las herramientas de software cmap tools®. los datos fueron analizados mediante la técnica de análisis de contenido, identificando 12 categorías. resultados: el subgrupo ii mostró resultados positivos en relación con el subgrupo i, ya que la asociación de los dos métodos de enseñanza que utilizan la técnica de mc podría promover la capacidad de articular los conceptos desarrollados con conocimientos previos. conclusión: se encontró que la asociación de la intervención docente con base teórica en la teoría del aprendizaje significativo, más el método tradicional y el uso de la técnica de mc estimulan un buen desempeño de los estudiantes en el proceso de enseñanza-aprendizaje. palabras claves educación en enfermería; aprendizaj; enfermería; enseñanza (fuente: decs, bireme). 384 aquichan issn 1657-5997 using concept maps: results with different teaching and learning methods abstract objective: to analyze the results of a teaching intervention that uses a traditional method to develop the concept of postoperative wound complications in the undergraduate nursing program. method: qualitative, quasi-experimental analysis implemented through a teaching intervention for students from the undergraduate nursing program. data collection was in two stages and students were randomly divided into subgroups i and ii. to facilitate data collection, students created concept maps with the cmap tools® software. the researchers used the content analysis method to analyze the data, identifying 12 categories. results: subgroup ii showed positive results compared to subgroup i, since the association of the two teaching methods using the cm technique could promote the ability to articulate the concepts developed with previous knowledge. conclusion: the researchers found that associating the teaching intervention based on the meaningful learning theory to the traditional method and using cm encourages the good performance of students in the teachinglearning process. keywords nursing education; learning; nursing; teaching (source: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 382-391 385 aplicação do mapa conceitual: resultados com diferentes métodos de ensino-aprendizagem l diana paula de souza rego pinto carvalho e outros introdução o ensino de graduação em enfermagem tem sofrido constantes mudanças curriculares e discussões de suas propostas pedagógicas ao longo da história do ensino no brasil. as diretrizes curriculares nacionais (dcn) para o curso de graduação em enfermagem trouxeram grandes avanços agregados a esse nível de formação, com destaque para uma formação claramente mais humanista (1, 2). é esperado que a instituição universitária esteja integrada aos assuntos do mundo e comprometida com o destino dos homens, para associar o máximo de qualificação acadêmica com o máximo de compromisso social, que sinaliza na direção da superação da fragmentação do conhecimento até então presente (3). para que essas mudanças sejam propostas, é necessário compreender o processo de ensino-aprendizagem de forma dinâmica e não como uma somatória de conteúdos que podem ser acrescidos aos anteriormente acumulados. trata-se de um processo complexo que exige ações direcionadas para que o estudante aprofunde e amplie os conhecimentos elaborados por meio de sua participação (1). assim, a educação promove o desenvolvi mento das capacidades intelectuais de pen sar, de raciocinar, de buscar informações, de analisar, de argumentar e de dar significado às novas informações adquiridas (4). dessa forma, com base em todas as modificações geradas por um mundo globalizado, dotado cada vez mais de recursos tecnológicos inovadores, bem como de produtos materiais advindos dessa tecnologia, as instituições formadoras devem repensar seus projetos pedagógicos. a formação superior em enfermagem precisa estar ciente dessa necessidade de revisão de suas propostas formadoras a fim de atender a uma realidade que muda a cada dia (1). este estudo tem como base os princípios do construtivismo, na perspectiva de uma formação baseada na aprendizagem que promova significado no sujeito envolvido no processo formativo, aliado à construção de mapas conceituais (mc) propostos por david joseph novak como forma de intervir no ensino até então praticado e denominado de ensino tradicional. tal proposta baseia-se na expectativa de apresentar uma alternativa educacional para a prática da educação nos cursos de graduação em enfermagem, a fim de facilitar a compreensão dos conceitos relacionados aos conteúdos específicos, aqui pontuados no desenvolvimento do conceito de complicações de pósoperatório mediato da ferida cirúrgica. o conceito de complicações de pós-operatório mediato da ferida cirúrgica permeia desde o conhecimento da prática perioperatória com as atividades desenvolvidas durante a assistência pré, intra e pós-operatória, que são tradicionalmente abordadas pela enfermagem nos cuidados perioperatórios, dos cuidados mais básicos aos mais avançados da assistência. destes, destacam-se a educação do paciente para o procedimento operatório, o aconselhamento cirúrgico, o levantamento dos dados para análise e subsídio da assistência a ser implementada, o próprio planejamento e aplicação dos cuidados, bem como a avaliação de todo processo (5). requer ainda do profissional enfermeiro a capacidade de relacionar esse conceito com conhecimentos adquiridos em disciplinas como anatomia, fisiologia, semiologia e semiotécnica de enfermagem, enfermagem clínica e as diversas doenças relacionadas ao paciente em tratamento. por isso, é importante que a formação desse profissional seja direcionada para as competências técnicas, teóricas, práticas e humanísticas com vistas ao desenvolvimento do raciocínio clínico e do pensamento crítico para a adaptação dos conceitos às mais diversas situações-problema reais. nesse contexto, a teoria da aprendizagem significativa (tas) de david paul ausubel emerge para subsidiar as técnicas de ensino e alcançar, assim, o objetivo de formar o egresso com o perfil almejado. desse modo, conforme postulado por ausubel, a aprendizagem é significativa quando uma nova informação adquire significados para o estudante a partir de uma ancoragem em aspectos relevantes da estrutura cognitiva preexistente. ou seja, quando conceitos, ideias, proposições são incorporados aos preexistentes na estrutura de conhecimentos (ou de significados) do aprendiz, com determinado grau de clareza, estabilidade e diferenciação (6). a aprendizagem é, portanto, considerada um processo idiossincrásico, influenciado por fatores sociais e pelo ensino na sala de aula. trata-se de uma teoria cognitivo-humanista na qual o 386 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 estudante recorre a pensamentos, sentimentos e ações para dar significado às experiências vivenciadas (7). a tas processa-se em vários níveis de desenvolvimento e complexidade, seja pelo domínio dos símbolos e das representações, seja pelo domínio dos conceitos, seja das proposições. no que concerne aos conceitos, representam uma das formas mais aplicáveis para a formação de nível superior, por acreditar que, se um determinado profissional domina plenamente um conceito, ele consegue resolver qualquer problema da prática cotidiana, de forma a adequar saberes a realidades e culturas distintas (8). a forma mais visual para ilustrar o domínio de um conceito é a sua representação gráfica, por meio da construção de um mc, que trata de uma estratégia de ensino que aproxima conceitos e fatos e que tem demonstrado ser metodologicamente favorável à construção do conhecimento de maneira interdisciplinar e individualizada. os mc permitem que o estudante elabore conceitos e os organize em sua estrutura cognitiva, a fim de elaborar uma rede hierárquica e linear para cada novo conhecimento que será ancorado no que previamente apresenta (9). dessa forma, este estudo objetiva analisar o resultado de uma intervenção de ensino aliada ao método tradicional para o desenvolvimento do conceito de complicações de pós-operatório mediato da ferida cirúrgica como proposta para aplicação nos cursos de graduação em enfermagem. método trata-se de um recorte da dissertação de mestrado intitulada “a formação de conceitos no ensino de graduação em enfermagem à luz da teoria da aprendizagem significativa”. este consiste em um estudo com foco na aprendizagem dos estudantes, realizado à luz da tas quanto ao desenvolvimento de conceitos. com delineamento do tipo quase-experimental e análise qualitativa, aplicado por meio de uma intervenção de ensino aos estudantes do curso de graduação em enfermagem da universidade federal do rio grande do norte (ufrn). foram incluídos os estudantes regularmente matriculados na disciplina de atenção integral à saúde i, oferecida no quinto semestre do curso de graduação em enfermagem da ufrn, excluídos aqueles que estavam matriculados nesse mesmo período, porém em outras disciplinas que não a descrita. dos 50 estudantes matriculados na disciplina, 25 alunos foram selecionados, aleatoriamente, por meio de sorteio, para comparecerem à primeira etapa e constituírem o subgrupo i (grupo intervenção), na etapa i da pesquisa, quando apenas 18 aceitaram participar e atenderam aos critérios de inclusão/exclusão. esse grupo participou também da etapa ii da pesquisa, o mesmo grupo intervenção após duas exposições, método pautado na tas e pelo método tradicional de ensino em que aconteceu a aula do mesmo conteúdo programático embasado no método tradicional de ensino. na etapa ii, compareceram apenas 12 estudantes e constituíram o subgrupo ii. o subgrupo i recebeu uma aula que foi preparada com base nos pressupostos da tas para desenvolvimento de domínio do conceito de “complicações de pós-operatório mediato da ferida cirúrgica”, ministrada pelos pesquisadores que aplicaram a intervenção. dessa forma, a aula foi desenvolvida a partir do conhecimento prévio do estudante e o docente era responsável por guiar as proposições de situações que proporcionassem a aprendizagem. ao final, todos os participantes foram convidados a elaborar os mc sobre o tema com uso do software cmap tools®. no início da coleta de dados, esses estudantes receberam um treinamento sobre o uso do software em horário diferente ao de oferta da disciplina. a etapa ii aconteceu 15 dias após a primeira, quando foi ministrada a aula curricular da disciplina sobre o mesmo assunto, como previsto no cronograma com a docente responsável pela temática abordada. da mesma forma que na primeira etapa, após a aula, foram elaborados os mc referentes ao conceito em estudo. assim, buscou-se diminuir ao máximo os possíveis vieses da pesquisa, visto que esta aconteceu em um único semestre, com a mesma turma e possibilitou que todos os estudantes que desejaram pudessem participar da aula com a docente da disciplina responsável pela temática abordada. a construção dos mc foi realizada em um horário diferente do horário curricular da disciplina, com o apoio dos pesquisadores e monitores previamente treinados com uma explanação a respeito da descrição e da forma de elaboração e aplicação destes com uso do software adotado. assim, pretendeu-se analisar o resultado de uma intervenção de ensino aliada ao método tradicional para o desenvolvimento do conceito de complicações de pós-operatório mediato 387 aplicação do mapa conceitual: resultados com diferentes métodos de ensino-aprendizagem l diana paula de souza rego pinto carvalho e outros da ferida cirúrgica como proposta para uso nos cursos de graduação em enfermagem. vale ressaltar que nenhum material foi identificado de modo a não caracterizar os participantes, bem como a entrega foi realizada por meio de depósito em local destinado para tal finalidade. com vistas a garantir a não identificação dos participantes da pesquisa, os termos de consentimento livre e esclarecido (tcle) foram depositados em local distinto dos mc elaborados e recolhidos depois de finalizado o prazo estabelecido para a devolução. a análise dos dados foi realizada mediante o cumprimento das três fases de análise de conteúdo, a saber: 1) pré-análise — por meio da leitura flutuante, da escolha dos documentos, preparação do material e a referenciação dos índices e a elaboração de indicadores; 2) exploração do material; 3) tratamento dos resultados, a inferência e a interpretação (10). o protocolo desta pesquisa foi submetido e aprovado em seus aspectos éticos e metodológicos pelo comitê de ética em pesquisa da universidade federal do rio grande do norte, sob o parecer 262.679 e certificado de apresentação para apreciação ética (caae) 11706412.3.0000.5537. antes do início do estudo, todos os participantes assinaram o tcle. resultados e discussão um mc foi elaborado inicialmente para servir de “espelho” para análise e como base para estabelecer categorias a priori, representado na figura 1. a partir desse mc, foram construídas 11 categorias iniciais para análise; entretanto, durante a leitura flutuante dos mc elaborados pelos estudantes e do referencial teórico sobre o conceito em questão, foi elencada uma categoria a posteriori, que trata dos recursos humanos envolvidos com o conceito. foram analisados 18 mc do subgrupo i (grupo intervenção) e 12 mc do subgrupo ii (grupo intervenção após duas metodologias de ensino), em um total de 30 mc. vale ressaltar que o subgrupo i elaborou os mc após a intervenção de ensino realizada com base nos postulados da tas, sem receber a aula ofertada pela disciplina, e depois o subgrupo ii, elaborou mc após a aula do docente responsável pelos conteúdos relacionados ao conceito estudado, por meio do método tradicional de ensino. de forma geral, as categorias de análise foram divididas em três grandes grupos, um que abordou conteúdos pré-conceituais, outro com os conteúdos diretamente relacionados ao conceito, e um terceiro que focou a articulação do conceito em estudo dentro do campo de saberes da área. figura 1. mapa conceitual “espelho” sobre complicações de pós-operatório mediato da ferida cirúrgica fonte: elaboração própria. 388 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 categoria pré-conceitual nesta classificação, encontram-se três categorias referentes à contextualização do conteúdo trabalhado, à capacidade do estudante de diferenciar conceitos próximos e à busca por todos ou o máximo possível de exemplos para a aplicação conceitual. a tabela 1 representa uma análise comparativa referente às subcategorias pré-conceituais entre os dois subgrupos, i e ii, e demonstra que, embora fosse esperado que o subgrupo ii tivesse um desempenho superior ao subgrupo i, uma vez que aquele participou da intervenção com as duas metodologias de ensino, foi obtida uma melhor expressividade do subgrupo i. por isso, percebe-se que a intervenção de ensino associada aos mc promove uma melhoria da estrutura cognitiva nos estudantes, entretanto, é válido ressaltar que o método de ensino tradicional não pode ser descartado, uma vez que vários estudos mostram que a aprendizagem é favorecida com a associação dos diversos métodos de ensino para que as necessidades dos estudantes sejam supridas. um estudo de meta-análise de estudantes de negócios também encontrou uma variabilidade de estilos de aprendizagem entre os docentes. acredita-se que nenhum estilo de aprendizagem sozinho deve prevalecer entre os estudantes, mas sim uma variedade de estratégias de ensino, dentre elas, o método tradicional (12, 13). categorias conceituais quanto às categorias presentes nessa classificação, houve uma diferença expressiva em relação aos subgrupos i e ii. nesse caso, é válido destacar que o número de alunos do subgrupo ii é um pouco menor quando comparado com o subgrupo i, com seis alunos a menos, quando se espera um quantitativo de conceitos inferior, como pode ser observado na tabela 2 a seguir. tabela 2. categorias conceituais nos subgrupos i (intervenção) e subgrupo ii (intervenção após duas metodologias de ensino) (*) tabela 1. categorias pré-conceituais nos subgrupos i (intervenção) e subgrupo ii (intervenção após duas metodologias de ensino) (*) subcategorias subgrupo i (intervenção) subgrupo ii (intervenção**) ( f ) % ( f ) % contextualização do conceito-chave 38 28,15 56 46,28 diferenciação entre conceitos próximos 38 28,15 55 45,45 exemplos da aplicação conceitual 59 43,70 10 8,27 total 135 100 121 100 (*) os totais foram calculados a partir do número de termos encontrados nos mc, e não pelo número de mapas/sujeitos. (**) subgrupo ii após submissão à intervenção e ao método tradicional de ensino. fonte: elaboração própria. os mc ajudam a organizar os pensamentos individuais e a representar o conhecimento. conceitos ou tópicos que são representados em círculos ou caixas estão ligados por palavras ou frases que explicam a ligação entre as ideias. essa estrutura é útil para estudantes como forma de organizar seus pensamentos para descobrir novos relacionamentos (11). dessa maneira, a aprendizagem significativa associada ao uso de mc consiste na ampliação da estrutura cognitiva por meio da incorporação de novas ideias a ela. depende do tipo de relacionamento que se tem entre as ideias já existentes nessa estrutura e as novas que se internalizam, quando pode ocorrer um aprendizado que varia do mecânico ao significativo (4). subcategorias subgrupo i (intervenção) subgrupo ii (intervenção**) ( f ) % ( f ) % aspectos morfológicos 27 15,97 05 8,62 aspectos fisiológicos 56 33,13 15 25,64 aspectos patológicos 09 5,34 12 20,68 recursos materiais 26 15,38 01 1,72 recursos humanos 17 10,05 05 8,64 características da ferida cirúrgica 32 18,95 19 32,75 definição do conceito 02 1,18 01 1,72 total 169 100 58 100 (*) os totais foram calculados a partir do número de termos encontrados nos mc, e não pelo número de mapas/sujeitos. (**) subgrupo ii após submissão à intervenção e ao método tradicional de ensino. fonte: elaboração própria. 389 aplicação do mapa conceitual: resultados com diferentes métodos de ensino-aprendizagem l diana paula de souza rego pinto carvalho e outros contudo, ao analisar os mc qualitativamente, constata-se que os alunos do subgrupo ii também apresentaram de forma expressiva características conceituais do conteúdo trabalhado, diferente dos alunos do subgrupo i que apresentaram esses conceitos em maior quantidade e representaram também a categoria em questão, como percebido na figura 2. de maneira análoga, nunca se deve esperar que o estudante apresentasse um mc “correto” de um dado conteúdo. isso praticamente não existe, pois o que o estudante apresentará é o seu mapa, e o importante não é se este estará correto ou não, mas sim se ele dará evidências de que o estudante apresenta sinais de aprendizagem significativa do conteúdo (6). em uma meta-análise de 19 estudos que compararam os mc com outras estratégias de ensino utilizadas em sala de aula, verificou-se que tanto o desempenho do estudante quanto a atitude foram afetados positivamente pelo uso de mc. o maior efeito foi encontrado quando os estudantes criaram os mc e os termos em vez do professor. quando usado por estudantes do curso de medicina, durante seus rodízios nas clínicas, os mc foram encontrados para motivar a aprendizagem e identificar equívocos (14). é válido ressaltar que os mc constituem uma estratégia de aprendizagem construtivista eficaz para ajudar os alunos a aplicar os novos conhecimentos e habilidades para clientes com necessidades de cuidados de saúde complexos (15). neste estudo, a utilização da técnica de mc foi eficiente em ambos os subgrupos; todavia, houve algumas dificuldades encontradas no percurso da pesquisa quanto à disponibilidade e à disposição de todos os estudantes a participarem, o que requer que novos estudos sejam realizados para que se obtenha resultados mais expressivos sobre a associação das metodologias de ensino e o processo de ensino-aprendizagem no estudante de graduação. o uso dos mc pode servir como um guia para ajudar os estudantes a organizar e integrar informações, avaliar o conhecimento existente, obter insights sobre conhecimentos novos e existentes, além de relacionar os conceitos básicos para apresentações clínicas dos pacientes. outro estudo concluiu que o mc é uma inovação para um ensino criativo que indica as relações conceituais e padrões em um domínio de conteúdo útil como uma ferramenta cognitiva para melhorar o pensamento crítico do aluno e a capacidade metacognitiva (16). categorias de articulação as categorias de articulação representam a capacidade do estudante em relacionar os diversos conhecimentos adquiridos até esse nível com o conceito de complicações de pós-operatório mediato da ferida cirúrgica desenvolvido neste estudo. figura 2. mc elaborado por sujeito do subgrupo ii, com exemplo de aplicações do conceito fonte: elaborado por sujeito do subgrupo ii. 390 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 dentre todas as categorias, esta exigiu dos estudantes a capacidade de raciocínio clínico e de articulação de conceitos com aplicação de possíveis problemas reais. logo, ao visualizar o resultado comparativo para essa categoria obtido entre os dois subgrupos, é possível perceber que o subgrupo ii, mesmo com quantitativo de sujeitos inferior ao subgrupo i, conseguiu manter uma capacidade de raciocínio esperada, o que demonstra que a intervenção após as duas metodologias de ensino associadas ao uso de mc foi efetiva, conforme os dados da tabela 3. além disso, um ponto interessante trata da possibilidade de que algum aspecto do ensino de enfermagem pela abordagem tradicional iniba a capacidade do estudante para fazer inferências e que o mapeamento do conceito ajuda a moderar esse efeito (14). nesse sentido, entende-se que a associação das duas metodologias de ensino com o uso da técnica de mc favorece o estudante no desenvolvimento de habilidades necessárias para a resolução de situações-problemas reais, que exijam do profissional enfermeiro competências técnicas, teóricas, práticas e humanísticas, além do raciocínio clínico e do pensamento crítico. os resultados sugerem que o desenvolvimento do conceito em estudo, mediante o uso de duas abordagens pedagógicas, foi maior e melhor, visto que as informações foram ancoradas, modificadas e ampliadas na estrutura cognitiva dos sujeitos. conclusões este estudo sugere que a intervenção de ensino embasada nos preceitos teóricos da tas associada ao modelo tradicional de ensino e ao uso de mc favoreceu para o bom desempenho dos estudantes. entretanto, é importante destacar que mesmo com um resultado não tão expressivo, o subgrupo que teve a intervenção após as duas metodologias de ensino apresentou um bom desempenho quanto ao processo de ensino-aprendizagem relacionado ao conceito de complicações de pós-operatório mediato da ferida cirúrgica. assim, com vistas à formação de um profissional enfermeiro competente e que atenda às exigências da sociedade atual, é fundamental que as metodologias utilizadas estejam de encontro com o conceito a ser trabalhado e que as abordagens pedagógicas utilizadas pelos docentes consigam suprir todas as necessidades dos estudantes, o que obviamente não exclui a abordagem tradicional, uma vez que, quando associada à tas e aos mc, conseguem obter bons resultados na formação do estudante de graduação em enfermagem. tabela 3. categorias de articulação do conceito nos subgrupos i (intervenção) e subgrupo ii (intervenção após duas metodologias de ensino) (*) (*) os totais foram calculados a partir do número de termos encontrados nos mc, e não pelo número de mapas/sujeitos. (**) subgrupo ii após submissão à intervenção e ao método tradicional de ensino. fonte: elaboração própria. subcategorias subgrupo i (intervenção) subgrupo ii (intervenção**) ( f ) % ( f ) % intervenções 20 83,33 11 68,75 articulações com outros conceitos 04 16,66 05 31,25 total 24 100 16 100 este estudo demonstrou que as demandas do ambiente de cuidados de saúde, juntamente com a necessidade de “conhecer” o paciente, sugerem que os critérios de resultados para o ensino de enfermagem precisam enfatizar o desenvolvimento do pensamento crítico e as habilidades de resolução de problemas. tanto a associação americana de faculdades de enfermagem (aacn) quanto a liga nacional de enfermagem — comissão de acreditação (nlnac) identificaram o pensamento crítico como a principal competência necessária para fazer julgamentos clínicos eficazes (14). 391 aplicação do mapa conceitual: resultados com diferentes métodos de ensino-aprendizagem l diana paula de souza rego pinto carvalho e outros referências 1. waterkemper r, prado ml. estratégias de ensino-aprendizagem em cursos de graduação em enfermagem. avanc enferm. 2011; xxix(2): 234-46. 2. ministério da educação (brasil). conselho nacional de educação. câmara de educação superior. resolução cne/ces n.º 3 de 7 de novembro de 2001: diretrizes curriculares nacionais do curso de graduação em enfermagem. brasília (df): mec; 2001. 3. leal df, rauber jj. a concepção de ética dos profissionais da enfermagem. rev min enferm. 2012; 16(4): 554-63. 4. mendoza iyq, peniche acg, püschel vaa. conhecimento sobre hipotermia dos profissionais de enfermagem do centro cirúrgico. rev esc enferm usp. 2012; 46: 123-9. 5. smeltzer sc, bare bg. brunner & suddarth. tratado de enfermagem médico cirúrgico. 11ª ed. rio de janeiro: guanabara e koogan, 2011. 6. moreira ma. mapas conceituais e aprendizagem significativa. rev chil educ cient. 2012; 4(2): 38-44. 7. valadares j. a teoria da aprendizagem significativa como teoria construtivista. aprendiz signific rev. 2011; 1(1): 36-57. 8. ausubel dp, novak jd, hanesian h. (1978). educational psychology. nova york: holt, rinehart and winston. publicado em português pela editora interamericana, rio de janeiro; 1980. em espanhol por editorial trillas, méxico, 1981. reimpresso em inglês por werbel & peck, nova york; 1986. 9. ferreira pb, cohrs cr, de domenico ebl. software cmap tools® para a construção de mapas conceituais: a avaliação dos estudantes de enfermagem. rev esc enferm usp. 2012; 46(4): 967-72. 10. bardin l. análise de conteúdo. lisboa, portugal: edições 70, lda; 1977. 11. gerdeman jl, lux k, jacko j. using concept mapping to build clinical judgment skills. nurs educ pract. 2013; 13: 11-7. 12. kostovich ct, poradzisz m, wood k, o’brien kl. learning style preference and student aptitude for concept maps. j nurs educ. 2007; 46(5 ). 13. andreou c, papastavrou e. merkouris a. learning styles and critical thinking relationship in baccalaureate nursing education: a systematic review. nurse education today. 2014; 34: 362-71. 14. wheeler la. collins skr. the influence of concepts mapping on critical thinking. j profe nurs. 2003; 19(6): 339-46. 15. hsu l-l, pan h-c, hsieh s-i. randomized comparison between objective-based lectures and outcome-based concept mapping for teaching neurological care to nursing students. nurs educ today. 2016; 37: 83-90. 16. mendoza iyq, peniche acg. intervenção educativa sobre hipertermia: uma estratégia de ensino para aprendizagem em centro cirúrgico. rev esc enferm usp. 2011; 46(4): 851-7. 06. mujeres a caminar(50-59) revista aquichan issn 1657-5997 año 4 nº 4 50-59 bogotá, colombia octubre 2004 50 resumen el artículo es una revisión de la autora, para mostrar a las mujeres la importancia de la actividad física introyectada en el diario vivir y más enfocada hacia el cambio comportamental al que se debe llegar, para tener, a través de ella, una actitud preventiva en contra o a favor de la salud. parte de unos interrogantes que aún las mujeres se hacen, para tomar determinaciones de sus actitudes frente a la actividad física. muestra resultados de estudios practicados en otros países del mundo, pero también reporta datos de investigaciones realizadas en el contexto. además, incluye los beneficios físicos, psicológicos y emocionales que la actividad física puede aportar a todas las personas. el objetivo es mostrar, al género femenino, indicadores sólidos y comportamientos preventivos, que orienten a favor de la actividad física, con planteamientos acerca de las diferentes posibilidades para realizar la actividad física y sobre su importancia. palabras clave actividad física, ejercicio, prevención de la enfermedad, cuidado de la salud, actitudes preventivas. abstract this article is a review done by the author, to show women the importance of physical activity in daily life focused to reach a behavioral change, and a preventive attitude to improve health. it starts from some women’s questioning, to state their attitudes facing physical activity. it shows the results of studies done in other countries, and also informs data of investigations. moreover, it includes the physical, psychological and emotional benefits of physical activity for everybody. the objective is to show women, solid indicators and preventive behaviors, to guide physical activity, stating different possibilities of physical activity and its importance. key words physical activity, exercise, disease prevention, health care, preventive attitudes. * profesora asociada, facultad de enfermería, universidad nacional de colombia. rnpintoa@unal.edu.co natividad pinto afanador* recibido: el 29 de octubre de 2003 aprobado: el 27 de abril de 2004 mujeres, a caminar por nuestra salud 51 ¿por qué hacer ejercicio? el incremento de la actividad física da un mejor nivel de salud. según j. e. manson2, el punto fundamental es que las mujeres que caminan enérgicamente, o hacen ejercicio activo tres horas semanales o más, pueden reducir el riesgo de sufrir alguna afección coronaria. caminar reduce la mortalidad, sea por causas coronarias o de otra índole. en hombres japoneses retirados, en hawai, se encontró reducción de las tasas de mortalidad, en relación con el ejercicio. los beneficios del ejercicio moderado son conocidos desde hace tiempo y las evidencias continúan acumulándose. la magnitud de los efectos crece continuamente, lo cual indica que los hábitos de vida saludables, basados en evidencias, son algo en lo que deberíamos centrarnos más. actualmente, el sedentarismo se considera el factor de riesgo de muerte que más prevalece en todo el mundo (50-70%), con relación a otros factores ya bien conocidos de enfermedades crónicas no transmisibles. estos factores se comportan de forma similar en los países en desarrollo. un estudio realizado en el brasil, por el doctor victor matsudo y colaboradores3, presentado en el primer congreso de cardiología virtual, muestra cómo, entre los factores de riesgo, el 89,3% lo ocupa el sedentarismo (gráfico 1). n los últimos 50 años ha emergido un estilo de vida en la sociedad moderna, libre de actividad física y carente de gasto calórico, que se denomina sedentarismo y cuyas consecuencias se están comenzando a sentir. como resultado, se observa una clara disminución de la calidad de vida, un aumento cada vez mayor de las enfermedades crónicas e incapacidades, e incremento de la enfermedad cardiovascular, que es la principal causa de muerte en la mujer. aproximadamente, una de cada dos mujeres morirá por algún evento cardiovascular, infarto de miocardio o accidente cerebrovascular, y estos fallecimientos superan en número la mortalidad debida a todos los cánceres combinados1. frente a esta panorámica, las mujeres se preguntan cada día: ¿por qué hacer ejercicio? ¿es igual el ejercicio y la actividad física? ¿cómo debo hacer la actividad física? ¿cómo me ayuda la actividad física a evitar un problema grave de salud? ¿en qué forma hago actividad física, sin tener tiempo? si me enfermo, ¿quién cuidará de los míos? ¿qué relación hay entre el ejercicio y la enfermedad del corazón que puedo llegar a sufrir? a cada momento surgen estos y un sinnúmero más de interrogantes. en este artículo la autora hace una revisión, para tratar de contestar a las mujeres, de manera sencilla, las anteriores preguntas. para ello se basa en estudios científicos revisados y en una investigación previa que realizó en colaboración con otros profesores de la facultad de enfermería de la universidad nacional de colombia. introducción 1. kuhn, f. e.; rackley, c. e. “coronary artery disease in women. risk factors, evaluation, treatment and prevention”. arch. intern. med.: 2.626-2.636, 1993. 2. manson, j. e. “a prospective study of walking as compared with vigorous exercise in the prevention of coronary herat disease in women”. en: new england journal of medicine, 341: 650-8, 1999. 3. matsudo, v., y cols. estrategias de actividad física en países en desarrollo: una experiencia del programa agita, san pablo, celafiscs, 2002. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 52 con base en estos datos epidemiológicos, los países desarrollados comenzaron programas de intervención para aumentar el nivel de actividad física (canadá, inglaterra, finlandia, ee. uu., australia y brasil). sin embargo, a pesar de tener el mismo problema, ningún país en desarrollo lanzó un programa de este tipo. todas las propuestas de estos proyectos se basan en las evidencias científicas más recientes, que muestran que sesiones cortas de treinta minutos por día, la mayor parte de los días de la semana, de forma continua o acumulada, de 10 a 15 minutos en intensidad moderada, puede representar el límite para que la población pueda obtener efectos beneficiosos para la salud. para esto, los investigadores sugieren que las personas adopten un estilo de vida activo, o sea, que incluyan actividades como salir a pasear por el barrio, cuidar el jardín, lavar el carro, caminatas a ritmo ligero, bailar, montar en bicicleta, nadar y otros. las sugerencias de aumentar la actividad física son recomendadas y reconfirmadas por instituciones como la oms (organización mundial de la salud), el consejo internacional de ciencias del deporte y educación física (icsspe), el centro de control y prevención de enfermedades (cdc), el colegio americano de medicina deportiva (acsm), la federación internacional de medicina deportiva y la asociación americana de cardiología. a partir de estas tendencias internacionales, en latinoamérica se han creado programas que cubren una mayor población, como “agita sao paulo” (brasil) y “muévete bogotá” (colombia), y otros países están trabajando en el desarrollo de propuestas, retomando experiencias de quienes ya los han llevado a cabo. datos de la oms establecen que, en el mundo, cerca de dos millones de personas mueren anualmente por enfermedades crónicas asociadas al sedentarismo. en estudios realizados en el brasil por el instituto celafiscs, de san caetano, dirigido por el doctor victor matsudo y colaboradores, se informa que actualmente el sedentarismo es el factor de riesgo de muerte que más prevalece en el mundo (5070%), con relación a otros factores ya bien conocidos de enfermedades crónicas no transmisibles; estos últimos se comportan de forma similar en los países en desarrollo4. además, el ejercicio quema calorías, y este efecto es bien importante, pero lo más valioso es el resultado a largo plazo. si una persona camina 30 minutos diariamente, estará quemando cerca de 150 calorías por día. asimismo, si mantiene una ingestión constante de alimentos bajos en grasa durante el mismo tiempo, quemará calorías adicionales y bajará de peso. así, es necesario que realice ejercicio en forma continua, y no solo habrá bajado de peso, sino que es poco probable que recupere ese peso perdido. gráfico 1. prevalencia de factores de riesgo en el estado de sao paulo, brasil. tomado de victor matsudo y colaboradores3. 4. matsudo, victor. primer congreso virtual de cardiología. estrategias de promoción de la actividad física en los países en desarrollo: la experiencia del programa agita, sao paulo, 2002. alcoholismo obesidad hipertensión tabaquismo sedentarismo mujeres, a caminar por nuestra salud 53 se requiere entender que el ejercicio estimula la pérdida de grasa, y desarrolla al mismo tiempo la masa muscular, lo cual permite activar la tasa metabólica en reposo y ayuda a quemar más calorías. al contrario de la creencia popular, el ejercicio no aumenta el apetito, sino que lo disminuye, después de haberlo practicado con moderación. el aumento de la actividad física, que produce un incremento de los niveles del estado físico, supone: una forma de prevención primaria, ya que contribuye a prevenir factores de riesgo de enfermedad, como obesidad, hipertensión, diabetes tipo ii o dislipidemias; una clase de prevención secundaria, pues ayuda a disminuir la morbimortalidad en determinadas enfermedades, como cardiopatías isquémicas, accidentes cerebrovasculares, osteoporosis, cáncer de colon, depresión; una forma de promoción de la salud, ya que ayuda a vivir más años y a que funcione mejor el organismo durante todo ese tiempo, y una manera de aumentar la calidad de vida, pues contribuye a mejorar el acondicionamiento físico, permite dar más calidad a todas las tareas, una mejor vivencia, y sirve para neutralizar determinados efectos que el envejecimiento tiene sobre el organismo. entonces, es importante considerar que la actividad física, definida como cualquier movimiento corporal producido por los músculos esqueléticos, que da como resultado un gasto calórico, para lo cual debe tener determinadas características de intensidad, duración y frecuencia, es beneficiosa para la salud de la mujer. por ello, la intensidad debe ser suficiente para mantener las pulsaciones entre el 60 y el 85% de la frecuencia cardiaca máxima teórica (220edad). la duración no debe ser inferior a 30 minutos, con una frecuencia mínima de tres días por semana. la actividad física en la mujer (y en todas las personas) debe ser independiente de las labores del trabajo y del hogar; sin embargo, ella no lo está haciendo, y mantiene un sedentarismo cada día más marcado, cuya relación con las enfermedades cardiovasculares es muy grande. a todo esto se suman los cambios hormonales que sufre la mujer y que la llevan a tener un alto riesgo de sufrir problemas cardiovasculares. en un estudio realizado en la universidad de antioquia5, con mujeres remitidas al programa de prevención de enfermedad cardiovascular, se encontró que el 81,5% estaban en el periodo del climaterio; 51,1% presentaban hipercolesterolemia; 42,4% eran sedentarias; 33,7%, hipertensas; 15,2% eran fumadoras, y el 1,1%, diabéticas. sin embargo, estos factores de riesgo, en su mayor parte, pueden ser prevenidos con la actividad física. según el c. d. c. (centers for disease control and prevention)6, en más del 60% de la población adulta de casi todos los países desarrollados, y en las áreas urbanas del mundo con menor desarrollo, no se alcanzan los niveles suficientes de actividad física. la mayor prevalencia de inactividad se observa entre las mujeres, las personas de edad avanzada, los individuos de grupos socioeconómicos bajos y los incapacitados. el ejercicio también disminuye con la edad, en especial durante la adolescencia, y este descenso continúa en la edad adulta. en muchos países, desarrollados y en desarrollo, menos de un tercio de los jóvenes son lo suficientemente activos para lograr un efecto sobre la salud, presente y futura; además, las mujeres adolescentes son menos activas que los varones. la disminución de la actividad física y de los programas de educación física en colegios y escuelas es una tendencia alarmante en todo el mundo; al mismo tiempo, las tasas de obesidad entre los jóvenes van en aumento. esto nos lleva a proponer la promoción de la actividad física, tanto en colegios como en universidades, y además aprovechar los espacios de tiempo y locativos para la práctica de diferentes deportes, más como conductas preventivas que en cumplimiento de requisitos académicos. 5. caravallo, domingo i. detección oportuna de enfermedad coronaria en mujeres de la universidad de antioquia, enviadas a programa de prevención de enfermedades cardiovasculares, 1999. 6. c. d. c. promoción de la actividad física: la mejor inversión en salud pública, 2003. varios estudios epidemiológicos han expuesto la menor prevalencia de diferentes formas de cáncer entre las personas físicamente activas. experiencias recientes han sugerido que las mujeres que realizan ejercicios físicos en forma regular, tendrán menor predisposición a tumores de mama y útero. gráfico 2. actividades que realizan las mujeres en su tiempo libre, en funza, cundinamarca. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 54 en nuestro medio, la magnitud que alcanza el sedentarismo o la inactividad física se ha estudiado muy poco, y está muy mal cuantificada. diferentes países han tratado de hacer estudios que les permitan visualizar cómo es el comportamiento de las personas en cuanto a la actividad física, principalmente en la población adulta. esto ha permitido saber qué sucede en distintas regiones. hoy se conoce cómo los estudios nacionales de salud (ens), en los diferentes países, presentan datos de valiosa importancia para motivar a la población hacia la práctica de la actividad física y el no sedentarismo, como prevención de la enfermedad. haciendo una revisión, se encuentra cómo el ens83, en españa, afirma que el 55% de la población mayor de 16 años es inactiva, el 32% hace ejercicio o deporte ocasionalmente, el 9% lo practica de forma regular y el 4% realiza entrenamientos periódicos para algún deporte, pero no se sabe cuántas personas hacen ejercicio a un nivel que suponga suficiente estímulo para el mantenimiento de la salud o la prevención de la enfermedad. respecto a la actividad ocupacional, el porcentaje de individuos mayores de 16 años que declaran estar sentados durante dicha actividad es de 33%, 51% el de los que están de pie, 11% el de los que caminan durante su trabajo, y un 4% declaran que realizan trabajo pesado, pero no aclaran qué profesiones pueden considerarse sedentarias y cuáles activas. según los anteriores datos del ens, es posible que el porcentaje de individuos de la población española que mantienen unos niveles de actividad física suficientes para obtener beneficios apreciables en su salud sea inferior al 13%, mientras en ee. uu., en su última encuesta de salud (1988), fijaban esta proporción en el 7%7. la tecnología, la urbanización, los cambios demográficos, la necesidad de producir, los compromisos y el estrés han influido en los cambios en los estilos de vida, que están conduciendo a inactividad física, hábitos de alimentación deficientes y mayor consumo de tabaco. todas estas causas son las responsables del rápido incremento de las enfermedades crónicas no transmisibles, como las cardiocerebrovasculares, diabetes tipo ii y algunos cánceres. según la oms8, estas enfermedades crónicas representan un 60% de las muertes a nivel global, cifra que ascenderá a 73% para el año 2020. actualmente, el 77% de las enfermedades no transmisibles se presentan en los países en vías de desarrollo, y afectan gravemente a adultos que se encuentran en la plenitud de su vida y en el momento de mayor productividad. en un estudio realizado en el municipio de funza (colombia), en el año 2000, se informa que tanto mujeres como hombres la mayor parte del tiempo libre (85%) lo dedican a dormir, ver televisión y descansar, y solo en el 15% realizan una actividad como caminar, hacer algún deporte, montar en bicicleta u otros. al preguntar más específicamente en qué invierten las mujeres el tiempo libre, se encontró que el 70% de ellas lo utilizan en ver televisión, el 12% en actividades como coser, tejer, bordar o hacer manualidades, un 10% en leer y un 8% manifiestan salir a pasear, hacer caminatas con la familia o ir a un parque a realizar ejercicio (gráfico 2). 7. guía de educación sanitaria sobre actividad física de tiempo libre. programa de actividades preventivas y promoción de la salud en la sociedad española de medicina familiar y comunitaria, 2002, p. 2. 8. oms-ops. move for health. energize your life, april 2002, p. 7. 9. sánchez, beatriz; pinto, natividad. estilo de vida como fomento de un programa de prevención de enfermedades crónicas para los habitantes del barrio méxico, en funza, cundinamarca, universidad nacional de colombia, facultad de enfermería, 2000. tomado de beatriz sánchez y natividad pinto9. situación actual ver televisión actividades manuales leer actividad física mujeres, a caminar por nuestra salud 55 según la organización panamericana de la salud (ops)10, la urbanización y los cambios demográficos en las américas han resultado en importantes cambios en los estilos de vida, como se mencionó anteriormente. los parámetros de la actividad física varían con las características demográficas. los hombres están mejor dispuestos que las mujeres para iniciar programas de ejercicios vigorosos y de deportes. el tiempo total dedicado a la actividad física disminuye con los años. las personas en edad de jubilarse, 55-60 años o más, declinan continuamente la práctica de ejercicio físico con el incremento de la edad. personas de origen afroamericano y otros grupos étnicos son menos activas que los norteamericanos promedio, y esta diferencia es más pronunciada en las mujeres. los individuos con mejores niveles educativos participan en mayor medida en la realización de actividad física en el tiempo libre. las diferencias que se observan en los niveles de educación y el estatus socioeconómico se mantienen en el promedio de participación en programas de actividad física de tiempo libre11. el sedentarismo y la enfermedad las enfermedades del corazón y las arterias ocupan un triste primer lugar como causa de mortalidad en el mundo occidental. en su aparición y desarrollo están involucrados múltiples factores de riesgo, dentro de los cuales ocupan un lugar especial el tabaquismo, las alteraciones del colesterol, la hipertensión arterial, el sedentarismo, la diabetes, el estrés mental y la obesidad. el ejercicio físico regular contribuye a combatir todos estos factores. más aún, al actuar directamente sobre el corazón y los vasos sanguíneos, se convierte en uno de los elementos más eficaces para prevenir la aparición y la progresión de la enfermedad. en las personas que ya han sufrido una afección cardiaca, se ha comprobado que el ejercicio colabora en el tratamiento, y mejora la calidad y cantidad de años vividos. las enfermedades del corazón constituyen la principal causa de fallecimiento en las mujeres a nivel mundial, hasta el punto de que superan las muertes producidas por todos los tipos de cáncer sumados. sin embargo, es evidente que muy pocas veces se tiene en cuenta esta realidad, lo cual produce falta de controles adecuados para la prevención, la mejor herramienta que existe contra esta y muchas otras enfermedades. según las estadísticas, es evidente cómo las mujeres tienen mayor probabilidad de presentar complicaciones y de morir en el primer infarto. además, la presentación no siempre es clara y específica, ya que los síntomas frecuentemente no son los “clásicos” (dolor en el pecho, diaforesis, fatiga y otros); esto hace, en el caso de los hombres, que el diagnóstico y el tratamiento sean más difíciles. se insiste en que es definitivo controlar el estilo de vida. asimismo, estudios científicos demuestran que el reemplazo hormonal en la menopausia no genera la protección cardiovascular que se pensaba con anterioridad, entonces, no queda más remedio que dedicarse a manejar los riesgos que nosotros mismos nos causamos, dejando el cigarrillo, bajando los triglicéridos, controlando el peso y la presión arterial y, sin lugar a dudas, reduciendo el estrés y aumentando la actividad física, con acciones como caminar durante 30 minutos diarios. sobre esto último, también se logran beneficios en tiempos fraccionados en un mismo día. los beneficios del ejercicio físico no solo se relacionan con la prevención de las enfermedades cardiacas. los individuos que llevan un estilo de vida más activo se “sienten mejor” y producen en sus cuerpos una resistencia superior ante las distintas agresiones que la vida y el proceso de envejecimiento provocan. los adultos que mantienen una vida más activa llegan a edades mayores, con mejor predisposición al trabajo y menor depen10. organización panamericana de la salud. muévete américa. una vida activa te da salud y energía, abril 7 de 2002. 11. propia informática. actividad física, salud y prevención, universidad nacional de la plata, facultad de ciencias médicas, argentina, 2002. si una persona camina 30 minutos diariamente, estará quemando cerca de 150 calorías por día. asimismo, si mantiene una ingestión constante de alimentos bajos en grasa durante el mismo tiempo, quemará calorías adicionales y bajará de peso. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 56 dencia de aquellos que los rodean. de igual manera, se han comprobado efectos beneficiosos del ejercicio sobre la conservación de la densidad ósea, con un alto impacto en la prevención de la osteoporosis, enfermedad que afecta en un alto porcentaje a las mujeres. en la masa ósea influyen los estrógenos, la actividad física, la nutrición y determinados factores metabólicos. los estrógenos estimulan los osteoblastos y suprimen la actividad osteoclástica. la actividad física ayuda al crecimiento óseo, mediante la tensión ejercida por la carga de peso y el empuje de los músculos en el hueso. un adecuado aporte de calcio y vitamina d garantiza el crecimiento y la preservación de los huesos. la masa ósea cambia a lo largo de la vida de una persona: se duplica desde el nacimiento hasta los dos años, se duplica de nuevo hasta los diez años, y hacia los 18 años se tiene un 90% del máximo de masa ósea. cuando una mujer llega a la mitad de la década de los treinta años, empieza a perder dicha masa a un ritmo de 0,5%-1% anual. después de la menopausia, esta pérdida se acelera excesivamente, y puede llegar hasta un 15% en los cinco años siguientes al climaterio. esto equivale a un tercio de la pérdida de la masa ósea de toda una vida. hacia los 80 años, la mujer puede llegar a tener solo un 50% de la masa ósea que poseía en su juventud. así, la osteoporosis es una de las enfermedades que más afectan a las mujeres, y se observa más a menudo cuando el proceso de envejecimiento se acelera. esta afección se entiende como una disminución de la masa ósea, o de su densidad por unidad de volumen, hasta un nivel inferior al requerido para la función adecuada de apoyo mecánico. es más frecuente en el climaterio, y puede llevar a la mujer a sufrir dolores, fracturas y otros problemas, que junto con el sedentarismo podrían llevar a una situación crónica de enfermedad. en las mujeres también se presentan trastornos venosos en los miembros inferiores, para los cuales la actividad física constituye una de las más importantes y probadas formas de tratamiento. las molestias físicas y los problemas estéticos que genera la insuficiencia venosa, en miles de ellas, pueden ser prevenidos y tratados con programas adecuados de ejercicios físicos. para esto es necesario que adopten rutinas de ejercicios pasivos, así sea en horas laborales, con el objeto de realizar cambios posturales, que a la vez permitan momentos de relajación. varios estudios epidemiológicos han expuesto la menor prevalencia de diferentes formas de cáncer entre las personas físicamente activas. experiencias recientes han sugerido que las mujeres que realizan ejercicios físicos en forma regular, tendrán menor predisposición a tumores de mama y útero12. en un estudio realizado por científicos canadienses, se hizo un sondeo entre 2.470 mujeres, la mitad de ellas con cáncer de mama y el resto sanas. el resultado fue que las posmenopáusicas que habían realizado una mayor actividad física moderada, como un trabajo de limpieza o de ensamblaje durante su vida, tenían 30% menos riesgo de sufrir cáncer de mama. pese a que el ejercicio recreativo no mostró ningún beneficio, ello se debió a que las mujeres no practicaron un ejercicio organizado o algún deporte, afirmó la doctora chirstine friedenreich, epidemióloga del centro de cáncer de alberta, georgia, y autora del estudio. sin embargo, otras investigaciones han demostrado una notable reducción de los riesgos con actividades recreativas vigorosas, como el trote. los investigadores manifiestan que la actividad protege mediante la reducción de los niveles hormonales de alto riesgo, así como evitando el aumento de peso, que es un factor de riesgo adicional para el cáncer de mama. además, el ejercicio físico contribuye a disfrutar la vida con mayor plenitud, y si se practica con regularidad, ofrece una serie de posibilidades para “verse y sentirse mejor”. la actividad física aumenta la resistencia a la fatiga e incrementa la capacidad de trabajo físico y mental. también ayuda a combatir la 12. peidro, roberto m. “ejercicio físico para la salud y la calidad de vida”. en: bago, “ética al servicio de la salud”, diciembre 2 de 2002, p. 2. los beneficios del ejercicio físico no solo se relacionan con la prevención de las enfermedades cardiacas. los individuos que llevan un estilo de vida más activo se “sienten mejor” y producen en sus cuerpos una resistencia superior ante las distintas agresiones que la vida y el proceso de envejecimiento provocan. mujeres, a caminar por nuestra salud 57 ansiedad, la depresión y el estrés mental, mejora la capacidad para conciliar el sueño, provee una manera sencilla de compartir actividades con amigos y familiares, y contribuye a mejorar los aspectos sociales. asimismo, ofrece mayor energía para las actividades diarias, tonifica los músculos e incrementa su fuerza, mejora el funcionamiento de las articulaciones y ayuda a la pérdida de peso cuando es necesario. la actividad física promueve el incremento de la capacidad respiratoria de la personas, facilita una mejor oxigenación de la sangre y reduce los riesgos de enfermedades pulmonares crónicas. adicionalmente, disminuye la concentración de triglicéridos y el colesterol, ayuda al funcionamiento de la insulina –indispensable en los diabéticos– y a reducir y controlar el peso corporal; a la vez, logra disminuir los niveles de adrenalina, lo cual se refleja en una reducción de la ansiedad, el estrés, la agresividad y la depresión. algunos autores relacionan la práctica sistemática del ejercicio físico con una sensación acentuada de control sobre sí mismo y de las funciones corporales, de modo que se genera una mejor percepción del estado general de bienestar. asimismo, la motivación debe incluirse como un elemento básico para comprobar el efecto del ejercicio físico en la salud psicológica de quien lo practica. en diversos estudios se considera que el ejercicio distrae o aleja la tentación del individuo de ansiedades de origen cognitivo, liberándolo de las mismas (garnier y waysfeld)13; además, se produce cierta sensación de mejoría frente al estrés y un sentimiento de bienestar corporal, con su consecuente mejoramiento de la autopercepción del cuerpo y la autoestima, al grado de que los adultos mayores se perciben más jóvenes, lo cual lleva a un aumento de la capacidad de sentir placer hedonista y lúdico, así como mayor integración social. ¿por qué las mujeres? actualmente las mujeres ocupan gran parte de su vida en actividades laborales, que en la mayoría de los casos son frente al computador; en reuniones, por lo general sentadas, sin ninguna actividad. ellas salen de sus trabajos y agilizan el tiempo para llegar pronto a sus hogares, con el objeto de atender tareas escolares, preparar los alimentos, terminar el trabajo que llevan de la oficina y compartir algunos momentos con su familia; luego viene el descanso nocturno, y al otro día nuevamente continúa la rutina. si se contabilizara cuántas horas dura una mujer sentada, se establecería que casi el 80 a 90% del día. no realiza ninguna actividad física, menos ejercicios especiales, y la mayoría de las veces no practica deporte alguno. las mujeres, actualmente, deben asumir grandes responsabilidades, compromisos económicos, el cuidado de la familia, la formación de los hijos y obligaciones laborales, lo cual las lleva a manejar grandes niveles de estrés negativo, entendiendo este como el ciclo constante e ininterrumpido de tensión que afecta negativamente la salud y el bienestar general. el estrés negativo se ha relacionado con muchos trastornos físicos, desde el dolor de cabeza por tensión, hasta enfermedad coronaria. esto, acompañado del sedentarismo mencionado anteriormente, lleva a entender por qué las mujeres están sufriendo, en mayor medida, de problemas cardiocerebrovasculares. las mujeres, durante la historia, han asumido su papel de cuidadoras. ellas son las responsables del cuidado de quien está enfermo, sea su hijo (su corazón de madre no les permite dejar su cuidado en manos de otros), sus padres o sus hermanos. además, cuidan de todos los miembros de la familia, incluyendo a su esposo o compañero, independientemente de cómo esté la relación en los momentos en que se presenta la situación de enfermedad, y más cuando se trata de una afección crónica. por este motivo y muchos más, también se deben promover comportamientos preventivos en las familias, con el objeto de prever en un futuro situaciones de enfermedad. en estudios realizados en cuidadores de pacientes crónicos, en la universidad nacional de colombia (sánchez, b.; barrera, l.; pinto, n.)14, se encuentran datos precisos sobre el porcentaje de mujeres que son cuidadoras, y resulta una proporción de 85 a 15%, en relación con los hombres. las mujeres, en su mayoría, continúan cumpliendo las funciones de cuidadoras que se les ha asignado a lo largo de la 13. sánchez, bañuelos. revista digital, nos. 38 y 56, buenos aires, 1996. 14. sánchez, b. habilidad de cuidado de los cuidadores, universidad nacional de colombia, 2002. al contrario de la creencia popular, el ejercicio no aumenta el apetito, sino que lo disminuye, después de haberlo practicado con moderación. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 58 historia. según marie francoise colliere15, “las mujeres siempre han sido curanderas, han curado gracias a las plantas y han intercambiado los secretos de sus prácticas entre ellas. las comadronas se desplazan de una casa a otra. sin tener acceso a los libros ni a ningún tipo de enseñanza, las mujeres han ejercido duramente una medicina sin diplomas; han forjado su saber por contacto de unas con otras, trasmitiéndolo por el espacio y el tiempo de vecina a vecina, de madre a hija (...)”. una de las principales razones de que las cuidadoras sean las mujeres es que, a través de la educación recibida y los mensajes que transmite la sociedad, se favorece la concepción de que la mujer está mejor preparada que el hombre para el cuidado, ya que tiene más capacidad de abnegación y de sufrimiento, y es más voluntariosa. a pesar del claro predominio de las mujeres en el ámbito del cuidado, los hombres participan cada vez más en la atención de las personas mayores, bien como cuidadores directos o como ayudantes de las cuidadoras principales, lo cual significa un cambio progresivo de la situación. por último, este artículo se fundamenta, además, en la aplicación del modelo transteorético del cambio de comportamiento en salud, descrito en la década de los 70, gracias a un análisis comparativo de teorías relevantes para explicar cambios en el comportamiento de dependientes de la droga; su nombre se desprendió de la integración de los principios y componentes teóricos de los sistemas terapéuticos. hoy, el modelo transteorético (mt)16 explica el cambio de comportamiento según cinco variables: etapas y procesos de cambio, balance decisorio, autoeficacia y tentación. entonces, es fundamental que las mujeres pongan en práctica estos principios, con el fin de lograr cambios trascendentales en sus vidas. la actividad física debe entenderse como movimiento humano intencional, y como tal, es invisible en los aspectos físicos, psicológicos, sociales y otros. en consecuencia, la actividad física es necesaria, básica y fundamental para las mujeres (y para todas las personas), pues gracias a ella se incrementan la salud y el bienestar. aunque el ritmo de vida en esta sociedad no permite ni la frecuencia, ni el volumen de ejercicio físico suficiente para promover una calidad de vida acorde con la salud, es fundamental practicar la actividad física y comprender la importancia de su realización, en pro de la salud y de la vida. una vez hechas las consideraciones generales, hay que tener en cuenta que la vinculación a un programa de actividad física depende en gran medida de los intereses y preferencias personales. se considera muy importante conocer y prescribir, dentro de lo posible, aquellas actividades que reportan no solo un beneficio orgánico, sino también uno psicológico o, como mínimo, las que comparten un cierto grado de entretenimiento y diversión, y que no supongan una carga sobreañadida al régimen habitual de actividad laboral o doméstica. esto no suele ser una tarea fácil. algunas personas, generalmente de carácter introvertido, prefieren las actividades individuales, que pueden realizarse sin compañía, pues les brindan la posibilidad de aislarse, distraerse de las preocupaciones y disfrutar la soledad. estas personas suelen optar por la marcha, la carrera, la natación o el ciclismo. en cambio, otras más extrovertidas tienden a aburrirse con ese tipo de actividades, y prefieren algunas más variadas, que pueden realizarse en grupo o en pareja, y con un carácter lúdico más marcado. para ellas se recomiendan los juegos, la danza y las actividades deportivas de equipo. algunas personas, en cambio, tienen el suficiente grado de autocontrol y autodisciplina como para conseguir un programa sin ayuda o soporte externo. sin embargo, en general, resulta más útil sugerir que el ejercicio se realice en pareja, en familia o en grupo, de forma que esté presente el refuerzo positivo de compartir intereses comunes. de todos modos, lo más importante es lograr un cambio de comportamiento, que les permita a las personas llegar a tener unas constantes de actividad física en su diario vivir, y así lograr grandes beneficios para su salud, a fin de que caminen ellas mismas por sus propias vidas. los adultos que mantienen una vida más activa llegan a edades mayores, con mejor predisposición al trabajo y menor dependencia 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salud. dimensiones del cuidado, unibiblos, 1998. 25. http/www.lgcorg/freepub/pdp/land-use/focus/plan-to.walkpdf. 26. http/www.celafiscs.com.br/index.htm. 27. burker, shelly. “revisión de la osteoporosis”, nursing, vol. 20, nº 4, abril del 2002. 28. annicchiarico, rubén josé. “la actividad física y su influencia en la vida saludable”, revista digital, buenos aires, año 8, nº 51, agosto 2002. 29. devis, j. actividad física, deporte y salud, inde, barcelona, 2000. 30. reynaga estraga, pedro. revista digital, año 7, nº 40, buenos aires, septiembre del 2001. 407 420 icresai-imeci.indd 407 olga rocío gómez-ortega1 maría consuelo del pilar amaya-rey2 icresai-imeci: instrumentos para elegir y evaluar artículos científi cos para la investigación y la práctica basada en evidencia3 1 enfermera. especialista en atención de enfermería en cuidado crítico. universidad nacional de colombia, colombia. orgomezo@unal.edu.co 2 doctora en filosofía. profesora titular, universidad nacional de colombia, colombia. mcamayad@unal.edu.co 3 este trabajo se adelantó durante el desarrollo del proyecto de tesis de doctorado titulada metaanálisis: calidad de vida de personas adultas en pre y post trasplante de órganos. evidencia para enfermería. universidad nacional de colombia, 2009-2013 4 registro de instrumentos icresai e imeci: www.derechodeautor.gov.co. para acceder a los instrumentos escribir a ambas autoras: orgomezo@unal.edu.co, mcamayad@unal.edu.co recibido: 28 de agosto de 2012 enviado a pares: 3 de septiembre de 2012 aceptado por pares: 15 de julio de 2013 aprobado: 1 de noviembre de 2013 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 407-420 para citar este artículo / to reference this article / para citar este artigo gómez ortega, o. r., amaya rey, m. c. (2013). icresai-imeci: instrumentos para elegir y evaluar artículos científicos para la investigación y la práctica basada en evidencia. aquichan. vol. 13, no. 3, 407-420. resumen objetivo: el incremento en la producción de conocimiento representa para los científicos una preocupación, dado que diariamente se enfrentan a la decisión de elegir la literatura de mayor mérito científico para respaldar la toma de decisiones para la investigación y la práctica. la presente investigación tiene por objeto construir dos instrumentos registrados4, con propiedades psicométricas, validez facial y validez de contenido. materiales y métodos: para el instrumento de criterios de elegibilidad de los artículos de investigación para el metaanálisis (icresai) se proponen los criterios que se deben evaluar para determinar cuáles artículos de investigación deben ser elegibles para una revisión sistemática (rs) o metaanálisis (ma); así mismo, se calculó la fiabilidad interevaluador. el segundo es el instrumento de criterios para evaluar el mérito científico de los artículos seleccionados para el metaanálisis (imeci), el cual propone criterios que se deben evaluar para calificar el mérito científico y la calidad metodológica de los artículos seleccionados para adelantar una rs. los cálculos para validez facial y de contenido se hicieron con tres investigadores expertos en metodología de la investigación y en medición. la validez de contenido se calculó con el índice de lawshe modificado (tristán-lópez, 2008), y la fiabilidad intercodificador se midió para variables cualitativas con el índice de kappa de cohen. resultados: el instrumento icresai obtuvo un índice de validez de contenido (cvi) de 1,0. para el instrumento imeci, el cvi fue de 0,75. en el instrumento icresai los valores para el índice de fiabilidad o concordancia intercodificador estuvieron entre 0,547 y 0,973, considerados buenos de acuerdo con la interpretación propuesta por cohen. conclusiones: los dos instrumentos generados cuentan con validez (cvi y lawshe) para realizar la selección y evaluación del mérito científico de las piezas de investigación. estas dos herramientas son útiles en el estudio de cualquier área temática y al orientar el uso de la información para la toma de decisiones en la investigación y la práctica basada en evidencia. palabras clave validez de las pruebas, evaluación de la investigación en salud, características de los estudios, enfermería basada en la evidencia, metaanálisis. (fuente: decs-bireme). 408 aquichan issn 1657-5997 icresai imeci : tools for selecting and evaluating scientific articles for research and evidence-based practice abstract objective: the increase in the production of scientific knowledge is of concern to scientists, who must decide daily on selecting literature of utmost scientific merit to support decisionmaking on research and practice the purpose of this study is to construct two registered instruments5 with psychometric properties, face validity and content validity. materials and methods: the research article eligibility criteria instrument (icresai) proposes standards to be assessed to determine which research papers should be eligible for a systematic review (sr) or meta-analysis (ma). inter-reevaluator reliability was calculated as well. the second instrument involves criteria for evaluating the scientific merit of articles selected for meta-analysis (imeci) , which proposes standards to be evaluated to rate the scientific merit and methodological quality of the articles selected for a sr. the estimates for face and content validity were made with three researchers who are experts in research methodology and measurement. content validity was calculated using the modified lawshe index (tristán -lópez , 2008) and inter-codifier reliability was measured for qualitative variables using cohen’s kappa index. results: the icresai instrument obtained a content validity index (cvi) of 1.0 . the cvi for the imeci instrument was 0.75. with the icresai instrument, the values for the inter-codifier reliability or concordance index were between 0.547 and 0.973, which is considered good according to the interpretation proposed by cohen. conclusions: both instruments are valid (cvi and lawshe) for selecting and evaluating the scientific merit of research articles. these two tools are useful to the study of any subject area and to guide the use of information for decision-making in research and evidence-based practice. key words validity of tests, health research evaluation, study characteristics evidence-based nursing, meta-analysis. (source: decs, bireme). 5 icresai and imeci registration: www.derechodeautor.gov.co. to access these instruments, contact both authors: orgomezo@unal.edu.co, mcamayad@unal.edu.co año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 407-420 409 icresai-imeci: instrumentos para elegir y evaluar artículos científicos para la investigación y la práctica basada en evidencia l olga rocío gómez-ortega y otro. icresai-imeci: instrumentos para escolher e avaliar artigos científicos para a pesquisa e prática baseada em evidência resumo objetivos: o aumento na produção de conhecimento representa para os cientistas uma preocupação porque diariamente lidam com a decisão de escolher a literatura de maior mérito científico para respaldar a tomada de decisões para a pesquisa e prática. esta pesquisa tem por objetivo construir dois instrumentos registrados6, com propriedades psicométricas, validade facial e validez de conteúdo. materiais e métodos: para o instrumento de critérios de escolha dos artigos de pesquisa para a meta-análise (icresai), propõem-se os critérios que se devem avaliar para determinar quais artigos de pesquisa devem ser eleitos para uma revisão sistemática (rs) ou metaanálise (ma); além disso, calculou-se a fiabilidade interavaliador. o segundo é o instrumento de critérios para avaliar o mérito científico dos artigos selecionados para a meta-análise (imeci), o qual propõe critérios que se devem avaliar para qualificar o mérito científico e a qualidade metodológica dos artigos selecionados para realizar uma rs. os cálculos para validade facial e de conteúdo foram feitos com três pesquisadores especialistas em metodologia da pesquisa e em medição. a validade de conteúdo foi calculada com o índice de lawshe modificado (tristán-lópez, 2008), e a fiabilidade intercodificador foi medida para variáveis qualitativas com o índice de kappa de cohen. resultados: o instrumento icresai obteve um índice de validade de conteúdo (cvi) de 1,0. para o instrumento imeci, o cvi foi de 0,75. no instrumento icresai os valores para o índice de fiabilidade ou concordância intercodificador estiveram entre 0,547 e 0,973, considerados bons de acordo com a interpretação proposta por cohen. conclusões: os dois instrumentos gerados possuem validade (cvi e lawshe) para realizar a seleção e avaliação do mérito científico das peças da pesquisa. estas duas ferramentas são úteis no estudo de qualquer área temática e na orientação do uso da informação para a tomada de decisões em pesquisa e prática baseada em evidência. palavras-chave validade dos testes, avaliação da pesquisa em saúde, características dos estudos, enfermagem baseada em evidências, metanálise (fonte: decs, bireme). 6 registro de instrumentos icresai e imeci: www.derechodeautor.gov.co. para acessar os instrumentos, escreva a ambas as autoras: orgomezo@unal.edu.co, mcamayad@unal.edu.co. año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 407-420 410 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 introducción en las últimas décadas se ha evidenciado un incremento importante en el número de publicaciones científicas generadas desde diferentes disciplinas y áreas temáticas. como consecuencia, el interés en ejes temáticos específicos ha impulsado la formación de sociedades científicas y académicas, que día a día trabajan para ofrecer a la comunidad un conocimiento nuevo e innovador que permita entender mejor los problemas o fenómenos que se presentan en la práctica profesional (1, 2). este incremento en el volumen de difusión de la producción de conocimiento ha despertado en los científicos y profesionales un interés primordial en poder contar con herramientas para elegir la literatura más relevante, que oriente la toma de decisiones y resolución de problemas relacionados con el ejercicio profesional de diferentes disciplinas. por ello, el objetivo de esta investigación es la creación y validación de dos instrumentos que respondan a la necesidad de disponer de herramientas útiles para facilitar la realización de revisiones sistemáticas (rs) o investigaciones secundarias como metaanálisis. las revisiones sistemáticas tienen como propósito consolidar de forma objetiva y condensada el estado del arte de un área temática, basándose en la crítica y las evaluaciones de los resultados de investigaciones u otros documentos publicados previamente a las rs o metaanálisis. una revisión sistemática de una área temática exige que el investigador, a partir de la búsqueda del planteamiento de una pregunta de investigación, realice una selección amplia de la literatura, de varias fuentes de información, bases de datos, a fin de consolidar la información disponible para luego presentarla de manera clara, precisa y comprensible, a través de un artículo científico (3). ahora bien, la sistematización y metodología con que se realiza la selección y crítica de las publicaciones o los estudios de investigación, el análisis estadístico, metodológico y conceptual de los contenidos, y la forma en que se consolidan los resultados de las investigaciones primarias, hacen posible la realización de diferentes tipos de revisiones sistemáticas de la literatura que se pueden clasificar de tres formas (35): a. la revisión narrativa, temática o documental: también se conoce como revisión general. en ella se organizan ejes temáticos del conocimiento publicado, con el propósito de dar una visión general del problema en investigación. este tipo de revisión motiva discusiones, presenta nuevas ideas de investigación y permite aclarar significados de algunos conceptos. b. la revisión sistemática cualitativa, metasíntesis o revisiones integrativas (ri): analiza estudios con abordaje cualitativo, sigue un proceso sistemático y metódico, permite entender los fenómenos y los procesos, además de esclarecer significados de los conceptos. c. revisión sistemática cuantitativa: también conocida como metaanálisis (ma), es la revisión de literatura que incluye solo estudios de abordaje cuantitativo, que permiten dar respuesta a una sola pregunta de investigación a partir de la consolidación de hallazgos obtenidos en investigaciones primarias. los datos centrales de análisis son los resultados estadísticos de estos estudios primarios. sigue un método sistemático que permite identificar, escoger y criticar la mejor evidencia existente sobre un problema específico. los resultados obtenidos de este tipo de revisión conforman el nivel más alto de evidencia. las revisiones sistemáticas corresponden a un tipo de investigación metodológica o secundaria, que hoy ha ido ganando espacio en el mundo de la ciencia. en la actualidad se destacan grupos de profesionales que se han dedicado a orientar sobre la metodología correcta para llevar a cabo este tipo de estudios, por ejemplo: la colaboración cochrane, el instituto joanna briggs y el grupo jama de medicina basada en evidencia (57). estos grupos de investigadores defienden un nuevo paradigma dentro de la investigación que se conoce en la actualidad con el concepto de práctica basada en la evidencia, en el que se busca demostrar que a partir del conocimiento construido es posible encontrar los mejores argumentos científicos para lograr la comprensión y resolución de los problemas de la investigación y de la práctica. como cualquier otro tipo de investigación, la realización de una revisión sistemática cuantitativa, o metaanálisis (ma), debe acoger todas las etapas propias del desarrollo de un proyecto de investigación: el planteamiento de una pregunta o problema de investigación, la definición de unos objetivos e hipótesis, la búsqueda de la literatura que permita tener una visión más amplia y precisa del fenómeno que se está investigando. una vez se ha dado cumplimiento a cada una de las anteriores etapas, el proceso que se debe seguir es la selección de la literatura más relevante sobre el tema estudiado y la cualificación o evaluación de mérito científico de la literatura seleccionada, para luego lograr la consolidación del conocimiento y decidir, a partir de los hallazgos 411 icresai-imeci: instrumentos para elegir y evaluar artículos científicos para la investigación y la práctica basada en evidencia l olga rocío gómez-ortega y otro. obtenidos, cuáles son las posibilidades de solución del problema y tomar decisiones frente a la práctica (6, 7). un aspecto importante sobre el que se sigue adelantando investigación, y no hay unificación en los grupos de científicos, es cuál es el mejor método para evaluar el conocimiento existente sobre una temática. la evaluación del conocimiento construido hace parte de la práctica habitual de los profesionales y debe ser considerada un aspecto primordial al realizar una revisión sistemática de la literatura, ya que cualificar la calidad científica de los estudios existentes permite tener un panorama general de lo que se conoce o desconoce de un fenómeno específico. en la actualidad existen organismos y autores que proponen estrategias para realizar la lectura y evaluación crítica de la literatura (critical appraisal), entre los que sobresalen: agency for health care research and quality, cochrane, critical appraisal skills programme español (caspe) (8), normas para la crítica de artículos originales en salud (9, 10), bases para la revisión crítica de artículos médicos (11, 12) , el sistema grade para evaluar la calidad de la evidencia y la graduación de la fuerza de las recomendaciones (13). por otra parte, gómez-gómez et al., des jarlais et al., berra et al., y caspe proponen que la evaluación crítica de los estudios debe dividirse en las siguientes secciones: 1) evaluación de la estructura básica de un artículo, 2) evaluación de aspectos específicos de acuerdo con los principales diseños de investigación, 3) evaluación del contenido del estudio, 4) valoración de las relaciones de causalidad reportadas y 5) evaluar si la selección de las pruebas estadísticas es adecuada (8, 11-13). ante esta diversidad de propuestas para determinar la calidad o el mérito científico del conocimiento construido sobre un área temática específica surge la inquietud acerca de cuál es el mejor método para evaluar si un estudio constituye un insumo apropiado para un metaanálisis (ma), retomando que el ma se define como un estudio que utiliza métodos cuantitativos para analizar, combinar e integrar de manera comprensiva los resultados obtenidos en investigaciones científicas realizadas sobre un problema concreto (14-16). al igual que cualquier otro tipo de investigación, sigue un proceso sistemático, metodológico y riguroso, que garantiza validez, precisión, objetividad y reproducibilidad de los resultados y conclusiones (15). sus aplicaciones incluyen la evaluación de la eficiencia de terapias y la planificación de nuevos estudios, entre otros (14, 17). dentro de las fases descritas en la realización de un metaanálisis, la selección de los estudios y cualificación de estos es un paso fundamental. al no contar con instrumentos con propiedades psicométricas para determinar cuáles estudios incluir en un ma y cómo evaluar de manera objetiva el mérito científico, el presente estudio tiene por objeto la construcción de dos instrumentos: icresai, que facilita determinar cuáles artículos científicos son aptos para conformar el metaanálisis, así como imeci, que busca determinar cuál es el mérito científico y la calidad metodológica de las publicaciones científicas. este proceso demandó realizar una revisión de la literatura sobre temas que se consideran primordiales a fin de responder a las siguientes preguntas: 1) ¿cómo decidir qué artículos elegir para ser incluidos en un ma o una revisión sistemática? y 2) ¿qué criterios permiten establecer el mérito científico de los artículos que resultan elegidos? para dar respuesta a estos dos interrogantes se consideraron a) el análisis de la estructura que debe tener el informe escrito de una investigación, y b) el cumplimiento del rigor conceptual, metodológico y empírico de la investigación seleccionada. marco conceptual a continuación se presentan los conceptos centrales: área temática, crítica de la literatura, criterios de calidad, mérito científico, validez facial, validez de contenido, fiabilidad intercodificador, investigación metodológica-instrumental y pregunta o ítem: área temática: consolidado de conocimientos afines, unificados conceptual y teóricamente, existentes sobre un campo de trabajo o problema por investigar en una disciplina (18). se usa con múltiples fines en la investigación y la práctica basada en la evidencia. crítica de la literatura: conlleva el análisis y la valoración de los escritos científicos. permite determinar la coherencia entre el planteamiento problemático, los objetivos, la metodología y los resultados presentados en una investigación, así como los artículos que por la solvencia científica contribuyen a la toma de decisiones para la investigación y la práctica (9, 10, 17). criterios de calidad o criterios para evaluar el mérito científico: corresponden a preguntas, pautas o ítems de evaluación que garantizan alta rigurosidad metodológica, la validez interna y la utilidad de los resultados de una investigación en el 412 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 abordaje y la comprensión de un problema existente en una disciplina (3, 7, 9, 10, 11). mérito científico: resultado afirmativo del cumplimiento de la crítica rigurosa desde lo conceptual, metodológico y empírico, dependiendo del fenómeno en estudio. es útil para la sistematización y el ordenamiento de los antecedentes de investigación y de lo que se conoce del área temática como referente para las innovaciones de la práctica (18). validez facial: también llamada validez de apariencia o validez de expertos. se refiere al grado en que aparentemente un instrumento mide la variable en cuestión, de acuerdo con “voces calificadas”. según sánchez, echeverry y gómez, la validez facial es el grado en que una situación de medida parece ser válida desde el punto de vista del observador. “no supone un concepto estadístico, sino que depende del acuerdo que el juicio de los expertos haga sobre la pertinencia de los ítems de la escala” (19, 20). según echeverri (20), en validez facial cada experto debe evaluar para cada ítem: • claridad: “frase o ítem con lenguaje y redacción fácil de comprender”. • precisión: “frase o ítem puntual y exacto que no da lugar a dudas”. • comprensión: “entendimiento de lo que se quiere decir al leer el ítem”. validez de contenido: grado en que un instrumento refleja un dominio específico de contenido de lo que mide. es el grado en el que la medición representa al concepto o variable medida (21-24). cuando se desarrolla o se quiere evaluar una escala, se debe pretender que los ítems o las preguntas de la escala cubran adecuadamente todos los dominios (o las principales categoría o dimensiones) de la entidad (concepto) que se quiere medir. un dominio, dimensión o categoría es un grupo de características que se encuentran comúnmente presentes en la entidad; los ítems o preguntas son unidades de exploración que permiten evaluar la presencia de estos atributos en los diferentes dominios, dimensiones o categorías (23). existen múltiples pruebas estadísticas con las cuales se puede llevar a efecto el análisis de la validez de contenido (22). para el presente estudio el análisis estadístico de validez de contenido se realizó con la prueba de lawshe modificado de tristán-lópez (23, 24), que califica cada pregunta o ítem como esencial, útil o no necesario, y describe que solo las preguntas o ítems evaluados como esenciales son relevantes para el concepto o dimensión, atributo(s) que se mide(n). evaluación fiabilidad intercodificador: corresponde a la aplicación de pruebas estadísticas que tienen por objeto maximizar la fiabilidad, controlar la posibilidad de errores y asegurar que los datos por analizar son correctos, de acuerdo con lo que previamente se ha planeado evaluar y extraer de cada estudio. es aplicada por un mínimo dos jueces/evaluadores o codificadores y verificada, según se necesite, por un tercer juez/evaluador o codificador. este cálculo de la fiabilidad en la codificación de las características de los estudios es a su vez una medida de la calidad de una revisión sistemática o metaanálisis (25-28). investigación metodológica-instrumental: la investigación metodológica-instrumental se refiere a investigación controlada sobre las formas para obtener, organizar y analizar datos. los estudios metodológicos abordan la creación, el desarrollo, la prueba, la validación, la evaluación y la estandarización de los instrumentos o técnicas de investigación. el objetivo es desarrollar un instrumento confiable, eficaz y funcional, que otros investigadores o profesionales puedan utilizar para evaluar el (los) concepto(s), y así lograr sus propósitos para la investigación y la práctica (29, 30). pregunta o ítem: cada una de las partes o unidades de que se compone una prueba, un test, un cuestionario (31). el término ítem se utiliza en evaluación para referirse a una pregunta en una prueba de corrección objetiva. en muchas ocasiones, en español el término ítem puede utilizarse indistintamente como sinónimo de pregunta. se pueden clasificar los ítems con referencia al tipo de respuesta que deberá dar la persona encargada de responder. así, tenemos ítems de respuesta abierta e ítems de respuesta cerrada. en los instrumentos propuestos los ítems son de respuesta cerrada; la persona que evalúa debe marcar una alternativa o seleccionar una opción entre las dos o más que se proponen (32). materiales y métodos para los dos instrumentos: icresai e imeci el estudio corresponde a una investigación metodológicainstrumental, que tuvo por objetivos, en primer lugar, diseñar 413 icresai-imeci: instrumentos para elegir y evaluar artículos científicos para la investigación y la práctica basada en evidencia l olga rocío gómez-ortega y otro. dos instrumentos: instrumento de criterios de elegibilidad para la selección de artículos de investigación (icresai), que permite determinar cuáles artículos son elegibles para ser parte de una revisión sistemática, e instrumento de criterios para evaluar el mérito científico de los artículos de investigación seleccionados para el metaanálisis (imeci), en el cual se evalúa la calidad de las piezas de investigación sobre un área temática específica. posteriormente se presenta la evaluación de la validez facial y la validez de contenido de los dos instrumentos, así como los índices de fiabilidad en la codificación o evaluación interevaluador. para el diseño y la validez de los dos instrumentos propuestos de criterios de elegibilidad y evaluación del mérito científico de los artículos para un metaanálisis se utilizó la metodología propuesta por lobiondo-wood y haber (33), la cual contempla: • la definición del constructo que se va a medir. • la formulación de los ítems del instrumento. • el desarrollo de instrucciones para los expertos. • la validez del instrumento. • este estudio se realizó en dos fases: fase a: construcción de los instrumentos. fase b: validez facial o de apariencia y validez de contenido del instrumento. construcción de los dos instrumentos previo a la creación de los instrumentos icresai e imeci se llevó a cabo una extensa revisión de la literatura para evaluar los parámetros propuestos por autores y grupos de científicos organizados, sobre aspectos centrales por evaluar en el momento de realizar la selección y la lectura crítica para definir el mérito científico de una publicación. se encontraron diversas propuestas (5, 6, 9, 10, 13, 14), pero ninguna de ellas ofrecía un instrumento con propiedades psicométricas evaluadas y pautas de interpretación de los resultados. correspondían más a una lista de chequeo donde se presentan los contenidos y la calidad de los contenidos que deben estar presentes en un artículo, que permitan dar una evaluación y calificación objetiva de los productos de investigación científica publicados. por ello, se procedió a determinar las preguntas o pautas y puntajes asignados que permitan obtener la calificación definitiva. para ambos instrumentos, los ítems definitivos se crearon a partir de la revisión de diferentes listas de chequeo generadas para evaluar, con base en la lectura crítica, la calidad de los estudios científicos. luego estos fueron organizados en categorías que correspondieron con los apartados o contenidos que hacen parte de la estructura de una publicación científica, que a la vez se corresponden con las fases de desarrollo de un proyecto de investigación (9, 10). se generó una escala de calificación para cada ítem. para los instrumentos propuestos correspondió a las respuestas sí (si en el artículo se cumple con lo evaluado, se le asignó un valor de uno 1), no (cuando en el artículo no se cumple con lo evaluado, se asignó un valor de cero 0) o no aplica (na) (corresponde a una opción que solo es susceptible de responder en aquellos artículos con características específicas en el diseño, como estudios comparativos, correlacionales o experimentales, etc.). para la opción na no se asignó un puntaje de calificación (no suma en el balance total). una vez se tuvieron las primeras versiones de los instrumentos, se remitieron a un experto en lingüística, quien procedió a revisar la semántica y sintaxis de cada pregunta o ítem. posteriormente, los dos instrumentos se llevaron a un juicio de expertos, quienes tenían por función en primera instancia evaluar la validez facial de cada ítem o pregunta. siguiendo las recomendaciones de sánchez y echeverri (20, 34), a cada pregunta o ítem se le evaluó la claridad, precisión y comprensión. el grupo de expertos evaluadores estuvo conformado por tres profesionales calificados con formación académica de maestría o doctorado, con experiencia académica y profesional, autores de artículos científicos, con experiencia en metodología de investigación y medición de fenómenos en salud, en crítica de publicaciones científicas, que actúan como pares evaluadores en comités editoriales de revistas científicas indexadas. uno de ellos, además de las anteriores competencias, tenía conocimiento en análisis estadísticos de estudios metaanalíticos. análisis estadístico para el cálculo de la validez de contenido, la prueba estadística utilizada fue el lawshe modificado de tristán-lópez (24). este autor propone una modificación al modelo de lawshe original, argumentando que una de las mayores dificultades para evaluar la validez de contenido de una escala es poder reunir el número suficiente de expertos; con su propuesta se demuestra que en 414 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 mediciones con un mínimo de participación de expertos es posible obtener valores válidos en cuanto al contenido; señala que el valor de referencia mínimo aceptable para la razón de validez de contenido (cvr) es de 0,5823, el cual será estable independientemente del número de expertos que participen en el proceso. por otra parte, el índice de validez de contenido de la prueba (cvi) se calcula tomando todas las cvr que dieron valores iguales o superiores a 0,5823, sumándolos y luego dividiéndolos entre el número de valores aceptados. la cvr busca determinar, en cada una de las categorías, cuáles son los ítem más relevantes de medir para garantizar que un constructo o concepto se calcula adecuadamente. desde la propuesta de tristán cada ítem puede ser evaluado como esencial (el ítem es importante e indispensable), útil (importante aunque no indispensable) o no necesario (ni importante ni indispensable). solo se consideraron los ítems que recibieron calificación de esencial por el mayor número de expertos y mostraron una cvr mayor de 0,5823. luego todos los ítems que superaron este valor se sumaron y promediaron. el valor obtenido correspondió al cvi (índice de validez de contenido de cada una de las dimensiones y de todo el instrumento). las fórmulas para hallar estos dos valores se explican a continuación: cvr: número de acuerdo (# evaluadores que califican el ítem como esencial). número total de evaluaciones realizadas (para nuestro ejemplo, 3 evaluadores). valores por encima de 0,5823 son considerados aceptables y el ítem se retiene como parte del instrumento. cvi: sumatoria de todos los valores de los ítems con cvr ≥ 0,5823. número total de ítems con evaluación aceptable (cvr ≥ 0,5823). la fórmula para calcular la fiabilidad o acuerdo entre dos evaluadores depende de la escala en que es medida cada una de las variables o características codificadas para cada estudio (2528). para características nominales, categóricas o cualitativas se utiliza como indicador de la fiabilidad el coeficiente kappa de cohen (caracterizado con el símbolo k). este coeficiente permite cuantificar el nivel del acuerdo interobservador para disminuir la subjetividad del método utilizado y descartar que el grado de acuerdo se deba al azar. se define como un estadístico de concordancia entre dos investigadores que corrige el azar. al ser una probabilidad, toma su valor en el intervalo (0, 1). la máxima concordancia posible corresponde a k = 1. el valor k = 0 se obtiene cuando la concordancia observada es precisamente la que se espera a causa exclusivamente del azar. si la concordancia es mayor que la esperada simplemente a causa del azar, k > 0, mientras que si es menor, k < 0. el mínimo valor de k depende de las distribuciones marginales. kappa es “un corrector de la medida de acuerdo interevaluador” que permite verificar que el nivel de acuerdos exceda los niveles de suerte. se representa según la fórmula: donde: po: proporción de concordancia observada realmente y se calcula sumando las marcas que representan la concordancia y dividiendo entre el número total de ellas. pa: proporción esperada por azar, se calcula sumando las probabilidades de acuerdo por azar para cada categoría. donde los valores k obtenidos deben interpretarse de la siguiente manera: • < 0,20: pobre • 0,21 y 0,40: débil • 0,41 y 0,60: moderada • 0,61 y 0,80: buena • 0,81 y 1,00: muy buena un cálculo que reporte un coeficiente kappa de 0,4 puede considerarse como el límite de fiabilidad aceptable de una prueba. resultados los resultados del estudio se presentan por separado para cada uno de los dos instrumentos diseñados y validados. k = po – pa 1 – pa 415 icresai-imeci: instrumentos para elegir y evaluar artículos científicos para la investigación y la práctica basada en evidencia l olga rocío gómez-ortega y otro. construcción y validez del instrumento de criterios de elegibilidad de los artículos de investigación para el metaanálisis (icresai) una vez concluida la revisión de literatura, el instrumento icresai de criterios de elegibilidad quedó compuesto por 5 categorías que se mantienen hasta la versión final del instrumento, y 11 ítems o preguntas que se fueron definiendo a partir de las recomendaciones y la evaluación de los expertos. para cada ítem se revisó la semántica y sintaxis por un experto en lingüística y se realizaron las correcciones sugeridas. posteriormente, los tres profesionales expertos en medición evaluaron la validez facial de cada una de las dimensiones e ítems. se calculó el índice de acuerdo, se realizaron los ajustes y las recomendaciones dadas, y se les devolvió a los expertos con las correcciones realizadas hasta tener una última versión clara, precisa y comprensible de los tres evaluadores. una vez concluida la validez facial del instrumento se procedió a medir la validez de contenido; para ello se aplicó la prueba estadística de lawshe modificada de tristán-lópez, 2008, la cual arrojó la conveniencia de retirar un ítem de la dimensión muestra por considerarse no esencial. el instrumento finalmente quedó constituido por cinco categorías y diez ítems, de los cuales los nueve primeros eran de obligatorio cumplimiento para que el artículo en evaluación se considerara elegido para la inclusión en el metaanálisis. el segundo ítem de la dimensión de resultados solo era evaluable en estudios experimentales, correlacionales o comparativos. en consulta realizada a un profesional experto en medición y en la metodología de metaanálisis, se recomendó para icresai modificar la dimensión instrumento de medición, retirando el ítem de propiedades psicométricas con el fin de evitar el sesgo de selección que podría conllevar la exclusión de gran parte de los artículos disponibles por fijar criterios de elección muy rígidos. se recomienda trasladar este ítem fundamental al instrumento de evaluación del mérito científico. por lo anterior, la versión definitiva del instrumento se constituye de cinco dimensiones y nueve ítems (tabla 1). los primeros siete ítems se consideraron de obligatorio cumplimiento (entiéndase por obligatorio cumplimiento aquellos ítems que deben estar presentes en las piezas de investigación para ser parte del metaanálisis o de la revisión sistemática). para los ítems 8 y 9 se consideró que el cumplimento de uno de ellos, en conjunto con los anteriores siete, era suficiente para tomar la decisión de incluir o excluir un estudio del metaanálisis. en el cálculo de la validez de contenido se tuvo en cuenta que todas las dimensiones e ítems propuestos eran esenciales para decidir qué literatura elegir como parte de una revisión sistemática. se obtuvo un índice de validez de contenido (cvi) del icresai de 1,0. categoría evaluada índice lawshe por categoría 1 objetivos del estudios (1 ítem) 1 2 muestra (2 ítems) 1 3 instrumento de medición (2 ítems) 1 4 procedimiento de recolección y análisis de los datos (2 ítems) 1 5 presentación de los resultados (2 ítems) 1 índice de validez del instrumento icresai contenido (cvi) 1 de los resultados se concluye que el instrumento diseñado cuenta con validez aparente y de contenido adecuada, y puede ser utilizado para decidir cuáles piezas de la literatura cumplen con los requisitos para ser parte de la investigación metodológica: metaanálisis. para el cálculo del índice de fiabilidad o concordancia interevaluador del instrumento icresai, compuesto por ítems medidos en una escala dicótoma o nominal, la prueba estadística aplicada fue el kappa de cohen. la medición se realizó en 263 estudios considerados elegibles para un metaanálisis que abordaba el estudio de la calidad de vida de las personas adultas que experimentan un trasplante de órganos. los resultados de la prueba de fiabilidad fueron (tabla 2): el kappa de cohen es una prueba que presenta resultados de difícil interpretación para los ítems en que las respuestas se tabla 1. resultados de la validez de contenido de los instrumentos de criterios de elegibilidad de los estudios (icresai) (5 categorías y 9 ítems) 416 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 concentran en una única opción, o donde una de las marginales tiene valor de cero. da resultados bajos o negativos, aunque el nivel de porcentaje de acuerdo sea alto. es por ello que se presenta, además del índice de kappa, el porcentaje de acuerdo entre las respuestas emitidas por los dos evaluadores. en general se obtuvieron índices de kappa de cohen buenos y muy buenos para todos los ítems evaluados. construcción y validez del instrumento de criterios para evaluar el mérito científico de los artículos seleccionados para el metaanálisis (imeci) en el diseño del presente instrumento, inicialmente a partir de una robusta revisión de la literatura (5-14, 17), se definieron las categorías e ítems considerados importantes para la evaluación crítica de literatura científica. el instrumento de evaluación del mérito científico inicialmente estaba constituido de la siguiente manera: 10 categorías, que a su vez correspondían a los apartados de la estructura de un artículo científico, y 78 ítems, con los cuales se evaluaba la solvencia conceptual, metodológica y empírica de la investigación profundizada en un artículo científico. dimensiones e ítems del instrumento imeci: 1. pautas generales a evaluar (6 ítems) 2. pautas para evaluar título (3 ítems) 3. pautas para evaluar autores (4 ítems) 4. pautas para evaluar resumen (6 ítems) 5. pautas para evaluar introducción y marco teórico (24) 6. pautas para evaluar diseño (5 ítems) 7. procedimiento de recolección de la información (1 ítem) 8. pautas para evaluación de los resultados (14 ítems) 9. pautas para evaluar discusión, conclusiones y recomendaciones (9 ítems) 10. pautas para evaluar bibliografía (6 ítems) el instrumento imeci se sometió a la revisión semántica y sintáctica de un experto en lingüística y, una vez realizados los cambios sugeridos, se sometió al juicio de expertos para evaluar la validez facial de acuerdo con los parámetros dados por echeverri (20). el instrumento fue reconstruido siguiendo las recomendaciones para validez aparente: se retiraron los ítems considerados repetitivos o redundantes y se especificaron las dimensiones en las cuales iba a ubicarse cada ítem. después de la prueba de validez facial, el primero quedó constituido por 11 categorías o dimensiones y 61 ítems. se organizó la versión preliminar del instrumento y se procedió a calcular la validez de contenido de acuerdo con la propuesta de tristán-lópez, 2008, obteniéndose para el imeci un cvi aceptable de 0,778. la versión final de los instrumentos quedó conformada de la siguiente manera: 11 categorías o dimensiones y 55 preguntas. pero dada la recomendación de los expertos metodológicos en metaanálisis, para dar mayor validez a los resultados obtenidos tras la aplicación del instrumento se decidió incluir un nuevo ítem tabla 2. fiabilidad interevaluador del instrumento icresai artículos evaluados: 263 ítem no. categoría / ítem índice kappa cohen p # acuerdo % acuerdo 1 objetivos del estudio: ítem elegibilidad 1 0,973 0,000* 255 96,96 2 muestra: ítem elegibilidad 2 -0.004 0,951 261 99,24 3 muestra: ítem elegibilidad 3 0,853 0,000* 261 99,24 4 instrumento de medición: ítem elegibilidad 4 0,665 0,000* 262 99,62 5 instrumento de medición: ítem elegibilidad 5 -0,005 0,930 260 98,86 6 procedimiento de recolección y análisis de los datos: ítem elegibilidad 6 0,000 262 99,62 7 procedimiento de recolección y análisis de los datos: ítem elegibilidad 7 0,855 0,000* 262 99,62 8 presentación de los resultados: ítem elegibilidad 8 0,547 0,000* 251 95,44 9 presentación de los resultados: ítem elegibilidad 9 0,785 0,000* 237 90,11 10 elegibilidad definitiva 0,967 0,000* 259 98,48 417 icresai-imeci: instrumentos para elegir y evaluar artículos científicos para la investigación y la práctica basada en evidencia l olga rocío gómez-ortega y otro. para la categoría de pautas a fin de evaluar la muestra que valora el porcentaje de atrición (pérdida) de la muestra en el estudio. además se generó una nueva categoría con un ítem que correspondió a evaluación psicométrica del (los) instrumento(s) de medición utilizado(s) en el estudio, que inicialmente hacía parte del instrumento de criterios de elegibilidad (icresai). también se suprimió un ítem de la dimensión de muestra por considerarse duplicado. la versión definitiva del instrumento quedó constituida por 12 dimensiones o categorías y 56 preguntas o ítems. para la última versión del instrumento imeci se recalculó el índice de validez de contenido y se obtuvo un cvi aceptable de 0,75. evaluado, se asignó un valor de cero 0) o no aplica (na) (corresponde a una opción que solo es susceptible de responder en los artículos con características específicas en el diseño, como estudios comparativos, correlacionales o experimentales, etc.). para la opción na, no se asignó un puntaje de calificación (no suma en el balance total). se consideraron como ítems especiales que puntúan, según su alcance, aspectos como tipo de publicación de 1 a 4, tipo de muestra de 1 a 2, diseño de 1 a 2 y propiedades psicométricas del instrumento de medición de 1 a 3. a estos ítems se les otorgó un valor diferente de puntuación (0, 1 o no aplica), por ser los que garantizan el valor metodológico. los valores asignados a cada opción de respuesta se explican en el manual de diligenciamiento del instrumento. la puntuación definitiva del artículo evaluado se obtiene de la suma de las respuestas obtenidas en cada ítem examinado. una vez evaluados todos los ítems, se suman los valores obtenidos por el total de ítems que aplican. el máximo valor de calificación está dado por la suma de los ítems estimados como positivos más los negativos (todos los ítems que aplican a cada artículo). así, se evaluó el mérito científico de acuerdo con los percentiles 25-50 y 75. se definieron para ello tres categorías para calificar la calidad del mérito científico de la pieza de investigación: alta, media o baja, de acuerdo con la proporción de la sumatoria de los ítems que cargaron puntos, sobre el total de aquellos que aplican. si la proporción está por debajo del 50% de los que aplican, es bajo; si está entre 50-75% de los que aplican, es medio, y si es superior al 75% de los que aplican, es alto el mérito científico. el imeci cumple con propiedades psicométricas y puede ser utilizado para realizar la crítica del mérito científico de artículos de investigación seleccionados sobre un área temática específica, así como para valorar la calidad del conocimiento basado en la rigurosidad conceptual, metodológica y empírica con que una investigación es realizada. el instrumento generado propone dos formas de interpretar los resultados. el puntaje obtenido de la evaluación de la totalidad de los ítems será un indicador del mérito científico del estudio y 18 ítems del instrumento se integraron para obtener una medida de la calidad metodológica del estudio. estos ítems se distribuyen dentro de cada categoría de la siguiente manera (tabla 4): tabla 3. validez de contenido del instrumento para evaluar el mérito científico de los estudios para el metaanálisis (imeci) (12 categorías y 56 ítems) categoría evaluada índice lawshe por categoría pautas generales claves a evaluar (4 ítems) 0,74 pautas para evaluar el título (2 ítems) 0,67 pautas para evaluar autores (2 ítems) 0,67 pautas para evaluar el resumen (6 ítems) 0,84 evaluación de la introducción y marco teórico (11 ítems) 0,84 pautas para evaluar el diseño (4 ítems) 0,74 pautas para evaluar instrumento de medición (1 ítem) 0,67 pautas para evaluar muestra (7 ítems)* 0,73 pautas para evaluar el procedimiento de recolección y análisis de la información (3 ítems) 1 pautas para evaluación de los resultados (8 ítems) 0,79 pautas para evaluar discusión, conclusiones y recomendaciones (6 ítems) 0,67 pautas para evaluar las referencias (2 ítems) 0,67 índice total de validez de contenido 0,75 * este cálculo del índice de lawshe de esta categoría se realizó solo con 6 ítems, dado que el ítem que evalúa el porcentaje de pérdida de tamaño de muestra (atrición de la muestra) se incluyó después, durante la fase de aplicación del instrumento de los estudios seleccionados para un metaanálisis. la escala de calificación para cada ítem propuesto en el instrumento correspondió a las siguientes opciones de respuesta: sí (si en el artículo se cumple con lo evaluado, se le asignó un valor de uno 1), no (cuando en el artículo no se cumple con lo 418 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 conclusiones y proyección futura la aplicación de los instrumentos icresai e imeci permitirá determinar la selección, el mérito científico y la calidad metodológica de los artículos originales existentes sobre un área temática especificada según el fenómeno o fenómenos de interés, objeto de análisis en una revisión sistemática. pero se considera que puede ser útil para leer, criticar o analizar de forma más profunda artículos originales de abordaje cuantitativo y diferente alcance investigativo. aunque con estos resultados se demuestra la utilidad de los instrumentos para el estudio cuidadoso de piezas de investigación, es opcional que posteriormente se lleven a cabo otras pruebas de validez de criterio y confiabilidad a fin de precisar la estabilidad de los mismos. este aspecto será presentado posteriormente por las autoras, que están haciendo uso del instrumento dentro del desarrollo del proyecto de investigación centrado en ma. en resumen, los instrumentos pueden ser tomados como base para evaluar diferentes tipos de estudios de abordaje cuantitativo. se diferencian de otros porque no solo presentan el listado de características que deben evaluarse, sino que proponen una escala de puntuación para clasificar, según la calidad metodológica y el mérito científico de los artículos, la evidencia existente. este aspecto puede ayudar a determinar qué literatura es útil para responder a problemas de la práctica profesional. a futuro se espera fortalecer la práctica basada en evidencia y poder ofrecer al mundo de la investigación y de la práctica instrumentos con dotes psicométricas adicionales útiles para la selección y la lectura crítica de la literatura científica en las disciplinas de la salud. agradecimientos al programa de doctorado en enfermería de la universidad nacional de colombia; a colciencias por el apoyo para adelantar estudios de doctorado; al departamento de metodología de la investigación de la facultad de psicología de la universidad de murcia (españa), por el apoyo recibido durante la realización de este estudio. referencias 1. aguillo if, correa e, martínez c. producción científica y tecnológica nacional y presencia web de instituciones académicas en iberoamérica. interciencia 2010; 35(2):92-98. 2. ríos c, herrero v. producción científica latinoamericana y la ciencia mundial: una revisión bibliográfica (1989-2003). rev interamericana de bibliotecología. 2005; 28(1):43-61. 3. green bn, johnson cd, adams a. writing narrative literature. reviews for peer-reviewed journals: secrets of the trade. j sport chiropr y rehabil. 2001; 15(1):5-19. 4. rodríguez v. conociendo sobre revisiones sistemáticas. rev arch col med. 2008; 1(2):64-68. 5. the cochrane collaboration. the systematic review [citado 2012 mayo 20]. disponible en: www.cochrane.org/review/ revstruc.html 6. the joanna briggs institute (jbi). [citado 2012 mayo 20]. disponible en: http://connect.jbiconnectplus.org tabla 4. categorías e ítems para evaluar la calidad metodológica de los estudios categoría evaluada no. de ítems evaluados evaluación de la introducción y marco teórico 2 pautas para evaluar el diseño 3 pautas para evaluar el instrumento de medición 1 pautas para evaluar muestra 5 pautas para evaluar el procedimiento de recolección y análisis de la información 2 pautas para evaluación de los resultados 3 pautas para evaluar discusión, conclusiones y recomendaciones 2 total de ítems que definen la calidad metodológica 18 419 icresai-imeci: instrumentos para elegir y evaluar artículos científicos para la investigación y la práctica basada en evidencia l olga rocío gómez-ortega y otro. 7. junquera lm, baladron j, albertos jm, olay s. medicina basada en la evidencia (mbe): ventajas. rev esp cirug oral y maxilofac. 2003;(25)5:265-272. disponible en: http://dx.doi.org/10.4321/s1130-05582003000500003. 8. lectura crítica. 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(fuente: decs, bireme). para citar este artículo / to reference this article / para citar este artigo pérez parra, j. e., henao lema, c. p. (2013). relación entre complicaciones clínicas y discapacidad en población colombiana con lesión medular: resultados desde el whodas ii. aquichan. vol. 13, no. 2, 173-185. 174 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 relationship between clinical complications and disability in colombians with spinal cord injury: results from who-das ii abstract introduction: clinical complications in persons with spinal cord injury are associated with increased morbidity and mortality, aggravated disability and prolonged rehabilitation processes. recognizing these difficulties is important to developing strategies for prevention and early detection to mitigate their impact on disability and to improve the quality of life for this population. objective: the study was intended to identify the relationship between clinical complications and the degree of disability among colombians with spinal cord injury. materials and methods: the frequency of clinical complications in the last year was determined and the relationship between these complications and the degree of disability was identified, evaluated with who-das ii, through the student’s t-test and an exploration of simple linear regression models. the participants included 363 persons over 18 years of age with a spinal cord injury sustained more than six months before. the participants were from eight colombian cities. results: there were seven clinical complications per patient, on average. the most frequent complications were urinary tract infections, spasticity, hyperesthesia, psychological stress and chronic pain. the complications that best explain the disability, using simple regression models, are depression and psychological stress, followed by respiratory complications, intestinal problems, pressure ulcers, malnutrition and spasticity (p <0.01). conclusions: the clinical complications associated with spinal cord injury are still frequent in colombia, despite the improvement in processes for care and rehabilitation. many of these complications are associated fundamentally with the generation of disability. keywords physical therapy specialty, spinal cord injuries, complications, disability evaluation. (source: decs, bireme). 175 relación entre complicaciones clínicas y discapacidad en población colombiana con lesión medular: resultados desde el who-das ii l julio ernesto pérez-parra y otro. relação entre complicações clínicas e deficiências em população colombiana com lesão medular: resultados a partir do who-das ii resumo introdução: as complicações clínicas em pessoas com lesão muscular se associam ao aumento da morbimortalidade, agravamento da condição de deficiência e à prolongação dos processos de reabilitação. é importante seu reconhecimento para o desenvolvimento de estratégias de prevenção e tenro atendimento mais eficazes que amenizem seu impacto sobre a deficiência e melhorem a qualidade de vida dessa população. objetivo: estabelecer as relações entre complicações clínicas e o grau de deficiência em população colombiana com lesão medular. materiais e métodos: determinou-se a frequência de complicações clínicas no último ano e se estabeleceu a relação entre estas com o grau de deficiência avaliado com o who-das ii, por meio da prova t de student e da exploração de modelos de regressão linear simples. participaram 363 pessoas maiores de 18 anos com lesão medular de mais de seis meses de evolução, de oito cidades colombianas. resultados: a média de complicações clínicas foi de sete por paciente. as complicações mais frequentes foram as infecções urinárias, espasticidade, hiperestesia, estresse psicológico e dor crônica. as complicações que melhor explicam a deficiência utilizando modelos de regressão simples são a depressão e o estresse psicológico, seguido de complicações respiratórias, problemas intestinais, úlceras de pressão, desnutrição e espasticidade (p < 0,01). conclusões: as complicações clínicas associadas à lesão medular continuam sendo condições frequentes em nosso meio apesar dos avanços nos processos de atendimento e reabilitação. muitas dessas complicações se associam em grande medida à geração de deficiência. palavras-chave fisioterapia, traumatismos da medula espinal, complicações, avaliação da deficiência. (fonte: decs, bireme). 176 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 introducción la lesión medular (lm) es una condición neurológica que genera importantes repercusiones en la vida del individuo y produce diferentes grados de discapacidad (1). a pesar de los grandes avances en atención prehospitalaria y en el manejo médico y quirúrgico de la condición aguda que han aumentado de forma importante la sobrevida de los pacientes, las complicaciones clínicas siguen siendo uno de los principales problemas por prevenir en las diferentes etapas de la enfermedad debido a la complejidad del cuadro clínico que las acompaña (2). aunque muchas de estas complicaciones son en cierta medida evitables (3), no son infrecuentes en nuestro medio y se asocian a aumento de la morbimortalidad, agravamiento de la condición de discapacidad y a prolongación de los procesos de rehabilitación. este tipo de situaciones repercute de manera directa en la calidad de vida tanto de la persona como de su familia y genera un impacto importante en el sistema de salud puesto que en su manejo se deben invertir grandes recursos asociados a rehospitalizaciones, necesidad de atención especializada y disminución de la capacidad productiva de la persona (2, 4, 5). con base en las anteriores consideraciones, esta investigación tuvo como objetivo determinar la frecuencia de complicaciones clínicas secundarias a la lm en nuestro medio y establecer las relaciones bivariadas y multivariadas que existen entre estas complicaciones y el grado de discapacidad asociado a la lesión evaluado con el who-das ii. este último aspecto se convierte en un elemento importante que puede dar mayor soporte al planteamiento de estrategias más eficaces de prevención e intervención de complicaciones, que en últimas contribuyen a una mayor sobrevida de las personas, atenuando su situación de discapacidad y mejorando su calidad de vida. el who-das ii se reconoce en la actualidad como una importante herramienta para evaluar de forma multidimensional el funcionamiento y la discapacidad en población con diversas condiciones de salud. como medida de discapacidad tiene a su favor que es compatible con el principal sistema de clasificación internacional de discapacidad, la cif de la organización mundial de la salud (oms), fue desarrollado y validado con personas de gran diversidad cultural, e incluye la evaluación de todos los posibles trastornos asociados con la discapacidad, determinando el nivel de funcionamiento de la persona desde los ámbitos de actividad y participación. adicionalmente, fue validado en su versión en lengua española (6). materiales y métodos este estudio fue aprobado por el comité de bioética de la universidad autónoma de manizales y se ciñe a las normas éticas emanadas de la declaración de helsinki y de la resolución 8430 de 1993 del ministerio de salud de colombia. se realizó un estudio de corte descriptivo correlacional trasversal con 363 adultos con lm de ocho ciudades colombianas, que al momento de la evaluación tenían más de seis meses de evolución de la lesión. debido a que hasta el momento no se habían publicado estudios de prevalencia de lm en colombia, para estimar la población que padece esta condición de las diferentes ciudades que participaron en el estudio se tomó como valor máximo esperable el límite superior del rango reportado por wyndaele y wyndaele (7) sobre prevalencia de lm a nivel mundial (755 personas/millón de habitantes). con este límite superior se garantizó una adecuada prevalencia de la población con lm, dadas las condiciones de violencia que vive el país y el alto índice de accidentalidad vehicular. para efectos del cálculo del tamaño de la muestra se tomó como referencia el estudio de henao y pérez (8, 9) en el que se encontró que el 100 % de las personas con lm de la ciudad de manizales presentaban algún grado de discapacidad (53 % moderada, 38 % leve y 9 % severa) con una media de 31,27 en una escala de 0 a 100 y una desviación estándar de 13,68. con estos últimos datos se realizó un muestreo simple para cada una de las ciudades con un nivel de confianza del 95 % y una precisión de 4 puntos de discapacidad; la muestra se ajustó 10% por posibles pérdidas. la muestra final por ciudad puede consultarse en la tabla 1 (procedencia de los participantes). se realizó un muestreo no probabilístico de sujetos voluntarios con técnica de bola de nieve en instituciones de salud y rehabilitación de la ciudades participantes en el estudio. dichas personas debían ser mayores de 18 años y tener al menos seis meses de evolución de la lm, la cual podía ser de cualquier etiología, nivel y completitud. no debían padecer en el momento de la evaluación otro tipo de enfermedades concomitantes, no secundarias a su lm y que pudieran explicar su discapacidad. cada persona participante en el estudio, previa firma de un consentimiento informado, contestó un cuestionario que indagaba sobre aspectos sociodemográficos y clínicos, entre estos las complicaciones clínicas autorreportadas sufridas en el último año. el grado de compromiso funcional se evaluó con la escala de deficiencia ais (american spinal injury association (asia) impairment scale), la cual es la más utilizada a nivel internacional 177 relación entre complicaciones clínicas y discapacidad en población colombiana con lesión medular: resultados desde el who-das ii l julio ernesto pérez-parra y otro. para evaluar la extensión o completitud de la lesión medular y sigue los estándares del sistema de clasificación neurológica de la asociación americana de lesiones medulares (asia); esta clasificación se utiliza para definir tanto el nivel neurológico de la lesión como para clasificar las lesiones en completas o incompletas, a partir de la evaluación estandarizada de las funciones motora y sensitiva correspondientes a las diferentes metámeras (10). para establecer el grado de discapacidad se utilizó la versión española del who-das ii 36 ítems (6). para evitar sesgos en la recolección de la información, uno de los investigadores evaluó las variables sociodemográficas y la discapacidad (who-das ii) y otro investigador evaluó las variables clínicas. todos los datos se analizaron con el software estadístico spss versión 19.0 (statistical package for the social science – spss), excepto el test de white, que se hizo con cálculos propios. se realizaron análisis descriptivos de todas las variables. se determinó la frecuencia de las complicaciones clínicas en el último año y se evaluó la relación entre estas y el grado de discapacidad, evaluando las diferencias en la media de discapacidad entre el grupo que poseía la complicación y el que no (prueba t de student). se realizaron análisis multivariados mediante modelos de regresión lineal múltiple para la discapacidad global tomando como variables explicativas la cantidad de complicaciones clínicas presentes en cada paciente y aquellas que mostraron diferencias significativas en la prueba t de student. debido a que ninguno de los modelos múltiples explorados superó todas las pruebas de validación, particularmente las referidas a normalidad y homocedasticidad de los residuos, solo se presentan en este artículo los resultados de los modelos de regresión lineal simple para cada una de las complicaciones estudiadas, con el fin de determinar el porcentaje en que cada una de ellas puede explicar por sí misma el grado de discapacidad de los pacientes con lm (r cuadrado corregida). para todos los casos se consideró significancia estadística cuando p fue igual o menor a 0,05. resultados las características sociodemográficas y clínicas de los participantes en el estudio se resumen en la tabla 1. se evaluaron 363 pacientes con lm con una edad promedio de 38 años, el 58 % de ellos adultos jóvenes, 86 % hombres. solo siete pacientes no estaban afiliados al sistema de seguridad social en salud. el 91 % presentaron lm de origen traumático con una edad promedio de ocurrencia de la lesión de 28 años. la mayoría de lesiones fueron completas y se ubicaron en la región torácica, seguida de cervicales y lumbares. la discapacidad media fue de 33/100, la totalidad de pacientes presentó algún grado de discapacidad según la clasificación propuesta por la oms: 44 % moderado, 38 % leve y 18 % severo. el promedio de complicaciones clínicas autorreportadas como ocurridas en el último año fue de 7 por paciente. solo cuatro pacientes no presentaron ninguna complicación. el 63 % presentó entre 4 y 9 complicaciones, mientras que el 23 % presentó 10 o más (tabla 1). las complicaciones más frecuentes en su orden fueron: infecciones urinarias, espasticidad, parestesias y disestesias, estrés psicológico, dolor crónico, problemas intestinales y depresión, con una prevalencia por encima del 40 %, seguidas de úlceras de presión, hombro doloroso, contracturas musculares, aumento de peso y edema, con una prevalencia por encima del 30 %. las complicaciones menos frecuentes en su orden fueron: osteomielitis, trombosis, osificación heterotópica, complicaciones cardíacas, adicción a drogas o a alcohol y fracturas, con una prevalencia por debajo del 6 %. el comportamiento de las demás complicaciones puede observarse en la tabla 2. en todas las complicaciones clínicas estudiadas la media de discapacidad fue mayor en el grupo que contaba con ella (entre 35 y 47 puntos) en comparación con el grupo que no la tuvo (entre 27 y 33 puntos) (tabla 3). en la mayoría de estas complicaciones (20 de 29) la diferencia fue significativa según la prueba t de student (p < 0,05). en su orden se destacan: depresión, estrés psicológico, complicaciones respiratorias, disreflexia autonómica, problemas intestinales, úlceras de presión, desnutrición-anemia, alteraciones posturales y deformidades, espasticidad, hombro doloroso, alteraciones de la presión arterial e infecciones urinarias (p < 0,001). en la tabla 4 se exponen los resultados de los modelos de regresión lineal simple para las complicaciones que mostraron diferencias significativas en la prueba t de student. todos los modelos fueron estadísticamente significativos superando la prueba global del modelo (anova). asimismo, los beta de cada una de las complicaciones resultaron significativos (p < 0,05). las complicaciones que mejor explican la discapacidad, analizadas individualmente, son la depresión y el estrés psicológico con un coeficiente de determinación de 0,141 y 0,117 respectivamente. también sobresalen las complicaciones respiratorias, problemas intestinales y úlceras de presión con un coeficiente de determinación superior 178 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 al 0,05 (tabla 4). lo anterior significa, por ejemplo, en el caso de la depresión, que esta complicación por sí misma puede explicar el 14,1 % de la discapacidad del paciente con lm de más de seis meses de evolución. el porcentaje restante de discapacidad se explicaría por otras complicaciones y variables de orden sociodemográfico, clínico y de acceso a servicios de rehabilitación que requieren un análisis multivariado a través de modelos de regresión múltiple. discusión en nuestro estudio el 99 % de los pacientes manifestaron haber tenido al menos una complicación en el último año, con un promedio de siete complicaciones por paciente. a pesar de que los distintos estudios a nivel internacional reportan una alta incidencia y prevalencia de complicaciones en personas con lm, nuestra muestra sobrepasa la de países desarrollados. en un estudio estadounidense con 940 pacientes evaluados en el primero y segundo años poslesión, solo doce personas tenían tres o más complicaciones (11). en un estudio italiano encontraron que el 54 % de pacientes con lm tuvieron complicaciones clínicas en los seis meses precedentes (12). en países en desarrollo como el nuestro, la prevalencia de complicaciones es cercana a nuestros hallazgos. en la casuística hondureña de chang y zelaya el 54 % de los pacientes tuvieron alguna complicación aguda y el 79 % crónica (13). amatachaya, en un estudio tailandés prospectivo de seis meses posalta hospitalaria encontró que el 91 % de los sujetos experimentó al menos una complicación clínica durante el periodo de seguimiento (14). según bender et al., en su serie de pacientes con lm atendidos en un centro de neuro-rehabilitación en cuba, procedentes de veinte países, la incidencia de complicaciones fue muy alta, al menos el 90 % presentaron vejiga neurogénica y el 74 % infecciones urinarias (15). en un estudio mexicano se encontró que el 61 % de los pacientes tenían el antecedente de haber cursado con una úlcera de presión (16). a pesar de que la mayoría de complicaciones clínicas en la población con lm son condiciones potencialmente prevenibles, la alta prevalencia de estas en nuestro medio llama la atención respecto a si realmente se están implementando estrategias de prevención desde el inicio de la lesión, o estas estrategias resultan ser inadecuadas o poco efectivas. la prevención se convierte en la piedra angular para disminuir la incidencia de complicaciones puesto que el desarrollo de una primera complicación clínica pone en riesgo a la persona de volverla a presentar en el futuro. charlifue et al., mediante un análisis de regresión, demostraron que el mejor predictor para la aparición de una complicación en personas con lm es su existencia previa aun en sobrevivientes de largo tiempo; encontraron que el número de úlceras de presión aumentó con el tiempo. sostienen que las complicaciones anuncian la recurrencia de esa misma complicación en el futuro, destacando la importancia de la intervención temprana para su prevención (17). en nuestro estudio la complicación más frecuente fue la infección urinaria, seguida de espasticidad, parestesias y disestesias, estrés psicológico, dolor crónico, problemas intestinales y depresión. estos hallazgos son coherentes con los encontrados en otros estudios, como el de chang y zelaya en honduras donde las complicaciones agudas y causas de hospitalización más frecuentes fueron las infecciones del tracto urinario y las úlceras por presión; entre tanto, las complicaciones crónicas más frecuentes fueron la espasticidad y el dolor neuropático (13). en su casuística, bender et al. encontraron que las complicaciones más frecuentes fueron vejiga neurogénica, osteoporosis, infecciones urinarias, constipación y espasticidad con prevalencias por encima del 40 %; la depresión psicológica se presentó en el 10 % de los casos, el dolor neuropático en el 21 % y las úlceras por presión en el 29 % (15). en una serie alemana se encontró que las complicaciones más frecuentes reportadas en el año precedente al estudio fueron en su orden los problemas vesicales, problemas intestinales, espasmos, dolor, edema y úlceras por presión (18). por su parte, hitzig et al., en su serie canadiense, encontraron que las complicaciones más frecuentemente reportadas fueron la espasticidad, dolor de hombro, dolor crónico, infecciones urinarias, problemas intestinales, depresión y estrés psicológico (4). en el estudio tailandés las más frecuentes, tanto en fase subaguda como crónica, fueron dolor neuropático, infecciones del tracto urinario y úlceras de presión, sin embargo, la incidencia fue mayor en la lm crónica (14). como puede observarse, las infecciones urinarias continúan siendo una de las complicaciones más frecuentes en todas las series reportadas. la presencia de vejiga neurogénica y el uso inadecuado o por tiempo prolongado de catéteres para evacuación vesical predispone su desarrollo. a largo plazo, la recurrencia de esta complicación puede originar importantes disfunciones renales, deteriorar la calidad de vida de la persona y, en muchos casos, poner en riesgo su vida. una adecuada educación a la per179 relación entre complicaciones clínicas y discapacidad en población colombiana con lesión medular: resultados desde el who-das ii l julio ernesto pérez-parra y otro. sona y su familia en cuanto a la prevención y el manejo precoz de las infecciones se convierte en uno de los elementos más importantes para evitar su aparición. en este estudio encontramos que en las complicaciones clínicas estudiadas la media de discapacidad fue mayor en el grupo que contaba con esta en comparación con el grupo que no la tuvo, en la mayoría de ellas la diferencia fue significativa. las complicaciones que más generan discapacidad fueron depresión, estrés psicológico, complicaciones respiratorias, disreflexia autonómica, problemas intestinales, úlceras de presión, desnutrición-anemia, alteraciones posturales y deformidades, espasticidad, hombro doloroso, alteraciones de la presión arterial e infecciones urinarias. no encontramos estudios a nivel mundial que valoren la relación entre las complicaciones presentes en los pacientes con lm y su grado de discapacidad en la perspectiva biopsicosocial, pero sí hay reportes de su relación con otras variables asociadas al compromiso funcional, morbimortalidad, rehospitalización, calidad y expectativa de vida, entre otras. en estos se evidencia el impacto negativo de las complicaciones clínicas sobre la condición de salud de la persona con lm que podrían ser determinantes en la magnitud de la situación de discapacidad. putzke et al., reportaron diferencias significativas entre la cantidad de complicaciones clínicas y el puntaje obtenido en la escala de satisfacción con la vida (satisfaction with life scale swls): a mayor número de complicaciones menor nivel de satisfacción (11). se ha encontrado que las respuestas emocionales negativas como depresión y ansiedad, estrategias de afrontamiento tipo negación y evitación, y la severidad y el impacto de la discapacidad fueron relacionadas con bajos niveles de adaptación a la lm (19). bloemen-vrencken et al., encontraron una relación significativa entre la cantidad de complicaciones y el puntaje obtenido en una escala de comportamientos para el autocuidado de la salud (18). en cuanto a estudios sobre la asociación entre complicaciones con readmisiones y mortalidad, pagliacci et al., reportaron que la ocurrencia de rehospitalizaciones y la mortalidad mostraron correlación significativa con la pérdida de autonomía vesical e intestinal; asimismo, la mortalidad se correlacionó con úlceras de presión. en su análisis multivariado la pérdida de autonomía vesical e intestinal fue la variable más importante con un fuerte valor predictivo de mortalidad y readmisiones (12). en un estudio australiano se encontró que el 59 % de los pacientes con lm requirieron una o más readmisiones hospitalarias relacionadas con su lesión en los últimos diez años. las causas más frecuentes de rehospitalización fueron las complicaciones genitourinarias, seguidas de las gastrointestinales, las relacionadas con la piel, las músculo-esqueléticas y los desórdenes psiquiátricos; las úlceras de presión fueron causa de solo el 6,6 % de todas las readmisiones, sin embargo, contribuyeron con un número desproporcionado de días en cama (28 %), con un promedio de 66 días (20). klotz et al. estudiaron los resultados globales de rehabilitación a largo plazo de pacientes cuadripléjicos franceses y los correlacionaron con las complicaciones médicas que originaron su rehospitalización; encontraron una tasa de rehospitalización del 74,4 % causada en su orden por: complicaciones urinarias, úlceras de presión, complicaciones respiratorias, contracturas, complicaciones intestinales, dolor y fracturas secundarias en miembros inferiores (21). en un estudio estadounidense que hizo seguimiento de 9.225 personas con lm cinco años después de la lesión se encontró que la probabilidad de ocurrencia de complicaciones médicas disminuye durante la hospitalización pero incrementa en la fase ambulatoria. el riesgo de desarrollar neumonía y trombosis venosa profunda disminuye de manera significativa en el tiempo; entre tanto, el riesgo de desarrollar trombosis venosa profunda, úlceras de presión, cálculos renales y depresión incrementa significativamente durante los primeros cinco años poslesión (22). en cuanto a la asociación entre complicaciones y deficiencia neurológica asociada a la lm, garzón encontró que la incidencia de complicaciones tuvo relación con la pobre recuperación neurológica a largo plazo; a mayor frecuencia de complicaciones peor asia a los seis meses (23). la presencia de úlceras de presión se ha asociado con la lesión medular completa medida en la escala de asia (16). en la casuística de klotz et al., las personas con lesión completa motora reportaron con mayor frecuencia las complicaciones urinarias y las úlceras de presión, mientras en aquellas con lesión incompleta las más frecuentes fueron las contracturas y el dolor (21). por su parte, mediante un análisis de regresión logística, hitzig et al. encontraron un incremento de la relación de tasas (odds ratio) de las complicaciones cardiacas, presión arterial alta y complicaciones respiratorias respecto a la edad, mientras decreció con la disreflexia autonómica, infecciones vesicales, osificación heterotópica, estrés psicológico y adicción a drogas. en cuanto al tiempo de evolución esta relación de tasas se incremen180 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 tó para las úlceras de presión, disreflexia autonómica y osificación heterotópica, en tanto disminuyó para la presión arterial alta, problemas intestinales, estrés psicológico y depresión. las lesiones completas se asociaron con infecciones urinarias, úlceras de presión y disreflexia autonómica, la paraplejia con la presión arterial alta y la cuadriplejia con la disreflexia autonómica (4). en nuestros modelos de regresión lineal simple las complicaciones que mejor explican la discapacidad son la depresión y el estrés psicológico, seguidas por complicaciones respiratorias, problemas intestinales y úlceras de presión. coherente con este hallazgo krause y saunders, mediante un modelo de regresión logística con una muestra estadounidense de pacientes con lm de al menos un año de evolución, encontraron que tener antecedentes de desórdenes depresivos, úlceras de presión crónica, amputaciones, infecciones y haber sido hospitalizado durante el año anterior, fueron todos predictores de mortalidad y disminución en la expectativa de vida (24). en nuestro estudio, el 40 % de los pacientes informaron haber estado deprimidos en el último año y el 49 % reportó haber sufrido estrés psicológico. fann et al., en una muestra diversa de pacientes con lm, encontraron una prevalencia de depresión moderada del 23 % diagnosticada a través de la escala de depresión phq-9 (patient health questionnarie-9), tres veces superior a la prevalencia de desórdenes de depresión mayor en población general; de los pacientes que al momento de la evaluación no estaban deprimidos, 24 % de ellos reportaron una historia de diagnóstico de depresión (25). fann et al. sostienen que aunque existe una clara evidencia de la necesidad de hacer una efectiva intervención de la depresión después de la lm, los actuales tratamientos no están siendo usados en la mayoría de pacientes con lm y depresión. esta ha sido asociada con largos periodos de rehabilitación y menor independencia funcional y movilidad al momento del alta hospitalaria (25). según boekamp et al., la depresión puede interferir en gran medida con el proceso de rehabilitación de pacientes con lm debido a que ocasiona reducción de energía, expectativas negativas y aislamiento social; la identificación de factores que propician su desarrollo puede mejorar tanto el diagnóstico y tratamiento del desorden depresivo como los resultados de la rehabilitación de la lm. sostienen que los pacientes son menos propensos a deprimirse si su independencia se fomenta y se les anima a desarrollar nuevas fuentes de autoestima, y recomienda que los parientes reciban asesoramiento para ayudar a mantener relaciones de apoyo dentro de la familia (26). finalmente, es importante aclarar que algunas de las complicaciones podrían no ser consideradas como tales sino como procesos intercurrentes, como es el caso de la adicción a drogas o a alcohol, depresión y estrés psicológico, o bien considerarse que pertenecen al propio curso clínico de la lesión medular, como las parestesias/disestesias o la espasticidad. este análisis sería objeto de estudios posteriores de carácter longitudinal que evalúen clínicamente las complicaciones y demás manifestaciones inherentes e intercurrentes a la lesión medular. conclusiones las complicaciones clínicas asociadas a la lesión medular siguen siendo condiciones frecuentes en nuestro medio a pesar de los avances en los procesos de atención y rehabilitación. muchas de estas complicaciones se asocian en gran medida a la generación de discapacidad. es importante determinar los factores de riesgo inherentes al desarrollo de las diferentes complicaciones clínicas en la población con lm, con el objetivo de que sean identificados de forma temprana, y de esta manera desarrollar programas efectivos de prevención de complicaciones clínicas en lesión medular que involucren la adecuada asistencia sanitaria y la educación de las personas y sus familias. en tal sentido, se requieren estudios de corte longitudinal que caractericen clínicamente el desarrollo de las complicaciones y evalúen su severidad, utilizando escalas validadas internacionalmente. asimismo, se requieren investigaciones que indaguen sobre las medidas de autocuidado que siguen los pacientes con lm para promover su salud general y evitar complicaciones clínicas. otros estudios podrían evaluar las relaciones entre el proceso de envejecimiento y la incidencia y prevalencia de las complicaciones clínicas secundarias en población con lm. agradecimientos los autores expresamos nuestros agradecimientos a los pacientes participantes en el estudio y a las instituciones de salud y rehabilitación que facilitaron su desarrollo en las ciudades de bogotá, medellín, cali, bucaramanga, manizales, popayán, pasto y buenaventura. asimismo, a los estudiantes de la segunda cohorte de la maestría en neuro-rehabilitación de la universidad autónoma de manizales quienes auspiciaron como coinvestigadores en el estudio: m. l. acosta, l. a. cardona, s. m. daza, i. c. gómez, l. r. imbachi, j. londoño, l. j. lucio, c. marín, s. j. medina, s. j. parra, a. c. quino, m. a. ramírez, d. m. rivera, e. roldán, m. l. salazar, a. i. silva, l. k. sossa, l. g. suárez, l. m. torres y f. valencia. 181 relación entre complicaciones clínicas y discapacidad en población colombiana con lesión medular: resultados desde el who-das ii l julio ernesto pérez-parra y otro. referencias 1. henao cp, pérez je. lesiones medulares y discapacidad: revisión bibliográfica aquichán. 2010;10(2):157-72. 2. johnson r, gerhart k, mccray j, menconi j, whiteneck g. secondary conditions following spinal cord injury in a population-based sample. spinal cord. 1998;36(1):45-50. 3. richards j, waites k, chen y, kogos s, schmitt m. the epidemiology of secondary conditions following spinal cord injury. top spinal cord inj rehabil. 2004;10(1):15-29. 4. hitzig sl, tonack m, campbell ka et al. secondary health complications in an aging canadian spinal cord injury sample. am j phys med rehabil. 2008;87:545-55. 5. meade ma, forchheimer mb, krause js, charlifue s. the influence of secondary conditions on job acquisition and retention in adults with spinal cord injury. arch phys med rehabil. 2011;92(3):425-32. 6. vásquez-barquero jl, herrera s, vásquez e, gaite i. cuestionario para la evaluación de discapacidad de la organización mundial de la salud – who-das ii (versión española del world health organization disability assessment schedule ii). ministerio de trabajo y asuntos sociales, madrid; 2006. 7. wyndaele m, wyndaele jj. incident, prevalence and epidemiology of spinal cord injury: what learns a worldwide literature survey? spinal cord. 2006;44:523-9. 8. henao cp, pérez je. situación de discapacidad de la población adulta con lesión medular de la ciudad de manizales. hacia la promoción de la salud. 2011;16(2):52-67. 9. henao-lema cp, pérez-parra je. modelo predictivo del grado de discapacidad en adultos con lesión medular: resultados desde el who-das ii. rev cienc salud. 2011;9(2):159-72. 10. standards for neurological classification of sci [homepage on the internet]. american spinal injury association asia. [visitado sep. 2011]. disponible en: http://www.asia-spinalinjury.org 11. putzke jd, richards js, hicken bl, devivo mj. predictors of life satisfaction: a spinal cord injury cohort study. arch phys med rehabil. 2002;83:555-61. 12. pagliacci mc, franceschini m, di clemente b, agosti m, spizzichino l. a multicentre follow-up of clinical aspects of traumatic spinal cord injury. spinal cord. 2007; 45:404-10. 13. chang k, zelaya i. caracterización de pacientes con lesión medular atendidos en un centro de rehabilitación (teletón) en honduras. rev med hondur. 2007;75:174-180. 14. amatachaya s, wannapakhe j, arrayawichanon p, siritarathiwat w, wattanapun p. functional abilities, incidences of complications and falls of patients with spinal cord injury 6 months after discharge. spinal cord. 2011;49:520-4. 15. bender je, hernández e, prida m, araujo f, zamora f. caracterización clínica de pacientes con lesión medular traumática. rev mex neuroci. 2002;3(3):135-42. 16. pérez r, rodríguez e, escobar a. frecuencia de úlceras por presión en el paciente lesionado medular, su correlación con el nivel neurológico y escala de asia. rev mex med fis rehab. 2007;19(1):16-23. 17. charlifue s, lammertse dp, adkins rh. aging with spinal cord injury: changes in selected health indices and life satisfaction. arch phys med rehabil. 2004;85:1848-53. 18. bloemen-vrencken jha, de witte lp, post mwm, van den heuvel wja. health behaviour of persons with spinal cord injury. spinal cord. 2007;45:243-9. 19. martz e, livneh h, priebe m, wuermser la, ottomanelli l. predictors of psychosocial adaptation among people with spinal cord injury or disorder. arch phys med rehabil. 2005;86:1182-92. 20. middleton jw, lim k, taylor l, soden r, rutkowski s. patterns of morbidity and rehospitalisation following spinal cord injury. spinal cord. 2004;42:359-67. 21. klotz r, joseph pa, ravaud jf, wiart l, barat m and the tetrafigap group. the tetrafigap survey on the long-term 182 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 outcome of tetraplegic spinal ord injured persons: part iii. medical complications and associated factors. spinal cord. 2002;40:457-67. 22. devivo mj. trends in spinal cord injury rehabilitation outcomes from model systems in the united states: 1973-2006. spinal cord. 2007;45:713-21. 23. garzón m. trauma raquimedular. factores predictivos de recuperación neurológica a largo plazo. repertorio de medicina y cirugía. 2005;14(2):74-8. 24. krause j, saunders l. health secondary conditions and life expectancy after spinal cord injury. arch phys med rehabil. 2011;92(11):1770-5. 25. fann jr, bombardier ch, richards js, tate dg, wilson cs, temkin n, for de prims investigators. depression after spinal cord injury: comorbities, mental health service use, and adequacy of treatment. arch phys med rehabil. 2011;92:352-60. 26. boekamp j, overholser j, schubert d. depression following a spinal cord injury. int j psychiatry med. 1996;26(3):329-49. variable muestra (n = 363) edad (años) 38,3 ± 11,95 rango de edad (años) (%) 18-25 54 (15) 26-40 158 (43) 41-60 133 (37) mayor de 60 18 ( 5) masculino (%) 313 (86) afiliado al sgsss (%) 356 (98) procedencia (%) bogotá 51 (14,0) bucaramanga 48 (13,2) buenaventura 41 (11,3) cali 48 (13,2) manizales 45 (12,4) medellín 49 (13,5) pasto 42 (11,6) popayán 39 (10,7) edad de ocurrencia de la lesión (años) 27,9 ± 11,55 tiempo de evolución de la lesión (meses) 126 ± 105 lesión traumática, % 329 (91) tabla 1. características sociodemográficas y clínicas de la muestra variable muestra (n = 363) nivel neurológico de la lesión, % cervicales 95 (26) torácicas 246 (78) lumbares 22 ( 6) grado compromiso funcional ais a 251 (69) b, c y d 112 (31) discapacidad global (0-100) 33 ± 16,4 grado de discapacidad según el who-das ii leve 138 (38) moderado 159 (44) severo 66 (18) cantidad de complicaciones en el último año 7 ± 3,4 cantidad de complicaciones por rangos 0 4 ( 1) 1-3 48 (13) 4-6 125 (34) 7-9 104 (29) 10 y más 82 (23) valores: media ± desviación estándar 183 relación entre complicaciones clínicas y discapacidad en población colombiana con lesión medular: resultados desde el who-das ii l julio ernesto pérez-parra y otro. tabla 2. frecuencia de complicaciones complicación n (363) porcentaje infecciones urinarias 248 68,3 espasticidad 227 62,5 parestesias y disestesias 192 52,9 estrés psicológico 178 49,0 dolor crónico 175 48,2 problemas intestinales 151 41,6 depresión 146 40,2 úlceras de presión 140 38,6 hombro doloroso 132 36,4 contracturas musculares 120 33,1 aumento de peso 114 31,4 edema 110 30,3 dolor articular artritis 100 27,5 alteraciones posturales y deformidades 75 20,7 problemas renales y vesicales 69 19,0 otros problemas en la piel 66 18,2 alteraciones de la presión arterial 54 14,9 disreflexia autonómica 45 12,4 complicaciones respiratorias 39 10,7 desnutrición anemia 24 6,6 deterioro neurológico 23 6,3 esguinces y luxaciones 22 6,1 otros problemas circulatorios 22 6,1 fracturas 20 5,5 adicción a drogas o alcohol 18 5,0 complicaciones cardiacas 12 3,3 osificación heterotópica 10 2,8 trombosis 8 2,2 osteomielitis 8 2,2 184 año 13 vol. 13 nº 2 chía, colombia agosto 2013 aquichan issn 1657-5997 tabla 3. media de discapacidad (0-100) según presencia o no de la complicación complicación grupo sí grupo no diferencias entre grupos m±de n m±de n t pvalor ic 95 % depresión 40,77 ± 17,12 146 28,14 ± 13,77 217 7,442 0,000 9,29-15,97 estrés psicológico 38,96 ± 16,83 179 27,63 ± 13,88 184 6,992 0,000 8,15-14,53 complicaciones respiratorias 46,88 ± 15,89 39 31,57 ± 15,70 324 5,748 0,000 10,07-20,55 disrreflexia autonómica 45,07 ± 16,94 45 31,54 ± 15,63 318 5,379 0,000 8,59-18,49 problemas intestinales 38,13 ± 16,18 151 29,72 ± 15,67 212 4,969 0,000 5,08-11,73 úlceras de presión 38,23 ± 16,07 140 30,07 ± 15,84 223 4,749 0,000 4,78-11,54 desnutrición – anemia 46,65 ± 16,35 24 32,27 ± 16,00 339 4,239 0,000 7,73-21,04 alteraciones posturales y deformidades 40,05 ± 16,42 75 31,44 ± 15,95 288 4,142 0,000 4,52-12,70 espasticidad 35,92 ± 16,34 227 28,71 ± 15,54 136 4,141 0,000 3,78-10,63 hombro doloroso 37,73 ± 17,44 132 30,64 ± 15,22 231 4,047 0,000 3,65-10,54 alteraciones de la presión arterial 41,22 ± 16,98 54 31,82 ± 15,91 309 3,968 0,000 4,75-14,07 infecciones urinarias 35,28 ± 16,56 248 28,77 ± 15,19 115 3,574 0,000 2,93-10,09 dolor articular – artritis 38,34 ± 17,73 100 31,27 ± 15,46 263 3,511 0,001 3,09-11,04 contracturas musculares 36,78 ± 15,80 120 31,46 ± 16,43 243 2,939 0,003 1,76-8,88 edema 36,71 ± 16,73 110 31,70 ± 16,05 253 2,702 0,007 1,37-8,67 problemas renales y vesicales 37,61 ± 17,07 69 32,18 ± 16,09 294 2,494 0,013 1,15-9,71 otros problemas circulatorios 41,44 ± 19,82 22 32,69 ± 16,04 341 2,445 0,015 1,71-15,81 aumento de peso 36,25 ± 17,85 114 31,83 ± 15,53 249 2,281 0,024 0,60-8,25 parestesias y disestesias 35,03 ± 16,98 192 31,18 ± 15,52 171 2,249 0,025 0,49-7,23 dolor crónico 35,04 ± 16,55 175 31,52 ± 16,11 188 2,055 0,041 0,15-6,90 trombosis 42,66 ± 18,26 8 33,00 ± 16,32 355 1,652 0,099 -1,84-21,16 otros problemas en la piel 35,81 ± 16,88 66 32,64 ± 16,26 297 1,421 0,156 -1,22-7,55 adicción a drogas o alcohol 37,76 ± 19,14 18 32,98 ± 16,24 345 1,206 0,229 -3,03-12,57 osificación heterotópica 37,50 ± 18,54 10 33,09 ± 16,35 353 0,837 0,403 -5,95-14,75 fracturas 35,95 ± 17,16 20 33,06 ± 16,36 343 0,768 0,443 -4,53-10,32 osteomielitis 37,22 ± 17,45 8 33,13 ± 16,39 355 0,698 0,486 -7,45-15,63 esguinces y luxaciones 35,56 ± 16,32 22 33,06 ± 16,42 341 0,692 0,489 -4,60-9,60 complicaciones cardíacas 36,32 ± 19,76 12 33,11 ± 16,29 351 0,667 0,505 -6,26-12,69 deterioro neurológico 35,28 ± 13,24 23 33,08 ± 16,60 340 0,624 0,533 -4,75-9,16 m: media; de: desviación estándar; n: cantidad; t: prueba t de student; pvalor: significancia bilateral; ic 95 %: intervalo de confianza al 95 % para la diferencia de medias. 185 relación entre complicaciones clínicas y discapacidad en población colombiana con lesión medular: resultados desde el who-das ii l julio ernesto pérez-parra y otro. tabla 4. pruebas de modelos de regresión lineal simple para cada una de las variables que componen el modelo final variable explicativa (modelo de regresión lineal simple) resumen del modelo prueba global del modelo (anova) significancia de los beta r cuadrado corregida (coeficiente de determinación) error típico estimado f sig beta sig. depresión 0,141 15,201 60,239 0,000 12,629 0,000 estrés psicológico 0,117 15,405 49,151 0,000 11,338 0,000 complicaciones respiratorias 0,081 15,717 33,036 0,000 15,311 0,000 problemas intestinales 0,064 15,886 24,689 0,000 8,406 0,000 úlceras de presión 0,056 15,93 22,549 0,000 8,157 0,000 desnutrición anemia 0,045 16,025 18,054 0,000 14,382 0,000 espasticidad 0,043 16.044 17,15 0,000 7,205 0,000 alteraciones posturales y deformidades 0,043 16,044 17,155 0,000 8,614 0,000 hombro doloroso 0,041 16,06 16,377 0,000 7,091 0,000 disreflexia autonómica 0,039 16,074 15,715 0,000 5,451 0,000 alteraciones de la presión arterial 0,039 16,074 15,744 0,000 9,407 0,000 dolor articular – artritis 0,035 16,112 13,939 0,000 7,067 0,000 infecciones urinarias 0,031 16,137 12,772 0,000 6,506 0,000 contracturas musculares 0,021 16,227 8,64 0,003 5,322 0,003 edema 0,017 16,257 7,302 0,007 5,017 0,007 problemas renales y vesicales 0,014 16,281 6,219 0,013 5,431 0,013 otros problemas circulatorios 0,014 16,286 5,978 0,015 8,759 0,015 aumento de peso 0,013 16,291 5,766 0,017 4,424 0,017 parestesias y disestesias 0,011 16,307 5,059 0,025 3,856 0,025 dolor crónico 0,009 16,325 4,224 0,041 3,524 0,041 43 55 significado de las practicas.indd 43 maribel muñoz-henríquez1 myriam patricia pardo-torres2 signifi cado de las prácticas de cuidado cultural en gestantes adolescentes de barranquilla (colombia)3 1 ministerio de salud, colombia. marmuh3815@hotmail.com 2 universidad nacional de colombia, colombia. mppardot@unal.edu.co 3 artículo original derivado de la investigación: significado de las prácticas de cuidado de sí y de su hijo por nacer, en un grupo de gestantes adolescentes de barranquilla. recibido: 03 de febrero de 2014 enviado a pares: 03 de marzo de 2014 aceptado por pares: 09 de septiembre de 2015 aprobado: 09 de noviembre de 2015 doi: 10.5294/aqui.2016.16.1.6 para citar este artículo / to reference this article / para citar este artigo muñoz-henríquez m, pardo-torres mp. significado de las prácticas de cuidado cultural en gestantes adolescentes de barranquilla. aquichan. 2016;16(1): 43-55. doi: 10.5294/aqui.2016.16.1.6 resumen objetivo: describir el significado de las prácticas de cuidado cultural en un grupo de gestantes adolescentes asistentes al control prenatal del hospital niño jesús de barranquilla, colombia, y de su hijo por nacer. método: estudio cualitativo etnográfico, en el que se aplicó el concepto propuesto por leininger. las participantes fueron: 10 gestantes adolescentes entre 15 y 19 años, y 12 enfermeras con experiencia en el área. las primeras como informantes clave, y las segundas como informantes generales. resultados: el significado de las prácticas de cuidado cultural, para las gestantes adolescentes, se clasifica en tres temas: 1) prácticas de cuidado transmitidas de generación en generación, predominando la línea femenina; 2) la confianza en dios y el apoyo de la familia como una forma de cuidarse; 3) dar a luz un hijo sano. conclusiones: las prácticas de cuidado de las gestantes adolecentes están enraizadas en sus creencias, mitos y valores culturales heredados de generación en generación, lo que muestra patrones de cuidado cultural. este aspecto debe ser identificado por enfermería para ofrecer cuidados que sean culturalmente congruentes con esta población. palabras clave significado; cuidado cultural; adolescente; mujer embarazada; etnoenfermería; cultura (fuente: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 43-55 44 aquichan issn 1657-5997 año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 43-55 what cultural care practices mean to pregnant teenagers in barranquilla (colombia) abstract objective: describe what cultural care practices mean for a group of pregnant teenagers receiving prenatal care at the hospital niño jesús in barranquilla (colombia) and for their unborn children. method: this is a qualitative ethnographic study in which the concept proposed by leininger was applied. the participants included 10 pregnant teenagers between 15 and 19 years of age, and 12 nurses with experience in the area. the teenagers took part as key informants and the nurses, as general informants. results: the meaning of cultural care practices for pregnant teenagers is classified according to three themes: 1) care practices handed down from generation to generation, predominantly through the female line; 2) trust in god and support from the family as a type of care; 3) giving birth to a healthy child. conclusions: the care practices of pregnant teenagers are rooted in their beliefs, myths and the cultural values handed down from one generation to the next, all of which reveal cultural care patterns. nursing should identify this aspect in an effort to provide care that is culturally congruent with this population. keywords meaning; cultural care; teenager; pregnant women; ethnonursing; culture (source: decs, bireme). 45 significado de las prácticas de cuidado cultural en gestantes adolescentes de barranquilla (colombia) l maribel muñoz-henríquez, myriam patricia pardo-torres significado das práticas de cuidado cultural em gestantes adolescentes de barranquilla (colômbia) resumo objetivo: descrever o significado das práticas de cuidado cultural num grupo de gestantes adolescentes participantes do controle pré-natal do hospital niño jesús de barranquilla (colômbia) e de seu filho que está por nascer. método: estudo qualitativo etnográfico, no qual se aplicou o conceito proposto por leininger. as participantes foram: dez gestantes adolescentes entre 15 e 19 anos, e 12 enfermeiras com experiência na área. as primeiras como informantes-chave, e as segundas, como informantes gerais. resultados: o significado das práticas de cuidado cultural para as gestantes adolescentes se classifica em três temas: 1) práticas de cuidado transmitidas de geração em geração, com predomínio da linha feminina; 2) a confiança em deus e o apoio da família como uma forma de se cuidar; 3) dar à luz um filho saudável. conclusões: as práticas de cuidado das gestantes adolescentes estão enraizadas em suas crenças, mitos e valores culturais herdados de geração em geração, o que mostra padrões de cuidado cultural. esse aspecto deve ser identificado por enfermagem para oferecer cuidados que sejam culturalmente congruentes com essa população. palavras-chave significado; cuidado cultural; adolescente; mulher grávida; etnoenfermagem; cultura (fonte: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 43-55 46 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 introducción la adolescencia es una etapa importante en el ciclo vital de la mujer, que puede hacerse difícil cuando va acompañada de un evento muchas veces no esperado, como la gestación. en diversos estudios, en los que se ha explorado el impacto de la gestación en los procesos de salud-enfermedad materna y neonatal, se ha encontrado que dicho impacto es más relevante cuando se trata de una gestante adolescente. al comparar datos estadísticos sobre gestación en adolescentes y en mujeres adultas, se observa que se presentan más complicaciones médicas en la adolescente, viéndose afectada la salud materna y la del niño por nacer, debido a que el riesgo aumenta por la edad y la inmadurez de su cuerpo. en este sentido, algunos autores afirman que las adolescentes tienen mayor probabilidad de desarrollar complicaciones durante la gestación en comparación con las mujeres adultas (1-3). lo anterior indica que las gestantes adolescentes se constituyen en una población vulnerable, y que la maternidad en esta etapa de la vida determina un evento de alto riesgo (4), que requiere cuidados específicos que pueden ser practicados por las mismas gestantes adolescentes desde el ámbito de su cultura, o proporcionados por enfermería desde una perspectiva profesional. desde una óptica cultural, la maternidad frecuentemente involucra creencias, mitos, valores y prácticas tradicionales que se traducen en patrones culturales. estos patrones, generalmente, son producto de costumbres ancestrales que se heredan de generación en generación, y cuyas raíces se mantienen vigentes durante el desarrollo del ciclo vital de la persona. por ello, el cuidado en la gestación, como patrón cultural, involucra a la familia y está rodeado de elementos culturales encaminados a favorecer la salud de la madre y de su hijo, con el fin de prevenir complicaciones en ambos. estudios previos como el realizado por zambrano (3), rátiva y ruiz (5) y parra et al. (6), muestran que las gestantes adolescentes realizan dos tipos de prácticas: prácticas de cuidado beneficiosas en pro de la promoción de su salud y la de su hijo por nacer, y prácticas no beneficiosas que quizás son atribuidas al desconocimiento y a tradiciones culturalmente aceptadas. por otra parte, el estudio de garcía revela que en el grupo de gestantes adultas existían diferencias significativas en las prácticas de cuidado, y específicamente en las dimensiones de estimulación prenatal, higiene, cuidados personales, alimentación y consumo de sustancias no beneficiosas, comparadas con las gestantes adolescentes (7); hallazgo similar al encontrado por parra et al. (6). en razón de lo anterior, es importante que el profesional de enfermería se interese por el cuidado de la futura madre adolescente, el contexto bajo el cual se desarrolla y su familia, de manera que se conozcan las diferentes formas culturales en las que se concibe el cuidado de sí mismas y de su hijo por nacer, frente a la educación que se les imparte en el control prenatal. al respecto, leininger afirma que una de las formas para lograrlo, es brindando cuidados que sean culturalmente congruentes. es decir, teniendo en cuenta su contexto, sus creencias, el conjunto de valores, los estilos de vida y las prácticas tradicionales (8, 9). el presente estudio tuvo como objetivo describir el significado de las prácticas de cuidado cultural en un grupo de gestantes adolescentes asistentes al control prenatal del hospital niño jesús de barranquilla y de su hijo por nacer. metodología se desarrolló un estudio cualitativo de tipo etnográfico, en el que se utilizó el método de la etnoenfermería propuesto por leininger. este método permite ingresar en el mundo de la gestante adolescente y sus experiencias relacionadas con el cuidado cultural, los símbolos, las ideas, las creencias, los valores y las prácticas. además, facilita el descubrimiento de hechos escondidos y desconocidos en la cultura y el cuidado desde la perspectiva émica de las personas, de manera que puedan ser comparados con el conocimiento profesional de enfermería (8, 10). la muestra fue determinada con base en los criterios propuestos por leininger: pertinencia, adecuación, conveniencia, oportunidad y disponibilidad hasta cumplir con los criterios de saturación teórica (8). un total de 10 gestantes adolescentes entre 15 y 19 años que asistieron al control prenatal en el hospital niño jesús de barranquilla fueron las informantes clave de la investigación. asimismo, 12 enfermeras docentes, especialistas en materno-infantil, con experiencia mínima de 5 años en la atención de gestantes, fueron entrevistadas como informantes generales para afianzar y corroborar los datos suministrados por las informantes clave. posteriormente, se amplió la información a través de un grupo focal que se realizó cuando se habían entrevistado ocho gestantes adolescentes. es decir, cuando ya se contaba con 47 significado de las prácticas de cuidado cultural en gestantes adolescentes de barranquilla (colombia) l maribel muñoz-henríquez, myriam patricia pardo-torres suficiente información de las entrevistas y se había logrado la saturación por parte de las adolescentes participantes. a partir de las respuestas de las gestantes se prepararon las preguntas para las informantes generales. es importante resaltar que ninguna de las enfermeras que participaron como informantes generales se encontraba vinculada laboralmente a la institución centro de estudio. como técnicas para la recolección de la información se utilizaron la observación-participación-reflexión, la entrevista semiestructurada, las notas de campo y los facilitadores, como son: facilitador extraño-amigo y facilitador del modelo del sol naciente (8). para el desarrollo de la investigación, se contó con el aval del comité de ética de la universidad nacional de colombia. de igual forma, se tuvieron en cuenta los principios establecidos en la ley 911 de 2004 (11), los lineamientos instituidos en la resolución 008430 de 1993 (12) y las pautas del consejo de organizaciones internacionales de las ciencias médicas (cioms) (13). por tratarse de participantes menores de edad, se garantizaron los requisitos exigidos en el código de infancia y adolescencia del que trata la ley 1098 de 2006 (14). procedimiento se captaron las gestantes adolescentes asistentes al programa de control prenatal en el hospital niño jesús de barranquilla, previo cumplimiento de criterios de inclusión. luego de que cada participante conociera y aceptara formar parte del estudio de manera voluntaria, con la firma del consentimiento informado, se concertaba la visita para realizar las entrevistas, las cuales se llevaron a cabo en el domicilio de la participante. como parte de la inmersión al campo, primeramente se inició la observación. con este facilitador, el investigador se movió gradualmente de la observación a la participación, y aún más, a la reflexión, la cual ayuda al investigador a enfocarse en los aspectos contextuales antes de la interpretación de una idea y confirmación de los datos. seguidamente, se iniciaron las entrevistas etnográficas con el objetivo de confirmar los datos. a cada una de las informantes clave se le realizaron de dos a tres entrevistas con un tiempo de duración de 45 minutos a 1 hora aproximadamente. cada una de las entrevistas fue grabada y transcrita fielmente, por el mismo investigador, en las primeras 24 horas posteriores a la grabación. la entrevista implicó de dos a tres encuentros con la misma adolescente gestante; cada entrevista se inició con una pregunta general, luego preguntas estructurales, y, finalmente, preguntas de contraste. todos estos interrogantes permitieron seleccionar los datos más significativos, verbales y no verbales, que se constituyeron en insumos para identificar los acontecimientos más relevantes. durante el proceso, se mantuvo contacto constante y buenas relaciones con personas expertas en el tema. simultáneamente a la inmersión al campo, se fue procesando la información en una matriz de datos, que facilitó la organización y el análisis de los mismos, junto con las notas de campo que contenían análisis y reflexiones. para ello, se tuvo en cuenta la guía de análisis de las fases del método de la etnoenfermería propuesta por leininger (10). posterior a la transcripción de las entrevistas, se les daba una copia impresa a las participantes para confirmar los datos y revisar su credibilidad e información. esto se hacía con el fin de que ellas avalaran lo escrito a partir de sus participaciones durante el proceso de investigación. la investigadora siempre mantuvo la precaución de registrar todo lo que se compartió con las participantes y trató de captar vínculos comunes y diversos sobre el cuidado humano. el proceso de análisis de los datos se realizó de una forma detallada y rigurosa cumpliendo con los criterios de credibilidad, patrones recurrentes, confirmabilidad y los significados en contexto (figura 1). figura 1. fases del proceso de análisis de la información fuente: guía de análisis de las fases del método de la etnoenfermería de leininger (7). 48 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 resultados después de realizar el análisis de los datos obtenidos en las diferentes entrevistas, utilizando la guía de análisis de las fases del método de la etnoenfermería propuesto por leininger (figura 1), se encontró que el significado de las prácticas de cuidado cultural, para las gestantes adolescentes, se clasifica en tres grandes temas: 1) prácticas de cuidado transmitidas de generación en generación predominando la línea femenina, 2) la confianza en dios y el apoyo de la familia como una forma de cuidarse, y 3) dar a luz un hijo sano. a continuación se describen cada uno de los temas. tema 1. prácticas de cuidado transmitidas de generación en generación predominando la línea femenina se observó que cuando las adolescentes se apropian de su proceso de gestación, inician una serie de cuidados consigo mismas y con su hijo por nacer. dichos cuidado son retomados del contexto en el cual se desenvuelven, es decir, los aprenden de las mujeres que las rodean, entre ellas la madre, las cuñadas, la abuela y la suegra, quienes con su experiencia transmiten legados intergeneracionales. de esta manera, las gestantes adolescentes aprenden técnicas y cuidados básicos para cuidarse a sí mismas y a su bebé. el objetivo principal de estos cuidados está encaminado a llevar a feliz término el proceso de gestación, que el niño nazca sano y en el futuro no presente complicaciones. estos cuidados los realizan no solamente con el apoyo de la familia, sino que también aprenden de las mujeres de la comunidad, las cuales, según las participantes, “tienen experiencia”. ella como madre que también tuvo cinco hijos, ella también tiene mucha experiencia. ella me aconseja de lo que debo y lo que no debo hacer. está susana a. que es una amiga de nosotras aquí en la casa, que ella ha tenido tres hijos y ella también tiene mucha experiencia y me ha dado muchos consejos que los he valorado y cada consejo tiene su significado, entonces ¡son cosas importantes que no se deben olvidar! (7 ag) con respecto a la gestación, hay mitos que se han socializado de generación en generación, y es por eso que se dice que es algo vivido por las mujeres que ya han pasado por la experiencia de un embarazo. las adolescentes gestantes de este estudio, que vivían con la mamá, la suegra y la abuela, recibían de parte de ellas los consejos y las recomendaciones ancestrales, arraigadas en creencias culturales, mitos y prácticas cotidianas, los cuales se sostienen de generación en generación. durante la investigación, se encontró que la mayoría de las adolescentes gestantes se cuidan de sentarse en el piso frío, porque para ellas eso significa que tendrán problemas a la hora del parto. uno de ellos es que se les “pegue la placenta”, lo que les causa temor porque ellas quieren que su parto sea normal. bueno, acerca de este cuidado me ha hablado mi suegra y mi mamá porque son personas con experiencia, mis vecinas también me lo han dicho que no me siente en el piso ya que aunque se sientan frío siempre votan un fogaje y cuando están calientes no puedo estar sentada por eso como lo digo se me pega la placenta. (9 s) pues mi abuela que no me siente ni en el piso caliente ni en el piso frío porque eso, más en el piso caliente porque me puedo inflamar y en el piso frío porque puedo coger frío en la matriz. (6 yg) las participantes consideran de suma importancia el caminar, y lo hacen para evitar que el bebé se “pegue en la placenta”, y permitir que su parto sea más rápido. estas prácticas de cuidado las reciben apoyándose en las creencias de la madre, la suegra y las abuelas que ya vivieron esta experiencia. yo creo que eso es ya como un mito, “yo creo que caminar es para que no se le pegue la placenta a uno”, entonces por eso lo hago, yo creo que todo el mundo sabe ya eso, eso es popular ya, entonces por eso lo hago. (5 j) …eso sí me lo ha dicho mi mamá porque ella dice que ya ella ha tenido experiencia de eso, tuvo cuatro hijos, y ella dice que no, que lo mejor es mantenerse en movimiento como caminando, barriendo, así, o sea no agitarse mucho, pero sí mantenerse en el día haciendo cualquier cosa, no acostado ni sentado, porque ella tuvo cuatro hijos y todos los tuvo normales; y ella dice que eso es lo mejor, para que todo salga más rápido. (3 lp) al respecto, las informantes generales profundizaron según su experiencia de lo que ellas, a partir de la práctica, ven que hacen las adolescentes embarazadas para cuidarse: 49 significado de las prácticas de cuidado cultural en gestantes adolescentes de barranquilla (colombia) l maribel muñoz-henríquez, myriam patricia pardo-torres realmente los esfuerzos son primarios debido a su nivel escolar y el afianzamiento de sus responsabilidades son mínimamente alcanzadas puesto que las abuelas, madres y tías de la adolescentes asumen más esta responsabilidad que la propia joven quien se considera inexperta y por eso se deja cuidar y hace lo que el entorno le recomienda, como son las prácticas de cuidado según las creencias y tradiciones de las mujeres de su comunidad. de acuerdo con hernández (15), el concepto de “vivencia” es un prisma a través del cual se debe releer y reestructurar el viejo conocimiento, y mirar y construir el nuevo saber psicológico; de esta manera, las vivencias pueden ser almacenadas en la memoria humana y pueden ser activadas o traídas ante experiencias actuales que contengan elementos similares a las que les dieron origen. en palabras de robinson, es una unidad de sentido productora de emociones que integra lo consciente e inconsciente en las configuraciones subjetivas del sujeto (16). la experiencia contribuye sensiblemente a la sabiduría. una mejor manera de adquirir sabiduría, y que además ahorra tiempo, es beneficiarse y aprender de la experiencia de los que ya son sabios, prefiriendo su compañía a la de los inexpertos. las creencias han sido definidas como un conjunto de cogniciones que la gestante tiene acerca de cualquier aspecto de la realidad; creencias profundamente enraizadas, en las cuales se tiene una fe ciega y que, por tanto, se ven expresadas en las prácticas de cuidado que las mujeres en gestación realizan para preservar la salud de ellas y sus hijos por nacer (17, 18). entonces, ahora que tengo los ocho meses, me dijeron y que ¡no comas tanto! porque después no vas a poder parir el bebé, sino te van tener que rajar. mi abuela, mi abuela es una que me dice ¡no comas tanto porque el niño va a salir muy grande y no vas a poder! y te van a tener que picar. (10 am) el hecho de evitar esfuerzos físicos al levantar pesos, el temor de sentarse en el piso frío o caliente, el no consumir ciertos alimentos para proteger a su hijo, y el mantenerse en constante actividad para que su bebé no se “pegue” a la hora del parto, son prácticas de cuidado comúnmente realizadas en el grupo de mujeres participantes en esta investigación, prácticas que fueron transmitidas por línea femenina en la familia. dichas prácticas son mencionadas por leininger dentro de los factores socioculturales en su modelo del sol naciente (8, 19). tema 2. la confianza en dios y el apoyo de la familia como una forma de cuidarse al hablar de cuidado en las adolescentes gestantes, no se puede dejar de lado su componente espiritual. las sagradas escrituras refieren que el ser humano es espíritu, alma y cuerpo (20). el cuerpo con el que somos conscientes del mundo, el alma con la que somos conscientes de nosotros mismos, y el espíritu con el que somos conscientes de dios. según rodríguez (21) y morales (22), existe una asociación entre la espiritualidad y la salud. al respecto, king et al. (23) y valiente y garcía (24) refieren que la evidencia deja ver que las prácticas espirituales, y en especial las que se realizan dentro del marco de una cultura religiosa organizada, se asocian con mejores estados de salud, menor depresión, mejores hábitos y menor mortalidad. este patrón surgió en el grupo de adolescentes gestantes debido a todas las situaciones que ellas tienen que sobrellevar y adaptarse, y a las nuevas responsabilidades que deben asumir. ellas buscan refugio en un ser superior, tal como lo expresa leininger en su teoría (8). para ellas, el creer en dios y acoger su palabra en expresiones como: “venid a mi todos los que estáis trabajados y cargados y yo os haré descansar” (20), les genera esperanza y descanso desde el punto de vista espiritual, y ello les permite lograr un equilibrio integral. ella y yo le pedimos mucho a dios y me he encomendado mucho a dios y le he pedido a dios que me ayude, que me dé fuerza para lo que estoy enfrentando y para lo que tengo que enfrentar de ahora en adelante, que siempre esté conmigo, que nunca me deje sola, siempre tenemos a dios, en primera parte es a dios. (7 ag) las mujeres de la familia se aseguran de que las gestantes den continuidad a los conocimientos, valores e intereses que los distinguen como grupo, todo esto se logra mediante la transmisión de sus costumbres y tradiciones. las adolescentes gestantes saben que deben cuidarse y cuidar a su hijo por nacer: una de las maneras de cuidarse, según lo expresado, es colocarse en manos de dios. esto significa para ellas que todo va a salir bien y que su hijo no va a tener ninguna clase de problema. “entonces digo que es una forma de cuidar a mi bebé refugiándome en dios que yo confío mucho en dios, yo sé que dios nos ampara de todo mal y de todo peligro” (8 s). 50 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 estas afirmaciones fueron confirmadas por las informantes generales en la entrevista y grupo focal: el ser humano por naturaleza tiene la sensación y experiencia de que hay un ser superior y a ese ser o a esa creencia se aferra en sus momentos de mayor vulnerabilidad. en el caso específico de la gestante adolescente, el temor invade su vida ya que no está preparada físicamente, ni emocional para esta nueva etapa, por lo cual se aferran a dios para que las cuide y salgan bien de todo esto, es decir que el aferrarse a dios se puede considerar como una forma de cuidarse. la espiritualidad es un eslabón importante en la práctica de cuidado, independiente de las creencias propias de cada uno, el ser humano es un ser biopsicosocial, y la creencia hacia algo o alguien permite que aunque el camino se halle lleno de obstáculos eso da una fuerza para avanzar. para ellas es importante la parte espiritual, se aferran a dios y colocan su bebé en sus manos, sí es importante porque para ellas existe un dios que todo lo puede y las fortalece y que gracias a la fe podemos encontrar que su embarazo culmina favorablemente por la fe que han depositado en el señor. al aferrarse a dios ellas se están cuidando a su manera por las creencias que les ha transmitido su familia, especialmente las mujeres que son más creyentes que los varones. las creencias espirituales le permiten a las gestantes entender su lugar en el mundo. al vivir estas experiencias, ellas se sienten en armonía, tranquilas, es el apoyo que ellas tienen frente a la situación que están viviendo, y todo esto lo manifiestan a través de valores, ritos, creencias. por tanto, es en este momento donde el profesional de enfermería debe extender su mano, dedicarles tiempo, escucharlas, debido a los muchos sentimientos encontrados por los que atraviesan, a sus temores; todo esto forma parte de la cultura de las adolescentes gestantes, y es necesario conocerlo para poder proporcionar cuidados culturalmente congruentes y lograr la satisfacción de la paciente. de esta manera, el enfermero (a) irá creando empatía con la gestante para que ella pueda exteriorizar sus necesidades espirituales. por otra parte, las participantes consideran importante la aceptación de su estado de gestación en sus familias, amigos y allegados, sobre todo por el padre de su hijo que está por nacer. para ellas es muy satisfactoria la ayuda que reciben, el afecto, la atención y el apoyo económico. todo esto les permite sentirse cuidadas y, por consiguiente, más tranquilas. la información, las orientaciones y enseñanzas recibidas en su entorno familiar, social y por el equipo de salud, fortalecen sus prácticas de cuidado y la seguridad interior debido a la experiencia de estas personas. gracias a dios yo tengo a mi familia conmigo ¡apoyándome! y no tengo que estar pasando de pronto necesidades acá en el embarazo y para mí es grande! satisfactorio tener el apoyo de mi familia conmigo para un bien de mi bebé. (1 ep) el apoyo me lo brindan mi suegra y mi esposo, ellos me cuidan, me tratan con amor para que yo sienta todo lo que ellos me dicen, me apoyan, mi compañero sentimental me da amor a mí y a mi bebé, me soba la barriga, me trata con amor, me soba la barriga, no me trata con rabia, mi suegra también me trata con amor, todos aquí me tratan con amor, me cuidan para que no coja rabia ni nada. (9 a) el apoyo de la familia es de suma importancia para las gestantes, ellas necesitan que las traten con amor, que las cuidan, no sentirse rechazadas, que están pendientes de ellas. esto hace que se sientan bien y satisfechas, puesto que se les está supliendo la necesidad de amor y afecto. esto constituye una práctica de cuidado muy importante durante este periodo, pues es una forma de apoyo que las gestantes requieren por la situación que están enfrentando. durante los controles prenatales las informantes refieren que reciben información, educación y orientación del equipo de salud, en el que enfermería juega un papel importante. de igual forma, las gestantes realizan los cuidados guiados por sus familiares de acuerdo con sus creencias y experiencias. de allí la importancia de que enfermería conozca las prácticas de cuidado cultural de este grupo de gestantes y brinde cuidados que permitan hacer sentir a las gestantes satisfechas. bueno, me atiende la enfermera jefe y me enseña los cuidados, que no puedo estar abierta de piernas, no coger peso, no coger rabia, no puedo estar descalza, me recomienda las pastillas para que el niño nazca completo, para que salga con calcio. (10 am) estos son cuidados valiosos en la etapa de gestación que están viviendo las informantes clave. este soporte se da en las relaciones o el intercambio y se manifiesta a través de la ayuda, el amor, el afecto, la aceptación, el respeto y, de esta manera, se sienten cuidadas, porque las ayudan en sus quehaceres, les demuestran amor, comprensión, las apoyan económicamente. apo51 significado de las prácticas de cuidado cultural en gestantes adolescentes de barranquilla (colombia) l maribel muñoz-henríquez, myriam patricia pardo-torres yo que las lleva a sentir confianza y satisfacción, y contribuye a reducir el estrés, la ansiedad, los temores propios de la situación que están viviendo. además, las gestantes se apoyan en la atención y los cuidados que se les brindan en el control prenatal. enfermería debe capitalizar este espacio para ofrecer un cuidado holístico, humanizado y culturalmente coherente, teniendo en cuenta el entorno cultural y la influencia que este tiene en las gestantes adolescentes que acuden a su consulta. tema 3. dar a luz un hijo sano las gestantes adolescentes siempre manifiestan una prioridad, y es que su hijo nazca sano. los cuidados que tienen de sí mismas y de su hijo por nacer van en dirección a esta meta. ellas buscan la asesoría de otras mujeres como su madre, suegra, abuela, que ya tienen la experiencia sobre los cuidados del embarazo, cuidados basados en creencias y vivencias. y además se apoyan en los cuidados que les enseña el personal de salud. para ellas, “alimentarse bien” significa consumir alimentos que ayuden en el crecimiento y desarrollo del niño, que contengan calcio y proteínas, alimentos preparados en casa; es decir, seguir una dieta balanceada. la alimentación es un pilar fundamental del cuidado de la gestante, por la necesidad de crecimiento y desarrollo fetal a partir de los nutrientes y los atributos asociados a los mismos, que en ocasiones constituyen valores o parte del legado que la gestante transmite durante la gestación a su hijo (18). bueno, una buena alimentación significa para mí alimentarme bien: con minerales, con proteínas, con lácteos, con granos, con todo lo que lleva una buena alimentación; que todo lleve vitaminas, lo principal de todo las frutas, los lácteos, también yogures, la leche es importante en este estado de embarazo. (7 ag) las gestantes se cuidan consumiendo alimentos ricos en calcio y los medicamentos que lo contienen, por las recomendaciones que reciben del personal de salud y de la madre que siempre está al cuidado de su hija. para las gestantes adolescentes, consumir estos alimentos ricos en calcio significa que están cuidando su salud y protegiendo la salud de su bebé. que tengo que consumir calcio porque hay veces que la dentadura se daña porque el bebé se roba todo el calcio que uno consume, entonces ella siempre me decía: “consume calcio para que el bebé te nazca bueno, que nazca sano y no te descalcifiques tú al momento del parto”. (4 mf) en este grupo de gestantes el consumo de frutos rojos para aumentar la hemoglobina es un mito arraigado en su cultura. ellas consumen esta clase de frutas rojas para aumentar su hemoglobina y estar preparadas para el parto, además de evitar complicaciones derivadas de la hemorragia. ellas escuchan las recomendaciones de las mujeres que tienen experiencia, y uno de los consejos que reciben es que deben consumir alimentos como mora, agraz, remolacha, cañandonga. me dicen que coma hígado porque es eso es bueno que me da sangre, que tome jugo de mora. a mí, mi suegra me compra agraz porque eso es bueno para la hemoglobina mía y del bebé, porque el bebé tiene que recibir sangre. (9 a) la literatura reporta que este tipo de frutas no solamente proveen agua, vitaminas y fibras, sino que también actúan como antioxidantes. sí, ha cambiado mucho, porque yo antes no le paraba bolas, si comía o no. comía pura harina, no comía granos, ni jugos, pura gaseosa. ¡pero ahora sí cambié para que el bebé esté bien! (10 am) el consumo de comida chatarra es visto como dañino por la alta carga de harinas, salsas y grasas. esta percepción es fortalecida por las orientaciones que reciben de parte de las mujeres de la familia y las madres. mi alimentación antes de yo salir embarazada era totalmente desordenada, ¡si comía bien si no también!... y yo comía mucha chatarra, gaseosas, bebidas negras, especialmente la coca cola. (8 s) mi suegra me dice que eso es malo para mí y para el bebé y yo no tomo alcohol por eso, porque después el niño me vaya a salir con alguna dificultad o alguna enfermedad. (par 9 a) los valores, las creencias y los hábitos de vida a los que se refiere leininger están arraigados en este grupo de adolescentes gestantes, los cuales emergen del diario vivir y cada día cobran fuerza por los resultados que ellas consideran que han sido beneficiosos durante la gestación y en el momento del parto, pues se protegen ellas y a sus hijos por nacer. algunas de estas prácticas de cuidado se podrían negociar o modificar, pero otras se deben conservar. 52 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 en las investigaciones que se han realizado sobre estimulación intrauterina, se ha demostrado que esta práctica es beneficiosa para el feto porque se potencializa su capacidad cognitiva, emocional y social, generando un ser humano más crítico y adaptable, excepcionalmente dotado de inteligencia emocional (25-29). bueno, hablarle para que él salga inteligente, salga y conozca quién es su mamá, que cuando yo le hable el entienda quién es su mamá, quién le habla, le hablo mucho, [...] y mi esposo también, le hablamos mucho. (10 am) mi abuela, cuando me ve peleando con mis hermanas, “niña deja de gritar que el peladito va a salir espantao, ¿tú crees que cuando gritas él no se asusta?” (6 yg) me dicen ¡no cojas rabia!, ¡no llores!, porque todo lo que sientes el bebé lo siente, entonces tú vas a estar cogiendo rabia, el corazoncito se le puede disparar, o no llores porque él siente que tú estás triste y te puede salir así todo triste. (10 am) el bebé es totalmente dependiente de su madre, en sus dimensiones física, emocional y psicológica. ellos están en una etapa de desarrollo que requiere mucho cuidado con el tipo de ambiente y las influencias que reciben. asimismo, la estimulación del bebé durante el periodo prenatal es importante para el desarrollo mental y sensorial del recién nacido. su significado más profundo es el de construir un elemento modelador del desarrollo del ser humano, y, por ende, de la sociedad (6). cuidados generales las gestantes adolescentes manifiestan que se cuidan de diferentes formas: bañarse varias veces al día, usar ropa holgada, levantar los pies, descansar, caminar, cuidados con la piel. estos cuidados los realizan para protegerse ellas y a su hijo por nacer. estas prácticas las realizan porque reciben los consejos y las recomendaciones de las mujeres que están cerca de ellas, las cuales tienen mucha experiencia, sin menospreciar las enseñanzas que reciben en su control prenatal. las adolescentes gestantes saben que por una infección vaginal se les puede adelantar el parto, por lo que les ha ocurrido a otras personas; por eso se cuidan con su higiene corporal: “porque si no me mantengo limpia puedo tener alguna infección y eso puede, la infección puede traerme problemas a mi bebé y se me puede adelantar el parto”. (par 6 yg) los baños diarios de las embarazadas son convenientes para mantener una buena higiene. además, se aconseja ampliar las prácticas de higiene de los genitales externos debido al aumento de las secreciones —la sudoración y el flujo vaginal— durante el embarazo. en la región caribe, las mujeres tienden a bañarse más por causa del calor, de esta manera se refrescan más. las prácticas de ejercicio suave ayudan a mejorar el proceso circulatorio, previenen o controlan la aparición de varices, mejoran la condición muscular que favorece el trabajo de parto, previenen una ganancia exagerada de peso, favorecen la relajación y mejoran la oxigenación de los tejidos (30-34). sí, así me dicen, ahora más dicen que trate de hacerlo, que camine, que va a salir más rápido el bebé, que entonces va a estar pegado, que estoy sentada y que va a estar ahí pegado y que no va a querer salir. (1 ep) otro cuidado que tienen muy en cuenta es que evitan levantar objetos pesados porque creen que el bebé se les puede desprender: “no me deja levantar cosas pesadas porque me dice que no debo hacer fuerza y después se me sale el niño, entonces yo les hago caso”. (9 a) el vestuario que usa la gestante debe ser cómodo, no debe estar ajustado al cuerpo, y a medida que avanza el embarazo, los vestidos deben ser más anchos, con la finalidad de no comprimir el abdomen ni las mamas. el brassier debe ser cómodo para evitar que se dificulten los movimientos respiratorios. el tacón de los zapatos debe ser bajo y cómodo. bueno yo no utilizo esa clase de vestidos tan apretados porque pues me han dicho que es malo, porque de pronto tanto apretarse uno este… el niño puede salir defectuoso, puede salir con la naricita [se pone un dedo sobre la nariz] porque como ellos están tan vichecitos que cualquier cosita que les apriete pues por eso no me los pongo. (3 lp) conclusiones esta es una oportunidad para fortalecer la disciplina y la práctica, apropiándose de la enfermería transcultural como herramienta útil para ampliar los conocimientos del profesional sobre las creencias y las prácticas culturales de cuidado relacionadas con la salud, que forman parte de las experiencias procedentes de las gestantes adolescentes de barranquilla. 53 significado de las prácticas de cuidado cultural en gestantes adolescentes de barranquilla (colombia) l maribel muñoz-henríquez, myriam patricia pardo-torres con el presente estudio las investigadoras tuvieron la oportunidad de explorar, entender y aprender las bases culturales de los cuidados que tienen las gestantes adolescentes con miras a ofrecer un cuidado holístico a este grupo cultural en su ambiente cotidiano. la mayoría de las prácticas realizadas por las informantes clave en la investigación son favorables para ellas y su hijo por nacer. la enfermera no debe desconocer estas prácticas de cuidado de las adolescentes gestantes, sino concientizarse de las mismas como parte de la construcción social de la realidad de la gestante. de esta manera, enfermería visualizará el cuidado émico, en la medida que los cuidados de la gestación en este grupo cultural están influenciados por elementos arraigados en la estructura social, familiar y espiritual, y se trasmiten de generación en generación. enfermería debe apropiarse de estos conocimientos y de los conocimientos propios “étic”, para integrar estos dos tipos de saberes y proporcionar cuidados que den seguridad a las mujeres que acuden al servicio de salud. cuidados eficaces y coherentes con su cultura, que permitan evitar confrontaciones derivadas de choques culturales. entre los patrones recurrentes develados en la presente investigación, y que podrían reestructurarse con acciones propias de enfermería, como la educación para la salud, están: • el valor nutritivo real de algunos alimentos. • fortalecer la educación en estimulación prenatal, debido a que las gestantes adolescentes no realizan todas las prácticas que tienen que ver con la misma. en la investigación se encontró que realizan prácticas orientadas básicamente a la estimulación de dos sentidos: el oído y el tacto. la primera la hacen a través de prácticas como hablarle al feto y colocarle música. la segunda, por medio del masaje en el abdomen. • las prácticas de higiene, especialmente de los genitales. es necesario clarificarles la forma de hacerlo, los elementos y la frecuencia con que este aseo debe practicarse, por el riesgo de alterar la flora vaginal normal, lo cual puede generar complicaciones. • aclarar los elementos que tienen que ver con complicaciones en el parto, como la retención de la placenta. • mejorar el conocimiento de las gestantes en relación con las propiedades benéficas de la actividad física, y la frecuencia y el tiempo durante el cual se debe realizar. para las gestantes adolescentes que participaron en este estudio, el significado de las prácticas de cuidado cultural consigo mismas y con su hijo por nacer, está evidenciado en los tres temas principales identificados, en los cuales se refleja la semejanza y diferencia con otras investigaciones relacionadas con el tema. dichas prácticas están fuertemente enraizadas en creencias, mitos y valores. es decir, están rodeadas de un saber cultural que ha pasado de generación en generación, mostrando patrones de cuidado cultural. financiamiento. los recursos para el desarrollo de este estudio provinieron de las siguientes fuentes: recursos propios, apoyo de la universidad simón bolívar y universidad nacional de colombia. conflicto de intereses. ninguno declarado. agradecimientos. a las adolescentes gestantes, por permitirnos trabajar con ellas y conocer su cultura, y al msc yeis miguel borré ortiz por sus significativos aportes al manuscrito. 54 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 referencias 1. huang ch-ch, lin y-ch, huang y-t, huang k-h. comparison of medical issues in antenatal and perinatal periods in early youth, adolescent, and young adult mothers in taiwan: a 10-year nationwide study. bmc pregnancy and childbirth [internet]. 2014 [citado 2015 ago 30]; 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psicoprofilaxis obstétrica: actualización, definiciones y conceptos. horiz med. 2014;14(3):53-57. 30. arévalo e. gestación y prácticas de cuidado. av enferm. 2007;25(2):50-57. 31. mata f, chulvi i, roig j, heredia jr, isidro f, benítez jd, guillén m. prescripción del ejercicio físico durante el embarazo. rev andal med deporte. 2010;3(2):68-79. 32. suárez dp, muñoz de rodríguez l. la condición materna y el ejercicio en la gestación favorecen el bienestar del hijo y el parto. av enferm. 2008;26(2):51-58. 33. romero-morante m, jiménez-reguera b. actuación del fisioterapeuta durante la gestación, parto y posparto. fisioterapia. 2010;32(3):123-130. 34. szymanski lm, satin aj. exercise during pregnancy: fetal responses to current public health guidelines. obstet gynecol. 2012;119(3):603-610. 486 498 validacion de la escala rapid.indd 486 aquichan issn 1657-5997 j. carola pérez1 claudia bustamante2 solange campos3 hugo sánchez4 angela beltrán5 margarita medina6 validación de la escala rapid assessment of physical activity (rapa) en población chilena adulta consultante en atención primaria 1 doctora en psicología. universidad del desarrollo, chile. janetperez@udd.cl 2 magíster en enfermería. pontificia universidad católica de chile, chile. cqbustam@uc.cl 3 magíster en psicología. pontificia universidad católica de chile, chile. scamposr@uc.cl 4 magíster en salud pública. universidad de chile, chile. hsanchez@inta.uchile.cl 5 socióloga. ayudante de investigación proyecto fonis modelo de atención remota de apoyo a las personas con prediabetes, chile. paxbeltran@gmail.com 6 enfermera-matrona. centro de salud familiar josé alvo, la florida, chile. mmedina@comudef.cl recibido: 18 de julio de 2013 enviado a pares: 10 de agosto de 2013 aceptado por pares: 19 de abril de 2015 aprobado: 04 de mayo de 2015 doi: 10.5294/aqui.2015.15.4.4 para citar este artículo / to reference this article / para citar este artigo pérez jc, bustamante c, campos s, sánchez h, beltrán a, medina m. validación de la escala rapid assessment of physical activity (rapa) en población chilena adulta consultante en atención primaria. aquichan. 2015; 15 (4): 486-498. doi: 10.5294/aqui.2015.15.4.4 resumen introducción: la práctica de actividad física es esencial para el cuidado de la salud. se requiere contar con instrumentos que permitan medirla y monitorear los cambios en las personas que la practican. objetivos: adaptar culturalmente el cuestionario rapid assessment of physical activity (rapa), y estimar sus propiedades psicométricas, su validez y confiabilidad, para medir el nivel de actividad física en personas adultas consultantes en centros de atención primaria en santiago (chile). materiales y métodos: el rapa adaptado fue aplicado a 180 adultos asistentes a 5 centros de salud. se determinó su índice de masa corporal (imc) y circunferencia de cintura (cc). resultados: las puntuaciones en la escala rapa se relacionaron en forma inversa y significativa con el perímetro de cintura y el imc. las personas categorizadas con bajo nivel de actividad física (poco activo y poco activo regular ligero) presentan un imc promedio más elevado y son más frecuentemente categorizados con cc alterada. la confiabilidad del instrumento fue moderada (r = 0,61; k = 0,34). conclusiones: el rapa en su versión en español adaptada para chile, es un instrumento de fácil aplicación, que pese a su moderada confiabilidad, logra ser sensible al desarrollo de actividad física, que presenta una relación coherente con los parámetros antropométricos de imc y cc sensibles a dicha actividad. palabras clave estudios de validación, actividad motora, autorreporte, atención primaria de salud, autocuidado (fuente: decs, bireme). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 486-498 487 validación de la escala rapid assessment of physical activity (rapa) en población chilena adulta consultante en atención primaria l j. carola pérez y otros año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 486-498 validation of the rapid assessment of physical activity scale (rapa) in an adult chilean population seeking primary care abstract introduction: physical activity is vital to health care and having instruments to measure and monitor changes in people who are physically active is essential. objectives: culturally adapt the rapid assessment of physical activity (rapa) questionnaire and estimate its psychometric properties, validity and reliability as an instrument to measure the level of physical activity among adults seeking primary care at health centers in santiago (chile). materials and methods: the adapted rapa was applied to 180 adults who were being treated at five health centers. their body mass index (bmi) and waist circumference (wc) was determined. results: the scores on the rapa scale were inversely and significantly linked to waist circumference and bmi. persons categorized as having low levels of physical activity (i.e., little activity and little regular light activity) have a higher bmi, on average, and are more often categorized with altered wc. the reliability of the instrument was moderate (r = 61; k = 0.34). conclusions: the spanish language version of the rapid assessment of physical activity (rapa) questionnaire adapted for chile is a user-friendly application. despite being only moderately reliable, it is sensitive to the development of physical activity, which shows a coherent connection to the anthropometric parameters of bmi and wc that are sensitive to this kind of activity. keywords validation studies, motor activity, self-reporting, primary health care, self-care (source: decs, birime). 488 aquichan issn 1657-5997 validação da escala rapid assessment of physical activity (rapa) em população chilena idosa consultante em atenção primária resumo introdução: a prática de atividade física é essencial para o cuidado da saúde. requer-se contar com instrumentos que permitam medi-la e monitorar as mudanças nas pessoas que a praticam. objetivos: adaptar culturalmente o questionário rapid assessment of physical activity (rapa) e estimar suas propriedades psicométricas, sua validade e confiabilidade para medir o nível de atividade física em pessoas idosas consultantes em centros de atenção primária em santiago (chile). materiais e método: o rapa adaptado foi aplicado a 180 idosos frequentadores de cinco unidades de saúde. determinou-se seu índice de massa corporal (imc) e circunferência de cintura (cc). resultados: as pontuações na escala rapa se relacionaram em forma inversa e significativa com o perímetro de cintura e o imc. as pessoas categorizadas com baixo nível de atividade física (pouco ativo e pouco ativo regular leve) apresentaram um imc médio mais elevado e são mais frequentemente categorizadas com cc alterada. a confiabilidade do instrumento foi moderada (r = ,61; k = 0,34). conclusões: o rapa em sua versão em espanhol adaptada para o chile é um instrumento de fácil aplicação, que, mesmo com sua moderada confiabilidade, consegue ser sensível ao desenvolvimento da atividade física, que apresenta uma relação coerente com os parâmetros antropométricos de imc e cc sensíveis a essa atividade. palavras-chave estudos de validação, atividade motora, autorrelatório, atenção primária em saúde, autocuidado (fonte: decs, bireme). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 486-498 489 validación de la escala rapid assessment of physical activity (rapa) en población chilena adulta consultante en atención primaria l j. carola pérez y otros introducción las enfermedades crónicas presentan una alta prevalencia a nivel mundial (1). generalmente, su tratamiento considera la incorporación y realización de actividad física de manera constante (2-4). la actividad física es definida como cualquier movimiento corporal producido por los músculos esqueléticos y que resulta en gasto energético (5). en términos generales, la población chilena presenta escasos niveles de actividad física, fenómeno que también se observa en otras poblaciones latinoamericas (6-9). por ejemplo, en la última encuesta nacional de salud (2009-2010) el 88,6 % de la población chilena presentó sedentarismo en su tiempo libre. este problema presenta mayor prevalencia en los estratos bajos, en mujeres y en adultos mayores (10). dada la relevancia de la actividad física para el cuidado de la salud, se requiere contar con instrumentos de medición que permitan identificar los cambios que se van a implementar en la actividad física y realizar un adecuado seguimiento de estos. diferentes métodos se han usado con este propósito, como la observación de conductas, cuestionarios, entrevistas y marcadores fisiológicos (p. ej.: ritmo cardiaco, calorimetría, sensores de movimiento) (11-13). el gold estándar para las mediciones de actividad física es la técnica de “agua doblemente marcada” (doubly labeled water), que permite obtener el gasto de energía total de la persona. sin embargo, su uso es limitado a nivel poblacional, debido a los requerimientos técnicos y costos asociados a su uso (12, 13). en este sentido, los cuestionarios representan una buena opción como método de medición, dada la relación entre la gran cobertura lograda frente a sus limitados costos. sin embargo, sus dificultades se relacionan con la baja validez y confiabilidad (13). existen diversos cuestionarios para medir el nivel de actividad (p. ej., en español: champs, gpaq, ipaq, rapa, etc.). la mayoría de ellos han sido desarrollados para cuantificar el gasto energético asociado a la frecuencia y duración de un conjunto de actividades físicas predefinidas, siendo utilizados prioritariamente en estudios epidemiológicos (14). en chile, la encuesta nacional de salud utilizó el cuestionario de actividad física global (10) (gpaq), que evalúa la actividad física en tres dominios: trabajo, traslados y recreación. la suma de las tres actividades, permite determinar el nivel de actividad física de un individuo tanto como variable categórica (actividad física baja, moderada y alta) como variable continua (indicador de gasto energético) (15). sin embargo, también se han utilizado otros cuestionarios para mediciones a nivel poblacional (16, 17). el programa de salud cardiovascular del sistema de salud público chileno, plantea como meta para las personas que presentan patologías como diabetes tipo 2, hipertensión arterial o dislipidemias, entre otras, aumentar su práctica de actividad física, hasta alcanzar un gasto mínimo de 700 kcal a la semana realizando 30 minutos de caminata rápida o su equivalente por 5 días a la semana, es decir, 2 horas y media de actividad física en la semana (18, 19). sin embargo, no se dispone de un instrumento aplicable durante una atención en salud, que evalúe el cumplimiento de esta recomendación. de hecho, la utilización de varios de los cuestionarios —antes mencionados— en el contexto de atención primaria podría ser muy difícil por su extensión (20). el rapid assessment of physical activity (rapa) (21) es un instrumento de autorreporte, que presenta las siguientes características que lo posicionan como una buena herramienta de medición de actividad física en contextos clínicos: a) utiliza imágenes para representar las diferentes actividades físicas, facilitando la comprensión por parte de los usuarios, b) requiere poco tiempo en su aplicación (2 minutos aprox.); c) permite distinguir si las personas realizan la actividad física recomendada para quienes presentan condiciones crónicas cardiovasculares; y d) puede utilizarse como una herramienta educativa en salud. respecto al estudio original de validez, el instrumento presentó una relación positiva y moderada con el champs y obtuvo una sensibilidad de 81 %, mientras que su especificidad alcanzó el 69 %. además, el rapa fue capaz de discriminar entre aquellas personas que reportan o no desarrollar el nivel de actividad física recomendado por center for disease control and prevention (21, 22). el presente estudio tiene por objetivo adaptar culturalmente el cuestionario rapa para ser aplicado como parte de una entrevista con adultos usuarios del sistema de atención primaria de salud, y validarla para su uso en población adulta. en este estudio se selecciona el rango etario adulto (18-64 años) como población objetivo, ya que en esta se pueden realizar estrategias de promoción, prevención y tratamiento en salud. por 490 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 ejemplo, para disminuir la prevalencia de sedentarismo que alcanza aproximadamente el 25 % en adultos (25-64 años), o incorporar la actividad física en personas con diagnóstico de prediabetes, con miras a prevenir o demorar la transición a la diabetes. para estudiar su validez de constructo, se establecieron relaciones entre la actividad física reportada por los participantes y parámetros antropométricos sensibles al gasto energético asociado a la realización de actividad física, en una población heterogénea desde el punto de vista nutricional (desde rango normal a obeso). se espera que a mayor reporte de práctica de actividad física, menores sean los valores en los parámetros medidos. además, se midió la fiabilidad test-retest del instrumento. materiales y métodos sujetos. el universo lo constituyeron sujetos adultos (18-64 años), consultantes en cinco centros de salud de atención primaria en santiago (chile). la muestra constó de 180 personas7. instrumentos. el cuestionario rapa fue diseñado para medir el nivel de actividad física realizada por adultos mayores (21). el cuestionario consta de 9 ítems, siete de los cuales buscan determinar si las personas cumplen la recomendación de realizar 30 minutos o más de actividad física moderada, al menos 5 días a la semana (22). los ítemes distinguen la frecuencia y el tipo de actividad realizada (ligera, moderada y vigorosa/energética). los dos ítems adicionales miden si las personas realizan ejercicios de flexibilidad y fuerza. los autores del instrumento establecieron su validez concurrente en un estudio realizado en población de adultos mayores estadounidenses (21). en su versión original, la aplicación del instrumento considera la presentación gráfica de los tres tipos de actividad física. cada ítem —respecto del que le precede— involucra un nivel superior de actividad física en su intensidad y frecuencia, debiendo las personas indicar si realizan (o no) dicha actividad. los puntajes de los ítems son sumados (escala 1-7 puntos), estableciendo las siguientes categorías de actividad física: “sedentario”, “poco activo”, “poco activo regular ligero”, “poco activo regular” y “activo” (tabla 1) (21). 7 el tamaño muestral mínimo para el estudio fue de 127 participantes. se definió utilizando los criterios de alfa 0,05, potencia 0,80 y utilizando como valor referencial del monto de la correlación estudios similares. se estableció un tamaño de efecto pequeño (r = 0,01) conforme a los datos de relación entre actividad física e imc: r = -0,10 en mora, lee, buring, ridker (23), y b = -0,103 en arteaga, bustos, soto, velasco y amigo (24), utilizando para la estimación la calculadora online (http://www.cct.cuhk.edu.hk/stat/other/correlation.htm). tabla 1. descripción de las categorías de actividad física según rapa categoría (número categoría) descripción puntajes brutos sedentario (1) realiza actividades físicas muy pocas veces. 1 pt. poco activo (2) realiza algunas actividades físicas ligeras y/o moderadas, pero no cada semana. 2 pts. poco activo regular – ligero (3) realiza algunas actividades físicas ligeras cada semana. 3 pts. poco activo regular (4) realiza actividades físicas moderadas cada semana, pero menos de cinco días a la semana, o menos de 30 minutos diarios en esos días. realiza actividades físicas vigorosas cada semana, pero menos de tres días por semana, o menos de 20 minutos diarios en esos días. 4 a 5 pts. activo (5) realiza 30 minutos o más de actividades físicas moderadas por día, 5 o más días por semana. realiza 20 minutos o más de actividades físicas vigorosas por día, 3 o más días por semana. 6 a 7 pts. procedimientos adaptación del instrumento. se obtuvo la autorización del autor para realizar la adaptación del cuestionario. se utilizó la versión en español para población mexicana del rapa. conforme indican quienes desarrollaron el instrumento, esta versión fue sometida al proceso de adaptación lingüística, por lo que el cuestionario fue traducido (inglés-español) por dos traductores independientes y la versión conciliada fue retraducida.8 esta versión retraducida fue comparada con el instrumento original. adicionalmente, se condujeron grupos focales con hispano-parlantes para verificar los ejemplos y el parafraseo del instrumento. se procedió a la adaptación de las imágenes y del lenguaje del instrumento para ser aplicado en el contexto de atención primaria en salud. 8 http://depts.washington.edu/hprc/rapa 491 validación de la escala rapid assessment of physical activity (rapa) en población chilena adulta consultante en atención primaria l j. carola pérez y otros para verificar si las imágenes representaban adecuadamente las actividades físicas indicadas (p. ej., “fútbol” en actividad física vigorosa) en el contexto local, se encuestaron 10 personas (50 % mujeres, promedio de edad 41,4 años). se les preguntaba: “¿qué parecen estar haciendo la/s personas de la/s imagen/es?” esta pregunta era seguida de dos preguntas cerradas que buscaban determinar: a) si percibían que las imágenes daban cuenta de la actividad específica y b) en caso de que respondieran afirmativamente, indicar: ¿cuán clara es la imagen para mostrarlo?, en una escala de 1 a 7 puntos; se estableció un índice de aceptación, medido como el porcentaje de personas que valoran en forma positiva cada imagen, y, adicionalmente, un valor promedio de claridad de la imagen. dichas modificaciones fueron evaluadas en dos ocasiones sucesivas (10 y 12 personas diferentes en cada ocasión), hasta alcanzar —al menos— un 75 % de aceptación y un valor promedio de 5 puntos en la claridad de esta, definiéndose las imágenes definitivas del instrumento para chile (tabla 2). la correspondencia idiomática del cuestionario fue revisada por dos jueces con conocimientos lingüísticos, quienes sugirieron cambios al fraseo y estructura de las instrucciones en algunos de los ítemes. finalmente, se realizó una aplicación piloto en 10 personas (50 % mujeres, edad promedio = 40,2 años), quienes señalaron dificultades en la comprensión de las frases. considerando esta información, el equipo de investigación elaboró la versión definitiva del instrumento rapa para ser aplicada en la muestra local. en el proceso de adaptación, además de la adecuación de las imágenes, se incluyeron dos cambios respecto del instrumento original: 1. la medición de la actividad física se realiza en función de un periodo temporal de un mes (no una semana). tabla 2. valoración de las imágenes del rapa imágenes originales modificación versión final n (%) a m ± dsb n (%) a nota b n (%) a m ± ds b actividades ligeras 1. caminata ligera 5 (50 %) 4,9 ± 1,76 3 (30 %) 3,7 ± 1,20 9 (75 %) 4,8 ± 1,55 2. ejercicios de elasticidad 8 (80 %) 5,9 ± 1,18 8 (80 %) 4,5 ± 1,94 12 (100 %) 6,5 ± 0,91 3. barrer/jardinería ligera 8 (80 %) 5,6 ± 1,73 9 (90 %) 4,3 ± 1,86 12 (100 %) 6,5 ± 1,00 actividades moderadas 4. caminata rápida 5 (50 %) 5,9 ± 0,83 9 (90 %) 5,6 ± 1,90 5. clases de aeróbicos 10 (100 %) 6,8 ± 0,44 6. levantamiento de pesas ligeras 10 (100 %) 6,5 ± 0,53 7. bailar 9 (90 %) 6,4 ± 1,41 10 (100 %) 6,3 ± 0,87 actividades vigorosas o energéticas 8. escaladora 10 (100 %) 6,5 ± 0,88 9. voleibol 10 (100 %) 6,9 ± 0,33 sustituida por imagen de andar en bicicleta 10. andar en bicicleta 12 (100 %) 7 ± 0,0 11. trotar o correr 10 (100 %) 6,4±1,12 12. fútbol 9 (90 %) 6,7 ± 0,50 9 (90 %) 6,1 ± 1,27 nota. a: porcentaje de personas que responden en forma positiva ante la pregunta ¿las personas de la imagen podrían…? b: promedio de las notas en escala 1 a 7 que indican cuán claramente la imagen muestra la actividad física que realizan. aquellas imágenes en las cuales el 100 % de los entrevistados indicaban que era un buen ejemplo de la actividad física referida no fueron modificadas, a excepción de la imagen 9, la cual fue reemplazada por la imagen 10 (andar en bicicleta) actividad más difundida a nivel local. el símbolo "-" indica que dicha imagen no fue evaluada en una nueva aplicación, ya que su evaluación sugiere que no debía sufrir modificaciones. 492 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 2. se simplificaron los ítems, de manera que primero se consultara sobre la realización de los diferentes tipos de actividad física (ligera, moderada y vigorosa) y luego —según el tipo de actividad realizada— se indicara su frecuencia. en cambio, en la versión original, tanto el tipo de actividad como su frecuencia se incluían en forma conjunta en un mismo ítem. la aplicación. el desarrollo del proceso de validación del rapa forma parte del proyecto “modelo de atención remota de apoyo a las personas con pre-diabetes” (fonis9 sa10i20017), el cual fue aprobado por los comités de ética respectivos (universidad y servicio de salud). las personas fueron contactadas en la sala de espera de los centros de salud, por una ayudante de investigación. aquellas personas que aceptaron participar, firmaron un consentimiento y fueron encuestadas para completar los datos sociodemográficos y el cuestionario rapa. se incluyó una pregunta adicional sobre actividad física, que diera cuenta del número de días de la última semana, en que la persona realizó, al menos, 30 minutos de actividad física. esta pregunta es una —de las dos— destinadas a medir realización de actividad física en la versión revisada del summary of diabetes self-care activities (sdsca) (25). posteriormente, se midieron los parámetros antropométricos: a) imc, estimado según peso (kg)/talla2 (m). el peso se determinó en una balanza (marca haus) con ropa ligera, sin zapatos ni objetos contenidos en los bolsillos. las personas reportaron su talla (en cm). las categorías de imc utilizadas fueron: normal (18,5-24,99), sobrepeso (25-29,99) obeso (≥ 30); b) la circunferencia de cintura (cc) fue medida con la persona de pie, rodeando la cintura con una cinta métrica, identificando el punto medio que se encuentra entre la parte inferior de la última costilla y la parte más alta de la cadera, realizando la medición al final de una espiración normal (26). la circunferencia de cintura fue medida dos veces, estimando su promedio como valor final. la categoría cc “alterada” se conformó tomando los valores de referencia de 88 cm en mujeres y 102 en hombres, conforme a las recomendaciones del ncep/atp iii utilizada en chile (27, 28). análisis de datos. los datos fueron analizados usando el spss 17.0. se realizó estadística descriptiva de la muestra y distribu9 fondo de investigación en salud, de la comisión nacional de investigación científica y tecnológica. ción de las categorías de actividad física. para la determinación de la validez concurrente del instrumento, se desarrollaron tres análisis estadísticos: a) se estimaron correlaciones (no paramétricas) entre las variables actividad física (ítem sdsca y rapa), peso, imc y cc. se utilizó como medida el nivel ordinal de las categorías ordenadas del rapa (va de un valor mínimo de 1 a 5 puntos); b) se determinó si existían diferencias en la proporción de personas ubicadas en las categorías normal vs. alterado en sus parámetros antropométricos (imc y cc) de acuerdo con las categorías de actividad física que establece el instrumento; c) se determinó si el promedio de estos parámetros variaba según las categorías de actividad física. finalmente, se determinó la confiabilidad test-retest10 del instrumento, a través del icc (fórmula icc de acuerdo absoluto, modelo de efectos aleatorios de dos factores) (29) y kappa entre los puntajes del rapa, en dos mediciones en el tiempo de una nueva muestra de usuarios de atención primaria en salud. resultados sujetos. la muestra está constituida mayoritariamente por mujeres (80 %), con una edad promedio de 40,1 años (ds: 13,81 años). la edad promedio de las mujeres es de 39,66 años (ds: 13,86) y de 41,69 años (ds: 13,59) en el caso de los hombres (tabla 3). los criterios de ingreso eran ser adulto (18 a 64 años) consultante en centros de atención primaria de la comuna de la florida (chile). los criterios de exclusión fueron no saber leer/escribir, o presentar problemas visuales o auditivos severos (ceguera, sordera o similar), por impedir la adecuada aplicación de los instrumentos. resultados descriptivos. el instrumento fue contestado por 178 personas. dos personas respondieron que ninguno de los ítemes representaba la actividad física que ellos realizaban (n = 180). según las respuestas al rapa, solo una persona fue categorizada como “poco activo”, un 48,9 % de los encuestados como “poco activo regular ligero”, un 37,6 % corresponden a la categoría “poco activo regular” y un 12,9 % son “activos”, con un patrón de categorías similar entre hombres y mujeres (p > 0,05). 10 la determinación de confiabilidad a través de test-retest fue elegida para medir la fiabilidad del cuestionario dado que los índices de consistencia interna habitualmente utilizados no son adecuados para la forma de corrección del instrumento. 493 validación de la escala rapid assessment of physical activity (rapa) en población chilena adulta consultante en atención primaria l j. carola pérez y otros tabla 3. descripción de la muestra muestra total n (%) poco activo y poco activo regular ligero n (%) poco activo regular n (%) activo n (%) género hombre 36 (20) 12 (34,3) 15 (42,9) 8 (22,9) mujer 144 (80) 76 (53,1) 52 (36,4) 15 (10,5) edad 18-29 51 (28,3) 20 (39,2) 27 (52,9) 04 (7,8) 30-39 39 (21,7) 19 (48,7) 08 (20,5) 12 (30,8) 40-49 32 (17,8) 18 (58,1) 11 (35,5) 02 (6,5) 50-64 58 (32,2) 31 (54,4) 21 (36,8) 05 (8,8) escolaridad e. básica incompleta 25(14,0) 16 (64,0) 08 (32,0) 01 (4,0) e. básica completa 14 (7,8) 06 (42,9) 08 (57,1) 0 (0) e. media incompleta 36(20,1) 21 (58,3) 10 (27,8) 05 (13,9) e. media completa 83 (46,4) 38 (46,9) 32 (39,5) 11 (13,6) e. universitaria a 21 (11,7) 7 (33,3) 08 (38,1) 6 (28,6) actividad dueña/o de casa 89 (49,4) 45 (50,6) 36 (40,4) 08 (9,0) obrero o actividad no requiere calificación 63 (35,0) 37 (39,7) 14 (22,6) 11 (17,7) sin actividad laboral 07 (3,9) 03 (42,9) 4 (57,1) 0 (0) estudiante 07 (3,9) 01 (14,3) 6 (87,5) 0 (0) técnicos o actividad con calificación 11 (6,1) 02 (18,2) 6 (54,5) 3 (27,3) otros 3 (1,7) 01 (33,3) 01 (33,3) 01 (33,3) total 178 (100) 88 (49,4) 67 (37,6) 23 (12,9) nota: a: educación universitaria completa y/o incompleta. b: incluye pensionados, jubilados y cesantes. tabla 4. distribución de las categorías de actividad física según sexo de los participantes categorías actividad física hombre mujer total n % n % poco activo 0 0 1 0,7 1 poco activo regular ligero 12 34,29 75 52,45 87 poco activo regular 15 42,86 52 36,36 67 activo 8 22,86 15 10,49 23 total 35 100 143 100 178 494 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 resultados de la validez concurrente del instrumento. las puntuaciones en la escala rapa se relacionaron en forma inversa con el imc (r = -0,020, p < 0,01) y perímetro de cintura (r = -0,16, p < 0,05). en cambio, no se relacionaron con el peso (r = -0,06, p ≥ 0,05). por su parte, la pregunta habitualmente usada para medir actividad física en el sdsca, si bien se relaciona con la medición rapa (r = 0,36, p < 0,001), no lo hace con las mediciones de peso, imc y perímetro de cintura (p ≥ 0,05). índice de masa corporal (imc). los resultados indicaron que no hay diferencias significativas (p = 0,12) al considerar la distribución de los participantes según las categorías de imc y actividad física (tabla 5). en cambio, se presentan diferencias al considerar el imc promedio de las personas (p < 0,001), una vez que se controlan las variables edad y género. el promedio de imc de los sujetos categorizados como “poco activo” y “poco activo regular ligero” es mayor que el imc de los sujetos con actividad física mayor (p < 0,01). no se encuentran diferencias en el imc en las personas de las categorías “poco regular activo” vs. “activo” (p = 0,83). circunferencia de cintura (cc). los resultados señalaron diferencias significativas (p < 0,05) al considerar la distribución de los participantes según las categorías de cc y actividad física (tabla 6), indicando que el mayor porcentaje de las personas pertenecientes a las categorías “poco activo” y “poco activo regular ligero” tenían una cc alterada. en cambio, no se presentaron diferencias al considerar el promedio de la cc en mujeres y hombres (p ≥ 0,05), una vez que se controla la variable edad11. resultados relacionados con la confiabilidad. la confiabilidad test-retest del instrumento fue estimada en una segunda etapa. la nueva muestra (n = 35) constó en un 74,3 % de mujeres, con una edad promedio de 44,91 años. transcurrió una semana entre la primera y segunda aplicación del cuestionario. 11 se realizan análisis de promedios separados por sexo, dado que los puntajes considerados adecuados son diferentes para hombres y mujeres. tabla 5. imc según categorías de actividad física: porcentajes y nivel promedio poco activo y poco activo regular ligero poco activo regular activo total nivel promedio imc a promedio ± ds 29,64 ± 5,05 27,45 ± 3,70 27,68 ± 5,36 28,26 ± 4,74 estado nutricional n (%) normal 18 18 7 43 (20,54 %) (26,9 %) (30,4 %) (24,2 %) sobrepeso 30 32 8 70 (34,1 %) (47,7 %) (34,8 %) (39,3 %) obesidad 40 17 8 65 (45,5 %) (25,4 %) (34,8 %) (36,5 %) total 88 67 23 178 (100 %) (100 %) (100 %) (100 %) 495 validación de la escala rapid assessment of physical activity (rapa) en población chilena adulta consultante en atención primaria l j. carola pérez y otros el icc entre la primera y segunda medición de los puntajes —en escala 1 a 7 puntos— en la escala rapa fue de: r = 61, p < 0,001. al considerar el acuerdo absoluto en la clasificación de las categorías entre ambas aplicaciones el kappa = 0,34 (ic 95 %: 0,05-0,63), p < 0,05. discusión la escala rapa en su versión adaptada para chile, es un instrumento de fácil aplicación, que presenta una moderada confiabilidad y que establece relaciones coherentes con los parámetros antropométricos de imc y cc, en usuarios de la atención primaria de salud, pero discrimina de mejor forma solo en las categorías que indican menor nivel de actividad física. el instrumento indicó que solo un 12,9 % de los encuestados eran “activos”, es decir, realizaban 30 minutos o más de actividad físicas moderadas por día (5 o más días por semana) o realizaban 20 minutos o más de actividades físicas vigorosas por día (3 o más días por semana) y que el mayor porcentaje realizaban algunas actividades físicas ligeras cada semana (categoría “poco activo regular ligero”). estos resultados son coherentes con el bajo nivel de actividad que reportan los estudios poblacionales desarrollados en chile (17) para estudiar la validez del instrumento, se establecieron relaciones entre la actividad física reportada por los participantes y parámetros antropométricos de imc y cc. ambos parámetros son sensibles al gasto energético asociado a la realización de actividad física, por lo que fueron considerados indicadores adecuados para la estimación de la validez concurrente del rapa. sin embargo, estas mediciones también son sensibles a otros aspectos como la cantidad y calidad de la ingesta alimenticia, de tal manera que las correlaciones entre ellas son solo pequeñas. a este respecto, los resultados indican que las puntuaciones en la escala rapa, al considerar los puntajes de las categorías ordenadas (1 = sedentario a 5 = activo), se relacionan en forma coherente con lo esperado. es decir, en la medida que aumenta el reporte de actividad física, disminuyen los valores de los parámetros imc y cc, y aumenta el número de días que se reporta haber realizado actividades moderadas (ítem sdsca). asimismo, coherente con lo esperado desde un punto de vista teórico, el promedio de imc de los sujetos con bajo nivel de activitabla 6. circunferencia de cintura según categorías de actividad física: porcentajes y nivel promedio poco activo y poco activo regular ligero poco activo regular activo total mujeres nivel promedio cc a promedio ± ds n 93,84 ± 10,9 90,57 ± 10,0 91,54 ± 11,6 91,99 ± 10,7 76 52 15 143 hombres nivel promedio cc b promedio ± ds n 102,26 ± 18,5 96,34 ± 7,6 92,69 ± 11,2 97,03 ± 13,3 12 15 8 35 circunferencia de cintura (en categorías) alterado c 60 34 11 105 (68,2 %) (50,7 %) (47,8 %) (59,0 %) total 88 67 23 178 (100 %) (100 %) (100 %) (100 %) nota. a: promedios de mujeres ajustados según edad (valor 39,57 años) y b) promedios de hombres ajustados según edad (valor 41,51 años). c) la categoría alterado se conformó según cc > 88 en mujeres y > 102 en hombres. 496 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 dad física (categorizados como “poco activo” y “poco activo regular ligero”) es significativamente mayor que el imc de los sujetos con categorías de actividad física mayor. lo mismo acontece respecto a la cc, los sujetos que reportaron estas categorías de actividad física presentaron con mayor frecuencia una cc alterada. sin embargo, no se encontraron diferencias al considerar la distribución de los participantes según las categorías de imc y actividad física, ni se presentaron diferencias al considerar el promedio de cc en mujeres y hombres. este último resultado podría explicarse por la falta de potencia del análisis para detectar diferencias, asociado al reducido tamaño muestral, particularmente en el grupo de hombres. como se mencionó, los parámetros de imc y cc dependen del equilibrio entre ingesta alimentaria y gasto energético; en este sentido, la falta de incorporación de información sobre alimentación en el estudio es una de sus principales limitaciones. adicionalmente, el haber medido la talla de las personas (para conformar el imc) por autorreporte (y no en forma directa), constituye otra limitación del estudio. adicionalmente, dado que la población estudiada es heterogénea desde el punto de vista nutricional, un elemento adicional que podría estar afectando los resultados podría ser la tendencia a sobredimensionar la actividad realizada, particularmente en el conjunto de personas con obesidad, generándose un comportamiento en espejo al fenómeno del subreporte de la ingesta energética en estudio sobre comportamiento alimentario (30). llama la atención que ninguno de los sujetos fue clasificado como sedentario en el presente estudio. este resultado indica que el ítem y criterio de clasificación debería ser revisado. respecto a su confiabilidad, el puntaje obtenido es moderado y es menor que el obtenido en otros estudios, los cuales oscilan entre 0,58-0,88 (13). recientemente, en el año 2014 se publicó un estudio sobre la validez y confiabilidad del rapa en su versión en español (para población mexicana), indicando que esta tiene una correlación moderada (0,45) con mediciones de actividad física medida a través de acelerómetro (actigraph). la confiabilidad test-retest fue de 0,65, con una sensibilidad de 73 % y especificidad de 75 % (31). asimismo, una nueva versión en portugués fue desarrollada obteniendo adecuados indicadores de validez de convergencia y discriminante con indicadores de desempeño físico y who disability assessment schedule 2.0 (respectivamente), pero reportando niveles de confiabilidad inferiores a lo adecuado (kappa ponderado de 0,67), en una medición test-retest con un lapso de 1 semana de diferencia entre ellas (32). estos hallazgos son coherentes con los resultados del presente estudio, que muestran una adecuada validez pero debilidades en su confiabilidad test-retest. como otra limitación importante del presente estudio, es no haber utilizado un cuestionario adicional de actividad física para aportar a la validez de constructo del instrumento. shepard (13) concluye que, pese al extendido uso de los cuestionarios, su validez y confiabilidad siguen siendo limitadas. incluso en los procesos de validación de cuestionarios a través de métodos más precisos —que involucran el uso de agua doblemente marcada, o el uso de podómetros o acelerómetros— los resultados no son homogéneos. sin embargo, reconoce que tienen un valor práctico para monitorear los cambios en el nivel de actividad y que pueden ser más adecuados entregando una clasificación del nivel de actividad física, que dando cuenta del gasto energético específico de las personas (13). de hecho, este instrumento está siendo usado como herramienta de detección de personas sedentarias en población hispano-parlante (33-35) y como medición basal de la actividad física en intervenciones (36), mostrando que 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[citado 2012 agosto 22]. disponible en: http://sedici.unlp.edu.ar/handle/10915/42272 460 472 satisfaccion con el manejo del dolor.indd 460 aquichan issn 1657-5997 maría guadalupe moreno-monsiváis1 maría del refugio muñoz-rodríguez2 ma. guadalupe interial-guzmán3 satisfacción con el manejo del dolor posoperatorio en pacientes hospitalizados 1 doctora en filosofía con especialidad en administración. magíster en enfermería. maestro de tiempo completo. universidad autónoma de nuevo león, facultad de enfermería, monterrey (méxico). mgmoreno@hotmail.com 2 magíster en ciencias de enfermería, hospital san josé tec, monterrey (méxico). mmunoz@hsj.com.mx 3 magíster en ciencias de enfermería. maestro de tiempo completo. universidad autónoma de nuevo león, facultad de enfermería, monterrey (méxico). mginterial@hotmail.com recibido: 27 de febrero de 2014 enviado a pares: 28 de febrero de 2014 aceptado por pares: 28 de junio de 2014 aprobado: 8 de julio de 2014 doi: 10.5294/aqui.2014.14.4.2 para citar este artículo / to reference this article / para citar este artigo moreno-monsiváis mg, muñoz-rodríguez mr, interial-guzmán mg. satisfacción con el manejo del dolor posoperatorio en pacientes hospitalizados. aquichan. 2014; 14 (4): 460-472. doi: 10.5294/aqui.2014.14.4.2 resumen objetivo: determinar la satisfacción con el manejo del dolor en pacientes hospitalizados y su relación con la intensidad del mismo, el alivio y la orientación proporcionada al paciente para el manejo del dolor posoperatorio. materiales y métodos: estudio descriptivo correlacional. muestreo aleatorio sistemático en una muestra de 193 pacientes. se utilizó el cuestionario de intensidad del dolor y una cédula de datos. resultados: el 48,2 % de los participantes manifestaron dolor severo como máximo dolor durante las primeras 24 horas. en relación con el alivio del dolor, el 77,7 % tuvo un manejo adecuado y el 85,5 % recibió orientación preoperatoria. la satisfacción se ubicó en 9,54 (de = 1,08). se encontró diferencia significativa en la satisfacción del paciente según si recibió o no orientación (t = 71,23, p = 0,001), con mayor satisfacción en los que recibieron orientación (m = 9,65) (de = 0,84). la satisfacción del paciente con el manejo del dolor está determinada por el máximo dolor posoperatorio y por la orientación preoperatoria recibida para el manejo del mismo (r2 = 0,17, p = 0,000). conclusiones: el adecuado manejo del dolor en el paciente posoperatorio hospitalizado requiere valorar oportunamente el nivel de dolor y la orientación al paciente, aspectos elementales en los que enfermería juega un rol fundamental y son clave para incrementar la satisfacción. palabras clave satisfacción del paciente, manejo del dolor, dolor posoperatorio, intensidad del dolor, atención de enfermería. (fuente: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 460-472 461 satisfacción con el manejo del dolor posoperatorio en pacientes hospitalizados l maría guadalupe moreno-monsiváis y otros año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 460-472 satisfaction with postoperative pain management in hospitalized patients abstract purpose: the purpose of this study was to identify satisfaction with pain management in hospitalized patients and how it relates to the intensity of pain, relief and the guidance provided to the patient for postoperative pain management. study materials and methods: this is a descriptive/correlational study featuring systematic random sampling in a group of 193 patients. the pain intensity questionnaire and a fact sheet were used. results: in all, 48.2% of the participants reported severe pain as the most pain experienced during the first 24 hours. with regard to pain relief, 77.7% had adequate management and 85.5% received preoperative guidance. satisfaction was at 9.54 (sd = 1.08). there was a significant difference in patient satisfaction, depending on whether or not the patient received guidance (t = 71.23, p = 0.001). satisfaction was greater among those who received guidance (m = 9.65) (sd = 0.84). patient satisfaction with pain management is determined by maximum postoperative pain and the preoperative guidance received for its management (r2 = 0.17, p = 0.000). conclusions: appropriate management of pain in postoperative patients who are hospitalized requires assessing of the level of pain at the appropriate time and offering guidance to the patient. these are fundamental aspects in which nursing plays a vital role and are key to increasing satisfaction. key words patient satisfaction, pain management, postoperative pain, pain intensity, nursing care. (source: decs, bireme). 462 aquichan issn 1657-5997 satisfação com a administração da dor pós-operatória em pacientes resumo objetivo: determinar a satisfação com a administração da dor em pacientes hospitalizados e sua relação com a intensidade desta, o alívio e a orientação proporcionada ao paciente para a administração da dor pós-operatória. materiais e métodos: estudo descritivo correlacional. amostra aleatória sistemática com 193 pacientes. utilizou-se o questionário de intensidade da dor e uma cédula de dados. resultados: 48,2 % dos participantes manifestaram dor aguda como máxima dor durante as primeiras 24 horas. quanto ao alívio da dor, 77,7 % tiveram uma administração adequada e 85,5 % receberam orientação pré-operatória. a satisfação se posicionou em 9,54 (de = 1,08). constatou-se diferença significativa na satisfação do paciente dependendo de se este tinha recebido ou não orientação (t = 71,23, p = 0,001), com maior satisfação nos que receberam orientação (m = 9,65) (de = 0,84). a satisfação do paciente com a administração da dor está determinada pela máxima dor pós-operatória e pela orientação pré-operatória recebida para a administração desta (r2 = 0,17, p = 0,000). conclusões: a adequada administração da dor no paciente pós-operatório hospitalizado requer avaliar oportunamente o nível de dor e a orientação ao paciente, aspectos elementares nos quais a enfermagem desempenha um papel fundamental e são chaves para aumentar a satisfação. palavras-chave satisfação do paciente, administração da dor, dor pós-operatória, intensidade da dor, atendimento de enfermagem. (fonte: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 460-472 463 satisfacción con el manejo del dolor posoperatorio en pacientes hospitalizados l maría guadalupe moreno-monsiváis y otros introducción el adecuado manejo del dolor es un indicador de buena práctica y de calidad asistencial que influye en la satisfacción del paciente. este aspecto se considera relevante, sobre todo por la tendencia nacional e internacional de contar con hospitales libres de dolor que contribuyan a la satisfacción del cliente (1, 2). lograr la ausencia de dolor en los pacientes se ha vuelto una necesidad, la asociación internacional para el estudio del dolor lo define como una experiencia sensorial y emocional displacentera, que se encuentra asociada a daño tisular, ya sea real o potencial (3). si bien se requiere un manejo adecuado en todos los pacientes que cursan con dolor, se considera relevante por sus altas prevalencias el dolor agudo de tipo posoperatorio, el cual se presenta en el paciente como respuesta a una lesión quirúrgica. en los hallazgos de investigación se reporta que aproximadamente el 96 % de los pacientes hospitalizados refiere dolor agudo en algún momento durante su internamiento (4). en relación con el dolor posoperatorio, la literatura reporta que una proporción superior al 50 % de los pacientes experimenta algún grado de dolor de moderado a severo en sus primeras 24 horas posteriores a una intervención quirúrgica; asimismo, se ha documentado que alrededor de un 50 % lo describe como severo en intensidad, y en similar proporción es percibido como moderado a severo (5-9). en cuanto a la satisfacción del paciente con el manejo del dolor, algunos estudios reportan altos porcentajes de satisfacción a pesar de la presencia de dolor de intensidad de moderada a severa (5, 6). sin embargo, otros estudios reportan insatisfacción, y esto lo atribuyen al tiempo de espera para recibir la medicación, así como a la deficiente información recibida para el manejo del dolor posoperatorio sobre los efectos secundarios de los analgésicos y las alternativas para calmar el dolor (8, 9). la intensidad y duración del dolor posoperatorio se asocian con características individuales, así como las relacionadas con el procedimiento quirúrgico y con el tratamiento farmacológico que se brinda en las instituciones. respecto a las características individuales se pueden señalar la edad y el género. en algunos estudios se reportan diferencias en la percepción del dolor de acuerdo con estas características; sin embargo, los hallazgos no son conclusivos (10). en relación con el procedimiento quirúrgico, existe variación en la presencia e intensidad del dolor por tipo de cirugía según la especialidad quirúrgica. se reporta que las intervenciones valoradas como las más dolorosas corresponden a cirugía general, seguidas por las de traumatología, ginecología, cirugía maxilofacial, otorrinolaringología, urología, neurocirugía y oftalmología (11, 12). en cuanto al tratamiento farmacológico, los analgésicos utilizados para el manejo del dolor se consideran un aspecto fundamental ya que sus principales deficiencias se relacionan con la subutilización de los analgésicos y opioides, aunado al bajo cumplimiento de las pautas analgésicas prescritas por la organización mundial de la salud (oms) (13). respecto al uso de opioides se reporta que no se administran las dosis adecuadas debido al temor de causar depresión respiratoria y adicción, asociado al bajo conocimiento por parte de los profesionales de la salud (8). como se observa, el manejo del dolor posoperatorio es muy complejo. sánchez (14) argumenta que se han desarrollado diferentes teorías para comprender el dolor y hacer un manejo efectivo, estas se centran en aspectos como explicar la naturaleza del dolor y comprender su percepción; la autora destaca dos teorías específicas de enfermería que han contribuido a hacer un manejo adecuado del dolor (teoría de rango medio de los síntomas desagradables y la del equilibrio entre la analgesia y los efectos colaterales de good y moore). en el presente estudio se utilizó como sustento teórico la teoría de enfermería de rango medio para el manejo del dolor de good y moore (15), en virtud de que fue propuesta para el manejo del dolor agudo posoperatorio (14); esta teoría explica que el alivio del dolor está determinado por el manejo farmacológico y no farmacológico, la valoración del dolor y sus efectos de manera regular, la educación que se proporciona al paciente para que contribuya en el manejo del dolor y el establecimiento de objetivos para aliviar y manejar el mismo. esta teoría tiene sus bases en las guías de práctica clínica enfocadas en el alivio del dolor. la teoría contiene tres postulados: • proporcionar el medicamento para el dolor con la potencia adecuada, junto con coadyuvantes farmacológicos y no farmacológicos, contribuirá al balance entre la analgesia y sus efectos adversos. • valorar el dolor y sus efectos de manera regular, así como identificar los métodos inadecuados para el alivio, además de 464 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 verificar el manejo de procesos de intervención, revaloración y reintervención, con el fin de contribuir al establecimiento de un equilibrio entre la analgesia y sus efectos. • brindar educación al paciente y establecer objetivos para aliviar y manejar el dolor, con el fin de contribuir a lograr un equilibrio entre la analgesia y sus efectos colaterales. el alivio del dolor es un reto que requiere de la participación de todo el equipo multidisciplinario involucrado en la atención. existe evidencia de que un adecuado alivio del dolor no solo aumenta el confort y la satisfacción de los pacientes, sino que además contribuye a disminuir la morbilidad posoperatoria y, en algunos casos, reduce la estancia hospitalaria (16). el alivio del dolor depende de su manejo por los profesionales de salud, donde enfermería juega un rol fundamental en su valoración, manejo de la medicación y educación al paciente (17, 18). es importante destacar que no solo se debe valorar el dolor, proporcionar un manejo farmacológico y educar al paciente al respecto, también es elemental evaluar la respuesta en la disminución o eliminación del dolor. una herramienta de utilidad para determinar si el manejo es el adecuado y está contribuyendo satisfactoriamente al alivio del dolor es el índice de manejo del dolor (imd), este se establece a través de la relación entre el analgésico indicado de mayor potencia menos la intensidad del dolor durante las últimas 24 horas (19). a partir de la revisión de literatura y teniendo en cuenta los aspectos relevantes para el manejo del dolor de acuerdo con la teoría de enfermería de rango medio de good y moore (15), se plantearon los siguientes objetivos: 1. identificar la intensidad del dolor de acuerdo con las características del paciente (edad y sexo), así como con el tipo de intervención quirúrgica. 2. determinar el alivio del dolor en el paciente posoperatorio hospitalizado. 3. identificar la proporción de pacientes que recibe orientación para el manejo del dolor posoperatorio. 4. determinar la satisfacción del paciente con el manejo del dolor posoperatorio y su relación con la intensidad, el alivio y la orientación para su manejo. materiales y métodos estudio descriptivo correlacional (20). la población se conformó por pacientes adultos en posoperatorio, hospitalizados en una institución privada del área metropolitana de monterrey, nuevo león (méxico). el tipo de muestreo fue aleatorio estratificado con asignación proporcional al tamaño de cada estrato. se consideraron tres estratos de acuerdo con las especialidades de cirugía general, ginecología y traumatología. la técnica de muestreo en cada estrato fue aleatoria, sistemática de uno en dos con inicio aleatorio. se entrevistaron a 193 pacientes con 24 horas posoperatorias consideradas a partir del egreso del quirófano y que fueron intervenidos de cirugía tradicional no laparoscópica ni clasificada como mínimamente invasiva (microcirugía). el cálculo del tamaño de la muestra se estimó con el paquete estadístico n-query advisor versión 4.0 (21), para un análisis de intervalo de confianza para estimación de medias. los parámetros que se consideraron fueron un nivel de confianza del 95 %, un intervalo de confianza bilateral, una desviación estándar de 2,0 de acuerdo con lo reportado en los estudios relacionados, un límite de error de estimación de 0,30, lo que dio como resultado una muestra de 171 pacientes. se consideró un 5 % de no respuesta por lo que el tamaño se incrementó a 193 participantes. para recolectar la información se acudió diariamente a la institución privada hasta completar el tamaño de la muestra; se verificó la hoja de control de cirugías realizadas a los pacientes; de acuerdo con ello, se elaboró un listado donde se consideró solamente a los que cubrieron los criterios de inclusión. posteriormente, se cotejaron los datos de los pacientes en el sistema de información para verificar su ubicación e identificar el servicio donde se encontraban hospitalizados. se acudió a los departamentos y se notificó a la enfermera responsable de cada paciente seleccionado que se realizaría una encuesta a su paciente con la previa autorización del mismo. se corroboraron los datos de identificación en el expediente clínico para comprobar que fuera el paciente seleccionado. la recolección de la información se inició con el llenado de una cédula de datos, que contiene información relacionada con edad, género (masculino o femenino), escolaridad (número de años de educación formal), tipo de intervención quirúrgica (cirugía mayor o menor), especialidad (cirugía general, traumatología y ginecología), tipo de anestesia (epidural o general) y tratamien465 satisfacción con el manejo del dolor posoperatorio en pacientes hospitalizados l maría guadalupe moreno-monsiváis y otros to farmacológico indicado las primeras 24 horas posoperatorias (nombre del analgésico, dosis, vía y horario). para medir la intensidad del dolor, la orientación proporcionada y la satisfacción con el manejo del mismo se aplicó el cuestionario de intensidad del dolor en el paciente (cid) (22). este instrumento se utiliza como una medida confiable para estimar la intensidad del dolor en el paciente posoperatorio, está compuesto por 18 reactivos, 11 de ellos miden la presencia e intensidad en el momento de la entrevista, el máximo dolor y el dolor promedio en las últimas 24 horas. se utiliza una escala visual numérica con valores de 0 a 10, donde 0 es la ausencia de dolor y 10 es el máximo dolor posible. se incluye una pregunta que mide la interferencia del dolor en la actividad, el estado de ánimo y el sueño; se midió con puntajes de 0 a 10, el 0 representa la ausencia de interferencia y el 10 la máxima interferencia. para medir la orientación proporcionada al paciente para el manejo del dolor se utilizó una pregunta dicotómica con opciones de sí recibió orientación o no la recibió. la satisfacción con el manejo del dolor posoperatorio se midió a través de tres preguntas que permiten identificar la percepción del paciente acerca del alivio del dolor como resultado de la atención brindada por el personal médico y de enfermería. se midió a través de una escala con valores de 0 a 10, donde el 0 significa ausencia total de satisfacción y el 10 la máxima satisfacción. el instrumento incluye dos preguntas relacionadas con el tiempo de espera para la aplicación del analgésico solicitado, así como el uso de otra alternativa no farmacológica para el manejo del dolor. en el presente estudio el alpha de cronbach reportó un valor de 0,78. para obtener el imd se consideró el analgésico de mayor potencia reportado en la cédula de datos en el apartado de tratamiento farmacológico indicado en las primeras 24 horas posoperatorias, y la intensidad del dolor se obtuvo del cuestionario de intensidad del dolor en el paciente. esta herramienta permite establecer la relación entre el analgésico indicado de mayor potencia menos la intensidad del dolor durante las últimas 24 horas. la escala para los analgésicos se determina de la siguiente manera: 0 = ningún analgésico, 1 = aines y coadyuvantes, 2 = opiodes débiles, aines y coadyuvantes, 3 = opioides fuertes, aines y coadyuvantes. la escala utilizada para la intensidad del dolor se clasificó de la siguiente manera: 0 = ausencia de dolor, 1 = intensidad de 1-3 (dolor leve), 2 = intensidad de 4 a 6 (dolor moderado), 3 = intensidad de 7 a 10 (dolor severo). el resultado del índice de valores de cero a números positivos representa un adecuado o efectivo manejo del dolor (alivio), mientras que los números negativos indican un inadecuado o inefectivo manejo del dolor. el estudio se realizó conforme a lo que dispone el reglamento de la ley general de salud en materia de investigación (23). se contó con la aprobación de los comités de ética e investigación de la facultad de enfermería de la universidad autónoma de nuevo león, se solicitó autorización de los participantes a través de la firma del consentimiento informado y en todo momento se respetó la dignidad, privacidad, bienestar y los derechos de los participantes. para el análisis de los datos se verificó la distribución de la variable intensidad del dolor a través de la prueba de kolmogorov-smirnov. se obtuvo una distribución normal de los datos por lo que se aplicó estadística paramétrica. para determinar la relación entre las variables del estudio se utilizó la prueba de correlación de pearson, para la diferencia de medias se usó la prueba de t de student, y para identificar las variables que determinan la satisfacción del paciente con el manejo del dolor, el análisis de regresión lineal múltiple. resultados la media de edad de los pacientes participantes fue de 49,53 (de = 16,33); respecto a los años de escolaridad, la media de años cursados se ubicó en 13,68 (de = 7,03). predominó el género femenino con 62,7 %. respecto a la especialidad, la mayor proporción correspondió a traumatología con 43,5 %, seguida de cirugía general con 35,8 % y ginecología con 20,7 %. de acuerdo al tipo de intervención quirúrgica, predominó la clasificada como cirugía mayor con 62,2 %. en relación con el tipo de anestesia, la más utilizada fue la epidural con 54,4 %. en la tabla 1 se muestra la intensidad del dolor que refirieron los pacientes de acuerdo con la escala visual numérica del dolor con rangos de 0 a 10. para el dolor promedio en las últimas 24 horas se obtuvo una media de 4,55 (de = 3,05). el máximo dolor en las primeras 24 horas se ubicó en 5,64 (de = 3,38). en cuanto al dolor al momento de la entrevista reportó una media de 2,33 (de = 2,90). en la tabla 2 se presenta la clasificación de la intensidad del dolor, en las primeras 24 horas, y el máximo dolor documenta466 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 do se clasificó como severo (31,6 y 48,2 %, respectivamente); al momento de la entrevista predominó la ausencia de dolor (47,5 %), seguido de dolor leve (23,3 %). cabe destacar que al momento de abordar al paciente para la entrevista, el 11,9 % presentó dolor severo y el 17,6 % dolor moderado, por lo que fue necesario referirlo a la enfermera y regresar posteriormente a la entrevista. en la tabla 3 se observa que la intensidad del dolor fue mayor en el género femenino, tanto en el dolor promedio, como en el máximo, y al momento de la entrevista. en la tabla 4 se presenta la intensidad del dolor de acuerdo al tipo de intervención quirúrgica, se encontró que el dolor promedio en las primeras 24 horas posoperatorias fue ligeramente mayor en los pacientes a quienes se les practicó cirugía menor, similar a lo reportado en el dolor al momento de la entrevista y en el máximo dolor. en cuanto a la intensidad del dolor de acuerdo al tipo de especialidad, fue mayor en los pacientes de ginecología, seguido de la especialidad de traumatología y cirugía general. para responder al objetivo número uno se determinó la asociación entre la intensidad del dolor con la edad, al aplicar la prueba de correlación de pearson no se encontró correlación entre la edad de los pacientes participantes con la intensidad del dolor (dolor promedio, máximo, al momento de la entrevista), p > 0,05. respecto al género, al aplicar la prueba t de student no se encontró diferencia significativa en la intensidad del dolor promedio, máximo dolor y al momento de la entrevista (p > 0,05). en cuanto al tipo de cirugía se encontró únicamente diferencia en la intensidad del dolor al momento de la entrevista (t = 4,16, p = 0,04). la intensidad más alta de dolor fue reportada por los pacientes a los que se les realizó cirugía menor, no se encontró diferencia significativa al analizar por especialidad. al analizar la interferencia del dolor en la actividad general, en el estado de ánimo y en el sueño, se observa mayor interferencia del dolor en la actividad general con una media de 3,08 (de = 3,63), seguido de la interferencia en el sueño con 2,06 (de = 3,38) y en el estado de ánimo con 1,96 (de = 3,08). en cuanto a la terapia analgésica indicada durante las primeras 24 horas posoperatorias se encontró que predominaron los aines y coadyuvantes en un 68,9 %, seguido de los opioides débiles, aines y coadyuvantes con 25,9 %. los opioides fuertes, aines y coadyuvantes se usaron en menor proporción (5,2 %). el alivio del dolor medido a través del imd indicó que en el 77,7 % de los participantes los valores de la relación entre el analgésico de mayor potencia y la intensidad del dolor promedio durante las últimas 24 horas se reportó en un rango de 0 a 3, lo que indica un manejo adecuado. en el 22,3 % el manejo se clasificó como inadecuado. en cuanto al tiempo de espera para recibir el analgésico, se observó una media de 4,66 minutos (de = 14,83). respecto a otra alternativa terapéutica para el manejo del dolor, el 9,8 % de los pacientes la solicitaron; entre las alternativas señalaron cambio de posición, hielo y fomento caliente. en la tabla 5 se describe el número de pacientes que recibieron orientación preoperatoria y quién se la proporcionó. se muestra que el 85,5 % de los pacientes señalaron haber recibido orientación, el 77,2 % fue proporcionada por personal médico y solo el 8,3 % por enfermería. respecto a la satisfacción del paciente con el manejo del dolor por el personal de enfermería, en una escala de 0 a 10, la media se ubicó en 9,33 (de = 1,60), por el personal médico 9,55 (de = 1,45) y con la atención en general 9,54 (de = 1,08). al aplicar la prueba t de student para determinar diferencia de medias en la satisfacción general del paciente de acuerdo a si recibió o no orientación, se encontró diferencia significativa (t = 71,23, p = 0,001). se encontró mayor satisfacción en los pacientes que recibieron orientación (satisfacción con orientación: m = 9,65, de = 0,84; satisfacción sin orientación: m = 7,73, de = 2,37). la satisfacción del paciente con el manejo del dolor posoperatorio se asoció con el máximo dolor reportado en las primeras 24 horas (r = -0,25, p = 0,03). a mayor intensidad de dolor en las primeras 24 horas posoperatorias menor satisfacción del paciente. el análisis a través de la regresión lineal múltiple permitió identificar que la satisfacción del paciente con el manejo del dolor está determinada por el máximo dolor posoperatorio y por la orientación recibida para el manejo del mismo. en la tabla 6 se presentan los resultados. 467 satisfacción con el manejo del dolor posoperatorio en pacientes hospitalizados l maría guadalupe moreno-monsiváis y otros discusión los resultados permitieron confirmar los postulados de la teoría de rango medio para el manejo del dolor utilizada como sustento teórico del estudio. en cuanto a la intensidad se identificó una alta proporción de pacientes con presencia de dolor de moderado a severo en las primeras 24 horas posoperatorias, esto coincide con lo reportado por bolibar (24), leal et al. (6), moreno et al. (7), sada, delgado y castellanos (9). este hallazgo confirma que el manejo adecuado del dolor sigue siendo un reto para las instituciones de salud, y en especial para el ámbito quirúrgico. respecto al comportamiento de la intensidad del dolor, casi la mitad de los pacientes reportaron como máximo dolor el de tipo severo y solo una tercera parte presentó dolor moderado; en cuanto al dolor al momento de la entrevista más de la mitad tuvo ausencia. estos hallazgos son similares a los reportados por moreno et al. (7), así como por sada et al. (9), quienes señalan una alta proporción de pacientes con dolor severo y escasa proporción de dolor al momento de la entrevista. de acuerdo con los resultados del presente estudio y con la literatura existente, el inadecuado manejo del dolor posoperatorio sigue siendo un problema de salud pública que requiere de intervenciones efectivas basadas, no solo en el tratamiento farmacológico, sino en una combinación de aspectos indispensables como son la valoración y orientación que en su interacción con la medicación permiten un adecuado alivio del dolor, tal y como lo señalan good y moore en su teoría (15). en la valoración del dolor es importante considerar algunos aspectos demográficos que pueden influir en su intensidad, en algunos estudios se ha tratado de determinar la diferencia en la intensidad del dolor de acuerdo con el género del paciente, debido a que se ha reportado que esta característica puede ser una variable diferencial en esta experiencia; en el presente estudio se observó una mayor intensidad de dolor en las mujeres; sin embargo, esta diferencia no es estadísticamente significativa. este hallazgo difiere de los resultados de moreno et al. (7), quienes reportan diferencia significativa respecto al género, con predominio del dolor en las mujeres. contrario a estos hallazgos, álvarez-ríos y manrique-carmona (25) encontraron que el dolor predominó en los hombres. otro aspecto demográfico que se ha asociado a la intensidad del dolor es la edad; en el presente estudio no se encontró asociación entre la edad de los pacientes participantes con la intensidad del dolor. esto coincide con ramírez-maestre et al. (26) y peñarrieta et al. (8); sin embargo, los hallazgos difieren de lo reportado por bolibar et al. (24) quienes señalan que a mayor edad mayor presencia de dolor de intensidad moderada. en relación con la intensidad del dolor según el tipo de cirugía, se encontró que la intensidad más alta fue reportada por los pacientes a los que se les realizó cirugía menor. esto puede atribuirse a que, al ser una cirugía menor, la prescripción farmacológica se basa en analgésicos de menor potencia, con un efecto insuficiente en la disminución del dolor. cabe destacar que no se encontró diferencia significativa en la intensidad del dolor de los pacientes por especialidad, contrario a lo reportado en la literatura por sobrino et al. (11). en cuanto al tratamiento farmacológico empleado se observó que más de la mitad recibieron tratamiento con aines, lo que coincide con lo reportado por bolibar et al. (24) y moreno et al. (7). en cuanto a los opioides, en el presente estudio predominaron los de tipo débil, a diferencia de bolibar et al. (24) donde predominaron los de tipo fuerte. esto evidencia que el manejo del dolor con opioides sigue siendo a criterio del médico tratante y según la disponibilidad farmacológica. este hallazgo es consistente con lo reportado por la oms (13), organismo que señala que existe una subutilización de los analgésicos y opioides de acuerdo con las pautas analgésicas preescritas. al estimar el imd como parámetro que permitió conocer el alivio del dolor a través de su manejo, se encontró que poco más de tres cuartas partes de los pacientes recibieron un manejo adecuado, estos hallazgos son muy similares a los reportados por moreno et al. (7); sin embargo, difieren de los resultados de peñarrieta et al. (8), quienes encontraron que más de la mitad de los pacientes recibieron un manejo inadecuado. estos hallazgos pudieran atribuirse a que el presente estudio se realizó en un hospital privado, a diferencia del estudio de peñarrieta et al. (8), quienes lo realizaron en un hospital público donde los recursos farmacológicos pueden estar supeditados a un cuadro básico. para la institución participante en este estudio, la proporción de pacientes con manejo inadecuado representa un área de oportunidad donde debe involucrarse tanto al personal médico (prescripción farmacológica) como al de enfermería (valoración). en cuanto a la orientación preoperatoria y posoperatoria para el manejo del dolor se encontró que la mayoría de los pacientes 468 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 recibieron orientación, esto difiere de lo reportado por leal et al. (6), donde predominó una alta proporción de pacientes que no recibió orientación. respecto a la persona que proporcionó la orientación, es relevante señalar que generalmente esta función es realizada por personal médico, una mínima proporción de pacientes reportó haber recibido orientación por parte de enfermería. este hallazgo es un área de oportunidad para el personal de enfermería, se requiere de un mayor involucramiento en esta función por ser el primer contacto con el paciente antes de ingresar al quirófano, así como por ser el profesional de la salud que permanece la mayor parte del tiempo junto al paciente. además, de acuerdo con los estándares internacionales, el adecuado manejo del dolor requiere de educación del paciente y del involucramiento del personal sanitario que participa en la atención (1). en relación con la satisfacción del paciente con el manejo del dolor por parte del personal médico y de enfermería se encontró que una alta proporción manifestó estar satisfecho, este hallazgo es semejante a lo referido por gallego et al. (27), moreno et al. (7), leal (6), así como arbónes et al. (5); pero contrasta con lo reportado por sada, delgado y castellanos (9) y peñarrieta et al. (8), quienes reportan que la mayoría de los pacientes manifestaron insatisfacción en relación con el manejo del dolor. se encontró que a mayor intensidad del dolor y a menor orientación del paciente, la satisfacción con el manejo del dolor disminuye, este aspecto es relevante de considerar sobre todo en una institución hospitalaria de tipo privado, donde la satisfacción es un indicador de calidad que puede contribuir a que el paciente solicite nuevamente los servicios de la institución. la satisfacción con el manejo del dolor está determinada por su intensidad y la orientación recibida para su manejo, estos factores son relevantes de considerar a fin de lograr la satisfacción del usuario. esto ayuda a explicar los resultados respecto a la satisfacción del paciente con la atención en general, una alta proporción recibió orientación pre y posoperatoria; además, el tiempo de respuesta por parte de enfermería para administrar el analgésico demandado por los pacientes ante la presencia del dolor fue menor a cinco minutos, lo cual contribuye a disminuir la intensidad del mismo. los hallazgos encontrados en este estudio permitirán a los administradores de enfermería la toma de decisiones orientadas a fortalecer la valoración del paciente para identificar la presencia e intensidad del dolor y desarrollar las medidas de atención pertinentes para disminuir su intensidad en el grupo de pacientes en el periodo posoperatorio, así como fomentar la participación de enfermería en la orientación del paciente con relación al manejo del dolor, aspectos considerados en los postulados de la teoría de rango medio para el manejo del dolor y confirmados como relevantes en el presente estudio. conclusiones los resultados del presente estudio son relevantes para mejorar la atención que se proporciona al paciente posoperatorio durante su hospitalización. los hallazgos revelan una alta proporción de pacientes con dolor moderado a severo como máximo dolor durante las primeras 24 horas posoperatorias, esto demanda un mayor esfuerzo en las instituciones de salud y una participación activa de los profesionales de salud que brindan atención al paciente durante el periodo posoperatorio. la satisfacción del paciente es considerada un indicador confiable y válido de la calidad de la atención. se encontró que dicha satisfacción con el manejo del dolor posoperatorio se ve afectada por la intensidad del mismo, específicamente por el máximo dolor que percibe el paciente y por la orientación que se proporciona para su manejo, resultado que confirma los planteamientos teóricos que sustentan el estudio. estos resultados demandan una participación activa del personal de enfermería en la valoración del dolor, de tal forma que sea identificado oportunamente, y con apoyo de medidas farmacológicas y no farmacológicas se evite que avance a un dolor de tipo severo; asimismo, se requiere un mayor involucramiento en la orientación que se proporciona al paciente para el manejo del dolor, principales áreas de oportunidad identificadas en el estudio. 469 satisfacción con el manejo del dolor posoperatorio en pacientes hospitalizados l maría guadalupe moreno-monsiváis y otros referencias 1. muñoz-ramón jm, carr db, sukiennik a, wurn wh. tratamiento del dolor agudo postoperatorio. protocolos y procedimientos del new england medical center de boston. rev soc esp dolor. 2009;9:176-188. 2. vidal m, torres l, de andrés j, moreno-azcoitia m. estudio observacional sobre el dolor postoperatorio leve o moderado desde el punto de vista del anestesiólogo. rev soc esp dolor. 2007;8:550-567. 3. guevara-lópez u, covarrubias-gómez a, rodríguez-cabrera r, carrasco-rojas a, aragón g, ayon-villanueva h. parámetros de práctica para el manejo del dolor en méxico. cir ciruj. 2007;75(4):385-407. 4. covarrubias-gómez a. manejo farmacológico del dolor perioperatorio. revista mexicana de anestesiología. 2007;30(1):240-245. 5. arbónes e, montes a, riu m, farriols c, mínguez s. el dolor en los pacientes hospitalizados: estudio transversal de la información, la evaluación y el tratamiento. rev soc esp dolor. 2009;16(6):314-322. 6. leal me, mendoza md, hernández ne, ávila h, frías b, gracia gn. satisfacción del control y alivio del dolor en usuarios postoperados hospitalizados. revista enfermería universitaria eneo-unam. 2009;6(6):32-35. 7. moreno-monsiváis mg, interial-guzmán mg, garza-elizondo me, hernández-fierro ea. intensidad y manejo del dolor posoperatorio en pacientes hospitalizados. rev cuid. 2012;3(3):355-362. 8. peñarrieta i, del ángel re, garcía m, vergel s, gonzález f, zavala mr. manejo del dolor y la satisfacción de pacientes postoperados hospitalizados. desarrollo científ enferm. 2006;14(1):20-26. 9. sada o, delgado h, castellanos o. prevalencia del dolor postoperatorio en cirugía electiva de pacientes del hospital de especialidades del centro médico nacional siglo xxi imss. rev soc esp dolor. 2011;18:91-97. 10. gonzález n. analgesia multimodal postoperatoria. rev soc esp dolor. 2005;12:112-118. 11. sobrino j, cabadas r, rodríguez j, ares x, pereira j. pain during the early postoperative period in outpatient major surgery: determining factors. rev soc esp dolor. 1999;6:175-179. 12. muñoz-blanco f, salmeron j, santiago j, marcote c. complicaciones del dolor postoperatorio. rev soc esp dolor. 2001;8:194-211. 13. organización mundial de la salud (oms). manejo integral en la enfermedad de los adolescentes y adultos. 2004 [citado 2011 nov 21]. disponible en: http://www.who.int/3by5/publications/documents/en/genericpalliativecare082004. pdf 14. sánchez b. abordajes teóricos para comprender el dolor humano. aquichan. 2003;3:32-41. 15. good m, moore s. clinical practice guidelines as a new source of middle-range theory: focus on acute pain. rev nurs outlook. 1996;2,44:74-9. 16. montes a, garcía j, trillo l. tratamiento del dolor postoperatorio: de la unidad de dolor agudo al programa de gestión del dolor postoperatorio. rev soc esp dolor. 2007;14(5):335-337. 17. moreno m, interial m, sauceda p, vázquez l, lópez j. satisfacción de las madres con la atención a sus hijos hospitalizados. aquichan. 2011;11(1):40-47. 18. achury d. dolor: la verdadera realidad. aquichan. 2008;8(2):146-158. 19. mcneill ja, sherwood gd, starck pl. the hidden error of mismanaged pain: a systems approach. j pain symptom manage. 2004;28:47-58. 20. grove s, burns n, gray j. the practice of nursing research appraisal, synthesis, and generation of evidence. elsevier. 2013;7:224-227. 21. elashoff d, dixon j, crede m, fothenrigham, n. n´query advisor program, versión 4.0. 2000. 22. mccaffery m, pasero c. pain: clinical manual. st. louis: mosby; 1999. 470 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 23. secretaría de salud. reglamento de la ley general de salud en materia de investigación para la salud. méxico: porrúa; 1987. 24. bolibar i, catala e, cadena r. el dolor en el hospital: de los estándares de prevalencia a los de calidad. rev esp anestesiol reanim. 2005;52,131-140. 25. álvarez ríos jj, manrique-carmona l. infusión continua de fentanil-ketoprofeno en analgesia postoperatoria de cirugía mayor: un estudio causi-experimental. revista anestesia en méxico. 2005;7(3),105-111. 26. ramírez-maestre c, esteve r, lópez-martínez ae, anarte mt. diferencias en la percepción del dolor relacionadas con las variables sexo y edad. revista sociedad española del dolor. 2001;8:562-568. 27. gallego jl, rodríguez jc, vázquez g, gil m. estimación de la prevalencia e intensidad del dolor postoperatorio y su relación con la satisfacción de los pacientes. rev soc esp dolor. 2004;11:197-202. 471 satisfacción con el manejo del dolor posoperatorio en pacientes hospitalizados l maría guadalupe moreno-monsiváis y otros anexo intensidad m mdn de intervalo de confianza al 95 % nivel promedio usual primeras 24 horas 4,55 5,00 3,05 4,12 4,98 máximo dolor en las primeras 24 horas 5,64 6,00 3,38 5,16 6,12 dolor al momento de la entrevista 2,33 1,00 2,90 1,92 2,74 tabla 1. intensidad del dolor fuente: cid n = 193 de = desviación estándar tabla 2. clasificación de la intensidad del dolor fuente: cid. n = 193 intensidad del dolor dolor en las primeras 24 horas máximo dolor en las primeras 24 horas dolor al momento de la entrevista clasificación f % f % f % ausencia del dolor 30 15,50 29 15,00 91 47,20 dolor leve 46 23,80 25 13,00 45 23,30 dolor moderado 56 29,00 46 23,80 34 17,60 dolor severo 61 31,60 93 48,20 23 11,90 tabla 3. intensidad del dolor de acuerdo al género fuente: cédula de datos y cid. n = 193 intensidad género m mdn de intervalo de confianza al 95% dolor promedio en las primeras 24 horas femenino 5,05 5,00 2,99 4,51 5,59 masculino 3,71 4,00 2,98 3,01 4,41 máximo dolor en las primeras 24 horas femenino 6,09 7,00 3,23 5,51 6,67 masculino 4,88 5,00 3,51 4,05 5,70 dolor al momento de la entrevista femenino 2,55 1,00 2,95 2,02 3,09 masculino 1,96 1,00 2,80 1,30 2,62 472 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 tabla 4. intensidad del dolor de acuerdo al tipo de intervención quirúrgica fuente: cédula de datos y cid. n = 193 de = desviación estándar intensidad tipo de intervención m mdn de intervalo de confianza al 95 % dolor promedio en las primeras 24 horas cirugía menor 4,74 5,00 3,13 4,01 5,47 cirugía mayor 4,43 4,00 3,01 3,89 4,98 máximo dolor en las primeras 24 horas cirugía menor 5,67 7,00 3,37 4,88 6,46 cirugía mayor 5,62 6,00 3,40 5,00 6,23 dolor al momento de la entrevista cirugía menor 2,56 0,00 3,17 1,82 3,30 cirugía mayor 2,19 1,00 2,73 1,70 2,69 tabla 5. orientación preoperatoria y posoperatoria proporcionada a los participantes fuente: cédula de datos. n = 193 orientación f % recibió orientación preoperatoria sí 165 85,50 no 28 14,50 recibió orientación posoperatoria sí 182 94,30 no 11 5,70 persona que proporcionó la orientación médico cirujano 68 35,20 anestesiólogo 81 42,00 enfermera 16 8,30 nadie 28 14,50 determinantes b beta estandarizada t p máximo dolor 0,05 -0,17 -2,34 0,02 alivio del dolor -0,10 -0,11 -1,51 0,13 orientación -1,12 -0,37 -5,51 0,00 tabla 6. determinantes de la satisfacción del paciente con el manejo del dolor posoperatorio r2 = 0,17; error estándar = 0,99; f = 12,41; p = 0,000 313 327 genero y efectividad.indd 313 cipriano viñas-vera1 ana maría garcía-parra2 isabel maría morales-gil3 género y efectividad de la metodología enfermera en pacientes con insufi ciencia cardiaca 1 hospital virgen de la victoria de málaga, españa. cipriano.vinas.sspa@juntadeandalucia.es 2 universidad de málaga, españa. amgp@uma.es 3 universidad de málaga, españa. inmorales@gmail.com recibido: 18 de mayo de 2015 enviado a pares: 14 de julio de 2015 aceptado por pares: 4 de abril de 2016 aprobado: 14 de abril de 2016 doi: 10.5294/aqui.2016.16.3.4 para citar este artículo / to reference this article / para citar este artigo viñas-vera c, garcía-parra am, morales-gil im. género y efectividad de la metodología enfermera en pacientes con insuficiencia cardiaca. aquichan. 2016; 16(3): 313-327. doi: 10.5294/aqui.2016.16.3.4 resumen estudios recientes demostraron que una intervención enfermera de educación sanitaría en la insuficiencia cardiaca (ic) evita descompensaciones. por otro lado, dado que existen diferencias de género en los patrones de la ic, las intervenciones tendrán también efectos distintos. objetivos: determinar la existencia de posibles diferencias según el género de los pacientes, en el efecto de una intervención enfermera respecto al autocuidado. materiales y métodos: se realizó un estudio cuasiexperimental con pacientes atendidos en consulta de ic (129), seleccionados en dos tiempos, primer trimestre año grupo control (62), y segundo trimestre año grupo intervención (67). todos se evaluaron tres veces: primera consulta, tres y seis meses. al grupo intervención se aplicó en cada visita una intervención enfermera que consistía en educación terapéutica, control y seguimiento de su ic. resultados: inicio: t.a. sistólica hombres 133,90 ± 0,96 (de 27,77); mujeres 119,64 ± 0,57 (de 18,72). cuidador 93 % hombres, 63 % mujeres. conducta terapéutica 2,07 ± 0,02 (de 0,20) hombres; 3,04 ± 0,01 (de 0,31) mujeres. final: autocuidado -16,00 ± 2,08 (de 10,99) hombres; -9,68 ± 2,22 (de 12,92) mujeres. adherencia terapéutica 1,32 ± 0,35 (de 1,83) hombres, 2,94 ± 1,87 (de 10,93) mujeres. mejoría muy similar de la nursing outcomes classification (noc) en todos. conclusiones: en el grupo de estudio participaron más mujeres. los hombres tuvieron más comorbilidad, consumo de tabaco, alcohol. inicialmente los hombres presentaban mejor calidad de vida. después de la intervención mejora el autocuidado en todos los participantes pero el doble en hombres. también mejora adhesión terapéutica en todos, en las mujeres mejora el doble. todos los pacientes mejoran respecto a la calidad de vida y resultados noc. palabras clave insuficiencia cardíaca; identidad de género; planificación de cuidados; intervenciones enfermería; enfermería cardiovascular (fuente: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 313-327 314 aquichan issn 1657-5997 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 313-327 gender and effectiveness of the nursing methodology in heart failure patients abstract recent studies show that nurse intervention in health education in heart failure (hf) prevents decompensation in heart failure (hf). furthermore, given gender differences in hf patterns, the interventions will also have different effects. objective: to determine the existence of possible differences in the effects of a nurse’s intervention regarding self-care based on the patient’s gender. materials and method: a quasi-experimental study was carried out with hf patients (129). they were selected at two different times: first quarter’s control group (62) and second quarter’s intervention group (67). they were all assessed three times: first appointment, three and six month check-ups. the intervention group underwent a nurse intervention during each visit, consisting of therapeutic education, control and monitoring of their hf. results: beginning: systolic blood pressure in men 133.90±0.96 (de 27.77), women 119.64±0.57 (de18.72). caregiver 93% male, 63% female. therapeutic approach 2.07+0.02 (de0.20) men, 3.04+0.01 (de 0.31) women. final: self-care -16.00±2.08 (de10.99) men, -9.68±2.22 (de12.92) women. therapeutic adherence 1.32±0.35 (de1.83) men, 2.94±1.87 (de10.93) women. very similar improvements in the noc of all patients. conclusions: more women participated in the study than men; [1] the former showed a higher percentage of comorbidity, smoking and alcohol consumption than women and they had an informal caregiver. as to self-care and adherence to treatment, no significant differences were found between genders, while quality of life was better in men. after the intervention, the researchers found that all patients improved in terms of quality of life and noc (nursing outcomes classification), as did the self-care and therapeutic adherence of all participants. [2] it is worth noting that men scored twice as high in self-care, while women did so in therapeutic adherence. keywords heart failure; gender identity; care planning; nursing interventions; cardiovascular nursing (source: decs, bireme). 315 género y efectividad de la metodología enfermera en pacientes con insuficiencia cardiaca l cipriano viñas vera y otros gênero e efetividade da metodologia enfermeira em pacientes com insuficiência cardíaca resumo estudos recentes demonstraram que uma intervenção enfermeira de educação sanitária na insuficiência cardíaca (ic) evita descompensações. no entanto, tendo em vista que existem diferenças de gênero nos padrões da ic, as intervenções terão também efeitos diferentes. objetivo: determinar a existência de possíveis diferenças segundo o gênero dos pacientes, no efeito de uma intervenção enfermeira a respeito do autocuidado. material e método: realizou-se um estudo quase experimental com pacientes atendidos em consultas de ic (129). selecionados em dois tempos, primeiro trimestre ano grupo controle (62) e segundo trimestre ano grupo intervenção (67). todos foram avaliados três vezes, primeira consulta, três e seis meses. ao grupo de intervenção, foi aplicada, em cada visita, uma intervenção enfermeira que consistia na educação terapêutica, controle e seguimento de sua ic. resultados: início: ta sistólica homens 133.90±0.96 (de 27.77), mulheres 119.64±0.57 (de18.72). cuidador 93% homens, 63% mulheres. comportamento terapêutico 2.07+0.02 (de0.20) homens, 3.04+0.01 (de 0.31) mulheres. final: autocuidado -16.00±2.08 (de10.99) homens, -9.68±2.22 (de12.92) mulheres. adesão terapêutica 1.32±0.35 (de1.83) homens, 2.94±1.87 (de10.93) mulheres. melhora muito semelhante dos noc (nursing outcomes classification) em todos. conclusão: do grupo de estudo, participaram mais mulheres do que homens; contudo, estes últimos tiveram mais comorbidade, consumo de tabaco e de álcool e dispunham de uma cuidadora informal. com relação ao autocuidado e a adesão ao tratamento, na valoração inicial, não se constatou uma diferença significativa entre ambos os gêneros, enquanto na qualidade de vida, o resultado foi melhor nos homens. após a intervenção, observou-se que todos os pacientes melhoraram os resultados em qualidade de vida e em nursing outcomes classification (noc), bem como no autocuidado e na adesão terapêutica. é relevante destacar que os homens dobraram a pontuação em autocuidado e as mulheres em adesão terapêutica. palavras-chave insuficiência cardíaca; identidade de gênero; planejamento de cuidados; intervenções enfermeiras; enfermagem cardiovascular (fonte: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 313-327 316 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 introducción un concepto que nos puede acercar al significado de la insuficiencia cardiaca (ic) es aquel que la define como un síndrome patológico caracterizado por la incapacidad del corazón para mantener un flujo sanguíneo adecuado a las necesidades metabólicas de los órganos periféricos (1). no hay un consenso sobre el orden en que aparecen los mecanismos que causan esta incapacidad, pero se sabe que la ic es, en casi todos los casos, el resultado final de la mayoría de las enfermedades cardiacas primarias, o del consecuente deterioro del corazón (2, 3). debido al envejecimiento progresivo de la población, y al aumento de la supervivencia de los pacientes con cardiopatía e hipertensión arterial, la prevalencia de la ic sigue en aumento, convirtiéndola en una verdadera “epidemia”, y un problema de salud pública de primer orden (4). la tasa total estimada gira entre 3 y 20 casos por cada mil habitantes, y en personas mayores de 65 años, sube entre 30 y 130 por cada mil personas de esa edad (5). es frecuente, además, que los pacientes con ic presenten un alto número de hospitalizaciones y entradas a urgencias debido, en muchas ocasiones, a una exacerbación de signos y síntomas, que suele deberse a un manejo inadecuado del régimen terapéutico (6). estos pacientes suelen desarrollar una alta dependencia del hospital, convirtiéndose en lo que se denomina híperfrecuentadores, tanto por el número de veces que acuden a las consultas de especialistas y a urgencias hospitalarias como por los ingresos debidos a descompensaciones de su enfermedad (7). este problema de manejo del régimen terapéutico lo encontramos incluso cuando intentamos llevar a la práctica los hallazgos de los ensayos clínicos. como en muchas enfermedades crónicas, y a diferencia de las agudas, las condiciones crónicas requieren mantener la adherencia a la medicación, el manejo de medidas no farmacológicas como la dieta, y un seguimiento prolongado a través de diferentes niveles de atención en los servicios de salud. en este sentido, se destaca la existencia de numerosos estudios en los que los programas asistenciales que potencian la continuidad asistencial y la orientación al autocuidado en la ic tienen resultados prometedores, existiendo una tasa menor de reingresos, con una menor frecuentación a urgencias, mejor calidad del tratamiento y de vida, mejor pronóstico y menor mortalidad (8, 9). son muchos los estudios que han demostrado que la educación para el autocuidado puede reducir los eventos clínicos adversos, disminuir los reingresos no programados, mejorar la calidad de vida o, incluso, mejorar el pronóstico de la enfermedad (10). en este sentido, ensayos clínicos recientes han demostrado que los pacientes con insuficiencia cardiaca han mejorado su autocuidado después del alta hospitalaria gracias a estrategias de visitas domiciliarias (11). en un ensayo clínico sobre la efectividad de un programa educativo en enfermería para el autocuidado de pacientes con insuficiencia cardiaca, se encontró que las intervenciones educativas de enfermería incluidas en los planes de cuidados de la ic tienen un efecto beneficioso en los comportamientos de autocuidado de estas personas(12). por otro lado, esta línea de trabajo que, como hemos visto, se ha evidenciado como efectiva para el cuidado de los pacientes con ic, no distingue qué características particulares se deben tener en cuenta en el abordaje de hombres y mujeres. lo anterior teniendo en cuenta que, actualmente en españa, las enfermedades cardiovasculares son la primera causa de mortalidad femenina, con 282,2 muertes por cada 100.000 habitantes y la segunda entre los hombres, con 239,4 (12). entre el año 2009 y 2013 se produjeron en españa una media de 17.212 fallecimientos por ic (13). dado que la mortalidad en mujeres por ic es preocupante, hay que tener en cuenta que las características específicas de la ic en esta población han sido poco estudiadas. la proporción de mujeres incluidas en los grandes ensayos clínicos sobre ic es inferior al 20 %, mientras que casi la mitad de los ingresos hospitalarios por esta causa son de mujeres (14). el abordaje integral de muchas enfermedades se realiza desde la perspectiva masculina, con frecuencia sin tener en cuenta los aspectos sociológicos y antropológicos relacionados con el género, factores que contribuyen a particularizar los procesos fisiológicos y patológicos de mujeres y hombres. además, las mujeres presentan la enfermedad en edades más avanzadas que los hombres, y un perfil cardiovascular mucho más 317 género y efectividad de la metodología enfermera en pacientes con insuficiencia cardiaca l cipriano viñas vera y otros desfavorable, con mayor prevalencia de la hipertensión arterial, la diabetes y la ic previa (15). según el registro hospitalario de icc en andalucía (registro raic), las mujeres que ingresan en un hospital por ic tienen mayor edad; el porcentaje de pacientes mayores de 75 años de sexo femenino es especialmente llamativo, están menos atendidas por el servicio de cardiología, es más probable que sean diabéticas, la etiología isquémica de la icc es menos frecuente que en varones, y la hta es más habitual. en el registro español de pacientes con icc atendidos ambulatoriamente en consultas especialidades (registro badapic), se detalla que los varones eran más jóvenes que las mujeres, tenían menor frecuencia de antecedentes de hipertensión arterial, diabetes e hiperlipemia, y mayor frecuencia de antecedentes de cardiopatía isquémica y revascularización coronaria. por tanto, siendo el tratamiento y el pronóstico diferente para hombres y mujeres, se entiende que también deberían serlo las pautas de cuidados. sobre todo si consideramos que existen diferencias entre hombres y mujeres en el conocimiento y las creencias sobre la enfermedad, así como en las actitudes adoptadas cuando aparecen los primeros síntomas (16). de esta forma, y teniendo en cuenta las discordancias que presentan hombres y mujeres en el curso de esta enfermedad, y que estas se traducen en distintos resultados de salud, surge la necesidad de valorar la efectividad de las terapéuticas que se están utilizando (14). entre otros aspectos, en los pacientes ingresados por ic, las mujeres presentaron un riesgo de muerte intrahospitalaria tres veces superior al de los varones (15). por todo lo expuesto, hemos desarrollado una investigación que nos oriente sobre las diferencias que según el sexo podemos encontrar en el efecto de una intervención enfermera orientada al autocuidado y adherencia terapéutica, con repercusión en la calidad de vida. objetivos objetivo general. determinar la existencia de posibles diferencias según el género de los pacientes, en el efecto de una intervención enfermera respecto al autocuidado. objetivos específicos 1. identificar las características sociodemográficas y los factores de riesgos de insuficiencia cardiaca, clasificación funcional según la escala nyha, y la necesidad de apoyo para su autocuidado, de la población estudiada en relación con su género. 2. conocer la situación inicial de los pacientes estudiados respecto a su autocuidado mediante la escala europea de autocuidado, adherencia terapéutica por la escala de morisky modificada, calidad de vida relacionada con la salud a partir de la escala minnesota living with heart failure questionnarie, e indicadores de la nursing outcomes classification (noc) seleccionados. 3. establecer diferencias en el efecto de una intervención enfermera, atribuibles al género de los pacientes estudiados, respecto a su autocuidado (escala europea de autocuidado en la ic), adherencia terapéutica (morisky modificada), calidad de vida relacionada con la salud (minnesota linving with heart failure questionnarie), e indicadores de resultados noc seleccionados. materiales y métodos diseño del estudio. estudio de intervención, cuasi experimental, con grupo control, prospectivo, con seguimiento de seis meses. la estructura del estudio se ha configurado teniendo en cuenta aquellos ítems del checklist de la extensión del consort que son de aplicación (17). ámbito de estudio. servicio de cardiología de la unidad de gestión clínica (ugc) médico quirúrgica de corazón y patología vascular del hospital regional universitario de málaga. cuenta con una unidad específica para la atención a la ic que atiende a unos 200 pacientes nuevos cada año. población. pacientes atendidos por primera vez en la unidad de ic que tiene esta ugc durante el periodo definido para el estudio, y que cumplan los criterios de inclusión señalados. tamaño de la muestra. se establecieron dos grupos, control e intervención; 62 pacientes formaron parte del grupo control, y 67 del grupo intervención. en total se estudiaron 129 pacientes. el 318 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 tamaño de la muestra corresponde a los pacientes nuevos que se atendieron en la unidad de ic durante los periodos en los que se realizó la selección. selección. la selección de los pacientes estudiados en cada grupo se llevó a cabo en dos épocas. en primer lugar, se seleccionaron los pacientes que formaron parte del grupo control, estudiando a aquellos que acudieron a la consulta de ic durante los tres primeros meses del año 2012, y que cumplían los criterios de inclusión. en estos se practicó la atención habitual establecida en el proceso asistencial integrado de ic, que consiste en la atención en consulta realizada por un médico especialista en cardiología, pero sin la atención estructurada de enfermería que se describe en la intervención aplicada en este estudio. a continuación, y durante el segundo trimestre del año 2012, se seleccionaron los pacientes que formaron parte del grupo intervención, incluyendo a los que acudieron a esta consulta de ic. los pacientes atendidos en esta unidad deben cumplir una serie de requisitos que se han asumido como criterios de inclusión. a los pacientes del grupo intervención se les aplicó la intervención enfermera estandarizada. criterios de inclusión de pacientes • pacientes mayores de 18 años atendidos en la unidad de ic de la unidad de gestión clínica de corazón y patología vascular del hospital regional universitario de málaga. • pacientes con ic con diagnóstico previo de esta patología, no secundaria a causa reversible. • pacientes que no padezcan una enfermedad terminal no cardiológica concomitante. • pacientes con mínima, o sin autonomía para su autocuidado. • pacientes que no presenten condición alguna o circunstancia que limite razonablemente el seguimiento o la participación en el estudio. • pacientes con capacidad para firmar el consentimiento informado, y que acepten hacerlo. procedimiento en ambos grupos, control e intervención, se realizaron tres valoraciones, primera consulta, y a los tres y seis meses de la primera consulta, valorando los siguientes parámetros • edad, sexo, residencia, nivel de estudios, ocupación, cuidador principal. • hábitos tóxicos, antecedentes familiares de ic, diabetes, hipertensión arterial, enfermedad arterial coronaria, otras patologías. • constantes vitales: temperatura, frecuencia cardiaca, frecuencia respiratoria, tensión arterial, clasificación ic. • autocuidado, adherencia terapéutica, calidad de vida relacionada con la salud, e indicadores noc. en la primera visita se firmaba el consentimiento informado. en el grupo intervención se aplicó, además de lo anterior, la intervención establecida en las tres visitas. con esta secuencia, el desarrollo temporal del estudio se prolongó de enero a diciembre de 2012, iniciando la captación y el seguimiento de pacientes a principios del mes de enero de 2012, y finalizando el 30 de junio de ese mismo año. con lo que el seguimiento de los seis meses del último paciente se realizó a finales de diciembre de 2012. descripción de instrumentos de medición escala europea de autocuidado en ic. la escala europea de autocuidado en ic ha sido desarrollada para evaluar el autocuidado de los pacientes, valorando los conocimientos necesarios. la puntuación es de 12 a 60, siendo los de menor valor los que representan un mejor autocuidado (18). la puntuación para cada una de las respuestas va de 1 a 5, donde 1 identifica que se cumple siempre el planteamiento realizado, y 5, que no se cumple nunca. teniendo en cuenta que las preguntas son 12, si a todas se responde con 1 (siempre se realizan las actividades de autocuidado), serían 12 los puntos, y si a todas se responde con 5 (nunca se realizan las actividades de autocuidado), las puntuación sería de 60. escala de morisky modificada. este cuestionario mide la adherencia terapéutica mediante cuatro sencillas y cortas preguntas, englobando los conceptos de cumplimiento de dosis, forma de administración y persistencia en la duración del tratamiento prescrito (19). 319 género y efectividad de la metodología enfermera en pacientes con insuficiencia cardiaca l cipriano viñas vera y otros en la valoración se distingue la motivación de los pacientes por un lado, y por otro su conocimiento, estableciendo, tanto para la motivación como para el conocimiento, una escala de valores que va de 0 a 3 puntos; donde una puntuación situada entre 0 y 1 puntos se traduce en una adherencia baja a la terapia con medicación, y puntuaciones superiores a 2 puntos en una adherencia alta (20). versión española del test minnesota living with heart failure questionnarie (mlhfq). este cuestionario es el instrumento más utilizado para la evaluación de la calidad de vida en pacientes con ic. realiza 21 preguntas referidas a la forma en que la insuficiencia cardiaca ha impactado en su vida durante el último mes (4 semanas) (21). cada pregunta tiene una valoración del 0 al 5, siendo 5 el que se atribuye a la mayor afectación posible en la calidad de vida de los pacientes, y 1 el de la menor. el valor 0 corresponde a los casos en los que la pregunta no se puede aplicar al paciente (22). si suponemos que se responde a todas las preguntas con el mismo valor, se puede establecer una escala de valores en calidad de vida que irían desde 0 en caso de que ninguna pregunta tenga aplicación, 21 en el caso en que todas las respuestas hayan sido 1 (mínimo impacto en calidad de vida), a 105 puntos cuando se haya respondido con 5 (máximo impacto en calidad de vida) a todas las preguntas (23). valoración indicadores de resultados noc. se han evaluado tanto en el grupo control como en el de intervención los indicadores de resultados noc incluidos en el plan de cuidados de la intervención. para ello, se ha utilizando una escala likert con puntuación del 1 al 5 donde, en todos los casos, 1 representa la peor valoración y 5 la mejor. existen estudios en los que se evidencia que los indicadores de resultado noc constituyen una buena herramienta de medida del conocimiento que tienen los pacientes de su enfermedad (24) descripción de la intervención (25) se ha proporcionado a los pacientes educación terapéutica estructurada sobre su enfermedad, tratamiento y expectativas de evolución, reforzando de forma individual aquellos aspectos relacionados con la idiosincrasia de los pacientes y el estadio evolutivo de la enfermedad en el que se encontraban. esta educación se basó en un plan de cuidados elaborado con metodologías nanda, nic, noc, así: a partir de una selección de diagnósticos enfermeros (nanda 2012), indicadores de resultados (noc 2009) e intervenciones enfermeras (nic 2008), realizada por consenso de expertos en metodología enfermera, y en el cuidado de pacientes con ic. este consenso se apoyó en una revisión de bibliografía sobre el cuidado de pacientes con ic. una vez determinados aspectos relativos al conocimiento de la enfermedad, como son el reconocimiento de signos y síntomas, y las señales de alerta en la evolución de la patología, se abordaron realizando una valoración destinada al control y seguimiento de la enfermedad. la intervención se aplicó en tres ocasiones: primera consulta, a los tres meses, y, por último, a los seis meses. en todas las consultas se valoraron los indicadores de los noc seleccionados y se trabajaron las áreas de mejora detectadas. además de valorar signos importantes para esta enfermedad (temperatura, tensión arterial, frecuencia cardiaca, respiratoria, peso), hábitos tóxicos, capacidad funcional y dependencia. los consejos que la enfermera ofrecía en la educación terapéutica se reforzaron mediante documentación impresa que se entregaba a los pacientes. la responsable de aplicar la intervención fue una enfermera, que participó en todos los casos realizando además las valoraciones tanto del grupo intervención como del control. nanda (26) 00126 conocimientos deficientes relacionados con insuficiencia cardiaca. 00078 gestión ineficaz de la propia salud. 00079 – incumplimiento. 00092 intolerancia a la actividad. 00026 exceso de volumen de líquidos. nic (26, 27) 5602 enseñanza: proceso de enfermedad. 5612 enseñanza: actividad/ejercicio prescrito. 5614 enseñanza: dieta prescrita. 5616 enseñanza: medicamentos prescritos. 320 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 noc (26) 1830 conocimiento: control de la enfermedad cardiaca. 1609 conducta terapéutica: enfermedad o lesión. 1601 conducta de cumplimiento. 0005 tolerancia a la actividad. 0414 estado cardiopulmonar. análisis de datos los datos obtenidos se sometieron a un triple análisis estadístico: análisis univariante para la descripción de las variables. en las cuantitativas se realizaron medidas de tendencia central y dispersión. en las cualitativas la distribución porcentual. análisis bivariante. utilizando, en función de la naturaleza de las variables, la prueba de chi cuadrado, t de student o anova. así como sus correspondientes no paramétricos cuando su distribución así lo requería. análisis multivariante. construyendo modelos de regresión multivariante con aquellas variables que en el análisis bivariante mostraron un patrón de relación significativa. aspectos éticos el presente estudio se ciñe en todo momento a la declaración de helsinki y a la ley de protección de derechos de los pacientes (ley 41/2002, de 14 de noviembre). todos los datos recogidos en este proyecto han sido registrados de forma anónima, siguiendo estrictamente las leyes y normas de protección de datos en vigor (ley 41/2002, de 14 de noviembre; ley 15/1999, de 13 de diciembre). el estudio fue aprobado por el comité de ética de la investigación de la provincia de málaga, y se solicitó consentimiento informado a los pacientes para el manejo de los datos con fines de investigación y garantizando su intimidad, mediante la firma de un documento donde consta el nombre y el dni, entre otros datos de filiación del paciente. resultados diferencias en la situación inicial de los participantes según el sexo. en el grupo control (tabla 1) las diferencias entre hombres y mujeres presentan significación estadística, así: en la valoración inicial las mujeres parten de mejores valores de tensión arterial sistólica que los hombres y presentan mejor conducta terapéutica que ellos. respecto a la persona cuidadora los hombres disponen de cuidador/a informal en mayor porcentaje. en el grupo de intervención (tabla 1) no encontramos significación estadística en la situación inicial de ingreso al estudio entre mujeres y hombres. diferencias en el efecto de la intervención según el sexo. para establecer la relación existente entre género y efectividad de la intervención, hemos analizado por separado la evolución que han tenido los hombres y las mujeres de cada uno de los dos grupos, desde el primer contacto (t1), hasta el último contacto previsto en el seguimiento del estudio (t3). en el grupo control (tabla 2), tanto los hombres como las mujeres apenas han tenido cambios en los indicadores estudiados al inicio y al final del estudio. se encontró significación estadística en que hombres y mujeres han mejorado su conducta terapéutica de forma muy parecida. en cambio, han sido solo los hombres los que han mejorado su tolerancia a la actividad y estado cardiopulmonar. presentando también significación estadística la diferencia de hombres y mujeres de este último indicador. en el grupo intervención (tabla 2), hombres y mujeres han mejorado su autocuidado, siendo esta mejoría mayor en los hombres, y presentando también la diferencia entre ambos significación estadística. los hombres han mejorado su adherencia terapéutica. tanto hombres como mujeres han mejorado de forma muy similar su conocimiento de la enfermedad cardiaca, conducta terapéutica: enfermedad o lesión, conducta de cumplimiento, tolerancia a la actividad y estado cardiopulmonar. discusión diferencias en la situación inicial de los pacientes en los distintos indicadores respecto al género de la población estudiada. 321 género y efectividad de la metodología enfermera en pacientes con insuficiencia cardiaca l cipriano viñas vera y otros la composición por sexos en los grupos estudiados era similar. en ambos grupos había una cantidad similar de hombres y mujeres, aunque el número de mujeres incluidas en el estudio es ligeramente superior al de los hombres. esta proporción coincide con los autores que han informado de una prevalencia de la ic similar en hombres y en mujeres (28). el grupo control presenta un mayor número de enfermedades concomitantes en hombres que en mujeres. en el grupo control un 20,69 % de los hombres presenta diabetes, frente a un 9 % de las mujeres. en la hta la diferencia, aunque similar, es más representativa: la padecían un 79,31 % de los hombres y un 66,6 % de las mujeres. en el grupo de intervención la presencia de otras patologías en los hombres es prácticamente igual que en las mujeres. estos resultados difieren de lo publicado por otros autores, que expresan que las mujeres con ic tienen una comorbilidad mayor que la de los hombres. de hecho, las mujeres, específicamente, presentan más hta y diabetes (15, 14). de forma parecida ocurre con los hábitos tóxicos que hemos encontrado, donde, tanto los hombres como las mujeres presentan un elevado consumo de tabaco. el porcentaje medio de fumadores en los dos grupos fue del 61,14 % de las mujeres y el 73,64 % de los hombres. respecto al alcohol, aunque con tasas menores, también hay un porcentaje alto de hombres y mujeres bebedoras; concretamente, el 22,9 % de los hombres y el 13,32 % de las mujeres. los datos publicados en este sentido exponen unas cifras menores en el consumo de tabaco y alcohol, tanto en hombres como en mujeres. concretamente, se ha situado el consumo de tabaco en cifras del 3,5 % de mujeres y 15,4 % hombres (29). mientras que el consumo de alcohol oscila en cifras del 1,3 % de los hombres y el 0,2 % de las mujeres (30). respecto a la capacidad física, que hemos valorado mediante la clasificación nyha, apenas existen diferencias según el sexo. en este apartado, los estudios consultados muestran una población más dependiente, con mayor presencia de niveles nyha iii, y los hombres tienen una dependencia mayor que las mujeres, hasta un 53 % tiene una clasificación iii-iv, frente a un 35 % de las mujeres (31, 32). respecto al autocuidado inicial, podemos apreciar valores muy similares para hombres y mujeres, con un mejor autocuidado de las mujeres del grupo intervención. resultado que contrasta con un mayor grado de conocimiento de los hombres en el manejo de problemas cardiacos (33), así como en el retraso en la búsqueda de ayuda médica, y la peor identificación de síntomas por parte de las mujeres (30). en la adhesión terapéutica hemos encontrado resultados de un cumplimiento importantes tanto en hombres como en mujeres, ya sean del grupo control o del grupo intervención. en la literatura consultada no hemos encontrado que hombres y mujeres tengan un perfil diferente en sus tratamientos farmacológicos (29). respecto a la calidad de vida, en nuestros resultados encontramos que es en el grupo intervención donde las mujeres muestran una calidad de vida peor que la de los hombres. resultados similares se han encontrado en estudios sobre determinantes asociados con la calidad de vida relacionada con la salud en pacientes con ic, donde la media obtenida después de haber aplicado la mlhfq en mujeres era de 39,3 puntos, y de 31,8 en hombres, salvando el contexto cultural de la población estudiada (31). en los resultados obtenidos en la valoración de los indicadores noc no se aprecian diferencias llamativas entre ambos sexos, salvo en la “conducta terapéutica” del grupo control, donde las mujeres presentaron un comportamiento mejor que el de los hombres. de cualquier forma hay que destacar que, excepto el punto anterior, en ninguno de los apartados precedentes se encontró significación estadística en las diferencias según el sexo de los pacientes. diferencias en el efecto de la intervención atribuibles al género de la población estudiada. el grupo control apenas ha tenido cambios en los parámetros estudiados entre el inicio y el final del estudio; en cambio, en el grupo intervención sí podemos apreciar evolución en los indicadores evaluados y diferencias según el género de los pacientes. se refleja una mejoría en el autocuidado tanto en hombres como en mujeres. siendo en los hombres casi el doble que en las mujeres. la adhesión terapéutica, que también mejora en hombres y mujeres, lo hace el doble en las mujeres que en los hombres. la calidad de vida, que presenta una leve mejoría, lo hace prácticamente por igual en hombres y mujeres. en la evolución detectada en los indicadores noc apenas encontramos diferencias en los resultados obtenidos en hombres y mujeres. de hecho, como podemos ver en la diferencias 322 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 de medias t1-t3 del grupo intervención según género, se trata de unos resultados muy satisfactorios y también muy similares. probablemente, en estas diferencias habrá factores ligados a la socialización y a los papeles que desempeñan las mujeres en la sociedad, determinadas por el género (30). otros estudios concluyeron que existían diferencias entre hombres y mujeres que no podían ser atribuidas totalmente a las diferencias de las características clínicas poblacionales de hombres y mujeres (32). de cualquier forma, entendemos que los resultados no hubieran sido diferentes en el caso de haber aleatorizado la intervención. conclusiones objetivo 1. el número de mujeres incluidas en el estudio es ligeramente superior al de los hombres. los hombres presentan más comorbilidad que las mujeres, siendo la hta y la diabetes las dos patologías concomitantes más frecuentes. los hombres presentan un consumo de tabaco y alcohol mayor que las mujeres. no hemos encontrado diferencias de género en la capacidad física, según clasificación nyha. los hombres disponen de cuidador/a informal en mayor porcentaje que las mujeres. objetivo 2. la situación inicial del autocuidado y la adhesión terapéutica, valorados en la primera consulta, presentan valores muy similares para hombres y mujeres. los hombres presentan inicialmente una calidad de vida relacionada con la salud mejor que la de las mujeres. en la valoración inicial de los indicadores noc no se aprecian diferencias significativas entre hombres y mujeres. objetivo 3. en el grupo intervención podemos apreciar una mejoría en el autocuidado tanto en hombres como en mujeres. siendo el de los hombres casi el doble que el de las mujeres. la adhesión terapéutica, que también mejora en los dos sexos, lo hace el doble en las mujeres que en los hombres. la calidad de vida, que presenta una leve mejoría, lo hace prácticamente por igual en hombres y mujeres. en la evolución detectada en los indicadores noc apenas encontramos diferencias en los resultados obtenidos. objetivo general. la intervención ha tenido resultados diferentes en el autocuidado de hombres y mujeres, demostrando un mayor efecto en el autocuidado de los primeros. referencias 1. de la serna f. insuficiencia cardíaca crónica. 3a ed. buenos aires: federación argentina de cardiología; 2010. p. 245-84. 2. ramírez-duque n, et al. perfil de prescripción 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(nic). 5a ed. madrid: mosby; 2009. 324 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 tabla 1. situación inicial ambos grupos variable grupo control grupo intervención p < 0,005 hombre mujer hombre mujer valor edad 64,86 ± 0,29 (de 8,42) 65,52 ± 0,27 (de 8,79) 60,86 ± 0,40 (de 11,16) 64,59 ± 0,33 (de 11,12) sexo cuidador hombre %(n) 18,52(5) 33,33(8) 16,00(4) 21,43(6) mujer %(n) 81,48(22) 66,67(16) 84,00(21) 78,57(22) antecedentes familiares %(n) 55,17(16) 30,30(10) 0,50 ± 0,02 (de 0,69) 0,47 ± 0,01 (de 0,51) otras patologías 1,79 ± 0,05 (de 1,52) 1,48 ± 0,03 (de 1,15) 1,93 ± 0,04 (de 1,25) 1,79 ± 0,03 (de 0,95) cuidador/a principal sí %(n) 93,10(27) 72,73(24) 89,29(25) 88,24(30) cuidador/a informal, sí %(n) 93,10(27) 63,64(21) 89,29(25) 82,35(28) 0,014* residencia urbana %(n) 72,41(21) 87,88(29) 85,71(24) 88,24(30) rural %(n) 27,59(8) 12,12(4) 14,29(4) 11,76(4) nivel de estudios ninguno %(n) 37,93(11) 42,42(14) 53,57(15) 50,00(17) primarios %(n) 41,38(12) 30,30(10) 28,57(8) 23,53(8) secundarios %(n) 17,24(5) 27,27(9) 14,29(4) 14,71(5) universitarios %(n) 3,45(1) 0,00(0) 3,57(1) 11,76(4) 28. anguita sánchez m, crespo leiro mg, de teresa galván e, jiménez navarro m, alonso-pulpón l, muñiz garcía j. prevalencia de la insuficiencia cardiaca en la población general española mayor de 45 años. estudio price. rev esp cardiol. 2008;61(10):1041-9. 29. galindo ortego g, esteve ic, gatius jr, santiago lg, lacruz cm, soler ps. pacientes con el diagnóstico de insuficiencia cardiaca en atención primaria: envejecimiento, comorbilidad y polifarmacia. aten primaria. 2011;43(2):61-7. 30. rohlfsa i, del mar garcía m, gavaldà l, medranod mj, juvinyà d, baltasara a, et al. género y cardiopatía isquémica. gac sanit. 2004;18(supl 2):55-64. 31. martinelli pelegrino m, spadeti dantas ra, clark am. health-related quality of life determinants in outpatients with heart failure. rev lat-am. enfermagen. 2011;19(3):451-7. 32. gonzález b, lupón j, parajón t, urrutia a, herreros j, valle v. aplicación de la escala europea de autocuidado en insuficiencia cardíaca (ehfscbs) en una unidad de insuficiencia cardíaca en españa. rev esp cardiol. 2006;59(2):166-70. 33. riesgo a, sant e, benito l, hoyo j, miró ò, mont l, et al. diferencias de género en el manejo de los pacientes con fibrilación auricular: análisis de base poblacional en un área básica de salud. rev esp cardiol. 2011;64(3):233-6. 325 género y efectividad de la metodología enfermera en pacientes con insuficiencia cardiaca l cipriano viñas vera y otros nyha: new york heart association de: desviación estándar fuente: elaboración propia. variable grupo control grupo intervención p < 0,005 hombre mujer hombre mujer valor ocupación trabaja %(n) 24,14(7) 24,24(8) 25,00(7) 14,71(5) desempleado %(n) 20,69(6) 21,21(7) 35,71(10) 38,24(13) jubilado %(n) 55,17(16) 54,55(18) 39,29(11) 47,06(16) hábitos tóxicos alcohol, sí %(n) 17,24(5) 6,06(2) 28,57(8) 20,59(7) tabaco, sí %(n) 75,86(22) 57,58(19) 71,43(20) 64,71(22) diabetes, sí %(n) 20,69(6) 9,09(3) 7,14(2) 5,88(2) frecuencia cardiaca 77,66 ± 0,50 (de 14,47) 83,48 ± 0,31 (de 10,23) 78,14 ± 0,45 (de 12,68) 79,50 ± 0,42 (de 14,20) hta, sí %(n) 79,31(23) 66,67(22) 57,14(16) 58,82(20) ta sistólica 133,90 ± 0,96 (de 27,77) 119,64 ± 0,57 (de 18,72) 124,71 ± 1,00 (de 28,00) 125,35 ± 0,75 (de 25,52) 0,020* ta diastólica 75,83 ± 0,51 (de 14,68) 68,94 ± 0,39 (de 12,79) 69,86 ± 0,51 (de 14,39) 74,09 ± 0,34 (de 11,47) escala nyha nyha i %(n) 17,24(5) 27,27(9) 32,14(9) 23,53(8) nyha ii %(n) 62,07(18) 66,67(22) 64,29(18) 58,82(20) nyha iii %(n) 20,69(6) 6,06(2) 3,57(1) 17,65(6) escala de autocuidado 36,21 ± 0,25 (de 7,16) 35,70 ± 0,18 (de 5,84) 40,96 ± 0,33 (de 9,23) 38,53 ± 0,28 (de 9,62) escala de morisky 4,83 ± 0,04 (de 1,07) 4,48 ± 0,04 (de 1,28) 4,54 ± 0,06 (de 1,60) 5,12 ± 0,04 (de 1,51) escala minnesota living 42,59 ± 0,46 (de 13,47) 42,70 ± 0,38 (de 12,58) 35,46 ± 0,81 (de 22,70) 44,65 ± 0,61 (de 20,57) resultados noc: conocimiento control de la enfermedad cardiaca 2,24 ± 0,02 (de 0,51) 2,27 ± 0,02 (de 0,67) 2,25 ± 0,03 (de 0,70) 2,12 ± 0,02 (de 0,59) conducta terapéutica: enfermedad o lesión 2,07+0,02 (de 0,20) 3,04+0,01 (de 0,31) 2,14 ± 0,03 (de 0,97) 2,06 ± 0,02 (de 0,81) 0,025* detección de gestión ineficiente de la propia salud 2,28 ± 0,02 (de 0,53) 2,36 ± 0,01 (de 0,49) 2,61 ± 0,04 (de 1,07) 2,85 ± 0,03 (de 0,89) tolerancia a la actividad 2,69 ± 0,02 (de 0,71) 2,73 ± 0,02 (de 0,67) 2,54 ± 0,03 (de 0,92) 2,74 ± 0,02 (de 0,75) estado cardiopulmonar 2,55 ± 0,02 (de 0,69) 2,70 ± 0,02 (de 0,59) 2,16 ± 0,02 (de 0,61) 2,56 ± 0,02 (de 0,69) 326 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 tabla 2. diferencia efecto entre hombres y mujeres t1-t3. ambos grupos variable sexo grupo control grupo intervención p. intra < 0,005 p. inter < 0,005 tiempo 1 tiempo 3 diferencia tiempo.1 tiempo 3 diferencia valor valor frecuencia cardiaca hombre 77,66 ± 2,69 (de 14,47) 81,62 ± 1,83 (de 9,88) 3,97 ± 2,58 (de 13,89) 78,14 ± 2,40 (de 12,68) 75,39 ± 2,12 (de 11,24) -2,75 ± 2,38 (de 12,62) frecuencia cardiaca mujer 83,48 ± 1,78 (de 10,23) 84,15 ± 1,57 (de 9,01) 0,67 ± 1,51 (de 8,68) 79,50 ± 2,44 (de 14,20) 77,47 ± 2,45 (de 14,29) -2,03 ± 2,32 (de 13,55) ta sistólica hombre 133,90 ± 5,16 (de 27,77) 133,24 ± 3,67 (de 19,77) -0,66 ± 4,92 (de 26,51) 124,71 ± 5,29 (de 28,00) 120,50 ± 4,76 (de 25,19) -4,21 ± 3,55 (de 18,80) ta sistólica mujer 119,64 ± 3,26 (de 18,72) 119,15 ± 3,03 (de 17,42) -0,48 ± 2,93 (de 16,82) 125,35 ± 4,38 (de 25,52) 125,62 ± 4,82 (de 28,08) 0,26 ± 3,66 (de 21,32) ta diastólica hombre 75,83 ± 2,73 (de 14,68) 76,31 ± 2,34 (de 12,61) 0,48 ± 2,45 (de 13,17) 69,86 ± 2,72 (de 14,39) 71,86 ± 2,68 (de 14,18) 2,00 ± 2,58 (de 13,64) ta diastólica mujer 68,94 ± 2,23 (de 12,79) 69,36 ± 2,26 (de 13,00) 0,42 ± 1,82 (de 10,43) 74,09 ± 1,97 (de 11,47) 75,68 ± 3,32 (de 19,34) 1,59 ± 2,96 (de 17,24) esc. autocuidado hombre 36,21 ± 1,33 (de 7,16) 35,24 ± 1,38 (de 7,45) -0,97 ± 1,24 (de 6,69) 40,96 ± 1,74 (de 9,23) 24,96 ± 1,65 (de 8,73) -16,00 ± 2,08 (de 10,99) < 0,001*** 0,045* esc. autocuidado mujer 35,70 ± 1,02 (de 5,84) 35,52 ± 0,96 (de 5,52) -0,18 ± 0,96 (de 5,49) 38,53 ± 1,65 (de 9,62) 28,85 ± 1,79 (de 10,43) -9,68 ± 2,22 (de 12,92) < 0,001*** esc. morisky hombre 4,83 ± 0,20 (de 1,07) 4,93 ± 0,22 (de 1,19) 0,10 ± 0,11 (de 0,62) 4,54 ± 0,30 (de 1,60) 5,86 ± 0,12 (de 0,65) 1,32 ± 0,35 (de 1,83) < 0,001*** esc. morisky mujer 4,48 ± 0,22 (de 1,28) 4,48 ± 0,19 (de 1,09) 0,00 ± 0,15 (de 0,87) 5,12 ± 0,26 (de 1,51) 8,06 ± 1,94 (de 11,31) 2,94 ± 1,87 (de 10,93) esc. minnlivi hombre 42,59 ± 2,50 (de 13,47) 42,66 ± 2,63 (de 14,18) 0,07 ± 0,67 (de 3,60) 35,46 ± 4,29 (de 22,70) 31,21 ± 4,38 (de 23,16) -4,25 ± 3,56 (de 18,85) esc. minnlivi mujer 42,70 ± 2,19 (de 12,58) 42,36 ± 2,23 (de 12,82) -0,33 ± 0,66 (de 3,81) 44,65 ± 3,53 (de 20,57) 40,03 ± 3,69 (de 21,49) -4,62 ± 2,86 (de 16,67) conocimiento control de la enfermedad cardiaca hombre 2,24 ± 0,09 (de 0,51) 2,45 ± 0,18 (de 0,95) 0,21 ± 0,17 (de 0,90) 2,25 ± 0,13 (de 0,70) 3,54 ± 0,17 (de 0,88) 1,29 ± 0,14 (de 0,76) < 0,001*** conocimiento control de la enfermedad cardiaca mujer 2,27 ± 0,12 (de 0,67) 2,33 ± 0,12 (de 0,69) 0,06 ± 0,15 (de 0,86) 2,12 ± 0,10 (de 0,59) 3,47 ± 0,14 (de 0,79) 1,35 ± 0,13 (de 0,77) < 0,001*** conducta terapéutica: enfermedad o lesión hombre 2,31 ± 0,09 (de 0,47) 2,59 ± 0,16 (de 0,87) 0,28 ± 0,10 (de 0,53) 2,04 ± 0,18 (de 0,96) 3,25 ± 0,22 (de 1,14) 1,21 ± 0,19 (de 0,99) < 0,001*** conducta terapéutica: enfermedad o lesión mujer 2,06 ± 0,04 (de 0,24) 2,30 ± 0,12 (de 0,68) 0,24 ± 0,12 (de 0,66) 2,18 ± 0,14 (de 0,83) 3,50 ± 0,18 (de 1,02) 1,32 ± 0,15 (de 0,88) < 0,001*** 327 género y efectividad de la metodología enfermera en pacientes con insuficiencia cardiaca l cipriano viñas vera y otros nyha: new york heart association de: desviación estándar fuente: elaboración propia. variable sexo grupo control grupo intervención p. intra < 0,005 p. inter < 0,005 tiempo 1 tiempo 3 diferencia tiempo.1 tiempo 3 diferencia valor valor detección de gestión ineficiente de la propia salud hombre 2,28 ± 0,10 (de 0,53) 2,45 ± 0,15 (de 0,83) 0,17 ± 0,12 (de 0,66) 2,14 ± 0,18 (de 0,97) 3,11 ± 0,22 (de 1,17) 0,96 ± 0,18 (de 0,96) < 0,001*** detección de gestión ineficiente de la propia salud mujer 2,36 ± 0,09 (de 0,49) 2,33 ± 0,13 (de 0,74) -0,03 ± 0,15 (de 0,85) 2,06 ± 0,14 (de 0,81) 3,35 ± 0,17 (de 1,01) 1,29 ± 0,16 (de 0,94) <0,001*** tolerancia a la actividad hombre 2,69 ± 0,13 (de 0,71) 2,90 ± 0,17 (de 0,90) 0,21 ± 0,09 (de 0,49) 2,61 ± 0,20 (de 1,07) 3,00 ± 0,22 (de 1,15) 0,39 ± 0,17 (de 0,92) 0,032* tolerancia a la actividad mujer 2,73 ± 0,12 (de 0,67) 2,76 ± 0,16 (de 0,94) 0,03 ± 0,12 (de 0,68) 2,85 ± 0,15 (de 0,89) 3,12 ± 0,15 (de 0,88) 0,26 ± 0,08 (de 0,45) 0,002** estado cardiopulmonar hombre 2,55 ± 0,13 (de 0,69) 2,86 ± 0,12 (de 0,64) 0,31 ± 0,13 (de 0,71) 2,54 ± 0,17 (de 0,92) 3,11 ± 0,21 (de 1,13) 0,57 ± 0,15 (de 0,79) <0,001*** 0,047* estado cardiopulmonar mujer 2,70 ± 0,10 (de 0,59) 2,70 ± 0,13 (de 0,73) 0,00 ± 0,08 (de 0,43) 2,74 ± 0,13 (de 0,75) 3,18 ± 0,16 (de 0,94) 0,44 ± 0,10 (de 0,56) <0,001*** 253 270 lo que no se ve no existe.indd 253 lucía stella tamayo-acevedo1 paola andrea gil-cano2 luz elena tamayo-acevedo3 lo que no se ve, no existe: percepciones sobre cáncer y papilomavirus humano en jóvenes universitarios, medellín, colombia, 2014 1 profesor asociado, escuela de microbiología, universidad de antioquia (colombia). lucia.tamayo@udea.edu.co 2 estudiante de la maestría microbiología y bioanálisis, línea salud sexual, universidad de antioquia, medellín (colombia). paolandreagil@gmail.com 3 profesor de cátedra, universidad de antioquia, medellín (colombia). magíster en salud pública. luzetamayoa@gmail.com recibido: 21 de julio de 2014 enviado a pares: 25 de agosto de 2014 aceptado por pares: 17 de abril de 2015 aprobado: 21 de abril de 2015 doi: 10.5294/aqui.2015.15.2.9 para citar este artículo / to reference this article / para citar este artigo tamayo-acevedo ls, gil-cano pa, tamayo-acevedo, le. lo que no se ve, no existe: percepciones sobre cáncer y papilomavirus humano en jóvenes universitarios, medellín, colombia, 2014. aquichan. 2015;15(2):253-270. doi: 10.5294/aqui.2015.15.2.9 resumen objetivo: comprender las percepciones de los estudiantes de pregrado de la universidad de antioquia, colombia, sobre los cánceres de cuello uterino, canal anal, orofaringe y pene, y cómo los relacionan con la infección por pvh. materiales y métodos: estudio etnográfico, realizado de marzo del 2013 a abril del 2014, participaron 23 mujeres y 14 hombres en ocho grupos de discusión. sus discursos fueron grabados, transcritos y analizados con el método argumentativo. resultados: en general, los/as jóvenes relacionaron el cáncer cervicouterino con el pvh, pero no con los tipos de cáncer en canal anal, orofaringe y pene, sobre los cuales tenían poco conocimiento o desconocían. el pensar que las mujeres son las que contraen el cáncer cervical y contagian a los hombres con el pvh no les permitió imaginar que existieran otros cánceres asociados al pvh. conclusión: las percepciones y la falta de claridad en la relación pvh y otros cánceres, pueden incrementar el riesgo de infección por las prácticas sexuales y en el tiempo aumentar la prevalencia de estos cánceres. palabras clave adulto joven, investigación cualitativa, infecciones por papilomavirus, neoplasias, percepción social (fuente: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 253-270 254 aquichan issn 1657-5997 año 15 vol. 15 nº 2 chía, colombia junio 2015 l 253-270 what you can’t see does not exist: what college students think about cancer and the human papillomavirus. medellín, colombia, 2014 abstract objective: understand what undergraduate students at the university of antioquia think about cervical, anal, oropharyngeal and penile cancer, and how they associate these types of cancer with human papillomavirus (hpv) infection. materials and methods: this is an ethnographic study conducted during the period from march 2013 to april 2014. it included 23 women and 14 men who were divided into eight discussion groups. what they had to say was recorded, transcribed and analyzed using the argumentative method. findings: overall, the young people who took part in the study associate hpv with cervical cancer, but not with anal, oropharyngeal and penile cancer. in fact, they had little knowledge or knew nothing about those types of cancer. thinking that women are the ones who contract cervical cancer and infect men with hpv prevented them from imagining there might be other types of cancer associated with hpv infection. conclusion: ignorance among women about other types of cancer associated with hpv infection might cause them to neglect preventive measures and increase the risk of infection through sexual practices. the study ratifies the need to develop programs to promote health and to prevent infection with this virus. keywords young adult, qualitative research, papillomavirus infections, neoplasia, social perception (source: decs, bireme). 255 lo que no se ve, no existe: percepciones sobre cáncer y papilomavirus humano en jóvenes universitarios, medellín, colombia, 2014 l lucía stella tamayo-acevedo y otros o que não se vê não existe: percepções sobre o câncer e papilomavírus humano em jovens universitários. medellín (colômbia), 2014 resumo objetivo: compreender as percepções dos estudantes de graduação da universidad de antioquia sobre os cânceres de colo uterino, canal anal, orofaringe, pênis e como os relacionam com a infecção por papilomavírus humano (hpv). materiais e métodos: estudo etnográfico realizado de março de 2013 a abril de 2014; participaram 23 mulheres e 14 homens em oito grupos de discussão. seus discursos foram gravados, transcritos e analisados com o método argumentativo. resultados: em geral os(as) jovens relacionaram o câncer cérvico-uterino com o hpv, mas não com os tipos de câncer em canal anal, orofaringe e pênis, sobre os quais tinham pouco conhecimento ou desconheciam. o fato de pensar que as mulheres são as que contraem o câncer cervical e contagiam os homens com o hpv não lhes permitiu imaginar que existissem outros cânceres associados com o hpv. conclusão: o desconhecimento das mulheres sobre a associação do hpv com o risco de padecer de outros cânceres podem ocasionar descuido nas medidas preventivas e aumentar o risco de infecção por práticas sexuais e ratifica-se a necessidade de desenvolver programas encaminhados à promoção da saúde e à prevenção da infecção por esse vírus. palavras-chave adulto jovem, pesquisa qualitativa, infecções por papilomavírus humano (hpv), neoplasias, percepção social (fonte: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 253-270 256 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 introducción el papilomavirus humano (pvh) es un virus de transmisión sexual, con más de 120 genotipos identificados y clasificados en oncogénicos y no oncogénicos, entre los cuales 40 tienen afinidad por la región ano-genital (1-4). en biopsias, el adn viral se ha identificado en el 99 % de los casos de cáncer de cuello uterino, cerca del 90 % en el cáncer anal, en el 60 % del cáncer de orofaringe y en el 35 % del cáncer de pene. la infección ocurre generalmente durante la juventud y con efectos oncogénicos en edades posteriores (2-7). por lo general, las investigaciones existentes sobre el pvh y el cáncer tienden a enfocarse en aspectos moleculares, epidemiológicos y clínicos; en otros casos, se estudian los conocimientos de las mujeres sobre el cáncer de cuello uterino y el acceso a la citología (8). son escasos los estudios que permitan identificar las percepciones sobre el cáncer y la relación con el pvh. la percepción entendida como el proceso biocultural en el que las personas dan significado y valores a las sensaciones. estas construcciones mentales están afectadas por juicios de valor que responden a los contextos culturales, que actúan de forma consciente e inconsciente y que son expresadas a través del lenguaje y la conducta (9). como antecedentes a este estudio de percepciones sobre el pvh y el cáncer se encontraron tres investigaciones. la primera, de mosavel y el-shaarawi, estudió las percepciones y los conocimientos de mujeres latinas y afroamericanas de norteamérica, entre 12 y 17 años, sobre el cáncer en general, incluido el cáncer de cuello uterino; encontraron una asociación del cáncer con la muerte, y que es mayor el conocimiento que tienen del cáncer de mama y de pulmón que del cáncer de cuello uterino, el cual no fue relacionado con el pvh (10). la segunda investigación, de tamayo y chávez, abordó las percepciones sobre el cáncer de cuello uterino en mujeres de antioquia (colombia) y de colima (méxico); hallaron que las mujeres antioqueñas no hacen ninguna relación entre pvh y este cáncer pero sí le atribuyen otras causas como la mala higiene genital, la inadecuada alimentación, el tabaquismo y no practicarse la citología (11). la tercera, realizada por carstens, estudió los conocimientos y las conductas asociadas al pvh en mujeres con y sin educación superior provenientes de chile y españa; reportó que las mujeres con educación reconocieron no recordar las enseñanzas sobre sexualidad recibidas en el colegio, tenían mayor conocimiento del vih que sobre el pvh, el cual relacionaron con la publicidad de la vacuna que puso al cáncer de cuello uterino y no a otros cánceres como consecuencia de este virus (12). según chávez et al., para comprender las necesidades de salud de cualquier persona, es indispensable estudiar el contexto de sus vidas y las percepciones que influyen y dan sentido a sus acciones; de tal modo, proponen las autoras, que las acciones de promoción de la salud y prevención de la enfermedad deben ser más plurales, críticas y reflexivas para lograr mejores resultados (13). para optimizar los resultados y el impacto de los programas es importante abordar el tema del cáncer asociado al pvh en una perspectiva sociocultural y como un problema de mayor complejidad, sobre el cual no serán suficientes, por sí solos, la vacunación contra el pvh y el tamizaje citológico. por consiguiente, es clave investigar sobre lo que las personas piensan, creen y practican en su contexto, cuyos resultados, entre otros propósitos, podrán aportar al diseño de programas de educación en salud y a la formación de profesionales, en particular de enfermería, capaces de interactuar en la transdisciplinariedad e interculturalidad en el cuidado de la salud y la enfermedad, al momento de tomar decisiones educativas y comunicativas dirigidas a individuos, familias y colectivos. el objetivo de este estudio fue comprender las percepciones de los estudiantes de pregrado de la universidad de antioquia, sobre los cánceres de cuello uterino, canal anal, orofaringe y pene, y cómo relacionan estos cánceres con la infección por pvh, en la perspectiva de identificar acciones y prácticas para el autocuidado, en particular referidas a la salud sexual. este trabajo hizo parte del proyecto de investigación “evaluación del programa promoción de la salud sexual y la afectividad, dirigido a estudiantes de la universidad de antioquia, bienestar universitario, 2012”, cofinanciado por el comité para el desarrollo de la investigación (codi) en la convocatoria temática universidad y educación superior del 2012. los resultados aportan bases para el abordaje de la infección por pvh y los cánceres en estudio por parte del personal de salud, en particular de enfermería y de profesionales de la comunicación. materiales y métodos estudio etnográfico que buscó aprehender el saber cultural y las creencias compartidas de los jóvenes universitarios sobre 257 lo que no se ve, no existe: percepciones sobre cáncer y papilomavirus humano en jóvenes universitarios, medellín, colombia, 2014 l lucía stella tamayo-acevedo y otros el cáncer y el pvh, ver los fenómenos en la perspectiva de los actores sociales y presentar la voz del sujeto a través de una construcción textual que representa la realidad del grupo. un investigador difícilmente puede comprender una acción si no entiende los términos en que la caracterizan sus protagonistas, por tanto, los sujetos para la etnografía son considerados interlocutores privilegiados, pues solo ellos pueden dar cuenta de su realidad (14). para la recolección de la información, se empleó el grupo de discusión como una estrategia metodológica apropiada para producir las manifestaciones de deseos y creencias que permite estudiar desde adentro el comportamiento de las personas, congrega los discursos en un medio parcialmente controlado y lleva en él las formas de discusión posibles entre grupos naturales, y, aunque el discurso es provocado por el coordinador, el grupo es el que determina los aspectos por considerar (15). el grupo de discusión comprende tres etapas: preproducción, producción y posproducción (16). en la preproducción se realizó una guía con detonantes basados en categorías a priori, que permitieron el diálogo orientado a la manifestación de las percepciones sobre las infecciones de transmisión sexual (its), la infección por pvh y los cánceres en estudio (tabla 1). estas categorías se agotaron en el muestreo teórico, o sea una vez que el discurso de los participantes se tornó repetitivo o no emergieron nuevas categorías. en la producción se realizaron ocho grupos de discusión con una duración aproximada de 45 minutos, que permitieron obtener el discurso de 14 hombres y 23 mujeres con edades entre 18 y 29 años, estudiantes de pregrado de la universidad de antioquia, sede medellín (tabla 2). la invitación a los estudiantes para participar en los grupos se hizo a través de correos electrónicos facilitados por el departamento de bienestar universitario, por contactos claves y por invitación directa de los profesionales responsables de las jornadas de salud en las dependencias académicas. en promedio, para realizar un grupo de discusión se convocaron entre 12 y 20 personas, entre hombres y mujeres, con una participación efectiva de 2 a 8 estudiantes. las razones expuestas fueron la carga académica, cruce de horarios y olvido. el lugar destinado para los grupos de discusión fue el aula de clase como sitio de interacción habitual de los jóvenes. las conversaciones se grabaron solo en audio por petición de los participantes. la fase de posproducción se inició con la transcripción, palabra por palabra, de los discursos de los estudiantes, como insumo para el análisis argumentativo que permitió construir esquemas interpretativos de los aportes de los jóvenes relacionados con el tema de investigación. se inició con la selección de fragmentos significativos a partir de los textos, luego se identificaron objetos (de lo que se habla) y predicados (qué se dice de los objetos); posteriormente, se establecieron vínculos entre los objetos y sus calificativos (16). finalmente, se esquematizó lo expresado por los jóvenes usando el programa freemind versión 0.8.0. el discurso analizado se sometió a triangulación con otros estudios, con el punto de vista de otros investigadores y con los jóvenes (16). este estudio cumplió con los principios éticos, se consideró una investigación sin riesgo según el artículo 11, numeral a, y artículo 16, parágrafo primero, de la resolución 008430 de 1993, del ministerio de salud de colombia (17). la participación de los estudiantes fue voluntaria, se solicitó el consentimiento informado y se protegió la privacidad y confidencialidad de sus discursos evitando el uso de nombres propios e identificando cada testimonio con un código que incluyó: el número del grupo de discusión, el sexo del participante, la ubicación ordinal en la mesa de discusión, el área de conocimiento. resultados a modo de esquema de representación, las figuras 1, 2 y 3 recogen las percepciones de los/as jóvenes estudiantes, así: figura 1, las relaciones sexuales y la prevención del pvh y el cáncer; figura 2, compara por sexo las percepciones sobre el pvh y los tipos de cáncer asociados a este virus; figura 3, también compara por sexo las percepciones sobre la prevención del pvh y los tipos de cáncer. del discurso de los estudiantes, surgieron tres categorías con sus respectivas subcategorías, a saber: 1) aprendizaje en sexualidad a partir de la experiencia y la imitación, 2) construcciones sociales de género y prevención en salud sexual y 3) cáncer: debilidad, aislamiento y muerte. aprendizaje en sexualidad a partir de la experiencia y la imitación. “una misma detecta la infección” esta categoría surgió cuando se abordó el tema de sexualidad y relaciones sexuales, de gran importancia para los/as jóvenes. en los discursos de las mujeres primó la vinculación con 258 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 tabla 1. composición, grupos de discusión grupo fecha sexo área semestre estrato económico estado civil religión gd1 marzo 01 de 2013 1 hombre, 5 mujeres sociales, exactas, salud y educación sin dato 2 y 3 5 solteros 1 unión libre 1 católico, 6 no practicantes gd2 marzo 22 de 2013 1 hombre, 1 mujer sociales, salud 6 y 7 2 y 3 solteros 1 católico 1 otra gd3 abril 05 de 2013 2 hombres economía, ingenierías 1 y 9 2 y 3 solteros católicos gd4 mayo 23 de 2013 1 hombre, 6 mujeres agrarias 2 y 4 2 y 3 6 solteros 1 casada 2 católicos, 5 no practicantes gd5 junio 20 de 2013 2 hombres economía, ingenierías 3 y 6 2 solteros 1 católico 1 otra gd6 septiembre 26 de 2013 1 hombre, 4 mujeres educación, ingenierías, artes. 1, 5 y 6 1 y 3 solteros 2 católicos, 1 otra, 2 no practicantes gd7 marzo 14 de 2014 3 hombres 2 mujeres educación, ingeniería, salud 1, 3, 4 y 5 2 y 3 solteros 4 católicos 1 otra gd8 abril 02 de 2014 3 hombres 5 mujeres salud 8, 9 y 11 3 y 4 solteros 5 católicos, 3 no practicantes fuente: elaboración propia. tabla 2. categorías y detonantes, grupos de discusión va m o s a h ab la r d e percepciones sobre el cáncer percepciones sobre el pvh percepciones sobre its lo que sabemos sobre el cáncer de cuello uterino, de pene, de ano y de orofaringe. lo que sabemos de la infección por papilomavirus o pvh. lo que conocemos sobre las its, también llamadas enfermedades venéreas. lo que representa para cada uno tener estos cánceres. lo que representa para ustedes tener una infección por pvh. lo que representa para ustedes tener una its. los cambios que se dan en la vida de las personas cuando se tiene uno de estos cánceres. los cambios que se dan en la vida personal, sexual y social a causa de esta infección. de las situaciones en las cuales se exponen al contagio de una its. características y comportamientos de las personas que padecen uno de estos cánceres. los cuidados en salud sexual que asumen para evitar la infección por pvh. de los cuidados que practican para evitar una its. los cuidados que hay que tener para evitar estos cánceres. las prácticas populares que conocemos para curar el pvh. la vacuna contra el pvh. las prácticas que conocemos para curar estas infecciones. las campañas de salud que se hacen por los medios de comunicación y de la información recibida en el programa de salud sexual y la afectividad. las campañas de salud y educativas para contrarrestar la infección por pvh. las campañas de salud y educativas a través de las cuales se han informado y aprendido sobre las its la información que da el programa de salud sexual y afectividad de la universidad sobre estos cánceres. el papel que cumple el pvh en el desarrollo o no del cáncer. fuente: elaboración propia. 259 lo que no se ve, no existe: percepciones sobre cáncer y papilomavirus humano en jóvenes universitarios, medellín, colombia, 2014 l lucía stella tamayo-acevedo y otros figura 1. representación general, percepciones del cáncer y relación con pvh fuente: elaboración propia. figura 2. percepciones sobre cáncer y relación con pvh según sexo fuente: elaboración propia. 260 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 figura 3. percepciones sobre prevención del cáncer y pvh según sexo fuente: elaboración propia. los sentimientos y la prohibición, mientras que para los hombres significó contacto físico, instinto y goce. en las subcategorías inherentes al aprendizaje, emergió la sexualidad como tema tabú que se aprende en la familia y la escuela, y en la práctica, el privilegio del placer sobre la prevención, además de la capacidad para identificar los signos y síntomas de its, visibles en el cuerpo. sexualidad como tema tabú. para los/as jóvenes, la educación en sexualidad que brindan la familia y la escuela está sesgada por creencias religiosas que los limitan a hablar abiertamente del tema; en consecuencia, para ellos, estas instituciones no son los espacios más apropiados para aclarar dudas. tal situación los motiva a aprender a través del diálogo con los pares y a buscar información en medios masivos de comunicación como la internet y la televisión. así, el conocimiento lo transmiten mediante experiencias propias o narradas por amigos, de quienes no reciben señalamientos ni prohibiciones, simplemente respuestas, tal como lo manifiesta uno de los hombres participantes. “el catolicismo, un montón de cosas que siempre ha satanizado. tenía que quedarme callado, evitar un montón de preguntas y consultar a través de la pornografía y de lo que escuchaba a mi alrededor con adultos” (gd6h5edu24). según los jóvenes, el espacio familiar pone la sexualidad en el silencio para conocerla y en la prohibición para vivenciarla, especialmente para las mujeres que son objeto de constante amenaza por parte de sus madres, al advertirles: “cuidado con un embarazo”. en general, manifestaron que recibieron alguna información sobre sexualidad en la educación básica secundaria y reconocieron lo poco que aprendieron y recuerdan. el siguiente testimonio de una mujer da cuenta de la ruptura en la comunicación; además, adjudica al emisor poca experiencia en el tema y el estigma religioso: “yo por ejemplo, no me acuerdo de nada de lo que a mí me decían en las mañanas del colegio, ¡no, yo que me iba a acordar! y eran monjas para acabar de ajustar” (gd4m1zoo19). 261 lo que no se ve, no existe: percepciones sobre cáncer y papilomavirus humano en jóvenes universitarios, medellín, colombia, 2014 l lucía stella tamayo-acevedo y otros los/as jóvenes asumieron las relaciones sexuales como algo usual, sin sentimientos de culpa, y simbolizan independencia y autonomía. para los hombres, las relaciones sexuales son más “normales” y consideran que la abstinencia es cosa de mujeres, bajo el argumento de que ellos no controlan el instinto sexual, en cambio las mujeres sí. manifestaron que la religión legitima y potencializa estas diferencias, tal como lo dice uno de los hombres en su discurso: “según la iglesia hay que llegar virgen al matrimonio, tanto el hombre como la mujer, aunque para el hombre no se le exige tanto […] según lo que yo he visto, les queda más fácil a las mujeres abstenerse que a uno” (gd7h2farm25). las relaciones sexuales son esenciales en la vida y limitarlas representa pérdida de libertad y control sobre el cuerpo. a pesar de dar importancia a la prevención de las infecciones de transmisión sexual (its) y del embarazo, los/as jóvenes expresaron la necesidad de vivir la sexualidad libremente y con responsabilidad, aun en los casos en que pueden exponerse a estos eventos. placer primero que prevención. los/as jóvenes reconocieron la importancia de prevenir comportamientos de riesgo para la salud sexual. la abstinencia no es para ellos una medida preventiva factible, al afirmarlo se miraron con malicia y se mofaron entre sí. esta alternativa implica sacrificar el placer. aunque conciben que es importante prevenir its y embarazos, nuevamente expresaron la necesidad de vivir libremente y con responsabilidad la sexualidad, aun en caso de inminente riesgo. con referencia a este sentir una estudiante manifestó: “yo no le diría: no tenga sexo, porque es como amarrarlo, pero que se cuide, porque yo creo que empeoraría su salud y dañaría también la otra gente” (gd2m2his23). uno mismo puede detectar la infección. en los discursos aportados por los/as jóvenes se interpreta que la salud obedece a un aprendizaje transmitido de generación en generación a través de la endo-culturación. creen reconocer cuando tienen una its, basados en los conocimientos adquiridos de comentarios de familiares sobre signos y síntomas de las enfermedades venéreas que hacen parte del saber popular. este argumento respaldó la decisión de acudir a un profesional de la salud solo cuando presentan alteraciones observables en el cuerpo. para ellos/as, lo que no se ve, no existe, y, por consiguiente, no hay que preocuparse por las its, por padecerlas o transmitirlas. los/as estudiantes de áreas de la salud restaron importancia al pvh por considerarse una infección comúnmente autolimitada. para ellos/as, el grado de afectación lo determina la frecuencia de la infección en el medio, a mayor frecuencia, mayor preocupación. para estos estudiantes, el pvh no representa un riesgo importante para la salud, pero sí afecta el ideal estético corporal. en palabras de uno de los hombres participantes: “si nos infectamos con pvh, estéticamente sí nos veríamos afectados. pues a mí me parece el condiloma acuminado es estéticamente feo, entonces yo digo que sí me afectaría” (gd8h6med23). construcciones sociales de género y prevención en salud sexual. “yo pienso que se basa es en la confianza” al hablar de prevención, los/las jóvenes resaltaron los relatos referentes a la disposición de la mujer para asumir las medidas preventivas, la abnegación y la renuncia al placer, en contraste con la indiferencia del hombre hacia el tema. responsabilizaron a las mujeres de la prevención, aún a costa de sus derechos sexuales y reproductivos; por consiguiente, comprender cuál es la construcción sociocultural referente al género y la sexualidad es clave para la prevención en salud sexual. its y pvh: asunto de mujeres. los hombres asociaron las its y el pvh con el hecho de “ser mujer”, creen que las mujeres son quienes padecen comúnmente las its. esta creencia la reafirman con la vacuna contra el pvh, que solo se aplica a las mujeres, por consiguiente, ellas son la fuente del virus. en tal sentido, el pvh no los afecta, por lo que no les interesa el tema y manifestaron que solo las mujeres deben buscar ayuda en los programas de salud sexual, lo cual queda expresado en el siguiente testimonio de un estudiante: “en las mujeres son comunes las infecciones, en un hombre no es tan común. la mujer tendrá más costumbre de estar pendiente de eso y llevar un control” (gd5h2ing24). pvh generador de crisis y estigmatización de la mujer. los/las jóvenes relacionan el pvh con la promiscuidad, el inicio temprano de relaciones sexuales y con el cáncer de cuello uterino. esta asociación causa un impacto psicológico negativo en las mujeres cuando reciben un diagnóstico de pvh. entre las reacciones emocionales están la culpa, el señalamiento y la angustia por la posible infidelidad de la pareja. una de ellas manifestó: “él [médico] me hizo la colposcopia y me dijo ¡ah sí, tenés papiloma humano! ¡qué trauma! ¡hasta carnet me dieron de enfermedad de transmisión sexual!” (gd1m6edes22). 262 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 con confianza se previenen las its. hombres y mujeres manifestaron conocer el condón, la forma de uso, sus beneficios y sugieren el uso. sin embargo, declaran que el condón pierde utilidad cuando se alcanza la confianza en la pareja. fue notable el hecho de que aunque exista confianza, es difícil comunicarle a la pareja el padecimiento de una its, lo cual los pone en la encrucijada entre disfrutar de las relaciones sexuales o limitar la vida sexual. para esta situación, uno de los estudiantes dijo: “si de pronto le cuenta, la otra persona podría desconfiar y no tener relaciones con él” (gd5h2ing24). las diferencias de género y la prevención. las mujeres ven en la confianza la oportunidad de lograr acuerdos de pareja para controlar el riesgo, sin embargo, reconocieron que existen dificultades a la hora de la negociación. en el siguiente testimonio, la prevención está basada en la práctica de exámenes para verificar la presencia o ausencia de its, motivada por la mujer: “yo me cansaba de decirle, vea hágase los exámenes, hágaselos. y él me decía: ‘!otra vez vos con eso! ¡vos si sos cansona’! yo me los hago, necesito es que te los hagas vos, porque yo me estoy cuidando y quiero que estemos bien y que me cuides” (gd6m3ing21); responsabilidad que recae sobre las mujeres. este escenario nuevamente evidencia desigualdades de género. percepción de los hombres ante el tema de las its. hablar de its se considera cosa de mujeres, fue algo incómodo para los hombres, prefirieron no saber del tema y preocuparse simplemente por evitar que la pareja quede embarazada; así lo expresó uno de ellos: “hay dos posibilidades en la vida, uno es conocer mucho del tema (its) o a veces no saber nada del tema y vivir mejor” (gd1h1poli24). cuando hablaron sobre el programa de salud sexual y la afectividad que ofrece la universidad a los estudiantes, en los hombres se develó cierta aversión por este tipo de servicios porque creen saberlo todo y solo buscarían ayuda profesional ante la observación de alteraciones físicas, de lo contrario no es necesario. además, expresaron que las mujeres son quienes hacen uso de estos servicios, así lo expresó uno de ellos: “yo ya sé todo, para qué voy a ir a charlas, son las mujeres que siempre tratan de buscar [la información en salud sexual]” (gd7h3ing18). también, hubo un temor manifiesto de llegar a ser objeto de burlas por parte de sus pares que consideran que asistir a este tipo de eventos es algo “gay” o de mujeres: “tú dices algo así en primero (que vas para una cita sobre sexualidad) y te la van a montar toda la vida. ¿quién fue el que hizo algo así como todo gay?” (gd8h8med22). cáncer: debilidad, aislamiento y muerte. “¿qué me falta por hacer? ¿qué me falta por vivir?” los/as jóvenes reconocieron la palabra cáncer en la perspectiva biológica. construcción posiblemente producto de la academia, en particular de los estudiantes de medicina que mostraron mayor dominio sobre el tema. en general, describieron al cáncer como masas que crecen sin control, causan debilidad, aislamiento y por último la muerte. los estudiantes de medicina señalaron que algunos tipos de cáncer no cursan con formación de masas. por el énfasis medicalizado que se encuentra en el imaginario colectivo, los/as jóvenes relacionaron el cáncer con quimioterapia, dolor, amputación o pérdida del órgano afectado, y manifestaron desconocimiento acerca de los sentimientos y pensamientos de las personas con cáncer. para ellos/as, tener un cáncer representa pasar de una vida activa, llena de afecto y libertades, a otra de restricciones, debilidad y cuidados médicos, que afectaría el desempeño de todas las actividades. percibieron a la persona con cáncer como quien experimenta al inicio una muerte social, al dejar de ser económicamente productiva, seguido del aislamiento. una de las mujeres lo expresó: “las personas se ponen súper flacas, se les cae el cabello. las quimioterapias algunos la asimilan, otros no. es un proceso súper complicado. mejor dicho, tener cáncer eso ya es como decir la muerte” (gd6m3ing21). finalmente, consideraron que la persona con cáncer experimenta la muerte corporal y torna su vida hacia lo espiritual para alcanzar la salvación y el perdón por los errores terrenales o, de forma alternativa, reconstruyen su armonía con la naturaleza. en este sentido, una mujer señaló: “yo optaría más por lo natural. aislarme en un lugar a campo abierto, tener más contacto con la naturaleza. porque soy de las que pienso, que cuando uno pasa de dimensión, como se dice normalmente, cuando uno muere, trasciende, uno pasa a ser parte de la naturaleza” (gd4m2zoo20). cáncer de cuello uterino. verrugas mortales que acaban con el placer sexual. los/as estudiantes de medicina tenían claro el concepto de cáncer de cuello uterino y la relación con al263 lo que no se ve, no existe: percepciones sobre cáncer y papilomavirus humano en jóvenes universitarios, medellín, colombia, 2014 l lucía stella tamayo-acevedo y otros gunos genotipos del pvh, incluso sabían de la existencia de otros genotipos causantes de los condilomas en la región perianal. en contraste, los/as jóvenes de las otras áreas de conocimiento mostraron confusión entre los virus pvh y vih, principalmente en los modos y las vías de transmisión. para ellos/as, la infección por pvh sucede con el inicio de relaciones sexuales, luego aparecen las verrugas y estas a su vez evolucionan a cáncer de cuello uterino. los discursos analizados muestran que los/as estudiantes perciben la presencia de verrugas seguida por el riesgo del cáncer, lo cual se observa en el siguiente testimonio de una mujer: “el pvh no tiene cura porque tiene un tratamiento en el cual se queman las verrugas, pero en un periodo de tiempo se vuelven a regenerar y si fuera muy grave ya llega a un cáncer de cuello uterino” (gd6m3ing21). para las mujeres, el cáncer de cuello uterino significaría un cambio en el modo de vivir la sexualidad. las relaciones sexuales serían dolorosas y limitarían el placer. tal situación la asociaron con la potencial pérdida de la pareja, a lo cual temen, y manifestaron: “de pronto hasta perder a la persona que quieres, porque uno no sabe de qué manera puede aceptar el otro el hecho de que te duela [la relación sexual]” (gd6m4art21). la sociedad, cómplice del cáncer de cuello uterino. los/ as estudiantes de medicina manifestaron que es difícil prevenir este cáncer porque el condón no protege contra el pvh. con esta afirmación, dan a conocer que las relaciones sexuales son determinantes y que evitarlas es más complicado que el mismo cáncer. en general, independientemente del área del conocimiento y el sexo, estuvieron de acuerdo en que las relaciones sexuales a temprana edad y la promiscuidad favorecen el desarrollo del cáncer de cuello uterino. asimismo, piensan que factores como la música y la falta de comunicación en las familias, posibilitan las relaciones sexuales. una de las mujeres se expresó así: “a mí me gusta el reguetón, me gusta toda la música, pero es que uno sabe qué induce. es que esa música hoy en día todo es directo ‘mami chula mete’. son movimientos que seducen” (gd4m1zoo19). cánceres desconocidos. “como no es alta la prevalencia, pues no es muy conocido”. en general, los/as jóvenes no asociaron el cáncer en canal anal, orofaringe y pene con el pvh. para prevenir estos cánceres, unos estudiantes adujeron que el deporte y la buena alimentación son una buena opción, mientras que otros aceptaron que frente al desconocimiento que tienen de estos cánceres, no habían pensado en prevenirlos. en uno de los grupos de discusión, expresaron la creencia de que “el cáncer lo tenemos todos, a unos se les desarrolla y a otros no”; mito que afecta de manera negativa la intención de prevención; en palabras de ellos: “¿para qué prevenir algo que ya todos tenemos?” • cáncer de canal anal: posiblemente por la penetración anal. algunos jóvenes relacionaron, de forma dudosa, el cáncer en canal anal con las prácticas sexuales, sin conectarlo con la infección por pvh. los hombres estudiantes de medicina y algunos de otras áreas piensan que son los homosexuales los afectados, tal como lo manifestó uno de ellos: “eso es más para las personas homosexuales, que practican la penetración anal” (gd5h2ing24). por su parte, las mujeres expresaron que la penetración anal no es exclusiva de los homosexuales y, por consiguiente, también ellas pueden llegar a desarrollar este cáncer. • cáncer de orofaringe: probablemente por sexo oral. gran parte de los estudiantes, incluyendo a los de medicina, consideró que el cáncer en la boca y garganta afecta a cualquier persona consumidora de tabaco y alcohol. los/as jóvenes, independientemente del área de estudio, se mostraron dudosos con la relación cáncer orofaríngeo y prácticas sexuales, lo cual se evidencia con las siguientes preguntas: “¿el sexo oral genera cáncer de faringe? quizás. ¿no? puede ser” (gd2h1odon21), “apenas esta semana me vine a enterar de que probablemente, porque creo que es un mito que el sexo oral dé cáncer. ¿pues cómo?” (gd5h1econ20). • cáncer de pene: afecta la masculinidad. los jóvenes declararon que nunca habían escuchado hablar sobre este cáncer. una estudiante del área de la salud justificó el desconocimiento en la baja frecuencia del cáncer de pene, y para los/as participantes del área de la salud, los cánceres más conocidos por las personas son los que más se diagnostican en el medio. se imaginaron el cáncer de pene como la formación de masas, la putrefacción y la amputación. cuando contemplaron la posibilidad de tener un cáncer de pene, los hombres vieron diezmada su masculinidad, evidenciando que para ellos el pene es el centro de esta; en su discurso, uno de ellos dijo: “esa parte de uno [el pene] es como símbolo de masculinidad, entonces para uno es un impacto muy fuerte, yo creo que para un hombre, aparte de cáncer y que sea en esa parte es como muy duro” (gd5h2ing24). 264 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 discusión aprendizaje a partir de la experiencia uribe et al., reportaron que los hombres consideran las relaciones sexuales como una forma de reafirmar su virilidad y de ser aceptados por el grupo (18). en este estudio se encontró que para hombres y mujeres, las relaciones sexuales son muestra de madurez y asunto importante en su grupo social. en general, al comparar los discursos de los estudiantes de las áreas de la salud con los estudiantes de las demás áreas, no hubo diferencias, a excepción de los conocimientos y las percepciones que tenían sobre la etiología del cáncer y la relación del pvh con el cáncer de cuello uterino, temas que fueron abordados con mayor complejidad por los estudiantes de las áreas de la salud. posiblemente, la razón de esta similitud en los discursos podría deberse en gran parte a que los/as estudiantes adquirieron los conocimientos de la experiencia indirecta de allegados y de los medios de comunicación. el aprendizaje arraigado de los conocimientos y las experiencias subyace en los aprendizajes durante la formación académica. a partir de las enseñanzas informales en salud y las experiencias propias y de otros, los/as estudiantes piensan que las infecciones son alteraciones observables en el cuerpo. por tal motivo, cuando en los diferentes grupos de discusión se habló de its, independientemente del área de conocimiento, hicieron alusión a la observación de signos y síntomas, lo que denota confusión entre los conceptos infección/enfermedad. un hallazgo similar fue reportado por wiesner et al., al encontrar en un estudio realizado en personal de salud que médicos generales y ginecólogos confundían ambos términos cuando daban explicaciones a sus pacientes sobre el pvh (19). en esta investigación, así como en el estudio realizado por muñoz, los/as jóvenes manifestaron la importancia del otro como fuente de conocimiento. el otro es importante porque hace posible la recreación de diversas situaciones que constituyen el conocimiento social y la construcción del sujeto, a través de la aprehensión de prácticas, comportamientos, actitudes y creencias (20). para los/as jóvenes, los pares son muy importantes, porque con ellos es posible desahogar sus experiencias en sexualidad, lo que no pueden hacer con otras personas. igualmente, en este estudio los jóvenes manifestaron la poca apertura entre padres e hijos para hablar de sexualidad, a pesar de que la familia es el primer espacio de aprendizaje (18). según noroozi, la familia se considera un espacio que genera desconfianza, miedos y silencios por la forma como se trata el tema en el mundo de los adultos, que encasilla la sexualidad en un sitio de prohibiciones, pudor y una valoración negativa (21). la falta de una fuente válida para aclarar las dudas, lleva a conductas sexuales riesgosas que, por lo general, están orientadas básicamente por la tradición. el paso generacional de información, influida por la intuición y la sociedad, seduce a los/ as jóvenes a iniciar la vida sexual de manera prematura; obliga a los adolescentes que aún no tienen la información necesaria para la toma de decisiones a valerse únicamente de la confianza que inspira su pareja para disminuir el riesgo de enfermedad. construcciones sociales de género y prevención en salud sexual la confianza. para los/las estudiantes, la confianza representa protección contra las infecciones, en consecuencia, es la medida de prevención que más practican. estrategia que también fue reportada en la investigación realizada por tamayo et al. (11). en ambos estudios, los participantes tenían conocimientos sobre el uso del condón como medida profiláctica; sin embargo, la decisión de uso estuvo basada en el grado de confianza al que ha llegado la relación de pareja. el condón adquiere, entonces, una connotación sentimental que eclipsa la utilidad original y biológicamente aceptada. la confianza influye sobre la decisión de usar o no el condón. según uribe et al., el uso del condón depende del tipo de relación de pareja en que se encuentren, si la relación es de noviazgo, los/ as estudiantes consideran que ya no es necesario utilizarlo (18). sin embargo, esta decisión no es ajena a la condición de género, tal y como lo corroboran las investigaciones realizadas por marques et al. y arraes et al., estudios en los cuales, el uso del condón fue decisión del hombre y se consideró necesario en los encuentros sexuales con personas desconocidas (22, 23). según estos autores, para los hombres jóvenes, la persona desconocida representa el riesgo y la culpa. en caso de un contagio, la culpa recae sobre la mujer por ser considerada la fuente de transmisión de infecciones, percepción que también se encontró en esta investigación (22, 23). 265 lo que no se ve, no existe: percepciones sobre cáncer y papilomavirus humano en jóvenes universitarios, medellín, colombia, 2014 l lucía stella tamayo-acevedo y otros para fenell, el abandono del uso del condón en las parejas, sucede principalmente porque afecta el placer durante la relación sexual, causa molestias e irritación, por lo que se opta por utilizar otras alternativas anticonceptivas (24), hallazgo que es compatible con lo descrito por los/as jóvenes de este estudio. con base en estos resultados, se podría afirmar que la confianza en la pareja aumenta el placer en las relaciones sexuales, al permitir que se renuncie al uso del condón. el significado de la confianza es difícil de definir; por lo general, las personas la asocian a la idea del bien, a la esperanza que se tiene en que la otra persona actúe como se desea. ante la realidad expuesta, cabe preguntarse ¿cuándo consideran los/as jóvenes que se logró la confianza?, ¿la confianza es asunto de méritos o de tiempo?, ¿cuánto tiempo es suficiente para que haya confianza?, ¿cuáles son los méritos necesarios para lograr esa confianza? en este estudio, para los/as jóvenes la confianza se basa en creer conocer a la persona, considerar la relación de pareja estable y la existencia de garantías por un acuerdo matrimonial. aunque exista confianza, en esta investigación fue manifiesto el miedo de comunicar a la pareja el padecimiento de una its, porque puede influir en los encuentros sexuales, así como en la posibilidad de acabar con la confianza lograda. hallazgo similar fue publicado por weisner et al., en mujeres de bogotá (colombia), quienes consideraron que la dificultad en el diálogo radica en que la sexualidad es un tema tabú y en el temor a la ruptura de la relación (19). la diferencia en las prioridades de hombres y mujeres dificulta la negociación. los hombres centraron su interés sexual en un cuerpo orgánico, por tanto, sus argumentos se basaron principalmente en aspectos físicos; contrario a las mujeres que manifestaron su interés en un cuerpo emocional. este hallazgo coincide con lo reportado por uribe et al., quienes afirman que lo que motivó a las mujeres a tomar la decisión de tener actividad sexual fue el sentirse enamoradas, mientras que los motivos de los hombres estuvieron centrados en la necesidad biológica, el placer y sentir a partir de la experiencia directa (18). el estudio de muñoz, reporta que el aspecto físico juega un papel preponderante en la actitud de los hombres hacia su propio cuerpo; el cuidado está condicionado por la aprobación del otro, a través de la demostración de vigor y fuerza en búsqueda del reconocimiento y la aceptación social (20). pese a la mirada del otro, los hombres adoptan más una perspectiva individual, piensan la salud como el sentirse bien —el bienestar propio—. en contraste con las mujeres para quienes, según vergara, es evidente la proyección del concepto salud a una dimensión grupal y social; en este sentido, hablan sobre sentirse bien y hacer sentir bien a los demás (25). es notorio que las prioridades entre los hombres y las mujeres son diferentes, así como su forma de pensar y actuar. en la perspectiva del hombre, es más importante evitar un embarazo que las infecciones. situación similar a la reportada por steern y por sanjaume, quienes afirmaron que la prevención del embarazo fue lo que motivó conductas protectoras en las relaciones sexuales (26, 27). percepción de los hombres ante el tema de its. en esta investigación fue notable la actitud evasiva del hombre para buscar consejería profesional en los programas de salud sexual, por considerar que esta es propiamente femenina y por el miedo a ser etiquetado “gay”. según los escritos de muñoz y de hernández et al., dentro de la construcción social dominante del rol masculino está el verse fuerte física y emocionalmente, pensarse independiente, asumir riesgos y no necesitar el cuidado de los demás, razón por la cual la enfermedad, la vejez dependiente y la búsqueda de apoyo se consideran manifestaciones de debilidad relacionadas con lo femenino (20, 28). la perpetuación de principios patriarcales en la sociedad colombiana actual, es la principal barrera de prevención de los cánceres asociados al pvh, incluidas otras its. ese miedo hacia lo femenino es reportado en algunas culturas indígenas como los baruya (papúa, nueva guinea) en donde para conquistar el estatus viril, el niño debe pasar por una serie de rituales en los que se va configurando su carácter masculino en la medida en que son borrados todos aquellos restos de feminidad (29). en la cultura tradicional colombiana, la masculinidad es producto de un esfuerzo sostenido y ejercido por negar todo aquello que sea considerado femenino; los hombres están ahí para oponerse a la realización de lo femenino en ellos y asegurar, mediante su negación, el rol aceptado por la sociedad como correcto (29). el comportamiento sexual esperado se relaciona estrechamente con los sistemas de género que, infortunadamente, en 266 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 esta época se siguen manifestando en desigualdad hacia las mujeres. en este sentido, cuando las necesidades de la pareja son diferentes, los hombres generalmente reaccionan con cierto desagrado, por lo que la mayor parte de las veces las mujeres terminan cediendo ante las demandas de estos para cuidar su relación de pareja (30). a pesar de los avances en la ciencia, la economía, la política y lo social, muchos de los problemas inherentes a la sexualidad que agobian a las mujeres de este siglo, son similares a los que agobiaron a las mujeres del siglo xix. la clave para que las mujeres salgan de la esclavitud, consiste en romper con los esquemas educativos que las forman para estar al servicio y bajo la tutela de los hombres, y más bien orientar la educación en la importancia de su rol en la sociedad actual (31) y fortalecer su capacidad de negociación con la pareja que sume a la autodeterminación. la negociación se opone al sacrificio porque implica regirse por un contrato en igualdad de condiciones, bajo la premisa de un reconocimiento recíproco como sujetos de pleno derecho, que comparten deberes, fijan límites, definen libertades y buscan elegir lo que se desea. la transacción no es solo con la pareja, sino consigo mismo, e implica un cambio en el sujeto y en la forma como es concebido por la sociedad (31). la consecuencia de la no negociación, por lo general es el sometimiento y el sacrificio que están inmersos en la fe de la mayoría de las religiones. según sigmund freud, la religión se ha apresurado a sancionar limitaciones y a promover renuncias que se traducen en sacrificios por la colectividad. el argumento religioso promulga una verdad que es histórica e invita a la “repetición sacrificial”, que arrastra inconscientemente el sujeto hacia dios, cortando su propio acceso a la verdad (32). cáncer de cuello uterino y cánceres desconocidos: relación con el pvh. los/as jóvenes relacionaron el cáncer de cuello uterino con el pvh. los medios de comunicación cumplieron un papel importante con la publicidad y las campañas adelantadas, una vez acogida la vacunación en colombia contra el pvh en el programa ampliado de inmunizaciones, lo cual posiblemente permitió que los/as jóvenes no pertenecientes al área de la salud asociaran el virus con este cáncer, hallazgo que es compatible con los reportes de otros estudios (11, 12, 19). en ningún momento, los/as jóvenes develaron la influencia del pvh en los cánceres del canal anal, pene y orofaringe, más bien les atribuyeron otras causas. coincidiendo con los hallazgos de carstens, la explicación podría basarse en el hecho de que piensan que son las mujeres quienes se enferman y los hombres solo portan el virus; por consiguiente, no se imaginan que otros cánceres diferentes al de cuello uterino puedan ser consecuencia del pvh (12). la frecuencia de ocurrencia del tipo de cáncer determina que este sea o no conocido por las personas (10); lo que apoya el hecho de que las vivencias y la observación generan conocimientos en salud entre los/as jóvenes: lo que más se ve, es lo que importa. igualmente, es notoria la formación positivista de los/ as estudiantes de las áreas de la salud, quienes piensan que las acciones se realizan según la frecuencia de la enfermedad. posiblemente por esta misma razón, la información sobre los cánceres asociados al pvh y su inclusión en campañas preventivas es prácticamente inexistente. cabe destacar que, en colombia, la frecuencia del cáncer de pene no está claramente establecida por dificultades y carencias de los sistemas de información y de los registros poblacionales de cáncer que no cubren a todo el país. cáncer: debilidad, aislamiento y muerte el cáncer de pene y el de cuello uterino afectan la vida. para los hombres, sufrir de cáncer de pene significa perder su virilidad, dejar de ser hombres. un estudio realizado por khan et al. evidenció que, para los hombres, el pene es el núcleo de la masculinidad. representa poder por su papel en la penetración, considerada necesaria para ganar a las mujeres (33). con el cáncer de pene, los jóvenes imaginaron la pérdida del órgano. para freud, el portar un pene envía un mensaje al otro: “no tengo miedo de ti, te desafío, tengo un pene”. la amenaza de perder el pene es asociada con la adopción de una imagen corporal femenina (34). la castración implicaría perder la omnipotencia y pondría en peligro la imagen narcisista masculina (35). según godelier, en este hecho se puede constatar el valor diferencial de los sexos en el orden psíquico, en la medida en que existe valoración positiva del órgano masculino y una desvalorización de lo femenino por su ausencia (29). para las mujeres, el pvh es causa de crisis y señalamientos posiblemente porque está asociado a la promiscuidad, la infidelidad, al cáncer de cuello uterino y a la muerte. de forma similar, castro y arellano observaron un impacto negativo en la vida se267 lo que no se ve, no existe: percepciones sobre cáncer y papilomavirus humano en jóvenes universitarios, medellín, colombia, 2014 l lucía stella tamayo-acevedo y otros xual de las mujeres a causa de la desconfianza en sus parejas (36). otros autores reportaron sentimientos de angustia, estigma y temor (37, 38). según weisner et al., tener una its, además de estar asociada al cáncer, puede desencadenar temor hacia las relaciones sexuales por considerarlas de riesgo para infectarse o desencadenar un cáncer (19). el cáncer de cuello uterino y el de pene ocasionaron reacciones similares en mujeres y hombres, respectivamente. en la mujer, el temor de perder el placer y la pareja, y en el hombre, significa el fin su masculinidad y de su vida sexual. ambas percepciones demuestran la creencia de que la fuente del placer sexual es el pene, que el placer solo es posible con la penetración, y que la mujer no puede vivirlo sin la presencia de un hombre. limitaciones del estudio la baja respuesta de los hombres a participar en los grupos de discusión, en lo cual pudo influir el haber informado, por ética, el tema por discutir, pudo obedecer posiblemente a los patrones culturales que catalogan las actividades educativas y preventivas de salud sexual propias de mujeres. debido a la baja participación masculina, las investigadoras consideraron apropiado incluir tres grupos con solo dos participantes, cinco de ellos hombres, quienes estuvieron dispuestos a dar sus testimonios. de igual modo, una limitante del estudio fue el no haber realizado, pese a los esfuerzos, grupos de discusión únicamente con hombres y con mayor número de participantes, que permitieran la expresión del discurso sin la presión y el condicionamiento que pudo generar la presencia de las mujeres. en este estudio, las percepciones de los jóvenes universitarios sobre el cáncer y el pvh no se abordaron desde las particularidades de la identidad y la orientación sexual, por no tratarse del objetivo del mismo; sin embargo, se reconoce la importancia de estas categorías que podrían ser incluidas en futuras investigaciones. conclusiones y recomendaciones los/as jóvenes relacionaron el cáncer de cuello uterino con el pvh, mas no a esta infección con el cáncer en canal anal, orofaringe y pene, cánceres que desconocían o sobre los que tenían muy poco conocimiento. pensar que el pvh solo afecta a las mujeres, no les permitió imaginarse al virus implicado en la etiología de otros cánceres. este estudio identificó algunas percepciones poco investigadas, que son de interés para la intervención en programas de educación sexual, tales como la influencia religiosa en la concepción de placer y sexualidad, ver el cuidado en salud sexual como asunto de mujeres o de personas “gay”, creer que todas las its se manifiestan con síntomas y signos, pensar que la confianza sustituye el uso del condón, considerar que el pvh solo se transmite por relaciones coitales, equiparar pvh con cáncer de cuello uterino, y, finalmente, creer que “todos tenemos cáncer, a unos se les desarrolla y a otros no”. los roles de género fueron determinantes al momento de asumir o no comportamientos preventivos, lo cual sugiere que las estrategias preventivas diferenciadas por género solo logran profundizar las desigualdades construidas culturalmente, por tanto, estas deberán enfocarse en la compleja tarea de construir y reconstruir los roles de género. para el abordaje de la sexualidad en los programas de salud, en el componente educativo, es necesario cualificar al personal de enfermería, profesional y técnico, más allá de lo biológico y medicalizado, para dar respuesta al cuidado integral de enfermería en la complejidad que implica la sexualidad, bajo el enfoque de género. igualmente, como cuidadoras es necesario conocer y reflexionar sobre las realidades de los/as jóvenes acerca de sus creencias, tabúes, conocimientos y prácticas de cómo viven la sexualidad. los hallazgos de esta investigación son importantes para la enfermería porque evidencian el desconocimiento en el segmento de la población de mayor riesgo, los jóvenes, de la relación existente entre el pvh y otros cánceres diferentes al de cuello uterino, vacíos que se deberán considerar en el cuidado de la salud a través de la educación. también, aporta conocimientos sobre aspectos poco o nada abordados en las actividades de promoción de la salud, como el autoerotismo en mujeres, la negociación en la pareja, la desigualdad de género, entre otros. 268 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 referencias 1. zaldívar l, de larrea g, molina mf, sosa cf, ávila j, lloret rivas m, et al. cáncer cérvicouterino y virus del papiloma humano. rev chil obstet gineco. 2012;77(4):15-321. 2. shack l, lau h, huang l, doll c, hao d. trends in the incidence of human papillomavirusrelated noncervical and cervical cancers in alberta, canada: a populationbased study. cmaj open [internet]. 2014 [visitado 2014 oct 31]; 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83(2):155-159. disponible en: http://www.ncbi.nlm.nih.gov/ pmc/articles/pmc2598611/ 07 17 o uso do aloe sp babosa.indd 7 lucélia terra chini1 roberta aparecida mendes2 lais reis siqueira3 sandreli pereira da silva4 patrícia costa dos santos silva5 eliza maria rezende dázio6 silvana maria coelho leite fava7 o uso do aloe sp (aloe vera) em feridas agudas e crônicas: revisão integrativa 1 orcid.org/0000-0003-0266-5295. escola de enfermagem da universidade federal de alfenas/unifal, brasil. lucelia.jonas@unifal-mg.edu.br 2 orcid.org/0000-0001-9209-1306. escola de enfermagem da universidade federal de alfenas/unifal, brasil. robertaaparecidamendes@hotmail.com 3 orcid.org/0000-0002-6720-7642. escola de enfermagem da universidade federal de alfenas/unifal, brasil. laisreis.siqueira@gmail.com 4 orcid.org/0000-0003-1717-7729. escola de enfermagem da universidade federal de alfenas/unifal, brasil. sandrelipereira@hotmail.com 5 orcid.org/0000-0001-9643-1865. escola de enfermagem de ribeirão preto, universidade de são paulo, brasil. patriciacostaunifenas@hotmail.com 6 orcid.org/0000-0001-9216-6283. escola de enfermagem da universidade federal de alfenas/unifal, brasil. eliza.dazio@unifal-mg.edu.br 7 orcid.org/0000-0003-3186-9596. escola de enfermagem da universidade federal de alfenas/unifal, brasil. silvana.fava@unifal-mg.edu.br recibido: 26 de junio de 2015 enviado a pares: 27 de julio de 2015 aceptado por pares: 18 de mayo de 2016 aprobado: 31 de mayo de 2016 doi: 10.5294/aqui.2017.17.1.2 para citar este artículo / to reference this article / para citar este artigo chini lr, et. all. o uso do aloe sp (babosa) em feridas agudas e crônicas: revisão integrativa. aquichan. 2017; 17(1): 7-17. doi: 10.5294/aqui.2017.17.1.2 resumo objetivos: buscar evidências disponíveis na literatura sobre o uso de aloe vera na cicatrização de feridas agudas e crônicas. materiais e método: trata-se de uma revisão integrativa realizada nas bases de dados lilacs, pubmed e scopus, no período de fevereiro a março de 2015. a busca resultou em 178 publicações. resultados: sete estudos constituíram a revisão, os quais envolveram pessoas com feridas cirúrgicas de cesariana, feridas de episiotomia, queimaduras, área doadora de enxerto, feridas pós-hemorroidectomia e feridas fissuras anais crônicas. evidenciou-se que aloe vera promove a cicatrização de feridas, além de diminuir a dor em fissuras anais crônicas e queimaduras. conclusões: aloe vera representa uma nova terapêutica no tratamento de feridas, no entanto as evidências disponíveis sobre sua eficácia e segurança são insuficientes para legitimar o seu uso na cicatrização de feridas agudas e crônicas; portanto, não podem ser generalizadas. palavras-chave aloe; cicatrização de feridas; ferimento e lesões; fitoterapia; plantas medicinais (fonte: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 7-17 8 aquichan issn 1657-5997 año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 7-17 el uso del aloe sp (sábila) en heridas agudas y crónicas: revisión integradora resumen objetivos: buscar evidencias disponibles en la literatura acerca del uso de aloe sp (sábila) en la cicatrización de heridas agudas y crónicas. materiales y método: se trata de una revisión integradora realizada en las bases de datos lilacs, pubmed y scopus, en el periodo de febrero a marzo del 2015. la búsqueda resultó en 178 publicaciones. resultados: siete estudios constituyeron la revisión, los cuales involucraron personas con heridas de cesárea, heridas de episiotomía, quemaduras, área donadora de injerto, heridas posthemorroidectomía y heridas fisuarias anales crónicas. se evidenció que la sábila promueve la cicatrización de heridas, además de disminuir el dolor en fisuras anales crónicas y quemaduras. conclusiones: la sábila representa una nueva terapéutica en el tratamiento de heridas; sin embargo, las evidencias disponibles sobre su eficacia y seguridad son ineficientes para legitimar su uso en la cicatrización de heridas agudas y crónicas; por lo tanto, no se pueden generalizar. palabras clave aloe; cicatrización de heridas; heridas y lesiones; fitoterapia; plantas medicinales (fuente: decs, bireme). 9 o uso do aloe sp (babosa) em feridas agudas e crônicas: revisão integrativa l lucélia terra chini e outros the use of aloe sp. (aloe vera) on acute and chronic wounds: an integrative review abstract objective: search for available evidence in literature on the use of aloe vera in healing acute and chronic wounds. method: this is an integrative review of the lilacs, pubmed and scopus databases from february to march 2015. the search turned up 178 publications. results: seven studies were included in the review, which involved persons with surgical wounds from caesarean sections, episiotomy wounds, burns, graft donor areas, post-hemorrhoidectomy wounds and chronic anal fissure wounds. it has been shown that aloe vera helps wound healing, in addition to reducing pain in chronic anal fissures and burns. conclusion: aloe vera represents a new therapy in the treatment of wounds. however, the available evidence on its effectiveness and safety is insufficient to legitimize the use of aloe in healing acute and chronic wounds. therefore, the findings cannot be generalized. keywords aloe; wound healing; wounds and lesions; phytotherapy; medicinal plants (source: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 7-17 10 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 introdução feridas constituem um problema de saúde pública, sendo a cicatrização de tecidos o principal objetivo da intervenção clínica (1). feridas podem resultar de muitas doenças e podem ser classificadas como aguda ou crônica conforme tempo de existência (2). ferida aguda segue um processo de reparação previsível e persiste até 14 dias após intervenção cirúrgica ou trauma. já ferida crônica pode ser definida como aquela que necessita de terapêutica após seis semanas do seu surgimento (3). embora haja uma gama de substâncias sintéticas para tratamentos de feridas, o consumo de práticas terapêuticas à base de ervas medicinais tem se destacado nos últimos anos no contexto da saúde, possivelmente associado à percepção de que o consumo de produtos naturais é sinônimo de bem-estar e qualidade de vida (4). sendo assim, estudos envolvendo fitoterápicos que atuam no processo de cicatrização estão sendo desenvolvidos e, entre eles, encontram-se estudos com uso de aloe vera, o qual tem sido reincorporado como alternativa ou complemento terapêutico. por sua vez, aloe vera, também conhecida como babosa, tem sido utilizada há muito tempo no tratamento de várias condições de saúde, como neoplasia, conjuntivite, hiperglicemia, dislipidemia e na cicatrização de feridas (5). devido ao seu poder emoliente e suavizante é muito utilizada nas lesões de pele. além disso, apresenta efeito anti-inflamatório, antioxidante, cicatrizante, bactericida e laxativo. aloe vera contém cerca de 70 componentes potencialmente ativos, dentre eles vitaminas, enzimas, minerais, açúcares, além de ácido salicílico e ácidos aminados (2,6). a divulgação dos potencias benefícios do aloe vera tem despertado crescente interesse na população. no entanto, um dos principais problemas no uso de fitoterápicos está relacionado à falta de evidências pautadas em estudos padronizados sobre sua eficácia e segurança bem como sobre a composição desses produtos (4,6). face ao exposto e considerando a importância de sintetizar o conhecimento acerca de novos biomateriais que podem acelerar o processo de cicatrização, decidiu-se pela elaboração deste estudo, o qual objetivou buscar evidências na literatura científica a respeito do uso de aloe vera na cicatrização de feridas agudas e crônicas. método trata-se de uma revisão integrativa, na qual foram percorridas as seguintes etapas: identificação do tema e seleção da questão de pesquisa; estabelecimento de critérios para inclusão e exclusão de estudos; avaliação dos artigos incluídos na revisão; síntese do conhecimento dos principais resultados evidenciados na análise dos artigos incluídos e apresentação da revisão (7). para nortear o estudo, formulou-se a seguinte questão norteadora: “quais evidências científicas acerca da aplicação tópica de aloe sp (babosa) na cicatrização de feridas agudas e crônicas em humanos?”. empregou-se a estratégia pico, na qual p referese à população do estudo, ou seja, as pessoas com feridas agudas ou crônicas; i refere-se à intervenção estudada, isto é, aplicação tópica de aloe vera nas feridas; c refere-se ao grupo controle ou à comparação com outra intervenção já conhecida; e o refere-se ao resultado buscado com a intervenção em estudo, que neste estudo consiste na cicatrização da ferida. para a seleção dos estudos, utilizaram-se bases de dados consideradas importantes no contexto da saúde e disponíveis on-line: literatura latino-americana e do caribe em ciências da saúde (lilacs), national library of medicine national institute of health (pubmed) e scopus. os critérios de inclusão estabelecidos para a seleção dos artigos foram: artigos primários publicados na íntegra que abordassem a aplicação de aloe vera em humanos com feridas agudas e crônicas, nos idiomas em português, inglês e espanhol. a revisão da literatura restringiu-se às publicações da última década (entre 2005 a 2015). os critérios utilizados para exclusão dos artigos foram: artigos do tipo revisão de literatura, cartas, editoriais, relatos de experiência, estudos de casos, dissertações e teses. além disso, foram excluídos estudos primários que abordavam a aplicação de aloe vera em animais, em testes in vitro e em lesões orais. o levantamento dos estudos foi realizado em fevereiro e março de 2015, ao mesmo tempo nas três bases, utilizando os seguintes unitermos: aloe e cicatrização de feridas (wound healing). realizou-se uma avaliação dos artigos por dois revisores, sendo posteriormente comparados os resultados, no intuito de certificar que os mesmos atendiam aos critérios de inclusão. as informações foram extraídas dos artigos por meio de um instrumento construído pelos autores, o qual foi submetido a um pro11 o uso do aloe sp (babosa) em feridas agudas e crônicas: revisão integrativa l lucélia terra chini e outros figura 1. processo de seleção de artigos da revisão integrativa — adaptação do flow diagram (9). cesso de refinamento com finalidade de analisar os itens quanto à aparência, pertinência e relevância. tal instrumento contempla os seguintes itens: identificação do autor, do título, do ano de publicação e da instituição, objetivo do estudo, características do método, nome científico da aloe vera, forma de preparação do produto (gel, creme, pomada), custo do tratamento, efeitos adversos, resultados e conclusões obtidas e, por fim, classificação da evidência quanto ao nível e quanto à força de recomendação. a apresentação da revisão foi realizada de forma descritiva a fim de oferecer elementos de cada estudo para permitir ao leitor o entendimento do mesmo e a avaliação crítica dos resultados obtidos no sentido de oferecer subsídios a sua aplicabilidade na prática clínica e identificação de lacunas do conhecimento para desenvolvimento de futuras investigações. para análise da qualidade de evidência dos estudos (8), adotou-se a seguinte classificação: nível i —evidência proveniente de resultados de revisões sistemáticas ou meta-análise de ensaios clínicos randomizados controlados (ecrc) relevantes, ou de diretrizes clínicas, fundamentadas em revisões sistemáticas de ecrc; nível ii —evidência obtida de ecrc bem delineado; nível iii —evidência obtida de ensaios clínicos bem delineados, sem randomização; nível iv —evidência proveniente de estudo caso controle ou coorte; nível v —evidência proveniente de revisão sistemática de estudos qualitativos e descritivos; nível vi —evidência derivada de estudo descritivo ou qualitativo; nível vii — evidência oriunda da opinião de autoridades e/ou relatórios de comitês de especialistas. com relação à classificação quanto à força de evidência, os níveis i e ii são considerados evidências fortes, iii e iv moderadas e v a vii fracas. quanto aos aspectos éticos, as informações específicas extraídas dos artigos foram acessadas por meio de bancos de dados, não necessitando de autorização para utilizá-las por se tratarem de material pertencente ao domínio público. resultados e discussão identificaram-se setes estudos na base de dados lilacs, 91 na pubmed e 80 na scopus, totalizando 178 publicações. seguindo os critérios de seleção, apenas 23 artigos envolviam seres humanos, dos quais 16 foram eliminados e, dessa forma, sete artigos foram incluídos na revisão integrativa. os detalhes dos passos percorridos para seleção dos artigos estão descritos na figura 1. fonte: adaptação do flow diagram (9). com relação à caracterização dos estudos, seis foram desenvolvidos no irã e apenas um no paquistão. quanto ao idioma, todos os artigos foram publicados em inglês. já com relação à instituição de origem dos autores, todos estão vinculados às universidades. circundando a questão referente ao país de desenvolvimento do estudo, observa-se que todos foram desenvolvidos no continente asiático, tendo em vista que uso de aloe vera com finalidade terapêutica de cicatrização de lesão é permitido nesses países. em contrapartida, nos estados unidos, o gel de aloe é aprovado pelo food and drug administration (fda) como um aromatizante natural e pequenas quantidades podem ser utilizadas em alimentos. em 1999, o fda determinou que medicamentos orais e injetáveis contendo aloe não podem ser vendidos para tratamento de doenças, entre elas câncer, herpes, moléstias autoimunes e constipação, tendo em vista que não há conhecimentos suficientes sobre a sua segurança e eficácia (10). 12 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 no brasil, produtos de uso tópico contendo aloe vera estão autorizados como fitoterápicos para fins de cicatrização (4). a agência nacional de vigilância sanitária (anvisa) proibiu a comercialização de sucos e outros alimentos à base de aloe vera devido ao relato de reações adversas (4) e visto que as evidências científicas são insuficientes para comprovar sua segurança (2,6). além disso, não há estudos sistemáticos sobre a toxicologia do aloe, considerando que estes são necessários para investigação de possíveis danos ao organismo. ademais, não existe uma fórmula padrão para preparação dos produtos contendo aloe vera (4). quanto ao nível de evidência dos estudos (8), seis estudos foram classificados como nível ii e apenas um como nível iii pelo fato de ser ensaio clínico sem randomização. dessa forma, seis estudos apresentam força de evidência forte e um apresenta força de evidência moderada. a identificação do nível de evidência oferece subsídios para uma avaliação crítica dos resultados de pesquisa e, por conseguinte, para subsidiar a tomada de melhores decisões clínicas. com relação à família da babosa, todos os artigos citaram como pertencente à família das liliáceas e do gênero aloe, conforme tabela 1. entre as espécies das liliáceas existentes, as mais conhecidas são: aloe socotrina, aloe arborescens, aloe chinensis, aloe ferox e aloe vera, sendo essa última também conhecida como aloe barbadenses. esta é a mais estudada pelas indústrias alimentícias, farmacêuticas, cosméticas e fitoterápicas (11). trata-se de uma planta herbácea, que necessita de luz solar direta, não exige muita água e se desenvolve melhor em solos leves e arenosos. popularmente é conhecida como babosa, aloe, aloe-de-barbados e aloe-de-curaçao (12). os estudos incluídos na presente revisão utilizaram várias formulações tópicas de aloe vera. observou-se que houve predominância do creme de aloe a 0,5 % (57 %). apenas um estudo (14,2 %) referiu a utilização de gel fresco natural e um (14,25 %) referiu a aplicação de gel de aloe, composto de 98 % do gel bruto do interior da folha da planta. por fim, um estudo (14,25 %) não revelou a forma de preparação do produto, como pode ser observado na tabela 1. conforme apresentado na tabela 1, no estudo 01, o gel fresco in natura foi usado a fim de preservar suas substâncias eficazes, tendo em vista que algumas destas substâncias são desperdiçadas no processo de preparação e conservação (20). este gel com aparência viscosa e incolor pode ser obtido a partir tabela 1. características dos estudos com relação ao nome científico da aloe, forma de preparação e tipo de lesão. es tu do nome científico/ família da aloe tipo de formulação tópica tipo de lesão lesões agudas 01 aloe vera (l.) burm. f. (sinonímia aloe barbadensis miller), família liliaceae gel fresco natural de aloe (in natura) ferida cirúrgica de cesariana (13) 02 aloe vera, família liliaceae não refere episiotomia (14) 03 aloe vera, família liliaceae gel de aloe vera, composto de 98 % do gel bruto do interior da folha da planta queimaduras (15) 04 aloe vera, família liliaceae creme de aloe a 0,5 %, processado, esterilizado queimaduras (16) 05 aloe vera, família liliaceae creme de aloe a 0,5 %, processado, esterilizado área doadora de enxerto (17) 06 aloe vera, família liliaceae creme de aloe a 0,5 %, processado, esterilizado ferida cirúrgica de hemorroidectomia (18) lesões crônicas 07 aloe vera, família liliaceae creme de aloe a 0,5 %, processado, esterilizado fissuras anais crônicas (19) fonte: elaboração própria. da eliminação dos tecidos mais externos da folha, e é constituído por água, polissacarídeos e outras substâncias como vitamina a, b, c e e, cálcio, potássio, magnésio, zinco, aminoácidos, enzimas e carboidratos (5). já nos estudos 04, 05, 06 e 07, o creme era composto de suco do interior da planta, além de parafina líquida e sólida, álcool estearílico, álcool cetílico, propileno, água desionizada, laurilsulfato de sódio e metil-parabeno. ademais, o conselho internacional de ciência de aloe (iasc), uma organização norte-americana sem fins lucrativos, determina que apenas produtos que contenham acemano ou o beta 1-4 glucomanonas acetilados, podem ser considerados como aloe vera (21). por sua vez, acemano é um 13 o uso do aloe sp (babosa) em feridas agudas e crônicas: revisão integrativa l lucélia terra chini e outros polissárideo que tem sido apontando como responsável pela proliferação de fibroblastos (5,6) e assim, promove a deposição de colágeno e reorganiza o tecido lesionado. com relação ao custo do tratamento, apenas um estudo referiu que o custo do tratamento com aloe vera é menor do que o tratamento do grupo controle, que neste caso foi a sulfadiazina de prata (15). já com relação aos efeitos adversos, cinco estudos (13,15,17-19) informaram que os pacientes não apresentaram quaisquer complicações e reações alérgicas em decorrência da aplicação da cobertura de aloe vera. feridas agudas e crônicas com relação ao tipo de ferida, seis estudos envolveram pessoas com feridas agudas; entre elas, feridas cirúrgicas de cesariana (13), feridas de episiotomia (14), queimaduras (15-16), área doadora de enxerto (17) e feridas pós-hemorroidectomia (18). apenas um estudo selecionou pessoas com feridas crônicas: fissuras anais crônicas (19). conforme o quadro 2, o estudo 01 foi conduzido com 90 mulheres divididas em dois grupos com a finalidade de determinar a eficácia do gel de aloe vera na cicatrização de feridas cirúrgicas de cesariana (13). no grupo de intervenção o gel de aloe foi aplicado diretamente sobre a ferida suturada e coberto com gaze seca. já no grupo controle, a ferida cirúrgica foi coberta somente com gaze seca. a cicatrização da ferida foi avaliada 24 horas e oito dias após a cesariana pelo pesquisador por meio da escala reeda (vermelhidão, edema, equimose, secreção e cicatrização). a pontuação total da escala varia de 0 a 15, quanto mais próximo de 15, menor o grau de cicatrização da ferida. o estudo 02 recrutou 111 mulheres primíparas submetidas à episiotomia, as quais foram distribuídas aleatoriamente em três grupos: grupo de aloe vera, grupo de pomada de calêndula e grupo controle (14). a intervenção foi realizada quatro horas após a episiotomia, e a primípara continuou usando o produto a cada 8 horas. o grupo controle recebeu a rotina do hospital (betadine em quatro copos de água a cada quatro horas). a avaliação da cicatrização da episiotomia foi feita cinco dias após a intervenção por meio da escala reeda. no estudo 03, 50 pacientes com queimaduras de segundo grau foram randomizados em dois grupos: um recebeu tratamento com aloe vera (25 pacientes) e outro recebeu sulfadiazina de prata —25 pacientes (15). o tratamento com agentes tópicos foi mantido duas vezes por dia até a completa reepitelização da ferida. dor e irritação local foram registrados regularmente. o estudo 04 também foi conduzido com pacientes queimados. foram recrutados 30 pacientes com tipos similares de queimaduras de segundo grau em dois locais, em diferentes partes do corpo (16). de forma, aleatória, cada paciente teve uma queimadura tratada com sulfadiazina de prata tópica e uma tratada com creme de aloe vera. o curativo foi aplicado duas vezes por dia. já o estudo 05 foi conduzido com 45 pessoas que se submeteram a coleta de enxerto de pele devido ao trauma ou tumor (17). foram divididas em três grupos: grupo do creme de aloe vera, do creme de placebo e grupo controle (gaze seca sem agente tópico). todos os enxertos de pele foram colhidos a partir de regiões anterolateral e posterior da coxa. os grupos de aloe vera e grupos de placebo receberam curativos três vezes por dia. a ferida foi avaliada no pós-operatório e até completa reepitelização. o estudo 06 recrutou 49 pacientes que apresentam hemorroidas sintomáticas grau iii ou iv e preencheram os critérios para cirurgia de hemorroidectomia (18). os pacientes foram randomizados em dois grupos: 24 (aloe) e 25 (placebo). os pacientes aplicaram creme (aloe ou placebo) imediatamente e 12 horas após a cirurgia. este tratamento foi continuado no local da cirurgia três vezes por dia até 28º dia pós-operatório. a dor pós-operatória foi avaliada por meio de uma escala visual analógica, com classificação de 0 (sem dor) a 10 (dor muito grave). escore de dor foi obtido imediatamente, 12 horas, 24 horas e 48 horas após a cirurgia e no 14º e 28º dia. as feridas foram classificadas como grau i (ferimento grave e fresco, com inflamação), grau ii (tecido de granulação na ferida) e grau iii (camada de células epiteliais que cobrem em ferida). por fim, o estudo 07 foi conduzido com 60 pacientes com fissuras anais crônicas. foram divididos em dois grupos de 30 pacientes (19). o grupo controle recebeu placebo e o grupo de intervenção a aplicação tópica de creme de aloe na ferida local três vezes ao dia, imediatamente após a instrução de um médico. o tratamento durou três semanas. todos os pacientes foram acompanhados após a alta do hospital. o protocolo de tratamento para pacientes do grupo controle foi similar ao grupo de tratamento; no entanto, o grupo controle recebeu creme de placebo. a tabela 2 apresenta a síntese dos principais resultados e das conclusões dos artigos incluídos na presente revisão. 14 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 tabela 2. síntese dos principais resultados e das conclusões dos artigos incluídos na presente revisão. título principais resultados conclusões 01. aloe vera gel and cesarean wound healing; a randomized controlled clinical trial (13) a pontuação na escala reeda com relação à cicatrização das feridas cirúrgicas de cesariana foi de 0,00 no grupo que utilizou aloe vera e 0,6 no grupo controle 24 horas após a operação, e a diferença foi estatisticamente significativa (p = 0,003). após 8 dias, a pontuação da escala foi de 0,11 no grupo de aloe vera e 0,29 no controle grupo, mas a diferença não foi estatisticamente significativa (p = 0,283). o gel de aloe vera foi eficaz na cicatrização de feridas cirúrgicas de cesariana. a aplicação cutânea de gel de aloe vera não tem quaisquer efeitos secundários e pode, portanto, ser utilizado como tratamento adjuvante na cicatrização de ferida de cesariana. 02. the impact of aloe vera and calendula on perineal healing after episiotomy in primiparous women: a randomized clinical trial (14) a média da escala reeda cinco dias após a intervenção indicou diferença estatisticamente significativa entre os três grupos (p <0,001). a média da pontuação da escala reeda cinco dias após episiotomia teve diferença estaticamente significativa entre grupo de aloe vera e o grupo controle (p <0,001) e entre grupo de calêndula e grupo controle (p <0,001), mas não houve diferença significativa entre aloe vera e grupo de pomada de calêndula (p = 0,98). aloe vera e pomada de calêndula aumentam consideravelmente a velocidade de cicatrização de feridas de episiotomia. os pesquisadores recomendam mais estudos a respeito do uso desses produtos sobre a cicatrização de feridas. 03. effectiveness of aloe vera gel compared with 1 % silver sulphadiazine cream as burn wound dressing in second degree burns (15) no grupo de aloe vera, a epitelização iniciou no quinto dia, e a média de cicatrização completa foi de 11 dias, enquanto que no grupo de sulfadiazina de prata, a média foi 24,24. no grupo de aloe, nove pacientes (36 %) tiveram um alívio completo da dor até o quinto dia; outros nove pacientes (36 %) tiveram alívio até o 12º dia. o alívio da dor foi lento no grupo sulfadiazina de prata e levou 26 dias para todos os pacientes sentirem alívio total da dor. o gel de aloe vera promoveu uma melhor cicatrização de feridas em queimaduras de segundo grau em comparação à sulfadiazina de prata, além de promover maior alívio da dor. 04. aloe versus silver sulfadiazine creams for second-degree burns: a randomized controlled study (16) os tempos médios para a cura foram 18,73 ± 2,65 e 15,9 ± 2 dias para o sulfadiazona de prata e creme de aloe, respectivamente, sendo significativamente mais curto para o creme de aloe (p <0,0001). os locais tratados com aloe cicatrizaram aproximadamente 3 dias mais cedo do que os locais tratados com sulfadiazina de prata em todos os pacientes. o processo de reepitelialização foi mais rápido na pele dos doentes tratados com aloe do que naqueles tratados com sulfadiazina de prata. o mecanismo eficaz de creme de aloe na cura de lesões por queimadura pode ser explicado pelos seus efeitos de proliferação celular, inflamatórios e antiantimicrobianos. 05. the effects of aloe vera cream on split-thickness skin graft donor site management: a randomized, blinded, placebo-controlled study (17) o tempo de reepitelização no grupo controle foi de 17 ± 8,6 dias, enquanto que no grupo de aloe vera e no grupo de placebo foi de 9,7 ± 2,9 dias e 8,8 ± 2,8 dias, respectivamente. o tempo para a cicatrização de feridas foi significativamente diferente no grupo controle em comparação com o grupo de aloe vera e com o grupo de placebo (p <0,005). não houve nenhuma diferença significativa no tempo médio reepitelização entre aloe vera e placebo (base) grupos (p = 0,9). o creme tópico contendo aloe vera ou placebo promove a cicatrização de feridas em áreas doadoras de enxertos de pele de espessura parcial, quando comparados com uma gaze seca. manutenção de umidade na superfície da área doadora pode explicar os efeitos benéficos observados. 06. effects of aloe vera cream on posthemorrhoidectomy pain and wound healing: results of a randomized, blind, placebocontrol study (18) creme de aloe promoveu significativamente a cicatrização de feridas duas semanas após a cirurgia (p <0,001), mas não foi observada diferença significativa no final da quarta semana. as feridas do grupo de aloe foram classificadas em grau iii de cicatrização, com revestimento epitelial. já a cicatrização de feridas no grupo controle foi classificada como grau i e ii 14 dias após a cirurgia. os pacientes do grupo de aloe tiveram significativamente menos dor nas 12, 24, e 48 horas e 2 semanas após cirurgia (p <0,001). a aplicação de creme de aloe vera sobre o local cirúrgico reduz a dor pós-operatória, tanto em repouso ou durante a defecação, diminui o tempo de cicatrização, e diminui a quantidade de analgésicos em pacientes em comparação com o grupo placebo. 07. effects of aloe vera cream on chronic anal fissure pain, wound healing and hemorrhaging upon defection: a prospective double blind clinical trial (19) creme de aloe vera aumentou significativamente a cicatrização da ferida em pacientes no final da primeira semana de tratamento. essa diferença foi estatisticamente significativa quando comparada com a semana anterior, ou seja, antes da aplicação (p <0,0001). no final da sexta semana de tratamento, um total de 29 pacientes (93 %) no grupo de tratamento teve um aumento no seu grau de cicatrização da ferida. o creme tópico contendo 0,5 % de suco de aloe vera diminuiu a dor em fissura anal crônica e hemorragia após deserção, bem como promoveu a cicatrização de feridas. aplicação tópica de creme aloe vera é uma forma eficaz e segura de tratamento e representa uma nova terapêutica no sentido de tratar fissuras anais crônicas. fonte: elaboração própria. 15 o uso do aloe sp (babosa) em feridas agudas e crônicas: revisão integrativa l lucélia terra chini e outros a presente revisão descreveu a eficácia da aloe vera sobre a cicatrização de feridas agudas e crônicas. após busca na literatura, foram incluídos sete ensaios clínicos com tamanho amostral médio de 62 pacientes. destes, cinco estudos evidenciaram que aloe vera diminui o tempo de cicatrização da ferida quando comparados com o grupo controle, ou seja, grupo com gaze seca sem agente tópico (13), grupo com sulfadiazina de prata (15,16) e grupo com creme de placebo (18,19). com relação ao uso de aloe vera na lesão por episiotomia (14), aloe vera e pomada de calêndula promovem considerável cicatrização cinco dias pós-parto em comparação com betadine. no entanto, há uma carência de estudos sobre o efeito de aloe e calêndula na cicatrização de feridas de episiotomia, porém pesquisas semelhantes foram feitas relacionadas aos efeitos de outras ervas medicinais. estudo realizado em um hospital coreano sobre os efeitos do extrato de lavanda na cicatrização de feridas de episiotomia revelou que a lavanda acelera a cicatrização da mesma (22). no estudo sobre cicatrização da área doadora de enxerto (17), o creme de aloe apresentou um tempo mais curto para a cicatrização de feridas com relação ao curativo de gaze, no entanto, seu efeito não foi melhor do que o creme de placebo. uma vantagem desta investigação foi o uso de creme de placebo, além de creme de aloe e curativo com gaze sem agente tópico, que forneceu dados confiáveis para determinar os efeitos benéficos do creme de aloe vera em feridas na área doadora. nos grupos tratados com cremes, estes foram aplicados de forma contínua nos locais doadores, os quais induziram um ambiente úmido em comparação com gaze seca. uma provável explicação para este resultado pode estar relacionada ao fato de curativos úmidos diminuírem o tempo de cicatrização em comparação com curativos semiúmidos (17). as evidências sobre a cicatrização de feridas à base de aloe vera são contraditórias. estudo realizado com pessoas com feridas infectadas e não cicatrizadas de cesariana e de cirurgia abdominal ginecológica, aloe vera causou um atraso na cicatrização de feridas (23). isto pode ser devido à diferença no método do estudo e do tipo de feridas dos pacientes, tendo em vista que usaram uma escala avaliação de cicatrização de feridas diferente do estudo incluído na revisão (13). uma das principais indicações de uso de gel de aloe vera é para cicatrização de queimaduras, no entanto poucos estudos têm comparado a eficácia deste gel com sulfadiazina de prata no tratamento de queimaduras. os dois estudos (15,16) envolvendo pacientes com queimaduras de segundo grau evidenciaram que a aloe vera diminui o tempo de cicatrização quando comparada com sulfadiazina de prata. uma das principais limitações dos ensaios clínicos está relacionada ao fato dos pacientes do grupo de intervenção e controle possuírem fatores diferentes, os quais podem influenciar nos resultados. dessa forma, os resultados do estudo conduzido por khorasani et al. (16) são relevantes pelo fato de selecionar paciente com duas queimaduras de tamanho e tipo similar, ou seja, o paciente é controle dele mesmo, eliminando, assim, os diversos parâmetros que poderiam causar divergências nos resultados. o estudo conduzido com pacientes submetidos à cirurgia de hemorroidectomia (18) demonstrou que creme de aloe vera foi eficaz na cicatrização da lesão cirúrgica e no alívio da dor. aloe vera aumenta a síntese de colágeno no tecido de granulação, bem como aumenta a proliferação de fibroblastos, que por sua vez proporciona resistência e integridade para a derme e outros tecidos (6). os efeitos anti-inflamatórios da aloe contribuem para alívio da dor pós-operatória. além disso, aloe tem efeito antimicrobiano, o qual está relacionado com os seus constituintes, incluindo antraquinonas e aloe-emodina. este efeito antimicrobiano pode contribuir para a redução da dor e promoção da cicatrização de feridas. em suma, o papel benéfico do aloe vera se deve às suas propriedades anti-inflamatórias, antimicrobianas e de cicatrização de feridas (5,6). o creme de aloe também teve efeito positivo sobre lesões crônicas, especificamente sobre fissuras anais crônicas (19). num estudo de caso envolvendo paciente com ferida isquêmica, no qual houve aplicação de aloe vera e colágeno, o produto mostrou-se eficaz na cicatrização de feridas (24). considerações finais a presente investigação buscou mostrar evidências científicas sobre a utilização de aloe vera na cicatrização de feridas agudas e crônicas. os estudos disponíveis evidenciaram que produtos à base de aloe vera aceleram o processo de cicatrização de feridas agudas e crônicas, quando comparados com placebo, sulfadiazina de prata e gaze sem agente tópico. além disso, diminui a dor em fissuras anais crônicas e queimaduras. 16 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 aloe vera representa uma nova terapêutica no tratamento de feridas, no entanto, as evidências disponíveis sobre sua eficácia e segurança são insuficientes para legitimar o uso de aloe na cicatrização de feridas agudas e crônicas, nem tão pouco para generalizações. isso se deve principalmente à carência de ensaios clínicos com métodos bem delineados. além do mais, não há uma padronização da composição dos produtos à base de aloe vera, da técnica de processamento e nem da sua forma de aplicação, considerando que essas questões são importantes para conservar suas características químicas e para maior efeito farmacológico esperado. referências 1. passadouro r, sousa a, santos c, costa h, craveiro i. características e prevalência da ferida crônica. revista spdv. 2016; 74(1):45-51. 2. dat ad, poon f, pham kbt, doust j. aloe vera for treating acute and chronic wounds. cochrane database syst rev. 2012; 2:1-30. 3. paço r. fisiologia da cicatrização e fatores que a influenciam. in: pinto e, vieira i. editores. prevenção e tratamento de feridas da evidência à prática [e-book]. 2014 [citado 2016 mai 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soares mjgo, rocha ps. uso de cobertura com colágeno e aloe vera no tratamento de ferida isquêmica: estudo de caso. rev esc enferm usp. 2010; 4(2):346-51. 84 92 associacao entre a autoeficacia.indd 84 aquichan issn 1657-5997 janaiana lemos uchoa1 emanuella silva joventino2 marly javorski3 paulo césar de almeida4 mônica oliveira batista oriá5 lorena barbosa ximenes6 associação entre a autoefi cácia no ciclo gravídico puerperal e o tipo de aleitamento materno7 1 orcid.org/0000-0003-2262-5397. hospital universitário walter cantídio/universidade federal do ceará, brasil. janaiana@hotmail.com 2 orcid.org/0000-0001-9786-5059. universidade federal do ceará, brasil. manujoventino@yahoo.com.br 3 orcid.org/0000-0002-3599-6501. universidade federal de pernambuco, brasil. marly.11j@gmail.com 4 orcid.org/0000-0002-2867-802x. universidade estadual do ceará. brasil. pc49almeida@gmail.com 5 orcid.org/ 0000-0002-1483-6656. universidade federal do ceará. brasil. profmonicaoria@gmail.com 6 orcid.org/0000-0001-9319-6492. universidade federal do ceará. brasil. lbximenes2005@uol.com.br 7 uchoa jl. autoeficácia das mulheres no ciclo gravídico-puerperal em amamentar. dissertação (mestrado). fortaleza, universidade federal do ceará, 2012. recibido: 29 de septiembre de 2015 enviado a pares: 01 de octubre de 2015 aceptado por pares: 23 de junio de 2016 aprobado: 28 de junio de 2016 doi: 10.5294/aqui.2017.17.1.8 para citar este artículo / to reference this article / para citar este artigo uchoa, j.l.; joventino, e.s.; javorski, m.; almeida p.c; oriá, m.o.b. & ximenes l.b. associação entre a autoefi cácia no ciclo gravídico puerperal e o tipo de aleitamento materno. 2017; 17(1): 84-92. doi: 10.5294/aqui.2017.17.1.8 resumo objetivos: analisar a associação das médias dos escores da breastfeeding self-efficacy-scale (short-form) de mulheres no pré-natal e no pós-parto com o tipo de aleitamento materno. materiais e método: estudo longitudinal e quantitativo, realizado em unidades básicas de saúde de pacatuba (ceará), com 50 mulheres com mais de 30 semanas gestacionais, no período de julho a novembro de 2011. foram quatro coletas: a primeira realizada na unidade de saúde durante a gravidez e as três outras por visita domiciliária no puerpério. utilizaram-se a escala nas duas primeiras coletas e o formulário de saúde infantil nas três últimas. resultados: observou-se significância estatística entre as médias dos escores da escala (p=0,009), no domínio técnico (ρ=0,001), entre uso de leite artificial ao nascer e tipo de aleitamento posterior à alta da maternidade (ρ=0,001). na maternidade, as mães de crianças que amamentavam exclusivamente apresentaram médias dos escores de autoeficácia mais elevados tanto no pré-natal quanto no pós-parto (p<0,005). conclusões: faz-se premente a atuação dos profissionais da saúde em estratégias de promoção do aleitamento materno pautadas na autoeficácia, devendo ser implementadas no ciclo gravídico-puerperal, pois é evidente que altos escores de autoeficácia estão diretamente relacionados ao maior tempo de aleitamento materno. palavras-chave aleitamento materno; autoeficácia; enfermagem; desmame; saúde da criança (fonte: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 84-92 85 representações sociais do cuidado de doentes terminais no domicílio: o olhar do cuidador familiar l stefanie griebeler oliveira e outros año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 84-92 asociación entre la autoeficacia en el ciclo gestacional puerperal y la clase de lactancia materna resumen objetivos: analizar la asociación de los promedios de los puntajes de breastfeeding self-efficacy-scale (short-form) de mujeres en el prenatal y el postparto con la clase de lactancia materna. materiales y método: estudio longitudinal y cuantitativo, realizado en unidades básicas de salud de pacatuba (ceará, brasil), con 50 mujeres con más de 30 semanas gestacionales, en el periodo de julio a noviembre del 2011. fueron cuatro recolecciones: la primera realizada en la unidad de salud durante el embarazo y las otras tres en visita domiciliaria en el puerperio. se utilizaron la escala en las dos primeras recolecciones y el formulario de salud infantil en las tres últimas. resultados: se observó significancia estadística entre los promedios de los puntajes de la escala (p=0,009), en el dominio técnico (ρ=0,001), entre uso de leche artificial al nacer y la clase de lactancia posterior a la salida de la maternidad (ρ=0,001). en la maternidad, las madres de niños que amamantaban exclusivamente presentaron promedios de los dos puntajes de autoeficacia más elevados tanto en el prenatal como en el postparto (p<0,005). conclusiones: urge la actuación de los profesionales de salud en estrategias de promoción de la lactancia materna pautadas en la autoeficacia, debiendo implementárselas en el ciclo gestacional-puerperal, pues es evidente que altos puntajes de autoeficacia están directamente relacionados con el mayor tiempo de lactancia materna. palabras clave autoeficacia; destete; enfermería; lactancia materna; salud de los niños (fuente: decs, bireme). 86 aquichan issn 1657-5997 the association between self-efficacy in the puerperal pregnancy cycle and the type of breastfeeding abstract objective: analyze the association between mean scores for pre-natal and postpartum women on the breastfeeding self-efficacy-scale (short-form) and the type of breastfeeding. method: this is a longitudinal, quantitative study conducted at basic health units in pacatuba (ceará) from july to november 2011. the sample included 50 women who were more than 30 weeks into their pregnancies. four sets of data were collected: the first one at the health unit during pregnancy and the other three through home visits during the postpartum period. the scale was used in the first two collections and the child health form in the last three. results: statistical significance was observed between the mean scale scores (p = 0.009) in the technical domain (ρ = 0.001), between artificial milk used at birth and the type of breastfeeding after maternity leave (ρ = 0.001). in the maternity unit, the mothers who breastfed their children exclusively had the highest average self-efficacy scores in both the prenatal and postpartum periods (p <0.005). conclusion: health professionals are strongly encouraged to adopt breastfeeding strategies based on self-efficacy. these strategies should be implemented during the pregnancy-puerperal cycle, since it is evident that high self-efficacy scores are directly related to breastfeeding for a longer period of time. keywords breastfeeding; self-efficacy; child health; nursing; weaning (source: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 84-92 87 representações sociais do cuidado de doentes terminais no domicílio: o olhar do cuidador familiar l stefanie griebeler oliveira e outros introdução o ato de amamentar, considerado inerente à maternidade, nem sempre é um processo tranquilo e natural para algumas mulheres. essa afirmação reflete na situação do brasil, uma vez que, já nos primeiros dias de vida, verificou-se uma acentuada queda na probabilidade de as crianças estarem em aleitamento materno exclusivo, apesar da evolução da mediana do aleitamento materno (1). estudo sobre prevalência e determinantes do aleitamento materno exclusivo (ame), realizado em um município de são paulo, constatou que a idade média, em dias, das crianças menores de seis meses que estavam em ame foi de apenas 60,6 dias (2). tal resultado demonstra que estamos muito aquém da recomendação dos 180 dias para o ame (1). dentre os fatores relatados pelas mães para a interrupção precoce do ame, estudos mencionam receio e dúvidas acerca da qualidade nutricional e da quantidade do leite materno produzido para saciar o bebê, dificuldade em amamentar, falta de informações e de segurança da mãe sobre as vantagens do leite materno, além do uso de chupeta, bicos, água e chás no intervalo das mamadas (15). vale destacar que tais fatores são considerados como modificáveis e apontam para a falta de confiança e de preparo da mulher para amamentar. assim, os profissionais de saúde devem considerar em suas práticas o aconselhamento, o acolhimento e a comunicação terapêutica, buscando a compreensão holística da mulher (3). para tanto, é necessário considerar, desde o pré-natal, a mulher no seu processo de empoderamento relacionado ao ato de amamentar, a partir de um diálogo com a equipe de saúde sobre todos os benefícios do aleitamento materno, para que ela possa avaliar e realizar suas tomadas de decisões (4, 6). ademais, a autoeficácia pode influenciar no julgamento da mulher sobre sua habilidade para iniciar o aleitamento materno, vencer as dificuldades que por ventura surjam e continuar o processo de amamentação (5). a autoeficácia para amamentar compreende as expectativas e as crenças da mulher em sua capacidade para executar tarefas específicas e comportamentos em prol de uma amamentação bem-sucedida. por sua vez, as expectativas e as crenças para o aleitamento materno estão atreladas às experiências pessoal e vicária, à persuasão verbal, além de fatores fisiológicos a serem minimizados como dor, ansiedade e fadiga (12). nesse contexto, a breastfeeding self-efficacy scale: psychometric assessment of the short-form (bses-sf), traduzida, validada e adaptada para o brasil, é um instrumento capaz de mensurar a confiança da mulher para amamentar. trata-se de uma ferramenta sensível e confiável para mensurar os escores de autoeficácia em amamentar e possibilita avaliar as nutrizes com maior risco de interromper precocemente o aleitamento materno, para que se intervenha de maneira eficaz (6, 12). uma vez que escores elevados da autoeficácia para amamentar estão associados ao tempo mais prolongado de amamentação, bem como ao ame (7, 10), a mensuração destes, tanto na gestação quanto no puerpério, são importantes para orientar e aperfeiçoar as intervenções educativas pelos profissionais de saúde. essas intervenções estão voltadas a aumentar a autoeficácia das gestantes e das puérperas para melhorar a adesão ao aleitamento materno, cuja taxa preconizada pela organização mundial de saúde (oms) ainda se encontra abaixo do esperado. assim, o estudo teve como objetivo analisar a associação das médias dos escores da bses-sf de mulheres no pré-natal e no pós-parto com o tipo de aleitamento materno. métodos tratou-se de um estudo longitudinal do tipo painel, no qual as mesmas variáveis são medidas para as mesmas unidades de análise para no mínimo dois períodos de tempo, e é adequado para a investigação de mudanças no nível individual. pacatuba (estado do ceará, brasil) é a terceira maior cidade em densidade demográfica da região metropolitana de fortaleza; a população de mulheres em idade fértil (10-49 anos) corresponde a 35,40 % da população e possui 14 unidades básicas de saúde da família (ubasf). essas 14 unidades têm atendido no pré-natal uma média de 18 gestantes por mês, totalizando 120 mulheres no período gravídico. optou-se por eleger apenas seis das 14 ubasf por elas estarem localizadas no perímetro territorial de maior concentração geográfica do município. adotaram-se como critérios de inclusão das participantes: com gestação única e estar a partir da 30ª semana de gravidez, conforme estudo piloto no canadá (11). os critérios de exclusão foram: restrições físicas e/ou mentais que impossibilitassem a coleta de dados, gestantes com pré-natal de risco e neonatos que tivessem permanência maior que 15 dias em unidades de tratamento intensivo. 88 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 realizou-se o estudo no período de julho a novembro de 2011. o recrutamento das gestantes foi de julho a setembro; após isso, à medida que as crianças nasciam, era reaplicada a escala e realizado o acompanhamento da criança e do seu tipo de aleitamento. portanto, o total foi de 50 gestantes que estavam cadastradas e acompanhadas no pré-natal em seis ubasf do município de pacatuba (ceará). a coleta de dados foi realizada tanto nas ubasf quanto por meio de visita domiciliária, tendo ocorrido em quatro momentos com a mesma mulher: primeiro momento no pré-natal; segundo momento do 1º ao 15º dia de puerpério de cada mulher; terceiro momento no primeiro mês de puerpério das participantes e quarto momento no segundo mês de puerpério. os instrumentos de coleta de dados foram: a bses-sf (12), com vistas a avaliar a relação do nível de confiança da mãe e seu êxito em amamentar, um formulário sobre a dieta da criança e outro que abordava dados sociodemográficos, ambos adaptados de outros estudos (12). a bses-sf é uma escala do tipo likert validada e confiável (alfa de cronbach 0,74), composta por 14 itens distribuídos em dois domínios (técnico e pensamentos intrapessoais) com cinco opções de resposta: 1) discordo totalmente; 2) discordo; 3) às vezes concordo; 4) concordo; 5) concordo totalmente. a pontuação total dessa escala pode variar de 14 a 70 pontos, de modo que, quanto mais elevados os escores da mãe no somatório dos itens, maior sua autoeficácia para amamentar (12). o domínio técnico da bses-sf reflete ações físicas que as mães deveriam realizar para amamentar com sucesso, como: aspectos relacionados ao manejo técnico, desde ações que reduzam a ansiedade materna nesse período significativo de suas vidas até o posicionamento apropriado, o conforto do neonato durante o ato de amamentar e o reconhecimento de sinais de uma lactação de qualidade, tal como a sucção do mamilo areolar, entre outros. os pensamentos intrapessoais refletem as percepções, as atitudes e as crenças da mãe com relação à amamentação bem-sucedida. referem-se à subjetividade envolvida no processo de amamentar e podem estar associados a um período mais longo do aleitamento materno porque dizem respeito às sensações de alegria, prazer ou realização pessoal durante a amamentação de seus filhos, além de demonstrarem o desejo, a motivação interna e a satisfação das mães com a experiência de amamentar. antes de serem realizados os testes estatísticos, foi verificada a normalidade das variáveis (teste de kolmogorov-smirnov), bem como a igualdade de variâncias (teste de levene); a análise exploratória foi realizada por meio de testes estatísticos descritivos, testes t de student e de wilcoxon, convencionando-se um nível de significância inferior a 0,05. os dados foram processados no statistical package for the social sciences (spss), versão 19.0. o projeto de pesquisa foi aprovado pelo comitê de ética em pesquisa da universidade federal do ceará, sob o protocolo 124/2011; foram respeitadas todas as normas éticas que envolvem seres humanos. cada participante assinou as duas vias do termo de consentimento livre e esclarecido, e ficou com uma via dele. resultados das mulheres participantes do estudo, a idade variou de 15 a 43 anos (m = 23; dp = ± 5,3), tendo predominado as casadas/ uniões consensuais (76 %), pardas (72 %), com oito ou mais anos de estudos (76 %), sem ocupação formal (66 %), com renda per capita maior que r$ 141,007 (66 %) e com média de três a quatro pessoas que residem no mesmo domicílio. as participantes envolvidas na pesquisa encontravam-se por volta das 36,4 semanas gestacionais no início do estudo. com relação às médias dos escores da bses-sf nos dois primeiros momentos de aplicação da escala (pré-natal e pós-parto), pôde-se verificar significância estatística (ρ = 0,009). já quanto aos domínios da escala, evidenciou-se que os escores tanto no domínio técnico quanto no domínio pensamento intrapessoal foram maiores no pós-parto. contudo, somente o domínio técnico apresentou significância estatística (ρ = 0,001) (tabela 1). além disso, observou-se que, das 50 crianças acompanhadas no estudo, oito (16 %) tomaram leite artificial (la) na maternidade. destas, três (6 %) estavam em amamentação parcial (am) no 15º dia de vida. com relação às 42 (84 %) crianças que não fizeram uso de la na maternidade, somente uma (2 %) encontrava-se em amamentação parcial no 15º dia de puerpério da mulher, constatando-se uma associação entre o uso de la ao nascer e o tipo de aleitamento posterior à alta da maternidade (ρ = 0,001) (figura 1). 7 aproximadamente usd$ 44. 89 representações sociais do cuidado de doentes terminais no domicílio: o olhar do cuidador familiar l stefanie griebeler oliveira e outros m: média; epm: erro padrão da média; mín.: mínimo; máx.: máximo; ρ: t de student. fonte: elaboração própria. figura 1. uso de leite artificial (na maternidade e tipo de amamentação no 15º dia do puerpério mediato (pacatuba, ceará, 2011) tabela 1. classificação bses-sf no pré-natal e no pós-parto (pacatuba, ceará, 2011) fonte: elaboração própria. variáveis m ± epm mín. máx. ρ bses-sf 0,009 1º momento — pré-natal 57,5 1,0 37 70 2º momento — 15º dia de puerpério 60,4 1,0 44 70 domínio técnico (5, 6, 7, 8, 10, 11, 12, 13) 0,001 1º momento — pré-natal 32,96 0,6 22 40 2º momento — 15º dias de puerpério 35,08 0,5 26 40 domínio intrapessoal (1, 2, 3, 4, 9, 14) 0,197 1º momento — pré-natal 24,50 0,5 14 30 2º momento — 15º dias de puerpério 25,38 0,6 12 30 diferença da bses-sf no 1º e 2º momentos 2,32 22 18 na maternidade, as mães de crianças que se encontravam em ame apresentaram médias dos escores da bses-sf mais elevados tanto no pré-natal quanto no pós-parto (ρ < 0,005; ρ = 0,015). a alimentação prevalente até os dois meses de idade foi a amamentação exclusiva, com média de 51,2 dias (dp = 22,9). já a média de dias de amamentação mista foi de 12,7 (dp = 23,2), e a média de la foi de 1,5 dias (dp = 6,6). observa-se que a média da bses-sf no pré-natal (1ª coleta) é menor se comparada à média da bses-sf coletada no puerpério (2ª coleta), o que ficou evidenciado na prevalência da amamentação exclusiva em vários pontos de coorte longitudinais: na maternidade (ρ = 0,015), nos 15 primeiros dias pós-parto (ρ = 0,011), no primeiro mês de vida (ρ = 0,009) e no segundo mês de vida (ρ < 0,0001) (tabela 2). 90 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 discussão resultados do presente estudo evidenciaram que houve um aumento nas médias dos escores da bses-sf tanto no pré-natal quanto no pós-parto em relação aos domínios técnico e pensamento intrapessoal. essa confiança pessoal é relevante para a continuidade da amamentação, pois se o indivíduo dominar as práticas e tiver os incentivos necessários, as expectativas de eficácia serão as principais determinantes das suas escolhas, de quanto esforço vai desenvolver e durante quanto tempo vai persistir perante os obstáculos que surgirem. acerca da autoeficácia, deve-se considerar também que experiências pessoais, vivências positivas de terceiros e incentivo por persuasão verbal levarão a mulher a lidar com os estados fisiológicos e afetivos diversos inerentes a essa etapa de sua vida, o que corrobora para a manutenção do ame ou do aleitamento continuado (12). os achados do presente estudo demonstraram, ainda, que a prática da amamentação hospitalar ou nas primeiras horas de vida ajuda a mulher a permanecer com esse comportamento no domicílio. tal fato é validado por estudo realizado em são paulo, o qual demonstrou que existe efeito significativo do alojamento conjunto (ac) (ρ = 0,0297) no tipo de aleitamento no pós-parto, isto é, havendo a possibilidade de mulheres em ac terem 35 vezes mais chances de manter ame, quando comparadas com as que não estiveram em ac (13). no presente estudo, em relação aos 15 primeiros dias de puerpério, primeiro e segundo meses de vida da criança, pode-se verificar que as médias dos escores da bses-sf na amamentação exclusiva foram maiores no pós-parto (ρ < 0,05), com um aumento de 0,3 a 5 escores em relação aos dados da aplicação da escala no pré-natal. pesquisa realizada na austrália corrobora esse achado, pois também constatou escores mais elevados da bses-sf tanto na primeira semana quanto no quarto mês pós-parto, tabela 2. bses-sf no pré-natal e no pós-parto e tipo de aleitamento infantil (pacatuba, ceará, 2011) m: média; m bses-sf pn: média dos escores da bses-sf no pré-natal; m bses-sf pp: média dos escores da bses-sf no pós-parto; epm: erro padrão médio; ρ: t de student; *teste de wilcoxon. fonte: elaboração própria. variáveis n % bses-sf pré-natal bses-sf pós-parto ρ m ± epm m ± epm maternidade amamentação exclusiva 42 84 57,7 ± 1,0 60,6 ± 0,9 0,015 fórmula infantil exclusiva 8 16 54,0 ± 4,2 58,0 ± 7,0 0,339* nos 15 primeiros dias de pós-parto amamentação exclusiva 46 92 57,83 ± 1,0 61,0 ± 0,9 0,011 amamentação mista 4 8 53,25 ± 3,5 54,5 ± 5,5 0,612* 1º mês de vida amamentação exclusiva 39 78 57,69 ± 1,2 61,2 ± 1,0 0,009 amamentação mista 11 22 56,64 ± 1,8 58,0 ± 2,5 0,589 2º mês de vida amamentação exclusiva 33 66 57,18 ± 1,3 62,2 ± 1,0 < 0,0001 amamentação mista 17 34 58 ± 1,4 57,1 ± 1,9 0,716 91 representações sociais do cuidado de doentes terminais no domicílio: o olhar do cuidador familiar l stefanie griebeler oliveira e outros sobretudo para aquelas mães que se encontravam em ame no hospital ou nas primeiras horas de vida (7, 8). outro estudo desenvolvido na austrália também verificou que a duração da amamentação parece ser maior em bebês que foram alimentados com leite materno de modo exclusivo e não receberam oferta de mamadeira, chupetas ou bicos enquanto estiveram no hospital. o risco para o desmame foi maior para os bebês de mães que usavam silicone no seio e optaram por usar mamadeira (15). é evidenciado que mães com escores menores no pré-natal ou no puerpério têm mais chances de desmame precoce em comparação às mães com escores mais altos, indicando que a autoeficácia de mães em amamentação exclusiva difere daquelas que não aderiram ou descontinuaram essa prática nos primeiros dias de puerpério (16). outro estudo realizado no canadá com mães adolescentes encontrou diferenças significativas nas médias dos escores da bses-sf (53,29 ± 6,83) no pré-natal e no pós-parto em relação ao início, à duração e à exclusividade do aleitamento materno (11). com isso, comprova-se que mulheres com altos escores de autoeficácia em amamentar, tanto no pré-natal como no puerpério, possuem mais chances de vivenciar e permanecer por mais tempo em aleitamento materno. dessa forma, levando-se em consideração que esse construto trata-se de uma variável modificável, esta deve ser considerada para o direcionamento de intervenções educativas a serem aplicadas por enfermeiros com vistas à autoeficácia materna para amamentar. estudos demonstraram o sucesso de intervenções pautadas na autoeficácia materna em diversos contextos, como no brasil, utilizando um álbum seriado criado a partir dos escores da bses-sf como intervenção na autoeficácia para amamentar (12), e no canadá com o uso de protocolo padronizado individualizado (9). assim, a autoeficácia deve ser considerada nas intervenções desenvolvidas e implementadas pela equipe de saúde relacionada ao aleitamento materno, tendo em vista que a avaliação dessa variável por meio da bses-sf é forte preditor da duração do aleitamento materno e pode contribuir para a aproximação da média nacional de ame à preconizada por organizações internacionais. conclusão ao analisar a autoeficácia das mulheres no ciclo gravídico-puerperal quanto ao seu potencial em amamentar, pode-se verificar que, além de as médias dos escores da bses-sf terem sido maiores no segundo momento da aplicação da escala (pós-parto), a autoeficácia em amamentar foi superior entre as mulheres que mantiveram o ame, principalmente nos 15 primeiros dias de puerpério, confirmando a validade preditiva da bses-sf, ou seja, quanto maior o escore da bses-sf no puerpério, maior a chance de amamentação exclusiva e maior duração desta em número de dias. além disso, ratificou que o uso de la no hospital ou nas primeiras horas de vida aumenta as possibilidades de a criança desmamar nos primeiros 15 dias de vida. em face disso, ressalta-se a necessidade da atuação dos profissionais de saúde em estratégias educativas de promoção ao aleitamento materno pautadas na autoeficácia. essas estratégias devem ser implementadas tanto antes quanto depois do parto para que se aumentem os escores de autoeficácia para amamentar, já que estes estão associados ao tempo mais prolongado de amamentação bem como à melhora da adesão ao ame. apesar de os achados terem fornecido evidências relevantes quanto à autoeficácia em amamentar, deve-se ressaltar como limitação do estudo o número amostral, mesmo tendo abrangido toda a população de mulheres acompanhadas no pré-natal que atendiam aos critérios de elegibilidade. assim, faz-se premente a realização de estudos em outras realidades nacionais que aprofundem a autoeficácia como fator interveniente na continuidade do ame, sobretudo no contexto do ac, tendo em vista que nesse local a puérpera encontra nos profissionais, nas experiências de outras mães e na sua própria vivência um apoio para promover essa prática com maior sucesso. 92 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 referências 1. demirci jr, sereika sm, bogen d. prevalence and predictors of early breastfeeding among late preterm mother–infant dyads. breastfeed med. 2013; (8): 277-85. 2. queluz mc, pereira mjb, santos cb, leite am, ricco rg. prevalência e determinantes do aleitamento materno exclusivo no município de serrana. rev esc enferm usp. 2012; 46 (3): 537-43. 3. clapis cv, fabbro mrc, beretta mir. a prática da amamentação de mães adolescentes nos primeiros seis meses de vida do filho. cienc cuid saúde. 2013 out.-dez.; 12 (4): 704-10. 4. boccolini cs, carvalho ml, oliveira mic, vasconcellos agg. fatores associados à amamentação na primeira hora de vida. revista de saúde pública. 2011; 45 (1): 69-78. 5. dennis cl. theorical underpinnings of breastfeeding confidence: a self-efficacy framework. j hum lact. 1999; 15 (3): 195-200. 6. nursan cinar, dilek köse, sevin altinkaynak. breastfeeding self-efficacy of mothers and the affecting factors. aquichán [internet]. 2014 set. [consultado em 24 abril 2016]; 14 (3): 327-35. disponível em: http://www.scielo.org.co/scielo. php?script=sci_arttext&pid=s1657-59972014000300005&lng=en. http://dx.doi.org/10.5294/aqui.2014.14.3.5 7. nanishi k, green j, taguri m, jimba m. determining a cut-off point for scores of the breastfeeding self-efficacy scale–short form: secondary data analysis of an intervention study in japan. simeoni u, ed. plos one. 2015; 10(6): e0129698. doi:10.1371/journal.pone.0129698. 8. dennis cl. the breastfeeding self-efficacy scale: psychometric assessment of the short form. j obstet gynecol neonatal nurs. 2003; 32 (6): 734-44. 9. mcqueen ka, dennis cl, stremler r, norman cd. a pilot randomized controlled trial of a breastfeeding self-efficacy intervention with primiparous mothers. j obstet gynecol neonatal nurs. 2011; 40 (1): 35-46. 10. smith jw. food for health: an investigation of infant feeding practices, breastfeeding self-efficacy, and perceived barriers and facilitators. [internet] [thesis]. university of western ontario; 2014 [consultado em 23 ago. 2016]. disponível em: http://ir.lib.uwo.ca/etd/2281. 11. dennis cl, heaman m, mossman m. psychometric testing of the breastfeeding self-ef-cacy scale — short-form among adolescents. j adolesc health. 2011; 49 (3): 265-71. 12. dodt rcm. elaboração e validação de tecnologia educativa para autoeficácia da amamentação [tese]. fortaleza (ce): universidade federal do ceará; 2011. 13. cavalcanti sh et al. fatores associados à prática do aleitamento materno exclusivo por pelo menos seis meses no estado de pernambuco. rev. bras. epidemiol. [internet]. 2015 mar. [consultado em 24 abril 2016]; 18 (1): 208-19. disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=s1415-790x2015000100208 14. phillips g, brett k, mendola p. previous breastfeeding paractices and duration of exclusive breastfeeding in the united states. matern child health j. 2011; 15 (8): 1210-6. 15. moimaz sas, rocha nb, garbin aji, saliba o. a influência da prática do aleitamento materno na aquisição de hábitos de sucção não nutritivos e prevenção de oclusopatias. rev. odontol. unesp [internet]. 2013 fev. [consultado em 24 abril 2016]; 42 (1): 31-6. disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=s180725772013000100006&lng=en 16. margotti e. fatores associados ao desmame precoce: autoeficácia no aleitamento materno e depressão pós-natal. porto alegre: pontifícia universidade católica do rio grande do sul; 2013. 219 229 sentimentos e dificuldades.indd 219 helena moro stochero1 elisabeta albertina nietsche2 cléton salbego3 adrieli pivetta4 marília von ende schwertner5 fernanda almeida fettermann6 márcia gabriela rodrigues de lima7 sentimentos e difi culdades no enfrentamento do processo de morrer e de morte por graduandos de enfermagem 1 universidade federal de santa maria (ufsm). brasil. nena-ms@hotmail.com 2 universidade federal de santa maria (ufsm). brasil. eanietsche@gmail.com 3 universidade federal de santa maria (ufsm). brasil. cletonsalbego@hotmail.com 4 prefeitura municipal de caiçara. brasil. adri_pivetta@hotmail.com 5 hospital virvi ramos. brasil. marilia.enf.ufsm@hotmail.com 6 universidade federal de santa maria (ufsm). brasil. fefettermann@hotmail.com 7 universidade federal de santa maria (ufsm). brasil. grlmarcia@yahoo.com.br recibido: 22 de julio de 2015 enviado a pares: 21 de agosto de 2015 aceptado por pares: 07 de febrero de 2016 aprobado: 26 de febrero de 2016 doi: 10.5294/aqui.2016.16.2.9 para citar este artículo / to reference this article / para citar este artigo stochero hm, nietsche ea, salbego c, pivetta a, schwertner mve, fettermann fa & rodrigues de lima mg. sentimentos e dificuldades no enfrentamento do processo de morrer e morte por graduandos de enfermagem. aquichan. 2016; 16(2): 219-229. doi: 10.5294/aqui.2016.16.2.9 resumo objetivo: identificar dificuldades encontradas pelos graduandos de enfermagem no enfrentamento do processo de morrer e morte durante a assistência de pacientes hospitalizados. metodologia: revisão integrativa da literatura realizada nas bases de dados lilacs, medline e bdenf, em junho de 2014, e compreende o período de 2001 a 2014. utilizaram-se as palavras-chave: “morte”, “estudantes” e “enfermagem”. resultados: foram encontrados 293 artigos e selecionados 10. identificam-se como dificuldades: o lidar com a finitude; as relações entre aluno e familiares; os vínculos estabelecidos entre aluno-paciente; os sentimentos vivenciados ao cuidar de pacientes terminais. conclusão: observa-se a necessidade de fomentar questões que permeiam a morte nos currículos dos cursos de graduação da área da saúde. acredita-se que abordar esse assunto no processo formativo trará reflexos positivos para a construção do “ser profissional”, comprometido com a assistência crítica, reflexiva e humanística a pacientes em fase terminal e seus familiares, que vivenciam esse processo. palavras-chave morte, estudantes, enfermagem, atitude frente a morte, educação em enfermagem (fonte: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 219-229 220 aquichan issn 1657-5997 año 16 vol. 16 nº 2 chía, colombia junio 2016 l 219-229 sentimientos y dificultades en el afrontamiento del proceso de morir y la muerte por estudiantes de enfermería resumen objetivo: identificar dificultades encontradas por los estudiantes de enfermería en el afrontamiento del proceso de morir y la muerte durante la asistencia de pacientes hospitalizados. metodología: revisión integradora de literatura realizada en las bases de datos lilacs, medline y bdenf, en junio de 2014, y comprende el periodo de 2001 a 2014. se emplearon las palabras clave: “muerte”, “estudiantes” y “enfermería”. resultados: se encontraron 293 artículos y se seleccionaron 10. se identificaron como dificultades: el manejo de la finitud; las relaciones entre estudiante y familiares; los vínculos establecidos entre estudiante y paciente; los sentimientos vivenciados al cuidar de pacientes terminales. conclusión: se observa la necesidad de fomentar cuestiones que permean la muerte en los currículos de las carreras de pregrado del área de salud, lo que puede traer reflejos positivos para la construcción del “ser profesional”, comprometido con la asistencia crítica, reflexiva y humanística a pacientes en fase terminal y sus familiares, que vivencian este proceso. palabras clave muerte, estudiantes, enfermería, actitud ante la muerte, educación en enfermería (fuente: decs, bireme). 221 sentimentos e dificuldades no enfrentamento do processo de morrer e morte por graduandos de enfermagem l helena moro stochero e outros feelings and difficulties experienced by nursing students in coping with death and the process of dying abstract objective: identify the difficulties nursing students encounter in coping with death and the process of dying in inpatient care. method: an integrative literature review was conducted of the lilacs, medline and bdenf databases during june 2014, covering the period from 2001 to 2014. the keywords used were "death", "students" and "nursing". results: in all, 293 articles were found and 10 were selected. several difficulties were identified; namely, managing finitude; relations between the student and the family; the links established between the student and the patient; and the feelings student nurses experience when caring for terminally ill patients. conclusion: issues that deal with death should be encouraged and have more emphasis in curricula for undergraduate programs in the field of health care. this can bring about positive thinking in the interest of building "professionals" who are committed to critical, thoughtful and understanding care for terminally ill patients who are experiencing this process, and for their families. keywords death, students, nursing, attitude towards death, nursing education (source: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 219-229 222 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 introdução a morte é um fenômeno natural da vida humana que provoca aflições. o homem, desde a antiguidade, tem caracterizado a morte com magia, mistério e uma tendência a acreditar no sobrenatural. para os incrédulos, compreende o findar da consciência, justamente quando o cérebro deixa de desempenhar suas funções; entretanto, para a religião, a morte, geralmente, ganha uma característica de temporariedade, ou seja, a passagem de uma condição para outra (1). o adoecer, o morrer e a morte estão frequentemente presentes em nossas práticas diárias. o dualismo vida e morte, a característica de ser mortal e a brevidade da existência humana são elementos que, embora intrínsecos à vida, comumente geram sentimentos que dificultam seu enfrentamento. os profissionais da saúde, particularmente o enfermeiro, têm sua formação baseada na oferta de uma assistência integral ao ser humano em todas as fases da vida, inclusive no processo de morte (2, 3). não ocorrendo possibilidade de cura, é preciso lidar com as doenças até o final da vida do paciente visto que, na aproximação da morte, revelam-se atitudes e reações emocionais, que não resultam apenas de um aprendizado cultural (4). em síntese, embora essa realidade não possa ser alterada, podemos exercer um efeito significativo sobre a maneira pela qual os pacientes evoluem nesse processo, sobre como este ocorre e sobre as suas memórias resultantes para as famílias (5). é necessário que se disponibilizem recursos que permitam momentos nos quais os profissionais de saúde encontrem apoio e segurança, atualizem seus conhecimentos sobre a doença e ofereçam, assim, suporte ao familiar e ao paciente inseridos no processo de morrer e morte (4). aponta-se também a necessidade de um novo olhar sobre esse processo, que encare a sua complexidade e atenda às necessidades individuais dos envolvidos (5). o interesse e o desafio em trabalhar essa temática surgiu a partir de vivências realizadas no pronto atendimento de um hospital universitário no interior do estado do rio grande do sul (brasil). observou-se a problemática que os graduandos em enfermagem enfrentam ao vivenciar o processo de morrer e a morte de pacientes hospitalizados, por meio dos relatos das dificuldades encontradas por eles em enfrentar esse processo dos pacientes assistidos nos estágios, da dificuldade em lidar com os sentimentos gerados pela experiência, a “fuga” do contato com os familiares e de estabelecimento de vínculos. a pesquisa pretende contribuir para uma melhor compreensão das dificuldades evidenciadas nos estudos já publicados e demonstrar a necessidade de ampliar a abordagem relacionada ao processo de morrer e morte na formação acadêmica. diante do exposto, propõem-se como objetivo geral deste estudo identificar na literatura a existência de dificuldades encontradas pelos graduandos de enfermagem durante a assistência no processo de morrer e morte de pacientes hospitalizados. como objetivo específico, identificar os sentimentos gerados pelas vivências durante o processo de morrer e morte de pacientes hospitalizados. metodologia trata-se de um estudo de revisão integrativa da literatura (6), método de investigação que viabilizou a busca, a avaliação crítica e a síntese das evidências disponíveis sobre as dificuldades no enfrentamento do processo de morrer e morte por graduandos de enfermagem com os pacientes hospitalizados. foram seguidas as seis etapas desse método: o estabelecimento da questão de pesquisa, a busca na literatura, a categorização dos estudos, a avaliação dos estudos incluídos na revisão, a interpretação dos resultados e a apresentação da revisão. foi definida a seguinte questão de pesquisa: “quais as evidências científicas acerca das dificuldades encontradas pelos graduandos de enfermagem durante o processo de morrer e morte de pacientes hospitalizados?” como recorte temporal, delimitam-se estudos publicados entre 2001 a 2014, devido a que as diretrizes curriculares nacionais de enfermagem propõem mudanças nos conteúdos desenvolvidos nos cursos de graduação em enfermagem no brasil que podem refletir na formação acadêmica na temática do processo de morrer e morte. utilizaram-se as bases de dados: literatura latino-americana e do caribe em ciências da saúde (lilacs), medical literature analysis and retrieval system online (medline) e base de dados de enfermagem (bdenf). a busca dos artigos foi realizada em junho de 2014 com as palavras-chaves: “morte”, “estudantes”, “enfermagem”. destaca-se que a busca com tais descritores apresentou-se incipiente. os critérios de inclusão foram: artigos científicos completos disponíveis on-line, publicações na língua portuguesa e com recor223 sentimentos e dificuldades no enfrentamento do processo de morrer e morte por graduandos de enfermagem l helena moro stochero e outros te temporal dos últimos dez anos. foram excluídos dissertações, teses e artigos em outro idioma e resumos. foram identificados os níveis de evidência (7): 1) evidências provenientes de revisão sistemática ou metanálise de todos os ensaios clínicos randomizados controlados ou provenientes de diretrizes clínicas baseadas em revisões sistemáticas de ensaios clínicos randomizados controlados; 2) evidências provenientes de, pelo menos, um ensaio clínico randomizado controlado bem delineado; 3) evidências provenientes de ensaios clínicos bem delineados sem randomização; 4) evidências provenientes de estudos de coorte e de caso-controle bem delineados; 5) evidências provenientes de revisão sistemática de estudos descritivos e qualitativos; 6) evidências provenientes de um único estudo descritivo ou qualitativo; 7) evidências provenientes de opinião de autoridades e/ou relatório de comitês de especialistas. perante o exposto, foram encontrados 293 artigos na totalidade; destes, 49 no lilacs, 209 no medline e 35 na bdenf. no lilacs, dos 49 encontrados, selecionaram-se 7 artigos; dos 209 da medline, utilizaram-se 3 e, da bdenf, nenhum uma vez que seus artigos encontram-se repetidos nas duas outras bases. assim, integram a análise final dos dados 10 artigos. em seguida, a coleta de dados procedeu a partir da leitura criteriosa dos títulos, resumos e conteúdos dos artigos. na sequência, catalogaram-se os artigos em ficha de análise documental adaptada e organizada da seguinte forma: autores, periódico/ ano, tipo/abordagem, base de dados e nível de evidência. resultados e discussões do total de 293 artigos encontrados, consideram-se 10 (8-17) para a consolidação dos resultados da presente revisão integrativa. quanto ao ano de publicação dos artigos selecionados, obtiveram-se: dois artigos do ano de 2006 (9, 12), um artigo do ano de 2007 (16), dois artigos do ano de 2008 (10, 14), um artigo do ano de 2009 (8), um artigo do ano de 2010 (15), dois artigos do ano de 2011 (11, 13) e um artigo do ano de 2013 (17). no que se refere à metodologia dos estudos, nove artigos analisados eram de abordagem qualitativa, e um, de abordagem quali-quantitativa. sobre o idioma, todos os artigos selecionados são da língua portuguesa e de pesquisas realizadas no brasil. partindo dos aspectos referentes à metodologia de cada um dos estudos, foram classificados os níveis de evidência das produções que compuseram o corpus desta pesquisa de revisão integrativa. do total de 293 artigos encontrados, consideram-se 10 (8-17) para consolidação dos resultados da presente revisão integrativa. assim, todos os artigos analisados foram classificados com “nível de evidência 6” visto que todos são provenientes de estudos descritivos ou qualitativos, como disposto no quadro 1. de acordo com a questão norteadora do estudo, evidenciamse dificuldades no enfrentamento do processo de morrer e morte sob a percepção de graduandos em enfermagem, tais como: despreparo ao cuidar de pacientes terminais (reflexos da formação); dificuldades em lidar com a finitude; dificuldades nas relações entre aluno e familiares; dificuldades nas relações e vínculos estabelecidos entre aluno-paciente e sentimentos vivenciados ao cuidar de pacientes terminais. despreparo ao cuidar de pacientes terminais: reflexos da formação cabe destacar que o despreparo enfrentado pelos graduandos de enfermagem ao lidar com o processo de morrer e morte está diretamente relacionado com: a dificuldade de se desligarem da lógica do curar, pois não conseguem perceber as necessidades dos cuidados paliativos e tem a cura como prioridade (8-13, 16), bem como a insuficiência curricular, isto é, a carência de discussões sobre a temática durante sua graduação (8, 10-14). além disso, estudos trazem relatos de acadêmicos com visões sobre morte como sinônimo de fracasso ou que, então, agem questionando sua atuação, procurando encontrar falhas (10, 11, 13, 16); ainda, relatam as raras oportunidades de lidar com o paciente terminal (8, 11, 13). reforçando a ideia da dificuldade devido ao despreparo enfrentado pelos graduandos de enfermagem durante o processo de morrer e morte de pacientes hospitalizados, em pelo menos um estudo, evidenciam-se as diferentes dificuldades que remetem ao despreparo: conflito entre o impulso de fugir e o dever de ficar para ajudar (8); falta de apoio externo (8), os alunos não se sentem orientados/apoiados (8); relatos de inexperiência e insegurança (8); nos momentos de cuidado com o corpo após a morte (16) e ao noticiarem o óbito aos familiares (9). formar enfermeiros para o exercício profissional deve ir além das técnicas e teorias, é preciso lembrar-se de prepará-los para 224 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 quadro 1. distribuição dos artigos encontrados após revisão da literatura por variável de análise autor/ periódico/ano tipo/abordagem do estudo fonte principais resultados nível de evidência oliveira, amorim (8)/ rev gaúcha enferm/2008 qualitativa lilacs evidencia-se dificuldade de se enxergarem como seres finitos. também, dificuldades em lidarem com o relacionamento aluno-paciente e com os sentimentos que emergem após a morte. o apego pode gerar sentimento de culpa, impotência, tristeza, medo e indiferença, e o distanciamento pode amenizar a situação já que há uma dificuldade em expressar os sentimentos. 6 carvalho, silva, santos, oliveira, portela, regebe (9)/rev enferm uerj/2006 campo/exploratório/ qualitativa lilacs a situação da morte é experimentada pelo estudante como fracasso enquanto cuidador do outro e impotência diante do morrer. percebe-se dificuldade em lidar com a finitude e a sua negação. 6 cantídio, vieira, sena (10)/invest educ enferm/2011 exploratório/ descritivo/qualitativa lilacs vivenciar a terminalidade da criança não é momento fácil. o fenecimento torna-se de difícil aceitação para os acadêmicos, que questionam a assistência e refletem sobre o fazer técnico-científico. há também relatos da dificuldade de lidar com o envolvimento afetivo com o paciente e com o despreparo para atuar ante situações de morte. 6 sadala, silva (11)/rev esc enferm usp/2009 qualitativo medline sentimentos de medo, insegurança e dor. os alunos afirmam não se sentirem orientados e apoiados. demostraram dificuldades por não controlar seus próprios sentimentos, em lidar com a iminência de morte, medo de sofrer ao se envolver com o paciente, falta de apoio por parte dos profissionais da equipe e dificuldades de desligar-se da lógica de curar. 6 brêtas, oliveira, yamaguti (12)/ rev esc enferm usp/2006 exploratório/ descritivo/ qualitativa medline dificuldade em se relacionarem com pacientes com prognóstico de morte e fase terminal, dificuldades em lidarem com o assunto morte, quanto à maneira de dar a notícia de um óbito para familiares e à dificuldade interna que sentem ao lidar com o problema. 6 oliveira, brêtas, yamaguti (13)/rev esc enferm/2007 qualitativa medline mostra a dificuldade que o estudante de enfermagem enfrenta ao se relacionar com os familiares de quem morreu. por meio dos relatos, percebe-se a dificuldade gerada pelo envolvimento e vínculo desenvolvido com o paciente e pelo sentimento de impotência despertado nos graduandos. 6 benedetti, oliveira, oliveira, sales, ferreira (14)/rev gaúcha enferm/2013 qualitativo lilacs foi observada a dificuldade de compreender e aceitar o sofrimento causado pela morte, e a de falar da finitude. 6 takahashi, contrin, beccaria, goudinho, pereira (15)/arq ciênc. saúde /2008 descritivo lilacs a reação manifestada no primeiro momento em contato com a morte de alguém foi de pânico/desespero e também insegurança. o sentimento ante um paciente terminal agonizante é de impotência. 6 jardim, bernardes, campos, pimenta, resende, borges, santana (16) /rev baiana de saúde pública/2010 qualitativo lilacs o cuidado ao paciente terminal é cercado de dificuldade em trabalhar com o processo de morrer, a impotência do profissional de saúde perante a morte juntamente com o desejo pela cura do paciente, a dificuldade de lidar com o desgaste da família. 6 júnior, éltink (17)/ j health sci inst/2011 exploratório/ descritivo/ qualitativa lilacs dentre os aspectos que dificultariam a aceitação da morte de um paciente, estavam a aceitação dos familiares com a perda de um ente querido e a sua aceitação como profissional. também, a dificuldade em aceitar a morte quando esta acontece de uma forma inesperada, e a maioria dos entrevistados usa a idade como um dos itens que mais dificulta ou facilita a aceitação. 6 fonte: elaboração própria. 225 sentimentos e dificuldades no enfrentamento do processo de morrer e morte por graduandos de enfermagem l helena moro stochero e outros enfrentar situações que envolvam seus sentimentos como o processo de morrer e morte de pacientes em fase terminal. a insuficiência curricular (10) no processo de ensino e aprendizagem em enfermagem revela que esses estudantes são preparados para lidar com a vida, o que gera na prática profissional uma frequente batalha entre o viver e morrer. embora se compreenda a morte como um processo inerente à vida e não que a antagonize, é irrefutável que o processo de morte e seu enfrentamento são de difícil controle para os estudantes da área da saúde (10). essa inaptidão fica evidente no cotidiano de práticas curriculares, pois o aluno tende a se afastar do enfermo (12), o que origina sentimentos como impotência, vazio, medo e angústia. o despreparo para atuar ante situações de morte enfrentadas pelos graduandos de enfermagem (8-16) relaciona-se com a carência de discussões sobre a temática no decorrer da formação (11). “o ser humano é o único ser que tem consciência de sua finitude, porém poucos são capazes de falar abertamente sobre o assunto” (18:7). os estudantes analisam suas limitações e dificuldades decorrentes da sua inexperiência e insegurança, e buscam maneiras para enfrentar essas situações, como manter a calma e a tranquilidade, o que nem sempre é possível (8), pois esses sentimentos vivenciados repercutem na vida pessoal dos alunos; além disso, o luto pela morte dos pacientes é uma forma de remeter-se à sua própria morte (9). ainda que em alguns estudos se faça presente a esperança de que a vivência do dia a dia possa vir a complementar a preparação e melhorar a forma com que o profissional encara a situação, por se tratar um evento constante na prática dos profissionais da saúde, o envolvimento é característico ao processo de cuidar, pois o profissional cria vínculos com aquele de quem cuida e sente sua perda como um rompimento (11). outra dificuldade encontrada é a forma pela qual os estudantes de enfermagem participam do processo de morrer e morte dos pacientes sob seus cuidados, em que questionam a atuação (10, 11, 13, 16) à procura de falhas ou possíveis erros (13), e isso gera um sentimento de culpa por não saber as respostas. esse sentimento é reflexo da própria formação, pois os profissionais de saúde são preparados para uma assistência com o objetivo de preservar e manter a vida, e não para encarar a morte como parte inevitável dela, o que constrói a repulsa pela morte e reafirma a cura como prioridade (8-13, 16). em consequência disso, os alunos não conseguem visualizar outras possibilidades para esse cuidado em enfermagem, como desenvolver a capacidade de saber ouvir o paciente, compreender suas necessidades e oferecer-lhe alívio e conforto para ajudá-lo a viver da melhor forma nessa trajetória final. o prognóstico de morte gera frustrações para o estudante, pois mesmo causando esforços, ele sabe que serão apenas medidas de conforto para o paciente (8). a morte passou a ser um sinônimo de fracasso profissional (11-13, 16) para quem trabalha na área da saúde; muitas vezes, os acadêmicos vivenciam durante as suas práticas o conflito entre o impulso de fugir e o dever de ficar para ajudar (8). isso potencializa neles a sensação de despreparo pela falta de informação e conhecimentos que deveriam ser transmitidos durante o processo de formação. o preparo para o enfrentamento da morte deve acontecer desde a formação com um diálogo aberto e sem tabus entre discentes e docentes (19). pode-se perceber que a morte torna-se muito mais complicada e angustiante quando seu enfrentamento se dá sem o respaldo de outros profissionais da área, principalmente nas primeiras experiências vivenciadas pelos estudantes (8). também, raras são as oportunidades oferecidas nos estágios para cuidar de pacientes que se encontram no estágio final e, quando fazem, não se sentem orientados e apoiados devidamente, pois mesmo com o domínio da técnica, esta não reduz a dificuldade de trabalhar com esses pacientes; há necessidade de uma abordagem psicológica (8). outro fator importante e revelador do despreparo do graduando de enfermagem ante o processo de morte e morrer é o cuidado com o corpo pós-morte (16); é visível o impacto causado em estudantes de enfermagem durante procedimentos que envolvem o cuidado com o corpo do ser humano após o falecimento. também, evidencia-se a preocupação com a transmissão da notícia de um óbito para familiares (10). os estudantes reconhecem (12) o quanto é impactante a convivência com a morte e o morrer no seu cotidiano, como também a dificuldade de enfrentar e a necessidade de abordar na academia conteúdos que contemplem reflexões e possibilidades de lidar positivamente com a questão. 226 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 dificuldades em lidar com a finitude ao enfrentar a dificuldade interna que os estudantes de enfermagem sentem em lidar com o problema, muitos apresentam dificuldades em se relacionar com pacientes com prognóstico de morte e fase terminal (9). dessa forma, observa-se a dificuldade de compreender e aceitar o sofrimento causado pelo sentido obscuro trazido a cada indivíduo pela morte; processo doloroso sobre o qual muitas vezes preferem simplesmente não falar, na busca de minimizar esses sentimentos (17). evidencia-se também a dificuldade em se enxergarem como seres finitos, pois eles relacionam a morte com a morte de seus familiares ou até mesmo com a sua própria morte (8-15, 17). “o homem durante séculos conseguiu dominar o medo da morte e traduzi-lo em palavras. a sociedade permitia os ritos familiares, e a brevidade melancólica de um fim anunciado era tratada com dignidade sem fugas ou falsificações” (20:205). os estudantes demonstram desconforto quando questionados sobre a morte em seu cotidiano, observado no silêncio e na demora nas respostas, o que também denota que o tema é pouco trabalhado (10). percebe-se a dificuldade de discentes em lidar com a morte por considerá-la como um evento novo e distante (10), além do contato raro, ou inexistente, que os alunos têm com pessoas nessa condição (8, 11, 14). no âmbito de negação do processo de morte-morrer, podese perceber como a morte torna-se de difícil aceitação para os estudantes, que questionam a assistência e refletem sobre o fazer técnico-científico, incapaz de manter o controle sobre a vida (11). essa reação sentimental leva os estudantes a recordarem experiências marcantes em suas vidas, que se manifestam em lembranças (11). muitas destas estão ligadas ao seu primeiro convívio com a morte e trazem a todos os sentimentos gerados naquela situação. entre os agravantes da percepção desse sofrimento, são ressaltados aspectos relativos à faixa etária do paciente (9, 11, 13, 16); admite-se que é mais fácil a aceitação da morte quando se trata de ser humano adulto ou idoso, diferente do que ocorre com pessoas mais jovens e crianças. justifica-se um menor impacto porque não há interrupção precoce das etapas de vida, requer-se menos preparo para o enfrentamento e espera-se o porvir anunciado (11). para aceitar a morte do outro é preciso primeiramente aceitar a nossa condição de terminalidade (10). muitos dos estudantes não aceitam e sofrem durante o processo de morrer e morte dos pacientes sob seus cuidados, por compará-la à perda de entes queridos ou aludir à própria morte. dificuldades nas relações entre aluno e familiares observaram-se a preocupação e a dificuldade que o estudante de enfermagem enfrenta ao se relacionar com os familiares de quem morreu (8, 10, 11, 13, 15, 16). no momento de confortar a família e de realizar o acolhimento pela perda de um ente querido, os estudantes afirmam que não sabem como agir perante o luto; se contribuem com algum gesto ou palavra de carinho ou se, pelo contrário, se mantêm reprimidos de ações perante as reações inesperadas dos familiares (11). os estudos (10, 15-16) descrevem a visão dos acadêmicos com relação ao sentimento de responsabilidade que o profissional de enfermagem sente perante a família e acredita que esta fica desamparada no momento da morte (16). a relação com o paciente na fase terminal da doença torna-se mais complexa devido à interferência de variáveis e barreiras existentes nesse contexto. de modo geral, os resultados apontam que as maiores preocupações dos estudantes quanto aos aspectos que dificultam aceitar a morte de um paciente ficam entre a aceitação dos familiares com a perda de um ente querido e a sua aceitação como profissional (8). o cuidado ao paciente terminal é cercado de dificuldade em trabalhar com o processo de morrer, a impotência do profissional de saúde perante a morte juntamente com o desejo pela cura do paciente e a dificuldade de lidar com o desgaste da família (8). um dos estudos (15) revela que há uma reorganização familiar em longo prazo, porque a doença implanta-se no cotidiano, o que causa mudanças bruscas de papéis em todos os membros da família, em que o pai passa a ser mãe, a mãe passa a ser pai. a família torna-se essencial na assistência terapêutica e coopera na recuperação. observa-se que, para enfrentar todas essas dificuldades, a boa comunicação (8) estabelecida entre o profissional, o paciente e a família é imprescindível no cuidado ao paciente terminal. 227 sentimentos e dificuldades no enfrentamento do processo de morrer e morte por graduandos de enfermagem l helena moro stochero e outros dificuldades nas relações e vínculos estabelecidos entre aluno-paciente outro estudo sobre a morte e o morrer aborda as representações de estudantes de enfermagem, e considera que estes apresentam dificuldades em lidar com o relacionamento alunopaciente e com os sentimentos que emergem após a morte; para eles, o apego pode gerar sentimento de culpa (16). entre os artigos analisados, foram encontrados sete estudos (8-13, 16) que se referem ao envolvimento com paciente e à criação de vínculos, além da dificuldade no processo de aceitação da morte de um paciente sob os seus cuidados. o envolvimento com o paciente é um fator considerável na manifestação do sentimento presente nesse momento. a identificação do profissional em enfermagem com essa situação dependerá dos laços desenvolvidos durante a assistência prestada (16). um estudo (13) traz o apego, isto é, o vínculo estabelecido com o paciente durante a fase terminal, como resultado entre os aspectos que dificultam a aceitação da morte de um paciente. o apego revela o conteúdo afetivo que provém da relação que envolve o ato de cuidar (16). quanto maior o vínculo criado, maior a dificuldade em aceitar a morte do paciente (12); aqueles que se envolvem mais com o paciente revelaram um profundo sentimento de tristeza e angústia ligado a esse cuidado (8). isso se confirma quando autores também citam a dificuldade em elaborar perdas de pacientes com os quais se estabeleceu vínculos mais intensos (9). a relação entre acadêmico e paciente, quando muito intensa, acaba gerando um envolvimento afetivo e a comparação com a própria família pois imagina o enfrentamento da morte com os seus familiares. estudantes revelam a presença da imagem fixa no pensamento e a representação onírica desses laços de envolvimento criados com aqueles que estão sob seus cuidados (11). sentimentos vivenciados ao cuidar de pacientes terminais entre tantos sentimentos vivenciados pelos graduandos ao presenciarem o processo de morte e morrer, os estudos (8-16) revelam que a proximidade da morte de um paciente ao qual se dedicou horas de trabalho pode despertar sentimentos como impotência (9). esse sentimento pode levar a uma futura dificuldade de lidar com um paciente terminal (15). a situação de morte e do morrer pode ser vivenciada pelos estudantes como uma possibilidade de não terem realizado intervenções suficientes para salvar a vida dos pacientes sob seus cuidados, e isso pode ser visto como um fracasso enquanto cuidador. esse tema esteve presente em pelo menos quatro estudos (11-13, 16), em que a morte é visualizada pelos estudantes como um momento de derrota. com relação à impotência, faz-se uma analogia do processo de morte e morrer com uma luta imaginária que os profissionais precisam travar e, quando o paciente morre, significa perder a batalha (16). ao se depararem com a condição de terminalidade do paciente, os estudantes também apresentam como dificuldade a incapacidade em lidar e expressar os próprios sentimentos (8). o medo de expressar sentimentos é resultado da construção do mito de que o enfermeiro deve ser impassível diante da situação de morte (16). a tristeza esteve presente nos estudos analisados (8-17). além dela, coexistem outras manifestações sentimentais de luto mais comuns, tais como: sofrimento (8-17), medo (8, 10-11, 13, 15-17) e dor da perda (8-10, 12-13, 16-17). também ficou demonstrado que os graduandos atuam em prol da saúde-vida, que tem no cuidar uma única finalidade —a cura— e, quando isso já não se faz mais possível, sentem-se culpados (8-13, 17). sentimentos como: ansiedade (8, 9, 12, 14, 16), angústia (8-12), negação (9, 11-12, 16-17), insegurança (8, 10, 14-15), frustração (8-12), fracasso (11-13, 16), saudade (9, 12-14), indiferença (10, 13, 16), choque (8, 10, 11), vazio (10, 12), preocupação (16), desesperança (8), incapacidade (10), constrangimento (10), inconformismo (9), abalo (11), revolta (13), raiva/ódio (14), pânico/desespero (14), depressão (14), estresse (14), compaixão (14) e alívio (5) foram evidenciados nos estudos. “a vivência da morte provoca desgaste, uma vez que o sofrimento dos pacientes e familiares se reflete na vida dos futuros profissionais” (21:74). conclusões este estudo propôs o levantamento e a análise da literatura científica sobre as dificuldades encontradas por graduandos em enfermagem ao enfrentarem o processo de morrer e morte na assistência de pacientes hospitalizados. 228 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 salienta-se que foram alcançados os objetivos de revisão aqui propostos. foi possível identificar as evidências disponíveis na literatura, no que se refere às dificuldades enfrentadas e aos sentimentos manifestados por graduandos de enfermagem diante de situações relacionadas com a morte e o morrer de pacientes hospitalizados. para tanto, ficaram evidentes o despreparo enfrentado pelos graduandos de enfermagem ao lidarem com o processo de morrer e morte, e a insuficiência curricular no processo de ensino e aprendizagem em enfermagem. um ponto importante a destacar durante a realização deste 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[internet]. 2012 [citado 28 dez. 2014]; 1(1):1-7. disponível em: http://publicacoes.unigranrio.br/index.php/rcs/article/viewfile/1665/842 19. santos jl, bueno smv. a questão da morte e os profissionais de enfermagem. rev enferm uerj. 2010; 18(3):484-7. 20. medeiros la, lustosa ma. a difícil tarefa de falar sobre morte no hospital. rev. sbph [internet]. 2011 [citado 28 dez. 2014]; 14(2):203-27. disponível em: http://pepsic.bvsalud.org/scielo.php?script=sci_arttext&pid=s1516-08582011000200013 21. ferreira ra, lira npm, siqueira aln, queiroz e. percepções de psicólogos da saúde em relação aos conhecimentos, às habilidades e às atitudes diante da morte. revista psicologia: teoria e prática. 2013; 15(1):65-75. 75 89 la autoimagen de sí mismo.indd 75 patrícia britto ribeiro de jesus1 iraci dos santos2 euzeli da silva brandão3 a autoimagem e a autoestima das pessoas com transtornos de pele: uma revisão integrativa da literatura baseada no modelo de callista roy 1 enfermeira. mestre em enfermagem pelo programa de pós-graduação em enfermagem da universidade do estado do rio de janeiro, brasil. patty_brj@hotmail.com 2 enfermeira. doutora em enfermagem. professora titular da universidade do estado do rio de janeiro (uerj); atua no programa de pósgraduação em enfermagem (mestrado e doutorado) e no curso de graduação em enfermagem da faculdade de enfermagem da uerj. brasil. iraci.s@terra.com.br 3 enfermeira. doutora em enfermagem pelo programa de pós-graduação em enfermagem (mestrado e doutorado) da universidade do estado do rio de janeiro. diretora da associação brasileira de enfermagem em dermatologia (sobende) – regional rio de janeiro. professora assistente do departamento de fundamentos de enfermagem e administração da escola de enfermagem aurora de afonso costa da universidade federal fluminense. recibido: 30 de septiembre de 2013 enviado a pares: 23 de octubre de 2013 aceptado por pares: 04 de febrero de 2014 aprobado: 09 de julio de 2014 doi: 10.5294/aqui.2015.15.1.8 para citar este artículo / to reference this article / para citar este artigo jesus pbr, dos santos i, brandão es. a autoimagem e a autoestima das pessoas com transtornos de pele: uma revisão integrativa da literatura baseada no modelo de callista roy. aquichan. 2015; 15 (1):75-89. doi: 10.5294/aqui.2015.15.1.8 resumo objetivo: conhecer a relação entre os transtornos da pele e a alteração do autoconceito nas pessoas com afecção cutânea. método: revisão integrativa da literatura a partir dos descritores: lesões, dermatologia e autoimagem. a busca se fez nas bases lilacs, scielo e pubmed, em artigos publicados entre 2000 e 2012. resultados: a revisão integrativa mostrou os principais efeitos psicológicos causados pelas doenças da pele e confirmou que os fatores psicossociais relacionados com a autoimagem e a autoestima afetam a vida das pessoas. conclusão: os transtornos da pele podem levar o indivíduo a buscar estratégias que vão desde o isolamento do corpo e o isolamento social, a negação da doença até o uso de maquiagem de camuflagem, como aparecem nas publicações. a escassez de estudos publicados que mostrem as estratégias a adotar pelos enfermeiros para lidar com os efeitos psicológicos causados pela doença cutânea evidenciam a necessidade de se pesquisar sobre o tema. palavras-chave enfermagem, dermatologia, lesões, autoconceito, autoestima (fonte: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 75-89 76 aquichan issn 1657-5997 año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 75-89 la autoimagen y la autoestima de las personas con trastornos de piel: una revisión integradora de la literatura basada en el modelo de callista roy resumen objetivo: conocer la relación entre los trastornos de la piel y la alteración del autoconcepto en las personas con afección cutánea. método: revisión integradora de la literatura desde los descriptores: lesiones, dermatología, y autoimagen. la búsqueda se hizo en las bases lilacs, scielo y pubmed, en artículos publicados entre el año 2000 y 2012. resultados: la revisión integradora mostró los principales efectos psicológicos causados por las enfermedades de la piel y confirmó que los factores psicosociales relacionados con la autoimagen y la autoestima afectan la vida de las personas. conclusión: los trastornos de la piel pueden llevar al individuo a buscar estrategias que van desde el aislamiento del cuerpo y el aislamiento social, la negación de la enfermedad y hasta el uso de maquillaje de camuflaje, como muestran las publicaciones. la escasez de estudios publicados que muestran las estrategias a adoptar por los enfermeros para lidiar con los efectos psicológicos causados por la enfermedad cutánea evidencia la necesidad de investigar sobre el tema. palabras clave enfermería, dermatología, lesiones, autoconcepto, autoestima. (fuente: decs, bireme). 77 a autoimagem e a autoestima das pessoas com transtornos de pele:... l patrícia britto ribeiro de jesus, iraci dos santos, euzeli da silva brandão self-image and self-esteem in persons with skin disorders: an integrative literature review based callista roy’s model abstract purpose: the purpose of this study is to understand the relationship between skin disorders and alteration of self-image in persons who suffer from skin problems. method: an integrative literature review was done on the basis of three descriptors: lesions, dermatology, and self-image. the search centered on the lilacs, scielo and pubmed databases, among articles published between 2000 and 2012. findings: the integrative review showed the major psychological effects caused by skin disorders and confirmed that psycho-social factors related to self-image and self-esteem impact a person’s life. conclusion: skin disorders can prompt a person to resort to a variety of strategies ranging from physical seclusion and social isolation to denial of the aliment and even the use of camouflage makeup, as shown in publications. the scarcity of published studies showing the strategies adopted by nurses to deal with the psychological effects of skin disease demonstrate the need for research on the topic. keywords nurse, dermatology, injuries, self-concept, self-esteem (source: mesh, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 75-89 78 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 introdução com a principal função de revestimento exterior do organismo, a pele, o maior órgão do corpo humano, o qual representa 15 % do peso corporal, nos apresenta para o mundo. ela é o principal foco de atenção, aproximação e consequente interação entre as pessoas. isso porque a pele “ao mesmo tempo em que nos protege é a fachada que nos expõe” (1). nesse sentido, a pele funciona como importante órgão de comunicação social. sua visibilidade, não íntegra, pode estigmatizar e reprimir as relações psicossociais (2). além disso, expressa os sentimentos, mesmo quando não está a par deles, e colabora na compreensão e no conhecimento do seu meio (3). a pele é uma superfície que reflete todos os órgãos internos, além de um meio de contato com o exterior. qualquer distúrbio em um deles é refletido na epiderme, e cada estímulo na área correspondente da pele é transmitido outra vez para o interior do corpo (4). em uma sociedade que valoriza o belo e tem padrões estéticos preestabelecidos, a pele pode ser considerada um “cartão de visitas”, que atrai, assim, os olhares críticos e exigentes dos indivíduos. quando íntegra e saudável, promove a relação entre as pessoas e facilita o seu desenvolvimento nos aspectos social, emocional, financeiro e sexual. porém, quando acometida por afecções cutâneas, pode trazer sérias consequências. nesse contexto, destaca-se a ocorrência do afastamento bilateral: de um lado a sociedade que exclui os que não atendem aos padrões preestabelecidos, e de outro a pessoa com afecção cutânea, que diante da autoimagem alterada se sente exposta aos olhares curiosos e preconceituosos da sociedade. fato que interfere na autoestima e leva a pessoa ao isolamento social (5). a autoimagem ante um aspecto físico refere-se ao modo de como a pessoa se enxerga e como se percebe. já a autoestima é o sentimento que a pessoa tem em relação à sua autoimagem, como a pessoa se interpreta e se vê. portanto, a autoimagem gera a autoestima, que afeta a relação que o eu constrói nas pessoas; com uma baixa autoimagem consequentemente terá uma baixa autoestima. o conceito de autoestima tem sido estudado e considerado como um importante indicador da saúde mental. a crítica, em geral, enfoca a necessidade de aplicação de instrumentos precisos que permitam avaliar a necessidade de autoestima de cada indivíduo (7). é importante evidenciar que a autoimagem é uma condição de organização da própria pessoa, sendo constituída por uma parte mais real e por outra mais subjetiva, conduzindo-se para uma maneira determinante e compreensiva do meio em que se vive (8). assim, o ser humano constrói a sua imagem corporal na relação com o mundo vivido, sendo que essa percepção não ocorre sempre da mesma maneira, isto é, se for alterada negativa ou positivamente, mudará a sua autoimagem (9). nessa condição, além dos agravos sociais que envolvem a sua sexualidade, a pessoa com afecção cutânea pode sofrer agravos financeiros, tendo em vista que muitas são obrigadas a afastar-se de seu ambiente laboral (5). quanto ao impacto social, ressalta-se a frequente associação entre doença de pele, contágio e pouco asseio pessoal, que leva os indivíduos a se afastarem dos que possuem afecções cutâneas (10). o acometimento de algumas áreas da pele pode trazer maiores prejuízos, como revelam estudos sobre a incidência do vitiligo na população, referindo que o envolvimento da pele em áreas da face e das mãos frequentemente causa constrangimento (11). conforme descrevem alguns autores, as lesões de pele na face são mais perceptíveis para o olhar do outro. portanto, sua aparência visual terá um fundamental papel na percepção de si mesmo (12). a esse respeito, destaca-se que, apesar da suposta relação entre as alterações emocionais e as doenças dermatológicas, ainda é impossível definir com clareza as influências das alterações psicológicas nas enfermidades cutâneas e também se estas, quando cronificadas, carregam, necessariamente, alterações psicopatológicas significativas (13). porque tal vínculo não é recente, antigamente já se utilizava o termo “neurodermite” para demonstrar alguns tipos de eczema, referentes à sua origem nervosa (14). diante dessas observações, percebem-se os inúmeros desafios a serem enfrentados pelas pessoas com afecções dermatológicas. alguns enfrentam com mais facilidade e seguem a vida sem muitos traumas; e outros, inicialmente, recusam a mudança. porém, com o decorrer do tempo, são obrigados a conviver com limitações e também existem os que não conseguem lidar com suas limitações (14). 79 a autoimagem e a autoestima das pessoas com transtornos de pele:... l patrícia britto ribeiro de jesus, iraci dos santos, euzeli da silva brandão trata-se de um campo de pesquisas emergente e presente em publicações nacionais e internacionais, tanto por sua complexidade quanto pelos desafios em sua abordagem na prática clínica cotidiana. portanto, o exercício profissional do enfermeiro em dermatologia agrega um saber sobre a pessoa em sua totalidade corporal física, mental e espiritual (16). tal fato levou à elaboração do objeto de estudo — autoimagem e autoestima de pessoas com afecções dermatológicas. teve-se como objetivo identificar na literatura as influências do acometimento cutâneo na autoimagem e autoestima das pessoas. a partir desse objeto, buscou-se fundamentação na teoria de adaptação de sister callista roy (17), por ser um modelo de enfermagem conceitual, permite que a pessoa seja vista como um sistema composto por vertentes biopsicossociais, as quais requerem respostas para a sua adaptação aos estímulos ambientais. essa teórica identificou em seu modelo quatro modos adaptativos: fisiológico, de autoconceito, de função do papel e de interdependência. o modelo de adaptação de sister callista roy apresenta quatro conceitos essenciais: a pessoa receptora do cuidado, o ambiente, a saúde e a meta de enfermagem (18). assim, considera-se que as teorias de enfermagem representam, atualmente, os esforços coletivos e individuais dos enfermeiros para definir e conduzir essa profissão e proporcionar uma base para seu desenvolvimento teórico contínuo (19). os comportamentos resultantes desses subsistemas são observados a partir de quatro modos adaptativos: a) modo fisiológico — o modo como a pessoa responde como um ser físico aos incentivos ambientais. esse modo envolve cinco necessidades básicas de integridade fisiológica (oxigenação, nutrição, eliminação, atividade e repouso, e proteção) e quatro processos complexos (sensitivo líquido e eletrólitos, função neurológica e função endócrina); b) modo de autoconceito — enfoca aspectos psicológicos e espirituais da pessoa. trata-se da combinação de convicções e de sentimentos em um determinado momento. inclui dois componentes: o self-físico (abrange a sensação e a autoimagem corporal) e o self-pessoal (engloba o self-consistência, o self-ideal e o self-ético-moral-espiritual); c) modo de desempenho de papel — enfoca aspectos sociais relacionados aos papéis que a pessoa ocupa na sociedade e d) modo de interdependência — enfoca interações relacionadas a dar e receber afeto, respeito e valor. a necessidade básica encontrada nesse modo é a afetiva, ou seja, o sentimento de segurança que permeia as relações (17). materiais e método optou-se pela revisão integrativa de literatura (ril) por considerá-la um instrumento da prática baseada em evidências (pbe), uma abordagem voltada ao cuidado clínico e ao ensino fundamentado no conhecimento e na qualidade da evidência da prática clínica (20). foram seguidos seis passos metodológicos propostos (21), conforme se descreve a seguir. 1. selecionar as hipóteses ou questões para a revisão — o que revelam as publicações nacionais/internacionais sobre as influências do acometimento cutâneo na autoimagem e autoestima das pessoas? 2. estabelecer os critérios para a seleção da amostra (21) — foram critérios de inclusão dos artigos: publicados em periódicos nacionais e internacionais no período 2000 a 2012 que utilizassem a temática da autoimagem e da autoestima às pessoas com afecções dermatológicas, com resumo e texto disponíveis na íntegra nos idiomas português, inglês e espanhol. critérios de exclusão: artigos encontrados em mais de uma base de dados; abordagem sobre autoimagem relacionada às doenças não dermatológicas e acesso on-line indisponível. 3. apresentar as características da pesquisa primária. 4. análise dos dados: os dados produzidos foram analisados qualitativamente, à luz do referencial teórico de callista roy. 5. interpretação dos resultados. 6. apresentação da revisão (21). a coleta dos dados realizou-se de janeiro a fevereiro de 2013 por meio da busca on-line no site da biblioteca virtual em saúde (bvs), selecionando-se as bases de dados: literatura latino-americana e do caribe em ciências da saúde (lilacs), scientific electronic library online (scielo) e united states national library of medicine (pubmed). os textos na íntegra foram obtidos nas bases de dados citadas e utilizaram-se os descritores em ciências da saúde (decs), lesões, dermatologia e autoimagem. a palavra “autoestima” não foi inserida, pois no decs consta como sinônimo em português do descritor “autoimagem”. 80 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 os seguintes descritores foram pesquisados separadamente e em combinação, adaptados para a base de dados em questão: dermatologia e lesões e autoimagem; lesões e autoimagem; dermatologia e autoimagem; autoimagem. utilizando os descritores dermatologia, autoimagem e lesões na base de dados lilacs e scielo, não foram encontradas publicações; na pubmed foram encontradas três publicações porém apenas uma completa. com os descritores lesões e autoimagem, na lilacs foram encontrados 583 artigos, sendo 48 completos; na pubmed, foram encontrados quatro artigos completos; na scielo, foi encontrado um artigo disponível na íntegra. com os descritores dermatologia e autoimagem, na lilacs foram encontrados 13 artigos, dos quais, três completos; na base pubmed foram encontrados 38 artigos, destes sete completos; e na scielo, não foram encontradas publicações. o total foi de 64 artigos completos e disponíveis. a análise preliminar dos resumos dos 51 artigos encontrados na base de dados lilacs mostrou que cinco deles eram relevantes à temática do estudo, e dois artigos, apesar de aparecem como completos, encontravam-se indisponíveis para leitura de forma gratuita. na base scielo, só foi encontrado um artigo disponível. dos 11 artigos encontrados na pubmed, seis se adequavam ao objeto de estudo. desse modo, nove artigos foram submetidos à análise de conteúdo. os demais foram excluídos devido à repetição na base de dados ou por não responder à questão de pesquisa levantada nesta revisão. seguindo a metodologia da ril, cada artigo foi cuidadosamente examinado para redução, visualização, comparação de dados, desenho, conclusão e verificação (21). na primeira fase da redução, os artigos foram organizados da seguinte forma: autores, ano de publicação/periódico, método e nível de evidência, país, título profissional do primeiro autor e nome da instituição pertencente. a segunda fase da redução de dados foi realizada de acordo com a finalidade, a população, os resultados, a conclusão dos autores e a discussão. para cada artigo, os dados relevantes para efeitos desta ril foram extraídos e organizados em quadros comparáveis. a organização dos dados contemplou o modo de autoconceito desenvolvido por callista roy para análise dos dados. isto porque essa teórica entende a enfermagem como uma profissão destinada aos cuidados de saúde que se centra nos processos de vida humanos, enfatiza a promoção da saúde aos indivíduos, grupos e sociedade. ela acredita que a ciência e a prática expandem a capacidade de adaptação e melhora a transformação ambiental da pessoa (22). ressalta-se que a classificação hierárquica das evidências para a avaliação de pesquisas ou outras fontes de informação é baseada na categorização da agency for healthcare research and quality (ahrq) dos estados unidos da américa. portanto, apresenta-se essa classificação nos seguintes níveis: nível 1, metanálise de múltiplos estudos controlados; nível 2, estudo individual com desenho experimental; nível 3, estudo com desenho quase experimental como estudo sem randomização com grupo único pré e pós-teste, séries temporais ou caso-controle; nível 4, estudo com desenho não experimental como pesquisa descritiva correlacional e qualitativa ou estudos de caso; nível 5, relatório de casos ou dado obtido de forma sistemática, de qualidade verificável ou dados de avaliação de programas; nível 6, opinião de autoridades respeitáveis baseada na competência clínica ou opinião de comitês de especialistas, o que inclui interpretações de informações baseadas em pesquisas; opiniões reguladoras ou legais (23). resultados e discussão inicia-se apresentando ao perfil das publicações analisadas e, visando atender a primeira fase da redução dos dados, conforme se apresenta no quadro 1. dos artigos selecionados predominam os encontrados no pubmed, sendo dois publicados em 2009 e três, em 2012. em relação ao idioma, seis estudos foram publicados em inglês e três na língua portuguesa. provavelmente por ser considerado idioma universal, observou-se predomínio de artigos publicados em inglês, inclusive os que tiveram autoria de franceses, iranianos, alemãs, coreanos e poloneses. dos nove artigos, três foram publicados no brasil, os demais na austrália, frança, irã, alemanha, coreia e polônia. em relação aos autores, destacam-se que seis estudos foram publicados por médicos, alguns em parceria com enfermeiros, biomédicos e farmacêuticos. chama a atenção que dois artigos foram publicados apenas por enfermeiros e 1 por psicólogos. ressalta-se a predominância de publicações de cunho internacional, que utilizam diferentes métodos de pesquisa, tais como 81 a autoimagem e a autoestima das pessoas com transtornos de pele:... l patrícia britto ribeiro de jesus, iraci dos santos, euzeli da silva brandão estudos transversais, investigações piloto, estudos prospectivo, internacional e multicêntrico. os sujeitos abordados nas pesquisas apresentavam doenças dermatológicas ou sistêmicas com efeitos na pele, entre elas, lúpus eritematoso sistêmico, acne vulgaris, doença de von recklinghausen, feridas crônicas, doenças alérgicas (urticária, dermatite atópica e dermatite alérgica de contato), assim como cicatrizes, acne, rosácea, melasma, vitiligo ou hiperpigmentação, sardas, lúpus eritematoso crônico discoide. autores ano de publicação/ periódico método e nível de evidência país titulação e instituição boehncke wh, ochsendorf f, ipaeslack i, rkaufmann r, zollner tm 24 2002 european journal of dermatology. pilot investigation – 3 alemanha médicos johann wolfgang goetheuniversity mattje gd, turato er25 2006 revista latino-americana de enfermagem desenho clínicoqualitativo – 4 brasil enfermeiros unicamp magin p, adams j, heading g, pond d, smith w. 26 2006 canadian family physician abordagem com teoria fundamentada – 4 austrália médicos university of newcastle a. potocka, k. turczynjabloñska, d. merecz 27 2009 acta dermatoven apa estudo transversal – 4 polônia psicólogos nofer institute of occupational medicine jeong ed, sun-mi c, sung-il i, ki-young l, sungnack l; eun-so l 28 2009 annals of dermatology estudo transversal – 4 coreia médicos ajou university school of medicine e gachon medical school souza mkb, matos at 29 2010 revista de enfermagem da uerj trabalho de campo – 4 brasil enfermeiros universidade federal do recôncavo da bahia seité s, deshayes p, dréno b, misery l, reygagne p, saiag p, stengel f, roguedas-contios am, rougier a30 2012 clinical, cosmetic and investigational dermatology estudo prospectivo, internacional, multicêntrico, não comparativo aberto – 3 frança/ argentina médicos la roche-posay pharmaceutical laboratories oliveira ghr, oliveira, mvr, henrique ec 31 2012 revista brasileira de clínica médica estudo de caso – 4 brasil médicos universidade federal de são joão del rei safizadeh h, shamsimeymandy s, naeimi a 32 2012 dermatology research and practice estudo transversal – 4 irã médicos kerman university of medical sciences quadro 1. perfil das publicações. rio de janeiro, 2013 82 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 procedendo à análise do conteúdo dos artigos selecionados, a partir dos resultados e da conclusão dos autores foram delimitadas duas categorias temáticas: 1. efeitos psicológicos da afecção dermatológica e 2. estratégias para o alcance da qualidade de vida (qv). para a sua delimitação, foi construído um quadro demonstrativo com as categorias delimitadas e síntese dos resultados e conclusões (quadro 2). nesse sentido, com o surgimento dessas categorias o modo de autoconceito de roy fortalece que a utilização de uma teoria de enfermagem ajuda a definir claramente o caminho e leva-nos à realização do processo de investigação (33). assim, neste estudo, tem-se o enfoque no modo autoconceito que é definido como um modo composto de crença e de sentimentos que a pessoa mantém sobre ela mesma. possui dois componentes: eu físico, que inclui sensações e imagem do corpo; eu pessoal, compreendido do eu consistência, eu ideal e eu éticomoral-espiritual (34, 35). dessa maneira, acredita-se que, por meio do reconhecimento dos aspectos psicossociais que permeiam o paciente, desencadeados por experiências pessoais diretamente nos seus comportamentos, atitudes e sentimentos ante as diferentes situações diárias, geram influências em seu eu físico e eu pessoal (36). quadro 2. categorias delimitadas e síntese dos resultados e conclusões. rio de janeiro, abril de 2013 categorias síntese dos resultados e conclusões efeitos psicológicos da afecção dermatológica os relatos dos entrevistados coincidem com os dados da literatura, que apontam algumas características como sendo muito importantes para a reconstrução indispensável de seu próprio conceito ou imagem. fenômenos particulares do lúpus, tais como erupções na pele, perda de cabelo e inchaço devido aos tratamentos anti-inflamatórios, levam à mudança inevitável da representação mental relativa a seu corpo. assim, a doença é representada psicologicamente com alguma dificuldade pelos pacientes (25). os mais proeminentes efeitos psicológicos da acne relatados no artigo são autoconsciência, vergonha e problemas com a autoestima e autoimagem. ansiedade e depressão, como definido pelo manual diagnóstico e estatístico de transtornos mentais, eram menos proeminentes. os efeitos foram agravados por provocações e a sensação de estar exposto. outros foram atenuados pelo apoio de amigos e familiares, camuflagem com maquiagem e um senso de controle causado por medidas de autoajuda (26). constataram diferentes percepções e sentimentos, assim como enfrentamentos quanto à sexualidade. quanto aos sentimentos, configuraramse o constrangimento, a tristeza, a sensação de incapacidade e a vergonha que determinaram o isolamento social. além da diminuição da autoestima, mecanismos de camuflagem em parte das mulheres e a ansiedade como fonte de esperança de cura (29). estratégias para o alcance da qv enfatizou-se que a psicoterapia e o acompanhamento social são válidos para restaurar e reconstruir o indivíduo, em especial seu equilíbrio emocional e convívio social. além da importância do encaminhamento para demais especialidades médicas (24). a aplicação de cosméticos decorativos tem um impacto positivo na qv dos pacientes. pacientes com acne e aqueles com deficiência modesta de sua qv são mais susceptíveis de se beneficiarem dessa medida. além disso, a aplicação de cosméticos decorativos pode ser um aspecto valioso de tratamento para as dermatoses mais graves (27). a análise dos resultados mostra que não foram significativas as diferenças na avaliação da saúde mental e qv, dependendo do nível do doente de autoaceitação. um número considerável de pacientes é caracterizado por baixa autoaceitação, baixa autoestima, a imagem corporal negativa, ou um baixo senso de autoestima. as conclusões dessas observações não são surpreendentes, mudanças visíveis na pele são conhecidos por afetar o estado mental humano e resultam na ansiedade, depressão e atitudes pessimistas (28). revelaram-se descobertas com grupos clínicos que a acne está associada com morbidade psicológica aumentada. os participantes com acne definitiva tiveram significativamente alta pontuação em relação à autoavaliação de gravidade, estresse e distúrbios nas inter-relações pessoais, vida diária e desempenho acadêmico. esses prejuízos foram associados com duração da doença, o sexo feminino e a gravidade da percepção subjetiva. em paralelo com achados anteriores, as avaliações subjetivas estiveram mais relacionadas à autoimagem, à autoestima e às relações sociais (30). os resultados confirmam a importância da autoimagem para os pacientes, que têm sentimentos de vergonha e inibição social e têm interesse em usar maquiagem para restaurar a autoestima. logo após a autoaplicação da maquiagem na visita inicial, 99 % dos pacientes concordou com a notável melhora em seu rosto e 88 % se sentiam mais confortáveis em sua relação com os outros (31). o impacto da acne na qv dos pacientes foi de cerca de 51,8 % dos indivíduos. não houve relação significativa entre qv e duração das manifestações. comparações da qv com base no nível educacional apresentaram melhor qv de vida em pessoas com níveis mais elevados de ensino, que pode ser devido ao status social de pessoas educadas, o que as habilita a aceitarem sua doença e lidarem com seus resultados (32). 83 a autoimagem e a autoestima das pessoas com transtornos de pele:... l patrícia britto ribeiro de jesus, iraci dos santos, euzeli da silva brandão efeitos psicológicos da afecção dermatológica a presente categoria foi composta por três publicações (25, 26, 27). nesta, por meio da subárea do eu físico em que se inclui dois componentes: sensação e imagem corporal (34, 37), observou-se o componente mais acometido: o que pode desencadear uma imagem corporal, manifestada pelos sentimentos negativos em relação ao corpo, que leva a efeitos psicológicos. uma das publicações refere-se a um estudo clínico-quantitativo com clientes acometidos por lúpus eritematoso sistêmico (les) e aborda experiências negativas em relacionamentos, no qual se observou comportamentos de rejeição tanto familiar quanto social e retardo no descobrimento da doença por parte dos profissionais de saúde. a experiência da doença para os pacientes é percebida como um sofrimento diante do desconhecido e proibições recomendadas (25). percebe-se que a doença cutânea provoca sentimentos de irritabilidade, dificuldade em verbalizar o sofrimento, inibição do interesse sexual e reclusão social, o que pode provocar efeitos psicológicos (25). a identificação de uma autoimagem desfigurada e os sentimentos desencadeados pelo les devem ser investigados pelos profissionais de saúde e merecem a atenção destes para êxito e controle da doença. outra publicação teve como objetivo investigar sequelas psicológicas da acne vulgaris. nesta, 26 sujeitos com idades variadas foram entrevistados e foi possível perceber como a acne acomete a vida das pessoas, causando constrangimento, baixa autoestima e autoimagem, estigmatização e sentimentos de inferioridade (26). refletindo quanto a tais efeitos psicológicos, roy com o autoconceito permite envolver especificamente os aspectos psicológicos e espirituais do sistema humano, ao contemplar a imagem corporal, pelo ser pessoal, que engloba a autoconsciência, o autoideal ou expectativa, e pelo ser ético, moral e espiritual (17). a aparência física é um aspecto importante do processo de socialização normal. a acne é uma das anormalidades mais facilmente reconhecíveis na face, o que pode resultar em algumas consequências psicossociais adversas para a pessoa afetada (39). portanto, afetando o eu físico no que tange a sua aparência, os pacientes pareciam sentir que a acne afetava a sua personalidade, assim eles exibiam um comportamento mais evasivo e de fobia social. a fobia social pode ser causada pela exposição da imagem alterada, do julgamento alheio, olhares curiosos e preconceituosos da sociedade que afligem a pessoa acometida pela afecção cutânea (38). outro estudo descritivo aborda a análise da percepção do portador de ferida crônica sobre sua sexualidade. neste, oito pessoas atendidas em uma sala de curativos de um centro de saúde na cidade de salvador (bahia, brasil) foram entrevistadas e observou-se que a presença da ferida afetava a vida social, familiar e sexual, o que levou a efeitos psicológicos intensos no que tange ao isolamento social (29). nesse estudo, com foco na sexualidade e seus efeitos diante da presença de uma ferida crônica, os entrevistados relatam que esta acarreta tristeza, sensação de incapacidade, melancolia e constrangimento (29). alertando-se para a dificuldade de relacionamento, associado à diminuição da autoimagem e da autoestima provocada pela alteração da imagem corporal. assim, reitera-se ao modo autoconceito definido por um composto de crenças e sentimentos que a pessoa tem sobre si mesma em um dado momento (34). nesse modo, os problemas adaptativos podem interferir na habilidade da pessoa em fazer o que é necessário para manter os aspectos de saúde como são demonstrados nos estudos anteriores. reitera-se que as reações, as atitudes e os sentimentos dessas pessoas transitam entre a rejeição, a vergonha, a exclusão, o isolamento, a submissão e a passividade, o que os torna estigmatizados pela sua alteração física (40). a qv das pessoas com feridas crônicas também é afetada já que elas precisam modificar hábitos e se desvelar em processos adaptativos, com interferência no conforto e bem-estar individual e familiar. além disso, a ferida prejudica o estado de humor dos atores sociais e deixa-os irritados ou sem paciência; assim, destaca-se o papel da família e das redes sociais dos adoecidos no processo de enfrentamento do processo saúde-doença (41). nesse sentido, além da família e das redes sociais, o profissional de saúde que cuida da pessoa com ferida crônica e o ser cuidado podem colaborar na orientação de comportamentos adaptativos que poderão ser capazes de relacionar por intermédio 84 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 de um processo interativo, no qual compartilham experiências e resgatam a humanidade existente em cada um (42). o profissional de saúde juntamente com a equipe multiprofissional deve ajudar o paciente a superar os efeitos psicológicos inerentes à doença e a recuperar sua posição socioprofissional frequentemente perdida em função de seu estado patológico (43). estratégias para o alcance da qv esta categoria foi composta por seis publicações (24, 27, 28, 30, 31, 32). a qv foi definida pela organização mundial de saúde como a percepção do indivíduo de sua posição na vida no contexto da cultura e sistema de valores nos quais ele vive e em relação aos seus objetivos, expectativas, padrões e preocupações (44). através de seu caráter integrador, inter-relacional e multidimensional, a qv está pautada nos vários contextos da saúde e nas múltiplas dimensões humanas: biológicas, sociais, psicológicas e espirituais. tais dimensões se entrelaçam se inter-relacionam com o ambiente no qual se encontra e necessita de atendimento para possibilitar o equilíbrio e a sustentabilidade de todos os elementos participantes dessa totalidade (45). portanto, a relação entre qv e saúde vai além das condições materiais de cada um, pois o ser humano deve ter suas necessidades básicas respeitadas (46). assim, no que se refere à luz do referencial teórico desse estudo, quanto ao eu pessoal, outra subárea do modo de autoconceito é realizada uma avaliação individual de suas próprias características, expectativas, valores e méritos (37) que pela sua denominação pode-se remeter à compreensão da qv como uma forma de percepção do próprio existir (47). portanto, a primeira publicação refere-se a uma investigação piloto realizada com 20 mulheres com acne, lúpus eritematoso discoide crônico e vitiligo. elas participaram da pesquisa na qual usaram cosméticos decorativos e preencheram o dermatology life quality index —dlqi— (24). essa investigação revelou que o seu uso resultava em considerada camuflagem em algumas lesões da pele, porém as mais evidentes permaneciam expostas. ou seja, determinados tipos de manifestações dermatológicas são cobertas pelo uso dos cosméticos, outras não, o que torna seu uso limitado. pela avaliação dos cosméticos e a sua consequente mudança na qv, foi percebida uma melhoria significativa em alguns casos, como na acne papulopustulosa e conglobata. porém, os autores revelam que isso não foi devido à deterioração inicial da qv, porque não havia nenhuma diferença estatística das pontuações dlqi entre ambos os grupos de pacientes, além de não considerarem a idade como parâmetro relevante (24). o conceito de usar maquiagem está ganhando novas definições, com a indústria investindo em novas funções para esses produtos. além de embelezar, a maquiagem também é indicada para tratamento, devido aos novos compostos que estão sendo agregados a ela (48). em outro estudo com 112 pacientes, a maioria mulheres, com diagnósticos de urticária, dermatite alérgica de contato e dermatite atópica e idades variando de 18 a 72 anos, com média de 38 anos, buscou-se analisar os relacionamentos potenciais entre autoaceitação, saúde mental e qv por meio de três questionários: um de saúde geral, um de dlqi e uma escala de autoaceitação (26). revelando, dentre os seus aspectos, a existência de diferenças estatísticas significativas quanto à saúde mental e qv dependendo do nível de autoaceitação do paciente como, por exemplo, indivíduos com autoaceitação elevada são caracterizados pela melhor saúde mental do que aqueles com baixa. percebeu-se, assim, que doença dermatológica leva a sentimentos de autoestima alterada e ao reconhecimento da própria condição de vida. por serem aparentes, as dermatoses repercutem na vida pessoal, profissional e social das pessoas acometidas por elas (49). ante essas conclusões, o artigo traz possibilidades de estratégias de alcance de qv por meio de questionários que podem avaliar e colaborar no planejamento de ações como suporte psicológico, intervenções focadas no fortalecimento da autoimagem e na redução de sentimentos autodestrutivos, ou seja, a busca de mecanismos de enfrentamento eficientes para manutenção de sua integridade psíquica. o estudo transversal com 513 adolescentes coreanos com faixa etária de 13 a 16 anos teve como objetivo de determinar a prevalência da acne e o prejuízo desta nos aspectos emocional, 85 a autoimagem e a autoestima das pessoas com transtornos de pele:... l patrícia britto ribeiro de jesus, iraci dos santos, euzeli da silva brandão social e funcional. os resultados revelam o real comprometimento da qv dos estudantes causada pela presença de acne, devido a prejuízos nas relações interpessoais e distúrbios na vida diária, especialmente no desempenho acadêmico (28). a análise ampla desse estudo conclui-se que a acne acomete a vida dos adolescentes e pode levar a um distúrbio psicológico que advém da autopercepção, estresse, relações sociais comprometidas, baixa autoimagem e autoestima (28). nesse estudo, mostrou-se que a baixa autoestima é considerada um problema de adaptação, pois indica a presença de sentimentos de depressão, desvalorização, isolamento (37). outro estudo internacional, multicêntrico, prospectivo não comparativo realizado com 129 pacientes com dermatoses, com idade média de 18 anos, que afetavam a face onde foi avaliada a qv, o impacto mais significativo foi em relação aos sentimentos, e o menos foi em relação ao trabalho ou estudo; pacientes com cicatrizes são mais afetados do que aqueles cuja área afetada é menor (30). esse impacto significativo também foi citado em outro estudo que aborda as dificuldades e temas da vida de pessoas com vitiligo em que relatam a exposição das manchas; a aparência ou estética, que inclui a dificuldade de lidar com a aparência ao se olhar no espelho e o comprometimento da vaidade devido às alterações estéticas; as interações sociais; o aspecto emocional, que envolve a alteração da autoestima, o controle das emoções, o sentimento de vergonha (50). assim, a maquiagem de camuflagem consegue mascarar uma coloração não desejada, cicatrizes e lesões, e sua aplicação resulta numa melhora da aparência do paciente e minimizam a estigmatização pelo fato de diminuir os sinais visíveis da doença (30). a estigmatização é algo que faz parte do dia a dia desses clientes, seja na rua, em casa com a família, com amigos, onde ele estiver, estará propenso a vivenciar tais situações. no meio social em que os padrões estéticos são extremamente rígidos, a afecção cutânea é uma condição na qual o sujeito está fora dos padrões (38). nesse aspecto, ao refletir sobre os efeitos do uso e não uso dos cosméticos percebe-se que, no modo autoconceito ao estar intrinsecamente ligado à integridade psíquica, se conturba com a autoimagem alterada e baixa autoestima que diminui as expressões de valores do indivíduo quanto a si mesmo e as suas expectativas (51). a condição do sujeito de estar fora dos padrões no que concerne ao do corpo, observam-se ideais hedonistas e a moral do “aqui agora”, que convive lado a lado com a ideologia da saúde, da longevidade e da prevenção (52). a forma com a qual as pessoas reagirão ante os seus problemas e os mecanismos dos quais elas utilizarão para enfrentá-los estão intimamente relacionados às suas crenças, seus valores e ao apoio que recebem dos seus familiares (53). novamente, outro artigo de pesquisa (48) faz parte de uma iniciativa de indústrias farmacêuticas internacionais, portanto o alcance a essas estratégias para a melhoria da qv fica restrito e limitado, já que os custos serão elevados para a população em geral. com certeza, é uma medida favorável às pessoas acometidas por afecções na face e o seu uso restabelece a autoestima e melhora a qv, o que minimiza estigmas sociais por meio da camuflagem. remetendo-se ao eu ideal, que poderá ser alcançado por meio das estratégias citadas anteriormente, ressalta-se que, à medida que as pessoas são capazes de enfrentar situações de extremo estresse físico e emocional, permite-lhes perceber a possibilidade de superação, assim como dispor de meios eficientes para enfrentá-las (37). em um relato de caso de uma paciente do sexo feminino de 50 anos com diagnóstico de doença de von recklinghausen, o autor revelou o grande impacto na qv tanto do ponto de vista clínico quanto estético (31), diante de uma doença que acarreta sintomas sistêmicos como hipertensão arterial sistêmica, escoliose, cefaleia, macrocefalia, baixa estatura, catarata e pterígio conjuntival. além de afetar a aparência, que consequentemente compromete sua vida social e desempenho no trabalho. os aspectos relacionados à qv não foram descritos pelo autor, tendo em vista que a paciente abandonou as consultas de rotina, e também pelo fato de ser um relato de caso de apenas uma paciente. um estudo transversal com 220 pacientes objetivou investigar a qv dos pacientes com acne em um contexto iraniano. neste, foi utilizado o dlqi e o índice de deficiência da acne cardiff (cadi). em relação ao dlqi, a maior pontuação média foi atingida por 86 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 uma enfermidade, na qual o cliente apresenta sentimentos e emoções; e no cadi, a imagem corporal alcançou a maior pontuação média (32). novamente, mais um artigo demonstra a estreita relação entre uma afecção dermatológica e a qv e assim percebe-se que, quanto maior a severidade do caso, maiores serão os impactos psicossociais. as mulheres, em geral, são mais afetadas que os homens. portanto, os impactos psicossociais podem evoluir para um significativo decréscimo no bem-estar emocional, social, na produtividade escolar ou laboral, e influenciar significativamente na evolução da doença e na resposta às intervenções terapêuticas propostas (54). assim, as alterações causadas pelo acometimento cutâneo podem causar mal-estar, o que interferirá na qv. portanto, os profissionais de saúde devem contemplar os aspectos emocionais e sociais que visem à melhoria do bem-estar físico, mental e social e possibilitem a busca de uma ressignificação do sentido da vida. conclusões as afecções dermatológicas trazem mudanças significativas no aspecto psicossocial e na qv. esta revisão integrativa relevou os principais efeitos psicológicos provocados pelas afecções dermatológicas. o acometimento cutâneo pode levar o indivíduo a buscar estratégias que vão desde o isolamento do corpo e social, negação da doença até as maquiagens de camuflagem. algumas publicações revelam o investimento feito por indústrias farmacêuticas em relação ao uso de cosméticos (camuflagens) que visam à melhoria da qv, principalmente de pessoas que têm a face acometida por uma afecção dermatológica. porém, o seu uso se torna restrito e limitado em muitos casos. a associação estabelecida entre as afecções dermatológicas e os modos adaptativos permitiu reconhecer os problemas comuns de adaptação de callista roy na população estudada, assim como identificar os efeitos e influências a serem trabalhados como medida interventiva capaz de viabilizar a adaptação. além de constatar que os problemas de adaptação do modo autoconceito, isto é, os fatores psicossociais relacionados diretamente à afecção dermatológica no que tange à autoimagem e autoestima, ocasiona ou ocasionou modificações na vida das pessoas. esses problemas provocaram ansiedade e depressão, e interferiram na qv dessas pessoas. a compreensão do sofrimento das pessoas, nesse caso específico, causado pela alteração da autoimagem, permite assumir no cuidado a integralidade do ser humano, com um tratamento digno e humanizado. diante da escassez de estudos publicados que mostrem as estratégias a serem adotadas por enfermeiros para lidar com os efeitos psicológicos causados pela doença cutânea, evidencia-se uma lacuna no conhecimento, o que revela a necessidade de investir em pesquisas sobre a temática. 87 a autoimagem e a autoestima das 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[série on-line];15(4):845-850 [consultado em: 22 jan. 2014]. disponível em: http://www.scielo. br/scielo.php?script=sci_arttext&pid=s141481452011000400026&lng=en 53. severiano mfv, rêgo mo, montefusco evr. o corpo idealizado de consumo: paradoxos da hipermodernidade. rev. malestar e subjetividade, fortaleza 2010; 10(1):137-165. 54. lima afc, gualda dmr. reflexões sobre qualidade de vida do cliente renal crônico submetido à hemodiálise. rev nursing 2000; 3(30):20-22. 55. ue apf et al. estudo da qualidade de vida nos pacientes com urticária crônica. an. bras. dermatol. 2011; 86(5):879-904 [consultado em: 29 set. 2013]. disponível em :? script=sci_arttext&pid=s036505962011000500006&lng=en 53 69 percepcion de condiciones de seguridad.indd 53 elizabeth vargas-rosero1 rosa coral-ibarra2 delia moya-plata3 vilma tamara ortiz4 yancy mena5 esperanza romero-gonzález6 percepción de las condiciones de seguridad de pacientes con enfermedad crónica sobre el entorno hospitalario en colombia7 1 http://orcid.org/0000-0003-2710-4320. universidad nacional de colombia, colombia. evargasr@unal.edu.co 2 http://orcid.org/0000-0002-0244-5578. universidad de ciencias aplicadas y ambientales udca, colombia. rcoral@udca.edu.co 3 http://orcid.org/0000-0003-2394-9932. universidad de santander udes, colombia. deliamoyaplata@hotmail.com 4 http://orcid.org/0000-0001-6345-3267. universidad mariana, colombia. tabata269@gmail.com 5 http://orcid.org/0000-0002-1691-2253. universidad tecnológica del chocó, colombia. yalumeto@hotmail.com 6 http://orcid.org/0000-0002-4680-3082. universidad de los llanos, colombia. eromero@unillanos.edu.co 7 financiación: programa para disminuir la carga de la enfermedad crónica en colombia. convocatoria 5372010 colciencias. unión temporal carga de la enfermedad crónica en colombia. recibido: 30 de abril de 2015 enviado a pares: 25 de mayo de 2015 aceptado por pares: 19 de febrero de 2016 aprobado: 9 de marzo de 2016 doi: 10.5294/aqui.2017.17.1.6 para citar este artículo / to reference this article / para citar este artigo vargas-rosero e, coral-ibarra r, moya-plata d, ortiz vt, mena y, romero gonzález e. percepción de condiciones de seguridad del entorno hospitalario de pacientes con enfermedad crónica en colombia. aquichan. 2017;17(1):53-69. doi: 10.5294/aqui.2017.17.1.6 resumen objetivos: describir, comparar y relacionar la percepción de las condiciones de seguridad del entorno hospitalario de pacientes con enfermedad crónica en colombia y sus cinco macrorregiones geográficas (amazonía, andina, caribe, orinoquía y pacífico). materiales y método: estudio descriptivo, comparativo y de relación, cuya muestra fue de 484 personas con enfermedad crónica. se emplearon los instrumentos: encuesta de caracterización para el cuidado de la persona con enfermedad crónica y encuesta percepción de condiciones de seguridad del entorno hospitalario, versión paciente. resultados: frente a las categorías de percepción de riesgo, solamente la mitad de ellos conoce los riesgos a los que está expuesto y la forma de actuar para prevenirlos, y solo la mitad reportó conocer sus deberes y derechos durante la hospitalización. los riesgos que reflejan mayor materialización son las caídas y las flebitis. conclusiones: hay poca apropiación sobre el cuidado y la prevención del riesgo; en consecuencia, es alto el grado de vulnerabilidad frente a las condiciones del entorno hospitalario en las cinco macrorregiones geográficas de colombia. palabras clave seguridad; administración de la seguridad; seguridad del paciente; atención de enfermería (fuente: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 53-69 54 aquichan issn 1657-5997 año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 53-69 perception of safety conditions for chronically ill patients in the hospital environment in colombia abstract objectives: describe, compare and associate the perception of safety conditions for chronically ill patients in the hospital environment in colombia and in its five geographic macro-regions (amazon, andean, caribbean, orinoquía and pacifico). method: this is a descriptive, comparative and relationship-based study. the sample was comprised of 484 persons who have a chronic illness. the instruments used were the characterization survey for care of the person with chronic disease and the patient version of the survey of the perception of safety conditions in the hospital. results: compared to the risk perception categories, only half are aware of the risks to which they are exposed and how to prevent them, and only half reported knowing their rights and obligations during hospitalization. falls and phlebitis are the risks that are more likely to materialize. conclusion: there is little appropriation of risk prevention and care. consequently, there is a high degree of vulnerability to the conditions of the hospital environment in colombia’s five geographic macro-regions. keywords safety; safety management; patient safety; nursing care (source: decs, bireme). 55 percepción de condiciones de seguridad del entorno hospitalario de pacientes con enfermedad crónica en colombia l elizabeth vargas-rosero y otros percepção das condições de segurança de pacientes com doença crônica sobre o ambiente hospitalar na colômbia resumo objetivos: descrever, comparar e relacionar a percepção das condições de segurança do ambiente hospitalar de pacientes com doença crônica na colômbia e suas cinco macrorregiões geográficas (amazonía, andina, caribe, orinoquía e pacífico). materiais e método: estudo descritivo, comparativo e relacional, cuja amostra foi de 484 pessoas com doença crônica. foram empregados os instrumentos: pesquisa de caracterização para o cuidado da pessoa com doença crônica e pesquisa de percepção de condições de segurança do ambiente hospitalar, versão paciente. resultados: diante das categorias de percepção de risco, somente a metade deles conhece os riscos aos quais estão expostos e a forma de agir para preveni-los; também só a metade relatou conhecer seus direitos e deveres durante a hospitalização. os riscos que refletem maior materialização são as caídas e as flebites. conclusões: há pouca apropriação sobre o cuidado e a prevenção do risco; em consequência, é alto o grau de vulnerabilidade ante as condições do ambiente hospitalar nas cinco macrorregiões geográficas da colômbia. palavras chave administração da segurança; segurança do paciente; atenção de enfermagem; segurança (fonte: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 53-69 56 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 introducción la garantía de una atención segura en salud se ha reconocido como prioritaria en los ámbitos mundial, regional y local, tanto para el bienestar y calidad de vida de los pacientes como para la viabilidad de los sistemas de salud (1-4). cada día es mayor el número de personas con enfermedades crónicas que demanda atención especializada (5), y a esto se suman los cambios operativos del sistema de salud, con tendencia a la inestabilidad económica e insatisfacción del talento humano (6,7), y los impactos del desarrollo de la tecnología (8), lo que, en conjunto, ha creado un contexto complejo y vulnerable para la prestación de estos servicios. a pesar de estas dificultades, es una prioridad el cuidado seguro en salud como derecho de todo ciudadano (9). las condiciones de seguridad del paciente se definen como: […] todas aquellas circunstancias que inciden en su protección y que están determinadas por las acciones del equipo de salud que le atiende, la adecuada disposición de recursos humanos y físicos por parte de las organizaciones, así como por las acciones y previsiones por parte de los mismos pacientes y sus cuidadores. (10) en busca de garantizar que el punto de vista de los pacientes y familias, usuarios y ciudadanos sea un referente obligatorio para el trabajo en la seguridad en los servicios de salud, la organización mundial de la salud, impulsó en el 2010 la iniciativa pacientes en defensa de su seguridad (11). se asume que la participación de los beneficiarios de estos servicios puede ayudar a identificar de manera precoz los posibles riesgos, así como a aportar ideas que generan y facilitan soluciones más viables y realistas para eliminarlos o mitigarlos (12). sin embargo, pese a la relevancia de la estrategia, pocos estudios evalúan la percepción de los pacientes sobre las condiciones de seguridad de los entornos hospitalarios, y los que se han reportado no les dan a los pacientes el protagonismo que deben tener (13). por considerarlo importante para la disminución de la carga de la enfermedad crónica (ec), esta investigación describió, comparó y relacionó la percepción de las condiciones de seguridad del entorno hospitalario de personas con ec en las regiones colombianas de amazonía, andina, caribe, orinoquía y pacífico. método este fue un estudio de abordaje cuantitativo, de tipo descriptivo-comparativo y de relación, y fue realizado entre el 2013 y el 2014. su muestra la conformaron 484 personas con ec vinculadas como pacientes a instituciones de salud y captadas desde programas docente-asistenciales de enfermería en colombia, que se distribuyeron por regiones, así: 33 (6 %) personas de la amazonía, 309 (65 %) de la región andina, 47 (12 %) del caribe, 56 de la orinoquía (12 %) y 23 (5 %) del pacífico colombiano. los instrumentos empleados para la recolección de la información fueron: la encuesta de caracterización para el cuidado de la persona con ec (14) y la encuesta percepción de condiciones de seguridad del entorno hospitalario, versión paciente con ec (15). la primera es una encuesta de veintidós ítems que incluye tres categorías: 1) las condiciones del paciente y su perfil sociodemográfico, 2) la percepción de carga y apoyo y 3) el nivel de apropiación de las tecnologías de información y comunicación (tic). la segunda encuesta considera la percepción de condiciones de seguridad del entorno hospitalario como la apreciación que tienen los pacientes sobre todas aquellas circunstancias que inciden en su protección y que están determinadas por las acciones del equipo de salud que los atiende, la adecuada disposición de recursos humanos y físicos por parte de la organización, así como por las acciones y previsiones de los mismos pacientes. la encuesta está conformada por cinco categorías: 1) conocimiento, 2) pautas de prevención, 3) actitud personal frente al riesgo, 4) riesgo materializado y 5) percepción global de seguridad. las encuestas empleadas se validaron para el contexto colombiano (validez aparente y facial) y por medio de expertos (15). los hallazgos se analizaron con apoyo del programa spss versión 22.0, bajo licencia de la universidad nacional de colombia. para la caracterización y el análisis de la percepción de las condiciones de seguridad, se aplicó estadística descriptiva de frecuencias, por cada categoría y en la totalidad. se buscó comparar las cuatro primeras variables de la percepción de condiciones de seguridad frente a cada uno de los factores sociodemográficos (para lo cual se estandarizaron en una escala de 0 a 100), utilizando las pruebas de mann-whitney, kruskal-wallis y la última variable utilizando chi cuadrado (χ2), dado que es dicotómica. al comparar cada grupo de variables de la percepción de seguridad, se encontró que cada categoría está modelada fuertemente por aspectos de la caracterización sociodemográfica, es decir, se encontró un efecto modulador de algunas variables sobre las otras, por lo cual se afirma que existe alguna relación entre ellas. al tratarse de pruebas no paramétricas, no requieren evaluación de normalidad. 57 percepción de condiciones de seguridad del entorno hospitalario de pacientes con enfermedad crónica en colombia l elizabeth vargas-rosero y otros se tuvieron en cuenta los criterios éticos dispuestos en la resolución 008430 de 1993 (16), la ley 911 del 2004 (17), las pautas éticas internacionales para la investigación biomédica con seres humanos (18) y se contó con la aprobación de los comités de ética institucionales, previa presentación del consentimiento informado, que firmó cada paciente participante en el estudio. sus investigadores acataron la política de protección ambiental, en especial con el uso responsable de recursos (19). resultados caracterización de los participantes con respecto a las condiciones y perfil sociodemográfico de las personas con ec participantes en el estudio, el 39,5 % son hombres; mientras el 60,5 % son mujeres, con la mayor proporción femenina en la región pacífico (79,9 %), y la menor, en la región caribe (53,3 %). dentro del país, el mayor grupo se encuentra en el rango de edad de 36 a 59 años (32,6 %), seguido por el grupo de 60 a 74 (32,4 %). por tratarse de personas con ec, llama la atención que el grupo de menores de 35 años llegue al 20,6 %; mientras que el de personas de 75 y más años sea del 14,4 %. el mayor grupo de personas enfermas de menos de 60 años se encuentra en la amazonía (64,9 %); entre tanto, el mayor número de personas enfermas de 60 y más años está en el caribe (72,8 %). en cuanto a la escolaridad, el 69 % de los participantes tiene una educación menor al bachillerato completo. los menores niveles de escolaridad se encuentran en las regiones amazonía (82 %) y orinoquía (80 %), seguidos por el pacífico (71,9 %) y el caribe (75 %). el 85,9 % de los participantes habita en la zona urbana, y el 14,1 %, en la rural. de los participantes, el 30,9 % es casado, el 7,6 % está separado, el 29 % es soltero, el 15,4 % tiene una unión libre y el 17,1 % es viudo. es en el pacífico donde hay más personas sin vínculo estable (70,5 %), seguido por el caribe (57,5 %) y la región andina (55 %). cerca de la mitad de los participantes permanece en el hogar sin vínculo laboral (53 %), los demás son empleados (11,6 %), estudiantes (2,9 %), tienen trabajo independiente (20,4 %), no identifican actividad alguna (9,3 %) o son pensionados (2,9 %). en el grado de funcionalidad se encontró que la mayoría de estas personas son independientes (67 %), a pesar de estar enfermas. el estado mental, medido con el cuestionario abreviado sobre el estado mental, reflejó que la mayor parte de este grupo de pacientes tiene un estado mental intacto (78,2 %) o una alteración leve (13,7 %). sin embargo, el 8,2 % tiene alteración cognitiva entre moderada y severa; las personas más afectadas están en la región andina (9,8 %) y en el pacífico (8 %). en cuanto a la enfermedad reportada, priman los trastornos cardiovasculares (29,65 %), seguidos del cáncer (15,1 %) y la diabetes (13,4 %). esta prioridad se mantiene en todas las regiones. con respecto a la percepción de carga y apoyo, casi la mitad del grupo lleva más de tres años con la enfermedad (49,4 %). el 18 % señala que su enfermedad lleva entre 19 y 36 meses, el 12,1 %, de 7 a 18 meses, y el 20 %, menos de 7 meses a partir del diagnóstico. el 91,4 % de estas personas reconoce tener un cuidador. de ellos, la mitad señala que es un cuidador único, y la otra, que es más de un cuidador quien los apoya. mientras el 50,4 % requiere apoyo menos de 6 horas al día, el 15,6 % necesita entre 7 y 12 horas y el 21,3 % precisa entre 13 y 24 horas. sobre la percepción de apoyos con que cuentan estas personas, están en su orden: el apoyo familiar (90,4 %), el económico (62,1 %), el social (58,8 %), el religioso (55,8 %) y el psicológico (42,8 %). al calificar su grado de satisfacción con estos apoyos, los participantes señalaron estar satisfechos o muy satisfechos con los apoyos familiar (84 %), religioso (65,9 %), económico (60,8 %), social (58,8 %) y psicológico (40,1 %). en relación con la percepción de carga del paciente, el 79,2 % considera que es baja o media para su familia, y el 20,85 % que esta es alta o muy alta. en las regiones amazonía (97,0 %) y pacífico (94,9 %), los pacientes se consideran con menos carga, y en las regiones caribe (30,3 %), andina (24,4 %) y orinoquía (24 %) consideran la carga más alta. en cuanto a la apropiación del uso de las tic, se reportan a continuación los niveles de conocimiento, acceso y frecuencia de uso: los participantes califican en nivel alto el conocimiento de la televisión (32,9 %), la radio (54,8 %), el computador (20,8 %), el teléfono (45,6 %) y el internet (19 %). la tic que más se conoce en 58 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 colombia es el radio, con un 54,8 % de calificación en nivel alto y un 29,6 % en nivel medio. la posibilidad de acceso es calificada como alta para la televisión (59,1 %), la radio (47,1 %) y el teléfono (43,7 %). el computador y el internet tienen baja calificación, con 61,1 % y 64,3 %, respectivamente. el mayor acceso a la radio (51,5 %) y al teléfono (50,7 %) lo reporta la región andina; mientras que la región amazonía reporta accesos más altos a la televisión (62,6 %), el computador (32,8 %) y el internet (29 %). en cuanto a la frecuencia de uso, excepto por la televisión, que se valora en una frecuencia alta por el 39 %, todas las demás tic tienen una frecuencia de uso baja: radio (43,1 %), computador (78,3 %), teléfono (46,7 %) e internet (80,1 %). el uso de la televisión tiene un grupo mayoritario en la región caribe (53 %) y el grupo que menos la emplea está en la orinoquía (36,4 %). las tic, como elemento de apoyo para el cuidado de la salud, las emplean el 39,6 % de las personas con ec; mientras que el 60,4 % no las usa para este propósito. el grupo que mayor empleo reporta en este campo es el de amazonas (94 %), y el de menor empleo es el pacífico (89,1 %). el 64 % refiere que el apoyo percibido por las tic es bajo, y se mantiene el grupo más numeroso con percepción alta en la amazonía (26,1 %), y el que tiene la percepción más baja es el pacífico (87,6 %), seguido muy de cerca por los de las regiones caribe (87,1 %) y orinoquía (82,6 %). al priorizar las tic por su utilidad para recibir información para el cuidado, el 66,6 % consideró que la televisión es prioritaria; el 49,9 % calificó la radio como prioritaria; el 23,8 %, el computador; el 32,6 %, el teléfono, y el 25,6 %, internet. percepción de las condiciones de seguridad del entorno hospitalario a continuación, se presentan los resultados de la evaluación en las categorías: conocimiento, pautas de prevención, actitud personal frente al riesgo, riesgo materializado y percepción global de seguridad. en cuanto al conocimiento de su situación y riesgos hospitalarios, se pudo establecer que la mayor parte de los pacientes conoce el motivo de su hospitalización, tanto para colombia como para las regiones. sin embargo, frente a los riesgos, la forma de actuar para prevenirlos y sus deberes y derechos, las respuestas señalan que solo cerca de la mitad los conoce. llama la atención los bajos niveles de conocimiento que se presentan en la región pacífico y el desconocimiento total de deberes y derechos que se da en la amazonía (tabla 1). en cuanto a las pautas de prevención frente al riesgo hospitalario, se encontró que, en colombia, en promedio el 61,3 % de los pacientes ha sido instruido sobre pautas de seguridad. la menor instrucción se presenta en el amazonas (el 96,8 % señala tabla 1. distribución porcentual de personas con enfermedad crónica participantes, según conocimiento de su situación y riesgos fuente: datos de la investigación, 2014. ítem: conocimiento amazonía (%) andina (%) caribe (%) orinoquía (%) pacífico (%) nacional (%) razón por la cual se encuentra hospitalizado no 0,00 4,21 6,67 5,17 8 4,49 sí 100,00 95,79 93,33 94,83 92 95,51 riesgos que puedan ocurrir durante una hospitalización diferentes a su enfermedad no 6,45 45,95 35,56 29,31 68 41,45 sí 93,55 54,05 64,44 70,69 32 58,55 cómo prevenir y actuar frente a los riesgos no 58,06 47,57 64,44 46,55 88 51,92 sí 41,94 52,43 35,56 53,45 12 48,08 deberes y derechos como paciente durante la hospitalización no 96,77 54,05 33,33 44,83 80 55,13 sí 3,23 45,95 66,67 55,17 20 44,87 59 percepción de condiciones de seguridad del entorno hospitalario de pacientes con enfermedad crónica en colombia l elizabeth vargas-rosero y otros que nunca o algunas veces fueron instruidos) y la mejor está en la orinoquía, donde el 77,6 % señala que casi siempre o siempre ha recibido pautas de prevención. esta situación llama la atención, pues se espera que sea la misma institución de salud la que alerte a sus pacientes sobre los posibles riesgos para que ayuden a disminuir su ocurrencia. el 77,8 % de los pacientes recibe respuesta oportuna del personal a su llamado; sin embargo, el grupo de la amazonía es el que peor califica la respuesta oportuna (87,1 %). entre tanto, el de la orinoquía es el que mejor la evalúa (84,5 %). el 86,8 % de pacientes señala que es identificado por su nombre antes de cualquier procedimiento con el grupo de peor evaluación en la amazonía (58 %) y el mejor en la zona andina (94,2 %). el 82,3 % evalúa de forma positiva la comunicación con el personal de salud. la peor evaluación se da en la amazonía, con un 87,1 %, que evalúa de forma negativa. la mejor puntuación se ubica en la orinoquía, con 93,1 %, que la evalúa de manera positiva. en el ámbito nacional, el 68,6 % de los pacientes señala haber recibido información sobre riesgos y complicaciones y, de nuevo, es en la amazonía donde la evaluación negativa es más alta (43,3 %) y es en la orinoquía donde es mejor evaluada, con un 79,3 % de respuestas positivas. el 74,2 % de los pacientes indica que observa pautas de prevención frente al riesgo en el personal que lo atiende, aun cuando la amazonía tiene respuestas más negativas, con un 83,9 % de los pacientes, y la región andina evidencia el mayor número de respuestas positivas (81,6 %) (tabla 2). en general, los pacientes perciben que el mayor cumplimiento en pautas de prevención por parte del personal que los atiende es identificarlo por su nombre (86,6 %). el menor porcentaje de respuestas positivas lo tiene el ítem de pautas con respecto a las reglas y procedimientos de seguridad durante su hospitalización. la amazonía es la región que persistentemente en esta categoría obtiene las mayores evaluaciones negativas, lo cual lleva a afirmar que hay un déficit de acciones en cuanto a pautas de prevención que proteja a los usuarios de posibles riesgos. en cuanto a la actitud personal frente al riesgo hospitalario, se encontró que la actitud menos favorable está en la región amazónica y la que genera menor riesgo está en las regiones andina y orinoquía. en su orden, los ítems que reflejan mayor percepción del riesgo son la observación de los lugares nuevos (29,5 % con respuesta negativa); la confianza en el personal que lo atiende (27,8 % con respuesta negativa); la solicitud de apoyo frente al riesgo (25,9 % con respuesta negativa); la vigilancia frente a riesgos en el lugar de permanencia (con 22,7 % de respuesta negativa); la capacidad para manejar condiciones y eventualidades de la hospitalización (18 % de respuesta negativa); la proactividad para minimizar riesgos (16,03 % de respuesta negativa), y el acatamiento de las recomendaciones de seguridad (16,02 % de respuesta negativa) (tabla 3). al comparar las variables de la caracterización y las categorías conocimiento, pautas de prevención y actitud personal frente al riesgo, se encontró que existe relación entre algunas de ellas. así, se asociaron con un mayor riesgo en la categoría conocimiento el bajo nivel educativo, la mayor edad, la disponibilidad de servicios en la región de residencia y el estado civil sin compañero permanente. es decir, las personas con menor nivel educativo, mayores de 78 años, que residen en la región del pacífico y son viudos son quienes presentan los resultados más bajos en cuanto a conocimiento de su situación y riesgos en salud. las pautas de prevención se relacionaron de manera negativa con las malas condiciones del lugar de residencia y la ocupación independiente. la actitud personal frente al riesgo se relacionó con la región donde vive y la ocupación. por ejemplo, los pacientes residentes en la región pacífica y con ocupación como trabajador independiente son los que menor califican en actitud personal frente al riesgo (tabla 4). con respecto al riesgo materializado, este evalúa la ocurrencia de eventos adversos y la percepción de riesgo de que sucedan desde la perspectiva de los pacientes. en relación con los eventos adversos de mayor frecuencia, más del 20 % de los pacientes afirma haber sufrido una caída y haber tenido flebitis durante la hospitalización, y menos del 10 % afirma haber tenido un retiro accidental de dispositivos o haber sido confundido con otro paciente. por otra parte, en cuanto a la percepción del riesgo, los pacientes señalan haber percibido mayor riesgo de ocurrencia durante la hospitalización con respecto a las caídas y las flebitis, con valores cercanos al 30 %. los que menos perciben son el ser confundido con otro paciente, el retiro accidental de dispositivos y las úlceras por presión (tabla 5). 60 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 tabla 2. distribución porcentual de personas con enfermedad crónica participantes, según pautas de prevención ítem amazonía (%) andina (%) caribe (%) orinoquía (%) pacífico (%) nacional (%) ha recibido pautas respecto a las reglas y procedimientos de seguridad durante su hospitalización nunca 96,77 16,18 11,11 3,45 32 20,30 algunas veces 0,00 18,12 20,00 18,97 40 18,38 casi siempre 3,23 30,74 42,22 36,21 16 29,91 siempre 0,00 34,95 26,67 41,38 12 31,41 recibe respuesta oportuna del personal de salud frente a su llamado nunca 22,58 1,94 0,00 1,72 4 3,21 algunas veces 64,52 15,21 17,78 13,79 24 19,02 casi siempre 12,90 30,42 51,11 50,00 48 34,62 siempre 0,00 52,43 31,11 34,48 24 43,16 es identificado por su nombre por el personal de salud antes de realizar cualquier procedimiento nunca 22,58 0,65 0,00 0,00 0 1,92 algunas veces 58,06 5,83 13,33 10,34 20 11,32 casi siempre 19,35 27,18 37,78 18,97 48 27,78 siempre 0,00 66,34 48,89 70,69 32 58,97 la comunicación con el personal de salud es plena, clara y confidente nunca 64,52 1,94 2,22 0,00 0 5,77 algunas veces 22,58 9,71 17,78 6,90 28 11,97 casi siempre 12,90 29,13 57,78 29,31 48 31,84 siempre 0,00 59,22 22,22 63,79 24 50,43 recibió información sobre los riesgos y complicaciones de los tratamientos y procedimientos realizados durante la hospitalización nunca 22,58 11,65 8,89 5,17 8 11,11 algunas veces 70,97 16,18 22,22 15,52 16 20,30 casi siempre 6,45 31,39 31,11 22,41 48 29,49 siempre 0,00 40,78 37,78 56,90 28 39,10 observa pautas de prevención frente al riesgo del personal que lo atiende nunca 35,48 3,24 17,78 0,00 12 6,84 algunas veces 48,39 15,21 15,56 20,69 32 19,02 casi siempre 16,13 31,39 33,33 50,00 32 32,91 siempre 0,00 50,16 33,33 29,31 24 41,24 fuente: datos de la investigación, 2014. 61 percepción de condiciones de seguridad del entorno hospitalario de pacientes con enfermedad crónica en colombia l elizabeth vargas-rosero y otros tabla 3. distribución porcentual de personas con enfermedad crónica participantes, según actitud personal frente al riesgo ítem amazonía (%) andina (%) caribe (%) orinoquía (%) pacífico (%) nacional (%) usted observa con atención un lugar nuevo nunca 38,71 5,50 20 5,17 20 9,83 algunas veces 45,16 18,12 22,22 10,34 24 19,66 casi siempre 16,13 28,80 24,44 50 36 30,56 siempre 0,00 47,57 33,33 34,48 20 39,96 usted está pendiente de detectar posibles riesgos donde se encuentre nunca 32,26 4,85 15,56 0,00 16 7,69 algunas veces 48,39 12,30 17,78 6,90 20 14,96 casi siempre 19,35 29,13 40 58,62 28 33,12 siempre 0,00 53,72 26,67 34,48 36 44,23 cuando usted detecta un posible riesgo, ¿busca o pide apoyo? nunca 19,35 5,18 15,56 0,00 16 7,05 algunas veces 61,29 12,62 26,67 20,69 24 18,80 casi siempre 19,35 32,69 37,78 44,83 24 33,33 siempre 0,00 49,51 20 34,48 36 40,81 cuando detecta un posible riesgo, ¿hace algo para minimizarlo? nunca 6,45 0,97 0,00 0,00 8 1,50 algunas veces 80,65 7,77 15,56 13,79 16 14,53 casi siempre 12,90 28,80 42,22 44,83 36 31,41 siempre 0,00 62,46 42,22 41,38 40 52,56 ¿sigue (atiende oportunamente) las recomendaciones de seguridad formuladas por el personal de salud? nunca 48,39 1,94 2,22 0,00 12 5,34 algunas veces 45,16 8,09 11,11 5,2 12 10,68 casi siempre 6,45 22,01 42,22 36,2 32 25,21 siempre 0,00 67,96 44,44 58,6 44 58,76 ¿siente confianza en los profesionales que lo atienden en la hospitalización? nunca 22,58 2,91 8,89 1,7 16 5,34 algunas veces 74,19 16,50 22,22 20,7 36 22,44 casi siempre 3,23 28,80 44,44 39,7 20 29,49 siempre 0,00 51,78 24,44 37,9 28 42,74 ¿se siente capaz de manejar las condiciones y eventualidades propias de la hospitalización? nunca 25,81 1,94 11,11 0,00 0 4,06 algunas veces 67,74 7,44 17,78 13,79 20 13,89 casi siempre 6,45 30,42 33,33 70,69 48 35,04 siempre 0,00 60,19 37,78 15,52 32 47,01 fuente: datos de la investigación, 2014. 62 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 tabla 4. valor de las pruebas estadísticas de relación entre variables de la caracterización y las categorías conocimiento, pautas de prevención y actitud personal frente al riesgo tabla 5. distribución porcentual de personas con enfermedad crónica participantes, según ocurrencia o percepción de riesgo de eventos adversos variable de caracterización prueba estadística realizada valor de p en cada categoría de percepción de seguridad analizada conocimiento pautas de prevención actitud personal frente al riesgo sexo mann-whitney 0,888 0,073 0,053 nivel educativo kruskal-wallis menor de 0,001 0,888 0,491 edad 0,005 0,730 0,570 región menor de 0,001 menor de 0.001 menor de 0,001 estado civil 0,046 0,592 0,107 ocupación 0,550 0,003 menor de 0,001 fuente: datos de la investigación, 2014. ítem amazonía (%) andina (%) caribe (%) orinoquía (%) pacífico (%) nacional (%) caídas no 67,74 89,00 62,22 36,21 96,00 78,85 sí 32,26 11,00 37,78 63,79 4,00 21,15 sin riesgo 67,74 78,64 51,11 50,00 64,00 70,94 con riesgo 32,26 21,36 48,89 50,00 36,00 29,06 úlceras por presión no 96,77 90,29 95,56 77,59 96,00 89,96 sí 3,23 9,71 4,44 22,41 4,00 10,04 sin riesgo 93,55 85,76 95,56 79,31 92,00 86,75 con riesgo 6,45 14,24 4,44 20,69 8,00 13,25 reacción adversa a medicamentos no 67,74 86,41 84,44 79,31 88,00 84,19 sí 32,26 13,59 15,56 20,69 12,00 15,81 sin riesgo 67,74 81,55 75,56 81,03 68,00 79,27 con riesgo 32,26 18,45 24,44 18,97 32,00 20,73 administran medicamentos fuera del horario no 61,29 92,23 82,22 79,31 88,00 87,39 sí 38,71 7,77 17,78 20,69 12,00 12,61 sin riesgo 61,29 87,70 80 86,21 68,00 83,97 con riesgo 38,71 12,30 20 13,79 32,00 16,03 63 percepción de condiciones de seguridad del entorno hospitalario de pacientes con enfermedad crónica en colombia l elizabeth vargas-rosero y otros ítem amazonía (%) andina (%) caribe (%) orinoquía (%) pacífico (%) nacional (%) retiro o desplazamiento involuntario de dispositivos médicos no 70,97 90,94 97,78 91,38 96,00 90,60 sí 29,03 9,06 2,22 8,62 4,00 9,40 sin riesgo 70,97 83,82 97,78 100,00 88,00 86,54 con riesgo 29,03 16,18 2,22 0,00 12,00 13,46 infecciones intrahospitalarias no 64,52 84,14 88,89 98,28 96,00 85,68 sí 35,48 15,86 11,11 1,72 4,00 14,32 sin riesgo 58,06 77,99 80,00 100,00 84,00 79,91 con riesgo 41,94 22,01 20,00 0,00 16,00 20,09 flebitis no 61,29 76,70 77,78 91,38 76,00 77,56 sí 38,71 23,30 22,22 8,62 24,00 22,44 sin riesgo 61,29 68,61 77,78 94,83 68,00 72,22 con riesgo 38,71 31,39 22,22 5,17 32,00 27,78 ser confundido con otro paciente no 100,00 93,20 100,00 93,10 100,00 94,66 sí 0,00 6,80 0,00 6,90 0,00 5,34 sin riesgo 93,55 89,00 95,56 93,10 92,00 90,60 con riesgo 6,45 11,00 4,44 6,90 8,00 9,40 fuente: datos de la investigación, 2014. a la pregunta de percepción global de seguridad, los pacientes en su mayoría respondieron sentirse seguros (86,3 %), con percepciones más altas en la región andina (94,8 %), el caribe (93,3 %) y la orinoquía (93,1 %), y las más bajas en la región amazónica (6,45 %) y pacífica (52 %). por último, con base en la prueba chi cuadrado, se buscó asociación entre la percepción global de seguridad y las características sociodemográficas, pero no se encontró ninguna significativa (valores de p reportaron para sexo: 0,79; para edad: 0,16; y para escolaridad: 0,34.), por lo cual no se puede llegar a ningún análisis en particular. discusión por sexo, este estudio reflejó un mayor número de mujeres enfermas en colombia y en todas sus regiones. por edad, el grupo mayoritario está entre los 36 y los 74 años, y el nivel de escolaridad es bajo. estas condiciones hacen vulnerables a las personas, puesto que, por una parte, el género femenino se asocia con menor reporte de sintomatología y menor credibilidad de los profesionales de salud y la educación ha sido asociada con la prevención de las ec y sus complicaciones, pues se señala una relación positiva entre el nivel educativo y la conducta preventiva (20,21). el nivel de escolaridad ha mostrado una relación inversa con la prevalencia de obesidad, hipertensión y diabetes, lo que se traduce en un mayor promedio de factores de riesgo de ec en grupos educación básica y media incompleta (22). la procedencia urbana en estos pacientes es seis veces mayor que la procedencia rural, lo que excede la proporción nacional en la zona urbana (23). si bien se ha visto relacionado el sitio de vivienda con el tipo de enfermedad de los pacientes (24), también se puede suponer que algunos se deben desplazar a la zona urbana para atender con mayor facilidad el cuidado de su salud. en cuanto al estado civil, un poco más de la mitad del grupo analizado no vive con compañero permanente, lo cual puede 64 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 explicarse porque las mujeres, mayoría en este caso, viven más que los hombres; pero también porque el matrimonio es un factor protector para los hombres y no para las mujeres (25). con respecto a la ocupación, dos terceras partes de este grupo no identifican tener alguna. otros autores han documentado la asociación entre ec y ausencia de trabajo remunerado (26) y discapacidad y disminución de la productividad (27). de hecho, los años de vida productiva son parte central de las medidas de carga general para la ec (28-30). es preciso recordar que la mitad de estas personas tiene más de tres años enferma, casi la tercera parte tiene una afectación en su funcionalidad y que la cuarta parte tiene una alteración cognitiva. dentro de su condición de salud, en este estudio, para todas las regiones, se reportó una mayor frecuencia de enfermedades cardiovasculares, metabólicas y cáncer, lo que coincide con informes de la organización mundial de la salud (31). en este grupo de personas, mientras que un 10 % de los pacientes no identifica un cuidador, del grupo restante la mitad identifica tener uno, y la otra mitad, más de un cuidador. de los cuidadores, la mitad cuida más de siete horas y el 12 % lo hace de forma permanente. tener un cuidador redimensiona la experiencia de la enfermedad, en especial cuando se genera un vínculo de díada (32). para el cuidador, la experiencia también puede ser transformadora; sin embargo, la cantidad de horas de cuidado requeridas puede ser un indicador de lo desgastante que puede resultar (33). la dedicación exclusiva a los cuidados por parte del cuidador implica una restricción de su vida social, y si a esto se suman situaciones de menor funcionalidad de la persona a quien se cuida, se experimenta mayor carga y sentimientos de depresión, lo cual termina repercutiendo en la persona con ec (34). al comparar la forma como las personas con ec evalúan el bienestar, se evidencia que son calificados, de mejor a peor, el bienestar espiritual, el social, el psicológico y el físico, con mayor calificación positiva que negativa en todos los casos. los pacientes sienten que reciben apoyo psicológico en el 42,8 % de los casos, y el 40 % se encuentra satisfecho con este apoyo. reciben apoyo familiar en el 90,4 % y el 84,5 % se encuentra satisfecho con este. hay apoyo religioso para el 55,8 % y un 65,9 % se encuentra satisfecho con este. cuentan con apoyo económico el 62,1 % de los encuestados, y un 60,8 % se encuentra satisfecho. hay apoyo social en el 58,8 %, con esta misma cantidad de personas satisfechas. el 42,9 % se siente una carga y el 20,8 % considera que es una carga alta o muy alta. al respecto, debe recordarse que se ha señalado la relación entre carga, calidad de vida, bienestar y salud (35). por otra parte, se ratifica en varios estudios que las familias dan mayor y mejor apoyo a sus seres queridos durante los procesos de enfermedad (36). con respecto a las tic, son la radio y la televisión las de mayor apropiación, seguidas por el teléfono; sin embargo, es en el computador en el que las personas, a pesar de no conocer, no tener suficiente acceso y no frecuentar su uso, consideran que es más útil como herramienta de cuidado. estos hallazgos ratifican planteamientos del análisis de las tic con población colombiana (37). en cuanto a la percepción de seguridad en el entorno hospitalario, diversas investigaciones han demostrado que existe una asociación positiva entre el grado de conocimiento de los pacientes sobre su condición de salud y un mejor seguimiento de los tratamientos y recomendaciones que realiza el equipo que lo atiende. los pacientes pueden ser capacitados para participar en el cuidado de su condición de ec, a fin de mejorar el control de la situación, disminuir la posibilidad de reingreso hospitalario y, en general, de los riesgos a los que pueden estar expuestos (38-46). dentro de los derechos fundamentales del paciente se encuentra el de recibir información completa sobre su diagnóstico, tratamiento y pronóstico (47). conocer sus deberes y derechos le permitirá al paciente estar no solo al tanto para exigirlos, sino ser consciente de su participación y responsabilidad en la recuperación de su salud. así es como se ha definido por norma, en diferentes países, que todas las entidades promotoras de salud deben publicar y difundir entre sus afiliados la carta de derechos del paciente; un ejemplo de ello es la normativa colombiana (48). en la práctica, para mitigar o evitar los riesgos, es fundamental que el paciente reciba tal información y, además, que se verifique su comprensibilidad. en cuanto al conocimiento de los riesgos, con frecuencia, los pacientes no perciben con facilidad aquellos a los que se encuentran expuestos durante una hospitalización, en parte porque ingresan a las instituciones con la esperanza de la recuperación y se sienten seguros al ser atendidos por personal especializado que presume cómo tratar sus dolencias, sin imaginar que pue65 percepción de condiciones de seguridad del entorno hospitalario de pacientes con enfermedad crónica en colombia l elizabeth vargas-rosero y otros dan verse expuestos a riesgos durante el proceso de la atención hospitalaria (49). los pacientes se sienten más seguros cuando evidencian que el personal que los atiende, en especial el de enfermería, es atento, predecible y sensible e interactúa con ellos en el plano personal y aboga a su favor (50). con respecto a las pautas de prevención, la actitud se ha definido de diferentes maneras. desde la psicología social, por lo general, se ve como la predisposición aprendida a responder de un modo consistente a un objeto social, por lo que se constituye en un elemento valioso para la predicción de conductas. se reconocen tres componentes de las actitudes: el cognoscitivo, el afectivo y el conductual. así, frente a los riesgos en salud, se espera que los pacientes asuman actitudes de prevención y acción sobre estos, de modo que logren identificarlos, prevenirlos, controlarlos y obtener la ayuda que requieren en el momento oportuno. la capacidad de observación y atención debe recordarse y fortalecerse en pacientes, de modo que puedan advertirse los riesgos, de forma especial cuando las personas se encuentran en un ambiente diferente al habitual. de la confianza que sientan las personas para comunicarse dependerá en gran medida el que obtenga una atención oportuna y se ejerza control de los riesgos identificados. como parte de las acciones conducentes a minimizar los riesgos, resulta importante y muy efectivo advertir a los pacientes acerca de la exposición real a los riesgos y su materialización, bien sea como incidente o como evento adverso. poner en conocimiento e indagar sobre la ocurrencia de algunos de los eventos adversos más comunes durante la atención en salud es una estrategia clave para prevenirlos. esta investigación mostró que tanto en la percepción de riesgo como en el riesgo materializado las caídas y la flebitis son significativas. no obstante, estos riesgos son prevenibles y controlables. hay evidencia importante para señalar que es posible y necesario el manejo de errores en la identificación de los pacientes (51), caídas (52), errores en la administración de medicamentos (53), úlceras por presión (54), flebitis (55), infecciones intrahospitalarias (56), retiro accidental y desplazamiento de dispositivos médicos. si bien el fenómeno de la seguridad es complejo y en este inciden las diversas condiciones relacionadas con el paciente, la familia y el contexto hospitalario, cuando estas son evaluadas, pueden abordarse mejor. en especial, la percepción global de seguridad da una mirada integral; además, los resultados de esta percepción deben analizarse de forma particular para cada uno de los contextos en los que se explore, dado que el sentirse seguro puede constituirse en un factor riesgo para la ocurrencia de eventos adversos, toda vez que los pacientes estarían poco atentos a identificarlos y controlarlos. este estudio muestra cómo la materialización de los riesgos o los eventos adversos son, en algunos casos, inversos a la percepción de seguridad relacionada con el conocimiento, las pautas de prevención y la actitud personal. conclusiones la evaluación de la percepción de condiciones de seguridad en el entorno hospitalario por parte de los pacientes es esencial para aliviar la carga de la ec en colombia. a partir de esta evaluación, se buscó conocer el modo en que se expresan cada uno de los elementos que conforman las percepciones de los pacientes sobre seguridad, las cuales se enfocan en aspectos de conocimiento de la situación salud, pautas de prevención, actitud personal frente al riesgo, riesgo materializado y percepción global de seguridad. de acuerdo con los resultados, en cuanto a las tres primeras categorías, para los pacientes del estudio deben fortalecerse los aspectos referidos al conocimiento de los riesgos a los que se pueden ver expuestos durante una hospitalización, ya que el saber cómo actuar e informarse sobre los deberes y derechos de los pacientes los hace menos vulnerables. esta recomendación, aunque es general, debe fortalecerse en hombres de más de setenta años de edad, baja escolaridad, viudos y, en especial, en quienes residan en la región del pacífico, pues la comparación entre los diferentes grupos de variables permitió establecer una relación entre ellas, que definió este como el perfil con mayor riesgo. respecto a los eventos adversos, los pacientes coinciden en afirmar que las caídas son el evento que con mayor frecuencia se presenta, pues supera el 20 % de toda la muestra. este evento adverso puede acompañarse de otros que dificultan aún más la recuperación de las personas con ec. en este sentido, una asociación que se encontró con relativa frecuencia fue la de caídas con flebitis y flebitis con infecciones intrahospitalarias. por tanto, la percepción del riesgo de que ocurran eventos adversos para los pacientes se debe priorizar en cuanto a caídas, flebitis e infecciones. 66 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 la percepción global de seguridad fue positiva para la gran mayoría de pacientes, lo cual puede tener dos lecturas. la primera, que los pacientes tienen confianza en que los profesionales que laboran en las instituciones los ayudan a controlar los posibles riesgos; la segunda, que aún no son conscientes de la verdadera posibilidad de estar frente a riesgo en el ambiente hospitalario. por último, la evaluación de algunos aspectos sobre la percepción de seguridad en el ambiente hospitalario por parte de los pacientes arroja resultados llamativos, por cuanto, de forma general, las regiones andina y caribe muestran resultados más positivos que las demás. sin embargo, la amazonía, la orinoquía y el pacífico muestran mayores dificultades en el conocimiento y prácticas que favorezcan un cuidado seguro de sus usuarios. ratifican estos 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[citado 13 nov 2014]. disponible en: http://www.who.int/gpsc/country_work/burden_hcai/es/ 56. cardozo c, filosi al, franconerí r, petkovich mc, silva h. evaluación de la seguridad del paciente mediante criterios internacionales en un servicio de emergencia [internet]. tesis de grado, universidad de la república del uruguay, montevideo; 2009. disponible en: https://www.colibri.udelar.edu.uy/handle/123456789/2500 52 59 analisis evolutivo del concepto.indd 52 josé martín castro-espinoza1 esther c. gallegos-cabriales2 keville frederickson3 análisis evolutivo del concepto de adaptación a la diabetes tipo 2 1 doctor en ciencias de enfermería, instituto de servicios de salud pública del estado de baja california (méxico). martincastroe@hotmail 2 profesor de tiempo completo, doctorado en ciencias de enfermería, universidad autónoma de nuevo león (méxico). 3 doctor in nursing science program, the graduate center, the city university of new york, new york (usa). recibido: 31 de octubre de 2013 enviado a pares: 20 de noviembre de 2013 aceptado por pares: 15 de julio de 2014 aprobado: 10 de septiembre de 2014 doi: 10.5294/aqui.2015.15.1.6 para citar este artículo / to reference this article / para citar este artigo castro-espinoza jm, gallegos-cabriales ec, frederickson k. análisis evolutivo del concepto de adaptación a la diabetes tipo 2. aquichan. 2015;15(1):52-59. doi: 10.5294/ aqui.2015.15.1.6 resumen el concepto de adaptación tiene diferentes aplicaciones y acepciones. en personas que viven con diabetes tipo 2 (dt2) se asocia con la observancia del tratamiento y el control glucémico. es utilizado frecuentemente en la literatura de salud, pero no está claro qué significa en personas que viven con esta enfermedad, por lo que el propósito de esta investigación fue analizar el concepto de adaptación a la dt2. metodología: se utilizó el método de análisis evolutivo de concepto de rodgers. los datos se codificaron por autor, 16 en total, palabras clave, hallazgos, antecedentes, atributos y consecuencias, conceptos relativos y sustitutos. la guía del análisis respondió a tres preguntas: ¿cómo define el concepto el autor? ¿qué características o atributos se establecen? ¿qué idea da el autor acerca del concepto? resultados: el concepto de adaptación muestra atributos que permiten definirlo como un proceso que se presenta en tres fases: reacción, asimilación y respuesta. los antecedentes corresponden a conductas previas al proceso, los resultados incluyen desafíos y cambios. conclusiones: los atributos, los antecedentes y las consecuencias ofrecen guías para la investigación; es necesario ampliar el estudio en el contexto del hogar, la familia, el trabajo y el hospital. palabras clave formación de concepto, adaptación, atributos de enfermedad, diabetes mellitus, enfermería (fuente: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 52-59 53 análisis evolutivo del concepto de adaptación a la diabetes tipo 2 l josé martín castro-espinoza, esther c. gallegos-cabriales, keville frederickson año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 52-59 evolutionary analysis of the concept of adaptation to type 2 diabetes abstract the concept of adaptation has different applications and meanings. in persons who live with type 2 diabetes (t2d), it is associated with treatment adherence and glycemic control. it is used frequently in health literature, but it is unclear what it means to those living with the disease. accordingly, the purpose of this study was to analyze the concept of adaptation to t2d. method: rogers’ evolutionary concept analysis was the method used. the data were coded by author (16 in total), key words, findings, antecedents, attributes, consequences, and surrogate and relative concepts. the analysis guide answered three questions: how the author defines the concept? what features or attributes are established? what idea does the author provide about the concept? findings: the concept of adaptation has attributes that enable it to be defined as a process that occurs in three phases: reaction, assimilation and response. the antecedents pertain to preprocess behavior, while the results include challenges and changes. conclusions: the attributes, antecedents and consequences offer guidelines for research. it is necessary to broaden this research to include the context of home, family, work and the hospital. keywords concept formation, adaptation, attributes of disease, diabetes mellitus, nursing (source: mesh, bireme). 54 aquichan issn 1657-5997 análise evolutiva do conceito de adaptação à diabete tipo 2 resumo o conceito de adaptação tem diferentes aplicações e acepções. em pessoas que vivem com diabete tipo 2 (dt2), se associa com a observância do tratamento e o controle glicêmico. é utilizado frequentemente na literatura de saúde, mas não está claro o que significa em pessoas que vivem com essa doença; por isso, o propósito desta pesquisa foi analisar o conceito de adaptação à dt2. metodologia: utilizou-se o método de análise evolutiva de conceito de rodgers. os dados se codificaram por autor (16 em total), palavras-chave, antecedentes, atributos e consequências, conceitos relativos e substitutos. o guia da análise respondeu a três perguntas: como o autor define o conceito? que características ou atributos são estabelecidos? que ideia o autor dá sobre o conceito? resultados: o conceito de adoção mostra atributos que permitem defini-lo como um processo que se apresenta em três fases: reação, assimilação e resposta. os antecedentes correspondem a condutas prévias ao processo; os resultados incluem desafios e mudanças. conclusões: os atributos, os antecedentes e as consequências oferecem guias para a pesquisa. é necessário ampliar o estudo no contexto do lar, da família, do trabalho e do hospital. palavras-chave formação de conceito, adaptação, atributos de doença, diabete mellitus, enfermagem (fonte: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 52-59 55 análisis evolutivo del concepto de adaptación a la diabetes tipo 2 l josé martín castro-espinoza, esther c. gallegos-cabriales, keville frederickson introducción la adaptación es un proceso y un resultado que marca la pauta para una transformación, ajuste, conformación o equilibrio. en el caso de una enfermedad crónica, se origina a partir de que la persona es diagnosticada y tiene que afrontar las alteraciones que se presentan en las dimensiones biológicas, psicológicas y sociales, en búsqueda de la modificación de las condiciones en que interactúa con el medioambiente. dobzhanky fue el primero en describir la adaptación como un proceso evolutivo, por medio del cual un organismo busca mejores condiciones para vivir en un medioambiente determinado (1, 2). el concepto de adaptación tiene diversas aplicaciones y acepciones; por ejemplo, la modificación de un objeto o mecanismo para que cumpla una función diferente de aquella para la que fue construido. en personas que viven con diabetes tipo 2 (dt2), la adaptación se refleja en la observancia del tratamiento y, consecuentemente, en un buen control glucémico (3); este proceso se origina a partir de que la persona es diagnosticada con dt2 y tiene que afrontar la enfermedad y las alteraciones que se presentan con esta. la dt2 se define como “un grupo de enfermedades metabólicas caracterizadas por hiperglucemia como resultado de los defectos en la secreción y/o acción de la insulina, o ambos” (4). para callista roy (5), la adaptación es el proceso y resultado por medio del cual la persona utiliza la conciencia para crear una integración con el medioambiente donde vive o se desenvuelve. la adaptación es un concepto utilizado frecuentemente en la literatura de salud. sin embargo, no está claro qué significa en personas con dt2, por lo que es importante analizar el concepto para entender qué experimentan las personas durante este proceso a fin de facilitarlo (6). la utilidad de saber cómo se ha conceptualizado la adaptación a la dt2 radica en que si esta se analiza, se clarifica y sus definiciones están articuladas y entendidas, es posible explicar y caracterizar cómo se da el fenómeno. el propósito de esta investigación documental fue analizar el concepto de adaptación a la dt2, según se expresa en la literatura de salud, para lo que se utilizó el método de análisis evolutivo del concepto propuesto por rodgers (6). esta metodología sugiere un análisis sistemático, de acercamiento inductivo, y se puede reflexionar que la adaptación a la dt2 y la generación de su conocimiento se expanden o cambian (p. ej. debido al rol de la genética o el medioambiente). materiales y métodos el propósito de este trabajo fue analizar el uso del concepto de adaptación a la dt2. para el diseño de este análisis se utilizó el método evolutivo de rodgers (6) porque es apropiado para entender el desarrollo, el uso, la aplicación y el significado del concepto de adaptación a la dt2 en la práctica e investigación de enfermería. este método consiste en la identificación de términos sustitutos y usos relevantes del concepto, identificar y seleccionar una muestra adecuada con un mínimo de 20 % de la literatura encontrada, utilizar un enfoque sistemático, reconocer los atributos del concepto, identificar los antecedentes y las consecuencias del mismo, y, de ser posible, identificar conceptos relacionados y un caso modelo del concepto, si esto fuere apropiado (tabla 1). selección de la muestra se realizó una búsqueda electrónica utilizando las bases de datos ebsco host (medline, health source and nursing academic edition, cumulative index of nursing and allied health, psychology and behavioral sciences collection y socindex) y la base de datos scielo. la búsqueda se limitó a los idiomas español e inglés. se utilizaron los descriptores adaptación y diabetes en títulos y palabras clave, en español e inglés, lo cual arrojó más de 2632 artículos. después, se procedió a limitar la búsqueda de artículos por años de publicación a los años 2001 y 2012, reduciendo el número ya que en este proceso se obtuvo una muestra de 45 referencias. en el análisis no fueron incluidos editoriales, tesis doctorales y libros, y solamente las referencias primarias centradas en adaptación a la diabetes fueron retenidas. del total de 45 artículos, después de haber sido leídos minuciosamente, se eliminaron aquellos centrados en niños, adolescentes o diabetes tipo 1, así como los artículos centrados en probar instrumentos de adaptación a la dt2. se conservaron dos artículos clásicos acerca de adaptación escritos por enfermeras y tres más referentes a conceptos sustitutos y conceptos relacionados. aunque rodgers (6) sugiere mantener el 20 % de los hallazgos para darle sustento, en este caso se mantuvieron todos los que cumplieron los requisitos de tratarse de persona adultas viviendo con dt2, por ser una muestra pequeña. finalmente, en el análisis se incluyeron 16 artículos. en este asunto en particular, el caso modelo se consideró opcional, como lo menciona la autora del método evolutivo de análisis de concepto (6) y no se elaboró. 56 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 análisis y recolección de datos se elaboró una base de datos con las referencias, en la que se incluyó codificación por autor, palabras clave, tamaño de muestra y metodología, hallazgos, antecedentes, atributos y consecuencias identificadas, así como conceptos relativos y sustitutos. la guía del análisis respondió a tres preguntas: ¿cómo define el autor el concepto? ¿qué características o atributos establece? ¿qué idea da o discute el autor acerca del concepto? (7). los datos fueron analizados buscando los principales antecedentes, consecuencias y atributos del concepto. resultados identificación de atributos “la identificación de los atributos del concepto representa la primera parte de la realización del análisis” (6), y constituye la definición del fenómeno o concepto que lo hace diferente de otros. después de la revisión de la literatura, los hallazgos de este análisis de concepto mostraron siete atributos para la adaptación a la dt2: aceptación, reconocimiento, ajuste, afrontamiento, efectividad, eficiencia y resistencia. los atributos se resumen en la tabla 2 y cada uno es descrito en seguida. aceptación. es una respuesta adaptativa, representada por la tendencia de la persona a presentar perfiles positivos de adaptación (8). reconocimiento. es una fase de reacción en una respuesta adaptativa, en la que se utilizan estrategias de solución (8). ajuste. es la adaptación psicosocial, representada por estrategias utilizadas por el individuo en la solución de problemas. es una habilidad para obtener satisfacción y cohesión con el tratamiento, la apariencia y las actividades. en otras palabras, es la efectividad de las conductas ante un estresor o un estímulo (8-10). afrontamiento. es un proceso descrito como demandas ante situaciones de la vida diaria e incluye estrategias externas e internas. el individuo suele utilizar tres tipos de estrategias de afrontamiento para aceptar la realidad de la enfermedad y reestructurar el medioambiente —respuestas confrontativas, emotivas y paliativas—, por lo que el afrontamiento también es definido como lo que se hace acerca de una situación de adaptación (11-13). efectividad. es el uso de estrategias confrontativas para una adaptación adecuada, para aceptar la realidad de la enfermedad, reorganizar y reestructurar el medioambiente, de modo que haya significado y propósito en la vida, una vida de calidad que va más allá de las limitaciones impuestas por la enfermedad (14). eficiencia. es un proceso basado en la modificación progresiva de estructuras cognitivas para la transformación de conductas de autocuidado en resultados de salud. es también, el entendimiento de factores personales y el contexto psicosocial (soporte social) a fin de lograr una orientación positiva en actividades de autocuidado para afrontar los desajustes de la dt2 (15, 16). resistencia. es un conjunto específico de actitudes hacia los desafíos y el control de las respuestas mediadoras del estrés a la enfermedad crónica, en este caso, la dt2 (17). identificación de antecedentes y consecuencias de la adaptación a la dt2 el siguiente paso en el proceso del método evolutivo de análisis de concepto de rodgers es un examen de los antecedentes y las consecuencias del concepto ya que si se exploran sus aspectos contextuales, esta opción facilita el entendimiento de la situación en la cual se utilizó el concepto en diferentes situaciones y desde perspectivas potencialmente distintas (6). los antecedentes son los factores que más están presentes para que el fenómeno ocurra (6), identificándose en el concepto de adaptación a la dt2 los siguientes: conductas, confrontamiento, medioambiente y fortaleza. la conducta se describe como la efectividad de esta noción per se, manifestada en adaptativa o ineficaz, como resultado de un proceso activo por medio del cual el organismo se ajusta al medioambiente. el medioambiente actúa como un factor de influencia en la respuesta. el confrontamiento es utilizar la información recabada o disponible acerca de la enfermedad cuando se presentan las manifestaciones de desajustes de la misma. la fortaleza forma parte de la calidad de afrontamiento y se manifiesta en una mejor adaptación a la enfermedad. rodgers (6) menciona que las consecuencias se presentan como resultado de la propia ocurrencia del fenómeno. los hallazgos de este trabajo muestran seis consecuencias importantes de 57 análisis evolutivo del concepto de adaptación a la diabetes tipo 2 l josé martín castro-espinoza, esther c. gallegos-cabriales, keville frederickson ser consideradas. cuatro en sentido positivo: desafíos, cambios, control glucémico manifestado en la medición aceptable de hemoglobina glucosilada (a1c), automanejo (adherencia al tratamiento, aptitud, calidad de vida, ejercicio, peso y talla), y dos en sentido negativo: depresión y estrés. los desafíos implican el desarrollo de estrategias para manejar efectivamente todos los cambios en la adaptación a la dt2. las personas que viven con dt2 necesitan realizar cambios en sus conductas de salud para lograr los requerimientos de autocuidado, en este rubro se reconocen consecuencias como: control glucémico y mantener un óptimo nivel de salud física y es medido o manifestado en un aceptable manejo de a1c y en un buen control metabólico. el automanejo incluye el autocuidado, como cambios en las propias conductas de salud que son influenciadas por el medioambiente. se incluyen en estas consecuencias la adherencia, referida como una mayor adaptación a la enfermedad; la aptitud, como salud deseable a través de prácticas de cuidado como ejercicio, mantenimiento de peso adecuado, calidad de vida y reducción de riesgos. finalmente, es importante tener en consideración el estrés y la depresión, descritos como factores de influencia o estímulos que pueden tener consecuencias negativas en los resultados de salud. conceptos sustitutos y conceptos relacionados nuestra búsqueda en la bibliografía muestra algunos conceptos relacionados con el término adaptación, que son utilizados indistintamente: ajuste, resultados y afrontamiento. los términos resiliencia y conducta son utilizados como conceptos relativos a la adaptación. por otra parte, control, ajuste y afrontamiento son utilizados como conceptos sustitutos a la adaptación por los autores revisados. en el uso del concepto de afrontamiento estos hacen referencia a la definición de lazarus y folkman o bien a la definición de peyrot y mccurry. los autores revisados al utilizar el concepto de control, hacen referencia a la definición de thompson (18-20). discusión para describir el concepto de adaptación se utilizan varios términos indistintamente, pero estos no están ampliamente definidos en su uso. para obtener un óptimo avance en el entendimiento del uso del concepto de adaptación a la dt2 en adultos es necesario tener una definición consensual. el concepto de adaptación no solo tiene respuestas adaptativas o ineficaces como resultado de un estímulo o conducta, sino que se puede manifestar en diferentes niveles como adaptación integrada, compensatoria o comprometida. el concepto es multifacético e integra múltiples procesos y etapas en sus atributos, antecedentes y consecuencias. los atributos permiten analizar la adaptación como un proceso que se presenta en tres fases: reacción, asimilación y respuesta. en la reacción se reconoce la presencia de la dt2; la asimilación integra aceptación, fortaleza y eficiencia; la respuesta se compone por las estrategias de afrontamiento, ajuste y efectividad de la respuesta. los antecedentes que se identificaron correspondieron a conductas que se presentan previas al proceso a través del cual el organismo responde ajustándose o no a las influencias del medioambiente, recurriendo a la información recabada o disponible acerca de la enfermedad. en cuanto a los resultados, se incluyen desafíos como el desarrollo de estrategias para efectuar todos los retos ante la presencia de la dt2, cambios que se manifiestan en modificaciones de conductas de salud o en los estilos de vida, adherencia medicamentosa y un aceptable control glucémico. conclusión el análisis evolutivo del concepto de adaptación a la dt2 señala que este hace referencia al proceso mediante el cual las personas afrontan, aceptan y se ajustan afectivamente, con habilidad y apoyo social a la dt2, en respuesta a estresores del medioambiente interno y externo; esta adaptación se manifiesta en un buen control metabólico, en óptimos niveles de control glucémico y en habilidades para el automanejo de la enfermedad. se concluye que las implicaciones de este análisis de concepto son tres: primero, los propios atributos, antecedentes y consecuencias ofrecen guías para futuras investigaciones y para la práctica de la enfermería. segundo, es necesario ampliar la investigación acerca del uso del concepto de adaptación a la dt2 en el contexto del hogar, la familia, el trabajo y el hospital, pues 58 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 diferentes perspectivas pueden modificar su apreciación probablemente por influencia de factores ambientales. tercero, la revisión y clarificación del concepto de adaptación a la dt2 genera conocimiento útil para la disciplina de enfermería. tabla 1. pasos del método de análisis evolucionario de concepto rodgers • identificar los conceptos de interés. • identificar términos sustitutos y usos relevantes del concepto. • identificar y seleccionar una muestra adecuada con un mínimo de 20 % de la literatura examinada de la disciplina correspondiente, utilizando un enfoque sistemático. • identificar los atributos del concepto. • identificar las referencias, los antecedentes y las consecuencias el concepto. si es posible, identificar conceptos relacionados. • identificar un caso modelo del concepto (si es apropiado). nota: el proceso no está numerado porque es iterativo y cíclico (6). tabla 2. atributos identificados para adaptación a la dt2 en orden de aparición en el análisis 1. aceptación: respuestas adaptativas que contribuyen plenamente a la adaptación psicosocial (9). 2. reconocimiento: es una fase de reacción en una respuesta adaptativa (9). 3. ajuste: reacción adaptativa en la adaptación psicológica. habilidad para obtener satisfacción y cohesión con el tratamiento, la apariencia y las actividades. efectividad de las conductas ante un estresor o estímulo (9, 10). 4. afrontamiento: demandas en la vida diaria; incluyen estrategias innatas o adquiridas en la adaptación psicosocial. el individuo utiliza tres tipos para aceptar la realidad de la enfermedad y reestructurar el medio ambiente: confrontativas, emotivas y paliativas; es el qué hago ante una situación determinada (10-12). 5. efectividad: uso de estrategias confrontativas que ayudan a la adaptación (12). 6. eficiencia: proceso basado en la modificación progresiva de estructuras cognitivas y conductuales; factores personales y contexto psicosocial que brinda orientación positiva en actividades de autocuidado (14, 15). 7. fortaleza: conjunto específico de actitudes hacia el desafío, compromiso y control que media las respuestas al estrés (10). 59 análisis evolutivo del concepto de adaptación a la diabetes tipo 2 l josé martín castro-espinoza, esther c. gallegos-cabriales, keville frederickson referencias 1. dobzhansky t, hecht mk, steere wc. on some fundamental concepts of evolutionary biology. in: evolutionary biology, volume 2. new york: 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diabetes tipo 2 desde la perspectiva del autocuidado de orem 1 enfermera. doctora en ciencias de enfermería. profesora, universidad autónoma de tamaulipas, méxico. lcompean@uat.edu.mx 2 enfermera. magíster en ciencias de enfermería. profesora, universidad autónoma de tamaulipas, méxico. lquinter@uat.edu.mx 3 enfermera. magíster en ciencias de enfermería. profesora, universidad autónoma de tamaulipas, méxico. bdelange@uat.edu.mx 4 enfermera. doctora en ciencias de enfermería. profesor, universidad autónoma de tamaulipas, méxico. eresendi@uat.edu.mx 5 enfermera. phd. coordinadora, programa doctoral. universidad autónoma de nuevo león, méxico. bceci@hotmail.com 6 doctor en medicina. profesor, universidad autónoma de nuevo león, méxico. gergonz@hotmail.com recibido: 21 de marzo de 2012 enviado a pares: 1 de enero de 2013 aceptado por pares: 16 de octubre de 2013 aprobado: 22 de octubre de 2013 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 347-362 para citar este artículo / to reference this article / para citar este artigo compean-ortiz, l., quintero-valle, l. m., del á ngel-pé rez, b., resé ndiz-gonzá lez, e., et al. (2013). educación, actividad física y obesidad en adultos con diabetes tipo 2 desde la perspectiva del autocuidado de orem. aquichan. vol. 13, no. 3, 347-362. resumen objetivos: describir la relación de la actividad física (pasos/día)/ejercicio con la obesidad (índice de masa corporal, circunferencia de cintura y grasa corporal) en adultos con diabetes tipo 2. se planteó además: 1) determinar la relación de la educación/comprensión en diabetes con la actividad física/ejercicio, y 2) establecer diferencias de actividad física/ejercicio y obesidad/sobrepeso de acuerdo con variables sociodemográficas. materiales y métodos: diseño descriptivo correlacional, muestra aleatoria de 124 pacientes de 17 centros comunitarios de tampico, tamaulipas, méxico. las mediciones incluyeron: podómetro new-life style 2000, cuestionarios de autocuidado y perfil de cuidado en diabetes, imc, cc y grasa corporal. los datos se analizaron con medidas de tendencia central, correlación de spearman, prueba u de mann-whitney y kruskal wallis. resultados: el promedio de pasos/día mostró relación inversa con el imc (r s = 0,282, p < 0,01) y la cc (r s = 0,300, p < 0,01). la comprensión en diabetes tuvo relación positiva con el ejercicio (r s = 0,179, p = 0,04). las mujeres fueron quienes tuvieron mayor porcentaje de grasa corporal (p < 0,05). conclusiones: los hallazgos tienen implicaciones importantes para el ejercicio práctico de la profesión de enfermería que juega un papel esencial en el fomento de la actividad física y otros comportamientos básicos de autocuidado a través de la educación. la educación basada en teoría se hace necesaria para el avance en el conocimiento de la disciplina. palabras clave educación, actividad motora, obesidad, autocuidado, diabetes mellitus tipo 2. (decs, bireme). 348 aquichan issn 1657-5997 education, physical activity and obesity among adults with type ii diabetes from the standpoint of orem´s self-care theory abstract objectives: describe the relationship between physical activity (steps/day)/exercise and obesity (body mass index, waist circumference and body fat) in adults with type ii diabetes. the study also was intended to: 1) determine the relationship between education/ understanding of diabetes and physical activity / exercise, and 2) to identify differences in physical activity / exercise and overweight / obesity according to a set of socio-demographic variables. materials and methods: the study was descriptive and correlational in design, with a random sample of 124 patients from 17 community centers in tampico, tamaulipas, mexico. the measurements include: the new lifestyles 2000 pedometer, plus questionnaires on self-care and the diabetes care profile, bmi, wc and body fat. the data were analyzed with measures of central tendency, the spearman correlation, the mannwhitney u test and the kruskal wallis test. results: the average number of steps / day showed an inverse relationship to the bmi (r s = 0.282, p < 0.01) and wc (r s = 0.300, p < 0.01). understanding diabetes had a positive relationship to exercise (r s = 0.179, p = 0.04). those with a higher percentage of body fat were women (p < 0.05). conclusions: the findings have important implications for professional nursing practice, which plays a crucial role in promoting physical activity and other self-care behavior through education. theory-based education is necessary for the advancement of knowledge in the discipline. key words education, motor activity, obesity, self care, type ii diabetes mellitus. (source: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 347-362 349 educación, actividad física y obesidad en adultos con diabetes tipo 2 desde la perspectiva del autocuidado de orem l lidia guadalupe compean-ortiz y otros. educação, atividade física e obesidade em adultos com diabete tipo 2 a partir da perspectiva do autocuidado de orem resumo objetivos: descrever a relação da atividade física (passos/dia)/exercício com a obesidade (índice de massa corporal, circunferência de cintura e gordura corporal) em adultos com diabete tipo 2. além disso, propôs-se: 1) determinar a relação da educação/compreensão em diabete com a atividade física/exercício, e 2) estabelecer diferenças de atividade física/exercício e obesidade/excesso de peso de acordo com variáveis sociodemográficas. materiais e métodos: desenho descritivo correlacional, amostra aleatória de 124 pacientes de 17 centros comunitários de tampico, tamaulipas, méxico. as medições incluíram: pedômetro new-life style 2000, questionários de autocuidado e perfil de cuidado em diabete, imc, cc e gordura corporal. os dados foram analisados com medidas de tendência central, correlação de spearman, prova u de mann-whitney e kruskal wallis. resultados: a média de passos/dia mostrou relação inversa com o imc (rs = 0,282, p < 0,01) e a cc (rs = 0,300, p < 0,01). a compreensão em diabete teve relação positiva com o exercício (rs = 0,179, p = 0,04). as mulheres foram as que tiveram maior porcentagem de gordura corporal (p < 0,05). conclusões: as descobertas têm implicações importantes para o exercício prático da profissão de enfermagem que desenvolve papel essencial no fomento da atividade física e outros comportamentos básicos de autocuidado por meio da educação. a educação baseada em teoria se faz necessária para o avanço no conhecimento da disciplina. palavras-chave educação, atividade motora, obesidade, autocuidado, diabetes mellitus tipo 2. (fonte: decs, bireme). año 13 vol. 13 nº 3 chía, colombia diciembre 2013 l 347-362 350 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 introducción las enfermedades crónicas se han incrementado a nivel mundial desde hace algunas décadas siendo en el 2001 la causa de casi el 60 % de los 56 millones de defunciones anuales y el 47 % de la carga de morbilidad. los factores de riesgo reconocidos para desarrollarlas están directamente relacionados con una alimentación inadecuada y la falta de actividad física, que está demostrado influye directamente en la salud física y mental de las personas (1). mantener estilos de vida saludable se vuelve entonces indispensable para prevenir enfermedades crónicas, y en el caso de quien ya las padece representa un aspecto esencial para el autocuidado. una de estas enfermedades crónicas más prevalentes es sin duda la diabetes mellitus. en el 2001, aproximadamente más de 170 millones de personas la padecían y se proyectó que esta cantidad aumentaría al doble para el 2030 (2). en méxico esta enfermedad es la primera causa de mortalidad y la que consume el mayor gasto público (3); de acuerdo con las últimas estimaciones nacionales, la prevalencia total en mayores de 20 años fue de 14,42 % (4). la forma más común de la diabetes es la tipo 2 y una situación muy frecuente que coexiste es la presencia de obesidad/sobrepeso cuya prevalencia ha aumentado dramáticamente alcanzando casi al 70 % en el 2006 (5). la obesidad/sobrepeso en estas personas favorece la presencia de resistencia a la insulina y esta se asocia con el síndrome metabólico el cual, además de la hiperglucemia, se caracteriza por hipertensión arterial, dislipidemias y obesidad central (6). la obesidad se refiere a una masa excesiva de grasa corporal que se presenta cuando se consume más energía de la que se gasta en un periodo de tiempo, lo que ocasiona el aumento de peso corporal (7). el buen manejo y control de la diabetes tiene como meta el control glucémico, control de lípidos y mantenimiento del peso corporal, para lo cual la persona requiere llevar a cabo comportamientos de autocuidado básicos entre los que se destaca, en conjunto con la medicación, la alimentación y el monitoreo de glucosa sanguínea, la actividad física (8, 9). la actividad física (af) se define como cualquier movimiento producido por la contracción de los músculos esqueléticos del cuerpo que conlleva un gasto de energía presente en actividades cotidianas como caminar, trabajar y tareas domésticas (10), y es producto de una serie de conductas con rangos que van desde los movimientos leves hasta niveles de ejercicio de gran intensidad que requieren el uso de un número importante de grupos musculares; de hecho, la diferencia entre actividad física y ejercicio es que este último es un tipo de af planificada, estructurada y repetitiva. en la persona con diabetes la af es importante por los beneficios fisiológicos y psicológicos que conlleva, entre los que se encuentra la reducción del índice de masa corporal, control de la glucosa sanguínea, disminución de la resistencia a la insulina, reducción de la presión arterial, control de los lípidos y reducción del estrés (8, 9). de acuerdo con su intensidad, la af puede ser leve (caminar despacio, bicicleta estacionaria, nadar despacio, tareas domésticas simples, entre otros), moderada (caminar a paso rápido, bicicleta como transporte, nadar con esfuerzo moderado, trabajos domésticos exhaustivos), y vigorosa como caminar más rápido o trotar, bicicleta a alta velocidad, nadar rápidamente (11). la recomendación en personas con diabetes sin complicaciones es realizar actividad física aeróbica de intensidad moderada al menos 150 minutos a la semana distribuidos en al menos tres días, y si no hay contraindicaciones podría incorporarse actividad de resistencia dos veces a la semana (8). se debe cuidar que no transcurran más de dos días seguidos sin hacer actividad física (12). a pesar de los beneficios de realizar actividad física o ejercicio, la mayoría de las personas con diabetes no la hacen de manera regular (13, 14) o bien la hacen con bajos niveles (15-18). la evidencia científica señala que la caminata es la forma más recomendada de af en estos pacientes y se puede llevar a cabo durante actividades comunes como las de transporte, tareas de casa, tareas ocupacionales y de la vida diaria (19). un dispositivo preciso y objetivo para evaluar la actividad física, específicamente la ambulatoria, es el podómetro, el cual es de bajo costo y puede cuantificar de manera aproximada el número de pasos que se dan al caminar, trotar o correr diariamente, dando un panorama complementario a lo que el paciente refiera hacer de ejercicio a través de un cuestionario. los podómetros determinan la actividad ambulatoria del individuo y han sido utilizados y validados en diversas investigaciones (20, 21). un valor de 10.000 pasos diarios es considerado como físicamente activo; sin embargo, esta meta puede no ser apropiada para otros grupos como niños o adultos con enfermedad crónica (22). las personas con diabetes deben aprender a cuidar de sí mismas realizando af o ejercicio, para lo cual requieren estar capacitadas y de esta manera tomar decisiones informadas asumiendo la responsabilidad de su cuidado (23). es aquí donde la partici351 educación, actividad física y obesidad en adultos con diabetes tipo 2 desde la perspectiva del autocuidado de orem l lidia guadalupe compean-ortiz y otros. pación de los profesionales de la salud (entre ellos enfermería) puede marcar una diferencia, la educación en diabetes se vuelve una herramienta indispensable y debe favorecer las habilidades de los pacientes para que asuman un rol activo en su cuidado (8). marco teórico para abordar el fenómeno de estudio se tomó de referencia la teoría del déficit de autocuidado de orem, la cual está constituida por tres teorías de rango medio: teoría del autocuidado, que describe y explica el porqué y cómo las personas cuidan de sí mismas; teoría del déficit de autocuidado que describe y explica cómo la enfermería puede ayudar a las personas, y la teoría del sistema de enfermería que describe y explica las relaciones que hay que mantener. estas teorías contienen conceptos principales y secundarios, y es a través de estos que se pueden hacer aproximaciones a los fenómenos y aportaciones a las mismas: “la explicación de la estructura de conceptos secundarios permite la identificación de componentes del fenómeno, las características concretas de entidades conceptualizadas y combinación de entidades” (24). en el marco de la teoría de rango medio del autocuidado este concepto se define como “la práctica de actividades que los individuos inician y desarrollan en su propio beneficio en el mantenimiento de su vida, salud y bienestar” (24). las acciones de autocuidado a través del tiempo son aprendidas y desarrolladas por las personas en ambientes tanto estables como cambiantes, dentro del contexto de sus patrones de la vida diaria. el autocuidado debe ser aprendido y debe llevarse a cabo de manera continua. en este estudio se definió el autocuidado como las acciones que la persona con diabetes lleva a cabo en su rutina diaria respecto a la actividad física (pasos/día) y el ejercicio. otro concepto de la teoría que se consideró fue el de salud. el autocuidado está asociado a la salud como estado, el cual cambia a medida que lo hacen las características humanas y biológicas de las personas. los aspectos físicos, psicológicos, interpersonales y sociales son inseparables del individuo. la salud en esta investigación se abordó con algunos indicadores, que en el caso de quien tiene diabetes se consideraron importantes, estos son: el índice de masa corporal (imc), la circunferencia de cintura (cc) y el porcentaje de grasa corporal por el riesgo cardiovascular que una alteración de los mismos representa. el autocuidado está determinado por las capacidades de autocuidado (cac) también conocidas como agencia de autocuidado. se refiere a las habilidades de un individuo para comprometerse en las operaciones de autocuidado y posee una estructura compleja: las capacidades básicas que afectan el desarrollo de cualquier acción deliberada, un grupo de habilidades relacionadas con el compromiso para el autocuidado conocidas como componentes de poder, y un grupo de capacidades especializadas necesarias para desarrollar operaciones de autocuidado conformadas por las capacidades estimativas, transicionales y productivas (24). el subconcepto de interés en esta investigación fue el de capacidades estimativas las cuales se refieren al conocimiento empírico y técnico que la persona debe tener para posteriormente decidir qué es mejor para llevar a cabo su autocuidado. este subconcepto se exploró con la variable educación/comprensión en diabetes que se definió como la información previa que el paciente tenía sobre la enfermedad y la comprensión de algunos contenidos básicos. por todo lo anterior, y basándose en la propuesta de subestructuración conceptual teórico-empírica de fawcett (25), se propuso la estructura de la figura 1. existen iniciativas en las instituciones de salud de la región a través de programas educativos de ejercicio para estas poblaciones; sin embargo, al realizar la búsqueda de evidencia científica de cómo llevan su autocuidado en af las personas con diabetes —previa a estas intervenciones—, la información es limitada. los pacientes reciben educación en diabetes, pero las conductas no se mantienen. el uso del podómetro para la medición de af, en combinación con el cuestionario, así como la posible relación de la educación/ comprensión previa en diabetes dentro del marco teórico del autocuidado permitirá a los profesionales de la enfermería explorar el fenómeno y proponer estrategias educativas más reales a la práctica para favorecer que las personas incrementen su cuidado, lo que tendría un impacto en la reducción de riesgos en la salud en estos pacientes. por lo anterior, el objetivo principal de este estudio fue describir la relación del autocuidado en actividad física (pasos/día) y ejercicio con algunos indicadores de obesidad como el imc, circunferencia de cintura y porcentaje de grasa corporal en adultos con diabetes tipo 2. además: 1) determinar la relación de la educación/comprensión en diabetes con el autocuidado en actividad física y ejercicio, y 2) establecer diferencias de actividad física y obesidad/sobrepeso de acuerdo con variables sociodemográficas. 352 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 materiales y métodos diseño. el diseño fue de tipo descriptivo correlacional. la fase de recolección se llevó a cabo de julio a noviembre de 2008. población, muestreo y muestra. el presente trabajo se deriva del proyecto uat-exb 199: “impacto del autocuidado en marcadores bioquímicos y composición corporal de adultos con diabetes tipo 2” (26), cuya población estuvo integrada por 2000 adultos con diabetes tipo 2 adscritos a 17 centros comunitarios de salud de la jurisdicción sanitaria no. 2 correspondiente a tampico y madero, tamaulipas, méxico. se utilizó un muestreo aleatorio estratificado y la muestra se estimó con el paquete n-query advisor 4.0, calculada con un ic 95 % y una potencia del 90 % para un análisis de correlación de ,25. el tamaño muestral fue de 135 participantes, de los cuales para fines de este artículo se presentan datos de 124 pacientes quienes señalaron el uso del podómetro. criterios de elegibilidad. se incluyeron participantes con diabetes tipo 2, en edades de 18 a 60 años y capaces de seguir instrucciones. se excluyeron personas con depresión severa. procedimiento y mediciones. en una primera visita domiciliaria se aplicó una cédula de datos para obtener información sociodemográfica y se verificaron los criterios de elegibilidad utilizando el examen breve del estado mental (27) y el inventario de depresión de beck (28), los cuales han mostrado confiabilidad aceptable (alpha de cronbach 0,70-0,80) en poblaciones mexicanas. a quienes reunieron los requisitos se les invitó a participar a través del consentimiento informado verbal y escrito explicando los objetivos del mismo y el posible riesgo de acuerdo con el reglamento de la ley general de salud en materia de investigación (29). se realizaron mediciones antropométricas y de composición corporal, midiendo el peso corporal con el mínimo de ropa y sin zapatos en un monitor de composición corporal (tanita bc-554) con capacidad de hasta 150 kg y en una superficie plana. la talla se estimó con un estadímetro estandarizado con capacidad para 2 metros y precisión de 1 mm con la persona en bipedestación haciendo coincidir su línea media sagital con la línea media del estadímetro. la circunferencia de cintura fue medida con una cinta métrica de fibra de vidrio (marca seca, modelo 201, con un alcance de medición de 15 a 205 cm). se registró el porcentaje de grasa corporal total con el mismo monitor de composición corporal tanita a través de bioimpedancia eléctrica. se calculó el imc para clasificar a los participantes con obesidad/sobrepeso de acuerdo con la organización mundial de la salud (oms), y la circunferencia de cintura (cm) para determinar el riesgo de enfermedades metabólicas (30). así mismo, se utilizó la circunferencia de cintura para describir obesidad abdominal de acuerdo con la federación internacional de diabetes (31). otro indicador de obesidad que se consideró fue el porcentaje de grasa corporal ya que se ha demostrado que la reducción de los niveles excesivos disminuye el riesgo de ciertas enfermedades tales como la hipertensión arterial, cardiovasculares y cáncer. los puntos de corte utilizados fueron los de gallagher (32). en una segunda visita se aplicó el cuestionario acciones de autocuidado, dimensión ejercicio, integrado por tres ítems relacionados con la frecuencia con la que se realizó ejercicio siete días previos a la entrevista; este instrumento ha sido utilizado previamente en poblaciones mexicanas (0,70) y evaluado a partir de consistencia interna (33). una vez aplicado el cuestionario se explicó al paciente el uso del podómetro new life style —el cual ha mostrado en diferentes investigaciones ser uno de los más precisos y confiables para el conteo de pasos (21)— y se realizó una prueba de colocación correcta en la cintura pidiéndole que caminara veinte pasos a velocidad normal (se consideró un margen de error de ± 3 pasos). el participante fue instruido para colocarse el podómetro con un clip en su cintura sobre la ropa, desde el momento de levantarse y durante todo el día por una semana. se le solicitó realizar su actividad cotidiana y quitarse el podómetro cuando se diera un baño o fuera a ir a la playa o a la piscina. no se le solicitó hacer registros ya que el nl-2000 tiene capacidad de memoria por siete días. la actividad física se clasificó en tres categorías tomando como referencia el estudio descriptivo correlacional de tudor-locke et al. (13) quienes utilizaron el podómetro en población con diabetes, proponiendo baja, moderada y alta actividad física. se aplicó también el cuestionario del perfil de cuidado en diabetes (34), dimensión educación integrada, por cuatro reactivos con respuesta dicotómica y dimensión comprensión con 12 preguntas con respuesta tipo likert. en ambos casos los puntajes netos se transformaron a índices en escala de 0 a 100 donde mayor puntaje es equivalente a mejor educación y comprensión. en una tercera visita se recogió el podómetro en la casa del participante, se le explicaron los resultados, se le orientó respecto al inicio de af y se le invitó a asistir a la consulta de nutrición del centro de salud respectivo. análisis estadístico. se utilizó el programa spss para windows versión 17.0. se calcularon medidas de tendencia central 353 educación, actividad física y obesidad en adultos con diabetes tipo 2 desde la perspectiva del autocuidado de orem l lidia guadalupe compean-ortiz y otros. para las variables continuas así como cálculo de frecuencias y porcentajes para las variables categóricas. a través de percentiles se definieron categorías de af tales como: baja actividad (debajo del percentil 25 de distribución o ≤ 5.211 pasos/día), moderada (entre 25 y 75 percentil de distribución o 5.213-10.512 pasos/día) y alta (arriba del percentil 75 de distribución o ≥ 10.513 pasos/día). se llevó a cabo análisis bivariado a través del coeficiente de correlación de spearman para explorar la relación entre el promedio de pasos diarios y el imc, así también con la circunferencia de cintura y grasa corporal. este mismo análisis se realizó con el índice de ejercicio. se realizó también la prueba de spearman para determinar relación entre la educación/comprensión con la af/ejercicio. se utilizó la prueba u de mann whitney para diferencia de medias entre pasos/día, ejercicio, imc, cc y grasa corporal de acuerdo con el género, y la prueba de kruskal wallis para determinar diferencias de estas mismas variables de acuerdo con grupo de edad, nivel educativo y ocupación. resultados de los 124 participantes del estudio, 25 fueron de sexo masculino (20,2 %) y 99 de sexo femenino (79,8 %). la media de edad fue de 53,15 años ± 9,16, y de escolaridad de 6,12 ± 3,19 años. el promedio de años con diagnóstico de diabetes fue de 7,22 ± 6,2; el 94 % usaba como tratamiento los hipoglucemiantes y antihiperglucemiantes orales, y el 53 % tenía hipertensión arterial controlada. solo el 6,5 % manifestó tabaquismo positivo. la mayoría de los participantes tenía una escolaridad primaria o menor, entre 51 y 70 años de edad, vivían con pareja y la ocupación que más predominó fue la de ama de casa (tabla 1). datos descriptivos el promedio general de pasos diarios fue de 8160 ± 3550. las mujeres, las personas más jóvenes, quienes tenían estudios profesionales y los desempleados fueron quienes tuvieron mayor promedio (tabla 2). el 50 % de los participantes mostró actividad física moderada con un rango de pasos diarios de 5213 hasta 10.512, el 25 % se ubicó en actividad baja con un promedio de 5212 pasos o menos, y el 25 % mostró buena actividad física con un promedio igual o mayor de 10.513 pasos diarios. respecto al ejercicio, la media total obtenida fue de 22,84 ± 29,14 (mujeres: 24,35 ± 29,53 y hombres: 16,88 ± 27,28). en relación con el imc, el promedio global fue de 30,43 kg/m2 ± 4,48 (mujeres: 30,66 ± 4,15 kg/m2 y hombres: 29,53 kg/m2 ± 5,59). en la tabla 3 se presentan las prevalencias encontradas de obesidad/sobrepeso global y por género. el promedio general de la cintura fue de 100,99 cm, ± 10,29 (mujeres: 100,52 cm ± 9,76 y hombres: 102,88 cm ± 12,24). al agrupar la cintura para determinar riesgo de complicaciones metabólicas se observó que el 83 % tenían riesgo sustancialmente incrementado, el 11 % riesgo incrementado y el 6 % sin riesgo. respecto a la grasa corporal se obtuvo un promedio general de 36,76 % ± 6,83 (mujeres: 38,7 % ± 5,31 y hombres: 29,09 % ± 6,82). en la tabla 4 se presenta la clasificación de obesidad por prevalencia de grasa corporal de los participantes por género. respecto a la educación/comprensión se obtuvo un índice de educación de 72,98 (de = 28,16) y de comprensión de 52,74 (de = 22,34). relaciones encontradas en la tabla 2 se presentan las relaciones encontradas entre el promedio de pasos diarios y los indicadores de obesidad. se encontró una relación negativa significativa entre el promedio de pasos diarios y el imc (p < 0,05), y entre el promedio de pasos diarios y la circunferencia de cintura (p < 0,05). el ejercicio percibido obtenido por el cuestionario no se relacionó con alguno de estos indicadores de obesidad (p > 0,05); sin embargo, el promedio de pasos diarios (medido con el podómetro) se relacionó con el ejercicio reportado en el cuestionario (r = ,197, p = 0,02). respecto a la educación/comprensión, solo la comprensión de los contenidos en diabetes mostró relación positiva significativa con el ejercicio (r = 0,179, p = 0,04). diferencias de acuerdo con variables sociodemográficas respecto a la actividad física (pasos/día) por género, grupo de edad, nivel educativo y ocupación se presentan los datos descriptivos en la tabla 2. aun cuando se observaron diferencias aparentes en las medianas, estas no fueron estadísticamente significativas (p > 0,05). cabe señalar que en el caso de los desempleados, el 100 % refirió estar buscando trabajo en el momento 354 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 del estudio, y los del sector informal el 100 % refirieron dedicarse a la venta de productos en la calle. en relación con el ejercicio y el imc, no hubo diferencias significativas (p > 0,05) según el género, la edad, el nivel educativo y la ocupación; sin embargo, de acuerdo con la grasa corporal las mujeres (mdn = 38,90) tuvieron significativamente (u = 327.500, p < 0,01) mayor cantidad que los hombres (mdn = 28,60). discusión el autocuidado en actividad física reportado a través del promedio de pasos diarios con el uso del podómetro en este estudio fue mejor que lo reportado por algunas investigaciones internacionales, tal es el caso de un estudio llevado a cabo en 160 adultos canadienses con diabetes tipo 2 entre 40 y 60 años de edad, donde se encontró un promedio de pasos/día más bajo (13). estos mismos autores, en otra investigación (35), mostraron en datos basales previos a una intervención en actividad física un promedio inferior de pasos diarios en 47 adultos canadienses con diabetes, obesidad y sedentarismo. así mismo, bjorgaas et al. (36) encontraron un promedio de 4194 pasos diarios en 29 hombres caucásicos con diabetes tipo 2. chan et al. (16) reportaron un promedio bajo de pasos/día en adultos con obesidad y alguna otra condición como hipertensión arterial, diabetes, hipercolesterolemia o algún problema del corazón comparado con aquellos que solo tenían obesidad. nuestro hallazgo sugiere que la población estudiada es ligeramente más activa, esto se observó además al clasificarla por percentiles en niveles de actividad física y donde la mayor proporción de los pacientes se ubicó en actividad física moderada. aun cuando no hubo diferencias significativas en af de acuerdo con las variables sociodemográficas, la ocupación de los participantes podría estar asociada al mayor promedio de pasos diarios encontrado, ya que los desempleados, aquellos dedicados al sector informal, con negocio propio, amas de casa y obreros fueron los que tuvieron un promedio de pasos/día mayor de 8000. en el caso de los adultos desempleados, estos se hallaban buscando empleo en el momento del estudio lo cual pudo influir para tener mayor actividad ambulatoria. las personas que se dedicaban al sector informal hacían grandes recorridos ya que su trabajo consiste en vender productos en la calle o el mercado tales como dulces, tortillas, comida, fruta, escobas, etc., lo que implica mayor caminata. las personas con negocio propio manifestaron andar activos ya que lo atienden personalmente (tiendas). las amas de casa realizan las labores del hogar y además salen a dejar y recoger a sus hijos o nietos a la escuela, hacer compras sencillas en su misma colonia, etc., lo que implica caminar diariamente. se reconoce que, además de la ocupación, algunos factores podrían estar influyendo en el promedio de pasos/ día por lo que este fenómeno requiere de futuras investigaciones. en contraste con el promedio de pasos encontrado en el presente estudio y en los mencionados anteriormente, otros autores han reportado mayor promedio de pasos/día (37); sin embargo, ellos implementaron el uso de podómetro en adultos con diabetes que ya estaban integrados en un programa de ejercicio, pudiendo ser esta una explicación de la diferencia ya que nuestros participantes no estaban enrolados en ningún programa y se les solicitó realizar su actividad cotidiana. en cuanto al autocuidado en ejercicio evaluado a través de cuestionario, los resultados mostraron una frecuencia muy baja, hallazgo que es congruente con otros estudios nacionales y extranjeros donde han utilizado alguna forma de autorreporte o cuestionario (13, 15, 17, 18, 37). la actividad ambulatoria reportada con el podómetro y la poca realización de ejercicio percibida que mostró el cuestionario tuvieron una relación positiva en nuestro estudio, lo que sugiere la pertinencia de utilizar conjuntamente cuestionarios para medir af o ejercicio con métodos más objetivos como el podómetro. respecto a los indicadores de obesidad/sobrepeso, en este estudio se encontró una prevalencia alta por imc que excede casi en un 20 % a la prevalencia nacional y estatal reportada por la encuesta nacional de salud y nutrición 2006. este hallazgo hay que considerarlo con cautela ya que la encuesta nacional se aplicó en población general y no exclusivamente en adultos con diabetes como en nuestro estudio. la evidencia científica sugiere la coexistencia de obesidad/sobrepeso con enfermedades no transmisibles como la diabetes como un indicador de la transición epidemiológica que está teniendo lugar en méxico (38). la prevalencia alta encontrada en nuestro estudio es congruente con algunos autores que trabajaron también con poblaciones similares (13, 18). este último estudio fue realizado en la ciudad de monterrey, n.l. vecino del estado de tamaulipas, méxico, ambos del norte del país; los estados del norte se han caracterizado por una mayor urbanización, un mayor consumo de dietas hipercalóricas y 355 educación, actividad física y obesidad en adultos con diabetes tipo 2 desde la perspectiva del autocuidado de orem l lidia guadalupe compean-ortiz y otros. estilos de vida más sedentarios que favorecen las altas prevalencias de obesidad/sobrepeso. otro indicador de salud fue la circunferencia de cintura, donde se observó una prevalencia de obesidad abdominal alta (98 %) rebasando el hallazgo nacional de 76 % y estatal del 83 % reportado por algunos autores (38), aunque cabe reconocer que esta última encuesta fue aplicada en población general. en la presente investigación se encontró además que gran parte de los adultos con diabetes tienen un riesgo incrementado y sustancialmente incrementado para el desarrollo de enfermedades cardiovasculares o síndrome metabólico, lo que coincide con la literatura y con el estudio llevado a cabo en el estado de nuevo león donde encontraron prevalencias similares en una muestra de adultos con diabetes tipo 2 (18). la obesidad también se observó en los porcentajes de grasa corporal donde la prevalencia alcanzó más de un 80 %. las mujeres tuvieron significativamente mayor porcentaje de grasa corporal que los hombres exponiéndolas a un mayor riesgo de enfermedades cardiometabólicas. se encontró una relación inversa entre la actividad física —por medio del número de pasos/día registrado en el podómetro— con la obesidad/sobrepeso a través del imc así como con la circunferencia de cintura. esta relación es congruente con algunos estudios llevados a cabo en población con diabetes (13, 16) y obesidad (39). dentro de los resultados reportados por la encuesta nacional de salud y nutrición (ensanut-2006) en méxico —llevada a cabo en población general mayor de 20 años— se encontró una asociación también inversa entre la prevalencia de obesidad/sobrepeso con la práctica de actividad física en población sana, aunque esta solo la observaron en los hombres y fue medida con cuestionario (40). respecto a la educación y comprensión, la gran mayoría de los pacientes que participaron en este estudio habían recibido educación en diabetes; sin embargo, la comprensión de esos contenidos no fue muy aceptable. de estas dimensiones la comprensión de estos contenidos estuvo relacionada con mejor índice de ejercicio. este hallazgo es interesante porque permite reflexionar sobre la importancia de la educación en diabetes para lograr el autocuidado. de acuerdo con la evidencia científica la educación debe proporcionarse de manera continuada para fortalecer los conocimientos, las aptitudes y las actitudes necesarias en las personas para cuidar su salud y optar por estilos de vida saludables (8). pero, además, el enfoque de esta educación debe cambiarse y pasar de una mera información otorgada como en esquemas tradicionales a una educación basada en modelos que ayude a los pacientes a que tomen decisiones informadas. el objetivo de la educación en diabetes debe dirigirse a apoyar la toma de decisiones informadas, resolución de problemas, mejor autocuidado y una colaboración activa con el equipo de salud (8). implicaciones teóricas las teorías son elementos indispensables en el fortalecimiento del conocimiento de enfermería para dar sustento a la práctica (41). en este sentido, la teoría de autocuidado de orem permitió explicar el fenómeno del autocuidado en el adulto con diabetes tipo 2 y obesidad, proponiendo la educación en diabetes como un aspecto esencial para fortalecer las capacidades estimativas de conocimiento y comprensión, y la operacionalización del autocuidado. el autocuidado en af/ejercicio que realizan los pacientes con diabetes fue moderado e incluye actividades cotidianas como caminar, tareas domésticas, entre otras; no obstante, el nivel de ejercicio realizado fue bajo. esta situación es coherente con las altas prevalencias de obesidad/sobrepeso encontradas donde siete de cada diez personas la padecían. el imc, la cc y porcentaje de grasa corporal denotan un estado de salud alterado que los pone en alto riesgo de otros problemas entre ellos los cardiovasculares. en este sentido, orem (25) señala que la salud puede cambiar a medida que cambian las características humanas y biológicas de las personas, si los pacientes no hacen algo por modificar su autocuidado se alterará su funcionamiento integrado. los buenos comportamientos de salud son necesarios para cambiar los comportamientos antiguos. la educación se vuelve necesaria y esto se sustenta en la relación encontrada entre la comprensión de contenidos de diabetes y el ejercicio, dado que para comprender primero hay que conocer y para esto se requiere educación continua, misma que dentro de la teoría de orem se señala como importante para el autocuidado. el paciente requiere fortalecer su capacidad estimativa de conocer y comprender lo que puede lograrse a través de la educación, para posteriormente llevar a cabo su autocuidado. este hallazgo fortalece el papel esencial de la enfermera en la educación en diabetes, ya que dentro de las instituciones de salud, principalmente en las de primer nivel de atención, ellas están en una posición estratégica para trabajar multidisciplina356 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 riamente y proponer estrategias psicoeducativas enfocadas al logro de un aprendizaje que el paciente pueda incorporar en su vida diaria. el cuidado de la diabetes está cambiando hacia una aproximación más centrada al paciente y a lo que le rodea incluida a la familia. conclusiones se reconocen algunas limitaciones del presente estudio tales como el hecho de que la población estudiada es representativa solo del sur de tamaulipas, estado del norte del país; así mismo, el podómetro utilizado no mide la intensidad de las actividades ambulatorias ni otras como nadar, andar en bicicleta, etc. aun con lo anterior, el presente estudio es uno de los primeros realizados en tamaulipas y méxico donde se describe la actividad física ambulatoria a través del uso de podómetro en población adulta con diabetes tipo 2, y se corrobora la alta prevalencia de obesidad/ sobrepeso lo que es congruente con las prevalencias estatales y nacionales vigentes. además, presenta evidencia científica del abordaje de esta situación desde la perspectiva de autocuidado de orem, y con base en esta primera aproximación se sugiere que la comprensión de contenidos en diabetes pueda ser considerada como una capacidad estimativa para llevar a cabo el autocuidado en ejercicio en pacientes con diabetes y obesidad. por último, es importante que este fenómeno se siga estudiando en futuras investigaciones y que se contemplen otras variables que no se consideraron en el presente estudio. se plantea, entonces, la necesidad de estrategias específicas a través de programas donde la labor del profesional de enfermería es determinante para promover comportamientos más saludables en af los que, en conjunto con la promoción de otros comportamientos de autocuidado básicos, contribuirán a prevenir complicaciones más serias entre las que figuran las enfermedades cardiovasculares y el síndrome metabólico que pueden llevar a quien tiene diabetes a una muerte temprana. agradecimientos los autores agradecen al programa de mejoramiento del profesorado de la secretaría de educación pública de méxico por el financiamiento otorgado al proyecto promep clave uat exb-199, del cual se deriva el presente trabajo. así mismo, agradecen a la universidad autónoma de tamaulipas por el apoyo complementario clave uat-b-sal-0412. los autores agradecen a la jurisdicción sanitaria no. 2 en tamaulipas por las facilidades otorgadas para la recolección de información, así como al personal de salud de los centros comunitarios que la integran. se agradece también la participación de las becarias de investigación margarita ramírez navarro, juana g. tobías valdovinos y keila argüelles lópez. resultados parciales de este estudio fueron presentados en el xx congreso internacional de investigación en enfermería del sigma theta tau international en vancouver, british columbia, canadá, en julio del 2009. 357 educación, actividad física y obesidad en adultos con diabetes tipo 2 desde la perspectiva del autocuidado de orem l lidia guadalupe compean-ortiz y otros. variable f % edad (años) 18-35 4 3,2 36-50 43 34,7 51-70 77 62,1 escolaridad primaria o menos 85 68,5 secundaria 24 19,4 preparatoria 6 4,8 profesional 9 7,3 ocupación empleado empresa privada 14 11,3 obrero empresa privada 5 4,0 negocio propio 5 4,0 sector informal 27 21,8 ama de casa 69 55,6 pensionado 2 1,6 desempleado 2 1,6 estado civil con pareja 88 71,0 sin pareja 36 29,0 tabla 1. descripción de variables sociodemográficas 358 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 variable x de mdn min max género mujer 8.366 3.454 7.796 2.105 18.033 hombre 7.349 3.874 6.996 1.916 15.797 edad 20-35 años 11.198 3.861 10.389 7.436 16.580 36-50 años 8.647 3.336 7.796 3.670 18.033 50 o más 7.731 3.585 6.977 1.916 16.627 escolaridad primaria o menos 7.994 3.301 7.994 1.916 16.627 secundaria 8.308 4.429 7.382 2.098 18.033 preparatoria 7.627 5.184 5.433 3.670 16.580 profesional 9.701 2.811 10.557 4.172 12.501 ocupación empleado empresa privada 6.857 3.602 6.857 2.098 12.331 obrero empresa privada 8.120 2.158 7.435 6.340 11.762 negocio propio 8.316 5.142 6.977 3.096 15.797 sector informal 8.768 3.729 7.273 3.289 14.925 pensionado 5.101 4.503 5.101 1.916 8.286 ama de casa 8.198 3.451 7.796 2.105 18.033 desempleado 10.597 912 10.597 9.952 11.242 tabla 2. pasos/día de acuerdo con variables sociodemográficas 359 educación, actividad física y obesidad en adultos con diabetes tipo 2 desde la perspectiva del autocuidado de orem l lidia guadalupe compean-ortiz y otros. tabla 3. prevalencia (%) de obesidad por imc en adultos mexicanos con diabetes tipo 2 mujeres hombres total variable f % f % f % normal 8 8,1 5 20,0 13 10,5 sobrepeso 40 40,4 9 36,0 49 39,5 obesidad grado i 35 35,4 8 32,0 43 34,7 obesidad grado ii 13 13,1 2 8,0 15 12,1 obesidad grado iii 3 3,0 1 4,0 4 3,2 tabla 4. prevalencia (%) de obesidad de acuerdo con porcentaje de grasa corporal en adultos mexicanos con diabetes tipo 2* mujeres hombres total variable f % f % f (%) bajo en grasa 1 1,0 0 0 1 ,8 saludable 18 18,4 4 16,0 22 17,9 sobrepeso 41 41,8 10 40,0 51 41,5 obesidad 38 38,8 11 44,0 49 39,8 * fueron considerados 123 casos. figura 1. estructura conceptual teórico-empírica 360 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 aquichan issn 1657-5997 figura 2. correlación entre la actividad física ambulatoria (promedio de pasos/día) e indicadores de obesidad (imc y cc) referencias 1. world health organization. global strategy on diet, physical activity and health. 2004 may. 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overweight/obesity in adult mexican population. the mexican national health and nutrition survey 2006. salud pública mex. 2009;51(suppl 4):s621-629. 41. castillo-arcos l, benavides-torres r. modelo de resiliencia sexual en el adolescente: teoría de rango medio. aquichán. 2012;12(2):169-182. 4 teorias.p65 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200520 año 5 vol. 5 nº 1 (5) 20-31 chía, colombia octubre 2005 zaider g. triviño v.1 olivia sanhueza a.2 recibido: 3 de noviembre de 2004 aprobado: 4 de abril de 2005 resumen el objetivo del presente trabajo es plantear la relación entre los modelos y las teorías que marcan conductas y acciones influyentes en forma general hacia conductas saludables, específicamente en personas con discapacidad por cáncer, mostrando herramientas que posibiliten mejor sobrevivencia. se presentan las teorías de autocuidado, incertidumbre, estrés, afrontamiento de crisis y el modelo de creencias en salud. la intención de este trabajo es visualizar la relación de las teorías en la terapéutica del cáncer y la presencia de enfermería, con la perspectiva de mejorar la calidad de vida en estos pacientes. palabras clave teorías psicosociológicas y enfermería, cáncer, calidad de vida. abstract the objective of the present work is to outline the relationship among the models and theories, which states general behaviors and influential actions, toward healthy behaviors, specifically in people with incapacity due to cancer, showing tools for a better survival. the following theories of self care are presented: uncertainty, stress, confrontation, crisis and the model of beliefs in health. the main idea in this work is to visualize the relationship of theories in cancer therapy and nursing presence, with a perspective of improving the quality of life in these patients. key words psycho sociological theories and nursing, cancer, quality of life. 1 enfermera magíster en salud pública; docente universidad santiago de cali-colombia; doctoranda en enfermería, universidad de concepción, chile. ztrivino@usc.edu.co 2 doctora en enfermería; profesora asociada, departamento de enfermería, facultad de medicina, universidad de concepción, chile. osanhue@udec.cl teorías y modelos relacionados con calidad de vida en cáncer y enfermería 21 introducción anto las personas sanas como aquellas que se encuentran en desequilibrio de su salud necesitan observar conductas saludables que les permitan afrontar situaciones de estrés, de crisis, de desadaptabilidad a través de manejos adecuados de autocuidado y afrontamiento. actualmente la disciplina de enfermería reconoce la necesidad de aplicar y desarrollar en su práctica teorías y modelos científicamente fundamentados, reconocidos empíricamente por su adecuada operativización en la promoción y la recuperación de la salud, en los procesos de manejo y terapéuticas, tanto en pacientes sanos como en aquellos que padecen enfermedades crónico-degenerativas, entre otras, el cáncer. en cuanto a la adaptabilidad, se buscan formas que les permitan aproximarse a una vida con mejor calidad. este trabajo plantea la relación entre los modelos y las teorías que marcan conductas y acciones influyentes de manera general hacia conductas saludables, específicamente en personas con discapacidad por cáncer, mostrando las herramientas que utiliza la enfermera, y que posibilitan una mejor sobrevivencia del paciente oncológico. se presenta la definición y conceptualización de las teorías de autocuidado, incertidumbre, estrés, afrontamiento, de crisis y el modelo de creencias en salud. en seguida se muestra la relación entre calidad de vida, las teorías expuestas y enfermería, posteriormente se mencionan algunos instrumentos de medición de calidad de vida de pacientes con cáncer. finalmente se presentan las conclusiones. teoría del autocuidado dorothea orem, enfermera creadora de esta teoría, la presentó por primera vez en la década de los cincuenta y se publicó en 1972. la define como déficit de autocuidado, compuesta por tres teorías relacionadas: el autocuidado: consiste en la práctica de actividades que las personas maduras o que están madurando, inician y llevan a cabo en determinados periodos de tiempo, por sus propios medios y con el interés de mantener un funcionamiento vivo y sano, y continuar con el desarrollo personal y el bienestar (1). el déficit de autocuidado descrito por orem se da cuando la relación entre las propiedades humanas de necesidad terapéutica y la capacidad de autocuidado desarrollada no son operativas o adecuadas para conocer y cubrir algunos o todos los componentes de la necesidad terapéutica de autocuidado existente (1). aquí actúan los sistemas de enfermería. sistemas de enfermería: son las acciones que realiza la enfermera de acuerdo con las necesidades terapéuticas de autocuidado de sus pacientes para proteger y regular el ejercicio o desarrollo de la actividad de autocuidado de los mismos (1). el autocuidado podría considerarse como la capacidad de un individuo para realizar todas las actividades necesarias para vivir y sobrevivir con bienestar. esta autora considera el concepto �auto� como la totalidad de un individuo, donde no sólo incluye sus necesidades físicas, sino también las necesidades psicológicas y espirituales, y el concepto �cuidado� como la totalidad de actividades que un individuo inicia para mantener la vida y desarrollarse de una forma que sea normal para él. así, el autocuidado es la práctica de actividades que los individuos inician y realizan en su propio beneficio para el mantenimiento de la salud, la vida y el bienestar. las capacidades de autocuidado están directamente influenciadas por la cultura, el grupo social en el que está inserta la persona, el conocimiento de habilidades de autocuidado y el repertorio para mantenerlas, así como por la capacidad para hacer frente a las dificultades con las que se encuentra a lo largo de su historia (2). en las variadas aplicaciones prácticas de esta teoría, entre las que se destaca el área de la promoción y el cuidado de la salud, está la oncología, donde la enfermera realiza actividades educativas para la detección precoz del cáncer, observando los factores de riesgo, y para mantener el autocuidado del paciente después de haberse diagnosticado. se ha encontrado el efecto de la consultoría en enfermería en ansiedad y, por otro lado, el efecto del autocuidado de los pacientes que están recibiendo terapia de irradiación, y el autocuidado en el manejo paliativo del dolor. aquí el sistema de revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200522 enfermería apoya al paciente oncológico, y opera brindando cuidados a los pacientes cuando éstos pierden transitoriamente la capacidad física, psicológica y espiritual de autocuidarse. esta teoría de enfermería aporta la enseñanza de manejo de signos y síntomas al paciente oncológico buscando conductas de independencia y bienestar. la enfermera tendrá en cuenta la cultura y habilidad de los pacientes al enseñarles y proporcionarles el cuidado. la independencia del paciente le genera mejor calidad de vida. teoría de incertidumbre teoría desarrollada por mishel merle, quien la define como la inhabilidad del sujeto para determinar el significado de los eventos relacionados con una enfermedad, y ocurre en situaciones donde debe tomar decisiones, siendo incapaz de asignar valores definitivos a objetos y eventos; y de predecir consecuencias con exactitud debido a la escasez de información y conocimiento (3). la incertidumbre, como un estado cognitivo, aparece cuando un evento no es adecuadamente estructurado o categorizado debido a que la información del paciente sobre el suceso en cuestión es escasa. estos eventos que causan incertidumbre pueden ser la mayor fuente de estrés, provocando reactividad fisiológica y aumentando la emocionalidad del paciente. el estudio de la incertidumbre representa un área inquisitiva de fenómenos conceptuales. el aporte técnico de enfermería junto a disciplinas relacionadas proveerá conceptos como cuidado y apoyo, probando la teoría y confirmando su generalización en los problemas de la práctica clínica de enfermería (4). la teoría de incertidumbre tiene su más fuerte apoyo entre los sujetos que están experimentando la fase aguda de una enfermedad, o están en una fase crónica con deterioro lento y progresivo de su cuerpo. esta teoría no ha sido aplicada en pacientes que viven con una incertidumbre específica en una enfermedad, con una fase aguda tratable y con una eventual recurrencia (4). los estudios sobre la incertidumbre como fenómeno o problema psicológico que influye en los pacientes como productora de síntomas psicológicos son escasos, la mayoría se refiere a estudios efectuados en pacientes con cáncer y solamente uno a enfermedades crónicas en general realizados en estados unidos. mishel desarrolló una escala de 29 ítems, midiendo en cien pacientes la incertidumbre en relación con el diagnóstico, la sintomatología, el tratamiento, la relación con proveedores de cuidado y el planteamiento para el futuro del paciente (5). en los acontecimientos de la vida real parece ser que la incertidumbre máxima suele ser estresante, pudiendo tener un efecto inmovilizador sobre procesos anticipatorios de afrontamiento, y puede provocar también confusión mental. la teoría de la incertidumbre es reconocida por la enfermera en su práctica para discutir una nueva probabilidad de afrontamiento con los pacientes con cáncer, a fin de tratar de evitar el efecto inmovilizador en el mismo. dado que la incertidumbre produce estrés, la habilidad de la enfermera podría disminuir este grado de incertidumbre, en la medida en que provea información periódica y cierta sobre su estado al paciente oncológico y a su familia. es importante que la enfermera propicie la manifestación de emociones del paciente para identificar situaciones de estrés, desadaptabilidad, crisis, temores, para trabajar en equipo un plan individual con el paciente. el afrontamiento le permite al paciente oncológico aceptar, manejar y sobreponerse a su proceso salud/ enfermedad, lo cual puede llegar a constituir avances en su mejor calidad de vida. teoría de afrontamiento, estrés y procesos cognitivos estrés. lazarus y folkman (6) hicieron su contribución a la investigación de los factores cognitivos implicados en el estrés y en la emoción. a partir de esta premisa comenzaron a tener gran importancia la apreciación de los estímulos, la naturaleza del estrés y los procesos de afrontamiento. lazarus sugirió que el estrés fuera tratado como un concepto organizador, y utilizado para entender un amplio grupo de fenómenos de gran importancia en la adaptación humana y animal. para el autor, el individuo enfrenta el estrés a través del enjuiciamiento funcional de la actila teoría de la incertidumbre es reconocida por la enfermera en su práctica para discutir una nueva probabilidad de afrontamiento con los pacientes con cáncer, a fin de tratar de evitar el efecto inmovilizador en el mismo. teorías y modelos relacionados con calidad de vida en cáncer y enfermería 23 vidad psíquica, y depende de fuerzas conscientes que se configuran como producto de una apreciación intuitiva de las demandas, los recursos y los resultados predecibles de la interacción con el medio, de acuerdo con modos peculiares de procesar la información y de integrar las experiencias. la teoría de lazarus dice que el estrés psicológico es una relación particular entre el individuo y su entorno, evaluado por éste como agravando o desbordando sus recursos, y que pone en peligro su bienestar (6). esta definición considera como fundamental la relación individuo-entorno. así, cuando un individuo ha tenido alguna experiencia con algún agente estresante, el enfrentarse a una situación similar sea quizá menos estresante que la primera vez. ello porque en su conciencia tiene la evaluación primaria de la situación y los procesos de afrontamiento serán más eficientes, con grandes posibilidades de que no se produzca un trastorno. la evaluación cognitiva es el proceso evaluativo que determina el porqué y hasta qué punto una relación o una serie de relaciones entre el individuo y el entorno es estresante. esta evaluación es el proceso que determina las consecuencias que un acontecimiento dado provocará en el individuo (6). la respuesta emocional y conductual desarrollada por un sujeto ante un acontecimiento depende de la forma en que éste lo analice. factores personales que influyen en la evaluación cognitiva al abordar el tema de los factores personales que influyen en la evaluación cognitiva es importante tener en cuenta dos características: los compromisos y las creencias. los compromisos son expresiones de aquello que es importante para la persona y determinan sus decisiones, también las alternativas que el individuo elige para conservar sus ideas y/o conseguir determinados objetivos. tiene que ver con algo o con alguien, por lo tanto, depende de una relación específica entre el individuo y el entorno. las creencias son configuraciones cognitivas formadas individualmente o compartidas culturalmente, son nociones preexistenciales de la realidad, que sirven de lente perceptual. en la evaluación, las creencias determinan la realidad de como son las cosas en el entorno, y modelan el entendimiento de su significado. las creencias existenciales, como la fe en dios o en otro orden natural del universo, son creencias generales que ayudan a la gente a conservar la esperanza y a buscar significado a la vida, a pesar de sus experiencias dolorosas (7). factores situacionales que influyen en la evaluación cognitiva al analizar estos factores es importante tener en cuenta tres características: la novedad, la predictibilidad y la incertidumbre del acontecimiento. una situación nueva, la novedad, es capaz de provocar amenaza si algún aspecto de ella se ha relacionado alguna vez con el daño. la predictibilidad de un acontecimiento ha sido estudiada, pero los hallazgos no han sido adecuados para explicar el estrés psicológico de los seres humanos, en parte porque no considera las diferencias individuales en la evaluación y el afrontamiento. en los acontecimientos de la vida real parece ser que la incertidumbre máxima suele ser estresante, pudiendo tener un efecto inmovilizador sobre procesos anticipatorios de afrontamiento, y puede provocar también confusión mental. teoría de afrontamiento tal como lo define lipowsky, el afrontamiento serían las estrategias que pone en juego el individuo ante un problema para mantener su integridad física y psicológica (8). la capacidad de afrontamiento de una persona depende de su trayectoria personal y de los valores y las creencias que ha ido incorporando con los años. hablar de un proceso de afrontamiento significa hablar de un cambio en los pensamientos y actos a medida que la interacción va desarrollándose; por lo tanto, el afrontamiento es un proceso cambiante en el que el individuo en determinados momentos debe la evaluación cognitiva es el proceso evaluativo que determina el porqué y hasta qué punto una relación o una serie de relaciones entre el individuo y el entorno es estresante. esta evaluación es el proceso que determina las consecuencias que un acontecimiento dado provocará en el individuo. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200524 contar principalmente con estrategias, ya sean defensivas o con otras que sirvan para resolver el problema, todo a medida que vaya cambiando su relación con el entorno (9). el afrontamiento o coping planteado por lazarus se define como esfuerzos cognitivos y conductuales constantemente cambiantes que el individuo desarrolla para manejar las demandas externas y/o internas, las cuales evalúa como excedentes o desbordantes de sus propias capacidades de manejo (10). modos de afrontamiento. existen dos tipos. por un lado el afrontamiento de problemas, que son estrategias dirigidas a la definición del problema, a la búsqueda de soluciones alternativas, y a la consideración de tales alternativas con base en su costo, beneficio, elección y aplicación. implica también un objetivo, un proceso analítico dirigido principalmente al entorno, y también las estrategias dirigidas al interior del sujeto. por otra parte, el afrontamiento de emoción está constituido por los procesos cognitivos encargados de disminuir el grado de trastorno emocional, e incluyen estrategias como la evitación, la atención selectiva, las comparaciones positivas y la extracción de valores positivos a los acontecimientos negativos; otras estrategias están dirigidas a aumentar el grado de trastorno emocional (algunas personas necesitan sentirse realmente mal para encontrar consuelo). utilizamos el afrontamiento para conservar la esperanza y el optimismo, para negar tanto el hecho como su implicación, para no tener que aceptar lo peor, para actuar como si lo ocurrido no nos importara. cuando se dice que una persona tiene muchos recursos no sólo significa que dispone de un gran número de ellos, sino que también tiene habilidad para aplicarlos ante las distintas demandas del entorno. los recursos pueden ser físicos, bioquímicos, materiales, cognitivos, emocionales, de actitud, interpersonales y macrosocioculturales. lazarus describe los recursos como la salud y la energía (recursos físicos), las creencias positivas (recursos psicológicos), las técnicas sociales (aptitudes) y de resolución de problemas, recursos sociales y materiales (recursos ambientales) (7). la salud y la energía facilitan el afrontamiento, es más fácil afrontar una situación cuando uno se encuentra bien que cuando se encuentra mal, pero las personas débiles y/o enfermas pueden movilizarse lo suficiente como para afrontar una situación cuando lo que está en juego es suficientemente importante para ellas. las creencias positivas, la esperanza, pueden ser alentadoras por la convicción de que la situación puede ser controlable, de que uno tiene la fuerza suficiente para cambiarla, de que una persona, o un programa resultarán eficaces, o bien por el hecho de tener fe en la justicia, la voluntad de dios. las técnicas sociales constituyen la capacidad de comunicarse y de actuar con los demás en forma adecuada y efectiva. este tipo de habilidad facilita la resolución de problemas, se coordina con otras personas, aumenta la capacidad de atraer su cooperación o apoyo y, en general, aporta al individuo un control más amplio sobre las interacciones sociales. la enfermera podría apoyar la resolución de problemas mediante la utilización de habilidades para conseguir información, analizar las situaciones, examinar alternativas, predecir opciones útiles para obtener los resultados deseados y elegir un plan de acción apropiado, con participación del paciente. estas técnicas derivan de otros recursos, como experiencias previas, almacenamiento de información, habilidades cognitivas para aplicar esa información y capacidades de autocontrol. los recursos ambientales son el dinero, y los bienes y servicios que pueden adquirirse con él. la esencia del afrontamiento dirigido a plantear alternativas previo conocimiento del problema, permite a la enfermera utilizar como herramienta la espiritualidad, la creencia del paciente oncológico en su dios u otras formas de energía para abordar con mayor propiedad y esperanza sus cuidados y un cambio de conducta. otra visión de cómo la enfermera relaciona este afrontamiento en el paciente oncológico es impartiendo educación sobre el proceso salud/enfermedad, explicando los aspectos relacionados con su enfermedad, con el cumplimiento de su terapia y algunos cambios en su estilo de vida, con información veraz sobre los signos y síntomas. la teoría nos indica la importancia de los procesos cognitivos, esto tiene que ver con el conocimiento de su estado, que le permite disminuir la tensión, el temor, el estrés, permitiendo el afrontamiento eficaz. la enfermera, entonces, apoya no sólo las resla enfermera podría apoyar la resolución de problemas mediante la utilización de habilidades para conseguir información, analizar las situaciones, examinar alternativas, predecir opciones útiles para obtener los resultados deseados y elegir un plan de acción apropiado, con participación del paciente. teorías y modelos relacionados con calidad de vida en cáncer y enfermería 25 puestas biológicas sino también humanas. disminuir el estrés, la tensión y el temor mejora la condición inmunológica o las defensas del paciente oncológico, actuando positivamente en su calidad de vida. teoría de la crisis una crisis surge cuando una persona enfrenta un obstáculo importante en relación con los objetivos de vida, y le es imposible superarlo mediante los métodos habituales de solución de problemas. no todas las circunstancias adversas provocan una crisis o una enfermedad, pero sí desestabilizan a la persona (11). las crisis se producen como una respuesta emocional a una situación peligrosa. históricamente esta teoría remite a freud y sus hipótesis originales que establecían la relación entre situaciones vitales conscientes o inconscientes y una respuesta emocional. en los años sesenta ericsson y su descripción de las crisis del desarrollo colaboró con una perspectiva evolutiva y de crecimiento a la �teoría de la crisis�. lindemann también aportó a esta teoría, pero más desde una perspectiva de atención comunitaria, con un especial énfasis en la atención clínica a personas que habían sufrido una situación de pérdida traumática de un ser querido. lindemann, en colaboración con kaplan, desarrolló esta teoría como un marco referencial para el tratamiento de situaciones de duelo. una crisis se define como una respuesta a eventos conflictivos, internos o externos, y experimentada como un estado doloroso. para defenderse de esta situación la persona utiliza mecanismos que le ayudan a aliviar su molestia y así volver a restablecer su equilibrio previo. estos mecanismos pueden ser adaptativos o desadaptativos (12). en ambos casos el dolor intenso puede ser superado, pero en el segundo el dolor puede ser intercambiado por síntomas psiquiátricos que en algunas personas pueden cristalizar en un estilo neurótico de conducta que restringe sus habilidades para funcionar libremente, en el peor de los casos la situación de crisis no logra ser estabilizada y puede llevar a la persona a reacciones aún menos adaptativas como el suicidio, el homicidio o ambos. la teoría de la crisis describe tres fases de la respuesta: 1) fase previa a la crisis. el individuo busca mantener el equi librio haciendo cambios físicos y psicosociales en el contexto de los sucesos normales de vida. el problema no constituye en sí mismo la crisis, ésta se produce como respuesta a aquél. en el contexto del cáncer, el grado de amenaza percibido por el descubrimiento de un tumor en la mama, por ejemplo, puede desencadenar una crisis si la mujer tiene antecedentes familiares de cáncer de mama. el factor importante es la percepción individual del peligro. las expectativas y los temores se derivan de los antecedentes familiares de cáncer. la crisis no surge de la confirmación del diagnóstico sino de la amenaza percibida. 2) la fase de crisis se caracteriza por la desorganización; se hacen intentos para resolver el problema, que puedan resultar o no. en el ejemplo anterior surgen diferentes posibilidades, la paciente puede responder tratando de ignorar el crecimiento mamario, pero se verá perseguida por la ansiedad que le produce la evolución de la enfermedad debido al retraso en la búsqueda de atención. la otra opción es aliviar la angustia mediante la evaluación médica inmediata y la participación activa en el plan de tratamiento. 3) en la fase posterior a la crisis también surgen varias posibilidades. este fundamento teórico lleva a la enfermera a posibilitar la manifestación de emociones al paciente para articularlo en su plan de intervención en equipo. modelo de creencias en salud uno de los modelos más utilizados en promoción de la salud y que incluye un importante componente cognitivoperceptivo es el modelo de creencias de salud (mcs). el mcs fue originalmente desarrollado en los años cincuenta por un grupo de especialistas en psicología social del departamento de salud pública norteamericano, encabezados por hochbaum, en su búsqueda por una explicación a la falta de participación pública en programas de detección precoz y prevención de enfermedades. posteriormente se adapta para tratar de explicar una variedad de conductas, como la respuesta individual ante ciertos síntomas de enfermedad, el cumplimiento del paciente con los tratamientos y las recomendaciones médicas, la práctica de autoexámenes exploratorios o el uso de tabaco (13). en su origen, el mcs se basa en otras clásicas y populauna crisis surge cuando una persona enfrenta un obstáculo importante en relación con los objetivos de vida, y le es imposible superarlo mediante los métodos habituales de solución de problemas. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200526 res teorías del aprendizaje, en particular la conductista, que defiende que todo tipo de comportamiento puede ser reducido a relaciones estímulo-respuesta elementales y justificado por sus inmediatas consecuencias; y en la cognitiva, que justifica el comportamiento como el resultado de procesos mentales en los que el sujeto otorga cierto valor a las consecuencias de su acción y sopesa la probabilidad de que ésta produzca el resultado deseado (13). aunque los defensores de ambas teorías consideran que el reforzamiento es un importante factor condicionante del comportamiento, los teóricos cognitivos lo sitúan influenciando las expectativas, o hipótesis, en lugar del comportamiento en sí. el mcs es una teoría construida en la valoración subjetiva de una determinada expectativa. en términos de salud, el valor será el deseo de evitar la enfermedad o el padecimiento, y la expectativa será la creencia en que una acción posible de realizar prevendrá o mejorará el proceso. con los años se han hecho adaptaciones del modelo para explicar conductas frente a una enfermedad ya diagnosticada, y se creó un paradigma que modela la adopción del rol de la enfermera y que agrupa diferentes factores motivacionales, subjetivos, elementos habilitantes o modificantes de la conducta, que influencian las decisiones que debe tomar el individuo frente a una enfermedad que se le ha diagnosticado y, dependiendo de estos factores, las personas tendrán mayor o menor probabilidad de tener una conducta en salud esperable, es decir, adherente o no a las prescripciones que se le dan para tratar su enfermedad (14). el mcs se basa en tres premisas: 1) la creencia �o percepción� de que un determinado problema es importante o suficientemente grave como para tenerlo en consideración; 2) la creencia �o percepción� de que uno es vulnerable a ese problema; 3) la creencia �o percepción� de que la acción a tomar producirá un beneficio a un costo personal aceptable. de acuerdo con el mcs, la concurrencia simultánea de estos tres factores favorece la adopción de determinados patrones de conducta, que serían en nuestro caso conducentes a conservar y mejorar la salud, evitar situaciones de riesgo y prevenir enfermedades. la aceptación de esto implica que es la percepción individual la que determina el comportamiento, y no el ambiente en el que vive y se desarrolla el individuo (15). en la investigación de sanhueza, los factores del modelo que determinan la conducta de salud son de dos tipos: la percepción de amenazas sobre la propia salud, y las creencias de los individuos sobre la posibilidad de reducir esas amenazas. una variable que completa el modelo es la presencia de estímulos internos o externos que se constituyen en claves para actuar. una clave interna puede ser el síntoma de una enfermedad, mientras que una clave externa puede ser una campaña acerca de la promoción en salud o las interacciones sociales con amigos afectados por alguna enfermedad. en el caso de la conducta autoexaminadora de mama las claves para la acción las dio una mujer que relata su historia de cáncer de mama a las profesoras (16). esta conducta amenazadora permitió que las mujeres se realizaran su autoexamen de mama, posibilitando un diagnóstico temprano y, por lo tanto, mejor calidad de vida. adicionalmente, el concepto de autoeficacia es útil para entender comportamientos relacionados con el cuidado de la enfermedad crónica que requiere cambios comportamentales en un largo periodo. de acuerdo con el modelo, las creencias sobre la importancia o gravedad de un determinado problema, la vulnerabilidad frente a ese problema y el que la acción que se debe implementar produzca más beneficios que costos personales, favorecen la conservación y el mejoramiento de la salud, la evitación de conductas de riesgo, la prevención de las enfermedades, y lo que en general puede denominarse la adopción de estilos de vida saludables. de acuerdo con lo anterior, la enfermera podría apoyarse en la percepción de amenazas y las creencias en la reducción de las mismas, para que las personas interioricen que el cáncer es grave, que están en gran riesgo, presentar indicadores de ese riesgo, dar a conocer factores de prevención del cáncer, reconocer el significado del cáncer en los pacientes para reconocer su motivación en realizar los esfuerzos, y ubicar recursos para desarrollar las conductas seguras. el mcs es una teoría construida en la valoración subjetiva de una determinada expectativa. en términos de salud, el valor será el deseo de evitar la enfermedad o el padecimiento, y la expectativa será la creencia en que una acción posible de realizar prevendrá o mejorará el proceso. teorías y modelos relacionados con calidad de vida en cáncer y enfermería 27 relación calidad de vida teorías expuestas y enfermería es frecuente hablar de promoción y prevención para referirse a estilo de vida saludable, como si fueran una misma cosa. algunos autores han expresado la promoción como una dinámica más ambiciosa que la prevención; la promoción apunta hacia la vida, el desarrollo y la realización del ser humano, pertenece más a los ámbitos sociales, es un intersectorial con acciones colectivas que posibilita factores protectores en la construcción de ambientes saludables y, consecuentemente, mejores estilos de vida. por calidad de vida se recoge la definición de font, quien la entiende como la valoración subjetiva que el paciente hace de diferentes aspectos de su vida en relación con su estado de salud. estos diferentes aspectos serían los del funcionamiento físico, psicológico, social y los síntomas de la enfermedad y efectos secundarios de los tratamientos (17). la calidad de vida, en un sentido general, puede definirse como el equilibrio entre estados de bienestar y malestar. si la promoción apunta hacia la vida vale la pena reflexionar que en una discapacidad por cáncer, la persona está con vida limitada y la reflexión sería qué promoción se debe llevar a cabo en este tipo de vida para que sea de calidad. en esencia, las teorías mencionadas se relacionan con la calidad de vida en el paciente oncológico, complementándose para brindar herramientas en el manejo terapéutico, multidimensional del paciente oncológico, interactuando en la calidad de vida como un todo integral, físico, biológico, social y espiritual; este factor multidimensional en el enfoque hacia la calidad de vida permite manejar el equilibrio entre sus estados de bienestar y malestar a consecuencia de los síntomas de la enfermedad. así, la persona con cáncer hará uso de su multidimensionalidad, con factores internos para determinar el significado de los eventos relacionados con su enfermedad, habilitándose para decidir, asignar valores definitivos a objetos y eventos, capaz de predecir consecuencias y factores externos, basadas en recursos que pueden ser físicos, bioquímicos, materiales, cognitivos, emocionales, de actitud, interpersonales y macrosocioculturales. para la enfermera, por su parte, dentro de un equipo multidisciplinario, el reto es ser cuidadora y facilitadora de dichos recursos para contribuir a esa mayor calidad de vida del paciente oncológico. la enfermera también relaciona los fundamentos de las teorías de afrontamiento, crisis, creencias y autocuidado para un mejor abordaje en el cambio de conductas y reducción de emociones negativas del paciente oncológico. los estilos de vida involucran la manera como la gente piensa, siente y actúa, lo cual va más allá del conocimiento individual que se tenga, y refleja valores y tradiciones. para algunos son el conjunto de hábitos, consumos y costumbres insertos en la vida cotidiana, que a la vez que se transmiten históricamente, son susceptibles de ser cambiados por medio de intervenciones ya sean positivas o negativas a través de la comunicación y la educación social (18). respecto a la promoción de la salud el consejo internacional de enfermeras (cie) expresó que las enfermeras pueden preparar, en colaboración con otros profesionales, el camino para la salud, ya que ellas trabajan en contextos diferentes que brindan oportunidades ideales para que con la promoción de la salud se creen hogares, lugares de trabajo, escuelas y ambientes saludables (19). este trabajo considera la necesidad de la promoción de la salud como un eje expansivo que también atraviese el concepto de enfermedad �aun en ésta se debe hacer promoción�. éste es un punto que podría llamarse de encuentro inicial hacia la calidad de vida y su relación con la vida del paciente con cáncer, dado que éste compite con grandes limitaciones. la adaptación a una vida con cáncer o el mantenimiento de un nivel razonable de calidad de vida puede considerarse como relativo a la reducción de las emociones negativas y a la creación de una situación vital con fuentes adecuadas de gratificación personal y satisfacciones diarias (20). las teorías expuestas apoyan la práctica del cuidado en la disciplina de enferla adaptación a una vida con cáncer o el mantenimiento de un nivel razonable de calidad de vida puede considerarse como relativo a la reducción de las emociones negativas y a la creación de una situación vital con fuentes adecuadas de gratificación personal y satisfacciones diarias. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200528 mería desde el referente de los procesos cognitivos, conductuales, preceptuales y significativos, cambiantes en el individuo en relación con su entorno; estos aspectos involucran la dimensión física, biológica, emocional y espiritual del individuo. estas teorías, originadas desde la psicosociología y la enfermería, aportan al surgimiento de nuevos modelos y teorías que generen el bienestar, el desarrollo humano, en beneficio de la persona y, por lo tanto, mejoren indicadores de dicha calidad de vida. los aspectos psicosociales hacen parte de los cuidados que brinda la enfermería en cáncer, y que surgen de las respuestas individuales de los pacientes, las familias o las personas que integran el mundo del paciente y del diagnóstico confirmado. de acuerdo con lo mencionado, la calidad de vida incluye múltiples dimensiones: físicas, sociales, psicológicas y espirituales, que la enfermera tiene en cuenta en su plan de cuidados. específicamente para el paciente con cáncer, las medidas de bienestar son actividades funcionales de manejo del dolor, la fatiga, el cansancio, el sueño, las náuseas, los vómitos y otros síntomas como respuestas individuales del paciente. las medidas de bienestar social son actividades funcionales de afecto, apariencia y relación con sus familiares, amigos, preocupaciones del trabajo, aceptación y apoyo familiar, y estar atenta a otros síntomas como respuestas individuales del paciente. las medidas de bienestar psicológico se relacionan con el apoyo en el control de la ansiedad, el estrés, la desadaptabilidad, la cognición y la angustia que generan la enfermedad como respuestas individuales del paciente. el bienestar espiritual se relaciona con la fe, las creencias y los significados interiores de cada paciente; sólo escuchando al paciente y observando sus respuestas la enfermera comparte confianza y buena terapéutica hacia mejor calidad de vida del paciente oncológico. algunos instrumentos de medición de calidad de vida en pacientes oncológicos en 1948 la organización mundial de la salud (oms) definió la salud como el completo estado de bienestar físico, mental y social, y no sólo la ausencia de enfermedad; este concepto ha evolucionado hasta métodos objetivos los cuales, mediante cuestionarios o instrumentos, generan escalas e índices que permiten medir las dimensiones que conforman el estado de salud. actualmente la salud de una persona se mide más allá de su capacidad física, teniendo en cuenta el contexto social y su salud mental. considerando que las expectativas de salud, el soporte social, la autoestima y la habilidad para competir con limitaciones y discapacidad, pueden afectar la calidad de vida, dos personas con el mismo estado de salud tienen diferente percepción personal de su salud. la consideración del factor multidimensional muestra un enfoque hacia la calidad de vida, otro puede ser la efectividad del tratamiento oncológico. las mediciones de calidad de vida van aumentando rápidamente, siendo obligatoria en algunos países como canadá. estas mediciones pueden ser útiles entre otras razones porque los métodos de valoración tradicionales no miden los efectos que el cáncer y su tratamiento ejercen en las dimensiones emocionales, espirituales y sociales, porque la calidad de vida puede estar afectada aunque el paciente esté curado, porque la calidad de vida puede mejorar aunque no se produzcan efectos en la supervivencia, o porque puede ayudar a conocer preferencias de los pacientes. se han observado diferentes interpretaciones en evaluaciones de calidad de vida entre el paciente, la familia y el equipo de salud. es el paciente quien debe emitir el juicio perceptivo de su calidad de vida. se ha evaluado la calidad de vida en diversos grupos con diferentes padecimientos y con distintos instrumentos (21). la opinión de muy diversos autores lleva a decir que hay un consenso en que la calidad de vida es un fenómeno subjetivo y debe ser el propio paciente quien la valore. las percepciones que el paciente tiene de su enfermedad son muy variables, y diversos factores, además de los físicos, entran en juego al medir la calidad de vida. por ejemplo, dos pacientes pueden entender de manera muy distinta el mismo alivio del dolor, si uno de ellos considera que es un signo de esperanza y el otro no. además, puede que las valoraciones de los pacientes sean diferentes de las de los médicos, y también de las de los familiares (17). el bienestar espiritual se relaciona con la fe, las creencias y los significados interiores de cada paciente; sólo escuchando al paciente y observando sus respuestas la enfermera comparte confianza y buena terapéutica hacia mejor calidad de vida del paciente oncológico. teorías y modelos relacionados con calidad de vida en cáncer y enfermería 29 históricamente, en los ensayos de la organización europea para la investigación y tratamiento del cáncer (eortc) y de otros grupos, ha sido el médico el que ha medido los niveles de funcionamiento físico y de toxicidad. actualmente, sin embargo, hay una corriente que cree que debe ser el paciente quien mida su calidad de vida. la posición desde esta perspectiva apoya la participación del paciente en la medición de su calidad de vida, dado que él visualizará sus significados realmente. en cuanto a los instrumentos, tal vez la primera escala desarrollada con el propósito de definir en una forma consistente el estado funcional de los pacientes con padecimientos crónicos fue la de karnosfky (kps); esta escala presentó 10 puntos para pacientes con cáncer pero por ser genérica se aplica a otras enfermedades crónicas; se consideró una escala confiable para predecir el estado funcional del paciente. es simple y de rápida aplicación, y ha demostrado su excelente reproductibilidad y validez (21). la calidad de vida es un concepto relativamente nuevo en la evaluación de la salud, pero los instrumentos genéricos permiten evaluar diversos grupos y poblaciones, y los instrumentos específicos permiten medir el impacto de un diagnóstico específico en condiciones crónicas. la organización europea para la investigación y el tratamiento del cáncer (eortc) ha trabajado dos generaciones del cuestionario: el qlq-c36 y el qlq-c30. la primera generación del cuestionario, el qlq-c36, constaba de 36 ítems, que se organizaban en cuatro escalas funcionales, dos escalas de síntomas y una escala global de salud/calidad de vida. unos ítems adicionales evaluaban otros síntomas comunes y el impacto financiero. el de gorgono-woodgate para abordar la exigencia multidimensional (esferas económica, física, somática y psicosocial), que incluye la evaluación cuantitativa, y se agregó la estimación subjetiva del paciente sobre el grado de satisfacción alcanzado. el programa nacional de cáncer en cuba utiliza el índice de karnofski (ik) para evaluar la condición física de los enfermos con cáncer paliativo y terminal. conclusiones 1. tanto las personas sanas como a q u e l l a s q u e s e e n c u e n t r a n e n desequilibrio de su salud, necesitan observar conductas saludables que les permitan afrontar situaciones de estrés, de crisis, de desadaptabilidad a través de manejos adecuados de autocuidado, afrontamiento, adaptabilidad, a fin de aproximarse a una vida más sana y con mejor calidad. 2. las teorías expuestas en este trabajo apoyan la práctica del cuidado en la disciplina de enfermería desde el referente de los procesos cognitivos, conductuales, preceptuales y significativos, cambiantes en el individuo en relación con su entorno; estos aspectos involucran las esferas física, biológica, emocional y espiritual del individuo. estas teorías, originadas desde la psicosociología y la propia enfermería, son importantes para el soporte de ellas y de otras, dando origen al surgimiento de nuevos modelos y teorías que generen bienestar y desarrollo humano en beneficio del hombre y, por lo tanto, mejores indicadores de calidad de vida. 3. se considera una excelente aproximación de calidad de vida, la descrita por font, entendida como la valoración subjetiva que el paciente hace de diferentes aspectos de su vida en relación con su estado de salud. estos diferentes aspectos serían los del funcionamiento físico, psicológico y social, y los síntomas de la enfermedad y efectos secundarios de los tratamientos. 4. la calidad de vida incluye múltiples dimensiones: físicas, sociales, psicológicas y espirituales, que la enfermera tendrá en cuenta en su plan de cuidados; específicamente para el paciente con cáncer, las medidas de bienestar serán actividades funcionales de manejo del dolor, la fatiga, el cansancio, sueño, náuseas, vómitos y otros síntomas como respuestas individuales del paciente. las medidas de bienestar social serán actividades funcionales de afecto, apariencia y relación con sus familiares, amigos, preocupaciones del trabajo, aceptación y apoyo familiar, y estar atenta a otros factores como respuestas indila calidad de vida es un concepto relativamente nuevo en la evaluación de la salud, pero los instrumentos genéricos permiten evaluar diversos grupos y poblaciones, y los instrumentos específicos permiten medir el impacto de un diagnóstico específico en condiciones crónicas. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200530 referencias bibliográficas 1. marriner a, raile m. modelos y teorías en enfermería. 5ª ed. madrid: el sevier science; 2003. 2. bastías e, sanhueza o. conductas de autocuidado y manifestaciones perimenopáusicas en mujeres de la comuna de concepción, chile. ciencia y enfermería 2004;10(1):41-56. 3. mishel m. reconceptualization of the uncertainty in illnes theory. image: journal of nursing scolarship 1990;22(4):256-257. 4. isla x. percepción de incertidumbre de los pacientes diabéticos, controlados en el consultorio adosado de especialidades del hospital herminia martín de chillán, chile, 1994-1995. ciencia y enfermería 1996; 2(1):71-80. 5. mishel m. the measurement of uncertainty in illness. nursing research 1981;30(5):261. 6. lazarus r, folkman s. estrés y procesos cognitivos. barcelona: martínez roca; 1996. 7. kaplan h, sadock. tratado de psiquiatría. 2ª ed. barcelona: ediciones científicas y técnicas; 1989. 8. montoya r. el afrontamiento y la pérdida: visiones positivas de la labor de un cuidador: nicolás robles gravi. index enferm digital 2004; 44-45 [en línea]. con acceso el 04/10/2004. disponible en: http:// www.indexf-enfermería/44revista/44artículo-5659.php 9. riquelme n, merino j. sistemas de afrontamiento en familias de enfermos alcohólicos. ciencia y enfermería 2002;8(1):37-47. 10. prieto v l. estilo y efectividad del afrontamiento de las esposas de los pacientes con infarto agudo del miocardio. ciencia y enfermería 1998;4(1):45-54. 11. otto se. enfermería oncológica. 3ª ed. barcelona: harcourt brace; 1999. 12. martínez gc. ilustración clínica de la técnica de intervención en crisis. rev de psiquiatría 1999; 15(3):169-174. 13. soto f, lacaste j, papenfess r y cols. el modelo de creencias en salud. un enfoque teórico para l a p r e vención de sida. rev esp salud pública 1997;71(4):335-341. 14. mendoza s, figueroa m. creencias en salud y adherencias en pacientes hipertensos controlados en centros de salud de la comuna de concepción chile. ciencia y enfermería 1998;4(1):63-76. viduales del paciente. las medidas de bienestar psicológico se relacionan con el apoyo en el control de la ansiedad, el estrés, la desadaptabilidad, la cognición y la angustia que genera la enfermedad como respuestas individuales del paciente. el bienestar espiritual se relaciona con la fe, las creencias y los significados interiores de cada paciente; sólo escuchando y observando sus respuestas se podrá compartir confianza y buena terapéutica hacia mejor calidad de vida del paciente oncológico. 5. la calidad de vida es un concepto relativamente nuevo en la evaluación de la salud; en ésta los instrumentos genéricos permiten evaluar diversos grupos y poblaciones, y los instrumentos específicos permiten medir el impacto de un diagnóstico determinado en condiciones crónicas. la medición de calidad de vida debe incorporar la dimensionalidad física, social, psicológica y espiritual. 6. la opinión de diversos autores lleva a decir que hay un consenso en que la calidad de vida es un fenómeno subjetivo y debe ser el propio paciente, quien la valore. finalmente, una buena calidad de vida habrá pasado por una adecuada promoción de la salud, considerada ésta en todas sus dimensiones. teorías y modelos relacionados con calidad de vida en cáncer y enfermería 31 15. arrivillaga m, salazar ic, correa d. creencias sobre la salud y su relación con las prácticas de riesgo o de protección en jóvenes universitarios. colomb med 2003;(34):186-195. 16. sanhueza o. efecto de un programa educativo reforzado en la conducta autoexaminadora de mama de profesoras del liceo de niñas de concepción. ciencia y enfermería 1995;i(1):53-59. 17. arrarás j, dueñas t, meiriño e, prujá e, villafranca j, valerdi j. la calidad de vida en el paciente oncológico: estudio del servicio de oncológia del hospital de navarra en el grupo de calidad de vida de la eortc [en línea]. con acceso en 04/10/2004. disponible en: http://www.cfnavarra.es/salud/anales/textos/ vol21/n1/revista2a.htm 18. espinosa de r. la epidemiología, las políticas públicas saludables. rev. facultad de salud pública. universidad de antioquia, medellín 1995;12(2):63-76. 19. consejo internacional de enfermeras. el cie y la movilización de las enfermeras para la promoción de la salud [en línea]. con acceso en 04/10/2004. disponible en: www.icn.ch 20. lugo j, bacallao j, rodríguez g. validez de contenido de un cuestionario para medir calidad de vida en pacientes con cáncer de mama. rev cubana oncol 2000;2(16):100-106. 21. velarde e, ávila c. evaluación de la calidad de vida. rev. salud pública de méxico 2002;44(4):349-361. 523 536 efectividad de un plan de apoyo.indd 523 berta gorlat-sánchez1 mª paz garcía-caro2 patricia peinado-gorlat3 concepción campos-calderón4 yolanda mejías-martín5 francisco cruz-quintana6 efectividad de un plan de apoyo a cuidadores en dos hospitales públicos de granada (españa) 1 enfermera doctora. hospital de baza, granada (españa). bertagorlat7@hotmail.com 2 enfermera antropóloga. profesora, facultad ciencias de la salud, universidad de granada (españa). mpazgc@ugr.es 3 enfermera, hospital de baza, granada (españa). patricia_wata@hotmail.com 4 psicóloga, fundación para la investigación de andalucía oriental (fibao), granada (españa). concha_campos@hotmail.com 5 enfermera, hospital virgen de las nieves, granada (españa). yolandamejiasmartin@yahoo.es 6 psicólogo doctor. profesor, facultad ciencias de la salud, universidad de granada (españa). fcruz@ugr.es recibido: 2 de marzo de 2013 enviado a pares: 19 de abril de 2013 aceptado por pares: 28 de noviembre de 2013 aprobado: 24 de febrero de 2014 doi: 10.5294/aqui.2014.14.4.7 para citar este artículo / to reference this article / para citar este artigo gorlat-sánchez b, garcía-caro mp, peinado-gorlat p, campos-calderón c, mejías martín y, cruz quintana f. efectividad de un plan de apoyo a cuidadores en dos hospitales públicos de granada (españa). aquichan. 2014; 14 (4): 523-536. doi: 10.5294/aqui.2014.14.4.7 resumen objetivo: dos hospitales granadinos realizan una experiencia pionera implementando medidas de apoyo innovadoras para personas cuidadoras. transcurridos dos años desde su implantación se plantea: ¿las medidas implementadas han logrado los beneficios esperados en personas cuidadoras en hospitalización? para responder se realiza un estudio con el objetivo de evaluar la efectividad de las medidas de apoyo a personas cuidadoras incluyendo propuestas de mejora. materiales y métodos: estudio cualitativo, interpretativo, basado en la teoría fundamentada. se realizaron 45 entrevistas en profundidad a personas cuidadoras con distintos perfiles, en los hospitales virgen de las nieves y baza. se ha seguido como estrategia de análisis la comparación constante y la codificación abierta y axial. se contó con el apoyo del software atlas.ti®. resultados: las personas cuidadoras valoran positivamente la mayoría de las medidas, destacando personalización, educación, hostelería y accesos prioritarios. la identificación de enfermera y auxiliar referentes no siempre ha funcionado bien. la utilización de zonas de descanso habilitadas ha sido escasa, debido principalmente a su ubicación. conclusiones: las medidas implementadas han mejorado el bienestar y la autoestima de las personas cuidadoras durante la hospitalización. aportan una evidencia que anima a extenderlas a otros hospitales y mejorar el trato y el apoyo a este colectivo. palabras clave cuidadores, hospitalización, dependencia, cuidado de enfermería, programas de bienestar. (fuente: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 523-536 524 aquichan issn 1657-5997 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 523-536 effectiveness of a plan to support caregivers at two public hospitals in granada (spain) abstract purpose: two hospitals in granada are involved in a pioneering experience to implement innovative measures to support caregivers. two years after the onset of that initiative, the question is: are the measures implemented achieving the expected benefits for caregivers during hospitalization? a study was conducted to answer that question by evaluating the effectiveness of those measures, including suggestions for improvement. study materials and methods: this is a qualitative, interpretive study based on grounded theory. forty-five (45) in-depth interviews were conducted at the virgen de las nieves and baza hospitals with caregivers who have different profiles. the strategy for analysis involved constant comparison and open and axial coding, supported by atlas.ti® software. results: the caregivers reacted positively to most of the measures, highlighting personalization, education, accommodation and priority access. use of the term nurse and auxiliary nurse as a form of identification has not always worked well. only limited use has been made of the areas outfitted for rest and relaxation, mainly due to their location. conclusions: the measures implemented have improved the well-being and self-esteem of caregivers during hospitalization. moreover, they provide evidence that encourages their extension to other hospitals to improve the way this group is treated and the support it receives. key words caregivers, hospitalization, dependency, nursing care, wellness programs. (source: decs, bireme). 525 efectividad de un plan de apoyo a cuidadores en dos hospitales públicos de granada (españa) l berta gorlat-sánchez y otros. efetividade de um plano de apoio a cuidadores em dois hospitais públicos de granada (espanha) resumo objetivo: dois hospitais granadinos realizam uma experiência pioneira implementando medidas de apoio inovadoras para pessoas cuidadoras. transcorridos dois anos de sua implantação, propõe-se: as medidas implantadas têm atingido os benefícios esperados em pessoas cuidadoras em hospitalização? para responder a essa pergunta, realiza-se um estudo com o objetivo de avaliar a efetividade das medidas de apoio a pessoas cuidadoras em que são incluídas propostas de melhoria. materiais e métodos: estudo qualitativo, interpretativo, baseado na teoria fundamentada. realizaram-se 45 entrevistas em profundidade a pessoas cuidadoras com diferentes perfis, nos hospitais virgen de las nieves e baza. como estratégia de análise, foi seguida a comparação constante e a codificação aberta e axial. contou-se com o apoio do software atlas.ti®. resultados: as pessoas cuidadoras valorizam positivamente a maioria das medidas e destacam: personalização, educação, hotelaria e acessos prioritários. a identificação de enfermeira e auxiliar referentes nem sempre tem funcionado bem. a utilização de áreas de descanso habilitadas é escassa, devido, principalmente, a sua localização. conclusões: as medidas implantadas têm melhorado o bem-estar e a autoestima das pessoas cuidadoras durante a hospitalização. além disso, estimulam sua extensão a outros hospitais e melhoram o tratamento e o apoio a esse coletivo. palavras-chave cuidadores, hospitalização, dependência, cuidado de enfermagem, programas de bem-estar. (fonte: decs, bireme). año 14 vol. 14 nº 4 chía, colombia diciembre 2014 l 523-536 526 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 introducción en la sociedad actual nos enfrentamos a un incremento de la demanda de cuidados de una población en la que aumenta el número de pacientes con enfermedades crónicas (1). para la mayoría de las familias el cuidado no es una opción, y cada vez más dependen de sus propios mecanismos de apoyo. distintos estudios ponen de manifiesto la importancia y las ventajas de la colaboración de los familiares en el cuidado de los pacientes, pero se ha comprobado que la asunción del cuidado supone una alta afectación personal, pudiendo tener un impacto importante en el seno familiar, que se agudiza en los casos de hospitalización por sus especiales connotaciones de entorno desconocido y pérdida de privacidad e intimidad (2-5). el hospital nunca se pensó para las personas cuidadoras (en adelante pc), y su apoyo durante la hospitalización es un tema poco desarrollado en la bibliografía (6). a nivel internacional se conocen distintas actuaciones con pc, destacando las realizadas en países miembros de la unión europea, nueva zelanda, canadá y en países de américa latina, que pueden servir de referencia para analizar la eficiencia y efectividad de los actuales modelos de gestión de cara a cubrir las necesidades sociosanitarias de las personas dependientes y de sus cuidadores. por otra parte, el constante aumento de pacientes dependientes insta a analizar y sopesar los costes directos e indirectos de la intervención de las pc. en este sentido, la organización para la cooperación y el desarrollo económico (ocde) y la comisión europea, contemplan acciones y apoyos importantes de los estados miembros en relación con los cuidados de larga duración y el apoyo a las pc (7-12). centrándonos en nuestro país, y más concretamente en la comunidad autónoma de andalucía, se comprueba que el sistema de provisión de cuidados se basa fundamentalmente en el cuidado informal, siendo lo más habitual que la pc tenga una relación familiar directa y conviva con la persona a la que atiende, lo que supone una mayor fragilidad y exclusividad de los cuidados (13). puesto que los periodos de hospitalización de las personas dependientes son frecuentes, estos se convierten en una oportunidad para que las pc sean atendidas por profesionales del hospital durante el periodo de ingreso, pudiendo este acercamiento generar mejoras en su bienestar y, con ello, en el de las personas cuidadas (14). la consejería andaluza de salud y bienestar establece entre sus prioridades la mejora de la atención a las familias y a las pc, amparándose legislativamente en el decreto de apoyo a las familias andaluzas (2002) (15,) y en la ley de promoción de la autonomía personal y atención a las personas en situación de dependencia y a las familias (2006) (16). en este marco, se establece el plan de mejora de la atención a las pc, dentro del cual, en dos hospitales de granada (virgen de las nieves y baza), se desarrolla un plan funcional pionero con medidas de apoyo, de gestión y de priorización a las pc en hospitalización (17-18). las intervenciones de este plan funcional son realizadas fundamentalmente por el personal de enfermería, aunque también se cuenta con la participación de administrativos, trabajadores sociales, fisioterapeutas, técnicos especialistas, médicos, farmacéuticos, celadores, personal de hostelería y limpiadoras de los dos hospitales. se realizó un pilotaje para comprobar la adecuación de las medidas de apoyo, para lo cual dichas medidas se implementaron en las unidades donde se habían identificado anteriormente mayor número de pc (medicina interna, oncología, digestivo y cirugía). se realizó seguimiento y evaluación continua de su efectividad durante seis meses por un grupo multidisciplinar de profesionales constituido por: enfermeras, auxiliares de enfermería, trabajadoras sociales y gestores de casos. posteriormente, se realizó una evaluación final y se propusieron adaptaciones y mejoras de las medidas, quedando el plan funcional de apoyo a las pc implementado definitivamente en el hospital virgen de las nieves en enero de 2009 y en el hospital de baza en noviembre de 2010. las medidas implementadas en ambos hospitales han sido: asignación de enfermera y auxiliar referentes, información y personalización de cuidados a la pc en situación de ingreso; identificación de las pc con tarjetas personalizadas; educación individualizada y grupal en cuidados mediante talleres formativos; accesos prioritarios; apoyo al descanso y aseo; coordinación de citas y pruebas complementarias; atención sanitaria, farmacéutica y social a la pc y apoyo hostelero. pasado un tiempo tras su implementación en cada hospital, se ha realizado una investigación con el objetivo de evaluar la efectividad de las medidas de apoyo a las pc, incluyendo también propuestas de mejora. 527 efectividad de un plan de apoyo a cuidadores en dos hospitales públicos de granada (españa) l berta gorlat-sánchez y otros. materiales y métodos se realizó un estudio de diseño cualitativo interpretativo, basado en la teoría fundamentada (19-20). el ámbito de estudio fueron las plantas de hospitalización de adultos de los servicios de medicina interna, oncología, digestivo, cirugía, nefrología y neumología del hospital universitario virgen de las nieves de granada y del hospital comarcal de baza (granada). el periodo de estudio fue desde enero de 2010 a junio de 2012, siendo la recogida de datos desde marzo de 2010 a enero de 2012. participantes. los sujetos de estudio fueron las pc de los hospitales indicados que cumplían los siguientes criterios de inclusión: haber tenido experiencias previas a la implementación del plan funcional como pc en el mismo hospital; estar en ese momento identificada por su enfermera referente como pc, para ello habían de cumplir los criterios referidos al paciente y a la pc del plan funcional representados en la tabla 1; y aceptar participar en la investigación. el procedimiento de muestreo fue intencional o de casos. la selección de las pc se realizó teniendo en cuenta criterios de heterogeneidad y de homogeneidad. para determinar los criterios de heterogeneidad se realizó una búsqueda de evidencias, identificándose como principales criterios que podían hacer variar el discurso de las pc: el sexo, la edad, el ámbito donde viven habitualmente, la situación laboral, el nivel de estudios y las cargas familiares (9, 21-24). los criterios de homogeneidad fueron los mismos que los de inclusión. a partir de la combinación de los criterios de heterogeneidad se establecieron los distintos perfiles de pc: mujeres/hombres, menores/mayores de 55 años, ámbito urbano/rural, con/ sin cargas familiares, y nivel de estudios ningunos/primarios y secundarios/superiores. se seleccionaron aquellos casos más representativos de pc en función de su aportación conforme a los objetivos del estudio, buscando la saturación de los datos en todos los perfiles en los que fue posible. instrumentos. los datos generales se recogieron en un documento ad hoc con todas las variables sociodemográficas de las pc. para las entrevistas en profundidad se elaboro un guión semiestructurado de preguntas abiertas de acuerdo con los objetivos del estudio. la pregunta orientadora se centró en los cambios y apoyos percibidos por las pc en el hospital con respecto a ingresos anteriores (“con respecto a ingresos anteriores ¿ha notado cambios en la atención que se le ha prestado como pc?”); las preguntas secundarias que se derivaron posteriormente se refirieron al nivel de satisfacción con cada uno de los apoyos recibidos, a las propuestas de cambios y a las mejoras que realizarían las pc al plan funcional. procedimiento. las informantes clave que identificaron a las posibles pc candidatas al estudio fueron las supervisoras de las unidades de hospitalización incluidas en el estudio. a cada pc incluida en el estudio se le explicaron los objetivos del mismo, el procedimiento que se seguiría, en qué consistiría su colaboración, cuánto tiempo aproximadamente les podía tomar, y cuál iba a ser la utilización de los datos. además, se le hizo entrega de la hoja informativa y se procedió a la firma del consentimiento informado. los investigadores realizaron 45 entrevistas en profundidad. estas se hicieron de forma individual, en una sola sesión, y fueron lo suficientemente flexibles para que las pc entrevistadas pudieran expresar lo que desearan sin restricciones. la hora de realización fue pactada en cada caso con la pc que iba a ser entrevistada, adaptándose siempre los investigadores a sus preferencias. el lugar de realización fue un espacio situado en el propio hospital, este espacio reunía condiciones de comodidad e intimidad necesarias para llevar a cabo las entrevistas, permitiendo que las pc no tuviesen que desplazarse fuera del mismo. el tiempo de duración osciló entre 20 y 60 minutos, estas se grabaron en formato audio mediante grabadora y se transcribieron literalmente, volcándolas en la unidad hermenéutica del software atlas.ti® creada para la base de datos. análisis de la información. el enfoque fue interpretativo, mediante la estrategia de comparación constante de la teoría fundamentada. se adoptó la secuencia propuesta por strauss y corbin (25), para ello se partió de una serie de categorías que emergían del marco conceptual y que se emplazaron en las preguntas del guión de las entrevistas. posteriormente, se realizó 528 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 una codificación abierta y axial de los textos transcritos, con el objetivo de identificar en el texto aquellos códigos y categorías que las pc consideraron relevantes. por último, se identificaron las categorías y subcategorías principales de análisis (ver figura), y se formuló una teoría explicativa del fenómeno. se contó con el apoyo del software atlas.ti®, versión 5.0. para el control de calidad de la investigación se utilizó el procedimiento de triangulación de investigadores, realizando la confrontación de las opiniones de varios de ellos con el fin de reflexionar e interpretar los datos obtenidos, lo que resultó muy interesante y enriquecedor a la hora del análisis y la interpretación de los datos. en los resultados se identificaron las citas textuales diferenciándolas de las interpretaciones, y los resultados se compararon con la bibliografía existente en la discusión. aspectos éticos. el estudio fue aprobado por los comités éticos de investigaciones clínicas y de investigación de ambos hospitales. en todos los casos la participación de las pc fue precedida de información oral y escrita, y fue de carácter voluntario tras firmar el consentimiento informado. se mantuvo la confidencialidad de los datos (ley orgánica 15/1999 de 13 de diciembre, real decreto 994/99), y se numeraron las entrevistas para su identificación. no existieron conflictos éticos, ni de intereses. resultados desde marzo de 2010 a enero de 2012 se identificó en ambos hospitales un total de 1119 pc (899 en el hospital virgen de las nieves y 220 en el hospital de baza), de las cuales 223 personas cumplían los criterios de inclusión; de ellas, 29 rehusaron participar en el estudio, en 43 casos no fue posible realizar la entrevista (19 por coincidir con la realización de pruebas, no siendo posible realizarla con posterioridad; 24 casos por ausencia reiterada de la pc del hospital cada vez que se citaba para hacer la entrevista) y en 51 casos se produjo la muerte del paciente antes de que fuese posible la entrevista. de los 100 casos restantes se seleccionaron 45 que fueron representativos de los distintos perfiles que se pretendían estudiar, de ellos 18 casos pertenecían al hospital de baza y 27 al hospital virgen de las nieves. la descripción de las características de las pc participantes se resume en la tabla 2. los resultados de las entrevistas se presentan organizados en función de las principales categorías finales de análisis, tres de las cuales coincidieron con las iniciales, mientras que la categoría “quejas” emergió en el discurso de las participantes. por razones de espacio, las citas textuales se exponen organizadas según las categorías y subcategorías de análisis en las tablas 3 a 5. cambios percibidos con respecto a ingresos anteriores (tabla 3). para evaluar la efectividad de las medidas de apoyo, una de las categorías que se mostró como clave fue la de los cambios percibidos con respecto a ingresos anteriores. las pc constataron en su discurso diferencias en el trato y en la atención prestada al estar identificadas con la tarjeta específica en el hospital. las principales medidas nuevas que han destacado se refieren a “tener su enfermera en la sala”, disponer de aseo y duchas diferentes de las de los enfermos, que se les faciliten almohadas y mantas para dormir, que les den la comida, o que les estén enseñando a realizar los cuidados que necesita su familiar con destreza. en todo este contexto se identifica la personalización de cuidados por la enfermera y la auxiliar de enfermería como el elemento central que condiciona los demás. aquellas personas que además necesitaron moverse por el hospital e incluso requirieron atención médica, pudieron comprobar las facilidades de acceso y la prioridad en atenderlas o en darles cita al estar identificadas como pc del plan funcional. satisfacción con las medidas implementadas (tabla 4). esta categoría recoge el efecto que las medidas de apoyo han tenido sobre las pc. se refiere a cómo se han sentido al ser tratadas de forma especial (tabla 4). las pc valoran de manera destacada el que se hayan interesado por ellas y por su familiar ingresado, haber dispuesto de una enfermera y una auxiliar de referencia, que les hayan suministrado material de aseo y la comida sintiéndose casi como “en un hotel”, o incluso, para algunas de ellas, que las hayan ubicado cerca del control de enfermería para favorecer la vigilancia de su familiar y facilitar su ausencia cuando lo han necesitado. en relación con la posibilidad de ausentarse y darse un respiro, han sido pocas las que han consentido hacerlo y solo lo han hecho por la urgencia en realizar alguna gestión. sin embargo, lo que más las ha satisfecho ha sido la oportunidad de que su enfermera y auxiliar referentes las formen en cuidados y las animen a asistir a los talleres educativos donde, además de aprender, han podido conocer a otras personas en su 529 efectividad de un plan de apoyo a cuidadores en dos hospitales públicos de granada (españa) l berta gorlat-sánchez y otros. misma situación y compartir experiencias. una “subida de autoestima” muy necesaria para muchas de ellas. se destaca como medida menos valorada la zona de descanso habilitada para ellas. la utilizan poco porque deben separarse del paciente al encontrarse lejos de su habitación. por otro lado, el hecho de que el acceso esté restringido solo a la pc les atrae poco. el sentir más generalizado con la atención recibida lo expone claramente una de ellas: no es por la comida o por lo que te den… es por la intención… por saber que hay gente que se preocupa de que estés bien y de que te pregunta que si te hace falta algo, porque saben que eres cuidadora y eso te da fuerzas para seguir adelante (e34). quejas y propuestas de mejora. la categoría “quejas” se refiere a las situaciones generadas cuando las medidas de apoyo han fallado, no han sido implementadas o no han sido suficientes. las propuestas de mejora realizadas por las pc coinciden con sus quejas, por lo que se han considerado de forma conjunta. las pc que han expresado quejas o protestas, lo han hecho fundamentalmente referidas a la falta de información sobre todas las medidas de apoyo que incluye el plan funcional, a la deficiente o ausente identificación de la enfermera referente, a las escasas medidas de confort, especialmente para el descanso, y al trato recibido en algunas consultas o servicios en los que de nada les ha servido la identificación de pc del plan funcional. en aquellos casos en los que se personalizaron los cuidados y la pc tuvo su enfermera y auxiliar de referencia no se emitieron quejas (tabla 5). la categoría “propuestas de mejora” recoge las sugerencias y peticiones para mejorar o corregir medidas que no funcionan bien o no están implementadas en todos los servicios. las pc se refieren principalmente a mejoras del confort durante la hospitalización, a la incorporación de medidas de apoyo psicológico y emocional, y a mejorar la información tanto con respecto al plan funcional como a la información médica recibida. discusión – conclusión el perfil de las participantes coincide, en general, con el descrito en la bibliografía para este colectivo (9, 14, 23, 26). por otra parte, la presencia de un número importante de hombres en nuestro estudio, poco frecuente según las referencias, puede deberse a circunstancias puntuales como la coincidencia de encontrarse en paro o estar jubilados y poderse ocupar del cuidado. aunque también puede indicar un cambio de tendencia hacia una mayor participación y corresponsabilidad en el cuidado, en consonancia con el incremento de hombres identificado por larrañaga y por garcía calvente, entre otros autores (21, 22). los resultados obtenidos sugieren que las medidas de apoyo a las pc en ambos hospitales han sido efectivas y bien valoradas, lo que ha permitido aumentar el bienestar, la información, educación, protección y autoestima durante la hospitalización, principalmente debido a la asignación de enfermera y auxiliar de referencia, al reconocimiento a su labor, a la identificación pública como pc ante las demás personas en el hospital, y a la oportunidad de compartir con otras pc en el hospital sus experiencias en los talleres grupales. aunque también en algunos casos las pc han emitido quejas en relación con la falta de información, déficit en la identificación de enfermera y auxiliar de referencia, falta de apoyo a las medidas de confort/descanso y en el trato que han recibido. con frecuencia, la invisibilidad del cuidado implica la invisibilidad del cuidador, situación que ya había detectado en su estudio quero (6); en este sentido, las medidas implementadas en el plan funcional estudiado en esta investigación, han conseguido que las pc dejen de ser invisibles y pasen a ser importantes en el hospital. las medidas más eficaces han sido aquellas que facilitan la vida diaria de las pc en el hospital (apoyo hostelero, aseo y descanso), y aquellas que les ayudarán a encarar las necesidades que van a tener cuando se encuentren en su domicilio. ambas son situaciones muy demandadas según los estudios referenciados en la bibliografía (6, 24-29). son numerosos los trabajos donde se demuestra que cuidar a pacientes dependientes produce importantes repercusiones. se destaca el estudio realizado por pérez et al. (27), en el que trata la elevada morbilidad psicológica producida por la sobrecarga y el estrés que padecen las pc, recomendando el diseño de planes de intervención educativa dirigidos a ellas. también los realizados por vázquez (28) y losada et al. (29), sobre la presencia de pensamientos disfuncionales relacionados con el estrés generado por el cuidado prolongado, asociados a depresión de la pc, mayor sobrecarga y cansancio en el desempeño del rol de cuidador de 530 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 acuerdo con la clasificación nanda (30) de diagnósticos enfermeros. por otra parte, en la bibliografía consultada se comprueba que, aunque existen gran cantidad de investigaciones que tratan aspectos relacionados con las consecuencias negativas del cuidado sobre el cuidador, las publicaciones sobre intervenciones dirigidas a reducir tales consecuencias son escasas. la revisión de lópez y crespo (31) señala la necesidad de intervenciones multidisciplinares para apoyar individualmente a las pc tanto de forma preventiva como de soporte, con los consiguientes beneficios tanto para ellas como para la persona dependiente, mientras que en la realizada por vernooij-dassen et al. (32) se demuestra que aún no hay evidencias concretas de resultados. en esta línea, la presente investigación sí aporta resultados de la efectividad de implementar un programa pionero de apoyo a las pc en el hospital, que incluye medidas de diferente tipo, exponiéndolo desde el punto de vista de las propias pc. los resultados obtenidos permiten concluir que, de manera generalizada, las medidas implementadas en ambos hospitales de forma pionera han aumentado el bienestar y la autoestima de las pc durante la hospitalización, aportando novedades con respecto a estudios anteriores. esta realidad anima a hacerlas extensivas a otros hospitales, mejorando de esta forma el trato y el apoyo al colectivo de pc, favoreciendo la equidad en la atención a estas personas, sin obviar la adaptación que habrá de producirse en cada contexto. la categoría que se ha mostrado como central, esto es, la que se identifica como teoría principal, ha sido la personalización de cuidados a través de la asignación de enfermera y auxiliar de enfermería referentes como principales responsables de que las medidas del plan funcional sean efectivas, favoreciendo la satisfacción de las pc con las medidas y la propuesta de mejoras a este. en futuros trabajos deberá completarse el estudio de la efectividad de este plan mediante el análisis de los costes directos e indirectos del cuidado, y profundizarse en el análisis de las diferencias entre los ámbitos urbano y rural, con el objeto de adaptar las actividades del plan funcional a las necesidades en uno y otro ámbito. agradecimientos a todas las personas cuidadoras que amablemente nos contaron su realidad, y a los profesionales colaboradores de los hospitales virgen de las nieves y baza. referencias 1. sistema de información del sistema para la autonomía y atención a la dependencia (sisaad). españa: ministerio de sanidad, servicios sociales e igualdad. gobierno de españa; 2011. 2. oliva j, vilaplana c, osuna r. el valor de los cuidados informales provistos a las personas mayores en situación de dependencia en españa. gac sanit. 2011;25(s):108-114. 3. pinquart m, sorensen s. correlates of physical health of informal caregivers: a meta-analysis. j gerontol, series b, psychological sciences and social sciences. 2007;62(2):126-37. 4. masanet e, la parra d. relación entre el número de horas de cuidado informal y el estado de salud mental de las personas cuidadoras. rev esp salud pública. 2011;85:257-266. 5. plan de atención a cuidadoras familiares en andalucía. andalucía: consejería de salud, junta de andalucía; 2005. 6. quero rufián a. los cuidadores familiares en el hospital ruiz de alda de granada. [tesis doctoral]. granada: universidad de granada; 2007. 7. marin b, leichsenring k, rodrigues r, huber m. who cares? care coordination and cooperation to enhance quality in elderly care in the european union. viena: european centre for social welfare policy and research, affiliated to the united nations; 2009. 8. sapag jc, lange i, campos s, piette jd. estrategias innovadoras para el cuidado y el autocuidado de personas con enfermedades crónicas en américa latina. rev panam salud pública. 2010;27(1):1-9. 531 efectividad de un plan de apoyo a cuidadores en dos hospitales públicos de granada (españa) l berta gorlat-sánchez y otros. 9. world health organization. regional office for europe, tarricone r, tsouros ad. home care in europe. the solid facts. world health organization. regional office for europe [internet]. 2008 [citado 2012 dic 19] disponible en: http://www.euro.who.int/document/e91884.pdf 10. agence nationale de services à la personne. plan 2 de développement des services à la personne [internet]. 2009 [citado 2013 enero 3]. disponible en: http://www.servicesalapersonne.gouv.fr/le-plan-2-de-2009-(9010).cml? 11. busque ma. les besoins non comblés de services à domicile chez les aînés canadiens. hamilton: social and economic dimensions of an aging population (sedap) [internet]. 2009 [citado 2013 enero 27]. disponible en: http://socserv2. socsci.mcmaster.ca/~sedap/p/sedap251.pdf 12. armi f, guilley e, lalive d’eepinay cj. the interface between formal and informal support in advanced old age: a tenyear study. ijal [internet]. 2008 [citado 2013 feb 17]; 3(1):5-19. disponible en: http://www.ep.liu.se/ej/ijal/2008/v3/ i1/a1/ijal08v3i1a1.pdf 13. monleón just m, dávalos alvarado rk, polo gutiérrez a, villacañas novillo e. perfil sociocultural del cuidador principal de la persona mayor dependiente y su formación específica en cuidados. enferm comunitaria (gran). 2007;1(3):20-25. 14. lópez lópez b, casado mejía r, brea ruiz m, ruiz arias e. características de la provisión de cuidados a las personas dependientes. nure inv. [internet]. 2011 [citado 2013 feb 12]; 9(56):12. disponible en: http://www.fuden.es/ficheros_administrador/original/nure56_original_provisdep.pdf 15. decreto 137/2002 de 30 de abril de apoyo a las familias andaluzas. boja nº 52. 4 de mayo de 2002, (57)7:127-34. consejería de salud, junta de andalucía. 16. boletín oficial del estado. ley 39/2006 de 14 de diciembre de promoción de la autonomía personal y atención a las personas en situación de dependencia y a las familias. boe nº 299 de 15/12/2006 17. gorlat sánchez b, martín berrido m, alcántara díaz c, calle garcía mj, cueto rejón e, gonzález guerrero l, et al. plan funcional de personas cuidadoras en el hospital virgen de las nieves de granada. granada; 2010. 18. gorlat-sánchez b, sola-peral a, peinado-gorlat p, pérez-sáez f, lópez-hidalgo j, alarcón-cardona j, et al. medidas de apoyo a las personas cuidadoras en el hospital de baza. granada; 2012. 19. amezcua m, gálvez-toro a. los modos de análisis en investigación cualitativa en salud: perspectiva crítica y reflexiones en voz alta. rev esp salud pública. 2002;76:423-436. 20. taylor sj, bogdan r. introducción a los métodos cualitativos de investigación. barcelona: paidós; 1992. 21. larrañaga i, valderrama mj, martín u, begiristain jm, bacigalupe a, arregi b. mujeres y hombres ante el cuidado informal: diferencias en los significados y las estrategias. rev fac nac salud pública. 2009;27(1):50-55. 22. garcía-calvente m, del río-lozano m, marcos-marcos j. desigualdades de género en el deterioro de la salud como resultado del cuidado informal en españa. gac sanit. 2011;25(2 supl 2):100-7. 23. delicado useros mv, alcarria rozalen a, ortega martínez c, alfaro espin a, garcía alcaraz f, candel parra e. autoestima, apoyo familiar y social en cuidadores familiares de personas dependientes. metas de enfermería. 2010/11;10(13):26-32. 24. benito domingo ml, garcía manzano ai, lópez sagospe i. maría benito r, peláez ortiz r, rojas cabrera a. detección de necesidades de los familiares de pacientes ingresados en la unidad de ictus. rev cient soc esp enferm neurol. 2012;35(1):6-11. 25. strauss a, corbin j. editores. bases de la investigación cualitativa: técnicas y procedimientos para desarrollar la teoría (2ª ed.). medellín: universidad de antioquia; 2002. 26. harding r, list s, epiphaniou e, jones h. how can informal caregivers in cancer and palliative care be supported? an updated systematic literature review of interventions and their effectiveness. palliative medicine, 2012;26(1):7-22. 27. pérez martínez vt, de la vega pazitková t. repercusión de la demencia en los cuidadores primordiales del policlínico “ana betancourt”. rev cubana med gen integr. 2010:26(2). 28. vázquez-sánchez má, aguilar-trujillo mp, estébanez-carvajal fm, casals-vázquez c, casals-sánchez jl, heras-pérez mc. influencia de los pensamientos disfuncionales en la sobrecarga de los cuidadores de personas dependientes. enferm clin. 2012;22(1):11-7. 532 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 29. losada baltar a, montorio cerrato i, izal fernández de trocóniz m, márquez gonzález m. estudio e intervención sobre el malestar psicológico de los cuidadores de personas con demencia. el papel de los pensamientos disfuncionales. premio imserso “infanta cristina”. ministerio de trabajo y asuntos sociales; 2005. 30. diagnósticos enfermeros. definiciones y clasificación. nanda internacional. 2009-2011. españa: elsevier españa; 2010. 31. lópez j, crespo m. intervenciones con cuidadores de familiares mayores dependientes: una revisión. psicothema. 2007;19(1):72-80. 32. vernooij-dassen m, draskovic i, mccleery j, downs m. reconceptualización cognitiva para los cuidadores de los pacientes con demencia. cochrane database of systematic reviews. 2011;11(cd005318). tablas criterios referidos al paciente: (2 de los 3 siguientes criterios): 1. ingreso previsto con estancias superiores a 10 días en áreas médicas y 5 días en áreas quirúrgicas. 2. índice de barthel < 40, mantenido durante un periodo de al menos 7 días. 3. índice de pfeiffer ≥ 5 errores. criterios referidos a la pc: (2 de los 3 siguientes criterios): 1. asumir el rol de persona cuidadora en el domicilio. 2. presentar alto nivel de sobrecarga (índice de esfuerzo del cuidador ≥ 7 puntos). 3. capacidad para recibir información en cuidados y realizarlos de manera adecuada posteriormente en el domicilio. quedarán incluidas directamente como pc en el hospital todas aquellas personas que acudan al hospital identificadas como cgd. la identificación como pc la realizará cada enfermera referente durante la valoración inicial en las primeras 24 horas de ingreso del paciente. tabla 1. criterios de inclusión como persona cuidadora (pc) en el plan funcional fuente: plan funcional de pc en hospitalización. edad/sexo mujeres hombres estudios se/ep es/esp se/ep es/esp carga fam./ ámbito r u r u r u r u ≤ 55 con carga familiar 1 1 4 2 3 1 (44,4 %) sin carga familiar 1 2 2 1 1 1 >55 con carga familiar 3 4 1 1 (55,6 %) sin carga familiar 3 5 4 2 1 1 total 8 12 6 2 6 2 5 4 total 28 (62,2 %) 17 (37,8 %) tabla 2. características de las pc participantes en el estudio se/ep= sin estudios/estudios primarios. es/esp= estudios secundarios/estudios superiores. r= rural. u= urbano fuente: elaboración propia. 533 efectividad de un plan de apoyo a cuidadores en dos hospitales públicos de granada (españa) l berta gorlat-sánchez y otros. categoría cambios percibidos (con respecto a ingresos anteriores) personalización de cuidados ahora cuando ingresas tu enfermera te hace un montón de preguntas del enfermo y también pregunta por la cuidadora, y te dan una tarjeta especial para reconocerte, y eso no estaba antes cuando hemos venido al hospital (e6). el cambio mayor fue que vino una enfermera y me hizo muchas preguntas sobre mi madre, sobre mí y me contó que desde hace un tiempo en este hospital se está cuidando también a las cuidadoras como yo (e28). apoyo al aseo está mejor que en otras veces que hemos venido a ingresar, sobre todo porque, además, hay un aseo y unas duchas que están muy bien porque yo no me ducho en la de los enfermos (e26). apoyo al descanso en este ingreso he notado que están más amables con mi madre y conmigo, hasta si pueden, dejan la cama de al lado vacía para que me acueste yo por la noche, y cuando no puede ser, me dan almohadas y mantas para que me acomode en el sillón (e28). educación en cuidados nunca antes nadie me había dicho si lo que hago está bien o no, yo lo hago lo mejor que sé, …pero el otro día las auxiliares de la plante me enseñaron a ponerle la cuña sin hacerle daño, ellas tienen trucos que tú no sabes, …que luego te encuentras muy sola y sin saber a quién dirigirte (e17). he notado mucho cambio en el hospital, mucha mejoría de cómo me han tratado, hasta me han dado cita para ir a unas charlas que nos van a dar, aunque ya no me van a enseñar nada que yo no sepa, estar con otras mujeres como yo…, y hablar entre nosotras, y compartir lo que nos pasa, eso es también importante y ayuda a llevar el día a día (e27). información nuestra enfermera me ha dicho dónde me tengo que dirigir para solicitar ayudas y las ventajas que tengo al ser cuidadora. también me han enseñado para que yo le ayude a moverse y lo entienda mejor, y eso no lo han hecho otras veces que ha estado ingresado en el hospital (e30). atención sanitaria un día me puse muy mala con la garganta… la enfermera llamó a urgencias… y entonces… es que no esperaron, me atendieron de momento, dijo “vengo con esta señora, que está con su marido ingresado y la tienen que atender ahora”, y así fue. esa es una mejora que antes no estaba (e3). apoyo social he visto cambios y están muy bien, se agradecen,… cuando ingresamos la enfermera me hizo la tarjeta de cuidadora del hospital, que es distinta de la morada que yo traía…y la trabajadora social de aquí ha llamado a la del pueblo y juntas me están arreglando las cosas para que pueda cobrar la paga por encargarme yo de mi madre (e17). gestión de citas circuitos y traslados me han pedido una cita también con la enfermera del centro de salud y van a ver si me pueden mandar a una persona para que me ayude en la casa… esta vez mucho mejor, que en otro ingreso que tuvimos hace un año no me hicieron ni caso (e27). concesión de dieta alimenticia cuando estuve otra vez aquí en el hospital con él ingresado no había nada de esto y estuve comiendo bocadillos 2 semanas, a partir de ahí se me fastidió el estómago… pero ahora que me dan la comida mucho mejor (e23). tabla 3. citas de las entrevistas a pc incluidas en el estudio. categoría: cambios percibidos. fuente: elaboración propia. 534 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 categoría satisfacción con las medidas personalización de cuidados se han interesado mucho por los dos, por él y por mí, eso nunca lo habían hecho así, y me ha gustado (e30). estoy contenta, una enfermera vino y me dijo que ella sería mi enfermera y la de mi padre, …y empezó a hacerme preguntas, …incluso empezó a decirme cómo le tengo que dar la medicación (e25). apoyo al aseo es como en un hotel, te dan la toalla y el gel aquí en la planta (e3). apoyo al descanso fantástico, lo han puesto donde pueden vigilarlo y me han dicho que me vaya a descansar a mi casa,… lo necesitaba, no saben ellas lo que yo les agradezco eso, me encuentro mucho mejor (e8). a la sala de descanso de abajo voy solo cuando viene mi hija o hay alguien que se quede con él, allí te pones en los sillones y te relajas un poquillo o ves la tele, pero estás deseando de subirte para ver cómo está (e11). lo que pasa es que la sala de descanso la puede utilizar solo la persona que tenga la tarjeta,… y luego tengo que dejarlo solo porque está en el piso bajo,…yo en realidad no he bajado nunca (e12). educación en cuidados nos han explicado a mí y a mis hijos todo lo que hay que hacerle en la casa y hasta han llamado también a la enfermera del pueblo para contarle todo y que venga y vea si lo hacemos en condiciones… (e24). me ha subido la autoestima estar con otras personas cuidadoras y que nos digan en los talleres cómo cuidarnos también nosotros (e38). información cuando ingresamos en la planta nos preguntaron la enfermera y la auxiliar que quien era la cuidadora de mi tía, les dije que era yo y me comentaron que en este hospital hay un plan de apoyo a las personas cuidadoras. me informaron de en qué consiste y me llevé una agradable sorpresa, pensé que esto era a nivel del sas pero ya me dijeron ellas que no, que era una experiencia que se había puesto en marcha en dos hospitales de aquí de granada y me pareció muy acertado (e33). me hizo esta tarjeta, también me dijo que cuando nos fuésemos de alta se pondría en contacto con la enfermera del centro de salud para que me haga la tarjeta de cuidador de gran discapacitado, …me vendrá bien (e38). atención sanitaria mi nuera no me pudo traer los medicamentos, pero me los ha recetado el médico que tenemos aquí, así que muy bien (e8). apoyo social estoy más animada porque he hablado con la trabajadora social de aquí y va a ver si le puede buscar una residencia,…necesito tanto descansar (e45). les he contado que en la casa tenemos la habitación arriba y ella no puede subir las escaleras y nos van a ayudar, muchas gracias (e24). gestión de citas circuitos y traslados muy agradecido, incluso han arreglado las cosas para que venga nuestro fisioterapeuta aquí y así no pierda lo que lleva adelantado (e38). concesión de dieta alimenticia mi hermano también lo agradece, hasta a veces más que yo…cuando ve que me ponen la comida, se tranquiliza porque como me conoce, sabe que si dependiera de mí ni comía (e34). no es por la comida o por lo que te den, es por la intención …por saber que hay gente que se preocupa de que estés bien y de que te pregunta que si te hace falta algo, porque saben que eres cuidadora y eso te da fuerzas para seguir adelante (e34). tabla 4. citas de las entrevistas a pc incluidas en el estudio. categoría: satisfacción con las medidas fuente: elaboración propia. 535 efectividad de un plan de apoyo a cuidadores en dos hospitales públicos de granada (españa) l berta gorlat-sánchez y otros. categorías quejas propuestas de mejora personalización de cuidados a mí no me han hablado de que haya una enfermera que lleve a mi madre… me gustaría tener una referencia para que no me digan cada una cosas distintas (e19). a mí solo me han informado de que me darían la comida, pero de los demás no sé nada (e17). en general estoy satisfecho… pero me lo podían haber explicado mejor… no sabía muchas cosas, sobre todo que podían atenderme y darme la medicación que necesitaba… he pasado tres días horribles, hasta que mi familia me ha traído la medicación… (e19). apoyo al aseo si le digo la verdad incluiría que en cada planta pudiese haber un sitio donde ir al baño y que no tuviésemos que bajar… (e16). apoyo al descanso lo único que el sillón es malísimo porque es muy duro. llevo durmiendo 39 noches en el sillón con cuatro almohadas que me dieron las enfermeras (e15). …estar en una habitación solo, porque mire usted su compañero pesa 130 kilos, y claro cada vez que se mueve se le va toda la ropa, y yo que siempre he sido una persona que mira mucho por eso, y creo que deberían estar en una habitación individual …porque me da mucho reparo (e4). los sillones deberían ser más cómodos o poner una pequeña cama plegable (e14). si es posible que nos dejen en habitaciones individuales (e19). información cuando llegas a urgencias, a la persona que viene con el paciente que somos los familiares nadie se encarga de decirnos nada (e6). algunas veces los médicos se pasan unos la pelota a los otros y el caso es que no te dan información (e17). que nos informen de todo, que nos mantengan informados de cómo está la cosa y no te tengan en vilo sin saber (e15). atención sanitaria tengo una depresión y llevo quince días sin las pastillas porque no sabía dónde ir para que me las recetaran (e11). un apoyo por psicólogos vendría muy bien… hay casos en que se necesita (e5). me gustaría tener alguien con quién hablar… porque te hartas de llorar sola cuando él se queda dormido… y te sales al pasillo o al hueco de los ascensores… pero si hubiera alguien con quien desahogarte, que te entendiera… sería bueno (e15). apoyo social yo lo que quiero es irme a casa a descansar mientras lo tenéis aquí… tendré que ver si me ponen alguna ayuda en la casa, no sé cómo me las voy a arreglar… veo yo que cada día tengo menos fuerzas para cuidarlo (e22). que la trabajadora social del hospital te atienda y que intente solucionarte las cosas pronto (e34). gestión de citas circuitos y traslados cuando llegamos a urgencias y no me dejaron pasar con ella fue lo peor… no tienen derecho a separar a una persona tan frágil de sus seres queridos (e31). si eres cuidador… que te permitan estar con el enfermo, que no te separen de él cuando llegas a urgencias…, y que te identifiquen rápidamente (e6). tabla 5. citas de las entrevistas a pc incluidas en el estudio. categorías: quejas y propuestas de mejora fuente: elaboración propia. 536 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 aquichan issn 1657-5997 figura. categorías de las entrevistas a las pc incluidas en el estudio en sombreado las medidas más destacadas en cada categoría fuente: elaboración propia. 7 burnout.p65 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200556 año 5 vol. 5 nº 1 (5) 56-63 chía, colombia octubre 2005 viviane jofré a.1 sandra valenzuela s.2 recibido: 5 de abril de 2005 aprobado: 23 de mayo de 2005 resumen el síndrome de burnout (sb) se utiliza para hacer referencia a un tipo de estrés laboral institucional generado en profesiones que mantienen una relación constante y directa con personas, como es el caso del personal de enfermería; en él se distinguen tres dimensiones: cansancio emocional, despersonalización y realización personal. el objetivo de este estudio fue determinar la prevalencia del sb en el personal de enfermería de la unidad de cuidados intensivos pediátricos (ucip) del hospital guillermo grant benavente de concepción, chile, y los factores que se relacionan con él. en este estudio descriptivo exploratorio se aplicó un cuestionario de datos sociodemográficos y el inventario de burnout de maslach a una muestra en un periodo de tres meses. para el análisis de los datos se utilizó estadística descriptiva y pruebas no paramétricas para variables categóricas. los puntajes obtenidos en las dimensiones del sb en el personal de enfermería de la ucip evidenciaron mayores porcentajes de niveles de burnout bajo; más de la mitad de la población en estudio presentó un alto logro personal. el conocimiento de las variables relacionadas con el burnout permitirá diseñar estrategias preventivas y de tratamiento para finalmente mejorar la salud laboral y la calidad asistencial. palabras clave: personal de enfermería, síndrome de burnout, m b i . 1 profesora asociada; magíster en enfermería, departamento de enfermería, facultad de medicina, universidad de concepción, concepción, chile. vjofre@udec.cl 2 profesora asociada; doctora en enfermería, departamento de enfermería, facultad de medicina, universidad de concepción, concepción, chile. svalenzu@udec.cl abstract the burnout syndrome (bs) is used to refer to institutional working stress generated in professions which maintain a constant and direct relation with people, as the case of nursing; it has three dimensions: emotional fatigue, depersonalization and personal realization. the objective of this work was to determine the prevalence of bs in nursing staff in pediatric intensive care unit (picu) at guillermo grant benavente de concepción, chile hospital, and the factors related with it. in this descriptive exploratory study a questionnaire of socio demographic data and the inventory of burnout of maslach were applied to a sample during three months. for the analysis of data a descriptive statistics and non parametric tests for category variables were used. the scores obtained in the dimensions of bs on nursing staff at picu showed higher percentajes of low burnout levels; more than half the population in the study had high personal achievements. knowledge of variables related with burnout will allow the design of preventive strategies and the treatment to improve the health and the quality of assistance in the work area. key words nursing staff, burnout syndrome, mbi. burnout en personal de enfermería de la unidad de cuidados intensivos pediátricos 57 introducción l estrés se ha convertido, hoy en día, en un término de uso frecuente durante nuestra vida diaria, lo cual también incluye la vida laboral. la expresión �desgaste profesional� (burnout) se utiliza para hacer referencia a un tipo de estrés laboral institucional generado específicamente en profesiones que mantienen una relación constante y directa con personas, especialmente si esta relación es de ayuda, como profesores, policías, personal de salud, entre otras (1, 2 ). este concepto fue utilizado en psicología por primera vez por el psicoanalista freudenberger en la década de 1970, para dar una explicación al proceso de deterioro en los cuidados y atención profesional a los usuarios de las organizaciones de servicios. a lo largo de estos años, el síndrome de burnout (sb) ha quedado establecido como una respuesta al estrés laboral crónico que ocurre con frecuencia en los profesionales de las organizaciones de servicios que trabajan en contacto directo con los usuarios de tales entidades (3 ), entre las cuales se encuentra el personal de enfermería. el concepto de sb ha sido ampliamente utilizado en la literatura científica sobre estrés laboral; maslach y jackson, especialistas norteamericanas en psicología de la salud, lo han descrito como un proceso que se inicia con una carga emocional y su correspondiente tensión, que conduce al agotamiento del sujeto, el cual comienza a exhibir conductas de distanciamiento y actitudes cínicas respecto a las personas que atiende, lo que crea dudas en relación con la competencia y realización profesional. se trata de un concepto multidimensional, acompañado de síntomas físicos cuyos componentes fueron identificados por maslach y jackson como: agotamiento emocional, despersonalización y reducida realización personal. su modelo teórico ha conducido a la elaboración del maslach burnout inventory (mbi) (4 ). desde una perspectiva psicosocial el sb es un síndrome cuyos síntomas son: bajos niveles de realización personal y altos niveles de agotamiento emocional y de despersonalización. la falta de realización personal en el trabajo se define como la tendencia de los profesionales a evaluarse negativamente; esa evaluación negativa afecta de forma especial a la habilidad en la realización del trabajo y a la relación con las personas a las que atiende. los trabajadores se sienten descontentos consigo mismo e insatisfechos con sus resultados laborales (3). por agotamiento emocional se entiende la situación en la que los trabajadores sienten que ya no pueden dar más de sí mismos a nivel afectivo. es una situación de agotamiento de la energía, una sensación de estar emocionalmente agotado debido al contacto diario y mantenido con personas a las que hay que atender como objeto de trabajo (5 ). la despersonalización puede ser definida como el desarrollo de actitudes y sentimientos negativos, como el cinismo hacia las personas destinatarias del trabajo; así, son trabajadores deshumanizados debido al endurecimiento afectivo (6 ). revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200558 los profesionales de la salud han sido identificados en diversos estudios como uno de los grupos con medidas altas en los diferentes componentes del sb, y de hecho constituye uno de los grupos profesionales más estudiados bajo este concepto en el ámbito internacional, y sus consecuencias van desde una reducción de la calidad del trabajo y conflictos laborales hasta el desarrollo de trastornos mentales, problemas psicosomáticos y aun el suicidio. incluido en estos grupos de trabajo se encuentra el colectivo de enfermería, ya que su objetivo de trabajo es cuidar los intereses o satisfacer las necesidades de los pacientes, y se caracteriza por el contacto directo con las personas a las que destinan su trabajo. en especial, el personal de enfermería de las unidades de cuidados intensivos es un grupo que ha sido identificado como de alto riesgo de desarrollar sb, relacionado con las condiciones laborales y con las características del trabajo que desempeñan, ya que se requieren constantes demandas físicas y emocionales al enfrentar pacientes críticos, el dolor, la angustia e incertidumbre de sus familiares y, frecuentemente, la muerte (7, 8 ); además, debido a la doble carga que conlleva la práctica profesional y la tarea familiar. lo anterior es importante tenerlo en consideración puesto que, tanto profesionales como auxiliares de enfermería de la unidad de cuidado intensivo pediátrico (ucip) del hospital guillermo grant benavente de concepción (hggbc), se enfrentan a diario con diversas situaciones de difícil manejo a las que deben dar respuestas. entre estas situaciones se pueden mencionar: la constante preocupación por sus pacientes y familias debido a la incertidumbre de la situación; la ansiedad por la gravedad de los diagnósticos; el tipo de intervenciones, generalmente asociadas a la utilización de terapias y equipos sofisticados, los cuales no se encuentran exentos de riesgos, por lo tanto, existe un contacto permanente con el sufrimiento de los pacientes y sus allegados; la necesidad de intervenir en situaciones de crisis; exceso de trabajo, con numerosas situaciones de falta de recursos humanos y materiales y gran presión asistencial. muchas de estas situaciones pueden llegar a sobrepasar los niveles de afrontamiento de las personas, ocasionando un desequilibrio en el bienestar físico y psicológico, facilitando por lo tanto la aparición de diferentes niveles de estrés en el trabajo y, subsecuentemente, la aparición sb, lo cual afecta el rendimiento y el bienestar personal y conduce a elevadas tasas de ausentismo laboral, disminución en la satisfacción tanto de los trabajadores como de los pacientes, riesgo de conductas adictivas (9 ), entre otras consecuencias. lo expuesto sustenta la necesidad de que un problema de salud como el burnout deba ser estudiado, para establecer vías de intervención y posterior prevención. en virtud de lo expuesto, se diseñó este estudio con el objetivo de determinar la prevalencia del sb en el personal de enfermería de la unidad de cuidados intensivos pediátricos del hggbc, chile, y los factores asociados. desde una perspectiva psicosocial, el sb es un síndrome cuyos síntomas son: bajos niveles de realización personal y altos niveles de agotamiento emocional y de despersonalización. burnout en personal de enfermería de la unidad de cuidados intensivos pediátricos 59 para responder al objetivo planteado se trabajó con ocho variables derivadas de la aplicación del mbi y de un instrumento de características sociodemográficas aplicadas a una muestra de 26 personas que desarrollan trabajo de enfermería en la ucip del hggbc, las cuales cumplieron con los requisitos de ser contratadas y de desempeñarse, por lo menos durante un año, en ese servicio (ver cuadro). el personal de enfermería que conformó la muestra estuvo compuesto por: � enfermeras clínicas, cuyas funciones consisten en: programar, organizar, dirigir, coordinar, supervisar, controlar y evaluar las acciones de enfermería otorgadas durante su turno a los pacientes a su cargo, tanto hospitalizados como los que ingresan transitoriamente por procedimientos médicos; gestionar el cuidado en relación con promoción, mantenimiento y restauración de la salud y ejecución de actividades derivadas del diagnóstico y tratamiento médico; velar por la administración de los recursos físicos, materiales y humanos de asistencia al paciente. ellas realizan su trabajo cumpliendo dos sistemas de turno; un sistema de cuarto turno, es decir, primer día de 8 a.m. hasta las 20 p.m., segundo día desde las 20 p.m. hasta las 8 a.m., tercer día saliente de turno y cuarto día libre. y un turno diurno, que consiste en el trabajo de lunes a viernes en horario de 8 a.m. hasta 17 p.m. cuadro. variables del estudio variables valores cansancio emocional alto medio bajo despersonalización alto medio bajo realización personal alto medio bajo ocupación técnico paramédico enfermera auxiliar de servicio estado civil casada soltera separada tiene hijos sí no tipo de turno que realiza diurno cuarto turno otro antigüedad en la ucip menos de 10 años más de 10 años fuente: burnout en personal de enfermería de ucip. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200560 � técnico paramédico, cuyas actividades son cumplir ante sus superiores con las actividades de enfermería que le sean asignadas, participando como integrante del equipo de enfermería en la ejecución de la atención de los pacientes pediátricos en estado crítico y semicrítico. en jornada de cuarto turno. � auxiliar de servicio, quien participa en actividades de aseo y ornato, de colaboración con el técnico paramédico en traslados, y otros como mensajero o estafeta. su jornada de trabajo consiste en 44 horas semanales de lunes a domingo en horario diurno (10 ). material y método estudio descriptivo exploratorio, en donde la unidad de análisis estuvo constituida por personal de enfermería de la ucip del hggbc, chile. la muestra correspondió a 26 funcionarias que accedieron conformar el grupo de estudio, previo consentimiento informado. los datos se obtuvieron a través de un instrumento autoadministrado que contenía el mbi y un cuestionario de datos personales en el periodo de octubre a noviembre de 2004. el mbi ha demostrado una alta consistencia interna y una fiabilidad en variados estudios (11 ), aunque existen algunas controversias al respecto relacionadas con el número de casos que se han incluido en las investigaciones realizadas, los cuales pueden ejercer un papel muy importante en los valores que debe asumir un coeficiente de confiabilidad (12 ). para este estudio se utilizó la versión española del mbi, un cuestionario autoadministrado que consta de 22 ítems en forma de afirmaciones sobre los sentimientos y las actitudes del trabajador hacia su labor y hacia los pacientes (13 ). contiene tres subescalas: � cansancio emocional (ce): sus elementos describen los sentimientos de una persona emocionalmente exhausta por el trabajo, puede manifestarse física o psíquicamente, o como una combinación de ambas. � despersonalización (dp): los elementos de esta subescala describen una respuesta interpersonal fría hacia los receptores de los cuidados, acompañada de un incremento en la irritabilidad y una pérdida de motivación hacia los mismos. � realización personal (rp): contiene elementos que describen sentimientos de competencia y éxito en el trabajo propio con personas, supone una serie de respuestas negativas hacia uno mismo y hacia su trabajo. cada uno de los ítems tiene siete opciones de respuesta (escala tipo likert de 0 a 6), las puntuaciones de la escala total se obtienen al sumar los valores de los 22 ítems (14 ). altas puntuaciones en las dos primeras escalas (ce y dp) y bajas en la tercera (rp) permiten determinar el síndrome; los resultados se categorizan en niveles alto, medio y bajo, las puntuaciones se indican en la siguiente tabla. incluido en estos grupos de trabajo se encuentra el colectivo de enfermería, ya que su objetivo es cuidar los intereses o satisfacer las necesidades de los pacientes, y se caracteriza por el contacto directo con las personas a las que destinan su trabajo. burnout en personal de enfermería de la unidad de cuidados intensivos pediátricos 61 para el procesamiento de los datos se utilizó el programa spss v11, 5. para el análisis de los datos se utilizaron estadísticos descriptivos no paramétricos para variables nominales (chi cuadrado). resultados a continuación se muestran las respuestas obtenidas con base en las variables de trabajo planteadas. respecto a la caracterización de la muestra del personal de enfermería de la ucip del hggbc, todas son mujeres, el mayor porcentaje de la muestra (65,4%) corresponde a técnicas paramédicas; 30,8% son profesionales de enfermería y sólo una de ellas corresponde a auxiliar de servicio. la mitad de las funcionarias son solteras; el 46,2% son casadas y una es separada. la mayoría (65,4%) tiene hijos y desarrollan en un 84,6% el sistema de trabajo de cuarto turno. respecto a la antigüedad en la ucip, la mayoría del personal de enfermería (84,6%) trabaja hace menos de diez años en la unidad. en relación con los puntajes obtenidos en las dimensiones del sb, el personal de enfermería de la ucip, en ce y dp, evidenció en mayor porcentaje (65,4%) niveles bajos de burnout; respecto a la escala de rp, el 53,8% presentó un alto logro personal; un 38,5% presentó un nivel medio de realización personal, y sólo el 7,7% mostró niveles bajos de realización personal. en esta muestra no se encontraron diferencias significativas de la prevalencia del síndrome de burnout en relación con las variables analizadas (ocupación, estado civil, antigüedad en la ucip, presencia de hijos y tipo de turno). discusión en el grupo de estudio no se encontraron niveles altos de sb, especialmente en la subescala ce, lo cual no concuerda con estudios previos en poblaciones similares (1, 7, 8, 15, 16, 17 ), teniendo presente que a pesar de que el trabajo en ucip posee un alto grado de estrés, debido a las características de los pacientes que se atienden, lo cual podría indicar una prevalencia elevada de sb en comparación con el personal de enfermería de otros servicios hospitalarios, en este grupo no se evidencia de esta forma, posiblemente debido a las características propias de este colectivo, que se caracteriza por un personal adulto joven y con menos de 10 años de trabajo en la unidad, lo que también indicaría que este grupo de trabajadoras utiliza adecuadas estrategias de afrontamiento frente al estrés que les ocasiona su labor (3). por otra parte, este grupo de mujeres no cumple con el perfil de riesgo de padecer sb, que ha sido determinado en varias investigaciones, el cual sería: mujer de más de 44 años sin pareja estable, con más de 19 años de antigüedad en la profesión y más de 11 años en el mismo lugar de trabajo (18 ). en muchos artículos se vincula el ser mujer con tener una mayor vulnerabilidad a padecer estrés laboral crónico y subsecuentemente el sb, derivado de la responsabilidad de conciliar la vida familiar y la actividad profesional o laboral, sea ésta remunerada o no (19 ), en lo cual está incluida la labor de enfermería, agregando además sus singulares características (escasez de personal que supone sobrecarga laboral; trabajo en turnos; relación con pacientes y familiares; contacto directo con la enfermedad, el dolor y la muerte; falta puntuaciones de las subescalas de mbi escala ítem baja media alta ce 1, 2, 3, 6, 8, 13, 14, 16, 20 < 18 19 � 27 >27 dp 5, 10, 11, 15, 22 < 6 6 � 9 > 9 rp 4, 7, 9, 12, 17, 18, 19, 21 < 33 34 � 39 > 40 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200562 de reconocimiento profesional; falta de autonomía y autoridad en el trabajo para tomar decisiones, etc.); sin embargo, esto no se refleja en este estudio, con lo que podríamos deducir que este grupo está conformado por un personal preparado, con destrezas y habilidades para desarrollar su labor, hecho que deberíamos comprobar contrastándolo con su percepción respecto a la carga de trabajo desde los puntos de vista cuantitativo y cualitativo (20 ). el gran porcentaje de la muestra posee un bajo nivel de despersonalización, lo cual posiblemente esté relacionado con la forma como las mujeres han sido socializadas en nuestra cultura occidental para cuidar, educar, encargarse de los niños, las tareas del hogar, independiente de su labor en el trabajo, lo cual parece ser un factor protector ante el estrés laboral (20), aunque por otro lado estas consideraciones de género hayan frenado el desarrollo de la profesión de enfermería (21 ). si consideramos que la falta de realización personal como tercera dimensión del burnout, planteada por maslach y jackson, consiste en una actitud negativa hacia uno mismo y el trabajo incluyendo pérdida de interés por él, irritabilidad, baja productividad y, por lo tanto, una baja auto-estima (22 ), en este aspecto los hallazgos encontrados en este estudio mostraron que más de la mitad (53,8%) de la muestra presentó sensación de alto logro personal, lo que evidencia la tendencia que en los últimos tiempos tiene la mujer de no solamente sentirse realizada a través del matrimonio, sino que privilegia cada vez más la formación personal para tener la posibilidad de incluirse en ámbitos de trabajo de mayor complejidad, aunque ello signifique una mayor carga mental, exigencias técnicas y tener que actualizarse constantemente en nuevas tecnologías, debido a la complejidad que el trabajo de una ucip exige. por lo tanto, podríamos plantear que las mujeres que se sienten independientes y conformes con su desarrollo personal estarían menos expuestas a padecer sb, y deberíamos profundizar en el estudio de ello para considerarlo un factor protector. no obstante, dado el tamaño de la muestra del estudio, consideramos que son necesarias más investigaciones para poder elaborar conclusiones definitivas, a pesar de que los resultados concuerdan con otros estudios realizados en otros países con personal de enfermería que labora en unidades de cuidados intensivos (15, 23). para determinar si las mujeres tienen mayor riesgo de padecer de sb es necesario realizar un estudio comparativo en una muestra de hombres de similares características, y resaltar cuáles son las diferentes formas de enfrentamiento del estrés (24 ), más que las diferencias de género (23 ), para poder prevenir el sb. considerando que mundialmente el estudio de las variables relacionadas con el sb ha aumentado de manera significativa en las últimas dos décadas, en chile aún no existe evidencia empírica suficiente para determinar lo que ocurre en nuestra población, especialmente en lo referente al personal de salud, por lo cual es una necesidad evidente, ya que sin lugar a dudas se encuentra altamente ligado a los procesos de estrés laboral, unido a los aspectos de bienestar y salud laboral. el presente estudio constituye una primera aproximación al fenómeno del burnout, por lo que es recomendable realizar estudios similares con un mayor número de sujetos, en muestras con características similares y distintas, con el fin de conocer todas las variables implicadas y, por otro lado, continuar aplicando el mbi para probar su validez y confiabilidad y realizar los cambios pertinentes a fin de disponer de un instrumento fidedigno que permita tener una visión real del burnout en nuestra población sanitaria, de manera que se puedan diseñar estrategias de intervención que prevengan su aparición, para finalmente mejorar la calidad asistencial y la calidad de vida del trabajador/ra de los servicios de salud en todos los niveles de atención. burnout en personal de enfermería de la unidad de cuidados intensivos pediátricos 63 referencias bibliográficas 1. del río moro o, perezagua mc, vidal gómez b. el síndrome de burnout en los enfermeros/as del hospital virgen de la salud de toledo. rev. enferm cardiol 2003;(28)1:24-9. 2. bustinza a, lópez-herce j, carrillo md, vigil n, de lucas n, panadero e. situación de burnout de los pediatras intensivistas españoles. anales de pediatría 2000;52(5):418-23. 3. gilmonte p. el síndrome de quemarse por el 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contextos de trabajo y no trabajo [en línea]. actas i congreso hispano-portugués de psicología. simposio «aspectos psicosociales del estrés ocupacional�. santiago de compostela, 20-23 de septiembre 2000. con acceso en 10/11/2004. disponible en: url:http:// www.salves.com.br/virtua/burnour_en_muj.htm. 131 137 primeras paginas.indd 136 aquichan issn 1657-5997 año 14 vol. 14 nº 2 chía, colombia junio 2014 editorial (ylghqfld�flhqwt¿fd�\�dxwrqrptd 6flhqwl¿f�(ylghqfh�dqg�$xwrqrp\ $�hylgrqfld�flhqwt¿fd�h�dxwrqrpld en el editorial del número anterior de aquichan, sobre la “renovación del conocimiento y la práctica”, durán de villalobos (1) destacaba la importancia de la interacción entre el desarrollo del conocimiento y la práctica. esta es una necesidad imperiosa para enfermería que, como disciplina, busca autonomía y la única manera de obtenerla es mediante el reconocimiento de la fundamentación científica que ha desarrollado y que en la práctica contribuye a satisfacer las necesidades de salud de las personas. en el mundo existen múltiples publicaciones científicas de enfermería, que divulgan los productos de investigación. sin embargo, el tiempo que media entre la publicación de las investigaciones y su puesta en práctica es prolongado, razón por la cual todavía en algunas instituciones hay cuidados que se prescriben por tradición; ejemplo de esto son los cambios de posición cada dos horas para prevenir úlceras por presión. ante esta situación es importante identificar las barreras que dificultan la aplicación de los resultados de investigación y, sobre todo, las oportunidades para aplicar el nuevo conocimiento. entre las barreras resaltan: la falta de apoyo y reconocimiento institucional a los profesionales que fundamentan la práctica en investigación de enfermería, la multiplicidad de roles que desempeñan y que limita el tiempo para el ejercicio estricto de la profesión y, lo más grave, la falta de motivación para leer resultados de investigación (2). las oportunidades de aplicación de nuevo conocimiento son múltiples. la primera es el interés de las instituciones de salud y las instituciones educativas por garantizar altos estándares de calidad, tanto en la prestación de los servicios de salud, como en la formación de profesionales. los criterios de calidad se centran en la humanización de la atención, lo cual significa velar por la atención de las necesidades particulares y promover el bienestar de las personas y sus familias, en un ambiente seguro. para garantizar dicha calidad, las instituciones han desarrollado guías y protocolos de atención fundamentadas en evidencias científicas, que aseguran el éxito en los resultados, es decir, la satisfacción de los usuarios. esta tendencia constituye la oportunidad de oro y corresponde a los profesionales de enfermería garantizar la aplicabilidad de esas guías, evaluarlas y, con base en los resultados, proponer políticas públicas que permeen las instituciones y promuevan la contratación de profesionales de enfermería comprometidos con el efectivo desarrollo disciplinar. de esta manera surgirán nuevos proyectos y preguntas de investigación que dinamicen la enseñanza en las aulas y generen conocimiento aplicable en el ejercicio profesional. esta es una responsabilidad que les compete a los líderes de enfermería en las instituciones de salud, a los docentes e investigadores vinculados a las facultades y programas, y a quienes tienen bajo su responsabilidad la edición de revistas científicas y de libros que divulgan los nuevos conocimientos. por todo lo anterior, es el momento de replantear la enseñanza de la disciplina en las aulas de clase y llevarla a los escenarios de práctica, en donde se promueva el análisis de las situaciones particulares de las personas, familias y comunidades, se estimule 137 la consulta de la literatura científica y se analicen las mejores opciones para tomar las decisiones de cuidado. del mismo modo, es imperiosa la necesidad de vincular en los grupos de investigación a enfermeros de servicios porque su experiencia les permite identificar los problemas prioritarios, a la vez que fortalecen sus competencias para la investigación. por su parte, las revistas científicas deben promover la publicación de resultados de investigación centrados en el cuidado, con referentes teóricos disciplinares. esos artículos permiten conocer los procesos y significados que tienen para las personas, familias y comunidades las experiencias que viven en relación con su estado de salud, y el efecto de las intervenciones de enfermería encaminadas a promover la salud, prevenir la enfermedad y garantizar la calidad de vida. además, las revistas deben permitir el acceso libre a la información, de manera que esta beneficie no solo a los investigadores y a las comunidades académicas, sino a la mayoría de hombres y mujeres interesados y comprometidos con el cuidado de la salud. de esta forma, entre todos lograremos que el ejercicio de enfermería demuestre el liderazgo en la prestación de los servicios. en concordancia con lo anterior, en este número de aquichan se publican artículos relacionados con los resultados de intervenciones de enfermería, el significado de la experiencia de las personas en condiciones críticas y crónicas de salud, así como algunos encaminados a la promoción de la salud y la prevención de la enfermedad. son documentos que proporcionan información valiosa para el cuidado y deben ser tenidos en cuenta como evidencia a fin de mejorar la práctica de enfermería. maría elisa moreno-fergusson profesora titular y decana facultad de enfermería y rehabilitación universidad de la sabana mariae.moreno@unisabana.edu.co referencias 1. durán de villalobos mm. la renovación del conocimiento y la práctica. aquichan. 2014;14(1):5-6. 2. fink r, thompson c, bonnes d. overcoming barriers and promoting the use of research in practice. journal of nursing administration. 2005;35(3):121-129. 00. editorial (4-5) año 4 nº 4 4-5 bogotá, colombia octubre 2004 revista aquichan issn 1657-5997revista aquichan issn 1657-5997 4 uando vea la luz pública esta nueva edición de aquichan, se habrán cumplido las celebraciones del vigésimo quinto año de existencia de la universidad de la sabana, sus bodas de plata, y con estas la satisfacción de todos quienes trabajamos en ella, por la labor cumplida durante una existencia corta, en términos relativos frente a la mayoría de nuestras universidades colegas, pero pletórica de realizaciones, hasta tal punto que podemos considerarnos como una institución en plena madurez, superadas ya las etapas de una niñez, en la cual los propósitos de los fundadores aparecían ante muchos como utópicos e irrealizables, y de una juventud que mostró al país la maravillosa eclosión de una universidad muy joven, que pasó en poco tiempo a colocarse entre las mejores del país. esta historia corta, pero no por ello menos importante, nos obliga, primeramente, a volver los ojos hacia la divina providencia, que siempre estuvo con nosotros en los momentos duros, que ciertamente nunca han faltado, y en aquellos otros en que todo parecía salir muy bien. luego, hacia toda esa pléyade de personas que, desde diferentes posiciones, pero siempre con la misma ilusión, han trabajado abnegadamente para que hayamos podido llegar a este aniversario con las realizaciones obtenidas, a quienes va nuestro más sentido agradecimiento. igualmente, hacia esos miles de alumnos y ex alumnos, que comienzan a hacerse sentir en el país como una comunidad ligada por una misma formación, que debe ser como un sello que distinga a todas las personas que se vinculan a nuestra universidad y que se sienten partícipes y herederos de nuestra alma máter. por último, a todo un país que ha creído en nosotros y con el cual nos sentimos en deuda, debiendo aportarle lo mejor de nuestra proyección social, fruto de articular nuestra docencia con nuestra investigación. esta, todavía incipiente, pero ya en proceso de consolidación a través de varias de sus manifestaciones, algunas de las cuales han recibido reconocimiento externo. un aniversario como el que acabamos de celebrar, de una manera muy sobria, a la par que nos permite una mirada retrospectiva para celebrar todo cuanto hemos logrado, nos obliga a avizorar igualmente un futuro que está por construir. con todo cuanto hemos logrado hasta la fecha, los proyectos de nuestra universidad muestran que es mucho más aquello que falta por alcanzar. quizá sea ésta una perspectiva que deba estar siempre ligada a nuestro quehacer universitario, en tanto nos sentimos con una clara vocación hacia la excelencia; porque sólo llegaremos a realizar los propósitos de los fundadores, en la medida en que podamos llegar a ser el mejor centro universitario del país, en donde se formen aquellos que, por sus condiciones personales, por ser la flor y nata de nuestra juventud, con independencia de sus condiciones económicas, y por la preparación esmerada que hayan recibido, alcancen las mejores posiciones y puedan proyectar desde ellas la formación adquirida; en la medida en que contemos con la mejor y más formada planta de profesores de nuestro medio, y en la medida en que desde nuestra entidad se difunda un pensamiento con hondo sentido cristiano, como corresponde a la inspieditorial 5 ración de esta universidad, a pesar de su carácter civil y no confesional, que impregne todas las capas de nuestra nacionalidad. se dirá que las expresiones anteriores están impregnadas de un tinte de soberbia o que constituyen un querer poco menos que inalcanzable. ni lo uno, ni lo otro, ya que esta universidad fue fundada con esa vocación, de ir, como lo expresara su primer rector, a la excelencia a través de la exigencia. la primera es una meta propia de su vocación fundacional, porque solamente mediante ella logrará impactar de una manera seria a nuestra sociedad, y la segunda es el único camino que puede seguirse para alcanzar la finalidad querida, cuyas dificultades no se escapan a ninguno de nosotros. quienes no pudieran entender este mensaje, no estarían en condiciones de contribuir para sacar adelante los propósitos expresados en nuestro proyecto educativo educacional. de este proyecto, porque nuestras realidades son apenas una base para algo que deberemos alcanzar, forma parte muy importante nuestra facultad de enfermería, creada desde el 21 de marzo de 1991. es uno de nuestros primeros programas acreditados, que enfrenta los mismos retos de alcanzar un excelente nivel profesoral y académico; forma a sus alumnos en un modelo inspirado por la doctora callista roy, escogido desde los trabajos preparatorios de la facultad, claramente volcado hacia el cuidado de las personas y hacia la promoción de la salud, con una visión cristiana en el ejercicio de una de las más nobles profesiones, como que es de aquellas que están más cerca de quienes sufren. por todo ello, quiero invitar a nuestros profesores y a nuestras profesoras de enfermería, y a nuestros enfermeros y enfermeras, de la misma manera que a todos nuestros estudiantes de la facultad, no sólo a celebrar con nosotros el aniversario alcanzado y con él los logros de la universidad y los específicos del programa, sino igualmente a participar de los propósitos e ilusiones que deben ser la meta que guíe nuestro caminar a partir de este año. la traducción castiza del nombre de esta publicación debe ser para todos nosotros una luz en nuestro horizonte, no ya proyectada solamente a la atención a los demás, propia del profesional en enfermería, sino también al esfuerzo de superación que nos espera. este, para que sea algo más que una ilusión, debe ser objeto de un particular “cuidado”. que los logros alcanzados, como el reconocimiento otorgado por colciencias al grupo de estudio del modelo de adaptación (c. roy), como grupo de investigación, nos sirvan de pedestal para continuar en nuestro ascenso, es el mensaje que quiero dejar a toda la comunidad universitaria y, dentro de ella, particularmente a este grupo tan querido y tan cercano a los enunciados de nuestro pei, como son todas las personas vinculadas a nuestra facultad de enfermería. álvaro mendoza ramírez rector venticinco años 7 14 a proposal for certification.indd 7 debra r. hanna1 a proposal for certifi cation in nursing theory 1 professor division of nursing molloy college, estados unidos. dhanna@molloy.edu recibido: 16 de noviembre de 2015 enviado a pares: 20 de noviembre de 2015 aceptado por pares: 14 de enero de 2016 aprobado: 20 de enero de 2016 doi: 10.5294/aqui.2016.16.1.2 para citar este artículo / to reference this article / para citar este artigo hanna, dr. a proposal for certification in nursing theory. aquichan. 2016; 16 (1): 7-14. doi: 10.5294/aqui.2016.16.1.2 año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 7-14 abstract the author proposes the development of different levels of certification in the knowledge of nursing theory that would be based on the level of formal education attained. at present, nurses are being required to obtain higher levels of formal education in order to serve patients safely in a technologically complex health care system. although evidence-based practice is strongly desired in contemporary health care, less consideration has been given to the value of theory-based nursing practice or the relationship between theory and research. the author explains multiple background issues and then highlights several questions that are important for disciplinary discussion at this point in time. keywords nursing theory; theory-based practice; certification (source: decs, bireme). 8 aquichan issn 1657-5997 año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 7-14 una propuesta para la certificación en la teoría de enfermería resumen el autor propone el desarrollo de diferentes niveles de certificación en el conocimiento de la teoría de enfermería que se basan en el nivel de educación formal alcanzado. en la actualidad, se está exigiendo que las enfermeras obtengan niveles más altos de educación formal con el fin de atender a los pacientes de forma segura en un sistema de atención de la salud tecnológicamente compleja. a pesar de que la práctica basada en la evidencia es muy deseable en el cuidado de la salud contemporánea, menos atención se ha prestado al valor de la práctica de enfermería basada en la teoría o a la relación entre la teoría y la investigación. el autor explica los múltiples problemas de fondo y luego se ponen de relieve varias preguntas que son importantes para la discusión disciplinar en este momento en el tiempo. palabras clave teoría de enfermería; la práctica basada en la teoría; certificación (fuente: decs, bireme). 9 a proposal for certification in nursing theory l debra r. hanna año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 7-14 uma proposta para a certificação na teoria de enfermagem resumo o autor propõe o desenvolvimento de diferentes níveis de certificação no conhecimento da teoria de enfermagem que se baseiam no nível de educação formal atingido. na atualidade, exige-se que as enfermeiras obtenham níveis mais altos de educação formal a fim de atender os pacientes de forma segura num sistema de atenção da saúde tecnologicamente complexa. embora a prática baseada em evidência seja muito desejada no cuidado da saúde contemporânea, pouca atenção tem sido prestada ao valor da prática de enfermagem baseada na teoria ou na relação entre a teoria e a pesquisa. o autor explica os múltiplos problemas de fundo e, em seguida, destaca vários questionamentos que são importantes para a discussão disciplinar neste momento. palavras-chave teoria de enfermagem; prática baseada na teoria; certificação (fonte: decs, bireme). 10 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 a proposal for certification in nursing theory in 2010, nurses received a ‘call’ in the united states of america (usa) in the form of “the future of nursing,” (1) a document issued by the institute of medicine (iom) to increase the levels of formal education of nurses in general and to put more highly educated nurses into the health care workforce. according to its website, the institute of medicine is a division of the national academies of sciences, engineering and medicine. the academies are private, non-profit institutions that provide independent, objective analysis and advice to the nation [united states of america] and inform public policy decisions related to science, technology, and medicine. (http://iom.nationalaacademies.org/about-iom.aspx) “the future of nursing” report was requested by a private foundation, the robert wood johnson foundation (rwjf), and was jointly sponsored by rwjf and the iom. since the intent of iomsponsored documents is to inform public policy decisions, this report has already influenced many policies and public laws affecting nursing in the united states. shortly before “the future of nursing” report was issued, another document called the “lace initiative” was released in 2008 by the advanced practice registered nurse joint dialogue group (2). lace is an acronym that stands for the formal document called: consensus model for aprn regulation: licensure, accreditation, certification, and education. by addressing licensing, accreditation, certification, and education in one document, nursing was provided with a model to show how these elements are all related to the knowledge needed for advanced practice nursing. this same model can now be considered for four different levels of nursing practice. by doing so, the relationship of theory to practice and of theory to research, as well as the standards for teaching theory at these different levels of education can be made clear. in the five years since the iom report was issued, nursing has continually built upon its existing educational structure, which traditionally included basic nursing education that led to the first rn license, graduate nursing education that could lead to advanced practice or other leadership roles, and doctoral nursing education. for the purpose of this discussion about certification in nursing theory, i would like to address four clearly defined levels of nursing practice in the united states that each requires a different depth and breadth of nursing knowledge. the different types of knowledge needed by nurses with different levels of education are not only related to the work they will do, but also to how they will use the nursing knowledge they need for different nursing roles. i contend there are four distinct levels of nursing practice that are based on four different levels of education. the purpose for each level of education affects the type, breadth and depth of content taught at each level. the first level is generalist practice, which requires basic education for registered nurses that leads to the first nursing license. at this level, student nurses are expected to use nursing knowledge to think critically, carefully, and in a way that protects patient safety. the definition of nursing as has been advanced by the american nurses association should be able to be upheld by a nurse who has attained this first, basic level of education. the second level of education is advanced practice, which requires graduate education that can lead to an advanced practice certification or an advanced practice license. the third level of nursing practice is a clinical doctorate, which requires the doctor of nursing practice (dnp) level of education. for the dnp, educational preparation further develops advanced practice clinical leadership and translational research activities. please note that the dnp degree is not the only clinical doctorate, but to streamline this discussion, only that degree is mentioned here. finally, the fourth level of nursing practice is the research doctorate, at the phd doctoral level of education. the phd level of education leads to knowledge generation activities, such as primary research. to provide the public with some indication that the competency needed for each level of practice has been attained, credentials must be obtained by a particular nurse. the credentials for safe generalist practice usually include graduation from an accredited school/program and a test for basic licensure. the credentials for safe advanced practice usually include graduation from an accredited school/program and either taking a test for advanced practice certification or, in some geographic areas, presenting a portfolio of the applicant’s work. at present, the credentials for doctoral advanced practice include those for generalist and advanced practice, and graduation from an accredited dnp (or similar) program. depending on the geographic location where a research doctorate is earned, the structure of the phd program can differ. the credentials for a research doctorate can include an earned degree from an accredited school with a phd program. 11 a proposal for certification in nursing theory l debra r. hanna the value of the phd degree is related to the quality of the phd program itself. for nurses with a phd in nursing, others evaluating the nurse scholar’s credentials might want to see additional credentials such as a basic nursing license and earned degrees at the undergraduate and graduate level of education; they might also request credentials for advanced practice. when considering these different levels of education and practice, and the factor of patient safety, which credentialing is meant to protect, the abilities of individual nurses to evaluate, use, and develop nursing knowledge now have greater importance. it seems the time has come for the nursing discipline to consider formal certification of theoretical nursing knowledge at each of those levels. background when carper (3) described four fundamental patterns of knowing in nursing, she categorized types of knowledge, such as empirical, aesthetic, personal, and ethical. carper’s work was essential to advance the development of nursing knowledge, since it helped nurse scholars engage in discussion about the many types of knowledge needed. since 1978, additional patterns of knowing, such as socio-political knowledge (4) or evidence-based knowledge (5), have been added to carper’s original four patterns. as it was not part of carper’s original research question, carper’s paper did not address the depth or the breadth of nursing knowledge at that time. however, carper’s work from the 1970s remains foundational to nursing knowledge today and it is partly because of her work then that today’s nurse scholars can now discuss the depth and breadth of knowledge that certification is meant to address. donaldson and crowley’s 1978 paper entitled “the discipline of nursing” (6) helped nurse scholars to classify the two sides of our disciplinary knowledge: the professional practice side and the academic side. the professional practice side of knowledge addresses the clinical knowledge nurses need to practice their profession. the academic side of knowledge is the theoretical knowledge that professors use when teaching disciplinary content to students of nursing. since 1978, many other scholars’ insights that were inspired by donaldson and crowley’s paper have helped us to consider our nursing knowledge more carefully. the most important nurse scholar who addressed all aspects of credentialing in nursing, including the certification of nursing knowledge, was margaretta styles (7). styles’ work began in the united states, and it evolved to achieve international scope when she led the international council of nurses. nurse scholars began to understand the relationship between credentialing the schools where nurses are educated (accreditation of educational institutions) and credentialing individual nurses through proper educational preparation, licensure, and certification. whenever different kinds of credentialing were debated throughout the 1980s, 90s, and early 2000s, new questions arose and insights emerged. the essential elements that styles helped us to understand were that credentialing exists to protect patient safety, that there is a mutually reinforcing relationship among the different types of credentials, and that each credential has its own scope and standards. accreditation of educational programs is related to the scope of education. (7, p. 30) licensure for generalist or basic practice is earned by an individual nurse when minimal competency to practice safely in the discipline can be demonstrated through educational preparation in an accredited program and through a licensing exam. the licensing exam is the credential for the individual nurse’s scope of practice. (7, p. 30) the credentials earned at the basic level do not guarantee the individual nurse will never make a mistake. rather, the credentialing process is meant to show that certain standards have been upheld throughout the educational and licensing processes. what often happened after a nurse completed basic education and received the privilege of a license to work was that many nurses developed specialty-based knowledge in one particular area of professional nursing. determining who could be called a ‘specialist’ in a particular type of nursing resulted in more discussion. certification was another credential that was developed to demonstrate to the public that the certified nurse had achieved competency in a particular specialty area within the discipline of nursing. however, certification, such as the test for a basic nursing license, demanded certain standards and required formal testing that was meaningful for the credential being provided. according to styles’ model, certification is meant to testify to the individual nurse’s scope of expertise. (7, p. 30) since expertise is often related to on-going development of knowledge in a specialty, this credential is often given for limited periods of time. its renewal depends on the individual’s ability to show that certain standards have been maintained. another point that came into this particular discussion of specialty-based practice, advanced practice roles, and credentialing was where graduate education should or must fit. in the 1980s, 12 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 there were some nurses who would call themselves advanced practice nurses who did not have proper education or credentials. however, at that point in time, the standards for credentialing were not well-delineated for all advanced practice roles. (7) this part of the discussion involved a concept called ‘title protection,’ which meant that only people who have obtained the proper credentials may call themselves by a particular title. the discussions that occurred during the 1980s, 90s, and early 2000s helped to develop credentialing standards at the advanced practice registered nurse level (aprn). in 2008, a major milestone was achieved when the “lace initiative” was formally approved in the usa. the lace initiative was developed by a panel of representatives from many specialty nursing organizations, but was possible because of styles’ scholarly work to delineate individual and institutional credentials. considering nursing knowledge use, evaluation, and development although so much has already been accomplished with credentialing in nursing, there is still more to discuss about the depth and breadth of our nursing knowledge and about the ability of nurses to evaluate, use, and develop nursing knowledge, especially in relation to the levels of academic preparation that nurses need today. a particular need is related to theoretical nursing knowledge, how it is taught at each level of education, and how it is used at each level of practice. the “2010 future of nursing” document was not about types of knowledge like carper said. it was not about the two sides of knowledge like donaldson and crowley said. it was not about the types of credentialing that styles worked so hard to develop. rather, the “2010 future of nursing” report was more clearly aimed at the depth and breadth of nursing knowledge needed at each level of practice so that formal nursing education could reach its full potential in nurses’ work. at the 2015 roy adaptation association-international conference held at boston college, an international group of nurse scholars discussed how we might help others learn the true value of theory-based nursing practice. the idea of certification for nursing theory, especially for certification in using the roy adaptation model, was discussed briefly. it seemed that by discussing the certification of a nurse’s theoretical knowledge, nurse scholars might develop ways to affirm the depth and breadth of knowledge that nurses need at each level of practice. after the conference ended, i was still thinking about that idea. i reflected on my own personal journey as a nurse. it occurred to me that the level of theoretical knowledge staff nurses need is different from the level of theoretical knowledge that advanced practice nurses need. likewise, nurses with dnp degrees and with phd degrees would use theoretical knowledge in different ways for the different kinds of scholarly work they each do. in 1988-90, when i was a graduate student, i had the privilege of working with dr. keville frederickson on her research project called “linkages in nursing excellence.” while working under dr. frederickson’s direction, i taught staff nurses about the roy adaptation model (ram) to help them understand how the four modes, three levels of stimuli, and two coping processes of the ram could be used to nurse patients in a neuroscience nursing unit. later, when i became a credentialed clinical nurse specialist, i used middle range theories in combination with the ram conceptual model for very complex clinical cases. using multiple theories or combining a conceptual model with middle range theories should happen with ease for advanced practice registered nurses. there should be some facility with using, evaluating and even developing theory-based as well as evidence-based knowledge at that advanced practice level of nursing. currently, the emphasis is on developing evidence-based knowledge as if evidence and theory are opponents. however, if the proposal to use the term “theory-based evidence” were supported more widely, then the blending of theory and evidence in practice would enrich the quality of patient care provided (8). later, in my own career, when i was in doctoral studies, the underlying philosophical assumptions of the roy adaptation model became so much more important to me. perhaps understanding philosophical assumptions is the depth of knowledge needed at the phd level to influence policy-making or to conduct research with insight and understanding. doctoral education at the phd level helps to hone analysis and interpretation skills, so it seems necessary that the phd level of education would be where the grasp of theoretical knowledge would require the greatest depth and breadth. my understanding of a dnp degree is that nurses with this education will direct their scholarly work toward translational research. working with other disciplines to develop the theory-based evidence for nursing practice would require firm grounding in a nursing approach to theoretical knowledge that differs from the 13 a proposal for certification in nursing theory l debra r. hanna use of theoretical knowledge made by team members from other disciplines, even when the same theoretical constructs are used by team members. for example, wouldn’t nurses who are grounded in the roy adaptation model use a different theoretical approach to patients and families under stress than other members of the team, such as physicians and social workers? whereas ram nurses would seek to examine the adaptation level outcomes and the coping processes, physicians and social workers might focus on other aspects of patient and familial stress. it is mainly because each professional offers a different disciplinary perspective to that team’s collaborative effort on behalf of the patient that outcomes of care are strengthened. questions for disciplinary discussion these reflections on the stages of my own professional journey led me to a series of questions that might be discussed in our discipline. the questions listed here are not the only ones, but they are listed as a way to start disciplinary discussion. first question: would it be worthwhile to establish a structure for certification of theoretical nursing knowledge at four levels: basic practice (bs); advanced practice (ms); translational practice (dnp); and knowledge generation practice (phd)? if certification of individual nurses is aimed at the scope of expertise, should expertise in theory be developed at each level so that the expectations for use, evaluation, and development of nursing knowledge are clear? second question: if we define the relationship between theory and practice at each level of education, how should the teaching of theory be differentiated at each level so that each level of education builds upon the other levels? what standards for teaching might be developed to ensure theory is taught in a useful, practical way? third question: could the discipline of nursing develop standards to determine who would be certified or not? if so, at which levels would nurses be certified in theoretical nursing knowledge? fourth question: which criteria would be best suited to determine the scope of expertise in theoretical nursing knowledge for each level? where we have cultural assumptions acting in certain cultures, how will the certification criteria accommodate those differences? could we use something like a portfolio format for awarding different levels of certification? could we provide a test at a very basic level, another test at the aprn level, and after passing those, something like a portfolio of the applicant’s work related to the model, such as a completed theory-based research project? fifth question: for the dnp level, would a capstone translational research project such as the process outlined in roy’s book (9) generating middle range theories be sufficient to award certification at that level? for the phd level, perhaps the publication of a primary theory-based research study would be needed. a final question that needs discussion is: would certification in nursing theory be something that would be achieved once and kept for life or is it something that would require periodic updates? conclusion these questions, prompted by our discussion at the 2015 roy adaptation association international conference, need discussion in our discipline. for years, nurses have been obtaining higher levels of formal education and have been contributing to the development of nursing knowledge. here is a chance to elevate the status of our theoretical nursing knowledge by developing clear criteria for teaching, learning, and using the theoretical knowledge needed for each level of practice. if the “2010 future of nursing” report issued a ‘call’ for nurses to be able to work to the full level of their education, let us now respond by saying it is time to certify nurses for the depth and breadth of theoretical knowledge needed at each level of nursing. declaration the author declares no conflict of interest with the journal. the author declares this manuscript represents the original thinking and writing of the author. this manuscript has not been offered to any other journal for consideration. 14 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 references 1. committee on the robert wood johnson foundation initiative on the future of nursing at the institute of medicine. the future of nursing: leading change, advancing health. washington, d. c.: national academies press. 2. american nurses association. nursing: scope and standards of practice, third edition. silver spring, maryland: author; 2015. 3. carper b. four fundamental patterns of knowing in nursing. advnursci. 1978; 1(1): 13-24. 4. white j. patterns of knowing: review, critique and update. advnursci. 1995; 17(4): 73-86. 5. porter s. fundamental patterns of knowing in nursing: the challenge of evidence-based practice. advnursci. 2010; 33(1):3-14. 6. donaldson sk, crowley dm. the discipline of nursing. nursoutlook. 1978;26(2): 113-120. 7. styles mm, schumann mj, bickford c, white km. specialization and credentialing in nursing revisited: understanding the issues, advancing the profession. silver spring, maryland: american nurses association; 2008. 8. fawcett j, watson j, neumann b, walker jh, fitzpatrick jj. on nursing theories and evidence. j nurs scholarship. 2001;33(2): 115-119. 9. roy, c. generating middle range theories: from evidence to practice. new york: springer publishing company; 2013. 8 etica profesional.p65 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200564 año 5 vol. 5 nº 1 (5) 64-71 chía, colombia octubre 2005 nelly garzón alarcón1 recibido: 7 de junio de 2005 aprobado: 17 de junio de 2005 1 rn., bsn., msn.; profesora emérita y honoraria. universidad nacional de colombia; presidenta del tribunal nacional de ética de enfermería, colombia. resumen las siguientes reflexiones plantean un acercamiento al desarrollo y a la evolución de la enfermería y de su práctica, que en la actualidad han incorporado importantes aportes teóricos, conceptuales y éticos. resalta, igualmente, la contribución de destacados teorístas de esta disciplina en la definición de los paradigmas, modelos y teorías orientados a describir y explicar los fenómenos de la práctica desde las perspectivas ética, de la persona, el ambiente, la atención de salud y el acto de cuidado. palabras clave ética, teorías de enfermería, cuidado, persona, paradigmas . abstract the following ponderings present an approach for the development of nursing and its practice, that currently have incorporated important theoretical, conceptual and ethical contributions. also, it mentions the contribution of important theorizers of this discipline in the definition of paradigms, models and theories, oriented to describe and explain the phenomenon of practice from an ethical, personal, environmental, health care and the act of caring, perspective. key words ethics, nursing theory, care, person, paradigms. ética profesional y teorías de enfermería 65 introducción l avance de la enfermería como profesión, como disciplina, como ciencia y tecnología, ha exigido a sus profesionales hacer evidente, por medio de la investigación científica, la fundamentación teórica de la práctica que muestre la relación del conocimiento con los valores y los principios éticos y bioéticos que sustentan el ejercicio profesional de la enfermería como práctica social. la evolución que ha tenido la enfermería al pasar de un oficio o trabajo artesanal con labores de cuidado basadas en el espíritu de servicio y en la intuición, a fin de actuar para hacer el bien, constituyen prácticas que fueron miradas con aprecio por las personas beneficiadas debido al espíritu de bondad y de acompañamiento que mostraron en su momento. las prácticas de enfermería, en la segunda mitad del siglo xx, han sufrido una reconocida transformación hacia un proceso de acción sistematizado, sustentado en conocimientos con fundamentos teóricos y aplicación progresiva de los adelantos de la tecno-ciencia y de la ética que hoy, con los cambios y progresos alcanzados, le imprimen a dichas prácticas de cuidado el carácter de una disciplina y práctica profesionales con su propia naturaleza, su carácter disciplinar e interdisciplinar, y su dimensión ética. reflexiones generales sobre la teoría y la ética de enfermería el sustento teórico de la enfermería comienza a desarrollarse y adquirir mayor precisión y validez con estudios de investigación desde hace un poco más de cien años, a partir de las reflexiones y los trabajos de observación, recolección y análisis de datos que hizo nightingale en los hospitales donde prestó sus servicios, y que le sirvieron para sustentar sus proyectos de mejoramiento de los servicios de salud. sin embargo, es apenas hacia la mitad del siglo pasado cuando en verdad se concreta con el estudio sistematizado de la enfermería, con resultados de investigaciones realizadas con rigor metodológico, y la formulación de varias propuestas de modelos teóricos y teorías de enfermería que dan sustento a la práctica. la fundamentación ética y humanitaria de la enfermería, por el contrario, se ha hecho evidente desde épocas antiguas. se ilustra con el ejemplo del acto de cuidar que prodigó el buen samaritano al herido que encontró en el camino, y en su reconocimiento del valor de la persona humana, sin ningún tipo de discriminación racial o religiosa. su actuación mostró la responsabilidad o conciencia de hacer el bien al otro, limpiando sus heridas y asegurando la continuidad de su cuidado para dar atención a sus necesidades básicas, al solicitar y pagar por los servicios de cuidado que le brindaría el dueño de la posada. es en las últimas décadas del siglo pasado cuando también se aprecia un progreso significativo en la investigación en enfermería con el propósito de definir paradigmas, modelos y enfoques teóricos orientados a describir y explicar la naturaleza de los fenómenos y los cuidados de enfermería, y para probarlos en diferentes escenarios. enfermeras investigadoras, individualmente y en grupos, prueban, evalúan, modifican y enriquecen sus trabajos sobre teorías de enfermería con diversos tipos de investigación y con proyectos de aplicación de sus hallazgos en la práctica y en la educación de enfermería. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200566 durante el seminario sobre los avances en la aplicación de teorías de enfermería en la práctica y en la investigación en enfermería, realizado en la universidad de la sabana los días 25 y 26 de octubre de 2004, se tuvo la fortuna de apreciar algunos adelantos en este campo. se conocieron algunos resultados de las investigaciones de las enfermeras y teoristas de enfermería invitadas al mencionado evento y algunos resultados parciales de las investigaciones y los trabajos que durante varios años han venido realizando los docentes y estudiantes de la facultad de enfermería de la universidad de la sabana con la participación de enfermeras de entidades de servicio con las cuales se desarrollan actividades de extensión para poner en práctica los avanc e s y r e sultados de los trabajos de investigación. las experiencias y los logros alcanzados en el trabajo sobre modelos teóricos en enfermería realizado por enfermeras docentes investigadoras de colombia, en asocio con enfermeras investigadoras de otros países, muestran los adelantos que se han logrado con el trabajo cooperativo de grupos y de redes de investigadores. es innegable que estas formas de trabajo cooperativo en investigación son un imperativo en el mundo de hoy que lleva a promover la investigación en líneas, en grupos y en redes de grupos de investigadores, con el fin de profundizar en los temas o problemas de investigación y en el conocimiento de una realidad o de un fenómeno, y así poder plantear acciones de cambio y de mejoramiento para el bienestar de la sociedad y de las personas. esta dinámica se relaciona con la dimensión ética en este campo de estudio. es interesante observar que los primeros modelos teóricos y conceptuales de enfermería llevan el nombre de su autor o autora porque fueron iniciativas individuales, tales como henderson, orem, rogers, roy, y otros, los cuales se enriquecieron después con el trabajo de comprobación de grupos de enfermeras en diferentes escenarios de la práctica. en los desarrollos más recientes, las teorías de enfermería de mediano rango llevan el nombre no de los autores sino del fenómeno de enfermería que estudian, por ejemplo, la teoría de síntomas desagradables, de la autotrascendencia, de las transiciones, del estrés y adaptación de la familia, entre otras, y las llevaron cabo o están realizando grupos de investigadores. estos enfoques conceptuales y teorías tienen como punto de partida la dimensión ética relacionada con el reconocimiento del valor y respeto a la dignidad del ser humano, el valor de la vida, la búsqueda del bienestar de la persona y las formas efectivas de atender sus necesidades y sus derechos. es también importante reconocer que el progreso de la ciencia y la tecnología es una respuesta a la crítica que se hace a la investigación para resolver interrogantes conceptuales o metodológicos, para aclarar dudas sobre procesos o resultados, o para resolver cuestionamientos de validez; éstos y otros aspectos también se relacionan con la dimensión ética de la investigación, que hoy se considera un criterio fundamental para su evaluación y crítica. es por esta razón que la crítica es esencial para el progreso de la ciencia en todas sus dimensiones. las teorías de enfermería y su dimensión ética samar noureddine planteó un interrogante después de revisar y hacer un análisis crítico de algunos resultados y adelantos logrados en el campo de la teoría de enfermería, al no encontrar explícitos los elementos de ética. ella consideró que si la teoría de enfermería tenía el proel sustento teórico de la enfermería comienza a desarrollarse y a adquirir mayor precisión y validez con estudios de investigación desde hace un poco más de cien años, a partir de las reflexiones y los trabajos de observación, recolección y análisis de datos que hizo nightingale en los hospitales donde prestó sus servicios, y que le sirvieron para sustentar sus proyectos de mejoramiento de los servicios de salud. ética profesional y teorías de enfermería 67 pósito de guiar y dar calidad a su práctica, su componente ético no debía faltar y tampoco debía mantenerse apenas como un elemento implícito. en el artículo que publicó con el título �el desarrollo de la dimensión ética en la teoría de enfermería�, expresó que se proponía identificar el componente ético relevante a la teoría y determinar los criterios para evaluar esta dimensión en las teorías de enfermería (1). para este trabajo se toman algunos de los elementos que ella propone y se agregan otros a los cuales esta autora no hace explícita referencia. estos mismos elementos conceptuales ya habían sido identificados en la revisión y el análisis de varias teorías de enfermería que realizó fawcett (2), como se presentará más adelante. debe tenerse presente que estas dos investigadoras hacen referencia a teóricos de la década de los ochenta, por tanto, es posible que en la última década se hayan hecho algunos adelantos que utilicen los avances en el estudio y aplicación de la ética y la bioética en las ciencias y en la práctica de las profesiones en general y, en especial, en las de la salud. esta suposición se hace teniendo en cuenta las aplicaciones que hizo larrabee al estudiar la calidad de algunos procesos en la organización de la atención de salud. en 1996, june h. larrabee (3) desarrolló un modelo teórico de calidad que incluyó conceptos éticos y económicos con el fin de proponer un marco de referencia para mejorar la calidad de la atención de salud frente a los problemas relacionados con los costos, las dificultades de financiamiento, de acceso a los servicios de salud y el logro de metas esperadas. este modelo teórico estableció las relaciones entre los valores, la prudencia, la beneficencia y la justicia para lograr un cuidado de calidad. aunque este modelo de calidad no es una teoría de enfermería que fundamente la práctica de esta profesión, es una evidencia o ejemplo de la conciencia que existe entre los teóricos de prestar atención a la dimensión ética e incluirla como aspecto relacionado con los postulados teóricos. la ética y los elementos del paradigma de enfermería la doctora jacqueline fawcett (2), estudiosa de las teorías de enfermería, expresó que la disciplina de enfermería, a través de los trabajos de investigación en este campo, ha permitido concretar elementos e interrelaciones comunes, con los cuales se ha enunciado y formalizado un metaparadigma, éstos son: persona, ambiente, salud y enfermería, conceptos globales que se identifican en un fenómeno de enfermería. hace más de dos décadas esta autora expresó que quienes en esa época revisaron el desarrollo de la enfermería como disciplina señalaron que se apreciaba que muchos de estos trabajos aparecían desenfocados y descoordinados, porque los autores se movían rápidamente de un tema a otro, y muy pocos académicos dedicados a estas empresa compartían o aunaban sus acciones de investigación en determinadas áreas (2). es posible que hoy, con la investigación organizada en líneas y desarrollada por grupos de investigadores, se esté profundizando en el estudio de los fenómenos de enfermería con resultados más coordinados para enriquecer el conocimiento de la profesión. los trabajos de fawcett muestran un gran esfuerzo y un análisis serio para identificar los conceptos comunes en las teorías de enfermería con miras a dar mayor es también importante reconocer que el progreso de la ciencia y la tecnología es una respuesta a la crítica que se hace a la investigación para resolver interrogantes conceptuales o metodológicos, para aclarar dudas sobre procesos o resultados, o para resolver cuestionamientos de validez; éstos y otros aspectos también se relacionan con la dimensión ética de la investigación, que hoy se considera un criterio fundamental para su evaluación y crítica. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200568 sustento al metaparadigma que ha permitido explicar la naturaleza del conocimiento de la disciplina. la posibilidad de construir el metaparadigma de enfermería ha sido un trabajo progresivo y acumulativo, a través del cual fawcett y otros autores han promovido el análisis y enriquecimiento del significado y la operacionalización de los conceptos globales de la disciplina antes mencionados, los cuales tienen un significado que se nutre en las distintas corrientes de la filosofía, las ciencias sociales, la historia, la política, y otras formas de pensamiento (4). los trabajos realizados con este propósito ofrecen una base muy valiosa. si bien es cierto que no existe un acuerdo entre las teóricas en la definición que ellas proponen de los conceptos, situación explicable por los diferentes fundamentos, orientaciones y enfoques que utilizan en sus respectivas teorías o modelos teóricos, se considera que es una tarea importante por hacer en la cual es evidente que se viene avanzando y se está enriqueciendo constantemente a la luz de los cambios sociales y políticos; por lo tanto, los profesionales de enfermería requieren mantener una ilustración actualizada sobre los cambios que ocurren y los enunciados que se proponen en los nuevos enfoques teóricos y las nuevas teorías de enfermería que se formulan. con los trabajos de las teóricas de enfermería, que de una u otra forma definen estos conceptos, en concordancia con el enfoque de su teoría se ha podido avanzar en precisar la visión de la naturaleza de enfermería, y la comprensión de los fenómenos que vienen a construir, actualizar y enriquecer el conocimiento de la disciplina desde lo filosófico y, específicamente, desde lo ético, lo ontológico, lo epistemológico y lo estético. la visión que se tenga de la naturaleza de la enfermería, y la comprensión de sus fenómenos, fortalece en diversas formas las bases de la práctica y ofrece nuevas orientaciones para adaptarla a las exigencias de los diferentes contextos y a los avances de la ciencia y la tecnología incorporada a la atención de salud y a la organización de los servicios. para discutir la aproximación ética y bioética en el conocimiento teórico de enfermería, se tomarán los elementos conceptuales identificados en el paradigma de enfermería propuesto por fawcett: persona, ambiente y salud; y para no incurrir en la tautología ya reconocida, no se hablará de enfermería sino de cuidado de enfermería o del acto de cuidado de enfermería. es importante recordar que en el paradigma no solamente se consideran los elementos, sino las diferentes interrelaciones entre ellos. en las teorías de enfermería las mayores diferencias, o características propias de cada enfoque teórico, se aprecian en las interrelaciones que se proponen entre los mencionados elementos del paradigma de enfermería. estas interrelaciones también son importantes en el momento de analizar la dimensión ética. la ética, como sabemos, se refiere a los comportamientos de la persona en sus relaciones con los otros y con su ambiente, por lo tanto, para reflexionar sobre este aspecto es necesario identificar las interrelaciones entre los elementos del paradigma propuesto, a fin de resaltar los principales comportamientos éticos y bioéticos en las relaciones de la persona con el otro, tomando como guía los valores, los principios éticos (ética principialista), los aspectos o comportamientos humanitarios (ética personalista), y los aspectos bioéticos relacionados con el respeto y valor de la vida humana y de todas las formas de vida, y las condiciones y los comportamientos de las personas para preservarla. para discutir la aproximación ética y bioética en el conocimiento teórico de enfermería, se tomarán los elementos conceptuales identificados en el paradigma de enfermería propuesto por fawcett: persona, ambiente y salud; y para no incurrir en la tautología ya reconocida, no se hablará de enfermería sino de cuidado de enfermería o del acto de cuidado de enfermería. ética profesional y teorías de enfermería 69 los aspectos éticos y la persona el ser humano, la persona, se aprecia en el valor de sí mismo y en la ética de sus comportamientos e interrelaciones con los otros, con la familia, con la sociedad, con la comunidad. la persona que da cuidado de enfermería se valora en su comportamiento, en las relaciones con la persona cuidada, que a veces se denomina paciente, o cliente, con quien se relaciona individualmente, o como miembro de una familia o de un grupo comunitario, siempre respetando su individualidad, su valor y dignidad, sus derechos, sus necesidades y sus prioridades, su cultura, su historia y el ejercicio de su autonomía. en la relación enfermera (cuidador)paciente (persona cuidada) es fundamental la aplicación de la ética comunicativa o dialógica de habermans, en la cual la persona se respeta como un interlocutor válido, que tiene derecho y capacidad para razonar y participar en las decisiones sobre su cuidado, sobre su salud. en la interacción del profesional de enfermería como cuidador y la persona cuidada se emplean las diversas formas de comunicación verbal y no verbal, a través de las cuales se intercambia y valora la información para interpretar las necesidades, los valores y los deseos de la persona cuidada. los aspectos éticos y el ambiente los valores de la persona, la familia o el grupo de personas que reciben el cuidado reflejan la influencia de su historia, su cultura, los factores que se deben respetar y comprender, porque estos aspectos forman parte de ella, y se relacionan con sus costumbres, creencias, valores y prácticas de salud que se deben respetar. en la relación cuidador-persona cuidada también se debe considerar y respetar el ambiente psicoafectivo familiar, el valor y las expresiones de amistad, de amor, la privacidad, la autoridad y el manejo del poder en su ambiente familiar y social. otros factores que se relacionan con el estilo de vida de la persona cuidada son el ambiente físico del vecindario y la vivienda, las costumbres y las formas de recreación, la organización y las normas sociales para mantener la comodidad y la convivencia. los aspectos éticos y la atención de la salud en la atención de la salud se incluyen en forma primordial los principios éticos de beneficencia, autonomía, justicia y equidad para hacer accesibles los servicios de salud y de cuidado de enfermería a todas las personas, sin ningún tipo de discriminación o exclusión. la accesibilidad de los servicios de salud se relaciona con la accesibilidad cultural, económica y no solamente geográfica. es parte del derecho a la atención de salud, que se debe prestar con calidad y oportunidad, y que en algunos momentos se relaciona con el valor de la vida humana, el respeto a la persona, sus derechos, su cultura, su capacidad socioeconómica, y el respeto al uso de su autonomía para decidir y dar su consentimiento. la disponibilidad y el acceso a los servicios de salud es ante todo un derecho de la persona, con dignidad e igualdad, sin la persona que da cuidado de enfermería se valora en su comportamiento, en las relaciones con la persona cuidada, que a veces se denomina paciente o cliente, con quien se relaciona individualmente, o como miembro de una familia o de un grupo comunitario, siempre respetando su individualidad, su valor y dignidad, sus derechos, sus necesidades y sus prioridades, su cultura, su historia y el ejercicio de su autonomía. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200570 importar su condición o posición social, económica, cultural, la enfermedad que sufra o su estatus relacionado con condiciones sociales discriminadas tales como la de prisionero, guerrillero, asesino, drogadicto, ciudadano de la calle, homosexual, desplazado, inmigrante y otras categorías similares. los aspectos éticos en el acto de cuidado de enfermería el cuidado de enfermería es un derecho; tiene las características individuales propias de la persona que recibe el cuidado, es respetuoso de los derechos del ser humano, del valor de su vida, su dignidad y sus valores. se fundamenta en el respeto a la integralidad del ser humano, por lo tanto considera todas sus características individuales al administrarle el cuidado, el cual debe ser libre de riesgos, con miras a mantener y proteger su integridad. este aspecto hace referencia a la calidad del cuidado, que comprende la atención de las necesidades básicas de la persona en forma oportuna y segura, atendiendo las dimensiones social, biológica, espiritual, mental que se basan en los principios éticos de beneficencia, no maleficencia, equidad y justicia. el cuidado comprende también el respeto a la autonomía, la privacidad, la confidencialidad, confiabilidad y la fidelidad. un elemento fundamental en el cuidado es la relación enfermera-paciente, que se construye sobre la ética del respeto al otro como interlocutor válido, y la intersubjetividad y la comunicación efectiva teniendo en cuenta y respetando los aspectos culturales, los valores y las creencias. el cuidado del ser humano es indispensable desde la concepción hasta la muerte; en las etapas de crecimiento y desarrollo normal, en los estados de salud, como los de enfermedad, en las discapacidades, así como en las etapas de duelo por pérdidas diferentes, exigen comprensión, respeto y cuidado bondadoso. la ética en el cuidado, responsabilidad profesional de enfermería el consejo internacional de enfermeras ha declarado que el cuidado de enfermería es una necesidad y un derecho universal. es responsabilidad del profesional de enfermería orientar sus acciones para ayudar a mantener, proteger, y restaurar la salud, evitar las enfermedades, aliviar el sufrimiento y, en fin, ayudar a mantener la calidad de vida de las personas. el respeto por la vida, la dignidad y los derechos del ser humano son condiciones esenciales de la enfermería, que se practicarán sin ningún tipo de discriminación (5). con estos enunciados se encabeza el código deontológico de enfermería, del consejo internacional de enfermeras. en la ley 911 de 2004, que establece la responsabilidad deontológica para el ejercicio de la profesión de enfermería en colombia, se define el acto de cuidado de enfermería como sigue: el acto de cuidado de enfermería es el ser, la esencia del ejercicio de la profesión. se fundamenta en sus propias teorías y tecnologías, y en conocimientos actualizados de las ciencias biológicas, sociales y humanísticas. se da a partir de la comunicación y relación interpersonal y humanizada entre el profesional y el ser humano, sujeto de cuidado, la familia o el grupo social, en las distintas etapas de la vida, situación de salud y del entorno (6). janice morse (7) identificó cinco categorías de cuidado: 1) el cuidado como una característica humana, 2) el cuidado como un imperativo moral, 3) el cuidado como una forma de afecto, 4) el cuidado como una relación interpersonal, y 5) el cuidado como una intervención terapéutica. también identificó el cuidado como una experiencia subjetiva del paciente y el cuidado como una respuesta física. esta clasificación, que se describe como un proceso, lo utiliza la teórica para clarificar el significado de cuidar, por tanto, se considera como una perspectiva epistemológica de la autora. al considerar el cuidado como un proceso, morse identifica las relaciones que existen entre las diferentes categorías de cuidado observadas. en todas estas categorías se hace evidente la dimensión ética. morse cita como ejemplo de este proceso el constructo teórico de leninger en el cual reitera que los humanos son seres que reciben y dan cuidado, y que el tener la necesidad de ser cuidado es una característica vital para la supervivencia humana. en el ser humano se encuentran los atributos comportamentales de cuidado. en este sentido, la definición del concepto de cuidar se extiende desde la categoría de la característica humana de cuidar hasta la categoría de la intervención terapéutica del cuidado (7). como se ha discutido en apartes anteriores de este trabajo, cada una de estas categorías de cuidar, y las interrelaciones entre ellas, tienen su fundamentación en los valores y principios éticos y bioéticos. conclusión en los diferentes comportamientos, conductas e intervenciones del profesional de enfermería y de su equipo, al realizar el acto de ética profesional y teorías de enfermería 71 referencias bibliográficas 1. nouredine s, development of the ethical dimension in nursing theory, international journal of nursing practice 2001;7:2-7. 2. fawcett j, the metaparadigm of nursing: present status and future refinement, image: journal of nursing scholarship 1984;xvi(3): 84. 3. larrabee jh. emerging model of quality, image: journal of nursing scholarship1996;28(4):353. cuidado se debe traducir la dimensión filosófica, ética y bioética, de humanización y científico-técnica que fundamenta su conocimiento y su actuar, y que la sociedad percibe y valora como buen cuidado. infortunadamente, en ocasiones el contexto de la práctica y el sistema de organización no permiten mantener la coherencia esperada entre el saber ético y el saber de enfermería que debe traducirse en las prácticas de cuidado, y por tanto, la percepción de la persona que recibe el cuidado lo califica como mal cuidado o cuidado deshuma-nizado, al sentir o percibir que no se tienen en cuenta su valor y sus derechos como persona. nuestro gran reto profesional frente a estas realidades que afectan el cuidado de enfermería es promover los cambios necesarios para salvaguardar la calidad ética, científica y técnica del cuidado; es demostrar por medio de la investigación la bondad del cuidado de enfermería que ofrece directamente el profesional o a través de su equipo humano con su permanente dirección y liderazgo. se requiere un trabajo arduo y consistente de los profesionales de enfermería que muestre resultados convincentes de investigación para introducir políticas y sistemas de prácticas de cuidado guiados por los conocimientos teóricos de enfermería y por los componentes de ética, bioética y humanización que sustentan todas las intervenciones. 4. bredow t, analysis and evaluation of middle range nursing theory. in: middle range theories, application to nursing research. philadelphia: lippincott will and wilkins; 2004. 5. consejo internacional de enfermeras (cie), código para enfermeras; 1989. 6. república de colombia, ley 911 de 2004. 7. morse jm et al. concepts of caring and caring as a concept, advances of nursing science 1990;3-4. 02. òlceras por presišn (10-17) revista aquichan issn 1657-5997 año 4 nº 4 10-17 bogotá, colombia octubre 2004 10 resumen con este estudio se evaluó el riesgo de presentar úlceras por presión, de todos los niños que ingresaron a la unidad de cuidado intensivo pediátrica de la fundación hospital de la misericordia, entre el 1º de febrero y el 15 de mayo de 2003. se utilizó la escala de bárbara braden, de seis variables, que determina el grado de riesgo al cual está expuesto el paciente. se evaluaron 133 niños, y se encontró que el 36% estaban en alto riesgo y el 64% en riesgo medio. por lo anterior, se crearon nuevas estrategias para disminuir el riesgo de úlcera por presión, entre ellas la utilización del formato de evaluación de la piel. como dato relevante, se observó que la zona más frecuentemente afectada era la región occipital. palabras clave evaluación del riesgo, úlceras por presión en niños, estrategias de cuidado. abstract with this study the risk to get pressure ulcers in all children entering to pediatric intensive care unit of “fundación hospital de la misericordia”, between february 1st and may 15, 2003, was evaluate. the scale of barbara braden of six variables was use, to determine the risk grade exposure of the patient. 133 children were evaluate, in which 36% were in high risk and 64% in medium risk. according to this, new strategies were create to diminish the risk to get pressure ulcers, among them the use of skin evaluation form. as an important data, the occipital zone was the most frequently affected. key words: risk evaluation, pressure ulcers in children, care strategies. * enfermera especialista en cuidado crítico pediátrico, unidad funcional de urgencias, fundación hospital de la misericordia, colombia. ana_c_net@hotmail.com ** enfermera especialista en cuidado crítico pediátrico, unidad neonatal, hospital simón bolívar, colombia. mariac05790@unisabana.edu.co ana ceneth bernal bellón* maría clara nieto torres** recepción: 19 de abril de 2004 aprobación: 23 de junio de 2004 este trabajo se desarrolló en la especialización en cuidado crítico pediátrico, de la facultad de enfermería de la universidad de la sabana. asesora: beatriz suárez de sarmiento úlceras por presión en niños 11 el desarrollo de úlceras por presión constituye uno de los problemas que se presentan con mayor frecuencia en los pacientes hospitalizados en las unidades de cuidado intensivo (uci), debido a la situación crítica de salud en que se encuentran. por esta razón, la sección de enfermería, que es la directa responsable del cuidado de la piel de estos pacientes, debe establecer medidas encaminadas a la prevención de dicha situación. a la unidad de cuidado intensivo pediátrica del hospital de la misericordia ingresaron 51 niños, en agosto del 2002. de ellos, 38 (74%) requirieron ventilación mecánica, el uso de sedantes, relajantes y analgésicos, como parte integral de su tratamiento, con una duración promedio de cuatro a cinco días en estas condiciones. estos niños tienen mayor susceptibilidad a presentar zonas de presión, pues están expuestos a inmovilidad prolongada, a alteración del estado de conciencia, a disminución de la sensibilidad y a otros factores de riesgo, como el uso de inotrópicos y la presencia de edema generalizado en algunos de ellos. en la valoración inicial de enfermería que se realiza al ingreso al servicio de cuidados intermedios, en agosto y septiembre del 2002 se detectó la presencia de úlceras por presión en el área occipital y en el pabellón auricular, en dos niños politraumatizados y en tres con diagnóstico de choque séptico, que requirieron ventilación mecánica y el uso de sedantes, relajantes, analgésicos e inotrópicos. los niños mencionados provenían de la unidad de cuidado intensivo. esta es una de las razones por las cuales en la unidad se hace necesario establecer una valoración formal, encaminada a identificar factores de riesgo que predisponen a los niños a presentar úlceras por presión, pues esta situación prolonga la estancia hospitalaria e incrementa los costos de hospitalización. para determinar el tipo de cuidado que se brindará a los niños en riesgo de presentar dicha afección, se contempla a la persona como un sistema adaptativo, holístico, en continua interacción con un medio ambiente cambiante y que se ve influenciado por una serie de estímulos, los cuales promueven o no su adaptación. como lo propone sor callista roy, en su modelo conceptual de adaptación1: estos estímulos pueden provenir de un ambiente interno, dado por el nivel de adaptación de la persona, y representa la condición de los procesos vitales, descritos en tres niveles, integrados, compensatorios y comprometidos. en el niño críticamente enfermo, la sedación y la relajación se convierten en un estímulo focal, que afecta la capacidad de respuesta de los procesos de enfrentamiento regulador y cognitivo y, por lo tanto, el nivel de adaptación, que en estos casos se encuentra comprometido. el subsistema regulador incluye nueve componentes fisiológicos: las necesidades básicas de oxigenación, nutrición, eliminación, actividad y descanso y protección, y los cuatro procesos complejos de los sentidos, los líquidos y electrólitos, el equilibrio ácido-básico y la función endocrina. estos elementos fisiológicos son los que se deben tener en cuenta al realizar la valoración de comportamientos, pues pueden ser efectivos, porque promueven la adaptación, o inefectivos, porque alteran la integridad de la persona. introducción 1 roy, callista. the roy adaptation model, editorial appleton y lange, 2ª ed., 1999, pp. 35-37. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 12 l otro subsistema regulador es el cognitivo, relacionado con la experiencia y con la percepción que tiene la persona sobre su estado de salud, que la lleva a utilizar todos sus conocimientos y emociones para promover su adaptación. al realizar la valoración en estos niños se encuentran comportamientos inefectivos a nivel fisiológico, porque presentan disminución de la motricidad, de la sensibilidad, de la actividad, del estado de conciencia, debido a tratamientos necesarios para su recuperación, y de sus necesidades básicas de oxigenación, protección, nutrición, eliminación y actividad y descanso. ellos dependen de un soporte externo, debido a su estado. para lograr la adaptación del niño cuando se encuentra críticamente enfermo, es necesario establecer estrategias de cuidado que contemplen los riesgos a los cuales está expuesto, especialmente por la inducción de la sedación y la relajación, durante la ventilación mecánica y la separación de su medio familiar, que afecta su desarrollo normal; lo anterior facilita problemas inherentes a su inmovilidad e inactividad prolongada, como las úlceras por presión. estas úlceras son áreas de necrosis focal en la piel y el tejido subyacente, causadas por una interrupción del flujo sanguíneo en la zona afectada, como consecuencia de presión prolongada entre una prominencia ósea y una superficie externa. este estudio pretende evaluar el riesgo de presentar úlceras por presión, de todos los niños que ingresan a la uci pediátrica de la fundación hospital de la misericordia, mediante la utilización de la escala propuesta por bárbara braden en 1987, con el fin de contribuir a disminuir la incidencia de dichas úlceras. la escala mencionada evalúa factores extrínsecos e intrínsecos, que se encuentran directamente relacionados con la presentación de las úlceras, y los describe mediante seis variables o subescalas, que son: percepción sensorial, movilidad, actividad, estado nutricional, grado de humedad, fricción o cizallamiento. desarrollo de úlceras por presión intensidad y duración de la presión tolerancia de los tejidos movilidad actividad percepción sensorial factores extrínsecos factores intrínsecos humedad fricción nutrición cizallamiento baja presión arteriolar baja presión estas variables las agrupa y las define mediante el siguiente esquema: úlceras por presión en niños 13 según la escala de braden, se asigna la siguiente puntuación a cada una de las subescalas: • percepción sensorial: donde la persona completamente limitada obtiene una puntuación de uno; dos, si es muy limitada; tres, si es escasamente limitada, y cuatro, si no hay daño aparente. • humedad: si la persona está constantemente húmeda, tiene una puntuación de uno; húmeda, dos; ocasionalmente húmeda, tres, y rara vez húmeda, cuatro. • actividad: cuando el paciente se encuentra acostado, puntuación de uno; sentado, dos; camina ocasionalmente, tres, y camina con frecuencia, cuatro. • movilidad: completamente inmóvil, puntuación de uno; muy limitado, dos; ligeramente limitado, tres, y no hay limitaciones, cuatro. • nutrición: de acuerdo con el consumo de comida, si es muy pobre, recibe una puntuación de uno; si es muy limitado, dos; si es adecuado, tres, y si come todas sus comidas, cuatro. • fricción y descamación: puntuación de uno cuando requiere asistencia en el movimiento, de moderada a máxima; dos, requiere mínima asistencia, y tres, no hay problema aparente. si la puntuación total es menor o igual a 12, la persona tiene un alto riesgo de que se presente zona de presión; si está entre 13 y 14 puntos, el riesgo es moderado, y si está entre 15 y 16, el riesgo es bajo. detectado el riesgo de zona de presión en el paciente, se debe realizar una evaluación sistemática de la piel, para determinar la integridad o alteración que en ella se pueda presentar durante la estancia hospitalaria. para realizar la valoración de la zona de la piel se utilizará la clasificación descrita por la agency for health care policy and research, 1992, la cual establece cuatro estadios, que se describen en el cuadro 1. materiales y métodos el presente es un estudio de tipo cuantitativo, descriptivo y prospectivo, en un periodo comprendido entre el 1º de febrero y el 15 de mayo de 2003, en la fundación hospital de la misericordia, uci pediátrica. se evaluó el riesgo de presentar úlceras por presión, utilizando la escala de braden, al ingreso del niño a la unidad de cuidado intensivo (gráfica 1). se realizó la valoración de la piel de las zonas expuestas a la presión, mediante el instrumento diseñado para este fin, de los niños en quienes se detectó alto riesgo de desarrollar úlcera por presión (gráficas 2 a 5). se determinaron las medidas de prevención, de acuerdo con el índice de riesgo y los hallazgos en la valoración, especialmente encaminadas a disminuir la presión. dentro de ellas se tuvieron en cuenta los cambios de posición cada dos horas, en la medida en que el estado físico del niño lo permitió, y la modificación de la superficie de apoyo del área occipital, de elementos circulares a bolsas de aire. en el desarrollo de una úlcera por presión es importante tener en cuenta la intensidad y duración de la presión, que es la fuerza que ejerce la gravedad y provoca un aplastamiento tisular, debido a dos factores: el peso del paciente y la superficie de apoyo del mismo. la presión capilar oscila entre 6 y 32 mm de mercurio, pero si se excede esta cifra, se presenta oclusión del flujo sanguíneo y la consiguiente necrosis. esta es una de las razones por las cuales en los niños se presume que el área occipital, por tener un peso mayor relacionado con el cuerpo, es más susceptible a presentar zonas de presión, la cual se encuentra regulada por la movilidad, la actividad y la percepción sensorial de la persona. el otro componente del desarrollo de la úlcera por presión es la tolerancia de los tejidos, en la cual influyen factores extrínsecos, como la fricción, fenómeno que produce erosión en el estrato córneo y se genera cuando hay roce de la piel sobre la superficie de apoyo durante el movimiento. en el niño en estado crítico, este fenómeno aparece en el momento de transición de la sedación al despertar, cuando se ve alterada su percepción, pero aumentada su motricidad. el cizallamiento es un desgarro del tejido, o estiramiento del mismo, y se produce cuando resbala el paciente en la cama; el tejido externo se adhiere a la sábana, mientras el interno se desliza hacia abajo. la humedad disminuye la tolerancia del tejido a la presión. dentro de los factores intrínsecos se puede contemplar la presencia de enfermedades sistémicas, que desencadenan alteraciones de la perfusión de la piel, dentro de las cuales se encuentra el estado nutricional deficiente, las condiciones locales circulatorias, los estados de desequilibrio hidroelectrolítico y la vasodilatación producida en la sepsis, que pueden producir disminución de la tensión arterial media, lo cual a su vez reduce la perfusión tisular. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 14 fundación hospital de la misericordia departamento de enfermería instrumento de valoración de zona de presión datos de identificación: __________________________________________________________________________________________________ nombre: ______________________________________________________________________________________________________________________ historia clínica:______________________________________________________________ mes _______________________________________ diagnóstico:__________________________________________________________________________________________________________________ valoración:_______________________________________________________________________________________________________________________________________________________________ fe cha: glosario: eritema. enrojecimiento de la piel (estadio grado 1). flictena. acumulación de líquido bajo la piel (estadio grado 2). necrósis. costra seca (estadio grado 3). abrasión. desgaste de la piel (epidermis) por roce, frote o fricción. úlcera superficial. piel roja, ampollada, que se pela o agrieta. escaras. pérdida de espesor, formación de úlcera crateriforme (estadio grado 4). iniciales nombres convenciones: piel intacta p eritema e flictena f abrasión a úlceras superficiales u necrósis n escaras es m: mañana. t: tarde. n: noche. cuadro 1 zonas de presión m t n m t n m t n m t n m t n m t n 1 occipital 2 pabellón auricular derecho pabellón auricular izquierdo 3 escápula derecha escápula izquierda 4 columna dorsal 5 codo derecho codo izquierdo 6 isquión derecho isquión izquierdo 7 trocánter derecho trocánter izquierdo 8 sacro 9 cóccix 10 glúteo derecho glúteo izquierdo 11 cóndilo interno der.(tibia) cóndilo interno izq.(tibia) 12 maléolo interno derecho maléolo interno izquierdo 13 maléolo externo derecho maléolo externo izquierdo 14 talón derecho talón izquierdo 15 planta del pie derecho planta del pie izquierdo úlceras por presión en niños 15 de un total de 133 pacientes que ingresaron a la uci pediátrica de la fundación hospital de la misericordia, entre el 1º de febrero y el 15 de mayo de 2003, 48 (36%) presentaron un riesgo alto de sufrir úlceras por presión y 85 (64%) un riesgo medio, aplicando la escala de valoración propuesta por bárbara braden. esto equivale a decir que el 100% de ellos tuvieron algún grado de riesgo. en estos pacientes se encontró alteración en la percepción sensorial, inmovilidad y disminución de la actividad, inducidos por el tratamiento instaurado con medicamentos que producen sedación, relajación muscular y analgesia. es importante recalcar que en todos los niños que ingresaron a la uci, por presentar un alto riesgo de desarrollar úlceras por presión, fue necesario establecer medidas de prevención con base en los hallazgos de la evaluación, para evitar la aparición de dichas lesiones. evaluación de riesgo úlceras por presión zonas de presión específica de riesgo alto occipital pabellón auricular izquierdo gráfica 1 gráfica 2 gráfica 3 64% 36% 16% 4% 4%80% 96% riesgo alto riesgo medio piel intacta grado i grado ii piel intacta grado i grado ii revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 16 según los registros analizados de los 48 pacientes catalogados como de alto riesgo, la zona de presión más frecuente fue el área occipital, que se encontró en un 16%. dos de ellos evolucionaron a un estadio ii en un 25%. siguen las zonas de presión en el pabellón auricular izquierdo y en el talón izquierdo, con un 4%; esta última evolucionó a estadio ii en un 50%. la zona de presión en la región sacra se presentó solo en un 2% del total de la población valorada, y llegó en su totalidad a estadio ii. según el análisis de los datos, la mayor incidencia de úlceras por presión, en los pacientes evaluados, fue el área occipital. de estos, el 25% evolucionaron a un estadio ii, y para proteger el área, en el 50% de estos últimos se utilizaron dispositivos circulares, que aunque disminuyen la presión, porque evitan el contacto con la superficie de apoyo, facilitan la presencia de edema y disminuyen la perfusión tisular. por lo anterior se abolió su uso, y se determinó cambiar la superficie de apoyo por bolsas de agua, que junto con los cambios de posición evitaron que los niños evolucionaran de un estadio i al ii. de todos los niños estudiados, solo presentaron zonas de presión quienes fueron valorados como de alto riesgo, según braden. de otro lado, la aparición de la lesión se detectó en su totalidad en el estadio i, lo cual permitó que se realizaran cuidados específicos para frenar su evolución. sacro talón izquierdo gráfica 4 gráfica 5 piel intacta grado i grado ii piel intacta grado i grado ii 96%2% 2%4% 94%2% úlceras por presión en niños 17 bibliografía cañón abuchar, hilda maría. guía de intervención en enfermería basada en la evidencia científica, no. 11, acofaen, 1996. curley, m. a.; razmus, i. s. “predicting pressure ulcer risk in pediatric patients: the braden q scale”, nursing research, 52 (1): 22-23, jan.feb. 2003. durán echeverri, elsa. actualizaciones en enfermería, 2 (4): 29-37, diciembre 1999. guía para la presentación de un proyecto de investigación científica, www.colciencias.gov.co. luengas, ángela. guía de manejo para prevenir úlceras por presión, www.abcmedicus.com/articulo/id/332/pagina/1/guia_manejo_enfermeria.html. meehan, m.; o'hara, l.; morrison, y. m. “report on the prevalence of skin ulcers in a home health agency population”, advances in wound care: the journal for prevention and healing, 12 (9): 459-67, nov.-dec. 1999. ayello, e. a.; braden, b. “clinical management extra: pressure ulcers. how and why to do pressure ulcer risk assessment”, advances in skin & wound care, 15 (3, part 1): 125-33, may-jun. 2002. miranda-miranda, juan josé. gestión de proyectos, identificación, formulación, evaluación, bogotá, d.c., editorial guadalupe lta., 1997, pp. 542. ruiz, juan gabriel. investigación clínica: epidemiología clínica aplicada, centro editorial javeriana, 2001, pp. 17-21. beaglehole, r.; bonita, r.; kellstrom, t. epidemiología básica, organización panamericana de la salud, 1999. conclusión el 100% de los niños que ingresaron a la uci tienen un nivel de adaptación comprometido, por presentar riesgo de desarrollar úlceras por presión. al aplicar la escala de bárbara braden, se encuentra que el 36% están en alto riesgo y el 64% en riesgo medio. mediante la evaluación periódica de la piel, en todos los pacientes de alto riesgo, se observó la aparición de zonas de presión en un estadio temprano. una vez detectado el riesgo de presentar úlceras por presión, en los niños que ingresaron a la uci pediátrica de la fundación hospital de la misericordia, y la aparición de esas lesiones en quienes tenían alto riesgo, se recomendó implementar el uso de la escala de braden para la valoración del riesgo, como primer paso en la prevención de esta situación, y además evaluar la piel utilizando el formato diseñado para este fin. asimismo, se aconsejó unificar los criterios que se deben tener en cuenta en los cuidados de enfermería, para evitar la aparición de úlceras por presión. se recomienda establecer el registro continuo de estos eventos, como indicador de calidad del cuidado de enfermería en la unidad. aunque existen estudios que hacen referencia a la prevención y tratamiento de las úlceras por presión en los adultos, es importante tener en cuenta que no está documentado lo referente a esta situación en pacientes pediátricos. como la fundación hospital de la misericordia es el sitio que concentra la mayor población infantil atendida, tiene la responsabilidad de documentar la incidencia, establecer protocolos para disminuirla y evaluar si las actividades que se realizan surten el efecto deseado o si requieren ser modificadas. es importante tener en cuenta que los niños con un nivel de adaptación comprometido requieren del apoyo del personal de enfermería y de su familia, para que desarrollen los cuidados necesarios, con el fin de promover su adaptación y, en este caso particular, prevenir las lesiones de piel. entre ellos, vale la pena destacar los cambios frecuentes de posición, el mantenimiento de la piel limpia y seca, el uso de almohadas pequeñas en zonas de alto riesgo, los masajes con una crema humectante, y todas aquellas estrategias de comunicación y contacto físico que ayuden al niño a enfrentar las situaciones de estrés. recomendaciones 12 la nueva.p65 revista aquichan issn 1657-5997 108 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005108 año 5 vol. 5 nº 1 (5) 108-113 chía, colombia octubre 2005 gloria maritza céspedes1 recibido: 7 de junio de 2005 aprobado: 22 de agosto de 2005 resumen el presente artículo tiene como propósito principal dar a conocer los planteamientos teóricos sobre la nueva concepción de la discapacidad orientada desde el reconocimiento de los derechos humanos, la autonomía, la integración, las capacidades y los apoyos, enfatizando en la interacción de la persona con discapacidad y el ambiente donde vive. por otra parte, se describen algunos de los modelos de rehabilitación que han sido utilizados a lo largo del tiempo, pero que han resultado ineficaces hacia la atención integral de la persona con discapacidad. por esto, finalmente se plantea el modelo ecológico como una alternativa que aborda de manera integral los diferentes aspectos de la vida de cada persona. palabras clave: discapacidad, rehabilitación, inclusión, modelo e c o l ó g i c o . abstract the main purpose of this article is to present theoretical statements on the new concept of disability from the recognition of human rights, autonomy, integration, capacities and support, emphasizing in the interaction of the disabled person and its environment. on the other hand, some models of rehabilitation are described that have been used through time, being ineffective for integral care of the disabled person. finally, the ecological model is presented as an alternative to approach in an integral way, different aspects of the person�s life. key words: disability, rehabilitation, inclusion, ecologic m o d e l . 1 fisioterapeuta, magíster en integración de personas con discapacidad (rehabilitación y habilitación), universidad de salamanca, españa. fundación teletón; docente de la escuela colombiana de rehabilitación. g l o r i a . c e s p e d e s @ u n i s a b a n a . e d u . c o la nueva cultura de la discapacidad y los modelos de rehabilitación 109 n los últimos años la atención en rehabilitación a las personas con discapacidad se ha contextualizado en un concepto integrador de las actuaciones sociales dirigido a garantizar la igualdad de oportunidades a estas personas, en el contexto social y en el de los enfoques que dan prioridad al desarrollo personal y la aparición de nuevos escenarios de intervención. para entender que la discapacidad es una circunstancia social es preciso partir del conocimiento real y del manejo de los marcos conceptuales. desde esta perspectiva, se ha venido presentando una evolución significativa en la manera en que la sociedad se relaciona con las personas con discapacidad, fundamentada en una posición transformadora constituida por las posibilidades de vida digna y equitativa desde la inclusión, el apoyo, la autodeterminación y las capacidades para desarrollarse como personas autosuficientes. así, el planteamiento de una nueva cultura de la discapacidad parte de la interacción entre la persona y el ambiente donde vive, y se apoya fundamentalmente en la concepción de la propia capacidad del individuo, en sus destrezas personales, en la posibilidad de desarrollar actividades de manera independiente, partiendo de sus intereses y de la capacidad de elegir. por esto, la meta de cualquier proceso de rehabilitación integral debe ser la inclusión social, y no sólo la rehabilitación médico funcional. esta inclusión social, como meta del proceso de rehabilitación, incluye el acceso de las personas con discapacidad a todos los servicios y recursos existentes en la comunidad, centrándose en las necesidades y los deseos individuales, pues esto lleva a un verdadero proceso de integración que es la única vía hacia la normalización que es parte fundamental en el desarrollo de la sociedad. al analizar la discapacidad como fenómeno cultural aparecen diferentes modelos que, de una u otra forma, han constituido un marco conceptual sobre lo que hoy se entiende por situación de discapacidad. en los párrafos siguientes se analizarán algunos modelos de rehabilitación que han existido a través del tiempo. en colombia, hasta hace aproximadamente 30 años, la rehabilitación de las personas con discapacidad se llevaba a cabo en centros hospitalarios, en centros de rehabilitación, asilos para enfermos mentales y en centros para atender necesidades educativas especiales. este tipo de tratamiento ocasionaba lo que se conoce con el nombre de hospitalismo, es decir, una gran dependencia de las personas y las familias a estos servicios, donde se sentían protegidos de la discriminación y de las barreras arquitectónicas y sociales, limitando su posibilidad de adaptación a la discapacidad y a su posterior reinserción social. el modelo médico el modelo médico considera que la discapacidad es un comportamiento anormal del individuo, el síntoma o la manifestación externa de una alteración de su organismo (1). esta visión médica juzga todas las afecciones de la condición de la salud como una enfermedad, donde se persigue una idea abstracta de salud, es decir, que la persona con discapacidad se considera como enferma permanente, en espera de una cura que en la mayoría de los casos es improbable. revista aquichan issn 1657-5997 110 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005110 aquí la discapacidad es vista como un problema del individuo, pues es él quien presenta una anormalidad física, sensorial o mental, lo que hace que su deficiencia y su falta de destreza sean el origen de sus dificultades, las mismas que hacen necesaria la rehabilitación centrada en el sujeto como paciente, quien requiere intervención médica individualizada, que debe ser dada por un profesional de la salud. uno de los componentes más significativos y negativos de este modelo médico tradicional es que la persona tiende a asumir y aceptar un rol de enfermo sin tener en cuenta sus derechos, pero tampoco sus deberes en los contextos cercanos �familia, comunidad, trabajo, etc.�, por lo que se transforma en un individuo pasivo que ve el proceso de la rehabilitación como responsabilidad del personal de salud (2). otro de los componentes negativos y que puede sesgar el modelo es la percepción de la persona con discapacidad sobre su situación, al tener una percepción de él como enfermo o minusválido, y los factores sociales que no forman parte de este modelo. la atención en salud es considerada como una cuestión primordial. este modelo se caracteriza porque existe una relación estricta de médico-paciente. finalmente, está la creación de servicios especiales como la solución de los problemas, abriendo espacios de atención social y rehabilitación aislados como hospitales psiquiátricos, centros de educación especial, talleres protegidos, entre otros (3). el modelo biopsicosocial es una integración de los componentes del modelo médico y del modelo social; este último ubica la discapacidad como un problema dentro de la sociedad y no exclusivamente como una característica de la persona (4). se enfatiza en la importancia de la expresión y la participación plena en todos los contextos ambientales capaces de influir positiva o negativamente sobre la persona con discapacidad y, por tanto, su manejo requiere de la participación de otros. es así como se da paso al modelo biopsicosocial, donde el ser humano es el eje central, y que toma los elementos biológicos, psicológicos y las condiciones sociales. ve la discapacidad como una deficiencia del individuo en actividades personales y en participación social. este modelo aborda la discapacidad principalmente como un problema del sujeto desde diferentes dimensiones, aproximándose a un concepto integrador. sin embargo, algunos de los aspectos discutidos en este modelo son la fragmentación de los aspectos psicológicos, biológicos y sociales, así como la falta de integración de estos aspectos con elementos ambientales y sociales. modelo de rehabilitación basado en la comunidad el problema de la discapacidad no está limitado únicamente a la persona, involucra también a la familia, a la comunidad, a la sociedad y a la cultura en general. este concepto, y la falta de oportunidades de las personas con escasos recursos económicos para acceder a programas de rehabilitación formal, dieron origen a la rehabilitación basada en la comunidad (1998) (5), como una metodología de trabajo que permite integrar de manera coordinada los diferentes actores sociales (personas con discapacidad, familia, escuela, empleadores, estado y sociedad civil) en la búsqueda de alternativas orientadas a la integración social de las personas con discapacidad, a través de la participación activa de la sociedad y tomando en cuenta los recursos existentes. el concepto de rehabilitación basada en la comunidad (5) debe interpretarse como un enfoque extenso que abarca desde la prevención de la discapacidad y la rehabilitación en la atención primaria, hasta la inserción de niños con discapacidad en centros escolares normales, y la posibilidad de desarrollar actividades económicas lucrativas en el caso de las personas adultas con alguna discapacidad. es una alternativa para brindar atención integral, aprovechando los recursos personales, comunitarios y del estado. según la organización internacional del trabajo (6), la rehabilitación basada en la comunidad debe considerarse ante todo como un programa que pertenece a la comunidad representada por el gobierno o autoridades locales, debiendo formar parte constitutiva de la política social, educativa y sanitaria en todos los ámbitos, pero sobre todo en el más descentralizado del sector público. esta metodología ha sido utilizada ampliamente y con resultados positivos en diferentes países latinoamericanos como méxico, bolivia, nicaragua. el salvador y colombia. el problema de la discapacidad no está limitado únicamente a la persona, involucra también a la familia, a la comunidad, a la sociedad y a la cultura en general. la nueva cultura de la discapacidad y los modelos de rehabilitación 111 desarrolló el programa piloto de rehabilitación basada en la comunidad (2000) (9). el objetivo principal del proyecto era trabajar en la prevención primaria, secundaria y terciaria de las discapacidades como mecanismo para el mejoramiento de la calidad de vida de las personas con discapacidad. como actividades del proceso se realizaron charlas y talleres de sensibilización y prevención de la discapacidad dirigidos a la comunidad en general; también se realizó la capacitación de promotores de salud que pertenecen a estas comunidades, los cuales adelantaron el trabajo de detección y registro de casos los cuales eran remitidos a los respectivos especialistas, y son los encargados de realizar el acompañamiento, mediante visitas domiciliarias a los procesos de rehabilitación diseñados en cada caso. asimismo, en el departamento del guainía se creó el proyecto apoyo al fortalecimiento de la asociación de discapacitados y familiares del guainía (asodifa). el objetivo de la asociación es lograr en la población discapacitada y organizada del municipio de inírida la iniciación y puesta en marcha de un proceso de desarrollo propio que permita incrementar sus posibilidades de acceso a servicios y oportunidades, a través de la capacitación, asesoría y acompañamiento de asodifa de manera que logre incidir en los procesos políticos y económicos del departamento. estas experiencias demuestran resultados positivos cuando la comunidad se apropia de ellas, y no dependen para su realización de las políticas de los gobiernos municipales y departamentales. finalmente, se recomienda que el enfoque de un programa de rehabilitación basada en comunidad, debe salirse del modelo médico: diagnóstico-prescripción, para pensar más bien en un modelo de integración que comprenda la readaptación profesional, la reinserción laboral y la adaptación a la comunidad, por esto la propuesta es más bien hacia un programa de integración comunitaria (10). este tipo de programas tiene tres pilares: � organización de los servicios: personal profesional, especialistas en readaptación, disponibilidad de recursos financieros, materiales, etc. � formación del personal de desarrollo comunitario y apoyo técnico. � promoción de la integración. dentro de estas experiencias citaremos algunas como ejemplo. en latinoamérica bolivia ha sido uno de los países pioneros en rehabilitación basada en la comunidad (rbc). el programa ric (7), rehabilitación integral en la comunidad boliviana, inicia su desarrollo en 1995; este proyecto describe el contexto socioeconómico de bolivia, el análisis de la situación en que se encuentra el problema de la discapacidad, y propone el cambio de la orientación institucional hacia un enfoque integral en el tratamiento del tema. la formulación de este proyecto es fruto de un trabajo de grupo de discapacitadas, grupos regionales, organizaciones no gubernamentales (ong) y representantes del gobierno y la comunidad. el proyecto de rehabilitación integral en la comunidad tiene carácter experimental interdepartamental, con el fin de hacer un proyecto nacional, pues su contenido está dirigido a involucrar, coordinar y reformar el modelo nacional de atención a la discapacidad. la participación coordinada del sector estatal, las organizaciones no gubernamentales, las personas con discapacidad, los padres de familia y las comunidades, desde la generación del proyecto, y su actuación directa en la implementación y evaluación del mismo, constituyen el eje organizativo articulador que garantiza la factibilidad y viabilidad del proyecto. en colombia tiene un gran reconocimiento el programa de rehabilitación con participación comunitaria de antioquia (8), que funciona en cien municipios desde 1998; este proyecto ha implementado un modelo educativo y formativo cuya finalidad es brindar a las comunidades más vulnerables de los municipios de colombia herramientas teóricas y prácticas que les permitan transformar su realidad y mejorar la calidad de vida de las personas con discapacidad, para asumir con responsabilidad sus propios procesos de rehabilitación. para lograr este propósito enfoca su trabajo en la formación de agentes de cambio comunitarios quienes lideran el proceso de rehabilitación de las diferentes comunidades, por medio del aprovechamiento de los recursos propios de cada comunidad, y utilizando metodologías participativas en el campo de la rehabilitación. en el valle del cauca, a través de la corporación regional de rehabilitación, que desarrolló un programa en la costa pacífica, se el proyecto de rehabilitación integral en la comunidad tiene carácter experimental interdepartamental, con el fin de hacer un proyecto nacional, pues su contenido está dirigido a involucrar, coordinar y reformar el modelo nacional de atención a la discapacidad. revista aquichan issn 1657-5997 112 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005112 como se observa, han surgido nuevos modelos más integradores y que toman elementos propios del individuo, sus necesidades, habilidades y los apoyos que requieran para la integración de estos componentes. a fin de generar un cambio en el lenguaje, la organización mundial de la salud (oms) propone un cambio de la concepción de la discapacidad expresado en la clasificación internacional del funcionamiento, la discapacidad y la salud (cif) (11) de la oms, aprobado el 22 de mayo de 2001. la cif enfatiza tres aspectos: 1. funcionamiento: como término genérico para designar todas las funciones y estructuras corporales, la capacidad de desarrollar actividades y la posibilidad de participación del ser humano. 2. discapacidad: de igual manera, como término genérico que recoge las deficiencias en las funciones y estructuras corporales, las limitaciones en la capacidad de llevar a cabo actividades, las restricciones en la participación social del individuo. 3. salud: como elemento clave que relaciona a los dos anteriores. el objetivo principal de la cif es brindar un lenguaje unificado y estandarizado, un marco conceptual para la descripción de la salud y los estados relacionados con la misma. la oms abandona el enfoque conservador de consecuencia de la enfermedad, para centrar el objetivo hacia �la salud y los estados relacionados con la salud�. trata, por lo tanto, de poner en positivo su terminología desde el primer momento. el término �enfermedad� ya no es empleado y a cambio aparece la expresión de �condición de salud�. el enfoque de esta nueva clasificación es centrado en los componentes biopsicosocial y ecológico, superando la perspectiva biomédica manejada por muchos años. finalmente, es importante resaltar que existen otras dimensiones como el trabajo, y la participación en espacios educativos y de ocio, que permiten tener una visión integral de la situación de discapacidad. el análisis de la cif nos orienta hacia la propuesta de un modelo que tome como referencia los componentes de funcionamiento, condición de salud y discapacidad desde el enfoque de interacción de la persona con el entorno, desde una perspectiva multifactorial, esto nos permite analizar el modelo ecológico. el modelo ecológico hoy en día se ha dado paso a una visión todavía más amplia, holística, para el abordaje de la problemática de la discapacidad, con el ánimo de mejorar la calidad de vida de esta población, fundamentada en que las experiencias de los seres humanos son únicas e individuales, y se relacionan básicamente con la percepción que tienen del ambiente, con el conocimiento aprendido en vivencias anteriores, con sus sentimientos, costumbres y tradiciones. los modelos ecológicos son ampliamente reconocidos en el trabajo desarrollado por bronfenbrenner (1987) (12), quien ha realizado grandes aportaciones en el campo de la psicología evolutiva y que resultan aplicables a la discapacidad. en los párrafos siguientes se analizará el modelo expuesto por este autor, que es el modelo de rehabilitación integral que enmarca todos los componentes necesarios para lograr integrar el nuevo concepto de la discapacidad y el verdadero significado de la calidad de vida, lo que brinda un sentido de referencia y orientación desde una perspectiva individual, principio primordial para mejorar el bienestar de la persona en situación de discapacidad. el modelo ecológico está constituido por cuatro componentes: proceso, contexto, tiempo y persona. dicho modelo plantea que la persona se ve influenciada por tres sistemas, cada uno de ellos incluido dentro del otro. esto quiere decir que la persona con discapacidad está influencia por diferentes factores a lo largo de su vida, dichos factores van ejercer una influencia única, así como una respuesta particular en cada persona. el primer nivel, denominado microsistema, hace referencia a las características propias del individuo como su apariencia física, temperamento, tipo de discapacidad; es el contexto social inmediato como la familia, hogar, grupo de iguales, que afecta directamente a la vida de la persona. el mesosistema refleja la comunidad donde vive la persona, su familia, y afecta directamente el funcionamiento del microsistema; por último, estos sistemas están dentro del macrosistema que refleja las influencias sociales, políticas y culturales de la sociedad en general. al analizar cada uno de los componentes expuestos anteriormente, se observa que una situación de discapacidad es un eje transversal en cada sistema. así, en el microsistema se parte del sujeto como persona autónoma, que decide, que participa, que es influenciada por los ambientes como la escuela, el trabajo, los amigos, la pareja. el modelo ecológico está constituido por cuatro componentes: proceso, contexto, tiempo y persona. la nueva cultura de la discapacidad y los modelos de rehabilitación 113 finalmente, al profundizar en el macrosistema, éste incluye los tres niveles expuestos anteriormente; hacen parte de este sistema los patrones culturales, las tendencias políticas, los sistemas económicos, las creencias y, en fin, todos los factores de la sociedad en general que pueden afectar al individuo. son muchos los factores que influyen en el proceso de integración de las personas con discapacidad a la sociedad, pero tal vez uno de los más significativos son las barreras que estas personas encuentran diariamente y no se habla aquí de las barreras arquitectónicas que abundan en las calles, ni de la falta de accesibilidad a sitios públicos como bancos, cines, edificios o simplemente en su propio hogar, se habla de las barreras actitudinales. en el macrosistema las actitudes y las creencias hacia la discapacidad son importantes para promover la integración social; es aquí donde se debe reconocer el concepto de �persona�, por encima de otros calificativos o etiquetas que se puedan añadir para referirse a las personas con discapacidad. ello representa no sólo un cambio en la perspectiva social del sujeto, sino también en las demandas laborales, familiares y sociales. para finalizar, en este sistema la legislación, la política, los grupos representativos, el plan nacional de desarrollo y la política pública ejercerán una influencia directa y trascendente en las personas con discapacidad, donde son ellas quienes deben apropiarse de los espacios participativos para formar una nueva cultura de la rehabilitación. en este sistema también la familia se convierte en aquel apoyo natural con que cuenta la persona; es el principal sistema en el que convive el individuo y del que depende en gran medida el proceso de adaptación a la nueva situación de discapacidad, una inadecuada adaptación familiar afectará negativamente el desarrollo de la persona con discapacidad, reduciendo la capacidad de ésta a integrarse en los diferentes roles de su comunidad. el mesosistema muestra la relación de la persona con discapacidad y la comunidad cercana, es decir, la escuela, los amigos, la iglesia, los grupos comunales, deportivos, culturales. aquí la persona con discapacidad hace parte activa de su propia comunidad, desarrollando habilidades que le permitan integrarse a sistemas sociales diferentes a su familia. el mesosistema también hace referencia a ese concepto integrador donde la sociedad tiene la obligación de aceptar y de trabajar con las personas con discapacidad para tratar de proporcionarles diferentes opciones dentro de la comunidad a la cual pertenecen. la capacitación para el trabajo, la integración a la aulas escolares, la participación en grupos representativos culturales y deportivos, así como el entrenamiento en habilidades sociales, y los ambientes normalizados como las empresas, las universidades, las entidades públicas y privadas son los elementos que hacen parte de este sistema. referencias bibliográficas 1. cuervo c, escobar m, trujillo. más allá de una visión clínica de discapacidad. revista ocupación humana 2000;8(4):12-16. 2. casado d, panorámica de la discapacidad. barcelona: ed. intress; 1998. 3. cruz pr. panorama y perspectiva del movimiento de vida independiente en iberoamérica. madrid: amarú ediciones; 2001. 4. secretaría distrital de salud de bogotá, d.c. dirección de salud pública. lineamiento de atención en salud para personas con discapacidad en bogotá; 2001. 5. organización panamericana de salud (ops). rehabilitación basada en la comunidad. manual del facilitador. nicaragua; 1988. 6. organización internacional del trabajo (oit) unesco. rbc con y para personas con discapacidad. ponencia conjunta. ginebra; 1994. 7. secretaría nacional de bolivia. programa ric. rehabilitación integral en la comunidad. bolivia; 1995. 8. comité de rehabilitación de antioquia. folleto informativo del ripc. medellín; 1999. 9. márquez f. rbc en la costa pacífica. revista fundamentos 2002;13(3):38-43. 10. momm w, könig a. de la rehabilitación basada en la comunidad a los programas de integración comunitaria: nuevo concepto de servicios para personas incapacitadas. experiencias y reflexiones. ginebra: oficina internacional de trabajo; 1990. 11. organización mundial de la salud (oms). clasificación internacional del funcionamiento y la discapacidad � cif. ginebra; 2000. 12. bronfenbrenner u. la ecología del desarrollo humano. barcelona: paidos; 1987. 285 293 primeras paginas.indd 289 editorial tendencias de investigación en enfermería trends in nursing research tendências de pesquisa em enfermagem me siento muy honrada con la invitación para escribir este editorial sobre las tendencias en la investigación en enfermería para la revista aquichan. mis opiniones se centran en la evolución de los temas que las enfermeras deciden estudiar, la influencia de la financiación sobre los temas que se consideran importantes para el estudio y el peso de las posiciones editoriales sobre la publicación de informes de investigación en enfermería. la historia de la investigación en enfermería debe ser considerada dentro del contexto de la sociedad en la que la investigación se lleva a cabo (1). dadas las similitudes en el contexto social de la enfermería alrededor del mundo —típicamente considerado como un arte y apenas recientemente también como una ciencia, de bajo estatus y servil a la medicina y, últimamente, solo como socio colaborativo en otros campos relacionados con el estudio de la salud; con una distribución de género predominantemente femenina que solo recientemente incluye un mayor porcentaje de varones; con un enfoque de aprendizaje hacia la educación en enfermería que hace relativamente poco tiempo evolucionó hacia un enfoque profesional; y siempre con pocos recursos para llevar a cabo la investigación—, se desprende que la investigación en enfermería ha progresado de una manera similar en la mayoría de todos los países, si no en todos (1, 2). la evolución de los temas para la investigación en enfermería la investigación en enfermería se inició en la década de 1850 con florence nightingale, cuya perspectiva de la enfermería se centró en la interacción entre la persona y su entorno (2, 3), y se institucionalizó en la medida en que la educación en enfermería evolucionó desde programas de diplomado en hospitales, hasta la enseñanza universitaria, que incluía programas de doctorado, a partir de la década de los veinte. las enfermeras siempre han estado interesadas en la realización de investigaciones sobre la atención al paciente. sin embargo, la mayoría de los temas de investigación desde los años veinte hasta finales de los sesenta se centraron en la educación en enfermería y en las enfermeras (3). las facultades de enfermería querían saber cómo facilitar el aprendizaje de los estudiantes en cuanto a las habilidades necesarias para la práctica de la enfermería, y los administradores de la disciplina querían saber cómo pasaban su tiempo y qué hacían las enfermeras cuando se dedicaban a la práctica de la profesión. la investigación al respecto fue denominada “estudios de tiempo y movimiento”. la investigación sobre la educación en enfermería continúa hoy en día, pero en menor medida que en el pasado. por ejemplo, un tema importante en la investigación contemporánea al respecto es la eficacia de la simulación con el fin de que los estudiantes puedan aprender las habilidades de la práctica de enfermería. los estudios sobre enfermeras también continúan hoy en día, pero de igual manera en menor grado que en el pasado. por ejemplo, los típicos temas contemporáneos son las experiencias de las enfermeras en la atención de pacientes con determinados problemas de salud, como cáncer o enfermedades cardiacas, respiratorias o infecciosas. en la década de los setenta hubo una recomposición de los principales temas de investigación en enfermería, desde la educación y las enfermeras hacia las experiencias relacionadas con la doi: 10.5294/aqui.2014.14.3.1 290 aquichan issn 1657-5997 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 salud de las personas, las familias y las comunidades. este enfoque sustantivo de la investigación en enfermería, que representa lo que siempre ha estado implícito pero ahora es una búsqueda más explícita de evidencia para la práctica de la enfermería ha evolucionado de una manera similar en todo el mundo. hoy en día el objetivo final explícito de la investigación en enfermería es encontrar pruebas que se puedan utilizar en la práctica (3). en cuanto a la investigación en enfermería, el énfasis contemporáneo en la práctica basada en la evidencia ha evolucionado a partir de la utilización de la investigación, que fue el enfoque de muchas publicaciones desde la década de los setenta hasta finales de los noventa. la utilización de la investigación se refiere a “las medidas preparatorias necesarias para las acciones relacionadas con la investigación que —cuando son implementadas y se sostienen— llevan a [la práctica basada en la evidencia]” (4). la utilización de la investigación se ha convertido recientemente en investigación traslacional, la cual “es un proceso de investigación utilizado para determinar qué condiciones, costos y recursos se necesitan para pasar de la generación y la comprobación de la teoría a la utilización de la misma o a la práctica basada en la evidencia” (5). aunque se ha avanzado mucho desde los tiempos de nightingale en cuanto a la cantidad de investigación en enfermería y a la diversidad de los temas estudiados, una gran parte de esa investigación se ha llevado a cabo sin una base conceptual o teórica explícita. poco a poco las enfermeras están comenzando a reconocer que toda la investigación se guía por un modelo conceptual (6), se lleva a cabo para desarrollar teorías, los hallazgos de la investigación son teorías, y las teorías son la evidencia para la práctica (5). yo sostengo que toda la investigación en enfermería tendrá mucho más valor si es guiada por un modelo conceptual de la disciplina (7), en vez de que el modelo conceptual que guía la investigación continúe siendo implícito. por ejemplo, he explicado cómo mis colegas, estudiantes de posgrado y yo realizamos un programa de investigación guiado explícitamente por el modelo de adaptación de roy (8) y otro programa de investigación orientado explícitamente por la teoría de rogers (9) sobre seres humanos unitarios (10). la influencia de la financiación en la investigación en enfermería la sociedad de honor de enfermería, sigma theta tau, fue la primera organización en estados unidos que proveyó fondos para la investigación en enfermería en 1936. hoy en día, esta organización internacional y sus subdivisiones locales proporcionan financiación para la investigación en enfermería llevada a cabo por sus miembros en muchos países. en estados unidos, el gobierno federal comenzó a financiar la investigación en enfermería en la década de los cuarenta; la mayoría de los fondos federales ahora provienen de los institutos nacionales de salud. las fundaciones privadas comenzaron a financiar la investigación en enfermería en estados unidos en la década de los cincuenta, y los filántropos comenzaron su financiación en la década de los sesenta. una revisión de las revistas de enfermería que contienen los informes de las investigaciones llevadas a cabo por las enfermeras en todo el mundo indica que cierto grado de financiamiento gubernamental y algún tipo de financiamiento otorgado por organizaciones profesionales están disponibles en varios países. la financiación de la investigación en enfermería en cada país depende de la economía general del mismo, especialmente en los que se encuentran en vía de desarrollo (11). sin embargo, como parahoo (2) señaló: “no es prudente generalizar en cuanto a los países en desarrollo, ya que varían de acuerdo con sus niveles de desarrollo económico. en algunos de esos países la investigación de enfermería es más desarrollada que en los demás”, a pesar de la economía general. las prioridades de investigación establecidas por las agencias gubernamentales, las organizaciones, las fundaciones privadas y los filántropos han dado forma al tipo y a los temas de los estudios realizados por las enfermeras. la investigación experimental diseñada para probar las intervenciones innovadoras en enfermería ha sido una prioridad constante, incluso cuando aún no se comprenden las descripciones y las explicaciones de las intervenciones experimentales. es probable que el énfasis en la investigación experimental sobre la disciplina refleje la preocupación tanto de las enfermeras como de los financiadores por la práctica basada en la evidencia dirigida a la mejora de la calidad de vida de las personas que requieren cuidados de enfermería. sin embargo, la tendencia a comenzar con la experimentación resulta en las llamadas “cajas negras” del conocimiento; es decir, el desarrollo del conocimiento de los efectos de una intervención sin entender el contenido detallado de la misma y por qué ella es eficaz o ineficaz (12). el enfoque de la caja negra 291 se centra solo en si la intervención fue eficaz en el cumplimiento de los resultados esperados, pero no tiene en cuenta las posibles variables exógenas al cumplimiento de estos resultados. en consecuencia, el enfoque de la caja negra puede resultar en una intervención que cumple con los resultados esperados en un ensayo clínico en particular, pero carece de la fiabilidad y validez para seguir cumpliendo con los resultados a través del tiempo o para otras muestras de la misma población (13). por tanto, no se sabe cuál intervención es eficaz; cuándo, dónde y para quién, y por qué y cómo la intervención es eficaz (14). cuando se lleva a cabo una investigación de caja negra los hallazgos no constituyen teorías bien desarrolladas las cuales son la mejor prueba de la práctica, sino que proporcionan evidencia para la práctica basada en creencias clínicas obstinadas, opiniones de las autoridades y el sentido común (5, 15). es posible evitar la investigación estilo “caja negra” si las enfermeras están dispuestas a llevar a cabo programas de investigación que comiencen con estudios cualitativos y descriptivos diseñados para comprender las experiencias de la gente en cuanto a condiciones relacionadas con la salud, para luego avanzar hacia los estudios de correlación de las relaciones entre las experiencias relacionadas con la salud y los factores que influyen en esas experiencias, y solo así pasar a los estudios experimentales de las pruebas de los efectos de las intervenciones sobre los resultados que reflejen una mejora en las experiencias relacionadas con la salud. otra fuente de financiación para la investigación en enfermería son las universidades que ofrecen becas para profesores y estudiantes de posgrado. la financiación proporcionada por las universidades tiende a aumentar a medida que la institución amplía su misión para incluir no solamente la docencia sino también la investigación. por ejemplo, la universidad de massachusetts en boston ha evolucionado desde una misión casi exclusivamente centrada en la enseñanza al momento de su fundación en 1964, hasta el punto en que se considera a sí misma como una “excelente universidad pública dedicada a la investigación y con alma para la enseñanza” (declaración de la visión de la universidad de massachusetts en boston, 2010). algunas universidades establecen las prioridades generales para la investigación en relación directa con la misión y los objetivos de la universidad. por ejemplo, la mencionada universidad ofrece financiación para investigaciones a cargo de la facultad y los estudiantes de posgrado que aborden sus metas en cuanto a la mayor participación de la comunidad y la colaboración internacional. la publicación de investigaciones en enfermería la difusión de la investigación en enfermería se produce a través de conferencias internacionales, nacionales, regionales y locales en muchos países. sin embargo, las presentaciones en las conferencias solo llegan a audiencias relativamente pequeñas. los artículos de revistas, por el contrario, tienen el potencial de llegar a cientos o incluso miles de lectores en todo el mundo a través de material impreso y la internet. por tanto, es imperativo que las enfermeras que realizan investigación transfieran rápidamente sus presentaciones a artículos que luego sean enviados a las revistas con el fin de ser considerados para publicación. los editores de revistas y los miembros del comité editorial pueden animar a la presentación de dichos artículos cuando asistan a conferencias y cuando interactúen con colegas de su institución de origen. también es imprescindible identificar explícitamente en las publicaciones el modelo conceptual que orienta la investigación y la teoría que se genera o que se encuentra bajo prueba. la inclusión de modelos y teorías conceptuales explícitos en los informes de investigación sería mucho más habitual de lo que se observa en la actualidad si los editores de revistas y los revisores son receptivos a tales informes de investigación y les dan apoyo. esto se convertirá en la norma cuando los editores de revistas de enfermería exijan que los investigadores expliquen clara e integralmente toda la estructura conceptual-teórica-empírica de sus estudios (5). la gran mayoría de las revistas de enfermería en todo el mundo incluyen informes de las investigaciones realizadas por las enfermeras en muchos países. por ejemplo, la international journal of nursing studies, el journal of advanced nursing, el journal of nursing scholarship y la revista aquichan publican trabajos desarrollados por enfermeras investigadoras de varios países. los estudios publicados en estas y muchas otras revistas son excelentes ejemplos de las “muchas historias [que hay que contar] de diferentes personas en distintos momentos con diversas visiones sobre los tipos de ‘buena’ ciencia, ‘técnicas válidas’ y conocimiento ‘valioso’ necesarios para atender a los pacientes, [y] avanzar la disciplina” (1). la transición de informes de investigación de un solo autor a informes escritos por equipos de investigadores se está haciendo evidente en las revistas de enfermería. este cambio refleja la creeditorial 292 aquichan issn 1657-5997 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 ciente complejidad de los temas estudiados y el énfasis contemporáneo en los diseños de investigación de métodos mixtos que requieren equipos de investigadores, algunos de los cuales son expertos en diseños cualitativos, otros son expertos en diseños cuantitativos, y otros más lo son en la integración de los datos cualitativos y cuantitativos (16). preveo que la colaboración entre equipos de investigadores en enfermería al interior de y entre las universidades y los organismos clínicos dentro de un país y entre países aumentará a medida que avancemos en nuestra búsqueda de teorías empíricamente adecuadas que sirvan de evidencia para la práctica de la enfermería (5). aunque la creación y gestión de equipos de investigadores para la realización y el informe de la investigación son un reto, la riqueza y la profundidad de este tipo de investigación colaborativa pueden superan los desafíos. parahoo (2) hizo una advertencia acerca de las colaboraciones entre países que presenta un reto particularmente intrigante. explicó que los proyectos conjuntos de investigación entre las enfermeras de los países más ricos y las de los más pobres pueden ser beneficiosos o pueden ser un obstáculo. “los proyectos en conjunto implican la transferencia de habilidades y oportunidades útiles de aprendizaje. sin embargo, pueden dar lugar a cambios en la imagen de las sociedades occidentales” (2) que impidan la igualdad de las relaciones entre los investigadores de enfermería de los países más ricos y de los más pobres. este desafío puede superarse solo si las enfermeras colaboradoras que realizan investigación entienden y respetan la cultura de cada país, incluyendo el estilo de vida, el lenguaje y las percepciones sobre la investigación y los investigadores. aunque la necesidad de tener equipos de investigadores es reconocida y alentada por las universidades y los organismos clínicos, no es fácil evaluar de manera justa la contribución particular al estudio y al informe de cada miembro del equipo de investigación. los editores de revistas pueden evitar la existencia de este desafío al exigir una declaración de las contribuciones específicas de cada investigador al estudio y al informe de investigación. para terminar, quiero dar las gracias a maría elisa moreno fergusson, editora de la revista aquichan, y a los miembros del consejo de redacción de la revista por la oportunidad de compartir con los lectores mis pensamientos acerca de las tendencias en la investigación en enfermería. jacqueline fawcett, rn, phd, scd (hon), faan profesora del departamento de enfermería universidad de massachusetts, boston (ee.uu.). jacqueline.fawcett@umb.edu referencias 1. d’antonio p. toward a history of research in nursing. nursing research. 1997;46:105-110. 2. parahoo k. nursing research: principles, process, and issues. 2nded. new york: palgrave macmillan; 2006. 3. grove sk, burns n, gray jr. the practice of nursing research: appraisal, synthesis, and generation of evidence. 7thed. st. louis: elsevier/saunders; 2013. 4. stetler cb. updating the stetler model of research utilization to facilitate evidence-based practice. nursing outlook. 2001b;49:272-279. 5. fawcett j, garity j. evaluating research for evidence-based nursing research. philadelphia: f. a. davis; 2009. 6. popper kr. conjectures and refutations: the growth of scientific knowledge. new york: harper and row; 1965. 7. fawcett j. the added value of nursing conceptual model-based research. journal of advanced nursing. 2008;61:583. 8. roy c. the roy adaptation model. 3rd ed. upper saddle river, nj: pearson; 2009. 9. rogers me. nursing science and the space age. nursing science quarterly. 1992;5:27-34. 10. clarke pn, fawcett j. life as a nurse researcher. nursing science quarterly. 2014;27:37-41. 11. tierney aj. organization report: the development of nursing research in europe. european nurse. 1997;2:73-81. 293 12. conn vs. unpacking the black box: countering the problem of inadequate intervention descriptions in research reports. western journal of nursing research. 2012;34:427-433. 13. wallace kazer m, bailey de, whittemore r. out of the black box: expansion of a theory-based intervention to selfmanage the uncertainty associated with active surveillance (as) for prostate cancer. research and theory for nursing practice. 2010;24:101-112. 14. sidani s, braden cj. evaluating nursing interventions: a theory-driven approach. thousand oaks: sage; 1998. 15. pomeroy vm, niven ds, barrow s, faragher eb, tallis rc. unpacking the black box of nursing and therapy practice for post-stroke shoulder pain: a precursor to evaluation. clinical rehabilitation. 2001;15:67-63. 16. creswell jw. a concise introduction to mixed methods research. los angeles: sage; 2015. editorial 05. practicas indigenas prácticas indígenas relacionadas con la enfermedad 11 resumen las prácticas de cuidado de la salud, relacionadas con la enfermedad, han estado presentes a través de la historia de la humanidad. el presente artículo relaciona dichas prácticas en algunas de las principales tribus indígenas que poblaban el territorio colombiano a la llegada de los españoles. estas tribus, representadas por las culturas chibcha y caribe, contaban con conocimientos médicos avanzados, y en sus comunidades la figura de los chamanes, los brujos, los adivinos y hechiceros eran relevantes. palabras clave salud, enfermedad, prácticas, creencias, mitos, tribus indígenas. abstract health care practices, related with disease, have been present through human history. this article relates the practices of some of the main indigenous tribes who lived in the colombian territory at the arrival of the spanish. these tribes, represented by “chibcha” and caribbean culture, had advanced medical knowledge, and in their communities the figure of the “chamanes”, witches, fortuneteller, were relevant. key words health, disease, practices, believes, myths, indigenous tribes. maría clara quintero laverde año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 12 l gran legado del indio consiste en la manera como comprendió y manejó la tierra. el largo camino que recorrió el indio colombiano desde las cuevas de abra hasta el templo del sol constituye una gran enseñanza ecológica para nuestra época, ya que nos muestra los fracasos y los éxitos, los errores y los logros de aquellos hombres que, con sus mentes y manos, supieron adaptarse a una tierra bravía... el legado consiste en la manera como apreciaron y explotaron los diversos medios ambientes...1. en el momento del descubrimiento de américa, numerosas tribus indígenas poblaban el territorio de lo que hoy en día es la república de colombia, de las cuales la chibcha (muisca) y la caribe se referencian en muchos documentos y reseñas recopilados por los historiadores. los chibchas habitaban las regiones andinas y los caribes poblaban las costas y riberas de los grandes ríos y mares. estas culturas alcanzaron un mayor desarrollo y lograron constituirse en confederaciones. los españoles llegaron a américa durante el periodo formativo. en los comienzos de esta etapa (aproximadamente año 1200 d. de c.) aparecen los primeros agricultores, grupos sedentarios que viven en comunidades y aldeas. cuando se inicia el proceso de la conquista, las poblaciones indígenas no habían logrado la estabilidad política que las hubiera llevado a convertirse en un verdadero estado. se calcula que a la llegada de los españoles, américa tenía una población de entre 40 y 50 millones de indígenas. en el primer siglo de conquista, la población americana se redujo en un 90%. la conquista significó su exterminio por la acción violenta y armada de los conquistadores, las múltiples enfermedades y pestes que llegaron de europa, los procesos de aculturación, la mezcla de razas y el cambio de costumbres, creencias e idioma. en la actualidad sobreviven algunas tribus del amazonas y la guajira, cuyo proceso de aculturación ha sido muy lento, que mantienen sus costumbres y tradiciones, lo que permite su estudio y comprensión. en ciertas tribus del amazonas existe aún la costumbre de que la mujer dé a luz a la orilla del río. mientras ella está en ese trance, su pareja se tiende en la hamaca y se queja de los dolores del parto. este rito tiene por objeto engañar a los malos espíritus para que actúen sobre el hombre, y de esta manera la mujer y el niño queden protegidos. desde la antigüedad, el hombre ha querido dar explicación a múltiples fenómenos y circunstancias. entre ellos, la enfermedad ha tenido un papel relevante en culturas y civilizaciones. el concepto de castigo se da como explicación de todos los males. en este orden de ideas, la enfermedad es el principal castigo, y solo el ayuno, las mortificaciones y diversos sacrificios son utilizados para apaciguar la cólera de los dioses. en el pensamiento mágico o primitivo hay una relación entre el mundo de lo cotidiano y el cosmos; el sol y la luna como conceptos religiosos desempeñaron un papel preponderante en las comunidades indígenas, así como el mundo sobrenatural formado por otros dioses y demonios. la religión estaba íntimamente relacionada con el calendario; los solsticios y equinoccios señalaban con precisión el inicio y fin de las temporadas de lluvias y sequías, determinantes de la vida y costumbres de las comunidades. en la concepción del hombre primitivo, la naturaleza, los ríos, la lluvia y las plantas estaban dotados de alma. llama la atención la interesante ubicación de templos, monumentos sagrados y lugares de observación solar, que permiten deducir el gran desarrollo alcanzado por estas culturas. en las comunidades indígenas, los chamanes, los brujos, los adivinos y los hechiceros eran personajes de gran importancia. para algunos grupos, la causa de la enfermedad era la penetración en el cuerpo de una materia maligna o de un espíritu maligno. la terapéutica indígena buscaba, entonces, eliminar1 reichel-dolmatoff, g. nueva historia de colombia, tomo i: conquista y colonia, editorial planeta. p. 61, 1989. ¿cuál es entonces el legado indígena? ¿qué significado tienen para nosotros los vestigios de estas culturas de antaño? prácticas indígenas relacionadas con la enfermedad 13 los, y uno de los recursos utilizados era el masaje, que transfería la enfermedad a otra persona o animal. igualmente, a los dementes y “locos” se los consideraba poseídos por espíritus y demonios; su curación mágica consistía en la restitución del alma al cuerpo a través de ritos, cantos y bailes, lo mismo que la utilización de plantas como la coca, la belladona y otras sustancias alucinógenas. los muiscas contaban con conocimientos médicos avanzados, que aplicaban, según los cronistas, en el tratamiento de afecciones respiratorias y cutáneas, úlceras y estados febriles, para lo que también se valían de prácticas religiosas y hierbas medicinales. la alimentación indígena estaba íntimamente relacionada con diversas enfermedades, entre ellas la desnutrición, causada por un bajo consumo de proteínas y hierro, ya que la dieta se basaba en un alto consumo de maíz, yuca y papa. eran pueblos herbívoros; solamente las personas importantes del grupo social, como los jefes, chamanes y sacerdotes, tenían acceso al consumo de proteínas animales, como la carne de venado, aves y pescado. con anestesia rudimentaria, a base de plantas como el borrachero (brugmasia candida), que contiene atropina y escopolamina, y la utilización de instrumentos rudimentarios de piedra y madera, practicaban intervenciones como la trepanación del cráneo, gracias a los conocimientos de anatomía obtenidos del embalsamamiento de cadáveres. la trepanación era una medida terapéutica, derivada de la concepción mágica religiosa de las enfermedades. la enfermedad suponía la existencia de demonios incorporados a la persona. desde este punto de vista, las cefaleas, los vértigos y las demencias eran interpretados por la existencia de un demonio en la cabeza del enfermo, y la trepanación permitía entonces su expulsión. igualmente, la coca era utilizada por los jefes, sacerdotes y médicos. sus hojas eran mezcladas con polvo de caracoles o cal y almacenadas en calabazos. la coca permitía al indígena ayunos prolongados durante largos viajes y soportar las frías temperaturas; actuaba igualmente como anestésico local. el chamán era el guía de las almas en el otro mundo y el intermediario entre los hombres y los poderes sobrenaturales. su función esencial era la curación mágica de las enfermedades, realizando acciones buenas o maléficas. el trance chamánico hacía parte esencial del proceso curativo y a través de él se encontraba la causa de la enfermedad. estos chamanes desempeñaban un papel igualmente importante en relación con el clima, la agricultura, la pesca y la caza. durante su etapa de formación permanecían recluidos en templos y dedicaban su tiempo al ayuno y al estudio de los rituales religiosos. entre las principales costumbres funerarias se encuentran el enterramiento bibliografía de zubiría, r. la medicina en la cultura muisca, editorial universidad nacional de colombia, 1986. historia de américa, temas didácticos, editorial universitas. reichel-dolmatoff, g. nueva historia de colombia, tomo i: conquista y colonia, editorial planeta, 1989. seggiaro, l. medicina indígena de américa, editorial universitaria de buenos aires, 1969. en urnas, previo embalsamamiento o disección del cadáver, la incineración y los entierros en cavernas o en cámaras, que dependían de la categoría social del muerto. cuando los españoles ingresaron al territorio de los muiscas, estos imaginaron que aquellos eran hijos del sol y los llamaron “sue”, una denominación mágica de su figura y especialmente de la figura del caballo. posteriormente, observaron que los españoles morían igual que ellos; que el caballo y el jinete eran dos sujetos diferentes y por lo tanto estos perdieron el status de dioses. las enfermedades importadas desde españa al nuevo reino, como la lepra, la viruela y la sífilis, entre otras, se incrementaron con la venta de esclavos o trata de negros procedentes del áfrica. los reyes católicos fernando e isabel impusieron leyes con el propósito de evitar y controlar el contagio de terribles enfermedades. el hospital san lázaro, de granada, fue rodeado de muros y habilitado para la atención de sacerdotes enfermos. la historia refiere que entre los primeros casos de lepra de un español notable estaba el del conquistador gonzalo jiménez de quesada. con la colonización española comenzaron a viajar al nuevo mundo botánicos, boticarios y médicos, cuyos trabajos fueron influenciados por las prácticas de curanderismo y hechicería propias de los indígenas, algunas de las cuales prevalecen hoy. (17 rese\321as.pdf) revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005154 la bioética surge como resultado de los dilemas éticos que enfrentan los profesionales de la salud frente al impacto que el desarrollo tecnológico y sus consecuencias tienen sobre la persona y la sociedad. pretende anticiparse a las consecuencias de la implementación de múltiples técnicas y procedimientos. el libro, ética y bioética, de muy reciente publicación, escrito por la enfermera ángela lopera de peña, presenta un importante abordaje de estas temáticas y recoge la experiencia de muchos años de trabajo como docente universitaria e investigadora. la obra lleva al lector por un interesante recorrido y reflexión en sus cinco capítulos. desde la introducción, la autora destaca los conceptos de vida y salud, presentes a través de toda la obra, como valores y derechos fundamentales de la existencia humana. es un texto didáctico, con una clara fundamentación antropológica de todos aquellos temas, desde el origen y comienzo de la vida hasta su fin, pasando por temas como: vida, persona y sujeto moral, acto moral, consentimiento informado, secreto profesional, ética y medio ambiente, ética del menor y cuidados paliativos, entre otros. en cada uno de los capítulos plantea con claridad y sencillez los diversos dilemas que enfrenta el hombre en el mundo contemporáneo. la autora demuestra un serio y amplio conocimiento de las temáticas desarrolladas. el texto está dirigido a profesionales y estudiantes de las distintas disciplinas de las áreas social y de la salud, y a otros profesionales que tienen la responsabilidad de cuidar la vida, garantizando a la persona y su familia el respeto a su dignidad y trascendencia por encima de las múltiples posibilidades tecnológicas. en conclusión, se trata de una importante obra de consulta y referencia, de actualidad y pertinencia. maría clara quintero laverde profesora asociada, universidad de la sabana, colombia. ética y bioética ángela lopera de peña bogotá, orion editores, 2005, 193 págs. 169 175 primeras paginas.indd 174 año 15 vol. 15 nº 2 chía, colombia junio 2015 editorial buenas prácticas en la publicación de artículos científicos best practices for publishing scientific articles boas práticas na publicação de artigos científicos doi: 10.5294/aqui.2015.15.2.1 dos de los criterios que determinan la calidad y la acreditación de las instituciones educativas y de las relacionadas con la prestación de servicios de salud, son la investigación y la innovación. su importancia radica en que fundamentan la práctica basada en evidencia, lo cual se refleja en las guías de manejo para la atención de las personas. de allí la trascendencia de motivar a los profesionales y científicos para que comprendan los problemas de salud de la población, y busquen alternativas de solución que promuevan su bienestar y garanticen una práctica segura. la necesidad de desarrollar conocimiento de alta calidad para atender esta demanda, y de las instituciones de ser identificadas por estos estándares, ha supeditado el reconocimiento de los académicos y de las instituciones a la medición de su producción científica, en términos de la calidad y cantidad de sus publicaciones en revistas indexadas en bases de datos reconocidas en el ámbito internacional. esta situación trae como consecuencia, que los investigadores sean presionados a demostrar su productividad académica a fin de obtener beneficios en términos de visibilidad, reconocimiento social y promoción laboral, con las ventajas que trae alcanzar estos méritos a nivel personal e institucional (1). para los científicos constituye un reto permanente ampliar la frontera del conocimiento, incrementar la visibilidad de las disciplinas y, lo más importante, que sus resultados mejoren la práctica profesional y la prestación de los servicios a las personas, familias y comunidades. las revistas, por su parte, son el medio de difusión de este desarrollo y, por ello, deben garantizar la calidad de los escritos. schoenwolf sostiene que “esta está calificada por los editores y los revisores, quienes determinan la contribución para el desarrollo de nuevo conocimiento y el impacto de los resultados para el desarrollo de la ciencia” (1). por tanto, dos aspectos fundamentales para determinar la calidad son la novedad y la originalidad de los escritos. el primero pretende que los resultados “expandan el horizonte para el desarrollo de la disciplina, mediante la síntesis de una nueva teoría, la consolidación de teorías existentes, y la explicación de los fenómenos observados, entre otros” (2), mientras que el segundo, se refiere a que los resultados del estudio no sean redundantes, ni hayan sido divulgados en todo o en parte en otra publicación científica. sin embargo, el afán de los investigadores por alcanzar los más altos beneficios, ha incrementado el riesgo de realizar prácticas inapropiadas para la publicación de los resultados de los proyectos, lo cual, infortunadamente, ha llevado a comprometer en algunos casos la ética del investigador. una de estas prácticas frecuentes es el plagio (3). the office of research integrity (ori), define el plagio como: “tomar como propias las ideas, métodos, resultados de otro y no citarlo” (4). existen diferentes formas de plagio, como son la copia textual de un documento, el parafraseo, el resumen de una parte de un documento o la síntesis de la información. por ello, con el objeto de evitarlo es necesario poner entre comillas las frases 175 textuales, darle el crédito a los autores y mantener el significado del texto original (4, 5). otra forma común, es el autoplagio. este ocurre cuando un autor toma parte de un documento escrito por él y lo publica en otro, sin darle crédito o referenciar el primer manuscrito publicado. también sucede cuando, en el afán de obtener múltiples publicaciones de una investigación, el autor recicla el documento y lo publica en un idioma diferente, o divide los resultados y los publica en distintas revistas, fenómeno denominado “publicación salami”. del mismo modo, se presenta cuando los autores someten en forma simultánea el artículo a dos revistas diferentes, con el ánimo de que este se publique lo más pronto posible, y no informan a los editores esta situación (4). esta duplicación genera sesgos en los resultados objetivos de la ciencia, altera la evidencia científica y, cuando se trata de intervenciones o tratamientos, puede llegar a poner en riesgo la salud de las personas. estas prácticas inadecuadas, según juyal et al., afectan la credibilidad de los centros de investigación y de los investigadores, quienes son reconocidos socialmente por su rigor y honestidad (3). en aquichan hemos identificado un incremento en este tipo de prácticas, por ello hacemos un llamado a los autores que desean publicar en la revista y los invitamos a incrementar su productividad y, por ende, su visibilidad. en primer lugar, queremos recordarles que la producción científica de un investigador se mide con el índice h, que hace referencia al número de citas que ha recibido, con relación al número de artículos que ha publicado en revistas de alto impacto, en un periodo de tiempo determinado (6). en segundo lugar, plantear que las publicaciones serán más visibles y, por consiguiente, más citadas, en la medida en que aborden temas relacionados con las tendencias actuales de interés para la disciplina, analicen los resultados de sus estudios frente a referentes internacionales y no locales, y eviten al máximo las autocitas. desde el punto de vista de los editores y revisores, es necesario ser rigurosos en la selección, y agilizar los procesos de evaluación y edición de los artículos para mejorar la calidad de la publicación y reducir los tiempos de espera para los autores. maría elisa moreno fergusson editora revista aquichan referencias 1. schoenwolf gc. getting published well requires fulfilling editors’ and reviewers’ needs and desires. development grow & differentiation. 2013;55(9):735-43. doi: 10.1111/dgd.12092. epub 2013 oct 17. 2. alberola jb. las fronteras del conocimiento. lección magistral leída en el solemne acto de apertura del curso 20122013. publicaciones universitat de valencia; 2012 [visitado 2015 mayo 12]. disponible en: https://www.i-cpan.es/doc/ leccionmagistral_cas.pdf. 3. juyal d, thawani v, thaledi s. plagiarism: an egregious form of misconduct. north american journal of medical sciences. 2015 [visitado 2015 mayo 25]; 7(2):77-80 disponible en: http://www.najms.org 4. office of research integrity: plagiarism [visitado 2015 mayo 26]. disponible en: https://ori.hhs.gov/plagiarism-3 5. ética editorial y el problema del autoplagio. scielo en perspectiva [visitado 2015 mayo 26]. disponible en: http://blog. scielo.org/es/2013/11/11/etica-editorial-y-el-problema-del-autoplagio/ 6. sjr scimago journal & country rank. disponible en: http://www.scimagojr.com/journalrank.php. editorial 195 203 jogo da postura programa de intervencao.indd 195 carla sílvia fernandes1 tânia martins2 nair silva-rocha3 mónica mendes4 “jogo da postura”: programa de intervenção de enfermagem em crianças 1 orcid.org/0000-0001-7251-5829. escola superior de enfermagem santa maria, portugal. carla.fernandes@santamariasdaude.pt 2 orcid.org/0000-0001-8390-191x. escola superior de enfermagem santa maria, portugal. tania.martins@santamariasdaude.pt 3 orcid.org/0000-0002-3846-2943. universidade do porto fmup e ispup, brasil. gabinete.saude@cm-maia.pt 4 orcid.org/0000-0003-2739-9376. escola superior de enfermagem santa maria, portugal. secped.monica.mendes@santamariasaude.pt recibido: 20 de abril de 2016 enviado a pares: 16 de junio de 2016 aceptado por pares: 10 de octubre de 2016 aprobado: 11 de octubre de 2016 doi: 10.5294/aqui.2017.17.2.8 para citar este artículo / to reference this article / para citar este artigo fernandes cs, martins t, rocha ns, mendes m. "jogo da postura": programa de intervenção de enfermagem em crianças. aquichan. 2017;17(2):195-203. doi: 10.5294/aqui.2017.17.2.8 resumo objetivo: evidenciar o impacto de um jogo para promover a educação postural das crianças. o enfermeiro tem um papel preponderante na educação para a saúde, pelo que procuramos um caminho que adicionasse alguma inovação às escolas posturais já existentes incorporando uma estratégia formativa inovadora: “um jogo”. materiais e método: trata-se de um estudo quase experimental com delineamento de tempo. a amostra é constituída por 215 crianças do ensino pré-escolar e do 1º ciclo do ensino básico, de uma cidade do norte de portugal. a intervenção é composta pela aplicação de um jogo intitulado “jogo da postura”; para avaliar o seu impacto, foi aplicado um questionário sobre hábitos posturais antes e após a intervenção. resultados: os resultados evidenciam uma elevada prevalência de queixas músculo-esqueléticas (48,8 %) e um aumento de respostas corretas após a intervenção. houve mudança no conhecimento de hábitos posturais antes da participação dos alunos num programa de educação postural e depois dela. conclusões: o jogo é uma estratégia ativa útil e eficaz a ser utilizada pelos formadores no âmbito da enfermagem e deve ser replicada a outras áreas temáticas. palavras-chave criança; educação em saúde; enfermagem em reabilitação; postura; promoção da saúde (fonte: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 195-203 196 aquichan issn 1657-5997 eissn 2027-5374 año 17 vol. 17 nº 2 chía, colombia junio 2017 l 195-203 “juego de la postura”: programa de intervención de enfermería en niños resumen objetivo: evidenciar el impacto de un juego para impulsar la educación postural de los niños. el enfermero tiene un rol preponderante en la educación para la salud, por lo cual buscamos un camino que les agregara alguna innovación a las escuelas posturales ya existentes incorporando una estrategia formativa novedosa: “un juego”. materiales y método: estudio casi experimental con delineamiento de tiempo. la muestra se constituye de 215 niños del preescolar y el 1º ciclo de la enseñanza básica, de una ciudad del norte de portugal. la intervención se realiza por medio de la aplicación del “juego de la postura”; para evaluar su impacto, se administró un cuestionario sobre hábitos posturales antes y después de la intervención. resultados: los resultados dan cuenta de una elevada prevalencia de quejas músculo-esqueléticas (48,8 %) y un incremento de respuestas correctas tras la intervención. hubo cambio en el conocimiento de hábitos posturales antes de la participación de los alumnos en un programa de educación postural y luego de ella. conclusiones: el juego es una estrategia activa útil y eficaz, que puede ser utilizada por los formadores en el contexto de la enfermería y debe replicarse a otras áreas temáticas. palabras clave educación en salud; enfermería en rehabilitación; fomento de la salud; niño; postura (fuente: decs, bireme). 197 “jogo da postura”: programa de intervenção de enfermagem em crianças l carla sílvia fernandes e outros “posture play”: a nursing intervention program for children abstract objective: demonstrate the impact of a game to help teach children to be mindful of their posture. nurses have a preeminent role in health education; hence, the importance of finding a way for them to add innovation to the posture schools that already exist, by including a novel training strategy: "a game." materials and method: this is a quasi-experimental study with a time line. the sample was comprised of 215 pre-school children and first-graders [rd1] in a city in northern portugal. the intervention was carried out through a game known as posture play, and a questionnaire was administered before and afterwards to assess its impact. results: the results show a high prevalence of musculoskeletal complaints (48.8%) and an increase in correct responses subsequent to the intervention. there was a change in what the students knew about posture and their posture habits before and after taking part in the posture education program. conclusions: play is a useful and effective strategy educators can use in the context of nursing and should be replicated to other subject areas. keywords health education; nursing in rehabilitation; health promotion; child; posture (source: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 195-203 198 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 introdução a promoção da educação postural pelas crianças é um objetivo prioritário ao nível da intervenção na área da saúde escolar. os profissionais de saúde, nomeadamente os enfermeiros que intervêm a este nível, têm um papel importante no meio escolar no âmbito da prevenção primária em saúde. as alterações posturais são problemas comuns em crianças e adolescentes nos últimos anos, entre os fatores que contribuem para o aparecimento desses problemas está a postura inadequada (1) e o sobrepeso (2). nesse período escolar, o sistema músculo-esquelético encontra-se em processo de crescimento, onde o uso de mobiliário inadequado, o transporte de cargas excessivas e a manutenção prolongada de posturas estáticas são fatores de risco para o desenvolvimento corporal que podem causar desconforto, dor ou incapacidades (3,4). uma opção para atenuar os problemas de má postura são as escolas posturais, que, independentemente da sua concepção teórica (5,6), têm o objetivo de modificar as más atitudes diárias que conduzem a danos na coluna vertebral, podendo causar danos irreversíveis (6). a escola postural sueca, proposta em 1969, foi um dos primeiros programas de educação postural (1,2). depois disso outros programas têm vindo a ser aplicados em ambiente escolar (6,7). estas podem ser oferecidas a públicos distintos, como, por exemplo, terceira idade, crianças, adolescentes e jovens, desde que seus conteúdos teóricos e práticos sejam adaptados às diferentes necessidades (6). no entanto, os hábitos posturais começam a ser incorporados nos primeiros anos da vida escolar, sendo relevante a realização de atividades nesta faixa etária de modo que possam estimular uma execução adequada destas atividades, para a promoção da saúde cinético-funcional (1,2). o presente estudo destaca-se em relação aos já realizados, por combinar à educação teórica e prática um jogo sobre postura. os jogos experimentais são uma forma de motivar, são esperadas aprendizagens dos participantes que duram além do jogo em si (8). também foi atribuído ao jogo o facto de promover a integração de conteúdos e reforçar a ligação entre a teoria e a prática (9). com base no supracitado, o objetivo principal do estudo foi verificar o impacto de um jogo para promover a educação postural das crianças. método trata-se de um estudo quase-experimental, realizado no ano letivo de 2014-2015. a população total do estudo era constituída por 960 alunos das escolas pré-escolar e primeiro ciclo de um concelho do norte de portugal, participaram do presente estudo 215 alunos. neste estudo com delineamento no tempo foi usado o desenho antesapós com grupo testemunho sem randomização. a técnica de amostragem foi aleatória simples considerando como critérios de inclusão: terem completado o questionário antes e após a intervenção, assim como, terem participado nas diferentes etapas. de modo a avaliar o impacto da intervenção foi aplicado um questionário antes e após a intervenção. o questionário incluiu dados pessoais do aluno, presença e localização de dores músculo-esqueléticas e avaliação dos hábitos posturais, em pé, sentado, no transporte da mochila escolar e nas técnicas de levantamento de objeto. o questionário de avaliação de hábitos posturais deste estudo foi adaptado do projeto da dissertação de mestrado de rebolho (11). este instrumento apresenta as alternativas de respostas para as questões dirigidas aos hábitos posturais, na escolha das seguintes opções: posicionamento correcto, incorrecto, não sei. o instrumento é ilustrado com desenhos representativos das opções disponíveis para a resposta, facilitando a escolha da alternativa. este instrumento, criado por rebolho (11), tem vindo a ser utilizado em outros estudos (11,12,17). ao longo das diferentes etapas foram salvaguardados os procedimentos éticos inerentes a um percurso de investigação. as escolas candidataram-se ao projeto por meio da autarquia local, em que foram explicados os objetivos da intervenção, assim como, os procedimentos de colheita de dados a serem realizados. a intervenção incluiu uma componente teórica, uma componente prática e o jogo da postura. a intervenção foi realizada por estudantes do curso de enfermagem de uma escola de enfermagem do norte de portugal, sob supervisão de um docente. estas atividades estão integradas num projeto de voluntariado em parceria com a câmara de uma autarquia local. 199 “jogo da postura”: programa de intervenção de enfermagem em crianças l carla sílvia fernandes e outros a componente teórica com uma duração de cerca de 30min, cujos objetivos consistiam em sensibilizar para a importância de posturas correctas e transmissão de princípios essenciais a adoptar para uma melhor postura. os temas incorporados integravam conhecimentos sobre anatomia, fisiologia, biomecânica da coluna, orientações ergonómicas e posturais nas atividades de vida diária. posteriormente, os conteúdos relacionados com as orientações ergonómicas e posturais referentes ao transporte de mochila, posicionamento na cadeira e mobilização de cargas, era aplicado em demonstração prática. de seguida era aplicado o jogo, o que permitia um feedback imediato dos conhecimentos adquiridos. os jogos devem ser cuidadosamente planeados de forma a atingir os resultados da aprendizagem (10). o jogo implica um conjunto de regras, critérios, e objetivos para determinar os vencedores (8,10), podendo assumir diversas formas (9), onde neste estudo recorreu-se a um jogo de tabuleiro. figura 1. jogo da postura, portugal, 2015. primeira e a última casa do jogo leva em média uma hora para ser completado, os vencedores são a primeira equipa a chegar à última casa (ver figura 1). os questionários foram preenchidos em sala de aula, com o auxílio de cada professor. a primeira aplicação dos questionários ocorreu em novembro de 2014, depois se realizou a intervenção entre janeiro e março de 2015 e posteriormente foi novamente aplicado o questionário nos meses de maio e junho de 2015. esta atividade decorreu ao longo de um ano letivo. para a análise estatística foi utilizado o statistical package for the social sciences (versão 18.0). para comparar as pontuações dos participantes, antes e depois da intervenção, recorreu-se ao teste de wilcoxon, uma vez que se tem amostras emparelhadas e que as pontuações não têm distribuição normal. resultados a amostra foi constituída por 215 crianças, 106 do género masculino e 109 do género feminino. a idade variou entre os 5 e 12 anos, sendo a média de idade de 7,7 anos. quando questionados os estudantes sobre queixas álgicas 105 (48,8%) referiram que sim, estando ilustradas na figura 2 as localizações mais frequentes. figura 2. localização da dor, portugal, 2015. fonte: elaboração própria. o jogo da postura® é um jogo de tabuleiro gigante em que o progresso é determinado pela capacidade da equipa responder às questões sobre hábitos posturais, anatomia e biomecânica. cada equipa elege um elemento que assume o papel de peão no jogo, um dado grande insuflável é lançado, cada equipa responde às questões apresentadas nos cartões e os alunos andam pelo tabuleiro até completarem o jogo. o trajeto entre a fonte: elaboração própria. no que se refere à avaliação dos hábitos posturais (em pé; sentada; no transporte da mochila escolar e nas técnicas de levantamento de objeto), na tabela 1 é apresentada a frequência de respostas incorrectas antes da intervenção. 200 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 tabela 1. avaliação de hábitos posturais antes da intervenção, portugal, 2015. na tabela 3 é realizada a comparação entre os dois momentos, onde se observa que na globalidade o questionário sobre os hábitos posturais obteve um valor-p inferior a p=0,05, sendo inferior ao nível de significância adoptado de 5%, mostrando que são estatisticamente significativos, demonstrando que a intervenção foi eficaz. porém observa-se que na pergunta 4, a intervenção não foi eficaz, dado que na primeira avaliação as crianças já descreviam a tarefa de transportar a mochila de forma adequada. discussão neste estudo, verificamos uma alta prevalência de dor referida pelos inquiridos (48,8%). as dores na coluna e no sistema músculo-esquelético apresentam uma alta prevalência entre as crianças (12), em que a dor nas costas é actualmente um motivo de preocupação (1), manifestando-se em grandes proporções na infância e adolescência (13). num estudo sobre prevalência de dores músculo-esqueléticas em alunos entre os seis a 12 anos esta ocorreu em 51,1% (14). a maior prevalência de dores foi referida pelo género feminino 56%, em oposição aos 43% do género masculino indo ao encontro de um estudo realizado sobre prevalência de lombalgia em crianças (15). com relação à localização das dores músculo-esqueléticas, as regiões de maior frequência foram a coluna, nomeadamente a nível dorsal (6,1%), cervical (14,9%) e lombar (21,6%) e os membros inferiores (33%). outros estudos também referem a dor na coluna e membros inferiores como principal queixa (12,14-16). com relação às causas prováveis das queixas de dores nas costas entre as crianças e adolescentes, a permanência na postura sentada por períodos prolongados na escola ou utilizando jogos e computadores é apontada como um fator (12), assim como o uso e transporte inadequado das mochilas e as atividades físicas em excesso (14). a postura sentada gera uma maior pressão nos discos intervertebrais da coluna lombar do que a posição em pé podendo daí advir consequências irreversíveis para a coluna vertebral (1). o objetivo principal deste estudo era verificar o impacto de uma intervenção ao qual se associou um jogo para promover a educação postural das crianças. um dado interessante deste estudo é que as crianças já detinham algum conhecimento prévio sobre a postura correcta, embora fosse visível nos momentos de intervenção que não a colocavam em prática, aspecto referido por outros autores (17,7). as informações que as crianças mais desfonte: elaboração própria. estes dados revelaram que os alunos desconheciam a postura corporal adequada nas diferentes categorias estudadas, principalmente no posicionamento de pé e na técnica de levantamento de objeto. tabela 2. avaliação de hábitos posturais depois da intervenção, portugal, 2015. fonte: elaboração própria. na tabela 2 é apresentada a frequência de respostas incorrectas após a intervenção, podem observar-se diferenças significativas após a intervenção. tabela 3. avaliação de hábitos posturais — comparação entre os dois momentos, portugal, 2015. nível de significância: *p≤0,05 fonte: elaboração própria. 201 “jogo da postura”: programa de intervenção de enfermagem em crianças l carla sílvia fernandes e outros conheciam eram as posturas correctas dos pés em pé e a forma de levantar um objeto. no que se refere à questão 3.2, sobre o posicionamento dos pés, apesar de ao longo da intervenção e da aplicação do jogo ter sido perceptível a incorporação por parte das crianças da importância de uma maior base de sustentação, esta não foi validada pelo questionário, o que consideramos poder estar relacionado com a má interpretação da imagem. no entanto, foi possível verificar uma melhoria significativa em todas as respostas ao questionário. a estratégia de ensino utilizada demonstrou ser efectiva para fixar conceitos de hábitos posturais, incluindo conhecimentos de anatomia, biomecânica. os achados deste percurso confirmam os apresentados por outros estudos (1,5,6,7,11,18), ou seja houve mudança no conhecimento de hábitos posturais antes e após a participação dos alunos num programa de educação postural. num estudo realizado sobre o modo de transportar mochilas escolares após sessões educativas, observaram que as mesmas promoveram mudanças, revelando adesão satisfatória ao modelo de intervenção proposto (5). por outro lado, também um estudo realizado com a utilização de uma história em quadrinhos e a experiência prática de posturas correctas e incorrectas aplicadas em três encontros com crianças com idades entre 7 e 11 anos, os resultados indicaram que houve um aumento significativo na aprendizagem e memorização dos hábitos posturais correctos (7). estes dados vão ao encontro dos obtidos neste estudo, reforçando que as escolas são locais ideais para a realização de ações que favoreçam o adequado desenvolvimento físico e motor de crianças, possibilitando a melhor compreensão da relação entre a dor músculo-esquelética e os fatores associados e garantindo o sucesso da intervenção por meio da informação, prevenção e diagnóstico precoce em ambientes escolares (19). desde a criação das escolas posturais têm surgido algumas modificações na sua forma de aplicação e nos parâmetros de avaliação porém, sem se desvincular do seu fundamento principal, a prevenção e tratamento de pacientes com dor lombar e sua relação com o aumento de tensão mecânica na realização das atividades da vida diária (20). no que se refere à utilização do jogo, várias estratégias têm sido utilizadas para optimizar o processo de ensino, nomeadamente vídeos, circuitos práticos, técnicas de dramatização, cartazes, demonstração das posturas com uso de bonecos, história aos quadradinhos (7). embora na literatura extensa existente não tenha sido encontrado aplicação de um jogo nesta temática, este se revelou eficaz podendo ser utilizado como estratégia pedagógica. com relação às limitações deste estudo, seria importante a avaliação em longo prazo do impacto desta intervenção na vida dos participantes, nomeadamente por meio da observação. dado que, o autorrelato muitas vezes não descreve a real maneira da realização da atividade diária, já que a criança assinala a forma como acredita que realiza a tarefa. conforme salientado num estudo de revisão sistemática sobre o tema a estrutura dos programas é bastante diversificada, o que dificulta a comparação entre os estudos, além de que existe falta de publicações que avaliem os resultados no médio e longo prazo (21). conclusão os resultados deste estudo demonstraram que as medidas de intervenção adoptadas promoveram mudanças no conhecimento por parte das crianças em idade escolar decorrente do programa de educação realizado pelos enfermeiros. a prevalência de dor, principalmente na coluna e membros inferiores foi um achado relevante entre a população escolar, com maior prevalência no género feminino. este estudo reforça a necessidade de serem adoptados programas educativos de promoção da saúde escolar, com ações voltadas para a educação postural. embora a literatura internacional seja extensa com relação à educação postural de crianças e adolescentes em idade escolar, evidencia-se a escassez de estudos com a intervenção de enfermeiros e envolvendo a população portuguesa, cujos hábitos e condições de saúde podem não ser semelhantes aos de outros países. propomos a continuidade deste estudo por meio de reforços de conteúdos e de futuras avaliações para que as crianças possam efectivamente incorporar os hábitos posturais adequados no seu dia a dia. conclui-se que o jogo da postura foi uma intervenção eficaz apresentando reacções muito positivas, na sua aplicação “you can experiment a game, without risk”. 202 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 referências 1. vieira a, treichel t, candotti c, noll m, bartz p. effects of a postural education program for students of the third year of elementary school in a state school in porto alegre, state of rio grande do sul state, brazil. fisioter pesqui. 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[autor do livro] m bradshaw e a lowenstein. innovative teaching strategies in nursing and related health professions. 5ª. boston : jones and bartlett publishers; 2011. p. 175-87. 9. fonseca a, espírito santo f, silva s, silvino z. games to promote health education for children: integrative review. journal of nursing ufpe / revista de enfermagem ufpe [internet]. jun 2015 [acesso em 11 out 2016]; p. 8444-52. 10. akl, e. educational games for health professionals. cochrane database of systematic reviews [internet]. fev 2013 [acesso em 11 out 2016]; 1(3):1-46 11. rebolho, m. efeitos da educação postural nas mudanças de hábitos em escolares das 1ª a 4ª série do ensino fundamental [dissertação]. são paulo: universidade de são paulo, faculdade de medicina; 2005 [acesso em 5 abr 2016]. 12. rebolho m, rocha le, teixeira lr, casarotto ra. prevalência de dor músculo esquelética e percepção de hábitos posturais entre estudantes do ensino fundamental. rev med (são paulo). 2011;90(2):68-77. 13. cruz a, nunes h. prevalência e fatores de risco de dores nas costas em adolescentes: uma revisão sistemática da literatura. rev enf ref. [internet]. mar 2012 [acesso em 11 out 2016]; seriii (6):131-46. http://dx.doi.org/10.12707/riii1183 14. pereira d, castro s, bertoncello d, damião r, walsh i. relação da dor musculoesquelética com variáveis físicas, funcionais e alterações posturais em escolares de seis a 12 anos. braz. j phys ther [internet]. agos 2013 [acesso em 5 abr 2016]; 17(4):392-400. 15. garetth tj, gary jm. predicting persistent low back pain in schoolchildren: a prospective cohort study. arthritis & rheumatism (arthritis care & research). 2009;61(10):1359-66. 16. el-metwally a, salminen j, auvinen a, macfarlane g, mikkelsson m. risk factors for development of non-specific musculoskeletal pain in preteens and early adolescents: a prospective 1-year follow-up study. bmc musculoskelet disord. 2007;1(8):41-46. http://dx.doi.org/10.1186/1471-2474-8-46 17. benini j, karolczak a. benefício de um programa de educação postural para alunos de uma escola municipal de garibaldi, rs. fisioter pesqui. [internet]. dez 2010 [acesso em 4 mar 2016]; 17(4):346-51. 18. vidal j, borràs p, ponseti f, cantallops j, ortega f, palou p. effects of a postural education program on school backpack habits related to low back pain in children. european spine journal: official publication of the european spine society, the european spinal deformity society, and the european section of the cervical spine research society [internet]. abr 2013 [acesso em 11 out 2016]; 22(4):782-7. 203 “jogo da postura”: programa de intervenção de enfermagem em crianças l carla sílvia fernandes e outros 19. pereira d, castro s, bertoncello d, damião r, walsh i. relação da dor músculo-esquelética com variáveis físicas, funcionais e alterações posturais em escolares de seis a 12 anos. braz. j. phys ther. [internet]. agos 2013 [acesso em 28 set 2016]; 17(4):392-400. 20. andrade s, araújo a, vilar m. escola de coluna: revisão histórica e sua aplicação na lombalgia crônica. rev bras reumatol. [internet]. agos 2005 [acesso em 4 out 2016]; 45(4):224-8. http://dx.doi.org/10.1590/s0482-50042005000400006. 21. noll m, vieira a, darski c, candotti c t. escolas posturais desenvolvidas no brasil: revisão sobre os instrumentos de avaliação, as metodologias de intervenção e seus resultados. rev. bras. reumatol. [internet]. fev 2014 [acesso em 4 out 2016]; 54(1):51-8. http://dx.doi.org/10.1016/j.rbr.2013.04.007 22. vidal j, borràs p, ponseti f, cantallops j, ortega f, palou p. effects of a postural education program on school backpack habits related to low back pain in children. european spine journal: official publication of the european spine society, the european spinal deformity society, and the european section of the cervical spine research society [internet]. abr 2013, [acesso em 11 out 2016]; 22(4):782-7. 03. un sueœo un sueño hecho realidad 7 ño de 1987. en los estatutos fundacionales de la universidad de la sabana se dispone la creación del programa de ciencias de la salud. el consejo superior decide que se debe iniciar el estudio de factibilidad del programa de enfermería. eran épocas complejas, pues las directivas educativas nacionales consideraban que el país no requería de nuevos programas académicos, y menos en el área de la salud; sin embargo, la decisión del consejo se acata, y se inicia todo el proceso de programación de la propuesta, para solicitarle al icfes la autorización de la apertura del nuevo programa. el programa de enfermería debería ser novedoso, con planteamientos curriculares modernos, actualizados, competitivos, y que estuvieran orientados a la formación de un profesional de la enfermería con una base humanística muy sólida, conocimientos profundos de su saber específico, con capacidad y motivación para el servicio, investigador, líder, educador, y con una formación ética sólida y gran responsabilidad en el desempeño de sus funciones profesionales. definidos los principios enumerados, se requería, no menos difícil, por cierto, conseguir a la o las personas que con sus conocimientos, prestigio y desempeño ético aceptaran el reto de estructurar el programa de enfermería, de modo que pudiera ser aprobado por el icfes para la formación del personal de enfermería. se entrevistaron varias personas y se tocaron distintas puertas, y fue recomeneduardo borda camacho año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 8 dada una enfermera egresada de la universidad javeriana, santandereana, con experiencia desarrollada en la universidad industrial de santander y con una excelente hoja de vida. se citó para entrevista, y llegó una mujer pequeña, joven, franca, de hablar y razonar inteligente, optimista, y con una característica que demostró, desde el inicio de la entrevista, su temple de carácter, decidida, con voluntad, que no se amilanó ante la propuesta audaz que se le estaba haciendo. esta candidata, leonor pardo, propuesta por la enfermera inés durana, persona reconocida en el medio nacional de enfermeras, fue acogida por el consejo superior de la universidad. posteriormente es nombrada, y propone que se constituya su equipo de trabajo, el cual sirva de complemento y ayuda en la elaboración del documento para la aprobación del programa. como se requería otra persona con las mismas características de la licenciada pardo, la candidata fue lucía restrepo, a quien se nombró, y posteriormente se integró maría del carmen de giraldo, enfermera que tenía, además de los requisitos exigidos, un postgrado en educación, que complementaba e integraba, con una nueva faceta, el equipo gestor del programa. se debía trabajar según los requisitos exigidos por la ley 80 de 1980, sobre educación superior. una de las primeras propuestas fue definir cuál de las nuevas escuelas ideológicas de enfermería debía acogerse, que resultara compatible con los principios filosóficos de la universidad de la sabana. después de un profundo análisis y estudio, se estableció que debería ser la propuesta por sor callista roy, pues sus principios están basados en un humanismo cristiano, con proyección a la atención integral del enfermo y preocupación grande por su recuperación e incorporación al medio familiar, laboral y social; así, bajo estos postulados, se decidió aceptarla. esta nueva escuela corresponde a la enfermería de la edad atómica, del tercer milenio, con una enorme apertura en un campo laboral que requiere de los profesionales de enfermería. florence nightingale, revolucionaria en la concepción de la enfermera, dentro del concepto de modernización orientó la capacitación hacia la formación de enfermeras hospitalarias y enfermeras instructoras, que además fueran docentes con un profundo sentido humanístico para el cuidado de los pobres; asimismo, amplió el área de los conocimientos, y los orientó hacia la salud pública, la estadística, la administración hospitalaria y la sanidad militar. además de lo anterior, hoy en día se ofrecen a nuestras enfermeras más campos laborales, como el manejo de unidades de cuidados intensivos, tanto de adultos como de niños, neumología, psiquiatría, cardiología y muchos más. con estos antecedentes y los principios de la escuela de callista roy, se inicia el estudio y elaboración del documento con los contenidos curriculares. son tres largos años de preparación, con la asesoría de varios grupos de enfermeras expertas en currículo, hasta que se obtiene la aprobación del consejo superior y la autorización para iniciar labores en el segundo semestre de 1991. diez años después de la aprobación dada por el icfes, el sueño del grupo gestor, leonor pardo, lucía restrepo y maría del carmen giraldo, se convierte en una realidad, positiva, dinámica y con proyección de futuro, con importantes y decisivas aportaciones a la carrera de enfermería, a nivel nacional. ahora se puede entregar a la sociedad un grupo de profesionales dignos, seriamente capacitados, éticos, con gran sentido de servicio, humanistas, preocupados por atender con cariño y afecto a los pacientes puestos a su cuidado. en esta fecha tan importante para la universidad, la facultad de enfermería, sus directivas y personal docente nos unimos a su aniversario, y le deseamos mayores logros, desarrollos científicos e investigativos y una amplia proyección social; además, que junto con los otros miembros de los equipos de salud nos convirtamos en soporte imprescindible de la labor del médico, para que podamos lograr importantes y positivos avances en la mejoría de nuestro pueblo colombiano. deseámosle, como a los marinos, buen viento y buena mar. 01 06 primeras paginas.indd 5 editorial application of mixed-methods research in clinical practice aplicación de métodos mixtos de investigación en la práctica clínica aplicação de métodos mistos de pesquisa na prática clínica doi: 10.5294/aqui.2017.17.1.1 study. for instance, the aim of a study might be to explore modes of infant feeding during the first six weeks of life. in this case, the quantitative question could be: ‘what is the infant’s health status?’ the study could be conceived as quantitativelydriven (quan3) (with, for instance, infant health as measured by weight gain, length and hemoglobin level) and have a simultaneous component (qual) comprised of qualitative interviews addressing the question: is the infant described as content? in this case contentedness would be defined as the mother’s description of the infant’s sleep patterns, episodes of hard crying, and indicators of hunger (periods of fist sucking, etc.). on the other hand, if the researcher is interested in the experience of breast-feeding during the first six weeks of life, the researcher could obtain a qualitative description of breast-feeding contentedness as the core qual component. many nursing research questions are amenable to mixed designs. consider a project with the aim of exploring the effect of icu alarms: 1. what effect does noise in the icu have on the patient? this question demands measurement of the noise, and the physiological measurement of the patient when the alarms sounded (i.e., a quan + quan design). of interface and integrated as the results narrative. the results narrative section is then followed by the discussion (morse & niehaus, 2007). 3 the notation for mixed-methods design is qual, quan (upper case), indicating the core (complete) component, and qual, quan (lower case, italics), indicating the supplemental component. in the results narrative, the core component provides the main findings, and the supplemental findings are integrated to support the core findings (see morse & neihaus, 2009). nursing is a discipline that traditionally considers the whole person and, following this mandate, nursing research is also considered to have a holistic perspective. yet, research methods demanded the researcher focus on some part of the person in order to quantitatively measure some biological, psychological, or social aspect of the person, or to qualitatively describe an experience within the context of the family, work or illness. mixedmethods design overcomes this limitation and expands the scope of research considerably; nurses now can do both. we can both measure and describe the experience in the same project. thus, mixed-methods research adds another dimension to research design, enabling our questions to be more holistic. for instance, a single project may qualitatively describe the patient’s illness or caregiving experience, along with a quantitative psychological measure. alternatively, the mixed-methods project may quantitatively measure various physiological parameters and include a qualitative description of the experience. what kinds of questions do mixedmethods address? mixed-methods studies generally have one overarching aim that encompasses both methods used in the study, with a separate research question addressing each “component”2 of the 1 university of utah, united stated. janice.morse@nurs.utah.edu 2 mixed-methods studies usually are conducted with a separate component for each question and method. the results of each component are then brought together at the point janice m. morse1 6 aquichan issn 1657-5997 año 17 vol. 17 nº 1 chía, colombia marzo 2017 2. what is the experience of noise in the icu for the patient? this is a qualitative question (qual), with measurement of the number of alarms and their intensity (+ quan) providing a contextual description. 3. what is the effect of icu noise on the patient’s perceived quality of sleep? (a qual + qual design). 4. what is the effect of nurses’ alarm fatigue (quan) on the patient’s care experience (qual)? when to apply mixed-methods? mixed-methods are used appropriately when the researcher’s conceptual framework is broad, and when it is clear that using one research method will not suffice. however, combining research methods in the same study is not a quick and easy task, nor is it without difficulties. first, every time a researcher adds a data set to the design, it greatly expands the investigator’s work, costs, and the time the project will take. so, deciding on a mixed-methods design should not be a decision made lightly. of course, when considered for a broader perspective, mixed-methods also shorten your research program, perhaps by allowing you to answer a question in the present project-one that may shortcut a separate project that would be conducted at a later date. it allows you to do it sooner, more cheaply and faster than if you were to conduct a separate study. one additional point: mixed-methods usually consist of a qualitative and a quantitative component used at the same time (simultaneous) or sequentially. however, mixed-methods may also be composed of two quantitative components (as quan + quan) or two qualitative components (as qual + qual)4 (morse, 2017, morse & neihaus 2009). the technicalities of applying mixed-methods using more than one method in the same project also can stretch the skills of a researcher. investigators usually consider themselves as qualitative or quantitative researchers, but not 4 the + sign is used to indicate simultaneous design, and the —> symbol, sequential design (morse & neihaus, 2009). as researchers with expertise in both paradigms. therefore, in order to conduct a study using more than one method, often a second researcher—or sometimes a whole team—will have to be recruited. yet, the real anathema for mixed-methods design is in the sampling. if you are conducting a quantitatively-driven mixedmethod with a qualitative supplemental component, your main sample (the quantitative one) is too large for the qualitative component and has been selected randomly. on the contrary, if your project is qualitatively-driven, the sample is too small and will have been purposefully selected. the sample does not meet quantitative criteria for size or randomness, and a new sample will have to be pulled for the supplemental component. the final problem when doing mixed-methods is what i call “making it mixed.” a mixed-methods design is not simply a matter of doing two different projects; there must be reflexivity between the two components. in other words, if a question arises when analyzing one method, it is theoretically possible the emerging question will have to be answered in the supplementary component. a mixed-methods design has flexibility, even for incorporating additional, supplemental sequential components, if indicated. when combining the results of the components in the research narrative, the results of the two methods are integrated. if qual, the core findings usually provide the theoretical foundation of the results, with the supplementary findings providing complementary information. if quan, the qualitative supplementary data provide description throughout. importantly, the results are not the sequential paragraphs of description from each component. in summary, mixed-methods design is a tool well suited to nursing research and a way to obtain holistic data that fits well with the nursing perspective. it is more efficient (both in cost and the researcher’s time) than conducting two separate projects, and has the potential for moving a project forward. references 1. morse, j.m. (2017). developing qualitative-driven mixed-methods design. new york: routledge. 2. morse, j. m. & niehaus, l. (2009). mixed-method design: principles and procedures. walnut creek, ca: left coast press. 171 182 significado de salud.indd 171 maría de lourdes vargas-santillán1 beatriz arana-gómez2 maría de lourdes garcía-hernández3 maría guadalupe ruelas-gonzález4 estela melguizo-herrera5 ana olivia ruiz-martínez6 signifi cado de salud: la vivencia del adulto mayor 1 orcid.org/0000-0002-9089-6423. centro universitario uaem, zumpango, méxico. mlvargass@uaemex.mx 2 orcid.org/0000-0002-5177-4220. universidad autónoma del estado de méxico, méxico. baranag@uaemex.mx 3 orcid.org/0000-0001-8422-0665. universidad autónoma del estado de méxico, méxico. mlgarciah@uaemex.mx 4 orcid.org/0000-0002-9692-3509. instituto nacional de salud pública, méxico. guadalupe.ruelas@insp.mx 5 orcid.org/0000-0002-8087-9718. universidad de cartagena, colombia. emelguizoh@unicartagena.edu.co 6 orcid.org/0000-0002-9286-5946. centro universitario uaem, zumpango, méxico. aoruizm@uaemex.mx recibido: 15 de junio de 2016 enviado a pares: 18 de julio de 2016 aceptado por pares: 13 de octubre de 2016 aprobado: 19 de octubre de 2016 doi: 10.5294/aqui.2017.17.2.6 para citar este artículo / to reference this article / para citar este artigo vargas-santillán ml, arana-gómez b, garcía-hernández ml, ruelas-gonzález mg, melguizo-herrera e, ruiz-martínez ao. significado de salud: la vivencia del adulto mayor. aquichan. 2017; 17(2): 171-182. doi: 10.5294/aqui.2017.17.2.6 resumen durante la vejez, el significado de salud se basa en alcanzar un estado de bienestar; por ello, es importante comprender los factores que benefician o afectan el logro de este propósito. objetivo: analizar los significados de salud que los adultos mayores construyen a partir de sus vivencias y experiencias. materiales y métodos: investigación cualitativa con técnica de análisis de contenido y entrevista semiestructurada. participaron veinte adultos mayores, que acudieron a un centro de atención geriátrica, seleccionados de manera intencionada y determinada por índice de saturación. resultados: el significado de salud se manifiesta en la capacidad de poder hacer cosas; así, la salud se concibe como un medio útil para obtener un beneficio, ya sea material, moral o físico. los vínculos familiares son importantes, incluso los comparan con la salud; también, identifican la salud con la ausencia de dolor y enfermedad. conclusión: la salud del adulto mayor es vivida en contexto familiar; el bienestar es percibido como la capacidad de hacer cosas, aunque el dolor y la enfermedad estén presentes. palabras clave enfermería geriátrica; anciano; percepción; relaciones familiares; atención de enfermería (fuente: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 171-182 172 aquichan issn 1657-5997 eissn 2027-5374 año 17 vol. 17 nº 2 chía, colombia junio 2017 l 171-182 meaning of health: the experience of the elderly abstract the meaning of health during old age is based on achieving a state of well-being. therefore, it is important to understand the factors that benefit or affect accomplishing that goal. objective: analyze what health means to older adults, based on their experiences. materials and methods: this is a qualitative study based on content analysis and semi-structured interviews. twenty elderly adults who frequented a geriatric care center were selected intentionally and determined by means of a saturation index. results: the meaning of health is manifest in the ability to do things. accordingly, health is conceived as a useful means to obtain a benefit, be it material, moral or physical. family ties are important and were even compared to health. the participants also equated health with the absence of pain and disease. conclusion: health is experienced by the elderly in a family context. well-being is perceived as the ability to do things, even if pain and illness are present. keywords geriatric nursing; the elderly; perception; family relationships; nursing care (source: decs, bireme). 173 significado de salud: la vivencia del adulto mayor l maría de lourdes vargas-santillán y otros significado de saúde: a vivência do idoso resumo durante a velhice, o significado de saúde está baseado em atingir um estado de bem-estar; por isso, é importante compreender os fatores que beneficiam ou afetam conquistar esse propósito. objetivo: analisar os significados de saúde que os idosos constroem a partir de suas vivências e experiências. materiais e método: pesquisa qualitativa com técnica de análise de conteúdo e entrevista semiestruturada. participaram vinte idosos que foram a um centro de atenção geriátrica, selecionados de maneira intencionada e determinada por índice de saturação. resultados: o significado de saúde se manifesta na capacidade de poder fazer coisas; assim, a saúde é concebida como um meio útil para obter um benefício — material, moral ou físico. os vínculos familiares são importantes, inclusive os comparam com a saúde; também identificam a saúde com a ausência de dor e doença. conclusões: a saúde do idoso é vivida em contexto familiar; o bem-estar é percebido como a capacidade de fazer coisas, embora a dor e a doença estejam presentes. palavras chave ancião; atenção em enfermagem; enfermagem geriátrica; percepção; relações familiares (fonte: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 171-182 174 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 introducción la organización mundial de la salud (oms) ha posicionado el concepto de salud centrado en aspectos positivistas relacionados con tres dimensiones que integran al ser humano: física, mental y social. en el caso de los adultos mayores (am), la salud está prioritariamente enfocada en mantener la autonomía y la funcionalidad (1, 2); sin embargo, la oms ha cuestionado que medir y fomentar la salud del am tomando como parámetro principal la presencia o ausencia de enfermedad o discapacidad es insuficiente, dada la complejidad y variedad de los estados de salud y funcionalidad que caracterizan esta etapa de la vida. por tanto, sugiere explorar nuevos conceptos basados en las repercusiones que la salud tiene sobre el bienestar subjetivo del am (3). la salud es el estado idealizado al que todo ser humano aspira; en el caso de los am, que son conscientes de sus limitaciones producto de la edad y los estereotipos sociales sobre la vejez; estas concepciones y percepciones acerca de lo que para ellos puede significar la salud sufren modificaciones (4). la autopercepción del estado de salud es influenciada por diversos factores que no necesariamente tienen relación con el estado físico y funcional, sino que dependen de circunstancias personales y contextuales; aspectos que van más allá de lo que para el médico puede ser relevante en la clínica (5-7). estudios acerca del significado de salud en am han encontrado que esta se encuentra relacionada con aspectos físicos como el no estar enfermo, no tener dolor y valerse por sí mismo, pero también con aspectos económicos como tener dinero, trabajar y estar pensionado (8-11), y sociales y familiares como el salir de casa, no vivir solo o estar rodeado de la familia (12, 13). estas concepciones no se pueden generalizar, pero son de interés para conocer los aspectos que directa o indirectamente podrían influir en la percepción del estado de salud con la que el am lidia en la cotidianidad, con sus particularidades culturales y socioeconómicas. en el estado de méxico, durante el 2014, se inició un programa de atención al am, con base en la creación de clínicas geriátricas que otorgan atención médica, gerontológica, psicológica, dental, nutricional, fisiátrica y de enfermería. la experiencia clínica ha llevado a desarrollar un sistema de referencia interna entre los diferentes especialistas de manera improvisada, que ha permitido identificar problemas de salud que se encuentran interrelacionados con situaciones específicas que viven los am. a partir de estas experiencias surgió el interés por conocer en qué forma estos aspectos afectaban los significados de salud en dichos pacientes a partir de sus vivencias, con el propósito de identificar elementos que podrían ser infravalorados y que requieran de atención multidisciplinar en estas clínicas de reciente creación en méxico. por esta razón, la propuesta de este estudio es analizar los significados de salud de am residentes en una comunidad del estado de méxico que acuden a una clínica geriátrica. materiales y métodos investigación con enfoque cualitativo utilizando el análisis de contenido. la población estudiada fue la de am que acuden a una clínica de atención geriátrica de una comunidad del estado de méxico. para definir la muestra se utilizó un muestreo por conveniencia con determinación en el índice de saturación, para un total de veinte participantes (tabla 1). se seleccionaron am que no presentaran deterioro cognitivo, se tomó como base la valoración de la escala rápida mini-mental state folstein (1975), y con capacidad de expresarse y comunicarse. la información se obtuvo por medio de entrevistas semiestructuradas, algunas preguntas base fueron: ¿qué opina de su vida actual?, descríbala; ¿cómo considera su estado de salud y por qué?; ¿cómo se siente tener salud?; descríbame momentos, situaciones o experiencias en las que se percibe con salud y con mala salud. también se indagaron aspectos sociodemográficos y enfermedades presentes. las entrevistas fueron grabadas con la autorización previa de los participantes; una vez transcritas, fueron validadas por los participantes para su posterior análisis. la duración de cada entrevista fue de cuarenta minutos en promedio, en general se aplicó solo una por participante, a excepción de dos casos en los que los participantes difirieron con el primer reporte de análisis y se les pidió dar continuidad a la entrevista para clarificar sus narraciones. a partir de la entrevista 20 los datos no aportaron nuevos hallazgos, por lo que los investigadores decidieron que se había llegado al punto de saturación. el análisis de contenido se basó en la técnica propuesta por cáceres (14). este proceso se llevó a cabo en los siguientes pasos: previo al análisis se establecieron los códigos con base en la teoría: salud como funcionalidad, salud como ausencia de enfermedad y salud como ausencia de dolor; conforme se fue analizando la información surgieron códigos emergentes como: salud como utilidad, salud como familia, etc., que complementaron los 175 significado de salud: la vivencia del adulto mayor l maría de lourdes vargas-santillán y otros fuente: entrevistas. tabla 1. características de los participantes seudónimo género edad estado civil ocupación dependencia económica enfermedades ámbito residencia carlos hombre 72 viudo campesino independiente ninguna rural lucy mujer 64 madre soltera hogar hijos diabetes rural beto hombre 74 viudo profesor independiente diabetes y lesiones musculo-esqueléticas urbana jovita mujer 66 separada comerciante independiente depresión, hipertensión, migraña y dolencias urbana charly hombre 93 casado artesano independiente prostatitis rural adela mujer 63 casada hogar hijos y esposo artritis reumatoide rural magaly mujer 66 madre soltera comerciante independiente diabetes, artritis reumatoide rural gaby mujer 67 casada hogar hijos y esposo cáncer de mama, hipertensión urbana eduardo hombre 67 casado comerciante independiente diabetes e hipertensión urbana pepe hombre 74 casado jubilado independiente diabetes e hipertensión urbana paty mujer 69 viuda hogar, pensionada independiente hipertensión, lesiones musculoesqueléticas rural maría mujer 63 casada hogar dependiente esposo depresión rural rosalba mujer 63 separada comerciante independiente hipertensa, lesión musculoesquelética, colitis y gastritis urbana pilar mujer 74 casada hogar/ dependencia física dependiente hijos diabetes, hipertensión, fractura de pelvis rural evelyn mujer 64 viuda pensionada independiente artritis reumatoide urbana antonio hombre 71 casado campesino independiente prostatitis rural jesús hombre 69 casado campesino independiente ninguna rural emilio hombre 81 casado campesino independiente ninguna urbana alfredo hombre 75 casado fontanero independiente ninguna urbana andrés hombre 78 casado pensionado independiente ninguna urbana 176 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 tabla 2. proceso de categorización categorías definitivas precategorías códigos “estar bien con la familia” sintiendo que realmente se vive sentir la vida sentir emoción sentirse bendecido sentirse amado por mi familia sentir que se ama sentirse contento sentirse positivo teniendo ganas de vivir sentir ansias de vivir para disfrutar mi familia sentir ganas de cuidarse o que haya quien nos cuide estando bien emocionalmente estar bien espiritualmente no tener rencor no tener odio querer a la familia querer a toda la gente la malas emociones afectan la salud sintiendo que los hijos están bien sentir que los hijos están bien ver que los hijos triunfan estar con los hijos sintiéndose integrado con la pareja ver que la pareja lo quiere a uno uno quiere a la pareja evitando darles molestias a los hijos estar bien físicamente para no dar molestias ni preocupaciones a los hijos no depender es triste depender de los hijos disfrutando de la vida con los hijos disfrutar de la vida con mis hijos lo más grande de la vida son mis hijos “ausencia de dolor y enfermedad” idealizando la salud estar bien no enfermarse no quejarse no tener la enfermedad estar al 100% no tener dolor estar bien de todas las partes del cuerpo estando conscientes de sus limitaciones a esta edad todo tiene uno 177 significado de salud: la vivencia del adulto mayor l maría de lourdes vargas-santillán y otros categorías definitivas precategorías códigos “poder hacer” adaptándose al dolor y las molestias por medio del movimiento mientras se ande parado se adapta no desesperarse adaptarse a todo adaptarse al calor adaptarse al frío atenuar el dolor estar tranquilo no importa que duela no estar nada más allí sentada porque uno se encoge de los pies no alterarse de la presión sintiéndose a través del movimiento levantarse estar parada poder moverme andar no estar tirada en cama andar de allá para acá estar caminando motivándose para hacer tener ganas de correr tener ganas de comer tener ganas de pensar hacer algo no olvidar hacer ejercicio haciendo para no pensar en morir ya me hubiera muerto de no poder hacer evitar pensar en morir es una distracción siendo funcional estar en posibilidades trabajar siempre he trabajado me gusta todavía trabajar salud para trabajar desempeñar cualquier actividad 178 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 códigos iniciales (tabla 2), que fueron consensuados por los investigadores de manera constante. posteriormente, se fueron integrando los códigos preestablecidos con los emergentes, estos se reagruparon para reducir los datos con base en una ponderación y con el propósito de representar los distintos significados se construyeron tres categorías, las cuales fueron consensuadas por los investigadores mediante un trabajo colectivo permanente (tabla 2). las categorías se definieron e interpretaron a partir de un análisis comparativo entre la teoría y los significados empíricos encontrados. para garantizar la calidad del análisis cualitativo se consideraron los aspectos de credibilidad, transferibilidad, consistencia, confirmabilidad, relevancia y adecuación teórica. los aspectos éticos considerados se basaron en la norma de la ley general de salud, artículo 17-1, que por sus características la clasifica como una investigación sin riesgo; además, se obtuvo la aprobación por parte del comité de ética del centro de investigación en ciencias médicas, de la universidad autónoma del estado de méxico. los am firmaron el consentimiento informado previa explicación del objetivo, y para asegurar la confidencialidad se utilizaron seudónimos que los participantes sugirieron. resultados se entrevistaron 20 am con edades entre los 63 a 93 años, de los cuales 10 fueron del género masculino y 10 del femenino; 10 manifestaron vivir en zona rural y 10 en zona urbana. las enfermedades de mayor frecuencia que autorreportaron los am son crónico-degenerativas, diabetes mellitus tipo 2, hipertensión arterial y artritis reumatoide; además tres am sin enfermedad previamente diagnosticada. la percepción de tener mala salud se presentó en 5 de las 10 mujeres, en comparación con los hombres quienes en general se percibieron con buena salud. el análisis permitió construir las siguientes categorías relacionadas con el significado de salud: la salud como “poder hacer” el adulto mayor experimenta la salud cuando percibe que puede hacer cosas, este “poder hacer” fue expresado en diferentes niveles de capacidad, desde la capacidad de moverse para valerse por sí mismo y evitar la dependencia física, hasta la de trabajar para lograr la autosuficiencia económica. estas formas de concebir la salud dependían de la situación en la que se encontraba cada am; por ejemplo, si contaban con el apoyo de la familia, los medios económicos para solventar sus necesidades de salud, si trabajaban, si vivían solos o acompañados, o el tipo de enfermedad que padecían. el “poder hacer” como significado de salud fue interpretado como una necesidad vital en los casos de am con poca solvencia económica, y se relacionó con autonomía y dignidad en los am con dependencia física; ambas construcciones fueron asociadas a sentirse útil. “...¡me da gusto de ver la cosecha de mi trabajo!… yo no pienso en otra cosa más que en trabajar para vivir… para mí es una fuente: entrevistas. categorías definitivas precategorías códigos “poder hacer” siendo funcional duele tener que valerse por sí mismo beneficios económicos sufragar gastos de la vida diaria no depender de aparatos levantarse no molestar a los hijos es triste depender poder servir 179 significado de salud: la vivencia del adulto mayor l maría de lourdes vargas-santillán y otros distracción, me siento a gusto de trabajar porque si ya no pudiera, yo creo que entonces sí, ya me hubiera muerto de decir ya no puedo… al contrario, yo le pido a dios que me deje otros años más con salud, de lo que me haga falta yo veré en dónde lo consigo, en dónde lo hallo, en dónde lo busco”. (carlos) el “poder hacer” también fue relacionado con la reafirmación de un autoconcepto positivo y la preservación de su autoestima, aspectos que parecen ayudarlos a conservar un estatus social valorado a partir de sus capacidades físicas. poder servir y sentirse útiles representan la posibilidad de considerarse integrados en la sociedad. además, es necesario contextualizar que los am trabajaron toda su vida, provienen de generaciones en donde el trabajo duro se consideraba una forma de vida, por tanto, trabajar es una satisfacción en algunos casos; y no importa si esto repercute en el estado físico. “…yo me siento muy satisfecha que yo esté así, porque gracias a dios, me he acabado de mis huesos, porque si yo hubiera sido floja no me sentiría contenta, porque diría yo: he desperdiciado mi vida, pero como la hemos aprovechado... decía mi marido: mira, trabajes o no trabajes, te vas a morir, dice, lo más bonito es mejor que trabajemos y satisfecha te vas a morir y tiene razón porque si no lo hubiera yo hecho, ¿que satisfacciones me iba yo a llevar?, al menos así me siento satisfecha, digo: dios mío, me he acabado de mis huesos, de lo que tú quieras, pero satisfecha, porque sanamente estoy aquí en mi hogar, con mis hijos, tranquila y feliz”. (adela) no obstante, es necesario puntualizar que la importancia que el am le da a la capacidad de hacer se encuentra influenciada por la necesidad de sobrevivir, especialmente en los casos en donde se vive solo y no se cuenta con el apoyo de la familia. cuando el “poder hacer” se convierte en una necesidad, entonces se sufre y sale de un contexto de salud: “es estar al cien por ciento, pues no tener enfermedades, nada de lo que yo tengo, porque la verdad para mí es muy doloroso estar enferma, porque tengo que trabajar para valerme por mí misma”. (rosalba) los adultos mayores establecen una relación directa entre movimiento y sentirse bien, sentirse vivo. por tanto, la merma en el movimiento es interpretada como la pérdida de independencia, la falta de movimiento, del poder hacer, de la libertad de decidir a dónde ir y qué hacer; que en consecuencia también los afecta física y emocionalmente: “por lo menos poder caminar, estar lúcido, no tener que depender de aparatos, caminar, con que camine uno bien y se levante uno tranquilo, ya para mí eso es salud”. (evelyn) también el “poder hacer” como salud le permite al am olvidarse de sí mismo, de sus enfermedades, dolencias, nostalgias, y concentrarse en las cosas de la vida; por el contrario, caer en cama produce temor e incertidumbre, le hace pensarse vulnerable, sentir que ya no va a levantarse más; quizá por esta razón, la salud se vivencia en formas de ocupación que distraen y permiten concentrarse en vivir: “es poder moverme y poder servir en lo que pueda... es una satisfacción para mí porque me tiene tranquilo, no estar pensando que me vaya a morir”. (charly) la salud como el “estar bien con la familia” esta categoría se refiere a las formas en que el am experimenta la vida, disfruta y goza de estar sano. al pedirles que describieran los sucesos en donde se perciben sanos y disfrutan de esta condición, inmediatamente piensan en situaciones familiares, expresándolo como “estar bien con la familia”. esta relación salud / familia es entendible pues es en el entorno familiar en donde el am construye y da sentido a su vida. la salud como el “estar bien con la familia” dependió de aspectos como el papel dentro del entorno familiar, el apoyo y la atención que le presten los integrantes de la familia: “no me preocupa [la enfermedad], no estoy viviendo la enfermedad, yo estoy viviendo mi momento, yo vivo a mis hijos, vivo a mi familia, vivo a mis nietos, estoy contento con ellos y las enfermedades pues, no las tomo en cuenta”. (pepe) el papel que ejerce la familia dentro de las formas de construir el significado de la salud en los am es muy importante; aunque este aspecto no fue medido en esta población en contextos de alberges, sí puede decirse que la familia forma parte de la construcción de escenarios en donde se vivencia el disfrutar de la salud. también se encontró la posibilidad de tener conflictos con la familia, situación que representa el antónimo del significado de salud. esta condición generalmente viene representada por la falta de atención que el grupo familiar tenga hacia el am, aunque vivan 180 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 juntos; el abandono, o incluso el hecho de que los hijos tengan problemas, representa para los am una forma de no tener salud, de vivir intranquilos y preocupados por ellos: “porque uno sabe, como madre uno presiente cuando su hijo tiene problemas… ellos no te dicen pero yo lo sé; porque vienen y no están bien… entonces no duermo y no más pienso que yo quisiera arreglarle su problema… yo no vivo tranquila”. (jovita) la salud como ausencia de dolor y enfermedad los am tienen presente el concepto de salud ampliamente difundido en la sociedad como la ausencia de enfermedad y dolor; de tal forma que les resultaba muy complicado definir a partir de sus propias vivencias y palabras un concepto de salud propio; sin embargo, coincidieron en que aunque este concepto no siempre estaba a su alcance, por medio de adaptaciones del medio ambiente podían subsanar síntomas como el dolor, la enfermedad, la tristeza y la falta de movimiento. no obstante, en el discurso de la vivencia se percibían con salud. esta situación los llevó a reflexionar acerca de que la salud no solo implicaba aspectos físicos: “salud es que uno esté bien, que no tenga nada, pero llegando a la edad todo tiene uno… pero yo veo a tantos jóvenes sin ganas, sin aspiraciones … y yo me digo que estoy bien, que estoy sano”. (ernesto) discusión los significados de la salud que expresaron los am estudiados a partir de sus vivencias dieron lugar a tres categorías: “poder hacer”, “estar bien con la familia” y “no tener dolor y enfermedad”. estos tres componentes coinciden con los significados encontrados en la metasíntesis hecha por song y kong (15) quienes, al analizar las investigaciones hechas durante las dos últimas décadas en diferentes poblaciones y bajo el método de investigación cualitativa, encontraron temas similares, denominándolos “la salud como capacidad de hacer algo de forma independiente”, “la ausencia de síntomas” y “la conexión con lo demás”; lo que coincide con las categorías encontradas. de igual forma, la “capacidad de hacer” fue el tema central encontrado en estos estudios. el estar bien o mal con la familia representaron aspectos que influyen en la vivencia de la salud y la enfermedad del am. un ambiente familiar de afecto, cariño y atención es favorable para la salud; por el contrario, cuando el ambiente familiar es inhóspito se convierte en campo propicio para la enfermedad. estudios demuestran que en el caso positivo se ha comprobado que el apoyo social —en específico el apoyo familiar a partir de la convivencia, el contacto físico, el afecto, la compañía y la protección— sirve como protector ante la presencia de enfermedad y discapacidad, y hace al am más resistente a los problemas de salud; de la misma manera, influye en la disminución de días de hospitalización (12, 16-19). las implicaciones negativas de la relación con la familia y el significado de salud se encuentran entremezcladas por factores que, en muchos casos, no son controlados por los familiares; por ejemplo, la situación económica de la familia, la falta de recursos para brindar la atención que requiere el am (20), la necesidad de trabajar fuera, la desintegración del hogar y la falta de cultura de apoyo al am; estos factores actúan como determinantes sociales que influyen indirectamente en la vivencia de la mala salud de los am y que no son considerados en la clínica. estas situaciones suelen presentarse en hogares intergeneracionales, muchas veces a causa de problemas económicos frecuentemente vistos en el contexto latinoamericano (21, 22). song y kong, además, encontraron que la categoría “conectividad con los otros” como concepto de salud implicaba no solo el contacto familiar, sino otras redes de apoyo, como amigos, vecinos, la relación con dios y su relación con lo geográfico y lo social. sin embargo, estos aspectos no fueron expresados por los am de este estudio, considerando fundamentalmente a la familia como su principal soporte; este aspecto pudiera verse influenciado por aspectos culturales en las relaciones familiares dentro del contexto de méxico, muy a pesar de los problemas sociales y económicos que dificultan su interacción (23). la salud vivenciada a partir del “poder hacer” implicó el poder moverse, ser funcional y, en su caso, trabajar. estos significados ya se han reportado en otras investigaciones (8, 9, 11) y en am en condición de pobreza y discapacidad (24). a diferencia de estos estudios, además de constituirse como una necesidad económica en los participantes, se percibe el beneficio moral de ser autosuficientes, sentirse útiles y tener un rol social, lo que coincide con lo reportado por cardona-arias et al. (13) en adultos mayores institucionalizados en colombia. por otro lado, este “poder hacer” también es vivenciado como una manera de evitar pensar y estar consciente ante la idea de morir, lo que representa, desde un enfoque existencialista, la garantía de que estamos viviendo, estamos en-el-mundo, existimos (25). 181 significado de salud: la vivencia del adulto mayor l maría de lourdes vargas-santillán y otros el am es consciente de que por sus condiciones físicas, la enfermedad y el dolor son una posibilidad, por tanto, el significado de salud que poseen no se sustenta únicamente en el aspecto físico, por lo que se puede considerar que en el caso de las personas que están en un proceso de cronicidad y discapacidad, esta pudiese no ser la única forma en que se puede concebir la salud. los am no solo se ven afectados por el dolor y la enfermedad, también por las implicaciones que estas representan para continuar con sus vidas en lo económico, alimentario, familiar y social, en donde el soporte social y familiar representa un aliado fundamental (26). por otro lado, ajustan sus actividades y buscan maneras de atenuar sus molestias físicas, con el propósito de que no interfieran demasiado en sus vidas, en la medida de sus posibilidades. conclusiones el significado de salud en el am se vive y experimenta a través de tres aspectos: la capacidad de hacer cosas, el estar en armonía con la familia y el bienestar físico controlando y adaptándose al dolor y la enfermedad. estos significados de salud proponen reconocer la importancia y poner atención en la calidad de las relaciones familiares del am, así como reorientar las capacidades físicas en sus contextos de convivencia y no solo sustentados en la funcionalidad o ausencia de enfermedad. el estudio aporta información acerca de cómo se vive la salud en la vejez según el género. las mujeres en méxico tradicionalmente desempeñan roles funcionales en el ámbito familiar, que influyen de manera muy importante en el significado de salud. el hombre se enfoca mayormente en su rol de proveedor, y cuando se jubila este significado se ve afectado. tomando como referencia estos resultados, se considera pertinente implementar estrategias que cambien este paradigma mental en los am, tales como el uso de terapias ocupacionales que resignifiquen el autoconcepto de ser am, que podrían ir desde el hábito de realizar las tareas más sencillas en el hogar, hasta aquellas que les permitan interactuar con su entorno para que, por medio de ellas, la percepción de que pueden seguir aportando a la sociedad sea mayor. limitaciones del estudio. una de las limitaciones está relacionada con el tipo de participantes, lo que lleva a sugerir continuar la investigación en otros contextos, como albergues, dado que el significado de la salud está condicionado por el contexto y no es único; en este caso, la población estuvo delimitada a am domiciliados, sin embargo, es importante reconocer que sus necesidades de salud son muy variadas, esto podría ampliar la comprensión de la influencia familiar en la vivencia de la salud. referencias 1. lloyd-sherlock p, mckee m, ebrahim s, gorman m, green-gross s, prince m, et al. population ageing and health. lancet 2012;379 (9823):1295-1296. 2. gutiérrez jp, rivera-dommarco j, shamah-levy t, villalpando-hernández s, franco a, cuevas-nasu l, et al. encuesta nacional de salud y nutrición 2012. resultados nacionales, cuernavaca, méxico: instituto nacional de salud pública (mx); 2012. 3. oms. resumen. informe mundial sobre el envejecimiento y la salud; 2015. 4. oms. la buena salud añade vida a los años. información general para el día mundial de la salud 2012 [visitado: 2016 octubre 18]. disponible en: http://apps.who.int/iris/bitstream/10665/75254/1/who_dco_whd_2012.2_spa.pdf 5. gadamer hg. el estado oculto de la salud. barcelona: gedisa; 1996. 6. feyto l. la definición de salud. revista diálogo filosófico. 1996;34:61-84. 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[citado 2 de feb 2016]. doi: http//dx.doi.org/10.15446/rsap.v17n2.30730 182 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 9. castillo-carniglia a, albala c, dangour a, uauy r. factores asociados a satisfacción vital en una cohorte de adultos mayores de santiago, chile. gaceta sanitaria. 2012;26(5):414-420. disponible en: http://dx.doi.org/10.1016/j.gaceta.2011.11.021 10. melguizo e. cultura del cuidado de la salud. cartagena: editorial universitaria, universidad de cartagena; 2012; p. 79-82. 11. aldana g, fonseca h, garcía g. el significado de la vejez y su relación con la salud en ancianas y ancianos integrados a un programa de envejecimiento activo. revista digital universitaria. 2013;14(4):1067-1079. 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[citado 2 de feb 2016]. disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=s172781202008000100002&lng=es 26. rodríguez a, collazo m, álvarez l, calero j, castañeda i, gálvez m. necesidades de atención en salud percibidas por adultos mayores cubanos. revista cubana de salud pública. 2015;41(3):401-412. 150 161 calidad de vida.indd 150 olga janneth gómez-ramírez1 arlen patricia gómez-ramírez2 calidad de vida, nivel de salud percibido y factores sociodemográfi cos en personas con artritis reumatoide 1 orcid.org/0000-0002-9160-4170. universidad nacional de colombia, colombia. ojgomezr@unal.edu.co 2 orcid.org/0000-0002-0429-4822. universidad nacional de colombia, colombia. apgomezr@unal.edu.co recibido: 22 de febrero de 2016 enviado a pares: 29 de abril de 2016 aceptado por pares: 18 de agosto de 2016 aprobado: 03 de octubre de 2016 doi: 10.5294/aqui.2017.17.2.4 para citar este artículo / to reference this article / para citar este artigo gómez-ramírez oj, gómez-ramírez ap. calidad de vida, nivel de salud percibido y factores sociodemográficos en personas con artritis reumatoide. aquichan. 2017;17(2): 150-161. doi: 10.5294/aqui.2017.17.2.4 resumen objetivo: determinar la relación entre la calidad de vida, el nivel de salud y los factores sociodemográficos en personas con artritis reumatoide (ar). materiales y método: estudio correlacional explicativo. se realizó una entrevista directa en el momento de la consulta de enfermería antes del control médico de reumatología. a través de un muestreo intencional no probabilístico de sujetos tipo se contó con la participación de 635 personas. resultados: se encontró una frecuencia de presentación de ar mayor en mujeres (87%). también se evidenció una correlación positiva (0,596; p<0,001) entre calidad de vida y nivel de salud. sociodemográficamente, las mujeres con educación básica y bajo estrato socioeconómico presentan una menor percepción de calidad de vida y nivel de salud. estas variables se sometieron a un proceso de prueba con el uso de un modelo path de análisis de covarianza. conclusiones: las condiciones sociales que viven las personas con ar son factores que determinan la puesta en marcha de acciones de intervención dirigidas a solucionar la problemática de la calidad de vida en esta población. palabras clave artritis; calidad de vida; estado de salud; seguridad social; factores socieconómicos (fuente: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 150-161 151 calidad de vida, nivel de salud percibido y factores sociodemográficos en personas con artritis reumatoide l olga janneth gómez-ramírez y otro año 17 vol. 17 nº 2 chía, colombia junio 2017 l 150-161 quality of life, perceived health status and sociodemographic factors among persons with rheumatoid arthritis abstract objective: determine the relationship between quality of life, health status and sociodemographic factors among persons with rheumatoid arthritis (ra). materials and methods: this is an explanatory correlational study. a direct interview was conducted during the nursing consultation prior to the medical check-up concerning rheumatic diseases. a non-probability intentional sampling of type subjects included 635 individuals. results: a higher frequency of ra was found among women (87%). there also was a positive correlation (0.596; p <0.001) between quality of life and health status. socio-demographically speaking, women with a basic education and a low socioeconomic status have a lower perception of quality of life and health status. these variables were subjected to a test process using a path model to analyze covariance. conclusions: the social conditions of persons with ra are factors that determine the implementation of action for intervention aimed at solving the problem this population faces in terms of quality of life. keywords arthritis; quality of life; health status; social security; socioeconomic factors (source: decs, bireme). 152 aquichan issn 1657-5997 eissn 2027-5374 qualidade de vida, nível de saúde percebido e fatores sociodemográficos em pessoas com artrite reumatoide resumo objetivo: determinar a relação entre a qualidade de vida, o nível de saúde e os fatores sociodemográficos em pessoas com artrite reumatoide (ar). materiais e método: estudo correlacional explicativo. realizou-se uma entrevista direta no momento da consulta de enfermagem antes da consulta médica de reumatologia. por meio de uma amostra intencional não probabilística de sujeitos tipo, contou-se com a participação de 635 pessoas. resultados: constatou-se uma frequência de apresentação de ar maior em mulheres (87 %). também se evidenciou uma correlação positiva (0,596; p<0,001) entre qualidade de vida e nível de saúde. no aspecto sociodemográfico, as mulheres com educação básica e baixa classe socioeconômica apresentam uma menor percepção de qualidade de vida e nível de saúde. essas variáveis foram submetidas a um processo de teste com o uso de um modelo path de análise de covariância. conclusões: as condições sociais em que as pessoas com ar vivem são fatores que determinam a manifestação de ações de intervenção direcionadas a solucionar a problemática da qualidade de vida nessa população. palavras-chave artrite; estado de saúde; fatores socioeconômicos; qualidade de vida; segurança social (fonte: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 150-161 153 calidad de vida, nivel de salud percibido y factores sociodemográficos en personas con artritis reumatoide l olga janneth gómez-ramírez y otro introducción la artritis reumatoide (ar) es una enfermedad crónica autoinmune, de afectación sistémica, la cual genera un daño estructural en las articulaciones con consecuencias graves en la capacidad funcional de las personas (1). de acuerdo con lo reportado por seca et al. (2), la ar se considera un problema de salud pública porque afecta la calidad de vida de las personas y puede producir una mortalidad prematura. en colombia, el grupo latinoamericano para el estudio de la ar afirma que esta patología autoinmune es compleja en su manejo, por lo que se espera que cada vez se ofrezca un abordaje biopsicosocial a las personas y se realicen estudios de investigación a gran escala que permitan mostrar el impacto de esta enfermedad en la salud pública y en la productividad de la población (3). la calidad de vida y el nivel de salud percibidos por las personas con artritis reumatoide son fenómenos complejos de gran importancia porque implican el entendimiento de las variables que caracterizan la experiencia de vivir con una enfermedad catastrófica debido a la ausencia de cura y la condición de cronicidad de la misma (4, 5). de esta forma, al no existir un tratamiento efectivo que contrarreste los signos y síntomas de daño articular y de afectación sistémica, se hace imprescindible que los profesionales de la salud conozcan la complejidad del fenómeno y trabajen en el fomento del bienestar y de servicios de salud apropiados para estas personas. los estudios de mora et al. (6) y díaz-rojas et al. (7) reafirman que en colombia se desconoce cuál es la carga derivada de las enfermedades reumatológicas crónicas en términos de costos y afectación física y social. lo que se conoce de las variables psicosociales y de carga económica de la enfermedad se ha realizado en trabajos de muestras pequeñas no representativas de la población afectada. por lo anterior, el propósito del estudio fue conocer la relación entre las variables calidad de vida y nivel de salud percibido por las personas que viven con ar, así como establecer los factores asociados a la calidad de vida que aporten evidencias para el entendimiento de este fenómeno. materiales y métodos diseño del estudio. por medio de un tipo de estudio cuantitativo transversal y un diseño correlacional se determinó la relación entre la calidad de vida y el nivel de salud percibido en personas con ar. la elección del diseño correlacional se realizó con base en el análisis de los estudios previos a nivel internacional que brindan un sustento metodológico acerca de la importancia de estudiar la relación entre las variables que caracterizan la calidad de vida y el nivel de salud, incluidos factores asociados como los sociodemográficos y de acceso a los servicios de salud (8-10). análisis estadístico. la prueba usada para el análisis estadístico de correlación fue el rho de spearman; para el análisis inferencial se realizó un procedimiento de regresiones múltiples y path análisis para evidenciar las asociaciones más significativas entre las variables, las cuales han sido útiles en las ciencias de la salud para probar las variables que explicarían mejor ciertos fenómenos como la calidad de vida y la cronicidad de la enfermedad (11, 12). estas técnicas de análisis permiten predecir y explicar la variable dependiente, en este caso, la calidad de vida, a partir de variables explicativas o independientes, como el nivel de salud en ar y los factores sociodemográficos y de acceso a la seguridad social que puedan estar presentes. población y muestra. la recolección de datos se realizó durante en el primer semestre de 2013, previo cumplimiento de los requisitos y el aval del comité de ética correspondiente. la entrevista directa se realizó en el momento de la consulta de enfermería, antes del control médico de reumatología. a través de un muestreo intencional no probabilístico de sujetos tipo se contó con la participación de 635 personas. la estimación muestral se hizo teniendo como guía el estadístico para estudios con población finita, es decir, cuando se conoce el total de la población a la cual se busca inferir los análisis (13). lo que se indaga es cuántos adultos emergentes del total se tendrán que estudiar a partir de la prevalencia estimada de personas con ar para colombia con una proporción de 1 % (14): n = 36818; α = 0,05; ic: 95 %; z = 1,96 (a = 0,05); e = 4 error de aproximación de la media poblacional de acuerdo con la siguiente fórmula: los criterios de inclusión que se establecieron fueron: 1) personas mayores de 18 años de edad con diagnóstico de ar, de acuerdo con los criterios del american college of rheumatology (acr), que hacen parte de la guía basada en evidencia de la asociación colombiana de reumatología; 2) personas vinculadas a un servicio de seguimiento médico de reumatología, que no se encontraran hospitalizadas; y 3) personas que no estuvieran cursando un proceso agudo comórbido o de complicación de la enfermedad. 154 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 variables del estudio. las variables de respuesta que se plantearon para el estudio fueron: variables sociodemográficas: se tuvieron en cuenta las características de importancia que tuvieran relación con los participantes, como edad, género, estrato socioeconómico (según clasificación de estratos de la secretaría de hacienda para colombia, donde un mayor número de estrato constituye un mayor nivel de ingreso económico) (15), nivel educativo y ocupación. variables de seguridad social: se consideraron variables de acceso a la seguridad social relacionadas con el tipo de vinculación a la misma (régimen contributivo, subsidiado, régimen especial, plan complementario de salud), dificultades con la entidad promotora de salud (eps), y aspectos puntuales de acceso al tratamiento de la enfermedad (oportunidad en el tratamiento especializado, trámites y condiciones de servicio de salud). calidad de vida (variable dependiente): esta variable se considera como la satisfacción con importantes funciones y dimensiones de la vida. se midieron las variables física, social y psicológica, teniendo en cuenta la propuesta teórica de padilla y grant (16), que incluye también el apoyo de la familia. nivel de salud percibido (variable independiente): incluye dominios específicos de la afectación de la artritis en la movilidad, actividad física, destreza y dolor. el componente de desempeño social, actividad social, actividades cotidianas, y el componente psicológico que explora el nivel de depresión y ansiedad. estas variables fueron extraídas de la propuesta del instrumento de impacto de la enfermedad de meenan et al. (17). instrumentos de medición. el instrumento que se utilizó para medir la calidad de vida corresponde al desarrollado y validado al español por padilla et al. (18), específicamente diseñado para personas con artritis denominado qol-ra. se trata de un cuestionario de 8 ítems, en el que cada uno de ellos contiene una definición del elemento considerado, seguido por una escala horizontal numerada con 10 puntos entre 1 (muy mal) y 10 (excelente). los elementos sobre los que se interroga son: capacidad física, dolor, interacción con la familia y los amigos, ayuda de la familia y los amigos, depresión, ansiedad, ar y salud. el cuestionario es sencillo y demuestra validez, los coeficientes alfa de cronbach van de 0,87 a 0,90. la escala qol-ra se correlaciona significativamente con la arthritis impact measurement scale 2 (19). el nivel de salud se midió a través del instrumento diseñado por meenan et al. (17, 19) denominado arthritis impact measurement scales (aims), el cual valora las dimensiones física, mental y social en nueve dominios: movilidad, actividad física, actividades de la vida diaria, destreza, actividades del hogar, dolor, actividad social, depresión y ansiedad. cada escala contiene de 4 a 7 ítems, y entre 2 y 6 posibles respuestas. la fiabilidad test-retest de la validación al español fue estadísticamente significativa para todas las escalas. el coeficiente de confiabilidad es > 0,7 para todas las escalas. para controlar el sesgo de administración de pruebas se realizó una ensayo piloto con 36 personas con el fin de garantizar la validez aparente y de contenido de los instrumentos y encontrar aspectos por mejorar en el procedimiento de entrevista. resultados características sociodemográficas. en la tabla 1 se resumen los hallazgos obtenidos en la caracterización de las variables sociodemográficas del estudio. se destaca la mayor frecuencia de presentación de la ar en mujeres, así como en el rango de edad mayor a 36 años y en los estratos socioeconómicos dos y tres. tabla 1. frecuencia y proporción de personas con artritis reumatoide (ar) en cada una de las características sociodemográficas analizadas en el estudio característica frecuencia proporción ( %) género masculino 81 13 femenino 554 87 edad 18 a 35 años 57 9 36 a 59 años 325 51 mayores de 60 años 253 40 escolaridad primaria 130 20 secundaria 179 28 técnico 66 10 universidad 260 41 155 calidad de vida, nivel de salud percibido y factores sociodemográficos en personas con artritis reumatoide l olga janneth gómez-ramírez y otro n = 635 personas que cumplieron con los criterios de inclusión del estudio. fuente: elaboración propia. acceso a la seguridad social. en general, el 45 % de los participantes refiere no tener dificultades en los servicios de salud; sin embargo, el 55 % informó algún tipo de dificultad de acceso a la seguridad social. análisis de correlación. los datos presentaron una correlación positiva (rho de spearman = 0,596) estadísticamente significativa (p < 0,001) entre la calidad de vida y el nivel de salud, tal como se muestra en la figura 1. figura 1. correlación entre calidad de vida y nivel de salud en pacientes con artritis reumatoide característica frecuencia proporción ( %) estado civil soltero 137 22 casado 321 51 separado 70 11 viudo 62 10 unión libre 45 7 ocupación hogar 263 41 empleado(a) 163 26 trabajo independiente 68 11 estudiante 14 2 pensionado(a) 127 20 estrato socioeconómico uno 13 2 dos 127 20 tres 328 52 cuatro 135 21 cinco 19 3 seis 13 2 tiempo con la enfermedad 0 a 6 meses 30 5 7 a 18 meses 48 8 19 a 36 meses 118 19 más de 36 meses 439 69 n = 635; rho de spearman = 0,596; p < 0,001. fuente: elaboración propia. en la tabla 2 se muestran las correlaciones entre las diferentes dimensiones del instrumento de percepción de salud y la calificación total de calidad de vida. se encontró una correlación positiva (0,662) y estadísticamente significativa (p = 0,001) entre los dominios de actividad física y movilidad, así como en la calificación total de nivel de salud con los dominios de actividad física (0,744), movilidad (0,763), destreza (0,730) y desempeño (0,703). realizar labores manuales y labores domésticas como lavar la ropa también presentó una correlación positiva (0,669). también se evidenció que la variable sociodemográfica de género, en la característica ser mujer, reduce significativamente el nivel promedio de calidad de vida en -4,116 puntos (valor beta) y el de nivel de salud en -19,83 puntos con respecto a ser hombre. en el análisis de regresión múltiple se encontró que ser mujer predice un nivel bajo de calidad de vida con respecto a ser hombre -17,413, el pertenecer a un estrato igual o inferior a cuatro reduce significativamente el nivel de calidad de vida en comparación con pertenecer a un estrato igual o superior a cinco. al analizar al interior de los estratos se observó que estas diferencias se acentúan cuando se compara el estrato dos o menos con el estrato cinco o más: 28.859. en cuanto a la escolaridad, tener una escolaridad menor o igual a bachillerato se asocia con una reducción en la 156 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 calificación promedio de la calidad de vida respecto de tener algún grado de educación superior (técnico, universitario y posgrado); esta diferencia se acentúa en las personas con un nivel de educación básica o menos -31,655. asimismo, presentar dificultades con la eps reduce el nivel de calidad de vida respecto a las personas que manifestaron no tener dificultades con la eps -13,494. construcción del diagrama teórico path y modelo de ecuaciones estructurales. la figura 2 presenta el diagrama path con la propuesta teórica de un modelo conjunto que esquematiza los resultados encontrados en el presente trabajo. en ella se asume que el nivel de salud percibido (nsp) está relacionado con el comportamiento de la variable movilidad de los individuos, así como con las variables: actividad física, destreza, dinámica social, actividad social, actividades cotidianas, dolor, niveles de depresión y ansiedad. también se asume que el nivel de salud está correlacionado con el constructo calidad de vida (cv). por otra parte, se presume que el comportamiento observado en el nsp y la cv de los pacientes estudiados se ve reflejado en aspectos sociodemográficos como: el género, la escolaridad, el estrato socioeconómico y las posibles dificultades que se han tenido con las respectivas eps (d_eps). es necesario aclarar que, adicional a las variables tabla 2. matriz de correlaciones entre atributos de calidad de vida y dimensiones del nivel de salud en pacientes con artritis reumatoide dominios tqol td1 td2 td3 td4 td5 td6 td7 td8 td9 taims tqol 1 td1 0,424 1 td2 0,399 0,662 1 td3 0,34 0,45 0,507 1 td4 0,301 0,545 0,588 0,477 1 td5 0,462 0,255 0,258 0,213 0,25 1 td6 0,317 0,399 0,4 0,396 0,451 0,266 1 td7 0,387 0,44 0,452 0,504 0,336 0,09 0,168 1 td8 0,458 0,376 0,323 0,397 0,252 0,229 0,203 0,4 1 td9 0,442 0,322 0,25 0,28 0,217 0,263 0,245 0,244 0,649 1 taims 0,596 0,744 0,763 0,73 0,703 0,485 0,536 0,607 0,649 0,578 1 tqol: total calidad de vida; td1: total dominio movilidad; td2: total dominio actividad física; td3: total dominio ansiedad; td4: total dominio desempeño social; td5: total dominio actividad social; td6: total dominio actividades de la vida diaria; td7: total dominio dolor; td8: total dominio depresión; td9: total dominio ansiedad; taims: total nivel de salud percibido. fuente: elaboración propia. tabla 3. regresiones múltiples de las variables socioeconómicas y demográficas que se asocian con el nivel de salud en pacientes con artritis reumatoide variable beta (b) et t p valor (constante) 62,858 2,409 26,092 0,000 género (mujer) -4,044 1,391 -2,907 0,004 nivel educativo primaria incompleta -7,976 2,057 -3,878 0,000 primaria completa -5,930 1,515 -3,914 0,000 bachillerato incompleto -4,156 1,725 -2,409 0,016 bachillerato completo -3,288 1,307 -2,516 0,012 técnico -4,029 1,630 -2,472 0,014 estrato socioeconómico estrato 2 o menos -4,711 2,410 -1,955 0,051 estrato 3 -4,416 2,205 -2,003 0,046 estrato 4 -6,108 2,300 -2,656 0,008 dificultades eps (sí) -2,147 0,952 -2,255 0,024 fuente: elaboración propia. 157 calidad de vida, nivel de salud percibido y factores sociodemográficos en personas con artritis reumatoide l olga janneth gómez-ramírez y otro sociodemográficas, existen otras de igual importancia como el tipo de acceso al sistema de seguridad en salud, la ocupación (en especial el hogar) y, en una menor medida, el acceso a terapias biológicas las cuales, como se evidencia en los primeros planos factoriales de los análisis de correspondencias múltiples, están altamente correlacionadas con las variables sociodemográficas presentadas en la figura 2. a partir de los resultados del modelo de ecuaciones estructurales se encontró que un cambio significativo en el nivel de salud percibido afecta de manera significativa el comportamiento de los individuos en su capacidad de movilizarse independientemente, realizar actividades físicas y en sus niveles de destreza. figura 2. modelo path de calidad de vida y nivel de salud en pacientes con artritis reumatoide fuente: elaboración propia. discusión a través de esta investigación se determinó la relación entre la calidad de vida, el nivel de salud y los factores sociodemográficos en personas con ar, donde se destaca la mayor frecuencia de afectación en mujeres (20), siendo este dato similar al presentado por bautista-molano et al. (21), que establece una proporción del 85,3 %. este hallazgo se corroboró con los reportes que muestran una prevalencia alta en el género femenino, asociada con las características hormonales y genéticas propias de la mujer, las cuales hacen que las enfermedades autoinmunes sean más frecuentes en ellas (22-24). en la afectación por grupo de edad se evidenció que el mayor porcentaje está en la etapa laboral productiva. sin embargo, según lo reportado por gamal et al., en un estudio conducido en pacientes con ra en egipto se evidenció que los que trabajaban mostraban mejores condiciones tanto físicas como mentales (25). asimismo, se encontró que la frecuencia de la enfermedad aumenta con la edad, ya que el 40 % de las personas afectadas fueron mayores de 60 años, lo cual concuerda con los datos del estudio de francoaguirre et al., donde los pacientes tenían una edad promedio de 53 ± 12 años (26). los datos coinciden con lo reportado por branco et al. (27), donde se evidenció que el inicio más frecuente de la enfermedad está durante el cuarto y quinto decenios de la vida, de 158 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 forma que el 80 % de todos los pacientes presenta la enfermedad entre los 35 y los 50 años de edad. asimismo, el tiempo de la enfermedad mayor a 36 reafirma la consideración de la misma como una enfermedad crónica de alto costo. entre los problemas referidos por los participantes de esta investigación se incluyen los trámites excesivos para la atención especializada, así como la demora en la cita de reumatología. esta situación, de acuerdo con lo informado por pasma et al. (28) y emery et al. (29), expone a las personas a complicaciones y cierra la posibilidad de aplicar la ventana de oportunidad que establece que entre más oportuno sea el inicio del tratamiento ordenado por los especialistas es más probable retrasar el efecto sistémico y de daño articular. se plantea que el deterioro radiológico y funcional progresa lentamente durante todo el curso de la enfermedad, y la máxima velocidad de desarrollo de las lesiones estructurales ocurre durante los primeros dos años de manifestaciones clínicas (29); por esta razón, es prioritario el abordaje precoz de la enfermedad, ya que el pronóstico de daño articular mejora cuando se tiene un acceso temprano a los protocolos y esquemas de tratamiento más eficaces (30). la correlación positiva y estadísticamente significativa entre los dominios de actividad física y movilidad (31), así como en la calificación total de nivel de salud con los dominios de actividad física, movilidad, destreza y desempeño, está acorde con los resultados del estudio episer 2000 en españa, con 2192 participantes, en el que se evidenció la asociación positiva entre los dominios de actividad física, movilidad y la capacidad para trabajar (32-34). por otro lado, se observó que la variable sociodemográfica de ser mujer reduce significativamente el nivel promedio de calidad de vida y de nivel de salud con respecto a ser hombre. este hallazgo se complementa con lo reportado por pease et al. (35), en el que ser mujer se asocia a presentar incapacidad funcional 4 años después del comienzo de la enfermedad (or = 3,0). la correlación moderada observada bivariadamente entre los constructos nivel de salud percibido y calidad de vida tiende a diluirse en el modelo teórico planteado. esto llamaría la atención para estudiar de forma separada los constructos y de esta forma extraer las variables más significativas sin asumir relaciones causales a priori. al advertir el comportamiento de las variables sociodemográficas planteadas en el modelo teórico propuesto se encuentra que ser mujer afecta tanto el nivel de salud percibido como la calidad de vida observada; el pertenecer a un estrato menor o inferior al 1 o 2 afecta de manera negativa el nsp y la cv, y tiende a diluirse el efecto negativo observado en las personas pertenecientes a los estrato 2 y 3 sobre la salud y la calidad de vida percibidas; haber cursado estudios de primaria o poseer máximo este nivel de formación afecta de manera negativa el nsp y la cv. las dificultades percibidas con el acceso a las eps no se confirmaron en la propuesta teórica expuesta, hecho que exigiría a futuro un análisis a profundidad con el fin de verificar si esto se debe a problemas de tipo estadístico o a posibles correlaciones aún no observadas dentro del modelo propuesto. de esta forma, los resultados de este estudio demuestran que existe una influencia importante de algunas variables socioeconómicas y demográficas sobre la calidad de vida y el nivel de salud en las personas con ar. para ampliar esta argumentación, la revisión de la literatura realizada por anaya y calixto (36) presenta el concepto de estatus socioeconómico (socioeconomic status ses) como una clasificación social jerárquica asociada a diferentes resultados en la salud y la enfermedad. los factores más importantes que influyen en el ses son los ingresos económicos, el nivel educativo, el perfil laboral y la clase social. entre los factores que resalta la literatura está el estudio de bengtsson et al. (37), que encontró en personas con artritis de un nivel de escolaridad de diez años o menos una correlación positiva con un aumento de dos veces en un mal pronóstico. estos hallazgos son coherentes con otros autores que afirman que el menor nivel educativo está relacionado con una mayor probabilidad de mortalidad temprana y menor capacidad funcional. teniendo en cuenta el constructo ses, se infiere que las personas con un estatus socioeconómico bajo pueden presentar una situación que empeora la enfermedad, la salud física, la salud mental y calidad de vida (38, 39). conclusiones a partir de los resultados se confirmó la relación entre las percepciones del estado de salud y la calidad de vida en personas con ar; asimismo, con el uso de ecuaciones estructurales se describieron las variables que aportaron significativamente al entendimiento de las necesidades más sentidas por las personas y, con base en esta evidencia, se realizó un acercamiento teórico a un modelo que aporta a la comprensión del fenómeno de la calidad de vida y el nivel de salud para las personas que viven con ar. la afectación se da a partir de la tercera y cuarta década de vida, en una etapa muy importante de desarrollo del potencial laboral del ser humano; por esta razón, esta enfermedad se considera de 159 calidad de vida, nivel de salud percibido y factores sociodemográficos en personas con artritis reumatoide l olga janneth gómez-ramírez y otro interés en salud pública, y a la disciplina de enfermería le corresponde tomar parte en el proceso de atención a fin de poner en marcha acciones para el cuidado de la salud y la promoción de la calidad de vida de estas personas. en cuanto a los métodos, se sugiere avanzar en estudios que combinen abordajes cualitativos y cuantitativos para conocer la experiencia y el significado de la enfermedad de manera más completa, que abarque el constructo de enfoque de género. igualmente, se motiva a realizar estudios posteriores que permitan validar y probar con mayor profundidad estadística el modelo teórico planteado. la problemática identificada por la inoportunidad y las fallas de acceso al tratamiento especializado que sufren las personas con ar en el actual sistema de salud colombiano constituye una alerta para los actores en salud y la comunidad en general, a fin de exigir un cambio en el modelo de atención en colombia que permita dar prioridad al tratamiento especializado, sin distinciones por la capacidad de pago o el nivel socioeconómico, de tal manera que el mayor número de personas se beneficien de la eficacia farmacológica, la prevención de complicaciones y las medidas que contrarrestan el daño articular que se produce cuando no se tiene un esquema de seguimiento y atención estructurado. un aporte de gran relevancia es la oportunidad de construir un rol de enfermería en reumatología, que permita abrir un campo nuevo a la disciplina para estructurar formalmente el cuidado para las personas con enfermedades autoinmunes. por esta razón, el presente estudio aporta a la justificación de la participación de enfermería en el cuidado de personas con ar en el contexto latinoamericano. se reconoce la limitación del uso de un muestreo no probabilístico en un estudio descriptivo cuantitativo, lo que condiciona la generalización de los resultados; sin embargo, se aclara la importancia que tuvo contar con una muestra grande y el procedimiento de entrevista en el contexto natural de la consulta de enfermería en reumatología, lo que otorgó al estudio la ventaja de ser trasladable a situaciones naturales de un fenómeno psicosocial como la percepción de calidad de vida. se invita a la realización de trabajos posteriores con muestras grandes como la presente investigación, con el uso de técnicas de muestreo aleatorio estratificado. agradecimientos este estudio fue financiado por la división de investigación de la universidad nacional de colombia sede bogotá, a través del grupo de investigación de cuidado y práctica, de la 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arthritis: a systematic literature review. joint bone spine. 2016;5(16):30129-4. 35. pease ct, bhakta bb, devlin j, emery p. does the age of onset of rheumatoid arthritis influence phenotype? a prospective study of outcome and prognostic factors. rheumatology (oxford). 1999;38:228-34. 36. calixto oj, anaya jm. socioeconomic status. the relationship with health and autoimmune diseases. autoimmun rev. 2014;13(6):641-54. 37. bengtsson c, et al. socioeconomic status and the risk of developing rheumatoid arthritis: results from the swedish eira study. ann rheum dis. 2005;64:1588-94. 38. rogers hl, brothertona ht, olivera plaza sl, segura durán ma, pena altamar ml. depressive and anxiety symptoms and social support are independently associated with disease-specific quality of life in colombian patients with rheumatoid arthritis. rev bras reumatol. 2015;55(5):406-413. 39. baldassari a, cleveland r, luong m, jonas b, conn d, bridges s, et al. socioeconomic factors and self-reported health outcomes in african americans with rheumatoid arthritis from the southeastern united states: the contribution of childhood socioeconomic status. bmc musculoskelet disord. 2016; 171. 368 380 entrevista percepcion de carga-----.indd 368 ruth vivian barreto-osorio1 maría stella campos de aldana2 gloria mabel carrillo-gonzález3 rosa coral-ibarra4 lorena chaparro-díaz5 myriam durán-parra6 rosario rosales-jiménez7 vilma tamara ortiz-nievas8 entrevista percepción de carga del cuidado de zarit: pruebas psicométricas para colombia9 1 enfermera. magíster en enfermería. universidad de ciencias aplicadas y ambientales u.d.c.a., bogotá (colombia). rbarreto@udca.edu.co 2 enfermera. magíster en enfermería en salud familiar. universidad de santander (udes), bucaramanga (colombia). scamposaldana@hotmail.com 3 enfermera. magíster en enfermería. universidad nacional de colombia, bogotá (colombia). gmcarrillog@unal.edu.co 4 enfermera. magíster en docencia universitaria. universidad de ciencias aplicadas y ambientales u.d.c.a., bogotá (colombia). rcoral@udca.edu.co 5 enfermera. doctora en enfermería. universidad nacional de colombia, bogotá (colombia). olchaparrod@unal.edu.co 6 enfermera. magíster en enfermería. universidad de santander udes, bucaramanga (colombia). enfermería@udes.edu.co 7 enfermera. magíster en docencia universitaria. universidad mariana, san juan de pasto (colombia). rrosalesj25@gmail.com. 8 enfermera. magíster en enfermería. universidad mariana, san juan de pasto (colombia). tabata269@gmail.com 9 financiación: programa para disminuir la carga de la enfermedad crónica en colombia. convocatoria 5372010, colciencias. recibido: 15 de diciembre de 2013 enviado a pares: 05 de marzo de 2014 aceptado por pares: 12 de diciembre de 2014 aprobado: 11 de marzo de 2015 doi: 10.5294/aqui.2015.15.3.5 para citar este artículo / to reference this article / para citar este artigo barreto-osorio rv, campos ms, carrillo-gonzález gm, coral-ibarra r, chaparro-díaz l, durán-parra m, et al. entrevista percepción de carga del cuidado de zarit: pruebas psicométricas para colombia. aquichan. 2015;15(3):368-380. doi: 10.5294/aqui.2015.15.3.5 resumen objetivo: determinar la validez y confiabilidad de la entrevista de percepción de carga del cuidado de zarit, versión de 22 ítems en español, con cuidadores familiares de personas con enfermedades crónicas en colombia. materiales y métodos: estudio metodológico de corte transversal, con 652 cuidadores familiares de personas con enfermedades crónicas, residentes en las cinco regiones de colombia, con el fin de establecer la validez de constructo, con un análisis factorial y la confiabilidad a través de la consistencia interna determinando el alfa de cronbach. resultado: respecto a la validez de constructo, el estudio reporta a partir de la asociación libre de la rotación varimax la carga total, y en sus dimensiones que incluyen carga interpersonal, impacto del cuidado, y las competencias y expectativas sobre el cuidado. las cargas factoriales corresponden a los ítems planteados para medir cada una de las dimensiones propuestas. conclusión: el instrumento entrevista de percepción de carga del cuidado de zarit, versión de 22 ítems en español, es una herramienta de fácil aplicación y comprensión en población colombiana de diferente nivel educativo, socioeconómico y cultural; además, mostró ser válido y confiable para evaluar la carga del cuidado en cuidadores familiares de personas con enfermedad crónica. año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 368-380 369 entrevista percepción de carga del cuidado de zarit: pruebas psicométricas para colombia l ruth vivian barreto-osorio y otros año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 368-380 palabras clave psicometría, cuidadores familiares, enfermedad crónica, costos del tratamiento (fuente: decs, bireme). zarit burden interview: psychometric tests for colombia abstract objective: this research was designed to determine the validity and reliability of the zarit burden interview, specifically the 22-item spanish version, as an instrument to measure the burden of care perceived by family caregivers of patients in colombia with chronic diseases. materials and methods: a cross-sectional study of 652 family caregivers of patients with chronic diseases who reside in five regions of colombia was conducted to establish construct validity, with a factor analysis and internal consistency reliability measured by determining the cronbach’s alpha value. result: in terms of construct validity, the study reports the total loading, based on free association of a varimax rotation, and in the dimensions that include interpersonal burden, impact of care, and skills and expectations about care. the factor loadings pertain to the items introduced to measure each of the proposed dimensions. conclusion: the results showed the 22-item spanish version of the zarit burden interview is an instrument that can be applied and understood easily in a colombian population with different educational, socio-economic and cultural levels. it also proved to be valid and reliable for assessing the burden of care perceived by family caregivers of patients with chronic diseases. keywords psychometrics, family caregivers, chronic disease treatment costs (source: decs, bireme). 370 aquichan issn 1657-5997 entrevista de percepção de carga do cuidado de zarit: provas psicométricas para a colômbia resumo objetivo: determinar a validade e confiabilidade da entrevista de percepção de carga do cuidado de zarit, versão de 22 itens em espanhol, com cuidadores familiares de pessoas com doenças crônicas na colômbia. materiais e métodos: estudo metodológico de corte transversal, com 652 cuidadores familiares de pessoas com doenças crônicas, residentes nas cinco regiões da colômbia, para estabelecer a validade de constructo, com uma análise fatorial, e a confiabilidade por meio da consistência interna que determina o alfa de cronbach. resultado: a respeito da validade de constructo, o estudo relata, a partir da associação livre da rotação varimax, a carga total, e em suas dimensões que incluem carga interpessoal, impacto do cuidado, bem como as competências e expectativas sobre o cuidado. as cargas fatoriais correspondem aos itens apresentados para mediar cada uma das dimensões propostas. conclusão: o instrumento entrevista de percepção de carga do cuidado de zarit, versão de 22 itens em espanhol, é uma ferramenta de fácil aplicação e compreensão em população colombiana de diferente nível educativo, socioeconômico e cultural; além disso, mostrou ser válido e confiável para avaliar a carga do cuidado em cuidadores familiares de pessoas com doença crônica. palavras-chave psicometria, cuidadores familiares, doença crônica, custos do tratamento (fonte: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 368-380 371 entrevista percepción de carga del cuidado de zarit: pruebas psicométricas para colombia l ruth vivian barreto-osorio y otros introducción américa latina vive un problema de salud pública con las enfermedades crónicas no transmisibles (ecnt) y su manejo debe atenderse de manera prioritaria (1, 2). este cambio genera nuevos retos al sistema general de seguridad social en salud (sgsss) colombiano. al revisar la carga y los costos de la enfermedad se pueden identificar como sujetos del cuidado a las personas con la ecnt y sus cuidadores familiares, que son sin duda quienes reciben el mayor impacto de esta situación. aparecen también los profesionales de la salud y las instituciones como instancias que viven el impacto de este cambio epidemiológico (3). frente a estas situaciones, son múltiples los llamados para transformar en acción la preocupación por el impacto de la ecnt en el medio. el concepto de carga ha sido ampliamente estudiado. de acuerdo con barrera et al.: “carga significa trabajo, dificultad, peso, desgaste, energía necesaria para algo”. cuando se habla de la carga de la ecnt o de la carga del cuidado de la ecnt para la díada cuidador familiar-paciente, se hace referencia al esfuerzo adicional que implica para ellos satisfacer las necesidades de las personas que cursan con la enfermedad. este esfuerzo es en gran parte desconocido, y debe ser descrito y cuantificado al igual que los factores contextuales que lo aumentan o disminuyen, para poder ser atendido. la carga se ha definido también como: 1) la valoración que da el cuidador al balance entre el nivel de las demandas del cuidado y la calidad de la relación entre el cuidador y el receptor del cuidado; 2) el impacto de vivir con un enfermo en el estilo de vida o en la salud de los miembros de la familia; 3) el efecto del paciente sobre la familia. asimismo, la carga del cuidado que tiene el cuidador hace referencia a las alteraciones en la salud física y emocional que pueden ocurrir cuando el cuidado demanda más de los recursos disponibles. la definición de carga del cuidado de una persona con ecnt es multidimensional e incluye en ella aspectos sociales, emocionales, relación entre el dador y el receptor del cuidado y otras personas, tiempo y finanzas, aunque la manera como estas se interrelacionan se concibe de forma muy distinta. algunos autores (4-6) refieren que existe falta de claridad sobre la carga del cuidado, inconsistencia entre su conceptualización y puesta en práctica, y empleo incorrecto en medio de un paradigma del estrés, así como marginalidad en la política social. con una intencionalidad compartida y el compromiso de transformar la práctica del cuidado de las personas con ecnt y sus familias, un grupo investigador interesado en generar un programa para disminuir la carga de la enfermedad crónica en colombia inició una revisión de las escalas e instrumentos disponibles en la literatura para medir la percepción de carga del cuidado por parte de los cuidadores familiares y seleccionó entre ellas la entrevista de percepción de carga del cuidado de zarit (4), que ha sido empleada con éxito en varios países y en diferentes versiones (5-9). a partir del trabajo conceptual que este grupo ha adelantado, de la experiencia del programa cuidando a los cuidadores© para el fortalecimiento de la habilidad de cuidado de los cuidadores familiares de personas con enfermedad crónica (10, 11), y respondiendo a las demandas de salud pública en el campo de la enfermedad crónica, se retoma la entrevista de percepción de carga del cuidado de zarit, versión de 22 ítems en español. para contar con la versión en español de la entrevista de percepción de carga del cuidado de zarit que cumpla con las pruebas de validez y confiabilidad requeridas para su uso en el contexto local, el objetivo del presente estudio fue realizar la validez de constructo y confiabilidad, con cuidadores colombianos en diferentes regiones del país. materiales y métodos diseño. estudio metodológico de corte transversal que como parte del programa para la disminución de la carga de la enfermedad crónica en colombia aplicó el instrumento entrevista de percepción de carga del cuidado de zarit, versión de 22 ítems en español. participantes. para establecer la validez de constructo y confiabilidad de la entrevista de percepción de carga del cuidado de zarit, versión de 22 ítems para colombia, se aplicó a 652 cuidadores pertenecientes a las cinco grandes regiones geográficas de colombia, atendiendo con ello las particularidades culturales y sociales que las caracterizan (12). 372 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 en un muestreo intencionado por cuotas, el número de cuidadores fue distribuido por región (tabla 1). tabla 1. distribución de cuidadores a quienes se aplicó la entrevista de percepción de carga del cuidado de zarit, por región niendo en cuenta el bajo nivel de escolaridad de algunos de ellos, se previó apoyo de los investigadores para su diligenciamiento. se efectuó el análisis factorial de componentes principales para determinar la validez de constructo del instrumento utilizando el método de normalización varimax, y se analizaron los valores de los pesos factoriales rotados, confirmando que su agrupación correspondiera a los factores teóricos del instrumento utilizando el criterio de 0,75 como satisfactorio. se entiende por confiabilidad la revisión de la condición de consistencia, coherencia, estabilidad y fiabilidad del instrumento, es decir, su nivel de confianza para que al ser aplicado en repetidas ocasiones arroje los mismos resultados (13). para estimar la confiabilidad de la encuesta, se calculó el coeficiente alfa de cronbach y se consideró que un valor superior a 0,75 indicaría que la consistencia interna del instrumento sería satisfactoria. instrumento. el estudio empleó dos instrumentos: 1) para la caracterización de los cuidadores se utilizó el gcc-un-c© (13), con autorización de los autores. este incluye características socioeconómicas, datos de cuidado de la salud e identificación de mecanismos de soporte social disponible. 2) la entrevista de percepción de carga del cuidado de zarit, versión de 22 ítems en español. esta escala incluye preguntas tipo likert de 5 opciones (nunca, rara vez, algunas veces, bastantes veces y casi siempre). la puntuación va desde 22 a 110 puntos y la sobrecarga se califica: ausencia de sobrecarga (< o igual a 46), sobrecarga ligera (47 a 55), sobrecarga intensa (> o igual a 56). la entrevista de percepción de carga del cuidado de zarit cuenta con pruebas psicométricas en español, una validez de 0,92 y una confiabilidad de 0,81; sin embargo, no hay documentación sobre la misma en población colombiana. procedimiento y análisis para este trabajo, el grupo investigador recibió aval del autor y su versión disponible en español. se capacitó a los investigadores y sus auxiliares en cada una de las regiones del país y se afinó el protocolo acordado. una vez revisado, se puso a disposición de todos por escrito y se dejó un teléfono para apoyo permanente durante la aplicación de la caracterización y de la entrevista de percepción de carga del cuidado de zarit. ambos instrumentos fueron respondidos individualmente por cada cuidador, a quien se no. de cuidadores región de colombia lugar de la entrevista 55 región amazónica amazonas putumayo caquetá vaupés 377 región andina santander antioquia caldas huila tolima cundinamarca boyacá bogotá, d.c. valle nariño (pasto) 114 región caribe san andrés cesar atlántico bolívar córdoba la guajira 51 región de la orinoquia arauca meta casanare 55 región pacífica nariño (tumaco) total 652 fuente: datos del estudio, 2013. se incluyeron cuidadores familiares de personas con ecnt que voluntariamente aceptaran participar en el estudio y que no presentaran dificultad para comprender las instrucciones. te373 entrevista percepción de carga del cuidado de zarit: pruebas psicométricas para colombia l ruth vivian barreto-osorio y otros le orientó sobre la forma de responder si así lo requería, o se le apoyó en registrar la información si no sabía o no podía hacerlo. los datos fueron registrados directamente en el formato físico y tabulados por los investigadores en el sistema spss, versión 17.0. esta investigación mantuvo rigor ético y tuvo en cuenta la resolución 8430 de 1993 del ministerio de salud de colombia, lo que incluyó, entre otros aspectos, el consentimiento informado de cada participante y el manejo confidencial de la información. teniendo en cuenta que se identificaron cuidadores menores de edad, entre 15 a 17 años, se aplicó en estos el asentimiento informado y el procedimiento de consentimiento informado para los adultos responsables. el proyecto contó con el aval del autor del instrumento y de cada una de las instituciones que lo adelantaron. de otra parte, se acató la política ambiental de la universidad nacional de colombia y el uso responsable de los recursos (14). resultados la caracterización de los cuidadores entrevistados se detalla en la tabla 2. en relación con la carga percibida por los cuidadores, se encontró que el 54,29 % no percibe sobrecarga, el 21,63 % presenta sobrecarga ligera y el 24,08 % percibe sobrecarga intensa. validez de constructo respecto a las pruebas psicométricas realizadas a la entrevista de percepción de carga del cuidado de zarit, versión de 22 ítems en español, con el análisis factorial se calculó el número de componentes; se obtuvieron 4 para la rotación varimax. (tablas 3 y 4). confiabilidad consistencia interna la consistencia interna de la entrevista de percepción de carga del cuidado de zarit, versión 22 ítems en español, mediante el coeficiente alfa de cronbach, correspondió a un valor para la escala total de 0,861, considerado alto según parámetros previstos. sin embargo, el alfa de cronbach fue mayor a 0,800 solo en la dimensión impacto (tabla 5). discusión los hallazgos de género, edad, nivel socioeconómico definido por estrato y escolaridad de este grupo de cuidadores coinciden con los reportados en diferentes estudios (15-19). con respecto al estado civil vale la pena señalar que la mayor parte cuenta con una pareja estable, aunque en algunos casos (23,2 %) puede inferirse que la pareja es la persona con ecnt (11, 20-26) la ocupación indica que menos de la mitad son empleados, proporción baja con respecto a la situación nacional de empleabilidad (27). esto podría significar que su actividad de cuidadores interfiere con la posibilidad de desempeñarse laboralmente. la mayor parte de las personas reportan ser creyentes con alto o medio compromiso religioso, lo que puede apoyar su experiencia como cuidadores de personas con ecnt (28). la mayor parte cuidan a su familiar desde el inicio de la ecnt, con tiempos superiores a siete meses y por más de siete horas diarias, lo que puede significar una labor agobiante e incompatible con una buena calidad de vida (29-32). sin embargo, un poco más de la mitad reportan no ser únicos cuidadores y tener apoyos de la familia, espirituales y sociales. resulta preocupante que 8,6 % de los cuidadores reportan disfunción y, en particular, 3,6 % reflejan deterioro del estado mental, con lo cual el riesgo de la ocurrencia de eventos adversos para ellos mismos y sus familiares con ecnt es muy alto. en cuanto al conocimiento y acceso a las tecnologías de información y comunicación (tic), en su mayor parte medio y alto, constituyen una oportunidad incalculable de soporte social para este grupo (33). de los cuidadores, solo 42,8 % se reporta sano. las condiciones de enfermedad que refieren son el estrés o la mayor parte de patologías que han sido ampliamente asociadas con esta situación, como son la hipertensión (34, 35), diabetes (15, 36), gastritis (16, 17), migraña (18, 19), cáncer (37, 38) y enfermedades osteo-articulares (39). los resultados de la carga corroboran que el rol de cuidador se asocia con un amplio desgaste y ratifican hallazgos de diferentes estudios que analizan la carga del cuidado. en relación con las pruebas psicométricas, se puede señalar que el estudio coincide con los hallazgos de confiabilidad de la entrevista de percepción de carga del cuidado de zarit que ha sido reportada en diferentes idiomas, que incluyen: español, en méxico (8), chile (4) y españa; inglés (24); alemán (7); japonés; francés (6). 374 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 tabla 2. características de los cuidadores a quienes se aplicó la entrevista de percepción de carga del cuidado de zarit en colombia ítem categoría número porcentaje (%) género masculino 143 21,9 femenino 509 78,1 edad menor de 18 15 2,3 de 18 a 35 191 29,3 de 39 a 59 334 51,2 de 60 a 75 101 15,5 más de 75 11 1,7 teniendo en cuenta los grupos de edad anteriores, la edad del paciente es mayor que el rango de edad del cuidador 339 52,0 del mismo rango de edad del cuidador 135 20,7 menor que el rango de edad del cuidador 178 27,3 sabe leer y escribir sí 624 95,7 no 28 4,3 grado de escolaridad primaria incompleta 89 13,7 primaria completa 65 10,0 bachillerato incompleto 133 20,4 bachillerato completo 136 20,9 técnico 95 14,6 universidad incompleta 41 6,3 universidad completa 69 10,6 posgrados 22 3,4 no responde 2 0,3 estado civil soltero(a) 198 30,4 casado(a) 229 35,1 separado(a) 55 8,4 viudo(a) 23 3,5 unión libre 147 22,5 375 entrevista percepción de carga del cuidado de zarit: pruebas psicométricas para colombia l ruth vivian barreto-osorio y otros ítem categoría número porcentaje (%) ocupación hogar 268 41,1 empleado 135 20,7 trabajo independiente 155 23,8 estudiante 36 5,5 otro 58 8,9 religión católica 494 75,8 cristiana 98 15,0 otro 44 6,7 ninguna 16 2,5 nivel de compromiso religioso alto 196 30,1 medio 254 39,0 bajo 186 28,5 no responde 16 2,5 estrato socioeconómico 1 (muy bajo) 215 33,0 2 (bajo) 223 34,2 3 (medio) 163 25,0 4 (medioalto) 40 6,1 5 (alto) 5 0,8 6 (muy alto) 3 0,5 no responde 3 0,5 cuida a la persona a su cargo desde el momento de su diagnóstico sí 516 79,1 no 136 20,9 tiempo que lleva como cuidador menos de 7 meses 178 27,3 7 a 18 meses 134 20,6 19 a 36 meses 78 12,0 más de 36 meses 262 40,2 no. de horas que usted cree que dedica diariamente al cuidado menos de 6 horas 228 35,0 7 a 12 horas 198 30,4 13 a 23 horas 71 10,9 24 horas 155 23,8 376 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 fuente: datos del estudio, 2013. ítem categoría número porcentaje (%) único cuidador sí 293 44,9 no 359 55,1 apoyos con los que cuenta familia 375 57,5 espiritual 62 9,5 social 215 33,0 relación suya con la persona a quien cuida esposo(a) 151 23,2 madre/padre 149 22,9 hijo(a) 177 27,1 abuelo(a) 2 0,3 amigo(a) 23 3,5 otro 150 23,0 nivel de funcionalidad con la prueba pulses total 6 a 8 596 91,4 9 a 11 43 6,6 12 a 24 13 2,0 estado mental de acuerdo con el test spmsq 0 a 2 629 96,5 5 a 7 22 3,4 8 a 10 1 0,2 nivel de conocimiento de las tecnologías de información y comunicación (tic) alto 427 65,5 medio 155 23,8 bajo 70 10,7 posibilidad de acceso a las tecnologías de información y comunicación (tic) alto 495 75,9 medio 119 18,3 bajo 38 5,8 enfermedades que reporta el cuidador según diagnóstico dx médico hipotiroidismo 5 0,8 estrés 34 5,2 hipertensión 79 12,1 diabetes 12 1,8 gastritis 62 9,5 migraña 38 5,8 cáncer 12 1,8 enfermedades osteoarticulares 37 5,7 ninguna 373 57,2 377 entrevista percepción de carga del cuidado de zarit: pruebas psicométricas para colombia l ruth vivian barreto-osorio y otros fuente: datos del estudio. tabla 3. rotación varimax por ítem de la entrevista percepción de carga del cuidado de zarit, versión 22 ítems en español datos por ítem rotación varimax no. de ítem componente libre 1 2 3 4 ez1 0,116 0,376 0,557 -0,002 ez2 0,416 0,622 0,100 -0,023 ez3 0,433 0,512 0,027 0,147 ez4 0,527 -0,194 0,360 0,027 ez5 0,634 -0,122 0,199 0,071 ez6 0,580 0,143 0,088 0,065 ez7 0,248 0,176 -0,089 0,528 ez8 0,163 0,670 0,140 0,098 ez9 0,559 0,316 0,044 0,046 ez10 0,612 0,028 0,205 0,108 ez11 0,554 0,299 0,140 0,020 ez12 0,660 0,306 0,101 -0,088 ez13 0,581 0,148 0,345 -0,049 ez14 -0,001 0,644 0,169 0,132 ez15 0,069 0,515 0,005 0,435 ez16 0,219 0,093 0,660 0,149 ez17 0,548 0,213 0,350 0,094 ez18 0,163 0,095 0,717 -0,074 ez19 0,444 0,056 0,525 0,253 ez20 -0,058 0,085 0,130 0,830 ez21 0,058 0,054 0,092 0,816 ez22 0,466 0,174 -0,003 0,129 378 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 tabla 4. rotación varimax, entrevista de percepción de carga del cuidado de zarit, versión 22 ítems en español tabla 5. alfa de cronbach general y por subescalas, entrevista percepción de carga del cuidado de zarit componentes ítems componente 1 4, 5, 6, 9, 10, 11, 12, 13, 17, 22 componente 2 2, 3, 8, 14, 15 componente 3 1, 16, 18, 19 componente 4 7, 20, 21 fuente: datos del estudio. instrumento y dimensiones alfa de cronbach no. de ítems instrumento total 0,861 22 impacto 0,808 12 interpersonal 0,699 6 competencias y expectativas 0,596 4 sin embargo, a diferencia de los estudios anteriores, que en algunos casos no describen dimensiones y en otros se mencionan tres: el impacto del cuidado, la carga interpersonal y las expectativas de autoeficacia, el presente estudio reporta a partir de la asociación libre de la rotación varimax cuatro dimensiones que incluyen los ítems del componente 1 correspondientes a la dimensión carga interpersonal; los ítems del componente dos para la dimensión impacto del cuidado; los ítems de la dimensión tres correspondientes a la carga interpersonal y los del componente 4 relacionados con la indecisión sobre el cuidado. se propone así una cuarta dimensión denominada indecisión sobre el cuidado, cuya inclusión no solo se puede soportar teóricamente como parte del concepto de carga, sino que además genera una mejor confiabilidad con respecto a las medidas internas que la entrevista de percepción de carga del cuidado de zarit, versión de 22 ítems en español genera. conclusión el estudio permite concluir que la entrevista de percepción de carga del cuidado de zarit, versión de 22 ítems en español con cuidadores familiares de personas con enfermedad crónica no transmisible (ecnt) es un instrumento válido y confiable para ser aplicado en colombia. referencias 1. organización mundial de la salud (oms). informe estadísticas sanitarias mundiales. ginebra: oms [internet]; 2012 [citado 2013 jun 15]. disponible en: 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kruk j, aboul-enein h. psychological stress and the risk of breast cancer: a case–control study. cancer detec prev. 2004;28(6):399-408. 38. melhem a, conzen s. connecting environmental stress to cancer cell biology through the neuroendocrine response. en nriagu jo (editor). encyclopedia of environmental health. burlington: elsevier; 2011. 39. araya vc, oliva bp, ananías n, de los santos p, mendoza me. trastornos ansiosos y desórdenes temporomandibulares en funcionarios de un centro de salud familiar en la comuna de concepción, chile. int jf odontostomat [internet]. 2011 [visitado 2013 jul 08]; 5(3):235-9. disponible en: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=s0718381x2011000300005&lng=es 93 103 fatores que influenciam.indd 93 sandra cristina alvarenga1 denise silveira de castro2 franciéle marabotti costa leite3 marcos antônio gomes brandão4 eliana zandonade5 cândida caniçali primo6 fatores que infl uenciam o desmame precoce 1 orcid.org/0000-0002-9333-3845. universidade federal do espírito santo, brasil. alvarengasandra@terra.com.br 2 orcid.org/0000-0001-8026-7984. universidade federal do espírito santo, brasil. dsmcastro@terra.com.br 3 orcid.org/0000-0002-6171-6972. universidade federal do espírito santo, brasil. francielemarabotti@gmail.com 4 orcid.org/0000-0002-8368-8343. universidade federal do rio de janeiro, rio de janeiro, brasil. marcosbrandao@ufrj.br 5 orcid.org/0000-0001-5160-3280. universidade federal do espírito santo, brasil. eliana.zandonade@ufes.br 6 orcid.org/0000-0001-5141-2898. universidade federal do espírito santo, brasil. candida.primo@ufes.br recibido: 21 de marzo de 2015 enviado a pares: 31 agosto de 2015 aceptado por pares: 8 de agosto de 2016 aprobado: 19 de agosto de 2016 doi: 10.5294/aqui.2017.17.1.9 para citar este artículo / to reference this article / para citar este artigo alvarenga sc & et all. fatores que infl uenciam o desmame precoce. 2017; 17(1): 93-103. doi: 10.5294/aqui.2017.17.1.9 resumo objetivo: identificar na literatura científica os principais fatores associados ao desmame precoce. método: trata-se de uma revisão sistemática realizada nas bases lilacs e medline com artigos completos do período de 2004 a 2013, nos idiomas inglês, espanhol e português, a partir da pergunta norteadora: “quais são os fatores que influenciam no desmame precoce?”. resultados: identificaram-se 1.481 artigos e 39 atenderam aos critérios de inclusão. entre os principais fatores que influenciam o desmame precoce, verificou-se trabalho materno (33,3 %); uso de chupeta (30,8 %); leite fraco (17,9 %); trauma e dor mamilar (17,9 %); introdução de outros tipos de leites (15,4 %) e escolaridade da mãe/pai (15,4 %). conclusão: diversos fatores estão relacionados ao desmame precoce, o que exibe forte determinação sociocultural e histórica que pode ser evidenciada pela comparação dos padrões de amamentação entre diferentes populações e através dos tempos. palavras-chave aleitamento materno; fatores de risco; desmame; chupeta; trabalho feminino (fonte: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 93-103 94 aquichan issn 1657-5997 año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 93-103 factores que influyen el destete temprano resumen objetivos: identificar en la literatura científica los principales factores asociados al destete temprano. materiales y método: se trata de una revisión sistemática realizada en las bases de datos lilacs y medline con artículos completos del periodo de 2004 a 2013, en inglés, español y portugués, desde la pregunta orientadora: “¿cuáles son los factores que influyen el destete temprano?”. resultados: se identificaron 1.481 artículos y 39 atendieron a los criterios de inclusión. entre los principales factores que influyen el destete temprano, se encontraron trabajo materno (33,3 %); uso de chupo de entretención (30,8 %); leche materna débil (17,9 %); trauma y dolor mamilar (17,9 %); introducción de otros tipos de leche (15,4 %) y nivel educacional de la madre o del padre (15,4 %). conclusiones: diversos factores están relacionados al destete temprano, lo que apunta fuerte determinación sociocultural e histórica que se puede evidenciar por la comparación de los estándares de lactancia entre diferentes poblaciones y a través de los tiempos. palabras clave chupo de entretención; destete; factores de riesgo; lactancia materna; trabajo femenino (fuente: decs, bireme). 95 fatores que influenciam o desmame precoce l sandra cristina alvarenga e outros factors that influence early weaning abstract objective: identify, in scientific literature, the main factors associated with early weaning. method: this study is a systematic review of the lilacs and medline databases. the focus is on complete articles in english, spanish and portuguese published between 2004 and 2013. the guiding question is: "what factors influence early weaning?" results: in all, 1,481 articles were identified and 39 met the inclusion criteria. the main factors that influence early weaning included, among others, maternal labor (33.3%), use of pacifiers (30.8%), weak milk (17.9%), trauma and nipple pain (17.9%), introduction of other types of milk (15.4%), and the mother’s/father’s education (15.4%). conclusion: several factors are related to early weaning, which exhibits a strong sociocultural and historical determination that can be evidenced by a comparison of breastfeeding patterns among different populations and in the course of time. keywords breastfeeding; risk factors; weaning; pacifiers; maternal work (source: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 93-103 96 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 introdução apesar dos avanços nos índices de amamentação exclusiva no mundo e de suas diversas vantagens, vários fatores ainda contribuem para o insucesso ou interrupção da amamentação, o que leva ao desmame precoce. entre os problemas mais comuns observa-se o ingurgitamento mamário, dor/trauma mamilar, infecção mamilar por staphylococcus aureus, candidíase, fenômeno de raynaud, bloqueio de ductos lactíferos, mastite, abscesso mamário e galactocele, além da hipogalactia ou produção insuficiente de leite (1). outro fator relacionado são os recém-nascidos que apresentam movimentos orais atípicos (disfunções orais) durante a mamada, os quais podem ocasionar problemas decorrentes de alterações temporárias do próprio funcionamento oral, ou mesmo algumas características particulares anatômicas que atrapalham o encaixe adequado entre a boca do bebê e o peito, e também fatores iatrogênicos (2). um estudo realizado constatou que 57,3% dos binômios mães/recém-nascidos apresentavam alteração da mamada e a frequência da disfunção oral foi de aproximadamente 30% (3). algumas pesquisas avaliam que mães adolescentes frequentemente alcançam um índice menor de amamentação, o que representa um risco 2,2 vezes maior de desmamarem precocemente seus filhos, possivelmente porque essas aliam muitas vezes insegurança e ausência de confiança em si mesmas, além de imaturidade e dificuldades com autoimagem, o que atrapalha ainda mais o estabelecimento da lactação (4). estudos mostram que existe uma consonância ao relatarem que primíparas apresentam chance maior de ter mamada insatisfatória, pois a carência de experiência é considerada fator de risco para o desmame precoce, uma vez que mães que tiveram experiência prévia positiva possivelmente terão mais facilidade em estabelecer a lactação com os demais filhos (5,6). o desmame precoce é um fator predisponente para doenças evitáveis, como desnutrição, diarreia, obesidade infantil, entre outros problemas de saúde pública no mundo, além de contribuir para o aumento da mortalidade infantil (7). por isso, pontua-se a relevância de se investigar os elementos que influenciam no desmame precoce para que assim seja possível delimitar ações que culminem com a preservação de todos os benefícios da amamentação. diante do fato de que já existem estudos sobre o tema, mas que ainda há um desafio de agregar e sintetizar o conhecimento específico disponível para contribuir com sua aplicabilidade, foi traçado o objetivo de descrever os fatores que influenciam no desmame precoce. método trata-se de uma revisão sistemática que consiste em uma síntese das informações disponíveis em dado momento, sobre um problema específico, de forma objetiva e reproduzível. esse tipo de pesquisa apresenta um método rigoroso de busca e seleção de estudos, com avaliação da relevância e da validade dos resultados evidenciados; coleta, síntese e interpretação dos dados (8). dessa forma, no presente estudo, foi elaborado um protocolo, a fim de garantir o rigor do processo de pesquisa, que dispunha dos seguintes componentes: pergunta de revisão, critérios de inclusão e exclusão, estratégias para a busca do universo de pesquisas, orientação para a seleção do material, análise e síntese dos dados. a presente revisão teve como questão norteadora: “quais são os fatores que influenciam no desmame precoce?”. foi realizada uma busca em duas importantes bases de dados do sítio da biblioteca virtual em saúde — literatura latino-americana e do caribe em ciências da saúde (lilacs) e medical literature analysis and retrieval sistem on-line (medline). utilizou-se a terminologia em saúde consultada nos descritores em ciências da saúde (decs), no qual se encontram os seguintes descritores em português e inglês: aleitamento materno, fatores de risco, desmame precoce. os critérios de inclusão foram: artigos completos, disponíveis eletronicamente; nos idiomas português, inglês ou espanhol; que abordem a temática desmame precoce e os fatores que o influenciam, no período de 2004 a 2013. já os critérios de exclusão adotados foram: artigos de editoriais; cartas ao editor; monografias; teses e artigos de congressos ou eventos científicos. devido ao amplo quantitativo de artigos encontrados optou-se por trabalhar com o cruzamento de dois em dois descritores para a seleção dos artigos estudados. para identificação do nível de evidência dos artigos foi utilizada a classificação proposta por melnyk e fineout-overholt (2005) (9): 97 fatores que influenciam o desmame precoce l sandra cristina alvarenga e outros nível 1 — evidências provenientes de revisão sistemática ou meta-análise de todos os relevantes ensaios clínicos randomizados controlados ou oriundos de diretrizes clínicas, baseadas em revisões sistemáticas de ensaios clínicos randomizados controlados; nível 2 —evidências derivadas de pelo menos um ensaio clínico randomizado controlado bem delineado; nível 3 —evidências obtidas de ensaios clínicos bem delineados sem randomização; nível 4 —evidências provenientes de estudo de coorte e de caso-controle bem delineados; nível 5 —evidências originárias de revisão sistemática de estudos descritivos e qualitativos; nível 6 —evidências derivadas de um único estudo descritivo ou qualitativo; nível 7 —evidências oriundas de opinião de autoridades e/ou relatórios de comitê de especialistas. as buscas foram realizadas no mês de maio de 2014, de forma independente, por duas pesquisadoras experientes em estudos de revisão. a primeira seleção dos estudos foi feita a partir da análise dos títulos e resumos e, nos casos de dúvidas, a leitura dos textos completos das publicações. vale destacar que, em situações de divergências, as mesmas foram resolvidas por meio do consenso. para a seleção das publicações, inicialmente, leu-se exaustivamente cada título e resumo para confirmar se eles contemplavam a pergunta norteadora desta investigação e se atenderiam aos critérios estabelecidos. foram encontrados 1.481 artigos nas duas bases e, após refinamento segundo os critérios, foram excluídos 1.420 artigos que não atenderam à questão norteadora e 22 artigos por duplicidade, o que totalizou uma amostra final de 39 artigos —24 da base lilacs e 15 do medline. resultados foram encontrados 24 artigos na base de dados lilacs e 15 pesquisas no medline, os quais perfizeram uma amostra total de 39 artigos. destes, 48,7 % são apresentados no idioma português; 43,6 % em inglês e 7,7 % em espanhol. verifica-se quanto aos anos de publicação que grande parte (66,7%) é recente, visto que foi publicada a partir de 2009 até 2013, enquanto 33,3 % dos artigos apresentam data de publicação entre 2004 e 2008. a maioria (69 %) dos estudos dessa base de dados teve o brasil como país de publicação, seguido dos estados unidos (7,6 %), hong kong, suécia, irã, reino unido, noruega, irlanda, austrália, colômbia e chile (esses com 2,6 % cada). quanto ao nível de evidência, 64,1 % apresentaram nível 6, que são os estudos descritivos (transversais). a prevalência de figura 1. fluxograma da seleção amostral dos estudos incluídos na revisão sistemática. vitória – es, brasil, 2014. fonte: elaboração própria. questão norteadora: quais são os fatores que influenciam no desmame precoce? artigos selecionados para leitura na íntegra: lilacs: 24 medline: 15 total: 39 busca em maio/2014. descritores: aleitamento materno; fatores de risco; desmame precoce. leitura dos títulos e resumos para a seleção: excluídos: 1.420 duplicados: 22 total: 39 critérios de inclusão: publicações nos idiomas português, inglês e espanhol, no período de 2004 a 2013, nas bases lilacs e medline. referências encontradas: lilacs: 323 medline: 1.158 98 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 estudos transversais se dá pelo fato de eles proporcionarem a frequência de uma ou várias características de uma população; são relativamente baratos, fáceis de realizar e úteis na investigação do grau de exposição a determinadas condições por características individuais fixas, como etnia e nível socioeconômico. seu objetivo deve ser claramente definido, assim como a população-alvo e a população de estudo, a determinação dos dados a serem coletados, entre outros (10). e 35,9 % apresentaram nível de evidência 4, que são evidências provenientes de estudo de coorte. o termo coorte é utilizado para designar um grupo de indivíduos que têm em comum um conjunto de características e que são observados durante um período de tempo com o intuito de analisar a sua evolução (10). os principais resultados desses artigos foram sintetizados em 6 (seis) categorias temáticas: categoria i —características do recém-nascido, categoria ii —características da mãe, categoria iii —mitos quanto à amamentação, categoria iv —manejo da lactação, categoria v —substitutos do leite materno, categoria vi —orientação profissional; que estão apresentadas na tabela 1. o número de artigos (n) mostrado na coluna refere-se à frequência com que esse fator se repetiu em diferentes pesquisas, pois um artigo pode trazer uma ou várias características. tabela 1. síntese das categorias temáticas após análise dos artigos da revisão sistemática. vitória – es, brasil, 2014. categorias temáticas frequência n = 39 % características do recém-nascido bebê recusa o peito ou não quer mais mamar 5 12,8 doença/hospitalização da criança, baixo peso ao nascer 3 7,7 gemelaridade 2 5,1 bebê morde o peito, ganho peso insuficiente 1 2,6 características da mãe trabalho materno 13 33,3 escolaridade materna/paterna 6 15,4 idade materna 5 12,8 renda familiar baixa 4 10,2 tabagismo 3 7,7 tipo de parto, decisão materna (mãe não quer mais), depressão, paridade, dificuldades para amamentar, não morar com companheiro ou pai fora de casa 2 5,1 indução do trabalho de parto, uso de medicamento, estética da mãe, estado civil, experiência da mãe, doença/hospitalização da mãe, posicionamento inadequado, consulta no pré-natal < 6 1 2,6 mitos quanto à amamentação uso de chupeta 14 30,8 leite fraco 7 17,9 leite insuficiente ou pouco 4 10,2 leite secou, choro do bebê (interpretado como fome) ou fome percebida 2 5,1 99 fatores que influenciam o desmame precoce l sandra cristina alvarenga e outros discussão categoria i —características do recémnascido estão incluídos, nesta categoria, todos os fatores de risco relacionados ao recém-nascido que levaram ao desmame precoce. entre as características do recém-nascido foram associados os seguintes fatores: o bebê recusa o peito ou não quer mais mamar (12,8 %), doença/hospitalização (7,7 %), baixo peso ao nascer (7,7 %), gemelaridade (5,1 %), bebê morde o peito (2,6 %) e ganho de peso insuficiente (2,6 %). sabe-se que os benefícios do leite materno e a amamentação exclusiva em livre demanda são determinantes para o crescimento e o desenvolvimento infantil nos primeiros seis meses de vida (11). no entanto, alguns lactentes podem apresentar patologias e necessitarem de internação, o que faz com que a doença/hospitalização do bebê seja a causa de desmame precoce. a falta de rotinas e práticas de incentivo ao aleitamento, além de dificuldades de ordem física, como o desconforto das acomodações para as mães e o fornecimento de poucas refeições ao dia, foram obstáculos significativos à prática da amamentação dos lactentes internados (12,13). a recusa do bebê ao peito ou o desinteresse da criança na amamentação podem influenciar a interrupção precoce da amamentação exclusiva. essa recusa pode ocorrer devido a uma má postura ou causas físicas, como: o bebê possuir uma boca demasiado pequena ou o peito ser grande porque a aréola está tensa e faz com que o peito fique mais plano; também, os bebês imaturos que ainda não desenvolveram o reflexo de sucção; ou algumas iatrogenias decorridas do parto, como luxação de ombros, que produz dor no bebê pela posição e, consequentemente, faz com que não queira mamar. de forma geral, trata-se de qualquer alteração fisiológica que afete o recém-nascido na hora de mamar, o que pode alterar o seu desejo (3,13). algumas situações especiais, como baixo peso ao nascer e gemelaridade, demandam da equipe de saúde maior habilidade para o sucesso da amamentação (14,15). apesar de ser possível fazer com que toda mulher seja capaz de amamentar gêmeos exclusivamente, existem as dificuldades, o cansaço e a indisponibilidade da mulher. portanto, é imprescindível que as nutrizes de parto múltiplo tenham suporte adicional, pois requererá disponibilidade de tempo, uma grande dose de dedicação e muita organização e ajuda (2). categoria ii —características da mãe nesta categoria, os fatores associados ao desmame precoce foram: trabalho (33,3 %), escolaridade materna/paterna (15,4 %), renda familiar baixa (12,8 %), idade materna (10,2 %), tabagismo fonte: elaboração própria. categorias temáticas frequência n = 39 % manejo da lactação traumas mamilares e dor 7 17,9 horários rígidos (pré-determinados) para mamar 1 2,6 substitutos do leite materno outros tipos de leites 6 15,4 líquidos não nutritivos e outros alimentos (semissólidos e sólidos) 4 10,2 uso de mamadeira 2 5,1 orientação profissional falta de apoio na maternidade, falta de orientação sobre amamentação 2 5,1 recomendação médica 1 2,6 100 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 (7,7 %), tipo de parto (5,1 %), decisão materna (mãe não quer mais) (5,1 %), depressão (5,1 %), paridade (5,1 %), dificuldades para amamentar (5,1 %), não morar com companheiro ou pai fora de casa (5,1 %), indução do trabalho de parto (2,6 %), uso de medicamento (2,6 %), estética da mãe (2,6 %), estado civil (2,6 %), experiência da mãe (2,6 %), doença/hospitalização da mãe (2,6 %), posicionamento inadequado (2,6 %), consulta no pré-natal < 6 (2,6 %). o trabalho materno foi o fator que mais favoreceu o desmame precoce, pois as mulheres muitas vezes trabalham para ajudar nas despesas de casa e em outros casos assumem o papel de chefes de família. assim, por necessidade financeira, são conduzidas a trabalhar fora de casa e deixam de amamentar exclusivamente seus filhos (16,17). a capacidade de continuar amamentando no regresso do trabalho é multifatorial, já que as mulheres tentam equilibrar as demandas da família e do trabalho com a disponibilidade de cuidados com o lactente (18). dispor de espaços para a prática da amamentação no ambiente de trabalho é uma estratégia que contribui para sua maior duração (19). por outro lado, o fato de o empregador não conhecer as leis referentes à mulher que amamenta faz com que não proporcione às mães um local apropriado para ordenha, além de não lhes oferecer condições necessárias para a guarda do filho. esses são fatores que merecem atenção no que tange os direitos e deveres da trabalhadora (20). nas variáveis socioeconômicas, os níveis de escolaridade da mãe e do pai têm sido associados à prática da amamentação exclusiva. estudos demonstram que mães de maior escolaridade tiveram maiores frequências de amamentação exclusiva (21) e valorizam mais o ato de amamentar (22). bebês provenientes de famílias de baixa renda familiar (entre um e três salários mínimos) tiveram maior chance de interromper a amamentação exclusiva antes do terceiro mês. esse achado reveste-se de importância singular, na medida em que essas crianças são justamente as que estão mais expostas a outros fatores que aumentam a morbimortalidade infantil (23). categoria iii —mitos quanto à amamentação entre os fatores que influenciam no desmame precoce nessa categoria temos o uso de chupeta (35,9 %), leite fraco (17,9 %), leite insuficiente ou pouco (10,2 %), leite secou (5,1 %), choro do bebê (interpretado como fome) ou fome percebida (5,1 %). a chupeta tem sido frequentemente associada ao desmame precoce, pois se percebem manifestações de dificuldades das mães em lidar com o choro do bebê e a fome da criança, o que as leva à concepção de que a composição e a quantidade do leite são insatisfatórias às necessidades da criança. o choro associado à fome é sustentado pela cultura em decorrência dos problemas relacionados à produção/qualidade do leite (21,24). a inobservância da ejeção do leite e a manifestação de insatisfação da criança com o choro põe em dúvida a condição do leite materno e essas razões são utilizadas como justificativas para interromper a amamentação ou oferecer outros tipos de leite e alimentos (4,22). com relação ao leite fraco, insuficiente ou pouco, cabe destacar que a produção de leite materno pode diminuir quando: há a introdução da alimentação complementar com leite artificial, água ou chá, pois a criança vai perdendo o apetite; ocorre a introdução de chupetas e mamadeiras, o que proporciona uma sucção incorreta e implica em mamadas curtas e pouco frequentes e tem como resultado mamas cheias e ingurgitadas; ocorre pouca ingestão de líquidos e alimentação incorreta da mãe; nota-se despreparo da equipe de saúde em perceber posicionamento inadequado e pega incorreta; e todas essas questões podem levar ao desmame precoce (18,25). uma das justificativas utilizadas pelas nutrizes em diversas culturas para explicar o abandono da amamentação é o leite fraco, porém, do ponto de vista biológico, o leite materno é ideal e são pouco frequentes as intercorrências que inviabilizam a amamentação (26). categoria iv —manejo da lactação outro fator que influencia na amamentação são os traumas mamilares/dor (17,9 %) e os horários rigorosos para as mamadas (2,6 %). estudos apontam que cerca de 80 % a 96 % das puérperas apresentam dor até o décimo dia pós-parto (27,28). uma pesquisa realizada com profissionais de enfermagem apontou que a falta de informação e de conhecimento das mães sobre a amamentação contribui para o aparecimento de complicações como dor, trauma mamilar e medo devido aos relatos de dor (29). a dor durante a mamada interfere no reflexo de ejeção do leite e, em consequência, a criança não consegue mamar ade101 fatores que influenciam o desmame precoce l sandra cristina alvarenga e outros quadamente. isso gera na mãe sentimento de culpa e angústia, que, por sua vez, acaba por inibir a ejeção láctea, o que pode levar ao fracasso desse processo (30). os traumas mamilares/dor devem ser percebidos pela equipe de saúde como marcadores de dificuldades e podem ser evitados quando se adotam medidas profiláticas durante as consultas de pré-natal, momento em que há a oportunidade de promoção e incentivo à amamentação (31). categoria v —substitutos do leite materno (alimentação complementar) os principais fatores associados ao desmame precoce nessa categoria foram a introdução de outros tipos de leites (15,4 %), líquidos não nutritivos e outros alimentos (semissólidos e sólidos) (10,2 %) e o uso de mamadeira (2,6 %). entende-se por alimentação complementar qualquer introdução de alimentos líquidos ou sólidos, diferentes do leite materno, oferecidos ao lactente até o segundo semestre de vida. quando introduzida precocemente, antes dos seis meses de vida, sob o aspecto nutricional, pode ser nociva à saúde da criança e agir como fonte de contaminação, o que aumenta o risco de diarreia e outras doenças infecciosas. além disso, esses alimentos, às vezes, possuem aporte nutricional inferior ao leite materno e impedem a absorção de ferro e zinco. essa introdução precoce tem sido associada ao desenvolvimento de doenças atópicas, como a asma, e a amamentação exclusiva parece proteger contra o diabetes mellitus tipo i e a obesidade (32). a complementação do leite materno com líquidos não nutritivos como água e chás é desnecessária. no entanto, estudos revelam que essa é uma prática difundida culturalmente, pois as mães acreditam que os líquidos são necessários para a criança devido à sede e assim os adotam especialmente no verão com o intuito de prevenir a desidratação (33). uma pesquisa evidenciou que a convivência com a avó teve associação positiva com dar água ou infusões durante a amamentação (34). categoria vi —orientação profissional verificou-se que os seguintes fatores podem interferir negativamente na amamentação: não receber orientação sobre amamentação (5,1 %), falta de apoio na maternidade (5,1 %) e recomendação médica (2,6 %). um estudo constatou que os profissionais, em unidades básicas de saúde, desenvolvem apoio dúbio ou não apoiam a amamentação e nesses serviços as mulheres ainda estão expostas ao falatório relacionado ao tema, que representa o excesso de informação e o autoritarismo que o profissional de saúde tem com elas, com predomínio de impessoalidade, ou até mesmo a atenção igual para todas ou a ausência de atenção (35). com relação à assistência de enfermagem no puerpério imediato, uma pesquisa apontou que o incentivo à prática da amamentação exclusiva não foi satisfatório, uma vez que as mulheres participantes relataram que passaram por dificuldades, às vezes de fácil solução, mas como não houve apoio e incentivo, acabaram por abandonar a amamentação (31). orientações e aconselhamento no pré-natal e apoio no puerpério imediato, principalmente quando surgem problemas relacionados às mamas, e acompanhamento após a alta hospitalar são estratégias que promovem, protegem e apoiam a amamentação com eficiência. o profissional, além de competências, precisa ter a capacidade de comunicar-se eficientemente com a nutriz para apoiá-la na sua decisão pela amamentação (36). conclusão essa revisão sistemática possibilitou conhecer os fatores que influenciam o desmame precoce e os mais citados foram: trabalho materno (33,3 %); uso de chupeta (30,8 %); leite fraco (17,9 %); trauma e dor mamilar (17,9 %); introdução de outros tipos de leites (15,4 %) e escolaridade da mãe/pai (15,4 %). a síntese dos diferentes estudos evidenciou que a amamentação é um fenômeno que ultrapassa o simples desejo e decisão autônoma das mulheres/mães, pois exibe forte determinação sociocultural e histórica, que pode ser comprovada por meio de comparações de padrões de amamentação entre diferentes populações e através dos tempos. as taxas de desmame ainda são prevalentes e acredita-se que este estudo pode oferecer subsídios para o planejamento de ações que visem à atenção integral à saúde da mulher e da criança, tendo em vista que a atuação da equipe de saúde é essencial nessa área. a equipe deve atuar junto a essas mulheres desde o pré-natal para sensibilizar e informar acerca do valor da amamentação exclusiva até o sexto mês de vida. 102 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 além disso, espera-se que os resultados aqui apresentados venham contribuir para a prática assistencial da enfermagem e com o debate acerca dessa temática, de maneira que possibilite a ampliação do conhecimento e permita uma reflexão sobre as ações de promoção e apoio a amamentação. ainda, busca-se relembrar que os cuidados não devem ser fragmentados e sim realizados com foco em uma abordagem biopsicossocial e cultural, além da promoção da autonomia feminina e da garantia dos direitos. acredita-se que é preciso repensar a prática do cuidado, em busca da intersetorialidade e interdisciplinaridade, visando a redução nas taxas de desmame precoce. entre as limitações deste estudo podemos citar o acesso apenas a algumas bases de dados eletrônicas e a heterogeneidade metodológica dos estudos que não 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north terrace (austrália); 2009. 29. filho mds, neto pntg, martins mcc. avaliação dos problemas relacionados à amamentação a partir do olhar da enfermagem. cogitare enferm. 2011;16(1):70-5. 30. annagür a, annagür bb, sahin a, örs r, kara f. is maternal depressive symptomatology effective on success of exclusive breastfeeding during postpartum 6 weeks? breastfeed med. 2013;8(1):53-7. 31. batista kra, farias mcad, melo wsn. influência da assistência de enfermagem na prática da amamentação no puerpério imediato. saude debate. 2013;37(96):130-8. 32. brasil. ministério da saúde. secretaria de atenção à saúde. departamento de atenção básica. saúde da criança: aleitamento materno e alimentação. brasília: ministério da saúde, 2015. 33. souza nkt, medeiros mp, silva ms, cavalcanti sb, dias rs, valente fa. aspectos envolvidos na interrupção do aleitamento materno exclusivo. com cienc saude. 2011;22(4):231-8. 34. primo cc, dutra pr, lima efa, alvarenga sc, leite fmc. redes sociais que apoiam a mulher durante a amamentação. cogitare enferm [internet]. 2015 [acesso em: 20 fev 16];20(2):426-33. disponível em: http://dx.doi.org/10.5380/ ce.v20i2.37453 35. oliveira mic, souza ieo, santos em, camacho lab. avaliação do apoio recebido para amamentar: significados de mulheres usuárias de unidades básicas de saúde do estado do rio de janeiro. cienc saude colet. 2010;15(2):599-608. 36. primo cc, nunes bp, lima efa, leite fmc, pontes mb, brandão mag. which factors influence women in the decision to breastfeed? invest educ enferm. 2016;34(1):198-210. 271 275 primeras paginas.indd 275 editorial working at the edge of unknown knowledge trabajando al límite del conocimiento desconocido trabalhando ao limite do conhecimento desconhecido doi: 10.5294/aqui.2016.16.3.1 mune-deficiency syndrome (aids) was unknown. in 1985, when the human immunodeficiency retrovirus (hiv) was discovered, a cure was not readily available. it would take another year for a diagnostic test to be developed. then more years passed before medications to treat this disease were developed. from 1980 until about 1986, nurses and physicians who had no previous clinical experience with retrovirus illnesses had a duty to care for patients infected with hiv. all of us worked at the edge of unknown knowledge. these two historical examples show that when clinicians arrive at the edge of unknown knowledge, it is clear that something that needs to be known is not yet known. the clinical imperative to act remains. given these past models of unknown knowledge we can imagine future situations where there will be very little ‘known’ knowledge, and yet, there will be a duty to provide care. our graduate nursing students hope to hold a leadership or an advanced practice role when they graduate. they realize that solving very complex problems is expected when they hold such roles. my challenge to my students is to consider being the leader at the edge of unknown knowledge: how will they advise others to act where there is no ‘known’ knowledge? my answer is: with theoretical thinking they will be able to meet the clinical imperative to act and they will understand how to frame questions to engage in needed research. 1. oshinsky dm. polio: an american story. new york: oxford university press; 2005. whenever i teach the graduate level course in nursing theory, my students and i discuss why experienced, licensed, professional nurses will benefit from learning nursing theory very well. our conversation revolves around the idea that leaders are those professional people who often work at the edge of unknown knowledge. what is unknown knowledge? unknown knowledge is found whenever professional nurses encounter situations that have no pre-established answers at all. nurses know that they must act on behalf of their patients, but when they encounter a situation that is a mystery, they are at the edge of unknown knowledge. history gives many examples of times when there was a clinical imperative to do something, but there was not enough knowledge to act with certainty. one example of unknown knowledge was polio, which occurred in epidemics in the early twentieth century. the reasons for polio epidemics were not understood at that time. even today, polio cannot be cured, so prevention remains our best effort. the work of elizabeth kenny of australia, which was successful in preventing long-term paralysis, was rejected during her lifetime because neither kenny nor physicians could explain how or why her methods worked. although kenny succeeded clinically, her knowledge was so limited that she was discredited during her lifetime as a ‘quack’ and a fraud (1, p. 78). another example of when nurses worked at the edge of unknown knowledge was when the aids epidemic erupted in the early 1980s. for nearly five years (1980-1985) the cause of acquired im04. palabras saludo palabras de saludo al consejo directivo de acofaen 9 señor rector, álvaro mendoza ramírez; señora vicerrectora académica, liliana ospina de guerrero; colega leonor pardo novoa, decana de la facultad de enfermería; colegas decanas y directoras, integrantes del consejo: n nombre de la junta directiva de nuestra asociación, quiero expresar, en primer término, mi sentido agradecimiento a las directivas de la universidad de la sabana, a sus docentes, trabajadores/as y estudiantes, por la cálida y esmerada acogida que nos han dispensado. con mucho gusto y beneplácito hemos aceptado la invitación de la decana de enfermería, para desarrollar en este claustro un día de trabajo con nuestro consejo. es nuestro pequeño homenaje a los diez años de vida académica de la facultad de enfermería de la universidad de la sabana. ha transcurrido ya una década. una década de arduo trasegar y batallar. una década de realizaciones y satisfacciones. una década que recoge no solo la historia de una institución, sino la historia de vida de un grupo de mujeres decididas a ampliar coberturas y mantener en alto el nombre de una profesión que se ha cimentado en el poder de lucha y en la capacidad para trascender en el concierto de las demás profesiones. esta facultad de enfermería, liderada por nuestra querida leonor y con el compromiso de más de 20 colegas, ha emprendido el reto de construir una propuesta académica a la luz de una de las teorías propias de la enfermería: el modelo de adaptación de sister callista roy, caso excepcional en el concierto de nuestras facultades. esto les permite, de manera coherente, preparar un profesional con excelentes capacidades, para ofrecer un cuidado armónico a la persona en su núcleo familiar, laboral y social. además de iniciar prácticas de cuidado desde el primer semestre, varias de sus maría nubia romero * * mayo, 2001. año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 10 docentes son enfermeras asistenciales de los campos de práctica, lo que da vida a la relación docente/asistencial. nuestras colegas de esta universidad, que conservan un espíritu de trabajo amplio y abierto a las perspectivas nacionales e internacionales, mantienen, en calidad de asesoras, un grupo de ocho enfermeras con alto prestigio académico y profesional, entre las cuales se encuentran maricel manfredi, myriam ovalle, maría mercedes durán de villalobos y nelly garzón. esta figura también es un toque de personalidad de la facultad, digno de imitar por las bondades de interlocución que ofrece el compartir saberes y prácticas con colegas de amplia trayectoria. de manera especial, quiero destacar el hecho de que, desde sus primeros pasos, esta facultad de enfermería, que hoy festejamos, ha estado vinculada activamente a acofaen. y es que la experiencia de trabajo de nuestras colegas aquí nos ayuda a visualizar la importancia y lo fructífero del trabajo colectivo enraizado en organizaciones académicas como nuestra asociación. es claro que los avances y desarrollos de las facultades nuevas no se producen solo gracias al apoyo de las instituciones, apoyo fundamental para que puedan ser y crecer, por supuesto, sino también al arraigo en un colectivo de trabajo como es acofaen, expresión fiel de comunidad académica organizada. todas las experiencias académicas que recogemos en nuestras reuniones de consejos nos hablan del sentido de comunidad académica que construimos día a día en cada rincón de nuestra colombia. comunidad académica es la que construimos en el acto de analizar, evaluar y proponer desarrollos colectivos de la profesión, en el marco de la construcción disciplinar; es ese hacer seguimiento conjunto de los procesos; es retroalimentarnos con la crítica; es proyectarnos con nuevas acciones y propuestas; es aportar al análisis político y social de los proyectos de ley; es defender el espacio disciplinar construyendo argumentos y conceptos a partir de la investigación seria, rigurosa y sistemática; es construir colectivamente nuevas miradas a la compleja tarea de cuidar la vida en medio del fuego cruzado, de las situaciones dolorosas y antiéticas en que el mundo de hoy se mueve y con el cual tenemos responsabilidades históricas. todas y cada una de estas acciones, que hacen comunidad académica, contribuyen a resignificar y dar sentido a la academia que desarrollamos día a día en nuestros respectivos claustros, y también han de contribuir a esclarecer el sentido de calidad de la educación que hemos de entregar a la sociedad. por tal razón nos hemos convocado en esta 45 reunión, con una agenda que centra, continúa o reinicia la discusión sobre el tema de “calidad y autorregulación de la profesión”, desde donde buscamos cohesionarnos en la diferencia, porque no pretendemos uniformarnos ideológica y profesionalmente, sino buscamos consensos para la acción individual y colectiva, en armonía con el devenir del cual somos responsables por ser sujetos constructores de historia. por ello, señor rector, señora vicerrectora académica y demás directivas de la universidad, apreciadas colegas docentes de esta unidad académica, trabajadores y trabajadoras, reciban de la junta directiva, del consejo de decanas en pleno, de la directora ejecutiva y de la asistente de presidencia de acofaen, un efusivo abrazo de felicitación. que los éxitos obtenidos en este proyecto institucional y de vida de cada uno de ustedes sigan por el camino del avance, que la buenaventura los siga acompañando. mis parabienes para leíto, maría clara, maría eulalia, martha yolanda, maría del carmen, leticia, beatriz, lucía (mi profesora), ángela, margaritas, maría cristina, clara, elizabeth, blanca cecilia, gloria patricia y maría elisa, docentes de esta facultad. hoy trabajaremos bajo el calor humano de la universidad de la sabana, y mañana lo haremos en la fundación universitaria de ciencias de la salud, en donde nos regocijaremos de los 25 años de vida académica de su programa de enfermería. finalmente, con mi fraterno saludo de bienvenida a todas las integrantes del consejo de decanas de acofaen, declaro inaugurada esta cuadragesimaquinta reunión. todas las experiencias académicas que recogemos en nuestras reuniones de consejos nos hablan del sentido de comunidad académica que construimos día a día en cada rincón de nuestra colombia. 390 400 the biopsychosocial sphere.indd 390 fagner pereira-da silva1 fabio alexandre pereira-de oliveira2 samara varela3 regiane aparecida batista4 luciene rodrigues-barbosa5 the biopsychosocial sphere of women victims of violence: a systematic review 1 orcid.org/0000-0002-6453-2407. faculdade anhanguera de guarulhos. brazil. fagpsilva@haoc.com.br 2 orcid.org/0000-0001-5083-807x. faculdade anhanguera de guarulhos. brazil. fabiodeoliveira.binho@aedu.com 3 orcid.org/0000-0002-1049-9226. faculdade anhanguera de guarulhos. brazil. samara.varela@aedu.com 4 orcid.org/0000-0002-2657-0058. faculdade anhanguera de guarulhos. brazil. regiane.batista@aedu.com 5 orcid.org/0000-0002-8065-8210. faculdade anhanguera de guarulhos. brazil. lucienebarbosa@anhanguera.com recibido: 18 de enero de 2016 enviado a pares: 30 de enero de 2016 aceptado por pares: 04 de noviembre de 2016 aprobado: 03 de marzo de 2017 doi: 10.5294/aqui.2017.17.4.3 para citar este artículo / to reference this article / para citar este artigo pereira-da silva f, pereira-de oliveira fa, varela s, batista ra, rodrigues-barbosa l. the biopsychosocial sphere of women victims of violence: a systematic review. 2017; 17(4): 390-400. doi: 10.5294/aqui.2017.17.4.3 abstract objective: identify the contribution of developed research to a biopsychosocial sphere of women victims of violence and the meaning attributed to these experiences in their lives. method: an integrative review conducted in medline/pubmed and lilacs databases, covering the years from 2009 to 2015. results: we selected and analyzed 18 studies with the selection criteria being the reasons given by women for remaining with a violent partner, the reasons for not seeking help to break the cycle of violence, or the meaning attributed to this experience in their lives, including the social, religious, ethical and moral meaning, as well as the suffering derived from the experience. discussion: interventions at health institutions allow for the development of strategies for coping with this issue. a complaint lodged by the wife against her attacker demonstrates an early break in the cycle of violence. conclusion: the results evidence aspects that can help to improve the quality of health among these women and show the importance of research to support practices in caring for women who are victims of violence. keywords violence against women; intimate partner violence domestic violence; nursing care; social representation (source: decs, bireme). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 390-400 391 the biopsychosocial sphere of women victims of violence: a systematic review l fagner pereira-da silva and others año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 390-400 la esfera biopsicosocial de las mujeres víctimas de la violencia: una revisión sistemática resumen objetivo: identificar la contribución de la investigación desarrollada a una esfera biopsicosocial de mujeres víctimas de violencia y el significado atribuido a estas experiencias en sus vidas. método: revisión integradora realizada en los bases de datos medline / pubmed y lilacs, que cubre los años de 2009 a 2015. resultados: se seleccionaron y analizaron 18 estudios, con los criterios de selección siendo las razones dadas por las mujeres para permanecer con un compañero violento, las razones para no buscar ayuda para romper el ciclo de violencia o el significado atribuido a esta experiencia en sus vidas, incluyendo el significado religioso, ético y moral, así como el sufrimiento derivado de la experiencia. discusión: las intervenciones llevadas a cabo en las instituciones de salud permiten el desarrollo de estratificaciones para hacer frente a este problema. una denuncia presentada por una esposa contra su atacante demuestra una ruptura temprana en el ciclo de violencia. conclusión: los resultados evidencian aspectos que pueden ayudar a mejorar la calidad de la salud de estas mujeres y muestran la importancia de la investigación para apoyar las prácticas en el cuidado de las mujeres víctimas de la violencia. palabras clave violencia contra la mujer; violencia de pareja; violencia doméstica; cuidado de enfermería; representación social (fuente: decs, bireme). 392 aquichan issn 1657-5997 eissn 2027-5374 a esfera biopsicossocial de mulheres vítimas de violência: uma revisão sistemática resumo objetivo: identificar a contribuição de pesquisas desenvolvidas na esfera biopsicossocial de mulheres vítimas de violência e o significado atribuído a essas experiências em suas vidas. materiais e método: revisão integrativa conduzida nas bases de dados medline/ pubmed e lilacs, abrangendo os anos desde 2009 até 2015. resultados: selecionamos e analisamos 18 trabalhos com os critérios de seleção: os motivos dados pelas mulheres para ficar com um parceiro violento, os motivos por não procurarem ajuda para quebrar o ciclo de violência ou o significado atribuído a essa experiência em suas vidas, incluindo o significado social, religioso, ético e moral, como também o sofrimento derivado da experiência. discussão: intervenções em instituições de saúde permitem o desenvolvimento de estratégias para lidar com esse assunto. a denúncia da esposa contra seu atacante demonstra uma quebra precoce no ciclo de violência. conclusões: os resultados evidenciam aspectos que podem ajudar a melhorar a qualidade da saúde de mulheres que são vítimas de violência e mostrar a importância da pesquisa para apoiar práticas de cuidados para elas. palavras-chave cuidado de enfermagem; representação social; violência contra as mulheres; violência doméstica; violência provocada por parceiro íntimo (fonte: decs, bireme). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 390-400 393 the biopsychosocial sphere of women victims of violence: a systematic review l fagner pereira-da silva and others introduction violence is understood by the world health organization as the intentional use of physical force or power, real or threatened, against oneself, against another person, or against a group or community that either results in or has a possibility of resulting in injury, death, psychological harm, developmental disability or deprivation (1). nowadays, violence against women is a target of concern for public health in brazil and worldwide (2, 3), since many are victims of violence within the family and, in most situations, that violence is perpetrated by someone they live with every day (2, 4, 5). the number of cases involving women who are victims of aggression but fail to take any decision due to fear and/or lack of information is significant (5). this problem tends to affect the nuclear family and causes a disruption in its organization (6, 7). according to one study, 1.5 to 5.3 million women per year report having been physically or sexually victimized by their male partners at some time in their life (8). the so-called “maria da penha” law, enacted in 2006 in brazil, defines physical violence as any action that jeopardizes a woman’s integrity or physical health, being characterized as any action, omission or suffering of a sexual, physical, psychological and bodily, property or moral nature that occurs within the family or home. the same law defines moral violence as an action that involves injury, defamation or libel. it defines psychological violence as any action that causes emotional damage or decreased self-esteem and well-being. finally, it defines sexual violence as any action that causes embarrassment and the performance of sexual intercourse without consent or through coercion and/or physical strength (9). domestic violence has been the subject of many studies around the world, both for its various forms of expression and for the consequences for those involved. it is regarded as a transgenerational and interactional phenomenon (10). following a study conducted by the pan american health organization in collaboration with the us centers for disease control (cdc), a report was produced that highlights sexual violence against women as being widespread throughout latin america and the caribbean, which is where the survey data was collected. it is noteworthy that between 17% and 53% of the women interviewed reported having suffered physical or sexual violence perpetrated by an intimate partner (11). the intervention of health services plays a fundamental role for women in situations of violence and ensures their human rights, given that most of these victims have contact with some type of health service at some point, even for reasons other than those related to aggression. this contact is necessary to identify violence and requires maximum attention from health professionals (12). one study found that a significant number of health professionals believe issues related to violence are closely linked to the field of justice and security, and they are fearful of getting involved with issues or even calls of this nature (13). it is also observed that some health professionals who provide assistance to victims of violence are not adequately prepared for this type of care and experience a psychic discomfort due to the feelings of powerlessness and frustration that are generated during such care (14). thus, in order to subsidize the reflection on violence suffered by women, we decided to conduct this study aimed at identifying the contribution of developed research to a biopsychosocial sphere of women victims of violence and the meaning attributed to these experiences in their lives. method an exploratory study was done, featuring a systematic review conducted through a critical analysis of the articles. a rigorous review was planned to summarize original research, highlighting the relevant research questions. a clear method was used to identify, select, describe the quality, collect data and analyze the studies. the research began by asking a guiding question: “what literature has brought about social representations of women victims of violence?” national and international databases were used to search and select the articles: lilacs (latin american center and information caribbean health sciences) and pubmed (public medline). these articles were published between the year 2009 and june 2015. 394 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 instrument for a systematic review the methodological tool used in the evaluation of scientific papers was prisma (15). it was used for the systematic review, so as to ensure quality and make this type of study clear (16). identification and classification inclusion and exclusion criteria were established to select the articles. these criteria certify the accuracy and reliability of the study. eligibility the selection was determined by reading the articles obtained by two reviewers, who performed a rigorous analysis based on pre-established inclusion criteria (table 1). table 1. literary style search results the selection of articles in the first filter turned up 66 in lilacs (latin american center and information caribbean health sciences), 42 in pubmed (public medline), and 74 in medline (medical literature analysis and retrieval system online). articles that do not fit the theme, are not available full, and are outside the established publication period were excluded. in all, there were 164. after reading and analyzing the articles, 18 remained (figure 1). figure 1. flowchart of articles selected for analysis literary search selection for inclusion based on the title lilacs, medline/ pubmed • violence • woman • nursing • denunciation of violence selection criteria • published between 2009 and june 2017 • in english • mesh and decs: nursing care, violence against women and gender violence selection for inclusion based on abstract and stage and eligibility inclusion: • explanation of articles relating to violence against women • available in full and free of charge • related to the study goals exclusion: • incomplete articles • outside of the established publication year • opinion articles, letters to the editor and dissertations source: own elaboration. source: own elaboration. an analysis of the 19 selected studies showed that four of them used a quantitative approach, thirteen used a qualitative approach, and one study used a quantitative/qualitative approach. among the studies with a qualitative approach, one used the phenomenological theoretical framework developed by alfred schütz. the most frequent descriptors were: domestic violence/ violence against women/intimate partner violence/women’s health. as for data collection, semi-structured questionnaires were used in nine studies and structured interviews in three. there were two focus groups, while two studies used the conflict 395 the biopsychosocial sphere of women victims of violence: a systematic review l fagner pereira-da silva and others tactics scale and the multi-country study on women’s health and life experiences questionnaire, both of which are validated instruments. one study based data collection on an interview. in terms of age groups, the respondents were between 15 and 72 years old. six of the studies addressed only domestic violence; five addressed domestic violence; four dealt with physical and psychological violence, and three focused on sexual violence. table 2 shows some of the data analyzed. as to the objectives set out by the authors of the selected studies, one of the prime ones is the concern to seek scientific answers to everyday issues that permeate the difficulty and the current challenges in health to serving these women. thus, some studies have sought to identify what motivates women to not report their abusers, with a focus on different angles; namely, through a reflection on the biopsychosocial aspects involved, the context in which cases of violence occur, the reasons that lead women to file a complaint, and even the perceptions of health professionals who serve these women. the results of this review were classified into two categories: meanings of the experience of violence endured by women and reasons to break the cycle of violence. meanings of the experience of violence endured by women: out of the 18 studies selected for this review, twelve contemplated the question of the meaning of the experience of violence endured by women, whether in the household or in the care of a health service (12, 17). feelings of uncertainty, fear and submission were noted, and some women reported increased anxiety, insecurity, a greater number of nightmares, and feelings of panic (18). violence against women is felt by them as cultural privatization and symbolic; one laid the blame on those who fail to do anything. other no less worrying feelings, though on a smaller scale, also involved socio-political and health actions, namely: anger, pain, shame, feelings of anguish and abandonment, low self-esteem, helplessness, grief, desire to break off the relationship with the partner, depression, sadness, loneliness, and suicidal thoughts, among others (5, 7). to be treated at the hospital has added a sense of embarrassment to the problem these women face, a feeling of discomfort at needing to present their case (17). the denial and lack of comprehensive care perceived by women are often the result of professionals who are unprepared to deal with their own values and beliefs on the subject. this can trigger many feelings that will reflect on or impact the meaning women who have been raped will give to this experience. the service providedinvolves technicalities that prevent a humanized approach, specifically one that seeks sensitive listening and a dialogue between user and professional in search of a close relationship to establish trust for adequate care (14-21). recognition of disorganization in customer service is evidenced as one of the impediments to developing the provision of assistance, as was the difficulty in identifying and treating the silence victims displayed during consultation, so as to confirm suspicions of violence (13) . reasons related to perpetuation or a break in the cycle of violence. the most cited are socioeconomic factors (unemployment or fear of losing their jobs); domestic violence (sexual, physical and psychological coercion perpetrated by intimate partners and family); the difficulty in accessing services to file a complaint; fear of death; fear of the family or fear of disappointing the family; and the desire not to abandon the children and their home. in relation to breaking the cycle of violence, the women identified despair at changes in the offender’s behavior; a desire for freedom and control of one’s own life; and a yearning for a definitive separation from their companion, among other less cited reasons. when asked about the forms of psychological aggression suffered, the most cited were: insults, verbal threats and intimidating looks, and external communication deprivation, either through verbal or electronic means (3, 5, 22). psychological abuse was identified as a factor triggering physical aggression, because it usually is the primary act of an individual who intends to offend a woman. in terms of physical violence, types of aggression such as slaps, kicks and jerks, intentional burns, use of a weapon or fire and property damage are the most common means adopted by the aggressor (3, 5). there are also sexual violence situations where the woman is forced to have sex with her partner against her will or to perform unconventional sex acts (5, 22, 23). 396 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 table 2. description of the studies included in the review for analysis references aims theoretical reference subjects instrument for data collection nascimento et al. (13) identify perceptions and practices among health professionals in angola concerning intimate partner violence against women. qualitative/crosssectional study 13 professionals at three hospitals semi-structured questionnaire gomes & erdmann (12) construct a theoretical matrix based on the meanings of interaction and action experienced by professionals regarding nursing care practices and the health of women in situations of conjugal violence, all within the ambit of the family health strategy. qualitative/crosssectional study 52 professionals working in family health teams semi-structured questionnaire leitão (2) understand the trajectories that women go through between entering and leaving relationships, in terms of intimate partner violence (ipv), and identify the stages of the transition process. qualitative/crosssectional study 28 women ages 23–62 semi-structured questionnaire costa & lopes (19) identify and analyze the practice of health care professionals regarding rural women who are victims of violence, doing so from the perspective of comprehensive care in in cities located in southern rio grande do sul state. qualitative/crosssectional study 43 women providing services to women victims of violence semi-structured questionnaire trigueiro & labronici (20) identify risk factors that trigger domestic violence. qualitative/crosssectional study 8 women victims of domestic violence semi-structured questionnaire netto et al. (21) analyze the consequences of intimate partner violence, from the perspective of women, as an intervention proposal for nurses in health care. qualitative/crosssectional study 16 women who reported violence on the part of a companion semi-structured questionnaire silva et al. (22) analyze limiting and potentializing situations during the assistance provided by family health teams to women in situations of violence. qualitative/crosssectional study 13 women who reported companion violence semi-structured questionnaire vieira et al. (23) understand the “motives” of the woman who takes action to denounce her situation of violence. qualitative/crosssectional study 11 women victims of conjugal violence semi-structured questionnaire gomes et al. (24) describe, based on the representations of women with a history of undergoing conjugal violence, the elements that constitute the social support network for confronting this health problem. qualitative/crosssectional study 13 women who reported partner violence to police at the station interview svavarsdottir & orlygsdottir (14) identify the incidence of violence against women seeking healthcare services and evaluate the use of clinical guidelines to identify interpersonal violence. quantitative/crosssectional study 14 nursing professional, 10 midwives and 208 women semi-structured questionnaire viviescasvargas et al. (25) estimate the effective coverage of primary health care services in the management of domestic violence against women in three mexican cities. qualitative/crosssectional study 545 women ages 18–70 conflict tactics scale nasrabadi et al. (3) estimate the prevalence of any violence against women referring to health centers and explore the factors associated with risk of violence in ahvaz, iran. quantitative/crosssectional study 68 married women aged 15–55 years structured questionnaire taherkhani et al (17) understand the experience of iranian victims of intimate partner violence. qualitative / crosssectional study 11 married women ages 22–72 semi-structured questionnaire hajian (5) estimate the prevalence of physical and mental violence perpetrated by men against their intimate partners and assess the factors associated with partner violence among women in shroud in the northeastern region of iran in 2010. quantitative / crosssectional study 600 married women structured questionnaire semagegn et al. (26) determine the magnitude of domestic violence and identify its predictors among married women of reproductive age in northwestern ethiopia. qualitative/crosssectional study 682 married women focus group 397 the biopsychosocial sphere of women victims of violence: a systematic review l fagner pereira-da silva and others references aims theoretical reference subjects instrument for data collection ali et al. (27) explore women’s percep-tions of the consequences of violence, its adverse effects on health, and how women resist violence within marital life in urban pakistan. qualitative/crosssectional study 28 women focus group guruge et al. (18) examine women’s experience with violence throughout their lives and the presence of physical and mental health symptoms in a sample of iranian and sri lankan tamil immigrants and refugee women in canada. quantitative/crosssectional study 60 women structured questionnaire ali et al. (28) investigate the prevalence of physical and sexual violence and psychological abuse perpetrated by husbands against their wives, and any associated sociodemographic risk factors. quantitative/crosssectional study 759 married women ages 25-60 multi-country study on women’s health and life experiences questionnaire netto et al. (25) analyze social networks and types of support for women in situations of violence perpetrated by an intimate partner. qualitative and analytical research 20 women who experienced partner violence a semi-structured and individual instrument was used. source: own elaboration. the submission that many women adopt for cultural reasons is also identified as a triggering factor in the perpetuation of violence (26). most women omit the violence suffered because there is the hope the abuser’s feelings will prevail, thereby overcoming the situation, and the apologies and promises he made will be genuine (2). this mutes the problem and results in a situation where the relationship is maintained, all of which complicates making a decision. in an effort to break this situation, some women report their attacker, demonstrating an attitude of non-compliance with the isolated or successive acts of violence they have suffered. the complaint is characterized as a way to disclose their rejection of a situation that has become progressively unsustainable (26). the review showed evidence that the school has no direct relationship to violence. however, it did show that women living in situations of violence while unmarried tend to continue being abused even after being married. what changes in this condition is the aggressor. discussion there was a consensus among the authors of the study that the production of scientific knowledge on the subject of violence against women represents a guiding principle for health policy by applying science to the concerns of those who use health services and await humanized action in this universe of biopsychosocial needs. when observing the list of feelings triggered in women who are victims of violence, one sees a gap in the image created by common thinking in the sense that women who are caught in this cycle are devoid of feelings and are happy to live this way. anger and anguish, which appeared in five studies (3, 5, 7, 29), imply that living in these conditions requires attention to a woman’s emotional state, which is commonly overlooked. it is known that most of them neglect to get the health care they require, which means the act and the aggressor end up being subdued and the woman’s real needs are neglected. this silence on the part of the victim must be respected as a need to understand what has occurred and the need for emotional reorganization. however, it should not blind the health professional into believing the woman wanted to be raped. the definition given by women with respect to violence as being “an experience permeated by great humiliation” reinforces this as a public health problem that requires important action, starting with the way women are treated when seeking services (13). the denial and lack of comprehensive care that often occur at the hands of unprepared professionals who do not know how to deal with their own values and beliefs on the subject can trigger many feelings that will have an impact on the meaning the raped woman will give this experience, especially when the situation at the local hospital is uncomfortable and embarrassing (25). this 398 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 leads to anger, pain, shame and feelings of anguish and abandonment, among others. services provided in a highly technical way prevent a humanized approach, which seeks sensitive listening and a dialogue between the user and the professional in search of a closer relationship that results in trust for adequate care (6, 19). empowering women victims of violence by their silence shows a lack of understanding of the conditions concerning their right to free will. the reception they receive in dimensional spheres has proven to be quite effective, since it is extremely important that a woman who is a victim of violence feels welcomed and understood in the face of her traumatic experience. it is necessary to create a relationship between the professional and the patient in order to discover other possible forms of violence experienced. it is noticeably easier to approach these women when trust is established (24). recognition of disorganization in customer service is evidenced as one of the impediments to providing assistance, as is the difficulty in identifying and treating the silence displayed by victims during the consultation, which requires further evaluation to confirm any suspicion (13). the use of counseling, and the implementation of strategies and prevention for these abused women guarantees better care, thus allowing their quality of life to benefit. it is possible to emphasize that women who suffer physical or verbal violence feel the need to expose their feelings and it is in this context that health professionals should seek improvements in the way these victims are received (1). it is essential that these professionals use caution, not only when observing the complaints presented by the patient, but also in terms of detecting the signs and symptoms displayed during the service that is provided (6, 19). as the initial treatment afforded to these victims commonly occurs in primary care services, these are clearly potential, local instances for identifying cases of violence, especially of the domestic variety, because women suffering from this type of violence seek health services more often (29). the nurse needs to provide holistic care in order to support a woman who is a victim of aggression. this implies knowing how to deal with the patient and, after reception, trying to understand what has happened to her. the woman should be advised to denounce her aggressor or to seek help from institutions that also deal with women who have experienced or gone through situations like the one she has endured (13). activities such as group meetings where women have an opportunity to report their experiences and to share their stories can be used as a time to rethink solutions to their problems. they also offer an opportunity to start a new life in society (24). conclusion the violence women routinely face disrupts their biopsychosocial appearance and has consequences that last for a long time. the results obtained in this study reveal the indispensability of hosting, support, empathy, professional training for multidisciplinary teams or individual professionals, and a willingness to help women who are affected by violence, regardless of how that assistance is rendered or of the form it takes. understanding the biopsychosocial aspects of abused women has yet to receive much attention from researchers, but was explored to some degree during the search for articles for this review. this study shows the fragility of the assistance being provided to women who are victims of violence. the analysis of the studies selected here demonstrates that not all health professionals who are confronted with these situations are prepared to approach them correctly or know how to direct these victims towards the most appropriate form of behavior in response to violence. the need to expand the knowledge of health professionals who work directly with these situations is a point to be considered. there is also the need to understand the magnitude of the difficulty of breaking this cycle of violence and the socio-demographic situations in which women are inserted that have a direct effect on their choices. 399 the biopsychosocial sphere of women victims of violence: a systematic review l fagner pereira-da silva and others references 1. krug eg et al., eds. world report on violence and health. geneva, world health organization, 2002. 2. leitão mndc. women survivors of intimate partner violence: the difficult transition to independence. rev esc enferm usp. 2014;48:7-15. 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[cited 2015 jun 21]. available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=s0080-62342013000400781&ln g=es&nrm=iso&tlng=en 26. semahegn a, belachew t, abdulahi m. domestic violence and its predictors among married women in reproductive age in fagitalekoma woreda, awi zone, amhara regional state, north western ethiopia. reprod health. 2013;10:63. [cited 2015 jun 21]. available from: /pmc/articles/pmc3879008/?report=abstract 27. ali ts, krantz g, mogren i. violence permeating daily life: a qualitative study investigating perspectives on violence among women in karachi, pakistan. int j womens health. 2012;4:577-85. 28. ali ts, asad n, mogren i, krantz g. intimate partner violence in urban pakistan: prevalence, frequency, and risk factors. int j womens health. 2011;3:105-15. 29. okabe i, fonseca rmgs da. woman abuse: contributions and shortcomings of the information system. rev da esc enferm. 2009;43(2):453-8. 381 392 validez y confiabilidad del instrumento.indd 381 oscar javier gonzález-hernández1 validez y confi abilidad del instrumento “percepción de comportamientos de cuidado humanizado de enfermería pche 3ª versión” 1 magíster en enfermería con énfasis en cuidado al paciente crónico, universidad de ciencias aplicadas y ambientales (udca), colombia. o_ragazzo@hotmail.com recibido: 19 de noviembre de 2014 enviado a evaluadores: 25 de noviembre de 2014 aceptado por evaluadores: 10 de julio de 2015 aprobado: 13 de julio de 2015 doi: 10.5294/aqui.2015.15.3.6 para citar este artículo / to reference this article / para citar este artigo gonzález-hernández oj. validez y confiabilidad del instrumento “percepción de comportamientos de cuidado humanizado de enfermería 3ª versión”. aquichan. 2015;15(3): 381-392. doi: 10.5294/aqui.2015.15.3.6 resumen objetivo: determinar la validez y confiabilidad del instrumento “percepción de comportamientos de cuidado humanizado de enfermería (pche) 3ª versión”. método: estudio descriptivo de tipo metodológico que hizo pruebas psicométricas al instrumento pche, que evalúa las características de la atención de enfermería en escenarios hospitalarios. el instrumento se revisó con la participación de 320 pacientes hospitalizados, y se realizaron mediciones de validez y confiabilidad mediante la valoración de la consistencia interna. resultados: se obtuvo un índice de acuerdo de 0,92 y un índice de validez de contenido de 0,98 por el grupo de expertos. en el análisis factorial, se obtuvo una prueba de kmo de 0,956 y una prueba de esfericidad de bartlett de 0,0; estos indicadores permitieron calcular las cargas factoriales y así determinar estadísticamente el constructo del instrumento que llevó a definir teóricamente tres dimensiones: cualidades del hacer de enfermería, apertura a la comunicación enfermera(o)-paciente y disposición para la atención. conclusiones: el instrumento “percepción de comportamientos de cuidado humanizado de enfermería 3ª versión” es válido y confiable para su aplicación en ámbitos hospitalarios. palabras clave validez de las pruebas, confiabilidad, percepción, comportamiento, humanización de la atención (fuente: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 381-392 382 aquichan issn 1657-5997 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 381-392 validity and reliability of “perception of behavior related to humanized nursing care (pche), 3rd version” abstract objective: the purpose of this study was to determine the validity and reliability of the third version of "perception of behavior related to humanized nursing care” (pche: spanish acronym). method: this is a descriptive methodological study that included psychometric texts of the pche as an instrument to evaluate the characteristics of nursing care provided in hospital settings. the instrument was reviewed with the participation of 320 hospitalized patients, and validity and reliability were measured through an assessment of internal consistency. results: an agreement index of 0.92 and a content validity index of 0.98 were obtained by the group of experts. in the factor analysis, 0.956 was obtained for the kmo index and 0.0 on bartlett’s sphericity test. these indicators made it possible to calculate the factor loadings and, therefore, to determine statistically the construct of the instrument, which led to defining three dimensions hypothetically: qualities of nursing, openness to nurse-patient communication, and willingness to provide care. conclusions: the third version of "perception of behavior related to humanized nursing care” is a valid and reliable instrument for use in hospital settings. keywords test validity, reliability, perception, behavior, humanization of care (sourcte: decs, bireme). 383 validez y confiabilidad del instrumento “percepción de comportamientos de cuidado humanizado de enfermería pche 3ª versión” l oscar javier gonzález-hernández validade e confiabilidade do instrumento “percepção de comportamentos de cuidado humanizado de enfermagem 3ª versão” resumo objetivo: determinar a validade e a confiabilidade do instrumento “percepção de comportamentos de cuidado humanizado de enfermagem (pche) 3ª versão”. método: estudo descritivo de tipo metodológico realizou provas psicométricas no instrumento pche, que avalia as características da atenção de enfermagem em cenários hospitalares. o instrumento foi revisado com a participação de 320 pacientes hospitalizados e foram realizadas medições de validade e confiabilidade mediante a valoração da consistência interna. resultados: obteve-se um índice de acordo de 0,92 e um índice de validade de conteúdo de 0,98 pelo grupo de especialistas. na análise fatorial, obteve-se uma prova de kmo de 0,956 e uma prova de esfericidade de bartlett de 0,0; esses indicadores permitiram calcular as cargas fatoriais e, assim, determinar estatisticamente o constructo do instrumento que levou a definir teoricamente três dimensões: qualidades do fazer de enfermagem, abertura à comunicação enfermeiro(a)-paciente e disposição para a atenção. conclusões: o instrumento de “percepção de comportamentos de cuidado humanizado de enfermagem 3ª versão” é válido e confiável para sua aplicação em âmbitos hospitalares. palavras-chave validade das provas, confiabilidade, percepção, comportamento, humanização da atenção (fonte: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 381-392 384 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 introducción la enfermería, desde su inicio, ha tenido permanente interés por la humanización, manteniendo un claro deseo de buscar nuevas fuentes rejuvenecedoras que amplíen las posibilidades de satisfacer las necesidades de cuidado de la persona. “en tal sentido, es importante que el profesional de enfermería muestre un alto sentido de compromiso, lealtad, valores y humanismo en la aplicación del cuidado a todo ser humano que así lo requiera” (1). asimismo, la esencia de la profesión de enfermería es el cuidado que, en sí, es un acto profundamente humano; cuidar implica entretejer una relación amorosa con la realidad y con cada ser de la creación. es investir de corazón, afecto y subjetividad a esta sensibilidad. las cosas son más que cosas que podemos usar, son valores que podemos apreciar, símbolos que podemos descifrar. cuidar significa implicarse con las personas y las cosas, darles atención, colocarse junto a ellas, sentirlas dentro del corazón, entrar en comunión con ellas, valorizarlas y comprenderlas en su interioridad. todo lo que cuidamos es lo que amamos. y todo lo que amamos lo cuidamos. por el hecho de ligarnos afectivamente con las personas y las cosas nos preocupamos y sentimos responsabilidad por ellas (2). en este sentido, es importante propiciar el análisis y el actuar entre los profesionales de la salud sobre la humanización de la atención y su relación cotidiana durante el proceso de atención. según escudero, citado por barbero (3), la humanización no es algo que suceda de manera espontánea, sino que debe ser fomentada, aprendida y practicada. además, como reflexiona hernández, citado por barbero (3), “solo un ser humano es capaz de reconocer la dignidad del otro y respetar sus derechos, asumiendo en consecuencia el deber ético de asistirlo, cuidarlo, consolarlo y acompañarlo en su fragilidad”. se puede afirmar, entonces, que la humanización se opone a la violencia y que esta reorganiza las relaciones de trabajo, los comportamientos (4). es así, que la humanización ha hecho realmente un cambio en las prácticas de salud, y ha llevado a que las organizaciones opten por el mejoramiento continuo del sistema de gestión. por tal razón, el tema de la vulneración y violación de los derechos de los pacientes en un contexto hospitalario ha llamado la atención de enfermería para detenerse a analizar este aspecto que impacta de manera negativa la posibilidad de brindar un buen cuidado (5). al respecto, ceballos señala que watson, en 2009, remarcó la importancia de centrar la mirada hacia este componente de la atención y dice: ante el riesgo de deshumanización en el cuidado del paciente, a causa de la gran reestructuración administrativa de la mayoría de los sistemas del cuidado de salud en el mundo, se hace necesario el rescate del aspecto humano, espiritual y transpersonal, en la práctica clínica, administrativa, educativa y de investigación por parte de los profesionales de enfermería (6). frente a este componente, se plantea otra situación: en la práctica somos profesionales preparados para rechazar el fracaso, cumplimos estándares, procedimientos, pero aún no tenemos una norma, o mejor, protocolos de enfermería, que indiquen cómo debemos actuar en la dimensión del cuidado sensible; en la atención de las demandas de cuidados de aquellos que enfrentan los sufrimientos provenientes de la enfermedad. ni siquiera conseguimos cualificar algunos comportamientos esperados en el proceso del cuidado de aquellos usuarios de los servicios de salud, que buscan resolver los desequilibrios en sus procesos vitales, estando en condiciones reales o de riesgo en relación con los problemas de salud (7). por otra parte, el cuidado humanizado (8) se desarrolla en el ámbito de las organizaciones hospitalarias y ambulatorias; al respecto merhy, citada por poblete y valenzuela (9), refiere que las instituciones de salud cumplen la función de otorgar cuidados a través de un trabajo vivo, y se espera de ellas que sean un núcleo de cuidado para los usuarios; sin embargo, el acto de cuidar es deficiente debido a que los diferentes profesionales que trabajan en los servicios de salud no realizan acciones de cuidados centrados en el paciente, sino centrados en los procedimientos o en la técnica, lo que actualmente ha provocado la crisis de estas instituciones; además, se agrega el hecho de que la hegemonía del modelo de acción clínica médica empobrece y hasta anula las acciones cuidadoras del resto del equipo de salud. por esta razón, según fujita et al. (10), cuando se introduce el cuidado humanizado en el hospital, tanto los pacientes como los trabajadores se benefician al punto que perciben que cambian sus puestos de trabajo, la comunicación mejora, tienen mayor autoestima y se fortalece el liderazgo institucional. por otra parte, romero et al. (11) consideran que: ...el cuidado humano involucra valores, voluntad y un compromiso para cuidar, conocimiento, acciones de cuidado y consecuen385 validez y confiabilidad del instrumento “percepción de comportamientos de cuidado humanizado de enfermería pche 3ª versión” l oscar javier gonzález-hernández cias. al ser considerado el cuidado como intersubjetivo, responde a procesos de salud-enfermedad, interacción persona-medioambiente, conocimientos de los procesos de cuidado de enfermería, autoconocimiento, conocimiento del poder de sí mismo y limitaciones en la relación de cuidado. al involucrarse en el cuidado humanizado, el profesional de enfermería debe explorar componentes de su actuar que le permitan entrar en ese vínculo con el paciente, que los lleve a un crecimiento permanente. para el avance del conocimiento científico de enfermería, es de suma importancia contar y disponer con herramientas que garanticen una validez y confiabilidad que, al momento de abordar este tipo de fenómenos, permitan descubrir o redescubrir elementos en los escenarios de atención que hagan posible cualificar el cuidado. en la actualidad, la investigación ha permitido que las disciplinas desarrollen instrumentos para que las nuevas generaciones de investigadores analicen otras perspectivas de estos fenómenos estudiados. en el presente artículo, se explora el instrumento “percepción de comportamientos de cuidado humanizado de enfermería (pche) 3ª versión”, que lleva una trayectoria de diez años de construcción, generado desde el interés de profesionales por la percepción de los pacientes frente a la atención, para este caso, “la atención humanizada”. la medición se realizó en el ámbito hospitalario de centro policlínico del olaya, ips de tercer nivel de la ciudad de bogotá (colombia), en donde se vienen desarrollando proyectos orientados a una atención humanizada, sustentados a través de una línea estratégica organizacional, lo que generó mayor interés en la institución para su participación y disponer los espacios para la recolección de la muestra con sus pacientes hospitalizados. la primera etapa para la materialización del pche surgió a partir de un estudio del 2001 que retoman sus autores, donde un grupo de enfermeras se interesaron por abordar el fenómeno del cuidado humanizado en pacientes hospitalizados en la ciudad de bogotá. ellas realizaron un estudio fenomenológico con abordaje cualitativo, donde se procedió al desarrollo de entrevistas, con una pregunta central: ¿cómo fue la experiencia de recibir cuidado de enfermería humanizado durante la hospitalización? (12). allí, las investigadoras solicitaban a los participantes que describieran su respuesta lo más completa posible y manifestaran cómo se habían sentido durante esta. el grupo investigador encontró nueve categorías orientadas a: sentimientos del paciente, características de la enfermera, dar apoyo emocional, dar apoyo físico, cualidades del hacer de la enfermera, proactividad, empatía, priorizar al ser cuidado, disponibilidad para la atención. con este insumo, los autores, movidos por el interés de conocer la percepción de las personas a quienes cuidaban, de sus familias y en respuesta a la búsqueda del departamento de enfermería de dar un cuidado humanizado, adelantaron un estado del arte acerca del concepto de cuidado de enfermería y cuidado humanizado. dentro de esa revisión se abordan los fundamentos de la teoría de cuidado humano de jean watson (13) y la teoría de la enfermería como cuidado de boykin y schoenhofer (14), base conceptual que posibilitó la construcción un instrumento para ser utilizado en la práctica. una vez diseñado, el pche fue sometido a panel de expertos y a validez facial. de esta manera, se llegó a la definición y construcción del instrumento pche versión 1, con 50 ítems, con el uso de una escala likert de 4 opciones (nunca, algunas veces, casi siempre y siempre), donde se retoman las nueve categorías planteadas por el estudio de alvis, moreno y muñoz. en el 2005, y con el fin de determinar y evaluar la validez del instrumento pche, los investigadores llevaron a cabo su aplicación, con un grupo de 274 personas entre pacientes y familiares. dentro de las recomendaciones obtenidas a partir del estudio, se sugiere evaluar la confiabilidad y validez de constructo del instrumento pche, junto con el análisis de psicometría (15). en el 2008, a partir de la experiencia de un estudio de maestría, se propuso determinar la validez de contenido y la validez facial del instrumento. este estudio, realizado por nadia reina y asesorado por elizabeth vargas, presentó los resultados del proceso de validez a través de pruebas psicométricas donde se señala que el instrumento tiene una validez facial alta con pacientes, expresado en un índice de 0,94; una validez facial con expertos a nivel medio, con un índice de acuerdo de 0,78, y un índice de contenido de 0,83; sin embargo, los expertos en el análisis cualitativo de la validez facial y de contenido hicieron diversas observaciones, entre estas, fortalecer el respaldo teórico y, dentro del estudio, se sugiere reducir el número de ítems y hacer ajustes semánticos de las preguntas; a su vez, la autora del estudio sugiere enfrentar la investigación a la determinación del nivel de confiabilidad del instrumento (16). 386 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 con lo anterior, los autores del instrumento, con la participación de sonia espitia, enfermera de la clínica del country, inician un proceso de reingeniería del instrumento pche versión 1, siguiendo los referentes teóricos del concepto de cuidado humanizado y los lineamientos de los expertos. esto permitió la construcción de la 2ª versión de pche y la realización de una validación fácil y de contenido, presentando en la actualidad un instrumento de 32 ítems. el presente estudio pretendió retomar y terminar las pruebas psicométricas del instrumento en construcción. metodología la presente investigación es un estudio metodológico (17) que desarrolló pruebas psicométricas al instrumento pche en tres fases: en la primera fase se realizó un ajuste semántico, el cual se desarrolló con 176 participantes, los cuales no eran profesionales de la salud, que quisieran participar en el ejercicio para evaluar qué tan claros y comprensibles eran los ítems del instrumento. luego, en la segunda fase, se realizó la validez (18) por expertos, donde se contó con la participación de ocho enfermeras, quienes laboran en varios ámbitos del cuidado (asistencia, administración y docencia). esta selección se basó en los siguientes parámetros: profesionales en enfermería, con una trayectoria en áreas asistenciales, administrativas o docentes, y con experiencia investigativa en fenómenos de cuidado, principalmente la humanización. en la tercera y última fase, se aplicaron las pruebas de validez de constructo y confiabilidad (19), se contó con una muestra de 320 pacientes hospitalizados en la ips centro policlínico del olaya entre los servicios hospitalarios (20). se garantizó la privacidad de la aplicación del instrumento, de acuerdo con las condiciones de infraestructura que contempla la institución donde se desarrolló el estudio. para la validez de constructo se aplicó el análisis factorial exploratorio debido a que en las mediciones anteriores el constructo solo tenía un soporte teórico y faltaba el estadístico, para el fortalecimiento del instrumento y la determinación de sus dimensiones mediante esta medición. y para la confiabilidad, se calculó el alfa de cronbach. resultados para la fase inicial, se realizó la adaptación semántica de los ítems de la 2ª versión facilitada por sus autores, con el fin de lograr una mejor comprensión de los mismos por parte del lector, lo que posteriormente requirió ajustar el sentido de la escala likert que maneja el instrumento para la calificación de las diferentes afirmaciones. se contó con la colaboración de 176 personas (no relacionadas directamente con el área de la salud), para que dieran su opinión de qué tan entendibles eran los ítems. a partir de este momento se realizaron ajustes a 12 ítems, y se organizó la propuesta de la 3ª versión, la cual posteriormente se sometió a panel de expertos en la fase ii. en la segunda fase, la propuesta de la 3ª versión del instrumento fue sometida a la validez facial y de contenido por parte de un panel de expertos. en este panel se contó con la participación de ocho enfermeras con trayectoria clínica, académica y administrativa, además de contar con formación como especialistas en distintas áreas de la salud, magísteres y doctoras en enfermería, y hacer parte de la red latinoamericana de cuidado al paciente crónico. durante el proceso se les suministró un instrumento con la información básica de los criterios de evaluación (claridad, precisión, comprensión, relevancia y pertinencia), los conceptos abordados por los autores y las categorías definidas por estos. posterior a esto, evaluaron los 32 ítems del instrumento y expresaron sus observaciones. para esta medición de la validez, se determinó un índice de aceptabilidad o acuerdo por parte de las expertas de 0,92 en cuanto la validez facial y un índice de validez de contenido (ivc) de 0,98. esto significa que el instrumento en el conjunto de sus ítems demuestra una validez facial y de contenido frente a esta nueva versión. en la tercera fase, y a partir de las observaciones planteadas, se estableció el instrumento en su tercera versión y se realizó su aplicación a 320 pacientes hospitalizados en la ips centro policlínico del olaya, institución en la cual actualmente se vienen desarrollando acciones encaminadas a la atención humanizada, lo que permitió articular el estudio con las políticas institucionales; cabe aclarar que este hecho no generó un sesgo en el estudio, ya que la participación de la institución se limitó a la autorización para el acceso a la población que se requería a fin de lograr la muestra necesaria para las pruebas psicométricas. esta muestra permitiría determinar la validez de constructo y calcular el alfa de cronbach. respecto a la validez de constructo mediante el análisis factorial exploratorio, se usó el programa spss para calcular 387 validez y confiabilidad del instrumento “percepción de comportamientos de cuidado humanizado de enfermería pche 3ª versión” l oscar javier gonzález-hernández las mediciones correspondientes. dentro de la aplicación de esta técnica, se obtuvieron los siguientes resultados: una prueba de kmo de 0,956 y una prueba de esfericidad de bartlett 0,0; esto indica la posibilidad de determinar de manera factible el análisis factorial. al respecto de las diferentes rotaciones y agrupaciones por las cargas factoriales, se consideró optar por la rotación de tres factores (tabla 1), los cuales explicaron el 55,5 % de la varianza. además, estos tres factores presentaban una mejor distribución de los ítems; a pesar de que no se articulaban a la propuesta original de los autores, sí se adecuaban mejor a las características del instrumento. luego se realizó una revisión de cada uno de los ítems por factores analizando su relación donde mantuvieran un mismo sentido y enfoque, y luego de su relación teórica, se construyeron sus definiciones. en la tabla 2 se presenta la nueva categorización del instrumento pche para su tercera versión. la confiabilidad del instrumento mediante la consistencia interna, una de las características de este tipo de medición, donde se calculó el alfa de cronbach, arrojó una calificación de 0,96 debido a que la correlación de los ítems dentro del instrumento mide las mismas características, en este caso asociadas al fenómeno de la humanización, y plantea que el instrumento es confiable para su aplicación. finalmente, uno de los productos de este estudio es la aplicación del instrumento que determinó unos resultados descriptivos, donde se identificó que el 84,7 % de los pacientes hospitalizados participantes en el estudio consideran que en la ips centro policlínico del olaya siempre se perciben comportamientos de cuidado humanizado de enfermería. para esta organización, es un resultado importante que debe continuar trabajando para fortalecer prácticas y actitudes en el personal que afectan una real atención humanizada por parte de enfermería. discusión en la cotidianidad, el profesional de enfermería se ve enfrentado a distintos fenómenos del quehacer, que se centran en las realidades de los pacientes a quienes se les brinda cuidado donde, por diversas condiciones, no se tiene la posibilidad de un momento de retroalimentación entre paciente-enfermera(o), que permita el crecimiento de esta diada y el fortalecimiento del cuidado que se brinda. además, se hace necesaria la evaluación de componente 1 2 3 item 1 ,168 ,218 ,791 item 2 ,354 ,277 ,661 item 3 ,559 ,205 ,544 item 4 ,144 ,554 ,334 item 5 ,140 ,651 ,323 item 6 ,239 ,488 ,628 item 7 ,334 ,343 ,655 item 8 ,328 ,301 ,652 item 9 ,399 ,552 ,214 item 10 ,174 ,692 ,266 item 11 ,297 ,665 ,323 item 12 ,364 ,628 ,074 item 13 ,495 ,470 ,342 item 14 ,327 ,604 ,291 item 15 ,420 ,338 ,448 item 16 ,438 ,104 ,246 item 17 ,313 ,165 ,619 item 18 ,554 ,214 ,322 item 19 ,432 ,604 ,164 item 20 ,727 ,296 ,142 item 21 ,596 ,397 ,242 item 22 ,642 ,227 ,248 item 23 ,536 ,464 ,051 item 24 ,534 ,437 ,253 item 25 ,598 ,374 ,132 item 26 ,737 ,179 ,298 item 27 ,563 ,287 ,391 item 28 ,677 ,225 ,444 item 29 ,617 ,259 ,351 item 30 ,517 ,210 ,387 item 31 ,499 ,253 ,383 item 32 ,534 ,301 ,212 tabla 1. matriz de componentes rotadosa método de extracción: análisis de componentes principales. método de rotación: normalización varimax con kaiser. a. la rotación ha convergido en 10 iteraciones. 388 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 las condiciones en que se ofrece el cuidado, los comportamientos, las percepciones de quienes se ven involucrados en él, pero también se debe disponer en los escenarios de enfermería de herramientas válidas y confiables que logren objetivizar las realidades que se experimentan diariamente. al respecto, frías y soler (21) mencionan “que cualquier instrumento de medida refleja el constructo teórico que se desea medir y también el error de medida. por ello, es necesario que los instrumentos sean sometidos a procesos de validación a través de los estudios psicométricos de validez del constructo y fiabilidad de la medida”. en la fase i del estudio, momento preliminar para el desarrollo de la propuesta de la 3ª versión, se obtuvo un ajuste semántico de los 32 ítems a partir de la participación de 176 personas del común, donde a partir de sus apreciaciones, se realizó el ajuste a 12 ítems. estos cambios se dan desde el enfoque de la validez aparente o facial, que busca medir el grado en el que los ítems parecen medir lo que se proponen (22). en experiencias de otros estudios, se ha identificado que este momento en el uso de los instrumentos es fundamental para hacer más comprensible la herramienta de medición. al respecto, camargo y caro (23), al aplicar el instrumento de inventarios de comportamientos de cuidado de wolf, realizó una prueba de validez facial en el contexto panameño, posterior a la cual se sugirieron ajustes en 11 de los ítems del instrumento original, relacionados con la redacción de cada uno de ellos. luego, en la fase ii, a partir de la propuesta de una tercera versión, se sometió a validez facial y de contenido por expertos, con la participación de ocho enfermeras. al evaluar el instrumento basado en los criterios antes descritos, se identifica un índice de aceptabilidad para la validez facial de 0,92 y un índice de validez de contenido de 0,98. a pesar de los índices altos, los expertos hicieron sugerencias de ajuste de palabras y propuestas para la complementariedad de los ítems. al revisar la literatura y los antecedentes del instrumento pche, se evidencia que para el estudio de reina y vargas (16), se obtuvo un índice de aceptabilidad de 0,78 y un índice de validez de contenido de 0,83 por expertos. para la medición de estos índices en la construcción de la segunda versión8 se obtuvieron un índice de aceptabilidad de 0,81 y un índice de validez de contenido de 0,89. de acuerdo con estos datos, el instrumento para su tercera versión ofrece unas características de validez mejores que las versiones anteriores. según la literatura, por ejemplo, un índice de validez de contenido se considera 8 estos datos fueron suministrados por los autores del instrumento pche, segunda versión. como aceptable (24) si obtiene una puntuación igual o superior a 0,58. los ítems que logran esta puntuación se pueden integrar al instrumento, pero por debajo de estos puntajes deben ser revisados, corregidos y sometidos nuevamente al panel de expertos. en la fase iii, luego de aplicar el instrumento pche en su tercera versión a los pacientes hospitalizados en la ips centro policlínico del olaya s.a., se determinaron dos medidas: el constructo por análisis factorial y la confidencialidad por el alfa de cronbach. en primer lugar, para determinar el constructo de un instrumento desde las medidas estadísticas, se encuentra el análisis factorial, pero para aplicarlo, se deben cumplir las siguientes pruebas a fin de proseguir con la medición, estas son la prueba de adecuación muestral kmo (22) y la prueba de esfericidad de bartlett (22). para este estudio, estas medidas fueron un kmo de 0,955 y la prueba de bartlett de 0,000. el kmo indica el grado de intercorrelación de la variables, si es mayor de 0,7 se considera factible; la prueba de bartlett se considera adecuada con un nivel de significado menor de 0,05. dado que las pruebas fueron favorables, el análisis factorial sugirió una mejor agrupación de los ítems por sus cargas factorial y por rotación varimax forzada a tres factores. al revisar la trayectoria del instrumento, este nunca había sido sometido a esta medición, pero se hizo una definición teórica del constructo, y, al comparar las categorías, no hay una relación entre la versión anterior y esta. la agrupación final se definió en tres categorías denominadas: actitudes del hacer de enfermería, apertura a la comunicación (25, 26) enfermera(o)-paciente y disposición para la atención, que se sustentan en los soportes teóricos planteados para este estudio. a esta definición de las categorías se llegó luego de determinar los factores y su agrupación de ítems en la validez del constructo, a través de una revisión de la literatura, la definición de los autores y la categorización realizada en el estudio de alvis et al. a partir de esta revisión, se concertaron las definiciones más asociadas a las agrupaciones de los ítems. en cuanto a la confiabilidad, se calculó el alfa de cronbach para medición de la consistencia interna, que arrojó una calificación de 0,96 (27), lo cual significa que la correlación de los ítems dentro del instrumento mide las mismas características, en este caso asociadas al fenómeno de la humanización, y plantea que el instrumento es confiable para su aplicación. según george y mallery (22), un nivel de fiabilidad con un valor superior a 0,9 se clasifica como excelente. 389 validez y confiabilidad del instrumento “percepción de comportamientos de cuidado humanizado de enfermería pche 3ª versión” l oscar javier gonzález-hernández tabla 2. definición de categorías y distribución de ítems del instrumento pche 3a versión fuente: resultados del medición del constructo. definición de categorías a partir de la validez de constructo del instrumento pche 3 versión categoría definición ítems relacionados cualidades del hacer de enfermería se refiere a las cualidades y valores que caracterizan al personal de enfermería que brinda cuidado. en esta categoría se destacan aspectos como facilitar que el paciente experimente sensaciones de bienestar y confianza, logrando que perciba un vínculo respetuoso en la relación enfermera(o)-paciente. 1. le hacen sentirse como una persona 2. le tratan con amabilidad 6. le hacen sentirse bien atendido cuando dialogan con usted 7. le hacen sentirse tranquilo(a), cuando están con usted 8. le generan confianza cuando lo(la) cuidan 15. le explican los cuidados usando un tono de voz pausado 17. le demuestran respeto por sus creencias y valores apertura a la comunicación enfermera(o)paciente esta categoría se refiere a la apertura por parte de quien brinda el cuidado (enfermera(o)) a un proceso dinámico, fundamental para el crecimiento, el cambio y la conducta, que permiten la interacción con el sujeto de cuidado (paciente) a través de habilidades comunicativas que posibilitan la trasmisión de una realidad y la interacción con la misma. esta apertura se orienta a la escucha activa, al diálogo, a la presencia y la comprensión de quien es cuidado. 4. le miran a los ojos, cuando le hablan 5. le dedican tiempo para aclararle sus inquietudes 9. le facilitan el diálogo 10. le explican previamente los procedimientos 11. le responden con seguridad y claridad a sus preguntas 12. le indican su nombre y cargo antes de realizarle los procedimientos 14. le dan indicaciones sobre su atención cuando usted lo requiere o según su situación de salud 19. le proporcionan información suficiente y oportuna para que pueda tomar decisiones sobre su situación de salud disposición para la atención se refiere a la disposición que surge de ser solicitado por el sujeto de cuidado, que no se limita a un acto de observar sino que requiere en una inmersión en su realidad para descubrir sus necesidades y fortalecer el vínculo que los une en el cuidado 3. le muestran interés por brindarle comodidad durante su hospitalización 13. le dedican el tiempo requerido para su atención 16. le llaman por su nombre 18. le atienden oportunamente sus necesidades básicas (higiene, alimentación, evacuación urinaria e intestinal) 20. le manifiestan que están pendientes de usted 21. le permiten expresar sus sentimientos sobre la enfermedad y el tratamiento 22. responden oportunamente a su llamado 23. identifican sus necesidades de tipo físico, psicológico y espiritual 24. le escuchan atentamente 25. le preguntan y se preocupan por su estado de ánimo 26. le brindan un cuidado cálido y delicado 27. le ayudan a manejar el dolor físico 28. le demuestran que son responsables con su atención 29. le respetan sus decisiones 30. le indican que cuando requiera algo, usted les puede llamar 31. le respetan su intimidad 32. le administran a tiempo los medicamentos ordenados por el médico 390 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 conclusiones se determina que el instrumento pche, adaptado por oscar j. gonzález h., es válido y confiable para su aplicación en ámbitos hospitalarios, y está disponible para la comunidad científica a nivel nacional e internacional. además, se determinó que esta versión cuenta con una validez facial y de contenido, por tener un índice de aceptabilidad del 0,92 y un índice de validez de contenido de 0,98 por expertos, y de constructo a través de la medición de un análisis factorial exploratorio que generó tres categorías denominadas: cualidades del hacer de enfermería, apertura a la comunicación enfermera(o)-paciente y disposición para la atención, las cuales miden el constructo del instrumento comportamientos de cuidado humanizado. finalmente, se determinó que el instrumento pche, para su nueva versión, es confiable, ya que obtuvo un alfa de cronbach de 0,96. recomendaciones durante el proceso de recolección de la muestra, algunos participantes requirieron el apoyo para el diligenciamiento del instrumento por su situación de salud o como requerimiento para su participación. frente a esto, es importante que los investigadores interesados en el instrumento, tengan en cuenta estas realidades con los pacientes. otro aspecto que es relevante tener en cuenta en próximas aplicaciones del instrumento, es la adaptación a otros ámbitos no hospitalarios, esto permitirá una mejor apropiación del fenómeno de la humanización en los diferentes escenarios de la atención en salud. se sugiere que en futuras investigaciones que quieran hacer nuevas pruebas a este instrumento, se tome la muestra de varias instituciones para tener una visión más amplia del mismo. aunque el hecho de hacer las actuales pruebas en una sola institución no invalida los resultados del presente estudio, sí podría constituir una limitación en la aplicación de sus resultados en contextos diferentes. al reflexionar sobre el fenómeno de la humanización de la atención en general, se identifica la importancia de que los entes de vigilancia y control retomen la realidad de la humanización en las instituciones de salud y definan líneas de acción que lleven a la construcción de una política nacional de atención humanizada en el país, en dos direcciones: hacia el paciente y hacia el trabajador de la salud, para que en esa armonía se generen verdaderos ambientes sensibles a la realidad del otro. es importante que en los escenarios de la práctica, los colegas de enfermería hagan uso de este tipo de instrumentos que permiten ofrecer un espacio para la reflexión sobre el actuar de la disciplina en el día a día, y a los pacientes se les genera un momento de retroalimentación frente a la atención, que contribuye al crecimiento mutuo. agradecimientos el logro de este estudio es la manifestación del esfuerzo, la perseverancia y la oración. expreso mi agradecimiento a la profesora beatriz sánchez herrera, quien fue la directora de la tesis de maestría en enfermería en la cual se adelantó este estudio. al programa para la disminución de la carga de la enfermedad crónica no transmisible en colombia, por su apoyo y patrocinio para el desarrollo del mismo. a la ips centro policlínico del olaya, que se interesó en aplicar este estudio con sus pacientes hospitalizados buscando tener día a día un cuidado más humanizado. y a cada una de las personas que hicieron parte de este estudio. 391 validez y confiabilidad del instrumento “percepción de comportamientos de cuidado humanizado de enfermería pche 3ª versión” l oscar javier gonzález-hernández referencias 1. collado r. cuidado espiritual, labor del profesional de enfermería. revista 360 [internet]. 2010 [citado 2014 nov 1]; 5:1-3. disponible en: http://cremc.ponce.inter.edu/360/revista360/ciencia/cuidado%20espiritual%20enfermeria.pdf 2. guillén velasco rc. la connotación humana y cultural del cuidado. biblioteca lascasas [internet]. 2010 [citado 2015 jul 15]; 6(3). disponible en 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disponible en: http:// publicaciones.konradlorenz.edu.co/index.php/sumapsi/article/view/1141/707 22. carvajal a, centeno c, watson r, martínez m, sanz rubiales a. ¿cómo validar un instrumento de medida de la salud? an sist saint navar [internet]. 2011 [citado 2014 nov 11]; 34(1):63-72. disponible en: scielo.isciii.es/pdf/asisna/v34n1/ revision1.pdf 23. camargo il, caro cv. comportamientos de cuidado del anciano y de los profesionales de enfermería: evidencia para la cualificación profesional. provincia de coclé, panamá. av enferm [internet]. 2009 [citado 2014 nov 13]; xxvii(1):48-59. disponible en: http://www.enfermeria.unal.edu.co/revista/articulos/xxvii1_6.pdf 24. tristán lópez a. modificación al modelo de lawshe para el dictamen cuantitativo de la validez de contenido de un instrumento objetivo. avances en medición [internet]. 2008 [citado 2014 nov 14]; 6:37-48. disponible en: http://www. humanas.unal.edu.co/psicometria/files/8413/8574/6036/articulo4_indice_de_validez_de_contenido_37-48.pdf 25. medina ap. el impacto de la comunicación interpersonal en la motivación del personal hospitalario. revista universidad y salud [internet]. 2010 [citado 2014 nov 14]; 12(1):110-119. disponible en: http://www.scielo.org.co/scielo. php?script=sci_arttext&pid=s0124-71072010000100013&lng=en. 26. gausvik c, lautar a, miller l, pallerla h, schlaudecker j. structured nursing communication on interdisciplinary acute care teams improves perceptions of safety, efficiency, understanding of care plan and teamwork as well as job satisfaction. journal of multidisciplinary healthcare [internet]. 2015 [citado 2015 feb 5]; 8:33-37. disponible en: http://www. ncbi.nlm.nih.gov/pubmed/25609978 27. cruz orduna i, aguera ortiz lf, montorio cerrato i, león salas b, valle de juan mc, martínez martin p. fiabilidad y validez de la batería de evaluación del deterioro grave, versión abreviada (sib-s), en pacientes con demencia en españa. revista de neurología [internet]. 2015 [citado 2015 feb 5]; 60(1):1-9. disponible en: http://www.ncbi.nlm.nih.gov/ pubmed/25522858 116 128 processo de enfermagem no conforto.indd 116 fabíola vládia freire da silva1 lúcia de fátima da silva2 ana cleide silva rabelo3 processo de enfermagem no conforto do paciente com insufi ciência cardíaca no domicílio 1 enfermeira. mestre em cuidados clínicos em enfermagem e saúde. doutoranda do programa de pós-graduação cuidados clínicos em enfermagem e saúde da universidade estadual do ceará. integrante do grupo de pesquisa enfermagem, educação, saúde e sociedade, da universidade estadual do ceará. fortaleza, ceará, brasil. fabiolafreire@yahoo.com.br 2 enfermeira. doutora em enfermagem. professora adjunta do curso de graduação em enfermagem e do programa de pós-graduação cuidados clínicos em enfermagem e saúde da universidade estadual do ceará. enfermeira do hospital de messejana dr. carlos alberto studart gomes. pesquisadora do grupo de pesquisa enfermagem, educação, saúde e sociedade, da universidade estadual do ceará. fortaleza, ceará, brasil. lucia.fatima@uece.br 3 enfermeira. mestre em cuidados clínicos em enfermagem e saúde, pela universidade estadual do ceará. integrante do grupo de pesquisa enfermagem, educação, saúde e sociedade, da universidade estadual do ceará. fortaleza, ceará, brasil. anacleidesr@hotmail.com recibido: 11 de febrero de 2014 enviado a pares: 20 de febrero de 2014 aceptado por pares: 30 de marzo de 2014 aprobado: 19 de julio de 2014 doi: 10.5294/aqui.2015.15.1.11 para citar este artículo / to reference this article / para citar este artigo freire da silva fv, da silva l, silva rabelo ac. processo de enfermagem no conforto do paciente com insuficiência cardíaca no domicílio. aquichan. 2015; 15 (1): 116-128. doi: 10.5294/aqui.2015.15.1.11 resumo este estudo objetivou descrever uma prática de enfermagem com a implementação do processo de enfermagem, elaborado de acordo com as necessidades de conforto do paciente com insuficiência cardíaca em condição domiciliar e teve como referencial a teoria do conforto de kolcaba, com vista a proporcionar conforto ao paciente. trata-se de estudo de caso clínico. a coleta dos dados ocorreu por meio de formulário, escala de conforto, entrevista, anamnese, exame físico e observação, com um paciente assistido pelo programa de acompanhamento domiciliar de um hospital público estadual, localizado em fortaleza (ceará, brasil), em julho de 2013. para cada contexto onde se produz conforto, segundo kolcaba —físico, ambiental, sociocultural e psicoespiritual—, listaram-se os diagnósticos de enfermagem relacionados às necessidades de conforto, os resultados esperados (alívio, tranquilidade e/ou transcendência) e as intervenções/ ações pertinentes ao seu alcance. concluiu-se que a aplicação do processo de enfermagem, baseado na teoria de kolcaba, proporcionou conforto e melhoria na qualidade de vida do paciente no domicílio. palavras-chave cuidados de enfermagem, teoria de enfermagem, insuficiência cardíaca, pacientes domiciliares, processos de enfermagem, serviços de assistência domiciliar (fonte: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 116-128 117 processo de enfermagem no conforto do paciente com insuficiência cardíaca no domicílio l fabíola vládia freire da silva, lúcia de fátima da silva, ana cleide silva rabelo año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 116-128 proceso de enfermería en la comodidad del paciente con insuficiencia cardiaca en el domicilio resumen el estudio buscó describir una práctica de enfermería con la implementación del proceso de enfermería, elaborado de acuerdo con las necesidades de comodidad del paciente con insuficiencia cardiaca en condición domiciliar y tuvo como referencial la teoría de la comodidad de kolcaba con vocación de proporcionar comodidad al paciente. se trata de estudio de caso clínico. la recolección de los datos se dio por medio de formulario, escala de comodidad, entrevista, anamnesis, examen físico y observación, con un paciente asistido por el programa de acompañamiento domiciliar de un hospital público estadual, localizado en fortaleza (ceará, brasil), en julio de 2013. para cada contexto donde se produce comodidad, según kolcaba —físico, ambiental, sociocultural y psicoespiritual—, se listaron los diagnósticos de enfermería relacionados a las necesidades de comodidad, los resultados esperados (alivio, tranquilidad o transcendencia) y las intervenciones/acciones pertinentes a su alcance. se concluye que la aplicación del proceso de enfermería, basado en la teoría de kolcaba, ha proporcionado comodidad y mejora en la calidad de vida del paciente en el domicilio. palabras clave cuidados en enfermería, teoría de enfermería, insuficiencia cardiaca, pacientes domiciliares, procesos de enfermería, servicios de atención de salud a domicilio (fuente: decs, bireme). 118 aquichan issn 1657-5997 hospice nursing comfort care for patients with heart failure abstract the study describes a type of hospice nursing practice that is implemented according to the comfort needs of patients with heart failure and is based on kolcaba’s theory of comfort care. it is clinical case study. the data were collected using a format, comfort scale, interview, anamnesis, physical examination and observation involving a patient who was being served by the hospice care program of a public hospital in fortaleza (ceará, brazil) during july 2013. nursing diagnoses associated with comfort needs, expected results (relief, tranquility and / or transcendence), and relevant interventions/actions within the scope of possibilities for hospice nursing care were listed for each context (physical, environmental, socio-cultural and psycho-spiritual) where comfort is produced, according to kolcaba. the conclusion is that application of a nursing process based on kolcaba’s theory has provided comfort and improved the quality of life for hospice care patients. keywords nursing care, nursing theory, heart failure, hospice patients, nursing process, hospice care services (source: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 116-128 119 processo de enfermagem no conforto do paciente com insuficiência cardíaca no domicílio l fabíola vládia freire da silva, lúcia de fátima da silva, ana cleide silva rabelo introdução trata-se de estudo acerca do cuidado clínico prestado pelo enfermeiro à pessoa com insuficiência cardíaca (ic) na busca de, por meio da teoria do conforto de katharine kolcaba (1), utilizar o processo de enfermagem (pe) no cuidado a esse paciente, com vistas a promover-lhe conforto no domicílio. compreende-se que o cuidado é um constructo amplo e complexo, uma forma de estar com, de perceber, relacionar-se e preocupar-se com outro ser humano em determinado tempo e espaço compartilhados no face a face. assim, esse cuidado é constituído e permeado por diferentes elementos, como a responsabilidade, as habilidades, as relações interpessoais, os saberes e conhecimentos instituídos (2). o cuidado é desvelo, responsabilidade, atenção e cautela, conceitos que são atribuídos ao cuidado humano, representam atitude de ocupação, de preocupação e de envolvimento efetivo e afetivo com o outro (3). o cuidado como processo sistêmico não representa somente uma ação pontual e unilateral, mas envolve um sentimento de pertença e de comunicação com o todo integrado, isto é, com o entorno social (4). o enfermeiro, ao desenvolver a sistematização das suas práticas, deve proporcionar um espaço de fala e escuta, o que contribuirá para a fortificação do vínculo entre profissional e usuário (5). nessa perspectiva, compreende-se cuidado clínico como práticas, intervenções e ações sistematizadas, de cuidado direto, desenvolvido pela equipe de enfermagem e dirigido ao ser humano, seja individualizado ou coletivo, fundamentado em evidências quantitativas e/ou qualitativas, com bases filosóficas, ética, estética, teórica, científica, técnica e política, que consideram as manifestações ou respostas das pessoas ao seu processo de viver no continuum saúde-doença (6). quando esse cuidado envolve uma mudança no estilo de vida e a não perspectiva de cura e cessação do problema em curto intervalo de tempo, como no caso de adoecimentos crônicos, como os cardiovasculares, é exigido do enfermeiro mais empenho e paciência, já que o cuidador e a pessoa cuidada devem estabelecer uma relação de mútua confiança e empenho para restabelecimento da qualidade de vida (7). em geral, os portadores de problemas cardíacos sofrem modificação em seu padrão de vida normal, em virtude da incapacidade para executar determinadas tarefas cotidianas decorrente dos seus sinais e sintomas. a ic é uma complicação grave, geralmente progressiva e irreversível, que pode comprometer a maioria dos pacientes cardíacos e, especialmente, aqueles que padecem de doença coronária, hipertensão arterial, valvulopatias ou miocardiopatias. seus sintomas clínicos incluem dispneia, fadiga e edema, que provocam grande desconforto aos seus portadores, com grande prejuízo da qualidade de vida e redução de sobrevida. durante as últimas décadas, a ic tem se revelado como um dos problemas de saúde pública de maior envergadura, por sua crescente incidência, principalmente, nos países desenvolvidos, com população mais idosa. tem grande impacto social, econômico e, sobretudo, humano, visto que impõe uma grande limitação física aos pacientes e implicação em aposentadorias precoces e com altos custos governamentais (8). por possuir condição de adoecimento crônico, os pacientes com ic devem possuir uma rede de apoio, tanto com os serviços de saúde quanto com a família e a comunidade, que lhes permitam qualidade de vida. as internações e intercorrências, por mais que possam ser frequentes, não são maiores que a permanência do paciente em domicílio. assim, o acompanhamento destes em suas residências, com capacitação para o autocuidado e inserção da família nesse processo são imperiosos. portanto, o enfermeiro deve estar preparado para prestar assistência de forma a atender às necessidades biológicas dos pacientes, e assim proporcionar-lhes conforto; e também às necessidades psicossociais, e levá-los a superarem limitações e adquirirem mecanismos de enfrentamento (9). no entanto, para que a enfermagem atue eficientemente nesse processo, necessita desenvolver seu trabalho fundamentado no método científico. a investigação científica deve ser guiada pela teoria, que orienta a prática de enfermagem, descrevendo, explicando ou prevendo fenômenos. assim, este estudo objetivou descrever uma prática de enfermagem com a implementação do pe, elaborado de acordo com as necessidades de conforto do paciente com ic em condição domiciliar, e teve como referencial a teoria do conforto de katharine kolcaba, com vista a proporcionar conforto ao paciente. 120 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 métodos trata-se de estudo de caso clínico, extraído de dados preliminares de um estudo de dissertação com pessoas acompanhadas em domicílio (10). a essência de um estudo de caso está no fato de ser uma estratégia para pesquisa empírica empregada para a investigação de um fenômeno contemporâneo, em seu contexto real, o que possibilita a explicação de ligações causais de situações singulares (11). a coleta dos dados ocorreu em domicílio, com um paciente assistido pelo programa de acompanhamento domiciliar (pad) de um hospital público estadual, do sistema único de saúde (sus), localizado na cidade de fortaleza (ceará, brasil), no mês de julho de 2013. o sujeito do estudo é um indivíduo adulto e que possui diagnóstico médico de ic. as informações foram coletadas em três visitas domiciliares, por meio de entrevista, anamnese, exame físico, preenchimento de formulário e escala de conforto, além de observação assistemática. a coleta foi realizada seguindo as fases propostas pelo pe. primeira etapa: correspondeu à primeira fase —histórico de enfermagem, em que é feita a avaliação inicial do paciente—. foi realizada em uma primeira visita domiciliar e proporcionou à pesquisadora o conhecimento do paciente estudado. esse reconhecimento foi feito por meio de preenchimento de um formulário, o qual foi aplicado após esclarecimentos sobre os objetivos da pesquisa e assinatura do termo de consentimento livre e esclarecido. o formulário contou com questões para caracterização do participante da pesquisa, com variáveis sociodemográficas e sobre as condições do domicílio. dados sobre necessidades de conforto foram coletados por entrevista semiestruturada e preenchimento de uma escala adaptada a partir da construída por gameiro & apóstolo em 2004, segundo o modelo operacional do “conforto” desenvolvido por kolcaba (1). também foram realizados exame físico e anamnese direcionados para o contexto cardiovascular, além de observação assistemática. esta ocorreu em todas as etapas da coleta. segunda etapa: antecedeu a segunda visita domiciliar e correspondeu à segunda fase do pe, em que são identificados os diagnósticos de enfermagem (de). uma das pesquisadoras, de posse dos dados coletados na primeira visita domiciliar, identificou os de, segundo a taxonomia ii da north american nursing diagnosis association —nanda internacional— (12), no domínio 12 —conforto, pertinentes às situações/ações de conforto. assim, fez-se a separação dos dados obtidos pelos instrumentos/meios de coleta de dados usados na primeira etapa (anamnese, exame físico, escala de conforto, entrevista e observação assistemática). após apreciação crítica desses dados, seguiu-se à categorização das necessidades de conforto de acordo com o contexto em que este pode ocorrer, conforme teoriza kolcaba (1), em nível físico, ambiental, sociocultural e psicoespiritual. essas necessidades de conforto foram então agrupadas segundo uma identificação de padrões, inferência diagnóstica e determinação das relações. terceira etapa: de posse dos de identificados para cada caso, deu-se início à terceira etapa. esta correspondeu às fases do pe de planejamento e implementação das intervenções, guiadas pela nursing intervention classification —nic— (13) e baseadas nos resultados esperados conforme a nursing outcomes classifications —noc (14)—. para cada de listado (com suas características definidoras e seus fatores relacionados), elencaram-se os resultados de enfermagem esperados (re). estes foram eleitos segundo as necessidades de conforto do paciente e classificados segundo o grau de conforto que poderiam proporcionar, conforme os tipos de conforto descritos por kolcaba (1): alívio, tranquilidade e transcendência. dando continuidade à etapa de planejamento (do pe), selecionaram-se intervenções de enfermagem (ie) que dessem subsídio ao alcance dos re. a operacionalização das ie se deu mediante sugestões de atividades como recomendações ao paciente e às suas famílias sobre medidas de conforto e participação no cuidado do familiar. algumas atividades foram propostas para serem realizadas pelo paciente de forma autônoma, outras pela família de forma auxiliar e ainda outras, que contariam com a participação do paciente e família de forma conjunta. quarta etapa: dando prosseguimento ao pe, foi realizada a segunda visita domiciliar. nesta, a pesquisadora apresentou ao sujeito pesquisado as intervenções propostas para as necessidades de conforto percebidas mediante análise dos dados coletados na primeira visita. quinta etapa: correspondeu à última fase do pe —avaliação dos resultados— e foi realizada em uma terceira visita domiciliar. nesta, foram identificados quais resultados foram alcança121 processo de enfermagem no conforto do paciente com insuficiência cardíaca no domicílio l fabíola vládia freire da silva, lúcia de fátima da silva, ana cleide silva rabelo dos através das intervenções planejadas e propostas na segunda etapa. essa identificação se deu por meio de entrevista semiestruturada e observação assistemática. utilizou-se como estratégia para apreciação dos dados obtidos pelas entrevistas, realizadas nas visitas domiciliárias, a análise de conteúdo. os dados foram categorizados de acordo com as dimensões de conforto teorizadas por kolcaba (1), quais sejam: dimensão física, ambiental, sociocultural e psicoespiritual. o processo de análise dos resultados foi fundamentado na teoria do conforto de katharine kolcaba (1) e teve base na literatura pertinente ao tema em questão. o participante da pesquisa foi esclarecido quanto aos objetivos do estudo e convidado a assinar o termo de consentimento livre e esclarecido, além de ter sido informado quanto ao direito ao sigilo, ao anonimato, acesso aos dados a qualquer tempo e liberdade para se retirar do estudo a qualquer momento, sem que esse fato representasse qualquer tipo de prejuízo. também lhe informamos sobre a divulgação e publicação dos resultados em revistas científicas e congressos. foram considerados, durante todo o desenvolvimento da investigação, os preceitos éticos e legais da resolução 466/2012, do conselho nacional de saúde (15), que tratam dos encaminhamentos quando as pesquisas envolvem seres humanos. ainda atendendo aos preceitos éticos e legais da pesquisa com humanos, o projeto foi apreciado pelo comitê de ética em pesquisa da universidade estadual do ceará, na qualidade de unidade proponente, e aprovado pelo parecer número 252.879, além de ter a anuência do hospital sede do pad, como unidade coparticipante. resultados relato de caso perfil sociodemográfico: c.r.f, 57 anos, sexo masculino, pardo, casado, dois filhos, natural de são luiz de montes belos (goiás, brasil). aposentado, católico, concluiu o ensino fundamental. renda familiar de um salário-mínimo, o qual provém de sua aposentadoria (outros membros da família não contribuem com a renda). reside no bairro parque genibaú, no município de fortaleza (ceará, brasil), em domicílio próprio, feito de alvenaria, com oito cômodos, com serviços de saneamento básico, água encanada e eletricidade. moram no domicílio cinco pessoas —paciente, esposa, filha, genro e neto—. quanto ao histórico de saúde: negou possuir alergias, hábitos de fumar e ingerir bebidas alcoólicas. não pratica atividades físicas devido a sintomas relacionados à ic e à diabetes mellitus (dm), mas menciona sentir falta de ser mais ativo. quanto à história da doença atual: foi diagnosticado com ic em 2008, quando iniciou tratamento. as principais queixas são dor e dormência em membro inferior esquerdo (mie). sente piora dessa sintomatologia quando permanece um pouco mais de tempo em pé. possui comorbidades associadas, dentre elas hipertensão arterial sistêmica (has), dm e insuficiência aórtica. já passou por cinco internamentos hospitalares. realizou procedimento cirúrgico de angioplastia e outro para colocar prótese de válvula aórtica. faz uso de medicamentos vasodilatadores, antiagregantes plaquetários, antiulcerosos, betabloqueadores, antagonistas dos receptores da angiotensina, antidiabéticos, diuréticos, suplementos nutricionais e benzodiazepínicos. ao exame físico apresentou-se normotenso (120/60 mmhg), bradicárdico (58bpm), com pulso palpável, filiforme e arrítmico. o índice de massa corpórea (imc) de 27,6 indicou sobrepeso. bom estado geral, orientado no tempo e espaço, humor calmo. bom padrão de sono (noturno). eutrófico, desidratado, edema em mie, presença de lesão (raladura) nesse mesmo membro. dieta irregular quanto à quantidade e conteúdo. necessita de auxílio para se locomover. negou dispneia. menciona dor torácica pouco frequente. possui alteração torácica devido à cicatrização de ferida operatória de cirurgia cardíaca. nega alterações no sistema gastrointestinal e geniturinário. relacionando-se aos contextos em que se produz conforto, kolcaba (1) os descreve como sendo quatro: físico, psicoespiritual, ambiental e sociocultural. o contexto físico pertencente às sensações do corpo; o ambiental inclui o ambiente, as condições e influências externas; o sociocultural pertence às relações interpessoais, familiares e sociais, que englobam ainda aspectos financeiros e informações da vida social; e o psicoespiritual refere-se à consciência de si próprio, o que inclui a autoestima, o autoconceito, a sexualidade e o sentido da vida e relação com um ser supremo. 122 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 kolcaba também descreve o conforto em três formas: alívio, tranquilidade e transcendência (1). o alívio é descrito como estado de um paciente que tem satisfeita uma necessidade específica. é satisfazer a necessidade por meio do controle de fatores de caráter global que causam desconforto, o que pode levar o cliente a um estado de calma ou contentamento; uma condição imediata. a tranquilidade é tida como o estado de calma ou satisfação. é satisfazer necessidades específicas que causam desconforto ou interferem com o conforto, resultantes de uma experiência individual. a tranquilidade pressupõe uma condição mais duradoura e contínua, um estado de contentamento e bem-estar. já a transcendência é o estado em que se está por cima dos problemas ou da dor própria. a transcendência, como o mais elevado estado do conforto, traduz-se na satisfação de necessidades de educação e motivação, implica crescimento pessoal, ou seja, preparar o cliente para desenvolver os seus potenciais e realizar as suas atividades com a máxima independência possível adotando hábitos de vida saudáveis (1). ao ter em mente os contextos em que o conforto pode acontecer ou ser percebido pela pessoa, identificaram-se necessidades de conforto detectadas pelos dados coletados por cada instrumento e pertinentes a cada contexto descrito pela teorista. com a identificação das necessidades, também foi apreendido, objetivamente pela escala de conforto e subjetivamente pelos outros instrumentos, o tipo de conforto requerido pelas necessidades em particular, o qual é singular a cada pessoa. na sequência se apresenta quadro demonstrativo das etapas do pe de identificação de de, elencamento dos re e sugestões de ie, conforme descrito. tais fases foram desenvolvidas com base na teoria do conforto, com enquadramentos dos de em contextos e dos re e ie por contextos e tipos de conforto teorizados por kolcaba (1). para o contexto físico, identificaram-se os problemas: mediante anamnese e exame físico (edema, formigamento e lesão em mie, desconforto ao ficar em pé, desidratação, necessidade de auxílio para locomover-se, dor em mie devido ao edema); pela escala de conforto e entrevista (dificuldade de locomoção) e pela observação (necessidade de realizar atividades físicas). os dados obtidos pela escala de conforto demonstraram necessidade de medidas que proporcionassem conforto em nível de transcendência, pois o sujeito teve pontuação 11, quando poderiam alcançar 15. tal pontuação proveio do escore baixo atribuído pelo paciente à afirmação contida na escala: “evito sair de casa devido às alterações do meu aspecto físico”. essa resposta corrobora com dados encontrados na anamnese e no exame físico. observouse edema em mie, além de referências de dor, dormência e piora destes ao locomover-se ou manter-se de pé por um período maior. além disso, a dificuldade em locomover-se, decorrente da sintomatologia citada, acaba ocasionando alguns acidentes que geram lesões na pele. essas lesões levam mais tempo para cicatrizar devido à comorbidade associada —dm—. além disso, o paciente sente-se com a aparência corporal desagradável devido às alterações torácicas ocasionadas pela cicatrização de ferida operatória de cirurgia cardíaca. diante disso, seguiu-se ao estabelecimento dos de relacionados às necessidades detectadas. cabe salientar que a escolha do domínio 12 —conforto da taxonomia ii da nanda-i (12)—, para obtenção dos de, foi feita por proximidade com o referencial teórico de katharine kolcaba (1). assim, no contexto físico, os de do domínio conforto pertinentes foram: conforto prejudicado, caracterizado por relato de sentir-se desconfortável, relacionado com sintomas decorrentes da doença (edema, desidratação da pele, lesões e desconforto ao permanecer muito tempo de pé); conforto prejudicado, caracterizado com relato de falta de satisfação com a situação, relacionado com a falta de controle da situação (dificuldade de locomover-se); dor crônica, caracterizado por relato verbal de dor, relacionado a agentes lesivos (sintomas relacionados à doença —edema); e disposição para melhora de conforto, caracterizado pelo desejo expresso de aumentar contentamento, relacionado à vontade de se tornar mais fisicamente ativo. seguindo o proposto pelo pe, estabeleceram-se os resultados esperados (re) para cada de a fim de propor intervenções que objetivassem seu alcance. os re foram classificados de acordo com o tipo de conforto que poderiam proporcionar, como descritos por kolcaba —alívio, tranquilidade ou transcendência (1)—. assim, para o de conforto prejudicado, foram selecionados os re: controle de sintomas (em nível de alívio); nível de conforto, locomoção: caminhar (em nível de tranquilidade); e mobilidade (em nível de transcendência). para o de dor crônica, selecionaramse os re: controle da dor (em nível de alívio); nível de conforto (em nível de tranquilidade). para o de disposição para melhora do conforto, selecionaram-se os re: autocuidado: atividades de vida 123 processo de enfermagem no conforto do paciente com insuficiência cardíaca no domicílio l fabíola vládia freire da silva, lúcia de fátima da silva, ana cleide silva rabelo contexto (segundo a teoria do conforto) de (nanda-i, domínio conforto) de (fatores relacionados) resultados esperados (noc) tipos de conforto, segundo kolcaba alívio tranquilidade transcendência físico conforto prejudicado sintomas relacionados à doença (edema, desidratação da pele, lesões e desconforto ao permanecer muito tempo de pé) controle de sintomas nível de conforto falta de controle da situação (dificuldade de locomover-se) locomoção: caminhar mobilidade dor aguda agentes lesivos (sintomas relacionados à doença – edema) controle da dor nível de conforto disposição para melhora do conforto expressa vontade de realizar atividades físicas autocuidado: atividades da vida diária autocuidado: atividades instrumentais da vida diária sociocultural conforto prejudicado falta de controle da situação (dependência de outras pessoas para o seu cuidado) adaptação psicossocial: mudança de vida autonomia pessoal falta de controle da situação (cuidador não tem tempo para dedicação exclusiva ao cuidado, parou de trabalhar para cuidar do paciente) bem-estar do cuidador potencial de resistência do cuidador para cuidado prolongado psicoespiritual conforto prejudicado falta de controle da situação (sua situação o deixa triste) aceitação: estado de saúde quadro 1. diagnósticos de enfermagem para cada contexto onde se produz conforto, segundo kolcaba (1), com distribuição dos resultados esperados para alcance dos diversos tipos de conforto diária (em nível de alívio); autocuidado: atividades instrumentais de vida diária (em nível de tranquilidade). para o alcance dos re selecionados, as ie acompanhadas de ações sugeridas foram: para o de conforto prejudicado — controle do ambiente: conforto (posicionar o paciente para facilitar o conforto; monitorar a pele, especialmente sobre as saliências corporais, na busca de sinais de pressão ou irritação; criar um ambiente seguro para o paciente; e remover perigos ambientais); cuidados cardíacos (comer refeições pequenas e fracionadas; diminuir consumo de sódio, líquido e carboidratos); ensino: processo de doença (explicar a fisiopatologia da doença e como ela se relaciona à anatomia e à fisiologia, quando adequado; orientar o paciente sobre medidas de controle/minimização de sintomas); monitoração das extremidades inferiores (examinar as extremidades inferiores em busca de presença de edema; examinar as unhas dos pés quanto a mudanças; examinar a pele quanto a cor, temperatura, hidratação, crescimento dos pelos, textura e fissuras ou lesões); cuidado com lesões (orientar o paciente ou o(s) membro(s) da família sobre os procedimentos de cuidados com a ferida; posicionar o paciente de modo a evitar tensão sobre a lesão); cuidados com a pele: tratamentos tópicos (evitar o uso de lençóis com materiais de textura mais grossa; aplicar emolientes na área afetada); massagem simples; e terapia com exercício: deambulação (auxiliar o paciente a usar calçados que facilitem o andar e previnam lesões; oferecer recurso auxiliar, como uma bengala). para o de dor crônica, as ie sugeridas foram: controle da dor (ensinar o uso de técnicas não farmacológicas; incorporar a família na modalidade de alívio da dor, se possível; oferecer 124 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 informações sobre a dor, como suas causas, tempo de duração e desconfortos); massagem simples; e posicionamento (elevar a parte do corpo afetada; oferecer apoio à área edemaciada). para o de disposição para melhora do conforto, as ie sugeridas foram: cuidados cardíacos (orientar o paciente e a família sobre as restrições e a progressão das atividades); assistência no autocuidado (encorajar o paciente a realizar atividades normais da vida diária de acordo com seu nível de capacidade; orientar os familiares a encorajarem a independência do paciente e a interferirem apenas quando o paciente não conseguir executar algo); e controle de energia (estimular períodos alternados de repouso e atividade; organizar atividades físicas que reduzam a competição pelo suprimento de oxigênio às funções vitais do organismo; encorajar a realização de atividades físicas compatíveis com os recursos energéticos do paciente; orientar o paciente/pessoas significativas a reconhecer sinais e sintomas de fadiga que requeiram a redução da atividade; auxiliar o paciente/pessoas significativas a estabelecer metas de atividade realistas). após a fase de implementação das recomendações de medidas de conforto, seguiu-se à avaliação de suas repercussões, o que se deu em uma terceira visita domiciliária, por meio de entrevista e observação. não foram utilizadas as escalas de avaliação sugeridas pela noc (14), pois se pretendeu uma avaliação qualitativa primada no descrito na teoria do conforto, quanto ao alcance dos resultados em nível de alívio, tranquilidade e transcendência. assim, os resultados da avaliação por escalas, sugeridas na noc (14), não forneceriam subsídios a esta análise em particular, posto que informações subjetivas poderiam ser desconsideradas. os resultados alcançados no contexto físico foram: alívio (paciente apresentou melhora no aspecto da pele, com cicatrização de lesão; cuidadora afirmou utilizar hidratantes para hidratar a pele e os dois estão tendo maior atenção a qualquer tipo de lesão que aparecer, com o cuidado de relatar aos profissionais quando da visita domiciliar); e tranquilidade (paciente refere considerável melhora do edema, com diminuição da dor e maior conforto ao permanecer em pé ou locomover-se, o que o tem deixado mais ativo). para o contexto ambiental, não foram detectadas necessidades de conforto a serem trabalhadas. para o contexto sociocultural, identificaram-se os problemas: mediante escala de conforto (dependência de outras pessoas), pela observação (necessidade de maior conforto do cuidador) e pela anamnese, exame físico e entrevista (não foram detectadas necessidades). o problema detectado pela escala de conforto sugeriu necessidade de conforto em nível de alívio. o sujeito apontou desconforto no contexto da afirmativa “sinto-me dependente dos outros”. esse dado soma ao encontrado na anamnese e exame físico, quanto à sua necessidade de auxílio para locomover-se. essa dependência também foi evidenciada pela falta de conhecimento do sujeito sobre seu regime terapêutico, enfatizado pelo desconhecimento das medicações em uso e de suas indicações, as quais foram bem descritas pela sua cuidadora (esposa). neste contexto, o de pertinente foi: conforto prejudicado, caracterizado por relato de falta de satisfação com a situação, relacionado com falta de controle da situação (dependência de outras pessoas para o seu cuidado; e falta de tempo do cuidador para dedicação exclusiva ao cuidado, o que o levou a parar de trabalhar para cuidar do paciente). os re para esse de, em nível de alívio, não foram eleitos; em nível de tranquilidade: adaptação psicossocial: mudança de vida e bem-estar do cuidador; e em nível de transcendência: autonomia pessoal e potencial de resistência do cuidador para cuidado prolongado. as ie e ações sugeridas para o alcance dos re listados foram: melhora do enfrentamento (promover situações que estimulem a autonomia do paciente; encorajar o paciente a identificar seus pontos fortes e capacidades); e apoio ao cuidador (fazer afirmações positivas sobre os esforços do cuidador; estimular o cuidador a manter uma vida social). os resultados alcançados depois de feitas as recomendações ao paciente e família das medidas de conforto foram: alívio (paciente se mostrou com mais força de enfrentar a doença); e tranquilidade (cuidadora se mostrou mais tranquila quanto às suas demasiadas preocupações com o paciente. também referiu estar cuidando mais de si). para o contexto psicoespiritual, identificaram-se os problemas: pela escala de conforto (tristeza associada ao estado de saúde), pelos outros instrumentos não foram detectadas nenhuma necessidade. 125 processo de enfermagem no conforto do paciente com insuficiência cardíaca no domicílio l fabíola vládia freire da silva, lúcia de fátima da silva, ana cleide silva rabelo quanto à necessidade identificada pela escala de conforto, esta se deu em nível de alívio. tal necessidade foi aludida no escore atribuído à afirmativa “a minha situação me deixa triste”. esse estado de descontentamento é pelo paciente justificado devido a sua situação de adoecimento e perda de autonomia. neste contexto, o de pertinente foi: conforto prejudicado, caracterizado por relato de falta de satisfação com a situação, relacionado à falta de controle da situação (sua situação o deixa triste). os re listados foram: aceitação: estado de saúde (em nível de alívio); imagem corporal (em nível de tranquilidade); e bem-estar pessoal (em nível de transcendência). a ie e ação proposta para o alcance desses resultados foi: melhora do enfrentamento (auxiliar o paciente a identificar estratégias positivas para lidar com as limitações e administrar mudanças necessárias no estilo de vida e no desempenho de papéis). o resultado alcançado para este contexto foi alívio (paciente e cuidadora se mostraram mais confiantes quanto ao lidar com a doença, mesmo que ainda de forma insipiente). discussão muitas das necessidades de conforto relacionadas ao contexto físico são consequências diretas das alterações advindas da ic. exemplo disso é o edema e a necessidade de praticar atividades físicas citadas pelo participante. sabe-se que o edema é sintoma clássico da ic devido à ineficiência cardíaca e que a prática de atividades físicas é proibida pela sobrecarga que estas causam ao coração, que já está fragilizado (16). uma das características marcantes dos pacientes acometidos por ic é a piora da capacidade funcional e conforto. em geral, sofrem modificações em seu padrão de vida normal, pois sintomas como dispneia, fadiga, edema, síncope e palpitações interferem na execução de determinadas tarefas do cotidiano. além disso, existem fatores psicológicos, como o medo e a ansiedade diante das restrições a que são expostos. assim, tanto os aspectos físicos quanto emocionais são afetados pela doença (17). a prática de promover medidas de conforto é imprescindível ao cuidado humanizado e de qualidade ao paciente. ressalta-se sua relevância no restabelecimento da saúde do indivíduo, uma vez que é por meio de medidas de conforto que os enfermeiros e sua equipe promovem reforço, esperança, consolo, apoio, encorajamento e assistência de qualidade (18). também, enfatiza-se que a prática do enfermeiro enquanto educador no cuidado ao paciente é fator propiciador de conforto, ao passo que o esclarecimento de dúvidas e a disponibilização de informações sobre o estado de saúde (fisiopatologia, sintomatologia e tratamento) podem conferir ao paciente maior segurança e apropriação de seu cuidado. um estudo realizado com pacientes com ic ressaltou que o déficit de conhecimento sobre a doença é fator influenciador sobre a dependência de familiares e sobre a dificuldade de controlar hábitos de vida (19). a responsabilidade que recai sobre o familiar que assume o papel de cuidador também se traduz em des(conforto). a observação das necessidades do cuidador é papel fundamental da enfermagem, que deve, juntamente com o cuidador, pensar nas possibilidades de recompor as energias físicas e emocionais deste. a exposição contínua dos cuidadores aos eventos estressantes da situação de cuidado implica alteração gradual e generalizada dos seus recursos pessoais e do seu bem-estar. alguns estudos identificaram associação entre maior duração do cuidado e pior qualidade de vida do cuidador (20, 21). necessidades referentes à falta de informação e suas consequências negativas ao paciente e seus familiares foram detectadas e trabalhadas no contexto sociocultural. já no contexto psicoespiritual destacou-se como des(conforto) a tristeza relacionada ao estado de saúde alterado. a literatura enfatiza que as limitações impostas pela mudança no estilo de vida, incapacidade de realizar atividades da vida diária, hospitalizações frequentes, interrupção das atividades profissionais e a consequente redução da renda são fatores que causam sentimentos negativos (16). no caso de portadores de morbidades crônicas, muitas vezes se encontram quadros depressivos ou de desesperança associados ao seu prognóstico. o fator emocional afeta diretamente a saúde cardiovascular (22). assim, o cuidado dispensado ao paciente deve visar a um conforto holístico, pois os contextos físico, ambiental, sociocultural 126 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 e psicoespiritual são influenciados e influenciadores entre si no bem-estar do sujeito. deve-se, portanto, estar atento não apenas à abordagem de todos esses aspectos, mas também à adequação dos re estabelecidos e dos ie propostos quanto às possibilidades de alcance e de execução pelo paciente ante as limitações impostas pela doença. assim, no caso do participante, a maioria os resultados propostos visava a um estado de alívio ou tranquilidade. isso decorreu do fato de resultados de conforto do tipo transcendência, da classificação de kolcaba (1), serem os mais difíceis de ser alcançados, pois se referem a um estado em que os problemas são superados. no caso de pacientes com adoecimentos crônicos, algumas das necessidades identificadas são improváveis de atingir alívio do tipo transcendência. com relação aos re eleitos no contexto físico, houve a necessidade dessa adaptação de medidas que propiciassem conforto, mas não sobrecarregassem o participante. assim, como indicador de conforto relacionado com a necessidade de realizar atividades físicas, optou-se por eleger atividades de vida diária (autocuidado), pois, em geral, médicos não orientam pacientes com ic para a realização de exercício (23). as medidas propostas conformaram-se à capacidade funcional do participante e consideraram seus aspectos físicos, emocionais, sociais, econômicos e culturais, o que lhe possibilita autonomia e apropriação do seu cuidado. o controle inadequado da doença e a não realização da prática do autocuidado representam uma ameaça para a vida do paciente com ic, pois favorece o aparecimento de complicações (24). no contexto sociocultural, percebeu-se que as necessidades expostas pelo participante eram decorrentes do repasse da responsabilização do seu cuidado para sua cuidadora. essa observação conveio ao estabelecimento de resultados e intervenções que contemplassem a necessidade de conforto da cuidadora ante tal responsabilidade. a discussão referente à sobrecarga familiar diante da dependência é algo que já vem acontecendo há décadas, sendo situação comum nos domicílios com familiares dependentes, principalmente na ausência de apoio (25, 26). a falta de tempo para atender às necessidades e interesses pessoais e dedicar-se ao bem-estar de outrem compromete e ameaça o bem-estar do cuidador. abrir mão de si para cuidar do outro é algo que pode ser sustentado durante certo período, mas, quando ultrapassa o limite, gera a frustração pela falta de tempo para atender às necessidades e interesses pessoais (27). já o que se refere ao contexto psicoespiritual, os re e ie voltaram-se ao conforto do paciente em nível de bem-estar pessoal, o qual fortaleceria sua capacidade de enfrentamento diante da sua condição de adoecimento crônico. o bem-estar pessoal, segundo vecchia (28), juntamente com a autoestima, são fatores influenciadores da qualidade de vida e incluem uma série de aspectos, como a capacidade funcional, o nível socioeconômico, o estado emocional, a interação social, a atividade intelectual, o autocuidado, o suporte familiar, o próprio estado de saúde, os valores culturais, éticos e a religiosidade, o estilo de vida, a satisfação com o emprego e com atividades diárias e o ambiente em que se vive. portanto, o bem-estar pessoal aparece como um fator de satisfação pessoal, característico de transcendência individual. considerações finais este estudo possibilitou a utilização da teoria do conforto de katharine kolcaba no cuidado ao indivíduo com ic. trata-se de uma teoria de médio alcance, que demonstrou fácil aplicabilidade e afinidade com o objetivo do estudo, o qual foi proporcionar conforto por meio do cuidado de enfermagem em domicílio. ressalta-se, portanto, a importância de o processo de enfermagem dirigido à pessoa cardiopata ter como fundamento uma teoria de enfermagem. isso porque a teoria, ao ser aplicada, revela-se como um complexo teórico que fortifica a enfermagem enquanto ciência, além de se revelar como um modo de ser com o outro, que incentiva a proximidade, a empatia, a interação e o compromisso, buscando sempre a autonomia e valorização do indivíduo. pretendeu-se, no desenvolvimento deste estudo, realizar atividades que abarcassem, além de conhecimento científico, um cuidar legítimo, em uma relação de envolvimento entre ser cuidado e ser cuidador. 127 processo de enfermagem no conforto do paciente com insuficiência cardíaca no domicílio l fabíola vládia freire da silva, lúcia de fátima da silva, ana cleide silva rabelo a aplicação da teoria do conforto, com vistas à fundamentação do desenvolvimento do pe, possibilita, ao enfermeiro, neste caso aquele que trabalha no campo da saúde em cardiologia, uma melhor compreensão das reais necessidades do ser com ic, além de direcionar o olhar do enfermeiro para o cuidado humanístico. dessa forma, favorece uma melhor qualidade no cuidado de enfermagem a essa população. como proposta à humanização no cuidado ao indivíduo com ic, sugere-se que os profissionais enfermeiros apliquem em sua prática profissional os elementos da teoria do conforto de katharine kolcaba, que visam a um cuidar individualizado e eficaz, o qual amenize o sofrimento desses indivíduos e reduza suas ansiedades e preocupações. propõe-se, também, que as instituições formadoras de enfermeiros incluam em seus planos pedagógicos o conforto como meta a ser alcançado após as atividades de enfermagem. ressalta-se que, apesar de o estudo não ser definitivo, ele permite e visa ao despertar de pesquisadores para que novos estudos sejam realizados na busca da melhoria do conforto ao ser com adoecimento cardíaco no ambiente domiciliar. referências 1. kolcaba k. comfort theory and practice: a vision for holistic health care and research. nova york: springer publishing company, inc; 2003. 264 p. 2. schaurich d, crossetti mgo. o elemento dialógico no cuidado de enfermagem: um ensaio com base em martin buber. esc anna nery rev enferm. 2008; 12(3):544-48. 3. waldow vr. atualização do cuidar. aquichan 2008; 8(1):85-96. 4. backes mts, erdmann al, backes ds. cuidado ecológico: o significado para profissionais de um hospital geral. acta paul enferm. 2009; 22(2):183-91. 5. varela gc, fernandes sca, queiroz jc, vieira an, azevedo vrc. sistematização da assistência de enfermagem na estratégia saúde da família: limites e possibilidades. rev rene. 2012; 13(4):816-24. 6. universidade estadual do ceará/cmacclis. regimento do programa de pós-graduação em cuidados clínicos da uece. fortaleza, 2011. (mimeo). 7. silva fvf, silva lf, guedes mvc, moreira tmm, rabelo acs, ponte kma. cuidado de enfermagem a pessoas com hipertensão fundamentado na teoria de parse. esc anna nery rev enferm (impr.). 2013; 17(1):111-9. 8. loures va, noronha mfa, bastos rg, girardi jm. aspectos clínicos e epidemiológicos da insuficiência cardíaca. hu revista, juiz de fora. 2009; 35(2):89-96. 9. soares da, toledo jas, santos lf, lima rmb, galdeano le. qualidade de vida de portadores de insuficiência cardíaca. acta paul enferm. 2008; 21(2):243-8. 10. silva fvf. processo de enfermagem com vistas ao cuidado clínico de conforto do paciente com insuficiência cardíaca. 2013. 167f. dissertação (mestrado acadêmico em cuidados clínicos e saúde). programa de pós-graduação em cuidados clínicos em enfermagem e saúde, centro de ciências da saúde, universidade estadual do ceará, fortaleza; 2013. 11. yin rk. estudo de caso: planejamento de métodos. 4ª ed. porto alegre: bookman; 2010. 12. nanda internacional. diagnósticos de enfermagem da nanda: definições e classificação 2012-2014. porto alegre: artmed; 2013. 606 p. 13. dochterma jm, bulechek gm. classificação das intervenções de enfermagem (nic). 4ª ed. porto alegre: artmed; 2008. 14. moorhead s, johnson m, maas m. classificação dos resultados de enfermagem (noc). 4ª ed. rio de janeiro: elsevier; 2010. 15. ministério da saúde (br). conselho nacional de saúde, comissão nacional de ética em pesquisa. resolução 466/2012: aprova as diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. dou n. 12 (seção 1):59; 2013. 128 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 16. bocchi ea, marcondes-braga fg, ayub-ferreira sm, rohde le, oliveira wa, almeida dr, e cols. sociedade brasileira de cardiologia. iii diretriz brasileira de insuficiência cardíaca crônica. arq bras cardiol. 2009; 93(1 supl 1):1-71. 17. helito rab, branco jnr, d’innocenzo m, machado rc, buffolo e. qualidade de vida dos candidatos a transplante de coração. rev bras cir cardiovasc. 2009; 24(1):50-7. 18. pott fs, stahlhoefer t, felix jvc, meier mj. medidas de conforto e comunicação nas ações de cuidado de enfermagem ao paciente crítico. rev bras enferm. 2013; 66(2):174-9. 19. corrêa la, santos i, sousa to, rocha rm, abuquerque dc. research and nursing care of clients with congestive heart failure: an exploratory study. online braz j nurs [internet]. 2006; 5(3). 20. franco mc; jorge msb. sofrimento do familiar frente à hospitalização. em: elsen i, marcon ss, silva mrs. o viver em família e sua interface com a saúde e a doença. 2ª ed. maringá: eduem; 2004. p.169-81. 21. fernandes mgm, garcia tr. atributos da tensão do cuidador familiar de idosos dependentes. rev. esc. enferm. usp. 2009; 43(4):818-24. 22. reza cg. o cotidiano do hipertenso na perspectiva do modelo de campo de saúde de lalonde [tese]. ribeirão preto(sp): escola de enfermagem de ribeirão preto; 2007. 23. guimarães gv, carvalho vo, torlai v, bocchi ea. physical activity profile in heart failure patients from a brazilian tertiary cardiology hospital. cardiol j. 2010; 17(2):143-5. 24. oliveira skp, lima fet, pessoa vlmp, caetano ja, meneses lst, mendonça lba. práticas de autocuidado de pacientes com insuficiência cardíaca. rev. cienc. med. 2013; 22(1):23-30. 25. brito es, rabinovich ep. a família também adoece!: mudanças secundárias à ocorrência de um acidente vascular encefálico na família. interface (botucatu) 2008; 12(27);783-94. 26. pinto mf, barbosa da, ferreti cel, souza lf, fram ds, belasco ags. acta paul. enferm. 2009; 22(5):652-57. 27. gallagher s, phillips ac, carroll d. parental stress is associated with poor sleep quality in parents caring for children with developmental disabilities. j. pediatr. psychol. 2010; 35(7):728-37. 28. vecchia rd, ruiz t, bocchi scm, corrente je. qualidade de vida na terceira idade: um conceito subjetivo. rev. bras. epidemiol. 2005; 8(3):246-52. 08. al. internacional (59 a 60) actualidad 59 olaboración, asociaciones y alianzas estratégicas son las palabras que circulan de boca en boca de la enfermería y de la educación de enfermería, desde hace más o menos diez años. esta situación se debe a que la comunidad internacional de enfermería reconoce que la sinergia entre organizaciones locales, nacionales e internacionales es sumamente productiva, en términos del desarrollo de la práctica, la educación y la investigación. tradicionalmente, las alianzas que se han generado entre las instituciones educativas de enfermería se han mantenido dentro de los ámbitos nacional o regional y, en esencia, se han sustentado en las relaciones bilaterales de instituciones, o uno a uno de personas, dependiendo de las necesidades institucionales y las relaciones individuales entre académicos. sin embargo, durante los últimos años se han generado movimientos para promover alianzas profesionales y académicas, con un nuevo nivel de sofisticación e integración. las universidades han establecido consorcios internacionales para ofrecer programas académicos educativos e investigativos, y los programas de doctorado en enfermería han establecido una red, que les permite comunicación permanente. además, los profesionales de los servicios, tales como especialistas y expertos, han promovido la formación y utilización de redes. para apoyar estas propuestas, una gran ventaja con que se cuenta en la actualidad es la tecnología, en particular internet, que permite la creación de “aldeas globales”, tanto para educadores y expertos clínicos como para los consumidores del cuidado de enfermería pacientes. en la actualidad se ha dado un paso importante para los académicos de la enfermería, con el establecimiento reciente de la alianza internacional académica de enfermería iana, la cual tiene como meta crear un foro internacional en línea, donde las alianzas mencionadas logren la coordinación, se facilite su conocimiento y se publiquen sus productos. la alianza está comprometida con los principios de equidad y diversidad que profesan los profesionales de enfermería de los países del mundo. para asegurar la representación de todos los miembros de la alianza, se han promovido los mecanismos de participación necesarios y, además, se ha eliminado la posibilidad de imponer “modelos y tradiciones establecidos por costumbre” como las propuestas que se deben promover y aceptar. la alianza será una red internacional electrónica de escuelas y facultades de enfermería de carácter universitario. será la única alianza de enfermería con enlaces y vínculos globales entre instituciones educativas de nivel académico universitario, y es por esta razón que puede convertirse en un instrumento poderoso para el avance de la ciencia, la educación y la práctica de la enfermería. la alianza no propone una organización burocrática. estará enfocada a facilitar el desarrollo de la enfermería y tendrá una amplia base de sustento; por ejemplo, una base mucho más amplia que la red de educación doctoral de enfermería, la cual tiene como meta exclusiva promover el avance y el mejoramiento de la calidad de la educación doctoral de enfermería. maría mercedes de villalobos profesora titular y emérita, facultad de enfermería, universidad nacional de colombia. asesora facultad de enfermería, universidad de la sabana revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 60 cuando la alianza esté en pleno funcionamiento brindará, inter alia, bien sea directamente o a través de enlaces, al personal docente interesado y motivado para el intercambio internacional con otras redes, directorios de escuelas y facultades, pero en especial facilitará el acceso a programas de postgrado y al contacto entre estudiantes de doctorado. para facilitar los lazos entre los docentes y estudiantes de doctorado, para el intercambio, los seminarios de investigación, las labores de educación a distancia y otras actividades posibles, se contará con una página web o portal y “chat rooms”, los cuales se están diseñando actualmente. la alianza iana no está diseñada para hacer actividades de supervisión o acreditación, pero sí servirá de enlace para la colaboración entre grupos ya establecidos, tales como universitas 21 y la red mundial de universidades, los cuales tienen entre sus miembros universidades acreditadas mundialmente, que pueden ayudar a otras en su empeño de lograr acreditación y credenciales, al asociarse con pares de estas características. el desarrollo de la alianza ha tenido apoyo significativo de sigma theta tau internacional. en septiembre de 1999, un grupo de 31 enfermeras líderes de diferentes partes del mundo se reunieron, para discutir el interés y la factibilidad de su conformación. luego, en octubre de 2000, un grupo de representantes de 28 países se reunieron en atlanta, georgia, para establecer un comité asesor y diez grupos de trabajo, que funcionarían como motores del desarrollo inicial. en marzo de 2001, el comité asesor acogió la misión y visión de la alianza y acordó un cronograma de trabajo. su inauguración se llevó a cabo, de manera formal, en asociación con el consejo internacional de enfermeras, en dinamarca, en junio de 2001. la afiliación a la alianza será institucional; existirán cuotas de mantenimiento anuales, las cuales todavía no se han propuesto. personalmente, se sugiere a todas las facultades y escuelas de enfermería, y a aquellas instituciones que aspiren a ubicarse en universidades, unirse a la alianza. iana tiene un potencial muy grande para facilitar el acceso a un amplio espectro de recursos internacionales de enfermería. es en este sentido que queremos cumplir con su visión, de “crear una comunidad global de enfermeras educadoras y académicas, que lideren e influyan positivamente en el mejoramiento de la educación y la práctica de la enfermería y, por lo tanto, en el cuidado de la salud, utilizando como medios la tecnología, la colaboración y el conocimiento actualizado”. otros detalles y mayor información pueden obtenerse de manera directa con la doctora: genevieve gray (genevieve.gray@ualberta.ca), decana de la facultad de enfermería de la universidad de alberta, en canadá, o a través de sigma theta tau internacional. genevieve gray presidenta, junta directiva iana propósito el propósito de la alianza internacional académica de enfermería es promover el desarrollo académico de la educación y la práctica de la enfermería, a través de conexiones y enlaces internacionales de instituciones educativas universitarias de enfermería, para facilitar la colaboración, los intercambios, la mentoría, la investigación y el desarrollo de docentes, pero, sobre todo, para la promoción de altos estándares en la educación de enfermería. misión la alianza internacional académica de enfermería es una comunidad electrónica e internacional de académicos de la enfermería, unidos por ideales y metas profesionales comunes y una cultura del cuidado, dedicados al desarrollo y la colaboración académicos. la alianza se esfuerza, decididamente, en la utilización estratégica de pares, oportunidades y recursos, para promover estándares de desarrollo académico y facilitar el progreso de la educación de la enfermería en todo el mundo y, consecuentemente, para mejorar la práctica de la enfermería y dar respuesta a las necesidades del cuidado de la salud de la gente. visión la visión de la alianza internacional académica de enfermería es crear una comunidad global de enfermeras educadoras y académicas, que lideren e influyan positivamente en el mejoramiento de la educación y la práctica de la enfermería y, por lo tanto, en el cuidado de la salud, utilizando como medios la tecnología, la colaboración y el conocimiento actualizado. la institución la alianza internacional académica de enfermería se constituyó como una organización sin ánimo de lucro (501 © 3), en septiembre de 2001. el consejo directivo es la junta de gobierno que toma las decisiones políticas de la alianza, y se compone de miembros internacionales. la sociedad honoraria de enfermería, sigma theta tau internacional, ha brindado apoyo administrativo y logístico a la alianza, desde sus comienzos y en la actualidad. 04. abordajes tešric.(32 a 41) año 3 nº 3 • bogotá, colombia octubre 2003 32 resumen el artículo presenta el dolor como el síntoma más frecuente con el que se identifican problemas de salud. para apoyar la comprensión de su naturaleza compleja, propone formas de clasificarlo, según su origen, duración, intensidad, localización y velocidad de conducción. además, presenta algunas teorías que explican la naturaleza de la experiencia dolorosa, como la de la especificidad del dolor y la del patrón del dolor, dos teorías sobre la percepción del dolor, que incluyen la teoría del control de las compuertas y la teoría de las endorfinas y de los no opiáceos, la teoría de los multirreceptores opiáceos para la sensación dolorosa, la teoría psicológica del dolor y, por último, como aportes importantes de la enfermería a este campo, las teorías de mediano rango de los síntomas desagradables, la del equilibrio entre la analgesia y los efectos colaterales. el artículo finaliza presentando un breve análisis de la utilidad del abordaje teórico sobre el dolor para la práctica de enfermería. palabras clave: dolor, teoría del dolor, analgesia. abstract this article presents pain as the most frequent symptom with which health problems are identified. to support the comprehension of its complex nature, it propose ways to classify it, according to its origin, duration, intensity, localization and speed of conduction. moreover, it presents some theories to explain the nature of pain experience, such as the one of specific pain and pain model, two theories about pain perception, including control theory of entries and theory of endorphins and non opium, theory of multiple receptors of opium for pain sensation, theory of psychological pain as an important contribution for nursing, theories of medium range of unpleasant symptoms, of equilibrium between analgesia and side effects. the article ends presenting a brief analysis of the utility of a theoretical approach about pain for nursing practice. key words: pain, theory of pain, analgesia. beatriz sánchez herrera magíster en enfermería, universidad de pensilvania profesora asociada, facultad de enfermería, universidad nacional de colombia. abordajes teóricos para comprender el dolor humano 33 i. clasificación del dolor según la revisión hecha por ganong (2), dagnino (3) y torrecillas (4), esta clasificación se ha realizado de acuerdo con el origen, la intensidad, la duración, la conducción o la ubicación que el dolor tenga. a continuación se presentan las principales clasificaciones, de empleo internacional, con el fin de que puedan ser aplicadas en la práctica de la enfermería. 1. clasificación del dolor según su origen dependiendo de su origen, el dolor humano se divide en espiritual, físico o psicológico. 1.1. espiritual. este dolor es producido por las incomprensiones, la muerte de un ser querido, las injusticias, la depresión, la soledad. el dolor espiritual, al igual que el físico, tiene una razón de ser. según solimine y cols. (5), es una señal de alarma de algo que no anda bien, y se asocia muchas veces a alteraciones físicas o psicológicas. en el caso de incapacidad o enfermedad de una persona, afirman las autoras, el espíritu va a actuar primero como un mediador para el individuo, para ganar fortaleza y superar la desarmonía, que es experimentada como desorganización, interrupción, tristeza, rabia, culpa, ansiedad, desespero o desesperanza. luego el espíritu va a aydar a la reorganización y, finalmente, a la resolución de la incapacidad en la vida de la persona, creando un sentido general de bienestar, que unifica al individuo con otros, la naturaleza y un poder superior. cuando ese espíritu no está bien, cuando hay dolor espiritual, la etiología de esta “falta de espíritu” es también múltiple y diversa, y las necesidades espirituales se manifiestan a través de los síntomas físicos de dolor, duda, inquietud o desesperación, y por las conductas psicosociales, el lenguaje corporal, el habla y/o el silencio. la naturaleza intangible e indescriptible propia de lo espiritual hace que este dolor sea difícil de comprender para terceros, cuando no lo han vivido. l dolor es el síntoma aislado por el cual la gente consulta con mayor frecuencia a los profesionales de la salud y a personas que considera expertas en el campo. de acuerdo con la definición formulada en 1980 por la asociación internacional para el estudio del dolor, que sigue vigente, el dolor es una experiencia sensitiva y emocional desagradable, asociada con una lesión real o potencial de un tejido; es decir, se admite que además de una lesión, existe la contribución psicológica a la experiencia del dolor. el mismo grupo ha empleado también el término nocicepción, que procede de la palabra nocivo, para describir la experiencia de un estímulo que lesiona los tejidos. la complejidad e impacto del dolor humano ha generado múltiples abordajes teóricos, que pretenden clasificarlo y explicarlo, con el fin de que pueda ser abordado de manera más acertada. las teorías no representan un hecho real, sino que pueden describirlo, relacionarlo o predecirlo. en su conjunto, ellas ofrecen un marco de análisis que da la estructura para sistematizar la información, de manera que pueda ser empleada en la investigación, la educación o la asistencia. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 34 1.2. físico. el dolor físico es una sensación subjetiva de molestia de alguna parte del cuerpo, que se produce por mecanismos orgánicos originados por lesiones o disfunciones con una variabilidad inmensa de causas. el dolor físico puede ser de carácter nociceptivo o neuropático. 1.2.1. nociceptivo: resulta de la activación de nociceptores periféricos, que transmiten impulsos nerviosos a través de vías aferentes sensoriales, sin daño del nervio periférico ni del sistema nervioso central (snc). este tipo de dolor se clasifica a su vez en: a. dolor somático: es característicamente bien localizado, punzante, definido, y puede ser atribuido a una estructura anatómica específica. b. dolor visceral: se caracteriza por ser difuso, mal localizado, sordo, agotador, y por acompañarse de respuestas autonómicas como salivación, hipotensión, náuseas, vómitos. c. dolor profundo: puede definirse como el que se percibe en una zona del cuerpo diferente del lugar que le da origen. 1.2.2. neuropático: es el dolor que resulta de una lesión directa sobre los nervios periféricos, los receptores nociceptivos o el snc. típicamente se describe como un dolor quemante, lacerante, que suele tener una distribución dermatómica clara. 1.3. psicológico. es un dolor real, aunque no tenga una base orgánica explicable. se presenta en sujetos personalmente predispuestos, con reacciones exageradas a mínimos estímulos. el problema central es la amplificación involuntaria, con distorsión de esos impulsos periféricos por razones psicológicas. 2. clasificación del dolor según su duración 2.1. dolor agudo. sirve como un mecanismo fisiológico protector, que nos informa cuando algo está mal en nuestro cuerpo o que previene daño adicional de los tejidos, al limitar el movimiento de partes lesionadas. se presenta con respuestas comportamentales o del sistema autónomo y es limitado en el tiempo. cede cuando sana el tejido, y por lo general se puede controlar con medicamentos. el dolor agudo genera ansiedad, que persiste en función de las dimensiones temporales del paciente. tiene una duración inferior a los tres meses y es el resultado de una lesión. su misión es alertar al individuo sobre algo que no funciona correctamente. 2.2. dolor crónico. así se denomina el dolor que persiste por algún tiempo, casi siempre se establece entre tres y seis meses, ocurre en intervalos de meses o años o se asocia a patología permanente. si el individuo presenta este dolor, el cuerpo se ha adaptado y por lo general no hay respuestas fisiológicas o autonómicas. el dolor crónico suele ser continuo, intratable, intermitente o recurrente. aun cuando sea leve, puede ser tan perverso que se vuelve una condición en sí mismo, y con frecuencia requiere manejo diario. también puede ir acompañado de alteraciones psíquicas concomitantes y no cumple, como el dolor agudo, una función definida, sino que hace parte de la enfermedad. genera sentimientos de impotencia, desesperación y absurdidad. dentro del dolor crónico se distinguen a la vez dos categorías mayores, que son: 2.2.1. el dolor crónico no maligno, paradójicamente llamado dolor benigno, puesto que no se asocia con enfermedad terminal, pero no responde de manera adecuada al tratamiento médico convencional, por lo que se le denomina también dolor intratable. 2.2.2. el dolor crónico maligno, que está asociado a enfermedad terminal progresiva. 3.clasificación del dolor según su intensidad según esta clasificación, el dolor refleja la fuerza o grado con que una persona lo experimenta. por lo general, este nivel se mide con escalas que reflejan la forma como es percibido. dentro de estas, las más utilizadas son la escala numérica, que va de 0 a 10, donde 0 es ausencia y 10 el máximo dolor abordajes teóricos para comprender el dolor humano 35 soportable, y la escala visual análoga (e.v.a.), que corresponde a una representación gráfica de la anterior. con base en la medición de la intensidad del dolor, este se clasifica en: 3.1. leve. en él interviene básicamente la piel (o sea, la sensación cutánea), por medio de los receptores de presión, temperatura, tacto fino, que pueden ser lesionados por quemaduras, machucones, golpes, etc. se considera dolor leve si la e.v.a. está entre 1 y 3. 3.2. moderado. es un estado intermedio entre el dolor leve y el severo; en él generalmente está involucrada la epidermis y el tejido celular subcutáneo. se considera dolor moderado si la e.v.a. está entre 4 y 6. 3.3. severo. en él se comprometen los músculos, las articulaciones, los huesos y otros tejidos (tendones, tejido conectivo, etc.). se considera dolor severo si la e.v.a. está entre 7 y 10. vale la pena recordar que el umbral para la percepción dolorosa es individual y diferente en cada sujeto, por lo cual frente al mismo estímulo la percepción puede ser distinta. 4. clasificación del dolor según su localización 4.1. dolor localizado. es producido por lesiones o condiciones agudas o crónicas, y reconocible por cuanto es un tipo de dolor limitado a la estructura inflamada o lesionada. por lo general se acompaña de limitación del movimiento, como mecanismo de defensa para impedir su aparición o aumento de la intensidad. 4.2. dolor difuso o propagado. es aquel que se siente en estructuras sanas, como resultado de la lesión en otras estructuras. el dolor difuso puede ser irradiado o referido. • dolor irradiado. es el tipo de dolor que se produce por lesión a nivel de una fibra sensitiva dolorosa, a distancia de su terminación. por ejemplo, es el que se observa en la radiculitis ciática secundaria a hernia discal. • dolor referido. es percibido a distancia de su origen, pero se diferencia del anterior en que mientras en él las partes lesionadas son las vías de su circuito, en este las vías nerviosas están indemnes. en el dolor referido, la lesión se produce en las estructuras esqueléticas, no en las neurales. 5. clasificación del dolor según su velocidad de conducción los receptores para el dolor son terminaciones nerviosas desnudas, que se encuentran en casi todos los tejidos del organismo. los impulsos dolorosos son transmitidos al snc por dos tipos de fibras. uno está compuesto de pequeñas fibras mielinizadas n, que conducen a velocidades de 12 a 30 m/segundo. el otro consiste en fibras c no mielinizadas, más gruesas, que se encuentran en la división lateral de las raíces dorsales; ellas conducen impulsos a velocidades bajas de 0,5 2 m/segundo. los dos tipos terminan en el fascículo espinotalámico lateral, donde relevan a sus neuronas, y los impulsos dolorosos ascienden a través de este fascículo y de los núcleos posteroexternos ventrales del tálamo. de ahí, ellos relevan la circunvolución posrolándica de la corteza cerebral. aunque no hay fibras de dolor en los cordones posteriores, la sección de estas fibras puede hacer los estímulos dolorosos más intensos y desagradables. la presencia de dos vías para el dolor, una lenta y otra rápida, explica la observación fisiológica de que existen dos clases de dolor. estas dos sensaciones se llaman indistintamente dolor rápido y dolor lento. mientras más lejos del encéfalo se aplique el estímulo, mayor es la separación temporal de los dos componentes. 5.1. dolor rápido. se llama también primer dolor. se caracteriza por ser una sensación viva, aguda, localizada. se debe a la actividad de las fibras pequeñas de conducción rápida. 5.2. dolor lento. se llama también segundo dolor. sigue a la sensación rápida, pero esta es una sensación de tipo sordo, doloroso, difuso y desagradable. este dolor se debe a la actividad de las fibras c, que son gruesas y de conducción lenta. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 36 ii. teorías que explican el dolor son múltiples las teorías que han buscado explicar la experiencia dolorosa. han surgido teorías desde la fisiología, la psicología y la antropología, y algunas más recientes han combinado las anteriores, considerado el dolor como parte de una experiencia total y compleja que afecta al ser humano. a continuación se resumen los principales abordajes teóricos, presentados por mccaffery y beebe (6), novel (7), lenz y cols. (8, 9), y good y moore (10), que se han complementado entre sí para permitir la comprensión de esta experiencia humana. 1. teoría de la especificidad del dolor es una de las más antiguas, con las cuales se explica la transmisión del dolor. se basa en la concepción de que siempre hay una relación de causa-efecto en la percepción del dolor, y propone que hay receptores específicos del dolor (nociceptores), que proyectan impulsos sobre vías nerviosas específicas de dolor (a-delta y fibras c) por la médula espinal hacia el cerebro. 2. teoría del patrón del dolor esta teoría surgió cuando se demostró que los nociceptores respondían a estímulos como la presión y la temperatura, y no solo al dolor. sugiere que no hay nociceptores específicos para el dolor, y que este resulta de una combinación de intensidad de estímulos y del patrón de suma central de impulsos en el cuerno dorsal de la médula espinal. 3. teoría del control de las compuertas en la percepción del dolor esta teoría se basa en las dos anteriores y es ampliamente utilizada en la clínica, aunque no tiene completo apoyo de evidencia experimental. fue propuesta originalmente por melzack y wall, en 1965. según ella, el dolor pasa por una serie de vías nerviosas, en donde tiene que atravesar compuertas. esta teoría propone que el dolor debe alcanzar un nivel de conciencia antes de ser percibido, y si este puede ser prevenido, la percepción disminuye o se elimina. es decir, puesto que las fibras nerviosas periféricas hacen sinapsis en la materia gris del cuerno dorsal, esta área sirve como compuerta, y permite o inhibe la transmisión de impulsos dolorosos. cuando la compuerta está total o parcialmente cerrada, se frenan los impulsos dolorosos y se evita que lleguen al cerebro. si la compuerta está abierta, la sensación dolorosa se presentará, puesto que logra el nivel de conciencia requerido para ello. lo que resulta importante de esta teoría es que el mecanismo de cierre de las compuertas puede ser estimulado de varias formas, para contribuir al alivio del dolor. en la actualidad son claras tres formas de estímulo de esas compuertas, que incluyen: 1. la activación de fibras nerviosas de diámetro grueso. puesto que la piel cuenta con un gran número de fibras de este tipo, la estimulación que se haga a nivel cutáneo resulta en un cierre efectivo de compuertas en las fibras de conducción dolorosa, lo que en muchos casos permite lograr alivio. dicha estimulación puede producirse con vibración, con masaje en la zona álgida o en otras zonas, o con frotamiento rítmico como parte de la distracción. 2. la generación de estímulos sensoriales diferentes al dolor. al parecer, el sistema reticular del tronco del encéfalo puede inhibir los estímulos que le llegan, incluido el dolor, si la persona está recibiendo estímulos sensoriales diferentes, porque emite señales que cierran las compuertas. con base en ello se emplea la visualización dirigida, que implica concentración en experiencias visuales imaginadas. 3. disminuir la angustia o la depresión innecesarias. las compuertas se cierran mediante señales inhibitorias procedentes de la corteza cerebral y el tálamo, producidas al recibir información adecuada sobre las condiciones que genera la sensación dolorosa. en ese sentido, la sensación de control, a través de información precisa o de evocación de experiencias pasadas en donde se manejó el dolor adecuadamente, inhibe el estímulo doloroso de la misma forma. la compañía, como una forma de disminuir la angustia, puede apoyar en el alivio del dolor, más aún si quien la brinda genera mecanismos que disminuyan abordajes teóricos para comprender el dolor humano 37 la sensación de impotencia en estas personas. la teoría de control de la compuerta es útil para la enfermería, porque presenta un modelo conceptual integrado para la apreciación de los diversos factores que contribuyen en la experiencia y el alivio del dolor. 4. teoría de las endorfinas y de los no opiáceos para la percepción del dolor en 1977 se logra un avance muy importante en la comprensión de la percepción del dolor y de su alivio, con base en el aporte de snyder, quien identificó sustancias secretadas por el cuerpo humano semejantes a los narcóticos, las cuales se denominan endorfinas. estas actúan encajándose en los receptores narcóticos de las terminaciones nerviosas, en el cerebro y la médula espinal, para bloquear la transmisión de la señal dolorosa y así evitar que el impulso alcance el nivel de conciencia. según esta teoría, los niveles de endorfinas que tiene cada persona son diferentes, y los distintos estímulos pueden generar mayor o menor nivel de generación de estas sustancias, con lo cual se explican mejor algunos factores relacionados con las diferencias en la percepción o el umbral del dolor de las diferentes personas, y de una misma persona en distintas situaciones. dentro de los factores conocidos que tienden a aumentar o disminuir las endorfinas se encuentran los siguientes: 1. factores que las incrementan: dolor breve, estrés breve, el ejercicio físico, la acupuntura, la estimulación eléctrica transcutánea y la actividad sexual. 2. factores que las disminuyen: el dolor prolongado, el estrés recurrente, la ansiedad y la depresión. investigaciones recientes han señalado que en el cerebro y en la médula espinal existen regiones específicas que presentan afinidad por los opiáceos, y estos receptores cerebrales se localizan en las mismas áreas generales donde se piensa que están los centros para el dolor. se ha logrado aislar compuestos, llamados encefalinas, que el propio organismo produce para reducir el dolor, y que están formados por cinco aminoácidos. parece que pueden deprimir las neuronas de todo el snc. estas sustancias pertenecen al grupo de las endorfinas formadas por muchos aminoácidos, que se han aislado también en el organismo y que son producidos por la hipófisis. la administración de endorfinas, incluidas las encefalinas, produce efectos similares a los originados por los opiáceos. el descubrimiento de un tipo de compuestos que son antagonistas específicos de la acción de los opiáceos ha hecho posible que el tratamiento de la sobredosis por opiáceos sea rápido y eficaz. el fármaco que se emplea habitualmente con este fin es la naloxona. algunos de los antagonistas poseen también propiedades del tipo de los opiáceos, y esto ha conducido a la introducción de una nueva clase de analgésicos, los agonistas-antagonistas mixtos. existe la esperanza de que estos medicamentos produzcan analgesia sin euforia, lo cual reduce su potencial para crear dependencia. aunque esta teoría ha permitido avances en la comprensión del dolor, se ha conocido, con posterioridad a la misma, que la analgesia por endorfinas no es un sistema único para el alivio del dolor; en ese sentido, se ha hecho necesario aceptar la analgesia por vías no opiáceas. 5. teoría de los multirreceptores opiáceos para la sensación dolorosa de las tres teorías fisiológicas del dolor, la de los multirreceptores opiáceos es la más reciente. ella expone que en el snc, a nivel espinal y supraespinal, los narcóticos alivian el dolor por diversas vías, que pueden complementarse, competir o ser específicas para ello. para explicar esto, se debe establecer inicialmente que existen tres zonas receptoras efectivas para el uso acertado de los narcóticos, denominadas zonas mi, kappa y sigma. la zona receptora mi produce analgesia supraespinal y probablemente espinal, depresión respiratoria, dependencia física, tolerancia, estreñimiento y euforia. la zona receptora kappa produce analgesia a nivel espinal y sedación, pero no depresión respiratoria, ni dependencia física, y la zona receptora sigma produce estimulación vasomotora y posibles efectos psicóticomiméticos (alucinaciones). revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 38 los fármacos se unen a las zonas receptoras de opiáceos con distintos grados de afinidad o intensidad; es decir, algunos se unen muy estrechamente, y se denominan “puros”, y otros lo hacen de manera débil, y se denominan “parciales”. cuando un fármaco se une a una zona receptora, la acción puede ser agonista o antagonista, pura o parcial. la compresión de las zonas receptoras opiáceas nos permitirá determinar el fármaco más apropiado para ciertas vías de administración. por ejemplo, un analgésico con afinidad solo por zonas receptoras opiáceas espinales podría ser la elección más lógica para una administración epidural o intratecal. de igual forma, la tolerancia a la analgesia se controla con más facilidad identificando los fármacos que actúan en las diversas zonas receptoras opiáceas. 6. teoría psicológica del dolor el enfoque psicológico del dolor se basa en el comportamiento humano. esta teoría tiene varios participantes, que han aportado su conocimiento y han considerado al paciente como producto de la interacción de su personalidad, de sus valores sociales aprendidos, con lo cual se genera una respuesta individual. acepta que el dolor es un concepto abstracto, que se refiere a una sensación personal y privada de daño, y más que una sensación se trata de una experiencia emocional desagradable, que queda mejor definida como el conocimiento de un estado de necesidad. la teoría reconoce que existen múltiples factores, tanto de orden individual como colectivo, que influyen en la percepción y en la expresión dolorosa. entre estos factores están los propios del individuo (endógenos), como la personalidad, y los exógenos, como el medio ambiente, los culturales, sociales y educativos. la teoría enfatiza, por lo tanto, que lo importante para tener en cuenta no es la idea que tenemos sobre el dolor que sufre el paciente, sino cómo lo percibe el mismo. en ese sentido, se proponen como medidas psicológicas para aliviar el dolor: 1. la relajación y técnicas de sugestión. 2. la administración de placebos. 3. el facilitar elementos de distracción. 4. buscar el cambio de una actitud personal dolorosa hacia la experiencia dolorosa. 7. teoría de mediano rango de los síntomas desagradables más recientemente, la enfermería ha contribuido al abordaje teórico del dolor. en un desarrollo colaborativo de una teoría de rango medio, que inició con dos investigaciones sobre fatiga y disnea, un grupo norteamericano de enfermeras, liderado por lenz (8, 9), encontró que sus observaciones podrían ser aplicables a otros síntomas desagradables, como el dolor. esta teoría considera la naturaleza compleja de los síntomas desagradables, que se puede apreciar en la medida en que a todo síntoma de esta clase se le pueden identificar al menos tres componentes, que son: unos factores relacionados, una forma de expresión particular y unas implicaciones de la experiencia. los factores relacionados son tres e incluyen los fisiológicos, los psicológicos y los situacionales. a continuación se aborda brevemente cada uno de ellos: 1. los factores fisiológicos están relacionados con los sistemas orgánicos normales, las patologías y los niveles de nutrición, entre otros. 2. los factores psicológicos se asocian con el estado anímico, la personalidad y el grado de ansiedad. 3. los factores situacionales se relacionan con las experiencias personales, el estilo de vida y el apoyo social. las expresiones también tienen diferentes matices, que pueden buscarse para describir la experiencia del síntoma desagradable. estos incluyen la duración y frecuencia del síntoma, su calidad y su intensidad, y la angustia. al definir estas cuatro expresiones, como lo hicieran lenz y sus colaboradoras, se pueden establecer: 1. la duración y frecuencia del síntoma. 2. la calidad del síntoma. abordajes teóricos para comprender el dolor humano 39 3. la intensidad del síntoma. 4. la angustia. por último, las autoras afirman que el impacto de la experiencia de un síntoma desagradable se puede ver a nivel funcional o de desempeño del rol; a nivel físico o de actividad, y a nivel cognitivo o de capacidad de resolver problemas. estos niveles se describen como se explicita a continuación: 1. a nivel funcional o de desempeño del rol. 2. a nivel físico o de actividad. 3. a nivel cognitivo o de capacidad de resolver problemas. como se puede evidenciar de manera clara, esta teoría, a diferencia de las anteriores, permite analizar la experiencia dolorosa contextualizada, y le da una connotación que a la vez tiene unicidad y totalidad, para poder hacer un análisis como lo exige la práctica de la enfermería en cada situación en la que se aborde el cuidado de la experiencia de la salud humana. parte de su importancia radica en que ella constituye un ejemplo en la construcción colectiva de un postulado teórico, con base en el cual se puede direccionar la valoración de los condicionantes, las expresiones y las implicaciones de este y otros síntomas desagradables. de otra parte, por ser una teoría de rango medio, tiene un alto nivel de aplicabilidad directa en la práctica, en donde es evidente que la aparición, expresión y consecuencias del dolor se asocian. esta característica se hizo más evidente al destacar su utilidad para la investigación, comparándola con las clasificaciones internacionales de diagnóstico para la práctica de la enfermería (nanda) y con la clasificación internacional de intervenciones de esta misma profesión (nic). para la enfermería es esencial valorar estos factores, así como las características del dolor, como un aspecto fundamental para tener en cuenta en el momento de planear los cuidados de enfermería. esta información permite interpretar las experiencias del dolor como las vive la persona y da opciones de cuidado de enfermería que son complementarias a la administración de analgésicos o inclusive pueden llegar a reducir la necesidad de suministrar estos. así mismo, esta teoría da herramientas para evaluar la efectividad del plan, porque tiene en cuenta la funcionalidad de cada individuo. de igual forma, esta teoría permite incluir al cuidador de la persona enferma, ya que el mismo hace parte de la situación o del contexto de la experiencia dolorosa, con lo cual se operacionaliza el carácter integral con que la enfermería aborda al ser humano. 8. teoría de mediano rango del equilibrio entre la analgesia y los efectos colaterales, propuesta por la enfermería esta teoría de enfermería, que posee un rango medio, tiene como fin proponer unos pasos para orientar la acción profesional de la enfermería en el alivio del dolor agudo. un grupo de enfermeras norteamericanas iniciaron un proceso de investigación, en el cual se incluyó la revisión de guías para el manejo del dolor agudo, una revisión de la literatura sobre este manejo, la opinión de algunos usuarios y la de expertos. con base en su estudio, propusieron esta teoría para el manejo del dolor agudo postoperatorio, en donde la meta fue lograr el equilibrio entre la analgesia y los efectos secundarios. los pasos propuestos incluyen que la enfermera realice lo siguiente: 1. administrar al paciente una medicación potente para el dolor agudo, junto con ayuda farmacológica. 2. valorar de manera continua el dolor y sus efectos secundarios, para identificar las situaciones en que o bien no hay alivio o los efectos secundarios son evidentes. 3. intervenir, cuando sea necesario, con nueva valoración de seguimiento y reintervención. 4. enseñar al paciente y establecer con él las metas para el alivio del dolor. con el surgimiento de esta nueva teoría, para aplicación en el dolor postoperatorio agudo, se hace tangible que las guías de evidencia científica son aportes importantes para la construcción de una mejor práctica en enfermería. acá revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 40 se permite buscar un equilibrio entre la analgesia y los efectos secundarios, con valoración, seguimiento, ayudas farmacológicas y no farmacológicas, y con la participación del paciente y su cuidador. iii. utilidad del abordaje teórico sobre el dolor para la práctica de enfermería el saber y los conceptos relacionados con la enfermería, sus fuentes, sus criterios, los tipos de conocimiento posible, el grado con el que cada uno resulta cierto y la relación exacta entre el que conoce y el objeto conocido, han sido permanente motivo de preocupación para la enfermería. como profesionales buscamos un conocimiento fiable y objetivo, para responder a fenómenos de cuidado de la salud humana. las teorías, como lo establece parker (11), son patrones que guían el pensamiento sobre cómo ser y hacer en enfermería. las teorías proporcionan conceptos y diseños, que definen el lugar de la enfermería en el cuidado de la salud, y al mismo tiempo suministran estructura y terreno para fortalecer la práctica. las teorías relacionadas con el dolor humano son múltiples, y en su mayoría han surgido de otras disciplinas. ello amerita que en estos casos se tenga un proceso “retroductivo”, es decir, que la enfermería conozca y analice estos abordajes desde su perspectiva, para que de esta forma le resulten útiles. los avances que se han generado en las últimas décadas por parte de la enfermería, para ver la experiencia del dolor humano como un fenómeno de totalidad, constituyen un aporte muy significativo en el avance disciplinar en el campo. su comprensión y empleo permitirán que se entienda el fenómeno, y se pueda relacionar, explicar y anticipar en muchos casos. la cualificación de la práctica del cuidado, evitando o aliviando el dolor innecesario, hace parte de la respuesta social que la profesión se debe exigir en la cotidianeidad. en resumen, el trabajo alrededor de evitar el dolor humano, como una experiencia sensitiva y emocional desagradable y nociva, exige a la enfermera tener esquemas simples que lleven a minimizar su impacto. los abordajes teóricos que se presentan pretenden apoyar la sistematización y comprensión de la información y procesos de la experiencia del dolor humano, para mejorar la investigación y la educación y cualificar la asistencia, con miras a generar un mejor alivio del dolor en cada una de las personas con quienes se interactúa en el cuidado. el saber y los conceptos relacionados con la enfermería, sus fuentes, sus criterios, los tipos de conocimiento posible, el grado con el que cada uno resulta cierto y la relación exacta entre el que conoce y el objeto conocido, han sido permanente motivo de preocupación para la enfermería. abordajes teóricos para comprender el dolor humano 41 referencias 1. dolor. enciclopedia® microsoft® encarta 2001. © 1993-2000, microsoft corporation. 2. ganong, william. manual de fisiología médica, el manual moderno, 2000, pp. 91-97. 3. dagnino, j. definiciones y clasificaciones del dolor. boletín, escuela de medicina, pontificia universidad católica de chile, 23: 148-151,1994. 4. torrecillas, l. funciones de enfermería en los cuidados y tratamiento del dolor. evaluación y control del dolor. escalas de valoración. artículo publicado en la web saludbalear.com. 5. solimine, mary ann, y hoeman, shirley p. “la espiritualidad: una perspectiva de rehabilitación”. en: enfermería en rehabilitación: progreso y aplicación, cap. 28, editorial mosby year book, 1996. 6. mccaffery, m. y beebe, a. dolor: manual clínico para la práctica de enfermería, salvat editores, “teorías sobre el dolor”, pp. 39-45, 1992. 7. novel, g. “aspectos psicológicos del dolor”. revista rol de enfermería, no. 104, pp. 41-48, 1986. 8. lenz, e.; suppe, f.; gift, a. y cols. adv. nsg. sci., 17 (3): 1-13, 1995. 9. lenz, elizabeth y cols. adv. nsg. sci., 19 (3): 14-27, 1997. 10. good, marion, y moore, shirley. “guías de la práctica clínica como una fuente de teoría de mediano rango: foco en el dolor agudo”. nursing outlook, 44 (2): 74-79, 1996. 11. parker, marilyn. teorías de enfermería y práctica de enfermería, ed. f. a. davis, usa, 2001. 261 271 historia enfermeria en peru.indd 261 bárbara barrionuevo-bonini1 genival fernandes-de-freitas2 margarita del pilar cerna-barba3 historia de la enfermería en el perú: determinantes sociales de su construcción en el siglo xx 1 enfermera. magí ster en ciencias, universidade de sã o paulo, brasil. bonini@usp.br 2 enfermero. abogado. profesor asociado, universidad de são paulo, brasil. genivalf@usp.br 3 enfermera. doctora en enfermerí a. docente principal, universidad nacional de cajamarca, perú . mpcb28@gmail.com recibido: 20 de mayo de 2013 enviado a pares: 4 de junio de 2013 aceptado por pares: 2 de septiembre de 2013 aprobado: 28 de enero de 2014 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 261-271 para citar este artículo / to reference this article / para citar este artigo barrionuevo-bonini b, fernandes-de-freitas g, cerna-barba mp. historia de la enfermería en el perú: determinantes sociales de su construcción en el siglo xx. aquichan 2014; 14(2): 261-271. resumen objetivos: estudiar las características sociales, culturales y sanitarias como determinantes sociales de la creación, formación y desarrollo de la enfermería profesional del perú en el siglo xx. materiales y métodos: estudio descriptivo histórico-social a partir de búsqueda documental y transversal y fuentes orales. se seleccionaron siete escuelas/facultades de enfermería y 16 entrevistas de profesionales docentes. el referencial teórico de análisis fue el materialismo histórico y dialéctico. resultados: los datos revelaron que esos eventos están intrínsecamente relacionados con las transformaciones sociales, políticas, culturales y sanitarias ocurridas en la sociedad peruana durante su trayectoria histórica. la problemática en el ejercicio profesional viene mostrando las mismas características de las profesiones identificadas como femeninas, y está relacionada con las mismas determinantes sociales que derivan en la limitada valoración social de la profesión. conclusiones: el estudio pretende que las situaciones encontradas sean útiles a futuros investigadores de las escuelas y facultades de enfermería, las asociaciones profesionales de enfermería del perú, la organización mundial de la salud y la organización panamericana de la salud, para continuar profundizando en situaciones relacionadas con la profesión en el perú y en los países de américa latina. palabras clave historia de la enfermería, escuelas de enfermería, enfermería, historia, historiografía (fuente: decs, bireme). 262 aquichan issn 1657-5997 año 14 vol. 14 nº 2 chía, colombia junio 2014 l 261-271 the history of nursing in peru: social determinants of its construction in the twentieth century abstract objectives: examine social, cultural and health characteristics as social determinants in the creation, training and development of professional nursing in peru during the twentieth century. materials and methods: this descriptive, socio-historical study is based on documentary, cross-sectional research combined with oral sources. seven nursing schools/faculties and 16 interviews with teaching professionals were selected. historical and dialectic materialism served as the theoretical reference for the analysis. results: the data showed those events to be linked intrinsically to the social, political, cultural and health changes in peruvian society during its history. the problem in professional practice has the same characteristics as professions identified as feminine and is related to the same social determinants that result in limited social status for the profession. conclusions: this study is intended to reveal situations that will be useful to future researchers in nursing schools and faculties, professional nursing associations in peru, the world health organization and the pan american health organization as part of an effort to continue to delve into situations related to the nursing profession in peru and throughout latin america. key words history of nursing, schools, nursing, history, historiography (source: decs, bireme). 263 historia de la enfermería en el perú: determinantes sociales de su construcción en el siglo xx l bárbara barrionuevo-bonini y otros. año 14 vol. 14 nº 2 chía, colombia junio 2014 l 261-271 história da enfermagem no peru: determinantes sociais de sua construção no século xx resumo objetivos: estudar as características sociais, culturais e sanitárias como determinantes sociais da criação, formação e desenvolvimento da enfermagem profissional do peru no século xx. materiais e métodos: estudo descritivo histórico-social a partir da busca documental e transversal e fontes orais. selecionaram-se sete escolas/faculdades de enfermagem e 16 entrevistas de profissionais docentes. o referencial teórico da análise foi o materialismo histórico e dialético. resultados: os dados revelaram que esses eventos estão intrinsicamente relacionados com as transformações sociais, políticas, culturais e sanitárias ocorridas na sociedade peruana durante sua trajetória histórica. a problemática no exercício profissional vem mostrando as mesmas características das profissões identificadas como femininas, e está relacionada com as mesmas determinantes sociais que derivam na limitada valorização social da profissão. conclusões: o estudo pretende que as situações encontradas sejam úteis a futuros pesquisadores das escolas e faculdades de enfermagem, às associações profissionais de enfermagem do peru, à organização mundial da saúde e à organização pan-americana da saúde, para continuar aprofundando em situações relacionadas com a profissão no peru e nos países da américa latina. palavras-chave história da enfermagem, escolas de enfermagem, enfermagem, história, historiografia (fonte: decs, bireme). 264 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 introducción el presente estudio discute las prácticas de salud considerando que, dentro del contexto peruano, es imposible entender la evolución de esta profesión sin establecer su relación con los acontecimientos históricos. no obstante, se tiene muy claro que la enfermería como profesión viene sufriendo transformaciones a través de su historia y algunos de esos aspectos fueron decisivos para el desarrollo de la profesión. como profesionales de enfermería esa situación nos conduce a cuestionarnos: ¿es posible tener sentido en el mundo sin aproximarse a nuestra historia? considerando la trayectoria de la enfermería peruana ¿cómo comprender su contexto profesional sin conocer su historia? los estudiosos refieren que la historia sirve para ilustrar el contexto vivido y fortalecer los detonantes significativos de este contexto. así, el estudio se justifica por el factor del conocimiento histórico de la enfermería peruana que permite elucidar ese contexto y fortalecer los significados de la profesión en los contextos social, económico, político y cultural. al respecto comprendemos que el papel de la universidad, y dentro de esta las escuelas/facultades de enfermería, debe fomentar, además de sus responsabilidades en la enseñanza, la investigación, desarrollar el conocimiento en relación con los recursos humanos que forma, la práctica que desarrollan y las condiciones en que viene desarrollándose dentro del contexto. los estudios sobre la historia de enfermería son muy importantes debido a su función social y posibilitan la toma de conciencia de lo que somos en cuanto producto histórico, así como el desarrollo de la autocrítica y la construcción de nuestra identidad profesional. así mismo, tales estudios tienen una utilidad fundamental en el proceso de enseñanza en las escuelas y facultades, con una propuesta de formación crítica del enfermero para una praxis social de cambio frente a las realidades socio-sanitarias. el presente estudio tiene como objetivos discutir las determinantes sociales de la creación, formación y desarrollo de la enfermería peruana en el siglo xx, y analizarlas de acuerdo con las condiciones histórico-sociales de conformación de nuestra sociedad. materiales y métodos por tratarse de un estudio descriptivo de naturaleza históricosocial, fueron seleccionados como fuentes: acervos de bibliotecas de escuelas y entidades de clase peruanas como biblioteca nacional del perú, biblioteca del congreso de la república, centro de la mujer peruana flora tristán, asociación peruana de facultades y escuelas de enfermería (aspefeen), colegio de enfermeros (cep), entre otros. el material bibliográfico se clasificó y ordenó según esas épocas históricas para su descripción y análisis. los datos del personal de enfermería fueron obtenidos a partir de los testimonios de dieciséis colaboradores por medio de entrevistas que fueron grabadas y transcritas después de su realización. los datos obtenidos fueron agrupados en los siguientes temas: creación, formación y desarrollo de la enfermería profesional en el perú, razones sociales alrededor de estos eventos; desarrollo de los planes de estudio; desarrollo de la profesión en las áreas asistencial, de enseñanza, investigación y otros; limitantes y propuestas para el enfrentamiento de los problemas en la profesión en el escenario peruano. el tratamiento de los datos incluyó la descripción y el análisis cuantitativo y cualitativo de acuerdo con la naturaleza de los mismos. los aspectos considerados para el análisis y la interpretación de la historia de la enfermería profesional del país fueron emergiendo del referencial del materialismo histórico dialéctico con el recorte de género. la fase de organización, sistematización y análisis de la información facilitó una mejor comprensión de la trayectoria de la enfermería en el siglo xx —que se considera necesaria para la formación de una conciencia crítica—, además del conocimiento de la historia de la enfermería peruana. respetando los patrones éticos en investigación con personas, el proyecto fue sometido a análisis del comité de ética en investigaciones del instituto nacional de salud de lima, perú, el cual consideró que no existían observaciones éticas para la realización del estudio. resultados y discusión como parte de los resultados fueron recogidos dieciséis testimonios: dos de la facultad de enfermería de la universidad nacional de huamanga, ayacucho; cuatro de la facultad de enfermería de la universidad nacional del altiplano, puno; tres de la escuela de enfermería de la universidad nacional de cajamarca; uno de la escuela de enfermería de la universidad nacional mayor de san marcos de lima; uno de la facultad de enfermería 265 historia de la enfermería en el perú: determinantes sociales de su construcción en el siglo xx l bárbara barrionuevo-bonini y otros. de la universidad peruana cayetano heredia de lima; cuatro de la facultad de enfermería de la universidad nacional san agustín de arequipa, y uno de la clínica anglo americana de lima. en las primeras décadas del siglo xx el estado no manifestaba interés en dictaminar políticas sociales en general, y mucho menos políticas dirigidas a la atención de los problemas de salud de la población, no obstante la epidemia de peste que estaba diezmando a las poblaciones porteñas. lo que se tiene registrado es el inicio de la colaboración internacional en el campo de la salud en américa; así, la organización panamericana de la salud (ops) y la fundación rockefeller, a través de la comisión internacional de la salud, iniciarían el apoyo para el combate de las endemias rurales: fiebre amarilla y malaria dirigida a los centros de producción agrícola y centros mineros, a manera de proteger la fuerza de trabajo. estas organizaciones intentaban implantar los conceptos de salud pública y tuvieron gran influencia en el proceso de creación de las primeras escuelas de enfermería anexadas a los hospitales de beneficencia, como el hospital arzobispo loayza en 1915 con la escuela mixta de enfermeras(os), con un plan de estudios de tres años. el mismo proceso se seguiría con la creación de otras escuelas de enfermería en otros hospitales. se observa que, en este periodo, los proyectos de los gobiernos centralistas fueron solamente orientados para paliar con tratamientos empíricos las enfermedades de la población pobre —que era la mayoría—, siendo los profesionales médicos exclusivamente para la atención de los nuevos ricos, las familias pudientes y políticos del gobierno que ejercían cargos oficiales de poder. para la atención de los problemas de salud de la población existían los hospitales de beneficencia, por ejemplo, el hospital arzobispo loayza para atención de las mujeres y el hospital dos de mayo para atención de hombres. el número de médicos era muy limitado, los estudiantes se encargaban de la atención de casos de cirugía y de los más delicados (1). en la primera década del siglo xx —año 1906—, la compañía anónima “casa de salud de bellavista”, localizada en el primer puerto del callao donde se daba el intercambio comercial con embarcaciones del extranjero, creó un moderno centro hospitalario privado, la clínica angloamericana, para atender a los enfermos extranjeros, especialmente, empresarios y comerciantes italianos e ingleses que mantenía contratos comerciales con el gobierno. los médicos extranjeros nino barazzini y jose mazzini fueron los pioneros de este hecho. en este nosocomio se concibió la necesidad de crear una escuela exclusiva para enfermeras de clase social alta, dentro de los cánones de la escuela nightingale (2), registrándose así como la primera escuela de enfermería profesional en el país. en este periodo, al igual que en los anteriores, la atención que ofrecía este nosocomio reflejaba el interés del gobierno solamente por las clases sociales ricas del país, ofreciendo incluso el apoyo financiero para su funcionamiento. la formación de los profesionales médicos y también de las enfermeras seguía los cánones del paradigma francés, así la enseñanza y el desarrollo en la atención de la salud para esos profesionales tenía como meta parís, “los que miran para arriba”, como manifestaba el doctor fortunato quesada (2). para enfrentar la problemática de salud, sobre todo de la masa trabajadora, se proyectaba programar algunas acciones sanitarias para el control de las epidemias y el manejo de las enfermedades infectocontagiosas en las grandes ciudades, en los puertos marítimos y en las zonas de exportación. acciones mayoritariamente promovidas por los poderosos grupos capitalistas dominantes interesados en facilitar la exportación de materias primas para los países desarrollados (3, 4), y por los organismos internacionales como la organización mundial de la salud (oms) y la organización panamericana de la salud (ops). es así que, articulando el concepto de salud a la capacidad productiva de la masa trabajadora, la atención sanitaria mostró, desde su inicio, ser eminentemente curativa y recuperativa, además de discriminatoria y diferenciadora con relación a la clase social e, incluso, a la raza, y estar subordinada a la capacidad de los servicios privados, servicios de beneficencia y a la buena voluntad filantrópica de los sectores con poder económico. según laguna (3), el descanso en el domicilio por enfermedad era privilegio de la clase dominante; para los pobres restaban los hospitales de beneficencia, y para la población rural indígena, totalmente marginalizada, se aplicaban los cánones de la medicina andina popular. los historiadores resaltan la presencia y participación de mujeres que se convirtieron en grandes personajes a nivel nacional, por su temperamento de solidaridad y ayuda al prójimo en los hospitales y casas de salud. muchas mujeres participaron de esos eventos como enfermeras heroicas. zegarra (5) resaltaba en su libro que la inquietud que animó a las mujeres de proyectar sus 266 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 vidas a la solución de las necesidades de otros tuvo sus manifestaciones dentro del desarrollo de la vida del país, en el siglo xix, en hospitales y asilos a partir de acciones de prevención y protección en la comunidad. respecto a la educación, en las primeras décadas del siglo xx los estudios señalan que, para el pueblo, esta continuaba siendo dirigida por las congregaciones religiosas, hecho histórico que determinó la creación de las primeras escuelas de enfermería en la capital del país, lima, regentadas por las hermanas de san vicente de paul y que, dentro de los cánones de las escuelas francesa e inglesa, acogieron el paradigma nightingeliano en la formación de las enfermeras y permaneció hasta la década de los cincuenta en las escuelas y facultades de nivel universitario. hasta mediados del siglo xx en lima se habían creado varias escuelas de enfermería anexadas a los hospitales de beneficencia, fenómeno que también se registra en algunas ciudades del interior del país como respuesta a la gran problemática de salud ocasionada, por un lado, por la implementación del modelo capitalista de desarrollo con sus nefastas consecuencias, sobre todo, para las masas trabajadoras de las grandes fábricas; por otro lado, por la gente que migraba del interior del país en busca de trabajo y que se constituyó en poblaciones marginales que vivían en paupérrimas condiciones en los alrededores de las grandes ciudades denominados “cinturones de pobreza”. además de esto, el modelo económico era propicio para el interés de los grupos capitalistas que iniciaron la creación de instituciones de salud privada. en este periodo también fueron frecuentes los movimientos sociales de los trabajadores en reclamo de sus reivindicaciones. en esta época se resalta que la implementación del modelo industrial, aunque reiterativamente tendía a marginalizar sobre todo a las regiones del interior del país, determinó que en el ámbito gubernamental se iniciaran políticas sociales en general, y políticas relacionadas con la atención a la problemática de salud, en particular, lo que supone los antecedentes de los principios orientadores de la seguridad social en la constitución política de 1933, la creación de los ministerios de educación, de salud, del trabajo y seguridad social (1935), la creación del seguro social del trabajador (1936) y, en general, la concepción moderna de los servicios sociales como derechos públicos, expresión de la democratización de la sociedad peruana respecto de la rigidez técnicoestamental de la república oligárquica (6). en estos eventos se observa la gran participación de los trabajadores —mujeres y hombres— de las grandes fábricas manufactureras de la capital, los que con sus justas luchas reclamaban sus derechos sociales. a partir de la década de los sesenta, muchos acontecimientos se sucedieron en el contexto socioeconómico peruano que influenciaron el desarrollo de prácticas de atención en salud por las instituciones formadoras de médicos y enfermeras profesionales. así, la revisión de la evolución económica, social y política desde 1963 revelaba la ausencia de una estrategia de desarrollo sustentable que lograra elevar el bienestar de todos los peruanos. la mitad de la población registraba una situación de pobreza, y la extrema desigualdad en la distribución de la riqueza y los ingresos era una característica de la sociedad peruana que provocó diversos esquemas de política. sin embargo, todas estas estrategias se vieron limitadas por diversas causas, especialmente económicas y políticas, ya que las políticas sociales en general no son independientes de estas y no se aplican en contextos iguales sino en entornos cambiantes en los planes institucionales, políticos, internacionales y especialmente históricos. en el perú, la dependencia económica se acentuaba y la crisis generaba condiciones de vida infrahumanas con problemas de salud derivados de enfermedades infectocontagiosas, particularmente. en los años sesenta y setenta los gobiernos intentaron mitigar la situación con políticas de asistencialismo, construyendo por ejemplo escuelas a nivel nacional y emitiendo la ley de la educación secundaria gratuita (7). un elemento de interés político-ideológico para el control social de los gobiernos burgueses es la educación pública. así la reforma educativa se dio con la propuesta de forjar “el hombre nuevo”, pero las medidas que se implantaron resultaron incoherentes; ejemplo de esto fue que, aunque se estableció la educación dirigida al trabajo, no se crearon industrias y talleres para su preparación en los centros educativos; se reguló la educación universitaria bajo la dirección del consejo nacional de la universidad peruana (conup), limitando la libertad y creatividad de los centros superiores; los programas y departamentos académicos en las universidades se crearon a partir del modelo norteamericano, con una clara intención de manejo centralizado. en esta época también se definió la educación inicial como proceso de aprestamiento infantil, entre otros. no obstante la situación des267 historia de la enfermería en el perú: determinantes sociales de su construcción en el siglo xx l bárbara barrionuevo-bonini y otros. crita, en el planeamiento de la educación superior se crearon más universidades e institutos tecnológicos privados y centralizados en las ciudades progresistas. en 1968, la crisis económica estructural cedía al golpe del estado militar como un intento radical por mejorar la situación social caótica en el país. el gobierno nacionalista revolucionario de las fuerzas armadas (general velasco alvarado) tuvo entre sus planes reivindicar lo social, pero se percibirían enormes limitaciones en la estrategia económica. el fracaso de este modelo se verifica en 1975 con una economía en profunda crisis, no solamente en el plano económico, sino también en los aspectos políticos e institucionales. en 1979, la pobreza en el perú afectaba al 46 % de la población. en términos absolutos el número de pobres aumentó durante la década de los setenta. algunas cifras disponibles de 1979 mostraban lo siguiente: pobreza en la zona urbana, 35 %; en la zona rural, 65 %; indigencia en zona urbana, 12 %; en zona rural, 37 %. la inversión en el sector educación constituía el 4,7 % del pbi en 1975, y el 2,3 % en 1979; en salud 1,7 % en 1975 y 3,0 % en 1979 (8). en cuanto a la atención de la problemática de salud se registra la creación de un mayor número de clínicas privadas a nivel nacional; a su vez, los consorcios de empresas privadas proyectaron la formación de profesionales y técnicos de salud a nivel de institutos, universidades privadas y del ministerio de salud que, por resolución suprema aprueba la nomenclatura única de formación de auxiliares de enfermería en seis meses con requisito mínimo de instrucción primaria, y que posteriormente en 1964 fue con tercer año de secundaria. esta situación respondía al modelo de desarrollo económico del gobierno en el periodo anterior que promovía la industria hospitalaria y que, entre 1940 y 1960, sustentaba un crecimiento vertiginoso. elevados porcentajes de inversión en salud se orientaban a los servicios curativos en los hospitales y en la especialización clínica del personal médico y de enfermería. en este periodo predominaba la atención médica recuperativa sobre la práctica preventiva. este enfoque se mantiene hasta el presente. sin embargo, haciendo eco de los acuerdos de los ministerios de salud del continente americano, dentro de estos del perú, se oficializó el plan decenal de salud para las américas (1972-1981). en 1977, la octava asamblea de la oms, aprueba una resolución en la cual se establece como meta de los gobiernos y de la oms “salud para todos en el año 2000”, siendo la “atención primaria” la estrategia clave para alcanzar esa meta. en el siglo xx se crea el mayor número de escuelas de enfermería, algunas afiliadas a las clínicas privadas y hospitales y otras a las universidades de la capital, lima, y en el interior del país. un hecho importante es lo referente a la creación y el reconocimiento de la enfermería universitaria en 1964 como resultado del convenio entre la universidad nacional mayor de san marcos (unmsm), el ministerio de salud y la ops con el fin de elevar la formación de enfermería a nivel universitario. este hecho impulsó el desarrollo de la educación en los servicios de enfermería a través de programas complementarios y la creación de facultades y escuelas de enfermería a nivel universitario; lo anterior es antecedido por la creación en 1958 de la escuela de enfermería de la universidad nacional de san cristóbal de huamanga en ayacucho, departamento del interior del país. además, se iniciaron los programas de posgraduación con la creación del instituto de posgrado en 1958, en el ministerio de salud pública, que ofrecería cursos básicos de educación y administración en enfermería (9). la realidad mostraba el interés del estado por enfrentar, aunque muy superficialmente, los graves problemas sociales sobre todo de salud y educación, como consecuencia de la implantación del modelo capitalista industrial, al igual que en otros países de américa latina. en esta realidad, la historia registra que los problemas de salud se acrecentaron y necesitaron de ser atendidos, sobre todo, los del campo de la salud del trabajador para recuperar la mano de obra explotada. esta situación es determinante para el desarrollo de la industria hospitalaria, así, entre 1940 y 1960 se dio un vertiginoso crecimiento de escuelas de enfermería en la capital del país, y de facultades de medicina, estableciéndose la hegemonía de la atención médica hospitalaria. otros eventos sucederían en este periodo relacionados con la organización de los profesionales de la salud y la educación a nivel de asociaciones y sindicatos, y en enfermería con la creación del colegio de enfermeros del perú como entidad encargada del desarrollo de la profesión. es necesario resaltar que si bien esas organizaciones fueron reconocidas socialmente, no tuvieron influencia en las decisiones del trabajo, y la formación de estos profesionales en los establecimientos de salud y escuelas permaneció centralizada; dichas organizaciones solamente cumplieron funciones de defensa de sus intereses. 268 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 la realidad es que en el año 1977 las condiciones sociales en el país determinaron constantes protestas de los trabajadores de la salud, la educación, la minería, los transportes, etc., que culminaron en jornadas de huelgas nacionales que obligaron al gobierno militar a retirarse del poder. la burguesía se aferró al control estatal y sustituyó a los militares por los civiles en una aparente renovación política. el hecho histórico más sanguinario habría de acontecer en este periodo con el surgimiento del terrorismo en el sur del país, donde se concentraba la pobreza, como ayacucho, y en la ciudad de huamanga, en el centro académico de la universidad nacional de huamanga. se percibe en este periodo la poca o nula atención del estado por la problemática de salud, ya que eran las empresas privadas las más interesadas en crear el mayor número de instituciones formadoras de profesionales de salud en la capital del país para la atención centralizada en los hospitales. en esta época, los pueblos del interior del país, dentro de este cajamarca, hicieron muchas movilizaciones, huelgas de hambre, entre otras para llamar la atención del estado en cuanto a la problemática de salud y de educación, entre otras. en el año 1967 se creó la primera escuela de enfermería en el departamento de cajamarca, para atención de los pacientes que acudían al único hospital belén de la región, en la versión de una enfermera entrevistada. el perfil epidemiológico del país registraba, en la década de los noventa, enfermedades asociadas a la pobreza como desnutrición crónica, tuberculosis, enfermedades infectocontagiosas, respiratorias, muertes maternas y de niños, cólera, entre otras, además de las enfermedades crónico-degenerativas. mientras que la inversión gubernamental en este sector de un año a otro se reducía: entre 1987 y 1988 se redujo en 75 %. en 1991, el gasto en salud representó solamente 0,31 % del pib, restricción que afectó el desarrollo de los diversos programas del área y el adecuado equipamento de los establecimientos públicos de salud (10). las determinantes de esta situación se encuentran articuladas al hecho de que, a través de su historia, el perú ha pasado por diversos momentos de crisis sociales, económicas y públicas como consecuencia de los vicios estructurales en los modelos de desarrollo practicados en el país. la crisis de los años, iniciada aproximadamente en 1975 y agudizada en la década de los noventa, es considerada como la más grave de toda su historia. esto como consecuencia de la dependencia económica y del papel subalterno y periférico que ocupa el país en el sistema capitalista mundial. esta situación viene generando una aguda recesión económica que hace que el aparato productivo se vea estancado y sin perspectivas a medio plazo. esto es válido tanto para los hombres como para las mujeres, aunque son ellas las que llevan siempre la peor parte (11). existen evidencias empíricas que muestran la persistente desigualdad entre la población económicamente activa masculina y femenina, incluso en el interior de las ocupaciones o en el ejercicio profesional. en la enfermería, por ejemplo, en tanto las mujeres aumentaban en número por la mayor creación de escuelas y facultades de enfermería a nivel nacional, se registraban altas tasas de desempleo y subempleo —hechos muy discutidos en los eventos organizados por el colegio de enfermeros—; sin embargo, no se mostraba abiertamente como una necesidad el tratamiento de esta problemática que precisaba ser enfrentada y solucionada a nivel de las instituciones empleadoras como el ministerio de salud (minsa). según ingianna (12), las largas jornadas de trabajo de algunas mujeres del sector salud absorbían de 10 a 12 horas diarias en tareas que demandaban un gran desgaste de energía y esfuerzo físico, tanto por el tipo de trabajo como por la concentración que requiere la dedicación exclusiva al cuidado de personas enfermas, como es el caso de los profesionales de enfermería. además de esto, el trabajo doméstico no es considerado como generador de valores de uso (bienes y servicios), aunque signifique la reproducción de la fuerza de trabajo. no obstante la situación descrita, la disponibilidad global de recursos humanos en el área de salud creció significativamente en esta época. el número de médicos pasó de 5.325 a 19.635, de 1964 a 1986. en 1990 eran 23 mil. el personal de enfermería también se cuadriplicó, entre 1964 y 1986, de 3.163 a 14.709, y en 1996 se registraban 28.000 profesionales. estos se encuentran concentrados en la capital y en las grandes ciudades del país. en lima, por ejemplo, permanecían 73 % de los médicos y 55 % de las enfermeras, lo que contabiliza un médico para cada 440 habitantes, mientras que en el resto del país la media era de un médico para 2.500 habitantes (13). en el sector salud, la tendencia en las políticas de expansión de los servicios determinó el aumento de las instituciones de salud y, consecuentemente, de aquellas formadoras del personal, 269 historia de la enfermería en el perú: determinantes sociales de su construcción en el siglo xx l bárbara barrionuevo-bonini y otros. particularmente de enfermería de nivel superior. las instituciones formadoras de profesionales de salud —escuelas y facultades de medicina y enfermería— también aumentaron en el sector privado en este periodo. por ejemplo, en 1996, el colegio de enfermeros del perú refería que en 1960 existían 12 escuelas de enfermería, en 1990, 28 y en 1996, 34 escuelas con una producción anual de 1600 enfermeras (14). este crecimiento en el número de escuelas y facultades no significo una mejora en la atención de la problemática de salud de la población, ya que en su mayoría estos profesionales continúan concentrados en las instituciones públicas y privadas —hospitales, clínicas— de la capital del país y ciudades progresistas de la región de la costa, sin mejora en sus condiciones de trabajo. la verdad es que no se tiene un registro real de la situación laboral de estos profesionales y, en general, del recurso humano en salud a nivel nacional. los colegios profesionales registran un crecimiento de sus inscritos determinado por la creación de mayores instituciones privadas formadoras de estos profesionales: enfermeros, médicos, obstetras, entre otros. según cerna (11), este periodo registra un crecimiento de universidades privadas formadoras de médicos, enfermeros, técnicos de enfermería, etc., para atención en las clínicas privadas localizadas preferentemente en lima, consorcios de médicos con institutos privados formadores de técnicos en salud y, en general, un sector privado productivo de salud acorde con el modelo neoliberal implantado para el desarrollo del país. entre tanto, la expansión de la pobreza crítica viene generando un aumento de la automedicación y de la medicina tradicional y, consecuentemente, una disminución de la demanda de los servicios de salud del país. este fenómeno ocurre también por la elevación de las tarifas de los servicios hospitalarios del minsa que venía ocurriendo desde 1991 (15). según el estudio “demanda de salud por el lugar de consulta, 1985-1994”, los pobres extremos disminuyeron su participación en la demanda hospitalaria de 1991 a 1994, de 30,1 a 28 %, y los pobres de 37,3 a 34 % (16). en suma, el sistema de servicios de salud continuaba mostrando un elevado grado de dispersión institucional, con escasa coordinación de sus sectores, lo que contribuye a su limitada operatividad en el desarrollo de las acciones sanitarias del país. además de esto, la variedad de instituciones para desarrollar dichas acciones hace más visible aún la falta de articulación y coordinación en la ejecución de los programas de salud, conglomerado de estilos de administración que evidencia la existencia de múltiples organismos paralelos superpuestos y hasta contradictorios para el desarrollo de los programas de salud, lógica de la hiperburocratización del gobierno peruano. en este periodo, el colegio de enfermeros del perú manifestaba su preocupación por la situación de sus agremiados: el desempleo y subempleo que determinaba la migración de estos profesionales a otros países: 3.000 enfermeras fueron a italia, a españa y ee. uu. en busca de trabajo y de mejores condiciones laborales; sin embargo, se continuaba —aún es así— con la tendencia a formar profesionales, sobre todo en las escuelas/facultades privadas, para el servicio de desocupados y subempleados a nivel nacional. esta problemática ha venido siendo discutida en los congresos de enfermería reconociéndose que estaba determinada por la falta de políticas de formación de recursos humanos de salud, lo que genera a su vez la problemática de formación de estos profesionales como recurso de crecimiento numérico, pero con una formación alejada de las reales necesidades sanitarias de la población, y con perfiles que no responden a la atención de la problemática de salud del país. así, cerramos el siglo xx arrastrando una problemática que tiene que ver no solamente con la creación, formación y desarrollo de la enfermería profesional en particular, sino con la situación social, económica, política y cultural del país, cuya crisis se torna más profunda por el modelo de desarrollo que viene implementándose con mucha más fuerza desde el inicio del siglo xx: el neoliberalismo. conclusiones consideramos que dentro del contexto peruano es imposible entender la evolución de la profesión de enfermería sin establecer su relación con los acontecimientos históricos que ocurrieron a lo largo del siglo xx. no obstante, se tiene muy claro que la enfermería como profesión viene sufriendo transformaciones a través de su historia, y algunos de esos aspectos fueron decisivos para el desarrollo de la profesión. la enfermería profesional, como ejecutora de las acciones de salud y de la formación de recurso para esas acciones, sufre 270 año 14 vol. 14 nº 2 chía, colombia junio 2014 aquichan issn 1657-5997 de cerca las consecuencias de las contradicciones de ese contexto social peruano que, sin embargo, no son visualizadas incluso por los mismos profesionales, como se observó en las entrevistas del estudio. la problemática en el desarrollo del ejercicio profesional viene mostrándose con las mismas características de las profesiones identificadas como femeninas y, en la investigación, se muestra en relación con las mismas determinantes sociales que derivan en la poca o limitada valoración social, hecho que aún hasta finales del siglo xx prevalece como una gran situación problemática no superada. en el perú, hasta finalizar la década de los noventa, se dio un retroceso en las políticas sociales que, en la coyuntura socioeconómica y política actual, se reflejaría aún más en el impulso que fue dándose a la privatización de los sectores sociales, principalmente, salud y educación. el retorno de la atención de la salud de la población al sector privado significa que los servicios de salud serán basados solamente en la capacidad de los salarios y no en las inversiones sociales del estado. en este contexto, la cuestión social tiende a considerarse como un asunto privado, situación que conduce a que las políticas de salud en el país dejen de ser parte de las políticas de desarrollo y, por tanto, la difusión de los sistemas de medicina gratuita, la descentralización del sistema integrado de salud, el fortalecimiento de la calidad de los servicios de salud están al margen y aun desarticulados del desarrollo social del país. con la apertura a la globalización de la economía ocurrida a partir de 1990 se generó una dualidad económica y, de cierta forma, una modernización aparente para un importante sector de la población nacional. solo un sector minoritario tiene acceso a los beneficios de esa modernidad, y participa e interviene activamente en el proceso de globalización económica. en el otro extremo está el país de las grandes mayorías que no participa ni se integra en esta modernidad. en este contexto, es necesario reconocer que se viene generando una violencia estructural que atenta contra la calidad de vida de la población, agrede y deteriora las posibilidades de trabajo de la población económicamente activa, limita el progreso y se refleja en el deterioro de las condiciones de salud, índices altos de morbimortalidad infantil y materna, bajo consumo de calorías y desnutrición, presencia de epidemias y, en general, en un perfil de salud de países subdesarrollados paralelo al de países desarrollados. así las cosas, las prácticas de salud y los profesionales de esta área, particularmente de enfermería, vienen desarrollándose determinados por esas situaciones sociales, económicas, políticas, culturales y sanitarias. se requiere seguir investigando sobre las determinantes del desarrollo de la profesión en nuestro país, temática que sigue las tendencias regionales, nacionales e internacionales en materia de investigación sobre el recurso humano de salud. referencias 1. paz-soldán ce. una doctrina y un templo. lima: ausonia; 1959. 2. clínica anglo americana, editores. libro de oro. lima: clínica anglo americana; 1971. 3. laguna ja. políticas sociales y de salud. en: consejo nacional del colegio de enfermeros del perú. nuevas opciones en salud y enfermería para el desarrollo social. lima: consejo nacional del colegio de enfermeros del perú; 1994. 4. macera p. historia del perú i, ii, iii. lima: editora bruño, 1985. 5. zegarra jp. mujer, poder y desarrollo del perú. lima: editorial dorcha; 1980. 6. de la guerra. el racismo silencioso y la superioridad de los intelectuales en el perú. socialismo y participación. lima: editorial instituto de estudios peruanos; 1965. 7. instituto de ciencias y humanidades. historia del perú. lima: instituto de ciencias y humanidades; 2008. 8. wise c. perú post 1968: the political limits to state-led economic development. new york: columbia university; 1990. 271 historia de la enfermería en el perú: determinantes sociales de su construcción en el siglo xx l bárbara barrionuevo-bonini y otros. 9. benites vt. evolución histórica social de la enfermería en el perú. actas del seminario taller de historia de la enfermería en el perú, 15 al 17 de agosto, trujillo, perú. trujillo: universidad nacional de trujillo; 1990. 10. instituto nacional de estadística e informática, perú. compendio estadístico 1991-1992. lima; 1992. 11. cerna mb. enfermeiras de cajamarca (perú): condições de vida e trabalho. [tese]. são paulo: escola de enfermagem da universidade de são paulo, 1999. 12. ingianna my. la construcción social del género y su articulación con los elementos de la realidad y de la sociedad. actas del 11º congreso nacional de enfermería, 10 al 12 de noviembre, lima, perú. lima: colegio de enfermeros; 1991. 13. consejo nacional de población, perú. programa nacional de población de la mujer (1990-1995). lima; 1990. 14. colegio de enfermeros del perú. situación actual de enfermería en el perú. lima: editorial colegio de enfermeros del perú; 1996. 15. aguinaga le. la política macroeconómica y su repercusión en los servicios de salud. actas del seminario políticas sociales vs políticas de salud; 13 al 14 de noviembre, cajamarca, perú. cajamarca: escuela de posgrado unc; 1996. 16. perú. demanda de salud por el lugar de consulta 1985-1994. lima; 1994. 131 136 primeras paginas.indd 135 editorial from the past into the future desde el pasado hacia el futuro do passado ao futuro doi: 10.5294/aqui.2016.16.2.1 also will change and meet the changing demands. if we extend the trends of today, we can begin to predict what we will face in the future. in reading about the future in health care, i noted three of the most often mentioned issues that are trending in health care across countries. first, preventive care will soar and will include the use of online and other technology that align health providers and people who need care. at the same time, consumerism will be a major trend, as more people have access to information through technology. people will be self-educated in health. the third major trend that likely will continue to gain strength is collaboration, as nurses align with a variety of providers across the continuum of health. what does this future ask of us and our knowledge in nursing? i will address the role of nurses in responding to these three trends. nurses who understand how people adapt to a changing environment will continue to promote healing at the same time that they expand their practice to provide preventive services. preventive services are assessments or interventions to prevent illnesses before they cause symptoms or problems. they include screening tests, counseling services and preventive medicines. in the united states, the preventive services task force is one group that develops recommendations on preventive services based on a review of good scientific evidence. for each recommendation, the group provides materials that include guides, fact sheets, slideshows and videos available for viewing and download. as of march 2016, the website had 75 entries in categories such as behavioral counseling interventions to promote a healthful diet and anniversaries are a time to look backward and a time to look forward. as the school of nursing and rehabilitation at universidad de la sabana celebrates 25 years, you already have a heritage that provides a proud basis for the future. the future before you is very promising. the basis of scholarship in this journal and at your school creates and reflects your heritage and your future. in the last decade of the last century, you took the best of global nursing and created forward thinking educational programs in nursing. you understood that both theory and research were important in articulating the academic discipline and the clinical practice of nursing. i met members of your faculty for the first time at an international conference in el salvador in february 2002 (aquichan, 2002). they were well prepared to spend the interview time clarifying fine points about the roy adaptation model. since then, i have had the privilege of visiting la sabana twice and each time was impressed by the scholarship of the programs, the increasing education of the faculty and the impact you have on nursing in latin america. between my visits in 2006 and 2011, i am aware that your school and town recovered from a severe flood. this reflects the resiliency you bring from your past into the future. what does the future hold? the one thing we know for certain is that the future will be different from what we know today. still, with a strong heritage in nursing knowledge development, significant research, relevant teaching and updated practice, you 1 phd, rn, faan, professor and nurse theorist, connell school of nursing, boston college. callista roy1 136 aquichan issn 1657-5997 año 16 vol. 16 nº 2 chía, colombia junio 2016 physical activity for cardiovascular disease prevention in adults. with all nurses have to do, can we also increase preventive services? yes, we can; teaching for health can become part of all we do. nurses can help to create both the recommendations and the teaching materials relevant for our populations. nurses know best about all the influencing factors that affect people as they try to take preventive approaches. eventually, the efforts of nurses will lead to fewer people with chronic conditions requiring repeated and expensive care. as the second trend moves forward, millions of consumers will have more access to information about health from magazines, television and the internet. we know that some of the information is reliable and up to date, and some is not. what can nurses do about this trend? in examining the shortcomings of health information on the internet, two authors (benigeri & pluye, 2003) identified four specific concerns. (i) the uneven quality of the health information available; (ii) difficulties in finding, understanding and appropriately using this information; (iii) lack of access for the unconnected population; and (iv) the potential for risk and harm from over-consumption. nurses understand that, to adapt, people often need help in processing health information. nurses can be key providers who help to overcome the dangers of internet information. nurses will be involved in the design, dissemination and evaluation of web-based health information that is well-matched to how people process health information, both cognitively and emotionally. the last trend for the future i want to address is collaboration. we are hearing more about health providers working together to meet needs across the continuum of health and illness. nurses have worked hard to define nursing and to develop our own voice in health care. are we being asked to give this up and meld together with physicians, social workers, physical therapists, pharmacists and others? in a collaborative model of delivering health care, the voice of nursing is ever more important. some of the trends noted and many others stem from technological advances. nurses have the dignity of the person as the core of our knowledge. as nurses work with other health care providers in an increasingly technologic world, our voices are needed more than ever to keep the focus of all health providers on the needs of persons, as individuals, families and communities. our assessments, from a holistic perspective, will be brought to each collaborative venture, in practice, in education and in research. all issues raised in health care need the voice of nursing. just as thousands of people have benefited from the first 25 years of the focus the school of nursing and rehabilitation at universidad de la sabana, so will you respond to and lead trends in health care in the decades to come for the benefit of hundreds of thousands more citizens in your country and others. references 1. aquichan. entrevista con callista roy. aquichan. 2002;2(2):36-39. 2. benigeri m, pluye p. shortcomings of health information on the internet. health promotion international. aquichan; 18(4):381-386. 9 niveles.p65 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200572 año 5 vol. 5 nº 1 (5) 72-85 chía, colombia octubre 2005 martha v. whetsell1, keville frederickson2, paulina aguilera3, juan luis maya4 recibido: 26 de julio de 2005 aprobado: 16 de agosto de 2005 resumen este estudio investigó la relación entre niveles de bienestar espiritual y fortaleza relacionada con la salud en una población mexicana de adultos mayores de 65 años. el proyecto se basó en el modelo de adaptación de roy, el modelo de pollock (fortaleza relacionada con la salud) y el de reed (bienestar espiritual). el diseño fue descriptivo correlacional, la muestra fue probabilística y se hizo al azar. la muestra (n=160) tuvo un nivel de significancia de 0,05 para una diferencia media de 1,6, un efecto de tamaño y potencia de 80. los instrumentos fueron la escala de fortaleza relacionada con la salud, y la de bienestar espiritual, y presentaron un alfa de 0,801 y 0,973 respectivamente. se utilizó la regresión lineal múltiple para investigar el efecto de las variables demográficas sobre el bienestar espiritual. la edad media de los sujetos fue de 73,9 (de=4,3), el 62,5% fueron mujeres. el coeficiente de correlación entre el bienestar espiritual y la fortaleza relacionada con la salud fue significativo, los niveles más altos de bienestar espiritual tienen niveles igualmente elevados de fortaleza relacionada con la salud. el sexo, la edad, la educación y el estado civil mostraron una relación positiva con los niveles de bienestar espiritual (p<,005). las mujeres mostraron un nivel mayor de bienestar espiritual que los hombres. palabras clave adultos mayores, nivel de bienestar espiritual, fortaleza relacionada con salud. 1 rn, arnp, phd; profesora, facultad de enfermería universidad autónoma de tamaulipas, méxico. marwhet@att.net.mx 2 rn, edd; faan; profesora y directora de programas de posgrado, facultad de enfermería, lehman college, universidad autónoma de nueva york, bronx, ee. uu. tomassons@aol.com 3 profesora de tiempo completo, campus tampico. universidad autónoma de tamaulipas, méxico. paguiler@aut.edu.mx 4 enfermero e investigador, instituto mexicano de seguro social umf no. 28, méxico. pueriles@gmail.com abstract this study investigated the relationship between the levels of spiritual well-being and the levels of health related hardiness in mexican population of abuts 65 years and older. the framework was based on the roy adaptation model, pollock�s, health related hardiness and spiritual well-being of reed. the design was descriptive co relational, the sampling was probabilistic random. the sample (n=160) had a level of significance of 0.05 for a mean difference of medium 1.6, a size effect and a potency of 80. the instruments were the health related hardiness scale, with an alpha of 0.801 and the spiritual well being with an alpha of 0.973. multiple linear regression was used to investigate the effect of the demographic variables on the spiritual well-being. the mean age of the subjects was of 73.9 (de=4.3) 62.5% were females. the correlation coefficient between spiritual well-being and health related hardiness was r. 684 p<.05, meaning that higher levels of spiritual well-being have higher levels of health related hardiness. sex, age, education, and marital status showed a positive correlation with the levels of spiritual well being (p<.005). the women showed a higher level of spiritual well-being than the males. key words elderly persons, level of spiritual well-being, health related hardiness. relacionados con la salud en adultos mayores niveles de bienestar espiritual y de fortaleza relacionados con la salud en adultos mayores 73 introducción a población de personas de edad avanzada en américa latina, y especialmente en méxico, está aumentando en forma rápida. el censo de 2000 reportó un crecimiento explosivo en la población mexicana. actualmente hay 6 millones de personas de edad avanzada que viven en este país (65 años y mayores), y se reporta que diariamente 491 personas han entrado a formar parte de este grupo; la proyección actual es que para el año 2050, ésta será de 17 millones de personas. además, se ha calculado que en américa latina el 43% de las personas con edad avanzada y las mujeres que están viviendo en las zonas urbanas hoy en día afrontan un estrés muy alto, por estar sufriendo la pérdida de miembros de la familia debido a la inestabilidad política, la guerrilla, las enfermedades crónicas y los problemas económicos. el envejecimiento en méxico representa una carga extra, ya que los cambios socioculturales modifican la estructura familiar, la cual no cuenta con medios y condiciones aptos para los mayores de edad. la capacidad de esta población para adaptarse a estos problemas se basará en la habilidad para evitar la institucionalización y hospitalización, con el fin de tener una buena calidad de vida (1). selye, en su libro the stress of life, hace énfasis en que no son los estímulos estresantes en sí mismos, sino la reacción a dichos estímulos, lo que tiene un efecto negativo en nuestros cuerpos (2). en las últimas cuatro décadas, al tratar de descubrir la manera cómo la mente puede ayudar a una persona a comprender el origen de su estrés y así reducirlo, los investigadores han buscado en las fuentes de la medicina tradicional que han sido utilizadas en la curación. dichas técnicas, como la meditación y el yoga, entre otras, han ayudado a tranquilizar el espíritu y la mente, han aumentado el bienestar espiritual e interactúan con el cuerpo para su curación. basados en las premisas anteriores, estos investigadores creen que el bienestar espiritual podría representar un papel muy importante en la promoción de la salud del individuo. en 1859 nightingale creyó en el componente espiritual de la vida humana (3). watson opinó que la espiritualidad era un aspecto esencial que influía en las condiciones emocionales y físicas de la persona (4). reed y peri están de acuerdo en que existe una conexión entre una espiritualidad fuerte y una mejoría en la salud mental, con la habilidad para afrontar el estrés de una enfermedad y el duelo (5, 6). carson y green encontraron que la espiritualidad estaba positivamente unida con la fortaleza en víctimas de vih (7). el concepto de fortaleza, como lo define kobasa, sugiere una �constelación de características de la personalidad que funcionan como un medio de resistencia ante los eventos desencadenantes del estrés de la vida� (8, 9). la estructura de la personalidad está formada por tres características principales: �control, reto y compromiso�; las tres, que son una combinación del conocimiento, la emoción y la acción, son ideales tanto para sobrevivir, como para enriquecer el desarrollo de la vida. pollock fue la primera en introducir una escala de fortaleza relacionada con la salud (health related hardiness scale-hrhs, en la disciplina de enfermería). pollock probó la hrhs en estudiantes de enfermería graduados usando una encuesta de 48 preguntas (10). con base en los resultados iniciales, se agregaron tres preguntas para un total de 51. se computarizó un índice de interés que indicó que por lo menos era necesario tener octavo grado de educarevista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200574 ción para esta escala (11). en 1990, pollock probó la escala en 200 pacientes con enfermedades crónicas tales como la esclerosis múltiple, hipertensión, artritis reumatoide y diabetes mellitus. el resultado del estudio mostró que las personas con diabetes mellitus eran más fuertes que aquellas con artritis (10). éste es otro factor importante que tiene una influencia en la calidad de vida de hombres y mujeres de edad avanzada. revisión de literatura y marco teórico considerando el número de personas de edad avanzada en américa latina, es importante tener en cuenta la forma de dar apoyo y cuidado adecuado a estos hombres y mujeres, para asegurar una mayor calidad y dignidad en sus vidas. con este ideal en mente, los conceptos de bienestar espiritual y fortaleza relacionada con la salud han sido investigados como factores especialmente favorables para un envejecimiento exitoso. la creencia de que hay una conexión entre el cuerpo y la mente no es nueva, pero ha recibido mayor atención a medida que los investigadores en salud estudian los síntomas psicosomáticos; las uniones entre la mente y el sistema inmune; esta medicina mente-cuerpo nos permite considerar la interconexión posible de bienestar espiritual y fortaleza relacionada con la salud y cómo éstas contribuyen a la salud de los mayores y la calidad de sus vidas (12). convertirse en anciano puede significar muchas cosas para cada individuo, ya que contiene varios factores: la carga genética, el ambiente en que se vive, los factores físicos, sociales, económicos y emocionales, entre otros (13). sin embargo, volverse anciano es incuestionablemente un proceso de cambio constante e irreversible. la salud física, la pérdida de los seres queridos, el retiro forzoso, la situación económica y el grado de independencia en todas las áreas, son elementos fundamentales para tener en cuenta cuando se mide el bienestar de las personas de edad avanzada. como se mencionó, de acuerdo con selye, lo que afecta esencialmente la vida de cualquier persona y determina su calidad no son tanto los factores de estrés en sí mismos sino la forma como la persona reacciona ante éste, y su habilidad para adaptarse al cambio (2). selye definió el estrés como una respuesta no específica del cuerpo a cualquier demanda hecha a éste, bien sea una amenaza, un reto o cambios que requieren adaptación. él pensó en la conexión del cuerpo y la mente en la reacción al estrés y subrayó la habilidad para reaccionar ante el estímulo como responsable del deseo de una salud duradera (2). también aseveró que gran parte del envejecimiento fisiológico (opuesto al cronológico), resulta del uso y abuso del cuerpo, y consideró que la espiritualidad, en la medida en que induce una actitud relajada hacia lo que sucede y cuando sucede, puede resultar en una reacción favorable. estas reacciones, a su vez, permiten que la fortaleza sea un canal de bienestar espiritual que hace que el individuo no fije su atención en los factores negativos desencadenantes del estrés �tal como el causado por la preocupación que en sí misma en un factor desencadenante del estrés autoimpuesto� (2), aliviándolo. considerando que la gente de edad avanzada a menudo está bajo estrés debido a que ha sufrido serias pérdidas, está sola o enferma, tiene sentido pensar, como lo hace selye, que lo que marca la diferencia en la calidad de vida es la forma en la cual ellos reaccionan y se adaptan a estos cambios mayores, los cuales pueden depender o estar influenciados por su sistema de creencias y valores. considerando que la gente de edad avanzada a menudo está bajo estrés debido a que ha sufrido serias pérdidas, está sola o enferma, tiene sentido pensar, como lo hace selye, que lo que marca la diferencia en la calidad de vida es la forma en la cual ellos reaccionan y se adaptan a estos cambios mayores, los cuales pueden depender o estar influenciados por su sistema de creencias y valores. niveles de bienestar espiritual y de fortaleza relacionados con la salud en adultos mayores 75 existe también una fortaleza personal. frankl ha sugerido la relación entre la espiritualidad y las reacciones positivas a los factores desencadenantes del estrés (14). este autor considera la habilidad para encontrar un significado existencial y espiritual a la vida a pesar de los factores importantes que desencadenan el estrés, como un indicador de la habilidad para permanecer mental y físicamente sano a pesar de las situaciones de conflicto. carson y green estudiaron esta relación en individuos con vih y sida, y encontraron también una relación importante (7). si esta relación entre la espiritualidad y u n a r e a c ción positiva a los factores desencadenantes del estrés fuera encontrada entre la gente de edad avanzada, entonces estimular el bienestar espiritual sería un medio viable para hacer de la fortaleza la habilidad que conserve la salud a pesar de la presencia de factores desencadenantes del estrés. definición de fortaleza la palabra fortaleza parece originarse en el campo agrícola. fortaleza, literalmente, significa �ser capaz de resistir a las condiciones adversas del clima� (15). el término se usó a fin de describir la calidad de la cosecha para superar las condiciones desfavorables del clima. kobasa adaptó la definición de fortaleza en 1979 para incluir la personalidad que actúa como un buffer contra el estrés que afecta el cuerpo (9). webster define la fortaleza en relación con los seres humanos, como la condición de resistir la fatiga o la capacidad de tolerancia y sufrimiento (16). estudios anteriores que consideraron el concepto de fortaleza en lo relativo a la salud, aparecieron de nuevo después del popular término de estrés y el estudio de la enfermedad, a finales de 1970. la psicóloga susan kobasa explica por qué algunas personas permanecen sanas cuando están en prisión, mientras otras no, lo que demuestra una personalidad fuerte (9). al conceptualizar la fortaleza, kobasa pudo trabajar sobre el fenómeno de la psicología existencial y sobre los trabajos de hans selye. el modelo de selye de la respuesta general a la adaptación (gas, por sus siglas en inglés) establece que �los eventos positivos y negativos, los menores y los graves, evocan esfuerzos de adaptación incompletos tanto en el tipo como en la duración, disminuyen la resistencia del cuerpo y aumentan la probabilidad de la enfermedad� (2). kobasa, y sobre todo selye, reconocieron que algunos organismos humanos están �constituidos de tal forma que manejan el estrés sin riesgo� (17-19). kobasa y selye entienden las conexiones de la mediación del estrés y de la enfermedad como �la forma específica en la cual cada individuo reacciona al estrés� (2, 9). basándose en el enunciado anterior, kobasa desarrolló la teoría de la fortaleza. más tarde pollock, una enfermera, refinó los conceptos de kobasa sobre control, compromiso y retos para que fueran más específicos sobre el tema de la salud. ella definió el control como �el manejo de la autoconfianza necesaria para interpretar y valorar los elementos que producen estrés�. esto significa que no todo el estrés es prevenible (11). el compromiso es para el individuo que está motivado y tiene interés en promover su salud, haciéndole la competencia a los factores que producen estrés. las personas comprometidas son aquellas que tienen una visión positiva hacia la salud (11). el reto, que es el último concepto de pollock, se refiere a un estímulo emocionante y no a una amenaza. la gente que se siente positiva con los cambios los percibe como el compromiso es para el individuo que está motivado y tiene interés en promover su salud, haciéndole la competencia a los factores que producen estrés. las personas comprometidas son aquellas que tienen una visión positiva hacia la salud. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200576 crecimiento. los individuos expresan confianza en sí mismos al ser capaces de afrontar los factores que producen estrés. los retos relacionados con la salud reflejan una actitud de total confianza hacia la forma de afrontar los cambios (11). conceptos sobre la fortaleza la teoría de sentido de coherencia (soc) se relaciona con el concepto de fortaleza. de acuerdo con esto, �soc es un elemento importante del estrés/distrés continuo de la salud� (20, 21). esta teoría tiene tres componentes: 1) comprensión, 2) manejo, 3) significado. las personas que tienen un soc fuerte cuentan con un puntaje alto en los tres componentes (21). comprensión es �el alcance que tiene una persona para percibir el estímulo, derivado del ambiente interno o externo, dándole sentido cognitivo�. la persona con un soc alto verá que los factores que producen estrés son predecibles y explicables (21-24). el manejo en la teoría soc se refiere a la percepción de recursos adecuados para afrontar las necesidades producidas por el estrés o el estímulo (21-24). la persona con un incentivo alto de manejo no se sentirá amenazada por los elementos que producen estrés. cuando éstos se presentan, la persona es capaz de afrontar la situación. el último componente de la teoría soc es el significado. éste identifica la importancia de estar implicado �como participante en el proceso de moldear el destino y las experiencias diarias� (21). este componente es similar al compromiso d e kobasa, quien lo describe como �involucrarse profundamente consigo mismo� (9). el concepto de kobasa sobre la fortaleza y el componente de soc están muy entrelazados. las dos teorías tienen aspectos similares y diferentes (25). lee amplía el concepto de fortaleza para incluir cuatro componentes de la personalidad: resistencia, fuerza, audacia y control. de los cuatro, uno se refiere a los tres componentes de kobasa. el primer componente es la resistencia, que es la firmeza fisiológica y psicológica para continuar. el segundo es la fortaleza, que significa la habilidad para resistir el estrés, la fuerza y las penas. el tercer componente es la audacia, que implica coraje, interés y valentía. el último componente es el control, que es la habilidad de tener autoridad (26). pollock desarrolló la primera escala fortaleza relacionada con la salud (hrhs, por sus siglas en inglés) (11). este instrumento se usó para medir la fortaleza personal en individuos que presentaban problemas de salud existentes o potenciales. la escala inicial de hrhs tenía 48 reactivos con una escala de likert de 6 puntos, compuesta a su vez de tres categorías: �control, reto y compromiso� (27). la mayor diferencia entre la definición de fortaleza de kobasa y la de pollock, es que la segunda está relacionada específicamente con la salud (11, 28). fortaleza, mujeres y hombres de edad avanzada mangani estudió la relación entre fortaleza, autopercepción de salud y actividad entre adultos mayores con actividades independientes (29). su muestra estaba formada por 115 individuos, entre hombres y mujeres mayores no institucionalizados, con edades entre 60 y 90 años, que vivían en el área de nueva york. la edad promedio fue de 71,89, el moda 74, y la media 72. había 85, número que coincidía con la tasa para la edad del grupo en dicha área de nueva york. estas mujeres recibieron los 36 reactivos abreviados de la escala de fortaleza, una valoración de salud dada por comprensión es �el alcance que tiene una persona para percibir el estímulo, derivado del ambiente interno o externo, dándole sentido cognitivo�. la persona con un sentido de coherencia alto verá que los factores que producen estrés son predecibles y explicables. niveles de bienestar espiritual y de fortaleza relacionados con la salud en adultos mayores 77 cada una de ellas y una sobre actividad. los resultados obtenidos apoyaron la hipótesis de que los adultos mayores con niveles más altos de actividad tenían niveles más altos de fortaleza. estos resultados también mostraron que aquéllos con una cifra alta en los dos instrumentos, tenían un nivel de actividad más alto que aquéllos con una cifra alta en un solo instrumento (19). es interesante notar que cuando se analizan los datos de control, compromiso y reto, los dos primeros están correlacionados con niveles más altos de actividad, mientras que el reto no lo está. magnani postuló que el reto puede ser menos importante para los mayores de edad que para los jóvenes (29). predicción de fortaleza si la fortaleza es un factor importante para determinar si una persona maneja efectivamente el estrés (adaptándose), entonces es importante entender sus antecedentes. kobasa cree que la fortaleza en el individuo está influenciada por varias experiencias de su niñez, tales como recibir aprobación y admiración por lo que se hace, estímulo y apoyo por tener la capacidad de utilizar símbolos, imaginación y juicio, y tener modelos que defienden la fortaleza (17-19, 30, 31). antonovsky defiende una teoría de orientación �salutogénica�, que es similar a la fortaleza (21). cree que la personalidad salutogénica tiene la habilidad de permanecer física y psicológicamente saludable a pesar de tener factores significativos que desencadenen estrés. sus tres elementos �significado, comprensión y flexibilidad� corresponden al control, compromiso y reto de kobasa. sin embargo, no son conceptos idénticos. el significado y el compromiso son muy similares, ya que los dos reflejan la visión de la vida como algo que tiene sentido y valor personal. la flexibilidad y el control se refieren a los recursos disponibles para ayudar a afrontar los cambios en la vida, y al sentimiento de su influencia en los eventos de ésta. la mayor diferencia está entre el reto y la comprensión, donde el primero se refiere a considerar el cambio como algo esperado y bueno, y el segundo a la percepción del estímulo como algo que tiene sentido. antonovsky opina que el componente más importante de una personalidad salutogénica es el sentido de coherencia o una creencia básica de que el ambiente interno y externo son predecibles y/o explicables, y que las cosas saldrán tan bien como razonablemente se puede esperar. antonosky y kobasa creen que sus elementos están moldeados por las experiencias caracterizadas por la participación en la configuración de los resultados, el éxito y el fracaso, y la consistencia (31). frankl, un psiquiatra que estuvo preso en los campos de concentración nazis, consideró el deseo de dar significado como un ingrediente esencial de una vida sana. él creyó que el significado de la vida podría encontrarse creando algo, experimentando algo, encontrando a alguien, o teniendo una relación consciente con el sufrimiento. opinó que la clave para ser capaz de manejar la propia vida en forma satisfactoria y exitosa era descubrir lo que hace que ésta tenga significado. una vez se descubre y se entiende este aspecto, se puede vivir en armonía (14). esto permitirá enfrentar el sufrimiento y las dificultades con tolerancia. espiritualidad la investigación sobre saneamiento holístico ha hecho énfasis en la importancia de establecer los aspectos espirituales como esenciales para la curación de enfermedades y el manejo de la salud. los prokobasa cree que la fortaleza en el individuo está influenciada por varias experiencias de su niñez, tales como recibir aprobación y admiración por lo que se hace, estímulo y apoyo por tener la capacidad de utilizar símbolos, imaginación y juicio, y tener modelos que defienden la fortaleza. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200578 fesionales médicos han tratado de comprender el concepto de bienestar espiritual y su relación con la salud para la adaptación a la enfermedad y al proceso de envejecimiento. enfermería, por ejemplo, como una disciplina holística, ha entendido la importancia de la espiritualidad en el proceso de curación. emblen analizó las definiciones de bienestar espiritual en la literatura de enfermería (32). éstas parten de considerar la espiritualidad como un principio vivificante en la vida (33, 34) haciendo énfasis en una relación trascendental con dios u otros seres inmateriales (35). emblen concluyó que la falta de una definición unificada sobre espiritualidad para enfermería obstaculiza la investigación y el desarrollo de intervenciones espirituales por parte de las enfermeras. burkhardt usó la palabra �espiritualidad� como un concepto que connota un proceso y como tal es más útil para enfermería. ella definió espiritualidad como �el misterio revelado por medio de una interconexión armoniosa que nace de la fortaleza íntima� (36). en el intento por definir espiritualidad. reed, quien hizo varios estudios de investigación clínica sobre la relación del bienestar espiritual y la salud, describe la espiritualidad como la inclinación por encontrar significado en la vida por medio de un sentido de interrelación con algo mayor, que trasciende el yo y lo fortalece. esta interrelación puede ser experimentada en forma intrapersonal, interpersonal o transpersonal (5, 37-40). goddard, usando un análisis filosófico del concepto, propone una definición de espiritualidad como una energía integradora que es capaz de producir armonía interna y holística, que combina cuerpo, mente y espíritu. algunos atributos de la espiritualidad que goddard identifica son la corporeidad, la vitalidad y la fortaleza (41). en 1981, la conferencia de la casa blanca sobre envejecimiento recomendó que la investigación sobre este tema incluyera la relación entre los aspectos religiosos, el bienestar espiritual, la longevidad y la calidad de vida de la gente de edad avanzada. varios estudios de enfermería han investigado esta relación. hungelman llevó a cabo un estudio cualitativo para determinar los componentes del bienestar espiritual (42) utilizando una teoría fundamental; 31 participantes con edades entre 65 y 85 años fueron entrevistados y se observaron durante 150 horas. el estudio tuvo tres categorías relativas al vínculo: 1) a otro último; 2) a otros y la naturaleza; a sí mismo, y 3) en relación con el tiempo; percepción y aceptación del pasado, presente y futuro de cada uno. la teoría que unificó todo lo anterior fue la interconexión armónica. este estudio preparó el camino del método para explorar el bienestar espiritual. trice llevó a cabo un estudio cualitativo para entender qué experiencias vitales tenían significado para las personas ancianas (43). los participantes fueron 9 mujeres y 2 hombres con edades entre 65 y 87 años. a cada participante se le pidió que describiera las experiencias y los sentimientos que daban significado a su vida. los temas comunes que resultaron estaban conectados con las experiencias relacionadas con la preocupación por otros. esto coincide con un sentido de bienestar espiritual, y el significado y la habilidad para relacionarse con otros de forma trascendente. otro hallazgo fue la satisfacción que recibieron los participantes al compartir estas experiencias. williams informa sobre visitas a siete personas ancianas con el fin de discutir si la espiritualidad los ha ayudado a ellos y a sus cuidadores (44). estos temas se recolectaron anecdóticamente en su artículo. no se reportó un método para el análisis cualitativo, por lo tanto, los resultados son menos confiables. la espiritualidad se manifiesta como hacer oración, ayudar a burkhardt usó la palabra �espiritualidad� como un concepto que connota un proceso y como tal es más útil para enfermería. ella definió espiritualidad como �el misterio revelado por medio de una interconexión armoniosa que nace de la fortaleza íntima�. niveles de bienestar espiritual y de fortaleza relacionados con la salud en adultos mayores 79 otros, siendo reportada como útil para todos los participantes; éstos expresaron satisfacción con la interacción y sugirieron que discusiones similares entre las enfermeras y los clientes podrían tener un efecto benéfico en los dos grupos. reed estudió la autotrascendencia y la salud mental en individuos con edades entre 80 y 100 años. una muestra de 55 personas ancianas que estaban viviendo en la comunidad, con edades entre 80 y 97, participaron en el estudio (5). se utilizó la escala de autotrascendencia (sts, por sus siglas en inglés), compuesta por 15 ítems para medir una visión más amplia de sí mismo en experiencias interpersonales, intrapersonales y temporales. la prueba de fiabilidad del instrumento fue de 95. se utilizó una entrevista semiestructurada que permitió a los participantes describir su enfoque en cosas diferentes a ellos mismos, las perspectivas sobre sus cambios físicos y las perspectivas de su pasado, presente y futuro. la salud mental se midió con la escala de depresión del centro de estudios epidemiológicos, y la escala de sintomatología de salud mental. el análisis matriz de la entrevista cualitativa obtuvo cuatro categorías: 1) generalidad: ayuda a otros y participación de la familia; 2) introyección: aprendizaje a través de los años y pasatiempos, viajes y trabajo en el hogar; 3) integración temporal: sentimientos sobre el pasado, presente y futuro; 4) trascendencia del cuerpo. las correlaciones entre el sts y las dos medidas de salud mental fueron significativas. esto fue respaldado en el análisis de la matriz. se aplicó la escala de perspectiva espiritual (sps, por sus siglas en inglés) de reed (1997), y el índice de experiencias espirituales en la versión del autotest, y inspirit-r9 (45). en este estudio se desarrolló la intervención de enfermería para el inventario de cuidado espiritual (nisci) a fin de medir la importancia de las intervenciones de enfermería. se encontró una correlación positiva entre el sts, el sps y el inspirit: los ítems preferidos en el nisci fueron aquellos dirigidos hacia una actitud de cuidado, respeto por las creencias religiosas, ayuda a sentirse esperanzado, escucha, y dar privacidad a la actividad espiritual. los menos preferidos fueron las intervenciones, que incluyeron rezar con la persona y discutir ideas sobre dios. este fue un hallazgo interesante que según bauer y barron podría estar relacionado con el sentimiento de que el papel de la enfermera no es participar con el individuo en aspectos privados de su vida (46). espiritualidad y salud relacionada con fortaleza carson y green estudiaron la relación entre la espiritualidad y la fortaleza en un grupo de 100 personas vih positivas o que tenían diagnóstico de sida (7). se les aplicó la escala del bienestar espiritual (47) y la encuesta de los puntos de vista personales, desarrollada por kobasa y colaboradores en el instituto de fortaleza (48). hubo una correlación positiva entre fortaleza y bienestar espiritual, encontrando que el bienestar espiritual predice la fortaleza y sugiere que la enfermera debe promover y estimular la espiritualidad entre personas vih positivas como una forma de promover el bienestar. materiales y métodos esta investigación se guió por el modelo de adaptación de roy. en este estudio el estímulo focal es el envejecimiento, que afecta a la persona en sus cuatro modalidades. los cambios psicológicos de la edad incluyen la pérdida sensorial, la disgoddard, usando un análisis filosófico del concepto, propone una definición de espiritualidad como una energía integradora que es capaz de producir armonía interna y holística, que combina cuerpo, mente y espíritu. algunos atributos de la espiritualidad que goddard identifica son la corporeidad, la vitalidad y la fortaleza. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200580 minución de la lubricación de las membranas mucosas y la pérdida de la densidad de los huesos. la función del rol incluye cambios o pérdida de los roles ocupacionales y familiares. la interdependencia está amenazada por la muerte o por la enfermedad de la pareja o de los amigos, y los cambios geográficos. el autoconcepto está afectado por la edad. algunos estímulos focales, tales como una enfermedad aguda o la pobreza, pueden afectar a la persona directamente. otros estímulos focales del envejecimiento son inevitables, por lo tanto, la ayuda a la adaptación debe estar enfocada a la identificación de los estímulos contextuales positivos. la presente investigación es la primera fase de un programa de estudios que evaluarán la hipótesis de que la salud relacionada con la fortaleza y el bienestar espiritual representan factores importantes en la adaptación al envejecimiento. diseño y muestra se utilizó un diseño de estudio descriptivo correlacional. la muestra estaba conformada por 160 adultos, mujeres y hombres, con edades entre 60 y 85 años, que vivían en una zona urbana de méxico. a todos se les pidió que contestaran tres cuestionarios, la escala de fortaleza relacionada con salud, la escala de bienestar espiritual y la encuesta demográfica. el criterio para excluir sujetos fue que no tuvieran demencia. el acercamiento a los participantes se hizo en forma individual o colectiva. se les dio una explicación del estudio y se les preguntó si estaban interesados en participar. a los que estaban interesados se les pidió firmar una carta de consentimiento informado y se les dijo que podían retirarse del estudio cuando quisieran. análisis de datos después de obtener la información, ésta fue procesada en el programa estadístico spss versión 13 (49). el análisis de datos se realizó en dos etapas: en la primera se obtuvieron estadísticas porcentuales y descriptivas, además del coeficiente de alpha de cronbach de los instrumentos. se aplicó la prueba de kolmogorov-smirnov para verificar la normalidad de las variables, previo a ello se obtuvieron los índices de los instrumentos. posteriormente, en la segunda etapa, se realizaron estadísticas no paramétricas debido a que los datos no mostraron normalidad en su distribución: se realizó correlación binaria. resultados los datos que se muestran a continuación corresponden a características sociodemográficas de los participantes en el estudio. el cuadro 1 muestra que la mayoría de la población en estudio está en una edad que oscila entre 71 y 74 años de edad y que la mayor proporción la ocupa el sexo femenino. el cuadro 2 indica que los participantes tienen una mayor educación en primaria. la mayor proporción respecto a religión corresponde a la católica. un poco más del 60% se encuentran actualmente casados. cuadro 1. características sociodemográficas de la población en estudio (edad y sexo) grupos de edad n % 65-70 25 15,6 71-74 96 60,0 75-85 39 24,4 sexo n % masculino 60 37,5 femenino 100 62,5 n=160 edad media 73,9 de 4,3 min 65 max 85 mediana 74,0 niveles de bienestar espiritual y de fortaleza relacionados con la salud en adultos mayores 81 confiabilidad de los instrumentos el cuadro 3 muestra que los dos instrumentos obtuvieron una consistencia interna aceptable. matriz de correlación en el cuadro 4 se observa que la espiritualidad se relaciona positivamente con fortaleza, sexo, edad, educación y religión, y de forma negativa con estado civil y salario. también se observa que la fortaleza se relaciona de forma positiva con espiritualidad, sexo edad, educación y religión así como de forma negativa con estado civil. discusión este estudio mostró una relación positiva entre los niveles de bienestar espiritual y los de la fortaleza relacionada con la salud en una población de personas en edad avanzada que vivían en la zona urbana de la república mexicana. esta relación coincide con los estudios mencionados en la literatura que mostraron cómo la fortaleza relacionada con la salud y el bienestar espiritual, actuando en conjunto, tuvieron efectos positivos en los individuos que estaban afrontando diferentes situaciones con estrés (pollock, kobasa, maddi y khan, reed). el análisis de esta relación puede ayudar a comprender mejor el impacto que tienen estas dos características de la personalidad en la vida de los ancianos y puede ser usado para guiar el desarrollo de intervenciones de enfermería. los análisis de la relación entre los factores demográficos y los del bienestar espiritual son importantes. esto puede sugerir que las circunstancias de vida no tienen un efecto negativo en sus prácticas espirituales. la calidad de vida de los ancianos en méxico �y probablemente en américa latina� es multidimensional, ya que son multiculturales. los caminos para obtener una óptima calidad de vida durante el envejecimiento se basan en la percepción e intervención en la salud física y psicológica del anciano. en este estudio se ha discutido que la salud relacionada con la cuadro 2. características sociodemográficas de la población en estudio (educación, religión y estado civil) escolaridad n % primaria 100 62,5 media superior 18 11,3 universidad 2 1,3 sin educación 40 25,0 religión católico 143 89,4 otro 17 10,6 estado civil casado 104 65, soltero 56 35,0 n=160 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200582 cuadro 4. correlación de spearman de las variables espiritualidad, fortaleza, sexo, edad, educación, religión, estado civil y salario. correlación de variables 1 2 3 4 5 6 7 8 1. espiritualidad 1.000 2. fortaleza .684 1.000 .000 3. sexo .657 .617 1.000 .000 .000 4. edad .265 .310 .584 1.000 .001 .000 .000 5. educación .312 .457 .195 .304 1.000 .000 .000 .013 .000 6. religión -.188 -.197 -.278 -.181 .028 1.000 .017 .013 .000 .022 .724 7. estado civil -.405 -.362 -.677 -.768 -.158 .172 1.000 .000 .000 .000 .000 .045 .029 8. salario -.227 -.100 -.470 -.666 -.301 .073 .456 1.000 .004 .211 .000 .000 .000 .363 .000 cuadro 3. consistencia interna de los instrumentos instrumento reactivos alpha de cronbach cuestionario de espiritualidad 10 0,973 cuestionario de fortaleza (shrhs) 34 0,801 total 44 0,916 n=160 niveles de bienestar espiritual y de fortaleza relacionados con la salud en adultos mayores 83 fortaleza y el bienestar espiritual son dimensiones significativas que ayudan a mantener saludables a los ancianos. dado que no es posible dar una definición de bienestar espiritual que satisfaga a todos, es importante educarlos en el desarrollo de una fortaleza relacionada con su salud y bienestar espiritual a fin de mejorar sus vidas, lo cual significa básicamente estimularlos para que desarrollen actitudes de autocuidado y cuidado a otros. implicaciones teóricas y conexiones este estudio confirma que la fortaleza relacionada con la salud y el bienestar espiritual se pueden clasificar como estímulos contextuales positivos. la presencia de la fortaleza relacionada con la salud es una característica significativa que contribuye al bienestar de los ancianos, y a la adaptación a los cambios de la vejez. entre más alto sea el nivel de fortaleza relacionada con la salud que posea el anciano, más podrá cuidar de sí mismo. también, niveles altos de bienestar espiritual para esta población significan que la cercanía con dios muestra el camino para lograr la adaptación ante los retos del envejecimiento (percepción del ambiente como fuente de oportunidades y no de obstáculos). implicaciones para enfermería los resultados de este estudio también tienen implicaciones para la práctica, la educación y la investigación. práctica de enfermería para la práctica de enfermería gerontológica, la fortaleza relacionada con la salud y el bienestar espiritual parecen ser dimensiones significativas que ayudan a la adaptación al cambio que se produce durante la transición de adultos mayores a ancianos. el cuestionario de la fortaleza relacionada con la salud parece ser un instrumento apropiado para la medición de este concepto en la población mexicana. ejemplo: si se descubre que un individuo tiene niveles bajos de fortaleza relacionada con la salud, las intervenciones específicas de enfermería pueden ser utilizadas con la finalidad de incrementar su fortaleza relacionada con la salud. pollock propuso que una instrucción basada en el concepto de fortaleza puede promover el cuidado óptimo de la salud o la adaptación a enfermedades crónicas. en este aspecto el rol de enfermería está dirigido en identificar o apoyar al anciano a desarrollar prácticas de salud apropiadas para obtener una fortaleza de salud que lo ayude a mantener una adaptación positiva frente a la situación en la que se encuentra. para la población de ancianos mexicanos, el bienestar espiritual, o cercanía con dios, muestra el camino para predecir la adaptación a los retos del envejecimiento. en este sentido, el rol de enfermería es facilitar apoyo para que esta población pueda mantener sus prácticas religiosas. educación en enfermería los resultados de este estudio tienen implicaciones para la educación de ancianos y cuidadores de la salud. la educación en enfermería se debe enfocar en desarrollar estrategias para enseñar a los ancianos cómo mantenerse independientes no obstante las limitaciones que poseen. enseñándoles cómo mantenerse saludables, se puede generar una población que no dependa excesivamente de cuidados hospitalarios y, por ende, conlleve menores costos y mayores beneficios a la sociedad, la comunidad y las instituciones de salud (50). con la creación de nuevos programas de maestría y doctorado en enfermería, en los últimos años nuestra ciencia ha cambiado radicalmente en latinoamérica. la forma de educar a nuevas generaciones para el futuro debe estar basada en la investigación científica del conocimiento propio de enfermería, a fin de desarrollar programas de educación que respondan a las necesidades de nuestras sociedades y de nuestro tiempo. investigación en enfermería existen en américa latina áreas muy fértiles para investigaciones en fortaleza relacionada con la salud y bienestar espiritual, como problemas de enfermedades crónicas, cáncer en poblaciones femeninas, obesidad, enfermedades cardiovasculares, sobrevivientes de abuso y rapto, entre otras. es necesario realizar estas investigaciones para conocer y aprender cómo estas poblaciones sobreviven y se recuperan. los resultados nos enseñarán cómo desarrollar intervenciones basadas en la fortaleza relacionada con la salud y el bienestar espiritual para ayudar a nuestros clientes a adaptarse a los cambios necesarios para confrontar sus condiciones. la contribución de los conceptos de la fortaleza relacionada con la salud y el bienestar espiritual es y ha sido un importante hallazgo para nuestra ciencia. la importancia del entendimiento de estas características de la personalidad (reto, control, compromiso) nos ayudará a entender cómo funcionan en un medio de resistencia a los efectos de los múltiples problemas que confrontan a los ancianos. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200584 referencias bibliográficas 1. ruiz s. envejecen en méxico 491 personas al día. reforma 2002:8a. 2. selye h. the stress of life. new york mcgraw hill; 1975. 3. nightingale f. notes on nursing: what it is and what it is not. london; 1859. 4. watson j. nursing: human science and human care: a theory of nursing. norwalk, ct: appleton-century-crofts; 1985. 5. reed pg. self-transcendence and mental health in older adults. nursing research 1991;4(3):5-11. 6. peri ta. promoting spirituality in persons with acquired immunodeficiency syndrome: a nursing intervention. holisitc nursing practice 1995;10(1):68-76. 7. carson vb, green h. spiritual well-bein: a predictor of hardiness in patients with acquired immunodeficiency syndrome. j prof nurs 1992;8(4):209-220. 8. bigbee jl. hardiness: a new perspective 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the community-based elderly. holistic nursing 1995;13(3):268-269. 47. ellison cw. spiritual well-being: conceptualization and measurement. journal of psychology and theology 1983;11 (4):330-340. 48. kobasa sc, maddi sr, puccetti mc, zola ma. effectiveness of hardiness, exercise, and social support as resources against illness. journal of psychomatic research 1985;29 (5):525533. 49. spss. statiscal package for the social sciencies versión 13;2003. 50. resnick b. motivating older adults to engage in self-care. patient care for the nurse practitioner 2001;4(9):13-19. 487 500 aplicacao do modelo calgary.indd 487 gicely regina sobral da silva monteiro1 janaine chiara oliveira moraes2 solange fátima geraldo da costa3 betânia da mata ribeiro gomes4 inácia sátirto xavier de frança5 regina célia de oliveira6 aplicação do modelo calgary de avaliação familiar no contexto hospitalar e na atenção primária à saúde. revisão integrativa 1 orcid.org/0000-0002-9773-6916. universidade de pernambuco. brasil. gicely_regina@hotmail.com 2 orcid.org/0000-0002-0266-4762. universidade de pernambuco. brasil. janainechiara@hotmail.com 3 orcid.org/0000-0002-6555-8225. universidade de pernambuco. brasil. solangefgc@gmail.com 4 orcid.org/0000-0002-6503-0222. universidade de permambuco. brasil. betania.mata@upe.br 5 orcid.org/0000-0002-2695-510x. universidade estadual de paraíba. brasil. inácia.satiro@gmail.com 6 orcid.org/0000-0002-6559-5872. universidade de permambuco, brasil. reginac_oliveira@terra.com.br recibido: 13 de agosto de 2015 enviado a pares: 28 de febrero de 2016 aceptado por pares: 19 de julio de 2016 aprobado: 19 de agosto de 2016 doi: 10.5294/aqui.2016.16.4.7 para citar este artículo / to reference this article / para citar este artigo monteiro grss, moraes jco, costa sfg, gomes bmr, franca isx, oliveira rc. aplicação do modelo calgary de avaliação familiar no contexto hospitalar e na atenção primária à saúde. revisão integrativa. aquichan. 2016; 16 (4): 487-500. doi: 10.5294/aqui.2016.16.4.7 resumo objetivo: caracterizar as publicações sobre a aplicação do modelo calgary de avaliação familiar, no contexto hospitalar e na atenção primária à saúde, divulgadas em periódicos on-line da área de saúde. material e método: revisão integrativa da literatura. o levantamento do material foi realizado mediante a busca no portal capes, pubmed, medline, lilacs, bdenf, na cidsaúde e ibecs. foram adotados os seguintes critérios de inclusão: artigos on-line, disponíveis na íntegra, publicados nos idiomas português, inglês e espanhol, entre janeiro de 2008 a dezembro de 2013. a amostra foi composta por 25 trabalhos. resultados: os anos 2008, 2010 e 2013 evidenciaram um número maior de produções, predominaram artigos originais, 64,0 % dos estudos foram realizados na atenção primária à saúde. quanto à autoria dos estudos, a pesquisa mostrou que houve a participação do enfermeiro em 88,0 % das publicações. conclusões: foi possível evidenciar que a aplicação do mcaf, tanto no contexto hospitalar quanto na atenção primária à saúde, possibilita uma abordagem mais aprofundada sobre a estrutura, o desenvolvimento e o funcionamento familiar, o que se configura como uma ferramenta efetiva para identificar diagnósticos familiares. palavras-chave enfermagem familiar; família; atenção primária à saúde; assistência hospitalar (fonte: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 487-500 488 aquichan issn 1657-5997 eissn 2027-5374 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 487-500 aplicación del modelo calgary de evaluación familiar en el contexto hospitalario y en la atención primaria a la salud. revisión integradora resumen objetivo: caracterizar las publicaciones sobre la aplicación del modelo calgary de evaluación familiar, en el contexto hospitalario y en la atención primaria a la salud, divulgadas en periódicos en línea del área de salud. material y método: revisión integradora de la literatura. la compilación del material se realizó mediante la búsqueda en el portal capes, pubmed, medline, lilacs, bdenf, en la cidsaúde e ibecs. se adoptaron los siguientes criterios de inclusión: artículos en línea, disponibles en su totalidad, publicados en los idiomas portugués, inglés y español, entre enero de 2008 y diciembre del 2013. la muestra estuvo compuesta por 25 trabajos. resultados: en los años 2008, 2010 y 2013 se evidenció un número mayor de producciones, predominaron artículos originales, 64,0 % de los estudios se realizaron en la atención primaria a la salud. en cuanto a la autoría de los estudios, la investigación mostró que hubo la participación del enfermero en 88,0 % de las publicaciones. conclusiones: fue posible evidenciar que la aplicación del mcaf, tanto en el contexto hospitalario como en la atención primaria a la salud, posibilita un abordaje más profundizado sobre la estructura, el desarrollo y el funcionamiento familiar, lo que se configura como una herramienta efectiva para identificar diagnósticos familiares. palabras clave asistencia hospitalaria; atención primaria a la salud; enfermería; familia; familiar (fuente: decs, bireme). 489 aplicação do modelo calgary de avaliação familiar no contexto hospitalar e na atenção primária à saúde. revisão integrativa l gicely regina sobral da silva monteiro e outros application of the calgary family assessment model in hospitals and in primary health care: an integrative review abstract objective: characterize articles published in online health journals concerning application of the calgary family assessment model (cfam) in hospitals and in primary health care. material and methods: an integrative review of the literature was conducted through a search of capes, pubmed, medline, lilacs, bdenf, cidsaúde and ibecs. the following inclusion criteria were adopted: online articles available in full, published in portuguese, english and spanish from january 2008 to december 2013. the sample included of 25 works. results: the largest output was in the years 2008, 2010 and 2013. original articles predominated and 64.0% of the studies were carried out in the context of primary health care. as for authorship of the studies, the research showed that nurses participated in 88.0% of the publications. conclusions: it was demonstrated that application of the cfam, both in hospitals and in primary health care, allows for a more in-depth focus on the structure, development and functioning of the family, which is organized as a diagnosis of family identification. keywords family nursing; family; primary health care; hospital care (source: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 487-500 490 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 introdução a família é um espaço de cuidados reconhecido naturalmente e confirmado pelas responsabilidades que seus membros atribuem a ela. é na família que se observam os primeiros cuidados, o que possibilita que o indivíduo não só desenvolva seu corpo biológico, mas também sua inserção social, a transmissão da cultura e a socialização. para entender a família, é necessário avaliá-la levando em conta alguns aspectos estruturais como: composição, gênero, orientação sexual, seus subsistemas, os vínculos existentes, as atividades da vida diária, a comunicação não verbal e a circular, a solução de problemas, os papéis desempenhados individualmente, a influência e o poder, as crenças estabelecidas, as alianças e as uniões (1). essa unidade complexa também apresenta outras demandas relativas aos aspectos materiais, incluindo custos financeiros, moradia, transporte e acesso aos serviços de saúde, bem como aos aspectos emocionais que envolvem sentimentos como a raiva, a frustração e a desaprovação e que, aliados à falta de informação, necessitam de suporte emocional e de uma rede de cuidados que ligue a família às pessoas e serviços de apoio que garantam a qualidade de vida a todos os seus membros (2). quanto aos aspectos financeiros, as elevações dos custos estão relacionadas com o aumento do número de internações hospitalares dos pacientes com doenças crônicas ou a procura pelos demais serviços de saúde, diante desse impacto as famílias sentem-se angustiadas e ansiosas principalmente quando não possuem recursos suficientes para desempenhar as ações de cuidado (3), influenciando o contexto social e as relações familiares. nesse contexto, os familiares constituem conexão crucial para a obtenção de resultados positivos frente ao adoecimento. é fundamental que a equipe de saúde multidisciplinar se aproxime mais dessa família, com o intuito de ouvi-la, conhecê-la, explorar seus recursos e dificuldades, trocar saberes e ajudá-la para que, a partir da satisfação de suas necessidades, ela possa desempenhar e legitimar seu papel de apoio e de cuidado aos seus parentes enfermos e a si própria (4,5). vale salientar que, nas últimas décadas, houve um crescente desenvolvimento da literatura acerca do tema “família” e a busca de novas estratégias direcionadas para promover a assistência a esse grupo. nesse sentido, merece destaque o modelo calgary, que é considerado uma ferramenta apropriada para abordar famílias em diferentes situações de saúde e conformações familiares (4,5). ele foi elaborado pelas enfermeiras norte-americanas lorraine e maureen, em 1984, e envolve dois componentes específicos: o de avaliação e o de intervenção na família. o modelo calgary de avaliação familiar é composto por três categorias principais: a estrutural, a de desenvolvimento e a funcional. já o modelo calgary de intervenção familiar (mcif) realiza a intersecção dos domínios de funcionamento (cognitivo, afetivo e comportamental) com as intervenções familiares (1). logo, é inegável a valiosa contribuição do modelo calgary, como um instrumento capaz de proporcionar subsídios nos mais diversos campos de atenção à saúde da família, visto que este modelo está sendo utilizado mundialmente e seguem as tendências internacionais e nacionais com relação aos estudos com famílias. assim, considerando a relevância do modelo calgary para a prática assistencial do enfermeiro, é de fundamental importância a realização de estudos que busquem socializar o conhecimento produzido na literatura nacional e na internacional sobre a mencionada temática. isso justifica nosso interesse em realizar uma pesquisa de revisão integrativa da literatura tendo como fio condutor o seguinte questionamento: qual a caracterização das publicações acerca da aplicação do modelo calgary de avaliação familiar no contexto hospitalar e na atenção primária à saúde, disseminadas em periódicos on-line da área de saúde? diante do exposto, elaboramos este estudo, com o objetivo de caracterizar as publicações sobre a aplicação do modelo calgary de avaliação familiar, no contexto hospitalar e na atenção primária à saúde, divulgadas em periódicos on-line da área de saúde. metodologia trata-se de uma pesquisa de revisão integrativa da literatura pertinente à produção científica acerca da aplicação do mcaf nos diversos contextos de saúde. esse método de pesquisa é bastante utilizado na prática baseada em evidências, visto que, por meio dele, é possível reunir e sintetizar o conhecimento e a incorporação da aplicabilidade de resultados de pesquisas significativas na prática (6). para desenvolver esta revisão, consideramos as etapas referenciadas por mendes, silveira e galvão (7). para tanto, elaboramos 491 aplicação do modelo calgary de avaliação familiar no contexto hospitalar e na atenção primária à saúde. revisão integrativa l gicely regina sobral da silva monteiro e outros a questão norteadora do estudo; em seguida, procedemos à busca da literatura, à coleta dos dados, à leitura crítica do material inicial obtido, à avaliação, à categorização do conteúdo e, posteriormente, à análise e à interpretação das publicações selecionadas. o levantamento do material bibliográfico sobre a temática proposta para a condução desta pesquisa foi realizado mediante a busca on-line, no portal da coordenação de aperfeiçoamento de pessoal de ensino superior (capes), na united states national library of medicine (pubmed) e na biblioteca virtual de saúde (bvs), nas bases de dados medical literature analysis and retrieval system on-line (medline), literatura latino-americana e do caribe em ciências da saúde (lilacs), na base de dados de enfermagem (bdenf), na cidsaúde e no índice bibliográfico espanhol de ciências da saúde (ibecs). para selecionar a amostra, adotamos os seguintes critérios de inclusão: artigos on-line, disponíveis na íntegra, publicados nos idiomas português, inglês e espanhol, entre o período de 2008 a dezembro de 2013, e que abordassem o assunto pertinente à temática estudada, excluindo-se teses e dissertações, as publicações em duplicidade e os artigos que abordassem exclusivamente o modelo calgary de intervenção familiar. os dados foram coletados durante os meses de fevereiro e março de 2014. nas bases de dados selecionadas para o estudo, utilizando-se a palavra “modelo calgary” de forma isolada e associada aos descritores “hospital”, “hospitalização” e “atenção primária à saúde” pela combinação do operador boleano “and”, foi encontrado um total de 54 artigos, dos quais 23 foram considerados para a amostra. no portal capes, o emprego do termo “calgary family assessment model” possibilitou a obtenção de 27 trabalhos, dos quais 16 já haviam sido selecionados, e nove foram excluídos por não atenderem aos critérios de seleção. diante disso, apenas duas publicações foram incluídas para compor a amostra. para a busca na pubmed, aplicamos o mesmo termo em inglês já referido, o que resultou em 33 artigos. desses, 25 atenderam aos critérios previamente estabelecidos —21 em português, três, em inglês, e um, em espanhol. para viabilizar a coleta dos dados, utilizamos um instrumento validado direcionado para a revisão integrativa, contemplando os seguintes itens: identificação: título do artigo, do periódico, autores, idioma e ano de publicação; características metodológicas do estudo: objetivos e tipo de publicação (8). foram acrescentados o contexto de realização do estudo e a área de formação dos autores para responder aos objetivos propostos da pesquisa. convém ressaltar que algumas questões foram suprimidas durante sua aplicação. a análise seguiu com a interpretação e a síntese dos resultados, comparando-se os dados evidenciados em cada artigo. os dados foram agrupados e apresentados em duas categorias: uma relacionada às publicações desenvolvidas com foco no contexto hospitalar, e a outra, com relação aos estudos voltados para a atenção primária à saúde. os artigos selecionados foram classificados hierarquicamente, no que se refere ao seu nível de evidência. optamos pelo método de categorização da agency for healthcare research and quality (ahrq), dos estados unidos da américa, no qual a qualidade das evidências é elencada em seis níveis: • nível 1 —metanálise de múltiplos estudos controlados; • nível 2 —estudo individual com delineamento experimental; • nível 3 —estudo com delineamento quase experimental, como estudo sem randomização com grupo único pré e pósteste, séries temporais ou caso-controle; • nível 4 —estudo com delineamento não experimental como pesquisa descritiva correlacional e qualitativa ou estudos de caso; • nível 5 —relatório de casos ou dado obtido de forma sistemática, de qualidade verificável ou dados de avaliação de programas; • nível 6 —opinião de autoridades respeitáveis, baseada na competência clínica ou na opinião de comitês de especialistas, incluindo interpretações de informações não baseadas em pesquisas (9). resultados a amostra foi constituída por 25 artigos, dos quais 21 publicações foram disseminadas em periódicos nacionais e em quatro revistas internacionais. as revistas nacionais com o maior quantitativo de trabalhos foram: ciência, cuidado e saúde, escola ana neri, revista de enfermagem e pesquisa, cuidado é fundamental, cada uma com três produções (12,0 %) (tabela 1). no que diz respeito aos periódicos internacionais, foram os seguintes: journal of family nursing; journal of research fundamental care 492 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 online; nursing education today e revista eletrónica trimestral de enfermería. todos com uma publicação acerca da temática investigada (tabela 1). quanto à distribuição das produções no período de 2008 a 2013, os anos 2008, 2010 e 2013 evidenciaram um número maior de produções, com cinco publicações cada (20,0 %), respectivamente. com relação aos artigos originais, predominaram (56,0 %), entre os estudos pesquisados. todos os estudos foram descritivos, qualitativos e classificados com nível de evidência 4. com relação aos artigos de revisão, o estudo mostrou que não há nenhum acerca do assunto na amostra selecionada para o estudo proposto. isso aponta para a necessidade de se desenvolverem mais estudos sobre essa modalidade, especialmente sobre a revisão integrativa, haja vista a importância da compilação e da socialização do conhecimento produzido sobre essa temática. quanto ao contexto em que foram desenvolvidas as pesquisas com a aplicação do mcaf, 16 (64,0 %) foram realizatabela 1. distribuição dos estudos segundo periódicos, ano de publicação, área de formação dos autores, tipo de publicação e contexto de realização do estudo (n = 25). título do periódico artigos porcentagem ciência, cuidado e saúde 3 12,0 escola ana neri revista de enfermagem 3 12,0 journal of family nursing 1 4,0 journal of research fundamental care online 1 4,0 nursing education today 1 4,0 revista brasileira em promoção da saúde 1 4,0 revista brasileira de enfermagem 2 8,0 revista da escola de enfermagem da usp 2 8,0 revista de pesquisa: cuidado é fundamental 3 12,0 revista eletrônica de enfermagem 1 4,0 revista eletrónica trimestral de enfermería 1 4,0 revista gaúcha de enfermagem 2 8,0 revista rene 1 4,0 saúde e sociedade de são paulo 1 4,0 texto e contexto em enfermagem 2 8,0 total 25 100 das na atenção primária à saúde. desse total, 14 (56,0 %), em unidades de saúde da família e duas (8,0 %) em domicílio dos pacientes atendidos pelos centros de atenção psicossocial (caps). no ambiente hospitalar, foram realizadas nove, totalizando 36,0 % da amostra do estudo. quanto à autoria dos estudos, a pesquisa mostrou que houve a participação do enfermeiro em 88,0 % das publicações. esse dado deixa claro o interesse desse profissional em disseminar o conhecimento produzido acerca do mcaf, visto que se trata de uma ferramenta sobremaneira importante para respaldar a prática assistencial de enfermagem direcionada para a família. além disso, verificamos o interesse de outros profissionais em realizar estudos com o mencionado modelo, como médico, psicólogo e terapeuta ocupacional. a tabela 1, a seguir, destaca os nomes dos periódicos que disseminaram os artigos que constituíram a amostra do estudo, bem como o ano de publicação, área de formação dos autores dos manuscritos, tipo de publicação e contexto de realização dos estudos. 493 aplicação do modelo calgary de avaliação familiar no contexto hospitalar e na atenção primária à saúde. revisão integrativa l gicely regina sobral da silva monteiro e outros fonte: dados da pesquisa, 2014. ano de publicação 2008 5 20,0 2009 3 12,0 2010 5 20,0 2011 4 16,0 2012 3 12,0 2013 5 20,0 total 25 100 área de formação dos autores enfermagem 22 88,0 medicina 1 4,0 psicologia 1 4,0 terapia ocupacional 1 4,0 total 25 100 tipo de publicação estudo de caso 9 36,0 pesquisa original 14 56,0 relato de experiência 2 8,0 total 25 100 contexto de realização estudo hospital 9 36,0 centro de atenção psicossocial 2 8,0 unidade de saúde da família 14 56,0 total 25 100 o quadro 1, apresenta as publicações que foram desenvolvidas no contexto hospitalar. ele contempla os autores, o título e o(s) objetivo(s) dos artigos inseridos na categoria i. o quadro 2 destaca a categoria ii pertinente aos artigos selecionados para o estudo que foram desenvolvidos sobre atenção primária à saúde, com ênfase nos autores, título e objetivo(s) das publicações elegidas para tal categoria. discussão os resultados do presente estudo apresentados no quadro 1 (categoria i) consideram a utilização do mcaf, no âmbito hospitalar, como uma estratégia facilitadora para a investigação de demandas apresentados pelas famílias. estudos destacam que os eventos críticos não previsíveis, como doenças, traumas, entre outros, ocorridos nas famílias causam grande impacto no contexto familiar (4). 494 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 quadro 1. distribuição dos artigos da categoria i, de acordo com os autores, título e objetivo(s) das publicações fonte: dados da pesquisa, 2014. categoria i utilização do modelo calgary de avaliação familiar no âmbito hospitalar: estratégia facilitadora para a identificação de demandas da família autores título objetivo fráguas g, soares sm, silva pab (9). a família no contexto do cuidado ao portador de nefropatia diabética: demandas e recursos identificar as principais demandas e recursos da família no conviver e no cuidar de pessoas com nefropatia diabética. carvalho fl, rossi la, ciofisilva cl (4). a queimadura e a experiência do familiar frente ao processo de hospitalização descrever o impacto da queimadura e hospitalização sobre a dinâmica familiar. montefusco sra, bachion mm, nakatani ayk (10). avaliação de famílias no contexto hospitalar: uma aproximação entre o modelo calgary e a taxonomia da nanda analisar os diagnósticos de enfermagem da north american nursing diagnosis association (2006) identificados em famílias em situação de acompanhamento de pessoas hospitalizadas para tratamento de doenças crônicas não transmissíveis, mediante abordagem baseada no modelo calgary de avaliação. montefusco sra, bachion mm, carvalho ec, munari db (11). comunicação verbal prejudicada da família: evidenciando a necessidade de desenvolver um novo diagnóstico de enfermagem analisar a ocorrência do diagnóstico de enfermagem “comunicação verbal prejudicada em famílias”. meireles gs, pellon lhc, barreiro filho rd (12). avaliação das famílias de crianças com cardiopatia congênita e a intervenção de enfermagem avaliar como a família é afetada pela descoberta de um caso de cardiopatia congênita em um de seus membros e; discutir a intervenção de enfermagem direcionada à família de criança portadora de cardiopatia congênita. pereira as, lira svg, moreira dp, barbosa il, vieira ljes (13). determinação de fatores de risco para a queda infantil a partir do modelo calgary de avaliação familiar determinar fatores de risco para quedas em crianças a partir do modelo calgary de avaliação familiar (mcaf). fráguas g, salviano mem, fernandes mto, soares sm, bittencourt hns (14). transplante de medula óssea e a assistência de enfermagem fundamentada no modelo calgary discutir a experiência de uma família com relação a um transplante de medula óssea e à assistência de enfermagem fundamentada no modelo calgary de avaliação e intervenção de família. montefusco sra, bachion mm, vera i, caixeta c, munari db (15). tensão do papel de cuidador: ocorrência em familiares de pessoas com doenças crônicas hospitalizadas identificar e analisar a ocorrência de “tensão do papel de cuidador” em familiares de pacientes internados para tratamento de doenças crônicas. svavarsdottir ek, tryggvadottir gb, sigurdardottir ao (16). knowledge translation in family nursing: does a short-term therapeutic conversation intervention benefit families of children and adolescents in a hospital setting? findings from the landspitali university hospital family nursing implementation project avaliar a eficácia da intervenção conversa-terapêutica de curto prazo com as famílias que estavam recebendo os serviços de saúde no hospital infantil do hospital universitário landspitali na islândia relacionados à infância e doenças agudas e crônicas em adolescentes. 495 aplicação do modelo calgary de avaliação familiar no contexto hospitalar e na atenção primária à saúde. revisão integrativa l gicely regina sobral da silva monteiro e outros quadro 2. distribuição dos artigos da categoria ii, de acordo com os autores, título e objetivo(s) das publicações categoria ii aplicação do mcaf no contexto da atenção primária à saúde: avaliar a estrutura, o desenvolvimento e a funcionalidade da família autores título objetivo (s) vieira ljes, pordeus amj, ferreira rc, moreira dp; maia pb, saviolli ks (17). fatores de risco para violência contra a mulher no contexto doméstico e coletivo descrever os fatores de risco para violência doméstica e coletiva contra a mulher, a compreensão dessas mulheres sobre a violência doméstica e coletiva e a aplicação do modelo calgary de avaliação em famílias (mcaf). christoffel mm, pacheco sta, reis csc (18). modelo calgary de avaliação da família de recém-nascidos: estratégia pedagógica para alunos de enfermagem descrever a experiência da utilização do modelo calgary de avaliação e intervenção familiar na consulta de enfermagem à criança. silva l, boussoi rs, galera saf (19). aplicação do modelo calgary para avaliação de famílias de idosos na prática clínica apresentar a experiência de avaliar famílias de idosos dependentes sob o enfoque sistêmico. horta alm, ferreira dco, zhao lm (20). envelhecimento, estratégias de enfrentamento do idoso e repercussões na família conhecer a percepção de idosos, usuários de unidade básica de saúde de são paulo, sobre envelhecimento, estratégias de enfrentamento e repercussões na família. mota frn, oliveira et, marques mb, bessa mep, leite bmb, silva mj (21). família e redes sociais de apoio para o atendimento das demandas de saúde do idoso avaliar as redes sociais de apoio das famílias com idosos segundo o modelo calgary de avaliação de família (mcaf). goddard l, mackey s, davidson pm (22). estágios clínicos funcionais: um motor de mudança criar um modelo de colocação de experiência profissional supervisionado envolvendo estudantes de graduação em enfermagem, famílias de crianças com deficiência intelectual e docentes de enfermagem. silva mclsr, moules nj, silva l, bousso rs (23). entrevista de 15 minutos: uma ferramenta de abordagem à família na estratégia saúde da família conhecer a experiência de enfermeiros da estratégia saúde da família (esf) no uso da entrevista de 15 minutos nas visitas domiciliárias realizadas no período puerperal. diógenes mar, oliveira mg, carvalho yaxb (24). aspectos estruturais, desenvolvimentais e funcionais da família de adolescente grávida fundamentados no modelo calgary avaliar a estrutura, o desenvolvimento e o funcionamento da família de uma adolescente grávida. pinho lb, oliveira ir, cardozo gonzáles ri, harter j (25). consumo de crack: repercussões na estrutura e na dinâmica das relações familiares conhecer repercussões do uso contínuo de crack na estrutura e na dinâmica das relações familiares. leite mt, flores js, hildebrandt lm, perlini nmg, linck cl (26). idosos mais velhos no domicílio: a família como unidade de cuidado o estudo objetivou analisar como a família se organiza no papel de unidade de cuidado a idosos mais velhos no espaço domiciliar, com base no modelo calgary de avaliação familiar. sassá ah, marcon ss (27). avaliação de famílias de bebês nascidos com muito baixo peso durante o cuidado domiciliar avaliar famílias de bebês nascidos com muito baixo peso baseando-se no modelo calgary de avaliação familiar. radovanovic, cat, cecilio hpm, marcon ss (28). avaliação estrutural, desenvolvimental e funcional da família de indivíduos com hipertensão arterial avaliar a estrutura, o desenvolvimento e a funcionalidade da família que convive com a hipertensão arterial. 496 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 apesar da presença da família cada vez maior nesse cenário, estudos apontam que, na prática, a abordagem a esses sujeitos não é feita de maneira dinâmica (11). é possível assinalar, também, em dois estudos (11,12) sobre os diagnósticos de enfermagem da north american nursing diagnosis association (2006) identificados por meio do mcaf com famílias de pacientes internados por doenças crônicas. quanto aos diagnósticos, os resultados foram os seguintes: “tensão do papel de cuidador” foi detectado em 100 % das famílias; “comunicação verbal familiar prejudicada”, em 75 %; “processos familiares interrompidos” e “manutenção do lar prejudicada”, em 66 % delas. no que se refere às demandas relacionadas à responsabilidade pertinente às 24 horas de cuidado, foram identificados: a falta de apoio da equipe de saúde, o ambiente físico impróprio e a imprevisibilidade do curso da doença. ressalte-se, ainda, que, no total dos casos apresentados, a figura do cuidador era a mulher, constituindo-se em grande repercussão nas suas atribuições de trabalho. essa categoria reforça que as famílias têm um papel central na construção do plano de cuidados. por outro lado, enfrentam inúmeras dificuldades para desempenhar esse papel. estudo sobre como as famílias enfrentam o processo de internação devido a queimaduras identificou que dormir menos com pior qualidade de sono, reduzir ou aumentar a ingestão de alimentos, aumentar o uso de cigarros, álcool e de automedicação foram demandas frequentemente retratadas pelos acompanhantes. as alterações emocionais também foram reportadas e incluem desde sentimentos de desespero, piedade pelo parente, angústia, ansiedade e impotência, até comportamento compulsivo e choro. além disso, o estudo aponta modificações no relacionamento ou intensificação de conflitos pré-existentes na família em detrimento da condição de enfermidade e internação de um membro (4). fato análogo foi identificado em outro estudo que trata do aumento das dificuldades na vigência do agravamento da dependência física da pessoa doente, o que requer da família mais esforço para lidar com a situação. segundo os autores, a necessidade de informação apresentou-se como a demanda mais relevante, na forma de incapacidade da família de lidar com a pessoa doente durante o período de internação. esse resultado demonstra uma fragilidade dos profissionais de saúde em asfonte: dados da pesquisa, 2014. categoria ii aplicação do mcaf no contexto da atenção primária à saúde: avaliar a estrutura, o desenvolvimento e a funcionalidade da família autores título objetivo (s) sales ds, oliveira en, brito mcc, rodrigues tb, souza ama (29). cuidado de enfermagem segundo a teoria de orem: assistência a paciente com transtorno afetivo bipolar analisar a sistematização da assistência de enfermagem (sae) oferecida a uma idosa portadora de transtorno afetivo bipolar (tab), norteando-se pelos preceitos da teoria do autocuidado de orem. lagana mtc, malvieira faz, melo jkf, silva rts, carvalho rf, cabral amf (30). estratégia de inovação no ensino de enfermagem na atenção domiciliar a idosas proporcionar aos estudantes a ampliação do escopo da atenção básica para além das atividades de assistência domiciliar, introduzindo atividades de internação domiciliar, para a compreensão das interfaces do sistema único de saúde. souza md, kantorski lp, schwartz e, galera saf, teixeira júnior s (31). a convivência em família com o portador de transtorno psíquico conhecer as experiências da família no convívio com o portador de transtorno psíquico, utilizando-se da avaliação estrutural deste grupo familiar. filizola cla, teixeira imc, milioni db, pavarini sci (32). saúde mental e economia solidária: a família na inclusão pelo trabalho identificar a composição e relações das famílias de integrantes desse empreendimento; conhecer as percepções dos familiares sobre a inclusão pelo trabalho dos usuários e a possibilidade de protagonismo da família nesse processo. 497 aplicação do modelo calgary de avaliação familiar no contexto hospitalar e na atenção primária à saúde. revisão integrativa l gicely regina sobral da silva monteiro e outros sumirem o papel de educadores e preparadores para o cuidado durante a internação e depois dela (10). outro aspecto avaliado nas famílias presentes no contexto hospitalar foram as questões socioeconômicas, principalmente relacionadas à renda. os autores mostram que os gastos com despesas associadas ao tratamento são muitos, e isso é um contratempo gerador de estresse para a família (13). contudo, apesar das diversas problemáticas reveladas na abordagem das famílias perante a enfermidade e a hospitalização, os estudos (13,15) demonstram que algumas famílias conseguem desenvolver recursos que auxiliam a superar essa situação. pode-se citar que a religião, atrelada à crença em deus, à união familiar, ao cuidado e à atenção de uns com os outros com relação à saúde mental, o consolo em si mesmos, a esperança, o apoio da comunidade, dos vizinhos e dos profissionais de saúde são referidos como formas de amparo e de sustentação familiar. o envolvimento familiar favorece a formação de uma rede de apoio entre seus integrantes, confortando o sofrimento da pessoa doente ou simplesmente estando presente. os membros da família planejam melhores meios para colaborarem um com o outro, e isso diminui a sobrecarga de trabalho (15). para atender à necessidade de trabalhar famílias, analisando seus componentes estruturais e suas experiências, o mcaf oferece essa possibilidade, orientando os profissionais de enfermagem na assistência, no sentido de ajudar as famílias a amenizarem seu sofrimento e promover bem-estar e boa qualidade de vida diante de um quadro agudo de doença, em que esse profissional deve adaptar suas intervenções para cada família e para o domínio escolhido do seu funcionamento (17). por meio do conhecimento estrutural dessas famílias e do modo como vivem e convivem como seres sociais, a equipe de saúde pode elencar os fatores de risco que favorecem a ocorrência de agravos (14). a categoria ii é composta por artigos que analisaram os benefícios obtidos com a utilização do mcaf, principalmente para melhorar a sistematização da assistência do enfermeiro, na atenção primária à saúde, incluindo as dificuldades apresentadas durante a aplicação do modelo. pesquisas acerca da avaliação familiar de idosos ressaltam a estrutura multidimensional do mcaf, baseada no conceito de sistemas, na cibernética, na comunicação e na mudança. é constituído por três categorias principais: estrutural, de desenvolvimento e funcional (20). os resultados dessa pesquisa corroboram os achados com relação às categorias, incluindo subsídios para a utilização e a elaboração das ferramentas genograma e ecomapa, que permitem a visualização gráfica das relações familiares e suas redes de apoio (28). o genograma e o ecomapa, de acordo com o estudo (19), também parecem adequados para ser utilizados como instrumentos complementares no processo de ensino-aprendizagem entre graduandos e pós-graduandos em enfermagem, ampliando a visão da integralidade do cuidado às famílias nos diversos cenários da saúde, especialmente na atenção primária (20). outra metodologia que auxiliou os acadêmicos de enfermagem a detectarem necessidades de saúde das famílias foi a aproximação com a comunidade, onde a aplicação do mcaf possibilitou identificar pontos fortes, competências e recursos que colaboram para solucionar os problemas no núcleo familiar (23). apenas um dos estudos (24) realizado na atenção primária utilizou como suporte a entrevista de 15 minutos. essa é uma forma condensada do mcaif, que visa contribuir para estabelecer o relacionamento entre enfermeiro e família e pode ser utilizado também por outros profissionais. a aplicação desse recurso permitiu a ampliação das informações referentes às famílias, indica intervenções na promoção à saúde, o alívio do sofrimento, respeitando crenças e valores individuais. autores evidenciam facilidades ao utilizar o mcaf na atenção básica, incluindo o genograma e o ecomapa depois do segundo contato com a família, fato que pode favorecer a empatia, a identificação das particularidades familiares e contribuir para a elaboração de intervenções. além disso, o mcaf revelou-se como uma peça de auxílio durante a prescrição e a implementação de ações que proporcionam apoio, promoção, prevenção, recuperação e reabilitação das condições de saúde/doença, o que aflige a unidade familiar, potencializando a consulta de enfermagem (19). contudo, também houve dificuldades na utilização desse modelo na atenção primária, provenientes, principalmente, da fragilidade na formação do vínculo entre acadêmicos e familiares —foram necessários muitos encontros para tal construção; do tempo preciso para realizar a entrevista que, frequentemente, é superior a 30 minutos, fazendo despertar a impaciência dos entrevistados; da complexidade do modelo e que, por esse motivo, requer acompanhamento longitudinal e a participação da equipe multiprofissional. a pesquisa aponta como outro fator de dificuldade a necessidade da participação de mais de um membro da família para complementar as informações (19,21). 498 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 com relação à enfermagem, os estudos (29,31) colaboram com o argumento de que a atenção domiciliar proporciona uma relação terapêutica que facilita o planejamento de cuidados por meio da sistematização da assistência de enfermagem para as famílias (30). essa assistência só é possível em ambientes onde não há estratégia de saúde da família implantada e em locais economicamente precários. a realização de visita domiciliar com a utilização do mcaf permite a elaboração de diagnósticos de enfermagem de acordo com a north american nursing diagnosis association (nanda), sob a ótica do suporte familiar e social (31). nesse enfoque, vários são os estudiosos (18,28) no assunto que sugerem a aplicação do mcaf pelos profissionais enfermeiros da atenção básica, considerando os recursos existentes e as condições em que a família está inserida. no âmbito da assistência psicossocial, os serviços de saúde impõem limites devido a sua rede restrita de equipamentos sociais voltados para seus usuários, o que influencia na dinâmica familiar (26). o mcaf representa um substrato teórico sistêmico para os enfermeiros, em todas as suas áreas de atuação, inclusive nos centros de atenção psicossociais (caps), constituindo-se também de uma fundamentação para o processo de cuidado em saúde mental (32). diante desse contexto, o mcaf incita o desenvolvimento de um olhar holístico por parte da enfermagem, propondo intervenções eficazes que as assessorem a superar dificuldades e possibilitar mudanças (25). o referencial metodológico desse modelo promove, sobretudo, o conhecimento da estrutura, das relações familiares, seus sentimentos e sofrimentos, proporciona um momento de escuta e responsabilização do cuidado e estimula a aproximação dos pesquisadores com esses sujeitos na atenção primária à saúde (33). assim o modelo calgary de avaliação familiar permitiu analisar detalhadamente as famílias, elencando as fragilidades e fortalezas diante de cada especificidade (34). considerações finais com base na revisão proposta, foi possível evidenciar, nas publicações investigadas, que a aplicação do mcaf, tanto no contexto hospitalar quanto na atenção primária à saúde, apresenta como pontos fortes uma abordagem mais aprofundada sobre a estrutura, o desenvolvimento e o funcionamento familiar, o que se configura como uma ferramenta efetiva para identificar diagnósticos familiares que, muitas vezes, são desconsiderados pela equipe de saúde, seja na atenção primária seja na secundária, em que os cuidados prestados são direcionados ao sujeito isolado do seu sistema familiar, e a assistência a essa unidade tão complexa é relegada a um segundo plano. é importante frisar que os profissionais, em especial, os enfermeiros sejam bem preparados e utilizem os instrumentos pertinentes para avaliar as demandas apresentadas pela conjuntura familiar e intervir nelas, respeitando a integridade, a dignidade e a individualidade de cada sujeito, na perspectiva de resolver efetivamente os problemas de saúde da família e de promover um cuidado mais humanizado e integral. como pontos fracos ressalta-se a pouca utilização desse modelo pelas demais categorias profissionais, como as internações recorrentes e altas hospitalares podem dificultar o acompanhamento longitudinal das famílias pelos profissionais de saúde. este estudo apresenta como lacuna o fato de que, como o termo “modelo calgary” não foi considerado um descritor controlado e indexado no descritor em ciências da saúde (desc), a busca pela literatura para o desenvolvimento do presente teve que ser realizada mediante a investigação criteriosa dessa palavra em todos os títulos e resumos encontrados, o que dificultou a seleção dos artigos e, consequentemente, a obtenção de uma amostra mais consistente. atribuímos a isso a pouca abordagem da literatura acerca do mcaf, devido ao fato de o enfoque das produções ser mais voltado para o modelo calgary de intervenção familiar. espera-se que esta revisão integrativa possa contribuir para promover discussões e reflexões sobre a necessidade de se reorganizarem os serviços de saúde acerca da assistência familiar, ultrapassando a barreira da determinação política, para que essas famílias sejam consideradas realmente como unidade de cuidado, e isso comece a fazer parte da formação profissional. logo, essa mudança pode ser iniciada, também, no processo de ensino-aprendizagem nas universidades, estimulando o desenvolvimento de competência dos profissionais de inclusão do indivíduo/família no processo saúde/ doença independentemente do cenário de atuação. diante do exposto, a utilização do mcaf é de suma relevância para promover a assistência à família e para fundamentar a prática assistencial do enfermeiro 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(17 rese\321as.pdf) reseñas 155 la segunda edición del libro conocimiento contemporáneo de enfermería: análisis y evaluación de modelos y teorías de enfermería, de jacqueline fawcett, es uno de los más recientes títulos sobre desarrollo teórico que todo académico de enfermería debería adquirir para su biblioteca. a pesar de no existir ediciones en español de las obras de la doctora fawcett, esta última es un compendio que engloba aspectos que dan sentido a la manera como se proyecta el desarrollo teórico de enfermería. es de anotar que la propuesta de fawcett pretende ubicar al lector en el contexto �holárquico� (palabra acuñada por fawcett) de la estructura del conocimiento desde el punto de vista de la epistemología y de la traducción de los elementos propuestos a la práctica de enfermería. el libro está organizado en cuatro partes: la primera se refiere a la estructura del conocimiento de enfermería y la utilización de modelos y teorías en la práctica; la segunda plantea el análisis y la evaluación de modelos conceptuales de enfermería, la tercera revisa las teorías y, finalmente, la cuarta propone elementos para el desarrollo teórico del siglo xxi. la primera parte introduce al lector en los componentes del conocimiento contemporáneo de enfermería formalizados con los elementos del metaparadigma, las propuestas filosóficas que influyen en el desarrollo del conocimiento propio de la disciplina, los modelos conceptuales, los diversos tipos de teorías e indicadores empíricos que de forma articulada y dependiendo de los niveles de abstracción correspondientes a cada aspecto, figuran claramente expuestos y explicados de forma tal que se comprende su relación y, a la vez, el papel fundamental que juega cada uno de ellos al ser traducidos a la práctica. la segunda parte propone las estrategias que se deben utilizar para introducir en la práctica modelos conceptuales y teorías de enfermería. este capítulo explica, de manera profunda, el significado y la necesidad de articular modelos conceptuales, teorías e indicadores empíricos como elementos generadores de sistemas de conocimiento de enfermería que se puedan utilizar como referentes para la educación, investigación y la práctica disciplinaria. más específicamente, se presenta una discusión de los elementos sustantivos y de los procesos que se requieren para construir sistemas conceptuales-teóricos-empíricos de conocimiento de enfermería. la tercera parte, continuando el orden de ideas de fawcett, plantea un marco de referencia para el análisis y la evaluación de los modelos de enfermería. este marco señala con precisión los aspectos que se deben tener en cuenta para llevar a cabo los procesos mencionados, utilizando contemporary nursing knowledge: analysis and evaluation of nursing models and theories jacqueline fawcett university of massachusetts, boston, 2nd. edition, 2005, 623 págs. herramientas apropiadas para el nivel de abstracción que permitan exponer las fortalezas y debilidades inherentes a los modelos, y que es necesario aclarar con antelación a su utilización en la práctica o investigación. a continuación fawcett presenta el análisis y la evaluación de los modelos de johnson, king, levine, neuman, orem, rogers y roy, que son los que, a su juicio, se pueden categorizar en la modalidad de modelos conceptuales de enfermería. la parte tres, al igual que la anterior, presenta un marco distintivo para el análisis y la evaluación de las teorías de enfermería clasificando como teorías de gran alcance las de newman y parse, y como teorías de rango medio las de orlando, peplau y watson. finalmente, la parte cuatro analiza las posibilidades de desarrollo del conocimiento de enfermería en el futuro, dentro de contextos integradores que enfatizan la utilización de los resultados de investigación para la solución de los problemas de la práctica, desde un punto de vista explícito relacionado con la disciplina. el interés que muestra esta parte del libro se basa en la necesidad de utilizar los sistemas articulados de conocimiento-teoríaindicadores empíricos y las estrategias para ponerlos en práctica. uno de los aspectos más llamativos de este texto es la forma como se expresa la relación conceptual de los modelos y la �holarquía� del conocimiento. así mismo, la utilización de un lenguaje que permite tener una visión real de la práctica de enfermería en sus ambientes múltiples y enfocada a los seres humanos y sus experiencias de salud. la riqueza documental del texto es indiscutible. cada capítulo es fuente de referencias bibliográficas de pertinencia y actualización indiscutibles. de esta manera el lector puede enriquecerse y profundizar en aquellos aspectos que por su complejidad o extensión requieren de mayor dedicación y profundización. esta parte del libro es de valor único si se desea comprender la extensión y complejidad de la epistemología de enfermería. aunque como se señaló, las obras de fawcett no se han traducido al español, este texto no puede pasar desapercibido y debe convertirse en libro de consulta de docentes y estudiantes de posgrados de enfermería. maría mercedes durán de villalobos profesora titular y emérita, universidad nacional de colombia. 129 140 una reflexion sobre la autonomia.indd 129 sara guerrero-núñez1 patricia cid-henríquez2 una refl exión sobre la autonomía y el liderazgo en enfermería 1 magíster en salud pública. estudiante del programa doctorado en enfermería, universidad de concepción. chile. académica en universidad de atacama, copiapó, chile. saraguerrero@udec.cl, sara.guerrero@uda.cl 2 doctora en enfermería. departamento de enfermería, facultad de medicina, universidad de concepción, chile. patcid@udec.cl recibido: 26 de julio de 2013 enviado a pares: 4 de septiembre de 2013 aceptado por pares: 3 de febrero de 2014 aprobado: 19 de marzo de 2014 doi: 10.5294/aqui.2015.15.1.12 para citar este artículo / to reference this article / para citar este artigo guerrero-núñez s, cid-henríquez p. una reflexión sobre la autonomía y el liderazgo en enfermería. aquichan. 2015;15(1):129-140. doi: 10.5294/aqui.2015.15.1.12 resumen artículo de reflexión sobre los conceptos de autonomía y liderazgo en la enfermería y cómo ellos se relacionan con el quehacer profesional, especialmente en chile. se analizan las limitaciones existentes y, finalmente, se hacen sugerencias, con la finalidad de orientar a las enfermeras para que lideren con autonomía el cuidado y su gestión. palabras clave autonomía profesional, liderazgo, enfermería (fuente: decs, bireme). thoughts on autonomy and leadership in nursing abstract the article reflects on the concepts of autonomy and leadership in nursing and how they relate to professional practice, especially in chile. existing constraints are analyzed and, ultimately, suggestions are made to guide nurses on leading care and care management in an autonomous way. keywords professional autonomy, leadership, nursing (source: mesh, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 129-140 130 aquichan issn 1657-5997 año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 129-140 uma reflexão sobre a autonomia e a liderança na enfermagem resumo artigo de reflexão sobre os conceitos de autonomia e liderança na enfermagem e como eles se relacionam no fazer profissional, especialmente no chile. analisam-se as limitações existentes e, finalmente, fazem-se sugestões a fim de orientar os enfermeiros para que liderem com autonomia o cuidado e sua gestão. palavras-chave autonomia profissional, liderança, enfermagem (fonte: decs, bireme). 131 una reflexión sobre la autonomía y el liderazgo en enfermería l sara guerrero-núñez, patricia cid-henríquez introducción la historia de la enfermería da cuenta de una evolución importante en cuanto a profesión y disciplina. lo anterior ha permitido la incorporación de conceptos hoy imperativos, entre ellos la autonomía y el liderazgo, los cuales no siempre fueron considerados con el mismo valor. estos cambios significaron el posicionamiento de la enfermería como profesión autónoma, satisfaciendo las necesidades de cuidados y asumiendo la responsabilidad de liderar la gestión de los mismos en las personas, las familias, los grupos y la comunidad, conforme a los fundamentos históricos, filosóficos, científicos y legislativos. la autonomía y el liderazgo corresponden a conceptos necesarios en la enfermería, y si bien estos han sido cuestionados por poderes hegemónicos en el sistema de salud, surgen como deber ético producto de la profesionalización del cuidado. desde 1997, la legislación chilena reconoce la función de la enfermera, incorporándola por medio de la ley 19.536 al código sanitario del país. el artículo 113 del código señalado, da cuenta del rol social que la enfermera cumple en el país. posteriormente, y como producto de la reforma en la salud chilena, la ley 19.937 de autoridad sanitaria establece la gestión del cuidado como requisito mínimo y común en la reorganización de los servicios de salud, hospitales y centros de atención ambulatoria, lo cual estructura la legalidad en la instalación de unidades responsables de dicha gestión. sumado a lo anterior, en el año 2007, y con la finalidad de hacer operativa la implementación de las unidades de gestión del cuidado, se aprueba la norma general administrativa 19, que establece el modelo de gestión del cuidado para la atención cerrada. si bien la legislación ha incorporado aspectos que fortalecen el quehacer autónomo de enfermería, esto no necesariamente ha desarrollado en las profesionales la capacidad de liderar, condición necesaria en todas las enfermeras, pues la sociedad ha demandado a estas profesionales la gestión del cuidado. para ejercer el liderazgo se requiere la aplicación del pensamiento crítico en la toma de decisiones, resolución de conflictos y también en la gestión del cuidado con estándares de calidad. el liderazgo como habilidad humana que fortalece la dirección y la gestión, se constituirá en la condición para que la enfermera y su equipo alcancen los objetivos del sistema de cuidados. este documento tiene por objetivo efectuar una reflexión sobre la autonomía y el liderazgo en enfermería, y pretende iniciar un análisis con miradas al futuro sobre el estado del arte en el país, las limitaciones existentes y las estrategias que las enfermeras deberían considerar para potenciar un liderazgo y ejercicio autónomo del cuidado y su gestión. de sumisión a posición autónoma los diferentes roles que la enfermería ha ostentado en la sociedad han sido producto de la influencia ocasionada por los contextos históricos, políticos, económicos y sociales, incluyendo la mirada de género (1-3). por tanto, es necesario que previo a un análisis sobre el estado del arte actual, en tanto al ejercicio de la autonomía y el liderazgo, se recuerden dichas influencias para comprender el impacto que han ocasionado en el presente siglo. al efectuar un recorrido a través de la historia, se logra visualizar que los cuidados transitaron desde una etapa doméstica a una profesional, donde el cuidado basado en la experiencia y el conocimiento natural, se transforma en uno caracterizado por concepciones cristianas y religiosas, para pasar luego por una tecnificación de los cuidados. finalmente, los cuidados de enfermería se convierten en una actividad profesional, momento en que se teorizó sobre este concepto (4). lo anterior significó pasar desde un sitial de desconocimiento y sin identidad profesional, producido por la carencia de un cuerpo de conocimientos propios de la enfermería, a ubicarse en una profesión cuyo centro de estudio es el cuidado, acto de exclusiva responsabilidad de la enfermera (5, 6). en esta transición, pareciera ser que poco antes de la enfermería moderna, las características de sumisión, docilidad y carencia de cuestionamientos a las labores médicas se consideraban una impronta necesaria en la formación de las enfermeras (7). el cuidado era realizado de manera dependiente; “esta idea de cuidado va estrechamente unida a la obediencia y a la capacidad de ejecutar eficazmente las órdenes del médico” (8). en chile, en las décadas de cuarenta y sesenta, las escuelas de enfermería tenían como requisito de admisibilidad la sumisión, obediencia y respeto a las estructuras de poder (1). dado lo anterior, la práctica de la enfermería en esta época no requería de conocimientos especializados sobre el cuidado, lo que generaba así un desvalor de los conceptos de autonomía y liderazgo en la disciplina que tanto se valoran en la actualidad. 132 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 el momento histórico internacional más importante para enfermería, en cuanto a autonomía y liderazgo se refiere, concierne a la etapa profesional de los cuidados, especialmente en la segunda mitad del siglo xx, periodo donde surge un fenómeno de búsqueda del cuerpo de conocimientos propios, destacando así los postulados en las filosofías, los modelos y las teorías de enfermería, convirtiéndola en una disciplina académica y en una profesión con su propio cuerpo de conocimientos (9). de esta manera, enfermería, por su concepción filosófica e histórica, se instala en una posición reconocida internacionalmente, distinguiéndola como profesión autónoma en el trabajo interdisciplinario y líder en la entrega de cuidados a las personas, familias y comunidades (10, 11). el consejo internacional de enfermeras declara que: [...] la enfermería abarca los cuidados, autónomos y en colaboración, que se prestan a las personas de todas las edades, familias, grupos y comunidades, enfermos o sanos, en todos los contextos, e incluye la promoción de la salud, la prevención de la enfermedad, y los cuidados de los enfermos, discapacitados, y personas moribundas. funciones esenciales de la enfermería son la defensa, el fomento de un entorno seguro, la investigación, la participación en la política de salud y en la gestión de los pacientes y los sistemas de salud, y la formación (12). para la citada definición, es conveniente tener presente que patricia w. iyer clasifica las actividades de enfermería en tres áreas: independientes, interdependientes y dependientes, señalando que el ejercicio de la profesión contempla la toma de decisiones y su actuación correspondiente (13). por tanto, la actividad de cognición en la toma de decisiones y, por consiguiente, el acto mismo que involucra, requieren de un pensamiento crítico que corresponde a un evento de permanente ejercicio en las enfermeras, con la finalidad de intervenir con decisiones asertivas y que brinden bienestar en los pacientes y las instituciones de salud. la deliberación en la toma de decisiones y la ejecución de la decisión, corresponden a un actuar autónomo de la profesión, especialmente en aquellas actividades de tipo independiente. en chile, el progreso autónomo de la profesión de enfermería evidencia un crecimiento y consolidación en términos de las facultades legales que respaldan el quehacer de las enfermeras. desde el año 1997, la ley 19.536 incorpora la profesión enfermera al código sanitario, definiendo su rol en sociedad y categorizando sus actividades en tres funciones principales: gestión del cuidado, ejecución de acciones derivadas del diagnóstico y tratamiento médico y el velar por la mejor administración de los recursos de asistencia para el paciente (14). para la implementación de la última reforma de salud, el gobierno declaró cinco leyes como pilares para el fortalecimiento del sistema de salud, una de ellas corresponde a la ley de autoridad sanitaria (19.937), que establece la gestión del cuidado como requisito mínimo y común en la reorganización de los servicios de salud, hospitales y centros de atención ambulatoria (15). posteriormente, el ministerio de salud instauró la norma general administrativa 19, dirigida a la gestión del cuidado de enfermería para la atención cerrada, definiendo a esta gestión como la aplicación de un juicio profesional en la planificación, organización, motivación y control de la provisión de cuidados (16). la norma establece la implementación de un modelo de gestión del cuidado de enfermería en los establecimientos de alta y mediana complejidad de la atención cerrada en el sistema nacional de servicios de salud, donde las unidades de gestión del cuidado contarán con atribuciones para organizar, supervisar, evaluar y promover el mejoramiento de la calidad de los cuidados de enfermería, a fin de otorgar una atención segura, oportuna, continua, con pertinencia cultural, y en concordancia con las políticas y normas establecidas por el ministerio de salud (16). con base en lo anterior, y por medio de la gestión del cuidado, las enfermeras deberán generar un modelo de gestión que permita dar cumplimiento a los tres deberes que establece la legislación (gestión del cuidado, ejecución de acciones derivadas del diagnóstico y tratamiento médico, y velar por la mejor administración de los recursos de asistencia para el paciente), especialmente en la gestión del cuidado, que corresponde al acto de exclusividad para la profesión de enfermería. por tanto en chile, el legislador ha otorgado a la profesión de enfermería la responsabilidad y atribución para su quehacer autónomo, pues se han definido los tres deberes en el código sanitario, y por medio de la ley 19.937 y la norma general administrativa 19, se han precisado los alcances que la profesional puede llegar a realizar. es innegable que lo demandado por el legislador manifiesta el progreso autónomo en la profesión, lo cual es coherente con lo requerido a nivel internacional, pues necesariamente involucra la incorporación de conocimientos, actitudes y destrezas, las cuales antes no eran requeridas en las enfermeras. los cambios sociales han exigido que enfermería como profesión evolucione, 133 una reflexión sobre la autonomía y el liderazgo en enfermería l sara guerrero-núñez, patricia cid-henríquez de tal manera de ser relevante para la sociedad (17); por esta razón, la disciplina ha dado un salto importante desde el cuidado doméstico hasta la profesionalización del mismo. dado lo anterior, resulta provechoso para estas profesionales aprender de su legado histórico, reconocer dicha importancia y proyectarse en esta realidad profesionalizada. después del análisis expuesto, y en razón de las condiciones legales que posee la enfermería en chile, no es cuestionable que sea considerada una profesión autónoma. lo que sí es discutible es si ella, con todos sus fundamentos históricos, filosóficos, científicos y legales, ejerce la autonomía y el liderazgo que la sociedad le ha conferido y los cuales demanda permanentemente. autonomía y liderazgo en enfermería: piedras angulares para la entrega de cuidados la real academia española ha definido, entre muchas otras acepciones, que autonomía es la “condición de quien, para ciertas cosas, no depende de nadie” (18). en este sentido, y para fines del actual análisis, se entenderá por autonomía en enfermería a la toma de decisiones, y la ejecución de actos del cuidar, en que no medie la necesidad de supervisión por parte de un profesional del equipo interdisciplinario. para ello, la enfermera fundamentará su actuar con el conocimiento de su disciplina, y también se apoyará en otras que permitan un abordaje integral de la persona, la familia, el grupo o la comunidad receptora de dicho cuidado. la formación profesional de la enfermera debe forjar el actuar con libertad y responsabilidad, y la posesión de conocimientos, actitudes y habilidades en la toma de decisiones (19), las cuales deberán ser ejercidas con la autonomía reconocida por la legislación chilena, señalada en el código sanitario, ley de autoridad sanitaria y norma general administrativa 19, brindando así una gestión del cuidado cimentada en aspectos filosóficos, históricos, científicos y también legislativos. si bien las condiciones legales chilenas presuponen un ejercicio autónomo de la profesión, estableciendo un ámbito de acción independiente y colaborativo, la real ejecución de una labor profesional autónoma sigue siendo aún tema de reflexión. el filósofo francés foucault efectúa un análisis sobre el poder y cómo enfermería se relaciona y convive con él. amezcua se refiere al filósofo y señala: ya el mismo foucault, desde su cátedra del collège de france, se refirió al saber enfermero como uno de los muchos saberes sometidos (foucault, 2002), un saber silencioso y silenciado que según meleis se da cuando se deja de abstraer y organizar todo el conocimiento que cada día miles de enfermeras producen pero que no llegan a sistematizar y mucho menos a publicar (meleis, 1997) (20). dialogando sobre este saber silencioso que define foucault, meleis señala cómo este puede develarse por medio de la sistematización y publicación de dicho conocimiento. enfermería, como profesión autónoma, y con la finalidad de contravenir a los poderes que pudieran surgir para someter y no develar la autonomía que posee producto de su saber (poder experto), debe hacer uso del amplio conocimiento del cual dispone como disciplina. en este sentido, ann marriner indica que “una profesión hace referencia a un campo especializado de la práctica; está creada sobre la estructura teórica de la ciencia o conocimiento de esa disciplina y las habilidades prácticas que la acompañan” (9). la misma autora menciona que por la incorporación de la teoría de enfermería en la profesión, esta “funciona de manera autónoma para formular estrategias profesionales y, por tanto, controlar la actividad profesional” (9). cabe, entonces, reconocer la importancia tal del conocimiento y la aplicación de la disciplina de enfermería a los deberes del cuidar, pues de esta manera serán las mismas enfermeras quienes confeccionen las estrategias, controlen y regulen su actividad profesional, sin requerir para ello la supervisión de otro profesional. para que el saber silencioso mencionado por foucault se libere de esta sumisión y sigilo, se debe no solo estudiar en el pregrado o posgrado las teorías de enfermería, sino además incorporarlas en el acto mismo del cuidar, lo cual permitirá un actuar autónomo y fundado en la ciencia. en sintonía con lo anterior, la práctica de enfermería basada en la evidencia se sitúa como una estrategia fundamental, donde gracias a la investigación en el área se transita de un paradigma del hacer rutinario y “porque siempre se hizo así” a una práctica basada en la ciencia y con demostración de evidencias que aseguren, de cierta manera, una entrega de cuidados de calidad. la práctica de enfermería basada en la evidencia enfatiza en su evaluación sistemática, no solo para verificar la calidad, sino también para evaluar su aplicabilidad (21). lo anterior requiere de un desarrollo en la investigación, y si bien en enfermería ha existido un crecimiento científico con implicaciones en la práctica (22), este ha sido incipiente y con una 134 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 evolución lenta, lo cual ha repercutido en la atención del paciente. la investigación sigue estando muy distanciada de la realidad práctica, ocasionando que las enfermeras clínicas sigan viendo a la investigación como algo complejo, distanciado y difícil de comprender (23). en esta segregación donde la enfermería investigativa se distancia de la práctica, se genera un panorama en que la disciplina delimita parcelas de conocimiento que reserva para sí (20), lo cual repercute en el desarrollo de su autonomía y liderazgo, de su saber y su hacer. la investigación traslacional viene a resolver este problema, pues une indisolublemente la investigación y la práctica (24), generando un diálogo permanente entre ambas. en esta reflexión del ejercicio autónomo de la profesión, en la cual se cuestiona si para ello se han tomado las medidas que conciernen a la incorporación de la disciplina de enfermería a la práctica del cuidar, con la finalidad de ahondar en la esencia profesional y proyectar al medio su actuar profesional, es inquietante razonar sobre lo referido por algunos autores (25), quienes citando a fajardo y germán, señalan: “este cuidado se puede dividir en dos categorías, el cuidado técnico relacionado con la tecnología médica, reconocido social y profesionalmente; y el cuidado invisible, que acompaña al acto médico, infravalorado universalmente” (3). producto del aumento y la incorporación de la tecnología a todas las áreas del saber humano, entre ellas también las disciplinas y profesiones de la salud, la atención en salud se ha hecho más tecnificada en cuanto al diagnóstico y tratamiento de las enfermedades, arrastrando al cuidado a un área de completa tecnicidad, donde la calidad de los cuidados se orienta a una gestión del cuidado con breve tiempo destinado a la atención directa de las personas, otorgando mayor importancia a la administración que al cuidado mismo. en este sentido, el riesgo para enfermería consiste en que ella se pliegue a las demandas del poder hegemónico médico, sin responder a las demandas de su profesión y aquellas que emanan de la sociedad (26). en esta clasificación del cuidado (visible e invisible), el primero de ellos ha sido comentado como el acto de mayor valor en la sociedad y entre los profesionales del equipo interdisciplinario. por otra parte, el cuidado invisible reúne en su esencia la ciencia de la enfermería, pues permite un cuidado integral de la persona, la familia y la comunidad, para aplicar entre ellos la contención, la escucha activa, la educación, la investigación y todos aquellos cuidados propios de una asistencia directa. es importante reflexionar que los cuidados visibles no siempre median la autonomía profesional, pues según el código sanitario chileno, hacen referencia a los actos derivados del diagnóstico y tratamiento médico. por otra parte, un aspecto menos visible en las instituciones de salud corresponde a la gestión del cuidado, es decir, actos que deben ser gobernados por el ejercicio autónomo de la profesión. en este artículo ya se ha señalado que en chile la enfermería dispone de las condiciones legales que podrían suponer un ejercicio autónomo de la profesión, además de los fundamentos históricos, filosóficos y científicos que respaldarían dicho ejercicio. para ello, las enfermeras deben ejercer la gestión del cuidado en el continuo salud-enfermedad, y desde el ciclo vital individual del recién nacido hasta el adulto mayor, con la incorporación de las familias, los grupos y las comunidades a las cuales pertenecen. conforme a lo señalado, será su desafío seguir en la búsqueda de ahondar en la consolidación de esa autonomía, por medio de la investigación y el fortalecimiento de su identidad profesional. dado el avance de la reflexión, es conveniente reforzar entonces que enfermería dispone de autonomía en cuanto al saber, es decir, los conocimientos que respaldan una práctica autónoma, pero lo que sigue siendo confuso es el ejercicio de la autonomía en cuando al saber ser (actitud) y al saber hacer (habilidades), pues la adquisición de autonomía conlleva una integralidad, y no concierne solamente a la aplicación de técnicas específicas sin la supervisión de otro profesional, sino que además se refiere a la toma de decisiones, la libertad de acción y la aplicación de criterios en los cuidados otorgados. en este mismo sentido, y relacionado con la dificultad en el saber ser y saber hacer, la enfermera en su trabajo “posee dificultades en tratar con conflictos y en desempeñar el liderazgo en el ámbito hospitalario” (27). esta dificultad en el desarrollo de habilidades para la gestión de los cuidados (liderazgo y autonomía) puede ocasionar frustración del líder y de los miembros del equipo. el liderazgo en enfermería tiene directa relación con la iniciativa del ejercicio autónomo. el liderazgo se puede entender como la influencia para hacer que las personas se esfuercen voluntariamente hacia el logro de las metas de grupo (28). la enfermera deberá guiar al equipo de profesionales y técnicos a su cargo, utilizando el máximo de sus capacidades, y motivando al equipo que lidera (29), con la finalidad de llegar al cumplimiento no solo de las metas institucionales, sino de aquellas metas u objetivos del cuidado (30), entre ellas la promoción de salud en las personas y los grupos, la satisfacción de los usuarios y seguridad de los 135 una reflexión sobre la autonomía y el liderazgo en enfermería l sara guerrero-núñez, patricia cid-henríquez pacientes (31) y, también, la administración de los recursos de asistencia. teorizando al respecto, el liderazgo es un concepto que se ha instaurado en la administración y gestión de enfermería, pues ha resultado ser un elemento importante para la organización de los cuidados y para el devenir de las instituciones de salud (29). el liderazgo se construye a lo largo de la formación profesional y como seres humanos (30), y debe ser una característica necesaria en quien dirige. lamentablemente, solo algunos la poseen, pues no todos la han sabido desarrollar. esta cualidad permite obtener el reconocimiento del grupo, comunicarse efectivamente y resolver los problemas de manera oportuna. en su deber de gestionar el cuidado, las enfermeras tienen la responsabilidad de liderar su mejor administración, usando para ello un pensamiento crítico que gobierne las capacidades cognitivas, y persuadiendo positivamente con habilidades y actitudes que orienten al logro de las metas propuestas para la ejecución del cuidado. dada la estructura y dinámica del sistema de cuidado, las enfermeras pertenecerán a un equipo de salud y también serán responsables de liderar a profesionales, técnicos en enfermería y auxiliares. esta forma de trabajo demanda que las enfermeras no solo asuman la dirección del sistema de cuidado, sino que además acompañen a la dirección con un adecuado liderazgo. para ello, se debe tener presente el contexto en el cual se desenvolverán, pues se debe analizar el tipo de liderazgo que se ha de ejercer, considerando para ello la decisión por sí misma, las personas que participan en la organización, los beneficios o las consecuencias de la decisión, y la experiencia o los conocimientos necesarios para la resolución de conflictos. balderas hace referencia a tres tipos de liderazgo (28): el liderazgo autocrático, que pone énfasis en el enfermero líder, siendo él quien toma las decisiones, imponiendo su criterio e informando las órdenes al personal a cargo. en cuanto al liderazgo democrático, el enfermero líder es un integrante más del equipo, estimulando al personal a cargo en la elección y realización de sus funciones y tareas. finalmente, en el liderazgo liberal, el enfermero líder limita su participación, centrando su interés en el personal y entrega a este la capacidad de decidir. es indudable que en la medida que se ejerza un adecuado liderazgo, los problemas en la gerencia serán más sencillos de resolver. lamentablemente, esto no siempre sucede en la realidad, pues en un extremo se encuentran las enfermeras que en su interés de no enfrentarse a posibles conflictos, delegan al personal técnico las actividades de su responsabilidad. este liderazgo de tipo liberal, trae consigo una dispersión en la toma de decisiones, con una dirección acéfala y, por consiguiente, un personal con escasa identificación con los valores y compromisos laborales. paralelo a ello, existe el riesgo de haber tomado decisiones que requirieron de la experiencia y el conocimiento de quien dirige, pero que desfavorablemente acentuaron la arbitrariedad perceptiva en la decisión. en el otro extremo, pero no menos ejercido, están quienes siempre lideran de manera autocrática, lo que lleva a una resistencia permanente en el equipo, donde probablemente se puede llegar al logro de objetivos, pero ocasionará una continua desmotivación de quienes participan en la entrega del cuidado, e impedirá estimular el pensamiento crítico del grupo. una inadecuada elección del tipo de liderazgo podría generar lo referido por algunos autores (32), quienes citando a tyler indican que “existe en la sociedad contemporánea una tendencia hacia la desvinculación con las instituciones sociales y una falta de deferencia hacia la autoridad” (32). la falta de vinculación con las metas institucionales, y el poco interés de las directrices entregadas por quien dirige, podrían significar que el cuidado se fragmente y mecanice, impidiendo la integralidad en el cuidado y distanciándolo cada vez más de las expectativas de los pacientes. de acuerdo con la literatura, es sabido que el tener personas a cargo trae consigo el ejercicio del poder, que también puede entenderse como la capacidad de liderar a otros. para ello se debe recordar la clasificación de french y raven, quienes mencionan cinco tipos de poder (28): recompensa, como la capacidad para ofrecer un estímulo; coercitivo, como la capacidad de obligar por medio de fuerzas; experto, derivado del conocimiento y la experiencia; de referencia, obtenido por la identificación de seguidores, y, finalmente, el poder legítimo, que se obtiene conforme a lo normado o por el cargo en sí mismo. el punto clave y de discusión es el siguiente: ¿cuál es el tipo de poder por el cual está siendo reconocida la enfermería? la clasificación del poder es relevante a la hora de responder a la interrogante planteada, pues de cierta manera permite reflexionar sobre las formas en que se está liderando. por sobre todo tipo de poder, y con la finalidad de desarrollar aún más la autonomía que enfermería posee en el país, las enfermeras deben no solo conformarse con el poder legítimo, sino bien, deben aspirar a ser reconocidas por su poder experto. en otras palabras, alcanzar la real identidad profesional y su respectiva distinción en sociedad. el liderazgo en enfermería tiene mayor probabilidad de avanzar, en la medida que voluntariamente sea incentivado por 136 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 actitudes innovadoras en proyectos e inversiones personales y grupales, destacando en ello la necesaria unión entre las profesionales (33). el liderazgo en enfermería se constituye en una habilidad humana necesaria para la resolución de conflictos y para la mejor gestión de los cuidados. practicar un liderazgo positivo está asociado no solo a consecuencias positivas para el paciente y la institución de salud, sino también para la enfermería (34), pues una enfermera líder deberá implementar estrategias para que en la práctica de enfermería se apliquen los conocimientos científicos (29). es por tanto primordial que las profesionales sean formadas en estos aspectos, con una educación de pregrado basada en competencias que dirijan a la formación de líderes y gestores del cuidado, aunando esfuerzos, motivaciones y capacidades entre la atención cerrada y abierta de salud, con estrecha relación entre los sectores académicos e investigativos en enfermería. debido al contexto sanitario chileno, con el desplegado escenario para las enfermeras, es fundamental que enfermería analice la formación de estos profesionales respecto al liderazgo, pues de no incorporarlo adecuadamente al ámbito profesional, quedará “desarticulada frente a los cambios existentes en los sistemas de salud” (35). si bien se ha logrado un posicionamiento del quehacer de la profesión en las subdirecciones o los departamentos de enfermería, incluyendo además la dirección de establecimientos de salud, holmes y gastaldo señalan que las enfermeras creen que no son tomadas en cuenta, sintiéndose víctimas de las instituciones que ellas mismas han ayudado a construir, administrar y mantener (36). por lo anterior, es conveniente centrar el análisis en los factores de restricción intrínsecos a la enfermería y cómo a causa de ellos la imagen proyectada en sociedad ha significado la restricción a la autonomía y el liderazgo: 1. participación de la propia opresión: se puede comprender la opresión como un “sistema de vectores de fuerzas y barreras interrelacionadas que inmovilizan, reducen y moldean a personas (el contenido de su conciencia) pertenecientes a un grupo determinado generando su subordinación a otro grupo” (37). conforme a esta definición, ¿el concepto opresión tiene relación con el saber (conocimiento), saber ser (actitud) y saber hacer (habilidad) de la enfermería? la opresión ha surgido en las diferentes aristas del vivir en sociedad, siendo siempre atribuida a una connotación de carácter opositor a las banderas de libertad y democracia de los gobiernos o sistemas actuales. en la dinámica asistencial, las relaciones de poder son evidentes en el trabajo interdisciplinario, y también ellas se reflejan en conformidad con los modelos imperantes en los sistemas de salud. en este sentido, enfermería como profesión establece relaciones con distintos profesionales, técnicos, auxiliares, personas receptoras del cuidado y también sus respectivos familiares, donde se manifiesta la opresión a la cual ha estado sometida por la fuerza hegemónica de la medicina (37). gastaldo menciona que las enfermeras experimentan sentimientos contradictorios al participar activamente en su propia opresión y que, de alguna manera, no son conscientes de ejercer algún tipo de poder (38). esto coincide con lo mencionado por freire sobre la adherencia que experimenta el oprimido hacia el opresor (39). para enfermería, dicha opresión corresponde a la adherencia hacia los modelos o sistemas imperantes que restringen la ejecución autónoma de su práctica. las enfermeras deben reconocer que el no ejercicio de su autonomía y el vivir en completa dependencia del modelo médico ahondan en la sumisión equívoca de una relación que repercute insatisfactoriamente en el cuidado de la salud de las personas y la sociedad. freire señala: ¿quién sentirá mejor que ellos los efectos de la opresión? ¿quién más que ellos para ir comprendiendo la necesidad de liberación? liberación a la que no llegarán por casualidad, sino por la praxis de su búsqueda; por el conocimiento y reconocimiento de la necesidad de luchar por ella. lucha que, por la finalidad que le darán los oprimidos, será un acto de amor, con el cual se opondrán al desamor contenido en la violencia del opresor (39). de lo citado, y comprendiendo que enfermería es un grupo de profesionales que ha experimentado la opresión, cabe entonces cuestionarse si estas profesionales han comprendido la “necesidad de liberación”. pareciera ser que el miedo a la libertad es mayor que el deseo de ejercer su autonomía y liderazgo profesional, pudiendo experimentar lo señalado por freire, que ese miedo a la libertad puede conducirlas a pretender ser opresores (39). el transitar de oprimido a opresor puede trastocar nocivamente las relaciones éticas que surgen con otros profesionales, técnicos, incluyendo a estudiantes y quienes reciben la atención, los cuales se verían perjudicados por la hostilidad de la relación que se establece. en este escenario, y por existir un contacto directo del actuar profesional con quienes se encuentran en formación, se pone en franco riesgo la formación de futuras generaciones, pues se podría dar una transmisión de la opresión a los 137 una reflexión sobre la autonomía y el liderazgo en enfermería l sara guerrero-núñez, patricia cid-henríquez estudiantes, con una supresión de la autonomía en el saber, saber hacer y saber ser. la educación universitaria se convierte en un vehículo privilegiado para fomentar el cambio social (40), es aquí donde se deben aplicar las estrategias que empoderen a las futuras generaciones profesionales respecto al rol que deben ejercer. 2. débil identidad profesional: actualmente existen estereotipos del rol profesional que socialmente ubican a las enfermeras en una posición de valor distinta a la de otros profesionales (41), una imagen contradictoria de lo que debería proyectar esta profesión. entre estos estereotipos se encuentra una imagen de sumisión, pasividad, falta de control y docilidad, entre otras (42). la identidad profesional es fundamental a la hora de trabajar dentro de un equipo multidisciplinario. para enfermería, generar y proyectar una adecuada identidad le permitirá el reconocimiento como única profesión en sus labores de asistencia, educación, administración e investigación. la identidad se construye en los espacios de trabajo, y también con el grupo profesional de referencia; dicha identidad contempla un carácter individual, es decir, una imagen creada por los mismos profesionales, y también un carácter social, que tiene relación con la interacción con los otros (43). en muchas ocasiones, las condiciones laborales generan en las enfermeras desmotivación y falta de interés por su trabajo (44), debido a las condiciones económicas, la realización de un trabajo rutinario, el no cumplimiento de sus expectativas, etc. lo anterior ocasiona el vivir en continua frustración, lo cual afecta el autoconcepto, y puede ocasionar falta de autoridad y reducido liderazgo. las enfermeras sienten que deben demostrar su valor y credibilidad profesional constantemente (44), por tanto, el trabajar en instituciones con relaciones más horizontales y con roles claramente definidos, provoca en ellas un trabajo autónomo, disminuyendo el estrés y sin asumir la responsabilidad de otros. pero aun cuando las condiciones laborales sean propicias, en ocasiones las propias enfermeras son las que limitan los procesos de desarrollo y autonomía en la profesión, debido a una autoestima baja, disminuyendo así su valor en la sociedad. lo anterior responde probablemente a un desconocimiento de su identidad, demostrando invisibilidad en su trabajo, y, en consecuencia, una falta de reconocimiento de su autonomía profesional en sociedad. la autoestima profesional requiere de un aporte adecuado de factores conjugados como la estima personal, la autoimagen y la imagen proyectada a la sociedad. el que enfermería no posea una adecuada identidad y autoestima profesional, afectará el ejercicio autónomo de la profesión y el liderazgo en la gestión del cuidado. 3. falta de interés por ejercer el rol profesional: un análisis sobre la falta de interés en liderar la gestión del cuidado y la “comodidad” de realizar solo intervenciones dependientes, responde a lo señalado por autores como anorexia del poder (38). ¿es que enfermería no desea ser una profesión autónoma? ¿existe aún confusión del rol autónomo en la profesión? ¿se está transmitiendo a los estudiantes este carácter autónomo o simplemente resulta más cómodo el trabajo dependiente, puesto que libera de ciertas responsabilidades que podrían llegar a ser civiles, éticas e incluso penales? llama la atención que por muchos años el rol profesional de la enfermera se ha invisibilizado, sobre todo en la toma de decisiones sobre el sistema sanitario y en lo que respecta a las políticas sociales (26). de esta manera, y respondiendo al compromiso ético y legal que la sociedad ha transferido a las enfermeras, es importante que la formación por competencias desarrolle en ellas las capacidades gerenciales para un adecuado ejercicio del rol profesional, entre estas, capacidades para un adecuado razonamiento clínico, toma de decisiones, resolución de conflictos y desarrollo de las habilidades para establecer relaciones interpersonales. se necesita estimular el desarrollo de liderazgo (30, 45), pues de esta manera las enfermeras asumirán la responsabilidad que ha recaído en ellas, empoderándose de su rol en el ámbito hospitalario y ambulatorio, con el fin de proporcionar cuidados de calidad al paciente (46). de esta manera, para ejercer el rol profesional que le corresponde, es decir, liderar una práctica autónoma de los cuidados, la enfermera debe ser competente y tomar el control de las situaciones en las que es responsable (47). las profesionales deben introducir su punto de vista en las políticas de salud y en la respectiva administración de los recursos; participar en discusiones sobre el tema en entidades gubernamentales, organizaciones internacionales, administradores de salud, y, entre otros, con inversionistas privados (48). conclusiones y sugerencias la enfermería dispone de un recorrido histórico que da cuenta de los importantes avances para que hoy pueda ser considerada como una disciplina profesional autónoma, puesto que dispone de los fundamentos históricos, filosóficos, éticos y legales para 138 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 desenvolverse en su ámbito de experticia, esto es, el cuidado y la gestión de este. su responsabilidad en la sociedad manifiesta la demanda que el entorno requiere y del cual debe hacerse cargo, liderando permanentemente y asumiendo con autonomía la función que solo ella puede cumplir. la enfermería chilena cuenta con importantes avances en cuanto a la legalización de sus funciones, por tanto, son las enfermeras quienes deben asumir el desafío de ahondar en la consolidación de la autonomía y el liderazgo, esenciales para la entrega de cuidados oportunos, de calidad y con la mayor eficacia. la posesión de autonomía y liderazgo en enfermería siguen siendo condiciones hoy cuestionadas a nivel internacional. contravenir estas posturas dependerá de la resolución de los factores intrínsecos a la profesión, y de implementar las estrategias que permitan una consolidación de dichos conceptos en el saber, saber ser y saber hacer de la enfermería. de acuerdo con lo anterior, se proponen estrategias de solución para fortalecer la autonomía y el liderazgo en la enfermería. se ha de entender que existirán otras que probablemente fortalecerán lo declarado por las autoras: • mayor sinergia entre la enfermería de la atención de salud abierta y cerrada, aunando capacidades con instituciones académicas o de investigación en el área. • fortalecimiento de la administración y gestión de enfermería en pregrado, aumentando por medio de la educación continua la oferta de programas en estas áreas. • fortalecimiento del desarrollo de habilidades blandas en la formación profesional: inteligencia emocional, liderazgo, habilidades de comunicación y resolución de problemas, entre otros. • instancias de reflexión permanente entre la academia y práctica de la enfermería, sobre la identidad profesional, imagen proyectada en sociedad, autoestima, liderazgo, autonomía y responsabilidad social. • aumentar la publicación científica para demostrar poder experto en su área. referencias 1. paredes p, rivas e. historia del ejercicio profesional de enfermeras hospitalarias del sur de chile (1940-1980). ciencia y enfermería. 2014;xx(1):9-21. 2. siles j. la construcción social de la historia de la enfermería. index enferm. 2004;13(47):07-10. 3. fajardo m, germán c. influencia del género en el reconocimiento de los cuidados enfermeros visibles e invisibles. index enferm. 2004;13(46):09-12. 4. martínez m, 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l. the historical social positioning of nursing and medicine: implications for career choice, early socialization and interprofessional collaboration. j interprof care. 2014;28(2):103-109. 42. calvo m. sexist stereotypes and biases associated with the female nursing model in advertising communication. texto contexto enferm. 2014; 23(3): 530-537. 43. alonso m, lópez k, medina m, esparza s, alonso m, álvarez m. el cuidado como fundamento de la identidad de enfermería: las voces del profesorado. desarrollo cientif enferm. 2009;17(9):386-391. 44. lapeña y, cibanal l, pedraz a, macía m. interpersonal relationships among hospital nurses and the use of communication skills. text context nursing. 2014;23(3): 555-562. 45. buckner e, anderson d, garzon n, hafsteinsdottir t, lai c, roshan r. perspectives on global nursing leadership: international experiences from the field. international nursing review. 2014;61(4):463-471. 46. metzger r, rivers c. advanced practice nursing organizational leadership model. journal for nurse practitioners. 2014;10(5):337-343. 47. skar r. the meaning of autonomy in nursing practice. journal of clinical nursing. 2010;19(15-16):2226-2234. 48. cano d, correa n, flórez w, giraldo y, monsalve m, restrepo a. management of resources in nursing: beyond leadership. our will to be and do. invest educ enferm. 2013;31(2):305-314. 284 291 cuidado del paciente moribundo.indd 284 martha adiela lopera-betancur1 cuidado del paciente moribundo: una confrontación entre mostrar sentimientos y desempeño profesional 1 orcid.org/0000-0002-7006-8698. universidad de antioquia, colombia. martha.lopera@udea.edu.co recibido: 10 de octubre de 2015 enviado a pares: 29 de octubre de 2015 aceptado por pares: 13 de octubre de 2016 aprobado: 21 de octubre de 2016 doi: 10.5294/aqui.2017.17.3.5 para citar este artículo / to reference this article / para citar este artigo lopera-betancur ma. cuidado del paciente moribundo: una confrontación entre mostrar sentimientos y desempeño profesional. aquichan. 2017; 17(3): 284-291. doi: 10.5294/ aqui.2017.17.3.5 resumen objetivo: comprender el significado que las enfermeras le dan al cuidado del paciente ad portas de la muerte. método: se realizaron entrevistas a 23 enfermeras que han cuidado a pacientes ad portas de la muerte y se realizó observación participante en un hospital de tercer nivel de medellín, colombia. los datos se analizaron por proceso inductivo para obtener categorías y sub categorías. resultados: el cuidado del paciente que está ad portas de la muerte significa una confrontación interna, pues ellas tienen la concepción que mostrar sentimientos por la muerte no es profesional, pero al no hacerlo sienten que ejercen una práctica profesional poco humanizada. discusión: cuando un paciente va a morir, las enfermeras evalúan qué tan profesional es mostrar sentimientos y que tan deshumanizado es no hacerlo. conclusión: cuidar a un paciente ad portas de morir significa ejercer una profesión humanística que deben aceptar. palabras clave atención de enfermería; muerte; estrés psicológico; relaciones interpersonales; actitud frente a la muerte, humanización de la atención; antropologia cultural (fuente: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 284-291 285 cuidado del paciente moribundo: una confrontación entre mostrar sentimientos y desempeño profesional l martha adiela lopera-betancur año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 284-291 dying patient care: the conflict between showing feelings and professional performance abstract objective: the objective of the study was to understand the meaning nurses afford to the care of patients who are on the verge of death. method: interviews were carried out with 23 nurses who have cared for dying patients, and participant observation was done at a third level hospital in the city of medellín (colombia). the data were analyzed through an inductive process to establish categories and subcategories. results: caring for a patient who is on the brink of death implies an internal conflict, since nurses believe that showing their feelings in the face of death is unprofessional. however, when they fail to do so, they sense their professional practice is less humane. discussion: when a patient is about to die, nurses evaluate how professional it is to show their feelings and how inhumane it is not to do so. conclusion: caring for a dying patient calls for exercising the humanistic aspects of the profession that must be accepted. keywords nursing care; death; psychological stress; interpersonal relations; attitude towards death; humanization of care; cultural anthropology (source: decs, bireme). 286 aquichan issn 1657-5997 eissn 2027-5374 cuidado do paciente terminal: um confronto entre demonstrar sentimentos e desempenhar-se como profissional resumo objetivo: compreender o significado que as enfermeiras dão ao cuidado do paciente na fase terminal. método: foram realizadas entrevistas com 23 enfermeiras que cuidaram de pacientes em fase terminal e foi realizada observação participante num hospital de nível terciário em medellín (colômbia). os dados foram analisados por processo indutivo para obter categorias e subcategorias. resultados: o cuidado do paciente em fase terminal significa um confronto interno, pois elas acreditam que mostrar sentimentos pela morte não é profissional, mas ao não fazer isso sentem que exercem uma prática profissional pouco humanizada. discussão: quando um paciente está prestes a morrer, as enfermeiras avaliam que tão profissional é mostrar sentimentos e que tão desumanizado é não fazer isso. conclusões: cuidar de um paciente em fase terminal significa exercer uma profissão humanizada que os enfermeiros devem aceitar. palavras-chave antropologia cultural; atenção de enfermagem; atitude diante da morte; estresse psicológico; humanização do atendimento; relações interpessoais (fonte: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 284-291 287 cuidado del paciente moribundo: una confrontación entre mostrar sentimientos y desempeño profesional l martha adiela lopera-betancur introducción el cuidado humano no solo implica ayudar al paciente a superar una enfermedad, sino también ayudarlo a afrontar las situaciones que no tienen remedio, como la muerte, y buscar significados en ellas. como expresa woldow, “enfermería es una profesión que tiene el privilegio de estar junto al paciente en estas situaciones ofreciendo confort” (1). pero este acompañamiento no siempre es efectivo, lo cual es un problema, pues deja a los pacientes y familiares sin la presencia de una enfermera2 que cuide y acompañe. una razón puede ser el impacto emocional que la muerte produce en los profesionales de enfermería (2); de manera que es mejor escucharlas para comprender qué motiva este comportamiento de ausencia en lugar de hacer juicios. ante esto surge la pregunta: ¿cuál es el significado que las enfermeras le dan al cuidado del paciente en proceso de fallecer? el objetivo de este artículo es comprender el significado que las enfermeras le dan al cuidado del paciente en proceso de fallecer. por otro lado, las profesionales se educan en una disciplina cuya esencia es el cuidado, así para waldow, “el cuidado, tiene relevancia fundamental como una acción que hace la diferencia al lidiar con el dolor, la ansiedad, la angustia, el sentimiento de pérdida, el temor de lo desconocido y tantos otros sentimientos que acometen al sujeto cuidado” (1). este trabajo reviste importancia, pues al comprender el significado que tiene para las enfermeras el cuidado del paciente en proceso de morir, se puede hacer un programa educativo tanto en las universidades como en las instituciones, que resalte el carácter humanístico de las enfermeras y les permita ventilar sus emociones ante su diario vivir. materiales y métodos para este estudio se utilizó la etnografía particularista, por el contenido cultural que rodea la muerte y el cuidado del moribundo. para la elección de los participantes se tuvo en cuenta que fueran enfermeras que hubieran cuidado por lo menos una vez a un paciente en proceso de morir. participaron 23 profesionales de diferentes edades, 19 mujeres y 4 hombres, 8 contaban con posgrados en diferentes áreas. 2 la palabra "enfermera" se utiliza por facilidad de lenguaje y se refiere al hombre o la mujer que ejerce la enfermería de manera profesional. la información se recolectó mediante entrevistas con preguntas que dependían del desarrollo de las mismas, se les permitió a los participantes hablar libremente de sus puntos de vista. se realizó una por participante, los datos se recolectaron hasta lograr la saturación de categorías (3). también se realizaron cien horas de observación participante, en una institución hospitalaria de tercer nivel de la ciudad de medellín (colombia), en diferentes áreas y a distintas horas. se llevó un diario de campo donde se registraron las notas necesarias para continuar con la búsqueda de información y el análisis. la información se recolectó entre 2014 y 2015. los resultados surgen de manera inductiva en un proceso de análisis, en el cual se seleccionaron códigos que se cortaron y agruparon en categorías de manera manual y paralelo a la obtención de los datos. a fin de garantizar el rigor se tomó en cuenta el criterio de credibilidad, para ello se presentaron los resultados a algunos participantes, enfermeras asistentes y pares académicos; para velar por la auditabilidad y la transferibilidad se detalló la ruta metodológica (4). durante la investigación se cuidaron aspectos éticos y las disposiciones consignadas en la resolución 8430 de 1993 para investigaciones de bajo riesgo (5), como el respeto por los participantes y por los datos del estudio. los datos se analizaron de manera global y se usaron seudónimos para proteger la privacidad y confidencialidad de las personas. los datos son exclusivos para este proyecto y se guardarán por dos años después de publicados. se tuvo consentimiento informado antes de la entrevista y las observaciones. esta investigación recibió aval del comité de ética de la facultad de enfermería de la universidad de antioquia, con acta n0_cei-fe 2012-3, y del comité de investigaciones de la institución donde se realizaron las observaciones. resultados se encontró que las enfermeras sienten cercanía con quien está próximo a morir, de tal manera que aumentan su cuidado directo y su compañía a medida que se acerca la muerte: “constantemente estoy pendiente, […] cuando veo que es inminente el proceso de fallecimiento me paro allá” (julieta). 288 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 el ámbito profesional. en este entorno impera la razón, las enfermeras no quieren dar paso a las emociones. sin embargo, ante la imposibilidad de su pretensión, ellas tratan de ocultarlas, lo que significa aguantar. las enfermeras tratan de no mostrar sus sentimientos como un acto de solidaridad, pues creen que si demuestran aflicción, los familiares van a sentir más dolor: “pero la verdad yo hasta ese día concebía que nosotros no deberíamos llorar delante de un familiar, porque era precisamente incrementar ese dolor, tú deberías ser la parte fuerte del asunto” (celestina). por otro lado, estar en el mundo de la racionalidad les permite tener la cabeza fría para tomar decisiones en favor del paciente, de esta manera intentan mostrarse fuertes y confiables, así lo expresa la participante: “uno tiene que aprender a ser fuerte y a dar esa fortaleza” (pocahontas). otra intención es evitar que las critiquen y juzguen como malas profesionales: “alguien una vez me criticó porque sentí tristeza por la muerte de un paciente, me dijo que éramos enfermeras y no familiares” (pocahontas). además, las enfermeras pueden enfrentar burlas, según dice la participante: “se lo gozan a uno, pero bueno, a mí no me importa” (julieta). también, las enfermeras tienen algunas estrategias para no mostrar sus sentimientos, tales como: aplazar la exteriorización de los sentimientos, como indica esta participante: “me mordí los dientes, por no llorar, cuando me senté lloré” (maya), y mantener una relación lejana con los pacientes y sus familiares para evitar apegos, como muestra este relato: “cuando vi a las auxiliares que lloraban con la muerte de un paciente dije no, esta conmigo no pasa, por eso yo con la familia no tenía relación” (escarlett). a pesar de los intentos por permanecer en un ambiente profesional, las emociones se comunican con un lenguaje no verbal, sin lágrimas y sin palabras: “paran de hacer las labores, cuando entra la familiar todos la miran con expresión de tristeza” (observación). el ámbito humano. en este entorno, las enfermeras demuestran sus emociones ante la muerte de los pacientes, contrario a lo que pasa en el mundo profesional, en el cual, si bien comunican sus emociones, no tienen la intención de hacerlo. llorar es una de las formas para exteriorizar emociones, de esta manera las lágrimas se convierten en un signo humano que no las avergüenza, por esto no se aplaza: “me he quedado ahí porque veo que ya es inminente la hora del fallecimiento, y lloro, no voy y me escondo” (julieta). también exteriorizan sus emociones al hablar con otros miembros del equipo de salud: “es un tema común en mi equipo de trabajo, simplemente nosotros lo hacemos, es inevitable porque es lo que vivimos todo el tiempo” (pocahontas). las emociones de las enfermeras aparecen por diferentes motivos, uno es perder la lucha contra la muerte cuando los profesionales tenían esperanza en su recuperación: “se lucha para que el paciente salga, cuando no se puede es muy duro” (maya). otro motivo de emociones es la pérdida del paciente como persona: “es el saber que ya no estará” (pocahontas), y la expresión de dolor emocional de los familiares, sea llorando: “me acuerdo mucho de una paciente que murió y el muchacho se daba contra la pared, y se daba duro, duro, y a mí como que se me venían las lágrimas” (emma), o queriendo mostrar fortaleza: “sentimientos por ver el sufrimiento de la familia como me tocó a mí ver una mamá una noche entera parada al lado de la niña, […], eso duele mucho verlo” (escarlett). pero, más allá de esta expresión de sentimientos, está la sensación de percibirlos, los participantes se expresan en sentido figurado, como si pudieran verlos y palparlos: “el dolor [emocional] se ve” (pocahontas), sea en las expresiones de las personas o en los cambios en el ambiente, como un profundo silencio que aparece donde muere alguien: “se siente pena, es que hay como un espacio de silencio y vacío” (maya), o una especie de oscuridad figurada: “ensombrecido, como esa oscuridad” (mafalda). las emociones que se encontraron son: angustia: por las múltiples necesidades de cuidado de los pacientes y su larga agonía: “hay un tipo de paciente que me generan mucha angustia y son los pacientes, […] que tienen una agonía muy larga” (ana karenina), lo mismo sucede con la situación contraria, cuando la muerte no se esperaba. también, ante el paciente con heridas o lesiones grandes y que ellas consideran que llevarán a que sus familiares sufran más: “sobre todo para la familia ver a su paciente a veces que son tan desfigurados y destrozados que me angustian” (ana karenina). además, sienten angustia por el paciente que muere en soledad: “a mí me genera mucha angustia el paciente que se nos muere solito” (julieta). 289 cuidado del paciente moribundo: una confrontación entre mostrar sentimientos y desempeño profesional l martha adiela lopera-betancur rabia: cuando sienten que el paciente no es tratado como una persona digna de cuidados: “es que me da tanta rabia, a estos pacientes nadie les presta atención, son los últimos por la ronda, son los últimos en quien piensan” (sherazada). tristeza: nace cuando las enfermeras toman la muerte del paciente como un asunto personal, o cuando el paciente muere a pesar de los pronósticos: “en un caso hubo mucha tristeza porque era un paciente que no pensamos que iba a fallecer” (escarlett). sufrimiento: está relacionado con el dolor y los síntomas físicos que producen sufrimiento en los pacientes y sus familiares, como se lee en este relato: “se ve el dolor y uno empieza a sufrir con ellos” (ana karenina). tranquilidad: esta llega cuando las enfermeras sienten que cumplieron con su función de cuidado: “en algunos casos tranquilidad, el regocijo de saber que fallecía pero que había sido bien cuidado y que de todas maneras no había nada para hacer” (escarlett). culpa: en ocasiones las enfermeras sienten una culpa ligada con la responsabilidad ante el cuidado de la vida, como en este testimonio: “entonces hago una retrospectiva, ¿qué hice?, ¿qué no hice?, ¿será que no avisé al médico rápido, será que no le corrimos?” (joel). la lucha entre los mundos la exteriorización de emociones ante la muerte de sus pacientes significa para las enfermeras una lucha entre el ámbito humano, donde sienten la libertad para hacerlo, y el profesional, donde no deben mostrarlos. la lucha tiene implícito un conflicto de concepciones de lo que significa cada ámbito. las enfermeras deben luchar contra unas concepciones de la cultura profesional que dictan que las emociones pertenecen al ámbito humano; también, que la experiencia profesional da herramientas para acostumbrarse a la muerte, hasta el punto de insensibilizarse; contrario a esto, se encontró que la muerte de los pacientes causa emociones independientemente del número de muertes que se hubieran presenciado: “lo que siempre le pregunta a uno todo el mundo, ustedes ya, me imagino que usted ha visto morir a tanta gente que ya se volvió insensible, ya no le importa, y no; uno siempre siente dolor en ese momento” (dulcinea). ante esta concepción cultural las enfermeras sienten temor de mostrarse inmaduras e inexpertas. pero si las enfermeras muestran una faceta profesional se sienten malas personas y deben cargar con la imagen de un ser duro y frío, como lo muestra este testimonio: “yo trataba de hablar con los pacientes, para no ser más mala persona de lo que ya era porque no me acercaba a la familia, ni me ponía a llorar con ellos” (escarlett). otra concepción muestra una enfermera amable, que expresa ternura y comprensión, de la cual la sociedad espera apoyo verbal o algún tipo de contacto físico, como lo manifiesta este participante: “cuando el paciente está muriendo, la familia ni siquiera se remite al médico, sino que buscan al enfermero como apoyo y esperando que él le dé esa palmada en la espalda” (joel). en esta lucha las enfermeras siempre salen sintiéndose perdedoras, puesto que si muestran sus emociones y se ubican en el ámbito humano se sienten malas profesionales, pero si no lo hacen se sienten malas personas: “claro, y he notado que uno no se atreve a expresarlo, uno no lo habla y por eso pasa como insensible o inhumano con las familias, porque uno cree que eso no se debe, que no es profesional y la familia cree que a uno no le importa y a uno sí le importa” (aureliano). conciliación de la lucha ante la lucha entre el mundo profesional y el humano, las enfermeras deben intentar una conciliación que busca que ellas puedan encontrar un equilibrio y vivir entre ambos mundos, es decir, sostener al paciente y sus familiares sin dureza: “uno trata de ser fuerte frente a las familias, pero a veces se quebranta esa ‘dureza’, pienso que es importante no perder la sensibilidad” (manuela). para efectos de la conciliación emergieron varias estrategias, como llorar por turnos para no dejar solos a los pacientes y familiares sin mostrar emociones: “nos pasábamos un rato, la auxiliar asistía a la familia yo iba y lloraba y cambiamos y ella iba y lloraba al cafetín” (celestina). otra forma de resolver esta lucha es la convicción de que la enfermería permite tener sensibilidad por lo que le pasa a las personas, por esto, ellas se niegan a dejar de sentir: “yo tengo un lema personal que el día que yo deje de sentir dolor por las personas y no haga ese acompañamiento, dejo de ser enfermera, hasta ese día llego” (ana karenina). además, las enfermeras 290 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 comprenden que estar en el ámbito humano no desdice del profesional, por el contrario, hace que el paciente y sus familiares se sientan mejor: “yo creo que eso es lo que debería hacer una enfermera, quitarse ese paño de títulos y cosas y ser una persona que acompaña” (mafalda). discusión las enfermeras comprenden que el proceso de cuidar ocurre independientemente de la curación (1); no obstante, la muerte de los pacientes las lleva a tener diferentes emociones, lo cual concuerda con garcía y rivas, quienes encontraron que la muerte de los pacientes es una “tragedia que impacta y afecta emocionalmente a la enfermera” (6). en este estudio se encontró que las enfermeras buscan habitar en un mundo profesional donde deben mostrarse fuertes para sostener a los pacientes y familiares en su momento de vulnerabilidad. frente a esto, morse (7) opina que mostrarse fuerte de manera consciente o no es un signo de sufrimiento, y es una forma de tener la cabeza fría para hacer lo que hay que hacer, y sostener a los pacientes y sus familiares; así, entonces, se muestra que las enfermeras sufren en los dos ámbitos, el profesional y el humano, lo cual coincide con los hallazgos de schaefer y vieira (8) en materia de sufrimiento moral de las enfermeras. pero evitar este contacto humano es negar el carácter humano de la enfermería. así las cosas, las enfermeras son las cuidadoras de los que padecen, entienden su pesadumbre, ofrecen su hombro y alivian el sufrimiento, pero según gómez et al. (9), esto las pueden llevar a mostrar diferentes estados emocionales como tristeza, angustia, ansiedad e impotencia. no obstante, las enfermeras participantes consideran que no es profesional mostrar emociones, como lo afirman celma y strasser: “el saber científico anula el saber sociocultural” (10). para ocultarlas, las enfermeras tienen diferentes estrategias como mantener una relación lejana con los pacientes y sus familiares, y así llegan a una cierta despersonalización, tal como lo describen ramos et al. (11). adicionalmente, gómez (12) encontró que en colombia las personas aprenden desde la niñez la autorrestricción en la expresión afectiva, especialmente en lo que se refiere a la muerte. por otra parte, existe una lucha interna entre su visión de ser profesional, que no admite dejarse conmover, y el no poder evitarlo; jhonson y gray encontraron la misma lucha (13), sustentada en parte en una racionalización técnica, que relega la subjetividad (10), contrario al deber profesional de interacción (14) y comunicación que, según achury (15), facilita el “cuidado holístico y humanizado al paciente y sus familiares”, y permite tomar decisiones acerca de lo que es bueno para el paciente (16). la respuesta parece ser conocerse a sí mismo, y trabajar en la mejor forma de abordar las emociones sin endurecerse, al mismo tiempo, pensar en la enfermería como una ciencia humanística que no admite el abandono del paciente y sus familiares. conclusiones cuidar a un paciente en proceso de fallecer significa para las enfermeras ejercer su profesión entre dos ámbitos: uno profesional que es objetivo e insensible, y otro humano que se permite mostrar emociones. ambas caras de la enfermería llevan a una lucha de la cual sale perdedora obligándola a llevar una conciliación en la cual aprenden el lado humano de la enfermería que les permite ser un soporte, pero también sentir. es preciso fortalecer la capacidad comunicativa de las enfermeras, a fin de que puedan escuchar los temores y las angustias de los pacientes y familiares, a la vez que puedan expresar los suyos ante sus pares, con el fin de evitar el temor al juicio y la crítica, o ausentarse y dejar solo el paciente y sus familiares. recomendaciones es necesario que la formación de las enfermeras rescate cada componente de la disciplina que les permita ser un soporte para los pacientes y sus familiares, a la vez que se comprometan con su cuidado de manera más sensible, así no quedarán culpas o temores. asimismo, es necesario crear programas en las instituciones de salud en los cuales las enfermeras periódicamente puedan ventilar sus emociones ante la muerte. sería importante diseñar investigaciones que exploren el concepto de apego y sufrimiento de las enfermeras. conflicto de intereses: ninguno declarado. 291 cuidado del paciente moribundo: una confrontación entre mostrar sentimientos y desempeño profesional l martha adiela lopera-betancur referencias 1. waldow v. cuidado humano: la vulnerabilidad del ser enfermo y su dimensión de trascendencia. index enferm. 2014 [visitado 2015 sep 23];23(4):234-38. disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s113212962014000300009&lng=es. 2. edo m, monforte c, tomás j. afrontar el sufrimiento y la muerte: desafíos para el cuidado en el siglo xxi. enferm clin. 2015 [visitado 2016 oct 20];25(1):42-3. http://dx.doi.org/10.1016/j.enfcli.2014.10.002 3. strauss a, corbin j. bases de la investigación cualitativa: técnicas y procedimientos para desarrollar la teoría fundamentada. medellín: facultad de enfermería de la universidad de antioquia; 2002. 4. castillo e, vásquez m. el rigor metodológico en la investigación cualitativa. colomb med 2003 [visitado 2014 ago 20];34(3). disponible en: https://tspace.library.utoronto.ca/bitstream/1807/3460/1/rc03025.pdf 5. ministerio de salud. resolución 8430 de octubre 4 de 1993. bogotá; 1993. 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holist nurs pract. 2013 [visitado 2015 oct 27];27(6):318-28. disponible en: http://journals.lww.com/hnpjournal/fulltext/2013/11000/understanding_nurses__experiences_of_providing.3.aspx?cid=mr-ejp-hottopics-nursinga-nursinghnp-nopromo 14. colombia. ley 911 de octubre 5 de 2004, por la cual se dictan disposiciones en materia de responsabilidad deontológica para el ejercicio de la profesión de enfermería en colombia; se establece el régimen disciplinario correspondiente y se dictan otras disposiciones. bogotá: tribunal nacional ético de enfermería; 2004. 15. achury d. la comunicación con la familia del paciente que se encuentra al final de la vida. enferm univ. 2016 [visitado 2017 jun 13]; 13(1):55-60. disponible en: http:// http://www.elsevier.es/es-revista-enfermeria-universitaria-400-articulo-la-comunicacion-con-familia-del-s1665706315000925. http://dx.doi.org/10.1016/j.reu.2015.12.001. 16. siles j. la utilidad práctica de la epistemología en la clarificación de la pertinencia teórica y metodológica en la disciplina enfermera. index enferm 2016;25(1-2):86-92. 95 109 seroprevalencia en zona hiperendemia.indd 95 rafael de jesús tuesca-molina1 edgar navarro-lechuga2 eloína del carmen goenaga-jiménez3 juan carlos martínez-garcés4 jorge acosta-reyes5 seroprevalencia en una zona de hiperendemia por dengue, barranquilla, colombia 1 orcid.org/0000-0003-3095-7199. universidad del norte, colombia. rtuesca@uninorte.edu.co 2 orcid.org/0000-0002-3181-2891. universidad del norte, colombia. enavarro@uninorte.edu.co 3 orcid.org/0000-0001-7435-9073. universidad del norte/secretaría de salud distrital de barranquilla, colombia. egoenaga@uninorte.edu.co 4 orcid.org/0000-0001-9134-9889, universidad del norte, colombia. ancm@banalsa.co 5 orcid.org/0000-0003-4303-3243. universidad del norte, colombia. acostajl@uninorte.edu.co recibido: 15 de julio de 2016 enviado a pares: 02 de septiembre de 2016 aceptado por pares: 27 de febrero de 2017 aprobado: 12 de mayo de 2017 doi: 10.5294/aqui.2018.18.1.9 para citar este artículo / to reference this article / para citar este artigo tuesca-molina rj, navarro-lechuga e, goenaga-jiménez ec, martínez-garcés jc, acosta-reyes j. seroprevalencia en una zona de hiperendemia por dengue, barranquilla, colombia. 2018; 18(1): 95-109. doi: 10.5294/aqui.2018.18.1.9 resumen objetivo: estimar seroprevalencia de anticuerpos igg e igm para dengue y factores asociados. método: estudio transversal, mediante la aplicación de encuesta y estimación serológica para igg e igm para dengue en mayores de 15 años con representabilidad por localidad y sexo. 478 sujetos encuestados en la ciudad de barranquilla colombia análisis estadístico, mediante el programa spss®, versión 22. se estimó la sero-prevalencia para el análisis univariado y el análisis bivariado mediante la odds ratio de proporciones con una p<0,05. resultados: la seroprevalencia para igg fue 88,2% (ic 95% =85,2-91,1) y para igm de 11,8% (ic 95%= 8,80-14,75). se encontró asociación estadística en edades de 30 a 49 y 50-69 años (or=7,09 [2,6-19,3] y or= 8,93 [2,9-27,0] respectivamente), pertenecer al régimen de salud subsidiado (or=2,56[1,18-5,53]) y ocupación hogar (or= 3,38[1,31-8,67]. conclusiones: la alta seroprevalencia para igg es explicada por la circulación de los cuatro serotipos en el país, los brotes epidémicos cada dos a tres años y los comportamientos y prácticas desfavorables relacionadas con el manejo de agua. se requiere cambios de conducta frente al manejo de factores predisponentes, la atención oportuna de sintomáticos y vigilancia activa comunitaria e institucional ante casos sospechosos. palabras clave estudios seroepidemiológicos; dengue; factores de riesgo; estudios transversales; prevalencia (fuente: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 95-109 96 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 95-109 sero-prevalence in a hyperendemic area of dengue: barranquilla-colombia abstract objective: estimate the sero-prevalence of igg and igm antibodies for dengue and associated factors. method: a cross-sectional study was done by means of a survey and serological estimation for igg and igm for dengue in subjects over 15 years of age with representability by location and gender. in all, 478 subjects were surveyed in the city of barranquilla, colombia. the spss® program, version 22, was used for the statistical analysis. sero-prevalence was estimated for univariate analysis and bivariate analysis using the odds ratio of proportions with p <0.05. results: the sero-prevalence for igg was 88.2% (95% ci = 85.2-91.1); for igm, it was 11.8% (95% ci = 8.80-14.75). a statistical association was found between subjects ages 30 to 49 and those ages 50 to 69 (or = 7.09 [2.6-19.3] and or = 8.93 [2.9-27.0] respectively) who are part of the subsidized health system (or = 2.56 [1.18-5.53]) and list homemaker as their occupation (or = 3.38 [1.31-8.67]) conclusions: the high sero-prevalence for igg is explained by circulation of the four serotypes in the country, epidemic outbreaks every two to three years, and unfavorable behavior and practices related to water management. behavioral changes are needed when it comes to dealing with predisposing factors, timely symptomatic care and active community and institutional surveillance in response to suspected cases. key words sero-epidemiological studies; dengue; risk factors; cross-sectional studies; prevalence (source: decs). 97 seroprevalencia en una zona de hiperendemia por dengue, barranquilla, colombia l rafael de jesús tuesca-molina y otros soroprevalência numa área de hiperendemia por dengue, barranquilla-colômbia resumo objetivo: estimar a soroprevalência de anticorpos igg e igm para dengue e fatores associados. método: estudo transversal, realizado com a aplicação de questionário e estimativa sorológica para igg e igm para dengue em maiores de 15 anos com representabilidade por localidade e sexo. 478 sujeitos entrevistados na cidade de barranquilla, colômbia. análise estatística por meio do programa spss®, versão 22. foi estimada a soroprevalência para a análise univariada e a análise bivariada mediante a odds ratio de proporções com p<0,05. resultados: a soroprevalência para igg foi 88,2 % (ic 95 % =85,2-91,1) e para igm de 11,8 % (ic 95%= 8,80-14,75). constatouse associação estatística em idades de 30 a 49 e 50 a 69 anos (or=7,09 [2,6-19,3] e or= 8,93 [2,9-27,0] respectivamente), pertencer ao sistema de saúde subsidiado (or=2,56[1,18-5,53]) e ocupação do lar (or= 3,38[1,31-8,67]. conclusões: a alta soroprevalência para igg é explicada pela circulação dos quatro sorotipos no país, os surtos epidêmicos a cada dois ou três anos e os comportamentos e práticas desfavoráveis relacionados com o uso da água. são requeridas mudanças de comportamento diante dos fatores predisponentes, atenção oportuna de sintomáticos e vigilância ativa comunitária e institucional ante casos suspeitos. palavras-chave dengue; estudos soroepidemiológicos; estudos transversais; fatores de risco; prevalência (fonte: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 95-109 98 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 introducción en colombia, la incidencia del dengue se caracteriza por brotes epidémicos cíclicos en poblaciones urbanas localizadas por debajo de los 2.000 msnm. al igual que brasil, venezuela, bolivia y paraguay, las tasas de morbilidad por dengue oscilan entre un 200,01 a 1.078,48/100.000 habitantes, y son las más elevadas de suramérica, las cuales representan el 50-70 % de los casos de la región. en la mayoría de los países afectados, las áreas geográficas con mayor riesgo presentan problemas de abastecimiento de agua potable, inadecuados sistemas de eliminación de aguas residuales y desechos sólidos, debilidades en el ordenamiento territorial, ambiental y de vivienda, que son determinantes para criaderos de mosquitos (1-7). este evento es de gran preocupación para la salud pública por su impacto en la morbilidad y la mortalidad, la amplia distribución en el territorio nacional condicionada por el sistema de salud, y por determinantes ambientales, conductuales y culturales. en estos inciden las actuaciones del equipo de atención de salud, y la debilidad en la calidad y oportunidad de la notificación epidemiológica (1-10). la organización panamericana de la salud (ops) y la organización mundial de la salud (oms) estimaron que del 2000 al 2014 se presentaron 14,2 millones de casos y 7.000 muertes en las américas; circularon los cuatro serotipos de dengue, con incremento del riesgo de casos de dengue grave (1). durante el 2016 se redujo a 2’427.290 casos en las américas; el 67 % lo aportó brasil, y el 11 % la región andina —donde está ubicada colombia—, que registra el 35 % de los casos, y 8 % el istmo centroamericano (5, 11). en colombia, de acuerdo con el reporte de vigilancia epidemiológica, para la semana 23 de 2015 se registraron 46.538 casos de dengue (98,7 % correspondió a dengue y 1,3 % dengue grave), un incremento de 0,1 % con respecto al 2014. para el año 2016 se reportaron 103.822 casos, 50 % correspondió a dengue sin signos de alarma, 40 % con signos de alarma y 1 % dengue grave. en este periodo, el dengue afectó preferencialmente a menores de 14 años, varones, del régimen contributivo de salud (personas con capacidad de pago). el dengue grave impactó a personas del régimen subsidiado de salud (personas sin capacidad de pago), lo que supone una diferencia en el comportamiento de la enfermedad y en la atención de salud. de otra parte, el informe de vigilancia epidemiológica nacional ha identificado la circulación de los cuatro serotipos de manera simultánea, con incremento del serotipo 1 (12). la ubicación geográfica de barranquilla, su topografía y sus condiciones climáticas, en especial la humedad, al igual que los aspectos culturales en la región del caribe colombiano son favorables para la reproducción del vector transmisor del dengue. los factores demográficos relacionados con el incremento de la población urbana conllevan su concentración en las grandes ciudades. por otra parte, esta movilidad no organizada que vive el país, y las condiciones de hábitat no planeadas, propician condiciones favorables para la reproducción del vector (1-6, 8, 10, 13). la secretaría de salud distrital de barranquilla, en la semana 14 de 2014, estimó una tasa de 79,5/100.000 (14). presumiblemente se notifica un mayor número de casos en la ciudad comparados con otras ciudades de la región que genera una disparidad entre la realidad y la notificación. actualmente se han implementado acciones de prevención y control promovidas por la ops/oms, tales como el decálogo para la prevención y control del dengue, nueva generación de programas y, a partir del 2003, la estrategia de gestión integrada (egi) para la prevención y control del dengue, que incluye el desarrollo de planes de comunicación y movilización social para el incremento de factores protectores (8, 15-17). de otro lado, en la mayoría de los casos la enfermedad adquiere un comportamiento poco específico, con sintomatología leve, que induce a los sujetos a no buscar ayuda médica, o se puede confundir con otras patologías como influenza, malaria o leptospirosis y ello lleva a que los profesionales de la salud diagnostiquen de manera errónea el caso. por lo anterior, la vigilancia del dengue de parte de la autoridad sanitaria y de los equipos de atención básica es de especial interés (8, 15-17). los estudios de seroprevalencia, como actividades de vigilancia epidemiológica, identifican debilidades de los sistemas de salud, fundamentalmente relacionadas con la notificación e información. además, posibilitan entender la dinámica poblacional de transmisibilidad, el patrón de difusión del dengue a nivel poblacional y el acumulado de antecedente de exposición (2, 4, 6, 7, 10, 13, 18-25). el ministerio de salud de colombia, junto con la secretaría distrital de salud de barranquilla, y el grupo de investigación proyecto uni de la universidad del norte desarrollaron un proyecto de gestión y fortalecimiento del programa de promoción, prevención y control de enfermedades transmitidas por vectores y zoonosis, a fin de prevenir y mitigar los efectos por cambio cli99 seroprevalencia en una zona de hiperendemia por dengue, barranquilla, colombia l rafael de jesús tuesca-molina y otros mático para municipios con alta carga endémica de dengue (resolución 04485 de 2012). el propósito del presente trabajo fue determinar la seroprevalencia de anticuerpos igg e igm para el virus del dengue, e identificar factores asociados en barranquilla, colombia, durante el año 2014, que permitan tener un marco de referencia para estudios posteriores y facilitar el direccionamiento de políticas pública (26, 27). materiales y métodos el estudio se desarrolló en la ciudad de barranquilla, colombia, ubicada a 10° 59’ 16’’ de latitud norte y 74º 47’ 20’’ de longitud oeste, en el vértice nororiental del departamento del atlántico, a orillas del río magdalena, sobre la orilla occidental cerca a la desembocadura en el mar caribe. la ciudad tiene una extensión de 154 kilómetros cuadrados. la temperatura presenta variaciones que oscilan de 24 a 32 ºc, con una mediana de 27,4 ºc, una humedad del 80 % y una precipitación de 821 mm anual. la organización política y administrativa de la municipalidad se distribuye en cinco localidades: riomar, norte centro histórico, metropolitana, sur occidente y sur oriente; estas localidades están conformadas por 188 barrios y 7611 manzanas. diseño del estudio y selección de la muestra se realizó un estudio transversal, en el cual se estimó la seroprevalencia a partir de la determinación de anticuerpos tipo elisa dengue igg indirecto y elisa dengue igm de captura, acompañado con la aplicación de una encuesta de conocimiento de la enfermedad, y variables personales y del entorno durante los meses de marzo a mayo de 2014. la muestra estimada fue de 504 sujetos; se calculó a través del paquete estadístico epiinfo en statcal; la población diana tomada como referencia fueron 1’193.667 habitantes de barranquilla pertenecientes a las cinco localidades. se consideró una seroprevalencia similar para países con alta endemicidad del 10 % (8, 9), con un efecto de diseño de 1,62, una confianza del 95 % y un máximo de 4, con un ajuste del 10 % por no respuesta. el muestreo fue aleatorio estratificado por localidad y por sexo; el tamaño de la muestra se definió proporcionalmente por localidad y se ajustó por peso proporcional de la población de referencia. la unidad de muestreo fue la vivienda y la unidad de análisis fue el individuo residente en la vivienda seleccionada que representa su localidad o barrio. el marco muestral se construyó con varias fuentes que permitieron crear clúster: la base de datos de la empresa de energía de la ciudad, los mapas por localidades suministrados por la secretaría distrital de salud, provenientes de planeación distrital y del instituto geográfico agustín codazzi (igac), al igual que identificación de zonas obtenidas por gloogle map. para la selección de los barrios se tuvo en cuenta la tendencia del comportamiento de dengue relacionada con notificación de casos. se identificaron zonas que permitieron jerarquizar los barrios por el número de casos notificados y se seleccionaron de manera aleatoria los barrios en cada localidad. en la segunda fase del muestreo, luego de identificarse el barrio, se ubicó la zona perteneciente a la localidad. para la siguiente unidad muestral se definió que ésta siempre fuese una casa o hábitat residencial, y se descartaron áreas comerciales; la unidad de observación final fue el individuo presumiblemente “sano”, una vez preseleccionado el domicilio. se contó con el apoyo del equipo de técnicos ambientales de la secretaría de salud. para la elección de los sujetos se contactaron en las viviendas personas mayores de 15 años que desearan participar de manera voluntaria. se excluyeron gestantes, personas con problemas para comunicarse y casos con sospecha de dengue o fiebre. los sujetos recibieron información con respecto al estudio. se les entregó y socializó el consentimiento y asentimiento informado. a los participantes se les extrajeron muestras de sangre de acuerdo con el protocolo establecido (procedimiento de extracción, embalaje, transporte y análisis), y cada participante diligenció la encuesta. la toma de sangre se realizó por profesionales de la salud entrenados (bacteriólogos). la encuesta indagó datos personales, conocimiento de haber padecido dengue en algún momento de su vida, antecedentes relacionados con presencia de fiebre tres semanas antes de la encuesta, disponibilidad de servicios públicos y conocimiento de dengue relacionado con: síntomas, forma de transmisión, acciones de prevención y conocimiento de señales para acudir a una institución de salud. las preguntas seleccionadas en el cuestionario hacen parte de instrumentos aplicados para investigación de dengue previamente estandarizados y validados, derivados de estudios realizados en la ciudad y en otras latitudes. 100 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 fundamentación de la utilización de igg e igm en el estudio de seroprevalencia de acuerdo con los requerimientos del ministerio de salud de colombia y los lineamientos de la oms, se empleó la prueba de panbio dengue elisa duo (elisa dengue igg indirecta y elisa dengue igm de captura viircell) teniendo en cuenta los criterios de sensibilidad y especificad de la prueba, al igual que la capacidad de evidenciar probabilidad de aparición de casos de dengue grave en la población, especialmente en áreas de alta intensidad de la transmisión. la prueba determina anticuerpos igg en un periodo de 10 meses posinfección y, además, favorece identificar los anticuerpos igm que estén ausentes, bajas concentraciones o dudoso, a menos que haya habido una infección por dengue durante los últimos tres meses (28-33). el análisis de serología para dengue se realizó en los laboratorios de la universidad del norte; se aplicó el protocolo de análisis y tratamiento seguro de las muestras colectadas; además, se realizó control interno de calidad. la encuesta sobre conocimientos de dengue y datos sociodemográficos se realizó por personal previamente entrenado y se asignó un código a la encuesta que se anexó a la toma de muestra de sangre. el equipo de campo, junto con los investigadores, retroalimentaron el proceso y a cada participante le fue entregado su reporte de serología para dengue igg e igm, previa aceptación de conocer los resultados. la interpretación para igg e igm de captura de elisa de panbio se llevó a cabo de la siguiente manera: por debajo de 9 unidades de panbio negativo, de 9 a 11 unidades de panbio “dudoso” y mayores de 11 unidades correspondió a positividad según las especificaciones (panbio diagnostic®www.panbio.com). de acuerdo con la serología, los sujetos se clasificaron en positivos y negativos para ambas pruebas. análisis estadístico se realizó un análisis descriptivo de las características personales y los aspectos relacionados con el conocimiento y las medidas de prevención del dengue. se estimaron las prevalencias para igm e igg para dengue. a fin de establecer los posibles factores de riesgo con el análisis de las variables epidemiológicas y los resultados de la pruebas serológicas se empleó la razón de probabilidades ((odds ratio or) (31). para el procesamiento y análisis estadístico se utilizó microsoft excel® 2010 y ibm-spss®, versión 22. aspectos éticos en el proceso de recolección de la información cada uno de los participantes firmó un consentimiento informado y asentimiento en menores de 18 años (22). esta investigación se clasificó de riesgo mínimo de acuerdo con la resolución 8430 de 1993 y contó con aval del comité de ética de la universidad del norte. resultados un total de 478 sujetos respondieron la encuesta de conocimiento de dengue, que corresponde a un 94,8 %. en el componente de seroepidemiología se procesaron 484 muestras (96,03 % de la muestra estimada). las muestras faltantes correspondieron a sujetos que no acudieron a la segunda cita o no diligenciaron la encuesta. la mayor representación de la población corresponde al grupo de 30-49 años (32,6 %), seguido del grupo de 50 a 69 años (30,3 %), y una menor proporción de mayores de 70 años (5,9 %). la mayoría de los sujetos eran empleados formales e informales: 38,9 %). el 56 % manifestó pertenecer al régimen contributivo. la mayoría 433 (90,6 %) de los encuestados se autoidentificó como otros (no indígena, no palenquero o afrodescendientes, no raizal) (tabla 1). el 8,4 % reconoció haber sido diagnosticado o recuerda haber padecido dengue alguna vez en la vida, y en este grupo, el 87,5 % (34) refiere haberlo padecido hace más de un año. al indagar acerca del conocimiento de transmisión de dengue en su barrio, el 41,4 % refirió tener conocimiento de transmisión y el 82 % reconoce la palabra dengue. el 55,8 % reconoce vacunación contra fiebre amarilla. el 93,1 % de los participantes reconocen signos y síntomas de dengue (4,8 % identificó correctamente los signos y síntomas, y el 88,3 % relaciona fiebre y mialgias/dolor). el 78 % de los encuestados reconoce que el mecanismo de transmisión es por la picadura del mosquito infectado, y el 4,6 % identificó las acciones correctas para prevenir el dengue. con respecto a la actuación para acudir a una institución de salud a quienes manifestaron que padecieron dengue, el 0,4 % identificó de manera correcta todos los síntomas de gravedad, mientras que el 10 % reconoce un solo síntoma (fiebre que no se quita) y el 1 % fiebre y hemorragia. 101 seroprevalencia en una zona de hiperendemia por dengue, barranquilla, colombia l rafael de jesús tuesca-molina y otros tabla 1. características de la población encuestada y conocimiento del dengue características frecuencia absoluta y relativa intervalo de confianza al 95 % edad en grupos < de 18 años 56(11,8 %) (8,7-14,7) 19 a 29 años 93 (19,5 %) (15,8-23,1) 30 a 49 años 155(32,6 %) (28,1-36,7) 50 a 69 años 144 (30,3 %) (25,9-34,3) > de 70 años 28 (5,9 %) (3,6-8,0) ocupación hogar 179(37,4 %) (33,0-41,8) estudia 82(17,2 %) (13,6-20,6) trabajador formal 154 (32,2 %) (27,9-36,5) trabajador informal 32 (6,7 %) (4,3-9,0) pensionado 10 (2,1 %) (0,7-3,4) desempleado 14 (2,9 %) (1,3-4,5) nr 7 (1,5 %) (0,2-2,6) etnia afrodescendiente 32(6,7 %) (4,3-9,0) palenquero 1(0,2 %) (0,005-1,16) raizal 1(0,2 %) (0,005-1,16) indígena 4 (0,8 %) (0,2-2,1) otro 433 (90,6 %) (87,8-93,3) nr 7 (1,5 %) (0,2-2,6) afiliación contributivo 267 (55,9 %) (51,3-60,4) subsidiado 176 (36,8 %) (32,3-41,2) especial 12 (2,5 %) (1,0-4,0) vinculado 16 (3,3 %) (1,6-5,0) nr 7 (1,5 %) (0,2-2,6) le han diagnosticado dengue en algún momento sí 40 (8,4 %) (5,7-10,9) no 406 (84,9 %) (81,6-88,2) no sabe 25 (5,25 %) (3,1-7,3) en caso (+) 35 (87,5 %) (73,1-95,8) hace más de 1 año < de 1 año 5 (12,5 %) (4,1-26,8) 102 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 características frecuencia absoluta y relativa intervalo de confianza al 95 % personas por vivienda mediana 4 (p25: 4-p75: 6) media y de 5,05 ± 2,43 moda 4 fiebre en las últimas tres semanas sí 24 (5,0 %) (2,9-7,0) no 447 (93,5 %) (91,2-95,8) nr 7 (1,5 %) (0,2-2,6) vacuna de fiebre amarilla sí 263 (55,8 %) (51,2-60,4) no 95 (20,2 %) (16,4-23,9) no recuerda 113 (24 %) (20,0-27,9) sabe si se transmite dengue en su barrio sí 198 (41,4 %) (36,9-45,9) no 235 (49,2 %) (44,5-53,7) nr 45 (9,4 %) (6,6-12,1) ha escuchado una enfermedad llamada dengue sí 395 (82,6 %) (79,1-86,1) no 38 (7,9 %) (5,4-10,4) nr 45 (9,4 %) (6,6-12,1) conoce signos y síntomas de dengue identifica fiebre y dolor 422 (88,3 %) (85,2-91,2) identifica correctamente 23 (4,8 %) (2,7-6,8) desconoce 31 (6,5 %) (4,1-8,7) principal forma de transmisión del dengue picadura (sí) 374 (78,2 %) (74,4-82,0) no sabe 21 (4,4 %) (2,4-6,3) respuesta errada 38 (7,9 %) (5,4-10,4) nr 45 (9,4 %) (6,6-12,1) acciones para prevenir identifica correctamente 4 (0,8 %) (0,2-2,1) no sabe 8 (1,6 %) (0,4-2,9) identifica algunas correctamente 22 (4,6 %) (2,6-6,5) 103 seroprevalencia en una zona de hiperendemia por dengue, barranquilla, colombia l rafael de jesús tuesca-molina y otros la seroprevalencia para igg positiva fue del 88,2 % (ic 95 %: 85,2-91,1) e igg negativa del 8,1 % (ic 95 %: 5,5-10,6), y el resto se clasificó en dudosa. con respecto a la infección reciente, 57 sujetos resultaron con igm positiva, que representan el 11,8 % (ic 95 %: 8,8-14,7), y dudosa en 48 sujetos 9,9 % (ic 95 %: 7,1-12,6). del total de la población, 258 mujeres fueron seroclasificadas de igg positivas, lo que representa el 93,1 % (ic 95 %: 89,9-96,2) (tabla 2). de acuerdo con el grupo de edad, 95,7 % (ic 95 %: 92,099,4) en el grupo de 50 a 69 años, seguido del grupo de 30 a 39 años, 95,5 % (ic 95 %: 91,9-99,0). mientras que para la infección reciente, la seropositividad para igm se detectó en el grupo etario más joven, menores de 18 años, 22,4 % (ic 95 %: 9,7-35,1), seguido del grupo de 19 a 29 años, 14,1 % (ic 95 %: 6,4 %-21,7) y, en menor proporción, los menores de 70 años, 11,1% (ic 95 %: 2,3-29,1). de los 18 que refirieron la presencia de fiebre en las últimas tres semanas antes de la encuesta/extracción de sangre, al 81 % (ic 95 %: 59,7-94,8) se les detectó positividad contra igg, mientras que en el 9,1 % (ic 95 %: 1,1-29,1) para igm. el 93 % de seroprevalencia para igg reside en la localidad de sur oriente, y el 92,3 % de seroprevalencia de igg en sur occidente que representan aproximadamente el 48 % de la muestra, mientras que para igm se detectó en el estrato alto (estratos 5 y 6 reagrupados), con el 38,5 %, que afecta preferencialmente la localidad de riomar, 28,6 % (ic 95 %: 13,7-43,4). al estimar factores asociados a haber tenido dengue (tabla 3) se observó asociación estadística en los grupos etarios a partir de los 30 años comparados con menores de 18. las estimaciones de interés corresponden a 30-49 años, or = 7,09 (ic 95 %: 2,60-19,30), y a los 50-69 años: or = 8,93 (ic 95 %: 2,95-27,0). al introducir la edad como variable continua se estimó un or = 1,04 (ic 95 %: 1,02-1,06); por cada año que se avance se incrementa la probabilidad de 1,04 de haber padecido dengue en algún momento de la vida. de igual manera, se encontró asociación estadísticamente significativa para quienes pertenecen al régimen subsidiado: estos presentan dos veces y media riesgo, comparado con el régimen contributivo, or = 2,56 (ic 95 %: 1,18-5,53), y se triplica para quienes se encuentran en el hogar, or = 3,38 (ic 95 %: 1,31-8,67). las variables sexo, localidad, estrato y número de convivientes no resultaron significativas. discusión este estudio identificó una seroprevalencia para dengue en el 88,2 % de la muestra, lo que significa una circulación de este virus en gran parte de la población. este hallazgo debe sugerir una serie de actuaciones por parte del sector salud que deben alertar sobre la probabilidad del incremento de la proporción de dengue grave, como aseguran algunos autores, debido a la exposición de características frecuencia absoluta y relativa intervalo de confianza al 95 % identifica síntomas para acudir a una institución de salud correctamente (todos) 2 (0,4 %) (0,05-1,5) fiebre que no se quita 48 (10,0 %) (7,2-12,8) fiebre + hemorragia 5 (1,0 %) (0,3-2,4) fiebre, hemorragia y dolor abdominal 2 (0,4 %) (0,05-1,5) no sabe 19 (4,0 %) (2,1-5,8) seroprevalencia ig g (positivo) 427 (88,2 %) (85,2-91,1) ig g (negativo) 39 (8,1 %) (5,5-10,6) ig g (dudoso) 18 (3,7 %) (1,9-5,5) ig m (positivo) 57 (11,8 %) (8,8-14,7) ig m (negativo) 379 (78,3 %) 74,5-82,0) ig m (dudoso) 48 (9,9 %) (7,1-12,6) fuente: elaboración propia. 104 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 tabla 2. seroprevalencia de anticuerpos igg e igm para el virus del dengue y algunos factores personales variable seroprevalencia de igg ( ic 95 %) seroprevalencia de igm (ic 95 %) sexo hombres 169 (87,6 %) [82,6-92,4] 23 (11,9 %) [7,0-16,7] mujeres 258 (93,1 %) [89,9-96,2] 34 (12,3 %) [8,2-16,3] edad (en años) < de 18 36 (73,5 %) [60,0-86,8] 11 (22,4 %) [9,7-35,1] 19 a 29 77 (83,7 %) [75,6-91,7] 13 (14,1 %) [6,4-21,7] 30 a 49 149 (95,5 %) [91,9-99,0] 16 (10,3 %) [5,1-15,3] 50 a 69 134 (95,7 %) [92,0-99,4] 14 (10,0 %) [4,6-15,3] > de 70 25 (92,6 %) [75,7-99,0] 3 (11,1 %) [2,3-29,1] fiebre en las últimas tres semanas (sí) 18 (81,8 %) [59,7-94,8] 2 (9,1 %) [1,12-29,1] estrato reagrupado bajo 254 (92,4 %) [88,6-96,0] 28 (10,2 %) [6,4-13,9] medio 145 (89,0 %) [83,8-94,0] 19 (11,7 %) [6,4-16.8] alto 22 (84,6 %) [65,1-95,6] 10 (38,5 %) [17,8-59,0] localidad sur oriente 106 (93,0 %) [87,8-98,1] 10 (8,8 %) [3,1-14,4] sur occidente 131 (92,3 %) [87,5 -97,0] 12 (8,5 %) [3,5-13,3] metropolitana 91 (91,9 %) [86,0-97,7] 14 (14,1 %) [6,7-21,5] centro histórico 54 (83,1 %) [73,1-92,9] 8 (12,3 %) [3,5-21,0] riomar 37 (88,1 %) [74,3-96,0] 12 (28,6 %) [13,7-43,4] tabla 3. factores de riesgo relacionados con ig g para dengue en barranquilla variables total positivos n % or (ic 95 %) sexo hombres 190 169 (88,9) 0,56 (0,29-1,08) mujeres 276 258 (93,4) ref estrato bajo 273 254 (93,0) 2,43 (0,76-7,77) medio 161 145 (90,0) 1,64 (0,50-5,38) alto 26 22 (84,6) ref fuente: elaboración propia. 105 seroprevalencia en una zona de hiperendemia por dengue, barranquilla, colombia l rafael de jesús tuesca-molina y otros serotipos previos y al hecho de la circulación de los 4 serotipos en la localidad (1, 4-7, 24, 25, 29, 35-37). con respecto a quienes padecieron fiebre tres semanas antes de la encuesta, un 83 % resultó positivo para las dos pruebas, con el 81,8 % de seropositividad para igg, por tanto, estos sujetos presumiblemente no fueron diagnosticados y, de estos, al 9 % se le informó que padecía actualmente de dengue. por ello esta presentación, que puede ser presumiblemente asintomática, o el hecho de no acudir a centros de salud, plantean riesgos para la circulación del dengue e impactan la carga de la enfermedad. a partir de estos hallazgos es variables total positivos n % or (ic 95 %) edad < 18 años 48 36 (75,0) ref 19-29 años 90 77 (85,5) 1,97 (0,82-4,75) 30-49 años 159 149 (97,7) 7,09 (2,60-19,30) 50-69 años 139 134 (96,4) 8,93 (2,95-27,0) > 70 años 27 25 (92,6) 4,16 (0,85-20,2) número de convivientes en casa 01-mar 102 93 (91,1) ref 04-jun 268 242 (90,2) 0,90 (0,40-1,99) 7y más 90 86 (95,5) 2,08 (0,61-7,00) régimen de salud contributivo 268 238 (88,8) ref subsidiado 192 183 (95,3) 2,56 (1,18-5,53) ocupación hogar 180 174 (96,6) 3,38 (1,31-8,67) estudios 74 61 (82,4) 0,57 (0,25-1,17) desempleado 14 13 (92,8) 1,51 (0,18-12,23) empleado 190 163 (85,7) ref localidad sur oriente 111 106 (95,4) 2,86 (0,78-10,4) sur occidente 142 131 (92,2) 1,60 (0,52-4,92) metropolitana 98 91 (92,8) 1,75 (0,52-5,88) norte ch 65 54 (83,0) 0,66 (0,21-2,06) riomar 42 37 (88,0) ref necesario reforzar mensajes en áreas endémicas para reconocimiento de signos y síntomas, diagnóstico oportuno y reducción de las barreras en la prestación de servicios de salud. de otra parte, la mayor probabilidad de padecer dengue en los sujetos del régimen subsidiado puede indicar que este hallazgo relaciona factores socioeconómicos y de estratificación social, entre ellos características de las viviendas, el entorno ambiental, y se identifica que quienes están en el hogar con mayor permanencia refieren mayor seroprevalencia dada la ecología de vida del mosquito (1, 35, 38-41). fuente: elaboración propia. 106 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 los resultados de seroprevalencia reflejan similitudes con los hallazgos en el norte de áfrica (2), managua (23), méxico (4, 34), recife (35), laos (31), trinidad (33), puerto rico (42) y colombia (38); no obstante, en otras latitudes, en entornos de clima tropical para el caso de brasil (36), se estimó una seroprevalencia más baja, 11,9 % (ic 95 %: 9, 7-14, 6) comparado con otras ciudades del mismo territorio para periodos de tiempo similares. este comportamiento es similar en sudán (37) y pakistán (29), en donde se presenta el mismo fenómeno de variación de la seroprevalencia que plantea interrogantes en la dinámica de transmisibilidad y difusión del dengue. con respecto a los grupos etarios, a medida que se avanza en edad se incrementa la seroprevalencia, lo que refleja una tendencia lineal (21, 30, 31, 36) que afecta preferencialmente a las mujeres (21, 23). estos hallazgos coinciden con el estudio realizado por restrepo (38) en el urabá antioqueño, donde la seroprevalencia para igg fue del 59,1 %, con prevalencias por encima del 50 % para los grupos etarios; se encontraron tasas de 88,9 % en mayores de 55 años y tasas más bajas en menores de 5 años. en centroamérica (43) se ha identificado que el dengue puede pasar desapercibido para el sujeto y para el equipo de salud por cursar de manera asintomática o por el carácter leve que no amerita la búsqueda de atención médica; sin embargo, esta estimación de seroprevalencia puede estar subestimada o se debe a una reacción cruzada con la vacuna de fiebre amarilla o por el antecedente de encefalitis en sus habitantes. la alta prevalencia influye en la sensibilidad del sistema de vigilancia epidemiológica; la pérdida de la percepción de gravedad, la circulación de eventos no graves y la circulación de distintos serotipos puede ser un fenómeno que favorezca la aparición de casos que adopten un comportamiento más agresivo o presentación de dengue hemorrágico (36). los hallazgos relacionados con la identificación de señales de riesgo, conocimiento de los signos y síntomas, y cuándo acudir a la consulta médica no difieren de los hallazgos reportados en el 2007 derivados de la encuesta nacional de salud para el país. en un estudio de bucaramanga, cáceres et al. (39) identifican hallazgos similares a los nuestros. fiebre y dolor son elementos trazadores para dengue, sin embargo el 6,5 % desconoce los signos y síntomas, lo que favorece la consulta médica inoportuna y la forma subclínica de presentación de esta entidad, lo que refleja un pobre conocimiento de la enfermedad y de las medidas de control. lo anterior lleva a reconocer como fundamental incentivar acciones que movilicen y motiven a la comunidad en mantener y mejorar sus conocimientos y llevarlos a la práctica. además, se requiere mejorar la participación comunitaria para lograr el empoderamiento y conseguir el éxito de las campañas de actuación frente al dengue (38). dado que a la fecha no existe un mecanismo de protección específico en el territorio, las acciones deben estar orientadas a cambios de conductas y comportamientos ecológicos socialmente aceptados que garanticen el control del dengue (22, 42, 43). al igual que en vietnam (21), la presencia de inservibles cercanos o próximos a las viviendas, así como recipientes plásticos u otros objetos receptores de agua influyen negativamente en las acciones de vigilancia si no se incorporan acciones sostenibles. es destacable el impacto de acciones educativas acerca del dengue en población escolar, pues favorece la adopción de prácticas saludables y cambios en la actitud y el conocimiento frente al virus (22). es fácil que la población identifique una simbiosis entre dengue y mosquito, y no posicione al virus en el proceso, especialmente al sujeto infectado que es susceptible de ser picado por el vector, y favorezca la persistencia de la enfermedad. en este mismo sentido, el estudio en westmoreland, jamaica (40), a pesar de identificar un adecuado conocimiento acerca del dengue en la comunidad, señala que este no se traduce en implementar actitudes preventivas, lo que sugiere que la autoridad sanitaria debe eliminar barreras y favorecer cambios en la conducta. asimismo, es interesante la experiencia de las escuelas de tapachula, en chiapas, méxico (44), en donde se entrenaron niños escolarizados para fomentar acciones contra el dengue, enfocadas a un cambio actitudinal sobre esta enfermedad en sus hogares. benítez-leite s. et al. (41) consideran que el “rociado con insecticidas para combatir los mosquitos adultos no ha sido efectivo, al contrario, ha dado una sensación de falsa seguridad”. esta situación observada en la comunidad de asunción-paraguay refleja similitudes con lo observado en nuestra región. se recomienda que “las campañas deben estar encaminadas a educar y estimular a individuos y familias a fin de que adopten acciones preventivas simples y económicas, tales como el uso de mosquiteros de cama tratados con insecticida y el uso de mallas de protección en las casas” (40). 107 seroprevalencia en una zona de hiperendemia por dengue, barranquilla, colombia l rafael de jesús tuesca-molina y otros conclusión es válido reconocer las intervenciones en programas y proyectos que ha desarrollado el ministerio de salud y protección social mediante la estrategia egi, lo que se traduce en que algunos territorios muestren una reducción en la incidencia de casos de dengue. sin embargo, el nivel de población por debajo de los 2.000 msnm, junto con la franja de población en situación de necesidades básicas insatisfecha plantea retos para la salud pública y la atención de salud. a partir de estas consideraciones se concluye que se requieren acciones educativas masivas para el público en general a través de medios tales como prensa, radio y televisión, que busquen hacer prioritario el reconocimiento de los signos y síntomas de alarma del dengue, y cuándo consultar, y concientizar al personal de salud, especialmente a los médicos, en la detección oportuna de los sujetos vulnerables: mujeres, adultos medios que no reconocen la enfermedad. estos hallazgos sugieren que se requiere fortalecer y mantener acciones para la atención oportuna de residentes en las localidades de sur oriente, sur occidente y metropolitana dadas sus condiciones de pobreza, vulnerabilidad y riesgo ambiental (41). en síntesis, los factores responsables de la transmisión endemo-epidémica (13) en aumento del dengue son complejos y están estrechamente asociados a la urbanización, a la que se suman cambios sociales y demográficos que crean las condiciones ideales para el incremento de la población de mosquitos, derivados del impacto de la globalización y la persistencia de la enfermedad. este estudio se convierte en una herramienta que permite estimar una línea base para la seroprevalencia del dengue y enfermedades conexas (chikungunya y zika). se enfatiza que las políticas de salud pública se han estructurado con el objetivo de responder a las epidemias, en vez de implementar acciones de saneamiento ambiental para reducir la población de mosquitos eliminando su hábitat o actuando sobre estadios inmaduros del vector, o transformar prácticas relacionadas con el cuidado del ambiente. por lo anterior, se requiere integrar actuaciones transectoriales frente al cambio climático de cara a los desafíos de las amenazas y los retos de la globalización. agradecimientos a todos los participantes que permitieron el desarrollo de la encuesta y la determinación de pruebas para dengue. a julio padilla rodríguez, referente nacional del programa de prevención y control de las enfermedades transmitidas por vectores del ministerio de salud. a claudia romero vivas y su equipo técnico, por el desarrollo de la determinación de igg e igm de panbio kit® en los laboratorios de la universidad del norte. agradecemos, igualmente, a la secretaría de salud distrital de barranquilla por el apoyo logístico y acompañamiento, al igual que la retroalimentación en el marco del proyecto, y a los laboratorios clínico y bacteriológico: olimpus y continental ltda. de barranquilla por facilitarnos el acceso a sujetos de estratos medio y alto de la ciudad. financiación: el presente artículo es producto de la investigación “fortalecimiento de la capacidad de respuesta técnicooperativa del programa de etv para prevenir y mitigar los efectos por cambio climático para municipios con alta carga endémica de dengue”, financiada por 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health. 2005;10(4):379-86. 22. wilder a, foo w, earnest a, sremulanathan s, paton ni. seroepidemiology of dengue in the adult population of singapore. trop med int health. 2004;9(2):305-8. 23. balmaseda a, hammond sn, tellez y, imhoff l, rodriguez y, saborio si, et al. high seroprevalence of antibodies against dengue virus in a prospective study of school children in managua, nicaragua. trop med int health. 2006;11(6):935-42. 24. ukey pm, bondade sa, paunipagar pv, powar rm, akulwar sl. study of seroprevalence of dengue fever in central india. indian j community med. 2010;35(4):517-19. 25. ang lw, cutter j, james l, goh kt. seroepidemiology of dengue virus infection in the adult population in tropical singapore. epidemiol infect. 2015;143:1585-593. 109 seroprevalencia en una zona de hiperendemia por dengue, barranquilla, colombia l rafael de jesús tuesca-molina y otros 26. alcaldía de barranquilla. secretaría distrital de salud pública. plan de salud territorial distrito de barranquilla análisis de situación de salud. disponible en: http://www.minsalud.gov.co/plandecenal/mapa/analisis-de-situacion-saludbarranquilla-2012-2015.pdf 27. ministerio de salud de colombia. resolución 8430 de octubre 4 de 1993. por la cual se establecen las normas científicas, técnicas y administrativas para la investigación en salud. bogotá: ministerio de salud; 1993 [visitado 2017 abr 25]. disponible en: https://www.minsalud.gov.co/sites/rid/lists/bibliotecadigital/ride/de/dij/resolucion8430-de-1993.pdf 28. sanchez c, hamer dh, chen lh, wilson me, benoit c, hunsperger e, et al. prevalence of dengue virus infection in us travelers who have lived in or traveled to dengue-endemic countries. journal of travel medicine. 2013;20(6):352-60. 29. padhi s, dash m, panda p, parida b, mohanty i, sahu s, et al. a three year retrospective study on the increasing trend in seroprevalence of dengue infection from southern odisha, india. indian j med res. 2014;140(5):660-4. 30. lo cl, yip sp, leung ph. seroprevalence of dengue in the general population of hong kong. trop med int health. 2012;18(9):1097-102. 31. peyerl g, schwöbel b, jordan s, vamisaveth v, phetsouvanh r, christophel em, et al. serological investigation of the prevalence of anti-dengue igm and igg antibodies in attapeu province, south laos. clin microbiol infect. 2004;10(2):181-4. 32. cuzzubbo aj, vaughn dw, nisalak a, solomon t, kalayanarooj s, aaskov j, et al. comparison of panbio dengue duo igm and igg capture elisa and venture technologies dengue igm and igg dot blot. j clin viro. 2000;16(2):135-44. 33. campbell ca, george a, salas ra, williams sa, doon r, chadee dd. seroprevalence of dengue in trinidad using rapid test kits: a cord blood survey. acta trop. 2007;101(2):153-58. 34. amaya iy, martínez ra, mayer s, galeana m, comas a, sepúlveda kj, et al. seroprevalence of neutralizing antibodies against dengue virus in two localities in the state of morelos, mexico. am j trop med hyg. 2014; 91(5):1057-65. 35. braga c, luna cf, turchi cm, vieira w, cordeiro mt, alexander n, et al. seroprevalence and risk factors for dengue in socioe-conomically distinct areas of recife, brazil. acta trop, 2010;113(3):234-40. 36. pessanha jem, caiaffa wt, de mattos mc, brandão st, proietti fa. diffusion pattern and hotspot detection of dengue in belo horizonte, minas gerais, brazil. j trop med. 2012;1-11. 37. himatt s, osman k, okoued si, seidahmed oe, beatty me, soghaier ma, et al. sero-prevalence of dengue infections in the kassala state in the eastern part of the sudan in 2011. j infec pub health. 2015;8(5):487-92. 38. restrepo b, arboleda m, lopera t. estudio seroepidemiológico de dengue en la región del urabá antioqueño, colombia. infectio. 2004;8(4):255-62. 39. cáceres f, vesga c, perea x, ruitort m, talbot y. conocimientos, actitudes y prácticas sobre dengue en dos barrios de bucaramanga, colombia. rev salud pública. 2009;11(1): 27-38. 40. shuaib f, todd d, campbell d, ehiri j, jolly pe. knowledge, attitudes and practices regarding dengue infection in westmoreland, jamaica. west indian med j. 2010;59(2):139-46. 41. benítez s, machi ml, gibert e, rivarola k. conocimientos, actitudes y prácticas acerca del dengue en un barrio de asunción. rev chil pediatr. 2002;73(1):64-72. 42. mohammed h, tomashek km, stramer sl, hunsperger e. prevalence of anti-dengue immunoglobulin g antibodies among american red cross blood donors in puerto rico, 2006. transfusion. 2012;52:1652-56. 43. espinoza f, hernández cm, rendón r, carrillo ml, flórez jc. transmisión interepidémica del dengue en la ciudad de colima, méxico. salud pública de méxico. 2003;45(5):365-70. 44. torres jl, ordoñez jg, vázquez mg. conocimientos, actitudes y prácticas sobre el dengue en las escuelas primarias de tapachula, chiapas, méxico. rev panam salud publica. 2014; 35(3):214-18. 230 239 uso de tecnologia leve-dura.indd 230 leidiane minervina moraes de sabino1 débora rabelo magalhães brasil2 joselany áfio caetano3 míria conceição lavinas santos4 maria dalva santos alves5 uso de tecnologia leve-dura nas práticas de enfermagem: análise de conceito 1 universidade federal do ceará. brasil. leidinhamoraes@hotmail.com 2 universidade federal do ceará. brasil. debbora_maggalhaes@hotmail.com 3 universidade federal do ceará. brasil. joselany@ufc.br 4 universidade federal do ceará. brasil. mlavinas@fortalnet.com.br 5 universidade federal do ceará. brasil. profdalvaalves@uol.com.br recibido: 12 de junio de 2014 enviado a pares: 26 de octubre de 2014 aceptado por pares: 26 de julio de 2015 aprobado: 16 de agosto de 2015 doi: 10.5294/aqui.2016.16.2.10 para citar este artículo / to reference this article / para citar este artigo moraes de sabino lm, tabelo maglhaes brasil d, afio caetano j, lavinas santos mc, santos alves md. uso de tecnologia leve-dura nas práticas de enfermagem: análise de conceito. aquichan. 2016; 16(2): 230-239. doi: 10.5294/aqui.2016.16.2.10 resumo objetivo: esclarecer o conceito de tecnologia leve-dura nas práticas de enfermagem. materiais e método: estudo reflexivo, com aplicação do método de análise conceitual de walker e avant, que utiliza os seguintes passos: seleção de um conceito, determinação dos objetivos da análise, dos atributos definidores, identificação de um caso modelo e contrário, e identificação dos antecedentes e das consequências. o estudo foi realizado a partir de busca nas bases de dados das produções científicas disponíveis em ambiente virtual, no período de abril e maio de 2014. resultados e discussão: inicialmente, o conceito de tecnologia estava relacionado ao de técnica; ao longo do tempo, sofreu mudanças e passou a se relacionar aos aspectos subjetivos e objetivos do cuidar. a tecnologia leve-dura ultrapassa os conhecimentos tecnológicos estruturados e apresenta grau de liberdade que proporciona aos profissionais inúmeras possibilidades de ações. o uso das tecnologias no cuidado da enfermagem é capaz de promover a saúde e intensificar o vínculo entre profissional e cliente. conclusão: o método de walker e avant possibilita delimitar os aspectos e a formação de um conceito a partir de atributos, antecedentes e consequentes, bem como analisar a utilização dos termos na prática. palavras-chave educação de pacientes como assunto, prospecto para educação de pacientes, educação em enfermagem, enfermagem, formação de conceito (fonte: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 230-239 231 uso de tecnologia leve-dura nas práticas de enfermagem: análise de conceito l leidiane minervina moraes de sabino e outros año 16 vol. 16 nº 2 chía, colombia junio 2016 l 230-239 uso de tecnología blanda-dura en las prácticas de enfermería: análisis de concepto resumen objetivo: establecer el concepto de tecnología blanda-dura en las prácticas de enfermería. materiales y métodos: estudio reflexivo, con aplicación del método de análisis conceptual de walker e avant, que utiliza los siguientes pasos: selección de un concepto; determinación de los objetivos de análisis, de los atributos definidores; identificación de un caso modelo y contrario, e identificación de los antecedentes y las consecuencias. el estudio se llevó a cabo desde la búsqueda en bases de datos de las producciones científicas disponibles en ambiente virtual, en el periodo de abril y mayo de 2014. resultados y discusión: inicialmente, el concepto de tecnología estaba relacionado al de técnica; con el del tiempo, sufrió cambios y pasó a relacionarse con los aspectos subjetivos y objetivos del cuidador. la tecnología blanda-dura sobrepasa los conocimientos tecnológicos estructurados y presenta libertad que les permite a los profesionales diversas posibilidades de acción. el uso de tecnologías en el cuidado de la enfermería es capaz de promover la salud e intensificar el vínculo entre profesional y cliente. conclusión: el método de walker e avant posibilita demarcar los aspectos y la formación de un concepto desde atributos, antecedentes y consecuentes, además de analizar la utilización de los términos en la práctica. palabras clave educación de pacientes como asunto, prospecto para educación de pacientes, educación en enfermería, enfermería, formación de concepto (fuente: decs, bireme). 232 aquichan issn 1657-5997 the use of soft-hard technology in nursing practice: concept analysis abstract objective: establish the concept of soft-hard technology in nursing practice. materials and methods: this is a reflective study. walker and avant’s concept analysis approach was applied, based on the following steps: selecting a concept, determining the purpose of the analysis, clarifying the defining attributes, constructing a model and contrary case, and identifying the antecedents and consequences of patient outcomes. the research was conducted through a search of databases for scientific productions available in the virtual environment during the period from april to may 2014. results and discussion: the concept of technology was related initially to what is technical. however, with time, it underwent changes and became related to the subjective and objective aspects of the caregiver. soft-hard technology goes beyond structured technological know-how and offers a degree of freedom that allows countless professionals a range of possibilities for action. the use of technology in nursing care is able to promote health and strengthen the link between the professional and client. conclusion: walker and avant’s approach to concept analysis makes it possible to define the aspects and formation of a concept based on attributes, antecedents and consequences of patient outcomes, in addition to analyzing the use of these terms in practice. keywords patient education as a subject, prospects for educating patients, nursing education, nursing, concept formation (source: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 230-239 233 uso de tecnologia leve-dura nas práticas de enfermagem: análise de conceito l leidiane minervina moraes de sabino e outros resultados alcançados com essa ação são importantes. pesquisas que empregaram tecnologias para construção do conhecimento lograram resultados positivos (8, 9). a enfermagem vem ganhando destaque na aplicação das tecnologias, com oportunidades de implementá-las e/ou desenvolvê-las para maior crescimento da profissão e benefícios da relação entre profissional e cliente (10). destaca-se que existem diversos estudos que utilizam o termo tecnologia, usado em múltiplos cenários. dessa forma, é importante que esse termo seja bem empregado com o intuito de evitar o seu uso de forma inadequada. dessa forma, ressalta-se a importância da realização de análises de conceito; nesse sentido, o método de walker e avant, empregado amplamente em pesquisas nacionais e internacionais, é um dos mais comuns utilizados na área da enfermagem (11, 12). assim, é importante elucidar o conceito de tecnologia para a profissão de enfermagem visto que, cada vez mais, esses profissionais estão fazendo uso de tecnologias educacionais para a prestação do cuidado. além disso, é considerável compreender adequadamente esse termo a fim de tornar a assistência de enfermagem mais científica e baseada em definições e conceitos consistentes. ante o exposto, objetivou-se realizar a análise de conceito de tecnologia leve-dura nas práticas de enfermagem, de acordo com o modelo de walker e avant (13). metodologia trata-se de um estudo reflexivo, realizado entre abril e maio de 2014, ao qual se aplicou o método de análise conceitual de walker e avant em busca da formação do conceito de uso de tecnologia leve-dura nas práticas de enfermagem. a análise de conceito é definida como uma busca pela compreensão de um termo e seus usos na prática, e deve diferenciar-se de outras palavras que possam estar relacionadas com a estudada (13). para analisar um conceito, é necessário redimensioná-lo para o contexto em que é utilizado com o propósito de refletir sobre a vivência da palavra (14). o modelo de walker e avant segue um percurso metodológico composto por oito passos, os quais estão apresentados na figura 1 (13). introdução entre as variadas transformações que vêm ocorrendo no mundo, pode-se citar o avanço tecnológico como processo que tem contribuído para facilitar e auxiliar as ações diárias das pessoas. as mudanças também ocorrem no campo da enfermagem, em que se podem utilizar as tecnologias em diferentes contextos, tanto assistencial quanto educacional (1). atualmente, é ampla a discussão sobre as tecnologias relacionadas ao setor saúde. dentre as práticas realizadas por enfermeiros, é comum a utilização de tecnologias, compreendidas em uma concepção de produto e processo. na tecnologia como produto, estão abordadas as informatizações, informações e artefatos; na tecnologia como processo, os recursos relacionados ao ensino e à aprendizagem do indivíduo (2). as tecnologias podem ser divididas em: leve —a constituição de relações para implementação do cuidado (vínculo, gestão de serviços e acolhimento)—; leve-dura —a construção do conhecimento por meio de saberes estruturados (teorias, modelos de cuidado, cuidado de enfermagem)— e dura —a utilização de instrumentos, normas e equipamentos tecnológicos— (3). as tecnologias leves são consideradas atributos da relação humana do cuidado, reconhecidas na área da enfermagem como o conjunto de relações que resumem o cuidar em si, cuja relação entre o profissional e o cliente acontece de forma direta, com conexão interpessoal, isto é, troca de aprendizado entre os envolvidos. assim, o acolhimento e a relação/interação são marcos definidores dessa tecnologia (4). a tecnologia leve-dura é compreendida como a utilização de conhecimentos estruturados, que não precisam de um recurso de alta tecnologia para realização, como massagens, banho de imersão e aromaterapia (5). a tecnologia dura é exemplificada pelo uso de alta tecnologia, como bombas de infusão, ventiladores mecânicos e demais maquinários que demandam grande tecnologia (6). além disso, também se classificam como tecnologia dura os softwares e vídeos (7). o enfermeiro, durante a assistência prestada, utiliza materiais educativos que são denominados tecnologia leve-dura, e os 234 año 16 vol. 16 nº 1 chía, colombia enero 2016 aquichan issn 1657-5997 nesta pesquisa, foram empregados os seguintes passos do método escolhido: seleção do conceito, determinação dos objetivos da análise, dos atributos definidores, identificação de um caso modelo e contrário, e identificação de antecedentes e consequentes, correspondentes aos passos 1, 2, 4, 5, 6 e 7. esses passos foram suficientes para atender ao objetivo deste estudo. para seleção de conceito, deve-se buscar um termo que esteja relacionado à vivência profissional. a determinação dos objetivos da análise é importante para que se possa realizar a pesquisa de forma direcionada (11). na presente pesquisa, intentou-se esclarecer o conceito de tecnologia leve-dura nas práticas de enfermagem fazendo com que as comparações errôneas fossem evitadas, e o significado exato, elucidado. ao estudar a tecnologia, é possível dividi-la em leve, leve-dura e dura, e é importante diferenciar cada uma com o intuito de traçar aspectos definidores e diferenciadores entre elas. na identificação dos possíveis usos do conceito, é fundamental a realização de pesquisa acerca do termo, de como é utilizado e aplicado. a determinação dos atributos críticos é realizada de acordo com os termos utilizados na literatura (11). quanto ao método, foi indicada a formação de antecedentes e consequências, em que foram vistas as ocorrências antes e após a elucidação do termo (11). estudos utilizaram o método de walker e avant, e obtiveram êxito na análise do conceito. dentre eles, pode-se citar a análise realizada sobre o conceito de contaminação (12) e a expressão cuidado transpessoal em enfermagem (15). para construção do estudo, foi realizada pesquisa nas bases de dados scientific eletronic library online (scielo), biblioteca virtual em saúde (bvs), medical literature analysis and retrievel system on-line (medline), por meio dos descritores em ciências da saúde (decs) “patient education as topic”, “patient education handout” e “education nursing”. buscaram-se os estudos relacionados à temática, os quais foram selecionados nos idiomas português, inglês e espanhol. durante a leitura dos artigos, buscou-se responder às perguntas: como o autor define o conceito? quais características ou atributos apontados? quais ideias os autores discutem sobre o conceito (antecedentes e consequentes)? por se tratar de estudo conceitual, não foi restringido o ano de publicação do artigo e considerou-se, sobretudo, a importância figura 1. diagrama do modelo de análise conceitual de walker e avant (2011) fonte: elaborado pelas autoras. 235 uso de tecnologia leve-dura nas práticas de enfermagem: análise de conceito l leidiane minervina moraes de sabino e outros da análise de publicações que abordassem a compreensão inicial de tecnologia. resultados e discussão atributos de acordo com walker e avant, os atributos correspondem à peça fundamental para o direcionamento da pesquisa. os atributos definidores permitem que o autor tenha um amplo discernimento do conceito visto que este pode se modificar ao longo do tempo ou de acordo com o ambiente em que é utilizado. dessa forma, é preciso julgar quais são os significados mais úteis e que proporcionarão maior ajuda a respeito dos objetivos da análise que está sendo realizada (13). existem vários conceitos para tecnologia, que pode ser entendida como um meio de habilidades e conhecimentos em saúde e está relacionada ao uso e à aplicação dos recursos e objetos (16). atualmente, são amplas as discussões acerca do uso das tecnologias no âmbito da saúde e é necessária elucidação teórica pela análise conceitual e atribuições na prática. assim, o conceito de tecnologia pode ser percebido como processo, isto é, formação e estrutura de materiais didático-pedagógicos, e, como produto, por meio da criação de artefatos e novas formações (17). a tecnologia é uma forma de conhecimento que se relaciona de maneira ética com outros instrumentos de trabalho da enfermagem; está relacionada a escolhas quanto ao uso, aos interesses a que atenderá, bem como aos meios para utilização e o fim almejado (18). ademais, é um artefato palpável, baseado no conhecimento científico, que busca benefícios para condição de saúde, além de objetivar a emancipação e a formação de conhecimento (2). a junção entre os saberes e os fazeres que estão relacionados aos produtos e materiais que definem uma terapêutica e um processo de trabalho pode se figurar como instrumento para realização de ações de produção da saúde e pode, também, ser classificada como tecnologia (19). a tecnologia em enfermagem compreende o conjunto de conhecimentos, sejam científicos, sejam empíricos sistematizados, os quais requerem a presença humana, que visa à qualidade de vida, representada pelo ato de cuidar, e considera questões éticas e processos reflexivos (18). é um processo que envolve diferentes dimensões, do qual resulta um produto, que pode ser um bem durável, uma teoria, um novo modo de fazer algo, em bens ou produtos simbólicos (20). os processos de cuidado em enfermagem são, em muitas situações, subjetivos e podem apresentar resultados não palpáveis. portanto, o uso de tecnologias para esse fim também pode apresentar tais características. desse modo, pode-se pensar nas tecnologias enquanto conceito abrangente que ultrapassa a simples utilização de máquinas; não é apenas considerada produto, mas também resultado de trabalho e de um conjunto de ações abstratas que possuem um objetivo: o cuidado em saúde (18). a tecnologia leve-dura ultrapassa a compreensão de conhecimentos tecnológicos estruturados e apresenta grau de liberdade que proporciona aos profissionais possibilidades de ações, de modo que o trabalho em saúde sempre será permeado de subjetividades, as quais são conferidas àqueles que interagem com pessoas (21). tecnologia leve-dura consiste em saberes estruturados, compostos tanto pelo conhecimento dos profissionais de saúde como pelas disciplinas características, como clínica e epidemiologia, que organizam o processo de trabalho (5). identificação do caso modelo e contrário nessas etapas, walker e avant propõem a apresentação de um caso modelo e contrário acerca do conceito estudado. destaca-se que os casos podem ser exemplos da vida real, achados na literatura ou construídos pelo pesquisador (13). • caso modelo: adriana, 56 anos, estava internada em um hospital e, durante o período que permaneceu no local, recebeu os cuidados de enfermagem por meio da sistematização da assistência de enfermagem (sae), o que conferiu ao enfermeiro maior compreensão acerca das necessidades da paciente e possibilidade da estruturação do cuidado. • caso contrário: júlia, 42 anos, chegou a uma unidade de saúde e buscou atendimento com a enfermeira. a profissional acolheu a paciente, buscou compreender o que a levou a buscar o atendimento e, por meio de uma conversa, possibilitou o aumento do vínculo entre profissional e paciente. 236 año 16 vol. 16 nº 1 chía, colombia enero 2016 aquichan issn 1657-5997 a partir da comparação entre os dois casos, é possível perceber que o cuidado de enfermagem mediado pela tecnologia levedura ultrapassa apenas a formação de vínculo e acolhimento. dessa forma, observa-se que a tecnologia leve-dura possibilita a prestação de um cuidado estruturado e voltado às necessidades do paciente. antecedentes segundo walker e avant, os antecedentes são compreendidos, assim como o nome já o define, como acontecimentos que ocorrem anteriormente à ocorrência do conceito, que compreendem fenômenos que precedem à utilização do conceito e sua compreensão dentro de um contexto (13). ao analisar o termo tecnologia, encontrou-se considerável relação com o conceito de técnica, com uma conexão no sentido do saber e fazer, cujos termos se aplicam na prática e estão conectados ao conceito de tecnologia surgido inicialmente (22). muitas vezes, o termo tecnologia é usado incorretamente na prática do profissional e está relacionado aos cuidados referentes à utilização de equipamentos de alta tecnologia ao se deixar de reconhecer a tecnologia do ponto de vista das relações entre as pessoas (10). estudar o enfermeiro utilizando tecnologias na prática é fundamental, uma vez que o profissional precisa continuar com o foco voltado para a humanização. assim, existem discussões acerca das dimensões objetivas e subjetivas da enfermagem durante o cuidado ao paciente. como dimensão objetiva, compreende-se a aplicação dos saberes estruturados e da manipulação das máquinas; como dimensão subjetiva, as formas de articulação do cuidar (17). com a interpretação das informações objetivas e subjetivas, pode-se inferir que as tecnologias dura e leve-dura relacionamse com a primeira, enquanto a tecnologia leve está direcionada para a segunda dimensão. ou seja, os saberes que devem ser estruturados e a utilização e a manipulação de máquinas requerem maior planejamento e conhecimento, cuja dimensão subjetiva relaciona-se com as tecnologias que se pautam no vínculo entre profissional e cliente. consequentes walker e avant defendem que os consequentes acontecem como resultado da ocorrência do conceito e são importantes para determinar ideias, variáveis ou relações que podem fornecer importantes direcionamentos para novas pesquisas (13). a utilização de tecnologia leve-dura nas práticas da enfermagem permite maior relação entre o profissional e o cliente, pois o enfermeiro poderá empregar a tecnologia para tentar esclarecer dúvidas e formar meios de enfrentamento ante alguma dificuldade manifestada. dessa forma, a comunicação acontecerá de forma mais direcionada e permitirá maior troca de informações entre os envolvidos (9). além disso, é possível perceber a importância e a eficácia da utilização dessa tecnologia no âmbito das atividades educativas realizadas por enfermeiros, em que se pode ter a mudança do conhecimento, da atitude e da prática ao aplicar esse tipo de tecnologia com grupo específico e objetivos delimitados (8). os avanços obtidos no âmbito da ciência e tecnologia revelaram modificações nas ações de cuidado, fundamental e essencial para o processo de trabalho, de forma que geraram melhorias na estrutura do funcionamento, o que favoreceu os processos de diagnóstico e cura (18). no quadro 1, está exposto os principais antecedentes, atributos e consequentes identificados a partir da pesquisa realizada. conclusão o método de walker e avant possibilitou delimitar os aspectos e a formação de um conceito, a partir de atributos, caso modelo e contrário e antecedentes e consequentes, bem como da análise da utilização dos termos na prática. assim, esse método foi considerado adequado para o alcance do objetivo proposto. a análise do conceito de tecnologia leve-dura permitiu uma maior aproximação com a temática, de forma a clarificar algumas ideias e suscitar indagações. percebeu-se que o uso do termo tecnologia vem sendo utilizado há muito tempo e pode ser empregado em diversos ambientes, além de poder ser usado no campo da enfermagem com o objetivo de melhorar o cuidado do profissional. 237 uso de tecnologia leve-dura nas práticas de enfermagem: análise de conceito l leidiane minervina moraes de sabino e outros portanto, faz-se necessário exemplificar os tipos de tecnologias utilizadas em enfermagem e aplicar as tecnologias leveduras nesse âmbito visto que os benefícios para relação entre profissional-cliente e construção de conhecimento do paciente são destacados como pontos positivos. assim, ressalta-se a importância da inserção do conceito abordado neste estudo dentro da pesquisa e da assistência de enfermagem, e espera-se que este texto possa contribuir para os estudos dos enfermeiros nos mais diversos ambientes de atuação. quadro 1. apresentação dos antecedentes, atributos e consequentes antecedentes dimensão subjetiva e objetiva do cuidado (17). o saber e o fazer do conceito de técnica (22). cuidados relacionados com máquinas (10). saberes estruturados, caracterizados pelas disciplinas que operam em saúde, a exemplo da clínica médica, odontológica, epidemiológica, entre outras (3). informatização, informação e artefato (2). atributos forma de conhecer que se relaciona de maneira ética, em conjunto com outros instrumentos de trabalho da enfermagem (18). processo, produto agente (22). saberes, habilidades, ações abstratas ou concretas que apresentam uma finalidade (20). habilidades e conhecimentos (16). consequentes tecnologia para melhorar a comunicação entre profissional e cliente (9). eficácia da utilização da tecnologia (8). modificações nas ações de cuidado, fundamento e essência do processo de trabalho, melhorias do funcionamento, o que favorece diagnóstico e cura (18). fonte: elaborado pelas autoras. a delimitação do conceito de tecnologia leve-dura, no contexto da enfermagem, auxilia o uso e a elaboração desta, na medida em que se compreendem a definição e as características primordiais, das quais as diferenciam das demais, o que possibilita desenvolvimento consciente de um instrumento com a classificação apropriada para uso. constatou-se, também, que muitos estudos utilizavam tecnologia leve-dura, mas não a classificavam dessa forma, empregavam expressões como tecnologia emancipatória para utilização desse tipo de tecnologia na prática. 238 año 16 vol. 16 nº 1 chía, colombia enero 2016 aquichan issn 1657-5997 referências 1. lopes em, pinheiro akb, pinheiro pnc, vieira nfc. technology and nursing practice — a bibliographical research. online braz j nurs. 2009 [acesso em 25 maio 2014]; 8(1). disponível em: http://www.objnursing.uff.br/index.php/nursing/ article/view/j.1676-4285.2009.1883. 2. aquino ps, melo rp, lopes mvo, pinheiro akb. análise do conceito de 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isis moura sueiro1 liliane faria silva2 fernanda garcia bezerra goes3 juliana rezende montenegro medeiros moraes4 a enfermagem ante os desafi os enfrentados pela família na alimentação de criança em quimioterapia 1 enfermeira. universidade federal fluminense. brasil. isis.sueiro@gmail.com 2 doutora em enfermagem. universidade federal fluminense. brasil. lili.05@hotmail.com 3 doutora em enfermagem. instituto de puericultura e pediatria martagão gesteira. brasil. ferbezerra@gmail.com 4 doutora em enfermagem. escola de enfermagem anna nery. brasil. jumoraes@ig.com.br recibido: 27 de abril de 2014 enviado a evaluadores: 28 de abril de 2014 aceptado por evaluadores: 24 de agosto de 2015 aprobado: 07 de septiembre de 2015 doi: 10.5294/aqui.2015.15.4.6 para citar este artículo / to reference this article / para citar este artigo sueiro im. silva lf. goes fgb. moraes jmrm. a enfermagem ante os desafios enfrentados pela família na alimentação de criança em quimioterapia. aquichan. 2015; 15 (4): 508-520. doi: 10.5294/aqui.2015.15.4.6 resumo objetivos: identificar os desafios enfrentados pela família na alimentação da criança em quimioterapia antineoplásica e descrever as estratégias utilizadas pela família para superação dos desafios e as possibilidades de atuação da enfermagem. método: pesquisa qualitativa descritiva, realizada em maio de 2013, por meio de entrevista semiestruturada com 12 familiares de crianças em tratamento quimioterápico, internados na enfermaria de um hospital público pediátrico do rio de janeiro. os dados foram submetidos à análise temática. resultados: dentre os desafios enfrentados pelas famílias na alimentação da criança em quimioterapia, estão os efeitos adversos das medicações no sistema gastrintestinal e a adaptação às mudanças alimentares em casa e no hospital. as estratégias utilizadas por eles para superação desses desafios são perguntar e oferecer o que a criança gosta e deixar a refeição mais atrativa. dentre as principais formas de atuação da enfermagem destacadas pelos familiares, encontram-se a orientação e o apoio à família e à criança. conclusão: que é importante a realização de cuidados de enfermagem para minimizar os danos resultantes do processo do adoecimento e do tratamento. palavras-chave enfermagem pediátrica, quimioterapia, neoplasias, alimentação, saúde da criança (fonte: decs, bireme). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 508-520 509 a enfermagem ante os desafios enfrentados pela família na alimentação de criança em quimioterapia l isis moura sueiro, e outros año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 508-520 la enfermería ante los retos afrontados por la familia en la alimentación de niños en quimioterapia resumen objetivos: identificar los retos afrontados por la familia en la alimentación de niños en quimioterapia antineoplásica y describir las estrategias empleadas para superar los retos y las posibilidades de actuación en enfermería. método: investigación cualitativa descriptiva realizada en mayo de 2013 por medio de entrevistas semiestructuradas con 12 familiares de niños en tratamiento quimioterápico internados en la enfermería de un hospital público pediátrico de río de janeiro (brasil). los dados se sometieron a análisis temático. resultados: a partir del proceso de análisis de los datos, se encontró que, dentro de los retos afrontados por las familias en la alimentación de niños en quimioterapia, están los efectos adversos de los medicamentos en el sistema gastrointestinal y la adaptación a los cambios alimenticios en la casa y el hospital. las estrategias empleadas por ellos para superar tales retos son preguntar y ofrecerle lo que le gusta al niño y dejar la comida más atractiva. las principales formas de actuación de la enfermería destacadas por los familiares son la orientación y el apoyo a la familia y al niño. conclusiones: es importante la realización de cuidados de enfermería para minimizar los daños resultantes del proceso de enfermedad y del tratamiento. palabras clave enfermería pediátrica, quimioterapia, neoplasias, alimentación, salud del niño (fuente: decs, bireme). 510 aquichan issn 1657-5997 nursing in response to the challenges faced by the family in feeding children in chemotherapy abstract objectives: identify the challenges families face in feeding children with cancer who are undergoing chemotherapy, and describe the strategies used to overcome those challenges and the possibilities for action with respect to nursing care. method: this is a descriptive qualitative study conducted in may 2013 through semi-structured interviews with 12 relatives of children in chemotherapy who were hospitalized at a public pediatric facility in rio de janeiro (brazil). thematic analysis was used to process the data. results: the analysis showed the adverse effects of drugs on gastrointestinal system and adapting to dietary changes at home and in the hospital are some of the challenges families face in feeding children who are undergoing chemotherapy. the strategies they use to overcome those challenges include asking and offering foods the child likes and making food more attractive. counseling and support for the family and the child are the primary aspects of nursing care emphasized by the families. conclusions: it is important to conduct nursing care in a way that minimizes the damage resulting from the disease and its treatment. descriptors pediatric nursing, chemotherapy, neoplasias, food, health of the child (source: decs, birime). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 508-520 511 a enfermagem ante os desafios enfrentados pela família na alimentação de criança em quimioterapia l isis moura sueiro, e outros introdução câncer é o nome dado a um conjunto de mais de 100 doenças que têm em comum o crescimento desordenado de células que invadem tecidos e órgãos. dividindo-se rapidamente, essas células podem ser muito agressivas e incontroláveis, e causar a formação de tumores malignos, os quais podem espalhar-se para outras regiões do corpo (1). as modalidades de tratamento do câncer são divididas em: cirurgia, radioterapia e tratamento clínico; este engloba quimioterapia, hormonioterapia, imunoterapia e uso de bloqueadores enzimáticos (1). a quimioterapia é uma modalidade de tratamento sistêmico na qual os agentes antineoplásicos são tóxicos a qualquer tecido de rápida proliferação, normais ou cancerosos. nesse sentido, tem-se como consequência o aparecimento de inúmeros efeitos colaterais que alteram a qualidade de vida do paciente e levam à mudança de alguns hábitos de vida em sua rotina (1, 2). entre os hábitos de vida, o alimentar foi foco desta pesquisa, pois a alimentação é um hábito relacionado com a cultura de cada indivíduo e é construída desde os primeiros anos de vida; portanto, é relevante que a equipe de enfermagem esteja preparada para atuar ante as mudanças nos hábitos alimentares decorrentes da quimioterapia. a aceitação dos alimentos pelas crianças em tratamento quimioterápico é fortemente diminuída em decorrência dos vômitos e das alterações do paladar; além disso, é frequente a perda de apetite, de peso, náusea, vômitos e inflamação da mucosa oral (2). além dos efeitos colaterais no sistema gastrointestinal, o preparo de alimentos para as crianças em tratamento do câncer requer cuidados para evitar as infecções que podem ocorrer decorrente da neutropenia, que significa a redução dos neutrófilos, e predispõe o organismo a infecções (1, 2). por conta disso, destaca-se a importância da implantação de ações educativas com objetivo de alertar as famílias sobre a importância da higiene no momento do preparo dos alimentos, assim como outros aspectos direcionados aos cuidados com a alimentação. frise-se que as práticas alimentares estão na origem de todos os hábitos de vida, independentemente das crenças dos indivíduos. assim, constitui um erro abordá-las e propor possíveis modificações sem a compreensão do significado dessas práticas para as pessoas envolvidas (3). nesse sentido, faz-se necessário que o enfermeiro, como membro integrante da equipe multiprofissional de saúde, conheça os desafios e as estratégias utilizadas pela família para alimentação da criança em tratamento quimioterápico. com isso, poderá elaborar um plano de cuidados que vise a uma assistência mais qualificada, a qual resulte em uma melhor qualidade de vida tanto da criança quanto da família. além disso, percebe-se que essa temática é citada na literatura, mas é pouco explorada em estudos da enfermagem, como se evidencia em uma revisão integrativa de literatura sobre cuidados de enfermagem à criança com câncer, na qual destacou que, entre as atribuições do enfermeiro, está a melhora do estado nutricional da criança (4). no entanto, sem avançar para inclusão da família nesse cuidado nem identificar os desafios enfrentados por ela e as estratégias para sua superação. tais informações são valiosas para a discussão acerca da atuação da enfermagem junto à criança em quimioterapia e sua família da criança. embora seja amplamente reconhecido que a quimioterapia afeta a alimentação da criança, decorrente de suas complicações gastrointestinais, que incluem náuseas, vômitos, mucosite, diarreia, alterações no paladar e anorexia, na maioria dos centros pediátricos para tratamento do câncer não há uma abordagem consistente dos aspectos relacionados com o estado nutricional da criança (5). na condução deste estudo, foram utilizados os preceitos teóricos de collière (3), que em suas obras abordou a evolução das práticas de cuidados e suas diferentes naturezas mediante as mudanças sócio-históricas da humanidade. essa teórica distingue dois tipos de cuidados com naturezas diferentes: 1) os cuidados cotidianos e habituais, que asseguram a continuidade da vida, que são relacionados com alimentação, hidratação, eliminação, aquecimento, energia, deslocamento, bem como com a necessidade de afeto e 2) os cuidados de reparação ou tratamento da doença, que visam limitá-la. cuidar é, portanto, manter a vida e garantir a satisfação de um conjunto de necessidades indispensáveis para viver. ainda de acordo com essa autora, é essencial que a primeira fonte de 512 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 conhecimento para a prestação qualificada dos cuidados de enfermagem seja a pessoa ou grupo que vivenciam o problema, por isso é fundamental incluir a família na dinâmica do cuidado à criança (3). com base no exposto, esta pesquisa teve como objetivos: identificar os desafios enfrentados pela família na alimentação da criança em quimioterapia antineoplásica e descrever as estratégias utilizadas pela família para superação dos desafios, além das possibilidades de atuação da enfermagem. materiais e métodos trata-se de uma pesquisa qualitativa descritiva (6). o cenário foi o ambulatório de um hospital público localizado no estado do rio de janeiro (brasil), que atende crianças com doença oncológica em tratamento quimioterápico. os participantes foram 12 familiares de crianças em tratamento quimioterápico antineoplásico. a saturação dos dados foi evidenciada quando os participantes, em suas falas, apresentaram recorrência de ideias, práticas e visões de mundo, sobre os desafios e estratégias da família para alimentação da criança em quimioterapia antineoplásica (7). os critérios para inclusão dos participantes foram: ser familiar de criança que tivesse terminado o primeiro ciclo de quimioterapia ou mais, pois os efeitos colaterais surgem já nas primeiras aplicações, e ter idade maior ou igual a 18 anos. os critérios para exclusão foram: familiares acompanhantes de crianças que estavam se sentindo mal no período da coleta de dados e necessitavam da atenção em tempo integral do familiar. destacase que as crianças que eles estavam acompanhando tinham idade entre 2 e 11 anos. a coleta de dados se deu em maio de 2013 por meio de uma entrevista semiestruturada. foi utilizado um roteiro de entrevista, em que constavam perguntas abertas e fechadas. as perguntas fechadas foram cruciais para a identificação dos participantes. as perguntas abertas versavam sobre a alimentação das crianças em tratamento quimioterápico e permitiram que os familiares se posicionassem acerca da temática de estudo. a pesquisa foi aprovada pelo comitê de ética e pesquisa da instituição onde foi realizada (caae: 12438213.9.0000.5264/parecer: 246.959), e respeitaram-se todos os aspectos contidos na resolução 466/2012 do conselho nacional de saúde do brasil. nesse sentido, após autorização do comitê de ética, foi realizado contato com os familiares. inicialmente, a pesquisadora apresentou-se e falou sobre a pesquisa destacando seus objetivos, assim como os aspectos contidos no termo de consentimento livre e esclarecido (tcle). posteriormente, foi feito convite para os familiares atuarem como participantes voluntários da pesquisa. o aceite foi formalizado com a assinatura do tcle. o anonimato dos participantes foi mantido durante todo o tempo; assim, para identificá-los, foi utilizada a letra f para os familiares, seguida da ordem numérica sequencial das entrevistas. as falas dos entrevistados foram transcritas na íntegra e a análise dos dados foi realizada seguindo as três fases da análise de temática (6): 1) pré-análise, quando realizamos a leitura flutuante para conhecer o conteúdo do material empírico gerado pelas entrevistas e nos deixamos invadir por impressões e orientações; 2) fase de exploração do material, quando a partir de leituras exaustivas, os dados brutos foram transformados em unidades que representavam significados e depois agregados nas categorias preestabelecidas que responderam aos objetivos da pesquisa; 3) fase de tratamento e interpretação dos resultados, quando foi possível fazer inferências à luz da literatura científica sobre orientações de alimentação aos familiares de crianças em tratamento quimioterápico. resultados com o processo de análise dos dados, emergiram as seguintes unidades temáticas: desafios enfrentados pelas famílias na alimentação da criança em quimioterapia; estratégias utilizadas pelas famílias para melhorar a alimentação da criança em tratamento quimioterápico; atuação da enfermagem ante os desafios enfrentados pela família na alimentação da criança em quimioterapia. desafios enfrentados pelas famílias na alimentação da criança em quimioterapia ao falar dos desafios enfrentados na alimentação da criança em tratamento quimioterápico, os familiares apontaram os decorrentes das reações adversas do sistema gastrintestinal, como enjoos, náuseas, vômitos, constipação e mucosite: ah, ela ficou enjoada [...] a criança quando faz a quimioterapia fica enjoada, nauseada, com muito vômito, não quer comer nada, não consegue comer direito. o ruim é isso! [...] evacuar é difícil, 513 a enfermagem ante os desafios enfrentados pela família na alimentação de criança em quimioterapia l isis moura sueiro, e outros entendeu? ela ficou constipada uns três meses, porque a quimioterapia prendeu o intestino dela (f3). o problema é quando ele está com a boquinha machucada (mucosite) porque não consegue comer (f12). além dos efeitos do sistema gastrintestinal, os familiares destacaram a neutropenia, que é um efeito adverso hematológico, como modificador do hábito alimentar da criança: tem que ser tudo limpinho, lavado e bem cozido. quando está neutropênica não pode comer nada cru. ela gosta de coisa crua, aí quando fica neutropênica, não come nada [...] fruta nenhuma, porque não gostava de nada cozido (f3). outro aspecto apontado pelo familiar foi a adaptação da criança e família à mudança alimentar. ao falarem a respeito da adaptação da criança, foi exposta a dificuldade na impossibilidade de oferecer à criança o que ela gosta e deseja no momento: a gente não pode dar o que ela gosta: hambúrguer, doce, salgadinho, essas coisas... às vezes tem restrições e aquilo que ela quer não pode dar e ela fala: “então, não vou comer”. aí, se forçar, ela bota pra fora, então a gente nem força (f9). outros relatos evidenciaram dificuldades por parte dos familiares na adaptação à mudança alimentar durante o tratamento da criança, pois essas pessoas também se restringiram à alimentação dos filhos: o desafio maior é ficar restrito à alimentação dela [...] a gente não compra fritura, salgadinhos e alimentação de rua. essas coisas a gente não dá e pelo fato dela [sic] ter outros irmãos até menores é bem complicado! porque acaba que todo mundo tem que entrar nesse ritmo, porque, se os irmãos comerem, ela quer comer (f6). nas respostas dos familiares, entres os desafios apontados, houve destaque para a alimentação da criança durante a hospitalização: ela não gosta de comer a comida do hospital; quando ela está internada, ela não come muito. eu acho que deveriam selecionar realmente aquilo que as crianças gostam de comer. porque não pode trazer comida da rua, mas a gente acaba trazendo. a gente traz meio que escondido que é para ela comer, entendeu? (f6). o mais difícil é quando ele fica internado, porque tem que comer a comida do hospital. a gente não pode escolher o que vai dar, tem que se limitar ao que o hospital te oferece (f10). estratégias utilizadas pelas famílias para melhorar a alimentação da criança em tratamento quimioterápico ao serem perguntados sobre as estratégias que utilizam para melhorar a alimentação da criança em tratamento quimioterápico, os familiares apontaram: perguntar o que a criança quer comer e fazer o que ela mais gosta; deixar a comida mais interessante e atrativa; oferecer algo em troca e dar os alimentos escondidos. a estratégia relacionada a perguntar sobre a preferência alimentar da criança fica evidenciado nas falas abaixo: a estratégia que a gente usa é chegar e perguntar o que ela quer comer, para facilitar. a melhor estratégia é essa, não adianta forçar nada (f1). ah, eu sempre faço o que ela gosta. às vezes, ela não quer uma comida, eu pergunto o que ela quer e faço para ela comer direito (f4). também foi apontado pelos familiares, como estratégia, elaborar algo que deixe a comida mais interessante e atrativa: eu tento de tudo. faço o que ela gosta, faço carinha na comida. tento fazer de tudo por ela, enfrento tudo por ela (f3). eu tento fazer assim: coisas coloridas, legumes coloridos, cozinhar vários legumes. tento fazer com que ela se interesse pela comida (f9). quando ele não quer comer, a gente começa a brincar, diz que vamos dar alguma coisa se ele comer (f12). outras estratégias citadas foram: a barganha, ou seja, oferecer coisas em troca para a criança se alimentar e oferecer alimentos escondidos durante as refeições: a estratégia que a gente usa para melhorar a alimentação é oferecer outras coisas em troca, a gente sabe que é errado e não é indicado, mas é o que a gente costuma fazer pra que ela possa se alimentar melhor (f6). às vezes eu dou as coisas escondido. pego um espinafre, uma couve e feijão, inhame e bato tudo no liquidificador. tudo isso tem que dar escondido se não ele não come (f8). 514 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 com o passar do tempo de tratamento e as vivências do dia a dia no cuidado da criança em quimioterapia, os familiares adquirem experiência e passam a usá-la a favor da melhora alimentar da criança: a gente sempre procura substituir, tem certas coisas que ele aceita melhor. ele teve aftas na boca e coisas duras que ele não conseguia comer, então a gente foi substituindo. com o tempo, a gente vai adquirindo certa experiência, então as coisas tornam mais fáceis (f10). atuação da enfermagem ante os desafios enfrentados pela família na alimentação da criança em quimioterapia entre as possibilidades de atuação da enfermagem ante os desafios que a família enfrenta na alimentação da criança em quimioterapia, houve destaque para as orientações voltadas aos familiares das crianças: a enfermagem pode ajudar aconselhando e orientando os pais. assim, os pais vão ter uma visão de como proceder dentro de casa (f1). eu acho importante ter orientações, para ver qual é o melhor alimento para criança comer, porque a gente às vezes dá alguma coisa que não pode [...] falar o que pode e o que não pode comer é muito importante (f2). a enfermagem pode ensinar o que você pode fazer. por exemplo, quando está com afta pode falar: “ah, mãe, lava a boca com isso, faz assim que é melhor”. também falar sobre os efeitos da medicação, falar “oh, pode acontecer isso”, te prevenir do que pode acontecer e te auxiliar caso aconteça (f10). como foi visto, é importante para a família ser orientada sobre os efeitos colaterais dos quimioterápicos. assim, os familiares poderão identificá-los para atuarem da melhor forma possível para o bem-estar da criança. além das orientações dadas à família, também se faz relevante as orientações voltadas à criança: acho que pode ajudar dando conselho para ele [criança], orientando, dizendo o que tem que comer, o que precisa comer e o que não pode comer. porque às vezes ele acha que a mãe que é chata, que está pegando no pé, ai tem que ter alguém para orientar ele (f5). também foram citadas como forma de atuação da enfermagem a elaboração de formulários e as listas com os cuidados necessários na alimentação das crianças: seria muito legal montar um formulário com orientações para que logo no começo a família já ficar sabendo o que tem que fazer e como tem que fazer (f1). seria bom dar um papelzinho com uma lista de tudo que a criança pode comer e o que não pode (f3). discussão os familiares apontam que muitos efeitos adversos do sistema gastrintestinal estão presentes no cotidiano da criança com câncer em tratamento quimioterápico. em oncologia, episódios de náuseas e vômitos são efeitos colaterais associados à terapia antineoplásica bastante frequentes, e é um desafio preveni-las (2, 5). tais manifestações levam à mudança de hábitos alimentares e de problemas nutricionais à criança, como desnutrição, que, por sua vez, aumenta o risco de infecção, diminui a tolerância ao tratamento, afeta qualidade de vida da criança (5). também foi apontado como fator relacionado com prejuízos na alimentação a mucosite, que é conhecida como uma inflamação da mucosa bucal induzida pela toxicidade sistêmica ocasionada pela quimioterapia antineoplásica. sua presença reduz a qualidade de vida e o estado nutricional do paciente, o que leva ao aumento do seu grau de morbidade e interfere no tratamento oncológico. medidas educativas por parte da enfermagem, relativas ao cuidado diário da criança, como o uso de vaselina para proteção labial, orientação para evitar alimentos picantes e manutenção de higiene bucal diária com uso de escova de dente com cerdas macias ajudam a prevenir e a reduzir os efeitos indesejáveis da mucosite. a criança com mucosite oral pode ser beneficiada de tratamento com aplicação de laser na mucosa oral pelos odontólogos. tal terapia promove analgesia e tem efeito anti-inflamatório nos tecidos bucais. assim, permite ao paciente continuar o tratamento quimioterápico ou radioterápico sem interrupções decorrentes da mucosite e com maior qualidade de vida (8). outro aspecto mencionado foi a neutropenia. com a possibilidade dessa situação, os familiares começaram a ter cuidados diferenciados com a alimentação da criança, como maior higiene 515 a enfermagem ante os desafios enfrentados pela família na alimentação de criança em quimioterapia l isis moura sueiro, e outros e a proibição da ingesta de alimentos crus. a preocupação com a neutropenia é entendida pelo fato de ser um evento adverso da quimioterapia antineoplásica, que aumenta a morbidade e a mortalidade e interfere diretamente no limite da dosagem do quimioterápico (1, 2). a proibição de alimentos crus foi apontada como desafio, pois a maioria das crianças tinha o hábito de comer frutas cruas. frise-se que medidas extremas são realizadas em pacientes neutropênicos, como não comer legumes e frutas que não estejam bem cozidas, pelo fato de esses pacientes estarem muito propensos a infecções. além disso, é importante que o alimento seja de boa qualidade, que seja consumido à temperatura ambiente, ou seja, não muito quente nem muito frio, e que seja preferencialmente de consistência macia (9). durante muito tempo, acreditou-se que esses cuidados eram indispensáveis, pois poderiam reduzir o risco de infecção na criança; entretanto, atualmente, não há consenso sobre a proibição na ingestão de alimentos crus em caso de neutropenia (2). os argumentos pela não realização dessa dieta são pautadas em investigação científica insuficiente, no alto custo dessas dietas e no aumento da restrição alimentar que elas causam. os argumentos pela manutenção estão centrados na prudência e na cautela de só oferecer alimentos cozidos por acreditar que possuem baixa microbiana e no fato de ela ser praticada há cerca de 30 anos, apesar da falta de evidência clínica atual. existe tendência internacional em não manter restrições alimentares severas para pacientes neutropênicos; contudo, no brasil, ainda existem diferenças entre os profissionais a respeito de quais alimentos são permitidos, principalmente durante o período crítico de baixa imunidade (10). quanto às adaptações nas mudanças alimentares, seja em casa seja no hospital, foi visto que a negação por parte da família de um pedido alimentar da criança é uma tarefa difícil. observamos que as crianças possuem seus gostos e preferências; no entanto, com o tratamento antineoplásico, algumas dessas preferências precisam ser excluídas da dieta durante algum tempo. o hábito de consumir guloseimas como balas, chocolates, biscoitos, sorvetes, salgadinhos, refrigerantes, hambúrgueres e frituras é cada vez mais frequente entre as crianças brasileiras. quando o consumo desse tipo de alimento pela criança é proibido, gera revolta, irritação, muitas vezes recusa a comer outros alimentos, isso causa transtornos tanto para criança quanto para família (11). o hábito alimentar das crianças sofre uma influência de diversos fatores, nos quais se destacam a influência dos pais, da escola e da mídia (12). dessa forma, a transição dos antigos hábitos para novos requer cuidado, conversa e ajuda, para que a criança possa se adaptar à sua nova dieta, que algumas vezes pode restringir o que ela mais gosta. segundo collière (3), a modificação de hábitos cotidianos e habituais, como as práticas alimentares, não pode acontecer mediante a imposição de novos conhecimentos, oriundos de todo o processo científico, pois isso pode perturbar as crenças anteriores, o que gera desconfiança e insegurança. assim, o profissional de enfermagem precisa orientar e trocar informações com a criança para assim auxiliar essa modificação alimentar. além das orientações junto à criança, os profissionais devem reconhecer que o papel da família está estreitamente relacionado com a necessidade de reeducação alimentar do paciente portador de doença crônica. as restrições alimentares constituem fatores de impacto para o portador; portanto, a orientação familiar no processo de enfrentamento dessas mudanças emerge como um dos determinantes favoráveis para o sucesso do tratamento (14). quando o familiar não muda seus hábitos alimentares juntamente com a criança, prejudica sua adaptação à doença e contribui para a não adesão do plano terapêutico. assim, entende-se a mudança de hábitos alimentares como um cuidado de manutenção da vida e como uma mudança na rotina não só da criança, mas também da família (3, 14). percebemos que a hospitalização representa uma nova realidade na vida da criança, na qual seus hábitos, rotinas e costumes também são modificados. em casa, a criança é acostumada com um tipo de alimentação e a ter seus desejos e vontades muitas vezes atendidos por aqueles que cuidam dela, o que não acontece no ambiente hospitalar. nesse contexto, entre os desafios que a família enfrenta, estão as limitações que o hospital impõe e a alimentação é uma delas (15). quanto aos resultados relacionados com os desafios enfrentados na alimentação das crianças em quimioterapia, foi evidenciado, pelos depoimentos dos familiares, que elas não gostam da comida do hospital e, por isso, a recusam. nesse sentido, a hospitalização é configurada como uma experiência perturbadora, já que distancia a criança da vida cotidiana, de seus hábitos de descanso, 516 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 lazer, higiene e alimentação, amigos e família. isso pode fazer com que rejeite tudo que o ambiente hospitalar oferece (16). a dieta hospitalar é importante para garantir o aporte de nutrientes, por isso merecem consideração já que a aceitação alimentar e o estado nutricional estão ligados à resposta da criança ao tratamento (5). assim, justifica-se a importância dada pelos familiares diante da dificuldade da alimentação dentro do hospital. diante do exposto, verifica-se que o tratamento quimioterápico em crianças transforma os hábitos cotidianos e habituais desses pequenos no que tange à sua alimentação e, consequentemente, novas dificuldades surgem aos seus familiares para que estes possam manter suas práticas cuidativas. no surgimento das dificuldades enfrentadas pelas famílias, os membros da equipe multiprofissional precisam manter interações com os familiares, pois eles se sentem ansiosos para falar e discutir questões relativas ao apetite ou perda de peso das crianças. além disso, ao manter o diálogo mais próximo, é possível a identificação precoce de fatores de risco, ou mesmo dos primeiros sinais de desnutrição. nesse sentido, é importante acompanhamento nutricional mensal para obtenção do peso, altura e índice de massa corpórea (imc), e o planejamento dos cuidados e intervenções necessárias com os membros da equipe multiprofissional (5). com relação às possíveis estratégias para melhorar a alimentação da criança, foi visto que, durante a quimioterapia, ela se desinteressa pela comida. ante essa situação, deixá-la comer sempre que tiver fome e que consuma o que gosta, além de perguntar o que deseja, levando em conta as restrições e as orientações feitas pelos profissionais da saúde, são formas de melhorar a aceitação alimentar (17). contudo, havendo flexibilidade e respeito, insistências leves para que ela coma aquilo que é recusado, sem que haja imposições, e verbalizações encorajadoras realizadas pelos familiares também são importantes durante as refeições (18). diante da necessidade de melhorar a aceitação alimentar, distrair a criança com atividades divertidas que evitem a monotonia durante a alimentação, variar o cardápio com alimentos de diferentes consistências, texturas, sabores e com apresentações coloridas aumentam o interesse da criança pela comida (17). brincadeiras, estórias, desenhos é algo que agrada às crianças. a utilização da distração como ferramenta para melhorar a alimentação é algo simples e eficaz que pode ser utilizado pelos familiares de crianças com dificuldade na alimentação (19). para esse fim, o lúdico é reconhecido como uma medida terapêutica, capaz de promover a continuidade do desenvolvimento infantil e possibilita o restabelecimento físico e emocional por tornar o processo de adoecimento menos traumatizante (20). apesar de a diversão ser uma forma de atrair a criança para a comida, a adoção de brincadeiras quando realizadas de forma inadequada, pode despertar um interesse maior da criança pelo momento da diversão do que pelo momento da alimentação. contudo, se faz ideal que as crianças estejam envolvidas no planejamento e preparo das refeições e que estas sejam realizadas em local apropriado, tranquilo e harmonioso, de modo que a criança possa interagir positivamente com os alimentos que lhes são expostos (21). uma das estratégias usadas pela família ante a recusa de alimentos é a barganha. a barganha é uma forma de tentar, de qualquer modo, aliviar a angústia do adulto diante de uma situação percebida como difícil, na tentativa de permutar uma condição árdua por uma compensatória. é uma tática em que muitas vezes se obtém sucesso (19). a estratégia de ceder algo para que a criança se alimente é utilizada com frequência, mas essa atitude pode fazer com que os familiares não consigam mais impor limites e controlar as crianças, o que pode torná-las mimadas e desobedientes (18). na resposta de um dos familiares, observa-se a ciência de que essa estratégia não é indicada por profissionais da saúde, em especial os psicólogos. no entanto, diante do desespero gerado pela rejeição da criança à comida que lhe é dada, os pais tendem a recorrer à forma que de fato a faz se alimentar. nesse sentido, o cuidado com a alimentação da criança em tratamento quimioterápico deve envolver toda a equipe multiprofissional, pois cada membro poderá trazer contribuições dentro da sua área para ajudar a família e a criança na superação dos desafios impostos pelo tratamento e manutenção de uma boa condução nutricional (5). outra estratégia revelada pelos familiares foi inserir os alimentos nas refeições de forma que a criança os coma sem perceber. essa camuflagem impede a criança de conhecer os alimentos e não estimula a ingestão regular. por isso, no lugar da camuflagem, a família deve adequar a forma de preparo ao paladar da criança e estimular seu consumo (22). 517 a enfermagem ante os desafios enfrentados pela família na alimentação de criança em quimioterapia l isis moura sueiro, e outros vale destacar que os familiares, no decorrer da doença, adquirem experiências que são somadas aos valores, crenças e costumes familiares, o que influencia no cuidado prestado à criança (23). assim, os familiares precisam apreender e desenvolver novas estratégias para manter a alimentação de suas crianças que tiveram os hábitos alimentares modificados devido ao tratamento quimioterápico. a necessidade de orientações acerca de como agir ante os desafios surgiu de forma evidente nas entrevistas, o que destacou a importância da atuação do enfermeiro como educador, para esclarecer dúvidas e diminuir os anseios da família. nota-se que a informação é uma estratégia indispensável para se lidar com o adoecimento pelo câncer (24). esse dado corrobora com os pressupostos de collière (3) ao expor que todas as substituições no modo de cuidar cotidiano e habitual dependem diretamente do aprendizado de novos cuidados, muitos dos quais provenientes do campo de competência da enfermagem, que requerem, portanto, a atuação do enfermeiro na orientação das famílias. desse modo, a família da criança necessita de apoio, orientação e cuidados permanentes de profissionais envolvidos e comprometidos com o tratamento; portanto, é imprescindível considerar as características e as necessidades de cada família (25). nesse sentido, os familiares destacaram que os enfermeiros se desempenham como educadores, pois possuem a habilidade de ensinar e orientar as crianças e suas famílias para manutenção de cuidados cotidianos, habituais e de reparação, que asseguram a continuidade da vida (3). as ações do enfermeiro educador devem ser centradas em uma relação dialógica pautada na escuta sensível, no respeito, na valorização das experiências, das histórias de vida, da visão de mundo e na realidade concreta dos familiares e criança. deve-se ainda levar em consideração as dúvidas e dificuldades dos sujeitos, auxiliá-los a superarem suas situações de desafios relativas ao cuidado alimentar da criança em tratamento quimioterápico (26). assim, profissionais e familiares, juntos, podem negociar estratégias e reconstruir saberes e práticas para superar os efeitos colaterais do tratamento quimioterápico que interferem na alimentação da criança. o principal objetivo da terapia nutricional é garantir níveis adequados de todos os nutrientes necessários para preservação ou restauração da massa corporal e magra, bem como a manutenção do crescimento e desenvolvimento adequado (12). como observado, as orientações junto aos familiares é importante para a realização dos cuidados à criança, mas é preciso considerar que as orientações junto às crianças também podem ser desenvolvidas, pois, a partir da idade escolar, já conseguem entender a respeito de sua patologia e seu tratamento, conhecem a si mesmas e conseguem perceber quando algo está diferente (27). com relação à importância de orientação da criança, estudo realizado em três principais centros de tratamento oncológico no reino unido mostrou que as crianças se preocupam com seus sintomas e se incomodam com o fato de a comunicação a respeito do seu adoecimento e tratamento acontecer entre os seus pais e os profissionais de saúde, sem incluí-las (28). as orientações apenas para a família pode causar conflitos entre a criança e o cuidador, pois sem informações sobre suas restrições e proibições, ela entende que o seu familiar, por negar o que deseja, é o responsável pelas proibições e isso a leva ao sentimento de raiva. nota-se, assim, que a orientação direcionada às crianças é importante, pois elas são capazes de compreender e perceber indícios que não sejam reconhecidos como normal por elas próprias de maneira precoce (27). como instrumento para educação em saúde, o uso de um material escrito com orientação pode evitar o esquecimento, melhorar o aprendizado dos familiares e guiá-los no que podem ou não oferecer à criança. vale destacar que o enfermeiro, no seu papel de educador, precisa elaborar e selecionar materiais educativos que produzam significados para as famílias para que as reais necessidades desses indivíduos possam ser atendidas. a elaboração de um material educativo escrito destaca-se por modificar a prática de educação em saúde, pois visa ao preparo do familiar na alta hospitalar, auxilia em casos de dúvidas, direciona o cuidado, além de padronizar as orientações que evitam a ocorrência de informações contraditórias (28). o uso de material educativo, mediado pelo enfermeiro, permite avaliar se as orientações estão sendo compreendidas, ajuda a quebrar tabus, fantasias, diminui as dificuldades de comunicação entre os familiares, a criança e os profissionais, além de ser um material que pode ser consultado a qualquer momento. entretanto, a elaboração desse material deve levar em consideração a necessidade de conhecimento dos familiares, e sua validação junto ao público-alvo servirá para validar as informações, tornar o processo mais dialógico, sem mensagens fragmentadas, sem ser unidirecional, tecnicista, linear e limitado (29). 518 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 conclusões o presente estudo permitiu identificar os desafios enfrentados pela família na alimentação da criança em quimioterapia antineoplásica, assim como descrever as estratégias utilizadas pela família para superação dos desafios e as possibilidades de atuação da enfermagem. os desafios dos familiares foram relacionados com os efeitos adversos dos medicamentos referentes ao sistema gastrointestinal e hematológico, com a adaptação à mudança alimentar e a hospitalização. para superação desses desafios, os familiares utilizaram estratégias como: perguntar o que a criança quer comer, fazer a comida que ela mais gosta, deixar a refeição mais interessante e atrativa, barganhar e camuflar os alimentos. constatou-se que, mediante as modificações nos hábitos cotidianos e habituais das crianças em tratamento quimioterápico, o enfermeiro atua como educador junto às famílias e às crianças, além de auxiliar nas modificações das práticas alimentares a fim de dar continuidade ao cuidado em casa com segurança e qualidade. a elaboração de um material educativo com orientações destinadas aos familiares de criança com câncer foi apontado como uma forma de a enfermagem atuar, o que ajudaria a família nos cuidados que se deve ter na alimentação da criança em casa. por fim, considera-se fundamental que a enfermagem atue na orientação a respeito da alimentação da criança com câncer e que abranja os problemas que dela surgem; além disso, busque soluções para auxiliar a família no enfrentamento e otimize a qualidade de vida da criança e também do seu familiar. a inclusão de outros profissionais de saúde no cuidado alimentar da criança em tratamento quimioterápico, em especial os nutricionistas, psicólogos e médicos, também colabora na superação desses desafios. como limitação da pesquisa, aponta-se que não houve destaque para os desafios enfrentados pela família de acordo com cada faixa etária da infância, uma vez que pode haver necessidades e dificuldades específicas. assim, sugere-se realização de novas pesquisas que abordem a temática com familiares de crianças, tendo em vista as diferentes fases do crescimento e desenvolvimento infantil, inclusive que deem voz às próprias crianças quando possível, respeitando os diferentes graus de entendimento. referências 1. brasil. ministério da saúde. estimativa 2012 — incidência de câncer no brasil. rio de janeiro: instituto nacional de câncer; 2012. 2. cicogna ec, nascimento lc, lima rag. children and adolescents with cancer: experiences with chemotherapy. rev latino-am enfermagem [internet] 2010 [acesso 10 maio 2011]; 18 (5): 864-72. disponível em: http://www.scielo.br/ pdf/rlae/v18n5/05.pdf 3. collière mf. promover a vida: da prática das mulheres de virtude aos cuidados de enfermagem. lisboa: sindicato dos enfermeiros portugueses; 1999. 4. silva tp, leite jl, santos nlp, silva ir, mendonça aca, santos mjc, silva, js. cuidados de enfermagem à criança com câncer: uma revisão integrativa da literatura. revista de enfermagem da ufsm [internet] 2013 [acesso 14 fev. 2014]; 3 (1): 68-78. disponível em: http://cascavel.ufsm.br/revistas/ojs-2.2.2/index.php/reufsm/article/view/6918. 5. robinson dl, loman dg, balakas k, flowers m. nutritional screening and early intervention in children, adolescents, and young adults with cancer. journal of pediatric oncology nursing 2012; 29 (6): 346-55. 6. minayo mcs. o desafio do conhecimento: pesquisa qualitativa em saúde. 12 ed. são paulo: hucitec; 2010. 7. fontanella bjb, luchesi bm, saidel mgb, ricas j, turato er, melo dm. amostragem em pesquisas qualitativas: proposta de procedimentos para constatar saturação teórica. cad saúde pública 2011; 27 (2): 389-94. 8. lino mdmc, carvalho fb, oliveira lr, magalhães eb, pinheiro alb, ramalho lmp. laser phototherapy as a treatment for radiotherapy-induced oral mucositis. braz dent j 2011; 22 (2): 162-5. 519 a enfermagem ante os desafios enfrentados pela família na alimentação de criança em quimioterapia l isis moura sueiro, e outros 9. orue it, alonso br, hernández aij, garcet ac. rol del enfermero en la prevención de infecciones del paciente oncológico con neutropenia febril. nure investigación [internet] 2011 [acesso 10 jul. 2014]; 50. disponível em: http://www. fuden.es/ficheros_administrador/protocolo/nure50_protocolo_rolenfneutropenia.pdf 10. garófolo a. neutropenic diet and quality of food: a critical analysis. rev bra hematol hemoter [internet] 2013 [acesso 13 jul. 2014]; 35 (2): 79-80. disponível em: http://www.scielo.br/pdf/rbhh/v35n2/v35n2a03.pdf 11. rodrigues vm, fiates gmr. hábitos alimentares e comportamento de consumo infantil: influência da renda familiar e do hábito de assistir à televisão. rev nutr [internet] 2012 [acesso 10 jan. 2014]; 25 (3): 353-62. disponível em: http:// www.scielo.br/pdf/rn/v25n3/05.pdf. 12. henriques p, sally eo, burlandy l, beiler rm. regulamentação da propaganda de alimentos infantis como estratégia para a promoção da saúde. ciênc saúde coletiva 2012; 17 (2); 481-90. 13. gibson f, aldiss s, horstman m, kumpunen s, richardson a. children and young people’s experiences of cancer care: a qualitative research study using participatory methods. international journal of nursing studies 2010; 47: 1397-407. 14. cederborg ac, hultman e, magnusson kf. living with children who have coeliac disease: a parental perspective. child care health dev 2011; 38 (4): 484-9. 15. duarte mlc, zanini ln, nedel mnb. cotidiano dos pais de crianças com câncer e hospitalizadas. rev gaúcha enferm 2012; 33 (3): 111-8. 16. fraser lk, van laar m, miller m, aldridge j, mckinney pa, parslow r, et al. does referral to specialist paediatric palliative care services reduce hospital admissions in oncology patients at the end of life? british journal of cancer 2013; 108: 1273-9. 17. álvarez cnd, velasco cmd, portilla cmd. náuseas, vómitos, diarrea, estreñimiento e hiporexia en la alimentación del niño con cáncer. rev gastrohnup 2012; 14 (1): 27-30. 18. perosa gb, carvalhaes mabl, benício mha, silveira fcp. estratégias alimentares de mães de crianças desnutridas e eutróficas: estudo qualitativo mediante observação gravada em vídeo. ciênc saúde coletiva 2011; 16 (11): 4445-64. 19. juzwiak cr. era uma vez... um olhar sobre o uso dos contos de fada como ferramenta de educação alimentar e nutricional. interface 2013; 17 (45): 473-84. 20. li wh, chung jo, ho ek. the effectiveness of therapeutic play, using virtual reality computer games, in promoting the psychological well-being of children hospitalised with cancer. journal of clinical nursing 2011; 20 (15-16): 2135-43. 21. lindsay ac, sussner km, greaney m, wang ml, davis r, peterson ke. using qualitative methods to design a culturally appropriate child feeding questionnaire for low-income, latina mothers. matern child health j [internet] 2012 [acesso 30 out. 2014]; 16 (4): 860-6. disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3178008/?tool=pubmed 22. jansen e, mallan km, nicholson jm, daniels la. the feeding practices and structure questionnaire: construction and initial validation in a sample of australian first-time mothers and their 2-year olds. int j behav nutr phys act [internet] 2014 [acesso 30 out. 2014]; 11(72): [13 screens]. disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/ pmc4053399/?tool=pubmed 23. okido acc, pizzignacco tmp, furtado mcc, lima rag. criança dependente de tecnologia: a experiência do cuidado materno. rev esc enferm usp 2012; 46 (5): 1066-73. 24. morais gsn, costa sfg. experiência existencial de mães de crianças hospitalizadas em unidade de terapia intensiva pediátrica. rev esc enferm usp 2009; 43 (3): 639-46. 25. nóbrega rd, collet n, gomes ip, holanda er, araújo yb. criança em idade escolar hospitalizada: significado da condição crônica. texto contexto enferm [internet] 2010 [acesso 13 out. 2013]; 19 (3): 425-33. disponível em: http://www. scielo.br/pdf/tce/v19n3/a03v19n3.pdf 520 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 26. cervera dpp; parreira bdm, goulart bf. educação em saúde: percepção dos enfermeiros da atenção básica em uberaba (mg). ciênc saúde coletiva 2011; 16 (supl.1): 1547-54. 27. ferecini gm, fonseca lmm, leite am, daré mf, assis cs, scochi cgs. perceptions of mothers of premature babies regarding their experience with a health educational program. acta paul enferm 2009; 22 (3): 250-6. 28. gibson f, aldiss s, horstman m, kumpunen s, richardson a. children and young people’s experiences of cancer care: a qualitative research study using participatory methods. international journal of nursing studies 2010; 47: 1397-407. 29. salles ps, castro rcbr. validação de material informativo a pacientes em tratamento quimioterápico e aos seus familiares. rev esc enferm usp 2010; 44 (1): 182-9. 20 31 cuidado enfermeria personas con diabetes.indd 20 sandra valenzuela-suazo1 sara guerrero-núñez2 patricia cid-henríquez3 cuidado de enfermería en personas con diabetes mellitus tipo 2, según la teoría de la atención burocrática 1 orcid.org/0000-0002-1308-4835. universidad de concepción, chile. svalenzu@udec.cl 2 orcid.org/0000-0001-5004-3760. universidad de atacama, chile. sara.guerrero@uda.cl 3 orcid.org/0000-0002-2821-0558. universidad de concepción, chile. patcid@udec.cl recibido: 21 de agosto de 2016 enviado a pares: 05 de diciembre de 2016 aceptado por pares: 27 de febrero de 2017 aprobado: 7 de abril de 2017 doi: 10.5294/aqui.2018.18.1.3 para citar este artículo / to reference this article / para citar este artigo guerrero-núñez s, valenzuela-suazo s, cid-henríquez p. cuidado de enfermería en personas con diabetes mellitus tipo 2, según la teoría de la atención burocrática. 2018;18(1):20-31. doi: 10.5294/aqui.2018.18.1.3 resumen objetivo: describir las características de la práctica de enfermería en el cuidado de personas con diabetes mellitus tipo 2 en la atención primaria de salud, según la teoría de la atención burocrática. material y método: investigación cualitativa que exploró la práctica de enfermería en el cuidado del paciente con diabetes mellitus tipo 2, por medio de la observación no participante; se realizó durante tres semanas en dos centros de salud familiar en la región de atacama, chile; se utilizaron notas de campo y se analizó la información por medio de comparación constante, según el referente filosófico seleccionado. resultados: el cuidado de enfermería en personas con diabetes mellitus tipo 2 en los centros de salud familiar se encuentra vinculado a todos los factores señalados en la teoría de la atención burocrática, es decir, factores educativos, físicos, socioculturales, legales, tecnológicos, económicos y políticos. conclusiones: por medio de la teoría de la atención burocrática es posible describir la práctica del cuidado de enfermería en personas con diabetes mellitus tipo 2. enfermería debe considerar los factores propios a la burocracia de toda organización, especialmente al momento de gestionar el cuidado en este tipo de pacientes. palabras clave enfermería; diabetes mellitus tipo 2; observación; filosofía en enfermería; atención primaria de salud (fuente: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 20-31 21 cuidado de enfermería en personas con diabetes mellitus tipo 2, según la teoría de la atención burocrática l sandra valenzuela-suazo y otros año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 20-31 nursing care for persons with diabetes mellitus type 2, according to the theory of bureaucratic care abstract objective: describe the characteristics of nursing practice regarding the care of persons with diabetes mellitus type 2 within the scope of primary health care, according to the theory of bureaucratic caring. materials and method: a qualitative study was done to explore nursing practice with respect to the care of patients with diabetes mellitus type 2, through non-participant observation over a period of three weeks at two family healthcare centers in the atacama region of chile. field notes were used and the information was analyzed through constant comparison, according to the selected philosophical referent. results: nursing care provided at family healthcare centers to persons with diabetes mellitus type 2 is linked to all the factors indicated in the theory of bureaucratic caring; that is, educational, physical, sociocultural, legal, technological, economic and political factors. conclusions: the theory of bureaucratic caring can be used to describe nursing practice in the care of persons with diabetes mellitus type 2. nursing should consider the factors inherent in the bureaucracy of any organization, especially when managing care for patients of this type. keywords nursing; diabetes mellitus type 2; observation; philosophy in nursing; primary health care (source: decs). 22 aquichan issn 1657-5997 eissn 2027-5374 cuidado de enfermagem em pessoas com diabetes mellitus tipo 2, segundo a teoria da atenção burocrática resumo objetivo: descrever as características da prática de enfermagem no cuidado de pessoas com diabetes mellitus tipo 2 na atenção primária de saúde, segundo a teoria da atenção burocrática. material e método: pesquisa qualitativa que explorou a prática de enfermagem no cuidado do paciente com diabetes mellitus tipo 2 por meio da observação não participante; realizou-se durante três semanas em duas unidades de saúde da família na região de atacama, chile; utilizaram-se anotações de campo e analisou-se a informação pela comparação constante, conforme o referencial filosófico selecionado. resultados: o cuidado de enfermagem em pessoas com diabetes mellitus tipo 2 nas unidades de saúde da família encontra-se vinculado com todos os fatores apontados na teoria da atenção burocrática, isto é, fatores educativos, físicos, socioculturais, legais, tecnológicos, econômicos e políticos. conclusões: por meio da teoria da atenção burocrática, é possível descrever a prática do cuidado de enfermagem em pessoas com diabetes mellitus tipo 2. a enfermagem deve considerar os fatores próprios à burocracia de toda organização, em especial, no momento de administrar o cuidado nesse tipo de paciente. palavras-chave atenção primária de saúde; diabetes mellitus tipo 2; enfermagem; filosofia em enfermagem; observação (fonte: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 20-31 23 cuidado de enfermería en personas con diabetes mellitus tipo 2, según la teoría de la atención burocrática l sandra valenzuela-suazo y otros introducción la comprensión de los conceptos de cuidado y enfermería ha evolucionado a través del tiempo, en función de los cambios históricos, políticos y científicos, entre otros. nightingale describió a la enfermera como gestora del medio ambiente para promover la salud y prevenir complicaciones (1), pero hoy enfermería, a través de su disciplina, concibe el cuidado según diversas miradas paradigmáticas, que han estructurado el conocimiento enfermero en filosofías, modelos y teorías de diverso alcance (2). es importante comprender el cuidado teniendo presentes las concepciones teóricas desarrolladas, pues abordan el metaparadigma de la disciplina, lo cual permite una comprensión integradora de los elementos que participan en este fenómeno. la disciplina de enfermería guía y orienta la práctica, y genera un conocimiento propio por medio de la investigación (3), muy útil para la comprensión del cuidado, especialmente en condiciones de salud que producen alta carga sanitaria y económica en la población y el sistema de salud. tal es el caso de la diabetes mellitus tipo 2 (dm 2), que tiene una alta prevalencia (4, 5) y mortalidad a nivel global (6-9). si bien en chile se garantiza el acceso a la atención en salud de personas con dm 2, persisten elementos como la alta descompensación (10, 11), que hacen del sistema y de las estrategias sanitarias medidas e intervenciones que no garantizan efectividad. por esta razón, es fundamental comprender el cuidado de enfermería en este contexto, no solo para describirlo, sino también para intervenir en los factores o elementos clave, pues la evidencia científica muestra el importante rol de enfermería en el control metabólico de la dm 2 (12-14). en esta vía, la teoría de la atención burocrática de marilyn anne ray permite una comprensión del cuidado en un escenario complejo como lo es un centro de salud familiar, donde surge un orden implícito (el todo) y un orden explícito (la parte), representados en la interconexión del cuidado espiritual y ético con la estructura social de la organización (15). el cuidado está influenciado por la estructura social de la organización, donde intervienen elementos burocráticos como factores educativos, físicos, socioculturales, legales, tecnológicos, económicos y políticos. sobre este escenario se desarrolla este artículo, que tiene por objetivo describir las características de la práctica de enfermería en el cuidado de personas con dm 2 en la atención primaria de salud, según la teoría de la atención burocrática. materiales y métodos investigación cualitativa que, por medio de la observación no participante, exploró la práctica del cuidado de enfermería en personas con dm 2. la observación se realizó por un periodo de tres semanas en dos centros de salud familiar de la región de atacama, chile, posterior a las reuniones de coordinación con la dirección y el equipo del programa de salud cardiovascular de cada establecimiento. este estudio corresponde a la primera etapa de la tesis doctoral de una de las investigadoras, y es el fundamento para la aplicación de otras técnicas de recolección. el proyecto de investigación donde se enmarca el actual estudio fue aprobado por el comité ético científico del programa académico, y posteriormente se recibió la aprobación de las autoridades de salud regional donde se realizó la observación, además de los consentimientos informados aplicados a enfermeros y pacientes que aprobaron ser observados durante el control en salud. las observaciones fueron realizadas por una de las investigadoras, quien contactó a las personas que deseaban participar. la investigadora se mantuvo ajena a la situación observada en lo que respecta a ejecución de intervenciones, fueran estas procedimientos clínicos, educativos u otras. la observación fue no estructurada, estableciendo con anticipación los contextos por observar, a saber: actividades de enfermería señaladas en el listado de prestaciones garantizadas para este tipo de pacientes; consulta o control; educación de grupo y consulta para curación por pie diabético. este listado de prestaciones se enmarca en la ley 19.966, donde se estandarizó la atención de patologías priorizadas, a fin de garantizar acceso, calidad, oportunidad y apoyo financiero. respecto a esto último, la dm 2 es una de las patologías con listado de prestaciones garantizadas, donde los beneficiarios poseen protección financiera dependiendo del tipo de afiliación al sistema previsional. los afiliados al fondo nacional de salud (fonasa) de los tramos a y b no deben pagar por las prestaciones en salud, los afiliados del tramo c pagan un copago del 10 % del arancel establecido, y los del tramo d, junto a los afiliados a instituciones de salud previsional (isapre), pagan el 20 % de copago. la consulta para curación por pie diabético no fue observada debido a la inasistencia de pacientes en los días programados. a pesar de ello, se entrevistó a la enfermera y al personal que 24 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 participa de las curaciones, quienes explicaron la dinámica y permitieron el ingreso al box de curaciones. se utilizaron notas de campo con dos tipos de registros no sistemáticos: notas descriptivas, que reflejaban lo que sucedía en el contexto (conducta, diálogo o situaciones que llamaron el interés de la investigadora), y las notas reflexivas, que reflejaban los propios pensamientos y percepciones (fueron analíticas e interpretativas). la jornada de observación se dividió en observación directa, transcripción y análisis preliminar de lo observado. los registros se consolidaron en un documento word y fueron analizados durante el mes de diciembre de 2015 por medio de comparación constante de la codificación, utilizando la teoría de la atención burocrática (2), con la intención de organizar los resultados según los siete factores del referente filosófico. la codificación se realizó por medio de lectura repetitiva de las notas de campo, añadiendo un comentario preliminar dirigido a las características de la práctica del cuidado de enfermería en el paciente con dm 2. las categorías emergieron después de la lectura y comparación constante de los comentarios preliminares. en la medida que avanzó la relectura y comparación de las notas de campo y de sus respectivos comentarios, las categorías tendieron a la saturación. emergieron 32 categorías que representan las principales características de la práctica del cuidado de enfermería en el paciente con dm 2. las categorías se agruparon en los siete factores de la teoría de la atención burocrática, asignándoles un significado que corresponde a la interpretación dada por las investigadoras a lo observado en el contexto del referente filosófico, y sobre lo cual es posible de ahondar por medio de otras técnicas como entrevistas, con la intención de profundizar en el fenómeno de estudio. resultados los resultados descritos inicialmente en la figura 1 manifiestan una relación entre el cuidado espiritual-ético y la estructura social de la organización. la tabla 1 incorpora las categorías emergentes según factor, que representan las características de la práctica del cuidado de enfermería en el paciente con dm 2. figura 1. cuidado de enfermería en la diabetes mellitus tipo 2 según la teoría de la atención burocrática fuente: extraído con modificaciones de la presentación holográfica de la teoría de la atención burocrática (16). 25 cuidado de enfermería en personas con diabetes mellitus tipo 2, según la teoría de la atención burocrática l sandra valenzuela-suazo y otros tabla 1. categorías emergentes que describen las características de la práctica del cuidado de enfermería en el paciente con diabetes mellitus tipo 2, según factores determinados por la teoría de la atención burocrática factor categorías emergentes n° educativo intervención de tipo educativo 5 educación en el cuidado de la alimentación educación en el cuidado del tratamiento farmacológico educación en el cuidado de la actividad física recurso humano enfermero capacitado físico participación del paciente 2 medición de parámetros clínicos sociocultural integración de personas significativas 10 relación enfermero(a)-paciente valoración del rol de enfermería comprensión del lenguaje comprensión del estado de salud cuidado integral cuidado centrado en la persona cuidado que promueve la vinculación a redes de apoyo credibilidad del profesional manejo de factores protectores legal rendimiento del cuidado 3ejecución o derivación a prestaciones garantizadas consentimiento informado tecnológico sistema informático de registro 3sistema de información sobre exámenes clínicos significado otorgado al procedimiento clínico económico pago por atención de salud 2 disponibilidad de recurso humano político estructura física destinada al cuidado 7 continuidad del cuidado de enfermería articulación entre sistemas tiempo de espera criterios de continuidad en la atención de salud resolución del sistema toma de decisiones efectivas total 32 fuente: elaboración propia. 26 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 a continuación se describen las características de la práctica del cuidado de enfermería en el escenario del estudio: factores educativos 1. intervención de tipo educativo: educación realizada al paciente incorporando material educativo como dípticos y trípticos, exposiciones audiovisuales, y el compartir experiencias en los talleres. esto involucra trabajar conforme a las necesidades del paciente y según su contexto. 2. educación en el cuidado de la alimentación: intervención del profesional enfermero(a) dirigida a alimentación saludable. es más que una recogida de datos, pues corresponde a una educación significativa y comprensiva para las personas. 3. educación en el cuidado del tratamiento farmacológico: intervención del profesional enfermero(a) dirigida a la adherencia al tratamiento y los cuidados propios de la enfermedad. es más que una recogida de datos, pues corresponde a una educación significativa y comprensiva para las personas. 4. educación en el cuidado de la actividad física: intervención del profesional enfermero(a) dirigida a la promoción de actividad física. es más que una recogida de datos, pues corresponde a una educación significativa y comprensiva para las personas. 5. recurso humano enfermero capacitado: profesional capacitado que otorga garantía para una atención conforme a las prestaciones establecidas. involucra competencias cognitivas, actitudinales y de tipo procedimental que permiten un abordaje integral del paciente y de su contexto familiar o comunitario. factores físicos 1. participación del paciente: elementos o factores que condicionan la participación del paciente en las prestaciones garantizadas y que repercuten en la continuidad de la atención de salud. 2. medición de parámetros clínicos: medición estandarizada de parámetros, o según lo establecido en guía clínica. entre ellos se encuentra la medición de presión arterial, talla, peso y el índice de masa corporal, perímetro abdominal, en algunos casos la glicemia capilar, y, últimamente, la sensibilidad en los pies. factores socioculturales 1. integración de personas significativas: cuando la persona asiste al control con un familiar o persona significativa y el(la) enfermero(a) incorpora el acompañamiento del paciente como actividad elemental del control de salud. también consiste en promover el acceso y la continuidad al sistema de salud (oferta de día y horario favorable al acompañamiento). 2. relación enfermero(a)-paciente: indica el vínculo establecido entre paciente y enfermero(a). influyen factores como la comunicación (lenguaje y escucha activa, entre otros), confianza, respeto, credibilidad, etc. 3. valoración del rol de enfermería: significado que otorga el paciente y el equipo de salud al control realizado por el enfermero(a) en relación con la compensación de la dm 2. 4. comprensión del lenguaje: comunicación efectiva en cuanto a la comprensión del lenguaje utilizado por el enfermero(a). en el control se establece una comunicación bidireccional, con un diálogo permanente que permite la retroalimentación constante (verificación de la comprensión del lenguaje). 5. comprensión del estado de salud: cuando el profesional es capaz de comunicar comprensivamente el resumen de la información más relevante sobre el estado de salud del paciente, y este es capaz de transmitir la información a otros como la familia o personas significativas. 6. cuidado integral: capacidad del profesional enfermero(a) de reconocer factores que permiten un abordaje integral del cuidado, evitando la búsqueda de causales parciales de descompensación. esto conlleva una comprensión del paciente sobre la necesidad un cuidado integral y no solo farmacológico. 7. cuidado centrado en la persona: cuando el(la) enfermero(a) otorga una atención centrada en la persona y no en el profesional o sistema. las intervenciones deben relacionarse con lo experimentado por el paciente y conforme a sus necesidades. 8. cuidado que promueve la vinculación a redes de apoyo: consiste en incentivar la integración del paciente con redes de apoyo formales e informales. 27 cuidado de enfermería en personas con diabetes mellitus tipo 2, según la teoría de la atención burocrática l sandra valenzuela-suazo y otros 9. credibilidad del profesional: credibilidad que otorga el(la) profesional enfermero(a) al paciente y la familia. también involucra un registro veraz de las intervenciones realizadas en los controles de salud. 10. manejo de factores protectores: refuerzo positivo que el(la) profesional enfermero(a) realiza para trabajar con los activos en salud, fortaleciendo los factores protectores y motivando al paciente por tales condiciones o por logros en salud alcanzados. factores legales 1. rendimiento del cuidado: control realizado por el(la) enfermero(a) en el tiempo establecido. 2. ejecución o derivación a prestaciones garantizadas: realización de las intervenciones garantizadas por profesional enfermero(a), además de orientar y derivar a prestaciones garantizadas para personas con dm 2, sean estas controles de salud e intervenciones establecidas. 3. consentimiento informado: corresponde a la autorización del paciente para ser atendido por persona (estudiante) externa al centro de salud. 4. factores tecnológicos 5. sistema informático de registro: consiste en el sistema de apoyo tecnológico que contiene información clínica del paciente. relacionado con ello surge la percepción de utilidad y eficiencia del sistema informático, en tanto opinión de paciente y profesional enfermero(a). 6. sistema de información sobre exámenes clínicos: información clínica del paciente, digital y de fácil acceso para el profesional enfermero(a). 7. significado otorgado al procedimiento clínico: apreciación del paciente sobre el procedimiento clínico al cual se expone. factores económicos 1. pago por atención de salud: desembolso que realiza el paciente y familia por una atención de salud privada, que resuelve lo que el sistema público no logra hacer, o por desconfianza en este. estas situaciones son conocidas cuando el(la) profesional enfermero(a) consulta al paciente por su ausencia al control anterior. la no resolución del sistema público consiste en la no disponibilidad de horas en el centro de salud familiar, ocasionada por ausentismo laboral de los profesionales, entre algunos de los factores señalados. la desconfianza se dirige principalmente al tratamiento farmacológico y la utilización de recursos materiales en procedimientos clínicos, lo que ocasiona que algunos pacientes acudan a la consulta esporádica en el sector privado. 2. disponibilidad de recurso humano: acceso al recurso humano necesario para prestaciones garantizadas. factores políticos 1. estructura física destinada al cuidado: espacios específicos que permiten la visibilidad del cuidado, siendo identificados por los pacientes como propios de ese tipo de atención en salud. esto facilita el acceso de la población al cuidado de la salud. 2. continuidad del cuidado de enfermería: condiciones organizacionales del establecimiento que permiten la continuidad del cuidado durante el control de salud realizado por el enfermero(a), y también a través del tiempo, conforme al calendario de control establecido por el centro de salud familiar. 3. articulación entre sistemas: cuando el paciente asiste al sistema privado por mayor confianza en el mismo, o para resolver problemas que el sistema público no logró solucionar, y luego continúa con la atención en el centro de salud familiar. lo anterior genera una aparente desarticulación por falta de comunicación, con dificultad para integrar las modificaciones al tratamiento o a nuevas indicaciones. 4. tiempo de espera: tiene relación con el tiempo de espera en la atención de salud (cuidado oportuno). 5. criterios de continuidad en la atención de salud: continuidad de la atención de salud según criterios definidos y comprensibles para quienes participan de la atención en el centro de salud familiar, y que no obedecen a la arbitrariedad o a criterios personales del profesional enfermero(a). 6. resolución del sistema: atención que da solución a los problemas o las necesidades del paciente. responsabilidad indelegable del sistema. repercute sobre la confianza del paciente y la familia en el sistema y el profesional. 28 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 7. toma de decisiones efectivas: percepción de la efectividad de las decisiones clínicas y de gestión realizadas por el(la) enfermero(a). discusión al considerar el cuidado de personas con diagnóstico de dm 2 en el contexto de la teoría de la atención burocrática, se debe entender que el cuidado es el todo, pero, asimismo, es parte de la complejidad organizacional (15) de la atención primaria de salud. de esta manera, el cuidado de enfermería se enfrenta a una relación con factores de la burocracia propia al centro de salud familiar. el referente filosófico del estudio define un proceso relacional transcultural complejo, asentado en un contexto ético y espiritual, con múltiples entradas en el sistema, interconectadas con el cuidado en el conjunto de la cultura de la organización (16). de esta manera, el cuidado de enfermería en pacientes con dm 2 se enfrenta a factores propios del establecimiento de salud. en los factores educativos se encuentra la formación del profesional de enfermería, que conlleva una mirada integral del paciente y su contexto. las competencias desarrolladas por medio de la educación continua capacitan a los(as) enfermeros(as) en la oferta de un cuidado de calidad, en tanto prestaciones garantizadas. también son parte de este factor las intervenciones educativas realizadas durante el control de salud. si bien el control es registrado digitalmente en un sistema informático de apoyo, que podría limitar el tiempo destinado a la atención, dando importancia al registro antes que a las necesidades de las personas, es necesario intervenir con programas educativos formales (talleres de educación grupal) e informales (intervenciones educativas durante el control de salud) para evitar las complicaciones ocasionadas por el desconocimiento (17). tanto las intervenciones educativas grupales como las individuales han demostrado ser efectivas (18, 19), y resultan más beneficiosas cuando utilizan medios o estrategias que favorecen la construcción del conocimiento, antes que la transmisión del mismo realizada en el modelo tradicional (18). es importante acercarse a una comprensión dialogada de los saberes y eliminar la transmisión de información de manera unidireccional, pues esta ha demostrado no ser suficiente en el autocuidado del paciente, e incluso en la capacitación profesional (20). una intervención efectiva se orientará hacia una educación integral que propenda por la compensación metabólica y el bienestar de las personas que adolecen de dm 2. los factores físicos hacen referencia a un estado físico de la persona, incluidos patrones biológicos y mentales. este factor tiene relación con elementos que condicionan la participación del paciente en las prestaciones garantizadas, y que repercuten en la continuidad de la atención de salud, entre ellos, condición física, creencias o patrones mentales que favorecen la integración y continuidad. estudios evidencian que el comportamiento de estos pacientes es acompañado de sus creencias en torno a la enfermedad y el contexto (21). también surge la medición de patrones clínicos que son parte de la atención de salud, lo cual entrega una información sobre la condición de salud del paciente. los factores socioculturales se enlazan al rol que el(la) enfermero(a) ejerce, desde la relación o el vínculo con el paciente, hasta las características del cuidado, en tanto orientación y características propias de esta intervención. la relación entre enfermero(a) y el paciente diabético es fundamental, especialmente debido al rol educativo, al personalizar la intervención con cada paciente y hacerlo partícipe del control de su enfermedad (22). de esta forma, la comunicación con el paciente contribuye a alcanzar la eficacia y satisfacción del mismo. además, “el ejercicio del diálogo y de la comunicación llevará a una mejor comprensión del problema y la mejor aceptación de las orientaciones y recomendaciones” (23), siendo esto relevante en el cuidado de personas con dm 2. este factor también incorpora principios del modelo de atención integral de salud familiar y comunitaria, tales como el cuidado centrado en la persona y la integralidad (24). los factores legales están estrechamente relacionados con las prestaciones garantizadas para este tipo de pacientes, incorporando el tiempo destinado al control (rendimiento), y así también el resguardo de la autonomía del paciente en cuanto a la elección de ser atendido por personal externo al establecimiento de salud. el régimen de garantías explícitas (25) y el listado de prestaciones específicas establecen la participación de los(as) enfermeros(as), consulta o control, educación de grupo y consulta para curación, en caso de herida de pie diabético. en este sentido, es fundamental que enfermería gestione adecuadamente los elementos legales que son parte de la dinámica organizacional, y que les dé cumplimiento para garantizar un cuidado ético. en lo que respecta a los factores tecnológicos, estos reflejan los elementos de apoyo tecnológico que acompañan la oferta de cuidado. los centros de salud familiar poseen un sistema informático que favorece la actualización de los registros y el acceso a la información del paciente, fortaleciendo los procesos clínicos de 29 cuidado de enfermería en personas con diabetes mellitus tipo 2, según la teoría de la atención burocrática l sandra valenzuela-suazo y otros los establecimientos, y, asimismo, sirviendo de apoyo a las necesidades del paciente, es decir, facilitar el acceso a la información por parte del paciente o familia. los profesionales de enfermería sienten que los sistemas sanitarios han incorporado una cultura y herramientas empresariales (26), donde priman criterios mercantilistas sobre los valores humanistas, es decir, “los sistemas de control burocrático existentes han generado una demanda de actividad burocrática tan alta que ha desestabilizado el equilibrio entre actividad clínica y burocrática en favor de la segunda. las enfermeras han dejado de mirar al paciente para mirar la pantalla del ordenador” (26); por esta razón, es fundamental dar un correcto uso a las herramientas tecnológicas, por ser ellas un medio y no un fin (27), pues estas contribuyen al estado de salud del paciente (28), sin sustituir el cuidado relacional que este requiere. además, estos factores están relacionados con las percepciones de los pacientes al momento de exponerse a los procedimientos clínicos que incorporan el uso de tecnologías. el temor, la ansiedad, y, entre otros, las creencias propias del paciente, son elementos que intervienen en esta percepción. respecto a los factores económicos involucrados en el cuidado de estos pacientes, es necesaria la disponibilidad de recursos para otorgar un cuidado de calidad, y para derivar a las prestaciones garantizadas. entre estos factores se encuentra la disponibilidad de recursos materiales y profesionales. por otra parte, como factor económico también se destaca el desembolso que los pacientes y las familias deben hacer para resolver sus problemas de salud, o para recibir atención de salud segura y de calidad. esto se da a conocer durante la interacción del profesional enfermero(a) con el paciente en el control de salud. los pacientes señalan que la consulta en el sector privado se debe a imprevistos en el centro de salud familiar, como no disponibilidad horaria en el tiempo que le corresponde el control, o bien, debido a su interés por realizar en el sector privado procedimientos clínicos como curaciones o consultas por ajustes al tratamiento farmacológico. esto surge por el deseo de recibir, conforme a su percepción, una atención segura y de calidad. es importante tener presente este factor, porque la relación enfermero(a)-paciente es considerada como un recurso económico en la estructura sanitaria (29, 30). en relación con los factores políticos involucrados en el cuidado de enfermería del paciente con dm 2, estos contemplan elementos políticos y estructurales en la administración y gestión sanitaria, los cuales influyen en la imagen y valoración de enfermería en la atención sanitaria. este factor también se relaciona con las condiciones que hacen posible, o dificultan, el acceso del paciente al sistema de cuidado. es necesario que enfermería considere este escenario, con el fin de hacer ver la importancia del rol profesional, defendiendo el derecho universal a la salud y a los cuidados seguros y de calidad (31). cardoso (32) señala que la síntesis dialéctica del cuidado tiene como tesis el cuidado humanístico, educativo, ético y espiritual, y la antítesis (la burocracia) del cuidar, donde influyen los factores económicos, políticos, legales y tecnológicos que son parte de la gestión organizacional de una institución. conforme a lo expuesto, el cuidado de la persona con dm 2 en el contexto de la teoría de la atención burocrática sintetiza un cuidado espiritual y ético (orden implícito), integrado a estructuras de la organización (orden explícito) de tipo educativo, físico, sociocultural, legal, tecnológico, económico y político. conclusión el cuidado de enfermería en la persona con dm 2 debe ser considerado como el todo y como parte de la atención sanitaria. existen elementos de la estructura burocrática de los centros de salud familiar que influyen en la oferta de cuidado, los cuales han sido descritos en la teoría de la atención burocrática como factores educativos, físicos, socioculturales, legales, tecnológicos, económicos y políticos. para ofertar un cuidado de calidad, y conforme a las necesidades de las personas con diagnóstico de diabetes, enfermería debe tener presentes estos factores al momento de planificar y ejecutar el cuidado. de esta forma se proporcionará un cuidado espiritual y ético, tal como lo describe la filosofía de ray. conflicto de interés: los autores declaran no tener ningún conflicto de interés 30 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 referencias 1. frello a, carraro t. florence nightingale’scontributions: anintegrativereview of the literatura. esc anna nery. 2013;17(3):573-579. 2. marriner a, raile m. modelos y teorías en enfermería. 6ª ed. madrid: elsevier; 2007. 3. aguayo m, castelló m, monereo c. la identidad del académico de enfermería: entre la docencia y la 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2013;22(3):156-60. 28. da silva r, ferreira m. tecnología en la atención de enfermería: un análisis desde el marco conceptual de enfermería fundamental. rev bras enferm. 2014;67(1):111-18. 29. turkel m, ray m. relational complexity: from grounded theory to instrument development and theoretical testing. nurs sci q. 2001;15(4):281-87. 30. turkel m, ray m. relational complexity: a theory of the nurse-patient relationship within an economic context. nurs sci q. 2000;13(4):306-13. 31. pires d. transformações necessárias para o avanço da enfermagem como ciência do cuidar. rev bras enferm. 2013;66:39-44. 32. cardoso a. referencial de cuidar em enfermagem psiquiátrica: um processo de reflexão de um grupo de enfermeiras. esc anna nery. 2009;13(1):51-5. 149 159 nursing care with a human approach.indd 149 elsa yolanda carvajal hermida1 beatriz sánchez-herrera2 “nursing care with a human approach”: a model for practice with service excellence recibido: 23/02/2017 enviado a pares: 03/04/2017 aceptado por pares: 07/11/2017 aprobado: 15/02/2018 doi: 10.5294/aqui.2018.18.2.3 para citar este artículo / to reference this article / para citar este artigo carvajal hermida ey, sánchez-herrera b. “nursing care with a human approach”: a model for practice with service excellence. aquichan 2018; 18(2): 149-159. doi: 10.5294/aqui.2018.18.2.3 abstract objective: develop a model of care for clinical the practice that allows for a continuous improvement in nursing care at the fundación santa fe university hospital in de bogotá (fsfb). materials and methodology: this is a descriptive methodological study developed in sequential phases that included: 1) identification of the need to have a model of care for nursing practice; 2) a characterization of the context and the desired scenario; 3) a literature review; 4) a description of the model; and 5) validation of the theoretical proposal. the study was conducted in 2016. results: the global trend in the use of nursing models in clinical practice recognizes common aspects and emphasizes relevance, methodologies and different roles in their implementation. the context and projection of excellence for nursing at the fsfb necessitated the evident orientation of a model for the practice that guides care and responds to the vocation of service centered on the experience of human health. conclusion: the model known as "nursing care with a human approach" helps to understand and communicate the essential components of nursing at the institutional level. it also develops parameters to measure and qualify nursing practice at the fsfb on a permanent basis. keywords nursing models; nursing theory; nursing care; nursing methodological research; patient focused care (source: decs). año 18 vol. 18 nº 2 chía, colombia abril 2018 l 149-159 the topic: theory based practice contribution to the discipline: a nursing professional practice model, such as the one developed in this study, allows us to reflect and focus on the practice of nursing, and to generate a collective vision and a common language to communicate developments and significant advances. this model also intends to be understandable and close to daily practice, to build identity, to have bases that allow for the generation of scientific evidence, to mobilize collective leadership by generating conditions of empowerment for nursing, and, thus, to achieve an autonomous practice that cares for the experience of people in whichever health condition they may find themselves. in that sense, this work responds to the most significant global trends in the development of the professional discipline of nursing. 1 orcid.org/0000-0001-8751-6867. former director of nursing at the fundación santa fe de bogotá, university hospital in bogotá, colombia. 2 orcid.org/0000-0002-8029-7187. professor of high academic prestige, school of nursing and rehabilitation, universidad de la sabana, colombia. clara.sanchez@unisabana.edu.co 150 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 2 chía, colombia abril 2018 l 149-159 modelo “cuidado de enfermería con enfoque humano” para una práctica con excelencia en el servicio resumen objetivo: desarrollar un modelo de atención para la práctica clínica que permita una mejora continua en la atención de enfermería en el hospital universitario de la fundación santa fe de bogotá (fsfb). materiales y metodología: este es un estudio metodológico descriptivo desarrollado en fases secuenciales que incluyó: 1) identificación de la necesidad de tener un modelo de atención para la práctica de la enfermería; 2) una caracterización del contexto y el escenario deseado; 3) una revisión de la literatura; 4) una descripción del modelo; y 5) validación de la propuesta teórica. el estudio se realizó en 2016. resultados: la tendencia global en el uso de modelos de enfermería en la práctica clínica reconoce aspectos comunes y enfatiza la relevancia, las metodologías y los diferentes roles en su implementación. el contexto y la proyección de la excelencia para la enfermería en la fsfb exigieron la orientación evidente de un modelo para la práctica que guía la atención y responde a la vocación de servicio centrada en la experiencia de la salud humana. conclusión: el modelo conocido como "atención de enfermería con un enfoque humano" ayuda a comprender y comunicar los componentes esenciales de la enfermería a nivel institucional. también desarrolla parámetros para medir y calificar la práctica de enfermería en la fsfb de manera permanente. palabras clave modelos de enfermería; teoría de enfermería; atención de enfermería; investigación metodológica de enfermería; atención centrada en el paciente (fuente: decs). 151 “nursing care with a human approach”: a model for practice with service excellence l elsa yolanda carvajal hermida y otro cuidados de enfermagem com uma abordagem humana”. modelos para uma prática com excelência no serviço resumo objetivo: desenvolver um modelo de atenção para a prática clínica que permita melhorar continuamente a atenção de enfermagem no hospital universitário da fundação santa fé de bogotá (fsfb). materiais e método: estudo metodológico descritivo, desenvolvido em fases sequenciais, que incluiu: 1) identificação da necessidade de ter um modelo de atenção para a prática da enfermagem; 2) caracterização do contexto e do cenário esperado; 3) revisão da literatura; 4) descrição do modelo e 5) validação da proposta teórica. o estudo foi realizado em 2016. resultados: a tendência mundial no uso de modelos de enfermagem na prática clínica reconhece aspectos comuns e enfatiza a relevância, as metodologias e os diferentes papéis em sua implementação. o contexto e projeção da excelência para a enfermagem na fsfb exigiram a orientação evidente de um modelo para a prática que guia a atenção e responde ao propósito de serviço centrado na experiência da saúde humana. conclusão: o modelo conhecido como “atenção de enfermagem com uma abordagem humana” ajuda a compreender e comunicar os componentes essenciais da enfermagem no âmbito institucional. também desenvolve parâmetros para medir e qualificar a prática de enfermagem na fsfb de maneira permanente. palavras-chave modelos de enfermagem; teoria de enfermagem; atenção de enfermagem; pesquisa metodológica de enfermagem; atenção centrada no paciente (fonte: decs). año 18 vol. 18 nº 2 chía, colombia abril 2018 l 149-159 152 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 introduction service teaching alliances respond to the call of worldwide trends that look to qualify nursing practice (1-5). recent advances in this field of nursing indicate these models are an appropriate response to the demands of the global agenda (6), and to the development of leadership required by the profession (7). they are a way of articulating the practice of nursing with the health system (8), complementing the theoretical development of other levels in the knowledge hierarchy (9, 10), and responding to the highest accreditation criteria, while allowing for a link between the academy and assistance (11), generating an impact on nursing practice (12). in the midst of the partnership between the nursing department at the fundación santa fe university hospital of bogotá (fsfb) and the faculty of nursing and rehabilitation at la sabana university (universidad de la sabana us), we identified the need to develop a model for practice or functional care that would allow for continuous improvement in the nursing task at the fsfb university hospital. the idea is to respond to the challenge of excellence in service, while focused on the care user, as has occurred in other contexts (13). methodology we summarized the contributions of partner institutions and those of the nursing staff currently working at the institution in order to develop a model for practice. this invaluable input was based on four decades of nursing work at the fsfb. the us contributed in the form of methodological support and validation by experts of national and international renown in the field of nursing ontology and epistemology. this descriptive methodological study sought to document and systematize nursing information in order to generate a practice model that allows for a better understanding of nursing care in the human health experience and within a specific institutional context. the study considered the ethical and environmental aspects in each of its phases. due to the methodological approach, it is considered a risk-free study. it was endorsed institutionally, respected the rights and credits of each of the authors consulted, and called for voluntary participation in each of its workshops and in the validation. we encouraged the rational use of resources throughout its development. the study included five different stages: 1. identify the need to develop a model for nursing practice in order for nursing, as a working group, to identify the need to develop a model for practice, there was an initial review and training on the characteristics and relevance of the use of nursing models in practice. to this end, we called upon each of the services provided by the institution, which together comprise an intramural and extramural practice that expresses the different roles of nursing (14). through nursing groupwork workshops at in the fsfb, advised by the us, we studied the hierarchy of knowledge and its relationship with the practice and development of nursing at the institution. the workshops were coordinated by the nursing department, with the participation of service coordinators, in addition to several strategic guests. 2. characterization of the context and desired scenarios we analyzed the trajectory and nursing situation at the fsfb by reviewing and examining the historical documents available in the nursing directorate, such as minutes and advisory reports and audits, including their vision for 2022 and their position and relationships within the framework of the mission, vision and development plan in force at the institution. 3. experience and global nursing trend review in the use of nursing models the next step in the process was to conduct an integrated review of the literature on nursing models applied to clinical practice. the review was developed with a 20-year observation window, in english and spanish, and included the revision of 17 databases, with the use of the meta-search engine “discoverer”. we developed this review following the steps proposed by ganong (15): selection of the research question; definition of inclusion criteria and selection of the sample; representation of the selected study tables, considering all the characteristics in common; critical analysis of findings, identifying complementarities, differences or conflicts; interpretation of results and communication of them. 4. description of nursing practice based on a care model based on an analysis of local and global contexts, and considering the state of the art and the desired scenario for nursing at the fsfb, we identified the meta-paradigmatic elements of nursing through a survey developed for this specific purpose. 153 “nursing care with a human approach”: a model for practice with service excellence l elsa yolanda carvajal hermida y otro the survey was applied to 145 nurses whose profile represented the nursing staff of the fsfb. we included professionals with different experience times, different shifts, services and academic levels. once we identified the profile of the participants, we asked whom the subjects of nursing care at the fsfb are, what is the goal of that care, in what context is it provided, and what is the role of nursing. in order to confirm what they perceived as the most important part of nursing practice at the fsfb, we asked the participants what made them most proud and what worried them that they would modify. from this exercise, and considering each of the responses received through the surveys, we achieved a description of the fundamental concepts for nursing practice. in a subsequent intervention, a new group of nurses from the institution participated in an exercise developed in small groups to see how these concepts were associated. this exercise produced the assumptions of care, which are the second component of the model. 5. validation of the model experts validated the concepts and assumptions internally and externally. this was done along with a cross analysis of congratulatory and complaint letters from patients and other health professionals. finally, we submitted the study to be reviewed by international peers with recognized experience, and the product was revised based on standards of evaluation of current nursing theory. results the study made it possible to understand why the development of a model to guide the practice of nursing based on care is essential to qualify it, since it allows nursing care to be guided to fulfill its true purpose. only by understanding the essentials of nursing care is it possible to respond to the commitment to institutional excellence. to accomplish this, it was necessary to identify what type of care-based model for practice was required, considering that it should respond to the institutional framework of highvalue service and be functional at the same time to reflect the commitment of nursing to care in service, when implemented. it was also determined that the model should allow for an indicator based on follow-up to guarantee a permanent improvement in four fields: humanization in care, risk management, knowledge management and technology management. with respect to characterization of the context and the desired scenario, and considering the institutional mission, we accepted the institutional vision of nursing, which states: by 2022, the nursing department at the fsfb university hospital will be able to lead practices in comprehensive care of the patient with family participation, which generate the best results for the recovery of health. it will be recognized nationally and internationally for the practice of nursing based on evidence, scientific input, teaching and research. it will be a source of improvement in practice innovation, assistance, teaching and an influential opinion leader on the strategic direction of the fsfb. it will lead health promotion and disease prevention programs that positively affect the quality of health in the community, and will be recognized for its participation in the generation and implementation of national health policies. the review of experiences and global trends in the use of nursing models allowed us to conclude that every nurse has a model, a theoretical perspective or an ideal that guides her/his practice, which, by making it explicit, allows the nurse to reflect on it. however, an institutional practice model based on care requires clear agreements in accordance with the mission and vision of each institution. for an institution, having a model of practice based on nursing care is a starting point to strengthen nursing autonomy by recognizing the fundamentals of the nurse’s work and qualifying them. a theory is the set of concepts, definitions and propositions that project a systematic vision of a phenomenon, designating the relationships and interactions between the concepts with the purpose of describing, explaining, predicting or controlling said phenomenon. in the case of nursing theories, these are statements that attempt to describe, explain, predict or control nursing as a phenomenon of study (16,17). within the review, we accepted fawcett’s scheme of knowledge hierarchy (18) and its interpretation for the practice of nursing by morse (19), understanding that at the highest level of abstraction is the metaparadigm of nursing or the basic agreement on what nursing is and that has to do with the care experience of human health. this metaparadigm is traversed by different philosophical conceptions of care that give different 154 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 meaning to its essential components, which include the subject of care, the nurse, the context and health. the result of these conceptions with respect to the four metaparadigmatic elements are the macro theories or conceptual models of nursing. in order to bring these conceptualizations into practice, they are applied through medium-range theories, which are closer to the tangible reality handled by the nurse, with a higher level of concreteness and a more restricted scope of action. finally, there are the micro theories of nursing, the highly specialized ones that allow us to measure specific phenomena the nurse faces in daily life. when talking about models at the last three theoretical levels, it should be noted that there are conceptual models at the macro-theoretical level, functional ones at the mid-range level, and specific models, practice guides, protocols or indicators of measurement of a specific phenomenon at the micro theoretical level (20). the same essential elements of the metaparadigm appear at all theoretical levels of nursing. in other words, they must express how the human health experience is taken care of and respond to who is cared for and where, what is taken care of, how and by whom. from its inception, nursing at the fsfb has had a reciprocal philosophy; it finds care in the interactive and integrative nature between the nurse and the subject of care. nursing at the fsfb is viewed as an exchange in which the patient-nurse relationship is fundamental. the nurse herself or himself must be well in order to provide care, and when caring she/he gains knowledge and experience as a caregiver. in turn, we see the patient, the family and even the community that receives care express their gratitude in different ways. nursing care models allow nursing to develop an intellectual activity, and for others to comply with orders to control and respond for their performance (21). they also help to generate change through our own knowledge, and to integrate nursing into the health system, which is why the use of such models is recommended as a guide to practice (22). conceptual models are a general theoretical guide for the thoughts and actions of nursing, hence the term macro theory, while the functional or practice models are a theoretical guide for the thoughts and actions of nurses in their daily lives, pursuant to the guidelines of a conceptual model. each one articulates and communicates a mental image of the order that must exist in the practice of nursing, by pointing out what their metaparadigmatic concepts are and the relationship between them (23). in the specific case of the fsfb, it was found that a practice model based on nursing care gives the nurse a general perspective of what is important as part of nursing practice in a specific institutional context, orienting it towards what it is valuable, and affecting the nature of the intervention that is performed. this model is only useful insofar as it does not remain solely on paper. this is the only way to better understand nursing practice as a requisite and, therefore, to be able to improve it by strengthening the nurse’s professional identity. the model determines processes and indicators of care in practice, supports an analysis of intangible processes that affect the results of care, and helps to determine factors that affect nursing care either positively or negatively. moreover, it guides the evaluation and improvement of nursing care. once we reviewed and clarified the general theoretical aspects of the nursing exercise as a professional discipline, we then proceeded to choose the best practice model for the fsfb. this was done based on identification of what the members considered to be their ideal model. one hundred forty-five (145) professional nurses participated in this exercise and were distributed as follows: 22.8% had less than a year’s experience; 29.7% had from one to five years; 15.2%, from six 6 to 10 years; 17.2%, from 11 to 20 years; and 9.0%, from 21 to 30 years of experience. in all, 6.2% of the nurses who took part did not answer this question. regarding the shifts the nurses work, 22.1% said they did it in the morning, 18.0% in the afternoon, 22.8% at night, 14.5% all day, 17.2% rotated schedules, and 6.2% did not answer the question. the academic level of the nurses who participated reflects the training pattern of the fsfb. specifically, 4.1% were students, 51.7% had an undergraduate degree, 2.8% had a postgraduate degree with no specific level, 27.6% had a specialization, 5.5% had a master’s degree, 0.7%, had a doctorate, and 7.6% of the nurses did not respond to the question. regarding the services in which they work, it was found the nurses who took part came from all the different areas of the institution. these include emergency services, the renal unit, the intensive care unit, pulmonary rehabilitation, radiology, oncology, internal medicine, hospitalization, obstetrics and gynecology, 155 “nursing care with a human approach”: a model for practice with service excellence l elsa yolanda carvajal hermida y otro clinical management, management, coordination and nursing management, palliative care, education, urology, the wound clinic, surgery and outpatient services. when asked about who they recognize as the subject of nursing care at the fsfb, most of them indicated they see it as the human being (60%), followed by the person with an illness and a family or family caregiver (22.8%), the person, family or community that requires care (8.3%), the patient or the healthy or ill family (4.8%), and the healthy or ill person or family 4.1%. the goal of care for nursing practice reflected that most people expect a better quality of life, recovery, comfort or wellbeing (95.9%). as for the context of care that is kept in mind when caring for the subject, in order to know if it is limited to the hospital environment or transcends the daily life of the person, family or community, the participants, in general, answered that this is where the subject is and needs to be cared for (100%). given the definition of the role of nursing in light of the subject of care, the importance of the nursing process as a fundamental tool of that care was evident (66.2%). the respondents also highlighted education (12.41%), company (6.9%), encouragement of comfort (3.4%), and other responses (3.4%). they identified human care and the development of human potential as the most important aspect of nursing practice at the fsfb. they also were most disturbed by the workload, which was expressed in terms of the number of patients assigned, and hoped for a more equitable distribution. this exercise showed the description of the fundamental components for nursing practice to be the following: the subject of nursing care is the human being. this subject, who can be a healthy or ill person, a family caregiver, a family and even a community, needs to be cared for. the nurse focuses his/her work on human care, based on the nursing process that assesses, diagnoses, plans, executes and evaluates this care, considering the integrality, totality, safety and continuity required by the care subject at different times and in different scenarios. by attending to the subject of care, the nurse comforts, educates to maintain or restore health, prevent illness or prevent complications, and accompanies the subject of care during the disease process, in recovery or at the end of life, while coordinating activities in favor of said subject with other professionals and growing in his/her their own capacity to provide care. the goal of nursing care is to seek the healthiest condition for the subject of care, with the best possible quality of life, doing so constantly, dynamically, comfortably and while caring for the subject’s well-being. this goal assumes that integrity in the identification and satisfaction of the subject’s needs and expectations is maintained by preventing complications and supporting the subject so their normal condition is restored, or the subject can adapt to a new state. the context of nursing care is the place where the nurse interacts with the subject, in person or using information and communication technologies. this includes the infrastructure of the university hospital with its different services, the home, or another context in which the subject of care is located. the relationship between these concepts resulted in the second component of the model; that is, the assumptions of care. here, and by way of example, we cite 12 of the 25 defined cases: 1. the nurse who gives nursing care with a human focus prioritizes the subject of care in the care she or he provides. 2. prioritizing and involving the subject of care in the care being provided allows nursing to identify the subject’s needs, appropriately use technology, and make the right decisions regarding care. 3. application of the nursing process as part of the service makes it possible to transform care into nursing care with a human approach. 4. a care plan with a human approach based on the nursing process can be partially standardized. 5. nursing care with a human approach must be individualized, safe, continuous, reliable, and focused on the needs of the subject of care. 6. nursing care with a human approach requires self-recognition, knowledge, commitment, competence, decision, education, participation and teamwork. 156 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 7. giving and receiving nursing care with a human approach gratifies and generates well-being for those who participate in this interaction. 8. an adequate environment for nursing care with a human approach must be available and have sufficient physical and technological resources that help to guarantee the care subject’s welfare and quality of life. 9. nursing care with a human approach, along with the appropriate time, attitude and knowledge, reflects nursing autonomy. 10. a nurse who provides nursing care with a human approach cares for the right environment for the subject (s) of care. 11. the institutional environment must reflect respect for differences, facilitate timely attention, and promote the importance and participation of the subject in his or her own care. 12. the availability and adequate use of technology, including information and communication technologies, constitute part of the requirements for nursing care with a human approach. as for the internal validation, the nurses found the model reflected their ideal of practice and was familiar to them. on the outside, the experts suggested an analysis of coherence with the institutional mission and vision, based on the quality parameters of the fsfb, and an analysis of the comprehensibility of the product, which also needs to be diagrammed to communicate it in a simpler way. the other professionals indicated the model allowed them to understand aspects of nursing that they did not know beforehand and were compatible with the work developed in other areas of the institution, which places a priority on service, a user-centered practice, and the quality of care that users look for. the opinions of the patients coincided with these approaches, especially with respect to the assessment of the human approach, which the patients perceived as being warm and personalized treatment in the midst of complex life situations that affect their health. international nursing peers of the fsfb reviewed the name of the model, and allowed several clarifications to be made when editing this document. finally, the analysis of theoretical development confirmed that it meets banum’s the criteria of internal and external criticism, the theoretical description and critical reflection of chin and kramer, the analysis and evaluation proposed by the models and theories of fawcett, the parse process, and the criteria for a nursing theory in line with the mid-range practice and external analysis proposed by whall (24). discusion the pertinence of these theoretical models to guide the practice of nursing is not subject to discussion, due to an important disciplinary consensus (21, 25-28). in colombia, for example, the use of models produced changes from professionalization to professionalism, and their application has become increasingly frequent (29), thus seeking to guide excellent care, as claimed by the fsfb. when reviewing the model that should be used for clinical practice, we found it works with similar purposes, but with a different methodological approach (30). in this case, the advances of the nursing department at the fsfb allowed us to conduct a reflective deductive exercise, and through it, to make the make the agreements on care explicit. the exercise, which calls for the collective participation of institutional nursing, has starting points similar to those of successful exercises that have been reported previously at the international level (31, 32). some of them have led to an improvement in the delivery of care, with positive results for patients and service personnel (33, 34). others have been shown to empower the nursing staff (35) and to help strengthen leadership capacity (36), based on adjustments in the work schedules of nurses. they have also helped to strengthen, in a special way, the autonomy and dignity of the people who are being cared for (37). in this case, establishment of the model known as “nursing care with a human approach,” based on a care practice model (38), allows for nursing practice at the fsfb with principles of excellence, and is an important step in the approach between theory and practice in order to qualify it. because of its very nature, which begins with the everyday reality of nursing practice to identify the theoretical guide that allows for its improvement, the next step will be to make the relationship with a conceptual human care model of nursing evident. 157 “nursing care with a human approach”: a model for practice with service excellence l elsa yolanda carvajal hermida y otro conclusion theoretical models of nursing have existed since the beginning of the discipline. they help to visualize and qualify clinical practice, and respond to the nursing paradigm of caring for the human health experience. these nursing models, applied to clinical practice, can transform it since they allow for improvement that results in greater professional autonomy. nursing care models focus on service provided to the subject of care, and help us to understand the subject’s interaction with the environment and with the nurse in order to preserve the subject’s health. the implementation of models favors the quality of the institutional service, nursing training, research in care, and the construction of public policy. it is necessary to evaluate the effect of this implementation, through the indicators of such models, and to document this process in an effort to support the development of nursing knowledge and practice. the practice model known as “nursing care with a human approach,” which was developed based on an internal and external analysis of nursing practice, helps to understand this practice by communicating its essence and qualifying it permanently to achieve the excellence desired for the fsfb university hospital. conflict of interes: the authors declare no conflict of interest. special thanks our thanks go to all the nurses whose contributions made this work possible. we also wish to thank the directors of the fsfb for their support and commitment to the development of nursing as an axis of institutional quality, and dr. karen haller, vice president of nursing and clinical affairs of johns hopkins, for her review and contributions. in addition, we would like to give special acknowledgement to the support provided by our colleagues from the us, an 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nursing care in cancer. invest educ enferm. 2014; 32(2):206–15. 31. parreira p, freitas m, marôco j. a nursing staff model: the impact in nursing care / un modelo de personal de enfermería: el impacto en la atención de enfermería. international j integr care. 2015;15(8). 32. edmundson e. the quality caring nursing model: a journey to selection and implementation. j pediatr nurs. 2012; 27(4):411–5. 33. cann t, gardner a. change for the better: an innovative model of care delivering positive patient and workforce outcomes. collegian. 2012;19(2):107–13. 159 “nursing care with a human approach”: a model for practice with service excellence l elsa yolanda carvajal hermida y otro 34. luther v, hammersley d, chekairi a. improving patient handover between teams using a business improvement model: pdsa cycle. br j hosp med (lond). 2014; 75(1):44–7 35. maxson-cooper pa. empowering nurses through an innovative scheduling model. nurs clin north am. 2011; 46(1):59–65. 36. shalala de. nursing 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(17 rese\321as.pdf) reseñas 153 el cuidado hace parte de la enfermería, es la esencia de su quehacer, es igualmente una actividad inherente a la vida. para enfermería, este cuidado se da como resultado de un proceso de formación, pero no siempre se hace visible su realidad como una práctica informal o de cuidado familiar, como lo afirma y demuestra carmen de la cuesta b., en su libro cuidado artesanal la invención ante la adversidad. la sólida formación académica de su autora, su experiencia y amplia trayectoria como profesora titular e investigadora de la facultad de enfermería de la universidad de antioquia, se ven reflejados en esta nueva obra. a través del estudio cualitativo se acerca a comprender el cuidado familiar de pacientes con demencia avanzada utilizando la teoría fundamentada. el libro está organizado en seis capítulos. la autora no se pierde en el mundo de las demencias, al contrario, es a través de éste que encuentra un nuevo camino inesperado y maravilloso, que convierte a los cuidadores familiares en artesanos, quienes con paciencia, creatividad y amor establecen nuevas formas de acoger, ayudar y proteger, es decir, de cuidar. la obra permite apreciar la enorme riqueza y complejidad de estos cuidadores en contextos tan dolorosos y adversos como los estados avanzados de demencia. el cuidado que proporcionan va más allá de la descripción de una serie de tareas y actividades cotidianas; la autora profundiza hasta llegar a la idea del cuidado artesanal. refleja el oficio de los cuidadores familiares en la adversidad y el dolor que produce la demencia de sus seres queridos quienes sufren �la enfermedad del olvido�. es una obra original, plasmada de emoción, afecto y ternura, con una amplia y rigurosa revisión bibliográfica y un dominio de la metodología cualitativa y la teoría fundamentada. la autora encuentra una nueva ruta en el hacer del cuidador, es una ruta sorprendente que refleja el valor del cuidado familiar; sin embargo, afirma que existe un gran desconocimiento de la realidad y del mundo cotidiano de estos cuidadores. en la familia todos cuidan, por lo tanto, es difícil encontrar un cuidador principal. �los cuidadores son artesanos en el sentido que crean un trabajo que es útil y estético�. para la autora, el hallazgo principal del estudio �cuidado familiar de pacientes con demencia avanzada� es la categoría de artesanía del cuidado, e invita a la realización de nuevos y futuros estudios que permitan ampliar la comprensión de este tema. maría clara quintero laverde profesora asociada, universidad de la sabana, colombia. cuidado artesanalla invención ante la adversidad carmen de la cuesta b. medellín, editorial universidad de antioquia, 2004, 223 págs. 186 197 indicadores de calidad de la atencion.indd 186 carolina puchi-gómez1 tatiana paravic-klijn2 alide salazar3 indicadores de calidad de la atención en salud en hospitalización domiciliaria: revisión integradora 1 orcid.org/0000-0001-7042-7016. universidad de concepción, chile. caropuchi@udec.cl 2 orcid.org/0000-0002-4034-0187. universidad de concepción, chile. tparavic@udec.cl 3 orcid.org/0000-0002-6427-0515. universidad de concepción, chile. alisalaz@udec.cl recibido: 07/04/2017 enviado a pares: 02/05/2017 aceptado por pares: 28/08/2017 aprobado: 15/02/2018 doi: 10.5294/aqui.2018.18.2.6 para citar este artículo / to reference this article / para citar este artigo puchi-gómez c, paravic-klijn t, salazar a. indicadores de calidad de la atención en salud en hospitalización domiciliaria: revisión integradora. aquichan 2018; 18(2): 186-197. doi: 10.5294/aqui.2018.18.2.6 resumen objetivo: describir la producción empírica sobre indicadores para evaluar la calidad de la atención en salud otorgada a usuarios de unidades de hospitalización domiciliaria (hd). materiales y métodos: se realizó una revisión integradora en las bases pubmed, web of science, ibecs, scielo y biblioteca cochrane. el periodo de búsqueda se extendió del año 1990 hasta el 2017. resultados: se hallaron 10 documentos, de los cuales 6 correspondieron a artículos originales y 4 a revisiones sistemáticas. solo en 3 de los 6 artículos originales hallados se mencionaron indicadores relacionados con reingresos hospitalarios no planificados, llamadas telefónicas no planificadas realizadas por los pacientes y/o el equipo de salud de hd, negativa de los pacientes a ser ingresados a hd y errores en la administración de medicamentos. conclusión: la investigación de la evaluación de la calidad de la atención en salud en hd mediante indicadores ha tenido un escaso desarrollo, especialmente en enfermería. los indicadores pesquisados han sido desarrollados solo en algunos países europeos, pero sin reportar bases conceptuales claras y sin asegurar la solidez científica y factibilidad de las medidas. palabras clave indicadores de servicios; calidad de la atención de salud; servicios de atención a domicilio provisto por hospital; indicadores de calidad de la atención de salud; investigación en administración de enfermería (fuente: decs). año 18 vol. 18 nº 2 chía, colombia abril 2018 l 186-197 temática: práctica basada en la evidencia aporte a la disciplina: existen escasos indicadores que midan la calidad de la atención en salud en hospitalización domiciliaria desde la perspectiva de enfermería. se puede mejorar la calidad de los servicios de enfermería con la definición de criterios que se traduzcan en indicadores que garanticen las condiciones indispensables para que los cuidados que proporciona enfermería se otorguen con oportunidad y equidad, en un ambiente seguro, eficiente, eficaz y centrado en el paciente en todas las unidades de hospitalización domiciliaria. 187 indicadores de calidad de la atención en salud en hospitalización domiciliaria: revisión integradora l carolina andrea puchi-gómez y otros año 18 vol. 18 nº 2 chía, colombia abril 2018 l 186-197 indicators of the quality of health care in home hospitalization: an integrative review abstract objective: describe the empirical production of indicators to evaluate the quality of health care provided to users of home hospitalization units (hh). materials and methods: an integrative review was conducted using the pubmed, web of science, ibecs, scielo and the cochrane library databases. the search period went from 1990 to 2017. results: ten (10) documents were found: six original articles and four systematic reviews. only three of the six original articles in question mention indicators related to unplanned hospital readmissions, unplanned telephone calls made by patients and / or the hh health team, refusal of patients to be admitted to hh, and errors in the administration of medication. conclusion: research on evaluation of the quality of health care in hh using indicators is very limited, especially in the field of nursing. the researched indicators were developed only in several european countries, but with no clear conceptual basis and without ensuring the scientific soundness and feasibility of the measurements. keywords service indicators; quality of health care; home care services provided by the hospital; health-care quality indicators; research in nursing administration (source: decs). 188 aquichan issn 1657-5997 eissn 2027-5374 indicadores de qualidade da atenção em saúde na hospitalização domiciliar: revisão integrativa resumo objetivo: descrever a produção empírica sobre indicadores para avaliar a qualidade da atenção em saúde outorgada a usuários de unidades de hospitalização domiciliar (hd). materiais e método: realizou-se uma revisão integrativa nas bases pubmed, web of science, ibecs, scielo e biblioteca cochrane. o período de busca foi de 1990 a 2017. resultados: foram encontrados 10 documentos, dos quais 6 corresponderam a artigos originais e 4 a revisões sistemáticas. somente em 3 dos 6 artigos originais, mencionaram-se indicadores relacionados com reinternação hospitalar não planejada, ligações não esperadas pelos pacientes e/ou pela equipe de saúde de hd, negativa dos pacientes a serem inseridos na hd e erros na administração de medicamentos. conclusão: a pesquisa da avaliação da qualidade da atenção em saúde em hd, mediante indicadores, tem tido pouco desenvolvimento, especialmente em enfermagem. os indicadores pesquisados foram desenvolvidos somente em alguns países europeus, mas sem relatar bases conceituais claras e sem garantir a solidez científica e factibilidade das medidas. palavras-chave indicadores de serviços; qualidade da atenção de saúde serviços de atenção domiciliar oferecidos pelo hospital; indicadores de qualidade da atenção de saúde; pesquisa em administração de enfermagem (fonte: decs). año 18 vol. 18 nº 2 chía, colombia abril 2018 l 186-197 189 indicadores de calidad de la atención en salud en hospitalización domiciliaria: revisión integradora l carolina andrea puchi-gómez y otros introducción actualmente, en las instituciones de salud tanto públicas como privadas existe un creciente interés por evaluar la calidad de la atención (1), más aún cuando se trata de evaluar programas o servicios de salud nuevos o se intenta implementar procedimientos de mayor complejidad. instituciones como la organización mundial de la salud (oms) (2), el instituto de medicina de estados unidos (3) y la organización para la cooperación y el desarrollo económico (ocde) (4) sugieren que un sistema de salud debe considerar mejoras en seis áreas o dimensiones de la calidad de la atención en salud para obtener buenos resultados en los cuidados que se otorgan a los usuarios del sistema sanitario (2, 3). estas dimensiones son: efectividad, eficiencia, oportunidad, atención centrada en el paciente, equidad y seguridad (2). una modalidad asistencial que surgió como respuesta a la creciente demanda asistencial hospitalaria y los altos costos vinculados a procesos diagnósticos y tratamientos de enfermedades agudas y crónicas descompensadas fue la hospitalización domiciliaria (hd) (5, 6), alternativa asistencial del sector salud que consiste en un modelo organizativo capaz de dispensar un conjunto de atenciones y cuidados médicos y de enfermería de rango hospitalario, tanto en calidad como en cantidad, a los pacientes en su domicilio, cuando ya no precisan de la infraestructura hospitalaria pero todavía necesitan vigilancia activa y asistencia compleja (7). este tipo de cuidados, otorgados en un contexto domiciliario, requieren ser evaluados desde el punto de vista de la calidad así como cualquier otro servicio de salud convencional (8), con el propósito de demostrar, como mínimo, su eficacia, eficiencia y seguridad en la atención a los usuarios. la calidad de la atención en salud es una prioridad para enfermería (9), por tanto, es de interés para la disciplina en la medida en que incorpora en su abordaje la calidad del cuidado que se brinda. diversos autores manifiestan que las enfermeras son moral y legalmente responsables de otorgar cuidados de calidad, y que esto debería estar representado en la práctica profesional (10). las enfermeras están bien posicionadas para trabajar en pro de la mejora de la calidad en las instituciones de salud, ya que son los profesionales de la salud que pasan más tiempo junto al paciente y, por tanto, están en una posición particularmente buena para influir de manera positiva en la experiencia y los resultados de los usuarios (11). una de las formas de lograr una atención en salud de calidad y, por ende, cuidados de enfermería de calidad es a través del desarrollo de investigación en los ámbitos de trabajo de enfermería como lo es la hospitalización domiciliaria. la medición de un concepto abstracto como la calidad de la atención en salud necesita de una operacionalización cuantitativa que permita comparaciones en el tiempo y en el espacio, y la determinación de patrones que consideren la identificación de fallos o logros (12). la medida cuantitativa que se ha utilizado por excelencia para lograr dicho cometido ha sido el indicador (13). este corresponde a una serie estadística o cualquier forma de indicación que, según bauer (14), “facilita estudiar dónde estamos y hacia dónde nos dirigimos con respecto a determinados objetivos y metas, así como evaluar programas específicos y determinar su impacto”. la calidad de la atención en salud en hd ha sido medida en distintos países mediante diferentes métodos, principalmente a través de resultados clínicos u outcomes (15, 16) e indicadores simples (17) desarrollados sin un marco teórico claro y que, según plantea el institute of medicine (iom) (18), solo tributan a algunas dimensiones de la calidad de la atención en salud. esta situación evidencia que no se ha logrado evaluar la calidad de la atención en salud en hd de manera integral, lo que hace necesario generar indicadores que tributen a todas las dimensiones de la calidad de la atención en salud. de acuerdo con lo anterior, se planteó la siguiente pregunta orientadora: ¿cuál es la producción empírica en torno al desarrollo de indicadores para evaluar la calidad de la atención en salud otorgada a usuarios adultos de unidades de hospitalización domiciliaria diagnosticados con patologías agudas a nivel mundial? el objetivo de esta revisión se centra en describir la producción empírica sobre indicadores para evaluar la calidad de la atención en salud otorgada a usuarios de unidades de hospitalización domiciliaria. materiales y métodos se desarrolló una revisión integradora de la literatura mediante la ejecución de las seis etapas planteadas por ganong (19): 1) preparación de la pregunta orientadora; 2) establecimiento de criterios de inclusión y exclusión de los estudios; 3) recolección de los datos; 4) análisis crítico de los estudios incluidos; 5) discusión de los resultados; y 6) presentación de la revisión integradora. la pregunta de investigación que guió la búsqueda bibliográfica fue formulada mediante la estrategia pio (tabla 1), la cual 190 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 sirve para mejorar la especificidad y claridad conceptual de los problemas clínicos por estudiar, así como para realizar búsquedas que arrojen resultados con mayor calidad y precisión (20). es importante mencionar que originalmente esta estrategia de búsqueda recibe el nombre de pico (population, intervention, comparison y outcome), pero en el presente estudio no se utilizó el componente “c” ya que no se buscó comparar alternativas de intervención (20), por tanto, se omitió dicha letra. tabla 1. descripción de los componentes pio en la búsqueda bibliográfica en estudio cuidados paliativos domiciliarios, cuidados domiciliarios otorgados por atención primaria o comunitarios, o cuidados domiciliarios otorgados por cuidadores informales o familiares. posteriormente, para responder a la pregunta de investigación, se identificaron palabras relacionadas con los términos de cada elemento de pio (tabla 2) que orientaron la búsqueda bibliográfica (21). a todos los descriptores indicados se les agregó el operador de búsqueda and y el término “healthcare quality indicators”. las bases de datos consultadas fueron web of science, pubmed, scielo, ibecs (índice bibliográfico español en ciencias de la salud) y biblioteca cochrane. se usaron los siguientes filtros para las cuatro primeras bases de datos: año de publicación (1990-2017); tipo de documento (artículo o revisión); lenguaje (español, inglés, portugués, francés e italiano); disponibilidad del texto (full text). para realizar la búsqueda en la biblioteca cochrane se usó el filtro “review”. tabla 2. palabras clave relacionadas con cada elemento de pio acrónimo y componente descripción componentes p (paciente) pacientes adultos de 18 o más años ingresados a unidades de hospitalización domiciliaria a nivel mundial. i (intervención) intervención terapéutica de patologías agudas, es decir, tratamientos médicos o cuidados de enfermería que requieran administración de medicamentos por vía parenteral o rehabilitación, que sean proporcionados en el domicilio del paciente por un equipo de salud proveniente del hospital. corresponden entonces a cuidados en el domicilio que se desarrollarían en un hospital si no existiese hospitalización domiciliaria. o (outcome o resultado) indicadores de la calidad de la atención en salud otorgada a pacientes de hospitalización domiciliaria tales como reingresos, mortalidad, eventos adversos u otros. deben estar explicitadas las fórmulas para la construcción de los indicadores. fuente: adaptado de landa-ramírez y arredondo-pantaleón (20). el periodo de estudio se extendió desde el año 1990 hasta el año 2017. los criterios para la inclusión de los artículos seleccionados fueron: artículos primarios publicados, completos, o revisiones sistemáticas que abordasen la evaluación de la calidad de la atención en salud otorgada a usuarios adultos o adultos mayores que cursaran con patologías agudas en una unidad de hospitalización domiciliaria. los criterios de exclusión fueron: carta, editorial, estudio de caso, artículos de opinión; evaluaciones de calidad de la atención en salud otorgada a menores de 18 años; palabras clave p i o adult aged aged, 80 and over acute disease home care services-hospital-based home care services hospital at home hospital in the home hospitalisation á domicile hospital care at home hospital based at home healthcare quality indicators fuente: adaptado de landa-ramírez y arredondo-pantaleón (20). la primera búsqueda arrojo un listado de 1674 estudios. luego de eliminar los artículos duplicados se obtuvo un total de 617 estudios. la evaluación de los artículos incluidos en la revisión se realizó con la lectura de los títulos de las publicaciones, se eligieron aquellos en los cuales se hiciera explícito el tema de evaluación de la calidad de la atención en salud en hospitalización domiciliaria mediante indicadores. en los artículos donde se presentaba duda respecto al tema, se realizó lectura completa de los resúmenes. se hizo una lista de los estudios potencialmente relevantes, los cuales se identificaron y seleccionaron, para finalmente aplicar los criterios de selección y conformar un listado 191 indicadores de calidad de la atención en salud en hospitalización domiciliaria: revisión integradora l carolina andrea puchi-gómez y otros de 10 títulos. de esta manera, se hallaron documentos como lo muestra la figura 1 desarrollada según el marco analítico salsa (22) (search, appraisal, synthesis and analysis), constituido por 4 pasos críticos –búsqueda, evaluación, síntesis y análisis–, los cuales se utilizan para caracterizar los distintos tipos de revisiones de la literatura disponibles. figura 1. diagrama de flujo de la información del método salsa aplicado a la revisión integradora en estudio periodo de búsqueda fue entre los años 1990 y 2017, pero solo se encontraron publicaciones hasta el año 2012. entre las bases de datos consultadas, 5 documentos pertenecían a pubmed y el resto de los estudios fueron encontrados en librería cochrane y en el ibecs. tabla 3. caracterización de los documentos incluidos en la revisión integradora fuente: adaptado de grant y booth (22). una vez finalizada la búsqueda, se realizó la etapa de interpretación de los resultados. la última etapa de síntesis del conocimiento muestra un análisis descriptivo de los resultados por categorías. los documentos se agruparon según las categorías “indicadores” y “resultados clínicos”. resultados del total de documentos hallados (n = 10), 6 correspondieron a artículos originales y 4 a revisiones sistemáticas (tabla 3). el autores a ño pu bl ic ac ió n ti po d e do cu m en to revista país base de datos in di ca do re s ex pl íc it os r es ul ta do s c lín ic os kramer 1990 artículo original the milbank quarterly estados unidos pubmed no no shepperd 1998 revisión sistemática j public health med gran bretaña pubmed no sí montalto 1999 artículo original int j qual health care australia pubmed sí no mazo 2006 artículo original rev calidad asistencial españa ibecs no sí lui 2007 artículo original aust fam physician australia pubmed sí sí shepperd 2008 revisión sistemática librería cochrane reino unido librería cochrane no sí montalto 2010 artículo original aust health rev australia pubmed sí sí shepperd 2011 revisión sistemática librería cochrane reino unido librería cochrane no sí jimenez 2011 artículo original med clin (barc) españa ibecs no sí jeppesen 2012 revisión sistemática librería cochrane noruega librería cochrane no sí fuente: elaboración propia. en 4 de los documentos recuperados, que correspondieron a las revisiones sistemáticas, solo se identificaron resultados clínicos u outcomes relacionados con dicha modalidad asistencial. en 3 de los 10 estudios hallados se especificó de manera explícita la fórmula de los indicadores que evaluaban la calidad de la atención en salud en hospitalización domiciliaria. en el resto de los artículos originales (n = 3) se mencionaron indicadores, pero no su fórmula. a continuación se describen los resultados según las categorías “indicadores” (tabla 4) y “resultados clínicos”. 192 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 tabla 4. indicadores para evaluar la calidad de la atención en salud en hospitalización domiciliaria llazgos obtenidos mediante la revisión de la literatura disponible en este tema. de esta forma, se definieron 5 indicadores clínicos para hospitalización domiciliaria: indicador 1: llamadas telefónicas no programadas (inesperadas) recibidas por los pacientes de hospitalización domiciliaria durante su estadía; indicador 2: describe la tasa de llamadas realizadas por el equipo a los pacientes de hospitalización domiciliaria durante su estadía; indicador 3: se refiere a la negativa de los pacientes a ser ingresados a hospitalización domiciliaria; indicador 4: se refiere a los reingresos hospitalarios no planificados de pacientes durante su estadía en hospitalización domiciliaria; indicador 5: aborda los errores de administración de medicamentos en hospitalización domiciliaria. mazo y emparán (24) desarrollaron un estudio cuyo objetivo fue delimitar los indicadores establecidos en un plan de implementación de una unidad de hospitalización domiciliaria en españa con el empleo de 2 herramientas de gestión de calidad: el cuadro de mandos integral (cmi) y un proceso asistencial que sigue la normativa iso 9001:2000. el trabajo se realizó en cuatro fases donde se incluían mapas de proceso, indicadores asistenciales y de gestión y sistemas de información del hospital de origen de la unidad de hd, así como información de otras unidades de hd. de esta manera se seleccionaron 15 indicadores estratégicos en el cmi y 10 indicadores del proceso asistencial. los autores no explicitaron la fórmula para su cálculo en el estudio. con base en algunos de los indicadores propuestos por el australian council on healthcare standards (achs) (25), los autores lui, tran y montalto (26) desarrollaron en el año 2007 un estudio retrospectivo de 5 años en una muestra de 21 pacientes adultos con diagnóstico de embolismo pulmonar hospitalizados en su domicilio. el objetivo de esta investigación fue examinar los resultados vinculados a la duración de la estancia, llamadas inesperadas del personal, los retornos inesperados al hospital, embolia recurrente, hemorragia y muerte de los pacientes que fueron trasladados a hd dentro de las 24 horas de la presentación para el tratamiento con heparina de bajo peso molecular (hbpm), así como los indicadores clínicos: tasa de llamadas realizadas por el equipo a los pacientes de hospitalización domiciliaria durante su estadía, reingresos hospitalarios no planificados de pacientes durante su estadía en hospitalización domiciliaria, fallecimiento durante la admisión a hd y tiempo de espera en el departamento de emergencia. nuevamente, montalto y lui, pero ahora junto a mullins y woodmason (27), realizaron un estudio cuyo objetivo fue determinar si la gestión médica de hd era un método seguro y efiautores indicadores montalto (1999) llamadas telefónicas no programadas (inesperadas) recibidas por los pacientes de hd durante su estadía. tasa de llamadas realizadas por el equipo a los pacientes de hd durante su estadía. negativa de los pacientes a ser ingresados a hd. reingresos hospitalarios no planificados de pacientes durante su estadía en hd. errores de administración de medicamentos en hd. lui (2007) tasa de llamadas realizadas por el equipo a los pacientes de hd durante su estadía. reingresos hospitalarios no planificados de pacientes durante su estadía en hd. fallecimiento durante la admisión a hd. montalto (2010) días de estancia. tasa de llamadas realizadas por el equipo a los pacientes de hd durante su estadía. llamadas telefónicas no programadas (inesperadas) recibidas por los pacientes de hd durante su estadía. reingresos hospitalarios no planificados de pacientes durante su estadía en hd. fallecimiento inesperado. fuente: elaboración propia. indicadores la evaluación y garantía de calidad en hospitalización domiciliaria fue estudiada por cuatro autores en el año 1990 (23). ellos utilizaron el término “indicador de calidad” para referirse a constructos, características de los pacientes o atributos de los servicios. de esta manera se definieron 16 grupos de indicadores de calidad relacionados con los diagnósticos médicos más prevalentes de los pacientes. luego, para cada uno de estos grupos se creó un total de 20 indicadores que se categorizaron en indicadores de resultados e indicadores de proceso. en este estudio no se explicitaron los indicadores propuestos. montalto, portelli y collopy (17) desarrollaron indicadores clínicos para evaluar el cuidado en hospitalización domiciliaria donde la selección de los mismos se llevó a cabo mediante grupos de trabajo integrados por profesionales que trabajaban en unidades de hd, y también por los ha193 indicadores de calidad de la atención en salud en hospitalización domiciliaria: revisión integradora l carolina andrea puchi-gómez y otros caz en la entrega de cuidado agudo hospitalario, y qué tipo de paciente, condición o tratamiento contribuía a un mayor riesgo de fracaso en el cuidado de estos pacientes en unidades de hd. en este estudio, los indicadores utilizados fueron: días de estancia (total de estancia en días y días de estancia en hd), tasa de llamadas realizadas por el equipo a los pacientes de hospitalización domiciliaria durante su estadía, llamadas telefónicas no programadas (inesperadas) recibidas por los pacientes de hospitalización domiciliaria durante su estadía, reingresos hospitalarios no planificados de pacientes durante su estadía en hospitalización domiciliaria y fallecimiento inesperado. jiménez et al. (28) desarrollaron un estudio que buscó comparar la calidad técnica, los resultados de salud y el grado de satisfacción de los pacientes ingresados en una unidad de hd desde urgencias, con aquellos que lo hicieron desde una sala de hospitalización convencional. los resultados en general no mostraron diferencias entre ambos grupos de pacientes, solo el tiempo de estancia hospitalaria fue inferior en los pacientes procedentes de urgencias. en este estudio los autores mencionaron indicadores de calidad técnica (número de derivaciones al hospital durante la hospitalización domiciliaria, ingresos hospitalarios, visitas a urgencias posteriores y desarrollo de infecciones multirresistentes y nosocomiales durante y tras el alta de la unidad de hd) pero, nuevamente, no expusieron la fórmula para el cálculo de los mismos. resultados clínicos todas las revisiones sistemáticas halladas (n = 4) mencionaron resultados clínicos para evaluar la calidad de la atención en salud otorgada a usuarios de hd. dentro de estos outcomes se encontraban complicaciones clínicas (por ej.: embolia, hemorragia) (26), carga del cuidador, capacidad funcional, retraso en la atención, mortalidad, reingreso hospitalario, costos, días de hospital ahorrados por traslado del paciente a hd, destino al alta hospitalaria, bienestar psicológico, satisfacción del paciente, satisfacción del cuidador (29), uso de broncodilatador y medidas de la función pulmonar, entre otros (30). discusión los resultados señalan el escaso desarrollo que existe respecto a la investigación de la evaluación de la calidad de la atención en salud en unidades de hospitalización domiciliaria mediante indicadores. la búsqueda bibliográfica solo arrojó 3 resultados vinculados a artículos originales que lograron generar indicadores para evaluar la calidad de la atención en estas unidades (17, 26, 27). el formato de construcción o fórmula de dichos indicadores aparece explícito en estas investigaciones, pero no así su clasificación, frecuencia de medida, umbral de cumplimiento, unidad de medida ni fuente de obtención de los datos. esta situación es relevante, ya que según la agency for healthcare research and quality (ahrq) de estados unidos (31), un indicador que evalúe la calidad de la atención en salud debería asegurar, entre otros, la solidez científica de la medida y su importancia relativa para los usuarios y el equipo de salud, y, además, especificar de manera explícita los datos necesarios para definir el numerador y denominador de cada medida (31). globalmente se observó que se suele utilizar el término “indicador” para nombrar resultados (outcomes) clínicos que no responden a la definición de dicho concepto; no se muestra la fórmula para construir el indicador; no se especifica la unidad de medida ni la frecuencia de medición, y no se explicita el umbral de cumplimiento ni la fuente de datos para el desarrollo de los mismos. preocupa que en esta revisión se constató además que ninguno de los documentos incluidos puso en evidencia con datos objetivos la validez de los indicadores propuestos (32, 33), ni tampoco queda claro de qué manera se basaron en la evidencia científica para generar dichos indicadores. asimismo, se observó gran disparidad en el foco de atención de los indicadores y outcomes entre los distintos autores ya que algunos (17, 26, 27) se centraron solo en variables relacionadas con el reingreso hospitalario no planificado y llamadas telefónicas inesperadas del paciente o del equipo, mientras que otros (16, 29) desarrollaron medidas de resultados clínicos basados en tópicos tan dispares como la satisfacción usuaria, capacidad funcional, destino al alta hospitalaria, bienestar psicológico, carga del cuidador, entre otros. esta variabilidad muestra que no existe consenso acerca de qué áreas de hospitalización domiciliaria se deberían evaluar para fundamentar con datos objetivos el nivel de calidad de atención en salud que se otorga en este tipo de unidades asistenciales. se debe considerar que el concepto de calidad de la atención en salud, según la organización para la cooperación y el desarrollo económico (ocde), el health care quality indicator (hcqi) project (4), proyecto que busca desarrollar un conjunto de indicadores que reflejen una imagen sólida de la calidad asistencial entre países, junto con la oms (34) y el instituto de medicina (3) identificaron 6 dimensiones a través de las cuales la calidad debería ser expresada (3, 34): la eficacia, la seguridad, la sensibilidad (centrada en el paciente), la oportunidad, la equidad y la eficiencia. por tanto, una 194 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 evaluación completa de la calidad de la atención en salud, en todo contexto asistencial, incluida la hd, debería considerar la valoración de dichas dimensiones en el planteamiento de su estrategia de evaluación. en esta revisión, la estrategia de evaluación de la calidad de la atención en salud correspondió al desarrollo de indicadores, y en ninguno de los estudios consultados que cumplieron con los criterios de elegibilidad según pio en este documento los autores consideraron evaluar desde dichas dimensiones el concepto de calidad de la atención en salud en hd. la calidad del cuidado es una de las principales preocupaciones de los profesionales de enfermería, y es hacia donde deben ir dirigidas todas las intervenciones con la meta de lograr el mejoramiento del cuidado proporcionado a los usuarios. la enfermera es la depositaria de la gestión del cuidado, entendida esta como la aplicación de un juicio profesional en la planificación, organización y control de la provisión de cuidados: directos, oportunos, seguros, integrales, continuos y personalizados, en el contexto de la atención en salud (35). el concepto de un cuidado seguro, que encierra la gestión del cuidado, es precisado por el consejo internacional de enfermeras (cie) que declara, entre otros, que el fomento de un entorno seguro es una función esencial de las enfermeras y que la seguridad de los pacientes es fundamental para una atención de salud y de enfermería de calidad (36). las contribuciones que han realizado enfermeras en el ámbito de la calidad de la atención en salud son amplias y abarcan diversas iniciativas, principalmente vinculadas a la evaluación de la misma en contextos hospitalarios (37-40). para enfermería, la preocupación por la calidad de la atención en salud se inició con florence nightingale. ella fue una de las primeras en desarrollar un enfoque teórico del mejoramiento de la calidad, abordó los compromisos con la calidad de la enfermería y la salud al identificar y trabajar para eliminar los factores que dificultaban los procesos de curación en los hospitales de la época. casi 140 años después, las ideas de nightingale continúan influyendo en nuestro panorama sanitario (41). estos hallazgos hacen evidente la importancia que tiene para enfermería el hecho de que los usuarios perciban como buenas las acciones de cuidado. no obstante, a pesar de que existe evidencia que muestra el rol de enfermería en el aseguramiento de la calidad de la atención en salud, su participación en investigaciones vinculadas a la calidad en hospitalización domiciliaria es escasa. la evidencia hallada respecto al tema en discusión tiene autoría en su mayoría médica (16, 17, 26), por lo que también los indicadores indagados tienen relación con complicaciones clínicas de esa índole, entre otras temáticas. esto es un llamado de atención para los profesionales de enfermería que trabajan en hd. es necesario generar una participación más activa de la profesión en la investigación de la calidad de la atención en salud en hd, pero desde la mirada de enfermería, recordando que son estos los profesionales que configuran la fuerza laboral más numerosa y la que está mayor tiempo junto al paciente y su familia cuando se otorgan cuidados en el domicilio (42). conclusión la hd es una modalidad asistencial que requiere ser validada desde el punto de vista de la calidad de la atención para convertirse en un servicio que responda de forma óptima a las necesidades de los usuarios. hoy en día, en todos los niveles asistenciales, la calidad y seguridad de la atención son una prioridad indiscutida y una meta que buscan alcanzar todas las instituciones sanitarias. los resultados logrados en esta revisión dejan de manifiesto el escaso desarrollo que existe respecto a la investigación de la evaluación de la calidad de la atención en salud en unidades de hd mediante indicadores. la calidad de la atención en salud en hd ha sido medida en distintos países con diferentes métodos, principalmente a través de resultados clínicos u outcomes, y, en menor medida, mediante indicadores, por lo que se plantea como imprescindible incrementar el desarrollo de estos últimos; en su construcción se debe asegurar la validez, factibilidad y fiabilidad de estas medidas, así como también, que logren evaluar de manera multidimensional el concepto de calidad de la atención en salud. esta revisión permitió tener una panorámica mucho más clara de cómo se ha abordado el estudio de la calidad de la atención en salud en unidades de hd, y el rol que enfermería ha tenido en ella. se observó escaso desarrollo de indicadores en esta temática desde el propio quehacer de enfermería, por lo mismo, se insta a construir nuevas teorías o modelos conceptuales que den respuesta a esta necesidad. limitaciones del estudio se plantea como gran limitación para el desarrollo de esta revisión integradora el que aún no exista un descriptor universal ampliamente utilizado para la modalidad asistencial hospitalización domiciliaria. a pesar de que existe el mesh (medical subject headings) “home care services hospital based”, los autores no identifican dicho concepto con hd y esto dificulta mucho la búsqueda bibliográfica de cualquier temática relacionada. conflicto de interés: ninguno declarado. 195 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[visitado 2015 jun 08];1. disponible en: http://www. enfermeria21.com/revistas/aladefe/articulo/146/. 501 512 o pensamento complexo.indd 501 fernanda hannah da silva copelli1 roberta juliane tono de oliveira2 claudia manuela siqueira de oliveira3 betina hörner schlindwein meirelles4 ana lúcia schaefer ferreira de mello5 aline lima pestana magalhães6 o pensamento complexo e suas repercussões na gestão em enfermagem e saúde 1 orcid.org/0000-0002-5914-2922. universidade federal de santa catarina. brasil. fernandacopelli@hotmail.com 2 orcid.org/0000-0003-4489-319x. universidade federal de santa catarina. brasil. roberta_tono@hotmail.com 3 orcid.org/0000-0002-0775-2243. universidade federal de santa catarina. brasil. claudiamanuela@hotmail.com 4 orcid.org/0000-0003-1940-1608. universidade federal de santa catarina. brasil. betina.hsm@ufsc.br 5 orcid.org/0000-0001-9591-7361. universidade federal de santa catarina. brasil. alfm@terra.com.br 6 orcid.org/0000-0001-7553-1648. universidade federal de santa catarina. brasil. aline.pestana84@gmail.com recibido: 03 de diciembre de 2014 enviado a pares: 28 de marzo de 2015 aceptado por pares: 24 de febrero de 2016 aprobado: 31 de marzo de 2016 doi: 10.5294/aqui.2016.16.4.8 para citar este artículo / to reference this article / para citar este artigo copelli fhs, oliveira rjt, oliveira cms, meirelles bhs, mello alsf, magalhaes alp. o pensamento complexo e suas repercussões na gestão em enfermagem e saúde. aquichan. 2016; 16 (4): 501-512. doi: 10.5294/aqui.2016.16.4.8 resumo objetivo: evidenciar o conhecimento científico sobre a teoria da complexidade nas publicações científicas sobre gestão em enfermagem e saúde. método: trata-se de uma revisão integrativa que foi realizada em maio de 2014, nas bases de dados lilacs, bdenf e pubmed por meio da combinação das seguintes palavras-chave: teoria da complexidade, pensamento complexo, edgar morin, enfermeiros, enfermagem, organização, administração, gestão e gerência. resultados: foram incluídos dez artigos. interpretação: evidenciou-se o crescimento da produção científica sobre o pensamento complexo na gestão de enfermagem e saúde. todos eram artigos originais; sete de abordagem qualitativa. construíram-se duas categorias temáticas: “pensamento complexo que sustenta as práticas da gerência do cuidado” e “administração complexa na perspectiva das organizações de enfermagem e saúde”. conclusões: o pensamento complexo é um paradigma relacionado a integralidade, muldisciplinaridade, atenção às redes de apoio e articulação dos saberes. foi empregado como modelo de gestão em organizações vivas e imprevisíveis para promover a organização dos sistemas complexos adaptativos. este estudo contribui com a aproximação do referencial da complexidade com os conceitos de gestão em enfermagem e saúde, conferindo maior visibilidade para futuras publicações. palavras-chave pesquisa em administração de enfermagem; gestão em saúde; administração de serviços de saúde; enfermagem (fonte: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 501-512 502 aquichan issn 1657-5997 eissn 2027-5374 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 501-512 el pensamiento complejo y sus repercusiones en la gestión en enfermería y salud resumen objetivo: evidenciar el conocimiento científico sobre la teoría de la complejidad en las publicaciones científicas sobre gestión en enfermería y salud. método: revisión integrativa que se realizó en mayo del 2014, en las bases de datos lilacs, bdenf y pubmed por medio de la combinación de las siguientes palabras clave: teoría de la complejidad, pensamiento complejo, edgar morin, enfermeros, enfermería, organización, administración, gestión y gerencia. se incluyeron diez artículos, publicados entre 2004 y 2013. resultados: se evidenció el crecimiento de la producción científica sobre el pensamiento complejo en la gestión de enfermería y salud. todos eran artículos originales; siete de abordaje cualitativo. interpretación: se construyeron dos categorías temáticas: “pensamiento complejo que sostiene las prácticas de la gerencia del cuidado” y “administración compleja en la perspectiva de las organizaciones de enfermería y salud”. conclusiones: el pensamiento complejo es un paradigma relacionado a la integralidad, multidisciplinariedad, atención a las redes de apoyo y articulación de los saberes. se ha usado como modelo de gestión en organizaciones vivas e imprevisibles para promover la organización de los sistemas complejos adaptativos. este estudio contribuye con la aproximación del referencial de la complejidad con los conceptos de gestión en enfermería y salud, dando mayor visibilidad para futuras publicaciones. palabras clave administración de servicios de salud; enfermería; gestión en salud; investigación en administración de enfermería (fuente: decs, bireme). 503 o pensamento complexo e suas repercussões na gestão em enfermagem e saúde l fernanda hannah da silva copelli e outros complex thinking and its impact on nursing and health management abstract objective: demonstrate scientific knowledge on the complexity theory in scientific publications on management in nursing and health. method: this is an integrative review of the lilacs, bdenf and pubmed databases. it was conducted in may 2014 by combining the following keywords: complex theory, complex thinking, edgar morin, nurses, nursing, organization, management, administration and management. it includes ten articles published between 2004 and 2013. results: growth is evident, according to the scientific literature on complex thinking in nursing and health management. all the articles were original and seven took a qualitative approach. interpretation: two thematic categories were constructed: "complex thinking that is compatible with care management practices" and "complex management from the standpoint of nursing and health organizations." conclusions: complex thinking is a paradigm relative to completeness, multidisciplinarity, attention to support networks and articulation of knowledge. it was employed as a management model in living and unpredictable organizations to promote the organization of complex adaptive systems. this study contributes to the complexity of the framework approach with concepts of management in nursing and health, and provides greater insight for future publications. keywords research on nursing administration; health management; health services administration; nursing (source: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 501-512 504 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 introdução ao longo da existência humana, várias correntes de pensamento fundamentaram a história mundial. diferentes modos de conceber os aspectos do viver foram consolidando as concepções e as práticas da humanidade, e, a cada época, modelos são rompidos para o surgimento de novos paradigmas. no mundo moderno, o modelo cartesiano-newtoniano fundamentou este período no qual a visão reducionista e mecanicista do mundo e da vida foi proeminente. contudo, com o passar do tempo, discussões sobre novas abordagens e formas de entendimento se tornaram evidentes e hoje representam a contemporaneidade. é dessa forma que o pensamento complexo começa a ter importância, com todas as suas concepções baseadas em conjeturas contrárias ao paradigma mecanicista ainda vigente (1). a palavra complexidade exprime o incômodo, a confusão, a incapacidade de esclarecer de maneira simples, de nomear de modo claro, de ordenar as ideias. contudo, os modos simplificadores de conhecimento mutilam mais do que exprimem as realidades ou os fenômenos que o tratam, ficando evidente que eles produzem mais cegueira do que elucidação. o pensamento complexo surge quando o pensamento simplificador falha, integrando em si ordem, clareza, distinção e precisão no conhecimento, recusando as consequências mutiladoras e redutoras. a complexidade aspira ao conhecimento multidimensional (2). é um tipo de pensamento que não separa, mas sim que une e procura as relações essenciais e interdependentes da vida humana, integrando as diferentes maneiras de pensar (3). diante das ideias mencionadas, vislumbra-se a possibilidade de promover a gestão das práticas em saúde e enfermagem na perspectiva do pensamento complexo. isso porque a gestão das práticas em saúde exige a discussão sobre a diversidade humana, o diálogo entre parceiros e atores sociais, reconhecendo as igualdades e diferenças biológicas, sociais, culturais e políticas. o agir individual também apresenta os aspectos citados, que estão inter-relacionados na complexidade do ser humano e nas relações de cuidado (4). o gerenciamento do cuidado em enfermagem é uma atribuição do enfermeiro que impacta diretamente na promoção da qualidade assistencial e das melhores condições de trabalho para os profissionais. para isso, o enfermeiro realiza o cuidado, gerencia os recursos materiais e humanos, lidera, planeja a assistência, capacita a equipe de enfermagem, coordena a produção de cuidado e avalia as ações de enfermagem (5). tendo em vista que a gestão das práticas em saúde e o gerenciamento do cuidado são atividades inerentes ao enfermeiro, torna-se relevante a perspectiva do pensamento complexo, considerando a multidimensionalidade da prática de enfermagem. ante o exposto, tem-se como questão de pesquisa: como o pensamento complexo vem sendo utilizado nas publicações científicas de gestão em enfermagem e saúde? para responder a essa pergunta, objetivou-se evidenciar o conhecimento científico sobre o pensamento complexo nas publicações científicas de gestão em enfermagem e saúde. materiais e métodos esse estudo trata de uma revisão integrativa da literatura (6), que é um método qualitativo específico que analisa a literatura de modo a fornecer uma compreensão mais abrangente a respeito de determinado fenômeno ou problema. é uma abordagem que permite ser aplicada em diversos tipos de estudos e/ou temas, contribuindo para a prática de enfermagem baseada em evidências científicas. a revisão integrativa auxilia na construção da ciência de enfermagem apresentando o estado da ciência (6). para construção dessa revisão integrativa da literatura, utilizaram-se as seguintes etapas: formulação do protocolo para orientação da revisão, juntamente com a formulação da pergunta de pesquisa; coleta de dados nas bases de dados; avaliação dos dados; análise e interpretação dos dados; divisão dos dados em categorias e apresentação dos resultados e conclusões (6). a coleta de dados foi realizada em maio de 2014, nas bases de dados da literatura latino-americana e do caribe em ciências da saúde (lilacs), bases de dados de enfermagem (bdenf) e publisher medline (pubmed), utilizando-se a combinação das seguintes palavras-chave: teoria da complexidade, pensamento complexo, edgar morin, enfermeiros, enfermagem, organização, administração, gestão e gerência. no quadro 1, apresenta-se a sintaxe das palavras-chave, isto é, as estratégias de busca empregadas em cada uma das bases de dados selecionadas. essas combinações de palavras-chave foram necessárias para garantir uma busca mais fidedigna e ampla dos estudos. 505 o pensamento complexo e suas repercussões na gestão em enfermagem e saúde l fernanda hannah da silva copelli e outros quadro 1. estratégias de busca utilizadas nas bases lilacs, bdenf e pubmed somente uma vez. ademais, não foi utilizado recorte temporal. assim, obteve-se uma amostra de 114 artigos, dos quais 82 foram encontrados na pubmed, 19 na lilacs e 13 na bdenf. em seguida, foi realizada a primeira etapa de avaliação, que consistiu na leitura flutuante dos 114 resumos dos artigos, com o objetivo de analisar os títulos e objetivos dos trabalhos de forma a incluir ou excluí-los de análises posteriores. dessa etapa, resultaram 23 artigos: 12 da pubmed, 6 da lilacs e 5 da bdenf. a partir da leitura dos 23 artigos na íntegra, foi feita a segunda etapa, que resultou em 10 artigos, sendo 7 encontrados na pubmed, 1 na lilacs e 2 na bdenf. essa exclusão foi feita com vistas a responder à questão de pesquisa. esse desenvolvimento pode ser observado na figura 1. figura 1. estrutura de desenvolvimento da pesquisa base estratégia de busca lilacs (“teoria da complexidade” or “pensamento complexo” or “edgar morin” or “teoria de morin” or (complex* and (teoria or pensamento))) and (enfermagem or enfermeir*) and (gestão or organização or administração or gerência or “organização and administração”) bdenf (“teoria da complexidade” or “pensamento complexo” or “edgar morin” or “teoria de morin” or (complex* and (teoria or pensamento))) and (enfermagem or enfermeir*) and (gestão or organização or administração or gerência or “organização and administração”) pubmed ((((“complexity theory”[all fields] or “complexity thinking”[all fields] or “complex thinking”[all fields] or “edgar morin”[all fields]) or (“complexity”[all fields] or complex[all fields] and (“thinking”[mesh terms] or “thinking”[all fields] or theory[all fields])))) and (“nursing”[subheading] or “nursing”[title/abstract] or “nursing”[mesh terms] or “nurses”[mesh terms] or “nurses”[title/ abstract] or “nurse”[title/abstract])) and ((“organization and administration”[mesh terms] or “organization and administration”[all fields] or “organization”[all fields] or “administration”[all fields] or “management”[all fields]) fonte: elaborado pelas autoras. a partir dessas combinações, foi localizado um total de 1019 produções. posteriormente, foram aplicados os critérios de inclusão e exclusão. os critérios de inclusão adotados foram: artigos disponíveis na íntegra que abordassem a temática administração/ gestão/complexidade aliado às áreas de interesse da enfermagem; publicados em português, espanhol ou inglês, independentemente do método de pesquisa utilizado. foram excluídos artigos de revisão de literatura, ensaios teóricos, reflexões, editoriais, resumos de anais, teses, dissertações, trabalhos de conclusão de curso, boletins epidemiológicos, relatórios, documentos oficiais de programas nacionais e internacionais, livros e estudos que não comtemplassem a pergunta de pesquisa estabelecida. estudos encontrados em mais de uma base de dados foram contabilizados fonte: elaborada pelas autoras, adaptada de whittemore e knafl (6). a análise e a interpretação dos dados foram realizadas considerando o conteúdo expresso nos textos, por meio de leitura intensiva e atenta dos pesquisadores, que se utilizaram da sensibilidade teórica, própria dos métodos qualitativos. para a identificação dos artigos, foram extraídas informações e procedeu-se à classificação de acordo com alguns indicadores de análise: ano, país, periódico e tipo de publicação, cenário do estudo, abordagem metodológica e nível de evidência científica. foi elaborado um quadro no software word® para que, de forma organizada e sintetizada, as informações fossem extraídas e interpretadas pelos pesquisadores. 506 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 para a classificação dos níveis de evidência científica dos artigos, foi utilizada a classificação proposta por pompeo, rossi e galvão (7), detalhada no quadro 2. quadro 2. classificação dos níveis de evidência científica três (30%) das dez publicações analisadas neste estudo. no que se refere ao país de origem das publicações, cinco (50%) delas ocorreram no brasil. dos artigos analisados, observou-se que os periódicos que obtiveram maior destaque foram a revista latino americana de enfermagem e a online brazilian journal of nursing, com duas (20%) publicações cada uma. quanto ao cenário do estudo, os resultados apontaram duas (20%) publicações exclusivamente no âmbito hospitalar assim como duas (20%) publicações realizadas exclusivamente na atenção primária. com relação ao tipo de pesquisa, sete (70%) eram de abordagem qualitativa. a respeito do nível de evidência, apenas um (10%) artigo apresentou nível ii. abaixo, apresenta-se um quadro demonstrativo das publicações analisadas (quadro 2). a partir da análise dos conteúdos dos artigos, construíram-se duas categorias de análise: “pensamento complexo sustentando as práticas da gerência do cuidado” e “administração complexa na perspectiva das organizações de enfermagem e saúde”. constatou-se que o pensamento complexo, nas publicações científicas de gestão em enfermagem e saúde, é retratado sob duas principais formas: uma enquanto referencial teórico para as discussões de gerência do cuidado e outra enquanto modelo de gestão para as organizações de enfermagem e saúde. pensamento complexo que sustenta as práticas da gerência do cuidado a relação entre os artigos demonstrou a importância de novas formas de cuidado por meio do uso de novas tecnologias de cuidado, reconhecendo a necessidade em vislumbrar a assistência sob novos olhares e referenciais. o referencial da complexidade enxerga a integralidade do ser, as relações e as interações que existem entre as organizações de saúde mediante as redes de cuidado, bem como a necessidade de interações entre os profissionais da saúde. a importância da articulação entre as diferentes profissões para a construção do conhecimento e de melhores práticas de cuidado é abordada em diferentes artigos. assim, percebe-se que há uma perspectiva dialógica em caminhar na direção da complementaridade, da interdisciplinaridade, da transdisciplinaridade, com a articulação entre os profissionais da saúde (8-11). os pensamentos disjuntivos e simplificadores, por vezes, permeiam o cuidado, fragmentando-o. os achados apontaram que essa perspectiva de dissociação é influenciada por modelos tradicionais pautados no mecanicismo, na divisão de tarefas e na nível de evidência tipo de estudo i (maior evidência) evidências oriundas de revisão sistemática ou meta-análise de todos os relevantes ensaios clínicos randomizados controlados ou provenientes de diretrizes clínicas baseadas em revisões sistemáticas de ensaios clínicos randomizados controlados. ii evidências derivadas de, pelo menos, um ensaio clínico randomizado controlado bem-delineado. iii evidências obtidas de ensaios clínicos bemdelineados sem randomização. iv evidências provenientes de estudos de coorte e de caso-controle bem-delineados. v evidências originárias de revisão sistemática de estudos descritivos e qualitativos. vi evidências derivadas de um único estudo descritivo ou qualitativo. vii (menor evidência) evidências oriundas de opinião de autoridades e/ou relatório de comitês de especialistas. fonte: elaborado pelas autoras e adaptado da classificação utilizada por pompeo, rossi e galvão (7). para a análise do conhecimento científico produzido sobre o pensamento complexo nos artigos selecionados, os pesquisadores agruparam os artigos conforme as similaridades temáticas, relacionadas especificamente à forma como o referencial da teoria da complexidade foi abordado no texto, bem como a sua relação com a gestão em enfermagem e saúde. os conteúdos foram classificados em categorias de análise, assim determinadas a fim de responder à questão de pesquisa. resultados pode-se constatar que foi crescente a produção acerca do pensamento complexo nas publicações científicas de gestão em enfermagem e saúde. o ano de 2013, por exemplo, concentrou 507 o pensamento complexo e suas repercussões na gestão em enfermagem e saúde l fernanda hannah da silva copelli e outros quadro 2. demonstrativo das publicações analisadas fonte: elaborado pelas autoras. ano/ país título periódico cenário do estudo tipo de publicação e abordagem nível de evidência 2004 eua improving assessment and treatment of pain in the critically ill international journal for quality in health care unidades de terapia intensiva artigo original quantitativo estudo observacional vi 2004 eua complexity science and the dynamics of climate and communication: reducing nursing home turnover gerontologist lares de idosos artigo original quantitativo estudo observacional vi 2007 brasil construindo um modelo de sistema de cuidados acta paulista de enfermagem hospitais, um do sul e outro do nordeste brasileiro artigo original qualitativo teoria fundamentada nos dados vi 2008 brasil sistematização da assistência de enfermagem como fenômeno interativo e multidimensional revista latinoamericana de enfermagem diferentes instituições de saúde de florianópolis, brasil artigo original qualitativo teoria fundamentada nos dados vi 2009 brasil evidenciando o cuidado de enfermagem como prática social revista latinoamericana de enfermagem diferentes instituições de saúde artigo original qualitativo teoria fundamentada nos dados vi 2011 brasil organização das práticas de cuidado na rede de atenção à saúde online brazilian journal of nursing secretaria de estado da saúde, no sul do brasil e a respectiva secretaria municipal de saúde da sua capital artigo original qualitativo teoria fundamentada nos dados vi 2012 brasil ensino de gerenciamento do cuidado: olhar de graduandos — teoria fundamentada nos dados online brazilian journal of nursing departamento de enfermagem da universidade federal de santa catarina (ufsc) e a faculdade de enfermagem da universidade do estado do rio de janeiro (fenf/ uerj) artigo original qualitativo teoria fundamentada nos dados vi 2013 austrália healthcare improvement as planned system change or complex responsive processes? a longitudinal case study in general practice family practice atenção primária artigo original qualitativo estudo de caso vi 2013 eua tool for evaluating research implementation challenges: a sense-making protocol for addressing implementation challenges in complex research settings implementation science casas de repouso para idosos artigo original quantitativo estudo controlado randomizado ii 2013 canadá helping primary care teams emerge through a quality improvement program family practice atenção primária artigo original qualitativo estudo de caso ii 508 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 forma de apreender o cuidado. consequentemente, o cuidado ao paciente sofre o paradoxo da tentativa do cuidado multiprofissional dividido em partes (8, 10, 12). do mesmo modo, a articulação entre a gerência e a assistência e entre o saber e o fazer é vista de modo desarticulado; além disso, é percebido um distanciamento entre os conceitos teóricos e a prática assistencial. para resolução desse dilema, as concepções de gerência do cuidado trazem noções de articulação entre o cuidar assistencial e o cuidar gerencial, com ideias e conceitos integrados para aprimorar a qualidade do cuidado que é oferecido (8, 10, 12). o pensamento complexo permite um cuidado que perpassa ideias de redes de cuidado e interconexões, funcionando de modo articulado e fazendo com que essas redes de cuidado proporcionem uma interação entre os indivíduos e a realidade, entre os próprios profissionais, entre os sistemas de apoio, à medida que rejeita o pensamento redutor, disjuntivo e simplificador. nessa perspectiva, o pensamento complexo trata a saúde com um enfoque mais amplo, em que, para ser alcançada, necessita das ações e dos envolvimentos dos mais variados sistemas da sociedade, conferindo importância às organizações dos sistemas de cuidado em saúde (9, 10). o cuidado de enfermagem, como parte do sistema de cuidado à saúde, é percebido como prática social que visa tanto à compreensão do indivíduo em sua integralidade como à compreensão de seus contextos sociais, que envolvem família e comunidade. nessa ótica, umas das potencialidades dos enfermeiros encontradas nos estudos associados à gerência do cuidado é a capacidade de compreensão do ser humano como um todo e em suas diferentes dimensões. percebe-se que a enfermagem está em uma constante busca da compreensão do indivíduo como um ser integral, isto é, um ser uno, complexo e multidimensional (8, 11, 12). os achados apontaram ainda para a construção de novos modelos de gestão do cuidado para a obtenção da sua qualidade nos sistemas complexos. a construção de novos modelos requer um esforço dos profissionais na busca de novas formas de interações e na busca do novo e das novas formas de enfrentamento das práticas de saúde, como possibilidades de transformação do cuidado (8, 9, 10, 12). observa-se que o grande avanço nos artigos que retratam o cuidado na perspectiva do olhar da complexidade se dá ao avanço do cuidado enquanto sistema complexo, que contempla a dinamicidade e a multiplicidade de interações nos diversos aspectos da realidade, enxergando o todo nas partes e as partes no todo, além de enxergar o indivíduo em sua multidimensionalidade (8-10). a administração complexa na perspectiva das organizações de enfermagem e saúde a administração complexa é entendida, nesta investigação, como a utilização da teoria da complexidade como modelo de gestão nas organizações de enfermagem e saúde (13). contudo, seus conceitos também foram aplicados em outras perspectivas de acordo com o objetivo do estudo investigado. dessa forma, a administração complexa foi empregada como fator contribuinte para a melhoria do cuidado aos portadores de doenças crônicas (14); como instrumento que auxilia na definição da intervenção e desenho de estudo em sistemas complexos adaptativos (15), e como fator redutor da rotatividade dos profissionais de enfermagem em lares de idosos (13). assim, a partir do processo de leitura e análise, identificou-se que o conceito mais substancialmente abordado dentro dessa perspectiva foi o dos sistemas complexos adaptativos (14, 15). dentre os ambientes definidos como tal, pontuam-se a atenção primária (14), os lares de idosos, os hospitais, os consultórios médicos e as clínicas (13, 15, 16). os lares de idosos, por exemplo, são citados como sistemas complexos adaptativos pelo fato de serem compostos por um conjunto de agentes individuais (funcionários, moradores e familiares), com liberdade de agir de forma imprevisível (15). além disso, a não linearidade das decisões, a interação comunicativa e o caos também foram utilizados para caracterizar um sistema complexo adaptativo (13, 14, 16). a comunicação, nessa perspectiva, fortalece as relações interpessoais e favorece o ressurgimento da ordem e da coerência organizacional sem planejamento central na atenção primária em situações de caos (13, 14). outra publicação, porém, com enfoque metodológico, retrata que os pesquisadores que planejam sua intervenção de pesquisa sem a participação da organização estudada terão mais dificuldade em resolver desafios inesperados porque os sistemas complexos adaptativos são inerentes à participação dos envolvidos 509 o pensamento complexo e suas repercussões na gestão em enfermagem e saúde l fernanda hannah da silva copelli e outros na intervenção para a resolução dos problemas. retratam ainda que a utilização de protocolos em sistemas complexos adaptativos não são uma boa opção na implementação de intervenções de pesquisa para a mudança do sistema, apesar de a pesquisa construir um instrumento que guia o planejamento do projeto dela e que norteia para a definição da intervenção e desenho de estudo em lares de idosos, entre outros (15). a teoria da complexidade, no contexto da atenção básica, também foi utilizada como referencial teórico para sustentar a interdisciplinaridade, a qual propiciou aumento da motivação profissional, coesão da equipe de estratégia saúde da família e melhor compreensão dos papéis dos colegas de trabalho. isso repercutiu na melhoria da qualidade do trabalho, na união da equipe de estratégia saúde da família e na gestão organizacional pouco hierárquica (16). a rotatividade (turnover) de profissionais da enfermagem foi um aspecto relevante elencado, pois ficou constatado que modelos de gestão pautados na recompensa reduzem os índices de rotatividade quando comparados com modelos deixar-fazer (laissez-faire). os modelos de recompensa reduzem a rotatividade por utilizarem os conceitos e princípios dos sistemas complexos adaptativos como a autogestão, o compartilhamento das decisões e o bom relacionamento. além disso, verificou-se que a rotatividade dos profissionais da enfermagem é maior quando a demanda de pacientes aumenta e é necessário que trabalhem mais horas por dia do que o previsto (13). discussão o cuidado na modernidade é realizado por organizações complexas, destinadas à produção de cuidado. para a produção desse cuidado, esperam-se novas formas de organização e gerência deste, aliadas a organizações estruturadas que busquem estratégias para promoção do cuidado qualificado. assim, para a construção de organizações que façam uso de novos modelos de organização, com diferentes olhares a respeito da prática do cuidado, pressupõem-se novos olhares voltados às organizações de saúde, que utilizem modelos com o tema da complexidade durante o repensar das estratégias de novas práticas (17). sendo o cuidado um objeto resultante do conhecimento de enfermagem presente nas organizações de saúde e inserido em um mercado, é possível entendê-lo sob uma perspectiva empresarial. diante dessa constatação, o pensamento complexo destaca a necessidade que, ao produzir coisas e serviços, a empresa se autoproduz. assim, existe a produção de objetos e serviços, que necessitam de auto-organização. e, ao contrário, ao progredir positivamente, promove o autodesenvolvimento da sua produção. portanto, o produtor é o seu próprio produto e, como consequência, apresenta-se um problema de causalidade (18). esta pode ser vista por três ângulos: a causalidade linear, a causalidade circular retroativa e a causalidade retroativa. a primeira acontece quando uma matéria-prima, ao ser transformada, produz um objeto de consumo —movimento linear—, ou seja, tal causa produz determinado efeito. a segunda reforça que uma empresa precisa ser controlada; que sua produção é fruto das solicitações externas e dependente do trabalho interno. assim, o resultado pode ser fonte de estímulo ou regressão à produção de objetos e serviços. na terceira causalidade, o produto é produtor do que o produz, isto é, efeitos e produtos são geradores deles mesmos. as três causalidades estão em todos os níveis de organizações complexas (18). adotar novas ideias e referenciais sobre o cuidado não significa abandonar totalmente as ideias preexistentes já que toda organização é formada por tradição e inovação, estando em constante renovação e mudança, em um processo dinâmico, refletindo as diferentes formas de pensar e interagir das pessoas que dela fazem parte (17). o pensamento disjuntivo e simplificador que permeia o cuidado em alguns estudos revela os limites da racionalidade lógica e a complexidade do real uma vez que as ideias de gerência e assistência são vistas como contraditórias ou díspares. entretanto, pode-se afirmar que toda introdução da contradição ou da incerteza pode transformar-se em ganho de complexidade. o complexo envolve o incerto, o ambíguo e o contraditório (17, 18). a contradição pode ser demonstrada por meio da ordem e da desordem inerentes às organizações. nesse sentido, o mercado é um estímulo para a reorganização de uma empresa que ao mesmo tempo é ordenada, organizada e aleatória, pois não existem certezas absolutas sobre as chances e as possibilidades de se vender produtos e serviços. o universo é repleto de ordem, desordem e organização. a ordem é a repetição, a constância, a invariância. a desordem é a irregularidade, o acaso, a imprevisibilidade. em um universo de ordem plena, não há inovação, criação, evolução. na desordem total, não haveria a estabilidade para instituir uma organização. por isso, ambos os 510 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 aspectos são necessários, visto que toda organização é um fenômeno físico, vivo, organizacional. o fenômeno da desintegração é normal, contudo não pode ser permanente; portanto, a única maneira de evitar a degenerescência está na atitude conjunta da organização quanto à regeneração e à reorganização ante todos os processos de desintegração (18). falar em sistemas e organizações de saúde é reconhecer as redes de relações e interações que existem e estão a ela conectadas. assim, muitos sistemas fazem parte e interagem com os sistemas de saúde, contribuindo para seu funcionamento. redes de apoio, sistemas dos mais diversos setores da sociedade permitem a ampliação e a articulação das redes de saúde, imprescindível para a compreensão e a contextualização da própria saúde na sua totalidade (17). nesta investigação, os resultados apontaram para a utilização da teoria da complexidade como modelo de gestão das organizações de enfermagem e saúde. tal fato corrobora com o conceito da administração complexa de agostinho (19). para essa autora, administração complexa é uma abordagem gerencial que insere no universo das organizações os conhecimentos da teoria da complexidade (19). a teoria da complexidade como modelo de gestão, além de ser chamada de administração complexa, também pode ser nomeada de modelo de gestão não linear, justamente por fugir das predeterminações verticais em situações de caos. a administração complexa baseia-se nos conceitos dos sistemas complexos adaptativos (19, 20) visto que as organizações, nesse contexto, são ambientes vivos, dinâmicos e imprevisíveis como as organizações de enfermagem e saúde. o “sistema”, nessa perspectiva, significa uma série de itens conectados e interdependentes; o “complexo” implica diversidade e conexões entre vários elementos e o “adaptativo” deriva da capacidade de alterar, mudar e aprender com as experiências (21, 22). os sistemas complexos adaptativos são sistemas que exibem coerência sob a mudança sem direcionamento central (19). exibir “coerência” sem “direção central” significa dizer que tais sistemas se auto-organizam (19). isto é, o sistema se adapta sem a necessidade de um planejamento central predeterminado. os resultados apontam para a utilização de um instrumento que auxilia na definição da intervenção e do desenho de estudo em sistemas complexos adaptativos. esse instrumento não se refere a uma decisão predeterminada, mas sim a um modelo que norteia a pesquisa em ambientes vivos, complexos e imprevisíveis, a partir de uma construção conjunta, participativa e autônoma dos envolvidos (15). tais achados convergem com a ideia de que em um sistema complexo adaptativo pode existir planejamento; contudo, esse planejamento não pode ser limitante da autonomia e da criatividade dos envolvidos (19). a administração complexa toma como base os conceitos dos sistemas complexos adaptativos, tendo quatro princípios que se inter-relacionam: autonomia, cooperação, agregação e auto-organização. a autonomia refere-se à capacidade do indivíduo de orientar sua ação com base no seu julgamento prévio. a cooperação entre os indivíduos visa contribuir com o desempenho da organização. a agregação se caracteriza por um agregado de indivíduos que, em torno dos objetivos globais, se unem, contribuindo com seus conhecimentos e habilidades para a competência do todo. finalmente, a auto-organização retrata a capacidade dos seres humanos escolherem como as ações se operacionalizarão na prática (19). o princípio da auto-organização foi amplamente trazido nos resultados desta investigação, sendo aplicado juntamente com a implantação de políticas públicas e reformulação de processos de cuidado para apoiar a tomada de decisão autônoma do portador de doença crônica (14). esse indivíduo em posse do princípio da auto-organização foi capaz de reconhecer os pontos de maior e menor efeito multiplicador para o seu cuidado, bem como escolher como este será operado na prática (19). além disso, o princípio da autonomia articulado com o princípio da auto-organização foi utilizado para sustentar a tomada de decisão autônoma dos portadores de doenças crônicas (14). estudo com o objetivo de abordar a educação em saúde relacionando-a com as doenças crônicas e sua implicação com as redes sociais também retrata a autonomia como fator contribuinte para o cuidado de doenças crônicas enfatizando a importância da educação em saúde (aprendizagem) no processo (23). a autonomia, dessa forma, garante aprendizado e adaptabilidade no cuidado, vantagens devidamente reconhecidas no campo das organizações que podem ser aplicadas à prática de cuidado em enfermagem e saúde. o princípio da cooperação também ganhou destaque nesta investigação, visto as constantes referências a comunicação, relação interpessoal, participação e interdisciplinaridade (13, 14, 16). resultado semelhante foi encontrado em um estudo que objetivou discutir as influências do relacionamento interpessoal para o cuidado em saúde. concluiu-se, com esse estudo, que a inadequada 511 o pensamento complexo e suas repercussões na gestão em enfermagem e saúde l fernanda hannah da silva copelli e outros utilização das habilidades sociais, em especial da comunicação, pode comprometer as relações que subsidiam a prática de cuidado devido aos conflitos interpessoais que esta pode resultar (24). a administração complexa como modelo de gestão também repercutiu como redutor da rotatividade dos profissionais de enfermagem (13). estudo com o propósito de identificar as condições intervenientes à governança da prática de enfermagem no centro obstétrico também mostrou que a governança, ou seja, o controle sobre a prática profissional, repercute positivamente na autonomia profissional, na comunicação interpessoal, na satisfação e no envolvimento com a profissão (25), fatores nevrálgicos para as organizações de saúde, em especial as públicas, no que diz respeito às condições de trabalho, ao absenteísmo e à falta de profissionais. considerações finais os estudos analisados nesta revisão possibilitaram avaliar as evidências disponíveis na literatura sobre o pensamento complexo nas publicações científicas de gestão em enfermagem e saúde. constatou-se que a maioria das publicações se desenvolve no contexto brasileiro e que o pensamento complexo está despontando como novo modelo de cuidado, tanto no âmbito hospitalar quanto na atenção básica, com vistas à integralidade, à muldisciplinaridade, às redes de atenção e à articulação dos saberes. além disso, foi empregado como modelo de gestão em organizações vivas e imprevisíveis, com o objetivo de promover a organização dos sistemas complexos adaptativos que tentem explicar a dinâmica das organizações de uma forma mais profunda e contextualizada. acredita-se que este estudo contribuiu com a aproximação do referencial da complexidade e dos conceitos de gestão em enfermagem e saúde, de modo que confere a esse pensamento maior visibilidade para futuras publicações. além de apresentar um panorama das publicações a respeito do pensamento complexo voltado à gestão em enfermagem e saúde, visa contribuir para a importância da reflexão e de novos estudos sobre o tema. referências 1. terra mg, camponogara s, silva lc, girondi jbr, nascimento k, radünz v et al. o significado de cuidar no contexto do pensamento complexo: novas possibilidades para a enfermagem. texto & contexto enferm. 2006; 15(spe):164-9. 2. morin e. introdução ao pensamento complexo. 4. ed. porto alegre: sulina; 2011. 3. pradebon vm, erdmann al, leite jl, lima sbs, prochnow ag. a teoria da complexidade no cotidiano da chefia de enfermagem. acta paulista enferm. 2011; 24(1):13-22. 4. erdmann al, andrade sr, mello alsf, meirelles bhs. gestão das práticas de saúde na perspectiva do cuidado complexo. texto & contexto enferm. 2006; (15)3:483-91. 5. santos jlg, pestana al, guerrero p, meirelles bhs, erdmann al. práticas de enfermeiros na gerencia do cuidado em enfermagem e saúde: revisão integrativa. rev bras enferm. 2013; 66(2):257-63. 6. whittemore r, knafl k. the integrative review: updated methodology. j adv nurs. 2005; 52(5):546-53. 7. pompeo da, rossi la, galvão cm. revisão integrativa: etapa inicial do processo de validação de diagnóstico de enfermagem. acta paul enferm. 2009; 22(4):434-8. 8. santos i, erdmann al, santos jlg, klock p, martins vv, brandão es. ensino de gerenciamento do cuidado: olhar de graduandos — teoria fundamentada nos dados. online braz j nurs. 2012; 11(3):621-37. 9. erdmann al, mello alsf, andrade sr, drago lc. organização das práticas de cuidado na rede de atenção à saúde. online braz j nurs. [on-line] 2011; 10(1):1-11. 10. erdmann al, sousa fgm, backes ds, mello alsf. construindo um modelo de sistema de cuidados. acta paul. enferm. 2007; 20(2):180-5. 11. backes ds, erdmann al, büscher a. evidenciando o cuidado de enfermagem como prática social. rev latino-am enfermagem. 2009; 17(6):988-94. 512 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 12. backes ds, koerich ms, nascimento kc, erdmann al. sistematização da assistência de enfermagem como fenômeno interativo e multidimensional. rev latino-am enfermagem. [on-line]. 2008; 16(6):979-85. 13. anderson ra, corazzini kn, mcdaniel jr rr. complexity science and the dynamics of climate and communication: reducing nursing home turnover. gerontologist. 2004; 44(3):378-88. 14. booth bj, zwar n, harris mf. healthcare improvement as planned system change or complex responsive processes? a longitudinal case study in general practice. bmc family practice. 2013; 14(51):1-12. 15. simpson km, porter k, mcconnell es, cólon-emeric c, daily ka, stalzer a et al. tool for evaluating research implementation challenges: a sense-making protocol for addressing implementation challenges in complex research settings. implementation science. 2013; 8(2):1-12. 16. hilts l, howard m, price d, risdon c, agarwal g, childs a. helping primary care teams emerge through a quality improvement program. family practice. 2013; 30:204-11. 17. erdmann al, mello alsf, meirelles bhs, andrade sr. as organizações de saúde na perspectiva da complexidade dos sistemas de cuidado. rev bras enferm. 2004; 57(4):467-71. 18. morin e. o método 4: as ideias, habitat, vida, costumes, organização. 5. ed. são paulo: europa america; 2011. 19. agostinho mce. “administração complexa”: revendo as bases científicas da administração. rae-eletrônica. 2003; 2(1):1-18. 20. amestoy sc, schveitzer mc, meirelles bhs, backes vms, erdmann al. paralelo entre educação permanente em saúde e administração complexa. rev gaúcha enferm. 2010; 31(2):383-7. 21. cembranel p. teoria da complexidade e racionalidade ambiental: um estudo bibliométrico acerca dos estudos de leff e morin. ciências sociais unisinos. 2015; 51(2):144-51. 22. silva ab, rebelo lmb. a emergência do pensamento complexo. rap. 2003; 37(4):777-96. 23. taddeo ps, gomes kwl, caprara a, gomes ama, oliveira gc, moreira tmm. acesso, prática educative e empoderamento de pacientes com doenças crônicas. ciênc saúde coletiva. 2012; 17(11):2923-30. 24. formozo ga, oliveira dc, costa tl, gomes amt. as relações interpessoais no cuidado em saúde: uma aproximação ao problema. rev enferm uerj. 2012; 20(1):124-7. 25. oliveira rjt, copelli fhs, pestana al, santos jlg, gregório vrp. condições intervenientes à governança da prática de enfermagem no centro obstétrico. rev gaúcha enferm. 2014; 35(1):47-54. 315 321 primeras paginas.indd 320 aquichan issn 1657-5997 año 13 vol. 13 nº 3 chía, colombia diciembre 2013 editorial problemática y condiciones para la investigación en enfermería problems and conditions for nursing research problemas e condições para pesquisa em enfermagem “para aquel que dedica su vida a la ciencia, nada le puede dar mayor felicidad que incrementar el número de descubrimientos, pero la satisfacción será plena cuando sus estudios encuentren una aplicación práctica". louis pasteur, citado por guttmacher (1) las organizaciones científicas y los gremios de enfermería en el ámbito mundial, entre ellas el consejo internacional de enfermeras, el instituto nacional de investigación en los estados unidos, la sigma theta tau internacional, la asociación latinoamericana de facultades y escuelas de enfermería, han establecido unas prioridades de investigación disciplinar que se fundamentan en las necesidades de salud de la población, las metas del milenio propuestas por las naciones unidas, las demandas institucionales para garantizar la calidad de la atención que se presta a los usuarios, las necesidades de formación del recurso humano y las necesidades de desarrollo de conocimiento en enfermería. los artículos que llegan a las revistas científicas de enfermería reflejan qué tipo de estudios están realizando las enfermeras, los métodos que utilizan y, sobre todo la fundamentación teórica sobre la cual están desarrollando el nuevo conocimiento. si la perspectiva teórica que fundamenta la investigación no es de enfermería, el producto y su aplicación práctica tampoco lo serán. esto se refleja en el estudio realizado por mendoza-parra et al. (3) sobre la visibilidad de la investigación de enfermería latinoamericana entre 1959 y 2005, en el cual encontraron que el 32 % de los estudios revisados correspondía a la categoría de medicina, el 25,1 % al área de salud pública, y tan solo el 8,6 % al en el año 2000 fawcett escribió un editorial en el western journal of nursing research, en el cual preguntaba a los lectores: ¿qué es la investigación en enfermería? en este ella se cuestionaba si los investigadores, los editores de las revistas científicas de enfermería y los lectores realmente estaban respaldando el desarrollo del conocimiento de esta disciplina cuando aceptaban que el contenido de los artículos publicados en las revistas científicas de “enfermería” se fundamentaba en el conocimiento de otras disciplinas (2). la enfermería es una ciencia humanística, los modelos conceptuales y las teorías constituyen el conocimiento propio que la identifica como disciplina y determinan su particularidad frente a otras del área de la salud. la aplicación de modelos y teorías motiva a las enfermeras (os) a centrar su atención en las personas como seres holísticos, que participan activamente en sus decisiones de cuidado, a reflexionar sobre “el ser” de enfermería, a resolver los interrogantes de la práctica para, a partir de ellos, generar otros nuevos, incentivando el desarrollo del conocimiento disciplinar. los investigadores de enfermería tienen la responsabilidad de profundizar en este conocimiento propio, desarrollar y validar instrumentos, medir el efecto de sus intervenciones y establecer su impacto en la práctica, a través de estudios cuantitativos (práctica basada en la evidencia) y cualitativos (evidencia basada en la práctica). 321 referencias 1. guttmacher ae, collins f. welcome to the genomic era. new england journal of medicine. 2003;349(10):96. 2. fawcett j. editorial: but it is nursing research? western journal of nursing research. 2000;22(5);524-25. 3. mendoza-parra s, paravic-klijn t, muñoz-muñoz am, barriga oa, jiménez-contreras e. visibility of latin american nursing research (1959-2005). journal of nursing scholarship. 2009;41(1):54-63. área de enfermería. es decir, la producción de enfermería es muy limitada frente a la de otras disciplinas del área de la salud, y los profesionales de enfermería estamos contribuyendo al desarrollo del conocimiento de otras ciencias sin dar cumplimiento a lo planteado por las organizaciones científicas sobre las prioridades de investigación de la disciplina. el comité editorial de aquichan, desde sus inicios, tomó la decisión de promover el desarrollo del conocimiento de enfermería, como lo expresa la misión de la revista. al hacer un análisis de los 93 artículos publicados a partir del 2010, se encontró que el 89 % de estos son artículos fundamentados en teoría de enfermería. de ellos, el 32 % son producto de estudios cuantitativos, 24 % de estudios cualitativos, 27 % de revisiones de literatura, 8,4 % metodológicos, 4,8 % de reflexión y 2 % históricos. los resultados de este análisis muestran coherencia con la misión de la revista y, en este orden de ideas, seguiremos impulsando la divulgación de estos productos y motivando a nuestros lectores para que continúen avanzando y profundizando en los resultados publicados, y promoviendo la aplicación de los mismos en los diferentes escenarios de la práctica. estamos seguros de que el conocimiento de enfermería debe transformar la práctica en beneficio de las personas a quienes cuidamos, pues solo así la práctica, la investigación y el desarrollo del conocimiento de enfermería tendrán sentido. maría elisa moreno fergusson, phd profesora titular y decana facultad de enfermería y rehabilitación universidad de la sabana ic u n ur si ng t ea m m en ta l h ea lt h in t he f ac e of t he c o v id -1 9 pa nd em ic : a n in te gr at iv e re vi ew 1 renata marinho fernandes https://orcid.org /0000-0001-7358-9061 universidade federal do rio grande do norte, brazil renata.fernandes.018@ufrn.edu.br ana carolina costa carino https://orcid.org /0000-0002-9938-6546 universidade federal do rio grande do norte, brazil ana.carino.017@ufrn.edu.br anna thays dias almeida https://orcid.org /0000-0001-5511-6121 universidade federal do rio grande do norte, brazil anna.dias.026@ufrn.edu.br larissa beatriz francisca de souza https://orcid.org /0000-0002-0232-7707 universidade federal do rio grande do norte, brazil larissa.beatriz.701@ufrn.edu.br maria de lourdes alves da cruz https://orcid.org /0000-0003-1794-8810 universidade federal do rio grande do norte, brazil maria.alves.082@ufrn.edu.br ana luisa brandão de carvalho lira https://orcid.org /0000-0002-7256-960x universidade federal do ceará, brazil analuisalira@ufc.br artículo icu nursing team mental health in the face of the covid-19 pandemic: an integrative review received: 13/12/2022 sent to peers: 31/01/2023 approved by peers: 12/04/2023 accepted: 13/04/2023 doi: 10.5294/aqui.2023.23.2.6 to reference this article / para citar este artigo / para citar este artículo fernandes rm, carino acc, almeida atd, souza lbf, cruz mla, lira albc. icu nursing team mental health in the face of the covid-19 pandemic: an integrative review. aquichán. 2023;23(2):e2326. doi: https://doi.org/10.5294/aqui.2023.23.2.6 https://orcid.org/0000-0001-7358-9061 mailto:renata.fernandes.018@ufrn.edu.br https://orcid.org/0000-0002-9938-6546 mailto:ana.carino.017@ufrn.edu.br https://orcid.org/0000-0001-5511-6121 mailto:anna.dias.026@ufrn.edu.br https://orcid.org/0000-0002-0232-7707 mailto:larissa.beatriz.701@ufrn.edu.br https://orcid.org/0000-0003-1794-8810 mailto:maria.alves.082@ufrn.edu.br https://orcid.org/0000-0002-7256-960x mailto:analuisalira@ufc.br https://doi.org/10.5294/aqui.2023.23.2.6 https://doi.org/10.5294/aqui.2023.23.2.6 https://crossmark.crossref.org/dialog/?doi=10.5294/aqui.2023.23.2.6&amp;domain=pdf&amp;date_stamp=2023-06-23 theme: health, well-being, and quality of life promotion contribution to the subject: this integrative literature review allowed identifying the mental health conditions among the nursing professionals working in intensive care units during the covid-19 pandemic. this study is essential because it maps the impacts triggered by the pandemic on these professionals’ health and life aspects; thus, its results can be used as a basis to develop strategies and actions for the care and health assistance of icu nursing professionals. ic u n ur si ng t ea m m en ta l h ea lt h in t he f ac e of t he c o v id -1 9 pa nd em ic : a n in te gr at iv e re vi ew 3 abstract introduction: during the covid-19 pandemic, health professionals were at an increased risk of developing psychological conditions, especially in intensive care units. a gap is verified in the knowledge about icu nursing teams’ mental health in the care provided to patients affected by covid-19. objective: to review the literature to identify the mental health conditions of icu nursing professionals during the covid-19 pandemic. materials and method: this is an integrative literature review with data collection from january to april 2022 in the embase, cumulative index to nursing and allied health literature, pubmed, scopus content overview and web of science databases. the following descriptors were listed: “intensive care units,” “covid-19,” “mental health,” and “nurse.” the materials included were studies produced since 2020, available in full in the spanish, english and portuguese languages, and which answered the research question. search and selection of the articles were the duty of two duly trained researchers, who worked independently through peer discussion. the preferred reporting items for systematic reviews and meta-analyses recommendations were followed. results: from a sample of 16 articles, it was observed that the critical care of covid-19 patients affected nursing professionals’ mental health with an emphasis on depression, anxiety, stress and fear. this was associated with a lack of evidence-based training, scarcity of human and physical resources, work overload and insufficient work experience. conclusions: icu nursing professionals are mentally shaken; therefore, it is imperative to implement policies, strategies and methods to improve the psychological conditions of these professionals, to ensure the quality of services. keywords (fonte: decs) nursing; coronavirus infections; intensive care units; mental health; health promotion. 4 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 26 salud mental de los profesionales de enfermería intensivistas ante la pandemia de la covid-19: revisión integradora resumen introducción: durante la pandemia de la covid-19, los profesionales de la salud han presentado riesgo aumentado para el desarrollo de afecciones psíquicas, especialmente en la unidad de terapia intensiva. se encuentra vacío de conocimiento acerca de la salud mental de los profesionales de enfermería intensivistas en la atención a los pacientes acometidos por la covid-19. objetivo: identificar, en la literatura científica, las condiciones de la salud mental del profesional de enfermería intensivista durante la pandemia de la covid-19. materiales y método: se trata de una revisión integradora de la literatura; la recolección de datos ocurrió de enero a abril de 2022 en las fuentes de dados embase, cumulative index to nursing and allied health literature, pubmed, scopus content overview y web of science. se han relacionado los siguientes descriptores: “intensive care units”, “covid 19”, “mental health”, “nurse”. se han incluido estudios producidos desde el 2020, disponibles de forma integral, en español, inglés y portugués, y que atendieran a la pregunta de investigación. la búsqueda y selección de los artículos se ejecutaron por dos investigadores capacitados, de modo independiente, mediante discusión por pares. se siguieron las recomendaciones del preferred reporting items for systematic reviews and meta-analyses. resultados: desde una amuestra de 16 artículos, se ha observado que la atención crítica a pacientes con covid-19 ha afectado la salud mental de los profesionales de enfermería con énfasis para depresión, ansiedad, estrés y miedo. lo anterior se asocia a la falta de tratamiento basado en evidencia, la carencia de recursos humanos y físico, la sobrecarga de trabajo y las experiencias de trabajo insuficientes. conclusiones: los profesionales de enfermería intensivistas están mentalmente debilitados; por lo tanto, urge la implantación de políticas, estrategias y métodos para mejorar las condiciones psicológicas de estos profesionales para, así, asegurar la calidad en los servicios. palabras clave (fuente: decs) enfermería; infecciones por coronavírus; unidades de cuidados intensivo; salud mental; promoción de la salud. ic u n ur si ng t ea m m en ta l h ea lt h in t he f ac e of t he c o v id -1 9 pa nd em ic : a n in te gr at iv e re vi ew 5 saúde mental da equipe de enfermagem intensivista ante a pandemia da covid-19: revisão integrativa resumo introdução: durante a pandemia da covid-19, os profissionais de saúde apresentaram risco aumentado para o desenvolvimento de afecções psíquicas, especialmente na unidade de terapia intensiva. verifica-se lacuna de conhecimento sobre a saúde mental da equipe de enfermagem intensivista no atendimento aos pacientes acometidos pela covid-19. objetivo: identificar, na literatura científica, as condições da saúde mental do profissional de enfermagem intensivista durante a pandemia da covid-19. materiais e método: esta é uma revisão integrativa da literatura; a coleta de dados ocorreu de janeiro a abril de 2022 nas fontes de dados embase, cumulative index to nursing and allied health literature, pubmed, scopus content overview e web of science. elencaram-se os seguintes descritores: “intensive care units”, “covid 19”, “mental health”, “nurse”. incluíram-se estudos produzidos desde 2020, disponíveis na íntegra, em espanhol, inglês e português, e que respondessem à questão de pesquisa. a busca e seleção dos artigos foram executadas por dois pesquisadores treinados, de modo independente, mediante discussão por pares. as recomendações do preferred reporting items for systematic reviews and meta-analyses foram seguidas. resultados: a partir de uma amostra de 16 artigos, observou-se que o cuidado crítico de pacientes com covid-19 afetou a saúde mental dos profissionais de enfermagem com destaque para depressão, ansiedade, estresse e medo. isso se associou à falta de tratamento baseado em evidências, à carência de recursos humanos e físicos, à sobrecarga de trabalho e às experiências de trabalho insuficientes. conclusões: os profissionais de enfermagem intensivistas estão mentalmente abalados; portanto, é imperativa a implantação de políticas, estratégias e métodos para melhorar as condições psicológicas desses profissionais, para, assim, garantir a qualidade nos serviços. palavras-chave (fonte decs) enfermagem; infecções por coronavirus; unidades de terapia intensiva; saúde mental; promoção da saúde. 6 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 26 introduction covid-19 is an infectious disease caused by the sars-cov-2, with a predominance of respiratory symptoms. the world health organization (who) declared it a pandemic in march 2020. until december 2022, more than 651 million cases and 6 million deaths were recorded worldwide (1). it was a fact the general population presented negative reactions to the pandemic, which represented a complex and multifaceted issue (2). people have different ways of dealing with stressful situations depending on their training, life story, individual characteristics, and the community where they live. during the pandemic, in addition to the fear of contracting the disease, there was a constant impression of insecurity towards the daily activities of living in society, with changes in interpersonal relationships (3). in addition, some groups responded more intensely to the covid-19 pandemic stress, namely: younger individuals, females or those with chronic diseases; patients affected by covid-19; health professionals who worked in assistance to covid-19, and individuals with mental disorders, including problems related to substance use, such as alcohol and other drugs (2, 4). a brazilian study indicates an increase in psychological factors such as sadness or depression (40.4 %), anxiety or nervousness (52.6 %) and sleep problems (43.5 %), amid this social niche (5). several studies show that health workers working on the front line of care for people infected with the covid-19 virus are at an increased risk of developing psychological disorders, especially nursing professionals (2, 6, 7). intensive care units (icus [8]) stand out among the hospital environments for health care during these pandemic times. in this environment, nursing care during the critical pandemic period was based on excessive working hours, inadequate staffing, a high number of admitted patients, and lack of professional training; in addition to the need to deal with the grief, pain, and suffering of others (9, 10). nursing professionals are among the most devalued groups in the health area, even when representing the pillar of health services around the world. within an icu, nursing professionals are the main caregivers and those with the longest contact times with the patients (11). thus, the mental illness process in nursing professionals responsible for the immediate and continuous care of critically-ill patients affected by covid-19 and with higher rates of infection and death due to the disease stands out (12-14). various studies evidence the need to prioritize protection measures for the sake of preserving the optimization of their capacities (6, 7). the mental health care of an icu nursing team cannot be interrupted or minimized in the post-pandemic period, as certain individuals may be slow to externalize the psychological distress signs and symptoms (15). ic u n ur si ng t ea m m en ta l h ea lt h in t he f ac e of t he c o v id -1 9 pa nd em ic : a n in te gr at iv e re vi ew 7 given the above, a gap is verified in the knowledge about icu nursing professionals’ mental health in the care provided to patients affected by covid-19. to establish targeted and effective health promotion and prevention actions, this study aims at identifying, in the scientific literature, the mental health conditions of icu nursing professionals during the covid-19 pandemic. materials and methods this is an integrative literature review. this approach provides a synthesis of knowledge and grouping of relevant research results in the practice, generating a solid and accessible overview of complex concepts, theories or related health problems (16). to develop the guiding question, the “population-concept-context” (pcc) strategy was applied, where “p” is the icu nursing team, “c” is mental health and “c” is the covid-19 pandemic. likewise, the following question was formulated: what is the icu nursing team’s mental health like during the covid-19 pandemic? data collection took place from january to april 2022, in the following data sources: cumulative index to nursing and allied health literature (cinahl); scopus content overview (scopus), pubmed, embase and web of science. the following descriptors available in the medical subject headings (mesh) were listed: “intensive care units,” “covid-19,” “mental health,” and “nurse”. and and or boolean operators were used. the following crossing was obtained: ((“intensive care units”) and (“nurse” or “nurses” or “nursing”) and (“mental health” or “mental illness” or “mental disorder” or “psychiatric illness”) and (“covid-19”)). the studies included were those conducted since 2020 (the year when the covid-19 pandemic was declared), available in full in spanish, english and portuguese, which answered the research question. the articles excluded were those duplicated across the databases, as well as editorials, letters to the author, theoretical essays, literature reviews, dissertations, theses, and protocols. search and selection of the articles were the responsibility of two duly trained researchers, who worked independently through peer discussion. the state of the art through systematic review software was used as a support, which allows methodically organizing the development of literature reviews. another researcher was consulted in case of disagreement. the preferred reporting items for systematic reviews and meta-analyses (prisma) recommendations were adapted for this review (17). the data were extracted through a data collection instrument prepared by the researcher in charge, including the following variables: title, authors, year of publication, country, journal, impact factor, language, type of study, level of evidence, and the evidenced mental health conditions. the data were organized in a microsoft excel 2010 spreadsheet. 8 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 26 figure 1. flowchart corresponding to the process to select the articles included in the research, according to the prisma 2020 adapted recommendations. brazil, 2022 source: prepared by the authors. regarding the analysis of the levels of evidence corresponding to the studies included in this research, the recommendations proposed by oxford’s centre for evidence-based medicine (18) were followed. for the diagnostic, treatment, and intervention studies, the following classification was observed: level i — randomized clinical trials; level ii — prospective cohort studies; level iii — retrospective cohort studies and case-control studies; level iv — case series; and level v — opinions or consensus. studies related to etiology and prognosis followed this classification: level i — synthesis of cohort or case-control studies; level ii — prospective cohort studies; level iii — retrospective cohort studies; level iv — case series; and level v — opinions or consensus. in addition, the results were presented descriptively and visually, with the elaboration of figures and tables the main findings were interpreted and discussed against the pertinent literature. for being an integrative literature review, this research waived submission to any research ethics committee. results a total of 45 manuscripts were identified. while selecting the materials, duplicate studies (n = 65) and those that did not meet the inclusion criteria (n = 289) were excluded. in the eligibility stage, 29 studies were read in full. after the thoughtful full-reading analysis, 16 articles were included in the current sample. figure 1 presents the flowchart corresponding to the process to select the studies and comprise the sample. no. of studies identi�ed in the search databases (n = 415) cinahl (n = 73) scopus (n = 82) selected studies (n = 415) publications selected for eligibility (n = 59) studies excluded (n = 354) duplicated studies (n = 65) did not meet the inclusion criteria (n = 236) editorials, letters to the author, literature reviews, or protocols (n = 34) other reasons (n = 21) total studies included (n = 16) studies excluded (n = 43) research not exclusively conducted in icus (n = 22) research involving other professionals (n = 13) intervention research (n = 3) research investigating the patients' mental health (n = 2) other reasons (n = 3) pubmed (n = 78) embase (n = 145) web of science (n = 37) no. of studies identi�ed in other sources (n = 0) id en ti � ca ti o n se le ct io n el ig ib ili ty in cl u si o n ic u n ur si ng t ea m m en ta l h ea lt h in t he f ac e of t he c o v id -1 9 pa nd em ic : a n in te gr at iv e re vi ew 9 the final study sample evidenced more publications in 2021 (80.5 %), from countries in europe (43.75 %) and asia (37.5 %), with methodological designs corresponding to retrospective (62.5 %) and prospective (25 %) cohort studies, written in english (93.75 %). table 1 shows the characterization of the articles included in the study according to publication journal, impact factor, method, level of evidence, and country of origin. the main findings from each selected study can be seen in table 2, along with their authors and years of publication. table 1. characterization of the studies. brazil, 2022 no. journal/impact factor* method/level of evidence country of origin a1 (19) revista da escola de enfermagem da usp jcr 1.123 retrospective cohort study/iii brazil a2 (20) bmj open jcr 3.006 case series/vi china a3 (21) nursing in critical care jcr 2.897 prospective cohort study/ii china a4 (22) frontiers in psychiatry jcr 5.5 prospective cohort study/ii china a5 (23) journal of pain and symptom management jcr 5.576 prospective cohort study/ii china a6 (24) nursing in critical care jcr 2.897 prospective cohort study/ii egypt a7 (25) nursing in critical care jcr 2.897 retrospective cohort study/iii spain a8 (26) american journal of critical care jcr 2.207 retrospective cohort study/iii united states a9 (27) intensive & critical care nursing jcr 4.235 retrospective cohort study/iii netherlands a10 (28) journal of family medicine and primary care jcr -2.82 retrospective cohort study/iii iran a11 (29) acta biomed for health professions sjr 1.8 retrospective cohort study/iii italy a12 (30) nursing in critical care jcr 2.897 case-control study/iii nepal a13 (31) healthcare jcr 3.160 retrospective cohort study/iii romania a14 (32) australian critical care jcr 3.265 retrospective cohort study/iii sweden a15 (33) journal of clinical nursing jcr 4.442 retrospective cohort study/iv turkey a16 (34) intensive & critical care nursing jcr 4.235 retrospective cohort study/iii turkey key: impact factor according to scimago journal rank (sjr) or to journal citation reports (jcr), 2021. source: prepared by the authors. 10 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 26 table 2. main findings from the studies related to the icu nursing team’s mental health. brazil, 2022 no. authorship/year main findings a119 conz ca, braga vas, vasconcelos r, machado fhr da s, de jesus mcp, merighi mab, 2021 the critical care of patients with covid-19 affected nurses’ mental and physical health. emotional wear out was evidenced by experiencing illness and distancing from family members. the uncertainty regarding the care of patients with covid-19 generated fear of contamination. a220 hu f, ma j, ding xb, li j, zeng j, xu d et al., 2021 the nurses that provided care to patients infected by covid-19 felt higher stress levels. all participants felt despair and abandonment. a321 leng m, wei l, shi x, cao g, wei y, xu h et al., 2021 throughout the covid-19 pandemic, icu nurses showed some level of mental distress, such as post-traumatic stress disorder symptoms and perceived stress. the stress sources included working in an isolated environment, concerns about lack and use of equipment, high workload, fear of contagion, and insufficient work experience. a422 li j, zhang y, li l, yi w, hao y, bi y, 2021 during the pandemic, 44.9 % of icu nurses had depression. in addition, the obligation to work overtime generated tension and difficulty to relax. a523 yifan t, ying l, chunhong g, jing s, rong w, zhenyu l et al., 2020 icu nurses presented somatic symptom disorder, among which was the prevalence of chest discomfort and palpitations, dyspnea, nausea, headache, dizziness, dry mouth, fatigue, drowsiness, sweating, and waist pain. a624 baraka aae, ramadan fh, hassan ea, 2021 in this study, 38.5 % of the nurses presented severe stress; 10 %, extremely severe stress; 62 %, severe anxiety, and 34.5 %, moderate depression. the hospital’s lack of human and physical resources and the number of colleagues infected with covid-19 were the strongest predictors of stress, anxiety and depression. a725 peñacoba c, catala p, velasco l, carmonamonge fj, garciahedrera fj, gilalmagro f, 2021 nurses who worked in icus with patients infected with the sars-cov-2 virus showed high-stress levels and mental health deterioration. a826 guttormson jl, calkins k, mcandrew n, fitzgerald j, losurdo h, loonsfoot d, 2022 the nurses reported stress related to the lack of evidence-based treatment, poor patient prognosis, and absence of family members in the icu. physical and emotional symptoms were found, including exhaustion, anxiety, insomnia, and moral distress. fear of contracting covid-19 or infecting family members and friends was also prevalent. a927 heesakkers h, zegers m, van mol mmc, van den boogaard m, 2021 there was a prevalence of anxiety (27 %), depression (18.6 %), and post-traumatic stress disorder (22.2 %) symptoms, found in 256 (35.3 %) nurses in the covid-19 icu; whereas 41.7 % presented high work fatigue. a1028 belash i, barzagar f, mousavi g, janbazian k, aghasi z, ladari at et al., 2021 the increased anxiety among nurses working in the covid-19 icu was associated with age, weekly working hours, pregnancy, cases of direct participation in resuscitation procedures, and observing patient death cases. a1129 vitale e, galatola v, mea r, 2021 the nurses reported a high anxiety component, especially linked to the fear of becoming infected and infecting their family members. in addition, there were reports of mild, moderate, and severe depressive status (37.4 %). ic u n ur si ng t ea m m en ta l h ea lt h in t he f ac e of t he c o v id -1 9 pa nd em ic : a n in te gr at iv e re vi ew 11 no. authorship/year main findings a1230 tamrakar p, pant sb, acharya sp, 2021 covid-19 icu nurses showed more psychiatric symptoms (90.4 %), anxiety (36.5 %) and depression (21.2 %) when compared to nurses in non-covid-19 icus. two participants had suicidal ideation, and all nurses (100 %) were afraid to pass the infection on to their family members. a1331 petrișor c, breazu c, doroftei m, mărieș i, popescu c, 2021 icu nurses presented high moral distress levels throughout the pandemic, which was associated with anxiety, depression, and the intention to quit their jobs. a1432 hallgren j, larsson m, kjellén m, lagerroth d, bäckström c, 2022 the icu nurses reported feeling insecure due to limited knowledge about the covid-19 virus and how it spread. in addition, they experienced the fear of being infected and the uncertainty related to the safety of personal protective equipment. they also presented somatic symptom disorder and feelings of helplessness, nervousness, and stress. a1533 kandemir d, temiz z, ozhanli y, erdogan h, kanbay y, 2021 the icu nurses presented scores for moderate to extremely severe depression (65.5 %), anxiety (58.3 %), stress (72.3 %), and moderate or severe insomnia (39.7 %). a1634 şanlıtürk d, 2021 among the participants, 63 % and 20 % presented moderate and high-stress levels, respectively. this result was because of the fear of contracting the virus at any moment, due to the asymptomatic characteristic of the covid-19 disease in some people. source: prepared by the authors. thus, it was possible to create a summary chart of the mental dysfunctions in the icu nursing teams during the covid-19 pandemic. anxiety, depression, stress, and fear stand out as the most prevalent conditions in the nursing team. table 3 shows the disorders and the studies in which they were found. table 3. synthesis chart of the mental disorders in the icu nursing professionals during the covid-19 pandemic. brazil, 2022 anxiety (a6; a8; a9; a10; a11; a12; a13; a15) depression (a4; a6; a8; a9; a11; a12; a13; a15) stress (a2; a3; a6; a7; a8; a9; a14; a15; a16) fear (a1; a3; a8; a11; a12; a14; a16) fatigue (a5; a9) insomnia (a8; a11; a15) somatic symptom disorder (a5; a14) insecurity (a14) nervousness (a14) suicidal ideation (a12) sensation of impotence (a14) emotional wear out (a1) source: prepared by the authors. 12 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 26 additionally, this study evidenced causal factors associated with the presence of these disorders in the mental health of these professionals. uncertainty regarding patient care due to the lack of evidence-based treatment, absence of human and physical resources, work overload, and insufficient work experience was included. in the icu, there is the aggravation inherent to the structural physical scope, as it is an isolated environment permeated by poor health prognoses, with frequent deaths. finally, the number of colleagues infected and the fear of infecting themselves and their family members due to the virus’ high transmissibility rate are also mentioned. discussion the icu nursing work in the treatment of covid-19 patients during the pandemic led to damages to these individuals’ mental health. these professionals presented high anxiety, depression, stress and fear levels. the pandemic exerted an immense effect on health professionals’ general and mental health, many of whom faced this challenge in dire conditions and without institutional support, with impacts not only at a professional level but also on their morale and overall determination (35-37). the anxiety of health professionals who worked on the front line against the pandemic was shown in this study as the most prevalent impairment, a fact that corroborates with studies showing the significant increase of this condition when compared to previous periods (37). nurses are the most affected due to factors such as being mainly female, pre-existing diseases, physical symptoms of covid-19, prolonged exposure to patients with covid-19, and the fact that they work in an icu (38). the prevalence of depression in the studies analyzed denotes an extremely relevant factor. this phenomenon is associated with nursing professionals’ mental overload caused by concern about increased covid-19 infection rates among professionals and excessive work in inappropriate conditions. thus, the professionals who experienced the pandemic were more prone to developing psychological disorders, such as depression (36, 39). the feeling of fear was found in most of the studies selected for this research; the motivations were associated with the fear of becoming infected or infecting family members and, consequently, leading them to death. a previous research study pointed to fear as one of the main feelings stated by the nursing team, involving the fear of contaminating themselves or others and losing family members (40). in addition, a significant increase in work-related fatigue and the presence of insomnia in icu professionals were evidenced. a study observed that most of the professionals presented loss of sleep quality and constant tiredness, mainly due to the high work demand to which they were subjected. in addition, symptoms such as ic u n ur si ng t ea m m en ta l h ea lt h in t he f ac e of t he c o v id -1 9 pa nd em ic : a n in te gr at iv e re vi ew 13 headache, nervousness and sadness were found, confirming the physical and psychological effects of the pandemic period (41). thus, health professionals that work directly with patients with covid-19 in high-risk environments presented more psychological symptoms when compared to those from other sectors. direct assistance to people infected with the virus led to increased concerns about infecting family members and to higher anxiety, stress, insomnia and depression levels due to increased fear. in addition, nurses have the highest workload and the longest contact time in care provision, which act as determining factors in the deterioration of their mental health (42). in this regard, the increase in the number of professionals infected and away from work caused overload to the teams, contributing to psychological exhaustion and feelings of loneliness and increased stress in this population (43, 44). a study developed with an icu nursing team showed that the prevalence of burnout syndrome was 25.5 % throughout the covid-19 pandemic, a consequence of the high-stress levels in this population segment, among other reasons. within the main causal factors, there is emotional exhaustion and depersonalization, arising from overtime and rigid workloads (37, 43). these data corroborate those found in the current study. thus, it is indispensable to consider the relevance of icu nursing work, especially in emergencies, such as the covid-19 pandemic situation. in addition to that, it is necessary to provide adequate working conditions and psychosocial support to preserve these professionals’ mental health to guarantee the quality of the care provided (42). countless studies reveal the need to offer psychological monitoring to the professionals who worked directly in coping with the pandemic, both in the shortand long-term, due to the intrinsic and unique characteristics of a global public health emergency (45-47). studies on the harms caused to icu nursing professionals’ mental health during the pandemic period contribute to implementing actions targeted at five-year prevention, which aims at providing biopsychosocial care to the professionals, given the importance of preserving their health to ensure patient safety (48, 49). the pandemic period evidenced the relevance of this fifth aspect as indispensable to maintaining quality in terms of care and the work environment, reflecting on the strengthening of the health system (50). thus, investments in the area of caregivers’ health are necessary to ensure safe health care. nursing professionals are important actors in the provision of humanized care, focused on welcoming, directed listening and comforting patients. however, when these professionals are emotionally shaken, the nature of care is weakened. thus, it is encouraged to carry out new research studies 14 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 26 with greater methodological depth, to point out the mental health indicators of this population group and the measures adopted for its mitigation during the viral infection by the new coronavirus. the type of study and the number of databases listed stand out as a limitation, which precludes comparing the articles analyzed and monitoring the daily evolution of the findings. for being an emerging topic, new scientific findings are published every day. conclusions the results allowed identifying the conditions that affected the mental health of icu nursing teams during the covid-19 pandemic, focusing on depression, anxiety, stress, and fear. such conditions were mainly caused by the lack of evidence-based health-disease treatment, the deficit in human and physical resources, the care environment that was isolated from the other sectors, and the constant increase in the number of viral infections among professionals and their family members. thus, it is emphasized that preventing mental illness in nursing teams should be considered an indispensable element for care quality and safety. it is necessary to implement policies, strategies, and methods to improve the psychological conditions of these professionals and thus ensure better quality in the services provided. conflict of interest: none declared references 1. world health organization. who covid-19 dashboard [internet]. available from: https://covid19.who.int/ 2. talevi d, socci v, carai m, carnaghi g, faleri s, trebbi e et al. mental health outcomes of the covid-19 pandemic. riv psichiatr. 2020;55( 3):137-44. doi: https://doi.org /10.1708/3382.33569 3. lima ckt, carvalho pmm, lima ia as, nunes jvao, saraiva js, de souza ri et al. the emotional impact of coronavirus 2019-ncov (new coronavirus disease). psychiatry res. 2020;287:112915. doi: 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https://doi.org/10.1016/j.hrtlng.2022.04.015 https://doi.org/10.3389/fpubh.2021.796591 https://doi.org/10.3389/fpubh.2021.796591 https://doi.org/10.3389/fpsyt.2021.804525 https://journalhss.com/wp-content/uploads/jhhs_62_209-220.pdf https://journalhss.com/wp-content/uploads/jhhs_62_209-220.pdf 16 a q u ic h a n | ei ss n 2 02 753 74 | a ñ o 23 v o l. 2 3 n º 2 ch ía , c o lo m bi a a br il -j u n io 2 02 3 | e 23 26 40. humerez dc, ohl rib, silva mcn. saúde mental dos profissionais de enfermagem do brasil no contexto da pandemia covid-19: ação do conselho federal de enfermagem. cogitare enfermagem. 2020;25:e74115. doi: https://doi.org /10.5380/ce.v25i0.74115 41. santos wj, liva rb, rodrigues df, farias icv, moura gjb. transtornos mentais comuns em trabalhadores de uma unidade de terapia intensiva durante pandemia de covid-19. rev psicolog. 2021;15(57):149-62. doi: https://doi.org /10.14295/idonline. v15i57.3179 42. chigwedere oc, sadath a , kabir z, arensman e. the impact of epidemics 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https://doi.org/10.5380/ce.v25i0.74115 https://doi.org/10.14295/idonline.v15i57.3179 https://doi.org/10.14295/idonline.v15i57.3179 https://doi.org/10.3390/ijerph18136695 https://doi.org/10.3390/ijerph18136695 https://doi.org/10.1590/0047-2085000000313 https://doi.org/10.1590/0047-2085000000313 https://doi.org/10.3390/ijerph19010568 https://doi.org/10.3390/ijerph19010568 https://doi.org/10.1056/nejmp2008017 https://doi.org/10.1056/nejmp2008017 https://doi.org/10.1111/jnu.12760 https://doi.org/10.1007/s11606-021-07251-0 https://doi.org/10.14295/jmphc.v13.1142 https://doi.org/10.32385/rpmgf.v30i3.11358 https://doi.org/10.32385/rpmgf.v30i3.11358 https://doi.org/10.47820/recima21.v4i1.2525 https://doi.org/10.47820/recima21.v4i1.2525 01. editorial -02.aquichan aquichan, cuidado 5 ingún nombre podía ser más apropiado que este de “cuidado”, expresado en lengua indígena, para una publicación vinculada con nuestra facultad de enfermería. si algo puede caracterizar los estudios respectivos y el ejercicio de la profesión resultante de ellos es esta palabra, en tanto los estudiantes de enfermería se preparan para ejercitar su personal solicitud frente a sus congéneres, en la mayoría de los casos con relación a aquellos sufrientes, mientras sus docentes deben tener muy cerca de su corazón la necesidad de inculcar permanentemente en sus alumnos este afán de “cuidado” por los demás, sin el cual la conducta del enfermero descendería a una ocupación meramente burocrática y desprovista de su sentido genuino. es verdad que toda actividad humana, en cualquier forma, está relacionada con aquella atención al prójimo, a quien el maestro, el hijo de dios, nos manda amar “como a nosotros mismos”, traduciendo este amor en conductas concretas, como maravillosamente se nos ejemplifica a través de la parábola del buen samaritano. leyendo recientemente un escrito del gran canciller de esta universidad, cuya visita a nosotros seguramente se habrá ya producido en el momento de la aparición de este escrito, nos prevenía contra dos expresiones, ambas igualmente desviadas, de este amor al prójimo que se nos exige, cuando él no se canaliza, como debe ser, a personas y a situaciones concretas, o cuando se hace un uso apenas reduccionista de él. una de estas desviaciones es la generalización meramente intelectual del sentimiento por el prójimo, sin descender este sentimiento a lo específico, a comportamientos que nos comprometan. la otra, entender que nuestro deber para con el prójimo se limita a nuestro círculo estrecho, familiar o social, desentendiéndonos de quienes no participan de esta condición. como bien lo expresa la parábola antes mencionada, el prójimo es “alguien”, “uno cualquiera”, “un hombre que bajaba por el camino”. 1 edición de 1987, editorial espasa y calpe s.a., madrid. álvaro mendoza ramírez año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 6 sin embargo de constituir la atención por los demás un imperativo de toda actividad humana, algunas de ellas, y entre estas sobresale particularmente la del enfermero, se sitúan necesariamente más próximas de las oportunidades concretas para actuar al servicio de los demás, para tener con ellos “cuidado”, como corresponde al nombre de esta publicación. esta voz de nuestra lengua, según el decir del diccionario de la real academia1, nos refiere, entre otros sentidos menos importantes, a la “solicitud y atención para hacer bien alguna cosa”, a lo cual podríamos añadir, sin peligro de quebrantar los alcances del término, “para hacer el bien a otra u otras personas”. ser solícito significa ser entregado, hacerlo con cariño, con esmerada atención. de esto se trata. el enfermero está llamado, por su específica vocación profesional, a tareas eminentemente de servicio, sea que se consagre, como probablemente ocurra con muchos de nuestros egresados, a los quehaceres de atención a los enfermos, sea que trabaje en labores de salud ocupacional, de prevención, etc. en últimas, todas estas ocupaciones están estrechamente relacionadas con el servicio al prójimo, y lo están mayormente y con más amplia frecuencia que la gran mayoría de las actividades de carácter diferente. aparece esta publicación con motivo de la celebración de los diez primeros años de nuestra facultad de enfermería, efemérides que en buena hora han decidido destacar las directivas de la facultad. en la vida de las instituciones, es algo que he tenido oportunidad de repetir con motivo de aniversarios similares, ocurre algo similar a cuanto acontece con las personas. conviene detenerse en ciertos hitos, precisar algunos mojones, que sirven para examinar el camino ya recorrido y para proyectar aquel que aún nos espera. un aniversario, y particularmente uno de alguna importancia, como ocurre con una década, es un motivo para varias conductas: en primer término, para agradecer, particularmente a la providencia, por todo cuanto se ha logrado (y en el caso de la facultad de enfermería es mucho); seguidamente, para que podamos reconocer el fruto de nuestros esfuerzos, de nuestro trabajo, de nuestros desvelos; también, para examinar las eventuales equivocaciones en el camino recorrido y adoptar los correctivos del caso; por último, y es algo de no poca importancia, para soñar un poco en aquello que nos espera. la vida, toda vida, también aquella institucional, en últimas, bien puede descomponerse en la memoria del pasado, en la ocupación del presente y en la ilusión del porvenir. termino felicitando de todo corazón a nuestra facultad de enfermería y a todo su personal docente y directivo por el aniversario, y aprovecho para reconocer la labor de un equipo de personas que ha sacado adelante esta facultad. dentro de este equipo, muy especialmente, la tarea siempre abnegada, tesonera, alegre y eficaz de su decana, la doctora leonor pardo novoa. como rector, sin por ello dejar de reconocer el mérito de otras autoridades académicas, siempre he sentido en la decana de la facultad de enfermería una muy particular devoción por su trabajo y, sobre todo, una muy agradable manera de defender y de sacar adelante los intereses de la unidad a su cargo. para ella, gestora incuestionable de cuanto hasta hoy ha sido alcanzado, unas felicitaciones muy cálidas. 104 115 percepcion de la calidad de vida.indd 104 clara rocío galvis-lópez1 luz h. aponte-garzón2 maría l. pinzón-rocha3 percepción de la calidad de vida de cuidadores de pacientes asistentes a un programa de crónicos, villavicencio, colombia 1 universidad de los llanos, colombia. cgalvis@unillanos.edu.co 2 universidad de los llanos, colombia. lhaponte@hotmail.com 3 universidad de los llanos, colombia. marialuisa.pinzón@unillanos.edu.co recibido: 05 de junio de 2014 enviado a pares: 09 de agosto de 2014 aceptado por pares: 24 de noviembre de 2015 aprobado: 30 de noviembre de 2015 doi: 10.5294/aqui.2016.16.1.11 para citar este artículo / to reference this article / para citar este artigo galvis-lópez cr, aponte-garzón lh, pinzón-rocha ml. percepción de la calidad de vida de cuidadores de pacientes asistentes a un programa de crónicos, villavicencio, colombia. aquichan. 2016;16(1):104-115. doi: 10.5294/aqui.2016.16.1.11 resumen objetivo: determinar la percepción de la calidad de vida de cuidadores informales de adultos que padecen enfermedad crónica, que asisten al programa de crónicos de la empresa social del estado de villavicencio, colombia. materiales y métodos: estudio descriptivo, de abordaje cuantitativo y de corte transversal en cuidadores informales (n = 180) de adultos crónico usuarios del programa de promoción y prevención de crónicos. con los cuidadores se utilizó el instrumento calidad de vida (qol) versión familiar de ferrell y grant, y para valorar la funcionalidad de los pacientes crónicos, se usó el perfil pulses adaptado por granger. se determinan rangos de puntaje, medidas de tendencia central y dispersión para los dominios de bienestar y calidad de vida. resultados: en la mayoría de los cuidadores se evidenció que los dominios de bienestar físico y social no se encuentran afectados, y las dimensiones de bienestar psicológico y espiritual están en nivel medio, al igual que la calidad de vida. conclusiones: para la enfermería, los resultados pueden orientar procesos de capacitación a fin de fortalecer habilidades de cuidado en cuidadores que permitan promover la salud y el bienestar, evitar el deterioro de la calidad de vida y cuidar oportunamente y en mejores condiciones al familiar que padece enfermedad crónica. palabras clave calidad de vida; bienestar físico; cuidadores; enfermedad crónica; paciente; salud de la familia (fuente: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 104-115 105 percepción de la calidad de vida de cuidadores de pacientes asistentes a un programa de crónicos, villavicencio, colombia l clara rocío galvis-lópez y otros año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 104-115 perception of the quality of life of caregivers of patients attending a program for the chronically, villavicencio, colombia abstract objective: identify perceptions about the quality of life of informal caregivers of chronically ill adults who are attending a program for the chronically ill sponsored by a state-run social welfare agency in villavicencio, colombia. materials and methods: this is a descriptive, cross-sectional study with a qualitative approach. the focus is on informal caregivers (n = 180) of chronically ill adults who are involved in the chronic illness awareness and prevention program. the quality of life (qol) instrument – family version developed by ferrell and grant was used with the caregivers, and the granger adapted version of the pluses profile was used to assess the functionality of chronically ill patients. the score ranges and measures of central tendency and dispersion for the domains of well-being and quality of life are determined. results: in most of the caregivers, there was evidence that the domains of physical and social well-being are not affected. the dimensions of psychological and spiritual well-being are at the middle level, as is quality of life. conclusions: the results can be used by nursing to guide training processes aimed at strengthening the skills caregivers have to promote health and wellbeing, prevent quality of life from deteriorating, and provide timely care and in better conditions for a family member who is suffering from a chronic illness. keywords quality of life; physical wellbeing; caregivers; chronic illness, patient; family health (source: decs, biremire). 106 aquichan issn 1657-5997 percepção da qualidade de vida de cuidadores de pacientes participantes de um programa de crônicos, villavicencio (colômbia) resumo objetivo: determinar a percepção da qualidade de vida de cuidadores informais de idosos que padecem doença crônica, que participam do programa de crônicos da empresa social do estado de villavicencio (colômbia). materiais e métodos: estudo descritivo, de abordagem quantitativa e de corte transversal em cuidadores informais (n = 180) de idosos crônicos usuários do programa de promoção e prevenção de crônicos. com os cuidadores, utilizou-se o instrumento qualidade de vida (qol, por sua sigla em inglês) versão familiar de ferrell e grant, e para avaliar funcionalidade dos pacientes crônicos, usou-se o perfil pulses, adaptado por granger. determinaramse faixas de pontuação, medidas de tendência central e dispersão para os domínios de bem-estar e qualidade de vida. resultados: na maioria dos cuidadores, evidenciou-se que os domínios de bem-estar físico e social estão em nível médio, assim como a qualidade de vida. conclusões: para a enfermagem, os resultados podem orientar processos de capacitação a fim de fortalecer habilidades de cuidado em cuidadores que permitam promover a saúde e o bem-estar, evitar a deterioração da qualidade de vida e cuidar oportunamente e em melhores condições do familiar que padece doença crônica. palavras-chave qualidade de vida; bem-estar físico; cuidadores; doença crônica; paciente; saúde da família (fonte: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 104-115 107 percepción de la calidad de vida de cuidadores de pacientes asistentes a un programa de crónicos, villavicencio, colombia l clara rocío galvis-lópez y otros introducción las enfermedades crónicas se incrementan y son un gran desafío en la prestación de servicios de salud; con el envejecimiento de la población y los factores de riesgo se prevé que las defunciones también aumenten a nivel mundial según la organización mundial de la salud (oms) (1); para el año 2020, serán la principal causa de discapacidad y el problema de más carga en los sistemas de salud (2). similar situación se presenta en colombia, y en el departamento del meta en particular, según los indicadores básicos, que registran a las enfermedades crónicas en personas de 45 y más años en el primer puesto (3); por su parte, en villavicencio son las principales causas de mortalidad en adultos mayores de 65 años (4). esta situación demanda de las instituciones prestadoras de salud, como la empresa social del estado (ese) de villavicencio, establecer programas de promoción y prevención para la atención de las personas con enfermedades crónicas, con el propósito de proveer servicios de salud, prevenir la discapacidad y la muerte prematura, incrementar los años de vida saludables y la calidad de vida. el cuidado cotidiano del paciente, a partir del diagnóstico de la enfermedad crónica, recae en la familia, específicamente en el cuidador informal, quien apoya, acompaña, gestiona y asiste al paciente en la consulta de crónicos y continúa los tratamientos en el domicilio y, sin esperarlo, termina asumiendo el rol de manera permanente, dedicando tiempo y esfuerzo al cuidado integral de su familiar durante el tiempo de su cronicidad. las características de las enfermedades crónicas irreversibles, de progresión lenta y larga duración, con periodos de remisión y recurrencia, las cuales generan cambios en los estilos de vida y repercusiones en la vida de las personas que las padecen y en los cuidadores (2), precisan que los enfermeros en los programas de promoción y prevención de crónicos promuevan la participación y el compromiso tanto del paciente como del cuidador en la gestión del cuidado. dependiendo de la funcionalidad y dependencia del paciente, y de la condición de su salud durante el proceso de cronicidad, el cuidador debe asumir, además de su propio cuidado, una diversidad de tareas para el paciente crónico, como ayudarlo en las actividades de la vida diaria, administrar tratamientos, proveer soporte para facilitar el afrontamiento y la adaptación a la enfermedad, a la incertidumbre por el pronóstico y a las condiciones de discapacidad, así como intervenciones para asumir cambios en los estilos de vida, controlar signos y síntomas propios de la enfermedad, identificar signos de alarma, prevenir secuelas y realizar gestiones ante los programas de servicios sanitarios (5) para garantizarle a su familiar una vida lo más saludable posible durante su etapa de cronicidad. ahora bien, aunque la experiencia de cuidar a una persona que vive con alteraciones crónicas de salud —desde el diagnóstico hasta su muerte— es gratificante y genera en el cuidador consecuencias positivas, como aumento de la autoestima, orgullo, satisfacción y afectos más profundos en las relaciones (6), también supone una labor extenuante que ocasiona en el cuidador afectaciones en su salud física, emocional, espiritual y social, que comprometen su calidad de vida (7, 8). en este contexto, el estudio aborda la calidad de vida desde la perspectiva de los cuidadores de adultos crónicos asistentes al programa de promoción y prevención de crónicos de la empresa social del estado del municipio, con miras a plantear algunas recomendaciones que promuevan el bienestar en el cuidador, considerado partícipe esencial en la vida y el cuidado del adulto que vive en cronicidad. materiales y métodos diseño de tipo descriptivo, de corte transversal y de abordaje cuantitativo, que explora la percepción de los dominios del bienestar físico, psicológico, social y espiritual en cuidadores de pacientes asistentes al programa de crónicos, que provienen de los centros de salud del popular, porvenir, esperanza, porfía, morichal y recreo, de la empresa social del estado de villavicencio. la muestra comprendió a 180 cuidadores de adultos en situación de cronicidad (n = 180); a través de la técnica de muestreo no probabilístico de tipo intencional se seleccionan 30 cuidadores de cada uno de los 6 centros de salud, que cumplieran los siguientes criterios de inclusión: ser cuidador mayor de 18 años y expresar su voluntad de participar, mediante la firma del consentimiento informado. se utilizó el instrumento quality of life family version (qol) de ferrell y grant, utilizado en países de habla hispana como honduras, san salvador, república dominicana, cuba y guatemala, y, en la última década, en colombia, en las ciudades de bogotá, medellín, santa marta, ibagué y cartagena. el qol se basa en estudios cualitativos y cuantitativos, inicialmente efectuados en pacientes que padecían cáncer y después en cuidadores familiares; fue revisado y probado entre 1994 y 1998, en un estudio de 219 cuidadores familiares de enfermos de cáncer, y validado por las autoras en población latina. presenta fiabilidad test-retest de r = 0,89, y consistencia interna alfa de r = 0,69. el 108 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 análisis factorial confirmó los 4 dominios de calidad de vida como las subescalas del instrumento. contiene 37 ítems que valoran los dominios de la calidad de vida: bienestar físico (preguntas 1 a 5, total 5 items), bienestar psicológico (preguntas 6 a 21, total 16 items), bienestar social (preguntas 31 a 37, total 9 items) y bienestar espiritual (preguntas 22 a 30, total 7 items); todas tienen dos adjetivos extremos, los negativos y los positivos, con 4 reactivos que corresponden a una escala tipo likert. las autoras del qol indican que es necesario invertir 21 items (1-4, 6, 13-20, 22, 24-29 y 33), dado que están formulados negativamente; así, en todas las dimensiones, la puntuación más alta refleja las percepciones positivas hacia la calidad de vida. la puntuación del qol, original de ferrell et al., se basa en una escala de 0 resultados peores a 10 mejores resultados; para el estudio se utiliza el qol adaptado por el grupo de cuidado de la facultad de enfermería de la universidad nacional de colombia, quienes con la aprobación y autorización de ferrell, ajustan la escala likert de 1 a 4, donde 1 representa los peores resultados y 4 los mejores resultados. la funcionalidad se valora con el perfil pulses de moskwitz y mccam, adaptado por granger, con fiabilidad test-retest de 0,87 y confiabilidad superior a 0,95. la selección de los cuidadores fue realizada por estudiantes de enfermería en opción de grado con capacitación previa quienes, luego de revisar las citas de consultas programadas para los pacientes usuarios del programa de crónicos, vía telefónica ubican al cuidador y acuerdan el encuentro en el día de la consulta de su familiar. en entrevista semiestructurada se expone al cuidador el propósito del estudio, el consentimiento informado y se diligencian los instrumentos. los datos se ingresan y procesan en excel 2007 para windows, y se determinan tres rangos: percepción negativa, nivel medio y percepción positiva para la descripción e interpretación de la calidad de vida según los dominios. todas las puntuaciones máximas equivalen a una percepción positiva de cada dimensión y de la calidad de vida. posteriormente, se calcula la proporción de los cuidadores según el nivel de afectación de la calidad de vida de acuerdo con las cuatro subescalas, y se determinan porcentajes, medias, medianas y desviación estándar. teniendo en cuenta estudios realizados por las autoras del qol, las medias de menos de 3 en los 37 items se interpretan como peores resultados. alfa de cronbach 0,911 para calidad de vida total en el estudio. la investigación contó con la aprobación y autorización del comité de investigaciones de la facultad de ciencias de la salud, del instituto de investigaciones de la orinoquia universidad de los llanos, de las directivas de la empresa social del estado municipal, de la autora del qol, del grupo de cuidado de la facultad de enfermería universidad nacional de colombia, y de los cuidadores, a quienes luego de la lectura de los propósitos del estudio, se les garantiza que su participación será voluntaria y no afectará la atención de la salud, que la entrevista será individual y reservada, y que si está de acuerdo en participar se le solicitará la firma del consentimiento informado. cumple además con los parámetros éticos para estudios con seres humanos estipulados en la resolución 008430 de 1993 del ministerio de la protección social en colombia. resultados las características sociodemográficas de los cuidadores de pacientes que viven con alteraciones crónicas de salud, los cuales asisten al programa de promoción y prevención de la empresa social del estado del municipio de villavicencio, que participaron en el estudio, corresponden en su mayoría a mujeres adultas jóvenes y maduras, casadas, amas de casa, con primaria o bachillerato incompleto, madre, hija o esposa, quienes conviven con el adulto que padece enfermedades crónicas, a quien cuidan. la información detallada del perfil social, educativo, de salud y desempeño del rol del cuidador y del paciente es objeto de otra publicación. los hallazgos reportados en el estudio (tablas 1 y 2) muestran que un poco más de la mitad de cuidadores (ẋ = 2,9) perciben en un nivel medio su calidad de vida, con tendencia a positiva (47 %). al discriminar las dimensiones se encuentra que el 65 % (ẋ = 3,2) y el 60,6 % (ẋ = 3,04) de los cuidadores, respectivamente, perciben el bienestar físico y social de manera positiva, y el 55 % (ẋ = 2,82) y el 48,3 % (ẋ = 2,82), respectivamente, describen el bienestar psicológico y el bienestar espiritual en el nivel medio. la puntuación 1 representa siempre los peores resultados y la puntuación 4 los mejores resultados. el bienestar físico fue el mejor clasificado, no hay alteración importante en cambios en el apetito (ẋ = 3,37), la fatiga (ẋ = 3,24) y al dormir (ẋ = 3,21). para el caso del bienestar psicológico, como mejores resultados los cuidadores informan sentirse útiles (ẋ = 3,5), clasifican su estado psicológico como excelente (ẋ = 3,31), tienen control de lo que sucede en sus vidas (ẋ = 3,31), sienten felicidad (ẋ = 3,26) y les satisfacen sus 109 percepción de la calidad de vida de cuidadores de pacientes asistentes a un programa de crónicos, villavicencio, colombia l clara rocío galvis-lópez y otros tabla 1. percepción del nivel de afectación según bienestar y calidad de vida (n = 180) fuente: bases de datos de la investigación, programa excell 2007 para windows. dimensiones afectación negativa afectación media afectación positiva fr % fr % fr % física 6 3,3 57 31,7 117 65,0 psicológica 9 5,0 99 55,0 72 40,0 social 7 3,9 64 35,6 109 60,6 espiritual 13 7,2 87 48,3 80 44,4 cv total 4 2,2 91 50,6 85 47,2 vidas (ẋ = 3,22). aflicción por el diagnóstico, los tratamientos, la propagación y las recaídas son las más bajas puntuaciones. en el bienestar social, los cuidadores perciben que la enfermedad y el tratamiento brindado al paciente no interfieren con su sexualidad (ẋ = 3,48), el empleo (ẋ = 3,38), las actividades del hogar (ẋ = 3,27) y las relaciones personales (ẋ = 3,20), y tampoco sienten aislamiento social; sin embargo, les genera aflicción (ẋ = 2,24) y carga económica (ẋ = 2,93). adicionalmente, perciben que el apoyo social que reciben es suficiente para satisfacer las necesidades (ẋ = 2,48). en cuanto al bienestar espiritual, los cuidadores sienten esperanza (ẋ = 3,32) y propósito en sus vidas (ẋ = 3,0), y aunque consideran excelente su estado de salud espiritual (ẋ = 3,10), piensan que es insuficiente el apoyo espiritual en cuanto a las actividades religiosas (ẋ = 2,76) y las actividades espirituales para satisfacer sus necesidades. resaltan que la enfermedad de su familiar genera pocos cambios positivos en sus vidas (ẋ = 2,37) y sienten incertidumbre por el futuro de su familiar (ẋ = 2,32). discusión calidad de vida la literatura reporta múltiples hallazgos sobre la valoración que hace el cuidador acerca de su calidad de vida. los resultados muestran percepción media en la calidad de vida total, que coincide con la reportada en estudios de vargas y pinto (9) y ferrell et al. (10) y contraria por la afectación negativa (11-13). dar atención a un paciente crónico por periodos largos genera en el proveedor de cuidados demandas superiores a sus capacidades de adaptación, lo que genera estrés crónico, sufrimiento, aislamiento, abandono, conflicto de roles, de pareja y problemas económicos (14), como puede llegar a suceder con el cuidador de las personas que asisten a los programas de promoción y prevención de crónicos; esto sucede debido a la implementación de diferentes terapéuticas y a la ejecución cotidiana y permanente durante toda la etapa de cronicidad de las recomendaciones indicadas en el programa lo que, con el tiempo, afecta negativamente su calidad de vida, más si se tiene en cuenta que el ...rol del cuidador no solo se puede conceptualizar en tareas y procedimientos sino que implica procesos como proporcionar cuidado directo, trabajar con participación del enfermo crónico, monitorizar, interpretar lo observado, tomar decisiones y actuar en consecuencia, ajustar las actividades, obtener recursos para el cuidado y negociar con el sistema de prestación de salud para que se satisfagan las necesidades de la persona enferma (15). bienestar físico el bienestar físico no se ve afectado en la mayoría de los cuidadores, lo que coincide con otros estudios revisados (9, 10, 16), y diferente e incluso superiores a los encontrados en la bibliografía explorada (11, 13, 17-20). no obstante, debido a que la cronicidad implica hacerse cargo de la persona enferma por periodos prolongados y genera en la salud física del cuidador problemas como fatiga, dolor, cambios en el apetito y en el dormir (21), mareo, náuseas, dolor de cabeza, de espalda, de piernas, sensación de cansancio (22), pérdida energía, alteraciones en el patrón de sueño (23), astenia y fatiga crónica (24, 25), alteraciones osteomusculares 110 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 tabla 2. indicadores de calidad de vida de cuidadores (n = 180) fuente: bases de datos de la investigación, programa excell 2007 para windows. categorías % media ds mediana bienestar físico fatiga /agotamiento cambios en el apetito dolor cambios en el dormir estado de salud física en general total dimensión física 78,3 80,6 70,6 75,0 71,1 65,0 3,24 3,37 3,09 3,21 2,95 3,20 0,93 0,83 1,03 0,92 0,83 0,69 4 4 3 3,5 3 3,4 bienestar psicológico facilidad para lidiar con la vida calidad felicidad control de las cosas satisfacción con la vida concentración y recordar sentirse útil aflicción / angustia / diagnóstico enfermedad aflicción / angustia / tratamiento enfermedad aflicción / angustia final primer tratamiento ansiedad / desesperación depresión / decaimiento miedo / temor / segunda enfermedad miedo /temor / recurra enfermedad miedo / temor / propague enfermedad estado de salud psicológico en general total dimensión psicológica 73,8 81,7 82,2 85,0 81,7 73,9 89,4 31,1 36,1 57,2 66,1 68,3 38,3 36,7 32,8 89,4 40,0 3,11 3,10 3,26 3,31 3,22 2,93 3,50 2,10 2,23 2,67 2,93 3,05 2,18 2,17 2,13 3,31 2,82 0,92 0,71 0,80 0,78 0,77 0,88 0,71 0,96 0,96 0,89 1,04 1,04 1,03 1,01 1,03 0,65 0,50 3 3 3 3 3 3 4 2 2 3 3 3 2 2 2 3 2,84 bienestar social aflicción / angustia / enfermedad apoyo suficiente interferencia en relaciones personales impacto en la sexualidad impacto en el empleo interferencia actividades hogar aislamiento carga económica estado de salud social en general total dimensión social 37,2 48,3 71,1 83,9 79,4 78,9 84,4 67,8 73,9 60,6 2,24 2,48 3,20 3,48 3,38 3,27 3,41 2,93 2,98 3,04 0,95 1,07 0,94 0,86 0,90 0,93 0,83 1,01 0,83 0,59 2 2 4 4 4 4 4 3 3 3,11 bienestar espiritual apoyo actividades religiosas satisfactorias apoyo actividades espirituales satisfactorias incertidumbre del futuro de su familiar enfermedades / cambios positivos en la vida propósito / misión de la vida sentimientos de esperanza estado de salud espiritual general total dimensión espiritual puntuación total qol versión familiar 60,6 66,1 38,3 46,7 69,4 83,3 79,44 44,4 47,2 2,76 2,86 2,32 2,37 3,00 3,32 3,10 2,82 2,90 0,99 0,98 1,03 1,02 0,94 0,87 0,84 0,57 0,45 3 3 2 2 3 4 3 2,86 2,94 111 percepción de la calidad de vida de cuidadores de pacientes asistentes a un programa de crónicos, villavicencio, colombia l clara rocío galvis-lópez y otros y cardiovasculares (26), es importante que enfermería proponga, en la consulta del paciente crónico, intervenciones para promover la salud física y controlar los factores de riesgo en el cuidador, dado que la sintomatología aún no es percibida por los cuidadores del estudio, quizás porque los pacientes que asisten al programa de crónicos están controlados, lo que no implica cuidados ante situaciones críticas o terminales en la mayoría de las veces. un síntoma para destacar y de interés para enfermería porque aún no se manifiesta en la mayoría de los cuidadores de los centros de salud del estudio, es la fatiga; según la literatura, esta impacta negativamente todas las dimensiones de la calidad de vida y el bienestar físico al producir “disminución del nivel de energía, incapacidad para realizar las actividades cotidianas y las instrumentales de la vida, para ser útiles, para el ejercicio, impacto negativo en el trabajo, en el ocio, alteraciones en las tareas ordinarias del hogar, la movilidad, en el dormir, e interactúa con otros síntomas como el dolor” (27), y ocasiona escasa participación en actividades que giran alrededor del cuidador (28). bienestar psicológico los cuidadores perciben el bienestar psicológico en un nivel medio de afectación, contrario al deteriorado reportado en los estudios consultados (9, 11-13, 16-20). fortalecer en los cuidadores que acompañan a las personas del programa de promoción y prevención de crónicos sentimientos de felicidad, control de las cosas y satisfacción con la vida, es imperativo para enfermería porque cuidar a un enfermo puede generar “pérdida de sensación de control” y, a “mayor dependencia de las personas en cronicidad hay menor sensación de eficacia y de control de la situación en los cuidadores, ocasionando una menor satisfacción con el cuidado” (29), situación que aún no se evidencia en el estudio, posiblemente porque la valoración funcional de los pacientes por perfil pulses indica que el 55 % de los adultos que asisten al programa son funcionales, y el 24,4 % tienen dependencia leve de sus cuidadores. con la misma importancia se requiere promover en los cuidadores estrategias para incrementar la autoestima y el autoconocimiento según los recursos y las diversas formas de afrontar y cumplir con el rol del cuidador (15), así como sentimientos de utilidad y facilidad para lidiar con su situación, encontrados como factores protectores para la calidad de vida en los cuidadores de este y otro estudio (30), a fin de que no se presenten situaciones de deterioro como las reportadas en la literatura revisada (16, 18, 19). dos categorías igualmente afectadas en los cuidadores del estudio son la percepción de aflicción y angustia por el diagnóstico, tratamiento, propagación y recurrencia de las enfermedades de sus seres queridos, similar a lo reportado por otras investigaciones (19, 20, 22 y 23), y ansiedad y desesperación; estos procesos difieren en varios trabajos (11, 26). se destaca además la presencia de problemas en la capacidad para concentrarse y recordar aspectos relacionados con su vida, y con las gestiones y los cuidados de su familiar enfermo, contrario a los hallazgos en cuidadores de cartagena (31). el cuidar de manera constante y por tiempos prolongados a una persona en condición de cronicidad produce con frecuencia en el cuidador sensación de fracaso, pérdida de sentido de la prioridad, falta de organización, pobre concentración y rendimiento (25), además de ansiedad, escasa habilidad para resolver los problemas, estados depresivos (26) y abatimiento. asimismo, la inquietud, el no poder gozar de la vida diaria y la tensión emocional permanente son percibidas y consideradas condiciones que impactan negativamente en la calidad de vida (6) del cuidador. bienestar social el bienestar social reporta una tendencia positiva, a diferencia de estudios consultados con tendencia media (13, 18, 20, 30) y negativa (9-12, 16, 17, 19, 20). si bien la interferencia en la vida sexual, la presencia de aislamiento social, la afectación en el empleo, en las actividades de la vida diaria y en las relaciones personales, no son referidas por un porcentaje de los cuidadores, investigaciones muestran que las altas demandas del cuidado implican además de la disminución en la actividad sexual (32), carga económica (12) y percepción de apoyo insuficiente (8). una posible explicación de la diferencia con los resultados de este estudio es la independencia del paciente según perfil pulses, y que cerca de la mitad de los cuidadores están dedicados al hogar y dependen de sus propios ingresos (33). si bien el aislamiento es “la soledad que se experimenta como negativa, amenazadora e impuesta por otros” (34), y aún no es manifestada por los cuidadores del estudio, se debe evitar su aparición mediante estrategias dirigidas a los cuidadores que asisten con la persona en situación de cronicidad a los programas de promoción y prevención, como disfrutar el tiempo libre y reunirse con sus familiares para satisfacer las necesidades sociales y promover su calidad de vida (35). sobre la aflicción que genera en el cuidador la enfermedad del familiar, identificada como la categoría más afectada, podría argumentarse que de no atenderla ocasionará aflicción crónica, que se 112 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 diagnostica cuando un cuidador presenta un “patrón cíclico, recurrente y potencialmente progresivo de tristeza en respuesta a una pérdida continua en el curso de una enfermedad o discapacidad que puede progresar e intensificarse en el tiempo” (34), afectando más el estado de la salud social y su calidad de vida en general. bienestar espiritual respecto al bienestar espiritual, el estudio muestra una afectación media, que coincide con los resultados de otras investigaciones (20, 23, 30) y es contrario a valores positivos (9, 16, 17, 19, 20) y puntuaciones negativas halladas en otros trabajos (12, 18). el resultado seguramente está relacionado con la percepción de incertidumbre sobre el futuro del familiar, los pocos cambios positivos para su vida, la enfermedad y la percepción de que el apoyo que reciben de las actividades religiosas y espirituales no es suficiente para cubrir las necesidades espirituales en un grupo de cuidadores; sin embargo, como factor protector, la experiencia de cuidador les genera sentimientos de esperanza, propósito, razón de vivir y buena salud espiritual en general. si bien el cuidar a una persona es estresante, el proveer cuidados también genera crecimiento espiritual y autotrascendencia (36) para hallar sentido, porque hace que el cuidador no se centre en sí mismo, sino en la otra persona, lo que ocasiona realización personal —siempre y cuando no exista un total olvido de sí mismo y de las propias necesidades— (37). estos hallazgos son importantes para potenciarlos en un programa de acompañamiento a cuidadores. la literatura informa que no se conoce la manera como la espiritualidad y la religión se encuentran relacionadas con la salud; sin embargo, prácticas espirituales o religiosas generan actitudes mentales positivas que promueven el bienestar porque “disminuyen la ansiedad, la depresión, el enojo, el malestar, el aislamiento, aumentan la capacidad para disfrutar la vida y sentimientos como la esperanza, optimismo, la satisfacción con la vida y sensación de paz interior, además es fuente de fortaleza” (38). la incertidumbre hacia el futuro que se genera por lo progresivo e irreversible del deterioro y de la remisión de la enfermedad afectan negativamente, ocasionando estrés y ansiedad (6), condiciones que pueden empeorar de no establecerse intervenciones que promuevan el bienestar espiritual. en el momento en que el cuidador se siente agobiado e impactado por atender a su familiar, se encuentra falto de esperanza y evidencia un incremento de ansiedad y depresión (39), condiciones que aún no se presentan en los cuidadores del estudio. para finalizar, y retomando lo afirmado por sánchez (40), la experiencia de ser cuidador se puede “convertir en una fuerza sanadora espiritual, porque son momentos para fortalecerse, empoderarse y aumentar la autoestima”. conclusión el estudio fortalece la formación de estudiantes al incluir en el plan de estudios del programa de enfermería contenidos específicos que comprenden cada dimensión del bienestar y la calidad de vida para la atención de los cuidadores en las prácticas formativas, lo que cualifica el ejercicio del profesional de enfermería en los diferentes programas de promoción y prevención de crónicos de villavicencio, y deja a consideración de la comunidad científica de enfermería semillas para profundizar el conocimiento del bienestar y la calidad de vida del cuidador. si bien la prestación de servicios de salud por parte de los programas de promoción y prevención de crónicos requiere el concurso de los cuidadores para el cuidado del paciente crónico, se hace necesario integrarlo en la consulta de enfermería, hacerlo visible y ser sujeto también de atención para potenciar factores protectores que favorezcan el bienestar físico y social, y controlar las condiciones que afectan el bienestar psicológico y espiritual, a fin de acrecentar la calidad de vida. se convierte en un reto desarrollar programas de capacitación a cuidadores de personas que asisten a los programas de promoción y prevención de crónicos que permitan acompañar al cuidador y fortalecer habilidades de autocuidado que repercutan positivamente en su bienestar y calidad de vida. agradecimientos a los cuidadores, por permitirme entrar en sus vidas; a los estudiantes del programa, por su responsabilidad y compromiso; a las directivas de la ese municipal, por el aval del estudio; a las autoras del qol versión familiar, por la autorización de su uso y el envío de las medidas paramétricas; al grupo de cuidado de la facultad de enfermería de la universidad nacional, por facilitar el instrumento ajustado y otorgar el permiso para su uso, y a las directivas de la universidad de los llanos, por el aval y apoyo para la realización del proyecto. conflicto de intereses. ninguno declarado. financiación. universidad de los llanos. 113 percepción de la calidad de vida de cuidadores de pacientes asistentes a un programa de crónicos, villavicencio, colombia l clara rocío galvis-lópez y otros referencias 1. organización mundial de la salud. prevención y control de las enfermedades no transmisibles: aplicación de la estrategia mundial [internet]. ginebra: oms; 2008 [citado 2013 jun 5]. disponible en: http://www.who.int/gard/publications/ b122_9-sp.pdf 2. moiso a. enfermedades crónicas no transmisibles: el desafío del siglo xxi. en barragán hl, moiso a, mestorino a de los a, ojea oa. fundamentos de salud pública [internet]. la plata: editorial de la universidad nacional de la plata; 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[citado 2014 feb 16]. dis115 percepción de la calidad de vida de cuidadores de pacientes asistentes a un programa de crónicos, villavicencio, colombia l clara rocío galvis-lópez y otros ponible en: http://siacurn.curnvirtual.edu.co:8080/xmlui/bitstream/handle/123456789/623/tesis%20impacto%20 biopsicosocial%20en%20cuidadores.pdf?sequence=1 32. kitrungrote l, cohen mz. quality of life of family caregivers of patients with cancer: a literature review. oncol nurs forum [internet]. 2006 [citado 2013 may 18]; 33(3):625-32. disponible en: http://ons.metapress.com/ content/72p2613746267002/ 33. universidad de los llanos. caracterización de cuidadores informales de personas en situación de cronicidad en villavicencio. villavicencio: universidad de los llanos; 2010 34. nanda international. diagnósticos enfermeros: definiciones y clasificación 2009-2011. barcelona: elsevier; 2010. 35. awadalla aw, ohaeri ju, salih aa, tawfiq am. subjective quality of life of family caregivers of community living sudanece psychiatric patients. soc psychiatry epidemiol [internet]. 2005 [citado 2013 jul 18]; 40(9):755-63. disponible en: http://link.springer.com/article/10.1007%2fs00127-005-0947-x#page-2 36. ferrell b, ervin k, smith s, marek t, melancon c. family perspectives of ovarian cancer. cancer pract [internet]. 2002 [citado 2013 jun 27]; 10(6):269-76. disponible en: http://prc.coh.org/fpovca.pdf 37. lópez j, rodríguez mi. la posibilidad de encontrar sentido en el cuidado de un ser querido con cáncer. psicooncología [internet]. 2007 [citado 2014 ene 24]; 4(1):11-2. disponible en: http://dspace.ceu.es/bitstream/10637/1642/1/ p111_120.pdf 38. instituto nacional del cáncer de los institutos nacionales de la salud de ee.uu. la espiritualidad y calidad de vida [internet]. 2012 [citado 2014 feb 22] disponible en: http://www.cancer.gov/espanol/pdq/cuidados-medicos-apoyo/ espiritualidad/patient/page2/allpages#1 39. crespo lópez m, lópez marínez j. el apoyo a los cuidadores de familiares mayores dependientes en el hogar: desarrollo del programa “como mantener su bienestar” [internet]. 2006 [citado 2013 ene 26]. disponible en: http://www. seg-social.es/imserso/documentación/pubca 40. sánchez herrera cb. dimensión espiritual del cuidado de enfermería en situaciones de cronicidad y muerte. aquichán [internet]. 2004 [citado 2014 mar 26]; 4(4):6-9. disponible en: http://aquichan.unisabana.edu.co/index.php/aquichan/ article/view/44/83 303 315 niveles de sedentarismo en poblacion.indd 303 consuelo vélez-álvarez1 josé armando vidarte-claros2 josé hernán parra-sánchez3 niveles de sedentarismo en población entre 18 y 60 años en manizales, pereira y armenia, colombia. análisis multivariado 1 docente investigadora departamento de salud pública. universidad autónoma de manizales, colombia. cva@autonoma.edu.co 2 docente investigador departamento movimiento corporal humano. universidad autónoma de manizales, colombia. jovida@autonoma.edu.co 3 docente departamento de economía. universidad autónoma de manizales, colombia. jhparrasa@unal.edu.co recibido: 04 de octubre de 2013 enviado a pares: 05 de noviembre de 2013 aceptado por pares: 14 de noviembre de 2013 aprobado: 30 de abril de 2014 doi: 10.5294/aqui.2014.14.3.3 para citar este artículo / to reference this article / para citar este artigo vélez-álvarez c, vidarte claros ja, parra-sánchez jh. niveles de sedentarismo en población entre 18 y 60 años en manizales, pereira y armenia, colombia. análisis multivariado. aquichan. 2014;14(3): 303-315. doi: 10.5294/aqui.2014.14.3.3 resumen objetivo: determinar las variables que predicen el nivel de sedentarismo en la población entre 18 y 60 años de manizales, pereira y armenia, 2012. materiales y métodos: estudio transversal, con fase correlacional en 1535 personas, seleccionadas por un muestreo aleatorio probabilístico. se analizaron: edad, género, frecuencia semanal de práctica, índice de masa corporal (imc), perímetro de cadera y frecuencia cardiaca inicial. se utilizó el test de pérez y rojas para medir el sedentarismo. resultados: el 58,7 % de las personas de la muestra realizan actividad física, las variables asociadas fueron: estado civil, escolaridad, nivel y frecuencia de actividad física, cigarrillo, alcohol, café, imc y edad (p < = 0,00). el género no se asocia con el nivel de sedentarismo; un factor de riesgo son los alucinógenos. conclusiones: en la población de 18 a 60 años el estado civil, la escolaridad, el nivel y la frecuencia de actividad física, el cigarrillo, el alcohol, el café, el imc y la edad explican el comportamiento de los niveles de sedentarismo de manera significativa. el modelo pronostica el 65,3% de los sedentarios. palabras clave actividad física, obesidad, género, estilo de vida sedentario. (fuente: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 303-315 304 aquichan issn 1657-5997 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 303-315 levels of sedentarism in the population between 18 and 60 years of age in manizales, pereira and armenia, colombia. a multivariate analysis abstract objective: determine the variables that predict the level of physical inactivity in the population between 18 and 60 years of age in manizales, pereira and armenia (2012). materials and methods: this is a cross-sectional study with phase correlation of 1,535 persons. the participants were selected through random probability sampling. the variables analyzed were age, gender, weekly practice, body mass index (bmi), hip circumference and initial heart rate. the pérez and rojas test was used to measure physical inactivity. results: in all, 58.7% of the people in the sample engage in physical activity. the associated variables were marital status, schooling, level and frequency of physical activity, smoking, alcohol, coffee, bmi and age (p <= 0.00 ). gender was not associated with the level of physical inactivity. hallucinogens are a risk factor. conclusions: marital status, schooling, level and frequency of physical activity, smoking, alcohol, coffee, bmi and age significantly explain the extent of physical inactivity in the population ages 18 to 60. the model predicts 65.3% of those who have a sedentary lifestyle. key words physical activity, obesity, gender, sedentary lifestyle. (source: decs, bireme). 305 niveles de sedentarismo en población entre 18 y 60 años en manizales, pereira y armenia, colombia. análisis multivariado l consuelo vélez-álvarez y otros. níveis de sedentarismo na população entre 18 e 60 anos em manizales, pereira e armenia, colombia. análise multivariada resumo objetivo: determinar as variáveis que predizem o nível de sedentarismo na população entre 18 e 60 anos de manizales, pereira e armenia, 2012. materiais e métodos: estudo transversal, com fase correlacional em 1.535 pessoas de 18 a 60 anos, selecionadas por uma amostra aleatória probabilística. analisaram-se: idade, gênero, frequência semanal de prática, índice de massa corporal (imc), perímetro de quadril e frequência cardíaca inicial. utilizou-se o teste de pérez e rojas para medir o sedentarismo. resultados: 58,7 % das pessoas da amostra realizam atividade física, as variáveis associadas foram: estado civil, escolaridade, nível e frequência de atividade física, cigarro, álcool, café, imc e idade (p < = 0,00). o gênero não se associa com o nível de sedentarismo; um fator de risco são os alucinógenos. conclusões: na população de 18 a 60 anos, o estado civil, a escolaridade, o nível e a frequência de atividade física, o cigarro, o álcool, o café, o imc e a idade explicam o comportamento dos níveis de sedentarismo de maneira significativa. o modelo prognostica 65,3% dos sedentários. palavras-chave atividade física, obesidade, gênero, estilo de vida sedentário. (fonte: decs, bireme). año 14 vol. 14 nº 3 chía, colombia septiembre 2014 l 303-315 306 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 introducción el sedentarismo se asocia con una gran cantidad de defunciones al año en el mundo, es un factor que predispone a enfermedades como la obesidad, la diabetes y los problemas cardiovasculares, entre otros. se calcula que en estados unidos la inactividad física y un régimen alimentario deficiente representan por lo menos el 14 % de las muertes anuales. el análisis de los datos mundiales indica que la inactividad física es responsable del 2 al 6 % de los gastos totales en salud. en estados unidos, esto equivale anualmente a 76 mil millones de dólares en gastos de asistencia sanitaria, potencialmente evitables (1). lo anterior muestra cómo el sedentarismo se ha convertido en una problemática de salud pública a nivel mundial, y tal como lo plantean garcía y correa (1), en colombia hasta el momento no existen datos unificados ni actualizados sobre la incidencia y la prevalencia del sedentarismo, ni hay estudios epidemiológicos o de salud pública en todo el territorio nacional, aclarando que los estudios realizados hasta el momento son particulares y desarrollados en contextos específicos. así mismo, los datos epidemiológicos en el mundo han puesto en evidencia la problemática del fenómeno del sedentarismo y su impacto en la salud de los pueblos. en el ámbito mundial ha aumentado rápidamente la carga de las enfermedades crónicas. en 2001, estas fueron la causa de casi el 60 % de 56 millones de defunciones anuales y el 47 % de la carga mundial de morbilidad (1). el término sedentario proviene del latín sedentar us, de sed re, estar sentado. en el año 2002 la organización mundial de la salud (oms) (2) lo definió como “la poca agitación o movimiento”. en términos de gasto energético se considera que una persona es sedentaria cuando en sus actividades cotidianas no aumenta más del 10 % la energía que gasta en reposo (metabolismo basal). este gasto de energía se mide en unidades de equivalencia metabólica (met), durante la realización de diferentes actividades físicas como caminar, podar el pasto, hacer el aseo de la casa, subir y bajar escaleras, entre otras (1). según el reporte de us surgeon generals, un individuo es sedentario cuando el total de energía utilizada en actividades de intensidad moderada (aquella que gasta de 3 a 4 equivalentes metabólicos met) es menor a 150 kcal por día. lo anterior significa que una persona es calificada como sedentaria cuando participa en actividades físicas por periodos menores de 20 min diarios con una frecuencia menor de tres veces por semana. se ha establecido una relación entre los niveles de actividad física y el número de pasos por día (2). se considera que una persona es activa cuando en sus actividades cotidianas camina más de 10 mil pasos diarios. el sedentarismo es un problema cultural, por ende, la actividad física está asociada a factores sociales y culturales situación descrita en algunos trabajos que abordan la práctica de la actividad física de manera masiva en los diferentes contextos y núcleos urbanos (3). en general, en los países desarrollados solamente un tercio de la población adulta cumple con los criterios mínimos de actividad física acumulable para traer beneficios para la salud. por el contrario, los dos tercios restantes, llevan una vida claramente sedentaria o desarrollan un trabajo físico insuficiente (mínimo 30 minutos diarios) (1). según la ops y la oms, en américa latina casi tres cuartos de la población tienen un estilo de vida sedentario, gran parte de los pobladores de todas las edades son inactivos, siendo las mujeres las de mayor tendencia, lo mismo que la población de escasos recursos (4). en relación con la actividad física las cifras muestran de que más del 60 % de las personas de edad avanzada no realizan ningún tipo de ejercicio físico (5). en estados unidos más del 60 % de los adultos no hace la cantidad recomendada de ejercicio, de igual manera se evidencia que solo el 30 % de estos realizan actividad física de manera regular, el 40 % de los adultos y el 23 % de los niños no hacen actividad física en su tiempo libre, y el 25 % de los estudiantes de bachillerato hacen al menos 30 min de actividad física 5 días o más a la semana (6, 7). en colombia, los datos sobre el sedentarismo son muy similares a los de los demás países aquí referenciados. el estudio nacional de factores de riesgo de enfermedades crónicas evidencia que el 52 % no realiza actividad física y solo el 35 % de la población encuestada lo hace con una frecuencia de una vez a la semana, el 21,2 % la realiza de manera regular mínimo 3 veces a la semana; en bogotá se reporta que el 20 % de los adolescentes es sedentario, el 50 % irregularmente activo, el 19 % regularmente activo y el 9,8 % activo (1). por otro lado, el sedentarismo prolongado lleva a la reducción acentuada y progresiva de la masa muscular, de la fuerza, de la flexibilidad y del equilibrio (4), y actualmente se plan307 niveles de sedentarismo en población entre 18 y 60 años en manizales, pereira y armenia, colombia. análisis multivariado l consuelo vélez-álvarez y otros. tea que hombres con más de 20 % de su peso corporal y mujeres con más de 30 % pueden ser consideradas obesas. estudios han demostrado que la actividad física regular, con una frecuencia de tres veces semanales como mínimo, promueve grandes diferencias en los índices de grasa corporal, disminuye significativamente los riesgos de contraer diversas enfermedades como aquellas de origen coronario (dac), hipertensión, resistencia a la insulina, dislipidemias, etc., influyendo de manera positiva sobre aspectos relacionados con la calidad de vida de los individuos (8-11). así mismo, la gran mayoría de las revisiones coinciden en afirmar que el estilo de vida sedentario, el género femenino, la edad, el nivel socioeconómico bajo y el hábito de fumar pueden estar relacionados con el sedentarismo. diferentes variables actúan como factores de riesgo asociadas al sobrepeso y la obesidad las cuales al conjugarse con la inactividad física producen 3,3 veces mayores posibilidades de riesgo cardiovascular en individuos con imc inadecuados, lo anterior lleva a plantear programas multidisciplinares tanto individuales como colectivos para mejorar la condición de salud (12). aunque muchos se han dedicado a conocer el nivel de sedentarismo de cierta población, también es claro que los métodos utilizados no son lo suficientemente objetivos; se han usado metodologías no experimentales que permiten determinar el sedentarismo registrando el tiempo destinado a actividades de ocio, con resultados confiables. la clasificación del sedentarismo ha sido tan confusa como su definición, entendiéndola como la ausencia de actividad física; dicha definición no ha tenido consenso a nivel mundial, lo que lleva a dificultades intrínsecas para su diagnóstico y, por tanto, para su intervención; no obstante, existen ciertas aproximaciones que son más aceptadas por la comunidad médica, con base en las cuales se han creado algunos sistemas de medición de esta conducta tanto de manera experimental como no experimental, que intentan objetivar el gasto energético de una forma indirecta. “la manera en que se determina el sedentarismo es identificando a través de encuestas, escalas, formularios y llamadas telefónicas para todos aquellos individuos que buscan cuantificar los tiempos destinados a actividades de bajo gasto energético a nivel individual y colectivo” (13, 14), mediciones que según lo reportado no permiten adecuados niveles de objetividad ya que los datos obtenidos son subjetivos. para el caso de este estudio la propuesta de clasificar el sedentarismo a través de un test físico con relación a la frecuencia cardiaca propuesto por pérez et al. (15) permite suministrar datos más directos y reales para la clasificación del sedentarismo, siendo una prueba más objetiva ya que permite la medición de variables fisiológicas. el objetivo de este trabajo es determinar las variables que predicen el nivel de sedentarismo de la población del eje cafetero, en colombia, entre los 18 y 60 años. materiales y métodos investigación de tipo descriptivo transversal, con una fase correlacional en la que se estimó una regresión logística binaria. la población estuvo constituida por personas de 18 a 60 años, que viven en las ciudades de manizales, pereira y armenia, con los siguientes criterios de inclusión: ser habitante de la ciudad desde hace más de cinco años, estar en el rango de edad en mención, no tener contraindicaciones para la realización de ejercicio físico, presentar signos vitales normales y aceptar la participación en la investigación por medio del diligenciamiento del consentimiento informado. el tipo de muestreo fue probabilístico (muestreo aleatorio simple, mas), para el cálculo de la muestra se utilizó la siguiente fórmula: la muestra se estimó con un margen de error del 5 % y confiabilidad del 95 %, el tamaño muestral para las ciudades de manizales, pereira y armenia fue de 1535 personas. para la recolección de la información se utilizó un instrumento con preguntas estructuradas y semiestructuradas que buscó dar cuenta de las variables sociodemográficas y de percepción sobre la práctica de actividad física, este fue autodiligenciado por las personas seleccionadas. para la definición del nivel de sedentarismo se aplicó la prueba física de sedentarismo y, una vez concluida, se le informó a la persona el nivel de clasificación en que se encontraba según el test establecido (15). los análisis estadísticos empleados fueron realizados con el programa estadístico spss versión 20 (licencia uam). se hizo un 308 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 análisis univariado y bivariado de las diferentes variables. en este último se realizaron distintas asociaciones y comparaciones entre las variables mediante las cuales se identificaron prevalencias, relaciones y asociaciones significativas utilizando pruebas de significancia estadística chi cuadrado de ajuste e independencia y, además, se efectuó el análisis de cluster o conglomerados con el paquete estadístico spad.n versión 4.5. también se realizó la regresión logística binaria a través de la cual se estimó el modelo para el sedentarismo. las implicaciones éticas del proyecto involucran un nivel de riesgo mínimo de acuerdo con lo estipulado por el decreto 08430 del ministerio de salud debido a que la manipulación de los participantes en el estudio fue mínima, siendo el proceso una valoración por observación y medición, aspectos que no atentaron contra la integridad física y mental de las personas. para tal efecto se solicitó el diligenciamiento del consentimiento informado y la participación voluntaria en el estudio; este proyecto fue aprobado por el comité de bioética de la universidad autónoma de manizales (acta 17). resultados la media de edad fue de 36,7 años +/12,8 años; el peso tuvo una media de 65,9 kg +/10,9 kg; la talla fue de 151, 5 cm +/41,8 cm, y el índice de masa corporal (imc) fue de 24, 4 kg/ m2 +/3,45 kg/m2. las variables que mostraron asociación estadísticamente significativa (p < 0,05) con el nivel de sedentarismo en la población estudiada al aplicar la prueba de chi cuadrado fueron: el estado civil, los niveles de escolaridad y de actividad física, la frecuencia semanal, el consumo de cigarrillo, alcohol y café, el imc y la edad. no se asocian con el nivel de sedentarismo el género y el consumo de sustancias psicoactivas (tabla 1). análisis cluster del estudio del sedentarismo en el eje cafetero con el fin de establecer grupos de personas que reunieran características similares se realizó un análisis cluster sobre las siguientes variables: ciudad, género, estado civil, escolaridad, nivel de actividad física, hábitos (fumar, alcohol, café), índice de masa corporal, categorías de edad y criterio de clasificación del nivel de sedentarismo. para este fin se ha usado el método jerárquico aglomerativo que supone que cada individuo es un pequeño grupo por sí mismo que no cambia a otro en todo el proceso de agrupación hasta que solo permanezca un único grupo que contenga todas las observaciones. la métrica del análisis ha sido la distancia euclídea al cuadrado de las variables estandarizadas y el criterio de conglomeración utilizado ha sido el de ward, en el cual la distancia entre dos grupos se mide desde el centro de gravedad de los puntos en un cluster a los puntos en otro cluster. en el dendograma se distinguen claramente dos grupos de individuos. una vez elegido el número de clases se obtiene la partición y los indicadores de la homogeneidad de las clases obtenidas. la partición del árbol en dos clases ha proporcionado clases compuestas por 693 y 842 personas respectivamente. la clase más homogénea y pequeña es la clase 2 (inercia 0,4743), la clase 1 es la más heterogénea (0,5707) y la que menos individuos tiene de las dos clases. en la tabla 2 se pueden observar las coordenadas de las clases sobre los ejes factoriales y sus valores-test. las clases se pueden interpretar al igual que la posición de los individuos sobre el primer plano factorial (figura 1). en la tabla 3 se encuentran las características de la clase 1, donde se resalta que son adultos, con nivel de sedentarismo moderado y severo, imc de sobrepeso, escolaridad hasta secundaria, ningún nivel de actividad física, fumadores y de género femenino. en cuanto a las características de la clase 2 se resalta que son jóvenes, con nivel de sedentarismo muy activo y activo, escolaridad universitaria, imc normal, realizan actividad física, consumen alcohol y son de género masculino (tabla 4). regresión logística se realizó una regresión logística para obtener un modelo que permitiera pronosticar el nivel se sedentarismo, variable dependiente dicotomizada como “0” activo y “1” sedentario. la tabla 5 muestra las variables incluidas como potenciales predictoras y sus categorías u operacionalización. la edad y el índice de masa corporal se incluyeron como variables numéricas, y en las variables categóricas la primera categoría como de referencia. según el modelo se puede observar que todas las covariables son significativas al 1 % con excepción del hábito de fumar. el modelo indica una relación directa entre la edad y la probabilidad de 309 niveles de sedentarismo en población entre 18 y 60 años en manizales, pereira y armenia, colombia. análisis multivariado l consuelo vélez-álvarez y otros. sedentarismo, al igual que con el índice de masa corporal. para las variables categóricas se puede establecer que un fumador tiene 22 % de riesgo de ser sedentario, mientras que quienes consumen alcohol y café tienen un riesgo 1,53 y 1,78 veces de ser sedentario, respectivamente. para determinar la bondad de un modelo ajustado por logit y contabilizar el porcentaje de aciertos del mismo se encuentra que el modelo predice correctamente un 65 % que puede considerarse como aceptable. la de hosmer-lesmeshow es una prueba de bondad de ajuste, donde la hipótesis nula indica que el modelo está bien ajustado. según los resultados del test se encontró que el valor de hosmer lemeshow fue de 12,79, lo que demuestra una buena calibración del modelo, además se observa un valor de p > 0,05, lo que lleva a no rechazar la hipótesis nula. además, la clasificación del sedentarismo para el eje cafetero fue de 65,3 % (tabla 6). discusión la prevalencia de actividad física en el presente estudio fue 58,7 %. este resultado se aproxima a lo reportado por gonzález, donde se encontró una prevalencia del 53,5 %, y difiere de los datos encontrados en bogotá con una prevalencia de 36,8 % (1, 16). al realizar las pruebas estadísticas de chi cuadrado y phi se encontró que existe una dependencia y asociación entre el nivel de sedentarismo y la edad, el nivel de escolaridad, el imc y el consumo de tabaco, alcohol y café, situación que al ser comparada con otros estudios (17, 18) muestra datos similares. en este sentido, con relación al índice de masa corporal se encontró que un poco más de la mitad de los participantes en el estudio están clasificados como normales, y una tercera parte presenta sobrepeso u obesidad, lo que puede ser secundario a los niveles de actividad física encontrados los cuales resultaron como hábitos poco o nada saludables. en función del imc reportado en la presente investigación se corrobora una relación inversa entre la ausencia de sedentarismo y la concordancia del peso y la talla. investigaciones realizadas evidencian cómo el género se ha convertido en una condición relacionada con el sedentarismo, donde las mujeres presentan mayor probabilidad de ser sedentarias, sumado esto al imc, donde se encuentran valores de 1,7 y 2,7 veces más de padecer sobrepeso, obesidad y obesidad central (18). en cuanto a los hábitos de vida, en el presente estudio se evidenció que el tabaquismo y el consumo de alcohol y de café permiten reconocer que la actividad física se reduce en forma directamente proporcional a dichos factores de riesgo, los cuales son causantes de enfermedades crónicas (19). con relación a la edad otros estudios (20-22) muestran que el sedentarismo se adopta en edad temprana y se mantiene a lo largo de la vida, y teniendo en cuenta que para la presente investigación la variable edad fue recodificada en jóvenes (entre 18 y 39 años) y adultos (entre 40 y 60 años), al comparar el nivel de sedentarismo y la edad se encontró que los jóvenes son activos en mayor porcentaje (77,3 %) y los adultos son más sedentarios (76,9 %). gonzález (7) describe que la prevalencia de sedentarismo fue directamente proporcional según aumenta el grupo de edad y además encontró que el estado civil también es una variable explicativa del estilo de vida sedentario, estos datos están en concordancia con lo encontrado en la presente investigación para las variables en mención. teniendo en cuenta el modelo de regresión realizado para la presente investigación, las variables edad, índice de masa corporal y consumo de alcohol, tabaco y café explican el sedentarismo en las personas que participaron en el estudio en las ciudades del eje cafetero, dato comparable con lo expuesto por castillo, quien plantea que la aparición de enfermedades crónicas es cada vez mayor debido al sedentarismo, tal como lo confirma el modelo de regresión de este estudio (23). en países como chile se ha descrito que cerca del 90 % de los chilenos son sedentarios y que más del 60 % de los adultos mayores de 17 años sufren de sobrepeso u obesidad, la mayoría de los cuales son producto no solo de los malos hábitos alimenticios sino del sedentarismo (24). para este mismo estudio la prevalencia de sobrepeso y obesidad es notoria entre las personas entre 17 y 24 años, los cuales corresponden a la edad universitaria, lo que se puede relacionar con que la formación académica a nivel de educación superior puede generar hábitos poco saludables, datos que resultan similares a lo encontrado en el presente estudio con relación al comportamiento de la edad con el sedentarismo. otro estudio realizado en españa (24) muestra una relación entre el imc y los niveles de sedentarismo, donde el sobrepeso explica el comportamiento de dichos niveles en adolescentes considerando un intervalo de confianza del 95 %, el cual concluye que los factores tenidos en cuenta para la regresión permitieron obtener un 310 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 modelo que pondera el efecto de distintas variables sobre el nivel de actividad física, por lo cual todos los factores de influencia resultantes en este estudio, con excepción del género, son modificables. los trabajos que han estudiado los predictores de la actividad física han estructurado el análisis entre factores personales, sociales y ambientales (23). desde el punto de vista de los factores personales se ha encontrado que la percepción de la competencia física o deportiva está asociada positivamente con la actividad física practicada por las personas —especialmente los adolescentes—; de igual forma, los hábitos de vida como consumo de café se convierten en factores protectores para la práctica de actividad física, y el consumo de alcohol y tabaco son factores predisponentes de enfermedades crónicas no transmisibles (25). adicional a esto, la literatura reporta con igual importancia variables que predicen el sedentarismo como el hábito de fumar y el consumo de alcohol (26). existe evidencia como los factores individuales como la edad, imc, y tiempo y frecuencia de práctica influencian de manera significativa el comportamiento del sedentarismo, a diferencia de lo que pasa con factores relacionados con el entorno (27). la predicción del sedentarismo a partir de procesos basados en la evaluación de la forma física del individuo y su clasificación hace necesario el reconocimiento y la apropiación teórica para el estudio, y la conceptualización del sedentarismo y los niveles de actividad e inactividad física. conclusiones en la población de 18 a 60 años del eje cafetero el estado civil, los niveles de escolaridad y de actividad física, la frecuencia de dicha actividad, fumar, consumir alcohol y café, el imc y la edad explican el comportamiento de los niveles de sedentarismo de manera significativa. el modelo plantea que las variables edad, imc, fumar, consumir alcohol, tabaco y café se convierten en predictoras de los niveles de sedentarismo, de igual manera pronostican el 65,3 % del mismo. referencias 1. garcía lv, correa je. muévase contra el sedentarismo. universidad ciencia y desarrollo. programa de divulgación científica. tomo ii, fascículo 7. universidad del rosario; 2007. 2. organización mundial de la salud (oms). informe sobre la salud en el mundo: reducir los riesgos y promover una vida sana; 2002. 3. moreno je, cruz hf, angarita a. evaluación de razones de prevalencia para sedentarismo y factores de riesgo en un grupo de estudiantes universitarios: chía colombia. enferm. glob. [revista en la internet]. 2014 abr [visitado 2014 ago 28]; 13(34): 114-122. disponible en: http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=s169561412014000200005&lng=es. 4. organización panamericana de la salud (ops). la inactividad física: un factor principal de riesgo para la salud en las américas. programa de alimentación y nutrición / división de promoción y protección de la salud. 2002 [visitado 2013 jun 15]. disponible en: http://www.ops-oms.org/spanish/hpp/hpn/whd2002-factsheet3. pdf. 5. jimeno r, peña p, exposito a, zagalaz ml. elders and physical activity. a simple proposal. journal of sport and health research. 2010; 2(3):305-328. 6. american heart association. el sedentarismo (inactividad física). 2007 [visitado 2010 feb 17]. disponible en: http:// www. americanheart.org/presenter.jhtml?identifier=3018677 7. gonzález ma, dennis rj, devia jh, echeverri d, briceño gd, gil f. et al. factores de riesgo cardiovascular y de enfermedades crónicas en población caficultora. rev salud pública. 2012;14(3):390-403. 8. sobejano i, moreno c, viñes jj, grijalba am, amézqueta c, serrano m. estudio poblacional de actividad física en tiempo libre. gac sanit [revista en la internet]. 2009 abr [visitado 2014 ago 28]; 23(2):127-132. disponible en: http://scielo. isciii.es/scielo.php?script=sci_arttext&pid=s0213-91112009000200009&lng=es. 311 niveles de sedentarismo en población entre 18 y 60 años en manizales, pereira y armenia, colombia. análisis multivariado l consuelo vélez-álvarez y otros. 9. márquez j, suárez g, márquez j. beneficios del ejercicio en la insuficiencia cardíaca. rev chil cardiol [revista en la internet]. 2013 [visitado 2014 ago 28]; 32(1):58-65. disponible en: http://www.scielo.cl/scielo.php?script=sci_ arttext&pid=s0718-85602013000100009&lng=es. http://dx.doi.org/10.4067/s0718-85602013000100009. 10. escalante y. actividad física, ejercicio físico y condición física en el ámbito de la salud pública. rev esp salud pública 2011;84:325-328. 11. ramírez be, rivera e. la influencia de la actividad física sobre el comportamiento social y conductas de riesgo en adolescentes. universidad de guanajuato. 2009 [visitado: 2013 may 23]. disponible en: http://www.cedaf.gob.mx/archivos/ capacitacion/trabajos_2009 12. amer n, silva s, getirana r. indice de masa corporal e hipertensión arterial en individuos adultos en el centro oeste del brasil. arq bras cardiol. 2011; 96(1):47-53. 13. buhring k, oliva p. bravo c. determinación no experimental de la conducta sedentaria en escolares. revista chilena de nutrición. 2009;36(1):23-30. 14. tremblay ms, colley rc, saunders tj, healy gn, owen n. physiological and health implications of a sedentary lifestyle. applied physiology, nutrition, and metabolism. 2010;35(6):725-740. 15. pérez fuentes a, suárez surí r, garcía castillo g, espinosa brito a, linares girela d. propuesta de variante del test de clasificación de sedentarismo y su validación estadística. cienfuegos, cuba. foro de cardiología transdisciplinaria [internet]. buenos aires: federación argentina de cardiología [visitado 2013 may 23]. disponible en: http://www.fac. org.ar/fec/foros/ cardtran/colab/sedentarismocuba.htm. 16. gonzález s, sarmiento ol, lozano o, ramírez a, grijalba c. niveles de actividad física de la población colombiana: desigualdades por sexo y condición socioeconómica. biomédica. 2014 [visitado: 2014 ago 12];34(3). disponible en: http:// www.revistabiomedica.org/index.php/biomedica/article/view/2258/2424 17. león m, moreno b, andres c, laclaustra m, alcalde v, peñalvo jl, ordovás jm, casasnovas ja. sedentarismo y su relación con el perfil de riesgo cardiovascular, la resistencia a la insulina y la inflamación. revista española de cardiología. 2014;67(6):449-455 18. caballero c, hernández b, moreno h, hernández-girdn c, campero l, cruz a, et al. obesidad, actividad e inactividad física en adolescentes de morelos, méxico: un estudio longitudinal. archivos latinoamericanos de nutrición órgano oficial de la sociedad latinoamericana de nutrición. 2007;57(3):231-237. 19. vaquero r, isorna m, ruiz, c. state of tobacco consumption and its relation ship to physical sports practice in spain. journal of sport and health research. 2013;5(2):131-148. 20. tribess s, virtuoso-júnior js, petroski el. fatores associados à inatividade física em mulheres idosas em comunidades de baixa renda. rev salud pública brasil. 2009;11(1):39-49. 21. paredes r, orraca o, marimón er, casanova mc, gonzález lm. influencia del sedentarismo y la dieta inadecuada en la salud de la población pinareña. rev ciencias médicas 2014;18(2):221-230. 22. ratner r, sabal j, hernández p. estilos de vida y estado nutricional de trabajadores en empresas públicas y privadas de dos regiones de chile. rev méd chile. 2008;136(11):1406-1414. 23. rodriguez e, garcía l, gómez ma, recio ji, mora s, pere d, et al. prevalencia de enfermedades cardiovasculares y de factores de riesgo cardiovascular en mayores de 65 años de un área urbana: estudio deriva. aten primaria. 2013;45(7):349-357. 24. cordente ca, garcía p, sillero m, stirling j. predicción del nivel de actividad física en adolescentes a partir de diversos factores biopsicosociales de influencia. ix congreso gallego de estadística e investigación e operaciones. ourense, 2009, 12-14 de noviembre. 25. castelo l, gomes n, ximenes i, venícios de oliveira m, leite de araújo t. nivel de actividad física en portadores de hipertensión arterial. rev latino-am enfermagem. 2009;17(4):462-46. 26. latorre pa, cámara jc, garcía f. búsqueda de sensaciones y hábitos de tabaquismo, consumo de alcohol y práctica deportiva en estudiantes de educación secundaria. salud mental 2014;37:145-152. 27. morales mm, clemente e, llopis a. relación del nivel de práctica de actividad física con marcadores de salud cardiovascular en adolescentes valencianos (españa). arch argent pediatr. 2013;111(5):398-404. 312 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 tabla 1. análisis bivariado. asociación de sedentarismo con variables de estudio variables chi cuadrado gl sig sedentarismo (sedentario-activo) género 3,722 3 0,293 estado civil 52,384 15 0,000* escolaridad 48,637 12 0,000* nivel de actividad física 16,098 3 0,001* frecuencia actividad física 35,134 15 0,002* fumar 10,568 3 0,014* alcohol 8,572 3 0,036* alucinógenos 5,330 3 0,149 café 66,254 3 0,000* imc 64,495 9 0,000* categoría de edad 64,2 3 0,000* ns > 0,05, *s < 0,05 fuente: elaboración de los autores. tabla 2. coordenadas y valores. test sobre los ejes factoriales clases valores test coordenadas eje 1 eje 2 eje 1 eje 2 clase 1 32,5 -4,5 0,39 -0,05 clase 2 -32,5 4,5 -0,32 0,04 fuente: elaboración de los autores. 313 niveles de sedentarismo en población entre 18 y 60 años en manizales, pereira y armenia, colombia. análisis multivariado l consuelo vélez-álvarez y otros. tabla 3. descripción de las clases. clase 1 etiquetas de las variables características % de la modalidad en la clase probabilidad frecuencia edad adultos 82,83 0,000 635 escolaridad primaria 24,82 0,000 188 estado civil casado 51,23 0,000 508 sedentarismo sedentario moderado 62,48 0,000 726 imc sobrepeso 59,16 0,000 680 escolaridad secundaria 44,16 0,000 506 estado civil viudo 6,78 0,000 47 café sí 49,64 0,000 597 escolaridad sin educación 5,19 0,000 38 estado civil separado 10,82 0,000 104 estado civil divorciado 4,91 0,000 38 nivel actividad física ninguno 48,77 0,000 634 ciudad manizales 46,32 0,000 631 alcohol no 78,21 0,000 1137 fuma sí 22,66 0,081 322 sedentarismo sedentario severo 15,30 0,083 213 género mujer 53,39 0,086 789 fuente: elaboración de los autores. 314 año 14 vol. 14 nº 3 chía, colombia septiembre 2014 aquichan issn 1657-5997 tabla 4. descripción de las clases. clase 2 etiquetas de las variables características % de la modalidad en la clase probabilidad frecuencia edad jóvenes 92,76 0,000 900 estado civil soltero 67,22 0,000 655 escolaridad universitaria 58,19 0,000 607 imc normal 67,93 0,000 855 sedentarismo muy activo 16,15 0,000 149 café no 69,95 0,000 938 sedentarismo activo 36,34 0,000 447 nivel actividad física actividad física 64,85 0,000 901 escolaridad otros estudios 15,91 0,000 196 alcohol sí 29,33 0,000 398 ciudad pereira 33,25 0,001 460 fuma no 80,40 0,081 1213 género hombre 50,24 0,086 746 fuente: elaboración de los autores. tabla 5. variables en la ecuación b et wald gl sig exp(b) paso 1a edad 0,030 0,005 42,237 1 0,000 1,030 imc 0,043 0,017 6,705 1 0,010 1,044 fuma -0,241 0,141 2,949 1 0,086 0,785 alcohol 0,430 0,137 9,800 1 0,002 1,538 café 0,578 0,117 24,577 1 0,000 1,782 constante -1,935 0,407 22,574 1 0,000 0,144 a. variable(s) introducida(s) en el paso 1: edad, imc, fuma, alcohol, café. fuente: elaboración de los autores. 315 niveles de sedentarismo en población entre 18 y 60 años en manizales, pereira y armenia, colombia. análisis multivariado l consuelo vélez-álvarez y otros. tabla 6. clasificación del sedentarismo figura 1. dendograma del análisis cluster pronosticado criterio binario porcentaje correcto paso 1 observado activo sedentario criterio binario activo 218 378 36,6 sedentario 155 783 83,5 porcentaje global 65,3 a. el valor de corte es 0,500 fuente: elaboración de los autores. fuente: elaboración de los autores. 413 425 calidad del cuidado de enfermeria.indd 413 claudia andrea lenis-victoria1 fred gustavo manrique-abril2 calidad del cuidado de enfermería percibida por pacientes hospitalizados3 1 enfermera. magíster en enfermería con énfasis en gerencia en salud; especialista en auditoría en salud. candrea1981@gmail.com 2 enfermero. phd en investigación clínica. magíster y doctor en salud pública; especialista en gerencia social. profesor titular, universidad nacional de colombia; profesor asociado, universidad pedagógica y tecnológica de colombia, bogotá (colombia). fgmanriquea@unal.edu.co 3 artículo original derivado de la investigación: “calidad del cuidado de enfermería percibida por pacientes hospitalizados en una institución de iii nivel, de barranquilla, 2013”. recibido: 03 de febrero de 2015 enviado a pares: 10 de febrero de 2015 aceptado por pares: 22 de junio de 2015 aprobado: 22 de junio de 2015 doi: 10.5294/aqui.2015.15.3.9 para citar este artículo / to reference this article / para citar este artigo lenis-victoria ca, manrique-abril fg. calidad del cuidado de enfermería percibida por pacientes hospitalizados en una clínica privada de barranquilla (colombia). 2015;15 (3): 413-425. doi: 10.5294/aqui.2015.15.3.9 resumen objetivo: determinar la calidad del cuidado de enfermería percibida por pacientes hospitalizados en una clínica privada de barranquilla, colombia. materiales y métodos: estudio descriptivo, transversal, cuantitativo. el tamaño muestral fue de 147 pacientes que tenían orden de egreso. se utilizó el cuestionario de calidad del cuidado de enfermería (cucace), versión en castellano, previo cumplimiento de criterios de inclusión. se tuvieron en cuenta aspectos éticos y normativos, guardando el rigor científico y metodológico. los datos fueron organizados en excel y procesados en spss. resultados: la satisfacción y las experiencias de los pacientes con el cuidado de enfermería están por encima del 70 %, lo que indica resultados altamente positivos según la escala del cucace. los resultados de asociación solo mostraron relación entre dichas variables y el sexo, mas no se encontró asociación significativa con el resto de las variables sociodemográficas. el 58,5 % fueron mujeres y el 41,5 %, hombres. el 96,6 % de los pacientes con que el cuidado de enfermería no requiere mejoría. discusión y conclusión: los pacientes tienen una percepción positiva sobre el cuidado de enfermería recibido en la institución, con una puntuación de 93,22 para la dimensión de experiencia con el cuidado y de 78,12 en la dimensión de satisfacción, lo cual indica que la calidad del cuidado de enfermería percibida por los pacientes en la institución es buena. los resultados son coherentes con lo hallado en estudios similares a nivel nacional e internacional. palabras clave cuidado de enfermería, calidad de la atención de salud, satisfacción del paciente, enfermería, hospitalización (fuente: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 413-425 414 aquichan issn 1657-5997 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 413-425 the quality of nursing care as perceived by hospitalized patients abstract objective: this research was intended to determine the quality of nursing care as perceived by patients hospitalized at a private clinic in barranquilla, colombia. materials and methods: a descriptive, cross-sectional quantitative study was conducted with a sample of 147 patients who had orders to be discharged. the spanish version of the cucace questionnaire was used, subsequent to compliance with the criteria for inclusion. ethical and regulatory aspects were taken into account, and scientific and methodological rigor was maintained. the data were organized in excel and processed in spss. results: patient satisfaction and experiences with nursing care are above 70%. this indicates very positive results according to the cucace scale. the results for association only showed a relationship between these variables and gender; no significant association with the other socio-demographic variables was found. women comprised 58.5% of the sample and men, 41.5%. in all, 96.6% of the patients in the sample felt no improvement in nursing care is required. discussion and conclusion: the patients have a positive perception of the nursing care they received at the institution. the score for experience with care was 93.22 and 78.12 for satisfaction, indicating patients perceive the quality of nursing care provided at the institution as being good. the results are consistent with those of similar studies conducted nationwide and internationally. keywords nursing care, quality health care, patient satisfaction, nursing, hospitalization (source: decs, bireme). 415 calidad del cuidado de enfermería percibida por pacientes hospitalizados en una clínica privada de barranquilla (colombia) l claudia andrea lenis-victoria y otro qualidade do cuidado de enfermagem percebida por pacientes hospitalizados resumo objetivo: determinar a qualidade do cuidado de enfermagem percebida por pacientes hospitalizados num hospital particular de barranquilla (colômbia). materiais e métodos: estudo descritivo, transversal e quantitativo. a amostra foi de 147 pacientes que tinham ordem de entrada. foi utilizado o questionário cucace, versão em espanhol, com prévio cumprimento de critérios de inclusão. foram considerados aspectos éticos e normativos, que guardam o rigor científico e metodológico. os dados foram organizados em excel e processados em spss. resultados: a satisfação e as experiências dos pacientes com o cuidado de enfermagem estão acima de 70%, o que indica resultados altamente positivos segundo a escala do cucace. os resultados de associação somente mostraram relação entre essas variáveis e o sexto, mas não se constatou associação significativa com o restante das variáveis sociodemográficas. 58,5% foram mulheres e 41,5%, homens. 96,6% dos pacientes consideraram que o cuidado de enfermagem não requer melhoras. discussão e conclusão: os pacientes têm uma percepção positiva sobre o cuidado de enfermagem recebido na instituição, com uma pontuação de 93,22 para a dimensão de experiência com o cuidado e de 78,12 na dimensão de satisfação, o que indica que a qualidade do cuidado de enfermagem percebida pelos pacientes na instituição é boa. os resultados são coerentes com as constatações em estudos no âmbito nacional e internacional. palavras-chave cuidado de enfermagem, qualidade da atenção de saúde, satisfação do paciente, enfermagem, hospitalização (fonte: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 413-425 416 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 introducción concebir la calidad como un aspecto único ligado a algo particular ha sido difícil. los enfoques de calidad que emergieron desde mediados del siglo xx han querido mostrar la calidad como una característica sustancial de los productos y servicios. no obstante, a pesar de que este concepto tiene una larga trayectoria, muchos aún consideran que es una utopía en vez de una realidad (1). debido a lo anterior, la calidad continúa siendo un tema de mucho interés en el ámbito industrial y empresarial, y, por ello, se constituye en un mecanismo de mucho valor para lograr los objetivos misionales y visionales de una organización. a nivel mundial, las instituciones de salud conscientes de los desafíos que impone el advenimiento de un mundo globalizado, cada día se esmeran en reconocer la calidad como un proceso de mejoramiento continuo, que promete buenos resultados. este esmero radica en el hecho de que la calidad puede verse desde dos perspectivas: objetiva y subjetiva (2). la primera, basada en los aspectos técnicos y estructurales de la organización; la segunda, fundamentada en la capacidad que tiene el consumidor para juzgar los servicios recibidos y develar satisfacción o insatisfacción. esta última, bajo el supuesto de que la calidad es vista en función de quien la recibe; por tanto, varía dependiendo de su punto de vista. en este sentido, la satisfacción del usuario, en cuanto a necesidades y expectativas, ha sido una forma de evaluar la calidad en la prestación de servicios de salud (3-5) y conocer cómo los sistemas de salud pueden responder mejor a las necesidades y preferencias individuales (4), puesto que la voz del mismo permite conocer cada aspecto de la atención debido a su experiencia en la institución. es decir, el usuario ha pasado de ser un sujeto pasivo a un sujeto más activo, con capacidades para valorar la calidad de la prestación del servicio de salud (6). es así como se ha venido desarrollando un nuevo enfoque basado en la participación del usuario como aspecto primordial para lograr la calidad (4). dicha participación se relaciona con los resultados deseados que ponen de manifiesto el impacto positivo de las instituciones de salud en medio de la sociedad. avedis donabedian, en su teoría de la evaluación de la calidad, fue el primer autor en identificar los elementos necesarios para evaluar la calidad de la atención en los servicios de salud y lograr la satisfacción del usuario (7). a partir de sus postulados teóricos, han surgido numerosas investigaciones en torno al tema de la calidad en salud. de igual forma, sus concepciones han servido como fundamento para establecer políticas de calidad en materia de normatividad en salud de muchos países. en colombia, con las reformas al sector salud mediante la ley 1122 de 2007 (8), la ley 1438 de 2011 (9) y el decreto 1011 de 2006 (10), se ha intentado garantizar la calidad en la prestación de los servicios de salud. sin embargo, aún existen dificultades en el abordaje de atención que inciden en la calidad y la satisfacción de los usuarios. aunque dicha dificultad está relacionada con diversos factores, muchas veces subyace en la labor que realizan los diferentes integrantes del equipo de salud, dentro de los cuales se encuentra el personal de enfermería, el cual ha sido considerado como el recurso humano más numeroso del sistema de salud (11-13). la razón de ser y del quehacer de enfermería en las instituciones de salud es el cuidado directo, continuo y permanente de personas en situación de enfermedad. por tanto, brindar calidad para enfermería es un proceso cuyo objetivo va encaminado a alcanzar un alto nivel de excelencia en la prestación del cuidado y la satisfacción de los usuarios. no obstante, para obtener este logro, es necesario tener en cuenta que la presencia, la permanencia, la continuidad y la contingencia, son condiciones específicas y distintivas de ese cuidado. además, se constituyen en insumos centrales de la atención de salud, a través de la cual es posible proveer protección, confort y apoyo libre de amenazas a la integridad de las personas bajo cuidado (14). la literatura muestra que el estudio de la calidad en enfermería ha tenido un auge relevante durante las dos últimas décadas; diversos autores dan fe de ello en sus publicaciones (2, 13, 15, 16). este hallazgo hace evidente la importancia que tiene para enfermería el hecho de que los usuarios perciban como buenas las acciones de cuidado. por tal motivo, la presente investigación tuvo como objetivo determinar la calidad del cuidado de enfermería percibida por los pacientes hospitalizados en una institución de iii nivel, de barranquilla (colombia). 417 calidad del cuidado de enfermería percibida por pacientes hospitalizados en una clínica privada de barranquilla (colombia) l claudia andrea lenis-victoria y otro materiales y método se llevó a cabo un estudio descriptivo, transversal, cuantitativo, con el fin de lograr el objetivo planteado. la muestra estuvo conformada por todos aquellos pacientes que, cumpliendo los criterios de inclusión, decidieron participar en el estudio firmando el consentimiento informado. los criterios de inclusión establecidos fueron: pacientes mayores de 18 años, con más de 2 días de hospitalización, con orden de egreso (alta hospitalaria), sin dificultad en el lenguaje, y que no estuvieran bajo efectos de sedación por medicamentos. para el cálculo del tamaño muestral se utilizó el programa epi-dat versión 2011, con base en la fórmula para poblaciones finitas, teniendo en cuenta el parámetro aproximado de egreso mensual (422 pacientes), un intervalo de confianza del 95 %, un error alfa del 5 %, y una prevalencia de calidad esperada de 72,41 y 66,15 (el primero, para satisfacción con los cuidados, y, el segundo, para experiencias con el cuidado, según estudio similar realizado por torres en bucaramanga) (16). el tamaño muestral final de este estudio fue de 147 pacientes, los cuales fueron seleccionados por cuotas hasta completar la muestra, al momento del egreso durante el primer trimestre del año 2013. el instrumento utilizado fue el cuestionario de calidad del cuidado de enfermería (cucace), versión en castellano validada por alonso et al. (17), de la versión original the newcastle satisfaction with nursing scales (nsns), validado por thomas et al. (18) en escocia. este instrumento es útil para recoger datos de pacientes individuales y consta de tres secciones: experiencia con los cuidados de enfermería (26 ítems), satisfacción con los cuidados de enfermería (19 ítems) y variables sociodemográficas como: edad, sexo, nivel educativo, días de estancia en el servicio y algunas preguntas de índole general. el cuestionario, en su versión original, muestra fiabilidad alfa de cronbach de 0,92 para la primera parte que mide “experiencia con los cuidados de enfermería”; y 0,97 para la segunda parte que explora la “satisfacción con los cuidados de enfermería” (18). la validación al castellano realizada por alonso et al. (17) muestra fiabilidad alfa de cronbach de 0,85 para la “experiencia con los cuidados de enfermería”; y 0,97 para la “satisfacción con los cuidados de enfermería”, alcanzando un nivel de confiabilidad total de 0,90. en colombia, la versión en español fue adaptada y validada por primera vez en bucaramanga. el resultado de fiabilidad mostró un alfa de cronbach de 0,83 para la dimensión de “experiencia con los cuidados de enfermería”, y 0,95 para la dimensión “satisfacción con los cuidados de enfermería”, el índice de validez de contendió fue superior a 0,84 y los autores reportan un constructo válido (16). de allí en adelante, el cuestionario ha demostrado tener validez y fiabilidad para medir la calidad del cuidado de enfermería en otros servicios diferentes a hospitalización —tal es el caso de unidades de oncología (19)—, demostrándose así su utilidad para medir el constructo de calidad del cuidado de enfermería evaluado en este estudio. el cuestionario de experiencias con los cuidados de enfermería está conformado por 26 preguntas: 14 formuladas en sentido positivo y 12 en sentido negativo. todas las preguntas poseen 7 opciones de respuesta de 1-7 (escala tipo likert). sin embargo, para el análisis, dichas respuestas fueron recodificadas de 0-6, de acuerdo con las sugerencias descritas en el manual del cucace. posterior a este procedimiento, se sumaron los puntajes recodificados por cada una de las preguntas seleccionadas como válidas, y, finalmente, se agruparon en tres niveles: positivo, neutro y negativo, con el fin de facilitar la interpretación de los datos. el cuestionario de satisfacción con los cuidados de enfermería está conformado por 19 preguntas, cada una de las cuales posee 5 opciones de respuesta de 1-5 (escala likert). teniendo en cuenta la recodificación recomendada por el manual del cucace, los resultados se agruparon en tres niveles: positivo, neutro y negativo. siendo positivo (“muy y completamente satisfecho”), neutro (“bastante satisfecho”), y negativo (“nada y poco satisfecho”). procedimiento. para la recolección de la información, se tuvo en cuenta el manual del cucace, en el cual se sugiere que los cuestionarios sean diligenciados directamente por los participantes para evitar el sesgo del investigador, guardando el rigor ético y metodológico correspondiente. durante el proceso, se entregó el consentimiento informado y el cuestionario cucace a cada uno de los pacientes que tenían orden de egreso, previa explicación de la investigación y su participación en ella. de igual forma, se le explicó al paciente la importancia de responder el cuestionario sin ayuda y en privado. para ello, se buscaron los mecanismos para que el paciente estuviera en un ambiente adecuado y se le pidió cortésmente a los familiares, amigos u otros acompañantes que no interviniesen en el proceso. 418 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 después de diligenciado el cuestionario y el consentimiento informado, los documentos fueron guardados en un sobre de manila y sellados delante del paciente para preservar la confidencialidad de la información. por otra parte, se tuvieron en consideración los aspectos éticos emitidos en la resolución 008430 de 1993 (20), los principios éticos de la ley 911 de 2004 (21), y las pautas del comité de organizaciones de las ciencias médicas (cioms) (22); el estudio fue aprobado por el comité de ética de la facultad de enfermería de la universidad nacional de colombia. los datos recolectados con el instrumento cucace se procesaron mediante un cuadro de ordenamiento de datos en excel y el programa estadístico spss®, para posteriormente ser graficados y analizados. resultados a continuación se presentan, primeramente, los resultados de los datos personales y las preguntas de índole general, luego los resultados según experiencia y satisfacción con los cuidados de enfermería, y, finalmente, los resultados de asociación entre las variables sociodemográficas y las dimensiones del cucace. se observó una media de edad de 44,73 años (de 17,23.); en la tabla 1 se observa que las mujeres y los hombres entre 25 y 50 años tuvieron la mayor representatividad de la población, seguidos por las mujeres y los hombres mayores o iguales a 51 años; este dato indica que el 84,3 % de la población estudiada era mayoritariamente adulta. en total, de los 147 pacientes, el 58,5 % eran mujeres y el 41,5 % eran hombres. al analizar las medias de edad frente al sexo, las edades mínima y máxima fueron iguales, con una leve diferencia en el promedio (tabla 2). en cuanto a los resultados de estancia hospitalaria, se encontró que el número mínimo de días de estancia fue de 2 días y máximo de 19 en el servicio de hospitalización, para un promedio de 7,62 días de estancia (de: 3,67). con relación al nivel educativo, un 27 % de los pacientes encuestados tiene estudios primarios incompletos, el 22 % completó estudios primarios, el 14 % manifestó tener un bachillerato incompleto, tabla 1. porcentajes de sexo según categorización de la edad tabla 2. media de edad según distribución por sexo fuente: cuestionario cucace, 2013. fuente: cuestionario cucace, 2013. sexo edad < 25 años entre 25 y 50 años > = 51 años total n % n % n % n % mujer 15 10,2 39 26,53 32 21,77 86 58,5 hombre 8 5,44 27 18,37 26 17,69 61 41,5 total 23 15,64 66 44,9 58 39,46 147 100 sexo n mínimo máximo media desv. tip. mujer 86 18 72 44,7 17,33 hombre 61 18 72 45 17,18 total 147 18 72 44,73 17,238 el 27 % logró terminar sus estudios secundarios, y solo el 11 % dijo tener estudios superiores, ya sean técnicos o universitarios. los resultados relacionados con las tres preguntas de índole general se encuentran en la tabla 3. al analizar estos resultados, se observa una tendencia significativamente alta hacia los tipos de respuesta: “buena”, “muy buena” y “excelente”. no obstante, cabe resaltar que el tipo de respuesta “muy buena”, sobresale en los dos primeros interrogantes. de igual forma, el hecho de que el 96,6 % de los pacientes considerara que el cuidado de enfermería no requiere mejoría. esto revela que la mayoría de los pacientes vieron cumplidas sus expectativas frente al cuidado ofrecido por enfermería. por otra parte, es importante tener en cuenta que, para los pacientes que participaron en este estudio, no hubo percepciones negativas. este hallazgo se corrobora al observar que ninguna de las preguntas de tipo negativo tuvieron respuesta (tabla 3). dentro de los aspectos valorados, el que mayor relevancia tuvo para los pacientes fue la buena comunicación basada en la confianza, la cual les generaba buenas relaciones y los hacía sentir tranquilos, lo que indica que este tipo de comportamiento en el personal de enfermería ayuda a la evolución de su estado de salud. 419 calidad del cuidado de enfermería percibida por pacientes hospitalizados en una clínica privada de barranquilla (colombia) l claudia andrea lenis-victoria y otro ítems negativos. no obstante, las preguntas: “las enfermeras se aseguraba de que los pacientes tuvieran intimidad cuando la necesitaban” y “los médicos y las enfermeras trabajaban juntos como un equipo” tuvieron puntajes relativamente bajos en relación con el resto de ítems. de igual forma, otro hallazgo interesante es el hecho de que en toda la escala de experiencias con el cuidado de enfermería, ninguna de las respuestas arrojó resultados neutros. calidad del cuidado de enfermería según la dimensión satisfacción al analizar las respuestas de cada uno de los ítems de esta escala, se observó que el resultado más alto lo tuvo la pregunta: “el grado de intimidad que le proporcionaron las enfermeras” en un 91,9 %. el comportamiento del resto de los ítems muestra resultados altamente positivos que están por encima del 60 %. por otra parte, se observa que, a diferencia de la escala de experiencias con el cuidado, en la escala de satisfacción los pacientes manifestaron un aumento en las respuestas de tipo neutro. no obstante, cabe resaltar que ninguno de los pacientes manifestó resultados negativos que denotaran insatisfacción con los cuidados (tabla 4). la tabla 5 muestra que en la dimensión de experiencia se obtuvo una media de 93,22 puntos y una desviación estándar de 1,46698, lo cual indica que los pacientes tuvieron una percepción positiva con los cuidados de enfermería. en cuanto a la dimensión satisfacción, se obtuvo un resultado global de 78,12 puntos sobre 100, y una desviación estándar de 5,17006, indicando satisfacción positiva. es decir, los pacientes tuvieron una percepción positiva en cuanto a la satisfacción con el cuidado de enfermería. en la tabla 6 se observa que existe correlación positiva entre la experiencia y la satisfacción con los cuidados de enfermería, puesto que el coeficiente de correlación de pearson es > 0 (r = 0,216), lo cual indica que al aumentar el tiempo de experiencia con los cuidados de enfermería en el servicio de hospitalización mediante los días de estancia, aumenta también la satisfacción con los mismos (p = 0,009), pero la asociación es débil porque el grado de correlación es menor que 0,3 (r < 0,3). tabla 3. resultados de preguntas de índole general fuente: cuestionario cucace, 2013. preguntas frecuencia absoluta porcentaje 1. ¿cómo valora usted el cuidado recibido por las enfermeras en esta institución? muy malo 0 0 malo 0 0 poco 0 0 regular 0 0 bueno 49 33,3 muy bueno 57 38,8 excelente 41 27,8 2. ¿cómo valoraría su estancia en el servicio? muy mala 0 0 mala 0 0 poca 0 0 regular 0 0 buena 31 21,1 muy buena 75 51 excelente 41 27,9 3. ¿el cuidado de las enfermeras podría ser mejorado en algún aspecto? no 142 96,6 sí 5 3,4 calidad del cuidado de enfermería según la dimensión: experiencia al analizar las respuestas de cada uno de los ítems de esta escala, se observó que en la pregunta: “las enfermeras tenían tiempo para sentarse y hablar conmigo”, se obtuvo un puntaje negativo por debajo del 70 %. este hallazgo debe tenerse en cuenta, puesto que la dedicación de tiempo en enfermería juega un papel importante. en general, la escala de experiencias con el cuidado muestra puntajes altos, por encima del 70 %. es decir, la mayoría de los pacientes respondieron “completamente de acuerdo” en los ítems positivos y “completamente en desacuerdo” en los 420 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 tabla 4. resultados de calidad del cuidado según la dimensión de satisfacción tabla 5. resultados de calidad del cuidado según experiencia y satisfacción no preguntas frecuencia porcentaje positivo neutro negativo positivo neutro negativo 1 la cantidad de tiempo que las enfermeras pasan con usted 130 17 0 88,4 11,6 0 2 la capacidad de las enfermeras para hacer bien su trabajo 114 33 0 77,5 22,4 0 3 había siempre una enfermera cerca si la necesitaba 112 35 0 76,2 23,8 0 4 el número de enfermeras que conocían sus cuidados 116 31 0 78,9 21,1 0 5 la rapidez con la que acudían cuando las llamaba 111 36 0 75,6 24,5 0 6 la manera en que las enfermeras le hacían sentir como en casa 124 23 0 84,4 15.6 0 7 la cantidad de información que las enfermeras le daban acerca de su situación y tratamiento 101 46 0 68,7 31,3 0 8 la frecuencia con la que las enfermeras comprobaban que se encontraban bien 95 52 0 64,6 35,4 0 9 la amabilidad de las enfermeras 99 48 0 67,4 32,7 0 10 la manera en que las enfermeras le explicaban las cosas 125 22 0 85 15, 0 11 la forma en que las enfermeras informaban a su familia 126 21 0 85,8 14,3 0 12 el modo como las enfermeras hacer su trabajo 131 16 0 89,1 10,9 0 13 el tipo de información que las enfermeras daban acerca de su situación y tratamiento 109 38 0 74,2 25,9 0 14 el trato que recibió de las enfermeras como persona 110 37 0 74,8 25,2 0 15 la forma como las enfermeras escuchaban sus preocupaciones 105 42 0 71,4 28,6 0 16 la cantidad de libertad que le fue dada en la planta 96 51 0 65,3 34,7 0 17 la disponibilidad de las enfermeras para responder a sus demandas 107 40 0 72,8 27,2 0 18 el grado de intimidad que le proporcionaron las enfermeras 135 12 0 91,9 8,2 0 19 la conciencia de las enfermeras sobre sus necesidades 112 35 0 76,2 23,8 0 fuente: cuestionario cucace, 2013. fuente: cuestionario cucace, 2013. dimensiones n mínimo máximo media desv. típ. experiencia 147 88,46 97,44 93,224 1,46698 satisfacción 147 61,84 89,47 78,1239 5,17006 421 calidad del cuidado de enfermería percibida por pacientes hospitalizados en una clínica privada de barranquilla (colombia) l claudia andrea lenis-victoria y otro dad de percibir el cuidado de enfermería y mostrar niveles altos de satisfacción posterior a la experiencia en la institución. discusión este es uno de los primeros estudios que utiliza el cuestionario cucace como instrumento para la recolección de la información, después de su validación en bucaramanga (colombia). por tanto, los resultados podrían ser comparados con los estudios de investigación previos realizados por torres (16, 23), torres y buitrago (19), alonso et al. (17) y thomas et al. (18). sin embargo, teniendo en cuenta que el fenómeno de calidad del cuidado es un tema de mucho interés para la práctica profesional, también es factible que los resultados del presente estudio se comparen con otras investigaciones que, aunque no hayan utilizado el mismo instrumento, muestran resultados confrontables. en barranquilla, en lo que respecta a la revisión de esta investigación, no se hallaron publicaciones de estudios en los que se haya evaluado, específicamente, la calidad del cuidado de enfermería. no obstante, es importante resaltar que se encontraron tres investigaciones realizadas por christoph (24), palmet (25), borré y vega (13), y borré et al. (26), en las cuales se evalúa la calidad de la atención de enfermería en servicios de hospitalización de instituciones de iii y iv nivel de atención en salud. con respecto a esto, cabe resaltar que aunque el concepto anglosajón care no muestre diferencias, lo cierto es que la traducción al castellano sí las tiene, puesto que el concepto cuidado se relaciona con aquellas actividades propias que realiza enfermería durante la interacción con el paciente, mientras que el concepto atención está relacionado con aspectos corporativos que tienen que ver con la prestación del servicio de salud (27). los resultados encontrados en este estudio con relación a la edad y el sexo guardan relación con lo hallado en estudios similares, los cuales muestran que la media de edad oscila entre 43 y 47 puntos en ambos sexos (16, 17, 19, 23). sin embargo, el estudio de thomas et al. (18) muestra que la media de edad se concentró en los participantes mayores de 65 años; esto quizás se deba a que la población de inglaterra, por lo general, es más longeva en relación con la población colombiana. en cuanto al resultado de estancia hospitalaria de 7,62 días, se observa que este es un dato que varía en el resto de los estudios. tabla 6. correlación entre resultados de experiencia y satisfacción tabla 7. anova para variables sociodemográficas categóricas y la satisfacción dimensiones experiencia satisfacción experiencia correlación de pearson 1 0,216** sig. (bilateral) 0,009 n 147 147 satisfacción correlación de pearson 0,216** 1 sig. (bilateral) 0,009 n 147 147 variable media ds f p sexo femenino 74,77 4,71 5,715 0,025 masculino 76,76 5,14 edad < 25 años 76,05 4,18 0,823 0,726 entre 25 y 50 años 78,82 5,17 > = 51 años 78,24 5,39 nivel de estudios primaria 78,25 5,41 0,092 0,964 bachiller 77,97 5,08 técnico 79,82 3,66 universitarios 76,89 6,05 **la correlación es significativa al nivel 0,01 (bilateral). fuente: cuestionario cucace, 2013. relación de las variables sociodemográficas y las dimensiones del cucace en la tabla 7 se resume, al aplicar anova de un factor, la relación entre la variable satisfacción con el cuidado y el sexo de los participantes (p < 0,05). no se encontró asociación significativa entre las dimensiones del cucace y las variables: edad y nivel de estudios. con relación al nivel educativo, el comportamiento es similar, lo cual evidencia que aunque algunos pacientes tenían bajos, y otros, altos de niveles de escolaridad, la mayoría tuvo la capaci422 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 no obstante, la literatura evidencia que los rangos de oscilación son de 3,95 a 12 días (16, 17, 19). teniendo en cuenta la teoría de calidad percibida y la experiencia en los servicios, esta variable puede tener significativas influencias en el nivel de percepción y satisfacción que pueda llegar a tener un paciente sobre el cuidado brindado en la institución. la influencia radica en el hecho de que cuando un paciente permanece mucho tiempo internado, sus percepciones pueden verse sesgadas hacia dos rumbos: el primero, que exista la posibilidad de evaluar el cuidado de forma negativa por no sentir mejoría en su recuperación y permanecer mucho tiempo en la institución; el segundo, que se acostumbre al diario vivir en el servicio y sesgue sus percepciones por la confianza y la empatía que se establece en el servicio con el personal de salud. los resultados de las preguntas de índole general fueron positivos, lo cual es coherente con lo hallado por torres (16) y alonso et al. (17), quienes manifiestan que los resultados en las preguntas de opinión global fueron altos, con valores por encima del 90 %. de igual forma, la pregunta acerca de si los pacientes creían que el cuidado de enfermería podría ser mejorado, tuvo un resultado positivo de 96,6 %. sin embargo, en el estudio de torres se observa que solo el 76,1 % mostró resultados positivos (16), hallazgo contrario en el estudio de alonso et al. (17), quienes manifiestan que el 60 % de los pacientes encuestados opinaron que el cuidado de enfermería pudo mejorarse en algún aspecto. en los resultados globales de las dimensiones del cucace, se observó que en la dimensión de experiencia los pacientes respondieron positivamente con una media de 93,22 y en la dimensión de satisfacción, con una media de 78,12. el resultado de experiencia supera lo encontrado por alonso et al. (17), quienes hallaron una media de 79,7 para esta dimensión, mientras que en el resultado de satisfacción el comportamiento es a la inversa. es decir, el 81,4, lo que supera el presente estudio. asimismo, este resultado está por encima de lo observado en el estudio de thomas et al. (18), los cuales encontraron una media de 84,6 para la dimensión experiencia, y una media de 84,1 para la satisfacción, mostrando el mismo comportamiento que el estudio de alonso et al. (17). en cuanto a estas dimensiones, el presente resultado supera lo hallado por torres, quien evidencia haber encontrado una media de 66,15 en la dimensión de experiencia y 72,41 en la dimensión de satisfacción con los cuidados de enfermería (16), posiblemente relacionado con la cultura y la idiosincrasia diferenciables entre el contexto de santander y el de barranquilla. por otra parte, torres y buitrago, en otro estudio con pacientes oncológicos, encontraron una media de 82,7 con la dimensión experiencia, y 80,4 con la dimensión satisfacción (19), mientras que joolaee et al. (5) hallaron niveles de satisfacción del 72 %. dentro de los aspectos mayormente valorados como positivos por los pacientes están: el saber hacer, la comunicación durante la entrega de turno y la oportunidad que buscaba la enfermera para estar con ellos, con puntuaciones por encima del 90 %; mientras que los aspectos menos valorados fueron: el hecho de sacar tiempo para dialogar, la preservación de la intimidad y el trabajo en equipo con los médicos, con porcentajes inferiores al 70 %. esto se relaciona con lo obtenido por torres y buitrago (19), quienes afirman haber obtenido un puntaje de 62,7 en la preservación de la intimidad del paciente por parte de la enfermera. un hallazgo significativo y de mucha relevancia es el hecho de que los pacientes hayan valorado positivamente la oportunidad que las enfermeras buscaban para estar con ellos. este aspecto es mencionado por swanson como una de las características del cuidado, cuando expresa que el “estar con” incluye estar allí con la persona y transmitir disponibilidad (28). teniendo en cuenta estos resultados, se hace necesario articularlos con los postulados de irvine y sidani en su modelo de efectividad del rol (29), en el cual se reconoce que las acciones de cuidado, llevadas a cabo por el personal de enfermería y percibidas por el paciente durante su experiencia en el servicio, están enmarcadas en los tres roles: dependiente, independiente e interdependiente (30). es decir, que aunque el paciente no identifique los roles de enfermería durante la interacción de cuidado, estos son susceptibles de ser evaluados por él desde una perspectiva general dentro de la atención en salud. por otra parte, cabe mencionar que durante el análisis de cada uno de los ítems, se observó que los 26 ítems del cucace que componen la escala de experiencias con el cuidado de enfermería, están estructurados de tal manera que miden de una u otra forma las acciones propias de la disciplina. es así como los resultados de experiencia y satisfacción con los cuidados, observados en este estudio, podrían comprobar lo afirmado por irvine y sidani, quienes expresan que una de las formas para medir los componentes, proceso y resultados del cuidado de enfermería, es a través de la relación enfermera-paciente y la percepción y satisfacción final del paciente respectivamente (29). 423 calidad del cuidado de enfermería percibida por pacientes hospitalizados en una clínica privada de barranquilla (colombia) l claudia andrea lenis-victoria y otro en el análisis de las variables sociodemográficas sexo y edad, con la dimensión de experiencia del cuidado de enfermería se encontró una relación significativa; las puntuaciones más altas estuvieron en la categoría de los pacientes con estudios a nivel técnico y en las edades < 25 años; lo anterior concuerda con lo hallado por torres y buitrago (19), quienes encontraron relación entre la dimensión de experiencia con los cuidados de enfermería, y sus puntajes más altos fueron en la categoría de primaria incompleta. al igual que torres, no se encontró diferencia importante entre edad, estancia y satisfacción con los cuidados de enfermería (16). lo anterior es evidente, en la medida en que los pacientes perciben y valoran todos aquellos aspectos relacionados con la estructura que utilizan los profesionales de enfermería para brindar el cuidado y los aspectos relacionados con el proceso durante la atención. conclusión se concluye que la calidad del cuidado de enfermería que se brinda en el servicio de hospitalización de la institución centro de estudio es buena, según la percepción de los pacientes. así lo demuestran los resultados satisfactorios obtenidos en las dimensiones: experiencia y satisfacción con el cuidado de enfermería. es importante resaltar que este estudio tiene algunas limitaciones relacionadas con el alcance del diseño, el cual no permite generalizar los resultados a otras instituciones de salud. no obstante, su importancia es evidente dada la escasez de investigaciones descriptivas que permitan conocer, de manera detallada, el fenómeno de calidad del cuidado de enfermería en barranquilla y la región caribe. es necesario seguir realizando estudios de este tipo, para que los resultados encontrados en la presente investigación puedan ser comparados; asimismo, esto permitiría seguir corroborando la validez y fiabilidad del cucace para medir el constructo de calidad del cuidado de enfermería. por otra parte, es importante resaltar la necesidad de seguir indagando sobre la influencia de las variables sociodemográficas y la percepción del paciente hospitalizado para evaluar el cuidado de enfermería, con el fin de establecer asociaciones que permitan mostrar resultados más generalizables. para ello, sería conveniente realizar estudios de correlaciones predictivos, multicéntricos y comparativos. de igual forma, teniendo en cuenta el carácter subjetivo de la percepción del paciente, se podría explorar la calidad del cuidado de enfermería a través de estudios de abordaje cualitativo para identificar las similitudes o diferencias con los estudios cuantitativos, y conocer con mayor profundidad dicho constructo. agradecimientos. los autores agradecen al msc yeis miguel borré ortiz, profesor de la universidad libre, seccional barranquilla (colombia), por la revisión y los aportes especiales al presente artículo. referencias 1. ávalos mi, priego hr. calidad en el mercado de la salud ¿realidad o utopía? horizonte sanitario. 2012;11(1):6-12. 2. barragán ja, moreno cm. calidad percibida por usuarios de enfermería en tres hospitales públicos. enfer glob. 2013;12(1):217-30. 3. gabriel cs, melo mr, rossi fl, bernardes a, miguelaci t, silva ml. use of performance indicators in the nursing service of a public hospital. rev latino-am enfermagem. 2011;19(5):1247-1254. 4. suhonen r, papastavrou e, efstathiou g, tsangari h, jarosova d, leino-kilpi h, et al. patient satisfaction as an outcome of individualised nursing care. scand j caring sci. 2012;26;372-380. 5. joolaee s, hajibabaee f, jafar jalal, e, bahrani n. assessment of patient satisfaction from nursing care in hospitals of iran university of medical sciences. hayat. 2011;17(1):35-44. 424 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 6. milutinović d, simin d, brkić n, brkić s. the patient satisfaction with nursing care quality: thepsychometric study of the serbian version of psncq questionnaire. scand j caring sci. 2012;26:595-606. 7. donabedian a. la calidad de la asistencia. ¿cómo podría ser evaluada? rev calidad asistencial. 2001;16:580-587. 8. ley 1122 de 2007. por la cual se hacen algunas modificaciones en el sistema general de seguridad social en salud y se dictan otras disposiciones. congreso de la república de colombia. diario oficial 46.506 (enero 9, 2007). 9. ley 1438 de 2011. por medio de la cual se reforma el sistema general de seguridad social en salud y se dictan otras disposiciones. congreso de la república de colombia. diario oficial 47.957 (enero 19, 2011). 10. decreto 1011 de 2006. por el cual se establece el sistema obligatorio de garantía de calidad de la atención de salud del sistema general de seguridad social en salud. presidencia de la república de colombia. diario oficial 46.230 (abril 3, 2006). 11. vega y. la administración que se enseña en el pregrado de enfermería. av enferm. 2012;3(1):95-06. 12. malvárez s. la regulación de la práctica y la educación en enfermería. nuevos determinantes. en: actas del xiii curso ops/oms-ciess. legislación de salud: la regulación de la práctica profesional en salud. méxico d.f: 4-8 septiembre; 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nurse care. qual. health care. 1996;5(2):67-72. 19. torres c, buitrago m. percepción de la calidad de los cuidados de enfermería en pacientes oncológicos hospitalizados. rev cuidarte. 2011;2(2):138-48. 20. resolución 008430 de 1993. por la cual se establecen las normas científicas, técnicas y administrativas para la investigación en salud. ministerio de salud de colombia; 1993. 21. ley 911 del 2004. por la cual se dictan disposiciones en materia de responsabilidad deontológica para el ejercicio de la profesión de enfermería en colombia; se establece el régimen disciplinario correspondiente y se dictan otras disposiciones. congreso de la república de colombia. diario oficial 45.693 (octubre 5, 2004). 22. comité de organizaciones internacionales de las ciencias médicas, organización mundial de la salud. pautas éticas internacionales para la investigación biomédica en seres humanos. ginebra: cioms-oms; 2002. 23. torres cc. valoración de aspectos cualitativos del cuidado de enfermería en pacientes hospitalizados. rev cuid. 2010;1(1):10-18. 24. christoph r. determinación de la calidad de la atención del profesional de enfermería en servicios de hospitalización de las instituciones prestadoras de salud especializadas en salud mental y psiquiatría de la ciudad de barranquilla [tesis de maestría]. bogotá. d.c.: facultad de enfermería universidad nacional de colombia; 2006. 425 calidad del cuidado de enfermería percibida por pacientes hospitalizados en una clínica privada de barranquilla (colombia) l claudia andrea lenis-victoria y otro 25. palmet mm. determinación de la calidad de atención del profesional de enfermería en servicios de hospitalización de las instituciones prestadoras de salud de tercer nivel de atención, privadas, de barranquilla, 2006. en: asociación nacional de enfermeras de colombia. actas del xvii congreso nacional de enfermería, noviembre 7-10, 2007; barranquilla, colombia. anec; 2007. p. 30-31. 26. borré ym, lenis-victoria c, gonzález-ruiz g. utilidad del cuestionario servqhos-e para medir calidad percibida de la atención de enfermería. rev ces salud pública. 2014;5(2):127-136. 27. barragán ja. manrique fg. validez y confiabilidad del servqhos para enfermería en boyacá, colombia. av enferm. 2010;28(2):48-61. 28. wojnar d. teoría de los cuidados de kristen swanson. en: marriner a, raile m. modelos y teorías en enfermería. 6ª ed. barcelona: elsevier; 2007. p. 766-777. 29. irvine d, sidani s, keatings m, doidge d. an empirical test of the nursing role effectiveness model. j adv nurs. 2002;38(1):29-39. 30. salgueiro af, lopes p, cardoso ml, vidinha t. implementation of the nursing role effectiveness model. inter j caring sci. 2014;7(3):757-770. 32 42 childbirth and postpartum.indd 32 nuray egelioğlu cetişli1 zubeyde denizci zirek2 fatma bakılan abalı3 childbirth and postpartum period fear in pregnant women and the affecting factors 1 izmir katip celebi university, faculty of health sciences, izmir, turkey. nurayegelioglu@gmail.com 2 izmir katip celebi university atatürk education and research hospital, izmir, turkey. zubeydedenizci@yahoo.com 3 izmir katip celebi university atatürk education and research hospital, izmir, turkey. fatosabali@hotmail.com recibido: 01 de octubre de 2014 enviado a pares: 23 de noviembre de 2014 aceptado por pares: 24 de noviembre de 2015 aprobado: 02 de diciembre de 2015 doi: 10.5294/aqui.2016.16.1.5 para citar este artículo / to reference this article / para citar este artigo egelioğlu cetişli n., denizci zirek z. y bakılan abalı f. childbirth and postpartum period fear in pregnant women and the affecting factors. aquichan. 2016;16(1):32-42. doi: 10.5294/aqui.2016.16.1.5 año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 32-42 abstract objective: the aim of this study was to identify the anxiety pregnant women feel about childbirth and the postpartum period and to determine the affecting factors. methods: a descriptive design was used in the study, which was conducted with pregnant women at two obstetric polyclinics of a university hospital in turkey from january 2014 to july 2014. the population consisted of 143 pregnant women. the data were collected using an individual identification form and the fear childbirth and postpartum anxiety scale. the percentage, kruskall wallis, mann-whitney u and independent sample t tests were used to evaluate the differences between the variables. results: the results of the study reveal that pregnant women are quite fearful of childbirth and the postpartum period. conclusions: it is necessary to decrease fear of childbirth, because of its negative effects. keywords pregnancy; labor; postpartum period; nursing care (source: decs, bireme). 33 childbirth and postpartum period fear in pregnant women and the affecting factors l nuray egelioğlu cetişli and others año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 32-42 el miedo del parto y puerperio en mujeres embarazadas y los factores que lo afectan resumen objetivo: el objetivo de este estudio fue determinar la ansiedad de las mujeres embarazadas en relación con el parto y el puerperio y determinar los factores que las afectan. métodos: se utilizó un diseño descriptivo y el estudio se llevó a cabo con un grupo de mujeres embarazadas en dos policlínicas obstétricas de un hospital universitario en turquía desde enero de 2014 hasta julio de 2014. la población estuvo constituida por 143 mujeres embarazadas. los datos fueron recolectados a través de un formulario de identificación individual y la escala de miedo al parto y el puerperio. las pruebas de porcentaje, kruskall wallis, u de mann-whitney y la prueba t para muestras independientes se utilizaron para evaluar las diferencias entre las variables. resultados: los resultados del estudio revelaron que las mujeres embarazadas tienen un alto nivel de miedo con respecto al parto y el puerperio. conclusiones: es necesario disminuir ese miedo debido a sus efectos negativos. palabras clave embarazo; parto; puerperio; cuidados de enfermería (fuente: decs, bireme). 34 aquichan issn 1657-5997 año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 32-42 o medo do parto e do puerpério em gestantes e os fatores que as afetam resumen objetivo: o objetivo deste estudo foi determinar a ansiedade das gestantes quanto ao parto e ao puerpério e determinar os fatores que as afetam. métodos: utilizou-se um desenho descritivo, e o estudo foi realizado com um grupo de gestantes em duas policlínicas obstétricas de um hospital universitário na turquia, de janeiro a julho de 2014. a população esteve constituída por 143 gestantes. os dados foram coletados por meio de um formulário de identificação individual e pela escala de medo do parto e do puerpério. os testes de porcentagem, kruskall wallis, u de mann-whitney e o teste-t para amostras independentes, foram utilizados para avaliar as diferenças entre as variáveis. resultados: os resultados do estudo revelaram que as gestantes têm um alto nível de medo do parto e do puerpério. conclusões: é necessário diminuir esse medo devido a seus efeitos negativos. palavras-chave gestação; parto; puerpério; cuidados de enfermagem (fonte: decs, bireme). 35 childbirth and postpartum period fear in pregnant women and the affecting factors l nuray egelioğlu cetişli and others introduction pregnancy is an important transition period for women moving into motherhood. it also is a time when women might experience a number of physiological and psychological changes. today, childbirth is thought to be a frightening matter requiring medical attention, rather than a normal condition (1, 2). the literature contains many studies on worries and anxiety about childbirth. the fears of women identified in these studies were pain, panic, sense of failure, losing control, injury to the child and the mother, emergency cesarean section, excessive bleeding, residual part of the placenta, and the development of complications during birth, such as hypertension, permanent damage to the child, episiotomy and death of mother or her child. the literature also shows that women fear damage to the perineum area, adverse effects on sexual life, the screams of the medical staff, failure at birth or insufficient support (1-21). as for the postpartum period, the fears of pregnant women were identified as being centered on infant care and the adverse effects it might have on their marriage and family life. during the third trimester in particular, as the birth time approaches, increasing anxiety can cause adverse effects and pain at birth, decreased pain tolerance, a longer birth process, more need for analgesics, a rise in arbitrary demand for caesarean sections, and an increase in the risk of psychological disorders during the postpartum period (22, 23). birth anxiety can be seen in many pregnant women because of the violence in the process of birth. therefore, the medical staff should be aware of the emotional changes and fears a woman can undergo during pregnancy, childbirth and the postpartum period. moreover, to reduce anxiety, they should be able to provide training and coaching on the process of pregnancy and birth. nurses, who are at the center of the team of health professionals, should continually evaluate the process of normal and/or abnormal pregnancy as it occurs during the birth process. according to the roy adaptation model, nurses are able to identify and determine appropriate/inappropriate behavior during this natural stage of human developmental from pregnancy to childbirth (15, 20, 27). the types of behavior to be identified are different in the development of a normal or abnormal process with respect to post conception, gestation, pregnancy complications, live birth and/or fetal death during the natural process of childbirth. also, nurses are able to determine the stimulant factors causing positive behavior during changes in labor. to plan the nursing care process, to provide appropriate care services and to reduce the fears of pregnant women, it is important to identify the affecting factors and, thus, reduce complications at the time of birth (1, 7-12, 20, 25, 27, 28). this study was conducted to determine the anxiety pregnant women experience during childbirth and the postpartum period, and to determine the factors affecting that fear. materials and methods design this descriptive study was carried out at two obstetric polyclinics of a university hospital in izmir, turkey. the working hours of the obstetric polyclinics where the study was conducted were from 8:00 a.m. to 5:00 p.m. the number of working days was five per week. participants and setting the sample for this research consisted of 143 women between the ages of 18 and 45 who went to the university obstetric polyclinic for routine pregnancy check-ups during the period from january 2014 to july 2014. the pregnant women in this sample were in the 37th week of their pregnancy or more, had no risk factors or psychological problems, and each of them consented to take part in the study. data collection the data were collected by the researchers during a face-toface interview with each pregnant woman before she was called in to see the doctor. the interview was conducted in a waiting room during a period of 15-20 minutes. the individual identification form and the fear of childbirth and postpartum anxiety scale (ffcp) were used to gather the data. measures the individual identification form was created by the researchers on the basis of relevant literature. the form consisted of 13 questions designed to collect data on the socio-demographic and obstetric characteristics of the pregnant women. the fear of childbirth and postpartum anxiety scale (fcpp), the reliability and validity of which was approved (cronbach alpha=0.955) by kitapçıoğlu et al., has 61 questions and 10 36 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 factors (kitapçıoğlu et al., 2008). the fcpp is likert-type and the scores are as follows: 1: completely disagree, 2: disagree, 3: not sure, 4: agree, 5: completely agree. in the scale, all the scores obtained from each factor are standardized before being summed up and divided by the factor number. then, the total score on the scale is calculated. the resulting scores are evaluated as very low: 0.00-2.00, low: 2.01-4.00, medium: 4.01-6, high: 6.01-8.00 and very high: 8.01-10.00 (11). analysis for this descriptive study, spss 16.00 statistical software was used in the calculations to determine the demographic and obstetric characteristics of the pregnant women. the results are statistically significant at the level of p<0.05. the kruskall wallis, mann-whitney u, and independent sample t tests were used to evaluate the differences between the variables. ethical considerations the consent to conduct of this research was officially approved. a signed written document was issued by the ethics committee of the izmir katip celebi university to perform the study. first, the pregnant women to be included in this study were informed about its purpose and methodology. those who agreed to participate were given a consent form to be signed. since they approved their participation by signing the form, they were asked to answer the research questionnaire. results the demographic characteristics of the pregnant women are shown in table 1. the average mean age of the participants was 27.02±5.02. in all, 45.4% were primary school graduates, 87.4% were housewives, 67.1% had an income equal to their expenses, and 83.4% had a nuclear family structure (table 1). moreover, 35.0% of the pregnant women in the sample were in their 37th week of pregnancy and 39.1% reported this was their second pregnancy; 71.3% were planning a vaginal birth, and 46.2% had a vaginal birth with their previous pregnancy. finally, 72.0% reported this pregnancy as being planned and 58.7% received antenatal training for the birth and the postpartum period (table 2). the average total score on the fcpp for the pregnant women was 6.17±1.56. the highest average subscale score for anxievariable number (n) percentage (%) age average 27.02±5.02 education primary 65 45.4 secondary 29 20.3 high school 39 27.3 university 10 7.0 working working 18 12.6 non-working 125 87.4 income level income is less than expense 47 32.9 income is equal to expense 96 67.1 family nuclear family 120 83.9 large family 23 16.1 total 143 100 table 1. demographic characteristics of pregnant. ty concerned the medical staff’s behavior, at 6.93±2.10. anxiety about a cesarean section comes next, with a score of 6.90±2.40. the average subscale score for anxiety over breast feeding was 6.76±2.32, while worries about the prenatal period had almost an equal score (6.75±2.35). other average subscale scores for anxiety, in descending order, were about labor (6.55±1.91), health of the mother and baby after childbirth (6.34±2.00), the baby (5.83±2.24), social life after childbirth (5.37±2.32), insufficient postnatal infant care (5.14±2.10) and, finally, lack of support from the husband (5.14±2.04). as for the total score averages, what the pregnant women feared the most was poor behavior by medical staff at the birth, followed by the risk of cesarean section, breastfeeding, the prenatal period, labor and postnatal infant care (table 3). when the authors checked the relationship between the average scores on the anxiety scale and the demographic and obstetric characteristics, a statistically significant difference was identified with respect to level of education, week of pregnancy, number of pregnancies, preferred mode of childbirth, previous 37 childbirth and postpartum period fear in pregnant women and the affecting factors l nuray egelioğlu cetişli and others table 2. obstetric characteristics of pregnant. variables number (n) percentage (%) week of the pregnant 37th week 50 35.0 38th week 37 25.9 39th week 42 29.4 40th week and older 14 9.7 pregnancy 1st 43 30.1 2nd 56 39.1 3rd 28 19.6 4th and more 16 11.2 birth type preference vaginal birth 102 71.3 caesarean section 41 28.7 previous birth type vaginal birth 66 46.2 caesarean section 34 23.7 none 43 30.1 is it a planned pregnancy? yes 103 72.0 no 40 28.0 have a training for the childbirth and postpartum period? yes 59 41.3 no 84 58.7 total 143 100 mode of childbirth, and training for the antenatal and postpartum period. the lowest anxiety scores were for the participants who were university graduates, had four or more pregnancies, preferred vaginal birth, underwent a vaginal birth in their previous pregnancy, and had training for the antenatal and postpartum period (table 4). table 3. fear score average of pregnant for the childbirth and postpartum period x± ss min-max total score of scale 6.17±1.56 0-10 factor 1 (worries about the baby) 5.83±2.24 0-10 factor 2 (worries about the birth activity) 6.55±1.91 0-10 factor 3 (worries about the breast feeding after the childbirth) 6.76±2.32 0-10 factor 4 (worries to fail down on baby care after the childbirth) 5.14±2.10 0-10 factor 5 (worries about the social life after childbirth) 5.37±2.32 0-10 factor 6 (worries about health of the baby and mother after the childbirth) 6.34±2.00 0-10 factor 7 (worries about nonsupporting husband) 5.14±2.04 0-10 factor 8 (worries before the prenatal period) 6.75±2.35 0-10 factor 9 (worries about the behavior of the medical staff at childbirth) 6.93±2.10 0-10 factor 10 (worries about the caesarean section risk) 6.90±2.40 0-10 discussion in many cultures, pregnancy is acknowledged as a natural and normal occurrence. anxiety about birth is seen frequently and causes several severe problems during childbirth (1-8, 12-15, 21). in this study, it was determined that pregnant women have a high level of anxiety about childbirth and the postpartum period, and worry about the negative behavior of the medical staff during labor. furthermore, pregnant women fear the risk of a caesarean section, the prenatal period and labor. the study also showed pregnant women fear they will fail at breast feeding and postnatal infant care. melender (2001) conducted a study to determine 38 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 demographic and obstetric characteristics factor 1 factor 2 factor 3 factor 4 factor 5 factor 6 factor 7 factor 8 factor 9 factor 10 total score education level primary secondary high school university p 5.76±2.12 6.20±2.45 5.95±2.34 4.76±1.79 0.38 6.59±1.91 6.85±1.75 6.32±2.08 6.32±1.82 0.67 7.26±2.01 7.68±1.25 5.54±2.69 5.60±2.94 0.00 5.36±1.95 5.35±2.00 4.83±2.35 4.25±2.22 0.11 5.64±2.227 5.55±2.10 4.64±2.38 6.00±2.62 0.09 6.75±1.71 6.69±1.84 5.62±2.30 5.40±2.08 0.01 5.42±1.89 5.40±1.85 4.73±2.46 4.12±1.14 0.03 6.98±2.34 7.49±1.76 6.10±2.57 5.73±2.35 0.04 7.23±2.09 7.55±1.75 6.38±2.21 5.35±1.63 0.00 7.24±2.20 7.34±2.02 6.58±2.68 4.60±2.50 0.01 6.42±1.35 6.61±1.32 5.67±1.91 5.21±1.30 0.00 pregnancy time 1st 2nd 3rd 4th and more p 6.12±2.50 5.85±2.26 5.38±2.15 5.82±1.44 0.76 7.32±1.68 6.34±1.93 6.45±2.06 5.41±1.47 0.00 7.76±1.64 6.57±2.34 6.07±2.70 5.95±2.39 0.01 6.30±2.15 4.76±2.00 4.40±2.03 4.60±1.01 0.00 5.58±2.37 5.15±2.41 5.73±2.21 5.00±2.04 0.49 6.86±1.85 6.12±2.03 6.28±1.97 5.81±2.18 0.13 5.87±2.25 4.82±2.00 4.84±1.67 4.80±1.83 0.04 7.93±2.02 6.67±2.02 5.95±2.79 5.29±2.11 0.00 7.03±2.33 7.09±1.96 7.00±1.91 6.00±2.22 0.34 7.32±2.19 7.19±2.27 6.32±2.72 5.75±2.51 0.08 6.81±1.58 6.06±1.47 5.84±1.53 5.44±1.43 0.00 childbirth type preference vaginal caesarean section p 5.40±2.14 6.90±2.14 0.00 6.36±1.85 7.02±2.00 0.06 6.16±2.41 8.24±1.19 0.00 4.76±2.07 6.06±1.90 0.00 5.09±2.24 6.08±2.38 0.02 5.84±1.91 7.59±1.64 0.00 4.78±1.97 6.02±1.95 0.00 6.34±2.32 7.78±2.12 0.00 6.51±2.15 7.98±1.56 0.00 6.57±2.48 7.70±2.02 0.01 5.78±1.43 7.14±1.47 0.00 previous childbirth type vaginal caesarean section p 5.29±2.05 6.51±2.01 0.00 5.97±1.89 6.59±2.04 0.13 5.46±2.41 7.91±1.65 0.00 4.21±1.83 5.40±1.76 0.00 4.95±2.26 6.02±2.26 0.02 5.48±1.88 7.25±1.88 0.00 4.48±1.81 5.55±1.80 0.00 5.77±2.20 7.07±2.40 0.00 6.37±2.08 7.79±1.62 0.00 6.50±2.60 7.05±2.22 0.29 5.45±1.30 6.72±1.51 0.00 have a training for the childbirth and postpartum period yes no p 5.07±2.19 6.37±2.12 0.00 5.96±2.13 6.97±1.63 0.00 5.82±2.77 7.42±1.67 0.00 4.67±2.16 5.46±2.01 0.02 5.37±2.37 5.38±2.29 0.98 5.91±2.14 6.63±1.84 0.03 4.65±1.97 5.48±2.03 0.01 5.85±2.48 7.39±2.04 0.00 6.46±2.13 7.26±2.03 0.02 6.37±2.75 7.27±2.06 0.02 5.61±1.59 6.56±1.43 0.00 table 4. fear score average of pregnant for the childbirth and postpartum period according to their demographic and obstetric characteristics the fear factors during pregnancy and at birth, their causes and formations. in that study, the results showed the fear factors concerned the health of the infant and the mother, the behavior of the medical staff, caesarean section, and the family after labor (13). sercekus and okumus (2009) conducted a study on nulliparous pregnant women and reported that labor and poor behavior on the part of the staff cause birth fear (20). a medical staff member who is well-informed and supportive of the birth process during the intrapartum period is very important to inspiring confidence and support for the pregnant woman and the family, and also can be highly effective in providing basic information (1-5, 7-10). sjögrenet et al. (1997) reported that pregnant women who were supported by the medical staff at the clinic felt more self-sufficient, their satisfaction ratio increased, and they had less fear of childbirth (22). nurses, who spend the most time with pregnant women in the intrapartum unit, should be aware of the stress diagnosis for women in birth activity; they also should be conscious of their physical and psychological needs, and help them to manage labor and to ensure the birth concludes with a healthy mother and baby. in this study, the fear factors in the prenatal period and during childbirth were identified as focused on being unable to go to the hospital in time, being alone when labor pains begin, early loss of amniotic fluid, loss of control during labor, prolonged labor, and loss or damage to the baby. fear causes severe problems and also results in an increased demand for caesarean sections. the world health organization (who, 2015) says the ratio of caesarean sections should be less than 15% (26). unfortunately, the caesarean ratio in turkey is higher than who’s recommendation. according to the turkey de39 childbirth and postpartum period fear in pregnant women and the affecting factors l nuray egelioğlu cetişli and others mographic and health survey (2013), the caesarean ratio in turkey was 48% (24). the opinion of women regarding a caesarean section and a vaginal birth differs among the different cultures (1-8, 12-15). studies conducted on the opinions of women report the following as the reasons why women prefer vaginal delivery: birth is regarded as a normal condition, the feeling of being in control of oneself, the experience of vaginal birth, shorter recovery time and earlier discharge from the hospital, lower complication ratios, fear of anesthesia and surgery, the sense of being safer for the mother, improved affection for the infant, less pain in the postpartum period, “better for health”, being able to breastfeed directly, considered trustworthy, “normal birth is best,” and the husband’s support for normal birth (13-16, 18, 21, 23, 25, 27, 28). the researchers reported a higher ratio of maternal mortality, postpartum hemorrhage, uterine rupture and infection. they also indicated that urinary area and placenta previa damage in the next pregnancy, still birth, spontaneous abortion and the risk of ectopic pregnancy was higher (17, 25, 27, 28). in this study, it was found that women who prefer vaginal birth and who experienced a vaginal birth in their previous pregnancy had less fear of birth and the postpartum period than women who preferred and experienced a caesarean section. the belief in turkey is that labor experienced during childbirth enhances the emotions and the body is cleansed by bleeding at birth. there is also the feeling that it helps to recover from certain gynecological complaints (23, 27). pregnant women reported that having a more active role in childbirth and directly experiencing birth affects their feelings and increases bonding with the infant. it is a common belief that experiencing more pain results in a rich feeling of motherhood (3, 23, 27). the results of this study showed the women were extremely anxious about infant care and breastfeeding after birth. for turkish women, recovering quickly after giving birth and taking care of the infant as soon as possible are very important (19, 20, 23). this social point of view for the mother was considered, in this study, to be the reason for anxiety about inability in infant care and breast feeding during the postpartum period. although there is some support from the family and help for the mother in terms of child care, it is important for women to look after and breast feed their infants themselves (18-20, 23). haines et al. (2011) reported that women who are primiparous and have less education experience higher birth fear levels (8). alehagen et al. (2006) conducted a study with 35 primipara and 39 multipara women, and compared birth fear between the two groups. they reported that primipara pregnant women have more fear compared to multipara pregnant women (2). the results in this study were consistent with the literature (4-6). not having experience with birth, ambiguous feelings and lack of knowledge were thought to be the reason for the high level of fear among primipara pregnant women. the study also showed the pregnant women who had no training for childbirth and the postpartum period experienced more birth fears compared to the pregnant women who had training. this result is consistent with other studies found in the literature. for example, cosar and demirci (2012) conducted a study to analyze the effect of birth preparatory training on the perception of birth and adaptation to it. the women in the group who received training experienced less fear of birth (3). haines et al. (2011) reported that training and care given in the antenatal period is an important factor in fear of birth and was shown to decrease the level of birth fear (8). finally, the results of this study were analyzed with respect to the adaptation model. the analysis showed that inappropriate behavior in adaptation area four causes birth fear (figure 1) (19, 20). identifying pregnant woman’s fears and expectations about childbirth is very important for nurses, if they are to provide effective nursing care. conclusion it was determined in this study that pregnant women have high levels of anxiety about childbirth and the postpartum period. the results showed the highest level of fear concerns the behavior of the medical staff. the other fear factors that were identified involve caesarean sections, antenatal labor, the birth itself, breast feeding and infant care after birth. the results also revealed that pregnant women who were primiparas, poorly educated and had a caesarean section in a previous birth or prefer a caesarean section experienced a higher level fear. recommendations for practice the results of this study suggest that broadening prenatal training classes and conducting training to develop the nurse’s awareness will help to lower the level of fear and anxiety about childbirth 40 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 and the postpartum period, and will contribute to healthy birth activity and effective preparation for birth, in conjunction with woman’s partner. it also will help to raise the couple’s awareness about birth. conflict of interest the authors stated no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. figure.1 results of the study regarding the roy’s adaptation model contextual stimuli information on birth, previous birth type, birth preference, gestastional age, number of gestastion focal stimuli birth residual stimuli believes about birth coping mechanism physiologic mode inability in baby care, inability in lactation, unfulfill the self needs at postpartum role function mode inability in motherhood role self concept mode childbirth fear interdependence mode insufficient support of partner at childbirth and postpartum period references 1. adams ss, eberhard-gran m, eskild a. fear of childbirth and duration of labour: a study of 2206 women with intended vaginal delivery. bjog: an international journal of obstetrics & gynaecology. 2012; 119: 1238–1246. 2. alehagen s, wijma b, wijma k. fear of childbirth before, during, and after childbirth. acta obstetrica et gynecologica scandinavica.2006;85(1):56–62. 3. coşar f, demirci n. the effect of childbirth education classes based on the philosophy of lamaze on the perception and orientation to labour process. süleyman demirel üniversity journal of health science. 2012; 3(1):18–30. 4. eriksson c, jansson l, hamberg k. women’s experiences of intense fear related to childbirth investigated in a swedish qualitative study. midwifery. 2006; 22(3): 240-248. 41 childbirth and postpartum period fear in pregnant women and the affecting factors l nuray egelioğlu cetişli and others 5. fenwick j, gamble j, nathan e, bayes s, hauck y. preand postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of australian women. journal of clinical nursing. 2009; 18(5):667–677. 6. fisher c, hauck y, fenwick j. how social context impacts on women’s fears of childbirth: a western australian example. social science& medicine. 2006; 63(1): 64-75. 7. fuglenes d, aas e, botten g, oian p, kristiansen is. why do some pregnant women prefer cesarean? 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(http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/cs-statement/en/) 27. yaşar ö, şahin f, coşar e, nadirgil-köken g, cevrioğluas. birth method choices of primiparous women and the factors which have an effect on these choices. turkiye klinikleri journal of gynecology and obstetrics. 2007; 17(6): 414-420. 28. zar m, wijma k, wijma b. pre – and postpartum fear of childbirth in nulliparous and parous women. scandinavian journal of behaviour therapy. 2001; 30(30):75–84. 328 339 adherencia al tratamiento.indd 328 jennifer rojas-reyes1 magda lucía flórez-flórez2 adherencia al tratamiento y calidad de vida en personas con infarto agudo de miocardio 1 orcid.org/0000-0001-8962-5135. universidad nacional de colombia, colombia. jrojasre@unal.edu.co 2 orcid.org/0000-0002-6886-1187. universidad nacional de colombia, colombia. mlflorezf@unal.edu.co recibido: 25 de mayo de 2015 enviado a pares: 22 de junio de 2015 aceptado por pares: 15 de diciembre de 2015 aprobado: 10 de febrero de 2016 doi: 10.5294/aqui.2016.16.3.5 para citas este artículo / to refence this article / para citar este artigo rojas-reyes j, flórez-flórez ml. adherencia al tratamiento y calidad de vida en personas con infarto agudo de miocardio. aquichan. 2016; 16(3):328-339. doi: 10.5294/ aqui.2016.16.3.5 resumen objetivo: identificar la asociación entre adherencia al tratamiento y calidad de vida relacionada con la salud (cvrs) en población con infarto agudo de miocardio (iam). materiales y método: estudio cuantitativo de diseño descriptivo correlacional de corte transversal. se eligieron 180 participantes por muestreo de tipo probabilístico con selección aleatoria simple. para el análisis estadístico, se utilizó estadística no paramétrica con correlación de spearman. resultados: la edad media fue de 63 años, el promedio de tiempo transcurrido después del infarto fue de 35 meses. frente al nivel de adherencia al tratamiento, predominó la adherencia total (54 %), adherencia parcial (45%); en cuanto a la calidad de vida relacionada con la salud, el 27 % tuvo un bajo nivel; respecto a la correlación de spearman, se estableció un coeficiente de -0,315 con una significancia de p=0,00, donde el número negativo es reflejo de la naturaleza de las escalas con las que fueron medidas las variables, por lo que la correlación es positiva, significativa, pero numéricamente modesta. conclusión: la asociación entre adherencia al tratamiento y calidad de vida relacionada con la salud evidencia en una correlación estadísticamente significativa, pero catalogada como modesta, siendo estos resultados coherentes con la multidimensionalidad de los fenómenos. palabras clave adherencia al tratamiento; calidad de vida; enfermedad coronaria; enfermería cardiovascular; cumplimiento de la medicación. (fuente: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 328-339 329 adherencia al tratamiento y calidad de vida en personas con infarto agudo de miocardio l jennifer rojas-reyes y otro año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 328-339 adherence to treatment and quality of life in people with acute myocardial infarction abstract objective: to identify the relationship between adherence to treatment and health-related quality of life (hrqol) in people with acute myocardial infarction (ami). materials and method: quantitative study of cross-sectional, descriptive and correlational design. the researchers used non-probability simple random sampling to select 180 participants and spearman’s nonparametric correlation for statistical analysis. results: the average age was 63 years, and the average time elapsed after infarction was 35 months. regarding level of adherence to treatment, total adherence (54%) predominated over partial adherence (45%). as to health-related quality of life, 27% showed a low level. regarding spearman’s correlation, a coefficient of -0.315 with a significance of p = 0.00 was established, where the negative number reflects the nature of the scales with which variables were measured, and therefore the correlation was positive, numerically modest but significant. conclusion: the relationship between adherence to treatment and health-related quality of life is evident in a correlation that is statistically significant but catalogues as modest, and these results are consistent with the multidimensionality of the phenomena. keywords adherence to treatment; quality of life; coronary heart disease; cardiovascular nursing; medication compliance. (source: decs, bireme). 330 aquichan issn 1657-5997 adesão ao tratamento e qualidade de vida em pessoas com infarto agudo de miocárdio resumo objetivo: identificar a associação entre adesão ao tratamento e qualidade de vida relacionada com a saúde (qvrs) em população com infarto agudo de miocárdio (iam). materiais e método: estudo quantitativo de desenho descritivo correlacional de corte transversal. escolheram-se 180 participantes por amostra de tipo probabilística com seleção aleatória simples. para a análise estatística, utilizou-se estatística não paramétrica com correlação de spearman. resultados: a idade média foi de 63 anos, a média de tempo transcorrido depois do infarto foi de 35 meses. diante do nível de adesão ao tratamento, predominou a adesão total (54%), adesão parcial (45%); quanto à qualidade de vida relacionada com a saúde, 27% tiveram um baixo nível; a respeito da correlação de spearman, estabeleceu-se um coeficiente de -0,315 com uma significância de p=0,00, em que o número negativo é reflexo da natureza das escalas com as quais as variáveis foram medidas, por isso a correlação é positiva, significativa, mas numericamente modesta. conclusão: a associação entre adesão ao tratamento e qualidade de vida relacionada com a saúde evidencia uma correlação estatisticamente significativa, mas catalogada como modesta, sendo esses resultados coerentes com a multidimensionalidade dos fenômenos. palavras-chave adesão ao tratamento; qualidade de vida; doença coronariana; enfermagem cardiovascular; cumprimento da adesão à medicação. (fonte: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 328-339 331 adherencia al tratamiento y calidad de vida en personas con infarto agudo de miocardio l jennifer rojas-reyes y otro introducción de acuerdo con la organización mundial de la salud (oms) (1), el panorama epidemiológico de las enfermedades cardiovasculares en 2011 evidencia que el 30 % de las muertes mundiales fueron por estas patologías; por otro lado, las cifras del departamento administrativo nacional de estadística (dane) (2), del 2012, arrojan que la enfermedad isquémica del corazón ocupa el primer lugar dentro de las 5 causas de mortalidad en colombia, de manera que estas cifras muestran la urgencia con que se deben desarrollar estrategias, programas y políticas para disminuir su incidencia. la adherencia al tratamiento se contempla como el pilar fundamental para generar este cambio, ya que tiene una repercusión positiva sobre el estado de salud de los pacientes con enfermedades cardiovasculares. la adherencia al tratamiento es un comportamiento de salud que implica un compromiso mutuo entre el paciente y el profesional, donde el primero asume una responsabilidad de acuerdo con la comprensión que tiene sobre su salud y el profesional de la salud reconoce las limitaciones y las circunstancias que influyen en la conducta de salud (3). una de las recomendaciones de la oms (4) frente al estudio de la adherencia describe bien el problema de investigación, y es que los estudios deben centrarse en áreas importantes como los indicadores de calidad de vida relacionada con la salud (cvrs), ya que debido a la falta de indagación en este aspecto, el fenómeno de adherencia pasa desapercibido dentro de las políticas y los programas de salud; de manera que es pertinente describir si los niveles de adherencia al tratamiento tienen o no una influencia o asociación significativa con la cvrs. la cvrs es un subconjunto de la calidad de vida, y hace referencia al impacto de la enfermedad y el tratamiento en la vida y en la percepción de bienestar de la persona (5), y, desde ese punto de vista, la satisfacción con el tratamiento es una característica básica de la adherencia, lo que evidencia una posible relación teórica, ya que ambos conceptos son multidimensionales y están relacionados con la persona. encontrar esta asociación es importante para la sociedad y para la disciplina de enfermería porque en colombia no se ha demostrado esta asociación, y a nivel mundial estudios han mostrado resultados opuestos en poblaciones similares (6, 7); así mismo, aunque la oms y los estudios contemplan la relación, no son específicos y utilizan los conceptos de manera genérica. de igual forma, los resultados de esta investigación respaldan la creación de programas como el plan de egreso, el cual se convierte en el eje para el fomento de la adherencia y mejoramiento de la cvrs de las personas. de acuerdo con lo anterior, se planteó como objetivo de este estudio identificar la asociación entre la adherencia al tratamiento y la cvrs en población con infarto agudo de miocardio en la ciudad de bogotá. materiales y métodos se llevó a cabo un estudio de abordaje cuantitativo de diseño descriptivo correlacional de corte transversal (8), en una institución prestadora de servicios de salud de tercer nivel en la ciudad de bogotá, que autorizó su desarrollo. se escogieron 180 participantes por muestreo probabilístico con selección aleatoria simple, contemplándose un error tipo 1 de 0,01 y un error tipo 2 de 0,02 para el cálculo de esta muestra. las personas seleccionadas cumplieron con los criterios de inclusión de ser mayores de 18 años, haber presentado infarto agudo de miocardio (iam) en un tiempo mayor a 6 meses y estar asistiendo a la consulta de cardiología, cirugía cardiovascular o rehabilitación cardiaca. se establecieron como criterios de exclusión personas que no tuvieran como diagnóstico principal iam o que tuvieran un deterioro neurológico o cognitivo. para este estudio se aplicaron dos variables principales y algunas variables intervinientes como se describe a continuación: 1. adherencia al tratamiento (variable independiente): grado en que el comportamiento de una persona se corresponde con las recomendaciones que fueron acordadas con su prestador de asistencia sanitaria (9). estadísticamente es una variable de razón. 2. calidad de vida relacionada con la salud (variable dependiente): medida que permite evaluar cómo se ven afectadas las actividades de la vida diaria, el funcionamiento físico, social y emocional de una persona con una enfermedad coronaria, sus secuelas, el tratamiento o las políticas de salud (10). estadísticamente es una variable de razón. 3. variables intervinientes: fueron variables sociodemográficas como edad, sexo, estado civil, nivel de escolaridad, estrato socioeconómico, ingresos económicos; y variables clínicas como tiempo de la enfermedad y comorbilidades. estadísticamente son variables ordinales. 332 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 además de esto, para medir las variables principales se aplicaron dos instrumentos, los cuales contaron con la autorización de los autores para su uso. a continuación se mencionan: • cuestionario mbg (martín bayare grau) para evaluar la adherencia terapéutica (9): este es un cuestionario cubano, genérico para la medición de la adherencia al tratamiento, que consta de 3 categorías (cumplimiento del tratamiento, implicación personal y relación transaccional) y 12 ítems con escala tipo likert de 0 a 4 puntos. frente a sus propiedades psicométricas, cuenta con una consistencia interna de 0,89 por alpha de cronbach y una validez de constructo que explica el 68,7 % de varianza acumulada. clasifica los niveles de adherencia así: total de 38 a 48 puntos, parcial de 18 a 37 puntos y no adheridos de 0 a 17 puntos. • cuestionario de velasco-del barrio para calidad de vida en pacientes posinfarto (11): este es un cuestionario español, específico para medir cvrs en personas que han sufrido iam, que consta de 3 áreas (capacidad funcional, síntomas, percepciones), que su vez se dividen en 8 subáreas y 44 ítems con escala tipo likert de 1 a 5 puntos. frente a sus propiedades psicométricas, cuenta con una consistencia interna de 0,9 por alpha de cronbach y una validez convergente con cuestionario patrón – macnew de 0,81 para una p < 0,000, siendo significativa. clasifica los niveles de cvrs, así: alta, menor a 74 puntos; media, de 75 a 99 puntos, y baja, mayor a 100 puntos. para la recolección de la información se aplicaron los cuestionarios previo consentimiento informado a los participantes; estos datos fueron almacenados en una base de excel para su posterior análisis estadístico en spss (stadistical package for social science) versión 17. el sistema de hipótesis estadística planteado fue que se aceptaba la hipótesis nula cuando el coeficiente de correlación fuera igual a cero, pero si este coeficiente era diferente de cero, entonces se aceptaba la hipótesis alterna (h0 cuando r = 0 frente a h1 cuando r ≠ 0), que indica que existe correlación entre las variables estudiadas. para este fin, se aplicó la prueba de normalidad a las variables, las cuales mostraron un comportamiento sin ajuste a la normal, por lo que se utilizó estadística no paramétrica empleando la prueba de correlación de rho de spearman (12) para comprobar la hipótesis alterna. respecto a los aspectos éticos de este estudio, se contó con el aval del comité de ética de la facultad de enfermería de la universidad nacional de colombia, se catalogó el nivel de riesgo de acuerdo con la resolución 8430 de 1993 (13), como una “investigación sin riesgo”, y se cumplió con los principios de beneficencia y no maleficencia, autonomía, privacidad, veracidad y justicia. resultados caracterización de la población como se evidencia en la figura 1, la edad de los participantes de este estudio osciló entre los 23 a 89 años, con un mayor porcentaje en el rango de 56 a 60 años, con un 19,4 % del total; con respecto al sexo, el mayor porcentaje corresponde al sexo masculino con un 68 %. figura 1. caracterización por rangos de edad y sexo de los participantes fuente: elaboración propia. frente a la variable de estrato socioeconómico, la muestra poblacional presentó que el 51,7 % pertenecía al estrato 3; para la variable de ingresos económicos, el 37,2 % tenía una asignación salarial de un mínimo y el 35 % hasta de 2 salarios mínimos. para el nivel educativo, se observó que el 28 % de los participantes tienen secundaria completa, el 23 % tienen algún estudio técnico, y el 1,6 % era analfabeta. en cuanto al tiempo transcurrido luego del iam, en la figura 2 se presenta que el promedio fue de 35 meses, aunque en general el 76,6 % de los participantes se concentra en el periodo de tiempo de 6 meses a 3 años. 333 adherencia al tratamiento y calidad de vida en personas con infarto agudo de miocardio l jennifer rojas-reyes y otro figura 2. tiempo transcurrido luego del iam y el sexo de los participantes tener indicación de dieta baja en sal y realizar ejercicio. el 100 % afirma tener indicado el consumo diario de medicamentos. es importante reconocer que el cuestionario mbg tiene 3 categorías donde el área de menor satisfacción para los participantes es la relación transaccional, con porcentajes moderados (7, 10 y 8 % en los ítems 7, 11 y 12 respectivamente) en la respuesta “nunca”, lo que evidencia que la relación de colaboración establecida entre el paciente y el profesional de la salud para instaurar el tratamiento y elaborar una estrategia que garantice su cumplimiento y aceptación por ambos no se percibe como adecuada para garantizar su adherencia. calidad de vida relacionada con la salud en cuanto a la cvrs, los datos indicaron que 37 % del total de participantes tenía un nivel de cvrs alto, el 36 % un nivel medio y el 27 % un bajo nivel, siendo predominante la población femenina en este último y el rango de edad de 76 a 80 años. frente a la cvrs, de acuerdo con el tiempo transcurrido desde el iam, los que mostraron una alta cvrs son los que llevaban de dos a tres años luego del evento (45 %); sin embargo, hubo una mayor prevalencia de la baja cvrs en los que llevaban de 6 meses a un año y de 5 a 6 años (34 y 38 % respectivamente). de forma general, respecto a la cvrs de esta muestra poblacional de personas con iam no predominó un nivel sobre otro; sin embargo, y a pesar de la homogeneidad en estos resultados, hubo un porcentaje relevante en el nivel bajo de cvrs (27 %). correlación entre adherencia al tratamiento y cvrs el análisis estadístico reporta que el coeficiente de correlación de spearman es de -0,315 con una significancia de p = 0,00001. el valor negativo de la correlación se aduce por la naturaleza de las escalas que miden las variables de adherencia y cvrs, porque en la variable independiente, a mayor puntaje mejor adherencia, y en la variable dependiente a mayor puntaje peor es la cvrs, de manera que si una aumenta la otra disminuye, pero en la interpretación van en la misma dirección, como lo muestra el figura 3, donde un puntaje alto de adherencia se asocia con un puntaje bajo de cvrs en las escalas, pero se interpreta como a mayor adherencia, mayor cvrs. fuente: elaboración propia. respecto a las comorbilidades referidas por los participantes, se refleja una alta prevalencia de hipertensión arterial y diabetes mellitus (45,5 y 17 % respectivamente, y de los hipertensos 16 % padece también de diabetes), en contraposición al 23 % que no las padece. adherencia al tratamiento esta variable fue medida en general por sexo, edad y tiempo transcurrido del iam de los participantes; los hallazgos muestran que el 54 % del total de participantes tiene adherencia total, 45 % adherencia parcial y un 1 % que no es adherente. de los que presentan adherencia total, 58 % son mujeres y 52 % son hombres. respecto a las edades, los grupos con mejor nivel de adherencia son los de 61 a 65 años y 66 a 70 años (62 y 63 % respectivamente) y aquellos con menor nivel de adherencia estaban entre los rangos de 51 a 55 años, con un 5 % del total para esa edad. en cuanto a la adherencia de acuerdo con el tiempo transcurrido desde el iam, los que representan mayor adherencia son los que llevan menos de 2 años o más de 5 años luego del evento (58 y 63 % respectivamente), en contraposición a un 2 % que se ubica en no adherentes sobre el rango de tiempo de 6 meses a un año; sin embargo, es importante señalar que el porcentaje de participantes que se catalogan como no adherentes es mínimo. con respecto a las indicaciones no farmacológicas, el 66,7 % afirma que tiene indicada una dieta baja en sal, consumo de grasa no animal y ejercicio físico, seguido de un 28,9 % que dice solo 334 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 figura 3. explicación del valor negativo de correlación fuente: elaboración propia. con el valor de p que presenta este estudio, se puede decir que la correlación entre las variables existe y es estadísticamente significativa; sin embrago, el valor de r, es catalogado como débil o numéricamente modesto, ya que este número (a nivel estadístico) evidencia la fuerza de la asociación, y entre más cerca de 1 mayor es su correlación (tabla 1). la matriz de correlación entre las dimensiones de adherencia y cvrs indican asociaciones significativas entre varias de estas. como se observa en la tabla 1, el total de adherencia no se asocia únicamente con la dimensión de sueño y descanso de cvrs; mientras que el total de cvrs solo se correlaciona con la dimensión de implicación personal de la adherencia. cabe resaltar que la dimensión de implicación personal de la adherencia al tratamiento se correlaciona con todas las dimensiones de cvrs excepto con sueño y descanso; mientras que las dimensiones de cumplimiento del tratamiento y relación transaccional de la adherencia solo se asocian con las dimensiones de movilidad y relaciones sociales respectivamente. es importante resaltar que la correlación presenta un valor relevante, que a pesar de no ser alto es evidencia estadística a favor de la hipótesis alterna, teniendo en cuenta la multidimensionalidad de los fenómenos que presenta este estudio. discusión la caracterización de la población descrita, es congruente con estudios como los de rubiera jiménez et al. (14), arroyave y cepeda (15), y sánchez torres et al. (16), quienes afirman que las enfermedades coronarias como el iam son predominantes en edades de 51 a 60 años y en el sexo masculino con un porcentaje del 71 %, ya que la mujer presenta un factor protector hormonal que previene eventos coronarios, por esta razón, la relación de morbilidad cardiovascular es de 7:1 de hombres frente a mujeres, donde el sexo femenino presenta su episodio cardiovascular en promedio 10 años después que los hombres y se nivelan en la séptima década de la vida. en relación con los factores socioeconómicos como los ingresos y el nivel educativo se deduce que, en este caso, la población estudiada cuenta con la disponibilidad económica adecuada, lo que en parte favorece el cumplimiento del tratamiento. adicional a esto, estudios como el de bonilla (17) y salcedo barajas y gómez ochoa (18) han demostrado que a mayor grado de escolaridad, mayor ventaja para la adherencia, por lo que el bajo porcentaje de no adherentes no dependerá de estos factores. con respecto a las comorbilidades de los participantes, se refleja una alta prevalencia de hipertensión arterial y diabetes mellitus. estos resultados los respalda cabrerizo y zalba (19) y rubiera jiménez et al. (14), quienes en sus investigaciones refieren que la hipertensión arterial, diabetes mellitus, estrés, dislipidemia, antecedentes familiares, sedentarismo, tabaquismo, alcoholismo y enfermedad coronaria previa son los 9 primeros factores de riesgo cardiovascular de la población colombiana; y de estos, los de mayor prevalencia son la diabetes mellitus, la hipertensión arterial y el sedentarismo, con porcentajes equivalentes al 44, 64 y 70 % respectivamente. al hablar de los niveles de adherencia al tratamiento, los datos mostraron que las mujeres y las personas entre los 61 y 70 años son los que más adherencia presentan, de manera que el estudio de casas piedrahita et al. (20) y de carhuallanqui et al. (21) respaldan estos resultados, donde en sus investigaciones con pacientes hipertensos indican que entre el 43 y 52 % de la población tenía buena adherencia y de ellos, los más cumplidores eran los mayores de 60 años y de sexo femenino. al analizar la adherencia de acuerdo con el tiempo transcurrido desde el iam, se puede decir que el tiempo de enfermedad también es determinante en el nivel de cumplimiento. los resultados frente a esta variable, donde el menor nivel de adherencia se presenta entre los 6 meses a un año luego del evento, se logran 335 adherencia al tratamiento y calidad de vida en personas con infarto agudo de miocardio l jennifer rojas-reyes y otro tabla 1. matriz de correlación entre adherencia al tratamiento y cvrs fuente: análisis estadístico de spss versión 17 derivado de la base de datos de la investigación. sustentar con estudios como el de rossi et al. (22), quienes señalaron que en una muestra de pacientes hipertensos, la adherencia no superó el 50 % luego de 6 meses de tratamiento. al hablar de las indicaciones no farmacológicas se observa que no todos los participantes tienen claros los hábitos saludables que deben adoptar luego del iam. de acuerdo con el estudio de rossi et al. (22), solo el 32 % de los pacientes con iam luego de tres años de finalizado el programa de rehabilitación cardiaca realizaban caminatas y un 20 % realizaba ejercicios de fuerza y movilidad, demostrando que la falta motivación y percepción del beneficio reducen su práctica, en comparación con la modificación de otros factores de riesgo cardiovascular como la dieta (el 71 % cumple con alimentación saludable). para las categorías que contempla el cuestionario mbg, la relación transaccional fue la que llamó más la atención debido a sus regulares puntajes, los cuales pueden ser sustentados con los resultados del estudio de casas piedrahíta et al. (20), quienes sostienen que el culpable es el modelo tradicional de atención, donde el rol del profesional consiste en comunicar la información claramente al paciente pasivo, lo que lleva a que estos últimos se sientan frustrados ante un tratamiento difícil y que no genera los resultados esperados, mientras que el profesional, por su parte, siente que actuó correctamente, transformando el vínculo paciente-profesional en una relación en la cual un sujeto vigila y el otro pone pretextos para justificar su fracaso. es así como, cazorla roca et al. (23) utilizaron consultas únicamente por enfermería para el seguimiento de los pacientes que finalizaban la rehabilitación 336 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 cardiaca, concluyendo que estos encontraban allí el apoyo necesario para conseguir, modificar y mantener la adherencia a los tratamientos, en especial los relacionados con el estilo de vida. en el caso de baez et al. (24), su estudio concluye que el manejo de la adherencia por un equipo multidisciplinario influye de manera positiva en el mejoramiento de la calidad de vida de los pacientes que han presentado un evento cardiovascular, y que la intervención personalizada constituye una herramienta básica para conseguir tal propósito. se podría asegurar que estos autores presentan la causa y la solución a los bajos niveles de la adherencia al tratamiento con respecto a la relación transaccional o a los factores relacionados con los prestadores de asistencia sanitaria, ya que al parecer la forma en que el profesional de la salud aborda la consulta influye en el cumplimiento, y enfermería es quien mejor entiende al paciente y empatiza con él, sin dejar de lado que, al ser un fenómeno multidimensional, como enfermeros se deben trabajar todos los factores implicados. por otro lado, en cuanto a los niveles de cvrs de esta población, estudios como el de dessotte et al. (25), realizado con personas con iam, respalda los resultados encontrados, donde los bajos niveles de cvrs tienen una prevalencia importante. gjeilo et al. (26), quienes realizaron su investigación con personas con revascularización miocárdica, determinaron que los pacientes mayores de 70 años reportaban puntuaciones más bajas de cvrs, en comparación con la población general, y en el sexo femenino se observó una tendencia a marcar un nivel de cvrs más bajo que en la población femenina en general. por su parte, en la cvrs, de acuerdo con el tiempo transcurrido desde el iam, diferentes estudios realizados a los tres meses y tres años luego del evento cardiovascular sustentan los resultados de esta investigación. failde y soto (27) realizaron seguimiento de la cvrs a pacientes con síndrome coronario luego de tres meses del evento, determinando que presentaron una disminución significativa en las dimensiones relacionadas con el componente físico. gjeilo et al. (26) evaluó la cvrs en los pacientes revascularizados luego de tres años, evidenciando que la cvrs total fue buena en comparación con la población general, demostrando la adaptación de los pacientes a los cambios. lo anterior puede indicar que con el paso del tiempo, al parecer, la persona se adapta a su enfermedad y tratamiento, la convierte en parte de su vida y, por ende, se percibe mejor cvrs luego un año del diagnóstico. correlación entre adherencia al tratamiento y cvrs en personas con iam en relación con la asociación entre la adherencia al tratamiento y la cvrs en personas con iam, estadísticamente se demuestra que existe una correlación positiva y significativa pero débil o moderada de acuerdo con la forma en que se analice, por lo que, cuando una variable aumenta, la otra lo hará, pero no con la misma pendiente. como lo muestra la literatura, la cvrs es un concepto multidimensional y subjetivo que la persona tiene frente a su salud, enfermedad y tratamiento, por lo que dentro de ella está implícita la adherencia al tratamiento, la cual puede funcionar como un aspecto positivo o negativo para la calidad de vida. la adherencia, a su vez, también tiene varios factores que influyen en ella y no se determina por uno solo al igual que la cvrs; no obstante, estos constructos se asocian porque al hablar de la percepción de salud en personas con enfermedades, necesariamente se encuentra la adhesión farmacológica y no farmacológica en el proceso, no queriendo decir que tienen una relación fuerte y lineal, solo que en algún momento se cruzan e influyen una en la otra. es importante resaltar que la correlación presenta un valor relevante que, a pesar de no ser alto, se evidencia estadísticamente a favor de la hipótesis alterna, ya que, como se explica, los dos constructos son multidimensionales y multifactoriales, por lo que cualquier aspecto en ese momento de medición puede influir, demostrando que a pesar de estas características, hay una conexión entre ellas que hace que vayan en la misma dirección, pero no a la misma velocidad. diversa literatura respalda o se contrapone a los resultados de esta investigación. entre quienes presentan resultados contradictorios están saleh et al. (28), quienes realizaron un estudio con pacientes diabéticos en bangladesh para verificar la asociación entre la adherencia a algunas prácticas de autocuidado y la cvrs, encontrando que no se asociaron significativamente; sin embargo, algunas variables como el cumplimiento en el cuidado de los pies, el ejercicio y el tabaquismo mostraron una correlación con la cvrs. sus autores concluyen que una educación orientada y eficaz culturalmente será una intervención para la mejora de la adherencia y, al mismo tiempo, de la calidad de vida. para saleem et al. (6), quienes desarrollaron un estudio en pakistán, con una muestra de pacientes hipertensos, en los que 337 adherencia al tratamiento y calidad de vida en personas con infarto agudo de miocardio l jennifer rojas-reyes y otro realizaron la correlación entre adherencia y cvrs, concluyeron que era negativa y débil, explicando estos resultados como la falta de interés y participación de los pacientes en mejorar su salud, y, por otra parte, la cvrs es una percepción compleja que tiene en cuenta las características psicosociales que pueden afectar la capacidad del paciente para manejar su enfermedad, y aquí el contexto social fue determinante en estos resultados, pues la violencia desplaza aspectos como la salud en enfermedades crónicas. por otra parte, están las investigaciones que sustentan los hallazgos de este estudio, la de castañeda hernández (29), quien realizó la misma asociación pero con pacientes oncológicos que tenían menos de 6 meses en tratamiento y encontró una correlación positiva débil (r = 0,23). respecto de los factores de la adherencia al tratamiento, se evidencia que los socioeconómicos, los relacionados con la terapia y con el paciente pueden generar afectación sobre la medición de la calidad de vida. con los resultados de esta investigación es relevante que enfermería intervenga para mejorar los niveles de cvrs en esta población; para ello, varios de los autores citados proponen el trabajo interdisciplinario como un modelo de atención que responda a las necesidades de adherencia y de calidad de vida, donde predominen la comunicación, la motivación y las intervenciones conductuales (30). conclusiones los resultados obtenidos sobre la adherencia al tratamiento ponen en evidencia que las dificultades en el cumplimiento de las recomendaciones pueden estar ligadas mayormente a la relación transaccional, a ese vínculo que se genera entre el profesional de la salud y el paciente, más que en la motivación propia. adicional a esto, los resultados con respecto a la dieta y la actividad física siguen siendo puntos álgidos en cuanto a la modificación en el estilo de vida, aspectos que tal vez se relacionen con las características propias de la persona o con la falta de apoyo en sus redes sociales. por otra parte, es preocupante la presencia de un porcentaje significativo de participantes con bajo nivel de cvrs (27 %), ya que estos niveles se relacionan con baja adherencia a los tratamientos; no obstante, no solo el cumplimiento se afecta, sino también se debe verificar la conducta, la motivación y el proceso de adaptación a la enfermedad, junto con factores externos que llevan a la persona a considerar que las cosas en su vida y específicamente en su salud no mejoran sino empeoran. por último, dando cumplimiento al objetivo general de este estudio, se demostró la asociación entre la adherencia al tratamiento y la cvrs en personas con iam, evidenciado en una correlación estadísticamente significativa, pero catalogada como modesta. estos resultados con coherentes con la multidimensionalidad de los fenómenos que presenta este estudio. limitaciones aunque la población de personas con iam es amplia, el sgsss es una limitación para acceder a ellos ambulatoriamente, ya que no es oportuno al momento de autorizar las consultas y, por esta razón, no asisten a ellas. además, la dificultad en la participación de la personas fue una limitante, esto debido a que ni los usuarios ni otros profesionales de la salud entienden la importancia de la investigación para el avance de la disciplina. agradecimientos agradecimientos a la clínica vascular navarra (bogotá, colombia) y a la universidad nacional de colombia por el apoyo con la asignación de la beca asistente docente. 338 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 referencias 1. organización mundial de la salud (oms). estadísticas sanitarias mundiales 2011. informe de un grupo científico de la oms. ginebra: oms; 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15 (4): 541553. doi: 10.5294/aqui.2015.15.4.9 resumen en el 2002, la facultad de enfermería de la pontificia universidad católica del ecuador introdujo la enseñanza de la práctica basada en evidencia científica en el proyecto de reforma curricular y diversificación de carreras y una década después se analiza la eficacia de su implementación. objetivo: realizar una aproximación exploratoria sobre las creencias, las oportunidades de implementación y el apoyo que la institución y su cultura organizativa dan a la formación de enfermería basada en evidencia (ebe). materiales y métodos: estudio exploratorio cualitativo y cuantitativo. universo: 18 profesores y 77 estudiantes. instrumento: dos encuestas (escala likert) para profesores y estudiantes. resultados: las encuestas fueron analizados con la diferente estratificación de datos: docentes, estudiantes, los cinco pasos del método ebe y otros criterios. se aplicó media ponderada; anova de uno y dos factores, con un nivel de significancia α = 0,05; y la prueba de comparaciones múltiples de tukey-kramer. discusión: es contradictorio el hallazgo relacionado con una alta valoración sobre creencias referidas a la ebe, pero esta valoración no se le otorga a la implementación de cambios en la práctica o enseñanza basados en ebe, al comparar las respuestas de ambos grupos. conclusión: la percepción de docentes y estudiantes según las dimensiones de creencias e implementación de la ebe resultó muy similar en ambos grupos. la dimensión de la cultura organizacional fue diferente y resultó más severa la percepción de los docentes. palabras clave enfermería basada en evidencia (ebe), práctica basada en evidencia, educación en enfermería, cultura organizacional (fuente: decs, bireme). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 541-553 542 aquichan issn 1657-5997 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 541-553 introducing the teaching of nursing practice based on scientific evidence abstract in 2002, the school of nursing at the pontificia universidad católica in ecuador introduced the teaching of evidence-based practice as part of the curriculum reform and career diversification project. now, over a decade later, the effectiveness of its implementation is being analyzed. objective: explore the beliefs, opportunities for implementation and support provided by the institution and its organizational culture to the teaching of evidence-based nursing practice (ebn). materials and methods. this is a qualitative and quantitative exploratory study involving 18 teachers and 77 students. the instruments included two surveys (likert scale): one for professors and another for students. results: the results of the surveys were analyzed with different data stratification: professors, students, the five steps in the ebn method and other criteria. a weighted mean was applied, as was a one-way and two-way anova, with a significance level of α = 0.05, and tukey-kramer’s multiple comparison method. discussion: a comparison of the responses of both groups showed considerable importance was attributed to beliefs about ebn, but not to implementing changes in ebn practice or teaching, which is contradictory. conclusion: the perception of teachers and students on the dimensions of ebn beliefs and implementation was quite similar in both groups. the dimension of the organizational culture was different and the professors had a more severe view. keywords evidence-based nursing (ebn), evidence-based practice, nursing education, organizational culture (source: decks, birime). 543 integración de la enseñanza de la práctica de enfermería basada en la evidencia científica l carmen falconí morales y otros integração do ensino da prática de enfermagem baseado na evidência científica resumo em 2002, a faculdade de enfermagem da pontifícia universidade católica do equador introduziu o ensino da prática baseada em evidência no projeto de reforma curricular e diversificação de cursos e, uma década depois, analisa-se a eficácia de sua implantação. objetivo: realizar uma aproximação exploratória sobre as crenças, as oportunidades de implantação e o apoio que a instituição e sua cultura organizacional dão à formação de enfermagem baseada evidência (ebe). materiais e método: estudo exploratório qualitativo e quantitativo. universo: 18 professores e 77 estudantes. instrumento: dois questionários (escala likert) para professores e estudantes. resultados: os questionários foram analisados com a diferente classificação de dados: docentes, estudantes, os cinco passos do método ebe e outros critérios. aplicou-se média ponderada anova de um e dois fatores, com um nível de significância α = 0,05; e a prova de comparações múltiplas de tukey-kramer. discussão: é contraditória a constatação relacionada com uma alta valoração sobre crenças referidas à ebe, mas essa valoração não outorga à implementação de mudanças na prática ou ensino baseados na ebe, ao comparar as respostas de ambos os grupos. conclusão: a percepção de docentes e estudantes, segundo as dimensões de crenças e implantação da ebe, resultou muito similar em ambos os grupos. a dimensão da cultura organizacional foi diferente e a percepção dos docentes resultou mais forte. palavras-chave enfermagem baseada em evidência (ebe), prática baseada em evidência, educação em enfermagem, cultura organizacional (fonte: decs, bireme). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 541-553 544 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 introducción la facultad de enfermería de la pontificia universidad católica del ecuador introdujo la enseñanza de la práctica basada en evidencia científica en el proyecto de reforma curricular y diversificación de carreras del año 2002 (1), que permitió la oferta de dos nuevas carreras: nutrición humana y terapia física; después de una década, el presente estudio analiza la eficacia de la implementación de las estrategias de enseñanza e integración de la enfermería basada en la evidencia (ebe). este estudio multicéntrico se llevó a cabo en seis países de américa latina, en irlanda y en estados unidos, en los que ya se ha producido el movimiento para la integración de la ebe en el currículo. en el ecuador se realizó en el año 2013, y el informe general del estudio multipaís (estados unidos, irlanda, méxico, argentina, brasil, chile, colombia y ecuador), será motivo de otro informe y artículo de investigación. si bien esta estrategia metodológica aparece en el reino unido como un modelo denominado medicina basada en la evidencia (mbe), por iniciativa del epidemiólogo archibald cochrane, sustentado en que en la práctica médica las decisiones no estaban fundamentadas en resultados provenientes de la investigación, posteriormente se estructura como un concepto más delimitado concebido por sackett (2). este método ha sido adoptado por otras disciplinas de salud, tal es el caso de enfermería en la pontificia universidad católica del ecuador (puce), que implementó un curso de ebe en el currículo de las cohortes que ingresaron a la carrera a partir del año 2003. un valor agregado de la reforma curricular de la facultad de enfermería de la puce, fue el aportar, desde el año 2003, estrategias de formación del talento humano de salud bajo un enfoque interdisciplinario, por lo que el curso de práctica basada en evidencia constituyó un componente único de la malla curricular para las tres carreras, pero que a partir del año 2009, por mandato del reglamento codificado de régimen académico del sistema nacional de educación superior del ecuador, emitido por el consejo nacional de universidades y escuelas politécnicas (3), este mismo curso se individualizó para cada carrera: enfermería, nutrición y terapia física basada en la evidencia. en la práctica clínica diaria, los profesionales de la salud se encuentran con la necesidad de tomar decisiones permanentemente. de forma habitual, estas decisiones parten de los conocimientos adquiridos durante la etapa de formación; de indicaciones de otros profesionales o de la experiencia propia (4). en años recientes, el uso de la práctica basada en la evidencia (pbe) ha revolucionado los planteamientos del mundo sanitario. la aplicación de la pbe se basa en la utilización de la evidencia científica disponible para la toma de decisiones en el cuidado de los pacientes (5). urra, retamal, tapia y rodríguez (6), sostienen que la expresión enfermería basada en la evidencia (ebe), se ha empezado a incorporar en el ambiente de latinoamérica, tanto en publicaciones científicas y profesionales así como en los coloquios panamericanos de investigación en enfermería realizados en buenos aires en 2006 y en quito en 2008. según los organizadores de estos eventos, los cuidados de salud basados en la evidencia han cobrado gran importancia en razón de los limitados recursos económicos con los que generalmente cuentan las instituciones sanitarias. una idea relevante es que, en una práctica de ebe, una enfermera adopte para la toma de decisiones del cuidado la mejor evidencia de investigación junto con la experiencia clínica, y, además, considere las preferencias de los pacientes y los recursos disponibles en los diferentes escenarios de salud. para díaz et al. (7) la ebe puede ser considerada en sus orígenes como consecuencia del movimiento de la medicina basada en la evidencia (mbe), liderado por cochrane y sackett, donde la evolución de la mbe favoreció al concepto de ebe, al involucrar elementos adicionales referidos no solo a la disponibilidad de la principal evidencia científica obtenida a través de la investigación, sino también al uso del juicio derivado de la experiencia, las preferencias de los pacientes y los recursos disponibles (6). subirana, fargues, martínez y serret (8) sostienen que desde sus inicios y siguiendo el marco conceptual positivista de la medicina, la ebe se desarrolla en países de habla inglesa, por cuanto en el año 1997 se celebraron en inglaterra las primeras conferencias sobre ebe, y así surgen los centros de evidence based nursing. en 1998, se inició la publicación de las revistas evidence based nursing y outcome management for nursing practice, y se introdujeron los centros de evidence based nursing (9). fineout-overholt, citada por nursing research, sostiene que “… la enfermería basada en la evidencia es un enfoque de resolución de problemas para la prestación de asistencia sanitaria que in545 integración de la enseñanza de la práctica de enfermería basada en la evidencia científica l carmen falconí morales y otros tegra la mejor evidencia de los estudios y los datos de atención de pacientes con experiencia clínica y los valores del paciente” (10). así, el cuidado de la salud basado en la evidencia y que se lleva a cabo en un contexto de interés, lleva a mejores decisiones clínicas y permite obtener los mejores resultados en los pacientes. el conseguir conocimientos y habilidades en el proceso de ebp ofrece a enfermeras y otro personal de salud los instrumentos necesarios para posesionarse de sus prácticas y mejorar la atención de salud y el cuidado del paciente. los elementos clave de una mejor cultura de la práctica son los tutores ebp y las asociaciones entre el ambiente académico y clínico; asimismo, la investigación; el tiempo y los recursos; y el apoyo administrativo son fundamentales para direccionar la asociación de la evidencia a la práctica enfermera (11). urra et al. (6) insisten que en latinoamérica se está produciendo un cambio importante en lo conductual y en la cultura investigativa en la preparación y la práctica de las enfermeras, hacia la práctica de una ebe significativa. los docentes y el personal de cuidado de pacientes deben ser lectores activos de las publicaciones sobre ebe. además, existe el desafío de lograr que las instituciones de salud concedan recursos y tiempo para aplicar la ebe porque aprecian la investigación y no solamente porque buscan reducir los costos. melnyck y fineout-overholt, en su obra evidence-based practice in nursing & healthcare: a guide to best practice, presentan de forma detallada los cinco pasos del proceso de la ebe, el mismo que fundamentó la recolección y sistematización de los hallazgos del presente estudio: 1. “hacer la pregunta de importancia clínica. 2. recolección de la evidencia mejor y más relevante. 3. valorar críticamente la evidencia. 4. integración de la evidencia. 5. evaluar los resultados” (12). gálvez toro (13) opina que existen barreras institucionales y organizativas, pero que tienen mayor impacto las generadas por la cultura profesional y la tendencia al inmovilismo de las enfermeras, dadas por diferentes razones, entre las que nombra la falta de conocimiento, la desmotivación y la negativa a asumir responsabilidades. passalenti (4) considera que la insuficiente motivación para el estudio, las pocas probabilidades de avance profesional y el inexistente reconocimiento hacen más evidente la falta de desarrollo en el campo de la enfermería, en detrimento de los conocimientos y la práctica clínica. conocer las barreras que se presentan en la búsqueda y aplicación de la evidencia que apoye la práctica enfermera, favorece encontrar las estrategias para implementar la ebe. estas estrategias deberían permitir superar estas barreras “usando la persistencia y un plan que guíe el curso de las acciones” (14), porque no basta con conocer la mejor forma de dar cuidado, si no existe la capacidad de implementarla en la práctica y evaluar sus resultados (15). la elaboración de evidencia científica en cualquier profesión, incluida enfermería, demanda formación y destrezas específicas, pero sobre todo una actitud comprometida hacia el ser y quehacer de la profesión. esta actitud encierra la inquietud por desarrollar cotidianamente un mejor desempeño, así como por estimar y validar los desarrollos logrados por otros colegas y profesionales, incorporándolos a la práctica, porque “el conocimiento per se, sin aplicación en profesiones prácticas como la de enfermería, pierde el sentido” (16). adicionalmente en la ii reunión ebe de la fundación index (17), se señaló que una gran parte de enfermeras expresaron que realizan una “práctica profesional de supervivencia”, lo que involucra: prestar poca atención al paciente, realizar un trabajo técnico, desarrollar funciones delegadas, dejar de lado la función independiente de valoración y cuidados profesionales e intentar sobrevivir hasta el final del turno. si las instituciones no aprecian a las enfermeras, tal vez es la oportunidad para exponer el impacto de esta situación en la calidad del cuidado y en los resultados de salud evaluados en los pacientes. de igual forma, es el momento de revelar la capacidad de la enfermera para producir cambios significativos en los resultados de salud, en el bienestar del paciente y en los costes, cuando el cuidado enfermero se establece fundamentado en pruebas y descubrimientos originados en la investigación, y, en ese sentido, la disminución de personal enfermero y la consecuente falta de cuidados de enfermería no son costo-efectivos. en cuanto a la relevancia de incorporar la ebe en el currículo de enfermería, alcolea, oter y robledo et al. (18) consideran que 546 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 la sociedad del conocimiento que enmarca la formación universitaria en la actualidad, donde el “saber” relativo a un área concreta se amplía y moderniza continuamente, obliga a que la institución académica ponga en marcha estrategias destinadas a dotar al estudiante de la capacidad de “aprender a aprender” durante toda su vida, de manera que en su trabajo profesional futuro integre y agregue los últimos avances en ciencias de la salud. además, se requiere de la incorporación de nuevas metodologías pedagógicas que fomenten la autorresponsabilidad del discente en su propio aprendizaje, dotándolo de un papel más activo y dinámico en el mismo, en el marco de un proceso destinado a la adquisición de una serie de competencias consideradas básicas para cada campo disciplinar. en los últimos años, ha aumentado la presión para que enfermería realice investigaciones y publicaciones; sin embargo, la evidencia señala que las investigaciones publicadas siguen siendo insuficientes. esto se podría explicar, según hicks (citado por harrison et al.) (19), por una falta de confianza por parte de las enfermeras para publicar sus investigaciones. lo observado a nivel internacional se replica en el país. en el ecuador no se encontraron estudios publicados sobre la integración de la ebe en la formación y práctica de la enfermera. en nuestro país, de las 24 universidades que ofertan la carrera de enfermería, y que a su vez son miembros de la asociación de escuelas y facultades de enfermería del ecuador (asedefe) (20), que al mismo tiempo es miembro de la asociación latinoamericana de escuelas y facultades de enfermería (aladefe), únicamente la puce tiene introducido el componente formal de evidencia científica en su malla curricular, por lo que los hallazgos de este estudio aportan con elementos que permitan fortalecer o superar las limitaciones asociadas a este esfuerzo de innovación que tiene una data de una década de introducción en la facultad de enfermería de la puce. por otro lado, en la medida que las graduadas de la puce se vinculan a los servicios de salud del país, se propone que en una investigación futura, se constaten y evalúen los cambios que ellas pudieron haber introducido en la práctica con base en esta metodología y, finalmente, producto de esta exploración, las investigadoras propondrán unas estrategias prácticas las cuales la institución en la que se realizó el estudio pueden acogerlas o no, si fuere el caso. las investigadoras consideran, adicionalmente, que los supuestos o la fundamentación teórica y metodológica de la ebe contribuirán a que los académicos de la carrera de enfermería, asuman el reto de indagar y modificar aspectos curriculares basados en la evidencia científica. objetivo el presente estudio pretende realizar una aproximación exploratoria acerca de si las creencias, oportunidades de implementación y el apoyo de la institución —expresado en las variables de su cultura organizativa— han favorecido o limitado la competencia en el manejo de esta estrategia metodológica que principalmente contribuye a elevar la calidad del desempeño de la enfermera en los servicios de salud. materiales y métodos se realizó un estudio exploratorio con el uso de una metodología cualitativa y cuantitativa. como universo se consideró a todos los profesores y estudiantes de enfermería matriculados en los niveles 1, 3, 5, 7, y a los matriculados en disertación de grado de la facultad, en el año 2013. se trabajó con el universo de docentes y estudiantes de la carrera de enfermería, por lo tanto no se seleccionó muestra. para cuantificar los resultados se diseñaron dos encuestas: una para los profesores, que tuvo cuatro secciones: demografía de docentes (18 preguntas); escala de creencias de ebp (21 preguntas); escala de implementación del ebp (19 preguntas); escala de cultura organizacional (19 preguntas). la encuesta fue enviada a 29 docentes de la carrera de enfermería y se recibió respuesta de 18. la segunda encuesta se aplicó a los estudiantes, estructurada en cuatro secciones: demografía estudiantes (15 preguntas); creencias (16 preguntas); implementación (18 preguntas); y cultura organizacional (19 preguntas). este segundo instrumento se envió a 95 estudiantes y respondieron 77. en las dos encuestas se combinaron preguntas de opción múltiple, preguntas abiertas y se utilizó la escala likert con cinco opciones de respuesta. el pilotaje, la determinación de validez y confiabilidad, y de adaptación idiomática de las preguntas de ambas encuestas, se hicieron en el estudio multipaís. 547 integración de la enseñanza de la práctica de enfermería basada en la evidencia científica l carmen falconí morales y otros aspectos éticos. se obtuvo la aprobación del comité de bioética en la puce, proyecto multipaís obtuvo la aprobación del comité de bioética de la universidad del estado de arizona (ee.uu.). al responder el cuestionario en línea, mediante la aplicación survey monkey, los docentes y estudiantes proporcionaron su consentimiento para recoger, analizar y comunicar en su conjunto los hallazgos. no se identificó a ninguno de los participantes del estudio. recolección de datos. en la aplicación de las encuestas se utilizó la herramienta survey monkey, que permitió, entre otros: el acceso masivo, grabación de los datos suministrados y procesamiento estadístico de la información de manera inmediata. el contacto con los participantes se estableció a través de entrevista personal y correo electrónico, previa formalización de la invitación a vincularse en el estudio. el procesamiento de datos obtenidos por las dos encuestas se realizó mediante el software spss pasw statistics 18; se aplicaron las herramientas de la estadística descriptiva: media ponderada (21); y de la estadística inferencial: anova de uno y dos factores, con un nivel de significancia α = 0,05; y la prueba de comparaciones múltiples de tukey-kramer (21). el análisis de la información se realizó tomando como referencia los cinco pasos de la ebe de melnyck y fineout-overholt. resultados los resultados de las encuestas fueron analizados con la diferente estratificación de datos: docentes, estudiantes, los cinco pasos del método ebe. los docentes encuestados ocupaban puestos de trabajo y diferentes funciones, la mayoría a nivel de gerencia, asesoría y enfermería. la gran mayoría (57,1 %) trabajó más de ocho años en el mismo puesto. algunos encuestados combinan la docencia con el trabajo en unidades de salud, por lo que respondieron de la siguiente manera: turno de día, 16,7 % y el resto se adecua a las demandas laborales de su institución de salud. el 66,7 % de los encuestados han sido enfermeros con más de 10 años. en lo relacionado con la experiencia docente, el 50 % de los encuestados tiene más de 10 años; 22,2 % entre 5 y 10 años. el 61,1 % de profesores enseña en los primeros niveles de la carrera (de primer a tercer semestre). el 93,5 % de los encuestados fueron estudiantes regulares; el resto de estudiantes se encontraban cumpliendo requisitos conducentes a la titulación de grado. el 96,1 % indica que tomó el curso en la modalidad presencial y el resto mencionan otras modalidades. el 85,7 % de los estudiantes tiene a la carrera de enfermería como su primer grado de estudios de nivel superior. el 67,5 % de los estudiantes indicó que no saben mucho acerca de ebe y el 22,1 % expresó que aprendió ebe en la facultad. referente a su situación laboral, dentro del campo de atención de salud, 50,6 % no tiene vinculación laboral, 19,5 % trabaja como enfermera clínica, 9,1 % ejercen como auxiliar de enfermería y 20,8 % ocupan otras responsabilidades laborales. la duración en la posición laboral está distribuida de la siguiente manera: de los 36 estudiantes que indicaron el tiempo de su vinculación laboral, el 38,9 % (14 personas) tiene menos de un año; el mismo porcentaje (38,9 %) corresponde a las personas que laboraron entre 1 y 3 años. el 22,2 % (8 personas) laboró más de tres años. de las personas que contestaron la pregunta concerniente al turno en el que trabajan, el 38,2 % trabaja en los turnos de día, 3,9 % en los turnos de tarde y el mismo porcentaje en los turnos de noche; el 44,1 % tiene otro tipo de horario de trabajo. a continuación, en la tabla 1 se presentan los resultados de las dos encuestas de opinión aplicadas a los docentes y estudiantes sobre creencias, implementación y cultura organizacional, conforme a los pasos del método ebe. clave: paso 1: formulación de pregunta pico paso 2: búsqueda de evidencia científica paso 3: análisis crítico de la evidencia paso 4: introducción de cambios en el cuidado de enfermería o en la docencia paso 5: evaluación del cambio introducido con el propósito de analizar la percepción de los docentes y estudiantes referente a creencias, implementación y cultura organizacional, se aplicaron las herramientas de la estadística inferencial prueba anova y prueba de comparaciones múltiples de tukey-kramer (21). para el grupo de los docentes se concluye que existen diferencias de los promedios entre creencias e implementación, y también, entre creencias y cultura organizacional. sin embargo, los promedios de implementación y cultura organizacional pueden ser considerados iguales. en el grupo de los 548 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 tabla 1 opinión de docentes y estudiantes de la facultad de enfermería de la puce sobre creencias, implementación de acciones y cultura organizacional, según pasos del método ebe quito, diciembre de 2013 docentes estudiantes pasos método ebe no. de preguntas preguntas (%) puntaje promedio pasos método ebe no. de preguntas preguntas (%) puntaje promedio creencias docentes paso 1 1 4,8 72,22 creencias estudiantes paso 1 0 0,0 n/a paso 2 3 14,3 82,59 paso 2 2 12,5 76,58 paso 3 1 4,8 88,89 paso 3 1 6,3 81,32 paso 4 7 33,3 80,32 paso 4 7 43,8 75,26 paso 5 9 42,9 71,48 paso 5 6 37,5 66,32 total 21 76,88 total 16 72,45 implementación docentes paso 1 1 5,6 42,22 implementación estudiantes paso 1 1 5,6 36,27 paso 2 4 22,2 48,89 paso 2 4 22,2 35,47 paso 3 2 11,1 48,89 paso 3 3 16,7 38,58 paso 4 9 50,0 43,95 paso 4 8 44,4 30,67 paso 5 2 11,1 45,56 paso 5 2 11,1 35,73 total 18 45,68 total 18 33,93 cultura organizacional docentes paso 1 0 0,0 n/a cultura organizacional estudiantes paso 1 0 0,0 n/a paso 2 0 0,0 n/a paso 2 0 0,0 n/a paso 3 0 0,0 n/a paso 3 0 0,0 n/a paso 4 14 56,0 46,95 paso 4 14 56,0 65,28 paso 5 11 44,0 46,59 paso 5 11 44,0 66,70 total 25 46,80 total 25 65,91 nota. para la comprensión de la información sistematizada en los 15 cuadros y gráficos del presente estudio se utiliza la siguiente nomenclatura que recoge los pasos de la metodología de la evidencia científica en enfermería. estudiantes se llega a la conclusión de que existe la diferencia de los promedios entre todos los grupos de preguntas relacionadas con creencias, implementación y cultura organizacional. los resultados de este análisis se presentan en el gráfico 1. se realizó el análisis anova de un factor, para determinar si existe diferencia significativa entre los puntajes promedios por pasos del método pbe para los estratos de docentes y estudiantes. en ambos casos, se concluye que no existe evidencia de que los promedios de cada paso sean diferentes; es decir, los puntajes promedio de cada paso pueden considerarse iguales tanto para el estrato de los docentes como para el de los estudiantes. se realizó la prueba anova de dos factores para identificar si existe correlación entre encuestados (docente o estudiante) y grupo de dimensiones del estudio (creencias, implementación y cultura) referente al puntaje promedio obtenido en el conjunto de las preguntas. debido a que p-value = 0,92311773, es mucho mayor a nivel de significancia α = 0,05; se concluye que el puntaje 549 integración de la enseñanza de la práctica de enfermería basada en la evidencia científica l carmen falconí morales y otros de las encuestas no se ve afectado por el grupo de docentes o estudiantes, es decir, no tiene importancia quién contesta las preguntas, sea un docente o un estudiante. adicionalmente, debido a que p-value = 0,04301836 es menor a nivel de significancia α = 0,05, se concluye que el puntaje de las encuestas depende de si las preguntas se relacionan con la dimensión determinada como: creencias, implementación de acciones y cultura organizacional. discusión este estudio permitió conocer algunos aspectos importantes que se describen a continuación. 1. en el grupo de estudiantes, las medias ponderadas son diferentes entre las dimensiones de las creencias sobre la ebe, la implementación de acciones referidas al cuidado y la cultura organizacional. sin embargo, no sucedió lo mismo en el grupo de docentes, en el que las medias ponderadas referidas a las creencias y a la implementación de acciones educativas son diferentes, pero no se encontró diferencia en las medias referidas a la relación de la misma dimensión de la implementación de cambios en la educación con la cultura organizacional. el estudio realizado por morán et al. (22) en méxico, y que forma parte del proyecto multicéntrico, al cual también se vincula la presente investigación, encontró que los docentes no demuestran fortaleza en la enseñanza e implementación de ebe, y que la cultura organizacional tampoco fortalece la integración de esta metodología en el currículo de enfermería. por esta razón, las investigadoras recomiendan realizar el diagnóstico de la situación previo a la introducción de metodologías innovadoras, tal como ebe en la enseñanza de enfermería en el pregrado. posiblemente esto se debió a los hallazgos del estudio que determinó que muchos de los docentes no enseñen la asignatura de la evidencia científica en la práctica de enfermería o que la cultura organizacional no ha favorecido su evolución en el dominio del método ebe en la década transcurrida desde su introducción en la facultad de enfermería. los aspectos descritos contrastan con el estudio de ammouri et al. (23), quienes aportan nuevos elementos referidos a la ebp, tales como los diferentes obstáculos para su desarrollo entre las enfermeras en oman, y mencionan la falta de tiempo para la investigación y la insuficiencia de recursos para cambiar las prácticas. enfermeras con más años de experiencia reportaron un aumento en el uso de la ebp, actitudes más positivas hacia esta y menos barreras a la investigación. se encontraron correlaciones positivas significativas entre los años de experiencia, la práctica y las actitudes. profesionales con un título de licenciatura reportaron menos barreras a la investigación que los calificados a nivel de diploma. las enfermeras que perciben más barreras a la investigación informaron de un menor uso de ebp, actitudes menos positivas hacia esta y limitados conocimientos/habilidades hacia el método. lo anterior refuerza el convencimiento de las investigadoras gráfico 1. puntajes promedio de datos agrupados de opinión de docentes y estudiantes sobre creencias, implementación y cultura organizacional, relacionadas con los pasos del método ebe quito, diciembre de 2013 550 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 de que la metodología de ebp debe enseñarse de un modo sostenido y gradual en el programa de licenciatura de enfermería, para que los graduados lo implementen más tarde en los servicios de salud a los que se vinculan. 2. si bien los valores de los promedios ponderados sobre las creencias de la importancia de la ebe son muy similares en ambos grupos, el valor promedio descendió a su punto más bajo en la opinión de los estudiantes sobre la implementación de cambios basados en ebe. en cambio, los docentes valoraron en bajos porcentajes promediados a la misma dimensión de la implementación y en la cultura organizacional, lo que refleja limitaciones en introducir cambios basados en evidencia científica y guarda, asimismo, concordancia con las limitaciones que ellos detectan en el apoyo al desarrollo de la ebe. 3. al relacionar las tres dimensiones del estudio (creencias sobre la ebe, implementación de acciones y cultura organizacional), con los cinco pasos del método ebe; los encuestados (docentes y estudiantes) valoraron con menos de 50 a las dimensiones de implementación y cultura organizacional, lo que se traduciría en una importante debilidad cuando se intente trasladar la teoría del método ebe a la práctica. además, en la medida en que la dimensión cultura organizacional resultó evaluada de modo más negativo por los docentes, permite concluir, según su percepción, que la organización no favoreció el desarrollo de competencias para aplicar el método ebe. 4. al comparar los modelos de ebe y las metodologías que se utilizan en universidades del exterior, se recomienda que la facultad revise la secuencia del eje de investigación y metodología del curso, pues posiblemente una temprana introducción y familiarización con esta importante metodología modifique las limitaciones encontradas en cuanto a la implementación de acciones basadas en evidencia científica, sea en la docencia o en los servicios de salud y en el cuidado de enfermería principalmente, a la par que ayudaría de modo muy importante al desarrollo del pensamiento crítico en la educación universitaria, aspecto altamente propiciado por la ley orgánica de educación superior vigente en el país. en lugar de ser una asignatura de fin de la secuencia del eje de investigación, se la debe introducir desde el inicio de la formación de la enfermera y continuar a través de todo el programa académico, definiéndolo como un sólido eje de contenido y praxis, a fin de ir desarrollando secuencialmente las competencias que se logran con cada uno de los pasos del método ebe. esta recomendación es muy oportuna, por la futura reforma curricular que es mandatoria, y por la vigencia de un nuevo reglamento de régimen académico en la educación superior ecuatoriana. 5. finalmente, la educación superior del país tiene el desafío de evidenciar un mayor desarrollo de la investigación y las publicaciones científicas. este enfoque del método de la ebe contribuye de modo directo a ello, por lo que habrá que constatar nuevamente los cambios en el corto y mediano plazo. 6. la educación continuada, los cursos en línea sobre el método, la vinculación con los servicios de salud y unidades de enfermería, así como los cambios en la cultura organizacional a favor del enfoque de la ebe, pueden marcar la diferencia con los hallazgos del presente estudio. conclusiones el método ebe se introdujo al plan de estudios de la carrera de enfermería de la puce, como respuesta a una tendencia mundial contemporánea en la formación y en la práctica profesional de la enfermería. luego de haber transcurrido una década, los resultados de este estudio demuestran el desconocimiento por parte de los estudiantes y de los docentes sobre el tema de ebe. la práctica basada en la evidencia (ebp) es una competencia básica esperada para todos los profesionales de la salud por lo que se requiere integrar el método a los currículos de enfermería. en el estudio de llasus et al. (24) se examinó el proceso de traducir el conocimiento ebp a comportamientos de aplicación del método entre los estudiantes que se gradúan de bachillerato de enfermería (equivalente a licenciatura en el ecuador). los resultados mostraron que los estudiantes calificaron bajo en su examen de conocimientos sobre ebp y la participación en las conductas de ejecución de la misma. sin embargo, los estudiantes fueron moderadamente confiados en su disposición sobre este método. la educación de enfermería debe centrarse en el aumento de la autoconfianza de los estudiantes en sus competencias de ebp para apoyar la participación en las conductas de ejecución de la ebp, ya que una fuerza de trabajo de enfermería lista para ofrecer una atención con un enfoque basado en la evidencia tiene un gran potencial para mejorar los resultados del paciente. 551 integración de la enseñanza de la práctica de enfermería basada en la evidencia científica l carmen falconí morales y otros en nuestra investigación, resulta notorio y contradictorio el hallazgo de una alta valoración sobre creencias referidas a la ebe pero, al mismo tiempo, esta valoración alta no se le otorga a la implementación de cambios en la práctica o enseñanza basados en ebe, al comparar las respuestas de ambos grupos. la percepción de docentes y estudiantes acerca de las dimensiones de creencias e implementación de la ebe resultó muy similar en ambos grupos encuestados; es decir, no tuvo importancia quién respondió. solamente, la dimensión de la cultura organizacional fue diferente y la percepción de los docentes resultó más severa. proyecciones del estudio al ser la facultad de enfermería de la puce, el único programa académico de las 24 escuelas y facultades de enfermería del ecuador, que tiene la asignatura “enfermería basada en la evidencia” en el pénsum, esta primera aproximación exploratoria aporta elementos para el diseño de una nueva medición sobre la relación entre los pasos del método ebe y las dimensiones que se consideraron en este estudio u otras. se recomienda replicar este mismo estudio en las otras carreras de salud que introdujo la facultad de enfermería en el año 2002, cuando se aprobó y puso en vigencia el proyecto de rediseño curricular de la carrera de enfermería, y se inició con la oferta de las nuevas carreras de nutrición humana y terapia física. se podría indagar comparativamente lo que acontece en otras carreras de salud de la puce que también tienen incorporado el método de la práctica basada en la evidencia científica, como medicina, y otras carreras relacionadas como sicología y gestión social. se podría medir, asimismo, el impacto de la ebe en los servicios de salud y cómo aplican este método las enfermeras graduadas en la facultad de enfermería de la puce que trabajan en diferentes instituciones públicas o privadas. finalmente, con base en los hallazgos, se puede reforzar la enseñanza de ebe en la facultad y en los servicios de salud. se debería revisar y posiblemente modificar la malla curricular y el eje de investigación de la facultad. las autoras de la presente investigación coinciden con linton y prasun (25), quienes presentaron como hallazgo de su estudio que el apoyo administrativo de la práctica basada en la evidencia fue solo el 5,5 y señalan como implicación para la gestión de enfermería la necesidad de una intervención educativa para desarrollar la práctica de las enfermeras sobre la práctica basada en la evidencia. recomiendan el modelado de clases, y la colaboración de las enfermeras gestoras y educadores para promover la transición de la evidencia a la práctica clínica. adicionalmente, debería fortalecerse de modo sostenido y prioritario la reflexión crítica en los espacios académicos, lo que constituyó un motivo adicional para la realización de nuestro estudio en el ámbito de la educación superior del tercer nivel. agradecimientos las investigadoras agradecen a la doctora ellen fineout-overholt por la invitación e inclusión en el estudio multicéntrico en ocho países; a la puce/facultad de enfermería, a sus docentes y estudiantes por haber permitido y colaborado en la realización de este estudio-país. si bien este trabajo aporta hallazgos novedosos, el estudio multicéntrico contribuirá con nuevos elementos y reflexiones sobre la integración de la ebe a la formación y práctica profesional de enfermería. 552 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 referencias 1. pontificia universidad católica del ecuador/facultad de enfermería. proyecto de rediseño curricular y diversificación de carreras. quito; 2002. 2. ramírez-elizondo, n. enfermería basada en la evidencia, una ruta hacia la aplicación en la práctica profesional. enfermería en costa rica [internet]. 2011 [visitado 2013 mayo]; 32 (2). disponible en: http://www.binasss.sa.cr/revistas/ enfermeria/v32n2/art7.pdf 3. consejo nacional de universidades y escuelas politécnicas. reglamento codificado de régimen académico del sistema 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estadística para administración. cuarta edición. méxico: pearson educación; 2006. 22. morán-peña l, pérez s, zumano b, espinosa p. perspectiva de estudiantes y docentes de enfermería sobre pbe: creencias, implementación y cultura organizacional. memorias xiv coloquio panamericano de investigación en enfermería, 2014. cartagena de indias (colombia). 23. ammouri aa, raddaha aa, dsouza p, geethakrishnan r, noronha ja, obeidat aa, et al. evidence-based practice: knowledge, attitudes, practice and perceived barriers among nurses in oman. sultan qaboos univ med j. 2014;14(4):e537-45. 24. llasus l, angosta ad, clark m. graduating baccalaureate students’ evidence-based practice knowledge, readiness, and implementation. j nurs educ. 2014;53(9):s82-s89. 25. linton mj, prasun ma. evidence-based practice: collaboration between education and nursing management. j nurs manag. 201301;21(1):5-16. 137 147 efecto de una intervencion.indd 137 noelia vázquez1 pilar ramos2 m. cruz molina3 lucía artazcoz4 efecto de una intervención de promoción de la parentalidad positiva sobre el estrés parental 1 universidad de barcelona (españa). nvazquez@ub.edu 2 agencia de salud pública de barcelona (españa). pramos@aspb.cat 3 universidad de barcelona (españa). cmolina@ub.edu 4 agencia de salud pública de barcelona, ciber (españa). lartazco@aspb.cat recibido: 04 de mayo de 2015 enviado a pares: 23 de junio de 2015 aceptado por pares: 15 de noviembre de 2015 aprobado: 24 de enero de 2016 doi: 10.5294/aqui.2016.16.2.2 para citar este artículo / to reference this article / para citar este artigo vázquez n, ramos p, molina mc, artazcoz l. efecto de una intervención de promoción de la parentalidad positiva sobre el estrés parental. aquichan. 2016; 16(2): 137-147. doi: 10.5294/aqui.2016.16.2.2 año 16 vol. 16 nº 2 chía, colombia junio 2016 l 137-147 resumen fundamentos: los programas de educación parental, promotores de la parentalidad positiva, reducen el estrés parental. en españa y latinoamérica son escasas las evaluaciones que evidencian dichos efectos y en ningún caso exploran los predictores de éxito. este estudio analiza los cambios producidos por el “programa de desarrollo de habilidades parentales para familias” (php), basado en la educación parental y promovido por enfermeras comunitarias sobre el estrés parental, e identifica los factores sociodemográficos asociados a una mayor reducción de estrés. métodos: se recogió información sociodemográfica de 257 participantes, antes de la intervención y de estrés parental antes y después de esta. se empleó la versión española de parental stress scale. se aplicaron test no paramétricos y una regresión logística binaria. resultados: el análisis bivariado identificó reducción del estrés parental para todas las categorías de las variables predictoras. el análisis multivariado mostró que los hombres, las personas con menor nivel de estudios y las desempleadas presentaron mayor probabilidad de reducir el estrés. conclusiones: el php es una intervención efectiva para reducir el estrés parental en diferentes grupos poblacionales. este estudio contribuye a reforzar los incipientes hallazgos de estudios internacionales, y a dar respuesta al vacío de los países latinos, en cuanto al papel de los determinantes sociales como predictores de la reducción del estrés parental generados por los programas de educación parental. palabras clave salud mental, estrés psicológico, responsabilidad parental, educación parental (fuente: decs, bireme). 138 aquichan issn 1657-5997 año 16 vol. 16 nº 2 chía, colombia junio 2016 l 137-147 how an intervention to promote positive parenting affects parental stress abstract fundamentals: parental education programs, promoting positive parenting, reducing parental stress. assessments that demonstrate these effects are rare in spain and latin america and in no case do they explore predictors of success. this study analyzes the changes in parental stress brought about by the "parenting skills development program for families" (psp), which is based on parental education, promoted by community nurses, and identifies the socio-demographic factors associated with added stress reduction. method: sociodemographic information was collected on 257 participants prior to the intervention and on parental stress before and after the intervention. the spanish version of the parental stress scale was used. a nonparametric test and binary logistic regression were applied. results: a bivariate analysis identified a reduction in parental stress in all the categories of predictor variables. a multivariate analysis showed that men, as well as persons with lower levels of education and unemployed persons had more likelihood of reducing stress. conclusions: psp is an effective intervention to reduce parental stress in different population groups. this study helps to strengthen the incipient findings of international research and to respond to the void in latin american countries concerning the role of social determinants as predictors of parental stress reduction generated through parental education programs. keywords mental health, psychological stress, parental responsibility, parental education (source: decs, bireme). 139 efecto de una intervención de promoción de la parentalidad positiva sobre el estrés parental l noelia vázquez y otros año 16 vol. 16 nº 2 chía, colombia junio 2016 l 137-147 efeito de uma intervenção de promoção da parentalidade positiva sobre o estresse parental resumo fundamentos: os programas de educação que promovem a parentalidade positiva reduzem o estresse parental. na espanha e na américa latina, são escassas as avaliações que evidenciam esses efeitos e, em nenhum caso, exploram-se os preditores de sucesso. este estudo analisa as mudanças produzidas pelo “programa de desenvolvimento de habilidades parentais para famílias (php)”, baseado na educação parental e promovido por enfermeiras comunitárias, sobre o estresse parental; além disso, identifica os fatores sociodemográficos associados a uma maior redução de estresse. métodos: coletou-se informação sociodemográfica de 257 participantes, antes da intervenção, e de estresse parental antes e depois desta. empregou-se a versão espanhola de parental stress scale e aplicaram-se testes não paramétricos e uma regressão logística binária. resultados: a análise bivariada identificou redução do estresse parental para todas as categorias das variáveis preditoras. a análise multivariada mostrou que os homens, as pessoas com menor nível de escolaridade e as desempregadas apresentaram maior probabilidade de reduzir o estresse. conclusões: o php é uma intervenção efetiva para reduzir o estresse parental em diferentes grupos populacionais. este estudo contribui para reforçar os incipientes achados de estudos internacionais e dar resposta ao vazio dos países latino-americanos quanto ao papel dos determinantes sociais como preditores da redução do estresse parental gerados pelos programas de educação parental. palavras-chave saúde mental, estresse psicológico, responsabilidade parental, educação parental (fonte: decs, bireme). 140 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 introducción la paternidad o la maternidad representa un importante momento de la etapa adulta para una gran parte de la población, ya que conlleva el desarrollo personal a través del cuidado y el apoyo al desarrollo de otros miembros de la sociedad, y concretamente de los hijos/a (1, 2); sin embargo, diversos estudios muestran los efectos negativos que puede generar la crianza para la salud mental de padres y madres (3-5), llegando ser una de las mayores fuentes de estrés (6). pese a que el término "estrés" fue acuñado hace décadas (7), no existe una definición clara. las distintas definiciones se han clasificado en función de la conceptualización del estrés como estímulo, como percepción, como respuesta, o a partir de las consecuencias que este genera a corto o medio plazo sobre la salud de las personas (8). en el caso del estrés parental, el estresor corresponde a las necesidades específicas y del comportamiento del niño o la niña que generan unas demandas en el padre o la madre (9). las percepciones y creencias negativas del padre o la madre, como la baja percepción de autoeficacia parental, o las dificultades de relación en la pareja en el desarrollo de la parentalidad, entre otras, derivan en una falta de recursos para responder a las demandas del rol parental (10). en relación con la respuesta a los estresores, se ha documentado que la percepción de autoeficacia en el desarrollo de la parentalidad se asocia a unos recursos psicológicos que permiten afrontar mejor las demandas asociadas al rol parental (11). el desarrollo de un rol parental efectivo se relaciona con un menor riesgo de estrés, de manera que cuanto más seguros se sienten los progenitores en su capacidad para ser padres/madres, menor es el estrés y mejores los comportamientos parentales (6) y las conductas infantiles (12). además, se ha señalado que los padres y las madres que muestran niveles más altos de estrés o menores capacidades para gestionarlo, tienden a emplear conductas parentales más coercitivas (13, 14). la prevalencia de estrés parental es superior entre las personas en situación de vulnerabilidad (15). algunos de los factores que se han asociado con mayor riesgo de estrés parental son el ser mujer (16), el nivel de estudios bajo (11), la monoparentalidad (17), la pertenencia a una etnia minoritaria (18), las dificultades económicas o el desempleo (19). además, estos factores influyen sobre la percepción de incompetencia parental y la dificultad de desarrollar el rol parental (4). una de las intervenciones de salud pública que en la actualidad está en expansión en los países europeos y norteamericanos es la aplicación de programas socioeducativos para promover la parentalidad positiva (20). diversos estudios llevados a cabo en europa y norteamérica han mostrado los efectos positivos de dichos programas en la reducción del estrés parental (21, 22). sin embargo, en el ámbito latino son escasas las evaluaciones que evidencian los efectos de los programas de educación parental en la salud mental de padres y madres (23). en ningún caso se exploran los determinantes sociales que pueden actuar como predictores de éxito, pese a que otras intervenciones comunitarias para la salud familiar en el entorno latino han mostrado el importante papel de los determinantes sociales sobre los efectos en padres, madres e infancia. desde el año 2011, la agència de salut pública de barcelona, a través de su equipo de enfermeras de salud comunitaria y con la colaboración de los servicios sociales, centros educativos, centros de atención primaria de salud, equipos de atención psicopedagógica y espacios de ocio y tiempo libre, implementa el “programa de desarrollo de habilidades parentales para familias” (php) en diversos barrios de barcelona. el php consta de 9 a 11 sesiones semanales lideradas por uno o dos profesionales, de las cuales dos son sesiones compartidas entre progenitores e hijo/as. se aplica una metodología experiencial para abordar los aspectos relacionados con la autoestima parental; la comunicación asertiva y empatía; la comprensión del desarrollo del menor; la regulación del comportamiento infantil; la resolución de conflictos y el establecimiento de acuerdos; la autorregulación emocional. estas sesiones se desarrollan en lugares próximos a las familias y en ellas participan entre 10 y 12 padres/madres aproximadamente con hijo/as/ entre 2 y 17 años. los objetivos de este estudio son: 1) analizar los cambios producidos por el php sobre los niveles de estrés parental y 2) identificar los factores sociodemográficos asociados a una mayor reducción de este estrés. material y métodos diseño estudio cuasiexperimental antes-después sin grupo control (24). la población de estudio fue la totalidad de participantes en el php (257 padres y madres). los criterios de inclusión fueron tener un hijo entre 2 y 17 años de edad y ser capaz de comprender y expresarse en castellano o catalán. 141 efecto de una intervención de promoción de la parentalidad positiva sobre el estrés parental l noelia vázquez y otros recogida de datos se recogió información sobre los niveles de estrés parental antes y después de la intervención de los 257 padres y madres participantes en los 22 grupos de implementación del php realizados en barcelona y alrededores, de septiembre de 2013 a diciembre de 2014. la recogida de datos se realizó a través de un cuestionario autoadministrado inmediatamente antes de la intervención y al finalizar. todos los participantes fueron informados de la confidencialidad de los datos. se solicitó su consentimiento y se pidió expresamente la participación voluntaria en el estudio de evaluación del php. las familias no recibieron ninguna recompensa económica. todo el proceso se desarrolló de acuerdo con el código ético de la agència de salut pública de barcelona y la universitat de barcelona. los datos fueron codificados y los investigadores en ningún momento conocieron los datos personales de los participantes. variables la variable principal fue la de intervención, ya que todos los datos analizados provienen de padres/madres que participaron de las sesiones del php indicadas en apartados anteriores. el estrés parental se midió con la versión adaptada al español y reducida por oronoz, alonso-arbiol y balluerka (9), que está validada en castellano y es relativamente corta. este instrumento tiene 12 ítems distribuidos en dos subescalas con una escala de likert de 5 opciones (1 = totalmente en desacuerdo, 2 = bastante en desacuerdo, 3 = ni de acuerdo ni desacuerdo, 4 = bastante de acuerdo, 5 = totalmente de acuerdo). la subescala 1 (α de cronbach = 0,77) está conformada por 7 ítems que recogen información sobre las fuentes de estrés (35 es la máxima puntuación). la subescala 2 (α de cronbach = 0,76) contiene 5 ítems sobre las recompensas recibidas por el menor (25 es la máxima puntuación). las puntuaciones de esta subescala han sido transformadas antes de realizar la sumatoria, ya que la máxima puntuación implica la no percepción de estrés parental. el máximo nivel de estrés parental es la suma de todos los ítems de ambas subescalas (60 puntos) y el mínimo nivel es 0 puntos. las variables predictoras fueron el sexo, el país de origen (españa u otro), el nivel de estudios (superior, secundario y primario o sin estudios), la situación laboral (trabaja, desempleado, tareas del hogar u otros), el estado de convivencia (en pareja o no) y la edad (menos de 30, 30-35, 36-40 y más de 40). en el análisis multivariado la variable dependiente fue la diferencia entre estrés pos y preintervención. la variable fue dicotomizada tomando como punto de corte la mediana de la distribución. dado que de acuerdo con el test de kolgomorov-smirnov los datos no seguían una distribución normal, para el análisis bivariado se aplicó el test no paramétrico de kruskal-wallis para identificar diferencias antes y después de la intervención entre los diferentes grupos, así como el test de wilcoxon para comparar dos muestras relacionadas (pre y posintervención). para identificar las características sociodemográficas asociadas al éxito en la reducción de estrés, se ajustó un modelo de regresión logística multivariada. se analizó la existencia de tendencia para el nivel de estudios con el test de wald. el análisis estadístico se realizó con el paquete estadístico spss.20. resultados características generales de la población de estudio de los 257 participantes, el 84 % finalizó la intervención y autocumplimentó el cuestionario posintervención. el 16 % restante no finalizó la intervención por motivos laborales (cambios de horario, encontrar un trabajo, entre otros), familiares (nacimiento de un nuevo hijo/a o cuidado de un familiar) o por cambio de residencia. en la tabla 1 se muestran las características generales de la población participante. el 87,2 % de los participantes fueron mujeres y la edad media fue 36,3 (de = 7,98). el 40,6 % eran personas inmigrantes procedentes de 30 países distintos, siendo los más frecuentes ecuador y marruecos. el 24 % de los participantes no tenía estudios. el 41,2 % tenía un trabajo remunerado, el 19,6 % se dedicaba a las tareas del hogar y el 31,4 % estaba en situación de desempleo. el 76,9 % de los participantes vivía en pareja. resultados de la intervención la tabla 1 muestra los resultados descriptivos y del análisis bivariado comparando los diferentes grupos. se identificaron diferencias significativas en los niveles de estrés antes de la intervención en cuanto al sexo, el nivel de estudios, la situación laboral y la edad. por el contrario, tan solo se vieron diferencias significativas en el nivel de estrés después de la intervención en cuanto sexo y nivel de estudios. en la tabla 2 se presenta la reducción del nivel de estrés parental tras la participación en la intervención. el análisis bivariado identifica que el estrés se redujo de forma significativa para todas las categorías de las variables predictoras. 142 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 tabla 1. características generales de la población de estudio y niveles de estrés parental antes y después de la intervención. resultados del análisis bivariado (prueba de kruskal-wallis) antes_intervención después_intervención n media (de) n media (de) sexo * ** mujer 224 30,34 (11,66)* 191 23,55 (6,58) hombre 33 37,72 (17,02) 25 18,84 (6,96) edad *** menos de 30 50 40 (15,15) 42 21,04 (9,22) 30-35 64 31,87 (11,52) 55 23,79 (6,35) 36-40 81 27,86 (11,62) 65 23,02 (6,29) más de 40 60 27,95 (9,45) 52 23,73 (5,36) país de origen españa 152 29,99 (11,67) 131 22,87 (5,92) inmigrante 104 33,21 (13,92) 84 23,09 (7,94) estado de convivencia vive en pareja 196 30,65 (11,97) 165 23,40 (6,52) no vive en pareja 59 33,54 (14,36) 49 21,50 (7,5) nivel de estudios *** *** superiores 92 27,13 (7,57) 79 24,78 (4,76) secundarios 90 29,45 (11,42) 68 22,85 (6,65) sin estudios o primarios 61 41 (15,72) 57 20,32 (8,39) situación laboral *** ama de casa 50 33,56 (13,18) 45 25,51 (8,16) empleado 105 27,01 (8,47) 89 23,90 (5,02) desempleado 80 35,46 (14,89) 65 22,01 (7,72) otros 20 31,7 (14,61) 15 19,93 (6,22) *p<0,05; **p<0,01 ; ***p<0,001 fuente: elaboración propia en la tabla 3 se presentan los resultados correspondientes al análisis multivariado. los hombres (ora = 3,62; ic 95 % = 1,1711,18), las personas con menor nivel de estudios (ora = 3,16; ic 95 % = 1,19-8,56) y los participantes en situación de desempleo (ora = 2,69; ic 95 % = 1,40-6,59) presentaron mayor probabilidad de reducir el estrés. además, se observó una tendencia estadísticamente significativa para el nivel de estudios. discusión participar en el php se considera una estrategia efectiva para reducir significativamente el nivel de estrés parental de los padres y las madres participantes. desarrollar un estilo parental positivo, basado en la asertividad, en el ejercicio de la parentalidad en la edad adulta se asocia a una mejora del bienestar de hijos 143 efecto de una intervención de promoción de la parentalidad positiva sobre el estrés parental l noelia vázquez y otros diferencia después-antes_intervención n media (de) total 257 31,29 (12,68) sexo mujer 191 -7,57 (15,37)*** hombre 25 -23,6 (22,10)*** edad menos de 30 42 -21,16 (22,01)*** 30-35 55 -9,21 (16,41)*** 36-40 65 -5,9 (14,87)** más de 40 52 -4,56 (10,87)** país de origen españa 131 -7,95 (15,53)*** inmigrante 84 -11,88 (19,03)*** estado de convivencia vive en pareja 165 -8,26 (16,08)*** no vive en pareja 49 -13,73 (19,71)*** nivel de estudios superiores 79 -2,88 (9,19)** secundarios 68 -7,76 (14,26)*** sin estudios o primarios 57 -21,54 (22,05)*** situación laboral ama de casa 45 -10,96 (18,62)** empleado 89 -3,74 (9,61)*** desempleado 65 -15,03 (21,05)*** otros 15 -15,53 (18,63)** tabla 2. diferencia del nivel de estrés tras participar en la intervención. resultados del análisis bivariado (prueba de wilcoxon) *p<0,05; **p<0,01 ; ***p<0,001 fuente: elaboración propia. y padres, ya que el cuidado y el apoyo para el desarrollo de los demás se considera una máxima del propio desarrollo psicosocial de esta etapa (25). en este estudio se confirma que el fomento de las habilidades para desarrollar la parentalidad positiva mejora el bienestar parental, concretamente a través de una reducción del estrés. otras intervenciones promotoras de parentalidad positiva como la aquí presentada han mostrado resultados similares a nivel internacional (26-30). además, estos efectos positivos se han mostrado en todos los grupos poblacionales, siendo más beneficiados en diversos casos los grupos más vulnerables, y con peores niveles de estrés parental iniciales (hombres, personas sin estudios o con estudios primarios y personas en situación de desempleo). los factores asociados a un nivel elevado de estrés parental previo a la intervención son consistentes con otros estudios. se identifican las situaciones de vulnerabilidad (15), ya sea laboral (desempleados o personas dedicadas a las tareas del hogar) (19) u otras situaciones de riesgo como los niveles de estudios bajos (11, 31) como determinantes del estrés parental. en cuanto a los factores asociados a una mayor reducción del estrés parental tras la participación en el programa los hallazgos de este estudio son inéditos. el éxito en esta reducción, asociado a tener un nivel de estudios bajo, contrasta con los hallazgos significativos en sentido opuesto (32) o con la no significación de esta variable (27) descrita por otros estudios. esto puede ser debido a que muchos de los estudios se basan en intervenciones centradas únicamente en la población más vulnerable (impulsados solo desde los ser144 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 tabla 3. factores asociados al éxito del php. porcentaje de éxito, odds ratios ajustadas (ora) e intervalos de confianza del 95 % (ic 95 %) % ora ic 95 % sexo mujer 49,2 1 hombre 80 3,62* 1,17-11,18 edad menos de 30 69 30-35 52,7 1,37 0,46-4,07 36-40 53,8 1,39 0,49-3,93 más de 40 36,5 0,52 0,18-1,52 país de origen españa 54,2 1 inmigrante 51,2 0,78 0,41-1,50 estado de convivencia vive en pareja 52,3 1 no vive en pareja 53 1,35 0,65-2,84 nivel de estudios superiores 41,7 secundarios 52,94 1,57 0,71-3,43 sin estudios o primarios 70,18 3,16* 1,19-8,56 situación laboral ama de casa 46,7 empleado/a 41,57 1.50 0,60-3,73 desempleado/a 64,62 2,69* 1,40-6,59 otras 86,7 8,45* 1,50-47,76 vicios sociales), y en el caso de estudios de intervenciones de carácter universal no se describen las diferencias de acuerdo con los ejes de desigualdad en salud (33). en cuanto a los hallazgos asociados a los peores resultados en las personas dedicadas a las tareas del hogar, estos son congruentes con otros estudios similares (34), y también con estudios relacionados con la salud mental general de las mujeres empleadas y las amas de casa (35). el sexo del progenitor como predictor de éxito en la reducción de estrés parental de los programas de apoyo parental es escaso dentro de la literatura, y los resultados en ocasiones son analizados en el marco de un conglomerado de variables para conformar un perfil de riesgo (36). tan solo encontramos algunos hallazgos en programas específicos dirigidos a padres y madres de niños con trastornos mentales concretos (37). este aspecto puede ser debido a que muchos de los estudios sobre efectividad de intervenciones parentales plantean como limitación contar solo con mujeres en su muestra, o con escaso número de hombres (28). en cuanto a las limitaciones del estudio, debemos destacar la falta de datos posintervención 3, 6 o 12 meses después de la finalización del programa, ya que permitirían confirmar si los cambios producidos por la intervención son mantenidos con el paso del tiempo. la falta de información de seguimiento se da en otros estudios, sin embargo, en la actualidad se recomienda su incorporación (21, 26). este factor complementará esta investigación en el futuro para mejorar los resultados actuales. otra limitación fue el no contar con grupo control. el diseño experimental con dos grupos y con aleatorización de participantes es considerado el más robusto para confirmar que los cambios en la población son atribuibles a la intervención, y por tanto esta es eficaz (38). no se empleó grupo control por la dificultad de conformar un número suficiente de padres/madres en lista de espera, así como de aceptar que una persona no se pudiera beneficiar de la intervención en el momento en que mostraba mayor interés para el cambio. el principal beneficio de un diseño aleatorio con grupo control es situar en condiciones notablemente diferentes a ambos grupos. sin embargo, en las intervenciones de educación parental la motivación para el cambio y la imposibilidad de situarse como placebo no aseguran que ambos grupos sean tan diferentes. diversos autores plantean que es común (39) y adecuado (40, 41) no emplear diseños con aleatorización de participantes en la evaluación de intervenciones sociales y de salud pública. finalmente, debemos concluir que este estudio representa no únicamente una oportunidad para mostrar los efectos positivos que una intervención universal de educación parental puede generar sobre la salud mental de padres y madres, sino que lo hace desde una perspectiva de los determinantes sociales de la salud. existe un vacío en cuanto a la evaluación de programas de educación parental en los países latinos, y pese al aumento a nivel europeo, y especialmente en los países anglosajones, de estudios que muestran los efectos de dichos programas sobre la salud de fuente: elaboración propia. 145 efecto de una intervención de promoción de la parentalidad positiva sobre el estrés parental l noelia vázquez y otros padres y 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http://www.emeraldinsight.com/doi/abs/10.1108/17466661111190929 41. stewart-brown s. more thoughts on the rct question: a rejoinder to forrester and ritter. j child serv. emerald group publishing limited; 2012;7(2):153-8. disponible en: http://www.emeraldinsight.com/doi/abs/10.1108/17466661211238718 193 204 presenca da familia durante.indd 193 jamyle rubio soares1 andrea regina martin2 juliana furlan rabelo3 mayckel da silva barreto4 sonia silva marcon5 presença da família durante o atendimento emergencial: percepção do paciente vítima de trauma 1 universidade estadual de maringá. brasil. jamylle_rubio@hotmail.com 2 faculdade de filosofia, ciências e letras de mandaguari. brasil. andrea-deh@hotmail.com 3 faculdade de filosofia, ciências e letras de mandaguari. brasil. jufurlanrabelo@hotmail.com 4 universidade estadual de maringá e faculdade de filosofia, ciências e letras de mandaguari. brasil. mayckelbar@gmail.com 5 universidade estadual de maringá. brasil. soniasilva.marcon@gmail.com recibido: 10 de marzo de 2015 enviado a pares: 28 de abril de 2015 aceptado por pares: 02 de febrero de 2016 aprobado: 09 de febrero de 2016 doi: 10.5294/aqui.2016.16.2.7 para citar este artículo / to reference this article / para citar este artigo soares jr, martin ar, rabelo jf, barreto ms, marcon ss. presença da família durante o atendimento emergencial: percepção do paciente vítima de trauma. aquichan. 2016; 16 (2): 193-204. doi: 10.5294/aqui.2016.16.2.7 resumo objetivo: apreender como pacientes vítimas de trauma percebem a presença da família durante o atendimento emergencial. métodos: estudo descritivo, de natureza qualitativa, realizado com 29 pacientes assistidos em uma unidade de pronto atendimento no sul do brasil. os dados, coletados em outubro de 2013, por meio de entrevista aberta, foram submetidos à análise de conteúdo, modalidade temática. resultados: os pacientes vítimas de trauma percebiam como positiva a presença da família durante o atendimento emergencial e desejavam-na; acreditavam que seus familiares também gostariam de estar presentes. a motivação principal para desejar a presença da família na sala de emergência era a possibilidade de esta proporcionar confiança e conforto ao paciente e, ao mesmo tempo, tranquilizar os familiares à medida que lhes permite obter mais informações sobre a evolução do quadro clínico e acompanhar o atendimento. conclusão: profissionais de saúde atuantes em salas de emergência devem considerar a possibilidade de integrar a família no espaço de cuidado às vítimas de trauma já que os pacientes consideraram essa prática vantajosa para si próprios e seus familiares. palavras-chave ferimentos e lesões, serviços médicos de emergência, família, percepção, enfermagem familiar (fonte: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 193-204 194 aquichan issn 1657-5997 año 16 vol. 16 nº 2 chía, colombia junio 2016 l 193-204 presencia de la familia durante la atención de emergencia: percepción del paciente víctima de trauma resumen objetivo: aprehender cómo pacientes víctimas de trauma perciben la presencia de la familia durante la atención de emergencia. métodos: estudio descriptivo, de naturaleza cualitativa, realizado con 29 pacientes asistidos en una unidad de urgencias en el sur de brasil. los datos, recolectados en octubre de 2013, por medio de entrevista abierta, se sometieron a análisis de contenido, modalidad temática. resultados: los pacientes víctimas de trauma percibían como positiva la presencia de la familia durante la atención de emergencia y la deseaban; creían que a sus familiares también les gustaría estar presentes. la motivación principal para desear la presencia de la familia en urgencias era la posibilidad de que esta proporcionara confianza y comodidad al paciente y, al mismo tiempo, tranquilizar a los familiares en la medida en que pueden obtener más informaciones acerca de la evolución del estado clínico y acompañar la atención. conclusión: profesionales del área de salud que actúan en urgencias deben considerar la posibilidad de integrar la familia al espacio de cuidado a las víctimas de trauma, ya que los pacientes consideraron esta práctica beneficiosa para ellos y sus familiares. palabras clave heridas y lesiones, servicios médicos de urgencia, familia, percepción, enfermería familiar (fuente: decs, bireme). 195 presença da família durante o atendimento emergencial: percepção do paciente vítima de trauma l jamyle rubio soares e outros family presence during emergency care: perception of the patient who is a trauma victim abstract objective: understand how patients who are trauma victims perceive the presence of family members during emergency care. methods: this is a qualitative descriptive study conducted with 29 patients who were admitted to an emergency care unit in southern brazil. the data were collected in october 2013, through open interviews, and subject to thematic content analysis. results: the trauma patients in the sample perceive the presence of family members during emergency care as positive and desirable. they believe their relatives also want to be present in such situations. the main motivation for wanting family members to be in the emergency room is the possibility of the confidence and comfort their presence provides to the patient. it is also reassuring for the family, insofar as being in the emergency room allows them to be present while care is being administered and to obtain more information about the patient’s the clinical status and progress. conclusion: health care professionals working in emergency units should consider integrating the family into the venue where care is provided to trauma victims, since patients regard this practice as beneficial for themselves and their families. keywords wounds and injuries, emergency medical services, family, perception, family nursing (source: decs, bireme) año 16 vol. 16 nº 2 chía, colombia junio 2016 l 193-204 196 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 introdução o aumento no número de indivíduos atendidos por traumas decorrentes de causas externas tem se caracterizado como um grave e atual desafio para a saúde pública mundial, com forte impacto na elevação dos índices de morbimortalidade na população economicamente ativa (1-2). no brasil, em 2012, por exemplo, quase um milhão de pessoas foram hospitalizadas por causas externas no sistema único de saúde, das quais mais de 152 mil evoluíram para o óbito; aproximadamente 53% das hospitalizações e 77% das mortes ocorreram em pessoas com idade entre 15 e 59 anos (3). o trauma, independentemente do fator desencadeador, comumente acarreta em suas vítimas lesões, danos, feridas, dores e inclusive alterações pscioemocionais que podem agravar o quadro clínico do paciente (4). por ser um acontecimento indesejável e imprevisto, é vivenciado com intenso sofrimento pelos indivíduos e seus familiares (1). entretanto, mesmo em sofrimento, as famílias têm sido descritas como parte integrante e indispensável na prestação de cuidados emergenciais, pois apoiam a vivência e a adaptação de seus membros à enfermidade aguda e grave (5-6). assim, diante da atual conjuntura, a busca pela oferta de atenção qualificada aos indivíduos vítimas de trauma e a seus familiares nos serviços de pronto atendimento deve ser progressiva, e constituir prioridade entre gestores e profissionais de saúde (4). a inserção da família no ambiente hospitalar de atendimento às situações de emergência é uma prática recente e ainda não totalmente instituída no brasil (7) e na américa latina, conforme apontam estudos realizados no chile (8), colômbia (9) e méxico (10). segundo a emergency nurse association, a definição conceitual da presença da família durante o atendimento emergencial, que também pode ser denominada de presença da família à beira do leito, é descrita como a permanência de um ou mais membros familiares em local que permita contato visual e/ou físico com o paciente durante a realização dos procedimentos (11). em outros contextos assistenciais, sobretudo na europa e estados unidos, a inserção de familiares durante a realização de procedimentos invasivos e/ou atendimentos emergenciais já é uma realidade e constitui uma abordagem pautada no cuidado centrado na família (ccf) (12). segundo esse referencial, que consistiu as bases teóricas da presente investigação, a família é considerada unidade fundamental no cuidado a seus membros, e o isolamento social do paciente configura como fator de risco. por isso, deve-se assegurar que a própria família defina seus problemas e, a partir de então, participe do planejamento das ações e dos cuidados a serem desenvolvidos (12). quando os profissionais envolvem a família no plano de cuidados, independentemente do tipo de serviço de saúde no qual estejam inseridos, pautam a assistência nos princípios do ccf. ou seja, em uma abordagem que garante a prestação do cuidado para toda a unidade familiar por meio de uma parceria que beneficia ao mesmo tempo profissionais de saúde, pacientes e familiares (12). nessa perspectiva, evidencia-se a crescente e a urgente necessidade de modificar os paradigmas do trabalho da enfermagem e dos demais profissionais de saúde tanto no brasil como na américa latina, no sentido de lançar um olhar diferenciado sobre a família, principalmente diante de uma situação extraordinária, representada pela ocorrência de trauma em um de seus membros (5). para uma assistência integral e de qualidade à vítima de trauma, é necessário considerar, além do atendimento às alterações fisiopatológicas, sua unicidade, o que inclui a família, seja nuclear, seja extensa. destarte, os familiares também devem constituir objeto de cuidado nessas situações, pois o trauma e o atendimento emergencial são desafios para a família que sofre junto, especialmente quando faltam informações oportunas e em linguagem acessível (13). acredita-se que a oferta de informações poderia ocorrer em tempo hábil, caso o familiar estivesse presente durante o atendimento (5). estudos realizados em diversos países como estados unidos (13-14), china (15), austrália (16) e finlândia (17) têm sugerido que a família gostaria de estar presente durante o atendimento emergencial e que isso representa a construção de confiança entre família e profissionais de saúde, atende às necessidades informacionais da família e permite que seus membros se aproximem do paciente apoiando-o emocionalmente, o que em última instância aumenta a satisfação dos sujeitos com o serviço de saúde (13-17). assim, justifica-se o presente estudo pelo fato de a filosofia do ccf nas situações de trauma em adultos constituir importante modo de atuação dos profissionais para o atendimento aos pacientes e suas famílias, porém pouco explorada nas pesquisas (18). ainda, há que se considerar as inconclusivas evidências de que a presença da família durante o atendimento emergencial se197 presença da família durante o atendimento emergencial: percepção do paciente vítima de trauma l jamyle rubio soares e outros ria vantajoso para a vítima de trauma (13) e o diminuto conhecimento das perspectivas dos pacientes acerca da presença da família nas unidades de emergência, durante a realização de procedimentos invasivos e atendimentos emergenciais (4), configurando-se em uma lacuna a ser preenchida. diante desses apontamentos, questiona-se: qual a percepção dos pacientes vítimas de trauma assistidos em uma na sala de emergência acerca da presença da família durante o atendimento emergencial? a fim de se responder a essa questão, o presente estudo foi proposto com o objetivo de apreender como pacientes vítimas de trauma percebem a presença da família durante o atendimento emergencial. material e métodos tipo de estudo estudo descritivo, de natureza qualitativa, realizado em uma unidade pública de pronto atendimento no sul do brasil, com 29 pacientes vítimas de trauma. as investigações qualitativas propõem-se a conhecer de maneira mais profunda a construção de significados, as vivências e o modo como as pessoas enfrentam e compreendem as experiências e os fenômenos vividos (19). assim, diante da natureza subjetiva, complexa e multideterminada do objeto em estudo —percepção de pacientes vítimas de trauma sobre a presença da família durante o atendimento emergencial—, optou-se pelo desenvolvimento de uma pesquisa qualitativa, visto ser esta a mais adequada para responder à pergunta de investigação. local do estudo a unidade de saúde onde o estudo foi realizado atende em média 200 pacientes por dia. a equipe de saúde que atua em cada turno de trabalho é constituída por um enfermeiro, seis técnicos/ auxiliares em enfermagem, um técnico em radiologia e um médico clínico-geral. os pacientes admitidos em decorrência de trauma são encaminhados à sala de emergência, onde são realizados, entre outros cuidados, curativos, suturas e talas gessadas. a prestação de cuidados de baixa complexidade em salas de emergência é uma realidade comum e, em certa medida, partilhada por diversas unidades de pronto atendimento dos mais de 5037 (90,5%) municípios brasileiros que possuem menos de 50 mil habitantes (20). seleção dos sujeitos e coleta de dados para a seleção dos participantes, consideraram-se os seguintes critérios de inclusão: ser admitido na unidade de saúde com diagnóstico de trauma físico, independentemente do fator desencadeante e da gravidade da lesão, e possuir idade igual ou superior a 18 anos. foram excluídos os pacientes que necessitaram de sedação e intubação orotraqueal (seis casos); os que não conseguiam responder às questões em decorrência de trauma na região da boca (dois casos) e os que se negaram a participar do estudo (dois casos). os dados foram coletados no mês de outubro de 2013, de segunda a sexta-feira, das 7 às 13 horas, por meio de entrevistas semiestruturadas audiogravadas. elas foram realizadas em local privativo na própria unidade emergencial, logo após o atendimento médico e o término da assistência, o que incluía a implementação de cuidados pela equipe de enfermagem. as entrevistas foram norteadas pela seguinte questão: qual a sua percepção sobre a presença da família durante o atendimento de uma pessoa que sofreu um trauma? fale-me sobre isso. a busca por informações ocorreu até o momento em que os dados começaram a se tornar repetitivos e o objetivo da pesquisa respondido. análise dos dados durante o tratamento e a análise dos dados, utilizou-se a técnica de análise de conteúdo, modalidade temática, de modo a compreender as comunicações, o conteúdo manifesto ou latente, as manifestações explícitas ou ocultas, de acordo com as inferências do pesquisador. para o desenvolvimento dessa técnica, foram seguidas suas fases operacionais fundadas na constituição do corpus, leitura flutuante, exploração do material, composição das unidades de registro correspondente à unidade de significação (recorte das falas), as quais foram posteriormente classificadas com vistas a se compor as categorias (21). os conteúdos com sentidos semelhantes foram agrupados pelo critério semântico para compor as seguintes categorias temáticas: motivos favoráveis à presença da família durante o atendimento emergencial e motivos pelos quais as famílias gostariam de acompanhar o atendimento: crenças dos pacientes. rigor metodológico com o intuito de qualificar o material produzido e aprofundar os achados, os pesquisadores empregaram algumas técnicas du198 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 rante o processo de investigação. a primeira delas estava relacionada à coleta de dados. todas as entrevistas foram realizadas por pares de pesquisadores. ao permitir que distintas visões fossem contempladas durante a coleta das informações, proporcionou-se maior densidade ao material. outra técnica empregada foi a de validar as informações coletadas. isso foi realizado ao final de cada entrevista quando os investigadores liam as informações registradas a partir do relato do paciente que tinha a oportunidade, quando necessário, de aclarar e complementar determinados aspectos ou mesmo de solicitar a retirada de outros, para só então validar suas respostas. dessa forma, garantiu-se que os dados, a posteriori corpus de análise, fossem constituídos pelas percepções fidedignas dos participantes acerca do fenômeno investigado. ademais, ao longo do período investigativo, foram realizadas análise e interpretação dos dados com o exercício da reflexividade, em que as suposições prévias dos investigadores foram reconhecidas e deixadas em suspensão. o intuito desse processo foi o de facilitar a objetividade e o julgamento científico, ao permitir que fossem vistas com maior cautela e crítica as nuances particulares dos dados. essa reflexividade constitui requisito essencial às pesquisas antropológicas e qualitativas (22). por fim, o rigor metodológico e analítico foi impresso na pesquisa por meio da contínua discussão de todo o processo investigativo pela equipe de pesquisadores, o que se acredita diminuir os possíveis vieses ao se analisar e compreender o fenômeno a partir de diferentes perspectivas. aspectos éticos o estudo foi desenvolvido em consonância com as diretrizes disciplinadas pela resolução 466/12 do conselho nacional de saúde do brasil, e seu projeto foi aprovado pelo comitê de ética em pesquisa da universidade estadual de maringá (caae: 20517513.3.0000.0104). todos os participantes assinaram o termo de consentimento livre e esclarecido em duas vias e foram identificados com a letra “e” de entrevistado, seguido de dois números arábicos: um referente à ordem de realização da entrevista, e outro, à sua idade (exemplo: e01, 46 anos). resultados caracterização dos sujeitos foram entrevistados 29 pacientes vítimas de trauma que tinham idade entre 18 e 59 anos, com média de 44,5 anos. mais da metade era do sexo feminino (16). a maior parte era negra ou parda (20) e não havia completado o ensino médio (19). na maioria dos casos, o trauma foi ocasionado por acidentes domésticos e foram classificados como leves ou moderados, inclusive, todos os pacientes receberam alta após o atendimento inicial e a administração da medicação prescrita. com relação ao tipo de família a que pertenciam, 18 deles referiram residir com uma família extensa. vale ressaltar que nenhum dos participantes contou com a presença de familiar durante o atendimento na sala de emergência. motivos favoráveis à presença da família durante o atendimento emergencial os pacientes vítimas de trauma demonstraram em seus discursos que desejavam a presença da família durante o atendimento na sala de emergência e as principais motivações para isso se relacionavam ao respeito aos costumes e rotinas familiares; à intimidade e confiança que se tem na família decorrente do convívio diário, e aos possíveis benefícios percebidos a partir da sua presença nesse setor. nas falas a seguir, observa-se a valorização da presença da família durante o atendimento como forma de respeito aos costumes e às rotinas familiares, advindos da convivência diária e ao longo do tempo. a família tem a necessidade de estar junto, porque nós passamos a maior parte da nossa vida com ela. então é questão de costume, por exemplo, sempre que me machucava a minha mãe me ajudava. agora, só porque comecei a trabalhar, me machuquei no serviço e estou aqui neste hospital, que ela não pode entrar para me ajudar? (e12, 18 anos) seria bom que alguém da minha família estivesse aqui, porque é a família que está do nosso lado o todo tempo. nos conhecemos só pelo olhar! (e11, 34 anos) foi possível verificar que a convivência familiar caracterizada por profundidade da relação e longo tempo de convívio proporcionava maior intimidade entre seus membros. esta, por sua vez, levava ao estreitamento dos laços de confiança entre os sujeitos. por isso, esses dois fatores —intimidade e confiança— também emergiram com frequência nos discursos dos participantes como motivos para desejarem a presença da família durante a assistência na sala de emergência. 199 presença da família durante o atendimento emergencial: percepção do paciente vítima de trauma l jamyle rubio soares e outros acho que a família é importante durante o atendimento, porque temos mais intimidade com eles, aí não teríamos tanta aflição aqui dentro, seria melhor! (e25, 18 anos) a família é uma das coisas mais importantes na vida da gente. no momento que nos machucamos, precisaríamos de alguém para estar próximo à gente, e seria muito bom que fosse alguém da família, porque temos intimidade e assim confiamos neles. (e14, 26 anos) destaca-se que, para os participantes, o atendimento em uma unidade de emergência caracterizava-se como aflitivo e apreensivo, porque pouco se conhecia a respeito do ambiente e das rotinas de atendimento ali realizadas. nessa perspectiva, a presença da família impulsionada pela confiança que o paciente depositava nela poderia facilitar a vivência desta situação altamente estressora que é o atendimento emergencial, já que a família funcionaria como suporte para os momentos de medo, incertezas, dor e sofrimento. [...] nesse momento de medo do que pode acontecer com a gente, apesar de meu machucado não ter sido tão grande, a família tem um papel mais do que importante, porque independente do tamanho da ferida e da dor, nós precisamos muito do amparo de quem a gente confia. (e22, 28 anos) além do suporte que a família pode representar para pacientes vítimas de trauma nas unidades de emergência, percebeu-se que sua presença pode ser benéfica no sentido de proporcionar sensação de calma ao membro familiar que, naquele momento, se encontrava mais fragilizado. isso, por sua vez, impulsionava o desejo por ter a presença familiar por mais tempo no serviço de saúde. permitiram que meu esposo ficasse comigo só na chegada, até fazer a ficha, assim que fez, pediram para ele sair [...] enquanto ele esteve aqui foi bom. ele não fez nada, mas sua presença me acalmou, me senti protegida. (e02, 38 anos) a família é super importante nesse momento de estresse, a minha mãe veio depois que eu já tinha sido atendido, tomado a medicação e feito o raio-x, preferia que ela tivesse estado aqui comigo antes, mas mesmo assim me acalmou muito ela ter vindo, apesar do pior já ter passado. (e06, 23 anos) a presença de algum familiar antes ou após o atendimento desencadeou maior tranquilidade aos pacientes, muito embora eles não tenham realizado cuidados diretos ou participado das decisões terapêuticas. desse modo, faz-se necessário refletir que, caso fosse permitida a presença da família durante a prestação do atendimento, os benefícios percebidos seriam potencializados e estendidos para todo o período assistencial. em síntese, nessa categoria, verificou-se que, para os pacientes vítimas de trauma atendidos em uma unidade emergencial, o convívio familiar cotidiano acarretava maior intimidade com a família e, por conseguinte, maior confiança em seus membros. assim, desejavam a presença familiar, sobretudo por perceberem que o enfrentamento da experiência estressora do atendimento emergencial após um trauma físico poderia ser facilitado caso o familiar estivesse próximo por proporcionar a sensação de calma e proteção. motivos pelos quais as famílias gostariam de acompanhar o atendimento: crenças dos pacientes os pacientes acreditavam que seus familiares gostariam de estar presentes na sala de emergência durante a prestação da assistência. de acordo com suas percepções, entre os motivos que despertavam tal necessidade na família estavam: necessidade de receber informações sobre a evolução clínica do paciente, poder acalmar-se a partir do acompanhamento do atendimento e apoiar e tranquilizar o membro familiar vítima de trauma. mesmo não podendo, creio que minha mãe gostaria de estar aqui comigo nesse momento para acompanhar mais de perto o que estão fazendo comigo. ela é muito preocupada! (e04, 23 anos) tenho certeza que se fosse pelo meu marido ele teria estado ali na sala de emergência. deixaram ele entrar, mas só para fazer a ficha. quando as enfermeiras e o médico chegaram, ele já não estava mais. lá de fora ninguém pode acompanhar nada, não se sabe se está vivo ou morto aqui dentro. (e02, 38 anos) observou-se, segundo o relato dos pacientes, que os familiares tinham uma possibilidade muito limitada de estar com seus entes queridos nos serviços emergenciais de saúde. e, por isso, almejavam permanecer por mais tempo, principalmente porque assim conseguiriam acompanhar melhor a evolução do atendimento e do quadro clínico do paciente, o que, de certa forma, poderia acalmá-los. um paciente, ao relativizar sobre o tema, apontou que algumas famílias poderiam apresentar dificuldades para estar com 200 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 seus entes queridos nos serviços de emergência. entretanto, particularmente, os seus familiares apresentariam forte desejo por acompanhá-lo durante todo o período de atendimento para, inclusive, prestar cuidados. ainda, para exemplificar a unidade e coesão de sua família, fez uma analogia da vivência de momentos de alegria (festas) e de tristeza (enfermidade) como experienciados com a mesma unidade. acho que dependendo da família pode ter medo de entrar, sentir nojo, agonia, sei lá. mas, a minha preferiria estar junto, porque conheço a minha gente, e somos muito unidos, independente para o que, se festa ou momentos de doença. e a gente é daquele tipo que gosta de estar em cima, cuidando. por isso, tenho certeza que qualquer um iria querer estar aqui dentro comigo. (e14, 26 anos) outro aspecto relevante foi o reconhecimento, por parte dos pacientes, de que o cuidado prestado pela família é distinto daquele ofertado pelos profissionais de saúde; foi relatado, ainda, que os familiares teriam a mesma percepção. nesse sentido, há o entendimento de que os profissionais atuantes nas unidades de emergência estão habilitados e capacitados para oferecer um atendimento de qualidade. contudo, as diferenças existentes entre o cuidado técnico executado pelos profissionais e o cuidado emocional ofertado pelos familiares impulsionariam o membro da família a querer estar presente durante o atendimento emergencial. o papel dos profissionais é diferente do da família, o pessoal daqui do hospital vai fazer bem feita a lavagem da ferida, ver a pressão [arterial] e dar o remédio para diminuir a dor, mas a família iria estar junto para outras coisas, para poder ficar junto, segurando na mão, conversando com a gente, às vezes distraindo um pouco nossa cabeça. então, é diferente a maneira que os profissionais vão tratar a gente e o jeito que a nossa família vai tratar e por isso acredito que minha esposa queria estar aqui, porque ela sabe que me acalmaria. (e01, 46 anos) para além de acalmar a si próprio, os pacientes acreditavam que, ao estar presente durante o atendimento emergencial, o familiar também se sentiria mais calmo já que certamente os profissionais ofertariam informações oportunas e em tempo hábil sobre o quadro clínico e ainda poderiam verificar continuamente o estado de saúde de seu ente querido. acho que se meu filho estivesse aqui comigo ele teria ficado mais tranquilo. porque na hora que ele chegou estava muito nervoso e depois que viu que estava tudo bem e teve informações parece que ele deu uma acalmada. (e03, 56 anos) por fim, destaca-se a percepção dos pacientes, de que a permanência do familiar no espaço de cuidado emergencial é um direito das famílias e uma prática vantajosa para aqueles que constituem, ou ao menos deveriam constituir, o foco central no processo assistencial, que são os pacientes e seus familiares. assim, se você for pensar bem, é direito da família estar com a gente, porque é parte da nossa vida. e com certeza se você for ali fora, à portaria, perguntar para qualquer um dos meus filhos e para a minha esposa se eles queriam ter ficado comigo, eles vão dizer que sim. se no hospital pudesse ficar junto ali na salinha que chega e é atendido [sala de emergência] muita gente ia se sentir melhor, tanto nós pacientes quanto o próprio pessoal da família. (e18, 58 anos) destarte, os participantes percebiam que a presença do familiar na sala de emergência para acompanhar o atendimento constituía-se em um direito da família. acreditavam que seus familiares gostariam de estar presentes porque, de certa forma, poderiam prestar cuidados, sobretudo emocionais, o que, além de acalmar a díade família-paciente, facilitaria a compreensão familiar de todo o processo assistencial. isso, por sua vez, se refletiria em maior satisfação por parte da família e dos pacientes com a atuação dos profissionais de saúde e com a qualidade da assistência prestada nesses serviços. discussão conforme evidenciado pelos achados desta investigação, os pacientes vítimas de trauma anseiam a presença de suas famílias durante o atendimento emergencial e acreditam que seus familiares também comungam desse desejo. logo, os profissionais de saúde atuantes nas salas de emergência, para uma intervenção mais eficiente, eficaz e humanizada, devem considerar e valorizar a presença da família. nesse sentido, é premente que os serviços de saúde adotem como filosofia institucional o ccf, o qual se destina a ser oferecido nos diferentes ciclos da vida e em contextos diversos. nessa lógica, é mister permitir que a família se faça presente desde o nascimento até após a morte (18). inserir a família nos cenários de cuidados críticos e emergenciais não é tarefa fácil. há que se considerar os sentimentos iniciais de medo e pesar desencadeados, muitas vezes, nos fami201 presença da família durante o atendimento emergencial: percepção do paciente vítima de trauma l jamyle rubio soares e outros liares ao acompanharem o paciente vítima de trauma (5, 23). no entanto, após refletirem sobre seu papel, os familiares vislumbram a possibilidade de atender às necessidades de seu ente querido no concernente ao apoio emocional, pois acreditam que o momento do trauma caracteriza-se como extremamente desgastante para a vítima (5). nesse ínterim, os familiares referem criar forças internas para superar seus medos, com vistas a ajudar e acalmar o membro familiar mais fragilizado naquele momento (23). dessa forma, fica evidente a importância de o enfermeiro diagnosticar os receios iniciais da família e intervir de maneira precoce, o que pode facilitar o processo de entendimento do trauma e do quadro clínico do paciente. quanto melhor acolhida e preparada a família, mais facilmente ela vivenciará sua situação de acompanhante na sala de emergência. isso fomenta e intensifica a possibilidade de desempenhar seu papel de suporte emocional e proporcionar conforto visto que o apoio familiar representa elemento basilar para que se consiga superar os obstáculos associados ao trauma e suas consequências (13). pode-se perceber que as questões culturais e os costumes familiares, que são construídos a partir da vida em família e repassados de geração em geração, querem ser respeitados e mantidos pelas vítimas de trauma, mesmo fora de seu espaço de convívio cotidiano. estudo sobre a importância da família no tratamento de uma doença crônica evidenciou que ela representa proteção e que, nas situações estressoras, seus membros tendem a se unir mais e tornam, assim, os laços afetivos mais fortes (24). desse modo, quando colocada adiante da conjuntura de perigo, seja pela doença crônica, seja por uma situação inesperada, a família busca manter os laços de proximidade, com vistas a proporcionar bem-estar aos seus membros. nesse contexto, é preciso valorizar, além da união e do apoio familiar, seus conhecimentos, culturas, crenças e costumes. portanto, as relações familiares não podem passar despercebidas aos olhos dos profissionais de saúde atuantes nos serviços emergenciais, pois, apesar de os familiares necessitarem de atenção e cuidados na mesma proporção que a pessoa vitimada pelo trauma, ainda assim, conseguem apoiar o paciente e ajudar em sua recuperação (17). dessa forma, fica evidente que, caso atendida essa demanda pela presença da família, se poderia diminuir nos pacientes e seus familiares as angústias e aflições que ocorrem pelo evento extraordinário do trauma e de suas consequências e desdobramentos assistenciais. mesmo nos casos de lesões menores, há a necessidade da presença da família durante o atendimento, pois os pacientes percebem que o auxílio e o amparo psicoemocional, indispensáveis nesse momento, seriam alcançados com a proximidade de pessoas de sua confiança. a família, na maioria das vezes, atua afastando ou suprimindo estímulos dolorosos por meio do diálogo, do toque, manifestação de solicitudes e ainda satisfação de necessidades físicas e emocionais, o que pode proporcionar alívio e bem-estar. para a família, há a percepção de se estar contribuindo para a mais rápida e menos dolorosa recuperação da saúde do seu ente ao lhe dar atenção e carinho, o que a equipe de enfermagem não teria condições de fazer devido ao fato de ser diferente a relação entre paciente-família e paciente-equipe de enfermagem (23) e porque, em unidades de pronto atendimento, ocorre limitação nas atividades que são desenvolvidas junto aos pacientes pelo elevado número de indivíduos sob seus cuidados (25). outro aspecto que merece destaque é a percepção dos pacientes de que a atuação dos profissionais é indispensável dentro do serviço de saúde. mas, ao mesmo tempo, reconhecem que existe espaço para a atuação da família. portanto, os profissionais de saúde precisam compreender que cada tipo de cuidado —o profissional e o familiar— podem se complementar mutuamente e colaborar, desse modo, para um melhor atendimento às vítimas de trauma. estudo realizado nos estados unidos com 28 familiares que optaram por acompanhar o atendimento a seus entes queridos que haviam sofrido um acidente automobilístico ou um ferimento por arma de fogo evidenciou que eles compreendiam de maneira positiva a atuação dos profissionais de saúde e os procedimentos realizados. entretanto, reconheciam que, ao estarem dentro da sala de emergência, tiveram um papel importante, especialmente no que se refere à proteção e ao apoio ao paciente, o que lhe proporcionou conforto físico e emocional, além de ser útil ao fornecer informações aos profissionais, o que garantiu a realização de uma assistência mais segura e qualificada pela equipe de saúde (14). deveras o cuidado prestado pela família é mais personalíssimo e rico em manifestações de solicitude. dessa forma, o paciente deseja esse tipo de cuidado, e a família, por sua vez, ciente da qualidade e importância disso para a recuperação do paciente, 202 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 anseia por colaborar com a assistência realizando esse cuidado diferenciado. estudo realizado na china junto a 18 familiares de pacientes atendidos em uma unidade de emergência traumatológica constatou que nenhum dos membros da família pode acompanhar as intervenções de manutenção da vida. contudo, a maioria indicou forte preferência por estar presente se fosse facultada essa opção, o que decorria da ligação emocional entre paciente e família (15). ademais, investigações realizadas nos estados unidos (13) e finlândia (17) apontaram que é necessário reconhecer o paciente e os membros da família como participantes ativos nos cuidados médicos de emergência, a fim de que se respeite sua autonomia e aumente a satisfação com os serviços de saúde e seus profissionais. assim, devem-se criar políticas institucionais para cuidados centrados no paciente e na família, bem como incentivar o desenvolvimento de programas que reconheçam, valorizem e apoiem a autonomia e o bem-estar psicológico e emocional dos pacientes e seus familiares dentro dos departamentos de emergência (13, 18). estudo de revisão da literatura realizado na dinamarca demonstrou que os profissionais de saúde têm percebido cada vez mais essa presença como benéfica, o que provavelmente está correlacionado com o aumento de experiências práticas em que a assistência é prestada com o testemunho das famílias (26). então, é premente que profissionais e gestores dos serviços de pronto atendimento e pronto-socorro considerem a possibilidade de incluir a família durante o atendimento emergencial, ainda que isso seja iniciado paulatinamente e em casos mais leves. ressalta-se que familiares que estiveram presentes durante o atendimento a pacientes vítimas de acidentes por causas externas tendem a recomendar essa experiência para outros familiares (14). por isso, acredita-se que a inserção da família no espaço de cuidado ao paciente emergencial precisa ser posta e discutida no meio acadêmico e assistencial. contudo, há que se considerar que a inserção da família nas salas de emergência modifica, entre outros aspectos, a estrutura e a organização do processo de trabalho, o que requer dos profissionais maior compreensão acerca da dinâmica das relações interpessoais —entre a própria equipe e com as famílias—. outro aspecto que merece atenção é o fato de a família necessitar ser acompanhada e apoiada por um profissional que desempenharia o papel de decodificador dos procedimentos realizados, o que implica redimensionamento de pessoal nesses setores. por fim, sabe-se que atualmente essas unidades de atendimento não apresentam infraestrutura adequada e recursos humanos preparados para conviver com a presença da família em situações estressoras. entretanto, mesmo com essas limitações estruturais, organizacionais e de processo de trabalho, é necessário que se inicie um processo de preparação para receber as famílias já que este é um espaço que está sendo reivindicado por elas e pelos pacientes. considerações finais os resultados do estudo permitiram compreender melhor as percepções de pacientes vítimas de trauma acerca da presença da família nas unidades emergenciais. os pacientes revelaram que percebiam como positiva a presença da família durante o atendimento emergencial e desejavam-na; além disso, acreditavam que seus familiares também gostariam de estar presentes. o principal motivo para desejar a presença da família na sala de emergência era a calma proporcionada à díade familiar-paciente uma vez que traria confiança e conforto ao paciente e permitiria ao familiar acompanhar a evolução do quadro clínico e ter maiores informações sobre o atendimento. em última instância, isso favoreceria a maior satisfação com o serviço de saúde e a assistência prestada. assim, acredita-se que, para uma atenção mais humanizada aos pacientes vítimas de trauma, os profissionais de saúde e, mais especificamente, os enfermeiros atuantes em salas de emergência devem considerar a possibilidade de inserir a família no espaço de cuidado ao paciente vítima de trauma. contudo, intervenções de enfermagem adequadas só poderão existir se sustentadas por políticas e diretrizes institucionais voltadas para o atendimento das necessidades individuais, especialmente durante momentos críticos e de elevado estresse para a pessoa e sua família. diante da necessidade que os pacientes apresentaram de contar com a presença de algum familiar durante o recebimento de cuidados emergenciais, faz-se premente discutir e implementar o ensino desse tema na formação de enfermeiros e demais profissionais de saúde, bem como manter as discussões por meio de atividades de educação continuada, nos serviços de saúde. somente assim poderá ser paulatinamente modificado o atual panorama de exclusão familiar dos serviços de emergência. por fim, é importante destacar que este estudo possui limitações. a primeira delas se relaciona ao fato de as entrevistas 203 presença da família durante o atendimento emergencial: percepção do paciente vítima de trauma l jamyle rubio soares e outros terem sido realizadas apenas com pacientes vítimas de trauma, o que circunscreve os achados à percepção de apenas um dos atores envolvidos no processo de prestação e recebimento da assistência emergencial. a segunda decorre de que todos os pacientes tenham apresentado traumas classificados como leves. isso possivelmente influenciou suas percepções sobre a necessidade e a exequibilidade da presença da família na sala de emergência. diante dessas limitações, novos estudos necessitam ser desenvolvidos. nesse sentido, investigações futuras devem: 1) buscar englobar familiares de pacientes vítimas de trauma e profissionais de saúde atuantes em unidades de emergência, o que ampliará o entendimento do fenômeno, e 2) ser desenvolvidas com pessoas que tenham passado pela experiência de um trauma mais grave. isso permitirá a compreensão de como pacientes mais gravemente enfermos percebem a possibilidade de a família estar presente durante o atendimento, o que validará e expandirá os resultados da presente investigação. referências 1. kirkman ma, jenks t, bouamra o, edwards a, yates d, wilson mh. increased mortality associated with cerebral contusions following trauma in the elderly: bad patients or bad management? j neurotrauma. 2013; 30(16):1385-90. 2. rezende-neta ds, alves aks, leão gm, araújo aa. perfil das ocorrências de politrauma em condutores motociclísticos atendidos pelo samu de teresina-pi. rev bras enferm. 2012; 65(6):936-41. 3. brasil, ministério da saúde. banco de dados do sistema único de saúde-datasus; 2014 [citado 11 out. 2014]. disponível em: http://www.datasus.gov.br 4. rehn m, perel p, blackhall k, lossius hm. prognostic models for the early care of trauma patients: a systematic review. scand j trauma resusc emerg med. 2011; 19(17):1-8. 5. almeida as, aragão nro, moura e, lima gc, hora ec, silva lasm. sentimentos dos familiares em relação ao paciente internado na unidade de terapia intensiva. rev bras enferm. 2009; 62(6):844-9. 6. garcia rp, budó mld, simon bs, wünsch s, oliveira sg, barbosa ms. vivências da família após infarto agudo do miocárdio. rev gaúcha enferm. 2013; 34(3):171-8. 7. mekitarian ffp, angelo m. family’s presence in the pediatric emergency room: opinion of health’s professionals. rev paul de pediatr. 2015; 33(4):460-6. 8. dall’orso ms, concha pj. presencia familiar durante la reanimación cardiopulmonar: la mirada de enfermeros y familiares. cienc enferm. 2012; 18(3):83-99. 9. saldaña dma, arango ój, laverde gg, zerrate nh. percepciones relacionadas con la presencia de la familia en escenarios avanzados como la reanimación cerebro-cardio-pulmonar. inv enferm imagen desarro. 2012; 14(1):77-92. 10. garcia jega, regalado jfg; rocha als. reanimación cardiopulmonar presenciada en el contexto hospitalario mexicano: un estudio de caso en pacientes y familiares. desacatos. 2010; (34):149-64. 11. emergency nurses association. presenting the option for family presence. 3. ed. dallas (texas): eckle north; 2007. 12. coyne i, o’neill c, murphy m, costello t, o’shea r. what does family-centred care mean to nurses and how do they think it could be enhanced in practice. j adv nurs. 2011; 67(12):2561-73. 13. cypress bs. using the synergy model of patient care in understanding the lived emergency department experiences of patients, family members and their nurses during critical illness: a phenomenological study. dimens crit care nurs. 2013; 32(6):310-21. 14. leske js, mcandrew ns, brasel jk. experiences of families when present during re-suscitation in the emergency department after trauma. j trauma nurs. 2013; 20(2):77-85. 15. hung msy, pang smc. family presence preference when patients are receiving resuscitation in an accident and emergency department. j adv nurs. 2010; 67(1):56-67. 204 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 16. chapman r, watkins r, bushby a, combs s. assessing health professionals’ perceptions of family presence during resuscitation: a replication study. int emerg nurs. 2013; 21(1):17-25. 17. nikki l, lepsto s, paavilainen e. experiences of family members of elderly patients in the emergency department: a qualitative study. int emerg nurs. 2012; 20(4):193-200. 18. ganz fd, yoffe f. intensive care nurses’ perspectives of family-centered care and their attitudes toward family presence during resuscitation. j cardiovasc nurs 2012; 27(3):220-7. 19. streubert hj, carpenter dr. qualitative research in nursing: advancing the humanistic imperative. 5. ed. philadelphia, pa: lippincott williams & wilkins; 2011. 20. instituto brasileiro de geografia e estatística — ibge. pesquisa de informações básicas municipais: perfil dos municípios brasileiros. 2012. 21. bardin, l. análise de conteúdo. 20. ed. lisboa: ed 70; 2011. 22. minayo mcs, guerriero icz. reflexividade como éthos da pesquisa qualitativa. cienc saude colet 2014; 19(4):1103-12. 23. collet n. sujeitos em interação no cuidado à criança hospitalizada: desafios para a enfermagem pediátrica. rev bras enferm. 2012; 65(1):7-8. 24. szareski c, beuter m, brondani cm. situações de conforto e desconforto vivenciadas pelo acompanhante na hospitalização do familiar com doença crônica. cienc cuid saude. 2009; 8(3):378-84. 25. jorge vc, barreto ms, ferrer alm, santos eaq, rickli hc, marcon ss. equipe de enfermagem e detecção de indicadores de agravamento em pacientes de pronto-socorro. esc anna nery. 2012; 16(4):767-74. 26. bredahl p, lomholt m, larsen cf, gatke mr. parental presence during treatment of injured and acutely ill children. ugeskr laerger. 2011; 173(39):2403-7. 70 83 estilo de liderazgo en profesionales.indd 70 aquichan issn 1657-5997 claudio cárcamo-fuentes1 edith rivas-riveros2 estilo de liderazgo en profesionales de enfermería según su función en los sectores público o privado en temuco, chile, 20153 1 orcid.org/0000-0002-2479-6387. universidad de la frontera, chile. claudio.carcamo@ufrontera.cl 2 orcid.org/0000-0002-9832-4534. universidad de la frontera, chile. edith.rivas@ufrontera.cl 3 publicación derivada del programa de magíster en enfermería mención gestión del cuidado, universidad de la frontera, chile. no tuvo apoyo financiero. recibido: 2 de agosto de 2015 enviado a pares: 25 de septiembre de 2015 aceptado por pares: 1 de julio de 2016 aprobado: 26 de julio de 2016 doi: 10.5294/aqui.2017.17.1.7 para citar este artículo / to reference this article / para citar este artigo cárcamo-fuentes c. y rivas-riveros e. estilo de liderazgo en profesionales de enfermería según su función en los sectores público o privado en temuco, chile, 2015. aquichan. 2017;17(1):70-83. doi: 10.5294/aqui.2017.17.1.7 resumen introducción: el liderazgo de enfermería se considera una competencia fundamental, por su clara repercusión en la calidad de los cuidados. objetivo: conocer el estilo de liderazgo que ejercen enfermeras(os) asistenciales, docentes y supervisoras(es). material y método: investigación cuantitativa, descriptiva y transversal. la muestra está constituida por 165 profesionales de enfermería del área adulto-pediátrica, en una ciudad del sur de chile. la recolección de datos se realizó mediante el cuestionario multifactorial de liderazgo, en su forma corta, adaptado a la población chilena por vega y zabala. resultados: se evidencia que los profesionales en enfermería asistenciales desarrollan en menor grado los estilos transformacional y transaccional. por el contrario, aquellos de las áreas docente y de supervisión utilizan preferentemente un liderazgo transaccional, donde se destaca la recompensa contingente en docentes y la consideración individualizada en supervisores, como las principales. según el sexo, las mujeres utilizan con mayor frecuencia las conductas motivación inspiracional y carisma inspiracional. además, el liderazgo transaccional está más presente en mujeres, al igual que la consideración individualizada. conclusión: se aprecia el predominio del liderazgo transaccional en enfermeras(os) docentes y supervisoras(es), que afecta el desarrollo y el fortalecimiento de un liderazgo transformador esencial para una gestión del cuidado de calidad. palabras clave liderazgo; docentes de enfermería; enfermeras clínicas; supervisión de enfermería (fuente: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 70-83 71 estilo de liderazgo en profesionales de enfermería según su función en los sectores público o privado en temuco, chile, 2015 l claudio cárcamo-fuentes y otro año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 70-83 leadership style among nursing professionals according to their role in the public or private sectors in temuco, chile 2015 abstract introduction: nursing leadership is considered a fundamental competence, due to its impact on the quality of care. objective: know the style of leadership exercised by nurses, nursing assistants, nursing teachers and supervisors. materials and method: this is a quantitative, descriptive and transversal study. the sample is comprised of 165 nursing professionals from the adult-pediatric area in temuco, southern chile. data collection was done through the multifactorial leadership questionnaire, in its short form, adapted to the chilean population by vega and zabala. results: it was shown that nursing professionals develop transformational and transactional styles to a lesser degree. in the teaching and supervisory areas, they exercise transactional leadership, and contingent reward in teachers and individualized consideration in supervisors are elements that stand out. according to gender, women most often use inspirational motivational behavior and inspirational charisma. in addition, transactional leadership is found more in women, as is individualized consideration. conclusion: the predominance of transactional leadership in nurses (teachers) and supervisors (s), which favors the development and reinforcement of transformative leadership, is essential to quality care management. keywords leadership; nursing teachers; clinical nurses; nursing supervision (source: decs, bireme). 72 aquichan issn 1657-5997 estilo de liderança em profissionais de enfermagem segundo sua função nos setores público ou privado em temuco, chile, 2015 resumo introdução: a liderança de enfermagem é considerada uma competência fundamental por sua repercussão na qualidade dos cuidados. objetivos: conhecer o estilo de liderança que exercem enfermeiros(as) assistenciais, docentes e supervisores(as). materiais e método: pesquisa quantitativa, descritiva e transversal. a amostra está constituída por 165 profissionais de enfermagem da área adultopediátrica, em temuco, no sul do chile. a coleta de dados foi realizada mediante o questionário multifatorial de liderança, em sua forma curta, adaptado à população chilena por vega e zabala. resultados: evidencia-se que os profissionais em enfermagem assistenciais desenvolvem em menor grau os estilos transformacional e transacional; nas áreas docente e de supervisão, exercem liderança transacional e destaca-se a recompensa contingente em docentes e a consideração individualizada em supervisores. segundo o sexo, as mulheres utilizam com maior frequência os comportamentos motivação inspiracional e carisma inspiracional. além disso, a liderança transacional está mais presente em mulheres, assim como a consideração individualizada. conclusões: observa-se o predomínio da liderança transacional em enfermeiros(as) docentes e supervisores(as), que favorece o desenvolvimento e o fortalecimento de uma liderança transformadora essencial para uma gestão do cuidado de qualidade. palavras-chave docentes de enfermagem; enfermagem; enfermeiros(as) clínicas; liderança; supervisão de enfermagem (fonte: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 70-83 73 estilo de liderazgo en profesionales de enfermería según su función en los sectores público o privado en temuco, chile, 2015 l claudio cárcamo-fuentes y otro introducción la tendencia actual sobre el liderazgo señala que este se considera un factor esencial e inherente a todas las teorías organizacionales (1), y para enfermería es una competencia fundamental en la estructura organizativa de las instituciones de salud (2,3), debido a la necesidad de contar con instituciones eficientes y competitivas, con recurso humano preparado en habilidades de gestión y liderazgo, que fomente las relaciones humanas centradas en la cultura, la comunicación y la comunidad; al tiempo que genere procesos de análisis y posibilidad de cambio en las organizaciones (1), para así lograr una mejor calidad de atención al paciente, impacto en el ambiente de trabajo y bienestar del personal (4). actualmente existen tres líneas internacionales transcendentales de desarrollo del liderazgo en enfermería. una de ellas es el programa internacional de liderazgo de la escuela de enfermería de la universidad de birminghan, alabama, centro colaborador de la organización panamericana de la salud y de la organización mundial de la salud. otra es la que desarrolla el consejo internacional de enfermeras, el programa de liderazgo para el cambio, que incluye negociación y planificación estratégica (5). y la tercera es el programa del british columbia nursing leadership institute, enfocado en la formación de líderes en enfermería (4). estos programas han generado transformaciones en los servicios y programas de salud hacia la mejora de la calidad de atención. históricamente, los profesionales de enfermería han emergido como líderes del equipo de salud, debido a su formación y desarrollo profesional, con una amplia visión del “ser humano”, del “cuidado” y de la “salud”, más allá de lo visible, que articula conocimientos y acciones necesarias para ofrecer asistencia creativa y de calidad (6). poseen la capacidad de coordinar equipos y desarrollar estrategias para el cumplimiento de metas y objetivos propuestos por los sistemas de salud (7,8). el líder debe estar formado y ser capaz de aplicar habilidades de liderazgo en todas las funciones de enfermería; además, debe poseer la capacidad de generar, desarrollar, promocionar y evaluar procesos de transformación en los servicios de salud y educación profesional hacia la cobertura universal y la renovación de la atención primaria en salud a la más alta calidad del cuidado (5). a su vez, se debe destacar el sentido ético del liderazgo de estos profesionales, que responde y rinde cuentas al encargo social que las comunidades y naciones han otorgado a enfermeras(os), referido a la provisión de cuidado humano de la más alta calidad y universalidad en favor de la salud (5). de acuerdo con la asociación canadiense de enfermería (9), “el liderazgo juega un papel fundamental en la vida de las enfermeras” y “enfermería requiere líderes fuertes, coherentes y bien informados”. sin embargo, a pesar de numerosos estudios que han analizado y explicado el tema de estudio, no existe evidencia disponible sobre una teoría definitiva, eficaz y que guíe a los líderes. asimismo, la american organization of nurse executives reconoce el liderazgo como una competencia esencial en la administración que ejercen las(os) enfermeras(os), debido a la activa participación en políticas públicas, programas sanitarios, asignación de recursos, análisis de información y dirección de grupos de trabajo (10). a su vez, el institute of medicine apoya lo descrito, planteando que “el liderazgo es esencial para lograr los objetivos relacionados con la calidad de los cuidados y seguridad de los pacientes” (11). al mismo tiempo, señala el liderazgo transformacional, centrado en la calidad de la atención, como un elemento necesario en enfermeras(os) para hacer frente a las deficiencias del entorno de trabajo (11). por su parte, la organización mundial de la salud señala que es un reto mantener profesionales competentes, al plantear que “las(os) enfermeras(os) que ocupan posiciones de liderazgo deben ser capaces de influir en los mecanismos de adopción de decisiones que establecen prioridades y asignan recursos para la obtención de salud” (10). en instituciones hospitalarias, como supervisoras(es), los profesionales de enfermería necesitan una preparación para asumir roles de liderazgo, condición básica para generar cambios en su práctica diaria y garantizar calidad en la atención, a efectos de conciliar los objetivos institucionales con las necesidades del equipo de enfermería (12). dicha situación concuerda con el código sanitario y la norma general administrativa 19, que señala: “la enfermera debe poseer formación, competencias técnicas y genéricas en lo referente a la gestión del cuidado” (13,14). conjuntamente, el liderazgo se considera la capacidad más importante y presente en los administradores de instituciones acreditadas, de acuerdo con la visión de superiores jerárquicos (15). 74 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 en su función asistencial, estos profesionales son responsables de proveer cuidados integrales y de calidad, al tiempo que consideran aspectos psicológicos, sociales, culturales y biológicos, en busca de modificar la concepción enfocada en el cuidado físico (16) y asumir el liderazgo, el cual debe ser “comprensivo, generando un clima de trabajo favorable, participativo, fomentando el trabajo en equipo, haciendo partícipe a su personal en las decisiones” (13). por su parte, enfermeras(os) docentes deben tener claridad en cuanto al concepto de liderazgo y dominar las prácticas que promueven su desarrollo, porque la experiencia ha demostrado que esta noción tiene diferentes connotaciones para los mismos docentes (10). esto requiere flexibilidad en la aplicación de competencias de liderazgo y gestión, las cuales están directamente relacionadas con el trabajo en equipo, toma de decisiones y planificación (17), que utilizan diferentes estilos de liderazgo, dependiendo de la situación que se presente y en la medida necesaria. de este modo, podrá influir en las personas responsables del cuidado, motivando comportamientos y conductas del equipo de salud hacia prácticas de gestión humanizadas y de calidad (10,18). por lo tanto, los profesionales de enfermería tienen la responsabilidad de dirigir el camino al cambio, considerar los grandes problemas e identificar las estrategias cuyas acciones se requieren para ejercer todo su potencial de liderazgo (19). empero lo expresado, en su proceso de trabajo, la(el) enfermera(o) posee dificultades para tratar conflictos y desempeñar el liderazgo. su quehacer privilegia actividades excesivamente burocráticas, que ubican las normas en perjuicio del cuidado. esto se acentúa con recarga laboral, demandas y exigencias de las instituciones, así como déficit de recursos y la pluralidad del personal a su cargo, que afecta la forma de influir dentro del equipo de salud, la resolución de conflictos y el logro de objetivos (20). no obstante, aun cuando influye y modifica conductas en el paciente y su entorno, este proceso de liderazgo no es valorado por la sociedad y el propio equipo de salud (21). además, el hecho de asumir el liderazgo por sí mismo no garantiza su eficacia (2). no solo permite influir en el cuidado directo de los pacientes, sino que, además, influye en la administración, educación, decisiones y autonomía de pares (20), al tiempo que promueve la mejora de las condiciones de salud y vida de la población; el logro de objetivos de cuidado propios de la profesión, y el alcance de las metas propuestas en los servicios de salud. por ello, es un proceso que favorece el desarrollo social, profesional y organizacional (7), cuya magnitud abarca todas las áreas de gestión en enfermería, ya sea que se desempeñen funciones asistenciales, se esté a cargo de un grupo de técnicos paramédicos, se administre un servicio o se participe en la formación de nuevos profesionales. la investigación sobre liderazgo en enfermería desarrollada en américa latina también se basa en la teoría transformacional, que es parte del nuevo paradigma, uno de los más estudiados e influyente en la actualidad (2), aparte de ser considerado el estilo más adecuado para fomentar el liderazgo en enfermería (11). en la ciudad de temuco, chile, los profesionales de enfermería tienen la posibilidad de desempeñar varias de sus funciones: asistencial, administrativa y docencia en los sectores público y privado. de acuerdo con la observación y experiencia de enfermeras(os), se aprecia dificultad en el ejercicio del liderazgo, con estilos diversos, conflictos dentro del equipo, carencia en la toma de decisiones, dificultades en el manejo del personal e incumplimiento de objetivos planteados. ello puede deberse a déficit en conocimiento del liderazgo como una competencia, diferencias generacionales, falta de confianza, identidad y carencia de programas de formación que incluyan competencias en liderazgo. dada la importancia del liderazgo como elemento de desarrollo para la disciplina profesional de enfermería, en materia de competencia, calidad y productividad, es preponderante que en los espacios de la práctica y la aplicación profesional de la (del) enfermera(o) estén presentes sus características: que sea notorio, propositivo e impactante, no solo en su accionar laboral, sino también en aspectos relacionados con pacientes, grupos de trabajo, colegas y el entorno profesional en general (21). a raíz de esto, se realizó una investigación cuantitativa, con un diseño descriptivo de corte transversal, en relación con los estilos de liderazgo que ejercen los profesionales de enfermería. para ello se planteó la pregunta de investigación: ¿cuál es el estilo de liderazgo que ejercen enfermeras(os) asistenciales, supervisoras(es), y docentes de la ciudad de temuco en la región de la araucanía? el propósito fue contribuir al fortalecimiento del liderazgo de enfermería en la gestión del cuidado y formación de nuevos profesionales, identificando estos estilos como una primera etapa. para la recolección de datos se utilizó el cuestionario multifactorial de liderazgo en su forma corta (mlq 5x), adaptado a la población chilena por vega y zabala (22). 75 estilo de liderazgo en profesionales de enfermería según su función en los sectores público o privado en temuco, chile, 2015 l claudio cárcamo-fuentes y otro metodología este fue un estudio descriptivo de corte transversal, en relación con estilos de liderazgo de enfermeras(os) asistenciales, docentes y supervisoras(es), en temuco, chile, durante el 2015. la muestra estuvo constituida por 165 enfermeras(os) de los sectores público y privado. la recolección de datos se realizó mediante el mlq 5x, elaborado por bass y avolio, y adaptado a la población chilena por vega y zabala, el cual tiene un índice de confiabilidad de α = 0,97, y que fue validado en contenido y constructo (22). se le adicionó un ítem con datos sociodemográficos. consta de 82 ítems, los cuales discriminan entre líder transformacional, transaccional y ausencia de liderazgo (23). el estudio se estructuró como un modelo jerárquico de nueve variables, las cuales están compuestas por tres variables de alto orden, liderazgo transformacional (ltf), transaccional (ltr) y correctivo/evitador (lc/e). dentro del liderazgo transformacional se encuentran las de segundo orden: carisma/ inspiracional (c/i), la que incluye influencia idealizada atribuida (iia) y conductual (iic) y motivación inspiracional (mi), y estimulación intelectual (ei). en el liderazgo transaccional encontramos consideración individualizada (ci) y recompensa contingente (rc). por último, el liderazgo correctivo/evitador está formado por la dirección por excepción activa (dpe-a) y por liderazgo pasivo/evitador (lp/e), en el que encontramos la dirección por excepción pasiva (dpe-p) y laissez-faire (lf) (22,24). las variables se miden mediante las percepciones de actitudes y comportamientos exhibidos por el líder y de sus efectos en los seguidores. la escala de respuesta tiene un rango de 0 a 4, tipo likert, que corresponde a las categorías: nunca (0); rara vez (1); a veces (2); a menudo (3), y frecuentemente o siempre (4) (22). además, permite identificar resultados organizacionales por medio de tres escalas: a) esfuerzo extra, relacionado con la motivación hacia logros más altos; b) efectividad, capacidad para guiar y dirigir de forma exitosa, y c) satisfacción, relacionada con la gratificación en el grupo de trabajo, pues existe un clima organizacional sano (25). se realizó un análisis descriptivo exploratorio para determinar la calidad de los datos que se iban a analizar; posteriormente, análisis descriptivo para las características de las(os) enfermeras(os) y estilos de liderazgo, variables o dimensiones de acuerdo con la frecuencia y promedios de respuesta. luego siguió el análisis de relación entre las variables sociodemográficas y los estilos de liderazgo, y variables de resultado organizacional, y para esto se utilizaron las pruebas de análisis de varianza (anova) y el test según correspondiera. en el caso de la función que ejercen las(os) enfermeras(os) se trabajó con las pruebas anova y kruskal-wallis. finalmente, se correlacionó la edad y los años de trabajo de las(os) enfermeras(os) con los estilos de liderazgo. se utilizó un valor de p ≤ 0,05. el proceso se apoyó en el programa estadístico stata 11.0. aspectos éticos los aspectos éticos se resguardan según los principios propuestos por emanuel (26): el valor de este estudio significó un aporte a la gestión del cuidado de enfermería, identificando estilos de liderazgo ejercido por las(os) enfermeras(os) como un primer paso para el fortalecimiento del liderazgo en enfermería en la ciudad de temuco. su validez científica se basó en un diseño metodológico riguroso, que respeta cada etapa del proceso. se contó con la orientación de investigadores experimentados en el tema y metodología de investigación. además, de la asesoría de un estadístico experimentado para el análisis de datos. asimismo, el instrumento de recolección de datos está validado en la población chilena con una alta confiabilidad y validez. todos los participantes debieron firmar libremente un consentimiento informado en el momento de aceptar participar en este estudio. además de la autorización de los respectivos directores de las instituciones donde se llevó a cabo la investigación. se aseguró la confidencialidad de los participantes, mediante la entrega de cuestionarios numerados. dichos cuestionarios no llevaban el nombre del participante y tampoco el de las instituciones donde fue aplicado. existió la posibilidad de cambiar de opinión en cualquier etapa de la investigación; además, se entregarán los resultados al finalizar el estudio. resultados los participantes del estudio fueron 165, de quienes se obtuvo una tasa de respuesta del 100 %. del total de encuestados, el 85,5 % eran mujeres con una edad media de 34,97 ± 9,88, y el 14,5 % eran hombres, con una edad media de 31,54 ± 8,35. de acuerdo con los años de trabajo, en mujeres la media es de 10,43 ± 9,61, y en hombres es de 6,38 ± 8,03. con respecto a la fun76 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 ción que desempeñan, el 64,3 % es asistencial, el 21,8 % es docencia y el 13,9 % es supervisión. según el área de trabajo, un 62,4 % es en adultos y el 37,6 % es en pediatría. en cuanto a la organización en la cual trabajan, el 69,1 % lo hace en el sistema público, y un 30,9 %, en el privado. según los promedios de respuestas, los estilos transformacional (3,41 ± 0,38) y transaccional (3,33 ± 0,41) tienen promedios similares, lo cual implica que ambos se encuentran casi siempre presentes en los participantes del estudio, por lo que existe un leve predomino del estilo transformacional, sin diferencias significativas. empero, el liderazgo correctivo/evitador (1,77 ± 0,37) tiene un promedio de respuesta menor y evidencia que se encuentra a veces presente en los sujetos de estudio (tabla 1). tabla 1. estilos de liderazgo en enfermeras(os) asistenciales, docentes y supervisoras (es), temuco, chile, 2014 de acuerdo con la relación entre las variables sociodemográficas y los estilos de liderazgo y sus dimensiones, se aprecia que la motivación inspiracional es una conducta que se encuentra con mayor frecuencia en mujeres (p = 0,0092), al igual que el carisma/inspiracional (p = 0,0389). por su parte, el estilo transaccional de liderazgo, también se encuentra más presente en mujeres (p = 0,0064), donde la consideración individualizada es un comportamiento ejercido con mayor frecuencia en mujeres (p = 0,0014). asimismo, el estilo transformacional está casi siempre presente en ambos sexos, sin diferencias significativas, al igual que como ocurre en las subvariables influencia idealizada conductual y atribuida, y estimulación intelectual, según los promedios de respuesta. por su parte, la recompensa contingente tiene un promedio de respuesta mayor en mujeres, el cual no es significativo. a pesar de esto, ambos promedios de respuesta señalan que es una conducta que casi siempre está presente. al contrario, la dirección por excepción activa es un comportamiento que a menudo es ejercido por ambos sexos; no así el liderazgo correctivo/evitador, el cual rara vez se encuentra presente (tabla 2). en cuanto a la relación entre estilos de liderazgo y sus dimensiones con las funciones de enfermeras(os), se observa que el estilo transaccional se encuentra más presente en la función de supervisión (p = 0,0002) y docencia (p = 0,0011). se aprecia la consideración individualizada (p = 0,0040) como la principal conducta en supervisoras(es) y la recompensa contingente en la función de docencia. de acuerdo con los promedios de respuesta, el estilo transformacional es una conducta que se encuentra casi siempre desarrollada en todas las funciones, donde los promedios más bajos pertenecen a la función asistencial. en cambio, el estilo correctivo/evitador y sus variables son conductas que rara vez son utilizadas. los promedios más altos se encuentran en la función de supervisión, y el más bajo, en la asistencial. dentro del estilo correctivo/evitador, la variable dirección por excepción activa es la que tiene los promedios más altos, lo cual indica que los participantes del estudio a menudo ejercen esta conducta (tabla 3). en relación con las variables de resultado organizacional, se evidencia que el esfuerzo extra a menudo está más presente en mujeres (p = 0,0229). de acuerdo con los promedios de respuesta, la satisfacción muestra promedios similares en ambos sexos, aun cuando es levemente mayor en hombres, lo cual indica que a menudo se encuentra presente; en contraste, la variable efectividad presenta un promedio mayor en mujeres que en hombres, sin diferencia significativa (tabla 4). respecto a las funciones de variables  ± ds 1er orden 2o orden subvariable ltf c/i iic 3,57 ±0,37 iia 3,38 ± 0,47 mi 3,44 ± 0,45 total 3,47 ± 0,03 ei 3,25 ± 0,45 total 3,41 ± 0,38 ltr ci 3,32 ± 0,41 rc 3,35 ± 0,52 total 3,33 ± 0,41 lc/e dpe-a 2,89 ± 0,59 lp-e dpe-p 1,1 ± 0,69 lf 1,43 ± 0,49 total 1,29 ± 0,51 total 1,77 ± 0,37 ltf: liderazgo transformacional; ltr: liderazgo transaccional; lc/e: liderazgo correctivo/ evitador; ci: consideración individualizada; c/i: carisma/inspiracional; rc: recompensa contingente; dpe-a: dirección por excepción activa; lp-e: liderazgo pasivo/evitador; dpe-p: dirección por excepción pasiva; lf: laissez-faire; iic: influencia idealizada conductual; iia: influencia idealizada atribuida; mi: motivación inspiracional. fuente: elaboración propia según el cuestionario multifactorial de liderazgo. 77 estilo de liderazgo en profesionales de enfermería según su función en los sectores público o privado en temuco, chile, 2015 l claudio cárcamo-fuentes y otro tabla 2. relación de promedios entre estilos de liderazgo y sus variables, según sexo en enfermeras(os) asistenciales, docentes y supervisoras(es), temuco, chile, 2014 tabla 3. relación de promedios entre estilos de liderazgo y variables según función de enfermeras(os) asistenciales, docentes y supervisoras(es), temuco, chile, 2014 * ttest para varianzas distintas / ** anova. ltf: liderazgo transformacional; ltr: liderazgo transaccional; lc/e: liderazgo correctivo/evitador; ci: consideración individualizada; c/i: carisma/inspiracional; rc: recompensa contingente; dpe-a: dirección por excepción activa; lp-e: liderazgo pasivo/evitador; dpe-p: dirección por excepción pasiva; lf: laissez-faire; iic: influencia idealizada conductual; iia: influencia idealizada atribuida; mi: motivación inspiracional. fuente: elaboración propia según el cuestionario multifactorial de liderazgo. variables sexo p primer orden segundo orden subvariable mujer hombre  ± ds  ± ds ltf c/i iic 3,59 ± 0,35 3,45 ± 0,47 0,1684* iia 3,39 ± 0,44 3,30 ± 0,61 0,4954* mi 3,48 ± 0,44 3,22 ± 0,47 0,0092** total 3,50 ± 0,35 3,33 ± 0,45 0,0389** ei 3,25 ± 0,45 3,23 ± 0,47 0,8480** total 3,43 ± 0,36 3,3 ± 0,44 0,1819* ltr ci 3,36 ± 0,38 3,07 ± 0,50 0,0014** rc 3,38 ± 0,52 3,19 ± 0,50 0,0933** total 3,37 ± 0,40 3,12 ± 0,44 0,0064** lc/e dpe-a 2,88 ± 0,61 2,94 ± 0,49 0,6285** lp-e dpe-p 1,05 ± 0,67 1,39 ± 0,74 0,0271** lf 1,42 ± 0,50 1,49 ± 0,41 0,5107** total 1,26 ± 0,52 1,45 ± 0,40 0,0986** total 1,75 ± 0,38 1,90 ± 0,30 0,0704** variables función p primer orden segundo orden subvariable asistencial docencia supervisión  ± ds  ± ds  ± ds ltf c/i iic 3,53 ± 0,35 3,65 ± 0,45 3,64 ± 0,29 0,1485* iia 3,40 ± 0,42 3,35 ± 0,62 3,31 ± 0,39 0,5083** mi 3,40 ± 0,42 3,51 ± 0,54 3,54 ± 0,40 0,2359* total 3,45 ± 0,34 3,52 ± 0,50 3,51 ± 0,31 0,0969** ei 3,20 ± 0,43 3,32 ± 0,52 3,34 ± 0,39 0,2404* total 3,38 ± 0,34 3,46 ± 0,49 3,47 ± 0,32 0,0734* 78 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 enfermeras(os), el esfuerzo extra es desarrollado con mayor frecuencia en la función de supervisión (p = 0,0096). a su vez, la satisfacción y la efectividad no tienen diferencias significativas. según los promedios de respuesta, la satisfacción obtiene los promedios más altos en funciones asistenciales y supervisión, y en efectividad se encuentran en las funciones de docencia y supervisión. todas las variables se encuentran a menudo presentes en cada una de las funciones (tabla 5). tabla 4. relación de variables de resultado organizacional, satisfacción, efectividad y esfuerzo extra con sexo de enfermeras(os) asistenciales, docentes y supervisoras(es), temuco, chile, 2014 tabla 5. relación entre variables de resultado organizacional y la función de enfermeras(os) asistenciales, docentes y supervisoras(es), temuco, chile, 2014 variables función p primer orden segundo orden subvariable asistencial docencia supervisión  ± ds  ± ds  ± ds ltr ci 3,25 ± 0,37 3,39 ± 0,53 3,52 ± 0,31 0,0040** rc 3,24 ± 0,50 3,59 ± 0,55 3,5 ± 0,42 0,0011* total 3,25 ± 0,38 3,46 ± 0,50 3,51 ± 0,31 0,0002** lc/e dpe-a 2,91 ± 0,60 2,83 ± 0,63 2,89 ± 0,51 0,8073* lp-e dpe-p 1,18 ± 0,73 0,96 ± 0,56 0,98 ± 0,65 0,1678* lf 1,46 ± 0,51 1,39 ± 0,44 1,37 ± 0,47 0,5803* total 1,34 ± 0,53 1,20 ± 0,41 1,20 ± 0,50 0,2469* total 1,18 ± 0,39 1,69 ± 0,28 1,71 ± 0,44 0,1755* * ttest para varianzas distintas / ** anova. ltf: liderazgo transformacional; ltr: liderazgo transaccional; lc/e: liderazgo correctivo/evitador; ci: consideración individualizada; c/i: carisma/inspiracional; rc: recompensa contingente; dpe-a: dirección por excepción activa; lp-e: liderazgo pasivo/evitador; dpe-p: dirección por excepción pasiva; lf: laissez-faire; iic: influencia idealizada conductual; iia: influencia idealizada atribuida; mi: motivación inspiracional. fuente: elaboración propia según el cuestionario multifactorial de liderazgo. sexo pmujer hombre  ± sd  ± sd satisfacción 3,32 ± 0,49 3,35 ± 0,46 0,8047** efectividad 3,20 ± 0,49 3,04 ± 0,57 0,1489** esfuerzo extra 3,23 ± 0,50 2,97 ± 0,59 0,0229** ** anova. fuente: elaboración propia según el cuestionario multifactorial de liderazgo. función pasistencial docencia supervisión  ± sd  ± sd  ± sd satisfacción 3,34 ± 0,47 3,29 ± 0,56 3,34 ± 0,45 0,8670** efectividad 3,15 ± 0,47 3,23 ± 0,64 3,25 ± 0,43 0,3082* esfuerzo extra 3,12 ± 0,47 3,29 ± 0,65 3,36 ± 0,47 0,0096* * kruskal-wallis; ** anova. fuente: elaboración propia según el cuestionario multifactorial de liderazgo. discusión la literatura señala que el liderazgo transformacional es el más utilizado por enfermeras(os) asistenciales (11), quienes tienen características y desarrollan comportamientos que modifican la motivación de las personas (23,27). asimismo, los profesionales de enfermería tienden a estar más satisfechas(os) con estilos transformacionales por sobre el transaccional (28). no obstante, 79 estilo de liderazgo en profesionales de enfermería según su función en los sectores público o privado en temuco, chile, 2015 l claudio cárcamo-fuentes y otro la carga de trabajo y otras limitaciones afectan la manera de influir y se orientan a realizar acciones de tipo transaccional (17). a diferencia de lo señalado, los resultados obtenidos en esta investigación mostraron promedios más bajos del estilo transformacional en la función asistencial, en comparación con la docencia y supervisión, aspecto que también se aprecia en el estilo transaccional. sin embargo, ambos liderazgos a menudo se encuentran presentes y no existe un estilo predominante, pues se usan de manera indistinta. ello se puede deber a que las políticas de salud están orientadas al cumplimiento de objetivos concretos, establecidos con base en actividades realizadas en un tiempo determinado; este hecho obliga, de cierto modo, a tener conductas más bien transaccionales en la interacción enfermera-usuario, donde las metas que se plantean en el proceso de enfermería las establecen la(el) propia(o) enfermera(o) y, muchas veces, no existe una participación en definir cuáles serán los objetivos que deberán cumplir los usuarios, para lograr una mejoría o recuperación de su problema. a su vez, las políticas de recursos humanos, la gran carga laboral, la pluralidad del personal y la falta de recursos benefician un estilo centrado en la tarea, con un fuerte componente de autoridad, muy frecuente en las organizaciones verticales medicalizadas. el compromiso con la productividad obedece más a aspectos del cumplimiento con las tareas emanadas del propio puesto de trabajo y se olvidan conductas transformadoras que motiven la búsqueda de estrategias innovadoras para el logro de los objetivos. según la literatura sobre el tema, enfermeras(os) docentes ejercen un estilo de liderazgo principalmente transformacional (29), suelen ser optimistas y motivadores en su desempeño laboral; además, estimulan a sus estudiantes a realizar sus tareas, considerando las necesidades de cada uno (17,29). sin embargo, en el presente estudio se observa que el estilo transaccional es el más utilizado y que la recompensa contingente es la conducta más desarrollada. esto puede deberse a que histórica y culturalmente se trabaja a partir del cumplimiento de objetivos de aprendizaje y no todas las prácticas docentes están centradas en el estudiante. por su parte, el objetivo que buscan alcanzar los alumnos es la aprobación, es decir, una nota eficiente; conjuntamente, los docentes inducen al estudiante al logro de esta, de lo contrario serán sancionados (con la reprobación). esto último concuerda con que la recompensa contingente sea la principal conducta observada en enfermeras(os) docentes. de acuerdo con la literatura, las(os) enfermeras(os) con cargos de supervisión ejercen liderazgo transformacional (30). del mismo modo, rodríguez-gonzalo señala que las enfermeras subalternas perciben que sus supervisoras ejercen el mismo estilo (25). asimismo, las nuevas políticas de gestión del cuidado hospitalario implicaron cambios en los niveles jerárquicos en la administración del personal y consideraron funciones de gestión y administración; esto implicó que enfermeras(os) necesitaran de competencias como la motivación, la comunicación, la creatividad, las cualidades o las características que debiera tener un líder (17). en contraste, los resultados de este estudio revelaron que enfermeras(os) con funciones de supervisión desarrollan un estilo transaccional, donde la principal conducta observada es la consideración individualizada, seguida de la recompensa contingente. además, en relación con los resultados organizacionales, a pesar de ejercer un estilo transaccional, estas tienden a motivar al personal a su cargo hacia el logro de objetivo más elevados, al estimular el esfuerzo extra en su desempeño. en cuanto a los estilos de liderazgo y el sexo, la literatura señala que las mujeres son más transformacionales que los hombres (31,32), pues adoptan en mayor medida las conductas de recompensa contingente (33). en este sentido, el estilo de liderazgo femenino está orientado hacia las necesidades de las personas, la cooperación, el trabajo en equipo y el desarrollo individual como meta para conseguir los objetivos, lo que corresponde a un estilo de liderazgo transformacional (34). al respecto, en el estudio de base se revela que el estilo transformacional está presente indistintamente en hombres y mujeres, y que las mujeres utilizan las conductas, la motivación inspiracional y el carisma/ inspiracional con mayor frecuencia que los hombres. además, en relación con los resultados organizacionales, las mujeres tienden en mayor medida que los hombres a motivar a los subordinados hacia el logro de objetivos más elevados, lo cual favorece el esfuerzo extra en el desempeño del personal. además, en esta investigación, las mujeres utilizan el liderazgo transaccional con mayor frecuencia que los hombres, al igual que la conducta consideración individualizada. conclusión el liderazgo en enfermería es considerado esencial. este, de acuerdo con los resultados, es ejercido por la(el) enfermera(o) dentro de su equipo de trabajo, independiente de la edad, años de trabajo, tipo de organización, área de trabajo o función que 80 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 desempeñen. sin embargo, no existe un estilo de liderazgo claramente definido que teóricamente les permita enfrentarse a los nuevos retos, aun cuando existen conductas transformacionales y transaccionales, los cuales se complementan entre sí. en relación con la función docente de enfermeras(os), los resultados obtenidos muestran que mayoritariamente utilizan un liderazgo transaccional, cuya principal conducta es la recompensa contingente por sobre la consideración individualizada. por ello, se concluye que, a pesar de que las metodologías de aprendizajes de las universidades están basadas en competencias, las(os) enfermeras(os) con funciones de docencia, utilizan metodologías pedagógicas basadas en objetivos, más que en estimular las competencias y considerar las características propias de cada estudiante, pues les exigen el cumplimiento de tareas y objetivos, los cuales son considerados un premio (aprobación) o sanción (reprobación) según su rendimiento. esto obligaría a replantearse o evaluar estas metodologías, y orientarlas hacia el cambio motivacional de los estudiantes a fin de alcanzar desempeños sobresalientes. en este sentido, cabe preguntarse cómo evaluar de manera de que la nota no se transforme en el principal objetivo y que no se considere un premio o sanción de acuerdo con el rendimiento de los alumnos. además, es necesario que los estudiantes identifiquen a la(el) enfermera(o) como un modelo y no como una autoridad que entrega conocimientos y evalúa su desempeño. en la función de supervisión, enfermeras(os) con cargos de jefaturas utilizan el liderazgo transaccional, cuya principal conducta es la consideración individualizada. de acuerdo con esto, las(os) enfermeras(os) supervisoras(es) utilizan conductas orientadas hacia el cumplimiento de metas establecidas, generalmente político-institucionales, las cuales son exigidas por los directivos de las instituciones, lo cual obliga, de cierto modo, a este tipo de liderazgo. por otro lado, a pesar de tener la exigencia del cumplimiento de metas, son capaces de considerar a cada uno de sus subalternos de manera individual y mostrar una preocupación por el desarrollo personal de cada uno. por lo tanto, en este caso, el estilo de liderazgo podría estar influenciado por las exigencias políticoinstitucionales, desde donde se establecen metas de cumplimiento que obligan a trabajar en busca de esos objetivos y a dejar de lado conductas que permitan cambiar la motivación y estimulen a su personal hacia un desempeño sobresaliente, lo cual facilitaría, finalmente, el cumplimiento de las metas. por tal motivo, es esencial que tanto las políticas ministeriales e institucionales como los directivos de cada institución presenten una visión transformacional que permita generar cambios en la motivación y, así, alcanzar un elevado desempeño en el logro de los objetivos. con respecto al sexo en enfermeras(os) y su relación con el estilo de liderazgo, y de acuerdo con los resultados del estudio, se concluye que estos probablemente estén influenciados por la mayor proporción de mujeres que hombres en las funciones asistenciales, docencia y supervisión, lo cual coincide con los resultados obtenidos según su función. por lo tanto, es necesario continuar realizando investigaciones con una proporción más equilibrada entre hombres y mujeres en todas las funciones, a fin de tener una visión más real del liderazgo. finalmente, se declara que la mayoría de las investigaciones sobre liderazgo en enfermería muestran la visión o percepción que tienen los profesionales de enfermería, ya sea como líderes del equipo o subalternas(os). en consecuencia, es necesario conocer la visión, opinión y percepción que tienen los subalternos no profesionales, es decir, los técnicos en enfermería o auxiliares de enfermería y los estudiantes sobre el liderazgo de las(os) enfermeras(os) líderes. de este modo, nos acercaremos a conocer el verdadero liderazgo que ejercen en sus equipos de trabajo. 81 estilo de liderazgo en profesionales de enfermería según su función en los sectores público o privado en temuco, chile, 2015 l 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comparación por género de los estilos de liderazgo en una muestra de gerenciales en puerto rico. rev puertorriq psicol [internet]. 2010 [citado 8 may 2015];21:113-32. disponible en: http://pepsic.bvsalud. org/scielo.php?pid=s1946-20262010000100005&script=sci_arttext 461 474 apoyo social percibido y afrontamiento.indd 461 maría consuelo amaya-ropero1 gloria mabel carrillo-gonzález2 apoyo social percibido y afrontamiento en personas con dolor crónico no maligno 1 enfermera. magíster en enfermería con énfasis en cuidado al paciente crónico. universidad pedagógica y tecnológica de colombia. maria.amaya@uptc.edu.co 2 enfermera. magíster en enfermería. doctora en enfermería. universidad nacional de colombia, colombia. gmcarrillog@unal.edu.co recibido: 18 de julio de 2013 enviado a pares: 10 de agosto de 2013 aceptado por pares: 19 de abril de 2015 aprobado: 04 de mayo de 2015 doi: 10.5294/aqui.2015.15.4.2 para citar este artículo / to reference this article / para citar este artigo amaya ropero mc, carrillo gonzález gm. apoyo social percibido y afrontamiento en personas con dolor crónico no maligno. aquichan. 2015;15(4): 461-474. doi: 10.5294/ aqui.2015.15.4.2 resumen objetivo: determinar la asociación entre el apoyo social percibido y el afrontamiento de las personas con dolor crónico no maligno en la ciudad de tunja (colombia). materiales y método: estudio descriptivo, de correlación, con abordaje cuantitativo, de corte transversal, en el que participaron 340 personas con dolor crónico no maligno. el análisis se realizó empleando estadística descriptiva y determinación de la correlación a través del coeficiente de correlación de pearson. resultados: las personas con dolor crónico no maligno participantes en el estudio fueron en su mayoría mujeres, con edades comprendidas entre los 36 a los 59 años, con niveles de escolaridad heterogéneos, estratos socioeconómicos bajos y ocupación hogar. la mayoría con patologías neurológicas o neuroquirúrgicas, seguidas por las de origen óseo o articular. la presencia de dolor supera los tres años y su intensidad severa. se encontró alta percepción del apoyo social, así como alto uso de estrategias de afrontamiento, con predominio de la religión. se identifica correlación débil estadísticamente significativa entre apoyo social percibido y afrontamiento en personas con dolor crónico, y entre apoyo social percibido y afrontamiento activo. conclusiones: las intervenciones de apoyo social adaptadas a los contextos y ámbitos en los que se encuentran los usuarios, se deben considerar como iniciativas para fortalecer las estrategias de afrontamiento de personas con dolor crónico no maligno. palabras clave apoyo social, afrontamiento, dolor crónico (fuente: decs, bireme). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 461-474 462 aquichan issn 1657-5997 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 461-474 perceived social support and coping among people with chronic nonmalignant pain abstract objective: identify the association between perceived social support and coping on the part of people with chronic nonmalignant pain in the city of tunja (colombia). materials and methods: this is a descriptive, correlational study with a quantitative, cross-sectional design. the sample included 340 persons with chronic nonmalignant pain. the analysis was done using descriptive statistics and the correlation was determined with the pearson correlation coefficient. results: the persons with chronic nonmalignant pain who took part in the study were mostly women; specifically, housewives ages 36 to 59 who are in the low socio-economic bracket and have different levels of education. the majority had neurosurgical or neurological diseases, followed by those of bone or joint origin. they had been in pain for more than three years and its intensity was severe. a high perception of social support was found, along with considerable use of coping strategies, particularly religion. the study revealed a weak statistically significant correlation between perceived social support and coping in persons with chronic pain, and between perceived social support and active coping. conclusions: social support interventions tailored to the contexts and environments users find themselves in should be considered as initiatives to strengthen the coping strategies of persons with chronic nonmalignant pain. keywords social support, coping, chronic pain (source: decs, bireme). 463 apoyo social percibido y afrontamiento en personas con dolor crónico no maligno l maría consuelo amaya-ropero, gloria mabel carrillo-gonzález apoio social percebido e enfrentamento em pessoas com dor crônica não maligna resumo objetivo: determinar a associação entre o apoio social percebido e o enfrentamento das pessoas com dor crônica não maligna na cidade de tunja (colômbia). materiais e método: estudo descritivo, de correlação, com abordagem quantitativa, de corte transversal, do qual participaram 340 pessoas com dor crônica não maligna. a análise foi realizada utilizando estatística descritiva e determinação da correlação por meio do coeficiente de correlação de pearson. resultados: as pessoas com dor crônica não maligna participantes do estudo foram, em sua maioria, mulheres, na faixa-etária de 36 a 59 anos, com níveis de escolaridade heterogêneos, classes sociais baixas e donas de casa. a maioria com patologias neurológicas ou neurocirúrgicas, seguidas pelas de origem óssea ou articular. a presença da dor ultrapassa três anos e sua intensidade é forte. constatou-se alta percepção do apoio social, bem como alto uso de estratégias de enfrentamento, com predomínio da religião. identifica-se correlação fraca estatisticamente significativa entre apoio social percebido e enfrentamento em pessoas com dor crônica, e entre apoio social percebido e enfrentamento ativo. conclusões: as intervenções de apoio social adaptadas aos contextos e âmbitos nos quais os usuários se encontram devem ser consideradas como iniciativas para fortalecer as estratégias de enfrentamento de pessoas com dor crônica não maligna. palavras-chave apoio social, enfrentamento, dor crônica (fonte: decs, bireme). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 461-474 464 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 introducción el dolor es una de las experiencias presentes en la historia del ser humano y ha sido, sin duda alguna, un importante impulsor para el desarrollo de las ciencias de la salud (1); representa uno de los principales retos para los sistemas de salud a nivel mundial y un desafío para el cuidado de enfermería, por el impacto que constituye en la vida de las personas, las comunidades, los ambientes laborales, los sistemas económicos y la salud de las poblaciones. el dolor es una experiencia sensorial o emocional desagradable, asociada a un daño real o potencial en un tejido, o descrito en términos de dicho daño (2), el cual debe abordarse como una vivencia única, individual y totalizante para la persona, debido a que la compromete en forma multidimensional, y, por tanto, requiere para su tratamiento un enfoque holístico, integral, que tenga en cuenta factores físicos, psicológicos, espirituales, sociales y financieros (3). hoy, el reconocimiento de la importancia que tiene el alivio del dolor a nivel mundial, ha hecho que este se considere un derecho fundamental de la persona (4). la presencia de dolor crónico en la población representa un problema de salud pública por su alta prevalencia (5, 6), incremento ligado al aumento en la prevalencia de las enfermedades crónicas degenerativas e incapacitantes, teniendo en cuenta el alcance, los significados y el impacto multidimensional que la enfermedad crónica tiene en la calidad de vida de quienes la experimentan, superando incluso a otras enfermedades crónicas (5). se estima que en el año 2050 habrá 2 mil millones de personas con dolor crónico en el mundo (7). en colombia, los resultados del estudio epidemiológico de dolor crónico en caldas (estudio dolca, 2008), evidencian una prevalencia de dolor crónico (mayor de tres meses) de 31 % (8), y el quinto estudio del dolor, 2010, de la asociación colombiana para el estudio del dolor (aced), el cual se centra en el perfil sociodemográfico de la persona con dolor músculo-esquelético, reporta una prevalencia del 60 % en la población colombiana (9). respecto al dolor crónico no maligno, algunos autores plantean que a pesar de que representa un problema de salud pública con una significativa repercusión social y económica evidente en la actualidad, existen pocos datos sobre su epidemiología, lo que dificulta una estimación exacta del impacto global que supone este problema (10). el dolor crónico afecta todas las dimensiones y esferas, tanto de la persona como de su familia, con repercusiones emocionales, económicas, sociales y laborales. las investigaciones plantean que el 50 % de las personas con experiencia de dolor crónico desencadenan estados depresivos (7, 8, 11), y las actividades cotidianas (avd) se ven limitadas de manera parcial o total (8). a nivel familiar, se alteran las relaciones intrafamiliares y de pareja; en el ámbito laboral y económico, una de las principales consecuencias es el ausentismo laboral, que conlleva la pérdida de días trabajados e impacta directamente la economía de los países. para el sistema de salud, el costo es muy alto, si se tienen en cuenta los costos que genera la atención médica, los tratamientos, las incapacidades y las hospitalizaciones, que en países como estados unidos se estima en alrededor de 150 billones de dólares anuales (11), esto sin contar el costo que se deriva de la automedicación de analgésicos; en colombia, un alto porcentaje de la población manifiesta automedicación y uso de analgésicos diariamente o varios días a la semana (8, 9). este panorama del fenómeno de cronicidad del dolor propone un reto importante y de carácter urgente a los sistemas de salud y a los profesionales del área, en especial a enfermería, en el abordaje y cuidado a las personas con dolor crónico no maligno, y en el reconocimiento de aspectos fundamentales en el proceso, como el apoyo social y el afrontamiento del mismo, debido a que, como muestran los estudios, la relación entre el apoyo social percibido y el afrontamiento de la persona es fundamental, si se tiene en cuenta que las distintas formas de apoyo que presenta el sujeto generan diversos efectos sobre sus procesos de afrontamiento. desde esta perspectiva, el apoyo social puede favorecer la adaptación a acontecimientos vitales y proteger a las personas en crisis, de una gran variedad de estados patológicos (12, 13). para la disciplina de enfermería, el abordaje del dolor se constituye en uno de los fenómenos de mayor interés y pertinencia en la actualidad, que implica reconocerlo como uno de los problemas y necesidades de cuidado prioritarios en la atención de personas con enfermedad crónica. en este sentido, es indispensable identificar variables que puedan incidir en su alivio y manejo, ampliando los enfoques orientados en tratamientos farmacológicos. enfermería asume un papel determinante en el manejo de los usuarios con dolor, rol que está orientado a la identificación y el manejo del síntoma, a generar procesos educativos que tras465 apoyo social percibido y afrontamiento en personas con dolor crónico no maligno l maría consuelo amaya-ropero, gloria mabel carrillo-gonzález ciendan los aspectos informativos, a través de la consolidación de sistemas de apoyo y soporte social dirigidos a los usuarios, que incluyan las dimensiones de guía, educación, retroalimentación, interacción personal y social, entre otras. el dolor crónico no maligno, como un síntoma de gran complejidad, trae consecuencias relacionadas con reacciones emocionales y cambios corporales importantes que implican procesos de adaptación y afrontamiento. sin embargo, en la práctica de cuidado, se identifica que la persona no está preparada para hacer frente a esta complejidad. en este contexto, enfermería tiene un rol protagónico como parte del equipo multidisciplinario, para brindar información, orientación, educación y seguimiento a estos procesos de afrontamiento fundamentales en la nueva condición del paciente. humprey et al., a través del modelo para el manejo del síntoma, reafirman que los síntomas evolucionan de forma permanente, por lo que se requieren marcos generales para facilitar su comprensión, con el fin de diseñar, generar y probar estrategias que reporten impacto sobre indicadores de interés para las personas afectadas (14). ahora bien, investigaciones realizadas en población con enfermedad crónica, muestran el impacto que el apoyo social tiene, y documentan resultados positivos en relación con el desarrollo de mecanismos de afrontamiento, control de estrés, disminución de la ansiedad, la depresión y el aislamiento, generados por la experiencia de cronicidad. smith y mackie reportaron el gran impacto del apoyo social sobre la tasa de mortalidad de las personas con enfermedad crónica (15). el estudio retoma el referente teórico de enfermería planteado por hilberth, quien con base en la revisión de barrera y ainlay, define el apoyo social como “la diversidad de comportamientos naturales de ayuda de los que los individuos son receptores en interacciones sociales, la ayuda tangible, interacción íntima, la guía, la retroalimentación y la interacción social positiva” (16). de igual forma, plantea que el apoyo social percibido es el grado de satisfacción de la persona con enfermedad crónica, con cada uno de los comportamientos de ayuda a los que se ve expuesta por parte del proveedor de los mismos. de esta forma, el cuidado de enfermería se encuentra inmerso en los procesos de apoyo social de las personas, y reconoce en la familia y los amigos influencias importantes (16). el apoyo social se plantea como “una práctica de cuidado que se da en el intercambio de relaciones entre las personas y se caracteriza por expresiones de afecto, afirmación o respaldo de los comportamientos de otra persona, entrega de ayuda simbólica o material a otra persona” (17). el modelo teórico que más se ha empleado en el abordaje del afrontamiento es el planteado por lazarus y folkman, con su teoría del estrés y el afrontamiento; estos autores definen el afrontamiento como “los esfuerzos cognitivos y conductuales constantemente cambiantes que se desarrollan para manejar las demandas específicas externas o internas que son evaluadas como excedentes o desbordantes de los recursos del individuo” (18). la teoría planteada por lazurus y folkman busca explicar los mecanismos para enfrentar el estrés, es decir, aquellas demandas ambientales e internas que superan la capacidad de los recursos del individuo y ponen en peligro su bienestar. de tal manera, los estudios evidencian que las personas consideran el dolor como fuente primaria de estrés en sus vidas (19, 20). en este sentido, la experiencia de dolor crónico ha dejado de considerarse exclusivamente desde la dimensión física, para lograr un abordaje multidimensional en el que se destaca la importancia de la relación entre dolor crónico y estrés (21), donde las estrategias de afrontamiento son fundamentales en los procesos de adaptación y, por lo cual, el dolor crónico, se considera actualmente más que un síntoma, una enfermedad. por otra parte, lazarus y folkman han planteado la existencia de unas estrategias de afrontamiento más adaptativas que otras. las estrategias de afrontamiento activo se centran en el problema y el bienestar, e indican un mejor ajuste para confrontar la situación crítica, por tanto, se consideran más adaptativas (distracción, autoafirmación, autocontrol mental, búsqueda de información); por su parte, las estrategias de afrontamiento pasivo consisten en la ausencia de enfrentamiento o conductas de evitación y son consideradas desadaptativas; se centran en la emoción y en la enfermedad, se relacionan con un peor ajuste y se consideran estrategias menos adaptativas (religión y catarsis) (18). se debe resaltar que considerar una estrategia de afrontamiento como adaptativa o desadaptativa obedece a múltiples factores intra e interpersonales en un momento determinado. desde este punto de vista, no se puede establecer que hay una estrategia mejor que otra. sin embargo, varios estudios evidencian la correlación entre determinadas estrategias de afrontamiento y el grado de adaptación al dolor (19-22). 466 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 por lo anterior, surge la necesidad de realizar una investigación encaminada al abordaje de los fenómenos de apoyo social percibido y afrontamiento al dolor crónico no maligno que permita, desde el cuidado de enfermería, orientar la toma de decisiones, y el establecimiento y la implementación de acciones que generen impacto positivo en la salud de las personas y se conviertan en eje de las políticas en salud. el objetivo del presente estudio fue determinar la asociación entre el apoyo social percibido por las personas con dolor crónico no maligno de la ciudad de tunja y su afrontamiento. materiales y método estudio cuantitativo, descriptivo, de correlación, de corte transversal, realizado en la ciudad de tunja (colombia), a una muestra probabilística (23-25) de 340 personas con dolor crónico no maligno. los criterios de inclusión fueron: usuarios mayores de 18 años, que acudieron al servicio de consulta externa del hospital san rafael de tunja, en el periodo comprendido entre mayo y julio de 2012, con presencia de dolor crónico no maligno, y que consultaron en las diferentes especialidades de neurología, fisiatría, medicina interna y clínica del dolor. el estudio se enmarcó en el nivel de investigación de bajo riesgo, se garantizó el respeto a la dignidad humana, a la privacidad y a la intimidad; se soportó en los principios de beneficencia, justicia, autonomía, veracidad, lealtad, fidelidad y solidaridad, y contó con el aval del comité de ética en investigación de la facultad de enfermería y del comité de investigación de la ese hospital san rafael de tunja. se aplicaron los instrumentos a las personas que desearon participar voluntariamente, previo conocimiento por los participantes del propósito de la investigación y firma de consentimiento informado. se contó, además, con la autorización de los autores para el uso de los instrumentos. igualmente, se plantearon los mecanismos para garantizar la validez interna y externa del estudio; se garantizó la medición de las variables en un mismo momento (26). instrumentos se aplicaron los siguientes instrumentos: 1. caracterización de personas con enfermedad crónica: propuesto por el grupo de cuidado al paciente crónico y su familia, de la facultad de enfermería de la universidad nacional de colombia (27), que explora aspectos sociodemográficos del paciente así como tiempo de la enfermedad crónica, el número de horas que requiere para su cuidado, redes de apoyo, relación con la persona que lo cuida y grado de funcionalidad del paciente. 2. inventario de apoyo social en enfermedades crónicas (sscii, por sus siglas en inglés): diseñado en 1990 por gail hilbert (16), con el propósito de examinar los servicios brindados por los individuos en una situación específica: la enfermedad crónica. se mide la satisfacción percibida con cada uno de los comportamientos de apoyo. este instrumento presenta altos índices de validez y confiabilidad en su versión original. la traducción oficial al español se realizó en el año 2003, por el grupo de cuidado al paciente crónico y su familia, y la confiabilidad de la versión al español se hizo con 132 cuidadores principales de niños con enfermedad crónica, obteniéndose un alpha de cronbach de 0,95 (28). el instrumento tiene en total 38 ítems, agrupados en 5 subescalas de apoyo: interacción personal, guía, retroalimentación, asistencia tangible e interacción social positiva. estos ítems se evalúan con escala de likert de 6 puntos, desde “insatisfecho” hasta “muy satisfecho”: el número 1 indica insatisfacción, el número 6 indica satisfacción. los puntajes para cada uno de los 38 elementos se suman, con un rango posible entre 38 y 228. entre más alto el puntaje, mayor es el grado de satisfacción con el apoyo brindado por la persona. para su aplicación, se le pide a la persona identificar la persona más importante en su vida en el último mes. 3. cuestionario reducido de afrontamiento ante el dolor crónico (cad-r): elaborado por josé soriano y vicente monsalve en el año 2002, el instrumento estaba compuesto por 31 ítems distribuidos en 6 categorías (cad). en el año 2004, se valida la versión reducida del cuestionario cad (29), que consta de 24 ítems, distribuidos en 6 categorías: 1) autoafirmación: destaca la importancia que tiene en el paciente con dolor crónico no maligno, el no rendirse ante el dolor constante, dándose ánimos para hacer frente al mismo. 2) búsqueda de información: búsqueda de apoyo social instrumental, perseguir la obtención de información para poder controlar y disminuir el dolor. 3) religión: hace referencia a la necesidad de rezar y de emplear el uso de la religión para conseguir estabilidad y consuelo. 4) distracción: estrategia de afrontamiento adaptativa, que hace que el individuo deje de prestar atención al 467 apoyo social percibido y afrontamiento en personas con dolor crónico no maligno l maría consuelo amaya-ropero, gloria mabel carrillo-gonzález dolor. 5) catarsis: se refiere a la búsqueda de apoyo emocional desde el punto de vista de afrontamiento emocional. 6) autocontrol: se refiere a los esfuerzos mentales por controlar el dolor. estos ítems se evalúan con escala de likert de 5 puntos, 1 = nunca, 2 = pocas veces, 3 = ni muchas ni pocas, 4 = muchas veces, 5 = siempre. los puntajes para cada uno de los 38 elementos se suman, con un rango posible entre 24 y 120. el cad-r se revela como un instrumento equivalente a su antecesor (cad), al comprobar que, tras la eliminación de 7 ítems, el cuestionario mantiene su consistencia interna con un alfa de cronbach entre 0,74 y 0,94; análisis de correlación de pearson, entre 0,47 y 0,81. la confiabilidad del instrumento cad-r para el contexto local (tunja), se probó en una muestra de 100 individuos realizando análisis de la consistencia interna (alfa de cronbach) y prueba de la estabilidad temporal del cuestionario utilizando el coeficiente de correlación de pearson. los resultados de la confiabilidad del instrumento para el contexto local (tunja), corresponden a un alfa de cronbach de 0,86, con un análisis de correlación de pearson de 0,80. se aprecia una estabilidad que oscila de moderada a alta (entre 0,56 y 0,85) entre las puntuaciones de los individuos en cada una de las dimensiones. 4. escala visual análoga (eva): escala unidimensional ideada por huskinson en 1976; es el método de medición empleado con más frecuencia para valoración del dolor. consiste en una línea de 10 cm que representa el espectro continuo de la experiencia dolorosa. es un instrumento simple, sólido, sensible y reproducible, siendo útil para reevaluar el dolor en el paciente en diferentes ocasiones (30). los datos fueron analizados en el programa estadístico spsss versión 16.0 ®, se emplearon medidas de tendencia central y de dispersión, y análisis de correlación. las hipótesis planteadas fueron verificadas a un nivel de confianza del 95 %. resultados características sociodemográficas de las personas con dolor crónico no maligno de las 340 personas con dolor crónico no maligno participantes en el estudio, el 62,35 % son mujeres, con edades comprendidas en su mayoría entre los 36 a los 59 años (43,82 %). el 92,65 % de las personas saben leer y escribir; el nivel de escolaridad de la población es heterogéneo: el 27,06 % de los participantes ha cursado primaria incompleta, el 19,71 % alcanzó a terminarla. más de la mitad de la población (55,3 %) se encuentra casada o en unión libre; el 82,94 % pertenece a los estratos 1 y 2; el 47,06 % de las personas se desempeña en actividades propias del hogar. el 40 % de las personas con dolor crónico no maligno, participantes en el estudio, considera que la familia es su principal apoyo, frente a un 3,24 % de la población que refiere no tener ningún tipo de apoyo. características del dolor en las personas con dolor crónico no maligno el 70,59 % de los participantes tienen un diagnóstico médico relacionado con patologías de origen neurológico o neuroquirúrgico; entre las enfermedades más frecuentes de este origen, se encuentran las patologías de columna (29,71 %), migrañas y cefaleas de distinto origen (16,47 %), y con diagnóstico de neuropatía de extremidad superior o inferior el 7,65 % de las personas. en segundo lugar de diagnóstico médico, se halló la patología de origen óseo o articular, con un 14,12 %, siendo las más frecuentes en la población la osteoartritis y la artritis reumatoidea. en consecuencia, las personas refieren que el dolor se localiza en cabeza o cara (30,89 %), espalda (23,24 %), miembros inferiores (14,41 %). un 13,82 % de las personas manifiesta presentar dolor crónico en varias partes de su cuerpo. el dolor de tipo nociceptivo es el más frecuente, con un 46,76 %; el dolor neuropático representa el 39,12 %. la mayoría de los participantes (46,47 %) presenta el dolor hace más de tres años (> 37 meses). el 41,76 % manifiesta dolor severo (8-10), el 34,76 % moderado (5-7), con una intensidad de dolor promedio de 6,5, con un mínimo de 2 y un máximo de 10. características de la condición de cronicidad de las personas con dolor crónico no maligno el 62,35 % de las personas con dolor crónico no maligno tiene cuidador; en el 26,47 % de los casos el cuidador es el esposo (a), en el 18,53 % es un hijo (a), en el 11,76 % el cuidador es la madre o el padre; en menor porcentaje cumplen la función de cuidadores los hermanos, abuelos, amigos, nietos, sobrinos o una persona particular. el 34,71 % de los participantes manifestó que la edad de su cuidador es mayor que la suya. se evidencia que el número de horas de ayuda de cuidado al día que estas personas demandan es, en su mayoría, menor a 6 horas día (56,47 %). el 65 % tiene una baja dependencia de cuidado (6 a 8 puntos). 468 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 apoyo social percibido por las personas con dolor crónico no maligno la puntuación mínima obtenida fue de 43 y la máxima de 228, con una media de 175,2, mediana de 186 y una desviación estándar de 30,08, lo que indica que el apoyo social percibido por las personas con dolor crónico no maligno es alto (figura 1). figura 1. histograma apoyo social percibido en personas con dolor crónico no maligno fuente: datos de la investigación. el análisis por dimensiones evidencia los mayores porcentajes de satisfacción en: 1) guía/información: cuando les brindan indicación sobre cómo buscar asistencia (80 %) y lo que puede esperar en una situación a punto de ocurrir (78,24 %). 2) interacción personal: la persona que brinda el apoyo lo acepta totalmente, incluyendo “lo mejor o peor de sí” (76,47 %). 3) retroalimentación: la ayuda que le brinda la persona para comprender por qué no hace algo bien (75,59 %), así como el hecho de que “revisen con ellos los consejos que les dan” (75,29 %). 4) interacción social: puede contar con la persona que le brinda apoyo para distraerse de las preocupaciones (73,24 %). 5) ayuda tangible: cuando la persona identificada como su apoyo “realizó alguna tarea que normalmente ellos desarrollan” (71,47 %). el mayor grado de insatisfacción se presentó en las dimensiones: interacción personal, en el ítem “dicen que estoy bien como estoy” (21,47 %). interacción social: respecto al ofrecimiento de alternativas de distracción y recreación (7,65 %). ayuda tangible: insatisfacción en los ítems “me dan regalos” (6,76 %) y “me dieron transporte” (6,47 %). afrontamiento de las personas con dolor crónico no maligno la media obtenida en la investigación fue de 88,2; con una desviación estándar de 10,32; un mínimo de 55; un máximo de 115 puntos y una mediana de 115, lo que indica que las personas con dolor crónico no maligno tienden a emplear en alta proporción alguna estrategia de afrontamiento del dolor (figura 2). figura 2. histograma afrontamiento en personas con dolor crónico no maligno fuente: datos de la investigación. el análisis por dimensiones muestra que las estrategias de afrontamiento del dolor crónico más utilizadas son las de religión: más del 70 % de las personas manifiestan que “siempre rezan” y “emplean la fe para aliviar el dolor y obtener fuerza y guía sobre el mismo”. en su orden, le siguen la dimensión autoafirmación: el 67,65 % las personas se dicen a sí mismas que tienen que ser fuertes y el 63,24 % se dan ánimos para aguantar el dolor y piensan que han de tener fuerzas y no desfaller. distracción: el 61,76 % de las personas piensan en otra cosa cuando tienen el dolor. catarsis: el 57,65 % de los participantes “habla con la gente sobre su dolor porque lo hace sentir mejor”. búsqueda de información: muchas veces, el 55 % de las personas con dolor crónico intentan que les expliquen qué pueden hacer para disminuir el dolor. autocontrol mental: en muchas oportunidades, el 52,35 % de las personas se concentra en el punto que más le duele intentando disminuir el dolor. entre las estrategias de afrontamiento al dolor crónico menos empleadas se evidencia que el 25 % de las personas pocas veces 469 apoyo social percibido y afrontamiento en personas con dolor crónico no maligno l maría consuelo amaya-ropero, gloria mabel carrillo-gonzález hablan con un profesional del problema para que le ayude a hacerle frente (búsqueda de información); el 21,28 % pocas veces tabla 1. análisis porcentual por dimensiones de apoyo social percibido en personas con dolor crónico no maligno se olvida de todo para concentrarse en el dolor exclusivamente intentando que desaparezca (autocontrol mental) (tabla 1). ítem nunca % pocas veces % ni muchas ni pocas % muchas veces % siempre % religión rezo para curarme 2,06 4,12 6,76 9,41 77,65 rezo para conseguir fuerza y guía sobre el problema 2,65 4,12 2,65 15,88 74,71 utilizo la fe para aliviar mis dolores 2,94 4,41 3,53 14,41 74,71 rezo para que mis dolores desaparezcan 2,35 4,71 4,12 17,35 71,47 catarsis busco a algún amigo o allegado que me comprenda y me ayude a sentirme mejor con el dolor 7,35 19,71 22,65 40,59 9,71 cuando tengo dolor les digo a los demás lo mucho que me duele, pues el compartir mis sentimientos me hace encontrarme mejor 2,94 15,00 22,65 49,12 10,29 cuando tengo dolor intento hablar con alguien y contarle lo que me pasa. esto me ayuda a soportarlo 3,53 10,88 21,76 54,71 9,12 hablo con la gente de mi dolor, porque el hablar me ayuda a sentirme mejor 3,82 11,47 20,59 57,65 6,47 autocontrol mental me olvido de todo y me concentro en mi dolor intentando que desaparezca 10,0 21,28 25,00 35,59 8,24 cuando tengo dolor me concentro en él e intento disminuirlo mentalmente 4,71 13,82 23,82 49,12 8,53 cuando tengo dolor me concentro en su localización e intensidad para intentar controlarlo 3,82 19,12 21,18 49,71 6,18 me concentro en el punto en que más me duele intentando disminuir el dolor 5,29 18,82 18,53 52,35 5,00 distracción ignoro el dolor pensando en otra cosa 2,94 11,18 28,53 49,12 8,24 cuando tengo dolor pienso en otra cosa 2,35 8,24 17,65 61,76 10,00 intento recrear mentalmente un paisaje 12,35 17,35 18,53 49,12 2,65 cuando tengo dolor imagino situaciones placenteras 7,65 10,88 18,53 53,82 9,12 autoafirmación cuando tengo dolor no me rindo, peleo 7,65 12,65 19,12 50,29 10,29 me doy ánimos para aguantar el dolor 0,88 3,53 12,94 63,24 19,41 me digo a mí mismo que tengo que ser fuerte 0,29 2,65 7,94 67,65 21,47 pienso que he de tener fuerzas y no desfallecer 0,0 1,47 5,29 63,24 30,00 470 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 asociación entre apoyo social percibido y afrontamiento el análisis de la correlación entre el apoyo social percibido y el afrontamiento de personas con dolor crónico no maligno, evidencia una correlación débil (menor a 0,3) positiva, estadísticamente significativa (correlación diferente de cero, con valores p < 0,05) (figura 3). figura 3. diagrama de dispersión de la correlación existente entre apoyo social percibido y afrontamiento en personas con dolor crónico no maligno fuente: datos de la investigación. respecto a la correlación de los tipos de afrontamiento: pasivo (corresponde a las dimensiones catarsis y religión) y activo (consta de las dimensiones autocontrol mental, autoafirmación, distracción y búsqueda de información) que utilizan las personas con dolor crónico no maligno y el soporte social, se identificó que tanto para el afrontamiento pasivo como para el activo, existen correlaciones débiles (inferiores a 0,3), las cuales fueron correlaciones positivas y estadísticamente significativas (correlación diferente de cero, con valores p < 0,05) (tabla 3). tabla 3. correlación entre apoyo social percibido y afrontamiento pasivo y activo fuente: datos de la investigación. búsqueda de información hablo con un profesional (médico, psicólogo, sacerdote, etc.) del problema para que me ayude a hacerle frente 12,06 25,88 18,53 35,00 8,53 hablo con alguien que puede hacer algo concreto sobre mi dolor 4,71 17,06 20,59 49,12 8,53 intento que me expliquen qué puedo hacer para disminuir el dolor 3,53 12,94 12,35 55,00 16,18 busco a algún amigo, familiar o profesional para que me aconseje sobre cómo superar la situación 3,24 14,71 20,59 52,65 8,82 coeficiente apoyo social percibido y afrontamiento apoyo social percibido y afrontamiento pasivo apoyo social percibido y afrontamiento activo correlación de pearson 0,242 0,181 0,212 sig. (bilateral) 0,000 0,000 0,000 n 340 340 340 fuente: datos de la investigación. se observó relación estadísticamente significativa (correlación diferente de cero, con valores p < 0,05) entre las dimensiones: • afrontamiento y soporte social, interacción personal, guía, retroalimentación, asistencia tangible e interacción social positiva. • catarsis y soporte social, interacción personal, guía, retroalimentación, asistencia tangible e interacción social positiva. • autocontrol mental y soporte social, guía, retroalimentación e interacción social positiva. • distracción y soporte social, interacción personal, guía y retroalimentación. • búsqueda de información y soporte social, interacción personal, guía, retroalimentación, asistencia tangible e interacción social positiva. discusión la investigación apoya estudios realizados en distintos contextos poblacionales, que evidencian el predominio de las mujeres 471 apoyo social percibido y afrontamiento en personas con dolor crónico no maligno l maría consuelo amaya-ropero, gloria mabel carrillo-gonzález con la presencia de dolor crónico no maligno (8, 23, 31). dunn plantea que la edad, la raza y el sexo son estímulos contextuales, es decir, estímulos que están presentes en la situación y que contribuyen a las consecuencias que genera el dolor (estímulo focal) en la persona y que afecta su proceso de adaptación (32). la investigación evidencia la problemática de dolor crónico no maligno, con predominio en etapas de adulto maduro y adulto mayor; hallazgo similar al encontrado por duarte, con una edad media de 53,8 años (23). los participantes en esta etapa se encuentran en una fase de consolidación de roles sociales, disminución de funciones físicas, que implica modificación en el estilo de vida. su capacidad de aprendizaje y exploración está en un alto nivel, lo que le facilita la modificación de conductas y adopción de estrategias de afrontamiento activo ante el dolor. el estudio reporta bajos niveles de escolaridad en la población, lo cual, según plantean hoyos y castillo (33), representa un factor psicológico que interviene en el afrontamiento del dolor crónico y es predisponente al mismo. desde esta perspectiva, teniendo en cuenta que el afrontamiento del dolor crónico aborda las dimensiones de guía y búsqueda de información como estrategias de afrontamiento activo, es clave para los profesionales de enfermería que al brindar apoyo social, desde procesos educativos, se planeen intervenciones, teniendo en cuenta el nivel de formación de los grupos, empleando las herramientas que brinda la educación para la salud y los procesos dialógicos con un lenguaje claro, sencillo y pertinente. como en otras investigaciones (23), se reconoce a la pareja como un apoyo social significativo para la persona y para el afrontamiento en situación de enfermedad crónica; sin embargo, las relaciones de pareja pueden verse comprometidas de manera importante en las personas con dolor crónico, debido a que ven afectados sus hábitos de vida, rutina diaria y actividad sexual (9). la población de estudio se encuentra en una etapa de importante productividad laboral, que puede llevar a la exposición a factores de riesgo para la presencia de dolor crónico, y, en consecuencia, generar una problemática tanto para empleadores como trabajadores, con costos por ausentismo laboral que están por el orden de los 23 mil millones de pesos por dolor crónico incapacitante (9). igualmente, afecta el clima organizacional, debido a los cambios en la capacidad de trabajo, ejecución y estado de ánimo (34). por lo anterior, las intervenciones de cuidado a las personas con dolor crónico no maligno deben proveer herramientas dirigidas al ambiente laboral, como escenario clave para la prevención del dolor crónico, y, a su vez, este contexto representa una importante red de apoyo social, que facilita los procesos de afrontamiento activo del dolor para las personas. la investigación evidencia a la familia como principal fuente de apoyo, en concordancia con estudios realizados en personas con enfermedad crónica, que concluyen que la familia es el principal proveedor de apoyo social y emocional, a través del afecto y la afirmación; en relación con la enfermedad crónica, este apoyo permite asumir una actitud positiva ante la misma (35). el estudio apoya investigaciones a nivel mundial, que evidencian que las patologías que más se asocian con dolor crónico no maligno son de origen neurológico, neuroquirúrgico, osteoarticular y músculoesquelético, con importante compromiso en la vida diaria de las personas (10). en colombia, los estudios nacionales de dolor evidencian la migraña, artrosis, lumbalgia, hernias discales y tendinitis como los cinco diagnósticos más frecuentes en la población (9), y principales causantes de ausentismo laboral y de afectación en la calidad de vida de las personas en etapas productivas debido a que estas enfermedades tienen tendencia a ser limitantes e incapacitantes. similar a los resultados de la investigación, al indagar por localización del dolor, el craneofacial ocupa el primer lugar, no solo en el contexto colombiano, sino a nivel mundial. daza (36) plantea que el 47 % de la población del planeta padece cefalea, con un impacto significativo en la persona, la economía y la sociedad; afecta a más del 80 % de las mujeres, la entidad más incapacitante es la migraña, con afectación en el entorno familiar, social y laboral. sin embargo, de acuerdo con la organización mundial de la salud (oms), es poco reconocida en el sector salud. la investigación reporta que la población presenta dolor moderado a severo en forma crónica. varios estudios han encontrado resultados similares con antigüedad del dolor que supera los 5 años, intensidad de moderada a severa en porcentajes muy significativos y promedios de intensidad de 7 con valoración en la escala eva (5, 8). el análisis general del apoyo social percibido por personas con dolor crónico no maligno es, en general, alto. se identifican 472 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 elementos determinantes en alta percepción de apoyo social de las personas con dolor crónico no maligno como acompañamiento y retroalimentación, saber que pueden contar con alguien, disposición de escucha, intereses comunes, aceptación por el otro, orientación, diálogo, comprensión, motivación por el autocuidado, distracción y preocupación por el otro. en concordancia con lo planteado por barrera et al. (27), el apoyo social es un recurso de particular valor en la experiencia de cuidado, que minimiza los efectos negativos de la crisis, cuando la persona manifiesta elevada satisfacción respecto al mismo, desde el punto de vista instrumental y emocional. vinaccia et al. (12) plantean que el apoyo social percibido se relaciona ampliamente con un afrontamiento eficaz y adaptación a la enfermedad, y que es más importante la percepción que la persona tiene del adecuado apoyo social que el soporte que realmente recibe. el análisis general que surge en la investigación evidencia que la muestra estudiada emplea tanto estrategias de afrontamiento activo como pasivo. a nivel del afrontamiento activo, las dimensión que mayor relevancia mostró fue la autoafirmación. respecto a afrontamiento pasivo, la dimensión que más se utiliza es la religión, que a su vez ocupa el primer lugar entre todas las dimensiones. estos hallazgos se asemejan a los resultados encontrados en el estudio de soucase et al. (37), donde la autoafirmación, búsqueda de información y religión son las estrategias de afrontamiento más utilizadas por una muestra de personas diagnosticadas con fibromialgia. los resultados obtenidos evidencian la existencia de correlación, aunque débil, entre el apoyo social percibido y el afrontamiento, reafirmando los referentes teóricos y las investigaciones que han abordado el tema y concluyen la existencia de asociación (23, 38). igualmente, los hallazgos evidencian la correlación existente entre soporte social percibido y las estrategias de afrontamiento activo en mayor proporción frente al afrontamiento pasivo, similiar a los resultados obtenidos por duarte, quien reporta en su estudio que los mayores niveles de apoyo social se relacionan con estrategias de afrontamiento activas (23). por otra parte, se observa que la religión es la principal estrategia de afrontamiento del dolor crónico que tienen los participantes, estrategia que se reconoce como pasiva y que implica dificultad en los procesos de adaptación de la persona; el análisis subsiguiente se enmarca en el hecho de que la religión se encuentra arraigada en la cultura y creencias boyacenses. respecto a la búsqueda de información acerca de un profesional para dialogar sobre el dolor, el estudio demuestra que un porcentaje significativo manifiestó nunca o muy pocas veces emplear esta estrategia de afrontamiento, lo que puede relacionarse con el reconocimiento del dolor crónico por los profesionales de la salud, como lo menciona daza (36). por otro lado, las correlaciones estadísticamente significativas ponen de manifiesto la importancia de reconocer el soporte social como un derrotero clave para orientar las intervenciones de enfermería que puedan incidir en estrategias de afrontamiento de usuarios con dolor crónico no maligno. asimismo, las dimensiones de guía, retroalimentación e interacción social positiva del apoyo social se deben explorar como estrategias que pueden mediar la catarsis, el autocontrol mental, la distracción y la búsqueda de información. ahora bien, los valores obtenidos en el coeficiente de correlación evidencian la necesidad de explorar aún más el apoyo social y el afrontamiento en personas con dolor crónico no maligno. se requieren estudios con abordajes cualitativos que describan la experiencia de vivir con dolor crónico no maligo, comprender los significados del proceso de afrontamiento que los usuarios atribuyen a su condición de salud, así como las posibles fuentes, recursos y redes de apoyo social que reconocen en su contexto particular. por otro lado, se hace inminente la necesidad de abordar fenómenos relacionados propios de la disciplina de enfermería, como la adaptación, que cuentan con desarrollos teóricos y conceptuales que incluyen el afrontamiento dentro de sus marcos de referencia. conclusiones la investigación se considera un primer referente en colombia que aborda la asociación entre apoyo social y afrontamiento en personas con dolor crónico no maligno. el estudio proporciona un soporte teórico e investigativo para la generación de estrategias y lineamientos de atención en salud, direccionadas a la orientación, el acompañamiento y la facilitación de los procesos de afrontamiento y adaptación de las personas al dolor crónico no maligno. 473 apoyo social percibido y afrontamiento en personas con dolor crónico no maligno l maría consuelo amaya-ropero, gloria mabel carrillo-gonzález las intervenciones de apoyo social adaptadas a contextos y ámbitos en los que se encuentran los usuarios, se deben considerar como iniciativas para fortalecer las estrategias de afrontamiento de personas que cursan con dolor crónico no maligno. las acciones se pueden enfocar en las dimensiones de apoyo social: guía e información (fortaleza) y ayuda tangible (oportunidad). en afrontamiento activo, la autoafirmación (fortaleza) y distracción, y búsqueda de información en los profesionales de la salud (oportunidades de mejoramiento). agradecimientos las autoras agradecen a la ese hospital san rafael de tunja y a las personas que conformaron la muestra del estudio. el estudio obtuvo el apoyo financiero de la división de investigación de bogotá (dib) de la universidad nacional de colombia, y está enmarcado en los proyectos del grupo de investigación cuidado al paciente crónico y su familia. referencias 1. fernández b, márquez c, de las mulas m. pain and disease: historical evolution. i. from prehistory to enlightenment. rev soc esp dolor. 1999;6(4):281-91. 2. kapur b, lala p, shaw j. pharmacogenetics of chronic pain management. clinical biochemistry. 2014;47(13):1169-1187. 3. pautex s, rexach-cano l, van den noortgate n, cedraschi c, cruz-jentoft a. management of chronic pain in old patients: belgium, spain and switzerland. european geriatric medicine. 2013;4(4):281-287. 4. ibarra e. una nueva definición de “dolor”. un imperativo en nuestros días. editorial. rev soc esp dolor. 2006;6:65-72. 5. casals m, samper d. epidemiología, prevalencia y calidad de vida del dolor crónico no oncológico. estudio itaca. rev soc esp dolor. 2004;11(5):260-69. 6. breivik h, collett b, ventafridda v, cohen r, gallacher d. survey of chronic pain in europe: prevalence, impact on daily life, and treatment. eur j pain. 2006;10(4):287-333. 7. bistre s. el dolor crónico en américa latina. rev iberoamericana del dolor. 2007;3:7-9. 8. díaz r, marulanda f, sáenz x. estudio epidemiológico del dolor crónico en caldas, colombia (estudio dolca). acta med colomb. 2009;34(3):96-102. 9. asociación colombiana para el estudio del dolor. quinto estudio nacional del dolor. 2010. 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[visitado 2011 sept 18]. disponible en: http://bvs.sld.cu/revistas/san/vol10_4_06/san05406.htm 36. daza j, editor. dolor craneofacial. guías fisiopatológicas, diagnósticas y terapéuticas. bogotá: asociación colombiana para el estudio del dolor; 2012. 37. soucase b, monsalve v, soriano jf. estrategias de afrontamiento al dolor y calidad de vida en pacientes diagnosticados de fibromialgia. rev soc dolor. 2004;11(6):353-59. 38. pastor ma, rodríguez j, lópez s. afrontamiento, apoyo social, calidad de vida y enfermedad. psicothema. 1993;5(s): 349-372. 425 436 traducao e adaptacao transcultural.indd 425 arménio cruz1 antónio marcos tosoli-gomes2 pedro miguel parreira3 denize cristina de oliveira4 tradução e adaptação transcultural do hospitalized elderly needs awareness scale (henas) para a língua portuguesa (brasil e portugal) 1 orcid.org/0000-0003-3254-3176. escola superior de enfermagem de coimbra, portugal. acruz@esenfc.pt 2 orcid.org/0000-0003-4235-9647. universidade do estado do rio de janeiro, brasil. professor@uerj.com.br 3 orcid.org/0000-0002-3880-6590. escola superior de enfermagem de coimbra, portugal. parreira@esenfc.pt 4 orcid.org/0000-0002-0830-0935. universidade do estado do rio de janeiro, brasil. professor@uerj.com.br recibido: 30 de noviembre de 2015 enviado a pares: 16 de diciembre de 2015 aceptado por pares: 8 de agosto de 2016 aprobado: 12 de diciembre de 2016 doi: 10.5294/aqui.2017.17.4.6 para citar este artículo / to reference this article / para citar este artigo cruz a., tosoli-gomes am., parreira p. & oliveira dc. tradução e adaptação transcultural da hospitalized elderly needs awareness scale (henas) para a língua portuguesa (brasil e portugal). aquichan. 2017; 17(4): 425-436. doi: 10.5294/aqui.2017.17.4.6 resumo objetivos: traduzir e adaptar o hospitalized elderly needs awareness scale (henas) para o português do brasil e o de portugal. metodologia: seguiram-se os procedimentos metodológicos de adaptação cultural e linguística: tradução inicial, síntese das traduções, retroversão, avaliação por comitê de peritos da equivalência semântica, idiomática, cultural e conceitual. a versão adaptada foi testada (pré-teste) com aplicação da escala a 249 enfermeiros portugueses e brasileiros em 2014. resultados: não se encontraram palavras ou expressões consideradas divergentes, com exceção da palavra awareness no título do instrumento e da expressão medical acuity do item k. de acordo com o estágio iv do processo de tradução e adaptação cultural, o comitê de peritos propôs alterar a expressão 75 anos ou mais por 65 anos ou mais, na introdução do instrumento. na versão portuguesa do brasil, apenas se substituiu a palavra sanita por vaso sanitário. com relação à versão adaptada, os participantes não colocaram questões nem referiram dificuldades no preenchimento do instrumento. conclusões: o processo de tradução e adaptação cultural do henas para a língua portuguesa seguiu as etapas recomendadas internacionalmente, e do qual se obteve equivalência semântica, idiomática, cultural e conceitual. são necessárias novas pesquisas para avaliar outras propriedades do instrumento e seu comportamento em amostras diferentes. palavras-chave avaliação em saúde; enfermagem; qualidade da assistência à saúde; idoso fragilizado; serviços de diagnóstico ; estudos de validação (fonte: decs). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 425-436 426 aquichan issn 1657-5997 eissn 2027-5374 año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 425-436 traducción y adaptación transcultural del hospitalized elderly needs awareness scale (henas) para la lengua portuguesa (brasil y portugal) resumen objetivos: traducir y adaptar el hospitalized elderly needs awareness scale (henas) para el portugués de brasil y de portugal. metodología: se siguieron los procedimientos metodológicos de adaptación cultural y lingüística: traducción inicial, síntesis de las traducciones, retroversión, evaluación por comité de expertos de la equivalencia semántica, idiomática, cultural y conceptual. la versión adaptada fue probada (pre-test) con aplicación de la escala a 249 enfermeros brasileños y portugueses en el 2014. resultados: no se encontraron palabras o expresiones consideradas divergentes, a excepción de la palabra awareness en el título del instrumento y de la expresión medical acuity del ítem k. de acuerdo con la fase iv del proceso de traducción y adaptación cultural, el comité de expertos planteó alterar la expresión 75 años o más por 65 años o más en la introducción del instrumento. en la versión portuguesa de brasil, solo se reemplazó la palabra sanita por vaso sanitário. en cuanto la versión adaptada, los participantes no presentaron dudas ni refirieron dificultades en completar el instrumento. conclusiones: el proceso de traducción y adaptación cultural del henas para la lengua portuguesa siguió las etapas recomendadas internacionalmente y del cual se obtuvo equivalencia semántica, idiomática, cultural y conceptual. son necesarias nuevas investigaciones para evaluar otras propiedades del instrumento y su comportamiento en muestras distintas. palabras clave adulto debilitado; calidad de la asistencia a la salud; enfermería; estudios de validación; evaluación en salud; servicios de diagnóstico (fuente: decs). 427 tradução e adaptação transcultural do hospitalized elderly needs awareness scale (henas) para a língua portuguesa (brasil e portugal) l arménio cruz e outros translation and transcultural adaptation of the hospitalized elderly needs awareness scale (henas) for the portuguese language (brazil and portugal) abstract objectives: translate and adapt the hospitalized elderly needs awareness scale (henas) into portuguese for brazil and portugal. methodology: the methodological procedures for cultural and linguistic adaptation were followed; namely, initial translation, synthesis of translations, retroversion, and an evaluation of semantic, linguistic, cultural and conceptual equivalence carried out by a committee of experts. the adapted version was tested (pre-test) by applying the scale to 249 brazilian and portuguese nurses during 2014. results: no words or expressions considered divergent were found, with the exception of the word awareness in the title of the instrument and the expression medical acuity in item k. in keeping with phase iv of the cultural translation and adaptation process, the expert committee proposed changing the expression 75 years or more to 65 years or more in the introduction to the instrument. in the portuguese version for brazil, the word sanita was replaced by the expression vaso sanitário. as for the adapted version, the participants did not express doubts or refer to difficulties in completing the instrument. conclusions: the process of translation and cultural adaptation of henas for the portuguese language followed the stages recommended internationally and from which semantic, idiomatic, cultural and conceptual equivalence was obtained. further research is needed to evaluate other properties of the instrument and its behavior with different samples. keywords health evaluation; nursing; quality of health care; frail elderly adults; diagnostic services; validation studies (source: decs, bireme). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 425-436 428 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 introdução as alterações e as tendências demográficas que se verificam no mundo, em face das multipatologias e dos níveis acentuados de dependência apresentados pelas pessoas idosas, têm sido acompanhadas do aumento do risco de hospitalização dessa população. nesse contexto, os profissionais de saúde, nomeadamente os enfermeiros, veem aumentar a complexidade na sua prática de cuidados de enfermagem, inscrita dentro de um novo paradigma do cuidar. contudo, a realidade mostra que as práticas clínicas, de uma maneira geral, ainda não refletem essas mudanças que se verificam na estrutura e no contexto das problemáticas associadas ao processo saúde-doença da pessoa idosa, do qual o declínio funcional (df) é exemplo. o df e o descondicionamento dos idosos hospitalizados não é um fenômeno novo e continua a ser uma realidade nos serviços de internamento, apesar do esforço de seus gestores e dos profissionais de enfermagem. as pessoas idosas são os clientes que, proporcionalmente a outras faixas etárias, mais utilizam os serviços de internamento hospitalares; portanto, eles estão sujeitos à complexidade desse sistema e a todos os fatores nele inscritos (1). de fato, a causa do df dos idosos é multifacetada com responsabilidade partilhada entre a gestão do hospital, as equipas de saúde e o próprio idoso. alguns estudos confirmam o desenvolvimento do df e do descondicionamento de idosos no período de internamento, e observa-se associação entre o comprometimento funcional e o aumento do número de dias de hospitalização (2), justificado pelo repouso prolongado no leito durante o internamento (3). o df inclui mudanças na autonomia funcional e na mobilidade, e nele se identificam as complicações que os idosos podem desenvolver durante a hospitalização (4). os riscos do repouso no leito estão estabelecidos e podem incluir a imobilidade prolongada, a perda de tecido ósseo, a desidratação, a má nutrição, o delirium, a privação sensorial, o isolamento, a lesão por pressão e a incontinência (5-6). a evidência atual tem identificado alguns fatores de risco concorrentes para o df relacionados com a hospitalização: fatores demográficos, estado cognitivo e psicológico, estado funcional antes da hospitalização, fatores sociais, comorbilidade e polimedicação, mobilidade, estado nutricional, défices sensoriais e síndromes geriátricas (7). num estudo realizado em contexto hospitalar, os autores (8) reportaram que 65 % dos pacientes idosos admitidos apresentavam sinais de descondicionamento após dois dias de internamento. entre o segundo dia de internação e a alta clínica, 67 % deles não conseguiam melhorar, e em mais de 10 % das situações ocorreram agravamento da situação. noutro estudo, realizado num centro hospitalar universitário, em unidades de internamento de medicina, com uma amostra de 118 idosos, verificou-se que, por meio da avaliação da frequência de deambulação no corredor, a falta de atividade durante o período de internamento contribuía para o descondicionamento e o df (9). o df pode também colocar em risco a segurança do doente. falamos de quedas, que são consideradas os eventos adversos mais frequentes nos hospitais, normalmente, um fenómeno multifatorial que congrega causas individuais e/ou ambientais, com consequências significativas do ponto de vista físico, psicológico e social (10). o medo de cair pode também contribuir para limitar a atividade física e a mobilidade durante o internamento, o que resulta em df (11). outros fatores podem contribuir para o desenvolvimento desse fenómeno, reconhecendo-se que a hospitalização, mais do que a própria doença, pode ser a causa provável do declínio que se verifica (12). o ambiente e a cultura organizacional hospitalar, assim como a formação dos seus profissionais, os seus valores culturais e as representações sociais que estes têm da pessoa idosa podem também interferir em todo o processo de transição doença-saúde do idoso. assim, o processo de intervenção terapêutica holística, a segurança do idoso e a qualidade geral dos cuidados prestados serão afetados (13). embora exista uma conceção global na reabilitação para os cuidados de enfermagem no qual os enfermeiros se envolvem ativamente nas diversas atividades respeitantes à promoção ao autocuidado estimulando e incentivando a participação do utente em tais atividades, muitas vezes ocorre uma tendência para que os enfermeiros substituam os doentes, em vez de os ajudar na concretização de determinadas atividades (por exemplo, facultam um urinol em vez de o ajudar a ir até o vaso sanitário; o banho é dado no leito em vez de ajudar o doente a deslocar-se ao chuveiro) (14). ou seja, nem sempre o ambiente e a prestação de cuidados se realizam de forma que a independência funcional seja maximizada (2). 429 tradução e adaptação transcultural do hospitalized elderly needs awareness scale (henas) para a língua portuguesa (brasil e portugal) l arménio cruz e outros alguns autores referem também que pode existir alguma associação entre o df e a falta de consciencialização e/ou de conhecimentos que os profissionais de saúde têm dos referidos fatores de risco, e/ou de os poder prevenir ou minimizar (15-16). esse problema com características iatrogénicas levanta questões éticas em todo o processo de transição doença-saúde e na qualidade dos cuidados prestados a esse grupo de doentes, que deve preocupar cada vez mais os responsáveis pela área da formação e da prática clínica dos enfermeiros, na implementação de estratégias e medidas que permitam a mudança dessa realidade. nos últimos anos, tem havido maior preocupação com a execução de cuidados de enfermagem individualizados e holísticos, assente no aumento das competências dos enfermeiros perante exigências e responsabilidades profissionais cada vez maiores (17-18). é nesse contexto que alguns autores (13, 19) assinalam o impacto dos benefícios desse novo paradigma de cuidados na gestão hospitalar, nos enfermeiros ou nos próprios idosos hospitalizados, avaliado por meio de um processo de análise das perceções dos enfermeiros sobre as suas responsabilidades profissionais, conjuntamente com a avaliação das necessidades funcionais de seus pacientes idosos. embora seja um fenómeno reconhecido e multifatorial, existe necessidade de clarificação acerca da perceção e do conhecimento que os enfermeiros têm dos fatores que contribuem para o df e das suas implicações. as necessidades do idoso hospitalizado em termos de mobilidade tornam-se por isso fulcrais; em muitos aspectos, relacionam-se com a habilidade e a capacitação necessárias para manter autonomia na realização dos autocuidados, prevenindo complicações e promovendo a saúde nos seus componentes físico, mental e social, e a qualidade de vida. apesar das evidências existentes, é nesse enquadramento que se torna importante e pertinente conhecer a perceção que os enfermeiros têm dos fatores que contribuem para o aumento do df observado em idosos hospitalizados, nomeadamente sobre as suas necessidades funcionais, pelo que colocamos as seguintes questões: os enfermeiros estão conscientizados de que os idosos apresentam características únicas e necessidades que são diferentes de outros pacientes? os enfermeiros estão conscientizados e têm conhecimento dos múltiplos fatores que contribuem para o df observado no internamento agudo de idosos ou das suas implicações? o hospitalized elderly needs awareness scale (henas) desenvolvido por kimberling (20) avalia a perceção dos profissionais de enfermagem sobre as necessidades específicas de seus doentes idosos, especificamente, a manutenção de sua capacidade funcional e da qualidade de vida no que respeita aos fatores que podem interferir nas necessidades funcionais individuais dos idosos (65 anos ou mais) no contexto diário da prestação de cuidados de enfermagem. a versão original do henas (20) apresenta uma parte inicial de orientações gerais, constituindo-se por um total de 21 itens, demonstrada sob a forma de escala de likert de 5 pontos (1 — discordo completamente; 2 — discordo; 3 — não concordo nem discordo; 4 — concordo; 5 — concordo completamente). das 21 afirmações, 7 relacionam-se com uma dimensão fisiológica das atividades da vida diária (avds) e cuidados de enfermagem (a, b, c, e, f, k, p), 11 afirmações estão relacionadas com a dimensão psicológica/psicossocial dos pacientes idosos (g, h, i, j, m, n, o, q, r, s, t) e três relacionam-se com a dimensão ambiente hospitalar (d, l, u). 10 dos 21 itens constituem-se sob a forma de afirmações positivas (a, g, h, i, j, m, n, q, r, s), enquanto 11 são proposições na sua forma negativa (b, c, d, e, f, k, l, o, p, t, u). a versão original do henas passou por um processo de validação e confiabilidade por meio de estudo de campo, que incluiu validade de conteúdo, de constructo, de critério e análise fatorial. a validade de conteúdo foi realizada por meio de um processo de revisão da literatura que suportou os fatores a medir como representativos da manutenção da capacidade funcional de idosos hospitalizados. obteve-se também o contributo de diversos peritos nas diferentes áreas (enfermeiros, terapeutas, gestores) que analisaram e comentaram cada questão, bem como avaliaram a sua adequação ao conteúdo para medir cada fator. quanto à validade de constructo, foi realizada por avaliação da forma como cada fator contribuiu para o constructo geral da capacidade funcional de idosos hospitalizados. a validade de critério foi alcançada durante o teste de campo em que foi dada maior credibilidade aos participantes da área da saúde do que aos que não estavam familiarizados com aquela área (20). a cotação global do henas realiza-se pela soma das pontuações dos itens. escores mais altos refletem maior compreensão das questões que contribuem para a manutenção das necessidades funcionais dos pacientes idosos hospitalizados. 430 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 o henas inclui ainda questões sobre dados demográficos gerais, como idade, sexo, raça/etnia, anos de profissão de enfermagem, anos em situação atual, horas trabalhadas por semana e tipo de unidade de trabalho, ou seja, médico-cirúrgico, reabilitação, terapia intensiva ou outros para descrever os participantes da pesquisa. a autora do henas (20) reconhece que uma amostra maior poderia melhorar a confiabilidade e a validade da escala. no entanto, concluiu que pode ser um excelente instrumento de ensino para sensibilizar os estudantes de enfermagem antes da graduação e da prática clínica, e ser usado para identificar as necessidades funcionais de pacientes hospitalizados. nesse sentido, e integrado num estudo mais amplo sobre o df em idosos hospitalizados, desenvolveu-se o presente estudo com o objetivo de realizar a tradução e a adaptação transcultural para a língua portuguesa, do brasil e de portugal, do henas. a necessidade de utilização de uma versão transcultural adequada do henas para enfermeiros, a inexistência de estudos que avaliem a sua validade cultural em amostras brasileiras e portuguesas, o acordo ortográfico entre os países de língua oficial portuguesa e o interesse na realização de investigações futuras comparativas justificam a realização deste estudo. metodologia o presente estudo é de natureza quantitativa, de corte transversal tipo metodológico e visa à tradução e à adaptação transcultural do henas (20) para a língua portuguesa do brasil e de portugal. a qualidade da tradução do instrumento é essencial para garantir que os resultados obtidos em investigação entre diferentes culturas não sejam comprometidos por inadequação da linguagem. no entanto, não existe consenso sobre o melhor procedimento a adotar, sendo possível encontrar na literatura formas diversas de conduzir a tradução e a adaptação transcultural de instrumentos de pesquisa. a utilização de instrumentos em populações de outros países e culturas necessita de um conjunto de requisitos que têm de ser respeitados, passando por uma avaliação rigorosa da sua tradução e adaptação cultural, além de uma avaliação das propriedades de medida. com relação à adaptação ao português, o henas foi traduzido para o português de portugal por meio de um processo bem conhecido e estabelecido no âmbito internacional (21), que compreende cinco estágios: tradução inicial, síntese dessas traduções, retroversão, avaliação por um comité de peritos e teste de campo. estágio i: tradução inicial foi realizada uma tradução inicial por dois tradutores bilíngues (nativos da língua de origem), um deles com experiência clínica. as duas traduções foram comparadas, e identificadas as discrepâncias que podiam refletir palavras ambíguas na língua original ou discrepâncias próprias da tradução. cada um dos tradutores elaborou um relatório escrito da sua tradução (t1 e t2). foram incluídos comentários, de forma a destacar frases ou incertezas, acompanhados duma análise racional para as escolhas finais. estágio ii: síntese das traduções a síntese de ambas as traduções foi efetuada após uma reunião de avaliação das traduções entre os tradutores iniciais, com a participação duma terceira pessoa, que atuou como mediador perante a existência de possíveis diferenças. emitiu-se um documento final detalhado, e todos os assuntos foram esclarecidos e resultaram de consensos entre os intervenientes. estágio iii: retroversão a retroversão dos questionários foi realizada por dois tradutores bilíngues (nativos para o idioma original), sem experiência clínica. a retroversão emerge como processo de validade pois permite certificar se a versão traduzida reflete exatamente o conteúdo da versão original. estágio iv: comité de especialistas ou peritos o comité de especialistas ou peritos foi crucial para conseguir a equivalência do cruzamento cultural do instrumento traduzido e foi constituído por 10 indivíduos: 1 metodólogo, profissionais de saúde (2 médicos e 3 enfermeiros) e 4 tradutores, que avaliaram os questionários e participaram no processo de consenso. esse comité reviu todas as traduções e pronunciou-se sobre as discrepâncias encontradas. além disso, emitiu um do431 tradução e adaptação transcultural do hospitalized elderly needs awareness scale (henas) para a língua portuguesa (brasil e portugal) l arménio cruz e outros cumento de consenso final, no qual se refletem todo o processo e todas as decisões tomadas. para verificar a equivalência entre a versão inicial e a versão final, o comité de especialistas teve orientações por escrito sobre o objetivo do estudo e as definições adotadas sobre a equivalência semântica, a idiomática, a cultural e a conceitual, de forma a todos seguirem critérios claros sobre o julgamento das diversas versões. a versão em português do brasil do henas (henas-br) emerge da adaptação da versão em português de portugal da escala (henas-pt). essa adaptação foi realizada de forma independente por dois peritos cuja língua materna é o português do brasil; os desacordos foram resolvidos por discussão até ser obtido consenso. a equivalência conceitual das duas versões da escala foi avaliada por meio dos juízos de dois peritos e de comentários de outros investigadores cuja língua materna é o português do brasil. estágio v: teste da versão adaptada na fase do pré-teste, buscou-se a melhor equivalência entre a versão original e a traduzida, de forma que pudesse ser avaliada a compreensão pela população-alvo. dessa forma, a versão pré-final da escala foi aplicada em 30 pessoas com lesão medular traumática de maneira que fosse avaliado cada item quanto a clareza, pertinência e relevância. vale ressaltar que todos os participantes estavam na fase crônica da lesão medular, ou seja, após os seis primeiros meses do evento traumático. a fim de avaliar a compreensão pela população-alvo, nomeadamente com relação a clareza, pertinência e relevância, realizouse um teste com a versão pré-final (pré-teste), com aplicação da escala a 249 enfermeiros, 125 (50,2 %) de nacionalidade brasileira e 124 (49,8 %) de nacionalidade portuguesa, que frequentavam cursos de pós-graduação de enfermagem na faculdade de enfermagem da universidade do estado do rio de janeiro (feuerj), brasil, e na escola superior de enfermagem de coimbra (esenfc), portugal, respectivamente, tendo como critérios de inclusão: os(as) enfermeiros(as) cuidarem ou terem cuidado recentemente de idosos internados em fase aguda em unidades hospitalares. os dados foram recolhidos no período de julho a setembro de 2014 em contexto de sala de aula, após parecer positivo do comité de ética em pesquisa do hospital universitário pedro ernesto (parecer n.º 257.211/2014) e do parecer positivo da comissão de ética da unidade de investigação em ciências da saúde enfermagem (264/03-2015) assim como autorização da diretora da feuerj. os enfermeiros participaram voluntariamente após explicação prévia do estudo e dos seus objetivos, expressando a aceitação da participação por meio da assinatura do termo de consentimento livre e esclarecido, tendo sido salvaguardado o anonimato e a confidencialidade das respostas, bem como o direito de desistir da pesquisa sem prejuízos. foram registados o tempo de aplicação do instrumento e questões ou dúvidas colocadas durante o seu preenchimento. resultados o processo de tradução e adaptação da versão original para o português de portugal decorreu sem problemas na generalidade, tendo surgido pequenas divergências entre os tradutores com relação a algumas expressões e palavras. assim, nos estágios iniciais i e ii, verificou-se divergência quanto à palavra awareness no título do instrumento e da expressão medical acuity do item k. na versão t1, foi proposta consciência e acuidade médica e, na versão t2, perceção e gravidade resultante. essa divergência foi ultrapassada, tendo sido decidido, após reunião, ficar perceção e gravidade resultante, respetivamente. no estágio iii, os tradutores não relataram nenhuma palavra, frase ou expressão considerada problemática. no estágio iv, nas orientações iniciais do instrumento, o comité de peritos decidiu alterar a expressão 75 anos ou mais para 65 anos ou mais por considerar que a realidade portuguesa e brasileira, nomeadamente com relação à esperança de vida e aos conceitos de pessoa idosa, é diferente comparada com a do país de origem. também foram sugeridas por um dos elementos, e aceites por todos os peritos, alterações na formatação e na apresentação final do instrumento, para facilitar a leitura dos itens por parte dos participantes e a colocação das respetivas respostas. na avaliação de equivalências das versões realizadas pelo comité de peritos, nos casos de divergências encontradas, a opção foi manter a versão em que a maioria dos peritos avaliou como equivalente. na fase de adaptação da versão em português de portugal para português do brasil, realizada de forma independente por dois peritos cuja língua materna é o português do brasil, apenas 432 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 foi relatada alguma dificuldade na compreensão da palavra sanita, tendo sido sugerida e realizada a sua substituição por vaso sanitário no item c da versão portuguesa do brasil. participaram no último estágio, v, teste da versão adaptada (pré-teste), 249 enfermeiros que cuidam ou cuidaram de idosos hospitalizados em fase aguda, sendo 125 (50,2 %) de nacionalidade brasileira e 124 (49,8 %) de nacionalidade portuguesa. 206 enfermeiros eram do sexo feminino, e a média de idades foi de 32,63 (dp=7,81), mínimo de 22 anos e máximo de 59 anos. a maioria dos participantes é composta por solteiros (n=132; 53,2 %), licenciados em enfermagem (n=136; 55,1 %), exercia funções em serviços de medicina (n=74; 30 %) e prestava cuidados diretos (n=202; 81,8 %). a média de tempo de profissão era de 8,77 anos (dp=7,83), com um mínimo de 1 ano e um máximo de 37 anos. a média de tempo no serviço atual era de 5,62 anos (dp=6,13), mínimo de 1 ano e máximo de 34 anos. o tempo médio de contato semanal com idosos era de 34,45 horas (dp=12,70), mínimo de 4 horas e máximo de 70 horas, tal como apresentado nas tabelas 1 e 2. tabela 1. caracterização dos enfermeiros brasil-portugal: gênero, estado civil, habilitações acadêmicas e local de trabalho variáveis n brasil n (%) portugal n (%) brasilportugal n (%) gênero 125 (50,2) 124 (49,8) 249 (100) feminino 106 (42,6) 100 (40,2) 206 (82,7) masculino 19 (7,6) 24 (9,6) 43 (17,3) estado civil 125 (50,6) 122 (49,4) 247 (100) solteiro(a) 79 (59,8) 53 (40,2) 132 (53,4) casado(a) 39 (15,8) 61 (24,7) 100 (40,5) viúvo(a) 3 (75,0) 1 (25,0) 4 (1,6) divorciado(a)/separado(a) 4 (44,4) 5 (55,6) 9 (3,6) outro 0(0) 2(100) 2 (0,8) habilidades acadêmicas 123 (50,6) 122 (49,4) 247 (100) bacharelato 92 (37,2) 1 (0,4) 93 (37,7) licenciatura 22 (8,9) 114 (46,2) 136 (55,1) pós-graduação 8 (3,2) 7 (2,8) 16 (6,0) outra 3 (1,2) 0 (0,0) 3 (1,2) local de trabalho 125 (50,6) 122 (49,4) 247 (100) medicina 41 (16,6) 33 (13,4) 74 (30,0) variáveis n brasil n (%) portugal n (%) brasilportugal n (%) cirurgia geral 13 (5,3) 11 (4,5) 24 (9,7) pneumologia 3 (1,2) 2 (0,8) 5 (2,0) cardiologia 10 (4,0) 4 (1,6) 14 (5,7) neurologia 7 (2,8) 17 (6,9) 24 (9,7) urologia 0 (0,0) 5 (2,0) 5 (2,0) ortopedia/traumatologia 4 (1,6) 18 (7,3) 22 (8,9) psiquiatria 3 (1,2) 4 (1,6) 7 (2,8) cuidados intensivos 28 (11,3) 3 (1,2) 31 (12,6) urgência 11 (4,5) 7 (2,8) 18 (7,3) outro 5 (2,0) 18 (7,3) 23 (9,3) função desempenhada 125 (50,6) 122 (49,4) 247 (100) prestação de cuidados 97 (39,8) 105 (42,5) 202 (81,8) gestão 2 (0,8) 6 (2,4) 8 (3,2) ambas 26 (10,5) 11 (4,5) 37 (15,0) fonte: elaboração própria. tabela 2. caracterização dos participantes brasil-portugal: idade, tempo de profissão, horas semanais de contacto com o idoso variáveis n brasil portugal brasil-portugal idade média 35,45; dp=7,81; min.= 24; máx.= 59 média 29,88; dp=6,75; min.= 22; máx.= 59 média 32,63; dp= 7,81; min.= 22; máx.= 59 tempo de profissão média 4,7; dp= 5,54; min.= 1; máx.= 35 média 12,84; dp= 7,62; min.= 2; máx.= 37 média 8,77; dp= 7,83; min.= 1; máx.= 34 tempo de serviço atual média 3,29; dp= 4,36; min.= 1; máx.= 34 média 7,95; dp= 6,72; min. = 1; máx. = 32 média 5,72; dp= 6,13; min. = 1; máx. = 34 horas semanais de contato com o idoso média 33,5; dp= 15,48; min. = 4; máx. = 70 média 35,5; dp= 8,27; min.= 4; máx.= 70 média 34,45; dp= 12,70; min.= 4; máx.= 70 fonte: elaboração própria. 433 tradução e adaptação transcultural do hospitalized elderly needs awareness scale (henas) para a língua portuguesa (brasil e portugal) l arménio cruz e outros durante o preenchimento da versão adaptada do instrumento, os participantes (brasileiros e portugueses) não levantaram questões nem referiram dificuldades de compreensão e interpretação, e o tempo médio de preenchimento foi de 20 minutos. o escore médio global do henas foi de 3,79 (dp=0,323), com um mínimo de 2,47 e um máximo de 4,67. o escore médio global do henas-pt foi de 3,77 (dp= 0,307), com um mínimo de 2,81 e um máximo de 4,57, enquanto o escore médio global do henas-br foi de 3,82 (dp=0,338), com um mínimo de 3,00 e um máximo de 4,67. apresentam-se, na tabela 3, a média, o desvio-padrão, o mínimo e o máximo obtidos nos itens da escala henas para os dois países. tabela 3. estatística descritiva dos itens da escala henas global (brasil-portugal) n mín. máx. média desviopadrão a. os doentes idosos devem caminhar várias vezes ao dia, quer queiram, quer não. 246 1 5 2,47 ,955 b. é aceitável que os doentes idosos possam comer as suas refeições na cama. 246 1 5 2,65 1,048 c. usar a cadeira higiênica é a mesma coisa que usar o vaso sanitário no banheiro. 246 1 5 4,09 ,81 d. é mais importante manter os meus doentes seguros do que promover a sua independência. 246 1 5 3,65 1,05 e. os doentes idosos devem poder ficar na cama se assim o pretenderem. 246 1 5 3,34 1,00 f. os doentes idosos merecem toda a ajuda que lhes consiga dar nas atividades da vida diária. 246 1 5 2,12 1,11 g. preciso entender o estado psicológico dos meus doentes idosos para prestar cuidados eficazes. 246 1 5 4,57 ,70 h. tenho que saber qual o nível de clareza mental dos meus doentes idosos para prestar cuidados eficazes. 246 1 5 4,42 ,838 i. ter consciência das diferenças geracionais com relação aos meus doentes idosos contribui para a forma como interajo com eles. 246 1 5 4,31 ,74 j. os doentes idosos devem pôr em prática as suas próprias competências para as atividades da vida diária da melhor forma que conseguirem. 246 1 5 4,46 ,69 n mín. máx. média desviopadrão k. a gravidade resultante das doenças dos meus doentes idosos impede-me de prestar cuidados personalizados. 246 1 5 3,96 ,97 l. os ruídos hospitalares são inevitáveis, e os meus idosos têm de aprender a tolerá-los. 246 1 5 3,99 ,89 m. os doentes idosos cognitivamente conscientes são capazes de tomar as suas próprias decisões com relação aos seus cuidados e tratamento. 246 1 5 3,78 ,96 n. é muito importante para mim saber quais as condições de vida e os sistemas de apoio social pré-hospitalares dos meus doentes idosos. 246 2 5 4,45 ,676 o. as necessidades dos meus doentes idosos não são diferentes das necessidades dos meus doentes mais jovens. 246 1 5 4,00 1,04 p. os meus doentes idosos irão sofrer um declínio funcional no hospital independentemente da minha diligência em satisfazer as suas necessidades. 246 1 5 3,41 1,13 q. manter a qualidade de vida dos meus doentes idosos é tão importante como manter a qualidade de vida dos meus doentes mais jovens. 246 1 5 4,45 ,79 r. as necessidades individuais dos meus doentes idosos estão entre as minhas maiores prioridades. 246 1 5 3,91 ,836 s. faz parte das minhas funções defender os meus doentes idosos. 246 2 5 4,19 ,77 t. os doentes idosos não necessitam de apoios adicionais para se adaptarem a estar no hospital visto que muitos já estiveram hospitalizados anteriormente. 245 1 5 4,28 ,87 u. é difícil dar privacidade aos doentes idosos num ambiente hospitalar. 245 1 5 3,25 1,21 fonte: elaboração própria. com relação às dimensões definidas na versão original, a saber: fisiológica, psicológica/social e ambiente hospitalar, observamos que, tal como apresentado na tabela 4, os valores são muito aproximados entre os participantes de portugal e do brasil. a dimensão psicológica/social apresenta valores médios mais elevados, e a dimensão fisiológica, os valores médios mais baixos. 434 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 tabela 4. valores médios das dimensões fisiológica, psicológica/social e ambiente hospitalar fonte: elaboração própria. os dados deste estudo sugerem que os participantes tenham globalmente uma perceção elevada dos fatores que beneficiam a capacidade dos pacientes idosos a manterem a sua capacidade funcional, com um escore global médio de 3,79 (dp=0,32), valores similares ao da versão original, com um escore global médio de 3,96 (dp=0,30). quanto às dimensões definidas na versão original, os resultados sugerem que os participantes tenham uma perceção mais elevada a respeito da dimensão psicológica/social e mais baixa com relação à dimensão fisiológica. discussão o df dos idosos hospitalizados em fase aguda é uma realidade da maioria dos serviços de internamento hospitalar. as necessidades do idoso hospitalizado em termos de mobilidade tornam-se fulcrais em muitos aspetos relacionados com as habilidades e a capacitação necessárias para manter autonomia na realização dos autocuidados e, entre outras complicações, prevenir o df (3, 8). com este estudo, pretendeu-se traduzir e adaptar culturalmente o henas (20) para a língua portuguesa do brasil e a de portugal, escala que avalia as perceções dos enfermeiros sobre os fatores que podem interferir com as necessidades funcionais individuais dos doentes idosos (65 anos ou mais) no contexto diário da prestação de cuidados de enfermagem em ambiente hospitalar. a avaliação da equivalência conceitual, semântica e idiomática revelou-se importante, dada a especificidade de alguns termos e sua significação em cada cultura e língua mãe, muitas vezes alicerçada num simbolismo idiomático cujo significado é de difícil tradução. daí a necessidade do processo de validação, com traduções e retroversões independentes e idôneas, e a participação multidisciplinar de revisores, que se tornaram fulcrais para garantir a sua equivalência. dimensões henas global henas-pt henas-br fisiológica 3,15 3,23 3,07 psicológica/social 4,25 4,27 4,24 ambiente hospitalar 3,63 3,56 3,7 a impressão inicial dos enfermeiros brasileiros e portugueses após a aplicação do questionário foi de que o instrumento é de fácil compreensão. a versão para a língua portuguesa do henas (20) apresentase adequada, tendo em vista a equivalência obtida e ajuizada pelo painel de peritos acerca do processo de tradução e retrotradução, bem como de avaliação de consensos. vale ressaltar que o processo de tradução e a adaptação transcultural de instrumentos de pesquisa exigem menos tempo e gastos do que a criação de novos instrumentos, além de permitir comparações de resultados em diversas populações, o que caracteriza um avanço científico importante para o desenvolvimento do conhecimento sobre determinado conceito (21). gostaríamos de salientar que, à data de publicação deste relatório, o henas-pt e o henas-br não se encontram aferidos para as respetivas populações. tal significa que o resultado ou escore obtido nessa escala não tem um significado absoluto e não é passível de interpretação clínica ou outras aplicações práticas. nesse sentido, o henas-pt e o henas-br apenas podem ser utilizados responsavelmente para fins de investigação, com as devidas precauções éticas que o seu estatuto implica. a versão em português (do brasil e de portugal) do henas poderá constituir um estímulo ao desenvolvimento de novos estudos e uma mais-valia para o estudo do df de idosos hospitalizados, e também para a prática clínica e a qualidade dos cuidados de enfermagem. concluindo, o henas pretende ser um instrumento para avaliar a perceção/consciência dos enfermeiros sobre os multifatores que contribuem para o df de idosos hospitalizados e das suas implicações, e pode constituir-se um ponto de partida para o despertar de consciências, ajudando os enfermeiros a refletirem sobre a sua intervenção a esse grupo de doentes cada vez mais numeroso; simultaneamente, contribuirá para sensibilizar os diferentes profissionais para a especificidade dos cuidados ao idoso hospitalizado. o processo de tradução e adaptação cultural do henas para a língua portuguesa do brasil e de portugal seguiu as etapas recomendadas internacionalmente e foi realizado com sucesso. 435 tradução e adaptação transcultural do hospitalized elderly needs awareness scale (henas) para a língua portuguesa (brasil e portugal) l arménio cruz e outros assim, o henas teve as suas dimensões mais bem exploradas, tendo passado por rigoroso processo de tradução e adaptação do conteúdo ao contexto português e ao brasileiro. conforme recomendado pela literatura, o instrumento deve passar, ainda, por outras etapas de validação, nomeadamente validação de conteúdo, consistência interna e estabilidade temporal, a fim de encontrar-se disponível para avaliar as perceções dos enfermeiros sobre os fatores que podem interferir com as necessidades funcionais dos doentes idosos hospitalizados em contexto agudo de cuidados. novas pesquisas nesta área precisam ser feitas para verificar outras propriedades do instrumento e sua aplicabilidade em populações com características diferentes. agradecimentos os autores expressam os seus agradecimentos aos enfermeiros participantes na investigação e às instituições que facilitaram a sua realização, a feuerj e a esenfc. isenção de responsabilidade os autores declaram que não há conflito de interesses no presente artigo. o estudo teve apoio financeiro da fundação para a ciência e tecnologia e da escola superior de enfermagem de coimbra (portugal). a tradução e a adaptação do henas para a língua portuguesa foi autorizada pela sua autora (20). referências 1. carvalhais m & sousa l. promover a qualidade de cuidados de enfermagem a pessoas idosas hospitalizadas. rev. enf. ref. 2011; iii série(3): 75-84. 2. hanna a, efrat s, hagar b & anna z. from research to reality: minimizing the effects of hospitalization on older adults. rambam maimonides med j. 2015; 6(2): e0017. 3. hoogerduijn j, buurman b, korevaar j, drobbee d, rooij s & schuurmans m. the prediction of functional decline in 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61: 1387-93. doi: 10.1111/jgs.12324 19. suhonen r, välimäki m, katajisto j. & leino-kilpi h. patient characteristics in relation to perceptions of how individualized care is delivered — research into the sensitivity of the individualized care scale. j prof nurs. 2006; 22(4): 253-61. doi: 10.1016/j.profnurs.2006.03.001 20. kimberling bs. nurses’ awareness and ability to attend to the functional needs of hospitalized elderly patients (tese de doutorado em filosofia). minnesota, eua: capella university, minneapolis; 2011. 21. beaton d, bombardiere c, guillemin f & ferraz m. guidelines for the process of cross-cultural adaptation of self report measures. spine. 2000; 25(24): 3186-91. 139 148 considering nursing theory.indd 139 debra r. hanna1 ellen b. buckner2 considering nursing theory certifi cation 1 orcid.org. 0000-0001-5100-5256. hagan school of nursing, molloy college, usa. dhanna@molloy.edu 2 orcid.org.0000-0001-9676-2445. samford university, usa. ellen.buckner@samford.edu recibido: 18/07/2017 enviado a pares: 22/08/2017 aceptado por pares: 26/09/2017 aprobado: 28/11/2017 doi: 10.5294/aqui.2018.18.2.2 para citar este artículo / to reference this article / para citar este artigo hanna dr, buckner en. considering nursing theory certification. aquichan 2018; 18(2): 139-148. doi: 10.5294/aqui.2018.18.2.2 abstract objective: a workshop to discuss development of nursing theory certifications at four levels of nursing knowledge was held as part of the 2016 annual conference of roy adaptation association international. method: eight questions were discussed in small and large group formats. discussion points hand recorded on a flip chart. these points are summarized in this article. results: 35 international nurse scholars participated. they discussed benefits, limitations, and strategies of a new type of certification for nursing theory knowledge at four levels of education and practice. conclusion: nursing theory certification would affirm nursing knowledge, without becoming a burden to nurses. it can potentially affect how nurses are educated about theory at each of the four levels of education, how nurses use theory in practice, and the quality of nursing care provided. continued dialog is warranted. keywords nursing theory; certification; models; nursing (fuente: decs). año 18 vol. 18 nº 2 chía, colombia abril 2018 l 139-148 the topic: epistemology contribution to the discipline: this manuscript contributes a new way to think about the goals of teaching and learning theoretical nursing knowledge at four different levels of formal nursing education. it encourages dialog to develop certification for nursing theory that could promote clinician, faculty, administrator development and collaboration based on mutual nursing theory use. 140 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 2 chía, colombia abril 2018 l 139-148 considerando la certificación de la teoría de enfermería resumen objetivo: se realizó un taller para discutir el desarrollo de las certificaciones teóricas de enfermería en cuatro niveles de conocimiento de enfermería como parte de la conferencia anual de 2016 de la roy adaptation association international. método: se discutieron ocho preguntas en formatos de grupos pequeños y grandes. los puntos de discusión fueron grabados a mano en un rotafolio. estos puntos se resumen en este artículo. resultados: 35 académicos internacionales de enfermería participaron. discutieron los beneficios, las limitaciones y las estrategias de un nuevo tipo de certificación para el conocimiento de la teoría de enfermería en cuatro niveles de educación y práctica. conclusión: la certificación de la teoría de enfermería confirmaría el conocimiento de enfermería, sin convertirse en una carga para las enfermeras. puede afectar potencialmente cómo se educa a las enfermeras sobre la teoría en cada uno de los cuatro niveles de educación, cómo las enfermeras usan la teoría en la práctica, y la calidad de la atención de enfermería brindada. hay una necesidad de un diálogo continuo al respecto. palabras clave teoría de la enfermería; certificación; modelos de enfermería (fuente: decs). 141 considering nursing theory certification l debra r. hanna y otro considerações acerca da certificação da teoria da enfermagem resumo objetivo: realizou-se uma oficina para discutir o desenvolvimento das certificações teóricas de enfermagem em quatro níveis de conhecimento de enfermagem como parte da conferência anual de 2016 da roy adaptation association international. materiais e método: discutiram-se oito perguntas em grupos pequenos e grandes. os pontos de discussão foram escritos num quadro tipo flipchart. esses pontos foram resumidos neste artigo. resultados: 35 acadêmicos internacionais de enfermagem participaram. discutiram os benefícios, limitações e estratégias de um novo tipo de certificação para o conhecimento da teoria da enfermagem em quatro níveis de educação e prática. conclusão: a certificação da teoria da enfermagem confirmaria o conhecimento de enfermagem sem se tornar uma carga para os enfermeiros. pode afetar potencialmente como se educam os enfermeiros sobre a teoria em cada um dos quatro níveis de educação, como esses profissionais usam a teoria na prática e a qualidade da atenção de enfermagem oferecida. há necessidade de dialogar continuamente a respeito do tema. palavras-chave teoria da enfermagem; certificação; modelos de enfermagem (fonte: decs). año 18 vol. 18 nº 2 chía, colombia abril 2018 l 139-148 142 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 a question was posed at the end of the 2015 annual conference of the roy adaptation association international (raa-i) (1): where should the scholarly work in nursing theory go next? one idea was to develop a certification credential for nursing theory. after the conference, that idea was considered carefully. several thoughts emerged that became a formal effort to invite disciplinary discussion about ways to develop nursing theory certification. documents related to different types of nursing knowledge were consulted, as were styles’ ideas about certification and accreditation. a workshop entitled “levels of theory knowledge: implications for education and practice” was conducted twice: on june 10, 2016 at the 2016 raa-i conference (2). in this article, the workshop conversations are summarized and reported. a total of 35 nurse scholars from six countries (panama, colombia, mexico, el salvador, japan, and the united states) participated in the workshops. many attendees at the workshops have developed their scholarship using the roy adaptation model. however, the workshop was not aimed specifically at developing certification in the roy adaptation model or for the roy adaptation association international. it was aimed at identifying differences among the four levels of nursing education, practice, and knowledge, as well as clarifying the expectations for teaching and using theory at each of those four levels of education and practice (see table 1 at p. 147). eight questions about the value of certification of nursing theory knowledge at the four levels of nursing education and practice were discussed by those who took part in the workshop (see table 2 at p. 147). the purpose of this article is to present a summary of those workshop conversations. background before developing the workshop content, the leaders consulted original writings by margaretta styles regarding certification to grasp foundational ideas related to certification, accreditation, regulation, and quality of care as it relates to nurses’ knowledge. in addition, core curricula content and principles developed by the american association for colleges of nursing (aacn) for baccalaureate, graduate, and two types of doctoral programs were used to further refine the eight questions to be discussed at the conference (3-6). from these documents, the expectations for how nursing theory would be used at each level of formal education were extracted. (see table 1) to develop a common understanding among attendees with regard to the eight questions posed at the workshop, a brief introduction was provided by the workshop leaders that related the four levels of formal nursing education to four levels of nursing practice. basic education was defined as the level of formal education that leads to the first nursing license. although several types of basic nursing education still exist, to simplify the workshop discussions, the baccalaureate degree was used to represent the basic level of education. this means that, although students who complete a diploma or associate degree program are eligible to take a nursing license exam in the united states, those forms of basic nursing education were not considered in this discussion. according to the aacn, graduates of basic nursing education programs should be able to read, understand and use theory in clinical practice (3). after completing the basic level of education, most newly licensed nurses enter clinical practice as nurses at a basic practice level. the expectation for nursing theory use in the clinical setting also relates to what is asked of new employees by employers. depending on an institution’s mission and goals, new nurses might be asked to use a single nursing theory selected by nurse administrators for the entire institution. graduate nursing education, the second level, builds upon the content of basic nursing education. this second level adds necessary specialty-role-based coursework for advanced practice nursing and leadership roles (4). after completing a master’s degree in nursing, graduates should be able to use nursing and non-nursing theories for specialty-based advanced clinical practice, and for leadership roles in administration, education, and research. they should be able to use conceptual models and middle range theories. the expectation is that master’s prepared nurses would be able to select and use a variety of grand and middle-range theories to explain and problem-solve work-related situations. however, as smith and mccarthy have pointed out, the 2011 aacn master’s curriculum document reduced its stress on nursing-specific theories, while emphasizing knowledge from other disciplines (7). their point is that formal nursing education no longer accentuates the focus of the discipline of nursing, since it emphasizes theoretical knowledge from other disciplines, such as medicine, pharmacology, and psychology, more than nursing-specific theoretical knowledge (7). a similar claim about the movement away from nursing knowledge has been made by others (8-10). doctoral education is available along two lines: a doctor of nursing practice (dnp) degree (5), also called a practice doctorate, and a doctor of philosophy (phd) degree, also known as a research doctorate (6). although the dnp and phd degrees share several kinds of content, neither builds upon the other, since neither doctoral degree is required before obtaining the 143 considering nursing theory certification l debra r. hanna y otro other, if both doctoral degrees are pursued. an advanced practice nurse or nurse leader with a dnp degree is expected to: 1) translate published research into practice, so nurses can use it, and 2) conduct secondary research for evidence-based practice from primary studies found in the literature (5). during the workshop, this level of practice based on the dnp was called translational advanced practice nursing. the dnp curriculum, as stated by the aacn. does not require a greater depth of nursing theory knowledge than education at the master’s level. in contrast, nurses who earn a phd degree; that is, a research doctorate, are expected to: 1) design and conduct primary research; 2) use their own primary research to test nursing theory; 3) develop new theory using philosophical knowledge and theorybuilding skills; 4) translate existing and newly developed nursing theory for use in clinical practice, education, administration, or research; and 5) combine primary and secondary research strategies to develop new nursing knowledge (6). during the workshop, this level of practice based on a phd degree was referred to as knowledge development nursing practice. one implication of these four levels of education is that each time a nurse returns for additional formal schooling that next level of education probably would be matched by the student’s ongoing development in terms of personal maturity and professional growth. nurses who return for formal education at different times would combine personal/professional maturity with higher levels of education. the effect could be a more complex, highly refined contribution at each new level of nursing practice. although the four levels of formal nursing education and levels of practice can be differentiated, the discipline has not developed clear standards for differentiating the depth and breadth of nursing theory to be taught at each level. workshop strategy the workshop presenters briefly gave background information about why this question of certification in nursing theory was raised, and how nursing theory is included in the aacn recommended curriculums for nursing education at the four levels of practice/education: 1) basic practice/baccalaureate, 2) advanced practice/master’s, 3) translational practice/doctor of nursing practice, and 4) knowledge development practice/phd program levels. participants worked in small groups to discuss two assigned questions. each small group reported a summary of its discussion on each question to the larger group, followed by a large group discussion of each question. the workshops were not considered research, but were viewed as working conversations among like-minded nurse colleagues interested in advancing nursing theory and nursing knowledge. many participants were academic nurse scholars (faculty), and a smaller portion of the attendees (approximately 15%) was comprised of either clinicians or doctoral students interested in nursing theory. all eight questions were not discussed equally, and the conversation flowed with the interest of those present. discussion points discussion of the first question led to new questions about what counts as theory to be certified. although many people agreed that certification of nursing theory knowledge could raise the standards for teaching, learning, and using nursing theory, some questioned the need for certification of nursing theory at all. several excellent points were raised about the purpose, process, and effect of certification of nursing theory knowledge within discussions of each of the eight questions. for example, should certification be for all kinds of theoretical knowledge that nurses learn and need, or should certification be only for the knowledge of nursing-specific theories, such as those developed by nightingale, roy or rogers, to name a few? another point was that nurses learn role-related theories during graduate education, such as educational theories for nurse educators or leadership theories for nurse administrators, in addition to nursing theories. some participants considered these non-nursing rolerelated theories as necessary for leadership and advanced practice nursing roles. the new question raised by participants was: are all kinds of theoretical knowledge to be certified or should only nursing theory be certified? the idea behind the question was that nursing theories and non-nursing theories have nothing to do with each other. this point reinforces a common misunderstanding that nurses do not need nursing theory as much as they need theory of pathophysiology or pharmacology. this misunderstanding and concern have arisen due to the new emphasis in the aacn master’s curriculum document that has severely curtailed the emphasis on nursing theory, with greatly increased emphasis on non-nursing theories (4). some participants questioned the need for certification of nursing theory, viewing certification only as a test to be taken periodically that would add a layer of regulatory burden upon nurses. 144 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 the workshop leaders encouraged participants to think of certification as an affirmation of mastery of knowledge of the discipline. strategies to achieve nursing theory certification without adding a regulatory burden will be addressed in the discussion section. the second question of how to differentiate teaching of nursing theory at different levels of formal education needs additional thought and discussion within the discipline. a few nursing professors from panama and colombia said they have been in conversations in south & central america to develop standards for teaching nursing theory. nurse scholars in north america have not yet had this conversation, as evidenced by the way nursing theory has been included in the aacn documents for education at the baccalaureate and master’s levels (3, 4). since discussion was intense for several questions, the third, fourth, and fifth questions regarding standards, criteria, and scope were not discussed as well as they might have been. question number six regarding cultural assumptions elicited another question posed by participants: what criteria could be established that would apply around the world, given that other countries and regions have very different health care systems? participants agreed that specific content may change in a program, but principles are not changed until there is evidence to disprove one set of principles and to adopt a set of new ones. therefore, it seemed possible to develop general standards that could apply worldwide, but would not impede any culture or country from adopting more stringent ones. the final workshop questions addressed the points of whether the final independent doctoral work for dnp and phd programs (a capstone project or dissertation) could qualify for certification at the doctoral level of education, and whether such certification at the doctoral level, once earned, could be kept for life, or if periodic re-evaluation would be needed. participants discussed whether the inclusion of nursing theory in a capstone project at the end of the dnp level of education or a doctoral dissertation at the end of phd level education would qualify as sufficient evidence of scholarly work to warrant certification at the doctoral level. this discussion included points regarding the depth, breadth, and sophistication of how nursing theory had been included in capstone projects or dissertations. if the work for a capstone project or a dissertation could be compared to standards for mastery of nursing theory, then such work could be accepted as a portfolio contribution toward certification at the translational level of practice or at the knowledge development level of practice. portfolio certification, if achieved at this level, would be retained for life, since the investment of time, effort and thought would be a transformative experience. at the completion of either doctoral program (dnp/phd), graduates practice as independent scholars at the level related to the doctoral degree earned. this explains why theory certification at the doctoral level differs from theory certification at the baccalaureate and master’s levels. since formal education at the four different levels produces increasing depth of understanding of theory, it seems that basic and master’s education could be tested at least once, with the initial licensing exam and with the first advanced certification exam to demonstrate mastery at each level. for example, a sub-score for the specific portion of the licensing exam that relates to nursing theory could be generated with the final test score. in-depth theoretical knowledge could be tested periodically with repeated advanced practice certification exams, but once a nurse progresses from basic to advanced level practice with a master’s degree, there would be no further need to test at the basic level. the test at the master’s level should supersede the test at the basic level. likewise, once a doctoral student has engaged in using nursing theory for either a capstone project or a doctoral dissertation, then the project or dissertation could be certified as a lifetime achievement if it meets the criteria for mastery of that theory. some workshop participants still thought continued review was essential, but it was not agreed that all levels of knowledge and practice would be treated in the same manner with a separate, periodic test. methods of demonstrating mastery could also include portfolios, published writing, and continued research using that theory or any other nursing theory. discussion at all levels of practice, nurses are required to hold an active, unimpeded license to engage in professional nursing. nurses are not required to be certified at the basic level of practice. certification of nursing knowledge has long been associated in nursing with affirmation of the mastery of either specialty-based or role-related knowledge. therefore, it has been linked to graduate education and the use of knowledge for advanced practice and leadership roles. certification in specialty-based knowledge also has been tied to an affirmation of the content of basic practice in a clinical specialty such as critical care or oncology nursing, among others. licensing exams provide the credential needed for admis145 considering nursing theory certification l debra r. hanna y otro sion to basic professional practice. licensing exams affirm that the student has attained the minimal disciplinary knowledge required to provide professional nursing care safely. achieving certification of basic theoretical nursing knowledge at the same time as taking the licensing exam for one’s first license could seem like a burden to new nurses. however, certification of theoretical nursing knowledge could be accomplished during licensing exams if the exam included a subset score for items about nursing theory. if passing the license exam requires a certain percent of correct items, and if certification of basic knowledge requires a higher percentage of correct items the subset of theory items, then someone who passes the license exam with very high marks in general content and in nursing theory items could show distinction by obtaining a license and a basic theory certification credential at the same time, with a single test. such a certification derived from the basic licensing exam would help employers who seek nurses who are knowledgeable, even if they are inexperienced. since a former expectation for accreditation was that nursing programs should be developed according to a conceptual model or grand nursing theory, some nursing schools and faculty have continued using this approach to nursing education. however, due to revised documents from the aacn, emphasis has shifted to the non-nursing theories more strongly recommended in the aacn documents. smith and mccarthy have noted that this shift in emphasis has placed the focus of the discipline of nursing at risk for future generations of students (8). magnet® recognition and the link to nursing theory in clinical practice magnet® recognition is an internationally known designation of excellence for hospitals and health systems (11). to obtain magnet® recognition, hospitals are required to show evidence of exemplary clinical practice that is based on a nursing theory (12). this requirement has given new life to the use of nursing theory in clinical settings. when this point was raised by participants during the workshop discussions, it became clear that nursing theory can be a bridge to strengthen the practice-to-academic education relationship. one point from the workshop conversations was that a practice-to-academic education gap has replaced the long-held idea of a theory-to-practice gap. in an era with increased academic-practice collaborations, nursing theory can provide a common language for clinicians and educators. it could strengthen collaborative partnerships. certification in nursing theory knowledge for staff nurses and leadership nurses could strengthen hiring practices in clinical areas, and could strengthen the evidence needed for magnet recognition. this echoes the aacn recommendation for strengthening collaboration between academic health centers and faculty in schools of nursing, as outlined in the 2016 report entitled advancing healthcare transformation: a new era for academic nursing (13). teaching nursing theory across the curriculum as faculty seek new strategies for teaching nursing theory, exemplars from practice linked to nursing theory are essential in clinical experiences and simulation laboratories. undergraduate nursing education prepares the practice-based, frontline nurse who provides care for individuals, families, groups, communities, and populations (3). critical to that role is an understanding of the theoretical ideas that define nursing. nursing’s unique body of knowledge has a substantive theory base evident throughout the historical development of the profession. from nightingale’s time to the present day, nurses have used observation, compassion, presence, and empathy to provide and coordinate care. students want to learn the nursing perspective that makes nursing a unique profession (7). advanced practice roles require nursing theory use. graduate education programs intentionally incorporate nursing theory into advanced practice clinical expectations and final capstone projects. some nursing programs now focus on baccalaureate to dnp degrees, or baccalaureate to phd degrees, with theory-guided practice and research as essential theoretical underpinnings and core educational components (4). cody stated that nurses have an obligation to apply the specific knowledge base of the discipline, to contribute to its development, and to evaluate its use by peers and colleagues (14). he differentiated generic or non-nursing theory used in nursing, for example, pharmacology or nutrition, or specialty concepts such as health promotion, from nursing theory built upon a well-articulated philosophy of nursing. nurses’ values guide practice and provide meaning to nursing care. nursing will only develop as a scholarly discipline to the extent that nursing theory guides it. considering the need for a common nursing theory base, it is important to contemplate what is needed to assure transfer and expansion of nursing knowledge 146 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 globally and to future generations. nursing theory certification at the four different levels of a nurse’s career could guide that muchneeded foundation. approaches to reducing the regulatory burden and brainstorming certification strategies certification can be accomplished in many other ways than by means of a periodic exam. if nursing theory certification could be merged with other required licensing and certification processes that already exist, certification would not become a burden. for example, could a subset score about theoretical thinking ability be derived from future basic licensing exams that might make those nurses who have a good score in theoretical thinking more appealing to hire or more likely to succeed in graduate and doctoral studies? latin american and south american participants explained that, in their countries, the national exam to become licensed already includes testing of nursing theory. the same is true of the nclex licensing exam in the united states. although aggregate scores and sub-scores for graduates of nursing programs can be analyzed according to the test blueprint, those sub-scores are not currently provided to individual nurses. only the final status of pass/fail is provided. participants agreed that standards for teaching and learning nursing theory should be standardized worldwide. some suggested a basic level and advanced level of teaching standards with increasing breadth, depth, and evident use of theory-based knowledge from basic to advanced levels. at present, the blueprints for advanced practice nursing certification exams in the united states require knowledge of several nursing theories. however, the items for nursing theory are not reported as a separate score. if a sub-score regarding theoretical thinking could be generated from the exam, this would present a chance for certification of advanced practice knowledge of nursing theory that would not add a burden for a separate nursing theory certification. the first license exam usually is passed one time, but advanced practice certification is accomplished approximately every five years for many certifications. re-certification can be accomplished without a new test, through a combination of practice hours and continuing education hours. if some of the continuing education could come from nursing theory activities, a separate certification in nursing theory could be maintained. once someone has progressed from basic to advanced practice, then it seems that certification at the basic level is no longer needed. likewise, once someone has progressed from the advanced practice level to either the translational practice or knowledge development level, then certification at the advanced practice level would no longer be needed. conclusion and next steps the pursuit of evidence-based practice has provided an incentive to some within nursing for the continued development and use of nursing knowledge. just when theoretical thinking is needed to guide this pursuit, curriculum guidelines have deemphasized it. based on the discussion of the participants in this international theory-focused workshop, there is an opportunity to collaborate by starting an engaged international dialog. nurses from practice, education, and research can discuss strategies for nursing theory certification that are not a burden, as well as the educational content about nursing theory for each level of practice, and, lastly, who will be responsible for affirming certification at each level. nursing theory certification is one way to affirm nursing theory knowledge for the benefit of nursing as a discipline. however, the purpose of professional certification is to benefit patients by certifying knowledge that supports safe patient care. the goal of this work is not simply to initiate a dialog but, more importantly, to create authentic, thoughtful discussion of nursing knowledge at all levels and to ensure that nurses will preserve the focus of our discipline at all levels of education and in all forms of nursing practice. conflict of interest: none was declared. 147 considering nursing theory certification l debra r. hanna y otro table 1. four levels of nursing education and corresponding levels of practice table 2. eight questions for workshop small-group discussion levels of nursing education attained levels of nursing practice expectations for each level of nursing knowledge as it is used in practice undergraduate basic practice reads, understands, and uses nursing theory in clinical practice graduate advanced practice [builds on basic practice] uses many theories in practice including middle range, conceptual models, and role-related theories [education, administration, leadership] doctoral (dnp) (practice doctorate) translational practice [builds on advanced practice] translates published research into practice; conducts secondary research. theory use expectation is the same as aprn level of practice doctoral (phd) (research doctorate) knowledge development practice [builds on basic and advanced practice] develops new theory; tests existing theories; translates theory for use in education, administration, practice, and research; designs and conducts primary research to produce new knowledge; combines primary and secondary research strategies to develop new knowledge. 1. would it be worthwhile to establish a structure for certification of theoretical nursing knowledge at four levels? if so, what criteria should be used for each level? 2. if we define the relationship between theory and practice for each level of education, how should teaching theory be differentiated so that each level of education builds upon the others? 3. what standards for teaching theory at each level should be established to ensure that it is being taught in an accurate, useful, and practical way? 4. could the discipline of nursing develop standards to determine who would be certified in theory or not certified? if so, at which levels should nurses be certified? 5. which criteria would be best suited to determine the scope of expertise in theoretical nursing knowledge for each level? 6. where we have cultural assumptions working in certain cultures, how will the criteria accommodate those differences? 7. at the dnp and phd levels, would the conduct of a capstone project or a primary research study qualify as sufficient for certification at those levels? 8. would certification in nursing theory be earned once and kept for life, or would it need periodic updates? source: american association of colleges of nursing. source: own elaboration. 148 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 references 1. global perspective of the roy adaptation model—countries and cultures. annual conference of the roy adaptation association—international; 2015 june 12-13; chestnut hill, ma, usa. 2. hanna dr, buckner eb. levels of theory knowledge: implications for education and practice. workshop conducted at: roadmap for the next 25 years: knowledge based on the roy adaptation model. annual conference of the roy adaptation association—international; 2016 june 10-11; chestnut hill, ma, usa. 3. american association of colleges of nursing. the essentials of baccalaureate education for professional nursing practice. washington dc: american association of colleges of nursing; 2008. 4. american association of colleges of nursing. the essentials of master’s education in nursing. washington dc: american association of colleges of nursing; 2011. 5. american association of colleges of nursing. the essentials of doctoral education for advanced nursing practice. washington dc: american association of colleges of nursing; 2006. 6. american association of colleges of nursing. the research-focused doctoral program in nursing: pathways to excellence. report from the aacn task force on the research-focused doctorate in nursing; 2010. retrieved from http://www. aacn.nche.edu/education-resources/phdposition.pdf 7. smith m, mccarthy mp. disciplinary knowledge in nursing education: going beyond the blueprints. nurs outlook 2010; 58: 44-51. doi: 10.1016/j.outlook.2009.09.002 8. grace p, willis d, roy c, jones da. profession at the crossroads: a dialog concerning the preparation of nurse scholars and leaders. nurs outlook 2016;64(1):61-70. https://doi.org/10.1016/j.outlook.2015.10.002 9. barrett eam. again, what is nursing science? nurs sci quarterly 2017;30(2):129-133. doi: 10.1177/0894318417693313 10. donohue-porter p, forbes mo, white jh, bauman s. transforming nursing education and the formation of students: using the human becoming paradigm. nurs sci quarterly 2017;30(2):134-142. doi: 1.101177/0894318417693287 11. american nurses credentialing center. magnet model: exemplary professional practice. 2016; retrieved from http:// www.nursecredentialing.org/magnet/programoverview/new-magnet-model#exemplaryprofessionalpractice. 12. ancc magnet recognition program®. (n.d.). retrieved june 28, 2017 from http://www.nursecredentialing.org/magnet 13. american association of colleges of nursing. advancing healthcare transformation: a new era for academic nursing. american association of colleges of nursing: washington, dc; 2016. 14. cody, wk. nursing theory-guided practice: what it is and what it is not. in cody, wk (ed.), philosophical and theoretical perspectives for advanced nursing practice (fifth edition, p. 47-50). burlington, ma: jones & bartlett learning; 2011. 60 74 rede social e virtual de apoio.indd 60 gabriela silva dos santos1 cláudia mara de melo tavares2 rejane eleutério ferreira3 cosme sueli de faria pereira4 rede social e virtual de apoio ao adolescente que convive com doença crônica: uma revisão integrativa 1 enfermeira. discente do mestrado acadêmico em ciências do cuidado em saúde na escola de enfermagem aurora de afonso costa (uff). bolsista da coordenação de aperfeiçoamento de pessoal de nível superior (capes). e-mail: sisan.gabi@hotmail.com 2 enfermeira. doutora em enfermagem. coordenadora do mestrado profissional ensino na saúde e coordenadora do núcleo de pesquisa: ensino, criatividade e cuidado em saúde e enfermagem na escola de enfermagem aurora de afonso costa (uff). claudiamarauff@gmail.com 3 enfermeira. discente do mestrado acadêmico em ciências do cuidado em saúde na escola de enfermagem aurora de afonso costa da (uff). e-mail: rejane_eleuterio@hotmail.com 4 enfermeira. discente do mestrado profissional em ensino na saúde na escola de enfermagem aurora de afonso costa (uff). tutora da residência multiprofissional em saúde da mulher hospital escola são francisco de assis (hesfa/universidade federal do rio de janeiro). e-mail: cosmehesfa@yahoo.com.br recibido: 08 de enero de 2014 enviado a pares: 12 de febrero de 2014 aceptado por pares: 09 de septiembre de 2014 aprobado: 19 diciembre de 2014 doi: 10.5294/aqui.2015.15.1.7 para citar este artículo / to reference this article / para citar este artigo santos gs, tavares cmm, ferreira re, pereira csf. rede social e virtual de apoio ao adolescente que convive com doença crônica: uma revisão integrativa. aquichan. 2015; 15 (1):60-74. doi: 10.5294/aqui.2015.15.1.7 resumo objetivo: identificar o papel do enfermeiro na rede social e virtual de apoio aos adolescentes que convivem com o diagnóstico de doença crônica. metodologia: trata-se de uma revisão integrativa, realizada na base de dados: medline, lilacs e bdenf, no período de junho a novembro de 2013, com artigos indexados a partir de 2008 até 2013 e os descritores: “enfermagem”, “apoio social”, “adolescentes”, “doenças crônicas” e “rede social”. resultados: os artigos descrevem que o apoio social de forma direta aos portadores de doenças crônicas ou por meio do apoio que os pais recebem, afetará positivamente no estado de saúde do portador. conclusão: o enfermeiro deve estar preparado para fornecer o apoio necessário às famílias e ao portador de doença crônica com o objetivo de melhorar a saúde do paciente. esse apoio por meio das redes sociais virtuais é um novo método que vem conquistando espaço e trazendo grandes benefícios para esses pacientes e seus familiares. palavras-chave rede social, apoio social, enfermagem, doenças crônicas, adolescentes (fonte: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 60-74 61 rede social e virtual de apoio ao adolescente que convive com doença crônica: uma revisão integrativa l gabriela silva dos santos e outros. año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 60-74 red social y virtual de apoyo al adolescente que convive con enfermedad crónica: una revisión integradora resumen objetivo: identificar el rol del enfermero en la red social y virtual de apoyo a los adolescentes que conviven con el diagnóstico de enfermedad crónica. metodología: se trata de una revisión integradora, realizada en la base de datos: medline, lilacs e bdenf, en el periodo de junio a noviembre de 2013, con artículos indexados del 2008 hasta el 2013 y los descriptores: enfermería, apoyo social, adolescentes, enfermedades crónicas y red social. resultados: los artículos describen que el apoyo social de forma directa a los portadores de enfermedades crónicas o por medio del apoyo que los padres reciben, afectará positivamente en el estado de salud del portador. conclusión: el enfermero debe estar preparado para brindarles el apoyo necesario a las familias y al portador de enfermedad crónica con el objetivo de mejorar la salud del paciente. este apoyo por medio de las redes sociales virtuales es un nuevo método que ha conquistado espacio y traído grandes beneficios para dichos pacientes y sus familiares. palabras clave red social, apoyo social, enfermería, enfermedades crónicas, adolescentes (fuente: decs, bireme). 62 aquichan issn 1657-5997 social and virtual support network for teenagers living with chronic disease: an integrative review abstract purpose: the study was intended to identify the nurse’s role in social and virtual support networks for adolescents who live with a chronic disease diagnosis. methodology: this is an integrative review conducted in several databases (medline, lilacs and bdenf) during the period from june to november 2013, with articles indexed from 2008 to 2013. nursing, social support, adolescents, chronic diseases, and social network were the descriptors used. findings: the articles explain that social support provided directly to patients with chronic diseases, or through support the parents receive, will have a positive impact on the health of the patient with a chronic disease. conclusion: nurses must be prepared to provide the necessary support to patients with a chronic disease and their families, in the hope of improving the patient’s health. this support provided through virtual social networks constitutes a new method that has gained space and brought considerable benefit to chronically ill patients and their families. keywords social network, social support, nursing, chronic diseases, adolescents (source: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 60-74 63 rede social e virtual de apoio ao adolescente que convive com doença crônica: uma revisão integrativa l gabriela silva dos santos e outros. introdução o que motivou a realização deste estudo foi o interesse em conhecer sobre a rede social e a rede virtual que apoiam os adolescentes que convivem com diagnóstico crônico, sabendo que as doenças crônicas não transmissíveis (dcnt) compõem o problema de saúde de máxima extensão em muitos países, seja de alta, média ou baixa condição econômica (1-3). entende-se por dcnt as enfermidades que apresentam como características uma etiologia incerta, múltiplos fatores de risco, longos períodos de latência, curso prolongado, origem não infecciosa e associação a deficiências e incapacidades funcionais (4). para national commission on chronic illness, doença crônica são todos os obstáculos ou desvios do normal, os quais têm uma ou mais das seguintes características: são permanentes, deixam incapacidade residual, são causadas por alterações patológicas irreversíveis e requerem treinamento especial do paciente para sua reabilitação; portanto, necessitam um longo período de supervisão e cuidado (5). um público que merece uma atenção em especial quando se trata de doenças crônicas é o adolescente, pois nesse período de transição o processo é por vezes conturbador; a adolescência é uma etapa do processo de crescimento e desenvolvimento cuja marca primordial são as modificações de natureza física e psicoemocional, as quais se interligam à cultura, às relações sociais, à religião e às questões de gênero (6, 7). segundo a organização mundial de saúde (oms), adolescentes são jovens de 10 a 19 anos (8). no brasil, o estatuto da criança e do adolescente (eca), lei 8.069 de 1990, define a adolescência como a faixa etária de 12 a 18 anos de idade (artigo 2º) e, em casos excepcionais e quando disposto na lei, o estatuto é aplicável até aos 21 anos de idade (artigos 121 e 142) (9). a adolescência é um período de transição para a maturidade, com o desenvolvimento físico sempre precedendo o psicológico, nessa fase da vida, ocorrem aceleração e desaceleração do crescimento físico, mudança da composição corporal, eclosão hormonal, que envolve hormônios sexuais, e evolução da maturidade sexual, acompanhada pelo desenvolvimento de caracteres sexuais secundários masculinos e femininos (10). durante a adolescência, ocorrem inúmeros conflitos, pois ao mesmo tempo em que não são mais vistos como crianças dependentes, eles também não são considerados adultos o suficiente aptos para tomarem as próprias decisões e serem donos de suas próprias vidas; assim, uma fase de turbulências, descobertas e amadurecimento para a vida adulta (11, 12). é ainda um momento de crise, e uma doença nessa fase pode corresponder à outra crise (13). em se tratando de uma doença crônica, esse diagnóstico afeta os relacionamentos interpessoais dos adolescentes, pois, para eles, é difícil aceitar a doença; porquanto, além das mudanças e conflitos da própria idade, ser portador de uma condição crônica potencializa tais conflitos com repercussões no seu ambiente social, nas suas atividades diárias, na sexualidade e no relacionamento com outras pessoas, o que gera limitações físicas e psicológicas (14). assim, o apoio social pode reduzir o sofrimento psicológico do adolescente que passa por esse momento difícil ao se deparar com uma enfermidade crônica (15). segundo a teoria humanística de paterson e zderad, as autoras relatam que, independentemente de sua doença, o indivíduo pode estar saudável se estiver aberto às experiências da vida, ou seja, pelo diálogo a pessoa pode encontrar o conforto; mesmo numa condição crônica, o adolescente pode vir a se sentir confortável na medida em que há relações verdadeiras, principalmente com o enfermeiro (16). nessa fase, além do núcleo familiar, o papel da rede de amigos tem uma grande importância tanto para proteção quanto para constituição de identidade (17), já que os amigos têm muitas funções na vida dos adolescentes, o que inclui apoio emocional, espiritual, material, social e até em tarefas escolares (18). inúmeras pesquisas relatam sobre o tema com uma dualidade na denominação, falam de rede social, outra hora tratam como apoio social. a questão da denominação ainda não se chegou à unanimidade (19, 20). os conceitos de redes sociais e apoio social, embora distintos, estão intimamente relacionados, pois a rede social faz parte do contexto mais amplo do apoio social e é muito utilizada a associação desses dois conceitos nos estudos sobre saúde (21). podemos considerar ainda que apoio social é quando um grupo de pessoas, seja este de qualquer círculo de convivência do indivíduo, contribui de alguma maneira para que ele mesmo possa enfrentar determinada situação que venha acontecer em sua vida (11). alguns autores reconhecem que o conceito de apoio social é complexo e o seu significado depende do contexto (20). faz64 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 se fundamental diferenciar apoio social de rede social, pois são conceitos interligados, porém, com diferenças entre si (22). a rede social se refere à dimensão estrutural ou institucional ligada a um indivíduo, enquanto o apoio social encontra-se na dimensão pessoal e é constituído por membros dessa rede social, efetivamente importantes para as famílias; além disso, a rede social é uma teia de relações que liga os diversos indivíduos que possuem vínculos sociais, o que propicia que os recursos de apoio fluam através desses vínculos (22). o surgimento e a expansão da internet estão relacionados ao processo de globalização, que tem proporcionado uma mudança estrutural nas sociedades contemporâneas ou pós-modernas. as tecnologias da informação revolucionaram as formas de acesso ao saber e de comunicação humana, e introduziram a possibilidade de relacionamentos virtuais entre pessoas de todo o mundo com o auxílio das mídias sociais (23). mídia social vem a ser uma expressão generalizada para um grupo de ferramentas de software on-line que permitem uma maior interação, autoria e desenvolvimento de conteúdo on-line por qualquer usuário da web. as mídias sociais incluem os sites de redes sociais bem conhecidos, tais como o facebook, linkedin e twitter, mas também wikis, como o wikipédia por exemplo, blogs, microblogs, podcasting, outras redes sociais e demais sites (24-26). com esse acesso ao alcance da população, tem se tornado cada vez mais comum a busca nas redes virtuais com o uso da internet por diagnósticos a fim de compreender os sinais e sintomas presentes no indivíduo que está enfrentando uma situação de enfermidade; em 2011 a procura de informações de saúde chegou a ser a terceira atividade on-line mais comum (25). a internet oferece um meio interativo e dinâmico para divulgação de informações, mudanças de atitudes e comportamento; por meio dela e de outros meios de comunicação eletrônicos, ocasionam grande impacto na disseminação de informações e pesquisas (27). fontes disponíveis como blogs, weblogs, páginas pessoais em redes sociais e grupos de apoio virtual produzem conhecimento baseado na experiência vivida de cada paciente, conhecimento esse que é trocado, compartilhado e multiplicado nas formas diversas de contato virtual (28). vale ressaltar que outros estudos demonstram a eficácia inicial e a viabilidade de intervenções via on-line com jovens com condições crônicas de saúde (29, 30). assim, este estudo tem como objetivo revisar nas publicações científicas o papel do enfermeiro nas redes sociais virtuais de apoio aos portadores de doenças crônicas e promover uma relação interpessoal mais próxima e, consequentemente, a melhoria no quadro de saúde do paciente. metodologia trata-se de uma revisão integrativa, a qual é a mais ampla abordagem metodológica referente às revisões, o que permite a inclusão de estudos experimentais e não experimentais para uma compreensão completa do fenômeno analisado. uma combinação de dados da literatura teórica e empírica, além de incorporar um vasto leque de propó sitos: definição de conceitos, revisão de teorias e evidên cias, e análise de problemas metodológicos de um tópico particular (31). esta revisão tem como seguinte questão norteadora: “qual o papel do enfermeiro nas redes sociais virtuais de apoio aos portadores de doenças crônicas?”. buscando materiais para esse questionamento, a coleta de dados foi realizada nas bases de dados da web: medline, lilacs e bdenf, no período de junho a novembro de 2013; utilizaram-se os descritores em ciências da saúde (decs): “enfermagem”, “apoio social”, “adolescentes”, “doenças crônicas” e “rede social”. a forma de busca ocorreu por meio das associações dos descritores; primeiramente utilizou-se o operador booleano (ob) “and” para os descritores: “adolescentes”, “doenças crônicas” e “rede social”; obtiveram-se 43 trabalhos, dos quais 13 estavam disponíveis e destes sete foram selecionados por se relacionarem com a temática abordada. posteriormente foi realizada uma nova busca, na qual se associaram os descritores: “rede social”, “enfermagem” e “doenças crônicas” com o operador booleano “and”, o que resultou em 54 trabalhos, dos quais 27 estavam disponíveis e apenas seis foram selecionados. para uma nova busca, foram combinados da seguinte forma os descritores “adolescentes and apoio social or rede social and enfermagem and doenças crônicas”, apresentando uma lista com 80 trabalhos, porém 19 estavam disponíveis e apenas dois artigos foram selecionados para este estudo. uma quarta busca foi realizada ainda, dessa vez agrupando os decs: “adolescentes”, “apoio social”, “doenças crônicas”; recorrendo ao ob “and”, obteve-se uma apresentação de 519 artigos, dos quais 141 estavam disponíveis e destes 14 foram selecionados. os critérios para seleção dos artigos incluem um recorte temporal, trabalhos científicos publicados a partir de 2008, nas línguas inglesa e portuguesa, trabalhos que trouxessem o tema rede social e/ou rede virtual dos adolescentes que convivem com 65 rede social e virtual de apoio ao adolescente que convive com doença crônica: uma revisão integrativa l gabriela silva dos santos e outros. alguma doença crônica, além de estudos que relatassem a experiência do uso de programas na web para promover a assistência para adolescentes crônicos. excluíram-se documentos em teses, trabalhos incompletos e que não se referiam à enfermagem, e sim às demais profissões da saúde, além de estudos sobre a rede social e/ou virtual no qual o público-alvo não se tratasse de adolescente. foram selecionados 29 artigos, dentre os quais haviam estudos idênticos, pois foram coletados de bases distintas, por esse critério foram excluídos, o que totalizou 13 artigos. após a leitura completa destes, foram excluídos dois por não se adequarem à temática, pois abordavam sobre a rede social do cuidador do doente crônico. portanto, resultaram 11 artigos para a realização desta revisão. resultados e discussão dos 11 artigos analisados para este documento, dois são trabalhos nacionais compreendem os anos de 2010 e 2011 de publicação, e é possível localizá-los nas bases de dados da lilacs e bdenf; um dentre eles ainda está disponível na base de dados da medline, porém para este estudo foi considerada a versão em português. os outros trabalhos são internacionais, encontram-se disponíveis na base de dados da medline e foram publicados no período de 2008 até 2013. os trabalhos foram analisados pelos autores tendo como pressuposto a questão norteadora para esta revisão; posteriormente foram categorizados pela semelhança na temática abordada nos artigos selecionados, tendo como referencial de enfermagem a teoria de paterson e zderad, pois para elas a enfermagem é uma resposta de cuidado de uma pessoa para com a outra num período de necessidade, ajudando-a a alcançar bem-estar e a ser mais; além disso, o diálogo vivido é visto como conceito central para o cuidado humanístico (16). as categorias emergentes após análises são: 1) as redes sociais presentes na vida dos adolescentes com diagnóstico crônico; 2) a importância das redes sociais na vida dos adolescentes, e 3) as contribuições do enfermeiro nas redes sociais dos adolescentes em condições crônicas. essas categorias serão apresentadas de forma mais detalhada logo a seguir. os estudos (32, 33, 34, 35, 36) tratam das redes sociais presentes na vida dos adolescentes; incluem-se nessas categorias as redes virtuais, bem como a utilização das mídias. as redes sociais podem ser primárias ou secundárias; as primárias se referem às relações significativas que uma ou mais pessoas estabelecem ao fluxograma 1. caminho percorrido 66 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 quadro 1. artigos para a categoria: as redes sociais presentes na vida dos adolescentes com diagnóstico crônico autor/ano/periódico objetivo principais resultados timpka t. et al/ 2008/ bmc medical informatics and decision making (32) especificar uma arquitetura geral para sistemas web 2.0 de apoio às crianças com doenças crônicas e suas famílias. apresenta a criação de um programa informativo sobre diabetes tipo 1; nota-se a preocupação com a linguagem para leigos. após diversas reuniões com a equipe multiprofissional e definida a linguagem padrão para fornecer as informações, foi então implantado o programa de web 2.0, o qual foi apresentado aos pacientes, familiares e cuidadores; encontra-se on-line desde 2006. araújo yb, collet n, gomes ip, nóbrega rd/2011/ revista brasileira de enfermagem (33) investigar a influência da rede social no enfrentamento do adolescente em condição crônica. a condição crônica requer uma adaptação do adolescente e de sua família a uma nova rotina. os profissionais de saúde podem potencializar as possibilidades de enfrentamento dessa situação ajudando o adolescente e sua família a identificarem redes e apoios sociais a partir do contato com recursos disponíveis. newcombe pa, dunn tl, casey lm, sheffield jk, petsky h, andersonjames s, chang ab/ 2012/ journal of medical internet research (34) avaliar a eficácia de uma intervenção on-line para crianças e adolescentes com doença respiratória crônica, socialmente isolada, para melhorar o bem-estar psicossocial. foram divididos dois grupos de crianças e adolescentes, em que apenas um grupo recebeu as intervenções on-line; esse grupo recebeu um computador portátil toshiba e um modem para acesso à internet de banda larga para a duração do estudo. as crianças e pais do grupo de intervenção on-line avaliaram o módulo on-line como favorável. destaca-se a necessidade de maior atenção da pesquisa para programas on-line projetada especificamente como uma intervenção com crianças e adolescentes com condição crônica de saúde. velden mv, khaled ee/2013/ journal of the american medical informatics association (35) entender como os adolescentes doentes crônicos controlam sua privacidade em sites de mídia social. além do facebook, uma rede específica do hospital, upopolis, é vista como uma rede de um paciente. pacientes adolescentes não usam as redes sociais para entrarem em contato com outras pessoas nas mesmas condições, nem informar sobre seu diagnóstico. também mostra que a maioria dos adolescentes modifica a privacidade de público para amigos, pois a necessidade de privacidade pode mudar após um diagnóstico. margolis pa, peterson le, seid m/2013/official journal of the american academy of pediatrics (36) fornecer a descrição dos atributos de uma rede de atenção crônica colaborativa (c3n) e um projeto c3n. descreve um site, atualmente ativo. a c3n é uma plataforma que compreende sistemas operacionais sociais, científico e técnico nos quais há projetos, testes e implementações de um conjunto de processos interligados a intervenções para melhorar a saúde. longo de suas vidas, entre elas temos as relações de familiaridade, parentesco, vizinhança, amizade, sem esquecer as interações virtuais e demais grupos que estabelecem forma de socialização, apoio e contribuições para uma nova maneira de enfrentamento das doenças crônicas (37). as mídias estão presentes no cotidiano das pessoas. o crescente número de blogs e portais para pacientes mostra que muitos estão ativos nessas redes virtuais (35). o facebook tem sido um ponto importante de encontro on-line, com mais de 400 milhões de usuários registrados em todo o mundo (38). nele, muitos sites de grupos sobre doença, como o diabetes, surgiram representando fontes de informação, apoio para pacientes com doenças crônicas (39, 40). os estudos (32, 34, 35, 36) apontam para a utilização das mídias pelos adolescentes que convivem com algum tipo de doença crônica, como uma ferramenta para a busca de informações a res67 rede social e virtual de apoio ao adolescente que convive com doença crônica: uma revisão integrativa l gabriela silva dos santos e outros. peito do seu diagnóstico, a fim de obter uma melhor compreensão sobre ela, além de ter uma nova maneira de enfrentamento. os adolescentes consideram a internet como uma valiosa fonte de informação de saúde, pois é fácil de acessar, não é ameaçador e é vista por eles como confidencial (41). infelizmente, os profissionais de saúde têm pouco tempo para a educação do paciente (42), e os enfermeiros, de oncologia em específico, são muitas vezes impossibilitados de educar adequadamente os pacientes sobre o câncer, por exemplo, devido a agendas lotadas, limitações de tempo e à escassez de enfermagem (43). esses estudos (32, 36) relatam experiências de criações de programas na web para fornecer informações para o público crônico, em especial os adolescentes. outros, porém (34, 35), apresentam relatos sobre intervenções realizadas por meio virtual e seus efeitos positivos com a utilização delas; essa nova estratégia já vem sendo divulgada em outros experimentos com jovens em situações crônicas (29, 30). algumas redes virtuais foram mencionadas pelos adolescentes, sendo elas públicas ou privadas, tais como o facebook, upopolis, e um programa de web 2.0 criado para fornecer informações a respeito da diabetes mellitus (32, 35). o facebook foi visto como um dos espaços para eles se sentirem melhor, se apresentarem como uma pessoa “normal”, sem doença. nesse espaço, eles podem gerenciar sua privacidade, escolher o que informar sobre seu tratamento, e quem pode visualizar suas informações, pois, na sua concepção, a divulgação de um diagnóstico pode interferir no relacionamento com seus pares (35). além desses vínculos virtuais, há também os vínculos mais próximos, já que a necessidade de tratamento fora do domicílio faz com que a presença dessa rede social não seja tão frequente. assim, além da utilização das mídias para ampliação das redes sociais, fazem parte dessa rede os amigos, profissionais de saúde, os pais, professores, bem como os outros pacientes e seus acompanhantes (33). podem ser também membros presentes dessa rede os vizinhos, membros de congregações religiosas e outras organizações, cuja finalidade é fornecer o apoio para que essas pessoas, que muitas vezes são afastadas por um longo período para o seu tratamento, não sofram tanto com o isolamento (44). logo, a possibilidade de redes é ampla e existem muitos meios para que não somente o adolescente, mas também seus pais participem e mantenham o vínculo social. sobre esse aspecto, paterson e zderad descrevem que o homem é um ser individual, necessariamente relacionado com outros homens no tempo e no espaço, e é por meio do relacionamento com os outros que o ser humano torna-se pessoa, o que, por sua vez, permite que a individualidade única de cada pessoa torne-se atualizada. logo, tornam-se inerentes ao ser humano os vínculos sociais (16). para essa categoria foram selecionados os estudos (45, 46, 47, 48) que falavam do impacto ante o diagnóstico, os sentimentos envolvidos nessa situação, tais como fragilidade, tristeza, preocupação, nervosismo, as dúvidas emergentes em como lidar com essa nova fase da vida, além do futuro do adolescente após saber que tem uma doença crônica e precisa lidar com ela para prolongar a sua vida. são características próprias da adolescência viver para o presente e não pensar no futuro, acreditar que são invulneráveis aos acontecimentos ruins e às consequências futuras (49). por isso, ao se depararem com essa condição crônica, o impacto é imediato. logo, a rede social tem um importante papel nessa situação, ela é fonte de fortalecimento para os cuidadores, bem como para os seres cuidados que, nesse caso, são os adolescentes que recebem a assistência. a rede social contribuirá para o enfrentamento das adversidades que surgem no decorrer do processo da doença crônica, visando a uma adaptação menos traumática, além da melhoria na qualidade de vida dos envolvidos nesse processo (46). a existência de uma doença crônica requer da pessoa afetada mudanças no estilo de vida que exigem uma readaptação diante da nova situação (50), e o enfrentamento eficaz associa-se ao senso de controle sobre suas expectativas, emoções positivas, bem como recursos disponíveis (51). no decorrer do tratamento prolongado, muitos tendem a se afastar da sua vida social e se restringir ao ambiente hospitalar para desenvolverem o seu tratamento, portanto muitos ficam longe dos colegas e professores. esse afastamento despertou em alguns adolescentes o desejo de ser “normal”, de ter uma vida com a rotina igual à dos demais colegas, além de se sentirem mal por estarem longe dos amigos, já que, mesmo com o apoio dos pais, os adolescentes necessitam a interação com o grupo da mesma idade (45, 47). outro estudo apresentou que a rede social contribui com a forma de enfrentamento de adolescentes que convivem com a doença 68 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 quadro 2. artigos para a categoria: a importância das redes sociais na vida dos adolescentes crônicos autor/ano/periódico objetivo principais resultados herzer m, umfress k, aljadeff g, ghai k, zakowski sg/2009/ journal of developmental & behavioral pediatrics (45) examinar se os efeitos negativos de relações tensas com os entes queridos podem ser amenizados quando as crianças se sentem apoiadas por indivíduos de diferentes redes de apoio. as amizades são fatores de proteção para as crianças e adolescentes que tiveram relações tensas com os pais. os resultados ressaltam ainda a importância de promover a conectividade social em crianças cronicamente doentes para maximizar as oportunidades para experimentar relações sociais positivas. curiosamente, o apoio dos pais não compensa os efeitos negativos de se sentir deixado de fora por amigos, mesmo que os pais sejam fortes contribuintes. isso sugere que, entre as crianças e adolescentes com doenças crônicas, as amizades são especialmente importantes para a qualidade de vida, autoestima e funcionamento geral das emoções e do comportamento. nóbrega vm, collet n, silva kl, coutinho sed/2010/ revista eletrônica de enfermagem (46) identificar a rede social e os tipos de apoio social avaliando os vínculos apoiadores, na perspectiva das famílias de crianças em condição crônica. a rede social é a fonte de fortalecimento para a família e para a criança superarem adversidades relacionadas à doença crônica. sua rede e apoio social são formados pela assistência hospitalar, acompanhantes de outras crianças hospitalizadas e apoio espiritual, que contribuiu expressivamente com as famílias no enfrentamento das adversidades que surgem no decorrer da doença crônica da criança e favorece uma adaptação menos traumática, o que se vê refletido positivamente no equilíbrio familiar e na qualidade de vida dos membros envolvidos nesse processo. nicholas db, picone g, selkirk ek/2011/ qualitative health research (47) examinar as percepções de crianças e adolescentes com doença renal terminal. as crianças e adolescentes não se sentiam como uma pessoa “normal” devido à doença renal e por estarem envolvidas com o tratamento. elas expressaram sobre ter que assumir responsabilidades com o tratamento e sobre a necessidade de se ausentar da escola para passar mais tempo no hospital. alguns falaram sobre o medo, sobre o futuro com essa doença e as emoções envolvidas com o diagnóstico, além do apoio necessário nessa fase. fee rj; hinton vj/2011/ journal of developmental and behavioral pediatrics: jdbp (48) analisar a resiliência entre um grupo de crianças com uma doença neuromuscular crônica, progressiva e, eventualmente, fatal, distrofia muscular de duchenne (dmd). por ser a dmd uma doença ligada ao cromossomo x, todos os participantes eram do sexo masculino. ao encontrar o que pôde contribuir para sua resiliência, isso pode ajudar as crianças afetadas a viverem uma vida melhor. as redes sociais fortes andam de mãos dadas com o comportamento resiliente em meninos com dmd. o aumento da participação nas organizações, número de amizades e relações positivas entre pares foram associados com uma diminuição do risco de um menino com dmd desenvolver problemas comportamentais. crônica; eles apresentavam uma melhoria na qualidade de vida ao saber que, mesmo com esse diagnóstico, seus amigos estavam presentes, apoiavam-nos e mantinham vínculos, não davam importância para a doença, mas para a amizade que eles tinham (48). o apoio adequado, de maneira positiva, fornecido pela rede social dos adolescentes funciona como um importante suporte para minimizar o sofrimento do indivíduo; portanto, cabe ao profissional de saúde estimular o uso dela (52). é perceptível que, diante da descoberta do diagnóstico, surgem muitas inquietações. nesse sentido, as redes sociais têm uma importante tarefa, porque podem apoiar o adolescente e 69 rede social e virtual de apoio ao adolescente que convive com doença crônica: uma revisão integrativa l gabriela silva dos santos e outros. também os profissionais de saúde, em especial a figura do enfermeiro. as teóricas descrevem que a saúde pode ser encontrada na vontade que uma pessoa tem de estar aberta às experiências da vida, isso não depende do seu estado físico, social, psicológico ou espiritual, pois é algo mais que ausência da doença, ou seja, independente de sua doença, condição crônica ou não. o indivíduo pode estar saudável se estiver aberto às experiências de vida, pela troca de experiências, pelo diálogo, pelas redes (16). nesta revisão, alguns trabalhos abordaram a participação do enfermeiro na forma de enfrentamento das condições crônicas vividas pelos adolescentes (53, 54). um estudo de caso controle mostrou que os pais que recebiam intervenções comunicativas dos enfermeiros tinham uma nova maneira de lidar com os filhos que estavam vivendo com a cronicidade em comparação aos pais que não tinham essa conversa terapêutica. mesmo que de poucos minutos, essas intervenções, eles recebiam as informações e repassavam aos filhos e estes, por sua vez, tinham uma melhora em seu diagnóstico (54). “a informação só tem sentido e só se concretiza se provoca redução de incerteza no receptor” (55:25). logo, é na atitude de o enfermeiro esclarecer dúvidas, orientar a respeito das possíveis ocorrências que o adolescente enfrentará e explicar aos responsáveis sobre a saúde do paciente, tirando as incertezas, que será concretizado o processo da informação. segundo a teoria das informações, o emissor é aquele que tem por objetivo levar informação ao receptor e que, para tanto, lançará mão dos seus conhecimentos técnicos sobre os canais disponíveis e sobre as características do receptor (55). assim, o profissional de saúde, ao transmitir seus conhecimentos a respeito do diagnóstico do adolescente, utilizando os meios adequados para repassar essa informação, que podem ser por meio das mídias, da linguagem falada ou escrita, interferirá de forma positiva na vida dos familiares e de todos os envolvidos no tratamento desse indivíduo. isso porque a educação em saúde divulgada na web é vista com uma possível ferramenta eficaz para os enfermeiros usarem com os pacientes, uma vez que oferece uma variedade de vantagens sobre os materiais impressos (51). foi apresentado ainda a valorização dos pais aos enfermeiros atenciosos e dedicados desenvolvedores de um bom relacionamento com a criança doente; esse relacionamento é fortalecido pela troca de informações e experiências (35). quadro 3. artigos para a categoria: as contribuições do enfermeiro nas redes sociais dos adolescentes em condições crônicas autor/ano/periódico objetivo principais resultados tong a, lowe a, sainsbury p, craig jc/2009 child: care, health and development (53) explorar as experiências de pais que têm filhos com doença renal crônica (drc). as crianças diagnosticadas com drc dependem de seus pais para apoio complexo, contínuo e intensivo. os pais experimentaram incerteza e estresse emocional no hospital, que foi muitas vezes relacionado ao receber o diagnóstico, procedimentos cirúrgicos e a incerteza de resultados. foram valorizado pelos pais os enfermeiros atenciosos e dedicados que tinham um bom relacionamento com a criança doente, além das visitas domiciliares, educação e apoio fornecidos por eles. svavarsdottir ek, tryggvadottir gb, sigurdardottir ao/ 2012/ journal of family nursign (54) avaliar a eficácia de uma conversa terapêutica de curta duração como intervenção às famílias que recebiam serviços no hospital da universidade de landspitali, um hospital da islândia especializado em doenças agudas e crônicas em crianças e adolescentes. 41 pais foram designados para um grupo experimental; eles recebiam a conversa terapêutica de curta duração. enquanto 35 pais do grupo controle, recebiam o tratamento tradicional. os pais que recebiam a conversa eram mais seguros quanto ao tratamento de suas crianças e, assim, repassavam a elas tranquilidade, o que melhorou a forma de enfrentamento da doença. por outro lado, os pais que não tinham essa intervenção eram mais angustiados e não conseguiam ajudar os filhos tanto quanto os pais do outro grupo. 70 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 é papel do enfermeiro orientar e estimular o vínculo social dos pacientes, uma vez que esses laços afetivos contribuem também para a melhoria do quadro de saúde do adolescente. além das orientações referentes ao diagnóstico, o enfermeiro pode fornecer apoio emocional, afeto, aconselhamento e opiniões, tudo como cuidado ao indivíduo, com o foco em atender às necessidades tanto dos pais como dos próprios adolescentes. para paterson e zderad, o encontro do enfermeiro com o cliente pode resultar então em conforto, porque a pessoa pode se sentir confortável mesmo enfrentando uma doença, na medida em que há envolvimento com o outro, em relações verdadeiras, troca de informações, orientações etc. (16). faz-se necessária a participação e inclusão desse profissional nas redes sociais dos adolescentes, pois esse recurso beneficia as pessoas que ficam restritas a um determinado espaço, impossibilitadas de alguma forma de acesso ao meio social real (7). e, ainda, os pacientes podem procurar sites de redes sociais desenvolvidos e monitorados por profissionais de saúde para promover a troca de informações precisas e imparciais (56), já que a preocupação sobre a veracidade das informações na internet é frequentemente manifestada. uma sugestão para solução desse problema de credibilidade seria a participação de profissionais de saúde mais envolvidos em grupos de apoio na internet (56). na enfermagem o inter-relacionamento é propositalmente direcionado para fortalecer o estar bem ou o estar melhor de uma pessoa com necessidades percebidas relativas à qualidade de vida de saúde-doença (16). tal interação dos seres humanos, produto do apoio social, vem a ser um elemento essencial na doença crônica tanto para o paciente quanto para a família e as pessoas possuidoras de boas redes sociais, as quais aprendem a lidar melhor com o estresse gerado pela doença e buscam desenvolver respostas para o enfrentamento da doença (57). conclusão este estudo foi realizado a partir da busca de materiais na web, a fim de construir a revisão relacionada à temática rede social e virtual de apoio ao adolescente que convive com doença crônica e o papel do enfermeiro nessas redes de apoio. tais artigos descrevem que o apoio social dado diretamente aos adolescentes portadores de doenças crônicas ou o apoio que os seus pais recebem, afetará positivamente no estado de saúde. descobrimos que rede social não é uma expressão fácil de definir, já que não há um conceito específico. a rede social é ampla e fácil de identificar no cotidiano por se apresentar em diferentes formas, como instituições, grupos de socialização grandes, pequenos, grupos de rede social virtual, antigos ou adquiridos com as situações da vida de cada ser humano, independentemente de se ter ou não alguma patologia. com a internet e as mídias, inúmeras redes virtuais têm se tornado ferramentas de grande utilidade tanto para os profissionais de saúde quanto para as pessoas envolvidas no processo saúde e doença do adolescente, o que contribui de forma positiva para o enfrentamento da doença crônica, seja por meio dos conteúdos disponibilizados relacionados à saúde ou de bate-papo. segundo paterson e zderad, a pessoa com doença pode vir a se sentir bem, confortável quando há relações verdadeiras, quando o enfermeiro oferece ao adolescente informações e orientações acerca do processo que está vivenciando, respeitando-o, valorizando-o, para juntos planejarem o cuidado individualizado. assim, o envolvimento do enfermeiro nessas redes ocasiona uma diferença significativa, pois esses profissionais desenvolvem papéis importantes como a prática educativa, além da manutenção de laços afetivos ao promoverem incentivos aos adolescentes que convivem com a doença crônica, bem como aos seus familiares, ou responsáveis, o que contribui para a melhoria e o bem-estar destes. portanto, este estudo deseja incentivar a participação ativa do enfermeiro nas redes virtuais por ser um ambiente pouco explorado por tais profissionais, porém com um crescimento expressivo de pessoas à procura de conteúdos informativos principalmente relacionados à saúde. além disso, este estudo constata a necessidade de que novas pesquisas sobre essa temática sejam realizadas a fim de proporcionar outras contribuições para a saúde. 71 rede social e virtual de apoio ao adolescente que convive com doença crônica: uma revisão integrativa l gabriela silva dos santos e outros. referências 1. ministério da saúde brasil; secretaria de vigilância em saúde. departamento de análise de situação de saúde. plano de ações estratégicas para o enfrentamento das doenças crônicas não transmissíveis (dcnt) no brasil 2011-2022. brasília: ministério da saúde; 2011. 2. 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2014]; 30(5):827-34. disponível em: http://tde-sagepub-com.ez24.periodicos.capes.gov.br/content/30/5/827.full.pdf 57. herrera a, torres ief, massa er, montalvo a. soporte social a cuidadores familiares de personas con enfermidad crónica en cartagena. aquichan [on-line] 2012 [acesso 14 set. 2014]; 12(3):286-97. disponível em: http://aquichan.unisabana. edu.co/index.php/aquichan/article/view/2308/pdf 513 -525 indicios de profesionalizacion.indd 513 manuel-ángel calvo-calvo1 indicios de profesionalización de la enfermería en españa en el siglo xvii, según los estatutos de hospitales de sevilla 1 orcid.org/0000-0002-8806-8645. universidad de sevilla. españa. macalvo@us.es recibido: 12 de enero de 2016 enviado a pares: 06 de mayo de 2016 aceptado por pares: 30 de junio de 2016 aprobado: 11 de julio de 2016 doi: 10.5294/aqui.2016.16.4.9 para citar este artículo / to reference this article / para citar este artigo calvo-calvo ma. indicios de profesionalización de la enfermería en españa en el siglo xvii, según los estatutos de hospitales de sevilla. aquichan. 2016; 16(4): 513-525. doi: 10.5294/aqui.2016.16.4.9 resumen objetivo: conocer los rasgos de profesionalización de enfermeras/os que ejercían en hospitales de sevilla (españa), en el siglo xvii. método: investigación cualitativa de tipo histórico, abordada desde la microhistoria, mediante el análisis de contenido de los estatutos que regían en el siglo xvii en los hospitales sevillanos de las cinco llagas, del espíritu santo, de la santa caridad y de los venerables sacerdotes. también se aportaron dos pinturas de esa época. resultados y discusión: en las enfermeras que ejercieron en hospitales sevillanos en el siglo xvii se identificaron seis rasgos de profesionalización, pues se constató que la actividad enfermera era regulada por las autoridades hospitalarias; algunos hospitales exigían a los enfermeros requisitos académicos y formativos para ejercer; se impartía formación a enfermeras; la actividad cuidadora tenía un alto reconocimiento social; había enfermeros que además de cuidar asumían tareas de gestión del contexto hospitalario y supervisaban oficios paramédicos, y también había enfermeras remuneradas a cambio de su trabajo. el único rasgo de profesionalización no constatado fue la regulación de los contenidos curriculares formativos de los enfermeros. la ausencia de este importante rasgo impedía culminar definitivamente el proceso de profesionalización de las enfermeras. palabras clave rol profesional; enfermería; historia de la enfermería; historia del siglo xvii; personal de enfermería en hospital (fuente: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 513-525 514 aquichan issn 1657-5997 eissn 2027-5374 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 513-525 indications of professionalization in nursing in spain in the seventeenth century according to hospital statutes in seville abstract objective: become acquainted with the characteristics of professionalization among nurses working at hospitals in seville (spain) during the 17th century. method: this is a qualitative study of a historical nature approached through microhistory, with content analysis of seventeenth century statutes governing the sevillian hospitals of cinco llagas, espiritu santo, santa caridad and venerables sacerdotes. two paintings from that era are included as well. results and discussion: nursing activity was found to be regulated by hospital authorities, and six features of professionalization were identified among the nurses who worked at sevillian hospitals in the 17th century. some hospitals had academic and training requirements for nurses in order to practice. nurses were given training, and being a caregiver was held in high regard by society. there were nurses who, in addition to providing care, assumed hospital management duties and supervised paramedical tasks. some nurses were paid in exchange for their work. the only feature of professionalization that was not verified was the regulation of curricular content in education, a shortcoming that prevented the process of nursing professionalization from culminating definitively. keywords professional role; nursing; history of nursing; history of the seventeenth century; nursing staff in hospital (source: decs, bireme). 515 indicios de profesionalización de la enfermería en españa en el siglo xvii, según los estatutos de hospitales de sevilla l manuel-ángel calvo-calvo indícios de profissionalização da enfermagem na espanha no século xvii, segundo os estatutos de hospitais de sevilha resumo objetivo: conhecer as características de profissionalização de enfermeiras/os que trabalhavam em hospitais de sevilla (espanha), no século xvii. método: pesquisa qualitativa de tipo histórico, abordada a partir da micro-história, mediante a análise de conteúdo dos estatutos do século xvii nos hospitais sevilhanos das cinco llagas, do espíritu santo, da santa caridad e dos venerables sacerdotes. também foram fornecidas duas pinturas dessa época. resultados e discussão: identificaram-se seis características de profissionalização nas enfermeiras que trabalharam em hospitais sevilhanos no século xvii, pois se constatou que a atividade de enfermagem era regulada pelas autoridades hospitalares; alguns hospitais exigiam dos enfermeiros requisitos acadêmicos e formativos para exercer a atividade; dava-se formação a enfermeiras; a atividade cuidadora tinha um alto reconhecimento social; havia enfermeiros que, além de cuidar, assumiam tarefas de gerenciamento do contexto hospitalar e supervisionavam trabalhos paramédicos; também havia enfermeiras remuneradas em troca de seu trabalho. a única característica de profissionalização que não consta foi a regulação dos conteúdos curriculares formativos; a ausência destes impedia culminar definitivamente o processo de profissionalização das enfermeiras. palavras-chave enfermagem; história da enfermagem; história do século xvii; papel profissional; pessoal de enfermagem em hospital (fonte: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 513-525 516 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 introducción tradicionalmente se sitúa a la enfermería en españa durante el siglo xvii inmersa en una etapa religiosa e institucional, y se establecen los siglos xviii y xix como un periodo de enfermería preprofesional, que evolucionaba pausada y tardíamente hacia la profesionalización. ciertamente, la enfermería no alcanzó en españa el estatus de profesión hasta el primer tercio del siglo xx, coincidiendo con el progresivo movimiento emancipador de la mujer y su integración en el mundo laboral, y más concretamente, en el sector terciario. mientras tanto, en inglaterra y estados unidos existía una enfermería cualitativamente superior, integrada por profesionales cualificados a los que avalaba un título oficial, como resultado de la consolidación de la profesión enfermera como actividad laica dentro del sector terciario, como profesión de servicios (1). así, por ejemplo, en inglaterra, las enfermeras profesionalizadas ya habían surgido treinta años antes que en españa (2). existe cierto consenso sobre el proceso de profesionalización de la enfermería, entendiendo que se inicia en el momento en que además de regularse su actividad y los contenidos curriculares, las enfermeras reciben un salario por ejercer como tales, son reconocidas en la sociedad por lo que hacen, aspiran a obtener un prestigio similar al de otros sanitarios (3, 4), o en su práctica asistencial anteponen los intereses de los pacientes. a finales del siglo xix, según florence nightingale, se dan esas condiciones y aparece un profesional de enfermería laico, cuyo modelo se exporta al resto de europa y américa, en donde se fundan escuelas de enfermeras y hospitales que necesitan y requieren este tipo de profesional (3). esas enfermeras, formadas bajo la filosofía de florence nightingale, asumieron su propia responsabilidad en los hospitales bajo las órdenes, no de médicos, sino de enfermeras formadas, ocupándose de la organización interna, de la disciplina y con poder respecto a las cuestiones de enfermería (4). recientemente, se ha situado este punto de inflexión del cambio de una enfermería doméstica a otra profesional en la guerra civil norteamericana, entre 1861 y 1865. además, se incluye también como rasgo de profesionalización de la enfermería, el hecho de que las enfermeras asuman funciones de gestión, sin limitarse solo a cuidar al enfermo, es decir, cuando también organizan el contexto hospitalario y gestionan la labor de otros colaboradores médicos (5, 6). en españa y la europa católica, la transición de los oficios dedicados a los cuidados básicos de salud hacia una enfermería profesional fue un proceso lento y tardío. particulares razones históricas acaecidas en españa favorecieron una intensa actividad asistencial de las órdenes religiosas en los hospitales públicos y privados, perviviendo mayoritariamente los cuidados en manos de estos institutos religiosos e impidiendo una normal conciencia profesional entre las enfermeras. por tanto, es conveniente conocer los rasgos de profesionalización de las enfermeras en determinados periodos históricos, y obtener así un mejor conocimiento del proceso que llevó a la enfermera desde unos cuidados domésticos a otros profesionales (4). en este sentido, durante el siglo xvii confluyeron una serie de hechos que marcaron positivamente el devenir de la enfermería en españa, tales como la expansión de importantes órdenes religiosas dedicadas al cuidado de los enfermos y la aparición de textos escritos por enfermeros para formar a enfermeros (7). entre esas órdenes destacaron la congregación de los enfermeros obregones (8) y los hermanos de san juan de dios (9), y entre los textos de formación en cuidados, sobresalen el manual instrucción de enfermeros, realizado por la referida congregación de los enfermeros obregones, en 1625, y el directorio de enfermeros, cuyo autor fue el enfermero simón lópez, en 1668 (8, 10). paralelamente a las aportaciones de las órdenes religiosas, al cuidado de los enfermos en españa entre los siglos xvi y xviii, también se conoce la existencia en ese periodo de numerosas mujeres laicas españolas, casadas y con hijos, que como medio de vida ejercían como enfermeras en los grandes hospitales y también en el entorno domiciliario. cabe pensar, por tanto, que estas mujeres laicas no se guiasen exclusivamente por criterios vocacionales para trabajar como enfermeras y que ya tuviesen determinados objetivos profesionales en su ejercicio asistencial (11). por tanto, parece interesante conocer esos rasgos de profesionalización de las enfermeras en un espacio temporal tan determinado como el siglo xvii, pues además de lo anteriormente expresado, ese periodo recogió toda la herencia renacentista, alumbró al hombre del barroco y quedaba lejos todavía del siglo xx, donde la enfermera española se hizo definitivamente profesional. en consecuencia, el objeto de este trabajo fue conocer los rasgos de profesionalización que se dieron en las enfermeras y enfermeros que ejercían en hospitales de sevilla en el siglo xvii, averiguando quiénes proporcionaban los cuidados de salud en esas instituciones, de quiénes dependían, cuál era el perfil o las características de las enfermeras que trabajaban en esos hospitales, si se les exigía o recibían formación para ejercer, su re517 indicios de profesionalización de la enfermería en españa en el siglo xvii, según los estatutos de hospitales de sevilla l manuel-ángel calvo-calvo conocimiento en la sociedad, quiénes regulaban y contrataban a las enfermeras, si además de prestar cuidados básicos de salud también desarrollaban tareas de gestión, y si recibían un salario a cambio de ejercer su actividad. método se realizó una investigación cualitativa de tipo histórico, abordada desde la microhistoria, pues se eligió un ámbito local de estudio centrado en las enfermeras que ejercían en hospitales sanitarios de sevilla, lo cual sirvió también para conocer el grado de profesionalización de las enfermeras españolas en el siglo xvii, dado que el contexto histórico de aquel momento permite extrapolar los resultados locales de este estudio a contextos más amplios (2). para realizar este trabajo, mediante análisis de contenido se analizaron las reglas, los estatutos o las constituciones vigentes en el siglo xvii, de importantes y significativos hospitales sevillanos como el hospital de las cinco llagas (12), el hospital del espíritu santo (13), el hospital de la santa caridad (14) y el hospital de los venerables sacerdotes (15). estos documentos recogían un conjunto principal de normas escritas con fuerza de ley para regir y gobernar a esos hospitales. por tanto, constituían un régimen jurídico al que estaban sometidos todas las personas, actividades y bienes que tenían alguna relación con esas instituciones (16). estas constituciones de los hospitales sanitarios determinaban también la tipología de enfermedades que se curaban en cada hospital, organizaban la gestión de sus recursos, la administración de sus bienes y también la asistencia sanitaria que en ellos se prestaba (9, 17). por tanto, esta investigación histórica, al estar tan centrada en el estudio de la hospitalidad, contribuirá al conocimiento del pasado de las enfermeras y de su actividad de cuidar, aportando a su vez una visión de la acción asistencial y benéfica de los hospitales, de sus recursos e incluso de las mentalidades (18, 19). también, para conseguir los objetivos de este trabajo se tuvieron en cuenta las aportaciones de dos pinturas al óleo: el retrato de don miguel mañara leyendo la regla de la santa caridad (figura 1), que juan valdés leal pintó hacia 1681 (20), y la asistencia a los sacerdotes en la enfermería (figura 2), realizada en 1699 por lucas valdés, hijo de valdés leal (21). figura 1. retrato de d. miguel mañara leyendo la regla de la santa caridad, ca. 1681 fuente: hermandad de la santa caridad, sevilla (españa). figura 2. asistencia a los sacerdotes en la enfermería, 1699 fuente: hospital de los venerables sacerdotes, sevilla (españa). 518 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 resultados y discusión antecedentes y finalidad de los hospitales de sevilla estudiados el hospital de las cinco llagas (hcll) fue creado en 1500 por iniciativa individual de catalina de rivera, hija, esposa y madre de sucesivos adelantados mayores o gobernadores de la región española de andalucía. durante el siglo xvii, este hospital se rigió por las constituciones y reglamentos del hospital de las cinco llagas de sevilla, promulgadas el 18 de enero de 1624, y que estuvieron vigentes hasta 1734 (12, 16, 22). este era un hospital de medicina y cirugía, cuya finalidad era la asistencia sanitaria de mujeres sin recursos, para curarse de enfermedades de “calenturas” y de “cámaras” (diarreas), “heridas”, “postemas” (abscesos supurados), “llagas frescas” (úlceras), fracturas y dislocaciones, o de cualquier enfermedad que se considerase como curable y no contagiosa (12, 16). el hospital del espíritu santo (hes) se creó en 1590 con los bienes y rentas de 38 de los 75 hospitales suprimidos durante el proceso de reducción de hospitales que ocurrió en sevilla a finales del siglo xvi. el arzobispo de sevilla, rodrigo de castro, fue su fundador y responsable máximo, lo dotó de constituciones el 26 de abril de 1590 (13, 16), las cuales gobernaron el hospital durante todo el siglo xvii. el hes fue creado expresamente con la finalidad de prestar asistencia sanitaria a mujeres y hombres afectados por sífilis, entonces conocida como “enfermedad de bubas” (13), y a partir de 1637, también atendería a mujeres tísicas o afectadas de tuberculosis (23). el hospital de la santa caridad de sevilla (hsc) fue creado por iniciativa de la hermandad de la santa caridad, concretamente, por el hermano mayor de esta hermandad, miguel mañara. el 27 de septiembre de 1675, este caballero sevillano dotó a dicha hermandad de nuevas reglas y estatutos para su gobierno (14, 24), que también sirvieron para regir al hsc. mediante esas reglas, que perduraron el resto del siglo xvii, a las primitivas funciones caritativas de dicha hermandad, miguel mañara añadió dos nuevas finalidades: hospedar a los pobres más desamparados, de sexo masculino (14, 24), que no tenían dónde recogerse durante la noche, y asistir y curar a los acogidos en su hospicio que estuviesen enfermos y aquellos enfermos que por tener enfermedades incurables no fuesen admitidos en otros hospitales de sevilla. para realizar estas dos nuevas funciones, miguel mañara fundó y construyó primeramente el hospicio de peregrinos y posteriormente el hospital para la curación de enfermos pobres, ambos al amparo de la hermandad de la santa caridad (24). el hospital de los venerables sacerdotes de sevilla (hvs), también surgió a mediados del siglo xvii, para asistir a los sacerdotes enfermos y transeúntes por sevilla, que estuviesen enfermos, pobres o desamparados. concretamente, en 1673, el canónigo justino de neve y chaves fundó la hermandad de venerables sacerdotes para asistir a los “venerables sacerdotes”. esta hermandad, en el actual barrio de santa cruz (sevilla), construyó un hospital conocido vulgarmente como el hospital de los venerables, para dicha asistencia a los sacerdotes enfermos y necesitados (25). el 6 de mayo de 1676, se dotó de reglas y estatutos a la hermandad de los venerables sacerdotes (15), por las cuales también se rigió el hospital del mismo nombre. estructura asistencial y cuidados en los hospitales sevillanos durante el siglo xvii, en el hcll hubo médico, cirujano, boticario, barbero, un enfermero y enfermeras para asistir a las enfermas. entre las enfermeras se diferenciaba a una “madre enfermera” o “enfermera mayor” para asistir en las dos salas de medicina, con cinco “hijas” que le ayudaban a cuidar a las enfermas. en la sala de cirugía asistía una enfermera denominada “madre cirujana”, la cual tenía dos “hijas” que le ayudaban. para atender la enfermería de clérigos, que se creó en el siglo xvii, había un único “enfermero de los clérigos” (12, 16, 22). dada la función de este hospital de atender a enfermas pobres, y a causa de la separación de los sexos de aquella época, se formó una enfermería femenina para el cuidado de estas mujeres. las “madres enfermeras” y sus “hijas” trabajaron en la llamada clausura femenina del hcll, “como si fuesen monasterios en reclusión, completamente separadas del resto del hospital y con acceso restringido a los varones” (26). durante el siglo xvii, el equipo asistencial del hes fue similar al del hcll, pues estuvo formado por médico, cirujano, boticario y mozo de botica, barbero y enfermeros y enfermeras. en ese hospital ejercía un enfermero mayor, del cual dependían sus ayudantes o enfermeros menores, siendo rodrigo vázquez el primer enfermero mayor que ejerció en dicho hospital. este enfermero mayor tenía la consideración de “oficial” del hes, y como tal debía jurar su cargo. igualmente, en el hes también ejercieron una en519 indicios de profesionalización de la enfermería en españa en el siglo xvii, según los estatutos de hospitales de sevilla l manuel-ángel calvo-calvo fermera mayor y enfermeras menores, las cuales asistían solo a las mujeres ingresadas en el hospital (13, 16). sin embargo, en el hsc, la estructura asistencial y del equipo cuidador era totalmente distinta a la del hcll y del hes. concretamente, la regla que gobernaba al hsc no establecía que debiese haber médico, barbero ni boticario en ese hospital, y al único personal asistencial que dedicaba un capítulo para regular sus tareas era a los enfermeros que habían de ejercer allí. no obstante, sabemos por esa misma regla que al menos un cirujano visitaba a los enfermos por la tarde (14, 27). también, la composición del equipo cuidador del hsc difería de los dos hospitales vistos anteriormente, pues en él se podían diferenciar dos clases de personas que cuidaban a los enfermos: los “hermanos hospicieros” y los “hermanos enfermeros del hábito de penitencia”. cada mes eran nombrados tres hermanos de la hermandad de la santa caridad, denominados “hermanos hospicieros”, que de modo altruista dedicaban parte de su tiempo a “cuidar de los dichos pobres” ingresados en el hsc (27), como obra caritativa (14). posteriormente, el hermano mayor de dicha hermandad, miguel mañara, entendió que para conseguir una mejor atención a los enfermos, también era necesario un personal dedicado exclusivamente a las tareas de cuidar y con vocación de servicio, guiados solo por las ideas de caridad y humildad cristiana, y sin perseguir recompensas materiales y salarios a cambio de su trabajo (24, 27). por ello, mañara desechó la idea de contratar enfermeros asalariados para el hsc y propuso que un grupo de hombres “virtuosos, libres de matrimonio y otro estado”, se dedicasen de modo continuo y exclusivo a cuidar a los enfermos, solo por vocación (28). a este grupo de personas los llamó “hermanos del hábito de penitencia”, e incluía a los enfermeros y “sirvientes inmediatos de los enfermos” (27). el 29 de noviembre de 1673, el arzobispo de sevilla aprobaba que seis de estos hermanos viviesen dentro del hsc, “para servir á los pobres”. entre ellos había un enfermero mayor y un segundo enfermero que debía “ayudar en todo al enfermero mayor” (14). para que a estos “hermanos de penitencia” les reconociesen como enfermeros y sirvientes del hsc, el vicario de la diócesis de sevilla los autorizó a vestir un “hábito de paño de color pardo, al modo que acostumbran a vestir los ermitaños” y “una cruz en el escapulario” (24), de color azul, igual que la del escudo de la hermandad de la santa caridad. ese hábito que vestían los enfermeros del hsc es el mismo que viste el niño que aparece en el ángulo inferior izquierdo del ya mencionado retrato de miguel mañara (figura 1). esta consagración voluntaria de determinados hombres con el único objeto de servir y cuidar a los pobres y enfermos del hsc, con la mayor caridad posible, estuvo favorecida por la concepción vocacional y caritativa cristiana que entonces tenía la actividad de cuidar, donde colmar las necesidades espirituales de las personas se anteponía a las necesidades físicas y materiales, tanto de aquellos que cuidaban como de las personas que necesitaban asistencia y eran cuidadas. en consecuencia, la aparición de estos “hermanos enfermeros de penitencia”, con esos exclusivos objetivos vocacionales y caritativos, muestra que en el siglo xvii los cuidados no tenían como objeto el de constituirse en una disciplina. esto contribuía a imposibilitar que esos enfermeros evolucionasen de algún modo hacia la profesionalización, dado que esta surge fuera del concepto caritativo de los cuidados. respecto al hospital de los venerables sacerdotes (hvs), su estructura asistencial y del equipo cuidador durante el siglo xvii fue muy similar a la del hospital de la santa caridad. concretamente, la regla que regía el hvs tampoco establecía que en él debiesen existir médico, barbero, ni boticario, y al único personal asistencial que regulaba era a las personas que debían cuidar a los enfermos en ese hospital. no obstante, por esa misma regla sabemos que un médico visitaba a los enfermos del hvs (15). en el equipo cuidador del hvs, al igual que en el hsc, se diferenciaban dos clases de cuidadores: dos “hospicieros” y un enfermero. los dos “hospicieros” eran hermanos de la hermandad de los venerables sacerdotes, que altruistamente durante una semana debían asistir para visitar y dar de comer a los sacerdotes enfermos e impedidos. el enfermero, dedicado únicamente a cuidar de los enfermos, era uno de los “ministros” del hvs, junto al comprador, portero y sacristán (15). perfil y características requeridas para ejercer como enfermero en el siglo xvii en los cuatro hospitales estudiados se exigían para trabajar como enfermero una serie de características personales de carácter religioso y ético, vinculadas al cristianismo, como las de tratar a los enfermos con mucha caridad, amor y templanza, y ser resignados y humildes (12-15), pues con “amor y caridad” se servía mejor a los pobres y enfermos (14). 520 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 las constituciones del hes, además, señalaban que “se a de procurar que [el enfermero mayor] sea persona de mucha confianza y celo” (13), por lo que en ese hospital también exigían para trabajar como enfermero, poseer unas características personales de tipo moral, como la de ser una persona cumplidora de su deber y de confianza del hospital. a diferencia del resto de hospitales estudiados, en el hes y desde finales del siglo xvi, también exigían para ejercer como enfermero mayor el ser “practicante en medicina y cirugía” o como mínimo tener conocimientos suficientes sobre las enfermedades, para poder informar al médico y cirujano de las enfermedades de los enfermos y “sucesos de ellas, y que [el enfermero mayor] pueda acudir a los casos repentinos que de día y de noche suelen acontecer” (13). la particular y temprana exigencia de esta característica académica-profesional, que requería que el enfermero mayor dispusiese de una titulación que lo habilitase para ejercer su oficio o bien tuviese determinados conocimientos propios de su oficio, constituye un rasgo de profesionalización en la práctica de los cuidados. no obstante, la mayoría de hospitales estudiados aún no consideraban imprescindibles que los enfermeros poseyeran requisitos académicos ni profesionales para ejercer. esto confirma que durante el siglo xvii, la enfermería era una ocupación sanitaria que todavía no gozaba del estatus conveniente para ser considerada como profesión. este hecho explicaría que la mentalidad social imperante en esa época aún no permitía a las enfermeras tener como uno de sus objetivos el de constituir un saber enfermero, creemos debido a que todavía, a las labores del cuidado, socialmente solo se le asignaban objetivos religiosos-espirituales. en el hcll, sus constituciones mandaban que la “madre mayor”, una mujer que en principio no consta que fuese enfermera, “entre y visite todos los oficios de las mujeres y vea como se hacen y enseñe por su persona a hacerlos” (12). es decir, esa “madre mayor” enseñaba todos los oficios ejercidos por mujeres en el hcll, y por tanto, también enseñaba a las enfermeras a ejercer su oficio. por tanto, esa formadora de las enfermeras creemos que debía conocer el oficio de enfermera, siendo lógico pensar que anteriormente debió ejercer como tal. en consecuencia, en el hcll también se exigía que las enfermeras adquiriesen y tuviesen los conocimientos propios de su oficio para poder ejercerlo. esta formación de las enfermeras, aunque no consta que se impartiese mediante un sistema y con contenidos curriculares regulados y organizados, constituye un indicio temprano de profesionalización de los cuidados. respecto a la figura del niño vestido con el hábito de los “enfermeros de penitencia” que ejercían en el hsc y que aparece en el retrato de miguel mañara (figura 1), guichot sostiene que ese niño pudo ser un “monaguillo, un aprendiz o novicio” que se instruía en el hsc para ejercer posteriormente como “hermano enfermero de penitencia”, cuidando a los enfermos en ese hospital. también concluye que la escena de ese retrato representa las reuniones de cada viernes, entre mañara, el capellán mayor y los “hermanos del hábito de penitencia”, para rezar en comunidad e instruir a esos enfermeros en sus deberes y oficios (20), tal como ordena la regla por la que se regía el hsc (14). todo esto permite sostener que en el hsc, al igual que en el hcll, se requería y se impartía determinada formación en cuidados, tanto para sus futuros enfermeros como para los que ya ejercían en él. la formación de enfermeros en el hcll y en el hsc son indicios de profesionalización de la actividad de cuidar, nada habituales en la enfermería del siglo xvii. no obstante, las ya comentadas connotaciones de ayuda, caridad y servicio a los pobres y enfermos con que el cristianismo caracterizaba a los cuidados y a quienes los prestaban, creemos que seguían siendo un obstáculo decisivo para el desarrollo de la enfermería como profesión, pues también impidieron que esa formación a enfermeras en hospitales sevillanos se generalizara y evolucionara hacia una formación organizada. reconocimiento y significado social de los cuidados en las constituciones del hes se consideraba que “el offiçio de enfermero mayor es de mucha consideración porque del pende la mayor parte de la cura y regalo de los enfermos” (13). se reconocía así, directamente por la máxima autoridad del sistema asistencial público sevillano, el arzobispo rodrigo de castro, que fue quien promulgó dichas constituciones, lo necesarias e imprescindibles que eran las aportaciones de las enfermeras para la curación y el restablecimiento de la salud de los enfermos. esto demuestra la consideración y el reconocimiento que socialmente se atribuía entonces a los cuidados y a los enfermeros, pues distinguía positivamente a los cuidados por sus características y rasgos, sobre otras actividades asistenciales de aquellos momentos. ese alto reconocimiento social de lo necesario del trabajo de los enfermeros para la cura de los enfermos es también un rasgo de profesionalización en la práctica de los cuidados, en ese periodo del siglo xvii. 521 indicios de profesionalización de la enfermería en españa en el siglo xvii, según los estatutos de hospitales de sevilla l manuel-ángel calvo-calvo también, dichas constituciones del hes de 1590, asignaban al enfermero mayor la responsabilidad de supervisar tareas asistenciales de otros miembros del equipo asistencial del hes que no pertenecían al equipo cuidador, como el boticario, el barbero y los “criados” del hospital. concretamente, el enfermero mayor debía supervisar y vigilar que el boticario administrase los jarabes, purgas y medicamentos, y que el barbero hiciese las sangrías y otros remedios, según había indicado el médico (13). asignar al enfermero mayor del hes que gestionase la labor de otros colaboradores médicos confirmaba la importancia institucional que entonces se daba al quehacer de los enfermeros en la recuperación de la salud de los enfermos, y además constituye otro rasgo de profesionalización de los cuidados de enfermería. por otro lado, la regla que rigió al hvs durante el siglo xvii, en su capítulo dedicado al “enfermero y su obligación”, señala que “de lo que más se necesita es de un enfermero, persona de mucha caridad, y prudencia, que pueda asistir a los impedidos y enfermos que huviere…” (15). es decir, claramente se reconoce que el quehacer de un enfermero es imprescindible en la asistencia hospitalaria. reconocer este hecho es importante, porque esa regla debió recoger el pensamiento de quienes la promulgaron y que a su vez debieron basarse en el reconocimiento social que en aquel siglo xvii se otorgaba a los cuidados como quehacer propio de los enfermeros. la regla que regía el hsc transmite la importancia, el papel clave y la especial relevancia que esa hermandad y el propio miguel mañara daban a los enfermeros y a los cuidados para el mantenimiento de la vida material y espiritual de los enfermos. granero recoge esa especial preocupación e interés que mañara daba al papel de los enfermeros “en el servicio a los pobres” (24), preocupación que, como ya se ha dicho, mañara llevó a la realidad con la creación de un cuerpo específico de enfermeros, los “hermanos enfermeros de penitencia”, con el único objeto de asistir y cuidar mejor a los enfermos. igualmente, en el ya mencionado retrato de miguel mañara (figura 1), el “hábito pardo” que viste el niño que aparece en el retrato es el que vestían esos enfermeros que ejercían en el hsc, por lo cual esa obra de arte alude directamente a la prestación de cuidados como pilar de la asistencia a los enfermos. esto sugiere que la elección de una alegoría o motivo enfermero, para ser representado en el retrato de una figura tan relevante como miguel mañara, está en consonancia con la importancia que entonces se daba a los cuidados para mantener la salud corporal y espiritual. igualmente, el cuadro de lucas valdés (figura 2) representa a un enfermero y dos hospicieros de la hermandad de los venerables sacerdotes que asisten y prestan cuidados para cubrir las necesidades básicas de los sacerdotes enfermos. la elección de este tema de los cuidados por el pintor, para representar la actividad asistencial desarrollada en el hvs, creemos que también denota la importancia social que se daba entonces a los cuidados y a quienes los dispensaban. igualmente, en las reglas que rigieron al hsc y al hvs, al único personal asistencial que regulan sus tareas es a los “hospicieros” y a los enfermeros, por lo que esas reglas solo determinaron la actividad de las personas que dispensaban cuidados a los enfermos en esos hospitales (14, 15). esto también argumenta la idea de que entonces los cuidados enfermeros eran considerados claves y fundamentales para superar la enfermedad y sustentar la salud física y espiritual, y por ello debían ser regulados por las constituciones de los hospitales. tareas y responsabilidades del equipo cuidador las constituciones del hcll asignaban responsabilidades o tareas asistenciales a las enfermeras. concretamente, les encargaban asistir a las visitas del médico y cirujano a las enfermas, que hiciesen “las unciones y eche los serviciales que se mandaren y limpie las enfermerías, traiga las comidas y sirva en todo lo demás necesario y cuando alguno de sus enfermos estuviere oleado avise al cura semanero para que le ayude a bien morir” (12, 22). la enfermera mayor y la “madre cirujana”, o enfermera de la sala de cirugía del hcll, también gestionaban cuidados y supervisaban las actividades asistenciales de sus ayudantes, pues debían tener “gran cuidado con el regalo de las enfermas y que las hijas las traten [a las enfermas] con mucho amor”, y que “se ejecuten con mucho cuidado y puntualidad las unciones y servicios y demás remedios que el médico ordenare” (12, 22). también la enfermera mayor gestionaba recursos materiales pues debía “repartir la comida de las enfermas por su persona” y avisar al administrador del hcll de lo que faltase en las enfermerías para que este lo repusiese. también, custodiaba “los regalos” para las enfermas y asistía diariamente con el médico a recibir a las mujeres que solicitaban ser curadas en el hcll. luego, acompañaba a las enfermas que ingresaban en el hospital y les adjudicaba cama en la enfermería. igualmente, la enfermera mayor y la “madre cirujana” gestionaban recursos humanos pues de ellas dependían jerárquicamente sus ayudantes o “hijas”. además, de la enfermera mayor dependía la enfermera de cirugía (12, 22). 522 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 en esta misma línea, la regla de 1675 que gobernó al hsc, asignaba al enfermero mayor tareas asistenciales como dormir en una celda próxima a la enfermería para atender los casos urgentes de los enfermos, barrer, “saumar” y asear las enfermerías, hacer las camas de los enfermos, repartir la comida y “limpiar a los pobres”. también, entre los hermanos del hábito de penitencia había un “segundo enfermero” que debía “ayudar en todo al enfermero mayor, así en barrer como en hacer las camas” (14). mediante esas tareas asistenciales, se puede afirmar que las enfermeras y enfermeros de los hospitales estudiados prestaban cuidados de salud en el siglo xvii para satisfacer necesidades básicas de los enfermos relacionadas con la alimentación, la eliminación, la higiene corporal, sueño y descanso, evitar peligros ambientales, mantener la temperatura corporal, vestir adecuadamente y rendir culto de acuerdo con la propia fe. el enfermero mayor del hsc, también gestionaba recursos humanos pues asignaba al resto de hermanos de penitencia los horarios “de vela” o vigilancia de los enfermos, “cuando había algún enfermo moribundo que velar”. además, ejercía tareas de gestión pues debía tener “en una tablica, en cada cama, el nombre del enfermo, su mujer y patria”, y comunicar al portero las defunciones para que las asentara en el libro correspondiente. la referida regla también asignaba al enfermero mayor tareas de gestión de recursos materiales pues debía encargar al cocinero la comida de los enfermos tras preguntarles a estos lo que querían comer, custodiaba los “dulces, bizcochos, azúcar y demás regalos de la botillería” y el “agua, azeytes y los ungüentos necesarios”, para las curas y los cuidados a los enfermos (14). la regla que regía al hvs (15), así como las constituciones del hes de 1590 (13), también asignaban tareas asistenciales y de gestión a los enfermeros, similares a las vistas en los dos hospitales anteriores. de esta manera, el enfermero mayor del hes era responsable inmediato de los recursos y de la organización interna de las enfermerías del hes, pues ese enfermero “a de tener la superintendencia en todas las enfermerias y enfermeros distribuyendo y ordenando a los demas lo que an de hacer sinalando a cada uno a lo que an de acudir”. igualmente, el administrador del hes debía escuchar la opinión del enfermero mayor, antes de aumentar o disminuir la plantilla de enfermeros menores (13). a diferencia de lo que ocurría en los otros hospitales estudiados, ese enfermero mayor del hes no solo coordinaba a los enfermeros menores y gestionaba cuidados, sino que, como se comentó anteriormente, también supervisaba las tareas de colaboradores del médico en el hes, que no pertenecían al equipo cuidador, como el boticario y el barbero. e igualmente, el enfermero mayor era responsable del trato personal que los criados o ayudantes de los otros oficiales del hes, como mozos de botica o cocina, daban a los enfermos, y que era un personal que igualmente no pertenecía al equipo cuidador (13). en consecuencia, se observa que en los hospitales de sevilla en el siglo xvii, había enfermeros que no solo se limitaban a cuidar del enfermo, sino que además asumían funciones de gestión de los cuidados y de la labor de otros miembros del equipo asistencial, ajenos al equipo cuidador, por lo que de este modo los enfermeros también contribuían a organizar el contexto hospitalario. esto constituye un nuevo e importante rasgo de profesionalización hallado en los enfermeros de hospitales sevillanos, y que era poco habitual en ese xvii. remuneración de los enfermeros en el siglo xvii las constituciones del hcll y las del hes señalaban los salarios que las enfermeras y los enfermeros que trabajaban en esos hospitales debían cobrar, lo cual es también otro rasgo de profesionalización de los cuidados, presente en la enfermería sevillana del siglo xvii. concretamente, el “enfermero de clérigos” del hcll tenía asignado un salario de “ducado y medio cada mes” (dieciséis reales y medio), igual que el portero, sacristán, barrendero y el mozo de la huerta. este era el salario en dinero más bajo de los oficios desempeñados por hombres en el hcll, superado por oficios como el de pastor, panadero o el hortelano, que ganaban tres y dos ducados, respectivamente. también, al enfermero de clérigos se le asignaba una ración diaria de alimentos igual a la del hortelano, consistente en “media libra de carnero, media libra de vaca y los viernes media libra de pescado fresco y media de salado, medio açumbre de vino, tres libras de pan baço y si lo quisiere blanco,2 dos libras” (12). la enfermera mayor y la enfermera de cirugía del hcll tenían un salario de “14 reales al mes y cada día media libra de vaca ó pescado y libra y media de pan blanco”, que era de menor cuantía que el salario del enfermero de sexo masculino que ejercía en el hcll. sus ayudantes, las “hijas”, “gana cada una 11 reales al mes y al día media libra de vaca ó pescado y media hogaza de pan baço” (12). 2 pan “blanco” se refiere al pan candeal, de más valor que el pan “baço” o pan negro o moreno. 523 indicios de profesionalización de la enfermería en españa en el siglo xvii, según los estatutos de hospitales de sevilla l manuel-ángel calvo-calvo el enfermero mayor del hes tenía estipulado un sueldo de dos ducados mensuales (22 reales), más la ración como pago en especie: “una libra de carnero un pan una açumbre de vino”. los enfermeros menores percibían un salario mensual de doce reales y la ración consistente en una libra de vaca, media “açumbre” de vino y un pan (13). a la enfermera mayor se le estipulaba un sueldo de dieciséis reales mensuales y a las enfermeras menores, de once reales mensuales cada una. a diferencia de los hombres, e igual que al resto de mujeres que ejercían en el hes, a las enfermeras no se les pagaba en especie la denominada ración, pues señalaba el administrador del hes “que a las mujeres no se les de racion como a los hombres porque el hospital en esto aorra y se quitan yncombenientes. que ansi se a echo hasta aquí y ba vien con ello si no que se les probea la comida” (13). esta discriminación salarial era acorde con la situación social marginal de la que era objeto la mujer en la época estudiada y, en particular, de las dedicadas a la enfermería. la regla de la hermandad de la santa caridad exhortaba a los enfermeros al servicio a los pobres y enfermos, sin esperar a cambio ni salario ni otra recompensa más que la salvación eterna de su alma (14). por tanto, ni los “hermanos hospicieros” ni los “hermanos enfermeros del hábito de penitencia” del hsc recibían recompensa salarial a cambio de su trabajo cuidando a los enfermos. la única compensación material que percibían los “hermanos enfermeros” era en especie, pues vivían y comían en el hsc (14). lo mismo ocurría en el hvs, donde los “hospicieros” cuidaban a los enfermos como obra de caridad y al enfermero no se le adjudicaba un salario, pues este debía desarrollar su trabajo “solo por dios, y por el premio eterno, que por su piedad ha de recibir” (15). esta idea cristiana no solo justifica la ausencia de remuneración de estos enfermeros del hsc, también justifica que los salarios de los enfermeros del hcll y del hes fuesen, en general, inferiores o iguales a oficios que entonces tenían menos consideración social que la enfermería, como los de portero, hortelano, pastor, etc. todos estos rasgos indicadores de profesionalización encontrados en las enfermeras y los enfermeros que ejercieron en hospitales sevillanos durante el siglo xvii, aunque no se dieron de manera uniforme en todos los enfermeros, constituyen indicios de la evolución de los cuidados, desde una actividad doméstica al ejercicio profesional de los enfermeros. dado que dicha profesionalización no ocurrió hasta pasados casi tres siglos, se entiende que la evolución hasta configurar a las enfermeras dentro de una profesión fue un proceso largo e irregular, con avances y retrocesos. conclusiones en el siglo xvii, en los hospitales sevillanos de las cinco llagas, del espíritu santo, de la santa caridad y de los venerables sacerdotes, los enfermeros y las enfermeras proporcionaban cuidados de salud de elevada calidad, para satisfacer las necesidades básicas de los enfermos. en los enfermeros y las enfermeras de los hospitales de sevilla del siglo xvii, se han evidenciado seis rasgos de profesionalización, de los siete que se han estudiado, dado que la actividad enfermera estaba regulada por las autoridades hospitalarias; para ejercer, a todos los enfermeros se les exigían características personales, éticas y morales acordes con la filosofía cristiana, y a algunos enfermeros también se les exigían requisitos académicos y formativos; en algunos hospitales se formaba a las enfermeras y se les enseñaba su oficio; en esos momentos ya había un alto reconocimiento social de los cuidados, porque estos se consideraban indispensables para que los enfermos recuperaran la salud; existieron enfermeros que coordinaban el trabajo de otros enfermeros, que gestionaban recursos y el contexto hospitalario, e incluso supervisaban oficios paramédicos; y, finalmente, la gran mayoría de los enfermeros y las enfermeras sevillanos del siglo xvii percibían remuneración salarial a cambio de su trabajo en los hospitales. sin embargo, en ese periodo, el único rasgo de profesionalización de los cuidados que no se constató fue la regulación de los contenidos curriculares formativos de los enfermeros. la ausencia de este importante rasgo, fruto de concebir entonces a la enfermería sin necesidad de constituirse en una disciplina, impediría culminar en esos momentos el proceso de profesionalización de los cuidados. en consecuencia, existen evidencias de que en españa, en el siglo xvii, los cuidados enfermeros presentaban signos tempranos de profesionalización y estaban altamente profesionalizados, contrariamente a lo que se ha venido sosteniendo hasta ahora, pues tradicionalmente a la enfermería española de ese periodo se la ha situado inmersa en una etapa religiosa e institucional, y muy alejada de la profesionalización, la cual no culminó hasta el primer tercio del siglo xx. 524 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 referencias 1. silex j. historia de la enfermería. alicante: editorial aguaclara; 1999. 2. gonzález c. cuidados y bienestar: el trabajo sanitario femenino en respuesta a la “cuestión social” (1857-1936). dynamis [internet]. 2007 [citado 2014 dic 16 ]; 27:211-35. disponible en http://www.raco.cat/index.php/dynamis/article/ view/114423/143233 3. casas mf, miralles mt. (coords.). la enfermería profesional. alcalá de henares: servicio de publicaciones universidad de alcalá; 2003. 4. santo-tomás m. antecedentes de la enfermería que contribuirán al reconocimiento legal de la profesión. en fernández ml, garcía ac, garcía mj, (coords.). un siglo cuidando a la sociedad. centenario del reconocimiento oficial de la enfermería en españa. santander: colegio de enfermería de cantabria; 2015. p. 45-56. 5. choperena a. autobiografías de enfermeras: la profesionalización de enfermería durante las guerras. cul cuid [internet]. 2013 [citado 2016 abr 28]; xvi(34):51-55. disponible en http://culturacuidados.ua.es/enfermeria/article/ view/460 6. choperena a. memorias de enfermeras en la guerra civil americana: de la dimensión doméstica a la profesional [tesis doctoral]. navarra: universidad de navarra; 2014. 7. lópez n, gracia mi, fernández ac, bara g, gonzález d, barrado mj. la enfermería en españa desde el reinado de carlos i a felipe iv. temperamentvm [internet]. 2013 [citado 2016 abr 27]; 18. disponible en http://www.index-f.com/temperamentum/tn18/t7998.php 8. garcía mj, garcía ac. el manual instrucción de enfermeros (1625), compuesto por los enfermeros obregones y los cuidados urológicos en los hospitales del siglo xvii. enfuro [internet]. 2012 [citado 2016 abr 27 ]; 122:4-10. disponible en http://enfuro.es/images/revistas%20enfuro/enfuro122.pdf 9. benavides f, valverde jm. creación y gestión de dispositivos hospitalarios en los siglos xvii-xviii. la sala de convalecencia del hospital san juan de dios de granada. archivo hospitalario. 2013;11:353-82. 10. garcía mj. la hospitalización y la peste en el siglo xvii en directorio de enfermeros, de simón lópez. erebea [internet]. 2014 [citado 2016 abr 27]; 4:119-43. disponible en http://rabida.uhu.es/dspace/bitstream/handle/10272/10895/ la_hospitalizacion_y_la_peste.pdf?sequence=2 11. garcía ac. enfermeras laicas en el madrid de los siglos xvii y xviii: ¿vocación religiosa o práctica profesional? híades. 2015;11:241-58. 12. constituciones y reglamentos del hospital de las cinco llagas de sevilla. 18 ene 1624. archivo de la diputación de sevilla; sección hospital de las cinco llagas, legajo 1-a. p. 4, 2, 42-50. 13. estatutos y constituciones del hospital del espíritu santo de sevilla. 26 abr 1590. archivo de la diputación de sevilla; sección espíritu santo, legajo 2-c. p. 6-13 y documentos añadidos. 14. regla de la muy humilde hermandad de la ospitalidad de la santa caridad de nuestro señor jesu-christo, sita en su casa y hospital del señor san jorge de la ciudad de sevilla. 27 sep 1675. biblioteca general de la universidad de sevilla, signatura a 180/071. p. 355-82. 15. regla y estatutos de la venerable hermandad, nuevamente fundada en esta ciudad de sevilla, para el amparo, curación y hospicio de todos los sacerdotes pobres, desvalidos y enfermos que a ella concurrieren. sevilla: biblioteca del hospital de los venerables; 1676. 16. garcía ac. las constituciones de los hospitales y los cuidados enfermeros en la españa de los austrias (siglos xvixvii). erebea [internet]. 2014 [citado 2016 abr 27]; 4:43-80. disponible en http://rabida.uhu.es/dspace/bitstream/ handle/10272/10893/las_constituciones_de_los_hospitales.pdf?sequence=2 17. mestre pa. los libros de protocolo de bienes de las instituciones hospitalarias sevillanas durante la edad moderna [tesis] [internet]. sevilla: universidad de sevilla; 2015 [citado 2016 abr 27]. disponible en http://fondosdigitales.us.es/ media/thesis/2612/geohis-prov26.pdf 525 indicios de profesionalización de la enfermería en españa en el siglo xvii, según los estatutos de hospitales de sevilla l manuel-ángel calvo-calvo 18. pérez mj. el hospital de la encarnación de zamora en el siglo xviii: reglamentación y evolución asistencial. revista de historia moderna [internet] 2013 [citado 2016 abr 27]; 31:73-89. disponible en http://hdl.handle.net/10045/35427 19. pérez mj. los pacientes del “hospital de paisanos” de zamora en el siglo xviii. asclepio [internet]. 2014 [citado 2016 abr 27]; 66(1):038. disponible en http://asclepio.revistas.csic.es/index.php/asclepio/article/viewarticle/590/701 20. guichot a. del notable retrato de mañara que hizo valdés leal, y de errores relativos a endebles pinturas, existentes en el hospital de la caridad de sevilla. sevilla: imprenta de álvarez y zambrano; 1931. 21. fernández lópez j. programas iconográficos de la pintura barroca sevillana del siglo xvii. 2ª ed. sevilla: secretariado de publicaciones de la universidad de sevilla; 2002. 22. robles j, vega fj, pachón e. epidemia de peste en 1649. enfermería en el hospital de las cinco llagas. cul cuid [internet]. 2012 [citado 2016 abr 27]; xvi(33):38-42. disponible en http://dx.doi.org/10.7184/cuid.2012.33.05 23. collantes f. memorias históricas de los establecimientos de caridad de sevilla. descripción artística de los mismos. sevilla: imprenta y litografía de josé maría ariza; 1884. 24. granero jm. d. miguel mañara. sevilla: gráfica salesiana; 1963. 25. aranda g. vida del padre contreras. sevilla: imprenta de thomas lópez de haro; 1692. 26. rivasplata pe. la clausura femenina del hospital de las cinco llagas de sevilla en el antiguo régimen. cul cuid [internet]. 2014 [citado 2016 abr 28]; xviii(39):48-62. disponible en http://culturacuidados.ua.es/enfermeria/article/ view/524. 27. cárdenas j. breve relación de la muerte, vida y virtudes del venerable caballero don miguel de mañara. sevilla: imprenta castellana y latina de diego lópez de haro; 1732. 28. acta del cabildo de 12 de noviembre de 1673. archivo de la santa caridad, sevilla; libro ii de cabildos y acuerdos de la hermandad de la santa caridad. 03. transit la adoles.(18.-29). revista aquichan issn 1657-5997 año 4 nº 4 18-29 bogotá, colombia octubre 2004 18 resumen entender las costumbres, los valores y los mitos asociados a la “dieta”, término con el que las adolescentes se refieren al postparto en colombia, permite ofrecer un cuidado culturalmente congruente. con ese propósito se entrevistaron 16 adolescentes, en dos ciudades capitales, utilizando la etnografía focalizada. los conceptos y las prácticas de las jóvenes presentan un agudo contraste con aquellos promovidos en el modelo biomédico de la procreación en la medicina occidental. un aspecto que transita en casi todas las prácticas que desarrollan las adolescentes es el mantenimiento del balance calor-frío, dentro de su cuerpo y con el ambiente. el descubrimiento cultural por parte de las enfermeras permite renovar la práctica profesional y propiciar la sensibilidad en el cuidado. palabras clave cuidado cultural, puerperio, adolescentes. abstract understanding adolescent mothers´ habits, values and myths regarding the diet, a term used by them to talk about the postpartum in colombia, allows providers to offer a culturally congruent health care to this group. to understand their self care belief and practices, 16 adolescent mothers were interviewed in two main cities using the miniethnography methodology. the adolescent´beliefs and practices are quite different to the ones promoted by the biomedical model regarding procreation. maintaining hot-cold balance within the body and between the body and the environment is an common aspect of the adolescents’ practices. discovering the culture allows the nurses to renovate their professional practice promoting care sensibility. key words cultural care, postpartum, teenagers. 1. profesora titular, escuela de enfermería, universidad del valle, colombia. margote@univalle.edu.co 2. profesora asociada, facultad de enfermería, universidad nacional de colombia. nlbejarano@unal.edu.co 3. profesora asociada, facultad de enfermería, universidad nacional de colombia. cruiz@unal.edu.co 4. profesora asesora postgrados, facultad de enfermería, universidad nacional de colombia. lucymdero@yahoo.com 5. profesora titular, escuela de enfermería, universidad del valle, colombia.maluvasq@mafalda.univalle.edu.co luz ángela argote o. (1) nancy lucía bejarano b. (2) carmen helena ruiz de cárdenas. (3) lucy muñoz de rodríguez. (4) martha lucía vásquez t. (5) recibido: el 8 de marzo de 2004 aprobado: el 3 de junio de 2004 transitando la adolescente por el puerperio 19 omo consecuencia de los grandes cambios que se han presentado en el mundo en los últimos tiempos, las adolescentes están comenzando las relaciones sexuales a edades cada vez más tempranas1. de acuerdo con un estudio realizado en colombia2, los jóvenes inician su vida sexual, en promedio, a los 13,4 años, y las mujeres a los 14,8 años. estas tienen su primer hijo alrededor de los 16,2 años. con relación a la fecundidad en adolescentes, en colombia3 ha habido un aumento, puesto que en 1995 el 17% de las jóvenes entre 15 y 19 años ya habían tenido su primer embarazo, en comparación con el 19% para el 2000. de esta manera, la gestación en la adolescencia se ha convertido en una preocupación de la sociedad, pues no se sabe a ciencia cierta hasta qué punto los y las jóvenes están preparados para ejercer su sexualidad, afrontar el embarazo y asumir la paternidad y maternidad en forma responsable4. por ello, el proceso gestacional durante la adolescencia plantea unas necesidades especiales de cuidado para la madre y su hijo, que deben ser atendidas por la propia madre, su familia y el sector salud. la madre adolescente tiene que afrontar el periodo del puerperio llevando a cabo acciones de cuidado que usualmente son realizadas por ellas mismas y/o su familia. la mayoría de estas acciones provienen de tradiciones familiares, las cuales reflejan normas de cuidado y comportamientos importantes en esta etapa del ciclo vital, y cuyas creencias y prácticas se transmiten a las nuevas generaciones. si bien muchas de ellas son inocuas y pueden fomentar la unidad y cohesión familiar, otras prácticas, como los tabúes alimentarios y los cuidados durante el puerperio, pueden menoscabar la salud física y el bienestar de las adolescentes durante este periodo. en colombia, las adolescentes informaron haber padecido, más que las mujeres mayores de 20 años, problemas de salud durante el postparto. entre ellos figuran: sangrado intenso de la vagina (18%), desmayo o pérdida de la conciencia (6,4%), fiebre, temperatura y escalofríos (20%), dolor y ardor al orinar (19%), flujo vaginal (23%) y pérdida involuntaria de orina. sin embargo, las creencias culturales para enfrentar estos problemas son poderosas, y solo cuidadosos esfuerzos podrán modificarlas o eliminarlas. a veces las presiones para lograr cambios, del sector salud en general y de las enfermeras en particular, se han llevado a cabo de manera desconsiderada, con lo cual los intentos por cambiar las prácticas tradicionales no son eficaces. para ofrecer un cuidado culturalmente congruente se deben conocer esas especificidades, en lo que concierne a las creencias y prácticas relacionadas con el cuidado que la misma madre adolescente se provee, y así se podrá determinar cuáles de ellas es importante preservar, reacomodar y reestructurar, para que su estado de salud y bienestar sea el mejor posible5. las enfermeras desconocen las prácticas de cuidado que durante el puerperio realizan las madres adolescentes en nuestro medio. el hecho de conocerlas favorece que se establezca un proceso empático entre estas y las enfermeras, para ofrecer un cuidado congruente con la cultura6. este estudio se llevó a cabo con el propósito de contribuir a entender el 1. garzón, l. m.; ojeda, g. estudio sobre conocimientos, actitudes y comportamiento sexual de los adolescentes en seis ciudades de colombia, dirección de planeación e investigación profamilia, bogotá, 1994, pp. 45-51. 2. iss-profamilia-instituto nacional de cancerología. encuesta sobre cap en adolescentes, 1995. 3. profamilia. encuesta nacional de demografía y salud, printex impresores ltda., bogotá, 2000. 4. gutiérrez de g., myriam. embarazo y aborto en la adolescencia, ii curso de atención integral al adolescente, cafam, 1989, pp. 61-63. 5. leininger, m. culture care diversity and universality: a theory of nursing, new york, national league for nursing press, 1991. 6. ibíd. los hallazgos del presente estudio corroboran que el puerperio no es solamente un hecho fisiológico, sino también un proceso social, que implica un ritual durante los cuarenta días postparto, en el cual, para entrar y salir de él, se debe realizar una serie de interacciones, que promuevan el pasaje de un estado social viejo a uno nuevo. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 20 sentido de las costumbres y prácticas asociadas al cuidado de la “dieta”, término con el que generalmente las adolescentes, en colombia, se refieren al periodo postparto. los hallazgos del presente trabajo pueden proporcionar elementos que debemos incorporar en nuestras interacciones con las adolescentes, como profesionales de enfermería, no solo en los espacios de los servicios hospitalarios, sino en otros escenarios comunitarios, donde con frecuencia interactuamos con ellas. método para el estudio se eligieron dos ciudades de colombia, cali y bogotá, ambas con tasas de fecundidad relativamente altas entre la población adolescente: cali con 21,2% y bogotá con 16,7%7. para conducir el estudio se utilizó la etnografía focalizada. este método se ocupa de describir una cultura, y para ello el investigador debe realizar descripciones narrativas e interpretaciones del fenómeno cultural, dentro del contexto donde él ocurre8. el número de participantes en la etnografía focalizada es pequeño y la investigación se limita a una parte de un grupo social específico9. el punto de vista del nativo, o visión “emic”, es importante cuando se estudian subculturas en las cuales se ha desarrollado poca investigación, como es el caso del significado del cuidado de sí de las adolescentes puérperas. como método de recolección de la información se utilizó la entrevista no estructurada. para corroborar los hallazgos, se realizaron entrevistas grupales a informantes generales10. muestreo y recolección de los datos los datos de este estudio fueron obtenidos de entrevistas a profundidad durante el periodo comprendido entre marzo del 2001 y agosto del 2002. como los partos de las adolescentes, en las ciudades mencionadas, son atendidos en su mayoría en hospitales de alta complejidad, la captación de las informantes se llevó a cabo en dos hospitales de tercer nivel. allí se contactaba a la enfermera jefe de la sala de puerperio, quien indicaba a las investigadoras cuáles eran las adolescentes con menos de 8 horas de haber tenido su parto y cuyo bebé se había diagnosticado como recién nacido sano. los datos que proveía la enfermera jefe del servicio se contrastaban con la historia clínica, y luego se procedía a contactar a la joven, para explicarle el propósito del estudio y lo relacionado con el consentimiento informado. seguidamente, cada adolescente indicaba el día y la hora en que se podía realizar, en su domicilio, la entrevista con la investigadora. para la primera entrevista de cada informante se desarrolló un proceso de interacción, que permitió ganar confianza entre ella y la investigadora, situación que facilitó la obtención de datos. en su totalidad, las entrevistas eran grabadas, transcritas y analizadas el mismo día en que se realizaban. con base en ese análisis se preparaba la entrevista subsiguiente. a cada informante se le pidió que describiera las acciones de cuidado que ella misma y sus allegados le proporcionaban. como una manera de asegurar la credibilidad del estudio, se presentaba a 7. profamilia. salud sexual y reproductiva, resultados encuesta nacional de demografía y salud, bogotá, printex impresores ltda., 2000. 8. spradley, j. participant observation, fortworth, harcourt brace jovanovich college publishers, 1980. 9. streubert, helen; carpenter, dona. “ethnographic research approach”. in: qualitative research in nursing, philadelphia, j. b. lippincott company, 1995. 10. spradley, j. the ethnographic interview, fortworth, harcourt brace jovanovich college publishers, 1979. el punto de vista del nativo, o visión “emic”, es importante cuando se estudian subculturas en las cuales se ha desarrollado poca investigación, como es el caso del significado del cuidado de sí de las adolescentes puérperas. transitando la adolescente por el puerperio 21 cada informante el análisis generado de cada entrevista. los dominios y taxonomías que surgían del análisis de los datos eran confrontados permanentemente con las informantes, por medio de preguntas descriptivas, estructurales y de contraste11. en total, se entrevistaron ocho adolescentes en cali y ocho en bogotá, cuyas edades oscilaron entre 13 y 17 años. en promedio se realizaron cuatro entrevistas por informante, con una duración aproximada de hora y media cada una. el criterio para determinar el número de entrevistas que se debían realizar fue el de saturación de datos, que se refiere a buscar nuevos informantes, hasta que dejen de aparecer conceptos nuevos. la saturación se alcanza cuando hay una redundancia en la información, en la cual el investigador consigue iguales o similares datos, y los informantes no aportan nada diferente a lo dicho o hecho anteriormente12. entrevistas grupales se llevaron a cabo tres entrevistas grupales, para confirmar la credibilidad de los datos recogidos. en bogotá participaron tres parteras tradicionales, y en cali, dos parteras y un curandero de reconocida trayectoria en uno de los sectores de la ciudad. estas personas actuaron como informantes generales. el propósito de las entrevistas fue mejorar la comprensión de datos vagos y confirmar hallazgos significativos. en cali, las entrevistas se realizaron en centros de salud, a los cuales los informantes generales remitían a sus pacientes, y en bogotá, en el lugar de residencia de las parteras. cada una de las entrevistas grupales tuvo una duración promedio de dos horas. se utilizaron preguntas introductorias al tema, como: ¿pueden decir ustedes cómo se cuidan las adolescentes durante la dieta? ¿cómo les indican ustedes a las adolescentes que se cuiden? aspectos éticos el estudio recibió la aprobación del comité de ética de la facultad de salud de la universidad del valle y del comité de investigaciones de la facultad de enfermería de la universidad nacional de colombia. toda la información se consideró confidencial. las identidades de las informantes fueron alteradas, a través del uso de seudónimos; para ello se solicitó el permiso a las mismas adolescentes. cada informante aceptó verbalmente y firmó el consentimiento para participar en el estudio, después de explicar el propósito de la investigación. se obtuvo permiso para grabar las entrevistas y se indicó que los resultados o hallazgos solo podrían ser presentados en eventos científicos y en revistas para la publicación de artículos de investigación. análisis de datos el proceso de análisis de los datos etnográficos implica una búsqueda de patrones, lo cual incluye un examen sistemático de los mismos para determinar sus partes, y las relaciones entre estas y con el todo. el análisis se realizó utilizando el concepto de análisis etnográfico de spradley13, el cual incluye los dominios, taxonomías, análisis componencial y temas. spradley considera un dominio como una categoría. cada vez que se realizaba una entrevista, se transcribía y se leía varias veces, buscando categorías nativas y relaciones semánticas, lo cual facilitaba el descubrimiento de dominios. este ejercicio ermitió el análisis crítico de las informaciones, con lo cual se prepararon nuevas preguntas, cuyas respuestas se intentaba encontrar en el trabajo de 11. spradley, op. cit., 1980. 12. streubert, h.; carpenter, d. qualitative research in nursing: advancing the humanistic imperative, philadelphia, j. b. lippincott company, 1995. 13. spradley, op. cit.,1980. el proceso de análisis de los datos etnográficos implica una búsqueda de patrones, lo cual incluye un examen sistemático de los mismos, para determinar sus partes y las relaciones entre estas y con el todo. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 22 campo. una vez identificados los dominios, se elaboraban preguntas estructurales y de contraste, que permitieran encontrar las taxonomías, a través de las cuales se pudo descubrir la saturación de ideas y patrones recurrentes, y finalmente se delimitaron los grandes temas. en el presente trabajo se encontraron cinco dominios generales y un tema cultural. para su configuración se trató de elucidar cómo estaban relacionados los dominios y qué patrones recurrentes se encontraban entre ellos. hallazgos identificación y discusión de dominios y temas los conceptos y las prácticas de las adolescentes, de las dos ciudades estudiadas, presentaron un agudo contraste con aquellos promovidos por la medicina occidental y del conocimiento profesional de enfermería, o conocimiento “etic”, los cuales se basan en el modelo biomédico de la procreación. en este último, el embarazo, el parto, el cuidado del niño y el puerperio son vistos como procesos que deben ser intervenidos; hay trastornos biológicos y es indispensable la medicalización; por lo tanto, la mujer es separada de su entorno social y familiar. en el caso de las adolescentes que participaron en el estudio, su parto fue atendido en el medio hospitalario de nivel iii, porque, de acuerdo con la norma técnica de atención14, estas mujeres tienen riesgo de complicación, por su inmadurez fisiológica, y, por lo tanto, deben ser atendidas en instituciones que posean los recursos que permitan disminuir la probabilidad de enfermedad y muerte de la mujer y de su hijo. en los hospitales, las creencias de las adolescentes son puestas a prueba, ya que deben ajustarse al sistema de creencias imperante en esas instituciones. un aspecto que permea casi todas las prácticas de cuidado que desarrollan las adolescentes durante el puerperio es el mantenimiento del balance del calor y el frío dentro de su cuerpo, y de este con el ambiente. este equilibrio parece estar relacionado con el balance limpiezaimpureza. se debe resaltar que para las adolescentes es indispensable mantener limpieza en sus prácticas cotidianas, porque con ello garantizan conservarse sanas en el futuro. a pesar de que el grado de compromiso y el tiempo dedicado a las prácticas de cuidado eran variables entre una y otra informante, para todas el puerperio constituía una etapa durante la cual se debía evitar que el frío entrara al cuerpo, propiciar que el vientre se cerrara, alimentarse bien, limpiar el cuerpo de impurezas y cuidarse el día 40. los hallazgos del presente estudio corroboran que el puerperio no es solamente un hecho fisiológico, sino también un proceso social, que implica un ritual durante los cuarenta días postparto, en el cual, para entrar y salir de él, se debe realizar una serie de interacciones, que promuevan el pasaje de un estado social viejo a uno nuevo. el puerperio como rito de pasaje es importante observar que, en todas las sociedades humanas, el embarazo, el nacimiento y el puerperio significan más que simples eventos biológicos, pues son integrantes también de una importante transición del estatus social de “mujer” al de “madre”. a menudo, el cambio de un estado a otro se ve como un periodo de 14. ministerio de salud de colombia. resolución 412, 2000. es importante observar que, en todas las sociedades humanas, el embarazo, el nacimiento y el puerperio significan más que simples eventos biológicos, pues son integrantes también de una importante transición del estatus social de “mujer” al de “madre”. transitando la adolescente por el puerperio 23 incertidumbre y peligro, en el cual se lleva a la persona de un estatus social “viejo” a uno nuevo. si nosotros vemos el puerperio como un rito, los patrones de interacción entre los individuos afloran claramente. los ritos transicionales definen y regulan el pasaje de un estado social a otro. en nuestro caso, la adolescente puérpera transita entre dos clases de identidad social. dicho control y protección está marcado sustancialmente por una mujer que pueda apoyar a la madre puérpera adolescente en los cuidados de salud. usualmente, las mamás, las suegras o las hermanas son las que se ocupan de que se alcance cuidadosamente la transición. durante los primeros cuarenta días, la joven adolescente deberá guardar con pulcritud las pautas de cuidado que le garantizarán en el futuro cierto bienestar físico y mental. la “dieta”, como se denomina este periodo, es un tiempo en el cual se diferencian con alguna claridad los estadios de un ritual. las tradiciones que comprende la “dieta” probablemente son de origen español15, y esta es el tiempo durante el cual la joven debe permanecer “encerrada con el bebé” en su casa, de preferencia en su cuarto. los ritos de transición tienen tres momentos: la separación, la liminaridad y la entrada al nuevo estado social. con la separación, la adolescente es física y simbólicamente apartada. solo se puede tener contacto con ella a través de las visitas. sus actividades durante ese tiempo se limitan al cuidado de sí y al de su bebé. existen restricciones para deambular, comer, bañarse y tener relaciones sexuales. en buena parte sus cuidados dependen de la mujer que la acompaña, quien le suministra los “alimentos permitidos” y le ayuda a realizase baños y sahumerios para equilibrar el calor que ha salido de su cuerpo. en esta primera fase de separación se puede “salir” a la calle o dentro de la misma casa con algunas precauciones, las cuales están orientadas principalmente a minimizar que el frío entre al cuerpo, particularmente por los oídos, la cabeza y los pies. por lo tanto, “salir” para la joven debe ser un acto debidamente justificado e impostergable. se justifica “salir”, por ejemplo, para llevar al bebé al control médico. esta misión solo debe ser realizada por la madre, a quien compete estar atenta de la evolución de su hijo. dentro de la casa “se sale” para tomar el baño en la mañana o para hacer las necesidades fisiológicas. las visitas y las comidas deben realizarse preferiblemente en el cuarto. si se “sale” dentro de la casa, se deben colocar pedacitos de algodón en el canal auditivo externo, y cerrar puertas y ventanas por donde pueden entrar corrientes de aire. si se transita por el cuarto o por la casa, debe usarse calzado, y por la noche, para dormir, es importante ponerse medias. para desplazarse fuera del hogar es preciso, además de las recomendaciones anteriores, cubrirse la cabeza con una pañoleta o manta, pues el frío entra por la parte superior de la misma. durante la separación o primera fase de este rito, la adolescente se aparta del grupo social al cual pertenece, y sus relaciones sociales quedan reducidas, en gran parte, a las familiares. la segunda fase del rito, es decir, la liminaridad, se presenta el día 40. esta fecha la indica con precisión la joven. el momento se espera con gran expectativa y las restricciones sociales son aún mayores. se cuenta con el apoyo de una figura femenina, representada por la suegra o la mamá de la adolescente. las preparaciones usualmente comienzan el día previo al 40 del postparto, cuando la madre, o la suegra, va al 15. foster, g. “culture and conquest”, viking fund publication in anthropology, nº 27, chicago, quadrangle books. in: “ethnography of fertility and birth”, carol p. maccormack, 1982, academic press london, 1960. los ritos de transición tienen tres momentos: la separación, la liminaridad y la entrada al nuevo estado social. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 24 mercado a comprar las yerbas para el baño y el sahumerio16, que tienen la particularidad de “sacar el frío del cuerpo”. el eucalipto, el cidrón y el matarratón poseen esta capacidad y garantizan “sacar todo lo malo” que ha sido recogido durante esos 40 días anteriores. el día 40 del postparto, la joven, atendida por su madre o suegra, permanece encerrada en su habitación y desayuna con chocolate caliente y nuez moscada. alrededor de las 4 ó 5 de la tarde se baña con agua hervida, a la que se han incorporado yerbas. el agua debe estar tibia al momento del baño, y el cuarto, completamente cerrado. de inmediato se realiza el sahumerio, esparciendo el humo por la habitación; la joven se dispone a dormir, arropándose hasta el otro día. la salida del frío se asegura, porque entra calor cuando se bebe el chocolate, la piel se pone en contacto con el agua tibia y el ambiente cálido se mantiene con el humo y las ventanas y puerta cerradas. estos actos conjuran el frío y, por lo tanto, evitan en un futuro, “con los años”, dolores de cabeza, escalofríos y fiebres, en el mejor de los casos, y la locura en circunstancias extremas. la tercera fase del rito, o reincorporación al nuevo estado social, se evidencia después del día 40, cuando la joven puede realizar paulatinamente sus actividades usuales. gracias a la cuarentena se logran la ayuda y los cuidados que en raras ocasiones se tendrían: una alimentación proteico-calórica, un ambiente de protección con el bebé, que facilita la compenetración de la madre y el niño, y, finalmente, un apoyo de las mujeres de la familia, para evitar que la joven realice acciones que pongan en riesgo su recuperación. en la cultura del cuidado de la adolescente puérpera predomina la creencia de que, para sentirse bien y funcionar, debe procurarse una armonía consigo misma y con la naturaleza. la falta de esta causa enfermedad e incapacidades. estar en armonía implica, como se indicó anteriormente, evitar que la matriz se descuelgue, alimentarse bien, limpiar el cuerpo de impurezas, cuidar los senos e impedir con gran esmero que el frío entre al cuerpo. evitar que el frío entre y se quede en el cuerpo: una misión trascendente durante el puerperio durante el parto, las adolescentes perciben que el cuerpo se abre y es vulnerable a la entrada de frío. en el puerperio continúa la entrada del mismo, a través de los poros, la vagina, la cabeza y los oídos, y puede producir desde leves malestares, hasta dolencias que afectarán para siempre su estado de salud, sin posibilidades de que la medicina occidental pueda remediarlo. las adolescentes puérperas entienden que su cuerpo tiene puertas de entrada para el frío. este, representado principalmente por el sereno, enfría la sangre y se distribuye por todo el cuerpo. esta creencia es narrada por uno de los informantes generales como sigue: “en el momento que nace la criatura se abren todos los poros. las mujeres que no tienen en cuenta eso, entonces se desvisten, abren la llave del baño y se bañan. ese frío, ese pasmo, ese hielo del agua, se concentra, le entra por los poros y ahí viene el enfriamiento de la sangre, la mala circulación, el dolor de cintura, de los huesos, de la cabeza, de los ojos, de los oídos...”. rosa (partera). 16. humo aromático producido cuando se colocan yerbas secas al fuego. en la cultura del cuidado de la adolescente puérpera predomina la creencia de que, para sentirse bien y funcionar, debe procurarse una armonía consigo misma y con la naturaleza. transitando la adolescente por el puerperio 25 en esta ecuación simbólica, la sangre es clasificada como caliente, y el viento y el agua como fríos. para entender la lógica del cuidado durante el puerperio, es necesario saber que el cuerpo femenino se representa como algo que se abre y se cierra. en este sistema simbólico de polaridad, el cuidado está orientado a preservar el balance entre lo caliente (la sangre) y lo frío que entra a la adolescente (el viento, el agua). se toman las medidas necesarias para que no entre demasiado frío, porque aunque este ingrese durante los 40 primeros días después del parto, cuando el cuerpo permanece abierto, no es conveniente que lo haga en grandes proporciones, puesto que puede producir daño. se trata de obstaculizar la entrada, y durante el sahumerio sacar el frío que pudo filtrarse. existen maneras para cerrar o bloquear el ingreso del frío: usar algodones en los oídos, colocarse una pañoleta en la cabeza, fajarse con una sábana, bañarse con agua tibia y abrigarse bien. de otro lado, además de las medidas que se toman para bloquear la entrada del frío en el cuerpo, hay otras que se llevan a cabo en el ambiente donde reside la adolescente. por ejemplo, es necesario mantener las ventanas cerradas, para evitar las corrientes de aire. otras formas de evitar el ingreso del frío es ingerir alimentos calientes, pues estos al penetrar, como en los casos anteriores, bloquean la entrada al cuerpo del pasmo o frío. como los objetos metálicos también son transmisores de bajas temperaturas, deben evitarse. igualmente, el frío puede afectar la lactancia; entonces, además de evitar los alimentos fríos, deben ingerirse aguas aromáticas calientes. realmente se justifican todos los esfuerzos que hace la adolescente puérpera para evitar que el frío ingrese a su cuerpo, pues a lo que se apuesta es a la prevención de enfermedades derivadas de la exposición a temperaturas bajas. de lo anterior se puede deducir que el nacimiento, por cualquier vía, coloca al cuerpo de la mujer en situación de riesgo, pues lo “abre” y facilita el ingreso del frío por diferentes vías. así, la adolescente debe protegerse de él, pues aunque los estragos que produce no siempre son inmediatos, no tienen curación, ni a corto ni a largo plazo. se trata de un tratamiento profiláctico orientado a mantener un balance entre el frío y el calor, para lo cual una misión trascendente, durante el periodo de la “dieta”, es evitar que el frío entre y se quede en el cuerpo de la joven. cerrando el vientre para mantener la matriz en su lugar como se indicó, después del parto el cuerpo queda abierto y vulnerable. dos de las partes afectadas con el nacimiento son “la cadera” y “el vientre”. este se abre, y el útero queda “blandito” y “delicado”, lo cual favorece su desplazamiento a un lado o hacia fuera. desde el primer día postparto, la adolescente debe apretarse el abdomen, bien sea con una sábana, una pantaloneta o una faja elástica. las mujeres que la cuidan saben sobar y colocar la sábana alrededor del abdomen, de las nalgas y las caderas. de esta forma se cierran los músculos, el útero se acomoda y se evita que el abdomen quede grande. el siguiente relato ilustra la manera como se puede efectuar este cerramiento: se trata de un tratamiento profiláctico orientado a mantener un balance entre el frío y el calor, para lo cual una misión trascendente, durante el periodo de la “dieta”, es evitar que el frío entre y se quede en el cuerpo de la joven. revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 26 “yo las sobo después de haber tenido al bebé, hago masaje corporal, les arreglo la matriz. luego las apreto desde la espalda y la cadera con una sábana”. rosa (partera). “me coloco una pantaloneta que apriete los músculos para cerrarlos, especialmente de la cadera y el vientre. así logro que el útero se acomode y evito que se descuelgue. se trata de sostener el útero con la faja. como el útero estaba tan grande toca sostenerlo, porque él solo no va a poder volver a la normalidad, aunque por naturaleza volvería, pero si uno no se cuida, quedan la barriguita y las caderas anchas”. liz, 14 años. para contrarrestar la salida del útero, la adolescente puérpera debe reposar, no hacer fuerza y evitar las relaciones sexuales durante la dieta. “hay que tener mucho cuidado con la matriz, uno la tiene muy delicada, muy blandita. con cualquier fuerza que uno haga se puede salir. por eso, durante la dieta no se debe barrer, trapear, lavar, agacharse o cargar demasiado al niño”. nini, 16 años. como se observa, además de la polaridad frío-calor, descrita en el dominio anterior, se encuentra el pensamiento dual de abrir y cerrar. en ambos casos hay un énfasis en el orden, el balance y la jerarquía. la salud de las adolescentes durante el puerperio depende del balance con el mundo natural, y la salud de un órgano (útero), del equilibrio de este con las estructuras aledañas. la doble garantía de alimentarse bien: beneficios para la madre y el bebé durante la “dieta” como se indicó anteriormente, la madre, además de no recibir sereno, debe tomar precauciones para que el frío no entre al cuerpo través de los alimentos. por ello, en lo posible debe consumir los alimentos tibios o calientes. esta precaución favorece también al bebé, pues evita la producción de gases y los cólicos resultantes de tomar leche materna cuando la madre ha ingerido alimentos fríos. durante el periodo de confinamiento, se aconsejan ciertas restricciones dietéticas: los alimentos poco cocidos, salados o grasosos son perjudiciales, porque inflaman la matriz, irritan los puntos de la episiorrafia y demoran la cicatrización de la misma. adicionalmente, los alimentos con grasa tienen efectos nocivos en el recién nacido, principalmente gastrointestinales, como vómito, diarrea e irritación en el ombligo. al respecto, las informantes relatan: “mi mamá cuida para que no coma fritos, carne de cerdo o huevos. los alimentos que como con grasa hacen que mi bebé ensucie blandito, con frecuencia y le dan cólicos”. rosa, 14 años. “yo evito comer cosas con grasa, porque los puntos (de la episiorrafia) se demoran en caer y además le pueden irritar el ombligo al niño”. amelia, 15 años. “la carne frita, el cuero de pollo y la carne de cerdo producen inflamación de la matriz. uno durante la dieta no debe comer cosas con grasa”. nini, 16 años. para la adolescente, alimentarse bien implica comer a las horas establecidas. los horarios deben observarse con regularidad, pues ello contribuye a garantizar una buena nutrición. ingerir “cosas que alimenten”, como el sancocho, el caldo de gallina, el pollo, agua de panela con canela, coladas de avena, hígado y verduras, ayuda a recobrar la fuerza disminuida por el proceso del parto, y aumenta la producción de leche. por el hecho de “alimentarse bien”, la adolescente tiene fuerzas para criar a su bebé y para que este se “críe fuerte”. para la adolescente, alimentarse bien implica comer a las horas establecidas. los horarios deben observarse con regularidad, pues ello contribuye a garantizar una buena nutrición. transitando la adolescente por el puerperio 27 limpiar el cuerpo de impurezas: un empeño de la puérpera durante la “dieta” en las prácticas de resguardo se encuentra el principio de que la sangre tiene que fluir, salir. esto hace parte del equilibrio de las cosas y del presupuesto y necesidad de circulación de los fluidos. de nuevo, las dicotomías se hacen presentes en este dominio: entrar y salir. el fluir, concebido como principio ordenador del cuerpo, tiene que ver con la necesidad de la puérpera adolescente de expulsar de su cuerpo todo lo que quedó de residuo en su organismo. después de expulsada la placenta, viene un proceso de limpieza de la matriz, donde todos los coágulos tienen que salir. el puerperio, desde esta perspectiva, pareciera concebido como algo que está en proceso de purificación, especialmente para expulsar la sangre acumulada durante los nueve meses de gestación. esta debe ser evacuada, porque es sangre “mala”, “residuos” o “restos”, como generalmente la llaman. aquella acumulada, que no sale, produce inflamación de los ovarios y dolor e infección de la matriz. el empeño de las puérperas adolescentes por limpiar el cuerpo durante la dieta, conduce a que ellas lo hagan tanto por dentro como por fuera. con este propósito, toman aguas aromáticas de diferentes yerbas, se aprietan el abdomen para expulsar lo “malo” y, por último, se hacen el sahumerio el día 40. las aguas aromáticas se ingieren en infusión con agua caliente, o agua de panela también caliente; esta situación ayuda aún más a salir los coágulos, puesto que se creía que el agua fría volvía la sangre con coágulos. es aquí donde el proceso de purificación del cuerpo, por dentro del mismo, se logra con la ingestión de aguas aromáticas. una de las puérperas adolescentes lo narra así: “las aguas de manzanilla, hierbabuena, caléndula, albahaca, toronjil, limpian las partes de adentro del cuerpo, como los riñones y los ovarios”. diana, 15 años. apretarse el abdomen es una tarea que las puérperas adolescentes hacen con mucho esmero, porque además de ayudarles a mantener su figura, para no quedar gordas, y cerrar las caderas, les facilita la expulsión de los coágulos y, por consiguiente, la salida de los restos que quedan dentro de la matriz. esta es una manera externa de limpiar las impurezas, al propiciar que los restos de sangre presentes en el útero sean expulsados mediante la aplicación de fuerza sobre el abdomen. los elementos utilizados pueden ser fajas bien apretadas o sábanas. la limpieza externa del cuerpo se lleva a cabo mediante el baño con agua tibia y jabón, cada tercer día, el aseo de los genitales, y colocándose ropa limpia. las prácticas de cuidado que desarrollan las adolescentes, durante el puerperio o “dieta”, están orientadas de una manera holística. así, no es un fragmento de su cuerpo el que es objeto de atención, sino, por el contrario, es su corporalidad, en el sentido de totalidad, la que debe ser protegida del desequilibrio, de la inestabilidad o del desajuste generados por el proceso del embarazo y el parto. la adolescente, desde el embarazo, se prepara para enfrentar los peligros y amenazas que implica el mismo embarazo y el parto. el concepto que ella incorpora, transmitido en su entorno social y familiar por sus amigos y parientes, es que el postparto implica un camino por el cual se puede transitar con cautela, pues durante el trayecto hay peligros que se deben sortear. el camino, a pesar de sus fronteras difusas, tiene la especial connotación de que debe ser transitado la adolescente, desde el embarazo, se prepara para enfrentar los peligros y amenazas que implican el mismo embarazo y el parto. el concepto que ella incorpora, transmitido en su entorno social y familiar por sus amigos y parientes, es que el postparto implica un camino por el cual se pueden transitar con cautela, pues durante el trayecto hay peligros que se deben sortear revista aquichan issn 1657-5997 año 4 nº 4 • bogotá, colombia octubre 2004 28 por un tiempo límite, 40-42 días después del parto, al cabo del cual el cuerpo, dependiendo del cuidado, logra el ajuste completo. durante la dieta, todo el cuidado debe estar orientado a tratar de mantener rigurosamente el balance, tanto dentro del cuerpo, como de este con el ambiente en que está inmerso. puede presentarse un desequilibrio entre el frío y el calor, entre la limpieza y la impureza o entre la apertura y el cerramiento del cuerpo. la dimensión equilibrio-desequilibrio, en la tríada embarazo-parto-puerperio, opera de la siguiente manera: la mujer embarazada se considera en una condición de calor; el cuerpo se abre a causa del parto, y la mujer entra en un estado de frío, ya que la sangre, como elemento que mantiene caliente el cuerpo, se pierde. esta amenaza se incrementa, porque a la pérdida de sangre se adiciona la abertura de los poros, la cabeza y el vientre, lugares por donde entra el frío. de otra parte, el frío o “pasmo”, y la sangre acumulada durante nueve meses, son elementos considerados peligrosos, pues distorsionan el lábil equilibrio de la adolescente durante la “dieta”. ellos deben ser “limpiados” antes del día 40, aprovechando que el cuerpo está abierto. con esta representación se puede deducir que la mujer se ve abocada a luchar contra fuerzas difíciles de controlar o aniquilar, porque están fuera del alcance de su voluntad. por lo tanto, la única defensa de la adolescente puérpera es realizar con esmero los cuidados, para que, como escudos, no permitan la entrada a dichas fuerzas. así se impide que se produzcan estragos en el futuro reproductivo de la mujer y los que se generan por adquirir el “pasmo”. implicaciones para la enfermería tener como referencia los resultados de este estudio ayudará a mejorar la visión simplista y unilateral que, a veces, suele acompañarnos cuando ofrecemos el cuidado. en el contexto cultural de las jóvenes, también nos puede ayudar a incorporar el cuidado con un toque más sensitivo y congruente, es decir, más humano. entonces, el gran desafío consiste en un cambio de actitud, que debe comenzar con una evaluación de nuestros valores y creencias. este es un paso indispensable, para que la comunicación con las jóvenes sea lo más asertiva posible. aclarando nuestros valores tendremos el camino más expedito, no solo para reconocer la diferencia de ellos con los valores y creencias de los demás, sino también para respetar y entender esa distinción. ganar conocimiento de la cultura de los otros facilita la interacción en el cuidado, porque la enfermera puede concertar, con las personas y su familia, las acciones potenciales y las alternativas de cuidado, con base en sus propias creencias y valores. así, el plan de cuidado se determina conjuntamente, para hacerlo aceptable y congruente con la cultura17. 17. leuning ch.; swiggum, p.; barmore, h; mccullough-zander, k. “proposed standards for transcultural nursing”, j.t.n., 13 (1): 40-46, 2002. las prácticas de cuidado que desarrollan las adolescentes, durante el puerperio o “dieta”, están orientadas de una manera holística. así, no es un fragmento de su cuerpo el que es objeto de atención, sino, por el contrario, es su corporalidad, en el sentido de totalidad, la que debe ser protegida del desequilibrio, de la inestabilidad o del desajuste generados por el proceso del embarazo y el parto. transitando la adolescente por el puerperio 29 bibliografía 1. maccormack, carol p. “quadrangle books”. in: ethnography of fertility and birth, chicago, academic press london, 1982. 2. foster, g. “culture and conquest”, viking fund publications in anthropology, no. 27, 1960. 3. garzón, l. m.; ojeda, g. estudio sobre conocimientos, actitudes y comportamiento sexual de los adolescentes en seis ciudades de 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printex impresores ltda., bogotá, 2000. 12. spradley, j. the ethnographic interview, fortworth, harcourt brace jovanovich college publishers, 1979. 13. spradley, j. participant observation, fortworth, harcourt brace jovanovich college publishers, 1980. 14. streubert, helen, & carpenter, dona. “ethnographic research approach”. in: qualitative research in nursing, philadelphia, j. b. lippincott company, 1995. 15. streubert, h., & carpenter, d. qualitative research in nursing: advancing the humanistic imperative, philadelphia, j. b. lippincott company, 1995. 237 242 primeras paginas.indd 241 editorial el cuidado centrado en la persona en fase avanzada de la enfermedad care focused on the person in the advanced stages of disease o cuidado focado na pessoa em fase avançada da doença doi: 10.5294/aqui.2017.17.3.1 ella decía: “usted importa por lo que es, usted importa hasta el último momento de su vida y haremos todo lo que esté a nuestro alcance, no solo para ayudarle a morir en paz, sino también para que, mientras viva, lo haga con dignidad”. esto es un ejemplo de cuidado con la mirada puesta en la persona que sufre, buscando comprenderla para encontrar el mejor modo de cuidarla. hay dos aspectos que son importantes para garantizar que centramos nuestro cuidado en la persona: por una parte, conocerla y, por otra, acompañarla a lo largo de toda su trayectoria de salud-enfermedad. respecto al conocimiento de las personas que cuidamos debemos tener presente que cada una tiene una biografía y la enfermedad forma parte de ella. por tanto, es nuestro deber como profesionales de enfermería conocerlas, y hacernos cargo del impacto que la enfermedad tiene en todas las dimensiones de su vida y en su entorno. este es el primer paso para reconocer las verdaderas necesidades de la persona y poder tomar decisiones clínicas más certeras. en nuestra práctica profesional hemos cuidado a muchos pacientes y a sus familias, y nos hemos acercado a sus vidas con competencia profesional para conocer qué les pasa y cómo repercute la enfermedad en su vida personal y familiar. esto nos ha llevado a identificar no solo sus problemas de salud, sino también a reconocer la experiencia que viven y el significado que le dan a ese proceso. cuántas veces les hemos oído decir: “con la enfermera me muestro como soy”, “ella sí que me conoce”. hoy en día, en el contexto de salud, los avances tecnológicos y la diversidad de especialidades han ayudado a la detección precoz y la elaboración de nuevos tratamientos para distintas enfermedades. esto ha llevado a los profesionales de la salud a poner el punto de mira principalmente en la enfermedad, y se ha perdido de vista que quien la padece es cada persona de manera individual, con su historia, circunstancias, entorno y creencias. sin embargo, la evidencia ha mostrado que un cuidado centrado en la persona aumenta la satisfacción de los pacientes y sus familias, favorece estilos de vida saludables y, además, reduce los costes sanitarios. por tanto, los profesionales de la enfermería tenemos un desafío por delante: transmitir con nuestro conocimiento nuestro saber ser y saber estar, que un sistema sanitario costo-efectivo y de calidad solo se consigue cuando se busca el bienestar de toda la persona, su familia y la comunidad, en cualquier etapa de la vida, incluida la etapa final. una de las pioneras en el cuidado en la etapa final de la vida fue cicely saunders; ella fue la fundadora del movimiento actual de los cuidados paliativos. se formó como enfermera, trabajadora social y médico. con su formación y afán de superación en toda su trayectoria profesional consiguió desarrollar un modelo de cuidado competente y compasivo para la persona que se encuentra en la fase avanzada de la enfermedad, cuidando también a sus familias. ana carvajal1 1 universidad de navarra, españa. acarvajal@unav.es 242 aquichan issn 1657-5997 eissn 2027-5374 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 referencias 1. velad conmigo. inspiración para una vida en cuidados paliativos. cicely saunders. (traducción de watch with me: inspiration for a life in hospice care. cicely saunders). (2011).sociedad española de cuidados paliativos (secpal). 2. centeno, c., gómez sancho, m., nabal m., pascual a. (2009) manual de medicina paliativa. editorial eunsa. 3. somerville, j. (2009). development and psychometric testing of patient´s perception of feeling know by their nurse scale. international journal of human caring, 13(4), 38-43. este conocimiento de la persona solo es posible en un clima de confianza, desde una relación de respeto, mostrando que la persona y su entorno nos importan; en una relación auténtica, en la que nos mostramos como somos; y con una mirada atenta, que nos ayude a descubrir su grandeza. todo esto permitirá que el paciente reflexione sobre sí mismo y su dignidad, y encuentre así el mejor modo de aceptar y vivir su situación. cada vez que nos acercamos a una persona, ponemos en práctica el arte de nuestra profesión, creando una nueva relación que nunca se repite y que depende de nuestro saber, nuestro modo de relacionarnos y nuestra creatividad personal para conocer, comprender y cuidar a la persona, en todas sus dimensiones y circunstancias. el segundo aspecto importante por tratar es el acompañamiento. durante todo el proceso de la enfermedad de la persona, tenemos el privilegio, como enfermeras y enfermeros, de acompañarla desde la cercanía; esto significa estar ahí con y para ella, abiertos a lo que necesite en cada momento, respetando sus ritmos y estilo, haciéndonos cargo de lo que vive. se puede acompañar de muchas maneras: prestando un cuidado, escuchando o simplemente estando presentes en todo lo que necesite en cualquier fase de la enfermedad. muchas veces hemos oído frases de los pacientes refiriéndose a las enfermeras: “cuando necesito algo siempre están ahí”, o simplemente “siguen viniendo a estar conmigo”. esta seguridad ayudará a los pacientes a saber que no están solos, les dará la fuerza para seguir afrontando su enfermedad. por tanto, podemos decir que conocer y acompañar a la persona implica un compromiso personal y profesional. solo desde ese compromiso se puede llegar a descubrir la riqueza que se encuentra detrás de la vulnerabilidad y dependencia de la persona. este modo de cuidar, además, repercutirá positivamente no solo en el paciente y en los profesionales de enfermería, sino también en otros profesionales de la salud: médicos, psicólogos, etc., verán nuestra competencia profesional, nuestra satisfacción personal en el trabajo y, por supuesto, el beneficio que proporcionamos al paciente y a su familia. y cómo no recordar que cuando cuidamos reflejamos nuestra forma de ser, nos enfrentamos a nosotros mismos y enriquecemos nuestra existencia. en nuestra vida profesional hemos escuchado y vivido muchas historias de pacientes y familias que nos han ayudado a reflexionar y crecer personalmente; hemos palpado el agradecimiento que nos han transmitido con sus palabras y obras, y hemos vivido muchas historias y recibido muchos agradecimientos; que esto sea un impulso para enriquecer nuestra vida personal y seguir trabajando con la misma pasión y entusiasmo que hasta ahora, sin perder de vista que el centro de nuestro cuidado es la persona. 179 192 atencao as necessidades.indd 179 lucila castanheira nascimento1 fabiane cristina santos de oliveira2 tabatha de freitas moreira santos3 raquel pan4 milena flória-santos5 willyane andrade alvarenga6 semiramis melani melo rocha7 atenção às necessidades espirituais na prática clínica de enfermeiros 1 universidade de são paulo, brasil. lucila@eerp.usp.br 2 centro colaborador da oms para o desenvolvimento da pesquisa em enfermagem, sp, brasil. fabioli.enf@hotmail.com 3 centro colaborador da oms para o desenvolvimento da pesquisa em enfermagem, sp, brasil. tabathasathi@hotmail.com 4 universidade de são paulo, brasil. raquelpan01@gmail.com 5 universidade de são paulo, brasil. milena@usp.br 6 universidade de são paulo, brasil. willyanealvarenga@usp.br 7 universidade de são paulo, brasil. smmrocha@eerp.usp.br recibido: 13 de julio de 2014 enviado a pares: 08 de agosto de 2014 aceptado por pares: 13 de enero de 2016 aprobado: 08 de febrero de 2016 doi: 10.5294/aqui.2016.16.2.6 para citar este artículo / to reference this article / para citar este artigo nascimento lc., oliveira fcs., santos tfm., et. all. atenção às necessidades espirituais na prática clínica de enfermeiros. aquichan. 2016; 16(2):179-192. doi: 10.5294/ aqui.2016.16.2.6 resumo ao considerar a integralidade do cuidado, é necessário que os enfermeiros sistematizem o cuidado espiritual e proponham intervenções nessa dimensão aos seus pacientes. objetivo: analisar a compreensão do enfermeiro acerca do cuidado espiritual e a sua experiência na promoção desse cuidado aos pacientes na prática clínica. método: pesquisa descritiva, com análise qualitativa dos dados, desenvolvida com 17 enfermeiros. a coleta de dados foi realizada por meio de entrevistas semiestruturadas, as quais foram analisadas mediante análise de conteúdo qualitativa. resultados: os enfermeiros identificaram a necessidade de intervenção na dimensão espiritual dos seus pacientes e consideraram importante atender a essa necessidade, porém eles apresentaram dificuldades em oferecer esse cuidado. falta de conhecimento e organização do processo de trabalho foram dificuldades citadas para a não realização do cuidado espiritual e para a priorização dos cuidados físicos. aponta-se, ainda, que o cuidado espiritual, quando oferecido, não foi sistematizado. conclusão: esta pesquisa apresenta potencial para suscitar discussões quanto à formação do enfermeiro para o oferecimento do cuidado espiritual, além de demonstrar suas dificuldades e facilidades para a prestação de tal cuidado no cotidiano do trabalho da enfermagem. palavras-chave espiritualidade, religião, enfermagem, relações profissional-paciente, terapias espirituais (fonte: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 179-192 180 aquichan issn 1657-5997 año 16 vol. 16 nº 2 chía, colombia junio 2016 l 179-192 attention to spiritual needs in clinical nursing practice abstract when looking at comprehensive care, nurses need to systematize spiritual care and propose these kinds of interventions for their patients. objective: analyze nurses’ understanding of spiritual care and their experience in encouraging this type of attention for patients in clinical practice. method: this is a descriptive study featuring a qualitative analysis of data. the sample included 17 nurses. the data were collected through semi-structured interviews and examined via qualitative content analysis. results: the nurses who participated in the study indicated there is a need for intervention to attend to the spiritual needs of patients and felt it is important to address this dimension of health care. however, they have difficulty in providing spiritual care. lack of know-how and the way their work is organized were cited as obstacles to providing spiritual care, as was the priority on physical care. the nurses in the sample also noted that spiritual care, when offered, is not systematized. conclusion: the research in question has the potential to encourage discussion on how nurses can be trained to offer spiritual care. it also demonstrates the difficulties they encounter and the kind of facilities or conditions they require to provide spiritual care in everyday nursing practice. keywords spirituality, religion, nursing, nurse-patient relationship, spiritual therapies (source: decs, bireme). 181 atenção às necessidades espirituais na prática clínica de enfermeiros l lucila castanheira nascimento e outros atención a las necesidades espirituales en la práctica clínica de enfermeros resumen al considerar la integralidad del cuidado, es necesario que los enfermeros sistematicen el cuidado espiritual y propongan intervenciones en esta dimensión a sus pacientes. objetivo: analizar la comprensión del enfermero acerca del cuidado espiritual y su experiencia en la promoción de este cuidado a los pacientes en la práctica clínica. método: investigación descriptiva, con análisis cualitativo de los datos, desarrollada con 17 enfermeros. se recolectaron los datos por medio de entrevistas semiestructuradas, analizadas mediante análisis de contenido cualitativo. resultados: los enfermeros identificaron la necesidad de intervención en la dimensión espiritual de sus pacientes y consideraron importante atender a esta necesidad; sin embargo, ellos presentaron dificultades en brindar este cuidado. falta de conocimiento y organización del proceso de trabajo fueron dificultades citadas para la no realización del cuidado espiritual y la priorización de los cuidados físicos. se señala, aun, que el cuidado espiritual, cuando fue ofrecido, no fue sistematizado. conclusión: esta investigación presenta potencial para despertar discusiones en cuanto a la formación del enfermero para el ofrecimiento del cuidado espiritual, además demuestra sus dificultades y facilidades para la ejecución de tal cuidado en la cotidianidad del trabajo de enfermería. palabras clave espiritualidad, religión, enfermería, relación profesional-paciente, terapias espirituales (fuente: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 179-192 182 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 introdução é pressuposto que o cuidado de enfermagem seja baseado nas necessidades das pessoas. contudo, o conceito de necessidades é difícil de definir, e pacientes e cuidadores podem ter opiniões diferentes sobre elas. as necessidades podem ser classificadas em quatro categorias: 1) normativa — definida por peritos ou profissionais; 2) sentida — a que a pessoa quer; 3) expressa — a pessoa age mostrando o sentimento de necessidade e 4) comparativa — que aparece quando populações similares recebem serviços de níveis diferentes (1). o conceito de necessidades, do ponto de vista científico, é uma abstração com parâmetros definidos a partir da relação com uma disciplina, que pode ser a biologia, a psicologia ou as ciências sociais (2). no âmbito da enfermagem, as teorias se fundamentavam em necessidades objetivas e individuais; teoristas como henderson, abdellah e orem, ao discorrerem sobre necessidades, nos apresentam uma visão de seres humanos muito próxima do modelo biomédico, que implícita ou explicitamente, apresentam uma hierarquia (2, 3). dessa forma, as necessidades fisiológicas, ligadas à sobrevivência do indivíduo ou de grupos, são frequentemente apresentadas com a conotação de que devem ser satisfeitas primeiramente. no entanto, mais recentemente, as teorias de enfermagem têm valorizado o social, o psíquico e o político no cuidado à saúde e na enfermagem, em particular (2). atualmente, as conceituações de necessidades incorporadas pela enfermagem são mais amplas e referem-se às necessidades socialmente construídas, aos desejos e às satisfações. ao mesmo tempo, aumentaram os questionamentos sobre a universalidade das necessidades e o viés do ponto de vista da sociedade ocidental (3). olhar o indivíduo de forma integral tem contribuído para que a dimensão espiritual seja considerada como parte do ser humano e, cada vez mais, o enfermeiro tem se tornado sensível ao cuidado espiritual ao ser chamado a atender a essa necessidade (4, 5). o enfermeiro tem responsabilidade de avaliar as necessidades espirituais e de promover a saúde espiritual de pacientes (6). a dimensão espiritual integra a definição de saúde da organização mundial de saúde (oms) (7) e é inclusive contemplada no sistema de classificação taxonômica proposta pela north american nursing diagnosis association international (nanda-i) (8) para os diagnósticos de enfermagem, o que evidencia que o indivíduo tem uma natureza espiritual e que o enfermeiro deve estar preparado para oferecer cuidados relativos a essa dimensão. as necessidades espirituais podem ser alcançadas por meio da busca de significado e propósito na vida; da necessidade de dar e receber amor; do perdão; dos sentimentos de esperança, força, harmonia e confiança; da expressão de valores e crenças pessoais; das práticas espirituais; da criatividade e da transcendência ou divindade (4). essas necessidades se processam de forma diferente na pessoa doente e saudável, e têm implicações para o bem-estar e podem levar à angústia espiritual (9). a enfermagem tem a preocupação de assistir o paciente nas suas necessidades espirituais; entretanto, os profissionais manifestam dificuldades para identificá-las, talvez porque seja difícil mensurá-las e quantificá-las, ou por mobilizar a sua própria espiritualidade (10, 11, 12). apesar da expansão e das contribuições das pesquisas sobre o impacto da espiritualidade na dimensão física e mental do indivíduo, uma das barreiras mais identificadas para oferecer o cuidado espiritual é a carência de uma definição clara para a espiritualidade, o que tem levado o enfermeiro a incertezas a respeito das intervenções (9, 13). estudo (13) recente retrata a amplitude do uso desse conceito e reúne várias definições atreladas à saúde mental, à filosofia e aos constructos religiosos, além de reafirmar a falta de consenso sobre a compreensão da espiritualidade. há autores que defendem que a espiritualidade deve ser vista com um envolvimento religioso e ser definida como uma ligação com o transcendente, com o sobrenatural, que pode ser chamado de deus ou um poder superior (13, 14). outros pesquisadores (9, 15) apontam a espiritualidade como tendo uma forte relação com o sentido da vida, com o que dá significado e consistência às nossas experiências. consideramos esta última definição como a mais adequada para a proposta deste artigo, a qual considera a espiritualidade em um sentido mais amplo, na relação que o indivíduo tem dentro ou fora de uma esfera religiosa, capaz de dar sentido e propósito à sua vida. pacientes e seus familiares precisam de ajuda para satisfazer suas necessidades espirituais e, nesse sentido, práticas espirituais são importantes. para que o cuidado das necessidades espirituais seja incorporado à prática profissional, será necessário reformular teorias de enfermagem que definam necessidades, que incluam a espiritualidade como uma necessidade a ser aten183 atenção às necessidades espirituais na prática clínica de enfermeiros l lucila castanheira nascimento e outros dida. diante da importância desse cuidado e de assistir o indivíduo na sua integralidade, estudos empíricos com profissionais de enfermagem são essenciais para fundamentar reflexões sobre como o enfermeiro percebe e experiencia a atenção às necessidades espirituais de seus pacientes na prática clínica; a partir dessas reflexões, poderá ser construído conhecimento nessa área. dessa forma, o objetivo do presente estudo foi analisar a compreensão do enfermeiro acerca do cuidado das necessidades espirituais e a sua experiência na promoção desse cuidado aos pacientes na prática clínica. método este artigo é parte integrante de um projeto maior intitulado “o cuidado espiritual na prática da enfermagem”. é um estudo descritivo, caracterizado como pesquisa qualitativa genérica, como descrita pelas autoras caelli, ray e mill (16), as quais a definem como sendo aquela que não é orientada por um pressuposto teórico explícito ou por um conjunto de pressupostos filosóficos estabelecido em uma determinada metodologia qualitativa já conhecida. portanto, apresenta análise qualitativa dos dados e foi desenvolvido na perspectiva teórica do pragmatismo, com base nos conceitos de espiritualidade e necessidades espirituais. por envolver seres humanos, este estudo foi submetido à revisão ética e acompanhamento por um comitê de ética, e obteve aprovação sob o número de processo 1018/2009. elaborou-se o termo de consentimento livre e esclarecido (tcle) com uma linguagem clara e objetiva, no qual os participantes da pesquisa foram informados sobre os objetivos do estudo, os procedimentos usados para a coleta de dados e os possíveis constrangimentos ou benefícios, o que lhes garantiu o sigilo e respeito ao desejo ou não de participar da pesquisa. esse documento foi entregue e discutido com os participantes do estudo anteriormente ao início da entrevista e, para aqueles que concordaram em participar, lhes foi solicitado que assinassem o tcle; os participantes ficaram com uma via do documento. o estudo foi realizado em um hospital estadual localizado no interior do estado de são paulo (brasil); trata-se de um hospitalescola que prioriza o atendimento de nível secundário entre diversas especialidades. os enfermeiros que lá desenvolvem suas atividades estão alocados nos seguintes setores: ambulatório, enfermaria, centro cirúrgico, central de material, comissão de controle de infecção hospitalar e coordenação de enfermagem. participaram da pesquisa 17 enfermeiros que desenvolviam suas atividades nessa instituição, independentemente do tempo de formação e atuação profissional nela. a distribuição dos participantes, de acordo com o desenvolvimento de suas atividades de trabalho na instituição, não foi aqui descrita para preservar o seu anonimato já que determinado posto de trabalho era ocupado por um único enfermeiro. o número de participantes que ingressaram na pesquisa e o término da coleta de dados foram delimitados a partir do conjunto de dados obtidos, ou seja, a saída do campo empírico se deu quando o conjunto de dados foi suficiente para alcançar os objetivos da pesquisa, o que possibilitou a interpretação compreensiva do fenômeno. a coleta dos dados foi realizada por meio de entrevista semiestruturada, nas dependências da instituição selecionada, por três autoras da pesquisa, conforme disponibilidade dos participantes e sem interromper a sua rotina de trabalho. foi necessário apenas um encontro com cada participante para explorar o objeto de estudo. para manter a conversa centrada nos objetivos da pesquisa, elaborou-se um roteiro para orientar a condução da entrevista. a conversa com os participantes teve início utilizando a questão norteadora: você considera o cuidado espiritual como parte do cuidado oferecido pelo enfermeiro? fale-me mais sobre isso. na sequência, foram exploradas as experiências do enfermeiro para oferecer esse cuidado e solicitados exemplos de situações do cotidiano nas quais o enfermeiro oferecia esse tipo de cuidado aos seus pacientes. os enfermeiros foram identificados pela letra e, seguida de um número conforme o ingresso na pesquisa. portanto, e1 foi o primeiro enfermeiro entrevistado, e e17, o último. as entrevistas foram audiogravadas com a permissão dos participantes e transcritas na íntegra logo após sua realização. os dados empíricos foram submetidos à análise de conteúdo, como descrita por elo e kyngäs (17), que consiste nas fases de preparar, organizar e relatar os resultados. o primeiro passo da análise, que se refere à fase de preparação, consistiu no processo de transcrição dos dados empíricos e sua leitura, para obter o sentido do todo e para posterior seleção das unidades de análise e das unidades de significado, tais como palavras, frases ou parágrafos. na etapa seguinte, denominada de organização, o caminho indutivo escolhido previu a codificação, a criação e o agrupamento de categorias, com vistas à compreensão do fenômeno. na última etapa, os resultados foram apresentados, a partir do conjunto das categorias, descrevendo-se o fenômeno (17). os resultados foram discutidos com a literatura atualizada 184 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 da área. a análise foi realizada por um pesquisador e os demais acompanharam todo o processo de análise e categorização para verificar a adequação e discutir divergências, a fim de que critérios de fidedignidade dos dados fossem cuidadosamente considerados em cada fase do estudo (18). resultados e discussão o material empírico foi analisado e organizado em categorias, por meio das quais apresentamos a compreensão de enfermeiros sobre o cuidado das necessidades espirituais de seus pacientes, além da experiência desses profissionais para oferecer esse cuidado no seu cotidiano. participaram da pesquisa 17 enfermeiros (16 do sexo feminino e 1 do sexo masculino), na faixa etária entre 24 a 29 anos, com tempo de formação e de atuação profissional que varia entre 3 e 12 anos. o cuidado espiritual como prática do enfermeiro alguns enfermeiros, ao se expressarem acerca do papel da enfermagem na prestação do cuidado espiritual, se remeteram à história da profissão e às características religiosas que eram atreladas ao cuidado. de fato, a literatura aponta que a origem da enfermagem esteve arraigada às questões espirituais e religiosas, e o cuidado espiritual é uma parte da atenção oferecida ao paciente (19). [...] se a gente for ver a história da nossa profissão, a espiritualidade vem ao lado da religião. (e5) [...] [o cuidado espiritual] é um pouco da enfermagem, até pela própria história. (e2) neste estudo, 12 enfermeiros afirmaram acreditar que o cuidado espiritual compõe a assistência integral ao paciente e deve ser oferecido pela enfermagem em qualquer lugar, pois a espiritualidade faz parte do indivíduo. estudos mostram que o cuidado espiritual se constitui como um cuidado de enfermagem e ressaltam a necessidade do enfermeiro encontrar uma maneira de sistematizá-lo (20, 21, 22). [...] tem que ser um cuidado de enfermagem, cada um tem que encontrar a sua maneira de fazer isso. (e16) [...] tem gente que não acredita, mas enquanto enfermeiro tem que ter uma prática sim. é uma possibilidade de trabalho, trabalhar com a espiritualidade do paciente. (e1) [...] eu acho que não está na enfermaria, não está no centro cirúrgico, não está no ambulatório, está em todos os lugares. está dentro do enfermeiro, do profissional [...] e está dentro do paciente. então, em qualquer lugar ele pode ser abordado. (e9) o discurso dos enfermeiros reporta a integralidade do ser humano, a existência da dimensão espiritual e, ainda, que o olhar para essa dimensão vai além da enfermagem. estudos afirmam que a dimensão espiritual é inerente ao ser humano e o cuidado espiritual oferecido pela enfermagem parte desse reconhecimento (6, 9), pois o cuidado vai além da dimensão física (23, 24). a partir do momento que se fala de integralidade da assistência e de olhar esse paciente como um todo, não se pode deixar a espiritualidade de lado. (e5) [...] isso não tem como você separar na vida; acho que não é nem uma questão de enfermagem ou de engenharia, é realmente uma coisa do ser humano. (e16) apesar de a maioria dos enfermeiros acreditar que o cuidado espiritual é importante para a qualidade da assistência, dois participantes expressaram suas perspectivas e evidenciaram privilegiar a hierarquização de necessidades e a rotina do serviço, além de admitirem que a atenção às necessidades espirituais pode ou não ser contemplada no cuidado. tem que analisar a eficiência do trabalho como um todo. o cuidado espiritual diferencia para o paciente, mas não influencia para nós. para mim, o cuidado espiritual não pode influenciar no meu serviço, na minha avaliação como supervisora. eu tenho que avaliar outras coisas. (e11) [...] a nossa assistência não pode ser prejudicada; não se pode mudar a nossa rotina por causa das questões religiosas do paciente. (e8) há indícios de que alguns enfermeiros se ativeram à hierarquia de necessidades no seu plano de cuidados ao paciente priorizando o atendimento de necessidades fisiológicas. o enfermeiro precisa atender às necessidades do paciente de forma integral e, sobre isso, a literatura aponta que esse profissional 185 atenção às necessidades espirituais na prática clínica de enfermeiros l lucila castanheira nascimento e outros tem obrigação ética de compreender e incorporar as crenças e os valores espirituais do paciente no seu plano de cuidado (12). dessa forma, a dimensão espiritual do indivíduo não pode ser desconsiderada; deve haver sensibilidade e respeito para com o paciente (23). ao mesmo tempo em que os enfermeiros entrevistados consideraram o cuidado com a terapêutica estabelecida para os pacientes, a maioria abordou questões espirituais com seus pacientes, principalmente as relativas à religiosidade, e sempre com as particularidades de cada um deles respeitadas. estudos trazem que o cuidado espiritual deve ser oferecido e, para isso, é necessário criar condições para o diálogo com o paciente, de modo a movê-lo suavemente para um discurso espiritual, sem estabelecer controle ou manipulação (24). o enfermeiro deve avaliar a existência de qualquer resistência do paciente na abordagem da temática e não deve realizar qualquer intervenção ou discurso espiritual quando isso não for bem-recebido pelo paciente (23). eu quero aguçar no paciente não a minha religião [...]. eu não tenho que tirar os valores deles [...]. o que eu faço é estimular a religiosidade dele, sem ser a minha religião, para ele atingir talvez a espiritualidade. (e9) [...] pacientes falaram para mim que não têm religião. aí, tenho que respeitar, porque eu acho que se eu trouxesse alguma coisa de religião, a meu ver, eu iria afrontá-los. (e1) na presente pesquisa, a necessidade de cuidado espiritual esteve muito relacionada às situações de fragilidade do paciente, as quais são vistas como propícias para a prestação de um cuidado direcionado às necessidades relativas à condição de existência humana, à busca de explicações sobre a natureza da vida, seu significado e terminalidade. o reconhecimento da necessidade de cuidado espiritual e da fragilidade do paciente também esteve atrelado ao setor de atendimento ou nível de atenção em que o paciente se encontrava. estudos anteriores trazem que situações de fragilidade decorrentes de doença, cirurgia, alta hospitalar, condição de terminalidade, falta de apoio familiar ou outras situações que podem causar medo, insegurança, dor, angústia, sofrimento e carência foram os momentos mais propícios para o profissional prestar um cuidado direcionado à atenção às necessidades espirituais (20, 21, 25, 26). [...] na hora que ele entra na cirurgia também, porque é um momento que pode dar tudo certo e pode não dar. então, assim, é um momento de risco e nesses momentos a gente também aborda o lado espiritual. (e8) o cuidado físico, você consegue até certo ponto [...] mas, chega uma hora que não é mais o físico que está importando. (e4) lá no cti [centro de terapia intensiva] era muito evidente, mas pela situação dos pacientes. aqui, às vezes, a gente escuta em alguma orientação pré-operatória e a gente ouve muito: “ah, mas se deus quiser as coisas vão melhorar”. (e2) além de receber influência do contexto em que o enfermeiro e o paciente estão inseridos, o cuidado espiritual também pode ser influenciado pelas peculiaridades do profissional, que incluem valores pessoais e experiências profissionais (24, 27). os resultados desta pesquisa corroboram com esses estudos, pois, na percepção dos enfermeiros, profissionais religiosos e que creem em deus têm maior sensibilidade e facilidade para pensar espiritualidade na assistência, perceber essa necessidade e oferecer o cuidado espiritual. quando eu ia para trabalhar no cti, eu ia rezando, pedindo para que deus me iluminasse, me colocasse no lugar certo para ajudar as pessoas, [...] me fornecesse o que a pessoa precisasse. (e10) o profissional influencia. eu sinto que pessoas mais religiosas são pessoas que conseguem passar uma mensagem de conforto, de uma forma melhor [...] e fazem isso com mais frequência. tem a particularidade [do profissional], além da vivência, cultura e da própria religião. (e15) os discursos mostram que a iniciativa para a abordagem espiritual pode partir tanto do enfermeiro quanto do paciente, e que o enfermeiro, para iniciar a abordagem sobre a espiritualidade, em alguns casos, necessitou de indícios do paciente ou teve que lançar perguntas para fins de sua própria avaliação, de modo a se certificar de que se tratava de um momento adequado para esse enfoque. isso também foi referido por enfermeiros em outros estudos, embora o paciente também tenha iniciado e conduzido a conversa (24); o enfermeiro atentou-se às expressões faciais e à linguagem corporal dos pacientes e estabeleceu primeiramente um relacionamento com ele, para então abordar a espiritualidade e realizar intervenções (23). se eu tiver vontade, eu sempre pergunto se tem religião e eu falo: “vamos acreditar em deus”, mesmo que eu não saiba a 186 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 religião da pessoa [...] eu nunca tive receio de perguntar se tinha religião e qual era ela. (e1) na maioria das situações, é o paciente quem dá abertura sim. ele tem que te dar a abertura da crença que ele tem, sobre aquilo que ele acredita, que ele tem apego, para você entrar no mundo dele e conversar com ele. (e4) [...] eu espero o paciente. eu tento perceber, por exemplo, tem paciente que no quarto tem uma bíblia do lado, tem alguma coisa. então eu questiono, pergunto de qual religião ele é, [...] no que ele acredita, tento conversar nesse sentido. (e11) maneiras de prestar o cuidado espiritual os enfermeiros citaram as intervenções referentes ao cuidado espiritual mais realizadas na prática clínica, como por exemplo: ter empatia, oferecer apoio religioso, falar de deus, fazer orações com o paciente, permitir visitas à capela e de pessoas religiosas, oferecer missas e passeios em área de convívio, prestar assistência à família do paciente, além de oferecer a ela informações acerca do estado de saúde do paciente. esses tipos de cuidado espiritual prestados pelo enfermeiro também foram encontrados em outros estudos, como sendo capazes de promover bem-estar e qualidade de vida, com destaque para dar apoio emocional, propor ambientes mais positivos, dar apoio religioso, falar com um líder da igreja ou assistir a uma cerimônia religiosa e criar vínculos com a família (20, 23, 26). esses cuidados devem ser oferecidos quando há necessidade de apoio familiar e emocional, falta de perspectiva para o futuro, solidão e depressão (26). nesse contexto, as necessidades espirituais da família também foram mencionadas e a religião e a espiritualidade foram fontes de conforto importantes para lidar com a experiência de adoecimento de um membro familiar (28). eu quero cuidar da pessoa como se alguém cuidasse de mim. (e6) as situações que eu mais utilizei foram nas situações de sofrimento, mas eu vinculo à família, que está ali vendo seu ente em sofrimento [...] (e15) [...] eu consigo dar um conforto, sempre perguntando: “você acredita em deus? então, vamos rezar, para pedir a deus que o ajude e a dor vai passar”. (e1) [...] hoje é sábado, então, às seis horas da manhã, geralmente, eu convido todo mundo se quer que eu ligue a televisão na missa do padre marcelo. (e12) [...] cirurgia que começa a se estender, eu tento passar a informação [para a família] sobre ela: “eu acabei de ir lá, ele está operando, está tudo se mantendo normal [...] fica tranquilo, qualquer coisa, a gente volta”. (e6) os enfermeiros também mencionaram outras maneiras de prestar o cuidado espiritual, a partir de conversa e escuta, do toque, como pegar na mão do paciente ou dar-lhe um abraço, das trocas de sentimentos e de energia, de oferecimento de música e de acolhimento. estas são outras formas de prestar o cuidado espiritual, que, segundo estudos, oportunizam a criação de vínculo, que é fundamental dada a centralidade da conversa para o estabelecimento do cuidado espiritual (24, 26). se você entrar no quarto e para para ouvir, para conversar assim uns dez, quinze minutos, para eles já é muito importante. o fato de você parar para ouvir e para conversar. (e12) [...] eu acho que tem que ter essa troca, como o toque terapêutico mesmo; muitas vezes você pega na mão do paciente. (e9) [...] você tem que criar vínculos com as pessoas independentemente das questões relacionadas, principalmente dentro do ambiente hospitalar. (e16) o cuidado espiritual, como uma necessidade oriunda da dimensão humana merecedora de atenção profissional, foi destacado pelos enfermeiros e integrou-se no atendimento de todas as necessidades, objetivas, individuais ou socialmente construídas, percebidas na intersubjetividade de cuidadores e pacientes, daí a importância de se construírem espaços para suas manifestações. esses resultados corroboram com outros estudos (20, 21, 29) que destacam a importância de se reconhecer e promover o cuidado espiritual. eu acho que o paciente é um ser biopsicossocioespiritual. biológico porque é a patologia dele; psicológico porque ele tem os medos e os problemas dele; social porque ele está num contexto social e espiritual, porque ele tem uma religiosidade, um tipo de crença ou no que ele acredita. (e9) [...] se a gente não der oportunidade também para os pacientes manifestarem a espiritualidade deles, para gente tentar aumentar e melhorar a qualidade do nosso trabalho, eu acho que a gente não conseguiria cuidar da pessoa. (e1) 187 atenção às necessidades espirituais na prática clínica de enfermeiros l lucila castanheira nascimento e outros facilidades para prestar o cuidado espiritual embora todos os participantes tenham assumido o cuidado espiritual como parte dos atributos da enfermagem, a análise dos dados evidenciou que quatro dos entrevistados compartilharam as facilidades que a profissão de enfermagem tem para oferecer o cuidado espiritual. dentre as facilidades, o contato próximo com o paciente foi lembrado como favorecedor para a efetivação do cuidado espiritual, assim como a oportunidade obtida durante a visita de enfermagem para fazer a abordagem das questões espirituais. [...] a gente está sempre em contato e eu acho que facilita essa questão da gente estar percebendo o paciente que precisa e o que não precisa, que está precisando de um cuidado e acompanhamento mais de perto. então, a enfermagem, ela percebe isso com maior facilidade. (e11) apesar de você ter muitas tarefas burocráticas, muita coisa para fazer, é você quem tem aquele momento de contato com o paciente diariamente. todos os dias você faz a visita [...]. é entre fazer a técnica e conversar com esse paciente [que o cuidado espiritual pode ser oferecido], e acho que isso facilita bastante. (e4) a proximidade com o paciente é fator importante para o levantamento das necessidades espirituais (30). percebe-se que esse cuidado, assim como apontado em outro estudo (24), é oferecido associado a outros cuidados de enfermagem. dificuldades para prestar o cuidado espiritual organização do processo de trabalho e estrutura institucional entre as dificuldades apontadas pelos entrevistados, destacouse o dispêndio de tempo necessário para atender à organização do processo de trabalho predominante na instituição e às prioridades estabelecidas na gestão do cuidado, o que prejudicou a atenção às necessidades espirituais do paciente. nessa dinâmica de trabalho, a falta de tempo monopolizou os discursos que justificaram a não efetivação do cuidado espiritual. [no centro cirúrgico], às vezes, não dá tempo nem de fazer anotação. só dá tempo de falar: “bom dia! boa tarde!” e fazer as perguntas que tem que fazer: “tem alergia?” “toma medicamento?” e só. (e13) são pequenas coisas [...] porque, aqui, meu contato com o paciente é muito rápido, quando eu trabalhava na uti, era diferente. (e5) a partir dos discursos, observa-se que o trabalho burocrático, técnico e fragmentado com um grande número de tarefas a ser desempenhado por cada profissional prejudicou o olhar para as necessidades espirituais do paciente, o que levou o enfermeiro a estabelecer prioridades no cuidado e hierarquizar as necessidades do paciente. a prioridade nos cuidados realizados pelo profissional está muito relacionada à disponibilidade de tempo para estar com o paciente, o que faz com que o cuidado espiritual não seja considerado (22). é muitas vezes “tempo”. o enfermeiro, principalmente, se acaba ficando a cargo de muitos pacientes e muitas tarefas, acaba se preocupando com as coisas mais burocráticas, com as avaliações dos curativos. é a medicação que tem que ser dada na hora certa e tomar conta daquela quantidade de funcionários [...]. (e4) se a gente tivesse um pouco mais de tempo nas orientações com o paciente, isto também permitiria conhecê-lo melhor e, dessa forma, saber quais as crenças dele. (e2) não tem esse tipo de trabalho de ir lá para ouvir. eu acho que é pela questão da correria [...]. um enfermeiro está com vinte e seis pacientes. (e12) esses achados corroboram com o relato de alunos de que enfermeiros, na prática clínica, não fornecem um cuidado integral aos seus pacientes e negligenciam suas necessidades espirituais, ao passo que deveria ser uma obrigação a integralidade do cuidado, que considere as necessidades físicas e espirituais (6). alguns dos entrevistados mencionaram a falta de estrutura e ambiente para a prestação do cuidado espiritual, como ausência de capelas ou espaços de oração; além disso, percebe-se que os enfermeiros não veem a espiritualidade como algo separado de crenças e práticas religiosas. estudos apontam que a estrutura física das instituições de saúde pode favorecer, ou não, as questões espirituais dos usuários do serviço, o que exige organização das instituições para que práticas religiosas possam ser oferecidas e manifestadas (22, 27). 188 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 é tão bom ter a capela! às vezes a família [de um paciente] que vai para o centro cirúrgico, não tem um lugar para eles se voltarem. eu acho que uma capela é um local de conforto e seria legal. (e6) [...] a gente aqui, não tem capela, não tem grupo de oração, nenhum culto ecumênico. eu acho que falta bastante aqui no hospital. (e1) falta de conhecimento a maior dificuldade relatada pelos enfermeiros para realizar o cuidado espiritual esteve relacionada à falta de conhecimento para realizar essa abordagem. é importante que o enfermeiro saiba como conversar para avaliar e apoiar a espiritualidade do paciente (24). da mesma forma, a religiosidade deve ser melhor explorada para que efetivamente ela esteja presente no atendimento ao paciente (23). a gente tem muitas limitações ainda, acho que até mesmo pela falta de conhecimento. (e12) [...] estas coisas não são abordadas na graduação, não são abordadas durante o dia a dia do trabalho. estas coisas não são motivadas no profissional, não são discutidas entre os colegas, porque religião e fé são “tabus”. (e9) dez enfermeiros deste estudo mencionaram ter recebido orientação sobre a dimensão espiritual em disciplinas do curso de graduação; entretanto, de maneira pontual e pouco abrangente. entre aqueles que tiveram alguma abordagem sobre o tema, ela se deu por meio de atividades de pesquisa durante a graduação e em campos de atividade teórico-prática, o que foi valorizado pelos participantes, dadas as contribuições para a formação profissional. [...] eu acho que lá no curso, quando a gente está aprendendo a fazer técnica, é válido já começar a aprender sobre o cuidado espiritual. os cursos nem sempre têm essa abordagem; eles dão ênfase para o físico, para a fisiopatologia, ênfase para técnicas, até porque o curso é rápido. (e4) [...] eu acho que eu tive um pouco de contato com a religiosidade e a espiritualidade, por causa da minha iniciação científica. eu trabalhei com o tema da morte, então eu me aproximei mais dessas questões de bioética e de espiritualidade e conseguia levar isso para a prática hospitalar. também nos estágios, dentro de hospitais [...]. (e1) essas observações confirmam a ênfase dos pressupostos teóricos da enfermagem enquanto disciplina formadora visto que hierarquizam e priorizam as necessidades fisiológicas, ligadas à sobrevivência do indivíduo ou de grupos, frequentemente apresentadas com a conotação de que devem ser satisfeitas primeiramente. a espiritualidade deve ser mais amplamente incluída no ensino de enfermagem e isso também é afirmado por outros autores (6). o enfermeiro precisa ser preparado na sua formação para identificar, diagnosticar e intervir sobre as necessidades espirituais do paciente, o que reitera a importância da integração desses aspectos nos currículos (22, 29). o enfermeiro lida cotidianamente com o sofrimento, com a finitude da vida e com as vulnerabilidades do indivíduo, o que torna um desafio trabalhar com seres humanos e que exige dele o entendimento de questões acerca da espiritualidade (15). a falta de preparação acadêmica dos enfermeiros para prestarem o cuidado espiritual foi apontada como impactante em suas vidas profissionais, e os enfermeiros reconheceram a importância de incorporar a temática da espiritualidade na estrutura curricular dos cursos de enfermagem. eu acho que, na graduação, a gente acaba não tendo esse tema. eu me formei e eu não tive. se incluísse na graduação, eu acho que facilitaria a gente a lidar com o paciente. (e13) [...] a própria graduação não prepara a gente para isso. eu acho que é muito impactante a hora em que você entra para a enfermagem e vê tantos sentimentos, tanta coisa. (e9) desconforto ao abordar a espiritualidade os enfermeiros têm receio da resposta do paciente perante a realização do cuidado espiritual e supõem que ele os vê como incompetentes ou poucos científicos. esse receio pode ser fundamentado pela origem da enfermagem que era pouco científica e, conforme a literatura (19), permeada por práticas espirituais e religiosas, só ocorrendo a inserção do pensamento científico e da formação em nível universitário mais tardiamente. dessa forma, a prática do cuidado espiritual pode gerar receios nos profissionais por medo de serem mal-interpretados, incompetentes do ponto de vista científico ou temerosos ao tentarem prestar a assistência espiritual (28). às vezes, eu fico até com medo de falar sobre isso, do jeito que os pacientes vão receber. às vezes, eles enxergam isso como 189 atenção às necessidades espirituais na prática clínica de enfermeiros l lucila castanheira nascimento e outros uma fraqueza enquanto profissional. [eles podem pensar assim:] “ao invés de acreditar numa série de coisas científicas, você está pedindo a deus para te ajudar!”. (e8) além de preocupar-se com a percepção do paciente sobre o cuidado espiritual, há o receio do enfermeiro para com os profissionais que presenciam a efetivação desse cuidado, pois há a apreensão de ser desqualificado ou malvisto pelos colegas da profissão. assim, a dificuldade de abordar questões espirituais também está relacionada aos aspectos culturais, além de saber lidar com a espiritualidade do outro sem afetar suas próprias crenças. estudos afirmam que os enfermeiros podem ter desconforto e dificuldade em conversas sobre espiritualidade (24). você sabe que prestar, claramente, uma atenção espiritual é até meio “tabu”. depende de como você aborda o paciente, às vezes, a gente não presta esse cuidado. “será que o colega vai achar que eu estou louca?” “olha essa daí falando essas coisas para o paciente!”. é preconceito. (e6) [...] a aceitação da pessoa de que aquilo pode não ser importante para mim, mas é para o outro. então, se eu estou aqui para fazer o bem para o outro, eu tenho que me submeter a isso e aceitar aquela condição que para o paciente é importante. (e10) como foi destacado neste estudo, o contexto em que se manifesta o cuidado interfere na iniciativa do enfermeiro para abordar a espiritualidade, pois se teme o preconceito por parte do paciente e de outros profissionais. apesar de os resultados evidenciarem dificuldades para a prestação da assistência espiritual, alguns profissionais relataram não tê-las. estudos mostram que abordar a espiritualidade no local de trabalho é uma decisão individual, pois envolve uma definição do que é espiritualidade e cada um tem uma visão diferente (15), pela natureza subjetiva e abstrata do conceito (6). não, eu não tenho dificuldade mesmo, porque eu acho que eu consigo separar bem a minha prática religiosa da minha formação para poder trabalhar. eu acho que a gente tem que respeitar o lado espiritual. (e1) cuidado espiritual: benefícios para o paciente e para o profissional entre as justificativas para prestar o cuidado espiritual, os participantes destacaram os benefícios de mão dupla, ou seja, tanto para paciente quanto para o profissional. para o paciente, esse cuidado resultou em melhor enfretamento da situação, ressignificação da doença, conforto, aceitação, calma, otimismo, força e melhora terapêutica. estes foram benefícios citados e percebidos pelos participantes por meio do comportamento e de alterações fisiológicas do paciente. esses resultados também foram encontrados em outros estudos (20, 30); maior aceitação da enfermidade, paz, positividade, segurança, superação e esperança de cura foram outros benefícios para pacientes e suas famílias decorrentes da abordagem da espiritualidade (25). as pessoas se sentem mais confortadas. teve algo que as confortaram. aceita o tratamento de uma forma melhor, esboça até uma face que está mais animada, com esperança. (e15) [...] a parte espiritual é importante demais. você reza e torce pelo tratamento para dar certo, mas o que te mantém de pé é a parte espiritual. o que mantém o familiar de pé, o que mantém o paciente ali naquela confiança de que tudo vai dar certo é outra força, não é aquele tratamento mecânico, nem o banho. (e12) se você tem fé, acredita, tem um pensamento positivo, a chance de dar certo é muito maior. esse pensamento positivo fisiologicamente é importante, o seu sistema imunológico fica mais fortalecido, quando você é mais otimista, quando você é mais alegre, tanto é que a pessoa deprimida é mais susceptível a ter doença. então, sem dúvida nenhuma, a fé e a espiritualidade contribuem muito para a saúde do paciente. (e8) [...] eu já vejo que foi comprovado cientificamente, com questões do sistema imunológico da pessoa. quando ela tem uma fé e ela tem uma crença na espiritualidade, esta pessoa tem uma recuperação mais rápida. (e14) para o paciente, a assistência espiritual permite com que o outro se sinta valorizado e cuidado, o que o leva ao bem-estar espiritual (24), além de contribuir para a busca do significado do adoecimento (31). por outro lado, para o profissional, sentimento de satisfação pessoal por olhar o outro de forma humanizada e poder ajudá-lo foram também benefícios citados pelos enfermeiros desta pesquisa. resultados semelhantes foram encontrados em outros estudos, por exemplo, que acessar a espiritualidade do paciente permite uma melhor qualidade de vida no trabalho (31), além de ganho pessoal ao realizar o cuidado espiritual (23). atender às necessidades espirituais dos pacientes gerou emoções positivas nos enfermeiros entrevistados. 190 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 [...] eu acho que torna a gente mais humano. (e11) eu me sinto mais aliviada por estar fazendo alguma coisa, de uma maneira direta ou indiretamente. (e3) eu me senti muito, muito bem depois, porque ela [paciente] parou de chorar. ela apertou a minha mão bem forte e disse: “muito obrigada, muito obrigada!”. (e9) considerações finais a enfermagem tem usado a palavra necessidade como um conceito, um termo técnico e teórico, com importante papel na teoria e na prática profissional. como um conceito, necessidade funciona como uma entidade linguística abstrata, apartada da situação do paciente e da enfermagem enquanto uma prática social, isto é, enquanto um trabalho desempenhado em um sistema de saúde constituído por instituições com objetivos e finalidades diferentes. assumimos, neste estudo, que o cuidado deve atender às necessidades espirituais; contudo, necessidades espirituais não podem ser definidas de forma genérica e abstrata, o que poderia mascarar questões importantes como preconceito, cientificismo e, sobretudo, limitar a autonomia na relação enfermeiro-paciente. o cuidado de enfermagem deve atender às necessidades espirituais de seus pacientes, tendo em vista a integralidade do ser humano. o estudo permitiu explorar a experiência e a percepção de enfermeiros sobre o cuidado espiritual, e os resultados mostraram que o plano de cuidado de alguns enfermeiros era hierarquizado de acordo com as necessidades do paciente, com prioridade para as necessidades fisiológicas. apesar da importância dada à dimensão espiritual do paciente e da responsabilidade do enfermeiro no atendimento dessas necessidades, esse cuidado quando aconteceu, na prática clínica, se deu de forma assistemática e muito associada às manifestações religiosas. a falta de conhecimento para lidar com a espiritualidade no cuidado ao paciente, o desconforto em abordar esses aspectos na prática clínica e a organização do processo de trabalho foram as principais dificuldades citadas pelos enfermeiros. isso prejudicou a abordagem de questões espirituais, intervenções sobre necessidades identificadas e ainda pode ser um indício para que essa assistência tenha sido negligenciada por alguns enfermeiros. características relacionadas à religiosidade dos enfermeiros não foram exploradas neste estudo, bem como os tipos de cuidado espiritual realizados em cada setor de atendimento clínico do paciente e as diferenças de gênero do prestador desse cuidado, o que poderiam ter produzido resultados ainda mais ricos. apesar da prontidão dos enfermeiros para participar da pesquisa, a operacionalização das entrevistas pelos pesquisadores sem interferir na dinâmica de trabalho da instituição constitui-se na principal dificuldade deste estudo. estudos sobre as necessidades espirituais do paciente e de intervenções a serem realizadas pelo enfermeiro são necessários, sobretudo no contexto brasileiro, para guiar a prática assistencial e promover uma melhor compreensão do papel da enfermagem no cuidado integral ao ser humano. ademais, registra-se a carência de investigações que objetivam explorar sobre a formação dos estudantes de enfermagem acerca da atenção às necessidades espirituais do paciente, com vistas a habilitar os futuros enfermeiros a considerarem o paciente na sua diversidade e integralidade. da mesma forma, a abordagem da espiritualidade deve ser discutida nos serviços de saúde para que novas práticas sejam (re)elaboradas, o que contribuiria para uma reflexão ampla da espiritualidade e das necessidades a serem incluídas na assistência de enfermagem. 191 atenção às necessidades espirituais na prática clínica de enfermeiros l lucila castanheira nascimento e outros referências 1. hallström i, runesson i, elander g. observed parental needs during their child’s hospitalization. journal of pediatric nursing. 2002 abril; 17(2):140-8. 2. fortin j. human needs and nursing theory. em: kim hs, kollak i. nursing theories: conceptual and philosophical foundations. nova york: springer publishing; 2006, pp.10-26. 3. meleis ai. theoretical nursing: development and progress. 5a ed. filadélfia, pa: lippincott williams & wilkins; 2011. 4. narayanasamy a. the puzzle of spirituality for nursing: a guide to practical assessment. british journal of nursing. 2004 out.-nov.; 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espiritualidade em oncologia: concepções de profissionais de saúde. psicologia usp. 2013; 24(1):11-34. 29. caldeira s. a espiritualidade no currículo de enfermagem. revista nursing portuguesa. 2012 jul.-ago.; 282:18-21. 30. salmon b, bruick-sorge c, beckman sj, bosley-hrages s. the evolution of student nurses’ concepts of spirituality. holistic nursing practice. 2010 mar.-abril; 24(2):73-8. 31. santo cce, gomes amt, oliveira dc, pontes apm, santos ei, costa cpm. diálogos entre espiritualidade e enfermagem: uma revisão integrativa da literatura. cogitare enfermagem. 2013 abril-jun.; 18(2):372-8. 128 139 adesao ao tratamento de pessoas.indd 128 samilly márjore dantas liberato1 rhayssa de oliveira e araújo2 amanda jéssica gomes de souza3 aline maino pergola marconato4 isabelle katherinne fernandes costa5 gilson de vasconcelos torres6 adesão ao tratamento de pessoas com úlceras venosas atendidas na atenção primária à saúde 1 orcid.org/0000-0003-1611-286x. universidade federal do rio grande do norte, brasil. gvt@ufrnet.br 2 orcid.org/0000-0002-5068-2906. universidade federal do rio grande do norte, brasil. gvt@ufrnet.br 3 orcid.org/0000-0002-5611-0140. universidade federal do rio grande do norte, brasil. gvt@ufrnet.br 4 orcid.org/0000-0001-5071-865x. universidade estadual de campinas, brasil. apergola@unicamp.br 5 orcid.org/0000-0002-1476-8702. universidade federal do rio grande do norte, brasil. isabellekfc@pq.cnpq.br 6 orcid.org/0000-0003-2265-5078. universidade federal do rio grande do norte, brasil. gvt@ufrnet.br recibido: 14 de abril de 2015 enviado a pares: 23 de septiembre de 2015 aceptado por pares: 18 de agosto de 2016 aprobado: 22 de agosto de 2016 doi: 10.5294/aqui.2017.17.2.2 para citar este artículo / to reference this article / para citar este artigo liberato smd, araújo ro, souza ajg, marconato amp, costa ikf, torres gv. adesão ao tratamento de pessoas com úlceras venosas atendidas na atenção primária à saúde. aquichan. 2017;17(2):128-139. doi: 10.5294/aqui.2017.17.2.2 resumo objetivo: verificar a adesão ao tratamento de pessoas com úlceras venosas (uv) e sua associação com as características sociodemográficas, de saúde e assistenciais. materiais e métodos: trata-se de um estudo analítico, transversal, realizado com 101 pessoas com uv. utilizaram-se dois instrumentos: um formulário para caracterizar os aspectos sociodemográficos, de saúde e da assistência, e a escala multidimensional de adesão terapêutica. resultados: verificou-se pior adesão ao tratamento na dimensão terapia compressiva. identificou-se associação entre o domínio estilo de vida saudável e estado civil, e entre o domínio vigilância neurovascular e faixa etária, estado civil, profissão e etilismo. foram encontradas associações entre as dimensões de adesão e as caraterísticas da assistência: adesão à terapia compressiva, orientação para uso de terapia compressiva e orientação para exercícios regulares e quem realiza o curativo fora das unidades. conclusões: há maior dificuldade de adesão ao tratamento quanto à terapia compressiva, além disso a assistência prestada está associada à adesão à terapia compressiva, à orientação para uso de terapia compressiva e à orientação para exercícios regulares. palavras-chave atenção primária à saúde; cooperação do paciente; enfermagem; estratégia saúde da família; úlcera varicosa (fonte: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 128-139 129 adesão ao tratamento de pessoas com úlceras venosas atendidas na atenção primária à saúde l samilly márjore dantas-liberato e outros año 17 vol. 17 nº 2 chía, colombia junio 2017 l 128-139 adherencia al tratamiento de personas con úlceras venosas atendidas en la atención primaria a la salud resumen objetivo: estudiar la adherencia al tratamiento de personas con úlceras venosas (uv) y su asociación con las características sociodemográficas, de salud y asistenciales. materiales y métodos: se trata de un estudio analítico, transversal, realizado con 101 personas con uv. se emplearon dos instrumentos: un cuestionario para caracterizar los aspectos sociodemográficos, de salud y de asistencia, y la escala multidimensional de adherencia terapéutica. resultados: se halló peor adherencia al tratamiento en la dimensión terapia compresiva. se identificó asociación entre el dominio estilo de vida saludable y estado civil, y entre el dominio vigilancia neurovascular y rango de edades, estado civil, profesión y etilismo. se encontraron asociaciones entre las dimensiones de adherencia y las características de asistencia: adherencia a terapia compresiva, orientación para uso de terapia compresiva y orientación para ejercicios regulares y quien realiza la curación fuera de las unidades. conclusiones: hay mayor dificultad de adherencia al tratamiento en cuanto a terapia compresiva; la asistencia prestada está asociada a la adherencia a terapia compresiva, a orientación para uso de terapia compresiva y a orientación para ejercicios regulares. palabras clave atención primaria a salud; cooperación del paciente; enfermería; estrategia salud de la familia; úlcera venosa (fuente: decs, bireme). 130 aquichan issn 1657-5997 eissn 2027-5374 adherence to venous ulcer treatment among patients in primary health care abstract objective: adherence to treatment by patients with venous ulcers (vu) and how it that adherence is associated with sociodemographic characteristics and features of health and care. materials and methods: this is an analytical, cross-sectional study of 101 patients with venous ulcers. two instruments were used: a questionnaire designed to characterize sociodemographic aspects, health and care, and the multidimensional therapeutic adherence scale. results: the poorest adhesion to treatment was found with respect to compression therapy. the study identified an association between the domain of a healthy lifestyle and marital status, and between the domain of neurovascular surveillance and age range, marital status, profession and alcoholism. associations also were found between the dimensions of adherence and the characteristics of care: adherence to compression therapy, guidance on the use of compression therapy, guidance on regular exercises, and who applies treatment outside the primary care units. conclusions: there is greater difficulty in adhering to treatment in terms of compression therapy. the assistance given is associated with adherence to compression therapy, guidance on the use of compression therapy and guidance on exercises to be performed regularly. keywords primary health care; patient cooperation; nursing; family health strategy; venous ulcer (source: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 128-139 131 adesão ao tratamento de pessoas com úlceras venosas atendidas na atenção primária à saúde l samilly márjore dantas-liberato e outros introdução a úlcera da perna é uma síndrome em que há destruição de camadas cutâneas, tais como epiderme e derme, podendo atingir tecidos mais profundos. acomete geralmente o terço inferior dos membros inferiores. estas úlceras são consideradas lesões crônicas por serem de longa duração e com recorrência frequente (1). a úlcera venosa (uv) afeta a população adulta em diferentes faixas etárias e causa importante impacto social e econômico, visto que, pode resultar em afastamento do portador da lesão das atividades diárias, redução na qualidade de vida (qv), bem como necessidades de cuidados médicos e de enfermagem constantes. além disso, pode, por muitas vezes, gerar a aposentadoria precoce (2). a interferência na atividade de locomoção faz com que muitos indivíduos acometidos por úlceras venosas se declarem impotentes, insatisfeitos, dependentes, frágeis e desestimulados. acrescentase que a experiência dolorosa, muito frequente na vida desses pacientes, pode interferir ainda mais nas ações cotidianas (3). estudo mostrou que, em longo prazo, estes pacientes diminuem a adesão ao tratamento, pois passam a perceber a cura como improvável ou acreditam na inevitabilidade de recorrência da úlcera (4). isso levanta preocupações sobre a motivação destes em aderir às recomendações do tratamento. de acordo a organização mundial de saúde, a adesão terapêutica refere-se ao grau de concordância entre o comportamento de uma pessoa e as prescrições da equipe de saúde. o conceito remete à ideia de uma relação de colaboração entre paciente e profissional de saúde no desenvolvimento e ajuste do plano de cuidados (5). nesse sentido, a adesão terapêutica tem se mostrado um dos fatores responsáveis pela redução significativa do tempo de cicatrização, além de prolongar o período de recidiva da úlcera (6). entretanto, a adesão terapêutica ainda consiste em um grande problema entre os portadores da lesão, pois o tratamento é longo, dispendioso e demanda alterações no estilo de vida. acrescenta-se ainda que estudos desenvolvidos com pessoas acometidas por diferentes doenças crônicas constataram relação significativa entre adesão ao tratamento e qualidade de vida, sinalizando a relevância dessa temática (7). frente ao exposto, julga-se necessário a busca pelo aumento da compreensão do fenômeno da adesão ao tratamento das pessoas com úlceras venosas com vistas a subsidiar e auxiliar uma mudança na prática de atenção à saúde superando a visão simplista e limitada da assistência. elencaram-se como problemas desta pesquisa: como se caracteriza a adesão das pessoas com úlceras venosas ao tratamento? existe associação da adesão ao tratamento com as características sociodemográficas, de saúde e assistenciais? para tanto, o objetivo deste estudo foi verificar a adesão ao tratamento de pessoas com úlceras venosas atendidas na atenção primária à saúde e sua associação com as características sociodemográficas, de saúde e assistenciais. materiais e métodos trata-se de um estudo analítico, transversal, com abordagem quantitativa, tendo como cenário as unidades de saúde da família (usf) e unidades mistas da cidade de natal, capital do estado do rio grande do norte, que são coordenadas pela secretaria municipal de saúde (sms) e têm como eixo estruturante da atenção básica a estratégia de saúde da família (esf). a população alvo foi composta por pessoas com uv indicadas pelas equipes da esf durante o período da coleta de dados por acessibilidade e que atendessem aos seguintes critérios de inclusão: apresentar no mínimo uma úlcera venosa; estar orientado e em condições de ser entrevistado; ter idade mínima de 18 anos. foram excluídos os usuários que não concluíram todos os processos da coleta de dados e aqueles que apresentaram outros tipos de feridas: oncológicas, arterial ou de etiologia mista (venosa e arterial ou venosa e hansênica). tal condição justifica-se, porque estas feridas apresentam características diferenciadas das úlceras venosas típicas. o procedimento de coleta concretizou-se nos meses de fevereiro a setembro de 2014, resultando em uma amostra de 101 pessoas com uv. durante os meses de maio a julho, os servidores municipais das unidades deflagraram greve o que interrompeu temporariamente a continuidade da coleta. a coleta de dados concretizou-se por meio da aplicação de dois instrumentos, o primeiro corresponde a um protocolo assistencial (8) do qual foram utilizados 27 itens que caracterizam os 132 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 aspectos sociodemográficos, de saúde e da assistência. o segundo instrumento refere-se à escala multidimensional de adesão terapêutica (9), composta por 24 itens que correspondem a três dimensões: estilo de vida saudável, terapia compressiva e vigilância neurovascular. os itens recebem pontuação a partir de uma escala do tipo likert variando de 1 a 5, atentando que quanto mais próximo de 1 melhor a adesão. os dados obtidos foram organizados em uma planilha eletrônica, e, após correção, exportados para um software estatístico no qual foram realizadas a análise descritiva, com frequências absolutas, relativas e média dos escores de adesão, e a análise inferencial, com aplicação do teste de mann whitney, adotando-se como nível de significância estatística o p-valor menor que 0,05. destaca-se que o estudo está de acordo com a resolução 466/2012 (10), que envolve pesquisas com seres humanos, tendo sido apreciado e aprovado pela comissão de ética em pesquisa/ universidade federal do rio grande do norte (ufrn) com caae: 07556312.0.0000.5537. além disso, todos os participantes assinaram o termo de consentimento livre e esclarecido, concordando com a realização da pesquisa e utilização dos dados, desde que resguardadas as suas identidades. resultados o perfil sociodemográfico das pessoas com uv caracterizou-se por um predomínio do sexo feminino (66,3 %), com idade superior ou igual a 60 anos (61,4 %), casado/união estável (63,4 %), não alfabetizado/alfabetizado/ensino fundamental (85,1 %), sem profissão (75,2 %) e renda de até um salário mínimo (90,1 %). com relação à caracterização de saúde, evidenciou-se que a maioria das pessoas relataram doenças crônicas associadas, (60,4 %) afirmaram sono maior que seis horas, (82,2 %) dor presente, (88,1 %) negaram etilismo e tabagismo (80,2 %) e apresentaram número de recidivas maior ou igual a (71,3 %). os dados que caracterizam a assistência são apresentados na tabela 1, distribuídos conforme tempo de uv atual. com relação à adesão terapêutica e utilizando como referência o escore médio (pontuado de 1 a 5 para cada dimensão), é possível verificar por meio dos dados da tabela 2 que é na dimensão terapia compressiva em que há pior adesão. a tabela 3 apresenta as características sociodemográficas e de saúde segundo os escores de adesão terapêutica nos domínios estilo de vida saudável, terapia compressiva e vigilância neurovascular. identificou-se associação entre o domínio estilo de vida saudável e estado civil (p=0,040) e entre o domínio vigilância neurovascular e faixa etária (p=0,010), estado civil (p=0,034), profissão (p=0,014) e etilismo (p=0,032). a análise da associação entre as características da assistência e as dimensões da escala multidimensional de adesão ao tratamento mostrou que a adesão ao estilo de vida saudável esteve associada a orientações para realização de exercícios regulares (p=0,046). no caso da dimensão terapia compressiva observouse associação com o uso de terapia compressiva (p<0,001) e orientações para uso de terapia compressiva (p=0,002). a dimensão vigilância neurovascular apresentou associação com quem realiza o curativo fora das unidades (p=0,005) e com orientações para realização de exercícios regulares (p=0,037), como demonstrado na tabela 4. discussão analisando as características sociodemográficas, nota-se que o perfil da população estudada corrobora com o que tem sido constatado por outros estudos no cenário nacional (2,11) e internacional (12). com relação à caracterização de saúde, cabe destaque ao fato de que um elevado percentual dos participantes desta investigação negou tabagismo e etilismo. torna-se pertinente elucidar que esses hábitos sociais implicam em efeitos expressivamente negativos sobre o processo cicatricial, retardam a evolução da ferida e, portanto, devem ser completamente desencorajados às pessoas com uv (13). no que se refere ao número de recidivas, os dados desta pesquisa não diferem da maioria dos estudos, que sinalizam que as úlceras venosas têm elevadas taxas de recorrência (14,15). acredita-se que o principal motivo das recidivas é a não adesão do paciente com relação às medidas preventivas muitas vezes por não conhecê-las ou não ter sido bem orientado. no próprio estudo em questão, 60,4 % dos pesquisados referiram não terem sido orientados quanto ao uso de terapias compressivas, elevação de mmii e exercícios regulares, o que demonstra uma falha preocupante considerando o valor de tais medidas tanto para o tratamento quanto para a prevenção de recidivas. 133 adesão ao tratamento de pessoas com úlceras venosas atendidas na atenção primária à saúde l samilly márjore dantas-liberato e outros tabela 1. caracterização da assistência dos pacientes com uv segundo o tempo de uv atual. natal/rn, 2014. *unidade de saúde da família **unidade básica de saúde ***hospital universitário onofre lopes fonte: elaboração própria. caracterização da assistência tempo de uv atual >= 6 meses até 6 meses total n % n % n % adequação dos produtos utilizados adequado 45 44,6 20 19,8 65 64,4 inadequado 29 28,7 07 6,9 36 35,6 realização do curativo fora da usf*/unidade mista profissional/cuidador sem treinamento 42 41,6 15 14,9 57 56,4 profissional/cuidador treinado 32 31,7 12 11,9 44 43,6 local de tratamento da uv domicílio 30 29,7 17 16,8 47 46,5 ubs**/usf/huol***/hospital municipal 44 43,6 10 9,9 54 53,5 terapia compressiva ausente 63 62,4 25 24,8 88 87,1 presente 11 10,9 02 2,0 13 12,9 orientação para o uso de terapias compressivas, elevação de mmii e exercícios regulares ausente 42 41,6 19 18,8 61 60,4 presente 32 31,7 08 7,9 40 39,6 exames laboratoriais e específicos exames de sangue ou urina 37 36,6 17 16,8 54 53,5 exames de sangue ou urina e doppler 23 22,8 04 4,0 27 26,7 nenhum 11 10,9 06 5,9 17 16,8 doppler 03 3,0 00 0,0 03 3,0 número de consultas com o angiologista no último ano < de 4 consultas por ano 70 69,3 24 23,8 94 93,1 ≥ 4 consultas por ano 04 4,0 03 3,0 07 6,9 documentação dos achados clínicos com registro no prontuário 52 51,5 20 19,8 72 71,3 sem registro no prontuário 22 21,8 07 6,9 29 28,7 referência ausente 55 54,5 18 17,8 73 72,3 presente 19 18,8 09 8,9 28 27,7 134 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 tabela 2. valores mínimo, máximo, média e desvio padrão (dp) das dimensões da escala multidimensional de adesão terapêutica. natal/rn, 2014. tabela 3. características sociodemográficas e de saúde segundo escores de adesão terapêutica. natal/rn, 2014. dimensões mínimo máximo média dp estilo de vida saudável 1 4 2,30 0,50 terapia compressiva 3 5 4,83 0,47 vigilância neurovascular 1 5 2,31 1,31 fonte: elaboração própria. caracterização sociodemográfica e de saúde estilo de vida saudável terapia compressiva vigilância neurovascular n média (dp) p-valor* média (dp) p-valor* média (dp) p-valor* sexo feminino 67 2,56 (0,62) 0,222 4,77 (0,55) 0,085 2,34 (1,25) 0,399 masculino 34 2,74 (0,53) 4,96 (0,17) 2,24 (1,44) faixa etária 60 anos 62 2,57 (0,63) 0,364 4,87 (0,37) 0,638 2,54 (1,32) 0,010 até 59 anos 39 2,70 (0,55) 4,77 (0,59) 1,94 (1,22) estado civil solteiro/viúvo/ divorciado 37 2,79 (0,52) 0,040 4,84 (0,50) 0,565 2,58 (1,20) 0,034 casado/união estável 64 2,52 (0,62) 4,83 (0,45) 2,15 (1,35) escolaridade não alfabetizado/ alfabetizado/ ensino fundamental 86 2,66 (0,60) 0,103 4,83 (0,46) 0,431 2,37 (1,30) 0,193 ensino médio e superior 15 2,40 (0,52) 4,86 (0,51) 1,95 (1,34) profissão/ ocupação presente 25 2,80 (0,52) 0,775 4,86 (0,43) 0,803 1,82 (1,19) 0,014 ausente 76 2,56 (0,61) 4,82 (0,48) 2,47 (1,32) renda per capita até 1 sm** 91 2,60 (0,60) 0,130 4,82 (0,48) 0,650 2,32 (1,33) 0,958 >1 sm 10 2,88 (0,58) 4,92 (0,23) 2,22 (1,23) doenças crônicas associadas presente 61 2,54 (0,61) 0,156 4,80 (0,50) 0,370 2,39 (1,41) 0,759 ausente 40 2,75 (0,55) 4,88 (0,41) 2,18 (1,15) 135 adesão ao tratamento de pessoas com úlceras venosas atendidas na atenção primária à saúde l samilly márjore dantas-liberato e outros *teste de mann-whitney **salário mínimo fonte: elaboração própria. caracterização sociodemográfica e de saúde estilo de vida saudável terapia compressiva vigilância neurovascular n média (dp) p-valor* média (dp) p-valor* média (dp) p-valor* sono até 6 horas 18 2,59 (0,66) 0,993 4,93 (0,23) 0,636 2,26 (1,27) 0,839 maior igual 6 horas 83 2,63 (0,59) 4,81 (0,50) 2,32 (1,33) etilismo presente 13 2,60 (0,41) 0,730 4,85 (0,55) 0,549 1,75 (1,31) 0,032 ausente 88 2,62 (0,62) 4,83 (0,46) 2,39 (1,30) tabagismo presente 15 2,86 (0,32) 0,085 4,66 (0,72) 0,377 2,20 (1,32) 0,698 ausente 86 2,58 (0,63) 4,86 (0,41) 2,32 (1,32) dor presente 88 2,62 (0,61) 0,911 4,83 (0,46) 0,879 2,34 (1,36) 0,889 ausente 13 2,60 (0,53) 4,82 (0,55) 2,09 (0,91) recidivas 1 72 2,60 (0,59) 0,764 4,81 (0,48) 0,516 2,23 (1,22) 0,570 nenhuma 29 2,67 (0,63) 4,87 (0,42) 2,50 (1,51) tabela 4. características da assistência à saúde segundo escores de adesão terapêutica. natal/rn, 2014. caracterização da assistência à saúde n estilo de vida saudável terapia compressiva vigilância neurovascular média (dp) p-valor* média (dp) p-valor* média (dp) p-valor* adequação de materiais adequado 65 2,32 (0,47) 0,614 4,77 (0,55) 0,071 2,34 (1,34) 0,871 inadequado 36 2,27 (0,55) 4,94 (0,23) 2,25 (1,27) quem realiza o curativo fora das unidades profissional/cuidador treinado 44 2,32 (0,52) 0,495 4,92 (0,25) 0,190 2,71 (1,36) 0,005 profissional/cuidador sem treinamento 57 2,28 (0,49) 4,76 (0,57) 2,00 (1,19) local de tratamento da uv ubs, usf, huol, hosp. municipal 54 2,27 (0,53) 0,445 4,84 (0,45) 0,781 2,45 (1,38) 0,224 domicílio 47 2,34 (0,46) 4,81 (0,49) 2,13 (1,22) 136 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 nesse sentido, a prática de educação em saúde configura-se como medida de grande relevância uma vez que permite ao enfermeiro estimular o conhecimento da pessoa sobre sua condição de saúde e sensibilizar o usuário a aderir ao tratamento (16). a terapia compressiva é a base fundamental do tratamento da uv e tem demonstrado ser capaz de melhorar as taxas de cicatrização e reduzir a recorrência da lesão, pois melhora a microcirculação e a eficácia da bomba muscular da panturrilha, reduzindo o edema e a hipertensão venosa (17), no entanto na presente pesquisa essa prática estava instituída para apenas 12,9 % dos pesquisados. o reduzido número de pessoas que foram orientadas sobre o uso de terapia compressiva somado à baixa taxa de implementação dessa terapêutica refletiram nos achados referentes à medida de adesão ao tratamento. segundo os escores identificados, a terapia compressiva foi a dimensão em que se observou piores índices de adesão. a dimensão terapia compressiva apresentou associação significativa com o uso de terapia compressiva e orientações sobre terapia compressiva. essa constatação elucida a ideia de que a educação em saúde é capaz de influenciar positivamente alterações de comportamento e a adesão ao tratamento desde que os profissionais levem em consideração os contextos cultural e social de cada indivíduo ao elencar a linguagem mais adequada para nortear o processo de comunicação terapêutica (18). caracterização da assistência à saúde n estilo de vida saudável terapia compressiva vigilância neurovascular média (dp) p-valor* média (dp) p-valor* média (dp) p-valor* faz uso de terapia compressiva não 88 2,31 (0,51) 0,549 4,93 (0,28) <0,001 2,29 (1,29) 0,938 sim 13 2,21 (0,39) 4,17 (0,83) 2,38 (1,52) tempo de tratamento da uv 6 meses 84 2,32 (0,52) 0,388 4,81 (0,50) 0,706 2,28 (1,30) 0,638 até 6 meses 17 2,20 (0,39) 4,92 (0,24) 2,44 (1,39) orientações para uso de terapia compressiva ausente 54 2,28 (0,53) 0,581 4,94 (0,30) 0,002 2,47 (1,28) 0,072 presente 47 2,32 (0,46) 4,70 (0,58) 2,11 (1,33) orientações elevação dos mmii ausente 09 2,50 (0,77) 0,414 5,00 (0,00) 0,211 2,91 (1,60) 0,265 presente 92 2,28 (0,46) 4,81 (0,49) 2,25 (1,27) orientações exercícios regulares ausente 59 2,39 (0,52) 0,046 4,88 (0,38) 0,201 2,46 (1,24) 0,037 presente 42 2,18 (0,45) 4,76 (0,56) 2,08 (1,39) referência e contrarreferência ausente 73 2,30 (0,53) 0,973 4,87 (0,40) 0,397 2,43 (1,39) 0,199 presente 28 2,30 (0,42) 4,73 (0,61) 2,00 (1,03) *teste de mann-whitney fonte: elaboração própria. 137 adesão ao tratamento de pessoas com úlceras venosas atendidas na atenção primária à saúde l samilly márjore dantas-liberato e outros a dimensão estilo de vida saudável investiga a adesão a hábitos de vida importantes na cicatrização da uv e foi a dimensão em que se verificou melhor adesão. essa dimensão apresentou associação estatística significativa com estado civil e orientações para realização de exercícios regulares, demonstrando que pessoas que têm companheiro e que foram orientadas quanto à realização de exercícios físicos regulares aderem melhor à dimensão estilo de vida saudável. a presença de um companheiro configura-se como uma fonte adicional importante de apoio social, pois auxilia o enfrentamento de dificuldades e atua como agente facilitador no processo de tratamento, podendo, portanto, influenciar positivamente a adesão ao tratamento (19). no panorama das doenças crônicas, as mudanças comportamentais e adoção de hábitos saudáveis de vida constituem um desafio adicional que permeia toda a vida do usuário. alguns autores valorizam a estratégia de grupos de apoio no enfrentamento desse obstáculo e como meio alternativo para educação em saúde, verificando que esta ferramenta foi capaz de estimular a autonomia dos sujeitos, incentivar o autocuidado, promover mudanças de comportamentos e potencializar a adesão ao tratamento (20,21). a dimensão vigilância neurovascular avalia a atenção por parte da pessoa, no que concerne a sinais de comprometimento circulatório das extremidades, tais como o edema, a coloração, a sensibilidade e a mobilidade. os achados deste estudo mostraram melhor adesão à vigilância neurovascular do que em estudo desenvolvido em portugal (9). nessa dimensão, verificou-se associação estatística com faixa etária, estado civil, profissão/ ocupação, etilismo, quem realiza o curativo fora das unidades e orientações para realização de exercícios regulares. esse contexto remete à importância do papel do profissional enfermeiro no estímulo do autocuidado. em uma investigação com pessoas com úlceras venosas, os entrevistados expressaram que suas próprias ações não se relacionavam à cura ou eram vistas como de importância secundária, desconsiderando seu papel na promoção da saúde (22). analisando a faixa etária, autores alertam que, com frequência, o idoso é dissuadido quanto à capacidade para o autocuidado, em nome da eficiência e proteção e evidenciam que os idosos aceitam o controle sem questionar e têm pouco envolvimento na tomada de decisão (23), estando a adesão ao tratamento condicionada às ações de terceiros. quando se considera quem realiza o curativo fora das unidades de saúde, emerge a importância das ações sobre o conhecimento do paciente e de seus familiares com vistas a aumentar a colaboração em vários aspectos dos cuidados, principalmente no ambiente domiciliar, onde a continuidade do cuidado com a uv depende essencialmente das ações do usuário. ampliando a reflexão sobre o autocuidado para além de dados estatísticos há de se considerar que os valores adquiridos ao longo da vida e a própria história de vida também influenciam as decisões das pessoas no que diz respeito ao seu próprio cuidado. há, assim, fatores culturais, sociais e de vida pessoal que moldam o autocuidado e, portanto não podem ser desconsiderados pelo profissional de saúde, pois a experiência de adoecer é um conhecimento único de cada pessoa (23). conclusão mesmo sendo expressivamente reconhecida como a melhor prática no tratamento da úlcera venosa, a terapia compressiva foi a dimensão em que houve pior adesão, poucos pacientes receberam essa forma de tratamento e um número muito pequeno foi orientado quanto a essa medida. tal fato representa uma importante lacuna na assistência prestada a essa população no nível de atenção primária à saúde, o que inevitavelmente contribui para a cronicidade das lesões e aumento da ocorrência de complicações culminando com a demanda por cuidados dos outros níveis de atenção à saúde. além disso, a análise dos dados conseguiu sinalizar grupos que merecem maior atenção e variáveis que influenciam positivamente o comportamento de adesão. foi possível ainda elucidar o valor significativo das orientações realizadas pelos profissionais de saúde durante o processo terapêutico, o que denota que o cuidado prestado a essa população deve abarcar mais que somente a execução de um curativo. diante do exposto emerge a necessidade de que os profissionais, especialmente os enfermeiros, sejam sensibilizados e capacitados a estabelecer um cuidado holístico e verdadeiramente efetivo às pessoas com úlceras venosas. 138 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 referências 1. oliveira bgrp, nogueira ga, carvalho mr, abreu am. caracterização dos pacientes com úlcera venosa acompanhados no ambulatório de reparo de feridas. rev eletr enf [internet]. 2012 [acesso em 09 jul 2014]; 14(1):156-63. disponível em: http://www.fen.ufg.br/fen_revista/v14/n1/pdf/v14n1a18.pdf 2. evangelista dg, magalhães erm, moretão dic, stival mm, lima lr. impacto das feridas crônicas na qualidade de vida de usuários da estratégia de saúde da família. rev enferm cent-oeste min [internet]. 2012 [acesso em 29 mai 2014]; 2(2):254-63. disponível em: 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[internet]. 2013 [acesso em: 14 mar 2015]; seriii(9):151-60. disponível em: http://www.scielo.mec.pt/pdf/ref/vseriiin9/ seriiin9a16.pdf 148 158 obesidad infantil y su relacion.indd 148 josé arias-rico1 sandy marlene cortés-cortés2 esther ramírez-moreno3 ma. luisa sánchez-padilla4 reyna cristina jiménez-sánchez5 teresita de jesús saucedo-molina6 obesidad infantil y su relación con indicadores cardiopulmonares en escolares mexicanos7 1 doctor en farmacología. universidad autónoma del estado de hidalgo (méxico). josearias.rico@hotmail.com 2 licenciada en nutrición. universidad autónoma del estado de hidalgo (méxico). saney321_24@hotmail.com 3 doctora en ciencias de los alimentos. universidad autónoma del estado de hidalgo (méxico). rme1234@yahoo.com 4 maestra en ciencias de la enfermería. universidad autónoma del estado de hidalgo (méxico). marialuisasanchezpadilla@yahoo.com.mx 5 maestra en ciencias de la enfermería. universidad autónoma del estado de hidalgo (méxico). cristyji@hotmail.com 6 doctora en psicología. universidad autónoma del estado de hidalgo (méxico). saucemol@hotmail.com 7 este artículo se realiza con la contribución y asesoría de las maestras rosa maría guevara cabrera, rosa maría baltazar téllez y angelina álvarez. recibido: 7 de julio 2015 enviado a pares: 9 septiembre de 2015 aceptado por pares: 23 de diciembre de 2015 aprobado: 8 de febrero 2016 doi: 10.5294/aqui.2016.16.2.3 para citar este artículo / to reference this article / para citar este artigo arias-rico j, cortés-cortés sm, ramírez-moreno e, sánchez-padilla ml, jiménez-sánchez rc, saucedo-molina tj. obesidad infantil y su relación con indicadores cardiopulmonares en escolares mexicanos. aquichan. 2016; 16(2): 148-158. doi: 10.5294/aqui.2016.16.2.3 resumen objetivo: determinar la relación entre obesidad y anormalidades de parámetros cardiopulmonares en escolares. materiales y métodos: participaron 78 escolares entre 5 a 11 años de edad, 47 hombres (60,3 %) y 31 mujeres (39,7 %), pertenecientes a una escuela primaria particular de la ciudad de pachuca (méxico). se evaluó: índice de masa corporal (imc), circunferencia de cintura (cc), grasa corporal (gc), frecuencia cardiaca (fc), presión arterial (pa), frecuencia respiratoria (fr) y espirometría. se emplearon las pruebas estadísticas chi-cuadrado (x2), odds ratio y correlación de spearman (rs). resultados: 23,1 % de los escolares evaluados presentaron sobrepeso y 29,5 %, obesidad. el 38,5 y 11,5 % presentaron fc y pa superiores a los parámetros normales, respectivamente; 3,8 % de la población presentó fr arriba del promedio y 11,5 % mostró valores espirométricos anormales. se encontraron relaciones entre imc con gc y cc, gc y cc, cc y fc, gc y pa, y fc y fr. conclusiones: las prevalencias de sobrepeso y obesidad obtenidas en este estudio fueron altas. los niños con sobrepeso u obesidad podrían tener mayor riesgo de presentar anormalidades cardiopulmonares en comparación con niños de peso normal. se sugiere continuar con estudios en el tema en una muestra más amplia. palabras clave obesidad, niños, enfermedad cardiopulmonar, espirometría (fuente: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 148-158 149 obesidad infantil y su relación con indicadores cardiopulmonares en escolares mexicanos l josé arias-rico y otros año 16 vol. 16 nº 2 chía, colombia junio 2016 l 148-158 childhood obesity and its relation to cardiopulmonary indicators in mexican school children abstract objective: determine the relationship between obesity and abnormal cardiopulmonary parameters in school children. materials and methods: the sample involved 78 children between five and 11 years of age: 47 males (60.3%) and 31 females (39.7%). all were enrolled in a specific elementary school in the city of pachuca (mexico). body mass (bmi), waist circumference (wc), body fat (gc), heart rate (hr), blood pressure (bp), respiratory rate (rr) and spirometry were evaluated. a chi-square (x2) statistical test, the odds ratio and spearman’s rank-order correlation (rs) were used. results: in all, 23.1% of the students who were evaluated were overweight and 29.5% were obese; 38.5% and 11.5% had a hr and bp above the normal parameters, in that order; 3.8% of the population in question had a hr above average and 11.5% showed abnormal spirometric values. a relationship was found between bmi and bf and wc, bf and wc, wc and hr, bf and bp, and hr and rf. conclusions: the prevalence of overweight and obesity found in this study was high. children who are overweight or obese might be at increased risk of experiencing cardiopulmonary abnormalities compared to children of normal weight. it is suggested that studies on this subject be continued with a broader sample. keywords obesity, children, cardiopulmonary disease, spirometry (source: decs, bireme). 150 aquichan issn 1657-5997 obesidade infantil e sua relação com indicadores cardiopulmonares em estudantes mexicanos resumo objetivo: determinar a relação entre obesidade e anormalidades de parâmetros cardiopulmonares em estudantes do ensino fundamental. materiais e métodos: participaram do estudo 78 estudantes entre 5 a 11 anos de idade, 47 do gênero masculino (60,3 %) e 31 do feminino (39,7 %), pertencentes a uma escola primária particular da cidade de pachuca (méxico). avaliaram-se o índice de massa corporal (imc), a circunferência de cintura (cc), a gordura corporal (gc), a frequência cardíaca (fc), a pressão arterial (pa), a frequência respiratória (fr) e a espirometria. utilizaram-se os testes estatísticos qui-quadrado (x2), odds ratio e correlação de spearman (rs). resultados: 23,1 % dos estudantes avaliados apresentaram excesso de peso e 29,5 % obesidade. 38,5 e 11,5 % apresentaram fc e pa superiores aos parâmetros normais, respectivamente; 3,8 % da população apresentou fr acima da média e 11,5 % mostraram parâmetros espirométricos anormais. constataram-se relações entre imc com gc e cc, gc e cc, cc e fc, gc e pa, e fc e fr. conclusões: as prevalências de excesso de peso e obesidade obtidas neste estudo foram altas. as crianças com excesso de peso ou obesidade poderiam ter maior risco de apresentar anormalidades cardiopulmonares em comparação às de peso normal. sugere-se continuar com estudos sobre o tema com uma amostra mais ampla. palavras-chave obesidade, crianças, doença cardiopulmonar, espirometria (fonte: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 148-158 151 obesidad infantil y su relación con indicadores cardiopulmonares en escolares mexicanos l josé arias-rico y otros introducción el panorama mundial indica que por lo menos 155 millones de niños en edad escolar tienen sobrepeso u obesidad (1). en méxico, de acuerdo con la encuesta nacional de salud y nutrición (ensanut) realizada en el 2012, el 19,8 % de los escolares presentan sobrepeso y el 14,6 % obesidad, representando alrededor de 5’664.870 niños (2). hidalgo se encuentra entre los primeros lugares en el país con niños con estos padecimientos, siendo 121.800 los afectados (18,5 % para sobrepeso y 12,0 % de obesidad) (3). diferentes municipios del estado de hidalgo se encuentran afectados con esta problemática nutricional, entre ellos pachuca (35,5 %), que ocupa el octavo lugar entre los municipios pertenecientes al nivel de alta prevalencia de sobrepeso y obesidad (4). el sobrepeso y la obesidad se caracterizan por la acumulación anormal y excesiva de grasa corporal (gc) (5), lo que acompaña alteraciones metabólicas que incrementan el riesgo para desarrollar comorbilidades (6). en escolares, de acuerdo con la organización mundial salud (oms), el sobrepeso se determina cuando el índice de masa corporal (imc) se encuentra entre los percentiles 85 y 97, y la obesidad a partir del percentil 97, de acuerdo con las tablas de crecimiento correspondientes (7). la etiología de estos padecimientos es multifactorial; sin embargo, la principal causa es la combinación de las siguientes condiciones: a) susceptibilidad de padecer obesidad por la presencia de variaciones genéticas (8); b) pérdida del balance entre la ingestión de energía y el gasto que se produce con el ejercicio (1, 9-11) y c) un estilo de vida sedentario (1, 11, 12). el sobrepeso y la obesidad se consideran como una de las principales enfermedades crónicas no transmisibles (9, 10, 13), pues a su vez constituyen la base para el desarrollo de otras patologías que condicionan un deterioro de la calidad de vida (14-16). dentro de los problemas frecuentemente asociados al sobrepeso y a la obesidad están los trastornos cardiacos relacionados con dislipidemias, hipertensión arterial y un incremento anormal de la cantidad de grasa abdominal, intolerancia a la glucosa, marcadores inflamatorios y el estado protrombótico (1, 17). así mismo, como problemas respiratorios se ha establecido la reducción de la capacidad residual funcional (crf) y el deterioro de la difusión pulmonar como anormalidades pulmonares más comunes en niños con obesidad primaria (18). lazarus et al. (19) encontraron que la gc se asocia con menores niveles de la función ventilatoria, debido a que el tejido adiposo alrededor de la caja torácica y del abdomen incrementa la presión intraabdominal, lo que origina una limitación del pulmón para expandirse durante la inspiración, lo que da lugar lugar a una disminución en los volúmenes y en las dinámicas pulmonares, lo que ocasiona diferentes problemas como apnea del sueño, síndrome de hipoventilación, entre otros (9, 20). además, li et al. (18) encontraron en su estudio posibles cambios estructurales en el intersticio del pulmón, resultantes de la deposición de lípidos y la disminución del área de la superficie alveolar. el sobrepeso y la obesidad están influenciadas principalmente por el ámbito familiar, la sociedad y las características demográficas, por lo que es recomendable que las intervenciones de salud se enfoquen en todo contexto que pueda repercutir en la alimentación y la actividad del escolar (10, 14, 16, 21) con respecto a la promoción de un estilo de vida más saludable (10, 11, 22), a fin de prevenir precozmente factores de riesgo, como el sedentarismo y los malos hábitos alimentarios, y evitar la aparición de enfermedades prematuras (10). en méxico no existen estudios que demuestren la asociación entre obesidad y anormalidades cardiopulmonares en niños; sin embargo, en otros países sí se ha estudiado esta relación aunque algunos investigadores no han encontrado relaciones estadísticamente significativas (18, 19, 23). de acuerdo con algunos hallazgos de la literatura, la reducción del volumen pulmonar se correlaciona con el grado de la obesidad (19). sin embargo, tanto li et al. (18) como boran et al. (23) no hallaron una relación entre el déficit pulmonar y medidas antropométricas, concluyendo que un déficit pulmonar es más evidente en problemas de obesidad mayor (imc > = 34 kg/m2). la presente investigación tuvo como objetivo principal determinar la relación entre el sobrepeso y la obesidad con anormalidades de parámetros cardiopulmonares en escolares. materiales y métodos estudio piloto de tipo analítico transversal, con una muestra de 78 voluntarios, quienes fueron niños de edades entre 5 y 11 años ( = 8,37 ± 1,7), 47 hombres (60,3 %) y 31 mujeres (39,7 %), pertenecientes a una escuela primaria particular de la ciudad de pachuca, hidalgo. la población de niños habita en la zona suburbana con nivel socioeconómico medio. 152 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 como criterios de inclusión de la muestra fueron considerados candidatos a participar en el estudio todos aquellos niños y niñas carentes de alguna alteración cardiopulmonar diagnosticada y que contaron con la autorización, vía consentimiento informado, por parte de los padres o tutores. la investigación fue aprobada por el comité de ética e investigación del instituto de ciencias de la salud de la universidad autónoma del estado de hidalgo (número de folio 014). las mediciones se llevaron a cabo durante el curso académico 2014-2015, entre los meses de agosto-noviembre 2014. en primer lugar, se realizó una valoración del estado nutricional de todos los alumnos, mediante medidas antropométricas. se midió peso, estatura, imc, circunferencia de cintura (cc) y los pliegues cutáneos tricipital (pct) y subescapular (pcse). para el imc, se tomaron como referencia los patrones de crecimiento de la oms (7), donde el sobrepeso se presenta entre los percentiles 85-97 y la obesidad a partir del percentil 97. para cc, de acuerdo con las tablas de fernández et al. (24), se evidencia riesgo de comorbilidad en el percentil > = 90. para evaluar la gc, las tablas de frisancho (25) indican que a partir del percentil 75 existe un exceso. posteriormente, se midió la frecuencia cardiaca (fc), la presión arterial (pa), la frecuencia respiratoria (fr) y la espirometría para valorar la función cardiopulmonar. los valores de referencia fueron los siguientes: fc, 65-85 latidos por minuto (26, 27); pa normal cuando el promedio de la presión sistólica (pas) y diastólica (pad), o ambas, fueran inferiores al percentil 90 para edad y sexo, presión normal alta cuando el promedio de pas y pad, o de ambas, se ubicaba entre los percentiles 90 y 95, y presión arterial alta cuando el promedio de pas y pad, o de ambas, fuera mayor o igual al percentil 95 (28-30). los valores considerados normales en la fr fueron de 20-25 respiraciones por minuto (26, 31), y para la espirometría el umbral de anormalidad se consideró menos de 80 % de los valores normales predichos por el software del espirómetro utilizado en la medición (microquark®) (32). todas estas mediciones fueron realizadas por personal previamente capacitado y estandarizado de acuerdo con el método de habicht (33). a fin de valorar la relación entre las variables antropométricas (imc, cc y gc) y los parámetros cardiopulmonares (fc, pa, fr y espirometría), se realizó un análisis mediante las pruebas de chicuadrado (x2), odds ratio (or) y coeficiente de spearman (rs), utilizando el paquete estadístico spss, versión 22.0 para windows®. resultados como se muestra en la tabla 1, la evaluación del imc evidenció un 23,1 % de sobrepeso y 29,5 % de obesidad en los escolares, mientras que el porcentaje restante presentó normalidad (47,4 %). al considerar el sexo de los escolares, se observó mayor porcentaje de obesidad en los varones (36,2 %) en comparación con las niñas (19,4 %); y un mayor porcentaje de niñas (29 %) presentó sobrepeso en comparación con los niños (19,1 %). no se presentaron diferencias estadísticamente significativas para las proporciones de sobrepeso y obesidad entre mujeres y hombres (p = 0,180 y p = 0,458, respectivamente). el 28,2 % de los niños presentaron riesgo de sufrir alguna comorbilidad con base en la circunferencia de cintura (> = percentil 90), denotando mayor proporción en los hombres (31,9 %) que en las mujeres (22 6 %) (p = 0 524). más del 50 % de los escolares presentaron un porcentaje de gc aumentado (gc arriba del promedio y exceso de gc), con similar prevalencia entre mujeres y hombres, sin mostrar diferencias estadísticamente significativas entre sexos (p = 0,939). la población de hombres presentó mayor riesgo de anormalidades en parámetros pulmonares; la fc fue alta en el 38,5% de los niños en este estudio, siendo más evidente en los hombres, el porcentaje de niños con pa normal alta y alta fue del 11,5 %; para mujeres y hombres la prevalencia fue similar, aunque un mayor porcentaje de mujeres presentó una pa alta (9,7 %). el 96 % de los niños presentó una fr normal o baja, mientras que el 3,8 % presentó este parámetro arriba del promedio de lo que se considera normal; de manera similar, en la presente investigación esta se observó para ambos sexos. por otra parte, el 11,5 % de la muestra estudiada obtuvo valores espirométricos anormales, siendo en su mayoría varones (12,8 %) en comparación con las mujeres (9,7 %), aunque sin diferencias estadísticamente significativas entre sexos. respecto a las asociaciones entre los parámetros antropométricos (imc, cc y gc) y cardiopulmonares, se encontró que el imc tiene una relación directa con el riesgo de sufrir comorbilidad de acuerdo con la cc (x2 = 27,65; p < 0,000) y la gc (x2 = 27,71; p < 0,000). se encontró una significancia marginal entre el imc y la espirometría (x2 = 3,75; p < 0,053). en contraste, no se halló una relación significativa entre el imc y los demás parámetros cardiopulmonares (fc, pa y fr). todos estos valores se pueden apreciar en la tabla 2. 153 obesidad infantil y su relación con indicadores cardiopulmonares en escolares mexicanos l josé arias-rico y otros tabla 1. características clínicas de la muestra según el sexo mujeres % (n) hombres % (n) total % (n) total 39,7 % (n=31) 60,3% (n=47) 100 % (78) antropometría imc normal 51,6 % (n=16) 44,7 % (n=21) 47,4 % (n=37) sobrepeso 29 % (n=9) 19,1 % (n=9) 23,1 % (n=18) obesidad 19,4 % (n=6) 36,2 % (n=17) 29,5 % (n=23) cc sin riesgo 77,4 % (n=24) 68,1 % (n=32) 71,8 % (n=56) con riesgo 22,6 % (n=7) 31,9 % (n=15) 28,2 % (n=22) gc magro 2,2 % (n=1) 1,3 % (n=1) normal 45,2 % (n=14) 46,8 % (n=22) 46,1 % (n=36) alta 12,9 % (n=4) 17 % (n=8) 15,4 % (n=12) exceso 41,9 % (n=13) 34 % (n=16) 37,2 % (n=29) parámetros cardiopulmonares fc baja 16,1 % (n=5) 12,8 % (n=6) 14,1 % (n=11) normal 58,1 % (n=18) 40,4 % (n=19) 47,4 % (n=37) alta 25,8 % (n=8) 46,8 % (n=22) 38,5 % (n=30) pa normal 87,1 % (n=27) 89,3 % (n=42) 88,5 % (n=69) normal alta 3,2 % (n=1) 4,3 % (n=2) 3,8 % (n=3) alta 9,7 % (n=3) 6,4 % (n=3) 7,7 % (n=6) fr baja 45,2 % (n=14) 34 % (n=16) 38,5 % (n=30) normal 51,6 % (n=16) 61,7 % (n=29) 57,7 % (n=45) alta 3,2 % (n=1) 4,3 % (n=2) 3,8 % (n=3) espirometría normal 90,3 % (n=28) 87,2 % (n=41) 88,5 % (n=69) anormal 9,7 % (n=3) 12,8 % (n=6) 11,5 % (n=9) imc: índice de masa corporal; cc: circunferencia de cintura; gc: grasa corporal; fc: frecuencia cardiaca; pa: presión arterial; fr: frecuencia respiratoria. fuente: elaboración propia. la tabla 3 muestra los riesgos entre variables, encontrándose una fuerza de asociación significativa entre el imc y la gc (or = 20,12; p = 0,0001). se halló para anormalidad en la fc un or = 1,76, para pa un or = 3,60 y en los resultados espirométricos un or = 3,44; sin embargo, estas últimas asociaciones entre variables no resultaron estadísticamente significativas. la relación entre el imc con la valoración de la cc (con riesgo/sin riesgo de morbilidad) no se calculó debido a la inexistencia de casos en alguna de las casillas en la tabla de contingencia antes del cálculo del or. en la tabla 4 se comprueban las relaciones entre variables, observándose una alta correlación entre el imc con la gc (rs = 0,728; p < 0,01) y el riesgo de desarrollar comorbilidades por cc (rs = 0,744; p < 0,01). también se encontró relación entre la gc y el riesgo de desarrollar comorbilidades por la cc, siendo esta una correlación media significativa (rs = 0,595; p < 0,01). 154 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 otras correlaciones con bajo valor (rs ≈ 0,250-280) y con menor significancia estadística (p < 0,05) fueron encontradas entre fc y fr, gc con pa y riesgo de comorbilidad por cc con fc. discusión la población estudiada de escolares muestra una prevalencia de sobrepeso y obesidad más alta respecto al promedio nacional (19,8 y 14,6 %, respectivamente) y estatal (18,4 y 12 %) para niños de 5 a 11 años, según los resultados nacionales y por entidad federativa de la ensanut 2012 (2, 3), así como de otras investigaciones en nuestro país (34, 35). además en estos valores, comparados con estudios en otros países, sobre todo brasil, costa rica, cuba y perú resultan prevalencias bastante altas (10, 12, 36, 37). la prevalencia de sobrepeso mayor en mujeres escolares y la obesidad en hombres escolares, encontrada en este estudio, fue similar a la presentada por barberán et al. (38) en niños ecuatorianos y en la ensanut 2012 (2). esta distribución de sobrepeso y obesidad en los escolares podría explicarse mejor si se conocieran a fondo sus estilos de vida, así como antecedentes familiares, de acuerdo con lo explicado por otros investigadores, donde existe mayor frecuencia de niños con obesidad cuando los padres también la presentan (8, 39). la obesidad abdominal evidenciada por la cc en la muestra fue predominante en los varones (31,9 %), similar a lo reportado en escolares de secundaria por ceballos et al. (35), siguiendo el patrón donde normalmente la distribución de grasa en los hombres con obesidad es en forma de “manzana” (40). sin embargo, hall et al. (34), en su investigación con niños de mexicali, baja california (méxico), encontraron que la obesidad abdominal es predominante en niñas. por otro lado, la gc fue mayor en las mujeres (54,8 %), similar a estudios realizados en brasil (10) y costa rica (12), pero contrario a los reportado en la misma investigación de mexicali, donde el porcentaje de gc en sus diferentes clasificaciones fue mayor en niños (34). esta mayor prevalencia en niñas puede deberse a que en ellas comienza la acumulación de grasa corporal para iniciar la adolescencia y el segundo brote de crecimiento como resultado de los cambios propios de la pubertad (40). en esta investigación no se encontraron relaciones significativas, aunque sí marginales, en la prueba chi-cuadrado, entre los datos espirométricos con el imc. en otros estudios sí se han encontrado cambios en la función ventilatoria relacionados con el aumento de peso (19, 41, 42) y la masa grasa. de igual forma, tabla 2. relación entre índice de masa corporal (imc) y parámetros antropométricos y cardiopulmonares con chi-cuadrado x2 p cc 27,65 0,000* gc 27,71 0,000* fc 1,23 0,266 pa 2,59 0,107 fr 0,02 0,874 espirometría 3,75 0,053 x2: chi-cuadrado; * p < 0,05. cc: circunferencia de cintura; gc: grasa corporal; fc: frecuencia cardiaca; pa: presión arterial; fr: frecuencia respiratoria. fuente: elaboración propia. tabla 3. relación entre índice de masa corporal (imc) y parámetros antropométricos y cardiopulmonares con odds ratio or 95 % ic p cca gc 20,12 6,31-64,11 0,0001 fc 1,76 0,66-4,68 0,253 pa 3,60 0,69-18,58 0,125 fr 0,43 0,03-5,17 0,512 espirometría 3,44 0,15-74,61 0,431 or: odds ratio; ic: intervalo de confianza; cc: circunferencia de cintura; gc: grasa corporal; fc: frecuencia cardiaca; pa: presión arterial; fr: frecuencia respiratoria a: no fue calculada. fuente: elaboración propia. tabla 4. correlación entre parámetros antropométricos y cardiopulmonares cc gc fc pa fr imc 0,744** 0,728** cc 0,281* gc 0,595** 0,258* fc 0,280* imc: índice de masa corporal; cc: circunferencia de cintura; gc: grasa corporal; fc: frecuencia cardiaca; pa: presión arterial; fr: frecuencia respiratoria. * p < 0,05; ** p < 0,01 fuente: elaboración propia. 155 obesidad infantil y su relación con indicadores cardiopulmonares en escolares mexicanos l josé arias-rico y otros no se encontró relación significativa entre las variables antropométricas y cardiopulmonares de este estudio para or. estos resultados son atribuidos a que el tamaño de muestra no alcanzó a demostrar significancia estadística. se encontró una correlación entre el imc, la obesidad abdominal y el exceso de gc en niños, de la misma forma a lo hallado por otros investigadores (40, 43, 44). tomando en cuenta que la obesidad que comienza a temprana edad puede persistir hasta la edad adulta, como se ha mencionado en diferentes investigaciones (35, 44-46), se sugiere abordar una intervención temprana de salud; además que en mujeres el mayor depósito de grasa puede contribuir como factor de riesgo cardiovascular si no se toman medidas preventivas. por un lado, en este estudio se distingue una asociación positiva y significativa entre la obesidad abdominal con la fc, donde al haber un incremento anormal de la cantidad de grasa abdominal hay un aumento en el riesgo cardiovascular, datos que coinciden con lo reportado por ortiz et al. (1), thompson et al. (44), freedman et al. (46), weiss et al. (47), reilly et al. (48), bravo (49) y mahfouz et al. (50). en otros trabajos se han establecido asociaciones significativas entre el imc con la pa en niños (10, 38, 45); sin embargo, en esta investigación no se encontró significancia estadística. el presente estudio demostró que a mayores valores de gc mayores valores en la pa. por lo anterior, es evidente que un peso elevado, aunado al incremento de la gc, constituye un factor de riesgo para la aparición de anormalidades cardiacas, como se ha evidenciado en diferentes estudios (6, 44, 51). merecen especial atención los escolares limítrofes e hipertensos para pas y pad, por tratarse de niños con mayores riesgos de desarrollar problemas cardiovasculares en un futuro (10, 52, 53), junto con una mayor acumulación de gc, como lo observado en esta investigación, y la aparición de esta condición a edades tempranas. además, raj (6) concluye, por trabajos previos, que la obesidad es un factor de riesgo cardiovascular pues se correlaciona con adiposidad, estrés oxidativo y cambios estructurales y fisiológicos del sistema cardiaco. en relación con lo mencionado, en este estudio se observó que el aumento de peso y la gc afectan directamente la fc, evidenciado por valores anormales de este parámetro. por otro lado, se encontró que hay una mayor relación entre la fr y la fc por la correlación encontrada en estos parámetros. cabe mencionar que no hay estudios disponibles que se puedan comparar con los resultados obtenidos en esta investigación para la fr. además, en esta edad los niños suelen presentar fc y fr baja, lo cual se ha referenciado como normal (26). de manera general, diferentes estudios en niños con obesidad no han podido establecer una relación significativa entre el déficit pulmonar y la evaluación antropométrica que indique obesidad (18, 23, 54), lo que nos hace pensar que probablemente el déficit pulmonar pudiera representar un problema en infantes con obesidad severa (23). finalmente, el presente estudio no logró comprobar significancias estadísticas en todas las correlaciones entre variables, dado que la muestra no fue lo suficientemente grande, por lo que los resultados no se pueden extrapolar a la población general. se sugiere realizar el estudio en una población más amplia, de tal manera que nos permita tener conocimientos claros de lo que sucede en la función cardiopulmonar en niños con exceso de peso, gc o abdominal. conclusión en esta investigación se encontró que la prevalencia de sobrepeso y obesidad es elevada, lo que pone de manifiesto la necesidad de realizar intervenciones multidisciplinarias de prevención y promoción de la salud orientadas a mejorar estilos de vida saludables, principalmente en alimentación y actividad física, coadyuvando a disminuir los índices de morbilidad infantil. se observaron correlaciones entre imc, obesidad abdominal y alto porcentaje de gc en niños; así como asociación entre grasa abdominal y corporal con anormalidades en parámetros cardiacos (fc y pa), aunque no se mostró correlación entre el sobrepeso o la obesidad con la fr y la espirometría en los niños escolares. los resultados de este estudio no se pueden generalizar a toda la población, por lo que es necesario continuar con otros trabajos en el tema a fin de que la muestra sea probabilística y representativa, y permita validar la relación que existe entre el sobrepeso o la obesidad y la respuesta de la función cardiopulmonar en niños. 156 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 referencias 1. ortiz rm, nava g, muñoz s, veras m. epidemiología de la obesidad. en: morales ja, editor. obesidad un enfoque multidisciplinario. hidalgo: universidad autónoma del estado de hidalgo; 2010. p. 75-99. 2. gutiérrez jp, rivera-dommarco j, shamah-levy t, villalpando-hernández s, franco a, cuevas-nasu l, et al. encuesta nacional de salud y nutrición 2012. resultados nacionales [internet]. cuernavaca, méxico: instituto nacional de salud pública (mx); 2012 [citado 2015 ene 20]. recuperado de: 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2007;357(23):2371-9. 53. juonala m, järvisalo mj, mäki-torkko n, kähönen m, viikari js a, raitakari ot. risk factors identified in childhood and decreased carotid artery elasticity in adulthood: the cardiovascular risk in young finns study. circulation. 2005;112(10):1486-93. 54. mahut b, beydon n, delclaux c. overweight is not a comorbidity factor during childhood asthma: the growthob study. eur respir j. 2012;39(5):1120-6. 430 446 actitudes hacia el cuidado al final.indd 430 aquichan issn 1657-5997 eissn 2027-5374 maritza espinoza-venegas1 luis luengo-machuca2 olivia sanhueza-alvarado3 actitudes en profesionales de enfermería chilenos hacia el cuidado al fi nal de la vida. análisis multivariado 1 orcid.org/0000-0002-2361-211x. universidad de concepción. chile. mespinoz@udec.cl. 2 orcid.org/0000-0002-9643-4334. universidad de concepción. chile. lluengom@udec.cl 3 0000-0002-0184-8957. universidad de concepción. chile. osanhue@udec.cl recibido: 24 de agosto de 2015 enviado a pares: 13 de febrero de 2016 aceptado por pares: 19 de junio de 2016 aprobado: 22 de junio de 2016 doi: 10.5294/aqui.2016.16.4.3 para citar este artículo / to reference this article / para citar este artigo espinoza venegas m, luengo machuca l, sanhueza alvarado o. actitudes en profesionales de enfermería chilenos hacia el cuidado al final de la vida. análisis multivariado. aquichan. 2016; 16 (4): 430-446. doi: 10.5294/aqui.2016.16.4.3 resumen objetivo: evaluar las actitudes hacia el cuidado al final de la vida de enfermeras/os de la región bío bío, de chile, y determinar las variables que ejercen mayor influencia sobre estas. materiales y método: estudio descriptivo-correlacional y predictivo en 308 enfermeras/os que trabajaban en cuidados paliativos en centros de salud públicos. se utilizaron las escalas de actitudes hacia el cuidado al final de la vida de frommelt, inteligencia emocional, actitudes hacia la muerte, trabajo emocional y variables bio-sociodemográficas de experiencia y formación profesional. resultados: la actitud hacia el cuidado al final de la vida mostró una tendencia favorable, presentando una asociación directa y estadísticamente significativa con: edad, experiencia laboral, mayor vínculo en tiempo y número pacientes terminales atendidos, y con la comprensión y regulación emocional. también se presentó una mayor actitud en el sexo femenino. la preferencia por trabajar en cuidados paliativos y ser formador en el área influyeron favorablemente en la actitud; al contrario, el miedo a la muerte y el trabajo emocional fingido influyeron negativamente la actitud. conclusiones: se requiere formación profesional que aporte al modelo empírico, oriente la educación de actitudes hacia la muerte y que ayude al afrontamiento emocional y actitudinal hacia el cuidado al final de la vida. palabras clave cuidados paliativos; cuidados paliativos al final de la vida; enfermería; actitud frente a la muerte; inteligencia emocional (fuente: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 430-446 431 actitudes en profesionales de enfermería chilenos hacia el cuidado al final de la vida. análisis multivariado l maritza espinoza-venegas y otros año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 430-446 attitudes held by chilean nursing professionals on care of the dying. a multivariate analysis abstract objective: evaluate attitudes towards end-of-life care among nurses from the bío bío region of chile and determine the variables that exert the most influence in that respect. materials and methods: this is a descriptive-correlational and predictive study of 308 nurses who work in palliative care at public health centers. the frommelt attitudes toward care of the dying scale was used, as were scales on emotional intelligence, attitudes toward death, emotional work and bio-demographic variables of experience and professional training. results: the trend in attitude toward end-of-life care was shown to be favorable, and a direct and statistically significant association was found with age, work experience, more attachment over time, the number of terminal patients served, and with understanding and emotional regulation. the attitude was more prevalent among the females in the study and was influenced favorably by the preference for working in palliative care and by being a trainer in the area. on the contrary, it was negatively influenced by fear of death and feigned emotional work. conclusions: there is a need for professional training that contributes to the empirical model, orients education on attitudes toward death, and helps with emotional coping and attitudes toward end-of-life care. keywords palliative care; palliative care at the end of life; nursing; attitude towards death; emotional intelligence (source: decs, bireme). 432 aquichan issn 1657-5997 eissn 2027-5374 atitudes em profissionais de enfermagem chilenos para o cuidado no final da vida. análise multivariada resumo objetivo: avaliar as atitudes para o cuidado no final da vida de enfermeiras/os, da região bío bío, do chile, e determinar as variáveis que exercem maior influência sobre estas. materiais e método: estudo descritivo correlacional e preditivo com 308 enfermeiras/os que trabalhavam em cuidados paliativos em centros de saúde públicos. utilizaram-se as escalas de atitudes para o cuidado no final da vida de frommelt, inteligência emocional, atitudes para a morte, trabalho emocional e variáveis biossociodemográficas de experiência e formação profissional. resultados: a atitude para o cuidado no final da vida mostrou uma tendência favorável, que apresentava uma associação direta e estatisticamente significativa com: idade, experiência de trabalho, maior vínculo em tempo e número de pacientes terminais atendidos, e com a compreensão e regulação emocional. também se apresentou uma maior atitude no sexo feminino. a preferência por trabalhar em cuidados paliativos e ser formador na área influenciou favoravelmente a atitude; ao contrário, o medo da morte e o trabalho emocional fingido influíram negativamente na atitude. conclusões: requer-se formação profissional que contribua com o modelo empírico, oriente a educação de atitudes para a morte e que ajude o enfretamento emocional e atitudinal para o cuidado no final da vida. palavras chave atitude com relação à morte; cuidados paliativos; cuidados paliativos no final da vida; enfermagem; inteligência emocional (fonte: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 430-446 433 actitudes en profesionales de enfermería chilenos hacia el cuidado al final de la vida. análisis multivariado l maritza espinoza-venegas y otros introducción proporcionar un cuidado humano al final de la vida, cuando los medios curativos no son posibles, es parte esencial de los profesionales de enfermería. es además una necesidad desde la perspectiva de los pacientes. se espera de los profesionales actitudes que propicien una asistencia digna, donde no solo importen el alivio del dolor y el apoyo a las funciones fisiológicas, sino que exista un involucramiento emocional que lleve a la calidad de los cuidados de enfermería (1). estudios confirman que estos factores generan una mayor calidad de la atención que repercute positivamente en la calidad de vida al final de la vida de los pacientes. se ha reconocido, además, que uno de los factores predictores más significativos para trabajar efectivamente no es la tecnología o la estructura organizativa sino los atributos o actitudes que tienen los profesionales (2). las actitudes tienen componentes cognoscitivos, afectivos y también comportamentales, es decir, se aprende qué pensar, qué sentir y qué hacer con respecto al “proceso y cuidado al final de la vida” (3, 4). desde la teoría de las actitudes (5), constituye: “una predisposición aprendida a responder consistentemente de un modo favorable o desfavorable”, que dependería de las características sociodemográficas, los rasgos de la personalidad, las “creencias personales o conductuales” que posea con respecto del cuidado al final de la vida, así como de las “creencias normativas”, es decir aquellas convicciones que tiene el profesional de enfermería sobre lo que piensan o esperan de él sus referentes sociales. las convicciones del cuidado al final de la vida pueden estar, en este caso, determinadas por las teorías, los modelos y los códigos de enfermería que señalan qué es lo que se espera de la o el enfermera/o en el cuidado de los pacientes en situación de terminalidad. así entonces, la teoría de cuidado humano (1) orienta que el profesional de enfermería debe promover el desarrollo de interrelaciones eficaces, auténticas, empáticas con el paciente, que permitan estar preparados para los sentimientos positivos y negativos, reconociendo que la comprensión intelectual y emocional del cuidado son diferentes. por otra parte la muerte, tanto propia como la de otros, así como el proceso al final de la vida, puede ser una de las experiencias más significativas y proveedoras de sentido de vida, no solo para el paciente y su familia, sino también para el profesional que lo acompaña. no obstante, estas constituyen un gran tabú en nuestros tiempos. anteriormente, la muerte era aceptada como parte natural del ciclo vital. en la sociedad actual, el morir es visto como una disfunción, o un problema todavía sin resolver que los avances de la ciencia y las nuevas tecnologías intentan corregir. las costumbres y los valores sociales contemporáneos fomentan el rechazo y la evitación, en donde hablar de muerte es complicado y dificultoso. hoy no solo se teme a la muerte sino que esta se niega y se olvida (3, 6). esta forma tan común de afrontamiento no permite expresar las necesidades propias del final de la vida, quedando enmascaradas en los pacientes, en sus familias, así como en los propios profesionales sanitarios, las instituciones de salud y organizaciones sociales en su conjunto (3, 6, 7). a su vez, los significativos cambios demográficos y epidemiológicos de la población chilena han dado paso a enfermedades crónicas no transmisibles, generando una necesidad creciente de cuidado paliativo y, por consiguiente, cuidado al final de la vida (8). sin embargo, llevarlo a cabo puede verse dificultado por la escasa preparación de pre y posgrado en cuidado paliativo, reconociéndose a su vez que la formación no refleja la adquisición de actitudes y competencias afectivas para el cuidado holístico necesario, sobre todo al final de la vida. la formación general de los profesionales, en especial de enfermería, deja de lado aspectos metodológicos que permiten desarrollar actitudes específicas para el cuidado, especialmente al final de la vida, o transformar actitudes propias de su contexto cultural en actitudes que les permitan enfrentar el proceso de cuidado al final de la vida (9). los profesionales de enfermería experimentan intensas emociones en su trabajo de cuidar, que es una parte fundamental e inseparable de la acción humana de la disciplina. este trabajo emocional implícito en el cuidar, especialmente al final de la vida, es el holismo de la experiencia humana. es considerado, además, una variable que interactúa o puede influir en la forma de implicarse o de cuidado que se verá reflejada en la actitud y, consecuentemente, en su conducta (10). los profesionales de enfermería reconocen la importancia del cuidado humano que visualiza al ser holísticamente, así como el poder terapéutico que tiene el trabajo emocional que deben desempeñar, sobre todo, al final de la vida. sin embargo, algunas investigaciones revelan que las enfermeras/os se sienten limitadas/os por sentimientos personales e impotencia profesional, que se manifiestan en actitudes evasivas y falta de implicancia emocional. las emociones y actitudes jugarían un rol determinante en el modo como se conducen y en la toma de decisiones de enfermería al final de la vida. las actitudes que se manifestan, por ende, pueden provocar consecuencias favorables o desfavorables en este cuidado (11, 12). 434 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 por lo anterior, la presente investigación tiene como objetivo evaluar la actitud hacia el cuidado al final de la vida por parte de los profesionales de enfermería que otorgan estos cuidados en los centros de salud de la región del bío-bío, determinando los factores sociodemográficos, emocionales, actitudinales, profesionales y de formación que ejercen mayor influencia sobre esta. material y métodos estudio observacional de corte transversal, de alcance descriptivo-correlacional y predictivo. se llevó a cabo guardando el respeto de los principios bioéticos de helsinki (13). la población estuvo conformada por enfermeras/os que trabajaban en cuidados al final de la vida y en el programa de cuidados paliativos en centros de salud familar y hospitales de la región del bío-bío, chile. de esta población se obtuvo una muestra no probabilística por conveniencia de 308 profesionales que representaron el 58 % del total de la población de estudio. el criterio de inclusión consideró: profesionales de enfermería de distintos niveles de atención en salud que se desempeñaban otorgando cuidados paliativos o cuidados al final de la vida, sin importar el tiempo de experiencia. hubo un 17 % de rechazo a responder el instrumento de investigación (motivos: falta de tiempo, no le interesó participar). no se tuvo acceso al resto de la población debido a la falta de autorización del centro de salud y hospital, o a que se encontraban con licencia médica, permisos y de vacaciones. procedimiento de recolección de los datos la recolección de datos se llevó a cabo previa autorización ética de los establecimientos de salud. a cada profesional de enfermería se le solicitó el consentimiento verbal y escrito. el instrumento fue autoaplicado y anónimo, para dar la posibilidad de responder a situaciones personales en privado, garantizando así mayor confidencialidad en sus respuestas. descripción del instrumento el instrumento estuvo conformado por la escala que mide las actitudes hacia el cuidado al final de la vida de frommelt (fatcod) (14); escala de inteligencia emocional, actitudes hacia la muerte, trabajo emocional y cuestionario que incluyó preguntas sobre características sociodemográficas, profesionales, emocionales y actitudinales. la escala fatcod —versión original en inglés— fue diseñada especialmente para medir las actitudes de enfermeras/os hacia el cuidado en pacientes al final de al vida. consta de 30 ítems, tipo likert, que califican el grado de acuerdo con una escala de 1 a 5 puntos (que van de 1 = muy en desacuerdo a 5 = totalmente de acuerdo). la escala está compuesta por un número igual de ítems, redactados en forma positiva y negativamente. los resultados pueden variar desde 30 a 150 puntos. los puntajes más altos reflejan una actitud más favorable hacia el cuidado al final de la vida. se informa un índice de confiabilidad alfa de cronbach de 0,80 y una validez de criterio significativa al compararla con otras escalas. esta misma escala ha sido utilizada en varios países como: egipto (15), japón (16), suecia (17) e italia (18), confirmando las propiedades psicométricas. también se ha traducido y utilizado al idioma español (19). la escala de inteligencia emocional trait meta mood scale (tmms-24), de salovery y mayer, adaptada al español (20), mide la inteligencia emocional a través de la evaluación de las tendencias de comportamiento y percepciones que las personas tienen acerca de su capacidad de percibir las emociones, la comprensión con la que reconocen dichas emociones, y su capacidad de reparar o regular sus estados emocionales tanto propios como de otras personas. consta de 24 ítems subdivididos en tres subescalas: percepción, comprensión y regulación emocional. en la subescala de percepción emocional, las puntuaciones en rangos medios indican una mejor percepción emocional y las puntuaciones en rangos altos y bajos indican que debe mejorar; en las subescalas de comprensión y regulación emocional las puntuaciones altas indican mejor comprensión y regulación emocional, respectivamente. los sujetos deben valorar cada una de las afirmaciones acerca de sí mismos en una escala likert de 1 a 5 que representa su grado de acuerdo con cada una de ellas. el puntaje se obtiene sumando las respuestas por cada subescala, que puede ir de 8 a 40 puntos. este instrumento ha sido validado en chile en estudiantes de enfermería (21), obteniéndose buena confiabilidad total (alfa de cronbach de 0,88) y también por cada una de las subescalas (percepción 0,89; comprensión 0,88; regulación 0,86) y una estructura factorial concordante con el constructo teórico. el perfil revisado de actitudes hacia la muerte (pam-r) es una escala multidimensional desarrollada por geser, reker y wong en 1994 (22), representada en 32 ítems que miden las actitudes hacia la muerte mediante una escala de siete puntos (1 = total435 actitudes en profesionales de enfermería chilenos hacia el cuidado al final de la vida. análisis multivariado l maritza espinoza-venegas y otros mente en desacuerdo a 7 = muy de acuerdo). está constituido por 5 dimensiones derivadas factorialmente: 1) miedo a la muerte (7 ítems, que miden pensamientos y sentimientos negativos sobre la muerte), 2) evitación de la muerte (5 ítems, que miden la dificultad para afrontar pensamientos sobre la muerte), 3) aceptación de acercamiento (10 ítems, que miden hasta qué punto una persona ve la muerte como un punto de partida a una vida feliz), 4) aceptación de escape (5 ítems, que miden el grado de las opiniones sobre la muerte como una oportunidad para escapar de una existencia dolorosa), y 5) aceptación neutral (5 ítems, que miden la visión de una persona de manera neutral, ni bienvenida, ni temor a la muerte). para cada dimensión se puede calcular una puntuación media de la escala al dividir la puntuación total por el número de ítems que la conforman. existe validación de la escala en población de estudiantes de enfermería españoles (23), con resultados altamente confiables (alfa de cronbach total de 0,85) y con casi idéntica estructura factorial. la escala revisada de trabajo emocional (erte) (24) es una escala en inglés, de 9 ítems y 3 dimensiones confirmada factorialmente. cada dimensión está conformada por 3 ítems, que califican de 1 (nunca) a 5 (siempre) en escala de likert. la suma de la puntuación de los ítems de cada dimensión refleja el grado de actuación profunda o superficial respectivamente. el puntaje máximo es de 15 y el mínimo de 5 puntos. la primera dimensión de “actuación superficial de fingir emociones no sentidas” posee 3 ítems; se refiere a la modificación o falsificación de las expresiones emocionales verdaderas. la segunda dimensión de “actuación superficial de ocultar emociones genuinas” se refiere a no mostrar las verdaderas emociones. la tercera dimensión de “actuación profunda” se refiere a la modificación y expresión auténtica de las emociones y posee 3 ítems. la confiabilidad alfa de cronbach obtenida en estados unidos en cada una de las dimensiones fue de 0,70 o superior. las escalas y los cuestionarios mencionados se sometieron a un proceso inicial de validación en aspectos idiomáticos, culturales, lingüísticos, de apariencia con 2 expertos del área de cuidados paliativos y pruebas de confiabilidad en una muestra piloto de 30 profesionales de enfermería de características sociodemográficas similares a la población de estudio. la confiabilidad alfa de cronbach obtenida en esta prueba piloto para cada escala fue: fatcod, 0,74; pam-r, 0,88; tmms-24, 0,90; erte, 0,84. procesamiento de los datos se comenzó con un análisis descriptivo univariado (tablas de frecuencia, medidas de resumen, gráficos y verificación de normalidad) de variables sociodemográficas y de escalas utilizadas (puntaje global y por ítems). luego se continuó con análisis bivariado, incluyendo comparación de medias (t de student y anova) y análisis de correlación de pearson. finalmente, se realizó análisis multivariado a través de regresión lineal múltiple (método de introducción y por pasos) con verificación de supuestos. los contrastes se consideraron significativos al 5 %. para el análisis se utilizó el software spss versión 17. resultados la muestra final estuvo constituida por 308 profesionales de enfermería con edad promedio de 32,1 años (ds 10,27), mayoritariamente mujeres (88,3 %). el análisis descriptivo de la variable principal: actitudes hacia el cuidado al final de la vida (escala fatcod), mostró una distribución cercana a la curva normal (kolmogorov-smirov). la puntuación promedio indica actitudes favorables hacia el cuidado al final de la vida de los profesionales de enfemería (4,14; ds 0,34). la puntuación total fue de 124,23 (ds10,2). la descripción de los puntajes promedio por ítems de la escala fatcod indican puntajes más altos o mayor favorabilidad en aspectos relacionados especialmente con la familia, por ejemplo: que “la familia debería involucrarse en los cuidados básicos del paciente que se está muriendo” (ítem 12), “las familias necesitan soporte emocional para aceptar los cambios de comportamiento de la persona que se está muriendo” (ítem 16), “el cuidado de enfermería debería extenderse a las familias” (ítem 21). también se obtuvo un puntaje altamente favorable al considerar que “dar cuidados de enfermería a una persona en su fase final de la vida es una experiencia de aprendizaje que vale la pena” (ítem 1). los puntajes promedio que se ubicaron bajo la media correspondieron a ítems que tienen relación con: “los familiares que se mantienen cerca de la persona que está muriéndose a menudo interfieren en la prestación de cuidados al paciente” (ítem 29), y con aspectos que tienen relación con la comunicación con la persona que está muriendo, como el “sentirse incómoda/o al hablar de la muerte inminente con el paciente” (ítem 3), “que muera cuando no esté presente” (ítem 13), “sentirse mal si la persona deja de luchar” (ítem 8), “retirarse de la vinculación afectiva” (ítem 17) y el “miedo a la adicción de los calmantes” (ítem 25) (figura 1). 436 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 figura 1. descripción de los puntajes promedio por ítems de la escala de actitudes hacia el cuidado al final de la vida en profesionales de enfermería (n = 308) rango potencial va de uno (muy desfavorable) a cinco (más favorable). *inv.: significa que los puntajes se calcularon invertidos. fuente: datos obtenidos en la investigación actitudes hacia el cuidado al final de la vida en profesionales de enfermería, 2013. asociación de fatcod con variables de estudio el análisis inferencial de relación de fatcod con las variables sociodemográficas mostró que la edad de los profesionales de enfermería es una variable que se relacionó directa y significativamente con fatcod (r pearson = 0,223; p < 0,001), lo que indica que a mayor edad, la actitud se hace más favorable. los profesionales de enfermería hombres presentaron puntajes promedio más bajos en fatcod, que la media general y significativamente más bajos que las profesionales mujeres (t = 2,7; gl = 360; p < 0,001). la percepción de influencia de creencia religiosa y/o espiritual no se relacionó con fatcod (f = 0,89; gl = 2; p = 0,40). los profesionales que habían vivido una experiencia de muerte significativa presentaron promedios significativamente más altos en fatcod con respecto de los profesionales que no habían vivido una experiencia de muerte significativa (t = 3,14; gl = 3; p = 0,002) (tabla 1). en cuanto a las características profesionales y de formación, los datos reflejaron que los profesionales que tenían estudios de posgrado o postítulo presentaron diferencias de medias significativamente superiores en la actitud hacia el cuidado al final de la vida (t = 2,55; gl: 305; p = 0,01). la experiencia profesional en cuidados paliativos también se relacionó directa y significativamente con fatcod (f = 5,2; gl = 3; p < 0,002). los profesionales de enfermería que ejercían un rol directivo presentaron promedios significativamente mayores en las actitudes hacia el cuidado al final de la vida (t = 3,69; gl = 303; p < 0,001). así también, el número de horas destinadas a cuidados paliativos (f = 3,56; gl = 3; p = 0,015), junto con el mayor número de pacientes atendidos se relacionó con puntajes más favorables de actitud hacia el cuidado (f = 3,70; gl = 2; p = 0,026). los profesionales de enfermería que habían participado como formadores en el área de cuidados paliativos presentaron actitudes más favorables hacia el cuidado al final de la vida (t = 4,78; gl = 302; p > 0,001) (tabla 2). la tabla 3 muestra que los profesionales de enfermería que se sentían más involucrados en la formación de sus colegas en cuidados al final de la vida presentaban mayores puntajes promedios en actitudes hacia el cuidado al final de la vida. estas diferencias de medias son estadísticamente significativas (f = 5,37; gl = 4; p < 0,000). a su vez, en la medida que aumenta su grado de preferencia a trabajar en cuidados paliativos, se observan promedios significativamente mayores en actitudes hacia el cuidado al final de la vida (f = 14,08; gl = 4; p = 0,000). así mismo, la percepción 437 actitudes en profesionales de enfermería chilenos hacia el cuidado al final de la vida. análisis multivariado l maritza espinoza-venegas y otros tabla 1. características sociodemográficas de las enfermeras/os participantes del estudio, región del bío-bío, 2013, chile (n = 308) y su asociación con las actitudes hacia el cuidado al final de la vida (fatcod) ** la correlación es significativa al nivel 0,01 (bilateral). fuente: datos obtenidos en la investigación actitudes hacia el cuidado al final de la vida en profesionales de enfermería, 2013. características n % fatcod media (s) sig. edad total 302 98,1 ** p < 0,0001 (r pearson)no especifica 6 1,9 sexo mujer 272 88,3 4,16 (0,35) 3,99 (0,24) p < 0,001 (t de student)hombre 36 11,7 percepción de influencia de la creencia religiosa o espiritual en la actitud hacia la muerte y el morir no influye 51 16,6 4,12 (0,38) 4,08 (0,33) 4,15 (0,33) p = 0,40 (anova) ejercen pequeña influencia 52 16,9 ejercen fuerte influencia 204 66,2 total 307 99,7 no responde 1 0,3 experiencia de muerte significativa no 75 24,4 4,03 (0,31) 4,17 (0,34) p = 0,002 (t de student)sí 233 75,6 de mayor grado de preparación emocional en cuidados paliativos se asocia con promedios significativamente mayores en actitudes hacia el cuidado al final de la vida (f = 10,65; gl = 4; p < 0,000). en la tabla 4 se muestra que los promedios de actitud hacia la muerte tendieron a ubicarse en categorías medias (actitudes de miedo a la muerte, evitación y escape) o elavadas (actitudes neutral y de acercamiento). la correlación de esta variable con la escala fatcod mostró una relación positiva y estadísticamente significativa con la actitud neutral hacia la muerte (p = 0,003; r = 0,166). así también, resultó una relación negativa y estadísticamente significativa con la actitud de miedo a la muerte (p = 0,000; r = -0,331), y con la actitud de evitación (p = 0,000; r = -355). la muestra de enfermeras/os informó niveles de percepción, comprensión y regulación emocional en categorías adecuadas y excelente respectivamente. el trabajo emocional profundo presentó promedios medios, mientras que el trabajo emocional oculto y fingido presentó promedios menos intensos. la asociación de la escala fatcod y las dimensiones de la variable inteligencia emocional mostraron una relación positiva y significativa de las dimensiones: comprensión (p < 0,000; r = 0,232) y regulación emocional (p < 0,000; r = 0,221) . a mejor compresión y regulación emocional, las actitudes hacia el cuidado al final de la vida son más favorables. la asociación de la escala fatcod con las dimensiones del trabajo emocional mostró que las actitudes hacia el cuidado al final de la vida se relacionaron negativa y significativamente con las dimensiones de trabajo emocional profundo (p = 0,004; r = -0,162 ), fingido (p < 0,000; r = -0,347) y oculto (p < 0,000; r = -0,332). análisis de regresión múltiple tomando en cuenta las variables que resultaron relacionadas significativamente (variables independientes) con fatcod (variable dependiente) y para establecer la influencia sobre las actitudes hacia el cuidado al final de la vida, se realizó el análisis de regresión lineal con el método usado de stepwise o “pasos sucesivos”, que previamente comprobó los supuestos del modelo. los resultados seleccionaron cuatro variables, las que explicaron un 38 % de la varianza de la variable dependiente: actitudes hacia el cuidado al final de la vida, con r2 corregida = 0,38 (tabla 6). 438 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 tabla 2. características profesionales y su asociación con las actitudes hacia el cuidado al final de la vida de las enfermeras/os participantes del estudio, región del bío-bío, 2013, chile (n = 308) fuente: datos obtenidos en la investigación actitudes hacia el cuidado al final de la vida en profesionales de enfermería, 2013. características n % fatcod promedio (ds) relación fatcod significancia estudios de posgrado sin estudios de posgrado 144 47,1 4,08 (0,33) ***p < 0,01 (t de student) con estudios de posgrado/postítulo 162 52,5 4,18 (0,34) total 306 99 no especifica 2 0,6 experiencia en cuidados paliativos escasa (menos de 1 año) 121 39,3 4,05 (0,32) p < 0,002 (anova) baja ( menor a 3 años) 86 27,9 4,17 (0,33) media (4 a 10 años) 66 21,4 4,18 (0,33) alta (mayor a 10 años) 35 11,4 4,27 (0,35) rol directivo en cuidados paliativos sí 68 22,1 4,27 (0,32) p < 0,0001 (t de student) no 237 76,9 4,1 (0,33) total 305 99 no especifica 3 1 horas destinadas a cuidados paliativos no tiene 128 41,6 4,07 (0,32) p = 0,015 (anova) baja 94 30,5 4,12 (0,35) media 43 14 4,19 (0,35) alta 18 5,8 4,32 (0,32) total 283 91,9 no responde 25 8,1 número de pacientes atendidos al mes baja ( 0 a 1 pacientes al mes) 210 68,2 4,10 (0,33) p = 0,026 (anova) media ( 2 a 5 pacientes al mes) 59 19,2 4,20 (0,31) alta ( más de 6 pacientes al mes) 28 9,1 4,25 (0,37) total 297 96,4 no especifica 11 3,6 ha participado como formador del área de cuidados paliativos no 255 82,8 4,09 (0,33) p < 0,000 (t de student) sí 49 15,9 4,34 (0,30) total 304 98,7 no responde 4 1,3 439 actitudes en profesionales de enfermería chilenos hacia el cuidado al final de la vida. análisis multivariado l maritza espinoza-venegas y otros tabla 3. características actitudinales y su asociación con las actitudes hacia el cuidado al final de la vida de las enfermeras/os participantes del estudio, región del bío-bío, 2013, chile (n = 308) tabla 4. actitudes hacia la muerte y su asociación con las actitudes hacia el cuidado al final de la vida de las enfermeras/os participantes del estudio, región del bío-bío, 2013, chile (n = 308) características n % fatcod promedio (ds) relación fatcod significancia grado de involucramiento en la formación de colegas no 145 47,1 4,08 (0,34) p < 0,000 (anova) algo 82 26,6 4,10 (0,35) bastante 38 12,3 4,23 (0,29) más que bastante 11 3,6 4,38 (0,26) totalmente 11 3,6 4,43 (0,29) total 287 100 grado de preferencia a seguir trabajando en cuidados paliativos ninguna 15 4,9 3,78 (0,31) p < 0,000 (anova) regular 66 21,4 3,99 (0,27) indiferente 22 7,1 4,08 (0,35) alta 131 42,5 4,18 (0,33) muy alta 51 16,6 4,34 (0,28) no especifica 23 7,5 grado de preparación emocional que percibe para trabajar en cuidados paliativos mala 23 7,5 3,93 (0,42) p < 0,000 (anova) regular 56 18,2 4,00 (0,32) satisfactoria 77 25 4,08 (0,27) buena 109 35,4 4,23 (0,31) muy buena 33 10,7 4,33 (0,35) no especifica 10 3,2 100 fuente: datos obtenidos en la investigación actitudes hacia el cuidado al final de la vida en profesionales de enfermería, 2013. *rango potencial es de uno (más desfavorable hacia la muerte) a siete (más favorable hacia la muerte). ** rango potencial es de uno (más favorable hacia la muerte) a siete (más desfavorable hacia la muerte). 1, 2, 3 correlación es significativa al nivel 0,05 (bilateral). fuente: datos obtenidos en la investigación actitudes hacia el cuidado al final de la vida en profesionales de enfermería, 2013. actitudes hacia la muerte media (ds) relación fatcod significancia ( r de pearson) actitud de acercamiento* 5,11 (1,40) r = 0,062; p 0,276 actitud de escape** 3,62 (1,48) r = -0,104; p 0,068 actitud neutral* 5,86 (0,81) r = 0,166; p < 0,003 1 actitud de miedo a la muerte** 2,95 (1,22) r = -0,331; p < 0,000 2 actitud de evitación** 2,94 (1,43) r = -0,355; p < 0,000 3 440 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 tabla 5. variables emocionales y su asociación con las actitudes hacia el cuidado al final de la vida de las enfermeras/os participantes del estudio, región del bío-bío, 2013, chile (n = 308) tabla 6. regresión múltiple de las variables que influyen en las actitudes hacia el cuidado al final de la vida *rangos potenciales van de 8 a 40 puntos. **rangos potenciales van de 1 (actitud menos intensa) a 5 (actitud más intensa). *** la correlación es significativa al nivel 0,01 (bilateral). fuente: datos obtenidos en la investigación actitudes hacia el cuidado al final de la vida en profesionales de enfermería, 2013. variables emocionales puntaje relación fatcod significancia r pearson inteligencia emocional* percepción 25,68 (6,34) r = 0,019; p = 0 ,743 comprensión 29,92 (6,28) r = 0,232(***) p < 0,000 regulación 31,11 (5,92) r = 0,221(***) p < 0,000 trabajo emocional** profundo 2,64 (0,85) r = -0,162(***) p = 0,004 oculto 2,07 (0,63) r = -0,332(***) p < 0,000 fingido 1,81 (0,69) r = -0,347(***) p < 0,000 fuente: datos obtenidos en la investigación actitud hacia el cuidado al final de la vida en profesionales de enfermería, 2013. variable coeficientes no estandarizados coeficientes estandarizados b error típ. beta t sig. actitud de miedo a la muerte -,094 ,020 -,325 -4,781 ,000 preferencia a trabajar en cuidados paliativos ,107 ,023 ,315 4,628 ,000 formador del área de cuidados paliativos ,206 ,053 ,264 3,895 ,000 trabajo emocional fingido -,039 ,013 -,208 -3,058 ,003 la tabla 6 muestra los coeficientes de regresión estandarizados que permitieron valorar la importancia relativa de cada variable independiente dentro de la ecuación. la variable actitudes de miedo a la muerte es la que asumió el valor más alto, indicando que el miedo a la muerte y el trabajo emocional fingido ejercieron en esta muestra de estudio una influencia negativa sobre las actitudes hacia el cuidado al final de la vida de los profesionales de enfermería. lo contrario sucedió con la preferencia a trabajar en cuidados paliativos y el ser formador del área de cuidados paliativos, que influenciaron positivamente la actitud hacia el cuidado al final de la vida (sig. = 0,000). discusión el cuidado al final de la vida es especialmente difícil y exigente, ya que implica enfrentarse con la enfermedad en su etapa terminal que inevitablemente conducirá a la muerte. los profesionales de enfermería cumplen un rol esencial en todo su proceso, otorgando cuidado tanto al paciente como a su familia, para lo cual no solo se requieren conocimientos, sino también actitudes y habilidades emocionales especiales que propendan por una mejora en la calidad de estos cuidados (4, 6, 7). las/os profesionales de enfermería de la muestra de estudio presentaron, en promedio, un nivel favorable de actitudes hacia 441 actitudes en profesionales de enfermería chilenos hacia el cuidado al final de la vida. análisis multivariado l maritza espinoza-venegas y otros el cuidado al final de la vida. sin embargo, esta medida se debe considerar con cautela, porque corresponde a una predisposición subjetiva que se hace de la intensidad con que se perciben determinadas creencias, normas subjetivas y actitudes, que en conjunto conforman la actitud global en estudio (5). en comparación con estudios similares realizados en contextos internacionales que utilizaron el mismo instrumento, los profesionales de este estudio reportaron niveles más altos que profesionales de enfermería de egipto (15), japón (16), y españa (19), y niveles promedio más bajos que israel (25) y estados unidos (26). estas diferencias son explicadas en algunas investigaciones, por influencias culturales existentes en los diferentes países (17), que tendrían que ver con lo que significa la muerte y su proceso de aceptación, que a su vez estaría estrechamente relacionado con la cosmovisión religiosa ligada a la cultura y que influenciaría las creencias sobre cuidado al final de la vida. esto mismo es apoyado por una investigación sueca (17) que al evaluar las actitudes a través de la misma escala, determinó algunas diferencias con países como japón (16) y estados unidos (26), y que se explicarían también por las diferencias culturales implícitas en el cuidado de enfermería. se confirma a su vez en estos mismos estudios la presencia de actitudes personales y profesionales sensibles, necesarias para la práctica de la profesión de enfermería en el área del cuidado al final de la vida. a pesar de que los resultados reflejan en su mayoría actitudes favorables, estos mismos estudios, junto a otras evidencias similares (25, 27), dejan de manifiesto una necesidad de abordar este tema, sobre todo en los aspectos que se señalan más significativos y que favorecen o dificultan dicha actitud. un análisis detallado de los ítems de la escala fatcod muestra actitudes favorables, en varios ítems, como “el dar cuidados al final de la vida es una experiencia que vale la pena”, o que los profesionales “se sienten que pueden ayudar a los pacientes a prepararse para la muerte”, o que “el cuidado debe extenderse a la familia”, y consideran que “la familia debería involucrarse en los cuidados”. estas y otras manifestaciones sobre actitudes hacia el cuidado, que resultaron muy favorables, son coherentes con los supuestos teóricos de la ciencia, específicamente los postulados de la teoría del cuidado humano (1), cuando señala que esta se centra en las relaciones de cuidado transpersonales, que permiten alcanzar conexiones más profundas para la preservación de la dignidad humana. esto es lo que se espera de un profesional de enfermería, que desde la teoría de las actitudes es explicado como una creencia normativa (5), es decir, una convicción de los/ as enfermeros/as sobre lo que se espera de ellos como profesionales. sin embargo, las actitudes manifestadas en otros ítems no son favorables en algunos profesionales, al responder que les genera incomodidad hablar de muerte, que podrían rehuirlo o que no les corresponde, porque además sienten ganas de alejarse y no querrían que la persona fallezca cuando ellos estén presentes. estas actitudes reflejan ciertas creencias conductuales (5), de tal modo que sus creencias personales pueden estar en disonancia con otras creencias manifestadas en esta misma investigación. lo anterior se confirma además con los resultados encontrados en otros estudios (26, 17), que aunque realizados en otras culturas, reflejaron esta misma tendencia a manifestar su favorabilidad a prestar apoyo a pacientes y familias, pero también manifestaron que era poco probable hablar de muerte y no aceptar la participación del paciente y la familia en la toma de decisiones. las actitudes desfavorables manifestadas en esta investigación estuvieron relacionadas con la incomodidad de enfrentar la muerte al no poder hablar sobre ella, o sentirse mal, porque el paciente deja de luchar por la vida. estas son evidencias que emergen en numerosas investigaciones tanto cuantitativas como cualitativas (6, 7, 28), en ámbitos internacionales y nacionales, y que aparentemente no logran ser superados desde la formación de pregrado (3, 4, 17, 29). según estas mismas investigaciones, se menciona que se puede llegar a generar una “cortina de protección” o evasión al proporcionar los cuidados a un paciente que se encuentra en fase terminal. estos hallazgos se contradicen con el marco de actuación recomendado en los cuidados paliativos, ya que esta “barrera” impediría valorar adecuadamente las necesidades en el proceso de morir, y reconocer los verdaderos y frecuentes miedos que presentan los pacientes terminales, dificultando así un principio fundamental de los cuidados paliativos, como es el alivio del sufrimiento (30). de lo anterior se desprende la necesidad de desarrollar habilidades comunicacionales en temas que se reconocen de difícil abordaje como es la muerte, y que directamente contribuirían además a mejorar la calidad de vida al final de la vida de los pacientes y sus familias. la gran mayoría manifestó que la familia debería recibir apoyo e involucrarse en los cuidados; sin embargo, algunos de estos mismos profesionales respondieron que “educar a las familias no es una responsabilidad del profesional de enfermería”, y que esta “puede llegar a significar una interferencia frente al proceso de 442 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 cuidado al paciente”. este hallazgo deja ver una incongruencia entre lo que se señala como importante en el cuidado a la familia y lo que se manifiesta en el plano personal. esto no es aislado, ya que se reconoce también en algunas evidencias (30) que están relacionadas con el cuidado al final de la vida, y que son explicadas por algunos autores, como respuestas sobre creencias a temas de carácter general que serían diferentes a las creencias de índole personal. con esta predisposición se estaría desconociendo que la familia puede llegar a ser la principal fuente de apoyo para el paciente, así también, se podría estar descuidando la posibilidad de apoyarla durante el duelo. por otro lado, se observó en alguna medida una actitud desfavorable en el tratamiento para el dolor, al creer que su utilización debería limitarse frente a la posibilidad de provocar adicción en el paciente. este hallazgo indica la persistencia de mitos que han existido en el ámbito de los profesionales de la salud (31), que dificultan el buen manejo de dolor, y que se relacionan con una mejor calidad de vida al final de la vida. en cuanto a las actitudes hacia el cuidado al final de la vida y su asociación con variables sociodemográficas, esta investigación constató que las mujeres presentaron actitudes más favorables que los hombres, aunque no representaron una variable de influencia significativa sobre esta. de las investigaciones que han establecido estas diferencias, igualmente se constatan actitudes favorables mayoritariamente en mujeres (18, 32), en especial en actitudes relacionadas como la actitud de aceptación y miedo a la muerte (33), que corresponden a actitudes evaluadas principalmente en estudiantes de enfermería. no obstante, esta variable no constituyó un factor predictivo en ninguna de las investigaciones revisadas. igualmente, de acuerdo con los resultados de otro estudio (34), el sexo no parece ser un factor significativo en las actitudes hacia el cuidado al final de la vida. la edad de los profesionales resultó ser una variable relacionada con las actitudes hacia el cuidado al final de la vida, evidenciando que mientras mayor es esta, más favorables son las actitudes al respecto; sin embargo, no resultó ser un factor predictivo. la relación bivariada es coincidente, solo con algunos estudios (25, 35) realizados a partir de esta misma escala. en otros no se encontró ninguna asociación significativa (26, 27). no obstante, evidencias muestran que la menor edad en los profesionales jóvenes es más propicia para el cambio de actitud después de una intervención educativa (34). las actitudes hacia el cuidado al final de la vida se correlacionaron positiva y significativamente con variables profesionales relacionadas con la mayor preparación, experiencia en tiempo y cantidad con los pacientes de cuidados paliativos. esto es coincidente con todos los estudios revisados que analizaron del mismo modo estas variables (26, 27, 32, 35, 34). así, los resultados de esta y otras investigaciones (28) estarían confirmando que la experiencia profesional, especialmente con pacientes que vivencian un proceso de morir, ayudaría a desarrollar estrategias para hacer frente a su respuesta emocional de la muerte y el morir, permitiendo así la adquisición de actitudes o creencias favorables hacia el cuidado al final de la vida. con todo, la experiencia en cuidados paliativos, junto a las otras variables relacionadas, no resultaron ser factores predictores de actitudes más favorable hacia el cuidado al final de la vida. los profesionales con alguna formación en posgrado o postítulo presentaron actitudes más favorables respecto de los profesionales sin formación. diferentes estudios (15, 26) han confirmado que la preparación formal, especialmente en cuidados paliativos o cuidados al final de la vida, permite mejorar las actitudes hacia la muerte y el morir y, consecutivamente, hacia el cuidado al final de la vida. una revisión de literatura sobre la formación en cuidado al final de la vida reveló el escaso contenido sobre este tema, tanto en textos como en programas de enfermería (36). no obstante, el conocimiento por sí solo no contribuye de manera significativa a la formación de actitudes favorables (32). se reconoce que la formación es compleja y no solo se requiere un especial conocimiento, sino también la adquisición de actitudes y capacidades de cuidado para trabajar en situaciones emocionalmente difíciles (36). estudios recomiendan un tiempo mínimo necesario y continuidad en la educación, en intervalos regulares para desarrollar y mantener los efectos positivos sobre la actitud hacia el cuidado al final de la vida (26, 4). aún así, no todos los programas educativos generan la percepción de autoeficacia en los profesionales en el cuidado paliativo o logran la generación de actitudes favorables en esta área (4, 34, 37). la teoría del cuidado humano (1) enuncia que las capacidades necesarias serían el cultivo de la sensibilidad hacia los demás, el desarrollo de relaciones de “ayuda-confianza”, y la expresión de sentimientos positivos y negativos. estos elementos deben comenzar por la identificación de los propios sentimientos que conducirían a la autoaceptación, como los del paciente. los estudios que confirman estos planteamientos (1, 26, 36), y que demuestran un cambio favorable de actitudes hacia el cuidado al final de la vida, son aquellos que contemplan intervenciones acti443 actitudes en profesionales de enfermería chilenos hacia el cuidado al final de la vida. análisis multivariado l maritza espinoza-venegas y otros vas en el área afectiva. estas intervenciones consisten en hacer conciencia de sí mismo, de las creencias sobre su propia muerte y el morir, ya que la confrontación de las diferencias y similitudes entre su sistema de creencias con las de sus pacientes les permitirían cuidar a las personas de una manera más empática (4) y por ende humana. las actitudes hacia la muerte, en concreto el miedo, la evitación y la aceptación de escape, se asociaron de manera negativa con las actitudes hacia el cuidado al final de la vida. esto significa que los profesionales de enfermería que tenían mayor miedo, evitación y escape a la muerte presentaban una actitud menos favorable hacia el cuidado de enfermos terminales, siendo el miedo a la muerte la variable que mayormente predijo o influyó significativamente en las actitudes hacia el cuidado al final de la vida. los resultados son coincidentes con otros estudios (2, 3) que indagaron esta asociación, lo que confirmaría una vez más que la evitación y el escape serían mecanismos de afrontamiento a la muerte que pueden ser actitudes para hacer frente al propio miedo a la muerte, y dificultaría en algunas enfermeras/os proporcionar un cuidado más cercano. el miedo a la muerte resultó ser la variable que mayormente se evidencia como un predictor negativo en las actitudes hacia el cuidado en los profesionales, tanto en esta investigación como en otras (6, 15, 25, 28), confirmando así uno de los planteamientos iniciales de este estudio. estos resultados son explicados desde la teoría de la acción razonada (5), que señala que las actitudes hacia el cuidado y, consecuentemente, la conducta, son influidas por sentimientos de miedo y evitación que se tienen hacia la propia muerte, que correspondería a creencias conductuales resultado de las propias convicciones culturales, religiosas, sociales y filosóficas, que entorpecerían de manera consciente o inconsciente una mejor actitud hacia el cuidado en el profesional de enfermería. la misma explicación a la luz de esta teoría tendría la actitud de neutralidad hacia la muerte, que resultó ser una creencia favorable porque se asoció significativamente con mejores actitudes hacia el cuidado. esto también es concordante con algunos estudios (15, 16, 26). estos resultados, junto con otras evidencias (25, 27, 38), orientan a que el factor más significativo que predice un cambio favorable en las actitudes hacia el cuidado al final de la vida es la formación temprana en actitudes hacia la muerte y el morir. otra de las variables, que resultó tener una relación significativa con la actitud hacia el cuidado al final de la vida, fueron las dimensiones de la inteligencia emocional de regulación y comprensión. no se encontraron estudios que hayan establecido la relación entre estas dos variables. sin embargo, se observa indirectamente la importancia de esta asociación, al evidenciar en otras investigaciones (38) la relación entre el miedo a la muerte con estos elementos de la inteligencia emocional de regulación y comprensión. esta relación indica que, a mayor comprensión de las emociones y mayor capacidad de regulación, menor es el miedo a la muerte y al proceso de morir. es decir, aquellos profesionales, que comprenden adecuadamente sus emociones y tienen habilidades para controlarlas, presentan mejor ajuste psicológico, que se traduciría en una reducción de los promedios del miedo a la muerte. en términos conceptuales, estos resultados tienen estrecha relación con otra variable que tiene que ver con el trabajo emocional. los resultados aportan evidencias y orientan hacia la relación predictiva que existe entre la inteligencia emocional y la forma de acercamiento que se adopta. los mayores niveles de inteligencia emocional conducen a un trabajo emocional más auténtico y profundo (38) y, por tanto, más favorable en la relación de cuidado, porque es considerado “más humano”. en esta investigación se encontró un resultado homólogo, pero a la inversa, es decir, el trabajo emocional fingido resultó ser una variable influyente o predictiva de forma negativa en las actitudes hacia el cuidado al final de la vida. el trabajo emocional fingido es una falta de autenticidad que muestra expresiones discrepantes con los propios sentimientos. esto significa que los profesionales que no están a gusto con su trabajo, o a quienes las interacciones con sus pacientes les generan emociones negativas (como miedo o evasión), y que se sienten obligadas/os a mostrar emociones no sentidas (que van de acuerdo al modelo de cuidados de enfermería), generan indirectamente, consciente o inconscientemente, actitudes menos favorables hacia el cuidado al final de la vida. esta manifestación emocional es desventajosa para los profesionales y los pacientes porque puede llegar a provocar, según algunas investigaciones, agotamiento emocional y despersonalización del cuidado respectivamente (10, 39). la implicación emocional o falta de ella es el ingrediente humano de la relación de cuidado terapéutico, que se sostiene también desde la teoría del cuidado humano (1), y que deja en evidencia con estos resultados su importancia, porque “afectaría” o influiría en las actitudes hacia el cuidado a final de la vida. lo anterior se reafirma con otro hallazgo de esta misma investigación, que también evidenció una influencia sobre las actitudes 444 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 hacia el cuidado, que fue la preferencia manifestada a trabajar en cuidados paliativos. los profesionales que manifestaron mayor preferencia por esta área de cuidado presentaron una actitud más favorable hacia el cuidado al final de la vida. esta disposición, explicada a la luz de la teoría de acción razonada de fishbein y ajzen (5), constituye una “intención de conducta” que tiene especial significación, porque este es el último eslabón determinante de la conducta que puede llegar a predecir más fuertemente esta. las variables conductuales que reflejaban un compromiso mayor con el trabajo en esta área, como ejercer un rol directivo, el mayor involucramiento en la formación de colegas en cuidados paliativos y el participar como formador de cuidados en esta área, resultaron estar relacionadas con actitudes más favorables hacia el cuidado al final de la vida. de todas estas variables relacionadas, el participar como formador de cuidados paliativos resultó la variable conductual que predice o influye sobre las actitudes favorables hacia el cuidado al final de la vida. el análisis de estos resultados desde la teoría de acción razonada permite obtener una nueva evidencia para la teoría, al determinar que la conducta también puede ser determinante de actitudes. la explicación de cómo la conducta puede ser determinante de las actitudes se fundamenta en que siempre tratamos de ser consistentes entre lo que hacemos y lo que pensamos. el asumir nuevos “roles” requiere la ejecución de nuevas conductas que progresivamente van estructurando nuevas actitudes (5). limitaciones del estudio dentro de las limitaciones del estudio se consideran las dificultades para la aplicación del instrumento en las instituciones de salud, que imposibilitó en ocasiones la accesibilidad a todos los profesionales. otro aspecto por considerar es que el instrumento recolector de datos midió solo las actitudes o creencias contenidas en este, por lo que pudiera haber dejado fuera otras posibles actitudes hacia el cuidado, o variables que afecten a estas. se recomiendan nuevas investigaciones que puedan explorar otras posibles variables. implicancias del estudio los hallazgos de este estudio orientan un modelo empírico de predictores de la actitud hacia el cuidado al final de la vida, que sugiere intervenciones en la formación profesional temprana, proponiendo elementos actitudinales y emocionales que podrían estar enfocados a explorar y entender sus actitudes hacia la muerte, superar sus temores y ansiedades acerca de esta, aumentar su capacidad de comunicación, especialmente con los pacientes en su etapa final y sus familias, junto con mejorar sus estrategias de afrontamiento emocional con respecto a la muerte. evidencia además elementos necesarios para el cuidado humanizado, que involucra la adquisición de comportamientos críticos, como la habilidad emocional que implica comprender y regular las emociones, tanto propias como las de su paciente y familia, y que conlleven un involucramiento emocional auténtico y profundo. conclusiones los resultados de este estudio permitieron explorar las distintas actitudes hacia el cuidado al final de la vida en profesionales de enfermería, en una muestra que alcanzó el 58 % de la población de profesionales de enfermería, tanto en ámbitos hospitalarios como ambulatorios del sector público. en general, se encontraron actitudes favorables hacia el cuidado al final de la vida, que estarían relacionadas con algunas características personales y profesionales, siendo influenciadas principalmente por las actitudes que poseen hacia la muerte y el 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2012. 31. burfon j, piquer c, rubia a, ferrer e, real a. mitos de la morfina entre el personal de enfermería urológica. rev asoc esp ats urol. 2007;(103):19-24. 32. khader ka, jarrah ss, alasad j. influence of nurses’ characteristics and education on their attitudes towards death and dying: a review of literature. int j nurs midwifery. 2010;2(1):1-9. 33. bassah n, seymour j, cox k. a modified systematic review of research evidence about education for pre-registration nurses in palliative care. bmc palliative care. 2014;13:56. 34. barrere c, durkin, a, la coursiere, s. the influence of end-of life education on attitudes of nursing students. j nurs education scholarship. 2008;5(1):1-18. 35. lange m, thom b, kline ne. assessing nurses’ attitudes toward death and caring for dying patients in a comprehensive cancer center. oncol nurs forum. 2008;35(6):955-99. 36. gillan p, van der riet p, jeong s. end of life care education, past and present: a review of the literature. nurse educ today. 2014;34(3):331-42. 37. jafari m, rafiei h, nassehi a, soleimani f, arab m, noormohammadi mr. caring for dying patients: attitude of nursing students and effects of education. indian j palliat care. 2015;21(2):192-7. 38. aradilla-herrero a, tomás-sábado j, gómezbenito j. perceived emotional intelligence in nursing: psychometric properties of the trait meta-mood scale. j clin nurs. 2013;23:7-8. 39. pinero m. estrés y factores relacionados en el personal sanitario de hospitalización psiquiátrica: un estudio de prevalencia. enferm glob. 2013;12(31):125-10. 271 282 el cuidado en un programa de trasplante.indd 271 ana julia carrillo-algarra1 lorena mesa-melgarejo2 fanny moreno-rubio3 el cuidado en un programa de trasplante renal: un acompañamiento de vida 1 fundación universitaria de ciencias de la salud. investigadora grupo perspectivas del cuidado. bogotá (colombia). ajcarrillo@fucsalud.edu.co. 2 fundación universitaria de ciencias de la salud. bogotá (colombia). lpmesa1@fucsalud.edu.co 3 fundación universitaria de ciencias de la salud. bogotá (colombia). recibido: 06 de noviembre de 2013 enviado a pares: 14 de febrero de 2014 aceptado por pares: 3 de diciembre de 2014 aprobado: 28 de enero de 2015 doi: 10.5294/aqui.2015.15.2.10 para citar este artículo / to reference this article / para citar este artigo carrillo-algarra aj, mesa-melgarejo l, moreno-rubio f. el cuidado en un programa de trasplante renal: un acompañamiento de vida. aquichan. 2015; 15 (2): 271-282. doi: 10.5294/aqui.2015.15.2.10 resumen objetivo: comprender las experiencias de cuidado de enfermeras integrantes de grupos de trasplante de la ciudad de bogotá. materiales y métodos: investigación cualitativa, utilizó la estrategia de grupos focales; la organización y el análisis de datos siguieron la propuesta de codificación de janice m. morse; participaron, previo consentimiento informado, 10 de 20 enfermeras de unidades de trasplante. se realizó triangulación entre las integrantes del equipo investigador y la literatura relevante. resultados: emergieron 6 categorías: 1) los múltiples significados del trasplante: cambio, pasión, satisfacción, esperanza, libertad, mayor cercanía, responsabilidad, compromiso, complejidad; 2) las redes de apoyo: familia, asociación de enfermeras, grupo de trabajo interdisciplinario, empresas promotoras de salud, industria farmacéutica; 3) implicaciones del día a día: relación cercana con el paciente y la familia, fortalecimiento de la autoestima profesional, estatus dentro del grupo de trasplante, manejo de las cargas; 4) trayectorias del cuidado profesional: acompañamiento de la enfermera a través del ciclo vital del paciente y posibilidad de identificar necesidades por la estrecha relación con él; 5) el perfil de la enfermera: carácter, conocimiento, compromiso, disponibilidad permanente y capacidad de gestión; 6) contradicciones del trasplante: rechazo al injerto, sufrimiento, desesperanza, sistema de salud; para enfermería, las agotadoras jornadas de trabajo. palabras clave trasplante de riñón, acontecimientos que cambian la vida, investigación cualitativa, atención de enfermería, narración (fuente: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 271-282 272 aquichan issn 1657-5997 año 15 vol. 15 nº 2 chía, colombia junio 2015 l 271-282 care in a kidney transplant program: accompaniment and support abstract objective: understand the care experiences of nurses who are part of kidney transplant groups in the city of bogota (colombia). materials and methods: this is a qualitative study developed with a focus-group strategy. the information was organized and analyzed pursuant to the coding proposed by janice m. morse. ten out of 20 nurses from transplant units took part, after giving their informed consent. triangulation was done between the members of the research teamand the relevant literature. results: six categories emerged: 1) multiple meanings of the transplant: change, passion, satisfaction, hope, freedom, greater closeness, responsibility, commitment and complexity; 2) support networks: family, partnership among nurses, interdisciplinary working group, health insurers and the pharmaceutical industry; 3) day-to-day implications: close relationship with the patient and family, build-up in professional self-esteem, status within the transplant group and handling workloads; 4) the course of professional care: nursing accompaniment and support throughout the patient’s life cycle and the possibility of identifying needs in terms of a close relationship with the patient; 5) the nurse’s profile: character, knowledge, commitment, continuous availability and management capacity; and 6) contradictions of the transplant: transplant rejection, suffering, despair, health system and, for nurses, exhausting shifts. conclusion: the findings point to human interaction as a central element of nursing care for transplant patients. it is should prevail over the technical aspects associated with treatment. keywords kidney transplant, life-changing events, qualitative research, nursing care, narration (source: decs, bireme). 273 el cuidado en un programa de trasplante renal: un acompañamiento de vida l ana julia carrillo-algarra y otros o cuidado num programa de transplante renal: um acompanhamento de vida resumo objetivo: compreender as experiências de cuidado de enfermeiras integrantes de grupos de transplante da cidade de bogotá (colômbia). materiais e métodos: pesquisa qualitativa na qual se utilizou a estratégia de grupos focais; a organização e a análise de dados seguiram a proposta de codificação de janice m. morse; participaram, mediante assinatura do termo de consentimento informado, 10 de 20 enfermeiras de unidades de transplante. realizou-se triangulação entre as integrantes da equipe de pesquisa e a literatura relevante. resultados: surgiram seis categorias: 1ª) os múltiplos significados do transplante — mudança, paixão, satisfação, esperança, liberdade, maior aproximação, responsabilidade, compromisso, complexidade; 2ª) as redes de apoio — família, associação de enfermeiras, grupo de trabalho interdisciplinar, empresas promotoras de saúde, indústria farmacêutica; 3ª) implicações do dia a dia — relação próxima com o paciente e a família, fortalecimento da autoestima profissional, status dentro do grupo de transplante, gestão das cargas; 4ª) trajetórias do cuidado profissional — acompanhamento da enfermeira por meio do ciclo vital do paciente e possibilidade de identificar necessidades pela estreita relação com ele; 5ª) o perfil da enfermeira — caráter, conhecimento, compromisso, disponibilidade permanente e capacidade de gestão; 6ª) contradições do transplante — rejeição ao enxerto, sofrimento, falta de esperança, sistema de saúde; para enfermagem, as exaustivas jornadas de trabalho. conclusão: os resultados do estudo destacam como um aspecto central do cuidado de enfermagem dos pacientes com transplantes a interação humana, aspecto que deve prevalecer sobre os aspectos técnicos associados com o tratamento. palavras-chave transplante renal, acontecimentos que mudam a vida, pesquisa qualitativa, atenção de enfermagem, narração (fonte: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 271-282 274 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 introducción el proceso de trasplante renal genera en la persona la condición de paciente crónico, y una gran incertidumbre por esta misma circunstancia, por lo que requiere cuidado de enfermería desde la etapa pretrasplante, durante su realización y en el postrasplante con el fin de conservar la capacidad de realización personal. el paciente trasplantado experimenta resultados fisiológicos tempranos, reflejados en la función inmediata del injerto, y en corto tiempo pueden desaparecer problemas adquiridos durante la enfermedad renal crónica, aspecto que ha posicionado al trasplante como la terapia de sustitución renal de elección y crea expectativas personales, familiares y sociales elevadas, pero simultáneamente conlleva riesgos, temor, dependencia de tratamientos farmacológicos, alto impacto social y económico (1), lo que ha configurado el proceso de trasplante como un fenómeno en el cual confluyen todas las dimensiones humanas y diversos actores. los profesionales de enfermería hacen parte del grupo interdisciplinario de los programas de trasplante y son quienes aseguran que el paciente cumpla con lo inherente a cada etapa del proceso, para lo cual desempeñan diferentes roles a fin de posibilitar el cuidado integral del paciente (2), los cuales hacen que su actuar trascienda más allá de actividades por cumplir, pues debe planear, cuidar, acompañar, ejecutar y evaluar, lo que implica largas jornadas de trabajo, y el aporte de herramientas necesarias para un cuidado integral. la complejidad y continuidad de los cuidados en los diferentes momentos y escenarios en los que se desarrolla el trasplante, que se afecta por la alta rotación de profesionales, motivó a las investigadoras a describir y comprender las experiencias de cuidado de diferentes enfermeras integrantes de grupos de trasplante renal de la ciudad de bogotá. materiales y métodos para describir y comprender la experiencia de las enfermeras expertas, se desarrolló un proceso de investigación de carácter cualitativo, el cual reivindica el valor de lo subjetivo y de las experiencias del otro y la otra como datos que toman un valor vital en la comprensión de la realidad (3). se utilizó la estrategia de grupos focales en la que se procura que un grupo de personas seleccionadas por los investigadores discutan y elaboren, desde la experiencia personal, la temática objeto de investigación (4), el grupo reconstruye discursivamente sus particulares formas de referencia: “en los grupos se obtiene la norma lo que debe de ser en relación con el fenómeno social estudiado” (5), de manera que en los grupos emergen los discursos colectivos, en este caso el de los profesionales de enfermería frente al proceso de trasplante. la elaboración del guión de preguntas para las sesiones de grupo se realizó a partir de la experiencia del equipo investigador y de una revisión de la literatura publicada referente al cuidado de enfermería de pacientes en condición de enfermedad crónica y, específicamente, del paciente en trasplante renal. los resultados de los grupos focales fueron transcritos siguiendo la fidelidad de los discursos de los participantes y bajo el principio explícito de la confidencialidad y el anonimato, de manera que no se comprometió la dimensión ética de la investigación. la organización y el análisis de los datos siguió la propuesta de codificación de janice m. morse, para quien “el análisis es la interacción entre la creatividad de los investigadores y la interpretación de los datos” (6); así, los códigos obtenidos se comparan una y otra vez sistemáticamente, para integrarlos en categorías que también se comparan para establecer sus propiedades (6). en esencia, lo que hizo fue condensar el grueso de los datos hallados en unidades analizables y se crearon categorías temáticas emergentes a partir de la segmentación y codificación de los datos más significativos. se realizaron dos grupos focales con enfermeras expertas en el cuidado de pacientes en proceso de trasplante renal, previo consentimiento informado de participación, quienes hacen parte de la asociación nacional de enfermeros en trasplante (acet); en el equipo investigador se garantizó el anonimato de los participantes, razón por la cual se utilizarán las etiquetas de los códigos como referencias de los textos de las enfermeras participantes en el apartado de los resultados. participaron en el estudio 10 de las 20 enfermeras que laboran en unidades de trasplante renal en la ciudad de bogotá. el proceso de triangulación se llevó a cabo entre las integrantes del equipo investigador y la literatura relevante frente al tema del cuidado en trasplante renal. el proyecto recibió el aval del comité de ética institucional de la fundación universitaria de ciencias de la salud, bogotá (colombia). 275 el cuidado en un programa de trasplante renal: un acompañamiento de vida l ana julia carrillo-algarra y otros resultados una vez organizada y analizada la transcripción de los grupos focales emergen seis categorías que en conjunto permiten comprender la experiencia que viven las enfermeras en el cuidado a la persona que se encuentra en el proceso de trasplante renal, las categorías son: 1) los múltiples significados del trasplante; 2) redes de apoyo; 3) implicaciones del día a día: trascendencia de la experiencia profesional en la vida; 4) trayectorias de cuidado profesional; 5) el perfil de la enfermera; 6) contradicciones en el abordaje. 1. los múltiples significados del trasplante al indagar en las enfermeras sobre el significado de la palabra trasplante, emergen una diversidad de sentidos que dependen del enfoque desde el cual se analiza el proceso, es decir, ellas son conscientes de que intervienen distintos actores y para cada uno de ellos el trasplante tiene un significado diferente, pero es a partir de la conjunción de estos múltiples significados que ella construye uno propio. así, la palabra trasplante que se maneja en la cotidianidad, va mas allá de la definición de la oms, entidad que lo define como un “procedimiento por el cual se implanta un órgano o tejido procedente de un donante a un receptor” (7), y se expresa como cambio, pasión, satisfacción, esperanza, libertad, mayor cercanía, responsabilidad, compromiso, complejidad y hasta contradicción. el cambio es el concepto que se repite con mayor frecuencia en el discurso compartido por las enfermeras participantes del grupo focal. para ellas, “este cambio se refleja para el paciente en un mejoramiento de la calidad de vida” (g1c2, g1c4, g2c2), incluso dos de las participantes comentaron que el paciente manifiesta que el proceso de trasplante es “volver a nacer”, pues le permite “retornar a la normalidad”, a realizar actividades que eran cotidianas como: trabajar, estudiar, tener hijos, entre otras, y “no solo mejorar su estado general de salud” (g1c20). las enfermeras participantes, a partir de las voces de sus pacientes, han construido un sentido de profundo cambio ligado al trasplante; al escuchar expresiones tan contundentes como el “volver a nacer”, el profesional de enfermería tiene clara la fuerte expectativa generada por un trasplante, aspecto comprensible si lo contrastamos con las implicaciones de una enfermedad crónica como la renal, en la cual la mayoría de las personas deben abandonar su vida laboral (8), pues no solo el malestar les impide desarrollar algunas actividades, sino también los tiempos destinados para los tratamientos, como en el caso de la hemodiálisis (9, 10) en línea con lo anterior, otro significado que emerge es el de libertad porque retoman las actividades cotidianas y dejan atrás la realización de procedimientos que requieren de la dedicación de periodos de tiempo prolongados: “ya no va depender de una máquina” (g2c8). esta libertad se da “no solo para el paciente sino también para su familia” (g1c19). una participante recuerda que: “una mamá que dijo: dios los bendiga enormemente, no por el trasplante de mi hijo sino por la libertad que ocasionó a mi familia” (g2c12), resaltando las limitaciones que una enfermedad crónica genera en la dinámica familiar. el sentido de libertad que supone un trasplante renal ha sido un fenómeno que otros autores han evidenciado al estudiar las experiencias de pacientes en estas circunstancias; el estudio de schmid-mohler et al., por ejemplo, describe que para un grupo de pacientes de la división de nefrología del hospital universitario de zurich, la libertad es una de las emociones que les permite a los pacientes mantener o mejorar las relaciones con sus familias al disminuir los niveles de dependencia (11). cambio y libertad como significados del trasplante se justifican si se tiene en cuenta que el sujeto de cuidado viene de una situación de enfermedad crónica y no de normalidad; ellas expresan que escuchan de los pacientes afirmaciones como: “a diálisis no vuelvo jamás así este sea mi último día” (g1c109, g1c107); lo cual hace evidente que en el tratamiento sustitutivo el trasplante se ve como la única posibilidad de acercarse a una vida normal. simultáneamente, al significado del cambio está ligado el concepto de esperanza y de regalo, ellas afirman que: “evidenciar el cambio de vida de los pacientes es entregar el regalo que ellos añoran”, “es mejorar la calidad de vida” (g1c4, g1c5, g1c4, g2c2). en un estudio sobre promoción de la integración familiar durante la enfermedad crónica se encuentra, al igual que en el presente estudio, que la esperanza de recuperación es un dispositivo que promueve la integración pero, además, es una vía para la recuperación y mejoría del paciente (12, 13). en los dos grupos focales emergió otro significado de trasplante y es el de pasión, derivada de “trabajar en equipo, de evidenciar el cambio de vida de los pacientes, y de entregar el regalo que ellos añoran” (g1c4, g1c5); una de las participantes emotivamente expresa: “esto es de mucha pasión, de mucha vo276 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 cación y de mucho amor [...] cuando uno tiene que ser enfermera uno pone esta parte para ellos [muestra el corazón]” (g1c29). aunado a la pasión aparece otro significado para la enfermera que es la satisfacción, descrita como el deber cumplido, una de las participantes expresa: “lo más satisfactorio es ayudarlo,es involucrarse en la vida de estos pacientes” (g1c25), y en forma concordante hablan del sentido de mayor cercanía, aclarando que el término mayor implica un comparativo con otros servicios y con otros equipos de salud; en forma explícita hablan de la cercanía de las enfermeras de los equipos de trasplante con los pacientes, la familia y los demás miembros del equipo. la cercanía se hace explicita a través de expresiones como: “a través de esa interacción uno conoce muchas cosas de los pacientes” (g1c21); “convivimos todo el tiempo” (g1c23); “vivimos este proceso como si fuéramos parte de su familia” (g1c26). una de las participantes emotivamente expresa: “los pacientes han abierto toda su vida a mí, entonces creo que hago parte de su vida, es importante hacer empatía con ellos […] yo creo que la relación que nosotras tenemos con el paciente, es más estrecha que la que ellos tienen con cualquier otro profesional del grupo” (g1c27). esta cercanía con los pacientes le facilita a la enfermera una particular identificación de necesidades y, por tanto, las enfermeras de trasplante consideran que su cuidado es diferente. otro significado expresado es el de responsabilidad-compromiso, porque el cuidado de enfermería no se limita al tiempo que el paciente está hospitalizado, una de las participantes comentó: “nosotros convivimos con los pacientes 24 horas, ellos son conscientes de eso” (g1c47, g2c25). para la enfermera, cuidar es una responsabilidad demasiado grande, “sigue mi cuidado dándole la educación a este paciente o sea, es mi responsabilidad que ese paciente al cuarto o al quinto día que se va para su hogar, sepa en la casa cómo se debe cuidar, qué es lo que tiene que hacer” (g1c95). en este sentido, cumple una de las premisas de jean watson cuando dice que el cuidado de enfermería trasciende el tiempo y el espacio (14): “significa un compromiso, un compromiso grande, tanto para uno como enfermero de sacar adelante este órgano que se trasplanta, como de sacar adelante todo lo que rodea al paciente, entonces es motivarlo a cambiar su estilo de vida” (g1c33, g1c50). lo anterior es coherente con el deber de la enfermera de enseñar acciones de autocuidado, definidas por dorothea orem como la habilidad adquirida, compleja, para identificar las necesidades de asistencia de uno mismo (15). en este mismo sentido, el grupo hizo visible el significado de complejidad, “el paciente de trasplante es muy complejo, de por sí es un paciente crónico y en ocasiones el mismo empleador le bloquea. ¿cómo le bloquea? no le da la autorización o el permiso para ir al control” (g1c99). 2. redes de apoyo las participantes están de acuerdo en que el trabajo en trasplantes es tan arduo que requiere de redes de apoyo, ellas manifiestan: “hay tantas cosas […] para que uno tampoco se agobie con los problemas de los demás es necesario contar con ayuda” (g1c39). el grupo, sin excepción, ve a la familia como una red de apoyo; una de las participantes afirmó que “la familia es un soporte para el paciente y para el personal” (g2c11); “aunque su presencia cambia según la fase del proceso, en la lista de espera no están tan realmente involucrados, cuando uno los trasplanta esa familia se reactiva y vuelve y está en el seguimiento de ellos, también estuvieron de acuerdo en afirmar que el equipo de trasplante apoya al paciente y su familia. especialmente la enfermera” (g1c130). asimismo, las enfermeras manifiestan como un deber “darles ánimo, confiarles lo que uno tiene a ellos les ayuda mucho más” (g1c14), “saber que uno es como el bastón de ellos cuando van a decaer” (g1c28). otros actores identificados por las participantes como redes de apoyo son: “la asociación ha sido un apoyo para el grupo de enfermería” (g1c37); “las empresas promotoras de salud (eps), tiene uno que saber cuál es el contacto con la eps para que te libere responsabilidades porque por ejemplo no es mi responsabilidad que el paciente tenga acceso al medicamento, tengo que tener mi red de apoyo y saber a quién llamar en la eps” (g1c116); “la industria farmacéutica es una red de ayuda indirecta que nos apoya a nosotros, en el obsequio, un desayuno que les ofrece, eso hace que ellos se apeguen al grupo e indirectamente tienes un tercer actor que está involucrando más con tu paciente” (g1c31). otro aspecto reconocido por las enfermeras como importante es la relación entre los miembros del equipo, que se manifiesta cuando dicen que “es necesario hacer referencia a la relación con el grupo de trabajo porque hemos estado hablando durante toda la mañana de la experiencia de la enfermera con el paciente, de la enfermera con la familia, pero ¿cuál es la relación que yo llevo con mi grupo de trabajo? si es efectiva hace que yo también sea efectiva” (g1c117); dos de las participantes emotivamente se refieren a la muerte de un miembro del equipo y manifiestan que las dificultades “las unieron más y fortalecieron para poder afrontar el camino”, resaltando la unión y el acompañamiento: “nosotras 277 el cuidado en un programa de trasplante renal: un acompañamiento de vida l ana julia carrillo-algarra y otros pasamos a ser la mamá de cinco hombres renales y cinco hombres cardiacos, somos un grupo completo” (g1c120). 3. implicaciones del día a día: trascendencia de la experiencia profesional en la vida como fenómeno social, en un trasplante se relacionan muchos actores y cada uno de ellos se involucra de manera distinta: la familia, el equipo de salud, las instituciones y otras redes de apoyo; al respecto, en las descripciones las enfermeras comentan que en el equipo de salud ellas son las más cercanas al paciente. tal es el grado de compromiso por parte de las enfermeras participantes en el grupo que una de ellas manifiesta que el cuidado de los pacientes en trasplante implica riesgos como “dejar de vivir la propia vida… de poner en segundo plano su familia” (g1c57); la integrante de mayor trayectoria manifiesta que esta cercanía es muy demandante y hace la siguiente reflexión a sus colegas: “lo único que les digo es sí, seguir trabajando en pro de los pacientes, pero no llevarse tanta carga emocional porque tampoco es bueno … hay muchas cosas qué hacer por los programas de trasplante, pero no dejar uno su vida ahí” (g1c36), lo cual es reafirmado por otra de las integrantes quien dice: “como el paciente te ve como su bastón tampoco tú puedes llevarte toda esa carga sin que un tercero a ti te ayude, otra cosa importante es que uno involucra a su familia, uno se levanta a las dos de la mañana [la familia pregunta]: ¿te tienes que ir?, ¿cómo te fue?, ¿cómo le fue al paciente?, ¿el paciente viene de dónde?, en fin , uno involucra a su familia también y ellos son conocedores de lo que uno hace” (g1c33). al respecto, puialto durán et al., como propuesta para prevenir la aparición del síndrome de bournot recomiendan, además de evitar la sobrecarga laboral, intentar separar familia y trabajo (16). el acompañamiento y cuidado permanente de la enfermera generan un tipo de cansancio relacionado con aspectos emocionales, no solo existe un cansancio físico —y esto poco lo aborda la literatura científica—; esto tiene manifestaciones reales e impactos en el quehacer de las enfermeras: “la misma experiencia que me ha dado este tiempo es no cargarse uno de cosas, no llevarse esa carga emocional, porque cuando tú llevas mucho tiempo esto también te lleva a un cansancio, eso te cansa […] el cansancio que hace que hagas tus cosas de manera más mecánica” (g1c36). aún con la sensación de alta demanda emocional, las enfermeras manifiestan que cuidar pacientes en proceso de trasplante genera en ellas motivación y afirman que: “a uno lo motivan los muchos logros que ellos mismos tienen, me motiva el crecimiento profesional, el conocimiento, los pacientes y la evolución que ellos tienen” (g1c122). otra de las integrantes afirma: “yo creo que tenemos la opción de aprender absolutamente de todo porque estamos a disposición de ser entrenadas en todos los servicios” (g2c55); lo anterior puede explicar el hecho de que las enfermeras en trasplante manifiesten satisfacción por el desarrollo en este campo, pues desde su experiencia es inherente el fortalecimiento de la autoestima profesional: “la intervención que hago realmente es valiosa, es reconocida, sí, es reconocida y tenida en cuenta, con el grupo de trasplante renal es la primera vez que yo siento que tengo voz y voto, que hago parte de un grupo interdisciplinario y siento el reconocimiento” (g2c49). “me motiva que no somos unas enfermeras normales, tenemos voz y voto dentro del grupo, eso me motiva mucho” (g1c64). la autoestima profesional hace que la enfermera de trasplante se sienta superior y diferente a las colegas que ejercen en otros espacios clínicos, “ser enfermera de trasplante hace que tengas un estatus, que tu ego en cierta forma sea diferente” (g1c64); “te reconocen tienes voz y voto” (g1c65); “a diferencia de las otras enfermeras de otros servicios, es que nosotras tenemos voz y voto total” (g1c66); “tenemos un posicionamiento que nos lo hemos ganado, hemos aprendido mucho” (g1c68). las anteriores afirmaciones invitan a reflexionar respecto al significado que tiene la toma de decisiones sobre el quehacer cotidiano de la enfermera para alcanzar el empoderamiento profesional. por otro lado, el contenido sustantivo de la categoría implicaciones del día a día —trascendencia de la experiencia profesional en la vida— cuestiona sobre el relacionamiento de las esferas públicas y privadas del acto de cuidado, pues desde las experiencias de las enfermeras de trasplante es posible deducir que la separación del mundo del trabajo (público) con el mundo de lo personal-familiar (privado o doméstico) no es tajante, por el contrario, uno llega a ser soporte del otro; de allí que, como afirma robles, la experiencia del cuidar se entienda mejor como una práctica social y subjetiva (17). 4. trayectorias de cuidado profesional: tenemos pacientes toda una vida el concepto de trayectorias de cuidado ha sido desarrollado en investigaciones cualitativas sobre los cuidadores informales y está muy ligado a la experiencia de vida de personas que se han 278 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 dedicado al cuidado de sus familiares con enfermedades crónicas, pero pocos elementos teóricos y empíricos se encuentran en relación con las trayectorias de cuidado profesional, categoría que es emergente en la reconstrucción del discurso del grupo de enfermeras participantes en el estudio. esta categoría da cuenta de un fenómeno similar al de los cuidadores informales, pues la posibilidad de conocer a los pacientes durante largos periodos de tiempo posibilita un amplio manejo sobre las situaciones propias de los padecimientos (17), pero es diferencial porque este se da en espacios institucionales, está mediado por el conocimiento científico e implica otro tipo de vínculos. la trayectoria de cuidado, es decir, las largas temporalidades del quehacer profesional con el mismo paciente, emerge en expresiones como: “tenemos pacientes… toda una vida, entonces es conocer a muchos desde niños, después ya verlos universitarios hecha una vida y uno ha sido partícipe de todo ese proceso. tenemos pacientes de 15, 17 y de 22 años ya trasplantados de riñón, es toda una vida” (g1c54); “el cuidado de un paciente trasplantado para la enfermera es desde el día cero hasta que el paciente falleció” (g1c48). este acompañamiento de vida, no solo se hace con la persona, sino con su familia, con el entorno, con lo administrativo y no solo en el hospital sino también en el domicilio. la temporalidad tiene un doble sentido, pues el cuidado que se brinda a las personas durante los procesos de trasplante se da tanto a lo largo del ciclo vital del paciente como también durante el día a día de las profesionales; una enfermera del equipo menciona que: “sigue mi cuidado en el momento en que yo lo llamo, sea la 1 sean las 12, sean las 2 de la mañana, sean 48 horas de trabajo seguido, sea lo que sea, ahí sigue mi cuidado con ese paciente, la experiencia que tuve fue estar todo el tiempo con ellos… yo estaba todo el tiempo involucrada totalmente y dándole muchísimo ánimo al paciente” (g1c53). otra manifestación de la continuidad del cuidado se manifiesta cuando las participantes expresan: “la enfermera de trasplante ve el antes, el durante y el después, ve todo el proceso” (g1c61), lo cual se reafirma con las expresiones: “porque es que nosotras estamos durante todas esas etapas” (g1c62); “nosotros manejamos todos los frentes” (g1c63), “como enfermeras somos las que más estamos involucradas con el paciente durante su enfermedad” (g1c97); “hasta que se muera el paciente” (g1c98). como se mencionó, la trayectoria de cuidado profesional le permite a la enfermera un dominio sobre el cómo intervenir y sortear los diferentes acontecimientos que se presentan durante los procesos de trasplante y que no necesariamente tienen que ver con el conocimiento científico-técnico, “más que una intervención específica es la habilidad que nosotros tenemos porque tú los conoces” (g1c105), “a través de esa interacción uno conoce muchas cosas de ellos, los seis pacientes que tengo en consulta postrasplante han abierto toda su vida a mí” (g1c21). de acuerdo con forero, una enfermera en el equipo de trasplante tiene cuatro roles indispensables para el funcionamiento de las unidades: asistencial, educativo, gerencial e investigativo (2), estos y otros fueron identificados por nuestras enfermeras participantes: “el rol de la enfermera de trasplantes no es solo clínico, es un rol administrativo, es un rol investigativo y es un rol docente que también nos toca asumir a nosotras en nuestro grupo” (g2c24); hay un rol que, al igual que en los cuidadores informales, pareciese invisible y se convierte en el centro mismo del acto de cuidado: el rol del cuidado emocional que se da por la relación intersubjetiva descrita en afirmaciones como: “el saber manejar el dolor, la ansiedad, eso yo creo que nos lo da el conocerlos desde hace tanto tiempo” (g1c104); “lo que pasa después del sufrimiento de un paciente es que llega como a un punto de desesperanza, de angustia y uno está todo el tiempo con ese paciente cogido de la mano” (g1c106). estos testimonios reivindican el carácter subjetivo del cuidado, pues no se cuidan enfermedades sino experiencias humanas (18). la proximidad y trayectoria de cuidado de las enfermeras en los procesos de trasplante permite identificar otras necesidades del paciente en este proceso que no se perciben fácilmente en otros espacios de atención de enfermería y que no están relacionadas directamente con el cuidado clínico. los grupos de enfermeras expresan: “si tú me pides que identifique una necesidad del paciente yo diría la necesidad de reintegración laboral” (g1c114). es decir, la enfermera, por la estrecha relación que se crea con los pacientes, tiene la posibilidad de explorar otros espacios de la dimensión humana, en este caso la importancia del trabajo. otro aspecto que emerge sobre el abordaje de necesidades es que son diferentes, “hay muchas necesidades y las necesidades no son las mismas y no las podemos generalizar a todos los pacientes” (g1c90), aún tratándose del mismo tema, como es el caso de la familia. aspecto que hace recordar a callejo cuando habla de la individualidad del ser y manifiesta que “suele sostenerse que el hombre ha tenido hasta la modernidad un sentido mínimo 279 el cuidado en un programa de trasplante renal: un acompañamiento de vida l ana julia carrillo-algarra y otros del valor de su propia individualidad, pues, para él, su vida es valiosa no porque sea una singularidad irrepetible, sino justamente por lo contrario: su vida tiene sentido en cuanto que forma parte de una familia, de una comunidad” (19). para todas las personas, el tema de la familia es relevante, pero dependiendo de la edad del paciente difiere el enfoque de la necesidad: “de acuerdo al grupo de edad la necesidad o es de la familia o es del paciente mismo, en el escolar es más la necesidad de la familia, de verlo bien, de que el niño esté bien y de tener una vida lo más normal, pero si tú te vas al adulto, entonces su necesidad se traslada hacia el bienestar de su familia cuando hay periodos de hospitalizaciones prolongados” (g1c115); esto se da cuando el paciente es el proveedor económico y, en muchos casos, su enfermedad ha ocasionado la pérdida del empleo. las estrategias de cuidado que las enfermeras desarrollan para responder a esas necesidades no clínicas se dan con la educación y el fomento de hábitos de autocuidado, pues se reconoce que “otra de las necesidades del paciente es relacionada con sus prácticas de autocuidado… él tiene que buscar muchas cosas en él mismo para que promueva su cuidado” (g1c93); comentan que la educación que ofrece la enfermera para ese tipo de pacientes es mucho más profunda, debe trabajarse más, porque para “sacar adelante este órgano que se trasplanta y sacar adelante todo lo que rodea al paciente, es necesario cambiar su estilo de vida” (g1c45); al mismo tiempo, “uno puede identificar que la necesidad [de educación] también es muy grande, y no todos los pacientes son iguales, hay unos que te entienden en la primera sesión, hay otros que no, y pasan meses y meses y hasta un año y todavía tienen muchas dudas” (g1c95). es importante destacar la limitada investigación sobre educación a pacientes en postrasplante renal, como lo demuestran diversos estudios sobre la llamada health literacy, los cuales dan cuenta de que, a pesar de ser un tema tan importante para el éxito a largo plazo en la salud de las personas en postrasplante, hay escasa evidencia sobre el mismo, siendo además un reto para la enfermeras que acompañan el cuidado de estos pacientes (20-22). otra acción de cuidado que comentan las participantes, desde el punto de vista afectivo, es: “hacemos abrazo-terapia” (g1c103). 5. perfil de la enfermera de acuerdo con la construcción colectiva, las enfermeras consideran que a fin de cuidar pacientes de trasplante es necesario poseer carácter y seguridad para hacer las cosas: “tener carácter es importante, para ello requiere tener una buena escuela, si tienes conocimiento, el conocimiento a ti te lleva a hacer las cosas con exactitud” (g1c71); para ellas, la seguridad se traduce “en la entereza de enfrentar al paciente, de decirle quen no cumple criterios por equis razones” (g1c73). como una tercera cualidad emerge el compromiso: “es compromiso total, es entregarse” (g1c50), pues afirman que “se requiere disponibilidad de 24 horas” (g1c46, g1c47). otros aspectos del discurso del grupo, relacionados con las características de la enfermera para estar en un equipo de trasplante, son la “permanencia” (g1c48) y “la capacidad para desarrollar tareas muy arduas” (g1c49). es central la importancia de una buena escuela. al indagar con mayor profundidad, este concepto hace referencia a las herramientas teóricas y modelos humanos durante la formación profesional: “la enfermería nos lo aportó todo” (g1c69), “el hacer, el planear, el ejecutar; la parte administrativa […] de cómo se administra, de cómo se gestiona” (g1c70); “una buena escuela es donde tú vas a poner en práctica toda la teoría que aprendes” (g1c73); “toda la teoría y todo lo demás tiene que ir muy ligado a la práctica todo el tiempo y a la experiencia” (g1c82); “el peso del aprender de otras [colegas], yo soy de las personas que aprendo haciendo las cosas porque el resto del conocimiento se queda acá [señala la cabeza] pero se queda como un conocimiento de memoria y si no lo pones en práctica nunca va a funcionar” (g1c85); “no solo es el modelo teórico, es el modelo humano, del que se aprende, se cultiva y se apropia” (g1c83). 6. contradicciones en el abordaje las participantes hablan de contradicciones vinculadas al proceso de trasplante en cada uno de los actores involucrados. a pesar de manifestar que el trasplante representa para el paciente un volver a nacer o la libertad para él y su familia, también experimentan pérdidas, muerte, desesperanza, aspectos que se entienden, desde la experiencia de las enfermeras, como contradictorios. por ejemplo, cuando ocurre un rechazo, las expectativas puestas en el trasplante se desmoronan y el enfoque del cuidado cambia, en un caso específico implica “estar con él todo el tiempo y empezar a tener esa experiencia y vivir todo lo que ellos viven, verlos sufrir en ese momento, verlos cómo decaen en una semana, se bajan de peso, diez kilos en ese periodo de tiempo, y verlos decaídos y tú viéndolos hace quince días súper bien no era 280 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 nada fácil” (g1c106). “después del sufrimiento el paciente llega a un punto de desesperanza […] el sufrimiento en ellos igual siempre ha estado presente desde su insuficiencia renal y cuando se trasplantan también están enfrentados al sufrimiento de perder su riñón” (g1c110); “que se pierda un injerto porque ya se agotó el riñón porque ya le correspondía porque definitivamente ya no había nada más qué hacer y no porque el accionar del paciente o las consecuencias del sistema provoque perderlo” (g2c54). la desesperanza es explícita, una de las participantes recuerda un paciente que manifestó: “ya no quiero seguir, ya que pase lo que sea”. muchos pacientes que se trasplantan y fracasan dicen: “a diálisis no vuelvo jamás así este sea mi último día… entonces es apoyarlos en ese momento que ya dicen: oiga no más” (g1c114); a veces no hay respuesta a las preguntas de los pacientes, por ejemplo, “qué decir cuando un paciente con rechazo al injerto plantea el interrogante ‘¿jefe y si entran y me miran?, ¿usted cree que se pueda salvar?’” (g1c114). aunque un posible desenlace del trasplante es la muerte, como sociedad no estamos acostumbrados a ella y esto es una contradicción para las enfermeras quienes reproducen este hecho en las declaraciones de los grupos: “ya tres años de experiencia en esto y todavía no puedo afrontar la muerte de una persona” (g1c111); “yo he llorado con cada una de las pérdidas que he tenido” (g1c113). si bien es cierto que la cercanía al paciente y la familia es un factor de motivación, queda el interrogante de hasta dónde se debe implicar la enfermera: “hay muchas cosas qué hacer por los programas de trasplante, pero no dejar uno su vida ahí” (g1c17). aun con el sentimiento de pasión por su trabajo, comentan que es necesario guardar cierto nivel de independencia; así, una de las participantes expresa: “al principio, la pasión te lleva a hacer muchas cosas y la pasión te absorbe y después de un tiempo, te preguntas donde estoy… es una carga no solo laboral, sino emocional, tú también tienes tu familia, también tienes tu vida fuera de la institución, tienes también que buscar una red de apoyo porque sino el programa te absorbe completamente” (g1c40). la contradicción también se encuentra frente al rol del sistema de salud, el cual puede ser parte del apoyo cuando permite acceso oportuno, sobre todo en las personas que están en el régimen subsidiado, que es definido por el ministerio de protección como el mecanismo mediante el cual la población más pobre del país, sin capacidad de pago, tiene acceso a los servicios de salud a través de un subsidio que ofrece el estado (23); pero puede convertirse en un obstáculo cuando no autoriza exámenes o procedimientos que el paciente requiere en ese momento, lo cual genera responsabilidades que no son del rol de enfermería pero que interfieren y se relacionan con el cuidado del paciente; una de las participantes manifestó: “nuestro sistema de salud a veces no es tan grato con los pacientes y tan justo, y tan oportuno, a veces se encuentra que la necesidad básica de ellos es conseguir el medicamento o que lo atiendan oportunamente y a enfermería le corresponde hacer lo que pueda porque entonces si se requiere un procedimiento es importante que esté autorizado” (g1c86); “porque yo lo hago y quién me paga después por ejemplo, una biopsia” (g1c92). otra forma de contradicción del sistema es cuando se rompe la continuidad y trayectoria de cuidado profesional en el proceso de cambio de contrato, lo cual implica para el paciente y la enfermera construir una nueva relación. conclusiones las experiencias de las enfermeras durante el cuidado del paciente en proceso de trasplante son transversales en su rol profesional y la vida personal. desde el punto de vista profesional, generan contradicciones porque si bien es cierto que se producen aspectos positivos como mayor estatus, incremento en la autoestima, reconocimiento profesional, simultáneamente implican un alto nivel de compromiso y disponibilidad, lo cual puede llevar al cansancio. desde el punto de vista personal, implica temor, sensación de abandono de su propia familia y formación de un estrecho vínculo tanto con los pacientes como con sus familias. comprender las experiencias de las enfermeras en las unidades de trasplante reafirma el sentido subjetivo del cuidado y pone como centro del quehacer en enfermería las relaciones humanas; si bien es cierto que el trasplante es calificado como uno de los procedimientos de mayor tecnificación, al punto de considerarlo el milagro del siglo xxi, al aproximarse cualitativamente a este fenómeno se evidencia que en lo cotidiano se privilegia lo humano por encima de lo técnico, por lo menos desde el discurso de las enfermeras. llama la atención que durante la exploración de los grupos focales las referencias hacia aspectos técnicos estuvieron ausentes. de acuerdo con el discurso construido durante los grupos focales por las enfermeras participantes, el hecho de que en 281 el cuidado en un programa de trasplante renal: un acompañamiento de vida l ana julia carrillo-algarra y otros colombia se cuente con grupos de trasplante institucionalmente constituidos, como estrategia para abordar este fenómeno en particular, facilita y hace posible la integralidad del cuidado y de la atención que se brinda a las personas que ingresan al proceso de trasplante. de acuerdo con la experiencia compartida, estos grupos funcionan de un modo unificado, cohesionado, lo que genera un sentido de grupo y trabajo en equipo que se diferencia de otros escenarios de atención en salud, así esta estrategia sea en sí misma una experiencia favorable para las enfermeras y las acciones de cuidado que ellas desempeñan. referencias 1. mercado-martínez fj, hernández-ibarra e, ascencio-mera cd, díaz-medina ba, padilla-altamira c, kierans c. viviendo con trasplante renal, sin protección social en salud: ¿qué dicen los enfermos sobre las dificultades económicas que enfrentan y sus efectos? cad saúde pública [internet]. 2014 [citado 2014 ene 30]; 30(10):2092-2100. 2. forero e. roles de enfermería en los programas de trasplante de colombia [tesis para optar el título de: magister en enfermería]. bogotá: universidad nacional de colombia; 2012. 3. lozano f. contrastación de los paradigmas en el abordaje de la evidencia científica: neopositivismo vs. hermenéutica crítica. i jornada sobre sentido y pertinencia de la evidencia científica, uptc, tunja, agosto, 2004. 4. galeano me. estrategias de investigación social cualitativa. el giro en la mirada. medellín: la carreta editores; 2012. 5. callejo-gallego j. observación, entrevista y grupo de discusión: el silencio de tres prácticas de investigación. revista española de salud pública [internet]. 2002 [citado 2013 oct 17]; 76(5):409-422. disponible en: http://www.redalyc.org/ articulo.oa?id=17076504 6. morse mj. introducción. en asuntos críticos de los métodos de investigación cualitativa. medellín: editorial universidad de antioquia; 2003. 7. organización mundial de la salud (oms). boletín de la organización mundial de la salud. 2012;90(10):713-792. 8. sangalli v, dukes j, doppalapudi s, costa g, neri l. work ability and labor supply after kidney transplantation. am j nephrol. 2014;40:353-361. 9. ledon-llanes l. enfermedades crónicas y vida cotidiana. rev cubana salud pública [internet]. 2011 [citado 2013 jun 07]; 37(4):488-499. disponible en: http://scielo.sld.cu/scielo.php?script=sci_arttext&pid=s0864-34662011000400013&lng =es&nrm=iso 10. rocha rfp, santos i. health care necessities between clients with chronic renal disease: integrative review of literature. rev. de pesq. [internet]. 2009 [citado 2013 jun 07]; 1(2):423-433. disponible en: http://www.seer.unirio.br/index.php/ cuidadofundamental/article/view/374/385 11. schmid-mohler g, schäfer-keller p, frei a, fehr t, spirig r. a mixed-method study to explore patients’ perspective of self-management tasks in the early phase after kidney transplant. progress in transplantation. 2014;24(1):8-18. 12. kautz d, van e. promoting family integrating to inspire hope in rehab patients; strategies to provide evidence-based care. rehabil nurs. 2009;39:168-173. 13. kautz d. inspiring hope in rehabilitation patiens, their families and ourselves. rehabil nurs. 2008;33:148-153. 14. cara ch. a pragmatic view of jean watson’s caring theory. international journal of human caring. 2003;7(3):51-61. 15. marinner a, raile m. modelos y teorías de enfermería. barcelona: elsevier -mosby; 2007. 16. puialto durán mj, antolín rodríguez r, moure fernández l, fernández l. prevalencia del síndrome del quemad@ y estudio de factores relacionados en l@s enfermer@s del complexo hospitalario universitario de vigo. en global [internet]. 2006 [citado 2013 nov 11]; 5 (1). disponible en: http://revistas.um.es/eglobal/article/view/320 17. robles silva l. la invisibilidad del cuidado a los enfermos crónicos: un estudio cualitativo en el barrio de oblados. guadalajara: editorial universitaria; 2007. 282 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 18. urra me, jana a, garcía m. algunos aspectos esenciales del pensamiento de jean watson y su teoría de cuidados transpersonales. cienc enferm [internet]. 2011 [acceso 2013 nov 03]; 17(3):11-22. disponible en: http://www.scielo.cl/scielo.php?script=sci_arttext&pid=s0717-95532011000300002&lng=es. http://dx.doi.org/10.4067/s071795532011000300002 19. callejo-pérez, a. autobiografía y conciencia de la propia individualidad. la “historia de mis calamidades” de pedro abelardo. thémata. revista de filosofía de la universidad de málaga [internet]. 2007 [citado 2013 nov 03]; (39):[6 págs.]. disponible en: http://institucional.us.es/revistas/themata/39/art78.pdf 20. devraj r, gordon ej. health literacy and kidney disease: toward a new line of research. am j kidney dis. 2009;53(5): 884-889. 21. wright ja, wallston ka, elasy ta, ikizler ta, cavanaugh kl. development and results of a kidney disease knowledge survey given to patients with ckd. am j kidney dis. 2011;57(3):387-395. 22. dageforde la, cavanaugh kl. health literacy: emerging evidence and applications in kidney disease care. adv chronic kidney dis. 2013;20(4):311-9. 23. república de colombia. sistema general de seguridad social. ley 100 de 1993. libro segundo: sistema general de seguridad social en salud; 1993. 210 218 incertidumbre en adultos diabeticos.indd 210 isabel patricia gómez-palencia1 irma yolanda castillo-ávila2 luis reinaldo alvis-estrada3 incertidumbre en adultos diabéticos tipo 2 a partir de la teoría de merle mishel 1 universidad de cartagena (colombia). ipgomezp@unicartagena.edu.co 2 universidad de cartagena (colombia). icastilloa@unicartagena.edu.co 3 universidad de cartagena (colombia). lalvis20@yahoo.com recibido: 18 de febrero de 2014 enviado a pares: 25 de febrero de 2014 aceptado por pares: 10 de marzo de 2015 aprobado: 21 de abril de 2015 doi: 10.5294/aqui.2015.15.2.5 para citar este artículo / to reference this article / para citar este artigo gómez-palencia ip, castillo-ávila iy, alvis-estrada lr. incertidumbre en adultos diabéticos tipo 2 a partir de la teoría de merle mishel. aquichan. 2015; 15 (2): 210-218. doi: 10.5294/aqui.2015.15.2.5 resumen objetivo: describir el nivel de incertidumbre de adultos con diabetes mellitus tipo 2 atendidos en instituciones prestadoras de servicios de salud en cartagena (colombia). materiales y métodos: estudio descriptivo a partir de una muestra de 163 pacientes que tuvieran como mínimo dos meses de haber sido diagnosticados con diabetes mellitus tipo 2. el instrumento utilizado fue la escala de la incertidumbre ante la enfermedad de mishel y para el análisis de los datos fue utilizado el paquete estadístico spss versión 20.0. resultados: del total de participantes 76,1 % mostraron un nivel de incertidumbre regular. el fenómeno de la incertidumbre está más relacionado con la incapacidad para identificar si ha mejorado o no (86,5 %), de predecir o explicar la causa de un malestar físico (76,7 %) o predecir el cambio de los síntomas (60,1 %). conclusiones: para enfermería, abarcar este fenómeno permite una mejor aproximación al análisis de los desafíos y las expectativas de quienes viven con una enfermedad crónica y así proporcionar cuidados que permitan un proceso de adaptación óptimo, que apoyen y enriquezcan la práctica enfermera. palabras clave incertidumbre, enfermedad crónica, diabetes mellitus (fuente: decs bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 210-218 211 incertidumbre en adultos diabéticos tipo 2 a partir de la teoría de merle mishel l isabel patricia gómez-palencia y otros año 15 vol. 15 nº 2 chía, colombia junio 2015 l 210-218 uncertainty in adults with type 2 diabetes according to merle mishel’s theory abstract objective: describe the level of uncertainty experienced by adults with type 2 diabetes mellitus who are being treated at health care institutions in cartagena, colombia. materials and methods: this is descriptive study based on a sample of 163 patients who had been diagnosed with the disease at least two months earlier. mishel’suncertainty in illness scale was the instrument used and the information was analyzed with spss statistics 20.0. findings: a good portion of the participants (76.1%) showed normal levels of uncertainty. the phenomenon of uncertainty is related largely to an inability to identify whether or not there has been an improvement (86.5%), to predict or explain the cause of physical discomfort (76.7%) orto predict a change in symptoms (60.1%). conclusions: investigating this phenomenon allows for a better approach to analyzing the challenges facing those living with a chronic illness, as well as their expectations, in order to provide care that facilitatesthe best possible process of adaptation and supports and enriches nursing practice. keywords uncertainty, chronic illness, diabetes mellitus, nursing (source: decs, bireme). 212 aquichan issn 1657-5997 incerteza em adultos diabéticos tipo 2 a partir da teoria de merle mishel resumo objetivo: descrever o nível de incerteza de adultos com diabete mellitus tipo 2 atendidos em instituições prestadoras de serviços de saúde em cartagena (colômbia). materiais e métodos: estudo descritivo a partir de uma amostra de 163 pacientes que tiveram pelo menos dois meses de terem sido diagnosticados com essa doença. o instrumento utilizado foi a escala da incerteza ante a doença de mishel e, para a análise dos dados, foi utilizado o programa estatístico spss versão 20.0. resultados: do total de participantes, 76,1% mostraram níveis de incerteza regular. o fenômeno da incerteza está mais relacionado com a incapacidade para identificar se melhorou ou não (86,5%), de prever ou explicar a causa de um mal-estar físico (76,7%) ou de predizer a mudança dos sintomas (60,1%). conclusões: pesquisar esse fenômeno permite uma melhor aproximação à análise dos desafios e das expectativas dos que vivem com uma doença crônica e, assim, proporcionar cuidados que permitam um processo ótimo de adaptação e enriqueçam a prática enfermeira. palavras-chave incerteza, doença crônica, diabete mellitus, enfermagem (fonte: decs bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 210-218 213 incertidumbre en adultos diabéticos tipo 2 a partir de la teoría de merle mishel l isabel patricia gómez-palencia y otros introducción la incertidumbre frente a la enfermedad se describe como la incapacidad de las personas para dar sentido o significado a los procesos o las situaciones que tienen que ver con su estado de salud —lo que se traduce en una imposibilidad para predecir los resultados y manejarlos—, generalmente producida por la falta de información y conocimiento sobre la enfermedad (1, 2). no obstante, muchas veces el conocimiento sobre una situación genera más incertidumbre relacionada con la continua amenaza de desequilibrio o de revivificación de una situación de riesgo o daño, lo que lleva a diversas formas de afrontamiento (2). en situaciones de enfermedades crónicas, donde la aparición de signos y síntomas es variable y va evolucionando de manera impredecible, la incertidumbre carcome y afecta drásticamente la salud integral (física y psíquica) del paciente, y tiene un impacto negativo en la familia de este, ya que la aparición de este tipo de enfermedades ponen en primer plano la muerte, la tristeza, en fin, todas estas manifestaciones de la incertidumbre, de no saber qué depara el futuro. si este fenómeno no se interviene a tiempo, puede acelerar el progreso de la enfermedad, llevando al paciente a un deterioro físico y psíquico, lo que trae consigo efectos negativos como ansiedad, depresión, desesperación, entre otros. estos estados emocionales afectan la calidad de vida de pacientes con enfermedades crónicas como la diabetes (3, 4). según la organización mundial de la salud (oms), la diabetes mellitus (dm) es el tercer problema de salud pública más importante del mundo y afecta a más de 347 millones de personas. su incidencia va en aumento y se espera que para el año 2030 sea la séptima causa de mortalidad, especialmente en países en vía de desarrollo, debido a que en el 2012 fue la causa directa de 1,5 millones de muertes en todo el mundo (5). en colombia, la tasa de mortalidad para esta enfermedad por cada 100.000 habitantes, va desde 166,7 para mujeres y de 205,9 para hombres. para el caso del departamento de bolívar, la diabetes es la décima causa de mortalidad, con una tasa de 2,3 por cada 100 000 habitantes. en la ciudad de cartagena, su prevalencia es de 8,9 % en mayores de 30 años y es la novena causa de muerte en la población general (5, 6). dada su alta prevalencia e incidencia en la población, esta enfermedad crónica supone muchos desafíos para quienes la padecen. uno de ellos suele ser enfrentarse a situaciones desconocidas derivadas de la enfermedad, tales como síntomas, tratamientos y procesos de recuperación (7). por eso, las bases teóricas que sustentan el cuidado de enfermería, introducen el análisis del concepto de la incertidumbre frente a la enfermedad en las personas con este tipo de padecimientos, apoyadas en los conceptos de la teoría de rango medio de merle mishel. en esta teoría se analizan los elementos de la vida de las personas que pueden constituirse en antecedentes de incertidumbre, dado que los pacientes procesan cognitivamente estímulos relacionados con su enfermedad, para construir significados de los eventos que van sucediendo y configurándose en experiencias; la incertidumbre aparece cuando la persona no es capaz de estructurar esos significados (2, 8). la incertidumbre puede considerarse como un aspecto negativo (peligro), que provoca consecuencias psicológicas como ansiedad, depresión y afectación de la calidad de vida, que llevan al paciente a un déficit del autocuidado. los eventos inciertos evaluados como peligro implican detrimento o daño, por lo cual se implementan estrategias para reducir dichos eventos (9). la incertidumbre también se puede considerar como un aspecto positivo (oportunidad), este se presenta cuando el paciente con enfermedad crónica tiene la capacidad de aceptar su enfermedad como parte de la realidad en que vive; los eventos inciertos evaluados como una oportunidad implican resultados positivos, porque las estrategias de afrontamiento pueden ser más efectivas y conducir a una mejor adaptación (7). para que la incertidumbre sea considerada oportunidad, el paciente con enfermedad crónica debe tener una capacidad cognitiva amplia, debe entender y conocer su enfermedad, así como la sintomatología y la probabilidad de alcanzar un buen estado de ánimo; además, confiar en los recursos sociales y en el personal sanitario que lo atiende (9, 10). es así como el modelo de mishel plantea una estructura relacionada con el marco de estímulo en el cual intervienen factores como: tipología de los síntomas, y familiaridad y coherencia de los hechos, cada uno de estos relacionados con eventos asociados como síntomas, diagnósticos, tratamientos y pronósticos (8). si se considera que las situaciones que generan incertidumbre son parte de las vivencias de salud de la persona, puede esperarse que dicha incertidumbre provoque una forma de afrontamiento en relación con el patrón unitario de cada persona y el significado que esta le otorga a la situación en su vida. además, sus capacidades de autocuidado y de autogestión aparecerán involucradas en la definición de su perspectiva vital (2). 214 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 la congruencia de la diabetes mellitus tipo 2 como enfermedad crónica, indica que la incertidumbre es un componente de todas las experiencias que se desarrollan alrededor de la misma. diversas investigaciones han demostrado que los indicadores objetivos y subjetivos, tanto de la amenaza de muerte como de la sintomatología de la enfermedad, su duración e intensidad, están sin lugar a dudas relacionados con la incertidumbre; de modo similar, la ambigua naturaleza de la sintomatología de la enfermedad y la consecuente dificultad para determinar la significación de las sensaciones físicas se han identificado como fuente de incertidumbre (3). el modelo de incertidumbre, y la manera como esta es percibida con relación a la enfermedad, puede entenderse desde la perspectiva de la psicología, que identifica la incertidumbre como un estado cognitivo resultante de impulsos o señales que no son suficientes para formar un esquema cognitivo o una representación interna de un hecho. mishel toma este concepto de la psicología y lo actualiza en el campo de los estudios de enfermería. por esto, la perspectiva de la incertidumbre como factor estresante en el contexto de la enfermedad, hace que este marco resulte valioso para los profesionales de enfermería, permitiendo comprender las necesidades que van más allá de la enfermedad en las personas que sufren diabetes mellitus tipo 2, y aporta evidencia para el cuidado en la práctica profesional (2, 8-10). por todo lo anterior, este estudio se propuso describir el nivel de incertidumbre en personas con situación crónica por diabetes mellitus tipo 2, que son atendidas en las instituciones públicas de salud de primer nivel de la ciudad de cartagena. materiales y métodos se trató de un estudio descriptivo, con una población de 528 pacientes, en el cual se tomó una muestra de 163 para el estudio, adscritos a los programas de atención de patologías crónicas de las instituciones públicas de primer nivel de atención, prestadoras de servicios de salud, de la empresa social del estado (ese) cartagena de indias y de la fundación medicus “casa del diabético”. fueron incluidos pacientes que asistieron regularmente a controles médicos y de enfermería, con edades entre 30 y 80 años, de ambos sexos, diagnosticados con diabetes mellitus mínimo dos meses antes de la aplicación de la encuesta y que no presentaran alteraciones mentales que les limitaran responder al cuestionario. se recolectó información relacionada con variables sociodemográficas como: edad, sexo, escolaridad, estado civil, religión, procedencia, ocupación y estrato socioeconómico. para la medición de la incertidumbre se utilizó la escala de incertidumbre frente a la enfermedad, desarrollada por mishel. esta escala, en su versión original, ha sido usada en enfermos crónicos para determinar el significado que le da la persona a los eventos o hechos relacionados con su estado de salud, por lo que puede ser aplicada a pacientes con diabetes mellitus tipo 2. con este instrumento la persona emite su opinión de acuerdo con una serie de afirmaciones relacionadas con su salud física/psicológica y con el nivel de incertidumbre generado frente a diversas situaciones de la enfermedad o tratamiento, tales como: diagnóstico, síntomas, tratamiento, información recibida, relaciones con el equipo de salud y pronóstico. las opciones de respuestas para cada ítem se dan en una escala tipo likert, que va desde muy en desacuerdo a muy de acuerdo, con un valor mínimo de 1 a un valor máximo de 5 puntos, siendo 5 el nivel más alto de incertidumbre, salvo para las preguntas 6, 7, 10, 12, 21, 22, 25, 27 y 29, donde el puntaje es invertido. el puntaje máximo de la escala es de 145 puntos y el mínimo de 29, contemplando los siguientes puntos de corte para su evaluación: nivel de incertidumbre bajo: menor de 59 puntos; nivel de incertidumbre regular: entre 59 a 87 puntos; nivel de incertidumbre alto: mayor de 87 puntos. para este estudio, la escala mostró buena consistencia interna medida por un alfa de cronbach de 0,81. los instrumentos de recolección de la información se aplicaron en el momento en que el paciente esperaba su turno en sala para ingresar a la consulta médica, previo consentimiento informado. luego de la recolección de la información, se realizó un análisis descriptivo de la variable de incertidumbre. se calcularon frecuencias y porcentajes para las variables cualitativas y medias, y desviación estándar (de) para las variables cuantitativas. además, se utilizó el paquete estadístico spss versión 20.0. resultados el promedio de edad fue de 58,1 años. el tiempo promedio de diagnóstico en los pacientes fue de 6,4 años y el 70,6 % de los pacientes fueron mujeres. el 5,1 % de pacientes encuestados tiene estudios superiores a la secundaria. el 76,1 % de los pacientes reportó un nivel de incertidumbre regular, y solo el 8,6 % de los pacientes tienen un alto nivel de incertidumbre (tabla 1). 215 incertidumbre en adultos diabéticos tipo 2 a partir de la teoría de merle mishel l isabel patricia gómez-palencia y otros tabla 1. distribución según su nivel de incertidumbre de las personas con diabetes tipo 2, participantes del estudio. cartagena, 2014 de acuerdo con la familiaridad de los hechos, el 85,9 % no conoce su enfermedad; dos terceras partes de los pacientes encuestados aún tienen dudas acerca de la misma, mientras que el 81,6 % no tiene claro cuánto daño le hace su enfermedad. en relación con la dimensión de la coherencia de los hechos, el 82 % de los pacientes afirma que puede decir cuánto demorará su enfermedad, el 72 % no vislumbra un futuro debido a lo impredecible de esta, y el 79 % considera que es difícil determinar cuánto tiempo pasará para poder cuidarse solo, aunque se sienten en capacidad de predecir el curso de su enfermedad (tabla 3). tabla 3. frecuencia de respuestas a los ítems del factor coherencia con los hechos (pronóstico) nivel de incertidumbre n % bajo 25 15,3 regular 124 76,1 alto 14 8,6 total 163 100,0 fuente: datos del estudio. para el análisis de los datos los investigadores decidieron sumar los porcentajes de las casillas muy de acuerdo y de acuerdo, así como también las casillas en desacuerdo y muy en desacuerdo, la sumatoria de las anteriores son los resultados que se muestran a continuación. de acuerdo con la tipología de los síntomas, el 86,5 % de los pacientes encuestados no sabe si ha mejorado o empeorado y el 63,2 % de los pacientes no tiene certeza de lo que significa tener dolor para su salud (tabla 2). tabla 2. distribución según la tipología de los síntomas en los pacientes encuestados. cartagena, 2014 ítems ma (%) da (%) mi (%) ed (%) md (%) ¿no sabe si ha mejorado o empeorado? 27,0 59,5 4,3 5,5 3,7 ¿cuando tiene dolor sabe lo que significa para su salud? 1,8 23,9 11,1 35,6 27,6 ¿sus síntomas continúan cambiando impredeciblemente? 24,5 35,6 3,7 28,8 7,4 ¿el curso de su enfermedad se mantiene? 6,1 28,2 3,7 41,7 20,2 ¿generalmente sabe si tendrá un buen o mal día? 14,7 36,8 8,6 26,4 13,5 ¿es claro para usted cuando se va a sentir mejor? 4,3 16,0 4,9 52,1 22,7 ¿su malestar físico es predecible, usted sabe cuándo está mejorando o empeorando? 4,9 13,5 4,9 41,7 35,0 ma: muy de acuerdo. da: de acuerdo. mi: muy indiferente. ed: en desacuerdo. md: muy en desacuerdo. fuente: datos del estudio. ítems ma (%) da (%) mi (%) ed (%) md (%) ¿usted puede predecir cuánto demorará su enfermedad? 33,1 49,1 3,1 5,5 9,2 ¿debido a lo impredecible de su enfermedad no puede planear su futuro? 25,8 46,6 4,9 18,4 4,3 ¿usted no sabe cómo se manejará después que deje el hospital? 27,6 31,3 27,6 11,0 2,5 ¿es difícil determinar cuánto tiempo pasará antes de que pueda cuidarse por sí mismo? 32,5 46,6 3,7 16,6 0,6 ¿usted puede generalmente predecir el curso de su enfermedad? 27,6 51,5 3,7 14,1 3,1 ma: muy de acuerdo. da: de acuerdo. mi: muy indiferente. ed: en desacuerdo. md: muy en desacuerdo. fuente: datos del estudio. el 90,2 % de los pacientes diabéticos considera que es muy difícil saber si el tratamiento le está ayudando y el 84 % afirma no tener claridad con lo que les está sucediendo. de acuerdo con sus capacidades cognitivas, el 84,6 % de los pacientes considera que las explicaciones que le dan los profesionales de salud les parecen confusas, 86,5 % no entienden todo lo que se les explica y 82,2 % consideran que se les suministra demasiada información y por eso no saben cuál es la más importante (tabla 4). 216 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 tabla 4. frecuencia de respuestas a los ítems del factor capacidades cognitivas (información recibida) discusión la edad promedio de los pacientes participantes del presente estudio sugiere que estas personas tienen la posibilidad de convivir con su enfermedad en el futuro, mantener su calidad de vida y disminuir riesgos producidos por la diabetes. esto, y el tiempo promedio de diagnóstico encontrado, señalan que los pacientes requieren cuidados adicionales precisos para mitigar las dificultades presentes y alcanzar las capacidades suficientes para tener un mejor control de su situación personal (2, 7, 11). por otro lado, el bajo e incompleto nivel de escolaridad de los pacientes podría afectar su capacidad de asimilación y comprensión de la información médica recibida de su enfermedad. wallace revela elementos que fortalecen la evidencia de la relación entre educación y tiempo que dura la enfermedad e incertidumbre, concluyendo que a mayor nivel educativo, menor incertidumbre, y que cuanto más familiarizado está el enfermo con su situación de enfermedad, menor incertidumbre presenta (12). asimismo, mishel en su teoría afirma que cuando el paciente se siente extraño y ajeno al contexto clínico, y se le dificulta comprender el lenguaje utilizado por los médicos y otros profesionales de la salud para comunicarse con él, ve afectada su eficiencia cognitiva y se abstraen pocas ideas del discurso especializado que recibe, lo que es causal de incertidumbre (10). el nivel regular de incertidumbre de los pacientes de este estudio podría atribuirse a que los eventos que la generan cada vez son menos relevantes a medida que la enfermedad evoluciona y, por tanto, las necesidades psicosociales varían (13-15). dentro de este marco, es importante reseñar que según la teoría de mishel, la incertidumbre aumenta en las enfermedades con patrones de síntomas ambiguos, así como debido a la cronicidad, la experiencia de nuevas enfermedades, cuando las personas carecen de familiaridad con los hechos y en momentos en que las propias expectativas sobre los acontecimientos no se cumplen (10, 12, 16). las fuentes de las estructuras y las capacidades cognitivas son los ejes críticos de la incertidumbre, y si se considera que a los pacientes del estudio no les han dicho cómo tratar la enfermedad, resultado de las diversas opiniones relacionadas con la naturaleza de la misma, ellos podrían tener dificultad de interpretar lo que les sucede, pues no pueden identificar cuál información es más importante para su salud (14, 15, 17). esto termina generando inseguridades, confusión y frustraciones en los pacientes, ítems ma (%) da (%) mi (%) ed (%) md (%) ¿las explicaciones que le dan parecen confusas? 33,7 50,9 3,1 11,7 0,6 ¿usted entiende todo lo que se le explica? 1,2 8,6 3,7 55,2 31,3 ¿le entregan tanta información que no puede decir cuál es la más importante? 30,1 52,1 4,9 12,3 0,6 ma: muy de acuerdo. da: de acuerdo. mi: muy indiferente. ed: en desacuerdo. md: muy en desacuerdo. fuente: datos del estudio. en lo relacionado con fuente de la estructura, el 91,4 % de los pacientes consideran que las cosas que dicen los profesionales de la salud no tienen mucho significado, al 84,1 % le han entregado diferentes opiniones sobre la enfermedad, el 92,1 % manifestó que no le han dicho cómo tratar su enfermedad (tabla 5). tabla 5. respuestas a los ítems del factor autoridad con credibilidad en pacientes diabéticos participantes. cartagena, 2014 ítems ma (%) da (%) mi (%) ed (%) md (%) ¿los médicos dicen cosas que podrían tener mucho significado? 1,8 1,2 5,5 54,6 36,8 ¿le han estado entregando diferentes opiniones acerca de cuál es su enfermedad? 31,3 52,8 1,8 13,5 0,6 ¿no le han dicho cómo tratar su enfermedad? 34,4 57,7 0,0 7,4 0,6 ¿los médicos comparten la misma opinión acerca de cómo tratar la enfermedad? 0,6 5,5 1,2 54,0 38,7 ¿no le han dado un solo diagnóstico? 12,3 28,2 31,3 28,2 0,0 ma: muy de acuerdo. da: de acuerdo. mi: muy indiferente. ed: en desacuerdo. md: muy en desacuerdo. fuente: datos del estudio. 217 incertidumbre en adultos diabéticos tipo 2 a partir de la teoría de merle mishel l isabel patricia gómez-palencia y otros con un correspondiente deterioro de su salud física y emocional y un aumento de la incertidumbre. de allí la importancia de las capacidades cognitivas de los pacientes, las cuales deben ser estimuladas por el personal de salud brindando apoyo, educación e información clara y precisa al paciente y su familia acerca de la situación de cronicidad, en este caso la diabetes mellitus tipo 2. esta carencia de apoyo social derivado de la contradicción y la falta de trabajo coordinado del equipo de salud, lleva al paciente a crear su propio esquema cognitivo, que puede tener errores respecto al tratamiento y evolución de la enfermedad, y puede acarrear consecuencias desagradables y complicaciones graves, si no se solucionan a tiempo. por ello, machado muestra en sus resultados que, para mejorar la calidad de vida de estos pacientes, habría que promover tanto la prevención como un adecuado tratamiento psicológico de la sintomatología depresiva y ansiosa de los pacientes con diabetes (15, 17). en el presente estudio, la credibilidad de los pacientes en el personal de salud es débil, debido a inconsistencias al proveer información sobre las causas y consecuencias de los síntomas de la diabetes. esto está justificado por la falta de empoderamiento relacionado con los cuidados ofrecidos, afirmando así el aumento de la incertidumbre. algunos autores (14, 16-18) afirman que cuando la autoridad tiene una alta credibilidad, la incertidumbre disminuye. por otra parte, la información fiable y consistente, y la educación procedente de una autoridad creíble, reducen la incertidumbre y la ansiedad derivada, ayudando en la interpretación de la sintomatología, a comprender la situación y a predecir mejor su evolución (16-18). conclusiones a pesar de que los pacientes revelaron un nivel regular de incertidumbre sobre la enfermedad, dicen tener un alto nivel de incertidumbre en la sintomatología debido a la falta de conocimiento acerca de su padecimiento, además de no lograr identificar los signos o síntomas, e ignorar cuándo están mejorando o empeorando. la incertidumbre se encuentra presente en la percepción y el conocimiento de síntomas propios de la diabetes, en el desconocimiento de la enfermedad, y en la falta de apoyo social, de educación y credibilidad del personal de salud. la situación que atraviesan las instituciones de salud, específicamente las de primer nivel de atención, puede estar generando importantes implicaciones en el cuidado de enfermería. la incertidumbre interviene en el ser humano a partir de una situación de cronicidad como es la diabetes mellitus tipo 2, por eso, es indispensable el apoyo a pacientes a partir de un equipo interdisciplinario, donde el profesional de enfermería es una pieza clave en las intervenciones para asumir la incertidumbre positivamente, y convertirla en una oportunidad para el paciente y su familia. la enfermera puede disminuir el grado de incertidumbre en la medida en que provea toda la información necesaria para el paciente sobre su estado. dar soporte educativo y estructural a los pacientes para que puedan conocer y comprender el entorno y contexto en el que se está evolucionando, ayuda a poner en marcha mecanismos individuales de afrontamiento. estos resultados buscan que el personal de enfermería tenga una actitud revolucionaria, que se dé un cambio, que se innove y se comprometa a fondo con ofrecer un cuidado más integral, más holístico, sin perder las bases ni los principios de la enfermería. el reto para las enfermeras es abarcar de manera holística la atención de los pacientes con enfermedades crónicas como la diabetes mellitus tipo 2; estas, a través de sus teorías y prácticas, pueden hacer una importante contribución para mantener a los seres humanos dentro del contexto de sus experiencias del día a día. sin embargo, se necesita de un estudio continuado para medir las teorías y confirmar las posibilidades de generalización en la práctica de enfermería. 218 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 referencias 1. torres a, sanhueza o. modelo estructural de enfermería de calidad de vida e incertidumbre frente a la enfermedad. ciencia y enfermería. 2006:12(1):9-17. 2. magdalena a. el cuidado de la incertidumbre en la vida cotidiana de 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chía, colombia octubre 2005 maría mercedes durán de villalobos1 recibido: 20 de junio de 2005 aprobado: 16 de junio de 2005 resumen este artículo trata de discutir aspectos generales sobre los patrones de conocimiento de enfermería, elementos de fundamentación para el desarrollo del conocimiento y la práctica. en primera instancia muestra la importancia del desarrollo del conocimiento que sustenta la práctica y cómo ese conocimiento se expresa en cuatro patrones: empírico o ciencia de enfermería, ético, estético o arte de enfermería y el conocimiento personal. se hace asimismo una descripción de cada patrón de conocimiento, comenzando por el personal. el significado del patrón de conocimiento personal, el menos desarrollado de los cuatro, se muestra como algo básico para el desarrollo de los patrones ético y estético, ya que es casi condición sin la cual los mencionados patrones no pueden desarrollarse a plenitud ni ser expresados en la práctica de manera satisfactoria. se plantea la discusión de la evolución de las preguntas epistemológicas de los patrones hacia lo filosófico y ontológico. es decir, se pretende progresar del conocer hacia el ser o esencia de lo conocido para terminar resumiendo las repercusiones que tiene la inclusión de los patrones del conocimiento en la sintaxis de la disciplina de enfermería. palabras clave práctica de enfermería, patrón de conocimiento, patrón de conocimiento personal, patrón empírico o ciencia de enfermería, patrón ético y moral de enfermería, patrón estético o arte de enfermería. abstract this article tries to discuss general aspects on models of nursing knowledge, basic elements for its development and practice. first, it shows the importance of the development of knowledge sustained by the practice and the expression of it by means of four knowledge models: empirical or nursing science, ethical, esthetical or nursing art, and personal. a description of each model of knowledge takes place, beginning with the personal one. its meaning is showed as something basic for the development of ethical and aesthetical models, as it is a condition sine qua non such models are not totally developed or expressed satisfactorily in practice. it presents the discussion on evolution of epistemological questions toward philosophy and ontology. it tries to progress in the knowledge of the self or essence of what is known, to end with a summary on repercussions of knowledge models inclusion in syntax of nursing discipline. key words nursing practice, knowledge model, personal knowledge model, empirical model or nursing science, ethical model and nursing moral, aesthetic model or nursing art. * ponencia presentada en el �primer encuentro de profesionales universitarios del proceso diagnóstico de enfermería�, celebrado en la benemérita universidad autónoma de puebla, facultad de enfermería, el 12 de mayo de 2005. 1 profesora titular y emérita, facultad de enfermería, universidad nacional de colombia; profesora asesora, facultad de enfermería, universidad de la sabana, colombia. mmvillalobos@gmail.com la ciencia, la ética y el arte de enfermería a partir del conocimiento personal 87 l presente trabajo busca mostrar la íntima relación que existe entre el proceso diagnóstico de enfermería y su orientación hacia la utilización de las bases filosóficas, científicas y metodológicas como sustento de la disciplina. en este contexto, entonces, es obvio comentar que la expresión del conocimiento de enfermería y su relación con la filosofía y las metodologías utilizadas para el desarrollo del conocimiento particular de la disciplina y el manejo de la práctica tienen gran relación con los conocimientos científico-empíricos, éticos, estéticos y personales que según barbara carper (1) son los patrones de conocimiento de enfermería. esta relación se genera porque, sencillamente, la calidad de la práctica no se puede concebir sin comprender la interacción del cuidado y de las acciones o intervenciones de enfermería con el paciente. pero es atinado comenzar deteniéndonos un tanto en una palabra fund a mental para enfermería: la práctica disciplinaria. todos estamos familiarizados con ella. es lo que hacemos todos los días, ir al trabajo, ir a práctica. la práctica es la esencia de las disciplinas profesionales como enfermería. sin la práctica no existiríamos. ¿pero hasta qué punto estamos conscientes del significado de la práctica? para algunos significa �hacer cosas�, o �procedimientos básicos�, para otros la práctica es lo que se hace en los servicios. si aceptamos estos conceptos la práctica se torna en un conjunto de acciones que hace un profesional, lo cual nos puede dejar un tanto mal parados respecto a nuestro ejercicio. reflexionemos entonces� ¿no habrá una concepción al respecto que se ajuste más al concepto de práctica de una disciplina profesional? martha rogers (2) sugiere que la práctica es la expresión de la forma como utilizamos el conocimiento de enfermería. si enfermería es una ciencia, entonces ella tiene unos fenómenos propios sobre los cuales se debe desarrollar el conocimiento, y si tiene un cuerpo organizado de conocimientos el cual se utiliza en la práctica, el uso creativo de este conocimiento se manifiesta en el arte de la práctica de enfermería. rogers continúa sugiriendo que: muchas enfermeras expresan su preocupación por la teoría viéndola como "una teoría de torre de marfil sin mayor utilidad", pero nada más erróneo y para dar una respuesta a la idea de torre de marfil se puede utilizar esta analogía: los físicos teóricos, los ingenieros y los plomeros utilizan los mismos principios del mundo físico. la naturaleza y la profundidad de su conocimiento es lo que los diferencia, pero sobre todo la manera como lo utilizan (2). entonces, podemos decir que las enfermeras expresamos nuestro conocimiento a través de la práctica y si no pensamos en términos reales del conocimiento podemos entrar en la penumbra de la repetición y el estancamiento. asimismo, el conocimiento se extiende a la investigación, herramienta sin la cual nuestro desarrollo disciplinario fácilmente se estancaría y la práctica se convertiría en el manejo arcaico de actividades derivadas de la tradición o en la repetición de actividades totalmente delegadas por los médicos o los administradores, sin importar el grado de aplicación tecnológica que éstas conlleven. inicialmente la práctica de enfermería se desarrolló casi por imitación, junto a la enfermera experta. rara vez se sistematizaba esa práctica y menos aún el conocimiento que le daba soporte. las enfermeras podían cambiar información pero ésta se enfocaba más en el �cómo�. con la aparición del proceso de enfermería en los años sesenta, las enfermeras comenzaron a tener un lenguaje común que facilitó compartir aspectos de la práctica. cuando revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200588 las enfermeras comenzaron a compartir las experiencias de dar cuidado, el enfoque �procedimental� cambió hacia el de práctica basada en el conocimiento científico (3). la naturaleza de la práctica disciplinar sugiere que ésta debe ser guiada por teorías científicas. la idea de que la práctica y la teoría están separadas y que requieren ligarse es errónea. de igual manera que la teoría estructura a la investigación, la teoría da forma a la práctica. estas dos entidades no son diferentes, más bien son diferentes aspectos del mismo fenómeno. la teoría, la práctica y la investigación no son entidades diferentes de la práctica profesional y éste es el verdadero significado que debemos dar a nuestro quehacer. entonces, si la práctica es la expresión de nuestro conocimiento, es lógico que trabajemos sobre los patrones de conocimiento de enfermería. carper (1) definió que el cuerpo de conocimientos que da soporte a enfermería se manifiesta por patrones, o sea por medio de formas características de expresión externa e interna que dejan ver la manera como se piensa sobre un fenómeno. los patrones no aumentan el conocimiento, más bien ponen su atención en el significado de conocer y sobre las clases de conocimiento que son de mayor ayuda para la disciplina de enfermería. los patrones de conocimiento que identificó carper a partir de un análisis de la estructura conceptual y sintáctica del conocimiento de enfermería fueron cuatro: el empírico o ciencia de enfermería, el ético o componente moral, el estético o arte de enfermería y el conocimiento personal. más tarde, en 1995, silva, sorrell y sorrell (4) sugirieron la expansión de los patrones que va más allá del �conocer�, y proponen que debemos ir hacia la comprensión de las formas de �ser� de estos patrones, o sea, adentrarnos en su significado ontológico. en el mismo año, white (5) propuso una expansión y puesta al día de los patrones iniciales agregando el sociopolítico, el cual hace parte del conocimiento empírico y, por lo tanto, no será tratado de manera individual. chinn y kramer (6) plantean una discusión muy importante respecto al comportamiento de los patrones en su libro teoría y enfermería: desarrollo integrado del conocimiento; en el 2002 edwards (7) analiza los patrones desde las conexiones de éstos con la filosofía de la ciencia y las metodologías científicas, y en 2003, schmith y cols. (8), explican la forma como se puede artilos patrones de conocimiento que identificó carper a partir de un análisis de la estructura conceptual y sintáctica del conocimiento de enfermería fueron cuatro: el empírico o ciencia de enfermería, el ético o componente moral, el estético o arte de enfermería y el conocimiento personal. cular el currículo a partir de los patrones de conocimiento de enfermería, de manera semejante con la propuesta de boikyn en 1994 (9). todos estos autores coinciden en afirmar que los patrones se expresan de manera integrada y que entre ellos existen conexiones sin las cuales sería muy compleja la expresión del cuidado y de las intervenciones de enfermería de manera holística. también están de acuerdo en que la máxima expresión del conocimiento es el patrón estético. el conocimiento personal ¿pero por qué comenzar con el conocimiento personal? porque es a partir de éste que se logra el verdadero arte de enfermería. como se verá a continuación, nosotros podemos expresar el patrón empírico o ciencia de enfermería de manera neutra, pero la expresión de los patrones ético y estético es compleja si no existe un manejo experto del patrón de conocimiento personal por parte de la enfermera. según carper (1), el conocimiento personal es tal vez el patrón más importante cuando se trata de entender el significado de salud en términos de bienestar. si enfermería se entiende como un proceso interpersonal que requiere interacciones, relaciones y transacciones entre el paciente y la enfermera, no cabe duda de la necesidad de que la enfermera se conciba como un ser terapéutico y, por lo tanto, debe conocerse interiormente. existe evidencia �como lo anota mishel citada por carper (1)� de que la calidad de los contactos interpersonales influye en las personas enfermas o con problemas de salud a la hora de afrontar su situación y lograr mayor bienestar. eso hace pensar que "el uso terapéutico de sí mismo" implica una relala ciencia, la ética y el arte de enfermería a partir del conocimiento personal 89 integridad de cada encuentro con el otro, y busca conocer y afirmar la forma única de cada persona y las experiencias únicas de ellas. hall y allan (10) explican el vínculo vital entre el conocimiento personal y las relaciones con otros en su concepto de �ser-en-relación-con�� en donde el �ser� se percibe como un sistema abierto que pertenece a un sistema social. el conocimiento personal no emana de libros, revistas científicas, conferencias o discusiones académicas. se refiere a comprender sin darse cuenta (11). puede ser tan válido como el conocimiento científico y las enfermeras podemos estar seguras de su utilización como soporte para el cuidado. sin embargo, como sugiere edwards (7), este patrón que requiere conocimiento obtenido a través de la experiencia y la intuición no se utiliza para justificar la práctica ni al hablar de su credibilidad en términos de conocimiento empírico. finalmente, se puede agregar que el resultado de este patrón se traduce en la voluntad de aceptar la ambigüedad, la vaguedad y las discrepancias entre uno mismo y los demás. conduce a la discusión sobre las formas de intervenciones con los pacientes y el respeto por sus características individuales, al mismo tiempo que se mantiene la responsabilidad profesional por el bienestar del otro. el conocimiento empírico o ciencia de enfermería una vez aclarado el patrón anterior se puede proseguir con el patrón de conocimiento empírico. el término �ciencia� rara vez se usó en la literatura de enfermería antes de 1950. sin embargo, a partir de esa fecha ha habido un énfasis progresivo, o más bien urgencia por el desarrollo del cuerpo de conocimientos específicos de enfermería. parece existir consenso general sobre la necesidad crítica de generar conocimiento acerca del mundo empírico, el cual es sistemáticamente organizado en leyes generales y teorías que describen, predicen y prescriben sobre los fenómenos relacionados con la disciplina de enfermería. el desarrollo teórico y los esfuerzos investigativos están dirigidos a la generación de explicaciones sistemáticas y controladas, en las cuales las evidencias fácticas figuran en primer lugar para la organización y clasificación del conocimiento. lo que parece importante, por lo menos en el estado de desarrollo de la ciencia de enfermería, es que las estructuras paradigmáticas y teóricas presentan una nueva perspectiva para la consideración de los fenómenos relacionados con el doel conocimiento personal es un proceso dinámico de llegar a convertirse en un ser total y asimismo poder valorar al otro como un todo. es la base de las expresiones de autenticidad, de ser genuino, lo que a su vez es esencial para una relación de cuidado con una meta de bienestar en mente. ción en la cual se requiere conocerse y conocer al paciente porque el �ser� se crea en relación con otros. chinn y kramer (6), plantean un modelo de conocimiento personal que parte de dos preguntas fundamentales: ¿sé lo que hago? y ¿hago lo que sé? al responder afirmativamente a ellas se garantiza que la práctica se pueda llevar a cabo de una manera holística haciendo posible mi totalidad y la del otro en un contexto de experiencia de relación y trascendencia. el conocimiento personal es un proceso dinámico de llegar a convertirse en un ser total y asimismo poder valorar al otro como un todo. es la base de las expresiones de autenticidad, de ser genuino, lo que a su vez es esencial para una relación de cuidado con una meta de bienestar en mente. es extensivo en tanto nos hace asequibles y nos permite comprender la experiencia del otro. le da un significado compartido a la interacción. se expresa de manera congruente, auténtica y genuina en cuerpo-mente-espíritu. es decir, percibiendo al otro a través de cualidades que se logran al ser consciente de estar en el mundo y que expresan lo que la persona es, dentro de un contexto cultural. así, la comunicación se hace vital para una práctica disciplinar en donde es necesario crear una comprensión compartida, y para esto se requiere conocerse y desarrollarse a sí mismo. en última instancia, lo que es importante para crear una auténtica relación personal es valorar al otro en su libertad para crearse a sí mismo y tomar decisiones con autonomía, lo cual implica de nuestra parte dejar de lado generalizaciones, categorías y supuestos derivados de las formas empíricas de conocimiento así como las formas de tratamientos manipuladoras y de control, generalmente impersonales. el conocimiento personal valora la totalidad y la revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200590 minio de la disciplina, y que aspectos tan importantes como el bienestar, la salud, la evolución de los procesos de vida y otros se han legitimado, ya que permiten que la salud y el bienestar sean entendidos como algo dinámico, contextualizado y circunstancial, y se aceptan como elementos de estudio inherentes a la enfermería. este cambio de preguntas o interrogantes que previamente habrían sido imposibles de sugerir, hoy día forman parte necesaria de la indagación disciplinaria (12). es natural que la ciencia de enfermería presente en su desarrollo teórico gran afinidad con la tradición empírica de las ciencias naturales. sin embargo, la noción de lo que constituye el legítimo desarrollo de la ciencia de enfermería se ha ensanchado para incluir la evidencia derivada de la especulación a través de las formas inductivas y su generación consecuente de hipótesis de trabajo, tales como la descripción fenomenológica, la propuesta múltiple de la teoría fundamentada, la comprensión cultural de la etnografía y la hermenéutica y la historiografía. este cambio se refleja en la transición de un vocabulario observable hacia uno en el que los términos tienden a proponer significados diferentes y se definen dentro de un contexto correspondiente a la teoría explicativa (12). dos procesos están inmersos en la estructuración de fenómenos empíricos: 1) la creación del significado conceptual, y 2) la estructuración y contextualización de la teoría. existen además otras formas de conocimiento empírico tales como marcos o modelos conceptuales, principios y descripciones extensas de fenómenos empíricos, pero la teoría es la forma de conocimiento más formal y estructurada de las configuraciones de conocimiento empírico. sería largo explicar qué es teoría, y de todas maneras existen numerosas referencias que dan cuenta de ello; pero desde un punto de vista sencillo se puede sugerir que toda teoría es una articulación de ideas rigurosa y creativa, en donde las ideas se organizan como conceptos representados por palabras simbólicas que harán que la teoría refleje la visión sistemática de un fenómeno. los conceptos deben convergir en declaraciones de relaciones contextuales de la teoría, lo cual a la larga define la estructura sistémica de la teoría. la teoría genera un lenguaje y una estructura que le imprime naturaleza propia y propósito, es decir, que se ha creado por alguna razón pero que, sin embargo, es dinámica, presta a revisión y enraizada en supuestos y juicios de valor. el concepto de creatividad le imprime a la teoría expresión propia, es decir, que por ningún motivo la teoría se improvisa. requiere un proceso riguroso, sistemático, así como una concepción muy bien desarrollada que le crea la impronta de su creador. chinn y kramer (6) proponen una serie de definiciones y explicaciones interesantes para diferenciar los conceptos de ciencia, filosofía, hecho, modelo, marco conceptual o teórico, investigación y paradigma. estas diferenciaciones permiten aclarar términos que han sido utilizados de forma intercambiable al trabajar la epistemología de enfermería, pero que ameritan, hoy día, suficiente claridad. así podremos, de forma más clara y certera, referirnos al conocimiento empírico o ciencia de enfermería. varias teorías de enfermería, así como numerosos esfuerzos investigativos, han sido modeladas según el ideal de la investigación científica de corte positivista y pospositivista. sin embargo, los supuestos y propósitos de la teoría científica frente a los cuales han sido juzgadas las teorías de enfermería reflejan, de una u otra manera, que otros patrones de conocimiento, además del empírico, juegan roles de importancia en el enriquecimiento científico de la disciplina (13). por ejemplo, los modelos de sistemas explican el nivel de bienestar personal en un punto de tiempo particular y como una función de los efectos acumulados de interacciones internas y externas del ambiente del paciente. el concepto de adaptación es central para este tipo de explicación ya que responde a las demandas del ambiente y facilita el mantenimiento y el restablecimiento del estado que se ha denominado meta del sistema. los modelos de desarrollo muchas veces proponen una forma más genérica de explicación, en la cual ciertos eventos aparecen como condiciones principales y necesarias para el desarrollo normal del individuo. la investigación científica es el método por excelencia para la producción de conocimiento empírico debido a que la naturaleza práctica de enfermería, orientada por metas concretas, requiere la prueba teórica como elemento de desarrollo fundamental. la validación y, por ende, la réplica, se convierten en herramientas para la práctica inteligente. es por esta razón que, en nuestra práctica, debemos ir más allá de la simple utilización de teorías. el concepto de creatividad le imprime a la teoría expresión propia, es decir, que por ningún motivo la teoría se improvisa. la ciencia, la ética y el arte de enfermería a partir del conocimiento personal 91 los resultados de nuestra práctica dependen de la ética y la moral. en los últimos tiempos hemos estado muy sensibles por las dificultades de elección que deben tomarse dentro del contexto tan complejo de la salud. estos hechos tienen que ver con aspectos fundamentales de lo que es moralmente correcto en conexión con el cuidado de la salud. los dilemas morales surgen en situaciones de ambigüedad e incertidumbre, pero sobre todo cuando las consecuencias de nuestras acciones son difíciles de predecir y los principios tradicionales y los códigos éticos no ayudan para la solución de los problemas o resultan contradictorios. el código moral que guía la conducta ética de las enfermeras se basa en el principio primario de obligatoriedad emanado del concepto de servicio a la gente, respeto por la vida humana y autonomía de las personas. el patrón de conocimiento ético se enfoca hacia materias de obligatoriedad. va más allá del conocimiento de los códigos y las normas legales. incluye todas aquellas acciones voluntarias que son deliberadas y sujetas al juicio de lo bueno o malo, incluyendo juicios de valor moral relacionados con motivos, intenciones o formas de carácter (1). la enfermería es una acción deliberada, o una serie de acciones planeadas y desarrolladas para lograr metas determinadas; tanto las metas como las acciones conducen a la selección de alternativas que se basan en juicios normativos particulares y generales y, en ocasiones, los juicios y las normas están en conflicto, pero aún así el conocimiento ético se comprende y evalúa en relación con la práctica. se puede esperar que la práctica de enfermería que utiliza el conocimiento ético a través de un proceso disciplinario de diálogo y justificación crezca en su comportamiento moral. el comportamiento ético expresado en la práctica como conocimiento integrado puede conducir a cuestionamientos profundos; si esto ocurre se llegará a los procesos de valoración y clarificación (6). lo moral y lo ético se confunden muchas veces y se utilizan también como sinónimos en la literatura de enfermería. la distinción entre estos dos términos refleja la tensión entre la epistemología y la ontología, y la dificultad de separar lo que sabemos o conocemos de lo que somos. en general, la ética se refiere a aspectos epistemológicos, lo moral se refiere a lo ontológico. la ética es una disciplina, una rama del conocimiento que trata sobre lo correcto-incorrecto, el bien-el mal y por ello existen teorías éticas, principios, reglas, códigos, leyes, listas de obligaciones o deberes y descripciones de comportamientos éticos. en contraste, lo moral se la práctica se debe convertir en el dinamizador de ellas ya que es en la práctica en donde se prueban y se expanden. es decir, que la práctica basada en la teoría, su réplica y validación, contribuyen a nuestro desarrollo de la competencia científica ya que refinan los significados conceptuales y validan las relaciones teóricas y los resultados derivados de éstas. en resumen, se puede decir que el patrón empírico es fáctico, descriptivo en última instancia de acuerdo con los últimos desarrollos, deductivo y generador de teoría, aunque como se vio anteriormente, pueden incluirse en este patrón de conocimiento los paradigmas naturalista, relativista e interpretativo. es discutible y públicamente verificable (1, 13). sin ninguna duda, el conocimiento empírico es fundamental para los propósitos de enfermería. pero enfermería también requiere estar consciente del hecho de que los modelos humanos en s u abstracción son generalizables y categorizables siempre y cuando se refieran a lo común de las personas y los grupos. por ello ninguna de estas categorías puede expresar la individualidad de las personas en sí mismas. es por esta razón que enfermería debe promover el desarrollo y la expresión de otros patrones que nos permitan tratar de comprender de mejor manera las expresiones de la naturaleza humana. el patrón ético y el comportamiento moral de enfermería enfermería es una profesión que requiere conocimiento ético para guiar la práctica. cualquiera que sea la experiencia de la enfermera o su lugar de trabajo la investigación científica es el método por excelencia para la producción de conocimiento empírico debido a que la naturaleza práctica de enfermería, orientada por metas concretas, requiere la prueba teórica como elemento de desarrollo fundamental. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200592 refiere al comportamiento basado y expresado de acuerdo con nuestros valores. si la ética es trabajo cerebral, lo moral es trabajo del corazón. la moralidad se refleja en nuestra vida diaria y expresa nuestras apreciaciones valorativas, lo cual está profundamente fundamentado en la cultura y el carácter. lo que constituye el comportamiento moral puede variar dependiendo de lo que es importante dentro de una cultura. cuando las personas se comportan de acuerdo con sus valores, la integridad moral se puede apreciar claramente y, por el contrario, cuando el comportamiento moral se ve afectado por factores situacionales ocurre el dolor moral. finalmente, se puede agregar que el mérito del conocimiento ético está íntimamente relacionado con su habilidad para contribuir a la práctica. ello implica estar consciente de quiénes participan en la práctica de enfermería. implica acciones arraigadas en la creencia de la capacidad de elección del paciente y la enfermera. implica las acciones requeridas para disminuir la opresión moral que las enfermeras enfrentamos cuando nos debatimos entre dilemas éticos y morales. el patrón ético se relaciona directamente con las decisiones éticas de cada día. la ética va más allá de las propuestas discursivas. se sustenta en las decisiones de la práctica y se asume como la expresión de la práctica relacionada con los valores y la moral. y los valores y la moral se relacionan directamente con el conocimiento de sí mismo. de acuerdo con chinn y kramer (6), al examinar las cuestiones sobre el conocimiento ético surgen ciertas preguntas: ¿hacia dónde debe ir el conocimiento ético? ¿qué debe hacerse para que la práctica amerite ser llamada ética o moral? ¿qué valores respaldan la ética y la moral de enfermería? ¿qué tipo de perspectiva de desarrollo ético y moral debe desarrollarse y promoverse? y, asimismo, emergen múltiples preguntas relacionadas con la tecnología y otros factores que apuntan al desarrollo de la práctica no sólo del cuidado, sino de ámbitos complejos del contexto de la salud que por estar sujetos a decisiones externas e intereses diferentes a los relacionados con la promoción y el mantenimiento de la salud de las personas chocan con los esfuerzos por mantener prácticas éticas y morales. patrón estético o el arte de enfermería �el acto artístico significa hacer lo que se debe hacer, en el momento preciso, logrando que el paciente y la enfermera tengan certeza de la bondad de la intervención�. ninguna persona que esté familiarizada con la literatura de enfermería puede negar que el mayor énfasis que se ha dado al desarrollo del conocimiento está cifrado en la ciencia de enfermería. no obstante existe, por otro lado, una admisión tácita que se puede describir como que, por lo menos en parte, enfermería es un arte. pero lo que generalmente se entiende como arte en enfermería se refiere a las categorías de trabajos manuales o a las habilidades técnicas de la práctica de enfermería (1). nada más erróneo. el arte es el proceso de crear un objeto o una experiencia estética, también se utiliza el término para referirse al producto creado. el arte envuelve habilidades adquiridas de índole mecánica y técnica, y aspectos de trabajo con elementos que se requieren para elaborar el producto, además de capacidades internas que permitan imaginar el todo con anterioridad a que se convierta en experiencia e intuitivamente agrupar los elementos para que ésta se produzca (6). el arte expande las capacidades y posibilidades preceptuales. está presente en todas las actividades humanas que tienen que ver con relacionar elementos en un todo. a pesar de la abstracta y fluida definición de arte que se propone, el significado de estética se puede distinguir del significado de ciencia por varios factores. se debe reconocer que el arte es expresivo y no formal, y que la creación estética es una experiencia que involucra la creación y apreciación de una realidad que es única, particular, subjetiva, de múltiples posibilidades o realidades que se resisten a la proyección de una forma discursiva desde el punto de vista del lenguaje. esas cualidades estéticas, que según chinn y kramer (6), se construyen a partir de elementos ubicados en un patrón que da forma a un todo, y tienen un significado simbólico que se proyecta más allá de los elementos mismos, se reflejan en todos los aspectos de la práctica de enfermería. están presentes en las notas de enfermería, en formulaciones teóricas, en una breve interacción con una persona o en intervenciones sostenidas �el acto artístico significa hacer lo que se debe hacer, en el momento preciso, logrando que el paciente y la enfermera tengan certeza de la bondad de la intervención�. la ciencia, la ética y el arte de enfermería a partir del conocimiento personal 93 cuerda con la conceptualización temprana del arte de enfermería. esta habilidad se deriva de los continuos ensayos para mejorar la habilidad técnica, o lo que benner y wrubel (16) llaman conocimiento �a la mano�. el cuarto elemento se identifica como la habilidad para determinar un curso de acción de enfermería racional y apropiado, o lo que benner, tanner y chesla (17) llaman juicio clínico y razonamiento. finalmente, johnson expresa la habilidad de mantener la conducta moral de la práctica, lo que se convierte en un aspecto prioritario para poder generar un acto estético. de acuerdo con carper (1), silva y cols. (4), chinn en chinn y watson (18), chinn y kramer (6) y white (5), el proceso para desarrollar el conocimiento estético pasa por imaginar posibilidades y formar elementos que permitan percibir la realidad a través de representaciones creativas con posibilidades de transformar el comportamiento de los pacientes y de la enfermera con el fin de desarrollar significados expresados en su proceder. silva y cols. (4) explican la evolución de las preguntas epistemológicas de los patrones planteadas por carper como una expansión de lo epistemológico o lo relacionado con el conocimiento hacia lo ontológico o lo relacionado con la esencia de ser. en esta expansión las autoras tratan de profundizar en lo que denominan �los más allá� y �los en medio de� (traducción personal de villalobos [12]) mostrando estos dos nuevos conceptos: lo inexplicable y lo desconocido. en este orden de ideas podemos decir que: 1. las reflexiones epistemológicas del patrón empírico se relacionan con la pregunta ¿cómo se logra conocer lo conocido? carper enfoca esta cuestión en los procesos finales del conocimiento más que en el proceso de conocer. sin embargo, la filosofía idealista propone que existe un más allá que genera la verdadera naturaleza de los objetos. el significado de ese más allá no puede entenderse a través de las formas corrientes de relacionar objetos y eventos. tenemos, entonces, la oportunidad de echar un vistazo reflexivo a los �más allá� y �los en medio de� de las situaciones diarias de la práctica teniendo en cuenta que los significados inherentes a las reflexiones pueden estar eclipsados por la cotidianidad y oscurecen las percepciones. entonces, la pregunta epistemológica de cómo conocer lo conocido evoluciona a la ontológica de cómo encontrar sentido a lo que se conoce. lo cual es más importante, ya que sin comprender cómo se relacionan los objetos y los eventos, se pueden entender de forma distorsionada. 2. la cuestión de cómo conocer lo que ética y moralmente se debe hacer se transforma en cómo me debo comportar ética y moralmente. este tipo de conocimiento va más allá de lo que es conocer para determinar la validez de mis actos. con grupos y desde un encuentro inesperado hasta un sistema de cuidado pensado y planeado cuidadosamente. en todas estas experiencias se utilizan ciencia, ética, conocimiento personal y finalmente conocimiento estético. porque es el conocimiento estético el que globaliza los demás patrones de conocimiento y hace del acto de cuidar un acto artístico; pero, sin duda, el primer paso requerido para generar el acto estético se construye a partir del conocimiento personal. de acuerdo con johnson (14, 15) gran parte de la dificultad que tenemos para especificar el arte de enfermería se relaciona con el hecho de que reside en un plano ontológico; se expresa a través del �ser-conocer� de la enfermera. por este motivo no parece lógico separar lo que se percibe como estético y lo que se deriva de los otros patrones de conocimiento. podemos reconocer aquello específicamente estético pero, como se señaló, es imposible separarlo de los componentes científico y ético, y del uso terapéutico de sí mismo. silva y cols. (4) se preguntan ¿cómo se llega a conocer lo artístico? para entender lo artístico se requiere sincronía transformativa de movimientos y la respuesta puede estar en los planteamientos de johnson (14, 15). lo primero que se identifica es que el arte de enfermería requiere de la habilidad de comprender los significados en las relaciones o encuentros con el paciente. esta cualidad es necesaria si la enfermera desea transformar la experiencia de salud, para lo cual precisa eliminar las preconcepciones y los prejuicios para tratar a quien se cuida. lo segundo es la habilidad de establecer conexiones significativas con el paciente, lo cual requiere de la capacidad para comprender los significados ya que los movimientos transformativos deben estar en �la presencia del otro�, literal o simbólicamente. el tercer elemento señalado por johnson es la destreza para desarrollar con habilidad las actividades, lo cual conlo primero que se identifica es que el arte de enfermería requiere de la habilidad de comprender los significados en las relaciones o encuentros con el paciente. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200594 se reconoce que si se actúa en el deber conocer se pueden crear conflictos de conciencia. la conciencia requiere autorreflexión y juicio sobre la moralidad de los propios actos. es una sanción interna que llama la atención sobre la pérdid a r e a l o p o t e n c i a l d e l s e n t i d o d e totalidad e integración. entonces la pregunta ontológica, �el más allá�, se convierte en poder contestarnos si violamos nuestra propia conciencia y si se puede �y de qué forma se puede� articular el conjunto de elementos situacionales. 3. en tercer lugar está la cuestión estética. la pregunta epistemológica de cómo conocer lo estético se transforma en la necesidad ontológica de encontrar sentido a través de la sensibilidad por el arte y la belleza. sólo a través de la comprensión de �los más allá� y los �en medio de� se podrá comunicar con su verdadera esencia, aun en los actos más simples. es decir, el conocimiento estético puede ir más allá de lo planteado por harper, debe explicar cómo ese arte despierta las sensibilidades preceptuales que pueden dar sentido a la realidad de conocer y �ser� (4). 4. finalmente, la evolución del patrón de conocimiento personal que, como se dijo, es el más significativo a la hora de entender la salud en términos de bienestar personal. este patrón debe avanzar hacia la comprensión de cómo soy. el énfasis no lo debemos hacer acerca de ser, sino de conocer a ese �ser�. ¿se puede conocer al �ser� sin conocer los �más allá� y los �en medio de� que provienen de las sobreposiciones del conocimiento personal con los otros patrones de conocimiento? este hecho está tan íntimamente relacionado como el conocimiento personal, el ético y el estético. la enfermería está retornando a las cosas en sí mismas. benner y otras investigadoras han desarrollado indagaciones enfocadas al hecho ontológico concerniente a enfermería, y estas explicaciones han facilitado retomar la apreciación por la comprensión de formas de ser que dan sentido a la práctica disciplinaria (4). las repercusiones que tiene la inclusión de los patrones del conocimiento como elemento fundamental de la sintaxis de la disciplina, incluyendo como parte de ésta la práctica disciplinar, se pueden resumir así: 1. los patrones representan una perspectiva estructural del conjunto de conocimientos requeridos para sustentar la práctica de enfermería. 2. cada uno de los patrones de conocimiento representa una forma de conocimiento necesaria pero incompleta para abordar los problemas de la práctica. 3. mientras cada patrón puede tratarse aisladamente, hasta cierto punto, los métodos que determinan su credibilidad promueven cierto tipo de integración del conocimiento. 4. el método utilizado para trabajar un patrón no puede utilizarse para el tratamiento del otro, pero en el proceso de integración del conocimiento se puede hacer uso de varios de ellos. 5. todo el conocimiento está sujeto a cambio y revisión. por supuesto, la práctica merece el mismo tratamiento. cada solución de un problema sugiere nuevas inquietudes y plantea nuevos problemas no resueltos. los problemas nuevos requieren en la mayoría de los casos nuevos enfoques metodológicos y estructuras conceptuales, y esto cambia el patrón y la forma de conocer. con estos cambios la práctica y la enseñanza requieren renovarse. cuidar a otros requiere que logremos el desarrollo de la ciencia de enfermería, es decir, la sistematización y organización del conocimiento fáctico en forma de teorías que expresen claramente el comportamiento de los fenómenos de la salud. pero el conocimiento de nosotros mismos, la creatividad y nuestras decisiones morales también juegan un papel muy importante en la sintaxis del descubrimiento de la ciencia. la razón para desarrollar, a través de la investigación, los patrones de conocimiento es crear y redefinir la práctica de enfermería experta. el aporte que enfermería le hace al cuidado y su perspectiva única de cuidado se deriva del cuerpo de conocimientos de la disciplina el cual ha sobrevivido a pesar de la cultura y los contextos dominantes del conocimiento pospositivista (19). la idea de que el desarrollo del conocimiento se puede separar de la realidad práctica es desafortunada ya que para explicar la complejidad del ser humano en relación con su salud y las relaciones del cuidado entre ese ser humano y las enfermeras se requiere echar mano de las experiencias reales. en resumen, el mensaje que debe quedar en cada uno de los profesionales de la ciencia, la ética y el arte de enfermería a partir del conocimiento personal 95 enfermería es que el conocimiento de la disciplina es complejo y se expresa de formas diversas pero que se articulan de manera inseparable y que se deben investigar; además, para lograr una verdadera exprereferencias bibliográficas 1. carper b. fundamental patterns of knowing in nursing. adv nurs sci 1978;1(1):13-23. 2. rogers me. nursing science evolves. in: madrid m, barret ea, editors. roger�s scientific art of nursing practice. new york: national league for nursing press; 1994. 3. alligood mr. toward a unitary view of nursing practice. in: madrid m, barrett ea, editors. roger´s scientific art of nursing. new york: national league for nurssing press; 1994. 4. silva mc, sorrell jm, sorrell cd. from carper´s patterns of knowing to ways of being: an ontological philosophical shift in nursing. adv nurs sci 1995;18(1). 5. white j. patterns of knowing: review, critique and update. adv nurs sci 1995;17(4):73-86. 6. chinn pl, kramer m. theory and nursing: integrater knowledge development. 5th ed. saint louis: mosby; 1999. 7. edwards. nursing knowledge: defining new boundaries. nurs stand. 2002;17(2):40-44. 8. schmith l, nelson d, godfrey l. a clinical lader program based on carper�s fundamental patterns of knowing in nursing. nurs adm 2003;33(3):146-152. 9. boikyn a, editor. living a caring / based program. new york: national league for nursing press; 1994. 10. hall ba, allan jd. self in relation: a prolegomenon for holistic nursing. nurs outlook 1994;42(3):110-114. 11. benner p, tanner c. clinical judgement: how expert nurses use intuition. american journal of nursing 1987;87(1):23-31. 12. villalobos de mm. enfermería: desarrollo teórico e investigativo. bogotá: unibiblos; 1998. 13. chinn pl, jacobs m. theory and nursing. 2nd ed. st. louis: the cv mosby company; 1987. 14. johnson jl. a dialectical examination of nursing art. adv nurs sci 1994;17(1):1-14. 15. johnson jl. dialectical analysis concerning the rational aspect of the art of nursing. image j nurs sch 1996;28(2):169-175. 16. benner p, wrubel j. the primacy of caring: stress and coping in health and ilmess. 17. benner p, tanner ca, chesla ca. expertice in nursing practice: caring, clinical judgement and ethics. new york: springer publishing company; 1996. 18. chinn pl, watson j, editors. art and aesthetics in nursing. new york: national league for nursing press; 1994. 19. fry st. neglect of philosophical inquiry in nursing: cause and effect. in: kikuchi jf, simmons h, editors. philosophic inquiry in nursing. newburry psrk, ca: sage; 1992. sión del patrón estético se requiere a la vez la inclusión adecuada de los otros tres patrones, pero sin el desarrollo de nuestro patrón de conocimiento personal, es decir, sin ser capaces de generar una práctica en donde la interacción y la transacción con el paciente nos permitan crecer mutuamente, ponemos en duda la posibilidad de controlar las contingencias de la práctica de enfermería. 380 389 no es facil estar 24 horas.indd 380 indira islem tejada-pérez1 “no es fácil estar 24 horas en una cama”: confort del paciente con sedación en una unidad de cuidado intensivo2 1 orcid.org/0000-0001-8227-8812. universidad de antioquia, colombia. indira.tejada@udea.edu.co 2 artículo derivado de la investigación: el confort del paciente con sedación: mirada del enfermero en una unidad de cuidado intensivo recibido: 21 de junio de 2016 enviado a pares: 15 de julio de 2016 aceptado por pares: 20 de diciembre de 2016 aprobado: 13 de febrero de 2017 doi: 10.5294/aqui.2017.17.4.2 para citar este artículo / to reference this article / para citar este artigo tejada-pérez ii. “no es fácil estar 24 horas en una cama”: confort del paciente con sedación en uci. aquichan. 2017; 17(4): 380-389. doi: 10.5294/aqui.2017.17.4.2 resumen objetivo: comprender el significado que tiene para el enfermero el confort del paciente en estado crítico, que se encuentra bajo efectos de sedación en la unidad de cuidado intensivo. materiales y métodos: enfoque cualitativo, con herramientas de la etnografía particularista; se realizaron 100 horas de observación, 9 entrevistas, 1 grupo focal y registro en el diario de campo; lo anterior permitió triangular, codificar y categorizar la información para obtener una visión total del fenómeno; se garantizó la confidencialidad de los participantes. resultados: el significado que le otorgan los enfermeros al confort del paciente bajo efectos de sedación es “estar tranquilo”, entendido como la armonía entre tres filiaciones: ambiente y compañía, comodidad y protección, analgesia y sedación, cada una con elementos excluyentes pero interdependientes, que determinan la tranquilidad del paciente. conclusiones: el paciente en estado crítico, bajo efectos de sedación, no es consciente de sus necesidades, por tanto, depende del enfermero para identificarlas y satisfacerlas. para ello, el enfermero interpreta los signos manifestados por el paciente y aplica el cuidado compasivo, para brindar confort a la persona cuidada. palabras clave enfermería; pacientes; cuidados críticos; comodidad del paciente; sedación profunda (fuente: mesh, nlm). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 380-389 381 “no es fácil estar 24 horas en una cama”: confort del paciente con sedación en una unidad de cuidado intensivo l indira islem tejada-pérez año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 380-389 “it is not easy to stay in a bed for 24 hours.” comfort of the sedated patient in an intensive care unit abstract objective: comprehend what nurses understand as the comfort of a patient in critical condition who is under the effects of sedation in an intensive care unit. materials and methods: a qualitative approach was used, with particularistic ethnography tools. one hundred (100) hours of observation, nine interviews and one focus group were conducted and records were kept in a field diary, all of which made it possible to triangulate, codify and categorize the information in order to obtain a comprehensive view of the phenomenon. the confidentiality of the participants was guaranteed. results: the meaning nurses give to the comfort of a patient who is under the effects of sedation is "to be calm", which is understood as harmony between three associations: environment and company, comfort and protection, analgesia and sedation, each with exclusive but interdependent elements that determine the tranquility of the patient. conclusions: a patient who is in critical condition and under the effects of sedation is not aware of his or her needs. therefore, it is up to the nurse to identify and satisfy those needs. to do so, the nurse interprets the signs manifest by the patient and applies compassionate care to provide comfort to the person being cared for. key words nursing; patients; critical care; patient comfort; deep sedation (source: mesh, nlm). 382 aquichan issn 1657-5997 eissn 2027-5374 “não é fácil ficar 24 horas na cama”: conforto do paciente com sedação numa unidade de tratamento intensivo resumo objetivo: compreender o significado que tem para o enfermeiro o conforto do paciente em estado crítico, que se encontra sob efeitos de sedação na unidade de tratamento intensivo. materiais e métodos: abordagem qualitativa, com ferramentas da etnografia particularista; realizaram-se 100 horas de observação, 9 entrevistas, 1 grupo focal e registro no diário de campo; o anterior permitiu triangular, codificar e categorizar a informação para obter uma visão total do fenômeno; garantiu-se a confidencialidade dos participantes. resultados: o significado que os enfermeiros outorgam ao conforto do paciente sob efeitos de sedação é “estar tranquilo”, entendido como a harmonia entre: ambiente e companhia, conforto e proteção, analgesia e sedação, cada um com elementos excludentes, mas interdependentes, que determinam a tranquilidade do paciente. conclusões: o paciente em estado crítico, sob efeitos de sedação, não é consciente de suas necessidades, portanto depende do enfermeiro para identificá-las e satisfazê-las. para isso, o enfermeiro interpreta os sinais manifestados pelo paciente e aplica o cuidado compassivo, para oferecer conforto à pessoa cuidada. palavras-chave conforto do paciente; cuidados críticos; enfermagem; pacientes; sedação profunda (fonte: mesh, nlm). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 380-389 383 “no es fácil estar 24 horas en una cama”: confort del paciente con sedación en una unidad de cuidado intensivo l indira islem tejada-pérez introducción según ribeiro, al hablar de la disciplina de enfermería, “a pesar de que a lo largo de los años ha sido atribuido el concepto de confort a un significado de menor importancia, […] hoy se reconoce como un fenómeno de interés, considerado indispensable en el cuidado humano holístico” (1); esto, gracias a las transformaciones sociales, económicas, culturales y políticas que determinaron cambios importantes en el desarrollo histórico de la enfermería que, sumadas a la influencia de otras disciplinas, como la sociología, la filosofía y la antropología, permitieron dilucidar el concepto de confort desde diferentes perspectivas. asimismo, las intervenciones de enfermería en la búsqueda del confort del paciente han estado permeadas, no solo por la concepción que se tiene sobre esta noción, sino por los avances tecnológicos y científicos que han implicado variaciones en el cuidado. en el caso del paciente en estado crítico de salud, la influencia de dichos cambios ha sido más evidente, dado que la unidad de cuidado intensivo (uci) es un servicio donde se realizan procedimientos e intervenciones de alta complejidad (2), donde la tecnología es considerada una herramienta importante para el desarrollo de dichos procesos. más aún, el paciente que se encuentra en este servicio, como consecuencia de su proceso de enfermedad, recibe múltiples tratamientos, entre los cuales se encuentra la sedación; esta genera cambios neurológicos y limitaciones en la comunicación verbal, y dependencia de la persona de las intervenciones del enfermero, no solo para conseguir la recuperación de su estado de salud, sino para satisfacer sus necesidades, entre ellas el confort. en este sentido, k. kolcaba define el confort como el “estado que experimentan los pacientes, que han sido receptores de las intervenciones de cuidado cuando se abordan las necesidades de alivio, tranquilidad y trascendencia, en cuatro contextos: físico, psicoespiritual, sociocultural y ambiental” (3). materiales y métodos este estudio se abordó a partir de un enfoque cualitativo, de tipo etnográfico particularista; las técnicas de recolección de información utilizadas fueron la observación participante, la entrevista (grabada), el grupo focal y el diario de campo. los participantes fueron enfermeros que cuidaran o hubieran cuidado a pacientes adultos en estado crítico de salud, bajo efectos de sedación, en el contexto de la uci; no fueron criterios de inclusión o exclusión la edad, el sexo, la raza o la experiencia de los participantes en el momento de su selección. los participantes fueron 9 mujeres y 3 hombres; el promedio de edad fue de 30 años, con un tiempo de experiencia de 5 años en una uci. como resultado se llevaron a cabo cien horas de observación, hasta lograr la saturación de categorías. en la triangulación metodológica, durante la codificación y categorización, se empleó una técnica propia de la teoría fundamentada conocida como el método comparativo constante de glasser y strauss, por el cual “el investigador simultáneamente codifica y analiza información para desarrollar conceptos” (4). los registros fueron consignados inmediatamente terminada la observación en el diario de campo. con el fin de orientar la observación se plantearon referentes como la descripción del contexto, la dinámica de los participantes, los procesos de comunicación y de interrelación, las características del servicio y las acciones relacionadas con el cuidado de los pacientes que se encuentran bajo efectos de sedación. asimismo, se realizaron nueve entrevistas, teniendo en cuenta miradores como la experiencia de cuidar a pacientes en estado crítico bajo efectos de sedación y las prácticas implementadas para brindarles confort; antes de iniciar cada entrevista se recordó al participante el objetivo del estudio, y se hizo énfasis en el respeto por la confidencialidad de la identidad y de la información obtenida. se logró saturación de la información con nueve participantes, por tanto, se decidió realizar un grupo focal compuesto por tres enfermeros, con el fin de confirmar los resultados y dar credibilidad a los mismos. según morse, “en el ámbito de la investigación cualitativa se entiende por saturación el punto en el cual se ha escuchado ya una cierta diversidad de ideas y con cada entrevista u observación adicional no aparecen ya otros elementos” (5). los encuentros quedaron consignados en el diario de campo. a medida que se registraba la información obtenida a través de los diferentes instrumentos, se realizaban conclusiones preliminares donde se evidenciaba el contraste entre la información obtenida, la interpretación de la investigadora y los referentes teóricos pertinentes en cada caso (6). lo anterior permitió dar inicio al proceso de triangulación de la información, codificación y categorización. el proceso de codificación se desarrolló en dos fases. en primera instancia, se hizo codificación abierta, donde surgieron unas categorías iniciales, “estar tranquilo” y “confort: 384 año 17 vol. 17 nº 4 chía, colombia diciembre 2017 aquichan issn 1657-5997 eissn 2027-5374 utopía o realidad”; posteriormente, en la codificación axial, se relacionaron las categorías centrales con el fin de darle sentido a los hallazgos y describir el significado. “a lo largo del análisis, se trata de obtener una comprensión más profunda de lo que se ha estudiado, y se continúan refinando las interpretaciones” (4). se subraya que el proyecto fue avalado por el comité de bioética de investigación en humanos de la sede de investigación universitaria (cbe-siu), y recibió aprobación por parte de la institución de salud donde se llevaron a cabo las entrevistas y observaciones. a los participantes se les mostró y explicó el consentimiento informado, documento que fue elaborado de forma legible, clara y coherente; asimismo, se especificó la privacidad de los sujetos y la institución, se hizo énfasis en la participación voluntaria y en la posibilidad de retirarse del estudio si en algún momento lo consideraban. resultados los enfermeros que cuidan o han cuidado a pacientes en estado crítico de salud bajo efectos de sedación hacen referencia al confort de la persona cuidada como un estado de tranquilidad: “…es un estado donde cualquier ser humano no quiere salir, porque está con todas sus necesidades satisfechas, se siente tranquilo, no hay nada que lo agobie”. e5 de esta manera, para que el paciente pueda llegar a un estado de tranquilidad debe existir una armonía, en primer lugar, entre el ambiente y la compañía, es decir, los estímulos externos del entorno —sonidos, iluminación y temperatura—, unidos a la interacción con las personas que rodean al paciente, deben cumplir ciertas condiciones: “…es un paciente que está entre cuatro paredes, que necesita mucho cariño, mucha fe, y si la familia no se la da, se lo debemos dar nosotros”. egf1 como segundo elemento está la armonía entre la comodidad y la protección, entendida la primera como la ausencia de sensaciones desagradables, tanto físicas como emocionales; y la segunda, como la capacidad que tiene el enfermero de identificar las situaciones que puedan llevar a que el paciente esté expuesto a riesgos que deben ser prevenidos: “…es como uno sienta que ellos están cómodos; creyendo que de cierta manera estén cómodos a lo que cree uno”. e6 por último, la armonía entre la analgesia y la sedación, que hace referencia a las actividades que realiza el enfermero para lograr que el paciente no tenga dolor y que la sedación se encuentre en los niveles adecuados para brindar comodidad, tanto al paciente como al enfermero que lo cuida: “…de nada sirve tener al paciente sedado y con dolor”. e7 en este sentido es preciso señalar que, para los enfermeros, uno de los elementos principales del confort del paciente en estado crítico bajo efectos de sedación es la conciliación entre la comodidad y la protección, la cual hace referencia a las habilidades que tiene el enfermero para interpretar y satisfacer las necesidades de esa persona que es vulnerable y dependiente del cuidado de enfermería. ¿qué es la comodidad? la comodidad, entendida como la ausencia de sensaciones desagradables, tanto físicas como emocionales, es identificada por el enfermero mediante la interpretación de los signos endógenos o exógenos manifestados por el paciente. así pues, el enfermero, al ponerse en el lugar del paciente vulnerable, logra identificar las condiciones relacionadas con la higiene, la alimentación, la posición y los procedimientos de rutina que puedan generarle comodidad o incomodidad. ¿cómo interpretar al paciente? “se les nota por encima que están incómodos”. egf1 los participantes consideran que el paciente en estado crítico de salud, debido a los efectos producidos por la sedación, no puede expresar verbalmente sus necesidades insatisfechas; sin embargo, existen signos que el enfermero interpreta para poder identificar dichas necesidades y plantear intervenciones dirigidas a la satisfacción de las mismas. el profesional tiene en cuenta dos grupos de signos. los signos exógenos hacen mención de las alarmas de los monitores, ventiladores o equipos biomédicos, que de alguna manera le informan o señalan al enfermero que algo ocurre con el paciente; los signos endógenos son aquellos que se observan directamente en el paciente: movimientos oculares, gestos, sudoración e inquietud: “…hay signos, entre esos podrían ser la alteración de los signos vitales, facies de dolor o de incomodidad […] el mismo ventilador cuando hay fatiga ventilatoria o alguna alteración”. e1 385 “no es fácil estar 24 horas en una cama”: confort del paciente con sedación en una unidad de cuidado intensivo l indira islem tejada-pérez ¿cuáles son las condiciones de comodidad? “es como colocarse en el lugar de ese paciente”. e9 tener al paciente en condiciones de comodidad significa, para los participantes, suplir las necesidades que consideran, desde su propia percepción, como básicas para cualquier ser humano; ellas son alimentación, higiene, posición, temperatura, vestido, entre otros. ellos se sitúan en el lugar del paciente, y a partir de esta experiencia, plantean los cuidados que, consideran, contribuyen a la comodidad de la persona cuidada. “…yo pienso es, si yo estuviera ahí acostada, qué necesitaría, qué me gustaría que me hicieran […] es que me cambien de posición, es que me lubriquen la piel, es que me laven la boca, es que me bañen bien, es que me peinen”. egf1 higiene. la higiene del paciente es considerada por los participantes una necesidad fundamental, que contribuye a la tranquilidad. de ahí que enfatizan que, ponerse en el lugar del paciente y sentirse limpio, con aspecto y aroma agradable, genera comodidad y, por ende, tranquilidad: “… como es de bueno uno bañarse, como es de bueno cepillarse, como es de bueno uno peinarse”. e7 alimentación. es considerada por los participantes como una ayuda importante para la recuperación del paciente. sin embargo, la principal preocupación es la eliminación de los desechos del organismo, pues consideran que no hacerlo de forma frecuente genera incomodidad e intranquilidad: “… así suene feo, pero no hay mejor placer que cuando uno entra al baño, es que claro usted está liberando a su organismo de los desechos que son cosas incómodas. y los pacientes son felices cuando pueden, y cuando no, les duele y es incómodo”. egf1 posición. la permanencia en cama es reconocida como una condición de incomodidad. así pues, el enfermero, en búsqueda de proporcionar comodidad, realiza cambios de posición en el paciente a partir de su propio concepto de comodidad y de signos endógenos que le indican que la posición definida no satisface la necesidad de la persona cuidada: “…no es fácil estar 24 horas en una cama”. e2 “…lo otro es la cama, uno busca, no es el ladito que a mí me guste sino el que al paciente le guste, yo procuro eso, es que no es su cama, es que no es su almohada, es que no es su ambiente, entonces uno trata, hasta donde le es posible, que el paciente quede medio cómodo”. e1 procedimientos y dispositivos. el paciente, por razón de su tratamiento, necesita ser sometido a procedimientos y dispositivos médicos que, según los participantes, generan incomodidad que no puede ser mitigada por intervenciones enfermeras: “hay incomodidades que nos tocan”. e4 “…porque uno se quita lo que a uno le estorba y uno dormido, es que eso es incomodidad, eso me estorba... y en uci nosotros que le metemos sondas por todos los orificios, orificio que se respete está invadido de sondas”. egf1 ¿qué es la protección? la protección tiene que ver con las intervenciones que realiza el enfermero con el objetivo disminuir los riesgos a los que está expuesto el paciente en estado crítico, el cual es vulnerable y dependiente, no solo por su estado de salud, sino, además, por los efectos de los sedantes en su estado de conciencia. abarca dos elementos fundamentales: ser vulnerable y estar expuesto. ¿qué es ser vulnerable? los participantes describen al paciente como una persona vulnerable y dependiente de cuidado, pues, como consecuencia de los efectos de los medicamentos sedantes en el sistema nervioso central, este pierde su autonomía en cuidados básicos como la higiene, la alimentación y la movilidad; adicionalmente, y dado el uso de dispositivos como sondas, tubos y catéteres, hay mayor limitación en la comunicación verbal y, por ende, en la expresión de sus necesidades, lo que aumenta la dependencia del cuidado enfermero: “...ellos están en las manos de uno, uno hace con ellos lo que uno quiera”. e6. “…está totalmente dependiente de uno y si uno no hace nada, qué más riesgo que ese… si el personal no hace nada, sufre mucho un paciente en ese medio”. e7 ¿qué significa estar expuesto? el paciente, tanto por su condición de vulnerabilidad como de dependencia, está expuesto a riesgos relacionados con el tratamiento —nivel de sedación—, el ambiente que lo rodea y las personas que lo cuidan. nivel de conciencia “…está sedado, no creo que esté consciente de sus necesidades”. e6 386 año 17 vol. 17 nº 4 chía, colombia diciembre 2017 aquichan issn 1657-5997 eissn 2027-5374 los participantes describen al paciente consciente como aquel que evalúa el cuidado de enfermería, es autónomo para satisfacer sus necesidades básicas, y con capacidad de tomar decisiones e interactuar activamente con las personas que lo rodean. cuando el paciente es consciente decide si acepta o no el tratamiento propuesto, que incluye los dispositivos médicos necesarios para su recuperación. en contraste, el paciente “no consciente”, según la mirada de los participantes, es aquel que por efectos de la sedación no reconoce cuáles son sus necesidades; puede sentir los procedimientos, pero los identifica como estímulos externos que generan en él una respuesta interior. la respuesta es traducida en gestos o movimientos, que son interpretados por el enfermero y que le indican cuáles son las posibles intervenciones que puede llevar a cabo para satisfacer las necesidades del paciente: “…el paciente sedado a mí no me va a pedir nada, yo no sé qué necesidades pueda tener; de hecho pues está sedado, no creo que esté consciente de sus necesidades”. e6 riesgos: para el paciente y el enfermero “…está expuesto a diferentes riesgos ya sea del cuidado de nosotros, los medicamentos”. e4 el paciente sedado no es consciente de sus necesidades, lo que conlleva riesgos tanto para el paciente como para el enfermero que lo cuida. los riesgos a los que está expuesto el paciente corresponden con las intervenciones asociadas al cuidado, mientras que para el enfermero, estos se desencadenan por el estado de conciencia del paciente. el paciente bajo efectos de sedación se encuentra expuesto dado que, por su estado de conciencia, pierde la autonomía; esto conlleva una dependencia del cuidado enfermero. las acciones de enfermería se orientan a la recuperación de la salud, pero durante su realización existen riesgos de diferente índole, como caídas o lesiones musculares que se pueden presentar durante los cambios de posición y el baño en cama, lesiones cutáneas y orales, obstrucción de la vía aérea, entre otros; algunos de estos eventos son producto de la omisión de enfermería: “…está totalmente dependiente de uno y si uno no hace nada, qué más riesgo que ese; si el personal no hace nada, sufre mucho un paciente en ese medio”. e7 para el enfermero, el paciente bajo efectos de sedación implica riesgos, dado que este último no es consciente de sus necesidades y puede considerar los dispositivos médicos —tubos orotraqueales, sondas y catéteres— como algo incómodo, por tanto, intentará retirárselos, lo cual podría generar lesiones al paciente o sanciones al enfermero. lo anterior lleva a que este último, aunque reconoce el tratamiento brindado como algo incómodo para el paciente, pero necesario para su recuperación, tome medidas dirigidas a disminuir el riesgo de autolesiones del paciente y sanciones para el personal. es por esto que el enfermero utiliza dos técnicas de sujeción terapéutica: primero, inmovilizar las extremidades del paciente para disminuir el riesgo de extracción accidental de los dispositivos; segundo, la sedación, por los efectos que tienen los medicamentos en el estado de conciencia del paciente: “…yo soy una que siempre pregunto, mire que sí tenga sujeción para evitar que se hagan algún daño o si no, yo voy y lo busco y se lo coloco porque no quiero sustos”. e3 “…uno llega a un punto en el que encuentra los niveles de lo que necesitan en sedación para que no corran riesgos, de alguna manera también hacemos sujeción con este tipo de medicamentos, uno no lo puede negar…” e2 discusión confort es estar tranquilo la sedación se entiende como la “depresión de la conciencia inducida por medicamentos” (7); a partir de este concepto es necesario hacer referencia a ong, quien afirma que “la conciencia de cada ser humano está totalmente interiorizada, conocida por la persona desde el interior e inaccesible a otro individuo cualquiera” (8); para los participantes, es la capacidad que tiene una persona de autorreconocerse como sujeto con necesidades, diferenciarlas y además ejecutar acciones para satisfacerlas. ahora bien, la expresión de las necesidades en el caso del paciente bajo efectos de sedación, es decir, aquel que no es consciente, se puede ver alterada, pues los efectos de los sedantes, sumados al uso de algunos dispositivos médicos, afectan la comunicación verbal (9). por tanto, el paciente depende de la interpretación que haga el enfermero de los signos endógenos y exógenos reconocidos como comunicación no verbal para identi387 “no es fácil estar 24 horas en una cama”: confort del paciente con sedación en una unidad de cuidado intensivo l indira islem tejada-pérez ficar y satisfacer las necesidades de la persona que se encuentra dependiente de cuidado, lo que la hace estar expuesta y vulnerable. como lo afirma d. orem, “los individuos sometidos a limitaciones a causa de su salud o relacionadas con ella, no pueden asumir el autocuidado o el cuidado dependiente” (10), por lo cual queda como responsable de ello el enfermero. lo dicho hasta aquí permite inferir que el paciente en estado crítico es aquella persona que, por estar bajo efectos de sedación, no es consciente de sus necesidades, por tanto, para satisfacerlas depende de las intervenciones de enfermería; dicha dependencia genera en el paciente un estado de vulnerabilidad relacionado con factores internos y externos que pueden afectar a la persona cuidada en todas sus dimensiones. a partir de esta concepción de paciente, el enfermero construye el significado de confort y lo define en términos de tranquilidad. estar tranquilo se entiende como la armonía entre tres filiaciones: ambiente y compañía, comodidad y protección, analgesia y sedación, cada una con elementos excluyentes pero interdependientes, que determinan la tranquilidad del paciente. ahora bien, para carneiro et al., “considerando el confort o malestar como estados subjetivos, dinámicos y productos de la interacción, su comprensión debe buscarse en las interacciones de la persona consigo misma, con aquellos que la circundan durante el tratamiento y en las situaciones que enfrenta” (11). “ponerse en el lugar del otro vulnerable” la comodidad es la ausencia de sensaciones desagradables, tanto físicas como emocionales, es algo subjetivo y personal; en el caso del paciente dependiente, la comodidad está determinada por lo que el enfermero considere cómodo para el paciente y por las intervenciones que realice para lograrla. si bien la persona en estado crítico de salud, bajo efectos de sedación, no puede expresar verbalmente sus necesidades, sí las comunica a través de la comunicación no verbal. como lo expone madrigal, “no solo la palabra es mediación en la comunicación, pues cuando se habla de esta, hay que tener en cuenta aspectos que permiten leer o interpretar al otro que participa en el acto comunicativo, como gestos, sonidos, miradas y contacto” (12). más aún, el enfermero comprende a la persona dependiente tratando de “ponerse en el lugar del otro”; esto nace de la lectura que hace del paciente, pues lo interpreta y obra en consecuencia. torralba habla de esta actitud del enfermero al referirse a la compasión como la capacidad de “percibir como propio el sufrimiento ajeno, es decir, puede interiorizar el padecimiento de otro ser humano y vivirlo como si se tratara de una experiencia propia” (13). en este sentido, el enfermero brinda la comodidad al paciente a partir del cuidado compasivo, es decir, entiende el sufrimiento de la persona cuidada y lo asume como propio para poder satisfacer las necesidades y brindarle tranquilidad. ahora bien, conviene subrayar que el paciente es una persona dependiente y vulnerable, por tanto, las intervenciones de enfermería, como el paso de sondas, los cambios de posición, entre otros, deben basarse en el respeto y la compasión, pues como dice waldow, “los procedimientos, intervenciones y técnicas realizadas con el paciente, solo se caracterizan como cuidado, en el momento en que los comportamientos de cuidar son mostrados, tales como: respeto, consideración, gentileza, atención, cariño, compasión, entre otros” (14). el concepto de protección hace referencia a las intervenciones que realiza el enfermero con el objetivo de disminuir los riesgos a los que está expuesto el paciente en estado crítico. en este sentido, romero et al. plantean que “los pacientes ingresados en la uci consideran que los cuidados enfermeros son satisfactorios cuando estos se caracterizan por la combinación humanística y científica, se dispensan de forma integral y continuada, y van dirigidos a proporcionar a los pacientes seguridad, bienestar y confianza” (15). es de anotar que el cuidado de enfermería en la uci implica una ejecución constante de procedimientos e intervenciones que traen consigo consecuencias tanto para el paciente como para el enfermero; en el primero puede generarse algún daño o lesión que afecte su proceso de recuperación; en el caso del enfermero se pueden imponer sanciones o llamados de atención, pues se consideraría como una falencia en el cuidado del paciente. smythe, citado por lima, afirma que “la seguridad es un fenómeno singular, que depende de la percepción, interpretación y de los proyectos de vida de cada persona. un ambiente puede parecer seguro para profesionales y, a la vez, puede presentarse inseguro para el paciente” (16). una de las medidas de precaución tomadas por el enfermero es la sujeción terapéutica o inmovilización de las extremidades, con el objetivo de evitar lesiones al paciente o al personal de salud (17). es preciso mencionar que el enfermero, en ocasiones, emplea la sedación como mecanismo de sujeción, pues al afec388 año 17 vol. 17 nº 4 chía, colombia diciembre 2017 aquichan issn 1657-5997 eissn 2027-5374 tar la conciencia del paciente no se presentará agitación, desorientación y delirium, con lo cual se evitan eventos adversos. no obstante, no se puede obviar que el cuidado de enfermería tiene implícitos principios éticos que deben estar presentes en cualquier intervención que se proponga o realice; asimismo, dicha intervención debe estar fundamentada en el conocimiento científico, pero igualmente en los constructos éticos de la profesión, teniendo en cuenta que el ser humano “es una complejidad inmensurable, es una unidad indisoluble entre lo biológico, el aspecto emocional, espiritual y psicológico” (18). conclusiones el confort es un asunto importante para los participantes de este estudio, pues no solo lo definen, sino que están en capacidad de autocriticarse por la poca o ninguna atención que durante la cotidianidad le prestan. es indudable la impronta académica al respecto, lo que hace que los enfermeros estén en capacidad de hablar de dicho aspecto sin que exista un vínculo con el hacer. los participantes describen al paciente en estado crítico, bajo efectos de sedación, como una persona que no es consciente de sus necesidades, por tanto, es un sujeto dependiente del enfermero para identificarlas y satisfacerlas; para ello emplean dos estrategias: la primera es la capacidad que tiene el enfermero de interpretar los signos manifestados por el paciente, que indiquen disconfort; la segunda es el cuidado compasivo, pues existen situaciones en las que la lectura del paciente no es suficiente y el enfermero “se pone en el lugar del otro” para brindar cuidados de confort. referencias 1. ribeiro pc, costa mendes ma. o conforto do doente idoso crónico em contexto hospitalar: contributos para uma revisão sistemática da literatura. rev enf. ref. 2012 [visitado 2017 ago 21];7. disponible en: http://www.scielo.mec.pt/ scielo.php?pid=s0874-02832012000200016&script=sci_arttext&tln 2. rodríguez dm. cuidado de enfermería al paciente con soporte ventilatorio. en: pulgarín am, osorio sp, varela le. fundamentos de enfermería. medellín: corporación para investigaciones biológicas; 2012. 3. kolcaba k. la teoría del confort. en: modelos y teorías en enfermería. barcelona: mosby elsevier; 2011. p. 706-719. 4. taylor sj, bogdan r. introducción a los métodos cualitativos de investigación. barcelona: paidós; 1992. 5. morse j. the significance of saturation. qual health res. 1995;5(2):147-9. 6. sampieri r. metodología de la investigación. méxico: mcgraw-hill; 2014. 7. igea f et al. sedación en endoscopia digestiva: guía de práctica clínica de la sociedad española de endoscopia digestiva. rev esp enferm dig. 2014;106(3):195-211. 8. ong wj, hartley j. oralidad y escritura: tecnologías de la palabra. méxico: fondo de cultura económica; 2016. 9. varela le, rivera lm. consideraciones de enfermería sobre el paciente con alteraciones neurocríticas. en: pulgarín am, osorio sp, varela le. fundamentos de enfermería. medellín: corporación para investigaciones biológicas; 2012. 10. orem d. la teoría del autocuidado. en: modelos y teorías en enfermería. barcelona: mosby elsevier; 2011, p. 503-519. 11. carneiro mussi f, santana freitas k, almeida moraes g. prácticas del cuidar en enfermería para la promoción del confort. index de enferm. 2014;23(1-2):65-9. 12. madrigal ramírez mc, forero pulido c, escobar cl. la comunicación, piedra angular en el cuidado de enfermería. investig enferm imagen desarr. 2013 [visitado 2015 nov 13];15. disponible en: <http://www.redalyc.org/articulo. oa?id=145229803004> issn 0124-2059 13. torralba f. constructos éticos del cuidar. enferm intensiva [internet]. 2000 [visitado 2015 nov 03];11(136). disponible en: http://apps.elsevier.es/watermark/ctl_servlet?_f=10&pident_articulo=10017627&pident_usuario=0&pcontactid=&pident_re vista=142&ty=105&accion=l&origen=zonadelectura&web=www.elsevier.es&lan=es&fichero=142v11n3a10017627pdf001.pdf 389 “no es fácil estar 24 horas en una cama”: confort del paciente con sedación en una unidad de cuidado intensivo l indira islem tejada-pérez 14. waldow vr. cuidado humano. index de enferm. 2014;23(4):234. 15. romero garcía m, et al. la percepción del paciente crítico sobre los cuidados enfermeros: una aproximación al concepto de satisfacción. enferm intensiva. 2013;24(2):51-62. 16. lima, fabiane da silva severino, et al. implicaciones de la seguridad del paciente en la práctica del cuidado de enfermería. enferm global. 2014; 13(35):293-309. 17. corral cano j. contenciones físicas: reflexión sobre su vigencia. madrid: trabajos académicos; 2014. 18. molina me, forero c. la ética en el cuidado de enfermería, en una unidad de cuidado intensivo. en: pulgarín am, osorio sp, varela le. fundamentos de enfermería. medellín: corporación para investigaciones biológicas; 2012. 462 472 efectividad del proceso de formacion.indd 462 aquichan issn 1657-5997 eissn 2027-5374 blanca patricia mantilla-uribe1 maría constanza hakspiel-plata2 nury c. guerrero-parra3 lucila niño-bautista4 laura c. mantilla-hernández5 maría stela cárdenas-herrera6 efectividad del proceso de formación de escolares de 32 colegios públicos en habilidades psicosociales y hábitos saludables en engativá-bogotá d.c. 1 orcid.org/0000-0002-9404-4367. universidad industrial de santander. instituto proinapsa uis. colombia. bpmantil@uis.edu.co 2 orcid.org/0000-0002-1881-9351. universidad manuela beltrán. instituto proinapsa uis. colombia. mconina@yahoo.com 3 orcid.org/0000-0002-5183-326x. universidad el bosque. instituto proinapsa uis. colombia. ncgp1810@hotmail.com 4 orcid.org/0000-0003-2511-8294. universidad nacional de colombia. instituto proinapsa uis. colombia. lucinino@hotmail.com 5 orcid.org/0000-0003-2347-691x. universidad nacional de colombia. instituto proinapsa uis. colombia. lauritac11@hotmail.com 6 orcid.org/0000-0003-3753-6880. universidad industrial de santander. instituto proinapsa uis. colombia. maryst.ch@gmail.com recibido: 12 de diciembre de 2015 enviado a pares: 17 de abril de 2016 aceptado por pares: 01 de agosto de 2016 aprobado: 29 de agosto de 2016 doi: 10.5294/aqui.2016.16.4.5 para citar este artículo / to reference this article / para citar este artigo mantilla-uribe bp, hakspiel-plata mc, guerrero-parra nc, niño-bautista l, mantilla-hernández lc, cárdenas-herrera ms. efectividad del proceso de formación de escolares de 32 colegios públicos en habilidades psicosociales y hábitos saludables en engativá-bogotá d.c. aquichan. 2016; 16(4): 462-472. doi: 10.5294/aqui.2016.16.4.5 resumen objetivo: evaluar la efectividad del trabajo realizado por docentes para fortalecer habilidades psicosociales y hábitos saludables en escolares. metodología: estudio cuasi-experimental, longitudinal analítico con medición pre y postintervención educativa. el instrumento, elaborado a partir de la encuesta edex, fue utilizado para el estudio en 32 colegios públicos de engativá entre 2013 y 2014; en el análisis se utilizó la prueba t de student y la prueba exacta de fisher para tablas de contingencia; los cambios en habilidades psicosociales y hábitos saludables se establecieron mediante estadísticos de rasch. resultados: se aplicaron 930 encuestas iniciales y 549 finales. habilidades psicosociales: i) mejora de 0,18 lógitos en el promedio, equivalente a 11,6 % de escolares; ii) las habilidades cognitivas y sociales mejoraron, mientras las emocionales desmejoraron; iii) las mujeres obtuvieron resultados superiores estadísticamente significativos en habilidades cognitivas y sociales; iv) las personas con mayor tiempo en el programa mostraron mejores resultados, estadísticamente significativos, en habilidades cognitivas. hábitos saludables: comparando resultados de estadísticos de rasch, los hábitos saludables desmejoraron y no hubo diferencias por sexo o años en el programa. conclusiones: los resultados concuerdan con la prioridad que dieron los docentes al trabajo en habilidades psicosociales y hábitos saludables; se observaron resultados importantes de efectividad. se debe seguir investigando para aprender más sobre el fortalecimiento de las habilidades psicosociales y los hábitos saludables. palabras clave efectividad; habilidades; hábitos; escolares (fuente: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 462-472 463 efectividad del proceso de formación de escolares de 32 colegios públicos en habilidades psicosociales y hábitos saludables... l blanca patricia mantilla-uribe y otros año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 462-472 effectiveness of the process used to instruct 32 public school children in engativá (bogotá d.c.) on psychosocial skills and healthy habits abstract objective: evaluate the effectiveness of the work done by teachers to strengthen psychosocial skills and healthy habits among schoolchildren. methodology: this is a quasi-experimental, analytical longitudinal study with pre and post education intervention. the instrument, based on the edex survey, was used to conduct the study at 32 public schools in engativá between 2013 and 2014. the student t-test was employed in the analysis, along with fisher’s exact test for the contingency tables. changes in psychosocial skills and healthy habits were determined using rasch statistics. results: 930 initial and 549 final surveys were applied. psychosocial skills: i) there was an improvement of 0.18 log odd units, on average, equivalent to 11.6% of the schoolchildren; ii) cognitive and social skills improved, while emotional ones deteriorated; (iii) females scored statistically significantly higher in cognitive and social skills; and iv) students with more time in the program demonstrated better and statistically significant results for cognitive abilities. healthy habits: a comparison of the rasch statistic results showed healthy habits deteriorated and there were no differences by gender or years in the program. conclusions: the results coincide with the priority teachers give to work on psychosocial skills and healthy habits. significant results in terms of effectiveness were observed. further research is needed to learn more about strengthening psychosocial skills and healthy habits. keywords effectiveness; skills; habits; schoolchildren (source: decs, bireme). 464 aquichan issn 1657-5997 eissn 2027-5374 efetividade do processo de formação de estudantes de 32 colégios públicos em habilidades psicossociais e hábitos saudáveis em engativá – bogotá dc resumo objetivo: avaliar a efetividade do trabalho realizado por docentes para fortalecer habilidades psicossociais e hábitos saudáveis em estudantes. metodologia: estudo quase-experimental, longitudinal analítico com medida pré e pós-intervenção educativa. o instrumento, elaborado a partir da pesquisa edex, foi utilizado para o estudo em 32 colégios públicos de engativá entre 2013 e 2014; na análise utilizou-se o teste t de student e o teste exato de fisher para tabelas de contingência; as mudanças em habilidades psicossociais e hábitos saudáveis estabeleceram-se mediante o modelo rasch. resultados: aplicaram-se 930 questionários iniciais e 549 finais. habilidades psicossociais: i) melhora de 0,18 logitos na média, equivalente a 11,6 % de estudantes; ii) as habilidades cognitivas e sociais melhoraram, enquanto as emocionais desmelhoraram; iii) as mulheres obtiveram resultados superiores estatisticamente significativos em habilidades cognitivas e sociais; iv) as pessoas com maior tempo no programa mostraram melhores resultados, estatisticamente significativos, em habilidades cognitivas. hábitos saudáveis: comparando resultados do modelo rasch, os hábitos saudáveis desmelhoraram e não houve diferenças por sexo ou idade no programa. conclusões: os resultados concordam com a prioridade que deram os docentes ao trabalho em habilidades psicossociais e hábitos saudáveis; observaram-se resultados importantes de efetividade. deve-se continuar pesquisando para aprender mais sobre o fortalecimento das habilidades psicossociais e os hábitos saudáveis. palavras-chave efetividade; escolares; habilidades; hábitos (fonte: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 462-472 465 efectividad del proceso de formación de escolares de 32 colegios públicos en habilidades psicosociales y hábitos saludables... l blanca patricia mantilla-uribe y otros introducción los comportamientos sociales y los hábitos relacionados con la salud se aprenden a lo largo de la vida y comienzan desde la primera infancia, por tanto, los ámbitos familiar y escolar son vitales para que niñas y niños puedan tener ejemplos adecuados para su aprendizaje por imitación y oportunidades a fin de conocer, interrogar, practicar y recibir las orientaciones y los refuerzos necesarios para afianzar los aprendizajes. por ende, la relación familia-escuela es esencial para un desarrollo armónico. familias y docentes deben establecer acciones conjuntas y coordinadas encaminadas a favorecer la adquisición de hábitos básicos para su autonomía y desarrollo posterior (1). madres, padres, cuidadores en general y personal docente, juegan un papel determinante en la construcción de las habilidades y los hábitos que les permitirán a los pequeños tener unas relaciones armoniosas de cuidado y respeto consigo mismos, las otras personas y los demás seres vivos en el entorno en el que se desarrollan. al respecto, diversos estudios han demostrado la importancia del trabajo sobre habilidades psicosociales con menores dado que incide en la autoestima, la autorregulación del comportamiento, la adopción de roles, la adaptación, la convivencia pacífica y el rendimiento académico, entre otros (2-4). en los años noventa ya había suficiente evidencia sobre las bondades y el carácter protector y saludgénico de las habilidades psicosociales por lo cual, en 1993, la organización mundial de la salud (oms) lanzó su “iniciativa internacional” proponiendo incluir un conjunto de diez habilidades en la educación formal orientadas a preparar a niñas, niños y adolescentes para hacer frente a los retos de un mundo competitivo y cambiante; el programa se denominó “habilidades para la vida”, y una década después, mediante encuesta desarrollada por oms y unicef (2001-2002), se comprobó que ya se había implementado en instituciones educativas en américa latina y el caribe, norteamérica, europa, asia, áfrica y medio oriente (5). las habilidades para la vida fueron sólidamente construidas tomando como base las teorías de aprendizaje social de bandura, la conducta problemática de jessor, la influencia social de bandura, mcguire y evans, la solución cognitiva de problemas de luria y vygotsky, las inteligencias múltiples de gardner, la psicología constructivista sustentada en piaget y vygotsky, y la metateoría de la resiliencia y el riesgo. esta fundamentación permitió construir tres categorías de habilidades claves para la vida: habilidades sociales o interpersonales (comunicación, habilidades para negociación / rechazo, confianza, cooperación y empatía); habilidades cognitivas (solución de problemas, comprensión de consecuencias, toma de decisiones, pensamiento crítico y autoevaluación) y habilidades para el control de emociones (estrés, sentimientos, control y monitoreo personal) (6). ahora bien, es importante anotar que el desarrollo de las habilidades psicosociales en la infancia y adolescencia puede aportar recursos preventivos ante riesgos como tabaquismo, alcoholismo, abuso de sustancias psicoactivas, embarazo no deseado, enfermedades de transmisión sexual y comportamientos disfuncionales como agresividad y negativismo (3, 7-9). colombia comenzó en 1996 el proceso de validar y adecuar a la diversidad cultural del país la metodología propuesta por la oms para la formación en habilidades para la vida, con un proyecto piloto financiado por el ministerio de salud bajo la dirección de leonardo mantilla castellanos, médico especialista en salud mental y desarrollo psicosocial de niños y adolescentes, siendo fe y alegría la entidad ejecutora (10). mantilla castellanos también elaboró una guía metodológica para trabajar las habilidades para la vida, la cual ejemplifica de manera didáctica el qué, el cómo y el para qué de dichas habilidades (7). hoy, las habilidades para la vida hacen parte del proyecto educativo institucional (pei) en numerosos centros de educación básica y media en colombia, son promovidas desde el ministerio de educación (11) y parte del movimiento universidades promotoras de la salud (12). para trabajar el tema, la fundación edex de españa creó un programa educativo denominado “la aventura de la vida”, organizado en dos ejes: el temático, hábitos saludables (alimentación, actividad y descanso, alcohol, tabaco, medicamentos, higiene y seguridad) y el transversal, las habilidades psicosociales (autorrespeto, afrontar desafíos, manejar la tensión, relacionarse y tomar decisiones). sáenz rojas (13) en tibás, costa rica, utilizó “la aventura de la vida” para prevención del uso de drogas en nueve escuelas públicas; capacitaron 94 docentes quienes trabajaron con 2960 escolares. se reportaron beneficios para las niñas y los niños, tales como relacionarse mejor, ser más críticas/os, mejorar el autoconcepto, cuidar su salud y mejorar académicamente, entre otros. 466 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 en 2002, edex (14) evaluó con métodos mixtos el programa “la aventura de la vida” en españa y en nueve países de américa latina, el cual comprobó disponer de una herramienta válida y efectiva en educación para la salud, que facilita el aprendizaje significativo, previene del consumo de drogas, fortalece la autoestima, el manejo de la tensión, la resistencia a la presión grupal y mejora hábitos saludables. a partir de 2009, el instituto proinapsa de la universidad industrial de santander, en asocio con la fundación edex, llevaron a cabo durante cinco años una intervención educativa en instituciones públicas de básica primaria en engativá (bogotá), donde se capacitó al colectivo docente para trabajar por el fortalecimiento de habilidades psicosociales para la vida y hábitos saludables en los escolares. de manera paralela a la intervención educativa, entre 2012 y 2013 se realizó la presente investigación que tuvo como objetivo evaluar la efectividad del trabajo realizado por los docentes para fortalecer las habilidades psicosociales para la vida y los hábitos saludables de los escolares. metodología el estudio fue cuasiexperimental, de corte longitudinal analítico, en el que participaron las y los escolares de los cursos asignados al colectivo docente capacitado, de quienes recibieron la orientación, motivación y enseñanza en las dos temáticas. se realizó una medición antes de iniciar la capacitación del último grupo docente en febrero de 2012 y otra al terminar la intervención educativa en octubre de 2013, cuando se cubrió el 100 % de las instituciones públicas de básica primaria (32), en la localidad de engativá, bogotá. muestreo: se utilizó muestreo aleatorio simple con el total de escolares de 3° a 5° grado (con capacidad de lecto-escritura) con límite de confianza el 95 % y error máximo el 5 %; una vez se obtuvo el tamaño de muestra, se realizó la escogencia de los escolares al azar. instrumento: se tomó la encuesta elaborada por edex como base para construir el instrumento dado que el programa “la aventura de la vida” se desarrolla en múltiples instituciones educativas de colombia y otros países; se conservaron los componentes de los dos constructos: en habilidades psicosociales (autorrespeto, toma de decisiones, afrontar desafíos, relacionarse y manejo de tensiones) y en hábitos saludables (alimentación, actividad y descanso, higiene, alcohol, tabaco, drogas y seguridad). los ítems de la encuesta, 4 preguntas de identificación, 18 ítems sobre habilidades psicosociales y 19 sobre hábitos saludables, se elaboraron para autodiligenciamiento con opción de respuesta dicotómica (sí, no). la encuesta fue sometida a prueba de validez facial y prueba piloto para determinar su validez y confiabilidad utilizando el modelo de rasch. procedimiento: los padres o las madres del grupo de escolares seleccionados como muestra recibieron información sobre los objetivos de la investigación, usos posibles de sus resultados, importancia de la participación de sus hijos e hijas y el carácter voluntario de esta. a quienes decidieron no permitir la participación de hijas o hijos, en cualquier etapa del estudio, se les respetó su decisión. de igual manera, las instituciones educativas avalaron su participación en la investigación. las y los escolares respondieron la encuesta 1 “antes de la intervención”, previo a que sus docentes iniciaran, en 2012, su trabajo con el programa “la aventura de la vida”. el llenado de la encuesta se realizó en los respectivos salones de clase con el acompañamiento del equipo de profesionales de proinapsa uis que facilitó el proceso y participó en el equipo de la presente investigación, quienes brindaron las orientaciones para el diligenciamiento y respondieron a las preguntas que surgieron durante el llenado de la encuesta. luego, las y los escolares participaron de manera activa en el programa “la aventura de la vida”, orientados y apoyados por sus docentes, quienes estructuraron un plan de trabajo colectivo para cada una de las instituciones educativas participantes, priorizando los tópicos que trabajarían según los ejes que propone el programa y teniendo como orientación desarrollar en 2012 y 2013 los temas en el orden que, a su juicio, respondiera mejor al ciclo educativo de los grupos de escolares, las necesidades y demandas sociales y los lineamientos del pei; al final del segundo semestre de 2013, los escolares llenaron la encuesta 2 correspondiente al “después de la intervención”, igualmente acompañados por el equipo de proinapsa uis. procesamiento y análisis de datos: los datos recogidos tuvieron doble digitación en excel por diferente persona; se corrigieron errores y las bases de datos se transfirieron al paquete estadístico stata 10.0 (15) y winstep 3.81 (16) para su análisis. se utilizaron los promedios, la desviación estándar y el coeficiente de variación. a fin de establecer la significación de la asociación entre variables cualitativas o cuantitativas de la encuesta, se empleó la prueba t de student para comparación de promedios, y para tablas de contingencia la prueba exacta de fisher para proporciones. a 467 efectividad del proceso de formación de escolares de 32 colegios públicos en habilidades psicosociales y hábitos saludables... l blanca patricia mantilla-uribe y otros fin de determinar el cambio en habilidades psicosociales para la vida y hábitos saludables, se utilizaron las medidas producidas por el modelo de rasch para el análisis de las respuestas. resultados en la encuesta inicial 2012 participaron 930 escolares de 32 instituciones educativas, siendo el 54 % mujeres, y en la encuesta final 2013, 549 escolares de 27 instituciones educativas; la participación femenina se mantuvo sin variación importante (55 %) y en las dos encuestas fue superior a la poblacional según el dane a nivel país y de bogotá en 2012 (47,9 % de mujeres en educación básica) (17, 18). la disminución en el número de docentes en la segunda encuesta tuvo diversas razones: 5 colegios (50 docentes) se retiraron del programa en 2013, 88 docentes por traslado o edad de pensión y 60 por dificultades con el tiempo para responder la encuesta en la jornada laboral. antes de presentar los resultados de las encuestas es importante mostrar la prioridad que el colectivo docente estableció para su trabajo con los grupos de escolares en 2012 y 2013 (tabla 1). tabla 1. prioridad dada por los docentes al trabajo con “la aventura de la vida” este el único modelo de variables latentes que justifica el uso del resultado total en los ítems para apreciar el desempeño del grupo frente al constructo evaluado (19, 20) (tabla 2). tabla 2. resultados de medidas de grupo en habilidades psicosociales habilidades psicosociales pr* #** % hábitos saludables pr # % autorrespeto 1 32 100 higiene 3 27 84 relacionarse 2 28 87 alimentación 4 24 75 tomar decisiones 4 24 75 seguridad 5 18 56 manejar la tensión 6 12 37 consumo de tabaco 8 3 9 afrontar desafíos 7 11 34 consumo de alcohol 9 2 6 uso de medicamentos 0 0 *prioridad ** instituciones educativas fuente: datos de la investigación. 1. modificación en habilidades psicosociales el cambio se evaluó por comparación de promedios en medida de rasch antes y después de la intervención educativa por ser estadísticos de la medida resumen 929 medidas – 2012 resumen de 549 medidas – 2013 puntaje total medida* puntaje total medida* promedio 14,6 1,98 14,9 2,16 desviación estándar 2,4 1,16 2,3 1,17 máximo 18,0 4,37 18,0 4,24 mínimo 3,0 1,80 5,0 0,94 * en lógitos fuente: datos de la investigación. los resultados de las medidas en la primera y segunda evaluación se mantuvieron estables; el promedio subió 0,18 lógitos indicando que más escolares tuvieron mejores calificaciones en la segunda evaluación. ahora bien, para encontrar la proporción de estudiantes que mejoraron, se identificaron quienes estaban por encima del promedio en cada evaluación y, apoyados en el mapa de wright generado por winstep, se calculó el porcentaje siendo mayor en 11,6 % para 2013 (tabla 3). tabla 3. escolares por encima del promedio en cada evaluación calificaciones evaluación 2012 evaluación 2013 n° escolares % n° escolares % sobre el promedio 416 44,7 309 56,3 en y abajo del promedio 513 55,3 240 43,7 total 929 100 549 100 fuente: datos de la investigación. la segunda evaluación de cambio se hizo por comparación desagregada de las habilidades en las categorías planteadas por la organización panamericana de la salud (ops) (6): i) sociales o interpersonales, ii) cognitivas y iii) de control de emociones. en habilidades sociales o interpersonales se incluyó el autorrespeto 468 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 (ítems 5, 8, 9) y relacionarse (ítems 6, 7, 10, 22); en habilidades cognitivas, el afrontar desafíos (ítems 11, 13, 16) y toma de decisiones (ítems 12, 14, 19, 20, 21) y en habilidades para el control de emociones, el manejo de la tensión (ítems 15, 17, 18) (tabla 4). tabla 4. diferencias en habilidades psicosociales por categorías en cada evaluación excluidos de la base de datos antes de pasar al análisis de resultados en habilidades psicosociales para la vida por sexo. habilidades psicosociales por sexo: para comparar los cambios según el sexo se mantuvo el constructo en tres categorías (tabla 6). los resultados según el sexo de los escolares amplían la visión de cambio de la tabla 3, e indican que las mujeres obtuvieron resultados superiores y estadísticamente significativos en sus habilidades sociales y cognitivas. de nuevo las habilidades para el control de emociones retroceden tanto en hombres como en mujeres. tiempo de participación en el programa y cambios en habilidades psicosociales: para determinar la influencia del tiempo de exposición al proceso educativo en el incremento de las habilidades se trabajó con el grupo de estudiantes de la segunda evaluación. se subdividió en dos: grupo 1, quienes reportaron no haber participado en el programa (6) y quienes tuvieron un año de capacitación (63) para un total de 69 escolares, y grupo 2, con 483 estudiantes de dos y tres años de trabajo con “la aventura de la vida”; se utilizó la t de student una vez se constató que las dos submuestras tenían normalidad en las observaciones e igual varianza. la tabla 7 presenta los resultados obtenidos. el tiempo en el programa mostró significancia estadística en habilidades cognitivas para los estudiantes con 3 y 4 años en relación con los de 0 y 1 año. estadísticos de la medida habilidades sociales habilidades cognitivas habilidades para control de emociones 2012 2013 2012 2013 2012 2013 promedio 2,25 2,36 1,66 1,93 1,47 1,24 desviación estándar 1,10 1,04 1,17 1,17 1,20 1,11 escolares con puntaje máximo (%) 42,2 50,3 18 31,3 54 51,5 escolares con puntaje mínimo (%) ----1,4 1,8 fuente: datos de la investigación. las habilidades cognitivas fueron las de mayor cambio positivo en el grupo de escolares (0,27), seguidas de las habilidades sociales (0,11); las habilidades para el control de emociones retrocedieron en 0,23 entre la primera y la segunda evaluación. los escolares que respondieron bien todas las preguntas de la encuesta y obtuvieron el puntaje máximo, aumentaron también las habilidades cognitivas y sociales. este resultado indica, además, que la encuesta contiene muchos ítems fáciles de responder y que el grado de dificultad se hizo aún menor para las niñas y los niños en la segunda evaluación luego de recibir la capacitación para fortalecer dichas habilidades. el resultado en habilidades para el control de emociones es contrario a lo ocurrido con las anteriores (tabla 5). funcionamiento diferencial del ítem fdi por sexo: se presenta cuando dos grupos comparables tienen una probabilidad distinta de responder con éxito en función del grupo al que pertenecen (21). en la primera evaluación se encontró un ítem con fdi más fácil de responder por las mujeres, y en la segunda evaluación otro más fácil de responder por los hombres. en los dos casos se observa la carga semántica de las palabras utilizadas, las cuales condujeron a respuestas diferentes (estadísticamente significativas) influidas culturalmente por el sexo de quien respondió. estos ítems fueron tabla 5. funcionamiento diferencial de los ítems por sexo y categoría de habilidades en cada evaluación categoría 2012 2013 ítem hombre mmujer valor de p hab. sociales sí no tengo cualidades que me hacen una persona especial 0,84 -1,84 0,0072 hab. cognitivas no no ----hab. control emociones no sí sí creo que tengo derecho a algo, lo exijo -0,40 0,24 0,0085 fuente: datos de la investigación. 469 efectividad del proceso de formación de escolares de 32 colegios públicos en habilidades psicosociales y hábitos saludables... l blanca patricia mantilla-uribe y otros modificaciones en hábitos saludables para identificar los cambios ocurridos en hábitos saludables, se procedió en la misma forma que con habilidades psicosociales: se compararon promedios de rasch antes y después de la intervención educativa (tabla 8). tabla 8. resultados de medidas de grupo en hábitos saludables corroboró la disminución en competencias en hábitos saludables (de 46,9 se pasó al 36,2 %) y por último, utilizando el porcentaje de estudiantes que respondieron correctamente todos los ítems sobre hábitos saludables, de 9,9 % en la primera evaluación se pasó a 7,2 % en la segunda. funcionamiento diferencial del ítem fdi por sexo: no se identificó fdi. hábitos saludables por sexo: la comparación de promedios de rasch entre la primera y la segunda evaluación indican una disminución en la medida de hábitos saludables para ambos sexos en 2013; sin embargo, al buscar la significancia estadística de las diferencias se encontró que las mujeres obtuvieron resultados superiores y estadísticamente significativos para ambos años (tabla 9). tabla 9. cambios en hábitos saludables por sexo tabla 6. cambios en habilidades psicosociales por categorías y sexo estadísticos de la medida habilidades sociales habilidades cognitivas habilidades para control de emociones 2012 2013 2012 2013 2012 2013 h m h m h m h m h m h m promedio 2,05 2,39 2,17 2,49 1,48 1,79 1,66 2,13 1,30 1,60 1,17 1,28 valor de p 0,000 0,0004 0,000 0,000 0,0001 0,23 fuente: datos de la investigación. tabla 7. cambios en habilidades psicosociales por categoría y tiempo en el programa fuente: datos de la investigación. estadísticos de la medida habilidades sociales habilidades cognitivas habilidades para control de emociones grupo 1 grupo 2 grupo 1 grupo 2 grupo 1 grupo 2 promedio 2,28 2,36 1,63 1,96 1,11 1,25 valor de p 0,57 0,03 0,34 estadísticos de la medida resumen 929 medidas – 2012 resumen de 549 medidas – 2013 puntaje total medida (log) puntaje total medida (log) promedio 15,8 2,40 15,1 2,05 desviación estándar 2,4 1,17 2,7 1,14 máximo 19,0 4,74 19,0 4,67 mínimo 1,0 -1,34 ,0 -2,07 fuente: datos de la investigación. los resultados indican que en hábitos saludables hubo una disminución de 0,35 lógitos en el promedio de la calificación. la proporción de escolares por encima del promedio antes y después de la intervención educativa utilizando el mapa de wright estadísticos de la medida hábitos saludables 2012 2013 h m h m promedio 2,16 2,59 1,94 2,13 valor p de la diferencia 0,000 0,05 tiempo de participación en el programa y cambios en hábitos saludables: se conservaron para el análisis el grupo1 (0 y 1 año en el programa) y el grupo 2 (2 y 3 años en el programa). no se encontró diferencia estadísticamente significativa entre los dos grupos. discusión en relación con el objetivo de la investigación se puede anotar que el trabajo educativo orientado a fortalecer las habilidades psicosociales de los grupos de estudiantes tuvo diversos grados de efectividad; la proporción de estudiantes que incrementó 470 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 sus habilidades estuvo alrededor del 11 % reafirmando que los cambios en las formas de pensar, analizar, sentir y hacer son procesos que llevan tiempo y se requiere el compromiso, la creatividad y la innovación de los docentes (esta última es clave porque impulsa a analizar, repensar y encontrar el sentido a lo que se aprende) (22). el análisis de las habilidades desagregadas en tres categorías (sociales, cognitivas y para el control de emociones) mostró otro panorama y permitió focalizar los cambios en las habilidades sociales y en las cognitivas con un mejor desempeño por parte de las mujeres. los mejores resultados en habilidades sociales y cognitivas y los deficientes en habilidades para el control de emociones concuerdan claramente con las prioridades que el colectivo docente le dio a su trabajo con los escolares (tabla 1), lo cual muestra la efectividad de la labor docente cuando esta se hace con interés y compromiso. sin embargo, es conveniente incrementar el número de ítems [3] que quedaron al desagregar la encuesta en esta categoría, pues podrían ser insuficientes para evaluar habilidades dirigidas a lograr el control de las emociones, dado que en estas se involucra una situación desencadenante de reacciones fisiológicas, pensamientos e imágenes mentales y reacciones, lo cual implica una alta complejidad para el control adecuado, tal vez mayor cuando se trata de enseñar a niños y niñas en un contexto escolar que cada día es más agresivo y violento; la encuesta deberá ser mejorada en este componente. es importante subrayar la importancia de medir las habilidades por las tres categorías según clasificación ops, pues de no haberlo hecho así, se hubiera tenido un resultado de cambio positivo en todo el constructo dejando sin ver esta realidad. en los resultados obtenidos por otros grupos que han trabajado con habilidades para la vida como morales, benítez y agustín (23) se encontraron algunas diferencias con la presente investigación; dicho grupo reportó mejores resultados al trabajar primero las habilidades sociales básicas y las relacionadas con los sentimientos, y dejar para más adelante las habilidades cognitivas: “para que existan las segundas deben desarrollarse y fortalecerse las primeras”. de igual manera, recomendaron realizar intervenciones más prolongadas y profundas para el desarrollo de las habilidades cognitivas, que son más complejas, requieren mayor experiencia, madurez para lograrlas, y deben partir de la transformación de creencias arraigadas en los individuos, en lo cual coinciden morales, benites y agustin (23). es importante seguir investigando sobre la efectividad del trabajo en habilidades para la vida, insistiendo en que el análisis de las tres categorías por separado posiblemente permita una mejor comprensión de todos los elementos que se ponen en juego cuando se trata de aprender, desaprender y reaprender formas de pensar, manejar emociones y ejecutar acciones; posiblemente, estos procesos son diferentes en la facilidad de su comprensión y enseñanza, por ejemplo, si se trata de habilidades sociales o si se trata de manejar emociones. respecto del fortalecimiento de hábitos saludables, los resultados obtenidos no fueron de mejoramiento y dejan planteadas certezas e interrogantes. la primera es la concordancia de estos resultados con las prioridades que el colectivo docente asignó a componentes de habilidades psicosociales y no de hábitos saludables para su trabajo con escolares, lo cual fue una respuesta coherente y necesaria frente al contexto sociocultural que se vive en bogotá en localidades como engativá para escolares de colegios públicos. por otra parte, el grupo investigador se preguntó, a partir de la prueba de validez facial y la prueba piloto, hasta qué punto los escolares daban la respuesta correcta, que en muchos casos saben teóricamente sobre hábitos saludables, por deseabilidad social. este punto, a pesar de que trató de corregirse refraseando muchos ítems en la encuesta, siguió vigente y deberá ser investigado en específico para hábitos saludables en escolares. de igual manera, vale la pena preguntarse si la metodología fue adecuada, si fue suficiente el trabajo conjunto de docentes con madres y padres, y si hubo compromiso de los escolares para modificar sus hábitos poco saludables. justamente, estos puntos fueron reportados por pérez lópez y delgado fernández (24) como importantes en los buenos resultados obtenidos en la mejora de hábitos saludables. así mismo, sería importante revisar otras metodologías con resultados favorables como la utilizada por m. gonzález-gross, j. j. gómez-lorente, j. valtueña, j. c. ortiz y a. meléndez (25) y buscar respuestas a estas preguntas mediante una investigación cualitativa con madres, padres, docentes y escolares. es recomendable utilizar el modelo de rasch para evaluar resultados del trabajo docente a fin de mejorar habilidades psicosociales y hábitos saludables por todas las fortalezas que tiene en comparación con la teoría clásica de los test (26, 27) y porque podríamos hacer comparación y discusión de resultados con mayores posibilidades de avanzar en el mejoramiento tanto del instrumento de medición como en el proceso de formación para 471 efectividad del proceso de formación de escolares de 32 colegios públicos en habilidades psicosociales y hábitos saludables... l blanca patricia mantilla-uribe y otros afianzar las habilidades psicosociales para la vida y hábitos saludables en niñas, niños y adolescentes. agradecimientos agradecemos la colaboración de madres y padres de familia que aceptaron la participación de sus hijas e hijos en el estudio, y a las niñas y los niños por su interés al diligenciar la encuesta. nuestra gratitud para el profesor luis carlos orozco vargas, quien apoyó el análisis y la discusión de los resultados del trabajo. aspectos éticos se siguieron las recomendaciones para investigación en seres humanos de la declaración de helsinki y la resolución 008430 de 1993 del ministerio de salud de colombia; según esta última, esta investigación se consideró sin riesgo. conflicto de interés las autoras no tienen conflicto de interés de ningún tipo sobre los resultados presentados. referencias 1. cabria corral e. la importancia de la transmisión de hábitos y rutinas en educación infantil. españa: universidad de valladolid. escuela universitaria de educación (palencia); 2012 [citado 2016 ago 10]. disponible en http://uvadoc.uva. es/handle/10324/1735 2. betina lacunza a, contini de gonzalez n. las habilidades sociales en niños y adolescentes. su importancia en la prevención de trastornos psicopatológicos. fundamentos en humanidades. 2011;12(23):159-82. 3. betina lacunza a. las habilidades sociales y el comportamiento prosocial infantil desde la psicología positiva. revista pequén: escuela de psicología. 2012 [citado 2016 ago 10]; 1(2):1-20. disponible en http://revistas.ubiobio.cl/index. php/rp/article/view/1831/1775 4. lópez mesías d. las habilidades sociales y su incidencia en el trabajo colaborativo en los niños y niñas de séptimo grado de educación general básica del centro escolar francisco flor – gustavo eguez. ecuador: universidad técnica de ambato; 2016 [citado 2016 ago 11]. disponible en http://repositorio.uta.edu.ec/jspui/handle/123456789/16104 5. edex. habilidades para 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[citado 2014 jul 14]. disponible en http://antiguo.habilidadesparalavida.net/es/antecedentes_y_fundamentacion_teorica.html 6. organización panamericana de la salud. enfoque de habilidades para la vida para un desarrollo saludable de niños y adolescentes. washington: ops; 2001. 7. mantilla castellanos l. habilidades para la vida: una propuesta educativa para la promoción del desarrollo humano y la prevención de problemas psicosociales. bogotá: fe y alegría; 2001 [citado 2014 jul 16]. disponible en http://www. feyalegria.org/images/acrobat/72979810510810510097100101115_849.pdf 8. pérez de la barrera c. habilidades para la vida y consumo de drogas en adolescentes escolarizados mexicanos. adicciones. 2012; 24(2):153-60. 9. lestón valbuena r. educación sexual en la adolescencia: propuestas de intervención desde la educación social. españa: universidad de valladolid; 2015 [citado 2016 ago 11]. disponible en http://uvadoc.uva.es/handle/10324/15985 10. mantilla castellanos l. habilidades para la vida: una propuesta educativa para convivir mejor. investigación educativa. 2005;9(16):11-24. 11. ministerio de educación. aprendiendo a vivir en sociedad. 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[citado 2014 jul 16]. disponible en http://www.javeriana.edu.co/redcups/antecedentes.htm 13. sáenz rojas ma. evaluación de proceso de un programa de prevención de drogas en la escuela primaria costarricense. adicciones. 2001;13(3);323-34. 14. edex. evaluación de la aplicación en diez países de iberoamérica del programa de educación sobre drogas “la aventura de la vida”. bilbao: edex; 2002. 15. statacorp. stata statistical software. college station, texas: statacorp lp; 2010. 16. linacre jm. winsteps rasch measurement computer program. versión 3.1. chicago: winsteps.com; 2013. 17. colombia – dane. investigación de educación formal. boletín de prensa. 2014 [citado 2014 jul 21]. disponible en https://www.dane.gov.co/files/investigaciones/boletines/educacion/bol_educ_2012.pdf 18. alcaldía mayor de bogotá d.c. secretaría de educación. caracterización del sector educativo año 2012 [citado 2014 jul 21]. disponible en http://www.sedbogota.edu.co/archivos/sector_educativo/estadisticas_educativas/2013/ perfil %20educativo %20bogota %202012 %20 %20ver_4.pdf 19. álvarez martínez p, blanco sandía ma, guerrero manzano mm. la variable latente calidad medida a través de modelo de rasch. málaga: jornadas de asepuma; 1997 [citado 2014 jul 21]. disponible en http://almendralejo.cronista.zarandieta.com/index.php/libro-del-cronista-i/41-bibliografia/198-alvarez-martinez-pedro 20. arias b, arias vb, gómez le. calibración del índice de hiperactividad de conners mediante el modelo de rasch. universitas psychologica. 2013 [citado 2016 ago 11]; 12(3):957-70. disponible en http://revistas.javeriana.edu.co/index. php/revpsycho/article/viewfile/1871/5815 21. universidad de antioquia-centro de estudios de opinión (ceo). funcionamiento diferencial del ítem – dif [citado 2014 jul 25]. disponible en http://aprendeenlinea.udea.edu.co/revistas/index.php/ceo/article/viewfile/6547/5997 22. domínguez m, medina a, sánchez c. la innovación en el aula: referente para el diseño y desarrollo curricular. revista perspectiva educacional. 2011 [citado 2014 jul 21];50(1):61-86. disponible en http://www.perspectivaeducacional.cl/ index.php/peducacional/article/viewfile/15/13 23. morales m, benítez m, agustín d. habilidades para la vida (cognitivas y sociales) en adolescentes de una zona rural. revista electrónica de investigación educativa. 2013 [citado 2016 ago 11]; 15(3):98-113. disponible en http://redie. uabc.mx/vol15no3/contenido-moralesetal.html 24. pérez lópez ij, delgado fernández m. mejora de hábitos saludables en adolescentes desde la educación física escolar. revista de educación. 2013;360. 25. gonzález-gross m, gómez-lorente jj, valtueña j, ortiz c, meléndez a. la “pirámide del estilo de vida saludable” para niños y adolescentes. nutr hosp. 2008;23(2):159-68. 26. prieto adánez g, dias velasco a. uso del modelo de rasch para poner en la misma escala las puntuaciones de distintos tests. actualidades en psicología. 2003;19(106):5-23. 27. arias gonzález v. sintomatología hiperactiva en niños de 5 a 7 años: calibración de dos instrumentos de evaluación mediante modelos de teoría de respuesta a los ítems [tesis doctoral] salamanca: universidad de salamanca; 2012 [citado 2014 may 15]. disponible en http://gredos.usal.es/jspui/bitstream/10366/115552/1/dpetp_arias_gonzalez_vbgsintomatologiahiperactivaenninos.pdf 16 actualidad.p65 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005148 año 5 vol. 5 nº 1 (5) 148-149 chía, colombia octubre 2005148 l 9 y 10 de junio de este año se celebró en el campus universitario de boston college, la sexta conferencia anual de la roy adaptation association. en esta oportunidad los organizadores, atendiendo las sugerencias expresadas en la reunión del año anterior, programaron un taller previo a la conferencia denominado �el modelo de adaptación de roy: utilidad en la educación y la práctica�. en este taller se abordaron temas de gran interés como la revisión del desarrollo curricular, experiencias de aplicación del modelo de adaptación en el currículo, siendo de sumo interés la experiencia del mount st mary�s college, donde se aplicó por primera vez el modelo de adaptación hace más de 30 años, cuando la doctora roy era decana de esta facultad. también se presentaron experiencias acerca de la enseñanza clínica del modelo en instituciones hospitalarias y en la comunidad, y la aplicación como marco de referencia para la evaluación de un programa de clínica de dolor. para finalizar esta jornada se presentó una conferencia sobre evaluación: �medición de estudiantes basada en pensamiento crítico�. sexta conferencia anual roy adaptation association maría elisa moreno fergusson sexta conferencia anual roy adaptation association 149 el tema de la sexta conferencia anual de la asociación fue: �el modelo de adaptación de roy: integrando su utilidad en la educación, la práctica y la investigación�. en esta oportunidad la doctora roy presentó la conferencia denominada �el modelo de adaptación de roy como base para la integración del conocimiento en la educación, la práctica y la investigación�. en su intervención, la doctora roy hizo un análisis de los retos para enfermería que demanda el mundo actual, como son la globalización, los cambios en las instituciones de salud, los avances en las tecnologías de la información y la comunicación, y los retos para la integración del conocimiento de enfermería en la docencia, la práctica y la investigación. en su conferencia la doctora roy abordó el concepto expandido de �veritivity� para el siglo xxi, y el análisis de la investigación con base en el modelo para obtener y aplicar criterios de práctica basada en la evidencia. asimismo, se dieron a conocer los proyectos de investigación más sobresalientes en este año: el estudio realizado por la doctora christine thomas sobre �valoración del autoconcepto cognitivo y adherencia a los regímenes de salud recomendados en adultos con falla cardiaca�; el trabajo realizado por la doctora ellen buckner en un campo de verano para adolescentes con asma, �madurando la responsabilidad en adolescentes con asma que asistieron a un campo de verano: mecanismos adaptativos y resultados�. en esta ocasión la doctora keville frederickson mostró los resultados de la utilización de instrumentos para la investigación basada en los conceptos del modelo, haciendo énfasis en la escala de autoconsistencia elaborada por zhan. como aspectos positivos de la vinculación de la facultad de enfermería de la universidad de la sabana a la roy adaptation association desde el 2003, y de la participación del grupo de investigación sobre este modelo en nuestra facultad, vale la pena destacar: � la aceptación de la doctora callista roy de escribir el primer capítulo de la segunda edición del libro aplicación del modelo de adaptación en el ciclo vital humano, el cual será publicado en el 2006, con motivo de la celebración de los 15 años de la facultad. como parte de esta celebración, la doctora roy visitará nuestro programa en la primera semana de marzo de 2006. � la asesoría y retroalimentación recibida por parte de la doctora jacqueline fawcett, del análisis realizado por el grupo sobre el concepto �cuidado de enfermería para la adaptación�, el cual recomienda que sea presentado para su publicación en una revista internacional. � el contacto establecido con las doctoras martha whetsell y paulina aguilera, de la universidad autónoma de tamaulipas, tampico, méxico, y la enfermera keville frederickson de lehman college, new york, y mary wickman del mount st mary�s college en los ángeles, con el propósito de buscar mecanismos para establecer convenios de cooperación para el desarrollo de proyectos que fortalezcan la docencia, la práctica y la investigación. los avances del grupo de investigación y su participación en estos eventos han fortalecido el proceso de internacionalización del programa, y en este momento la roy adaptation association, reconoce a la facultad de enfermería de la universidad de la sabana como uno de los centros asesores para la aplicación del modelo en los países de habla hispana. 401 412 efectividad de un manual de autocuidado.indd 401 gladys eugenia canaval-erazo1 claudia patricia valencia-molina2 delia concepción burgos-dávila3 alexandra cossio4 efectividad de un manual de autocuidado para el manejo de síntomas en personas colombianas que viven con vih 1 orcid.org/0000-0001-9841-5084. universidad del valle, colombia. gladys.canaval@correounivalle.edu.co 2 orcid.org/0000-0002-9558-4146. universidad del valle, colombia. claudia.p.valencia@correounivalle.edu.co 3 orcid.org/0000-0002-4373-6427. universidad del valle, colombia. delia.burgos@correounivalle.edu.co 4 orcid.org/0000-0002-2247-5459. universidad del valle, colombia. acossio@cideim.org.co recibido: 17 de noviembre de 2015 enviado a pares: 16 de diciembre de 2015 aceptado por pares: 11 de diciembre de 2016 aprobado: 10 de enero de 2017 doi: 10.5294/aqui.2017.17.4.4 para citar este artículo / to reference this article / para citar este artigo canaval-erazo ge, valencia-molina cp, burgos-dávila dc, cossio a. efectividad de un manual para autocuidado de síntomas en personas colombianas que viven con vih. aquichan. 2017; 17(4): 401-412. doi: 10.5294/aqui.2017.17.4.4 resumen estudio con resultados del nodo cali, en colaboración con la red internacional de enfermeras investigadoras en vih-sida. objetivo: medir la efectividad de un manual de autocuidado para el manejo de síntomas por vih-sida, comparando frecuencia de síntomas, calidad de vida, adherencia y utilidad del manual en personas con el virus del sida que usaron el de autocuidado y las que usaron un manual de nutrición. materiales y métodos: estudio cuasiexperimental con grupo experimental (manual de autocuidado para el manejo de síntomas) y control (manual de nutrición) con 51 personas; mediciones al inicio y a los dos meses. resultados: los síntomas al inicio fueron 16, igual para los dos grupos. a los dos meses disminuyeron, la diferencia no fue significativa para la comparación entre grupos; se encontró aumento en el puntaje global de calidad de vida de 51 a 54 en el grupo experimental, y de 54 a 56 en el grupo control; la mayor utilidad fue para el manual de autocuidado con 88 %, comparado con el de nutrición, 75 %. se reconoce la importancia de diseñar materiales educativos para responder a las necesidades de las personas que viven con el virus del sida. conclusión: el manual de autocuidado fue considerado útil por la mayoría de los participantes del grupo experimental. palabras clave estudio de evaluación; efectividad; autocuidado; calidad de vida; vih-sida (fuente: decs, bireme). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 401-412 402 aquichan issn 1657-5997 eissn 2027-5374 año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 401-412 effectiveness of a self-care manual for the management of symptoms by colombians living with hiv abstract this is a study with results from the cali node, developed in collaboration with the international network of research nurses focused on hiv-aids. objective: measure the effectiveness of a self-care manual on how to manage hiv-aids symptoms by comparing frequency of symptoms, quality of life, and adherence and usefulness of the manual among people with the aids virus who used the self-care manual and those who used a manual on nutrition. materials and methods: a quasi-experimental study was conducted with an experimental group (a self-care manual for the management of symptoms) and a control group (a nutrition manual). there were 51 participants. measurements were taken at the start and after two months. results: there were 16 symptoms at the start, which were the same for both groups. they declined after two months. a comparison between the groups showed the difference was not significant. the increase in the overall quality of life score was from 51 to 54 in the experimental group and from 54 to 56 in the control group. the greatest benefit was for the self-care manual, with 88%, compared to the nutrition manual, with 75%. the importance of designing educational materials to respond to the needs of people who are living with the aids virus is recognized. conclusion: the self-care manual was considered to be useful by the majority of the participants in the experimental group. key words evaluation study; effectiveness; self-care; quality of life; hiv-aids (source: decs, bireme). 403 efectividad de un manual de autocuidado para el manejo de síntomas en personas colombianas que viven con vih l gladys eugenia canaval-erazo y otros efetividade de um manual de autocuidado para o manejo de sintomas em pessoas colombianas que vivem com hiv resumo estudo realizado em cali (colômbia), em colaboração com a rede internacional de enfermeiras pesquisadoras em hiv-aids. objetivo: medir a efetividade de um manual de autocuidado para o manejo de sintomas pelo hiv-aids, comparando frequência de sintomas, qualidade de vida, adesão e utilidade do manual em pessoas com o vírus da aids que usaram o de autocuidado e os que usaram um de nutrição. materiais e métodos: estudo quase-experimental com grupo experimental (manual de autocuidado para o manejo de sintomas) e controle (manual de nutrição) com 51 pessoas; medições ao início e aos dois meses. resultados: os sintomas ao início foram 16 para os dois grupos. aos dois meses, diminuíram; a diferença não foi significativa para a comparação entre grupos; constatou-se aumento na pontuação global de qualidade de vida de 51 a 54 no grupo experimental, e de 54 a 56 no grupo controle; a maior utilidade foi para o manual de autocuidado com 88 %, comparado com o de nutrição, 75 %. reconhece-se a importância de elaborar materiais educativos para atender às necessidades das pessoas que vivem com o vírus da aids. conclusões: o manual de autocuidado foi considerado útil pela maioria dos participantes do grupo experimental. palavras-chave autocuidado; efetividade; estudo de avaliação; hiv-aids; qualidade de vida (fonte: decs, bireme). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 401-412 404 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 introducción los últimos reportes del programa conjunto de las naciones unidas sobre el vih-sida (onusida) estiman que con el advenimiento de los medicamentos antirretrovirales, más de 4 millones de personas que viven con el vih en australia, europa y américa experimentan hoy una condición crónica (1). la transición de una enfermedad aguda a una enfermedad crónica significa que las personas afectadas deben estar en capacidad de atender autónomamente las molestias experimentadas que generan los medicamentos y la enfermedad en sí misma. esta situación constituye un reto para los pacientes y, particularmente, para los profesionales de enfermería quienes son los principales proveedores de cuidado. el autocuidado de las condiciones crónicas se dirige a la reducción de la progresión de la enfermedad, el manejo de los síntomas y la prevención de la discapacidad. el curso no predecible de la exacerbación súbita de los síntomas por el vih, las comorbilidades y el tratamiento antirretroviral (arv) producen distrés psicológico que, a su vez, favorece el comienzo de síntomas depresivos y la ansiedad (2). por ello, su control mediante el autocuidado para mantener una calidad de vida óptima se convierte en una tarea principal (3-5). varios estudios alrededor del mundo han explorado la utilidad y efectividad de programas educativos de autocuidado para mejorar sus habilidades cognitivas, actitudinales y comportamentales que promuevan la adherencia a los tratamientos, el manejo de los síntomas y los efectos adversos de los medicamentos. la mayoría de estos estudios incluyen programas educativos para promover el autocuidado mediante diferentes estrategias: educación formal (6, 7), educación por pares, manejo de síntomas (8) y adaptación a su condición (9) una revisión sistemática de literatura que incluyó varios de estos estudios mostró que los programas de autocuidado para las personas que viven con el vih-sida (pvvs) producen efectos positivos a corto plazo en los resultados físicos, psicosociales y de salud. sin embargo, no existen pruebas suficientes para proporcionar conclusiones sobre los resultados a largo plazo de las intervenciones de autocuidado específicas del vih (10). este artículo presenta los resultados obtenidos en el nodo cali, colombia, de un estudio colaborativo realizado por miembros de la red internacional de enfermeras investigadoras en vih-sida, coordinada por la universidad de california en san francisco. no existen publicaciones en el territorio colombiano relacionadas con la efectividad de manuales de autocuidado en este tema. con el propósito de aportar a la evaluación de la efectividad de un manual de autocuidado para el manejo de síntomas en pvvs y que consultan a instituciones de salud de manera ambulatoria, se plantearon las siguientes preguntas de investigación: 1) ¿cuál es la efectividad de un manual de autocuidado para el manejo de síntomas por vih, respecto a la frecuencia e intensidad de los síntomas, calidad de vida y adherencia al tratamiento en un grupo de personas que viven con el virus del sida, que recibe el manual de autocuidado para el manejo de síntomas comparado con un grupo control? 2) ¿las personas participantes en el grupo de intervención utilizan y encuentran útil el manual de autocuidado para el manejo de síntomas? objetivo medir la efectividad del manual de autocuidado para el manejo de síntomas por vih-sida, mediante la comparación de los síntomas, la calidad de vida, la adherencia y utilidad del manual entre personas de cali, colombia, con el virus del sida que usaron el manual de autocuidado y los que usaron un manual de nutrición. materiales y métodos estudio cuasiexperimental; los participantes fueron asignados al azar al grupo de intervención o experimental (ge) que recibieron el manual de autocuidado para manejo de síntomas de vih, y al grupo control (gc) que recibieron el manual de nutrición. en la figura 1 se muestra el diseño (d) de investigación que se siguió. figura 1. diseño (d) de investigación del estudio grupo experimental (ge): o 0 x ---x a o 1 x b o 2 d grupo control (gc): o 0 x ---x a o 1 x b o 2 grupo experimental (ge): recibe el manual del manejo de síntomas grupo control (gc): recibe el manual de nutrición 405 efectividad de un manual de autocuidado para el manejo de síntomas en personas colombianas que viven con vih l gladys eugenia canaval-erazo y otros x a : tres días más tarde una sección de refuerzo conducida vía teléfono o en persona xb: al mes de seguimiento, un reforzamiento que ocurre en el momento de la visita a la clínica o: observación o momento en el que se toman las medidas 0 = al inicio del estudio, línea de base (lb), tiempo 1 = un mes (t1); tiempo 2 = dos meses (t2) o2: al final, o sea a los dos meses, cada grupo recibirá el manual que no recibió originalmente fuente: adaptado de la propuesta denominada estudio iv de la red internacional de enfermeras investigadoras en vih-sida. muestra con datos de estudios anteriores realizados por la red internacional de enfermeras investigadoras en vih-sida (12) sobre frecuencia de síntomas y promedio de calidad de vida se calculó la muestra con base en un análisis de poder, con pruebas de dos colas, nivel de significancia de 95 % y un delta de 0,50; con ayuda de la tabla maestra se calculó una muestra al inicio del estudio de 72 personas por los dos grupos; después de las pérdidas esperadas para este tipo de estudios, del 20 %, la muestra final fue de 50 personas para los dos grupos en cada nodo o ciudad participante. para el nodo cali serían en el t2 un total de 25 personas para el ge y de 25 personas para el gc. muestra calculada: tiempo 0: línea de base/inducción n = 72. tiempo 1 (t1): mes 1, n = 60 (12 personas, pérdida estimada). tiempo 2 (t2): mes 2, n = 50 (10 personas, pérdida estimada). criterios de inclusión: 1. diagnóstico de vih-sida (confirmación determinada en cada sitio). 2. adultos mayores de 18 años (hombres, mujeres, transgénero). 3. presencia de al menos un síntoma en la última semana. 4. en tratamiento arv actualmente o al menos 1 mes antes de la fecha de participación en el estudio. 5. en capacidad de usar el manual con o sin el apoyo familiar. criterios de exclusión: 1. diagnóstico de demencia documentada. 2. incapaz de comprender los procedimientos de consentimiento de acuerdo con la persona que trata de obtener el consentimiento. 3. tener experiencia previa en el uso de manuales semejantes para el autocuidado de síntomas (respuesta afirmativa cuando se preguntó por experiencia previa). variables de resultado: cambio en la frecuencia e intensidad de los síntomas, calidad de vida y adherencia al tratamiento calculados como la diferencia entre las mediciones al inicio y a los dos meses de seguimiento. variables independientes: características sociodemográficas, condiciones clínicas como comorbilidad y uso de antirretrovirales medidas al inicio del estudio. al final del estudio se midieron el uso y la utilidad de los manuales. intervención: al grupo experimental, al momento de ingresar al estudio, se le entregó el “manual de autocuidado para el manejo de síntomas en personas que viven con el vih-sida”; al grupo control se le entregó el manual “soporte y cuidado nutricional para personas que viven con vih-sida”, ambos manuales en versión en español adaptados y ajustados por el grupo de investigación promesa de la universidad del valle a partir de la versión en inglés realizada por la red internacional de investigación en enfermería en vih-sida de la universidad de california. instrumentos • lista de chequeo revisada de signos y síntomas en personas con vih (ssc-hivrev sigla en inglés), que identifica la frecuencia e intensidad de síntomas y consta de tres partes: parte i, con 45 enunciados con estimados de confiabilidad que van de 0,76-0,9; parte ii, con 19 síntomas relacionados con vih-sida, y parte iii, con 8 síntomas ginecológicos (11). un estudio anterior de la red de enfermeras denominado estudio iii, con cerca de mil sujetos en cinco países, entre ellos colombia, mostró coeficientes alfa de cronbach de 0,65-0,90 (12). 406 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 • calidad de vida en personas con vih (hat-qol sigla en inglés), de 34 ítems (13), es específico para la enfermedad, con 9 dimensiones. el puntaje total es transformado a una escala estandarizada de 0 a 100 puntos, 0 es el peor marcador y 100 es el mejor. también ha sido validada por la red de internacional de enfermeras investigadoras en vih-sida en estudio anterior en cali. • adherencia de morinsky (14), contiene 4 preguntas, cada pregunta se califica con 1 o 0, la suma de la calificación es máximo 4 y mínimo 0. se denomina adherente a quien obtiene 4 puntos, más o menos adherente con 3 puntos y no adherente con 2 o menos puntaje. proceso de recolección de los datos los participantes se captaron en la consulta ambulatoria de diferentes instituciones de salud de la ciudad de cali entre julio de 2009 y marzo de 2012; el muestreo no probabilístico incluyó a los pacientes que asistían a citas de control en cada una de las instituciones participantes del estudio durante el periodo de la recolección de la muestra, en la que se incluyeron todas las personas que aceptaron participar y firmaron el consentimiento informado; cada persona se asignó al azar a cada uno de los dos grupos (experimental o control), se aplicaron las escalas para medir la frecuencia e intensidad de síntomas, calidad de vida y adherencia al tratamiento. los participantes respondieron las preguntas de los instrumentos al ingresar al estudio (lb, al mes y a los dos meses t2 de seguimiento), se les preguntó si experimentaron algún síntoma en las últimas 24 horas, se le pidió a cada grupo calificar el manual en términos de la utilidad y el número de veces que lo consultó en la última semana y el último mes. se contó con el aval del comité de protección de sujetos humanos (comité de ética) de todas las instituciones donde se recolectó la información y con la aprobación del comité de ética de la universidad del valle y de la universidad de california en san francisco, de acuerdo con las normas nacionales e internacionales sobre participación de seres de humanos en investigación. análisis de los datos: se usó estadística descriptiva e inferencial con el paquete estadístico para ciencias sociales (spss) (15). para cada una de las variables de resultado se estimó el cambio entre la medición pre (inicial o lb) y la medición pos (a los dos meses t2). se realizó prueba t de students pareada para establecer diferencias intra grupos y entre los grupos control y experimental. se realizó análisis previa validación de la normalidad de las variables. resultados de los 72 participantes contactados al inicio del estudio que llenaron la línea de base se obtuvo al final un total de 51 personas, 26 en el grupo experimental y 25 en el grupo control (figura 2). el número de pérdidas en los dos grupos fue similar. figura 2. tamaño de la muestra al final del tiempo 2 (t2) por grupo experimental y control muestra inicial n = 72 distribución aleatoria grupo experimental grupo control n = 37 n = 35 línea de base n = 72 n = 29 n = 28 n = 26 n = 25 pérdida de 11, pérdida de 10, igual al 29 % igual al 28 % t1, mes 1, n = 57 t2, mes 2, n = 51 resultados sociodemográficos un poco más del 60 % de la muestra, tanto en el grupo control como en el experimental, fue de sexo masculino. el rango de edad para el grupo experimental fue de 23 a 62 años, y para el control fue de 19 a 66 años. del total de la muestra en el ge el 39 % y en el gc el 25 % reportó unión con una pareja; el 71 % con estudios de bachillerato completo y del nivel técnico en el ge y de 47 % en el gc. en la tabla 1 se muestra la distribución de las variables sociodemográficas en los dos grupos. el promedio de edad fue de 38,2 años para los participantes del ge y de 44,9 años para los del gc; no se encontraron diferencias estadísticamente significativas entre los dos grupos (p: 0,06), tampoco en el promedio de años de estudio (p: 0,99), lo que los hace comparables (tabla 1), tanto en el ge como en el gc el 92 % contó con seguridad social en salud. 407 efectividad de un manual de autocuidado para el manejo de síntomas en personas colombianas que viven con vih l gladys eugenia canaval-erazo y otros tabla 1. características sociodemográficas de las personas que viven con el vih, participantes en el estudio, en los grupos control y experimental, cali, 2012 variable grupo control (n = 25) grupo experimental (n = 26) n % n % sexo mujeres 8 32 10 38 hombres 17 68 16 62 estado civil soltero 6 24 15 57 casado o en unión libre 10 40 7 27 separado 5 20 2 7,6 otro 4 16 2 7,6 escolaridad primaria incompleta 1 4 2 7,6 primaria completa 1 4 2 7,6 bachillerato incompleto 5 20 8 30 bachillerato completo 10 40 6 23 técnicos 8 32 6 23 universitarios 0 0 2 7,6 situación laboral sin empleo 13 52 14 54 con empleo 12 48 12 46 edad promedio 38,2 + 9,9 44,9 + 10,3 p: 0,06 escolaridad años de estudio 10,3 10,4 0,99 fuente: elaboración propia. condiciones clínicas el 81 % de los participantes del ge y 84 % del gc manifestaron no haber tenido diagnóstico de sida, un 4 % respondió no saber. el promedio de años con el diagnóstico de vih fue de 7,7 para el ge y de 7,8 para el gc, la diferencia no fue estadísticamente significativa (p: 0,91). el 80 % de las personas del ge y del gc estaban tomando medicamentos antirretrovirales al momento del estudio; el 35 % en el ge y el 48 % en el gc respondieron tener otras situaciones que afectan la salud. no se observaron diferencias estadísticamente significativas en estas comparaciones. frecuencia e intensidad de los síntomas: la frecuencia de síntomas en la línea de base (lb) fue de 16, igual en el ge y el gc; en el t2 fue de 10 síntomas para el ge y de 13 síntomas para el gc. el cambio en la frecuencia de los síntomas entre ambos grupos no fue significativo (p > 0,05). en la intensidad de los síntomas tampoco se encontró diferencia significativa entre grupos (tabla 2). adherencia el nivel de adherencia al tratamiento en lb para el ge fue de 67 % y para el gc fue de 62 %, en el t2 la adherencia fue de 86 % para el ge y de 74 % para el gc (tabla 2). no se encontró diferencia estadísticamente significativa en la adherencia entre los grupos al final del seguimiento en el t2. calidad de vida el puntaje global de la calidad de vida en la lb para el grupo experimental fue de 51 y para el grupo control de 54 (p > 0,05); en el tiempo 2 (t2), tanto para el ge como para el gc, se presentó un ligero aumento en el puntaje, este cambio no fue significativo (tabla 3) en la misma tabla se muestran los puntajes de las nueve dimensiones de la calidad de vida para la lb, y en t2 para los dos grupos, las diferencias no son significativas. 408 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 tabla 2. frecuencia e intensidad de los síntomas y porcentaje de personas adherentes al tratamiento en grupos experimental y control en línea de base (lb) y en el tiempo 2 (t2), cali, 2012 grupo experimental (manual de síntomas) (n = 25) grupo control (manual de nutrición) (n = 26) p* línea de base seguimiento t2 línea de base seguimiento t2 número de síntomas 16 10 16 13 ns intensidad de los síntomas 2,4 2,5 2,5 2,4 ns adherencia al tratamiento 67 % 86 % 62 % 74 % ns *prueba t pareada p > 0,05 ns fuente: elaboración propia. tabla 3. puntaje en las dimensiones de calidad de vida obtenidos por los participantes del estudio para los grupos experimental y control en línea de base y en el tiempo 2 (t2), cali, 2012 dimensión escala calidad de vida: cdev grupo experimental (manual de síntomas): ge (n = 25) grupo control (manual de nutrición): gc (n = 26) diferencia del cambio en cdev entre ge y gc valor de p* línea de base seguimiento t2 cambio línea de base seguimiento t2 cambio función general 66 73 7 66 69 3 0,34 satisfacción por la vida 30 23 -7 24 29 5 0,34 preocupaciones salud 69 77 12 71 78 7 0,96 preocupaciones financieras 42 53 11 48 49 1 0,67 medicamentos 81 82 1 77 83 6 0,,99 ser vih (+) 66 72 6 78 83 5 0,23 preocupación por expresar 46 52 6 49 50 1 0,80 atención por personal de salud 18 13 -5 18 19 1 0,27 función sexual 69 69 0 83 75 -8 0,48 puntaje global 51 54 3 54 56 2 0,72 *prueba t pareada fuente: elaboración propia. 409 efectividad de un manual de autocuidado para el manejo de síntomas en personas colombianas que viven con vih l gladys eugenia canaval-erazo y otros en general, para los dos grupos las dimensiones de calidad de vida con más baja puntuación fueron en línea de base: atención recibida por el personal de salud con 18 puntos para ambos grupos y satisfacción con la vida con un puntaje de 30 para el ge y de 24 en el gc; el puntaje en el t2 para atención recibida por el personal de salud en el grupo experimental disminuyó a 13 y en el grupo control aumentó a 19; la satisfacción por la vida disminuyó en el grupo experimental a 23 y en el control aumentó a 29, estas diferencias no fueron estadísticamente significativas (tabla 3). uso y utilidad de los manuales: el 60 % de las personas del ge y el 40 % del gc usaron el manual entre 1 a 3 veces en la última semana y el 90 % del ge y el 44 % del gc lo usaron entre 4 y 12 veces en el último mes. en cuanto a la utilidad del manual, el 88 % del ge y el 75 % del gc lo encuentran muy útil; el síntoma para el que más utilizaron el manual fue para la neuropatía. discusión se encontró predominio de hombres entre las pvvs en la muestra total, lo cual tiene implicaciones relacionadas con las visitas a los proveedores de salud y la realización del cuidado de sí; como se ha planteado en diferentes escenarios de salud, son las mujeres las que más se acercan a los servicios de salud, pero también las que desplazan su autocuidado por atender a otras personas de su núcleo familiar (16). casi la mitad de las personas de los dos grupos expresaron tener otras condiciones de salud diferentes a ser vih+, lo que es acorde con la evolución de la enfermedad y con la aparición de molestias relacionadas con múltiples síntomas que experimentan los pacientes (17). signos y síntomas el promedio de síntomas al inicio fue de 16, resultado similar al promedio de 18 síntomas reportados en un estudio realizado previamente en la ciudad de cali (12). aunque no hubo diferencias estadísticamente significativas en el t2, el hallazgo de disminución de los síntomas tiene significancia clínica y podría interpretarse que los dos manuales son un gran aporte para el autocuidado. wantland et al. (18) en un estudio con 885 personas de estados unidos, puerto rico y áfrica encontraron una disminución significativa en la frecuencia y en la intensidad de los síntomas en los pacientes que utilizaron el “manual de autocuidado para el manejo de síntomas” comparado con quienes utilizaron el de nutrición. en el presente estudio no se pudo evidenciar que el manual de síntomas mejora la frecuencia o la intensidad de los síntomas, probablemente porque se requiere mayor número de personas en la muestra para evidenciar un cambio en estos. un subanálisis del estudio de wantland mostró disminución significativa en la frecuencia de síntomas depresivos (p = 0,05) y en la intensidad al mes después de la intervención con el manual (p = 0,01); sin embargo, este efecto no perduró a los dos meses de seguimiento (19). estos datos son consistentes con los hallazgos encontrados por millard (10), quien en una revisión sistemática de literatura encontró que si bien se observan cambios en la mejoría de los síntomas y adherencia, estos no se prolongaban por mucho tiempo. un número de 16 síntomas en la línea de base es cifra importante para tener en cuenta en la práctica del cuidado y en la educación para el autocuidado en el manejo de los síntomas. adherencia la adherencia al tratamiento con medicamentos no cambió significativamente entre grupos, aunque en t2 se observó un ligero aumento en ambos grupos; este hallazgo del aumento en la adherencia para los dos grupos tiene implicaciones clínicas, se ha reportado que los síntomas molestos que pueden ser también ocasionados por los efectos colaterales de los medicamentos influyen en la decisión que toman las personas infectadas con vih de suspender los medicamentos. de acuerdo con chaiyachati et al. (20), las estrategias para mejorar la adherencia deben ser múltiples y simultáneas. por ello, además de las dificultades del bajo número en el tamaño de muestra para identificar diferencias estadísticamente significativas en la mejora del nivel de adherencia, la aplicación de solo intervenciones educativas es insuficiente para lograr una mejoría sostenida. la medición de la adherencia es un reto importante para el equipo de salud (20), y aún existen muchas inquietudes frente a la efectividad de las medidas y los instrumentos usados para realizarla. calidad de vida el promedio de calidad de vida es semejante a lo reportado en otros estudios hechos en población similar (21); se reconoce que la calidad de vida es multidimensional y está influenciada por múltiples aspectos, para mejorarla no solo interviene el manejo de los síntomas sino otros aspectos relacionados con el ambiente 410 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 y las condiciones socioeconómicas de la persona; por otro lado, el tiempo entre las dos mediciones fue muy corto. utilidad del manual los resultados coinciden con estudios multicentricos donde se reporta el manual como muy útil para la mayoría de la muestra (14). aplicación a la práctica y la disciplina de enfermería: con base en estos resultados es muy importante contar con profesionales, sobre todo con enfermeras preparadas para proporcionar cuidados en los servicios ambulatorios y en clínicas especializadas para el seguimiento de las personas infectadas con el virus del vih y la educación para la salud considerada como un elemento esencial para el autocuidado y el apoyo al cuidador primario (10, 22). es importante que el profesional de enfermería conozca cuáles son los síntomas asociados a esta enfermedad y las estrategias de autocuidado, dado que es el principal proveedor de información de los pacientes en las instituciones de salud (23). las profesionales de enfermería son las llamadas a mejorar las interacciones entre la institución de salud y las personas que acuden a los servicios, lo que redunda en la satisfacción del paciente y aporta a la calidad de vida. es de notar que la dimensión “atención recibida por el personal de salud” fue la que obtuvo la más baja calificación en el instrumento de calidad de vida para los dos grupos; enfermería juega un papel crucial para proporcionar cuidados a los pacientes por lo cual en la atención en salud se debe contar siempre con la participación de este profesional. fortaleza del estudio: los instrumentos utilizados para medir las diferentes variables han sido ampliamente validados y utilizados en investigaciones a nivel nacional e internacional. limitación del estudio: realizar cambios en las medidas de autocuidado para el alivio de los síntomas e implementar nuevas acciones es uno de los aspectos que podría influir en la calidad de vida, para ello se requiere mayor tiempo a fin de observar los resultados. conclusiones el “manual de autocuidado para el manejo de síntomas en personas que viven con el vihsida” resultó de gran utilidad. no se evidenció diferencia estadísticamente significativa entre los dos grupos en el t2, tanto en disminución del número de síntomas como en calidad de vida y en la adherencia; estos resultados tienen relevancia para la práctica clínica y ambulatoria de enfermería en orden a enfocar sus esfuerzos en el acompañamiento para el autocuidado de los síntomas, apoyada en herramientas educativas y manuales de fácil acceso. ello implica que para las enfermeras es necesario contar con tiempo para el desarrollo de procesos educativos con el uso de estas herramientas. consideraciones finales el “manual de autocuidado para el manejo de síntomas”, en términos de su efectividad, es útil para los programas preventivos y el cuidado en personas al iniciar el tratamiento antirretroviral, esto a su vez contribuiría a incrementar la calidad de vida de personas con vih-sida. el manual es fuente de orientación para el autocuidado; sin embargo, este estudio no reportó repercusiones importantes en la calidad de vida. este es un constructo multidimensional que se puede modificar con intervenciones a largo plazo y que depende de factores tanto internos como externos a las personas. recomendaciones realizar estudios que evalúen la efectividad del manual en un mayor tiempo posintervención que el realizado en el presente estudio, y con una muestra de mayor tamaño. en general, se recomienda la distribución de manuales de autocuidado de manera sistemática en la práctica clínica a las personas que viven con el virus del sida, a fin de contribuir al autocuidado y al cuidado de las personas con este diagnóstico. 411 efectividad de un manual de autocuidado para el manejo de síntomas en personas colombianas que viven con vih l gladys eugenia canaval-erazo y otros referencias 1. who, unaids, unicef. global hiv/aids response. epidemic up-date and health sector progress towards universal access. 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e, hughes j, tinise x, darner m. an investigation into the health-related quality of life of individuals living with vih who are receiving haart. aids care. 2005;17(5):579-88. 14. murphy da, lu mc, martín d, hoffman d, marelich wd. results of a pilot intervention trial to improve antiretroviral adherence among hiv positive patients. j assoc nurses aids care. 2002;13(6):57-69. 15. spss. spss base 13.0 for windows user’s guide. chicago: spss inc.; 2004. 16. musheke m, bond v, merten s. self-care practices and experiences of people living with hiv not receiving antiretroviral therapy in an urban community of lusaka, zambia: implications for hiv treatment programmes. aids res ther. 2013;10:12-25. 17. lorenc a, ananthavarathan p, lorigan j, jowata m, brook g, banarsee r. the prevalence of comorbidities among people living with hiv in brent: a diverse london borough. london j primary care. 2014;6(4):84-90. 18. wantland dj, holzemer wl, moezzi s, willard s, arudo j, kirksey k et al. a randomized controlled trial testing the efficacy of an hiv/aids symptom management manual. j pain symp man. 2008;36(3):235-46. 19. sanzero eller l, kirksey km, nicholas pk, corless i, holzemer wl, wantland d et al. a randomized controlled trial of an hiv/aids symptom management manual for depressive symptoms. aids care. 2013;25(4):391-9. 412 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 20. chaiyachati hk, ogbuoji o, price m, suthar ab, negussie ek, barnighausen t. improving adherence to antiretroviral therapy aids. 2014;28:s187-s204. 21. valencia cp, canaval ge, portillo cj, marin d. quality of life in persons living with hiv-aids in three healthcare institutions of cali. colomb med. 2010;41(3):197-294. 22. thompson ma, mugavero mj, amico kr et al. guidelines for improving entry into and retention in care and antiretroviral adherence for persons with hiv: evidence-based recommendations from an international association of physicians in aids care panel. ann intern med. 2012;156(11):817-33. 23. modeste rr, majeke sj. sources and types of information on self-care symptom management strategies for hiv and aids. curationis. 2014;37(1):127. 316 327 diagnosticos de enfermagem e modelo.indd 316 anna lívia de medeiros dantas1 isadora lorenna alves nogueira2 ana beatriz ferreira vitorino3 jéssica dantas de sá tinôco4 cecília maria farias de queiroz frazão5 ana luisa brandão de carvalho lira6 diagnósticos de enfermagem e modelo adaptativo de roy: análise em pacientes críticos 1 orcid.org/0000-0002-9908-2901. universidade federal do rio grande do norte (ufrn). brasil. livinhaenf@ufrn.edu.br 2 orcid.org/0000-0002-5654-6366. universidade federal do rio grande do norte (ufrn). brasil. isadoralorenna@ufrn.edu.br 3 orcid.org/0000-0002-1320-1667. universidade federal do rio grande do norte (ufrn). brasil. abvitorino@ufrn.edu.br 4 orcid.org/0000-0002-1111-0390. universidade federal do rio grande do norte (ufrn). brasil. jessicads@ufrn.edu.br 5 orcid.org/0000-0001-6403-7505. universidade federal de pernambuco. brasil. ceciliamfqueiroz@ufpe.br 6 orcid.org/0000-0002-7255-960x. universidade federal do rio grande do norte (ufrn). brasil. analuisalira@ufrnet.br recibido: 24 de febrero de 2016 enviado a pares: 17 de marzo de 2016 aceptado por pares: 16 de diciembre de 2016 aprobado: 16 de enero de 2017 doi: 10.5294/aqui.2017.17.3.8 para citar este artículo / to reference this article / para citar este artigo dantas alm, nogueira ila, vitorino abf, tinô co jds; frazã o cmfq, lira albc. diagnósticos de enfermagem e modelo adaptativo de roy: análise em pacientes críticos. aquichan. 2017; 17(3): 316-327. doi: 10.5294/aqui.2017.17.3.8 resumo objetivo: estabelecer relação dos diagnósticos de enfermagem presentes no domínio segurança e proteção da nanda internacional com os problemas adaptativos do modelo de roy para pacientes em unidade de terapia intensiva. materiais e métodos: estudo transversal, realizado na terapia intensiva de um hospital universitário em capital do nordeste brasileiro. a amostra foi composta por 86 indivíduos. os dados, coletados no período de outubro de 2013 a maio de 2014 mediante formulário de entrevista e exame físico, foram analisados através de estatística descritiva e inferencial. resultados: dentre os diagnósticos de enfermagem do domínio segurança e proteção, 29 estiveram presentes com frequências variáveis. quando relacionados aos problemas adaptativos propostos por roy, evidenciou-se 12 problemas adaptativos, sendo todos esses referentes ao modo adaptativo fisiológico, contemplando as categorias de sentidos, proteção, oxigenação, atividade e repouso e nutrição. conclusão: existe relação entre os diagnósticos de enfermagem do domínio segurança e proteção e os problemas adaptativos do modelo de roy para pacientes em terapia intensiva. palavras-chave enfermagem; diagnóstico de enfermagem; teoria de enfermagem; unidades de terapia intensiva; proteção (fonte: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 316-327 317 diagnósticos de enfermagem e modelo adaptativo de roy: análise em pacientes críticos l anna lívia de medeiros dantas e outros año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 316-327 diagnósticos de enfermería y modelo adaptativo de roy: análisis en pacientes críticos resumen objetivo: establecer relación de los diagnósticos de enfermería presentes en el dominio seguridad y protección de nanda internacional con los problemas adaptativos del modelo de roy para pacientes en unidad de cuidados intensivos (uci). métodos: estudio transversal, llevado a cabo en la uci de un hospital universitario en una capital del noreste brasileño. la muestra fue de 86 individuos. los datos, recolectados entre octubre del 2013 y mayo del 2014, mediante formato de entrevista y prueba física, se analizaron por medio de estadística descriptiva e inferencial. resultados: entre los diagnósticos de enfermería del dominio seguridad y protección, 29 estuvieron presentes con frecuencias variables. en cuanto a los relacionados con los problemas adaptativos propuestos por roy, se evidenciaron 12 problemas adaptativos en cuanto al modo adaptativo fisiológico, que abarca las categorías de sentidos, protección, oxigenación, actividad y reposo y nutrición. conclusiones: se encontró relación entre los diagnósticos de enfermería del dominio seguridad y protección y los problemas adaptativos del modelo de roy para pacientes en cuidados intensivos. palabras clave diagnóstico de enfermería; enfermería; protección; teoría de enfermería; unidades de cuidados intensivos (fuente: decs, bireme). 318 aquichan issn 1657-5997 eissn 2027-5374 nursing diagnosis and roy’s adaptation model: analysis in critical patients abstract objective: the objective of the study was to correlate the nursing diagnoses of the safety and protection domain of nanda international with the adaptive problems noted in the roy model for patients in intensive care units (icu). methods: a cross-sectional study carried out at the icu of a university hospital in a capital city of northeastern brazil. the sample consisted of 86 individuals. the data, collected between october 2013 and may 2014 through an interview and physical examination, were analyzed by means of descriptive and inferential statistics. results: among the nursing diagnoses of the security and protection domain, 29 were found with variable frequencies. when related to the adaptive problems proposed by roy, 12 adaptive problems were evidenced in the physiological adaptive mode, which includes the categories of senses, protection, oxygenation, activity, and rest and nutrition. conclusions: a relationship was found between the nursing diagnoses of the safety and protection domain and the adaptive problems indicated in the roy model for patients in intensive care. keywords nursing diagnosis; nursing; protection; nursing theory; intensive care units (source: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 316-327 319 diagnósticos de enfermagem e modelo adaptativo de roy: análise em pacientes críticos l anna lívia de medeiros dantas e outros introdução a unidade de terapia intensiva (uti) é responsável pela assistência contínua aos pacientes internados em estado crítico. o perfil epidemiológico desses pacientes é caracterizado por indivíduos na faixa etária entre 50 e 59 anos, advindos do centro cirúrgico e com enfermidades cardiovasculares (1). dentre os profissionais que trabalham na uti, ressalta-se o enfermeiro, que tem fundamental importância na prestação de uma assistência direta e contínua. esse profissional desenvolve ações com foco no cuidar, pautadas nas etapas do processo de enfermagem (pe), o que assegura confiabilidade, visibilidade e melhoria do cuidado prestado (2, 3). o pe deve ser respaldado por um referencial teórico. entre as teorias de enfermagem, destaca-se o modelo de callista roy, em que o eixo norteador do cuidado é a adaptação, base para o entendimento do indivíduo como um sistema capaz de se adaptar ao ambiente no qual está inserido (4-7). no modelo de roy, o pe apresenta seis fases, a saber: 1) avaliação de comportamento, 2) avaliação de estímulos, 3) diagnóstico de enfermagem, 4) estabelecimento de metas, 5) intervenção e 6) avaliação. para este estudo, foca-se na etapa dos diagnósticos de enfermagem (de), na qual é necessário identificar os comportamentos ou as reações que a pessoa demonstra a partir dos estímulos internos ou externos transmitidos pelo ambiente (5). para a padronização dos diagnósticos, existem sistemas de classificação, como a nanda internacional (nanda-i), que é dividida em domínios. no paciente crítico em uti, destaca-se o domínio segurança e proteção. esse domínio é definido como ausência de perigo, lesão física ou dano do sistema imunológico, conservação contra perdas e proteção da segurança e da ausência de perigos (8). na uti, o paciente crítico encontra-se vulnerável no que diz respeito à segurança e à proteção. cerca de 10 % dessa clientela é afetada por infecções nosocomiais. essas infecções são responsáveis pela ocorrência de desfechos negativos como morbimortalidade, aumento do tempo de internação, aumento das chances de reinternação e consequente aumento dos gastos hospitalares, em contextos nacionais e internacionais (9-13). estudos que apresentam problemas de enfermagem em paciente crítico na uti evidenciam a vulnerabilidade dessa clientela e frequências elevadas para os diagnósticos que compõem o domínio segurança e proteção. entretanto, esses estudos caracterizam-se por perfis diagnósticos de todos os domínios na nanda-i, o que demonstra a necessidade da realização de pesquisas que focalizem o domínio segurança e proteção (14-17). salienta-se ainda a relevância de relacionar esses achados ao modelo teórico de roy, no intuito de fornecer suporte a uma adaptação positiva do paciente crítico à sua nova condição de vulnerabilidade, o que proporcionará direcionamento e sustentabilidade teórica à assistência prestada. autores revelam a aplicabilidade e a contribuição do modelo teórico de roy em várias áreas da enfermagem, porém ressaltam o número reduzido de estudos que façam uso dela (4, 7). destarte, a identificação de diagnósticos de enfermagem do domínio segurança e proteção e a relação destes com os problemas adaptativos propostos por roy surgem como ponto fundamental para o levantamento dos problemas no contexto de uti e o planejamento de intervenções direcionadas às necessidades do indivíduo. isso posto, levantaram-se os seguintes questionamentos: quais diagnósticos de enfermagem do domínio segurança e proteção estão presentes em pacientes de uti? quais os problemas adaptativos evidenciados nesses pacientes? os problemas adaptativos identificados associam-se estatisticamente com estímulos e comportamentos? existe relação entre os diagnósticos identificados na nanda-i e os problemas adaptativos propostos por roy? a partir da reflexão acerca dessas questões, pretende-se estabelecer a relação dos diagnósticos de enfermagem da nanda-i presentes no domínio segurança e proteção e os problemas adaptativos do modelo teórico de roy para pacientes em uti. metodologia trata-se de um estudo de tipo transversal, realizado na uti adulto do hospital universitário onofre lopes, localizado no município de natal, rio grande do norte, brasil, a qual assiste indivíduos graves sem condição patológica específica. a população do estudo foi composta por 791 pacientes internados nessa unidade no período de janeiro a dezembro de 2012, 320 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 de acordo com os dados fornecidos pelo sistema informatizado do referido hospital. a amostra foi calculada com base na fórmula para populações finitas (18), considerando nível de confiança de 95 % (z∞ = 1,96), erro amostral de 10 % e população de 791 pacientes. na ausência de estudo que estimasse a prevalência de diagnósticos de enfermagem do domínio segurança e proteção em pacientes internados em uti, considerou-se um valor conservador de 50 %. assim, obteve-se uma amostra de 86 indivíduos. os critérios de inclusão foram: idade igual ou superior a 18 anos e pacientes submetidos a tratamento clínico ou cirúrgico internados na uti. os critérios de exclusão, por sua vez, foram: pacientes internados na uti por um período menor a 24 horas e pacientes que foram readmitidos. a amostragem foi por conveniência, de forma consecutiva. concernente ao processo de coleta de dados, houve um treinamento prévio com duas enfermeiras e uma aluna de graduação em enfermagem, que se submeteram a um curso sobre sistematização da assistência de enfermagem. este aconteceu durante o mês de setembro de 2013, com carga de oito horas, e objetivou reforçar o uso do instrumento utilizado no estudo e questões referentes à temática trabalhada. o instrumento que subsidiou a coleta de dados foi anteriormente submetido à validação de sua aparência e conteúdo por duas doutoras em enfermagem, especialistas em diagnósticos de enfermagem e problemas adaptativos de roy. como critérios para seleção das especialistas, elegeu-se: possuir publicações nas referidas áreas e participar do grupo de pesquisas do qual o presente estudo fez parte. o instrumento foi avaliado na perspectiva de sua aplicabilidade à clientela, e as alterações sugeridas se relacionaram à organização dos questionamentos e à sua realização, e todas foram acatadas. os dados foram coletados no período de outubro de 2013 a maio de 2014 por meio de um formulário de entrevista com perguntas abertas e fechadas sobre os dados socioeconômicos e as características definidoras, fatores relacionados e de risco presentes no domínio segurança e proteção da nanda-i, bem como nos problemas adaptativos propostos por roy, além de um exame físico. para análise inicial dos dados, foram construídas planilhas no software microsoft office excel 2010. na primeira, foram inseridos os dados socioeconômicos e clínicos; na segunda, as características definidoras, os fatores relacionados e de risco presentes no domínio segurança e proteção; na terceira, os estímulos e os comportamentos. a partir disso, iniciou-se o processo de inferência diagnóstica, que contou com a participação de três enfermeiros, mestres em enfermagem, os quais trabalhavam com diagnósticos de enfermagem ou possuíam experiência clínica em uti. assim, os diagnosticadores receberam as 86 planilhas com as características definidoras e os fatores relacionados e de risco de cada cliente do estudo; por meio do raciocínio clinico, julgaram quanto à presença ou à ausência de cada diagnóstico do domínio em estudo. realizou-se, então, a inferência dos problemas adaptativos observados nessa clientela e, por fim, estabeleceu-se a relação entre os diagnósticos de enfermagem identificados no domínio segurança e proteção presentes na nanda-i e os problemas adaptativos do modelo de roy aplicados aos pacientes em uti. a apreciação desses dados foi realizada por meio de estatística descritiva e inferencial com o auxílio do software ibm spss versão 20.0 para windows. a análise inferencial deu-se mediante os testes de qui-quadrado e exato de fisher, os quais permitiram observar a associação estatística entre os problemas adaptativos identificados e seus estímulos e comportamentos. considerou-se estatisticamente significante o valor p<0,05. os dados foram organizados em quadros e tabelas para melhor visualização. o projeto foi aprovado pelo comitê de ética em pesquisa do hospital universitário em questão e recebeu parecer favorável sob protocolo n.o 440/414. todos os aspectos éticos e legais foram respeitados. resultados dos 86 pacientes analisados no estudo descrito, 52,3 % eram do sexo feminino, 55,8 % de raça parda, 95,3 % pertenciam a alguma religião, 70,9 % tinham um companheiro e 79,1 % possuíam renda de um a três salários-mínimos. no tocante à procedência, 61,6 % eram provenientes do interior, com média de seis anos de estudo (±4,5), e média de idade de 53,4 anos (±16,5), com mínimo de 18 e máximo de 81 anos. dentre os diagnósticos de enfermagem do domínio segurança e proteção da taxonomia ii da nanda-i, cinco foram observados em 321 diagnósticos de enfermagem e modelo adaptativo de roy: análise em pacientes críticos l anna lívia de medeiros dantas e outros 100 % da clientela estudada, a saber: risco de contaminação, risco de lesão, risco de queda, risco de resposta alérgica e risco de trauma. apresentaram ainda maioria expressiva em pacientes críticos internados na uti: risco de infecção (98,8 %), risco de olho seco (98,8 %), risco de envenenamento (96,5 %), risco de trauma vascular (96,5 %), integridade da pele prejudicada (95,3 %), dentição prejudicada (93 %), risco de sangramento (83,7 %), risco de desequilíbrio da temperatura corporal (82,6 %), risco de lesão por posicionamento perioperatório (73,3 %), integridade tissular prejudicada (76,7 %), risco de disfunção neurovascular periférica (72,1 %), risco de resposta adversa ao meio de contraste com iodo (69,8 %) e risco de choque (61,6 %). no que concerne aos de com índice igual ou inferior a 50 %, têm-se: risco de aspiração (50 %), risco de lesão térmica (46,5 %), recuperação cirúrgica retardada (43 %), risco de sufocação (34,9 %), risco de integridade da pele prejudicada (17,4 %), risco de resposta alérgica ao látex (9,3 %), hipertermia (7 %), termorregulação ineficaz (5,8 %), mucosa oral prejudicada (5,3 %) e contaminação (1,2 %). os problemas adaptativos propostos por roy foram identificados na clientela em estudo por meio de estímulos focais e contextuais, bem como mediante comportamentos expressos. os problemas adaptativos integridade da pele prejudicada e potencial para enfrentamento ineficaz com resposta alérgica apresentaram frequências iguais a 100 % na clientela, e não admitiram a realização de associação por não originarem tabelas de contingência 2x2. realizou-se associação estatística entre os problemas adaptativos e seus estímulos e comportamentos. a tabela 1, portanto, evidencia a ocorrência de estímulos e comportamentos de cada problema identificado, de frequência superior a 50 %, bem como as associações estatísticas identificadas. tabela 1. estímulos e comportamentos identificados em pacientes críticos a partir da teoria proposta por roy (natal, 2015) problema adaptativo estímulo focal % valor p estímulo contextual % valor p comportamento % valor p infecção aumento da exposição ambiental a patógenos 98,8 0,0121* vacinação inadequada 82,6 0,1741 procedimentos invasivos 94,2 0,0581 doença crônica 79,1 0,2091 defesas primárias inadequadas 79,1 0,2091 conhecimento deficiente para evitar exposição a patógenos 66,3 0,3371 choque efeitos secundários relacionados ao tratamento 62,8 0,0061* conhecimento deficiente 62,8 0,0061* regulação da temperatura ineficaz taxa metabólica alterada 54,7 0,0002* inatividade 82,6 0,0001* cicatrização retardada de feridas adia o retorno às atividades de trabalho/emprego 72,1 0,0002* dificuldade para movimentar-se 72,1 0,0002* percepção de que é necessário mais tempo para a recuperação 70,9 0,0002* precisa de ajuda para completar o autocuidado 70,9 0,0002* síndrome do desuso imobilização 60,5 0,0002* legenda: 1 teste exato de fisher; 2 teste de qui-quadrado; *apresentou associação estatística. fonte: herdman (8); roy e andrews (5). 322 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 diante dos resultados, percebe-se que houve associação estatística significante (p<0,05) entre o problema adaptativo infecção e o estímulo focal aumento da exposição ambiental a patógenos; o problema choque e os estímulos focais estímulos secundários relacionados ao tratamento e ao conhecimento deficiente; regulação da temperatura ineficaz associou-se com o estímulo focal taxa metabólica alterada e o estímulo contextual inatividade; cicatrização de feridas retardada com comportamentos: adia o retorno às atividades de trabalho/emprego, dificuldade para movimentar-se, percepção de que é necessário mais tempo para a recuperação e precisa de ajuda para completar o autocuidado; o problema adaptativo síndrome do desuso relacionouse ao estímulo focal imobilização. após a inferência dos problemas adaptativos na clientela investigada, pôde-se realizar um agrupamento entre estes e os de traçados e estabelecer uma relação entre eles. a equivalência entre os de do domínio segurança e proteção e os problemas adaptativos propostos por roy estão descritos no quadro 1. quadro 1. diagnósticos de enfermagem do domínio segurança e proteção e os problemas adaptativos identificados em pacientes críticos (natal, 2015) diagnóstico de enfermagem problema adaptativo categoria integridade da pele prejudicada integridade tissular prejudicada risco de integridade da pele prejudicada risco de lesão risco de lesão por posicionamento perioperatório risco de lesão térmica risco de trauma integridade da pele prejudicada proteção risco de resposta alérgica potencial para o enfrentamento ineficaz com reação alérgica proteção risco de queda potencial para lesão sentidos risco de infecção risco de contaminação infecção proteção risco de choque risco de sangramento choque oxigenação risco de desequilíbrio da temperatura corporal termorregulação ineficaz regulação da temperatura ineficaz proteção recuperação cirúrgica retardada cicatrização retardada de feridas proteção risco de disfunção neurovascular periférica síndrome do desuso atividade e repouso mucosa oral prejudicada risco de aspiração náusea e vômito nutrição desobstrução ineficaz das vias aéreas troca inadequada de gases oxigenação risco de sufocação hipóxia oxigenação hipertermia febre proteção fonte: herdman (8); roy e andrews (5). 323 diagnósticos de enfermagem e modelo adaptativo de roy: análise em pacientes críticos l anna lívia de medeiros dantas e outros discussão no tocante às similaridades entre os de da nanda-i e os problemas adaptativos do modelo de adaptação proposto por roy, evidenciou-se que, dentre os quatro modos analisados, somente os problemas relacionados ao modo fisiológico apresentaram relação com os da nanda-i. estudos (19-20) destacam os principais problemas nessa clientela referentes às alterações fisiológicas como sendo decorrentes de alterações no aparelho circulatório, de doenças endócrinas, nutricionais e metabólicas, além de neoplasias. em determinados casos, há evidência de insuficiência orgânica, e a insuficiência renal é a de maior prevalência. dentre as categorias trazidas por roy no modo fisiológico, tem-se a categoria proteção cujo problema adaptativo integridade da pele prejudicada apresentou maior número de relações estabelecidas com os de. o problema adaptativo apresentou relação comum em pacientes de uti que são, em sua maioria, dependentes e acamados, características que se acercam aos estímulos para a ocorrência de tal problema adaptativo e levam ao maior acometimento por questões relacionadas à pele. a literatura (21) corrobora com o exposto ao trazer a alta prevalência de problemas relacionados à integridade da pele prejudicada nos pacientes adultos de uti, em sua maioria, restritos ao leito e com intervenções diárias exemplificadas por: monitorização contínua, acesso venoso, sonda nasogástrica/nasoenteral, sonda vesical de demora e curativos. na categoria proteção, houve ainda a relação do problema potencial para enfrentamento ineficaz com resposta alérgica e o diagnóstico risco de resposta alérgica. esse problema adaptativo apresentou os seguintes estímulos focais: medicamentos (penicilina), produtos químicos (alvejantes e cosméticos) e exposição repetida a substâncias do ambiente. a clientela de uti está sujeita a cuidados diários que incluem grande quantidade de medicamentos e, consequentemente, exposição repetida às substâncias circulantes no ambiente. as reações anafiláticas e anafilactoides (raas) resultam no aumento da morbimortalidade de pacientes em uti e são de grande interesse para os profissionais da saúde. há o aparecimento de sinais e sintomas como urticária, eritema, edema de glote/laringe, broncoespasmo e hipotensão arterial, resultantes, principalmente, do uso de bloqueadores neuromusculares, látex, antibióticos, hipnóticos, coloides e opioides (22). ante o exposto, sobressai a necessidade de cuidados da equipe de saúde direcionados à história clínica detalhada do paciente para antecedentes de reação alérgica, além da determinação de possíveis reações cruzadas pelo uso de medicamentos ou materiais disponíveis na unidade. o problema adaptativo infecção apresentou relação com os diagnósticos risco de infecção e risco de contaminação, surgindo com alta prevalência e apresentando associação estatística com o estímulo focal aumento da exposição ambiental a patógenos. estudo (19) corrobora com o achado ao atribuir esse estímulo ao ambiente de risco de uti, bem como às severas condições crônicas de saúde às quais os pacientes estão submetidos. essa elevada ocorrência explica-se pelo fato de os pacientes hospitalizados apresentarem maior exposição ambiental a patógenos, onde um grande número de procedimentos invasivos são normalmente realizados (21). assim, cuidados de enfermagem com a prevenção de infecções são fundamentais na clientela crítica, uma vez que prevenir tal evento adverso é de grande responsabilidade da equipe de enfermagem. a regulação da temperatura ineficaz correlaciona-se com os diagnósticos risco de desequilíbrio da temperatura corporal e termorregulação ineficaz e apresenta associação estatística com o estímulo focal taxa metabólica alterada e com o estímulo contextual inatividade. em estudo analisado (23), verificaram-se os fatores de risco extremos de idade, inatividade, sedação, taxa metabólica alterada, vasoconstrictores e vasodilatadores, frequentes em pacientes críticos, o que corrobora com o identificado no presente estudo. nesse sentido, cuidados direcionados ao controle da temperatura ambiental da uti em relação à temperatura verificada na clientela crítica bem como a atenção para o efeito hipotérmico dos medicamentos em uso devem ser priorizados. para tanto, a adoção de mantas térmicas e a verificação contínua da temperatura corporal individual são imprescindíveis à adaptação positiva desses pacientes à realidade da uti. o problema adaptativo cicatrização retardada de feridas estabeleceu relação com o diagnóstico recuperação cirúrgica retardada. apresentou, ainda, associação estatística com os seguintes comportamentos: adia o retorno às atividades de trabalho/emprego, dificuldade para movimentar-se, percepção de que é necessário mais tempo para a recuperação e precisa de ajuda para completar o autocuidado. 324 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 a literatura (24) destaca que as complicações cirúrgicas e a ocorrência de doenças crônicas precoces para a fase adulta, como anemia e hipertensão arterial sistêmica, são cada vez mais frequentes. nos idosos, prevaleceram os fatores comuns ao processo de envelhecimento, com diminuição da capacidade funcional, associados com doenças crônicas como hipertensão arterial sistêmica, diabetes mellitus e neoplasias (20). constatouse, ainda, a predominância dos comportamentos dificuldade para movimentar-se e precisa de ajuda para completar o autocuidado. ressalta-se que, no momento da realização do estudo, a versão 2015-2017 da nanda-i ainda não havia sido lançada, assim o diagnóstico risco de úlcera por pressão não existia na taxonomia, entretanto evidências para a ocorrência de tal diagnóstico são destacadas no presente estudo. outrossim, o aumento dos dias de pós-operatório surge como contribuinte para o adiamento ao retorno das atividades de vida diária devido à permanência prolongada nas unidades de internação. nos adultos, a queixa principal era a dificuldade para retornar ao trabalho; já nos idosos, consistia na dificuldade do retorno às atividades cotidianas e na dependência de terceiros para o autocuidado (24). ratifica-se, assim, o comportamento percepção da necessidade de mais tempo para recuperação nas duas faixas etárias, com a necessidade de cuidados de enfermagem que propiciem uma recuperação em tempo adequado, que reduzam desgastes e complicações para a clientela crítica. o problema adaptativo febre relacionou-se com o diagnóstico hipertermia. estudo (19) denota que, dentre os principais cuidados diários, está o monitoramento da temperatura corporal a cada duas horas como ação preventiva a possíveis complicações nessa clientela. em caso de alterações, são apontados alguns cuidados terapêuticos de resfriamento por meios físicos: o uso de esponjas úmidas, mantas resfriadoras e banhos com gelo (25). quanto à categoria oxigenação, o problema adaptativo troca inadequada de gases mostrou relação com desobstrução ineficaz das vias aéreas; o problema hipóxia com risco de sufocação e o problema choque com risco de sangramento e risco de choque. o choque, devido à elevada frequência, permitiu a observação da associação estatística com os seguintes estímulos focais: efeitos secundários relacionados ao tratamento e conhecimento deficiente. diante disso, problemas de enfermagem concernentes ao sistema respiratório tornam-se frequentes. estudo (23) corrobora ao evidenciar o problema adaptativo troca inadequada de gases em todos os pacientes investigados e associa-o às condições clínicas graves em que eles se encontram, a saber: insuficiência respiratória, complicações cirúrgicas com permanência em analgesia e ventilação mecânica. para o problema adaptativo hipóxia, a literatura (26-27) aponta a presença da via aérea artificial, as lesões decorrentes do tubo endotraqueal, o acúmulo de secreção nesse tubo e na cavidade oral, as baixas dosagens de sedativos e, ainda, a assincronia decorrente de drive respiratório presente no paciente, como possíveis agravantes desse processo. dentre os cuidados desempenhados pelos profissionais, está a monitorização constante do padrão respiratório por meio da oximetria de pulso e valores decorrentes da ventilação mecânica; para este último, é indispensável a capacitação dos envolvidos para o entendimento dos valores propostos e a adoção da conduta apropriada. nesse sentido, cuidados relacionados à oxigenação da clientela crítica em uti devem ser traçados a fim de proporcionar maior adaptação desses indivíduos ao estado crítico e, em consequência, alcançar respostas humanas positivas a esses problemas. a categoria atividade e repouso, por sua vez, traz o problema adaptativo síndrome do desuso relacionado ao risco de disfunção neurovascular periférica. tal problema adaptativo apresentou associação estatística com o estímulo focal imobilização. estudo (26) evidenciou o risco para síndrome do desuso com grande incidência em indivíduos críticos vítimas de disfunção neurovascular periférica decorrente de acidente vascular cerebral. esses pacientes demonstraram incapacidades desde relacionais até limitações físicas referentes à mobilidade, o que caracteriza a influência dessa condição na modificação de outros parâmetros fisiológicos, como o padrão respiratório, e apresenta melhora com a deambulação do indivíduo, consequentemente, evita a permanência prolongada do paciente na uti (28-30). na categoria sentidos, o problema adaptativo potencial para lesão relaciona-se ao risco de queda. o evento quedas é menos frequente em uti, lugar no qual o paciente, em sua maioria, está restrito ao leito, sob monitorização contínua e incapaz de deambular ou transferir-se para uma poltrona. existe, contudo, o risco de sua ocorrência nesse ambiente e, portanto, a prescrição de cuidados de enfermagem para minimizá-los, como: elevar grades do leito e observar mudança no estado cognitivo ou físico do pa325 diagnósticos de enfermagem e modelo adaptativo de roy: análise em pacientes críticos l anna lívia de medeiros dantas e outros ciente (sonolência, alterações visuais, agitação psicomotora, parestesias, imobilidade, dentre outros) (23). por fim, tem-se a categoria nutrição, que apresenta o problema adaptativo náusea e vômito associado aos diagnósticos mucosa oral prejudicada e risco de aspiração. os pacientes gravemente internados aparecem com maior risco de aspiração do conteúdo gástrico, o que leva à pneumonia aspirativa (31). assim, é necessário monitorar o nível de consciência, o reflexo da tosse, o reflexo do vômito e a capacidade de deglutir, além de monitorar a condição pulmonar, posicionar o paciente em decúbito de 90º graus e sempre verificar o posicionamento da sonda, caso necessário, antes de alimentar o paciente (32-33). a literatura (29) aponta ainda a ocorrência de mucosa oral prejudicada associada à presença de infecção em pacientes internados em uti, que, em sua maioria, se encontram dependentes dos cuidados de enfermagem e hemodinamicamente instáveis. estudo (34) relata que a taxonomia da nanda-i possui estreita relação com os diagnósticos propostos por roy devido à participação da estudiosa como membro da nanda-i desde os seus primeiros trabalhos. a identificação de problemas adaptativos e a correlação destes com de da nanda-i proporcionam maior direcionamento das ações da equipe de enfermagem no sentido de desenvolver uma adaptação positiva do paciente crítico à sua atual condição de saúde. conclusão conclui-se que existem relações entre os de do domínio segurança e proteção e os problemas adaptativos, com destaque para o aspecto fisiológico dos pacientes críticos, o que proporciona o direcionamento das necessidades de adaptação dessa clientela. ademais, as relações apresentadas auxiliam na identificação de dificuldades adaptativas por esses indivíduos, diante de respostas humanas, aproximando os elementos da ciência da enfermagem para a sua inserção na prática clínica, por meio da identificação de fenômenos próprios da profissão. assim, os profissionais de enfermagem poderão promover a adaptação positiva dessa população à atual condição de vulnerabilidade em que se encontram e atingir resultados positivos para a segurança do paciente. como limitação, destaca-se a realização do estudo em um único centro. entretanto, o fato de este se configurar como um centro de referência e de os achados do estudo corroborarem com a literatura pertinente minimiza a limitação evidenciada. assim, sugere-se a realização de novos estudos multicêntricos que possam confirmar as relações aqui identificadas, ademais de estudos que abordem intervenções de enfermagem para promover a adaptação positiva dessa clientela diante dos problemas identificados. destacam-se as contribuições deste estudo para o processo de trabalho do enfermeiro ao delimitar os fenômenos de enfermagem a partir dos diagnósticos identificados nessa clientela e os problemas adaptativos apontados no modelo de roy. para finalizar, conclui-se que este estudo reforça a importância da inferência diagnóstica na pesquisa, no ensino, na gestão e na assistência, o que demonstra o valor dos modelos teóricos da enfermagem para a elaboração de metas e ações individualizadas voltadas às necessidades reais do indivíduo assistido. referências 1. rodriguez ah, bub mbc, perão of, zandonadi g & rodriguez mjh. epidemiological characteristics and causes of deaths in hospitalized patients under intensive care. rev bras enferm. 2016; 69(2):210-4. 2. barra dcc, sasso gtmd & almeida srw. usabilidade do processo de enfermagem informatizado a partir da cipe em unidades de terapia intensiva. rev esc enferm usp. 2015; 49(2):326-34. 3. lunney m. pensamento crítico para o alcance de resultados positivos em saúde: análise e estudos de caso em enfermagem. porto alegre: artmed; 2011. 4. frazão cmfq, sá jd, medeiros aba, fernandes micd, lira albc & lopes mvo. problemas adaptativos de roy em pacientes em hemodiálise. rev latino-am enfermagem. 2014; 22(6):966-72. 326 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 5. roy c & andrews ha. teoria da enfermagem — o modelo de adaptação de roy. porto alegre: instituto piaget; 2001. 6. alves ef. o cuidador de enfermagem e o cuidar em uma unidade de terapia intensiva. unopar cient ciênc biol saúde. 2013; 15(2):115-22. 7. medeiros lp, souza mbc, sena jf, melo mdm, costa jws & costa ikf. modelo de adaptação de roy: revisão integrativa dos estudos realizados à luz da teoria. rev rene. 2015; 16(1):132-40. 8. herdman th. diagnósticos de enfermagem da nanda: definições e classificação (2012-2014). porto alegre: artmed; 2013. 9. oliveira rm, leitão imta, silva lms, figueiredo sv, sampaio rl & gondim mm. estratégias para promover segurança do paciente: da identificação dos riscos às práticas baseadas em evidências. esc anna nery. 2014; 18(1):122-9. 10. martín mc & ruiz j. acontecimientos adversos en medicina intensiva: gestionando el riesgo. med. intensiva. 2006; 30(6):284-92. 11. nangino go, oliveira cd, correia pc, machado nm & dias atb. impacto financeiro das infecções nosocomiais em unidades de terapia intensiva em hospital filantrópico de minas gerais. rev. bras ter intensiva. 2012; 24(4):35761. 12. oliveira ac, cardoso cs & mascarenhas d. precauções de contato em unidade de terapia intensiva: fatores facilitadores e dificultadores para adesão dos profissionais. rev. esc. enferm. usp. 2010; 44(1):161-5. 13. brown ses, ratcliffe sj, kahn jm & halpern sd. the epidemiology of intensive care unit readmissions in the united states. am. j. respir. crit. care med. 2012; 185(9):955-64. 14. benedet as & brasil n. a sistematização da assistência de enfermagem e as necessidades de cuidados de pacientes internados em terapia intensiva. rev eletr gest & saúde. 2012; 3(2):522-37. 15. pivoto fl, lunardi filho wd, santos ssc, almeida ma & silveira rs. diagnósticos de enfermagem em pacientes no período pós operatório de cirurgias cardíacas. acta paul. enferm. 2010; 23(5):665-70. 16. salomé gm. diagnóstico de enfermagem dos pacientes internados em uma unidade de terapia intensiva. saúde coletiva 2011; 8(47):24-8. 17. dutra csk, silveira lm, santos ao, pereira r & stabile am. prevalent nursing diagnosis in patients hospitalized with sepsis at the intensive care unit. cogitare enferm. 2014; 19(4):688-94. 18. rea l & parker r. metodologia de pesquisa: do planejamento à execução. 1. ed. são paulo: pioneira thompson learning; 2002. 19. ramos gs, santana sc, ferreira phc, chianca tcm & guedes hm. diagnósticos de enfermagem documentados em prontuários de pacientes em unidade de terapia intensiva. r. enferm. cent. o. min. 2013; 3(2):679-86. 20. nogueira ls, sousa rmc, padilha kg & koike km. características clínicas e gravidade de pacientes internados em utis públicas e privadas. texto contexto enferm. 2012; 21(1):59-67. 21. chianca tcm, lima aps & salgado po. nursing diagnoses identified in inpatients of an adult intensive care unit. rev esc enferm usp. 2012; 46(5):1101-7. 22. prado e & silva mjb. anafilaxia e reações. j. pediatr. (rio j.). 1999; 75(2):259-67. 23. lima aps, chianca tcm & tannure mc. avaliação da assistência de enfermagem utilizando indicadores gerados por um software. rev latino-am enfermagem. 2015; 23(2):234-41. 24. pereira sk, santana rf, santos i, soares ts, amaral dm & silva dm. análise do diagnóstico de enfermagem: recuperação cirúrgica retardada em adultos e idosos hospitalizados. rev min enferm. 2014; 18(3):660-6. 25. salgado po, silva lcr, paiva ira, macieira tgr & chianca tcm. nursing care to pacients with high body temperature: an integrative review. reme. 2015; 19(1):220-6. 26. benedet as & brasil n. a sistematização da assistência de enfermagem e as necessidades de cuidados de pacientes internados em terapia intensiva. rev eletr gest & saúde. 2012; 3(2):800-15. 27. dornelles c, oliveira gb, schwonke crgb & silva jrs. experiências de doentes críticos com a ventilação mecânica invasiva. esc anna nery. 2012; 16(4):796-801. 327 diagnósticos de enfermagem e modelo adaptativo de roy: análise em pacientes críticos l anna lívia de medeiros dantas e outros 28. dutra csk, silveira lm, santos ao, pereira r & stabile am. diagnósticos de enfermagem prevalentes no paciente internado com sepse no centro de terapia intensiva. cogitare enferm. 2014; 19(4):747-54. 29. cavalcanti im, cantinho faf & assad a. medicina perioperatória. rio de janeiro: saerj [sociedade de anestesiologia do estado do rio de janeiro]; 2006. 30. oliveira ars, costa ags, moreira rp, cavalcante tf & araújo tl. diagnósticos de enfermagem da classe atividade/exercício em pacientes com acidente vascular cerebral. rev enferm uerj. 2012; 20(2):221-8. 31. fernandes rl, franzói s & bueno fc. epidemiologia de pneumonia hospitalar associada à ventilação mecânica invasiva na unidade de terapia intensiva do hospital universitário de maringá. uningá review. 2011; 7(2):33-42. 32. docheterman jm & bulechek gm. classificação das intervenções de enfermagem (nic). porto alegre: artmed; 2010. 33. gomes atl, araújo jnm, fernandes micd, vítor af, lira albc & torres gv. cuidados de enfermagem à pessoa com insuficiência cardíaca descompensada. rev. bras. pesq. saúde. 2014; 16(2):124-9. 34. saldanha ea, fernandes micd, medeiros aba, frazão cmfq, costa ia & lira albc. a teoria de callista roy, a nanda-i e o cuidado ao paciente prostatectomizado. rev enferm uerj. 2012; 20(esp2):764-70. 18 29 aproximacion fenomenologica.indd 18 aquichan issn 1657-5997 manuel lillo-crespo1 purificación gironés-guillem2 maria cristina sierras-davó3 jorge riquelme-galindo4 juan mario domínguez-santamaría5 aproximación fenomenológica al signifi cado e impacto de la donación de órganos en la familia 1 orcid.org/0000-0003-2053-2808. clínica vista hermosa, españa. mlillo@clinicavistahermosa.es 2 orcid.org/0000-0003-2743-2949. hospital la fe, españa. piposmlc@hotmail.com 3 orcid.org/0000-0002-9940-0455. clínica vista hermosa, españa. mcristinasierras@gmail.com 4 orcid.org/0000-0002-6010-208x. clínica vista hermosa, españa. jrgrqlm@gmail.com 5 orcid.org/0000-0003-2462-3993. universidad de alicante, españa. dominguez.jm@ua.es recibido: 4 de abril de 2016 enviado a pares: 22 de abril de 2016 aceptado por pares: 13 de junio de 2016 aprobado: 11 de julio de 2016 doi: 10.5294/aqui.2017.17.1.3 para citar este artículo / to reference this article / para citar este artigo lilo-crespo m, gironés-guillem p, sierras-davó mc, riquelme-galindo j. y domínguez-santamaría jm. aproximación fenomenológica al significado e impacto de la donación de órganos en la familia. aquichan. 2017;17(1):18-29. doi: 10.5294/aqui.2017.17.1.3 resumen la donación de órganos es un acontecimiento crítico tras la pérdida de un ser querido. españa, a pesar de ser el país del mundo con mayor tasa de donantes, todavía mantiene una negativa familiar del 15,56 %. objetivos: conocer y analizar el impacto de la donación de órganos a través de los significados que tiene para la familia en el contexto español. materiales y método: estudio cualitativo fenomenológico según el marco conceptual y método de giorgi. luego de respetar, al menos, tres años de duelo desde la pérdida de un ser querido, se entrevistaron en profundidad a once familias que donaron órganos en el hospital la fe en valencia. resultados: tras el análisis de los resultados, se describieron veintisiete unidades de significado que fueron clasificadas en relativos a la pérdida y relativos a la donación de órganos y, posteriormente, correlacionadas. conclusiones: la donación aparece como mecanismo de alivio o compensación del fallecimiento del familiar. palabras clave obtención de tejidos y órganos; investigación cualitativa; significado; aflicción; pesar (fuente: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 18-29 19 aproximación fenomenológica al significado e impacto de la donación de órganos en la familia l manuel lillo-crespo y otros año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 18-29 phenomenological approach to the meaning and impact of organ donation in the family abstract organ donation is a critical event after the loss of a loved one. spain, despite being the country with the highest donor rate in the world, still maintains a family negative rate of 15.56%. objective: know and analyze the impact of organ donation based on its meaning for the family in the spanish context. materials and method: this is a phenomenological qualitative study based on giorgi’s conceptual framework and method. eleven families who had donated organs at the hospital la fe in valencia were interviewed in depth, following at least three years of mourning since the loss of a loved one. results: after the results were analyzed, twenty-seven units of meaning were described and classified as relative to the loss and relative to the organ donation. they were then correlated. conclusion: organ donation appears to be a relief mechanism or a kind of compensation for the death of a family member. keywords obtaining tissue and organs; qualitative research; meaning; affliction; grief (source: decs, bireme). 20 aquichan issn 1657-5997 aproximação fenomenológica ao significado e ao impacto da doação de órgãos na família resumo a doação de órgãos é um acontecimento crítico após a perda de um ser querido. a espanha, embora seja o país do mundo com maior taxa de doadores, ainda mantém uma negativa familiar de 15,56 %. objetivos: conhecer e analisar o impacto da doação de órgãos por meio dos significados que tem para a família no contexto espanhol. materiais e método: estudo qualitativo fenomenológico de acordo com o referencial conceitual e o método de giorgi. depois de respeitar, pelo menos, três anos de luto desde a perda de um ser querido, foram entrevistadas em profundidade 11 famílias que doaram órgãos no hospital la fe em valência. resultados: após a análise de resultados, descreveram-se 27 unidades de significado que foram classificadas em relativos à perda e relativos à doação de órgãos; em seguida, correlacionadas. conclusões: a doação aparece como mecanismo de alívio ou compensação do falecimento do familiar. palavras chave aflição; luto; obtenção de tecidos e órgãos; pesquisa qualitativa; significado (fonte: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 18-29 21 aproximación fenomenológica al significado e impacto de la donación de órganos en la familia l manuel lillo-crespo y otros introducción según el real decreto español 1723/2012, por el que se regulan las actividades relacionadas con los órganos humanos destinados al trasplante, se accede a la familia para conocer la voluntad de la persona fallecida sobre la donación de sus propios órganos (1) cuando esta no ha dejado constancia escrita de ella, situación habitual en la cultura española, donde la familia tiene un papel fundamental en la ratificación de la voluntad del fallecido. hay experiencias que muestran que la visión de los familiares impactados por la pérdida dista mucho de la visión de los profesionales (2), lo que crea una barrera que hace menos eficaz al profesional en la obtención de órganos, ya que no comprende la vivencia del familiar y, en consecuencia, no consigue entablar una relación de ayuda adecuada para acompañarlos en su duelo (3,4). llegados a este punto, es importante considerar los aspectos culturales de parentesco relacionados con el proceso que va desde el duelo por la pérdida del ser querido hasta la donación de órganos por parte de la familia, especialmente en núcleos familiares de origen latino, como es el caso de españa, y cuyos hallazgos podrían ser extrapolables a otros grupos culturales latinoamericanos. en contextos de culturas con una orientación grupal o familiar, se pone de manifiesto el fenómeno de choque cultural entre familiares y equipo profesional (5,6). este choque podría derivar en una respuesta negativa, debido a la actitud profesional y a cómo la perciben los miembros de la familia que toman dichas decisiones. se hace necesario conocer el significado de dicho proceso para la familia y el impacto que un acto como es la donación provoca, para así poder determinar las mejores pautas de actuación que desemboquen en unos resultados positivos, para la sociedad, la familia y el propio equipo profesional (6,7). españa tiene implantado un programa de donación y trasplantes instaurado desde hace más de veinticinco años, con un crecimiento exponencial reconocido internacionalmente, tanto en el número de donaciones por millón de habitantes como en la calidad y trasparencia de su sistema. sin embargo, según datos de la organización nacional de trasplantes (8), la negativa familiar suponía todavía en el 2013 un porcentaje elevado del 15,56 % en españa. conforme a la ley española 30-1979, de extracción y trasplante de órganos, y el real decreto 1723/2012, todos los españoles son donantes, aunque eso no exime de preservar el derecho a quien en vida se haya manifestado en contra. según las leyes españolas, el garante de la voluntad del fallecido es su familia (1,9), aun cuando el cerco se ha ampliado a sus allegados. esta circunstancia acaba convirtiendo la voluntad de la familia en la verdadera autorización; por lo tanto, el éxito o aceptación de la donación dependerá de la vivencia familiar en ese momento y de su significado. algunos autores sugieren que las familias no se encuentran en las circunstancias más adecuadas para tomar esa decisión (10). como objetivo se planteó conocer la experiencia vivida por la familia del recién fallecido en el momento en el que se le planteó que este fuera donante de órganos, como aproximación al significado e impacto en las familias españolas. el acercamiento a dicho objetivo puede ser la clave en el avance dentro del abordaje de la entrevista de donación y podría aumentar el número de donaciones, consecuentemente. material y métodos este artículo es el resultado de un estudio cualitativo de aproximación fenomenológica, según el método de giorgi (11), basado en la tradición de la psicología social y centrado en la descripción, la reducción fenomenológica y la búsqueda de esencias para llegar al significado. el investigador principal, coordinador de trasplantes durante veinticinco años, realizó el plan de investigación y reclutó a los informantes con un muestreo intencionado por conveniencia, de acuerdo con el objetivo de la investigación. así mismo, realizó las entrevistas personalmente e hizo el siguiente proceso de datos: transcribió las entrevistas; las leyó para producir el bracketing o epojé, para detectar esencias o unidades de significado, ayudándose de los códigos o subcategorías; posteriormente, y después de producirse una reducción, se llegó a la tematización o categorización, en un proceso circular que se retroalimenta numerosas veces. es importante destacar que los entrevistados, además de describir durante las entrevistas su experiencia vivida en el momento en el que se les planteó la donación de órganos del familiar fallecido, también aportaron información de la sensación y lo que había significado aceptar la donación en sus vidas posteriormente y hasta el mismo momento de la entrevista. dicha información fue aceptada por el equipo de investigación, por considerarse relevante para conocer el impacto que la decisión tuvo en esas familias. a modo retrospectivo, y teniendo en cuenta el condicionamiento ético del duelo en estos casos, se dejó un tiempo prudencial de tres años tras el fallecimiento del familiar (12). entre diciembre de 2011 y marzo de 2013, tras la correspondiente 22 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 aprobación por parte del comité ético del hospital universitario la fe, se entrevistaron en profundidad once familias que donaron los órganos de su familiar en el hospital la fe de valencia (españa) con aceptación y firma de consentimiento informado. las características sociodemográficas de los participantes en el estudio (actores principales en el momento del consentimiento de la donación), asociado a su relación con el fallecido, pueden observarse en tabla 1. todas las entrevistas duraron una hora aproximadamente. el emplazamiento lo decidió el propio entrevistado y se grabaron en audio tras obtención del consentimiento informado. según la perspectiva fenomenológica de giorgi (11), los investigadores deben hacer un paréntesis en sus propias suposiciones del fenómeno de estudio, a fin de permitir atender a las descripciones de los participantes sin clasificar de forma inamovible el significado de las unidades descriptivas en categorías ya predefinidas; por ello, dos investigadores ajenos al contexto de donación realizaron el análisis. con este procedimiento se logró que el entrevistado y el entrevistador adoptasen un rol similar: dos personas con similares conocimientos sobre un acontecimiento vital importante, utilizando la entrevista en profundidad, no estructurada, distendida y con poco control, para dejar que las familias se expresaran según sus sentimientos. sin embargo, fue necesario un guion orientador, que permitió conducir la entrevista hacia los significados que interesaban. generalmente, la entrevista fue individual entre el investigador y el informante. el análisis fue simultáneo a la recogida de datos. el interés del análisis se centró en la búsqueda de significados del fenómeno estudiado. tabla 1. descripción de los informantes sexo parentesco edad familia sexo del donante edad del donante lugar tiempo óbito (en años) codificación entrevista (e=entrevista) (mujer) madre 55 marido, 3 hijos mujer 12 hospital antiguo 18 e-1 (varón) (mujer) padres 40/45 otro hijo hombre 18 domicilio 5 e-2 (mujer) hermana 50 padres, 4 hermanos, esposa, hija hombre 45 hospital 3 e-3 (mujer) esposa 55 2 hijas, 1 nieta hombre 65 domicilio 8 e-4 (varón) (varón) marido hijo 50 19 padres mujer 44 hospital 5 3 e-5 (mujer) madre 55 marido otro hijo hombre 17 hospital 5 e-6 (mujer) esposa 55 hijo, hija, nieta hombre 52 domicilio 7 e-7 (mujer) esposa 55 hijo hombre 62 hospital 5 e-8 (varón) (mujer) (varón) hijos 20 22 24 otra familia hombre hospital 5 e-9 (mujer) hija 55 yerno, nieto mujer 78 hospital 11 e-10 (mujer) compañera 65 2 hijos de ella hombre 52 hospital 3 e-11 fuente: elaboración propia 23 aproximación fenomenológica al significado e impacto de la donación de órganos en la familia l manuel lillo-crespo y otros la saturación de los datos se intuyó desde la sexta y séptima entrevistas, en que las veinticuatro categorías ya habían aflorado. se continuó con las cuatro siguientes con el fin de ratificar la saturación. tras profundizar en los temas y descripciones, se generó una idea de cómo los participantes vivieron sus experiencias. se integró la interpretación de las diferentes unidades de significado categorizadas y trasformadas, para que reflejase “el qué” de la experiencia y “el cómo” (13-15), ya que ninguno de los entrevistados tuvo experiencia previa conocida. resultados siguiendo el método de giorgi, se extrajeron veintisiete unidades esenciales de significado, tras haber agrupado las unidades básicas obtenidas en un primer momento. estas, a su vez, se clasificaron en dos tipologías de análisis: las que se referían a la pérdida de su familiar y las que describían el impacto de la donación de órganos. las últimas tres unidades de significado en la columna “en relación con la donación” de la figura 1 no tienen correlación con las detectadas “en relación con la pérdida”, puesto que son significados que corresponden con el futuro tras la donación, es decir, aparecieron en todos los casos pasado un tiempo tras esta y, obviamente, surgieron en las entrevistas llevadas a cabo tras tres años de haberse realizado la donación. esas tres unidades de significado permiten una aproximación al impacto posterior en el tiempo, tras el momento concreto de la decisión de donar, tal y como explican las flechas de la figura 1. a continuación, se describen y narran los hallazgos obtenidos en las entrevistas con las familias a partir de las dos tipologías de análisis: en relación con la pérdida y en relación con la donación. en relación con la pérdida (según la experiencia de la familia) el impacto más importante, unas veces previsto, otras, repentino, es la muerte de su familiar (16). a partir de este momento comienza el duelo de las personas a su alrededor, situación inicialmente paralizante. sin embargo, se ha observado que el proceso de la donación de órganos posiciona a los familiares en un punto de decisión y reflexión hacia su propio familiar y el proceso, momento en el que los profesionales sanitarios pueden detectar duelos no resueltos o problemáticos. los profesionales de la salud ayudan a los familiares a evolucionar, al adoptar la concepción de que el órgano, estructura no necesaria para su familiar fallecido, recobrará sentido y será útil para otra persona, en este caso, el receptor. en los siguientes fragmentos se pueden observar características relativas a la pérdida, como el duelo y la conciencia de muerte, el dolor, la desesperanza, los recuerdos hacia su familiar y el cambio de vida al adaptarse a la ausencia del fallecido: “el dolor que tienes, te levantas por la mañana y no está” (e-1). “yo muchas veces digo, va, que paren el mundo que me bajo” (e-6). “yo entiendo muy bien las cosas en teoría; pero es complicado ponerlo en práctica. es muy duro. hay quien lo supera antes. nunca a va ser como antes, no” (e-2). “estás metida en una situación tan tensa y tan desagradable a la vez, que eres incapaz de interponer tus criterios de la donación; eso lo dejas totalmente de lado” (e-10). “… salieron a avisarnos, que nos hiciéramos la idea de que no iba a sobrevivir y tuviéramos los papeles preparados, era muy duro” (e-8). algunas personas no habían reflexionado sobre la muerte y su significado. este acontecimiento los hace tomar conciencia de forma muy clara e importante en su presente. la comprensión de la muerte cerebral añade otra dificultad en la aceptación del fallecimiento. “me quedé muy parada, porque me dijeron: ‘está en muerte cerebral’ y lo ves respirar él y entonces dices, ¡uh! no está muerto. yo que sé si es la máquina o no” (e-6). “siempre con la duda, intentando buscar un resquicio que dijera: está viva y yo decidiendo… ¿estaré cometiendo alguna barbaridad?” (e-10). los entrevistados tienden a mostrar una aceptación claramente relacionada con la necesidad de aproximación hacia su ser querido, modulada muchas veces en su contexto con las creencias. “… para mí ha supuesto que pierdas el miedo a la muerte. 24 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 figura 1. unidades de significado en relación con la pérdida y la donación según la experiencia de la familia fuente: elaboración propia. 25 aproximación fenomenológica al significado e impacto de la donación de órganos en la familia l manuel lillo-crespo y otros quizá ahí hay un poco de creencia. he creído en la buena disposición de personas…” (e-1). otras personas, en cambio, no pueden aceptarlo. se dan situaciones de evitación (hacia hablar del tema, hacia una fotografía, acudir al hospital…). “yo les había dicho (a las hijas): ‘¿queréis estar conmigo que va a venir esta señora?’, y me dijeron ‘no, mamá, no queremos’” (e-4). “mi hijo mayor, igual. sabe que estamos aquí, se ha ido, huye…” (e-2). “no me ha dicho ‘mamá, yo te acompaño’” (e-6). en el apartado siguiente se puede detectar la necesidad de información, apoyo y temporalidad que los allegados reclaman en los momentos iníciales de atención hospitalaria. aflora una cantidad de sentimientos a lo largo del proceso y necesidades asociadas que, tras su adaptación y asimilación, producen un crecimiento personal importante. “… demasiado tiempo sin información es la queja que podríamos hacer” (e-8). “soy más fuerte con lo que me ha pasado ahora” (e-2). son momentos en que la necesidad de apoyo social y apoyo familiar se hace presente de forma común a todas las personas en las mismas circunstancias, sea o no aceptado: “lo que más me ayudó con ese proceso fue el cariño” (e-11). el afecto hacia el fallecido, la ausencia y el vacío hacen que cuestiones pendientes, al parecer sin resolver, cobren importancia y que produzcan sufrimiento en los más allegados. los pequeños recuerdos también adquieren especial relevancia: “¿… mantienes conexión con él?” (entrevistador): “sí, yo le hablo de una manera natural” (e-3). en relación con la donación (según la experiencia de la familia) la comodidad (o no) en la donación dependerá de la decisión, la actitud profesional y el proceso de donación de órganos. generalmente, el proceso se inmiscuye en un momento que, visto desde fuera, no parece el más adecuado (2). en algunos casos, la familia no se encuentra en las circunstancias más adecuadas para tomar esa decisión. cuanto más se alarga el tiempo entre el óbito y la entrevista para la donación de órganos, más espacio tienen para reflexionar y existen más posibilidades de aceptación (10). todo esto produce un proceso de aprendizaje a largo plazo enriquecedor para la persona: “crecimiento personal. sí. totalmente convencida. a mí en concreto” (e-6). la relación que perciben los entrevistados con el sistema de salud, basada en sus antecedentes, experiencias anteriores, opiniones, noticias, significado cultural o, incluso, esta propia experiencia (trato del personal, cambios de hospital…) afecta, pues se hace presente en el momento de tomar la decisión, al asociar el sistema sanitario como el contexto adecuado para la donación de órganos: “el sitio donde te lo dicen es muy importante, una sala… un despacho amplio…” (e-3). “eso sí, no estuvimos solos. un poquito de intimidad con él, sola, y decirle ‘hijo, no me oyes, pero te quiero con locura’. y me daba vergüenza ...” (e-6). aplicar la relación de ayuda es fundamental en este momento, para sacar las fuerzas y las habilidades que los familiares tienen dentro, pues hacen que sean conscientes de su capacidad para afrontar la situación por sus propios medios. es la principal herramienta que utilizan los coordinadores de trasplantes en la entrevista para la donación de órganos. las consecuencias de la donación suelen ser de consuelo y satisfacción mental, ya que se entiende el órgano de su allegado como una estructura funcionante, útil. a veces, la donación es un consuelo; también lo es la carta de agradecimiento que se envía y saber que los órganos funcionan adecuadamente: “… cuando te llegó la carta y siguen funcionando, te reconforta” (e-3). el futuro se ve muy condicionado por los hechos acaecidos. suele haber cambios en las expectativas de los más allegados: “no he vuelto a bailar” (e-11). la familia es fundamental en todo el proceso como unidad en la toma de decisiones (17,18). queda patente en el momento de la decisión cuando se espera a algún familiar o se consulta a otro. 26 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 el apoyo familiar suele contribuir a la motivación para continuar con la vida y la salida del duelo suele estar relacionada con la familia (otros hijos, nietos…): “… yo pienso que entre todos…” (e-3). en general, se produce una colaboración con el personal y, sobre todo, con la coordinación de trasplantes, que permite aflorar sus emociones y producir alivio emocional, pues los lleva a la sensación de estar haciendo el bien: “sí se remueven siempre recuerdos, pero es todo desde la tristeza de algo que fue y no me molesta. muchas veces no sacas estos temas porque nadie te los saca” (e-11). casi todos los entrevistados idealizan a los receptores con los órganos de su familiar que funcionan en su interior. se comprueba que los familiares, para dignificar el acto de la donación, piden respeto al donante y que sean merecedores del órgano: “sus ojos miran y… el corazón tiene que arrancar, eso para mí es muy bonito” (e-5). “me gustaría que ya que tienen los órganos que tuvieran una vida sana” (e-2). todos los participantes en el proceso terminan con agradecimiento, sobre todo a los que han compartido con ellos esta experiencia. agradecen la sensibilidad de los coordinadores de trasplantes: “lucharon mucho por él” (e-2). “yo no tengo ninguna queja. ni de médicos… había gente maravillosa” (e-5). por último, los familiares destacan la falta de preparación para estas decisiones (17): “… y a partir de aquí yo digo siempre: es que no estamos preparados para lo que nos pedís. se había hablado: ¡ay! yo donante, pero y ¿cuando te piden los ojos? y ¿cuando te piden la piel? la sensación de que te están pidiendo una cosa detrás de la otra… desbordante…” (e-5) la creencia de hacer el bien (con la donación), junto con la gratitud (con la donación y hacia esta) y la motivación (para donar) aparecieron en todos los discursos de los participantes. discusión según se ha constatado en las unidades relacionadas con el fallecimiento, en un primer momento el hecho de la pérdida del ser querido y el dolor eclipsan la donación y la toma de decisiones al respecto. esta característica parece estar relacionada con un rasgo cultural basado en creencias sobre la muerte, la pérdida y la donación de la población española, con la que se ha trabajado, y donde las decisiones han sido tomadas en prácticamente todos los casos por mujeres; sin embargo, son necesarios otros estudios similares con otros grupos culturales para poder discernir cómo se produce esa transición de significados en poblaciones con otras características culturales. a la luz de los resultados, en los primeros momentos, la familia no está en las mejores condiciones para tomar la decisión de donar y el papel que desempeña el equipo de donación de trasplantes es fundamental. en este punto se observa la diferencia existente entre el apoyo familiar (como algo interno de la propia familia) y el apoyo social y profesional que procede del equipo de donación y trasplantes. este gesto parece reducir las dudas de la familia al respecto, debido al clima de confianza generado, que se convierte en un punto clave de mejora del proceso vivido o transición. tras el análisis de los datos y en consenso de los autores, se desarrolló el siguiente modelo interpretativo de toma de decisiones familiares en el proceso o transición desde la pérdida a la donación de órganos (figura 2), que aporta un marco útil para la comprensión del fenómeno estudiado. figura 2. modelo interpretativo de toma de decisiones familiares en el proceso o transición desde la pérdida a la donación de órganos, desarrollado a partir de los resultados fuente: elaboración propia. 27 aproximación fenomenológica al significado e impacto de la donación de órganos en la familia l manuel lillo-crespo y otros la ilustración muestra el modelo conceptual al que se ha llegado, basado en la teoría de transiciones de afaf meleis (7), así como las conclusiones y observaciones realizadas durante el proceso de investigación. de acuerdo con esta teoría (7), diversos procesos y cambios en la vida de las personas están determinados por factores internos y externos que repercuten en el manejo de la transición y determinarán si esta es saludable o no para la persona. la transición es definida por meleis como el paso de una etapa vital, condición o estado a otra, y el resultado de la interacción entre persona y entorno, que implica cambios en el estado de salud, en los roles, expectativas, habilidades y demandas. este proceso de transición tiene tres momentos: entrada, paso y salida, y se caracteriza por que las personas alcanzan estabilidad y crecimiento frente a los sucesos que deben afrontar. en la figura 2 se muestra la transición de los familiares a lo largo del duelo, que evoluciona desde una visión centrada en la pérdida en un primer momento, a una visión en la que tiene cabida la donación de órganos de su familiar, y ello conduciría a una transición positiva en forma de consuelo y alivio. la entrevista de donación, que aparece en la figura como punto central, aporta —a la luz de nuestros hallazgos— mejores resultados si, además, se lleva a cabo el acompañamiento desde el momento de la pérdida por los profesionales del equipo y tras aportar la suficiente información. en el momento intermedio y coincidiendo con la entrevista por parte del equipo, se pide la donación de órganos, momento adecuado entre el sentimiento de pérdida y el de donación (si finalmente es así), lo que facilita una transición positiva mediante técnicas de acompañamiento, escucha activa y counselling (14,15). respecto a las limitaciones del estudio es destacable la selección de la muestra; se deduce que las personas que voluntariamente aceptaron compartir su experiencia, generalmente, tenían un recuerdo positivo del familiar difunto e, incluso, una necesidad de compartirlo. todos los familiares contactados para el estudio de manera telefónica, que se negaron a la donación en su día, declinaron la invitación a participar, y así no aceptaron compartir su experiencia. dicha muestra hubiera aportado más información sobre personas que no han guardado tan buen recuerdo del proceso de donación de órganos. esto puede estar relacionado con que se hayan encontrado más unidades de significado positivas (tres más en concreto) en relación con la donación que aparecieron tiempo después de la decisión de donar. probablemente, si la decisión hubiese sido negativa, podrían haber emergido unidades de carácter negativo o relacionadas con un duelo todavía no cerrado, ya que la transición desde la pérdida hubiese sido también negativa. conclusiones • el conocimiento y la comprensión de la experiencia de la donación y su significado para los familiares del fallecido aportan pautas eficaces de actuación en la entrevista durante el proceso de donación de órganos, que mejora sus resultados. • el estudio muestra la existencia de significados claramente diferenciables entre el momento de la donación de órganos y el momento de la pérdida. los significados asociados a la donación fueron positivos frente a los relacionados con la pérdida. así, en los casos de donación positiva (como los explorados en este estudio) se da una transición de significados negativos desde la pérdida hacia significados positivos, como son los de la propia donación, que perduran en el tiempo con significados que actúan como un refuerzo positivo y, por lo tanto, evidencian el impacto positivo de la donación. en consecuencia, la donación aparece como mecanismo de alivio o compensación del fallecimiento del familiar, que determina una transición positiva y que produce una confrontación entre los pensamientos negativos derivados de la muerte y el duelo, frente a los pensamientos positivos asociados a la donación de órganos. • la donación de órganos fue, en todos los casos, un aliciente para superar el duelo, pues llevó a la familia a una transición positiva y, consecuentemente, ratificó que los supuestos de la teoría de transiciones de afaf meleis encajan con el fenómeno estudiado. • el acompañamiento a los familiares por parte del equipo profesional genera confianza y es valorado como muy importante para la familia, pues reduce las dudas al respecto de la donación. • el modelo interpretativo de toma de decisiones familiares en el proceso o transición, desde la pérdida hasta la donación de órganos, aporta al grupo profesional un esquema interpretativo para conseguir mayor eficacia en la entrevista y resultados en la donación de órganos. • los aspectos culturales, relacionados con creencias, parentesco y sexo, deben ser tenidos siempre en cuenta en el proceso de donación, ya que son variables capaces de modificar la toma de decisiones. 28 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 • el enfoque del marco teórico y método de giorgi para el análisis fenomenológico (basado en la tradición de la psicología social) resulta útil para el estudio de los significados en situaciones o fenómenos complejos como el descrito. referencias 1. real decreto 1723/2012, de regulación de las actividades de obtención, utilización clínica y coordinación territorial de los órganos humanos destinados al trasplante y se establecen requisitos de calidad y seguridad. boe 313.29 de diciembre de 2012:89315-48. 2. montero i, ruiz i. la entrevista familiar camberwell (cfi). rev la asoc española neuropsiquiatría. 1992;12(42):199-202. 3. moraes el de, dos santos mj, merighi ma, massarollo mc. vivencia de enfermeros en el proceso de donación de órganos y tejidos para trasplante. rev latino-am enfermagem. 2014 abr;22(2):226-33. doi: http://dx.doi.org/10.1590/01041169.3276.2406 4. olabuénaga jir. metodología de la investigación cualitativa. bilbao: universidad de deusto; 2012. 5. oberg k. culture shock. s. l.: citeseer; 1954. 6. virginio bcae, escudeiro cl. notification of brain death in an intensive care unit: a descriptive study. online brazilian journal of nursing [internet]. 2012 [citado 2016 jul 2];11(2):5469. disponible en: http://www.objnursing.uff.br/index. php/nursing/article/view/3787 7. meleis ai. theoretical nursing: development and progress. new york: lippincott williams & wilkins; 2011. 8. ministerio de sanidad, servicios sociales e igualdad. organización nacional de trasplantes (ont). datos globales de donación y trasplantes [internet]. 2013 [citado 2015 sep 25]. disponible en: http://www.ont.es/infesp/paginas/datosdedonacionytrasplante.aspx 9. price d. legal and ethical aspects of organ transplantation. cambridge: cambridge university press; 2000. 10. rodríguez rodríguez t, fonseca fernández m. guía de atención psicológica a pacientes y familiares en el proceso de donación y trasplante de órganos. medisur [internet]. 2015 ago [citado 2016 abr 08];13(4):560-8. disponible en: http:// scielo.sld.cu/scielo.php?script=sci_arttext&pid=s1727-897x2015000400014&lng=es 11. rubio acuña m, arias burgos m. fenomenología y conocimiento disciplinar de enfermería. rev cubana enfermer [internet]. 2013 sep [citado 2016 abr 8];29(3):191-8. disponible en: http://scielo.sld.cu/scielo.php?script=sci_ arttext&pid=s0864-03192013000300005&lng=es 12. valles ms. entrevistas cualitativas. madrid: centro de investigaciones sociológicas; 2014. 13. moraes el de, dos santos mj, merighi ma, massarollo mc. experience of nurses in the process of donation of organs and tissues for transplant. rev latino-am enfermagem. 2014;22(2):226-33. doi: http://dx.doi.org/10.1590/01041169.3276.2406 14. orøy a, strømskag ke, gjengedal e. approaching families on the subject of organ donation: a phenomenological study of the experience of healthcare professionals. intensive crit care nurs. 2013;29(4):202-11. doi: 10.1016/j. iccn.2013.02.003 15. carrillo-algarra aj, mesa-melgarejo l, moreno-rubio f. el cuidado en un programa de trasplante renal: un acompañamiento de vida. aquichan. 2015;15(2):271-82. doi: 10.5294/aqui.2015.15.2.10 29 aproximación fenomenológica al significado e impacto de la donación de órganos en la familia l manuel lillo-crespo y otros 16. mercado-martínez fj, padilla-altamira c, díaz-medina b, sánchez-pimienta c. views of health care personnel on organ donation and transplantation: a literature review. texto contexto-enferm. 2015 jun;24(2):574-83. doi: http://dx.doi. org/10.1590/0104-07072015003842014 17. da silva kn, schirmer j, aguiar rb. adaptación del modelo español de gestión en trasplante para la mejora en la negativa familiar y mantenimiento del donante potencial. texto contexto-enferm. 2011;20(spe):59-65. doi: http://dx.doi. org/10.1590/s0104-07072011000500007 18. solar s, ovalle a, simian me, escobar j, becajp. tres factores que influyen en la actitud de las personas ante la donación de órganos. rev chil cir. 2008 jun;60(3):262-7. doi: http://dx.doi.org/10.4067/s0718-40262008000300017 460 471 validez y confiabilidad del cuestionario.indd 460 luisa fernanda achury-beltrán1 validez y confi abilidad del cuestionario para medir la adherencia al tratamiento de pacientes con enfermedad cardiovascular 1 orcid.org/0000-0001-6931-396x. pontificia universidad javeriana, colombia. achuryl@javeriana.edu.co recibido: 05 de enero de 2016 enviado a pares: 30 de enero de 2016 aceptado por pares: 04 de diciembre de 2016 aprobado: 05 de diciembre de 2016 doi: 10.5294/aqui.2017.17.4.9 para citar este artículo / to reference this article / para citar este artigo achury-beltrán lf. validez y confiabilidad del cuestionario para medir la adherencia al tratamiento de pacientes con enfermedad cardiovascular. aquichan. 2017; 17(4): 460-471. doi: 10.5294/aqui.2017.17.4.9 resumen objetivo: elaborar y validar un instrumento para medir la adherencia al tratamiento farmacológico y no farmacológico de pacientes con diagnóstico de enfermedad cardiovascular, a partir de un referente teórico sustentado en las conductas de adherencia al tratamiento y la autoeficacia. materiales y métodos: se detalla el proceso de validez facial, de contenido y de constructo realizado al instrumento, así como las pruebas de confiabilidad. el instrumento fue sometido a evaluación por parte de 6 expertos, 380 adultos de diferentes características sociodemográficas y posteriormente aplicado a 145 pacientes con diagnóstico de enfermedad cardiovascular isquémica. resultados: se obtuvo un cuestionario con 29 ítems, 6 dimensiones, un alfa de cronbach de 0,837 y un puntaje entre 29-174, lo que indica que a mayor puntaje mejor adherencia. conclusiones: se considera un instrumento útil para determinar conductas terapéuticas de adherencia al tratamiento en pacientes con enfermedad cardiovascular isquémica, pues está sustentado en un constructo teórico que se fundamenta, por una parte, en las conductas de adherencia y, por otra, en la autoeficacia como predictor de esta, lo que amplía el abordaje de medición del fenómeno incluida la determinación de las capacidades que perciben los pacientes para poder llevar a cabo un tratamiento. palabras clave cumplimiento de la medicación; investigación metodológica en enfermería; conductas terapéuticas enfermería cardiovascular; enfermedades cardiovasculares; estudios de validación (fuente: decs, bireme). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 460-471 461 validez y confiabilidad del cuestionario para medir la adherencia al tratamiento de pacientes con enfermedad cardiovascular l luisa fernanda achury-beltrán año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 460-471 validity and reliability of a questionnaire to measure adherence to treatment by patients with cardiovascular disease abstract objective: develop and validate an instrument to measure adherence to pharmacological and non-pharmacological treatment on the part of patients diagnosed with cardiovascular disease, based on a theoretical reference supported by treatment adherence behavior and self-efficacy. materials and methods: the process of facial, content and construct validity performed on the instrument is outlined in detail, as are the reliability tests. the instrument was subject to evaluation by six experts and 380 adults with different sociodemographic characteristics, before being applied to 145 patients who had been diagnosed with ischemic cardiovascular disease. results: a questionnaire with 29 items, 6 dimensions, a cronbach’s alpha of 0.837 and a score of 29-174 was obtained, indicating that the higher the score, the better the adherence. conclusions: it is considered a useful instrument to determine therapeutic behavior in terms of adherence to treatment among patients with ischemic cardiovascular disease, since it is based on a theoretical construct that is founded on adherence behavior, on the one hand, and self-efficacy, on the other. the latter is a predictor of adherence behavior. this broadens the approach to measuring the phenomenon, including determining the abilities or capacity perceived by patients in order to complete a treatment. keywords compliance with medication; methodological research in nursing; therapeutic behavior; cardiovascular nursing; cardiovascular diseases; validation studies (source: decs, bireme). 462 aquichan issn 1657-5997 eissn 2027-5374 validade e confiabilidade do questionário para medir a adesão ao tratamento de pacientes com doença cardiovascular resumo objetivo: elaborar e validar um instrumento para medir a adesão ao tratamento farmacológico e não farmacológico de pacientes com diagnóstico de doença cardiovascular, a partir de um referencial teórico apoiado nos comportamentos de adesão ao tratamento e na autoeficácia. materiais e métodos: detalha-se o processo de validade facial, de conteúdo e de construto realizado ao instrumento, bem como os testes de confiabilidade. o instrumento foi submetido à avaliação por parte de 6 especialistas, 380 adultos de diferentes características sociodemográficas e, em seguida, aplicado a 145 pacientes com diagnóstico de doença cardiovascular isquêmica. resultados: obteve-se um questionário com 29 itens, 6 dimensões, um alfa de cronbach de 0.837 e uma pontuação entre 29-174, o que indica que quanto maior a pontuação, melhor a adesão. conclusões: considera-se um instrumento útil para determinar comportamentos terapêuticos de adesão ao tratamento em pacientes com doença cardiovascular isquêmica, pois está sustentado num construto teórico que se fundamenta, por um lado, nos comportamentos de adesão e, por outro, na autoeficácia como preditor desta, o que amplia a abordagem de medição do fenômeno incluída a determinação das capacidades que percebem os pacientes para poder realizar um tratamento. palavras-chave comportamentos terapêuticos; cumprimento da medição; doenças cardiovasculares; enfermagem cardiovascular; estudos de validação; pesquisa metodológica em enfermagem (fonte: decs, bireme). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 460-471 463 validez y confiabilidad del cuestionario para medir la adherencia al tratamiento de pacientes con enfermedad cardiovascular l luisa fernanda achury-beltrán introducción las enfermedades cardiovasculares hacen parte del grupo de las enfermedades no transmisibles, las cuales, según la organización mundial de la salud (oms), son las principales causas de morbilidad y mortalidad a nivel mundial. de acuerdo con las estadísticas de la oms, durante el 2012 se registraron 38 millones de muertes por enfermedades no transmisibles, de las cuales 17,5 millones correspondieron a enfermedad cardiovascular (1). por su parte, la american heart association reportó que en el 2013 la tasa de muertes atribuibles a enfermedades cardiovasculares fue de 222,9 por/100.000 americanos y, a pesar de que durante el periodo comprendido entre 2003 y 2013 la tasa se redujo en un 28,8 %, en el 2013 las enfermedades cardiovasculares todavía representaban el 30,8 % de la mortalidad (2). en la actualidad se estima que 85,6 millones de adultos americanos padecen de mínimo un tipo de enfermedad cardiovascular, de los cuales 15,5 millones corresponden a enfermedad coronaria. específicamente en la población latinoamericana, 7,8 % padece de enfermedad cardiovascular y el 4,9 % de enfermedad coronaria (2). en colombia, el panorama no es muy distinto, pues la enfermedad cardiovascular ocupa también el primer lugar como causa de mortalidad con 8.403 muertes derivadas de enfermedad isquémica del corazón, 1.899 de enfermedades hipertensivas, 1.002 de otras formas de enfermedad cardiaca, 573 de insuficiencia cardiaca y 3.741 de enfermedad cerebrovascular (3). se ha descrito cómo una adecuada adherencia al tratamiento farmacológico y no farmacológico se convierte en un aspecto imprescindible del manejo de la enfermedad cardiovascular, puesto que asegura su adecuado control, una menor tasa de descompensaciones y un incremento en la calidad de vida como desenlaces primarios (4). por esta razón, la medición de la adherencia se convierte en un aspecto esencial, ya que su identificación le permite al profesional de enfermería detectar las necesidades concretas de los pacientes y, a partir de allí, generar diversas estrategias con el fin de intervenir de forma oportuna y eficaz para mejorar la calidad de vida, reducir los reingresos hospitalarios, favorecer la reincorporación a la vida laboral, familiar y social de los pacientes, y reducir las complicaciones que pueden generarse de un manejo subóptimo de la situación de salud (5, 6). con el propósito de determinar la adherencia a los tratamientos de la enfermedad, algunos autores han implementado métodos objetivos como el recuento de tabletas, las tasas de asistencia a los programas, la obtención de resultados terapéuticos y las mediciones de fármacos cuando ello es posible (7, 8), sin embargo, dada la complejidad de dichos controles, otros autores han elaborado mediciones subjetivas que incluyen instrumentos que determinan la presencia de factores que influyen en la adherencia terapéutica, lo que permite pronosticarla pero no determinarla de forma concreta (9-13). adicionalmente, a pesar de la diversidad de técnicas de medición existentes, hay evidencia de que la adherencia está robustamente influenciada por la motivación, ya que esta guarda una fuerte relación con la importancia que el paciente le asigna al cumplimento de los tratamientos y, además, a la confianza que tiene en poder seguirlos (14), aspectos claves de la autoeficacia. al respecto, las teorías de albert bandura y bárbara resnick, citadas por resnick (15), abordan el concepto de la motivación en la medida en que explican cómo la autoeficacia influye en la generación de comportamientos motivados que finalmente son capaces de generar cambios de conductas en los pacientes y favorecer la adherencia terapéutica. por ese motivo, se hace necesario el diseño y la validación de un instrumento que además de evaluar las conductas que demuestran la adherencia de los pacientes con diagnóstico de enfermedad cardiovascular isquémica en términos del seguimiento a las recomendaciones de tratamiento farmacológico y no farmacológico, también valore la autoeficacia como un predictor de la motivación y, con ello, de la capacidad de los pacientes para llevar a cabo las acciones requeridas como parte del manejo. con este fin, el instrumento diseñado evalúa, por una parte, las conductas de los pacientes en términos de la adherencia al tratamiento no farmacológico de la enfermedad cardiovascular isquémica, dentro de las que se incluyen la dieta, la actividad física, el control de factores riesgo como el consumo de tabaco o alcohol y el manejo del estrés (16-18), y por otra, el tratamiento farmacológico que hace referencia al consumo de los medicamentos prescritos en las dosis y las frecuencias indicadas. además, incluye ítems que evalúan la autoeficacia como un elemento predictor de la adherencia, en la medida en que indagan acerca de la percepción de los pacientes para llevar a cabo diferentes acciones requeridas como parte del manejo de la enfermedad. objetivo elaborar y validar un instrumento para medir la adherencia al tratamiento farmacológico y no farmacológico de pacientes con enfermedad cardiovascular isquémica, a partir de un referente 464 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 teórico sustentado en las conductas de adherencia al tratamiento y la autoeficacia como predictor de esta. materiales y métodos el estudio se desarrolló bajo un enfoque metodológico con una perspectiva psicométrica que contempló la elaboración y validación del instrumento de medición de adherencia denominado “cuestionario para medir la adherencia al tratamiento en pacientes con enfermedad cardiovascular”. la muestra estuvo conformada por tres grupos: 6 expertos quienes realizaron el proceso de validez facial y de contenido del instrumento, 380 adultos de diferentes características sociodemográficas para determinar la validez facial a través del índice de comprensibilidad y, finalmente, 145 pacientes con enfermedad cardiovascular isquémica para determinar la validez de constructo y la confiabilidad del cuestionario. para la inclusión en el estudio, los expertos y demás participantes debieron ser mayores de 18 años, demostrar capacidad mental para responder o evaluar el instrumento y aceptar de forma voluntaria su participación en la investigación, aspectos que se enmarcan en la resolución 008430 de 1993 del entonces ministerio de salud de la república de colombia, y las pautas éticas del consejo de organizaciones de ciencias médicas y la oms. adicionalmente, el estudio fue avalado por los comités de ética e investigación de la universidad nacional de colombia y de la institución en donde se desarrolló el estudio según las actas 06 del 14 de abril de 2014 y 7-2014 del 24 de abril del mismo año. procedimiento el desarrollo de la investigación se produjo en dos fases: • la primera fase correspondió a la revisión de la literatura y la definición del constructo para la elaboración de los ítems del instrumento. • la segunda fase involucró la realización de la validez facial, de contenido y de constructo, así como el cálculo de la confiabilidad de la versión final del instrumento. para la primera fase de revisión de la literatura, el investigador realizó una búsqueda de artículos publicados durante el periodo 2000-2015 en español, inglés y portugués, en las bases de datos medline, proquest, ovid y science direct, bajo los descriptores “enfermería”, “enfermedad cardiovascular”, “enfermedad coronaria”, “adherencia terapéutica”, “infarto agudo de miocardio” y “rehabilitación cardiaca” con los conectores booleanos and y or, con el fin de determinar las conductas que deben contemplarse dentro de la evaluación de la adherencia al tratamiento farmacológico y no farmacológico de los pacientes con enfermedad cardiovascular isquémica, así como instrumentos de medición de adherencia; dicha búsqueda, además de facilitar la definición del constructo, dio lugar a la identificación de instrumentos tales como la “escala de adherencia terapéutica para pacientes con enfermedades crónicas basada en comportamientos explícitos” (19), el “cuestionario de adherencia al tratamiento para la hipertensión arterial (cat_hta)” (20) y el “cuestionario para la evaluación de la adherencia terapéutica de martin-bayarre-grau” (10). a partir de dicha revisión de la literatura y de la definición del constructo de la adherencia al tratamiento en el paciente con enfermedad cardiovascular isquémica, se construyó inicialmente un instrumento de 26 ítems, de los cuales dos evaluaban la ingesta de medicamentos, tres la ingesta de alimentos, tres la realización de actividad física, cuatro el manejo de factores de riesgo, seis el seguimiento y control de la enfermedad y, finalmente, ocho los resultados de autoeficacia. una vez el proyecto de investigación fue sometido a evaluación y aprobación por parte de los comités de ética e investigación de la universidad nacional de colombia y la institución hospitalaria seleccionada, el investigador eligió seis expertos que cumplían los criterios de skjong y wentworth (21), dentro de los que se incluyen: experiencia en la realización de juicios y decisiones basada en evidencia o experticia, reputación en la comunidad, disponibilidad y motivación para participar e imparcialidad, y posteriormente se diseñó un formato para realizar el proceso de validez facial y de contenido. para la validez de contenido se le solicitó a los expertos evaluar cada uno de los ítems en términos de “esencial”, “útil pero no esencial” y “no necesario” para, posteriormente, determinar la razón de validez de contenido (cvr’) por medio de la fórmula n e /n, en donde n e corresponde a la cantidad de expertos que calificaron el ítem como esencial y n el total de expertos que evaluaron el ítem. se consideró como límite inferior de aceptabilidad una cvr’ de 0,67, tal como lo estipula tristán cuando la evaluación es realizada con seis expertos (22). 465 validez y confiabilidad del cuestionario para medir la adherencia al tratamiento de pacientes con enfermedad cardiovascular l luisa fernanda achury-beltrán adicionalmente, la validez facial fue realizada tanto por los seis expertos a quienes se les pidió evaluar los ítems en términos de comprensión, claridad y precisión para calcular el índice de concordancia simple y el índice de kappa de fleiss, como por 380 individuos mayores de 18 años de diferentes características sociodemográficas como edad, estrato socioeconómico y escolaridad, quienes calificaron los ítems bajo los criterios de “se entiende”, “se entiende parcialmente” o “no se entiende”, lo que permitió determinar el grado de comprensión del instrumento a partir del cálculo del índice de comprensibilidad neta por ítem. el índice de kappa de fleiss fue interpretado a partir de los puntos de corte establecidos por landis y koch en donde < 0 = pobre acuerdo; 0,01-0,2 = acuerdo débil, 0,21-0,40 = acuerdo aceptable; 0,41-0,60 = acuerdo moderado; 0,61-0,8 = acuerdo sustancial y 0,81-1 = acuerdo casi perfecto (23). por otra parte, en el índice de comprensibilidad se codificaron las respuestas (se entiende = 2, se entiende parcialmente = 1 y no se entiende = 0) para posteriormente establecer el porcentaje de comprensibilidad de cada uno de los ítems, de manera que se estableció que un resultado menor al 90 % implicaba una restructuración a fondo del ítem, entre 90-95 % un ajuste menor y mayor al 95 % no requería modificación alguna. posteriormente, se realizó la validez de constructo. para ello, previa firma del consentimiento informado, se aplicó la última versión del instrumento a 145 pacientes con enfermedad cardiovascular isquémica con el objetivo de realizar un análisis factorial exploratorio con el método de extracción por componentes principales y rotación varimax, utilizando un criterio de extracción de 1,41 como lo estipula gorsuch, citado por campo, herazo y oviedo (24), y el programa estadístico spss versión 22 con licencia para la universidad nacional de colombia. por último, se determinó la consistencia interna del instrumento a partir del cálculo del alfa de cronbach. resultados a continuación se presentan los resultados de la validez facial, de contenido y de constructo, así como la consistencia interna del instrumento denominado “cuestionario para medir la adherencia al tratamiento en pacientes con enfermedad cardiovascular”. validez de contenido a partir de la evaluación de los ítems por parte de los expertos se aplicó la fórmula de razón de validez de contenido (cvr’) y, con base en el límite inferior de aceptabilidad que establece tristán (22), se decidió la eliminación de dos ítems (“como solo los alimentos que el personal de salud me indica”, “destino diariamente un tiempo específico para realizar ejercicio”) (tabla 1). de forma adicional, por sugerencia de los expertos, se incluyeron dos ítems que se consideraron relevantes para determinar el fenómeno de la adherencia en la población de estudio (“evito en mi alimentación el consumo de harinas y azúcares”, “consumo alimentos bajos en sal”); quedó así un instrumento de 26 ítems nuevamente. tabla 1. razón de validez de contenido de los ítems del “cuestionario para medir la adherencia al tratamiento en pacientes con enfermedad cardiovascular” ítem cvr’ ítem cvr’ 1 1,00 14 1,00 2 1,00 15 1,00 3 1,00 16 1,00 4 0,33 17 0,83 5 1,00 18 1,00 6 0,83 19 1,00 7 0,67 20 1,00 8 0,83 21 0,83 9 0,83 22 0,83 10 1,00 23 1,00 11 0,83 24 1,00 12 1,00 25 1,00 13 1,00 26 1,00 fuente: elaboración propia. validez facial a partir de la evaluación del instrumento por parte de los seis expertos se realizaron los ajustes correspondientes acatando las recomendaciones, y se calculó el índice de concordancia simple para cada uno de los ítems en los aspectos de compren466 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 sión, claridad y precisión. los resultados sustentaron la eliminación de los ítems 4 y 7, tal como lo había revelado el proceso de validez de contenido. por otra parte, como se muestra en la tabla 2, el índice de kappa de fleiss general y por dimensiones, a partir de los criterios de landis y koch señalados por cerda y villarroel (23), reveló un acuerdo sustancial en todas las dimensiones en el aspecto de comprensión; un acuerdo sustancial en términos de claridad en todas las dimensiones excepto en la de factores de riesgo, la cual mostró un acuerdo moderado, y para el aspecto de precisión, un acuerdo sustancial en las dimensiones de ingesta de medicamentos, seguimiento / control y resultados de autoeficacia; un acuerdo moderado en realización de actividad física y factores de riesgo y, finalmente, un acuerdo aceptable en la dimensión de ingesta de alimentos. de forma general, el instrumento reveló un acuerdo sustancial para los aspectos de compresión y claridad, y un acuerdo moderado para el aspecto de precisión, lo que llevó a sacar los dos ítems que correspondían a las preguntas de frecuencia de la escala likert y convertirlos en preguntas de selección múltiple. tabla 2. índice de kappa de fleiss general y por dimensiones del cuestionario de acuerdo con los aspectos de compresión, claridad y precisión. nómicos y escolaridades, con el fin de determinar la comprensibilidad neta de cada uno de los 26 ítems. a pesar de que la totalidad de los ítems del instrumento reportó una comprensibilidad neta superior al 95 %, con una mínima reportada de 96,05 %, se tuvieron en cuenta las apreciaciones de algunos de los participantes lo que llevó a dividir la pregunta 16 en 3 ítems (“por alguna razón suspendo mis medicamentos sin la indicación del personal de salud”, “por alguna razón dejo de seguir las recomendaciones de la alimentación dadas por el personal de salud”, “por alguna razón suspendo el ejercicio físico sin la indicación del personal de salud”). con ello, se obtuvo un instrumento de 29 ítems de los cuales 27 tienen una opción de respuesta tipo likert (nunca, casi nunca, pocas veces, frecuentemente, casi siempre y siempre), y los 2 ítems restantes respuestas de selección múltiple. para las preguntas 1, 2, 4, 5, 6, 7, 9, 11-17, 23-27, las opciones de respuesta tienen las siguientes puntuaciones: nunca = 1, casi nunca = 2, pocas veces = 3, frecuentemente = 4, casi siempre = 5 y siempre = 6. para los ítems 3, 8, 10, 18-22: nunca = 6, casi nunca = 5, pocas veces = 4, frecuentemente = 3, casi siempre = 2 y siempre = 1. finalmente, para las preguntas de selección múltiple (28 y 29), las puntuaciones son las siguientes: varias veces al día = 1, una vez al día = 2, varios días a la semana = 3, una vez a la semana = 4, de vez en cuando = 5 y no consumo bebidas alcohólicas / fumo = 6. en este sentido, el instrumento tiene una puntuación mínima de 29 y máxima de 174, de manera que un puntaje mayor indica una mejor adherencia al tratamiento. validez de constructo la validez de constructo del instrumento final fue evaluada a partir de un análisis factorial exploratorio con el método de extracción por componentes principales y rotación varimax, el cual arrojó una estructura de 6 componentes que dan cuenta del 57,36 % de la varianza explicada, lo que identifica las dimensiones que establecen las relaciones entre los ítems que componen el instrumento (25) (tabla 3). es importante mencionar que la matriz de componentes principales rotada que se obtuvo del procedimiento estadístico dejó ver una agrupación de los ítems que no coincide exactamente con la definida previamente en el instrumento; sin embargo, es posible redefinirlas en razón de que las expectativas de autoeficacia están presentes en todos los tratamientos de los pacientes con enfermedad cardiovascular. dimensión kappa de fleiss comprensión claridad precisión ingesta de medicamentos 0,77 sustancial 0,77 sustancial 0,65 sustancial ingesta de alimentos 0,76 sustancial 0,62 sustancial 0,28 aceptable realización de actividad física 0,76 sustancial 0,62 sustancial 0,48 moderado factores de riesgo 0,66 sustancial 0,59 moderado 0,46 moderado seguimiento / control 0,77 sustancial 0,77 sustancial 0,69 sustancial resultados de autoeficacia 0,71 sustancial 0,71 sustancial 0,66 sustancial general 0.73 sustancial 0,69 sustancial 0,57 moderado fuente: elaboración propia. posteriormente, el instrumento fue sometido a evaluación por parte de 380 individuos de diferentes edades, estratos socioeco467 validez y confiabilidad del cuestionario para medir la adherencia al tratamiento de pacientes con enfermedad cardiovascular l luisa fernanda achury-beltrán tabla 3. matriz rotada de componentes principales de los ítems del “cuestionario para medir la adherencia al tratamiento de pacientes con enfermedad cardiovascular” de este modo, las dimensiones se denominaron de la siguiente forma: expectativas y conductas de autoeficacia, seguimiento a las indicaciones del personal de salud en relación con la ingesta de medicamentos y alimentos, necesidad de apoyo para la adherencia, conductas esperadas de adherencia a largo plazo, manejo de situaciones tensionantes y realización de actividad física. confiabilidad: consistencia interna el alfa de cronbach para el instrumento general reportó 0,837, lo cual indica un buen nivel de fiabilidad y con ello de correlación entre los ítems del cuestionario. adicionalmente, se puede evidenciar que el alfa de cronbach no presenta variaciones significativas cuando alguno de los ítems del cuestionario es eliminado, de manera que este fluctúa entre 0,825 y 0,840 (tabla 4). por otra parte, el cálculo del alfa de cronbach para cada una de las dimensiones arrojadas por el análisis factorial demostró unos valores buenos de fiabilidad tanto para la dimensión de conductas y expectativas de autoeficacia como para la dimensión de necesidad de apoyo para la adherencia; un valor aceptable para la dimensión de seguimiento a las indicaciones del personal de salud en relación con la ingesta de medicamentos y alimentos; una fiabilidad débil para las dimensiones de realización de actividad física y manejo de las situaciones tensionantes y, finalmente, un valor pobre para la dimensión de conductas esperadas de adherencia a la largo plazo. discusión la adherencia al tratamiento es un fenómeno multicausal que se ve influenciado por un sinnúmero de condiciones que guardan relación con los factores derivados de la enfermedad, el tratamiento, el paciente, las características socioeconómicas y del equipo de salud; sin embargo, la literatura reporta que abordar el fenómeno de adherencia al tratamiento en la enfermedad cardiovascular implica, por una parte, conocer el cumplimiento de aspectos tanto farmacológicos como no farmacológicos dentro de los que se incluyen el consumo de medicamentos, la dieta, la actividad física, la asistencia a controles médicos y el manejo de los factores de riesgo, y por otra, determinar la autoeficacia como un aspecto relevante que influye en la motivación y adopción de conductas promotoras de salud. si bien es importante mencionar la existencia de algunos instrumentos relacionados con la medición de la adherencia al ítems componente 1 2 3 4 5 6 ítem 1 0,749 ítem 2 0,799 ítem 3 0,701 ítem 4 0,521 ítem 5 0,545 ítem 6 0,437 ítem 7 0,467 ítem 8 0,502 ítem 9 0,784 ítem 10 0,414 ítem 11 0,632 ítem 12 0,750 ítem 13 0,815 ítem 14 0,759 ítem 15 0,608 ítem 16 0,647 ítem 17 0,447 ítem 18 0,772 ítem 19 0,762 ítem 20 0,815 ítem 21 0,610 ítem 22 0,423 ítem 23 0,557 ítem 24 0,676 ítem 25 0,702 ítem 26 0,719 ítem 27 0,749 ítem 28 0,422 ítem 29 0,352 fuente: elaboración propia. 468 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 tabla 4. fiabilidad del “cuestionario para medir la adherencia al tratamiento de pacientes con enfermedad cardiovascular” no. ítem alfa de c. si se suprime el elemento 1 tomo mis medicamentos en el horario establecido 0,830 2 tomo diariamente todos mis medicamentos de acuerdo con la orden médica 0,830 3 por alguna razón suspendo mis medicamentos sin la indicación del personal de salud 0,833 4 sigo las indicaciones del personal de salud en relación con mi alimentación 0,825 5 evito en mi alimentación el consumo de grasa (pollo con piel, fritos, alimentos de paquete, leche entera, alimentos precocidos) 0,832 6 evito en mi alimentación el consumo de harinas y azúcares 0,828 7 consumo alimentos bajos en sal 0,835 8 por alguna razón dejo de seguir las recomendaciones de la alimentación dadas por el personal de salud 0,829 9 realizo el ejercicio físico indicado por el personal de salud 0,831 10 por alguna razón suspendo el ejercicio físico sin la indicación del personal de salud 0,832 11 realizo ejercicio físico al menos 3 veces por semana, con una duración mínima de 30 minutos en cada oportunidad 0,832 12 realizo actividades que me ayuden a manejar el estrés o las situaciones tensionantes 0,834 13 cuando estoy angustiado hago algo que me ayude a sentirme mejor 0,831 14 asisto a las consultas médicas programadas 0,830 15 asisto a los controles de enfermería programados 0,830 16 me realizo los exámenes de laboratorio y otros exámenes en los periodos que los profesionales de la salud me indican 0,832 17 estoy atento a cualquier signo o síntoma que demuestre un empeoramiento en mi estado de salud como: dolor en el pecho, presión arterial alta o baja, palpitaciones, ahogo o fatiga, inflamación de brazos y piernas 0,830 18 necesito que otras personas me recuerden que debo tomar mis medicamentos 0,831 19 necesito que otras personas me recuerden que debo seguir la alimentación ordenada por el personal de salud 0,832 20 necesito que otras personas me recuerden que debo hacer el ejercicio físico ordenado por el personal de salud 0,838 21 si en poco tiempo no presento mejoría en mi salud, suspendo mis medicamentos 0,832 22 si en poco tiempo no presento mejoría en mi salud, suspendo el ejercicio físico 0,835 23 puedo manejar las situaciones tensionantes o que me producen estrés 0,834 24 soy capaz de cambiar los comportamientos dañinos para mi salud 0,831 25 cumplo el tratamiento de mi enfermedad aunque me parezca complicado 0,829 26 hago lo que está a mi alcance para mejorarme cuando estoy enfermo 0,832 27 soy capaz de seguir las indicaciones que me da el personal de salud 0,831 28 ¿con qué frecuencia consume bebidas alcohólicas? 0,836 29 ¿con qué frecuencia fuma? 0,840 alfa de cronbach general 0,837 fuente: elaboración propia. 469 validez y confiabilidad del cuestionario para medir la adherencia al tratamiento de pacientes con enfermedad cardiovascular l luisa fernanda achury-beltrán tratamiento, como los elaborados por ortiz (12) y contreras et al. (13), se debe destacar que ninguno de ellos contempla explícitamente las conductas de adherencia y la autoeficacia como un factor predictor de la motivación y del cambio, lo que lleva al diseño y elaboración de un instrumento basado en los lineamientos de streiner, norman y cairney (26), quienes consideran dentro del procedimiento la definición del constructo, la elaboración de los ítems y su escala de medida, la validez facial, de contenido y de constructo, así como la confiabilidad del mismo. la validez de contenido de un instrumento determina qué tan apropiados son los ítems en relación con el constructo que se desea medir (27), y si bien como resultado de esta fase se determinó la eliminación de dos ítems, esto guarda relación con la presencia en el instrumento de otras preguntas que permiten identificar la adherencia de los pacientes a la dieta y al ejercicio, por lo que los resultados demuestran la pertinencia de los tópicos contemplados en el instrumento y el carácter multicausal de la adherencia al tratamiento, tal como lo evidencian ortego (28) y silva et al. (29), quienes consideran que en la medición de este fenómeno deben contemplarse el seguimiento de las indicaciones relacionadas con la dieta y el ejercicio, la evitación de conductas de riesgo, el cumplimiento de las citas programadas, el consumo correcto de la medicación y otros factores dentro de los cuales cobra especial relevancia la motivación. por su parte, la validez facial determina si en apariencia un instrumento mide lo que desea medir; para ello, se contempla el uso del índice de kappa de fleiss, el cual es una medida estadística que permite determinar la concordancia interobservador, en este caso, el acuerdo entre los expertos con respecto a la evaluación del instrumento en mención (23). es así como el proceso de validez facial realizado deja ver tanto la concordancia sustancial y moderada interobservador de los expertos, como la comprensión de cada una de las preguntas contempladas como parte de la evaluación de la adherencia al tratamiento del paciente con diagnóstico de enfermedad cardiovascular, lo que demuestra que este fenómeno debe ser evaluado a partir de la indagación de diferentes aspectos tal y como lo mencionan ortego (28), veliz, medoza y barrigac (30) y martin, grau y espinosa (31). la validez de constructo determina el grado en el que un instrumento mide la dimensión evaluativa para la que fue diseñado, es decir, la relación del instrumento con la teoría y con su conceptualización (32); a partir de esta se obtuvieron las nuevas dimensiones del instrumento, las cuales pueden articularse con los resultados de investigaciones existentes. olivari y urra-medina (33), por su parte, consideran que la autoeficacia influye sobre la percepción que tienen los pacientes acerca de sus capacidades y de los objetivos que pueden cumplirse tras la implementación de los tratamientos, lo que incrementa la probabilidad de llevar a cabo cambios de comportamiento y aumenta la adherencia, por tanto, es posible considerar que la autoeficacia es un concepto que resulta ser transversal a la mayoría de las conductas requeridas como parte del manejo, incluidos, entre otros, la realización de la actividad física tal como lo reporta reigal y cidera (34). por su parte, otros autores como silva et al. (29), berciano y ordovás (35), y perkl et al. (36) destacan la importancia del consumo de medicamentos, el seguimiento de la dieta, la realización de actividad física, la asistencia a controles médicos y la toma de paraclínicos ordenados como parte indispensable del tratamiento, por lo que dichos aspectos deben ser incluidos dentro de los instrumentos que tienen como finalidad determinar la adherencia. finalmente, el cálculo del alfa de cronbach permite determinar la correlación de los ítems dentro del cuestionario y valora la manera como cada uno de ellos estima las mismas características (37), por tanto, los valores obtenidos dejan ver la buena confiabilidad del instrumento en general y la homogeneidad de los enunciados del mismo, así como la correlación existente entre ellos, tal como lo establecen carvajal et al. (38), lo que lo hace un instrumento prometedor en la evaluación de la adherencia al tratamiento en pacientes con diagnóstico de enfermedad cardiovascular. conclusiones el estudio metodológico de enfoque psicométrico dio lugar a un instrumento con 6 dimensiones y 29 ítems, los cuales arrojan un puntaje que oscila entre 29 y 174 puntos, en donde un mayor puntaje revela una mayor adherencia al tratamiento. adicionalmente, se demostró de forma global un buen nivel de fiabilidad, con un alfa de cronbach de 0,837, que lo convierte en un instrumento prometedor para determinar conductas de adherencia al tratamiento en pacientes con diagnóstico de enfermedad cardiovascular isquémica. el cuestionario para medir la adherencia al tratamiento en pacientes con enfermedad cardiovascular está sustentado en un constructo teórico que se fundamenta, por una parte, en las conductas de adherencia y, por otra, en la autoeficacia como predic470 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 tor de esta, de manera que se amplía el abordaje de medición del fenómeno incluida la determinación de las capacidades que perciben los pacientes para poder llevar a cabo una determinada acción del tratamiento. dado que este instrumento permite determinar tanto las conductas de adherencia al tratamiento como las expectativas y conductas de autoeficacia, el profesional de enfermería podrá no solo identificar la adherencia de los pacientes, sino también diseñar e implementar estrategias que le permitan, desde diferentes abordajes, satisfacer las necesidades de los pacientes con enfermedad cardiovascular en los diferentes aspectos del tratamiento de la enfermedad. recomendaciones dado que la agrupación de los ítems resultante del análisis factorial exploratorio no coincide completamente con las dimensiones planteadas al inicio por el autor, se recomienda que investigaciones posteriores realicen un análisis factorial comprobatorio con el objetivo de seguir 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un instrumento de medida de la salud? anales sis san navarra. 2011;34(1):63-71. 13 fortaleciendo.p65 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005114 año 5 vol. 5 nº 1 (5) 114-127 chía, colombia octubre 2005 dianne tapp1 katherine stansfield2 janice stewart3 recibido: 26 de julio de 2005 aprobado: 16 de agosto de 2005 resumen la autonomía ha sido vista como un indicador de la profesionalización de la disciplina. la autonomía de enfermería ha sido identificada como una variable importante que afecta la percepción de la enfermera en relación con su satisfacción en el trabajo, los ambientes positivos de su práctica profesional y la calidad del cuidado de enfermería. la suposición de que un aspecto clave de la autonomía de enfermería es actuar con un juicio y práctica independiente, fue cuestionada en un estudio interpretativo que exploró la forma como las enfermeras entienden la autonomía en su práctica clínica y en su trabajo. este artículo describe el proyecto de investigación, y explora el énfasis que hacen las enfermeras sobre los aspectos inherentes al ejercicio de la autonomía en su trabajo clínico. las descripciones de sus relaciones con los médicos, colegas y directores de enfermería, ofrecen muchos ejemplos en los cuales la práctica autónoma puede ser respaldada y fortalecida. este artículo también discute estas posibilidades para que este concepto se pueda llevar a cabo en tres áreas claves: crear ambientes de práctica que enriquezcan la pericia clínica y la toma de decisiones; hacer posible que las enfermeras practiquen, aplicando todas sus capacidades educativas, sus experiencias y competencias; y fortalecer la práctica multidisciplinaria con colaboración. palabras clave autonomía de enfermería, toma de decisiones clínicas, alcances de la práctica, práctica m u l t i d i s c i p l i n a r i a . abstract autonomy has been viewed as a key indicator of disciplinary professionalization. nursing autonomy has been identified as an important variable that affects nurses� perceptions of job satisfaction, positive professional practice environments, and quality nursing care. the assumption that a key feature of nursing autonomy is the exercise of independent judgment and practice was challenged in an interpretive study that explored how nurses understand autonomy in their everyday clinical practice and worklife. this paper describes the research project, and explores nurses� emphasis on the relational features inherent in the exercise of autonomy in their clinical work. their descriptions of relationships with physicians, nursing peers, and nurse managers offered ample instances whereby autonomous practice could be supported and enhanced. this paper will also discuss these possibilities for enabling nursing autonomy in relation to three key areas: generating practice environments that nurture clinical expertise and decision-making; enabling nurses to practice to the full scope of their education, experience, and competence; and fostering collaborative multidisciplinary practice. key words nursing autonomy, clinical decision-making, scope of practice, multidisciplinary practice. 1 rn phd, associate professor faculty of nursing, university of calgary. dtapp@ucalgary.ca 2 rn mn, director, professional nursing resources, calgary health region. 3 rn msc, director, cardiac sciences, calgary health region. la autonomía en la práctica de enfermería 115 a autonomía de enfermería es un concepto de interés para los enfermeros clínicos y para los administradores de enfermería y otros líderes. dado que los enfermeros se han profesionalizado en el mundo entero, la autonomía en la práctica y la autonomía para aplicar un único cuerpo de conocimientos de la disciplina ha sido vista como un indicador importante de que enfermería es, sin duda, una profesión notable en su derecho propio. la autonomía ha sido relacionada con la calidad de la vida de los enfermeros, la satisfacción por su trabajo, los ambientes de práctica profesional positivos y las percepciones de la calidad del cuidado (1-6). en la literatura sobre autonomía de enfermería se han dado muchas definiciones, incluyendo los siguientes ejemplos: � libertad para actuar en lo que se sabe (4). � qué tanta independencia se tiene en el trabajo, la iniciativa y la libertad, ya sea permitida o necesaria en las actividades diarias (5). � control del trabajo (7). � considerar el juicio independiente para obtener un resultado deseado (8). � la habilidad para desempeñar funciones en forma independiente, sin tener supervisión cercana (9). la toma de decisiones independientes y la acción son elementos comunes de la mayoría de estas definiciones. el interés en los conceptos de autonomía, apoya el desarrollo de medidas para comparar las evaluaciones de la autonomía a través del tiempo o de diferentes áreas de práctica. sin embargo, el interés de este trabajo no es sólo en los aspectos teóricos o conceptuales de la autonomía de enfermería. este trabajo se enfocará en hechos relacionados con el ejercicio de la autonomía o la práctica de ésta en el trabajo del enfermero. en los complejos ambientes de práctica del sistema del cuidado de salud actual, los enfermeros tienen el reto de practicar la autonomía como miembros de un grupo o equipo, y cada vez son más confusas las distinciones sobre los roles (10-12). se describe un proyecto de investigación que explora la comprensión de los enfermeros clínicos sobre la autonomía. uno de los hallazgos más precisos en este estudio fue que la autonomía se describe como un fenómeno intensamente correlativo. los enfermeros la perciben como la habilidad para cumplir con las metas del cuidado por medio de la práctica interdependiente con otros cuidadores de salud. este trabajo explora las formas en las cuales este estudio reta muchas conjeturas sobre la práctica autónoma, y presenta hechos relacionados con la influencia de la cultura en la autonomía de enfermería, la capacidad para ejercer la práctica, y las expectativas crecientes para la práctica multidisciplinaria del cuidado de salud. durante esta discusión se destacarán las posibilidades para fortalecer la autonomía en la práctica clínica. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005116 el proyecto de investigación: �comprensión de la autonomía por parte de los enfermeros clínicos� durante los últimos seis años, una de las regiones más grandes de canadá ha estudiado con regularidad a los enfermeros para evaluar la satisfacción con el trabajo. la expectativa organizacional es que los directores desarrollen estrategias relevantes en sus áreas para identificar los hallazgos del estudio. basados en los hallazgos de 2002 en el portafolio de las ciencias cardiológicas, los directores encontraron que los enfermeros que estaban trabajando en unidades cardiovasculares, clínicas de consulta externa y servicios de diagnóstico, tenían una expectativa alta de autonomía en su trabajo, pero estaban moderadamente satisfechos con ésta. el estudio no dio a los directores suficiente información para comprender las expectativas de los enfermeros y la falta de satisfacción para identificar estrategias específicas que pudieran cambiar la práctica de enfermería o apoyar el fortalecimiento de su autonomía. con base en lo anterior, se buscó asistencia para dirigir un estudio que preguntara a los enfermeros qué significaba la autonomía, con el fin de ayudar a los directores a comprender la forma de influir en la satisfacción de los enfermeros con la autonomía en su trabajo. la directora de ciencias cardiacas, janice stewart, invitó a la directora de recursos de enfermería profesional, katherine stanfield, responsable del desarrollo profesional en la región, y a dianne tapp como investigadora, para desarrollar conjuntamente el proyecto de investigación. la pregunta presentada fue: ¿cómo entienden los enfermeros clínicos la autonomía en su práctica diaria de trabajo? un acercamiento cualitativo-interpretativo basado en el proceso del grupo comprometía a los enfermeros a hacer una exploración activa sobre el significado de la autonomía de enfermería y cómo se podía incrementar dentro de sus áreas de práctica. pequeños grupos de enfermeros discutieron ejemplos de su práctica clínica que mostraron el significado de autonomía de enfermería. la intención era escuchar la explicación de los enfermeros en sus propias palabras, permitiendo que la autonomía se interpretara dentro de una situación contextual que ilustrara totalmente las dificultades y los rasgos de la autonomía en la práctica clínica. los enfermeros representaron varias unidades de cardiología ubicadas en tres hospitales. se organizaron un total de 12 grupos, con 43 practicantes de enfermería (35 mujeres y 8 hombres). los participantes se agruparon de acuerdo con su área de práctica (unidades de cuidado crítico cardiaco, unidades de cirugía o clínicas de consulta externa/ educadores). una descripción más detallada del proceso de la investigación se ha publicado en la revista nursing administration, de octubre 2004 (13). el propósito del estudio era comprender el significado diario de la autonomía en la práctica de enfermería para apreciar cómo fortalecer y apoyar la autonomía de enfermería. es así que los hallazgos no aclaran el concepto y el debate sobre la definición de autonomía, y no se generalizan para todos los ambientes de práctica. sin embargo, estos hallazgos hacen que consideremos aspectos que pueden incrementar la práctica profesional de los enfermeros, al tener en cuenta los hechos percibidos que influyen en la autonomía de enfermería. pequeños grupos de enfermeros discutieron ejemplos de su práctica clínica que mostraron el significado de autonomía de enfermería. la intención era escuchar sus explicaciones, permitiendo que la autonomía se interpretara dentro de una situación contextual que ilustrara totalmente las dificultades y los rasgos en la práctica clínica. la autonomía en la práctica de enfermería 117 autonomía: cumplimiento continuo de las metas del cuidado al paciente por medio del conocimiento de enfermería el equipo investigativo anticipó que los relatos de los enfermeros dan ejemplos de la práctica en los cuales hay oportunidades de tomar decisiones y actuar. sin embargo, es importante anotar que fueron pocos los ejemplos de práctica independiente. había algunos ejemplos de enseñanza al paciente, apoyo psicológico, comodidad e intervenciones para el dolor que se ofrecieron para ilustrar la toma de decisiones independiente y la acción. los enfermeros experimentaron la autonomía cuando pudieron cumplir las metas del cuidado del paciente a través de sus conocimientos y habilidades. ellos describieron la autonomía dentro del contexto de la comprensión y contribución del plan de cuidado, valorando las necesidades y la condición del paciente, comunicando en forma efectiva las preocupaciones y prioridades del cuidado, y coordinando los recursos del equipo multidisciplinario. la práctica autónoma se consideró como obvia y poco notoria cuando los enfermeros podían implementar la continuidad del cuidado. su sentido de autonomía estaba claramente disminuido en situaciones en las cuales el conocimiento de enfermería se ignoraba, o no era valorado. los enfermeros ofrecieron muchos ejemplos en los cuales la autonomía tenía obstáculos, y la habilidad de comprender e influir en el plan de cuidado del paciente, resolver los conflictos o coordinar los recursos, era interrumpida o limitada. una característica importante de la descripción de la autonomía hecha por los enfermeros, era la visión que tenían de que la evolución del paciente se lograba del trabajo independiente de ellos y otros miembros del equipo de salud. interfase contextual y personal los enfermeros han citado en forma consistente la contribución de su conocimiento personal y su experiencia respecto a su sentido de autonomía. ellos han creído que la autonomía se ha venido desarrollando a través del tiempo y se relaciona con su desarrollo personal y profesional. la autonomía fue discutida algunas veces como una conveniencia y el deseo de adquirirla estaba relacionado con las preferencias personales. ¿qué tanta autonomía ha deseado? ¿cuánta autonomía se le ha permitido tener? especialmente como principiante, ¿cómo sabe cuando ha tenido mucha autonomía? los enfermeros estaban conscientes de su influencia en las áreas de práctica y su papel de acuerdo con su propia definición de enfermería y sus expectativas relacionadas con una práctica autónoma. los enfermeros que estaban trabajando en unidades quirúrgicas hacían énfasis en ejemplos de autonomía en sus roles como coordinadores y al hacer planes para la salida del paciente. aquéllos de cuidado crítico y los de laboratorio diagnóstico hacían más énfasis en la naturaleza técnica de su trabajo, en los protocolos para administrar medicamentos y en los procedimientos especializados. los enfermeros de clínicas de consulta externa hicieron énfasis en el conocimiento técnico de una población particular a la cual le hicieron los enfermeros experimentaron la autonomía cuando pudieron cumplir las metas del cuidado del paciente a través de sus conocimientos y habilidades. ellos describieron la autonomía dentro del contexto de la comprensión y contribución del plan de cuidado, valorando las necesidades y la condición del paciente, comunicando en forma efectiva las preocupaciones y prioridades del cuidado, y coordinando los recursos del equipo multidisciplinario. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005118 seguimiento con la colaboración cercana de los médicos. hubo consenso en que el deseo de los enfermeros de ser autónomos influye en sus decisiones en la práctica. los enfermeros también notaron cambios en su apertura al ser cuestionados en sus decisiones, y su confianza y persistencia en el seguimiento de la solución de conflictos. la autonomía se vio como una interacción entre los rasgos personales y las preferencias y el contexto de las situaciones de la práctica. aspectos relacionados con la autonomía así como el concepto de autonomía tradicionalmente implica independencia e individualismo (14, 8), los relatos de los enfermeros revelaron que la autonomía tiene muchas interrelaciones y se apoya en el mutuo respeto y reconocimiento de todos los miembros del equipo de salud. relación con los médicos los enfermeros creen que su relación con los médicos tiene una influencia significativa en el sentido de su autonomía. la naturaleza de esta relación varía en los diferentes campos de práctica. los enfermeros que trabajan en clínicas de consulta externa y cuidado crítico tienen un mayor acceso a los médicos para consultar la toma de decisiones. ellos trabajan típicamente con un grupo pequeño de médicos, y tienen un sentido de camaradería por el hecho de que se conocen. esto marcó una diferencia en la confianza mutua en el conocimiento y juicio, lo que consideran contribuye en el fortalecimiento de la autonomía. los enfermeros que trabajan en clínicas ambulatorias se sienten más supervisados por los médicos, y tienen que ganarse su confianza y reconocimiento. el deseo de ser respetados y reconocidos por los médicos se comentó en todos los grupos de discusión. los enfermeros quieren que su conocimiento y contribución única al cuidado del paciente sean reconocidos y valorados. en las unidades quirúrgicas, algunos comentaron que era más difícil para ellos conocer a los médicos. los enfermeros creían que los médicos apreciaban la fortaleza de trabajar con la misma persona diariamente, en vez de relacionarse con un gran número de enfermeros desconocidos, cuyo juicio clínico y experiencia eran difíciles de evaluar. los enfermeros creían que la autonomía disminuía cuando el conocimiento de enfermería y el potencial para contribuir al plan de tratamiento estaban subestimados, ignorados o no eran valorados por los médicos. cuando no había respeto y reconocimiento, describieron con resentimiento sus percepciones de la jerarquía del poder de las relaciones y la disminución implícita del conocimiento de enfermería. los enfermeros desean un contexto de estudio y aprendizaje que permita la exploración de diferentes perspectivas. se tuvo conocimiento de que algunas veces el enfermero simplemente no comprende las dificultades que tiene el médico al tratar al paciente o al escoger un tratamiento determinado. los enfermeros valoran mucho las oportunidades de aprendizaje sobre nuevas drogas y tratamientos, al discutir con el médico sobre estos temas y en las revistas médicas. con menor frecuencia se vio la necesidad de que los profesionales estén preparados para participar en debates de grupo y que sus perspectivas y decisiones sean sometidas a escrutinio y discusión. los enfermeros creían que la autonomía disminuía cuando el conocimiento de enfermería y el potencial para contribuir al plan de tratamiento estaban subestimados, ignorados o no eran valorados por los médicos. cuando no había respeto y reconocimiento, describieron con resentimiento sus percepciones de la jerarquía del poder de las relaciones y la disminución implícita del conocimiento de enfermería. la autonomía en la práctica de enfermería 119 relaciones entre enfermeros existe conciencia de la forma como las interrelaciones con sus colegas pueden apoyar o disminuir su sentido de autonomía en la práctica. los enfermeros discutieron la necesidad de orientar al personal nuevo y consultar con sus colegas, conocer las rutinas del servicio y ser discretos en los conflictos. estas medidas fueron vistas como factores que incrementan la autonomía construyendo confianza y respetando las diferencias en los juicios clínicos y la toma de decisiones. los enfermeros valoran altamente el aprendizaje en la práctica en la que son motivados a preguntar, consultar y discutir las decisiones difíciles. estos aspectos fortalecen la autonomía y la toma de decisiones. los enfermeros se consideran responsables de contribuir con un clima que construya el conocimiento y la confianza, al orientar las relaciones con los menos experimentados. algunos enfermeros comentaron su frustración sobre la forma en que las rutinas rígidas y las prácticas estrictas (por ejemplo, �esta es la forma en que siempre lo hemos hecho�) pueden disminuir la autonomía en la práctica clínica. ellos sugirieron que algunas veces los mismos enfermeros son los que obstaculizan la práctica autónoma. cuando el conflicto ocurre en las interrelaciones entre compañeros de trabajo, observaron el efecto destructivo sobre la moral y la capacidad profesional de su servicio. el conflicto no resuelto fue visto como una autonomía disminuida al reducir la capacidad de actuar en lo que la persona sabe. muchas enfermeras comentaron que la autonomía puede ser aumentada por medio de un ambiente que apoye el aprendizaje, sin presión o sin sentirse constantemente vulnerables, ganando confianza y experiencia en una práctica específica. algunos comentaron que de ellos dependía reconocer y establecer estas dificultades. los enfermeros de un servicio también reconocieron la forma en que sus roles pueden ser estructurados para limitar o apoyar la autonomía de los que dan cuidado directo. los enfermeros de un servicio pueden convertirse en supervisores o pueden llegar a tener un control excesivo en la toma de decisiones. algunos participantes también trabajaron regularmente como enfermeros de un servicio, compartiendo la toma de decisiones con los que dan cuidado directo. cuando el enfermero de un servicio conoce bien al que da cuidado directo y confía en su juicio clínico y su práctica, se gana autonomía y apoyo para el trabajo independiente. relación con los directores de enfermería los enfermeros creyeron que su relación con los directores de enfermería tiene una influencia importante en su autonomía, y expresaron muchas expectativas. enfatizaron en la necesidad de directores que apoyen la educación continuada, ya que ésta es una oportunidad para desarrollar el conocimiento profesional e incrementar la autonomía, al reforzar la competencia y confianza en la toma de decisiones. los enfermeros sintieron que su autonomía se incrementaba cuando los directores buscaban su consejo y escuchaban sus sugerencias. también requieren que los directores reconozcan y valoren sus conocimientos y su experiencia. los enfermeros valoran altamente el aprendizaje en la práctica en la que son motivados a preguntar, consultar y discutir las decisiones difíciles. estos aspectos fortalecen la autonomía y la toma de decisiones. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005120 los enfermeros aprecian el reconocimiento genuino de su esfuerzo y compromiso en la toma de decisiones correctas y el trabajo bien hecho, y algunas veces por los turnos pesados que tienen. algunos enfermeros comentaron sobre sus expectativas para que no se presenten errores, y la posibilidad de que sucedan. ellos esperan que sus decisiones sean apoyadas por el director de enfermería en situaciones difíciles (por ejemplo, �voy a estar al lado del personal de enfermería y tendré en cuenta sus juicios hasta que se pruebe que están equivocados�). quieren que sus decisiones sean cuestionadas y sus errores discutidos, pero insisten en que la crítica y retroalimentación de los directores debe darse en forma cuidadosa y en privado. ¿cómo se relaciona esto con la autonomía? si los enfermeros desarrollan discreción y juicio que apoyen su práctica clínica autónoma, deben tener oportunidades de aprendizaje al tomar decisiones, algunas de las cuales pueden ser más radicales que otras. esto requiere una atmósfera de apoyo al aprendizaje, y que si ocasionalmente se comenten errores, no se tenga temor al castigo. incremento de la autonomía de enfermería se han dado muchas indicaciones sobre la forma en que los enfermeros clínicos, los directores y administradores pueden incrementar la autonomía en la práctica de enfermería. casi dos años después de completar el proyecto descrito, este equipo de investigación se reunió para discutir los hallazgos. reflexionamos sobre la forma como este proyecto ha tenido influencia en nuestra práctica como administradores y directores de desarrollo profesional, y educadores de enfermería. quisimos ofrecerles nuestras impresiones y sugerencias basadas no sólo en los hallazgos del proyecto, sino también en nuestro esfuerzo para incorporar estos hallazgos a nuestra práctica. las tres ideas principales que salieron de esta discusión tienen que ver con tres preguntas interrelacionadas: 1. ¿cómo pueden la cultura, las rutinas y las normas de enfermería apoyar y fortalecer la autonomía? 2. ¿es posible que la autonomía de enfermería sea fortalecida cuando los enfermeros practican con todas sus capacidades y no sólo orientados hacia el cuidado del paciente? 3. ¿en qué forma se puede hacer énfasis en la autonomía de enfermería en contradicción con la tendencia actual en una práctica multidisciplinaria? ¿cómo pueden la cultura, las rutinas y las normas de enfermería apoyar y fortalecer la autonomía? los enfermeros que participaron en este proyecto ofrecieron muchos ejemplos y sugerencias para ilustrar cómo la autonomía puede ser incrementada y apoyada dentro del ambiente de la práctica. mu chas de estas sugerencias tienen implicaciones locales para el desarrollo profesional y la relación entre profesionales en un servicio. varias ideas se pueden llevar a cabo por colegas enfermeros que comparten la idea de la importancia de un ambiente de práctica que haga énfasis en el desarrollo de la experiencia clínica y la toma de decisiones. la autonomía de enfermería y la toma de decisiones no son lo los enfermeros aprecian el reconocimiento genuino de su esfuerzo y compromiso en la toma de decisiones correctas y el trabajo bien hecho, y algunas veces por los turnos pesados que tienen. algunos enfermeros comentaron sobre sus expectativas para que no se presenten errores, y la posibilidad de que sucedan. la autonomía en la práctica de enfermería 121 mismo. sin embargo, la habilidad de las enfermeras para poner en práctica sus conocimientos y habilidades por medio de la toma de decisiones, y el reconocimiento y la valoración de esta contribución, fueron vistas por los enfermeros como aspectos claves de su comprensión de la autonomía. apoyo para desarrollar la experiencia clínica y la toma de decisiones los enfermeros clínicos reconocen que la autonomía se desarrolla con el tiempo y está relacionada con la confianza y el juicio clínico competente. hacen énfasis en la necesidad de tener apoyo organizacional para contar con oportunidades de educación continuada. sin embargo, también reconocen las posibilidades dentro de la práctica para crear un clima de supervisión y consulta que ayude tanto a los principiantes como a los enfermeros experimentados a fortalecer su juicio clínico. ellos desean oportunidades para aprender en el contexto dentro de su práctica diaria. desean supervisar los nuevos enfermeros y ser supervisados por profesionales experimentados. los expertos clínicos también valoran las oportunidades para consultar con sus colegas sobre dilemas de su práctica. quieren hacer un trabajo conjunto en sus planes de cuidado, recibiendo apoyo en sus decisiones clínicas. requieren ser considerados como responsables en la toma de decisiones, y trabajar en una atmósfera donde los errores sean oportunidades de aprendizaje y no situaciones de crítica y castigo. desean participar en las revistas médicas para continuar aprendiendo sobre nuevas terapias y planear un tratamiento para sus pacientes. desean ser capaces de contribuir con sus valoraciones y conocimientos en la planeación del tratamiento. éstas no son expectativas extravagantes, pero llevarlas a cabo dentro de un servicio determinado requiere un compromiso. es obvio que el liderazgo del enfermero es crucial para mantener un ambiente que apoye el desarrollo de capacidades en la toma de decisiones clínicas. ¿cómo pueden los administradores de enfermería fortalecer y mantener este aspecto? los directores necesitan estar a tono con las situaciones que limitan la habilidad de los enfermeros para participar en la toma de decisiones clínicas, y escuchar lo que ellos dicen en relación con estas dificultades. dentro de estos dilemas hay importantes lecciones sobre valores, relaciones, rutinas y políticas que apoyan el ejercicio de la práctica de la autonomía dentro de su vida diaria. el liderazgo de enfermería en el servicio puede guiar las discusiones del equipo sobre la práctica, fortalecer los cambios en las rutinas, y hacer que los enfermeros vayan más allá en su sistema de cuidado. es posible que los directores de enfermería tengan que poner a prueba la complacencia de los enfermeros con las rutinas del servicio y las prácticas que se consideran obvias. los líderes clínicos dentro de los servicios pueden ayudar al personal de enfermería en el desarrollo de habilidades para manejar situaciones difíciles que se pueden presentar a pesar de las buenas intenciones y habilidades. estas situaciones son las que proporcionan confianza y discreción clínica en futuras prácticas. las habilidades requeridas incluyen la habilidad para comunicar en forma clara los hallazgos críticos, justificar la razón principal en la toma de decisiones, y negociar una solución adecuada cuando se trabaja en equipo para establecer un plan de cuidado. los enfermeros clínicos reconocen que la autonomía se desarrolla con el tiempo y está relacionada con la confianza y el juicio clínico competente. hacen énfasis en la necesidad de tener apoyo organizacional para contar con oportunidades de educación continuada. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005122 los directores de enfermería tienen una posición única para hacerle frente a los médicos y otros miembros del quipo de salud en la búsqueda de un ambiente que apoye la toma de decisiones de enfermería, y que promueva todo el campo de acción de su práctica. el director otorga autoridad legítima para manejar los resultados clínicos que se logran en el servicio. además, si las relaciones profesionales son positivas y todas las disciplinas se apoyan para participar en el desarrollo del plan del tratamiento, es posible que la toma de decisiones clínicas se fortalezca. el personal de enfermería en este proyecto de investigación hizo énfasis en la importancia de conocer y ser conocido por el médico, creando una relación en donde el conocimiento y el juicio de cada profesional se valoren y sean confiables. ¿qué se puede hacer para que las revistas médicas se organicen de tal forma que tengan en cuenta el cuidado directo del paciente y que su valoración y conocimiento se incorporen en el plan de cuidado? ¿cómo pueden los directores hacer que las funciones de enfermería y las rutinas del servicio no sólo sean apoyo a las preferencias del médico sino que todos los miembros del equipo de salud aporten los mejores conocimientos para el cuidado del paciente? los administradores de enfermería pueden contribuir a fortalecer la autonomía de la disciplina apoyando a los directores para crear ambientes como los arriba anotados. los directores pueden necesitar asesoría para iniciar estratégicamente y liderar cambios que impacten los procesos del sistema y el rol profesional. para iniciar los cambios en los roles y las rutinas se requiere habilidades de negociación y manejo inteligente del cambio. es posible que los directores de enfermería no puedan hacerlo inmediatamente, sino que deben seguir haciéndolo poco a poco. ¿se puede fortalecer la autonomía de enfermería cuando los enfermeros ponen en práctica todas sus capacidades y no están limitados sólo hacia el cuidado? esta pregunta salió de la discusión por la forma en que los enfermeros que toman parte en el proyecto de investigación han examinado o por lo menos se han limitado a las actividades que pueden claramente ilustrar la práctica autónoma. los enfermeros han citado algunos ejemplos de intervenciones relacionadas con la enseñanza al paciente, el apoyo psicológico, el manejo del dolor y las medidas de comodidad que el equipo de investigación pensó estarían dentro del campo de acción de la práctica de enfermería. esta observación nos invita a preguntarnos si estas actividades son subvaloradas, volviéndose aspectos invisibles de la práctica autónoma de enfermería. los enfermeros en este estudio han hecho énfasis, en forma repetida, en que la autonomía se disminuye cuando el conocimiento, las habilidades y la experiencia de los enfermeros no han sido valorados ni reconocidos. el equipo de investigación cuestiona si los mismos enfermeros no han reconocido y valorado estas intervenciones de enfermería que parecen estar obviamente contenidas en su práctica independiente. los enfermeros en el estudio describieron muchos ejemplos de riesgos al tomar decisiones que estaban por fuera del campo de acción de su práctica, incluyendo las órdenes de analgésicos, antiácidos, laxantes, antibióticos y anticoagulantes, y las órdenes de exámenes de laboratorio. los directores de enfermería tienen una posición única para hacerle frente a los médicos y otros miembros del quipo de salud en la búsqueda de un ambiente que apoye la toma de decisiones de enfermería, y que promueva todo el campo de acción de su práctica. la autonomía en la práctica de enfermería 123 estas actividades usualmente se presentan durante la noche, cuando los médicos no están disponibles, en especial cuando las enfermeras no desean molestar a los médicos que están de turno. los enfermeros observaron que había diferencias en el grado de autonomía requerida y esperada entre el turno del día y el de la noche (por ejemplo, el síndrome de cenicienta). en estas circunstancias, los enfermeros usualmente sabían que estaban infringiendo las políticas del hospital y las guías de las asociaciones profesionales relacionadas con el campo de acción de la práctica. estas diferentes circunstancias nos alertan sobre el campo de acción de la práctica y la autonomía de enfermería. el propósito de las guías de la práctica desarrolladas por las asociaciones profesionales afirma que los cuidadores deben �practicar de acuerdo con su educación, entrenamiento, habilidades, conocimiento, experiencia, competencia y juicio�, y �deben reflejar el grado de precisión, responsabilidad y autoridad asumidos por el cuidador de acuerdo con los resultados de su práctica� (15). dado que las consideraciones fiscales presentaron cambios en el sistema de cuidado de salud durante la pasada década en canadá, hemos sido testigos de la expansión en los hospitales de cuidado agudo de los asistentes con licencia y sin ésta. a pesar de que muchos estudios han documentado el efecto nocivo de la reducción en el personal de enfermeros registrados (rn) en la mortalidad de los pacientes y en los resultados que se obtienen, el alcance de la práctica tiene implicaciones en las decisiones sobre habilidades y contratos de diferentes categorías de los cuidadores de salud. dado que los planeadores de cuidado buscan una práctica multidisciplinaria para el futuro, los profesionales de la salud han sido presionados para tener en cuenta la transposición de funciones y las diferentes características de sus respectivas disciplinas. la negociación resultante de los campos de acción de la práctica para diferentes cuidadores deja el cuidado de enfermería aún más lejos del riesgo de una reducción de las tareas que le corresponden. los enfermeros en este estudio enfatizaron que es muy frecuente que no se tenga en cuenta la valoración holística y fisiológica de la situación del paciente. se sintieron resentidos cuando su conocimiento no era tenido en cuenta en la planeación del cuidado. cuando los procedimientos y la asignación de roles son revisados en la práctica, las valoraciones hechas por enfermeros experimentados son un elemento crucial que no se debe olvidar. por ejemplo, el área de salud ha estado revisando sus políticas en relación con las categorías de cuidadores que pueden participar en los procedimientos al administrar sangre. por un lado, se discutió que los rn deben hacer el procedimiento técnico relacionado con la colocación de la transfusión de sangre, y que una vez queda colocada, el auxiliar de enfermería debe ser responsable del control de signos vitales: ta, pulso y temperatura. luego, se discutió que el procedimiento de colocar la bolsa con la transfusión era una tarea técnica que podía ser hecha por el auxiliar de enfermería. se propuso que la enfermera profesional debía hacer la valoración física y el monitoreo de una posible reacción adversa a la transfusión. lo importante no era el control de signos vitales. la habilidad y el juicio para interpretar e intervenir ante cambios rápidos en el estado físico es lo que requiere la presencia de la enfermera profesional. este ejemplo invita a analizar el cuidado que se debe tener en los diferentes cam cuando los procedimientos y la asignación de roles son revisados en la práctica, las valoraciones hechas por enfermeros experimentados son un elemento crucial que no se debe olvidar. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005124 pos de acción. nos recuerda también que las guías deben ser diferentes de los procedimientos, y no deben sustituir el juicio crítico y la discreción. los procedimientos deben ser usados como una referencia rápida para apoyar un juicio y la toma de decisiones, en especial cuando otro colega no está disponible para ser consultado. sin embargo, los enfermeros necesitan confiar en las fuentes de conocimiento para guiar su práctica. es muy diferente acudir a las políticas administrativas para justificar la toma de decisiones clínicas, que utilizar la mejor evidencia disponible y establecer la razón fundamental de una acción. cuando el conocimiento, las habilidades y la experiencia no son reconocidos y valorados, los enfermeros no estarán dando el máximo de sus capacidades. en estas circunstancias, la habilidad para influir en la evolución del paciente será limitada. cuando los enfermeros no pueden practicar en toda su extensión todo lo que saben, sus habilidades y experiencia, su satisfacción con la autonomía y los resultados del cuidado serán muy limitados. esto no sólo es poco satisfactorio para los enfermeros sino también demuestra el uso inadecuado de los recursos para dar un óptimo cuidado de salud. ¿en qué forma puede el énfasis en la autonomía de enfermería ser una contradicción con la tendencia actual y el énfasis de una práctica multidisciplinaria? introducción a enfermería es una materia de pregrado en la que se trata de socializar a los estudiantes con el tema de enfermería como profesión. es interesante ver que una de las nociones importantes citadas por los teóricos sobre el tópico de la profesionalización, es que las disciplinas profesionales tienen autonomía e independencia en la práctica. este aspecto ha sido considerado como algo idealista, que tal vez no se ha guiado a los estudiantes en forma correcta en la naturaleza de su práctica y la complejidad de sus relaciones profesionales. henneman (16) propuso que la educación de enfermería ha estado caracterizada por �un intento bien intencionado para promover la unicidad de los enfermeros...[con una] tendencia a creer que ellos son los únicos que se preocupan del bienestar del paciente�. este proyecto ha llevado a reflexionar sobre la naturaleza de las habilidades que necesitan las generaciones actuales de enfermeros si quieren participar efectivamente en la toma de decisiones compartida, la colaboración y los acuerdos en la práctica clínica. el llamado a una educación multidisciplinaria y la práctica parece ser el mantra de nuestros tiempos. los planeadores de salud piden un acercamiento coordinado hacia el cuidado de salud que requiere una revaluación de los roles independientes e interdependientes de los profesionales de la salud. implícito en este movimiento está el deseo de mejorar la eficiencia del sistema por medio de la coordinación y colaboración, proveyendo los mejores recursos. esto, obviamente es lo deseable, pero para lograrlo, los profesionales de la salud deben colaborar en una forma sin precedentes. corser (17) resumió los resultados de la colaboración enfermero-médico que se han reportado en la literatura. estos resultados incluyeron una mejoría en la satisfacción que tienen los enfermeros y los médicos con su trabajo, su productividad y la disminución del estrés. sin embargo, el cuando el conocimiento, las habilidades y la experiencia no son reconocidos y valorados, los enfermeros no estarán dando el máximo de sus capacidades. en estas circunstancias, la habilidad para influir en la evolución del paciente será limitada. la autonomía en la práctica de enfermería 125 argumento más importante es el relacionado con la satisfacción del paciente, mejores decisiones y planeación del cuidado, disminución de muertes y mejor calidad del cuidado del paciente. las nociones de autonomía y multidisciplina parecen tener contrastes mutuos. autonomía implica independencia y control, como también un territorio único o dominio de la práctica. la multidisciplina implica colaboración para planear la toma de decisiones en relación con aspectos compartidos donde el dominio de la práctica puede ser complemento o estar superpuesto. la autonomía clínica se presenta en situaciones complejas donde la interdependencia no es opcional ni escogida, sino que depende de la toma de decisiones de la enfermera. henneman, lee y cohen (18) afirmaron que �el respeto hacia y el reconocimiento de los conocimientos y juicios de cada miembro del grupo es un prerrequisito de la colaboración�. los enfermeros que tomamos parte en la investigación concluimos que cuando no se tienen en cuenta el conocimiento y la experiencia de los enfermeros, se afecta la autonomía. los enfermeros se sienten responsables del monitoreo y la coordinación de todos l o s profesionales que participan en la planeación del cuidado del paciente. puede ser un reto para los enfermeros aceptar que otras disciplinas tengan la habilidad para tomar decisiones similares (por ejemplo, fisioterapeutas, dietistas). los enfermeros necesitan percibir que su tiempo y sus esfuerzos son recursos valiosos que pueden ser consultados para ayudar y orientar diferentes aspectos del cuidado. los profesionales de la salud deben comunicar y negociar efectivamente si la práctica multidisciplinaria y la colaboración entre colegas y médicos son verdaderamente productivas. en muchas ocasiones los enfermeros y médicos hablan diferentes dialectos. la valoración de las enfermeras es interpretativa en su contexto, teniendo en cuenta muchos aspectos de la situación del paciente, incluyendo las preferencias personales, físicas, psicológicas y sociales. los diagnósticos médicos eliminan el contexto para aislar los síntomas más relevantes. tanto los enfermeros como los médicos deben aprender cómo manejar estas diferencias en el lenguaje y el enfoque. los enfermeros deben ser capaces de explicar los aspectos más importantes de sus valoraciones y la toma de decisiones que son parte del plan de cuidado. los médicos aprenden a organizar su práctica en la presentación de casos durante las revistas médicas, en las cuales se debe coordinar la valoración clínica, indicar los problemas relevantes, explicar las causas, y discutir los diagnósticos y el tratamiento basados en la mejor evidencia. estas prácticas de enseñanza ofrecen claves para aprender a argumentar sobre las decisiones tomadas y el plan de cuidado. además, incluir los conocimientos de la enfermera en las revistas médicas y en las presentaciones de casos fortalece la toma de decisiones clínicas y el aprendizaje tanto de médicos como de enfermeros. los médicos como los enfermeros necesitan reconocer el enriquecimiento mutuo en sus relaciones profesionales. ¿qué recompensas resultan si la colaboración es más efectiva? ¿qué guía su práctica? ¿cómo pueden los sistemas de cuidado organizarse para responder a las necesidades de los médicos, enfermeros y otros profesionales de la salud? contestar estas preguntas requiere de sistemas que busquen comprender e influir no sólo los aspectos inmediatos. estas respuestas requieren la capacidad para negociar, inlos enfermeros deben ser capaces de explicar los aspectos más importantes de sus valoraciones y la toma de decisiones que son parte del plan de cuidado. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005126 fluir y resolver conflictos. dichas habilidades de comunicación no son necesariamente las mismas que típicamente enfatizan la relación enfermero-paciente. en estados unidos, �los hospitales eje� son conocidos por el excelente cuidado del paciente y los ambientes de trabajo profesional para enfermería (19). la comunicación efectiva entre enfermeros, médicos y administradores es una de las tres bases de un modelo de práctica profesional que proporciona un apoyo organizacional a la práctica profesional de enfermería. un estudio reciente de kramer y schmalenberg (20) examinó la naturaleza de la relación médico-enfermero estudiando y entrevistando enfermeros y administradores de catorce �hospitales eje� en estados unidos. no fue sorpresa que el poder fuera el tema dominante en cuatro categorías en las relaciones descritas. las dos categorías más positivas fueron la colaboración y el apoyo mutuo. las relaciones de colegas eran aquellas en las cuales tanto los enfermeros como los médicos reconocieron que ellos estaban en posiciones de poder y conocimiento �diferente pero igual�, cada uno contribuyendo en forma importante en el cuidado del paciente. la relación de colaboración se caracterizaba por confianza mutua, respeto y poder, siendo este último desigual. el poder de los enfermeros se derivó del contacto con el paciente, la longevidad, experiencia, o conocimiento, pero había un sentido de que �lo que él [el médico] dice, es más importante que lo que yo tengo que decir�. en las dos relaciones, la norma es el aprendizaje incidental, pero la enseñanza y el aprendizaje no son el foco o la meta de la relación. kramer y schmalenberg (20) concluyeron que los directores de enfermería juegan un papel crucial en el desarrollo y apoyo de un poder igual en las relaciones enfermero-médico. ellos sugirieron que los directores pueden �sembrar y cultivar la semilla igual pero diferente� y �crear una cultura que valora, espera y premia la relación de colegas enfermero-médico. ellos propusieron también que los directores deben apoyar los programas educativos de todo tipo ya que la competencia clínica es la base de �la igualdad de poder� en la relación de trabajo. la práctica de la autonomía de enfermería la autonomía es vista algunas veces como una capacidad individual o cualidad; se reconoce que la autonomía se ejercita dentro de un rol y un contexto particular. cash (21) argumentó que la autonomía clínica es una relación social construida en una situación particular en la cual es importante considerar cómo se establecen los límites de una práctica aceptable, y los efectos reales de dichos límites en la práctica. la autonomía de enfermería no es solamente el ejercicio de la práctica independiente, sino la aprobación del juicio crítico dentro de las �complejas redes de las relaciones personales e institucionales que hacen posible la escogencia de oportunidades reales� (22). el conocimiento y el juicio de enfermería tienen lugar en las relaciones profesionales complejas y los sistemas de cuidado. autonomía no es lo mismo que toma de decisiones clínicas, aunque el conocimiento clínico y la competencia se ubican en el centro de la práctica autónoma. la autonomía no se define por los límites alrededor de las funciones independientes o las tareas definidas por el campo de acción de la práctica. sin embargo, la autonomía disminuye cuando los enfermeros no pueden practicar, aplicando toda su preparación, entrenamiento, habilidades, conocimientos, competencia y juicio. las sugerencias presentadas en este artículo no son radicales o innovadoras. son sugerencias que en general tienen potencial para mejorar la calidad de vida en el trabajo de las enfermeras y su satisfacción con la práctica, y mejorar los resultados clínicos de los pacientes. éstas pueden ser introducidas exitosamente donde los enfermeros comparten el deseo de aprendizaje permanente en la práctica. el incremento de la autonomía de enfermería requiere el apoyo dentro del ambiente de la práctica para la educación continuada, la colaboración y las relaciones de trabajo positivas. esta exploración de la autonomía en la práctica de enfermería nos recuerda que debemos preparar enfermeros que trabajen en contextos donde se valore lo que ellos hacen. deben estar preparados no sólo para actuar con decisión basada en sus conocimientos clínicos y la valoración, sino también articular la evidencia y el juicio que guían su práctica. los ambientes que benefician estos aspectos son aquellos que explícitamente valoran el conocimiento de enfermería, apoyan su desarrollo y fortalecen una relación positiva entre los enfermeros y el equipo de salud. la autonomía en la práctica de enfermería 127 referencias bibliográficas 1. finn cp. autonomy: an important component for nurses� job satisfaction. international journal of nursing studies 2001;38(3):349-57. 2. freeman t, o�brien-pallas l. factors influencing job satisfaction on specialty nursing units. canadian journal of nursing administration 1998;11(3):25-51. 3. kramer m, schmalenberg ce. learning from success: autonomy and empowerment. nursing management 1993;24(5):58-64. 4. kramer m, schmalenberg ce. magnet hospital 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tendencies. scholarly inquiry for nursing practice: an international journal 1998;12(4):325-341. 18. henneman ea, lee jl, cohen ji. collaboration: a concept analysis. journal of advanced nursing 1995;21:103-109. 19. havens ds, aiken lh. shaping systems to promote desired outcomes: the magnet hospital model. journal of nursing administration 1999;29(2):14-20. 20. kramer m, schmalenberg ce. securing �good� nurse physician relationships. nursing management 2003;34-38. 21. cash k. clinical autonomy and contractual space. nursing philosophy 2001;2:36-41. 22. macdonald c. nurse autonomy as relational. nursing ethics 2002;9(2):194-201. 473 486 riesgo suicida segun la triada.indd 473 ronald alberto toro-tobar1 francy lorena grajales-giraldo2 julián camilo sarmiento-lópez3 riesgo suicida según la tríada cognitiva negativa, ideación, desesperanza y depresión 1 orcid.org/0000-0001-6061-3499. universidad manuela beltrán. colombia. ronald.toro@umb.edu.co 2 orcid.org/0000-0002-7286-6263. universidad manuela beltrán. colombia. fl-gg@hotmail.com 3 orcid.org/0000-0001-9279-6664. universidad manuela beltrán. colombia. julian.sarmiento@umb.edu.co recibido: 28 de enero de 2016 enviado a pares: 13 de marzo de 2016 aceptado por pares: 26 de mayo de 2016 aprobado: 07 de junio de 2016 doi: 10.5294/aqui.2016.16.4.6 para citar este artículo / to reference this article / para citar este artigo toro-tobar ra, grajales-giraldo fl, sarmiento-lópez jc. riesgo suicida según la tríada cognitiva negativa, ideación, desesperanza y depresión. aquichan. 2016; 16 (4): 473-486. doi: 10.5294/aqui.2016.16.4.6 resumen objetivo: establecer la relación entre ideación suicida, desesperanza, tríada cognitiva negativa y depresión, como evidencia del modelo cognitivo del riesgo suicida. método: estudio empírico-analítico con diseño descriptivo, correlacional y comparativo. las variables fueron medidas con los inventarios bdi-ii, pansi e itc y la escala bhs. la muestra final estuvo constituida por 90 personas de ambos sexos, con una media de edad de 24,2 años (dt = 8,65 años) pertenecientes a diversos niveles socioeconómicos, con estudios universitarios, principalmente. resultados: se encontraron correlaciones estadísticamente significativas entre ideación suicida, desesperanza, depresión y la tríada cognitiva negativa. las diferencias fueron significativas entre los grupos depresivos y no depresivos, con grandes efectos para las tres variables cognitivas. interpretación y conclusiones: estos resultados constituyen nueva evidencia del modelo cognitivo planteado acerca de la relación entre las variables depresión, tríada cognitiva negativa, ideación suicida y desesperanza, tal como se ha propuesto en distintas revisiones sobre cognición negativa y suicidio. se analizaron las limitaciones del estudio en cuanto el reducido tamaño muestral y las diferencias entre sexos para depresión ante estresores específicos, y las variaciones por grupos de edades en el riesgo suicida de los jóvenes. palabras clave depresión; suicidio; intento de suicidio; cognición; estadísticas no paramétricas (fuente: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 473-486 474 aquichan issn 1657-5997 eissn 2027-5374 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 473-486 suicide risk according to the negative cognitive triad, ideation, despair and depression abstract objective: determine the relationship between suicidal ideation, despair, the negative cognitive triad and depression, as evidence of the cognitive model of suicidal risk. method: this is an empirical-analytical study with a descriptive, correlational and comparative design. the variables were measured with the bdi-ii, pansi and itc inventories and the bhs scale. the final sample included 90 participants of both sexes, with a mean age of 24.2 years (dt = 8.65 years). they were from different socioeconomic brackets and most were college educated. results: statistically significant correlations were found between suicidal ideation, despair, depression and the negative cognitive triad. there were important differences between the depressive and non-depressive groups, with major effects for the three cognitive variables. interpretation and conclusions: these results constitute new evidence of the proposed cognitive model concerning the relationship between depression, the negative cognitive triad, suicidal ideation and despair, as proposed in different reviews on negative cognition and suicide. the limitations of the study were analyzed with respect to the small size of the sample, the differences between the sexes in terms of depression in the face of specific stressors, and the variations by age groups in suicidal risk among the young. keywords depression; suicide; attempted suicide; cognition; nonparametric statistics (source: decs, bireme). 475 riesgo suicida según la tríada cognitiva negativa, ideación, desesperanza y depresión l ronald alberto toro-tobar y otros risco de suicídio segundo a tríade cognitiva negativa, ideação, desesperança e depressão resumo objetivo: estabelecer a relação entre ideação suicida, desesperança, tríade cognitiva negativa e depressão, como evidência do modelo cognitivo do risco de suicídio. método: estudo empírico-analítico com desenho descritivo, correlacional e comparativo. as variáveis foram medidas com os inventários bdi-ii, pansi e itc e a escala bhs. a amostra final esteve constituída por 90 pessoas de ambos os sexos, com uma média de idade de 24,2 anos (dt = 8,65 anos) pertencentes a diversos níveis socioeconômicos, com estudos universitários, principalmente. resultados: encontraram-se correlações estatisticamente significativas entre ideação suicida, desesperança, depressão e a tríade cognitiva negativa. as diferenças foram significativas entre os grupos depressivos e não depressivos, com grandes efeitos para as três variáveis cognitivas. interpretação e conclusões: estes resultados constituem nova evidência do modelo cognitivo proposto a respeito da relação entre as variáveis depressão, tríade cognitiva negativa, ideação suicida e desesperança, tal como se propôs em diferentes revisões sobre cognição negativa e suicídio. analisaram-se as limitações do estudo no que se refere ao reduzido tamanho da amostra e as diferenças entre sexos para depressão diante de estressores específicos, e as variações por grupos de idades em no risco de suicídio dos jovens. palavras-chave cognição; depressão; estatísticas não paramétricas; suicídio; tentativa de suicídio (fonte: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 473-486 476 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 introducción el suicidio es definido como “el acto voluntario con resultado fatal con el conocimiento y fin de un cambio deseado” (1). en la clasificación internacional de las enfermedades, undécima revisión cie11 (2), se define como la muerte por lesión autoinfligida, deliberadamente iniciada por la persona. a su vez, la conducta suicida es toda acción dirigida a quitarse la vida, que va desde la intención e ideación hasta el intento; esta se ha relacionado a menudo con la depresión y la desesperanza, particularmente con una visión pesimista y generalizada del futuro, cuya relación se buscó de manera empírico-analítica en el presente trabajo de investigación. así, el suicidio como acto voluntario debe ser visto a la luz de estos dos constructos clave, ambos relacionados desde la investigación psicopatológica como derivados del síndrome depresivo, aunque dicha relación no es clara aún y requiere de mayores aportes de datos. ideación suicida y riesgo suicida la organización mundial de la salud (oms) define la ideación suicida (is) como aquellos pensamientos pasivos sobre querer estar muerto, o los pensamientos activos sobre asesinarse a sí mismo, no acompañados de conductas de preparación para ello. las is son aquellos pensamientos negativos que se constituyen principalmente por fantasías de muerte, es decir pensamientos, ideas, deseos e intenciones de servirse como agente de la propia muerte (1), además de inconformidad con la vida, preocupaciones con utopías autodestructivas y maquinación de planes explícitos y estructurados para matarse (3). la is es un factor de riesgo asociado a trastornos depresivos, consumo de sustancias, abuso de alcohol, violencia, sensación de pérdida, influencia del contexto; problemas académicos, financieros e interpersonales, dolor crónico e indefensión, violencia y dolor psicológico (4-10). al parecer, la edad avanzada se asocia al incremento de la is por las condiciones sociodemográficas propias de esta etapa de la vida, particularmente ante eventos estresantes como pérdidas, enfermedades crónicas, aislamiento o soledad, e indefensión por sus condiciones físicas, mentales y económicas (11). desde el modelo cognitivo, rush y beck (12) afirmaron que estas ideas responden al querer terminar con estados de angustia producidos por problemas o situaciones que se creen irresolubles e insoportables, y estos a su vez se derivan de la tríada cognitiva negativa (un yo imperfecto, un mundo hostil y despiadado, y un futuro desesperanzador). la is, por tanto, es todo pensamiento que tiene un contenido altamente relacionado con la muerte autoinfligida, ligado a situaciones de desespero e inconformidad con la vida. wenzel, brown y beck la definieron como “aquellos pensamientos, imágenes, creencias, voces u otras cogniciones reportadas por el individuo acerca de la intencionalidad de terminar con su propia vida” (13). investigaciones al respecto sustentan la aparición de is en condiciones específicas de riesgo. por ejemplo, las variables sociales (funcionamiento familiar, ajuste escolar y victimización escolar) y personales influyen en la aparición de is, lo que indica asociaciones entre variables personales como alimentación, tendencias depresivas, victimización escolar, comportamientos antisociales, baja autoestima y autoeficacia, y los actos suicidas. además, la cohesión o unión familiar están estrechamente relacionadas con la is de los adolescentes, es decir, en familias desunidas o con baja cohesión hay mayor is, lo que representa un mayor riesgo suicida (14-19); variables como el uso de drogas ilegales y aislamiento han tenido también evidencia reciente (20, 21). se puede afirmar, por tanto, que la is está precedida por variables psicosociales, familiares y personales, y puede dar lugar a comportamientos autolesivos que constituyen alto riesgo suicida (22-24). en población geriátrica se han reportado índices elevados de riesgo e is ante hospitalización, viudez, desempleo, conflictos, muerte de familiares y personas cercanas y aislamiento (25, 6), lo que ha sido relevante en el desarrollo de políticas públicas frente a la prevención de esta problemática social (26). desesperanza y riesgo suicida la desesperanza es fundamentalmente una creencia según la cual se considera un futuro no viable y de problemas que nunca se podrán resolver (13), donde la persona percibe una imposibilidad de lograr algo en el presente o el futuro, además de constantes imposibilidades, lo cual genera resignación y abandono de ambiciones y sueños. desde la teoría de la indefensión se afirma que las personas con probabilidad de depresión por desesperanza presentan atribuciones estables, globales e internas, dando lugar a cogniciones asociadas a expectativas de no poder conseguir lo que se desea o que sucederán cosas estrepitosamente indeseables, a las cuales no se podrá responder de una forma eficaz (27). la desesperanza como un predictor del suicidio se ha estudiado desde diferentes posturas. los investigadores han determinado que durante la is la desesperanza se presenta con mayor 477 riesgo suicida según la tríada cognitiva negativa, ideación, desesperanza y depresión l ronald alberto toro-tobar y otros intensidad y esto a su vez hace que se mantenga la ideación y el riesgo suicida, lo cual establece que este sentimiento es un factor importante en la conducta suicida (28-30). además, se ha indicado que los acontecimientos negativos de la vida influyen directamente sobre la desesperanza y el aislamiento, y estos a su vez intervienen de manera positiva sobre el riesgo de cometer actos suicidas (31, 32). escalas como el inventario de depresión y desesperanza de beck han demostrado precisión predictiva en los intentos suicidas (33). depresión y riesgo suicida la depresión se define como un trastorno mental que se caracteriza por la presencia de tristeza, pérdida de placer, sentimientos de culpa y baja autoestima, acompañado de alteraciones en el patrón de sueño y el apetito, sensación de cansancio y falta de concentración, que puede llegar a hacerse crónico y recurrente, hasta dificultar el desempeño en las labores de la vida cotidiana; cuando es leve puede ser tratada con psicoterapia, pero cuando es moderada o grave se pueden necesitar medicamentos y otros apoyos profesionales. además, en su forma más grave, puede conducir al suicidio (1, 13). según la american psychiatric association (apa) (34), en el manual diagnóstico y estadístico de los trastornos mentales, quinta versión (dsm-v), aparecen síntomas adicionales como pérdida de interés en todas o casi todas la actividades, indecisión, malestar que afecta en casi todas las esferas del individuo. para la oms (2), la depresión no responde estrictamente a cambios ambientales, ni suele variar de un día para otro, la forma en que se presenta depende del individuo puesto que puede estar oculta en un consumo exagerado de alcohol, un aumento de fobias y obsesiones preexistentes, intranquilidades hipocondriacas o comportamientos histriónicos. además, es posible que se presenten expectativas pesimistas del futuro y pensamientos o acciones autolesivas. según el modelo cognitivo tradicional, la depresión inicia y se mantiene por la interpretación que hace la persona de sí misma, el mundo y el futuro, proceso que beck (35) definió como tríada cognitiva negativa, la cual consiste en que el individuo presenta tres percepciones erróneas: una cognición negativa de sí mismo, un mundo despiadado y violento, y un futuro devastador y desesperanzador (36, 37); esto lleva a que la persona considere que todo en la vida es malo y que no hay razón para luchar, por ello la depresión se ha considerado como un predictor significativo de llegar a cometer actos suicidas (13). este modelo, basado en esquemas, resalta el papel fundamental de las representaciones mentales que el individuo hace de sí mismo y el entorno, constituido a partir de las experiencias almacenadas en la memoria que posteriormente evoca en situaciones futuras, conformando una tríada cognitiva negativa. los esquemas tienen un contenido particular y una estructura cuya interconexión se ha denominado modo; en la conducta suicida se afirma que el modo suicida se encuentra activo. el contenido esquemático se refiere a la experiencia almacenada y se compone de pensamientos y creencias, clasificados en tres niveles: uno básico denominado pensamientos automáticos; el segundo a ideas más estructuradas como criterios condicionales, actitudes y reglas (p. e. reglas lógicas de causalidad: siempre y cuando) llamados creencias intermedias, y el último constituye el nivel central como el autoconcepto, llamado creencias nucleares. la estructura, por otra parte, corresponde a la interrelación entre esquemas llamados modos, es decir, la cantidad de ideas relacionadas que por principios de economía cognitiva son las responsables del procesamiento de la información, fundamentalmente distorsionada a favor del funcionamiento esquemático, llamadas distorsiones cognitivas (38). la depresión se relaciona positiva y significativamente con el riesgo suicida, is y desesperanza (24); por ejemplo, un estudio que evaluó las is y distorsiones cognitivas en pacientes con bajo y alto riesgo, encontró que los pacientes con mayor riesgo presentaban mayores distorsiones, desesperanza y depresión en comparación con los grupos control (39). en las revisiones sistemáticas se ha encontrado que la depresión grave incrementa 2,2 veces el riesgo suicida (or = 2,20; ci 95 %: 1,05-4,60), de igual manera la desesperanza (or = 2,2; ci 95 %: 1,49-3,23) (40). en el contexto latinoamericano, durante la adaptación del “inventario de resiliencia ante el suicidio con jóvenes colombianos”, uno de los factores con mayor asociación con el riesgo suicida fue la depresión, con un 75 % de indicadores de conducta suicida (41). variables cognitivas en riesgo suicida las anteriores cifras muestran un panorama de las investigaciones en el contexto latinoamericano sobre las variables cognitivas asociadas al riesgo suicida como la depresión (42), 478 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 neuroticismo (43) e inflexibilidad cognitiva (44). estos modelos han obtenido evidencia en muestras conformadas en países como estados unidos, en especial en personal de las fuerzas armadas, en donde se han reportado relaciones entre is, síntomas depresivos, estrés postraumático y género (45, 46). sin embargo, la evidencia con muestras latinas o locales ha sido escasa. de forma similar, hay escasas investigaciones que soporten el modelo con poblaciones de diferentes edades. los estudios de revisión sobre las variables contextuales interpersonales, psicológicas, violencia intrafamiliar, abuso sexual y deficientes estrategias de afrontamiento han concluido que el suicidio es multicausal, que ha ido en aumento con las problemáticas recientes como el acoso escolar y trastornos de la conducta alimentaria, además de otras características de la conducta depresiva como la “desesperanza, vacíos existenciales, baja autoestima, desequilibrios psíquicos” (36), donde un bajo autoconcepto y los altos niveles de depresión explican la presencia de ideación suicida en los jóvenes (5, 40, 47). factores como el dolor psicológico (psychache), desesperanza y deseos de escape se han identificado como los principales motivos de los intentos suicidas (48). el objetivo del estudio, luego de la revisión documentada, fue establecer la relación entre ideación suicida, desesperanza, depresión y tríada cognitiva negativa, como evidencia del modelo cognitivo del riesgo suicida a partir de la correlación entre variables y comparaciones entre grupos sintomáticos y no sintomáticos, que se constituya como un soporte para el desarrollo de programas de intervención basados en la prevención de las muertes a distintos niveles. método diseño el tipo de estudio fue empírico-analítico con diseño descriptivo, correlacional y comparativo. las variables tenidas en cuenta fueron la sintomatología depresiva, is, desesperanza y tríada cognitiva (visión negativa de sí mismo, el mundo y el futuro), a partir de las siguientes hipótesis: 1) los participantes con altos niveles de sintomatología depresiva presentan altos niveles de is, desesperanza y tríada cognitiva negativa; 2) los participantes con altos niveles de is presentan altos niveles de desesperanza; y 3) los grupos depresivos se diferencian significativamente de los no depresivos en cuanto a desesperanza, is y tríada cognitiva. participantes la muestra final estuvo constituida por 90 personas de ambos sexos, seleccionadas por muestreo no probabilístico por conveniencia incidental en la ciudad de bogotá d.c. (colombia), con una media m = 24,2 años (dt = 8,65 años), un mínimo de 18 y un máximo de 52 años de edad, etapa del ciclo vital correspondiente a la adultez joven e intermedia, pertenecientes a diversos niveles socioeconómicos (estratos bajo-bajo, bajo, medio-bajo, medio, medio-alto y alto), con predominancia del estrato medio (56,7 %) y niveles educativos universitarios (78,9 %) principalmente. entre los criterios de inclusión se tuvo en cuenta que no estuviesen bajo los efectos de sustancias psicoactivas, ni reportar algún diagnóstico de trastorno psicótico en la actualidad, ni estar en estados iniciales de duelo. instrumentos medida de los niveles de sintomatología depresiva inventario de depresión de beck, segunda edición (bdi-ii). es un inventario de autoinforme, el cual tiene como objetivo medir la severidad de la depresión en adolescentes y adultos, sean o no psiquiátricos, mediante 21 ítems que evalúan síntomas de tristeza, pensamiento, fracaso, pérdida de placer, sentimiento de culpa y castigo, disconformidad personal, autocrítica, llanto, agitación, pensamientos suicidas, indecisión, pérdida de interés y energía, desvalorización, indecisión, cambios en los hábitos de sueño, cambios en el apetito, irritabilidad, cansancio, dificultad de concentración y pérdida de interés en el sexo. el diseño original fue realizado por beck, steer y brown (49) y fue adaptado al español en argentina (50). el bdi-ii presenta una elevada consistencia interna (alpha de cronbach = 0,94), lo que lo hace confiable en los estudios basados en síntomas depresivos. en cuanto a la calificación de cada ítem, se debe puntuar en una escala de 0 a 3 según lo que mejor describa al respondiente en la última semana; la calificación máxima es de 63 puntos siguiendo la siguiente clasificación: 0 a 13 corresponde a depresión mínima; 14 a 19 depresión leve; 20 a 28 depresión moderada; y 29 a 63 se considera depresión severa. se ha recomendado este instrumento para ser aplicado a partir de los 13 años de edad. medida de la ideación suicida inventario de ideación suicida positiva y negativa (pansi). es un inventario adaptado por villalobos-galvis (51) del original 479 riesgo suicida según la tríada cognitiva negativa, ideación, desesperanza y depresión l ronald alberto toro-tobar y otros creado por osman, gutiérrez, kopper, barrios y chiros (52), compuesto por catorce ítems de los cuales seis miden ideación suicida positiva que corresponden a los factores protectores (por ejemplo “tuviste confianza en lograr tus metas en el futuro?” “¿sentiste que valía la pena vivir la vida?”), y ocho de ideación suicida negativa para medir factores de riesgo (por ejemplo “¿pensaste en matarte porque no pudiste hacer algo que era muy importante en tu vida?”, “¿pensaste en matarte porque viste que tu vida era un fracaso?”). el pansi se diligencia teniendo en cuenta las dos últimas semanas respondiendo a qué tan frecuente se presentó la ideación de acuerdo con una escala que va de 0 a 4 (0 es nunca y 4 siempre). en la calificación se interpreta un alto riesgo suicida si la puntuación total es mayor a 9. este instrumento presentó una adecuada validez convergente con la escala de ideación suicida de roberts (is-cesd) (r = 0,42, p < 0,01) y un favorable índice de consistencia interna alfa de cronbach = 0,89. medida de la desesperanza escala de desesperanza de beck (bhs). la bhs fue creada por beck, weissman, lester y trexler (53) y ha sido adaptada a varios idiomas y contextos; para este estudio se usó la versión traducida y validada por mikulic, cassullo, crespi y marconi (54), la cual está compuesta por 20 reactivos diseñados para determinar la falta de esperanza que las personas tienen acerca de sus vidas, en tres factores: sentimientos sobre el futuro (ítems 1, 6, 13, 15 y 19), pérdida de la motivación (ítems 2, 3, 9, 11, 12, 16, 17 y 20) y expectativas sobre el futuro (ítems 4, 7, 8, 14 y 18), con ítems con formato de respuesta dicotómica (verdadero y falso) tales como “mejor me doy por vencido ya que nada puedo hacer para mejorar mi vida”, “mi futuro parece oscuro” y “las cosas nunca me salen como yo quiero que me salgan”. este instrumento interpreta la desesperanza según la sumatoria directa obtenida: 0 a 3 puntos corresponde a un nivel asintomático, 4 a 8 puntos es leve, 9 a 14 puntos es moderada y 15 a 20 puntos es severa. entre sus propiedades psicométricas presentó márgenes aceptables de consistencia interna (alfa de cronbach = 0,78) y unas adecuadas medidas convergentes con el bdi-ii (r = 0,43, p < 0,05) y el ítem de pesimismo del bdi-ii (ítem 2, r = 0,64, p < 0,01). medida de la visión de sí mismo, el mundo y el futuro (tríada cognitiva) inventario de la tríada cognitiva. es un instrumento elaborado por beckham, leber, watkins, boyer y cook (55) que permite determinar cómo se encuentra el paciente en autopercepción (ítems 5, 10, 13, 17, 21, 25, 29, 31, 33 y 35), visión del mundo (ítems 3, 8, 12, 18, 20, 23, 24, 27, 30 y 34) y visión del futuro (ítems 6, 9, 11, 15, 16, 19, 26, 28, 32 y 36), con ítems como “no tengo solución”, “el mundo es un lugar muy hostil” y “mi futuro es tan horroroso que no puedo ni pensar en él”. está compuesto por 36 ítems ante los cuales quien responde debe marcar con una “x” si está totalmente de acuerdo, moderadamente de acuerdo, ligeramente de acuerdo, neutro, ligeramente en desacuerdo, moderadamente en desacuerdo y totalmente en desacuerdo. la calificación se realiza puntuando de 1 a 7 (izquierda a derecha) la respuesta teniendo en cuenta los ítems invertidos y realizando la sumatoria entre números positivos y negativos. la interpretación se elabora teniendo en cuenta que entre más bajo (más negativo) sea el índice total obtenido, mayor es la visión negativa general obtenida. entre sus propiedades psicométricas obtuvo un favorable índice de consistencia interna alfa de cronbach = 0,95 y una adecuada validez convergente con el bdi (r = 0,67, p < 0,01). procedimiento el estudio se llevó a cabo inicialmente con la identificación de las características conceptuales del trastorno depresivo, tríada cognitiva negativa, ideación suicida y desesperanza, como variables cognitivas en la conducta suicida. a continuación, se convocaron los participantes posterior a una revisión de los criterios de inclusión y exclusión, además de la firma del consentimiento informado aprobado por el comité de ética de la institución universitaria, en el cual se consignaron indicaciones acerca de los riesgos, la confidencialidad y los beneficios de la investigación de manera clara y precisa, así como garantizar el trato digno, protector de los derechos y el bienestar, asegurando que los riesgos sean mínimos. en la fase siguiente se estableció el nivel de depresión, ideación suicida, desesperanza y tríada cognitiva negativa en los participantes, para posteriormente dividir los grupos sintomáticos depresivos y no depresivos según las puntuaciones altas y bajas en el bdi-ii para llevar a cabo los análisis comparativos. se concluyó la investigación con el análisis de los datos obtenidos en cuanto a correlaciones como comparaciones a la luz de la evidencia empírica. plan de análisis de resultados el análisis de los datos obtenidos se realizó por medio del software spss versión 21. en primera instancia, se hizo un análisis estadístico descriptivo de las variables sociodemográficas 480 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 como la edad (media, máximo, mínimo y desviación típica), sexo (frecuencia y porcentajes), estrato socioeconómico, estado civil y escolaridad (frecuencias y porcentajes). posteriormente, se realizó una prueba de adecuación de la muestra mediante el test kolmogorov-smirnov para poder realizar las correlaciones mediante el r de pearson entre las variables. finalmente, se analizaron las diferencias entre grupos depresivos y no depresivos con una prueba t de student y el tamaño del efecto con la d de cohen (56) para conocer los posibles alcances del estudio, teniendo en cuenta que para las investigaciones en el área clínica y educación, resultados alrededor de una d = 0,30 pueden ser relevantes y deben ser tenidos en cuenta puesto que están ligados a elevadas fuentes ajenas de varianza como la confiabilidad y validez de los instrumentos, la complejidad de las situaciones o incluso la interacción entre variables (57). resultados resultados descriptivos se hizo un análisis descriptivo de las variables sociodemográficas como edad, sexo, estrato socioeconómico, estado civil y escolaridad (tabla 1). se obtuvo para este estudio una muestra compuesta por un 78,9 % de población femenina, con un nivel socioeconómico predominante medio, con un total de 51 personas equivalentes al 56,7 %, con estado civil solteros (82,2 %) y un nivel de escolaridad predominantemente universitario (n = 71), el cual corresponde a un 78,9 % de la muestra total. por otra parte, se evidenció que en el bdi-ii se obtuvo una m = 11,47 (dt = 7,26) con un máximo de 33 puntos, en el pansi se obtuvo una m = 6,56 (dt = 4,64) con un máximo de 25, a su vez, en el bhs una m = 1,54 (dt = 1,76) con un máximo de 9, y finalmente, en el itctotal se obtuvo una m = -62,05 (dt = 22,83) con un máximo de 30 puntos (tabla 2). resultados correlacionales y comparativos posteriormente, se realizó una prueba de adecuación de la muestra mediante el test kolmogorov-smirnov, en la cual las variables estuvieron ajustadas a la curva normal (p ≥ 0,05). se procedió entonces a obtener las correlaciones entre variables mediante el r de pearson que es una medida que representa la tabla 1 estadísticos descriptivos obtenidos de la muestra total (n = 90) variable valor n % sexo hombres mujeres 19 71 21,1 78,9 edad años m: 24,2 años dt: 8,65 años mínimo 18, máximo 52 100 estrato socioeconómico 1. bajo-bajo 2. bajo 3. medio-bajo 4. medio 5. medio-alto 6. alto sin dato 1 4 25 51 9 0 0 1,1 4,4 27,8 56,7 10,0 0 0 estado civil 1. soltero 2. casado 3. unión libre 4. separado 5. viudo sin dato 74 7 6 3 0 0 82,2 10,6 7,8 6,7 3,3 0 escolaridad 1. sin estudio 2. primaria 3. secundaria 4. técnica 5. superior sin dato 0 3 10 4 71 2 0 3,3 11,1 4,4 78,9 2,2 n: frecuencia, m: media, dt: desviación típica fuente: elaboración propia. relación lineal entre dos variables. en la tabla 2 se presentan las correlaciones entre las variables del estudio; dentro de las más significativas fueron la ds según el ítem 2 del bdi-ii con la is según el pansi (r = 0,43, p < 0,01), la ds medida con el bhs que correlacionó significativamente con la is según el ítem 9 del bdi-ii y el pansi (r = 0,41, p < 0,01 y r = 0,43, p < 0,01 respectivamente); de igual forma, la is (ítem 9) y el pansi con el itctotal (r = 0,44, p < 0,01 y r = 0,55, p < 0,01 respectivamente), el itcfuturo con el pansi y el bhs (r = 0,55, p < 0,01 y r = 0,43, p < 0,01 respectivamente). es destacable que la única medida que tuvo una correlación alta con la depresión fue en el itc futuro (r = 0,49, p < 0,01). 481 riesgo suicida según la tríada cognitiva negativa, ideación, desesperanza y depresión l ronald alberto toro-tobar y otros tabla 2 correlaciones de pearson entre las variables sintomáticas y cognitivas (n = 90) variables 1 2 3 4 5 6 7 8 9 sintomatología depresiva 1. bdi-ii ideación suicida 2. i9 0,34** 3. pansi 0,37** 0,62** desesperanza 4. i2 0,36** 0,22* 0,43** 5. bhs 0,31** 0,41** 0,43** 0,02 visión negativa de sí mismo, el mundo y el futuro (tríada cognitiva negativa) 6. itc total 0,37** 0,44** 0,55** 0,31** 0,41** visión de sí mismo 7. itc si mismo 0,29** 0,34** 0,41** 0,21* 0,27** 0,89** visión del mundo 8. itc mundo 0,49** 0,40** 0,51** 0,34** 0,38** 0,89** 0,68** visión del futuro 9. itc futuro 0,01 0,43** 0,55** 0,27** 0,43** 0,89** 0,75** 0,66** media 11,47 0,14 6,56 0,17 1,54 -62,05 -26,74 -13,5 -21,81 dt 7,26 0,35 4,64 0,38 1,76 22,83 7,96 9,63 7,94 nota: * p < 0,05; ** p < 0,01, bdi-ii: inventario de depresión de beck, segunda edición, i2: ítem 2 del bdi-ii, indicador de desesperanza, i9: ítem 9 del bdi-ii, indicador de ideación suicida, pansi: inventario de ideación suicida positiva y negativa, bhs: escala de desesperanza de beck, itc: inventario de la tríada cognitiva, dt: desviación típica fuente: elaboración propia. a continuación, para identificar diferencias entre personas depresivas y no depresivas en cuanto a ideación suicida, desesperanza y tríada cognitiva negativa, se llevó a cabo una prueba t de student la cual es un método que permite evidenciar la existencia de diferencias significativas entre los datos obtenidos de dos grupos en la evaluación de una variable. en la tabla 3 se presentan los grupos comparados, los cuales evidenciaron diferencias estadísticamente significativas (p < 0,01). en la prueba del tamaño del efecto de cohen (56), denominada así para explicar “en qué grado la hipótesis nula es falsa” (57), los tamaños fueron grandes según el criterio del mismo cohen ya que oscilaron entre 0,57 y 0,64 con unos r entre 0,27 y 0,30, indicadores adecuados de relación entre las variables dependientes y los dos grupos evaluados. discusión el objetivo del presente estudio fue determinar la relación entre cognición según la ideación suicida, desesperanza, depresión y tríada cognitiva negativa como evidencia del modelo cognitivo del riesgo suicida. a partir de los resultados obtenidos, se puede afirmar que constituyen nueva evidencia del modelo planteado a partir de las variables evaluadas, tal como se ha propuesto en distintas revisiones sobre cognición negativa y suicidio (13, 27, 48). estos hallazgos coinciden con los reportados en investigaciones similares en las que se encontraron correlaciones positivas y significativas entre depresión y riesgo suicida (16, 25), lo que permite afirmar lo planteado en la hipótesis 1 del estudio, en la cual se señaló que posiblemente las conductas suicidas están estrechamente relacionadas con la depresión clínica (40, 58), y se constituye como evidencia para la evaluación de un elevado riesgo suicida, tal como se encontró en las diferencias t estadísticamente significativas en el presente estudio. se resalta, a su vez, que la correlación positiva obtenida entre desesperanza e is resultó acorde con los hallazgos reportados por smith, alloy y abramson (27) desde el modelo de depresión 482 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 por deseperanza, aspecto que apoya la aceptación de la segunda hipótesis del estudio. semejantes resultados se han reportado en las conclusiones en estudios llevados a cabo en distintas poblaciones (etnias distintas, asiáticos, rangos de edad) (16, 29, 30) sobre la relacion positiva y significativa entre estas dos variables, por tanto se puede afirmar que la is es más probable que se presente en personas con desesperanza, visión negativa de sí mismos, del mundo y del futuro, como componentes cognitivos de la depresión según el modelo explicativo de este trastorno (12, 39), donde aparece un continuo que inicia con las cogniciones negativas (tríada), sigue con desesperanza y termina con is (13), aspecto que se puede evidenciar también en las diferencias significativas entre depresivos y no depresivos, tal como fueron planteadas en la tercera hipótesis del estudio. según el modelo teórico, los datos parecen informar acerca del funcionamiento esquemático disfuncional que da lugar a la aparición del síndrome depresivo, con la presencia de síntomas como la abulia (pérdida de voluntad), desesperanza (pesimismo y pérdida de control), no confirmación de evidencia positiva (filtros atencionales), sobrestimación de dificultades cotidianas, autofocalización en el fracaso y posterior is (13, 27, 59). clark et al. (6) resaltaron este conjunto sintomático en el cual sobresalen las cogniciones negativas a partir de la hipótesis de la primacía, en la cual la cognición cumple un papel mediador no causal con los síntomas motivacionales, conductuales, somáticos y afectivos. evidencias a favor del papel mediador de la cognición se encuentran en estudios que sugieren que la tríada cognitiva debe ser integrada en el modelo de depresión por desesperaza, teniendo en cuenta además los estilos cognitivos inferenciales, apuntando a la generación de un modelo explicativo integrador (60), con mayor soporte empírico y claridad conceptual (61), particularmente en su papel en el desarrollo de trastornos depresivos y su comorbilidad (62). limitaciones los hallazgos reportados en el presente estudio deben ser tenidos en cuenta a la luz de las siguientes limitaciones. en primer lugar, para futuros estudios se deben considerar las diferencias entre hombres y mujeres de las muestras utilizadas, puesto que evidencia reciente ha indicado que los hombres presentan mayor vulnerabilidad de desarrollar depresión ante estresores específicos, mientras que las mujeres varían únicamente en su estilo inferencial, como moderadores de la respuesta depresiva (63). en segundo lugar, el uso de muestras subclínicas las cuales han sido objeto de investigaciones sobre is. al parecer, la is es tabla 3 diferencias en ideación suicida, desesperanza y tríada cognitiva negativa en depresivos y no depresivos pansi bhs itctotal m (dt) t (gl) (sig. bilateral) m (dt) t (gl) (sig. bilateral) m (dt) t (gl) (sig. bilateral) depresión depresivos (n = 37) 0,34 -1,27 2,72 -88 -0,008 2,18 -2,02 3,03 -88 -0,003 -54,21 -21,46 2,82 -88 -0,006no depresivos (n = 53) -0,26 -0,85 1,09 -1,4 -67,52 -22,34 d de cohen r 0,64 0,3 0,6 0,28 0,57 0,27 m: media, dt: desviación típica, t : t de student, pansi: inventario de ideación suicida positiva y negativa, bhs: escala de desesperanza de beck, itc: inventario de la tríada cognitiva, d de cohen: estadígrafo para determinar el tamaño del efecto en comparación de muestras no relacionadas. una puntuación superior a 0,60 es considerada grande; r: r de pearson para determinar la relación entre los grupos y las variables comparadas. fuente: elaboración propia. 483 riesgo suicida según la tríada cognitiva negativa, ideación, desesperanza y depresión l ronald alberto toro-tobar y otros más frecuente en jóvenes universitarios (54, 11) y no se limita a depresiones graves o profundas (55), también se evidencia un notable incremento de riesgo en personas pertenecientes a grupos raciales minoritarios (64) y población infantil (65, 66). en tercer lugar, otro elemento para el desarrollo de futuras investigaciones es tener en cuenta variables cognitivas adicionales que permitan complementar el modelo cognitivo del riesgo suicida, tales como la perspectiva hacia el futuro (future time perspective ftp), la cual ha demostrado servir como atenuador de la motivación suicida con síntomas depresivos y desesperanza (67). en cuarto lugar, con el objetivo de generar un mayor alcance de los resultados y la generalización de los mismos a nivel poblacional, se recomienda elaborar replicaciones con un tamaño muestral mayor siguiendo métodos específicos de muestreo que permitan abarcar diferentes grupos poblacionales. de igual manera, presentar los niveles de confiabilidad y validez de los instrumentos usados en el estudio, con el fin de contar a futuro con datos de adaptación al contexto local de los mismos, y así reducir las fuentes de error en la investigación. conclusiones los factores cognitivos desadaptativos, como la tríada cognitiva negativa, la desesperanza y la is son elementos derivados de la activación de modos disfuncionales que guían el procesamiento de la información en los casos de depresión y conducta suicida. el estudio expuesto, por tanto, se presenta como nueva evidencia acerca de la relación entre estos constructos que constituyen el riesgo suicida desde el modelo cognitivo explicativo. estos hallazgos permitirán, a futuro, servir de soporte empírico para el desarrollo de programas de promoción en salud mental y prevención de la conducta suicida, basados en la detección de los signos de alarma a nivel cognoscitivo en los cuales se identifiquen las cogniciones relacionadas con una visión negativa de sí mismos, de los demás y del futuro, acompañada de desesperanza y la aparición de is, la cual contiene el deseo de muerte e incluso la elaboración de un plan estructurado de muerte por suicidio, siempre y cuando se mantengan enfocados hacia la disminución del riesgo suicida y estén acompañados de una permanente intervención multidisciplinar. referencias 1. world health organization (who). for which strategies of suicide prevention is there evidence of effectiveness? copenhagen: who regional office for europe; 2012. 2. maj m, reed gm. 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universidade federal de santa maria, brasil. margridbeuter@gmail.com 4 universidade federal de pelotas, brasil. elena_meeg@hotmail.com 5 universidade federal de pelotas, brasil. aline_feijo@yahoo.com.br 6 universidade federal de pelotas, brasil. giani_cd@hotmail.com recibido: 16 de agosto de 2014 enviado a pares: 20 de octubre de 2014 aceptado por pares: 07 de marzo de 2015 aprobado: 27 de junio de 2015 doi: 10.5294/aqui.2016.16.1.9 para citar este artículo / to reference this article / para citar este artigo santos bp, schwartz e, beuter m, echevarría me, feijó am, duarte gc. transplante renal: análise comportamental a partir da técnica dos incidentes críticos. aquichan. 2016; 16 (1): 83-93. doi: 10.5294/aqui.2016.16.1.9 resumo objetivo: identificar os comportamentos das pessoas com o transplante renal empregando a técnica dos incidentes críticos. método: estudo com abordagem qualitativa do tipo descritivo utilizando a técnica dos incidentes críticos. os dados foram coletados por meio de entrevista semiestruturada e foram relacionados o perfil socioeconômico dos entrevistados e os incidentes críticos identificados. fizeram parte do estudo 20 pessoas, dez homens e dez mulheres. resultados: os resultados apontaram a ocorrência de 141 comportamentos, 108 positivos e 33 negativos, relacionados ao cuidado adotado à saúde, às atividades cotidianas e à vida com o transplante renal. conclusões: a aplicação da técnica dos incidentes críticos permitiu obter dados sobre o modo como o transplante renal influencia determinados comportamentos, positiva e negativamente, na vida da pessoa. palavras-chave insuficiência renal crônica; transplante de rim; comportamento; enfermagem (fuente: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 83-93 84 aquichan issn 1657-5997 año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 83-93 trasplante renal: análisis conductual desde la técnica de los incidentes críticos resumen objetivo: identificar las conductas de las personas con el trasplante renal utilizando la técnica de los incidentes críticos. método: estudio con abordaje cualitativo de tipo descriptivo empleando la técnica de los incidentes críticos. se recolectaron los datos por medio de entrevista semiestructurada y se relacionaron el perfil socioeconómico de los entrevistados y los incidentes críticos identificados. participaron en el estudio 20 personas, diez hombres y diez mujeres. resultados: los resultados señalaron que la ocurrencia de 141 conductas, 108 positivas y 33 negativas, relacionadas al cuidado adoptado a la salud, las actividades cotidianas y la vida con el trasplante renal. conclusiones: la aplicación de la técnica de los incidentes críticos permitió obtener datos acerca del modo como el trasplante renal influye determinadas conductas, positiva y negativamente, en la vida de la persona. palabras clave insuficiencia renal crónica; trasplante de riñón; conducta; enfermería (fuente: decs, bireme). 85 transplante renal: análise comportamental a partir da técnica dos incidentes críticos l bianca pozza dos santos e outros kidney transplants: behavioral analysis based on the critical incident technique abstract objective: identify the behavior of people with kidney transplants, using the critical incident technique. method: this is a qualitative, descriptive study based on the critical incident technique. the data were collected through semi-structured interviews, and the socioeconomic profile of the respondents was associated with the identified critical incidents. there were 20 participants: ten men and ten women. results: the results showed the occurrence of 141 behavioral responses (108 positive and 33 negative) related to the care adopted with respect to health, daily activities and living with a kidney transplant. conclusions: application of the critical incident technique provided data about the way a kidney transplant influences certain behavior in a person’s life, both positively and negatively. keywords chronic kidney failure; kidney transplant; behavior; nursing (source: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 83-93 86 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 introdução a insuficiência renal crônica (irc) consiste em um importante problema de saúde pública, caracterizada por resultados insatisfatórios de saúde e gastos elevados com a doença (1). trata-se de um desafio global que afeta principalmente pessoas mais idosas (2). tal enfermidade é clinicamente definida por uma taxa de filtração glomerular <15 ml/min/1,73 m2. os sintomas incluem edema, especialmente ao redor da face, antebraços, cotovelos e tornozelos causados pelo acúmulo de fluidos tóxicos, além de fadiga, cãibras, náuseas e prurido intenso (3). com a instalação da irc, também há alteração na rotina cotidiana em decorrência das frequentes consultas de saúde, do cumprimento do tratamento, da restrição alimentar e da limitação na execução de determinadas tarefas, em especial, aquelas que exigem esforços físicos, pois as pessoas podem se sentir fracas e cansadas (4). dessa forma, a experiência da pessoa com a doença é particular e complexa, além de ser caracterizada por intervenções médicas de longo prazo e terapias renais substitutivas, como diálise e transplante (3). o transplante renal é um tratamento de escolha para as pessoas com irc (5). no entanto, para alguns autores, esse tratamento é considerado uma necessidade para a maioria dessas pessoas (6) já que melhora o funcionamento fisiológico do corpo humano por normalizar a função renal (7). assim, o processo de transplantação possui um efeito transformador nas pessoas e nos seus familiares, e pode significar o retorno da qualidade de vida (8). ao contrário da hemodiálise e da diálise peritoneal, o transplante renal pode proporcionar uma melhor qualidade de vida. entretanto, está sujeito a ser compreendido, erroneamente, como a cura definitiva da doença renal. nesse caso, a pessoa poderá negligenciar condutas que são essenciais para os bons resultados dessa modalidade terapêutica, o que pode levar ao comprometimento do órgão transplantado (9). destaca-se que o comportamento adotado pelas pessoas, após a realização do transplante renal, também poderá estar diretamente relacionado ao contexto vivenciado. neste estudo, entende-se como comportamento o conjunto de eventos realizados pela pessoa a partir da sua condição de transplantada. ao definir essa palavra, observa-se a sua complexidade semântica, pois é usada de diversas maneiras no meio científico e no cotidiano (10), e constitui-se nas ações de um indivíduo observáveis objetivamente. nesse contexto, a técnica dos incidentes críticos (tic) tratase de um procedimento importante para a obtenção de dados sobre o comportamento de uma pessoa que vivencia determinada situação (11). sua aparição foi atribuída a john c. flanagan, após publicar, em 1954, um artigo no periódico científico psychological bulletin, no qual detalhava a utilização desse método. flanagan era um psicólogo que trabalhava no instituto americano de pesquisa e na universidade de pittsburgh, durante a década de 1940 (12-13). a tic ganhou repercussão por ter iniciado na área da psicologia, que estuda o comportamento humano, e passou a conquistar outros campos de atuação profissional (14). dentre estes, situase a área da saúde, na qual se pode afirmar que a instalação de uma doença crônica acarreta mudanças no modo de viver da pessoa. como é o caso da irc, que, pela sua fisiopatologia e pelo tratamento imposto, ocorrem importantes e significativas adaptações à vida (15), o que causa limitações e alterações de amplo impacto (4). a utilização da tic, neste estudo, visa ao conhecimento dos comportamentos das pessoas com irc a respeito do transplante renal. salienta-se que tal metodologia auxilia na obtenção do conhecimento dessas atitudes específicas, no intuito de fazer observações e avaliações necessárias (16), que possam levar à adoção de medidas para assessorar, profissionalmente, aquelas que se mostrarem negativas e ressaltar as que forem positivas, de modo a ajudar outras pessoas que vivenciam o transplante renal. na enfermagem, a tic vem contribuindo para o processo metodológico de pesquisas que possuem caráter qualitativo devido à sua capacidade em compreender a subjetividade das pessoas (17) que vivenciam o transplante renal. dessa maneira, pode-se afirmar que ela permite conhecer o comportamento humano a fim de facilitar a tomada de estratégias para a solução de problemas práticos (18-19). para a elaboração do presente estudo, teve-se como questão norteadora: quais os comportamentos manifestados pelas pessoas com o transplante renal? salienta-se que, na literatura, não foram encontrados estudos qualitativos que abordassem essa temática, principalmente que utilizassem a tic. portanto, justifica-se este trabalho já que seus resultados podem repercutir de maneira positiva no cuidado e na qualidade de vida das pessoas transplantadas. assim, o objetivo foi identificar os comportamentos das pessoas com o transplante renal. 87 transplante renal: análise comportamental a partir da técnica dos incidentes críticos l bianca pozza dos santos e outros materiais e métodos estudo de abordagem qualitativa de tipo descritivo. o método utilizado foi a tic, para o qual se sugere a análise do conteúdo das entrevistas (20). na sua aplicação, são percorridos cinco passos: 1) estabelecimento do objetivo geral do estudo; 2) desenvolvimento de um plano para a coleta das informações; 3) coleta dos dados (incidentes críticos); 4) agrupamento, categorização e levantamento das frequências dos comportamentos positivos e negativos; 5) interpretação dos dados (18). o período da coleta de dados foi de 20 de maio a 10 de julho de 2013. foram entrevistadas pessoas adultas que se encaixaram nos seguintes critérios de inclusão: ter idade igual ou superior a 18 anos; concordar com a gravação da entrevista; aceitar a divulgação dos dados nos meios científicos; não apresentar dificuldades de comunicação verbal; estar vinculada ao serviço de nefrologia, em que realizava tratamento dialítico; ter, no mínimo, um ano de realização do transplante renal e ter sido submetida a algum tratamento dialítico anterior. após o recebimento da relação de transplantados, cedida pelos três serviços de nefrologia de um município da região sul do estado do rio grande do sul (brasil), realizou-se a primeira abordagem à pessoa com o transplante renal por meio do contato telefônico. nesse momento, lançou-se o convite para participar do estudo e, ao receber o aceite, foram agendados a data, o horário e o local das entrevistas. antes de iniciar a entrevista, foi apresentado o termo de consentimento livre e esclarecido (tcle). este foi lido juntamente com o entrevistado, de modo a esclarecer as dúvidas e os procedimentos utilizados para o desenvolvimento do estudo. em seguida, foi solicitada a assinatura em duas vias, uma para o entrevistado e a outra para a entrevistadora. para a coleta de dados, utilizou-se entrevista semiestruturada, composta por dois roteiros. no primeiro, constavam perguntas direcionadas à caracterização do perfil dos entrevistados: idade, sexo, raça, estado civil, escolaridade, ocupação, renda individual, religião, procedência, serviço de nefrologia, tempo da doença renal, motivo da doença renal, tipo(s) de tratamento(s) dialítico(s) realizado(s), tempo do atual transplante renal, local de realização do transplante renal e fonte do órgão transplantado. o segundo roteiro continha questões norteadoras que auxiliaram na obtenção dos incidentes críticos. seu conteúdo era composto de perguntas que abrangiam como foi a vida após a realização do transplante renal e, com a sua realização, o que foi considerado fácil e difícil; abordou-se como a pessoa se sentiu, reagiu e que efeitos tais acontecimentos acarretaram na sua vida. após a coleta de dados, as entrevistas foram transcritas e os conteúdos submetidos à análise de conteúdo preconizada pela tic, por meio de uma leitura minuciosa e contínua, na qual se almejou a identificação de comportamentos adotados pelos participantes a partir da sua condição de transplantado renal. a seguir, foram construídas categorias que envolviam similaridades entre si e que continham a denominação e a definição, o mais operacional possível, do que elas significaram ou representaram para a pessoa com o transplante renal. importante frisar que as categorias formuladas, a partir da análise recomendada pela tic, precisavam ser exaustivas (com a inclusão de todos os casos obtidos), reciprocamente exclusivas (cada caso deverá pertencer a uma só categoria), definidas operacionalmente, o que gera elevado grau de homogeneidade e coerência entre elas (20). o projeto recebeu parecer de aprovação do comitê de ética em pesquisa, sob o número 192/2013. foram respeitados os princípios da resolução 196/1996 do conselho nacional de saúde do ministério da saúde, a qual regulamenta a pesquisa que envolve seres humanos (21), além dos princípios éticos do código de ética dos profissionais de enfermagem, resolução 311/2007 do conselho federal de enfermagem (22). para preservar o anonimato dos participantes, eles foram identificados por um código: e de entrevistado, seguido do número arábico, conforme a sequência em que ocorreram as entrevistas, acrescidos da idade (por exemplo: e1, 43 anos). resultados foram entrevistadas 20 pessoas, dez homens e dez mulheres. a idade variou entre 30 e 66 anos, com predomínio da quinta década de vida. de acordo com a posição socioeconômica, a maioria dos transplantados renais (15 pessoas) se considerou da raça branca, enquanto 4 referiram ser negro e 1 pardo. quanto à religião, 9 eram católicos, 4 espíritas, 4 evangélicos, 1 umbandista e 2 alegaram não possuir crença alguma. referente ao estado civil, 10 afirmaram serem casados, 8 solteiros, 1 divorciado e 1 viúvo. 88 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 com relação à escolaridade, 5 possuíam o ensino fundamental incompleto, 2 o ensino fundamental completo, 4 o ensino médio incompleto, 4 o ensino médio completo, 1 o ensino técnico, 2 o ensino superior incompleto e 2 o ensino superior completo. a renda individual variou de nenhum a cinco salários-mínimos. sobre a situação ocupacional, grande parte mencionou ser aposentada; em seguida, destacou-se a realização de atividades domésticas. além disso, 19 pessoas residiam na zona urbana e 1 na zona rural. a respeito dos dados referentes à irc, o tempo da doença variou de 4 a 28 anos. as causas foram hipertensão, diabetes, rins policísticos, glomerulonefrite, atrofia renal, síndrome nefrótica, lúpus eritematoso sistêmico, sucessivas infecções renais e de garganta, fator hereditário e causa desconhecida. os tratamentos dialíticos realizados antes do transplante incluíram hemodiálise, modalidade terapêutica utilizada por 18 pessoas, e diálise peritoneal, somente por uma pessoa. ainda, houve um entrevistado que teve a oportunidade de vivenciar as duas formas de terapia renal substitutiva. todos realizaram o transplante uma única vez. os órgãos foram provenientes de doadores cadáveres (16 transplantados) e de doadores vivos relacionados (4 transplantados). o tempo do transplante compreendeu entre 1 ano e 9 meses até 10 anos e 3 meses. ao analisar os dados do presente estudo, constatou-se a ocorrência de 141 comportamentos, 108 positivos e 33 negativos. estes foram subdivididos em três categorias: os cuidados adotados com a saúde, as atividades cotidianas e a vida com o transplante renal, descritos a seguir. cuidados adotados com a saúde ao relatar os cuidados destinados à manutenção do transplante renal, os entrevistados manifestaram 61 comportamentos positivos e 14 negativos. esses comportamentos estavam relacionados com a alimentação, com a ingesta hídrica, com o uso das medicações, com as revisões de saúde, com o seguimento das orientações médicas, dentre outros. a seguir, apresentam-se alguns dos depoimentos que foram avaliados como positivos. cuido o sal, principalmente, é uma coisa que eu cuido muito. [...] a minha dieta é uma dieta bem equilibrada. [...] tomate é uma coisa que eu custo a comer, porque me lembro da quantidade de potássio. [...] as frutas eu sempre selecionei se tivesse menos potássio ou não. [...] como carne branca só, proteína é uma quantidade não muito grande. aliás, eu como menos do que me manda, porque não me faz falta e eu não faço questão [...]. carne vermelha, se eu for a um jantar e tiver carne vermelha eu como, senão não. (e7, 58 anos) [...] eu pego as minhas frutas, eu despejo tudo na pia, lavo tudo com sabão, com detergente, bastante água para botar de molho com gotinhas de vinagre, deixo escorrer, eu embalo uma a uma. tipo a maçã, principalmente, eu embalo uma a uma num papel insulfilme e guardo na geladeira. [...] eu me cuido, por causa de uma bactéria. (e9, 55 anos) eu tomo, no mínimo, dois litros d’água por dia [...]. é como se fosse um remédio, eu já tenho aquelas garrafinhas d’água e, aonde eu vou, eu procuro levar elas. (e16, 40 anos) [...] no celular estão gravados todos os horários [das medicações], que ele chega na hora, toca, eu vou lá e tomo [...]. mas se passar e eu esquecer de tomar, eu tomo na hora que eu lembrar, eu vou lá e tomo, eu não fico sem [...]. (e9, 55 anos) dizem que não precisaria ser tão rígido, mas eu me sinto muito melhor indo [consultas médicas], porque o meu médico [...] é uma maravilha, dez. eu vou lá, recarrego minhas baterias, converso com ele. [...] que, claro, a gente fica naquela tensão de manter, de fazer tudo direito para não ter perigo de rejeição [...]. eu faço exatamente o que ele me manda, se ele mandar eu comer pedra, eu vou comer pedra. (e7, 58 anos) os cuidados que eu tenho são os mínimos e é o necessário. agora, como eu sempre falo, se eu sinto alguma coisa, eu já procuro o auxílio, já procuro o médico e nunca faltei a uma consulta, nunca faltei a um exame, é isso que eu faço. (e16, 40 anos) além do cuidado alimentar e hídrico, do uso de medicamentos e do acompanhamento profissional de saúde, os entrevistados expuseram outros, relacionados a evitar exposição à chuva, a lugares fechados e a aglomerações de pessoas. claro, dia de chuva eu já não posso sair, tenho que me cuidar, fico em casa, mas são cuidados meus [...]. também, mesmo que não estivesse com o transplante, não iria me molhar de propósito. (e9, 55 anos) [...] a gente evita de estar em lugares fechados [...]. eu não ando no ônibus, eu não ando porque é muita gente. são esses cuidados que deve ter. (e10, 46 anos) 89 transplante renal: análise comportamental a partir da técnica dos incidentes críticos l bianca pozza dos santos e outros [...] tem vários cuidados, pó, principalmente, animais, várias coisas. tem que usar luva, máscara, quase sempre que eu vou fazer alguma coisa diferente ou eu estou em algum lugar diferente. (e15, 39 anos) a maioria dos comportamentos proferidos negativamente esteve vinculada à questão alimentar, muitas vezes, houve semelhanças entre os depoimentos. procurou-se, neste estudo, os que demonstrassem a deficiência de outros cuidados adotados com a saúde, como a limitação em ingerir a quantidade de água indicada e a ausência nas consultas indicadas. eu sei que um [litro d’água] eu tomo, mas dois [litros d’água], eu acho que não consigo. (e8, 50 anos) mas eu nunca fui muito de respeitar alimentação, [...] eu sempre fui meio guloso. [...] eu nunca fui a uma consulta com a nutricionista. eles marcavam e eu não ia, porque eu sei que ela [nutricionista] vai: “deve comer isso e isso. não pode comer isso”, e eu não vou seguir, então eu não vou. (e11, 54 anos) atividades cotidianas em relação às atividades cotidianas realizadas pelas pessoas após o transplante renal, houve 25 comportamentos positivos e 6 negativos. os depoimentos fornecidos pelos entrevistados estiveram associados, de modo geral, aos afazeres diários, como os que são realizados no dia da consulta de revisão clínica, além da possibilidade no planejamento de futuras ações. assim, os que foram citados positivamente, destacaram-se: a lida da casa parece que a gente [...] se anima mais para fazer as coisas. antes, quando eu não era transplantada, não tinha vontade de fazer nada. agora eu faço tudo normal. (e2, 53 anos) [...] a gente pode fazer o que quer, dentro das restrições normais que a gente tem, por ser transplantado. (e3, 40 anos) é que veio o ânimo, veio tudo. caminho para qualquer lugar, não sinto nada mais, falta de ar que sentia, não podia subir uma escada, não podia fazer nada. [...] depois disso, [...] caminho, ando por tudo. (e4, 55 anos) eu ocupo o meu tempo, porque eu vou para o calçadão, eu faço as minhas compras, eu faço um monte de coisa, já chego quase na hora da consulta. (e9, 55 anos) fez eu voltar a fazer planos, voltar a querer fazer certas coisas que eu fazia antes do transplante [...]. acho que tu pensa muito no que vai ser o teu futuro e eu acho que depois do transplante, eu comecei a pensar num futuro mais distante. coisas que eu já me preocupava bastante com o hoje, mas eu não pensava muito no daqui a dois, três anos, que eu nem sabia o que iria acontecer até lá. e hoje não, hoje eu já tenho uma perspectiva bem melhor das coisas. [...] acho que o transplante voltou a me dar essa perspectiva de futuro. (e5, 30 anos) entre os comportamentos negativos, foram considerados aqueles que levaram à limitação das pessoas transplantadas a desenvolver suas atividades cotidianas. sejam as limitações provenientes da insegurança, sejam as orientações acerca da manutenção do transplante renal. tem certas coisas que tu quer fazer, mas tu fica com medo de fazer. (e11, 54 anos) eu não me animava, eu achava assim, que eu ia fazer alguma coisa que [...] eu vou ficar cansada [...]. então, eu tinha receio de fazer as coisas e me dar algum problema. (e13, 53 anos) não é que doa alguma coisa, mas eu evito de fazer isso aí [carregar peso] para não acarretar problema, até para o transplante em si. (e14, 41 anos) a vida com o transplante renal esta categoria procurou descrever os comportamentos adotados em decorrência do transplante na vida da pessoa com irc. nos relatos, identificaram-se 22 abordagens positivas e 13 negativas. os comportamentos citados positivamente evidenciaram sentimentos de gratidão, o lidar com o medo da possibilidade de perder o órgão transplantado, o aproveitar cada dia vivido com o transplante renal, além de outros. os seguintes depoimentos apresentaram tais referências: agradeço muito a deus por ter feito esse transplante e hoje eu estou feliz da vida. (e19, 52 anos) eu procuro focar no meu tratamento, procuro fazer tudo aquilo que o médico me disse que é o certo. [...] mesmo antes do transplante, eu já não bebia mais, não fumava. [...] não uso nenhum tipo de droga, procuro cuidar alimentação, procuro tomar os 90 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 remédios direitinho, procuro seguir a orientação do médico, é o meu jeito de lidar com esse medo. que eu penso assim, se por um motivo ou outro, se eu vir a perder o meu transplante [...], eu não quero me sentir culpado de pensar assim: “se eu tivesse me cuidado. se eu tivesse feito a medicação do jeito certo, se eu tivesse me alimentado da forma correta, se eu não tivesse feito os excessos, se eu não tivesse bebido, se eu não tivesse fumado”. enfim, eu não quero ter esse tipo de pensamento. se acontecer, vai ser porque realmente tem que acontecer. agora, eu não quero que seja por negligência minha, não quero que seja por uma falha minha. (e5, 30 anos) eu procuro aproveitar o tempo da melhor forma possível [...]. até pela religião da gente, é como se tu tem um presente, cada dia que tu tem, são 24 horas que tu ganhou de presente [...], cabe a nós aproveitar da melhor forma possível e aí a gente procura fazer o melhor possível para aproveitar. (e14, 41 anos) sabe que eu não procuro pensar nisso [no medo]. [...] não sei, acho que é de mim mesmo. [...] eu vivo um dia após o outro. um dia, claro, eu sei, eu estou ciente que eu tenho uma doença que não tem cura [referindo-se ao lúpus eritematoso sistêmico], eu estou ciente que a minha doença, talvez, possa afetar o meu rim novo do transplante. eu estou ciente que, amanhã ou depois, eu posso estar no hospital, precisando de outro rim, mas eu procuro não pensar nisso. [...] se tu vai começar a pensar nas coisas ruins, tu não vive. (e15, 39 anos) eu me sinto como uma pessoa que não fosse transplantada, normal. (e18, 55 anos) nos comportamentos negativos atribuídos à vida com o transplante renal, observou-se a presença de sentimentos relacionados à posse do órgão transplantado, à tristeza, à preocupação constante e ao aumento da ansiedade. a única coisa que eu tenho muito medo, que eu cuido muito, que eu sempre digo “o meu rim”. ninguém toca nesse meu lado direito aqui. não deixo ninguém tocar! [...] eu faço massagem, não sei o que, mas esse meu lado aqui, na barriga, pode ter a barriga que tiver, a estria que tiver, não me interessa, o meu rim é o meu rim. (e7, 58 anos) é assim, eu fico calada. eu me fecho muito, aí eu choro, choro às escondidas às vezes. às vezes, choro até quando os meus filhos estão juntos [...]. eu não chorava por qualquer coisa, hoje, qualquer palavra que tu me disser eu já choro [...] (e8, 50 anos) é que assim, tu tens aquela preocupação constante com o cuidado, que os teus exames estejam sempre bons, que não precise ficar preocupado. (e11, 54 anos) eu fiquei muito ansiosa, eu já era um pouco, fiquei mais ainda. então, se eu estou esperando uma coisa que aconteça, eu fico naquela expectativa, [...] naquela ansiedade. (e13, 53 anos) discussão o transplante renal é o tratamento de escolha para a maioria das pessoas com a doença renal em estágio final (6). quando a sua realização é bem-sucedida, a pessoa com irc vive uma nova realidade, o que lhe acarretará em novos comportamentos, diferentes daqueles que eram comuns no período do tratamento dialítico (23). no presente estudo, foram identificados diversos comportamentos positivos (aqueles que levam ao sucesso) e negativos (aqueles que levam ao fracasso), relacionados aos cuidados com a saúde, com as atividades cotidianas e, de forma geral, com a vida após o transplante renal. a pessoa transplantada pode ter voz ativa no seu processo de cuidado e fazer opções ante o seu tratamento (24). contudo, observou-se, neste estudo, que alguns entrevistados seguem um cuidado prescritivo, orientado pelo profissional de saúde, de modo a garantir a sobrevida do órgão transplantado, o que impede a sua autonomia na tomada de decisões do cuidado. fato esse encontrado nos depoimentos referentes à categoria cuidados adotados com a saúde, em que, após o transplante renal, inicia-se uma série deles que poderão durar enquanto o rim estiver funcionando adequadamente. dentre estes, incluem principalmente os cuidados alimentares, a rotina medicamentosa e a realização de revisões clínicas, sob a orientação do profissional de saúde. pelo fato de o transplante renal ser um tratamento, o seguimento de cuidados é indispensável para que a pessoa usufrua os benefícios adquiridos com essa modalidade terapêutica (25). a literatura aponta a responsabilidade da equipe multiprofissional, sobre os resultados que levam ao sucesso do transplante. todavia, é válido ressaltar que a pessoa é um ser ativo, a qual deve participar em conjunto no tratamento da doença renal, pois os resultados satisfatórios da modalidade terapêutica adotada também dependem dela. como cada um é um ser singular, o papel da enfermagem nesse contexto se torna fundamental, principal91 transplante renal: análise comportamental a partir da técnica dos incidentes críticos l bianca pozza dos santos e outros mente quando atua como educadora/orientadora das ações que permeiam a vida da pessoa com o transplante renal (9). o enfermeiro tem papel fundamental na educação em saúde ao abordar os benefícios de mudanças no estilo de vida, nos hábitos e na adesão ao tratamento para prevenir fatores de risco. a pessoa, ao receber uma preparação adequada, apoio emocional e educação continuada, poderá ter melhores resultados do transplante, o que repercutirá na sua sobrevida e na do enxerto, assim como na qualidade de vida e na reinserção social, laboral e escolar (26). salienta-se que o ponto essencial é a forma como a doença e o seguimento do tratamento são assimilados na vida da pessoa, de acordo com os seus aspectos sociais e culturais (27). conforme o destacado neste estudo, na categoria referente às atividades cotidianas, mesmo havendo manifestações de comportamentos positivos pelas pessoas com o transplante renal, não são raros os relatos de insegurança e de infelicidade, que geram comportamentos negativos. diante dessa conjuntura, é necessário que os profissionais da saúde avaliem de que forma as pessoas transplantadas estão se comportando com tais mudanças na sua vida. ademais, devem estabelecer apoio necessário para a compreensão das consequências psicossociais que podem se associar à falha da transplantação renal (28). acredita-se que a vida das pessoas com irc, quando transplantadas, possa melhorar completamente, principalmente aquelas que haviam sido submetidas previamente ao tratamento dialítico. neste estudo, os comportamentos emitidos revelaram a convivência de fatores que podem levar à gratidão em ter conquistado o transplante renal, o lidar com a convivência do medo, o desejo em aproveitar cada dia, assim como à presença de sentimentos de posse do órgão, de tristeza, de preocupação e de ansiedade. com base nos fatores que permeiam a vida com o transplante renal, alguns achados dessa categoria corroboram com os resultados de uma pesquisa de caráter qualitativo realizada em 2005, na irlanda, na qual uma participante revelou que o transplante renal desenvolveu nela uma ação de proteção, tanto que tinha medo de os médicos chegarem perto por acreditar que poderiam danificar o rim transplantado. fato esse que acarretou na presença do sentimento de posse do órgão transplantado. outro participante afirmou que ficou deprimido, isolado e solitário (29), o que se assemelha às manifestações de tristeza por um entrevistado deste estudo. quanto ao sentimento de preocupação constante, explanado por um entrevistado, enfatiza-se que a doença renal promove na pessoa uma mudança de vida. de tal modo que a manutenção da sua saúde, após ser transplantada, faz necessitar de cuidados para dar conta da complexidade vivida; assim, geralmente, há a preocupação com o futuro (30). além do mais, o fato de muitas vezes a pessoa não ter informações suficientes sobre o transplante leva à ansiedade. logo, pode-se concluir que os aspectos psicológicos envolvidos podem desestabilizá-la (31). portanto, com esse e os demais fatores apresentados na vida da pessoa com o transplante renal, faz-se necessária uma atenção psicológica que promova o desenvolvimento de estratégias comportamentais de enfrentamento no intuito de amenizar os sentimentos negativos. conclusões este estudo possibilitou o conhecimento da realidade vivenciada pelas pessoas com o transplante renal. a aplicação da tic, por sua vez, favoreceu a identificação de dados comportamentais e como estes influenciam, positiva e/ou negativamente, a vida da pessoa. assim, foi possível identificar os comportamentos das pessoas com o transplante renal relacionados aos cuidados adotados com a saúde (levando ao desenvolvimento do autocuidado), às atividades cotidianas (disponibilidade em executar tarefas que lhe competem) e à vida com o transplante renal (envolvendo os aspectos psicológicos e emocionais). entretanto, a limitação presente neste estudo decorreu da técnica utilizada, pois ela não esclarece a definição de positivo e de negativo, o que impede, por vezes, a sua classificação a partir dos relatos transmitidos pelos entrevistados. assim, a análise parte da subjetividade, em que a definição dependerá da capacidade do entrevistador em determinar os dados e interpretá-los de acordo com o contexto vivenciado. desse modo, pode-se afirmar que positivo e negativo são definições relativamente subjetivas. além do mais, considera-se que a questão dos transplantes tem uma das representações mais relevantes para a pessoa com irc. ela afeta a sua identidade e pode gerar mudanças comportamentais. entretanto, estas poderão estar relacionadas com a personalidade de cada ser que vivencia tal condição e repercutir em comportamentos positivos e/ou negativos, como foi evidenciado nos achados deste estudo. 92 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 como o transplante renal pode ser considerado o tratamento desejado pela maioria das pessoas que vivenciam a irc, cabe aos profissionais de saúde estarem atentos aos fatores comportamentais, que poderão implicar maleficamente a manutenção da terapêutica adotada. além de respaldar os comportamentos positivos, de modo a auxiliar na continuação dos cuidados com a saúde, que visem aos benefícios para as pessoas transplantadas. diante do contexto vivenciado, a enfermagem exerce um papel fundamental durante o cuidado ao transplantado renal. por essa profissão possuir como objeto de trabalho o cuidado, além de seus atores, enfermeiros e enfermeiras, estarem mais próximos da pessoa, devem assumir a função de orientadores e fornecer informações pertinentes para o sucesso do tratamento adotado. assim, para o favorecimento do processo de seu trabalho, devem ser capacitados por meio de cursos e/ou de palestras que visem à sua instrumentalização para a otimização e a qualificação da assistência prestada. referências 1. couser wg, remuzzi g, mendis s, tonelli m. the contribution of chronic kidney disease to the global burden of major noncommunicable diseases. kidney int. 2011; 80: 1258-70. 2. stevens la, viswanathan g, weiner de. chronic kidney disease and end-stage renal disease in the elderly population: current prevalence, future projections, and clinical significance. adv chronic kidney dis. 2010; 17(4): 293-301. 3. llewellyn h, lowj, smith g, hopkins katherine, burns a, jones l. narratives of continuity among older people with late stage chronic kidney disease who decline dialysis. soc sci med. 2014; 114: 49-56. 4. centenaro ga. a intervenção do serviço social ao paciente renal crônico e sua família. cienc saude colet. 2010; 15 (suppl 1: s1881-5). 5. freiberg m, chiurchiu c, capra r, eckhardt a, fuente j, douthat w et al. factores asociados y consecuencias clínicas de la anemia post trasplante renal. medicina. 2013; 73(2): 136-40. 6. british transplant society/renal association. united kingdom guidelines for living donor kidney transplantation. 3 ed. londres: bts/ra; 2011. 7. canché-arenas ap, reza-orozco m, rodríguez-weber fl. calidad de vida en pacientes con trasplante renal del hospital ángeles del pedregal. medicina interna de méxico. 2011; 27(5): 446-54. 8. gill p. stressors and coping mechanisms in live related renal transplantation. j clin nurs. 2012; 21: 1622-31. 9. furtado amo, souza sros, oliveira bl, garcia cn. o enfermeiro assistencial e educador em uma unidade de transplante renal: uma questão desafiadora. enfermería global. 2012; (27): 351-5. 10. todorov jc. sobre uma definição de comportamento. revista perspectivas. 2012; 3(1): 32-7. 11. silva y, del cerro a. liderazgo del formador en el área de recursos humanos: comparativa entre formadores internos y externos. psicoperspectivas [on-line]. 2012 [consultado em 1º set. 2013]; 11(2): 124-42. disponível em: http://www. psicoperspectivas.cl/index.php/psicoperspectivas/article/ viewfile/190/214 12. o’neill b. assessing program impact with the critical incident technique. journal of extension. 51(3): 1-4. 13. yanez gr, lopez-mena l, reyes rf. la técnica de incidentes críticos: una herramienta clásica y vigente en enfermería. cienc enferm. 2011; 17 (2): 27-36. 14. gremler dd. the critical incident technique. wiley encyclopedia of management. 2015; 9:1. 15. cardoso lb, sade pmc. o enfermeiro frente ao processo de resiliência do paciente em tratamento hemodialítico. revista eletrônica da faculdade evangélica do paraná [on-line]. 2012 [consultado em 15 set. 2013]; 2(1): 2-10. disponível em: http://www.fepar.edu.br/revistaeletronica/index.php/revfepar/article/download/35/45 16. flanagan jc. a técnica do incidente crítico. arq bras psicol apl. 1973; 25(2): 99-141. 93 transplante renal: análise comportamental a partir da técnica dos incidentes críticos l bianca pozza dos santos e outros 17. ribeiro lcm, souza acs, barreto rass, neves hcc, barbosa ma. técnica de incidente crítico e seu uso na enfermagem: revisão integrativa da literatura. rev bras enferm. 2012; 65(1): 162-71. 18. flanagan jc. the critical incident technique. psychological bulletin. 1954; (51): 327-58. 19. flanagan jc. a research approach to improving our quality of life. am psyc. 1978; 33: 138-47. 20. dela coleta ja, dela coleta mf. a técnica dos incidentes críticos: 30 anos de utilização no brasil na psicologia, administração, saúde e educação. taubaté (sp): cabral editora e livraria universitária; 2004. 21. brasil. ministério da saúde. conselho nacional de saúde. resolução 196, de 10 de outubro de 1996: diretrizes e normas regulamentadoras de pesquisa envolvendo seres humanos. brasília (df); 1996. 22. conselho federal de enfermagem. código de ética dos profissionais de enfermagem. resolução cofen 311/2007. [consultado em 13 ago. 2012]. disponível em: http://www.portalcofen. gov.br/2007/materias.asp?articleid=7323&sectio nid=37 23. barbosa kfs. a experiência em família frente à doença renal terminal e o transplante bem sucedido. [dissertação de mestrado]. faculdade de enfermagem, universidade estadual de londrina, londrina; 2013. 24. mantovani mf, mendes frp. the quality of life of elderly´s chronic disease sufferers: qualitative-quantitative research. online braz j nurs [on-line]. 2010 [consultado em 15 out. 2013]; 9 (1). disponível em: http://www.objnursing.uff.br/ index.php/nursing/article/view/j.1676-4285.2010. 2835/html_109 25. brahm mmt. adesão aos imunossupressores em pacientes transplantados renais. [dissertação de mestrado]. faculdade de medicina, universidade federal do rio grande do sul, porto alegre; 2012. 26. herzog co. educación al paciente y la familia en un programa de trasplante, experiencia en clc. rev med clin condes. 2010.; 21(2): 293-9. 27. perkinson ma, solimeo sl. aging in cultural context and as narrative process: conceptual foundations of the anthropology of aging as reflected in the works of margaret clark and sharon kaufman. gerontologist. 2014; 54(1): 101-7. 28. gill p, lowes l. renal transplant failure and disenfranchised grief: participants’ experiences in the first year post-graft failure. int j nurs stud. 2014; 51(9): 1271-80. 29. kierans c. narrating kidney disease: the significance of sensation and time in the emplotment of patient experience. cult med psychiatry. 2005; 29(3): 341-59. 30. sousa fa. do encontro ao sentido: o cuidado aos sujeitos adoecidos de câncer. [dissertação de mestrado]. instituto de medicina social, universidade do estado do rio de janeiro, rio de janeiro; 2011. 31. camargo vp, quintana am, weissheimer tks, junges n, martins bmc. transplante renal: um caminho para a vida ou um passo para a morte? rev contexto saúde. 2011; 10(20): 515-24. 222 233 diagnosticos de enfermagem segundo.indd 222 gilmara holanda da cunha1 ane kelly lima ramalho2 alyne mara maia cruz3 maria amanda correia lima4 katia barbosa franco5 reângela cintia rodrigues de oliveira lima6 diagnósticos de enfermagem segundo a teoria do autocuidado em pacientes com infarto do miocárdio 1 orcid.org/0000-0002-5425-1599. universidade federal do ceará (ufc), brasil. gilmaraholanda@ufc.br 2 orcid.org/0000-0003-4250-7697. universidade estadual do ceará (uece), brasil. 3 orcid.org/0000-0002-9419-9289. universidade estadual do ceará (uece), brasil. 4 orcid.org/0000-0001-6244-3964. universidade federal do ceará (ufc), brasil. 5 orcid.org/0000-0002-3435-7716. universidade federal do ceará (ufc), brasil. 6 orcid.org/0000-0002-7989-5104. universidade federal do ceará (ufc), brasil. recibido: 12/09/2017 enviado a pares: 05/10/2017 aprobado: 25/01/2018 aceptado: 02/03/2018 doi: 10.5294/aqui.2018.18.2.9 para citar este artículo / to reference this article / para citar este artigo holanda da cunha g, lima ak, maia am, correia ma, barbosa k, rodrigues de oliveira rc. diagnósticos de enfermagem segundo a teoria do autocuidado em pacientes com infarto do miocárdio. aquichan 2018; 18(2): 222-233. doi: 10.5294/aqui.2018.18.2.9 resumo objetivo: identificar os diagnósticos de enfermagem em pessoas com infarto do miocárdio em emergência hospitalar, segundo a teoria do autocuidado de orem. materiales y método: estudo transversal, realizado de fevereiro a agosto de 2016, com 50 pacientes infartados e que estavam em condições de participar da pesquisa. a coleta de dados ocorreu por meio de entrevista, utilizando-se um formulário segundo a teoria do autocuidado, e foram formulados diagnósticos de enfermagem com base na taxonomia da nanda-i. resultados: a maioria dos pacientes era mulheres (54%), na faixa etária de 60 a 69 anos (34%), renda familiar de um a dois salários mínimos (88%), com ensino fundamental (70%) e aposentados (76%). houve alta frequência de hipertensão arterial (62%), inatividade física (76%) e tabagismo (70%). o teste rápido para troponina foi positivo em 16 pessoas (32%). muitos infartados apresentavam déficits de autocuidado que apontaram 10 diagnósticos de enfermagem, destacando-se o estilo de vida sedentário (80%), mobilidade física prejudicada (76%) e risco de intolerância à atividade (76%). comportamentos de saúde propenso a risco e autonegligência tiveram relação com três requisitos de autocuidado. conclusão: os pacientes necessitavam de assistência em saúde quanto às mudanças no estilo de vida, medidas de conforto e realização de atividade e repouso. palavras-chave enfermagem; diagnóstico de enfermagem; autocuidado; teoria de enfermagem; infarto do miocárdio (fonte: decs, mesh). año 18 vol. 18 nº 2 chía, colombia abril 2018 l 222-233 temática: cuidado crônico contribuição à disciplina: o artigo contribui na assistência de enfermagem à pessoa com infarto do miocárdio, para que o cuidado seja realizado de forma efetiva, para a estabilização clínica em tempo hábil. 223 diagnósticos de enfermagem segundo a teoria do autocuidado em pacientes com infarto do miocárdio l gilmara holanda da cunha e outros año 18 vol. 18 nº 2 chía, colombia abril 2018 l 222-233 diagnósticos de enfermería según la teoría del autocuidado en pacientes con infarto de miocardio resumen objetivo: identificar los diagnósticos de enfermería en personas con infarto de miocardio en emergencia hospitalaria, según la teoría del autocuidado de orem. materiales y método: estudio transversal, realizado de febrero a agosto de 2016, con 50 pacientes infartados y que estaban en condiciones de participar en la investigación. la recolección de datos ocurrió a través de entrevista, utilizando cuestionario según la teoría del autocuidado, y se formularon diagnósticos de enfermería con base en la taxonomía de la nanda-i. resultados: la mayoría de los pacientes eran mujeres (54 %), con edades de 60 a 69 años (34 %), ingreso familiar de uno a dos salarios mínimos (88 %), con enseñanza básica (70 %) y jubilados (76 %). hubo alta frecuencia de hipertensión arterial (62 %), inactividad física (76 %) y tabaquismo (70 %). la prueba rápida para troponina fue positiva en 16 personas (32 %). muchos infartados presentaban déficits de autocuidado que apuntaron 10 diagnósticos de enfermería, destacándose estilo de vida sedentario (80 %), movilidad física perjudicada (76 %) y riesgo de intolerancia a la actividad (76 %). los comportamientos de salud propensos al riesgo y la autonegligencia tuvieron relación con tres requisitos de autocuidado. conclusión: los pacientes necesitaban de asistencia en salud para cambios en el estilo de vida, medidas de confort y realización de actividad y reposo. palabras clave enfermería; diagnóstico de enfermería; teoría de enfermería; infarto del miocardio (fuente: decs, mesh). 224 aquichan issn 1657-5997 eissn 2027-5374 nursing diagnostics according to the self-care theory in patients with myocardial infarction abstract objective: identify nursing diagnoses in patients with myocardial infarction in hospital emergency situations, according to orem´s self-care theory. materials and methods: this is a cross-sectional study that was conducted from february to august 2016 with 50 infarcted patients who were able to participate in the research. data collection was done through an interview, using a questionnaire pursuant to the self-care theory, and the nursing diagnoses were formulated based on the nanda-i taxonomy. results: the majority of patients were women (54%) ages 60 to 69 (34%), with family incomes ranging from one to two minimum wages (88%), with basic education (70%) and retirees (76%). there was a high frequency of arterial hypertension (62%), physical inactivity (76%) and smoking (70%). the rapid test for troponin was positive in 16 of the participants (32%). many of the infarcted patients had self-care deficits that were indicated in 10 nursing diagnoses, particularly sedentary lifestyles (80%), physically impaired mobility (76%), and risk of activity intolerance (76%). risk-prone health behavior and self-neglect were related to three self-care requirements. conclusion: the patients needed health assistance for changes in lifestyle, comfort measures, and the realization of activity and rest. keywords nursing; nursing diagnosis; nursing theory; myocardial infarction (source: decs, mesh). año 18 vol. 18 nº 2 chía, colombia abril 2018 l 222-233 225 diagnósticos de enfermagem segundo a teoria do autocuidado em pacientes com infarto do miocárdio l gilmara holanda da cunha e outros introdução as doenças cardiovasculares estão entre as maiores causas de morte, estimando-se que, para 2030, cerca de 23 milhões de pessoas morram por doenças cardiovasculares no mundo (1). dentre essas doenças, destaca-se o infarto agudo do miocárdio (iam), que tem como principais fatores de risco o tabagismo, os níveis séricos elevados de colesterol, a obesidade, a diabetes mellitus, o sedentarismo e a hipertensão arterial sistêmica (has) (2-3). diante disso, para nortear o trabalho do enfermeiro, o processo de enfermagem (pe) é um método científico que envolve raciocínio e julgamento diagnóstico, terapêutico e ético, de forma que fundamenta ações e aprimora o cuidado prestado pelo enfermeiro. o pe tem cinco etapas: coleta de dados, diagnóstico de enfermagem (de), planejamento, implementação e avaliação. destas, o de é o que evidencia a condição clínica do paciente para garantir o cuidado eficaz (4). para melhor identificação de problemas relacionados ao paciente, o pe pode ser embasado por teorias, dentre as quais está a teoria do autocuidado de orem. autocuidado é a prática de atividades que os indivíduos realizam em seu benefício para manter a vida, saúde e o bem-estar. os requisitos de autocuidado são divididos em três categorias: universais, de desenvolvimento e de desvio da saúde (5). a aplicabilidade prática da teoria do autocuidado de orem para pacientes com iam torna-se palpável, sobretudo, ao considerar os requisitos de autocuidado. em decorrência do processo de doença, quanto aos requisitos universais, esses indivíduos podem ter ingesta insuficiente de ar, água, alimentos, alterações nos processos de eliminação, interação social, atividade e repouso. nos requisitos de desenvolvimento de autocuidado, os pacientes podem não ser capazes de se adaptarem ao tratamento. e os requisitos de autocuidado envolvem os aspectos relacionados à adesão ao tratamento (5-6). a utilização dessa teoria neste estudo justifica-se por abordar o autocuidado e listar fatores que afetam sua provisão, sobretudo, considerando o iam, que muitas vezes decorre da falta de seguimento das medidas farmacológicas e não farmacológicas necessárias para a condução de doenças crônicas (7). ademais, acredita-se que o uso combinado dessa teoria e a determinação dos de podem identificar aspectos importantes para a tomada de decisões do enfermeiro na promoção da saúde dos pacientes. isso porque, ao se saber dos de mais comuns em pacientes infartados, apesar das particularidades existentes em cada caso, os enfermeiros podem agir de forma mais rápida, direcionada e efetiva. nesse contexto, este estudo teve por objetivo identificar os diagnósticos de enfermagem em indivíduos com iam atendidos em emergência hospitalar, segundo a teoria do autocuidado de orem. esta pesquisa contribui para a assistência de enfermagem direcionada a esses pacientes, porque identifica problemas comuns e, portanto, pode propor intervenções que permitam melhoras na condição de saúde, além da recuperação de forma integral. método trata-se de um estudo transversal, descritivo e quantitativo, desenvolvido no período de fevereiro a agosto de 2016, na emergência do hospital e casa de saúde de russas (hcsr), localizado na cidade de russas, no estado do ceará. a instituição é um hospital de nível secundário, vinculado ao sistema único de saúde (sus), composto por 131 leitos, que atende às especialidades de clínica médica, pediátrica, traumatológica, obstétrica e cirúrgica. a população do estudo foi composta por 80 pacientes, que correspondem a todos os indivíduos que foram admitidos por iam no hospital durante o período de estudo. destes, 50 foram selecionados pela técnica de amostragem não probabilística e por conveniência. os pacientes selecionados para a amostra deram entrada na emergência por demanda livre, referenciados da unidade de pronto atendimento (upa) ou transferidos de municípios próximos. os critérios de inclusão foram pacientes com idade igual ou superior a 18 anos, admitidos na emergência por iam e que estavam em condições de participar da pesquisa. da população total do estudo, 30 pacientes foram excluídos devido ao estado de saúde instável, sem condições para responder às perguntas da pesquisa. a coleta de dados foi realizada por duas enfermeiras especialistas em cardiologia. ocorreu uma entrevista, com duração média de 30 minutos e em ambiente privativo, utilizando-se um formulário elaborado de acordo com a teoria do autocuidado de orem, que envolve três etapas e considera as seguintes variáveis: 1. dados sociodemográficos (idade, sexo, cor da pele, renda familiar, escolaridade, situação ocupacional); 2. dados clínicos (história patológica pregressa, atividade física, uso de bebida alcoólica 226 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 e cigarro, teste rápido para troponina, frequência cardíaca e respiratória, pressão arterial, índice de massa corporal, sinais de iam, localização e irradiação da dor, alterações no eletrocardiograma) e dados da teoria do autocuidado de orem: 2.1 requisitos universais de autocuidado (manutenção de ingesta suficiente de ar, água e alimentos; provisão de cuidados com processos de eliminação e excrementos; manutenção do equilíbrio entre atividade e repouso; manutenção do equilíbrio entre solidão e interação social; prevenção dos perigos à vida humana, ao funcionamento e bem-estar do ser humano; promoção do funcionamento e desenvolvimento do ser humano dentro dos grupos sociais, de acordo com o potencial, as limitações conhecidas e o desejo de ser normal. 2.2. requisitos de desenvolvimento do autocuidado (expressões especializadas de requisitos universais de autocuidado particularizadas por processos de desenvolvimento ou novos requisitos derivados de uma condição ou associados a algum evento); 2.3. requisitos de autocuidado no desvio de saúde (buscar e garantir assistência médica apropriada; estar consciente e levar em conta os efeitos e resultados das condições e estados patológicos; realizar efetivamente medidas diagnósticas, terapêuticas e reabilitativas prescritas; estar consciente e regular os efeitos desconfortáveis e deletérios das medidas de cuidados prescritos; modificar o autoconceito, aceitando determinado estado de saúde e necessidades específicas de atendimento de saúde; aprender a viver com efeitos de condições, estados patológicos e consequências do diagnóstico médico e medidas de tratamento no estilo de vida, promovendo o desenvolvimento pessoal continuado) (6, 8). ressalta-se que esse instrumento de coleta de dados foi previamente validado por meio da aplicação em 10 pacientes com iam, os quais não fizeram parte da amostra. os dados obtidos foram analisados pelas duas enfermeiras especialistas em cardiologia para a identificação dos de conforme a taxonomia da nanda-i (9). três enfermeiras especialistas em de também participaram desse processo. foram selecionadas pesquisadoras com experiência em de, por meio da plataforma lattes (brasil), que representa uma integração de bases de dados de currículos, grupos de pesquisa e instituições em um único sistema de informações. os dados foram tabulados no microsoft excel e analisados no software statistical package for the social sciences (spss) versão 18. utilizou-se o teste de qui-quadrado de pearson, que mede a relação de dependência entre as variáveis, mediante a comparação das frequências observadas com as esperadas. adotou-se como estatisticamente significante um valor de p < 0,05. o projeto foi submetido ao comitê de ética em pesquisa da universidade estadual do ceará, com aprovação em 10 de janeiro de 2016, sob o protocolo n.° 1.386.058. resultados dentre os pacientes, a maioria era do sexo feminino (27; 54 %), destacando-se as faixas etárias entre 60 e 69 anos (17; 34 %) e 70 a 79 anos (11; 22 %), cor da pele autorreferida parda (37; 74 %), renda familiar de um a dois salários-mínimos mensais (44; 88 %), que estudaram somente até o ensino fundamental (35; 70 %) e aposentados (38; 76 %). quanto aos dados clínicos, a história patológica pregressa mostrou has (31; 62 %), diabetes mellitus tipo 2 (12; 24 %), iam prévio (10; 20 %), dislipidemias (8; 16 %) e acidente vascular encefálico (5; 10 %). a maioria não praticava atividade física (38; 76 %), era tabagista (35; 70 %) e não utilizava bebida alcoólica (45; 90 %). o teste rápido para troponina foi realizado em 46 pacientes, dando positivo em 16 (32 %). na admissão no hospital, a maioria possuía pressão alta, sobrepeso, sudorese, dispneia, náusea/vômito, dor precordial opressiva, que irradiava para o membro superior esquerdo, além do supradesnivelamento do seguimento st no eletrocardiograma (ver tabela 1). tabela 1. caracterização clínica dos pacientes com infarto agudo do miocárdio atendidos em emergência (n = 50) (russas, 2016) variáveis clínicas n % pressão arterial (sistólica/diastólica) < 100/ < 60 4 8 100 140/ 60 90 23 46 140 160/ 90 100 9 18 160 180/ 100 110 10 20 >180/ >110 4 8 frequência cardíaca (batimentos por minuto) < 60 4 8 60 100 41 82 > 100 5 10 frequência respiratória (movimentos respiratórios por minuto) 14 20 40 80 > 20 10 20 227 diagnósticos de enfermagem segundo a teoria do autocuidado em pacientes com infarto do miocárdio l gilmara holanda da cunha e outros de autocuidado, vários pacientes não se adaptaram à condição de cardiopata ou às restrições exigidas pelo tratamento (38 %). no autocuidado no desvio da saúde, destacou-se que alguns não realizavam de forma efetiva as medidas de saúde prescritas (32 %). dados expressos na tabela 2. tabela 2. requisitos universais, de desenvolvimento e de desvio da saúde relatados pelos pacientes com infarto agudo do miocárdio atendidos em emergência (n = 50) (russas, 2016) índice de massa corporal < 18,5 (abaixo do peso) 2 4 18,5 24,9 (peso normal) 11 22 25 29,9 (excesso de peso) 28 56 30 34,9 (obesidade classe i) 7 14 35 39,9 (obesidade classe ii) 2 4 sinais de infarto sudorese 24 48 pele fria 17 34 palidez 5 10 cianose 3 6 dispneia 22 44 náusea/vômito 22 44 localização da dor precordial 40 80 retroesternal 2 4 mandibular 5 10 epigástrica 8 16 pescoço 3 6 características da dor opressiva 20 40 peso/aperto 15 30 pontada 8 16 queimação 7 14 irradiação da dor membro superior esquerdo 40 80 dorso 10 20 alterações no eletrocardiograma supradesnivelamento do seguimento st 35 70 inversão de onda t 8 16 onda q patológica 7 14 fonte: elaboração própria. ocorreram alguns déficits de autocuidado entre os pacientes. em relação aos requisitos universais de autocuidado, alguns infartados não possuíam ingesta suficiente de ar (56 %), muitos não praticavam atividade física (76 %) e tinham comportamento de risco à integridade física (64 %). no requisito de desenvolvimento respostas sobre autocuidado n % 1. requisitos universais de autocuidado manutenção de ingesta suficiente de ar sim 22 44 não 28 56 hidratação adequada sim 49 98 não 1 2 alimentação adequada sim 47 94 não 3 6 eliminações corporais adequadas sim 50 100 prática de atividade física antes do infarto do miocárdio sim 12 24 não 38 76 interação social sim 50 100 comportamento de risco à integridade física sim 32 64 não 18 36 2. requisito de desenvolvimento de autocuidado adaptação à condição de cardiopata ou restrições sim 31 62 não 19 38 3. o autocuidado no desvio da saúde busca e garante a assistência médica sim 43 86 não 7 14 228 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 fonte: elaboração própria. foram identificados 10 diagnósticos, sendo o mais prevalente o estilo de vida sedentário. a tabela 3 mostra a relação entre os requisitos de autocuidado dos pacientes segundo a teoria do autocuidado de orem e os de. tabela 3. relação entre os requisitos de autocuidado e de de pacientes com infarto agudo do miocárdio atendidos em emergência (n = 50) (russas, 2016) *p < 0,05 pelo teste de qui-quadrado de pearson. fonte: elaboração própria. estilo de vida sedentário, relacionado ao interesse insuficiente pela atividade física, caracterizado por atividade física inferior à recomendada para o gênero e a idade, foi identificado no requisito universal de manutenção do equilíbrio entre atividade e repouso (p = 0,0001). ademais, esse diagnóstico teve associação com a idade aumentada (p = 0,029) e com a baixa escolaridade (p = 0,023), ou seja, as pessoas com mais idade e com menos escolaridade possuíam mais esse diagnóstico. mobilidade física prejudicada, relacionada com a intolerância à atividade, foi caracterizada por dispneia aos esforços, gerada também pela dor precordial, sendo obtida no requisito de autocuidado no desvio de saúde, que é estar consciente e levar em conta os efeitos e resultados dos estados patológicos (p = 0,040). já o diagnóstico risco de intolerância à atividade, relacionado ao problema circulatório, está associado com o requisito de autocuidado do desvio de saúde. o diagnóstico comportamento de saúde propenso a risco foi relacionado com a compreensão inadequada, caracterizada pela não aceitação da mudança no estado de saúde. esse diagnóstico teve associação nas três categorias de requisitos de autocuidado. em relação aos universais, houve associação estatística quanto à manutenção do equilíbrio entre atividade e repouso e à prevenção dos perigos à vida humana (p = 0,0001). também tem ciência da atual condição de saúde sim 43 86 não 7 14 realiza efetivamente as medidas prescritas sim 34 68 não 16 32 está consciente dos efeitos desconfortáveis do tratamento sim 50 100 não aceita a condição de saúde e de cuidados específicos sim 47 94 não 3 6 aprendeu a viver com os efeitos da atual condição de doença sim 44 88 não 6 12 de requisitos de autocuidado universais n (%) desenvolvimento n (%) desvio de saúde n (%) estilo de vida sedentário 40 (80) valor de p 0,0001* mobilidade física prejudicada 35 (70) valor de p 0,040* risco de intolerância à atividade 35 (70) valor de p 0,040* comportamentos de saúde propenso a risco 28 (56) 17 (34) 15 (30) valor de p 0,0001* 0,004* 0,049* autonegligência 28 (56) 18 (36) 15 (30) valor de p 0,009* 0,0001* 0,003* débito cardíaco diminuído 22 (44) valor de p 0,028* risco de síndrome do idoso frágil 21 (42) 21 (42) valor de p 0,009* 0,009* padrão respiratório ineficaz 19 (38) valor de p 0,009* ansiedade 16 (32) valor de p 0,003* conforto prejudicado 5 (10) valor de p 0,366 229 diagnósticos de enfermagem segundo a teoria do autocuidado em pacientes com infarto do miocárdio l gilmara holanda da cunha e outros houve relação estatística quanto aos requisitos de desenvolvimento (p = 0,004) e ao desvio de saúde, no que se refere a buscar e garantir assistência médica apropriada e a realizar medidas prescritas (p = 0,049), apesar da fraca associação. esse diagnóstico esteve relacionado com o aumento da idade (p = 0,026) e com a baixa escolaridade (p = 0,034). o diagnóstico autonegligência, relacionado com a escolha do estilo de vida não saudável, caracterizado por falta de adesão à atividade de saúde, esteve associado aos três requisitos de autocuidado. em relação aos universais, foram contempladas a manutenção do equilíbrio entre atividade e repouso e a prevenção dos perigos à vida humana (p = 0,009). com os requisitos de desenvolvimento, no que se refere a não se adaptar à condição de doença (p = 0,0001), e, com o desvio de saúde, em relação a buscar e garantir assistência médica apropriada e a realizar medidas prescritas (p = 0,003). o diagnóstico débito cardíaco diminuído, relacionado com o ritmo cardíaco alterado, caracterizado por cor anormal da pele, pele fria, úmida e pegajosa, causado pela oferta de oxigênio inferior à adequada para uma boa manutenção da oferta e troca gasosa, foi identificado no requisito universal, no que concerne à manutenção de ingesta insuficiente de ar e à manutenção do equilíbrio entre atividade e repouso (p = 0,028). risco de síndrome do idoso frágil, caracterizado por doença crônica, relacionado com a capacidade de autocuidado negativa, foi constatado no requisito universal manutenção do equilíbrio entre atividade e repouso e no prevenção dos perigos à vida humana (p = 0,009). também houve significância estatística com os requisitos de desenvolvimento (p = 0,009), visto que alguns pacientes não estavam adaptados ao envelhecimento (p = 0,000). ademais, esse diagnóstico foi mais prevalente entre os aposentados (p = 0,025). o diagnóstico padrão respiratório ineficaz, relacionado com a dor, caracterizado por dispneia, foi obtido no requisito universal manutenção de ingesta suficiente de ar (p = 0,009). ansiedade, relacionada com a mudança importante na condição de saúde caracterizada por medo, foi identificada no requisito de autocuidado universal, quanto à manutenção do equilíbrio entre atividade e repouso (p = 0,003) e também no requisito de autocuidado no desvio de saúde, relacionando-se com o aumento da idade (p = 0,017) e com a situação ocupacional de aposentado (p = 0,047), já que aposentados apresentaram com frequência esse diagnóstico. conforto prejudicado, relacionado com o regime de tratamento e com sintomas relativos à doença, caracterizado por desconforto com a situação, não mostrou associação estatística com nenhum dos três requisitos de autocuidado. discussão houve maior prevalência de pacientes do sexo feminino com iam, discordando de outros estudos em que se destacou o sexo masculino (2, 10). tem-se que indivíduos do sexo masculino apresentam maior risco de evento cardiovascular, mas o risco feminino tende a se igualar ao masculino, em parte pela perda do efeito protetor estrogênico, na menopausa (7, 11). já a ocorrência de muitos idosos no estudo justifica-se pela associação direta e linear entre envelhecimento e prevalência de doenças cardiovasculares, relacionada com o aumento da expectativa de vida da população brasileira, atualmente de 74,9 anos, em consequência, aumento da população de idosos na última década (7). destacaram-se pessoas com renda familiar reduzida e baixa escolaridade, que são características frequentes nos acometidos por iam (2). essas variáveis estão associadas com o risco aumentado de morte por doenças cardiovasculares, sobretudo, pela falta de informações e pela dificuldade que esses indivíduos possuem para ter acesso ao sistema de saúde e aderirem adequadamente às medidas de tratamento farmacológico e não farmacológico (12-13). a maioria dos pacientes autorreferiu cor da pele parda, mas, sobre esse aspecto, ainda não existe consenso na literatura pertinente; não se tem certeza do efeito da miscigenação sobre o desenvolvimento da has e de outras doenças cardiovasculares; no entanto, pessoas de pele mais escura tendem a ter mais doenças cardiovasculares (7). muitos indivíduos apresentavam has, que é um fator de risco importante para o iam, além de estar relacionada com índice expressivo de mortalidade hospitalar (2, 13-14). além da has, tabagismo, dislipidemias, sedentarismo e diabetes são fatores de risco significativos para a mortalidade por doenças cardiovasculares (15-16), de forma que vários pacientes que chegam às unidades de emergências com iam apresentam três ou mais desses fatores de risco (17). quanto aos exames realizados para o diagnóstico do iam, observou-se que muitos tiveram teste rápido positivo para a análise 230 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 de troponina e supradesnivelamento do segmento st no eletrocardiograma. as troponinas são enzimas que se elevam entre 4 e 8 horas após o início dos sintomas do iam, com pico entre 36 e 72 horas e normalização entre 5 e 14 dias (14, 18). juntamente com os sinais e sintomas clínicos clássicos do iam apresentados pelos pacientes, foi bastante observado, no eletrocardiograma, o supradesnivelamento do segmento st, o qual é um achado comum em pacientes com iam, caracterizando uma situação clínica de extrema gravidade, observando-se maior incidência de iam subsequente ou parada cardíaca em mais de 4 % dos que manifestam o supradesnível de st (7). constatou-se que muitos pacientes não praticavam atividade física e eram tabagistas. ademais, alguns déficits de autocuidado foram identificados, sobretudo, decorrentes das consequências do iam, assim como relacionados ao não seguimento das medidas farmacológicas e não farmacológicas relacionadas às doenças cardiovasculares preexistentes. nesse contexto, ressalta-se a importância da mudança do comportamento e do estilo de vida para a recuperação do paciente e para a diminuição do risco de infarto ou reinfarto, devendo sempre ser observada a capacidade de autocuidado que essas pessoas possuem, além das estratégias adequadas de educação em saúde a serem utilizadas (19-21). em relação aos de identificados, destacou-se o estilo de vida sedentário, o qual contribui para o sobrepeso e para a obesidade. o fato de esse diagnóstico ocorrer mais em idosos e em pessoas de baixa escolaridade pode ser decorrente das limitações físicas do envelhecimento, assim como da falta de orientação acerca desse aspecto. são bem conhecidos os benefícios da prática de atividade física regular, tendo-se que a realização de atividade física por 30 minutos, de quatro a sete dias por semana, é uma medida eficaz, que reduz a pressão arterial e o risco de complicações cardiovasculares, dentre elas o iam (7, 22). a mobilidade física prejudicada caracterizou-se por dispneia. nesse contexto, estudo aponta que a dispneia, um sintoma comum em pacientes com iam, pode ocorrer na atividade física mínima, moderada e também no repouso, devido à incapacidade do coração manter um débito cardíaco suficiente para satisfazer as necessidades teciduais de oxigênio, bem como da redução do fluxo sanguíneo periférico (7, 23). o risco de intolerância à atividade foi relacionado com o problema circulatório e associado à baixa perfusão muscular. tais alterações, geralmente, impedem que os indivíduos realizem suas atividades diárias. esse diagnóstico em pacientes com iam está associado ao desconforto respiratório, à fadiga e a palpitações que a pessoa sente ao desenvolver suas atividades cotidianas, pela incapacidade do coração manter um débito cardíaco suficiente para atender às necessidades teciduais de oxigênio, além da redução do fluxo sanguíneo periférico (24-25). os diagnósticos de comportamento de saúde propenso a risco e autonegligência foram aqueles que tiveram associação nas três categorias de requisitos de autocuidado. ambos tiveram importante relação com a manutenção do equilíbrio entre atividade e repouso e com a prevenção dos perigos à vida humana, com buscar e garantir assistência médica apropriada e com realizar medidas prescritas. quanto a esses aspectos, estudo mostra que os pacientes que apresentam falta de conhecimento sobre seu tratamento e não aderem à terapêutica prescrita, geralmente, desconhecem as medicações em uso e suas indicações (26). o conhecimento deficiente dos pacientes sobre sua doença pode estar associado às complicações no seu estado de saúde. portanto, para a compreensão da doença, o profissional de saúde deve oferecer aos pacientes informações completas e esclarecedoras, que propiciem a melhoria do seu tratamento e empodere-os em todo o processo de saúde-doença (20). o diagnóstico de débito cardíaco diminuído foi associado ao requisito universal referente à manutenção de ingesta insuficiente de ar e à manutenção do equilíbrio entre atividade e repouso. esse diagnóstico representa a insuficiência do coração como bomba e também foi identificado em outra pesquisa com cardiopatas hospitalizados, incluindo pessoas com insuficiência cardíaca e iam (25). esse diagnóstico também tem relação com o padrão respiratório ineficaz, o qual esteve relacionado à dor, tendo como requisito universal a manutenção de ingesta suficiente de ar. a dor aguda no iam tem duração de 15 a 30 minutos, mas pode perdurar e desencadear outras alterações fisiológicas, tais como a elevação da frequência cardíaca e respiratória, a dispneia e a fadiga (11). o diagnóstico risco de síndrome do idoso frágil foi observado em alguns pacientes que não estavam adaptados ao envelhecimento, apresentando capacidade de autocuidado negativa. ressalta-se que esse diagnóstico foi prevalente entre os aposentados. nesse contexto, todos os idosos, antes de alcançarem idades avançadas, merecem atenção com vistas à manutenção 231 diagnósticos de enfermagem segundo a teoria do autocuidado em pacientes com infarto do miocárdio l gilmara holanda da cunha e outros da independência, pois os idosos que possuem envelhecimento ativo tendem a permanecer mais independentes, e a manutenção dessa condição é primordial para retardar incapacidades (27). ansiedade foi um diagnóstico que teve relação com o aumento da idade e com a situação ocupacional de aposentado. tem-se que as doenças cardiovasculares, sobretudo o iam, trazem limitações à qualidade de vida. além disso, essas doenças e suas complicações ocasionam sinais e sintomas emocionais associados ao medo da morte e da dor; devido a isso, alguns pacientes possuem ansiedade (24-25). quanto ao conforto prejudicado, estudo mostra que esse é um diagnóstico comum em pacientes com iam e também naqueles submetidos a exames, procedimentos diagnósticos, cirurgias e hospitalizações, visto que esses processos interferem na rotina de vida diária e podem causar desconforto físico e mental aos pacientes (28-29). conclusão a aplicação do formulário segundo a teoria do autocuidado de orem foi eficaz para a coleta de dados e contribuiu no raciocínio clínico, facilitando a identificação dos déficits de autocuidado e os de de pacientes com iam. a maioria dos pacientes era mulher, na faixa etária de 60 a 69 anos, renda familiar de um a dois salários-mínimos, com ensino fundamental e aposentados. houve alta frequência de hipertensão arterial, inatividade física e tabagismo. o teste rápido para troponina foi positivo em 16 pessoas. foram identificados 10 de, destacando-se estilo de vida sedentário, mobilidade física prejudicada e risco de intolerância à atividade, o que evidencia a necessidade de assistência em saúde para mudanças no estilo de vida, medidas de conforto e realização de atividade e repouso. diante disso, a equipe de saúde deve estar atenta às alterações que provocam instabilidade psicológica e hemodinâmica nos pacientes, para observar precocemente as complicações de saúde. em especial os enfermeiros, em seu processo de cuidar, devem identificar os diagnósticos com o intuito de sistematizar o cuidado de forma eficaz, holística e individualizada. a limitação do estudo foi a dificuldade na coleta de dados, visto que o iam é um evento grave. houve muitos pacientes abordados, mas somente a amostra contemplada neste estudo foi capaz de participar da pesquisa por estar hemodinamicamente mais estável e receptiva a interagir com os pesquisadores. isso mostra a importância do estudo, por indicar as necessidades de saúde dos pacientes com iam, de forma a contribuir para uma assistência mais rápida e direcionada, que facilite as intervenções de enfermagem. devido à importância da assistência de enfermagem ao paciente em estado crítico, recomenda-se a realização de novas pesquisas que abordem a temática, para que o cuidado seja realizado de forma pertinente e rápida, com vistas à estabilização do paciente em tempo hábil. assim, este estudo apresenta novos desafios para a enfermagem, ao mesmo tempo que contribui para a execução do trabalho por parte da equipe de saúde, sobretudo, em relação aos aspectos em que esta deve intervir junto às pessoas com iam. conflito de interesse: nenhum declarado. 232 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 referências 1. dessotte cam, silva fs, furuya rk, ciol ma, hoffman jm, dantas ras. somatic and cognitive-affective depressive symptoms among patients with heart disease: differences by sex and age. rev latino-am enferm. 2015;23(2):208-15. 2. araújo if, santos isc, la longuiniere 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clinical nursing care to comfort women with acute myocardial infarction. text context nursing. 2014;23(1):56-64. 69 79 contextos de cuidado a crianca.indd 69 stella minasi de oliveira1 giovana calcagno gomes2 daiani modernel xavier3 aline campelo pintanel4 maria pilar montesó5 laurelize pereira rocha6 contextos de cuidado à criança/adolescente com diabetes mellitus: uma abordagem socioambiental 1 orcid.org/0000-0002-1363-717x. universidade federal do rio grande, brasil. stellaminasi@furg.br 2 orcid.org/ 0000-0002-2464-1537 universidade federal do rio grande, brasil. giovanacalcagno@furg.br 3 orcid.org /0000-0003-3832-2120. universidade federal do rio grande, brasil. daianixavier@furg.br 4 orcid.org /0000-0002-50768902. universidade federal do rio grande, brasil. acpintanel@furg.br 5 orcid.org /0000-0002-0833-2152. universitat rovira i virgili, espanha. mariapilar.monteso@urv.cat 6 orcid.org /0000-0001-9334-6550. universidade federal do rio grande, brasil. laurelizerocha@furg.br recibido: 25 de enero de 2017 enviado a pares: 24 de marzo de 2017 aceptado por pares: 31 de mayo de 2017 aprobado: 19 de julio de 2017 doi: 10.5294/aqui.2018.18.1.7 para citar este artículo / to reference this article / para citar este artigo oliveira sm, gomes gc, xavier dm, pintanel ac, rocha lp. contextos de cuidado à criança/adolescente com diabetes mellitus: uma abordagem socioambiental. 2018; 18(1): 69-79. doi: 10.5294/aqui.2018.18.1.7 resumo estudo de abordagem qualitativa, de caráter exploratório, descritivo e explicativo que teve como referencial metodológico a grounded theory. objetivo: objetivou-se conhecer os diferentes contextos de cuidado à criança e ao adolescente com diabetes mellitus (dm). materiais e método: foram entrevistados 14 familiares de março a dezembro de 2015, no brasil e na espanha. os dados obtidos por meio de entrevistas foram analisados pela codificação aberta, axial e seletiva. resultados: verificou-se que a família subsidia o cuidado à criança e ao adolescente com dm principalmente no ambiente domiciliar e escolar. a comunidade e os serviços de saúde foram outros contextos referidos para o cuidado. destacaram-se o vínculo e o apoio recebidos nos serviços de saúde. citaram-se o posto de saúde, as unidades básicas, o hospital e os serviços privados como contextos nos quais se realizam exames e consultas com especialistas, além de realizarem o controle da glicemia e a avaliação periódica dos pés. as crianças e os adolescentes geralmente são internados em situações de urgência. conclusões: concluiu-se como medidas necessárias o acompanhamento, o apoio e o seguimento contínuo da criança ou do adolescente com dm nos diferentes ambientes em que transita, pois elas influenciam seu viver e podem contribuir para sua saúde. palavras-chave adolescente; criança; diabetes mellitus; enfermagem; família (fonte: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 69-79 70 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 69-79 contextos de cuidado al niño/ adolescente con diabetes mellitus: un enfoque socioambiental resumen estudio de enfoque cualitativo, de carácter exploratorio, descriptivo y explicativo, que tuvo como marco metodológico la grounded theory. objetivo: conocer los distintos entornos de cuidado al niño y el adolecente con diabetes mellitus (dm). materiales y métodos: entrevista con 14 familiares en el periodo de marzo a diciembre del 2015, en brasil y españa. se obtuvieron los datos por medio de entrevista y se analizaron por la codificación abierta, axial y selectiva. resultados: se encontró que la familia subsidia el cuidado al niño y el adolecente con dm principalmente en el entorno domiciliar y escolar. la comunidad y servicios de salud fueron otros contextos referidos para el cuidado. se destacaron el vínculo y apoyo recibidos en los servicios de salud. se mencionaron el centro de salud, las unidades básicas, el hospital y los servicios privados como contextos en los que se realizan exámenes y citas médicas con especialistas, además de realizar el control de la glicemia y el examen periódico de los pies. los niños y adolescentes en general son hospitalizados en situaciones de emergencia. conclusiones: se concluyó como medidas necesarias el acompañamiento, apoyo y seguimiento continuos del niño o adolecente con dm en los distintos entornos en que transita, pues estas influyen su vivir y pueden aportar a su salud. palabras clave adolescente; diabetes mellitus; enfermería; familia; niño (fuente: decs). 71 contextos de cuidado à criança/adolescente com diabetes mellitus: uma abordagem socioambiental l stella minasi de oliveira e outros contexts of care for children / adolescents with diabetes mellitus: a socio-environmental approach abstract this is a qualitative study of an exploratory, descriptive and explanatory nature, with the grounded theory as a methodological framework. objective: the purpose is to understand the different environments or contexts for the care of children and adolescent with diabetes mellitus (dm). materials and methods: interviews were conducted with 14 family members in brazil and spain during the period from march to december 2015. the data obtained from these interviews were analyzed through open, axial and selective coding. results: it was found that the family supports the care of the child and the adolescent with dm, mainly in the home and school environment. the community and health services were also mentioned as contexts for care. involvement with health services and the support they provide were highlighted. the health center, the basic units, the hospital and private services were cited as contexts were examinations and medical appointments with specialists are conducted, in addition to glycaemia control and regular examination of the feet. in general, children and adolescents are hospitalized in emergency situations. conclusions: guidance, support and continuous follow-up for the child or adolescent with dm in the different contexts where they find themselves are necessary to influence their lives and contribute to their health. keywords diabetes mellitus; nursing; family; child (source: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 69-79 72 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 introdução o diabetes mellitus (dm) configura-se como uma doença de alta prevalência e que tem emergido em proporções epidêmicas nos últimos anos (1). assim, apresenta grande impacto econômico e social para as famílias das pessoas que têm essa doença. apesar da gravidade do dm1, não existem medidas de prevenção para evitar o seu surgimento, e sua incidência vem crescendo ao longo dos anos (2). no reino unido, o dm1 é a terceira doença crônica mais comum na infância e, nos últimos 20 anos, sua incidência dobrou. no brasil, a incidência estimada é de 7,6 por 100 000 indivíduos menores de 15 anos, o que corresponde a 30 900 crianças diagnosticadas (1-3). é notório o impacto da doença na sociedade devido ao número crescente de pessoas acometidas, de mortes prematuras, da presença de incapacitação e de complicações decorrentes da doença e dos elevados custos em seu controle e tratamento (4). estimam-se que há cinco milhões de pessoas com dm no brasil. destas, cerca de 300 mil possuem essa patologia e são menores de 15 anos (5). o ambiente onde as crianças e os adolescentes com dm estão inseridos remetem à reflexão de como as atividades humanas provocam mudanças no comportamento e no ecossistema. o ambiente é um fator que afeta o indivíduo, a família e a comunidade, e o ecossistema é uma teia de relações entre o ambiente e tudo que habita esse determinado espaço (6). nesse sentido, o ambiente e as pessoas com quem a criança ou o adolescente com dm interage exercem forte influência na aquisição ou não de hábitos saudáveis de vida. crianças têm dificuldade de identificar os sintomas do dm, de realizar o autocuidado, essas e outras situações de cronicidade apresentam imposições de acompanhamento contínuo do tratamento. na fase da adolescência, essas dificuldades se tornam mais evidentes por estarem concomitantes às transformações físicas e emocionais (7). a criança ou o adolescente com dm deve ser cuidada como um ser humano integral (que se considerem seus aspectos biológico, social, psicológico e espiritual), que se inter-relaciona com o ambiente no qual se encontra, o que possibilita o equilíbrio e a sustentabilidade de todos os elementos participantes dessa totalidade, além de contribuir para o enfrentamento das questões relacionadas ao manejo do dm. esses indivíduos passam a conviver em diferentes espaços, com limitações e restrições em suas atividades diárias que podem levar a dificuldades para o ingresso em determinados ambientes. na escola, ambiente que a criança frequenta diariamente, pode apresentar situações embaraçosas como a ida seguida ao sanitário durante as aulas ou quanto à prática de atividades físicas. tais fatos acabam constrangendo a criança ou o adolescente no convívio social e limitando suas possibilidades de se inter-relacionar com os demais (8). essas restrições influenciam no potencial de independência da criança ou do adolescente com dm e, em consequência, interferem na realização de atividades da vida diária e na forma de se relacionar com as pessoas à sua volta (9). assim, é importante que a família conheça a respeito do dm e compartilhe com a criança ou o adolescente esses conhecimentos, a fim de auxiliar a sua adaptação na sociedade e contribuir para o bem-estar e a saúde dela. nesse contexto, pensar num ambiente familiar saudável é conceber sua família explorando as possibilidades que o espaço lhe oferece para enfrentar o dm na sua complexidade. cuidar por meio de uma perspectiva socioambiental pode contribuir para a independência dos indivíduos envolvidos. nesse sentido, o ambiente onde as pessoas se encontram exerce, de forma dinâmica e constante, influências mútuas entre os elementos que o formam, suscita modos de viver com características próprias que possibilitam o desencadeamento de uma melhor ou pior qualidade de vida (10). assim, ratifica-se a importância deste estudo, pois ele aborda o cuidado familiar à criança ou ao adolescente com dm em diferentes contextos/ambientes e preenche algumas lacunas existentes na literatura a respeito da temática. além disso, repercute diretamente na convivência familiar e no fazer dos enfermeiros, de modo a subsidiar e melhorar a atuação desses profissionais de saúde. nesse sentido, este estudo tem como objetivo conhecer os diferentes contextos de cuidado familiar à criança ou ao adolescente com dm. materiais e método trata-se de uma pesquisa qualitativa de caráter exploratório, descritivo e explicativo que teve como referencial metodológico a grounded theory (gt). a pesquisa foi desenvolvida no centro integrado de diabetes (cid) de um hospital universitário no sul 73 contextos de cuidado à criança/adolescente com diabetes mellitus: uma abordagem socioambiental l stella minasi de oliveira e outros do brasil e na associação de pais de crianças ou adolescentes com dm em tortosa, na espanha. participaram oito familiares de crianças ou adolescentes com dm que consultavam no cid (brasil) e seis familiares que frequentavam a associação de pais de crianças ou adolescentes com dm em tortosa (espanha), totalizando 14 familiares. foram estabelecidos como critérios de inclusão para a escolha dos participantes: ser o principal familiar cuidador da criança ou do adolescente com dm, acompanhá-la no cid ou na associação de pais de tortosa. foram excluídos familiares acompanhantes das crianças ou dos adolescentes que lhes prestavam cuidados apenas eventualmente. foram divididos em quatro grupos amostrais. o número de participantes e de grupos amostrais foi determinado pelo processo de amostragem teórica, como recomenda a gt. o primeiro grupo foi composto por três famílias de crianças com dm que frequentavam o cid, assim identificadas para este estudo: f1, f2 e f3. o segundo foi composto por cinco famílias de adolescentes com dm que consultavam no cid: f4, f5, f6, f7 e f8. o terceiro grupo amostral foi composto por quatro famílias de adolescentes com dm que fazem parte da associação de pais de crianças ou adolescentes com dm em tortosa: f9, f10, f11 e f12. o quarto grupo amostral foi composto por duas famílias de crianças com dm que fazem parte da mesma associação: f13 e f14. os dados foram coletados por meio de entrevistas realizadas entre os meses de março a junho de 2015 no brasil e nos meses de setembro a novembro de 2015 na espanha. para a interpretação deles, as entrevistas foram gravadas e transcritas na íntegra. as entrevistas foram utilizadas para investigar o significado construído pelas famílias acerca do cuidado socioambiental que prestam à criança ou ao adolescente com dm, em vista das interações que ocorrem no interior delas. a análise dos dados foi realizada concomitante à sua coleta, de forma comparativa e constante, seguindo os passos: codificação aberta, axial e seletiva, e posterior formulação da teoria (11-14). na codificação aberta, os dados foram examinados linha a linha, recortando-se as unidades de análise (12). em seguida, foram diferenciadas e refinadas as categorias resultantes. essa é uma fase de codificação que explicita um nível analítico mais elevado, que emerge os temas salientes e, mais analiticamente, as categorias que são extraídas dos dados relacionando-as (12; 14). a terceira etapa é conceituada como codificação teórica ou seletiva; busca a core category (14), em que se desenvolve o nível máximo de abstração conceitual. para a elaboração do nível conceitual e, consequentemente, a elaboração da teoria, será considerado o processo de glaser (1978), que recomenda a utilização de famílias de códigos na codificação teórica no intuito de agrupá-los e torná-los mais práticos e fidedignos ao estabelecer a teoria (11). foi realizada a validação das categorias e suas relações entre elas, além disso a validação destas com o tema central desta pesquisa. o modelo construído foi submetido a duas famílias de forma individual, às quais foram apresentadas as categorias formuladas até se chegar ao tema central. foram escolhidas duas famílias com características semelhantes às dos das participantes dos grupos amostrais: f15 e f16. apresentaram-se, para cada família, um resumo do estudo, os seus objetivos e o método de coleta e de análise, com o intuito que compreendessem como foram construídas as categorias, os diagramas e os quadros, e como se chegou ao modelo teórico. foram ouvidas atentamente as colocações, no sentido de confirmarem ou não o modelo elaborado, chegando a um consenso. partindo-se dessa validação, foram feitas algumas alterações no modelo, com o propósito de dar-lhe maior clareza e validá-lo. todos os preceitos éticos da resolução n.º 466/2012 do conselho nacional da saúde do ministério da saúde, que trata dos aspectos éticos para a realização de pesquisas que envolvam seres humanos (15), foram levados em consideração. o projeto foi encaminhado e submetido ao comitê de ética da universidade federal do rio grande (furg), com parecer favorável sob o n.º 15/2015, caae 40608814.7.0000.5324. todos os participantes assinaram o termo de consentimento livre e esclarecido para participar do estudo, e foram informados que poderiam desistir da participação em qualquer momento. resultados a pesquisa teve como participantes 14 familiares de criança ou adolescente com dm: 12 mães, 1 pai e 1 avó. em relação aos filhos dos colaboradores, a maioria deles era adolescente, apenas 5 eram crianças; destas apenas 1 fazia uso de bomba subcutânea de insulina. a seguir, apresentam-se as categorias temáticas do estudo. 74 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 cuidando da criança ou do adolescente no domicílio o domicílio apresentou-se como o principal contexto de cuidado. as famílias relataram que a criança ou o adolescente com dm prefere permanecer a maior parte do tempo em casa, onde recebe vigilância constante e seu cuidado é planejado. “ele fica em casa, pois a gente observa ele melhor. às vezes, ele vai para a casa da minha irmã, mas preferimos que fique em casa, onde temos tudo para cuidar melhor.” (f5) “ele não é muito de sair, porque em casa temos tudo que precisamos para manter a glicemia dele bem.” (f4) ainda referiram que preferem que as crianças ou os adolescentes recebam seus amigos em casa devido à comodidade e ao medo de que comam o que não podem e, assim, apresentem problemas de saúde. “ele convida alguns amigos para irem lá em casa[...] ele não vai para casa de ninguém. [...]. temos medo de que na casa dos outros coma tudo o que não pode. se der uma hiperglicemia já viu.” (f7) “quando nós descobrimos, eu não deixei mais ela ir para a casa das amiguinhas. eu ficava com medo, pois como iriam saber identificar que ela não estava bem? tinha que fazer a insulina, complicado.” (f3) recebendo o cuidado na escola as famílias relataram receber apoio da escola para o cuidado da criança ou do adolescente com dm nesse ambiente. “na escola, eles me ajudam bastante. quando precisam, me ligam para avisar o que houve com ela.” (f6) “a escola sabe o que ela tem e entra em contato. eles me apoiam e ajudam.” (f3) as famílias informaram a escola sobre o diagnóstico da criança ou do adolescente apresentando um documento sobre a patologia. dessa forma, todos na escola são bem-informados, controlam e documentam tudo em relação ao cuidado. “levei um papel informando que ela tem dm. eu deixei meu telefone, levei os papéis mostrando para a diretora da escola o que ela tinha e como cuidar.” (f5) “lá na zona rural, lá a escola se desconfiassem que ele não estava bem, elas só me davam uma chamadinha, todos da escola sabiam.” (f7) “[...] lá no colégio todos sabem que ele tem este problema.” (f4) “eles são muito informados, e te repassam, é tudo controlado e documentado, anotam na agenda qualquer coisa, realizam exame, tem uma monitora que ajuda no cuidado. a escola está ciente de tudo.” (f13) algumas famílias referiram que, na escola, deveria haver uma monitora que supervisionasse a criança ou o adolescente e, quando necessário, chamasse os pais ou os avós para resolverem problemas relacionados ao dm. “eu penso que precisava ter alguém só para cuidar das crianças com o dm, para ajudar a monitorar, a supervisionar. a escola teria que ter alguém que se responsabilizasse, mas não temos aqui isso.” (f3) as famílias informaram os professores e a diretoria sobre a necessidade de conhecer os sinais e os sintomas da doença, como lidar com as alterações da glicemia e sobre a possibilidade de ter um aluno com dm em sala de aula. relataram que, em algumas escolas, há um cuidador que auxilia os professores o(a) professor(a) na sala para cuidar de crianças com dm. “os professores precisam saber que não têm problema ter um aluno com dm na aula. só precisam estar atentos e conhecerem os sintomas, saber como lidar com a glicemia, quando esta está alterada.” (f9) “na escola tem um cuidador que ajuda a professora, na sala de aula. [...] eles são muito informados, é tudo muito controlado e documentado.” (f13) familiares cuidadores da espanha referiram que existe uma profissional enfermeira educadora que trabalha na pediatria do hospital e, no início de cada ano letivo, ministra cursos para os professores das escolas da cidade sobre dm. “aqui na associação temos uma educadora-enfermeira, que todo início de ano letivo, realiza um encontro só para os professores para que estes saibam como lidar com um aluno com dm na aula, conhecer os sintomas e o que fazer. como lidar com a glicemia alterada e tudo mais. levam bonecos para poder pinçar e mostrar o teste de glicemia.” (f9) 75 contextos de cuidado à criança/adolescente com diabetes mellitus: uma abordagem socioambiental l stella minasi de oliveira e outros “no colégio, há mais uns quatro ou cinco colegas que têm dm, e a enfermeira e a médica foram lá e explicaram como atuar nos casos. ensinaram os professores. eles sabem se a criança pede para comer, é porque tem que comer na hora.” (f12) a família tem medo que o(a) professor(a) se descuide e a criança ou o adolescente passe mal na escola. “tu ficas preocupada às vezes quando ela vai para o colégio, pois pode acontecer alguma coisa com ela, e não tem quem cuide lá.” (f3) “[...] mas o fato de que, no ano que vem, ele tem que ir para escola, já fico angustiada. tem várias crianças, e o professor pode se descuidar e não perceber, e algo acontecer com ele.” (f2) as famílias referiram que a criança ou o adolescente com dm é conhecida e cuidada por todos na escola —professores, merendeira e demais colegas— e que, caso a criança ingira alguma alimentação que não possa, a família é rapidamente avisada pela escola. “qualquer problema eles olham; se ela está comendo alguma coisa, eles ligam, eles falam, nos orientam, todos cuidam dela. a alimentação da escola também mudou para ela poder comer.” (f6) “e, no colégio, chegando, eu encontrei o diretor, o tutor e a psicóloga infantil da escola, e todos sabiam da doença dele.” (f10) cuidando da criança e do adolescente na comunidade a família refere que recebia auxílio no cuidado com a criança ou adolescente quando residia na zona rural, mas que não tinha mais condições de ficar morando lá por causa da distância da residência com os serviços de saúde. assim, mudaram-se para a cidade para poder cuidar melhor do seu filho. “todos me ajudavam lá na ilha, mas tive que me mudar, não tinha mais condições de ficar morando lá por causa dele. demorava muito para chegar até a cidade. faz uns três anos que me mudei, que estou na cidade.” (f7) outra família refere que não há nenhum problema em se deslocar com a criança e que é possível conviver na comunidade e realizar o cuidado nela. “levo uma vida normal, não há nenhum problema. vamos a todos os lugares, a festas de aniversários, a todos os lugares. só preciso levar um lanchinho e os aparatos.” (f14) recebendo cuidado nos serviços de saúde a família procura criar vínculos com os serviços de saúde para o atendimento à criança e ao adolescente com dm. os participantes desta pesquisa referiram que, nesses locais, encontram apoio e acolhimento. “continuo indo no posto de saúde. sou muito bem recebida. todos já nos conhecem lá.” (f1) “pego a insulina dela no posto. é onde temos vínculo e recebemos apoio.” (f4) a família procura atendimento na atenção básica de saúde para realizar consulta com o médico, solicitação e aquisição dos aparatos necessários para o cuidado e, ainda, para a realização de exames de rotina. “esses tempos a glicose queria subir. o postinho perto de casa estava em obras, então levamos em outro posto de saúde.” (f4) “não, só no posto de saúde que a levamos. é bom, não tenho muito que reclamar.” (f6) a família também é usuária de serviços privados onde faz consultas que encaminharão para a realização de exames e para receber atendimento com médico endocrinologista. “nós levamos o resultado na assistência privada. meu ex-marido falou assim: ‘— vamos fazer um exame nela que, de repente, é alguma coisa.’ na época, tinha o convênio e nós fizemos. ter esse convênio nos possibilitou o diagnóstico rápido e o acesso ao especialista.” (f5) “a gente conseguiu umas consultas para ele pelo convênio com outro profissional endocrinologista.” (f2) a família relata que recebe atendimento médico especializado somente do médico, e não de outros profissionais da saúde. já outras relataram procurar especialistas (endocrinologista, oftalmologista, dentista) e levar a criança ou o adolescente a essas consultas especializadas mensalmente, além de realizar avaliação periódica dos pés. “eu levava na médica pediatra e depois no endocrinologista que atende aqui.” (f1) 76 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 “cada um mês, um mês e meio, vão às consultas com o médico endocrinologista, e levam em todos os especialistas e fazem todos os exames. e é muito bom, pois há um controle de oftalmologista, tem controle de dentista, tem controle dos pés, de tudo.” (f13) as famílias referiram fazer consulta médica semanalmente quando a doença foi diagnosticada e, logo depois, apenas uma vez por mês. tendo a estabilização do quadro clínico, a consulta passa a ser trimestral. “no início íamos uma vez por semana, e depois íamos uma vez por mês e agora a cada três meses.” (f12) “íamos uma vez por semana depois passou para uma vez por mês agora é a cada três meses a consulta.” (f1) a família procura ser atendida por uma instituição pública; na espanha, é a associação de pais de crianças e adolescentes com dm. “é uma instituição pública de pais que têm filhos diabéticos, onde presta ajuda aos outros pais que têm filhos com dm, uns ajudam os outros.” (f9) recebendo cuidado no hospital a família refere ser bem-atendida no ambiente hospitalar, pois realizavam um cuidado com qualidade e atenção. “a enfermeira do hospital foi bem atenciosa e me ensinou a aplicar a insulina. ela que me disse que eu precisava fazer para cuidar dela. não tenho muito do que reclamar.” (f6) “o hospital foi muito bom. atenderam meu filho muito bem, tinha uma enfermeira que sabia de tudo.” (f10) discussão após receber o diagnóstico de dm da criança e do adolescente, a família passa a cuidá-la em diferentes contextos, pois cada ambiente de convivência exige formas diversas de cuidados. a família precisa conhecer os diferentes ambientes para que a criança ou o adolescente possa adquirir habilidades e competências para transitar por eles de forma que possa garantir seu cuidado de forma competente. os diferentes contextos de (con)vivência da criança e do adolescente com dm precisam estar preparados para recebê-la. o dm, seus sinais e sintomas, e formas de mantê-los dentro da normalidade precisam ser conhecidos por todos e em cada um deles são necessárias pessoas com conhecimentos, habilidades e competências para o cuidado. o domicílio, a escola, a comunidade e os serviços de saúde foram citados pela família como ambientes em que precisam ser cuidadas. verificou-se que o domicílio sinaliza ser o principal ambiente de cuidado à criança e ao adolescente com dm. esse ambiente pode ser cercado por sinais e símbolos interpretados pela família que suscitem nela reações, conforme os significados atribuídos a essa experiência. o ambiente domiciliar é o primeiro espaço de convivência social da criança. nele, são construídos suas referências, conceitos e valores que traçarão sua personalidade e determinarão sua forma de atuação nas diferentes etapas da vida (16). quando se associa o dm com a infância, é indispensável a presença de um cuidador para aprender a lidar com sintomas, procedimentos terapêuticos e habilidades para o aprendizado do controle metabólico (17). um estudo que objetivava conhecer as percepções dos familiares sobre as situações de vulnerabilidade e seus componentes, relacionadas com o ambiente ecológico de crianças e adolescentes que convivem com doenças crônicas, mostrou que o familiar passa por um momento de ajustamento ao novo fato, de maneira única, uma vez que cada um tem histórias de vida e experiências diferentes. assim, mães jovens e imaturas amadurecem rapidamente, mobilizam forças, coragem e superação interiores, pois são o cerne da rede social, sustentáculos da vida dessas crianças ou adolescentes (18 -21). boa parte do tempo das crianças é transcorrida em interações familiares no domicílio, o que reforça a necessidade de compreender a influência familiar no desenvolvimento infantojuvenil (19). além da importância da família na socialização e na adaptação das crianças ou dos adolescentes com dm, a família também é a responsável por sua inserção nos diversos espaços que coabitam. a comunidade também faz parte do ambiente em que a criança ou o adolescente transita e deve incentivá-la, juntamente com a família, a se movimentar, a brincar e a se relacionar com outras pessoas. envolver a família e as relações existentes com os demais membros que compõem essa rede poderá firmar laços e vínculos no gerenciamento desse cuidado (20-21). 77 contextos de cuidado à criança/adolescente com diabetes mellitus: uma abordagem socioambiental l stella minasi de oliveira e outros ao receber o cuidado na escola, a criança ou o adolescente mostrou que esse espaço é de extrema importância e relevância, e que nele há a socialização e a convivência com pessoas que estão habilitadas a passar seus ensinamentos. tendo em vista que a escola é um ambiente no qual a criança ou o adolescente passa grande parte do seu tempo, é importante que os profissionais da educação estejam aptos a proporcionar-lhes essa atenção; para isso, é preciso capacitação no que diz respeito à doença para que a criança e o adolescente possam se sentir seguros. a escola deveria ser um ambiente estimulador, onde há mediação de condições que favoreçam a realização do autocuidado (22). nesse sentido, é necessário informar a escola acerca do diagnóstico da criança ou do adolescente para, assim, ter o seu apoio. embora o professor possa verificar as mudanças no modo de agir e na aparência da criança ou do adolescente com dm, é preciso que esteja apto a tomar a decisão certa sobre que atitude ter diante dessas situações (8). existe uma necessidade de que as escolas apresentem recursos, humanos e materiais, compatíveis com as condições de aprendizagem da criança e do adolescente. para isso ser possível, os professores precisam apresentar uma formação adequada; além de deter o conhecimento específico da sua área de atuação, deveriam apresentar, no mínimo, conhecimentos gerais sobre a saúde dos escolares (8). é fundamental saber compreender e identificar as necessidades dos escolares com dm, pois, dessa maneira, todos passariam a cuidá-los nesse ambiente. esse é um passo importante para que se alcance um planejamento intersetorial, já que o conhecimento das especificidades do aluno por parte de todos os que atuam nesse ambiente contribuiria para uma melhor atenção à sua singularidade (23). recebendo cuidado nos serviços de saúde mostrou que a família busca assistência na atenção básica de saúde, no hospital, em serviços de saúde privados e especializados, sendo atendida no cid no brasil e tendo acolhimento de instituições públicas de pais de filhos diabéticos na espanha. a informação adequada e compreensível contribui diretamente para o fortalecimento da família nesse momento angustiante (4). torna-se necessária a compreensão do significado de ser adolescente e criança e viver com uma doença crônica como o diabetes, pois, somente quando houver a compreensão desses sentimentos, a equipe de enfermagem conseguirá oferecer uma assistência com melhor eficácia, que atue em diferentes esferas de atendimento (7). os problemas no serviço público de saúde, vivenciados pelo familiar ao buscar a assistência médica para a criança ou o adolescente, levam à procura por atendimento em serviços privados, o que eleva ainda mais os gastos com consultas médicas. em estudo realizado sobre a doença e os sentimentos das mães de adolescentes que possuem o dm, evidenciou-se que os aspectos socioeconômicos e a assistência recebida pelo sistema de saúde influenciam diretamente na maneira de conviver com a doença e de seguir o tratamento (24). os profissionais de saúde podem contribuir no sentido de ajudar os familiares a manterem o equilíbrio, integrando o cuidado com práticas educativas, uma vez que o recebimento de informações sobre a doença contribui para o desenvolvimento de um círculo de confiança entre os envolvidos. o uso do referencial metodológico gt propiciou a importância de colocar-se no lugar das famílias que vivenciam a situação de cronicidade em seus filhos; além disso, possibilitou um entendimento singular das percepções dos familiares cuidadores nesse contexto. conclusões a criança ou o adolescente com dm é cuidada em diferentes contextos: no domicílio, na escola, na comunidade e nos serviços de saúde. o domicílio surge como principal ambiente onde a família vivencia o cuidado. no contexto escolar, constatou-se que professores e funcionários precisam aprender formas diferenciadas de manejar situações cronicidade que a doença impõe e enfrentálas. para proporcionar esse cuidado, é preciso que haja interação entre os profissionais da educação e a família da criança ou do adolescente com dm. a distinta relação entre a criança ou o adolescente com dm e os ambientes em que coabitam gera repercussões em todo o sistema, pois essas interligações são constantes e necessitam de um acompanhamento com subsídios para o gerenciamento desse cuidado. percebe-se que os ambientes influenciam o viver desses indivíduos e podem contribuir ou não para sua saúde. pensar socioambientalmente significa perceber a realidade de maneira dinâmica, viva e intensa, compreendendo que as modificações 78 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 que ocorrem a todo o momento resultam em novas posturas que vão sendo diariamente reorganizadas. portanto, é necessário estar consciente que a criança ou o adolescente com dm é e existe em sua totalidade e está inserida em diferentes ambientes, e que estes podem influenciar de forma positiva ou negativa na sua experiência com a doença e no seu viver. conhecer acerca desse tema pode contribuir para que a família, a escola e os profissionais de saúde possam intervir a partir de uma abordagem socioambiental. pretende-se seguir com pesquisas voltadas às famílias de crianças e adolescentes com dm com a finalidade de embasá-las para o cuidado, minimizando suas dificuldades e auxiliando-as na construção de novas estratégias. conflito de interesse: nenhum declarado. referências 1. international diabetes federation. idf diabetes atlas. brussels/belgium: international diabetes federation; 2015. 2. malaquias t da sm, marques cdc, faria ac de p, pupulim jsl, marcon ss, higarashi ih. cogitare enferm. 2016; 21(1):1-7. 3. sociedade brasileira de diabetes. diretrizes. tratamento e acompanhamento do diabetes mellitus. são paulo: sociedade brasileira de diabetes; 2015. 4. souza de ivb, marques dka, lacerda orm, collet n. percepção das mães frente ao diagnóstico do filho com diabetes mellitus tipo 1. cogitare enferm. 2011; 16(1):43-8. 5. nascimento lc, amaral mj, sparapani v de c, fonseca lmm, nunes mdr, duppas g. diabetes mellitus tipo 1: evidências da literatura para seu manejo adequado, na perspectiva de crianças. rev. esc. enferm. usp. 2011; 45(3):764-9. 6. laustsen g. environment, ecosystems and ecological behavior — dialogue toward developing nursing ecological theory. adv nurs sci. 2006; 29(1):43-54. 7. cavini fl, gonçalves ka, cordeiro sm, moreira, d da s, resck zmr. vivências de adolescentes com diabetes: uma abordagem fenomenológica. rev enferm ufpe on-line. 2016; 10(supl. 2):805-13. 8. simões al de a, stacciarin tsg, poggetto mtd, maruxo hb, soares hm. conhecimento dos professores sobre o manejo da criança com diabetes mellitus. texto contexto enferm. 2010; 19(4):651-7. 9. costa csl, prette ad. estudo comparativo de observação de habilidades sociais de gêmeas com e sem cegueira. rev. educ. espec. 2012; 25(42):75-88. 10. zamberlan c, calvetti am de, deisvaldi j, siqueira hch. ambiente, saúde e enfermagem no contexto ecossistêmico. rev bras enferm. 2013; 66(4),603-6. 11. glaser bg. theoretical sensitivy. mill valley, ca: the sociology press; 1978. 12. strauss a, corbin j. pesquisa qualitativa: técnicas e procedimentos para o desenvolvimento de teoria fundamentada. porto alegre: artmed; 2008. 13. strauss a, glaser bg. anguish: a case history of a dying trajectory. mill valley: the sociology press; 1970. 14. tarozzi m. o que é grounded theory? são paulo: vozes; 2011. 15. brasil. ministério da saúde. conselho nacional de saúde. resolução n.º 466, de 10 de outubro de 2012. brasília: ministério da saúde; 2012. 16. bhalerao sa, tandon m, singh s, dwivedi s, kumar s, rana j. visual impairment and blindness among the students of blind schools in allahabad and its vicinity: a causal assessment. indian j ophthalmol. 2015; 63(3):254-8. 17. martins emcs, ataíde mbc, silva dma, frota ma. vivência de mães no cuidado à criança diabética tipo 1. rev rene. [internet] 2013 [acessado em 20 out. 2016]; 14(1),42-9. disponível em: http://www.redalyc.org/html/3240/324027985006/ 18. pedroso mlr, motta mgc. cotidianos de famílias de crianças convivendo com doenças crônicas: microssistemas em intersecção com vulnerabilidades individuais. rev gaucha enferm. 2010; 31(4),633-9. 79 contextos de cuidado à criança/adolescente com diabetes mellitus: uma abordagem socioambiental l stella minasi de oliveira e outros 19. turiel e. domain specificity in social interactions, social thoughts and social development. child development. 2010; 81(3),720-6. 20. dias lm, gallo mta. a intervenção precoce em crianças com déficit visual: percepção dos pais. revista benjamin constant. 2010; (47). 21. pennafort vps, queiroz mvo, nascimento lc, guedes mvc. network and social support in family care of children with diabetes. rev bras enferm [internet]. 2016; 69(5):856-63. doi: http://dx.doi.org/10.1590/0034-7167-2015-0085 22. zhu jf, zou hd, he xg, lu ln, zhao r, xu hm, et al. cross-sectional investigation of visual impairing diseases in shanghai blind children school. chin med j (engl). 2012; 125(20):3654-9. 23. bomfim dp, braga tms, filho ds. o aluno com diabetes: como contribuir para atender às necessidades do aluno com diabetes. marília-sp: associação nacional de assistência ao diabético (anad); 2011. 24. leal dt, fialho fa, andrade f, dias imav, nascimento l, arruda wc. a vivência dos familiares de crianças e adolescentes portadores de diabetes mellitus tipo 1. rev. eletrônica enferm. [internet]. 2012; 14(1):189-96. disponível em: http://www.fen.ufg.br/revista/v14/n1/v14n1a22.htm 6 importancia.p65 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200544 año 5 vol. 5 nº 1 (5) 44-55 chía, colombia octubre 2005 maría elisa moreno fergusson1 recibido: 26 de mayo de 2005 aprobado: 17 de agosto de 2005 resumen la disciplina de enfermería ha tenido un desarrollo significativo desde los inicios del siglo xx, lo cual se evidencia en la formación de posgrado, y en el desarrollo de modelos conceptuales y teorías de enfermería, como producto de la actividad investigativa. el artículo destaca la importancia de llevar estos modelos y teorías a la práctica, como una estrategia para fortalecer el conocimiento disciplinar, con las consecuentes repercusiones en términos de calidad, autonomía y visibilidad del cuidado de enfermería. se presenta la experiencia de la aplicación del modelo de adaptación de roy como marco de referencia de las asignaturas del campo de fundamentación profesional en la facultad de enfermería de la universidad de la sabana, las etapas que se siguieron para su implementación y los resultados obtenidos. palabras clave modelos conceptuales, conocimiento de enfermería, modelo de adaptación de roy, educación en enfermería. abstract from the early years of the xx century, the discipline of nursing has had an important development, evidenced in post graduate formation, and in the development of conceptual models and nursing theories, as a product of investigative activity. the article highlights the importance of taking these models and theories into practice, as a strategy to strength disciplinary knowledge, with the corresponding repercussions in terms of quality, autonomy and visibility in nursing care. the experience of the application of the roy adaptation model is presented as a frame of reference of the professional foundation subjects at the nursing school of universidad de la sabana, the steps followed for its implementation and the results obtained. key words conceptual models, nursing knowledge, roy adaptation model, nursing education. 1 enfermera especialista en enfermería cardio-respiratoria, universidad nacional de colombia; profesora asociada universidad de la sabana, colombia. mariae.moreno@unisabana.edu.co experiencia de la facultad de enfermería de la universidad de la sabana importancia de los modelos conceptuales y teorías de enfermería: experiencia de la facultad de enfermería de la universidad de la sabana 45 n los últimos sesenta años el desarrollo de la enfermería como disciplina ha sido innegable, y esto se debe fundamentalmente al ingreso de enfermeras a programas de posgrado, como maestrías y doctorados, que han promovido el interés por el desarrollo del conocimiento y la investigación. como consecuencia de lo anterior se han desarrollado modelos conceptuales y teorías de enfermería que definen la disciplina y explican su razón de ser, sus principios científicos y filosóficos, y sus valores. en la medida en que éstos se han expandido, se han desarrollado teorías de mediano alcance que buscan operacionalizar conceptos específicos para facilitar su aplicación en la práctica (1). estos avances tan significativos no se aprecian en los diferentes escenarios de la práctica. algunos de los factores que han influido en esta situación son, según gunther (2), que muchas enfermeras continúan fundamentando su práctica en el modelo médico, lo cual les dificulta profundizar sobre aspectos que son de especial interés para el desarrollo del conocimiento de enfermería, generar teorías e indicadores de calidad. la calidad hace referencia a la visión de la realidad de enfermería, su lugar y su relación con la sociedad y su base de conocimientos única; los modelos facilitan establecer indicadores de calidad para enfermería, por esta razón, si se utilizan modelos prestados de otras disciplinas, ¿cómo se puede medir la calidad del cuidado de enfermería? por otra parte, hay una falta de credibilidad de las enfermeras en el desarrollo teórico de enfermería, y muchas asocian la aplicación de modelos con la elaboración de planes de cuidado que demandan una gran cantidad de tiempo y, en la práctica, son imposibles de aplicar por el elevado volumen de pacientes que tienen a cargo. según wimpenny (4), las enfermeras sienten que si no elaboran un trabajo escrito no están aplicando un modelo. es decir, en realidad no es claro para las enfermeras que los modelos son esquemas mentales que orientan la práctica, y constituyen un aspecto esencial de su pensamiento lógico para la toma de decisiones relacionadas con el cuidado de las personas. otro factor que influye en forma definitiva, es que las enfermeras cada día y con mayor frecuencia desarrollan actividades de carácter administrativo, que ocupan la mayor parte de su tiempo. las entidades de salud han delegado en los profesionales de enfermería la función de garantizar el cumplimiento de los procesos de normalización y estandarización de la calidad, atender las demandas de las normas legales y de auditoría en los servicios, y garantizar el cumplimiento de órdenes de otros profesionales. si bien no existe ninguna duda de la importancia de estos procesos, los profesionales de enfermería han delegado en el personal auxiliar el cuidado directo de las personas que, hasta hace no muchos años, era una actividad primordial por ser la fuente principal de su conocimiento. la falta de oportunidades para cuidar a otros empobrece el desarrollo disciplinar y éste puede ser uno de los factores que lamentablemente ha influido en que se esté desdibujando la práctica del cuidado holístico y sea cada vez más notoria la falta de reconocimiento social y de autonomía de los profesionales de enfermería. los cambios en las políticas de salud, la propuesta del gobierno de reglamentar la formación del recurso humano para las profesiones de este campo, la situación económica del país, y la necesidad de las instituciones de salud de demostrar resultados en términos de rentabirevista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200546 lidad, han reducido las oportunidades de trabajo para las enfermeras, y en los equipos interdisciplinarios muchas veces se decide contratar auxiliares y promotores de salud, en lugar de profesionales de enfermería con el propósito de reducir los costos. esto en la realidad significa que el impacto de sus intervenciones no es evidente en la salud de la población. ante esta situación crítica es importante tomar medidas de fondo, lograr un punto de equilibrio entre el cuidado del paciente y el control administrativo de los servicios para asumir un verdadero liderazgo. las enfermeras reclaman autonomía profesional, para lo cual han desarrollado un conocimiento y tienen un campo de dominio propio, que las orienta hacia las verdaderas metas de enfermería y les dan una perspectiva global del servicio donde se desempeñan (5). el propósito de este artículo es analizar la importancia de los modelos conceptuales y las teorías para la práctica, y presentar una estrategia para su implementación fundamentada en la experiencia de la facultad de enfermería de la universidad de la sabana, con el modelo de adaptación de callista roy. importancia de los modelos conceptuales y las teorías de enfermería las profesiones y disciplinas del área de la salud deben tener una visión clara de los principios científicos y filosóficos que orientan su práctica profesional, para actuar en concordancia con ellos. un modelo conceptual provee un marco de referencia para la práctica; estos modelos están fundamentados en principios filosóficos, éticos y científicos que reflejan el pensamiento, los valores, las creencias y la filosofía que tienen sobre la práctica de enfermería quienes los han propuesto. fawcett (6) los define como �un grupo de conceptos abstractos y generales que no pueden apreciarse directamente en la realidad; representan el fenómeno de interés de la disciplina, las proposiciones que describen estos conceptos y las proposiciones que establecen una relación entre ellos� (6). sánchez (7) los describe como guías teóricas que orientan la práctica. las teoristas en sus modelos conceptuales, presentan unas proposiciones fundamentadas en grandes teorías y corrientes filosóficas que definen desde su perspectiva particular los conceptos del modelo; plantean cómo se relacionan éstos entre sí y cómo deben establecerse las relaciones entre el profesional de enfermería y la persona que se cuida, además, describen las etapas del proceso de enfermería. en los modelos se refleja la estructura sustantiva o conceptual y la estructura sintáctica de la disciplina. la conceptual describe los conceptos y explica qué es y qué no es enfermería; su campo de interés y los métodos de indagación que deben utilizarse. la estructura sintáctica ayuda a las enfermeras a comprender los talentos, las destrezas y las habilidades que debe desarrollar; describe los datos que deben ser recolectados para demostrar el impacto de enfermería en la práctica (8, 9). por todo lo anterior, contribuyen a generar nuevo conocimiento e indicar en qué dirección debe desarrollarse la enfermería en el futuro. meleis (10) sostiene que los modelos conceptuales constituyen una carta de navegación para la práctica. evitan que ésta se base en preconcepciones, intuiciones, las enfermeras reclaman autonomía profesional, para lo cual han desarrollado un conocimiento y tienen un campo de dominio propio, que las orienta hacia las verdaderas metas de enfermería y les dan una perspectiva global del servicio donde se desempeñan. importancia de los modelos conceptuales y teorías de enfermería: experiencia de la facultad de enfermería de la universidad de la sabana 47 rutinas y rituales, refuerzan la identidad de las enfermeras como enfermeras al crear un pensamiento y un lenguaje compartido entre quienes las siguen, refuerzan la importancia del ser humano como centro de atención para el cuidado y, de esta manera, permiten identificar con mayor claridad cuál es la contribución de las enfermeras, como parte de un equipo interdisciplinario, a los servicios de salud. algunas enfermeras aceptan estos planteamientos como válidos; sin embargo, son escépticas en el momento de aplicarlos. esto se debe fundamentalmente a la complejidad y elevado nivel de abstracción de los modelos conceptuales, y al lenguaje que utilizan, el cual en ocasiones consideran incomprensible. según marriner (11) en la actualidad existen alrededor de veinticinco modelos conceptuales o grandes teorías y, dada la complejidad de la práctica y las escuelas que han influenciado el pensamiento de sus autores, es casi imposible pensar que algún día se pueda plantear un único modelo para enfermería (12, 13). según colley (14), las teorías se han clasificado de las siguientes formas: 1. según su función: como descriptivas, explicativas, predictivas y prescriptivas. 2. según la posibilidad de generalización de sus principios: metateorías, grandes teorías, teorías de mediano rango, teorías prácticas. 3. según los fundamentos filosóficos que las soportan: teorías de necesidades, teorías de interacción, teorías de resultados y teorías humanísticas. de la misma manera en que es variada su clasificación, lo es también el abordaje para su aplicación como marco de referencia en los diferentes escenarios de la práctica. los profesionales que desean implementar o, según fawcett (6), �traducir� un modelo conceptual en la práctica, pueden iniciar este proceso analizando el significado que tiene cada uno de los elementos del metaparadigma (persona, enfermería, salud y ambiente), y con base en éstos determinar su visión filosófica, llegando a acuerdos que les permitan emplear un lenguaje y una perspectiva común para todos los miembros de esta comunidad. otro abordaje consiste en analizar los supuestos científicos y filosóficos de los modelos conceptuales vigentes, revisar el nivel de desarrollo y el grado de expansión que han tenido desde que fueron propuestos, los campos de aplicación y, con base en éstos, escoger aquel que esté acorde con la misión y la filosofía de la institución y del departamento de enfermería. el modelo conceptual que se aplica en un currículo provee los lineamientos generales de los contenidos y de las estrategias de enseñanza-aprendizaje que deben emplearse, y otorga una visión particular a la educación en enfermería. jaqueline fawcett (6) sostiene que la estructura curricular y los procesos educativos se especifican en cinco reglas que son inherentes a cada modelo conceptual: 1. la primera regla identifica el enfoque distintivo del currículo y los propósitos que deben abarcarse con la educación de enfermería. 2. la segunda regla identifica la naturaleza general y la secuencia del contenido que será presentado. 3. la tercera regla identifica los escenarios en los cuales ocurrirá el proceso educativo. el modelo conceptual que se aplica en un currículo provee los lineamientos generales de los contenidos y de las estrategias de enseñanza-aprendizaje que deben emplearse, y otorga una visión particular a la educación en enfermería. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200548 4. la cuarta regla identifica las características de los estudiantes. 5. la quinta regla identifica las estrategias de enseñanza aprendizaje que se utilizarán (6). sostiene, además, que los fundamentos teóricos del currículo deben contemplar teorías de las ciencias básicas, de las ciencias humanas y de la educación. asimismo, deben establecerse indicadores empíricos, experiencias clínicas y tareas adecuadas que permitan alcanzar los fines propuestos en el proyecto educativo del programa. a continuación se presentará el proceso de aplicación del modelo de adaptación de callista roy en la facultad de enfermería de la universidad de la sabana, como marco de referencia del programa de pregrado y de la especialización en enfermería en cuidado crítico pediátrico. modelo roy en la universidad de la sabana primera etapa tal vez la primera etapa de este proceso es el deseo y la decisión de lograr un cambio positivo y novedoso para enfermería, en el que deben estar de acuerdo las personas encargadas de desarrollarlo y contar con el apoyo de los directivos de la institución. a las fundadoras de la facultad de enfermería de la universidad de la sabana se les sugirió que siendo éste un programa cuyo propósito era preparar profesionales para el siglo xxi, y reuniendo las características que se requieren para asumir este reto, debía tener como marco de referencia un modelo conceptual. en el caso particular de la aplicación de un modelo en la facultad de enfermería de la universidad de la sabana, se realizó un estudio exhaustivo de los modelos que habían tenido un mayor nivel de desarrollo y cuya filosofía estuviera acorde con los principios expresados en el proyecto educativo de la universidad y en el programa, entre los cuales vale la pena mencionar: � la universidad respeta la singularidad de la persona como miembro de la comunidad educativa, reconociendo y estimulando su creatividad, su libertad, su sociabilidad y su expresividad. � vela, entre otros aspectos, por �la dignidad trascendente de la persona, la defensa incondicional de la vida humana, la familia como institución primaria de la sociedad, la justa convivencia y la cooperación entre los hombres, siempre ordenados al bien común� (15). los supuestos filosóficos del modelo de adaptación de callista roy se asocian con los principios del humanismo y de la veritivity: � el humanismo es una corriente filosófica y psicológica en la cual se considera esencial conocer y valorar todas las dimensiones de la persona. roy sostiene que las personas como individuos o en grupos comparten un poder creativo, tienen un propósito para su existencia, poseen un holismo intrínseco, buscan mantener la integridad y se dan cuenta de la necesidad de establecer relaciones con los demás (16). � la veritivity es un término acuñado por roy, relacionado con un propósito común de la persona humana que trasciende hacia lo espiritual, a la actividad y creatividad para el bien común, y al valor y significado de la vida. veritivity es un término acuñado por roy, relacionado con un propósito común de la persona humana que trasciende hacia lo espiritual, a la actividad y creatividad para el bien común, y al valor y significado de la vida. importancia de los modelos conceptuales y teorías de enfermería: experiencia de la facultad de enfermería de la universidad de la sabana 49 se escogió el modelo de adaptación de callista roy porque los supuestos filosóficos que plantea y los principios de la universidad, descritos anteriormente, son congruentes; ambos están fundamentados en el humanismo y en la visión cristiana del hombre. su importancia, en el momento de escogerlo como marco de referencia para el plan de estudios, radica en que estos principios determinan un sello particular sobre las creencias, los valores y la forma como se espera que practiquen la enfermería tanto los docentes como los estudiantes y egresados de la universidad de la sabana. segunda etapa en esta etapa se tomaron decisiones sobre la organización del plan de estudios: se determinaron las asignaturas del campo de formación básico, del campo de formación humanístico, del profesional específico y del instrumental, que se consideraba eran esenciales para la formación de los estudiantes. en el campo de formación profesional, las asignaturas se organizaron teniendo en cuenta las etapas del ciclo vital, y sus contenidos se desarrollaron tomando como base los elementos estructurales del modelo y las etapas del proceso de enfermería propuestas por la doctora roy. en el desarrollo de esta fase los docentes identificaron que a pesar de los esfuerzos realizados en forma individual y en grupo para comprender el modelo, había algunas inconsistencias en su interpretación, situación que afectaba el desarrollo de las asignaturas de enfermería. por esta razón surgió la necesidad de realizar un estudio más profundo del modelo, y un análisis del estado del arte. la bibliografía disponible en español no reflejaba la expansión que había tenido el modelo, la cual era evidente en otras publicaciones más recientes, como los libros de las doctoras jaqueline fawcett y afaf meleis, los artículos publicados en revistas indexadas y especialmente en la segunda edición del libro sobre el modelo de adaptación de roy publicado en los estados unidos, en 1999. por esta razón se decidió organizar un grupo de estudio sobre el modelo, con la participación de todos los docentes de planta de la facultad, enfermeros de la clínica universitaria teletón y de un asesor externo. tercera etapa esta etapa se caracteriza por la conformación y el desarrollo del grupo de estudio sobre el modelo de adaptación de callista roy. este grupo se inició con el interés de profundizar el conocimiento de la facultad sobre el modelo, y desarrollar una línea de investigación que contribuyera al desarrollo del mismo y de la ciencia de enfermería. el grupo está integrado por los docentes de planta de la facultad, y algunas enfermeras de la clínica universitaria teletón y del servicio médico de la universidad. en esta etapa se han utilizado diferentes estrategias que son complementarias: 1. análisis de los componentes estructurales, los supuestos científicos y filosóficos y sus implicaciones para el quehacer de enfermería este fue un proceso muy importante e interesante, que tuvo como propósito haen el campo de formación profesional, las asignaturas se organizaron teniendo en cuenta las etapas del ciclo vital, y sus contenidos se desarrollaron tomando como base los elementos estructurales del modelo y las etapas del proceso de enfermería propuestas por la doctora roy. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200550 cer un estudio profundo de cada uno de los elementos del modelo con el ánimo de unificar criterios relacionados con su operacionalización y estrategias para la enseñanza del mismo. los modelos conceptuales son complejos y abstractos, por lo cual se requiere del análisis consistente y permanente en grupo con el ánimo de clarificar inquietudes y unificar criterios relacionados con su aplicación. como estrategia se utilizó el análisis de los conceptos principales del modelo (17), el diseño de instrumentos de valoración como el que desarrollaron díaz, gutiérrez y hernández (18), para valorar el modo fisiológico. venegas (19) plantea unos lineamientos para realizar la valoración de la función neurológica, y quintero y restrepo (20), presentan una propuesta para valorar el autoconcepto fundamentada en los resultados de una investigación cualitativa llevada a cabo con un grupo de adultos en el municipio de chía. como resultado de la experiencia acumulada por los docentes en los primeros diez años de aplicación del modelo, se publicó el libro aplicación del modelo de adaptación en el ciclo vital humano (21). otro aspecto esencial en este proceso es que al aplicar un modelo conceptual es esencial conocer la visión de la realidad del mismo y la forma como se relacionan los conceptos. a manera de ilustración se presenta un ejemplo: roy describe a las personas como �seres adaptativos holísticos que funcionan como unidad con algún propósito, no en una relación causa-efecto� (16). este concepto nos señala la visión filosófica de reciprocidad que tiene este modelo, en la cual la enfermera debe considerar a la persona como un ser único digno, autónomo y libre, que forma parte de un contexto del cual no se puede separar. los seres humanos son activos y la interacción con el ambiente es recíproca. el cambio es probabilístico, en él influyen múltiples factores. en general, las personas responden a las situaciones con base en su educación, sus experiencias anteriores, y en la forma como las interpretan. al aplicar el modelo de roy fundamentado en esta perspectiva filosófica, se debe estar seguro de valorar a la persona como un todo, buscando conocer sus experiencias anteriores, sabiendo que en su comportamiento refleja la interpretación que hace de la situación en un momento determinado, lo cual será fundamental en su proceso de adaptación. roy sostiene que la persona tiene un poder creativo y de autodeterminación, y que su integración con el ambiente resulta en adaptación. este planteamiento establece cómo se espera que sean las relaciones entre la enfermera y el paciente. en éstas el poder es mutuo, porque tanto la persona como el profesional de enfermería participan activamente en una relación de cuidado y reconocen la influencia que tienen el uno en el otro. la enfermera forma parte del ambiente al igual que todas las condiciones y circunstancias que rodean al paciente, por lo cual sus actitudes, conocimientos y su capacidad de interactuar con él serán un factor decisivo en el proceso de adaptación. la facultad, en su proceso docente-educativo, debe promover el desarrollo de competencias comunicativas e instrumentos de valoración que permitan a los estudiantes establecer la percepción que tiene el paciente sobre su situación como él la vive. en el proceso de formación se debe insistir a los estudiantes en la necesidad de esforzarse por conocer las partial aplicar el modelo de roy fundamentado en esta perspectiva filosófica, se debe estar seguro de valorar a la persona como un todo, buscando conocer sus experiencias anteriores, sabiendo que en su comportamiento refleja la interpretación que hace de la situación en un momento determinado, lo cual será fundamental en su proceso de adaptación. importancia de los modelos conceptuales y teorías de enfermería: experiencia de la facultad de enfermería de la universidad de la sabana 51 cularidades de los pacientes a su cargo, y que esta información sea evidente en los planes de cuidado y en las anotaciones de enfermería que realizan. algunas estrategias didácticas que han contribuido en forma decisiva en el conocimiento y aplicación del modelo por parte de los estudiantes ha sido el análisis de situaciones de enfermería en los campos de práctica, y la realización de ateneos semestrales. los ateneos son unas reuniones de carácter académico que se realizan con la participación de la facultad en su totalidad, en ellos se discuten y analizan situaciones de enfermería vividas por estudiantes o profesores. este espacio promueve la unificación de criterios frente a la aplicación del modelo, y permite profundizar sobre aspectos relevantes del cuidado de enfermería para promover la adaptación de las personas a su situación actual de salud. en el último año, y con el propósito de compartir experiencias relacionadas con la aplicación de los modelos conceptuales y estudiar una misma situación de enfermería desde perspectivas teóricas diferentes, se ha ampliado la participación en los ateneos a otras facultades de enfermería. esta experiencia ha sido muy interesante porque se tiene la oportunidad de verificar en la práctica cómo el abordaje inicial varía definitivamente según el modelo que se aplica, pero una vez analizada la situación, se establecen diagnósticos de enfermería similares. adicionalmente, con el ánimo de socializar los avances en la aplicación del modelo, los docentes han participado en eventos científicos nacionales e internacionales, en los cuales han tenido la oportunidad de presentar su experiencia con la aplicación del modelo en la facultad, presentada por arévalo, díaz, gutiérrez y hernández (22) en la vii conferencia iberoamericana de enfermería (medellín, 2003), en el encuentro binacional de enfermería organizado por la facultad de enfermería de la universidad francisco de paula santander en cúcuta (23), y en el seminario internacional de cuidado organizado por la facultad de enfermería de la universidad nacional de colombia (24), entre otros. 2. desarrollo de una línea de investigación: aplicación y desarrollo del modelo de adaptación de callista roy propósito avanzar en el desarrollo de la ciencia de enfermería al profundizar en el conocimiento sobre el cuidado para la adaptación, obtener mayor autonomía y autocontrol de la práctica, y evaluar la calidad de la práctica de los servicios de enfermería. estrategias revisión del estado del arte: se ha venido realizando una revisión permanente de las publicaciones sobre aplicación del modelo de adaptación; entre ellas vale la pena destacar la revisión de los 25 años de investigación sobre el modelo de roy (25). en ésta se pudieron establecer algunos vacíos de conocimiento que constituyen los lineamientos para el desarrollo de la línea de investigación, como son: a) desarrollar instrumentos y adaptar algunos con base en la visión de reciprocidad del modelo; b) desarrollar propuestas de intervenciolos ateneos son unas reuniones de carácter académico que se realizan con la participación de la facultad en su totalidad, en ellos se discuten y analizan situaciones de enfermería vividas por estudiantes o profesores. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200552 nes para promover la adaptación de las personas haciendo énfasis en el modo psicosocial, y c) desarrollar propuestas para promover la adaptación en el cuidado de grupos mediante la articulación del modelo con otras teorías de enfermería. en el estudio del modelo se ha identificado la necesidad de analizar otras teorías de enfermería que tengan un enfoque epistemológico y filosófico similar, para complementar algunos aspectos relacionados con su aplicación en la práctica. se han revisado los modelos de sistemas de betty neuman (26) y de ida orlando; teorías de mediano alcance como la teoría de los síntomas desagradables (27, 28), la teoría de la incertidumbre en la enfermedad (29, 30), la teoría de cuidado de enfermería (31, 32), y los avances del grupo de cuidado de la facultad de enfermería de la universidad nacional (33). los productos de la línea de investigación, como son los proyectos de investigación, el libro sobre la aplicación del modelo de adaptación en el ciclo vital humano, los artículos en revistas, las ponencias en eventos nacionales e internacionales, y los trabajos de grado de algunos estudiantes de la especialización en enfermería en cuidado crítico pediátrico, como los llevados a cabo por bernal (34) y barrios (35), llevaron al reconocimiento como grupo de investigación por colciencias en la categoría b, en 2005. 3. la implementación del modelo en servicios de enfermería los docentes y estudiantes de la facultad tienen la oportunidad de aplicar el modelo de adaptación en todos los escenarios donde realizan su práctica. sin embargo, la facultad ha demostrado un gran interés por implementar y evaluar esta experiencia en algunos servicios de enfermería con los cuales se tienen convenios especiales. por tal motivo, se ha implementado en el departamento de enfermería de la clínica universitaria teletón, en el servicio de hospitalización, en la consulta de enfermería prequirúrgica y en la consulta del servicio de rehabilitación (36). también se está aplicando en las unidades de cuidado intensivo pediátrico, neonatal y de adultos de la fundación cardio infantil � instituto de cardiología, institución con la cual la facultad tiene un convenio para el desarrollo de la especialización en enfermería en cuidado crítico pediátrico. esta estrategia ha permitido verificar la importancia de aplicar un modelo conceptual en la práctica, donde se ha podido establecer la contribución de enfermería en los equipos interdisciplinarios, y expandir el rol de los profesionales. asimismo, se han generado nuevas oportunidades de desempeño como en la consulta de enfermería en los servicios de rehabilitación, cirugía ambulatoria y consulta externa. 4. vinculación a la asociación de adaptación de roy la necesidad de estar en contacto con pares académicos que aplican este modelo motivó la inscripción de la facultad a la asociación de adaptación de roy (raa por sus siglas en inglés). esta vinculación ha favorecido el proceso de internacionalización de la facultad; a través de ella se han establecido contactos con las doctoras callista roy, jacqueline fawcett, prangtip chayaput y con otras enfermeras latinoamericanas interesadas en su estudio. en el estudio del modelo se ha identificado la necesidad de analizar otras teorías de enfermería que tengan un enfoque epistemológico y filosófico similar, para complementar algunos aspectos relacionados con su aplicación en la práctica. importancia de los modelos conceptuales y teorías de enfermería: experiencia de la facultad de enfermería de la universidad de la sabana 53 la doctora fawcett publicó una entrevista en la revista nursing science quarterly, donde compara la experiencia de aplicación del modelo en la universidad de la sabana, y su artículo �conceptual models of nursing: international in scope and substance? the case of the roy adaptation model�, publicado en nursing science quarterly (37). en la quinta conferencia anual de la raa, celebrada en new castle, new hampshire, se presentó un afiche con los avances del grupo (38), y se han generado propuestas para el desarrollo de proyectos de investigación como es el de determinar la �validez y confiabilidad de la versión en español de la escala de medición del proceso de afrontamiento y adaptación elaborada por la doctora callista roy�, que se encuentra actualmente en curso. conclusiones es necesario lograr un punto de equilibrio entre el cuidado del paciente y el control administrativo de los servicios para asumir un verdadero liderazgo. los profesionales de enfermería deben asumir el liderazgo del cuidado, para lo cual requieren de un marco de referencia que los centre en aquellos aspectos fundamentales del mismo y les dé una perspectiva global del servicio donde se desempeñan. en la práctica, el conocimiento de los principios filosóficos y científicos que fundamentan los modelos provee una orientación sobre cómo interpretar el fenómeno de interés de la disciplina; tales principios se ven reflejados en el quehacer profesional y, por lo tanto, en la actitud que éstos asumen frente a las situaciones de cuidado, al reconocer los beneficios de esta relación para el paciente, la familia y para su propio crecimiento personal, mejorando así la calidad del cuidado de enfermería en los diferentes escenarios. también favorece la comunicación entre los profesionales de enfermería al unificar criterios frente a la interpretación de las situaciones de cuidado, y la aplicación del proceso de enfermería. tener claridad sobre la razón de ser de la disciplina y las metas del cuidado permite a los profesionales diferenciar su campo de acción e identificar claramente su contribución para la promoción y recuperación de la salud de las personas, y los estimula a participar activamente en el equipo interdisciplinario; además, promueve su reconocimiento fortaleciendo la necesidad de contar con este recurso no sólo por parte de los profesionales del área de la salud, sino también de los usuarios y de las entidades prestadoras de servicios de salud. la enfermería se mantendrá en conflicto y su desarrollo se verá amenazado si no se logra un consenso entre los aspectos relacionados con la teoría (ciencia de enfermería) y la profesión (práctica). es necesario lograr un punto de equilibrio entre el cuidado del paciente y el control administrativo de los servicios para asumir un verdadero liderazgo. los modelos facilitarán establecer indicadores de calidad para enfermería. en la docencia es esencial que los programas de enfermería tengan un marco de referencia claro, esto facilita la orientación y el desarrollo de las asignaturas que integran el currículo, de tal forma que los estudiantes alcancen las competencias necesarias para desempeñarse con excelencia según las exigencias del medio. se debe ser claro en que la responsabilidad de la formación de los nuevos profesionales no solamente recae sobre las facultades de enfermería, también sobre las instituciolos profesionales de enfermería deben asumir el liderazgo del cuidado, para lo cual requieren de un marco de referencia que los centre en aquellos aspectos fundamentales del mismo, y les dé una perspectiva global del servicio donde se desempeñan. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200554 nes donde realizan sus prácticas. es fundamental, desde la docencia, fomentar el desarrollo de competencias esenciales como son el pensamiento crítico reflexivo, la creatividad, el interés por profundizar los conocimientos que adquieren, generar la necesidad de fortalecer un marco de referencia que oriente su ejercicio profesional, además de las habilidades necesarias para ofrecer un cuidado de alta calidad. desde las instituciones de salud, los profesionales de enfermería deben ser conscientes de que ellos son el ejemplo que se debe seguir, son un patrón para imitar, y que con sus actitudes y desempeño constituyen el modelo ideal que cualquier estudiante que sueña con ser enfermero desea alcanzar. la aplicación del modelo de adaptación y la vinculación a la raa, constituyen un aspecto fundamental para el desarrollo de la facultad de enfermería de la universidad de la sabana. si bien los estudiantes tienen la oportunidad de conocer otras perspectivas teóricas de enfermería en algunas de las asignaturas del programa y en los ateneos. contar con un modelo como el de roy, que ha evidenciado un gran desarrollo, provee un marco de referencia esencial para el análisis y el estudio del cuidado de enfermería en diferentes escenarios de la práctica, evitando que ésta se centre únicamente en el hacer y llevándolos a analizar la situación particular de cada persona como ser holístico y a estudiar las implicaciones de sus intervenciones en el proceso de adaptación de los individuos y grupos. así, pueden identificar con mayor claridad cuál es la contribución de las enfermeras en un equipo interdisciplinario de salud. la aplicación del modelo ha fortalecido el proceso de internacionalización de la facultad, estableciendo contacto con pares internacionales con quienes se plantea el desarrollo de algunos proyectos de investigación, y se ha obtenido el apoyo y la asesoría de enfermeras con una gran trayectoria académica en el ámbito internacional como son las doctoras roy y fawcett. con la aplicación del modelo en el campo asistencial, se ha logrado la expansión de su rol en los servicios de las instituciones mencionadas donde se aplica el modelo. además de mantener un equilibrio entre la demanda de producir a un bajo costo y prestar un servicio con calidad humana en la medida en que el cuidado de enfermería se centra en el usuario sin desconocer su contexto y su experiencia personal, y la participación de la familia en el cuidado. los profesionales han logrado integrarse en equipos interdisciplinarios, demostrando competencias únicas, manteniendo su rol profesional autónomo. bibliografía 1. tolley k. theory from practice for practice: is this a reality? journal of advanced nursing, 1995, 21 (1): 185. 2. gunther m. a discipline specific determation of high quality nursing care. journal of advanced nursing, 2002; 38 (4): 353-59. 3. moreno me. necesidad de un marco epistemológico para la práctica de enfermería. conferencia presentada en el taller precoloquio del xvi coloquio de investigación. manizales: universidad de caldas, acofaen, octubre de 2003. 4. wimpenny p. the meaning of models of nursing to practicing nurses. journal of advanced nursing 2002; 40 (3): 346-54. 5. fealy g. the good nurse: visions and values in images of the nurse. journal of advanced nursing 2004; 46 (6): 649-56. 6. fawcett j. analysis and evaluation of contemporary nursing knowledge. nursing models and theories. philadelphia: f.a. 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s, bredow t. middle range theories. application to nursing research. philadelphia: lippincott williams and wilkins; 2004. 28. lenz e, pugh l, milligan r, gift a, suppe f. the middle range theory of unpleasant symptoms. advances in nursing science 1997; 19 (3): 14-27. 29. mishel m. uncertainty in illness. en: image journal of nursing scholarship 1998; 20 (4): 225-35. 30. mishel m. reconceptualization the uncertainty in illness. image journal of nursing scholarship 1990; 22 (4): 256-62. 31. mayeroff m. on caring. us: harper perennial; 1971. 32. boykin a, shoenhofer s. nursing as caring. a model for transforming practice. boston: national league for nursing; 2001. 33. grupo de cuidado, facultad de enfermería de la universidad nacional avances conceptuales del grupo de cuidado. en: dimensiones del cuidado. bogotá: unibiblos, 1998; 8-16. 34. bernal jt, corredor sa, piñeros ae, quintero im. valoración de la función nutricional de los niños en postoperatorio de cirugía cardiovascular de la fundación cardio infantil. tesis para optar al título de especialista en enfermería en cuidado crítico pediátrico. universidad de la sabana, facultad de enfermería, chía, cundinamarca; 2004. 35. barrios ap, monroy p, pérez e, suárez c. diseño de un instrumento de valoración del niño en estado crítico para el cuidado de enfermería basado en el modelo de adaptación de callista roy. tesis para optar al título de especialista en enfermería en cuidado crítico pediátrico. universidad de la sabana, facultad de enfermería, chía, cundinamarca; 2003. 36. moreno me. aplicación del modelo de adaptación en un servicio de rehabilitación ambulatoria. aquichan 2001; 1 (1): 14-7. 37. fawcett j. conceptual models of nursing: international in scope and substance? the case of the roy adaptation model. nursing science quarterly 2003; 16 (4): 315-8. 38. grupo de estudio sobre el modelo de adaptación de roy. implementación del modelo de adaptación de roy en la facultad de enfermería de la universidad de la sabana. poster presentado en la 5th annual conference of the roy adaptation association. new castle, nh. may, 2004. habilidad de cuidadores familiares.pmd revista aquichan issn 1657-5997 22 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 abstract this study emerges while working in an international project in nursing when similar problems in health care of people were evident. chronicity and its family implications was one of the identified common problems. quantitative descriptive and transversal studies were done between the years 2003 y 2004 with a population of 270 family caregivers of people with chronic diseases. this population included 90 colombian caregivers, 90 argentineans caregivers and 90 guatemalan caregivers. the caring ability inventory, cai® of ngozi nkhongo was employed for the study with her authorization. the cai has three components that include: knowledge, courage and patience. similar findings were seen in the three countries all of them with difficulties in the caregiving responsibility and low ability in general and in each of its components. key words lucy barrera ortiz1 lidia blanco de camargo2 patricia figueroa ingrid3 natividad pinto afanador4 beatriz sánchez herrera5 recibido: 9 de abril de 2006 aprobado: 19 de mayo de 2006 resumen palabras clave cuidadores familiares, cronicidad (fuente: mesh, bireme). family caregivers, chronicity (source: decs, nlm). el estudio surge al trabajar internacionalmente en el campo de la enfermería, donde se comienzan a vislumbrar de forma clara problemáticas comunes en el cuidado de la salud de la población, como lo es la cronicidad y sus implicaciones en las familias. se realizaron estudios descriptivos, cuantitativos de cohorte transversal entre los años 2003 y 2004, con una población de 270 cuidadores familiares de personas en situación de enfermedad crónica divididos en tres grupos, 90 colombianos, 90 argentinos y 90 guatemaltecos. el instrumento utilizado fue el inventario de habilidad de cuidado (cai®), elaborado, validado y autorizado por ngozi nkhongo, que se compone de tres subescalas: conocimiento, valor y paciencia. se evidenció un comportamiento similar en los tres países con dificultades en la prestación del cuidado y habilidad insuficiente en general y por componentes. family care skill for chronic disease people: international approach 1 facultad de enfermería, universidad nacional de colombia. carrera 50 n°. 27 70 bloque b2 of. 501, bogotá, colombia. lbarrerao@unal.edu.co 2 universidad de la patagonia, comodoro rivadavia, argentina. ciudad universitaria comodoro rivadavia km. 4 chubut cp (9005). prodep@unpata.edu.ar 3 profesora de la escuela de enfermería, universidad de guatemala. inpafisa@latinmail.com 4 facultad de enfermería, universidad nacional de colombia. carrera 50 n°. 27 70 bloque b2 of. 501, bogotá, colombia. rnpintoa@unal.edu.co 5 facultad de enfermería, universidad nacional de colombia. carrera 50 n°. 27 70, bloque b2 of. 501, bogotá, colombia. cbsanchezh@unal.edu.co año 6 vol. 6 nº 1 (6) 22-33 chía, colombia octubre 2006 habilidad de cuidadores familiares de personas con enfermedad crónica. mirada internacional. family care skill for chronic disease people: international approach 23 introducción arios autores señalan que la enfermedad crónica se ha venido incrementando en los países de américa latina, y esta tendencia parece acrecentarse en la región (1). la vivencia de una situación de enfermedad crónica para las familias se relaciona con factores socioeconómicos, emocionales y espirituales que en conjunto generan un gran impacto en la vida de las personas implicadas. es importante apoyar a estas personas para conseguir una existencia más cómoda, eficaz y satisfactoria. para ello, es mandatoria la comprensión de la experiencia familiar de la cronicidad dentro de un marco de totalidad. la problemática de los cuidadores familiares dentro de un sistema que no los ha tenido encuenta debe hacerse visible para poder encontrarle alternativas de solución. el presente estudio surge al dar una mirada internacional al cuidado al paciente crónico y a sus cuidadores familiares. en este ámbito se encuentran tres estudios que reflejan esfuerzos aislados y paralelos que no logran ser contundentes. con el ánimo de hacer socialmente visibles los hallazgos de los mismos, las autoras decidieron comparar esos estudios que tenían un fenómeno de interés común sobre habilidad de cuidado de los cuidadores familiares de personas con enfermedad crónica. la facultad de enfermería de la universidad nacional de colombia, dentro de sus estudios de cuidado al paciente crónico, dio inicio a una propuesta de investigación en los diferentes escenarios denominada “macroproyecto de habilidad de cuidado de los cuidadores”, e invitó a enfermeras de diferentes países a vincularse al mismo. respondieron a su llamado las colegas de argentina y guatemala, con quienes hoy de manera conjunta se presenta este logro investigativo para la región de américa latina. este trabajo se inició con la convicción de que las exigencias conjuntas y soportadas en hechos reales presentados de manera sistematizada hagan reflexionar a los cuidadores sobre sus derechos y a los entes gubernamentales, las empresas prestadoras de servicios y las aseguradoras de riesgos en salud sobre sus deberes, y con ello se mejore su respuesta dando garantías de apoyo, asignando presupuesto y facilitando acciones que reflejen la importancia de los cuidadores familiares como parte del sistema de salud en nuestros países. con esta publicación se espera una respuesta mayor que convoque la voz de otras enfermeras y profesionales de la salud en la región que son testigos de las dificultades que viven los cuidadores familiares de personas con enfermedad crónica a quienes el sistema no tiene en cuenta dentro de su planeación y prestación de servicios, de manera que dé respuesta a sus dificultades para el cuidado de la salud propia y de sus seres queridos. el abordaje de los cuidadores ha sido integral y responde a la identificación de dificultades por parte de los usuarios, pero los esfuerzos no paran acá; actualmente el grupo trabaja en el diseño de una estrategia concreta de fomento de la habilidad de cuidado de los cuidadores familiares con la profunda convicción de que en ellos está en primera instancia la responsabilidad de modificar el sistema, de sacar su poder a flote y de ser capaces de exigir que sus derechos de ciudadanos sean tenidos en cuenta en la región. muchos de estos cuidadores han sido un ejemplo para otros y para el mismo grupo investigador en la revista aquichan issn 1657-5997 24 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 construcción de una red social que debe fortalecerse y respaldarse. el objetivo del estudio es describir, analizar y comparar la forma en que se presenta la habilidad de cuidado de los cuidadores familiares de personas en situación de enfermedad crónica discapacitante en tres países de américa latina. se consideraron tres conceptos esenciales: cuidador familiar, habilidades de cuidado de los cuidadores familiares, persona en situación de enfermedad crónica discapacitante. cuidador familiar: al hablar de cuidador familiar se hace referencia a la persona adulta, con vínculo de parentesco o cercanía que asume las responsabilidades del cuidado de un ser querido que vive en situación de enfermedad crónica discapacitante, y participan con ellos en la toma de decisiones. éstos realizan o supervisan las actividades de la vida diaria en busca de compensar las disfunciones existentes de parte del receptor del cuidado. las habilidades de cuidado de los cuidadores familiares son el potencial de cuidado que tiene la persona adulta que asume el rol de cuidador principal de un familiar o persona significativa que se encuentra en situación de enfermedad crónica discapacitante. esta habilidad incluye la dimensión cognoscitiva y la actitudinal, que son identificadas y medidas según los indicadores de conocimiento, valor y paciencia que propone ngozi o. nkongho (2). la habilidad vista así puede medirse a través de la comunicación directa con cada persona. persona con enfermedad crónica discapacitante: al hablar de vivir con enfermedad crónica discapacitante se hace referencia a la experiencia de tener un trastorno orgánico y funcional que genera discapacidad permanente y requiere largos periodos de cuidado, tratamiento paliativo y control, por lo cual la persona debe modificar su estilo de vida. las personas que se encuentran en estas situaciones son seres activos y trascendentes que viven y tienen la capacidad de crecer en el cuidado. se asume acá la conceptualización de salud propuesta por newman (3), que establece que salud es un patrón de totalidad que incluye expresiones de enfermedad y de no enfermedad, y se contempla al individuo como totalidad expresada a través de un patrón. el conocimiento del patrón puede ser útil a la gente para volverse consciente de su interacción con el todo. vivir en situación de enfermedad crónica discapacitante es identificarse a sí mismo como alguien cuyo patrón se mueve en expresiones de enfermedad crónica con permanencia en el tiempo, que le genera incapacidad residual, se asocia a una alteración patológica irreversible y requiere de cuidados especiales o paliativos por cuanto no se conoce curación para la misma. la vivencia de enfermedad crónica discapacitante es aquella expresión de enfermedad que se percibe por el individuo como una disfunción para cumplir con su rol según parámetros esperados, y que le ha acompañado por más de seis meses. esta investigación se justifica por el patrón epidemiológico que caracteriza la región de américa latina, que ha llevado a los primeros lugares la morbilidad y mortalidad por enfermedades crónicas no transmisibles (ecnt) con el consecuente desgaste de aquellas personas que, sin tener los elementos para asumir el cuidado, se ven obligadas a hacerlo, y el posible impacto que sobre las personas con enferlas habilidades de cuidado de los cuidadores familiares son el potencial de cuidado que tiene la persona adulta que asume el rol de cuidador principal de un familiar o persona significativa que se encuentra en situación de enfermedad crónica discapacitante. habilidad de cuidadores familiares de personas con enfermedad crónica. mirada internacional. family care skill for chronic disease people: international approach 25 medad crónica tiene el que sus cuidadores no estén preparados para responsabilizarse por estas tareas. el impacto de vivir con enfermedad crónica o de cuidar a una persona en esa situación señala que estas experiencias generan cambios profundos en las vidas de los implicados y pueden modificar su habilidad de cuidado (4, 5, 6, 7, 8). con base en la evidencia actual debe pensarse en fortalecer la habilidad de cuidado de los cuidadores familiares como un factor determinante en la adopción de nuevas políticas para atender situaciones de ecnt en la región. aunque la familia se ha visto afectada por su tendencia a ser nuclear, por su restricción de espacio de vivienda y por el cambio de rol femenino que ha comenzado a ser eje central del mercado laboral, la mujer continúa teniendo la función de cuidadora de las personas con enfermedad como una de sus principales responsabilidades. las familias, y en especial quienes cumplen responsabilidades de cuidado, tratan de organizarse y sobreponerse para afrontar de la mejor forma estas demandas. con alguna frecuencia, debido a la poca habilidad como cuidadores, se producen sentimientos de impotencia frente a estas tareas de cuidado (9), estos sentimientos varían dependiendo de la raza, la edad, el género y la cultura, pero siempre están presentes y generan un elevado nivel de estrés (10, 11, 12). no obstante, muchos cuidadores reportan encontrar un significado muy profundo en esta experiencia lo que los lleva a sentirse útiles e importantes (4). el ambiente es importante para debilitar o fortalecer la habilidad de cuidado de los cuidadores familiares, y dentro de este sobresalen el apoyo socio-emocional, las finanzas y los recursos en especial en términos de los cuidadores de apoyo que estén disponibles. para el cuidador principal, tanto las personas disponibles a ayudarle como su percepción de esa disponibilidad son parte fundamental de su habilidad (13). el soporte social se ha señalado como un aspecto relevante en el afrontamiento de esta y otras crisis en el curso de la vida (14, 15). de igual forma, la calidad y la naturaleza de las relaciones familiares son relevantes en el tipo de soporte que tienen las personas. el sentimiento de afecto parece en muchos casos fortalecer aspectos de bienestar de enfermos y cuidadores (16, 17), aunque por esto mismo en varios casos se ve que los cuidadores se mantienen en un segundo plano dentro de la familia (18). las experiencias con grupos de apoyo formal parecen ser un recurso valioso para las familias en especial si se les da información sobre la enfermedad, servicios disponibles y formas de afrontamiento (19). la aprobación social, la orientación, la compañía o la tregua que reciben los cuidadores son suficientes para reconocer o incrementar su propia habilidad (20, 21) y trascender de manera positiva en la vida de las familias (22). hay características de la propia enfermedad crónica que pueden tener impacto en la habilidad de cuidado de los cuidadores familiares (23, 24). las situaciones en que se presenta la enfermedad, el grado de incertidumbre, el tipo de enfermedad y el nivel de contacto con la situación son también variables que determinan la habilidad dentro de la experiencia. con base en ello se puede afirmar que trabajar una estructura organizada que oriente a los cuidadores y fomente su habilidad de cuidado es importante (25). el impacto de vivir con enfermedad crónica o de cuidar a una persona en esa situación señala que estas experiencias generan cambios profundos en las vidas de los implicados y pueden modificar su habilidad de cuidado. revista aquichan issn 1657-5997 26 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 la comparación de la problemática en los diferentes países permite contar con un parámetro que señale la variación o similitud de la habilidad de cuidado de los cuidadores y, por ende, abre una oportunidad para realizar una propuesta conjunta con estrategias complementarias que desde la enfermería permitan proponer un abordaje a la problemática ya que el nivel de habilidad es un aspecto que interviene en el bienestar general de las personas implicadas en el manejo de situaciones de cronicidad, y puede constituirse en un agente protector de la calidad de vida de las mismas. la región de américa latina, a diferencia de la cultura sajona, tiene conceptos diferentes de lo que significa ser cuidador, el de ser cuidador principal o el de privacidad son claros ejemplos de esto. de la misma forma, los problemas de comportamiento que surgen con la enfermedad crónica. la capacidad funcional del paciente y la del cuidador, y la posibilidad que tiene el cuidador para dar cuidado de manera tal que satisfaga los requerimientos sociales y del contexto resultan ser diferentes a las documentadas en otras regiones del mundo. el tipo, la cantidad y el tiempo esperado de cuidado necesario, contribuyen también a mantener o desarrollar habilidad en el cuidador y difieren de los reportados en otras latitudes (26); por último, la tregua en el cuidado es vivida de otra manera en especial en familias de estructura compleja y numerosa. dimensionar de manera adecuada la habilidad de cuidado de los cuidadores en diferentes contextos de la región de américa latina, donde hay divergencia en el soporte social con que cuentan los cuidadores, en los recursos disponibles y en las crisis políticas y sociales que caracterizan a la región, y que de alguna manera inciden en la atención en salud, es muy importante como parte del trabajo de modificar esta situación de atención a las personas con ecnt y sus familias. al reconocer que la mayoría de enfermos crónicos viven con sus familias, y que sus cuidadores están en condiciones vulnerables se puede ver la habilidad de cuidado a través de los sistemas familiares para considerar en el futuro un método útil en el desarrollo de dichas habilidades como una forma de apoyo a los cuidadores para afrontar esta problemática que afecta la salud del cuidador y la relación misma del cuidado (6). es importante reconocer y aliviar posibles sentimientos de carga generados por la responsabilidad de cuidar a otra persona, dependiente en muchos aspectos de la vida diaria, con el estrés de tomar constantemente decisiones que afectan la propia vida y la del ser querido (27). considerar a los cuidadores como un componente esencial del sistema de cuidado de la salud exige aceptar su potencial y sus limitaciones, y darle herramientas para mejorar su habilidad en términos de incrementar la capacidad de afrontamiento de manera tal que satisfaga las necesidades de la persona enferma, responda a la problemática familiar, mantenga su propia salud y fomente la buena relación cuidador persona cuidada, reconociendo y estableciendo apoyos formales e informales, manejando sentimientos de inadecuación o culpa, y planeando su propio futuro y el de su grupo familiar (28). la responsabilidad y las tareas de cuidado cambian según el contexto en que se presenten pero en cualquier caso requiela capacidad funcional del paciente y la del cuidador, y la posibilidad que tiene el cuidador para dar cuidado de manera tal que satisfaga los requerimientos sociales y del contexto resultan ser diferentes a las documentadas en otras regiones del mundo. habilidad de cuidadores familiares de personas con enfermedad crónica. mirada internacional. family care skill for chronic disease people: international approach 27 ren el desarrollo de habilidad de parte de quien las asume, y el reconocimiento de la misma es importante para promover los apoyos necesarios en su desarrollo (8). el fomento de la habilidad de cuidado como una forma de cuidar a los cuidadores es una tarea importante de enfermería. no se conocen reportes en la literatura sobre los efectos en el desarrollo de habilidad de cuidado de los cuidadores en la región ni estudios que discriminen la tarea por escenarios institucionales y comunitarios a pesar de reconocer que las funciones y posibilidades de los cuidadores familiares cambian de manera importante en cada uno de ellos (29). para concluir, es primordial señalar los múltiples potenciales, funciones y riesgos en salud que tienen los cuidadores familiares de personas con enfermedad crónica, y que los afectan tanto a ellos como a las personas receptoras de su cuidado. vale la pena resaltar la urgente necesidad de aplicar y validar este conocimiento en la región de américa latina en donde cada día se hace más evidente esta problemática. si bien es cierto que se han adelantado investigaciones sobre la habilidad de cuidado de los cuidadores en la última década, la mayoría de los estudios no aportan al conocimiento de la región y tienen poca aplicabilidad para generar alternativas útiles en la asistencia, diseño de políticas y formación frente a estas situaciones de cuidado de la salud. en respuesta a esas inquietudes, la presente investigación constituye un aporte importante que mostrará las habilidades de cuidado de cuidadores de personas con enfermedad crónica en tres países de américa latina en donde se trabajará en un futuro próximo y a partir de este diagnóstico en propuestas específicas de intervención. materiales y métodos en cuanto a los materiales y métodos vale la pena señalar que el estudio tiene un abordaje cuantitativo con un diseño de tipo descriptivo comparativo. su muestra fue intencional y la constituyeron 270 cuidadores familiares de personas en situación de enfermedad crónica divididas en tres grupos, el primero de noventa cuidadores colombianos, el segundo de noventa cuidadores argentinos y el tercero de noventa cuidadores guatemaltecos. dentro de cada grupo la mitad de los entrevistados tenían sus familiares hospitalizados y la mitad los tenían en su casa con atención por consulta externa. los cuidadores eran excluidos si tenían dificultades de comunicación o si no deseaban participar en la investigación. el instrumento para la recolección de la información fue el inventario de habilidad de cuidado (cai®) empleado con permiso escrito de la autora. este instrumento tiene 37 ítems con graduación de tipo likert, y se compone de tres subescalas: conocimiento, valor y paciencia. el cai permite cuantificar el grado de habilidad de cuidado que una persona puede tener con otros. según la autora, un cuidador con habilidad experimenta una sensación de pertenencia y vínculo y es estable y resilente al estrés. el cuidado para nkhongo debe tener al menos tres elementos del proceso de ayuda: la autenticidad de quien ayuda, el reconocimiento positivo hacia la otra persona y la comprensión empática (2). el cai supone que 1) el cuidado es multidimensional con componentes cognitivos y actitudinales; 2) todos los individuos tienen el potencial de ser cuidadores; 3) el cuidado se puede aprender, y 4) el cuidado es cuantificable. este instrumento es multidimensional e incluye dominios afectivos y cognitivos y puede emplearse para identificar el grado en que se tienen estas dimensiones. las respuestas tipo likert van de 1 a 7, con los puntajes más altos indicando mayor grado de cuidado para un ítem positivamente formulado. para los ítems negativamente formulados, el puntaje se invierte. las respuestas a los ítems se suman para cada subescala, dando un puntaje total para cada una. la subescala de conocimiento consiste en 14 ítems, el valor consiste en 13 ítems, y la paciencia tiene 10 ítems. la confiabilidad fue de 0,84 y la validez de 0,80. aunque el cai se hizo para autoadministrarse, las investigadoras decidieron apoyar su aplicación previo entrenamiento colectivo y desarrollo de pruebas piloto evitando así dificultades de interpretación con poblaciones de baja escolaridad. el instrumento recibió algunos ajustes idiomáticos para cada uno de los países, observando con apoyo de una traductora oficial que se mantuviera su significado semántico original. se diligenció además un instrumento de identificación del cuidador que incluía preguntas demográficas y de caracterización sobre él, su experiencia y la persona a su cargo. en todos los casos se diligenció un consentimiento informado. las entrevistas tomaron en promedio 35 minutos. los datos se manejaron de acuerdo con las instrucciones para la utilización del instrumento. se contó con la asesoría directa de la autora para revisar el proyecto y buscar así resultados de habilidad de cuidado general y de sus dimensiones conocimiento, valor y paciencia. los datos revista aquichan issn 1657-5997 28 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 se incorporaron a una matriz de excel y se procesaron en el software estadístico minitab versión 14.0, con el cual se generaron estadísticas descriptivas sobre las características demográficas de los grupos utilizando frecuencias absolutas y porcentajes, así como generación de promedios, desviaciones estándar, valores mínimo y máximo en cada grupo para la habilidad de cuidado total y por componentes que fueron clasificadas en alta, media o baja según lo determina el instrumento empleado. se revisaron además las similitudes y diferencias en la habilidad general y por componentes entre los tres grupos. se contó con el apoyo de una profesional especialista en estadística. dentro de los aspectos éticos se tuvo en cuenta demostrar antes de iniciar el estudio que la información es importante para cualificar el cuidado de enfermería. los participantes recibieron información acerca de los objetivos del estudio, sus métodos y la utilidad de sus resultados. su participación fue voluntaria, el participante podía retirarse en el momento que deseara. la información tuvo un manejo confidencial. los riesgos que corrieron los participantes eran mínimos, y de ser identificado lo contrario el estudio se hubiera suspendido de manera inmediata. se contó con el aval de la universidad nacional de colombia, la universidad de la patagonia y la escuela de enfermería de guatemala, además de la aprobación de jurados internos y externos para poder dar inicio al estudio. se solicitó autorización de la doctora ngozi nkhongo para el empleo del instrumento, y se recibió asesoría personalizada en una invitación realizada por las investigadoras durante el curso de la investigación. en cuanto al impacto ambiental esta investigación fue clasificada por expertos en cero, es decir, un estudio que no genera contaminación ni implicaciones ambientales.* resultados características de los cuidadores de la muestra a continuación se describe la caracterización de cada uno de los grupos de cuidadores estudiados así como su habilidad de cuidado. argentina. el grupo constó de 90 cuidadores. de acuerdo con el número, se encontraban proporcionalmente distribuidos en los servicios de consulta externa y de hospitalización; la mayoría eran mujeres; el grupo de edad predominante era de 36-59 años; la persona cuidada era menor que el cuidador, lo que correspondía a lo encontrado en la literatura; en el tiempo de experiencia como cuidador se encontraron altos puntajes en de 0-6 y de 7-18 meses de cuidado; la funcionalidad medida a través del perfil pulses reportó que el nivel de dependencia era medio alto y alto principalmente (tabla 1). guatemala. el grupo de guatemala constó de 90 cuidadores. en este grupo también se reportó una distribución en servicios y sexo del cuidador igual a la de argentina. en cuanto a la edad del cuidador predominaron los grupos de 18-35 y de 3659 años; así mismo, hubo cerca de una tercera parte de receptores del cuidado mayores que sus cuidadores; el tiempo de experiencia como cuidador era de 37 meses o más de cuidado continuo, y el nivel de dependencia medido a través del pulses era en su mayoría alto (tabla 1). colombia. el grupo de colombia fue de 90 cuidadores. este grupo tubo una variación con respecto al número por servicio, se tuvieron más cuidadores de consulta externa; con respecto a la edad y la edad del cuidador se encuentra un comportamiento similar a argentina y guatemala; así mismo, en la edad con relación al paciente se encuentra una semejanza con guatemala en donde la tercera parte de las personas receptoras del cuidado son mayores que el cuidador; con respecto al tiempo de cuidado continuo en meses éste fue de 37 y más meses de cuidado, y finalmente la funcionalidad de este grupo cambia radicalmente presentando un menor nivel de dependencia. nivel de habilidad de cuidado general y por componentes argentina. el nivel de habilidad de cuidado es óptimo en el 28,89% de los casos, y deficiente en un 71,11%. el nivel de conocimiento fue deficiente en el 64,44% de los casos y óptimo en el 35,56%. en un 68,89% de los casos el valor se tornó deficiente, y en un 31,11% óptimo. la paciencia fue deficiente en el 70% de los casos, y óptima en el 30 % (tabla 2). guatemala. el nivel de habilidad de cuidado es óptimo en el 32% de los casos y deficiente en un 68%. el nivel de conocimiento fue deficiente en el 74% de los casos y óptimo en el 26%. en un 71% de los casos el valor se tornó deficiente, y en un 29% óptimo. la paciencia fue deficiente en el 69% de los casos, y óptima en el 31% (tabla 2). colombia. en el 28,89% de los casos el nivel de habilidad de cuidado fue óptimo * ambiental consultores®. asesoría al proyecto a cargo del doctor luis bernardo sánchez, bogotá, 2001. habilidad de cuidadores familiares de personas con enfermedad crónica. mirada internacional. family care skill for chronic disease people: international approach 29 grupo no. % no. % no. % c.ext. 45 50,00 50 50,00 73 81,11 hosp. 45 50,00 50 50,00 17 18,89 hombres 18 20,00 27 27,00 15 16,67 mujeres 72 80,00 73 73,00 75 83,33 18-35 25 27,78 34 34,00 31 34,44 36-59 53 58,89 46 46,00 40 44,44 60y + 12 13,33 20 20,00 19 21,31 > que cuidador 51 56,67 38 38,00 31 34,44 = al cuidador 27 30,00 4 4,00 1 1,11 < que cuidador 12 13,33 58 58,00 58 64,44 0-6 27 30,00 13 13,00 13 14,44 7-18 35 38,89 15 15,00 15 16,67 19 -36 9 10,00 20 20,00 14 15,56 37 y + 19 21,11 52 52,00 48 53,33 6-8 16 17,78 1 1,00 62 68,89 9-10 25 27,78 4 4,00 7 7,78 11 y + 49 54,44 95 95,00 21 23,33 característica argentina guatemala colombia tabla 1. características de la muestra sexo fuente: datos de la investigación. número edad edad paciente tiempo de cuidado en meses pulses y deficiente en un 71,12% de ellos. el conocimiento fue deficiente en el 66,67% de los casos, y óptimo en un 33,33%. en un 71,12% el valor fue deficiente, y en un 28,89% fue óptimo. la paciencia fue deficiente en el 67,77% de los casos, y óptima en el 32,22% de ellos (tabla 2). comparación entre los niveles de habilidad de cuidado general y por componentes al hacer pruebas de comparación estadística entre los tres grupos no se encontraron unas diferencias estadísticamente significativas entre éstos ni en la habilidad de cuidado general ni en ninguno de sus componentes (tabla 3). discusión al analizar los datos de los tres países se encuentra que hay mayor número de mujeres que de hombres cuidadores, lo que ratifica los reportes de la literatura sobre una prioridad del género femenino asumiendo esta responsabilidad. de otra parte, se observa que hay un mayor número de cuidadores de la generación intermedia. esto es una clara demostración de las dificultades de una generación que la literatura denomina “generación sándwich” sobre la cual, además de la carga laboral y de crianza de los hijos, recae el cuidado de los familiares que se encuentran en situación de enfermedad o dependencia. revista aquichan issn 1657-5997 30 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 característica argentina guatemala colombia tabla 2. nivel de habilidad de cuidado general y por componentes fuente: datos de la investigación. grupo no. % no. % no. % baja 30 33,33 26 26,00 23 25,56 media 34 37,78 42 42,00 41 45,56 alta 26 28,89 32 32,00 26 28,89 baja 29 32,22 23 23,00 25 27,78 media 29 32,22 51 51,00 35 38,89 alta 32 35,56 26 26,00 30 33,33 baja 28 31,11 31 31,00 23 25,56 media 34 37,78 40 40,00 41 45,56 alta 28 31,11 29 29,00 26 28,89 baja 17 18,89 26 26,00 22 24,44 media 46 51,11 43 43,00 39 43,33 alta 27 30,00 31 31,00 29 32,22 habilidad de cuidado conocimiento valor paciencia fuente: datos de la investigación prueba chi. tabla 3. comparación estadística entre los niveles de habilidad de cuidado general y por componentes habilidad de cuidado 0,834 conocimiento 0,125 valor 0,832 paciencia 0,729 comparación argentina guatemala colombia valor de p (<0,05) habilidad de cuidadores familiares de personas con enfermedad crónica. mirada internacional. family care skill for chronic disease people: international approach 31 en cuanto a la relación de edad del cuidador con respecto a la persona cuidada, hay un comportamiento relativamente homogéneo en cuanto a los receptores con edad menor a la de sus cuidadores en dos de los países. esto podría llevarnos a pensar que es necesario en estos casos involucrar medidas de promoción de la salud para estos cuidadores, ya que pueden ser las próximas personas cuidadas por otros cuidadores. la revisión del tiempo de cuidado señala que predominan cuidadores familiares que llevan mucho tiempo en este oficio de cuidar a un familiar; ésta es una de las causas por las que se realiza esta clase de investigaciones, ya que proporcionan herramientas para iniciar procesos educativos en pro de incrementar la habilidad de los cuidadores que llevan mucho tiempo, como también en aquellos que inician esta ardua labor. al comparar el nivel de funcionalidad de las personas cuidadas se ve un mayor compromiso de los cuidadores, ya que de ellos dependen muchas de las necesidades del familiar con enfermedad crónica discapacitante, confirmando así la urgencia de vincularnos al trabajo dirigido a este grupo de personas. en cuanto a la habilidad de cuidado y su distribución por componentes se ve un comportamiento similar en los tres grupos. en ellos queda claro que la mayor parte de los cuidadores familiares que responden por sus seres queridos en situación de enfermedad crónica no tienen condiciones óptimas para la prestación del cuidado ni en la habilidad total ni en los componentes que la constituyen, que son el conocimiento, el valor y la paciencia. teniendo en cuenta que el rol del cuidador es definitivo para la persona que vive la revisión del tiempo de cuidado señala que predominan cuidadores familiares que llevan mucho tiempo en este oficio de cuidar a un familiar. situaciones de enfermedad crónica, que de este nivel de habilidad puede depender el alivio de un estado de incertidumbre permanente, es esencial fortalecer dicho nivel. más allá del tipo, la intensidad y el tiempo que tenga el cuidador ejerciendo su rol, es importante garantizar dentro del mismo un conocimiento adecuado, un respaldo suficiente en términos de soporte social, idoneidad en la toma de decisiones y un redimensionamiento de la experiencia misma. en estos grupos estudiados se muestra con claridad que el fomento de la habilidad de cuidado de los cuidadores de personas en situación de enfermedad crónica en el ámbito nacional debe ser prioritario para enfermería. paradójicamente, el sistema que los compromete a afrontar situaciones del cuidado de sus familiares cada vez más complejas no tiene políticas que respalden a estos cuidadores. enfermería debe generar un respaldo que modifique los componentes cognitivos y actitudinales para que los individuos potencien su capacidad de cuidadores protegiéndose a sí mismos y a las personas que por situación de discapacidad o enfermedad dependen de dicha habilidad. en muchas ocasiones las familias buscan evadir estas responsabilidades por falta de capacitación, motivación y respaldo adecuado. enfermería tiene la urgente necesidad de proponer alternativa de intervención que proteja a este segmento desprotegido y vulnerable de la población. conclusiones y sugerencias al describir y comparar la habilidad de cuidado de los cuidadores familiares de personas con enfermedad crónica en los cuirevista aquichan issn 1657-5997 32 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 1. sánchez b. el cuidado de la salud de personas que viven situaciones de enfermedad crónica en américa latina. actualizaciones en enfermería 2002; 5(1): 13-16. 2. nkongho n. the caring ability inventory. in: strickland ol and waltz cf. measurement of nursing outcomes: self care and coping. newyork: springer publishing company; part iii. 1990; (3 y 4): 3-16. 3. marriner ta. modelos y teorías de enfermería. 4 ed. madrid: harcourt brace; 1999, p. 477. 4. sánchez b. la experiencia de ser cuidadora de una persona en situación crónica de enfermedad. investigación y educación en enfermería 2001; 19(2): 36-51 referencias dadores de tres países de américa latina (argentina, guatemala y colombia), se determinó un comportamiento similar con dificultades en la prestación del cuidado, y habilidad deficiente en los componentes que la constituyen: conocimiento valor y paciencia. estos resultados responden a la vivencia de los cuidadores en el afrontamiento de cuidar a una persona con enfermedad crónica. cumpliendo los objetivos del estudio, al comparar cada uno de los componentes de conocimiento, valor y paciencia necesarios para el cuidado a cuidadores familiares de personas en situación de enfermedad crónica discapacitante de tres países de américa latina (argentina, guatemala y colombia), se identificó una situación de comportamiento similar en los tres grupos. aproximadamente una cuarta parte de cada uno, representado entre el 26 y 32% cuentan con un nivel alto; el resto no es óptimo, lo que contribuye a riesgos que implican deficiencias en el cuidado y en las características de éstos, que señalan crisis, ausencia de apoyo, percepciones débiles en su habilidad de cuidado. con resultados como los descritos se recomienda cuidar a los cuidadores permitiéndoles un crecimiento continuo, fortaleciendo su habilidad para cuidar a través del reconocimiento de su labor. en las unidades tanto académicas como asistenciales se deben implementar procesos de formación e investigativos que preparen a los profesionales de enfermería en el cuidado de los cuidadores de personas que viven situación de enfermedad crónica discapacitante en estos países. el cuidado del cuidador debe formar parte de las políticas de salud de cada país, y éstos deben ser incorporados en los programas asistenciales dirigidos a cada una de las poblaciones. se sugiere implementar programas de cuidado de enfermería dirigidos a los cuidadores de personas que viven situación de enfermedad crónica discapacitante que permitan fortalecer su habilidad de cuidado en la región. se sugiere el apoyo de instituciones nacionales e internacionales comprometidas con las personas en situación de enfermedad crónica discapacitante vinculadas a los tres países de américa latina (argentina, guatemala y colombia), para que busquen medidas a fin de fortalecer la habilidad el cuidado de los cuidadores. por último, es necesaria la urgente vinculación de las enfermeras en proyectos de investigación y en la generación de políticas dirigidas a estos grupos vulnerables. agradecimientos a la universidad nacional de colombia, a colciencias, a la universidad de la patagonia, a la universidad de guatemala y a la fundación w.k. kellogg por su apoyo, confianza y respaldo para lograr redes y alianzas en enfermería en pro del paciente crónico y su familia. 5. bernstein r. chronic illness: research and theory for nursing practice. new york: springer publishing co.; 2001, pp. 106-152. 6. lubkin i. chronic illness: impact and interventions. toronto: jones & barlett pub. 4th ed. usa, 1998, pp. 258-282. 7. lamendola f, newman m. la paradoja del vih/sida como expansor de la conciencia. advances nursing science 1994; 16(3): 13-21. 8. sánchez b. habilidad de cuidado del cuidador familiar de personas con enfermedad crónica. en: grupo de cuidado. el arte y la ciencia del cuidado. 1 º ed. bogotá: unibiblos; 2003, pp. 373-385. habilidad de cuidadores familiares de personas con enfermedad crónica. mirada internacional. family care skill for chronic disease people: international approach 33 9. davidhizar r. entendiendo la impotencia de los miembros de familia cuidadores de enfermos crónicos. geriatric nursing 1992; 13(2): 66. 10. mui a. la carga del cuidado entre hijas cuidadoras blancas y negras: la perspectiva de la teoría de rol. gerontologist 1992; 32(2): 203-212. 11. bowers, b. cuidado intergeneracional: cuidadores adultos y sus padres ancianos. advances nursing science1987; 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1999. 25. england m. dominio de contenidos para planeación del cuidado identificado por cuidadores adultos. image 1996; 28(1): 17-22. 26. butler r, lewis m. aging and mental health: positive psychosocial and biomedical approaches. 3 ed. st. louis: ed. mosby; 1982. 27. grupo de cuidado al paciente crónico. en: memorias del v seminario internacional de cuidado: enfermería sin fronteras. bogotá, mayo 30 y 31, facultad de enfermería universidad nacional de colombia; 2001. 28. griffin m. cuidando a los cuidadores: el rol de enfermería en un establecimiento corporativo. geriatric nursing 1993; 14(4): 200-204. 29. tillie a. cuidadores tengan cuidado. geriatric nursing 1987; 8(2): 78-79. << /ascii85encodepages false /allowtransparency false /autopositionepsfiles true /autorotatepages /all /binding /left /calgrayprofile (dot gain 20%) /calrgbprofile (srgb iec61966-2.1) /calcmykprofile (u.s. web coated \050swop\051 v2) /srgbprofile (srgb iec61966-2.1) /cannotembedfontpolicy /warning 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/untaggedcmykhandling /leaveuntagged /untaggedrgbhandling /leaveuntagged /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 228 238 espiritualidad esperanza y dependencia.indd 228 amparo oliver1 laura galiana2 patricia sancho3 josé m. tomás4 espiritualidad, esperanza y dependencia como predictores de la satisfacción vital y la percepción de salud: efecto moderador de ser muy mayor 1 doctora en psicología, departamento de metodología de las ciencias del comportamiento, universitat de valència (españa). oliver@uv.es 2 doctora en psicología, departamento de metodología de las ciencias del comportamiento, universitat de valència. beneficiaria de una beca vlc/campus, subprograma de atracció de talent, universitat de valència (españa). laura.galiana@uv.es 3 doctora en psicología, departamento de educación, universidad de san antonio murcia, murcia (españa). patricia.sancho@uv.es 4 doctor en psicología, departamento de metodología de las ciencias del comportamiento, universitat de valència (españa). tomasjm@uv.es recibido: 17 de junio de 2014 enviado a pares: 20 de julio de 2014 aceptado por pares: 14 de febrero de 2015 aprobado: 27 de abril de 2015 doi: 10.5294/aqui.2015.15.2.7 para citar este artículo / to reference this article / para citar este artigo oliver a, galiana l., sancho p, tomás jm. espiritualidad, esperanza y dependencia como predictores de la satisfacción vital y la percepción de salud: efecto moderador de ser muy mayor. aquichan. 2015; 15 (2): 228-238. doi: 10.5294/aqui.2015.15.2.7 resumen objetivo: analizar algunos predictores de la calidad de vida en personas mayores, diferenciando entre mayores jóvenes o muy mayores. esto es, se estudia un potencial efecto moderador debido a ser muy mayor, dado que este sector de la población está en rápido crecimiento en todo el mundo. materiales y métodos: estudio transversal analítico de encuesta a 224 personas mayores, en dos grupos diferenciales, menores de 75 años y 75 años o más, que viven en la ciudad de valencia (españa). resultados: se ajustó un modelo estructural multimuestra donde las dimensiones de espiritualidad y la esperanza predicen dos indicadores de calidad de vida en personas mayores: satisfacción vital y percepción de salud. se han encontrado relaciones estadísticamente significativas (p < 0,05) entre la espiritualidad y la esperanza, y los dos indicadores; especialmente potente es la predicción de la satisfacción vital. asimismo, los resultados multimuestra indican que la fe juega un papel diferencial relevante en los muy mayores. discusión: se ponen en relación los hallazgos con la literatura. conclusiones: existe un importante impacto, en algunos casos diferencial para los muy mayores, de la espiritualidad sobre indicadores de envejecimiento con éxito tales como la satisfacción vital y la salud, y la capacidad para realizar actividades, ya sea instrumentales de la vida diaria, o en general todo tipo de actividades productivas. palabras clave espiritualidad, calidad de vida, envejecimiento de la población, predicción (fuente: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 228-238 229 espiritualidad, esperanza y dependencia como predictores de la satisfacción vital y la percepción de salud: efecto moderador de ser muy mayor l amparo oliver y otros año 15 vol. 15 nº 2 chía, colombia junio 2015 l 228-238 spirituality, hope and dependence as predictors of satisfaction with life and perception of health: the moderating effect of being very old abstract objective: analyze several predictors of quality of life in older people, differentiating between relatively younger and much older senior citizens. methods: this is a cross-sectional survey of 224 elderly individualsliving in the city of valencia (spain), who were divided into two separate groups: those under age 75 and those age 75 or older. findings: a multi-sample structural model was adapted to include the dimensions of spirituality and hope so as to predict two indicators of quality of life in the elderly: satisfaction with life and perceived health. statistically significant relationships (p<0.05) were found between spirituality and hope and the two indicators. the prediction of life satisfaction is especially powerful. the multi-sample findings indicate faith plays a relevant differential role among the very elderly. discussion: the findings are compared to the literature. conclusions: for the very old, spirituality has an important impact, in some cases differential, on indicators of aging with quality of life, such as life satisfaction and health, and on the ability to perform tasks, whether instrumental in daily life or in productive activities. keywords spirituality, quality of life, aging population, prediction (source: decs, bireme). 230 aquichan issn 1657-5997 espiritualidade, esperança e dependência como preditoras da satisfação vital e a percepção de saúde: efeito moderador de ser muito mais velho resumo objetivo: analisar alguns preditores da qualidade de vida em pessoas adultas, diferenciando entre adultos jovens ou idosos. materiais e métodos: estudo transversal analítico de enquete a 224 pessoas adultas em dois grupos diferenciais, menores de 75 anos e 75 ou mais, que moram na cidade de valência (espanha). resultados: ajustou-se um modelo estrutural multiamostra em que as dimensões de espiritualidade e a esperança predizem dois indicadores de qualidade de vida em pessoas adultas: satisfação vital e percepção de saúde. constataram relações estatisticamente significativas (p < 0,05) entre a espiritualidade e a esperança, e os dois indicadores; especialmente potente é a predição da satisfação vital. além disso, os resultados multiamostra indicam que a fé desempenha um papel diferencial e relevante nos idosos. discussão: põem-se em relação as constatações com a literatura. conclusões: existe um importante impacto, em alguns casos diferencial, para os idosos, da espiritualidade sobre indicadores de envelhecimento com qualidade de vida, tais como: a satisfação vital e a saúde, e a capacidade para realizar atividades, tanto instrumentais da vida diária quanto em atividades produtivas. palavras-chave espiritualidade, qualidade de vida, envelhecimento da população, predição (fonte: decs, bireme). año 15 vol. 15 nº 2 chía, colombia junio 2015 l 228-238 231 espiritualidad, esperanza y dependencia como predictores de la satisfacción vital y la percepción de salud: efecto moderador de ser muy mayor l amparo oliver y otros introducción en 2012, el instituto nacional de estadística emitió un informe con la proyección de población en españa a largo plazo (hasta 2052) con resultados, no por esperados, menos interesantes (1). al ya conocido envejecimiento de la población, se le añadían cifras muy relevantes. por ejemplo, los mayores crecimientos de población se esperan en las edades avanzadas, con unos 7,2 millones de personas de 64 años o más, que en términos porcentuales pasarían a constituir el 37 % de la población total de españa. cuando se mira el crecimiento relativo en las bandas de edad más altas que ofrece el informe, los resultados son también esclarecedores: entre los 80-84 años habrá un 106,5 % más, entre 85-89 un 177,5 % de crecimiento, entre 90-94 un 332,2 %, entre 95-99 años un aumento del 554,5 %, y en 100 años o más el crecimiento será del 827,1 %. así, se observa que los más mayores entre los mayores son los que más van a crecer en los próximos años en españa. este mismo fenómeno, con diferentes tasas, ocurre en todo el mundo, y especialmente en los países desarrollados, al punto que ha producido ya una categorización de “muy mayores”. este aumento de personas de mucha edad o muy mayores, ha venido acompañado en la comunidad científica por un claro aumento de la investigación sobre este grupo de edad (2, 3), y especialmente sobre la calidad de vida que se mantiene en esta franja (3). entre las dimensiones o componentes de la calidad de vida, dos han recibido especial atención: la satisfacción con la vida y la salud, objetiva y subjetiva (4-7). esta literatura evidencia que esta nueva categoría de edad podría identificarse como cualitativamente diferente de la de los mayores más jóvenes, pues presentan más problemas funcionales, de salud y de dependencia (8). en este contexto, la salud percibida es de particular interés en el estudio de los muy mayores, no solo por su papel como signo de bienestar, sino incluso por su poder predictivo reconocido sobre la supervivencia (9). de la misma forma, el bienestar y la satisfacción vital son constructos que, de acuerdo con deci y ryan (10), tienen que ver con las experiencias y el funcionamiento óptimo del ser humano y, por tanto, son indicadores de envejecimiento con éxito (11-14). dado su papel central como indicador de experiencias positivas, las diversas dimensiones del bienestar subjetivo han merecido una gran cantidad de investigación en las últimas décadas (15-18), y entre ellas especialmente la satisfacción con la vida. en suma, bastantes trabajos han tratado de describir los factores relevantes en la consecución de adecuados niveles de bienestar en los mayores y sus posibles diferencias en función de ser mayor o muy mayor (19, 20). un primer macrocomponente ampliamente estudiado en la literatura gerontológica es el nivel de actividad, estatus funcional o capacidad para realizar las actividades rutinarias de la vida de forma independiente (21). se ha subrayado en este contexto que la evaluación de ser autoeficaces, muy relacionada en los mayores con estos aspectos, se encuentra ligada a las evaluaciones de calidad de vida (22), y, en la misma línea, la actividad se ha relacionado de forma positiva con el bienestar personal en mayores (23, 24). everard et al. (25) encontraron efectos significativos de la realización de actividades instrumentales, sociales y de placer sobre la percepción de salud física. o también, a modo de ejemplo, meléndez et al. (26) encontraron que un elevado nivel de actividad, evaluado a través de medidas de dominio del ambiente y autonomía, podía predecir satisfacción vital de los mayores. un constructo relacionado, que ha ido ganando presencia dentro de la investigación en psicología positiva (27), es el de esperanza (28). el modelo teórico de esperanza más empleado es el desarrollado por charles r. snyder, que la considera un estado motivacional positivo, derivado de la evaluación cognitiva de que se dispone de suficiente energía orientada al objetivo y se es capaz de dirigir esa energía para conseguirlo (29). este constructo, en lo que interesa a nuestro estudio, se ha relacionado sistemáticamente con el apoyo social (30) y, especialmente, con la satisfacción vital (27, 3133) y la espiritualidad (27). efectivamente, hay creciente interés en evaluar el papel que para un envejecimiento con éxito tiene la espiritualidad (34-36). al punto que el influyente trabajo de crowther, parker, achenbaum, larimore y koenig (37), habla de la espiritualidad como el cuarto pilar del envejecimiento con éxito, o como el factor olvidado en el paradigma del envejecimiento con éxito. en una revisión de trabajos cuantitativos y cualitativos sobre espiritualidad en hospitalizados, castelo-branco, brito y fernandes-sousa (38) señalan que la espiritualidad implica la búsqueda de sentido, estar en relación con los otros y con “algo” superior, y se asocia a conceptos tales como sentido de la vida, relaciones, transcendencia y prácticas religiosas. efectivamente, la espiritualidad ha ido ganando importancia en la explicación del bienestar en el proceso de envejecer (39, 35, 40). en concreto, kirby, coleman y daley (40) encontraron, en una muestra británica, que las creencias espirituales se 232 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 relacionaban positiva y significativamente con el bienestar psicológico, aun controlando por los factores sociodemográficos habituales (edad, estado civil, sexo, etc.) y los problemas de salud. en el mismo sentido, cowlishaw et al. (39) encontraron que la espiritualidad se relacionaba consistentemente a través del tiempo con la satisfacción vital. incluso en contextos y poblaciones muy específicos, como los mayores nativos de alaska, la espiritualidad aparece como uno de los elementos definidores del envejecimiento con éxito (41). tal y como se ha expuesto, hay una gran cantidad de evidencia acumulada sobre los predictores de calidad de vida en las personas mayores. sin embargo, es mucho menor, especialmente en el contexto español, el estudio de estos factores de forma conjunta, es decir multivariada, y diferenciando los efectos en función de ser muy mayor frente a menores edades. esto es, dado el rápido crecimiento de la franja de edad de los muy mayores en nuestro país, es de interés empezar a analizar posibles características diferenciales en los procesos que llevan a la calidad de vida de estos mayores. en esta línea, el objetivo de este trabajo es valorar los efectos de la espiritualidad, la esperanza y la dependencia sobre la salud y la satisfacción vital de las personas mayores, evaluando el efecto moderador que el pertenecer a la categoría de muy mayores tiene sobre estas relaciones. materiales y métodos diseño, procedimiento y muestra los datos provienen de una encuesta transversal a 224 personas mayores que viven en comunidad en la ciudad de valencia (españa). el muestreo fue incidental. todos los encuestados dieron su consentimiento informado. el comité de ética para la investigación en humanos de la universitat de valència dio el visto bueno al estudio. el 61,2 % eran mujeres. la media de edad de los participantes era de 73,06 años (dt = 7,68), y rango entre un mínimo de 60 años hasta un máximo de 102. en cuanto al estado civil, un 54,9 % estaban casados, el 29,9 % viudos, solteros un 9,8 % y el restante 5,4 % eran separados o divorciados. la mayoría vivían con sus parejas, seguidas de aquellos que vivían con sus hijos (23,5 %), vivían solos (21,7 %) y vivían con otros (9,5 %). para los propósitos del presente artículo se han categorizado las edades en dos grupos, los menores de 75 años y los de 75 años o más que empezarían a considerarse muy mayores, dejando una muestra de 84 muy mayores y 140 mayores. instrumentos de medida la encuesta incluía una información sociodemográfica básica, presentada en la descripción de la muestra, además de medidas relacionadas con el envejecimiento. todos los instrumentos son de uso libre en estudios científicos. las variables empleadas fueron: 1. una medida de espiritualidad, en concreto la subescala de medición del bienestar espiritual de la escala functional assessment of chronic illness therapy (facit-sp-12) validada por canada, murphy, fitchett, peterman y schover (42). es un instrumento de 12 ítems puntuados desde 0 (en absoluto) hasta 4 (mucho), y que mide tres dimensiones correlacionadas de espiritualidad: significado, paz y fe. el coeficiente de fiabilidad (alfa) en esta muestra es 0,81. ítems ejemplo de cada una de las dimensiones son: “siento un sentido de propósito en la vida” (significado), “noto un sentido de armonía dentro de mi” (paz) y “encuentro fuerza en mi fe o en mis creencias espirituales” (fe). 2. actividades instrumentales de la vida diaria, o índice de lawton y brody (43). consiste en ocho ítems que evalúan la capacidad de uso del teléfono, preparación de comida, hacer la compra, arreglar la casa, hacer la colada, transporte, consumo de medicinas y manejo del dinero de forma independiente. para los propósitos de este estudio, el sistema habitual de categorización se cambió por un sistema semicuantitativo tipo likert, en el que mayor puntuación indica más independencia o autonomía de la persona mayor. el objetivo era ser discriminativos más que diagnósticos. 3. escala disposicional de esperanza (29). esta escala presenta un total de 8 ítems para medir un estado motivacional positivo derivado de la evaluación cognitiva de que se dispone de suficiente energía orientada al objetivo y la capacidad de dirigir esa energía para conseguirlo (29). un ítem ejemplo sería: “incluso cuando los demás se desaniman, yo sé que puedo encontrar una forma de solucionar el problema”. la escala de respuesta oscila entre 1 (completamente falso) hasta 4 (completamente cierto). el alfa en esta muestra es de 0,88. 4. escala de satisfacción con la vida (44), compuesta de cinco ítems que evalúan satisfacción global con la vida, y con escala de respuesta desde 1 (totalmente en desacuerdo) hasta 7 (totalmente de acuerdo). el alfa en esta muestra es de 0,89. un ítem ejemplo de esta escala es: “hasta aquí he tenido todas las cosas importantes que he querido en mi vida”. 233 espiritualidad, esperanza y dependencia como predictores de la satisfacción vital y la percepción de salud: efecto moderador de ser muy mayor l amparo oliver y otros 5. escala de salud percibida (45). esta escala mide una única dimensión de percepción de salud mediante cinco ítems, como por ejemplo: “en los últimos doce meses, tu salud ha sido…”, desde 1 (mala) a 3 (buena). la consistencia interna en esta muestra fue de 0,79. análisis estadístico los análisis estadísticos incluyen un modelo estructural con variables observables (path analysis) de carácter predictivo en que se evalúa el impacto de la espiritualidad, la esperanza y la capacidad de realizar actividades instrumentales de la vida diaria, sobre dos indicadores de envejecimiento con éxito: la satisfacción vital y la percepción de salud. dado que el objetivo de investigación se centra en la comparación de las personas muy mayores frente a las mayores, en este caso se ha planteado una path analysis multimuestra (46); en concreto, en dos muestras, la de personas mayores y la de muy mayores. todos los análisis se han realizado en el paquete estadístico eqs 6.1. dada la falta de normalidad de algunas de las variables incluidas en el modelo se han empleado correcciones robustas de los estadísticos y de los errores estándar sobre el método de estimación de máxima verosimilitud. para evaluar la bondad de ajuste de estos modelos estructurales se han empleado diversos estadísticos e índices, todos ellos robustos. en concreto, se emplean los estadísticos robustos disponibles en eqs y recomendados en la literatura (47): a) el estadístico de chi-cuadrado; b) comparative fit index (cfi); c) root mean squared error of approximation (rmsea); y d) gfi. adicionalmente, y como se trata de valorar el ajuste relativo de modelos anidados en los que se ponen a prueba los distintos efectos moderadores potenciales de ser muy mayor, se han realizado pruebas de diferencias de chi-cuadrado robusta siguiendo el procedimiento de bentler (48), calculándolo mediante el programa ofrecido por crawford y henry (49). resultados el modelo puesto a prueba se presenta en la figura 1. es un modelo predictivo de la satisfacción vital y la percepción de salud a partir de tres factores de espiritualidad (sentido, paz y fe), la esperanza y la capacidad para realizar las actividades instrumentales de la vida diaria (aivd), por verificar en dos muestras mediante una secuencia de modelos con sucesivas constricciones, que permite poner a prueba potenciales efectos moderadores de la edad, y, en concreto, de ser muy mayor, sobre la predicción del modelo en su conjunto. en primer lugar, se ha puesto a prueba un modelo multimuestra sin constricciones. este primer modelo sirve a un doble motivo. primero, nos permitió ver si el ajuste del modelo en su conjunto es aceptable, y, en segundo lugar, fue el modelo base sobre el cual se valoró si hay o no efecto de moderación. se obtuvieron estimaciones de los parámetros del modelo por separado en ambas muestras. este modelo ajustó razonablemente a los datos (χ2(6) = 27,84, p = 0,0001; cfi = 0,95; rmsea = 0,18; gfi = 0,96). a continuación se puso a prueba el mismo modelo pero haciendo iguales todas las relaciones entre variables del modelo en ambas muestras. esto es, en lugar de dejar que estime los valores de los parámetros en ambas muestras escogiendo por tanto los mejores estimadores para cada una, ahora se estiman todos los parámetros de relación entre variables solamente en una muestra (la de menores de 75 años) y se fijan esos valores en la otra muestra, de forma que no se estiman. si el modelo siguiera ajustando de la misma forma que el anterior, sería indicativo de que las igualdades son razonables pues no empeoran el ajuste. en este caso, el ajuste del modelo sufrió considerablemente (χ2(24) = 76,92; p < ,0001; cfi = 0,87; rmsea = 0,14; gfi = 0,90). al poner a prueba las diferencias entre ambas pruebas de chi-cuadrado, se apreció que las diferencias en ajuste fueron estadísticamente significativas (δχ2 = 49,469; δgl = 18; p < 0,001). esto indicó que todas o algunas de las constricciones (igualdades) realizadas no eran razonables, y, por tanto, que hubo diferencias en los parámetros de los mayores y de los muy mayores. para evaluar qué constricciones (igualdades) fueron razonables y cuáles no, se empleó el test de multiplicadores de lagrange (lm-test), lo que llevó a relajar cinco igualdades. se probó este nuevo modelo con constricciones parciales resultando en un ajuste adecuado (χ2(19) = 42,69; p = 0,001; cfi = 0,95; rmsea = ,10; gfi = 0,94). la correspondiente prueba de las diferencias de chi-cuadrado frente al modelo base no resultó significativa (δχ2 = 15,61; δgl = 13; p = ,27), lo que indicó que este modelo, más parsimonioso que el modelo base de comparación, representó mejor los datos. por tanto, se retuvo este modelo como el de mejor ajuste. los resultados de la estimación de este modelo en ambas muestras están en la figura 1. la capacidad predictiva sobre ambas variables y en ambas muestras es elevada. en el caso de la satisfacción con la vida, en la muestra de menores de 75 años la r-cuadrado alcanza el valor de 0,52, mientras en el caso de los de 75 o más años, la capacidad predictiva es aún mayor (r2 = 0,67). 234 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 como puede verse en la figura, todas las dimensiones de espiritualidad y esperanza se relacionaron positivamente con la satisfacción. esto se observa especialmente en la muestra de muy mayores, en donde la fe juega un papel significativo, lo que no ocurre con los menos mayores. la capacidad para realizar actividades instrumentales de la vida diaria de forma independiente es poco importante en la satisfacción vital. por su parte, la capacidad predictiva de la salud es menor pues en el caso de los menores de 75 años se consigue predecir un 29 %, el mismo porcentaje que en los muy mayores. mientras la espiritualidad es un predictor irrelevante, sí presentan un importante efecto tanto la esperanza como la capacidad para realizar las actividades instrumentales de la vida diaria, y esto último especialmente en el grupo de muy mayores. los predictores, a su vez, muestran en algunos casos correlaciones relevantes entre ellos, las cuales se presentan en la tabla 1. figura 1. modelo estructural multimuestra final, con los efectos estandarizados* * el primer valor de cada par se corresponde con la estimación en el grupo de edad hasta 75 años y el segundo al del grupo de muy mayores. nota: las correlaciones entre las variables predictoras son eliminadas por simplicidad; todas las relaciones son estadísticamente significativas (p < 0,05) excepto si se marca como no significativa (ns); en negrita las relaciones que resultan estadísticamente diferentes para ambos grupos. tabla 1. correlaciones entre las variables predictoras en ambos grupos, la primera de cada par se corresponde con la estimación en el grupo de menos de 75 años y el segundo con la estimación en el grupo de muy mayores significado paz fe esperanza aivd significado 1 paz 0,63 / 0,64 1 fe 0,35 / 0,35 0,42 / 0,62 1 esperanza 0,54 / 0,49 0,54 / 0,65 0,31 / 0,34 1 aivd ------0,00 / 0,05 1 nota: todas las relaciones son estadísticamente significativas (p < 0,05) a excepción de las relativas a esperanza y actividades instrumentales de la vida diaria (aivd). en negrita aquellas que difieren a través de los dos grupos. 235 espiritualidad, esperanza y dependencia como predictores de la satisfacción vital y la percepción de salud: efecto moderador de ser muy mayor l amparo oliver y otros discusión y conclusiones tal y como smith et al. (50) señalaron, si los muy mayores van a vivir sus años finales dignamente, entender las relaciones entre salud y bienestar en la vejez es de gran importancia sociopolítica. este fue precisamente el objetivo del presente trabajo, estudiar las relaciones de diversos predictores con la salud y la satisfacción vital, en personas mayores distinguiendo dos grupos, los mayores y los muy mayores, para evaluar procesos potencialmente diferentes. respecto a los resultados sobre la satisfacción vital, puede verse que las dimensiones de la espiritualidad son protectoras de la satisfacción vital, es decir, se relacionan positivamente con esta. estos resultados generales son consistentes con la literatura sobre espiritualidad y envejecimiento, que señala su impacto positivo sobre un envejecimiento con éxito (35, 39, 40). un resultado interesante es que mientras los componentes de significado y paz de la espiritualidad se encuentran igualmente relacionados (positivamente) con la satisfacción en ambas muestras, la fe solo tiene un efecto significativo en los muy mayores, siendo no significativo en los menores de 75. evidentemente, en un diseño transversal como este, aun identificando un efecto moderador tan importante, no podemos aducir si a medida que avanza la edad, la fe “protege” más y genera satisfacción vital, o la fe es más relevante para esta edad por un efecto de cohorte. lo mismo ocurre con el constructo de esperanza, medida bastante relacionada con la capacidad de resolver los problemas, y, en general, con el dominio del ambiente. las relaciones encontradas con la satisfacción son las mismas en ambas muestras —positivas y de elevado tamaño—, lo que está en línea con la literatura sobre el tema (27, 31-33). los resultados acerca de la capacidad para realizar las actividades instrumentales de la vida diaria no son, sin embargo, consistentes con la literatura (22-24, 26), que hace esperable un impacto positivo sobre la satisfacción, que aquí no se ha producido en ninguna de las dos muestras. al ser la muestra de carácter no dependiente, el rango de actividades instrumentales que no pueden realizar es muy limitado, y la variabilidad en el indicador muy baja, lo que puede explicar estos resultados y emplazaría su estudio a mayores niveles de dependencia. otra parte del modelo predice la percepción de salud. en lo que tiene que ver con la espiritualidad, hay bastante evidencia acumulada de que una buena espiritualidad tiene efectos positivos sobre la salud percibida (37), pero también sobre los indicadores objetivos de salud, lo que puede explicarse en parte porque parece relacionarse con conductas más saludables, y también por el aumento que en determinados contextos tienen en la red social (51). este efecto positivo se mantiene en nuestros resultados y es consistente para ambas muestras, si bien de menor magnitud que lo encontrado en el caso de la satisfacción vital. asimismo, el constructo de esperanza también se ha visto relacionado de forma positiva y significativa con la percepción de salud. este resultado ha sido menos estudiado que la relación de esperanza y espiritualidad o calidad de vida, y es por tanto interesante, si bien en un diseño transversal es difícil establecer si una mayor independencia y dominio del ambiente, asociadas a la esperanza, se traduce en mejor salud o, por el contrario, una mejor salud lleva a verse como más capaz de llevar las cosas a término. el efecto de las actividades instrumentales de la vida diaria sí ha resultado significativo en la predicción de la percepción de salud, tal y como encontraron, por ejemplo, everard et al. (25), aunque solamente en el caso de los muy mayores, lo que podría ir en la línea de lo ya comentado sobre la falta de variabilidad de la medida en esta investigación particular en personas que viven en comunidad, lo que la haría jugar un papel solamente en el caso de los muy mayores que empiezan ya a sufrir estos problemas. en resumen, existe un importante impacto, en algunos casos diferencial para los muy mayores, de la espiritualidad sobre indicadores de envejecimiento con éxito tales como la satisfacción vital y la salud, aun controlando por la capacidad para realizar actividades, ya sea instrumentales de la vida diaria, o en general todo tipo de actividades productivas. entre las limitaciones del estudio se considera que las exigencias para la estimación de modelos han condicionado la configuración de grupos de mayores y muy mayores con un mínimo de participantes. se podría, en un futuro, poner a prueba la replicabilidad de los resultados obtenidos en el caso de grupos de muy mayores conformados a partir de 80 años, para converger con el survey of health, ageing and retirement in europe (52). estos futuros estudios también podrían avanzar en el conocimiento de la etiología del papel moderador de la cualidad de ser mayor o muy mayor en dimensiones de la espiritualidad como la fe. 236 año 15 vol. 15 nº 2 chía, colombia junio 2015 aquichan issn 1657-5997 referencias 1. ine. proyecciones de población 2012 [internet]. 2012. disponible en: http://www.ine.es/jaxi/menu.do?type=pcaxis&p ath=%2ft20%2fp251&file=inebase&l=0 2. gwozdz w, sousa-poza a. ageing, health and life satisfaction among the oldest old: an analysis for germany. soc indic res. 2010;97:397-417. 3. tomás jm, sancho p, gutiérrez m, galiana l. predicting life satisfaction in the oldest-old: a moderator effects study. soc indic res. 2014;117:601-613. 4. tomás jm, gutiérrez m, sancho p, galiana l. predicting perceived health in angolan elderly: the moderator effect of being oldest old. arch gerontol geriatr. 2013;55(3):605-610. 5. gutiérrez m, tomás jm, galiana l, sancho p, cebrià ma. predicting life satisfaction of the angolan elderly: a structural model. aging ment health. 2013;17(1):94-101. 6. sancho p, galiana l, gutiérrez m, francisco e, tomás jm. validating the portuguese version of the satisfaction with life scale in an elderly sample. soc indic res. 2014;115:457-466. 7. walker a. a european perspective on quality of life in old age. eur j ageing. 2005;2:2-12. 8. menec vh, chipperfield jg. remaining active in later life: the role of locus of control in seniors’ leisure activity participation, health, and life satisfaction. psychol health. 1997;15:341-55. 9. leinonen r, heikkinen e, jylha m. predictors of decline in self-assessments of health among older people: a 5-year longitudinal study. soc sci med. 2001;52:1329-41. 10. deci el, ryan rm. hedonia, eudamonia, and well-being: an introduction. j hapiness stud. 2008;9:1-11. 11. baltes pb, baltes mm. psychological perspectives on successful aging: the model of selective optimization with compensation. en baltes pb, baltes mm (editor). successful aging: perspectives from the behavioral sciences. new york: cambridge university press; 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2011. 48. bentler pm. eqs 6 structural equations program manual. encino, ca: multivariate software, inc.; 2015. 49. crawford jr, henry jd. the depression anxiety stress scales: normative data and latent structure in a large non-clinical sample. brit j clin psychol. 2003;42:111-131. 50. smith j, borchelt m, maier h, joop d. health and well-being in the young old and oldest old. j soc issues. 2002;58:715-32. 51. park cl. religious and spiritual issues in health and aging. enaldwin m, park cl, spiro iii a (editor). handbook of health psychology and aging. new york: the guilford press; 2007. p. 313-37. 52. share. the share respondents [internet]. 2012. disponible en: http://sharedev.mpisoc.mpg.de/uploads/tx_ sharepublications/3.1.pdf 276 295 metaanalisis efecto de las intervenciones.indd 276 beatriz villamizar-carvajal1 carolina vargas-porras2 olga rocío gómez-ortega3 metaanálisis: efecto de las intervenciones para disminuir el nivel de estrés en padres de prematuros 1 orcid.org/0000-0002-9430-7649. universidad industrial de santander, colombia. beatriz@uis.edu.co 2 orcid.org/0000-0002-5996-8732. universidad industrial de santander, colombia. cvargasporras@yahoo.com 3 orcid.org/0000-0002-0215-3137. universidad de santander, colombia. olgarociogomezortega@hotmail.com recibido: 7 de noviembre de 2015 enviado a pares: 15 de noviembre de 2015 aceptado por pares: 7 de abril de 2016 aprobado: 20 de abril de 2016 doi: 10.5294/aqui.2016.16.3.2 para citar este artículo / to refence this article / para citar este artigo villamizar-carvajal b, vargas-porras c, gómez-ortega or. metaanálisis: efecto de las intervenciones para disminuir el nivel de estrés en padres de prematuros. aquichan. 2016; 16(3):276-295. doi: 10.5294/aqui.2016.16.3.2 resumen introducción: el nacimiento prematuro de un bebé genera estrés en los padres, por el riesgo de aumento en la morbimortalidad que esto conlleva. existen intervenciones que disminuyen el nivel de estrés en los padres beneficiando a su vez el neurodesarrollo del recién nacido. objetivo: categorizar los principales componentes de los programas de intervención temprana y determinar el efecto de estas intervenciones en la disminución del nivel de estrés en padres de prematuros hospitalizados. método: metaanálisis con 9 ensayos clínicos controlados, que cumplieron los criterios de rigurosidad metodológica. resultados: las intervenciones aplicadas a los padres de prematuros hospitalizados mostraron efecto de intensidad media-baja sobre el nivel de estrés percibido (d=0,36 ic [-0.68, -0,05]). sin embargo, las pruebas de heterogeneidad indican alta variabilidad inter-estudio (q(df=8) = p-val: <0,00001), i2=85% ), explicada parcialmente por las características moderadoras codificadas para los estudios. conclusiones: aunque las intervenciones mostraron efectos positivos en la disminución del nivel de estrés en los padres, se evidencia que la educación y el apoyo emocional en conjunto logran un mejor efecto. las futuras investigaciones deben analizar aspectos como calidad de los estudios, intervenciones con apoyo emocional, edad de los padres y diversidad en los contextos de aplicación. palabras clave padres; prematuro; estrés psicológico; intervención; metaanálisis; instrumentos; enfermería neonatal (fuente: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 276-295 277 metaanálisis: efecto de las intervenciones para disminuir el nivel de estrés en padres de prematuros l beatriz villamizar-carvajal y otros año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 276-295 meta-analysis: effect of interventions to reduce the stress level of parents of premature babies abstract introduction: the preterm birth of a baby stresses the parents, due to the risk of increased morbidity and mortality. some interventions decrease parental stress levels while benefiting the neurodevelopment of the newborn. objective: to categorize the main components of early intervention programs and to determine their effect in decreasing the stress levels of parents of hospitalized premature babies. method: meta-analysis with 9 controlled clinical trials that met the criteria of methodological rigor. results: the interventions applied to parents of hospitalized premature babies showed a medium-low intensity effect on the perceived stress level (d=0.36 ic [-0.68, -0.05]). however, heterogeneity tests indicate high inter-study variability (q(df=8) = p-val: <0.00001), i2=85% ), partially explained by the moderating coded features for the studies. conclusions: even though the interventions revealed positive effects in reducing parental stress levels, it is shown that education and emotional support achieve a better effect together. future research should examine aspects such as the quality of studies, interventions with emotional support, parental age and diversity in application contexts. keywords parents; premature; psychological stress; intervention; meta-analysis; instruments; neonatal nursing (source: decs, bireme). 278 aquichan issn 1657-5997 meta-análise: efeito das intervenções para diminuir o nível de estresse em pais de prematuros resumo introdução: o nascimento prematuro de um bebê gera estresse nos pais devido ao risco de aumento na morbimortalidade que isso implica. existem intervenções que diminuem o nível de estresse nos pais, o que beneficia, por sua vez, o neurodesenvolvimento do recém-nascido. objetivo: categorizar os principais componentes dos programas de intervenção precoce e determinar o efeito dessas intervenções na diminuição do nível de estresse em pais de prematuros hospitalizados. método: meta-análise com nove ensaios clínicos controlados, que cumpriram com os critérios de rigorosidade metodológica. resultados: as intervenções aplicadas aos pais de prematuros hospitalizados mostraram efeito de intensidade média-baixa sobre o nível de estresse percebido (d=0,36 ic [-0.68, -0,05]). contudo, os testes de heterogeneidade indicam alta variabilidade interestudo (q(df=8) = p-val: <0,00001), i2=85%), explicada parcialmente pelas características moderadoras codificadas para os estudos. conclusão: embora as intervenções mostrem efeitos positivos na diminuição do nível de estresse nos pais, evidencia-se que a educação e o apoio emocional em conjunto conseguem um melhor efeito. as futuras pesquisas devem analisar aspectos como qualidade dos estudos, intervenções com apoio emocional, idade dos pais e diversidade nos contextos de aplicação. palavras-chave pais; prematuro; estresse psicológico; intervenção; meta-análise; instrumentos; enfermagem neonatal (fonte: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 276-295 279 metaanálisis: efecto de las intervenciones para disminuir el nivel de estrés en padres de prematuros l beatriz villamizar-carvajal y otros introducción descripción de la situación el nacimiento prematuro (antes de las 37 semanas de gestación) es un reto para el niño y para la familia, por la inmadurez de sus órganos y sistemas, con déficit en el desarrollo para la adaptación a la vida extrauterina, conllevando mayor número de complicaciones (1, 2), lo que genera mayor riesgo de alteración en el desarrollo neurológico como parálisis cerebral (3), retraso mental (4), trastornos visuales (5) y auditivos (6). por tanto, la morbilidad del recién nacido pretérmino (rnpt) a largo plazo es un grave problema de salud pública (7), que aumenta los costos de la atención, por la demanda de servicios médicos especializados y la pérdida de productividad asociada al cuidado del rnpt (8). los diferentes estudios han mostrado aumento en el nivel de estrés, ansiedad y depresión en las familias con rnpt (9, 10); factores que influyen en la sensibilidad materna y en la capacidad de respuesta a las interacciones con su hijo (11), afectando de manera indirecta los resultados del desarrollo del niño a mediano y largo plazo (12). por tanto, es importante revisar los estudios con intervenciones dirigidas a los padres (13), que buscan disminuir el nivel de estrés, lo cual, a su vez, puede disminuir el riesgo de complicaciones en el desarrollo del rnpt. el estrés de los padres en la unidad de cuidado intensivo neonatal un nacimiento prematuro es un evento impredecible, que puede sorprender a los padres (14) y ocasionar altos niveles de estrés, principalmente en las dos primeras semanas del nacimiento del bebé (15). se han reportado diversas fuentes de estrés como el ambiente de la unidad de cuidado intensivo neonatal (ucin), el comportamiento y la apariencia del bebé, el desempeño del rol paterno y la comunicación con el personal de salud (16). los padres se sienten angustiados cuando ven los diversos tubos en el cuerpo del bebé (17) o cuando este debe recibir procedimientos invasivos (18). aunque las claves del comportamiento de un rnpt representan la forma en que este se adapta a los estímulos del entorno (19), a menudo la carencia de conocimientos por parte de los padres en la comprensión de las necesidades de sus bebés (20), y el no saber cómo interactuar con ellos (21, 22), genera miedo de acercarse y tocar a su hijo, experimentando pérdida de control y de autoestima; además, cuando existen problemas de comunicación con el personal de salud se sienten inseguros para hacer preguntas sobre su bebé (23), lo que ocasiona que los padres presten más atención a los monitores y a los equipos, que interés por establecer la conexión y el apego con su bebé (24, 25). apoyo a los padres la literatura muestra diferentes intervenciones aplicadas a los padres para fortalecer conductas parentales positivas, que buscan disminuir su nivel de estrés e incluyen apoyo educativo y psicológico en la etapa temprana de la admisión del rnpt en la ucin. la mayoría de estas intervenciones fomentan el cuidado centrado en la familia y son lideradas por enfermería (26), quien debe capacitar e incluir a los padres en el cuidado del bebé hospitalizado (27). ¿qué tanto pueden funcionar las intervenciones tempranas para los rntp? la “intervención temprana” hace referencia a los programas enfocados al manejo del estrés que experimentan los padres a los pocos días del nacimiento del bebé, cuando es más evidente la neuroplasticidad cerebral del neonato; dichas intervenciones buscan tener mayor impacto en la salud del niño (28), siendo necesario, por tanto, establecer sus componentes claves. el apoyo psicosocial ofrecido a los padres contribuye a disminuir su nivel de estrés, aumentar la autoeficacia y la capacidad de respuesta en las interacciones con su hijo; lo cual, a su vez, puede tener un efecto positivo en el entorno del niño y mejorar los resultados del desarrollo. ¿por qué es importante realizar esta revisión? ninguna otra revisión sistemática ha examinado los componentes específicos de las intervenciones con el fin de aclarar los mecanismos subyacentes a los efectos sobre los resultados de los padres y, de alguna forma, en los resultados del niño. mccarton et al. (29) hicieron una revisión de estudios publicados desde 1971 hasta 1994 y analizaron 19 programas, los cuales permitieron concluir que las intervenciones para los rnpt con apoyo de los 280 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 padres y la educación pueden ofrecer un entorno más óptimo para el desarrollo del niño. estos estudios muestran los resultados en las habilidades de los padres, pero no analizan la calidad de los mismos. vanderveen et al. (30) evaluaron los ensayos clínicos controlados aleatorizados (eca) publicados desde 1966 hasta el año 2008 con intervenciones tempranas para los rnpt y los padres. los componentes de la intervención fueron diversos e incluyeron la educación para los padres, la estimulación infantil, las visitas al hogar y los cuidados para el desarrollo en la ucin. los resultados de esta revisión muestran la importancia de las primeras habilidades de intervención y enseñanza a los padres o la participación de estos en el cuidado de los prematuros para mejorar el desarrollo del niño. además, recomiendan continuar investigando en situaciones de riesgo como es el caso de los rnpt con secuelas biológicas, sobre la eficacia a largo plazo de esas intervenciones (30). pridham et al. realizaron una revisión integradora de 22 estudios de intervenciones dirigidas por enfermeras destinadas a promover la interacción entre padres e hijos. los rnpt no eran los objetivos específicos, pero algunos fueron incluidos. estos autores solicitan un mayor énfasis en los fundamentos teóricos sobre los factores que pueden llegar a afectar los resultados de las intervenciones (31). la etnia y el género de los padres (madres y padres) pueden influir en las interacciones con los rnpt, pero estas son variables que aún no han sido bien estudiadas. esta brecha de conocimiento se observó en una síntesis cualitativa de perspectivas de los padres sobre las relaciones entre ellos mismos y con sus hijos (32), que incluía algunos estudios de los padres con niños prematuros. de esta manera, las carencias anteriores observadas en las revisiones de la literatura necesitan ser analizadas. si bien es importante entender los efectos en los rnpt, ninguna de estas revisiones incluye los resultados para los padres específicamente. por tanto, el objetivo de esta revisión metaanalítica se centró en categorizar los principales componentes de los programas de intervención temprana y determinar el efecto de estas intervenciones en la disminución del nivel de estrés en padres de rnpt hospitalizados en la ucin. materiales y métodos el presente estudio, de abordaje cuantitativo, corresponde a un metaanálisis (ma), considerado un tipo de investigación que se centra en el análisis e integración de los resultados cuantitativos obtenidos en estudios primarios que cumplen con criterios de selección previamente definidos, a través de la aplicación de pruebas estadísticas (33-35). en el ma se garantizó el cumplimento de criterios de rigor metodológico, como: la precisión, la objetividad y la replicabilidad, esenciales para lograr resultados válidos, una mayor explicación a la variabilidad encontrada y posibilitar que otros investigadores, al aplicar los mismos criterios, puedan llegar a conclusiones cuantitativas similares (35). así mismo, se tomaron decisiones en cada uno de los procedimientos que se iban a seguir, a fin de tener un mayor control de los principales riesgos y sesgos a que están expuestos los estudios metaanalíticos, como son: el sesgo de publicación, el sesgo en la selección de las piezas de investigación, en la variabilidad de la calidad de las piezas de investigación, sesgos de lenguaje, de citación y ante la falta de unificación o no determinación de los parámetros de codificación de los estudios. un ma debe cumplir con una serie de etapas homólogas que se cumplen en la realización de un estudio primario. estas son descritas como: a) la formulación de la pregunta o el problema de investigación u objetivo del estudio, b) búsqueda de las piezas de investigación y selección de los estudios (elegibilidad), c) crítica y calificación de los estudios de investigación seleccionados, d) codificación y extracción de información de los estudios, e) medida de los resultados obtenidos en los estudios (conversión a una métrica común), f) análisis e interpretación de los resultados y g) publicación de los resultados del estudio (36-39). para dar cumplimiento a cada una de ellas, el presente metaanálisis se guió por los siguientes aspectos: a) identificar los resultados en particular, b) determinar la calidad de las pruebas de los eca, c) estimar los efectos de la intervención sobre los resultados de los padres, d) clasificar los componentes de las intervenciones clave asociadas con los resultados paternos y, posteriormente, los resultados del niño, y e) plantear la aplicabilidad de los resultados a la práctica clínica y a la investigación futura con el fin de promover intervenciones rentables, centradas, eficaces y preventivas para el rnpt y su familias. proceso de búsqueda y selección de los estudios inicialmente se identificaron las palabras clave, descriptores o términos mesh (medical subject heading) relacionados con el 281 metaanálisis: efecto de las intervenciones para disminuir el nivel de estrés en padres de prematuros l beatriz villamizar-carvajal y otros tema. pruebas preliminares con palabras clave elegidas de diversas revisiones aseguraron que todas las palabras fueran las adecuadas para la implementación de la estrategia de búsqueda final. con el fin de centrarse en las intervenciones para los padres, se utilizaron los términos mesh: “parents” y “premature infant” en cada base de datos consultada. como término texto se incluyeron: “pss:nicu”, “tools”, “stress”, “intervention”. para realizar la búsqueda de la literatura se utilizó la interfaz de ovid y ebscohost, y se accedió a las bases de datos medline vía pubmed, embase, cochrane database of systematic reviews, cinahl y eric. también, se revisaron las listas de referencias (búsqueda secundaria) de cada artículo elegido y para aquellos títulos que guardan relación con el tema del ma se hizo la búsqueda manual, la cual evidenció que la mayor parte de las publicaciones identificadas en este proceso de búsqueda secundaria eran informes adicionales de los eca que ya habían sido identificados. criterios de inclusión • haber sido publicados entre los años 2000 a 2014 (el 2000 fue seleccionado por ser la época donde se le da énfasis a la investigación en la implementación del cuidado para el neurodesarrollo y centrado en la familia (40), y aumenta la participación de los padres en el cuidado de los rnpt). • escrito en idiomas inglés, español o portugués. • estudio con diseño de ensayo clínico aleatorizado (eca). • intervención aplicada a padres de rnpt durante la hospitalización en ucin. • medición del nivel de estrés con la escala parental stress scala:neonatal intensive care unit (pss:nicu). descripción de la parental stress scala: neonatal intensive care unit aunque son diversas las escalas utilizadas para evaluar el nivel de estrés de los padres, para el presente ma se tomó como criterio de selección la escala pss: nicu, por ser la de mayor uso en investigación sobre el tema. esta escala fue desarrollada por miles et al. (41) en 1993 para medir el estrés que los padres perciben, derivado del entorno físico y psicosocial de la ucin. el instrumento contiene 34 ítems e incluye tres dimensiones: luces y sonidos de la unidad, el comportamiento y la apariencia del rnpt y la alteración del rol de los padres. los niveles de estrés se califican en una escala tipo likert de 5 puntos, que van desde “1 = nada estresante a 5 = muy estresante”. una puntuación alta representa un alto nivel de estrés paterno (41). al realizar la búsqueda científica esta fue la escala más utilizada en los diferentes estudios de medición del nivel de estrés por presentar el mayor rigor metodológico. criterios de exclusión • artículos de revisión. • intervención aplicada a la salida del hospital. • estudios centrados en un subconjunto de rnpt diagnosticados con problemas del desarrollo tales como trastorno neurológico o malformación. • estudios que evalúan el nivel de estrés en profesionales de enfermería u otro grupo de profesionales de la salud. para aquellos estudios que tenían diversas publicaciones derivadas del análisis de datos provenientes de una misma muestra, se decidió incluir en el ma el artículo de investigación que reportaba la mayor información requerida para los análisis; los demás estudios fueron excluidos y, en algunos casos, se tomaron como referencia para complementar información que no estaba disponible en el estudio elegido. las búsquedas se organizaron en carpetas que luego se fusionaron con el fin de eliminar los estudios duplicados y tener una matriz única de estudios identificados en el proceso de búsqueda, a los cuales se les verificó el cumplimiento de los criterios de inclusión y de exclusión para definir su utilidad en el ma. estrategia de búsqueda de la literatura la búsqueda en la literatura primaria produjo 1198 títulos y resúmenes, de los cuales 39 fueron identificados como potencialmente relevantes para la revisión del texto completo. luego de la revisión crítica, solo 9 artículos cumplieron los criterios de inclusión (véase la figura 1 para el diagrama de flujo de la selección del estudio). 282 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 un artículo de los incluidos correspondió al reporte del eca piloto y del eca definitivo, presentando dos muestras, y resultados diferentes y representativos, por lo que fueron tratados como estudios separados (42). análisis crítico y cualificación de los estudios para establecer la calidad metodológica y científica de los estudios se utilizó la escala pedro que, por medio de 11 ítems evalúa los parámetros básicos de un eca (43). este proceso fue realizado por dos evaluadores, quienes de manera independiente analizaron el cumplimiento de cada parámetro propuesto en esta escala para cada uno de los estudios incluidos en el ma. para aquellas características en las cuales se encontraron desacuerdos, con la participación de un tercer evaluador se definió la puntuación de estos ítems. los hallazgos obtenidos según la escala pedro mostraron que, en general, los estudios incluidos en el presente ma son metodológicamente de buena calidad, con una puntuación promedio de 8,3 ± 2,5. dentro de otros hallazgos evidenciados en la evaluación de la calidad metodológica se observó que el 70 % de los estudios que aplicaron la secuencia de asignación aleatoria explican adecuadamente cómo fue realizado este procedimiento, y cuatro estudios (44-47) describen de manera adecuada el enmascaramiento de la asignación al tratamiento. en general, la calidad de la información de los estudios fue apropiada. la evaluación de la calidad metodológica de los estudios se indica en la tabla 1. codificación de las características de los estudios para los estudios seleccionados para el ma se codificaron tres tipos de variables o características: sustantivas, metodológicas figura 1. flujograma de selección de estudios fuente: elaboración propia. 283 metaanálisis: efecto de las intervenciones para disminuir el nivel de estrés en padres de prematuros l beatriz villamizar-carvajal y otros tabla 1. evaluación de calidad de los estudios según la escala pedro fuente: elaboración propia. criterio de evaluación (ítems) 1 2 3 4 5 6 7 8 9 10 11 puntuación total autor-año abdeyazdan 2014 1 0 0 1 0 0 0 1 1 1 1 6 beheshtipour 2014 1 1 1 1 1 1 1 0 1 1 1 10 matricardi 2012 1 1 1 1 1 1 1 1 1 1 1 11 melnyk 2006 1 1 1 1 1 1 1 1 1 1 1 11 turan 2008 1 0 0 0 0 0 0 1 1 1 1 5 van der pal 2007 1 1 1 1 0 0 0 1 1 1 1 8 weis 2013 1 1 1 1 0 0 0 1 1 1 1 8 zelkowitz 2011 1 1 1 1 1 1 1 1 1 1 1 11 puntuación 0: indica que el criterio evaluación no se cumple. puntuación 1: indica que el criterio se cumple 1) criterios de elección; 2) asignación al azar; 3) enmascaramiento de la asignación; 4) equivalencia de grupos; 5) enmascaramiento de sujetos; 6) enmascaramiento del terapeuta; 7) enmascaramiento del evaluador; 8) nivel de atrición de la muestra menor del 15 %; 9) se presentan resultados de todos los sujetos; 10) informa pruebas de comparación entre grupos; 11) informa resultados exactos y variabilidad. y extrínsecas (48). los aspectos de tipo sustantivo son aquellos que permiten caracterizar el fenómeno sobre el cual se investiga e incluye características de los sujetos participantes como: si eran padres, madres y parejas, edad de los mismos. también considera aspectos del contexto sociodemográfico como: país donde se realizó el estudio, año de publicación, etc. los aspectos de tipo metodológico hacen referencia principalmente a la manera como se tipifican las variables, la calidad de las medidas de estrés, los procedimientos de análisis, la calidad metodológica de los mismos, entre otras. estos dos primeros grupos de variables son considerados los que mayor influencia pueden tener sobre los resultados obtenidos en el ma y los que con mayor precisión pueden explicar la variabilidad en los resultados. las características de tipo extrínseco pueden a su vez subdividirse en aspectos de tipo sustantivo, metodológico o factores relacionados con la codificación, que contemplan aspectos como género y disciplina del investigador (es), estudio, si se recibió financiación o no, tipo de publicación que se generó de la investigación, etc. estas últimas, aunque no debieran dar respuesta a la variabilidad de los resultados encontrados en un ma, muchas veces, al hallarse relacionadas, abren nuevos campos de investigación y sugieren la revisión de las propuestas teóricas que explican el fenómeno en estudio. en esta etapa del ma, al igual que en la etapa de cualificación o evaluación de la calidad de los estudios, el proceso fue realizado por dos investigadores expertos, quienes extraían los datos de cada estudio y luego, a través de la aplicación de las pruebas de fiabilidad, se definía si para algunas de ellas se requería de la participación de un tercer codificador que, en conjunto con los codificadores principales, determinaran el dato final por informar para cada característica codificada. a fin de establecer el índice de fiabilidad interevaluador e intercodificador se tomaron de referencia para las características cuantitativas el índice de confiabilidad interevaluador o intercodificador, y para las características de tipo cualitativo el índice de kappa de cohen, los cuales en general informaron valores de acuerdo entre evaluadores y codificadores clasificados como buenos o muy buenos (≥ 0,8). para la etapa de medida de los resultados obtenidos en los estudios (cálculo del tamaño del efecto de los estudios), uno de los procesos de un metaanálisis es llevar los resultados de los estudios primarios a una medida de resultados que permita la comparación entre sí. para el presente ma, el índice de tamaño 284 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 del efecto elegido para evaluar el impacto de la intervención sobre el estrés experimentado por los padres fue la d de cohen, que es una medida del tamaño del efecto obtenido a partir de la diferencia de medias estandarizadas. es decir, nos informa cuántas desviaciones típicas de diferencia hay entre los resultados de los dos grupos que se comparan (grupo experimental y grupo de control). a partir de los resultados informados en los estudios primarios se procedió a calcular para cada dimensión de la escala de pss:nicu como índice de tamaño de efecto el valor del índice d de cohen (diferencia media estandarizada) y, posteriormente, el promedio de la suma de los valores de d obtenidos de cada dimensión fue reportado con el tamaño de efecto medio de cada estudio para la dimensión global del pss:nicu (estrés global percibido). estos valores de tamaño de efecto medio calculado para cada estudio fueron utilizados a fin de determinar el tamaño del efecto medio global para el conjunto de estudios incluidos en el ma. la fórmula aplicada para obtener este cálculo es la siguiente: los análisis centrales del ma, que incluyeron cálculo del tamaño de efecto medio global del impacto que la intervención tenía sobre el estrés percibido por los padres, evaluación del riesgo de sesgo de publicación sobre los resultados, determinación del grado de homogeneidad en los resultados y pruebas de sensibilidad que expliquen la variabilidad de los resultados en caso de que esta se presente, fueron realizados con el software de uso gratuito creado por la colaboración cochrane rev-man 5 (49). el tamaño de efecto medio obtenido tras la consolidación de los tamaños medios obtenidos de cada estudio incluido se presentará gráficamente a través del forest plot. así mismo, el gráfico de funnel plot o de embudo fue utilizado para visualizar la distribución del tamaño de efecto medio de cada estudio respecto del tamaño del efecto medio global; este gráfico buscar identificar si los resultados pueden estar afectados por la presencia de sesgo de publicación. la heterogeneidad en los resultados se evaluó mediante la prueba q e índice i2, en donde valor-p estadísticamente significativo indica la presencia de heterogeneidad en los resultados. el resultado de la prueba q se suele complementar con el índice i2, que es un estadístico que permite identificar el porcentaje de la cantidad de heterogeneidad entre los estudios, es decir, cuánto de la heterogeneidad es debida a la varianza interestudio. el índice i2, en torno a 25, 50 y 75 %, se puede interpretar como heterogeneidad baja, media y alta, respectivamente. resultados el 55 % de los estudios fueron publicados en los últimos 5 años en holanda (42), irán (44, 50), italia (45), estados unidos (46), canadá (47), turquía (51) y dinamarca (52). en la tabla 2 se muestran las características de los estudios incluidos en la revisión. todos los estudios fueron eca, que incluyeron padres con rnpt hospitalizados en ucin, y contaron con un grupo de intervención y un grupo control. intervención a los participantes los estudios incluyeron intervenciones dirigidas a los padres, sin embargo, uno de los nueve estudios mostró una intervención aplicada al rnpt por parte de los padres (45). si bien este estudio hace una contribución importante a la comprensión de los efectos de la intervención en los rnpt, no muestra directamente el efecto diferencial en los padres (es decir, entre madres y padres). los nueve estudios informaron las mediciones de niveles de estrés para ellos. análisis de datos los procedimientos de análisis aplicados a los datos recolectados de los estudios primarios incluyeron la descripción de las características de tipo sustantivo, metodológico y extrínseco codificadas para el conjunto de estudios incluidos en el ma, procedimientos realizados con el paquete estadístico ibm-spss 22. para las variables categóricas cualitativas se calcularon las frecuencias y los porcentajes, y para las variables cuantitativas continuas se calcularon las medias, la desviación estándar, los rangos y los valores mínimo y máximo. los cálculos del tamaño de efecto medio para estrés global percibido por los padres para cada estudio fueron realizados en excel, previa definición de una matriz de cálculos construida por las investigadoras. 285 metaanálisis: efecto de las intervenciones para disminuir el nivel de estrés en padres de prematuros l beatriz villamizar-carvajal y otros tabla 2. características de tipo sustantivo, metodológico y extrínsecas de los estudios incluidos en el metaanálisis fuente: elaboración propia. estudio país participantes (n) edad de los padres (años) promedio edad gestacional de rn (semanas) promedio peso al nacer e c e c e c e c abdeyazdan 2014 irán 50 50 27,4 28,70 31,4 31,3 1626 1654 beheshtipour 2014 irán 49 51 27,4 27,43 30,5 30,5 1500 1500 matricardi 2012 italia 42 42 36,5 36,7 29,4 29,1 1214 1141 melnyk 2006 usa 136 109 29 29 31,3 31,4 1683 1627 turan 2008 turquía 37 39 26,5 27,7 31 31,5 1046 1045 vander 2007 eca1 holanda 67 66 29 28,9 1193 1185 vander 2007 eca2 holanda 75 75 29,6 29,3 1239 1247 weis 2013 dinamarca 74 60 32,5 32,5 29 30 1095 1135 zelkowitz 2011 canadá 48 50 31 30,8 28 27,9 993 973 componentes de la intervención aunque la mayoría de los estudios proporcionan alguna descripción de los componentes de la intervención, pocos informaron detalles suficientes para permitir la replicación. la mayoría entregó la intervención con un plan general. solo el estudio de melnyk et al. (46) presentó detalles sobre el tiempo, el número de sesiones, el contenido de la educación y la formación del personal del programa. las intervenciones examinadas tienen múltiples y diversos componentes. los componentes en general contienen estrategias para promover un cambio positivo en la interacción de los padres con el rnpt, a través de la interpretación del comportamiento y la capacidad de respuesta del niño, del apoyo al padre incluido el asesoramiento o apoyo emocional y del fortalecimiento del rol parental. bakersmans-kranenburg et al. (53) plantean una clasificación de las intervenciones en tres grandes categorías: a) apoyo a los padres (orientación psicológica y apoyo social), b) educación a los padres (información, demostración y discusión con un profesional) y c) el apoyo terapéutico al desarrollo infantil. esta clasificación se utilizó para organizar los estudios analizados, en los cuales se puede observar el uso de los componentes de la siguiente manera: cuatro de ellos los utilizaron todos, tres utilizaron dos componentes y dos solo utilizaron uno, con las respectivas dimensiones medidas como muestra la tabla 3. como se observa, diferentes aspectos educativos conformaban las intervenciones. el 55 % de los estudios proporcionaron los tres componentes educativos de la intervención (44, 45, 47, 50, 52); el 33 % utilizó solo la información (42, 46, 51) y el 22 % no proporcionó apoyo emocional parental (42, 46). los nueve estudios incluidos informaron resultados paternos de estrés. la prueba para el efecto general de las intervenciones sobre el estrés fue significativa. impacto de las intervenciones en el estrés percibido por los padres el modelo adoptado para los análisis realizados fue el modelo de efectos aleatorios, esta decisión obedece a que con este ma se busca que los resultados obtenidos puedan extrapolarse a poblaciones diferentes a las incluidas en el ma, y a priori se asume que en un ma siempre va a existir variabilidad en los tamaños del efecto. a continuación, en la tabla 4 se muestran los resultados del efecto que los programas de intervención tienen sobre 286 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 tabla 3. componentes de la intervención, categorías codificadas y resultados medidos en los padres fuente: elaboración propia. id estudio nombre de la intervención componentes de la intervención resultados medidos en los padres apoyo emocional categorías de educación a los padres apoyo al niño a b c d 1 2 3 abdeyazdan 2014 apoyo familiar + + + + + + + beheshtipour 2014 programa educativo + + + + + + + matricardi 2012 observación del rn y masaje + + + + + + + + melnyk 2006 cope + + + + + turan 2008 programa educativo + + + + + van der pal 2007 eca-a basic dc + + + + + van der pal 2007 eca-b nidcap + + + + + + + weis 2013 gfcc + + + + + + + + zelkowitz 2011 intervención basada en las señales del bebé + + + + + + + nombre de la intervención: cope: creating opportunities for parent empowerment nicu program; basic dc: basic developmental care; gfcc: guided familycentered care; nidcap: newborn individualized developmental care and assessment program categorías de codificación para los componentes de educación para padres: 1. información proporcionada: la información incluida es genérica (por ejemplo, una lectura, un audio o un video), individualizado para la familia (escrito o verbal). 2. observación guiada: incluye la observación de los padres o la demostración de una actividad con el niño. 3. participación activa: incluye la participación de padres en las experiencias con prácticas activas, con autoevaluación guiada o autorreflexión (por ejemplo, la retroalimentación de vídeo). mediciones en los padres pss:nicu: a = dimensión sonidos, b = dimensión comportamiento del rn, c = dimensión rol parental, d = relación con el personal de salud. el estrés parental global que experimentan los padres de rnpt hospitalizados en la ucin. en la tabla 4 se presentan los resultados para 1120 padres de rnpt (578 fueron del grupo intervenido y 542 del grupo control); así mismo, 8 de los 9 estudios reportan que la intervención utilizada produce resultados que disminuyen el estrés de los padres de rnpt hospitalizados en ucin, y solo un estudio (45) reporta un resultado en contra de la intervención. sin embargo, de los 8 estudios con resultados a favor de las intervenciones realizadas, 5 no lograron alcanzar la significancia estadística, esto se confirma con el hecho que los ic obtenidos para el tamaño de efecto medio de cada estudio cortan el valor nulo (“cero”) (42, 46, 47, 51, 52). respecto al resultado obtenido como tamaño de efecto medio global para el conjunto de estudios, el valor d = -0,36; ic 95 %: -0,68, -0,05 sobre el estrés global percibido por los padres de rnpt hospitalizados en ucin demuestra que las intervenciones 287 metaanálisis: efecto de las intervenciones para disminuir el nivel de estrés en padres de prematuros l beatriz villamizar-carvajal y otros tabla 4. forest plot del tamaño de efecto de la intervención de enfermería en el estrés parental fuente: elaboración propia. aplicadas por los profesionales de la salud tienen un impacto de intensidad media-baja, con significancia práctica y estadística relevante que indica una disminución en el nivel de estrés. la significancia estadística se confirma porque el ic no corta el valor nulo “0”, que valida un significado de beneficio de la intervención. la figura 2 muestra el funnel plot donde se puede observar que los tamaños de efecto de los nueve estudios incluidos en el ma, en general tienen una distribución simétrica, indicando que los resultados obtenidos no están afectados por la presencia del sesgo de publicación. por otra parte, la prueba de heterogeneidad (q(df = 8) = pval: < 0,00001), estadísticamente significativa, y un valor para el índice i2 = 85 %, indican la presencia de alta variabilidad interestudio. el análisis del conjunto de características codificadas (moderadores de resultados) para los estudios, con el que se busca identificar cuáles de estas variables podrían estar asociadas a esta variabilidad (tabla 5), no permite identificar una característica que explique por sí sola la presencia de dicha heterogeneidad. aunque, como se observa, estudios de calidad metodológica media presentan menor variabilidad (i2 = 41 %), los estudios realizados en el continente americano (i2 = 0 %) son completamente homogéneos y los publicados en el periodo de tiempo comprendido entre los años 2000-2009 (i2 = 19 %) tienen heterogeneidad baja, estos resultados no pueden ser generalizables y no puede descartarse que puedan estar afectados por la escasez de estudios disponibles para analizar con mayor certeza estas relaciones con las variables moderadoras propuestas dentro de los análisis del presente estudio, o por la falta de información completa en los informes de investigación identificados y seleccionados a partir de la búsqueda de literatura científica relevante (tabla 5). para ampliar este análisis se calcularon los anovas para la medidas de te del estrés global, respecto a cada una de las codificadas para los estudios (tabla 6); ninguna variable mostró tener una relación estadísticamente significativa con los resultados de la variable dependiente estrés percibido por los padres de rn prematuros, es decir, que los p-valores no significativos para todos los moderadores utilizados deben interpretarse así: que los 288 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 figura 2. funnel plot del tamaño de efecto de la intervención en el estrés parental (análisis de sesgo de publicación) tabla 5. análisis de variables moderadoras de la presencia de heterogeneidad en el ma fuente: elaboración propia. variable moderadora analizada estudios por dimensión de la variable (n) participantes (n) tamaño de efecto (diferencia media estandarizada ic 95 %) resultados de pruebas de heterogeneidad calidad metodológica baja 2 176 -0,97 [-2,04, 0,10] p-val = 0,0008, i2 = 91 % media 3 417 -0,24 [-0,49, 0,01] p-val = 0,18, i2 = 41 % alta 4 527 -0,18 [-0,65, 0,30] p-val = 0,0002, i2 = 85 % total 9 1120 -0,36 [-0,68, -0,05] p-val = 0,00001, i2 = 85 % continente américa 2 343 -0,20 [-0,41, 0,01] p-val = 0,68, i2 = 0 % europa 5 577 -0,13 [-0,45, 0,19] p-val = 0,005, i2 = 73 % asia 2 200 -1,17 [-1,83, -0,51] p-val = 0,03, i2 = 79 % total 9 1120 -0,36 [-0,68, -0,05] p-val = 0,00001, i2 = 85 % periodo de tiempo de publicación 2000-2009 4 604 -0,28 [-0,46, -0,10] p-val = 0,30, i2 = 19 % 2010-2014 5 516 -0,42 [-1,06, 0,21] p-val < 0,00001, i2 = 92 % total 9 1120 -0,36 [-0,68, -0,05] p-val < 0,00001, i2 = 85 % 289 metaanálisis: efecto de las intervenciones para disminuir el nivel de estrés en padres de prematuros l beatriz villamizar-carvajal y otros variable moderadora analizada estudios por dimensión de la variable (n) participantes (n) tamaño de efecto (diferencia media estandarizada ic 95 %) resultados de pruebas de heterogeneidad profesional que realiza la intervención multidisciplinar 4 527 -0,18 [-0,65, 0,30] p-val = 0,0002, i2 = 85 % médico 2 283 -0,27 [-0,69, 0,14] p-val = 0,08, i2 = 68 % enfermera 3 310 -0,70 [-1,50, 0,11] p-val < 0,0001, i2 = 91 % total 9 1120 -0,36 [-0,68, -0,05] p-val < 0,00001, i2 = 85 % participante al que se aplica la intervención madre o padre 8 1022 -0,39 [-0,74, -0,04] p-val < ,.00001, i2 = 87 % solo madres 1 98 -0,13 [-0,53, 0,27] no aplicable, total 9 1120 -0,36 [-0,68, -0,05] p-val < 0,00001, i2 = 85 % tipo de intervención educativa 3 276 -0,93 [-1,18, -0,68] p-val = 0,003, i2 = 83 % otra 6 844 -0,15 [-0,29, -0,01] p-val = 0,02, i2 = 63 % total 9 1120 -0,36 [-0,45, -0,21] p-val < 0,00001, i2 = 85 % edad de los padres hasta 30 años 4 521 -0,74 [-1,30, -0,18] p-val < 0,00001, i2 = 89 % 30 o más años 3 316 0,06 [-0,35, 0,47] p-val = 0,04, i2 = 70 % no informa 2 283 -0,27 [-0,69, -0,14] p-val = 0,08, i2 = 68 % total 9 1120 -0,36 [-0,68, -0,05] p-val < 0,00001, i2 = 85 % edad gestacional 28-31 semanas 6 699 -0,20 [-0,53, 0,13] p-val = 0,0003, i2 = 79 % 32-34 semanas 3 421 -0,71 [-1,48, 0,05] p-val < 0,00001, i2 = 92 % total 9 1120 -0,36 [-0,68, -0,05] p-val < 0,00001, i2 = 85 % nivel educativo del participante primaria 1 76 -0,43 [-0,88, 0,03] no aplicable secundaria 5 726 -0,46 [-0,89, -0,03] p-val < 0,00001, i2 = 87 % técnico o universitario 3 318 -0,17 [-0,88, 0,55] p-val < 0,00001, i2 = 90 % total 9 1120 -0,36 [-0,68, -0,05] p-val < 0,00001, i2 = 85 % fuente: elaboración propia. 290 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 tamaños de efecto para cada uno de los grupos de estudios analizados según las categorías de clasificación de cada una de estas variables son similares entre sí. otros hallazgos que pueden derivarse del análisis de moderadores son: cómo la variable de tipo metodológico —estudios de baja calidad— reportó resultados de intensidad alta en favor del grupo intervención (d = -0,97), resultados que son contrarios a lo que reportan los estudios evaluados como de alta calidad en donde la intensidad del efecto reportado es pobre o baja (d = -0,18). pero en todos los casos no logran ser estadísticamente significativos, es decir, que no es posible generalizar el hallazgo a otros contextos no incluidos en los análisis. respecto al continente donde se realizan los estudios, los análisis permiten deducir que los realizados en américa y europa logran un efecto de intensidad baja o despreciables de (d = -0,20) y (d = -0,13), respectivamente; los resultados son pobres y no significativos, mientras el estrés percibido por padres de rn nacidos en el continente asiático parece tabla 6. comparación de medias anova de un factor (te estrés global por variables moderadoras codificadas) fuente: elaboración propia. variable de contraste análisis suma de cuadrados gl media cuadrática f sig. calidad metodológica de los estudios entre grupos dentro de grupos total 0,003 1,082 1,085 2 6 8 0,001 0,180 0,007 0,993 estudio realizado en un continente entre grupos dentro de grupos total 0,202 0,883 1,085 2 6 8 0,101 0,147 0,685 0,540 década de realización del estudio entre grupos dentro de grupos total 0,025 1,060 1,085 1 7 8 0,025 0,151 0,163 0,698 profesiones de (los) autor(es) entre grupos dentro de grupos total 0,653 0,432 1,085 3 5 8 0,218 0,086 2,518 0,172 participantes de la muestra entre grupos dentro de grupos total 0,009 1,076 1,085 1 7 8 0,009 0,154 0,058 0,816 tipo de intervención entre grupos dentro de grupos total 0,292 0,792 1,085 1 7 8 0,292 0,113 2,583 0,152 rango de edad de los participantes (padres) entre grupos dentro de grupos total 0,412 0,672 1,085 2 6 8 0,206 0,112 1,838 0,238 rango de edad gestacional de los recién nacidos entre grupos dentro de grupos total 0,012 1,073 1,085 1 7 8 0,012 0,153 0,078 0,788 nivel educativo de los participantes entre grupos dentro de grupos total 0,371 0,713 1,085 2 6 8 0,186 0,119 1,562 0,284 291 metaanálisis: efecto de las intervenciones para disminuir el nivel de estrés en padres de prematuros l beatriz villamizar-carvajal y otros ser altamente beneficiado por las intervenciones de los profesionales de la salud (d = -1,17), hallazgo que reporta ser estadísticamente significativo a su vez. respecto al profesional que realiza la intervención, los hallazgos permiten concluir que los estudios realizados por enfermeras logran los mejores resultados sobre el nivel de estrés percibido por los padres (d = -0,70), si se compara con los realizados por otros grupos de profesionales. los resultados de las intervenciones pierden intensidad en el efecto, haciéndose este casi totalmente despreciable, en estudios donde solo se intervino al grupo de madres (d = -0,13), respecto de aquellos en donde se incluyeron las parejas de padres (d = -0,39). frente a la edad de los padres al momento de la intervención, los análisis permiten concluir que estudios en donde la edad promedio de los padres participantes excede los 30 años, la intervención no logra ningún efecto sobre el nivel de estrés percibido por ellos; por el contrario, este se hace aún mayor (d = 0,06). resultado similar se obtiene para la variable edad gestacional, en donde al parecer a menor edad gestacional, menor es el efecto que las intervenciones logran sobre el estrés experimentado por los padres (d = -0,20). desde las variables contextuales de tipo sociodemográfico, el ma permite afirmar que el nivel educativo de los padres de los recién nacidos tiene una relación inversa con el estrés de los padres, y a mayor nivel educativo (técnico o universitario) menos se logra impactar disminuyendo el estrés por ellos percibido tras la aplicación de la intervención. discusión las pruebas de ma informan que los programas que dan apoyo emocional, educación y atención del comportamiento para el neurodesarrollo reducen significativamente el estrés en las madres de rnpt, aumentan el conocimiento relacionado con la condición y el cuidado de su bebé, y mejoran la actitud y la confianza de la madre. los programas de aprendizaje interactivos parecen ser más exitosos en reducir el estrés y mejorar el conocimiento de la madre que otros donde solo se muestran sesiones de entrenamiento para los padres. un eca (45) mostró que el hecho de aplicar tanto el cuidado piel a piel como el masaje durante 8 sesiones con una duración de 1 hora mejoró significativamente la interacción madre-rntp y aumentó el sentido de competencia de la madre en el manejo de su bebé al reconocer los signos de estrés y bienestar. estas intervenciones se pueden introducir con relativa facilidad en la mayoría de las ucin. como resultado de las intervenciones tempranas para las madres de los rnpt, se observaron efectos positivos y clínicamente significativos en el desempeño del rol parental que ayudan a disminuir el nivel de estrés en los padres. esta revisión logró clasificar los componentes de las intervenciones tempranas y vincularlos a los resultados maternos. estos componentes fueron el apoyo psicosocial y la educación para los padres, y el apoyo en el desarrollo terapéutico para el niño aplicado por enfermería, psicología y fisioterapia. las intervenciones que incluyen apoyo psicosocial resultaron en mejores resultados para los padres. el estrés fue el constructo principal en esta medición, ya que la literatura lo reporta con frecuencia en las familias que tienen la experiencia de un nacimiento prematuro (54). sin embargo, el metaanálisis sugiere que las intervenciones examinadas tienen poco efecto sobre el estrés en general, dado que la escala mide cuatro dimensiones, de las cuales se ven afectadas unas más que otras. no fue claro por qué había efectos limitados sobre el estrés en general cuando se consideran en conjunto los nueve estudios. las dos intervenciones que muestran un efecto sobre el estrés (44,50) utilizan un componente de apoyo a los padres combinado con un tipo de participación activa de la educación, evidenciando además resultados positivos en el niño. la educación parental por sí sola no redujo el estrés porque no cuenta con el apoyo emocional adecuado. los seis estudios con poco o ningún efecto no tenían un componente de apoyo de los padres, que puede ser importante para abordar el estrés. la escala pss:nicu utilizada permitió la comparación entre los estudios, pero puede ser demasiado genérica como medida de estrés para los padres de los rnpt. no todos los estudios midieron la cuatro subescalas, lo que hace difícil deducir cuáles de los aspectos de estrés son motivo de preocupación para los padres de los rnpt. los estudios que no mostraron efectos positivos sobre el estrés no reportaron el momento en que se aplicó la intervención y en el que se midió el nivel de estrés, lo cual puede haber influido en la aparente efectividad de las intervenciones. 292 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 por otra parte, las intervenciones pueden tener diferentes efectos sobre el estrés de los padres en función de la gravedad de la enfermedad infantil. los momentos de la medición y el análisis de subgrupos deben ser considerados en futuras investigaciones. las intervenciones realizadas contemplaban diversos componentes, y se evidenció que un solo componente de manera aislada por intervención no se asoció con mejores resultados en los padres. de hecho, la educación de los padres fue el único componente utilizado en todas las intervenciones, y la entrega, el tipo y la dosis de educación para padres es muy variada. es importante tener en cuenta que los estudios que proporcionaron apoyo encontraron efectos positivos en los resultados de los padres que a menudo se asocian con mejores resultados de los niños. el apoyo emocional de los padres puede ser un componente importante de las intervenciones para los rnpt. la falta de muestras sociodemográficamente homogéneas puede haber influido en la capacidad de demostrar los efectos de las intervenciones. por último, la estadística i2 sugirió heterogeneidad significativa entre los estudios, incluso utilizando un modelo de efectos aleatorios; la heterogeneidad fue una limitación en esta revisión. un problema con algunos estudios en esta revisión fue que informaron los datos indistintamente, tanto del padre como de la madre. si las intervenciones se aplicaron por separado a madres y padres, entonces deben ser analizadas por separado o excluidas del análisis, porque lo que reporta la literatura es que el nivel de estrés es diferente en la madre y el padre (45). dado el pequeño número de padres que participaron en las intervenciones, es poco probable que esto hubiera tenido un efecto sustancial en los resultados generales. conclusiones los hallazgos presentados en el presente metaanálisis permiten identificar la necesidad de fortalecer desde la evidencia científica la implementación en la ucin de intervenciones centradas en la familia para lograr importantes beneficios clínicos costoefectivos y de mayor aceptabilidad en los padres. los profesionales de la salud deben considerar diferentes tipos de intervenciones en el ejercicio práctico de su quehacer en la ucin centrados en la disminución del nivel de estrés; si ya las han empezado a utilizar, es importante revisar los resultados de su aplicación para reevaluar el uso en la práctica actual y considerar si se requiere adaptación o cambio en los procesos de cuidado. estos cambios pueden ser difíciles y deben contemplar aspectos claves como: el contexto de la atención y otros aspectos que pueden limitar el logro de su implementación en la ucin. aunque las intervenciones que aplicaron los estudios primarios son diversas, en su mayoría contemplan aspectos que se orientan a fortalecer la educación y los apoyos emocionales a los padres que, ofrecidas en conjunto, presentan mejores efectos sobre la disminución del nivel de estrés por ellos percibidos. además, los diferentes artículos incluidos en la revisión demuestran que estas intervenciones disminuyeron la estancia hospitalaria en la ucin. los resultados obtenidos en el metaanálisis mostraron alto grado de variabilidad cuyas causas no están claramente definidas, pero el análisis de las mismas sí aporta aspectos relevantes para tener presentes en la planeación, ejecución y análisis de futuras investigaciones sobre el tema; entre ellos se destacan realizar estudios en donde se comparen las respuestas al estrés en diferentes contextos (continentes), se analicen resultados de manera independiente y comparativa entre madres y padres, y análisis de variables como edad de los padres, nivel educativo de los mismos y edad gestacional del rnpt, entre otros. una limitación de este ma fue el bajo número de estudios que lo conformaron, por tener unos criterios de inclusión muy estrictos. por tanto, los resultados obtenidos deben interpretarse con cautela, dado que las estimaciones pueden ser inestables. finalmente, desde lo metodológico, aun cuando todos los estudios incluidos fueron ensayos clínicos aleatorizados, los resultados obtenidos evidencian que la diferencia en la calidad de los mismos puede afectar los resultados, por lo cual se sugiere realizar estudios en donde esta variable sea tenida en cuenta al momento de interpretar los análisis y de planear la metodología por aplicar en este tipo de investigaciones. 293 metaanálisis: efecto de las intervenciones para disminuir el nivel de estrés en padres de prematuros l beatriz villamizar-carvajal y otros referencias4 1. teune mj, bakhuizen s, 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family support intervention to reduce stress among parents of preterm infants in neonatal intensive care unit. iranian journal of nursing and midwifery research. 2014;19(4):349-353.* 51. turan t, başbakkal z, özbek ş. effect of nursing interventions on stressors of parents of premature infants in neonatal intensive care unit. journal of clinical nursing. 2008;17(21): 2856-2866.* 52. weis j, zoffmann v, greisen g, egerod, i. the effect of person-centred communication on parental stress in a nicu: a randomized clinical trial. acta paediatrica. 2013;102(12),1130-1136.* 53. bakermans-kranenburg mj, van ijzendoorn mh, juffer f. less is more: meta-analyses of sensitivity and attachment interventions in early childhood. psychol bull. 2003;129:195-215. 54. schappin r, wijnroks l, uniken venema m, jongmans mj. rethinking stress in parents of preterm infants: a metaanalysis. plos one. 2013;8(2):e54992. 9 19 validacion del cuestionario ctm-3.indd 9 maría teresa roldán-chicano1 noelia berenguer-garcía2 javier rodríguez-tello3 maría del mar garcía-lópez4 rut dávila-martínez5 maría jesús bueno-garcía6 validación del cuestionario ctm-3-modifi cado sobre satisfacción con la continuidad de cuidados: un estudio de cohortes 1 orcid.org/0000-0002-8619-4816. hospital general universitario santa lucía de cartagena, españa. mteresa.roldan@carm.es 2 orcid.org/0000-0002-2331-2897. servicio murciano de salud, españa. noelia.berenguer1@um.es 3 orcid.org/0000-0001-7673-1019 hospital general universitario santa lucía de cartagena, españa. javier.rodriguez@carm.es 4 orcid.org/0000-0003-0522-7936. centro de salud de barrio peral, españa. mariam.garcia@carm.es 5 orcid.org/0000-0001-9555-5145. servicio murciano de salud, españa. rut.davila@um.es 6 orcid.org/0000-0002-6396-7599. servicio murciano de salud murcia, españa. mariajesus.bueno@um.es recibido: 01 de septiembre de 2016 enviado a pares: 13 de enero de 2017 aceptado por pares: 02 de marzo de 2017 aprobado: 06 de abril de 2017 doi: 10.5294/aqui.2018.18.1.2 para citar este artículo / to reference this article / para citar este artigo berenguer-garcía n, roldán-chicano mt, rodríguez-tello j, garcía-lópez mm, dávila-martínez r, bueno-garcía mj. validación del cuestionario ctm-3-modificado sobre satisfacción con la continuidad de cuidados: un estudio de cohortes. aquichan. 2018; 18(1): 9-19. doi: 10.5294/aqui.2018.18.1.2 resumen objetivos: validar el contenido y constructo de la encuesta ctm-3 (care transitions measure3 preguntas) modificada. determinar el nivel de satisfacción de los usuarios con la continuidad de cuidados de enfermería interniveles y relacionarlo con la presencia de informe de cuidados de enfermería tras su última hospitalización. material y método: estudio de cohortes retrospectivo, con 131 pacientes hospitalizados en el complejo hospitalario de cartagena (españa).la satisfacción con la continuidad de cuidados se valoró con el cuestionario ctm-3-modificado, resultado de un proceso de validación realizado sobre el mismo. resultados: un 94% de los encuestados presenta una satisfacción aceptable con el proceso de continuidad de cuidados. los pacientes con informe de cuidados tienen un nivel alto de satisfacción con la continuidad de cuidados, rr= 0,90 (ic 95%: 0,831-0,990). conclusiones: la validez de contenido y constructo realizadas, han permitido medir la satisfacción de los usuarios con la continuidad y su correlación con la presencia de informe, obteniendo como resultado que la realización de informe de cuidados influye ligeramente en la satisfacción con el proceso de continuidad de cuidados. sin embargo, el hecho de que el informe se entregue en mano y/o se explique no parece afectar a la misma. palabras clave continuidad de la atención al paciente; satisfacción del paciente; mecanismos de evaluación de la atención de salud; encuestas y cuestionarios; atención de enfermería (fuente: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 9-19 10 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 9-19 validation of the ctm-3-modified questionnaire on satisfaction with continuity of care: a cohort study abstract objectives: validate the content and construction of the modified ctm-3 survey (care transitions measure 3 questions). determine the level of user satisfaction with the continuity of intermediate-level nursing care and relate it to the presence of a nursing care report after the most recent hospitalization. material and method: a retrospective cohort study was conducted with 131 patients hospitalized at the cartagena hospital complex (spain). satisfaction with the continuity of care was assessed with the ctm-3-modified questionnaire, which is the result of an earlier validation process. results: ninety-four percent (94%) of those who responded to the questionnaire indicated acceptable satisfaction with the continuity-of-care process. patients with a care report have a high level of satisfaction with the continuity of care: rr = 0.90 (95% ci: 0.831-0.990). conclusions: the content and construct validity of the questionnaire make it possible to measure user satisfaction with the continuity of care and its correlation to the presence of a care report, the result being that preparation of a care report slightly influences the level of satisfaction with the continuity-of-care process. on the other hand, the fact that the report is delivered by hand and/or explained appears to have no effect. keywords continuity in patient care; patient satisfaction health care assessment mechanisms; surveys and questionnaires; nursing care (source: decs). 11 validación del cuestionario ctm-3-modificado sobre satisfacción con la continuidad de cuidados: un estudio de cohortes l maría teresa roldán-chicano y otros validação do questionário ctm-3-modificado sobre a satisfação com a continuidade de cuidados: um estudo de coortes resumo objetivos: validar o conteúdo e constructo do questionário ctm-3 (care transitions measure — três perguntas) modificado. determinar o nível de satisfação dos usuários com a continuidade de cuidados de enfermagem interníveis e relacioná-lo com a presença de relatório de cuidados de enfermagem após sua última hospitalização. material e método: estudo de coortes retrospectivo, com 131 pacientes hospitalizados no complexo hospitalar de cartagena (espanha). a satisfação com a continuidade de cuidados foi avaliada com o questionário ctm-3-modificado, resultado de um processo de validação realizado sobre este. resultados: 94 % dos entrevistados apresentam satisfação aceitável com o processo de continuidade de cuidados. os pacientes com relatório de cuidados têm nível alto de satisfação com a continuidade de cuidados, rr= 0,90 (ic 95 %: 0,831-0,990). conclusões: a validade de conteúdo e constructo realizada permite medir a satisfação dos usuários com a continuidade e sua correlação com a presença de relatório, obtendo como resultado que a realização de relatório de cuidados influencia levemente na satisfação com o processo de continuidade de cuidados. contudo, o fato de que o relatório seja entregue em mãos e/ou seja explicado não parece afetá-la. palavras-chave atenção de enfermagem; continuidade da atenção ao paciente; mecanismos de avaliação da atenção de saúde; pesquisas e questionários; satisfação do paciente (fonte: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 9-19 12 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 introducción la continuidad de cuidados requiere de la interconexión de diferentes elementos: entornos (atención especializada, atención primaria, etc.), personas (pacientes y profesionales), e información (diagnósticos, terapias, etc.). este proceso tiene mayor repercusión cuando afecta a grupos especialmente vulnerables de pacientes con un nivel de dependencia alto, pacientes crónicos, con ingresos frecuentes, pacientes con manejo inefectivo del régimen terapéutico, entre otros (1). son muchas las ventajas de una continuidad asistencial exitosa, pero la capacidad de los profesionales de salud para dar respuestas integradas y continuadas va a depender, entre otros elementos, de los procesos y medios utilizados para intercambiar información útil, válida y fiable entre diferentes niveles asistenciales. en el ámbito hospitalario este proceso comienza cuando el paciente es ingresado, y termina con la elaboración de un informe de cuidados a los pacientes que precisan atención tras el alta, y que son transferidos a otros niveles asistenciales. la información que se recoge en este informe facilita la comunicación interniveles y aumenta la posibilidad de que los cuidados de enfermería no se interrumpan (1-4). a pesar de los esfuerzos de las administraciones sanitarias para elaborar herramientas tales como este tipo de informes, que a priori facilitan una atención continua e integrada al usuario, esta tarea no resulta sencilla, ya que los servicios de salud suelen ser cada vez más complejos y especializados (1-4), y además suelen presentarse barreras, como falta de tiempo o de habilidades, para prestar cuidados centrados en la persona (5). hasta la fecha han sido pocos los instrumentos desarrollados que se centren en medir la satisfacción con la experiencia de la continuidad de cuidados desde la perspectiva del paciente. entre los existentes encontramos el cuestionario hospital consumer assessment of healthcare providers and systems (hcahps), que incluye varios ítems que abordan el alta hospitalaria, principalmente referidos a la satisfacción con la experiencia general del hospital, o el prescriptions. ready to re-enter community, education, placement, assurance of safety, realistics expectations, empowerment, directed to appropiate services (prepared), diseñado para evaluar la calidad de la planificación del alta basado en cuatro claves del proceso: el intercambio de información, la preparación para el afrontamiento, la administración de medicamentos y el control de los dominios circunstanciales (6, 7). los dominios del cuestionario prepared son similares a los que forman la base de la encuesta care transitions measure (ctm), desarrollada en 2005, y diseñada explícitamente para abarcar la experiencia global de la transición de cuidados. los autores de la encuesta ctm argumentaron que aunque las herramientas existentes hasta el momento pueden incluir algunos ítems relacionados con la continuidad de cuidados, la mayoría no había abordado adecuadamente la calidad de dicha continuidad desde la perspectiva del paciente y el cuidador. el paciente y el cuidador son a menudo el único hilo conductor en todos los entornos, y están en una posición única para informar sobre la calidad de los cuidados interniveles. la encuesta de transición de cuidados ctm fue creada para comprender mejor la experiencia de la continuidad de cuidados y evaluar rigurosamente su calidad. la ctm es, según los autores, sustantiva y metodológicamente coherente, y está centrada en el paciente. el desarrollo de la encuesta ctm se inició con una serie de grupos focales de pacientes de edad avanzada (y sus cuidadores) que habían sido dados de alta recientemente. se llevó a cabo un análisis cualitativo que identificó cuatro dominios: 1) transferencia de información, 2) el paciente y el cuidador, 3) apoyo a la autogestión; y 4) empoderamiento para afirmar preferencias (6). la encuesta ctm incluye 15 preguntas (ctm-15), y en relación con sus características psicométricas tiene alta consistencia interna (alpha de cronbach 0,93) y una validez de constructo que permite discriminar entre pacientes que se diferenciaron en la satisfacción con la continuidad si habían ingresado por urgencias, si habían tenido ingresos previos o si no cumplían ninguna de las circunstancias anteriores. no se encontraron diferencias importantes en la puntuación ctm por género. las puntuaciones tenían una pequeña pero significativa correlación negativa con la edad (r = 0,156; p = 0,033), y con el tiempo de estancia (r = 0,144; p = 0,049) (6). la versión reducida de este instrumento, la encuesta ctm-3, que consta de 3 preguntas, con las mismas 5 posibilidades de respuesta que la ctm-15, ha demostrado tener igual capacidad para detectar diferencias entre grupos que la encuesta ctm15, ya que sus tres preguntas explican el 88 % de la variación 13 validación del cuestionario ctm-3-modificado sobre satisfacción con la continuidad de cuidados: un estudio de cohortes l maría teresa roldán-chicano y otros de la medida total (7). la forma corta incluye dos de los cuatro dominios originalmente identificados por los investigadores (transferencia de la información y empoderamiento para afirmar preferencias). los autores argumentan que la información que se pierde al utilizar la encuesta ctm-3 es pequeña, comparada con la reducción de la carga de trabajo que se ahorra al utilizar un cuestionario sensiblemente más corto. la encuesta ctm-3 fue respaldada por el foro de calidad nacional e incluida en la evaluación de consumidor de proveedores de asistencia médica y sistemas (cahps) de estados unidos (8, 9). sin embargo, a pesar de estos buenos resultados, un estudio posterior, realizado en 2014, señalaba que la validación de este instrumento tuvo deficiencias, entre las que se destacan: muestra pequeña, “sesgo de aquiescencia” o “efecto techo”, que es la tendencia a estar de acuerdo con todas las preguntas, y dificultad de percibir las respuestas como mutuamente excluyentes por parte del encuestado (10). las deseables mejoras en la traducción al castellano del instrumento ctm-3, las deficiencias en la validación encontradas en las últimas publicaciones de la encuesta ctm-3, y algunas de sus preguntas demasiado orientadas a la terapia médica han determinado uno de los objetivos de este trabajo: realizar una validación de contenido y de constructo de una nueva versión de la herramienta ctm-3 (ctm-3-modificada), más orientada a los cuidados de enfermería; el segundo objetivo es medir la satisfacción del paciente con la continuidad de cuidados interniveles y determinar si la presencia del informe influía en esta. materiales y métodos validación de contenido y constructo de la herramienta ctm3-modificada y posterior estudio de cohortes retrospectivo, para determinar la satisfacción del usuario con la continuidad asistencial realizado en el hospital general universitario santa lucía (hgusl) de cartagena, un hospital público situado en la costa sureste de españa. para determinar el nivel de satisfacción del usuario con la continuidad de cuidados se utilizó la encuesta ctm-3-modificada (tabla 1), resultado de un proceso de validación realizado sobre la encuesta ctm-3 original. para el proceso de validación, en primer lugar se solicitó a uno de los autores principales de la encuesta ctm-3 consentimiento para su uso y modificación, y posteriormente se realizó una validación de contenido, que consistió en un pretest cognitivo donde se valoró la interpretabilidad y la adecuación de las preguntas y respuestas del ctm-3 original a través de un panel de expertos en el que participaron cinco profesionales de enfermería con experiencia en atención primaria y especializada, y con más de diez años de ejercicio profesional, y cinco usuarios con un ingreso hospitalario durante el último año en cualquiera de los hospitales públicos del servicio sanitario de la región. al tratarse de un instrumento multidimensional, en el que cada dimensión consta de menos de tres preguntas, no está tabla 1. comparación encuestas ctm-3* original y modificada ctm-3 original ctm-3-modificada ítems: ítems: 1. “al salir del hospital, el personal del mismo tomó en cuenta mis preferencias y las de mi familia o personas que me cuidan al decidir cuáles son mis necesidades de cuidado médico”. 1. “al salir del hospital, las enfermeras tuvieron en cuenta su opinión, o la de su familiar o cuidador, sobre los cuidados que necesitaría después de ser dado de alta”. 2. “al salir del hospital tuve un buen entendimiento de las cosas de las que yo tenía que tomar responsabilidad para el control de mi salud”. 2. “al salir del hospital entendió las cosas que tenía que hacer para el control de su salud”. 3. “al salir del hospital, entendí claramente por qué debo tomar cada una de mis medicinas”. 3. “al salir del hospital se sentía seguro de poder hacer las cosas necesarias para cuidar de su salud”. opciones de respuesta: opciones de respuesta: 1. estoy en completo desacuerdo. 1. no estoy de acuerdo. 2. estoy en desacuerdo. 2. estoy de acuerdo. 3. estoy de acuerdo. 3. no sé, no recuerdo, no sabría valorarlo. 4. estoy en completo acuerdo. 5. no sé / no recuerdo / no corresponde. * care transitions measure (versión abreviada-3 preguntas). fuente: elaboración propia. 14 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 indicado calcular la fiabilidad para su consistencia interna con el estadístico alpha de cronbach (11). en relación con la validez de constructo, se midió la correlación entre el principal atributo del proceso de continuidad estudiado (presencia de informe de cuidados) y la puntuación total de la encuesta ctm-3-modificada; esto quiere decir que si hay validez de constructo existirá correlación entre la presencia de informe y satisfacción con la continuidad. no se ha realizado análisis factorial sobre los datos obtenidos, porque la encuesta ctm-3 tiene solo 3 ítems; además, todas las variables de ctm-3 son dependientes, y existe a priori una dependencia conceptual. tampoco se ha realizado validez de criterio, ya que no se compara el resultado con ningún patrón de oro. durante la fase de validación de contenido, el grupo de expertos consultado corrigió algunos elementos gramaticales y de sintaxis que dificultaban la comprensión del cuestionario (a pesar de que este estaba ya traducido al español). posteriormente, se consideró que si el instrumento se utilizaba para medir la satisfacción con el proceso de continuidad de cuidados interniveles en enfermería, la primera pregunta se centrara en estos profesionales, en lugar de hacer alusión al personal sanitario en general. la versión definitiva fue: “al salir del hospital, las enfermeras tuvieron en cuenta su opinión, o la de su familiar o cuidador, sobre los cuidados que necesitaría después de ser dado de alta”. la tercera pregunta estaba demasiado orientada a la terapia médica, y se sugirió modificarla de forma que no solo hiciera alusión a la medicación, sino a los cuidados de salud desde una perspectiva más amplia (tabla 1). tanto el grupo de expertos como algunos de los usuarios consultados en la validación de contenido consideraron que era difícil discriminar entre algunas opciones de respuesta muy parecidas (estoy en completo desacuerdo o no estoy de acuerdo). esta última apreciación es considerada como uno de los posibles errores a la hora de diseñar cuestionarios, ya que da lugar al sesgo de aquiescencia o efecto techo, y recomienda utilizar opciones de respuesta dicotómicas, práctica ya sugerida en estudios de validación de este cuestionario (10, 12). además, este mismo error fue identificado en otro estudio, ya mencionado, sobre las características psicométricas de la encuesta ctm-3 (10). a partir de las conclusiones de estos trabajos se decidió modificar las opciones de respuesta, y pasar de 5 opciones a 3 (tabla 1). los creadores de ctm no han determinado un punto de corte para definir el nivel de satisfacción, solo establecen que los valores más bajos indican un menor nivel de satisfacción y los más altos un mayor nivel de satisfacción con la continuidad de cuidados. para calcular el valor global de la encuesta aconsejan realizar la medida de las respuestas y pasarlas a una escala de 0 a 100. valores superiores a 51 indicarían un nivel de satisfacción aceptable (5, 13). siguiendo las indicaciones de los creadores de ctm, en este trabajo de investigación se ha definido que para valores mayores de 51 existe un nivel de satisfacción bueno o aceptable, y para valores menores o iguales a 50 existiría un bajo nivel de satisfacción. una vez realizada la validación de constructo y contenido de la escala ctm-3-modificada se hizo un estudio de cohortes retrospectivo con el objeto de determinar, utilizando dicha herramienta, el nivel de satisfacción del usuario con la continuidad de cuidados y la influencia que los informes de cuidados tenían en esta. la población de estudio la constituyeron los 3958 pacientes que fueron hospitalizados en el hgusl, entre enero y marzo del año 2015. durante este periodo se dieron de alta 1161 pacientes a los que se les entregó a la salida del hospital un informe con datos sobre la planificación de cuidados de enfermería (expuestos) y 2797 pacientes a los que al alta no se les entregó ningún informe (no expuestos). los criterios de inclusión para formar parte de la muestra fueron: todos los pacientes dados de alta en el hgusl de cartagena, en las unidades de hospitalización de adultos entre enero y marzo de 2015. se excluyó de la muestra a personas con las que no fuese posible la comunicación verbal (un idioma diferente al español, problemas físicos o cognitivos que dificultaran la comunicación). también se excluyeron menores de 15 años y adultos ingresados en la unidad de ginecología y obstetricia. para el cálculo del tamaño muestral se aceptó un riesgo alpha de 0,05 y un riesgo beta de 0,2. a partir de un contraste bilateral se precisaron 131 sujetos en la cohorte de pacientes con informe y 131 en la de pacientes sin informe, para detectar un riesgo relativo mínimo de 1,5, si la tasa de satisfechos en el grupo de personas sin informe es del 0,5. se estimó una tasa de pérdidas de seguimiento del 50 %. se utilizó la aproximación de poisson. 15 validación del cuestionario ctm-3-modificado sobre satisfacción con la continuidad de cuidados: un estudio de cohortes l maría teresa roldán-chicano y otros se realizó muestreo aleatorio; la aleatorización de los sujetos de cada grupo facilitó la comparación entre estos y disminuyó el sesgo de selección. el periodo de reclutamiento de los sujetos para establecer las dos cohortes se llevó a cabo en abril de 2015, tras la exploración de la base de datos del programa informático utilizado en el medio asistencial estudiado. en el cálculo del tamaño muestral se contempló la posibilidad de no poder contactar con alguno de los sujetos seleccionados aleatoriamente (estimación de pérdidas aproximada del 50 %), por tanto, la sustitución de los missing data no se consideró necesaria. los datos relativos a las características demográficas del paciente y de información clínica (edad, sexo, unidad de hospitalización, duración del ingreso, diagnósticos de enfermería resueltos y no resueltos durante la hospitalización) fueron extraídos de la historia clínica digitalizada. los datos sobre la satisfacción del usuario con la continuidad de cuidados interniveles fueron recogidos a través de una encuesta telefónica durante la segunda quincena de mayo de 2015, la encuesta se realizó en pacientes dados de alta entre uno y cuatro meses antes de la misma, para evitar sesgo de memoria. las encuestas telefónicas se basaban en la herramienta ctm-3-modificada, e incluían preguntas sobre el nivel de instrucción del usuario y sobre la entrega o no del informe de cuidados (variable de exposición de las cohortes), y de si este, en el caso de que se entregara, había sido explicado por la enfermera del hospital. las fuentes de datos fueron las mismas para el grupo de expuestos (con informe) y de no expuestos (sin informe). no se contempló el seguimiento de los sujetos porque la medición de la satisfacción se realizó a través de una única valoración. el análisis de datos se realizó con el programa estadístico spss v.21. se utilizaron estadísticos descriptivos y de tendencia (dispersión y centralización); la relación entre las variables cualitativas se hizo con el estadístico chi cuadrado y, cuando resultó necesario, el test exacto de fisher. se requirió la evaluación del proyecto al comité ético de investigación clínica del área ii del servicio murciano de salud. el comité dio el visto bueno para la realización de la investigación. resultados validez de contenido y de constructo sobre la herramienta ctm-3-modificada durante el proceso de validez de contenido de la encuesta, además de adecuar algunos aspectos gramaticales y de sintaxis, se modificaron dos de los ítems: en uno se hizo alusión a los profesionales de enfermería, y en otro se modificó una pregunta que únicamente hacía referencia a la medicación y se sustituyó por otra en la que se preguntaba por la capacidad del paciente para llevar a cabo las recomendaciones dadas al alta (tabla 1). con estas modificaciones, el cuestionario dejó de tener una orientación exclusivamente médica y permitió medir la satisfacción del paciente con la continuidad interniveles que ofrecen los profesionales de enfermería. en relación con la validez de constructo, se midió la correlación entre la presencia de informe y la satisfacción con la continuidad, obteniendo como resultado que la realización del “informe de cuidados” influye ligeramente en la satisfacción con el proceso de continuidad de cuidados, ya que al ser el resultado del riesgo relativo < 1, el factor de exposición se convierte en uno de protección. por tanto, la presencia del “informe de cuidados” es un factor de protección frente a la insatisfacción, o, lo que es lo mismo, los pacientes con informe tienen una probabilidad del 10 % de estar más satisfechos con la continuidad. estudio de cohortes para determinar el nivel de satisfacción de los usuarios con la continuidad de cuidados de los 131 sujetos que se precisaron en el grupo de pacientes con informe, 69 completaron la encuesta, y de los 131 del grupo de pacientes sin informe, 66 la respondieron. las pérdidas fueron cercanas, pero menores, al 50 % estimado en el cálculo del tamaño muestral inicial. en todos los sujetos de la muestra final se recogieron la totalidad de las variables de interés. características de los pacientes con informe de cuidados en la muestra existe mayor presencia de hombres que de mujeres, de los 69 pacientes encuestados un 59,4 % fueron hombres 16 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 y un 40,6 % mujeres. la edad media de la muestra fue 67,62 años (ic 95 %: 63,3-72,1). en cuanto al nivel de instrucción, un 33,3 % no tenía estudios, un 46,6 % tenía estudios primarios, un 14,7 % estudios secundarios y un 4,4 % tenía estudios superiores. la media de días de hospitalización fue 8,95 días (ic 95 %: 7,31-10,58). las unidades con más pacientes dados de alta con informe de cuidados fueron: unidad de prealtas, 20,2 %; medicina interna, 15,8 %; traumatología, 14,5 %; cirugía general y digestiva, 10,1 %. en cuanto a la entrega y explicación al paciente del informe de cuidados, un 40,6 % de los encuestados afirmó que sí se le explicó el contenido del informe, un 37,7 % que no se le explicó y un 21,7 % no lo recordaba. un 42 % de los encuestados afirmó que sí se le entregó en la mano el informe de cuidados, un 39,1 % que no, y un 18,8 % no lo recordaba. características de los pacientes sin informe de cuidados en la muestra existe mayor presencia de hombres que de mujeres, de los 69 pacientes encuestados un 53 % fueron hombres y un 47 % mujeres. la edad media de la muestra fue 58,52 años (ic 95 %: 54,2-62,8). en cuanto al nivel de instrucción, un 28,8 % no tenía estudios, un 51,5 % tenía estudios primarios, un 12,1 % estudios secundarios y un 7,6 % estudios superiores. la media de días de hospitalización fue de 3,24 días (ic 95 %: 1,55-4,92). las unidades con más pacientes dados de alta sin informe de cuidados fueron: medicina interna, 15,2 %; traumatología, 13,6 %; cardiología y neumología, 10,6 % respectivamente. satisfacción general y de cada ítem un 94 % de los encuestados presenta una satisfacción aceptable con el proceso de continuidad de cuidados, y solo un 6 % presenta una baja satisfacción. en relación con el ítem 1: “al salir del hospital las enfermeras tuvieron en cuenta su opinión, o la de su familiar o cuidador, sobre los cuidados que necesitaría después de ser dado de alta”, un 66 % de los encuestados afirmó estar de acuerdo, un 17,2 % no estar de acuerdo y un 16,4 % no sabía o no recordaba. en cuanto al ítem 2: “al salir del hospital entendió las cosas que tenía que hacer para el control de su salud”, un 94 % afirmó estar de acuerdo, un 5,2 % respondió que no estaba de acuerdo y un 0,7 % no sabía o no recordaba. respecto al ítem 3: “al salir del hospital se sentía seguro de poder hacer las cosas necesarias para cuidar de su salud”, un 88,1 % afirmó estar de acuerdo, un 10,4 % manifestó no estar de acuerdo y un 1,5 % no recordaba. relación entre la satisfacción y las variables de la muestra solo se ha encontrado relación, p < 0,05, entre la duración del ingreso con la satisfacción: los pacientes ingresados cuatro días o menos presentan una satisfacción ligeramente más baja que los pacientes cuya hospitalización superó los cuatro días (84,9-98,5 %) (tabla 2). el resto de variables no ha demostrado guardar relación con la satisfacción. para determinar si existe diferencia significativa entre el nivel de satisfacción en el grupo de pacientes con informe y en el que no tiene informe, se ha utilizado el test exacto de fisher. el uso de chi cuadrado no estaba indicado porque varias casillas tenían una frecuencia esperada baja (inferior a 5) (tabla 3). se calculó, entonces, el riesgo relativo de insatisfacción con la continuidad y la presencia del informe (variable expositora). la existencia en la variable expositora —presencia de informe— es un factor de protección ante la baja satisfacción, es decir, los pacientes con informe de cuidados tienen un rr = 0,90 (ic 95 %: 0,831-0,990); tienen una probabilidad de estar satisfechos con la continuidad de los cuidados un 1,1 más que los que no tienen informe (tabla 4). no se encontró relación significativa entre la entrega en físico o la explicación del contenido del informe con la satisfacción de la continuidad de cuidados. 17 validación del cuestionario ctm-3-modificado sobre satisfacción con la continuidad de cuidados: un estudio de cohortes l maría teresa roldán-chicano y otros ctm_global (agrupado) total p valor satisfacción baja satisfacción alta duración_hosp_días (agrupado) ≤ 4 recuento 7 59 66 % dentro de duración_hosp (agrupado) 10,6 % 89,4 % 100,0 % > 4 recuento 1 66 67 % dentro de duración_hosp (agrupado) 1,5 % 98,5 % 100,0 % total recuento 8 125 133 % dentro de duración_hosp (agrupado) 6,0 % 94,0 % 100 < 0,05 tabla 2. relación entre la duración de la hospitalización y la satisfacción con la continuidad fuente: elaboración propia. tabla 3. puntuación ctm-3*-modificado relacionada con presencia de informe de cuidados tabla 4. riesgo relativo de satisfacción (puntuación ctm-3*-modificado) por cohortes satisfacción baja satisfacción alta total sin informe recuento 7 59 66 % sin informe 10,6 % 89,4 % 100,0 % % del total 5,2 % 43,7 % 48,9 % con informe recuento 1 68 69 % con informe 1,4 % 98,6 % 100,0 % % del total 0,7 % 50,4 % 51,1 % total recuento 8 127 135 % informe 5,9 % 94,1 % 100,0 % * care transitions measure (versión abreviada-3 preguntas). fuente: elaboración propia. rr† ic 95 %‡ para la cohorte satisfacción baja 7,318 0,925-57,876 para la cohorte satisfacción alta 0,907 0,831-0,990 n de casos válidos 135 * care transitions measure (versión abreviada-3 preguntas) † riesgo relativo ‡ intervalo de confianza fuente: elaboración propia. 18 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 discusión la care transmision measure ha sido validada y utilizada con éxito en entornos lingüísticos y culturales diferentes al anglosajón (5, 12, 14, 15), si bien no se han encontrado estudios que se hayan centrado en las características psicométricas de la encuesta en español. los resultados de esta investigación indican que la presencia de informe de cuidados es un factor de protección frente a la insatisfacción, de forma que los pacientes con informe tienen una probabilidad 10 % superior a los que no tienen informe de estar más satisfechos con la continuidad. otros estudios también han intentado medir las consecuencias de algunas intervenciones sobre la satisfacción con la continuidad de cuidados; en este sentido, las llamadas telefónicas para interesarse por la situación del paciente 72 horas después de la hospitalización (16), o los programas de entrenamiento para el autocuidado después de salir del hospital parecen tener resultados positivos sobre la satisfacción con la continuidad de cuidados (4). asimismo, se ha detectado una asociación entre la mejora de la continuidad de cuidados y una reducción de la tasa de reingreso a los 30, 60 días y al año (9, 17, 18), sin embargo, esto no parece afectar la calidad de vida del paciente (19). al igual que en otros trabajos que utilizan el ctm para medir la satisfacción del paciente, encontramos que la mayoría de usuarios están satisfechos con la continuidad de cuidados (8, 20). al usar la herramienta ctm-3 existe una tendencia entre los encuestados a contestar de forma afirmativa a las preguntas, es decir, a no entrar en conflicto con el encuestador, y afirmar que todo el proceso ha sido satisfactorio (10). esta deficiencia en la encuesta ctm-3 original se relaciona con la presencia de cinco posibles respuestas muy parecidas entre sí, por lo que el encuestado encontraba dificultades para responder. en la encuesta ctm-3-modificada se redujo el número de opciones de respuesta, con lo que es presumible que el sesgo de aquiescencia se haya reducido (10, 12). en relación con los resultados obtenidos, cabe destacar que la satisfacción con la continuidad de cuidados se relacionó de forma positiva con el tiempo de estancia hospitalaria, resultado que corrobora el obtenido en investigaciones similares (5, 6). la principal limitación del trabajo es que no se ha realizado una validación de criterio de la nueva versión de la escala, quedando este punto por desarrollar en próximos trabajos, con el objeto de obtener una validación completa de la herramienta. en este sentido, y puesto que en la adecuada continuidad de cuidados interniveles los profesionales de enfermería jugamos un papel esencial (4), es necesario desarrollar investigaciones que evalúen y propongan herramientas válidas y fiables que midan la aportación enfermera en la calidad de la transición del paciente de un nivel asistencial a otro (10, 12). otra limitación por destacar es la posible presencia de factores de confusión que influyen en la satisfacción con la continuidad y que no se han tenido en cuenta en este estudio. conclusión la modificación de la encuesta ctm-3 ha resultado adecuada para determinar el nivel de satisfacción de los usuarios con la continuidad de cuidados interniveles en el ámbito de los cuidados de enfermería, si bien hay aspectos relacionados con la validación de la misma que no se han abordado en este trabajo la mayoría de los encuestados (94 %) presentó satisfacción aceptable con el proceso de continuidad de cuidados. la comprensión de las recomendaciones dadas al alta, y la seguridad del usuario para llevarlas a cabo fueron mejor valoradas que su participación en la toma de decisiones respecto al control de su salud. solo se encontró relación estadísticamente significativa entre satisfacción con la continuidad y la duración del ingreso, estando los usuarios que ingresaron más de cuatro días más satisfechos con esta que los que ingresaron menos de cuatro días. los pacientes con informe de cuidados tienen un nivel alto de satisfacción con la continuidad de cuidados (rr = 0,90; ic 95 %: 0,831-0,990). este informe resultó ser un “factor de protección” para la insatisfacción con la continuidad de cuidados; sin embargo, el hecho de que se entregue en la mano o se explique no parece afectar a la misma. agradecimientos a todos los usuarios que de forma desinteresada participaron en este trabajo de investigación, y a todos los profesinales de enfermería del área ii del servicio murciano de salud, por su implicación con la continuidad de cuidados y la redacción de informes al alta del paciente. conflicto de interés: ninguno declarado. 19 validación del cuestionario ctm-3-modificado sobre satisfacción con la continuidad de cuidados: un estudio de cohortes l maría teresa roldán-chicano y otros referencias 1. hellín mf. mejora en la recepción de los informes de continuidad de cuidados en el área 1 murcia-oeste. [trabajo fin de máster]. murcia: departamento de ciencias sociosanitarias, facultad de medicina; 2012. 2. rivas cilleros e, velasco montes j, lópez alonso jc. valoración del informe de enfermería al alta tras la hospitalización. nuberos científica [en línea]. 2013 [acceso 2017 abr 6];2(8). disponible en: http://nc.enfermeriacantabria.com/index. php/nc/article/view/63 3. martínez vidal le, cantero gonzález ml. informe de cuidados en enfermería, revisión de su situación actual. enferm global. 2013 [acceso 2017 abr 6];12(4). disponible en: http://revistas.um.es/eglobal/article/view/162521 4. jeffs l, kuluski k, law m, saragosa m, espin s, ferris e, et al. identifying effective nurse-led care transition interventions for older adults with complex needs using a structured expert panel. worldviews evid based nurs (en prensa). 5. mosallam ra, metwally s. patients’ views on the quality of transitional care at a health insurance hospital in alexandria, egypt. j egypt public health assoc. 2014;89(2):74-80. 6. coleman ea, mahoney e, parry c. assessing the quality of preparation for posthospital care from the patient’s perspective: the care transitions measure. med care. 2005;43(3):246-55. 7. grimmer ka, moss jr, gill tk. discharge planning quality from the carer perspective. qual life res. 2000;9(9):1005-13. 8. coleman ea, parry c, chalmers sa, chugh a, mahoney e. the central role of performance measurement in improving the quality of transitional care. home health care serv q. 2007;26(4):93-104. 9. goldstein jn, hicks ls, kolm p, weintraub ws, elliott dj. is the care transitions measure associated with readmission risk? analysis from a single academic center. j gen intern med. 2016;31(7):732-8. 10. anatchkova md, barysauskas cm, kinney rl, kiefe ci, ash as, lombardini l, et al. psychometric evaluation of the care transition measure in trace-core: do we need a better measure? j am heart assoc. 2014;3(3):e001053-e001053. 11. celina oviedo h, campo arias a. aproximación al uso del coeficiente alfa de cronbach. revista colombiana de psiquiatría. 2005 [acceso 2017 abr 6];xxxiv(4). disponible en: http://www.redalyc.org/resumen.oa?id=80634409 12. shadmi e, zisberg a, coleman ea. translation and validation of the care transition measure into hebrew and arabic. int j qual health care. 2009;21(2):97-102. 13. coleman ea. scoring the ctm-3. the care transitions program [acceso 2017 abr 6]. disponible en: http://caretransitions.org/wp-content/uploads/2015/08/ctm-3-scoring.pdf 14. bakshi ab, wee s-l, tay c, wong l-m, leong iy-o, merchant ra, et al. validation of the care transition measure in multiethnic south-east asia in singapore. bmc health serv res. 2012;12:256. 15. cao x, chen l, diao y, tian l, liu w, jiang x. validity and reliability of the chinese version of the care transition measure. plos one. 2015;10(5):e0127403. 16. soong c, kurabi b, wells d, caines l, morgan mw, ramsden r, et al. do post discharge phone calls improve care transitions? a cluster-randomized trial. plos one. 2014;9(11):e112230. doi: 10.1371/journal.pane.0112230 17. brock j, mitchell j, irby k, stevens b, archibald t, goroski a, et al. association between quality improvement for care transitions in communities and rehospitalizations among medicare beneficiaries. jama. 2013;309(4):381-91. 18. li f, guo j, suga-nakagawa a, takahashi lk, renaud j. the impact of kaua’i care transition intervention on hospital readmission rates. am j manag care. 2015;21(10):e560-66. 19. faucher j, rosedahl j, finnie d, glasgow a, takahashi p. patient quality of life in the mayo clinic care transitions program: a survey study. patient prefer adherence. 2016;10:1679-85. 20. rayan n, admi h, shadmi e. transitions from hospital to community care: the role of patient–provider language concordance. isr j health policy res. 2014;3:24. 351 367 how nurses are using the international.indd 351 diéssica roggia piexak1 marta regina cezar-vaz2 clarice alves bonow3 silvana sidney costa santos4 how nurses are using the international classifi cation of functioning, disability and health: an integrative review 1 phd in nursing. federal university of rio grande, brasil. diessicap@yahoo.com.br 2 phd in nursing philosophy. federal university of rio grande, brasil. cezarvaz@vetorial.net 3 phd in nursing. federal university of pampa, brasil. enfcla@yahoo.com.br 4 nursing. federal university of rio grande, brasil. silvanasidney@terra.com.br received: 30 april 2014 submitted for peer review: 10 may 2014 accepted by peers: 21 may 2015 approved: 24 may 2015 doi: 10.5294/aqui.2015.15.3.4 para citar este artículo / to reference this article / para citar este artigo piexak dr, cezar-vaz mr, bonow ca, santos ssc. how nurses are using the international classification of functioning, disability and health: an integrative review. aquichan. 2015; 15(3): 351-367. doi: 10.5294/aqui.2015.15.3.4 abstract aim: the purpose of this study is to report the results of an integrative review of use of the international classification of functioning, disability and health (icf) by nurses. this review is justified by the need for further investigation into use of the icf in nursing, by nurses, so as to contribute to dialogue for the development of global, interdisciplinary and classification system comprehension. methods: this integrative review included studies from 2001 to may 2015 in peer-reviewed journals. two reviewers independently screened titles and abstracts for inclusion and completed data extraction. the papers were sourced from a number of electronic databases: medline/nml/ pubmed, web of science, lilacs, cinahl and scielo. results: twenty-six articles were included. three themes on use of the icf were identified: clinical nursing practice; teaching nursing students and nurses; and nursing research. conclusion: this review helps nurses to visualise how and in what care environments the icf is being used. it demonstrates the icf has been used specifically in the rehabilitation nursing field, but offers some evidence of its use in occupational health as well. keywords international classification of functioning, disability and health; nursing research; review; delivery of health care; nursing (source: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 351-367 352 aquichan issn 1657-5997 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 351-367 cómo las enfermeras están utilizando la clasificación internacional del funcionamiento, la discapacidad y la salud: una revisión integrativa resumen objetivo: el propósito de este estudio es reportar los resultados de una revisión integrativa de la utilización por parte de las enfermeras de la clasificación internacional del funcionamiento, la discapacidad y la salud (icf, por su sigla en inglés). esta revisión se justifica por la necesidad de una mayor investigación sobre el uso de la icf en enfermería, a cargo de las enfermeras, a fin de contribuir al diálogo para el desarrollo de la comprensión global e interdisciplinaria del sistema de clasificación. métodos: revisión integrativa que incluyó estudios del 2001 a mayo del 2015 publicados en revistas revisadas por colegas. de forma independiente, dos revisores inspeccionaron los títulos y los resúmenes para su inclusión y completaron la extracción de datos. los trabajos se obtuvieron a partir de una serie de bases electrónicas de datos: medline/nml/pubmed, web of science, lilacs, cinahl y scielo. resultados: veintiséis artículos fueron incluidos en el estudio. se identificaron tres temas en cuanto al uso del icf: la práctica clínica de enfermería; la enseñanza a los estudiantes de enfermería y a las enfermeras; y la investigación en enfermería. conclusión: esta revisión ayuda a las enfermeras a visualizar cómo y en qué entornos de atención se está aplicando la icf. demuestra cómo la icf se ha utilizado específicamente en el campo de la enfermería de rehabilitación, pero también ofrece alguna evidencia de su uso en salud ocupacional. palabras clave clasificación internacional del funcionamiento, la discapacidad y la salud; investigación en enfermería; revisión; prestación de asistencia en salud; enfermería (fuente: decs, bireme). 353 how nurses are using the international classification of functioning, disability and health: an integrative review l diéssica roggia piexak and others como as enfermeiras estão utilizando a classificação internacional do funcionamento, da deficiência e da saúde: uma revisão integradora resumo objetivo: o propósito deste estudo é relatar os resultados de uma revisão integradora da utilização, por parte das enfermeiras, da classificação internacional do funcionamento, da deficiência e da saúde (icf, por sua sigla em inglês). esta revisão se justifica devido à necessidade de uma maior investigação sobre o uso da icf em enfermagem, sob a responsabilidade das enfermeiras, a fim de contribuir com o diálogo para o desenvolvimento da compreensão global e interdisciplinar do sistema de classificação. métodos: revisão integradora que incluiu estudos de 2001 a maio de 2015, publicados em revistas revisadas por colegas. de forma independente, dois revisores analisaram os títulos e os resumos para sua inclusão e completaram a coleta de dados. os trabalhos foram obtidos a partir de uma série de bases eletrônicas de dados: medline, nml, pubmed, web of science, lilacs, cinahl e scielo. resultados: 26 artigos foram incluídos neste estudo. identificaram-se três temas a respeito do uso do icf: a prática clínica de enfermagem; o ensino aos estudantes de enfermagem e às enfermeiras; a pesquisa em enfermagem. conclusão: esta revisão ajuda as enfermeiras a visualizarem como e em que ambientes de atenção está sendo aplicada a icf. demonstra como a icf tem sido utilizada especificamente no campo da enfermagem de reabilitação, além de oferecer alguma evidência de seu uso em saúde ocupacional. palavras-chave classificação internacional do funcionamento, da deficiência e da saúde, pesquisa em enfermagem, revisão, prestação de assistência em saúde, enfermagem (fonte: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 351-367 354 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 introduction the international classification of functioning, disability and health (icf) provides a unified language and constitutes a framework for describing health and health-related states. the icf offers definitions of functioning and disability, based on the understanding that the term encompasses all aspects of the body’s functions, activities and restrictions to participation (1). the current icf model was approved by the world health assembly in may 2001, after several test versions. this model is based on the articulation of social and biomedical models, using a bio-psycho-social approach to visualise the integration of various dimensions of health (biological, individual and social) (1, 2). the concepts of the icf introduce a new paradigm of work impairment and disability, which are determined by health conditions/illness, context (physical and social environment), different cultural perceptions and attitudes towards disabilities, and the availability of services and legislation (3). functionality is prioritised as a health component within the icf, considering the environment both as a facilitator and as a barrier to performing activities and for participation. thus, disability is the result of a series of situations and conditions that include the environment, health and personal conditions (1). from this perspective, it is understood that healthcare professionals/nurses, along with other members of society, share responsibility in the planning and development of technology that constitutes facilitators for activities and the participation of people in different life situations. understanding, therefore, that the performance of these people can be enhanced by environmental changes, such as physical, social and/or attitudinal, it offers different perspectives of an expanded view of health: biological, individual and social. in the rankings of the world health organization (who), health states (including diseases and disorders) are classified according to the international classification of disease. the tenth revision (icd-10) provides a structured aetiological basis. functioning and disability associated with health conditions are classified in the icf. thus, icd-10 and the icf are complementary and provide a significant and broader view of human health, which may contribute to decision making (1). according to who (1), the icf is being used as a statistical, investigative, clinical, social and pedagogical tool. the icf is used in clinical practice for several specialties, assisting in both assessment and decision making. its socio-political application is evident in some countries within the framework of legislative changes or policy and social regulation. it also is used in the educational system as a conceptual framework for teaching/learning or for curricular units (4). the number of published papers related to the icf is increasing, but they are only evident in the areas of rehabilitation, paediatrics, care of the elderly, chronic disease, stroke, spinal cord injury and mental illness. these papers are written mainly by speech therapists, occupational therapists, physicians and physiotherapists (5). this review is justified by the need for further investigation into use of the icf in nursing, by nurses, to contribute to dialogue for the development of global, interdisciplinary and classification system comprehension. clearly, the icf is an important tool for nurses working in a number of different areas. it is, therefore, necessary to discover how it is used and how its use contributes to the work of nurses. three study questions were defined: how is the icf used by nurses? in what environments is the icf being used? and, how does the icf contribute to the work of nurses? aim the purpose of the study is to report the results of an integrative review of use of the international classification of functioning, disability and health (icf) by nurses. design it is an integrative review that offers the opportunity for a comprehensive understanding of certain phenomena by analysing specific theoretical or empirical literature. an integrative review has the potential expand nursing science, informative research and practice and policy initiatives, through a synthesis of evidence (6). evidence can be classified hierarchically, according to the methodological approach used in studies. in this integrative review, the following classification of level of evidence was adopted: level 1 – evidence from a systematic review or meta-analysis of randomised controlled trials or evidence derived from clinical 355 how nurses are using the international classification of functioning, disability and health: an integrative review l diéssica roggia piexak and others guidelines based on systematic reviews of randomized controlled trials; level 2 – evidence from at least one well delineated randomised controlled trial; level 3 – evidence from well-designed clinical trials without randomization; level 4 – evidence from cohort and case-control well delineated trials; level 5 – evidence from a systematic review of descriptive and qualitative studies; level 6 – evidence from a descriptive or qualitative study and; level 7 – evidence from the opinions of authorities and /or reports by expert committees (7). knowledge of this evidence classification in publications related to the icf system is crucial to be able to critically assess the results derived from these surveys, assisting in decision-making about the incorporation of evidence into clinical practice (8). the search strategy included literature from 2001 to may 2015 found in medline/nml/pubmed, web of science, lilacs, cinahl and scielo. the search terms were the “international classification of functioning, disability and health” and “nursing”. the inclusion criteria were: 1) full papers available electronically in medline/nml/pubmed, web of science, lilacs, cinahl and scielo, which met the aim of the research, 2) papers published since may 2001 with the approval of the current model of the icf by the world health assembly (1), 3) papers with at least one nurse among the authors, 4) summary presentation for initial examination, and 5) articles in portuguese, english or spanish. the items excluded were: abstracts published in proceedings, book chapters, theses, dissertations and editorials. the abstracts were read and analysed in order to refine the sample and select the articles according to the inclusion / exclusion criteria. articles repeated in more than one database were only considered once. table 1 lists the articles and their respective databases. the search strategy yielded a total of 130 references, many of which were duplicates. from the full analysis, a total of 26 articles were obtained: 17 from medline/nlm/pubmed, four from web of science, two from lilacs, two from scielo and one from cinahl. the studies were initially divided into groups, according to the methodological approach (quantitative, qualitative, theoretical discussions, critical and a theoretical model). they were evaluated independently by the lead author and a research assistant, using a quality appraisal checklist developed by bowling (9) and modified by desborough, et al. (10). discussion resolved any discrepancies to reach a 100% consensus. as appropriate for an integrative review, this appraisal included clarity in aims, methods, statistics, discussion and implications. the methods suggested by whittemore & knafl (6) were followed for the data abstraction and synthesis. two tables were developed to synthesise the data. table 1 lists: author, year, country, knowledge area, aims, methodological approach, results and database. table 2 lists: author, year, country, subject numbers, icf use, icf related instruments, environments in which the icf was used and icf contributions to the work of nurses. the format of the tables made the comparative analysis of the extracted information and patterns apparent, enabling identification of the themes. results the studies originated in germany/switzerland (n=6), brazil (n=5), the netherlands (n=3), australia (n=2), sweden (n=2), canada (n=1), the usa (n=1), the usa/canada (n=1), finland (n=1), norway (n=1), switzerland (n=1) and taiwan (n=1). the articles are dated between 2004 and 2015, with the largest number of publications in 2005 and 2013. the principal authors of the publications are: boldt c, with seven publications and stucki g, with five. most of the papers appeared in the following journals: journal of advanced nursing (n=5), with an impact factor of 1.477, and disability and rehabilitation (n=4), with an impact factor of 1.498 (11). sixteen were quantitative, four were qualitative, three were theoretical discussions, one was critical, one was a theoretical model and one was reflective. regarding the strength of the evidence, twenty articles (76.92%) were evidence level 6 and six articles (23.07%) were evidence level 7. seventeen articles presented research subjects and seven of these were conducted with patients, six with nurses, two with expert groups, one with undergraduate students, and one with healthy workers. the subject numbers in the studies ranged from one to 469. defining themes three themes were identified from the literature review: icf use in clinical nursing practice, icf use in teaching nursing students and nurses, and icf use in nursing research. 356 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 icf use in clinical nursing practice evidence showed there are attempts to apply the icf in clinical nursing practice in fourteen selected articles (12-26). in most articles (n=9), icf application in clinical practice is defined in the rehabilitation nursing area (13, 15-21, 26), directed primarily to nursing interventions (n=4) with patients in acute and post-acute situations requiring rehabilitation (13, 17) and patients with spinal cord injury (16, 21, 26). the study by boldt (13), which sought to determine if the icf covers the goals of nursing interventions and to identify areas of functioning, disability and health most relevant to nursing practice, found that one hundred and eighteen different nursing interventions were documented. for each intervention, nine icf categories were identified. nursing intervention goals were linked to 67 different icf categories at the second level. of the 67 categories, 30 belong to the component body functions, 19 to the component body structures, 13 to the component activities and participation, and five to the component environmental factors. all registered nursing interventions could be related to at least one icf category. mueller et al. (17), who identified the icf categories relevant to nursing care in acute situation and post-acute rehabilitation, showed eighty-seven percent of the categories defined by the icf may be related to goals of at least one variable of nursing intervention. the nursing interventions that were linked to the highest number of different icf-categories were “therapeutic intervention”, “patient-nurse communication/ information giving” and “mobilizing”. these results suggest the icf is relevant to rehabilitation nursing attempts to relate nursing interventions to the codes of the icf through the development of core sets, which can provide viable inter-professional communication, maintaining the patient’s needs as a priority. thus, the icf can be a useful tool to define nursing intervention goals (17). in seeking evidence of whether the icf covers nursing interventions and identifies the areas of functioning, disability and health most relevant to nursing practice in the treatment of patients with spinal cord injury, the study showed this initiative represented the first step towards identifying a list of categories relevant to nurses caring for patients with spinal cord injury intervention, according to the language of the icf (16). this fact has stimulated research in this respect. this is demonstrated in a study that shows implementation of the icf helps in the care for people with spinal cord injury, identifying 823 responses that have been linked to 143 icf categories (21). the icf use creates a data set that allows nurses to compare their contributions to patient care with those of other health professionals and on an international basis. however, the authors suggest future research should be conducted to confirm the usefulness of this set of data in clinical practice and to contribute to the process of icf updating (21). such evidence of the icf in clinical nursing practice, which confirms the identification of its use, has been developed mainly in the field of rehabilitation nursing. it is notable among these studies, particularly the study by machado & de figueiredo (18), that an assistive technology was planned and developed through the icf framework to reduce the level of dependency and to assist in the performance of daily activities and self-care for patients with large brain traumatic injury. two studies conducted at the university medical center showed the applicability of the icf in nursing, with a focus on processes/nursing diagnoses according to the north american nursing diagnosis association (nanda) taxonomy ii nursing diagnoses, their conceptual relations and their use in clinical practice (12, 14). it was found that the vast majority of topics addressed in nursing diagnoses can be classified by the icf and that more identified codes were related to the body functions and activities components (12). to systematically explore icf use for clinical nurses, it was found that the figures for the three-digit codes in the selected studies were substantial, showing a predominant focus on body functions (53%), activity components (38%), participation (19%) and environmental factors (37%) (14), demonstrating the icf can be a useful working tool for nurses to classify and report patient functionality aspects. it should be noted that studies concerning nursing interventions and procedures/nursing diagnoses in relation to the icf more easily identify the functions and structures of the body components than activities and participation and environmental 357 how nurses are using the international classification of functioning, disability and health: an integrative review l diéssica roggia piexak and others factors. this is more prevalent because the nursing care environment in these studies; namely, the hospital environment is inclined towards identifying these components. however, it is understood that nurses’ visualization of all icf components for expanded recognition of the patient’s needs in rehabilitation is required. lakke et al. (22) showed the application of the icf in clinical practice, unlike other selected studies. the icf was used in connection with tests of functional capacity (fc) in healthy workers, thereby revealing other possible uses. the study showed that material handling fc tests were related to physical factors, but not to the psychosocial factors recorded in this study. the construction of static work fc tests remained largely unexplained. one limitation of the study was that cross sectional design is not suitable for the prediction of future work performance or future work disability. icf use in teaching nursing students and nurses from the literature reviewed, it was found the icf contributes as a conceptual model for teaching nursing students and nurses. it also presents a comprehensive rhetoric, with numerous possibilities to contribute to nurses’ work, but without a well-defined clinical practice application. the icf conceptual model encourages undergraduate nursing students to think comprehensively, by considering people as biopsychosocial beings who are part of groups, such as the family and community. they have roles within these groups that influence and are influenced by these environments. in addition, the icf model enables re-conceptualisation of the term disability, understanding it as a social, political and cultural human experience (5). the study searched for icf evidence in assessing patients in rehabilitation, which was carried out by graduate students in nursing. it found there is evidence of the building blocks of the icf in the assessments. the assessments were designed using the form of daily activities to sustain life and/or participate in life. the documentation of information was found to be higher in relation to the body function and personal factors components, rather than activities and participation, supporting the suggestion that there is resonance between the building blocks of the icf and nursing (27). this demonstrates a possible icf contribution in assessing and planning of the health needs of people with disabilities who are under the care of nurses (27). another aspect that became evident was that the bio-psychosocial approach to the icf is required for all aspects of care. this approach provides the rehabilitation nurse with a look at the environmental, personal, external and internal factors, which can be modified to reduce, for example, the risk of pressure ulcers and frailty in the elderly (28). in presenting a discussion of icf conceptual relations and practices, nanda and their use in nursing practice, boldt et al. (29) showed nanda enables compliance with requirements that are exclusively related to nursing, and application of the icf is useful for nurses to communicate nursing problems with other health professionals in a common language. for nurses, sharing knowledge with other health care workers can contribute to a broader understanding of patients’ situation. icf use in nursing research the icf contributes as a theoretical framework for nursing research (30-32). it could play a part in the following: expanding the attitude towards the risk factors of pressure ulcers in frail elderly patients (28); understanding the process of disability caused by osteoarthritis (33); broadening nurses’ perspectives when caring for stroke survivors (15); and defining the goals of nursing intervention (17), as well as investigating the conceptual relationships and practices of the international taxonomy of nursing diagnoses (29). it also contributes to the international classification for nursing practice (35) and to discussions of how the icf can be useful in furthering social change through health promotion and health education for all persons with disabilities (35). however, five of these pieces of research (28, 29, 32, 33, 35) demonstrate results through methods with evidence level 7, which means evidence from the opinion of authorities (7). this is a weak factor for the immediate inclusion of this evidence into clinical practice. however, these findings provide insights for future research by incorporating methods that provide stronger levels of evidence. in quality analysis performed with a specific instrument (9, 10), six of the nine studies presented above reported discussions about the limitations of the study and the method used, which takes advantage of the verification of weaknesses and potential issues for further research. 358 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 studies (17, 19) highlighted the icf contribution to nursing research through the development of core sets for nursing interventions (17) and rheumatoid arthritis (19), which may facilitate clinical practice implementation in the specific area of rehabilitation nursing. the icf can serve as an instrument to clarify the measurement model of the scales of the paediatric evaluation of disability inventory (pedi) and as taxonomy to describe and clarify the content of the functional scales item (36). it also contributes to the construction of an evaluation tool adapted to the context of psychiatric nursing (37) and to testing the relationship between fc tests in healthy workers (22). discussion the results of this integrative review show publications about the icf were most likely to be produced by joint research teams from germany and switzerland (n=6). most of these researchers were part of who’s icf collaborating centre for research in germany, which has been one of the driving forces in europe for implementation and dissemination of the icf since 2004 and supports its pension scheme in the standings, despite initial difficulties in translating its concepts and construction (38). the years 2005 and 2013 had the highest number of publications (n=4). another study, which carried out a literature review on use of the icf in 2007 and analysed 243 publications in different fields, also found the largest number of publications was in 2005 (n=64) (39). most of the studies used a quantitative methodological approach. when it came to strength of evidence, twenty articles presented evidence derived from a single descriptive or qualitative study (evidence level 6) and six articles presented authoritative opinions, (evidence level 7) (7). another relevant aspect is the number of subjects in the selected articles, which ranged from one to 469, demonstrating it is possible to conduct icf-related research with a variable number of subjects. the results of this study identified icf use in clinical nursing practice, in teaching nursing students and nurses, and in nursing research, with emphasis on use of the icf in the rehabilitation nursing area in 18 publications. it is stressed that the area of rehabilitation is one of the fastest growing areas in publications related to the icf (39), providing a common language between the disciplines of generic rehabilitation health code information. it also promotes a common basis for understanding the functional states associated with health conditions and comparing data across countries (5, 40). the results of this study have shown a growth in icf literature on rehabilitation nursing. despite the fact that who (1) emphasizes the icf can be used for various areas of knowledge, these results indicate such a perspective is rarely explored in clinical nursing practice, with most of the articles (n=9) showing the specificity of clinical use in the rehabilitation area. this suggests further research should be done to explore other possibilities for icf use, such as the study by lakke et al. (22) who sought correlations between the icf components with tests of fc in healthy workers. this differentiated it from many studies. the number of icf nursing publications is still low compared to other areas of knowledge and it is necessary for nurses to carry out more research, as the icf now has a worldwide classification of reference for all disciplines (39). in taiwan, for example, since 2012, the law on protection of the rights and interests of citizens with disabilities has required health care providers to assess the level of disability according to the icf; this requires knowledge of the icf on the part of nurses (41). use of the icf offers opportunities for health professionals to provide standardisation between different disciplines and healthcare environments (42), assisting in the exchange of information between health professionals (43). most of the selected publications did not describe the physical, social and attitudinal specifications where the icf was used and this did not, therefore, allow for a deeper analysis. publications only stated the studies were developed in the following environments: rehabilitation clinics, neurological therapy centres and neurological hospitals, in the home, in psychiatric environments, in the community, in the work environment and at three university medical centres. according to the icf, environmental factors have an impact on all components of functioning and disability and are organised sequentially, connecting the person’s immediate environment to the general environment. thus, environmental factors constitute the physical, social and attitudinal environment in which 359 how nurses are using the international classification of functioning, disability and health: an integrative review l diéssica roggia piexak and others people live and conduct their lives (1), confirming the importance of knowledge about the environments where the icf is used. the area of rehabilitation nursing was the subject of the majority of the icf papers. therefore, it is evident we need more investment in studies that address disease prevention and health promotion through the icf. as indicated by who, the icf provides a conceptual framework for information applicable to health care personnel, including prevention, health promotion, improving participation by removing or mitigating social barriers, and encouraging the allocation of social support and facilitators (1). in addition, further research is needed to address the contents of the icf in relation to nursing, especially its use in patient care and the ability of nurses to write up records and specify nursing tasks. this requires expanding the icf to include detailed knowledge of nursing in healthcare (43). conclusions this review helps nurses to visualise how the icf is being used, in what care environments and the contribution it is making. it demonstrates the icf has been used specifically in the field of rehabilitation nursing, but offers some evidence of its use in occupational health. the icf also can be a useful tool for nurses’ work in a number of other areas. these include education, as a conceptual model in practice, by generating a set of data that allows nurses to compare their contributions to patient care with those of other health professionals in different environments at an international level and also in research to describe the research questions and facilitate interpretation. the advantages of use of the icf by nurses include: advancement in utilization of a multi-professional instrument that facilitates inter-professional and world communication and can be used to compare research results in different countries; developing and making use of core sets in clinical practice, according to the patient’s needs; helping to plan individual or collective nursing actions, considering environmental characteristics with the broadening of health/illness conceptions; and complementing conceptual models of nursing, by highlighting quantitative scores, which will serve as parameters for choices on heath/nursing interventions, as well as for assessing such interventions. from this perspective, we suggest complementary use of the icf with the already existing conceptual models of nursing, such as callista roy’s adaptation model (44), betty neuman’s model (45), and dorothea orem’s self-care framework (46). these conceptual models view the person as a holistic system (44, 45) and identify nine needs: oxygenation, nutrition, elimination, activity and rest, skin integrity, senses, fluids and electrolytes, neurological function and endocrine function (44). in addition, neuman’s model considers the person as an open system in constant interaction with the environment (45), and orem’s self-care theory aims to allow the person to be self-reliant (46). all these aspects are connected and described in the icf. most of the selected publications did not describe the physical, social and attitudinal specifications of where the icf was used, such as the number of patients seen per day, the number of nursing staff, size of the space, if the furniture was adapted to promote self-care and if the family and/or caregivers were present. this would provide a fuller analysis, as the icf prioritises environmental factors, treating them as barriers and/or facilitators. we are of the belief that more research needs to be carried out on use of the icf, in different care settings and in different knowledge areas, to confirm the usefulness of this data in clinical practice. such research also would help to update the icf, ensuring the who classification is explicitly adapted to the needs of nurses. moreover, there is still a need to encourage the use and dissemination of icf studies in developing countries. 360 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 references 1. who. world health organization. international classification of functioning, disability and health: icf. world health organization, geneva, 2001. 2. sampaio rf, luz mt. funcionalidade e incapacidade humana: explorando o escopo da classificação internacional da organização mundial da saúde. cad. saúde pública. 2009;25(3):475-83. 3. farias n, buchalla cm. a classificação internacional de funcionalidade, incapacidade e saúde da organização mundial da saúde: conceitos, usos e perspectivas. rev. bras. epidemiol. 2005;8(2):187-93. 4. fontes ap, fernandes aa, botelho ma. funcionalidade e incapacidade: aspectos conceptuais, estruturais e de aplicação da classificação internacional de funcionalidade, incapacidade e saúde (cif). rev. port. sau. pub. 2010;28(2):171-78. 5. kearney pm, pryor j. the international classification of functioning, disability and health (icf) and nursing. j adv nurs. 2004;46:162-70. 6. whittemore r, knafl k. the integrative review: updated methodology. j adv nurs. 2005;52(5):546-53. 7. melnyk bm, fineout-overholt e. making the case for evidence-based practice. in: melnyk bm, fineout-overholt e. evidence-based practice in nursing & healthcare. a guide to best practice. philadelphia: lippincot williams & wilkins; 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results pryor j et al. 2004 australia rehabilitation nursing report a secondary analysis of evaluations carried out by graduate students on nursing patients in search of icf evidence. quantitative there is some evidence the icf is being used by nursing graduates, supporting the suggestion that there is a resonance between the building blocks of the icf and nursing. kearney & pryor 2004 australia teaching, practice and research in nursing rehabilitation nursing present a critical overview of the concept of disability and its implications for nursing; propose its use as a conceptual framework for teaching, practice and research in nursing. critical review the icf is a useful conceptual framework for teaching, practice and nursing research. heinen et al. 2005 netherlands nursing process investigate the applicability of the icf in nursing practice, focusing on nursing diagnoses. quantitative most of the topics covered in nursing diagnoses can be classified by the icf. wang et al. 2005 taiwan rehabilitation nursing propose a theoretical model to prevent osteoarthritis (oa) and associated disabilities. theoretical model the model includes the trajectory of the disease, describing the sequence of events and disability associated with oa. boldt et al. 2005 germany/ switzerland rehabilitation nursing determine whether the icf covers the goals of nursing interventions and identify areas of functioning, disability and health most relevant to the practice of nursing acute and post-acute neurological patients in need of rehabilitation. quantitative one hundred and eighteen nursing interventions were documented by nursing staff. the objectives of the interventions were linked to 67 different categories at the second level of the icf. van achterberg et al. 2005 netherlands nursing practice report a study that systematically explored the use of the icf by nurses. quantitative the figures for the three-digit codes in the selected studies were substantial, revealing a predominant focus on body functions (53%), component activities (38%), and participation (19%), and environmental factors (37%). ostensjo et al. 2006 norway rehabilitation nursing examine the conceptual basis and contents of the pediatric evaluation of disability inventory (pedi), using the icf. qualitative the conceptual basis of the pedi scales largely coincided with the concepts of the icf components of activity / participation and environmental factors. both the pedi and the icf use the components of capacity and performance, but differ on how to put them into operation. pajalic et al. 2006 sweden rehabilitation nursing explore the functionality and subjective health of survivors of cerebrovascular accidents six months after discharge. investigate the patterns of functions and activities and associations between functionality and subjective health. quantitative the icf can be used as a framework for nursing care and is made operable for practical use. 363 how nurses are using the international classification of functioning, disability and health: an integrative review l diéssica roggia piexak and others author, year and countries knowledge area aims methodological approach results kanervisto et al. 2007 finland rehabilitation nursing describe the experiences of people with chronic obstructive pulmonary disease (copd) in their everyday lives, using the icf. qualitative the results show impairment of function of the body in people with copd. groups provide knowledge of the factors that promote the well-being of people with copd, highlighting the importance of the spouse. boldt et al. 2007 switzerland rehabilitation nursing discover if the icf covers nursing interventions and identify areas of functioning, disability and health most relevant to nursing practice in the treatment of patients with spinal cord injury. quantitative this study represents the first step in identifying a list of intervention categories relevant for nurses in the care of patients with spinal cord injury, according to the common language of the icf. howard et al. 2008 usa/ canada rehabilitation nursing discuss how the icf can be useful in social change through health promotion and health education for all people, especially for those with disabilities and chronic diseases. theoretical discussion future research should focus on the relationship between the political and social participation of people with disabilities in communities. the development of a new icf core set for accessibility and inclusion in the community improves social support interventions and strengthens the role of professionals in health promotion for people with disabilities or chronic health conditions. mueller et al. 2008 germany/ switzerland rehabilitation nursing identify the icf categories relevant to nursing care in acute and post-acute rehabilitation. quantitative eighty-seven percent of the categories defined by the icf targets can be linked to at least one variable nursing intervention: the leistungserfassung in der pflege (lep). campbell 2009 canada rehabilitation nursing use the icf as a conceptual framework to discuss pressure ulcers in frail elderly patients. theoretical discussion the icf bio-psychosocial approach is necessary for all aspects of care. this model provides the rehabilitation nurse with a look at environmental, personal, external and internal factors that can be modified to reduce the risk of pressure ulcers and frailty. machado & de figueiredo 2009 brazil physical medicine and rehabilitation rehabilitation nursing identify strategies to reduce the level of dependency of the person with large tbi sequel, for help in performing daily activities and selfcare. quantitative a guided prototype was developed in assistive technology to aid their mobilisation and transfers, with satisfactory results but restricted to the dynamics of protruding from one surface to another with body alignment. rauch et al. 2009 germany/ switzerland rehabilitation nursing validate the icf core set for rheumatoid arthritis (ra) from the perspective of nurses. quantitative the validity of the icf core set for ra was largely supported by nurses. however, a number of body functions that are related to the side effects of drug therapy are not included in the core of the icf for ra. boldt et al 2010 germany/ switzerland nursing process present a discussion of the conceptual relations and practices of the icf and nandanursing diagnoses from taxonomy ii, and its use in nursing practice. theoretical discussion nanda enables compliance with requirements that are exclusively nursing in nature. application of the icf is useful for nurses to communicate nursing problems with other health professionals in a common language. machado & scramin 2010 brazil rehabilitation nursing identify elements of the icf that are applicable to home care of quadriplegic adult men, with a view to reducing dependence on help from their parents for activities involved in daily living and self-care. qualitative evident: family support security for bodily functions of the disabled; assistive technology inventiveness for promoting quality of care; fears, uncertain future and loss of parents thresholds and human frailties and functional gain objective responses in terms of bodily functions. 364 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 author, year and countries knowledge area aims methodological approach results mueller et al. 2010 germany/ switzerland rehabilitation nursing examine the association between patients’ functioning, as encoded by categories of the acute icf core sets, and nursing workload in patients in an acute care situation; compare the variance in nursing workload explained by the icf core set categories and with the barthel index, and validate the acute icf core sets by their ability to predict nursing workload. quantitative in patients with neurological and cardiopulmonary conditions, selected icf categories and the barthel index score explained the same variance in nursing workload, whereas the icf was slightly superior to the barthel index score for musculoskeletal conditions. kim & coenen 2011 usa rehabilitation nursing examine to what extent the icf and the international classification for nursing practice (icnp) can be mapped to facilitate communication between professionals in health contexts. quantitative the major challenges to mapping the two ratings resulted from differences in terminology, representation of the concept, structure and specific content. boldt et al. 2012 germany/ switzerland rehabilitation nursing examine whether the icf can be used as a standard language for expressing goals of intervention by nurses who care for people with spinal cord injury. quantitative the results of this study contribute to implementation of the icf in nursing care for people with spinal cord injury. johansson et al. 2013 sweden psychiatric nursing describe the development of an assessment tool based on the icf adapted to a psychiatric nursing context where both the patient and the nurse assess the patient's ability to participate in various spheres of life. quantitative the results of an unweighted kappa value of 0.38, a linear weighted kappa value of 0.65 and a quadratic weighted kappa value of 0.73 were considered as acceptable when using simulated patient cases. lakke et al. 2013 netherlands worker health test relationships between functional capacity (fc) tests and other icf factors in a sample of healthy workers, and determine the amount of statistical variance in fc tests that can be explained by these factors. quantitative moderate correlations were detected between material handling fc tests and muscle strength, gender, body weight, and body height. as for static work fc tests; overhead working correlated fair with aerobic capacity and handgrip strength, and low with the sport-index and perception of work. for the standing forward bend fc test, all hypotheses were rejected. machado et al. 2013 brazil health of the elderly compare the ability and performance of basic activities of daily living by dependent elderly individuals cared for in a geriatric healthcare center. quantitative the average age was 81.0±7.1, with a predominance of women. the difference between ability and performance was statistically significant in most daily tasks. santos et al. 2013 brazil health of the elderly the objective was to reflect on the international classification of functioning, disability and health and its use in nursing care for the elderly. reflection a brief history of the classification was developed. functional assessment of the elderly and the importance of planning care actions properly were addressed. applicability of the icf by nurses was shown. barros et al. 2014 brazil health of elderly ostomy patients identify the ecosystem and gerontogeriatric technological actions to be done in complex nursing care for elderly ostomy patients. qualitative the ecosystem actions identified the construction of a therapeutic environment, a guaranty of physical access and environmental adaptation. li et al. 2015 china rehabilitation nursing explore a set of icf categories that cover spinal cord injury (sci) nursing practice in china, through a national expert survey. quantitative twenty-nine chinese experts in sci nursing participated. there were 81 icf categories that received more than 80% agreement among the experts, including 33 body functions categories, eight body structures, 24 activities and participation, six environmental factors and 10 personal factors items. 365 how nurses are using the international classification of functioning, disability and health: an integrative review l diéssica roggia piexak and others table 2. articles researched. prepared by the authors. author (year, country) number of subjects per research icf use instruments environments where icf is used icf contributions for nurses’ work pryor j et al. 2004 australia 27 undergraduates analytical framework evaluation form for activities of daily living (adl) to sustain life and to participate in life as dittmer rehabilitation clinic assists in evaluating and planning for the health needs of persons with disabilities who are under the care of nurses. kearney & pryor 2004 australia _ conceptual framework _ _ the icf can become a valuable tool in the search for best practices and positive outcomes for patients. heinen et al. 2005 netherlands six nurses conceptual framework nursing diagnoses from nanda. university medical centres the terminology and codes of the icf can be used in problem statements, as well as the etiology and signs and symptoms. wang et al. 2005 taiwan _ conceptual framework _ _ the model provides a conceptual framework that is useful for understanding the process of oa disability from a bio-psychosocial perspective and guides rehabilitation nursing interventions in the care of oa. boldt et al. 2005 germany/ switzerland 290 patients relationship between nursing interventions and the categories of the icf _ neurological therapy center and neurological hospital nursing interventions for neurological patients in need of acute and post-acute rehabilitation could be linked to the icf categories, supporting the usefulness of the icf in nursing. van achterberg et al. 2005 netherlands 469 nurses 178 other health professionals categories of the icf in nursing practice _ university medical centres the icf can be a useful tool for classifying and reporting aspects of the patient’s functionality. stimulates addition to evaluation of the functions and structures of the body. ostensjo et al. 2006 norway two researchers relation between the pediatric evaluation of disability inventory (pedi) and the icf pedi _ the icf can serve as a conceptual framework to clarify the measurement model and the pedi scales, such as taxonomy, in order to describe and clarify the content of the item, functional scales. pajalic et al. 2006 sweden 89 cva survivors conceptual framework katz index; evaluation of instrumental activities of daily living; scale berger short form health survey, sf-12. home adaptation of the icf in a practical questionnaire, incorporating dimensions of functions, activities, participation and health. it has the potential to broaden the perspective of nurses in caring for cva survivors. kanervisto et al. 2007 finland _ theoretical framework _ home theoretical framework for nursing research 2007 switzerland _ relationship between nursing interventions and the categories of the icf _ _ identification of a list of categories of interventions relevant for nurses in the care of patients with spinal cord injury, according to the common language of the icf. 366 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 author (year, country) number of subjects per research icf use instruments environments where icf is used icf contributions for nurses’ work howard et al. 2008 usa/canada _ use of the icf for social change through health promotion and health education _ community in health promotion and health education in the community. mueller et al. 2008 germany/ switzerland two nurses icf core set for nursing interventions nursing intervention (lep) relevant to acute and post-acute rehabilitation. rehabilitation hospital the icf core set for describing the goals of nursing interventions to facilitate interprofessional communication and respect for the needs of the patient. the icf may, thus, be a useful tool to set goals for nursing intervention. campbell 2009 canada _ conceptual framework _ _ enlarged view of the risk factors of pressure ulcers. machado & de figueiredo 2009 brazil one patient conceptual framework _ home how useful is the use of strategies for care guided by the components of the icf feature. rauch et al. 2009 germany/ switzerland 57 nurses practical use through the core set the icf core set for rheumatoid arthritis facilitates application of the icf in clinical practice. boldt et al 2010 germany/ switzerland _ relationship between the icf and nanda nursing diagnoses nanda _ the icf and nanda should be used jointly by nurses and can complement each other to improve the quality of team work and clinical nursing practice. machado & scramin 2010 brazil eight patients conceptual framework _ home conceptual framework mueller et al. 2010 germany/ switzerland patients undergoing rehabilitation conceptual framework barthel index score lep three universityaffiliated acute hospitals conceptual framework kim & coenen 2011 usa _ relationship between the icf and the international classification for nursing practice (icnp) icnp _ supports advancement in the area of harmonization of health terminologies. applications that combine the concepts of the icf and the icnp must be tested in practice. boldt et al. 2012 germany/ switzerland 35 nurses standard language for expressing intervention goals in the care of people with spinal cord injury _ different environments presents a list of icf categories and other areas relevant to nursing practice that can be used as a data set to document the problems and goals of nursing intervention and treatment for people with spinal cord injury. johansson et al. 2013 sweden expert groups conceptual framework for the development of an assessment tool _ psychiatric environments and community the tool potentially can serve as an aid to identify and discuss areas the patient considers as problematic in his or her everyday life. 367 how nurses are using the international classification of functioning, disability and health: an integrative review l diéssica roggia piexak and others author (year, country) number of subjects per research icf use instruments environments where icf is used icf contributions for nurses’ work lakke et al. 2013 netherlands 403 healthy workers conceptual framework five fce tests; dynamometer; bruce treadmill test; baecke physical activity; questionnaire (bpaq); questionnaire on psychosocial workload and workrelated stress work environment conceptual framework machado et al. 2013 brazil 60 elderly conceptual framework activities of daily living geriatric healthcare center the contribution of this study in terms of using the icf was achieved by semiquantitatively interpreting its qualifiers, which allowed for more objective comparisons and inferences, and revealed a clear distance between the performance and ability of these individuals in most of the assessed activities. santos et al. 2013 brazil conceptual framework the classification is able to direct the functional assessment of the elderly, by nurses, taking a holistic view of the human being as having a body, with the need to perform activities and participation, and belonging to a context /environment. barros et al. 2014razil 10 elderly ostomy patients conceptual framework estomatherapy service conceptual framework li et al. 2015 china twenty-nine chinese experts in sci nursing conceptual framework a set of icf categories that cover sci nursing practice in china was identified. it reflects the main issues that chinese nurses focus on in caring for sci patients. these categories can assist chinese nurses in using the icf in multidisciplinary teamwork and improve the participation of nurses in the team. 171 185 adopcion de comportamientos saludables.indd 171 luisa fernanda moscoso-loaiza1 luz patricia díaz-heredia2 adopción de comportamientos saludables en la niñez: análisis del concepto 1 orcid.org/0000-0002-0580-1865. universidad nacional de colombia, colombia. lfmoscosol@unal.edu.co 2 orcid.org/0000-0002-7167-282x. universidad nacional de colombia, colombia. lpdiazh@unal.edu.co recibido: 06/03/2017 enviado a pares: 24/03/2017 aceptado por pares: 17/10/2017 aprobado: 15/02/2018 doi: 10.5294/aqui.2018.18.2.5 para citar este artículo / to reference this article / para citar este artigo moscoso-loaiza lf, díaz-heredia lp. adopción de comportamientos saludables en la niñez: análisis del concepto. aquichan 2018; 18(2): 171-185. doi: 10.5294/aqui.2018.18.2.5 resumen objetivo: analizar el concepto de adopción de comportamientos saludables en la niñez. materiales y método: se utilizó la propuesta de walker y avant (2005) para examinar las características definitorias y atributos del concepto. la búsqueda bibliográfica se realizó en las bases de datos science direct, pubmed y scielo, en el período comprendido entre el 2000 y 2016. resultados: la adopción de comportamientos saludables en la niñez hace referencia al proceso de asimilación o apropiación de conductas, que puede ser ordenado, interrumpido o coordinado, o en algunos casos en el más completo desorden; incluye acciones, actitudes, interacciones y emociones del niño hacia su bienestar, las cuales pueden facilitar, reforzar o mejorar la salud. constituye un proceso de naturaleza evolutiva, continuamente influenciado por el contexto y puede conducir al establecimiento de un hábito. conclusiones: la clarificación de este concepto amplia el conocimiento acerca de este fenómeno, lo que permitirá consolidar y plantear estrategias de promoción, prevención e intervención, así como guiar la investigación y la práctica de cuidado de enfermería en la niñez. palabras clave conductas saludables; niño; salud del niño; promoción de la salud; enfermería (fuente: decs). año 18 vol. 18 nº 2 chía, colombia abril 2018 l 171-185 temática: promoción y prevención. aporte a la disciplina: el análisis y la clarificación del concepto de adopción de comportamientos saludables en la niñez permitirá su uso efectivo en la investigación de enfermería y su posterior traducción a la práctica, ya que es el primer paso en la comprensión del proceso y los patrones de comportamiento que influyen en el cambio constante de la salud de los niños. este aporte posibilitará el desarrollo de evidencia para la atención de calidad en la niñez, y facilitará a largo plazo la estructuración de estrategias de promoción desde la perspectiva de los niños. 172 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 2 chía, colombia abril 2018 l 171-185 adoption of healthy forms of behavior during childhood: analysis of the concept abstract objective: analyze the concept of the adoption of healthy behavior during childhood. materials and methods: walker and avant’s proposal (2005) was used to examine the defining characteristics and attributes of the concept. a bibliographic database search was done in science direct, pubmed and scielo for the period between 2000 and 2016. results: the adoption of healthy behavior during childhood refers to the process whereby forms of behavior are either assimilated or appropriated. it can be an ordered, interrupted, coordinated or, in some cases, completely disordered process. it includes the child’s actions, attitudes, interactions and emotions with respect to his or her their well-being, which can facilitate, reinforce or improve health. it is a process of an evolutionary nature that is continually influenced by the context and can lead to the establishment of a habit. conclusions: clarification of this concept broadens what we know about the phenomenon. this, in turn, will make it possible to consolidate and propose strategies for promotion, prevention and intervention, as well as to guide research and the practice of nursing care during childhood. keywords healthy behavior; child; children’s health; health promotion; nursing (source: decs). 173 adopción de comportamientos saludables en la niñez: análisis del concepto l luisa fernanda moscoso-loaiza y otro adoção de comportamentos saudáveis na infância: análise do conceito resumo objetivo: analisar o conceito de adoção de comportamentos saudáveis na infância. materiais e método: utilizou-se a proposta de walker e avant (2005) para examinar as características definidoras e atributos do conceito. a busca bibliográfica foi realizada nas bases de dados science direct, pubmed e scielo, no período compreendido entre 2000 e 2016. resultados: a adoção de comportamentos saudáveis na infância faz referência ao processo de assimilação ou apropriação de condutas, que pode ser ordenado, interrompido ou coordenado, ou, em alguns casos, na mais completa desorganização; inclui ações, atitudes, interações e emoções da criança sobre seu bem-estar, as quais podem facilitar, reforçar ou melhorar a saúde. constitui um processo de natureza evolutiva, continuamente influenciado pelo contexto, e pode levar ao estabelecimento de um hábito. conclusão: o esclarecimento desse conceito amplia o conhecimento acerca do fenômeno, o que permitirá consolidar e propor estratégias de promoção, prevenção e intervenção, bem como orientar a pesquisa e prática de cuidado de enfermagem na infância. palavras-chave condutas saudáveis; criança; saúde da criança; promoção da saúde; enfermagem (fonte: decs). año 18 vol. 18 nº 2 chía, colombia abril 2018 l 171-185 174 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 introducción el comportamiento humano es un factor crucial para la salud (1) debido a la influencia que sobre él ejercen las actitudes, las creencias, los significados y conocimientos, siendo determinantes para las decisiones que las personas toman, y que están presentes en forma de acciones que afectan la salud de manera positiva o negativa (2). la adopción de conductas saludables en la niñez está influenciada por la familia, la escuela, los amigos, los medios de comunicación y la organización social, ya que son aprendidos y, por tanto, susceptibles de ser modificados a lo largo de la vida (3). la importancia de conocer el fenómeno de la adopción de comportamientos saludables específicamente en los niños entre los 8 y 12 años de edad radica en que esta etapa es descrita como un periodo de cambios neurofisiológicos continuos, en el cual se establece la función ejecutiva que incluye el control de la atención, la memoria de trabajo, el razonamiento, la autorregulación del comportamiento, la inhibición, el procesamiento de información y la fijación de objetivos (4). socialmente, esta etapa se caracteriza por el establecimiento de estructuras nuevas que implican el aumento de los niveles de independencia y el mantenimiento de relaciones con los compañeros, la autorregulación, los desafíos intelectuales y los primeros cambios de la pubertad (4). estos tienen implicaciones para la salud, debido a que si se establecen conductas en este periodo pueden persistir en la transición a la adolescencia y la adultez (5) y, por tanto, mantenerse durante toda la vida. es importante reconocer que el niño es un ser activo en su salud, al construir su conducta con base en la interacción con el ambiente y desarrollar patrones de comportamiento que determinarán sus futuras formas de vida (6). para el desarrollo de este artículo el concepto de “niño” hace referencia a los niños y las niñas entre los 8 y 12 años de edad. importancia del análisis del concepto hasta el momento, los resultados de investigación permiten afirmar que el papel de enfermería en el estudio de los comportamientos saludables en los niños se ha fundamentado en sus determinantes, a partir de la visión de los padres, y en las consecuencias que estos tienen sobre la salud del infante, por lo que se han establecido intervenciones que se basan en la alimentación y la actividad física, principalmente (7-13). la alimentación en la infancia se ha relacionado con la adiposidad y con el riesgo de obesidad. el desarrollo y mantenimiento de un peso excesivo pueden verse afectados por factores ambientales, incluidos los relacionados con la familia, en donde sobresalen los comportamientos de los padres, sus creencias y percepciones, los cuales modelan la ingesta y accesibilidad de los alimentos. esto implica que la familia es un factor determinante en la adopción de comportamientos saludables (13). la actividad física en los niños proporciona beneficios para la salud mental y física, pues reduce el riesgo de desarrollar obesidad y enfermedades crónicas a edades tempranas como la diabetes y las enfermedades cardiovasculares. por el contrario, el tiempo utilizado en conductas sedentarias es determinante de la obesidad infantil (14, 15). la obesidad es el principal factor de riesgo cardiovascular durante la niñez, que contribuye al desarrollo de otros asociados como la hiperglucemia y la hipertensión arterial (5, 9, 12, 14). por esta razón, la promoción de la salud infantil desde enfermería debe facilitar y potenciar los factores que permiten la adopción de comportamientos que sostengan estilos de vida saludables. estos factores deben ser determinados a partir de las respuestas del niño frente a su salud y bienestar, por lo que entender el fenómeno de la adopción de comportamientos saludables a través de la clarificación de su concepto puede permitir la consolidación de estrategias de enfermería efectivas en la promoción y prevención, en donde se vincule de forma articulada a la familia y la escuela, principales actores sociales que enmarcan el desarrollo comportamental del niño. fines del análisis. la adopción de comportamientos saludables en la niñez, aunque de gran interés por los efectos que produce a nivel de la salud y el bienestar físico, emocional y social, no se ha definido claramente en la literatura, por lo que tiende a confundirse con otros conceptos, como estilos de vida saludables que, aunque se encuentran vinculados, enmarcan significados diferentes, por lo que el propósito de este análisis es clarificar el significado del concepto de adopción de comportamientos saludables en la niñez, a partir de la construcción de una definición constitutiva. materiales y métodos se utilizó la propuesta de walker y avant (16), quienes afirman que el análisis de conceptos es una vía para el desarrollo de 175 adopción de comportamientos saludables en la niñez: análisis del concepto l luisa fernanda moscoso-loaiza y otro la teoría que proporciona una oportunidad para explicar y describir fenómenos de interés para la práctica, por medio de la cual se examinan las características que definen el concepto y los atributos que permiten decidir qué fenómeno es buen ejemplo y cuál no (16). la búsqueda bibliográfica se realizó en las bases de datos science direct, pubmed y scielo, con los términos de búsqueda “child”, “health behavior”, “health attitude”, “child behavior” and “acquisition”; se incluyeron artículos científicos en inglés, español y portugués, en full text, en el periodo comprendido entre el 2000 y el 2016, teniendo en cuenta algunos clásicos de la psicología comportamental, así como capítulos de libros y diccionarios, como se observa en la figura 1. los artículos científicos fueron seleccionados de forma crítica según los criterios caspe 2016 (17). resultados definiciones y usos del concepto • en los descriptores de salud (decs) se define el comportamiento como la respuesta observable del ser humano o de un animal ante una situación, y se señala el término conducta como equivalente al comportamiento (19). • el comportamiento es la manera de conducirse; el conjunto de las acciones con que un ser vivo responde a una situación específica como resultado de la experiencia (20). figura 1. búsqueda bibliográfica para el análisis fuente: moscoso y díaz (18). 176 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 • saludable es la condición armónica del cuerpo, la mente o el alma; implica el tener buena salud y un aspecto sano. todo lo saludable contribuye a conservar o restablecer la salud (20). • el comportamiento saludable es la acción llevada a cabo por una persona para mantener, lograr o recuperar la salud, y para prevenir la enfermedad (21). • la adopción/adquisición hace referencia a elegir o tomar algo como propio, especialmente ideas o costumbres ajenas; hacerse suya una manera de pensar o de actuar, una actitud, una opinión, etc.; así como tomar una resolución o adquirir una determinada configuración (22). revisión de la literatura a continuación se presentan, en orden cronológico, las diferentes definiciones de conductas saludables y adopción de comportamientos que se encuentran en la revisión de la literatura, para finalizar con una breve descripción de las teorías de adopción y cambio de comportamientos relacionados con la salud que han sido extrapoladas a la investigación infantil, y que permiten establecer los atributos del concepto. comportamientos saludables • para kasl y cobb (23) los comportamientos saludables son conductas en las que toma parte un individuo cuando goza de buena salud, con el propósito de prevenir la enfermedad. • mcalister (24) los define como aquellas acciones realizadas por un sujeto que influyen en el bienestar físico, psicológico o social. • gochman (25) considera que en los niños se refiere a patrones de comportamiento, acciones y hábitos manifiestos que se relacionan con el mantenimiento de la salud y el bienestar, y con la restauración y mejora de la salud. • para rubio (2) son conductas instrumentales que los individuos realizan y que, disminuyen o aumentan la probabilidad de que se contraiga una enfermedad de forma directa o indirecta. las directas ponen en contacto con el agente patógeno o factor incapacitante (p. e., exponerse a radiaciones solares que devenguen en cáncer de piel). las indirectas aumentan la vulnerabilidad del organismo, aunque no lo pongan en contacto con tales factores (p. e., una dieta inadecuada). • en enfermería, los comportamientos saludables hacen referencia a las acciones y actitudes del individuo hacia su salud, las cuales pueden facilitarla y reforzarla, o predisponer el desarrollo de factores de riesgo; están relacionados principalmente con los hábitos dietéticos, la actividad física, el consumo de alcohol y de cigarrillo o tabaquismo (26). adopción de comportamientos • bandura (27) considera que pese a que el ambiente físico y social perfila la conducta, las personas no son entes pasivos en este proceso, sino que a su vez pueden influir sobre su propio ambiente, en una dinámica de reciprocidad. los contextos interpersonales son importantes; el comportamiento, las ideas, los consejos de los demás, y su ayuda o falta de esta, juegan un papel importante en las conductas asociadas a la salud. el círculo de influencia de la persona incluye los seres más cercanos, como familiares, amigos y pares, compañeros de trabajo, profesionales médicos y personas con las que uno se identifique, o a las que admire. la dinámica es recíproca: las personas se ven influidas e influyen en los demás. • rosenstock, strecher y becker (28) consideran que las personas tienen miedo de contraer enfermedades, y los comportamientos asociados a la salud reflejan el nivel de peligro que se percibe, y la reducción del miedo que la persona espera lograr al tomar una acción concreta. este cálculo incluye la percepción de si el beneficio del cambio de comportamiento supera los obstáculos psicológicos y prácticos, y la decisión de actuar en consecuencia o no. • para prochaska y diclemente (29), la adopción de un comportamiento nuevo es un proceso, no un acto aislado, ya que las personas tienen diferentes niveles de motivación y voluntad de cambio. • rimer y glanz (30) consideran que las personas atraviesan por una serie de etapas de cambio, por lo que las intervenciones pueden concentrarse en contribuir a la transición de una etapa a la otra, y debido a que puede ser difícil producir cambios dentro de los grupos, se necesita motivación, habilidades nuevas y confianza para llevar a cabo la transición con éxito. teorías de adopción y cambio de comportamientos relacionados con la salud del niño la literatura sobre las actitudes y el comportamiento de la salud de los niños puede organizarse alrededor de dos enfoques. 177 adopción de comportamientos saludables en la niñez: análisis del concepto l luisa fernanda moscoso-loaiza y otro el primero fundamentado en la comprensión y el conocimiento de los niños acerca de los conceptos de salud y enfermedad, y el segundo, que las considera desde las diferencias individuales (31). estos se han desarrollado a través de procesos investigativos con la tendencia inicial de evitar la presencia de niños como participantes activos en los estudios (32), y son con frecuencia los adultos, principalmente padres y profesionales, quienes suministraban las respuestas a las cuestiones que la investigación plantea en relación con los asuntos específicamente infantiles (33-35). bajo estos enfoques, las perspectivas teóricas más usadas en el estudio del comportamiento de la salud infantil, por diversas disciplinas como psicología y enfermería, son las siguientes: • el modelo de creencias de la salud (1950): se centra en el cambio de comportamiento a nivel individual; este modelo identifica cuatro aspectos relevantes: la percepción de la susceptibilidad hacia la gravedad de una enfermedad y sus problemas, los beneficios para reducir el riesgo, y las claves para la acción y la autoeficacia (28). gholizadeh et al. (36) consideran que el riesgo es percibido como un predictor importante de la mayoría de los comportamientos de salud preventivos, pero que no se aborda en el contexto sociocultural, donde la opinión colectiva y las actitudes pueden influir en los comportamientos. • teoría del comportamiento planificado de icek ajzen (1988, 1991): explica la relación entre las creencias y los comportamientos. sustenta que el comportamiento no es completamente voluntario y controlado. mediante la adición del control percibido conductual aclara la relación entre la intención de la conducta y el comportamiento real (37). ha guiado la explicación de los comportamientos que se generan en torno a la alimentación de los niños, a partir de las conductas de las madres (38), así como la evaluación del consumo de alcohol en escolares (39). • teoría de protección y motivación: desarrollada por rogers (1975-1983) considera los procesos cognitivos de la evaluación de amenazas y del afrontamiento, en donde los factores que influyen en las intenciones de salud y comportamientos incluyen la percepción de la vulnerabilidad y gravedad al resultado indeseable, la autoeficacia, la eficacia de respuesta y los costos percibidos. propone que la motivación de la protección se incrementará si la persona advierte la probabilidad y la gravedad de la amenaza para la salud. sin embargo, no tiene en cuenta el papel de los factores culturales, ambientales y sociales en la adopción o el rechazo de las recomendaciones de salud (40). se ha utilizado para evaluar los efectos de la promoción de la actividad física (41), y en el establecimiento de factores predictores en el consumo de cigarrillo en adolescentes escolares (42). • modelo de valoración de la familia de calgary (1983): valora la estructura, el desarrollo y el funcionamiento familiar, centrándose en los detalles cognitivos, afectivos y conductuales de los individuos que determinan la dinámica familiar (43). ha sido utilizado para determinar la influencia de los factores ambientales y culturales en el sobrepeso y la obesidad en las familias (44). • teoría de la autoeficacia: desarrollada por bandura como parte de la teoría social cognitiva (1986). considera que las medidas de autoeficacia deben ser específicas, contener diversos niveles de dificultad y permitir el registro del grado de la confianza que una persona tiene, acerca de que una conducta determinada será alcanzable. la autoeficacia es un factor importante y constante en la modificación del riesgo y en el cambio de comportamiento (45). ha sido ampliamente utilizada en la promoción de conductas saludables en las diadas niño/adolescente y sus padres, especialmente en torno a la actividad física y la alimentación (46-49). • modelo de promoción de la salud de pender (1982): considera que la conducta está motivada por el deseo de alcanzar el bienestar y el potencial humano. enfatiza el nexo entre las características personales y las experiencias, conocimientos, creencias y aspectos situacionales vinculados con los comportamientos de salud que se pretenden lograr (50). tiene en cuenta los beneficios y las barreras percibidos por la acción y la autoeficacia (51). ha guiado investigaciones para determinar la influencia de las conductas promotoras de salud de los padres en sus hijos (52), así como el desarrollo de herramientas para evaluar los predictores del consumo de alimentos en niños y adolescentes (53). estas perspectivas teóricas evidencian la manera como se han explorado la adopción y el cambio de comportamientos de los niños a través del adulto; pese a que estas orientaciones pueden ser de ayuda para motivar el cambio de comportamiento, no toman en cuenta las actitudes y respuestas de los niños frente al ambiente y cómo estas interactúan con el desarrollo cognitivo (31). 178 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 conceptos relacionados la adopción de comportamientos saludables suele estar relacionada en la literatura con los conceptos de estilos de vida y hábitos saludables. sin embargo, pese a que se vinculan, no son iguales, y difieren cuando se les examina de cerca. estilos de vida: son patrones de comportamiento colectivos que se configuran a partir de diferentes elecciones que hacen los seres humanos y están condicionados por las oportunidades de vida que les brinda el contexto en que se desarrollan (54). incorporan una relación entre las opciones y oportunidades de vida, las cuales se fundamentan en los elementos de la estructura que, junto con los de la agencia, dan forma a los estilos de vida. los elementos estructurales son las circunstancias de clase, las colectividades, la edad, el género, la etnia y las condiciones de vida, los cuales generan las oportunidades. la agencia, en tanto se trata de las opciones, está condicionada por la socialización y la experiencia de los individuos (55). los estilos de vida están determinados por la presencia de factores de riesgo o de factores protectores para el bienestar, por lo cual deben ser vistos como un proceso dinámico que no solo se compone de acciones y comportamientos individuales, sino también de los de naturaleza social (56). hábitos saludables: son un set de disposiciones durables para actuar de maneras específicas (57). el hábito es una forma de conservación del pasado, que constituye la habilidad para conducirse de determinada forma, por lo que requiere de aprendizaje y repetición de actos individuales. un hábito adquirido es, desde el punto de vista fisiológico, una nueva vía de descarga que se forma en el cerebro, por la cual han de escapar ciertas corrientes aferentes (58). son rutinas o patrones de comportamiento que se establecen en el organismo y que llegan a tener una base orgánica, biológica. la mayoría de estos se vuelven inconscientes, en el sentido en que operan mecánicamente. los hábitos se forman desde la infancia temprana, a partir de la existencia de un condicionamiento que sustituye la causa primitiva del acto, el cual se vuelve autónomo cuando se libera cada vez más de los estímulos exteriores y contiene las percepciones reguladoras necesarias. el aprendizaje del hábito se da por medio del adiestramiento. cada adquisición se refuerza mediante la repetición, la cual facilita el logro de los primeros y el aprendizaje de los siguientes (58). el habitus constituye la dimensión cultural del hábito, y se entiende como un sistema de esquemas adquiridos, permanentes y transferibles, a partir de los cuales los sujetos perciben el mundo y actúan en él (58). estos esquemas están estructurados socialmente e interiorizados por medio de la mediación semiótica, se han conformado a lo largo de la historia de cada sujeto y suponen la interiorización de la estructura social, del campo concreto de relaciones sociales en el que el agente se construye como tal (58). atributos del concepto • proceso multidimensional: individual y social (24, 29, 31, 32, 39-47). • implica múltiples acciones e interacciones que evolucionan y se desarrollan en el tiempo (26-29). • está determinado por las características individuales del niño, como son el nivel de conocimiento, las habilidades, las percepciones, las creencias, los valores, las motivaciones, las intenciones para la acción y la percepción de su capacidad para lograr un objetivo (29, 30, 31, 37-44, 48, 51). • tiene influencia del contexto interpersonal, social y organizacional del niño (21, 29, 45, 46). • es un proceso recíproco entre el niño y el contexto o ambiente: el niño influye en el contexto y este en el niño, de forma simultánea (21, 29, 45, 46). • conduce al bienestar y la salud (22, 25-28, 30). definición del concepto de adopción de comportamientos saludables en la niñez la adopción de comportamientos saludables en la niñez hace referencia al proceso de asimilación, aceptación o apropiación de conductas, que puede ser ordenado, interrumpido o coordinado, o en algunos casos darse en el más completo desorden; incluye acciones, actitudes, interacciones y emociones del niño hacia su bienestar, las cuales pueden facilitar, reforzar o mejorar la salud. constituye un proceso de naturaleza evolutiva con diferentes formas, ritmos y pasos, el cual está continuamente influenciado por el contexto, y puede conducir al establecimiento de un hábito. a continuación se presentan una serie de casos que ilustran el concepto. 179 adopción de comportamientos saludables en la niñez: análisis del concepto l luisa fernanda moscoso-loaiza y otro caso modelo juan es un niño de 8 años de edad que asiste a la escuela y se encuentra en tercer grado. refiere que le gustan mucho las frutas, especialmente la manzana y el banano, y que las prefiere comer en horas de la tarde después del almuerzo; no consume gaseosas, y solo de vez en cuando consume comida chatarra, ya que su mamá le dice que no es buena para su corazón. juan sabe que comer frutas y vegetales le ayuda a tener una buena salud. le gusta jugar fútbol desde los 4 años, ya que su papá le ha enseñado que hacer deporte le ayuda a estar en forma; juega en el parque del conjunto residencial donde vive y en las horas de recreo del colegio, este es su pasatiempo favorito. juan cuenta que quiere seguir jugando fútbol cuando sea más grande porque se divierte mucho y porque quiere llegar a ser un buen arquero. sabe que es importante alimentarse bien, ya que si no lo hace, no va a tener la energía suficiente para jugar e ir al colegio. los padres de juan señalan que es un niño muy activo y feliz, que es respetuoso, amable y solidario con los otros niños, y que se desempeña bien en las actividades del colegio. caso límite juliana es una niña de 10 años de edad que se encuentra en cuarto grado de la escuela primaria. juliana manifiesta que come algunas frutas en las horas de descanso porque su mamá se las envía en la lonchera, pero cada vez que tiene oportunidad las cambia por paquetes como papas o chitos debido a que estos le parecen más ricos. juliana no tiene preferencia por ninguna actividad física o deporte en especial, y solo se ejercita en las clases de educación física porque “le toca” y no quiere perder la asignatura. los padres de juliana sienten que ella se alimenta bien, y que realiza suficiente actividad física para su edad, además refieren que es una niña responsable y que se desenvuelve bien en todas las actividades del colegio. caso contrario maría es una niña de 11 años de edad, que cursa quinto grado. su comida preferida es la pizza, junto con los dulces y las gaseosas; refiere que no le gustan los vegetales, pero que las frutas se las come si van acompañadas de leche condensada o helado. maría no realiza ninguna actividad física, ya que manifiesta que le da pereza, por lo que prefiere ver televisión durante casi todo el día. en las horas de recreo escoge sentarse a jugar con su celular o a chatear con algunas amigas, ya que no le gusta sudar, ni entrar a clase acalorada. los padres de maría se sienten preocupados por su bajo ánimo, por su poca energía para hacer las labores del colegio, y por sus bajas notas. sin embargo, manifiestan que se sienten tranquilos sabiendo que pasa la mayoría del día dentro de casa, y no la dejan salir al parque porque piensan que es peligroso. antecedentes y consecuencias del concepto de adopción de comportamientos saludables en la niñez la revisión de la literatura científica nos muestra que la influencia de los padres es uno de los principales determinantes que favorecen la adquisición y el establecimiento de comportamientos saludables en la niñez, mientras que las consecuencias de la falta de estos conlleva el desarrollo de enfermedades crónicas no transmisibles a edades tempranas, como se muestra y amplía en la tabla 1. tabla 1. antecedentes y consecuencias del concepto de adopción de comportamientos saludables en la niñez antecedentes del concepto influencia de los padres: controlan la disponibilidad y accesibilidad de alimentos (restricción, presión para comer, promesa de recompensas) (11, 12), y las posibilidades de práctica de actividad física (af) en los niños (10, 59), desde: a) estilo de crianza: con resultados diversos crianza permisiva (sin restricciones): niños más activos físicamente (60) (61), con mayor riesgo de sobrepeso (62). crianza autoritaria (respeto por la opinión de los hijos, con límites claros): menos restricciones sobre la dieta (59, 63); niños menos propensos a tener sobrepeso (64), y con mayores niveles de af (10, 65). crianza muy autoritaria (muy estricta/disciplinada): niños con mayor riesgo de sobrepeso (61). b) nivel educativo de los padres mayor nivel educativo (técnico-universitario): crianza autoritaria. mayor control sobre la alimentación (59). menor nivel educativo (primaria-bachillerato): crianzas permisivas. no control sobre la alimentación (59). 180 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 fuente: moscoso y díaz (18). referentes empíricos para realizar una medición objetiva de la adopción de comportamientos saludables en la niñez se han utilizado principalmente los instrumentos y cuestionarios desarrollados bajo los enfoques teóricos que procuran explicar cómo las actitudes y percepciones que se tengan frente a la propia salud influyen en las conductas saludables de los niños. estos instrumentos se han utilizado principalmente en los adolescentes y niños mayores de 10 años, y se amplían en la tabla 2. tabla 2. referentes empíricos del concepto de adopción de comportamientos saludables en la niñez c) padres con menor ingreso económico: niños más propensos a pasar mayor tiempo frente a la televisión (66). televisión como estrategia para asegurar la estancia de los niños en casa y mantenerlos ocupados en el hogar (66). apoyo y aliento de los padres hacia la af: aumenta la percepción de que los niños participan más en actividades deportivas (14, 15), existe más control sobre la televisión y el uso de videojuegos (15). las conductas de salud en edades tempranas se asocian con las de edades posteriores (5, 65). consecuencias del concepto la falta de comportamientos saludables en la niñez lleva a: desarrollo de obesidad infantil (9, 12, 67, 68). trastornos del sueño, problemas osteomusculares y respiratorios en los niños (9, 68). hipertensión arterial, hiperglucemia, hipertrigliceridemia y elevación de las transaminasas (12, 67, 69, 70). sedentarismo asociado al sobrepeso y obesidad. aumento del riesgo de adquirir una enfermedad cardiovascular en edades tempranas (9, 14). depresión, ansiedad y baja autoestima (71). los factores de riesgo cardiovascular coexisten en la niñez (entre 3 a 5 años) y se refuerzan mutuamente (67, 68, 70). instrumento descripción escala del modelo de creencias en salud diseñada por becker en 1974 incluye 31 ítems que recogen información sobre las dimensiones de susceptibilidad a la enfermedad, severidad de la misma, barreras y beneficios percibidos. este instrumento se califica a través de una escala likert con 5 opciones de respuesta, las cuales oscilan entre “totalmente en desacuerdo” (1) y “totalmente de acuerdo” (5). de estos reactivos se diseñaron 12 para evaluar la severidad, 6 para la susceptibilidad, 5 para los beneficios y 8 para las barreras, de acuerdo con el análisis factorial realizado por los autores (72). la confiabilidad interna reportada en un estudio de promoción de la salud con 80 adolescentes con diabetes mellitus es de > 0,73, siendo el valor para cada uno de los componentes por separado como sigue: susceptibilidad = 0,78, severidad = 0,76, barreras = 0,76 y beneficios = 0,6 (73). cuestionario de la teoría de la conducta planeada desarrollado por gonzález, neipp, quiles y rodríguez-marín en el 2012 compuesto por un total de 20 ítems agrupados en cuatro factores: 1) norma subjetiva, 4 ítems; 2) intención, 4 ítems; 3) control comportamental percibido, 5 ítems; 4) actitud, 7 ítems. con una escala likert que oscila entre 1 para la actitud más negativa y 7 para la actitud más positiva (74, 75). los valores obtenidos con estudiantes entre los 12 y 16 años fueron de 0,85 para el factor control comportamental percibido, 0,87 para el factor intención, 0,76 para el factor norma subjetiva, y 0,86 para el factor actitud (76). la escala de autoeficacia desarrollada por schwarzer en 1979. traducida al español en 1993 esta escala consta de 10 ítems construidos a manera de una escala likert con 6 opciones de respuesta, que van de “totalmente en desacuerdo” (1) a “totalmente de acuerdo” (6), por lo que la sumatoria del puntaje oscila entre 6 y 60 puntos. la versión al español se tradujo por expertos en 1993 desde la escala original, con adaptaciones culturales necesarias para medir de manera contextualizada el constructo autoeficacia percibida en población costarricense, española y peruana (77, 78). los estudios de las características psicométricas de la escala de autoeficacia en español han demostrado empíricamente su confiabilidad y validez convergente y discriminante. la unidimensionalidad y homogeneidad de las versiones en español, chino y alemán se demostró a través del análisis de la correlación ítem-ítem total, factor carga y componentes principales (79). por lo que es una escala general se considera con una buena capacidad predictiva de las conductas de salud al tratarse como un recurso personal de afrontamiento. la escala ha mostrado una consistencia interna alfa de 0,76 a 0,74 (80). fuente: moscoso y díaz (18). 181 adopción de comportamientos saludables en la niñez: análisis del concepto l luisa fernanda moscoso-loaiza y otro conclusiones la adopción de comportamientos saludables es un fenómeno universal y social que se da a partir de la interacción de un ser humano con otras personas. constituye una experiencia subjetiva que se desarrolla bajo diversidad de causas, y produce una gran variedad de consecuencias físicas y psicosociales. así, la adopción de comportamientos saludables en la niñez es un conjunto abstracto de actitudes, interacciones y emociones del niño hacia su bienestar que influirá en su salud de por vida, por lo que clarificar el concepto amplía el conocimiento acerca del fenómeno, y es el primer paso para lograr entender cómo es su dinámica y conocer sus elementos constitutivos, consolidándolo a partir de la investigación y la práctica de enfermería. los comportamientos saludables se adquieren a edades tempranas y persisten en la transición hacia la adultez, por lo que la promoción de la salud en la niñez representa un gran reto para enfermería, que debe facilitar y potencializar los factores que determinan las conductas que sostienen los estilos de vida saludables, a partir de estrategias que incluyan programas escolares y comunitarios que promuevan la actividad física y la nutrición saludable para combatir la carga de enfermedades crónicas asociadas a la vida sedentaria y la obesidad. los espacios creados por enfermería para el cuidado infantil deben involucrar 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andrea alfaro-robles2 ignacio esteban díaz-mancilla3 violeta victoria martínez-guzmán4 riesgo de suicidio adolescente en localidades urbanas y rurales por género, región de coquimbo, chile 1 orcid.org/0000-0001-7427-7772. universidad santo tomás, chile. rodrigoardiles@santotomas.cl 2 orcid.org/0000-0002-2497-3662. ministerio de salud, chile. paola.alfaro@redsalud.gov.cl 3 orcid.org/0000-0002-4170-6937. universidad santo tomás, chile. ignacioesteban.diaz@alumnos.santotomas.cl 4 orcid.org/0000-0003-4782-9740. universidad santo tomás, chile. violeta.martinez@alumnos.santotomas.cl recibido: 05/01/2018 enviado a pares: 29/01/2018 aceptado por pares: 15/02/2018 aprobado: 13/03/2018 doi: 10.5294/aqui.2018.18.2.4 para citar este artículo / to reference this article / para citar este artigo ardiles-irarrázabal ra, alfaro-robles pa, díaz-mancilla ie, martínez-guzmán vv. riesgo de suicidio adolescente en localidades urbanas y rurales por género, región de coquimbo, chile. aquichan 2018; 18(2): 160-170. doi: 10.5294/aqui.2018.18.2.4 año 18 vol. 18 nº 2 chía, colombia abril 2018 l 160-170 temática: promoción y prevención. aporte a la disciplina: el estudio del riesgo de suicidio es de gran relevancia dentro de la enfermería y en el marco de la salud pública, ya que esta se dirige a brindar una atención integral en el ámbito biopsicosocial del ser humano y su entorno; los profesionales juegan un rol clave en el cuidado de las personas con conductas suicidas a través de la educación, prevención y provisión de cuidados. los resultados ayudarán a crear una mayor conciencia entre los distintos actores sociales y la comunidad sobre la importancia de la promoción y prevención, y de la creación de estrategias que reduzcan el riesgo de suicidio en los adolescentes, quienes constituyen la población con el menor número de atenciones en los centros de salud, dado que por décadas ha sido invisible a las políticas de salud, principalmente por considerarse a los adolescentes como una población sana. resumen objetivo: comparar el riesgo de suicidio de adolescentes de enseñanza media, residentes de localidades urbanas y rurales por género en la región de coquimbo, chile. material y método: la investigación es de tipo cuantitativo descriptivo no experimental, en una muestra no probabilística. en noviembre del 2016, de forma anónima, se aplicó el cuestionario de screening de suicidalidad de okasha, sobre tendencia suicida, a una muestra de 349 adolescentes de 14-19 años (48,7 % hombres-51,3 % mujeres), que asistían a establecimientos educativos urbanos y rurales, de la región de coquimbo, en chile. se utilizó una anova de dos vías para las variables localidad y género. resultados: no existen diferencias en el riesgo de suicidio según localización geográfica, pero sí por género; se presentó un 15,76 % de adolescentes femeninas con riesgo suicida. conclusiones: el suicidio es un problema de salud pública mundial, sobre el que no se ha abordado adecuadamente a nivel de prevención y promoción en salud; existe diversidad de factores que influyen en el riesgo suicida y el factor asociado al género femenino presenta un mayor riesgo; mientras que la ubicación geográfica de residencia no registra riesgo. palabras clave detección de suicidio; suicidio adolescente; urbano y rural; ideación suicida; intento de suicidio (fuente: decs). 161 riesgo de suicidio adolescente en localidades urbanas y rurales por género, región de coquimbo, chile l rodrigo alejandro ardiles-irarrázabal y otros año 18 vol. 18 nº 2 chía, colombia abril 2018 l 160-170 risk of adolescent suicide in urban and rural areas of the coquimbo region of chile, by gender abstract objective: compare the risk of suicide, by gender, among adolescent, secondary-school students who are residents of urban and rural areas in the coquimbo region of chile. materials and method: this is a non-experimental, descriptive quantitative study of a nonprobabilistic sample. in november 2016, okaska’s suicidality scale to gauge the tendency towards suicide was applied anonymously to a sample of 349 adolescents ages 14-19 (48.7% males and 51.3% females) who were attending urban and rural educational establishments in the coquimbo region of chile. a two-way anova was used for the locality and gender variables. results: there are no differences in the risk of suicide according to geographic location. however, by gender; 15.76% of the female adolescents were found to be at suicidal risk. conclusions: suicide is a global public health problem that has not been addressed adequately in terms of prevention and health promotion. there are varieties of factors that influence the risk of suicide. the female-gender factor presents a greater risk, while the geographical location of residence appears to pose risk. keywords suicide detection; adolescent suicide; urban and rural; suicidal ideation; suicide attempt (source: decs). 162 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 2 chía, colombia abril 2018 l 160-170 risco de suicídio adolescente em áreas urbanas e rurais por gênero, região de coquimbo, chile resumo objetivo: comparar o risco de suicídio de adolescentes por gênero, estudantes do ensino médio, residentes em áreas urbanas e rurais da região de coquimbo, chile. materiais e método: a pesquisa é de tipo quantitativo descritivo não experimental, numa amostra não probabilística. em novembro de 2016, de forma anônima, aplicou-se o questionário screening de suicidalidade de okasha, sobre tendência suicida, a uma amostra de 349 adolescentes entre 14 e 19 anos (48,7 % homens e 51,3 % mulheres), que se encontravam em estabelecimentos educativos urbanos e rurais da região de coquimbo. utilizou-se anova de duas vias para as variáveis área e gênero. resultados: não existem diferenças no risco de suicídio segundo a localização geográfica, mas sim por gênero; apresentaram-se 15,76 % de adolescentes do sexo feminino com risco suicida. conclusão: o suicídio é um problema de saúde pública mundial, sobre o qual não se tem abordado adequadamente, no que se refere à prevenção e promoção em saúde; há diversidade de fatores que influenciam no risco suicida, e o fator associado ao gênero feminino apresenta maior risco, enquanto a localização geográfica de residência não o registra. palavras-chave detecção de suicídio; suicídio adolescente; urbano e rural; ideação suicida; tentativa de suicídio (fonte: decs). 163 riesgo de suicidio adolescente en localidades urbanas y rurales por género, región de coquimbo, chile l rodrigo alejandro ardiles-irarrázabal y otros introducción el suicidio es una de las más graves manifestaciones de violencia humana. según la organización panamericana de la salud (ops), mueren más personas por suicidio que por conflictos bélicos (1). según la organización mundial de la salud (oms), en los últimos 45 años las tasas de suicidio han aumentado en un 60 % a nivel mundial, y son una de las tres primeras causas de defunción entre las personas entre 15 a 44 años. la tasa promedio mundial de suicidio es de 11,4 por 100 mil habitantes, siendo el doble en hombres que en mujeres. del total de suicidios anualmente, al menos 250.000 corresponden a menores de 25 años. el 78 % de todos ellos se producen en países de bajos y medianos ingresos de áfrica y en el mediterráneo oriental. este comportamiento posee múltiples causas interrelacionadas, asociadas a factores de riesgo sociodemográficos, biopsicosociales y ambientales (2). anualmente, alrededor del mundo se suicidan casi un millón de personas, es decir, una persona se suicida cada 40 segundos en algún lugar del planeta (3). cada intento de suicidio o suicidio afecta a un sinnúmero de otros individuos cercanos o no, los cuales sufren las consecuencias de los comportamientos suicidas (4); este comportamiento constituye un problema complejo, con múltiples causas interrelacionadas, y la enfermedad mental es uno de los factores más importantes (2) entre otros, como biológicos, psicológicos, sociológicos, culturales, ambientales y geográficos (5). estos antecedentes son los que lo han convertido en un problema de salud pública mundial (3). en américa fallecen anualmente por suicidio un promedio de 65.000 personas (6). en estados unidos el suicidio es la tercera causa principal de muerte en los jóvenes de 10 a 24 años (4.500 muertes cada año aproximadamente) (7). chile duplica la tasa de mortalidad adolescente por suicidio de latinoamérica y el caribe (8). según la organización para la cooperación y el desarrollo económicos (ocde), chile es el país donde más ha aumentado el suicidio, después de corea del sur, con una tasa de 13,3 muertes por cada 100.000 habitantes, con un crecimiento de 90 % entre los años 1990-2011 (9); diariamente fallecen en chile entre 5-6 personas al día a causa del suicidio, lo que representa casi un 2 % de las muertes (2). los hombres tienen las cifras más altas de suicidio respecto a las mujeres, con un promedio de 5:1 respectivamente (1). la población adolescente corresponde al 15,6 % de la población total, donde un 52 % corresponde a adolescentes entre 15-19 años (10). chile presentó un incremento progresivo en la tasa de suicidios entre los años 2000-2008, con un 12,36 por 100.000 habitantes y 12,92 en el grupo de 15-19 años. desde entonces, los índices han bajado gradualmente a tasas similares a las del año 2000, y actualmente son de 10,04 por 100.000 a nivel general, y de 8,17 en el grupo de 15-19 años (6). pese a ello, chile sigue figurando como el segundo país de latinoamérica con los más altos índices de suicidio infanto-adolescente seguido de uruguay y antecedido por guayana (11). las tasas de suicidio adolescente han crecido rápidamente en chile en los últimos 20 años (12), esto relacionado directamente con los pocos programas de prevención eficaces a nivel mundial (13). el plan nacional de salud mental 2000-2010 propuso reducir en un 10 % las tasas de crecimiento del suicidio en chile; no obstante, estas aumentaron en casi un 60 % (14). en respuesta, el ministerio de salud de chile (minsal) ha mejorado el acceso a la atención de salud mental, con la legislación sobre garantías universales en atención de salud, y con la creación de un plan nacional de prevención: “programa nacional de prevención de suicidio” (2013), que incluye estrategias de prevención recomendadas por la oms (12). la meta de impacto esperada al 2020 es disminuir en 15 % la tasa proyectada de 12 por 100.000 a 10,2 por 100.000 adolescentes (2). el suicidio es un evento que ha sido constante en las sociedades (15), las respuestas han variado de acuerdo con cada cultura. como fenómeno humano, el suicidio siempre ha estado presente en la historia (2). la oms define suicidio como: “todo acto por el que un individuo se causa a sí mismo una lesión, o un daño, con un grado variable en la intención de morir, cualquiera sea el grado de intención letal o de conocimiento del verdadero móvil” (12). define conceptos asociados al suicidio como: • intento de suicidio: todo comportamiento suicida que no causa la muerte, y se refiere a intoxicación autoinfligida, lesiones o autoagresiones intencionales que pueden o no tener una intención o resultado mortal (12). • comportamiento suicida: se entiende una diversidad de comportamientos que incluyen pensar en el suicidio (o ideación suicida), planificar el suicidio, intentar el suicidio y cometer un suicidio propiamente dicho (12). 164 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 según underwood y arango, más del 90 % de las personas que mueren por suicidio tienen un trastorno psiquiátrico importante, sobre todo trastornos del estado de ánimo como la depresión. aparte de los trastornos psiquiátricos, factores estresantes en la vida como eventos traumáticos generan cambios en el cerebro y, por tanto, tienen un impacto sobre la neurodegeneración y neuroplasticidad (16). la corteza prefrontal es responsable del juicio y el discernimiento. las personas que completan el suicidio tienen la habilidad de desarrollar un plan bien pensado, dejar notas, generar una voluntad y notificar a familiares y amigos. estas acciones indican una función intacta en la corteza prefrontal (17). en el cerebro, la corteza prefrontal orbital desempeña un rol importante en el proceso cognitivo, en la toma de decisiones, en la regulación de emociones y en el sistema de recompensas (18). una alteración de la corteza prefrontal orbital reduce la capacidad de producir y usar la serotonina, neurotransmisor fundamental para la regulación del humor y del control de los impulsos, lo que proporciona una explicación de los actos impulsivos en el suicidio (19). las personas que llegan a completar el suicidio envían menores cantidades de serotonina que lo normal a la corteza prefrontal orbital (18). de igual forma, la norepinefrina es responsable de regular el estrés, la ansiedad y el estado de ánimo. cuando ocurre un aumento de la concentración de los receptores de norepinefrina y alfa-adrenérgicos, el cerebro trata de producir más norepinefrina en el momento de suicidio, para así regular los niveles de ansiedad de la persona (20). la real academia española define la adolescencia como: “la edad que sucede a la niñez y que transcurre desde la pubertad hasta el completo desarrollo del organismo” (21). para la oms, la adolescencia es la etapa que transcurre entre los 10-19 años (3). según erikson, en esta etapa se presenta una crisis psicosocial relacionada con la “identidad versus confusión de identidad”. el adolescente experimentará una búsqueda y una crisis de identidad, donde revivirá los conflictos que tuvo en las etapas anteriores, se vuelve más independiente de sus padres y pasa mayor tiempo junto a sus pares, donde busca la identificación afectiva, cognitiva y conductual con aquellos con los cuales puede establecer relaciones autodefinitorias; superar la confusión de roles; establecer relaciones de confianza, estabilidad y fidelidad; consolidar las formas ideológicas y enfrentar la realidad de la industrialización y globalización (22). aberastury refiere que la adolescencia es un momento de duelos. es posible que en la adolescencia muchos sujetos no lleguen a responsabilizarse de su nuevo rol, no quieran o sientan que no son capaces de hacerse cargo de su nuevo cuerpo, de la nueva manera en que la sociedad los incluye o excluye, y el suicidio sea una forma de terminar con los asuntos que han comenzado a preocuparle (23). a nivel mundial se observa un importante aumento en la cantidad de adolescentes y jóvenes que ingresan a los servicios de salud por consultas vinculadas a intentos de suicidio y otras conductas autolesivas (2), ya que la adolescencia es una de las etapas de la vida con el mayor riesgo para la adopción de estos comportamientos (24). según la oms, el suicidio es la segunda causa de muerte en este periodo debido a que los adolescentes no buscan o no reciben ayuda psicológica ante su comportamiento suicida, las tasas de suicidio varían según el lugar de residencia (urbano/rural), la ubicación del individuo y el género (25). el riesgo de suicidio está conformado por una confluencia de factores multidimensionales (26). las causas de la conducta suicida no se entienden completamente; sin embargo, es claro que este comportamiento resulta de la compleja interacción de factores de riesgo, y si bien muchos han sido identificados, en su mayoría no se conoce por qué la gente trata de poner fin a sus vidas (27). el comportamiento suicida presenta múltiples causas interrelacionadas, y pueden agruparse en dos categorías (2): • predisposiciones internas de individuos a quitarse la vida, es decir, factores biológicos que predisponen la conducta suicida, como el decremento de la serotonina en el líquido cefalorraquídeo, lo que en estudios biológicos se demostró como una disfunción del sistema serotoninérgico en víctimas de suicidio y con intento de suicidio, que en términos psicopatológicos se correlaciona con una pérdida del control de los impulsos, agresividad, inestabilidad afectiva, y el intento de suicidio violento (28), así como las predisposiciones genéticas asociadas a su vez con los trastornos afectivos, el alcoholismo y las psicosis (2). • circunstancias externas, vinculadas a la comunidad y las relaciones humanas, como la guerra, la discriminación, la sensación de aislamiento, el abuso, la violencia y las relaciones conflictivas (1). los factores de riesgo implicados en el suicidio son la depresión, la desesperanza, los trastornos mentales, e incluso la impulsividad (29), que unidos a factores psicosociales o culturales pueden llevar a una persona al comportamiento suicida (1). en 165 riesgo de suicidio adolescente en localidades urbanas y rurales por género, región de coquimbo, chile l rodrigo alejandro ardiles-irarrázabal y otros chile, los factores de riesgo se clasifican en: sociodemográficos, biopsicosociales y ambientales. respecto a los factores sociodemográficos y epidemiológicos, un estudio realizado en china muestra que las tasas de suicidio son mucho más altas en las zonas rurales que en las urbanas (30) debido a que los jóvenes de las áreas rurales son más propensos a intentar el suicidio y concretarlo, al contrario de los jóvenes en zonas urbanas (7). en chile, los suicidios son más frecuentes entre individuos de sectores urbanos, sin embargo, la letalidad en zonas rurales es más alta (2). no obstante, existen estudios que demuestran que la residencia urbana o rural no se asociaría con la conducta suicida (31). con respecto a las diferencias de género, la tasa de mortalidad chilena por suicidio en mujeres es de 4,1 por 100.000 habitantes, y en hombres llega a 18,5 por 100.000 habitantes (32). no obstante, las mujeres realizan hasta tres veces más intentos suicidas que los hombres (33). los adolescentes varones son menos propensos a intentar suicidarse, pero son más propensos a completar el suicidio que las adolescentes mujeres (7), quedando en evidencia que el género es uno de los indicadores más fiables de las tendencias suicidas (1). materiales y métodos diseño. la investigación es de tipo cuantitativo descriptivo, no experimental, transversal. los datos fueron recogidos por medio del cuestionario escala de screening de suicidalidad de okasha, validado en chile en el año 2009 (34). el cuestionario fue aplicado durante el mes de noviembre de 2016 sobre una muestra no probabilística de alumnos de enseñanza media de establecimientos municipales de localidades urbanas y rurales de la región de coquimbo. para el resguardo ético de la investigación se utilizaron los “criterios de emanuel”. la legislación chilena sobre normas éticas en investigación está vigente en chile desde el año 2010 y el reglamento en salud fue promulgado el año 2013. en este marco legal, la institución patrocinante obliga a resguardar estos criterios éticos a través del consentimiento informado. se solicitaron los permisos respectivos a nivel de municipio y establecimientos educacionales, y en caso de necesidad se se debían realizar las coordinaciones internas del centro educacional con los centros de salud de derivación. obtenidos los permisos, se coordinaron reuniones con los apoderados para exponer el tema, resolver dudas y entregar los consentimientos informados. el instrumento fue aplicado a cada curso en sus respectivas aulas, recalcando la confidencialidad y voluntariedad del estudio. el tiempo de aplicación varió de 10 a 15 minutos. participantes. los criterios de inclusión fueron: adolescentes de enseñanza media, establecimiento educacional mixto, establecimiento rural con más de 10 alumnos por nivel, cursar estudios en establecimientos municipales en localidad urbana y rural, residencia en la región de coquimbo. el universo corresponde a 573 alumnos de enseñanza media de establecimientos municipales de localidades urbanas y rurales de la región de coquimbo, de 273 establecimientos urbanos y 300 a rurales. la muestra comprendió a 349 alumnos, 179 de establecimientos urbanos y 170 a rurales (61 % del universo, 95 % de confianza). instrumento. el cuestionario de suicidalidad de okasha detecta el riesgo suicida en adolescentes y puede ser utilizado por equipos de salud general, profesionales y técnicos, e incluso por monitores y agentes comunitarios. evalúa el riesgo suicida sin necesidad de realizar un diagnóstico psiquiátrico. la confiabilidad para población chilena es apropiada (α = 0,89) (34), y es incluido en el programa nacional de prevención del suicidio del minsal. esta escala diseñada por okasha, es autoadministrada, tipo likert, formada por 4 ítems, donde los tres primeros exploran ideación suicida y el cuarto consulta sobre intento de suicidio (34). 1. ¿has pensado alguna vez que la vida no vale la pena? 2. ¿has deseado alguna vez estar muerto? 3. ¿has pensado alguna vez terminar con tu vida? 4. ¿has intentado suicidarte? las respuestas de los ítems de ideas suicidas se recogen en una escala de frecuencia de categorías que se puntúa de 0-3 puntos para cada ítem; desde 0 (nunca) a 3 (muchas veces). la sumatoria de estos tres ítems conforma el subpuntaje de ideación suicida (oscila entre 0-9 puntos). el ítem de intento de suicidio también se puntúa de 0-3 según el número de intentos de suicidio, desde ningún intento (0) a tres o más intentos (3). 166 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 la puntuación total de la escala de suicidalidad se obtiene sumando el subpuntaje de ideación suicida más el puntaje del ítem de intento de suicidio. la suma total puede oscilar entre 0-12 puntos. a mayor puntuación mayor gravedad (34). resultados la muestra comprendió a 349 adolescentes, 170 hombres y 179 mujeres (48,7 y 51,3 % respectivamente) (tabla 1), con edades entre 14-19 años, con una edad promedio de 16,1. el rango de puntuaciones totales en la escala de screening de suicidalidad de okasha estuvo comprendido entre 0-12 puntos (media = 2,56; de = 2,92); 89 adolescentes, equivalentes a un 25,5 % del total, presentaron riesgo de suicidio, 9,74 % fueron hombres y un 15,76 % fueron mujeres (tabla 2) y 49 de estos adolescentes presentaron intento de suicidio, lo que equivale a un 14,04 % de la población total analizada. tabla 1. característica de la muestra distribución de las puntuaciones de suicidalidad de okasha para verificar la normalidad, a la muestra de puntajes totales se le aplicó el test de kolmogorov-smirnov, el cual mostró un nivel de significancia de 0,05, por lo que los datos no están distribuidos normalmente (figura 1). figura 1. frecuencia frente a puntaje total de la escala de screening de suicidalidad de okasha, en muestra total grupo de variables variables categoría distribución muestra total (%) sociodemográficas género hombre mujer 48,7 51,3 localidad urbano rural 51,3 48,7 fuente: elaboración propia. tabla 2. distribución del riesgo de suicidio por localidad y género fuente: elaboración propia. población total en riesgo género porcentaje de casos localidad porcentaje de casos 25,5 % hombres 9,74 % urbano 3,44 rural 6,3 mujeres 15,76 % urbano 8,56 rural 7,16 fuente: elaboración propia. la puntuación media de todos los ítems fue 0,6 con un mínimo de 0,2 y un máximo de 1,0. la tabla 3 muestra el rango por ítem y el rtot de pearson que indica que todos los ítems presentan una altísima correlación con la puntuación total. tabla 3. media, desviación estándar (de) y correlaciones corregidas ítem-total (rtot) de los ítems de la escala de screening de suicidalidad de okasha en la muestra total de adolescentes item media de rango rtot pregunta 1 1,0 1,0 0-3 0,8466 pregunta 2 0,8 1,0 0-3 0,9012 pregunta 3 0,5 0,9 0-3 0,8943 pregunta 4 0,2 0,6 0-3 0,6614 puntaje total 2,6 2,9 0-12 n = 349. fuente: elaboración propia. 167 riesgo de suicidio adolescente en localidades urbanas y rurales por género, región de coquimbo, chile l rodrigo alejandro ardiles-irarrázabal y otros se aplicó un test de anova de dos vías considerando el puntaje total de la escala de screening de suicidalidad de okasha como variable dependiente, y la localidad y el género como variables independientes, cuyo resultado fue que en el puntaje total de la escala no se observó efecto para la localidad (f = 0,024; p > 0,05), pero sí para el género (f = 17,861; p < 0,05), y ningún efecto de interacción significativo entre ambos (f = 2,305; p > 0,05). discusión los hallazgos de la presente investigación muestran una prevalencia de intento de suicidio de un 14,04 % en adolescentes de 14-19 años de la región de coquimbo; este resultado es menor comparado con el estudio realizado por valdivia et al., con una prevalencia de un 19,5 % de intento de suicidio en adolescentes de 14-20 años (31). la muestra utilizada en esta investigación se caracterizó por ser similar en cantidad de participantes según localidad, 51,3 % adolescentes de zonas urbanas y un 48,7 % de zonas rurales, en contraste con el estudio de valdivia et al., donde la muestra fue solo de adolescentes de localidades rurales. además, la mayoría de los estudios nacionales e internacionales se centran solo en un tipo de población según localidad de residencia, urbana o rural. en lo que respecta a la variable de género, cabe destacar que al igual que la variable anterior, la muestra fue similar entre hombres y mujeres, tanto en localidades urbanas como en las rurales. en la variable localidad, a través del análisis de anova de dos vías, donde se incluyen los adolescentes de zonas urbanas y rurales, los resultados concluyen que la localidad no se asocia al riesgo de suicidio. por tanto, es necesario investigar otras explicaciones en adolescentes de distintas poblaciones como, por ejemplo, identificar los posibles factores de riesgo que pueden ser atribuibles a los intentos de suicidios, tales como factores sociodemográficos, biopsicosociales o ambientales (2). como se planteó, no se encontraron diferencias significativas (p = 0,877) con respecto a que la localidad de residencia de los adolescentes sea un factor predisponente para aumentar el riesgo de suicidio. al comparar este aspecto de la investigación con publicaciones extranjeras, nuestro hallazgo no concuerda con lo descrito en estudios realizados en otros países, ya que en sus resultados demuestran una mayor prevalencia de suicidios en poblaciones rurales sobre las urbanas (7, 30, 35, 36). sin embargo, existen estudios cuyos resultados concuerdan con los nuestros, como el de freuchen et al. realizado en noruega; el de yao et al. aplicado en china, y el de husky et al. en estados unidos, donde ninguno de estos autores encontró diferencias significativas entre la población urbana y la rural para distintas conductas suicidas (37-39). al igual que en el estudio realizado en chile por valdivia et al. (31), que consistió en una muestra de 195 adolescentes estudiantes de enseñanza media de la comuna de santa juana (localidad rural), región del bio bío, a los que se les aplicó la escala de screening de suicidalidad de okasha, el cual arrojó que la residencia urbana o rural no se asocia con conducta suicida. la variable género bajo el análisis de una anova de dos vías dio como resultado que existe una diferencia significativa (p = 0,000) con respecto al sexo de los adolescentes y el riesgo de suicidio, donde se establece que las mujeres presentan un mayor riesgo de suicidio que el sexo masculino, independiente de la localidad; estos resultados coinciden con lo planteado en la literatura, donde prácticamente sin excepción se confiere un riesgo entre 2 y 4 veces mayor de intentar el suicidio en las adolescentes mujeres sobre los adolescentes hombres (40, 41). respecto a la realidad nacional, se identifica que estos resultados concuerdan con otros estudios realizados en chile, como los de valdivia et al. y por ventura et al. en la región metropolitana (31, 42), donde se plantea un mayor riesgo de suicidio en las adolescentes mujeres, pero una mayor letalidad en adolescentes hombres (2, 9, 31), esto debido principalmente, según estudios del minsal, a que las mujeres, cuando llegan a intentar el suicidio, utilizan métodos menos letales que los hombres (2). los factores de riesgo que subyacen a estas diferencias en el riesgo de suicidio según el género escapan al objetivo de este estudio, pero sí se puede plantear que son múltiples y que sumados pueden llevar al adolescente a intentar e incluso concretar su ideación suicida, tal como se observa en los estudios realizados por la oms y el minsal de los que destacan como principales factores de riesgo los antecedentes familiares de suicidio y enfermedad mental (2, 43). de acuerdo con los resultados actuales, estudios previos han demostrado que existe relación entre riesgo de suicidio adolescente y la localidad en países como estados unidos, china, sudáfrica y jamaica (7, 30, 35, 36); sin embargo, esta investigación arroja que no existe relación con estos hallazgos (f = 0,024; p > 0,05), lo que coincide con otros estudios nacionales e internacionales (27, 31-33). al hablar de género se establece que las mujeres, casi sin excepción, poseen mayor riesgo de suicidio que los hombres en casi la totalidad de las investigaciones 168 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 (31, 40, 41, 42), resultados que son coincidentes con los nuestros (f = 17,861; p > 0,05). según el análisis de datos, no se observó ningún efecto de interacción significativo entre el género y la localidad (f = 2,305; p > 0,05), resultado que es concordante con otras investigaciones a nivel nacional (31, 42). conclusión el suicidio es un problema de salud pública mundial, el cual no se ha abordado de forma adecuada debido a la falta de sensibilización acerca de su importancia y por el tabú que lo rodea e impide que se hable abiertamente de ello. para generar un cambio social se requieren tres factores: conocimientos (tanto científicos como adquiridos mediante experiencias prácticas), apoyo público (voluntad política) y una estrategia social, como una respuesta nacional para alcanzar las metas de prevención del suicidio. existen diferentes factores de riesgo que aumentan la conducta suicida en los adolescentes, y nuestro estudio se enfocó en dos de ellos: la localidad y el género. los resultados obtenidos señalan que localidad –urbana o rural– no es un factor de riesgo para aumentar la probabilidad de intentar o consumar un suicidio en los adolescentes, situación análoga a otros estudios nacionales. además, existen investigaciones internacionales donde no se encontraron diferencias significativas entre la población urbana y rural para distintas conductas suicidas, por lo que pareciera ser que en occidente este factor no posee una fuerte influencia, situación que habría que seguir investigando. asimismo, sería importante conocer las características de la ruralidad de los diferentes países para realmente descartar este factor. es necesario mencionar que las diferencias en el riesgo de suicidio por género muestran una vez más que dicha conducta afecta en gran mayoría al sexo femenino, por lo que deberían existir programas de prevención ante el suicidio enfocados en el género, ya que los varones son menos propensos a intentar suicidarse, pero son más propensos a completar el suicidio que las adolescentes mujeres. las limitantes de este estudio fueron la dificultad para acceder a la aplicación del instrumento en los establecimientos educacionales urbanos, esto se asocia al tabú cultural que existe sobre este tema, el cual impide que se hable abiertamente de esto en público. otra limitación es la no existencia de estudios que comparen el riesgo de suicidio con el instrumento de screening de suicidalidad de okasha en adolescentes de localidades urbanas y rurales en chile. conflicto de interés: ninguno declarado. referencias 1. pan american health organization (paho). suicide mortality in the americas: regional report 2014. washington: pan american health organization; 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2) se trasforma (autocontrol del desarrollo y crecimiento), y 3) se resignifica (condensación); y cuatro factores condicionantes para la construcción del significado de calidad de vida para el cuidador como son el soporte social, la espiritualidad, la habilidad para cuidar y el tiempo. conclusiones: la calidad de vida se afecta y se reconstruye en virtud del significado que el cuidador tenga de esta. palabras clave calidad de vida; cuidadores; enfermería basada en la evidencia; metasíntesis (fuente: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 447-461 448 aquichan issn 1657-5997 eissn 2027-5374 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 447-461 quality of life of caregivers for the chronically ill abstract the high epidemiological, social, economic and cultural impact of chronic non-communicable diseases affects what quality of life means to those who suffer from such illnesses and their family caregivers. objective: describe how the quality of life of those who care for the chronically ill is constructed. method: sandelowski and barroso’s proposal for qualitative metasynthesis was used to develop the study. results: there are three moments in the process: 1) it is affected (programmed cell destruction), 2) transformed (self-control of development and growth) and 3) redefined (condensation). construction of the meaning of quality of life for the caregiver is conditioned by four factors: social support, spirituality, ability to care and time. conclusions: quality of life is affected and reconstructed by virtue of the meaning the caregiver assigns to it. keywords quality of life; caregivers; evidence-based nursing; metasynthesis (source: decs, bireme). 449 calidad de vida de los cuidadores de personas con enfermedad crónica l sonia patricia carreño-moreno y otro qualidade de vida dos cuidadores de pessoas com doença crônica resumo o alto impacto epidemiológico, social, econômico e cultural das doenças crônicas não transmissíveis afeta o significado de qualidade de vida nas pessoas que as padecem e em seus cuidadores familiares. objetivo: descrever a forma como se constrói o significado de qualidade de vida de cuidadores de pessoas com doença crônica. método: pesquisa desenvolvida com a proposta de metassíntese qualitativa de sandelowski e barroso. resultados: apresentam-se três momentos na trajetória: i) afeta-se (destruição celular programada); ii) transforma-se (autocontrole do desenvolvimento e crescimento) e iii) ressignifica-se (condensação); além disso, quatro fatores condicionantes para a construção do significado de qualidade de vida para o cuidador como são o suporte social, a espiritualidade, a habilidade para cuidar e o tempo. conclusões: a qualidade de vida é afetada e reconstruída em virtude do significado que o cuidador tenha desta. palavras-chave cuidadores; enfermagem baseada na evidência; metassíntese; qualidade de vida (fonte: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 447-461 450 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 introducción la enfermedad crónica ha generado un gran impacto epidemiológico, social y económico en el mundo (1), con consecuencias no solo en la salud pública sino en la calidad de vida de las personas que la padecen y sus cuidadores familiares. existen múltiples abordajes frente a la problemática de las enfermedades crónicas no transmisibles (ecnt) desde las diferentes disciplinas; en enfermería, además del abordaje fisiopatológico de la enfermedad crónica como problema de salud pública, es imperante el abordaje de la cronicidad como parte de la experiencia humana de las personas que la padecen y, en particular, su cuidador familiar (2, 3). el diagnóstico de enfermedad crónica trae consigo diferentes niveles de dependencia para quien la padece, además de implicaciones a nivel psicológico, social y espiritual que fundamentan la importancia de abordar la enfermedad más allá de sus implicaciones orgánicas (4). ante esta situación, surge la figura de cuidador familiar como aquella persona que, por parentesco o afinidad, asume las responsabilidades de cuidado de su ser querido, siendo partícipe de su asistencia, su experiencia vivida y su toma de decisiones (5). el cuidador debe modificar su vida cotidiana para asumir la labor de cuidado, lo que trae consigo preocupación, estrés, gastos extra, autoabandono, abandono laboral, afecciones de salud, aislamiento social, entre otras (6, 7). estas modificaciones generan periodos de crisis que han sido denominados síndrome de agotamiento, síndrome de sobrecarga del cuidador o síndrome del cuidador (8-10), lo que por ende afecta la forma como percibe, vive y significa su calidad de vida. la calidad de vida se ha entendido como la búsqueda de lo bueno y se ha configurado como un concepto multidimensional y dinámico, en el que son clave las condiciones de vida y la satisfacción experimentada, las cuales son ponderadas en una escala de valores, aspiraciones y expectativas personales (2). en el caso particular de los cuidadores familiares de personas con enfermedad crónica, el concepto comparte múltiples elementos, destacándose el bienestar emocional, las relaciones interpersonales, el desarrollo personal, las necesidades materiales, los derechos, la autodeterminación e inclusión social (11, 12), la satisfacción de necesidades (13), además del bienestar propio y de la persona cuidada (14). estudios acerca del tema han mostrado que la mayoría de cuidadores familiares son mujeres, que ven su calidad de vida afectada en virtud del malestar emocional, físico y económico derivado de su nuevo rol como cuidadoras (15, 16), lo que evidencia un nivel leve a moderado de sobrecarga del cuidador (17-19), que se manifiesta con la aparición de problemas físicos como algias musculares y dolor, y problemas psicosociales como irritabilidad, ansiedad y depresión (20). además, en algunos casos el nivel de apoyo social y familiar se percibe como insuficiente hasta llegar a una condición denominada invisibilidad del cuidador (21), lo que pone de manifiesto en el cuidador la necesidad imperante de soporte social, estatal y familiar. de esta forma, el fenómeno de calidad de vida se constituye en un foco de interés para la disciplina de enfermería y, en este caso, por la implicación que tiene en el mejor bienestar en la cronicidad. dado lo anterior, la pregunta orientadora de esta investigación fue: ¿cómo es el significado que dan los cuidadores familiares de personas con enfermedad crónica a su calidad de vida?, en donde se buscó describir la forma como se construye aquel significado, a fin de aportar al conocimiento que puede ser una guía para la intervención basada en investigación. con la revisión del área temática de estudio se identificó un vacío investigativo en el campo de enfermería basada en la evidencia (ebe) (22, 23), ya que en la búsqueda en la literatura no se encontraron estudios enmarcados en este movimiento en el área de interés, y el estatus de generación de conocimiento derivado de investigación con abordaje cualitativo era amplio; por esta razón, se determinó la oportunidad de elaborar una metasíntesis cualitativa en el fenómeno de estudio. metodología para este estudio se revisaron diferentes métodos propuestos para la elaboración de metasíntesis, entre ellas la de noblit y hare (24), paterson et al. (25), estrabooks et al. (26), jensen y allen (27) y sandelowski y barroso (28); siendo este último el método seleccionado. la metasíntesis, un término enmarcado en la ebe, ha sido utilizada por diferentes autores para referirse a la integración de hallazgos derivados de investigación cualitativa, entendida como un “estudio de estudios” que procura elevar el nivel de evidencia científica (29). esta representa para las autoras del 451 calidad de vida de los cuidadores de personas con enfermedad crónica l sonia patricia carreño-moreno y otro método seleccionado, las teorías, narrativas globales, generalizaciones o traducciones interpretativas que integran o comparan hallazgos con el fin de crear representaciones interpretativas de estos (30-32). para el proceso de metasíntesis cualitativa, se inició por la selección de la pregunta de investigación, la que por constituirse en un estudio de ebe se formuló en el formato picot (33, 34), siendo pcuidador familiar, ide personas en situación de enfermedad crónica, csignifican, osu calidad de vida, testudios de 1997 a 2012. se realizó un muestreo basado en criterios de inclusión como: artículos publicados en revistas indexadas y tesis de maestría o doctorado, que abordaran el fenómeno de interés y que se hubieran publicado en los últimos 15 años (1997-2012); los criterios de exclusión fueron: artículos de revisión, investigaciones con falencias éticas y artículos con datos aislados o sin interpretación por parte del investigador primario. estos criterios fueron formulados de acuerdo con lo establecido por las autoras del método seleccionado (35, 36). para la búsqueda de la muestra se exploró en bases de datos como cinhal, science direct, lilacs, ebsco, scielo, entre otras, con los siguientes descriptores: calidad de vida, cuidadores, dimensión espiritual, dimensión psico lógica, dimensión social, dimensión física, espiritualidad, en donde se encontraron 52.666 artículos, de los cuales se seleccionaron 24 reportes de investigación cualitativa con diferentes metodologías ampliamente aceptadas por la comunidad científica, como fueron teoría fundamentada, fenomenología, etnografía, entre otros. con el fin de verificar la calidad de los artículos por seleccionar, estos pasaron por un proceso de lectura crítica en donde se estableció la pertinencia de incluirlos en la metasíntesis (37). de los artículos seleccionados, doce eran reportados en idioma inglés y dos en portugués, por lo que fue necesario someterlos a traducción por traductores oficiales con el fin de mantener al máximo la fidelidad a lo presentado por los investigadores primarios. ya seleccionada la muestra, se procedió a iniciar el proceso de síntesis de los hallazgos. para ello fue útil la herramienta informática atlas ti versión 6.0, la cual facilitó el manejo de los datos. el proceso de metasíntesis se dio a partir de la creación de una taxonomía de los hallazgos etiquetados con códigos, agrupados en categorías y variables y estas últimas en un planteamiento central que explicó los datos, sus propiedades teóricas y la variabilidad del fenómeno (38). para el presente reporte científico se presentan los resultados producto de la comparación constante, los cuales mostraron la trayectoria de la calidad de vida y se expresaron a través de la diagramación del fenómeno (39-41). en la tabla 1 se relacionan los estudios primarios incluidos en la metasíntesis. tabla 1. estudios primarios incluidos en la metasíntesis n ubicación país participantes método 1 melin-johansson c, axelsson b, danielson e. caregivers' perceptions about terminally ill family members' quality of life. eur j cancer care. 2007;16(4):338-45. suecia 4 cuidadores principales de personas con enfermedad crónica terminal análisis de contenido 2 santiago m, monte m, alburquerque m, souza j, da costa l, elpidio f. qualidade de vida do cuidador de crianças com paralisia cerebral. revista brasileira em promoção da saúde. 2008; 21(4): 275-280. brasil 8 cuidadores de niños con parálisis cerebral análisis de contenido 3 davis e, shelly a, waters e, boyd r, cook k, davern m, reddihough d. the impact of caring for a child with cerebral palsy: quality of life for mothers and fathers. child care health dev. 2010;36(1):63-73. australia 24 madres y 13 padres de niños con parálisis cerebral teoría fundamentada 452 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 n ubicación país participantes método 4 williams j, skirton h, paulsen j, tripp-reimer t, jarmon l, mcgonigal m et al. the emotional experiences of family carers in huntington disease. j adv nurs. 2009;65(4):789-98. usa 42 cuidadores de personas con enfermedad de huntington análisis de contenido 5 bergs d. "the hidden client" women caring for husbands with copd: their experience of quality of life. j clin nurs. 2002;11(5):613-21. islandia seis cuidadoras de pacientes con epoc fenomenología 6 green t, king k. green, theresa l. experiences of male patients and wife-caregivers in the first year postdischarge following minor stroke: a descriptive qualitative study . int j nurs stud. 2009 sep;46(9):194-200. canadá 26 cuidadoras de pacientes con accidente cerebrovascular análisis de contenido 7 vellone e, piras g, talucci c, cohen mz. quality of life for caregivers of people with alzheimer's disease. j adv nurs. 2008;61(2):222-31. italia 32 cuidadores de pacientes con alzheimer fenomenología 8 gallop k, wild d, verdian l, kerr m, jacoby a, baker g et al. lennox-gastaut syndrome (lgs): development of conceptual models of health-related quality of life (hrql) for caregivers and children. seizure. 2010;19(1):23-30. reino unido 40 padres de niños con síndrome de lennox-gastaut descriptivo 9 murphy n, christian b, caplin d, young p. the health of caregivers for children with disabilities: caregiver perspectives. child care health dev. 2007;33(2):180-7. usa 40 cuidadores de niños con discapacidad fenomenología 10 molassiotis a, wilson b, blair s, howe t, cavet j. living with multiple myeloma: experiences of patients and their informal caregivers. support care cancer. 2011;19(1):101-11 inglaterra 16 cuidadores de personas con mieloma múltiple descriptivo 11 pereira h, rebelo botelho ma. sudden informal caregivers: the lived experience of informal caregivers after an unexpected event. j clin nurs. 2011;20(1718):2448-57. portugal 14 cuidadores de personas con enfermedad crónica fenomenología 12 lane p, mckenna h, ryan a, fleming p. the experience of the family caregivers' role: a qualitative study. res theory nurs pract. 2003;17(2):137-51. irlanda 10 cuidadores de personas mayores descriptivo 13 sánchez b. la experiencia de ser cuidadora de una persona en situación de enfermedad crónica. investigación y educación en enfermería. 2001;19 (2): 36-49. colombia 18 cuidadoras de personas con enfermedad crónica fenomenología 14 portillo c, wilson j, saracibar i. estudio desde la percepción de pacientes y familiares del proceso de participación informal en el cuidado después de un ictus: metodología y primeros resultados. enfermería clínica. 12(3): 94-103. españa 14 cuidadores de personas que habían sufrido un ictus análisis de contenido 453 calidad de vida de los cuidadores de personas con enfermedad crónica l sonia patricia carreño-moreno y otro n ubicación país participantes método 15 algado t, basterra a, garrigos i. familia y enfermedad de alzheimer. una perspectiva cualitativa. anales de psicología. 13(1):19-29. españa 20 cuidadores de personas con enfermedad de alzheimer descriptivo 16 de la cuesta c. “estar tranquila”. la experiencia de descanso de cuidadores de pacientes con demencia avanzada. enfermería clínica. 2009; 19(1): 24-30. españa 17 cuidadoras de personas con demencia avanzada teoría fundamentada 17 iost s, coelho l, manara v, de souza f, zazzetta m, alves c et al. cuidando de idosos com alzheimer: a vivência de cuidadores familiares. revista electrónica de enfermagem. 2008;10(3):80-90. brasil 14 cuidadores de personas con demencia análisis de contenido 18 gil e, escudero m, prieto m, frias a. vivencias, expectativas y demandas de cuidadoras informales de pacientes en procesos de enfermedad de larga duración. enfermería clínica. 15(4): 220-226. españa 8 grupos focales, 8 entrevistas en profundidad a cuidadores de personas con enfermedades crónica análisis de contenido 19 bover a. el impacto de cuidar en el bienestar percibido por mujeres y varones de mediana edad: una perspectiva de género. enfermería clínica. 2006; 16(2): 69-76. españa 10 cuidadores de personas con enfermedad crónica posfeminista 20 alvarado a. adquiriendo habilidad de cuidado: “de la incertidumbre al nuevo compromiso”. bogotá; universidad nacional de colombia; 2006. colombia 11 cuidadores familiares con personas con enfermedad crónica teoría fundamentada 21 brewin a. the quality of life of carers of patients with severe lung disease. br j nurs. 2004;13(15):906-12. reino unido 7 cuidadores de personas con enfermedad pulmonar grave fenomenología 22 gómez m. estar ahí, al cuidado de un paciente con demencia. investigación y educación en enfermería. 2007; 25 (2); 60-71. colombia 22 cuidadores de personas con demencia teoría fundamentada resultados se evidencia que la percepción de calidad de vida del cuidador se expresa en virtud de su significado. así mismo, se observa un fenómeno dinámico y cambiante que no puede definirse de forma absoluta en el tiempo, pues a su paso por diferentes estadios derivados de factores condicionantes y predisponentes se afecta, se transforma y se resignifica. de esta manera se abre paso una trayectoria que inicia con el diagnóstico de enfermedad crónica, pasa por una imposición del rol de cuidador y va evolucionando en la organización y reflexión ante este. el cuidador familiar inicia esta experiencia con un significado de su propia calidad de vida, el cual pasa por diferentes transiciones, en un primer momento muy inestables, y posteriormente cada vez más organizadas, lo que hace que la percepción de la propia calidad de vida sea progresivamente más estable (figura 1). los resultados y el diagrama muestran la metáfora de la apoptosis, en donde se reconoce que la trayectoria de la calidad de vida en los cuidadores de personas con enfermedad crónica pasa por tres momentos: 1) se afecta (destrucción celular programada): crisis, distorsiona la realidad, genera inestabilidad y pone en riesgo de vulnerabilidad al cuidador familiar; 2) se trasforma (autocontrol del desarrollo y crecimiento): mecanismos de 454 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 adaptación, rutinización y organización; 3) se resignifica (condensación): surge la introspección mediante la reflexión. esto permite ver que el significado de calidad de vida es dinámico, pues en ningún caso vuelve a ser el mismo previo al diagnóstico de enfermedad crónica y al momento de asumir el rol de cuidador. existen cuatro factores condicionantes que son transversales a toda la experiencia de cuidar a una persona con enfermedad crónica y son determinantes: la habilidad de cuidado, la espiritualidad, el soporte social y el tiempo (transiciones). momento 1. se afecta la calidad de vida (destrucción celular programada) al inicio de la experiencia el cuidador está sumido en una crisis profunda que se deriva de la percepción de adversidad, vulnerabilidad, cansancio y desorientación. para él, es común vivir en una continuidad de sentimientos adversos como miedo, ansiedad, impotencia, incertidumbre, tristeza, soledad, frustración, rabia y culpa, los que a medida que la experiencia avanza pasan por momentos de ambigüedad, de una parte, como expresión de su cansancio e incertidumbre y, de otra, derivados de la satisfacción por la vivencia de esta experiencia al lado de la persona que ama. los sentimientos evolucionan hasta llegar a convertirse en una gran satisfacción, sosiego y felicidad (42-47). una expresión de la calidad de vida es la percepción de cansancio, la cual en un primer momento se manifiesta como dolencias físicas tales como mialgias, cefalea, malestares estomacales, trastornos menstruales y del sueño. posteriormente, con la adaptación y organización, además de la solicitud de ayuda, el cansancio va disminuyendo hasta desaparecer con el establecimiento paralelo de rutinas de autocuidado y de relevo. pero el cansancio no es solo físico, también es social, psicológico y espiritual, el cuidador se cansa de la monotonía, de no recibir ayuda, de no contar con el dinero suficiente para manejar aspectos de su vida, de asumir los aspectos de la vida de otro hasta llegar incluso en algunos casos a responder por dos hogares simultáneamente. estas formas de cansancio también responden a factores como la ayuda tangible y evolucionan hacia formas de satisfacción de diferentes necesidades del cuidador (48-53). momento 2. se transforma (autocontrol del desarrollo y crecimiento) la aceptación de su rol, aunque no sea percibido de forma literal como una imposición, da inicio a la invisibilidad del cuidador. el ser considerado y considerarse a sí mismo como la persona más idónea para realizar la labor de cuidar, redunda en su propia capacidad y se extralimita al intentar asumirlo todo solo. además, sentimientos como el temor y garantizar su idoneidad como cuidador genera la exclusividad que redunda directamente en que se afecte la calidad de vida, por percibir abandono y baja percepción del apoyo familiar y social. otro de los factores que se ve afectado es el ámbito laboral; el cuidador, que en un principio cuenta con un empleo o deriva su sustento económico de alguna actividad, empieza a ver afectada su disponibilidad para estas actividades viéndose afectado económicamente. esta afección económica va en aumento, pero puede transformarse en iniciativas de autosostenibilidad derivadas de actividades domésticas alternas o de acciones desarrolladas con sus redes de apoyo (47, 52-55). momento 3. se resignifica (condensación) el cuidador familiar desarrolla todas sus labores de cuidado en virtud de las necesidades de su ser querido, es decir, estas se priorizan por encima de las demás, incluso las propias, lo cual está condicionado por el nivel de dependencia que va en aumento. a mayor permanencia en el cuidado, la dependencia se va transformando en interdependencia, en donde la persona con ecnt depende para sus cuidados del cuidador, pero a su vez el cuidador depende de la persona con ecnt como parte irreemplazable de su diario vivir. sin embargo, con la disponibilidad de más tiempo para reflexionar hay un paso de la interdependencia al vínculo genuino, en donde el cuidador, al reconocer sus propias necesidades y la importancia del fortalecimiento del autocuidado, la autodeterminación y la autonomía en la persona con ecnt, permite que esta sea cada vez más independiente o, en su defecto, permite que otros le releven, lo que le proporciona más tiempo para satisfacer sus necesidades propias (45, 48, 49-52). a partir del reconocimiento de la necesidad de ayuda y la solicitud de la misma, además de la capacitación y la organización, el cuidador inicia un proceso de autorreconocimiento con proyección hacia su entorno, que le permite ser visible e incluso apoyar a otros en el proceso (42, 49-56). factores condicionantes de la calidad de vida la habilidad para cuidar es una condición que tiene antecedentes en el cuidador en su misma condición humana. sin em455 calidad de vida de los cuidadores de personas con enfermedad crónica l sonia patricia carreño-moreno y otro bargo, con el inicio de la experiencia de cuidado, se empieza a transitar por un camino inexplorado, el cual en sus comienzos se traduce en una serie de percepciones adversas derivadas de la desinformación, pero poco a poco, con la disponibilidad de información, de soporte social, con la experiencia misma y la disposición para aprender, va tomando una forma más estructurada hasta convertirse en un factor potenciador de capacidades en el cuidador y modulador de las crisis que se puedan presentar. de esta forma, la habilidad de cuidado va en aumento durante toda la experiencia de atención, la cual se define no solo por la capacidad de aplicar técnicas correctas, sino por aprovechar todas las oportunidades para hacer de esta una experiencia que permita la trascendencia de ser humano (42, 49, 50, 52, 55, 57). la espiritualidad se configura en un elemento presente en todo momento, entendida no solo como la conexión con un ser superior, sino como la capacidad de otorgar significado a las experiencias de vida, de comunicarse con su ser interior y trascender en medio de la adversidad. la percepción de caos y todo lo que ella conlleva para la calidad de vida del cuidador, es significada a través del lente de la espiritualidad. esta permea la experiencia haciéndola valiosa y sostenible a partir de la satisfacción del deber cumplido. la espiritualidad abre un espacio para la reflexión y la resignificación, lo que otorga al cuidador la oportunidad de cuestionarse acerca de su propia vida, en donde descubre que lo que se inició como una vicisitud, una obligación o un deber moral, es ahora una experiencia que lo insta a explorar su esencia, a conectarse consigo mismo, con su fuerza interior, con la naturaleza y con su ser superior en un proceso de representación del cuidado y la cronicidad. esta nueva perspectiva condiciona una reestructuración de la vida a través del cuidado (42, 45, 48-50, 54, 55, 58, 59). el soporte social aparece en diferentes momentos de la experiencia, al inicio como soporte instrumental, dadas las necesidades de información por parte del cuidador y luego como soporte emocional y espiritual, condicionando a su presencia transiciones entre diferentes momentos del cuidado. para el cuidador, quien en un principio se encuentra en una situación caótica, la disponibilidad de soporte instrumental da paso a la organización de rutinas de cuidado, las cuales le permiten tener una mayor percepción del control sobre el tiempo y las actividades, lo que se traduce en una mejora de su calidad de vida (42, 45, 46, 48, 49, 50-52, 55, 60). el tiempo también es un condicionante, el cual no puede definirse a partir de un estándar, pero sí puede visualizarse a través de la trayectoria y de todas las experiencias vividas en su transcurrir. al final de la experiencia, y si se dieron las condiciones necesarias para organizarse y reflexionar ante el rol, el cuidador mira hacia atrás, los momentos vividos, los aprendizajes adquiridos y el cambio en su vida, se aferra a la espiritualidad y a través de ella entiende que su vida se transformó, al igual que sus planes y sus expectativas. comprende que él también tiene necesidades, que existen otras personas que son capaces y pueden capacitarse para relevarlo con alguna frecuencia en sus actividades diarias de cuidado, además se muestra dispuesto a ofrecer capacitación, pues sabe que necesita tiempos de descanso a solas en los que pueda intensificar su autocuidado, el cual debe desarrollar en todo momento. el tiempo disponible para descansar le permite reencontrarse con su ser social, recuperar amigos e incluso hacer otros nuevos en el rol de cuidador (42, 47, 48, 55, 61, 62). discusión los hallazgos reportados por esta investigación poseen un alto nivel de evidencia científica puesto que son resultado de una metasíntesis. de la misma manera, dichos hallazgos son congruentes con otras investigaciones que abordan el fenómeno de interés. el proceso de resignificación de la calidad de vida demuestra que es un elemento muy arraigado al proceso de vivir y a las circunstancias del contexto en el que el cuidador se desarrolla. esto significa que indudablemente se tiene una calidad de vida diferente en cada momento especial de la vida, incluso en el que se debe cuidar una persona con ecnt (60). las investigaciones cualitativas posteriores al presente estudio, que buscaron conocer el impacto de la calidad de vida de los cuidadores confirma los hallazgos al encontrar que es una experiencia que afecta la salud del cuidador; así, se habla ahora de los conceptos de salud física, psicológica, mental, espiritual, social, financiera y de la vida diaria, lo que confirma la multidimensionalidad del fenómeno y la existencia de etapas y momentos a lo largo del tiempo. sin embargo, hablar de calidad de vida con los cuidadores familiares no es fácil, de hecho, el concepto no es claro para ellos, por lo que es necesario abordar la forma como han afrontado la experiencia y les haya afectado (63). en el primer momento de caos en el que se afecta la calidad de vida se manifiestan sentimientos de adversidad derivados del enfrentamiento de una situación nueva e inesperada (64-66); se muestra un cambio de planes en la vida del cuidador, lo que 456 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 genera sentimientos de frustración (12, 64). además, hay una percepción de miedo o de impotencia ante la sintomatología presentada por la persona con enfermedad crónica. de esta manera, es común que haya temor hacia la muerte, angustia, desesperanza, rabia y soledad (63, 67, 68). por otra parte, se muestra que el cuidar a una persona con ecnt genera una nueva forma de afrontar las relaciones familiares, donde se incluyen aspectos y, por tanto, sentimientos positivos y negativos. se muestra cómo la ambigüedad es una condición común en el cuidador (69, 70). lo que caracteriza este primer momento es sin duda la afectación física, psicológica y económica del cuidador, manifestada en el cansancio (71, 72). la asistencia directa es una de las causantes, sumada a actividades domésticas e incluso de índole económico (se administran los bienes de la persona con ecnt) (63). este cansancio se reporta con insomnio, dolor de espalda, aislamiento social, entre otros (8, 73). todos estos elementos se relacionan con la sobrecarga del cuidador, la cual está asociada en parte al tiempo de cuidado (74). en un segundo momento, los estudios reportan que la priorización de necesidades del ser cuidado por encima de otras afecta el tiempo de ocio con ocasión de su rol (75), restringe el tiempo para las actividades propias (63, 76) y genera dependencia de la persona con ecnt (77). el proceso de asumir el rol está muy relacionado con el género; aunque en esta investigación no se hizo explícito el género predominante de cada reporte, se asocia a características como el ser mujer o la relación directa con el cuidado (disponibilidad para cuidar) (76) y a la cultura latina (64). en el tercer momento, es indiscutible la afectación que sufre el cuidador como consecuencia del poco tiempo disponible para desarrollar sus actividades laborales previas (64, 78). es común que el cuidador dependa económicamente de otros miembros de su red social inmediata (63), aunque en algunos estudios se reporta que la búsqueda de una actividad alterna o empleo podría constituirse en un factor protector de la carga, ya que el cuidador sale de la monotonía (70). el proceso de la interdependencia resulta interesante en esta etapa, lo que concuerda con los resultados encontrados en cuidadores de personas con esquizofrenia (79), en donde no se reporta relación entre el nivel de dependencia y la calidad de vida, lo que significa que la funcionalidad de la persona con ecnt quizás no modifica el significado de calidad de vida, porque se va transformando y organizando mejor el rol del cuidador. en cuanto a los factores condicionantes, la habilidad de cuidado ha sido ampliamente estudiada en los cuidadores familiares, evidenciándose que aumenta ante factores como el soporte social y el tiempo transcurrido (80). en esta investigación se reporta un aumento progresivo de la habilidad de cuidado a medida que la experiencia se desarrolla con el paso del tiempo, lo que es congruente con lo reportado en la literatura (81, 82). la espiritualidad ha sido objeto de estudio central en el abordaje de cuidadores de personas con ecnt ya que se convierte en un factor determinante para el afrontamiento de la experiencia, lo que algunos reportan como “la lucha de la vida” (64). gran parte de la literatura reporta un fortalecimiento de la espiritualidad en la experiencia de la cronicidad, factor que promueve la calidad de vida del cuidador familiar por estar relacionado con el sentido de la enfermedad para el paciente y para el cuidador (63); sin embargo, es un elemento susceptible de afectarse a lo largo de la trayectoria (83). además, se reporta una equiparación de la espiritualidad con los valores, las creencias y lo moralmente aceptado (84), todos estos factores que promueven el mantenerse en el rol de cuidador. el soporte social se evidencia como una necesidad de los cuidadores familiares y un elemento que proporciona información, capacitación y apoyo al cuidador familiar. se reporta que este componente es importante para disminuir la sobrecarga (65) y mejora el proceso de adquisición de habilidades para cuidar (84). la intervención en soporte social con tecnologías de la información y la comunicación ha evidenciado ser efectiva y positiva para la mayoría de cuidadores familiares, particularmente en la guía, información e interacción personal (85). conclusiones la reconstrucción del significado de calidad de vida es un proceso que responde a los factores condicionantes mencionados, por lo que no todos los cuidadores avanzan hacia formas de organización y reflexión; por esta razón, es necesario en primera instancia que los cuidadores comprendan las implicaciones de esta compleja experiencia y, además, que los miembros del equipo de salud, principalmente la enfermera, movilicen acciones y 457 calidad de vida de los cuidadores de personas con enfermedad crónica l sonia patricia carreño-moreno y otro estrategias sobre los factores condicionantes con el fin de apoyar al cuidador familiar de forma tal que cuente con las condiciones necesarias para vivir esta experiencia, para mantenerse en ella y para reconstruir el significado de su calidad de vida. la percepción de calidad de vida del cuidador familiar es un proceso que depende del significado que esta contenga durante toda la experiencia de cuidado, lo que tiene como factor condicionante el tiempo. la percepción de calidad de vida, y con ella el significado que le otorga el cuidador familiar, responden a diferentes momentos en el tiempo transcurrido en la experiencia, durante el cual hay un proceso de introspección que implica transformación de los seres humanos involucrados. los factores que condicionan las transiciones de la percepción y el significado de calidad de vida para el cuidador familiar son la habilidad de cuidado, la espiritualidad, el soporte social y el tiempo. el significado de calidad de vida cambia con el transcurso del tiempo de cuidado: es uno previo al diagnóstico de ecnt, lo que determina el inicio del rol de cuidador, y es otro a través de cada transición, hasta llegar a reconstruirse gracias al ejercicio del cuidado y estructurarse en el cuidado mismo. existen tres momentos dentro de la experiencia de ser cuidador que reflejan el significado de calidad de vida: el inicio donde se afecta la calidad de vida; el segundo momento, de transformación, y el tercer momento, de resignificación. los hallazgos reportados en esta investigación se constituyen en evidencia científica actual que aporta al ejercicio de la enfermería basada en la evidencia. entre las limitaciones del estudio está la falta de discriminación de grupos de cuidadores, lo que afecta los resultados al no conocer trayectorias específicas por enfermedades crónicas. figura 1. diagramación 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their informal caregivers. support care cancer. 2011;1(19):101-11. 51. portillo m, wilson j, saracibar i. estudio desde la percepción de pacientes y familiares del proceso de participación informal en el cuidado después de un ictus: metodología y primeros resultados. enferm clin. 2002;12(3):94-103. 52. algado t, basterra a, garrigos i. familia y enfermedad de alzheimer. una perspectiva cualitativa. an psicol spain. 1997;13(1):19-29 53. iost s, coelho l, manara v, et al. cuidando de idosos com alzheimer: a vivência de cuidadores familiares. revista electrónica de enfermagem. 2008;10(3):58-90. 54. gallop k, wild d, verdian l, et al. lennox-gastaut syndrome (lgs): development of conceptual models of health-related quality of life (hrql) for caregivers and children. seizure. 2010;1(19):23-30. 55. alvarado a. adquiriendo habilidad de cuidado: “de la incertidumbre al nuevo compromiso”. bogotá; universidad nacional de colombia; 2006. 56. johansson c, axelsson b, danielson e. caregivers’ perceptions about terminally ill family members’ quality of life. eur j cancer care. 2007;16(4):338-45. 57. williams j, skirton h, paulsen j, et al. the emotional experiences of family carers in huntington disease. j adv nurs. 2008;65(4):789-98. 58. murphy n, christian b, caplin d, et al. the health of caregivers for children with disabilities: caregiver perspectives. child care health dev. 2007;33(2):180-7. 59. gil e, escudero m, angeles m, et al. vivencias, expectativas y demandas de cuidadoras informales de pacientes en procesos de enfermedad de larga duración. enferm clin. 2005;15(4):220-26. 60. brewin a. the quality of life of carers patients with severe lung disease. br j nurs. 2004;13(15):906-1005. 61. de la cuesta c. “estar tranquila”. la experiencia de descanso de cuidadores de pacientes con demencia avanzada. enferm clin. 2009;19(1):24-30. 62. bover a. el impacto de cuidar en el bienestar percibido por mujeres y varones de mediana edad: una perspectiva de género. enferm clin. 2006;16(2):69-76. 63. lee g, ow m, akhileswaran r, pang g, fan g, goh b, et al. quality of life domains important and relevant to family caregivers of advanced cancer patients in an asian population: a qualitative study. qual life res. 2015;24(4):817-28. doi: 10.1007/s11136-014-0832-3. 64. juárez g, branin j, rosales m. perceptions of qol among caregivers of mexican ancestry of adults with advanced cancer. qual life res. 2015;24(7):1729-40. 65. sánchez herrera b, chaparro l, carrillo gonzález gm. la carga del cuidado en la enfermedad crónica en la díada cuidador familiar-receptor del cuidado. investig enferm imagen desarr. 2016;18(2):43-60. 66. andrade s, alves r, melo m, rodrigues m. qualidade de vida e sobrecarga de cuidadores de crianças com câncer. psicol ciênc prof. 2014;34(4):1014-31. 461 calidad de vida de los cuidadores de personas con enfermedad crónica l sonia patricia carreño-moreno y otro 67. cabezas m, díaz m. nadie sabe cómo estoy por dentro. estudio acerca de la experiencia de ser cuidador de un paciente con cáncer. bogotá: universidad colegio mayor de cundinamarca; 2011. 68. klassen af, gulati s, granek l, rosenberg-yunger zr, watt l, sung l, klaassen r, dix d, shaw nt. understanding the health impact of caregiving: a qualitative study of immigrant parents and single parents of children with cancer. qual life res. 2012;21(9):1595-605. 69. shim b, barroso j, davis l. a comparative qualitative analysis of stories of spousal caregivers of people with dementia: negative, ambivalent, and positive experiences. int j nurs stud. 2012;49(2):220-9. doi: 10.1016/j.ijnurstu.2011.09.003. 70. barrera l, sánchez b, carrillo g. la carga del cuidado en cuidadores de niños con enfermedad crónica. rev cubana enfermer. 2013;29(1):39-47. 71. lenderking wr, mannix s, petrillo j, kenney c, landrian a, schrag ae. assessment of parkinson’s disease levodopainduced dyskinesia: a qualitative research study. qual life res. 2015;24(8):1899-910. 72. cardona d, segura a, berberí d, agudelo m. prevalencia y factores asociados al síndrome de sobrecarga del cuidador primario de ancianos. rev fac nac salud pública. 2013;31(1):30-9. 73. chen m, chen k, chu t. caregiver burden, health status, and learned resourcefulness of older caregivers. west j nurs res. 2015;37(6):767-80. doi: 10.1177/0193945914525280. 74. aubeeluck av, buchanan h, stupple ej. ‘all the burden on all the carers’: exploring quality of life with family caregivers of huntington’s disease patients. qual life res. 2012;21(8):1425-35. 75. schüz b, czerniawski a, davie n, miller l, quinn mg, king c, et al. leisure time activities and mental health in informal dementia caregivers. appl psychol health well being. 2015;7(2):230-48. doi: 10.1111/aphw.12046. 76. tellier m, rochette a, lefebvre h. impact of mild stroke on the quality of life of spouses. int j rehabil res. 2011;34(3):211-19. 77. romero r, losada a, marquez m, laidlaw k, fernández v, nogales c, et al. leisure, gender, and kinship in dementia caregiving: psychological vulnerability of caregiving daughters with feelings of guilt. j gerontol b psychol sci soc sci. 2014;69(4):502-13. doi: 10.1093/geronb/gbt027. 78. kavanaugh m, kramer b, walsh m, trentham-dietz a. factors contributing to economic burden in lung cancer spousal caregivers. palliat support care. 2015;13(3):691-700. doi: 10.1017/s1478951514000443. 79. suro g, weisman de mamani a. burden, interdependence, ethnicity, and mental health in caregivers of patients with schizophrenia. fam process. 2013;52(2):299-311. doi: 10.1111/famp.12002. 80. carrillo m, barrera l, sánchez b, carreño s, chaparro l. efecto del programa de habilidad de cuidado para cuidadores familiares de niños con cáncer. revista colombiana de cancerología. 2014;18(1):18-26. 81. carrillo m, sánchez b, barrera l. habilidad de cuidado de cuidadores familiares de niños con cáncer. rev salud pública. 2015;17(3):394-403. 82. gomez y, villareal g, baldovino k, madrid i, ordoñez l. habilidad del cuidador familiar y su relación con el tiempo de cuidado al adulto mayor con enfermedad crónica, sincelejo, colombia. revisalud unisucre. 2013;1(1):11-21. 83. montalvo a, romero e, flórez i. percepción de calidad de vida de cuidadores de niños con cardiopatía congénita en cartagena, colombia. invest educ enferm. 2011;29(1):9-18. 84. barrera l, carrillo g, chaparro l, sánchez b. modelo para abordar la carga del cuidado de la enfermedad crónica en colombia. orinoquia. 2015;19(1):89-99. 85. barrera l, carrillo m, chaparro l, pinto n, sánchez b. soporte social con el uso de tic’s para cuidadores familiares de personas con enfermedad crónica. rev. salud pública. 2011;13(3):446-57. 86. carreño m. metasíntesis de calidad de vida en cuidadores familiares de personas en situación de enfermedad crónica. tesis para optar el título de magíster en enfermería. bogotá: universidad nacional de colombia, facultad de enfermería; 2012. 05. una estrategia (42 a 47) año 3 nº 3 • bogotá, colombia octubre 2003 42 resumen durante un gran e importante espacio de la vida, todos los niños son acogidos por la escuela, tiempo en el cual las capacidades de desarrollo y acumulación de aptitudes y actitudes son fundamentales para la formación integral de la personalidad. la etapa de la niñez y la adolescencia es delicada y vulnerable, pues la población se encuentra en proceso de formación de hábitos, creencias y competencias, que permitirán desarrollar el propio concepto como persona y ciudadano. para el logro de este propósito es necesario un trabajo dinámico y permanente, a nivel interinstitucional y transdisciplinario, donde profesionales de la salud y la educación, familias, organizaciones comunitarias, autoridades estatales, el sector productivo y otros sectores de la sociedad trabajen unidos para ofrecer la mejor atención y cuidado a la población escolar. es así como los programas de salud escolar desarrollados en las instituciones de enseñanza pueden ayudar a los estudiantes a responder a esos riesgos, para lo cual deben plantear: una educación en estilos de vida saludable; acciones para el cuidado y protección de los niños y adolescentes, y mecanismos para la construcción de una verdadera cultura de la salud. para lograr un adecuado y completo programa de enfermería escolar, la promoción y la prevención deben considerarse como una estrategia fundamental e indispensable para el programa. la estrategia es un medio o instrumento para lograr los objetivos, que responden a la pregunta de cómo hacerlos. la estrategia exige la disposición de unos recursos y de las acciones para alcanzarlos. esto nos permite reconocer la importancia de considerar como tal la promoción y la prevención, pues refleja los elementos anteriormente expuestos y es oportuna para lograr la salud integral del escolar. palabras clave: salud, educación, escuela, comunidad educativa, escolares, adolescentes, estrategia, salud escolar, enfermería escolar. abstract during a large and important life stage, children go to school, developing capacities and attitudes basic for integral formation of the personality. the stage of childhood and adolescence is delicate, for the population in a process of habit, believes and competencies formation, to allow the development as person. to obtain this goal a dynamic and permanent work is necessary, at institutional and disciplinary work, in which health and education professionals, families, community organizations, state authorities, the productive sector and other sectors of society, work together to offer the best care to scholars. scholar health programs developed at educational institutions may help students to answer to risks, planning an education with a healthy way of life; actions for care and protection of children and adolescents and mechanisms for the construction of a true culture of health. to obtain an adequate and complete scholar nursing program, the promotion and prevention must be considered as an important strategy. the strategy is an instrument to reach the objectives, answering to the question of the adequate development. the strategy request the disposition of resources and actions to reach them. this allows us to recognize the importance of promotion and prevention, reflecting the above elements to obtain integral scholar health. palabras clave: health, education, school, educative community, scholars, adolescents, strategy, scholar health, scholar nursing. gloria patricia gallego de pardo enfermera. magíster en administración. docente de la facultad de enfermería, universidad de la sabana. una estrategia de enfermería escolar en la promoción de la salud y prevención de la enfermedad 43 niños, niñas y jóvenes colombianos en la declaración universal de derechos del niño se ha reconocido el derecho de los niños y los adolescentes a adquirir conocimientos y habilidades para la salud. en el desarrollo social de los niños, niñas y jóvenes influyen sus oportunidades educativas, su estado de salud, su entorno familiar y la comunidad donde viven. estos aspectos están interrelacionados, y como tales crean una alianza fundamental y eficaz, que permite dotar a los jóvenes de habilidades y oportunidades que les permitan llevar una vida productiva y satisfactoria1. la constitución política de colombia no es ajena a esta declaración, y para lograrlo ha experimentado profundos cambios en la últimas décadas. la carta magna de 1991 impuso, como un reto a todos los sectores del país, especialmente al educativo, la formación de personas integrales, saludables, felices, en permanente desarrollo, inteligentes, productoras de ciencia y tecnología2. nuestra población joven (niños y niñas entre los 5 y los 17 años) corresponde a cerca del 30% de la población total colombiana (40.214.723 en 1997), se encuentra especialmente ubicada en el sector urbano, el 50,9% del sexo femenino y el 49,1% del masculino, y la distribución entre los diferentes grupos de edad es equitativa. la mortalidad en este grupo es baja. los niños se enferman por causas que pueden prevenirse y por problemas de malnutrición, pero este último hecho lleva a que las vidas ganadas en la primera infancia no tengan la calidad que les permita el desarrollo de las potencialidades que de ellos se esperan. enfermería escolar en la formación durante la etapa escolar se encuentran especialmente comprometidos dos sectores, además de la familia: el de la salud y el de la educación; por ende, los profesionales de estas áreas tienen la responsabilidad de cumplir esta delicada tarea, a fin de lograr mejores oportunidades para la población de niños, niñas y jóvenes. hoy en día los niños y los jóvenes viven en un mundo complejo y cambiante, que a menudo los expone a riesgos significativos de salud. así, los programas de salud escolar desarrollados en las instituciones de enseñanza pueden ayudar a los estudiantes a responder a esos riesgos, para lo cual deben plantear: • una educación en estilos de vida saludable. • acciones para el cuidado y protección de los niños y adolescentes. • mecanismos para la construcción de una verdadera cultura de la salud. los niños y jóvenes que son sanos, física y emocionalmente, y que reciben su educación en un entorno adecuado, tienen más autoestima que aquellos que no poseen las mismas ventajas, les va mejor en la escuela y disfrutan de mejores relaciones con los demás. el bienestar de los niños es una obligación de la familia, pero también es una responsabilidad compartida de toda la comunidad y sus instituciones. la etapa de la niñez y la adolescencia es delicada y vulnerable, pues la población se encuentra en proceso de formación de hábitos, creencias y competencias, que le permitirán desarrollar su 1. st. leger, nuthbeam. promoción de la salud eficaz en los centros de enseñanza. la evidencia de la eficacia de la promoción de la salud, pág. 123. 2. república de colombia. constitución política de colombia,1991, arts. 44, 45, 49, 67. el bienestar de los niños es una obligación de la familia, pero también es una responsabilidad compartida de toda la comunidad y sus instituciones. la etapa de la niñez y la adolescencia es delicada y vulnerable, pues la población se encuentra en proceso de formación de hábitos, creencias y competencias, que le permitirán desarrollar su propio concepto como personas y ciudadanos. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 44 propio concepto como personas y ciudadanos. para el logro de este propósito es necesario un trabajo dinámico y permanente a nivel interinstitucional y transdisciplinario, donde profesionales de la salud y la educación, las familias, organizaciones comunitarias, autoridades estatales, el sector productivo y otros sectores de la sociedad, trabajen unidos para ofrecer la mejor atención y cuidado a la población escolar. durante un gran e importante espacio de la vida, todos los niños son acogidos por la escuela, tiempo en el cual las capacidades de desarrollo y acumulación de aptitudes y actitudes son fundamentales para la formación integral de la personalidad. en colombia, en este ámbito el niño pasa por las etapas de preescolar, escolar, pre-adolescente y adolescente. inicia la vida escolar alrededor de los cuatro años, con la educación básica, y termina hacia los 17 años la educación media. permanece más o menos trece años en la escuela, y a través de esta se tiene una relación directa con la familia del escolar; esto permite influir en los padres y las familias. la organización mundial de la salud (oms) manifiesta que las enseñanzas en salud siguen siendo pobres, a pesar de valiosos esfuerzos, situación que compromete a los profesionales de la salud a convertirse en verdaderos agentes para la salud. el agente de salud está llamado a fortalecer los estilos de vida saludable; así, debe poner énfasis en cuidar la salud, y ello ha de estimularse desde la más temprana infancia, en el seno de la familia y en la escuela, buscando fomentar la salud, pues es un bien imprescindible para la persona y un bien para la comunidad3. ante esta afirmación, podemos considerar que la enfermera es el profesional por excelencia que cuenta con la formación necesaria para desarrollar esta labor. su preparación le permite tener un manejo integral, para cuidar saludablemente a la persona, la familia y la comunidad, y en el caso de su desempeño dentro de una organización educativa, reconocida como lugar rentable para las intervenciones de promoción dirigidas a mejorar la salud de los niños y adolescentes, ella puede: • ofrecer conocimientos y cuidados en salud. • inculcar hábitos saludables en la población escolar. • contribuir a la formación de estilos de vida saludables en el niño y el adolescente. • fomentar en el niño, el adolescente y sus familias una cultura de salud. • colaborar en la creación o mejoramiento de ambientes saludables. • direccionar pautas de actuación para modelar temas implicados en las necesidades de salud. • llamar la atención sobre la problemática que en algún momento pueda sufrir esta población. • planear acciones en salud para los maestros y el personal escolar, que aumenten su bienestar, satisfacción y compromiso laboral. esta situación debe considerarse como una gran oportunidad y un reto para las enfermeras colombianas, pues les permitirá desarrollar un excelente trabajo en equipo, con docentes y administrativos de las instituciones educativas, siguiendo lo recomendado en el proyecto educativo institucional (pei). la promoción y la prevención, una estrategia fundamental en enfermería escolar para lograr un adecuado y completo programa de enfermería escolar, la promoción y la prevención deben considerarse como una estrategia fundamental e indispensable. la estrategia es un medio o instrumento para lograr los objetivos, pues responde a la pregunta de cómo alcanzarlos. la estrategia exige la disposición de unos recursos, y las acciones para lograrlos. esto nos permite reconocer la importancia de considerar como tal la promoción y la prevención, pues refleja los elementos anteriormente expuestos, y la oportunidad de lograr la salud integral del escolar. según la oms (1986), la promoción de la salud pretende capacitar a las personas, para incrementar el control sobre su salud y mejorarla. en la conferencia de ottawa se definieron cinco líneas esenciales para su acción en salud: 1. construir políticas saludables. 2. crear entornos favorables a la salud. 3. fortalecer la acción comunitaria. 4. desarrollar las habilidades personales. 3. st. leger, nuthbeam. op. cit., pág. 115. una estrategia de enfermería escolar en la promoción de la salud y prevención de la enfermedad 45 5. reorientar los servicios de salud. la promoción y la prevención se convierten en el eje fundamental de la reforma del sector salud, a través de la ley 100 de 1993, y su orientación es promover estilos de vida saludables, con la creación y fortalecimiento de condiciones ambientales en la familia, la escuela, el trabajo y la sociedad, adecuadas para el desarrollo integral, saludable y productivo de todos los colombianos. la promoción de la salud se debe iniciar en el interior de la familia, desarrollando habilidades personales en cada uno de sus miembros y estableciendo valores, que en los niños seguirán fortaleciéndose en las escuelas. las acciones de salud en las instituciones de enseñanza deben dirigirse básicamente a: 1. el desarrollo de habilidades personales. 2. la creación de entornos favorables a la salud. 3. la participación de la acción comunitaria. por lo tanto, es imprescindible la escuela como espacio fundamental para el desarrollo de la estrategia de promoción y prevención, por la siguiente razón: la educación para la salud pretende que el hombre sea el protagonista de su propio destino, dándole las bases para que pueda elegir la salud como uno de los bienes más preciados. para ello hacen falta conocimientos (saber), formación de la personalidad (ser), poder elegir bien y renunciar a lo que pueda dañar (voluntad). toda acción educativa pretende fortalecer la voluntad. el desarrollo humano tiene cinco componentes estrechamente ligados: salud, educación, crecimiento económico, ambiente inocuo y sano y una gama de libertades, como la democracia y los derechos humanos. “la promoción de la salud se convierte en una estrategia que pretende enfrentar los desafíos de reducir la inequidad, incrementar la prevención y fortalecer la capacidad de las personas para hacer frente a sus problemas. el nuevo enfoque de la promoción de la salud representa un proceso que habilita a los sujetos para el mejoramiento y/o control sobre su salud, fortaleciendo el autocuidado, las redes de apoyo social, su capacidad de elección sobre las maneras más saludables de vivir y de creación de ambientes favorables a la salud”4. la promoción de la salud privilegia su actuar en los niveles locales, donde es posible conocer las verdaderas necesidades de los pobladores, sus recursos, actividades, aspectos sociales, económicos, políticos, culturales, éticos y religiosos. la escuela, la familia y el barrio o comunidad (área de influencia) son espacios que podrán articular acciones para construir una sociedad justa y, por lo tanto, se deben privilegiar y favorecer en este nivel. a henry sigerist, uno de los más brillantes salubristas de todos los tiempos, se le puede considerar también como precursor de las “escuelas saludables”, cuando en uno de sus tratados dice: “la escuela es una de las instituciones más importantes de salud pública”. una promoción de la salud eficaz en los centros de enseñanza deberá ser de amplio alcance en su concepto y contenido, y estar adecuadamente dotada de recursos. por lo general, supondrá el desarrollo de políticas y prácticas escolares que fortalezcan la enseñanza orientada a la salud en el plan de estudios. es necesario establecer fuertes conexiones con los padres y los servicios sanitarios, a la vez que se crea un entorno físico y psicosocial de apoyo5. como una recomendación de la oms, se ha desarrollado un programa en colombia, denominado “estrategia de escuelas saludables”, como una propuesta integradora que adelanta acciones de promoción en el entorno educativo, en la búsqueda del desarrollo sostenible de los escolares, mediante el impulso de habilidades, valores y destrezas, y la vinculación de diversos sectores y la comunidad educativa6. aunque las acciones de salud en el sector educativo se refieren a acciones formativas y de promoción y prevención, en el momento de implementarse muchas de ellas se encuentran íntimamente ligadas, pues la promoción y prevención necesariamente tienen un componente formativo. las acciones formativas hacen parte del proceso de aprendizaje durante el ciclo vital de la persona, para lograr un desarrollo integral humano, y las acciones de promoción y prevención buscan mejorar la calidad de 4. promoción de la salud: cómo construir vida saludable, pág. 62. 5. la evidencia de la eficacia en la promoción de la salud, pág. 115. 6. portafolio de servicios de la promoción de la salud. agosto de 2000. revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 46 vida, evitando que se produzcan alteraciones en la salud del escolar y el adolescente. a continuación se listan acciones de este tipo, que deben ser tenidas en cuenta en un programa de salud escolar: • valoración del crecimiento y desarrollo: práctica periódica de examen físico, control de peso y talla y seguimiento del desarrollo. • vacunación: una forma de prevenir enfermedades propias de la etapa escolar. • salud oral, visual y auditiva: complementan el control de crecimiento y desarrollo. • salud sexual y reproductiva: es una temática controvertida e interesante. el desarrollo de sus contenidos y el seguimiento en la población deben ser contemplados en forma especial. • servicios de alimentación o complementación alimentaria: deben tenerse en cuenta las deficiencias por micronutrientes y desparasitación. • servicios para estudiantes con discapacidades: novedosos y oportunos. • manejo de factores de riesgo ambiental: seguimiento de los panoramas de riesgos. • mejoramiento o creación de ambientes sanos y saludables: iluminación, aire, acústica, servicios sanitarios y otros servicios públicos, zonas de trabajo, descanso, recreación y alimentación. • identificación precoz de problemas de salud en el escolar y adecuada remisión para su solución. • salud integral, identificando factores protectores y de riesgo. • prevención de tabaquismo, cáncer, alcoholismo, uso de sustancias psicoactivas y desórdenes alimentarios. • prevención de desastres. • prevención de accidentes: tránsito, hogar y escuela. • educación ambiental: agua, desechos, recursos naturales. • derechos y deberes de los escolares, según la legislación vigente en salud. • salud ocupacional. conclusión no es nada nuevo considerar que todo lo que se haga en beneficio de la población joven redundará, en un futuro, en mejores condiciones sociales y económicas del país. lo que vale la pena destacar es cómo se debe hacer para tener la certeza de su beneficio. las intervenciones de promoción de la salud y prevención de la enfermedad bien diseñadas e implantadas, como estrategias en el campo de la salud escolar, realizarán una aportación significativa a la reducción de problemas sociales, que tienen impacto en un futuro cercano en la economía de las naciones. sin embargo, no se puede esperar que exclusivamente los centros educativos solucionen los problemas de salud y sociales, sin tener en cuenta las obligaciones de otros estamentos. una estrategia de enfermería escolar en la promoción de la salud y prevención de la enfermedad 47 bibliografía • calero, j. del rey; calvo, j. r. cómo cuidar la salud: su educación y promoción, españa, hacourt brace, 1998. • cerqueira, maría teresa. promoción de la salud y educación para la salud. retos y perspectivas, ops. • dnp, pnud. informe sobre desarrollo humano para colombia, bogotá, 1998. • restrepo, málaga. promoción de la salud: cómo construir vida saludable, bogotá, colombia, editorial médica panamericana, 2001. • la evidencia de la eficacia de la promoción de la salud. un informe de la unión internacional de promoción de la salud y educación para la salud para la comisión europea. editado por el ministerio de sanidad y consumo, madrid, 1999. • ley 100 de 1993. la seguridad social en colombia. • ley 115 de 1994. ley general de educación. • ley 60 de 1993. distribución de competencias y recursos. • lineamientos para la educación en estilos de vida saludables. proyecto educativo institucional, serie documentos de trabajo, ministerio de educación nacional, república de colombia, bogotá, 1997. • ministerio de salud, república de colombia. portafolio de servicios de la promoción de la salud en el municipio, bogotá, agosto de 2000. 43 55 relacao entre estresse percebido.indd 43 gabriela feitosa esplendori1 ana lúcia siqueira costa2 juliana nery de souza-talarico3 relação entre estresse percebido com coping e estressores de pacientes em pré-operatório de revascularização miocárdica 1 orcid.org/0002-7654-8676. universidade de são paulo, brasil. gfesplendori@prosangue.sp.gov.br 2 orcid.org/0000-0001-7830-9751. universidade de são paulo, brasil. anascosta@usp.br 3 orcid.org/0000-0001-8820-0725. universidade de são paulo, brasil. junery@usp.br recibido: 30 de noviembre de 2016 enviado a pares: 05 de diciembre de 2016 aceptado por pares: 4 de abril de 2017 aprobado: 25 de abril de 2017 doi: 10.5294/aqui.2018.18.1.5 para citar este artículo / to reference this article / para citar este artigo esplendori, gf., siqueira costa al., nery de souza-talarico, j. relação entre estresse percebido com coping e estressores de pacientes em pré-operatório de revascularização miocárdica. aquichan. 2018; 18(1): 43-55. doi: 10.5294/aqui.2018.18.1.5 resumo a doença coronariana destaca-se entre as doenças cardiovasculares ao vitimizar pacientes mundialmente. no período pré-operatório de cirurgia de revascularização miocárdica (crm), ocorre estresse. objetivo: verificar a relação entre estresse percebido com coping e com estressores de pacientes em pré-operatório de crm. materiais e método: abordagem quantitativa e transversal. compuseram a amostra 105 pacientes coronariopatas internados em hospital cardiológico. utilizaram-se escala de estresse percebido, inventário de estratégias de coping e duas perguntas abertas cujas respostas foram quantificadas e categorizadas. para análise dos dados, utilizou-se regressão linear multivariada. resultados: maior estresse percebido relacionou-se com maior fuga e esquiva (β = 0,416, p < 0,001), maior confronto (β = 0,353, p = 0,001), menor autocontrole (β = –0,226, p = 0,024), sexo feminino (β = –0,173, p = 0,048) e “sintomas clínicos” (β = 0,235, p = 0,015). “procura por ocupar a mente” (β = –0,196, p = 0,047) e “enfrentar a cirurgia como instrumento de melhora/cura” (β = –0,255, p = 0,009) relacionaram-se com menor estresse percebido. conclusões: o estresse percebido sofre variabilidade de acordo com determinados estressores e coping. tais relações devem ser consideradas para o planejamento da assistência de enfermagem a fim de reduzir o estresse pré-operatório de pacientes coronariopatas. palavras-chave adaptação psicológica; cirurgia torácica; estresse psicológico; período pré-operatório; revascularização miocárdica (fonte: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 43-55 44 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 43-55 relación entre estrés percibido con coping y estresores de pacientes en preoperatorio de revascularización miocárdica resumen la enfermedad coronaria se destaca entre las enfermedades cardiovasculares al victimizar pacientes en todo el mundo. en el periodo preoperatorio de cirugía de revascularización miocárdica (crm), ocurre estrés. objetivo: averiguar la relación entre estrés percibido con coping y con estresores de pacientes en preoperatorio de crm. materiales y método: enfoque cuantitativo y transversal. la muestra se compuso de 105 pacientes coronariopatas internados en hospital cardiológico. se utilizaron escala de estrés percibido, inventario de estrategias de coping y dos preguntas abiertas cuyas respuestas fueron cuantificadas y categorizadas. para el análisis de datos, se utilizó regresión lineal multivariada. resultados: mayor estrés percibido se relacionó con mayor escape y esquiva (β = 0,416, p < 0,001), mayor afrontamiento (β = 0,353, p = 0,001), menor autocontrol (β = –0,226, p = 0,024), sexo femenino (β = –0,173, p = 0,048) y “síntomas clínicos” (β = 0,235, p = 0,015). “búsqueda por ocupar la mente” (β = –0,196, p = 0,047) y “afrontar la cirugía como instrumento de mejoría/cura” (β = –0,255, p = 0,009) se relacionaron con menor estrés percibido. conclusiones: el estrés percibido sufre variabilidad según determinados estresores y coping. tales relaciones se deben tener en cuenta para la planeación de la asistencia en enfermería con el fin de reducir el estrés preoperatorio de pacientes coronariopatas. palabras clave adaptación psicológica; cirugía torácica; estrés psicológico; periodo preoperatorio; revascularización miocárdica (fuente: decs). 45 relação entre estresse percebido com coping e estressores de pacientes em pré-operatório de revascularização miocárdica l gabriela feitosa esplendori e outros relationship between perceived stress with coping and with stressors of patients in preoperative myocardial revascularization abstract coronary disease stands out among the cardiovascular diseases victimizing patients around the world. stress occurs in the preoperative period of myocardial revascularization surgery (mrs). objective: the purpose of the study is to determine the relationship between perceived stress with coping and with stressors of patients in preoperative mrs. materials and method: a quantitative and transversal approach was used. the sample consisted of 105 patients with coronary artery disease who had been admitted to a cardiology hospital. the perceived stress scale coping strategies inventory was used, along with two open questions. the answers were quantified and categorized. a multivariate linear regression model was used for the data analysis. results: higher perceived stress was associated with greater escape and elusiveness (β = 0.416, p <0.001), more coping (β = 0.353, p = 0.001), less self-control (β = -0.226, p = 0.024), female gender (β = -0.173, p = 0.048) and "clinical symptoms" (β = 0.235, p = 0.015). "search to occupy the mind" (β = -0.196, p = 0.047) and "facing surgery as an improvement / cure instrument" (β = -0.255, p = 0.009) were associated with less perceived stress. conclusions: perceived stress varies according to certain stressors and coping. these relationships must be taken into account when planning nursing care in order to reduce preoperative stress in coronary patients. keywords psychological adaptation; thoracic surgery; psychological stress; preoperative period; myocardial revascularization (source: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 43-55 46 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 introdução a cirurgia de revascularização do miocárdio (crm) é o tratamento indicado em casos de doença arterial coronariana (dac) cujos sintomas são refratários a tratamento clínico, com uma carga substancial de risco aos episódios isquêmicos do miocárdico (1). a dac envolve modificação da parede arterial devido a interação de diferentes fatores, como lipoproteínas de baixa densidade, resposta imunológica e aspectos genéticos (2), assim como a tabagismo, sedentarismo, hipertensão arterial, diabetes mellitus, obesidade, elevada ingesta de sal e consumo de álcool (3). dentre as doenças cardiovasculares, a dac ocupa posição de destaque pois foi responsável, em 2015, por 8,75 milhões de mortes no mundo ao vitimizar 2,429 milhões na europa, 2,004 milhões no sudoeste asiático, 2,055 milhões na região do pacífico ocidental, 1,05 milhões na região das américas, 753 mil nos países do mediterrâneo ocidental e 441 mil no continente africano (4). embora, com diferentes taxas de mortalidade entre as regiões mundiais, a dac impulsiona países de todo o mundo a disponibilizar recursos para realização de revascularização miocárdica, como, por exemplo, austrália, brasil, canadá, cuba, egito, índia, itália (5). segundo a organização mundial da saúde (oms), estima-se que, em 2030, o número de mortes devido à dac seja de aproximadamente 9,3 milhões de mortes no mundo, o que a coloca como líder das principais causas de mortes, observando-se as variações nas taxas de mortalidade entre países dos diversos continentes (6). gênero e etnia também se destacam no contexto da dac pois, entre brancos hispânicos, a prevalência de dac é de 7,8 % para homens e 4,6 % para mulheres. entretanto, entre negros não hispânicos, a prevalência é de 7,2 % para homens e 7,0 % para mulheres (7). estresse, estressores e coping no contexto da crm inicialmente, estresse foi considerado uma resposta não específica diante de estímulos nocivos (8). posteriormente, foi descrito como sinônimo de eventos de vida que requerem adaptação aos estímulos daí provenientes (9). na década de 1980, o conceito de estresse ampliou-se com o modelo interacionista do estresse (referencial teórico adotado neste estudo), ao considerar que as situações são avaliadas por meio de processos cognitivos resultantes da interação entre o indivíduo e o ambiente, de forma que o estresse se estabelece quando um evento é avaliado como taxativo ou que excede os recursos de adaptação do indivíduo (10, 11). o modelo interacionista vem conceituar também as estratégias de coping como esforços cognitivos e comportamentais para lidar com as exigências (internas ou externas) percebidas como ameaça ou como um desafio, ou seja, para lidar com o estresse percebido (11). no âmbito fisiológico, ante uma situação estressante, ocorre secreção de catecolaminas e de glicocorticoides a fim de diminuir os efeitos nocivos provocados pelo reconhecimento do estressor (12). na esfera emocional e no contexto pré-operatório, o caráter estressante dependerá de alguns fatores envolvidos na vivência pré-operatória (13). o pré-operatório para coronariopatas configura-se como um momento estressante uma vez que há sentimentos de medo relacionados a complicações pós-cirúrgicas, a restrições e imobilidade, à dor e a problemas com o sono de acordo com o identificado entre pacientes alemães (14). além disso, o paciente se preocupa consigo, sente medo da morte e pode enfrentar problemas econômicos e relacionados ao trabalho e à família conforme identificado entre pacientes iranianos (15). soma-se a isso, a ameaça à independência (16). quanto às estratégias de coping adotadas por pacientes cardíacos —dentre eles, os coronariopatas—, há busca por aquisição de informações a respeito da situação vivida (17), busca pelo apoio familiar (17-18) e profissional (18), assim como há procura por apoio espiritual/religioso (17-19). no que se refere aos aspectos religiosos, a oração pré-operatória, a religiosidade subjetiva e o controle interno foram preditores positivos de suporte espiritual em estudo com pacientes cirúrgicos cardíacos após 30 meses da cirurgia (20). diante da percepção de estresse e desenvolvimento de estratégias de coping, é imperativo que os profissionais que assistem pacientes em pré-operatório de crm desenvolvam ações para auxiliá-los na vivência pré-operatória. de fato, intervenções realizadas por enfermeiros que utilizaram recursos computacionais ou audiovisuais auxiliaram coronariopatas em pré-operatório, quanto à redução de depressão (2122) em realidade, autores (23) sugerem o fornecimento de informações aos próprios pacientes coronariopatas e a seus cônjuges 47 relação entre estresse percebido com coping e estressores de pacientes em pré-operatório de revascularização miocárdica l gabriela feitosa esplendori e outros sobre os procedimentos que serão realizados. no entanto, aponta-se que, além de utilizar ferramentas educacionais padronizadas, é necessário individualizar estratégias educativas (24). desse modo, para auxiliar pacientes coronariopatas na vivência do pré-operatório em um cenário composto por estresse, estressores e estratégias de coping, são necessárias estratégias educativas mais direcionadas a esse perfil de paciente. para tanto, faz-se necessário primeiro identificar quais são os estressores reconhecidos por esses pacientes, bem como as estratégias de coping adotadas por eles; em seguida, conhecer a interação dessas variáveis com os níveis de estresse para se ter subsídios para elaborar planos de cuidados de enfermagem mais assertivos, como, por exemplo, estratégias educativas que procurem reduzir o impacto daqueles estressores que significativamente se relacionam com maiores níveis de estresse ou planos de cuidado que estimulem as estratégias de coping que se apresentam significativas na redução do estresse. nisso se concentra a justificativa deste estudo, pois se observa que pesquisas retratam estratégias de coping (17-19) e estressores (14-16) sem suas relações com os níveis de estresse percebido, não sendo encontrados, na literatura pesquisada, estudos que analisaram se há associações entre estresse percebido com coping e com estressores comuns de pacientes em período pré-operatório de crm e quais são elas. assim, o objetivo geral deste estudo foi verificar a relação entre níveis de estresse percebido com os estressores e com estratégias de coping de pacientes em pré-operatório de crm. para tanto, os objetivos específicos foram: identificar o nível de estresse percebido, os estressores e as estratégias de coping. materiais e método estudo com abordagem quantitativa, transversal e prospectiva realizado em unidades de internação de um hospital público especializado em cardiologia, na cidade de são paulo (estado de são paulo, brasil). os critérios de inclusão foram: indivíduos com idade igual ou superior a 18 anos, internação inferior ou igual a 48 horas para crm eletiva, sem antecedente de cirurgia cardíaca. os de exclusão foram: internação para crm em urgência ou emergência, diagnóstico médico de doenças psiquiátricas. a coleta de dados ocorreu entre dezembro de 2012 e julho de 2013, com uma amostra de 105 participantes. para a identificação da variável dependente (estresse percebido) e de variáveis independentes (estratégias de coping e estressores), foram utilizados os instrumentos a seguir. • escala de estresse percebido (pss-14): traduzida e validada no brasil (25), possui itens referentes a pensamentos e sentimentos experenciados no último mês, tem como referência a data de seu preenchimento. pode ser utilizada em diversos grupos etários, pois não contém questões específicas do contexto. as respostas são tipo likert —0 (nunca), 1 (quase nunca), 2 (às vezes), 3 (quase sempre), 4 (sempre)—. para a obtenção dos níveis de estresse, somam-se as pontuações dos 14 itens e observam-se as pontuações invertidas dos itens 4, 5, 6, 7, 9, 10 e 13 (26). a aplicação da pss foi feita pela pesquisadora e, conforme recomendação (25), utilizou-se a frase inicial “neste último mês, com que frequência o(a) sr.(a)...” antes de iniciar cada item da escala para que o participante refletisse sempre em relação às experiências do último mês. • inventário de estratégias de coping (iec): traduzido e validado no brasil (27), é composto por 46 estratégias (itens) de coping, agrupadas em oito domínios (confronto, afastamento, autocontrole, suporte social, aceitação da responsabilidade, fuga e esquiva, resolução de problemas, reavaliação positiva). as respostas são tipo likert —0 (não usei), 1 (usei de alguma forma), 2 (usei algumas vezes), 3 (usei muitas vezes)—. a aplicação do questionário foi feita pela pesquisadora, e os pacientes foram orientados que a situação a ser pensada para responder aos itens do iec (lidos pelas pesquisadora) era a necessidade de se submeter à crm. optou-se por realizar duas perguntas abertas para que o participante ficasse livre para responder a respeito dos estressores vivenciados e das ações tomadas no pré-operatório, diante da possibilidade de o iec não contemplar outros aspectos vivenciados pelos participantes. as perguntas foram: “o que ajudou o(a) sr.(a) a enfrentar a situação desde quando soube que precisava fazer a cirurgia até hoje?” e “o que mais estressou ou preocupou o(a) sr.(a) desde que a cirurgia foi marcada até o dia de hoje?” as respostas de cada participante foram gravadas e transcritas na íntegra. para as respostas provenientes das perguntas abertas, foi utilizada análise de conteúdo, segundo bardin, por abordagem quantitativa, que analisa a frequência de determinados elementos da mensagem por meio do processo de categorização (28). assim, 48 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 para as respostas às perguntas abertas, realizaram-se a organização e a operacionalização; em seguida, foi realizada a codificação do material para transformar os dados brutos em unidades de registro (categorias). posteriormente, realizaram-se tratamento estatístico e interpretação dos resultados (28). ressalta-se que, por vezes, as respostas de um mesmo participante se enquadraram em mais de uma categoria. o statistical package for the social sciences versão 14 foi utilizado para a análise dos dados. a consistência interna da pss-14 e do iec foi avaliada pelo coeficiente alpha de cronbach. variáveis demográficas e clínicas quantitativas foram descritas por estatísticas sumárias; as qualitativas, por frequência absoluta e relativa. a relação entre níveis de estresse percebido com estratégias de coping e com estressores foi verificada por regressão linear multivariada, em que variáveis qualitativas foram representadas com: 0 para feminino e 1 para masculino; 0 para até 8 anos de estudo e 1 para 9 anos ou mais; 0 para ausência de cirurgias prévias (não cardíacas) e 1 para presença; 0 para ausência de hipertensão arterial e/ou diabetes melittus e 1 para presença. de forma semelhante, para cada categoria de estressor e para cada categoria de ação que ajudou a enfrentar o pré-operatório, atribuiu-se 0 para não (citado) e 1 para sim (citado). valores de p < 0,05 foram considerados estatisticamente significantes. considerações éticas o estudo foi aprovado pelos comitês de ética em pesquisa da escola de enfermagem da universidade de são paulo e do hospital local de estudo (caee 08514212.6.0000.5392). todos os participantes elegíveis para o estudo foram convidados e assinaram o termo de consentimento livre e esclarecido após leitura e esclarecimento de todo o seu conteúdo. resultados caracterização demográfica e clínica a amostra foi constituída por 74 homens (70,5 %) e 31 mulheres (26,5 %), com média de idade de 60,1 anos (desvio padrão de 9,4, mínima = 33 e máxima = 80), com até oito anos de escolaridade (74 – 70,4 %), portadores de hipertensão arterial sistêmica e/ou diabetes mellitus (91 – 86,7 %). o tempo médio entre a notícia da necessidade cirúrgica e a internação pré-operatória foi de 80,2 dias. quanto à experiência cirúrgica prévia (não cardíaca), 61 participantes (58,1 %) referiram não ter se submetido a nenhum procedimento cirúrgico até o momento da coleta de dados. percepção de estresse, estratégias de coping e estressores obteve-se alfa de cronbach 0,74 para a pss-14, e 0,89 para o iec. a média da pontuação da pss-14 foi menor (20,5) do que a pontuação média possível de ser obtida com a escala (27 pontos). tabela 1. estresse percebido e estratégias de coping — iec de pacientes em pré-operatório de revascularização miocárdica (n = 105) variáveis média (dp ±) mínimo máximo estresse percebido (pss-14) 20,5 (8,2) 3-39 coping (iec) reavaliação positiva (9 itens, vpp*: 0-27) 17,1 (5,9) 2-27 suporte social (6 itens, vpp*: 0-18) 10,9 (4,2) 0-18 resolução de problemas (4 itens, vpp*: 0-12) 7,9 (2,8) 0-12 fuga e esquiva (2 itens, vpp*: 0-6) 3,5 (1,8) 0-06 aceitação da responsabilidade (7 itens, vpp*: 0-21) 10,5 (4,7) 0-21 autocontrole (5 itens, vpp*: 0-15) 7,5 (2,9) 0-15 afastamento (7 itens, vpp*: 0-21) 9,2 (3,9) 0-19 confronto (6 itens, vpp*: 0-18) 4,5 (3,4) 0-15 *vpp: variação de pontos possível. fonte: elaboração própria. ao observar a tabela 1, houve destaque para os domínios, na seguinte ordem decrescente: reavaliação positiva > suporte social = resolução de problemas > fuga e esquiva > aceitação da responsabilidade = autocontrole > afastamento > confronto. as categorias provenientes das respostas às perguntas abertas estão nomeadas nas figuras 1 e 2. 49 relação entre estresse percebido com coping e estressores de pacientes em pré-operatório de revascularização miocárdica l gabriela feitosa esplendori e outros figura 1. categorias das ações que ajudaram a enfrentar o pré-operatório de revascularização miocárdica fonte: elaboração própria. figura 2. categorias dos estressores percebidos durante o pré-operatório de revascularização miocárdica fonte: elaboração própria. 50 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 relação entre estratégias de coping e entre estressores com nível de estresse percebido quanto às estratégias de coping, identificou-se (tabela 2) que maiores níveis de estresse percebido se relacionaram, de forma estatisticamente significante, com menores pontuações nos domínios autocontrole e maiores pontuações em fuga e esquiva, confronto e sexo feminino; menores níveis de estresse percebido variáveis independentes pss pss β p r2 f p β p r2 f p inventário de estratégias de coping (iec) modelo 1 modelo 2 0,32 3,61 <0,001 0,306 7,206 < 0,001* sexo –0,170 0,068 –0,173 0,048* anos de estudo 0,019 0,837 _a _a cirurgia não cardíaca anterior –0,178 0,061 –0,172 0,054 hipertensão arterial e/ou diabetes mellitus 0,089 0,332 _a _a confronto 0,339 0,003 0,353 0,001* afastamento 0,025 0,82 _a _a autocontrole –0,209 0,055 –0,226 0,024* suporte social 0,03 0,805 _a _a aceitação da responsabilidade –0,152 0,241 –0,203 0,064 fuga e esquiva 0,419 <0,001 0,416 <0,001* resolução de problemas –0,076 0,51 _a _a reavaliação positiva –0,068 0,615 _a _a estratégias/ações relatadas modelo 1 modelo 2 0,153 1,389 0,186 0,097 3,616 0,016* sexo –0,147 0,167 _a _a anos de estudo –0,112 0,276 _a _a cirurgia não cardíaca anterior –0,072 0,484 _a _a hipertensão arterial e/ou diabetes mellitus 0,026 0,812 _a _a apoiou-se na fé, na oração ou na religião –0,161 0,165 –0,170 0,086 apoiou-se na família, em amigos e em outros –0,027 0,822 _a _a estiveram relacionados, de forma estatisticamente significante, com a adoção das atividades “procura por atividades para ocupar a mente” e “enfrentar a cirurgia como opção de tratamento para melhorar ou resolver o problema”. quanto aos estressores relatados pelos pacientes, identificou-se que somente “sintomas clínicos que interferem nas atividades diárias/domésticas” relacionou-se de forma estatisticamente significante com os níveis de estresse. tabela 2. relação entre coping e estresse percebido, ajustados para covariáveis, em pacientes em pré-operatório de revascularização miocárdica 51 relação entre estresse percebido com coping e estressores de pacientes em pré-operatório de revascularização miocárdica l gabriela feitosa esplendori e outros procurou atividades para ocupar a mente –0,144 0,247 –0,196 0,047* procurou adquirir informações sobre cirurgia, cirurgião e hospital –0,065 0,525 _a _a procurou seguir as orientações médicas 0,053 0,6 _a _a agiu como se nada acontecesse sem fazer nada ou pensar no assunto 0,029 0,799 _a _a tentou se controlar, manter a calma 0,096 0,408 _a _a enfrentou a cirurgia como opção de tratamento para melhorar ou resolver o problema –0,226 0,04 –0,255 0,009* tabela 3. relação entre estressores e estresse percebido, ajustados para covariáveis, em pacientes em pré-operatório de revascularização miocárdica anão incluído no modelo 2 devido ao efeito não significativo no modelo 1. *indica relação significativa (p ≤ 0,05). fonte: elaboração própria. outras variáveis independentes não incluídas no modelo 2 devido ao efeito não significativo no modelo 1. *indica relacionamento significativo (p ≤ 0,05). fonte: elaboração própria. variáveis independentes pss β p r2 f p modelo 1 0,183 1,438 0,152 sexo -0,131 0,223 anos de estudo -0,093 0,364 cirurgia não cardíaca anterior -0,073 0,511 hipertensão arterial e/ou diabetes mellitus 0,077 0,446 adiamento/espera pela cirurgia 0,081 0,461 medo do procedimento: o coração com problemas, anestesia/esternotomia 0,118 0,264 medo de morrer 0,180 0,096 preocupação com o andamento da cirurgia/resultados 0,069 0,498 equipe de saúde: comentários e experiência profissional -0,029 0,767 recuperação pós-operatória 0,108 0,316 novidade da situação/surpresa 0,135 0,182 família: aspecto financeiro 0,134 0,18 família: familiares com problemas de saúde 0,237 0,022 sintomas clínicos que interferem nas atividades diárias/domésticas 0,192 0,055 modelo 2 0,081 4,492 0,016* família: familiares com problemas de saúde 0,173 0,072 sintomas clínicos que interferem nas atividades diárias/domésticas 0,235 0,015* 52 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 discussão a média do nível de estresse dessa amostra foi maior quando comparada à de pacientes coronariopatas em atendimento clínico (29), provavelmente devido à novidade da situação e ao caráter ameaçador da cirurgia (complexidade). com relação ao coping, destacaram-se os domínios reavaliação positiva, suporte social e resolução de problemas. o domínio reavaliação positiva possui itens referentes à reflexão sobre aspectos positivos e possui dimensão religiosa (30). paralelamente, nessa amostra, aspectos religiosos se destacaram nos relatos de ações para enfrentar o pré-operatório, pois “apoio na fé, na oração ou na religião foi citado por 42,9 %. similarmente, práticas religiosas estiveram presentes também na vivência de pacientes acometidos por infarto agudo do miocárdio ou submetidos à revascularização miocárdica (31) e levaram à reflexão de que a religiosidade parece ter importante impacto na avaliação de situações adversas e no seu enfrentamento. o suporte social se destacou no iec e refere-se à busca por suporte emocional ou informativo (30). paralelamente, nessa amostra, apoio da família, dos amigos e de outros também se sobressaiu entre os relatos (42,9 %), o que corrobora resultados da literatura (32). quanto ao domínio resolução de problemas, ao observar seu destaque no iec, compreendeu-se que, para essa amostra, a realização do procedimento cirúrgico parece ter significado de resolução da obstrução coronariana, o que corrobora resultados da literatura (33). segundo o modelo de regressão linear multivariada, as estratégias de coping autocontrole, confronto e fuga e esquiva, juntamente com sexo feminino, configuraram-se como preditoras da variabilidade dos níveis de estresse percebido. talvez a contribuição do domínio autocontrole, com itens referentes ao controle de sentimentos e emoções (30), em menores níveis de estresse percebido, esteja relacionada com a percepção do indivíduo sobre a gestão interna (controle) do significado da situação vivida. dessa forma, pode ser que características individuais de resiliência estejam relacionadas ao desenvolvimento de ações voltadas ao autocontrole, uma vez que a resiliência pode ser entendida como manejo, adaptação e gestão de situações adversas (34), manifestada por coping positivo e controle (35). os domínios confronto e fuga e esquiva possuem itens sobre isolamento social, raiva, responsabilização de outro pela situação, desejos e fantasias sobre o evento (29). os resultados deste estudo apontaram que esses dois domínios contribuíram para a variabilidade do estresse percebido de forma que, quanto maior seus usos, maior o estresse percebido. isso levou ao entendimento de que essas estratégias não foram efetivas no controle do estresse percebido e apontou a necessidade de trabalho com equipe multiprofissional, a fim de auxiliar os pacientes na ressignificação/reavaliação da situação e na adoção de estratégias que sejam efetivas na redução do estresse. identificou-se também nessa amostra que a “procura por atividades para ocupar a mente” juntamente com “enfrentar a cirurgia como opção de tratamento para melhorar ou resolver o problema” foram preditoras de menores níveis de estresse. pode ser que a estratégia de avaliação da situação como opção de tratamento que viabiliza a solução do problema esteja relacionada à gestão interna e direcione pensamentos voltados à avaliação da situação como algo positivo (resolução da obstrução coronariana) em detrimento do pensamento focado nos riscos inerentes à cirurgia (ameaça). tal escolha provavelmente se relacione, assim como na estratégia de autocontrole, aos aspectos voltados à resiliência (no que se refere à autoeficácia), diante da crença na própria capacidade de superar um evento ou alcançar algum objetivo (36). a categoria “procura por atividades para ocupar a mente” foi composta de atividades voltadas à distração, como trabalho, confecção de rede de pesca, leituras, assistir à televisão. pode ser que tais atividades sejam emocionalmente significativas para os pacientes dessa amostra devido ao distanciamento dos pensamentos voltados ao significado ameaçador da cirurgia. de fato, distrações como viagens e trabalho doméstico estiveram presentes na vivência de pacientes coronariopatas como ações direcionadas para o desvio de problemas e preocupações (17). sexo feminino foi, juntamente com outras variáveis independentes, preditor de maiores níveis de estresse percebido, o que corroborou com o encontrado na literatura (37). a falta de qualquer experiência cirúrgica junto com sexo feminino e outras estratégias de coping do iec esteve presente no modelo de regressão multivariada e apresentou p = 0,054, valor próximo do nível de significância adotado neste estudo. dessa forma, merece uma reflexão diante do contexto pré-operatório. a novidade da situação, em razão da falta de qualquer experiência cirúrgica anterior, parece indicar influência nos níveis 53 relação entre estresse percebido com coping e estressores de pacientes em pré-operatório de revascularização miocárdica l gabriela feitosa esplendori e outros de estresse percebido. decerto, ações educativas podem tornar o momento pré-operatório “menos desconhecido” pelo paciente com estratégias que visem orientar esses pacientes a respeito do período perioperatório a fim de instrumentalizar o paciente quanto às fases pré e pós-operatórias (se assim o paciente desejar), pois estudos já identificaram que ações educativas no pré-operatório auxiliam os pacientes na vivência do processo cirúrgico cardíaco (38-40). os estressores identificados versaram sobre situações vividas no pré-operatório e também sobre situações que os pacientes imaginavam ser possíveis de acontecer nos períodos trans e pós-operatório. dentre as categorias de estressores, duas se destacaram, embora não tenham se relacionado de forma estatisticamente significante com níveis de estresse percebido. o “medo de morrer” foi a categoria mais citada (17,1 %), o que corrobora com os resultados os resultados encontrados com pacientes no sul do brasil (32). é provável que tal medo esteja relacionado à novidade da situação (desconhecido), à percepção do coração como um órgão vital (41) e à avaliação do evento como um procedimento complexo. “adiamento ou a espera pela cirurgia” também se destacou (15,2 %) entre os estressores relatados e evidenciou o desejo de realização do procedimento o mais breve possível, o que é consistente com os achados da literatura (32-33). essa categoria talvez tenha se destacado nessa amostra pelo desejo de resolução do problema. porém, o paciente se depara com a realidade dos serviços públicos de saúde, nos quais o tempo entre a indicação cirúrgica e a realização do procedimento pode demorar alguns meses e superar a expectativa do paciente. segundo o modelo de regressão linear multivariada, a categoria “sintomas clínicos que interferem nas atividades diárias e domésticas” relacionou-se de maneira estatisticamente significativa com maiores níveis de estresse percebido. tais implicações podem estar, direta ou indiretamente, relacionadas à percepção das limitações impostas pela coronariopatia na realização de necessidades humanas básicas, como a de locomoção. de fato, a dac interfere na rotina diária dos pacientes pois, segundo ghezeljeh e emami (17), pacientes coronariopatas reduzem as atividades diárias ou de trabalho para diminuir sintomas como a dor. diante dos estressores e das estratégias de coping identificados e de seus relacionamentos com os níveis de estresse percebido, seguem algumas sugestões para o planejamento dos cuidados de enfermagem a pacientes em pré-operatório de crm: trabalhar com equipe multidisciplinar (psicólogos, terapeutas ocupacionais) desde o pré-operatório mediato; desenvolver estratégias para conscientizar o paciente de que a cirurgia não exclui a necessidade de realizar mudanças de hábitos de vida e para reforçar a importância de tratamento medicamentoso e não medicamentoso a fim de reduzir o impacto dos sintomas clínicos no pré-operatório; favorecer o contato do paciente com líderes religiosos em todo o perioperatório e com familiares ou pessoas significativas para o paciente durante a internação, tendo em vista o suporte que familiares e amigos representam para o paciente; desenvolver estratégias para tornar o pré-operatório menos desconhecido, por meio de visita pré-operatória de enfermagem (oportunidade para educar/conscientizar sobre o pré e pós-operatório imediatos bem como sobre procedimentos iniciais no centro cirúrgico com ações educativas específicas ao perfil dos pacientes). conclusão os resultados deste estudo indicam que há relacionamento entre estresse percebido com estratégias de coping e com estressores. “enfrentar a cirurgia como opção de tratamento e resolução do problema” e “procura por atividades para ocupar a mente” foram, conjuntamente, preditoras da variabilidade dos níveis de estresse, assim como fuga e esquiva, confronto, autocontrole e sexo feminino de forma conjunta. “sintomas clínicos que interferem nas atividades diárias e domésticas” se destacou como estressor preditor da variabilidade dos níveis de estresse. uma vez relacionados com a variabilidade do estresse, estressores e estratégias de coping podem se configurar, respectivamente, como alvo e como instrumentos para planejar o cuidado de enfermagem ao paciente cirúrgico coronariopata, pois o entendimento sobre o relacionamento dessas variáveis com os níveis de estresse pode subsidiar ações educativas a serem implementadas por enfermeiras no período perioperatório. limitações da pesquisa esta pesquisa apresentou limitações para generalização de seus resultados devido ao número de pacientes incluídos em sua amostra e ao fato de ser realizada somente em uma instituição de saúde. estudos futuros poderiam ser realizados com maior tamanho amostral no pré-operatório ambulatorial com seguimento durante a internação cirúrgica. conflito de interesse: nenhum declarado. 54 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 referências 1. taggart dp. stents or surgery in coronary artery disease in 2013. 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beyersdorf f, fritzsche k. short-term intervention to reduce anxiety before coronary artery bypass surgery — a randomised controlled trial. j clin nurs. 2016; 25:351-61. doi:10.1111/jocn.13055 41. wottrich sh, quintana am, camargo vp, beck clc. “manifestos do coração”: significados atribuídos à doença por pacientes cardíacos pré-cirúrgicos. psic.: teor. e pesq. 2015; 31(2):213-9. http://dx.doi.org/10.1590/010237722015021127213219 plan de alta para personas.pmd revista aquichan issn 1657-5997 104 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 abstract the aim of this plan is to provide care according to the needs and requirements of the person who leaves the health institution, and should turn into a basic guide, specially for the assistance provided to people with chronic pathologies such as chronic obstructive lung disease that due to its complexity requires multiple care and in this way have an integral intervention that results in a better adaptation, detection of possible complications and a better life quality. being the daughter of a patient with chronic obstructive lung disease, and a nurse plus the high incidence of this disease made me think about the elaboration of the leave plan. there were many needs and a lot of care required, and a lot of questions that arouse every single day from making sure that there was a good communication, also a knowledge of the signs and symptoms of emergency that indicated an exarcerbation. the adequate use of medicine, the importance of oxygen therapy in the long run, the supply of an appropriate diet based on the given recommendations, and a favorable environment taking into account his health condition so that an armonic, physical, family and spiritual environment could be achieved. key words luz marina céspedes salgado1 ximena sáenz montoya2 1 universidad de caldas. calle 65 nº 26-10 manizales, colombia. luzmarianacespedes@chile.com 2 universidad de caldas. ximena_saenz4@hotmail.com recibido: 26 de enero de 2006 aprobado: 7 de junio de 2006 resumen palabras clave plan de alta, enfermedad pulmonar obstructiva crónica, cuidados, enfermería. leave plan, chronic obstructive lung disease, care, nursery. el plan de alta busca asegurar unos cuidados acordes con las necesidades y los requerimientos de la persona una vez egresa de la institución de salud, y debe constituirse en una guía básica en especial para la atención de aquéllos con patologías crónicas, como es la enfermedad pulmonar obstructiva crónica, que por su complejidad demanda múltiples cuidados para asegurar una intervención integral con miras al logro de una mejor adaptación, a identificar posibles complicaciones y a mejorar su calidad de vida. la experiencia de haber asumido el rol de hija y enfermera de un padre con enfermedad pulmonar obstructiva crónica (epoc), y la alta incidencia de esta enfermedad, motivaron la elaboración de este plan de alta; fueron muchos los cuidados y muchas las necesidades y los cuestionamientos que se daban día a día, desde asegurar una adecuada comunicación hasta un conocimiento de los signos y síntomas de urgencia que indicaban una exacerbación, del uso adecuado de los medicamentos, de la importancia de la oxigenoterapia a largo plazo, de proporcionarle una dieta acorde con las recomendaciones y un ambiente favorable para sus condiciones de salud para, en últimas, alcanzar un entorno armónico, físico, familiar y espiritual. discharging plan for chronic obstructive pulmonary disease patients año 6 vol. 6 nº 1 (6) 104-116 chía, colombia octubre 2006 plan de alta para personas con enfermedad pulmonar obstructiva crónica. discharging plan for chronic obstructive pulmonary disease patients 105 a enfermedad pulmonar obstructiva crónica es una patología frecuente que se caracteriza por limitación al flujo aéreo y por retardo de la espiración forzada como consecuencia de la obstrucción crónica difusa de las vías aéreas. en colombia la información sobre la prevalencia de esta enfermedad no es muy acertada; sin embargo, es una de las primeras causas de consulta en las personas mayores de 60 años. el conocimiento de los factores de riesgo de la epoc es básico para la prevención y el tratamiento de los individuos expuestos (1). factores de riesgo humo de cigarrillo: es el factor de riesgo más importante. la posibilidad de presentar la enfermedad aumenta con el número de cigarrillos fumados al día y la función pulmonar, que de por sí se encuentra disminuida en los fumadores, y se deteriora con mayor rapidez si la persona es susceptible al humo del cigarrillo. para predecir el riesgo de epoc se consideran factores como el grado de alteración de la función pulmonar, la edad en que se comenzó a fumar y la cantidad total de cigarrillos fumados al día. la morbilidad y mortalidad por epoc en los fumadores de pipa y tabaco es mayor que la de los no fumadores pero menor que la de los fumadores de cigarrillo (2). los niños y los adultos expuestos pasivamente al humo del cigarrillo presentan una mayor prevalencia de síntomas y enfermedades respiratorias que los que no lo están. humo de madera: en colombia se ha descrito una obstrucción crónica de la vías aéreas en personas de sexo femenino quienes nunca han fumado pero que han cocinado con leña en recintos cerrados por muchos años. la sociedad colombiana de neumología cree que la neumopatía por humo de leña debe considerarse una variante de la epoc, propia de los países subdesarrollados. cuadro 1. factores de riesgo de desarrollo de la epoc consumo de cigarrillo. exposición ocupacional (humo de madera). deficiencia de antitripsina . bajo peso al nacer. infecciones respiratorias en la infancia. historia familiar. atopía. iga no secretora. grupo sanguíneo a. contaminación ambiental. pobreza. exposición al humo por tiempo prolongado. alcohol. vías hiperreactivas. la posibilidad de presentar la enfermedad aumenta con el número de cigarrillos fumados al día y la función pulmonar, que de por sí se encuentra disminuida en los fumadores, y se deteriora con mayor rapidez si la persona es susceptible al humo del cigarrillo. establecidos probables posibles revista aquichan issn 1657-5997 106 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 deficiencia de antitripsina alfa -1: es un factor de riesgo demostrado para el desarrollo de enfisema panacinar difuso. las personas con concentraciones en suero menores de 50 mgs/dl tienen un riesgo superior al 80% de desarrollar esta patología (3). contaminación ambiental: la contaminación con partículas y so 2 se asocia con un aumento de la prevalencia de tos y expectoración, un incremento de la hiperactividad bronquial y una ligera disminución de la función pulmonar. cuando la contaminación es muy alta puede producir bronquitis crónica. hiperreactividad bronquial, asma, atopía: existe una relación significativa entre consumo de cigarrillo, niveles altos de ige, eosinofilia pulmonar e hiperreactividad bronquial, especialmente en personas con antecedentes de alergia. las exacerbaciones de la enfermedad pulmonar obstructiva crónica son causa frecuente de morbimortalidad, producen frecuentes ingresos hospitalarios, y elevan los costos sociales y económicos. las exacerbaciones agudas se han relacionado con factores precipitantes como infecciones bacterianas y virales, sobre todo por rinovirus y otros virus causantes del resfriado común, asociados con frecuencia a épocas de invierno. los contaminantes ambientales también pueden ser importantes. la experiencia profesional ha evidenciado el déficit de conocimientos que el enfermo tiene acerca del cuidado de su estado de salud; es común observar dificultades en el uso de los inhaladores, del oxígeno domiciliario, de los medicamentos formulados y de la dieta recomendada, entre otros; el desconocimiento de los signos y síntomas de alarma es frecuente. la educación es un elemento importante en la intervención terapéutica de estas personas, su objetivo fundamental es la promoción de la salud que debe necesariamente generar cambios de conducta. un estudio realizado por maría rodríguez r. y m. dolores sánchez fernández (4), el cual evaluó la efectividad de una intervención educativa individual y en grupo en pacientes con enfermedad pulmonar obstructiva crónica, demostró que posterior a la intervención educativa se redujeron los reingresos por descompensación (7 ingresos en los 12 meses anteriores, frente a 3 ingresos en los 12 meses tras el inicio de la intervención); a su vez, los síntomas se redujeron de 49,1 + -10,4 a 38,3 + 12,2 (p=0,063). lo anterior muestra que entre más conozca la persona su patología, tiene más herramientas para hacerle frente con mejores resultados, y un medio para alcanzar este objetivo es el plan de alta diseñado de acuerdo con los hallazgos obtenidos a través de una minuciosa valoración sistemática mediante la cual se determinan los diagnósticos de enfermería que son la base para la selección de las intervenciones. propuesta de plan la siguiente es una propuesta del plan de alta para personas con esta patología. ésta puede utilizarse como guía para adaptarla a situaciones individuales. este plan de alta se desarrolla con base en la siguiente nemotecnia: la sociedad colombiana de neumología cree que la neumopatía por humo de leña debe considerarse una variante de la epoc, propia de los países subdesarrollados. plan de alta para personas con enfermedad pulmonar obstructiva crónica. discharging plan for chronic obstructive pulmonary disease patients 107 c omunicación u rgencia i nformación d ieta a ambiente r ecreación medicamentos e spiritualidad esta nemotecnia integra todos los aspectos necesarios para un autocuidado eficaz; fue ideada por la docente lina pinzón de salazar* para intervenir en forma integral al individuo una vez egresa de la institución hospitalaria. se consideran los diagnósticos de enfermería más frecuentes observados durante la práctica. comunicación diagnóstico de enfermería: riesgo de cuidado ineficaz, aislamiento social e indiferencia frente al estado de salud actual, relacionado con procesos de comunicación inapropiados. meta: la relación enfermero-pacientefamilia o cuidador propiciará una comunicación eficaz para garantizar unos cuidados acordes con la situación. intervención: es fundamental que el profesional de enfermería identifique al familiar o cuidador del paciente en el hogar para involucrarlo en el plan de alta con el fin de comunicarle todos los aspectos relacionados con el cuidado ambulatorio, no sólo con la atención en el hogar, sino también a fin de identificar la institución a la cual debe recurrir para los controles periódicos o en caso de urgencia. el profesional de enfermería debe establecer una relación terapéutica de alta calidad en términos de respeto y confianza que permitan la expresión espontánea del paciente y familia en la búsqueda de opciones y resolución de interrogantes acerca del cuidado. esta comunicación propicia un crecimiento mutuo. es muy importante motivar a las personas con epoc para que se integren a grupos sociales en los cuales tendrán la oportunidad de compartir experiencias e intereses particulares y afines con su patología, y de recibir asesoría para el cuidado y mantenimiento de su salud. esta interacción es valiosa porque estimula y refuerza la motivación para continuar conviviendo con su enfermedad y realizar importantes ajustes al estilo de vida. urgencia diagnóstico de enfermería: riesgo de complicaciones relacionadas con exacerbación de la enfermedad, secundario a procesos infecciosos, manejo inadecuado de medicamentos e influencia de patologías concomitantes. meta: el paciente y su familia estarán en capacidad de valorar el estado de salud y determinar la importancia de la consulta oportuna. intervención: los signos y síntomas de alarma que sugieren exacerbación de la enfermedad son: aumento de la dificultad respiratoria, aumento y cambio en las características de las secreciones (se pueden tornar amarillentas o verdosas y con mayor viscosidad, lo que sugiere infección), aumento de la tos, disminución en la expectoración, estados confusionales y cefaleas matutinas que se asocian con hipoxemia e hipercapnia. algunas personas refieren sensación de ardor subesternal, generalmente acompañado de tos. es muy importante motivar a las personas con epoc para que se integren a grupos sociales en los cuales tendrán la oportunidad de compartir experiencias e intereses particulares y afines con su patología, y de recibir asesoría para el cuidado y mantenimiento de su salud. * enfermera; profesora titular, departamento de saludpública, universidad de caldas, colombia. revista aquichan issn 1657-5997 108 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 el cuidador puede observar en el paciente un mayor esfuerzo respiratorio y utilización de los músculos accesorios. se pueden percibir sibilancias sin fonendoscopio. los signos vitales evidencian taquicardia y taquipnea, la presión arterial puede encontrarse disminuida como respuesta a los efectos de la presión al final de la espiración autopositiva, o aumentada debido a la acidemia respiratoria aguda que genera calor, piel enrojecida, pulso periférico fuerte y somnolencia. en personas con compromiso cardiaco puede observarse edema periférico, distensión de las venas yugulares, hepatomegalia y ascitis. el papel del cuidador en la detección temprana de los signos y síntomas de deterioro es fundamental porque el enfermo con epoc acepta su incapacidad crónica y puede no notarlos precozmente. una consulta médica a tiempo puede evitar complicaciones. información diagnóstico de enfermería: posible alteración en el mantenimiento de la salud debido a una falta de conocimiento acerca de la enfermedad, tratamiento, prevención de exacerbaciones, ejercicios respiratorios, factores de riesgo, entre otros. meta: el paciente-familia o cuidador tendrán tanto el conocimiento de todos los aspectos relacionados con el manejo de la epoc, como de los servicios de salud a los cuales debe acudir. intervención: la persona con epoc tiene derecho a conocer todo lo relacionado con su patología (diagnóstico, alternativas terapéuticas y pronóstico), esta información debe partir en primera instancia del médico tratante, y corresponde al profesional de enfermería verificar la comprensión de ésta y aclarar dudas al respecto. hay otros tópicos sobre los cuales el usuario debe recibir información, como son los relacionados con los servicios del sistema de salud, sitio al cual debe asistir a los controles y, en caso de urgencia, a qué institución acudir. dieta diagnóstico de enfermería: posible alteración de la nutrición relacionada con disminución en la ingesta secundaria a disnea, hiperinsuflación pulmonar y efectos secundarios de algunos medicamentos. meta: lograr y conservar un equilibrio hidroelectrolítico, nutricional y metabólico. intervención: la enfermedad obstructiva crónica con frecuencia ocasiona pérdida severa de peso que varía entre el 25 y 65% del peso corporal. la etiología de esta pérdida no es bien conocida. hay varios factores que pueden influir como la disnea y la fatiga al momento de la preparación de las comidas o de la ingesta. la hiperinsuflación pulmonar y la deglución de aire disminuyen la capacidad del estómago para aceptar y tolerar la dieta: “las comidas abundantes requieren más oxígeno para su digestión y metabolismo, e interfieren con el descenso del diafragma” (5). en la enfermedad pulmonar obstructiva, en especial de predominio enfisematoso, hay disminución del lecho vascular pulmonar. en estas personas el aumento del gasto cardiaco se logra a expensas de un incremento en la presión vascular con frecuencia las personas con epoc requieren restricción de líquidos para disminuir la presión vascular pulmonar y el líquido extravascular pulmonar. plan de alta para personas con enfermedad pulmonar obstructiva crónica. discharging plan for chronic obstructive pulmonary disease patients 109 pulmonar, lo que disminuye la cantidad de oxígeno y nutrientes que llegan a los músculos y órganos vitales (6). otro factor que se debe considerar es el consumo de medicamentos que interfieren con la función gastrointestinal y pueden producir nauseas y anorexia. los inhaladores de esteroides pueden disminuir el gusto y precipitan las infecciones en la mucosa oral lo que lleva a la disminución de la ingesta. asociado a todos los factores descritos, estas personas presentan un aumento en los requerimientos calóricos debido probablemente al incremento en el trabajo respiratorio. brown y light (1983) “calcularon que el costo calórico varía entre 36 y 76 kcal/día en personas normales, pero aumenta diez veces en personas con epoc” (7). la composición de la dieta afecta la producción de dióxido de carbono y los movimientos respiratorios. la conversión de nutrientes mayores (carbohidratos, grasas y proteínas) en energía, consume oxígeno y produce dióxido de carbono. el metabolismo de los carbohidratos es el que más genera dióxido de carbono, produce un incremento en la ventilación minuto, en el volumen corriente, aumenta la producción de lactato y el consumo de oxígeno. las dietas en las cuales las grasas aportan una porción significativa (más del 50%) de las calorías no proteicas reducen la producción de dióxido de carbono, mejoran la función respiratoria y disminuyen los requerimientos ventilatorios. aunque es importante administrar suficiente proteína para el anabolismo, se debe evitar hacerlo en exceso porque aumentan el proceso de la ventilación. el aumento de la actividad respiratoria puede resultar beneficioso para los pacientes capaces de responder al estímulo; en los enfermos crónicos sin capacidad para aumentar la ventilación minuto, el estímulo puede aumentar el trabajo respiratorio y causar disnea. la depleción de proteínas lleva a una disminución de la masa del diafragma, lo que contribuye a un deterioro de la función pulmonar e inmunológica. estas alteraciones, sumadas a la disminución en la frecuencia de suspiros y a la desnutrición, pueden relacionarse con una mayor incidencia de infecciones. con frecuencia las personas con epoc requieren restricción de líquidos para disminuir la presión vascular pulmonar y el líquido extravascular pulmonar. no obstante, la deshidratación dificulta la eliminación de las secreciones pulmonares espesas. son frecuentes las deficiencias de algunos minerales como fosfatos, los cuales disminuyen la respuesta ventilatoria a la hipoxia; la hipomagnesemia produce fatiga de la musculatura respiratoria; la hiponatremia disminuye el apetito y la hipokalemia puede disminuir la fuerza de los músculos respiratorios. se ha encontrado depleción de elementos traza, en especial el hierro. el plan nutricional debe ser individualizado, considerando los hábitos alimentarios y las posibilidades económicas, lo que puede garantizar el cumplimiento de la dieta. se sugiere: fraccionar la dieta en varias comidas pequeñas al día. consumir alimentos de consistencia blanda. evitar alimentos productores de gases como el repollo y las leguminosas. aportar una buena cantidad de fibra para evitar el estreñimiento (naranja, avena, verduras). restringir el consumo de tortas, dulces y harinas. consumir carnes (pescado, pollo, res), huevos y lácteos, estos últimos teniendo en cuenta la tolerancia de cada paciente. consumir las leguminosas en pequeñas porciones y en horas tempranas del día, estas son fuente importante de proteínas (fríjol, lentejas). asegurar una ingesta diaria de frutas. evitar consumir bebidas heladas. ambiente diagnóstico de enfermería: riesgo de exacerbación de la enfermedad como consecuencia de situaciones ambientales nocivas. riesgo de lesiones asociadas con cambios propios del envejecimiento. meta: el individuo habitará en un ambiente que le propiciará bienestar y comodidad acorde con su situación social. intervención: es necesario conocer el medio cotidiano en el cual se desenvuelve la persona con epoc. se recomiendan espacios aireados; sin embargo, las corrientes de aire frío pueden desencadenar broncoespasmos, la exposición a gases, humo y disolventes puede generar reacciones inflamatorias en la vía aérea. las labores de limpieza se deben realizar mediante la aspiración y la utilización de paños húmedos, de tal forma que se impida el esparcimiento de partículas de polvo y ácaros. no se recomienda la convivencia con animales (perros, gatos, aves) porque el revista aquichan issn 1657-5997 110 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 pelo y las plumas pueden precipitar reacciones alérgicas e infecciosas. las personas con epoc deben realizar las actividades de la vida diaria sin que se incremente el esfuerzo físico porque esto aumenta el consumo de oxígeno y la disnea (subir escaleras, desplazarse rápidamente, levantar objetos pesados, entre otros). a medida que la enfermedad avanza se sugiere alternar la actividad física con periodos de descanso y relajación. la enfermedad pulmonar obstructiva crónica se presenta con mayor frecuencia en adultos mayores quienes pueden tener otras alteraciones asociadas como pérdida de visión, problemas osteomusculares, hipoacusia y otros, lo que amerita su consideración en el plan de alta. recreación y uso del tiempo libre diagnóstico: riesgo de intolerancia a la actividad, limitación en la capacidad física para ejecutar actividades recreativas y de la vida diaria. meta: restaurar y conservar el estado físico para satisfacer las demandas del entorno en el cual se desempeña. intervención: los pacientes con epoc tienden a disminuir la actividad física, con lo cual se establece un círculo vicioso de reducción del ejercicio, pérdida de la fuerza muscular y aumento de la disnea. la hipoxemia durante el ejercicio, y el aumento del costo metabólico de la respiración, incrementan la disnea y pueden producir pérdida de peso y desnutrición, todo esto afecta la calidad de vida y puede generar ansiedad y depresión. es importante motivar a la persona y a su grupo familiar para que participen en grupos de rehabilitación pulmonar a través de los cuales podrá mejorar su calidad de vida, contribuir a un mejor control de sus síntomas y disminuir el número y la duración de las hospitalizaciones, y la utilización excesiva de los servicios de salud. los programas de rehabilitación deben incluir intervenciones multidisciplinarias, múltiples componentes y ser personalizados. el proceso debe incluir un programa de entrenamiento físico, educación sobre la enfermedad, nutrición e intervenciones psicológicas y de comportamiento. dichos programas incluyen: fisioterapia: esta prepara al usuario en el manejo adecuado de las secreciones por medio de una tos efectiva y maniobras de aceleración de flujo espiratorio, enseña técnicas de relajación, espiración con los labios fruncidos, lo que facilita la normalización del cociente inhalación/exhalación, y control de la disnea. entrenamiento muscular: el ejercicio aeróbico (que puede incluir la administración de oxígeno durante éste) mejora la capacidad de los grupos musculares mayores utilizados en las actividades de la vida diaria tales como caminar y subir escaleras, entre otras. nutrición: este tópico fue tratado en las recomendaciones dietéticas. se sugiere un programa nutricional que busque mantener el peso ideal en cada paciente. psicoterapia y educación: estas acciones deben involucrar tanto a la persona enferma como a su familia. mejoran la calidad de vida al restaurar la capacidad los programas de rehabilitación deben incluir intervenciones multidisciplinarias, múltiples componentes y ser personalizados. plan de alta para personas con enfermedad pulmonar obstructiva crónica. discharging plan for chronic obstructive pulmonary disease patients 111 de adaptación, al proporcionar herramientas adecuadas para el manejo del estrés, al ofrecer pautas de manejo de crisis y uso de medicamentos, y de otros aspectos relacionados con la enfermedad. existen otras actividades que pueden asociarse con las acciones de rehabilitación como la lectura, el juego, la televisión, los grupos sociales y las reuniones familiares que promueven bienestar y pueden optimizar el estado de la salud. medicamentos diagnóstico: riesgo de uso inadecuado del plan farmacológico relacionado con los cambios fisiologicos del envejecimiento (disminución de la agudeza visual, alteraciones en la memoria, en la motricidad fina y coordinación) o incumplimiento del tratamiento con los consecuentes resultados inefectivos. riesgo de intoxicación secundario a ajustes incorrectos de la medicación sin previa valoración profesional. metas: lograr la adherencia al tratamiento farmacológico. disminuir la incidencia de complicaciones relacionadas con el uso inapropiado de los fármacos. intervención: el plan de alta debe hacer énfasis especial en el uso de los medicamentos. con frecuencia éstas se convierten en causa de complicaciones, sin embargo, son la piedra angular del tratamiento sintomático de las personas con epoc. la mayoría de los medicamentos están orientados hacia las cuatro causas potencialmente reversibles de la limitación del flujo aéreo que se encuentra en estos individuos: contracción de la musculatura lisa bronquial. congestión y edema de la mucosa bronquial. inflamación de la vía aérea. aumento de secreciones (8). broncodilatadores: los más utilizados son los agonistas beta tanto inhalados como orales, los anticolinérgicos inhalados y los preparados orales de teofilina. los agonistas beta son muy efectivos, mejoran la función de las cilias, aumentan la contractilidad del miocardio y producen vasodilatación pulmonar. se debe alertar al usuario sobre los efectos adversos como temblor, hipertensión arterial, palpitaciones, insomnio, reflujo gastroesofágico y calambres, y a dosis altas, arritmias e hipopotasemia. se encuentran en tres tipos de preparados inhalados: líquidos que pueden ser nebulizados. aerosoles que se administran mediante inhaladores de dosis medida. polvos secos que pueden ser inhalados mediante dispositivos autoactivados. cómo utilizar un inhalador con medidor de dosis no debe inhalar demasiado rápido. no debe sujetar el inhalador al revés o de lado. no debe hacer más de una presión por cada inspiración. debe estar bien incorporado. valorar la capacidad para sostener y manipular el inhalador. insertar el tubo de medicación en el interior del inhalador. debe agitar el inhalador y sujetarlo con el tubo en posición vertical a una distancia de 2,5 a 5 cm de la boca abierta. inclinar ligeramente la cabeza hacia atrás e inhalar despacio y profundamente por la boca. también puede colocar los labios firmemente alrededor de la boquilla del inhalador al realizar la inhalación. cuando se utiliza un inhalador de esteroide, debe usarse la técnica de la boca abierta. debe continuar inspirando durante 8 a 10 segundos mientras está liberando la medicación, exhalando a continuación con los labios fruncidos. la inhalación se debe repetir según la dosis a intervalos de un minuto. se debe extraer el tubo de medicación y limpiar el inhalador con agua caliente. es importante que el paciente evalúe la cantidad de medicamento existente en el tubo mediante la introducción de éste en un recipiente con agua. entre más vertical se observe el tubo dentro del agua mayor medicamento contiene. los espaciadores o inhalocámaras facilitan la administración en las personas a quienes se les dificulta y mejoran la distribución del medicamento en la vía aérea. cómo usar un broncodilatador líquido nebulizado no se debe inclinar el nebulizador. la persona debe estar sentada. debe respirar despacio con los labios entreabiertos. si se realiza con oxígeno asegurar que el flujo sea entre 4-6 litros por minuto. suspender la nebulización cuando el medicamento y el vehículo (usar siempre solución salina) se han consumido. lavar los implementos con agua y jabón, desinfectarlos con solución de hipoclorito de sodio durante 15 minurevista aquichan issn 1657-5997 112 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 tos, se enjuagan con agua de la llave, se secan y se conservan en una bolsa plástica. cómo usar un broncodilatador de polvo seco los inhaladores de polvo seco tienen la ventaja de activarse con la inspiración, por lo cual requieren menos coordinación motora, pero pueden ser de uso difícil para las enfermos debilitados que muchas veces no son capaces de generar el flujo inspiratorio necesario para activar el dispositivo (9). estos inhaladores serán los más utilizados en el futuro porque no requieren propelentes clorofluorocarbonados, los cuales deben ser eliminados en respuesta a problemas ambientales. para asegurar una adecuada utilización del inhalador: quitar el capuchón al protector. sujetar firmemente la base del inhalador y abrirlo girando la boquilla en la dirección que indica la flecha. insertar la cápsula en la ranura. cerrar el inhalador girando la boquilla. mantener el inhalador en posición vertical y pulsar los botones que perforan la cápsula una sola vez. espirar a fondo. introducir la boquilla en la boca, inclinar la cabeza hacia atrás, rodear la boquilla con los labios e inspirar rápida y profundamente. tras la inhalación, extraer la cápsula vacía, cerrar la boquilla y colocar la tapa protectora. se debe limpiar el polvo residual de la boquilla y del compartimiento de la cápsula con un cepillo o paño seco. anticolinérgicos: están disponibles en formas nebulizadas y en inhaladores de dosis medida. las sustancias orales no se utilizan. el comienzo de la acción es más lento que en los agonistas beta por lo que no se debe esperar una respuesta inmediata, pero la evidencia indica que producen mayor broncodilatación y, combinados con los agonistas beta, se ejerce una acción aditiva. los efectos adversos de este tipo de medicamentos son tos, resequedad en la boca, estreñimiento y, cuando hay contacto con los ojos, puede producir dilatación pupilar. se recomienda la utilización de broncodilatadores de larga acción concomitantemente con broncodilatadores de corta duración en pacientes que permanecen sintomáticos (grado de recomendación a) (10). metilxantinas: este grupo incluye la teofilina para administración oral y la aminofilina para administración oral o intravenosa. estos medicamentos tienen una acción broncodilatadora menos intensa que los beta adrenérgicos y que los anticolinérgicos. además del efecto broncodilatador moderado, tienen una acción vasodilatadora pulmonar y sistémica, aumentan el gasto cardiaco, la perfusión miocárdica, estimulan el centro respiratorio y los músculos de la respiración. es necesario instruir al paciente sobre los efectos adversos de la teofilina como náuseas, vómito, temblor, convulsiones y arritmias. debe conocer que algunas situaciones y el consumo de algunos medicamentos pueden modificar las concentraciones de la teofilina. cuadro 2. factores que influyen en la administración de teofilina consumo de cigarrillos. hipertiroidismo. dieta rica en proteínas. consumo de marihuana. cuando se reciben medicamentos: barbitúricos, difenilhidantoina rifampicina, carbamazepina. se requiere aumentar la dosis se requiere disminuir la dosis insuficiencia cardiaca. disfunción hepática. infección viral. personas mayores de 60 años. presión arterial de oxígeno menor de 45 mmhg. cuando se reciben medicamentos: alopurinol, cimetidina, ciprofloxacinoeritromicina, verapamilo. plan de alta para personas con enfermedad pulmonar obstructiva crónica. discharging plan for chronic obstructive pulmonary disease patients 113 corticoesteroides: con frecuencia son utilizados en las exacerbaciones donde la participación del componente inflamatorio es más relevante. la dosis debe ajustarse de acuerdo con los resultados y se debe disminuir gradualmente una vez se haya logrado el efecto terapéutico deseado hasta llegar a la dosis mínima efectiva, puede administrarse todos los días o en días alternos con lo cual se espera disminuir los efectos secundarios. una revisión sistemática publicada en cochrane, cuya estrategia incluyó búsquedas en el registro especializado del grupo cochrane de vías respiratorias, y en medline, entre diciembre de 2003 al 2004, que incluyó veinticuatro estudios con el objetivo de evaluar los efectos de los corticoesteroides sobre el estado de salud de los pacientes con epoc estable, concluyó que dosis mayores a treinta miligramos de prednisona mejoran la función pulmonar durante un corto periodo. los efectos adversos potencialmente perjudiciales como diabetes, hipertensión arterial y osteoporosis podrían impedir la recomendación a largo plazo de dosis altas. no hay pruebas para apoyar el uso a largo plazo en dosis menores de 10-15 mg diarios. los corticoesteroides pueden administrarse por vía oral, preferiblemente en una sola dosis diaria en las mañanas después del desayuno y por vía inhalada; esta última tiene menos efectos adversos, sin embargo, es recomendable el uso de un espaciador para reducir el depósito de partículas aerolizadas en la vía aérea alta, que puede provocar candidiasis oral y ronquera. enjuagarse la boca tras la inhalación reduce estos efectos y si además se usan otros inhaladores broncodilatadores los esteroides se administran posterior a éstos. mucolíticos: la administración de estos medicamentos es controvertida, por tanto, el uso generalizado de éstos no es recomendable. la viscosidad del moco se puede reducir mediante una adecuada hidratación. antibióticos: están indicados en las exacerbaciones agudas de acuerdo con el germen causal. la persona que los está recibiendo debe tener claro que estos fármacos no pueden suspenderse antes de la finalización del tratamiento a pesar de haber obtenido mejoría. es muy importante tener en cuenta, al momento de dar las instrucciones sobre los medicamentos, que la mayoría de las personas con epoc son adultas mayores y por tal razón pueden presentar algunos cambios relacionados con la edad o con la patología misma, como disminución de la visión y alteraciones en la memoria entre otras, que lo exponen a complicaciones relacionadas con el mal uso de éstos, tanto por exceso, como por dosis insuficientes. para una mayor seguridad, el profesional de enfermería debe entregar por escrito al paciente y su familia las recomendaciones para el manejo de su enfermedad e incluir una propuesta para el adecuado uso del medicamento. se puede utilizar el siguiente modelo: nombre vía de horas recomendaciones del medicamento administración sugeridas especiales para una mayor seguridad, el profesional de enfermería debe entregar por escrito al paciente y su familia las recomendaciones para el manejo de su enfermedad e incluir una propuesta para el adecuado uso del medicamento. revista aquichan issn 1657-5997 114 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 los medicamentos deben ser conservados en un lugar limpio y fresco, la fecha de vencimiento debe ser revisada con frecuencia. las personas con epoc deben recibir la vacuna contra la influenza cada año y asegurar la inmunización contra neumococo. oxígeno: la hipoxemia induce una respuesta fisiológica compleja que busca preservar el suministro de oxígeno a los tejidos, pero a largo plazo tiene consecuencias negativas que pueden afectar la calidad de vida y la supervivencia, por esto la corrección de la hipoxemia es fundamental en el tratamiento. con frecuencia las personas son reacias al uso de oxígeno por múltiples prejuicios; el profesional de enfermería debe motivarlas hacia el uso de éste por los beneficios que aporta: mejora el funcionamiento neurofisiológico, la capacidad para hacer ejercicio y las demás actividades de la vida diaria, fortalece el trabajo del corazón y mejora la insuficiencia cardíaca. la sobrevida aumenta en relación directa al tiempo de oxígeno administrado por día. el beneficio del uso crónico del oxígeno en los pacientes con epoc ha sido establecido en dos grandes estudios prospectivos, el medical research council working party trial en gran bretaña, y el nocturnal oxigen therapy trial (11) en estados unidos. en ambos la mortalidad en las personas con epoc hipoxémicos disminuyó al aumentar el número de horas de utilización del oxígeno al día. una revisión sistemática publicada en cochrane hace referencia al uso del oxígeno domiciliario para la enfermedad pulmonar obstructiva crónica, cuyo objetivo fue determinar el efecto de la oxigenoterapia domiciliaria en la supervivencia y calidad de vida en los pacientes con epoc. las búsquedas de esta revisión fueron actualizadas hasta enero de 2004, y se identificaron cinco ensayos aleatorios. la revisión concluyó que la oxigenoterapia a largo plazo mejoró la supervivencia en un grupo seleccionado de pacientes con hipoxemia grave. existen diferentes fuentes para la administración de oxígeno domiciliario: los cilindros de gas comprimido y los concentradores fijos de oxígeno que extraen o separan el oxígeno del aire ambiente. cuidados cuando se administra oxígeno a través de un cilindro evitar cubrir el cilindro. el equipo que se utiliza para administrar el oxígeno (cánula, humidificador) se debe lavar frecuentemente (2-3 veces por semana), y descontaminarlo con agua más hipoclorito de sodio. se enjuaga con agua corriente. el agua del humidificador debe estar en el nivel indicado. debe utilizarse agua de la llave para el humidificador y esta debe cambiarse todos los días. vigilar el manómetro con el fin de evaluar la cantidad de oxígeno que contiene el cilindro. cuando indique 500 lb es importante preparar el cambio de este. al momento de hacer el reemplazo el manómetro debe estar cerrado, de lo contrario se puede deteriorar (12). cuidados cuando se administra oxígeno con concentrador asegurar el nivel del agua del humidificador. lavar frecuentemente (cada 8 días) el filtro que posee en la cara posterior. utilizarlos siempre con estabilizador de voltaje. el método ideal para la administración de oxígeno es la cánula nasal con un flujo de 1,5 a 2,5 l/min (máximo 4 l/min), con el cual se puede lograr un pao 2 óptima, sin embargo, se recomienda ajustar la dosis de acuerdo con la gasometría u oximetría. durante el sueño es recomendable un flujo mayor de 1 l/min al usado durante el día al igual que durante el ejercicio. con el propósito de ahorrar oxígeno y disminuir costos, se dispone en el mercado –aunque no muy popularizado– cánulas nasales con un sistema de ahorro de oxígeno que almacena en una cámara pequeña el oxígeno proveniente del cilindro durante la espiración, y lo suministra durante la fase inicial de la inspiración, o un sistema de válvulas electrónicas que activadas por la inspiración suministran oxígeno y se cierran durante la espiración. es fundamental que el usuario y la familia tengan claro que los riesgos de toxicidad por oxígeno son poco frecuentes con la administración de éste a flujos bajos, sin embargo, puede presentar retención de co 2 e hipoventilación cuando no se determina adecuadamente la dosificación. el mayor riesgo del oxígeno domiciliario se relaciona con quemaduras en la cara y la nariz, que se producen por fumar cerca de la fuente de oxígeno. plan de alta para personas con enfermedad pulmonar obstructiva crónica. discharging plan for chronic obstructive pulmonary disease patients 115 espiritualidad diagnóstico de enfermería: riesgo de sufrimiento espiritual relacionado con la incapacidad de integrar el significado y propósito de la vida con el yo y los demás, secundario a sentimientos de abandono, impotencia y limitación física. meta: alcanzar un crecimiento personal y espiritual que le permita el disfrute de la vida a pesar de las limitaciones. intervención: la espiritualidad implica relaciones intersubjetivas y autoconciencia, da significado al ser, saber y hacer. esta dimensión permanece en los seres humanos, algunos la viven intensamente, otros la menosprecian. sin embargo, en situaciones difíciles de la vida, como la pérdida de la salud, surge la angustia espiritual que conduce a la persona a la el mayor riesgo del oxígeno domiciliario se relaciona con quemaduras en la cara y la nariz, que se producen por fumar cerca de la fuente de oxígeno. búsqueda del sentido del dolor, del sufrimiento, de las pérdidas y de la muerte, lo lleva hacia dios y hacia otros apoyos significativos. se ha reconocido la relación entre la espiritualidad y la salud, “la evidencia deja ver con claridad que las prácticas espirituales, y en especial las que se realizan dentro del marco de la cultura religiosa organizada, se asocian con mejores estados de salud, menor depresión, mejores hábitos y menor mortalidad” (13). el profesional de enfermería debe considerar la historia religiosa de la persona, sus prácticas, recursos espirituales, los sentimientos que tiene acerca de las pérdidas y del significado de su enfermedad con el fin de orientar al paciente y a su familia para que esta dimensión del cuidado tenga un ambiente propicio para su desarrollo (14). referencias 1. albert r, spiro s, jett j. enfermedad pulmonar obstructiva crónica. en: tratado de neumología, madrid: ediciones harcourt; 2001, p. 372. 2. maldonado d, bolívar f, caballero a, et al. recomendaciones para el diagnóstico y el manejo del paciente con enfermedad pulmonar obstructiva crónica – epoc. revista colombiana de neumología 1997; (supl: 9): s9. 3. lamban d, molina j, naberan k. epoc: definición, diagnóstico y clasificación. programa de formación en epoc en atención primaria; 2002: 13. 4. rodríguez m, sánchez m. efectividad de una intervención educativa individual y en grupo en pacientes con enfermedad pulmonar obstructiva crónica. enfermería clínica 2003; 13(3)4: 133-134. 5. hunter a, carey m. the nutritional status of patients with chronic obstructive pulmonary disease. am rev. respir bis 1981; 124:376-381. citado por el comité de educación de fenalpe. nutrición en enfermedad crónica. en: terapia nutricional total; 1997, p. 154. 6. giraldo h. manejo integral del paciente con epoc. 1 ed. bogotá: neira impresores; 1993, p. 97. 7. brown s, light r. what is now know about protein – energy depletion: when corp patients are malnourished. respir dis 1983; 436-50. citado por el comité de educación fenalpe. nutrición en enfermedad crónica. en terapia nutricional total; 1997, p. 154. 8. barnes p. enfermedad de la vía aérea: farmacologia de la vía aérea. en: albert r, spiro s, jett j. tratado revista aquichan issn 1657-5997 116 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 de neumología. madrid: harcourt. mosby; 2001, pp. 37-10. 9. maldonado d, bolívar f, caballero a, et al. recomendaciones para el diagnóstico y el manejo del paciente con enfermedad pulmonar obstructiva crónica – epoc. revista colombiana de neumología 1997; (supl: 9)s9: 520. 10. en: url: www.cochrane,ihcai.org-/programa-seguidadpaciente-costa-rica-tratamiento.epoc.agosto 2005. 11. long term domiciliary oxygen therapy in chronic hipoxic cor pulmonate complicating chronic bronchitis and enphysema. report of the medical research council working party; skeletal muscle adaptation to endurande training in patients with chronical obstructive pulmonary disease. lancey 1981; 28: 681-6; continuous or nocturnal oxygen therapy in hipoxemix chronical obstructive lung disease: a clinical trial. natural oxygen therapy trial group: an intern med. 1980; 93:391-8, citados por celli b, benditt j, albert r. enfermedad pulmonar obstructiva crónica. en tratado de neumología; 2001, pp. 13-37. 12. calderón c, sáenz x. pacientes con oxigeno. atención domiciliaria al paciente neurologico. 13. ross, l. nurses perception of spiritual care. avebury: sydney; 1997, p. 5-23. coyle j. spirituality and health: towards a framework for exploring the relationship between spirituality and health. journal of advanced nursing 2002; 37(6): 589-597. spiritual copong strategies: a revivir the nursing research literature. journal of advanced nursing 2001; 34(6): 833-841. citado por sánchez b. dimensión espiritual del cuidado en situaciones de cronicidad y muerte. en: aquichan 2004; (4): 6-9. 14. quintero mc. espiritualidad y afecto en el cuidado de enfermería. en: grupo de cuidado y práctica de enfermería. bogotá: unibiblos; 2000, pp. 184-191. << /ascii85encodepages false /allowtransparency false /autopositionepsfiles true /autorotatepages /all /binding /left /calgrayprofile (dot gain 20%) /calrgbprofile (srgb iec61966-2.1) /calcmykprofile (u.s. web coated \050swop\051 v2) /srgbprofile (srgb iec61966-2.1) /cannotembedfontpolicy /warning /compatibilitylevel 1.4 /compressobjects /tags /compresspages true /convertimagestoindexed true /passthroughjpegimages true /createjdffile false /createjobticket false /defaultrenderingintent /default /detectblends true /detectcurves 0.0000 /colorconversionstrategy /leavecolorunchanged /dothumbnails false /embedallfonts true /embedopentype false /parseiccprofilesincomments true /embedjoboptions true /dscreportinglevel 0 /emitdscwarnings 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/untaggedcmykhandling /leaveuntagged /untaggedrgbhandling /leaveuntagged /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 80 94 suporte aos pais que vivenciam.indd 80 larissa rodrigues lari1 antonieta keiko kakuda shimo2 elenice valentim carmona3 maria helena baena de moraes lopes4 claudinei josé gomes campos5 suporte aos pais que vivenciam a perda do fi lho neonato: revisão de literatura6 1 orcid.org/0000-0001-8714-7010. universidade estadual de campinas, brasil. l161735@dac.unicamp.br 2 orcid.org/0000-0001-7377-4590. universidade estadual de campinas, brasil. akkshimo@unicamp.br 3 orcid.org/0000-0001-9976-3603. universidade estadual de campinas, brasil. carmona@unicamp.br 4 orcid.org/0000-0001-7747-1140. universidade estadual de campinas, brasil. mhbaena@g.unicamp.br 5 orcid.org/0000-0001-9587-6694. universidade estadual de campinas, brasil. ccampos@unicamp.br 6 agradecimentos ao conselho nacional de desenvolvimento científico e tecnológico (cnpq) pela concessão de bolsa de mestrado à primeira autora. recibido: 20 de abril de 2017 enviado a pares: 04 de mayo de 2017 aceptado por pares: 18 de julio de 2017 aprobado: 05 de septiembre de 2017 doi: 10.5294/aqui.2018.18.1.8 para citar este artículo / to reference this article / para citar este artigo lari lr, shimo akk, carmona ev, de moraes mhbl, campos cjg. suporte aos pais que vivenciam a perda do filho neonato: revisão de literatura. aquichan. 2018; 18(1): 80-94. doi: 10.5294/aqui.2018.18.1.8 resumo objetivos: investigar e discutir publicações acerca do suporte relacionado ao luto de pais que vivenciam a perda do filho neonato. material e método: revisão crítica de literatura com busca nas bases de dados cinahl, embase, pubmed, psycinfo e scopus, de artigos publicados entre janeiro de 2010 e julho de 2017, utilizando análise temática para o tratamento dos dados coletados. resultados: foram construídas três categorias temáticas: 1) apoio e suporte aos pais que vivenciam a experiência da perda do filho neonato; 2) sentimentos dos pais ante situações de morte e desfechos do luto e 3) participação dos pais no processo de tratamento e prognóstico do filho. foram destacadas algumas necessidades: melhor preparo dos profissionais, comunicação adequada, formação de memória do neonato, envolvimento dos pais no processo de morte. conclusões: a diversidade cultural na experiência de luto fica evidente e deve ser considerada no cuidado ao enlutado; a continuação do vínculo com familiares após o processo de morte/morrer do neonato pode ser fonte de prevenção de transtornos durante o luto. refletir sobre diretrizes, políticas e formação curricular ampliada pode trazer diferencial à equipe de saúde na assistência ao luto e, portanto, à saúde mental. palavras-chave acontecimentos que mudam a vida; neonatologia; pais; pesar; recém-nascido (fonte: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 80-94 81 suporte aos pais que vivenciam a perda do filho neonato: revisão de literatura l larissa rodrigues lari e outros año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 80-94 soporte a los padres que vivencian la pérdida del hijo neonato: revisión de literatura resumen objetivos: investigar y discutir publicaciones acerca del soporte relacionado al duelo de padres que vivencian la pérdida del hijo neonato. material y método: revisión crítica de literatura con búsqueda en las bases de datos cinahl, embase, pubmed, psycinfo y scopus, de artículos publicados entre enero del 2010 y julio del 2017, utilizando análisis temática para el tratamiento de los datos recolectados. resultados: se diseñaron tres categorías temáticas: 1) apoyo y soporte a los padres que vivencian la experiencia de la pérdida del hijo neonato; 2) sentimientos de los padres ante situaciones de muerte y duelo, y 3) participación de los padres en el proceso de tratamiento y pronóstico del hijo. se destacaron algunas necesidades: mejor preparación de los profesionales, comunicación adecuada; formación de memoria del neonato, vínculo de los padres en el proceso de muerte. conclusiones: se evidencia la diversidad cultural en la experiencia de duelo, la que se debe considerar en el cuidado al enlutado; la continuidad del vínculo con familiares luego del proceso de muerte/morir del neonato puede ser fuente de prevención de trastornos durante el duelo. reflexionar sobre directrices, políticas y formación curricular ampliada puede traer diferencial al equipo de salud en la asistencia al duelo y, por ende, a la salud mental. palabras clave hechos que cambian la vida; neonatología; padres; pesar; recién nascido (fuente: decs). 82 aquichan issn 1657-5997 eissn 2027-5374 support for parents who experience the loss of a newborn child: a literature review abstract objectives: research and discuss publications on support for grieving parents who have lost a newborn child. materials and method: the cinahl, embassy, pubmed, psycinfo and scopus databases were searched for a critical review of literature. the focus was on articles published between january 2010 and july 2017. the collected data were subject to a thematic analysis. results: three thematic categories were created: 1) support and assistance for parents who experience the loss of a newborn child; 2) the feelings of parents in situations involving death and grief; and 3) participation of the parents in their child’s treatment and prognosis. several needs were highlighted; namely, better preparation on the part of medical professionals, adequate communication, formation of a memory of the newborn, the parental bond in the process of death. conclusions: cultural diversity is evident in the mourning experience and should be taken into account when caring for the mourner. the continuity of the bond with family members after the death / dying process involving a newborn can help to prevent disorders during grief. reflecting on guidelines, policies and expanded curricular training can make a difference for the health team in terms of assistance during grief and also when it comes to mental health. keywords life-changing events; neonatology; parents; to weigh; newborn child (source: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 80-94 83 suporte aos pais que vivenciam a perda do filho neonato: revisão de literatura l larissa rodrigues lari e outros introdução a morte de um filho traz grande impacto na vida dos pais, em âmbito pessoal, conjugal, familiar e social (1-5). há características particulares quando esse filho é um neonato, por terem sido repentinamente truncadas as expectativas criadas durante a gestação (1-6). a morte neonatal não parece ter lógica diante dos avanços científicos e tecnológicos na área de assistência à saúde, tanto no acompanhamento pré-natal do setor primário quanto no contexto da unidade de terapia intensiva neonatal (utin). as mortes dos bebês no período perinatal têm ocorrência registrada por volta de 2,6 milhões por ano no mundo (7). cada uma dessas mortes é acompanhada por grande tristeza e aflição, não só para os pais e familiares (8), como também para os profissionais de saúde. além dos pais, todos os parentes podem carregar sintomas psicológicos negativos no período pós-morte (9-10) e são vistas consequências extensas nas famílias (11). existem gastos econômicos com a morte: despesas com funerais e investigação da causa, mas o maior custo é inatingível, pois está relacionado com tristeza, ansiedade e medo, o que evidencia a necessidade de estratégias de apoio a essa população (12-14). durante o luto, pode haver experiências de ansiedade, estresse pós-traumático, ideação suicida, pânico e fobias (15-16), depressão, aumento do risco para diabetes e câncer, internações psiquiátricas e suicídio (17). assim, estudar o período perinatal é fundamental para pensarmos sobre a adequada assistência a esse grupo (18), especialmente acerca da saúde mental com foco na prevenção de agravos de saúde individual e de caráter social. a literatura atual aponta a existência de lacuna no conhecimento dos cuidados de saúde mental perinatal. portanto, são necessários estudos que possam preenchê-la assim como a utilização destes para formular ações direcionadas ao cuidado dessas mulheres e de seus familiares (19). então, destacamos como objetivo deste estudo investigar e discutir as publicações relacionadas ao suporte ao luto de pais que perderam filhos recém-nascidos com a finalidade de sintetizar o conteúdo sobre o tema e delimitar a lacuna da literatura associada a esse processo. material e método trata-se de uma revisão crítica da literatura que segue as premissas da revisão integrativa, método que reúne e sintetiza resultados de pesquisas sobre um delimitado tema ou questão (20-21). seguimos, por isso, seis passos bem-definidos: 1º) elaboração de uma hipótese ou questão de pesquisa; 2º) amostragem ou busca na literatura; 3º) categorização dos estudos; 4º) avaliação e análise dos estudos com potencial para inclusão na revisão; 5º) interpretação dos resultados e 6º) síntese do conhecimento e apresentação da revisão (22). para a execução desta revisão, foram explorados os estudos que discutem questões acerca dos pais no contexto da morte dos neonatos, compreendidas as seguintes atividades nas fases do processo: • 1ª etapa: elaboração da questão norteadora “como é a experiência dos pais no luto pela morte do filho neonato em relação ao suporte e apoio oferecidos?”; • 2ª etapa: busca pelas publicações nas bases de dados cinahl, embase, pubmed psycinfo e scopus, utilizados os seguintes descritores do medical subject headings (mesh): “infant, newborn” and parents and grief or mourning; • 3ª etapa: estabelecimento dos critérios de inclusão: 1) período de publicação entre 2010 e 2017, 2) método descrito de forma compreensível, 3) discussão com foco e relevância sobre o tema proposto e 4) contribuição para responder à questão norteadora. estabelecimento dos critérios de exclusão: 1) estudos acerca de pais enlutados por filhos adultos e 2) estudos que abordam a experiência de profissionais de saúde. a figura 1 apresenta o processo de busca e exclusão de artigos; • 4ª etapa: após a leitura dos títulos e resumos, 71 artigos com potencial para inclusão foram selecionados, lidos na íntegra e avaliados minuciosamente pelos autores. para a coleta de dados, utilizamos um instrumento (23) que permitiu a pormenorização dos dados relevantes de cada texto lido em formato de fichamento, o que facilitou a integração dos dados na discussão crítica; • 5ª etapa: a partir da leitura analítica, foram excluídos os artigos que não contribuíram para a construção da reflexão proposta e foram descritas unidades temáticas para a discussão. a análise dos dados coletados foi realizada sob os princípios 84 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 da análise temática (24), que segue a lógica de elencar categorias principais e agrupar informações a partir dos temas nelas contidos; • 6ª etapa: realização da discussão com base nos temas encontrados e considerações acerca das conclusões dos artigos e desta revisão; formatação final do estudo. figura 1. esquema representativo do processo de busca e exclusão de artigos fonte: elaboração própria. resultados pontos relevantes foram encontrados nos textos analisados e deram origem às categorias e subcategorias, fazendo pensar nas características necessárias aos profissionais e às instituições onde os sujeitos enlutados se encontram, e sobre o vínculo existente entre os enlutados e os serviços de assistência. utilizamos as denominações a seguir. • categoria a — apoio e suporte aos pais que vivenciam experiência da perda do filho neonato: o tipo de atendimento recebido pelos pais; os grupos de apoio ao enlutado; a formação de memória da criança que morreu; o apoio espiritual; a comunicação; a autonomia dos pais nos cuidados recebidos no processo de morte e morrer; o suporte da família e da comunidade. • categoria b — sentimentos dos pais ante a situação de morte: a aflição; o sentimento de tristeza e melancolia; a gratidão; • categoria c — participação dos pais no processo de tratamento e prognóstico do filho: a autonomia; a invisibilidade do luto. além disso, durante nossas leituras, observamos que os estudos a respeito do luto parental neonatal começaram a ser publicados em 1970 (25), mas foi durante a década de 1980 que o número de estudos publicados cresceu, e o tema foi consolidado para a discussão da assistência à saúde. com o propósito de investigar as discussões na atualidade, percebemos que o luto está dividido em temas quando a discussão é direcionada ao suporte e cuidado à saúde do enlutado. esses temas relacionados são explorados de formas diferentes em cada período, e, em diversos países, os estudos foram desenvolvidos com ênfase nas preocupações ou necessidades locais em cada momento. portanto, apontamos brevemente como o tema está localizado em cada período na figura 2. discussão podemos compreender que o luto requer grande movimentação por parte de quem o experimenta em virtude da perda de alguém amado (26-27) e mesmo por parte de quem atende os sujeitos enlutados (28-29). nesta seção, são apontadas as categorias e subcategorias emergentes nos resultados, e nelas há material para discutir acerca do suporte ao enlutado. categoria a — apoio e suporte aos pais que vivenciam a experiência da perda do filho neonato emerge do que nos é trazido sobre o significado de apoiar e dar suporte aos pais que passam pela experiência de perda, dando sentido às ações externas esperadas dentro dos serviços ou extrapolando a instituição e abarcando a família e a comunidade. 85 suporte aos pais que vivenciam a perda do filho neonato: revisão de literatura l larissa rodrigues lari e outros quadro 1. artigos incluídos dispostos em ordem cronológica autor e data objetivos desenho do estudo conclusões país base einaudi et al. (51) (2010) • compreender a resposta dos pais à morte perinatal. • entender as necessidades dos pais em um esforço para melhorar as intervenções para enlutados. questões abertas foram desenvolvidas para obter informações de pais que perderam uma criança durante o período perinatal no centro hospitalar universitário norte em marselha. nosso estudo revela a necessidade dos pais nas atitudes em relação à tomada de decisão ética e mostra que é difícil para os cuidadores de medicina perinatal respeitar a autonomia dos pais. frança pubmed rosenbaum, smith e zollfrank (37) (2010) • explorar a literatura de cuidados espirituais. • compartilhar narrativas de pais que experimentaram a perda de seu bebê em utin. estudo teórico que traz questões da prática em saúde e narrativas de mães. à medida que os profissionais de saúde se tornam mais conscientes das crenças religiosas e espirituais das famílias, eles se sentirão mais preparados para incorporar cuidados espirituais para apoiar as famílias na utin. estados unidos da américa (eua) scopus greeff, vansteenwegen e herbiest (50) (2011) • identificar e descrever qualidades de resiliência em famílias depois de perder uma criança. foram utilizados questionários que incluíam perguntas abertas para coletar dados; os participantes foram abordados individualmente em 89 famílias belgas. forças familiares de compromisso com a família em particular ajudaram na adaptação das famílias após a perda. apoio recebido de pessoas que já passaram por perdas na comunidade foi considerado importante para a redefinição de uma nova situação social. auxílio de profissionais foi fornecido quando considerado necessário pela família. bélgica psycinfo roose e blanford (49) (2011) • identificar e avaliar a utilização por irmãos e avós de um serviço de educação para o enfrentamento de perdas em relação a toda a família. avaliação do serviço de educação, coleta de relatos de pais e avós, acompanhamento e observação dos pais. os pais indicaram que, quando irmãos e avós foram incluídos no serviço, o suporte foi útil para toda a família. eua psycinfo branchett e stretton (31) (2012) • determinar o que os pais experimentaram em relação ao final da vida neonatal. • determinar como esse conhecimento poderia ser usado para melhorar experiências no futuro. realização de entrevistas com 54 mães e 3 pais. foi utilizada análise temática. as famílias não podem levar com elas o bebê, simplesmente lembranças e fotos. sua experiência do cuidado influenciará sua percepção dos eventos e será carregada com eles para sempre. reino unido (united kingdon — uk) scopus tejedor et al. (44) (2013) • estimular a reflexão sobre uma “boa morte”. • fornecer ferramenta para facilitar a tomada de decisões. • fornecer orientação aos procedimentos operacionais, de acordo com a boa prática clínica. neste trabalho, o grupo de trabalho de ética da sociedade espanhola de neonatologia reflete sobre a tomada de decisão durante o processo de morrer. os aspectos éticos são revisados, incluindo limites de tratamento. destaca a importância de cuidar da família em uma situação complexa e de grande sofrimento, quando confrontado com a recomendação de profissionais para limitar o tratamento por mau prognóstico do filho. espanha pubmed woodroffe (6) (2012) • reflexão teórica acerca de experiências clínicas. o sofrimento percebido nos pais na situações de internação e morte de seu bebê é discutido com base na teoria do luto. a valorização dos temas: o mundo psicológico das famílias, comunicação, emoção familiar / cultura da morte, cuidados paliativos, mortes hospitalares, gravidez futura. uk pubmed abib el halal et al. (43) (2013) • explorar as perspectivas dos pais sobre a qualidade do atendimento oferecido a eles e à criança terminal em seus últimos dias de vida em duas unidades de tratamento intensivo (uti) brasileiras. estudo qualitativo, exploratório, descritivo. 13 pais participaram das entrevistas com duração média de 30 minutos. foi utilizada análise temática. as prioridades dos pais em unidade de terapia intensiva pediátrica (utip) são informações completas, honestas e claras, e manutenção da dignidade no processo de morrer. brasil cinahl vasilescu, garel e caeymaex (53) (2013) • descrever como os pais de gêmeos, sendo um morto e um sobrevivente, vivenciam e lidam com a perda em longo prazo. foram realizadas entrevistas semiestruturadas três anos após a perda. entre os 166 pais participantes, 26 perderam um gêmeo recém-nascido em 4 utin na frança. na perda de um dos filhos, a questão não é somente a tristeza intensa, mas sim a coexistência de fortes sentimentos contraditórios: alegria e tristeza, esperança e desespero, investimento e desapego. frança pubmed 86 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 autor e data objetivos desenho do estudo conclusões país base youngblut et al. (8) (2013) • investigar a saúde e o funcionamento dos pais hispânicos, negros e brancos durante os 13 meses após a morte na utin/utip. os pais (176 mães, 73 pais) de 188 bebês ou crianças falecidos foram recrutados de 4 utin, 4 utip. treze meses após a morte do bebê ou da criança, 72 % dos pais permaneceram juntos, 2 mães tiveram câncer, os pais tiveram 98 hospitalizações (29 % relacionadas com estresse) e 132 condições de saúde crônica recém-diagnosticadas, 35 % das mães e 24 % dos pais tiveram depressão, e 35 % das mães e 30 % dos pais transtorno pós-traumático, 1 mãe tentou suicídio uma semana após a morte do filho; mais mães hispânicas e negras do que mães brancas tiveram depressão aos seis meses após a morte do bebê/filho. eua pubmed sisay et al. (52) (2014) • explorar valores relacionados à mortalidade neonatal, à morte fetal e à visibilidade dessas mortes na etiópia rural entre três gerações de mulheres. estudo qualitativo em seis distritos rurais dos estados regionais de oromiya e amhara durante o mês de maio de 2012. incluímos 30 grupos focais que representam avós, mulheres casadas e meninas solteiras selecionadas aleatoriamente. a invisibilidade dos neomortos e das mortes neonatais é complexa e profundamente enraizada em construções sociais da personalidade em contextos de alta mortalidade como a etiópia. essa invisibilidade impede investimentos adequados, estrutura sanitária e programação de melhorias. o desenvolvimento de um sistema nacional de registro vital, políticas de sistemas de saúde e intervenções de comunicação de mudança de comportamento são necessários para as mortes perinatais e também para as mortes maternas. etiópia embase flenady et al. (35) (2014) • refletir sobre a perda perinatal. estudo de revisão de conceitos da literatura. a morte perinatal é um dos eventos mais profundamente angustiantes que qualquer pai experimentará. essas mortes não são incomuns, mas muitas vezes são escondidas, juntamente com o sofrimento das mães, dos pais e das famílias. o estigma social e as atitudes negativas estão indissociavelmente ligadas à subnotificação das mortes de bebês em países de baixa e média renda. esse é um problema de saúde pública. uk pubmed tseng, chen e wang (41) (2014) • retratar o processo de recuperação de mulheres taiwanesas após a perda de seu recém-nascido. os dados foram gerados através de entrevistas individuais em profundidade com 21 mulheres selecionadas, usando amostragem proposital. três estágios foram encontrados em um período de recuperação emocional: sofrendo de tristeza silenciosa, procurando uma saída e alcançando paz e estabilidade mental. os resultados podem informar os profissionais de saúde no fornecimento de cuidados culturalmente sensíveis às mulheres taiwanesas para facilitar a cura após uma perda. taiwan pubmed sutan e miskam (30) (2012) • explorar e descrever o impacto psicossocial e o apoio social após a perda perinatal entre mulheres muçulmanas. estudo qualitativo realizado em um centro especializado entre 16 mães que tiveram perda perinatal recente de gravidez desejada e receberam acompanhamento prénatal público ou privado com entrevistas semiestruturadas e grupos focais. todas as mães mostraram algum nível de impacto psicossocial que afetou seus sentimentos. na prática muçulmana, temos que aceitar a fé de deus e encorajar o pensamento positivamente em qualquer evento estressante. entre a etnia malay com fundo muçulmano, a tomada de decisão é ainda dependente do marido. malásia pubmed mcguinness (34) (2015) • discutir o tema “maternidade” e o subtema “mães em sofrimento”. uma abordagem etnográfica qualitativa foi utilizada para explorar as perspectivas das mães enlutadas de uma maternidade em dublin. cuidados empáticos apoiam o desenvolvimento da identidade materna; a criação de memórias são ações reconfortantes para mães enlutadas. irlanda cinahl jordan, price e prior (48) (2015) • explorar experiências de pais ao longo da trajetória da doença da criança e na subsequente morte. o estudo adotou uma abordagem qualitativa interpretativa. foram realizadas entrevistas face a face com 25 pais (16 mães e 9 pais) de crianças que morreram. a questão da necessidade de contato permanente dos pais com os profissionais envolvidos com o cuidado de seus filhos e o final típico de tal contato logo após a morte de sua criança destaca uma disjunção fundamental entre a experiência subjetiva de liminaridade e a de individualidade. uk cinahl 87 suporte aos pais que vivenciam a perda do filho neonato: revisão de literatura l larissa rodrigues lari e outros autor e data objetivos desenho do estudo conclusões país base rosenbaum et al. (40) (2015) • testar o efeito de um dvd de apoio sobre o luto neonatal após a morte do bebê em uma utin. comparamos os pais que assistiram ao dvd com os pais que não assistiram ao dvd. os pais que assistiram ao dvd relataram menor sofrimento aos três meses de luto em comparação com os que não assistiram ao dvd. eua cinahl shelkowitz et al. (33) (2015) • explorar as percepções dos pais sobre o aconselhamento recebido sobre as opções de cuidados no final da vida de seus bebês. pais enlutados entre 1 e 6 anos após a perda escolheram entre entrevistas online, pesquisa em papel ou entrevistas por telefone. embora os pais tenham percepções diferentes em suas preferências, compartilham uma preferência comum: que lhes seja oferecida a oportunidade de conhecer as opções de tratamento e que sejam guiados e apoiados por profissionais capacitados. eua pubmed scholtes e browne (32) (2015) • examinar a relação entre continuing bonds e os resultados do sofrimento para os pais enlutados. 354 participantes (10 homens) foram recrutados a partir de suporte de grupos on-line e completaram um questionário na internet. ligações claras entre os laços internalizados e um status de sofrimento mais positivo em relação a laços externalizados que mostram uma relação oposta. foram encontrados efeitos diferentes em relação ao tempo de vida da criança, ao tempo desde a morte e ao tipo de morte. austrália cinahl brooten et al. (36) (2016) • examinar os rituais (funerais, enterros, celebrações) de pais brancos, negros e hispânicos pósmorte em utin. • avaliar a saúde e o funcionamento dos pais após a morte de uma criança na uti. a amostra de 63 pais (brancos não hispânicos, negros não hispânicos, hispânicos/ latinos) que foram recrutados de quatro hospitais no sul da flórida. entrevistas semiestruturadas foram utilizadas. o sofrimento é intensificado especialmente para os pais recém-imigrados e aqueles com barreiras idiomáticas, em que fazer arranjos é especialmente difícil e muitas vezes ficam muito isolados. eua cinahl hawthorne, youngblut e brooten (39) (2016) • testar as relações entre espiritualidade/religiosidade e estratégias de enfrentamento e sofrimento, saúde mental e crescimento para mães e pais em 1 e 3 meses após a morte do bebê/ criança na utin. a amostra para este estudo consistiu em 165 pais (114 mães, 51 pais) de 124 recémnascidos/crianças (69 utin e 55 utip) recrutados em 4 uti. estratégias e atividades espirituais ajudaram os pais a lidarem com sua dor e ajudaram mães a manterem sua saúde mental e experimentarem crescimento pessoal. eua cinahl sereshti et al. (42) (2016) • avaliar a percepção das mães sobre a qualidade dos serviços de saúde após a perda perinatal. os dados foram coletados entre 20142015, com 40 mães que vivem em teerã e shahrekord, irã, através de entrevistas semiestruturadas, em profundidade; foi utilizada a análise qualitativa de conteúdo para o tratamento dos dados. um tema e seis categorias principais foram desenvolvidos, e indicaram as experiências e compreensão da qualidade do serviço recebido após a perda perinatal. o tema principal era “insatisfação com a qualidade dos cuidados recebidos”. irã pubmed youngblut et al. (46) (2016) • descrever as mudanças no sofrimento das mães e dos pais de 1 a 13 meses após a internação em uti infantil e identificar fatores relacionados ao seu sofrimento. foi utilizado o checklist reação hogan grief em 1, 3, 6 e 13 meses após a morte do filho. participantes: mães (n=130) e pais (n=52) de 140 crianças. o sofrimento diminuiu de 3 anos para 13 meses para as mães e de 3 a 6 meses para os pais. a intensidade do sofrimento das mães e dos pais pode não coincidir e resultar em necessidades diferentes. eua psycinfo fonte: elaboração própria. a palavra “apoiar” nas situações de perda se relaciona a prevenir e promover a diminuição de estresse (30). dar suporte remete a um processo de cuidados para que o sujeito seja capaz de comunicar-se livremente sobre sua experiência e os sentimentos nela envolvidos, com o objetivo de sentir-se aceito, respeitado e cuidado (30). o tipo de atendimento recebido pelos pais pode aliviar ou agravar as angústias durante o luto neonatal pelo contato possível entre os familiares do neonato e a equipe de saúde; assim, uma equipe bem-preparada para apoiar e disposta para o cuidado dos pacientes e familiares envolvidos no contexto da perda pode ser eficiente para o processo de luto individualmente. os grupos de apoio ao enlutado são um tipo de suporte oferecido em alguns locais e têm seus benefícios relatados, especialmente para mulheres (31). compartilhar as experiências e sentir a equipe de saúde posicionada em seu auxílio em momentos e espaços específicos pode fazer os pais sentirem-se mais bem preparados para o enfrentamento do luto. 88 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 figura 2. representação de temas publicados no período pesquisado fonte: elaboração própria. os grupos virtuais são uma tendência contemporânea (32). recentemente foram criados grupos on-line de apoio e memorial de pais enlutados. diante do avanço tecnológico e do amplo acesso à internet na atualidade, essa estratégia pode, potencialmente, minimizar fatores como a não adesão à oferta de suporte e a timidez em relação à expressão de sentimentos. a formação de memória da criança que morreu aparece em alguns estudos como atividade fundamental para trazer conforto no processo de luto (33-35), assim como a possibilidade dos pais terem contato com a criança morta antes do funeral (33). a inserção do bebê na memória familiar com ações que o envolvam como: tirar fotos, marcar os pés em algum tecido ou papel ou guardar roupas e cobertores por ele usados trazem benefícios como menos emoções negativas durante o processo de luto (31), formando a identidade do bebê e desestruturando a possível percepção de desvalorização que os pais possam ter, o que permite a personalização do bebê (34). tais ações precisam ser realizadas oportunamente e com respeito à decisão familiar quanto ao tipo e tempo desse contato, além de ser considerada a diversidade cultural (31, 38), como quaisquer outras possibilidades de ação junto aos pais dos neonatos, pois diferenças entre pessoas de distintas culturas e de gerações diferentes são relatadas (36). pais imigrantes relatam grande dificuldade de comunicação atribuída, especialmente, ao idioma e aos costumes do país onde vivem (36). as relações emocionais formadas com o bebê no período em que estava vivo dão origem aos laços entre pais e filho; esses laços são significativos após a morte do bebê. pais com bons momentos juntos ao filho, enquanto estava vivo, evidenciam completude emocional; enquanto pais que vivenciaram momentos de sofrimento emocional durante a vida do filho percebem tristeza intensa (32). o apoio espiritual deve existir aos pais quando o bebê está internado, pois, com isso, é relatado que há maior entendimento durante o luto, o que faz a perda ser mais bem-entendida em sua vida, devendo cada profissional da equipe de saúde ter preparo suficiente para tal auxílio, ou ainda incorporar à equipe uma figura religiosa específica, se for oportuno, como um capelão (37-38). há evidência de que atividades espirituais trazem menores sintomas de desespero, desorganização e depressão aos pais enlutados (39). encontrar significado e propósito para viver a situação pode ajudar os familiares a lidarem com a morte de seus filhos, o que diminui seus sintomas de dor e melhora sua saúde mental (39-40). em relação à preparação para o apoio espiritual dentro da equipe de saúde, é descrito, em determinado campo, que 76 % dos profissionais pediatras consideram a comunicação sobre espiritualidade importante, mas 51 % nunca ou raramente falaram 89 suporte aos pais que vivenciam a perda do filho neonato: revisão de literatura l larissa rodrigues lari e outros sobre isso com a família do paciente e somente 10 % têm isso como prática (37). outros profissionais não foram citados nesse tipo de atividade, o que evidencia lacuna. em algumas instituições, o apoio de conselheiros religiosos como capelão tem sido válido. especialmente em países onde a diversidade religiosa é grande, há dificuldade de uma preparação ecumênica para assim minimizar interferências de idealizações pessoais. seria necessário incorporar nos currículos da área de saúde temas que remetessem à reflexão sobre espiritualidade e religiosidade; para tanto, há que se pensar na inserção do tema dentro do modelo biomédico dominante atualmente nas grades dos cursos dessa área. as práticas religiosas de cerimoniais de culto à morte como enterros, velórios, cremações são relatadas como ações positivas de despedida em relação à concretização do luto (31). a necessidade de respeito à diversidade de crenças e a disposição e preparação dos profissionais para essa comunicação devem ser consideradas. os orientais, por exemplo, relatam experiência de busca espiritual pelo contato com o bebê e estágios bem distintos no enfrentamento familiar do luto de tristeza, busca por recuperação e paz mental (41). a comunicação adequada é evidenciada como extrema necessidade no processo de perda (6, 33, 40), pois os pais sentem a dificuldade de comunicar-se e percebem a mesma dificuldade por parte da equipe (31), o que pode estar ligado a sentimentos de depressão e culpa (42-43). a informação adequada, a relação de confiança e a deliberação entre pais e profissionais podem auxiliar na tomada de decisão sobre o recém-nascido (44). o momento da comunicação da notícia da morte é crucial para o desenvolvimento do luto saudável. empatia, promoção de espaço e tempo com privacidade, entendimento, sensibilidade e apoio contínuo são relatados como necessidades dos pais no processo de perda no reino unido (31). encontramos a definição de “comunicação”, em um dos estudos incluídos, que compreende desde o espaço físico adequado, com ambiente tranquilo e cômodo, privacidade e possibilidade de manter conversas sem interrupções, até relações de confiança mútua. como condições prévias, indicam-se: disposição para escuta, informação com quantidade e qualidade adequadas, progressiva e gradual, consistente e sem contradições, compreensível, sensível, individualizada e com tempo suficiente para a expressão de sentimentos, valores e expectativas, além do gerenciamento do silêncio. ademais, incluem-se os registros das decisões tomadas como parte de uma comunicação adequada (44). em estudo com mães muçulmanas, selecionado nesta pesquisa, a maior parte das entrevistadas apontou que gostaria de uma comunicação mais clara sobre a morte do filho e sentiu como se o bebê fosse pouco representativo para os profissionais, desde o nascimento (30). a autonomia dos pais nos cuidados recebidos no processo de morte e morrer é desejada no processo de luto. diretrizes para os cuidados em uti de alta complexidade são seguidas em serviços do reino unido (45), onde fica determinado que se deve atender às necessidades das famílias nos períodos pré e pós-morte, e por período prolongado e indeterminado, inclusive com o auxílio em posteriores gestações. nos eua e no reino unido, os cuidados individualizados e a oferta de diferentes tipos de apoio começam a ser considerados, tendo como resultado as diferenças relatadas entre os sofrimentos de pais e mães enlutados (6, 46). no geral, é mostrada a premissa de que nem todos os pacientes e familiares podem ser beneficiados com o atendimento em serviços com práticas de excelência (47). essa questão é motivo de discussão por parte dos pais e de questionamentos sobre qualidade de atendimento recebido (33, 42). isso denota diferença de atendimento entre classes sociais e econômicas, o que reforça a heterogeneidade na garantia de direitos entre as pessoas. a questão do acompanhamento da criança em uti (33) é debatida fortemente, pois há obrigatoriedade de um dos pais ou responsável presente em tempo integral durante a internação de menores, porém a presença do acompanhante é parcialmente possível ou permitida somente em período de visitação por questões ainda não vencidas, como a falta de estrutura física e acomodação ou a dificuldade em lidar com familiares durante a hospitalização na maioria das unidades. falar da morte do filho e retornar ao hospital mostram-se como ponto positivo e remetem à sensação de paz pelos pais que participaram de um dos estudos analisados (31); por outro lado, há falta de estratégias e critérios bem-definidos para o suporte à vida, o que dificulta atitudes profissionais e participação dos pais no processo de morrer da criança. 90 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 o atendimento à saúde e a qualidade de vida proporcionada à criança irão ao encontro, portanto, dos interesses dos pais e ao contexto social (48). outro estudo (40) discute sobre o estímulo em relação à reflexão acerca da morte neonatal com material didático preparado para os pais; essa atividade fez emergir sentimentos e, com isso, discussões acerca do que é esperado pelas famílias e sobre a abertura delas para receber apoio e suporte. ainda outro texto traz a experiência da formação de serviço de educação e apoio específico para o luto e os relatos de claros benefícios vivenciados pelos familiares dos frequentadores (49). o suporte da família e da comunidade é querido pelos pais e já se encontra autonomia dos enlutados em direcionar a busca por encorajamento nesses grupos. o compromisso dos laços afetivos encontrados dentro da família representa grande apoio aos pais enlutados da bélgica; assim eles apontam que, além dela, a comunidade pode fornecer a reestruturação social após a perda e, somente quando são notadas insuficiências nesses dois grupos, os pais solicitam e recebem auxílio de profissionais da saúde, o que nos convoca a refletir sobre a formação da rede de cuidados (50). categoria b — sentimentos dos pais ante situações de morte e desfechos do luto é oriunda das falas expressas sobre o movimento interno percebido pelos pais no processo de morte do filho. a morte e o luto do filho serão enfrentados pelos pais de acordo com suas experiências anteriores relacionadas à morte e ao luto, pois os sentimentos e emoções gerados a partir desses acontecimentos serão vivenciados novamente no decorrer da vida, quando passarem por experiências semelhantes. os sentimentos envolvidos no processo de luto e a forma como serão reificados pelos pais constituirão o novo ser humano após essa experiência; assim, o compromisso de auxílio à promoção de saúde e à prevenção de doenças deve ser lembrado e ressaltado nos aspectos que envolvem o luto. os profissionais da saúde podem contribuir para a ressignificação da vida ou, simplesmente, por omissão ou imperícia, predispor os sujeitos a doenças psíquicas e físicas no decorrer do processo de luto. a aflição, o sentimento de tristeza e melancolia são esperados na dinâmica individual e familiar do luto; somente devem ser considerados preocupantes quando afetam rotinas da vida diária, com combinações de agravos cognitivos, emocionais, comportamentais, sociais e espirituais (37). entretanto, a observação e acompanhamento do processo de luto, junto ao auxílio especializado, deve ser uma prática organizada dentro das instituições de saúde. o abandono sentido pelos pais quando não há vínculo com serviços de oferta de apoio resulta em problemas acerca da saúde mental desses indivíduos, o que agrava um quadro social de deficiência em atendimento aos enlutados (34, 17). após um ano de luto, é relatado grande número de hospitalização, agravos de condições crônicas de saúde, ampla utilização de medicações e aparecimento de depressão; além disso, o rompimento do vínculo dos pais enlutados com os profissionais de saúde após a morte do filho pode fazer essas condições ficarem ocultas na prática assistencial (34, 17). equipes de saúde podem ter dificuldades com o imprevisível. o comportamento dos pais pode refletir raiva, medo, desconfiança, irracionalidade e exigência, o que gera dificuldades para o profissional despreparado (37). reafirmando que a relação com a espiritualidade e com outras formas de apoio trazem sentimentos de amor, confiança e esperança, o que reforça a necessidade de abordagem nesse contexto e de amadurecimento profissional, trazemos a importância da imparcialidade e da capacidade de lidar com esses sentimentos gerados pelo processo de luto que inevitavelmente atingirão a equipe em algum momento. a gratidão dos pais que relatam ter recebido apoio social e psicológico durante o luto pelos profissionais (43) fica registrada e é percebida como movimento confortante durante o luto. algumas intervenções são relatadas como eficientes no processo de morte/morrer dos neonatos e acabam por promover a valorização do vínculo entre família e serviço de assistência durante o processo de luto; exemplos dessas ações: a) permissão e incentivo a visitas de parentes e amigos da criança; b) treinamento para boa comunicação e c) discussão sobre casos específicos (43). há relatos da vontade dos pais em ter outros familiares envolvidos no processo de internação, morte/morrer do filho; assim, as visitas parecem ser fundamentais para alguns enlutados (39). 91 suporte aos pais que vivenciam a perda do filho neonato: revisão de literatura l larissa rodrigues lari e outros os pais sentem a necessidade de, além do entendimento estrutural da perda, concluir a experiência subjetiva em si, e, como pais enlutados que agora são, participar dos rituais relacionados ao filho e retornar às atividades sem pretensão de se tornarem novamente quem eram antes do acontecimento (51). inseridos em um contexto social restrito, entendem que os profissionais da saúde são como aliados nesse movimento (49). categoria c — participação dos pais no processo de tratamento e prognóstico do filho está relacionada com a expressão da necessidade de abertura a possibilidades de participação na vida e morte do filho sentida pelos pais. em um estudo selecionado, oriundo da frança, 50 % dos pais entrevistados sobre a qualidade do atendimento durante o processo de morte/morrer do filho relataram ter tido autonomia e poder nas tomadas de decisões, tiveram boa comunicação com a equipe de saúde e perceberam que suas crianças receberam tratamento necessário: de beneficência, a princípio e posteriormente, sem possibilidades terapêuticas, foram ofertados cuidados de não maleficência, podendo confortar-se pelo interesse demonstrado pela criança (52). a autonomia desejada por vezes não é sentida como possibilidade pelos pais. uma mãe, afastada do processo de morte do filho pelo pai da criança, não consegue manifestar seu ponto de vista (53). o que ratifica que a participação dos pais traz alguma concretização do luto (53). assim, os pais deixam expressa a queixa por não ter participado das decisões sobre os cuidados de seu filho, ou de não terem sido orientados adequadamente sobre esses cuidados e as opções existentes, tendo desrespeitadas as suas escolhas (33, 51, 53). alertando para as necessidades específicas dos pais enlutados (46) e voltando à importância da comunicação no processo de luto, sem a abordagem adequada aos pais e boas orientações, não é possível dar-lhes autonomia. trabalhar junto aos pais, processualmente pelo seu conhecimento do caso do filho e sua possibilidade de escolha, é fator marcante no processo de luto. no estudo brasileiro indexado nas bases de dados, a maioria dos pais declarou em entrevista a percepção de comunicação inadequada entre a equipe e a família, alegando que não foram informados com linguagem compreensível sobre o estado de seu filho, não entendendo a linguagem técnica da equipe e relatando, ainda, que não foram conhecedores das escolhas existentes para o tratamento dos filhos, e sim somente informados de decisões já tomadas (43). isso evidencia que a participação no processo de vida, morte e morrer do filho lhes foi negada. no momento da morte de seu filho, os pais desejavam privacidade e despedida fraterna, porém, diante do contrário, salientam a consideração de despreparo da equipe, principalmente do profissional médico (43). a invisibilidade do luto é culturalmente construída, mas também está relacionada à subnotificação dos óbitos de recém-nascidos; na etiópia, as mulheres indicaram que, embora sintam e lamentem a perda de seu filho, seus sentimentos são reprimidos pelas normas comunitárias; percebendo vivências de grande pesar, elas são encorajadas a não lamentar a perda. em algumas regiões desse país, especialmente por parte das pessoas mais velhas, acredita-se, por exemplo, que a mulher pode ter um espírito ruim dentro dela que propiciou a morte do recém-nascido (52). os autores afirmam que há a consciência da importância do registro desses óbitos para a saúde pública, mas, por convicções culturais, as famílias aceitam a imposição sobre manter o fato como inexistente, perpetuando a invisibilidade de seus bebês (52). considerações finais os profissionais de enfermagem precisam ter conhecimentos e práticas voltados para as ciências humanas e sociais de modo complementar; assim, temas como: comunicação, espiritualidade, escuta qualificada, preservação da autonomia e respeito à diversidade de comportamento precisam ser considerados. os profissionais da saúde devem ater-se às figuras parentais e à sua potencialidade para suporte dentro dos núcleos familiares. percebemos que a posição da figura paterna é pouco explorada na literatura, sendo necessárias novas pesquisas na área com vistas à atual valorização do trinômio familiar nos processos que envolvem a gestação, o nascimento e a criação dos filhos. a equipe necessita desenvolver habilidades de comunicação adequada e estabelecer bom uso dela durante o processo de morte dos neonatos. a abertura à participação dos pais nesse processo tem importância destacada nos textos. 92 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 o enfermeiro, junto à equipe, precisa estimular atividades de construção de memória e vínculo afetivo com o neonato falecido, questões de grande validade na incorporação da experiência do luto na vida familiar. o registro das mortes também deve ser uma preocupação do enfermeiro. grande atenção à forma de apoio espiritual e religioso é dada nos estudos, emergindo a necessidade de contextualização do tema por parte da equipe de saúde. um enfoque coletivo é dado à experiência de luto, mas a subjetividade parece ser pouco falada e explorada nos textos, tanto dos profissionais como dos pais enlutados e familiares. o enfermeiro deve prezar pela continuidade do vínculo entre o serviço de saúde e os familiares enlutados, pois, somente com o acompanhamento desses casos e o respeito à individualidade, poderemos discutir sobre a assistência a essa população. para finalizar, como limitação do estudo, temos que a busca foi realizada apenas nas principais bases de dados da área de saúde. por outro lado, o conhecimento agregado por meio deste trabalho traz síntese e crítica imediatas do cenário atual sobre o tema, além de fornecer subsídios para novas pesquisas e assistência ao enlutado. conflito de interesse: nenhum declarado. referências 1. frøen jf, friberg ik, lawn je, et al. the lancet ending preventable stillbirths series study group. stillbirths: progress and unfinished business. lancet 2016; 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mothers, and unmarried girls in rural amhara and oromiya regions, ethiopia: unheard souls in the backyard. j. midwif. womens health. 2014; 59(s1):s110-7. 53. vasilescu c, garel m, caeymaex l. vécu de parents ayant perdu un jumeau en réanimation néonatale : étude qualitative, 3 ans après le décès. arch. pédiatr.. 2013; 20(4):356-63. 105 115 valores personales en estudiantes.indd 105 francisca rosa jiménez-lópez1 jesús gil roales-nieto2 guillermo vallejo-seco3 gustavo rené garcía-vargas4 maría teresa lorente-molina5 genoveva granados-gámez6 valores personales en estudiantes y profesionales de enfermería 1 departamento de enfermería, fisioterapia y medicina. profesor contratado. doctor. universidad de almería (españa). rjimenez@ual.es 2 departamento de psicología. catedrático de psicología de la salud, universidad de almería (españa). jgil@ual.es 3 catedrático de metodología, facultad de psicología, universidad de oviedo (españa). gvallejoseco@gmail.es 4 doctor en psicología, facultad de humanidades y psicología, universidad de almería (españa). gustavogarcia@ual.es 5 profesorado universitario (ministerio de educación y ciencia, españa), facultad de humanidades y psicología, universidad de almería (españa). maytelm_19@hotmail.com 6 departamento de enfermería, fisioterapia y medicina, facultad de educación y ciencias de la salud, universidad de almería (españa). genoveva@ual.es recibido: 07 de junio de 2014 enviado a pares: 21 de junio de 2014 aceptado por pares: 09 de septiembre de 2014 aprobado: 14 de diciembre de 2014 doi: 10.5294/aqui.2015.15.1.10 para citar este artículo / to reference this article / para citar este artigo jiménez lópez fr, roales nieto jg, vallejo seco g, garcía vargas gr, lorente molina mt, granados gámez g. valores personales en estudiantes y profesionales de enfermería. aquichan. 2015;15(1):105-115. doi: 10.5294/aqui.2015.15.1.10 resumen el estudio explora el contraste intergeneracional entre valores personales en estudiantes y profesionales de enfermería y su ajuste a las predicciones de la teoría del cambio de valores. la muestra estuvo formada por 369 estudiantes y profesionales de enfermería distribuidos en tres grupos: estudiantes (n = 150), profesionales menores de 40 años (n = 114), y profesionales entre 41 y 60 años (n = 105). los participantes informaron de sus valores en orden de prioridad en un cuestionario abierto. los informes se organizaron en categorías de valores para analizar las diferencias entre grupos. se encuentran dos tendencias en el informe de valores personales, que se ajustan en algunos casos a lo predicho por la teoría del cambio de valores y, en otros casos, la contradicen. se discute la importancia de estos hallazgos y la necesidad de potenciar una formación orientada hacia los valores de la profesión de enfermería. el estudio contribuye al conocimiento del cambio de valores personales en profesionales de enfermería. palabras clave valores sociales, estudiantes de enfermería, enfermería, ética de enfermería (fuente: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 105-115 106 aquichan issn 1657-5997 año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 105-115 personal values among students and nurses abstract the study explores the generational contrast between personal values in students and nurses and their adjustment to the predictions of the theory of changing values. the sample was comprised of 369 students and nurses who were divided into three groups: students (n = 150), nurses under age 40 (n = 114), and nurses between 41 and 60 years of age (n = 105). the participants reported their values on an open questionnaire, in order of priority. the reports were organized into value categories to analyze the differences between groups. two trends were found in the report on personal values: in some cases, they fit what is predicted by the theory of changing values; in others, they contradict it. the importance of these findings and the need to empower training oriented towards the values of the nursing profession is discussed. the study contributes to what we know about the change in personal values among nursing professionals. keywords social values, student nurses, nursing, nursing ethics (source: mesh, bireme). 107 valores personales en estudiantes y profesionales de enfermería l francisca rosa jiménez-lópez y otros valores pessoais em estudantes e profissionais de enfermagem resumo este estudo explora o contraste intergeracional entre valores pessoais em estudantes e profissionais de enfermagem e seu ajuste às predições da teoria da mudança de valores. a amostra esteve conformada por 369 estudantes e profissionais de enfermagem distribuídos em três grupos: estudantes (n = 150), profissionais menores de 40 anos (n = 114) e profissionais entre 41 e 60 anos (n = 105). os participantes informaram sobre seus valores em ordem de prioridade num questionário aberto. os relatórios foram organizados por categorias de valores para analisar as diferenças entre grupos. constataram-se duas tendências no relatório de valores pessoais que se ajustam, em alguns casos, ao dito pela teoria da mudança de valores; em outros casos, contradizem-na. discute-se a importância dessas constatações e a necessidade de potencializar uma formação orientada aos valores da profissão de enfermagem. o estudo contribui para o conhecimento da mudança de valores pessoais em profissionais de enfermagem. palavras-chave valores sociais, estudantes de enfermagem, enfermagem, ética de enfermagem (fonte: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 105-115 108 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 introducción generalmente se acepta que los valores personales guían la conducta, y son considerados como determinantes de las actitudes y la conducta, elementos centrales de la personalidad, y metas que sirven a los intereses personales y sociales (1). numerosos autores han señalado que, a partir de los años sesenta del siglo pasado, se produjo un importante cambio social en la mayoría de los países del mundo occidental, que ha generado un viraje en los valores personales de las generaciones más jóvenes (2, 3). en la mayoría de los países, las generaciones más jóvenes se han vuelto más reflexivas, menos tradicionales y más proclives al cambio y a la dedicación a sí mismos (4, 5). sin embargo, el apoyo empírico a este planteamiento procede de estudios realizados con los resultados de dos encuestas masivas, la encuesta mundial de valores y el eurobarómetro. en ambos casos, se realizan numerosas encuestas que permiten un estudio longitudinal del cambio en valores. los resultados de ambas señalan una tendencia mundial al cambio en los valores considerados prioritarios por la población (4-6). el autor se basó en estas encuestas para formular su teoría del cambio intergeneracional de valores (4), según la cual las generaciones más viejas priorizan valores materialistas (o racionalseculares), que adquirieron como valores personales al afrontar unas condiciones de vida duras y exigentes, en climas sociales de escasez e inseguridad, con una alta valoración del trabajo y del esfuerzo. al contrario, las nuevas generaciones surgidas a partir del desarrollo económico de los años sesenta, priorizan valores posmaterialistas (o de autoexpresión), al haberse desarrollado en climas sociales de prosperidad y seguridad, que priorizan valores relacionados con el desarrollo y la autonomía personal, la autoexpresión, la concordia en las relaciones humanas. este cambio en valores se considera una tendencia firmemente establecida (4), y predice que los valores posmaterialistas terminarán por ser los de referencia conforme las generaciones más viejas vayan desapareciendo. por ejemplo, se predijo (6) que en europa, en 2010, la ratio posmaterialistas/materialistas sería de 6/5 en la población general. los estudios sobre cambio intergeneracional de valores se han hecho con muestras de población general. sin embargo, no se ha explorado a fondo si el cambio es realmente general y uniforme, afectando a toda la población por igual, o si existen sectores de población más proclives que otros al cambio. por ejemplo, en profesiones como enfermería, asistencia social y educación social, la actividad se desarrolla principalmente a través de las relaciones humanas, y exige una serie de valores personales de carácter altruista y vocacional, junto a otros de carácter ético y trascendental, que orientan el ejercicio profesional. esto podría verse afectado por la tendencia hacia valores centrados en sí mismo, como característica de los valores posmaterialistas. por tanto, resulta de interés estimar empíricamente el alcance del cambio de valores que predice la teoría (4) entre las personas dedicadas a estas profesiones. estudios y análisis teóricos se han centrado en cómo la práctica de la enfermería supone manejar una serie de valores en situaciones complejas, en las que la toma de decisiones debe asentarse en referentes éticos que exigen ciertas virtudes que configuran el perfil de valores profesionales de la enfermería (7-10). el estudio del ajuste de los valores personales a los profesionales es importante, porque el cambio hacia el predominio de valores posmaterialistas podría suponer un cambio profundo para la profesión de enfermería. se ha abierto un importante debate con algunos autores partidarios de la transformación (11-13), y otros que ven en esto un riesgo para la profesión y sus valores (14-16). aunque numerosos estudios (17-22) han indagado acerca de las virtudes personales en enfermería, sin embargo, no se encuentran estudios que analicen esta cuestión desde la perspectiva de la teoría del cambio intergeneracional, aunque algunos (23-27) han sugerido que las enfermeras y los enfermeros de distintas generaciones muestran diferencias en sus valores personales a consecuencia de los cambios sociales, educativos y económicos, centrándose en los valores relacionados con la satisfacción laboral y el entorno profesional. ampliando esta línea de investigación, este estudio analiza de manera explícita si se encuentran señales del cambio en valores personales entre distintas generaciones en una muestra de estudiantes y profesionales de enfermería, mediante un método de informe y ordenación de valores desarrollado por nuestro grupo de investigación (28-31). el estudio cubre dos objetivos. primero, explorar los valores que presentan alumnos y profesionales de enfermería, y comprobar las diferencias generacionales en el informe de valores. segundo, explorar en qué medida esas diferencias generacionales se ajustan o no al tipo de cambios que predice la teoría del cambio intergeneracional de valores. 109 valores personales en estudiantes y profesionales de enfermería l francisca rosa jiménez-lópez y otros materiales y métodos se trata de un estudio exploratorio, transversal y de carácter correlacional. la muestra se obtuvo entre 1050 profesionales activos en los hospitales universitarios y centros de atención primaria de la ciudad de almería (españa), y entre los 430 estudiantes de la carrera de enfermería en la universidad de almería. el criterio de participación incluía cumplir las condiciones de elegibilidad (ser profesional activo o estudiante) y aceptar completar un cuestionario sobre valores personales y facilitar sus datos sociodemográficos manteniendo el anonimato. se utilizó un muestreo de tipo no probabilístico, de conveniencia y juicio prudencial (32), por cuanto las muestras resultaron representativas de las poblaciones objetivo (profesionales y estudiantes) de acuerdo con la fórmula de representatividad de las muestras para poblaciones de n conocido (33) como es el caso: donde n es la muestra necesaria; k es una constante que depende de la confianza asignada (en este caso 1,96, con un nivel de confianza del 95 %); e es el error muestral (5 % en el estudio); p es la proporción de individuos con la característica por estudiar (los valores); q sería la parte que no posee, en este caso, valores por informar, y n la parte del total de encuestas por cubrir. aceptaron participar en el estudio 226 profesionales (22 % de la población objetivo) y 160 estudiantes (27 % de la población objetivo). la muestra final estuvo conformada por 150 estudiantes y 219 profesionales (369 participantes), después de eliminar las encuestas incompletas de 10 estudiantes y 7 profesionales que no permitían el análisis de datos. los participantes fueron adscritos a uno de los tres grupos organizados de acuerdo con su estatus profesional y edad: 1) grupo de estudiantes de enfermería (gee), con 150 participantes nacidos entre los años 1982-1989; 2) grupo de profesionales jóvenes (gpj), con 114 participantes menores de 40 años; 3) grupo de profesionales adultos (gpa), con 105 profesionales mayores de 41 años. para la recogida del informe de valores personales se empleó el cuestionario sobre valores personales, versión enfermería (cvp-e), adaptado del cuestionario sobre valores personales (28), que permite informar dichos valores en orden de prioridad. el cuestionario contiene preguntas sobre los datos sociodemográficos, seguidas de una pregunta abierta sobre los valores personales, en la que cada participante puede indicar hasta 10 valores a su libre elección, con las siguientes instrucciones para la respuesta: “por favor, indique los principales valores personales que orientan su vida. puede indicar los valores que desee hasta un máximo de 10. piense en aquellos valores que son los más importantes para usted y ordénelos por su importancia”. el cuestionario permite al participante elegir los valores más relevantes en su vida con total libertad, sin imposiciones preestablecidas sobre cuáles puntuar u ordenar. la toma de datos se realizó para los estudiantes de enfermería en la escuela de ciencias de la salud de la universidad de almería (españa), directamente en las aulas con la autorización del profesor responsable y la dirección de la escuela. en el caso de los profesionales, se llevó a cabo en cursos, conferencias y reuniones organizadas por el colegio oficial de enfermería en la misma ciudad, durante el periodo octubre 2009 a julio 2010. en el momento de entregar los cuestionarios se insistió en la sinceridad en las respuestas y en las garantías de anonimato y confidencialidad. cada participante recibió un sobre para introducir el cuestionario y entregarlo cerrado una vez cumplimentado. la recogida y el análisis de los datos se realizó durante el curso académico 2009-2010. análisis de datos los análisis estadísticos fueron realizados mediante el programa spss 20 utilizando medidas de porcentajes y tablas de contingencia con chi-cuadrado y residuos tipificados corregidos. al disponer de un formato abierto de respuesta en el que cada participante podía incluir hasta diez valores, se llevó a cabo un proceso de categorización de las respuestas directas que permitiera su manejo con un marco de datos equiparable al utilizado en los estudios sobre valores. los valores informados directamente por los participantes fueron 2094, y se agruparon en categorías siguiendo el método de construcción de un léxico de valores (34) realizado por cinco investigadores expertos exigiéndose el acuerdo de, al menos, cuatro de ellos para aceptar una categoría y para incluir valores en cada una. las categorías resultantes para la muestra completa se recogen en el cuadro 1, incluyendo 110 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 algunos ejemplos de los valores directamente informados por los participantes que se adscribieron a cada una de las 14 categorías resultantes. cuadro 1. categorías de valores resultantes del universo de respuestas emitidas por todos los participantes (gee, 79,6 %; gpj, 86 %; gpa, 73,5 %). también la distribución de la variable estado civil se ajustó al rango de edad de cada grupo (estudiantes solteros, 100 %; profesionales jóvenes: 64 % solteros, 30,7 % casados o con pareja estable, y 5,3 % separados/divorciados; profesionales adultos: 10,7 % solteros, 78,6 % casados/pareja estable, y 10,7 % separados/divorciados). por último, la variable nivel socioeconómico indicó una mayoría de participantes pertenecientes al nivel socioeconómico medio (gee, 76,7 %; gpj, 71,9 %; gpa, 74,3 %). el análisis estadístico mediante tablas de contingencias con residuos tipificados corregidos y chi-cuadrado de pearson, no indicó ninguna asociación significativa entre informe de valores personales y variables sociodemográficas. los resultados sobre los valores personales informados recogen los porcentajes de participantes que en cada grupo mencionaron valores pertenecientes a las distintas categorías. el análisis descriptivo de los resultados señala varios aspectos de interés. en primer lugar, se destacan tres categorías de valores predominantes (tabla 1): valores éticos, valores de relación social y valores de familia o familistas, que en todos los grupos son informados como personales por más del 50 % de los participantes. dentro de estas categorías de valores predominantes se observan ciertos detalles de interés; por ejemplo, el aumento importante del informe de valores de relación social como valores personales conforme desciende la edad de los informantes hasta alcanzar el 90 % en el gee, lo que significa que casi la totalidad de los estudiantes consideran que los de relación social son valores personales importantes. este aumento del informe de una categoría de valores conforme desciende la edad también ocurre con la categoría de valores familistas, aunque no de forma tan acusada (tabla 1). el resto de categorías de valores muestran porcentajes de informe mucho menores que las tres categorías predominantes, aunque se pueden destacar algunos resultados de particular interés. por ejemplo, categorías como los valores de solidaridad y tolerancia, universales, de orden social y afectivos, mostraron porcentajes de informe que como máximo alcanzaron solo la tercera parte de los participantes. igualmente, es relevante el escaso porcentaje de participantes en todos los grupos que informó valores religiosos como valores personales, y también lo es que los porcentajes de participantes que mencionaron valores hedonistas como valores personales superasen a quienes mencionan valores religiosos. categorías de valores ejemplos de respuestas directas incluidas en las categorías valores éticos respeto, sinceridad, fidelidad, honestidad, integridad, nobleza, responsabilidad valores familistas amor a los padres, amor a los hijos, abuelos, tener una familia… valores de religión religión, creencias, fe, dios… valores de profesión y trabajo profesión, vocación, trabajo, profesionalidad, ser un buen profesional… valores de orden y estabilidad social seguridad, estabilidad, orden, austeridad, civismo… valores afectivos amor, cariño… valores de relación social amistad, relaciones sociales, popularidad, compañerismo... valores individualistas respeto por sí mismo, superación, esfuerzo, formación, independencia… valores de salud salud, estar sano, llevar una vida saludable... valores de solidaridad y tolerancia tolerancia, empatía, humanitarismo, voluntariedad, dejar vivir... valores hedonistas divertirme, dedicarme a mis aficiones, ir de fiesta, pasarlo lo mejor posible... valores de bienestar felicidad, calidad de vida, comodidad, bienestar… valores universales justicia, libertad, igualdad, equidad, paz, democracia... valores de dinero/ consumo ganar dinero, ser rico, comprar... fuente: elaboración propia. resultados los resultados sociodemográficos mostraron que la distribución de la variable sexo refleja la realidad social de la profesión de enfermería con mayoría de mujeres en los tres grupos de edad 111 valores personales en estudiantes y profesionales de enfermería l francisca rosa jiménez-lópez y otros el contraste intergeneracional en los informes de valores personales en cada grupo se aprecia gráficamente en la figura 1, organizada para mostrar las dos tendencias intergeneracionales en los informes de valores. por un lado, la tendencia descendente que mostraron ciertas categorías de valores, cuyo informe desciende conforme se reduce la edad, de manera que se trata de valores más importantes para las generaciones mayores y menos para las más jóvenes. esto sucedió con categorías de valores importantes y, en algunos casos (i.e., solidaridad y tolerancia, universales y bienestar), con resultados estadísticamente significativos. por otro lado, la tendencia ascendente en aquellas categorías de valores cuyo informe se incrementa conforme disminuye la edad, que incluyen los valores de relación social, familistas, de salud, afectivos, de dinero, hedonistas e individualistas, y en todos los casos con diferencias estadísticamente significativas excepto en el de caso de los valores individualistas (figura 1). figura 1. contraste intergeneracional de categorías de valores propios informadas por los grupos participantes, agrupadas en las dos tendencias intergeneracionales tabla 1. porcentaje de participantes de cada grupo que mencionan las categorías de valores fuente: elaboración propia. categorías de valores % p. adultos % p. jóvenes % estudiantes valores éticos 66,6 52,6 55,3 valores de relación social*** 63,7 64 90 valores familistas*** 53,9 50 72 valores de solidaridad y tolerancia** 36,3 23,7 18,6 valores de trabajo/profesión 35,3 45,6 32 valores individualistas 28,4 28,9 30,6 valores universales** 24,5 14 9,3 valores de salud*** 20,6 37,7 52,6 valores de orden social 20,6 18,4 17,3 valores afectivos*** 15,7 36,8 34,6 valores de dinero/consumo*** 13,7 23,7 34 valores de bienestar personal** 10,8 20,2 8 valores de religión 7,8 3,5 3,3 valores hedonistas** 4,9 16,6 19,3 ** = p < 0,01 *** = p < 0,001 categorías con tendencia descendente categorías con tendencia ascendente ** = p < 0,01 *** = p < 0,001 fuente: elaboración propia. el contraste de estos resultados con las predicciones de la teoría intergeneracional del cambio de valores se incluye en la tabla 2, en la que se compara el porcentaje promedio de profesionales que informa cada categoría (que representarían el estado actual de esos valores entre los profesionales de la enfermería) con el porcentaje de estudiantes que los informa (que representaría el futuro de cada categoría de valores en la profesión de enfermería). la tabla 2 muestra cómo las categorías de valores se organizan en tres bloques. un primer bloque formado por las categorías de valores en las que el cambio intergeneracional que se produce confirma la teoría aunque mediante tendencias diferentes. por un lado, cuatro categorías (valores de relación social, de salud, afectivos y hedonistas) (tabla 2), que muestran un incremento del informe de valores entre las generaciones en el sentido predicho por la teoría, y que son valores que forman parte de la macrocategoría de valores posmaterialistas que la teoría predice que serán más relevantes en las generaciones más jóvenes (4). por otro, dos categorías (valores de trabajo/profesión y valores de religión) (tabla 2), que muestran un descenso entre las generaciones que también confirma las predicciones de la teoría, pues los valores de trabajo/profesión son de tipo materialista en la terminología de la teoría, y los valores de religión son de tipo 112 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 trascendental, contrarios al enfoque posmaterialista centrado en sí mismo que la teoría predice como dominantes. los resultados indican también un segundo bloque de valores que contradicen las predicciones de la teoría del cambio intergeneracional, de nuevo con dos tendencias distintas. una tendencia ascendente que contradice la teoría para los valores de dinero/ consumo, pues se trata de valores materialistas que deberían perder importancia para las generaciones más jóvenes, mientras que los resultados muestran lo contrario; y para los valores familistas, que deberían perder importancia por la mayor relevancia del sí mismo frente a los lazos tradicionales, cuyos resultados indican lo contrario. y una segunda tendencia descendente, también contraria a la teoría, con las categorías de valores universales, de solidaridad y tolerancia, y de bienestar social —valores de tipo posmaterialista— que, de acuerdo con lo predicho por la teoría, deberían ser muy relevantes para las generaciones jóvenes, mientras que los resultados indican lo contrario (tabla 2). tabla 2. contraste de los resultados con las predicciones de la teoría del cambio intergeneracional de valores finalmente, las categorías de valores éticos, de orden social e individualistas, han mostrado cambios intergeneracionales ambiguos, que no permiten ni confirmar ni rechazar lo predicho por la teoría del cambio intergeneracional de valores (tabla 2). discusión este estudio pretendía cubrir dos objetivos. el primero, explorar las diferencias entre generaciones en valores personales que informan profesionales y estudiantes de enfermería. el segundo, analizar en qué medida esas diferencias se ajustan o no a los cambios que predice la teoría del cambio intergeneracional de valores (4-6). el informe de los valores personales se obtuvo mediante evaluación abierta de aquellos que permiten a cada participante informar de sus valores personales en un orden priorizado sin restricciones en la respuesta, evitando al máximo la deseabilidad social y la inducción a la respuesta (que suelen afectar a los sistemas “cerrados” de evaluación, en los se debe elegir entre los valores de un listado, ordenándolos o puntuándolos). la evaluación abierta de los valores da lugar a un amplio universo de respuestas que obliga a categorizarlas, pero proporciona datos que permiten apreciar con detalle qué valores personales informa libremente cada participante y el orden de importancia de cada uno. también reduce al mínimo el informe de falsos positivos o valores que una persona puntuaría alto en un listado predeterminado y que, sin embargo, no menciona cuando se le da la opción de escribir libremente sus valores personales. los resultados del estudio muestran diferencias importantes entre los grupos en el informe de valores que reflejan un cambio entre las generaciones. algunas diferencias entre los grupos podrían tener especial importancia y podrían estar relacionadas con el futuro de la profesión, en la medida en que los valores que muestran un descenso en importancia entre los más jóvenes, son aquellos presentes en los códigos deontológicos y reconocidos universalmente como característicos de la profesión (35). por ejemplo, los valores éticos muestran una reducción del 14 % entre el gpa y el gpj, y del 11,3 % entre el gpa y el gee, señalando una tendencia entre las generaciones más jóvenes a informar menos valores éticos. igual sucede con la categoría de valores universales (igualdad, equidad, etc.), cuyo informe se reduce casi el 10 % entre el gpa y el gpj, y hasta más del 15 % entre el gpa y el gee. también es importante analizar qué categorías de valores muestran una tendencia ascendente (mayor presencia en las gecategorías de valores % promedio de profesionales % promedio de estudiantes tendencia (efectos teoría) valores de relación social 63,8 90 (+) valores de salud 29,2 52,6 (+) valores afectivos 26,2 34,6 (+) valores hedonistas 10,7 19,3 (+) valores de trabajo/profesión 40,5 32 (+) valores de religión 5,7 3,3 (+) valores de dinero/consumo 18,7 34 (-) valores familistas 51,9 72 (-) valores universales 19,3 9,3 (-) valores de solidaridad y tolerancia 30,0 18,6 (-) valores de bienestar personal 15,5 8 (-) valores éticos 59,6 55,3 (=) valores de orden social 19,5 17,3 (=) valores individualistas 28,7 30,6 (=) = tendencia ascendente; = tendencia descendente; (+) = confirma la teoría; (-) = contradice la teoría; (=) = resultado que ni confirma ni contradice claramente la teoría fuente: elaboración propia. 113 valores personales en estudiantes y profesionales de enfermería l francisca rosa jiménez-lópez y otros neraciones más jóvenes). sucede en siete categorías de valores con distinta intensidad e importancia. los cambios más importantes se producen en las categorías de valores de relación social, salud, afectivos, hedonistas, familistas, y los relacionados con el dinero y el consumo. en todos los casos, los resultados indican que estos valores son más apreciados por los estudiantes que por los profesionales, con resultados que en algunos casos multiplican la importancia otorgada. por ejemplo, valores hedonistas (divertirme, dedicarme a mis aficiones, ir de fiesta, pasarlo lo mejor posible, etc.), son informados como valores personales solo por el 4,9 % del gpa, tres veces más por el gpj y cinco veces más por el gee. esto supone que por cada profesional adulto que informa valores personales hedonistas, encontramos tres profesionales jóvenes y cinco estudiantes que lo hacen (aumento del 393 % entre las generaciones mayor y menor). el contraste general en el informe de valores entre profesionales que representan la enfermería actual y estudiantes que representan la del futuro confirmó las tendencias antes analizadas, pero arroja dudas sobre la generalidad del cambio intergeneracional que sostiene la teoría del cambio intergeneracional de valores (4-6). los resultados señalan que ciertos cambios de valores sí confirman la teoría pero otros no. por ejemplo, la confirma que las nuevas generaciones presenten un perfil de valores más cercano a los valores posmaterialistas (interés y preocupación por la salud personal, por las relaciones sociales, por las interacciones afectivas, por los objetivos hedonistas), y más alejado de los valores materialistas (valores relacionados con el trabajo y la profesión, éticos, etc.). sin embargo, otros resultados contradicen las predicciones de la teoría indicando que el cambio ni es tan completo ni tan uniforme como la teoría señala. los resultados también muestran un aumento en el interés por ciertos valores materialistas como los relacionados con el dinero y el consumo, y otros que no son materialistas pero sí contrarios a la característica central de los valores posmaterialistas, como ocurre con los centrados en la familia, más frecuentes entre estudiantes que entre profesionales, cuando la teoría del cambio de valores predice un descenso en importancia de la familia (4-6). esto invita a reflexionar sobre la necesidad de estudiar estos fenómenos con mayor detalle que en los estudios con población general, para confirmar si el cambio en valores es un fenómeno más variado y complejo en determinados sectores de la población, como los resultados de nuestro estudio parecen indicar. en la profesión de enfermería tiene gran importancia la presencia de ciertos valores, y sería necesario realizar nuevos estudios que profundicen en el análisis de este fenómeno. de los resultados de este primer estudio se desprende que los valores propios de la identidad profesional enfermera pueden necesitar una atención especial en los contextos educativos y profesionales, altamente tecnificados y orientados principalmente a la adquisición de competencias y no tanto a la socialización profesional (36) y a la relación entre profesional y paciente (37, 38). los resultados de la investigación están en la línea de los obtenidos en otros estudios (17-27) de la literatura internacional sobre valores en profesionales y estudiantes de enfermería, aunque no resultan comparables punto a punto tanto por el diferente sistema de medición empleado, como por el propósito principal de nuestro estudio de analizar los cambios entre generaciones de acuerdo con las predicciones del cambio social. nuestro estudio indica que el procedimiento de medición de los valores ofrece una variada y abundante información frente a las perspectivas de estudiar los valores en cuestionarios cerrados, y detectan cambios importantes que otros métodos más conservadores no pueden detectar. los resultados de este estudio permiten concluir que existen diferencias importantes entre generaciones de enfermeros/as y estudiantes en el informe de valores personales, encontrando dos tendencias: valores que reducen su importancia y valores que la aumentan conforme la edad disminuye. los resultados se ajustan parcialmente a la teoría del cambio de valores. sin embargo, también se puede concluir que la teoría no se confirma en otros aspectos, puesto que el informe de valores materialistas y tradicionales (por ejemplo, familistas) se mantiene a través de los grupos e incluso aumenta. el cambio generacional en profesionales y estudiantes de enfermería parece existir pero no tan extenso ni tan intenso como en la población general. otra conclusión es que ciertas categorías de valores importantes para la profesión están descendiendo entre las generaciones, como es el caso de los éticos, universales y los relacionados con el trabajo. conclusión que lleva a plantear la necesidad de prestar mayor atención a la socialización profesional de los estudiantes, y a una potenciación de los valores profesionales especificados en los códigos éticos (35). sin embargo, es en sí misma una cuestión de evidente fondo empírico qué actividades teóricas y prácticas potenciarían con eficacia determinados valores con tendencia descendente entre las generaciones, y son necesarios estudios que traten esta importante cuestión. 114 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 como estudio exploratorio, el presente representa una primera aproximación a esta importante cuestión, y los resultados y las conclusiones han de tomarse con cautela a la espera de nuevos estudios que repliquen y amplíen los hallazgos con muestras mayores. referencias 1. rokeach m. the nature of human values. new york: fress press; 1973. 2. baumann z. la sociedad individualizada. madrid: cátedra; 2001. 3. giddens a. un mundo desbocado. los efectos de la 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caa. inversiones en activos humanos de enfermería: educación y mentalidades de futuro. rev latino-am enfermagem. 2010:18(3):467-471. habilidad del cuidador.pmd habilidad del cuidador y funcionalidad de la persona cuidada. care ability and functionality of the caree 137 abstract this article shows the relationship between main carers ability of chronic disabling disease patients and functionality of carees registered in the disabling program of the municipality of chía (colombia). the study was conducted through a quantitative method, based on a correlative descriptive design. its results evidenced no relation between total care ability, disregarding knowledge, courage or patience of the main carer, and caree degree of functionality. the population sampling is mainly made of young adults and elderly people who are severely disabled due to a chronic disease. main carers are adult married women aged 35, whose educational level goes up to completed high school; they have been the single carer in each case for more than 37 months and their care ability is medium or low. key words blanca cecilia venegas bustos1 resumen palabras clave cuidador principal, habilidad de cuidado, funcionalidad de la persona cuidada. main carer, care ability, functionality of the caree. este artículo muestra la relación existente entre la habilidad de cuidado de los cuidadores principales de personas en situación de enfermedad crónica discapacitante y el nivel de funcionalidad de las personas que son cuidadas y pertenecen al programa de discapacidad del municipio de chía, colombia; el estudio se realizó con un abordaje de tipo cuantitativo y un diseño descriptivo correlacional. los resultados evidenciaron que no existe relación entre la habilidad de cuidado total ni por categoría de conocimiento, valor y paciencia del cuidador principal y el grado de funcionalidad de la persona que es cuidada; las personas que son cuidadas y pertenecen al programa de discapacidad, en su mayoría son adultos jóvenes y ancianos que poseen una disfunción severa a causa de su situación de enfermedad crónica; los cuidadores principales son mujeres mayores de 35 años, casadas, con una escolaridad entre primaria completa y bachillerato completo, cuidadoras únicas y con una experiencia de cuidado mayor de 37 meses; poseen una habilidad de cuidado media y baja; el grado de funcionalidad de las personas cuidadas es severo. 1 facultad de enfermería, universidad de la sabana. campus universitario del puente del común, km. 21, autopista norte de bogotá d.c., chía, cundinamarca, colombia. blanca.venegas@unisabana.edu.co care ability and functionality of the caree recibido: 23 de junio de 2006 aprobado: 15 de agosto de 2006 año 6 vol. 6 nº 1 (6) 137-147 chía, colombia octubre 2006 revista aquichan issn 1657-5997 138 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 el cuidar de un familiar que es dependiente cambia la dinámica de los seres humanos, porque los enfrenta a la imposición de nuevas metas que además son inesperadas, y afectan las satisfacciones personales tanto en lo psicosocial como en lo económico. introducción n américa latina el comportamiento epidemiológico muestra que en la mayoría de los países las enfermedades crónicas se han convertido en las primeras causas de morbilidad y mortalidad. refiere sánchez (1) “que el patrón epidemiológico de américa latina, señala que en muchos países las enfermedades crónicas comparten los primeros lugares de morbimortalidad con las enfermedades agudas, y que éstas tienen tendencia a incrementarse”. este aspecto genera necesariamente crecimiento en el volumen de personas que ofrecerán cuidado ya sea de tipo formal o informal, situación que lleva a pensar en generar mayor conocimiento sobre cómo se cuida, qué se siente cuidando, qué genera el cuidar y de qué forma se apoyará este proceso o tarea del cuidador por parte del personal de salud. en la medida que aumenta el número de cuidadores informales, se deben crear estrategias que brinden apoyo, no sólo a nivel institucional sino especialmente en la comunidad y en la familia, dado que la familia generalmente es el principal agente cuidador de una persona en situación de enfermedad crónica discapacitante. stober (2) señala que en las dos últimas décadas se ha observado un crecimiento en el número de familias que deciden tomar la responsabilidad de cuidar a sus parientes con enfermedades crónicas; exponiéndose a varios riesgos, ya que las tareas del cuidador se vuelven cada vez más complejas y les abarcan mayor cantidad de tiempo afectando tanto su salud física como mental. el cuidar de un familiar que es dependiente cambia la dinámica de los seres humanos, porque los enfrenta a la imposición de nuevas metas que además son inesperadas, y afectan las satisfacciones personales tanto en lo psicosocial como en lo económico. pinto (3) refiere que el cuidador, en cumplimiento de sus roles, experimenta diferentes sentimientos que pueden ir desde la culpa hasta la satisfacción. también se puede observar que hay otros sentimientos como la soledad, la tristeza, el sentirse abandonado, el nerviosismo, la falta de ocio y descanso, problemas para dormir que van generando en el cuidador una situación problemática que le impide ser feliz y lograr un mínimo de bienestar. frente a esta situación surge el estudio con los cuidadores principales de personas en situación de enfermedad crónica que se encuentran ubicados en el municipio de chía, una zona geográfica donde la temática del cuidado a cuidadores ha sido poco abordada; lo que se pretende es mostrar la habilidad de cuidado que poseen los cuidadores principales de personas en situación de enfermedad crónica discapacitante en términos de conocimiento, valor y paciencia; y el nivel de funcionalidad que poseen las personas que son cuidadas y pertenecen al programa de discapacidad liderado por la secretaría de salud del municipio, para identificar si existe relación o no entre las dos variables. escudero (4) dice que “es importante que el individuo que cuida se cuide para cuidar mejor y las formas para hacerlo no son negándose a la realidad sino enfrentándola, pidiendo ayuda, hablando con otros, tomando las circunstancias de manera positiva y viendo los problemas o dificultades como oportunidades”. en esta medida el personal de enfermería debe conocer qué está pasando con los cuidadores, para que pueda orientar sus cuidados hacia propiciar estilos de vida saludables, a que el cuidador aprenda a sentirse bien, y a habilidad del cuidador y funcionalidad de la persona cuidada. care ability and functionality of the caree 139 aliviar la tristeza y la depresión. este estudio contribuye a generar conocimiento sobre la habilidad de cuidado de personas, buscando si dicha habilidad se relaciona con el nivel de funcionalidad del ser querido a quien cuidan en el marco de un municipio, con zonas que en muchas oportunidades no son tenidas en cuenta por su ubicación geográfica, pero tal vez donde las personas cuidadoras tienen mayor número de necesidades para cuidar a otros y cuidarse a sí mismas. se hace necesario conocer si existe o no una relación entre la habilidad de cuidado y el grado de funcionalidad de las personas que son cuidadas, ya que en esa medida se identifican las necesidades principales de los cuidadores, y así se pueden implementar acciones que generen atención directa sobre éstas; sobre todo si se tiene en cuenta que esta población es poco atendida o invisible para las autoridades de salud municipal y gubernamental en general. es importante para el profesional de enfermería comprender la realidad del otro, y saber si hay relación entre los niveles de funcionalidad de las personas en situación de enfermedad y las habilidades de cuidado del cuidador para ofrecer apoyo, viendo al binomio cuidador-cuidado desde una dimensión más humana, con cualidades en la aplicación del cuidado, quizá en algunos casos mejor que las de los profesionales, pero también con limitaciones, anhelos, esperanzas y desconocimiento de su propia situación. galvis y cols. (5) afirman “que el conocimiento que los profesionales de enfermería tengan sobre el grado de complejidad de la situación crónica, la habilidad que tiene el cuidador principal para ofrecer cuidados y los apoyos disponibles para el cuidado permiten establecer prioridades de acción”. frente a este planteamiento es importante que los profesionales de enfermería– que son los que más se ocupan de las acciones de promoción de la salud– conozcan la implicación que tiene en los cuidadores cuidar de personas con una severa, moderada y baja funcionalidad, ya que esto les orientará a implementar estrategias que le proporcionen al cuidador familiar principal un apoyo y orientación sobre cómo cuidarse a sí mismos, para que de esta manera puedan crecer en el cuidado de sus familiares enfermos. objetivo general establecer la relación entre la habilidad de cuidado de un grupo de cuidadores de personas en situación de enfermedad crónica discapacitante y el nivel de funcionalidad de estas personas cuidadas en el programa de discapacidad en el municipio de chía, cundinamarca. objetivos específicos definir la habilidad de cuidado de los cuidadores principales de personas en situación crónica discapacitante que pertenecen al programa de discapacidad del municipio de chía en términos de conocimiento, valor y paciencia. determinar el nivel de funcionalidad de las personas que son cuidadas y pertenecen al programa de discapacidad del municipio de chía. hacer un análisis comparativo entre la habilidad de cuidado de los cuidadores principales de personas en situación de enfermedad crónica discapacitante y su nivel de funcionalidad. se hace necesario conocer si existe o no una relación entre la habilidad de cuidado y el grado de funcionalidad de las personas que son cuidadas, ya que en esa medida se identifican las necesidades principales de los cuidadores, y así se pueden implementar acciones que generen atención directa sobre éstas. revista aquichan issn 1657-5997 140 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 metodología el presente estudio se realizó con un abordaje de tipo cuantitativo dado que midió y relacionó la habilidad de cuidado que tienen los cuidadores de personas en situación de enfermedad crónica, y revisó el nivel de funcionalidad de las personas a su cargo. el diseño fue descriptivo, correlacional, porque además de que se describen las características y la habilidad de cuidado de los cuidadores principales de personas en situación de enfermedad crónica discapacitante, se relacionaron con la funcionalidad de las personas cuidadas. el universo tomado para este estudio son todas las personas cuidadoras principales y las personas a quienes ellos cuidan en el municipio de chía, departamento de cundinamarca, y pueden pertenecer al programa de discapacidad del municipio implementado por la alcaldía. la población del estudio fueron los cuidadores principales y las personas en situación de enfermedad crónica que son cuidadas; se caracterizaron durante la recolección de la muestra en todos los sectores y veredas del municipio de chía distribuidos en sus 23 sectores, para un total de 122 binomios cuidador-cuidado. los conceptos que se tuvieron en cuenta para este estudio son: habilidad de cuidado. considerada como el desarrollo de destrezas y capacidades de las que dispone un individuo para realizar acciones que ayuden a otros a crecer o a valorar su propio ser. no se puede apartar este concepto de lo que significa cuidar, que ha sido definido por mayeroff como “el ayudar a otro a crecer y actualizarse a sí mismo, un proceso, una manera de relacionarse con alguien que involucra desarrollo” (6). la habilidad de cuidado se mide en términos de conocimiento, valor y paciencia, donde el conocimiento “es el que involucra un reconocimiento del otro como algo separado, con necesidades únicas. implica entender quién es la persona que se cuida, sus necesidades, fortalezas y debilidades, y lo que refuerza su bienestar” (6). cuidador principal. es la persona familiar o cercana que se ocupa de brindar de forma prioritaria apoyo tanto físico como emocional a otro de manera permanente y comprometida. persona en situación de enfermedad crónica discapacitante. es el individuo que vive un proceso de deterioro progresivo de las funciones y capacidades a causa de una alteración específica que afecta su estado de salud por un periodo superior a seis meses. programa de discapacidad. serie de acciones programadas por la alcaldía municipal de chía con el fin de proporcionar un mejoramiento de la calidad de vida de la población con discapacidad y sus familias que habitan en las áreas rural y urbana del municipio. nivel de funcionalidad de la persona cuidada. grado de capacidad física, mental y social que posee una persona con enfermedad crónica discapacitante para realizar sus actividades de la vida cotidiana. procedimiento se estableció el contacto con la secretaría de salud del municipio de chía, que maneja el programa de discapacidad; se pasaron las cartas de solicitud para la realización del estudio; una vez aprobada, se realizó una capacitación a seis alumnos de la facultad de enfermería de la universidad de la sabana en tres momentos, con el fin de lograr la comprensión y unificación en el lenguaje a la hora de recolectar la información con los cuidadores y sus personas cuidadas. los criterios de inclusión de la muestra fueron los cuidadores y las personas a su cargo que viven en el municipio, vinculados al programa de discapacidad, que sean mayores de 18 años, cuyo nivel de comprensión sea apropiado para responder de forma coherente a una encuesta, que tengan más de seis meses de experiencia como cuidadores, y más de seis meses de requerir apoyo de cuidador, que sean cuidadores de personas con algún grado de dependencia, que sepan leer y escribir, que sean el cuidador principal y que voluntariamente quieran participar en el estudio; la muestra se recolectó en las viviendas de los cuidadores y sus pacientes cuidados. es importante aclarar que para la recolección de la muestra de este estudio se realizó una visita en el domicilio del cuidador y el paciente cuidado; el número de la muestra fue de 122 binomios cuidadorcuidado; para caracterizarlos se consideró la población total de discapacitados en el municipio de chía, que son 679 personas con discapacidad, pero todos estos discapacitados no requieren de cuidador; por tanto la muestra se tomó de manera intencional teniendo en cuenta los criterios de inclusión. teniendo en cuenta los principios éticos de la investigación, como son el consentimiento informado, el respeto por la autonomía de las personas, el respeto por habilidad del cuidador y funcionalidad de la persona cuidada. care ability and functionality of the caree 141 mantener la privacidad de la información recogida, y el tener la intención de hacer el bien común con la información analizada para beneficio de las personas que cuidan a otras que se encuentran con enfermedades crónicas y discapacitantes, se solicitó el consentimiento informado a los participantes; previamente se le explicaron los objetivos del estudio así como la utilidad para beneficio de los cuidadores de personas en situación de enfermedad crónica discapacitante. en el ámbito institucional se solicitaron las autorizaciones correspondientes, explicando los objetivos del estudio y justificando la utilidad de la información recogida para el fortalecimiento del cuidado a los cuidadores del municipio, y cómo este resultado puede arrojar información muy relevante que permita que los profesionales de enfermería puedan brindar más apoyo a los programas implementados por la secretaría de salud del municipio. este proyecto se realiza en un municipio donde la mayor parte de la población se ubica en el área rural; sin embargo, es importante mencionar que debido al tipo de estudio, este proyecto no tiene ningún riesgo físico para las personas ni implica riesgos para el medio ambiente. los instrumentos empleados en la ejecución del estudio son: instrumento cai: (inventario de la habilidad de cuidar) desarrollado por nogozi nkongho y validado en 1990, este instrumento consta de 37 ítems con escala tipo likert que evalúa con un puntaje de 1 a 7 e indica los grados de aceptación o rechazo respecto a tres variables que son conocimiento, valor y paciencia; además, cada uno de estos grados se califican en términos de alto, medio y bajo. el pulses: “escala de valoración funcional creada y empleada por moskowitz en 1957, este acrónimo inglés se refiere a seis funciones de importancia en rehabilitación así, p = estabilidad de la patología o condición física, u = utilización de miembros superiores, l = locomoción o función de los miembros inferiores, s = función sensorial, e = eliminación o control de esfínteres, s = capacidad de socializar. este perfil permite cuantificar a través de una escala numérica el nivel de funcionalidad” (7). este instrumento ha sido empleado desde hace mucho tiempo por diferentes autores e investigadores que buscan medir la funcionalidad de los individuos en rehabilitación o con distintas enfermedades como pacientes con acv; maneja una escala numérica de uno a cuatro, donde uno es independiente para la función, dos requiere de apoyo mecánico (aparato), tres requiere del apoyo mecánico y de otra persona y cuatro es completamente dependiente en cada una de las funciones que son valoradas. esta escala permite evaluar la condición del paciente cuidado, valoración que se relacionó con la habilidad para cuidar que tiene el cuidador; finalmente, se empleó el formato de caracterización de los cuidadores que permite observar las características generales del cuidador y el paciente que es cuidado. para el análisis de la información se utilizó el registro de datos estadísticos de pearson chisquare. este sistema generó los datos para realizar el análisis descriptivo y de relación entre las variables estudiadas. resultados al realizar el análisis de los datos sociodemográficos de los cuidadores y las personas a quienes ellos cuidan este estudio mostró que el 85,25 de la muestra son mujeres quienes se dedican a la tarea de cuidar, además son esposas, madres, hermanas o hijas, se encuentran en el rango de edad de 35 a 59 años. las personas cuidadas son en mayor proporción mayores que el rango de edad del cuidador; el nivel de escolaridad del cuidador se encuentra entre primaria incompleta hasta bachillerato completo; el 51,64% son casados y dedicados a las labores del hogar; el estrato al que pertenecen está principalmente entre dos y tres, el 67,21% son el único cuidador de la persona en situación de enfermedad crónica discapacitante, con una experiencia mayor de 37 meses de cuidado; de otra parte, el 72,13% de ellos siente que está dedicado las 24 horas del día a la tarea de cuidar. es significativo en este estudio sociodemográfico de los cuidadores, que el porcentaje de hombres dedicados a la tarea de cuidar se muestra en un 14,75% de la población tomada, a diferencia de otros donde la proporción es menor. moreno y cols. en el 2002, en su investigación sobre la habilidad de cuidado de los cuidadores principales de los enfermos crónicos hospitalizados, refieren que son las mujeres quienes asumen en la mayoría de los casos el rol de cuidadoras, “el sexo de los cuidadores en este estudio reporta que el 97,8% de la muestra tomada son mujeres y el 2,2% son hombres” (8). blanco y flores (9) en su estudio de investigación sobre caracterización de los cuidadores informales de niños con fibrosis quística, en el análisis de sus resultados encuentran que “el 89% de cuidadores son mujeres, y el 11% son hombres”; el comportamiento en la población tomada para este estudio muestra que el sexo masculino también está asumiendo un papel protagónico en la tarea de cuidar de sus familiares enfermos. revista aquichan issn 1657-5997 142 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 valoración de la funcionalidad de la persona en situación de enfermedad crónica discapacitante las personas en situación de enfermedad crónica discapacitante que pertenecen al programa de discapacidad del municipio de chía, tomadas para este estudio, presentan distintas situaciones de salud que han generado en ellas la necesidad de depender de otra persona para realizar sus actividades de la vida diaria. figura 1. distribución porcentual del nivel de funcionalidad de las personas cuidadas los datos obtenidos evidencian que el grado de funcionalidad de la persona cuidada tiene en un 63,93% de los casos una alteración severa, en un 19,67% se observa una alteración moderada, y el 16,39% de las personas en situación de enfermedad crónica discapacitante se encuentran en un nivel leve de funcionalidad. lo encontrado en este estudio es referido en la literatura sobre la implicación que tiene la pérdida de la funcionalidad de la persona cuidada en el cuidador; según blanco, “las tareas a las que debe enfrentarse el cuidador son múltiples, complejas y les exigen mucho tiempo debido a la pérdida de la funcionalidad de las personas cuidadas” (10). el hecho de que la limitación de la persona cuidada influya para que requiera de mayor apoyo del cuidador podría generar en este último mayor gasto de energía, tiempo, desgaste emocional y empleo de recursos materiales, físicos y financieros. la disfunción en este grupo estudiado se encuentra especialmente en lo relacionado con la locomoción y capacidad de traslado. se evidencia además que la estabilidad de la situación de salud de los pacientes es muy variable e inestable; la funcionalidad de los miembros superiores muestra alto grado de dependencia; los problemas de eliminación y la actividad social se presentan en menor proporción que los demás aspectos evaluados para caracterizar el grado de funcionalidad. teniendo en cuenta que la disfunción está más inclinada a la actividad física, el cuidado de este tipo de personas requiere esfuerzo físico, técnicas de acomodación para realizar los movimientos y mayor gasto de energía que podrían hacer que el cuidador se sienta cansado físicamente y termine con alteraciones músculo-esqueléticas que le produzcan dolor y con el tiempo limitación. en estudios sobre carga de cuidado en los cuidadores como el de manzini bocchi en 2004, que muestra que la sobrecarga física en el cuidador está más relacionada con pacientes más dependientes principalmente en el traslado y la deambulación (11), se evidencia que las personas cuidadas tienen una funcionalidad muy limitada, lo que con el tiempo podría ocasionar a sus cuidadores múltiples problemas de salud. habilidad del cuidador y funcionalidad de la persona cuidada. care ability and functionality of the caree 143 habilidad de cuidado de los cuidadores teniendo en cuenta que los resultados según el instrumento cai (inventario de habilidad de cuidado) pueden estar entre un mínimo de 37 y un máximo de 259, la información general de la habilidad de cuidado se clasifica en alta, media y baja. figura 2. distribución porcentual de los niveles de habilidad de cuidado de los cuidadores principales para los 122 cuidadores de personas en situaciones de enfermedad crónica discapacitante que pertenecen al programa de discapacidad del municipio de chía, el 37,70% presentan un nivel medio de habilidad de cuidado; el 33,61% presenta un alto nivel de habilidad de cuidado, y el 28,69% presenta un bajo nivel de habilidad de cuidado. estos datos significan que el 66,39% de la población tomada para el estudio no presenta un nivel óptimo de habilidad de cuidado para cumplir con el rol a su cargo. dadas las características de estos cuidadores, hay un porcentaje significativo de ellos que dedican la mayor parte de su tiempo al cuidado y lo han hecho por un periodo prolongado, lo que se podría interpretar como una fortaleza ya que entre más tiempo se tenga como cuidador se esperaría que se tenga mayor habilidad; así lo afirma la investigadora sánchez en su estudio “habilidad de cuidado de los cuidadores de personas en situación de enfermedad crónica” cuando dice que la experiencia de ser cuidadora de una persona en situación de enfermedad crónica, es vivir de una manera diferente, modificando las funciones a las que se está acostumbrado, tomando decisiones, asumiendo responsabilidades y realizando tareas y acciones de cuidado físico, social, psicológico y religioso para atender las necesidades cambiantes de la persona cuidada en las que progresivamente se va adquiriendo habilidad hasta superar muchas veces a los más conocedores (1). si se observa el grado de funcionalidad de las personas cuidadas se puede evidenciar que la mayoría de pacientes tienen un alto grado de discapacidad, lo que los hace más dependientes en sus actividades de la vida cotidiana y le implican mayor trabajo y esfuerzo al cuidador; aunque el cuidador va adquiriendo mayor destreza y conocimiento sobre el manejo no solo físico sino afectivo, el manejo de personas con alto grado de discapacidad requiere de preparación y adquisición de competencias especiales, y éstas no siempre se pueden adquirir a través del tiempo, en un crecimiento mutuo cuidador-cuidado. según figueroa, “el conocimiento para manejar familiares con discapacidad genera un panorama complejo, y requiere de competencias especiales” (12). nkongho refiere que “el conocimiento involucra un reconocimiento del otro como algo separado, con necesidades únicas. implica entender quién es la persona que se cuida, sus necesidades, fortalezas y debilidades y lo que refuerza su bienestar”; agrega que “un aspecto importante del conocimiento es conocer las propias forrevista aquichan issn 1657-5997 144 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 talezas y limitaciones” (6). en estos hallazgos podemos ver que el cuidador ve la situación de salud de su paciente cuidado como una oportunidad, la entiende, le hace sentir que puede contar con él, figura 3. comparación entre la habilidad de cuidado de los cuidadores y la funcionalidad de las personas cuidadas relación entre la habilidad de cuidado que poseen los cuidadores y la funcionalidad de las personas cuidadas que lo acepta tal como está, que lo cuida de forma sincera reconociendo sus propias limitaciones, y respetando el sentir y la privacidad de su paciente que es cuidado. una vez analizados cada uno de los componentes de la habilidad de cuidado –conocimiento, valor y paciencia–; haber identificado la habilidad de cuidado en general que poseen los cuidadores principales de personas en situación de enfermedad crónica discapacitante; y de haber identificado cuál es la funcionalidad que poseen cada una de las personas que son cuidadas por cada uno de estos cuidadores, se evidencia que no existe estadísticamente relación entre la habilidad de cuidado y la funcionalidad de la persona que es cuidada y se encuentra en situación de enfermedad crónica; sin embargo, se presenta un análisis comparativo de lo que evidencian los datos encontrados. el 63,93% de las personas que son cuidadas tienen una disfunción severa; al establecer el cruce de manera porcentual se identifican los siguientes datos numéricos: el 29,51% equivalente a 36 casos en los cuales la persona cuidada posee un nivel de disfunción severo, frente a una habilidad de cuidado de su cuidador, media; un 18,03% correspondiente a 22 casos de los cuales la persona cuidada posee un nivel de disfunción severo, frente a una habilidad de cuidado de su cuidador, alta; y un 16,39% correspondiente a 20 casos en los cuales la persona cuidada posee un nivel de disfunción severo, frente a una baja habilidad de su cuidador. se podría decir que el 45,9% de los casos donde el paciente que es cuidado posee una disfunción severa está siendo cuidado por un cuidador principal que no posee un nivel de habilidad óptimo para el cuidado. habilidad del cuidador y funcionalidad de la persona cuidada. care ability and functionality of the caree 145 estos datos encontrados reflejan que la tarea de ser cuidador no es tan fácil, aunque este grupo de cuidadores del municipio de chía cuenta con un tiempo prolongado de cuidado y gran parte del día lo dedican al cuidado de su familiar en situación de enfermedad crónica discapacitante, sin tener el nivel de habilidad que su discapacidad requiere para cuidarlos. la literatura refiere diferentes aspectos sobre lo que implica la tarea de cuidar a personas con situaciones de enfermedad crónica discapacitante; un aspecto que sobresale es que el emplear muchas horas al día y durante mucho tiempo con apoyo o sin él, cuidando del familiar enfermo, termina siendo una carga para el cuidador; reever refiere “que el cuidador percibe una carga objetiva y una carga subjetiva; la carga subjetiva puede definirse como las actitudes y reacciones emocionales ante la experiencia de cuidar; y la carga objetiva es el grado de perturbaciones o cambios en diversos aspectos del ámbito doméstico y de la vida de los cuidadores” (13); este aspecto hace suponer que los cuidadores de este estudio, al transcurrir el tiempo, van perdiendo algunas de las características que poseen como cuidadores, y la carga que les implica el cuidado les ha generado mayor dificultad para enfrentar su tarea. otra característica importante, vista en los casos de las personas que cuidan y las que son cuidadas, es que la severidad en la funcionalidad de estas últimas se presenta en un alto porcentaje, lo que implica unas variaciones en el proceso de la enfermedad crónica, y para el cuidador de este tipo de personas, porque en ellas existe la expectativa de permanentes debidos a los altibajos o fluctuaciones del curso de la enfermedad; es decir, hay momentos menos difíciles para el cuidador que otros. garcía, cuando se refiere al trabajo de cuidar que tiene el cuidador, dice que “el espectro de cuidados varía en relación con las características del paciente al que se cuida. por ejemplo, los niños pequeños y los que presentan problemas de salud mental requieren vigilancia con mayor frecuencia que otros grupos de niños; en este grupo de cuidadores el trabajo de cuidar significa aún más que en otros casos, una disponibilidad permanente” (14); esto hace relación en este estudio, a que las características de la severidad funcional en las personas cuidadas implican para el cuidador altibajos en su condición de cuidador, que le pueden generar mayor o menor habilidad de cuidado. si se toma en cuenta que para este estudio la habilidad de cuidado es considerada como el desarrollo de destrezas y capacidades de las que dispone un individuo para realizar acciones que ayuden a otros a crecer o a valorar su propio ser, y que para entender la habilidad de cuidado se toma como referente el concepto de cuidado definido por mayeroff como “el ayudar a otro a crecer y actualizarse a sí mismo, un proceso, una manera de relacionarse con alguien que involucra desarrollo” (6), se puede decir que en este estudio el cuidador principal de la persona en situación de enfermedad crónica discapacitante necesita fortalecer sus destrezas y capacidades, con el ánimo de que la interacción con la persona que cuida sea de un mutuo crecimiento; de esta forma crecen tanto el que es cuidado como el proveedor de cuidado. conclusiones estadísticamente no se evidencia relación entre la habilidad de cuidado que poseen los cuidadores principales de personas en situación de enfermedad crónica discapacitante y la funcionalidad de las personas que son cuidadas. para los cuidadores de este estudio la habilidad de cuidado, vista desde las destrezas y capacidades que deben poseer al realizar su acción de cuidado, no contribuye al crecimiento ni a la valoración de la persona a la que están cuidando, debido a que no poseen el conocimiento, el valor ni la paciencia óptimos para brindar el cuidado a su familiar en situación de enfermedad crónica. las personas que son cuidadas y pertenecen al programa de discapacidad en su mayoría son adultos jóvenes y ancianos, que poseen una disfunción severa a causa de su situación de enfermedad crónica, y requieren que se les apoye para el mejoramiento de su condición de salud, se les estimule para proveerse autocuidado y se les mejoren sus condiciones adversas de vida. los cuidadores de personas en situación de enfermedad crónica discapacitante del municipio de chía deben ser incluidos de manera más activa por quienes trabajan con el programa de discapacidad del municipio; aunque los cuidadores siempre están en compañía de sus personas enfermas cuando se les requiere, es importante brindarles mayor apoyo en la tarea de cuidado de su familiar, y crearles espacios que les favorezcan en su salud física y mental. los cuidadores de las personas en situación de enfermedad crónica discapacitante que pertenecen al programa de discapacidad del municipio de chía son adultos jóvenes que cuentan con elemenrevista aquichan issn 1657-5997 146 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 tos necesarios para brindar cuidado a sus familiares; sin embargo, requieren de todo el apoyo por parte del personal de salud y de los líderes del programa de discapacidad para adquirir una mejor habilidad de cuidado para ayudar a sus familiares enfermos. en los cuidadores principales de personas en situación de enfermedad crónica discapacitante que pertenecen al programa de discapacidad del municipio de chía se observa que para una severidad en la disfunción de la persona cuidada existe un cuidador con una mediana y baja habilidad para cuidar, lo que hace pensar que se debe brindar mayor apoyo a estos cuidadores con el fin de que puedan ofrecer un cuidado más oportuno y eficaz a sus personas enfermas. sugerencias con base en este estudio, y en el proceso realizado durante esta investigación, se sugiere que el programa de discapacidad del municipio de chía debe incorporar a los cuidadores, con el ánimo de brindarles mayor apoyo para su autocuidado y propiciarles espacios de recreación y descanso que les favorecerá en su estado físico y mental; además, se debe incluir a los cuidadores de personas con enfermedades crónicas discapacitantes en los programas de prevención de la salud promovidos por la secretaría de salud del municipio de chía en el plan de atención básica, con el ánimo de mejorarles la autoestima, hacerlos visibles para el sistema y contribuir a mejorarles su calidad de vida. es importante establecer redes de apoyo en el municipio de chía que ayuden en las tareas del cuidador principal de personas con situación de enfermedad crónica discapacitante ya que la mayoría son cuidadores únicos, llevan mucho tiempo cuidando de sus familiares y dedican la mayor parte de su tiempo a este rol; también se debe promover en las instituciones de salud o en las acciones del plan de atención básica en los municipios la implementación de talleres que incentiven y estimulen el autoestima de los cuidadores; este aspecto los hace sentir importantes, les permite sentirse como personas especiales y útiles, y pueden proyectar un bienestar físico y mental que se reflejará en la persona que es cuidada. se debe seguir investigando sobre la problemática de los cuidadores, esto contribuirá a conocer sus necesidades reales y, por tanto, se pueden implementar acciones preventivas y educativas que contribuyan a mejorar sus principales problemas; otro beneficio es que se puede mantener un censo actualizado en el municipio del binomio cuidador-cuidado a través de las promotoras de salud, ya que esto facilitará el poderles brindar apoyo para el mejoramiento de su calidad de vida. es importante que la academia conozca los resultados de este estudio para que pueda intervenir en la creación e implementación de políticas que contribuyan al mejoramiento de las condiciones de vida y de salud de los cuidadores no solo a nivel local sino nacional; sin embargo, se considera que es a nivel local donde se debe iniciar la implementación de un programa de apoyo a cuidadores que contribuya a mejorar los problemas presentados por ellos. es importante establecer redes de apoyo en el municipio de chía que ayuden en las tareas del cuidador principal de personas con situación de enfermedad crónica discapacitante ya que la mayoría son cuidadores únicos, llevan mucho tiempo cuidando de sus familiares y dedican la mayor parte de su tiempo a este rol. habilidad del cuidador y funcionalidad de la persona cuidada. care ability and functionality of the caree 147 1. sánchez b. habilidad de cuidado de los cuidadores de personas en situación de enfermedad crónica. el arte y la ciencia del cuidado. grupo de cuidado universidad nacional de colombia. bogotá; 2002, p. 373. 2. stober. efectividad de una intervención de consejería para ayudar a cuidadores familiares de parientes crónicamente enfermos. journal of psychosocial nursing 1998; 36(8): 26-32. 3. pinto n, sánchez. el reto de los cuidadores: familiares de personas en situación crónica de enfermedad. en: grupo de cuidado facultad de enfermería universidad nacional de colombia “cuidado y práctica de enfermería”; 2000, 172-183. 4. escuredo b, díaz e, pascual o. cuidadores informales necesidades y ayudas. revista rol de enfermería 2001; 24(3): 183-189. 5. galvis cr, pinzón ml, romero e. comparación entre la habilidad de cuidado de cuidadores de personas en situación de enfermedad crónica en villavicencio, meta. avances en enfermería 2004; xxii (1): 6. 6. nkongho, no. the caring ability inventory. in strickland o, waltz c. measurement of nursing outcomes; 1999, p. 4. 7. granger cv, albrech gl. hamilton, outcome of comprehensive medical rehabilitation messurement by pulses profile and the barthel index. arch physmed rehabil 1979; 60: 145-54. referencias 8. moreno, torres, vargas. medición de la habilidad de cuidado de los cuidadores principales de enfermos crónicos hospitalizados. universidad nacional de colombia, facultad de enfermería, bogotá; 2002. 9. blanco, flores. caracterización de los cuidadores informales de niños con fibrosis quística. tesis de maestría, facultad de enfermería. universidad nacional de colombia; 2002. 10. blanco l. habilidad de cuidado de los cuidadores de adultos en situación de enfermedad crónica discapacitante. tesis de maestría, universidad nacional de colombia. bogotá; 2002. 11. manzini sc. viviendo la sobrecarga al convertirse en cuidador familiar de personas con acv: análisis del conocimiento. revista latinoamericana de enfermería 2004; 12. 12. figueroa. habilidad de cuidado del cuidador principal de adultos que viven en situación de enfermedad crónica discapacitante. tesis de maestría, universidad nacional de colombia, bogotá; 2002. 13. reever z, peterson b. entrevista de carga del cuidador. sociedad española de geriatría y gerontología. madrid; 2005. 14. garcía mm. el sistema informal de atención a la salud. congreso de pediatría. escuela andaluza de salud pública. granada; 2000. << /ascii85encodepages false /allowtransparency false /autopositionepsfiles true 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5.0 and later.) >> /namespace [ (adobe) (common) (1.0) ] /othernamespaces [ << /asreaderspreads false /cropimagestoframes true /errorcontrol /warnandcontinue /flattenerignorespreadoverrides false /includeguidesgrids false /includenonprinting false /includeslug false /namespace [ (adobe) (indesign) (4.0) ] /omitplacedbitmaps false /omitplacedeps false /omitplacedpdf false /simulateoverprint /legacy >> << /addbleedmarks false /addcolorbars false /addcropmarks false /addpageinfo false /addregmarks false /convertcolors /noconversion /destinationprofilename () /destinationprofileselector /na /downsample16bitimages true /flattenerpreset << /presetselector /mediumresolution >> /formelements false /generatestructure true /includebookmarks false /includehyperlinks false /includeinteractive false /includelayers false /includeprofiles true /multimediahandling /useobjectsettings /namespace [ (adobe) (creativesuite) (2.0) ] /pdfxoutputintentprofileselector /na /preserveediting true /untaggedcmykhandling /leaveuntagged /untaggedrgbhandling /leaveuntagged /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 318 338 missed nursing care in hospitalized.indd 318 maría guadalupe moreno-monsiváis1 catalina moreno-rodríguez2 maría guadalupe interial-guzmán3 missed nursing care in hospitalized patients 1 doctora en filosofía, universidad autónoma de nuevo león, méxico. mgmoreno@hotmail.com 2 magister en ciencias de enfermería, hospital christus muguerza de alta especialidad, méxico. catalina.moreno@christusmuguerza.com.mx 3 magister en ciencias de la enfermería, universidad autónoma de nuevo león, méxico. mginterial@hotmail.com recibido: 10 de octubre de 2014 enviado a pares: 12 de octubre de 2014 aceptado por pares: 14 de mayo de 2015 aprobado: 19 de mayo de 2015 doi: 10.5294/aqui.2015.15.3.2 para citar este artículo / to reference this article / para citar este artigo moreno-monsiváis mg, moreno-rodríguez c, interial-guzmán mg. missed nursing care in hospitalized patients. aquichan. 2015; 15(3): 318-328. doi: 10.5294/aqui.2015.15.3.2 abstract objective: determine missed nursing care in hospitalized patients and the factors related to missed care, according to the perception of the nursing staff and the patient. method: correlational descriptive study of a sample of 160 nurses and hospitalized patients, using the misscare nursing survey. results: nursing personnel indicated there were fewer care omissions in continuous evaluation interventions (m=94.56; sd=11.10). the greatest number of omissions pertained to basic care interventions (m=80.2; sd=19.40). patients mentioned there were fewer omissions in continuous evaluation interventions (m=96.32; sd=7.96), while the greatest number of omissions pertained to patient discharge and education (m=45.00; sd=23.22). the factors that contributed to missed nursing care, according to the nursing staff, were related to human resources (m=80.67; sd=17.06) and material resources (m=69.72; sd=23.45); patients mentioned human resources and communication. conclusions: nursing care that is not carried out according to the needs of the patient, or is omitted or delayed, was identified. this aspect is relevant, since nursing care is fundamental to the recovery of hospitalized patients. keywords nursing care, care, hospitalization, nursing staff, quality (source: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 318-328 319 missed nursing care in hospitalized patients l maría guadalupe moreno-monsiváis and others año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 318-328 omissão no atendimento de enfermagem para pacientes hospitalizados resumo objetivo: determinar o cuidado de enfermagem não prestado a pacientes hospitalizados e os fatores relacionados com o atendimento não prestado, segundo a percepção da equipe de enfermagem e a do paciente. método: estudo descritivo correlacional de uma amostra de 160 enfermeiras e pacientes hospitalizados, no qual se utilizou a pesquisa misscare. resultados: a equipe de enfermagem indicou que houve menos omissões de atendimento em intervenções contínuas de avaliação (m = 94,56; de = 11,10). o maior número de omissões se referiu a intervenções de atendimento básico (m = 80,2; de = 19,40). os pacientes mencionaram que houve menos omissões em intervenções contínuas de avaliação (m = 96,32; de = 7,96), enquanto o maior número de omissões correspondeu a dar alta ao paciente e à educação (m = 45,00; dt = 23,22). os fatores que contribuíram para o atendimento de enfermagem não prestado, de acordo com a equipe de enfermagem, estiveram relacionados com recursos humanos (m= 80,67; de = 17,06) e recursos materiais (m = 69,72; de = 23,45); os pacientes mencionaram os recursos humanos e a comunicação como fatores determinantes nesse sentido. conclusões: identificou-se o cuidado de enfermagem que não se realiza de acordo com as necessidades do paciente, que se omite ou atrasa. esse aspecto é relevante já que a atenção de enfermagem é fundamental para a recuperação dos pacientes hospitalizados. palavras clave cuidados de enfermagem, atendimento, hospitalização, equipe de enfermagem, qualidade (fonte: decs, bireme). 320 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 introduction in developed countries, an estimated one out of ten hospitalized patients suffers harm resulting from the care received or the omission of care; in developing countries, the proportion is much higher. according to the world health organization [who] (1), the most important aspect in terms of patient safety is to protect against harm during treatment related to care. therefore, ensuring the quality of care and patient safety is the biggest challenge nurses and nursing leaders face today in managing care (2). hence, the commitment of staff to provide quality nursing care commensurate with the treatment plan and to identify and meet each patient’s specific needs in a timely manner is fundamental. nursing care pertains to activities that are developed by the nursing staff, such as administering medication, patient ambulation , changes of position, bathing patients, mouth care, recording vital signs, intake and output documentation, nutrition, and education for hospital discharge, among others. when these essential elements of care are not offered to the patient, it is known as missed nursing care or errors of omission (3, 4). previous studies show missed nursing care and errors of omission can be frequent at hospitals that attend to patients with acute health problems. according to who (1), an error is defined as the failure to complete a planned action, as intended, or the application of an incorrect plan. for example, an error can occur when something is done incorrectly (error of commission) or when something that should be done is not (error of omission). in the planning and implementation of care, regardless of whether the error is one of commission or omission, it is necessary to analyze why it occurred, to offer solutions, and to prevent any recurrence (3). according to the research agency for health care and quality, errors of omission are more difficult to recognize that errors of commission and, therefore, represent a major problem with serious implications for the quality and safety of care (5). the omission of nursing care can lead to adverse outcomes for patients, with significant harm, especially in vulnerable patient populations (6). the phenomenon of missed nursing care was first identified by kalisch (2) in a qualitative study designed to identify the types of nursing care that were regularly skipped during a hospital stay. according to the findings, kalisch identified the major omissions in nursing care as being ambulation, position changes, mouth care, food tray delayed or not delivered, patient education, discharge planning, intake and output documentation, as well as hygiene and surveillance. failure to comply with these elements of nursing care is attributed to lack of time, lack of staff for nursing interventions, poor teamwork, and ineffective delegation, among other factors. these findings were similar to those reported by ball et al. (7). kalisch’s missed nursing care model (2) is the theoretical basis on which this study was based. three concepts derived from the model of quality care by donabedian (8); namely, structure, process and outcome, are examined in this section. structure refers to the infrastructure of the hospital, the patient care unit and the individual characteristics of nurses. the process refers to nursing care given and nursing care or omitted care. the latter is regarded conceptually as an error by default and is defined as any aspect of required patient care that is omitted or delayed, all or in part (9). the result refers to the direct effects of nursing care on patient outcomes, such as falls, pressure ulcers and infections, and also on staff satisfaction with their current position and role. according to this model, both the characteristics of the unit and the nursing staff have been linked to patient outcomes. kalisch et al. (10) and schubert et al. (11) indicate staff characteristics are associated with missed nursing care and impact on patient outcomes in the form of higher mortality rates, infection rates, pressure ulcers and falls. these complications, in many cases, result in longer hospital stays and higher costs for care, adding negative implications for the quality and safety of hospital care. the literature reports lower rates of missed care among nurses with professional status, higher levels of education, and more work experience, length of service and professional experience (10, 11, 12, 13, 14). as for the shift, missed nursing care has been found to occur more often during the night shift (7). the missed nursing care model suggests there are factors that contribute to failure in care; the most common are attributed to human resources, material resources and communication. regarding human resources, the focus is on staff profile (category, level of education, length of service, work experience, assigned service and shift), insufficient teamwork, ineffective delegation, staff shortages, high turnover, refusal to perform some care habits (“that is not my job” syndrome), the nursepatient relationship, poor use of human resources, and long working hours (15, 16, 17). 321 missed nursing care in hospitalized patients l maría guadalupe moreno-monsiváis and others as for material resources, failure to provide the materials, equipment and supplies needed for care, and the availability of medical electrical equipment are two important factors. as for communication, the predominant factor is ineffective communication between support departments and the nursing and medical staff. identifying the type of missed or omitted nursing care and its associated factors is fundamental for nursing administrators; this knowledge allows for effective strategies that can contribute to the continuity of care. another important aspect is that most studies, so far, have focused on errors of commission and have given little relevance to errors of omission, which are directly associated with the quality of care and the safety of the patient, as well as with health outcomes. also, studies have focused on identifying the perception of nurses. the literature reports nurses are aware of the strengths and weaknesses in the care provided (18). however, there has been little emphasis on the opinions of the patient, who directly experiences the process of nursing care. information from the patient is very useful and accurate, because it includes the result of an individual process of reflection on the care received from the nursing staff. also, the patient may express his or her opinion according to the results of the attention received (19). therefore, in the case of this study, it was considered important to identify the patient’s perception as a recipient of care in order to contrast the perceptions of both (patient and nurse) about missed care. consequently, the findings may provide evidence to design strategies that effectively help to reduce care omissions . this study may contribute to the quality of nursing care by focusing on missed care, so as to design strategies to reduce care omissions. likewise, it may provide nurses with knowledge by highlighting interventions that are not performed but are essential to patient recovery . the following are the objectives of this study: 1. identify missed nursing care during hospitalization, based on the perception of the nursing staff and the patient. 2. identify missed nursing care according to the working characteristics of nurses (category, level of education, length of service, work experience and shift). 3. determine the relationship between the perception of nurses and patients regarding missed nursing care. 4. identify the factors whereby nursing care is missed during hospitalization, according to the perception of the nursing staff and the patient. method the study design was descriptive and correlational (20). the study population was comprised of nurses and adult patients who were hospitalized at a private institution in the metropolitan area of monterrey, nuevo leon, mexico. regarding the nurses, 160 participated out of a total census of 201 nurses assigned to inpatient service, where general surgery and internal medicine patients were being cared for. nurses who were absent during the data collection period, for reasons of illness or vacation, were excluded; as were those who did not want to participate. regarding the patients, 160 participated because they met the inclusion criteria: being conscious and situated in time and place, being 18 years of age or more, and having at least 48 hours of hospitalization. once the 160 nurses were identified, one patient they had been assigned to serve was selected randomly. in situations where the patient had been selected previously, another was chosen randomly. for collecting data on the nurses, the misscare (“missed nursing care”) survey designed by kalisch and williams (21) was used. it consists of 64 items divided in three sections. the first section, with a total of 23 items, includes demographic and employment data on the nurses. the second section, called “missed nursing care,” consists of 24 questions related to the elements of nursing care being provided to the patient. it is divided into four dimensions, including interventions to attend to individual needs, discharge planning and patient education, basic care interventions, and care interventions with continuous assessment. response options are likert-type and range from high to low: 5-always, 4-often, 3-occasionally, 2-rarely, 1-never and 0-does not apply. the “does not apply” option, was included in all the questions about nursing care that is not performed during the night shifts, such as feeding the patient and walking, among others. according to the authors, the answer choices are converted into a dichotomous scale; options 5 and 4 are regarded as care that was provide, while options 3, 2 and 1 are regarded as missed care. cronbach’s alpha obtained for this section was 0.89. the third section, called “reasons for missed nursing care,” consists of 17 items that pertain to the factors whereby nursing care is missed. it includes three dimensions for the factors involving human resources, material resources and communication. an 322 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 alpha value of 0.90 was reported for this section. the response rate is four-point likert, where 4 denotes significant reason, 3 moderate reason, 2 minor reason and 1 is no reason. the same misscare survey (21) was applied to measure missed nursing care from the patient’s point of view. however, the questions from the first section were removed, because they were directly related to the job profile of nurses. this left only the patient identification data. the “missed nursing care” section remained the same as was applied to the nursing staff, but care was taken to ensure the wording was consistent for the patient. the section entitled “reasons for missed nursing care” was discarded for the patient application, because “do not know” was the dominant answer to the items in this section in the pilot survey. therefore, the decision was made to formulate an open question: why do you think nurses do not “always” provide some aspects of care? the final survey was composed of 33 items. we asked permission from the authors (21) to use the survey and they allowed it to be translated for use in mexico. since the instrument had not been applied in the mexican population, a translation process was necessary and the latest version underwent to a pilot study prior to being implemented. for data collection, the hospital units were visited during each of the different shifts and the nursing staff was invited to participate. after the objective of the study had been explained, the staff members who agreed to participate were asked to sign an informed consent letter. after that, the staff members were asked if they wanted to answer the survey at that time; if they did, it was verified that doing so would not interfere with their planned activities. then, the misscare surveys were conducted. the participants received instructions on how to fill them out; likewise, they were told they were free to withdraw from the survey at any moment. after that, a patient was selected randomly from those who were assigned to the nursing staff that had answered the survey previously and met the inclusion criteria. the authors visited the patients in their rooms to make sure they were experiencing no pain or discomfort and the survey would not interfere with any procedure. the study was explained to the patients and their participation was requested. once the patients agreed to participate, each one was asked to sign an informed consent letter, then the authors proceeded to apply the misscare survey to each patient. moreover, it was verified beforehand that no staff member was in the room. this was done to obtain more openness in the patients’ responses. the study followed the ethical guidelines described in the regulations for the general law on research in health (22). in addition, the study was approved by the ethics and research committees of the universidad de nuevo leon school of nursing. authorization from the participants was requested and obtained by having them sign an informed consent letter, and the dignity, privacy, welfare and rights of the patients were properly respected at all times. the authors used the statistical package for the social sciences (spss),version 17, to process the data. descriptive statistics were used to profile the participants and to describe the variables of the study. index values from 0 to 100 were designed for each of the dimensions of care, as well as for the associated factors. the higher the score, the more care given (the difference between the score obtained and the maximum possible amount is 100 for missed nursing care), and the more significant the reason for missed care. inferential statistics, such as the kruskal wallis and spearman correlation, also were applied to meet the objectives of the study. results nursing staff characteristics the female gender predominated with 86.3%. the age range was 18-25 years (36.8%), followed by 41-50 years (20.7%), and the level of nursing education was registered nurse (53%) and nursing assistant (18.8 %). as for job characteristics, more than half were in the rn category (or) bsn (61.9%), followed by nursing assistant (33.1%). the highest proportion had seniority with the institution and had been in its service from one to five years: 55.6% and 61.3%, respectively. similarly, work experience was mainly one to five years (61.3%), and the swing shift dominated (41.2%), followed by the night shift (32.5%). the average number of patients assigned to nurses per shift was six (sd = 4.24), admitted patients were three per shift (m = 2.94, sd = 1.48), and discharged patients were two (m = 2.01, sd = 1.60). 323 missed nursing care in hospitalized patients l maría guadalupe moreno-monsiváis and others patient characteristics the largest proportion of patients was served in the area of internal medicine (81.3%). as for gender, there was a slight predominance of women (55% female, 45% male). regarding age, half of the participants were 51 or older; in relation to the level of education, over 50% had some degree of professional education and undergraduates predominated (46.3%). care elements perceived by the nursing staff table 1 shows the overall index and dimensions of the nursing care provided. the interventions that best pertain to fulfilled care-giving evaluations had an average of 94.56 (sd = 11.10), and basic care is where more missed or omitted care nursing was observed, at an average of 80.82 (sd = 19.40). when analyzing the elements of missed care for each of the dimensions in terms of interventions to satisfy individual needs, the staff noted a higher proportion of missed or omitted care in the following order: emotional support for the patient and / or family (21.3%), assistance in attending evaluation visits for interdisciplinary care (14.7%), and drugs administered within 30 minutes before or after the scheduled time (11.1%). as to discharge planning and patient education, care was perceived as missed by 5.7% with respect to patient education concerning the disease, testing and diagnostic studies, and 10.8%, in terms of the patient discharge plan and patient education. in basic care interventions, the attention that was found to have been missed most was assistance with ambulation three times per day or as ordered (42.0%), followed by feeding the patient while the food is hot (30.2%), and assistance with mouth care (21.3%). regarding care interventions with ongoing assessments, the main missed or omitted elements of care pertained to assessments and reassessments of patients per shift and health status: 13.5% and 12.8%, respectively. elements of care perceived by the patient table 2 shows the rates of nursing care, according to the patient’s perception. the patient perceived greater compliance with interventions related to ongoing assessments, with an average of 96.32 (sd = 7.96). the dimension that showed more missed care was discharge planning and patient education, with an average of 45.0 (sd = 23.22). by analyzing each of the dimensions, it was possible to identify the elements of care that were omitted most of the time. in the category of individual needs, the predominant missed or omitted care was emotional support for the patient and / or family (43.7%), followed by visits for assessments by other professionals (physician, nutritionist etc.),with 26.2%, and evaluating the effectiveness of drugs (16.7%). in terms of interventions for discharge planning and patient education, patients reported shortcomings in education during hospitalization (about the disease, diagnostic tests and studies), as well as in the discharge plan: 36.2% and 73.7 %, respectively. regarding basic care interventions, missed care was higher in assistance for mouth care (32.1%), followed by assistance with hand washing (29.4%), ambulation three times daily or as ordered (20.3%), and support for changing position every two hours or according to the patient’s needs (17%). concerning activities for continuous assessment, the highest proportion of omission pertained to complete documentation of all required data on the patient (9.5%). less omission was reported for this type of intervention . rates by nurses, according to their assigned category, level of education, length of service, work experience and assigned shift, were analyzed to identify differences in missed care according to the job characteristics of nursing care. very similar values were obtained within each of the occupational characteristics . no statistically significant differences were found between groups when applying the kruskal-wallis test (p> 0.05). the spearman correlation test was applied to determine the relationship between the perception of nurses and patients about the care given and received. the results showed no significant association (p> .05). factors related to missed nursing care perceived by nurses the factors where nursing care is missed or omitted, according to the perception of nurses, are shown in table 3. mainly, 324 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 they are attributed to the nursing workforce, with an average of 80.67% (sd = 17.06), followed by materials and supplies, with an average of 69.72% (sd = 23.45), and, finally, communication factors, with an average of 65.16% (sd = 21.95). regarding human resources, the elements the nursing staff perceived as a significant reason for more than 50% of missed nursing care included an unexpected increase in the volume of patients (65%), followed by insufficient staff (58.8%), and patient emergencies (46.9%). as for factors related to materials and supplies, nurses cited them as an important reason for missed care, specifically when drugs were not available (50%), followed by supplies / equipment not being on hand when needed, and supplies and equipment that do not work properly when required, with 36.9% and 33.8%, respectively. regarding the communication factors, unbalanced allocation of patients was perceived as the primary reason for missed care, with 40.6%, followed by too many tasks to be done for patients who are admitted and discharged, with 36.9%, and lack of support from team members, with 35.6%. factors related to missed nursing care perceived by patients the patients noted that lack of staff is the main factor related to missed care (18.1%), followed by staff with insufficient experience (13.8%), and lack of organization and teamwork (7.5%). in a lesser proportion, they mentioned lack of staff communication from one shift to another (6.3%) and the attitude of staff members (5%), among other factors. discussion there are elements of nursing care that are missed or omitted during a hospital stay, according to the perception of the nursing staff and patients. the dimensions where more nursing care is omitted, according to the perception of nurses, are related to basic care interventions, followed by interventions to satisfy individual needs. the patients agreed with the nursing staff about the omission of interventions to meet individual needs; however, they differed with the nurses by identifying a high degree of omission when it comes to discharge planning and patient education. the results regarding the omission of basic care interventions and those to satisfy individual needs were similar to the results reported by kalisch et al. (3) and kalisch and lee (15). the elements of nursing care omitted most often, as perceived by the nursing staff, were related to emotional support for the patient and / or family, attending evaluation visits for interdisciplinary care, and medication administered within 30 minutes before or after the scheduled time. likewise, the patients agreed with the nursing staff in perceiving higher rates of omitted care in terms of emotional support for the patient and / or family, followed by attending evaluation visits with other professionals (doctor, nutritionist, etc.),and evaluating the effectiveness of medication. these results match those reported in studies by kalisch (2) and kalisch et al. (3). as for discharge planning and patient education, both nurses and patients agreed these issues are missed continually during hospitalization. in addition, patients reported missed care for education about the disease, testing and diagnostic studies. these results coincide with those reported in studies by kalisch et al. (3) and kalisch and lee (15). consequently, these elements are important to emphasize. as pointed out by kalisch (2) and kalisch et al. (23), a lack of adequate patient education and little or no preparation for discharge has negative repercussions on patient outcomes, such as complications and readmissions. patient education is an important intervention that must be developed as a priority by the members of the nursing staff, because it helps them to improve their participation and to make informed decisions about care. on the other hand, the discharge plan ensures continuity of care and patient education during the hospital stay that is consistent with the patient’s specific needs. the goal, upon discharge, is to guarantee the patient and his/ her family can count on having adequate knowledge to manage treatment at home, if necessary (24). as for basic care interventions, both the nurses and the patients perceived a significant proportion of missed or omitted care for assistance in walking three times a day or as ordered, followed by feeding the patient while the food is still hot, and mouth care. also, the patients identified several aspects of missed care as being important, such as assistance in hand washing and support for position changes every two hours or as needed. these results agree with those reported by kalisch et al. (3). 325 missed nursing care in hospitalized patients l maría guadalupe moreno-monsiváis and others in general, basic care takes second place, since more priority is given to alternative care. nurses assume basic care is done by the patients themselves, provided they have no physical or cognitive impairment and, if so, a family member would help. they considered routine nursing care in most hospitals as part of the care that must be performed by nurses and they take this opportunity to interact with the patient and to identify needs. bittner and gravlin (16) reported such care should be provided according to the category of nursing. the nursing assistant is responsible for routine care; however, the staff must make sure it is provided. as for care that requires ongoing assessments, both nurses and patients perceived it as the type that is most likely to take place. however, both perceived omissions; the nurses said the care missed or omitted is that which includes the patient’s assessment of his/her health status. as for patients, they noted the care missed or omitted is that pertaining to full documentation of all required data. these findings are consistent with those of kalisch et al. (3); they reported full documentation of the assessment of the patient in the nursing record sheet was one of the omitted / missed elements of care. some studies have found that missed nursing care, in the case of public hospitals, is associated with certain job characteristics of the nursing staff (5). however, this study discovered no differences in the care provided and missed according to those characteristics. this can be attributed to the fact that our study was performed at a private hospital, where a significant proportion of the nurses have less than 10 years of experience working with the institution and professional training predominates. moreover, the participating institution has a continuing education program for nurses. while both the nurses and the patients perceived missed or omitted care, there was no association between the perceptions of both groups. this might be because they perceived omission of care differently, based on the dimensions considered in this study; while the patients perceived more missed care regarding discharge planning and patient education, as well as interventions to satisfy individual needs; the nursing staff perceived it in terms of basic care interventions and interventions to meet individual needs. most care omissions perceived by the patient are important to take into account. it is a priority for nursing to design strategies that allow for greater continuity of care in these key aspects, which are linked directly to the quality and safety of care provided to the patient during hospitalization. regarding the factors that might contribute to missed nursing care, the nurses mostly cited human resources, followed by material resources and communication. as for human resources, the predominant aspects were an unexpected increase in the volume of patients and not enough staff. the data in this respect are consistent with the results reported by kalisch and lee (15). having enough staff with specific skills is crucial to addressing the needs of patients. whenever this aspect is affected, it directly interferes with the results of care, because nurses are forced to reduce or sometimes even skip certain tasks, even if doing so might increase the risk of adverse patient outcomes (11, 12 14). material resources were seen by the nurses as the second most important factor, especially when medicines and supplies / equipment are not available or might not work when needed. these results are similar to those reported by kalisch et al. (3), kalisch et al. (5) and kalisch and williams (21), who noted the proper functioning of equipment is necessary, as is its availability in the opportunity to provide quality nursing care and patient safety. regarding communication factors, the relevant aspects identified by the nursing staff focused on an unbalanced allocation of patients, the considerable amount of care required for patients who enter and leave, a lack of support from team members, and communication failures with the medical staff. these aspects identified in the study were similar to those reported by schubert et al. (14) as ones that interfere with care. it is important to strengthen effective communication among all members of the health team at health-care institutions, because communication is one of the main elements that favors the continuity of care and helps to reduce care omissions through an adequate transfer of patient information. furthermore, it is important that subsequent studies on missed care and associated factors analyze the impact on patient outcomes, which is an aspect not considered in this study. conclusions the findings of this study helped to identify, through the perception of nurses and patients, certain elements of care that are 326 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 required, according to the patient’s specific needs, but not performed during hospitalization. they are omitted or delayed on occasion, which can affect the outcome of care. moreover, in this study, the bulk of the omissions were those perceived by patients. this can be considered an important contribution, especially since the emphasis in previous studies was on identifying the perception of nurses. notably, both nurses and patients mentioned the factors related to human resources and ranked them first and foremost as being associated with missed care. all in all, this finding should be considered by nursing administrators as an area of opportunity that requires strategies to manage human resources effectively in an effort to reduce missed care and to strengthen the continuity of care. references 1. organización mundial de la salud. marco conceptual de la clasificación internacional para la seguridad del paciente. versión 1.1; 2009. 2. kalisch b. missed nursing care: a qualitative study. j nurs qual 2006; 21 (4): 306-313. 3. kalisch b, landstrom g, williams r. missed nursing care: errors of omission. nurs outlook 2009; 57 (1): 3-9. 4. ausserhofer d, zander b, busse r, schubert m, de geest s, rafferty am, et ál. prevalence, patterns and predictors of nursing care left undone in european hospitals: results from the multi-country cross-sectional rn4cast study. bmj qual saf 2014; 23:126–135. doi:10.1136/bmjqs-2013-002318 5. kalisch b, tschannen d, lee h, friese c. hospital variation in missed nursing care. am j med qual 2011; 26 (4): 291-299. 6. bittner np, gravlin g, hansten r, kalisch bj. unraveling care omissions. j nurs adm 2011; 41 (12): 510-512. 7. ball je, murrells t, rafferty am, morrow e, griffiths p. “care left undone” during nursing shifts: associations with workload and perceived quality of care. bmj qual saf 2014; 23: 116-125. 8. donabedian a. evaluating the quality of medical care 1966. milbank q 2005; 83 (4): 691-729. 9. kalisch b, tschannen d, lee kh. missed nursing care, staffing, and patient falls. journal of nursing care quality 2012; 27 (1): 6-12. 10. kalisch b, tschannen d, lee kh. do staffing levels predict missed nursing care? int j qual health care 2011; 23 (3): 302-308. 11. ball j, murrells t, rafferty a, morrow e, griffiths p. “care left undone” during nursing shifts: associations with workload and perceived quality of care. bmj saf 2014; 23: 116-125. 12. heede kv, sermeus w, diya l, clarke sp, lesaffre e, vleugels a, et ál. nurse staffing and patient outcomes in belgian acute hospitals: cross-sectional analysis of administrative data. international journal of nursing studies 2009; 46: 928-939. 13. kane r, shamliyan t, mueller ch, surval s, wilt tj. the association of registered nurse staffing levels and patient outcomes. medical care 2007; 45(12): 1195-1204. 14. schubert m, glass t, clarke s, aiken l, schaffert-witvliet b, sloane d, gesst s. rationing of nursing care and its relationship to patient outcomes: the swiss extension of the international hospital outcomes study. int j qual health care 2008; 20 (4): 227-237. 15. kalisch b, lee kh. the impact of teamwork on missed nursing care. nurs outlook 2010; 58 (5): 233-241. 16. bittner np, gravlin g. critical thinking, delegation and missed care in nursing practice. j nurs adm 2009; 39 (3): 142-146. 17. wakefield, b.j. (2014). facing up to the reality of missed care. bmj qual saf 2014; 23:92-94. 18. moreno m, interial g. percepción del paciente acerca de su bienestar durante la hospitalización. index enferm 2012; 21(4), 185-189. 327 missed nursing care in hospitalized patients l maría guadalupe moreno-monsiváis and others 19. ibarrola s, beortegui e, oroviogoicoechea c, vázquez m. evaluación de la satisfacción con los cuidados de enfermería en el área de hospitalización de cardiología. enferm cardiol 2011; xviii(53), 27-33. 20. grove sk, burns n, gray jr. practice of nursing research. appraisal, synthesis, and generation of evidence. elsevier st. louis missouri; 2013. 21. kalisch b, williams r. the development and psychometric testing of a tool to measure missed nursing care. j nurs adm 2009; 39 (5): 211-219. 22. secretaría de salubridad y asistencia. reglamento de la ley general de salud en materia de investigación para la salud. méxico: porrúa; 1987. 23. kalisch b, landstrom g, & hinshaw as. missed nursing care: a concept analysis. journal of advanced nursing 2009; 65(7), 1509-1517. 24. consejo de salubridad general. estándares para certificar hospitales. version 2012. méxico; 2012. 328 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 table 1. overall index according to the dimensions of care performed by nurses indexes mean median sd confidence interval 95% lower limit upper limit overall nursing care provided 89.18 91.66 11.51 87.38 90.98 interventions for individual needs 90.83 100 15.32 88.44 93.23 discharge planning and patient education 91.82 100 20.95 88.54 95.10 basic care interventions 80.82 85.71 19.40 77.79 83.85 care interventions with ongoing assessments 94.56 100 11.10 92.82 96.29 source: misscare survey for nurses n=160 table 2. overall index according to dimensions of care performed by nurses, as noted by the patient indexes mean median sd confidence interval 95% lower limit upper limit overall nursing care provided 83.29 86.36 16.33 80.74 85.84 interventions for individual needs 80.84 83.33 23.22 77.21 84.47 discharge planning and patient education 45.00 50.00 23.22 38.92 51.07 basic care interventions 83.78 100 28.51 79.28 88.27 care interventions with ongoing assessments 96.32 100 7.96 95.08 97.56 source: misscare survey for patients n=160 table 3. indexes of factors contributing to missed nursing care, as perceived by nurses indexes mean median sd confidence interval 95% lower limit upper limit human resources 80.67 83.33 17.06 78.01 83.34 material resources / supplies 69.72 66.66 23.45 66.07 73.36 communication 65.16 66.66 21.95 61.27 68.16 source: misscare survey for nurses n=160 15 23 teoria de situacion especifica.indd 15 linda azucena rodríguez-puente1 maría magdalena alonso-castillo2 teoría de situación específi ca de autotrascendencia en dependientes del alcohol en proceso de recuperación 1 maestra en ciencias de enfermería, universidad autónoma de nuevo león, méxico. lrpuente88@hotmail.com 2 doctora en filosofía, universidad autónoma de nuevo león, méxico. magdalena_alonso@hotmail.com recibido: 10 de junio de 2015 enviado a pares: 10 de junio de 2015 aceptado por pares: 6 de noviembre de 2015 aprobado: 21 de noviembre de 2015 doi: 10.5294/aqui.2016.16.1.3 para citar este artículo / to reference this article / para citar este artigo rodríguez puente la, alonso castillo mm. teoría de situación específica de autotrascendencia en dependientes del alcohol en proceso de recuperación. aquichan. 2016; 16 (1): 15-23. doi: 10.5294/aqui.2016.16.1.3 resumen la creación de modelos y teorías de enfermería, enfocadas en fenómenos específicos, contribuye a la práctica y el desarrollo de la disciplina de enfermería. objetivo: presentar una derivación teórica y proponer un modelo sobre la teoría de autotrascendencia en personas dependientes del alcohol en proceso de recuperación. materiales y métodos: se realizó una derivación teórica mediante la metodología propuesta por walker y avant. resultados: adaptación del modelo de autotrascendencia en personas dependientes del alcohol en proceso de recuperación en alcohólicos anónimos. conclusiones: el modelo puede ser útil para explicar cómo las personas dependientes del alcohol, que se encuentran en tratamiento, logran el bienestar y cuáles son los factores que influyen durante el proceso. palabras clave alcohólicos anónimos; autotrascendencia; derivación (fuente: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 15-23 16 aquichan issn 1657-5997 año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 15-23 theory of the specific situation of self-transcendence in persons recovering from alcohol dependence abstract the creation of nursing models and theories focused on specific phenomena contributes to the practice and development of the discipline of nursing. objective: the purpose of this study is to present a theoretical derivation and propose a model on the theory of self-transcendence in persons recovering from alcohol dependence. materials and methods: a theoretical derivation was done using the method proposed by walker and avant. results: adaption of the self-transcendence model in alcohol-dependent persons who are involved in a recovery process as part of alcoholics anonymous. conclusions: the model can be useful in explaining how alcohol dependent persons, who are in treatment, achieve well-being and what are the influencing factors during the process. keywords alcoholics anonymous; self-transcendence; derivation (source: decs, bireme). 17 teoría de situación específica de autotrascendencia en dependientes del alcohol en proceso de recuperación l linda azucena rodríguez-puente y otro teoria de situação específica de autotranscendência em dependentes do álcool em processo de recuperação resumo a criação de modelos e teorias de enfermagem enfocados em fenômenos específicos contribui para a prática e desenvolvimento da disciplina de enfermagem. objetivo: apresentar uma derivação teórica e propor um modelo sobre a teoria de autotranscendência em pessoas dependentes do álcool em processo de recuperação. materiais e métodos: realizou-se uma derivação teórica mediante a metodologia proposta por walker e avant. resultados: adaptação do modelo de autotranscendência em pessoas dependentes do álcool em processo de recuperação em alcóolicos anônimos. conclusões: o modelo pode ser útil para explicar como as pessoas dependentes do álcool, que se encontram em tratamento, atingem o bem-estar e quais são os fatores que influenciam durante o processo. palavras-chave alcóolicos anônimos; autotranscendência; derivação (fonte: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 15-23 18 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 introducción el consumo excesivo de alcohol tiene graves repercusiones para la salud pública y contribuye de forma importante en la carga mundial de morbilidad, además de ocupar el tercer lugar entre los principales factores de riesgo de muerte prematura y discapacidad en el mundo (1). en méxico, la dependencia del alcohol afecta al 4,1% de los adolescentes y al 6,6% de los adultos, y se tienen registros que muestran que esta proporción sigue en aumento según la encuesta nacional de adicciones en el 2011 (2). hay evidencia de que el consumo de alcohol es perjudicial, y la dependencia, así como las limitaciones para la recuperación de la dependencia, pueden relacionarse con múltiples factores de riesgo personales, interpersonales y del medio ambiente (3, 4); entre ellos se pueden destacar los eventos estresantes de la vida (5, 6), la espiritualidad (7-9) y los valores existentes en la cultura, la familia, la sociedad y, de manera evidente, los valores propios que se han construido y modificado a lo largo de la vida (10). de igual manera, existen factores personales y contextuales que han sido relacionados con el consumo dependiente de alcohol y los daños ocasionados por esta conducta, algunos de estos factores son la edad, el sexo, la ocupación, el nivel educativo y la religión (11, 8). sin duda, los grupos de alcohólicos anónimos (aa) se han convertido en una de las opciones más importantes para combatir este problema de dependencia del alcohol y lograr mantener la recuperación. la adherencia o afiliación a aa puede ser benéfica para personas que viven esta problemática. sin embargo, la evidencia científica actual es limitada acerca del proceso que se sigue para lograr la abstinencia del alcohol (sobriedad) y con ella la recuperación; se destaca como constructo que apoya el proceso de recuperación de aa, la relación de la asistencia a reuniones y el nivel de participación en los grupos, y se indica que cuando mayor es el involucramiento con el programa de los doce pasos de aa, mejor es el pronóstico de recuperación. este programa de doce pasos conforma el legado de la recuperación, es un conjunto de principios orientados a que la persona dependiente del alcohol (alcohólico) logre una transformación personal y deje de consumir; este programa es utilizado en méxico y en el mundo por todos los grupos aa (12-15). en este sentido, las teorías de rango medio permiten explicar y expandir el conocimiento sobre fenómenos específicos que están relacionados con el proceso de cuidado. la teoría de autotrascendencia (16) propone un modelo que permite a la enfermería actuar como una ciencia del desarrollo y como una ciencia humana, es decir que enfermería puede abordar la capacidad interna de los seres humanos para lograr la salud, el bienestar y su desarrollo continuo. esta teoría postula que cada persona es capaz de encontrar recursos en sí mismo (valores, espiritualidad) y extenderlos hacia los demás y su entorno, en las diferentes etapas de su vida, con el propósito de lograr y mantener el bienestar físico, psíquico y social. además la autotrascendencia facilita la integración de elementos complejos y los conflictos de vivir, envejecer y morir, así como los eventos de salud a los que se enfrentan las personas tales como el diagnóstico de una enfermedad crónica como la dependencia al alcohol (alcoholismo) y la recuperación mediante la abstinencia o el abandono de la conducta; la autotrascendencia puede ayudar a las personas a organizar estrategias y herramientas para mantener el bienestar, y otorga un sentido de plenitud durante la trayectoria de la enfermedad y la recuperación; por ello, esta teoría se considera apropiada para tratar el fenómeno de la dependencia del alcohol. para desarrollar programas en individuos mexicanos dependientes del alcohol, que se encuentran en proceso de recuperación, se necesitan bases teóricas completas. sin embargo, no existen marcos o teorías que puedan explicar cómo se relaciona la autotrascendencia en las personas que buscan la sobriedad y de este modo alcanzar el bienestar. la derivación teórica es una forma creativa y enfocada al desarrollo de teoría en un nuevo campo —en este caso, la dependencia al alcohol y la recuperación del paciente—; es útil cuando se tiene un conjunto de conceptos relacionados entre sí, pero no se tiene una estructura para representar las relaciones. la derivación tiene como resultado que la teoría proporcione estructuras para la interpretación de la conducta, las situaciones y los eventos, unificando lo que se conoce (17). por tanto, el propósito de este artículo es presentar una teoría de situación específica a partir de la derivación teórica de la teoría de autotrascendencia de reed (16), y una revisión de la literatura relevante. derivación teórica de la teoría de autotrascendencia para realizar la derivación teórica de la teoría de autotrascendencia de pamela reed (16), se tomaron en cuenta los cinco pasos propuestos por walker y avant (17). 19 teoría de situación específica de autotrascendencia en dependientes del alcohol en proceso de recuperación l linda azucena rodríguez-puente y otro el primer paso es familiarizarse con la literatura del tópico de interés, por lo que se realizaron búsquedas sobre autotrascendencia, espiritualidad, vulnerabilidad, factores personales y contextuales, el consumo excesivo y la dependencia del alcohol por adultos y participantes de grupos de aa que pretenden la sobriedad. se revisaron a fin de familiarizarse con el tópico de interés mediante la búsqueda de literatura en bases de datos digitales reconocidas como scopus, ebsco, proquest, dialnet, medline y scielo. las palabras clave utilizadas fueron self-transcendence, spirituality, vulnerability, alcohol use, drinking, protective factors, alcohol consumption y alcoholics anonymous, y se realizaron distintas combinaciones en inglés y en español. en el segundo paso se identificaron formas nuevas de analizar la temática de interés, particularmente desde diferentes áreas de conocimiento. de acuerdo con la búsqueda realizada se identificaron algunas formas de analizar la temática desde perspectivas psicológicas, antropológicas, sociológicas y de salud. asimismo, se identificó que algunas de las proposiciones de la teoría de rango medio de autotrascenencia de reed permiten describir, explicar y predecir el resultado final, es decir el bienestar psicológico y social, en especial el abandono de la conducta de consumo excesivo, o alcanzar el estado de sobriedad de las personas con problemas de consumo dependiente de alcohol que participan del programa de doce pasos de alcohólicos anónimos. en el tercer paso se seleccionó una fuente de conocimiento; en este caso se eligió la teoría de rango medio de autotrascendencia de reed (trma) para realizar la derivación teórica conceptual empírica, y darle estructura y contenido específico a cada una de las proposiciones. la selección se fundamentó en los conceptos de dicha teoría, que tienen aplicación en el fenómeno de las drogas, en específico la dependencia al alcohol y la recuperación. la trma tiene como objetivo la comprensión y explicación del bienestar en la adultez o en el proceso de crecimiento, es una teoría empírica explicativa de enfermería, y fue construida para el reconocimiento del desarrollo natural del ser humano y la relevancia de los fenómenos para el logro del bienestar; ha sido utilizada para enfatizar el curso y el cambio que ocurre entre los seres humanos y su contexto ambiental (16). la teoría de autotrascendencia comprende tres conceptos principales: la vulnerabilidad, la autotrascendencia y el bienestar. la vulnerabilidad se refiere a la conciencia de la mortalidad personal y la probabilidad de experimentar eventos difíciles de la vida. la vulnerabilidad es el contexto en el que se da lugar a la maduración o el desarrollo de la vida; está asociada a la conciencia que se adquiere durante cualquier crisis vital, como la enfermedad, la discapacidad, la pérdida, los problemas profesionales y otras crisis vitales. otro concepto principal es la autotrascendencia, definida como la capacidad de expandir autolímites intrapersonales (hacia una mayor conciencia de la filosofía, valores y sueños de cada uno), interpersonales (para relacionarse con otros y su ambiente), temporales (para integrar el pasado y el futuro en una forma que tenga sentido para el presente) y transpersonales (para conectar con dimensiones más allá del típico mundo discernible). la autotrascendencia es una característica de la madurez de desarrollo en términos de una mejor conciencia del medio ambiente y una orientación hacia amplias perspectivas sobre la vida. este concepto es expresado mediante varios comportamientos y perspectivas, como compartir sabiduría con otros, integrar los cambios físicos de envejecer, aceptar la muerte como parte de la vida y encontrar significado en la vida espiritual. por último, el bienestar también es uno de los conceptos principales de esta teoría, definido como una sensación de sentirse completo y saludable, de acuerdo con el criterio de integridad y salud de cada persona. el bienestar puede ser definido de varias maneras, esto depende de cada individuo o grupos de pacientes, de esta manera, los indicadores de bienestar son tan diversos como las percepciones humanas de salud y bienestar (16). en el cuarto paso se desarrollaron nuevas propuestas sobre la temática de estudio, con base en el contenido y la estructura de las proposiciones de otros campos del conocimiento y del propio campo. la primera proposición indica que “el aumento de la vulnerabilidad está relacionado con un incremento de la autotrascendencia”. diferentes estudios señalan que los eventos estresantes pueden convertir a una persona vulnerable en dependencia del alcohol (18, 19). el experimentar eventos estresantes genera un grado de reacción que puede afectar el bienestar y salud de las personas (20, 5); además, existe evidencia que señala que un número elevado de eventos estresantes podrían ser un factor relacionado a la dependencia del alcohol (5, 21). otro aspecto documentado es que los eventos estresantes se pueden relacionar con la espiritualidad ya que se ha identificado que situaciones como traumas y enfermedad psiquiátrica, o la pérdida de un ser querido, se pueden afrontar mediante la espiritualidad (22-24). 20 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 por lo anterior, la proposición derivada indica que “el aumento de eventos estresantes está relacionado con el incremento de la espiritualidad y los valores”. la segunda proposición supone que la autotrascendencia está relacionada de forma positiva con el bienestar. la relación es postulada para ser directa y positiva, con indicadores positivos de bienestar. en la literatura de salud y enfermería la espiritualidad ha sido relacionada como un elemento que contribuye al bienestar mental y físico de las personas (25-27) y ha sido abordada desde dos perspectivas: la primera se enfoca en la religión, religiosidad, prácticas y compromisos religiosos, que han sido definidos como la participación en prácticas, creencias, actitudes y sentimientos asociados a una comunidad de fe organizada, y la segunda reconstruye la espiritualidad dentro de las disciplinas sociales, con una visión de dios más amplia, que incluye los valores y los principios que dan sentido y propósito a la vida (27). asimismo, el concepto de valor ha sido definido como creencias duraderas de un modo específico de conducta (valor instrumental) o un estado final de existencia (valor terminal), es personal o socialmente preferible a un modo de conducta o estado final de existencia opuesto. los valores son cogniciones acerca de lo deseable o preferible. poseer un valor implica decir que un sujeto conoce el camino o modo correcto de conducirse, o el fin último que desea alcanzar (28). con base en lo anterior, la segunda proposición derivada indica que “la espiritualidad y los valores están relacionados de manera positiva con el bienestar psicológico y físico”. una tercera proposición postula que existe una diversidad de factores personales y contextuales que pueden influir en la relación existente entre vulnerabilidad y autotrascendencia, y entre autotrascendencia y bienestar. es una sensación de sentirse completo y sano, de acuerdo con los propios criterios para la integridad y la salud. se teoriza cómo un patrón básico del desarrollo está lógicamente relacionado con experiencias positivas que promueven la salud y, por tanto, no es una correlación, sino es un predictor y recurso. el bienestar será descrito desde tres perspectivas: bienestar psicológico, bienestar social y bienestar físico, ya que el objetivo principal de las personas que presentan dependencia del alcohol y se encuentran en tratamiento, es lograr el bienestar (sobriedad y recuperación). la última proposición derivada propone que “la edad, sexo, ocupación, estado civil, el nivel educativo y la religión pueden influir en la relación entre las proposiciones anteriores”. la tabla 1 muestra las proposiciones realizadas por reed (16) en su teoría de autotrascendencia y las proposiciones hechas por el modelo de autotrascendencia en personas dependientes del alcohol en proceso de recuperación. tabla 1 derivación de proposiciones proposiciones de la teoría de autotrascendencia proposiciones de la teoría de situación específica de la autotrascendencia en personas dependientes del alcohol en proceso de recuperación 1. "el aumento de la vulnerabilidad está relacionado con un incremento de la autotrascendencia". 1. "el aumento de eventos estresantes está relacionado con el incremento de la espiritualidad y los valores". 2. "la autotrascendencia está relacionada de forma positiva con el bienestar". 2. "la espiritualidad y los valores están relacionados de manera positiva con el bienestar psicológico y físico". 3. "existe una diversidad de factores personales y contextuales que pueden influir en la relación existente entre vulnerabilidad y la autotrascendencia y entre la autotrascendencia y bienestar". 3. "la edad, sexo, ocupación, estado civil, el nivel educativo y la religión pueden influir en la relación entre las proposiciones anteriores". fuente: derivado de la teoría de autotrascendencia (16). finalmente, en el quinto paso se redefinieron los nuevos conceptos de las proposiciones derivadas y adaptadas en contenido a la temática de estudio, y se establecieron nuevas definiciones para los conceptos acordes con la teoría madre, considerando la evidencia científica recuperada de la revisión de literatura. vulnerabilidad: es la condición personal y actual de estar en riesgo de continuar con el consumo dependiente del alcohol y no obtener la recuperación mediante el abandono de la conducta, logrando la sobriedad o la abstinencia de la sustancia. la vulnerabilidad es considerada como la presencia de eventos estresantes de la vida. autotrascendencia: es la capacidad de ampliar los límites intrapersonales (valores) y transpersonales (espiritualidad) para no continuar con el consumo excesivo o dependiente de alcohol, obtener la sobriedad y la abstinencia de la sustancia. 21 teoría de situación específica de autotrascendencia en dependientes del alcohol en proceso de recuperación l linda azucena rodríguez-puente y otro bienestar: el bienestar psicológico es considerado como autoaceptación, relaciones positivas con otras personas, autonomía, dominio del entorno, propósito de vida y crecimiento personal; si la persona tiene bienestar psicológico esto se refleja en su salud mental y en la adopción de conductas que afectan positivamente su salud como es lograr la recuperación de la dependencia del alcohol o su abandono (abstinencia). el bienestar físico es considerado como la recuperación del paciente dependiente del alcohol o el abandono de la conducta observada a través de la abstinencia, por lo cual, cuando exista un consumo dependiente o la presencia de recaídas, se considera como falta de bienestar físico. en la figura 1 se muestra una adaptación al modelo original, que pretende ser comprobado mediante el modelamiento de ecuaciones estructurales (mee). figura 1. adaptación del modelo de autotrascendencia (16) en personas dependientes al alcohol en proceso de recuperación blicos, para contribuir con el tratamiento y el logro del bienestar en las personas que presentan un dependencia del alcohol. de acuerdo con las metas de enfermería enfocadas en el bienestar de las personas, existe un interés especial por el desarrollo de intervenciones preventivas enfocadas en evitar la dependencia del alcohol, así como también poder ofrecer cuidado en la rehabilitación y recuperación de pacientes con esta dependencia, para que logren la abstinencia, eviten las recaídas y alcancen el bienestar; por esta razón, se requiere la integración de la teoría a la práctica, lo cual es fundamental dada la complejidad del fenómeno de estudio. el desarrollo de nuevos modelos y teorías contribuye de manera esencial en el crecimiento y fortalecimiento de la disciplina de enfermería, además de que provee lineamientos importantes para guiar la práctica y para la generación de nuevas intervenciones enfocadas en la prevención y el tratamiento del consumo de alcohol dependiente. las teorías de rango medio son parte de la estructura de enfermería; ellas abordan el conocimiento sustantivo de la disciplina al explicar y expandir los fenómenos específicos relacionados con el proceso de cuidado. las teorías de rango medio proveen las herramientas específicas para ser utilizadas en la investigación y la práctica, es por esto que al contextualizarlas es más sencillo comprender o dar respuesta al fenómeno, como se hizo con la teoría de autotrascendencia en pacientes dependientes del alcohol en proceso de recuperación en el programa de doce pasos de alcohólicos anónimos, mediante la metodología propuesta por walker y avant (17). este modelo puede ser útil para explicar cómo las personas dependientes del alcohol que se encuentran en tratamiento de aa logran el bienestar psicológico y físico, y cuáles son los factores que influyen durante el proceso; además, la necesidad de estudiar, desde la perspectiva de enfermería, el fenómeno de la recuperación de la dependencia al alcohol, lograr la abstinencia o sobriedad y evitar la recaída es un área relevante por las implicaciones que tiene para el diseño de intervenciones enfocadas a apoyar la recuperación del paciente y su bienestar. conclusiones con base en este modelo, el personal de enfermería puede incursionar como personal de salud activo en las diferentes instituciones que aborden el problema de la dependencia del alcohol, como son los diferentes centros de rehabilitación privados y pú22 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 referencias 1. organización mundial de la salud. global status report on alcohol and health. ginebra: onu; 2014. 2. consejo nacional contra las adicciones-secretaría de salud [conadic-ss]. encuesta nacional de adicciones. cuernavaca, morelos: instituto nacional de salud pública; 2011. 3. alonso cmm, álvarez bj, lópez gk, rodríguez al, armendáriz na. factores de riesgo personales, psicosociales y consumo de alcohol en mujeres adultas. inv enf. 2009;11(1):97-115. 4. lema sl, varela am, duarte ac, bonilla gm. influencia familiar y social en el consumo de alcohol en jóvenes universitarios. rev fac nal sal púb. 2011;29(3):264-271. 5. alonso cb, palucci mmh, alonso cmm, guzmán ffr, gómez mmv. situaciones de la vida estresantes, uso y abuso de alcohol y drogas en adultos mayores de monterrey, nuevo león. rev latino-am enfermagem. 2008;16. 6. tamers sl, okechukwu c, bohl aa, guéguen a, goldberg m, zins m. the impact of stressful events on excesive alcohol consumption in the french population: findings from the gazel cohort study. plos one. 2014;9(1). 7. martins me, ribeiro lc, feital tj, baracho ra, ribeiro ms. religious-spiritual coping and the consumption of alcoholic beverages in male patients with liver disease. rev esc enferm usp. 2012;46(6):1341-1348. 8. kelly jf, stout rl, magill m, tonigan js, pagona me. spirituality in recovery: a lagged mediational analysis of alcoholics anonymous principal theoretical mechanism of behavior change. alcohol clin exp res. 2011;35(3):454-463. 9. robinson ea, krentzman ar, webb jr, brower kj. six-month changes in spirituality and religiousness in alcoholics predict drinking outcomes an nine months. j stud alcohol drugs. 2011;72(4):660-668. 10. rodríguez pla, alonso cba, alonso cmm, alonso cmtj, oliva rn, armendáriz gna. valores terminales, valores instrumentales y consumo de alcohol y tabaco en estudiantes de preparatoria. enferm comunitaria. 2015;11(1):1-7. 11. secretaría de salud. norma oficial mexicana para la prevención, tratamiento y control de las adicciones, nom-028ssa2-1999. disponible en: http://www.unet.com.mx/ceca/norma.htm. 12. gutiérrez rr, andrade pp, jiménez ta, saldivar hg, juárez gf. alcohólicos anónimos: aspectos relacionados con la adherencia (afiliación) y diferencias entre recaídas y no recaídas. salud ment. 2009;32:427-433. 13. rosovsky h, leyva g. movimiento de alcohólicos anónimos en méxico. anales. 1990;(1):5-8. 14. rosovsky h. alcohólicos anónimos. en beber de tierra generosa. ciencias de las bebidas alcohólicas en méxico. méxico: fundación de investigaciones sociales ac; 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1973. 90 104 relacion de la asignación de personal.indd 90 gloria l. arango1 beatriz peña2 yolanda vega3 relación de la asignación de personal de enfermería con indicadores de resultado de la calidad de la atención en unidades de cuidados intensivos de adultos 1 enfermera. especialista y doctora en bioética. magistra en administración de salud. profesora asociada, facultad de enfermería, universidad nacional de colombia, bogotá (colombia). glarangob@unal.edu.co 2 enfermera. magistra en salud pública. profesora pensionada, facultad de enfermería, universidad nacional de colombia, bogotá (colombia). yvegav@unal.edu.co 3 enfermera. magistra en salud pública. especialista en gerencia social. profesora pensionada, facultad de enfermería, universidad nacional de colombia, bogotá (colombia). bpenar@unal.edu.co recibido: 04 de febrero de 2014 enviado a pares: 22 de febrero de 2014 aceptado por pares: 19 de agosto de 2014 aprobado: 21 de agosto de 2014 doi: 10.5294/aqui.2015.15.1.9 para citar este artículo / to reference this article / para citar este artigo arango g, peña b, vega y. relación de la asignación de personal de enfermería con indicadores de resultado de la calidad de la atención en unidades de cuidados intensivos de adulto. aquichan. 2015;15(1):90-104. doi: 10.5294/aqui.2015.15.1.9 resumen objetivo: determinar la relación de la asignación de personal de enfermería con indicadores de resultado de la calidad de la atención en unidades de cuidados intensivos. materiales y métodos: se hizo un estudio descriptivo con un componente correlacional, en el que se observaron 4006 turnos y se analizaron las variables de asignación de personal (estructura) y de resultado, en términos de casos de shock o paro, infecciones asociadas a la atención en salud, número de muertes y totalidad de eventos negativos en salud. resultados: los resultados muestran que las enfermeras desarrollan un número reducido de actividades de cuidado directo al paciente, que se concentran en la administración de medicamentos y la supervisión de transfusiones, y otras tareas administrativas, mientras que el personal auxiliar se hace cargo del cuidado directo al paciente, incluidas las actividades complejas. la razón paciente/profesional de enfermería promedio fue de 5,4 pacientes por cada enfermera disponible en la unidad, y la razón paciente/auxiliar de enfermería promedio fue de 2,4. las correlaciones no son concluyentes. conclusiones: se sugiere estudiar con mayor profundidad el skill mix como una medida más sensible de asignación de personal, a la vez que se plantean recomendaciones en torno a la diferenciación de actividades entre profesionales y auxiliares de enfermería, y algunas consideraciones relativas a la asignación de personal. palabras clave asignación de recursos para la atención de salud, enfermería, recursos humanos en salud, organización y administración, relación enfermera-paciente, cuidados intensivos. (fuente: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 90-104 91 relación de la asignación de personal de enfermería con indicadores de resultado de la calidad de la atención en unidades de cuidados intensivos de adultos l gloria l. arango y otros año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 90-104 association between nurse staffing and indicators of healthcare quality in adult intensive care units abstract purpose: the purpose of the study is to identify the association between nursing staffing and indicators of healthcare quality in intensive care units. materials and methods: a descriptive study was done using a correlational component in which 4006 work shifts were observed and staffing variables (structure) and results were analyzed in terms of cases of shock or arrest, infections associated with health care, number of deaths, and all adverse health events. findings: the findings show nurses conduct a limited number of activities involving direct patient care. these focus on administering medication, supervising transfusions and other administrative tasks, while assistant nurses handle direct patient care, including complex activities. the average patient–to-nurse ratio was 5.4 patients per nurse available during the shift, while the average patient-to-nursing assistant ratio was 2.4. the correlations are inconclusive. conclusions: it is suggested the skill mix be explored further as a more sensitive measure of staffing, and recommendations are made on differentiating activities between nursing professionals and assistant nurses. several considerations are raise concerning staff allocation. keywords resource allocation for health care, nursing, health human resources, organization and administration, patient-to-nurse ratio, intensive care (source: mesh, bireme). 92 aquichan issn 1657-5997 relação da designação de pessoal de enfermagem com indicadores de resultado da qualidade do atendimento em unidades de tratamento intensivo de adultos resumo objetivo: determinar a relação da designação de pessoal de enfermagem com indicadores de resultado da qualidade do atendimento em unidades de tratamento intensivo. materiais e métodos: realizou-se um estudo descritivo com um componente correlacional, no qual foram observados 4.006 turnos e analisadas as variáveis de designação de pessoal (estrutura) e de resultado, em termos de caso de choque ou parada, infecções associadas à atenção em saúde, número de mortes e totalidade de eventos negativos em saúde. resultados: os resultados mostram que os enfermeiros desenvolvem um número reduzido de atividades de cuidado direto do paciente, que se concentram na administração de medicamentos e na supervisão de transfusões, além de outras tarefas administrativas, enquanto o pessoal auxiliar se responsabiliza pelo cuidado direto do paciente, o que inclui as atividades complexas. a razão paciente-profissional de enfermagem média foi de 5,4 pacientes por cada enfermeiro disponível na unidade, e a razão paciente-auxiliar de enfermagem foi de 2,4. as correlações não são conclusivas. conclusões: sugere-se estudar com maior profundidade o skill mix como uma medida mais sensível de designação de pessoal, ao mesmo tempo que se propõem recomendações sobre a diferenciação de atividades entre profissionais e auxiliares de enfermagem, bem como algumas considerações relativas à designação de pessoal. palavras-chave designação de verbas para o atendimento de saúde, enfermagem, recursos humanos em saúde, organização e administração, relação enfermeiro-paciente, unidade de tratamento intensivo (fonte: decs, bireme). año 15 vol. 15 nº 1 chía, colombia marzo 2015 l 90-104 93 relación de la asignación de personal de enfermería con indicadores de resultado de la calidad de la atención en unidades de cuidados intensivos de adultos l gloria l. arango y otros introducción dado que en colombia no se ha establecido por ley o formalmente una razón enfermero/paciente para los servicios de las instituciones hospitalarias, en el sistema de salud colombiano, desde 1993, se han venido implementando estrategias de reducción de costos a partir de la disminución de personal profesional de enfermería, con un aumento del número de pacientes por enfermero profesional. esta tendencia ha resultado preocupante, aun para el propio ministerio de salud y protección social (1), que destaca cómo el diseño organizacional y las condiciones de trabajo para promover un mejor desempeño en los profesionales de la salud se constituyen en dos de los elementos centrales cuando de la búsqueda de la seguridad del paciente se trata. refiriéndose particularmente a enfermería se ha pronunciado el consejo técnico nacional de enfermería (ctne), que alerta sobre la falta de estándares para regular la proporción de profesionales por paciente, área de desempeño y complejidad de los servicios y pacientes para garantizar la calidad de la atención que se brinda, así como sobre la sustitución por personal auxiliar, distorsionándose su perfil ocupacional (2). en términos de seguridad, es creciente la inquietud por la necesidad de contar con mejores razones enfermero/paciente para garantizar la seguridad de estos últimos (3), un asunto de enorme importancia para las instituciones hospitalarias. pero más allá de lo estrictamente numérico, la información sobre asignación de personal de enfermería, en especial de profesionales, revela la importancia que se le otorga al papel que desempeña el enfermero en las instituciones hospitalarias y a sus aportes a los resultados en los pacientes. sidani e irvine (4), basándose en donabedian, han propuesto un modelo de efectividad del rol de enfermería en cuyo componente de estructura se incluyen variables relacionadas con la cantidad de profesionales de enfermería disponibles y sus características, y se modela la relación con el componente de resultados en el paciente, entre los cuales se incluyen complicaciones y funcionalidad. de hecho, diversos estudios ilustran la relación que hay entre la asignación de enfermeras profesionales y resultados en el paciente. aiken, clarke, sloane, sochalsk y silber (5) hicieron un estudio a partir del cual concluyeron que cada paciente adicional por enfermera estaba asociado a un aumento del 7 % en las muertes dentro de los treinta días posteriores a la admisión, y un 7 % de aumento en la ocurrencia de fallas en el rescate. needleman, buerhaus y stewart (6) estudiaron el efecto de la razón enfermero/paciente sobre los resultados de los hospitales, encontrando que una mayor proporción de horas de atención proporcionadas por enfermeras se asociaba, entre otros, con tasas más bajas de paro cardiaco (p = 0,007) o fallas en el rescate (p = 0,05). unruh (7), usando un muestreo por conveniencia de hospitales de cuidado agudo de pennsylvania, examinó los cambios en el equipo de enfermeras licenciadas (incluidas enfermeras registradas y practicantes licenciadas) y su relación con seis eventos adversos: atelectasia, neumonía, úlceras por decúbito, infecciones por tratamientos y por cirugías e infecciones del tracto urinario. los resultados revelaron que el número de enfermeras licenciadas es un predictor más fuerte de eventos adversos que la proporción de enfermeros licenciados sobre el total de enfermeros. tallier (8) realizó un estudio en el cual calculó la relación entre el número de horas de cuidado por día y algunos eventos adversos, encontrando que no había relación estadísticamente significativa entre el número de horas de cuidado y las úlceras por presión o las infecciones del tracto urinario. sin embargo, halló una relación estadísticamente significativa entre el número de enfermeras registradas y las infecciones del tracto urinario. estos son algunos de los muchos estudios que se han efectuado, especialmente en estados unidos, y que dan cuenta de la importancia de la razón enfermero/paciente en los resultados de los pacientes hospitalizados (9), tras un procedimiento quirúrgico (10) y en unidades pediátricas (11). ahora bien, estudios en unidades de cuidados intensivos revelan que aumentar un tiempo completo equivalente de enfermera por paciente por día se asocia con una reducción del 60 % en la probabilidad de presentar falla respiratoria en estas unidades, así como una reducción del 28 % de la probabilidad de que ocurra un paro cardiaco. en los pacientes quirúrgicos la probabilidad de una sepsis nosocomial se reduce en 36 % (3). con base en ello, y dado que no se encontraron estudios realizados en colombia con respecto a la relación entre la asignación de personal de enfermería (tanto profesional como auxiliar) y los resultados en los pacientes, se diseñó una investigación orientada a determinar esta relación, particularmente en unidades de cuidados intensivos (uci) adulto de las ciudades de bogotá e ibagué que autorizaron la realización de la investigación. se recabó información de ambos miembros del equipo de enfermería considerando que, como señaló el ctne, el ejercicio de actividades propias 94 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 del profesional pudiera estar siendo realizado por personal auxiliar. se tomaron unidades de cuidado intensivo teniendo en cuenta que los eventos considerados por needleman y su equipo como potencialmente sensibles para enfermería ocurren con mayor frecuencia en estas unidades y, por tanto, podría reconocerse más fácilmente una relación entre la variable de estructura relacionada con el personal de enfermería asignado y las de resultados propuestas por estos autores. para lograr el objetivo general, reconociendo las particularidades del contexto colombiano, y a partir del modelo de calidad de la atención en salud de donabedian (estructura, proceso y resultado), se esperaba caracterizar a los enfermeros de las uci estudiadas para luego identificar las actividades que realizan. posteriormente, se establecerían las razones enfermero profesional-paciente y auxiliar de enfermería-paciente, así como el skill mix, y se identificarían los indicadores de resultado de la calidad de la atención de enfermería para finalmente determinar la relación existente entre los elementos de estructura (razones) y los de resultado. spetz, seago, coffman, rosenoff y o’neil (12) señalan que en la literatura se encuentran diferentes tipos de medidas de los requerimientos de enfermería. para efectos de este estudio, dos métodos resultan de interés: skill mix, que indica el grado en el cual un empleador depende de enfermeras profesionales comparado con otro tipo de personal y razón (ratio) enfermeropaciente, que coffman, seago y spetz (13) definen como el dato derivado de cada paciente hospitalizado que se obtiene de dividir el número de horas productivas trabajadas por el enfermero profesional y el auxiliar asignado a la unidad por el número de pacientes de esa unidad. materiales y métodos se trata de un estudio descriptivo, con un componente correlacional, que se basa en la observación de los turnos hospitalarios y en el análisis de los eventos que ocurren a lo largo de esos turnos. para establecer el tamaño de la muestra se tuvo en cuenta que la unidad de observación es el turno y la de análisis son los eventos que ocurren y el personal de enfermería asignado. usando el software epidat versión 3.0, se estableció un nivel de confianza de 95 %, y se presenta una matriz cuyo eje x presenta la potencia (80 a 95) y correlaciones esperadas entre 0,1 y 0,5. se requería recolectar información como mínimo de 1080 turnos con una potencia de 95 y una correlación esperada de 0,1, siendo el número de turnos observados de 4006 en 6 unidades de cuidados intensivos localizadas en bogotá e ibagué. la recolección de los datos fue hecha bajo la coordinación de las investigadoras y de tres estudiantes de maestría en enfermería cuyas tesis de grado formaban parte de este proyecto y en cuyas instituciones se les permitió realizar su tesis. para ello se solicitó autorización de los centros hospitalarios participantes y se contó con aval de los comités de ética institucionales. aprobado el proyecto, en primer lugar se hizo una capacitación a los directivos de los departamentos de enfermería y a los enfermeros jefes de las unidades de cuidados intensivos acerca del proyecto de investigación y el uso del formato en el que se consignarían los datos relativos a número de enfermeros, de auxiliares de enfermería y de pacientes (al empezar su turno), y datos sobre los indicadores de calidad (al finalizar su turno). el formato entregado contenía un cuadro en el que se registraba la información correspondiente a los 7 días de la semana, empezando por el día lunes, en cada uno de los turnos (mañana, tarde y noche) para cada una de las variables estudiadas en cada uno de los turnos a lo largo de 6 meses. fue necesario contrastar la información presentada en los formatos diligenciados por las enfermeras con otras fuentes como registros de estadística o de epidemiología de la institución según el caso, libros de carro de paro, libros de registro de novedades y registros de la morgue, reportes mensuales de epidemiología, comité de infecciones u oficina de seguridad del paciente, tomándose ante las inconsistencias el dato de la fuente considerada por la institución como la más confiable. para las infecciones asociadas a la atención en salud (iaas), se consignó en el formato la fecha en la cual era recibido el informe que confirmaba la existencia de un nuevo caso de infección en el servicio; por tanto, este resultado no indicaba en qué momento de la hospitalización se había detectado. los datos relacionados con las enfermeras y auxiliares de enfermería se recolectaron en periodos cortos de tiempo entregando personalmente los formularios a las enfermeras. en el formulario se solicitaba información social y laboral básica, y luego se presentaba un cuadro en el que se plasmaban una serie de actividades para cada una de las cuales la enfermera o auxiliar de enfermería debía señalar con qué frecuencia las realizaba en una escala ordinal con cuatro opciones de respuesta: siempre, frecuentemente, algunas veces o nunca. las actividades del listado son las que integran el prn 80 —que contiene todos los cuidados de enfermería posibles, siendo estos entre sí mutuamente excluyentes—. 95 relación de la asignación de personal de enfermería con indicadores de resultado de la calidad de la atención en unidades de cuidados intensivos de adultos l gloria l. arango y otros los datos fueron digitados en excel, y luego se exportaron a spss mediante stat-transfer para el procesamiento estadístico. en cuanto al análisis, para la caracterización de los enfermeros se hizo un análisis descriptivo a partir del cálculo de los valores relativos para las variables consideradas. a fin de identificar y comparar las actividades que realizan los profesionales y los auxiliares de enfermería en las unidades se tomó como base la encuesta que se aplicó a ambos grupos. debido a que se pretendía que el encuestado contestara con qué frecuencia realizaba la actividad mencionada, se sumaron los códigos que correspondían a cada una de las opciones de respuesta arrojando como resultados valores entre uno y cuatro. el valor 1 correspondía a “nunca”, mientras que el valor 4 correspondía a “siempre”. se obtuvo el promedio de calificación para cada actividad. a fin de establecer las correlaciones, ya que estudios anteriores han sugerido que algunas de las variables de eventos adversos podrían no tener una distribución normal (4), se utilizó el coeficiente de correlación de spearman. para hacer el análisis del skill mix y de las razones paciente/enfermero y paciente/auxiliar de enfermería se tuvieron en cuenta tres escenarios: escenario uno, se parean los datos originales (variables de estructura y resultado en el mismo turno). escenario dos: se parean variables de estructura de un turno y de resultado del siguiente. escenario tres: se parean variables de estructura de un turno y de resultado de dos turnos después. aspectos éticos. dado que los pacientes no fueron sujetos de investigación, para ellos no representó riesgo alguno. profesionales y auxiliares de enfermería aportaron al estudio información básica sobre su formación, experiencia y actividades, lo cual no suponía riesgo. sin embargo, se solicitó su consentimiento verbal. el formulario fue anónimo y pudieron diligenciarlo fuera de las instalaciones de la organización; con ello se procuró privacidad, aunque los datos recolectados no contenían información sensible. se mantuvo en el anonimato el nombre de las instituciones participantes. ni el personal de enfermería ni las instituciones recibieron retribución alguna por su participación en este estudio. resultados el estudio se realizó en tres unidades de cuidado intensivo mixto de la ciudad de ibagué, una unidad de cuidado intensivo mixto de un régimen especial en la ciudad de bogotá, una de cuidado mixto de una institución pública y otra más de carácter privado en la misma ciudad. todas las instituciones cuentan con servicios de alta complejidad y con servicios de especialidades y subespecialidades. caracterización de los enfermeros objeto de estudio según nivel educativo, género, tipo de contrato con la institución, área de trabajo, años de experiencia, entre otros. tanto el recurso humano profesional como el auxiliar en enfermería de las uci estudiadas es predominantemente femenino, alcanzando el 78 y el 85 % del grupo correspondiente. el equipo de enfermería está constituido por un importante porcentaje de profesionales jóvenes (48 % de ellos entre 20 y 30 años) y de auxiliares de enfermería un poco mayores (el mayor porcentaje de auxiliares, esto es, el 44 %, tiene entre 31 y 40 años), siendo el más bajo porcentaje de profesionales tanto como de auxiliares aquellos que tienen 41 años o más. se trata de población trabajadora joven, que en un 42 % tiene 30 años o menos. para el caso de los enfermeros, se exploró el nivel de formación posgraduada, encontrándose que el 43 % ha culminado estudios de especialización, sin que ninguno de ellos tenga un nivel de formación de maestría o doctorado; 31 % de los enfermeros tiene una experiencia laboral inferior a los cinco años, siendo la experiencia laboral entre 5 y 10 años aquella en la cual se concentra el mayor número de profesionales (38 %) y de auxiliares (41 %). la población que tiene entre 11 y 15 años de experiencia laboral es 11 puntos porcentuales más alta en auxiliares que en profesionales. el 65 % de los profesionales tienen experiencia inferior a los seis años en unidades de cuidados intensivos, mientras que en el grupo de auxiliares el 53 % tiene experiencia igual o superior a los seis años en este tipo de servicio. el 63 % de enfermeros y 60 % de auxiliares tienen experiencia inferior a 6 años en la institución. la forma de contratación del personal de enfermería se hace en 58 % de los casos a través de contratos, siendo más frecuente en los profesionales (59 %) que en los auxiliares (56 %). el 42 % restante se hace a través de contratos de personal de planta. con relación a las actividades que realizan profesionales y auxiliares de enfermería en las unidades de cuidados intensivos, en la gráfica 1 puede observarse que en términos de la frecuencia, actividades relacionadas con el apoyo a necesidades básicas como la alimentación, la evacuación, la movilización, la lubricación de la piel, los cambios de posición, el arreglo de la unidad y la recolección de orina en 24 horas son desarrolladas principalmente por las auxiliares. 96 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 las actividades desarrolladas fundamentalmente por los profesionales de enfermería son: administración de los medicamentos vía oral, intramuscular, subcutánea o intradérmica, y el manejo de la transfusión sanguínea. actividades como toma de muestras sanguíneas, manejo de línea arterial pulmonar, observación sistemática del paciente son desarrolladas con una frecuencia similar por ambos miembros del equipo. actividades relacionadas con la curación de heridas y el manejo y cambio de apósitos son realizadas con mayor frecuencia por auxiliares que por profesionales, en tanto que otras como la instalación de sondas o catéteres son ligeramente más frecuentes en profesionales que en auxiliares. en la tabla 1 se presentan las actividades que describieron profesionales y auxiliares como “otras” que realizan en el servicio. el uso de esta opción fue poco frecuente. asignación de personal de enfermería. para facilitar la comprensión de los resultados encontrados se decidió invertir la razón. por ello, a continuación se presentan las razones paciente/profesional de enfermería y paciente/auxiliar de enfermería. la razón paciente/profesional de enfermería promedio fue de 5,4 pacientes por cada enfermera disponible en la unidad; la razón paciente/ auxiliar de enfermería promedio fue de 2,4. para profesionales, el número máximo de pacientes asignados fue de 12 y el mínimo de 0,47. para las auxiliares, el número máximo de pacientes asignados fue de 6 y el mínimo de 0,85, siendo mayor la variabilidad en la asignación de pacientes para los profesionales. la variación del skill mix también fue alta, oscilando entre 0,11 y 0,77, con un promedio de 0,33. gráfica 1. comparación de las actividades realizadas por el profesional y el auxiliar de enfermería 97 relación de la asignación de personal de enfermería con indicadores de resultado de la calidad de la atención en unidades de cuidados intensivos de adultos l gloria l. arango y otros tabla 1. otras actividades realizadas por enfermeros y auxiliares de enfermería profesionales auxiliares confirmar interconsultas coordinar mantenimiento, aseo y lavandería gestión de ambulancias y traslado interinstitucional inventarios pedidos y recibo de insumos de farmacia, medicamentos, inventarios verificación de insumos y dispositivos médicos de uci verificación de insumos y chequeo del carro de paro verificar pacientes que sean llevados a procedimientos cambio de fijación de tubo orotraqueal y sondas charlas control y atención de visitas apoyo familiar medición de presión intraabdominal preparación de mezclas toma de gases arterio-venosos indicadores de resultado de la calidad de la atención de enfermería. ante la ausencia de registro de caídas, se encontró que en algunas de las instituciones los pacientes son sujetados para evitarlas. por esta razón este indicador fue descartado. el evento negativo que con mayor frecuencia se presentó en estas unidades fue el shock o paro, con un promedio de 0,21 episodios por turno, seguido por las muertes (0,11) y por iaas con un promedio de casos —según reporte— muy inferior a los dos primeros (0,06). mientras que el promedio de muertes suele ser ligeramente mayor en los turnos de la noche (0,13) frente a los otros dos turnos (0,10 en la tarde y 0,11 en la mañana), el comportamiento de la ocurrencia de shock o paro es prácticamente igual en todos los turnos (0,21 en turno mañana y 0,20 en tarde y noche). el reporte de iaas es similar en los turnos de la mañana (0,08) y la tarde (0,07), mientras que en la noche el promedio de los reportes se reduce considerablemente, (0,02), puesto que estos reportes con poca frecuencia se entregan en horas de la noche. la frecuencia de los eventos adversos resultó siendo muy baja. relación indicadores de asignación de personal con el número de eventos de shock o paro. con base en la interpretación propuesta por hernández, fernández y baptista (14), se encuentra una relación no nula, aunque muy débil, entre la razón paciente/enfermera y el número de eventos de shock o paro en los tres escenarios planteados, con un coeficiente de correlación que aumenta ligeramente, siendo menor en el primer escenario y mayor en el tercero. para la razón paciente/auxiliar de enfermería hay una relación no nula e inversa con el número de eventos de shock o paro en los tres escenarios, siendo esta correlación ligeramente menor en el tercer escenario. con respecto al skill mix, en los tres escenarios se encuentra que hay una relación no nula e inversa aunque muy débil entre la proporción de enfermeros profesionales sobre la totalidad del equipo de enfermería y el número de eventos de shock o paro. el coeficiente de correlación para la relación entre estas dos variables aumenta ligeramente en los escenarios dos y tres con respecto al escenario uno. mientras la relación de la razón paciente/enfermero con el número de eventos de shock o paro es directa, la relación de la razón paciente/auxiliar de enfermería con la misma variable es inversa (tabla 2). el hallazgo coincide con el relativo al skill mix, en el que se muestra una relación muy débil e inversa entre la proporción de enfermeros profesionales dentro del equipo y la frecuencia de estos eventos. relación indicadores de asignación de personal con el número de infecciones asociadas a la atención en salud. la relación entre las tres variables de entrada (razón paciente/enfermera, razón paciente auxiliar de enfermería y skill mix) con la variable de infecciones asociadas a la atención en salud es nula en todos los escenarios, por lo cual no se presenta tabla. relación indicadores de asignación de personal con el número de muertes. en la tabla 3 se presentan los resultados obtenidos para la variable número de muertes. la relación de la razón paciente/enfermera con el número de muertes es una relación no nula e inversa aunque muy débil en el escenario dos únicamente. las demás relaciones presentan coeficientes de correlación inferiores a 0,1, asumiéndose, conforme a lo descrito por hernández, fernández y baptista (14), que no existe correlación alguna entre las variables (tabla 3). relación indicadores de asignación de personal con el número total de eventos examinados. la tabla 4 presenta los 98 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 tabla 2. relación indicadores de asignación de personal con el número de eventos de shock o paro tabla 3. relación indicadores de asignación de personal con el número de muertes variable de salida: shock o paro escenario 1: variables de entrada y de salida en el mismo turno escenario 2: variables de entrada en un turno y de salida en el siguiente escenario 3: variables de entrada en un turno y de salida dos turnos después variables de entrada razón paciente enfermera coeficiente de correlación 0,110** 0,125** 0,135** sig. (bilateral) 0,0000 0,0000 0,0000 n 4006 4005 4004 razón paciente auxiliar coeficiente de correlación -0,164** -0,160** -0,147** sig. (bilateral) 0,0000 0,0000 0,0000 n 4006 4005 4004 skill mix coeficiente de correlación -0,156** -0,164** -0,164** sig. (bilateral) 0,0000 0,0000 0,0000 n 4006 4005 4004 variable de salida: número de muertes escenario 1: variables de entrada y de salida en el mismo turno escenario 2: variables entrada en un turno y de salida en el siguiente escenario 3: variables de entrada en un turno y de salida dos turnos después variables de entrada razón paciente enfermera coeficiente de correlación -0,064** -0,101** -0,058** sig. (bilateral) 0,0000 0,0000 0,0002 n 4006 4005 4004 razón paciente auxiliar coeficiente de correlación 0,043** 0,0036 0,044** sig. (bilateral) 0,0064 0,8199 0,0051 n 4006 4005 4004 skill mix coeficiente de correlación 0,068** 0,062** 0,062** sig. (bilateral) 0,0000 0,0001 0,0001 n 4006 4005 4004 99 relación de la asignación de personal de enfermería con indicadores de resultado de la calidad de la atención en unidades de cuidados intensivos de adultos l gloria l. arango y otros resultados de las correlaciones para la totalidad de los eventos estudiados. sobre la totalidad de los eventos estudiados se encuentra una relación nula entre la razón paciente/enfermera y el número total de eventos, con coeficientes de correlación inferiores a 0,10. hay una relación no nula, aunque muy débil e inversa, entre la razón paciente/auxiliar de enfermería y el número de eventos examinados que aumenta particularmente en el escenario 2 con respecto al uno y vuelve a disminuir en el escenario 3. finalmente, hay una relación no nula, muy débil e inversa entre el skill mix y el número de eventos examinados, que aumenta conforme a los escenarios presentados. los hallazgos sugieren entonces que a mayor número de enfermeras profesionales sobre la totalidad del equipo de enfermería es menor la frecuencia de los eventos examinados que son potencialmente sensibles para enfermería y, en todo caso, eventos negativos en salud. discusión este trabajo registra hallazgos que resultan interesantes para las instituciones hospitalarias y los centros de formación. más allá de evidenciarse que la profesión y el oficio de enfermería son predominantemente femeninos en las instituciones objeto de estudio, los hallazgos indican que las instituciones hospitalarias estudiadas prefieren contratar para las unidades de cuidados intensivos profesionales jóvenes, sin que sea un requisito para trabajar en estos servicios el contar con formación posgraduada en este campo. además de ello, se ajustan a las políticas neoliberales que promueven la flexibilización laboral mediante contratos de prestación de servicios o a través de cooperativas. con relación a las actividades que realizan profesionales y auxiliares llama la atención que en varias de ellas la diferencia en la frecuencia de la realización por parte de auxiliares o profesionales no es significativa, convirtiéndose ambos miembros del equipo en “sustituibles” para estas actividades. resulta particularmente notorio que actividades como la instalación de sondas o catéteres y aquellas relacionadas con el cuidado de las heridas, la vigilancia de línea arterial pulmonar, el manejo de presión intracraneana, entre otros, actividades de mayor complejidad que tienen un alto impacto sobre los resultados en el paciente y en la ocurrencia de eventos adversos, son realizadas en muy similar frecuencia por profesionales y auxiliares. el hallazgo sugiere algo parecido a lo presentado en un estudio de ruiz et al. (15) que indica que la profesión de enfermería es la que más alta tasa de sustitución tiene entre todas. en este caso, varias actividades son realizadas indistintamente por el profesional y el auxiliar. tabla 4. relación indicadores de asignación de personal con el número total de eventos examinados variable de salida: total de eventos (shock o paro + iaas + muertes) escenario 1: variables de entrada y de salida en el mismo turno escenario 2: variables entrada en un turno y de salida en el siguiente escenario 3: variables de entrada en un turno y de salida dos turnos después variables de entrada razón paciente enfermera coeficiente de correlación 0,072** 0,071** 0,096** sig. (bilateral) 0,0000 0,0000 0,0000 n 4006 4005 4004 razón paciente auxiliar coeficiente de correlación -0,124** -0,137** -0,109** sig. (bilateral) 0,0000 0,0000 0,0000 n 4006 4005 4004 skill mix coeficiente de correlación -0,106** -0,115** -0,117** sig. (bilateral) 0,0000 0,0000 0,0000 n 4006 4005 4004 100 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 con respecto a las razones enfermero/paciente y auxiliar de enfermería/paciente, las razones observadas para el caso de los profesionales superan en más del doble los estándares establecidos en algunos estados de estados unidos, en donde el número máximo de pacientes asignados a una profesional es de dos (16). adicionalmente, la razón paciente/profesional de enfermería supera en más del doble la razón paciente/auxiliar de enfermería. se ha documentado que cuando se asignan más pacientes a los enfermeros se reduce la posibilidad de hacer la vigilancia, de tomar los signos vitales y de brindar atención de enfermería oportuna y centrada en los resultados en el paciente más que en las actividades. del mismo modo, las fallas en el rescate no se pueden atender de manera oportuna cuando la cantidad de personal no es adecuada (17). en lo que tiene que ver con la distribución de los profesionales y auxiliares por turno, al igual que muestran otros estudios, en este no se encontró variación importante en el número de pacientes asignados a profesionales o auxiliares (18). en cuanto a los indicadores de resultado cabe destacar el hallazgo encontrado en las instituciones en cuanto al número de caídas, que es de cero, a costa de la sujeción de los pacientes. si bien, de acuerdo con la escala de riesgos de caída que se aplique a los pacientes en estas unidades eventualmente es necesario sujetarlos, evidentemente una de las condiciones para evitar las caídas en las uci es que se pueda aplicar la escala por lo menos una vez por turno y cuando las condiciones del paciente cambien (19), reconociendo que en este tipo de servicios las razones de las caídas difieren de aquellas que explican estos eventos adversos en unidades médico-quirúrgicas. de hecho, una de ellas es justamente la dificultad que tienen los pacientes críticos para adaptarse a las particularidades de una unidad de este tipo, en la cual la cantidad de tubos y drenajes que suelen tener representa un reto para su movilización y se constituye en un riesgo adicional para las caídas (20). sin embargo, son pocos los estudios sobre caídas en uci, y el registro de este evento en estas unidades en particular es bajo (21). aun así, se ha demostrado que contar con una enfermera más por paciente por día en una unidad de cuidado intensivo se asocia con una reducción del 3 % en la tasa de caídas, mientras que contar con personal auxiliar se asocia con una tasa de caídas entre un 2 y 4 % más alto en otro tipo de unidades (21). de la misma manera, se ha encontrado una asociación negativa entre las tasas de caídas y el total de horas de enfermería, el skill mix de enfermeras y su experiencia (22), si bien varios estudios han hallado que no hay tal relación entre caídas y personal profesional (3). de cualquier forma, la falta de vigilancia ante la ausencia de personal pone en riesgo la seguridad de los pacientes frente a las caídas (23). para el caso de muertes y shock o paro, la ocurrencia de estos eventos fue mayor en el turno de la mañana y menor en el de la noche, si bien la razón profesional o auxiliar de enfermería/ paciente no fue significativamente diferente entre los turnos. este dato resulta interesante por cuanto hay evidencia de que la tasa de supervivencia en caso de paro cardiaco es menor en la noche y en los fines de semana, precisamente porque la cantidad de personal disponible en este turno es menor (24). con respecto a la relación entre la razón enfermero/paciente y auxiliar de enfermería paciente con la ocurrencia de shock o paro, llama la atención que mientras esta relación es no nula, muy débil y positiva para la razón paciente enfermero, es no nula, muy débil e inversa para la razón paciente/auxiliar de enfermería. este hallazgo podría sugerir que actividades de vigilancia, así como de manejo o atención del paciente en esta condición tendrían que ser desarrolladas exclusivamente por el equipo de profesionales, es decir, se trata de actividades no sustituibles. esto lo confirma la relación no nula e inversa entre la proporción de enfermeros profesionales sobre la totalidad del equipo, y el número de eventos de shock o paro que sugiere que a mayor proporción de profesionales dentro del equipo menor número de estos eventos. el hallazgo podría sugerir que, ante mayor número de pacientes, es menor la capacidad del enfermero para detectar a tiempo el deterioro de uno de ellos (25), y plantea la probabilidad de que contar con más recurso de enfermeras profesionales aporta a la reducción de casos de paro cardiaco (3). en lo que tiene que ver con la relación entre las variables de entrada y iaas, el hecho de que se encuentre una relación nula en todos los escenarios podría sugerir que, probablemente, el dato se está registrando con un importante retraso con respecto a la fecha en que se detectó la infección. sin embargo, mientras que en algunos estudios (3, 26) se ha demostrado que en las unidades de cuidados intensivos con menos recurso de enfermería los pacientes tienen mayor riesgo de infecciones, entre ellas las sepsis (27), en otros como el de hugonnet, chevrolet y pittet (28) se ha encontrado que tener más personal no influye en la incidencia de infecciones. aun así, hay evidencia de que cuando hay más sobrecarga de trabajo en el equipo de salud, resulta más difícil adoptar medidas relacionadas con la higiene de manos y otras 101 relación de la asignación de personal de enfermería con indicadores de resultado de la calidad de la atención en unidades de cuidados intensivos de adultos l gloria l. arango y otros técnicas para reducir o evitar infecciones (29). se trata de medidas de asepsia y antisepsia que para autores como cho, ketefian, barkauskas y smith (9) requieren conocimientos y habilidades que, por tanto, deben ser practicadas por profesionales. con relación a la mortalidad, en este estudio se encontró en el escenario dos una relación no nula aunque muy débil e inversa entre la razón paciente/enfermera y el número de muertes. los resultados invitan a explorar más profundamente esta relación en atención a que estudios han mostrado que cuantos más pacientes tenga una enfermera mayor es el riesgo de muerte para ellos (30), así como cuanto mayor sea la proporción de profesionales menor será la probabilidad de muerte hospitalaria (31). para la totalidad de los eventos estudiados se observó una relación muy débil e inversa entre la razón paciente/auxiliar de enfermería y el número de eventos examinados, mientras que se observó una relación no nula, aunque muy débil, entre el skill mix y la totalidad de eventos estudiados. esto puede sugerir, de nuevo, que las actividades de los profesionales y los auxiliares, aunque en algunos casos llegan a ser realizadas con similar frecuencia por ambos miembros del equipo, no tienen las mismas implicaciones en los resultados del paciente. en otras palabras, se obtienen mejores resultados cuanto mayor sea la proporción de profesionales en el equipo de enfermería. limitaciones del estudio. en primer lugar, fue necesario incluir unidades de cuidado intensivo de dos ciudades que, por diversas razones, podrían tener características de estructura diferentes, así como condiciones disímiles de los pacientes que ingresan en las unidades de cuidados intensivos que no fue posible explorar por cuanto no se pudo disponer de esta información. hacer análisis del turno y no de los pacientes, que afectan en términos de cantidad y complejidad el trabajo de auxiliares y profesionales es otra limitación. una más, analizada por numata, schulzer, van derwal, globerman, semenuik, balka et al. (32), tiene que ver con la mínima variación que hay en el número de profesionales y auxiliares de enfermería en las instituciones objeto de estudio, que puede reducir la sensibilidad entre los eventos estudiados y los niveles de personal. por otra parte, no se pudo hacer ajuste por variables confusoras como número de ingresos y egresos durante el turno, por la poca confiabilidad de los datos. se encontró, además, que diferentes registros del mismo evento en una institución mostraban diferencias numéricas, por lo cual fue necesario trabajar con la fuente que para cada institución se consideraba más confiable. en lo que tiene que ver con el análisis de los datos, este estudio tiene las limitaciones propias de los estudios correlacionales. en adición a ello, dado que estudios sobre el tema no han usado este abordaje, no fue posible contrastar la información bajo la misma mirada de otras investigaciones. por otra parte, si bien se contó con un importante número de turnos estudiados, el estudio se hizo en un corto periodo de tiempo. siendo los fenómenos observados de baja ocurrencia, es necesario acopiar información durante periodos más largos que consideren las variaciones de estos eventos en el tiempo. finalmente, dado que se tomaron las instituciones que aceptaron participar no puede hacerse ninguna generalización de los hallazgos. conclusiones y recomendaciones los hallazgos de este estudio sugieren que hay varios asuntos en los cuales debe trabajarse en el futuro inmediato. el primero de ellos es, sin duda, la diferenciación que requiere hacerse de las funciones y actividades que realizan los profesionales y auxiliares de enfermería en las instituciones; las actividades que corresponden a unos y otros en el ámbito hospitalario deben estar claramente definidas. es evidente que hay funciones y actividades de enfermería que el profesional no puede delegar a su equipo de auxiliares, y que en este estudio en particular se encontraron poco diferenciadas, como las que tienen que ver con cuidado de heridas, procedimientos invasivos, así como la vigilancia e interpretación de datos del paciente, algunas de las cuales ya están definidas en la normatividad en ciudades como alberta en estados unidos (33). por otra parte, como lo han señalado varios teóricos de la calidad, la experiencia de los profesionales es un factor que afecta a los procesos y los resultados. aun así, en este estudio se encontró un importante porcentaje de profesionales jóvenes y con poca experiencia trabajando en las unidades de cuidado intensivo. es necesario en este sentido trabajar en políticas de talento humano que promuevan la transferencia de conocimientos de los expertos hacia los novatos. se requiere incentivar la formación posgraduada en cuidado crítico y promover que el profesional sea ubicado en el servicio para el cual se ha preparado a nivel de posgrado. habrá que trabajar en una cultura organizacional que reconozca, desde el nivel estratégico, que tener formación posgraduada en enfermería aporta a la organización. con respecto a la asignación de profesionales y auxiliares, se encontró una alta variabilidad en la asignación de pacientes a los enfermeros con un número máximo de doce pacientes por 102 año 15 vol. 15 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 un profesional, siendo este el único disponible en el servicio. esto significa, en otras palabras, que durante su ausencia en el servicio le corresponde a los auxiliares de enfermería realizar las actividades propias del profesional, o bien hay un retraso en la ejecución de las actividades propias del profesional, poniéndose en riesgo la oportunidad en la atención y con ello los resultados de los pacientes. en lo que tiene que ver con la relación que existe entre la razón paciente/profesional y paciente/auxiliar de enfermería, si bien los resultados no son concluyentes sugieren la necesidad de acopiar la información en periodos de tiempo mucho mayores y evidenciar qué indicadores de disponibilidad de personal pueden ser más sensibles cuando se trata de correlaciones con eventos adversos, en tanto que en este estudio se observó que el skill mix eventualmente podría ser un indicador más sensible. por otra parte, será necesario en el futuro trabajar con otras variables relacionadas con el paciente y algunas propias del profesional de enfermería tales como nivel de formación y años de experiencia. adicionalmente, esta investigación llama la atención de las instituciones hospitalarias y los organismos de vigilancia y control acerca de la importancia de un adecuado registro de los eventos adversos. de otro lado, si las instituciones hospitalarias dicen estar comprometidas con la seguridad del paciente, tendrán que asignar un número máximo de pacientes por profesional, que refleje la genuina preocupación de las organizaciones por este asunto. una unidad de cuidados intensivos con una enfermera a cargo de doce pacientes resulta, en términos de tiempo, en una imposibilidad importante para atender oportunamente los requerimientos de pacientes que requieren vigilancia estrecha y permanente, así como intervenciones delicadas y complejas. la opción de sustituir profesionales por auxiliares denota la falta de conocimiento del aporte del profesional, lesiona la profesión y puede tener efectos negativos sobre los pacientes, como los aquí explorados, y sobre los cuales, como se indicó, hay que trabajar con mayor profundidad. será necesario también, que desde la superintendencia nacional de salud se empiece a solicitar a las instituciones hospitalarias el reporte del personal de enfermería con el cual cuentan en las diferentes unidades, en aras de utilizar esta información para llevar a cabo estudios más robustos en torno a un asunto que, como este, requiere ser estudiado no solamente por su importancia para la profesión, sino, y sobre todo, por su efectos en la calidad de la atención que ofrecen las instituciones hospitalarias. si, como lo ha señalado el ministerio de salud y protección social, la adecuada cantidad de personal para la atención a los pacientes es una condición para su seguridad, el propio ministerio debe impulsar propuestas para investigar en profundidad al respecto y, con base en ello, en el futuro, expresar su preocupación contemplando en los requisitos de habilitación algún estándar para evitar que la falta de personal repercuta ocasionando resultados negativos en los pacientes. agradecimiento. las investigadoras agradecen al profesor fred gustavo manrique por su apoyo en el cálculo del tamaño de la muestra, y al profesor jorge humberto mayorga por su acompañamiento estadístico. declaración de conflictos de interés. los investigadores reconocen que han participado como docentes en algunas de las instituciones en las que se hizo el estudio. sin embargo, la condición principal como investigadores es académica y el grupo se comprometió a respetar el principio de veracidad y a mantener una conducta de 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2005 [citado 2014 ene 13]. disponible en: https://www.nurses.ab.ca/carna-admin/ uploads/hpa%20-%20restricted%20activities.pdf 94 103 influencia ambiental para.indd 94 aquichan issn 1657-5997 aline campelo pintanel1 giovana calcagno gomes2 daiani modernel xavier3 marta regina cezar-vaz4 mara regina santos da silva5 infl uência ambiental para a (in)dependência da criança cega: perspectiva da família 1 universidade federal do rio grande, brasil. acpintanel@furg.br 2 universidade federal do rio grande, brasil. giovanacalcagno@furg.br 3 universidade federal do rio grande, brasil. daiamoder@ibest.com.br 4 universidade federal do rio grande, brasil. cezarvaz@vetorial.net 5 universidade federal do rio grande, brasil. marare@brturbo.com.br recibido: 07 de julio de 2014 enviado a pares: 23 de julio de 2014 aceptado por pares: 08 de agosto de 2015 aprobado: 29 de septiembre de 2015 doi: 10.5294/aqui.2016.16.1.10 para citar este artículo / to reference this article / para citar este artigo pintanel ac, gomes gc, xavier dm, vaz mrc, silva mrs. influência ambiental para a (in)dependência da criança cega: perspectiva da família. aquichan. 2016; 16 (1): 94-103. doi: 10.5294/aqui.2016.16.1.10 resumo objetivo: compreender a influência dos ambientes onde a criança cega vive no exercício da sua (in)dependência na perspectiva da família. método: realizou-se pesquisa qualitativa no segundo semestre de 2011, com dez mães de crianças cegas atendidas em um centro de educação complementar para deficientes visuais. os dados foram coletados por meio de entrevistas semiestruturadas e analisados pela análise temática. interpretação: no ambiente domiciliar, o potencial de independência da criança cega é maior. nele, a criança desempenha suas atividades diárias sem necessidade de auxílio. quanto ao ambiente da escola convencional, a família referiu que a cegueira pode prejudicar o processo de ensino-aprendizagem e comprometer o processo educativo das crianças cegas. a família se organiza para ajudar a criança nas tarefas para que ela consiga acompanhar as outras crianças na escola. no entanto, referiram que elas sofrem discriminação e preconceito na escola devido à cegueira. conclusões: concluiu-se que os ambientes domiciliar e escolar são sistemas de suporte e influenciam a independência humana, bem como necessitam ser repensados e reorganizados para favorecer a criança cega. cabe aos profissionais da enfermagem a orientação adequada da família e os profissionais da escola, na qual se capacite a criança cega para o autocuidado, a mobilidade e a função social, o que possibilitaria sua independência. palavras-chave criança; família; cegueira; ecossistema; cuidados de enfermagem (fuente: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 94-103 95 influência ambiental para a (in)dependência da criança cega: perspectiva da família l aline campelo pintanel e outros año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 94-103 influencia ambiental para la (in)dependencia del niño invidente: perspectiva de la familia resumen objetivo: comprender la influencia de los ambientes donde el niño invidente vive en el ejercicio de su (in)dependencia en la perspectiva de la familia. método: se realizó una investigación cualitativa en el segundo semestre de 2011 con diez madres de niños invidentes atendidos en un centro de educación complementaria para discapacitados visuales. los datos se recolectaron por medio de entrevistas semiestructuradas y se analizaron por el análisis temático. interpretación: en el ambiente domiciliario, el potencial de independencia del niño invidente es más grande. en este, el niño desempeña sus actividades diarias sin necesidad de auxilio. en cuanto al ambiente de la escuela convencional, la familia refirió que la ceguera puede perjudicar el proceso de enseñanza y aprendizaje y afectar el proceso educativo de los niños invidentes. la familia se organiza para ayudar al niño en las tareas para que él logre seguir los demás en la escuela. sin embargo, refirió que ellos sufren discriminación en la escuela debido a la ceguera. conclusiones: se concluye que los ambientes domiciliario y escolar son sistemas de soporte e influyen la independencia humana, así como necesitan ser repensados y reorganizados para favorecer al niño invidente. es responsabilidad de los profesionales de enfermería la orientación adecuada de la familia y los profesionales de la escuela, en la que se capacite el niño invidente para el autocuidado, la movilidad y la función social, lo que posibilitaría su interdependencia. palabras clave niño; familia; ceguera; ecosistema; cuidados de enfermería (fuente: decs, bireme). 96 aquichan issn 1657-5997 environmental influence on (in) dependence of a blind child: a family perspective abstract objective: understand, from a family perspective, how the environments where a blind child lives influence his or her (in) dependence. method: a qualitative study was conducted during the second half of 2011 with ten mothers of blind children who were attending a supplementary education center for the visually impaired. the data were collected by means of semi-structured interviews and examined through thematic analysis. interpretation: a blind child´s potential for independence is greater in the home environment. there, the child performs his or her daily activities without assistance. as for the atmosphere at conventional schools, the family indicated blindness can jeopardize blind children’s teaching and learning process and their schooling. the family is organized to help the child with homework so he/she can keep up with the others in school. however, the family said these children are discriminated against at school because of their blindness. conclusions: home and school environments are support systems and influence human independence. accordingly, they need to be reconsidered and reorganized to favor the blind child. it is the responsibility of nurses to provide the family and school professionals with proper guidance. this includes training the blind child in self-care, mobility and to function socially, so as to make their interdependence possible. keywords child; family; blindness; ecosystem; nursing care (source: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 94-103 97 influência ambiental para a (in)dependência da criança cega: perspectiva da família l aline campelo pintanel e outros introdução o ambiente familiar é considerado como o primeiro espaço de interação e socialização infantil (1). é na família que ocorrem as relações de cuidado mais importantes por meio de ações de proteção, acolhimento, respeito e potencialização do outro. esse ambiente pode vir a ser afetado pelo nascimento de uma criança cega, acontecimento que requer o desenvolvimento de estratégias para o enfrentamento da situação e estimulação da criança para a independência (2). a cegueira pode ser herdada ou adquirida devido a diversas causas como: glaucoma ou catarata congênitos, retinopatia, sífilis, entre outras (3). impõe à criança restrições ao seu desenvolvimento nos ambientes sociais (família, escola, entre outros) e interfere nas interrelações entre si, o mundo e as pessoas. essas restrições influenciam no potencial de independência da criança cega, seja nas atividades que exigem conhecimentos sobre suas relações com o mundo a sua volta (4), seja consigo mesma na realização de atividades da vida diária. a cegueira influencia no desenvolvimento das crianças, o que compromete seu autocuidado e mobilidade, além de dificultar suas interações sociais e a aquisição da sua independência (5). crianças cegas apresentam restrições quanto à locomoção, exploração de locais e objetos, o que dificulta sua participação em atividades em grupo (6), isto é, possuem certa restrição de habilidades e de exploração dos ambientes. através da visão, a criança constrói suas percepções e representações acerca das coisas e do mundo. com uma limitação visual, além de ter dificuldades em organizar e construir definições e conceitos, ela apresenta dificuldades em circular livremente pelos diferentes ambientes. cuidar da criança cega exige da família ação e reflexão acerca dos ambientes nos quais ela está inserida, pois se entende que estes interferem no seu bem-estar e na sua saúde. o papel da família no cuidado e no desenvolvimento da criança é de fundamental importância uma vez que o núcleo familiar compreende sua primeira rede de apoio social (7). a família deve ser orientada pelos profissionais da saúde/enfermagem quanto à importância da estimulação infantil, da comunicação e da interação família-criança cega; além disso, deve organizar os diferentes ambientes de convivência para que a criança circule por eles de forma independente (5). cuidar por meio de uma abordagem ecossistêmica pode contribuir para a independência, pois os ambientes constituem-se como sistemas de suporte à vida (8). nessa abordagem, o ecossistema é entendido como comunidade de organismos que interagem entre si e mantêm relação com o ambiente em que vivem, isto é, concebe-se o ser humano como elemento integrante dessa comunidade e considera-se que a saúde depende dos ambientes (8). o conjunto de elementos, estruturantes dessa realidade, ao se relacionar entre si, é capaz de construir verdadeiras redes no espaço em que coabita e possibilitar o desenvolvimento de forma harmoniosa e saudável. nessa perspectiva, o ecossistema é um conjunto de elementos interdependentes integrados que formam o espaço/território/ambiente, lugar onde a rede de relações humanas perpetua a sua cultura pela contínua transferência de matéria e energia entre os seres vivos e o meio (9). pensar os ambientes onde a criança cega vive, nessa concepção, é explorar as possibilidades que o espaço lhe oferece para exercer sua independência. nesse sentido, o cuidado ecossistêmico apresenta-se como uma ferramenta que orienta perspectivas e novos caminhos, pois promove o bem viver por meio da atuação sobre os ambientes, o que propicia o equilíbrio dos elementos constituintes do ecossistema visto que, com base na teoria sistêmica, todos os elementos que compõem determinado espaço/ambiente se inter-relacionam, exercem interações, influenciam-se mutuamente e são capazes de transformá-lo (10). há um reconhecimento crescente de que muitos problemas de saúde pública são complexos e podem ser mais bem compreendidos por meio da análise da relação entre a saúde humana e a saúde dos ecossistemas em que as pessoas vivem (11). compreende-se a família como capaz de interferir positivamente na construção de ambientes propícios ao desenvolvimento da criança cega promovendo estratégias sistêmicas aos problemas que interferem no seu viver e na sua independência. espera-se, com o presente trabalho, sensibilizar os profissionais da saúde/ enfermagem que cuidam de crianças cegas para um novo olhar sobre os seus familiares cuidadores, de forma a garantir-lhes informações que os habilitem para o cuidado ecossistêmico à criança na perspectiva da sua independência (12). nesse contexto, teve-se como questão norteadora deste estudo: de que forma os ambientes onde a criança cega vive interferem para a sua independência? a partir disso, objetivou-se compreender a influência dos ambientes onde a criança cega vive no exercício da sua independência na perspectiva da família. 98 año 16 vol. 16 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 métodos trata-se de uma pesquisa descritiva com abordagem qualitativa. a pesquisa descritiva descreve o fenômeno investigado e possibilita, assim, sua compreensão por meio das experiências vividas (13). é qualitativa porque trabalha com um universo de significados, motivos, aspirações, crenças, valores e atitudes, o que permite maior profundidade das relações, dos processos e dos fenômenos que não podem ser traduzidos por meio de sua redução à operacionalização de variáveis (13). foi realizada no segundo semestre de 2011, em um centro de educação complementar para deficientes visuais localizado no sul do brasil. esse centro possui salas de aula nas quais os alunos têm o ensino do primeiro ao quarto ano do ensino fundamental, além de salas de recursos, estimulação sensorial, informática, biblioteca, artesanato, cerâmica e educação física, com a prática de esportes como futsal e judô, dança e de ensino na realização de atividades de vida diária (avds), como arrumar a cama, cozinhar e outras. por se tratar de uma instituição para deficientes visuais, alguns símbolos são facilmente observados: corrimãos para facilitar o deslocamento pela escola; trabalhos didáticos executados todos em alto relevo; salas onde são realizadas a estimulação das pessoas com limitações visuais, que possuem sinaleiras; softwares e maquinários em braile, como tradutor, impressão e xerox, e, ainda, uma sala de informática adaptada. participaram da pesquisa 10 mães de crianças cegas com idade entre 5 e 12 anos incompletos, que atenderam ao critério de inclusão: cuidar da criança cega continuamente no ambiente familiar. foram excluídos os cuidadores que não cuidam continuamente da criança cega. das 10 crianças, 8 frequentavam o centro de educação para deficientes visuais e 2, tanto o centro como a escola convencional. a cuidadora principal de todas as crianças é a mãe, com faixa-etária entre 21 e 43 anos, e com o ensino médio completo. essas mães cuidadoras vivenciam o cuidado da criança cega entre 5 a 12 anos. a maioria das mães não desenvolve atividade laboral remunerada: 3 nunca trabalharam fora do ambiente familiar; 4 tiveram que parar de trabalhar para cuidar da criança; 2 atuam como domésticas e 1 trabalha em uma fábrica de pescado. as mães participantes do estudo sobrevivem com suas famílias com uma renda de um a quatro salários-mínimos por mês (o equivalente a usd$ 882,90). a idade das crianças variou de 5 a 12 anos incompletos; 6 eram do sexo masculino e 4, do feminino. sobre o seu contexto familiar, 3 eram filhas únicas; as demais possuíam de 2 a 3 irmãos. quanto à saúde, 2 crianças, além da cegueira, possuíam paralisia cerebral devido à anoxia no parto. a coleta de dados foi realizada por meio de entrevistas semiestruturadas únicas com cada participante. foram operacionalizadas por um roteiro com perguntas acerca da influência do ambiente familiar e escolar para a (in)dependência da criança cega, cujas respostas foram analisadas pela técnica de análise temática (13), operacionalizada em três etapas: pré-análise, na qual foram identificadas as unidades de registro que orientaram a análise; exploração do material, na qual os dados iniciais obtidos foram classificados e agregados em categorias, e tratamento dos resultados obtidos, na qual se realizou a interpretação dos dados correlacionando-os com autores estudiosos da temática. os preceitos da resolução 196/1996 do conselho nacional de ética em saúde para a pesquisa com seres humanos foram levados em consideração (14). o projeto foi encaminhado ao comitê de ética e pesquisa, que o aprovou sob o número 105/2011. as falas dos sujeitos foram identificadas pela letra f, seguida do número da entrevista, a fim de garantir o seu anonimato. resultados a análise dos dados evidenciou duas categorias: influência do ambiente familiar para a independência da criança cega e influência do ambiente escolar para a independência da criança cega. influência do ambiente familiar para a independência da criança cega o estudo revelou que, no ambiente familiar, o potencial de independência da criança cega é maior e, com isso, a prestação do cuidado se torna mais fácil. ela faz tudo em casa, mas em casa é mais fácil. nos outros lugares, a gente tem que estar com ela (f1). foi possível constatar que as crianças cegas apresentam capacidades e desenvolvem ações independentes no lar, como banho, troca de roupas e higiene. referiram que, no domicílio, elas desempenham suas atividades diárias sem necessidade de auxílio. 99 influência ambiental para a (in)dependência da criança cega: perspectiva da família l aline campelo pintanel e outros ele toma banho, escolhe a roupa que vai colocar, toma café quando quer. ele não depende de mim. claro que tem coisas que ainda não deixo ele fazer, mas porque acho que não está na idade (f7). em casa, ele é independente pra tudo. uma pessoa não pode viver dependente a vida toda (f3). contudo, verificou-se que a mãe realiza ações que a criança é capaz como forma de compensação por sua deficiência. ela é bem preguiçosa. tem umas coisas que ela não faz, mas não é porque não sabe. é porque tem a mãe e a avó que fazem. tem dias que eu me dou conta que ela está “se fazendo”. me chama para fazer o leite dela, para buscar os brinquedos, para trocar de roupa na hora do banho. ganha tudo nas mãos. a gente faz para compensar ela pela cegueira (f9). diante da possibilidade de a cegueira dificultar a independência da criança, a família passa a estimulá-la e a desenvolvê-la. essa percepção faz com que a família lute contra a vontade de executar pela criança o que esta tem capacidade para fazer de forma independente. ela faz tudo sozinha: toma banho, faz café, toma os remédios na hora certa, separa a roupa que vai usar. quer a mesma liberdade que a irmã que enxerga. mas eu fico de olho. tenho que cuidar para não fazer por ela. acho perigoso deixar muita coisa pra ela (f4). ela depende de mim só para o essencial mesmo. sou eu que dou banho nela porque ela não se esfrega bem. no banheiro, ela vai sozinha, mas eu destaco o papel para ela. aí, estou sempre com ela, porque fico preocupada. sem enxergar e com dificuldade para andar. mas em casa tudo é adaptado e seguro para ela aprender a se virar. ela é encefalopata também e caminha com dificuldade (f5). além disso, constatou-se que as dificuldades da criança cega são inúmeras e desafiam a família para o seu cuidado no ambiente domiciliar. alguns familiares acreditam que a criança cega nunca será totalmente independente. todas as dificuldades. ela não vai ser independente nunca. imagina tu teres um filha assim? pra comer, te chama; pra tomar banho, te chama. pode passar três horas do horário da escola que ela não se dá por conta. é tudo isso. ela sabe que tem que comer porque dá fome (f1). algumas mães não introduzem no ambiente os estímulos necessários a um cuidado eficaz à criança cega por se preocuparem com sua integridade. a adequação ambiental torna-se fundamental para a facilitação das atividades de forma segura. eu vejo que ele vai ter dificuldades com a segurança. ele ainda é bem medroso, não consegue ficar sozinho. se eu deixo ele em casa e vou na venda e demorar, ele já vai pra baixo das cobertas com medo. precisaria se desenvolver melhor dentro de casa, mas tenho medo que ele ligue o fogão e se queime. então, tem coisas que eu não estimulo (f7). tendo em vista suas dificuldades e limitações, os deficientes visuais podem ser socialmente reconhecidos como pessoas doentes. esse fato pode limitar sua convivência nos ambientes e, assim, consolidar sua restrição ao ambiente domiciliar. ela sai comigo e, quando vai fazer alguma coisa, as pessoas dizem: “— ela vai cair!” mas ela não cai não. pensam que porque é cega é doente. ela não tem dificuldades em andar na rua, mas, para evitar fatos desagradáveis, ficamos mais limitados a casa (f8). não tenho dificuldades em cuidar dela em casa. mas os irmãos me perguntam: “— tu vais deixar ela sozinha?” “— tu vais deixar ela fazer isso ou aquilo?” então, é uma preocupação constante e, em casa, a gente se sente mais tranquila. é menos estresse (f4). percebem que a criança aprende por repetição e referiram que é importante não enfatizar seus erros, e sim seus acertos e conquistas. nesse sentido, a criança precisa ter um ambiente propício à aprendizagem e ter a liberdade vigiada para que possa se desenvolver e tornar-se independente. eu dava tudo nas mãos. agora ela conhece o lugar de cada coisa. hoje, eu arrumo a casa e digo pra ela me ajudar. eu elogio o esforço dela e as coisas boas que ela faz (f1). eu mando ele se levantar e fazer as coisas. não deixo ele ficar com peninha de si mesmo. faço ele ir na padaria comigo, no supermercado, na farmácia. isso tudo eu ensino. é aos poucos, mas a gente faz ele aprender a fazer as coisas. quando chego em caso, faço ele guardar tudo nos lugares. ele precisa repetir, repetir até aprender a se virar (f7). 100 año 16 vol. 16 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 influência do ambiente escolar para a independência da criança cega a cegueira pode prejudicar o processo de ensino e aprendizagem e a restrição de experiências pode comprometer o processo educativo das crianças cegas. observou-se a preocupação da família com sua escolarização, pois entendem o ensino convencional como importante para o seu desenvolvimento. tendo em vista que, após a quarta série, as crianças terão que ingressar na escola convencional, a família teme que suas necessidades especiais não sejam levadas em conta e que ela não consiga acompanhar as exigências escolares. tenho medo que ele não tenha um bom desempenho. ele até pode ter dificuldades porque precisa conhecer o lugar primeiro, mas tem condições de aprender e se sair bem (f9). acho que ela não ia se adaptar. as escolas estão acostumadas com crianças que enxergam. acho que não tem recursos nas escolas. quem vai saber lidar com ela? vai ter uma professora para ler só para ela? não vai! (f10) no sentido de auxiliar a criança no seu desenvolvimento escolar, a família se organiza para ajudar nas tarefas para que ela consiga acompanhar as outras crianças na escola. uma de minhas preocupações é auxiliá-la com as tarefas do colégio. ajudamos ela a fazer os temas. tem que ter paciência, pois não quero que ela tenha mais dificuldades que as outras crianças. se ela se sentir inferior, pode nem querer mais estudar (f8). nesse contexto, verificou-se o empenho da família na busca de um ensino que estimule a criança e possibilite sua inserção na sociedade. no entanto, não acreditam nessa possibilidade e veem difícil sua inclusão na escola, pois algumas sofrem discriminação e preconceito devido à cegueira. tem preconceito dos colegas. eles riem dela. por isso é difícil. ela chora e não quer ir (f1). na escola normal, chamam ela de quatro olhos, de criança cega. isso é brabo porque, além da dificuldade para enxergar, ela ainda aguenta isso. estive na escola várias vezes. falei com as professoras, mas nunca fazem nada (f2). discussão os ambientes domiciliar e escolar são entendidos pela família como potencializadores da independência da criança cega. o ambiente domiciliar é o primeiro espaço de convivência social da criança. neste, são construídas suas referências, conceitos e valores que traçarão sua personalidade e determinarão sua forma de atuação nas diferentes etapas da vida (15). no entanto, como se constatou na fala de uma das entrevistas, ante a cegueira, algumas famílias não introduzem no ambiente estímulos para propiciar a independência da criança por se preocuparem com sua integridade, uma vez que, para elas, ações independentes podem significar riscos à saúde e à vida da criança cega. esta depende, fundamentalmente, de explicações e descrições do que se passa ao seu redor, ou seja, tem o mundo traduzido por seus cuidadores. só assim poderá compreendê-lo, desenvolver-se satisfatoriamente e adaptar-se de forma integrada a ele. é preciso que a criança seja estimulada a interagir no ambiente por meio do uso de seus sentidos preservados com a finalidade de superar dificuldades oriundas da falta visual (16). cabe aos profissionais da saúde/enfermagem auxiliarem no desenvolvimento das capacidades e habilidades dessas crianças redirecionando a atenção, antes focada apenas na cegueira, para elas (17). as dificuldades ocasionadas pela cegueira devem ser sanadas e suas diferenças devem ser entendidas como desafios positivos; além disso, as ações dos profissionais devem ter como finalidade maximizar suas potencialidades (18). à medida que a família estimula a criança, garante seu desenvolvimento saudável e independente. a criança cega não terá dificuldades para aprender se lhe for propiciado um ambiente rico em experiências onde ela possa trabalhar seus canais de comunicação, o que lhe favorecerá seu desenvolvimento como um todo (2). a integração entre escola e família é fundamental no processo de inclusão a fim de minimizar barreiras na obtenção da independência infantil nesse ambiente (19). cabe ao enfermeiro o papel de facilitador no processo de escolarização da criança cega atuando junto aos profissionais da escola, orientando-os acerca das questões que envolvem a saúde e a condição limitante dessas crianças. deve realizar também assistência individual às crianças e suas famílias, o que as possibilita exporem as dificuldades enfrentadas durante sua 101 influência ambiental para a (in)dependência da criança cega: perspectiva da família l aline campelo pintanel e outros inclusão na escola; ele se torna, portanto, uma ponte entre a criança, a escola e a família na busca por soluções que facilitem esse processo (20). crianças cegas devem desfrutar de um ambiente escolar estimulador, onde há mediação de condições que favoreçam a exploração de seu referencial perceptivo particular (21). elas não são diferentes de outros educandos quanto ao desejo de aprender. têm as mesmas necessidades de proteção, afeto e de brincar. precisam aprender limites e a conviver, dentre outros aspectos relacionados com a formação de sua identidade e independência (22). estudo acerca da escolarização de crianças cegas evidenciou que apenas 17 % das mães entrevistadas identificaram a escola convencional como um local acolhedor. verificou-se que o fato de a criança estar matriculada não garantiu que suas necessidades estivessem sendo respeitadas (23). nesse sentido, é preciso que o ambiente escolar esteja preparado para receber a criança cega de forma a auxiliar no desenvolvimento de suas capacidades e potencialidades. a escolarização é uma importante estratégia para favorecer a interação e a independência infantil (24). a integração entre escola e família é fundamental no processo de inclusão da criança cega na sociedade, e minimiza barreiras na obtenção da independência infantil nesse ambiente. o enfermeiro pode atuar no processo de integração social da criança cega compondo a equipe de reabilitação, realizando ações educativas que ajudem na aquisição de habilidades para o autocuidado e de uma consciência crítica que facilite a sua integração social. deve orientar a família da criança para que se torne o principal núcleo de estimulação infantil, o que favorecerá sua escolarização (25). a família tem a função de facilitar a socialização da criança cega. percebe-se que seu entrosamento em grupos sociais diferentes possibilita à criança adquirir um desenvolvimento saudável e independente (21). exercitar suas potencialidades rumo à independência produz efeitos positivos sobre a autoestima e a interação social da criança cega nos diversos ambientes nos quais convive. ao vivenciar com mais frequência sua circulação nos ambientes, ela tem a oportunidade do conhecimento real e não apenas discursivo dos objetos, de vivenciar (re)ações afetivas com outras pessoas e de ampliar seus contatos sociais e culturais (26). fora do seu ambiente de conforto, tanto a criança como sua família podem sentir medo e insegurança em se arriscar. no entanto, em algum momento, a criança necessitará entrar em contato com o mundo fora de casa, pois disso dependerá sua escolarização, socialização e futuro profissional (12). a superação de estigmas e a integração da criança cega em diferentes ambientes podem refletir na formação da sua personalidade (27). para tanto, é importante que a família estimule precocemente a criança inserindo-a no contexto social, criando um ambiente propício para que esta alcance um desenvolvimento compatível com seu estágio de vida até que possa ter a capacidade de se tornar independente e ativa socialmente. conclusão a pesquisa leva à conclusão sobre a necessidade em se repensar a organização dos ambientes para favorecer não só a melhor circulação e locomoção da criança cega, mas também a dos que convivem com ela. os ambientes são sistemas de suporte e os ecossistemas influenciam o bem-estar, a saúde e a independência humana, que envolvem complexas relações causais. no entanto, a forma como estão (des)organizados podem limitar ou estimular a (in)dependência da criança cega. os elementos constituintes do ecossistema compõem determinado espaço/ambiente e se inter-relacionam ao exercerem interações capazes de influenciar a vida e transformá-la. nesse sentido, é necessário o preparo das famílias para o enfrentamento das limitações da cegueira na criança de forma a auxiliá-la na apreensão dos ambientes nos quais desenvolvem suas relações, o que pode torná-la independente e levá-la à construção da sua identidade como alguém capaz. a questão da acessibilidade dos cegos nos ambientes precisa ser discutida no sentido de sua inclusão social. o domicílio e a escola são sistemas de suporte e influenciam a independência humana que necessitam ser repensados e reorganizados para favorecer a circulação e a inclusão da criança cega. cabe aos profissionais da saúde/enfermagem a orientação adequada da família, que a habilite a se transformar em um núcleo de estimulação infantil, no qual a criança cega seja auxiliada na aquisição de habilidades, que seja capacitada para as avds nas áreas de autocuidado, mobilidade e função social, o que possibilitará sua independência. 102 año 16 vol. 16 nº 1 chía, colombia marzo 2015 aquichan issn 1657-5997 para finalizar, conclui-se que a família precisa ser auxiliada a organizar os ambientes de (con)vivência da criança cega como forma de promover sua inclusão e acessibilidade, o que a levará a uma melhor qualidade de vida. novos estudos devem ser realizados no sentido de explorar o cuidado ecossistêmico como alternativa para a organização dos ambientes e sua influência para a (in)dependência de crianças cegas. referências 1. turiel e. domain specificity in social interactions, social thoughts and social development. child development. 2010; 81(3):720-6. 2. seidl-de-moura ml, bandeira tta, campos kn, cruz em, amaral gs, marca rgc. parenting cultural models of a group of mothers from rio de janeiro. the spanish journal of psychology. 2009; 12(2):506-17. 3. heijthuijsen aam,beunders vaa,jiawan d, mesquita-voigt amb,pawiroredjo j,mourits m et al. causas de deficiência visual grave e cegueira em crianças na república do suriname. br j ophthalmol. 2013; 97(7):812-5. 4. hallemans a, ortibus e, truijen s, meire f. development of independent locomotion in children with a severe visual impairment. res dev disabil. 2011; 32(6):2069-74. 5. pintanel ac, gomes gc, xavier dm. mães de crianças com deficiência visual: dificuldades e facilidades enfrentadas no cuidado. rev gaúcha enferm. 2013; 34(2):86-92. 6. chien cw, brown t, mcdonald r. a framework of children’s hand skills for assessment and intervention. child care health dev. 2009; 35(6):873-84. 7. castilho cn, gontijo dt, alves hc, souza aca. a gente tenta mostrar e o povo não vê: análise da participação de pessoas com cegueira congênita nos diferentes ciclos da vida. cad ter ocup ufscar. 2011; 19(2):189-211. 8. muñoz g, mota l, bowie wr, quizhpe a, orrego e, spiegel jm, yassi a. enfoque ecosistémico de promoción del uso adecuado de antibióticos en niños de comunidades indígenas del ecuador. revista panamericana de salud pública. 2011; 30(6):566-73. 9. santos mc, siqueira hch, silva jrs. saúde coletiva na perspectiva ecossistêmica: uma possibilidade de ações do enfermeiro. rev gaúcha enferm. 2009 dez.; 30(4):750-4. 10. zamberlan c, calvetti a, deisvaldi j, siqueira hch. calidad de vida, salud y enfermería en la perspectiva ecosistémica. rev electrónica enfermería global. 2010; 20:1-7. 11. zee leung z, middleton d, morrison k. one health e ecohealth em ontário: um estudo qualitativo explorando como abordagens holísticas e integradoras estão moldando a prática da saúde pública em ontário. bmc public health. 2012; 12:358. 12. pintanel ac, gomes gc, xavier dm, fonseca ad. facilidades e dificuldades da criança com deficiência visual para o exercício da independência: percepções da família. rev enferm ufpe. 2013; 7(1):119-27. 13. minayo, mcs (org.). pesquisa social: teoria, método e criatividade. 29 ed. petrópolis, rj: vozes; 2010. 14. brasil. ministério da saúde. conselho nacional de saúde. normas de pesquisa envolvendo seres humanos. res. cns 196/1996. bioética. 1996; 4(suppl):15-25. 15. bhalerao sa, tandon m, singh s, dwivedi s, kumar s, rana j. visual impairment and blindness among the students of blind schools in allahabad and its vicinity: a causal assessment. indian j ophthalmol. 2015 mar.; 63(3):254-8. 16. gogate p, gilbert c, zin a. severe visual impairment and blindness in infants: causes and opportunities for control. middle east afr j ophthalmol. 2011; 18(2):109-14. 17. peterseim mm, papa ce, parades c, davidson j, sturges a, oslin c et al. combining automated vision screening with onsite examinations in 23 schools: refocus on children program 2012 to 2013. j pediatr ophthalmol strabismus. 2015; 52(1):20-4. 103 influência ambiental para a (in)dependência da criança cega: perspectiva da família l aline campelo pintanel e outros 18. lee fm, tsang jf, chui mm. the needs of parents of children with visual impairment studying in mainstream schools in hong kong. hong kong med j. 2014; 20(5):413-20. 19. ruhagaze p; njuguna kk; kandeke l; courtright p. cegueira e deficiência visual grave em alunos de escolas para cegos em burundi. middle east afr j ophthalmol. 2013; 20(1):61-5. 20. fathizadeh n, takfallah l, badrali n, shiran e, esfahani ms, akhavan h. experiences of blind children caregivers. iran j nursmidwifery res. 2012; 17(2 suppl1): s143-s149. 21. zhu jf1, zou hd, he xg, lu ln, zhao r, xu hm et al. cross-sectional investigation of visual impairing diseases in shanghai blind children school. chin med j. (engl). 2012 out. ;125(20):3654-9. 22. sá ed, campos im, silva mbc. atendimento educacional especializado em deficiência visual. brasília (df): gráfica e editora cromos; 1997. 23. resende, do, ferreira pm, rosa sm. a inclusão escolar de crianças e adolescentes com necessidades educacionais especiais: um olhar mães. cad. de terapia ocupacional da ufscar. 2010; 18(2):115-27. 24. resende apc, vital fmp. a convenção sobre os direitos das pessoas com deficiência — versão comentada. brasília: secretaria especial dos direitos humanos; 2008. 25. oliveira sc, negrão mv. ações de inclusão: valorização da acessibilidade em uma escola profissionalizante. e-tech. 2010; 3(1):48-62. 26. kuwabara m, smith lb. cross-cultural differences in cognitive development: attention to relations and objects. j exp child psychol. 2012; 113(1):20-35. 27. kreitz c, schnuerch r, gibbons h, memmert d. some see it, some don’t: exploring the relation between inattentional blindness and personality facto. plos one. 2015; 10(5): e0128158. 09. actualidad (70-72) l 26 de mayo de 2004 se celebró la quinta conferencia anual de la asociación de adaptación de roy (roy adaptation association, raa), en la ciudad de portsmouth, new hampshire. en este evento, dirigido por la doctora callista roy, autora del modelo de adaptación de enfermería, participaron importantes miembros de la asociación, como la doctora jacqueline fawcett, reconocida internacionalmente por sus aportes al desarrollo de la disciplina de enfermería; también enfermeras del boston college; de la universidad de massachusetts, boston y dartmouth; de la universidad de québec, en outaouais; de la universidad autónoma de nuevo león, en méxico; de la universidad de juárez, tabasco; de la universidad autónoma del estado de hidalgo: de la universidad de mahipol, tailandia, y un docente de la universidad de la sabana, entre otros. en la mañana, los puntos tratados en la conferencia estuvieron relacionados con distintos temas, como los siguientes: el desarrollo del modelo y sus implicaciones en el cuidado de la salud, y los resultados de diversos proyectos de investigación, como un estudio sobre la relación teoría, práctica e investigación, presentado por la doctora pamela senesac; el desarrollo de una teoría de mediano alcance sobre enfrentamiento y adaptación, por parte de la doctora roy y la estudiante de doctorado prangtip chayaput; la implementación de un proyecto multiinstitucional sobre la adaptación al nacimiento por cesárea, por las doctoras fawcett y cyntya aber; un análisis crítico de los instrumentos utilizados en investigaciones con el modelo en los últimos 25 años, por las doctoras keville frederickson, callista roy y stacy barone. en las horas de la tarde se realizó una sesión de grupos de trabajo sobre educación, práctica e investigación, en la cual se compartieron y discutieron aspectos relacionados con la aplicación del modelo en estos escenarios. resultó muy interesante la exhibición de pósteres, que reflejan los avances en investigación realizados por enfermeras americanas, canadienses, latinoamericanas y tailandesas. en ella participaron la mayoría de los asistentes. maría elisa moreno fergusson quinta conferencia roy adaptation association 70 año 4 nº 4 -70-72 bogotá, colombia octubre 2004 actualidad 71 el grupo de estudio sobre el modelo de adaptación de roy, de la facultad de enfermería de la universidad de la sabana, integrado por los docentes y algunas enfermeras de la clínica universitaria teletón y del servicio médico de la universidad, presentó un póster con los avances en la relación teoría, práctica e investigación, alcanzados en los últimos cinco años de aplicación del modelo (figura 1). entre ellos vale la pena destacar: en la relación de la teoría con la práctica se tienen en cuenta aspectos que se refieren a la aplicación en el programa de enfermería, en los servicios de enfermería y en la investigación. como el modelo constituye el marco de referencia para el desarrollo de las asignaturas del campo profesional, es la guía para la práctica. su aplicación ha creado la necesidad de generar estrategias didácticas para socializar los avances en la aplicación del modelo. una de estas son los ateneos, en los cuales, con la participación de los estudiantes y los profesores, se discute y analiza una situación de enfermería vivida por ellos, que por su complejidad ha sido seleccionada previamente. este espacio promueve la unificación de criterios frente a la aplicación del modelo y permite profundizar en aspectos relevantes del cuidado de enfermería, para promover la adaptación de las personas a su situación actual de salud. en cuanto a la aplicación en servicios de enfermería, vale la pena destacar la experiencia del departamento de enfermería de la clínica universitaria teletón, donde se han generado nuevas oportunidades de desempeño, como en la consulta de enfermería, en los servicios de rehabilitación, en cirugía ambulatoria y consulta externa. asimismo, en la fundación cardio infantil, instituto de cardiología, donde se ha venido implementando la aplicación del modelo con buenos resultados, en las unidades de cuidado intensivo, pediátrica y de adultos, y en la unidad de neonatos, como consecuencia del convenio docenteasistencial para la especialización en enfermería en cuidado crítico pediátrico. roy adaptation association 5th annual conference 2004 roy adaptation model academic group la sabana university • school of nursing bogotá, d.c. colombia revista aquichan issn 1657-5997 año 3 nº 3 • bogotá, colombia octubre 2003 72 como estrategias para su desarrollo, el grupo de estudio ha utilizado la revisión de documentos, a fin de determinar el estado del arte del modelo, el análisis y operacionalización de los conceptos principales, la aplicación de teorías de mediano alcance y el desarrollo del concepto de cuidado para la adaptación. en cuanto a los avances en investigación, la facultad tiene una línea sobre el modelo de adaptación: se han hecho estudios, encaminados principalmente al desarrollo de instrumentos para la valoración del modo psicosocial y fisiológico, y se encuentran en curso proyectos relacionados con la valoración de las respuestas de adaptación en niños, en las familias, y en las personas con discapacidad y sus familias. la aplicación del modelo de adaptación, y la vinculación a la raa, constituyen aspectos fundamentales para el desarrollo de la facultad. si bien los estudiantes tienen la oportunidad de conocer otras perspectivas teóricas de enfermería en algunas de las asignaturas del programa, el contar con un modelo como el de roy, que ha evidenciado un gran desarrollo, provee un marco de referencia, y su orientación filosófica, principios y valores, una visión de reciprocidad para el análisis y estudio del cuidado de enfermería en los diferentes escenarios. la aplicación del modelo evita que la práctica se centre únicamente en el hacer, y en desarrollar el proceso de enfermería sin un respaldo teórico, pues lleva a los docentes y estudiantes a pensar en la razón de ser de la atención de enfermería, y les permite identificar con mayor claridad cuál es su contribución en un equipo interdisciplinario de salud. por esto se ha logrado la expansión de su rol en los servicios de las instituciones mencionadas donde se aplica el modelo. desde el punto de vista de la internacionalización de la facultad, se ha logrado el reconocimiento del grupo por parte de la asociación de adaptación de roy, lo cual es evidente en la entrevista que realizó la doctora jacqueline fawcett, sobre la experiencia en la aplicación del modelo de roy a los integrantes del grupo, la cual fue publicada en la revista nursing science quarterly1. además, se han establecido vínculos con enfermeras de otros países, que permitirán compartir y replicar experiencias en países latinoamericanos con características culturales similares a las nuestras, y se promoverá el desarrollo de proyectos de investigación colaborativa. de grupo de estudio a grupo de investigación con gran satisfacción, la facultad de enfermería de la universidad de la sabana recibió el reconocimiento del grupo de estudio sobre el modelo de adaptación de callista roy, como grupo de investigación. este fue otorgado por el instituto colombiano para el desarrollo de la ciencia y la tecnología “francisco josé de caldas” (colciencias), el 3 de septiembre de 2004. fawcett, jacqueline. “conceptual models of nursing: international in scope and substance? the case of the roy adaptation model”, nursing science quarterly, 16 (4): 315-318, oct. 2003. 393 402 relacao familiar da pessoa idosa.indd 393 luana araújo dos reis1 nadirlene pereira gomes2 luciana araújo dos reis3 tânia maria de oliva menezes4 telmara menezes couto5 aline cristiane de souza azevedo aguiar6 margarida da silva neves de abreu7 relação familiar da pessoa idosa com comprometimento da capacidade funcional 1 enfermeira. universidade federal da bahia, brasil. luareis1@hotmail.com 2 doutora em enfermagem. universidade federal da bahia, brasil. nadirlenegomes@hotmail.com 3 doutora em ciências da saúde. universidade estadual do sudoeste da bahia, brasil. lucianauesb@yahoo.com.br 4 doutora em enfermagem. universidade federal da bahia, brasil. tomenezes50@gmail.com 5 doutora em enfermagem. universidade federal da bahia, brasil. telmaracouto@gmail.com 6 enfermeira. universidade federal da bahia, brasil. alinecte@hotmail.com 7 doutora em enfermagem. escola superior de enfermagem do porto, brasil. mabreu@esenf.pt recibido: 04 de mayo de 2015 enviado a evaluadores: 14 de mayo de 2015 aceptado por evaluadores: 21 de julio de 2015 aprobado: 28 de julio de 2015 doi: 10.5294/aqui.2015.15.3.7 para citar este artículo / to reference this article / para citar este artigo araújo dos reis l. pereira gomes n. araújo dos reis l. de oliva menezes tm. menezes couto t. de souza azevedo aguiar ac. da silva neves de abreu m. relação familiar da pessoa idosa com comprometimento da capacidade funcional. aquichan. 2015;15(3):393-402. doi: 10.5294/aqui.2015.15.3.7 resumo objetivo: compreender a relação familiar da pessoa idosa com comprometimento da capacidade funcional. materiais e métodos: estudo exploratório e descritivo de abordagem qualitativa, fundamentado no método da história oral, realizado com 15 pessoas idosas assistidas por uma unidade de saúde da família, residentes com familiares e que apresentavam comprometimento da capacidade funcional. os dados foram coletados no período de março a abril de 2012, por meio de entrevistas em profundidade. as categorias temáticas foram: bom relacionamento familiar, mudanças na relação familiar, sentindo-se um incômodo para a família, sentindo-se abandonado pela família. resultado: o estudo revelou que as pessoas idosas com comprometimento da capacidade funcional vivenciam sentimentos variados, que vão desde a alegria, por serem respeitadas e terem suas necessidades atendidas, à tristeza e revolta, pela adaptação negativa da família e o abandono dos filhos. conclusão: a relação familiar da pessoa idosa passa por reajustes após o comprometimento da capacidade funcional, o que repercute significativamente na dinâmica das relações. a partir dessa compreensão, os profissionais de saúde, sobretudo de enfermagem, devem reconhecer os desafios enfrentados pela família, orientá-la e capacitá-la para o atendimento às demandas de cuidado apresentadas pela pessoa idosa com comprometimento da capacidade funcional, e favorecer a realização do cuidado sem que haja desgaste das relações. palavras-chave idoso, relações familiares, incapacidade funcional, enfermagem (fonte: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 393-402 394 aquichan issn 1657-5997 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 393-402 relación familiar del adulto mayor con comprometimiento de la capacidad funcional resumen objetivo: comprender la relación familiar de la persona adulta con comprometimiento de la capacidad funcional. materiales y métodos: estudio exploratorio y descriptivo de abordaje cualitativo, fundamentado en el método de la historia oral, realizado con 15 adultos mayores asistidos por una unidad de salud de la familia, residentes con familiares y que presentaban comprometimiento de la capacidad funcional. se recolectaron los datos en el período de marzo y abril del 2012, por medio de entrevistas en profundidad. las categorías temáticas fueron: buena relación familiar, cambios en la relación familiar, sintiéndose un estorbo para la familia, sintiéndose abandonado por la familia. resultado: el estudio ha revelado que las personas mayores con comprometimiento de la capacidad funcional vivencian sentimientos diversos que van desde la alegría porque son respetadas y tienen sus necesidades atendidas, hasta la tristeza y revuelta, por la adaptación negativa de la familia y el abandono de los hijos. conclusión: la relación familiar de la persona mayor pasa por reajustes luego del comprometimiento de la capacidad funcional, lo que repercute significativamente en la dinámica de las relaciones. desde esta comprensión, los profesionales de salud, sobre todo de enfermería, deben reconocer los retos a los que la familia afronta, orientarla y capacitarla para la atención a las demandas de cuidado presentadas por la persona mayor con comprometimiento de la capacidad funcional, y favorecer la realización del cuidado sin que esto desgaste las relaciones. palabras clave adulto mayor, relaciones familiares, discapacidad funcional, enfermería (fuente: decs, bireme). 395 relação familiar da pessoa idosa com comprometimento da capacidade funcional l luana araújo dos reis e outros family relationships of elderly adults with compromised functional capacity abstract objective: this research was intended to understand the family relationships of adults with compromised functional capacity. materials and methods: it is an exploratory, descriptive study with a qualitative approach, based on the oral history method. the sample included 15 elderly adults who were being assisted by a family health unit, were living with family members, and had compromised functional capacity. the data were collected between march and april 2012, through in-depth interviews. the subject categories were: good family relationships, changes in family relationships, feeling of being a nuisance to the family, and feeling abandoned or neglected by the family. result: the study found that elderly adults with compromised functional capacity experience a variety of feelings that range from joy, because they are respected and their needs are met, to sadness and shock over their family’s negative adjustment to the situation and by being abandoned or neglected by their children. conclusion: the dynamics of the family relationships of elderly adults change significantly when the person’s functional capacity is compromised. with this in mind, health professionals, especially nurses, must recognize the challenges the family faces and be prepared to guide and train family members to satisfy the demands of caring for an elderly relative with compromised functional capacity and to favor rendering the care that is needed without jeopardizing family relationships. keywords elderly adults, family relationships, functional disability, nursing (source: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 393-402 396 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 introdução o cenário mundial experimenta uma transição demográfica, caracterizada por decréscimo no número de jovens e aumento expressivo de pessoas idosas. o brasil apresenta uma conjuntura semelhante ao restante do mundo visto que seu índice de envelhecimento elevou-se de 31,7% em 2001, para 51,8% em 2011, ou seja, aproximadamente uma pessoa de 60 anos ou mais de idade para cada duas pessoas com menos de 15 anos (1). dentre os problemas comumente desencadea dos pelo avançar da idade destaca-se a incapaci dade funcional, definida como um conjunto de alterações que acarreta maior dependência de cuidadores e traz importantes prejuízos à saúde e à qualidade de vida da pessoa idosa. resulta na diminuição da capacidade de autocuidado e, algumas vezes, de mobilidade, o que ocasiona baixa autoestima, depressão e menor vontade de viver (2, 3). quando a incapacidade funcional ocorre, a família passa a desempenhar o papel principal, no que se refere ao suporte à pessoa idosa dependente. em geral, a família assume a tarefa do cuidado diário, muitas vezes sem o preparo e o conhecimento adequados, além de escassos recursos físicos, financeiros e humanos (4, 5). embora a velhice não seja sinônimo de doença, existe uma associação entre o envelhecimento e o grau de dependência (6). a dependência é um estado no qual as pessoas necessitam de assistência ou ajuda para realizar os atos correntes de vida, em decorrência de falta ou perda de autonomia física, psíquica ou intelectual (4). no cuidado à pessoa idosa dependente e seus cuidadores, é importante observar em que medida o relacionamento familiar pode ser alterado pela situação de dependência, para que famílias vulneráveis sejam identificadas e mais bem assistidas (7). em 2008, o ministério da saúde lançou o guia prático do cuidador, que orienta sobre a prestação de cuidados à pessoa idosa dependente no domicílio e, assim, torna a família cada vez mais responsável pelo cuidado (8). a família permite a construção de relações profundas e sentimentos positivos de afeto, proporciona segurança e proteção aos que dela partilham, além de oferecer suporte nos momentos de dificuldades. no entanto, também pode ser um ambiente de desestabilização do indivíduo. logo, da mesma forma em que é um ambiente de proteção, a família também pode ser um lugar de conflitos e geração de doença (9, 10). com base nessas constatações e nas observações em campos de prática direcionadas a pessoas idosas, questiona-se: como é a relação familiar da pessoa idosa com comprometimento da capacidade funcional? tal inquietação justifica-se pela necessidade de os profissionais de saúde, sobretudo de enfermagem, reconhecerem os desafios enfrentados pela família no atendimento das demandas de cuidado apresentadas pela pessoa idosa com comprometimento da capacidade funcional e, desse modo, contribuírem com a promoção da saúde e prevenção das crises familiares decorrentes dos reajustes familiares necessários para o suporte adequado à pessoa idosa. assim, este estudo teve como objetivo compreender a relação familiar da pessoa idosa com comprometimento da capacidade funcional. materiais e métodos trata-se de um estudo exploratório e descritivo, de abordagem qualitativa, fundamentado pelo método da história oral. esse método consiste na narrativa do conjunto da experiência de vida de uma pessoa e possibilita maior qualidade e profundidade dos dados, além de permitir uma maior aproximação com a relação familiar vivenciada cotidianamente (11). o estudo foi desenvolvido junto a pessoas idosas assistidas por uma unidade da estratégia de saúde da família (esf) no interior da bahia (nordeste do brasil). o município, localizado no sudoeste baiano, conta com assistência primária à saúde com quatro centros de saúde, 16 unidades básicas de saúde (ubs), 18 unidades da esf, com 21 equipes, e o programa de agentes comunitários de saúde (acs), que totalizam 308 agentes. foram convidadas a participar do estudo 15 pessoas idosas (idade igual ou superior a 60 anos), de ambos os sexos, que atenderam aos critérios de inclusão: residir com familiares, apresentar comprometimento da capacidade funcional e demonstrar condições cognitivas para responder ao instrumento de coleta de dados. para avaliar o comprometimento da capacidade funcional, foi aplicado o índice de barthel (12), utilizado para avaliar 397 relação familiar da pessoa idosa com comprometimento da capacidade funcional l luana araújo dos reis e outros as atividades básicas de vida diária, e a escala de lawton (13), utilizada para avaliar as atividades instrumentais de vida diária; para avaliar o estado cognitivo, foi aplicado o miniexame do estado mental (meem) (14). considerou-se como critério de exclusão não estar presente na residência após duas visitas da pesquisadora. vale salientar que o contato com as pessoas idosas ocorreu por meio dos acs, que acompanharam a pesquisadora em visitas domiciliares para aproximação com as pessoas idosas, sendo, posteriormente, agendada data para a realização da entrevista. as entrevistas foram realizadas a partir de visitas às residências das pessoas idosas, em diferentes dias e horários, no período de março a abril de 2012. a pesquisadora realizou as visitas acompanhada dos acs da área; na primeira visita, aconteceu a aproximação com a pessoa idosa e seus familiares; na segunda, procedeu-se à entrevista. tal conduta intencionou garantir maior liberdade aos depoentes e fidedignidade de suas respostas ante as questões do instrumento de pesquisa: como era sua relação com seus familiares antes do comprometimento da capacidade funcional? como é sua relação com seus familiares hoje, depois do comprometimento da capacidade funcional? para facilitar a compressão dos participantes do estudo, explicou-se o que é capacidade funcional e quais as implicações de sua limitação na vida diária. os dados foram analisados concomitantemente às entrevistas. a inclusão de novos participantes no estudo foi interrompida a partir do momento em que as inquietações da pesquisadora foram respondidas e o objetivo do estudo alcançado. as entrevistas foram transcritas na íntegra e sistematizadas por meio da análise de conteúdo temática categorial, que consiste em procedimentos sistemáticos e objetivos de descrição do conteúdo das mensagens que viabilizam a análise das comunicações e, assim, a obtenção de indicadores. estes, por sua vez, possibilitam a inferência de conhecimentos relativos às condições de produção/ recepção das mensagens (15). com base nessa técnica, o processo de sistematização deuse da seguinte forma: inicialmente, realizou-se leitura flutuante do material bruto para identificação do corpus de sentido; em seguida, delinearam-se as categorias temáticas por meio das quais se organizaram as falas; por último, interpretaram-se os depoimentos. por se tratar de uma pesquisa que envolve seres humanos, foram observados os aspectos éticos disciplinados pela resolução 196/968, do conselho nacional de saúde — ministério da saúde, em vigor no momento da pesquisa, com aprovação do comitê de ética em pesquisa com seres humanos da escola de enfermagem da universidade federal da bahia, mediante parecer 41/2011. a participação no estudo se deu somente após a assinatura, em duas vias, do termo de consentimento livre e esclarecido; além disso, o anonimato dos participantes foi garantido e foram atribuídos a eles nomes fictícios de flores. resultados os 15 participantes, 11 mulheres e 4 homens, tinham entre 65 e 88 anos, 6 casados, 6 divorciados, 1 solteiro e 2 viúvos. no que se refere ao grau de escolaridade, 1 não era alfabetizado, 5 consideravam-se alfabetizados, 8 possuíam o ensino fundamental incompleto e apenas 1 pessoa idosa concluiu o ensino médio. quanto à renda média mensal, 13 possuíam renda média de um salário-mínimo e 2 recebiam mais de um salário-mínimo. a seguir, são apresentadas as representações da relação familiar dos participantes organizadas em quatro categorias temáticas: “bom relacionamento familiar”, “mudanças na relação familiar”, “sentindo-se um incômodo para a família”, “sentindose abandonado pela família”, tomando por base os depoimentos dos participantes. sua discussão fundamentou-se em autores que abordam a temática. bom relacionamento familiar entre as pessoas idosas com comprometimento da capacidade funcional em que houve satisfatória adaptação familiar para atender às novas demandas, foi destacado o respeito e a boa relação, o que despertava sentimentos positivos e possibilitava inferir que o cuidar do outro em sua plenitude contribui para o seu bem-estar. ressalta-se, pois, que se trata de pessoas idosas que coabitam com filhos que entendem e respeitam as limitações impostas pelo processo de envelhecimento. ah, a nossa relação é ótima. são cinco filhos [...]. eu trato meus filhos como se fossem meus amigos e eu sou para eles como se fosse confidente, sabe? então, eles têm liberdade de conversar o 8 a resolução 196/96 foi substituída pela resolução 466/2012, que trata de pesquisa e testes em seres humanos, publicada no dia 13 de junho de 2013, no diário oficial da união. a resolução foi aprovada pelo plenário do conselho nacional de saúde (cns) na 240ª reunião ordinária em dezembro de 2012. 398 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 que quiser comigo, falar da vida deles, como é que está. sempre com respeito (acácia). a relação é boa. ele [filho adotivo] é um menino de boa cabeça, não bebe, não fuma, só liga mesmo para o trabalho. a mulher [esposa do filho] trabalha num armarinho, trabalha lá mais a mãe (cravo). a nossa relação é maravilhosamente bem. o menino é adotado, mas eu tenho amor igual um filho. a nora, não tenho o que dizer dela também, nunca discutimos, nunca tivemos diferença nenhuma (orquídea). mudanças na relação familiar a pessoa idosa com comprometimento da capacidade funcional e sua família enfrentam muitas limitações que resultam em mudanças significativas na rotina familiar. tais limitações implicam diretamente as relações. antigamente, quando eu podia fazer as coisas, eles me respeitavam. mas, hoje em dia, falta amor, consideração, respeito. tem que ter mais amor e respeitar o outro. ter mais consideração (flor de lótus). a nossa relação hoje é ruim, me tratam muito mal. toda vida foi sempre boa. mas, agora que preciso deles, está assim (gardênia). constatou-se, também, o despreparo das famílias para lidar com o indivíduo que envelhece e com as mudanças que ocorreram nas relações familiares após o comprometimento funcional da pessoa idosa. a não adaptação positiva ou negativa da família para atender às necessidades da pessoa idosa dependente pode, inclusive, expressar-se em situações conflituosas e trazer sofrimento: [...] minha filha me maltratava muito por eu não estar mais ouvindo direito. hoje, eu prefiro não falar mais sobre isso, porque me traz muitas lembranças ruins. é muito sofrimento (jasmin). [...] quanto mais velhos ficamos, ficamos mais fracos e nos tornamos incapazes. parece que viramos criança de novo e dependemos de cuidados dos outros. por isso sofremos. isso é culpa da velhice (dália). sentindo-se um incômodo para a família diante da dependência e da dificuldade ou impossibilidade de assumir o autocuidado e controlar a própria vida, a pessoa idosa sente-se um incômodo para seus familiares: [...] sinto-me triste, incomodando, inválido por dar trabalho à minha família (lírio). [...] eu me sinto bem cuidada e querida por minha família, mas me sinto também incomodada por dar trabalho e acho que eles se preocupam demais comigo. não podem viajar, para não me deixar só, porque eu não aguento mais viajar muito. tenho medo de piorar e dar mais trabalho ainda (mimosa). o estudo revelou, ainda, que as pessoas idosas buscam alternativas para não mais dar trabalho aos familiares como, por exemplo, residir em instituição de longa permanência para idosos (ilpi). [...] queria mesmo ir morar em um abrigo de velhos (iris). [...] se eu não tivesse nessa cama, eu mesma ia fazer minhas coisas. [...] iria para o abrigo dos velhos (rosa). sentindo-se abandonado pela família na ausência da companhia de uma pessoa da família, as pessoas idosas enfrentam grandes desafios diários para lidar com as limitações impostas pelo comprometimento da capacidade funcional, mas, sobretudo, sentem-se abandonadas e infelizes por não contarem com os filhos no momento de fragilidade em que mais precisam de apoio e cuidado. minha família é bem distante. de ano em ano que um filho vem me visitar. só tem essa filha por mim (ciclame). é triste! nós criamos o filho e quando chega a idade, nos vemos sozinho. eu sei que eu fui uma boa mãe. eu deixei de comer para dar de comer aos meus filhos. os filhos casaram, se mudaram e não têm aquela obrigação comigo. não liga nem para saber se eu comi hoje, se eu estou viva. é muita dor para uma mãe viver assim, largada (dália). 399 relação familiar da pessoa idosa com comprometimento da capacidade funcional l luana araújo dos reis e outros discussão diante das limitações decorrentes do comprometimento da capacidade funcional, a pessoa idosa passa a depender da ajuda de seus familiares para o desempenho das atividades da vida diária, o que para elas representa uma satisfação ou um incômodo à família e isso desencadeia mudanças nos relacionamentos. tais mudanças podem ser positivas, com estreitamento das relações familiares em famílias com vínculos fortes e boa renda (7), mas, também, pode comprometer o equilíbrio e integridade das relações (6). sob esse pensar, apreendeu-se, pelos depoimentos dos participantes, que a família, em sua plenitude, revela-se como cuidadora ao assumir e compartilhar junto a seu ente querido as demandas por ele apresentadas, além de demonstrar respeito e favorecer a manutenção da boa relação familiar. essa afirmativa é reconhecida no discurso de acácia, que percebe a relação de confiança como algo benéfico não só para ela, mas também contribui para o fortalecimento do vínculo familiar. no entanto, em muitos casos, observou-se que a relação familiar com a pessoa idosa antes do surgimento do comprometimento da capacidade funcional, que gerou a dependência, era satisfatória, porém, à medida que ela passa a necessitar de auxílio para realização das atividades da vida diária (avd), faz-se necessário uma reorganização da estrutura familiar para atendimento de suas necessidades. nesse celeiro, o cuidado se apresenta, geralmente, como uma tarefa árdua, que pode acarretar consequências para família (6). ao cuidar da pessoa idosa dependente, a família pode apresentar desânimo e aborrecimento pela dificuldade de conviver com a pessoa idosa, que geralmente não aceita essa condição (16). mudanças negativas que se apresentam na relação familiar são influenciadas pela sobrecarga do cuidador familiar, principalmente quando sem apoio e submetido ao isolamento social em decorrência do cuidado (7). pesquisa realizada em ribeirão preto (são paulo, brasil) constatou que a dependência da pessoa idosa é um fator de risco para sobrecarga do cuidador e requer, assim, uma abordagem preventiva e a intervenção precoce como prioritárias para essa população (17). outro estudo realizado com 70 cuidadores de pacientes diagnosticados com a doença de alzheimer e 44 cuidadores de sobreviventes de acidente vascular cerebral (avc) mostrou melhor adaptação da família quando a situação geradora de dependência ocorreu de forma lenta e gradual, como na demência, do que quando ocorreu de forma súbita, como no avc (18). destaca-se que, em meio à capacidade comprometida ou fragilizada da família para o cuidado, a pessoa idosa se abre para outras possibilidades de cuidado, o que a faz desejar ir para uma ilpi. até tomar a decisão, ela avalia todas as consequências da sua atitude, pois tem ciência de que essa decisão, algumas vezes, será contrária à vontade de seus entes e aos preceitos sociais e legais, que julgam ser responsabilidade da família o cuidado à pessoa idosa. a institucionalização, então, é uma das soluções encontradas para o problema e a ipli insurge como uma alternativa não familiar de suprir as necessidades de moradia e cuidado dessa população (19). a manutenção de instituições asilares para abrigar pessoas idosas que não possuem condições de garantir sua própria sobrevivência é responsabilidade do estado, embora o estatuto do idoso saliente que o atendimento da pessoa idosa deve ser feito, preferencialmente, na modalidade não asilar (20). estudo realizado em ijuí (rio grande do sul, brasil) observou que muitas vezes a opção por residir em um asilo parte da própria pessoa idosa, motivada pelo desejo de encontrar um local no qual tenha atenção, conforto e, especialmente, atendimento a suas necessidades básicas. a situação econômica é um ponto preponderante para a decisão de morar em uma residência para idosos, além da possibilidade de não mais atrapalhar a vida dos familiares (21). no entanto, em outro estudo com 83 idosos institucionalizados em coimbra (portugal), concluiu-se que ter depressão e/ou solidão em determinado momento serão fatores de risco para a persistência dos sintomas depressivos. a pioria ao longo do tempo da solidão, da ansiedade e dos afetos positivos e negativos parece também contribuir para a persistência dos sintomas depressivos. assim, a solidão apresenta-se como fator de risco para o desenvolvimento da depressão (22). outro aspecto evidenciado no presente estudo foi a tristeza da pessoa idosa, revelada no sentimento de revolta, por não serem cuidadas na velhice no momento em que mais precisam de atenção e respeito. algumas referiram distanciamento e abandono dos filhos nessa fase da vida. constatações semelhantes foram encontradas em pesquisa com 96 integrantes da esf em 400 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 curitiba (paraná, brasil), que constatou que a pessoa idosa, muitas vezes, vivencia a violência intrafamiliar, sendo o abandono e a negligência as formas mais comum reconhecidas pelas equipes da esf (23). estudo realizado com 50 idosos do arquipélago de fernando de noronha (pernambuco, brasil) revelou que as pessoas idosas são pessoas solitárias e isoladas, podem apresentar depressão e baixa autoestima, reforçada por sentimentos de culpa e vergonha (24). nesse cenário, os profissionais de saúde, entre eles o enfermeiro, podem dar suporte à pessoa idosa, seus familiares ou cuidadores, ao discutir estratégias de adaptação da funcionalidade que visem à sua manutenção. ademais, podem identificar em sua área de abrangência instituições ou organizações que desenvolvem atividades com idosos, com intuito de ampliar a rede e o suporte social a essas pessoas (25). destaca-se, portanto, que o suporte à família tem efeito benéfico para todos os familiares, principalmente para a pessoa idosa. entendendo a situação, a família prepara-se de forma mais adequada para atender às necessidades da pessoa idosa, e os profissionais de saúde atuam na promoção à saúde e prevenção de agravos, conforme premissas da atenção primária à saúde. tal ação vai ao encontro do estatuto do idoso, que em seu artigo 3º afirma que é obrigação da família, da comunidade, da sociedade e do poder público assegurar à pessoa idosa, com absoluta prioridade, a efetivação do direito à vida, à saúde, à alimentação, à educação, à cultura, ao esporte, ao lazer, ao trabalho, à cidadania, à liberdade, à dignidade, ao respeito e à convivência familiar e comunitária (18). ademais, o conhecimento das representações da pessoa idosa acerca da relação familiar após o comprometimento da capacidade funcional pode orientar a conduta dos profissionais de saúde, sobretudo a enfermagem, no sentido de atuar na promoção da saúde, por meio da orientação para a manutenção de um suporte familiar adequado à pessoa idosa. conclusão o estudo permitiu compreender que a relação familiar da pessoa idosa passa por reajustes após o comprometimento da capacidade funcional, o que repercute significativamente na dinâmica das relações. salienta-se a vivência de variados sentimentos que vão desde a alegria, com a relação de confiança e respeito, até a tristeza e a revolta, pelo despreparo da família em lidar com a situação de dependência. após o comprometimento da capacidade funcional, as pessoas idosas sentem-se abandonadas pelos familiares e/ou um incômodo para estes, e manifestam o desejo de morar em uma ilpi. a limitação deste estudo está relacionada com a não generalização dos seus resultados para toda a população, pois representam pessoas idosas cadastradas em uma esf no interior da bahia. no entanto, os resultados podem ser aplicados a indivíduos que vivenciem situações similares às dos nossos participantes. assim, o presente estudo pode servir como referência para que os profissionais que prestam assistência à pessoa idosa, com destaque para enfermagem, possam atuar junto à sua família, no sentido de garantir um acompanhamento adequado, e minimizar o desgaste das relações, além de contribuir para uma melhor qualidade de vida nessa fase da vida. as constatações deste estudo sugerem a necessidade de realização de pesquisas sobre a temática abordada, tendo em vista a escassez de estudos internacionais que abordem a relação familiar da pessoa idosa com comprometimento da capacidade funcional e a dinâmica de suas relações. 401 relação familiar da pessoa idosa com comprometimento da capacidade funcional l luana araújo dos reis e outros referências 1. instituto brasileiro de geografia e estatística (ibge). síntese de indicadores sociais: uma análise das condições de vida da população brasileira 2012 [internet]. rio de janeiro, 2012 [acesso 3 mar. 2015]. disponível em: ftp://ftp.ibge.gov. br/indicadores_sociais/sintese_de_indicadores_sociais_2012/sis_2012.pdf 2. strobl r, muller m, emeny r, peters a, grill e. distri bution and determinants of functioning and disabiliti in aged adults — results from the german kora-age study. bmc public health [internet] 2013 [acesso 3 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(1): 70-9. disponível em: http://www.revistas2.uepg.br/index.php/conexao/article/viewfile/3685/2593 10. rocha smc, lima imso. a pessoa idosa e o contexto familiar: uma abordagem sociojurídica. congresso internacional interdisciplinar em sociais e humanidades [internet] niterói-rj: aninter-sh/ ppgsd-uff, 3 a 6 de setembro de 2012 [acesso 9 abril]. disponível em: http://www.aninter.com.br/anais%20i%20coniter/gt17%20estudos%20de%20 fam%edlia%20e%20gera%e7%f5es/a%20pessoa%20idosa%20e%20o%20contexto%20familiar%20uma%20abordagem%20sociojur%cddica%20-%20trabalho%20completo.pdf 11. meihy jcsb. manual de história oral. são paulo: edições loyola; 1998. 12. reis la, mascarenhas chm, torres gv. evaluation of functional capacity on institutionalized elderly in the city of jequié/ba. fiep bulletin 2008; 78(1): 89-92. 13. lawton mp, brody em. assessment of older people: self-maintaining and instrumental activities of daily living. gerontologist [internet] 1969 [acesso 18 abril 2015]; 9:179-86. disponível em: http://www.eurohex.eu/bibliography/pdf/ lawton_gerontol_1969-1502121986/lawton_gerontol_1969.pdf 14. folstein mf, folstein se, mchugh pr. mini-mental state: a practical method for grading the cognitive state of patients for the clinician. j psychiatric res. [internet] 1975 [acesso 18 abril 2015]: 12:189-98. disponível em: http://www.ncbi. nlm.nih.gov/pubmed/1202204 15. bardin l. análise de conteúdo. lisboa: edições 70; 2011. 16. vieira l, nobre jrs, bastos ccbc, tavares ko. idosos dependentes no domicílio: sentimentos vivenciados pelo cuidador familiar. rev bras crescimento desenvolv hum [internet] 2012 [acesso 11 mar. 2015]; 9(1): 46-56. disponível em: http://www.upf.br/seer/index.php/rbceh/article/view/2303/pdf 402 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 17. gratão acm, talmelli lfs, figueiredo lc, rosset i, freitas cp, rodrigues rap. functional dependency of older individuals and caregiver burden. rev esc enferm usp [internet] 2013 [acesso 9 mar. 2015]; 47(1): 137-44. disponível em: http://www.scielo.br/pdf/reeusp/v47n1/en_a17v47n1.pdf 18. mayor ms, ribeiro o, paul c. satisfaction in dementia and stroke caregivers: a comparative study. rev lat am enfermagem [internet] 2009 [acesso 2 mar. 2015]; 17(5): 620-4. disponível em: http://www.scielo.br/pdf/rlae/v17n5/04.pdf 19. camarano aa, kanso sr. as instituições de longa permanência para idosos no brasil. rev bras estud popul [internet] 2010 [acesso 3 mar. 2015]; 27(1): 233-5. disponível em: http://www.scielo.br/pdf/rbepop/v27n1/14.pdf 20. brasil. lei 10.741, de 1º de outubro de 2003. dispõe sobre o estatuto do idoso e dá outras providências [internet]. brasília; 2003 [acesso 5 abril 2011]. disponível em: http://www.planalto.gov.br/ccivil_03/leis/2003/l10.741.htm 21. perlini nmog, leite mt, furini ac. looking for a nursing home for an elderly person: reasons appointed by relatives. rev esc enferm usp [internet] 2007 [acesso 3 mar. 2015]; 41(2): 229-36. disponível em: http://www.scielo.br/pdf/ reeusp/v41n2/07.pdf 22. vicente f, espirito-santo h, cardoso d, silva f, costa m , martins s , torres-pena i, pascoal v , rodrigues f , pinto a , moitinho s , guadalupe s , vicente ht, lemos l. estudo longitudinal dos fatores associados à evolução de sintomas depressivos em idosos institucionalizados. j. bras. psiquiatr. [internet] 2014 [acesso 18 abril 2015]; 63(4): 308-16. disponível em: http://www.scielo.br/pdf/jbpsiq/v63n4/0047-2085-jbpsiq-63-4-0308.pdf 23. shimbo ay, labronici lm, mantovani mf. reconhecimento da violência intrafamiliar contra idosos. esc anna nery [internet] 2011 [acesso 18 abril 2015]; 15(3): 506-10. disponível em: http://www.scielo.br/pdf/ean/v15n3/a09v15n3.pdf 24. araújo lf, lobo filho, jg. análise psicossocial da violência contra idosos. psicol reflex crit [internet] 2010 [acesso 18 abril 2015]; 22(1): 153-60. disponível em: http://www.scielo.br/pdf/prc/v22n1/20.pdf 25. tavares dms, dias fa. capacidade funcional, morbidades e qualidade de vida de idosos. texto contexto — enferm [internet]. 2012 [acesso 18 abril 2015]; 21(1): 112-20. disponível em: http://www.scielo.br/pdf/tce/v21n1/a13v21n1.pdf (17 rese\321as.pdf) revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005152 simulación cibernética en la enseñanza de las ciencias de la salud �guías de procedimientos médicos� conocer la existencia de las nuevas técnicas en la enseñanza de las ciencias de la salud es indispensable para quienes están comprometidos en este quehacer (médicos, enfermeras). el doctor hernando matiz pone al alcance de profesores y alumnos el libro simulación cibernética en la enseñanza de las ciencias de la salud. �guías de procedimientos médicos�, donde hace una recopilación de su experiencia como profesor de laboratorios de simulación, demostrando la necesidad e importancia de modificar los ambientes de aprendizaje, utilizando las nuevas tecnologías y otros medios de ayudas didácticas, las cuales no deben ser marginadas de la realidad educativa especialmente en las áreas de la salud donde cada vez es más difícil tener acceso a campos de práctica, obligándolos a realizar una práctica simulada que tiene sus ventajas ya que el estudiante alcanzará mayores habilidades, y por lo tanto, cometerá menos errores. este texto resalta la importancia de la telemática por su capacidad para almacenar símbolos, expresarlos, escribirlos, copiarlos, ponerlos como texto o imágenes en movimiento, animación, video disco, música, voz y sonido; sus avances en las telecomunicaciones con posibilidades de teleconferencias, en resumen, su capacidad interactiva; por otro lado, el trabajo con simuladores o maniquís que le permiten al estudiante enfrentarse a experiencias de difícil acceso en las prácticas hospitalarias, elementos reutilizables que ayudan a disminuir costos en el proceso de enseñanza-aprendizaje. otra parte interesante del libro son las guías de procedimientos médicos, cuyos fines van a permitir al alumno el autoaprendizaje y la autoinstrucción mediante la construcción de un modelo mental que lo va a llevar a la interacción en un nuevo mundo y nuevas personas, y a adquirir el entrenamiento adecuado para una práctica tecnificada sin deshumanizar la atención. aquí se muestra al docente como el gran motivador por lo que se convierte en un agente importante del proceso de aprendizaje debido al papel que realiza dando una retroalimentación permanente, creando un contexto que tenga sentido de vida real, llevando al alumno a pensar y a dar soluciones a problemas simulados, permitiéndole formular preguntas y, a lo largo de todo este aprendizaje significativo, se vaya adaptando a su profesión. cabe resaltar la diagramación y los esquemas que le permiten al lector hacerse una idea clara del procedimiento que se debe realizar. yolanda gonzález de acuña profesora asistente, universidad de la sabana, colombia. hernando matiz c. y otros facultad de medicina, universidad el bosque, colección educación médica, vol. 39 editorial kimpres, 2005, 291 págs. 453 459 primeras paginas.indd 458 aquichan issn 1657-5997 año 14 vol. 14 nº 4 chía, colombia diciembre 2014 editorial el fenómeno de la cronicidad: su impacto en el individuo, en su familia y el cuidado de enfermería the phenomenon of chronicity: its impact on the person, the family and nursing care o fenômeno da cronicidade: seu impacto no indivíduo, em sua família e no cuidado de enfermagem doi: 10.5294/aqui.2014.14.4.1 el incremento en la expectativa de vida y el envejecimiento de la población constituyen unas de las causas del aumento en la incidencia de enfermedades crónicas no transmisibles. según la organización mundial de la salud (oms), estas son la principal causa de defunción en el mundo y afectan principalmente a las personas mayores, aunque la incidencia en menores de 60 años se ha venido incrementando, como consecuencia de las enfermedades cardiovasculares, el cáncer, las enfermedades respiratorias y la diabetes (1). en los ancianos es frecuente la enfermedad cerebrovascular, y las principales causas de discapacidad se derivan de los trastornos visuales y auditivos, la demencia y la artrosis (2). el inicio de la enfermedad crónica puede ser insidioso o súbito. en el primer caso, las personas tienen un periodo de relativa estabilidad para adaptarse a los cambios, adherirse a tratamientos prolongados y, en algunos casos, aprender a vivir con las limitaciones funcionales que traen con sigo las enfermedades discapacitantes (3). cuando se presentan en forma súbita, estas son acompañadas de una situación en la cual estuvo en riesgo la vida, como en el caso de las enfermedades cerebrovasculares o los accidentes, 1 editora revista aquichan. profesora titular y decana, facultad de enfermería y rehabilitación, universidad de la sabana, bogotá (colombia). mariamf@unisabana.edu.co maría elisa moreno-fergusson1 por tanto, constituyen una experiencia desestabilizadora que dificulta el proceso de adaptación (4). la condición de cronicidad trae consigo un cambio en el estilo de vida, en los roles y en la rutina de las personas afectadas y de los cuidadores familiares (2). dada la relación recíproca que existe entre la condición de salud, el bienestar de la persona enferma y el cuidador, es clave para unos y otros comprender el fenómeno de la cronicidad, que viene siendo estudiado por investigadores de diferentes latitudes. para los enfermeros(as), es fundamental entender este fenómeno ya que se convierten en el principal grupo de apoyo de las personas con enfermedad crónica y de sus familiares. en este contexto, las intervenciones de enfermería deben encaminarse hacia el conocimiento de la enfermedad, sus riesgos, secuelas y estrategias de tratamiento por parte del paciente y de su cuidador (6). este aspecto es fundamental para promover la autonomía en el manejo de la situación y la adhesión al tratamiento. cuando las personas perciben que tienen el poder de controlar su situación, se reducen los sentimientos negativos hacia la enfermedad, se promueven actitudes de optimismo, resiliencia, autoeficacia y compromiso con su propio estado de salud, favoreciendo la adaptación a la condición (5). 459 cuando las condiciones de salud no tienen oportunidad de tratamiento para controlar la situación, es importante comprender las experiencias de las personas para brindar cuidados paliativos y ayudar tanto al individuo como a los cuidadores a afrontar la realidad del final de la vida y promover una muerte digna (4). gracias a los estudios realizados en los últimos veinte años, se han desarrollado instrumentos de medición y de intervenciones encaminados a atender las necesidades de las personas en esta condición, para mejorar su calidad de vida y la de sus familias. se incluye aquí el cuidado de niños y adultos con enfermedades mentales y discapacitantes. del mismo modo, se han publicado los resultados de programas dirigidos a los cuidadores, para fortalecer sus habilidades y competencias, de manera que puedan brindar un mejor cuidado y apoyo (6). en este número de aquichan se publican artículos relacionados con el cuidado de las personas en condición de cronicidad y de los cuidadores. se presentan los resultados de la validación de un instrumento para medir los cuidados según dependencia y riesgo en pacientes con hemodiálisis, y los resultados de estudios que refieren experiencias, creencias, hábitos y calidad de vida de personas en condición de cronicidad. además, se describen prácticas socioculturales que los cuidadores desarrollan para atender a sus familiares, y experiencias del personal de enfermería al cuidar niños con cáncer. los resultados de estos estudios muestran la necesidad de avanzar en el desarrollo del conocimiento y, a través de ensayos clínicos, medir el efecto de las intervenciones y programas sobre la salud de las personas y de los cuidadores. referencias 1. organización mundial de la salud. enfermedades crónicas. disponible en: http://www.who.int/topics/chronic_diseases/es/ [citado 2014 noviembre 20]. 2. organización mundial de la salud. envejecimiento y ciclo de vida, datos y cifras [citado 2014 noviembre 20]. disponible en: http://www.who.int/features/factfiles/ageing/ageing_facts/es/index3.html.. 3. ferrer-arnedo c, fernández-batalla m, santamaría-garcía jm. the value of nursing care in the paradigm of chronicity and dependency. new roles and redesigns. investigación y educación en enfermería. 2014;32(3):488-497. 4. buckner e, hayden s. synthesis of middle range theory of adapting to chronic conditions: a life long process and a common journey. en: roy c. generating middle range theory from evidence to practice. new york: springer publishing company; 2014. p. 277-307. 5. edward k. chronic illness and wellbeing: using nursing practice to foster resilience as resistance. journal of british nursing. 2013;22(13):741-6 6. barrera l, carrillo gm, chaparro l, pinto n, rodríguez a, sánchez b. effect of the program “caring for caretakers”: findings of a multicenter study. colombia médica. 2011;42(2):35-44. 521 528 a analise do conceito seguranca.indd 521 kisna yasmin andrade alves1 viviane euzébia pereira santos2 cilene nunes dantas3 a análise do conceito segurança do paciente: a visão evolucionária de rodgers 1 enfermeira. doutoranda do programa de pós-graduação em enfermagem da universidade federal do rio grande do norte, brasil. kisnayasmin@hotmail.com 2 enfermeira. doutora em enfermagem. universidade federal do rio grande do norte, brasil. vivianeepsantos@gmail.com 3 enfermeira. doutoranda universidade federal do rio grande do norte, brasil. cilenunesdantas@bol.com.br recibido: 24 de enero de 2014 enviado a evaluadores: 28 de marzo de 2014 aceptado por evaluadores: 06 de agosto de 2015 aprobado: 14 de septiembre de 2015 doi: 10.5294/aqui.2015.15.4.7 para citar este artículo / to reference this article / para citar este artigo andrade alves k.y., pereira santos v.e., nunes dantas c. a análise do conceito segurança do paciente: a visão evolucionária de rodgers. aquichan. 2015; 15 (4): 521-528. doi: 10.5294/aqui.2015.15.4.7 resumo objetivo: analisar a evolução do conceito segurança do paciente empregado nas produções científicas sob a visão evolucionária de rodgers. método: trata-se de uma análise conceitual na visão evolucionária de rodgers acerca do conceito segurança do paciente. para tanto, foram analisadas, a partir de uma leitura reflexiva-crítica-indutiva, oito produções científicas: quatro dissertações de mestrado e quatro teses de doutoramento. resultados: são apresentados em três pilares temáticos: 1) antecedentes e consequentes; 2) termos substitutos e conceitos relacionados; 3) atributos e conceitos. considerações finais: destarte, promovem-se reflexões acerca da temática; proporciona-se embasamento conceitual para os diversos estudos acerca da segurança do paciente, independentemente de sua metodologia; fortalece-se a cultura de segurança de paciente e desmotivam-se as respostas punitivas ante os erros individuais. palavras-chave brasil, enfermagem, pesquisa em enfermagem, formação de conceito, segurança do paciente (fonte: decs, bireme). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 521-528 522 aquichan issn 1657-5997 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 521-528 el análisis del concepto seguridad del paciente: la visión evolucionaria de rodgers resumen objetivo: analizar la evolución del concepto seguridad del paciente empleado en las producciones científicas bajo la visión evolucionaria de rodgers. método: se trata de un análisis conceptual en la visión evolucionaria de rodgers acerca del concepto de seguridad del paciente. para tal, se analizaron, desde una lectura reflexiva-crítica-inductiva, ocho producciones científicas: cuatro tesis de doctorado y cuatro de maestría. resultados: los resultados son presentados en tres pilares temáticos: 1) antecedentes y consecuentes; 2) términos sustitutos y conceptos relacionados; 3) atributos y conceptos. conclusiones: de este modo, se promueven reflexiones acerca de la temática; se proporciona embasamiento conceptual a los diversos estudios acerca de la seguridad del paciente, independientemente de su metodología; se fortalece la cultura de seguridad del paciente y se desmotivan las respuestas punitivas ante los errores individuales. palabras clave brasil, enfermería, investigación en enfermería, formación de concepto, seguridad del paciente (fuente: decs, bireme). 523 a análise do conceito segurança do paciente: a visão evolucionária de rodgers l kisna yasmin andrade alves y otros an analysis of the concept of patient safety: rodger’s evolutionary vision abstract objective: analyze developments in the concept of patient safety used in scientific endeavors, pursuant to rodger’s evolutionary vision. method: a conceptual analysis of rodger’s transformative view on the notion of patient safety is offered, based on a reflectivecritical-inductive reading of eight scientific works: four doctoral dissertations and four master’s theses. results: the findings are grouped into three thematic pillars: 1) background and consequences; 2) substitute terms and related concepts; 3) attributes and concepts. conclusions: the study encourages reflection on the topic, provides a conceptual basis for studies on patient safety, regardless of the methodology, strengthens the culture of patient safety, and discourages punitive responses to individual errors. keywords brazil, nursing, nursing research, concept formation, patient safety (source: decs, birime). año 15 vol. 15 nº 4 chía, colombia diciembre 2015 l 521-528 524 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 introdução o conceito segurança do paciente (doravante, sp) é moldado por diversas influências de caráter negativo —como os erros médicos— e caráter positivo —busca e melhorias na qualidade do atendimento—. assim, a sp está relacionada com a prevenção de erros no atendimento médico-hospitalar, bem como a sua qualidade (1). a sp é compreendida como a redução, ao mínimo aceitável, do risco de dano associado ao cuidado. as práticas para a sua concretização devem contemplar o aprendizado organizacional a partir do erro (2). dessa forma, substitui-se a prática da culpabilidade individual pela ideia de repensar em processos da assistência que possam fazer as correções necessárias, que criem mecanismos que antecipem os erros e permita preveni-los dos danos (3). observa-se que o conceito da sp apresenta diversas faces e interfaces contextuais e conceituais. alguns dados estatísticos sobre danos à saúde, também denominados de eventos adversos (ea), revelam que, em 58 hospitais dos países da américa latina, 10 de cada 100 pacientes sofrem algum tipo de dano ao ingressar no ambiente hospitalar. conforme o tempo de internação, esse risco é duplicado (4). ante esses problemas, algumas iniciativas foram idealizadas e implementadas a fim de minimizar as estatísticas e as sequelas físico-emocionais-sociais nos pacientes. exemplificando, a 55ª assembleia da saúde mundial, em 2002, impulsionou os países a solidificarem a segurança da assistência. assim, a organização mundial de saúde (oms) assume a responsabilidade de estabelecimento de normas e padronizações que auxiliam os países a praticarem políticas públicas e práticas de sp. como produto, em maio de 2004, a 57ª a assembleia da saúde mundial cria a aliança mundial para a segurança, que objetiva melhorar, mundialmente, a sp (5). diante desse contexto, enxergou-se a necessidade de compreender mais profundamente a sp, mediante uma análise conceitual das produções científicas brasileiras acerca do conceito sp, a qual permitirá às autoras e aos leitores desvendar as faces e interfaces dessa expressão, bem como auxiliará em discussões e futuros estudos referentes à temática. partindo dessa preposição, para nortear o estudo, questiona-se: como o conceito sp é empregado nas produções científicas? qual a base contextual, os termos substitutos e os conceitos relacionados com o conceito sp? portanto, objetiva-se analisar a evolução do conceito sp empregado nas produções científicas sob a visão evolucionária de rodgers. método evolucionário de rodgers: referencial teórico e metodológico o método evolucionário de análise conceitual —outra denominação para o método evolucionário de rodgers— é caracterizado por considerar os aspectos contextuais como influenciadores do conceito de determinado termo. trata-se de um processo cíclico e conduzido por três elementos: significado (significance), uso (use) e aplicação (application). com outras palavras, o significado de determinado conceito depende do seu uso e aplicação (6). o método evolucionário de rodgers corresponde a um modelo indutivo e descritivo utilizado para investigar o consenso e o conhecimento histórico de determinado conceito (6). é desenvolvido em seis etapas, apresentadas no quadro 1. etapas do método evolucionário de rodgers 1. definir o conceito de interesse e as expressões associadas. 2. selecionar o campo para a coleta de dados. 3. destacar os atributos do conceito e bases contextuais (antecedentes e consequentes). 4. analisar as características do conceito (termos substitutos e conceitos relacionados, por exemplo). 5. identificar, se necessário, um exemplo de conceito. 6. determinar as implicações e hipóteses para o conceito. quadro 1. etapas do método evolucionário de rodgers: desenvolvimento contínuo e cíclico do conceito (2000) fonte: adaptado de rodgers (2000). 525 a análise do conceito segurança do paciente: a visão evolucionária de rodgers l kisna yasmin andrade alves y otros para este estudo, definiu-se como conceito de interesse a sp na perspectiva dos estudos publicados e indexados acerca da sp no campo de coleta de dados banco de teses da coordenação de aperfeiçoamento de pessoal de nível superior (capes). escolheu-se esse banco pela disposição de produções com discussões mais complexas e detalhadas sobre as temáticas elegidas. o seguimento da pesquisa pautou-se em um protocolo de pesquisa, o qual sistematizou a pesquisa, a leitura reflexiva-críticaindutiva e, por fim, a análise conceitual. o protocolo de pesquisa é constituído por oito indicadores de coleta de dados: referência; instituição de ensino superior; ano; atributos/conceito; base conceitual —antecedentes e consequentes—; termos substitutos; conceitos relacionados. observa-se que esses indicadores representam os do método evolucionário de rodgers, como supracitado. assim, a pesquisa no banco de teses da capes foi desenvolvida nos meses de março a junho de 2013, mediante o campo “assunto”, por meio do uso do descritor sp, pesquisa na modalidade “expressão exata”. não se determinou delimitação temporal de publicação para a seleção das produções científicas já que o principal objetivo é desenvolver uma análise conceitual. os estudos foram selecionados a partir dos critérios de inclusão —estudos do tipo dissertação ou teses disponíveis eletronicamente, na íntegra e que abordem a expressão segurança do paciente em seus títulos ou resumos— e critérios de exclusão —estudos que não abordem o tema segurança do paciente de forma a contemplar os indicadores de coleta de dados—. os indicadores de coleta de dados foram norteados pelas definições e questionamentos do método evolucionário de rodgers, apresentados no quadro 2. conceituando a segurança do paciente a amostra é composta por oito produções científicas —quatro dissertações de mestrado e quatro teses de doutoramento—, as quais proporcionaram concretizar a análise contextual do conceito sp à luz do método evolucionário de rodgers. antecedentes e consequentes do conceito segurança do paciente o conceito sp foi antecedido, na perspectiva da visão evolucionária de rodgers, por diversas situações, eventos ou fenômenos. as produções mostraram que os índices dramáticos de mortes quadro 2. itens, conceitos e questionamentos da análise conceitual da expressão segurança do paciente à luz do método evolucionário de rodgers (2013) item analisado conceito questionamento antecedentes representam as situações, eventos ou fenômenos que foram antecessores do conceito de interesse. quais eventos contribuíram para o surgimento da expressão segurança do paciente? consequentes correspondem aos resultados do emprego do fenômeno analisado. quais as consequências após a aplicação da expressão segurança do paciente? termos substitutos utilização de diversas palavras ou expressões no decorrer do corpo do texto. quais as palavras ou expressões que substituem a expressão segurança do paciente? conceitos relacionados correspondem às suposições filosóficas e à rede de outros conceitos que permitem a formulação de um significado para o fenômeno estudado. quais as suposições filosóficas que formulam o significado da expressão segurança do paciente? atributos/conceito definição real do termo, bem como as expressões ou palavras utilizadas para representarem os fenômenos. como os autores conceituam a sp? quais as principais características apresentadas pelos autores acerca da sp? fonte: adaptado de rodgers (2000). 526 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 evitáveis são decorrentes de procedimentos cirúrgicos e anestésicos, infecções hospitalares, erros na administração de medicamentos e outros danos inerentes do processo de cuidado, foram motivadores para o fomento de pesquisas referente à temática (7-10) e discussão desse conceito. o relatório to err is human (errar é humano), elaborado pelo comitê para a qualidade do cuidado à saúde na américa, publicado em 2000, foi uma importante situação que contribuiu para a conceituação da sp (11-14), uma vez que apresenta a frequência de eventos adversos no cuidado e enfatiza que pessoas que trabalham em sistemas complexos estão susceptíveis a cometer erros e, portanto, é necessária a mudança da cultura de culpa, a qual está centrada no erro individual e reparos de curta duração, o que converge para o aprendizado com base nos erros (1). o quadro 3 apresenta os principais antecedentes e consequentes evidenciados nas produções científicas. termos substitutos e conceitos relacionados da segurança do paciente os termos substitutos e os conceitos relacionados correlacionam-se com os aspectos inerentes do processo de cuidado e abrangem desde os princípios medulares do cuidado até o nível de satisfação dos envolvidos. nessa perspectiva, o quadro 4 revela os principais termos substitutos relacionados com as produções científicas. no que diz respeito aos conceitos relacionados com a sp, pode-se categorizar três grupos de suposições filosóficas: 1) suposição de processo de trabalho; 2) suposição de educação e 3) suposição de avaliação em saúde. suposição de processo de trabalho as suposições de processo de trabalho perpassam desde os princípios éticos até a satisfação dos pacientes e profissionais. assim, a ética, os aspectos legais, a organização hospitalar e de profissionais, a elaboração e uso de protocolos, o trabalho em equipe, os recursos tecnológicos, as intervenções baseadas em evidências e o fortalecimento da comunicação entre profissionais são condições inerentes para a sp (8-9). articulada a essa suposição, cita-se, também, o estresse vivenciado pelos profissionais (9), em especial, aqueles que atuam no serviço público de saúde. diante disso, reflete-se sobre o cuidar de si ao cuidar do outro, conceitos atuais e que abordam a importância dos profissionais adotarem uma relação saudável consigo e, assim, colaborarem com a melhoria da saúde do outro (15). acredita-se que, ao cuidar de si, o profissional adota uma atitude que reflete em sua prática e possibilita a sp. suposição de educação as suposições educativas, por sua vez, reforçam a educação como eixo basilar para a construção de ambiente e instrumentos quadro 3. principais antecedentes e consequentes do conceito sp (2013) antecedentes consequentes n. do estudo índices dramáticos de mortes evitáveis + danos inerentes do processo de cuidado + relatório to err is human elaboração de estratégias e recomendações para a sp. eliminações de barreiras culturais para a sp. 8 trabalho seguro e ético. ambiente seguro. bem-estar profissional. melhoria da sobrevida dos pacientes. melhoria emocional dos envolvidos. 9, 12 orientação profissional de técnicas corretas. 10, 13 fortalecimento da cultura de segurança. 7 proteção integral da saúde. 14 fonte: adaptado de rodgers (2000). 527 a análise do conceito segurança do paciente: a visão evolucionária de rodgers l kisna yasmin andrade alves y otros para a sp. os estudos elucidam a importância da gestão do conhecimento, das respostas não punitivas aos erros, da educação para o cuidado seguro, da tecnologia para a sp e dos sistemas de informações eficazes e sistemáticos (10). suposição de avaliação em saúde a avaliação em saúde mediante a tríade estrutura —processo e resultado de donabedian—, o programa nacional de avaliação de serviços de saúde, a acreditação hospitalar, a notificação dos eventos adversos e a atuação da vigilância sanitária (7-8,11-14) compõem o grupo da suposição de avaliação em saúde. atributos e conceitos da segurança do paciente de modo geral, observa-se que as produções científicas elegem conceitos apresentados por entidades internacionais como a oms, a agency for healthcare research and quality, institute of medicine, the canadian patient safety dictionary e advisory committee on the safety of nuclear installations. os atributos e os conceitos da sp podem ser categorizados em três grupos: elementos, faces conceituais e processos (figura 1). assim, a sp é compreendida como um elemento fundamental para a qualidade da assistência, como também o princípio basilar para o cuidado do paciente, que constitui, portanto, como um conjunto de ações e esforços complexos que ajudam na melhoria da segurança dos fatores ambientais e gerenciamento de riscos, como a segurança no manuseamento de medicamentos, equipamentos, prática clínica e ambiente de cuidado (8, 10). a redução, a um mínimo aceitável, ou ausência do risco de um dano —conceituado como prejuízo à estrutura ou função do corpo na unidade física-social-psicológica decorrente de efeito deletério, como doença, lesão, disfunção, incapacidade, sofrimento e morte— à saúde do paciente, representa uma das faces conceituais da sp. compreende-se que essa expressão é um produto de combinações multifatoriais organizacionais, individuais, grupais e de pacientes. assim, evidencia-se a necessidade de adaptação das instituições de saúde aos riscos humanos, como também aqueles referentes às condições de trabalho. é fundamental, com outras palavras, o “manejo do ato inseguro” (9, 12-14). além da ideia de prevenção de lesões acidentais, a sp relaciona-se com a estabilização de sistemas e processos operacionais que minimizem a probabilidade do erro e a interceptação destes quando eles ocorrem (7, 11); isso representa, portanto, uma norma, uma atitude, uma crença, uma prática, uma política, um valor, um comportamento da equipe, da instituição, do paciente (7, 14) e uma dimensão da qualidade do cuidado (11). considerações finais a análise conceitual das produções científicas na perspectiva da visão evolucionária de rodgers acerca da sp demonstrou as múltiplas faces e interfaces do conceito, as quais abarcam desde políticas governamentais até a cultura dos profissionais e pacientes acerca da prevenção dos danos inerentes ao processo de cuidar. quadro 4. termos substitutos do conceito sp (2013) fonte: elaboração própria. termos substitutos n. do estudo 1. atributo que expressa a qualidade do cuidado 8 2. princípio fundamental do cuidado 8, 10 3. segurança no cuidado à saúde 8, 14 4. assistência segura 10 5. prática segura 11 6. segurança 7, 14 7. cultura de segurança 7, 10 figura 1. atributos e conceitos da sp (2013) fonte: elaboração própria. 528 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 aquichan issn 1657-5997 de tal modo, a identificação desses aspectos permite compreender e melhor intervir no contexto da insegurança do paciente, o que fundamenta novos estudos e redirecionamento de outros. percebe-se que a sp perpassa um ambiente com riscos eliminados ou ausentes à saúde do paciente, mas alcança, por exemplo, gestão, serviços de saúde e profissionais organizados para atuar diante do erro. afinal, “to err is human”. assim, a sp é conceituada como um princípio e um qualificador do cuidado, concretizado a partir de medidas estruturais, organizacionais, gerenciais, de responsabilidade e formação profissional que anteparem as possibilidades de erros e, simultaneamente, garantam a satisfação do binômio paciente-profissional. a partir dessas concepções, as implicações deste estudo convergem para a promoção de reflexões acerca da temática, como também o embasamento conceitual para os diversos estudos acerca da sp, independentemente de sua metodologia. adicionalmente, deseja-se fortalecer a cultura da sp e desmotivar respostas punitivas ante os erros individuais. referências 1. sousa p, mendes w (orgs.). segurança do paciente: criando organizações de saúde seguras. rio de janeiro: ead/ensp; 2014. 2. ministério da saúde (br). portaria 529, de 1º de abril de 2013. institui o programa nacional de segurança do paciente (pnsp) [internet]. ministério da saúde; 2013 [acesso em 23 maio de 2015]. disponível em: http://bvsms.saude.gov.br/ bvs/saudelegis/gm/2013/prt0529_01_04_2013.html 3. wachter rm. compreendendo a segurança do paciente. porto alegre: artmed; 2010. 4. organização mundial de saúde. hacia una atención hospitalaria más segura [internet]. genebra; 2010 [acesso em 26 maio de 2015]. disponível em: http://www.who.int/patientsafety/research/ibeas_report_es.pdf 5. sousa p, mendes w (orgs.). segurança do paciente: conhecendo os riscos nas organizações de saúde. rio de janeiro: ead/ensp; 2014. 6. rodgers bl. concept analysis: an evolutionary. em: rodgers bl, knafl ka. concept developmente in nursing. 2ª ed. philadelphia: saunders; c2000. p. 77-101. 7. batalha emss. a cultura de segurança do paciente na percepção de profissionais de enfermagem de um hospital universitário [dissertação]. são paulo: escola de enfermagem da universidade de são paulo; 2012. 154 f. 8. teixeira tcat. análise de causa raiz de incidentes relacionados à segurança do paciente na assistência de enfermagem em unidades de internação, de um hospital privado, no interior do estado de são paulo [tese]. ribeirão preto: universidade de são paulo. escola de enfermagem de ribeirão preto; 2012. 236p. 9. gimenes fre. a segurança de pacientes na administração de medicamentos em uma unidade de terapia intensiva de um hospital geral do interior paulista: a abordagem restaurativa em saúde [doutorado]. ribeirão preto: universidade de são paulo; 2011. 231p. 10. paese f. cultura da segurança do paciente na atenção primária à saúde [dissertação]. florionópolis: universidade federal de santa catarina; 2010. 181 p. 11. capucho hc. sistemas manuscrito e informatizado de notificação voluntária de incidentes em saúde como base para a cultura de segurança do paciente [tese]. ribeirão preto: escola de enfermagem de ribeirão preto; 2012. 155p. 12. dias mae. segurança do paciente: rastreamento de resultados adversos no sistema de informação hospitalar (sih-sus) [dissertação]. rio de janeiro: fundação oswaldo cruz; 2010. 74p. 13. nascimento nb. segurança do paciente: violação às normas e prescrições em saúde [doutorado]. rio de janeiro: fundação oswaldo cruz; 2010. 183p. 14. wegner w. a segurança do paciente nas circunstâncias de cuidado: prevenção de eventos adversos na hospitalização infantil [doutorado]. porto alegre: universidade federal do rio grande do sul; 2011. 156p. 15. amorim, kpc. o cuidado de si para o cuidado do outro. revista bioethikos. 2013; 7 (4): 437441. 30 41 intervencion educativa para enfermeria.indd 30 aquichan issn 1657-5997 lina maría vargas-escobar1 intervención educativa para enfermería: cuidado espiritual durante la enfermedad crónica 1 orcid.org/0000-0003-0052-5467. universidad el bosque, colombia. lmvargase@unbosque.edu.co recibido: 11 de agosto de 2015 enviado a pares: 23 de septiembre de 2016 aceptado por pares: 10 de junio de 2016 aprobado: 13 de septiembre de 2016 doi: 10.5294/aqui.2017.17.1.4 para citar este artículo / to reference this article / para citar este artigo vargas-escobar lm. intervención educativa para enfermería: cuidado espiritual durante la enfermedad crónica. aquichan. 2017;17(1):30-41. doi: 10.5294/aqui.2017.17.1.4 resumen objetivos: evaluar la efectividad de la intervención educativa cuidado espiritual de enfermería: integralidad del ser humano en el cuidado en personal de enfermería que trabaja con personas con enfermedad crónica. materiales y método: se diseñó una intervención educativa para fortalecer la percepción de la espiritualidad y el cuidado espiritual del personal de enfermería. se planteó un diseño cuasi experimental, con grupo control y experimental y evaluación pre y posprueba. participaron enfermeras y auxiliares de enfermería de tres instituciones clínicas, seleccionadas en un muestreo no probabilístico, por conveniencia y asignación 1:1 para el grupo experimental (n = 112) y el control (n = 110). resultados: la intervención modificó significativamente la percepción final total de la espiritualidad y el cuidado espiritual (p ≤ 0,016), con un tamaño del efecto d = 0,4 y una p = 0,84. fue efectiva en modificar significativamente la percepción de la espiritualidad y el cuidado espiritual total (p ≤ 0,001), así como las subescalas de percepción de la espiritualidad, cuidado espiritual y cuidado personalizado (p ≤ 0,001); sin embargo, la subescala percepción del cuidado espiritual final no presentó diferencias significativas al comparar los grupos (p ≤ 0,024). grupos (p ≤ 0,024). conclusiones: la intervención fue efectiva en modificar la percepción de la espiritualidad y el cuidado espiritual. debe comprobarse su efectividad en entornos diferentes al de este estudio y se evidencia la necesidad de capacitar al personal de enfermería en esta temática a fin de que este cuidado se implemente en la práctica en el cuidado de personas en situaciones de enfermedad crónica. palabras clave investigación en evaluación de enfermería; atención de enfermería; espiritualidad; personal de enfermería; enfermedad crónica (fuente: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 30-41 31 intervención educativa para enfermería: cuidado espiritual durante la enfermedad crónica l lina maría vargas-escobar año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 30-41 educational intervention in nursing: spiritual care during chronic illness abstract objective: evaluate the effectiveness of the educational intervention known as spiritual nursing care: integrality of the human being in the care provided by nursing personnel working with chronically ill patients. method: an educational intervention was designed to strengthen the perception of spirituality and the spiritual care provided by the nursing staff. a quasi experimental design was proposed, with a control and experimental group and pre and post-test evaluation. nurses and nursing assistants from three clinical institutions, chosen through non-probabilistic sampling, were selected 1:1 for convenience and allocation to the experimental group (n = 112) and the control group (n = 110). results: the intervention significantly modified the total final perception of spirituality and spiritual care (p ≤ 0.016), with an effect size of d = 0.4 and p = 0.84. it was effective in significantly changing the perception of spirituality and total spiritual care (p ≤ 0.001), as well as the subscales concerning perception of spirituality, spiritual care and personalized care (p ≤ 0.001); however, the subscale on perception of final spiritual care showed no significant differences when the groups were compared (p ≤ 0.024). groups (p ≤ 0.024). conclusions: the intervention was effective in modifying the perception of spirituality and spiritual care. however, its effectiveness should be checked in environments different from the one in this study. moreover, the need to train nurses in this area is evident, so spiritual care can be implemented in practice as part of the care provided to those with a chronic illness. keywords research on nursing evaluation; nursing care; spirituality; nursing staff; chronic illness (source: decs, bireme). 32 aquichan issn 1657-5997 intervenção educativa para enfermagem: cuidado espiritual durante a doença crônica resumo objetivos: avaliar a efetividade da intervenção educativa “cuidado espiritual de enfermagem: integralidade do ser humano no cuidado em pessoal de enfermagem que trabalha com pessoas com doença crônica”. materiais e método: foi desenhada uma intervenção educativa para fortalecer a percepção da espiritualidade e do cuidado espiritual do pessoal de enfermagem. propôs-se um desenho quaseexperimental, com grupo controle e experimental, e avaliação pré e pós-teste. participaram enfermeiras e auxiliares de enfermagem de três instituições clínicas, selecionadas numa amostra não probabilística, por conveniência e atribuição 1:1 para o grupo experimental (n = 112) e para o grupo controle (n = 110). resultados: a intervenção modificou de forma significativa a percepção da espiritualidade e o cuidado espiritual total (p ≤ 0,001) bem como as subescalas de percepção da espiritualidade, cuidado espiritual e cuidado personalizado (p ≤ 0,001); contudo, a subescala percepção do cuidado espiritual final não apresentou diferenças significativas ao comparar os grupos (p ≤ 0,024). conclusões: a intervenção foi efetiva em modificar a percepção da espiritualidade e do cuidado espiritual. deve ser comprovada sua efetividade em contextos diferentes dos deste estudo; evidencia-se a necessidade de aperfeiçoar o pessoal de enfermagem nessa temática para que esse cuidado seja implantado na prática no cuidado de pessoas em situações de doença crônica. palavras chave atenção de enfermagem; doença crônica; espiritualidade; pessoal de enfermagem; pesquisa em avaliação de enfermagem (fonte: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 30-41 33 intervención educativa para enfermería: cuidado espiritual durante la enfermedad crónica l lina maría vargas-escobar introducción la espiritualidad es una dimensión presente en cada persona que involucra ideas filosóficas sobre la vida, su significado y su propósito; “es subjetiva, compleja e intangible y permea y vitaliza todas las otras dimensiones del ser humano, de manera tal que todos los valores, pensamientos, comportamientos, decisiones, experiencias y preocupaciones (de la persona) están relacionadas con ella” (1). es una fuerza que permite el crecimiento personal y la autotrascendencia, lo cual implica una profunda conciencia de sí mismo (en una conexión intrapersonal), la relación con los demás y el entorno natural (en una conexión interpersonal) y con el dios invisible o poder más grande (en una conexión transpersonal) (2,3). la palabra espiritualidad, que muchas veces se utiliza como sinónimo de religión o como variables psicológicas, es mucho más amplia y compleja. es una integración del cuerpo, la mente y el espíritu en la totalidad de la persona; es un fenómeno multidimensional que relaciona lo corpóreo e incorpóreo, lo abstracto, lo intangible y lo subjetivo y que permite la paz, la armonía, la fortaleza, la reciprocidad, la confianza, la esperanza, el vínculo y una forma de vida para encontrar significado (4). diferentes estudios documentan la importancia de la espiritualidad durante las situaciones de enfermedad crónica, por ejemplo, en pacientes con cáncer, diabetes, dolor crónico, enfermedad cardiovascular, hemodiálisis y vih/sida, así como en los procesos de duelo y rehabilitación. la espiritualidad mejora la respuesta inmunológica, la adaptación frente a situaciones de diagnóstico y tratamiento, la toma de decisiones, la perspectiva y crecimiento personal, la resolución de problemas y la responsabilidad frente al manejo de la enfermedad (5-8). igualmente, la espiritualidad permite un mejor afrontamiento del dolor, así como el manejo de los sentimientos de desesperación, depresión, soledad y ansiedad asociados a la cronicidad. promueve una mayor satisfacción con la vida, la adaptación psicológica, el equilibrio personal, la autoestima y una sensación de significado, propósito, esperanza y confianza (6,9). por otro lado, se ha establecido que la persona con enfermedad crónica vive una situación de vulnerabilidad personal y social secundaria a los cambios producidos en su vida por causa de la enfermedad, en la cual se producen periodos de remisión y recaída, alteraciones en los roles, en las redes sociales, en la escala de valores, en el equilibrio familiar, entre otros. cuando esto ocurre, la persona entra en un proceso de confrontación con su situación y consigo misma, que la lleva a experimentar una reevaluación de su propia espiritualidad en un proceso de tránsito en la búsqueda de significado, propósito y fortaleza (10). la espiritualidad proporciona respuestas a cuestionamientos personales, permite adquirir un nuevo significado de la vida y de la situación que se afronta y, en este sentido, la persona con enfermedad crónica aprende a vivir y aceptar su condición, pues adquiere bienestar espiritual y desarrolla una nueva perspectiva espiritual que influirá en sus dimensiones físicas y psicosociales (11). el hacerse consciente de la propia espiritualidad genera en la persona una serie de necesidades espirituales que deben ser resueltas; por lo tanto, la enfermera y el auxiliar de enfermería, como unidad de cuidado durante las situaciones de cronicidad y persona cercana al paciente y su familia, son responsables de la atención y promoción de estrategias espirituales como parte del cuidado integral. su compromiso en una relación de confianza con el otro facilitará la exteriorización de inquietudes espirituales que permitirán proveer cuidado espiritual de manera oportuna y fortalecer la salud espiritual de la persona, apoyándola en las crisis que genera la enfermedad crónica. sin embargo, a pesar de la importancia del cuidado espiritual de enfermería en estos casos, la evidencia señala la baja participación del personal de enfermería en el cuidado espiritual, resultado de falta de educación y formación en la temática (12,13). en la revisión de artículos efectuada para el presente estudio, se encontraron nueve trabajos que muestran experiencias educativas en la temática; seis muestran la efectividad de las intervenciones aplicadas, tres de ellos utilizaron un único grupo con medición preprueba y posprueba y los otros tres incluyeron dos grupos (experimental y control) con pre y posprueba. no obstante, la duración de estas intervenciones es usualmente muy larga para ser implementadas en enfermeras de la práctica clínica, cuya disponibilidad de tiempo es limitada; además, el tamaño de las muestras en que fueron probadas no fue lo suficientemente grande. el presente estudio es el primero en latinoamérica que se enfoca en el abordaje de la dimensión espiritual de las personas con enfermedad crónica y se dirige a enfermeras y auxiliares de enfermería de la práctica clínica que no cuentan con suficiente tiempo para recibir la capacitación (14-22). 34 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 por lo anterior, y considerando la necesidad de mejorar la percepción del personal de enfermería sobre el cuidado espiritual y la falta de estrategias en el medio para recibir formación en la temática, se planteó el diseño de una intervención educativa para fortalecer la percepción de la espiritualidad y el cuidado espiritual que resulte efectiva y viable en la práctica. el presente estudio tuvo como objetivo evaluar la efectividad de la intervención educativa titulada cuidado espiritual de enfermería: integralidad del ser humano en el cuidad en el personal de enfermería que trabaja con personas con enfermedad crónica, a fin de evaluar si esta fortalece su grado de percepción de la espiritualidad y el cuidado espiritual. la hipótesis alterna para el presente estudio fue la siguiente: la intervención educativa aplicada al personal de enfermería que trabaja con personas con enfermedad crónica es efectiva en modificar su percepción sobre la espiritualidad y el cuidado espiritual. la hipótesis nula fue la siguiente: la intervención educativa no modifica su percepción sobre la espiritualidad y el cuidado espiritual del personal de enfermería que trabaja con personas con enfermedad crónica. para esta investigación se concibe el cuidado espiritual como un encuentro intencionado y recíproco entre la enfermera y la persona con enfermedad crónica, en el cual se producen acciones y comportamientos dirigidos a satisfacer las necesidades espirituales y promover el bienestar y el desarrollo de la perspectiva espiritual personal existencial o religiosa (23). materiales y métodos el presente estudio es cuantitativo explicativo, cuasi experimental, con dos grupos (control y experimental) y evaluación con pre y posprueba. el grupo experimental recibió la medición inicial de la percepción de la espiritualidad y del cuidado espiritual con la escala de evaluación de la espiritualidad y el cuidado espiritual. posteriormente, le fue impartida la intervención educativa cuidado espiritual de enfermería: integralidad del ser humano en el cuidado y a los ocho y veinte días posteriores (media = 11,6 días; desviación estándar = 4,4) volvió a recibir la medición final con la misma escala. por su parte, el grupo control recibió una intervención en la temática de cuidado seguro que guardó las mismas características que la intervención del grupo experimental. se decidió abordar el tema de cuidado seguro, debido a que no se encontraron intervenciones específicas de cuidado espiritual realizadas por enfermería en el contexto colombiano o latinoamericano, contra las cuales se pudiera efectuar la comparación tradicional. así mismo, el tema de cuidado seguro resultó de interés en las instituciones y permitió observar el efecto de la intervención de cuidado espiritual que se estaba evaluando. la población estuvo conformada por el personal de enfermería que trabajaba o trabajó con personas en condición de enfermedad crónica en tres instituciones clínicas de la ciudad de bogotá, colombia. estas fueron de carácter privado, de tercer y cuarto nivel de atención, que aceptaron participar en el estudio. una de ellas fue un hospital universitario, con principios católicos y ubicado en la zona centro de la ciudad. otra fue una clínica ubicada en el sur de bogotá y que es centro de referencia para estratos medios y bajos de la ciudad y sus alrededores. la última es una clínica ubicada en la zona norte, que atiende personas de estratos medios y altos. la muestra se determinó a partir del procedimiento de comparación de medias y se estableció un tamaño de muestra n = 100 para cada grupo (experimental y control), con α = 0,01; β = 0,05; σ = 22,67 y ∆ = 10. el estudio inició con un muestreo probabilístico aleatorio; sin embargo, no fue posible darle continuidad, debido a las dificultades para aplicarlo en las tres instituciones de la misma manera, razón por la cual quedó por conveniencia y asignación 1:1 para cada grupo. el análisis final se realizó con 112 participantes en el grupo experimental y 110 en el control (figura 1). la pérdida de sujetos estuvo alrededor del 14,4 %, específicamente, por cambio de lugar de trabajo, de servicio o de turno, que no permitieron localizar a la enfermera en el momento de aplicar la segunda medición o posprueba. figura 1. muestreo del diseño cuasi experimental: reclutamiento, asignación de la intervención, seguimiento y análisis fuente: elaboración propia. 35 intervención educativa para enfermería: cuidado espiritual durante la enfermedad crónica l lina maría vargas-escobar los criterios de inclusión para el estudio fueron: enfermeras o auxiliares de enfermería que trabajaran o hubieran trabajado con personas en condición de enfermedad crónica, con un tiempo mínimo de experiencia en el área de seis meses, pertenecientes a cualquiera de las tres instituciones clínicas donde se llevó a cabo el estudio. los criterios de exclusión fueron: que la enfermera se encontrara participando en cualquier capacitación relacionada con temas sobre el cuidado o la espiritualidad durante el tiempo del estudio y que no logrará culminar la participación completa en el estudio (preprueba, intervención educativa y posprueba). para mantener la validez interna del estudio y establecer estrategias de control se consideraron los siguientes aspectos: verificación de la no participación en otra intervención educativa, búsqueda de equivalencia entre las instituciones participantes y su personal de enfermería, asignación proporcional en número para los dos grupos, observación en el grupo control de efectos derivados de la aplicación del cuestionario para así determinar si al final se presentaron efectos derivados de la aplicación de la preprueba, incorporación de muestras mayores a las requeridas para suplir las pérdidas de seguimiento en el estudio y solicitud de discreción a los participantes terminada cada sesión con los colegas que aún no habían asistido a la intervención educativa correspondiente. es importante manifestar que los participantes pudieron experimentar alguna vivencia espiritual personal con sus pacientes o familiares a cargo durante el estudio, que suscitara mayor sensibilidad espiritual, aspecto que no pudo ser controlado o mitigado. por otro lado, la validez externa del estudio se determinó por la confiabilidad del diseño y el grado de generalización de los resultados en la población del personal de enfermería de las instituciones que trabajan con personas con enfermedad crónica y que presentan las mismas características contempladas por el personal de enfermería del presente estudio. es importante mencionar que la investigadora estuvo en los procesos de medición e intervención, para lo cual trató de mantenerse neutral y en estabilidad emocional para impartir de la misma forma la información ofrecida a ambos grupos. la intervención educativa de cuidado espiritual fue diseñada de tal manera que permitiera reproducirla en otras poblaciones de enfermeras y evaluar su efectividad en cada caso. la intervención educativa cuidado espiritual de enfermería: integralidad del ser humano en el cuidado es una estrategia formativa de una sesión, dirigida a fortalecer la percepción de la espiritualidad y el cuidado espiritual del personal de enfermería que trabaja con personas en condición de enfermedad crónica. las temáticas que aborda son la realidad de la persona con enfermedad crónica, la conceptualización de la espiritualidad y el cuidado espiritual y las formas y momentos para proporcionar cuidado espiritual. la intervención es impartida por una enfermera mediante diapositivas, un video y un separador con información relacionada, y puede ser evaluada por medio de la escala de evaluación de la espiritualidad y el cuidado espiritual (23). el protocolo de la intervención educativa contó con dos opciones de aplicación, dependiendo de si se realizaba en un salón o auditorio o si debía aplicarse en el lugar de trabajo, es decir, en los servicios de enfermería. en la figura 2 se observa el protocolo implementado en el salón o auditorio. figura 2. protocolo de la intervención educativa en cuidado espiritual fuente: elaboración propia. 36 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 el protocolo de intervención aplicado en el servicio o lugar de trabajo del personal de enfermería guarda las mismas características que el mostrado en la figura 2, solo que se realiza con la ayuda de un computador portátil y es la investigadora quien se dirige a cada uno de los servicios de acuerdo con la hora establecida para el encuentro. además de lo anterior, se analizaron algunas variables reportadas por la literatura que podían ser consideradas intervinientes o confusas en las percepciones del personal de enfermería que eran imposibles de controlar. dichas variables son: nivel educativo, experiencia clínica, tiempo de práctica en la especialidad actual, educación sobre cuidado espiritual durante la formación como enfermera, espiritualidad personal, religiosidad y bienestar espiritual personal (24-26). así mismo, para mostrar mayor evidencia del efecto de la intervención educativa se calcularon los estadísticos d de cohen y eta cuadrado parcial. los datos del estudio se registraron en una base de datos de excel y, posteriormente, se analizaron en el programa spss versión 22, licenciado por la universidad nacional de colombia. el análisis estuvo organizado en cuatro partes: 1) análisis descriptivo de la muestra total y por grupos (experimental y control), en la cual se emplearon estadísticas descriptivas de tendencia central (mediana, media, desviación típica, valor mínimo y máximos); 2) análisis de normalidad de los datos con la prueba de kolmogrov-smirnov; 3) análisis inferencial de la muestra total y por grupos usando wilcoxon, u de mann-whitney, kruskallwallis y spearman, p ≤ 0,05, y 4) estimación del tamaño del efecto usando eta cuadrado parcial y d de cohen. para estos análisis se optó por llevar la escala total y cada subescala a una métrica entre 0 y 100, con el fin de poder efectuar comparaciones entre ellas. para la intervención se contemplaron los aspectos éticos universales de investigación en seres humanos. se mantuvo la confidencialidad y privacidad de los participantes, su autonomía para decidir si participar o no y retirarse cuando lo desearan, y se dejó copia del consentimiento informado con información sobre el estudio. así mismo, se obtuvo el aval del autor de la escala, así como del comité de ética de la facultad de enfermería de la universidad nacional de colombia y de las tres instituciones participantes en el estudio. medición la medición de la efectividad de la intervención educativa de cuidado espiritual se realizó a partir de la escala de evaluación de la espiritualidad y el cuidado espiritual propuesta por mcsherry, draper y kendrick (23). la escala tipo likert (donde uno es totalmente en desacuerdo y cinco es totalmente de acuerdo) tiene 17 ítems que miden la percepción de la espiritualidad y el cuidado espiritual del personal de enfermería en cuatro subescalas: percepción de la espiritualidad, del cuidado espiritual, de la religiosidad y del cuidado personalizado. fue adaptada culturalmente y sometida a pruebas de validez y confiabilidad por parte de la investigadora del estudio (27). la validez facial arrojó un porcentaje de acuerdo del 92 % en los criterios de claridad, comprensión y precisión. la validez de contenido, a través del índice de validez de contenido, fue de 0,99. la validez del constructo con rotación varimax reportó una estructura de cuatro factores, similar a la propuesta inicialmente por el autor, y una consistencia interna por alfa de cronbach de 0,73. resultados análisis descriptivo de la muestra total y por grupos (experimental y control) en su mayoría, el personal de enfermería participante está compuesto por mujeres (91,9 %) entre los 26 y los 35 años de edad (59,5 %). la experiencia laboral promedio fue de 10,3 años (con un mínimo de un año y un máximo de 34 años). el 100 % tenía experiencia en el área asistencial, seguida por la administrativa, con un 14,9 %. casi todas expresaron tener experiencia en pacientes con enfermedades de tipo cardiovascular, renal, oncológico, osteomuscular, respiratorio y, en menor proporción, en trasplantes, ginecobstetricia, pediatría, quirúrgicas y metabólicas (39,9 %). al comparar la caracterización entre el grupo experimental y el grupo control, se encontró que ambos presentan características similares en todas las variables, lo que implica que el personal de enfermería participante no presentaba diferencias significativas en ambos grupos (p = 0,951), como se observa en la tabla 1. percepción de la espiritualidad y el cuidado espiritual del personal de enfermería que trabaja con personas con enfermedad crónica comparación en el puntaje de la percepción inicial y final de la espiritualidad y el cuidado espiritual en el grupo experimental y en el grupo control. el puntaje de la percepción final presenta 37 intervención educativa para enfermería: cuidado espiritual durante la enfermedad crónica l lina maría vargas-escobar un cambio hacia puntajes superiores posteriores a la intervención educativa (mediana = 79,4; desviación estándar = 10), en comparación con el de la percepción inicial (mediana = 75; desviación estándar = 10,4) en el grupo experimental. así mismo, al comparar la percepción inicial y final en las subescalas en este grupo, se encontró que las cuatro presentaron mejoras en las puntuaciones de los participantes hacia valores superiores, sobre todo en los puntajes del 25 % y el 75 % de los participantes. en cuanto a las puntuaciones en el grupo control en la percepción inicial (mediana = 75; desviación estándar = 8,9) respecto a la final (mediana = 76,4; desviación estándar = 9,8) se mantienen casi iguales. esto evidencia que no se presentan diferencias en la percepción de la espiritualidad y el cuidado espiritual posterior a la intervención sobre cuidado seguro. así mismo, al comparar la percepción inicial y final en las subescalas de este grupo, ninguna mostró cambios significativos en la puntuación inicial respecto a la final, a excepción de la subescala de percepción de la espiritualidad, que pasó de una mediana de 62,5 a una mediana de 81,2 posterior a la intervención en cuidado seguro, en la cuarta parte de los participantes. comparación en el puntaje de la percepción de la espiritualidad y el cuidado espiritual entre el grupo experimental y control. al comparar las puntuaciones de ambos grupos desde lo descriptivo, es posible establecer que mejoraron en el grupo experimental (establa 1. distribución del personal de enfermería respecto a las variables intervinientes o confusas del fenómeno de estudio fuente: elaboración propia. variable total grupo experimental n = 112 grupo control n = 111 núm. % núm. % núm. % nivel educativo técnico 73 33 34 30,4 39 35,1 pregrado 81 36,7 46 41,1 38 34,2 especialización 57 25,8 30 26,8 27 24,3 maestría 9 4,1 2 1,8 7 6,3 formación en pacientes con enfermedad crónica sí 121 54,5 65 58 57 51,4 no 100 45 47 42 53 47,7 inclinación religiosa católica 188 84,7 93 83 95 85,6 cristiana no católica 23 10,4 10 8,9 13 11,7 agnóstico o ateo 3 1,4 3 2,7 1 0,9 no responde 3 1,4 1 0,9 0 0 ninguna 2 0,9 5 4,5 2 1,8 recibió formación en cuidado espiritual sí 50 22,5 24 21,4 26 23,4 no 172 77,5 88 78,6 85 76,6 turno de trabajo mañana 79 35,6 27 24,1 52 46,8 tarde 56 25,2 32 28,6 25 22,5 noche 43 19,4 25 22,3 18 16,2 jornada ordinaria 36 16,2 22 19,6 14 12,6 otro 2 0,9 1 0,9 1 0,9 más de un turno 6 2,7 5 4,5 1 0,9 38 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 pecialmente las ubicadas entre el cuartil 25 y el 75), en contraste con las del grupo control, que se mantuvieron similares en todas las subescalas. igualmente, en la mayor parte de las subescalas se presentaron puntuaciones superiores luego de la intervención educativa en el grupo experimental respecto al grupo control, excepto por la percepción de la espiritualidad, donde las puntuaciones fueron mayores en el grupo control respecto al experimental. análisis inferencial de la muestra total y por grupos (experimental y control). para el análisis inferencial se aplicó la prueba kolmogrov-smirnov, que indicó que los datos de la variable dependiente (percepción de la espiritualidad y el cuidado espiritual), no presentaban una distribución normal, por lo que se utilizaron estadísticos no paramétricos. en principio, se verificó que ambos grupos (experimental y control) estuvieran en las mismas condiciones antes de recibir la intervención correspondiente. con la u de mann-whitney no se mostraron diferencias significativas entre los dos grupos al inicio (mediana grupo experimental = 75; desviación estándar = 10; mediana del grupo control = 75; desviación estándar = 8,9; p > 0,05). después de la intervención educativa se compararon ambos grupos y se encontraron diferencias significativas en la distribución total (p = 0,002) en tres de las cuatro subescalas del instrumento: percepción de la espiritualidad (p = 0,16), de la religiosidad (p = 0,24) y del cuidado personalizado (p = 0,001). esto evidencia que la intervención educativa sí generó cambios significativos en la percepción de la espiritualidad y el cuidado espiritual del personal de enfermería del grupo experimental, con excepción de la subescala de percepción de cuidado espiritual, donde no se presentó una diferencia significativa (p = 0,73). comparación del total de la escala inicial y final del grupo experimental. continuando con el análisis, se comparó el mismo grupo antes de la intervención y después de esta, que cada uno recibió aplicando la prueba de wilcoxon. el personal de enfermería participante en el grupo experimental presentó una diferencia significativa entre el total de la escala inicial y el total de la escala final (p = 0,001), al igual que individualmente en las subescalas de percepción de la espiritualidad, cuidado espiritual y cuidado personalizado (p = 0,001). por su parte, la subescala percepción de la religiosidad no mostró un cambio significativo (p = 0,061). esto indica que la intervención educativa en cuidado espiritual es efectiva en mejorar de manera significativa la percepción de la espiritualidad y el cuidado espiritual total del personal de enfermería y en sus subescalas percepción de la espiritualidad, de la religiosidad y del cuidado personalizado. para el caso del grupo control, no se presentaron diferencias significativas en ninguna de las subescalas, ni en la escala total, luego de la intervención sobre cuidado seguro (p > 0,05). comparación entre la percepción de la espiritualidad, el cuidado espiritual del personal de enfermería y las variables influyentes o confusas. con la prueba kruskall-wallis no se encontraron diferencias significativas entre la percepción de la espiritualidad y el cuidado espiritual con las siguientes variables: nivel educativo, inclinación religiosa (a excepción de la variable percepción de la religiosidad inicial, que sí mostró una diferencia significativa previa al inicio de la intervención, p = 0,015), formación en el cuidado de pacientes con enfermedad crónica (exceptuando las variables percepción del cuidado espiritual final [p = 0,044] y percepción del cuidado personalizado final [p = 0,031]), formación en cuidado espiritual y turno laboral del personal de enfermería. estimación del tamaño del efecto. con el objeto de mostrar el efecto de la intervención educativa en cuidado espiritual, se calcularon los estadísticos d de cohen y eta cuadrado parcial. para el correcto uso de los estadísticos se calculó la prueba de igualdad de varianzas de levene, que con un valor de p = 0,763 permite aceptar la hipótesis nula de igualdad de varianzas para los grupos control y experimental y cumplir así con el supuesto de homocedasticidad. además de lo anterior, también se verificó el supuesto de que el puntaje total del instrumento provenga de una distribución normal, lo cual se cumplió con la prueba de normalidad de shapiro-wilk. el efecto que presenta el grupo en el puntaje total posterior a la intervención es estadísticamente significativo, pues arroja un valor de p de 0,004 para el estadístico eta cuadrado parcial. adicionalmente, se puede comprobar cómo el efecto de pertenecer al grupo experimental o control es considerable, dado que explica el 83,6 %, es decir, la potencia observada de la variabilidad existente en el puntaje total final posterior a la intervención de cuidado espiritual. para apoyar lo encontrado, el resultado para el estadístico d de cohen fue de 0,4, que muestra una percepción del efecto de la intervención baja-media (28). discusión el presente estudio tuvo como objetivo general evaluar la efectividad de la intervención educativa en cuidado espiritual 39 intervención educativa para enfermería: cuidado espiritual durante la enfermedad crónica l lina maría vargas-escobar aplicado al personal de enfermería que trabaja con personas con enfermedad crónica. específicamente, al comparar las puntuaciones de la percepción inicial y final de la espiritualidad y el cuidado espiritual en el grupo experimental, puede decirse que se generó un cambio positivo en el grado de percepción de los participantes en la escala total y en tres de las cuatro subescalas. solo la subescala de percepción de la religiosidad no mostró una asociación significativa posterior a la intervención educativa (p = 0,061). esta subescala abarca tres ítems planteados de manera inversa o negativa y aborda aspectos como ir a la iglesia o a un lugar de culto religioso, la inclusión del arte, la creatividad y la expresión de sí mismo como parte de la espiritualidad, y la inclusión de ateos o agnósticos en la dimensión espiritual. es posible que otras variables como la cultura, el espacio que ocupa la religión en la vida de una persona, las necesidades espirituales, la religiosidad personal y algunas competencias de las enfermeras como la comunicación efectiva o la conciencia espiritual personal, entre otras, puedan influir en la percepción del personal de enfermería en la religiosidad (29). por otro lado, al comparar los grupos experimental y control al inicio de la intervención y al final, puede establecerse que los contenidos, así como el diseño de la intervención educativa, generaron una modificación efectiva de las percepciones de la escala total y en las subescalas de percepción de la espiritualidad, la religiosidad y el cuidado personalizado. se movilizaron ideas y sentimientos en torno a la temática, se estableció un lenguaje común y unos conceptos más definidos sobre el tema, y se creó una mayor conciencia sobre el papel de la espiritualidad en quienes viven una condición de cronicidad. respecto a la subescala cuidado espiritual, algunos posibles factores que pudieron influir en el resultado, de acuerdo con mcsherry y colaboradores y con el enfoque desarrollado en el video de la intervención educativa, es que el cuidado espiritual se define y delimita por actitudes y aptitudes puntuales que realiza la enfermera en la práctica (23). el personal de enfermería participante pudo haber aprendido a identificar que varias acciones de su práctica con las personas en situación de enfermedad crónica hacen parte de lo que se denomina cuidado espiritual. tal vez esto motivó parte de la diferencia significativa en la medición inicial respecto a la final en el interior del grupo experimental. sin embargo, a pesar de este aprendizaje y del reconocimiento de nuevas actitudes y aptitudes relacionadas con el cuidado espiritual, que son producto de participar en la intervención, el personal de enfermería podría, por diferentes motivos, tener dificultades para poner en práctica muchas de ellas. en este sentido, mcewen (30) describió algunas variables consideradas barreras en la percepción y el actuar en el cuidado espiritual: las institucionales o ambientales (relacionadas con restricciones o espacios físicos), las barreras individuales (relacionadas con aspectos personales de la enfermera), las barreras situacionales (propias del encuentro entre la enfermera y la persona) y las de conocimiento (formación sobre el cuidado espiritual). es importante agregar que, aun cuando las comparaciones estadísticas entre el grupo experimental y control en esta escala no muestran diferencias significativas, en el grupo experimental sí se generó un cambio que pudo deberse a la intervención educativa y quizás a otros factores que también pudieron influir. al final, esta comprobación debe efectuarse en estudios futuros mediante diseños correlacionales y pruebas de análisis multivariados. de otra manera, al comparar la intervención educativa cuidado espiritual de enfermería: integralidad del ser humano en el cuidado con otras intervenciones descritas en la literatura sobre el tema y generadas en los últimos años, se evidencia que tres de ellas incluyeron dos grupos (experimental y control) con pre y posprueba (19,21,22). estas tres intervenciones aportan hallazgos de interés para determinar la efectividad de las intervenciones, y pese a que el tiempo en que se llevan a cabo es muy largo y el tamaño de las muestras no es grande, cada estudio aporta algo novedoso, incluido el abordaje de un modelo teórico propio. en relación con esto último, el presente estudio es el primero en latinoamérica que se enfoca en el abordaje de la dimensión espiritual de las personas con enfermedad crónica y se dirige a enfermeras y auxiliares de enfermería de la práctica clínica, en quienes es limitada la disponibilidad de tiempo para recibir la capacitación. sin embargo, es importante anotar que todas estas propuestas educativas generadas hasta el momento deben aplicarse en entornos y contextos diferentes a las de su origen con el fin de determinar su efectividad. finalmente, al comparar la percepción de la espiritualidad, el cuidado espiritual del personal de enfermería y las variables influyentes o confusas, se encontró que las únicas relaciones fueron entre la percepción de la religiosidad inicial, que sí mostró una 40 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 diferencia significativa previa al inicio de la intervención con la inclinación religiosa (p = 0,015), y la formación en el cuidado de pacientes con enfermedad crónica en las variables percepción del cuidado espiritual final (p = 0,044) y percepción del cuidado personalizado final (p = 0,031). en cuanto a la religiosidad inicial, cada participante respondió de acuerdo con lo que creía y pensaba según su sistema de fe o adoración personal. por ello era posible que se presentara esta diferencia. respecto a la formación en el cuidado de pacientes con enfermedad crónica, este es un aspecto que debe considerarse. la percepción del cuidado espiritual se refiere a acciones y aptitudes de la enfermera, como escuchar, pasar tiempo con el otro, promover la privacidad y dignidad, mantener las prácticas religiosas y brindar cuidado mostrando cualidades como bondad y preocupación. así mismo, el cuidado personalizado asocia la dimensión espiritual con la necesidad de un cuidado personalizado en las propias creencias, valores, moral y relaciones (23). cuando una enfermera es formada en el cuidado de las personas que padecen enfermedades crónicas, se promueve en ella una competencia para desarrollar sensibilidad ante el significado de la enfermedad y la vivencia de la persona que afronta esta condición. conclusiones y recomendaciones • la intervención educativa fue efectiva en modificar la percepción de la espiritualidad y el cuidado espiritual total del personal de enfermería que trabaja con personas con enfermedad crónica, así como, de manera significativa, en las subescalas de percepción de la espiritualidad, del cuidado espiritual y del cuidado personalizado. • la investigación pone el relieve en la necesidad de formar y capacitar en el cuidado espiritual para el personal de enfermería que cuida de personas con enfermedad crónica, a fin de que este cuidado se implemente en la práctica y los pacientes reciban un cuidado integral de calidad y humano. • el estudio aporta información de interés sobre la espiritualidad y el cuidado espiritual en el contexto colombiano, que resulta novedoso si se considera que no existen otros estudios que informen sobre la manera en que el personal de enfermería aborda la dimensión espiritual en la práctica clínica, ni las percepciones que tienen sobre la espiritualidad y el cuidado espiritual en el entorno latinoamericano. • la efectividad de la intervención debe comprobarse en entornos diferentes al colombiano. referencias 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holist nurs pract. 2005;19(4):161-8. 10. reseœas (73-75) 73 el libro de la enfermera nubia posada gonzález presenta una interesante revisión teórica sobre temas de gran actualidad, que van desde la manipulación genética y las técnicas de reproducción asistida, hasta enfermedades como el sida. hace un valioso análisis de la relación de los conceptos y definiciones de persona y ser humano, recogida en la colección de cuadernos del programa regional de bioética de la ops, según la coherencia y el rigor argumentativo, sin la intención expresa de establecer juicios y sacar conclusiones sobre cada uno de los autores citados. la autora confronta, desde una perspectiva jurídica, antropológica, histórica, bioética y psicológica, las ideas, postulados y conceptos que la ops recopila en esta colección, y reafirma a través de toda la obra la dignidad de la persona. plantea diversos interrogantes, como “¿el ser humano es persona y, por lo tanto, sujeto de derecho, solo en algunas etapas y circunstancias de la vida?”. el libro ofrece al lector capítulos interesantes y de gran actualidad, como los siguientes: ¿cómo se está definiendo y tratando al ser humano?, ¿en qué consiste ser humano y ser persona? y análisis de lo que dicen que somos. la obra invita a una profunda reflexión, análisis y discusión acerca de temas y planteamientos de gran relevancia y actualidad, para todas las disciplinas que se ocupan del ser humano. maría clara quintero l. profesora asociada nubia posada gonzález universidad de la sabana consejo episcopal latinoamericano, esfera editores, 2003. ser humano y persona revista aquichan issn 1657-5997 año 4 nº 4 73-75 bogotá, colombia octubre 2004 74 el presente libro es una obra publicada por la academia americana de pediatría, dedicada a la salud de todos los niños. el manual responde a las necesidades del personal de salud interesado en proveer cuidado a los niños en casa. escrito por expertos en el área, incluye la mayoría de los componentes y aspectos que se requieren para la atención por parte de un equipo interdisciplinario de salud, con un enfoque centrado en la familia. el libro consta de cinco partes, que incluyen diversos temas, dentro de los cuales cabe resaltar: la organización del cuidado pediátrico en casa, guías para desarrollar programas de cuidado en el hogar, programas para el manejo de las enfermedades y problemas de salud más frecuentes, consideraciones y discusiones éticas, prevención y control de infecciones en casa y calidad del cuidado. conviene resaltar que en la segunda parte se encuentran quince capítulos acerca del cuidado de enfermería, con respecto a nutrición enteral y parenteral, quimioterapia, administración de medicamentos, manejo del dolor, oxigenoterapia, tecnología asistida y transporte del niño con necesidades especiales. asimismo, en el manual se pone énfasis en la importancia de lograr una adecuada transición entre el hospital y la casa, para favorecer la adaptación del niño con necesidades y problemas especiales, junto con su familia. en la última parte se presentan algunos apéndices, donde aparecen instrumentos para emergencias, una evaluación familiar y sitios web para ampliar los temas tratados. se trata de un manual actualizado, práctico y bastante completo, que brinda la información esencial para los miembros del equipo de salud interesados en el cuidado de niños con problemas especiales, su familia y los cuidadores en casa. ángela hernández posada profesora asistente guidelines for pediatric home health care american academy of pediatrics, united states, 2002. reseñas 75 aplicación del modelo de adaptación en el ciclo vital humano universidad de la sabana, grupo de estudio del modelo de adaptación, 2003. este libro es el resultado del análisis del grupo de estudio conformado por las docentes de la facultad de enfermería de la universidad de la sabana, quienes motivadas por las inquietudes generadas de la experiencia y la práctica en la aplicación del modelo de adaptación en cada una de las etapas del ciclo vital humano, han visto la necesidad de profundizar y unificar los conceptos, para orientar así el cuidado que lleve a la persona a la adaptación. el texto enseña cómo aplicar el modelo de adaptación de callista roy, y especifica secuencialmente la manera de hacerlo operativo dentro del quehacer propio de la enfermera, para brindarle el cuidado conveniente a la persona en sus diferentes etapas de desarrollo. en el primer capítulo se presentan los elementos conceptuales del modelo de adaptación, los cuales aportan la fundamentación y los argumentos al saber profesional. de igual manera, ofrecen una visión de la persona dentro de un contexto interno y externo, que en determinada situación pueden afectar su nivel de adaptación, al manifestar respuestas que la enfermera valora e identifica como efectivas o no. otros capítulos se refieren a la aplicación del modelo según el desarrollo vital de la persona. comienzan con la orientación en el cuidado de enfermería que debe brindarse a la mujer en sus diferentes etapas de gestación, en el trabajo de parto, el parto y el postparto, y continúan con el cuidado del niño en sus diferentes momentos de desarrollo, y de la persona adulta y el anciano sano. es importante resaltar que cada uno de ellos se complementa con distintas situaciones de enfermería, en las que se presentan datos valorados en cada uno de los modos psicosocial y fisiológico, según el modelo de adaptación de callista roy. como complemento, el libro finaliza con el capítulo de las reflexiones acerca de la implementación del modelo en el proceso enseñanza-aprendizaje, en el cual se comparten experiencias de la implementación del modelo en la docencia y en el ejercicio laboral. esto motiva a que el desempeño del profesional de enfermería sea cada vez más autónomo dentro de un equipo de salud, con claridad de los principios de su práctica profesional y del trabajo interdisciplinario, cuyo fin es que la persona logre su adaptación en cualquier contexto en que se encuentre. leticia díaz de flórez profesora asociada estresores de la.pmd revista aquichan issn 1657-5997 156 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 resumen con el propósito de determinar el nivel de estrés e identificar los estresores que afectan al personal de enfermería que labora en la unidad de cuidados intensivos (uci) en el municipio de cúcuta norte de santander, colombia, durante el primer semestre de 2005, se desarrolló un estudio descriptivo de corte transversal, en una muestra conformada por 22 enfermeras y 59 auxiliares de enfermería para un total de 81 sujetos. para obtener la información se aplicó el cuestionario: “estresores laborales para enfermería”, diseñado por reig y caruana, en el que se presentan 68 estresores, valorando en qué medida cada situación representa una fuente de estrés. se encontró que la mayor parte del personal de enfermería que labora en la uci presenta algún grado de estrés (94%); los niveles altos y máximos de estrés son producidos por situaciones relacionadas con “conflicto con los superiores” (52%), seguido de la “sobrecarga laboral” (40%) y el “contacto con el dolor y la muerte” (26%). se observó un mayor grado de estrés en el personal de enfermería con el cargo de enfermeras, jóvenes, con estado civil casado, con menor experiencia laboral, que trabajan en instituciones privadas y que tienen contratación a término indefinido. palabras clave estrés, personal de enfermería, cuidados intensivos, estresores. gloria esperanza zambrano plata1 recibido: 24 de mayo de 2006 aprobado: 31 de julio de 2006 1 facultad de enfermería. universidad francisco de paula santander. avenida gran colombia nº 12e-96b colsag. cúcuta, norte de santander. colombia. gloriae91@hotmail.com abstract with the purpose of to determine the stress level and to identify the stressors that affect the intensive cares nursing staff that works of cúcuta (north of santander) during the first semester of the 2005, a descriptive of transverse court research has been done, with a sample conformed by 22 nurses and 59 nursing assistants for 81 people. the instrument used was: “job stressors for nursing” designed by reig and caruana, in which 68 estresores is presented, valuing in what measure each situation represents a stress source. it was found that most of the intensive cares nursing staff presents some stress degree (94%); the high levels and maxima of stress are produced by situations related with “conflict with the superiors” (52%), followed by the “work overloads” (40%) and the “the patients suffering an death of the patient” (26%). one observes a bigger stress grade in the nursing staff with the position of nurses, young, with married civil status, with smaller labor experience that they work in private institutions and they have recruiting to indefinite term. key words stress, nursing staff, intensive cares, stresors. stressors at intensive care units año 6 vol. 6 nº 1 (6) 156-169 chía, colombia octubre 2006 estresores en las unidades de cuidado intensivo. stressors at intensive care units 157 introducción nivel mundial se ha reconocido al estrés laboral como un problema cada vez más importante, que se presenta en todos los oficios pero especialmente en los trabajos asistenciales como es la enfermería. las investigaciones que se han llevado a cabo en torno a este tema sugieren que el personal de enfermería experimenta mayor estrés ocupacional que cualquier otro tipo de trabajadores, en ese sentido, la health education aututhority clasificó la enfermería como la cuarta profesión más estresante. igualmente, algunos estudios revelan que las unidades que generan mayor estrés son aquellas que reúnen pacientes críticos o terminales, observándose una alta prevalencia de estrés en el personal de enfermería que trabaja en estos servicios. cuando fallan las estrategias de afrontamiento que habitualmente emplea el individuo para manejar estos estresores, se pueden presentar diferentes tipos de alteración que resultan nocivos, ya que podrían provocar trastornos físicos, psicológicos, y afectar su desempeño familiar, social y laboral. toda esta problemática no sólo afecta al individuo que la presenta, sino también a los usuarios, las empresas y a la sociedad en general. el personal de enfermería de la ciudad de cúcuta no es ajeno a esta situación que se ha evidenciado en dos estudios realizados frente al estrés en esta población; el primero, realizado en 1994 por cáceres y gamboa (1) reportó que el 88% de las enfermeras profesionales del hospital universitario erasmo meoz (huem) presentan estrés agudo y el 12% crónico, manifestado por cefalea, diaforesis, ansiedad, irritabilidad y apatía. igualmente, se encontró que según el tipo de paciente, el que genera mayor probabilidad de estrés es el paciente de cuidados intensivos. en el estudio realizado por botia mantilla y cols. (2), en el 2004, se presentó una prevalencia de 10,4% del síndrome de bournot en las enfermeras del municipio de cúcuta, específicamente en cuidados intensivos la prevalencia fue de 12%. con base en la alta prevalencia del estrés y de sus complicaciones en el personal de enfermería, sumado a los escasos estudios en la región sobre esta problemática, surge la necesidad de realizar este estudio con el propósito de determinar el nivel de estrés e identificar los estresores que afectan a las enfermeras que laboran en cuidados intensivos en el municipio de cúcuta (norte de santander). marco conceptual estrés laboral es el grado de respuesta física, psicológica y comportamental que se presenta cuando el individuo percibe una situación amenazante que desborda sus recursos y pone en peligro su bienestar. las situaciones amenazantes son causadas por el desajuste entre la persona y el puesto de trabajo. la organización internacional del trabajo (oit) se refiere al estrés laboral en los siguientes términos: “esta enfermedad es un peligro para las economías de los países industrializados y en vías de desarrollo. resiente la productividad, al afectar la salud física y mental de los trabajadores” (3). la mayoría de los estudios reporcuando fallan las estrategias de afrontamiento que habitualmente emplea el individuo para manejar estos estresores, se pueden presentar diferentes tipos de alteración que resultan nocivos, ya que podrían provocar trastornos físicos, psicológicos, y afectar su desempeño familiar, social y laboral. revista aquichan issn 1657-5997 158 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 tan una alta prevalencia de estrés en los profesionales de enfermería. en alicante (españa) ribera y cols. encontraron que el 75% de las enfermeras referían la presencia de estrés, de éstas un importante grupo (19,8%) expresaron padecer un estrés máximo, mientras que el resto (65,9%) percibía un estrés débil o moderado (4). estresores en enfermería son todas aquellas situaciones estresantes relacionadas con el trabajo de enfermería, capaces de generar alteraciones físicas, emocionales y sociales. diversos autores se han interesado en identificar los estresores relacionados con este colectivo. reig a. y caruana (5), con base en una serie de investigaciones identificaron un grupo de estresores laborales específicos del desarrollo cotidiano de la profesión de enfermería, éstos son: a) contacto con el dolor y la muerte: los profesionales de enfermería en general se suelen mostrar satisfechos con la atención a los pacientes, que es la parte esencial de la profesión. sin embargo, la gran responsabilidad sobre la vida, la salud y el cuidado de otras personas, junto con el trato diario con los pacientes, son factores determinantes de la presencia de estrés y sus consecuencias (4). b) conflictos con pacientes y sus familiares: con la implementación de la ley 100 se ha ido construyendo una cultura de seguridad social, donde la salud es vista como un servicio público y un derecho irrenunciable de todos los habitantes del país; por tanto, cada vez el profesional de enfermería se enfrenta a un usuario más informado, con mayor conciencia de sus derechos como ciudadano, más exigente y dispuesto a demandar legalmente. esto genera temores y conflictos que son causantes de desgaste profesional en enfermería. c) conflictos con los superiores: la falta de apoyo de los superiores ha sido identificada como un estresor que tiene gran implicación en la salud de los profesionales de enfermería (6). d) situaciones urgentes y graves: la enfermera debe tomar en muchas ocasiones decisiones rápidas que pueden comprometer el bienestar del paciente, generando elevados niveles de estrés; situaciones que se vivencian especialmente en la uci, donde las decisiones a menudo son irreversibles y comprometen la vida del paciente. e) carencias: la insatisfacción con el trabajo es una situación que se presenta a menudo en los profesionales de enfermería (15,8%). la relación entre el estrés ocupacional y la insatisfacción laboral son dos conceptos estudiados frecuentemente y relacionados de manera positiva, es decir, a mayor estrés mayor insatisfacción y a menor estrés mayor satisfacción. igualmente, se ha encontrado la insatisfacción laboral como un factor relacionado con la salud de los profesionales de enfermería (4). f) estrés emocional: el cuidado del paciente crítico hace sentir al trabajador “desarmado” y lo lleva a adoptar conductas de huida y evitación, ya que la naturaleza de la enfermedad de sus pacientes le hace enfrentarse, en ocasiones, con el “fracaso terapéutico” o con un mal pronóstico y, a la vez, lo sensibiliza ante la muerte. en las enfermeras son frecuentes los sentila falta de apoyo de los superiores ha sido identificada como un estresor que tiene gran implicación en la salud de los profesionales de enfermería. estresores en las unidades de cuidado intensivo. stressors at intensive care units 159 mientos de impotencia, soledad y frustración ante el hecho de que incluso unos buenos cuidados no aseguran una muerte digna. g) sobrecarga laboral: la sobrecarga en el trabajo ha sido identificada como una de las principales causas de estrés en las enfermeras, éstas perciben que su trabajo es físicamente agotador y que los turnos rotatorios les generan mayor estrés (4). la jornada de trabajo excesiva produce desgaste físico y mental e impide al profesional hacer frente a las situaciones estresantes. el trabajo nocturno y por turnos produce alteraciones en las constantes biológicas determinadas por el ritmo circadiano, establecido a su vez por las secreciones hormonales, los ciclos del sueño y el ritmo metabólico. requiere un alto esfuerzo adaptativo, generando irritabilidad, disminución de la concentración, trastornos del sueño, fatiga, ansiedad, además de provocar modificaciones en la vida social, conyugal y sexual. los profesionales de enfermería que laboran en el turno nocturno presentan alteraciones digestivas (3). la sobrecarga de trabajo, tanto en los aspectos difíciles de la tarea como en la cantidad, tiene una relación directa entre horas de trabajo y muerte causada por enfermedad coronaria. la sobrecarga de trabajo también está relacionada significativamente con una serie de síntomas de estrés: consumo de alcohol, absentismo, baja motivación en el trabajo, baja autoestima, tensión en el trabajo, percepción de amenaza, desconcierto, alto nivel de colesterol, incremento de la tasa cardiaca y aumento de consumo de cigarrillos. materiales y métodos tipo de diseño: para el logro de los objetivos propuestos, se desarrolló un estudio cuantitativo de tipo descriptivo, de corte transversal. universo: enfermeras y auxiliares de enfermería que laboran en el municipio de cúcuta (norte de santander) durante el primer semestre de 2005. población y muestra: el estudio se realizó con la totalidad del personal de enfermería que labora en cuatro unidades de cuidados intensivos del municipio de cúcuta (norte de santander), que corresponde a 22 enfermeras y 59 auxiliares de enfermería. criterios de inclusión: enfermeras y auxiliares de enfermería que se encontraban laborando en la unidad de cuidados intensivos por un periodo mayor de un mes. escenario: la muestra que participó en el presente estudió se encontraban laborando en la empresa social del estado (ese) francisco de paula santander, ese hospital universitario erasmo meóz (huem), ips clínica san josé, ips clínica santa ana. procedimientos y recolección de datos: la información se obtuvo mediante una encuesta autoadministrada y recogida de forma confidencial en un sobre cerrado para garantizar el anonimato. para obtener la información se aplicó un instrumento organizado en dos partes: la primera hacía referencia a las características sociodemográficas y laborales, la segunda correspondía al “cuestionario de estresores el cuidado del paciente crítico hace sentir al trabajador “desarmado” y lo lleva a adoptar conductas de huida y evitación, ya que la naturaleza de la enfermedad de sus pacientes le hace enfrentarse, en ocasiones, con el “fracaso terapéutico” o con un mal pronóstico y, a la vez, lo sensibiliza ante la muerte. revista aquichan issn 1657-5997 160 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 laborales para enfermería”, desarrollado por reig y caruana(4, 5), que valora en qué medida cada situación representa una fuente de estrés, tensión o irritabilidad en su trabajo actual. se han desarrollado comprobaciones psicométricas de la validez y confiabilidad de este cuestionario, la consistencia interna está entre 0,75 y 0,91 según la fórmula utilizada (alpha de cronbach, r de winer o theta de cármines), y la confiabilidad del test-retes es de 0,78 para las 68 afirmaciones. marco del análisis: la información se tabuló en la medida que se fue recolectando, en una base de datos elaborada en el programa excel 2000 de windows. la información obtenida se analizó mediante estadística descriptiva como frecuencias, porcentajes, medidas de tendencia central: media. los resultados se presentan en tablas y gráficos. resultados y discusión en el presente estudio se observó un predominio del personal auxiliar de enfermería (73%) con respecto a las enfermeras, encontrándose que en las cuatro unidades donde se realizó el estudio hay una enfermera por cada tres auxiliares de enfermería. el promedio de edad de los participantes fue de 34 años, predominando el personal de enfermería que se encuentra en el rango de 2333 años (29,6%) seguido del grupo entre 34-39 años (22,2%). con respecto al estado civil sobresalió el casado (43%) seguido de soltero (33%). la mayor proporción del personal de enfermería presenta vinculación laboral mediante contrato a término indefinido (51,9%), seguido del personal que se encuentra vinculado con el nuevo sistema de contratación por cooperativas (35,8%). en promedio trabajan 47 horas semanales; en lo que respecta a la experiencia laboral en cuidados intensivos la mayoría tiene una experiencia entre 1 a 5 años (48%) seguido de 6 a 10 años (17%), estos resultados reflejan el desarrollo de las unidades de cuidados intensivos que se ha dado en los últimos 10 años en la ciudad. es evidente que el trabajo de la enfermera ocupa ese lugar de mediación, de represión de sentimientos, de contención de emociones y angustias, de contacto, donde el ser entero se juega en relación con otro ser (paciente) en la lucha, podría decirse, entre la vida y la muerte; de ahí que los estresores relacionados con “el contacto con el dolor y la muerte” causan, en la mayoría de la muestra estudiada, estrés moderado (44%), alto (17%) y máximo estrés (9%). la alta prevalencia de estrés generado por este factor coincide con lo reportado en estudios realizados en profesionales de enfermería que laboraban en servicios de hospitalización de tercer nivel en españa por pérez y cols. (8) y simón garcía y cols. (7); igualmente, en cuba este estresor fue reportado por herrera y figura 1. estresores relacionados con el contacto con el dolor y la muerte. personal de enfermería, unidades de cuidados intensivos, cúcuta, 2005. fuente: personal de enfermería que labora en cuidados intensivos. estresores en las unidades de cuidado intensivo. stressors at intensive care units 161 cassals (8) en enfermeras, quienes afirmaban que les genera una gran tensión el hecho de “ver morir a un paciente especial”. de las situaciones presentadas en el cuestionario sobre este factor, las que causaron los máximos niveles de estrés fueron: “la consecuencia de mis errores para el enfermo” (35%) y “los errores de otros compañeros de enfermería que afectan a mis enfermos” (25%); la relación de la enfermera con el paciente se refiere al bienestar del individuo en todas sus dimensiones, estableciéndose un contacto permanente con un ser humano en búsqueda de curación y alivio de su padecimiento, de ahí que no sea extraño que las situaciones derivadas de este factor generen gran tensión en las enfermeras. pérez y rodríguez encontraron que los enfermeros más depresivos y/o ansiosos son aquellos a los que más les estresan las situaciones relacionadas con el factor “contacto con el dolor y la muerte” (8). fuente: personal de enfermería que labora en cuidados intensivos. figura 2. estresores relacionados con conflictos con pacientes y sus familiares. personal de enfermería, unidades de cuidados intensivos, cúcuta, primer semestre de 2005. dentro de los siete estresores estudiados en esta investigación, el conflicto con pacientes y familiares produjo bajos niveles de estrés, el personal de enfermería manifestó que éste les produce estrés leve (40%). en la literatura revisada no se hallaron estudios que reporten este estresor dentro de las principales causas de estrés en el personal de enfermería. para este factor el estresor que más estrés produjo fue: “tratar con gente agresiva” (22%), el cual fue igualmente identificado por ribera y cols. (4), como una de las situaciones consideradas como muy estresantes por el 80% de los encuestados en españa. la otra situación de este estresor que presentó una alta prevalencia en el presente estudio fue: “quejas de los pacientes” (15%); cada vez el profesional de enfermería se enfrenta a un usuario más informado, con mayor conciencia de sus derechos como paciente, y por tanto, más exigente. en el presente estudio se observó que los estresores relacionados con conflictos con los superiores son los que más estrés producen en el personal de enfermería, causando niveles altos (33%) y máximos de estrés (19%). similar a lo reportado en el presente estudio, hernández (9) identificó, dentro de las fuentes de estrés más frecuentes en profesionales de atención primaria y secundaria, los conflictos con superiores. dentro de la situaciones que más estrés producen en el personal estudiado revista aquichan issn 1657-5997 162 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 fuente: personal de enfermería que labora en cuidados intensivos. figura 3. estresores relacionados con conflictos con los superiores. personal de enfermería, unidades de cuidados intensivos, cúcuta, primer semestre de 2005. fuente: personal de enfermería que labora en cuidados intensivos. figura 4. estresores relacionados con situaciones urgentes y graves. personal de enfermería, unidades de cuidados intensivos, cúcuta, primer semestre de 2005. estresores en las unidades de cuidado intensivo. stressors at intensive care units 163 están: “tener un superior incompetente” (33%) y “falta de apoyo de los superiores” (16%). en el estudio realizado en españa por ribera y cartagena (4), “la falta de apoyo de los superiores” fue el estresor que generó los niveles mayores de estrés en enfermería. para la mayor proporción del personal de enfermería que labora en cuidados intensivos los estresores relacionados con situaciones urgentes y graves les causan un estrés leve (37%) y moderado (30%). la enfermera de cuidados intensivos a diario se ve obligada a tomar decisiones rápidas que comprometen el bienestar del paciente y que le pueden generar elevados niveles de estrés, esto se pudo apreciar en la población estudiada, donde las situaciones que más estrés causan en este factor son: “no poder resolver los problemas que se me plantean” (19%) y “la excesiva responsabilidad de mi trabajo” (16%). fuente: personal de enfermería que labora en cuidados intensivos. figura 5. estresores relacionados con aspectos carenciales. personal de enfermería, unidades de cuidados intensivos, cúcuta, primer semestre de 2005. al indagar sobre los aspectos carenciales, la mayor proporción del personal de enfermería considera que este factor les produce un estrés moderado (41%). en españa, ribera y cartagena encontraron un porcentaje importante de insatisfacción laboral (15,8%) (4) en los profesionales de enfermería que laboran en los servicios de hospitalización de tercer nivel. dentro de los estresores relacionados con este factor, los que producen los máximos niveles de estrés son: “ganar poco dinero para disfrutar de un buen nivel de vida” (22%) y “que no se valore ni reconozca mi esfuerzo por hacer bien mi trabajo” (20%); las personas tienen una serie de necesidades y motivaciones que el trabajo debe ser capaz de satisfacer, por lo menos en parte (pertenencia a un grupo, reconocimiento, seguridad en el empleo... ); cuando esto no ocurre, se considera que la situación de trabajo es potencialmente nociva para el trabajador. el trabajo hospitalario es intenso, sobre todo en los servicios de urgencias y unidades de cuidados intensivos, donde se combina una gran responsabilidad y una continua disponibilidad a las necesidades de los enfermos, que resultan agotadoras y producen estrés emocional; no obstante, de los estresores evaluados en este estudio el “estrés emocional” fue el que presentó la prevalencia más baja, causando un estrés leve (40%) y moderado (30%). dentro revista aquichan issn 1657-5997 164 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 fuente: personal de enfermería que labora en cuidados intensivos. figura 6. estresores relacionados con estrés emocional. personal de enfermería, unidades de cuidados intensivos, cúcuta, primer semestre de 2005. fuente: personal de enfermería que labora en cuidados intensivos. figura 7. estresores relacionados con la sobrecarga laboral. personal de enfermería, unidades de cuidados intensivos, cúcuta, primer semestre de 2005. estresores en las unidades de cuidado intensivo. stressors at intensive care units 165 de los estresores relacionados con este factor, el que produce los máximos niveles de estrés es: “que sólo me digan lo que hago mal” (19%). dentro de los factores estudiados en la presente investigación, el estrés generado por la sobrecarga laboral ocupó el segundo lugar con respecto a los niveles más altos de estrés. la mayor parte del personal de enfermería encuestado evalúa el estrés relacionado con la sobrecarga labora como moderado (36%) y alto (33%). dentro de los estresores que más estrés causan son: “escasez de personal” (20%) y “que me hagan perder el tiempo” (19%). estos resultados son similares a los reportados por mendez diz (10), donde las enfermeras entrevistadas coinciden en el reconocimiento de factores tales como “la sobrecarga de trabajo”, “el cansancio”, “el no dormir”, y “el estar alejado de la familia”, que son características del trabajo en cuidados intensivos. fuente: personal de enfermería que labora en cuidados intensivos. figura 8. nivel de estrés del personal de enfermería, unidades de cuidados intensivos, cúcuta, primer semestre de 2005. la enfermería es, sin duda, una profesión generadora de gran estrés, ya que se viven situaciones de gran intensidad emocional, esto se refleja al analizar el nivel de estrés generado por los 68 estresores contemplados en el instrumento; así, se encontró que el 94% del personal de enfermería que labora en cuidados intensivos en el municipio de cúcuta presenta algún grado de estrés, predominando el nivel moderado (43%) y leve (32%). un porcentaje importante (18%) presenta niveles de altos y máximos, que pueden estar relacionados con la prevalencia (12%) de síndrome de bournot reportado por botia y cols. (2) en las unidades de cuidados intensivos de cúcuta. la prevalencia de estrés hallada en este estudio es superior a la reportada en alicante (españa) por ribera y cols. (4), que encontraron que el 75% de las enfermeras referían la presencia de estrés. sin embargo, la proporción de enfermeras con niveles altos y máximos (19,8%) es similar a la reportada en el presente estudio. los trabajadores con cargos de mayor jerarquía y responsabilidad presentan niveles más altos de estrés; al comparar el estrés de las enfermeras y el personal auxiliar de enfermería, se observa un nivel mayor en las enfermeras, así: moderado (59%) y las auxiliares presentan, en igual proporción, estrés leve y moderado revista aquichan issn 1657-5997 166 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 (37%). así mismo, el nivel de estrés alto se presenta en mayor proporción en las enfermeras (18%) en comparación con las auxiliares (15%). estos resultados son similares a los reportados por simon garcía y cols. (9), donde la media de estrés de las enfermeras fue significativamente más alta que en las auxiliares de enfermería, 38 (10) y 27,9 (9, 2). para las enfermeras encuestadas los estresores que generan los máximos niveles de estrés son: “la consecuencia de mis errores para el enfermo” (45%), “tener un superior incompetente” (32%) y en igual proporción “escasez de recursos esenciales”. las auxiliares consideran que los estresores que les producen los mayores niveles de estrés son: “tener un superior incompetente” (34%), “la consecuencia de mis errores para el enfermo” (31%), y “recibir un sueldo no acorde con las responsabilidades de mi trabajo” (24%). en el presente estudio se halló que el personal que labora en las instituciones privadas refiere niveles de estrés mayores. en las ausente 1 5 4 7 leve 4 18 22 37 moderado 13 59 22 37 alto 4 18 9 15 máximo 0 0 2 3 total 22 100 59 100 tabla 1. nivel de estrés según cargo del personal de enfermería, unidades de cuidados intensivos, cúcuta, primer semestre de 2005. cargo enfermera aux enf. nivel de estrés f % f % fuente: personal de enfermería que labora en cuidados intensivos. ausente 2 12 2 8 1 6 0 0 0 0 leve 7 41 4 17 6 33 5 45,5 4 36 mediano 3 18 13 54 7 39 5 45,5 7 64 alto 5 29 4 17 3 17 1 9,1 0 0 máximo 0 0 1 4 1 6 0 0 0 0 total 17 100 24 100 18 100 11 100 11 100 tabla 2. nivel de estrés según edad del personal de enfermería, unidades de cuidados intensivos, cúcuta, primer semestre de 2005. edad 21-26 27-33 34-39 40-45 46-51 nivel de estrés f % f % f % f % f % fuente: personal de enfermería que labora en cuidados intensivos. estresores en las unidades de cuidado intensivo. stressors at intensive care units 167 instituciones privadas 68% y en las públicas 57% presentaron niveles de estrés entre moderado y máximo. en las instituciones privadas se encontró un 6% con niveles de estrés máximo, y en las públicas ninguno de los participantes presentó niveles máximos de estrés. los niveles mayores de estrés aumentan al disminuir la edad, encontrándose que el grupo de 21 a 26 años presenta una elevada proporción (29%) con niveles de estrés alto seguido del grupo de ausente 3 11 2 6 0 0 0 0 0 0 leve 12 44 8 23 3 30 0 0,0 3 42,9 mediano 8 30 17 49 4 40 2 100,0 4 57,1 alto 4 15 7 20 2 20 0 0,0 0 0 máximo 0 0 1 3 1 10 0 0 0 0 total 27 100 35 100 10 100 2 100 7 100 estado civil soltero casado unión libre viudo separado nivel de estrés f % f % f % f % f % tabla 3. nivel de estrés según estado civil. personal de enfermería, unidades de cuidados intensivos, cúcuta, primer semestre de 2005. fuente: personal de enfermería que labora en cuidados intensivos. 27 a 33 años (17%) y de 34 a 38 años (17%). la población entre 46 y 51 años no presentó niveles de estrés alto o máximo. estos resultados coinciden con los reportados por ribera y cols. (4), en los que se observó que cuanto más joven es el trabajador, mayor incidencia de estrés profesional se presenta. la mayores niveles de estrés se presentaron en el personal que se encontraba en unión libre (alto: 20% y máximo: 10%), en contraste, los niveles de estrés más bajos se presentaron en los fuente: personal de enfermería que labora en cuidados intensivos. ausente 1 6 3 8 1 7 0 0 0 0 leve 6 35 11 28 5 36 2 22 2 100 mediano 4 24 21 54 4 29 6 67 0 0 alto 6 35 4 10 2 14 1 11 0 0 máximo 0 0 0 0 2 14 0 0 0 0 total 17 100 39 100 14 100 9 100 2 100 experiencia < 1 año 1-5 años 6-10 años 11-15 años >16 años nivel de estrés f % f % f % f % f % tabla 4. nivel de estrés según experiencia laboral. personal de enfermería, unidades de cuidados intensivos, cúcuta, primer semestre de 2005. revista aquichan issn 1657-5997 168 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 solteros (ausente: 11% y leve: 44%). llama la atención que los casados ocupan el segundo lugar tanto para los mayores niveles de estrés (alto: 20% y máximo: 3%), como para los más bajos (ausente: 6% y leve: 23%). con respecto a la experiencia laboral en cuidados intensivos, se encontró que los mayores niveles de estrés los presenta el grupo con experiencia menor de un año (alto: 35%, ausente: 6% y leve: 35%), y los más bajos se hallaron en el personal con mayor experiencia (mayor de 16 años). resultados similares fueron reportados norbeck (11), quien encontró que las enfermeras de cuidados intensivos con menor experiencia están más propensas a presentar mayor insatisfacción con el trabajo lo que conlleva mayor estrés. al analizar los niveles de estrés según el tipo de contratación se encontró que los mayores niveles de estrés los presenta el personal que se encuentra con contrato a término indefinido (alto: 17% y máximo: 5%), y los que presentan los niveles más bajos de estrés son los que se encuentran por cooperativas (ausente: 10% y leve: 40%). esto puede estar relacionado con la inestabilidad que se presenta en el sector salud a nivel público, donde es constante la amenaza de reestructuración con la consecuente reducción de cargos, situación que mantiene al personal de enfermería de planta en continua tensión emocional. conclusiones al analizar el grado de estrés producido por los siete estresores definidos en el presente estudio, se estableció que los que producen los mayores niveles de estrés son las situaciones relacionadas con “conflicto con los superiores”, seguido de la “sobrecarga laboral” y el “contacto con el dolor y la muerte”. el que menos estrés generó es el factor de “estrés emocional”. dentro de las situaciones específicas que producen los niveles más elevados de estrés en el personal de enfermería se destacan: “las consecuencias de mis errores para el enfermo”, “tener un superior incompetente”, “escasez de recursos esenciales” y “sobrecarga de trabajo”. la mayor parte del personal de enfermería que labora en la uci presenta algún grado de estrés (94%), observándose una prevalencia superior a la reportada en otros estudios. esto evidencia la continua tensión a que se ve sometido el personal de enfermería de cuidados intensivos de cúcuta, que brinda cuidado en diferentes situaciones relacionadas con la lucha entre la vida y la muerte, en instituciones, con pacientes, familias y equipo de salud con unas características muy particulares. se observó un mayor grado de estrés en el personal de enfermería con el cargo de enfermeras, jóvenes, con estado civil casado, con menor experiencia laboral, que trabajan en instituciones privadas y que tienen contratación a término indefinido. estresores en las unidades de cuidado intensivo. stressors at intensive care units 169 1. cáceres s, jaimes c. estrés en el profesional de enfermería del hospital erasmo meoz. trabajo de grado. universidad francisco de paula santander, facultad ciencias de la salud, escuela de enfermería; 1994, cúcuta. 2. botía le. moncada cc, rodríguez hh, villamizar le. prevalencia del síndrome de burnout en enfermeras del área de hospitalización de cúcuta durante el segundo semestre de 2004. trabajo de grado. universidad francisco de paula santander, facultad ciencias de la salud, escuela de enfermería, cúcuta; 2005, p. 72. 3. estrés en las enfermeras y área quirúrgica del hospital josé a. vargas de la ovallera, municipio libertador. estado aragua. disponible en: www.monografias.com 4. ribera e, cartagena a et al. estrés laboral y salud en profesionales de enfermería. universidad de alicante. editorial espasgrafic; 1993, pp. 12-50. 5. r e i g a , c a r u a n a a . e s t u d i o c o m p a r a t i v o d e estresores profesionales en personal de enfermería español y norteamericano. enfermería científica 1989; (91): 4-44. 6. estrés laboral. sindicato de enfermería de españa (satse). disponible en: http://www.satse.es/salud_ laboral/guia_prevencion_estres.htm 7. simón garcía mm, blesa malpica al, bermejo pablos v, calvo gutiérrez ma, gómez de enterría pérez c. estresores laborales y satisfacción en la enfermería de una unidad de críticos. enfermería intensiva 2005; 16 (1): 2. disponible en: http://www.seeiuc.com/ revista/res1612.htm 8. herrera sánchez r, cassals villa m. algunos factores influyentes en la calidad de vida laboral de enfermería. revista cubana de enfermería 2005; 21 (1):1-12. disponible en: www.scielo.sld.cu/ scielo.php?pid 9. hernández jr. estrés y burnout en profesionales de la salud de los niveles primario y secundario de atención. revista cubana salud pública 2003; 29(2): 104. 10. mendes diz am, korn al. el estrés laboral de los profesionales de la salud. disponible en: http:// w w w . a l a s t . o r g / p d f / w a l t e r / t e c mendesdizykornblit.pdf 11. norbeck j. j. tensión percibida en el trabajo, satisfacción en el trabajo y síntomas psicológicos en enfermería de cuidados intensivos. material fotocopiado. referencias << /ascii85encodepages false /allowtransparency false /autopositionepsfiles true 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/untaggedcmykhandling /leaveuntagged /untaggedrgbhandling /leaveuntagged /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 42 52 validacion del brief pain inventory.indd 42 aquichan issn 1657-5997 luís manuel mota de sousa1 cristina maria alves marques-vieira2 sandy silva pedro severino3 juan luis pozo-rosado4 helena maria guerreiro josé5 validación del brief pain inventory en personas con enfermedad renal crónica 1 orcid.org/0000-0002-9708-5690. universidade atlântica, portugal. luismmsousa@gmail.com 2 orcid.org/0000-0002-4409-7911. instituto de ciencias de la salud de la universidad católica portuguesa, portugal. cristina_marques@ics.lisboa.ucp.pt 3 orcid.org/0000-0002-5162-2980. hospital curry cabral, portugal. sandyseverino@gmail.com 4 orcid.org/0000-0002-5328-6992. hospital fernando da fonseca, portugal. juanrosado2009@hotmail.es 5 orcid.org/0000-0002-2626-8561. escuela de salud multipefil, angola. elena.jose@multiperfil.co.ao recibido: 13 de diciembre de 2015 enviado a pares: 17 de diciembre de 2015 aceptado por pares: 23 de junio de 2016 aprobado: 30 de junio de 2016 doi: 10.5294/aqui.2017.17.1.5 para citar este artículo / to reference this article / para citar este artigo sousa lmm, marques-vieira cma, severino ssp, pozo-rosado jl, josé hmg. validación del brief pain inventory en personas con enfermedad renal crónica. aquichan. 2017; 17(1):42-52. doi: 10.5294/aqui.2017.17.1.5 resumen objetivo: comprobar las propiedades psicométricas de la versión portuguesa del brief pain inventory, en personas con enfermedad renal crónica sometidas a hemodiálisis. método: estudio metodológico. la muestra seleccionada está compuesta por 171 personas con enfermedad renal crónica que presentan dolor durante al menos 24 horas y realizan hemodiálisis en dos clínicas de la región de lisboa, portugal. los datos se recogieron entre mayo y junio del 2015. se evaluaron las siguientes propiedades psicométricas: validez (constructo, convergente y discriminante), confiabilidad (α de cronbach) y estabilidad (test-retest). resultados: se obtuvo información que apoya adecuadamente una estructura bifactorial (interferencia del dolor y grado de severidad del dolor), con confiabilidad (α = 0,90 y α = 0,80, respectivamente) y estabilidad. las medidas registradas están correlacionadas de forma positiva con el afecto negativo, y de forma negativa, con las medidas de calidad de vida, que sustentan la validez concurrente. se comprobó la existencia de apoyo para la validez predictiva. conclusiones: las medidas del “grado de severidad del dolor” e “interferencia del dolor” que se obtuvieron a través del brief pain inventory son válidas y reproducibles en personas con enfermedad renal crónica que presentaron dolor en las últimas 24 horas, cuando se utiliza el cuestionario y la entrevista. palabras clave insuficiencia renal crónica; diálisis renal; dimensión del dolor; estudios de validación; psicometría (fuente: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 42-52 43 validación del brief pain inventory en personas con enfermedad renal crónica l luís manuel mota de sousa y otros año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 42-52 validation of the brief pain inventory in persons with chronic kidney disease abstract objective: verify the psychometric properties of the portuguese version of the brief pain inventory in persons with chronic kidney disease who are undergoing hemodialysis. method: this is a methodological study. the selected sample is comprised of 171 persons with chronic kidney disease who experience pain for at least 24 hours and are undergoing hemodialysis at two clinics in lisbon, portugal. the data were collected between may and june 2015. the psychometric properties that were evaluated include validity (construct, convergent and discriminant), reliability (cronbach’s α) and stability (test-retest). results: information was obtained that adequately supports a bi-factor structure (pain interference and degree of pain severity), with reliability (α = 0.90 and α = 0.80, respectively) and stability. the measures registered correlate positively with the negative effect, and negatively, with measures of quality of life, which support concurrent validity. the existence of support for predictive validity was verified. conclusions: the "pain severity" and "pain interference" measures obtained with the brief pain inventory are valid and reproducible in persons with chronic kidney disease who experienced pain during the 24 hours before the questionnaire was used and the interview was conducted. keywords chronic renal insufficiency; renal dialysis; pain dimension; validation studies; psychometry (source: decs, bireme). 44 aquichan issn 1657-5997 validação do brief pain inventory em pessoas com doença renal crônica resumo objetivos: comprovar as propriedades psicométricas da versão portuguesa do brief pain inventory em pessoas com doença renal crônica submetidas a hemodiálise. materiais e método: estudo metodológico. a amostra selecionada está composta por 171 pessoas com doença renal crônica que apresentam dor durante, pelo menos, 24 horas e realizam hemodiálise em duas clínicas de lisboa, portugal. os dados foram coletados entre maio e junho de 2015. foram avaliadas as seguintes propriedades psicométricas: validade (constructo, convergente e discriminante), confiabilidade (alfa de cronbach) e estabilidade (teste-reteste). resultados: obteve-se informação que apoia adequadamente uma estrutura bifatorial (interferência da dor e grau de severidade da dor), com confiabilidade (α = 0,90 e α = 0,80, respectivamente) e estabilidade. as medidas registradas estão correlacionadas de forma positiva com o afeto negativo, e de forma negativa, com as medidas de qualidade de vida, que sustentam a validade concorrente. comprovou-se a existência de apoio para validade preditiva. conclusões: as medidas do “grau de severidade da dor” e “interferência da dor” obtidas por meio do brief pain inventory são válidas e reproduzíveis em pessoas com doença renal crônica que apresentaram dor nas últimas 24 horas, quando se utiliza o questionário e a entrevista. palavras chave insuficiência renal crônica; diálise renal; dimensão da dor; estudos de validação; psicometria (fonte: decs, bireme). año 17 vol. 17 nº 1 chía, colombia marzo 2017 l 42-52 45 validación del brief pain inventory en personas con enfermedad renal crónica l luís manuel mota de sousa y otros introducción la enfermedad renal crónica (erc) está asociada con un aumento de las concentraciones séricas de urea y creatinina en la sangre, y sus principales causas son la hipertensión arterial, la diabetes mellitus y la glomerulonefritis (1,2). la consecuencia de esta situación clínica es que la persona afectada necesite utilizar técnicas de sustitución renal como la hemodiálisis (hd) y la diálisis peritoneal o, incluso, recurrir al trasplante renal (1). la hd es la terapia más utilizada en estas situaciones (3), y su frecuencia de realización está entre dos a cuatro veces por semana, con una duración de dos a cuatro horas en media. la realización de la hd provoca alteraciones en la vida de las personas afectadas, por ejemplo, pérdida del empleo, cambios de la imagen corporal, restricciones dietéticas e hídricas (2). el dolor crónico es otro síntoma que diariamente las personas con erc tienen que enfrentar. en una revisión de la literatura sobre la prevalencia del dolor grave en personas con erc, que incluyó 55 artículos publicados entre 1992 y 2009 (representa 7500 personas con erc), se confirmó que en 36 de los estudios realizados con personas sometidas a hd (más de 5200), cerca del 58 % refirió dolor y el 49 % cuantificaba el dolor como moderado o grave (4). el brief pain inventory (bpi) es un cuestionario desarrollado para evaluar la gravedad y el impacto del dolor en el desempeño diario de la persona. se utiliza en diferentes patologías y síndromes dolorosos que incluyen desde las situaciones de dolor agudo hasta las de dolor crónico (5). un grupo de consenso reciente —el initiative on methods, measurement, and pain assessment in clinical trials— recomendó la inclusión de la versión corta del bpi en todos los ensayos clínicos del dolor crónico; así mismo, un grupo de peritos de la european association of palliative care recomendó su utilización para el desarrollo de investigaciones científicas (6). la versión corta del bpi se compone de un diagrama que permite localizar el dolor en un área corporal concreta, e incluye, además, escalas para evaluar la intensidad y el impacto del dolor. de esta manera, el impacto del dolor se evalúa en función del grado en que este interfiere con las siguientes áreas: actividad general, estado de ánimo, capacidad de caminar, trabajo, relaciones sociales, sueño y capacidad de diversión (6,7). la versión corta del bpi se adaptó para varios países, por ejemplo, portugal (6,7), alemania (8), tailandia (9,10), grecia (11), españa (12), italia (13), noruega (14,15), estados unidos (16,17), corea (18), canadá (19), rusia (20), líbano (21) y brasil (22). la escala se adaptó con mayor frecuencia para su uso en personas con dolor de origen oncológico (9-12,14,17,18,20-22) y, posteriormente, en personas con las siguientes patologías: dolor crónico no maligno (13,16), dolor crónico músculo-esquelético (6,7), osteoartritis (15), estrés postraumático (19) y sida (17). el tamaño de las muestras utilizadas en los diferentes estudios varió entre 75 (21) y 520 (10) personas con dolor. el análisis cultural del bpi confirmó la existencia de adecuadas propiedades psicométricas, lo que permite considerarlo un instrumento válido y fiable para la medición del grado de intensidad del dolor y su interferencia en las actividades de la vida diaria. el dolor es recurrente en las personas con erc (24, 2330). la utilización de la escala bpi se recomienda en estudios experimentales que evalúan el impacto del dolor en las actividades de la vida diaria (31). por ello, la escala parece ser adecuada para su aplicación en personas con erc en el ámbito de los cuidados de enfermería. de acuerdo con lo referido, el objetivo principal del presente estudio fue comprobar si la versión portuguesa del bpi (6,7) mantiene las propiedades psicométricas de validez y reproducibilidad en personas con erc que realizan hd cuando se utilizan el cuestionario y la entrevista. los objetivos específicos son: 1) verificar si la intensidad del dolor y la interferencia del dolor, medidas por el bpi (6,7), presentan validez concurrente, cuando se comparan con otros instrumentos que miden el impacto del dolor, específicamente, en el bienestar (32,33), el afecto positivo, el afecto negativo (34) y la calidad de vida (7,19); 2) estudiar los factores predictores de la intensidad e interferencia del dolor, y 3) determinar los valores de la fiabilidad interna y del test-retest, tanto en la modalidad entrevista como en la modalidad cuestionario. material y método el estudio tiene enfoque cuantitativo (35) y se desarrolló en dos unidades de diálisis de la clínica diaverum en la región de lisboa, entre mayo y junio del 2015. la población de la muestra estuvo constituida por personas con erc sometidas a hd. los criterios de inclusión definidos fueron: personas con erc sometidas a hd desde hace, por lo menos, seis meses, con una edad igual o superior a 18 años. los criterios de exclusión considerados fueron: personas con déficit cognitivo o enfermedad psiquiátrica 46 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 activa. la población comprende un grupo de 248 personas con erc, que cumplieron los criterios de inclusión (139 procedentes de la clínica 1 y 114 de la clínica 2). en la selección de la muestra se respetaron criterios probabilísticos (aleatorio sin reposición, teniendo en cuenta los criterios de elegibilidad). el cálculo de la muestra presentó un intervalo de confianza del 95 % y un error de la muestra del 5 % (36), para una muestra mínima necesaria de 192 personas (103 en la clínica 1 y 89 en la clínica 2). posterior a esta fase, se realizó una selección aleatoria sin reposición. del grupo de personas escogidas en la clínica 1, seis personas rechazaron participar, dos fueron ingresadas y dos desistieron. ya en la clínica 2, cuatro personas rechazaron participar, dos fueron ingresadas y cinco desistieron. en total, se obtuvieron los datos de 171 personas, 93 de la clínica 1 (89 %) y 78 de la clínica 2 (88 %). la muestra se dividió en dos grupos: el primero, constituido por personas con erc que presentaron dolor en las últimas 24 horas, y el segundo, por personas con erc que no presentaron dolor. el cuestionario aplicado fue realizado por 93 personas con erc que presentaron dolor en las últimas 24 horas. para la recogida de los datos se utilizaron los siguientes instrumentos: la versión corta del bpi (6,7); el índice de bienestar personal (ibp) (32); la versión portuguesa de la subjective happiness scale (shs) (33), para evaluar la felicidad subjetiva; la versión portuguesa de la positive and negative affect schedule (panas) (34), para analizar el afecto positivo y el afecto negativo; y la 12-item short form health survey (sf-12) (7,19), un instrumento que permite caracterizar el perfil sociodemográfico y clínico de la muestra (edad, sexo, nacionalidad, escolaridad, actividad profesional, estado civil, tiempo de diálisis y presencia de hipertensión arterial y de diabetes mellitus). el ibp tiene siete ítems/dominios (satisfacción con el nivel de vida, salud, realización personal, relaciones personales, sentimiento de seguridad, integración en la comunidad y sentimiento de seguridad con el futuro) que pretenden evaluar la “satisfacción con la vida en general” (32). la shs está constituida por cuatro ítems, dos de los cuales corresponden a afirmaciones sobre la felicidad mediante comparación con los otros, tanto en valores absolutos como en relativos (ítems dos y tres), y los otros dos ítems son descripciones acerca de la felicidad y la infelicidad. la versión portuguesa presenta una solución unifactorial con una fiabilidad interna y un alfa de cronbach de 0,76 (33). la panas está constituida por dos subescalas: una referente al afecto positivo (ap) y otra al afecto negativo (an), cada una con diez ítems, que se evalúan mediante una escala tipo likert, con puntuaciones de uno a cinco. el ap y el an están más presentes cuanto mayor sea la puntuación, siendo 50 la puntuación máxima. las cualidades psicométricas de la panas, en su versión portuguesa, revela una estructura compuesta por dos factores, tal como la original. su consistencia interna presenta un valor alfa de cronbach de 0,86 (en la original es de 0,88) para la escala de ap y de 0,89 (en la original es de 0,87) para la escala de an (34). el sf-12 es un cuestionario de salud desarrollado en estados unidos, validado para varios países, de diferentes continentes. permite medir la calidad de vida relacionada con la salud o su percepción, mediante doce ítems con un componente sumario físico y uno mental, en que los constructos se evalúan mediante una escala tipo likert, con puntuaciones de tres a cinco (7). en su versión traducida y adaptada al portugués se confirma una fiabilidad y validez satisfactoria. la versión corta del bpi está constituida por un diagrama para registrar la localización del área dolorosa en una figura humana, por escalas para la evaluación de la intensidad e impacto del dolor, en las que la intensidad de dolor es registrada mediante escalas numéricas que varían entre 0 (ningún dolor) y 10 (el peor dolor posible) y por un conjunto de afirmaciones sobre las actividades de vida de la persona, la actividad general, el estado de ánimo, la capacidad de caminar, el trabajo, las relaciones sociales, el sueño y la capacidad de diversión, medidas en una escala con diez valores (desde ninguna interferencia hasta interfiere completamente) (5-7). el análisis factorial confirmatorio corroboró la presencia de un único factor (6,7). en la versión portuguesa del bpi, la consistencia interna presenta un valor alfa de cronbach de 0,82 (6) y de 0,91 (7). el análisis de los datos del sf12 se realizó mediante el quality metric health outcomes™ scoring software 4.5. los restantes análisis estadísticos se hicieron con el statistical package for social sciences (spss) versión 20.0. la reproductibilidad se estudió por medio de la confiabilidad interna y la estabilidad. el estudio de la confiabilidad se realizó mediante el cálculo del alfa de cronbach, y el de la estabilidad, a través del test-retest, en el que se calculó el coeficiente de correlación intraclase (cci) y el coeficiente de correlación de spearman-brown (21,37-38) (pasadas 48 a 96 horas, en 17 personas seleccionadas aleatoriamente; 9 a través de cuestionario y 8 47 validación del brief pain inventory en personas con enfermedad renal crónica l luís manuel mota de sousa y otros de entrevista). en el presente estudio se adoptó un valor mínimo satisfactorio de consistencia interna de 0,70 (37,38). en este estudio se analizó la validez de constructo, concurrente y discriminativa. para la validez de constructo se utilizó el análisis factorial exploratorio, mediante el método de máxima verosimilitud, con rotación varimax. la idoneidad se evaluó a través de la prueba kaiser-meyer-olkin (kmo) y test de esfericidad de bartlett. se consideró adecuada cuando la varianza fuese superior al 50 % y el valor de kmo fuera superior a 0,70 (37,38). para analizar la validez concurrente se utilizó el coeficiente de correlación de spearman entre la severidad del dolor y la interferencia del dolor (bpi), con recurso al ibp y la shs; la af y la an se obtuvieron mediante la panas, y el componente físico y mental de la calidad de vida se calcularon a través del sf12. para verificar la validez predictiva de las dimensiones del ibp se realizó un análisis de regresión múltiple jerarquizada. en el primer paso se introdujeron las variables edad, sexo, tiempo de diálisis, hipertensión arterial y diabetes. en el segundo paso se colocaron las variables de bienestar (felicidad subjetiva, índice de bienestar personal, afecto positivo y negativo) y calidad de vida (componente físico y mental). el valor de significancia adoptado fue p < 0,05. se solicitó y obtuvo la autorización de los autores de las versiones portuguesas de la shs (32), la ibp (31), la panas (33) y la bpi (6-7), para su utilización. se obtuvo una licencia retrospectiva del sf12 (n.º qm030904). la realización de este estudio fue aprobada por el comité de ética de diaverum (n.º 1/2015). todos los participantes firmaron el documento de consentimiento libre y esclarecido después de haber sido informados sobre la garantía de sigilo acerca de sus datos y de su derecho a desistir, sin perjuicio para este. resultados el perfil sociodemográfico y sanitario de los participantes en el estudio de validación de la versión corta de la bpi (6,7) se presenta a continuación: la media de edad de la muestra fue de 60,7 ± 14,7 años, constituida mayoritariamente por hombres (52,7 %). en relación con la nacionalidad, el 81,7 % de la muestra es portuguesa; el 10,8 %, caboverdiana; el 3,2 %, santotomense; el 3,2 %, angolana, y el 1,1 %, guineana. en lo concerniente a escolaridad, el 44,6 % realizó 4º grado de enseñanza obligatoria; el 15,2 %, 6º; el 15,2 %, 9º; el 10,9 %, 12º, de bachillerato; el 8,7 % tiene un curso superior, y el 5,4 % es analfabeta. en cuanto al estado civil de los participantes, un 55,9 % está casado; el 22,6 % se encuentra soltero; un 15,1 % está viudo, y un 6,5 % es divorciado. en lo que se refiere a la actividad profesional, el 75,6 % está jubilado y el 24,4 % tiene una actividad profesional regular. en referencia a los datos sanitarios, los sujetos de la muestra realizan hd hace 79,2 (±56,1) meses, el 67,7 % presenta hipertensión arterial y el 30,1 % tiene diabetes. en relación con las propiedades psicométricas de la bpi, el valor del coeficiente alfa de cronbach varió de 0,87 a 0,90, después de excluir cada una de las dimensiones existentes. en el estudio de la estabilidad (test-retest), los datos que se obtuvieron mediante cuestionario (n = 9) presentaron un alfa de cronbach global en la primera evaluación de 0,86, y en la segunda, de 0,94. se obtuvo un coeficiente de correlación de spearman-brown de 0,91 y un cci de 0,94 (ic 95 %: 0,86-0,98; p < 0,001). los datos obtenidos mediante entrevista (n = 8) reflejan un alfa de cronbach global en la primera evaluación de 0,82, y en la segunda, de 0,87. el coeficiente de correlación de spearman-brown fue de 0,85, y el cci, de 0,91 (ic 95 %: 0,78 a 0,97; p < 0,001), por lo que se puede inferir que la consistencia y estabilidad entre las diferentes evaluaciones fueron buenas, tanto mediante el autocuestionario como por entrevista. en la validez de constructo, el análisis factorial exploratorio presentó un kmo de 0,85; entre tanto, el test de esfericidad de bartlett χ2[55] = 703,412 con un p < 0,001 y una solución bifactorial que fue responsable por el 66,5 % de la varianza explicada del constructo. todos los ítems fueron cargados en los dos factores, con cargas factoriales adecuadas (es decir > 0,45; tabla 1). las comunalidades (h2) variaron entre 0,22 y 0,98. el coeficiente alfa de cronbach de la interferencia provocada por el dolor y la intensidad fueron superiores a 0,70. en la tabla 2 se comprueba que cada dimensión se correlaciona más fuertemente con el factor al que pertenece, y en relación con el otro factor. esto prueba la validez discriminativa de las dimensiones. en el estudio de la validez convergente se comprueba que la severidad del dolor presenta una correlación positiva moderada con la interferencia provocada por el dolor y con el an. por otro lado, la severidad del dolor presenta una correlación negativa moderada con el componente físico de la calidad de vida. la interferencia provocada por el dolor presenta una correlación positiva moderada con el an, y negativa moderada con los componentes físico y mental de la calidad de vida (tabla 3). 48 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 tabla 1. análisis factorial exploratorio de la bpi en personas con erc, lisboa, portugal, 2015 tabla 2. correlaciones bicaudales de spearman ítem/factores de la escala bpi, en personas con erc, lisboa, portugal, 2015 dimensiones de la brief pain inventory factor 1 id factor 2 sd h2 1. dolor máximo en 24 horas 0,53 0,66 0,71 2. dolor mínimo en 24 horas 0,08 0,60 0,37 3. dolor medio en 24 horas 0,27 0,95 0,98 4. dolor en el momento actual 0,14 0,45 0,22 5. actividad general 0,87 0,25 0,81 6. estado de ánimo 0,78 0,26 0,67 7. capacidad para andar a pie 0,78 0,11 0,61 8. trabajo normal 0,85 0,16 0,74 9. relaciones con otras personas 0,66 0,20 0,47 10. sueño 0,57 0,34 0,43 11. placer de vivir 0,58 0,19 0,38 números propios (eigen value) 4,43 1,679 varianza explicada 51,24 % 15,26 % coeficiente alfa 0,90 0,80 média (dp) 28,4 (± 19,9) 15 (± 8,3) h2: comunalidades; id: interferencia del dolor; sd: severidad del dolor. fuente: elaboración propia. dimensiones de la brief pain inventory factor 1 interferencia del dolor factor 2 severidad del dolor 1. dolor máximo en 24 horas 0,62*** 0,78*** 2. dolor mínimo en 24 horas 0,19 0,67*** 3. dolor medio en 24 horas 0,47*** 0,84*** 4. dolo en el momento actual 0,26* 0,67*** 5. actividad general 0,86*** 0,51*** 6. estado de ánimo 0,83*** 0,52*** 7. capacidad para andar a pie 0,78*** 0,36** 8. trabajo normal 0,85*** 0,41*** 9. relaciones con las otras personas 0,80*** 0,42*** 10. sueño 0,72*** 0,44*** 11. placer de vivir 0,71*** 0,44*** *p < 0,05; **p < 0,01; ***p < 0,001. fuente: elaboración propia. tabla 3. validez concurrente y confiabilidad de las medidas, lisboa, portugal, 2015 variables severidad del dolor interferencia del dolor sd id 0,54*** fs 0,04 −0,13 sgv/ibp −0,11 −0,09 ap 0,06 0,20 na 0,32** 0,34*** cfqv −0,33** −0,40*** cmqv −0,15 −0,47*** *p < 0,05; **p < 0,01; ***p < 0,001 id: interferencia del dolor; sd: severidad del dolor; fs: felicidad subjetiva; sgv/ibp: satisfacción general con la vida; ap: afectividad positiva; an: afectividad negativa; cfqv: componente físico de la calidad de vida; cmqv: componente mental de la calidad de vida. fuente: elaboración propia. en la tabla 4 se comprueba que la puntuación de la interferencia del dolor, después de controladas la edad, el sexo, el tiempo de diálisis, la hipertensión arterial y la diabetes se explica en un 63 % a través de la svg/ibp, la an y la calidad de vida. la interferencia del dolor recibe influencia positiva a través de la svg/ibp y el an; pero, pese a esto, recibe influencia negativa del componente físico y mental de la calidad de vida. la varianza de la severidad del dolor se explica en el 63 % mediante las variables predictivas. la severidad del dolor se ve influenciada positivamente por la felicidad subjetiva y el an, aunque también recibe influencia negativa de la ap. tabla 4. regresión múltiple de la bpi con variables predictivas, en personas con erc, lisboa, portugal, 2015 modelos interferencia del dolor severidad del dolor 1º β 2º β 1º β 2º β edad 0,058 0,108 sexo −0,151 −0,032 tiempo de diálisis 0,212 0,103 hipertensión arterial 0,095 −0,104 diabetes 0,164 0,032 edad −0,116 0,011 49 validación del brief pain inventory en personas con enfermedad renal crónica l luís manuel mota de sousa y otros *p < 0,05; **p < 0,01; ***p < 0,001 fs: felicidad subjetiva; sgv/ibp: satisfacción general con la vida; ap: afectividad positiva; an: afectividad negativa; cfqv: componente físico de la calidad de vida; cmqv: componente mental de la calidad de vida. fuente: elaboración propia. discusión los valores de confiabilidad obtenidos para la severidad del dolor fueron semejantes a la muestra de tailandia (α = 0,81) (9), del líbano (α = 0,82) (9) y china (α = 0,82) (21); presentaron diferencias con las muestras de rusia (α = 0,93) (20) y de corea (α = 0,96) (18). en la dimensión interferencia del dolor en las actividades de la vida, se presenta semejante a las muestras de tailandia (0,89 e 0,90) (9,10) y españa (0,89) (12); sin embargo, se obtuvieron valores diferentes de los de las muestras de grecia (α = 0,85) (11) y de corea (α = 0,96) (18). los valores alfa que se obtuvieron en este estudio se consideran buenos (37). en relación con la estabilidad, esta escala es reproducible en las dos modalidades de recogida de datos (cuestionario y entrevista). en el estudio que se realizó en alemania, el coeficiente de correlación entre las dos medidas (antes y después de la consulta) fue del 0,98 para la severidad del dolor y del 0,97 para la interferencia del dolor (8). en la muestra tailandesa, el coeficiente de correlación varió entre el 0,67 y el 0,80 (9). en el estudio español el test-retest fue de 0,77 para la severidad del dolor y de 0,54 para la interferencia del dolor (12). los valores de correlación en el presente estudio son superiores al 0,7, lo que indica que existe una buena estabilidad en las medidas realizadas (37). en la validez de constructo, todas las dimensiones se cargaron en un único factor, con cargas factoriales superiores al 0,57, que se confirmaron con valores idénticos a los de otros estudios (8,10,12,16,18,19). los valores de kmo son semejantes a los de otros estudios (0,86 [8] y 0,88 [12]) y diferentes a los de la muestra griega (0,79) (11). en este estudio, los valores de kmo son buenos y revelan que el modelo se adapta a los datos (37). se confirmaron los dos factores (severidad e interferencia del dolor), obtenidos en otras culturas (6-13,15,16,18-22) excepto en las muestras provenientes de noruega (14) y de estados unidos (17), que revelaron una estructura factorial con tres dimensiones (factor 1: interferencia en la actividad diaria; factor 2: interferencia en el humor; factor 3: severidad del dolor). la varianza explicada de los factores presenta un valor superior al 50 % (37,38), semejante a la muestra española (12), lo que difiere de los valores de las muestras de italia (51 %) (13) y de rusia (80 %) (20). en el análisis de la validez predictiva de los ítems/factor las correlaciones fueron próximas del 0,70, lo que indica que el ítem está fuertemente correlacionado con la dimensión a la que pertenece. en el estudio de la validez convergente, el bpi presenta correlaciones moderadas con el afecto negativo medido en la panas y con la calidad de vida medida por los sf12. cuando las puntuaciones de severidad del dolor aumentan, también lo hacen las puntuaciones del afecto negativo y disminuye la puntuación del componente físico de la calidad de vida. cuando la puntuación de la severidad del dolor aumenta, la puntuación del afecto negativo se incrementa y disminuye la puntuación del componente físico de la calidad de vida. para algunos autores existe validez concurrente con correlaciones superiores a los 0,3 (37). en estudios anteriores, la validez concurrente o validez criterio se confirmó a través de la correlación con la calidad de vida sf12 (6,7,19), sf36 (8), whoqol (19); la ansiedad y la depresión (hospital anxiety and depression scale) (6,7) y el dolor (visual analogue scale [6] y mcgill pain quest [22]). en el estudio de la validez de criterio, todas las correlaciones fueron superiores al 0,3 (6,8,22). en relación con la validez predictiva, los componentes físico y mental de la calidad de vida influencian negativamente la interferencia del dolor. modelos interferencia del dolor severidad del dolor 1º β 2º β 1º β 2º β sexo −0,042 −0,015 tiempo de diálisis 0,069 −0,116 hipertensión arterial 0,053 −0,078 diabetes 0 −0,005 fs −0,145 0,306*** svg 0,330** 0,093 ap 0,149 −0,071*** an 0,361*** 0,545*** cfqv −0,640*** −0,602 cmqv −0,342*** −0,015 f[gl] 1,964[5] 14,126[6] 0,559[5] 7,591[6] r 0,18 0,63 0,33 0,76 adjusted r2 0,05 0,52 −0,03 0,31 r2 change 0,11 0,47*** 0,03 0,36*** 50 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 las personas con erc con puntuaciones más bajas en los componentes físico y mental presentan una interferencia del dolor en las actividades de vida más elevada. las personas con una puntuación elevada de afecto negativo también presentan niveles más elevados en la interferencia del dolor en las actividades de vida. las puntuaciones altas en la satisfacción con la vida, en general, influencian las puntuaciones altas en la interferencia con el dolor. esto puede significar que las personas con erc, a pesar de presentar interferencia del dolor en sus actividades, continúan satisfechas con la vida en general. existieron otras variables moderadoras como la espiritualidad, o sea, que las personas más espirituales enfrentan mejor el dolor crónico, lo que ayuda a preservar la calidad de vida relacionada con la salud (39-41). estos resultados se asemejan a los de la versión del portugués europeo (6,7), y sugieren que las medidas de severidad del dolor e interferencia del dolor son válidas y confiables para evaluar el impacto del dolor. en otros estudios con personas con dolor no oncológico (42), lupus (43), dolor neuropático y nociceptivo (44), cáncer y leucemia tipo b (45) también quedó demostrado que el bpi es válido y fiable para evaluar la interferencia y la severidad del dolor. la versión portuguesa del bpi en personas con erc también presenta buenas propiedades psicométricas, por lo que es confiable y reproducible. este estudio utilizó una muestra representativa de personas con erc sometidas a hd. en futuras búsquedas se sugiere la realización de un análisis factorial confirmatoria del bpi y analizar la validez concurrente/divergente con medidas del estrés, ansiedad y depresión en esta población específica. una vez que estas medidas traducen indicadores sanitarios que influencian la calidad de vida en las personas con erc (4), se recomienda a los enfermeros e investigadores en salud la utilización de estas medidas de severidad e interferencia del dolor en investigaciones futuras en enfermería. el presente estudio presenta una limitación, relacionada con la utilización de la versión del sf12, que no ha sido aprobada por los autores; sin embargo, los autores concedieron la licencia para tratar los datos, alertando que pudiesen existir limitaciones en la fiabilidad y validez externa de los resultados. conclusiones la versión portuguesa del bpi presenta propiedades psicométricas adecuadas y ajustadas a las personas con erc. en el presente estudio se encontraron resultados que dan soporte para la estructura bifactorial de esta escala, así como para la confiabilidad y estabilidad. la bpi presenta dos medidas de severidad del dolor e interferencia del dolor en las actividades de vida, que son válidas y reproducibles para que sean aplicadas sobre la forma de cuestionario o entrevista, en personas con erc, para evaluar el impacto del 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1;13(11):1417-24. 159 168 management of continuous.indd 159 öznur tiryaki1 nursan cinar2 management of continuous positive airway pressure in the newborn: impact of lecture-based interactive workshops on training for neonatal intensive care nurses 1 sakarya maternity and children’s hospital, neonatal intensive care unit, sakarya/turkey. oznuritiryaki@gmail.com 2 sakarya university school of health sciences, department of peadiatric nursing, sakarya/turkey. ndede@sakarya.edu.tr recibido: 05 de noviembre de 2015 enviado a pares: 21 de noviembre de 2015 aceptado por pares: 27 de enero de 2016 aprobado: 29 de enero de 2016 doi: 10.5294/aqui.2016.16.2.4 para citar este artículo / to reference this article / para citar este artigo tiryaki o, cinar n. management of continuous positive airway pressure in the newborn: impact of lecture-based interactive workshops on training for neonatal intensive care nurses. aquichan. 2016; 16(2): 159-168. doi: 10.5294/aqui.2016.16.2.4 año 16 vol. 16 nº 2 chía, colombia junio 2016 l 159-168 abstract objectives: the aim of this study was to determine how training imparted via structured workshops related to management of continuous positive airway pressure in the newborn affects the knowledge of neonatal intensive care nurses. methods: a group of nurses attended an interactive lecture-based workshop on management of continuous positive airway pressure in the newborn. the nurses in question had accepted an invitation to the presentation prior to the training event. information on the participants’ differentiating features was collected via a questionnaire prepared by the researchers themselves. an evaluation of the nurses’ knowledge on the subject was performed through a multiple choice questionnaire (mcq) prepared by the researchers in relation to the literature. after the mcq was prepared, it was mailed to experts in turkey (7 people) and experts from abroad (5 people), and their opinions were considered. in light of their suggestions, the mcq was given its final form and the number of questions was set at 20. the mcq consisting of 20 questions was answered by the participants before and after the interactive workshop. the participants were not informed as to whether or not the test would be repeated after the training. results: thirty-six nurses from the neonatal unit took part in the study. each question in the mcq was considered as one (1) point. the maximum possible score on the test was 20. there was a significant improvement in the mean test score after the lecture, when compared to the pre-lecture score (mean = 19.6, sd=0.8 vs. mean =13.1, sd=3.0, p<0.001). conclusions: a lecture-based inter active workshop on management of continuous positive airway pressure in newborns helps to improve nurses’ knowledge. it also helps to overcome deficiencies in nurse training. 160 aquichan issn 1657-5997 año 16 vol. 16 nº 2 chía, colombia junio 2016 l 159-168 keywords continuous positive airway pressure, newborn health services, nurse, training, knowledge (source: decs, bireme). manejo de la presión positiva continua en las vías respiratorias en el recién nacido: el impacto de talleres interactivos basados en conferencias sobre la formación de las enfermeras de cuidados intensivos neonatales resumen objetivos: el objetivo de este estudio fue determinar cómo la formación impartida a través de talleres estructurados relacionados con el manejo de la presión positiva continua en las vías respiratorias en el recién nacido afecta el conocimiento de las enfermeras que trabajan en cuidados intensivos neonatales. métodos: un grupo de enfermeras asistieron a un taller interactivo basado en una conferencia sobre el manejo de la presión positiva continua en las vías respiratorias en el recién nacido. las enfermeras en cuestión habían aceptado una invitación para asistir a la presentación antes del evento de capacitación. la información sobre las características diferenciadoras de los participantes se recogió a través de un cuestionario elaborado por los propios investigadores. una evaluación de los conocimientos de las enfermeras sobre el tema se llevó a cabo a través de un cuestionario de selección múltiple (csm), el cual fue elaborado por los investigadores en relación con la literatura. el csm fue enviado por correo a unos expertos en turquía (siete personas) y unos expertos en el exterior (cinco personas), y sus opiniones fueron tomadas en cuenta. a la luz de sus sugerencias, al csm se le dio su forma final y el número de preguntas se fijó en 20. el csm, que consta de 20 preguntas, fue respondido por los participantes antes y después del taller interactivo. a los participantes no se les dijo si la prueba se repitió después del taller de formación. resultados: treinta y seis enfermeras de la unidad neonatal participaron en el estudio. cada pregunta en el csm se consideró como un (1) punto. la puntuación máxima posible en la prueba fue 20. hubo una mejora significativa en la puntuación de la prueba media después de la conferencia, si se compara con la puntuación preconferencia (media = 19,6, sd = 0,8 vs. media = 13,1, sd = 3.0, p <0,001). conclusiones: un taller interactivo basado en una conferencia sobre el manejo de la presión positiva continua en las vías respiratorias en el recién nacido ayuda a mejorar el conocimiento de las enfermeras. también ayuda a superar las deficiencias en la formación de enfermeras. palabras clave presión positiva continua en las vías respiratorias, servicios de salud para el recién nacido, enfermera, formación, conocimiento (fuente: decs, bireme) 161 management of continuous positive airway pressure in the newborn: impact of lecture-based interactive workshops on training for neonatal... l öznur tiryaki and other año 16 vol. 16 nº 2 chía, colombia junio 2016 l 159-168 manejo da pressão positiva contínua nas vias respiratórias no recém-nacido: o impacto de oficinas interativas baseadas em conferências sobre a formação das enfermeiras de cuidados intensivos neonatais resumo objetivos: o objetivo deste estudo é determinar como a formação ministrada nas oficinas estrturadas relacionadas com o manejo da pressão positiva contínua nas vias respiratórias no recém-nascido afeta o conhecimento das enfermeiras que trabalham em cuidados intesivos neonatais. métodos: um grupo de enfermeiras participaram de uma oficina interativa baseada numa conferência sobre o manejo da pressão contínua nas vias respiratórias no recém-nascido. as enferemeiras em questão tinham aceitado um convite para comparecer à apresentação antes do evento de aperfeiçoamento. a informação sobre as características diferenciadoras dos participantes foi coletada por meio de um questionário elaborado pelos próprios pesquisadores. uma avaliação dos conhecimentos das enfermeiras sobre o tema foi realizado mediante questionário de múltipla escolha (qme), o qual foi elaborado pelos pesquisadores de acordo com a literatura. o qme foi enviado por e-mail a sete especialistas na turquia e a outros cinco no exterior, e suas opiniões foram consideradas. à luz das sugestões, o qme, que consta de 20 perguntas, foi respondido pelos participantes antes e depois da oficina interativa. resultados: 36 enfermeiras da unidade neonatal participaram do estudo. cada pergunta do qme foi considerada como (1) ponto. a pontuação máxima possível na prova foi 20. houve uma melhora significativa na pontuação da prova média depois da conferência, se comparada com a pontuação pré-conferência (media = 19,6, sd = 0,8 vs. media = 13,1, sd = 3.0, p <0,001). conclusões: uma oficina interativa baseada numa conferência sobre o manejo da pressão positiva contínua nas vias respiratórias no recém-nascido ajuda a melhorar o conhecimento das enfermeiras e a superar as deficiências na sua formação. palavras-chave pressão positiva contínua nas vias respiratórias, serviços de saúde para o recém-nascido, enfermeira, formação, conhecimento (fonte: decs, bireme). 162 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 introduction the most common admission to neonatal intensive care units (nicu) is due to respiratory problems. the causes of respiratory distress are respiratory distress syndrome (rds), transient tachypnea of the newborn (ttn), meconium aspiration syndrome (mas) and pulmonary infection (1). the most commonly used treatment for supporting the respiration of a newborn and the first-preferred treatment option at the third level nicu is continuous positive airway pressure (cpap) administration (2). cpap was first defined in the literature by gregory et al. in 1971 (3) and was used to support respiration in infants diagnosed with rds (4). in general, several centimeters of water (cmh2o) are applied through the nose to the airways for cpap (5). this application also is used for preventing atelectasis and conserving the functional residual capacity (frc) remaining in the alveolar due to positive pressure in the newborn with spontaneous respiration (6). cpap through the nose can be applied with single or double prongs, in either short (into the nose) or long (nasopharynx) form and with masks (6,7). cpap is generated by exhalation against a constant opening pressure; this produces positive endexpiratory pressure (peep) (8). the treatment usually starts with 5 cmh 2 o pressure and can go up to 10 cmh 2 o pressure, depending on the clinical condition of the infant (7). among the cpap methods, the most popular and the most frequently used are bubble cpap (in b-cpap, the positive pressure in the circuit is achieved by simply immersing the distal expiratory tubing in a water column to a desired depth rather than using a variable resistor) and ventilatory cpap (in v-cpap, a variable resistance in a valve is adjusted to provide resistance to the flow of air) (9). cpap develops a synchronisation between thorax and abdominal movement and improves the function of the diaphragm (3), increases the formation of surfactant and frc, and reduces the need for intubation and surfactant treatment (10). it is also a popular alternative to intubation (11). cpap decreases the need for ventilation in infants born between 25 and -28 weeks of pregnancy, and the need to be transferred to hospitals with third level intensive care units for infants born before the 32nd week of pregnancy (3). early cpap use also decreases the incidence of bronchopulmonary dysplasia (bpd) and the administration of oxygen at home following discharge (12). a health staff (a doctor, a nurse) is needed for cpap administration. the nurse should be informed about the side effects of cpap (pneumothorax, distension, nasal injuries, etc.), and should be able to diagnose the presenting problem (4). being an inexpensive and safe application, cpap can be administered by nurses following short-term training; thus, its effectiveness or failure is related to adequacy of the nurse’s care and knowledge (4, 13, and 14). this study was performed starting with the hypothesis that this type of interactive training carried out via a powerpoint presentation, prepared according to the literature and in light of expert views, would be effective and meet the needs on the issue. we became interested in this subject given the lack of sources in turkish resources on cpap and its administration, and the fact that neonatal nurses require education on the subject. this study aims to determine how the training imparted to nicu nurses via an interactive workshop on the care of newborns requiring cpap affects their level of knowledge. our hypothesis in this study is that the mcq score for participating nurses increases after the interactive workshop. materials and methods this pre / posttest experimental study was conducted in a city in the marmara region during april 2014. approval for the study was obtained from the university ethical committee in that city. required approval for the nurses who would participate in the study was obtained from a university, a state hospital and two private hospitals. some of the participating nurses had to be on duty while the study was conducted, so it was possible to reach a total of 73.4 % (36/49) of the intended population . the sample group was comprised of 36 nurses who volunteered to take part in the study. information on the participants’ identifying features was collected via a questionnaire prepared by the researchers themselves. the evaluation of the data obtained from the participants was done by the researchers using a multiple choice questionnaire (mcq) prepared in light of the literature. after the mcq was prepared, it was presented to 14 experts for their opinion; 12 of those experts responded (85.7 %). it was sent to seven (7) people in turkey and five (5) people abroad who were considered to be experts on the subject, and their opinions were obtained. the experts found the mcq to be appropriate for specific research content. three expression changes were proposed and all 20 questions were found to be appropriate. based on their suggestions, the mcq was given its final form and the number of questions was set at 20 (attachment a). every true answer received 1 163 management of continuous positive airway pressure in the newborn: impact of lecture-based interactive workshops on training for neonatal... l öznur tiryaki and other point, and every false answer was scored as 0. the lowest possible score on the mcq is 0 and the highest is 20. the participating nurses attended an interactive lecture-based workshop on cpap management in newborns. they had accepted an invitation to the presentation prior to the training event. the study was conducted in the conference hall of a university hospital with the participation of 36 nurses who were working in neonatal departments. their participation in the study was voluntary. a pre-lecture mcq test was completed by the nurses to test their existing knowledge. the questions in the mcq were derived from the topic covered in the presentation. following the lecture, the mcq test was repeated to assess retention and application of the knowledge derived from the interactive lecture. the participants did not know they would be tested with an mcq, which would be repeated at end of the workshop. the lecture consisted of a powerpoint presentation. it was followed by an interactive session of discussions, questions and answers, which continued until it was noted the participants had increased their knowledge. statistical analysis the data were analyzed with spss 16. the kolmogrov simirnow test was used to determine if the data show a normal distribution . the wilcoxon signed rank test was used, since the data did not show a normal distribution. pre-test and post-test results were found to be statistically significant, according to the wilcoxon s rank test (z= -5.239, p= .000). the wilcoxon signed test was used because we compared the total score before and after the lecture, rather than each answer in the questionnaire, and the data did not have a normal distribution. the test is two dimensional, which meets the hypothesis that there is a difference (table 1). findings thirty-six female nurses participated in the study. in all, 36.1 % (13/36) of the nurses had a graduate degree, 50 % (18/36) had been working at the nicu for 1-5 years, 44.4% (16/36) had nicu nursing certificates, and 33.3 % (12/36) had neonatal resuscitation program certificates. thirty-six nurses attended the workshop. there was a statistically significant improvement in their test scores after the lecture, when compared to the prelecture scores (pre-test min. 6 points/max.19 points mean: 13.11 sd:3.022, post-test min.17 points/max.20 points mean:19.61 sd: 0.838, z= 5.239, p= .000) (table 2). discussion this study was conducted to determine the levels of knowledge nurses have with respect to cpap and to evaluate the effects of the training imparted on this subject. in general, the nurses were keen on the study since they found it interesting. the participants in this study were at nurse training grades, had been qualified four years previously, and were actively working at nicus. consequently, they would be expected to have a reasonable understanding of cpap management in newborns. the pre-test score on the 20 questions prepared through the suggestions of experts in light of the literature was low (mean: 13.1 sd: 3.022 ), indicating the nurses did not have enough knowledge on the subject. the participants were shown an interactive powerpoint presentation containing the answers of those questions, and a post-test was applied with the same questions. the post-lecture test score showed a significant increase (mean: 19.61 sd: 0.838). it is observed that these kinds of studies aimed at the nurse’s skills and knowledge aid improvement through appropriate practice (15,16,17). suggestions it is inevitable to have regular updates for nurses who perform a significant role in newborn care and to provide the necessary evidence-based nursing applications in cpap practice, which is being used increasing on a regional and international basis. the effectiveness of the teaching method, which can be used to meet this need, was examined in this research. the questions here can be used in both regional and international studies and in nurse training, if updated according to the literature. limitations of the study one of the limitations of this study was that all the nurses working in the study area related to the subject could not be reached. there are 49 nurses working at neonatal departments. a total of 74.3 % (36/49) were able to participate in the study. some of the nurses could not take part, because they were on 164 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 duty at the time the study was conducted. to compensate for this drawback, a new workshop program was planned for the nurses who could not participate initially. these kinds of educational studies conducted with small groups are an effective way to make up for a lack of information and to correct false beliefs. the methods applied and the information obtained could help future researchers set a base and establish more sample groups. it is possible to improve the quality and safety of newborn care by having nurses acquire sufficient knowledge and skills. the method used in this study proved to be efficient, since it helped to increase the knowledge of the nurses who took part. the nurses in our study were assessed only as to the extent of their knowledge. it is suggested that other studies be conducted to evaluate their skills on the subject in question. acknowledgements we wish to thank our esteemed specialists and nurses who participated and supported us by evaluating the multiple choice questions used in the study. references 1. yagui acz, vale lapa, hadda lb et al. bubble cpap versus cpap with variable flow in newborns with respiratory distress: a randomized controlled trial. journal de pediatria 2011;87:499-503. 2. roberts cl, badgery-parker t, algert cs et al. trends in use of neonatal cpap: a population-based study. bmc pediatrics 2011;11:89. 3. sankaran k, adegbite m. noninvasive respiratory support in neonates: a brief review. chin j contemp pediatr 2012; 14:643-652. 4. bonner km, mainous ro. the nursing care of the infant receiving bubble cpap therapy. advances in neonatal care 2008;8:78-95. 5. morley c. which neonatal nasal cpap device should we use in babies with transient tachypnea of the newborn? journal de pediatria 2011; 87:466-467. 6. petty j. factsheet: understanding neonatal noninvasive ventilation. journal of neonatal nursing 2013;19:10-14. 7. de paoli ag, morley c, davis pg. nasal cpap for neonates: what do we know in 2003? arch dis child fetal neonatal ed 2003;88:168-172. 8. duke t. cpap: a guide for clinicians in developing countries. paediatr int child health 2014;34(1):3-11. 9. bijari bb, malekiyan a, niknafs p et al. bubble-cpap vs. ventilatory-cpap in preterm infants with respiratory distress. iran j pediatri 2011; 21: 151-158. 10. diblasi rm. neonatal noninvasive ventilation techniques: do we really need to intubate? respir care 2011;56:12731294. 11. de winter jp, de vries mag, zimmermann lji. clinical practice noninvasive respiratory support in [the] newborn. european journal of pediatrics 2010;169:777-782. 12. tood ad, wright a, broom m et al. methods of weaning preterm babies <30 weeks gestation off cpap: a multicentre randomised controlled trial. arch dis child fetal neonatal ed 2012;97:236-240. 13. koyamaibole l, kado j, qovu jd et al. an evaluation of bubble-cpap in a neonatal unit in a developing country: effective respiratory support that can be applied by nurses. journal of tropical pediatrics 2006;52:249-253. 14. heuvel mvd, blencowe h, mittermayer k et al. introduction of bubble cpap in a teaching hospital in malawi. annals of tropical paediatrics 2011;31:59-65. 165 management of continuous positive airway pressure in the newborn: impact of lecture-based interactive workshops on training for neonatal... l öznur tiryaki and other 15. altun i̇, çınar nd, barin öc. best practice techniques for administration of ınjections: impact of lecture based ınteractive workshops on training of nurses. pakistan journal of medical sciences 2010;26:152-157. 16. altuni̇ , zencirci ad. management of fever and hyperthermia: impact of lecture based ınteractive workshops on training of nurses. libyan journal of medicine 2010;5:5140. 17. altuni̇ , zencirci ad. knowledge and management of pressure ulcers: impact of lecture-based ınteractive workshops on training of nurses. advances in skin &wound care, journal for prevention and healing 2011;24:262-266. attachment a for each question given, select the single best answer from the choices provided (a to e) 1. what should be the approximate pressure used in cpap? a. 2-10 cmh 2 o b. 2-8 cmh 2 o c. 2-6 cmh 2 o d. 5-10 cmh 2 o e. 4-12 cmh 2 o 2) which of the following statements includes false information about cpap? a. for cpap, usually a few cmh2o of pressure is applied to the airways through the nose. b. cpap may be applied even if there is no spontaneous respiration. c. cpap is used especially in premature infants who have breathing problems (dyspnoea) in order to save the volume of the lungs and provide oxygenation. d. it is less invasive compared to a mechanical ventilator. e. it balances the exchange of gases by maintaining functional residual capacity. 3) which of the following is among the basic parameters used in cpap adjustment? a. a/c ( assist control) b. pip (peak inspiratory pressure) c. peep (positive end-expiratory pressure) d. i:e (inspirationexpiration ratio) e. simv (synchronized intermittent mandatory ventilation) 4) which of the following cannot be used in cpap application? a. single prong b. double prong c. a piece of endotracheal tube d. hyperbaric chamber e. nasal mask 5) which of the following is an indication that is seen in cpap application? a. gastroschisis b. atelectasia c. choanal atresia d. tracheoesophageal fistula e. omphalosel 6) which of the following is a condition in which cpap application should be avoided? a. respiratory distress syndrome b. decreased functional residual capacity c. diaphragmatic hernia d. meconium aspiration syndrome e. sleep apnea 7) which of the following cannot be regarded as an advantage of cpap? a. it increases oxygenation by relieving respiration function. b. it decreases the need for surfactant treatment. c. it decreases the rate of nosocomial infection / sepsis. d. it decreases the need for oxygen treatment at home after discharge from the hospital. e. it increases the incidence of chronic lung disease (cld) and bpd. 166 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 8) which of the following is not a complication of cpap? a. nutrition intolerance b. hyperemia of the nose, bleeding c. pneumothorax d. nasal septum injury e. stomach distension 9) which of the following statements is not true of newborn care with cpap? a. evaluation starts with a detailed newborn history. b. it involves auscultation of the chest and abdomen and evaluation of dyspnoea, respiration sounds and speed, groaning, retraction and complexion in the infant . c. the infant should be monitored and supported by newborn assistive breathing methods before it has breathing problems. d. blood gases should be analyzed. e. the infant should be evaluated in terms of gastrointestinal, neurological and thermoregulatory systems, as well as respiratory and cardiovascular systems. 10) how should the newborn’s head be positioned during cpap application? a. the head should be in hyperextension. b. the head should be raised by approximately 300 . c. the armpit should be supported by a roll, minimally at 5 cm. and positioned. d. the head should be supported by a thin pillow. e. the head should be in hyperflexion. 11) which of the following statements is true for newborn nursing care with cpap? a. the infant’s bonnet should be tight, so the prong will not slip. b. the infant’s bonnet should be at the level of the forehead and hair in the front and at the level of the hair in the back. c. the initial level of oxygen should be fio2 %100 in cpap. d. the ears should not be left curled under the bonnet. e. the bonnet has no important role in the positioning of cpap. 12) how should a cpap prong be moisturized before being fitted into the nose? a. with an oil-containing solution b. with sterilized water c. with an antimicrobial pomade d. with analgesic creams e. with local anesthetic ointments 13) which of the following statements is not true of infant nasal care with cpap? a. there would be an increase in secretion due to the presence of the prong in the nose. b. the infant should be aspirated as often as his/her clinical condition requires. c. aspiration should not be stiff; otherwise, there would be irritation and bleeding in the nasopharynx. d. prongs should fit in the nostrils completely, so as to leave no space. e. keeping the nasal area dry and clean would decrease the risk of infection. 14) which of the following statements is not true of cpap application? a. the patient circuit kit connected to the prong should not be bent. b. the moisturizing probe on the patient circuit should stay in the incubator. c. the kit should be heated as close to neutral heat. d. the air-oxygen mixture should be fully moisturized. e. the air-oxygen mixture should be between 36.8-37.3 0c. 15) which of the following is an advantage of the moisturized and heated air-oxygen mixture in cpap application? a. causes hypothermia b. causes hyperthermia c. prevents the drying of secretions d. causes infections e. heated air damages the nasal mucosa 167 management of continuous positive airway pressure in the newborn: impact of lecture-based interactive workshops on training for neonatal... l öznur tiryaki and other 16) which of the following statements contains false information about position tracing for an infant during cpap application? a. infants should be positioned every 3-6 hours, in accordance with their neurodevelopment . b. reducing sound and light would help cpap positioning. c. the trendelenburg position is preferred by many nurses, since it improves oxygenation and decreases the frequency of desaturation attacks. d. regular position changes will help skin care and allow for better observation of the infant. e. bundling up and kangaroo care may be applied. 17) which of the following is not among the benefits of kangaroo care for an infant in cpap application? a. it decreases intensive care stress in infants. b. it decreases the family’s anxiety. c. it reduces pain. d. it decreases the need for oxygen. e. periods of rest and sleep are disrupted. 18) how should the orogastric (og) probe be administered to an infant receiving cpap ? a. the application of og through the mouth of an infant who has a nasal prong would cause respiratory problems. b. it should be applied during feeding times and removed after nutrition. c. minimally, a 10 fr probe should be used regardless of the infant’s age in weeks. d. the og should be applied and its end should be left open. after nutrition, it should be turned off for a short time and then turned on again. e. if the infant receives continuous or bolus feeding, the tube is never aspired. 19) which of the following is not among the criteria for transfer to a mechanical ventilator from cpap? a. apnea, desaturation b. pco2 >65mmhg c. pao2 > 60 mmhg d. progressive hypoxemia e. severe breathing problems 20) which of the following statements is false information about cpap? a. success / failure in cpap is related directly to the health staff’s knowledge . b. it is a simple and inexpensive method. c. it requires a long period of training. d. the most widely used types are ventilatory cpap and bubble cpap. e. it is the most widely used treatment choice for newborn respiratory problems. answers: 1)d 2)b 3)c4)d 5)b 6)c 7)e 8)a 9)c 10)b 11)e 12)b 13)d 14)b 15)c 16)c 17)e 18)d 19)c 20)c 168 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 table 1. pre-workshop and post-workshop test scores pre-workshop test (n=36) post-workshop test(n=36) test* p mean ± sd mean ±sd mean (sd) 13.11 ± 3.022 19.61 ± 0.838 z= -5.239 0.000 * wilcoxon signed rank test, p < 0.001 source: author. table 2. demographic features of the participants n % age mean: 28.47 (min. 20/max. 45) educational status health high schools associate degree bachelor’s degree master’s degree 10 9 13 4 27.8 25 36.1 11.1 time working at a neonatal department less than 1 year 1-5 years 6-10 years more than 10 years 7 18 8 3 19.4 50 22.2 8.3 neonatal icu nursing course certificate yes no 16 20 44.4 55.6 neonatal resuscitation program certificate yes no 12 24 33.3 67.3 source: author. dilemas eticos frente.pmd revista aquichan issn 1657-5997 54 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 resumen este artículo tiene como objetivo, a través del análisis del evento adverso, resaltar la importancia del acto de cuidado de enfermería en el marco de la prestación ética de los servicios de salud. para tal fin se revisarán conceptos generales sobre ética, evento adverso y evento adverso en enfermería, para finalizar con unas recomendaciones para la garantía de la seguridad en la atención de los pacientes en un proceso específico de atención en enfermería: la administración de medicamentos. palabras clave this article’s purpose, using the adverse event analysis, is to highlight the importance of care nursing activity within rendering an ethical health service framework. thus, there will be reviewed some general concepts about ethics, as well as the adverse event and the adverse event in nursing, and finally finishing with some recommendations to guarantee the patient’s assistance safety in a particular process of nursing assistance: administration of medicines. ana isabel gómez córdoba1 ángela fernanda espinosa2 1 programa de medicina de la universidad del rosario. carrera 6 no. 14-16, bogotá, d.c., colombia. agomezc@urosario.edu.co 2 universidad del rosario. carrera 6 no. 14-16, bogotá, d.c., colombia. afespin@urosario.edu.co recibido: 2 de agosto de 2006 aprobado: 28 de agosto de 2006 abstract key words bio-ethics, adverse event, patient’s safety, care.bioética, evento adverso, seguridad del paciente, cuidado. ethical dilemmas facing the patient’s safety. care means ponder año 6 vol. 6 nº 1 (6) 54-67 chía, colombia octubre 2006 dilemas éticos frente a la seguridad del paciente. cuidar es pensar. ethical dilemmas facing the patient’s safety. care means ponder 55 a enfermería es un arte y si se pretende que sea un arte, requiere una devoción tan exclusiva, una preparación tan dura, como el trabajo de un pintor o un escultor, pero ¿cómo pueden compararse la tela muerta o el frío mármol con el tener que trabajar con el cuerpo vivo, el templo del espíritu de dios? es una de las bellas artes, casi diría la más bella de las bellas artes”. florence nightingale el ejercicio de la enfermería como disciplina profesional no se circunscribe únicamente al ámbito del cuidado (autocuidado, cuidado del paciente y su familia, la comunidad, las personas del equipo de salud y el medio ambiente), sino que incluye las actividades de investigación, docencia y gestión de los recursos de salud; estas últimas han adquirido recientemente una mayor relevancia en el ejercicio profesional, incluso relegando en algunos casos a un segundo plano el deber ético primario con el sujeto de cuidado, el cual implica un “juicio de valor y un proceso dinámico y participativo para identificar y dar prioridad a las necesidades y decidir el plan de cuidado de enfermería” (1). hace parte de los deberes de la enfermera, expresados en los códigos de ética de enfermería nacionales e internacionales, propender por que el cuidado de la salud en los distintos ámbitos se dé dentro del marco del aseguramiento de la calidad, es decir, que cumpla con las dimensiones de la calidad enunciadas por avidis donabedian (2): unos aspectos de índole técnico-científico (como son la oportunidad, seguridad, continuidad, accesibilidad y pertinencia), la adecuada relación interpersonal (expresada en el respeto a los derechos de los pacientes y sus familias y los adecuados procesos de comunicación), y el uso racional de los recursos de salud (1, 3). vale la pena aclarar que el aseguramiento de la calidad en la prestación de los servicios no es una responsabilidad única de las enfermeras, sino que concierne a la totalidad de actores del sistema (4). la seguridad de los pacientes es una prioridad de salud pública expresada en las políticas de organizaciones internacionales que velan por la calidad de los servicios de salud como son la organización mundial de la salud (oms), the institute of medicine y the joint commission de estados unidos, entre otros. por esta razón, el tema del evento adverso es una de las temáticas de la línea de investigación de bioética y derecho médico y sanitario, del grupo de investigación en educación de la facultad de medicina del rosario, reconocido por colciencias como categoría b. bioética: marco conceptual rensselaer van potter (médico oncólogo), en su libro bioethics bridges to the future (1971), define la bioética como el puente entre dos culturas: la de las ciencias y la de las humanidades, que permite combinar el conocimiento científico centrado en lo biológico y el humanístico orientado al entendimiento de valores humanos; es el estudio sistemático de la conducta humana en el área de las ciencias de la vida y la atención de la salud, a la luz de principios y valores morales. la bioética surge asociada al desarrollo de las ciencias biomédicas y su interacción con la vida, la aparición de sociedades plurales y secularizadas el aseguramiento de la calidad en la prestación de los servicios no es una responsabilidad única de las enfermeras, sino que concierne a la totalidad de actores del sistema. revista aquichan issn 1657-5997 56 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 que hacen más compleja la toma de decisiones en la relación enfermera-sujeto de cuidado, los servicios de salud cada vez más tecnificados, costosos y deshumanizados, entre otras razones. fernando savater define la ética “como una propuesta de reflexión sobre la propia libertad que consiste en buscar lo mejor y ayudar a cumplir el ideal del hombre”. en un dilema ético la materia de decisión es de carácter moral, es decir, cómo garantizar el respeto a los principios fundamentales de beneficencia (hacer el bien y balancear riesgos y beneficios), no maleficencia (no hacer daño y proteger de éste), autonomía (respecto a la autodeterminación) y justicia (equidad en el acceso y uso de recursos) para lograr que las consecuencias de nuestros actos generen el mayor bienestar a la mayoría de las personas involucradas. rushworth kidder aclara que un dilema ético no consiste en tener que hacer una elección entre lo correcto y lo incorrecto, sino en elegir entre dos cosas que son correctas, pero desde perspectivas distintas. una enfermera(o) debe estar entonces en capacidad de prevenir problemas o reconocer rápidamente los dilemas éticos, analizar y argumentar, y encontrar las posibles soluciones a éstos (5, 6, 7). el deber de cuidado se valora a la luz de lo que una enfermera razonable y prudentemente podría hacer en circunstancias similares. en este contexto, los problemas de seguridad en la atención de los pacientes se deben valorar a la luz de “las circunstancias de tiempo, modo y lugar que rodearon los hechos, y las precauciones que frente al mismo hubiera aplicado un profesional prudente y diligente” (1). seguridad del sujeto de atención y evento adverso: marco conceptual definiciones las definiciones que se exponen a continuación pertenecen al documento del institute of medicine, to err is human: building a safer health system (8). por seguridad del paciente se entiende “el conjunto de elementos estructurales, procesos, instrumentos y metodologías basadas en evidencia científicamente probada, que propenden por minimizar el riesgo de sufrir un evento adverso en el proceso de atención de salud o de mitigar sus consecuencias”. la seguridad hace parte de la caracterización de calidad de un servicio de salud con la oportunidad, la accesibilidad, la pertinencia y la continuidad. el evento adverso es una lesión resultante de la intervención de los servicios de salud que produce una dishabilidad que puede ser medida, podría decirse que es el daño del paciente ocasionado por el contacto de éste con un sistema de salud. existen múltiples formas de clasificar el evento adverso, una de las más útiles respecto a la definición de la responsabilidad ética, penal, civil y administrativa, es aquella que lo divide en evento adverso prevenible y no prevenible. el evento adverso no prevenible es la complicación que no puede ser prevenida dado el estado actual del conocimiento; el evento adverso prevenible es el mal resultado de la atención que puede ser prevenido con el estado del conocimiento. la seguridad hace parte de la caracterización de calidad de un servicio de salud con la oportunidad, la accesibilidad, la pertinencia y la continuidad. dilemas éticos frente a la seguridad del paciente. cuidar es pensar. ethical dilemmas facing the patient’s safety. care means ponder 57 se emplean otras denominaciones, como accidente (evento que implica daño a un sistema definido e interrumpe el proceso o los resultados futuros del sistema), complicación (evento adverso relacionado con el procedimiento de carácter inevitable), errores latentes (errores en el diseño, la organización, el entrenamiento y mantenimiento que llevan al operador a problemas cuyos efectos permanecen dormidos en el sistema por largos periodos de tiempo) e incidente (situación que podría haber generado un mal resultado que no se produjo por azar o por una intervención oportuna). el acierto es “el acto de salud que integra los elementos técnico, científico, ético, humanístico y normativo a favor del paciente. este concepto es independiente de los resultados, en razón de la inexactitud del acto humano y de la variabilidad de respuesta y circunstancias de un paciente a otro”. la gestión del riesgo es “el análisis de los procesos de atención, de su estructura y resultados que permite la prevención de los eventos inesperados o el manejo oportuno de sus consecuencias para el paciente, el profesional de la salud, la instituciones prestadoras de salud y el sistema”. recientemente se ha propuesto una taxonomía para los errores de enfermería que los clasifica así: falta de la atención a las condiciones clínicas y reacción a los tratamientos instaurados, pérdida del rol de representante del mejor interés del paciente, inapropiado criterio clínico, errores de tratamiento, falta de la intervención sobre la evolución clínica del paciente, falta de la prevención en el cuidado, equivocación en la ejecución de la prescripción médica y errores en la documentación. aspectos epidemiológicos en el reporte “errar es humano: construyendo un sistema de salud más seguro” (to err is human: building a safer health system) (8) producido por the institute of medicine en 1999, se evidenciaba la carga sobre la mortalidad general de los errores del sistema de salud en estados unidos, siendo éstos la tercera causa de muerte, después de la enfermedad cardiaca y el cáncer. el número de errores potencialmente prevenibles cada año variaba entre 44.000 y 98.000 muertes, superando incluso los fallecimientos por accidentes de vehículos automotores, cáncer mamario y sida. cerca de 70% de los eventos adversos son prevenibles. los errores pueden evitarse si se diseñan sistemas que hagan que sea difícil equivocarse y fácil hacer las cosas bien (7). el evento adverso no sólo tiene impacto en el paciente y su familia por las lesiones físicas o el daño psicológico que produce, sino también en los profesionales de la salud responsables de estas situaciones (estrés postraumático, depresión, inicio de ejercicio profesional a la defensiva, costos en el patrimonio y en el buen nombre), en el sistema de salud por los costos que representan la atención de los eventos adversos (entre 17 y 29 billones de dólares al año), y en la sociedad por la pérdida en la credibilidad en la calidad de los servicios cuando estas situaciones emergen al público general (9, 10, 11, 12, 13). la organización mundial de la salud (oms), en el 2002, expide una resolución para mejorar la seguridad de los pacientes, que se concreta en el 2004 con el estael número de errores potencialmente prevenibles cada año variaba entre 44.000 y 98.000 muertes, superando incluso los fallecimientos por accidentes de vehículos automotores, cáncer mamario y sida. revista aquichan issn 1657-5997 58 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 blecimiento de la alianza mundial por la seguridad de los pacientes, como una de las prioridades de salud pública. define 21 indicadores para vigilar y evaluar el desempeño de los sistemas de salud en materia de seguridad del paciente, los cuales son (14): infecciones nosocomiales: neumonías por uso de respirador, herida quirúrgica infectada, infecciones atribuibles a la atención médica y úlceras de decúbito. eventos centinelas: reacciones por transfusión, transfusión de tipo de sangre equivocado, equivocación en sitio quirúrgico (15), cuerpos extraños dejados en el paciente durante los procedimientos quirúrgicos, eventos adversos relacionados con el equipo médico y errores de medicación. complicaciones quirúrgicas y posquirúrgicas: complicaciones por la anestesia, fractura de cadera posterior a una cirugía, embolia pulmonar posquirúrgica o trombosis venosa profunda, sepsis pos-quirúrgica y dificultades técnicas con los procedimientos quirúrgicos. complicaciones obstétricas: lesiones o traumatismo al momento del nacimiento en neonatos, trauma obstétrico en partos vaginales, trauma obstétrico en partos por cesárea y mortalidad materna. otros eventos adversos: caídas de los pacientes y fracturas de cadera. de otra parte, la reglamentación colombiana hace énfasis en la necesidad de garantizar la seguridad del paciente y hacer seguimiento y reporte a los eventos adversos en los ámbitos hospitalarios, de urgencias, quirúrgicos y de atención ginecoobstétrica, con obligatoriedad en la monitorización de resultados negativos de la atención como son: complicaciones, infección, muerte, comorbilidad y reacciones adversas a sangre y medicamentos. algunos de los eventos adversos mencionados como indicadores de resultado de la calidad de la atención se relacionan directamente con el cuidado de enfermería, como es el caso de la infección nosocomial, las reacciones a la administración de medicamentos, sangre y hemoderivados, la caída de los pacientes y las úlceras de decúbito, aunque cada evento adverso deberá ser siempre evaluado en un contexto de tiempo, modo y lugar. génesis del evento adverso cada actividad del proceso de atención tiene un riesgo intrínseco que depende de problemas en las prácticas, los productos, procedimientos y sistemas; el evento adverso se debe a una serie de sucesos que ocurren sin que exista un único responsable, resultado de la interacción de las personas, la tecnología y los procesos. se puede presentar en las fases de prevención, diagnóstico, tratamiento, y asociado con problemas de comunicación, equipos y sistemas, entre otros. como la atención en salud es un acto realizado por personas para personas, existe la posibilidad de que se cometan errores; por esta razón, las instituciones que proveen servicios deben contar con defensas o barreras que prevengan la ocurrencia de daño o que, en el caso de presentarse, mitiguen adecuadamente sus consecuencias..... cada actividad del proceso de atención tiene un riesgo intrínseco que depende de problemas en las prácticas, los productos, procedimientos y sistemas; el evento adverso se debe a una serie de sucesos que ocurren sin que exista un único responsable, resultado de la interacción de las personas, la tecnología y los procesos. dilemas éticos frente a la seguridad del paciente. cuidar es pensar. ethical dilemmas facing the patient’s safety. care means ponder 59 las barreras defensivas idealmente deberían permanecer intactas de manera continua, pero en la realidad, éstas están en continuo movimiento, y cuando estos orificios en las defensas momentáneamente se alinean en una misma trayectoria se puede presentar el evento adverso (teoría del queso suizo). las fallas en las defensas de la seguridad del paciente pueden ser activas o latentes. son barreras defensivas: las barreras tecnológicas (alarmas, medios físicos, apagadores automáticos), las conformadas por los proveedores (enfermeras, médicos) y los controles administrativos (auditoría en salud, uso de protocolos). se debe resaltar que el cuidado de enfermería es la primera barrera de seguridad de los pacientes, se consideran los centinelas primarios del cuidado del paciente. los eventos adversos se relacionan con factores directos e indirectos. son factores directos los problemas en la comunicación con el paciente y el equipo de salud, la falta de formación y destreza de los profesionales, el exceso de confianza, la inadecuada delegación de responsabilidades, la fatiga del recurso humano y la ausencia de seguimiento, entre otros. son factores indirectos el tipo de sistema de salud, la sobredemanda, la falta de recursos y la estandarización en los proceso de atención (16, 17). la atención de los pacientes depende de equipos multidisciplinarios, en los cuales la comunicación pierde su continuidad y se fragmenta, en este sentido la enfermera juega un papel fundamental debido a que la posición que ocupa le permite obtener y compartir información con el paciente y los distintos profesionales de la salud. el evento adverso puede originarse en la información que no está debidamente actualizada (por ejemplo, signos vitales en una condición aguda), se pierde por falta de registro, y no es debidamente priorizada para ser compartida con otros miembros del equipo de cuidado (signos de alarma en determinadas patologías). los elementos asociados a problemas en la comunicación que generan error son: la falta de cohesión y liderazgo en el equipo de enfermería, una alta proporción de recurso humano temporal, y debilidades en los procesos de orientación de este tipo de recurso (18). son causas de los errores asociados con el cuidado de enfermería (19, 20, 21, 22, 23, 24, 25, 26): sobrecarga de pacientes bajo la responsabilidad de una enfermera (que limitan el alcance y la calidad del trabajo, dilatando la realización de procesos terapéuticos, causando problemas en la identificación de los pacientes, monitorización en los cambios del estado de salud, detección oportuna de complicaciones y registro de éstos), en estados unidos se han planteado estándares como el de contar con una enfermera titulada por cada 32 pacientes y una auxiliar de enfermería para cada 8-5 pacientes, se debe mencionar que este tipo de estándares desaparecieron de la reglamentación colombiana. fatiga laboral: en estados unidos la relación de sobrecarga laboral semanal y evento adverso se ha documentando, por lo cual algunos han propugnado por limitar el trabajo de cada enfermera a no más de 12 horas al día y 60 horas a la semana, aunque algunos estudios reportan que el límite se debe fijar en 40 horas a la semana. se debe resaltar que el cuidado de enfermería es la primera barrera de seguridad de los pacientes, se consideran los centinelas primarios del cuidado del paciente. revista aquichan issn 1657-5997 60 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 inadecuada orientación y entrenamiento, ausencia de monitoreo de la capacidad de atención. la complejidad del trabajo en equipo. el fracaso en crear una cultura organizacional que fomente la responsabilidad compartida y la comunicación abierta entre las personas de distintas disciplinas. el miedo al castigo. la falta de análisis sistemático de los errores. vale la pena mencionar que la intervención sobre este tipo de factores requiere de la concurrencia de distintas instancias como son los responsables en el diseño de políticas y reglamentación del sector, administradores y otros profesionales de la salud. en los últimos años, debido al impacto de la medicina gestionada, el trabajo de las enfermeras ha sufrido sustanciales modificaciones; algunos estudios demuestran que el tiempo disponible para el cuidado directo del paciente ha disminuido y han aumentado las cargas asistenciales (27, 28). vale la pena anotar que la ley 911 de 2004, en el artículo 7 del capítulo ii del título ii, menciona: el profesional de enfermería solamente podrá responder por el cuidado directo de enfermería o por la administración del cuidado de enfermería, cuando la relación del número de personas asignadas para que sean cuidadas por el profesional de enfermería, con la participación de personal auxiliar, tenga en cuenta la complejidad de la situación de salud de las personas, y sea tal, que disminuya posibles riesgos, permita cumplir con los estándares de calidad y la oportunidad del cuidado. es un deber ético de las enfermeras alertar a las instancias pertinentes acerca de las situaciones de estructura, proceso o resultado que vulneren la seguridad de los pacientes, no sólo por su deber de cuidado con éstos y sus familias, sino por las responsabilidades éticas y legales que se generan del ejercicio profesional en el caso del evento adverso prevenible. esto incluye ser reflexivo y responsable frente al tipo de procedimientos que se realizan o se delegan acordes con la experticia o nivel de formación, así como estar pendiente de los signos de alarma para su reporte inmediato (29, 30). la ley 911 de 2004, en el parágrafo al artículo 9, del capítulo i del título iii, permite la objeción de conciencia “en los casos en que la ley o las normas de las instituciones permiten procedimientos que vulneren el respeto a la vida, la dignidad y derechos de los seres humanos”. los procedimientos de enfermería frecuentemente involucran el uso de equipos, como bombas de infusión, ventiladores y monitores, los errores en el cuidado se pueden dar por la falla en el uso de estos equipos o por no oír de forma oportuna las alarmas. el deber de cuidado incluye entonces inspeccionar su estado y mantenimiento previo a su empleo, seguir las instrucciones de uso y solamente con los propósitos previstos, notificar los daños, recibir entrenamiento en el uso instrumentos de mayor complejidad y responder de forma oportuna a las alarmas de monitoreo (31, 32). los servicios donde más frecuentemente se presenta el evento adverso son las áreas hospitalarias de mayor tecnololos procedimientos de enfermería frecuentemente involucran el uso de equipos, como bombas de infusión, ventiladores y monitores, los errores en el cuidado se pueden dar por la falla en el uso de estos equipos o por no oír de forma oportuna las alarmas. dilemas éticos frente a la seguridad del paciente. cuidar es pensar. ethical dilemmas facing the patient’s safety. care means ponder 61 gía, como son: cirugía vascular, cardiaca o neurocirugía, unidades de cuidado intensivo, salas de cirugía y servicios de urgencia. las personas más frecuentemente involucradas son: los mayores de 65 años, con patologías como infarto de miocardio, accidentes cerebrovasculares, paro cardiorrespiratorio, y los niños. evento adverso en enfermería los eventos adversos más frecuentemente relacionados con el cuidado de enfermería son: errores transfusionales, eventos adversos asociados a medicamentos, suicidio prevenible, infecciones nosocomiales, caídas, quemaduras, úlceras de presión, errores en identificación e inadecuada interpretación de signos y síntomas (33). a continuación se describirán, a manera de caso, algunas recomendaciones que permitan ejemplificar la gestión del riesgo de un evento adverso: el relacionado con la administración de medicamentos. evento adverso asociado a la administración de medicamentos caso un niño de dos años de edad muere después de recibir una sobredosis mortal de un sedante administrado por una enfermera responsable de un servicio de pediatría con sobrecarga de pacientes, quien interpretó de manera equivocada la prescripción médica registrada en historia clínica y la cual tenía problemas de legibilidad. el evento adverso en la administración de medicamentos es definido como “cualquier evento previsible que puede ser causado por el uso inconveniente o la falta de una medicación y que puede causar perjuicio al paciente, mientras que la medicación está bajo el control de los profesionales de la salud, el paciente o el consumidor”. existen distintas series de estudios respecto a la relevancia epidemiológica de este tipo de evento, aunque en el proceso de atención de enfermería sin lugar a dudas representa uno de los principales riesgos en la atención del paciente (4). el error se puede presentar en las fases de prescripción, transcripción, administración y monitoreo; la mayor frecuencia de presentación se asocia a la administración de medicamentos equivocados o de inadecuadas dosis (que se conoce como la “muerte por decimal”), vías, preparaciones, periodicidad e interacciones medicamentosas. las lesiones asociadas a la administración de medicamentos son diversas como: daño del sistema nervioso central, reacciones de hipersensibilidad, amputación de miembros, disminución de la agudeza visual y auditiva, aumento de dolor y hasta la muerte (34). son factores asociados a la presentación de eventos adversos en la administración de medicamentos las fallas en el cumplimiento de políticas y procedimientos, en el sistema de distribución y preparación de los medicamentos, en la comunicación (oral o escrita) y en el conocimiento. pensar es cuidar, es así como la administración de medicamentos debe ser un acto reflexivo, en donde a pesar de existir una prescripcicón médica, ésta debe estar el evento adverso en la administración de medicamentos es definido como “cualquier evento previsible que puede ser causado por el uso inconveniente o la falta de una medicación y que puede causar perjuicio al paciente, mientras que la medicación está bajo el control de los profesionales de la salud, el paciente o el consumidor”. revista aquichan issn 1657-5997 62 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 sujeta al análisis por parte de la enfermera que permita advertir dosis, vías, frecuencia o interacciones que coloquen en peligro la integridad del paciente. estos procesos de interacción entre miembros del equipo de cuidado deben estar soportados en adecuados procesos de comunicación que permitan proteger al paciente a pesar de los llamados “gradientes de autoridad”, soportados en el respeto independiente del nivel jerárquico. en la ley 911 de 2004 se precisa al respecto en el artículo 22: “cuando el profesional de enfermería considere que como consecuencia de una prescripción se puede llegar a causar daño, someter a riesgos o tratamientos injustificados al sujeto de cuidado, contactará a quien emitió la prescripción, a fin de discutir las dudas y los fundamentos de su preocupación. si el profesional tratante mantiene su posición invariable, el profesional de enfermería actuará de acuerdo con su criterio: bien sea de conformidad con el profesional o haciendo uso de la objeción de conciencia, dejando siempre constancia escrita de su actuación (1). de otra parte, en los servicios hospitalarios persisten, aunque de manera cada vez menos frecuente, las prescripciones verbales por parte de los médicos, sin el soporte de éstas en la historia clínica, siendo una fuente importante de error en la administración de los medicamentos; la ejecución de toda prescripción médica debe estar precedida de la anotación de ésta en los registros del paciente, de forma legible, correcta y actualizada, exceptuando los casos de emergencia (1, 35, 36). a pesar de que siguen vigentes los cinco principios que rigen la administración de medicamentos: el paciente correcto, el medicamento y la dosis correcta, la vía correcta, el tiempo correcto y el registro correcto, a continuación se enumerarán otras recomendaciones para prevenir la aparición de este tipo de evento adverso y que podrían hacer parte de la gestión del riesgo de este proceso (37). evite distracciones durante el proceso de preparación y administración de medicamentos. evite la sobrecarga de información con el recurso humano a su cargo, utilice listados de verificación en la administración de medicamentos, no confíe en la memoria. use registros preimpresos de fácil legibilidad. cuando se coloquen medicamentos por catéteres de doble vía, se debe: administrar uno a la vez, para no confundir las vías, hacer seguimiento gota a gota para verificar que efectivamente el medicamento está en la vía correcta, si se trata de un medicamento de alto riesgo (opiáceos, inotrópicos, anticoagulantes, heparina) buscar el apoyo de otra enfermera para realizar un doble chequeo del tipo, vía y dosis (se corrigen los errores en un 95% de los casos) e identificar cada canal de manera distinta (38). evite el uso de jeringas parenterales sin aguja para la administración de medicamentos orales. evite almacenar de manera cercana medicamentos con presentaciones o cualidades físicas similares, que propicien la confusión al momento del envase para su administración (39). pensar es cuidar, es así como la administración de medicamentos debe ser un acto reflexivo, en donde a pesar de existir una prescripcicón médica, ésta debe estar sujeta al análisis por parte de la enfermera que permita advertir dosis, vías, frecuencia o interacciones que coloquen en peligro la integridad del paciente. dilemas éticos frente a la seguridad del paciente. cuidar es pensar. ethical dilemmas facing the patient’s safety. care means ponder 63 evite “prestar medicamentos de un paciente a otro” por fuera del control de farmacia. antes de administrar un tratamiento verifique la identidad del paciente en el brazalete de identificación y por el nombre (cuando sea posible), y cerciórese de las alergias del paciente y de los medicamentos que está recibiendo. la tecnología no sustituye “el ojo atento de una enfermera bien entrenada”. evite el uso de abreviaturas o siglas en los registros del paciente. evite retirar la dosis del embalaje original antes de estar frente al paciente para evitar confusiones. registre la administración del medicamento inmediatamente después de colocado, nunca antes. por más que usted sea experta, realice los procedimientos con la atención propia del principiante. deberes éticos de la enfermera frente a la seguridad del paciente una vez se produce el evento adverso, respecto a los procesos de comunicación se presentan tres tipos de conductas: ocultar la información, manejar la información con grupos de pares o revelarla de manera responsable al paciente, su familia y al estado (40). frecuentemente, la conducta que se toma es la de no informar al paciente u otras instancias de calidad sobre la ocurrencia de eventos adversos, debido al temor de ser reprendido o incluso ser despedido, a dañar la historia laboral, a perder el respeto de los pares o porque consideran que son de carácter menor y no merecen ser reportados (41). esta manera de proceder vulnera los principios de autonomía, beneficencia, no maleficencia, justicia, veracidad, solidaridad, lealtad y fidelidad (expresados en el capítulo i artículo 2 de la ley 911 de 2004), daña la confianza en la relación profesional de la salud-sujeto de cuidado, y sugiere que los intereses del primero priman sobre los del segundo; de otra parte generan desconfianza, se asocian a un mayor índice de demandas y se podría considerar como un antecedente grave en el establecimiento de responsabilidad legal, ética o administrativa. el revelar la información en el ámbito de comités de calidad (de infecciones, mortalidad, medicamentos), propicia el mejoramiento de los servicios de salud pero vulnera la autonomía del paciente. la tercera conducta, en la cual se revela al paciente la información sobre el evento adverso, respeta los principios éticos antes enunciados así como el principio específico de la práctica de enfermería denominado dialogicidad, el cual busca asegurar “una comunicación efectiva, respetuosa basada en relaciones interpersonales simétricas conducentes al diálogo participativo” (1), y es la aconsejada por las distintas instancias internacionales que trabajan por la seguridad de los pacientes. se debe señalar que no existe relación entre la competencia profesional y la presentación de un evento adverso, a no ser que se trate de una conducta negligente. lamentablemente, la mayoría de los hospitales no cuentan con políticas que orienten en la forma como se debe revelar esta información, la cual de manera ideal debería incluir (42, 43): el revelar la información en el ámbito de comités de calidad (de infecciones, mortalidad, medicamentos), propicia el mejoramiento de los servicios de salud pero vulnera la autonomía del paciente. revista aquichan issn 1657-5997 64 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 quién debe ser responsable de hablar con el paciente, su familia o representante legal. qué información se debe entregar. qué otras instancias deben ser informadas de la ocurrencia del error. cómo se debe documentar el evento. los profesionales de la salud en general, y dentro de ellos las enfermeras, tienen los siguientes deberes éticos con el paciente y la sociedad respecto a la seguridad en el cuidado de la salud: no exponer al paciente o minimizar los riesgos previsibles, con la provisión de cuidado a los mismos, que incluye la garantía de calidad de los servicios en los aspectos de estructura, proceso y seguimiento a los resultados negativos de la atención (complicaciones, infección, comorbilidad, reacciones adversas, incapacidad, o inhabilidad permanente o temporal, parcial o total o incluso la muerte). una vez se produce el evento adverso mitigar las consecuencias de éste. reportar los eventos adversos a las instancias pertinentes para iniciar procesos de mejoramiento. informar al paciente de la ocurrencia de los eventos adversos. garantizar los ciclos de mejoramiento que impidan la repetición de eventos adversos. realizar búsqueda activa de los errores latentes. favorecer culturas organizacionales que garanticen la seguridad del paciente y la gestión del riesgo en cada puesto de trabajo. esto incluye que las organizaciones de salud entiendan que la ocurrencia de los eventos adversos es factible, y que parte del deber ético de todos los miembros de éstas, consiste en su reporte al paciente o su representante legal, así como a las instancias de gestión de la calidad de los servicios, sin que esto signifique el castigo o represalias al prestador(es) responsable de éste. respecto a esto el profesional de enfermería se debe abstener de censurar o descalificar las actuaciones de sus colegas o profesionales de la salud en presencia de terceros (1, 44, 45). cuidar es pensar; cuando se diseña un plan de cuidado de enfermería se debe evaluar el riesgo específico del paciente en razón de su edad, sexo, patologías, antecedentes, así como el riesgo inherente al ámbito y los procesos de atención en el que éste se encuentra, para garantizar las barreras de seguridad que requiera. implica decidir cuáles actividades de cuidado son delegables y cuáles no. en el 2004, en un artículo del american journal of nursing en donde se estudió durante tres años la cultura organizacional, las actitudes y la asignación de la responsabilidad en hospitales respecto a la seguridad del paciente, se evidenció que la mayoría de los errores caían dentro de la esfera de la práctica de enfermería, y que los médicos, los administradores y las enfermeras veían, en gran parte, la seguridad del paciente como una responsabilidad de enfermería; solamente el 22% se debe señalar que no existe relación entre la competencia profesional y la presentación de un evento adverso, a no ser que se trate de una conducta negligente. dilemas éticos frente a la seguridad del paciente. cuidar es pensar. ethical dilemmas facing the patient’s safety. care means ponder 65 de los encuestados creyeron que médicos, enfermeras, farmacéuticos y administradores compartían esta responsabilidad de manera equitativa, paradójicamente no se identificaba a las enfermeras como parte del equipo de toma de decisiones para prevenir el error (46). recomendaciones una vez se presenta el evento adverso se debe pensar y actuar orientados por la premisa de que el paciente está primero, instaurar las medidas que minimicen el daño, registrar en la historia clínica los hechos, informar inmediatamente al paciente (idealmente en presencia de testigos) y a las autoridades competentes, y revisar el estado del arte del problema en cuestión (47). los profesionales de la salud deben trabajar en el diseño de sistemas que reduzcan o eliminen los errores y que garanticen la mayor seguridad de los pacientes. a continuación se mencionan algunas estrategias en este sentido (48). proveer a las enfermeras durante su formación, y en la vida laboral, de información sobre la seguridad del paciente, así como el análisis de casos sobre evento adverso con los pacientes (aprender del error de otros) (49). participar en los espacios que propicien la reflexión ética sobre las situaciones cotidianas de la práctica y los problemas que inciden en las relaciones (1). generar culturas organizacionales que permitan revelar el error y trabajar en procesos de mejoramiento continuo de la calidad en un ambiente que propicie la crítica constructiva a favor del paciente. crear mecanismos para analizar y aprender de los errores. desarrollar planes estratégicos en las instituciones prestadoras de servicios de salud que estén alineados con los objetivos de garantía de la seguridad de los pacientes, los cuales deben estar desarrollados y acordados por todos los niveles de la organización y favorecer el trabajo sinérgico. garantizar los recursos en calidad y cantidad para la atención, así como mejorar los ambientes de trabajo de las enfermeras (50). rediseñar y comunicar los procesos de atención que aseguren desde el primer momento que se hace lo correcto de manera correcta. reducir el número de personas responsables de los procesos y procedimientos, así como la necesidad de cálculo y la dependencia de la memoria o la vigilancia. proveer el entrenamiento intensivo en las operaciones de rutina (incluye procesos de educación continua a lo largo de la vida). desarrollar sistemas de información que permitan el seguimiento de los resultados de la atención. para finalizar, citando a max thorek, aunque es humano errar, es inhumano no tratar, en lo posible, de prever las fallas evitables y los peligros a aquellos que confían sus vidas en nuestras manos. los profesionales de la salud deben trabajar en el diseño de sistemas que reduzcan o eliminen los errores y que garanticen la mayor seguridad de los pacientes. revista aquichan issn 1657-5997 66 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 1. tribunal nacional ético de enfermería. ley 911 de 2004. 2. donabedian a. la calidad de la atención médica. méxico df: prensa médica mexicana; 1984: 95-151. 3. congreso de colombia. ley 266, diario oficial número 42710 del 5 de febrero de 1996. 4. four elements of a successful quality program: alignment, collaboration, evidence-based practice, and excellence http://proquest.umi.com/pqdweb?rqt= 3 1 8 & p m i d = 3 6 0 2 0 & t s = 1 1 5 4 5 3 2 2 7 3 & c l i e n t i d = 65930&vtype=pqd&v name=pqd&vinst=prod http:/ /proquest.umi.com/pqdweb?rqt=572&vtype= 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/untaggedcmykhandling /leaveuntagged /untaggedrgbhandling /leaveuntagged /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 359 369 representacoes sociais do cuidado.indd 359 stefanie griebeler oliveira1 alberto manuel quintana2 maria de lourdes denardin-budó3 maria henriqueta luce-kruse4 raquel pötter garcia5 simone wünsch6 silvia francine sartor7 representações sociais do cuidado de doentes terminais no domicílio: o olhar do cuidador familiar 1 orcid.org/0000-0002-8672-6907. universidade federal de pelotas (ufpel), brasil. stefaniegriebeleroliveira@gmail.com 2 orcid.org/0000-0001-7356-6142. universidade federal de santa maria (ufsm), brasil. albertom.quintana@gmail.com 3 orcid.org/0000-0002-2539-0813. universidade federal de santa maria (ufsm), brasil. lourdesdenardin@gmail.com 4 orcid.org/000-0001-5320-0629. universidade federal do rio grande do sul (ufrgs), brasil. kruse@uol.com.br 5 orcid.org/0000-0002-5503-7981. universidade federal de santa maria (ufsm), brasil. raquelpotter_@hotmail.com 6 orcid.org/0000-0003-4074-8489. universidade federal de santa maria (ufsm), brasil. simone.wunsch@gmail.com 7 orcid.org/0000-0002-3270-5916. universidade federal de pelotas (ufpel), brasil. sii.sartor@hotmail.com recibido: 06 de agosto de 2014 enviado a pares: 28 de marzo de 2015 aceptado por pares: 11 de diciembre de 2015 aprobado: 03 de abril de 2016 doi: 10.5294/aqui.2016.16.3.7 para citar este artículo / to reference this article / para citar este artigo oliveira sg, quintana am, budó mld, kruse mhl, garcía rp, wünsh s, sartor af. representações sociais do cuidado de doentes terminais no domicílio: o olhar do cuidador familiar. aquichan. 2016; 16(3): 359-369. doi: 10.5294/aqui.2016.16.3.7 resumo objetivo: conhecer as representações sociais construídas pelos cuidadores familiares de pacientes terminais sobre o cuidado no domicílio. método: estudo qualitativo com referencial teórico-metodológico das representações sociais, realizado com 11 cuidadores familiares de doentes terminais, cadastrados no serviço de internação domiciliar de um hospital universitário do sul do brasil. realizaram-se entrevistas narrativas, analisadas por meio de análise de conteúdo. elaboraram-se quatro categorias: 1) cuidadores homens e mulheres — um olhar diferenciado; 2) a inversão de papéis e trocas a partir do cuidar; 3) experiências como fonte de conhecimento para o cuidado domiciliar; 4) desafios do cuidar. resultados: para os cuidadores homens, as representações diferem das mulheres, pois o cuidado inclui o ambiente, além do paciente. eles não atribuem a angústia gerada à sobrecarga, mas ao temor da perda do ente querido. outras representações remetem-se à falta de escolha para assumir o papel de cuidador e à inversão ou mudança de papéis, o que torna o paciente submisso ao cuidador. conclusão: esta pesquisa permitiu conhecer como os cuidadores familiares constroem os significados e interpretam o cuidado que realizam no domicílio por meio do programa de hospitalização domiciliar. destaca-se a função dos profissionais da saúde em orientar o cuidador familiar para realizar o cuidado. palavras-chave assistência domiciliar, cuidadores, acontecimentos que mudam a vida, enfermagem, enfermagem oncológica (fonte: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 359-369 360 aquichan issn 1657-5997 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 359-369 representaciones sociales de cuidadores de pacientes terminales en el domicilio: la visión del cuidador familiar resumen objetivo: conocer las representaciones sociales construidas por los cuidadores familiares de pacientes terminales sobre el cuidado en el domicilio. método: estudio cualitativo con once cuidadores familiares de enfermos terminales, registrados en el servicio de internación domiciliaria de un hospital universitario del sur de brasil. realizaron entrevistas narrativas, analizadas por medio del análisis de contenido. se definieron cuatro categorías: cuidadores hombres y mujeres, una visión diferente; la inversión de roles y los cambios en el cuidado; experiencias como fuente de conocimiento para el cuidado en el hogar; y desafíos del cuidado. resultados: para los cuidadores hombres, las representaciones difieren de las de las mujeres debido a que el cuidado incluye su entorno. los hombres no atribuyen la angustia a la sobrecarga, pero sí al temor de perder un ser. otras representaciones remiten a la imposibilidad de elección para asumir el papel de cuidador y a la inversión de roles, lo que vuelve al paciente sometido al cuidador. conclusión: esta investigación permitió conocer cómo los cuidadores familiares construyen los significados e interpretan el cuidado que realizan en el domicilio por medio del programa de hospitalización domiciliaria. se destaca la función de los profesionales de la salud en orientar al cuidador familiar para realizar el cuidado. palabras claves atención domiciliaria de salud; cuidadores; acontecimientos que cambian la vida; enfermería; enfermería oncológica (fuente: decs, bireme). 361 representações sociais do cuidado de doentes terminais no domicílio: o olhar do cuidador familiar l stefanie griebeler oliveira e outros social representations of in-home caregivers of terminally ill patients: the family caregiver’s point of view abstract objective: to learn about the social representations of home care by family caregivers of terminally ill patients. method: qualitative study with eleven family caregivers of terminally ill patients, registered in the home care service of a teaching hospital in southern brazil. the researchers conducted narrative interviews and used the content analysis method to analyze them. four categories were established: male and female caregivers, a different perspective; role reversal and changes in care; experiences as a source of knowledge for home care; and healthcare challenges. results: representations by male caregivers differ from those of female caregivers because care also includes the context. male caregivers do not associate distress to excessive burden but to the fear of losing someone. other representations refer to the impossibility of choice to assume the role of caregiver and to role reversal, which causes patients to be submissive with the caregiver. conclusion: the research revealed how family caregivers construct meanings and how they interpret the home care provided through the home care program. particular attention is given to the role of healthcare professionals in guiding family caregivers. keywords home health care; caregivers; life changing events; nursing; oncology nursing (source: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 359-369 362 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 introdução a família vem sendo integrada no processo de cuidado ao paciente crônico recentemente (1). é nela que as pessoas muitas vezes aprendem e desenvolvem suas práticas de cuidado. nem sempre é a forma mais adequada tecnicamente, mas há forte simbolismo por envolver afeto, aproximação, compartilhamento de experiências (2). o cuidado pode apresentar diversos significados e constituir-se em um termo polissêmico; além disso, expressa-se como um fenômeno universal na vida do ser humano desde a antiguidade e é organizado por comportamentos e atitudes diversos, dentre os quais se destacam o respeito, a consideração, a segurança, o conforto e a capacitação. o cuidado compreende, portanto, uma prática responsável pela sobrevivência humana e uma luta constante em prol da perpetuação da espécie (3). o cuidado pode ser realizado em diversos ambientes, dentre estes, destaca-se o domicílio. o cuidado domiciliar, disponibilizado por uma equipe de referência para o paciente e a família, possibilita a efetiva construção de vínculos e novas formas de cuidar (4-5). está voltado para pessoas com doenças que ameaçam a vida e contribui para a promoção do conforto e a satisfação das necessidades dos moribundos devido ao ambiente ser mais favorável para a realização dos cuidados ao paciente (6). nesse contexto domiciliário, abarcar o processo de morrer e de morte pode ser uma forma de resgate dos aspectos humanos nas práticas de saúde (5, 7-8). se, por um lado, o mundo científico considera o cuidado domiciliar uma ação benéfica, como será que os cuidadores familiares se veem quando inseridos repentinamente nesse contexto? como esse novo papel para que são designados impacta suas vidas? desse modo, faz-se relevante a presente pesquisa, pois o referencial teórico das representações sociais facilita aos profissionais de saúde conhecer como cuidadores familiares constroem os significados e interpretam o cuidado realizado no domicílio, o que possibilita melhor comunicação entre os envolvidos nesse processo. diante disso, com este estudo, buscou-se conhecer as representações sociais construídas pelos cuidadores familiares de pacientes terminais sobre o cuidado no domicílio. referencial teórico metodológico: representações sociais as representações sociais (rs) são formadas por interpretações da realidade e procuram reconhecer como os grupos constroem um mundo estável e previsível a partir das diferenças, uma vez que há como ponto de partida a diversidade dos indivíduos (9). elas também podem ser definidas como teorias do senso comum e ser reconhecidas tanto quanto as teorias científicas, pois satisfazem e são plausíveis ao intelecto do mesmo modo, embora sejam formadas com outros métodos e respondam a inquietações diferentes (10). para que as rs sejam criadas, é necessária a passagem de algo não familiar para familiar por meio de dois processos: a ancoragem e a objetivação. a ancoragem trata de classificar e dar nome a algo por meio de um processo que transforma algo estranho no sistema particular de categorias, comparando isso com um paradigma de uma categoria que se pensa ser apropriada. na objetivação, une-se a ideia da não familiaridade com a realidade, tornando-se a verdadeira essência da realidade. em outras palavras, seria apanhar algo da memória e comparar com o objeto a ser interpretado (9). método tratou-se de uma pesquisa qualitativa que foi desenvolvida com cuidadores familiares de pacientes terminais oncológicos vinculados a um serviço de internação domiciliar de um hospital universitário do sul do brasil. esse serviço, composto por uma equipe multiprofissional, presta assistência a pacientes portadores de enfermidades crônicas, que não precisam de internação hospitalar, clinicamente estáveis, e sem condições de acompanhamento ambulatorial. para ser inserido no programa, o paciente ou o responsável deve concordar com a internação domiciliar e dispor de um cuidador que se responsabilize pelos cuidados no domicílio. o serviço tem como intuito diminuir a ocupação dos leitos hospitalares e abater a média de permanência hospitalar, o que leva a um atendimento mais humanizado. além disso, o serviço tem como objetivo proporcionar apoio técnico e estrutural à família no retorno do paciente ao domicílio. essa organização aproxima-se das premissas do programa melhor em casa, instituído no brasil em 2011 (11) . a seleção desses participantes ocorreu de janeiro a junho de 2010, nos cadastros do referido serviço, por ordem alfabética. foram incluídos os cuidadores familiares, maiores de 18 anos, que realizavam cuidados ao paciente terminal oncológico, vinculado ou cadastrado no serviço de internação domiciliar do hospital universitário de santa maria (sidhusm). foram excluídos, neste 363 representações sociais do cuidado de doentes terminais no domicílio: o olhar do cuidador familiar l stefanie griebeler oliveira e outros estudo, cuidadores familiares de pacientes que não possuíam o diagnóstico de câncer, menores de 18 anos e fora do programa de internação domiciliar do hospital universitário de santa maria (husm). ao todo, foram entrevistados 11 cuidadores familiares. destes, quatro eram do sexo masculino e sete do sexo feminino. das mulheres, cinco eram filhas dos pacientes, e duas, esposas destes. dos homens, dois eram cônjuges, um era irmão e outro era pai. a totalidade de cuidadores que atendia aos critérios de inclusão no período da coleta de dados foi entrevistada. para a obtenção de dados, foi utilizada a entrevista narrativa (12), que possibilitou a exposição das rs por meio da vivência e experiência relatadas. nesse tipo de entrevista, o conhecimento científico é produzido de forma fidedigna aos relatos, o que viabiliza o aprofundamento das investigações a partir da contextualização destes. além disso, permite evidenciar aspectos a partir do que a pessoa registrou de sua história, indo além da transmissão de informações por abranger aspectos fundamentais para a compreensão do sujeito individualmente e no contexto que está inserido, e por ter como característica sensibilizar, fazer o ouvinte assimilar as experiências de acordo com as suas vivências e ainda possibilitar interpretações que envolvem as experiências prévias. para tanto, foram utilizados como eixos norteadores: a experiência de ser cuidador e as tarefas do cuidador. a execução do projeto foi posterior à aprovação do comitê de ética em pesquisa da universidade federal de santa maria, com o número de certificado de apresentação para apreciação ética 0246.0.243.000-09. a visita ao domicílio do paciente terminal para a entrevista era agendada previamente por contato telefônico e foi realizada individualmente com o cuidador familiar no domicílio do paciente. para melhor captação dos dados, as entrevistas foram gravadas e depois transcritas para a realização da análise dos dados. os encontros tiveram em média a duração de uma hora e ocorreram na sala do domicílio, para que os pacientes não estivessem presentes no momento da entrevista, o que permitiu que o cuidador familiar ficasse mais à vontade para falar sobre sua experiência. para a etapa de análise dos dados, utilizou-se a análise de conteúdo, a qual se define pela explicitação do sentido contido em um documento ou o modo em que pode ser transformado com a finalidade de oferecer um significado, levando-se em conta a frequência da repetição dos termos, o aparato e o andamento do discurso (13). seguindo os princípios éticos e respeitando a resolução 196/96 (14), que orienta pesquisas em seres humanos, os participantes leram e assinaram o termo de consentimento livre e esclarecido. o sigilo e o anonimato dos participantes do estudo foram preservados por meio da adoção de códigos para a identificação das falas, a fim de manter a sua privacidade. as letras que formaram esses códigos são cf para cuidador familiar, seguidas de números que indicam a ordem de realização das entrevistas e, ainda, com o acréscimo de f (feminino) ou m (masculino), os quais auxiliarão na identificação das falas, no concernente à análise. por exemplo: cf1-m, cf2-f, cf3-f, cf4-m, e assim sucessivamente. resultados a partir da análise dos dados, foram construídas quatro categorias. são elas: 1) cuidadores homens e mulheres: um olhar diferenciado; 2) inversão de papéis e trocas a partir do cuidar; 3) experiências como fonte de conhecimento para o cuidado domiciliar; 4) desafios do cuidar. cuidadores homens e mulheres: um olhar diferenciado ao longo da análise das narrativas, percebeu-se que existem representações diferenciadas entre homens e mulheres que assumem o papel de cuidador familiar. os entrevistados do sexo masculino expressaram em suas falas que o cuidado envolve o paciente e o ambiente. citaram ações como o preparo e o fornecimento de alimentos, higiene, tanto do paciente como do ambiente, e a administração da medicação: “aqui quem faz tudo é ele [o pai da paciente]. lava a louça, cozinha, troca três a quatro vezes o lençol que precisa ser lavado, seca, lava, seca, lava, passa, fraldas, fraldinhas, tudo. praticamente, vamos dizer 80% quem faz é ele” (cf3-m). ah, no cuidado, principalmente a alimentação. [...] que ela tem que comer. a comida também sou eu que faço [...] esse tipo de medicação que ela toma, tem sono, então a gente procura sempre dizer: “olha, não fica numa cadeira, deita na cama, pode deitar [...]”. as roupas também a gente bota na máquina, são tudo as coisas assim [...] eu estou fazendo tudo que ela fazia e mais o que eu faço. estou dando valor à mulher, como dizem. (cf7-m) já as mulheres cuidadoras entrevistadas nesta pesquisa destacaram atividades mais ligadas diretamente com o paciente: 364 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 dar banho, ela vai para o banheiro sozinha, mas ela está muito fraca, aí treme muito as pernas. daí ela vai meio que agarrada, a gente coloca numa cadeira, dá banho [...] comida, ela come só batida, é mais sopinha, caldinho, que ela não se afoga. e remédio tem que quebrar pra dar para ela. (cf8-f) a medicação dele toda é oral, só faz uma injetável no abdômen que é com aquelas agulhinhas pequenas [...] ele tá engolindo bem, agora ele já começou a ter crises de demência, de enxergar o que não tem [...] às vezes ele pede pra urinar, às vezes ele não pede, meio se urina. (cf9-f) auxiliar ele no banho, ver as roupas dele, botar ele para sentar, alimentar. isso aí sempre foi feito. desde quando ele estava com a sonda, de tanto em tanto tempo tinha que dar. tanto é que, que ele está há mais de cinco anos, porque nunca faltou nada para ele. (cf10-f) inversão de papéis e trocas a partir do cuidar em algumas situações do processo de cuidar, ocorrem mudanças de papéis, como quando os filhos assumem uma prática maternal com relação ao paciente. de certa forma, esse aspecto remete para uma situação de poder sobre o paciente, que passa a ser visto como criança, como submisso ao cuidador: “nos papéis aqui em casa houve uma inversão, hoje ela é a minha filha, e eu sou a mãe. a gente conversa isso, eu falo para ela: a senhora me obedeça!” (cf1-f). “eu nunca tinha cuidado de ninguém, nem de criança! aí ganhei um bebê gigante!” (cf8-f). ainda, na fala seguinte, pôde-se perceber que as condições de ser cuidado e de cuidar modificam não somente papéis, mas, até mesmo, comportamentos, gerando alteração de regras e hábitos. as filhas nunca se imaginavam dando banho no próprio pai: o pai mudou muito o comportamento dele. antes ele era muito ríspido. agora dificilmente ele perde a paciência. alterou um pouco a personalidade. ficou mais fácil lidar com ele. ele mesmo aceita as limitações, porque antes ele não aceitava. [...] mas nunca nosso pai ia estar imaginando que nós iríamos estar dando banho [nele]. agora não. ele aguenta a gente estar junto. (cf 10) ainda acontece de o cuidado poder significar um compromisso uma vez que o cuidador revela que foi escolhido para cuidar da paciente pelo fato de a paciente ter cuidado dele anteriormente, o que caracteriza outra inversão de papéis: “me escolheu para cuidar dela, porque ela me cuidou. eu tive internado [em um outro hospital]. tive câncer no pulmão e ela me cuidou. agora eu estou cuidando dela” (cf2-m). experiências como fonte de conhecimento para o cuidado domiciliar os cuidadores familiares referiram, inicialmente, que eram inexperientes com o cuidado, mas que, com o passar dos dias, adquiriram experiência para as atividades necessárias. o aprendizado pode ser iniciado quando a pessoa já foi cuidada por alguém; no entanto, por outro lado, a lembrança de que os profissionais de saúde são os mais preparados para a realização do cuidado gerou certa insegurança aos cuidadores: a gente faz toda a medicação. [...] fiz um cronograminha para poder me orientar, saber os horários, [...] [o] medicamento dela está para lá separado, para não misturar com nada [...] não sei se a gente faz a coisa certa, porque às vezes a gente acha que está fazendo. a gente não tem noção. as enfermeiras são todas treinadas, elas estão preparadas para aquilo. mas, graças a deus, até agora não deu nada que eu não pudesse resolver. no começo, foi só o susto, mas depois me dediquei, eu mesmo procurei fazer isso, então para mim está sendo o normal de um dia a dia. (cf7-m) as experiências individuais/pessoais também servem como fonte de conhecimento para o cuidado. em uma situação em que duas irmãs eram cuidadoras, uma delas passou pela formação de auxiliar de enfermagem e referiu que isso influencia no seu jeito de cuidar. por conta da formação profissional, ela assume uma posição mais impositiva e prática, quando comparada à da irmã. esta, por não ter experiência formativa em um curso na área da saúde, demonstra maior flexibilidade em suas ações: “ah, eu cursei auxiliar de enfermagem. então mais ou menos tem [experiência para o cuidado]. a minha irmã tem mais jeitinho, mais paciência [...] de fazer do jeitinho que ele quer. eu já sou de impor as coisas, de fazer o certo. acho que ele prefere ela” (cf10-f). as orientações recebidas durante o cuidado domiciliar de profissionais da saúde colaboraram para a experiência do cuidador, da mesma forma que o ajudaram a agregar e absorver o conhecimento: uma enfermeira me ensinou a fazer um soro glicosado! eu não sabia nada! cheguei na farmácia, comprei tudo que ela mandou. 365 representações sociais do cuidado de doentes terminais no domicílio: o olhar do cuidador familiar l stefanie griebeler oliveira e outros comprei o soro, a vitamina c, complexo b. tem a minha vizinha aqui de cima, ela é técnica em enfermagem, eu pedi para ela puncionar a veia. eu sabia que a mãe nunca teve glicose alta, nem nada. aí peguei e coloquei, era eu que trocava sempre, mas para puncionar a veia era ela [profissional de enfermagem]. eu ia de metida, aprendendo. (cf8-f) tinham ensinado, o [meu filho, e ele] não queria dar [a injeção], estava com medo. chamei uma vizinha [para ficar com o paciente], corri para arrumar uma [enfermeira], o postão [unidade de saúde] estava aberto, daí ela [enfermeira] veio e fez. daí eu comecei a olhar, aprendi na marra! eu mesmo dou! passo bastante álcool, depois dou a injeção. (cf5-f) desafios no cuidar alguns desafios no cuidar são também relacionados a determinadas ações, algumas simples e outras complexas, que envolvem desde fazer a higiene do familiar até movimentar um paciente com fratura de vértebras, apresentando-se como novas experiências: “eu mesma fiz a barba! eu nunca fiz na minha vida, aprendi tudo na marra. dou banho nele todos os dias. e cuido dele! uma novidade, bem dizer!” (cf5-f). “ela é pesada, e às vezes ele [o pai] sozinho tira ela da cama. e ela é uma pessoa que não pode pegar assim, só botar força. tem que ter jeito, porque senão pode afundar um osso, quebrar” (cf3-m). a rotina do cuidado parece estressar o cuidador, sobretudo, na situação de cuidar de um paciente terminal, que é bastante solicitante: “ah, a gente se estressa um pouco, sabe. de fazer a mesma coisa, todo dia de manhã tem que dar banho nela. ela fica às vezes um pouco rebelde, até por causa da doença, daí ela fica toda hora chamando” (cf8-f). além disso, o cuidador familiar acredita que os sentimentos daquele que cuida são transferidos ao ser cuidado. por isso, destaca a relevância de se manter alegre para transmitir isso ao doente: “para a pessoa que está doente tem que chegar alegre. se chegar triste, aí é triste” (cf2-m). o cuidado no domicílio representa uma atenção constante, ininterrupta, entendido, por alguns, como uma missão: “é um cuidado, minuto a minuto, direto, não pode estar nunca longe. não é fácil, é uma missão. a minha missão” (cf1-f). discussão as rs do cuidado são construídas de forma distinta pelos cuidadores familiares homens e mulheres, o que pode estar relacionado ao papel assumido por ambos os sexos na sociedade. assim, salientam-se algumas reflexões: a primeira delas refere-se ao destaque com que os cuidadores homens direcionam ao cuidado com o ambiente, além do paciente, o que inclui as tarefas domésticas nesse processo. diante disso, surgem alguns questionamentos: a inclusão dessas atividades nas tarefas de cuidado pelos homens ocorre porque eles, em geral, não as realizavam cotidianamente? um segundo questionamento seria se os cuidadores do sexo masculino assumiram o cuidado por ausência de alternativas ou por pouca disponibilidade de outros familiares? essas questões são pertinentes visto que, dos quatro homens cuidadores, dois deles eram cônjuges, um era pai, e outro era irmão. em nenhum desses casos, havia possibilidade de outro membro da família assumir esse cuidado. na perspectiva das mulheres, por sua vez, reflete-se acerca da abordagem do cuidado de forma restrita ao paciente. essa representação poderia estar relacionada ao fato de que as tarefas domésticas já seriam consideradas parte de suas atividades cotidianas. isso pode ser justificado uma vez que, historicamente, o cuidado desenvolvido pelas mulheres abarcava as práticas realizadas em casa, no terreno, com os alimentos, desde o momento do cultivo até o preparo e a ingestão destes. já para os homens, a caça lhes proporcionava a apropriação de cuidados mais complexos e distantes do domicílio devido aos ferimentos ocasionados pela luta com o animal, como suturas, o que restringiu os cuidados domésticos às mulheres (15). isso posto, pode-se afirmar que as rs sobre o cuidado realizado no domicílio ao paciente terminal foram construídas pelo processo de ancoragem (9), mas com interpretações diferentes para homens e mulheres, tendo em vista os fatores sociais, históricos, culturais e psicológicos, que parecem influenciar a formação de imagens e significados expressos nesta pesquisa. os homens veem-se desenvolvendo tarefas domésticas, talvez realizadas anteriormente de forma eventual. eles as assimilam para si como inerentes ao cuidado do paciente já que a manutenção do ambiente favorece também o bem-estar do enfermo. o desconhecido, ou seja, as tarefas domésticas somadas ao cuidado do paciente em internação domiciliar, torna-se cotidiano 366 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 ao cuidador familiar do sexo masculino, fazendo reproduzir essas representações. já, para as mulheres, o desconhecido seria apenas o cuidado direto ao paciente terminal, sendo as tarefas domésticas comuns em suas atividades cotidianas. assim como o papel assumido por homens e mulheres determina a produção das rs do cuidado, a situação de cuidado também parece produzir sentidos, em especial nas relações entre cuidador e paciente, gerando inversão ou mudança de papéis. um exemplo disso seria quando o paciente se torna submisso ao cuidador que impõe limites, como se colocam às crianças (16). essa condição de sujeição ao cuidador favorece a redução de autonomia do paciente, pois o familiar se posiciona em um papel de superioridade, como mãe ou pai do doente, fazendo com que este não decida quanto às suas terapêuticas. nos aspectos diários da vida do doente crônico, a sua autonomia deve ser incentivada pelo cuidador, de modo que a cronicidade não o torne totalmente dependente de alguém. em um estudo (17) demonstrou-se a importância de permitir que os pacientes possam participar ativamente no processo de tomada de decisão e tenham a possibilidade de ter uma vida boa no pouco tempo de vida que lhes resta. isso permite que os pacientes tenham liberdade e respeito para tomar decisões, e possam se perceber como pessoas com autonomia (17). a restrição da autonomia não se limita à situação de doença crônica; pode também se evidenciar no processo de terminalidade. para prevenir essa situação, é necessário que o cuidador estimule o doente a viver e realizar as atividades que sua condição permite, evitando transformar suas limitações em uma incapacidade geral (16). dessa forma, evitam-se situações de infantilização do paciente e recuo de sua própria autonomia. acredita-se que essas rs podem advir do modelo paternalista introduzido pelos próprios profissionais de saúde, pois, colocando o paciente em uma condição inferior, torna-se mais fácil o manejo das ações de cuidado. assim, essas rs foram construídas mediante o processo de objetivação (9) visto que os cuidadores familiares já foram cuidados pelos seus responsáveis, podendo remetê-los a uma lembrança de submissão. para o cuidador, quando o paciente aceita suas limitações, também aceita ser cuidado e, desse modo, as intervenções, tanto do cuidador familiar como da equipe, ficam mais facilitadas. quem cuida também necessita ou necessitará, talvez em um futuro próximo, de cuidados. e quem é cuidado por alguém poderá cuidar de alguém no futuro (2). diante disso, valorizar as rs que giram em torno do cuidado no domicílio, no olhar dos cuidadores familiares, pode permitir um melhor planejamento das ações e uma aproximação maior na relação e na comunicação entre enfermeiros, seus pares, o paciente e a família. em alguns momentos, fica implícita a dificuldade dos familiares assumirem o papel de cuidadores familiares, quando estes expõem que os enfermeiros são mais preparados para o cuidado dos pacientes. contudo, não é possível que pacientes com doenças crônicas de longa duração permaneçam continuamente no hospital e, desse modo, são necessários os cuidados dos familiares. destaca-se que não é aceitável negar o cuidado a quem precisa, sobretudo a um membro da família, e, assim, faz-se necessária uma adaptação para enfrentar tal situação. nesse sentido, os cuidadores criam estratégias para se organizar, como no caso do cronograma citado nas entrevistas, mas, apesar disso, permanece o receio e a insegurança de não prestarem os melhores cuidados por não terem o treinamento profissional. outros estudos também mostram que ser cuidador nem sempre é uma escolha (6, 18). muitos cuidadores e pacientes avaliam a atenção domiciliar como positiva ao considerar a proximidade do paciente com a família por estar em seu contexto, em sua casa (6). entretanto, muitos cuidadores sentem-se sobrecarregados, privados de necessidades básicas como sono e boa alimentação, vivendo em isolamento social por ficar em torno do paciente e longe de suas atividades (6, 18). para os cuidadores que já foram cuidados ou que já experimentaram cuidar, a vivência vai tornando-se consolidada e, de certa forma, parece proporcionar um melhor preparo. no entanto, isso não parece ser regra já que a vontade de aprender o cuidado é um fator que auxilia os cuidadores a adquirirem segurança. assumir o papel de cuidador implica uma ruptura da barreira que separa o cuidador familiar do profissional de saúde. parece que, quando os cuidadores falam de sua vontade de aprender e fazer, buscam se identificar com ele. nesse processo, passam a assumir funções que legalmente são restritas ao profissional e isso parece ser facilitado na sua necessidade de ensinar alguns procedimentos a serem realizados pelo familiar com o paciente. assim, para o cuidador, torna-se confusa a distinção entre as atividades restritas ao profissional de saúde e suas atividades como cuidador. é importante destacar que a família, recentemente, vem sendo (re)conhecida pela equipe de saúde como membro do processo de cuidado. ante o incentivo da internação domiciliar do paciente 367 representações sociais do cuidado de doentes terminais no domicílio: o olhar do cuidador familiar l stefanie griebeler oliveira e outros terminal, cabe ao enfermeiro o papel fundamental de preparar e apoiar os cuidadores familiares na reorganização familiar, de modo que possam assumir os cuidados. a atenção e a valorização das experiências dos cuidadores, por parte dos enfermeiros e profissionais de saúde, podem torná-los mais seguros. assim, as rs expressas neste estudo podem favorecer a maneira de abordar a família do doente terminal, especialmente nas orientações de como proceder nas ações de cuidado e papel desempenhado costumeiramente pelo enfermeiro. em estudo com cuidadores do programa de atenção domiciliar, demonstrou-se que cuidar de um paciente em situação de terminalidade torna possível a tomada de consciência da própria morte, fazendo pensar na finitude humana (2). na proposta de cuidados paliativos, o familiar torna-se um membro fundamental na etapa de morte e de morrer do paciente (5). nesse movimento, a enfermagem necessita desenvolver a escuta, em especial com os cuidadores familiares, pois estes não demandam somente esclarecer dúvidas acerca de como realizar os cuidados, mas também um acolhimento para seus sentimentos de insegurança sobre a relação cuidador-paciente, suas ansiedades e seu sofrimento de estar percebendo o morrer do outro. portanto, as rs são construídas nesse contexto transitório de entrega do paciente à família, que apresenta diversos sentimentos envolvidos no aprendizado do cuidado já que, para alguns cuidadores familiares, existiu a experiência e, para outros, as ações e sentimentos são novidades. as rs para aqueles que já experienciaram o cuidar e ser cuidado são repetidas. assim, quando um fenômeno se repete (9), ocorre um estabelecimento da relação entre os cuidadores, a situação, a experiência ou entre o desconhecido e o conhecido. é aqui que se diferenciam as rs da ciência, observadas na fala do cuidador familiar, quando relata que os enfermeiros sabem como deve ser feito e que, como ele não possui o treinamento, ainda apresenta insegurança quanto a fazer o cuidado correto. é condição necessária para uma pessoa com doença terminal permanecer em casa, tendo um cuidador informal que faça a ligação com a equipe de cuidados (5, 11). dessa forma, quando não há apoio e suporte da equipe profissional de saúde, muitas vezes, esses cuidadores podem sofrer pela falta de informação, acompanhamento e apoio (6, 19). tudo isso exigirá deles motivação e, principalmente, ação, compreensão e entendimento a respeito de assuntos e práticas dos quais pouco sabem como funcionam, ou para que servem. como resultado, o cuidador pode se encontrar em um estado de solidão. quando o cuidador vê o paciente como solicitante, pode expressar, de certa forma, que o familiar, ao assumir o papel de cuidador, passa a viver em torno do paciente terminal ou crônico para poder satisfazer suas necessidades. além disso, quando o papel de cuidar torna-se rotineiro e prolongado, o cuidador pode ficar estressado por realizar a mesma atividade. isso pode ser mais impactante quando se sabe que o cuidado desenvolvido é para ajudar um ente querido no processo de morrer, o que implica a aceitação da impossibilidade de cura de seu familiar. o cuidado no domicílio traz à família e ao paciente alguns desafios psicológicos e adaptação ambiental. nesse sentido, propiciar suporte ao cuidador garante uma assistência de qualidade uma vez que ele também necessita de cuidados, pois passa por adaptações físicas, sociais, emocionais e de sobrecarga, precisando de compreensão. a dinâmica no cuidado a domicílio envolve dedicação contínua de tempo e conhecimento básico ao ato de cuidar; entretanto, esse processo pode causar estresse e desgaste à família, ao usuário, ao cuidador e à equipe (20-22). destaca-se que a atitude do cuidador é parte integrante do cuidado. a pessoa doente sente quando o cuidador está sobrecarregado. sabe-se que, de fato, o paciente percebe que sua dependência pode atrapalhar quem cuida e isola-se. por outro lado, a dependência do doente potencializa a vontade do familiar responsável de cuidar. considerações finais esta pesquisa, que se desenvolveu fundamentada no referencial teórico das representações sociais, permitiu o conhecimento de como os cuidadores familiares constroem os significados e interpretam o cuidado realizado por eles no domicílio por meio da internação domiciliar. esses significados emergiram de forma diferente entre cuidadores homens e mulheres; os primeiros direcionam o cuidado ao ambiente, além do paciente, o que inclui as tarefas domésticas nesse processo. todavia, é fato que em suas representações não se visualizou o cuidado como algo esgotador, o que permitiu a reflexão de que os sentimentos de tristeza, angústia e ansiedade, revelados pelos cuidadores ao longo das entrevistas, referem-se mais à perda do ente querido, e não à sobrecarga de trabalho. 368 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 visualizou-se também a impossibilidade de escolha para assumir o papel de cuidador familiar, pois não é adequado negar o cuidado a quem precisa, sobretudo a um membro da família. dessa forma, faz-se necessária uma adaptação para o enfrentamento da situação a fim de facilitar o cuidado domiciliar. outra questão encontrada nas representações sociais, acerca do cuidado domiciliar, é a inversão ou a mudança de papéis, quando o paciente se torna submisso ao cuidador que impõe limites, o que pode ser trabalhado pela equipe de saúde para não haver prejuízo da autonomia do paciente. assim, este estudo pode ressaltar que os enfermeiros e demais profissionais de saúde relativizem o olhar de infantilização ao doente promovendo sua autonomia e favorecendo um posicionamento ativo do paciente ante a sua doença. a condução dos diálogos e o compartilhamento de informações entre equipe e família podem promover as potencialidades do paciente e ressaltar seu papel de protagonismo diante das atividades diárias de sua rotina, mesmo modificada pela doença. nas rs expressas pelos cuidadores familiares sobre o cuidado, destaca-se a necessidade da equipe de saúde —principalmente os enfermeiros, normalmente, os responsáveis pela orientação das ações do cuidado— estar atenta para as peculiaridades que os cuidadores apresentam com relação às suas vivências e experiências, com o objetivo de proporcionar segurança, apoio e amparo no processo de cuidado em situação de terminalidade. por outro lado, quando o cuidador já cuidou de outra pessoa com agravos à saúde, o preparo para o cuidar do paciente terminal é facilitado, bem como a aproximação para um diálogo sobre o processo de morte e de morrer desse indivíduo. nesse contexto, a enfermagem poderá preparar melhor o cuidador para as observações ante a situação do paciente, o que proporciona a condução do cuidado de maneira mais efetiva e traz conforto e tranquilidade ao ambiente domiciliar. observamos que, considerando a recente inserção da família no cuidado ao doente, é atribuição da enfermagem a identificação de sentimentos e necessidades advindos desse contexto, dando apoio aos cuidadores envolvidos no processo de cuidado. estes realizam diferentes atividades, como a administração de medicamentos por via subcutânea, realização de curativos, uso do oxigênio, entre outras, que, anteriormente, eram ações privativas aos profissionais de saúde. tais atividades necessitam ser conduzidas pelos profissionais de saúde que devem avaliar a capacidade do cuidador e, de acordo com programas de saúde instituídos, prepará-lo para executar os cuidados; desse modo, serão evitados a transferência de atividades aos cuidadores e o surgimento de sentimentos de insegurança e ansiedade. destaca-se que é função dos profissionais de saúde orientar e capacitar o cuidador familiar para realizar o cuidado, pois ao delegar procedimentos de enfermagem a um cuidador estarão amparando o melhor desenvolvimento do cuidado domiciliar. há pouco na literatura que aborde essa questão; portanto, sugere-se que mais estudos sejam realizados nesse campo para explorar tais possibilidades. o presente estudo apresenta limitações uma vez que o olhar das representações sociais acerca da internação domiciliar remete-se a um contexto de um coletivo permeado por experiências específicas de um determinado grupo. além disso, o uso da teoria das representações sociais foi um dos possíveis olhares para esse objeto de pesquisa. por fim, ainda se destaca, como limitante, que tais representações sociais podem ser restritas ao grupo pesquisado. desse modo, recomenda-se a realização de estudo semelhante em outros contextos e também com outros referenciais teórico-metodológicos. referências 1. oliveira sg. melhor em casa? um estudo sobre a atenção domiciliar [tese]. porto alegre: programa de pós-graduação em enfermagem da universidade federal do rio grande do sul; 2014. 2. lichtenfels p. o cuidador familiar, o paciente gravemente enfermo e a morte: a visão e os possíveis aprendizados de familiares cuidadores de pacientes gravemente enfermos em uma comunidade de baixa renda de um centro urbano brasileiro [tese]. porto alegre: programa de pós-graduação em educação da universidade federal do rio grande do sul; 2013. 3. torralbá-roselló ft. antropologia do cuidar. petrópolis: vozes; 2009. 369 representações sociais do cuidado de doentes terminais no domicílio: o olhar do cuidador familiar l stefanie griebeler oliveira e outros 4. brito mjm, andrade am, caçador bs, freitas lfc, penna cmm. atenção domiciliar na estruturação da rede de atenção à saúde: trilhando os caminhos da integralidade. esc anna nery. 2013; 17(4):603-10. 5. ministério da saúde do brasil, secretaria de atenção à saúde, departamento de atenção básica. caderno de atenção domiciliar. v. 2. brasília: ministério da saúde; 2013. 6. oliveira sg, kruse mhl, sartor sf, echevarría-guanilo me. enunciados sobre la atención domiciliaria en el panorama mundial: revisión narrativa. e global. 2015; 14(3):375-89. 7. hanratty b, addington-hall j, arthur a, cooper l, grande g, payne s, seymour j. what is different about living alone with cancer in older age? a qualitative study of experiences and preferences for care. bmc fam. pract. 2013; 14(1):14-22. 8. nietsche elisabeta albertina, vedoin stephanie cielo, bertolino karla cristiane de oliveira, lima márcia gabriela rodrigues de, terra larice gonçalves, bortoluzzi cátia regina loureiro. equipe de saúde e familiares cuidadores: atenção ao doente terminal no domicílio. rev enf ref. [internet]. 2013 jul. [citado 13 mar. 2016]; iii(10):55-62. disponível em: http://www.scielo.mec.pt/scielo.php?script=sci_arttext&pid=s0874-02832013000200007&lng=pt. http://dx.doi. org/10.12707/riii12137 9. moscovici s. representações sociais: investigações em psicologia social. 7. ed. petrópolis: vozes; 2010. 10. moscovici, s. prefácio. em: jodelet d. loucuras e representações sociais. petrópolis: vozes; 2005. p. 11-31. 11. brasil. ministério da saúde. portaria 1.208, de 18 de junho de 2013. dispõe sobre a integração do programa melhor em casa (atenção domiciliar no âmbito do sus) com o programa sos emergências, ambos inseridos na rede de atenção às urgências. diário oficial [da] república federativa do brasil. 19 jun. 2013. seção 1;37. 12. muylaert cj, sarubbi-jr v, gallo pr, neto mlr, reis aoa. entrevistas narrativas: um importante recurso em pesquisa qualitativa. rev esc enferm usp. 2014; 48(2):193-9. 13. turato er. tratado da metodologia da pesquisa clínico-qualitativa: construção teórico-epistemológica, discussão comparada e aplicação nas áreas da saúde e humanas. petrópolis: vozes; 2008. 14. brasil. conselho nacional de saúde. resolução 196/96: pesquisa em seres humanos. brasília: ministério da saúde; 1996. 15. collière mf. promover a vida: da prática das mulheres de virtude aos cuidados de enfermagem. 6. ed. lisboa: damaia; 2012. 16. floriano la, azevedo rcs, reiners aao, sudré mrs. cuidado realizado pelo cuidador familiar ao idoso dependente, em domicílio, no contexto da estratégia de saúde da família. texto context enferm. 2012; 21(3):543-8. 17. wittmann-vieira r, goldim jr. bioética e cuidados paliativos: tomada de decisões e qualidade de vida. acta paul enferm. 2012; 25(3):334-9. 18. kuo c, operario d, cluver l. global public health: an international journal for research, policy and practice. glob public health. 2012; 7(3):253-69. 19. cowan mm. the lived experiences of the sikh population of south east england when caring for a dying relative at home. int j palliat nurs. 2014; 20(4):179-86. 20. lago dmsk. qualidade de vida de cuidadores domiciliares: relação entre cuidados paliativos, sobrecarga e finitude humana [tese]. brasília: universidade de brasília, curso de pós-graduação em enfermagem, departamento de enfermagem; 2015. 21. sousa jm, alves ed. competências requeridas do enfermeiro para o cuidado paliativo na atenção domiciliar. acta paul. enferm. 2014; 28(3):264-9. 22. sousa jm, alves e d. cuidados paliativos de enfermagem na atenção domiciliar. rev enferm. ufpe on-line. 2015; 9(2):669-76. 56 66 impacto de ulceras venosas.indd 56 rhayssa de oliveira araújo1 dalva cezar da silva2 rafaella queiroga souto3 aline maino pergola-marconato4 isabelle katherinne fernandes costa5 gilson de vasconcelos-torres6 impacto de úlceras venosas na qualidade de vida de indivíduos atendidos na atenção primária 1 universidade federal do rio grande do norte, brasil. rhayssa.noe@hotmail.com 2 universidade federal de santa maria, brasil. dalvacezarsilva@yahoo.com.br 3 universidade federal do rio grande do norte, brasil. rafaellaqueiroga7@gmail.com 4 universidade federal do rio grande do norte, brasil. aline_pergola@yahoo.com.br 5 universidade federal do rio grande do norte, brasil. isabellekfc@yahoo.com.br 6 universidade federal do rio grande do norte, brasil. gilsonvtorres@hotmail.com recibido: 07 de julio de 2015 enviado a pares: 31 de agosto de 2015 aceptado por pares: 30 de noviembre de 2015 aprobado: 19 de diciembre de 2015 doi: 10.5294/aqui.2016.16.1.7 para citar este artículo / to reference this article / para citar este artigo araújo ro, silva dc, souto rq, pergola-marconato am, costa ikf, torres gv. impacto de úlceras venosas na qualidade de vida de indivíduos atendidos na atenção primária. aquichan. 2016;16(1): 56-66. doi: 10.5294/aqui.2016.16.1.7 resumo objetivo: analisar o impacto das úlceras venosas (uv) na qualidade de vida (qv) das pessoas atendidas na atenção primária à saúde. material e método: pesquisa quantitativa, descritiva e transversal, realizada com 101 usuários, atendidos em 42 serviços de saúde de natal, rio grande do norte, brasil. os dados foram coletados de fevereiro a setembro de 2014, por meio de um questionário sociodemográfico, clínico e de saúde, e do charing cross venous ulcer questionnaire. utilizou-se estatística descritiva e inferencial para a análise dos dados. resultados: a qv esteve comprometida, principalmente, no estado emocional e estético, com pior média entre os indivíduos com mais de um ano de lesão. identificou-se associação estatística significativa entre tempo de uv atual e estado emocional (p=0,008), com maior média (64,2) para aqueles com uv há mais de um ano. conclusões: as pessoas com uv há mais de ano apresentam maior comprometimento da qv. necessita-se de intervenções e ações de promoção à saúde dessa população. palavras-chave qualidade de vida; úlcera varicosa; enfermagem; atenção primária à saúde; afeto; promoção da saúde; feridas (fuente: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 56-66 57 impacto de úlceras venosas na qualidade de vida de indivíduos atendidos na atenção primária l rhayssa de oliveira araújo e outros año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 56-66 impacto de úlceras varicosas en la calidad de vida de individuos atendidos en atención primaria resumen objetivo: analizar el impacto de las úlceras varicosas (uv) en la calidad de vida (cv) de personas atendidas en la atención primaria a la salud. material y método: investigación cuantitativa, descriptiva y transversal, realizada con 101 usuarios, atendidos en 42 servicios de salud de natal, rio grande do norte (brasil). los datos se recolectaron de febrero a septiembre de 2014 por medio de un cuestionario sociodemográfico, clínico y de salud, y del charing cross venous ulcer questionnaire. se utilizó estadística descriptiva e inferencial para el análisis de los datos. resultados: la cv estuvo comprometida, sobre todo, en el estado emocional y estético, con peor promedio entre los individuos con más de un año de lesión. se identificó asociación estadística significativa entre tiempo de uv actual y estado emocional (p=0,008), con mayor promedio (64,2) para aquellos con uv desde hace más de un año. conclusiones: las personas con uv hace más de un año presentan mayor comprometimiento de la cv. se necesitan intervenciones y acciones de promoción a la salud de esta población. palabras clave calidad de vida; úlcera varicosa; enfermería; atención primaria en salud; afecto; promoción de la salud; heridas (fonte: decs, bireme). 58 aquichan issn 1657-5997 impact of varicose ulcers on the quality of life of persons receiving primary care abstract objective: analyze the impact of varicose ulcers (vu) on the quality of life (qol) of persons receiving primary health care. materials and methods: this is a quantitative, descriptive, cross-sectional study conducted with 101 patients who were treated at 42 health centers in natal, rio grande do norte (brazil). data collection was done from february to september 2014, using a socio-demographic, clinical and health questionnaire and the charing cross venous ulcer questionnaire. descriptive and inferential statistics were used to analyze the data. results: quality of life was compromised, especially in terms of the person’s emotional and aesthetic condition, with the worst average being for those with lesions that are more than a year old. a statistically significant association between the actual time or age of vu and emotional state (p = 0.008) was identified, with the highest average (64.2) applying to those with vu that are more than a year old. conclusions: persons with vu over a year old are more compromised in terms of their qol. intervention and action are needed to promote the health of this population. keywords quality of life; varicose ulcer; nursing; primary health care; affection; health promotion; lesions (source: decs, bireme). año 16 vol. 16 nº 1 chía, colombia marzo 2016 l 56-66 59 impacto de úlceras venosas na qualidade de vida de indivíduos atendidos na atenção primária l rhayssa de oliveira araújo e outros introdução a úlcera venosa (uv), causada principalmente pela insuficiência venosa crônica, é o mais frequente problema terapêutico de lesões nos membros inferiores. estima-se que, aproximadamente, um por cento da população de países industrializados poderá ter essa lesão em algum momento da vida. dessa forma, a uv é considerada um problema de saúde pública (1-6), em especial, devido ao aumento de sua incidência, à cronicidade, aos altos custos terapêuticos e de acompanhamento clínico, à complexidade do cuidado e ao alto índice de recidiva (1-3). além disso, as pessoas com uv podem apresentar sintomas como dor, feridas exsudativas e com odor fétido, alteração da autoimagem corporal, diminuição da mobilidade e desconforto devido aos curativos. isso pode levar ao isolamento social e a alterações na saúde física e mental, com possível impacto à qualidade de vida (qv). por isso, denota-se a necessidade de intervenções holísticas para melhorar a efetividade do tratamento e, por conseguinte, a qv (4-5). também o preparo do indivíduo para lidar com tal tratamento, o que, como consequência, poderia melhorar a qv. nesse sentido, o sistema único de saúde (sus) preconiza o atendimento integral e de qualidade, e a atenção primária de saúde (aps) é a entrada preferencial da pessoa com uv ao sistema de saúde. a estratégia saúde da família (esf), modelo de reorientação e reorganização da aps brasileira, desempenha papel imprescindível para a promoção da saúde e a prevenção dessa lesão, pois tem o atendimento integral, longitudinal, resolutivo e equânime como característica do processo de trabalho. nesse processo, consideram-se as necessidades dos usuários e objetiva-se o corresponsabilizar pelo controle dos determinantes e condicionantes do seu processo de saúde e doença (6). no contexto da esf, o enfermeiro destaca-se no atendimento à pessoa com uv, porém se identificou em pesquisa qualitativa realizada em um município de minas gerais (brasil), a falta de preparo profissional para atender às especificidades e à complexidade demandada por essa clientela e a precariedade das condições de trabalho na aps (7). devido ao potencial impacto negativo da uv na qv das pessoas e à falta de padronização e capacitação para seu atendimento, alguns instrumentos foram desenvolvimentos para avaliar e medir quantitativamente esse impacto. o instrumento charing cross venous ulcer questionnaire (ccvuq) foi criado e validado em londres para avaliar a qv em pessoas com uv (8-9). o ccvuq foi traduzido e adaptado transculturalmente para chinês (10), castelhano (11) e português brasileiro (12). ao ter em vista o longo tempo envolvido no tratamento das pessoas com uv e as limitações relacionadas ao processo de trabalho e cuidado nas esf, é possível que a qv dessas pessoas fique comprometida. assim, na presente pesquisa, o objetivo foi analisar o impacto das uv na qv das pessoas atendidas na aps. método pesquisa quantitativa, descritiva e transversal, realizada na rede de aps de natal, rio grande do norte (rn), brasil. foram incluídas todas as unidades de saúde da família (usf) (n = 37) e mistas (n = 5). as unidades básicas de saúde não participaram do estudo por não realizarem atendimento longitudinal aos seus usuários. todos os usuários dos referidos serviços que atendiam aos seguintes critérios de inclusão: idade igual ou superior a 18 anos, uv ativa no momento da coleta de dados, adscrição à unidade e capacidade de comunicação verbal foram convidados para participar do estudo. foram excluídas as pessoas com úlcera de origem mista devido à sintomatologia específica da doença venosa, o que poderia influenciar nas respostas. participaram, portanto, 101 pessoas com uv. na coleta de dados, utilizaram-se dois instrumentos: 1) formulário estruturado, aplicado por meio de entrevista, que continha dados de caracterização sociodemográfica, de saúde e de assistência, e 2) o ccvuq (12), composto por 21 itens que identificam quatro domínios importantes da saúde: interação social, atividades domésticas, estética e estado emocional. a pontuação do questionário pode ser obtida em sua totalidade ou dividida por domínios, que variam, nos dois casos, de 0 (zero), para melhor qualidade de vida, a 100 (cem), para pior qualidade de vida. a coleta de dados ocorreu nas unidades de atendimento ou nos domicílios dos participantes entre fevereiro e setembro de 2014 e foi realizada por enfermeiros e acadêmicos de enfermagem previamente capacitados. 60 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 os dados foram digitados e tabulados no microsoft excel e exportados para o software estatístico ibm spss, versão 20.0, no qual foram realizadas análises descritivas e inferenciais. os testes não paramétricos qui-quadrado e exato de fisher foram utilizados para identificar possíveis associações do tempo de uv atual com as características sociodemográficas e as condições de saúde e clínicas. uma vez que apresentou distribuição não normal segundo o teste de kolmogorov-smirnov, o teste de mann-whitney foi utilizado para analisar a relação entre o tempo de uv e cada domínio do ccvuq (interação social, atividades domésticas, estética e estado emocional). valores de p<0,05 foram considerados estatisticamente significativos. este estudo obedeceu à resolução 466/2012 (13) e obteve parecer favorável do comitê de ética em pesquisa da universidade federal do rio grande do norte (caae 07556312.0.0000.5537). os participantes que aceitaram participar da pesquisa assinaram o termo de consentimento livre e esclarecido. resultados diante da análise do escore total do ccvuq, os participantes do presente estudo apresentaram média de 52,1 com desvio padrão de 16,6 (mínima = 19,8; máxima = 90,1). a caracterização sociodemográfica das pessoas com uv atendidas na atenção primária à saúde conforme o tempo de lesão é apresentada na tabela 1. em relação às condições de saúde dos participantes, a maioria não possuía diabetes mellitus (dm), hipertensão arterial sistêmica (has) ou outras doenças associadas, dormia seis horas ou mais diariamente, não possuía hábitos de etilismo e tabagismo (tabela 2). como outras doenças associadas, foram consideradas quaisquer doenças crônicas, com exceção de dm ou has. destaca-se que o tempo máximo de lesão no momento da coleta foi de 48 anos, em uma pessoa com 85 anos; o tempo mínimo foi de um mês, em cinco pessoas. tabela 1. caracterização sociodemográfica de pessoas com úlcera venosa atendidas na atenção primária à saúde conforme tempo de lesão (natal-rn, 2014) caracterização sociodemográfica tempo atual de uv 1 ano > 1 ano total p-valor n % n % n % sexo feminino 17 16,8 50 49,5 67 66,3 0,181* masculino 13 12,9 21 20,8 34 33,7 faixa etária ≥ 60 anos 16 15,8 46 45,5 62 61,4 0,280* até 59 anos 14 13,9 25 24,8 39 38,6 estado civil casado/união estável 22 21,8 42 41,6 64 63,4 0,177* solteiro/viúvo/divorciado 08 7,9 29 28,7 37 36,6 escolaridade até o ensino fundamental 26 25,7 60 59,4 86 85,1 1,000** ensino médio e superior 04 4,0 11 10,9 15 14,9 profissão/ ocupação ausente 19 18,8 57 56,4 76 75,2 0,071* presente 11 10,9 14 13,9 25 24,8 renda per capita 1 salário-mínimo 23 22,8 50 49,5 73 72,3 0,522* ≥1 salário-mínimo 07 6,9 21 20,8 28 27,7 total 71 70,3 30 29,7 101 100,0 *teste qui-quadrado; ** teste exato de fisher. fonte: elaboração própria. 61 impacto de úlceras venosas na qualidade de vida de indivíduos atendidos na atenção primária l rhayssa de oliveira araújo e outros na tabela 2, identificou-se associação significativa (p = 0,041) entre o tempo atual de uv e a variável “etilismo”, de forma que a maior frequência desse hábito entre pessoas com uv há mais de um ano e que não se autorreferiam etilistas (64,4 %; n = 65). conforme a tabela 3, a maioria dos participantes referiu recidivas da uv e dor que variou de moderada à intensa. ao analisar a qv dos participantes a partir do escore de cada domínio do ccvuq, observou-se que os domínios estado emocional e estética obtiveram médias superiores a 50, e os domínios atividades domésticas e interação social apresentaram médias inferiores 50. no tabela 4, apresenta-se a comparação das médias de qualidade de vida dos indivíduos acometidos segundo cada domínio do ccvuq. observou-se também uma tendência de piora do escore total e em cada domínio do ccvuq entre as pessoas com tempo de uv atual maior que um ano. houve associação estatisticamente significativa entre o tempo de uv atual e a dimensão estado emocional (p=0,008), com maior média (64,2) para o grupo com uv há mais de um ano tabela 4. discussão quanto à caracterização sociodemográfica, os resultados obtidos corroboram com aqueles encontrados em pesquisas conduzidas no nordeste brasileiro (14-16), nos quais se identificou predomínio de uv em mulheres idosas. no entanto, em outros estudos transversais realizados no centro-oeste do brasil (17-18) e em portugal (19), identificou-se a predominância do sexo masculino. acredita-se que o homem que convive com a uv ainda precisa tabela 2. condições de saúde de pessoas com úlcera venosa atendidas na atenção primária à saúde conforme o tempo de lesão (natal-rn, 2014) *teste qui-quadrado; **teste exato de fisher. fonte: elaboração própria. condições de saúde tempo atual de uv 1 ano > 1 ano total p-valor n % n % n % diabetes mellitus ausente 19 18,8 57 56,4 76 75,2 0,071* presente 11 10,9 14 13,9 25 24,8 hipertensão arterial sistêmica ausente 16 15,8 40 39,6 56 55,4 0,781* presente 14 13,9 31 30,7 45 44,6 outras doenças ausente 29 28,7 64 63,4 93 92,1 0,430** presente 01 1,0 07 6,9 08 7,9 sono ≥ 6 horas 18 17,8 40 39,6 58 57,4 0,734* 6 horas 12 11,9 31 30,7 43 42,6 etilismo ausente 23 22,8 65 64,4 88 87,1 0,041* presente 07 6,9 06 5,9 13 12,9 tabagismo ausente 25 24,8 61 60,4 86 85,1 0,739* presente 05 5,0 10 9,9 15 14,9 total 30 29,7 71 70,3 101 100,0 62 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 tabela 3. condições clínicas de pessoas com úlcera venosa atendidas na atenção primária à saúde conforme tempo de lesão (natal-rn, 2014) condições clínicas tempo atual de uv 1 ano > 1 ano total p-valor* n % n % n % recidivas presente 14 13,9 55 54,5 69 68,3 0,002 ausente 16 15,8 16 15,8 32 31,7 dor presente 25 24,8 63 62,4 88 87,1 0,459 ausente 05 5,0 08 7,9 13 12,9 intensidade da dor ausente/leve 11 10,9 13 12,9 24 23,8 0,048 moderada/intensa 19 18,8 58 57,4 77 76,2 total 30 29,7 71 70,3 101 100,0 *teste qui-quadrado. fonte: elaboração própria. de acolhimento e melhoria de acesso às ações de saúde —assim como as mulheres são atendidas—, como orientações sobre a promoção do autocuidado (20), principalmente, nos serviços da aps. apesar de não ter sido identificada significância estatística entre as doenças crônicas e o tempo de uv atual, em outras pesquisas foram verificadas associações estatisticamente significativas entre a uv e a has (4, 14) e com dm (4). no que se refere às condições clínicas da pessoa com uv, houve predomínio daquelas que tiveram recidivas e referiram dor moderada/intensa. recidivas ocorrem em aproximadamente 70,0% dos casos de uv, fato que evidencia a necessidade de manutenção do acompanhamento individual pela equipe de saúde mesmo após a cicatrização da úlcera. ainda, a recorrência da lesão é responsável por altos custos, investimento de tempo e trabalho das equipes multidisciplinares e, por isso, precisa ser prevenida (21). destaca-se que, fisiologicamente, o inadequado funcionamento do sistema venoso, devido à insuficiência venosa crônica dificulta o retorno venoso dos membros inferiores, o que favorece a ocorrência da uv (3-4). quanto à dor, este é um dos sintomas comumente apresentados pela pessoa com uv e que interfere negativamente sobre a qv (4, 8, 22-23), apesar de nem sempre os profissionais de saúde, principalmente médicos e enfermeiros, realizarem o manejo longitudinal desse sintoma (5). isso é importante uma vez que a dor apresenta efeito negativo no processo de cicatrização das feridas e, consequentemente, necessita ser manejada de forma adequada pela equipe de saúde (4, 18). a baixa qv das pessoas com uv pode resultar também do isolamento social (17), da diminuição da autoestima, da alteração da imagem corporal e do sentimento de impotência (8). neste estudo, apesar de as médias dos domínios estado emocional e estético terem sido mais elevadas que os domínios atividades domésticas e interação social, não se observaram associações significativas. já em estudo transversal (15) realizado em alagoas (brasil) com 66 participantes apresentavam uma qv variável. todavia, o instrumento utilizado pelos autores foi o sf-36, que não apresenta especificidade para pessoas com uv. no presente estudo, o domínio estado emocional foi o mais comprometido e o único que apresentou associação estatisticamente significativa com o tempo atual de úlcera. as pessoas com mais de um ano de lesão apresentaram pior estado emocional, o que pode ser resultado do temor à cronicidade da ferida. 63 impacto de úlceras venosas na qualidade de vida de indivíduos atendidos na atenção primária l rhayssa de oliveira araújo e outros tabela 4. comparação da qualidade de vida de pessoas com úlcera venosa na atenção primária à saúde segundo o tempo de uv atual (natal-rn, 2014) domínios do ccvuq tempo de uv atual mínimo máximo média (dp) p-valor* atividades domésticas 1 ano 16,8 84,2 42,0 (25,8) 0,175 > 1ano 16,8 84,2 45,4 (20,6) interação social 1 ano 19,3 86,3 48,6 (21,3) 0,836 > 1ano 18,0 86,3 48,1 (21,8) estado emocional 1 ano 20,7 100,0 50,3 (24,9) 0,008 > 1ano 20,7 100,0 64,2 (24,8) estética 1 ano 20,7 100,0 53,8 (22,7) 0,122 > 1ano 20,7 100,0 64,2 (24,8) total 1 ano 19,8 89,8 49,6 (16,8) 0,115 > 1ano 20,3 90,1 54,8 (16,1) *teste mann-whitney fonte: elaboração própria. sobre a qv na dimensão estética, esteve mais comprometida nas pessoas que tinham lesão há mais de um ano, o que gera maior preocupação das pessoas com a aparência na medida em que a ferida vai se tornando crônica. a insatisfação com o próprio corpo leva à desvalorização de si próprio e à dificuldade de lidar com a incapacidade funcional e a dor, com impacto negativo à qv das pessoas (5). a respeito da dimensão interação social, encontra-se que a exclusão social e a perda de privacidade foram mudanças com as quais as pessoas com uv aprenderam a conviver. sabe-se que a reclusão social pode estar associada aos sintomas clínicos, como o odor e o exsudato da ferida, pois essas pessoas referem evitar transitar por locais públicos para não constranger as outras pessoas (5, 23). além disso, a convivência harmoniosa com os profissionais de saúde ajudou a diminuir o sentimento de solidão e melhorou consideravelmente a relação das pessoas com lesão crônica com a sociedade em geral. ações, como grupos de trabalho, foram aceitas pelos usuários (5). além disso, a convivência com a uv traz implicações à vida produtiva (trabalho e interações sociais) e sexual. por isso, os profissionais de saúde devem considerar esses aspectos durante os atendimentos (20). a dificuldade de deambulação também contribui para o isolamento social (23). pesquisa realizada no reino unido refere que 13,8 % dos seus participantes apresentaram úlceras em ambos os membros inferiores, o que compromete ainda mais a deambulação do usuário e contribui para o seu isolamento (24). nesse sentido, destaca-se a necessidade de uma avaliação, pelos profissionais de saúde, da capacidade funcional dos usuários. a dificuldade de deambulação também compromete a realização das atividades domésticas, limita a capacidade dos indivíduos e contribui para a diminuição de sua qv (24). assim, discute-se a abordagem clínica e integral dos médicos e enfermeiros diante do atendimento às pessoas com uv na aps. cabe aos enfermeiros que constituem as equipes de esf desenvolverem e aplicarem ações conforme preconizado pela política nacional de atenção básica (pnab), principalmente no que diz respeito à integralidade da atenção (6). a relação entre paciente e enfermeiro apresenta fundamental importância nos bons resultados da assistência à pessoa com uv (23). a avaliação da capacidade funcional dos indivíduos e a realização de atividades em grupo, como medidas de promoção da 64 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 saúde (5, 24), podem ser realizadas pelos profissionais da esf. a aps brasileira preconiza, entre outras coisas, a criação do vínculo entre profissionais e usuários como algo essencial para a continuidade do atendimento e empoderamento do sujeito. os trabalhos em grupos são ferramentas que devem ser utilizadas pelos profissionais, tanto para criar vínculos e escutar as demandas quanto para contribuir para a socialização e integração dos usuários do sus (6). outra estratégia que pode auxiliar na redução do tempo de cicatrização e melhoria da qualidade de vida é a implementação de protocolo para as pessoas com uv atendidas na aps. a utilização do protocolo pode contribuir para a padronização e a sistematização das ações de atenção, bem como para a continuidade de cuidados, o que aumenta a segurança ao reorientar a equipe da aps (25). assim, qualificar as práticas dos profissionais, que nem sempre são realizadas conforme a evidência científica, pode contribuir para uma melhor cicatrização da ferida e qv das pessoas com uv (26). sinaliza-se a importância de pesquisas de intervenção e novas evidências sobre a forma de melhorar a qv de pacientes com uv no intuito de oferecer uma abordagem integral, métodos de alívio da dor e tratamento para cura da ferida (8). nesse contexto, o ccvuq mostra-se como instrumento específico para a avaliação da qv em pessoas com uv. também poderia favorecer o planejamento de ações para cada paciente, com intervenções específicas, capazes de melhorar a qv e ampliar a assistência para além dos aspectos técnicos de tratamento da ferida, com o enfoque no paciente de forma global (8). assim, o instrumento possibilita suporte para avaliação da qualidade de vida nessa população e isso ajuda na tomada de decisão e planejamento assistencial. a baixa escolaridade dos participantes foi considerada um obstáculo, pois interferiu na compreensão das perguntas presentes nos instrumentos utilizados na coleta de dados e foi necessária a aplicação de maneira assistida, o que pode ser realizado com indivíduos de baixa escolaridade (12). além disso, a baixa escolaridade compromete o entendimento e a adesão a tratamentos complexos, como os exigidos às pessoas com uv (4, 16), e, portanto, deve ser considerada pelos profissionais da saúde ao planejarem a assistência (4). o fato de o estudo ter sido desenvolvido em uma realidade específica limita a generalização dos resultados e reforça a ideia de que a utilização do ccvuq deve ocorrer em diferentes regiões e populações brasileiras (12). conclusão identificou-se o comprometimento da qv das pessoas atendidas pela aps do município de natal-rn (brasil), com destaque para a qv nas dimensões estado emocional e estética, que foi menor nos que tinham mais de um ano de lesão. o tempo de uv atual esteve estatisticamente associado à dimensão estado emocional do ccvuq. a adoção do ccvuq permite avaliar a qv em pessoas com uv e faz-se necessário utilizar esse instrumento em diferentes cenários para subsidiar efetivas avaliações e medidas de tratamento, promoção de saúde e prevenção da uv. pontua-se a necessidade de implementação de ações efetivas que busquem garantir a melhoria da qv das pessoas com uv, principalmente, no que se refere à realização de atividades domésticas e à interação social. além disso, os profissionais devem atentar para a especificidade da demanda das pessoas com uv há mais de ano, pois tendem a apresentar maior comprometimento da qv em comparação aos usuários que convivem com a 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[on-line] set. 2014 [consultado em 25 nov. 2015]; 38 (1): [7 telas]. disponível em: http:// link.springer.com/article/10.1007%2fs00268-013-2228-x 5. maddox d. effects of venous leg ulceration on patients’ quality of life. nurs stand. 2012; 26(38):42-9. 6. brasil. ministério da saúde. secretaria de atenção à saúde. departamento de atenção básica. política nacional de atenção básica/ministério da saúde. secretaria de atenção à saúde. departamento de atenção básica. brasília: ministério da saúde; 2012. 7. silva mh, jesus mcp, merighi mab, oliveira dm. limites e possibilidades vivenciados por enfermeiras no tratamento de mulheres com úlcera venosa crônica. rev esc enferm usp. 2014;48(esp):54-9. 8. gonzález-consuegra rv, verdú j. quality of life in people with venous leg ulcers: an integrative review. j adv nurs. [on-line] maio 2011 [consultado 25 nov. 2015]; 67 (5): [18 telas]. disponível em: http://www.ncbi.nlm.nih.gov/pubmed/21241355 9. smith jj, guest mg, greenhalgh rm, davies ah. measuring the quality of life in patients with venous ulcers. j vasc surg. 2000;(31):642-9. 10. wong i, lee d, thompson dr. translation and validation of the chinese version of the charing cross venous ulcer questionnaire. j clin nurs. 2005;(15):356-7. 11. gonzález-consuegra rv, verdú j. proceso de adaptación al castellano del charing cross venous ulcer questionnaire (ccvuq) para medir la calidad de vida relacionada con la salud en pacientes con úlceras venosas. gerokomos. 2010;21(2):80-7. 12. couto rc, leal fj, pitta gbb, bezerra rcb, segundo wss, porto tm. translation and cultural adaptation of charing cross venous ulcer questionnaire. j vasc bras. 2012;11(2):102-7. 13. brasil. resolução 466/2012. diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos/ministério da saúde, conselho nacional de saúde. brasília: ministério da saúde; 2012. 14. costa ikf, nóbrega wg, costa ikf, torres gv, lira albc, tourinho fsv et al. pessoas com úlceras venosas: estudo do modo psicossocial do modelo adaptativo de roy. rev gaúcha enferm. 2011;32(3):161-8. 15. costa lm, higino wjf, leal fj, couto rc. perfil clínico e sociodemográfico dos portadores de doença venosa crônica atendidos em centros de saúde de maceió (al). j vasc bras. 2012;11(2):108-13. 16. camacho aclf, santos rc, joaquim fl, louredo ds, morais im, silva ea. estudo comparativo sobre a capacidade funcional de pacientes adultos e idosos com úlceras venosas. rev pesqui cuid fundam. [on-line] jan.-mar. 2015 [consultado em 25 nov. 2015]; 7 (1): [12 telas]. disponível em: http://www.seer.unirio.br/index.php/cuidadofundamental/article/ viewfile/3505/pdf_1435 17. malaquias sg, bachion mm, sant’ana smsc, dallarmi ccb, lino junior rs, ferreira ps. pessoas com úlceras vasculogênicas em atendimento ambulatorial de enfermagem: estudo das variáveis clínicas e sociodemográficas. rev esc enferm usp. 2012;46(2):302-10. 18. sant’ana smsc, bachion mm, santos qr, nunes cab, malaquias sg, oliveira bgrp. úlceras venosas: caracterização clínica e tratamento em usuários atendidos em rede ambulatorial. rev bras enferm. 2012;65(4):637-44. 66 año 16 vol. 16 nº 1 chía, colombia marzo 2016 aquichan issn 1657-5997 19. saraiva dmrf, bandarra ajf, agostinho es, pereira nmm, lopes ts. quality of life of service users with chronic venous ulcers. revista de enfermagem referência 2013;seriii (10):109-18. 20. silva mh, jesus mcp, marighi mab, oliveira dm, biscootto pr, silva gps. the daily life of men who lives with chronic venous ulcer: phenomenological study. rev. gaúcha enferm. 2013;34(3);95-101. 21. silva faa, moreira tmm. características sociodemográficas e clínicas de clientes com úlcera venosa de perna. rev enferm uerj. 2011;19(3):468-72. 22. salvetti mg, costa ikf, dantas dv, freitas ccs, vasconcelos qldaq, torres gv. prevalência de dor e fatores associados em pacientes com úlcera venosa. revista dor. 2014;15:245-8. 23. green j, jester r, mckinley r, pooler a. the impact of chronic venous leg ulcers: a systematic review. j wound care. [on-line] dez. 2014 [consultado 25 nov. 2015]; 23(12): [11 telas]. disponível em: http://www.ncbi.nlm.nih.gov/pubmed/25492276 24. green j, jester r. health-related quality of life and chronic venous leg ulceration: part 1. research review. br j community nurs. [on-line] mar. 2009 mar [consultado 25 nov. 2015]; 14 (12): [4 telas]. disponible en: http://web.a.ebscohost. com/ehost/pdfviewer/pdfviewer?sid=a4ced193-f36e-4f5c-9b75-70fc6b17aa2a%40sessionmgr4005&vid=1&hid=4209 25. costa ikf, salvetti mg, souza ajg, dias tyaf, dantas dv, torres gv. assistance protocol to people with venous ulcers: a methodological study. online braz j nurs. [on-line] abril 2015 [consultado 25 nov. 2015];14(1):[10 telas]. disponível em: http://www. objnursing.uff.br/index.php/nursing/article/view/4692 26. silva mh, jesus mcp, merighi mab, oliveira dm, santos smr, vicente ejd. o manejo clínico de úlceras venosas nos cuidados de saúde primários. acta paul enferm. 2012;25(3):329-33. 311 317 primeras paginas.indd 315 editorial la ética: más que un elemento integrador del proceso editorial ethics: more than an integrating element of the editorial process a ética: mais do que um elemento integrador do processo editorial doi: 10.5294/aqui.2015.15.3.1 a la luz de la filosofía, la palabra “cuidado” viene del latín cogitare, que significa pensar. en la edad media, cuidar significaba siempre pensar, reflexionar, juzgar. este énfasis reflexivo se ha ido perdiendo y se ha acentuado un sentido asistencial, protector y de ayuda. este es el sentido del cuidado para enfermería (1). cuidar es una actividad de reflexión y crítica que implica conocer y discernir... algo propio de la disciplina. la palabra cuidado nos evoca significados, actitudes, acciones y relaciones, todo ello alrededor de la ética como elemento integrador. los términos ética y moral comparten, en cierto modo, sus etimologías. en la cotidianidad se utilizan para expresar igual sentido. la palabra “ética” viene del griego ethos, que significa costumbre o hábito, y “moral” viene del latín, que tiene el mismo significado. la ética se considera una rama de la filosofía que estudia los comportamientos en cuanto pueden ser correctos o incorrectos, se relaciona con la moral y el actuar del ser humano. ¿por qué esta introducción para abordar la ética como elemento integrador del proceso editorial de revistas científicas? porque están íntimamente relacionados; publicamos para el desarrollo de la disciplina de enfermería. la divulgación y visibilidad de los trabajos de investigación de docentes e investigadores no solo aportan al desarrollo teórico, sino que contribuyen al mejoramiento de la calidad de vida de hombres y mujeres. la ética está presente en toda la producción de una revista científica y compromete a cada uno de los actores que intervienen en ella. no es exclusiva de autores, también compromete al editor, a evaluadores y árbitros, a comités editoriales y científicos; igualmente, a quienes adelantan los procesos editoriales. con el fortalecimiento y la expansión de redes de investigación, gracias a las tecnologías de información y comunicación (tic), que rompen y superan fronteras geográficas, culturales y de lenguaje, la ética se convierte en la médula de cualquier diálogo y dinámica integradora entre académicos e investigadores. en américa latina, como en los centros de investigación más avanzados del mundo, hemos pasado en pocas décadas a acciones de cooperación, alianzas estratégicas y convenios con enfoques multidisciplinarios. son redes complejas y dinámicas. las universidades se han acercado al sector real, con el modelo universidad-empresa, y participación activa de la sociedad (2). los escenarios de investigación se salen del aislamiento de los laboratorios, como lugares privados y herméticos. el laboratorio está ahí, en la misma sociedad. es en ese lugar en donde ocurren los fenómenos de estudio y, de manera particular, los fenómenos alrededor del cuidado de enfermería, del cuidado de la salud. 316 aquichan issn 1657-5997 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 y es justo en ese escenario, en donde la ética de los investigadores enfrenta sus primeros retos, al realizar trabajos de campo, y estudios de caso y cualitativos. se trata del consentimiento informado, entendido como la manifestación expresa de una persona de participar de manera libre y voluntaria en el estudio. este es resultado del cambio cultural y la evolución de la relación entre el investigador y las personas o los grupos participantes, reconociendo la autonomía y la responsabilidad de la práctica investigativa. de manera que la práctica y los procesos de investigación no están exentos de conflictos éticos; conflictos que, a su manera y circunstancias, debe afrontar igualmente el editor. son muchos los dilemas éticos de un editor; entre ellos, podríamos mencionar la validez del proceso investigativo y sus resultados a través del tiempo, las dificultades o la capacidad para comprender los resultados de determinados estudios y, en ocasiones, la desconfianza por aspectos no siempre transparentes. alrededor de una revista científica, se tejen una serie de procesos complejos sobre los cuales la comunidad académica espera altos niveles de calidad, transparencia, rigor y credibilidad, aspectos que no se logran si se incurre en faltas éticas (3). entre los protagonistas de primer orden en la edición científica están los evaluadores, a quienes se les ha dado el título de “certificadores del conocimiento”. ellos, los aseguradores de la calidad de los contenidos de una revista, son seleccionados bajo altas condiciones personales y académicas, y representan lo más autorizado de las comunidades científicas de una disciplina, por su trayectoria, reconocimiento y prestigio. entonces, se espera de ellos un exigente trabajo, cuyo resultado, también, es sometido al escrutinio de la comunidad científica. el evaluador debe analizar el trabajo con los criterios de originalidad, pertinencia y validez, al igual que con el mayor rigor para poder identificar los posibles conflictos de interés que, si no son resueltos, derivan en graves faltas éticas. pero la tarea y responsabilidad del evaluador van más allá del concepto de aceptado o rechazado; sus conceptos y sugerencias, también, contribuyen a la reflexión y argumentación temática (4). ahora bien, ¿qué decir acerca de la relación entre resultados de investigación y práctica de enfermería? ¿está la práctica de enfermería guiada por la ciencia? ¿se incorporan de manera frecuente los resultados de los estudios? ¿conocen los enfermeros(as) de servicio en las áreas clínicas y asistenciales estos resultados? ¿qué tanto contribuyen los resultados publicados en las revistas científicas, en la realidad de los servicios asistenciales? el esfuerzo de las publicaciones seriadas se ve altamente compensado, en la medida en que los resultados de novedosos y pertinentes estudios lleguen a la práctica para fortalecerla y transformarla. sin embargo, existe una brecha muy grande entre el momento en que se producen los resultados de los proyectos de investigación y la incorporación de estos en la práctica. desde el punto de vista ético, debemos hacer estas preguntas e intentar responderlas. la responsabilidad es conjunta, también de quienes estamos en el medio académico, en la formación de nuevos profesionales de programas de pre y posgrado. el principal reto del investigador en enfermería es lograr que los resultados de sus estudios y trabajos impacten y transformen la práctica. una buena estrategia para estimular e incrementar la consulta y aplicación de estos resultados por parte de enfermeros y enfermeras de áreas clínicas y asistenciales es ampliar las redes de trabajo y cooperación, incorporando a estos profesionales en grupos y proyectos de investigación, conjuntamente con sus resultados. no debemos olvidar que los fenómenos de estudio del cuidado están en la práctica. es allí donde suceden las principales acciones, por tanto, debemos incentivar que desde estos espacios se identifiquen los temas y problemas de investigación. escenarios clínicos, asistenciales, comunitarios, escolares y de salud ocupacional, por mencionar algunos, son espacios reales y cotidianos donde encontramos los problemas por resolver, con acciones de cuidado y educación. maría clara quintero laverde decana, facultad de enfermería y rehabilitación 317 editorial referencias 1. botero ud. si la naturaleza es sabia, el hombre no lo es. el cuidado de la vida a la luz de la filosofía. cátedra manuel ancizar cuidado de la vida. bogotá: universidad nacional; 2006. p. 15-34. 2. organización para la cooperación y el desarrollo económico (odce)-banco mundial (bm). investigación e innovación. en: evaluación de políticas nacionales de educación. la educación superior en colombia. bogotá: ocde-bm; 2012. 3. bravo tr. aspectos éticos en las publicaciones científicas. [citado 2015 agosto 18]. disponible en: http://www.infodoctor. org/rafabravo/fraude.htm 4. ramírez dc, martínez lc et al. divulgación y difusión del conocimiento: las revistas científicas. bogotá: universidad nacional de colombia; 2012. 133 138 primeras paginas.indd 137 editorial la educación debe traspasar las fronteras del entramado mundo education must straddle the borders of this tangled world a educação deve ir além dos limites do quadro mundial doi: 10.5294/aqui.2018.18.2.1 tivo, la interacción respetuosa intercultural e inclusiva, donde se tengan en cuenta la cultura, los valores y la ecología como ejes integradores de la vida de los seres humanos. ante esto nos tenemos que cuestionar permanentemente: ¿será que reproducimos en nuestra enseñanza lo tradicional, apegados al pasado mecánico y condicionados por la fragmentación y desintegración del conocimiento? ¿o enseñamos lo que necesitan nuestros educandos, enfocados hacia sus intereses y expectativas? ¿por qué no desechar esas ideas obsoletas de que solo se aprende a partir de la memoria y la repetición, con bastante información descontextualizada? ¿o será que el sistema ha condicionado la actuación y no ha permitido en los maestros o mediadores la reflexión pedagógica acerca de su quehacer? y por último vale la pena preguntarse, ¿quién formará a los educadores y las educadoras? estos interrogantes requieren que repensemos la educación que brindamos, que nos cuestionemos, que proyectemos ese cambio paradigmático emergente, donde se enfoque la educación hacia nuevos caminos flexibles y abiertos; donde se desarrolle el pensar, hacer y sentir, apoyados en la afectividad, la ética y la estética. donde la apertura, la incertidumbre, la imprevisibilidad, el diálogo y la búsqueda del saber sean la base para llegar a “resignificar”, es decir para dar sentido a lo que se hace en ese encuentro o mediación pedagógica, que conduzca a dar significado al mundo y a las propias experiencias de los y las interactuantes. actualmente, la educación sigue nadando a contracorriente; se continúa con la alineación de los estudiantes, se repite la misma información o la que se encuentra en los medios de comunicación (libros, internet, bases de datos, manuales), se fragmentan las asignaturas y se obliga a que todos y todas aprendan igual, por lo que se acorta en los y las aprendices el pensamiento y se inhibe su creatividad, aferrados a un sistema obsoleto, rígido y arbitrario. sin embargo, existen posturas que trazan lineamientos en contra de lo anterior, donde se describe que la educación debe reorientarse hacia los intereses y las necesidades de los educandos y las educandas, teniendo en cuenta el contexto, la cultura, el ambiente y los avances tecnológicos, aspectos que muchas instituciones ya han ido incorporando en su proceso educativo, pues se vislumbra un futuro del que no podemos alejarnos y al que debemos dar respuestas razonadas y deliberadas para hacer frente a las incertidumbres y controversias, a fin de poder contribuir a protagonizar la transformación social que se nos exige. por ello, al enfrentar nuestros retos, hacemos eco de las propuestas de julián de zubiría en su reciente publicación los desafíos de la educación colombiana (1), donde se habla de rediseñar el sistema, inventar y pensar nuevas formas para interactuar con los otros y las otras en los encuentros del acto educativo, con nuevas estrategias que involucren el trabajo en equipo, colaboramaría del carmen gutiérrez agudelo1 1 orcid.org/0000-0002-8403-2768. universidad de la sabana, colombia. mariac.gutierrez@unisabana.edu.co 138 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 2 chía, colombia abril 2018 esta propuesta, enfocada a la formación del enfermero(a), se debe orientar hacia el uso de estrategias o modelos de clase y de práctica donde se propicien las experiencias de cada participante y se exploten al máximo sus potencialidades, para que en conjunto con los otros, en esa red de interconexión, encuentren el sentido de lo que hacen, sean auténticos críticos, verdaderos creativos, y se comprometan a trabajar en beneficio de todos y todas, sin abandonar su contexto. para ello, en los encuentros mediadores en el aula o fuera de ella se deben utilizar estrategias generadoras o actividades de aprendizaje que involucren la experiencia individual, social y cósmica, donde exista correlación entre la realidad que nos habla, y la creatividad y el interés por hacer hablar dicha realidad. por ejemplo, tener en cuenta los aconteceres de cada día, ordinarios o extraordinarios, como un nacimiento, la enfermedad de un familiar, de un amigo; una experiencia hospitalaria o un tratamiento, así como las realidades analizadas, transformadas, codificadas y señaladas por científicos, escritores, poetas o pintores: artículos publicados, una poesía, textos sobre una teoría de cuidado, imágenes de hospitales, unidades o servicios de pacientes, epidemias o situaciones de enfermedades, entre otras. existe otro aspecto que no debemos olvidar, y es la práctica simulada, para que los avances y recursos tecnológicos que hoy se usan lleven a la formulación de preguntas, a definir un problema o situación, a buscar evidencias, a analizar diferentes alternativas de solución, y a tolerar las ambigüedades o los sesgos presentes. ya que en la práctica profesional estos retos se deben enfrentar con capacidad de crítica, con mente abierta, a partir de razonamientos y juicios reflexivos, honestos y prudentes basados en el hacer y el actuar. con estas experiencias de aprendizaje se busca el protagonismo de los y las participantes, la armonía entre el sentir y la razón, se provoca el sabor del saber, se despiertan el interés y la continuidad, se crean relaciones con el contexto que ayudan a transformar la realidad. el énfasis se debe poner en el acto de aprender, es decir en la autoorganización del conocimiento que cada ser humano debe ejecutar. pero, igualmente, se necesitan educadores y educadoras con identidad, perspectiva ética, racional y cognoscitiva; promotores de valores, maestros de vida que enseñen a vivir. que sean además creadores de nuevos conocimientos y visiones del mundo, diseñadores de ambientes educativos que involucren las tecnologías de la información y la comunicación. en la asociación colombiana de facultades y escuelas de enfermería (acofaen), cuya misión se enfoca en fortalecer la formación del profesional de enfermería en colombia, las perspectivas en educación se alinearán hacia la formación de profesionales con sentido humano, con responsabilidad social, capacidad para tomar decisiones y buscar soluciones dentro del equipo multidisciplinario en el cual interactúan, liderando el cuidado de la persona, la familia y la comundiad en el contexto donde ejerzan su quehacer profesional. para concluir citamos a francisco gutiérrez, quien señala: “hay que educar para las épocas futuras, no para las que se fueron” y “el presente, lo dejó escrito el maestro, es la gravitante transformación del pasado en futuro” (2). referencias 1. samper j. los desafíos de la educación colombiana. 2017. disponible en: http://www.semana.com/educacion/articulo/ plan-decenal-los-retos-de-la-educacion-en-colombia/534554 2. gutiérrez f. omar dengo educador de un pueblo. 2a ed. costa rica: editorial nueva década; 1986. 94 p. 15 programa.p65 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005138 año 5 vol. 5 nº 1 (5) 138-147 chía, colombia octubre 2005 martha lucía acosta otálora1 fanny yaneth gaviria nieto2 zaira liliana méndez agudelo3 recibido: 1 de junio de 2005 aprobado: 23 de junio de 2005 resumen el objetivo del proyecto realizado en la especialización de gestión en rehabilitación fue implementar un programa de vigilancia y control del área de la piscina del instituto de ortopedia infantil roosevelt, para mejorar las condiciones sanitarias del agua y evitar la aparición y reproducción de agentes patógenos en el medio y en los usuarios que ingresan a ella. el instituto roosevelt es una entidad prestadora de servicios de salud ubicada en bogotá, en donde la hidroterapia hace parte de la intervención fisioterapéutica. al realizar un diagnóstico del área se evidenció que no se estaban haciendo los procesos indispensables que aseguraran las condiciones higiénico-sanitarias del agua de la piscina, razón por la cual se vio la necesidad de realizar una serie de actividades encaminadas a garantizar la calidad del agua y el adecuado funcionamiento del área para la protección de la salud de los pacientes, acompañantes, estudiantes, fisioterapeutas y operadores. finalmente se logró en un alto porcentaje la implementación del programa, siendo evidente el compromiso e interés institucional por éste. palabras clave rehabilitación, piscina, vigilancia, control, agua. abstract the main objective for this project of management was to implement a vigilance and control programme for the swimming pool�s area at �instituto de ortopedia infantil roosevelt� (roosevelt institute for children�s orthopaedics), in order to improve the sanitary conditions of water and to avoid the presence and reproduction of pathogen agents in both the swimming pool�s area and its users. roosevelt institute is an healthcare services provider located in bogotá, dc �colombia, in which the hydrotherapy is a part of the physiotherapeutic treatment. when it was diagnosed the swimming pool�s area, it evidenced a lack of important processes in order to assure the proper hygienic conditions of the swimming pool�s water; for this reason there were carried out a series of activities with the main intention of warranting the water�s quality and the adequate operation of the swimming pool�s area in order to protect the patients, its companions, students, professionals and worker�s health. finally, the objective was fulfilled in an very high percentage, and the programme was implemented with an evident commitment and interest out of roosevelt institute. key words rehabilitation, pool, vigilance, control, water. 1 terapeuta física, clínica universitaria teletón, especialista en docencia universitaria y en gestión en rehabilitación, colombia. martha.acosta@unisabana.edu.co 2 fisioterapeuta, clínica universitaria teletón, especialista en gestión en rehabilitación, colombia. f a n n y . g a v i r i a @ c l i n i c a u n i v e r s i t a r i a t e l e t o n . c o m . c o 3 fisioterapeuta, clínica universitaria teletón, especialista en gestión en rehabilitacióncolombia, colombia. z a i r a m e n d e z @ c l i n i c a u n i v e r s i t a r i a t e l e t o n . c o m . c o * este proyecto se diseñó e implementó en la especialización de gestión en rehabilitación de la facultad de enfermería de la universidad de la sabana, en el primer semestre de 2004, con la asesoría de beatriz suárez de sarmiento. programa de vigilancia y control de la piscina del instituto de ortopedia infantil roosevelt 139 l instituto roosevelt es una entidad prestadora de servicios de salud ubicada en bogotá, en donde la hidroterapia hace parte de la intervención fisioterapéutica, por lo que gran parte de los pacientes debe asistir a esta área. los usuarios son tanto niños como adultos, con secuelas de diferentes patologías y/o afecciones neurológicas y/o osteomioarticulares, que por sus características especiales pueden presentar incontinencia urinaria y fecal, infecciones urinarias, lesiones en la piel, alteraciones en la sensibilidad, sialorrea (babeo) y discapacidades que comprometen de forma leve a severa el funcionamiento motor. el proyecto fue desarrollado a partir de un diagnóstico que contempló la forma como se venía realizando el control respecto a las condiciones químicas, microbiológicas y bacteriológicas del agua de la piscina; la temperatura, los elementos usados para el control y las personas responsables; las normas para el ingreso de los usuarios, los fisioterapeutas y estudiantes; la afluencia de usuarios, familiares y empleados de la institución que transitaban en el área; las condiciones higiénicas de la piscina y del área de hidroterapia; la revisión de la documentación relacionada con la vigilancia y el control de la piscina, y la percepción de los fisioterapeutas y estudiantes de fisioterapia respecto a las condiciones higiénico-sanitarias del agua. el diagnóstico se hizo por medio de la observación directa apoyada con videos y fotografías, entrevistas y aplicación de encuestas. a partir de los resultados del diagnóstico se detectó la presencia de algunas dificultades que podían favorecer la contaminación y la falta de desinfección adecuada, por lo cual se vio la necesidad de plantear el proyecto de gestión. objetivo general implementar un programa de vigilancia y control del área de la piscina del instituto de ortopedia infantil roosevelt basado en algunos artículos de la resolución 002191 de octubre 4 de 1991, expedida por la secretaría distrital de salud de bogotá d.c. (1) para mejorar las condiciones sanitarias del agua y evitar la aparición y reproducción de agentes patógenos en el medio y en los usuarios que ingresan a ella. objetivos específicos establecer la rutina de registro de los parámetros de cl, ph y temperatura del agua dos veces diarias según la resolución 002191 de octubre 4 de 1991 de la secretaría distrital de salud de santa fe de bogotá. implementar análisis periódicos microbiológico, bacteriológico y micológico del agua de la piscina del instituto de ortopedia infantil roosevelt por un laboratorio de microbiología industrial. divulgar al personal relacionado con el área la importancia del programa de vigilancia y control de la piscina del área de hidroterapia del instituto de ortopedia infantil roosevelt. la resolución respalda la creación de programas de vigilancia y control de piscinas en bogotá, cuyo objeto es garantizar la calidad del agua, el buen estudio y la suficiencia de las instalaciones aledañas a la piscina, el correcto funcionamiento del establecimiento en general y la protección de la salud de los usuarios. con el proyecto se pretendió evitar la presencia de situaciones adversas que comprometieran el bienestar de los usuarios, del personal del área, y la calidad asistencial. programas de vigilancia y control la secretaría distrital de salud de bogotá, d.c., a través de la dirección de salud pública, sus diferentes áreas, el laboratorio de salud pública y los hospitales de la red adscrita, a lo largo de varios años ha realizado un trabajo intersectorial e interinstitucional que revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005140 ha dado como resultado el sistema de vigilancia epidemiológica ambiental (sisvea) cuya primera edición fue en bogotá en el año 2001 (2). el sistema de vigilancia epidemiológica ambiental (sisvea) busca realizar un monitoreo crítico de los determinantes ambientales que inciden sobre el proceso salud-enfermedad de la población del distrito capital. por esto, el abordaje del sistema debe orientarse, fundamentalmente, a la caracterización de los factores de riesgo para su posterior intervención individual y colectiva. la secretaría distrital de salud decide publicar los protocolos de vigilancia en salud ambiental como parte del programa, buscando la unificación de criterios técnicos y la estandarización de procesos para encaminar el ejercicio de las autoridades sanitarias hacia la identificación, caracterización y clasificación de los diferentes factores de riesgo ambientales y, de acuerdo con el diagnóstico sanitario, orientar las acciones de control y prevención. teniendo en cuenta la manera como se relacionan los factores de riesgo con el individuo, cómo se apropia éste de los mismos y cómo se han venido dando las intervenciones en salud en la inspección, la vigilancia y el control de los mismos, los eventos que se deben vigilar se agrupan en cuatro factores de riesgo: del consumo, físicos, biológicos y químicos. en la vigilancia y el control de piscinas deben identificarse factores de riesgo físico, químico y biológico principalmente. dados los factores de riesgo para la salud relacionados con el agua de las piscinas, ya sea por contacto, consumo o manejo de sustancias químicas, y sumado al establecimiento de una normatividad por la secretaría de salud de bogotá para el manejo y mantenimiento de estas áreas de piscinas, en toda institución que preste estos servicios se requiere la existencia de un programa de vigilancia y control documentado, específico y puntual que describa los procedimientos que se deben realizar con el fin de mantener, optimizar y disponer de una adecuada atención. en el agua pueden existir diversos tipos de microorganismos como las bacterias, los hongos, los virus, los protozoos y las algas que causan afecciones en diferentes órganos y sistemas del cuerpo, como en la piel, los ojos, el aparato respiratorio, el digestivo y el genitourinario. la difusión de enfermedades infecciosas se ve favorecida por la acumulación de usuarios, factor de riesgo importante para el crecimiento de hongos, bacterias y virus, fácilmente transmisibles por la vía aérea, contacto directo o por el agua. todas las personas que hacen inmersión en el agua de la piscina �pacientes, familiares, fisioterapeutas y estudiantes de fisioterapia� son susceptibles, bajo estas condiciones, a contraer microorganismos patógenos que llevan a enfermedades y afecciones perjudiciales para la salud. el consumo del agua en lo que hace referencia a las piscinas de uso colectivo, la legislación actual establece la obligatoriedad de renovación diaria de una parte del agua y del vaciado total del vaso de la piscina, al menos una vez al año. es evidente que estas renovaciones benefician la calidad del agua y es obligación del responsable del mantenimiento de la piscina cumplir con la normativa vigente. (�) parece razonable que, si se establecen los sistemas adecuados que garanticen las condiciones higiénico-sanitarias exigidas para el agua de las piscinas, se tienda a reducir al máximo esta importante renovación. de esta manera disminuirá considerablemente el consumo de agua que ocasionan actualmente las piscinas de uso colectivo. (�) la acción de estas partículas (bacterias, algas, materia orgánica, sólidos en suspensión, etc.) provoca en el agua un cambio de color y un incremento de la turbiedad. estas alteraciones que son apreciables visualmente alertan de que el agua, además de disminuir considerablemente su estética, está perdiendo su calidad higiénicosanitaria (3). por lo tanto, para garantizar un agua sin microorganismos patógenos, olores y sabores desagradables, productos tóxicos y turbiedad, es imprescindible someterla a un profundo proceso de depuración. el mantenimiento del agua en buenas condiciones estéticas (transparente, cristalina, nítida, azul) y sanitarias (desinfectada con la consiguiente eliminación de gérmenes patógenos), requiere la combinación de dos tratamientos: el sistema de vigilancia epidemiológica ambiental (sisvea) busca realizar un monitoreo crítico de los determinantes ambientales que inciden sobre el proceso salud-enfermedad de la población del distrito capital. programa de vigilancia y control de la piscina del instituto de ortopedia infantil roosevelt 141 � tratamiento físico: recirculación del agua. reposición del agua. cambio del agua. renovación del agua. filtración del agua. limpieza del vaso. � tratamiento químico: desinfección del agua. control y regulación de alguna de sus características. el cloro es el desinfectante de uso más común en todo el mundo. para la cloración terminal debe haber un residuo de cloro libre de por lo menos 0,5 mg/l después de un tiempo de contacto mínimo de 30 minutos a un ph de menos de 8,0, lo mismo que para la inactivación de los virus entéricos. cuando se usa el cloro como desinfectante en sistemas de distribución por tuberías, es deseable tener un residuo de cloro libre de 0,2-0,5 mg/l en toda la instalación. un alto nivel de turbiedad puede proteger a los microorganismos de los efectos de la desinfección, estimular la proliferación de las bacterias y provocar una demanda considerable de cloro. para una desinfección eficaz es necesario que la turbiedad sea de menos de 5 unt (unidad nefelométrica de turbiedad); lo ideal es que la turbiedad media se sitúe por debajo de 1 unt. la contaminación se debe a: � los bañistas: contaminación de tipo microbiológico (gérmenes patógenos) y orgánico (sudor); la piel, las mucosas y el aparato genitourinario son los responsables de la aportación de la mayoría de estos microorganismos, los cuales pueden reducirse drásticamente si los bañistas, antes de introducirse en el agua, toman una ducha. � los no bañistas: pueden contaminar a través del calzado, por lo que debe prohibirse el acceso de estos visitantes a la zona. � el medio ambiente: a través del viento y la lluvia, estos fenómenos meteorológicos pueden introducir hojas, polvo, polen, tierra y arena que pueden transportar al agua gérmenes patógenos. � el agua de suministro: puede aportar contaminación si no está en las condiciones sanitarias adecuadas, por lo que es imprescindible asegurarse de que esta agua cumpla las condiciones sanitarias exigidas. � los productos químicos: cuando se utilizan incorrectamente ya sea por un exceso de producto (intoxicación), o bien por una insuficiente utilización. los responsables del mantenimiento de la piscina deben ser conscientes de que asumen la protección de la salud de los usuarios y, por lo tanto, deben garantizar la calidad higiénico-sanitaria del agua mediante el tratamiento y los controles correspondientes. análisis fisicoquímico del agua de la piscina para analizar los diferentes procesos donde hay cambios químicos se deben explicar varios conceptos físicos y químicos. los operadores de las piscinas deben tener conocimiento de química sanitaria para controlar los procesos y para medir la efectividad del tratamiento usado. es importante medir el ph al mismo tiempo que el cloro residual ya que la eficacia de la desinfección con cloro depende en alto grado del ph: cuando el ph pasa de 8,0 la desinfección es menos eficaz. acodal (4), en 1991, sugiere que el valor ideal del ph del agua de una piscina es de 7,4 o sea del lado alcalino. es absolutamente necesario mantener el ph entre 7,2 y 7,8, si se aleja de estos valores puede producir enturbiamiento del agua, disminución de la efectividad del desinfectante, molestias de los bañistas y el deterioro de los materiales. el mantenimiento del ph dentro de valores óptimos se consigue con la utilización de reactivos químicos llamados correctores o modificadores del ph. los valores de ph menores que 7,2 causan: � irritación de ojos y mucosas. � corrosión de partes metálicas y agresividad sobre concreto y sus derivados. los valores mayores que 7,6 causan: � si el ph es mayor que 8,3 puede producir irritación de la piel. � existe la posibilidad de que se precipite el calcio, produciendo enturbiamiento del agua. � disminuye la capacidad microbicida del cloro, con incremento de los costos de tratamiento por mayor consumo. los métodos para determinar el ph van desde los colorimétricos hasta los electrodigitales, se debe estar determinando con la frecuencia que se considere convenienrevista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005142 te para hacer las correcciones que lo sitúen en los parámetros ideales. si se analiza el comportamiento del cloro y sus derivados, se encuentra que a mayor temperatura corresponde una menor solubilidad, es decir, existe una mayor tendencia a que el cloro se pierda cuando las temperaturas son altas. tratamiento químico los objetivos del tratamiento químico son: � eliminar bacterias y otros microorganismos. � evitar el crecimiento de algas. � evitar daños en la piscina (corrosión, incrustaciones, entre otros). � ayudar a mantener el agua clara. el cuidado de las piscinas y los vestuarios resulta fundamental puesto que el agua, por sus condiciones características, actúa como transmisor ideal de enfermedades. el mantenimiento de la limpieza, los análisis periódicos y el correcto tratamiento del agua de las piscinas, controlando la cantidad de cloro libre residual (cloro desinfectante) que éstas contienen, debería bastar para eliminar prácticamente la posibilidad de transmisión de algunas enfermedades. el agua de la piscina debe recibir un aporte suficiente de cloro activo (cloro desinfectante) para garantizar su calidad higiénico-sanitaria. una parte importante de este cloro añadido se gastará para la desinfección. el cloro activo que sobra, una vez completada la desinfección, es el cloro que está disponible para continuar desinfectando y se le denomina cloro residual libre. es importante comprender que el agua debe tener siempre una cierta cantidad de cloro residual libre que garantizará su capacidad desinfectante. metodología la metodología utilizada fue la matriz del marco lógico, propuesta por el banco interamericano de desarrollo, herramienta de trabajo con la cual los evaluadores pueden examinar el desempeño de un programa en todas sus etapas (ver tabla). cabe anotar que todas las actividades descritas se desarrollaron en un 100%, y los medios de verificación planteados para el seguimiento de los indicadores permitieron hacer un balance favorable de los resultados del proyecto. el mantenimiento de la limpieza, los análisis periódicos y el correcto tratamiento del agua de las piscinas, controlando la cantidad de cloro libre residual (cloro desinfectante) que éstas contienen, debería bastar para eliminar prácticamente la posibilidad de transmisión de algunas enfermedades. programa de vigilancia y control de la piscina del instituto de ortopedia infantil roosevelt 143 metodología estructura del marco lógico resumen de componentes indicadores medios de verificación factores externos propósito: objetivos específicos 1. establecer la rutina de registro de los parámetros de cl, ph y temperatura del agua dos veces diarias según la resolución 002191 de octubre 4 de 1991 de la secretaría distrital de salud de santa fe de bogotá. � el 100% del formato de registro de tratamiento de piscina sgfo-0037-v1 debe estar diligenciado dos veces diarias los días que se toman las muestras. � registro de tratamiento de piscina sgfo-0037-v1 debidamente diligenciado. � tablero ubicado en la zona de la piscina que contenga fecha, hora y registro de los parámetros de cl, ph y temperatura. � resultados negativos del análisis del agua por parte del laboratorio de microbiología industrial. � carpeta con los resultados del análisis de la muestra. � asignación presupuestal del instituto de ortopedia infantil roosevelt para realizar mensualmente la toma de muestras para el análisis microbiológico, bacteriológico y micológico del agua de la piscina. � confiabilidad en la toma de muestras y en los resultados arrojados por el laboratorio. � que el operador registre los parámetros como se estipuló en el programa. � que el formato de registro esté disponible. 2. implementar el análisis periódico microbiológico, bacteriológico y micológico del agua de la piscina del instituto de ortopedia infantil roosevelt por un laboratorio de microbiología industrial una vez por mes. fin: objetivo general implementar un programa de vigilancia y control de la piscina del área de hidroterapia del instituto de ortopedia infantil roosevelt basado en algunos artículos de la resolución 002191 de octubre 4 de 1991 de la secretaría distrital de salud de santa fe de bogotá. � el 100% de los resultados del análisis microbiológico, bacteriológico y micológico del agua de la piscina deben ser negativos a partir de mayo. � los parámetros de ph, cloro y temperatura deben mantenerse constantemente en: ph: rango de 7,0 a 7,8 unidades cloro residual: 0,6 a 1 mg/l temperatura: 32 °c a 34 °c � carpeta donde mensualmente se archiven los resultados de los exámenes de microb i o logía, bacteriología y micología realizados al agua. � registro tratamiento de piscina sgfo-0037-v1 que contempla parámetros del agua de cl, ph y temperatura, dos veces en el día; sustancias químicas empleadas y tratamiento diario de piscina. � asignación presupuestal del instituto de ortopedia infantil roosevelt para realizar dos veces al día la toma de parámetros y mensualmente los análisis microbiológicos, bacte-riológicos y micológicos del agua de la piscina. � persona encargada del mantenimiento (operador) con motivación para aplicar lo propuesto en el programa. � que las directivas vean la necesidad de la implementación del programa. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005144 3. divulgar y capacitar al personal relacionado con el área sobre el programa de vigilancia y control de la piscina del área de hidroterapia del instituto de ortopedia infantil roosevelt. resumen de componentes indicadores medios de verificación factores externos � el 100% del personal relacionado con el área tendrá conocimiento del programa de vigilancia y control de la piscina del área de hidroterapia del instituto de ortopedia infantil roosevelt. � registro de asistencia a capacitación. � asignación por parte de las directivas de los tiempos solicitados para capacitación y divulgación. � documento escrito del programa. � volante para los pacientes. � formato de registro del tratamiento del agua de la piscina. actividades: 1. establecer la rutina de registro de los parámetros. a) definir proveedor y costo para la compra del instrumento necesario para hacer la toma de la temperatura. � disponibilidad de presupuesto en el instituto roosevelt para hacer contrato con los laboratorios de microbiología industrial. � operadores y fisioterapeutas motivados y capacitados para aplicar el programa. � disponibilidad de los instrumentos y su correspondiente representación comercial para hacer el mantenimiento. � realización de las tomas con la periodicidad establecida en el programa. � aprobación de las directivas en la implementación del programa. � registro en el formato del tratamiento de la piscina. � carpeta con los resultados del análisis de laboratorio del agua. � cotizaciones escritas. � registro del tiempo empleado para las cotizaciones, su revisión y selección. � recibo de compra del instrumento para la toma de la temperatura. � el proveedor seleccionado cumple con los requisitos exigidos para la toma de la temperatura. b) diseño de formato para el registro de tratamiento de piscina. � el formato de registro completa el 100% de lo requerido para el tratamiento. � formato que contenga información oportuna. � facilidades de contacto con los laboratorios. � oportuna respuesta con la cotización. � costos accesibles al presupuesto de la institución. resultados: productos programa de vigilancia y control de la piscina del área de hidroterapia del instituto de ortopedia infantil roosevelt. � formato escrito y en medio magnético. programa de vigilancia y control de la piscina del instituto de ortopedia infantil roosevelt 145 b) implementar el uso de una carpeta en donde se archiven los resultados del análisis de la muestra por parte del laboratorio de microbiología industrial. � el 100% de los resultados anexados en la carpeta. � el formato de registro contempla el 100% de lo requerido para la toma de muestras y el análisis de los resultados. � el laboratorio debe realizar el 100% de los análisis solicitados por parte del instituto. d) implementar el uso de un tablero que contenga la fecha, la hora y los parámetros tomados, ubicado en el área de la piscina. 2. realizar análisis microbiológicos, bacteriológicos y micológicos. a) definir el laboratorio de microbiología industrial que realice la toma de muestras y el análisis del agua. � registro, en el formato, del día y la hora en que se realiza la muestra con firma del representante del laboratorio y del instituto de ortopedia infantil roosevelt. � recibos de pago. � el 100% de los parámetros tomados deben registrarse en el tablero con hora, fecha y nombre de la persona que los realizó. resumen de componentes indicadores medios de verificación factores externos c) realizar la toma de parámetros de ph, cloro y temperatura por parte del instituto de ortopedia infantil roosevelt dos veces al día, los días que se hacen las tomas. � el operador debe realizar el 100% de los registros necesarios en el formato. � diligenciamiento del formato de registro de tratamiento de piscina sgfo-0037-v1. � firma de la persona que realiza la toma de parámetros. � cumplimiento con el horario para la toma de los parámetros. � registro adecuado de los parámetros tomados. � buen manejo de los instrumentos. � presupuesto para la adquisición del tablero. � diligenciamiento oportuno. � tablero en el área diligenciado por los operadores. � facilidades en hacer contacto con los laboratorios. � oportuna respuesta con la cotización. � el laboratorio seleccionado con el 100% de los requisitos establecidos para la toma y el análisis de muestras. � cotizaciones escritas. � registro del tiempo empleado para las cotizaciones, su revisión y selección. � formato escrito y en medio magnético. � carpeta disponible en el lugar asignado. � formato que contenga información oportuna. c) toma mensual de la muestra por parte del laborat o rio de microbiología industrial. � cumplimiento del laboratorio en la fecha de la toma. � procedimiento confiable de la toma de la muestra del agua. d) revisar los resultados del análisis del agua en la carpeta destinada para tal fin y, según el caso, tomar las medidas necesarias. � el 100% de los resultados del análisis microbiológico, bacteriológico y micológico del agua debe ser negativo y debe estar registrado. � se deben llevar a cabo el 100% de las medidas necesarias. � carpeta con los resultados mensuales de los análisis. � cumplimiento del laboratorio en la entrega de los resultados. � oportuna revisión de los resultados del análisis del agua, al igual que las medidas correctivas. � asignación del tiempo para el análisis y la revisión de los resultados. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005146 resultados los resultados más relevantes fueron: el 100% de los análisis realizados mensualmente desde el mes de mayo de 2004, en los aspectos microbiológicos, bacteriológicos y micológicos, arrojaron resultados negativos; el 91% de los resultados de ph se mantuvieron entre 7,0 y 7,8 unidades; el 50% de los resultados de cloro se mantuvieron entre 0,6 y 1 mg/l; el 73% de los registros de la temperatura están dentro del rango de 32 y 34 °c, y el 100% del personal relacionado con el área tiene conocimiento del programa de vigilancia y control de la piscina del área de hidroterapia. se adquirió el termómetro para el control de la temperatura, el cual está en uso actualmente. los resultados de los análisis microbiológicos, bacteriológicos y micológicos se están archivando en una carpeta destinada para este fin. el 87% de los registros realizados por los operadores en el formato �registro tratamiento de piscina� fueron correctos. se elaboró el documento del programa de vigilancia y control de la piscina del instituto con todos los procedimientos necesarios para su desarrollo. se implementó el uso obligatorio de elementos de protección personal de los operadores, durante la manipulación de los productos químicos. conclusiones con las capacitaciones realizadas por las autoras de este proyecto, los ajustes que se hicieron al reglamento para el ingreso a la piscina, el conocimiento del volante para entregar a los pacientes y la ubicación de un tablero en el área donde se registran los parámetros de ph, cloro y temperatura, se logró la sensibilización de los fisioterapeutas y los estudiantes sobre la imporresumen de componentes indicadores medios de verificación factores externos � el 100% de los operadores diligencia correctamente el formato las veces establecidas. 3. divulgación y capacitación. a) capacitar a los operadores sobre la importancia y el adecuado diligenciamiento del formato �registro tratamiento de piscina sgfo0037-v1� (cl, ph y t°) por medio de una charla y un taller teórico-práctico. � que las directivas asignen los tiempos solicitados. � que las personas convocadas asistan y apliquen los conocimientos adquiridos durante la capacitación. � disponibilidad de tiempo del operador para hacer los ajustes necesarios. � asignación por parte de las directivas de los tiempos solicitados para la capacitación y divulgación. � que las personas convocadas asistan y apliquen los conocimientos adquiridos durante la capacitación. � tiempo suficiente para realizar el material. � formato diligenciado y anexado en una carpeta para este fin. b) dar capacitación a los fisioterapeutas y estudiantes de fisioterapia sobre la importancia del programa de vigilancia y control del área de la piscina. � el 100% de los fisioterapeutas y estudiantes de fisioterapia conocen el programa de vigilancia y control del área de la piscina. � registro de asistencia a capacitación. c) realizar el documento que contenga el programa para el instituto de ortopedia infantil roosevelt. � el 100% del documento contiene los procedimientos para la vigilancia y el control de la piscina. � documento escrito. programa de vigilancia y control de la piscina del instituto de ortopedia infantil roosevelt 147 rias del agua fueron: el aislamiento de la piscina, la construcción de un lavapiés, el uso de vestido de neopreno para los fisioterapeutas, el uso obligatorio de pañales diseñados para ingresar al agua, la adquisición de una silla de ruedas exclusiva para el área, entre otras. referencias bibliográficas 1. secretaría distrital de salud de santafé de bogotá. resolución no. 002191 de octubre 4 de 1991. por la cual se reglamenta la vigilancia y control de piscinas de santafé de bogotá; 1991. 2. secretaría distrital de salud. dirección de salud pública. protocolos de vigilancia en salud ambiental. coordinación editorial, oficina de comunicaciones en salud, bogotá; 2001. tancia de su empoderamiento en el área, haciéndose necesaria la responsabilidad, el compromiso, la disposición y el trabajo en equipo para poder llevar a cabo con éxito el programa de vigilancia y control. se logró implementar el programa en el instituto, para el cual se elaboró un documento con todos los procedimientos necesarios para el desarrollo de éste. recomendaciones algunas de las recomendaciones para asegurar las condiciones higiénico-sanita3. allepuz suñé j, monbrú jg. el agua en la piscina: tratamiento químico del agua en las piscinas. 1ra. ed. barcelona: badalona; 1996. 4. asociación colombiana de ingeniería sanitaria y ambiental (acodal), seccional valle del cauca. operación y control de las piscinas. cali; 1991. 426 439 un mundo en transicion------.indd 426 aquichan issn 1657-5997 claudia patricia arredondo-gonzález1 carmen de la cuesta-benjumea2 josé antonio ávila-olivares3 un mundo en transición. objetos para los cuidados en españa entre 1855 y 1955 1 licenciada en enfermería, universidad de alicante, españa. claudia.arredondo@.ua.es 2 phd. universidad de alicante, españa. ccuesta@.ua.es 3 doctor en cultura de los cuidados. presidente del consejo de enfermería de la comunidad valenciana, españa. ja.avila@wanadoo.es recibido: 09 de noviembre de 2013 enviado a pares: 25 de febrero de 2014 aceptado por pares: 14 de marzo de 2015 aprobado: 11 de abril de 2015 doi: 10.5294/aqui.2015.15.3.10 para citar este artículo / to reference this article / para citar este artigo arredondo-gonzález cp, de la cuesta-benjumea c, ávila-olivares ja. un mundo en transición. los objetos para los cuidados en españa entre 1855 y 1955. aquichan. 2015; 15(3): 426-439. doi: 10.5294/aqui.2015.15.3.10 resumen objetivo: describir el mundo material para los cuidados de enfermería en españa entre 1855 y 1955. método: estudio histórico, con procedimientos de investigación cualitativa. las fuentes de información fueron manuales dirigidos a la formación de profesionales dedicados al cuidado de los enfermos. resultados: en los manuales revisados, el contexto, los escenarios y las personas dedicadas a los cuidados se presentan concurrentemente. la habitación con su mobiliario y condiciones físicas y ambientales era el escenario principal para cuidar. esta, junto a los objetos utilizados en ella con finalidad terapéutica, conformaba el mundo material para los cuidados. los objetos del mundo material tenían cuatro propiedades respecto al uso: 1) reutilizables, si se usaban más de una vez; 2) polivalentes, cuando tenían diferentes usos prácticos; 3) sustituibles, otros podían reemplazarlos en el uso, y 4) importados, se incorporaban objetos de otros contextos al escenario de los cuidados. discusión y conclusiones: el mundo material para los cuidados en españa en la época de interés se encontraba en un contexto de salud-enfermedad de transición: de la teoría de los miasmas a la de los gérmenes, de proporcionar cuidados generalistas a cuidados especializados y de la presencia de diferentes figuras profesionales dedicadas al cuidado a su unificación. este era un contexto amplio, tecnológico y heterogéneo. las propiedades de los objetos enriquecían este mundo material y facilitaban la compleja y creativa labor de quienes cuidaban, cuyas herramientas de trabajo se describían en los manuales como sencillas y vulgares. palabras clave historia de la enfermería, atención de enfermería, tecnología, investigación cualitativa (fuente: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 426-439 427 un mundo en transición. los objetos para los cuidados en españa entre 1855 y 1955 l claudia patricia arredondo gonzález y otros año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 426-439 a world in transition. objects used for care in spain between 1855 and 1955 abstract objective: this research was designed to describe the objects used in the world of nursing care in spain between 1855 and 1955. method: it is a historical study conducted with qualitative research methods. the sources of information were training manuals for professional nurses. results: the context, the settings and those involved in nursing care are presented concurrently in the manuals that were reviewed. the patient’s room, with its furniture and physical and environmental conditions, was the primary stage for nursing care. this setting, together with the objects used in it for therapeutic purposes, comprised the material world for nursing care. with respect to their use, the objects in that material world had four properties: 1) reusable, if used more than once; 2) multi-purpose, when they had different practical uses; 3) substitutable, when others could be used in their place, and 4) imported objects or those brought from other contexts and incorporated into the scenario of care. discussion and conclusions: the material world of care in spain during the period in question was in a context of health-illness transition from the miasmatic theory to the germ theory, from general care to specialized care, and from the presence of different professionals dedicated to care to their unification. it was a broad, technological and heterogeneous context. the properties of these objects enriched this material world and facilitated the complex and creative work of those who provided care and whose tools are described in the manuals as simple and unrefined. keywords history of nursing, nursing care, technology, qualitative research (source: decs, bireme). 428 aquichan issn 1657-5997 um mundo em transição. objetos para os cuidados na espanha entre 1855 e 1955 resumo objetivo: descrever o mundo material para os cuidados de enfermagem na espanha entre 1855 e 1955. método: estudo histórico, com procedimentos de pesquisa qualitativa. as fontes de informação foram manuais dirigidos à formação de profissionais dedicados ao cuidado dos doentes. resultados: nos manuais revisados, o contexto, os cenários e as pessoas dedicadas aos cuidados apresentam-se simultaneamente. o quarto, com seu mobiliário e condições físico-ambientais, era o cenário principal para cuidar. este, junto com os objetos utilizados nele com finalidade terapêutica, conformava o mundo material para os cuidados. os objetos do mundo material tinham quatro propriedades a respeito do uso: 1) reutilizáveis, se eram usados mais de uma vez; 2) polivalentes, quanto tinham diferentes usos práticos; 3) substituíveis, outros podiam substituí-los no uso e 4) importados, incorporavam-se objetos de outros contextos ao cenário dos cuidados. discussão e conclusões: o mundo material para os cuidados na espanha na época em questão se encontrava num contexto de saúde-doença de transição: da teoria dos miasmas à dos germes, de proporcionar cuidados gerais a cuidados especializados e da presença de diferentes figuras profissionais dedicadas ao cuidado da sua unificação. este era um contexto amplo, tecnológico e heterogêneo. as propriedades dos objetos enriqueciam esse mundo material e facilitavam o complexo e criativo trabalho de quem cuidava, cujas ferramentas de trabalho se descreviam nos manuais como simples e vulgares. palavras-chave história da enfermagem, atenção de enfermagem, tecnologia, pesquisa qualitativa (fonte: decs, bireme). año 15 vol. 15 nº 3 chía, colombia septiembre 2015 l 426-439 429 un mundo en transición. los objetos para los cuidados en españa entre 1855 y 1955 l claudia patricia arredondo gonzález y otros introducción en este artículo se describe el mundo material para los cuidados de enfermería en españa entre 1855 y 1955. un mundo que ocupaba un espacio físico y estaba conformado por elementos palpables, visibles, con formas y estructuras materiales diversas, y cuyo uso los dotaba de valor y significado. el texto nace de un estudio más amplio, del desarrollo de un proyecto de tesis doctoral inscrito en la universidad de alicante (españa), sobre los recursos materiales y la tecnología disponibles para los profesionales de enfermería en dicha época. el concepto de mundo material no es nuevo, sin embrago, en la historia de la enfermería española ha sido poco explorado (1). investigaciones antropológicas y etnoarqueológicas han contribuido al aprendizaje del pasado histórico-material de la humanidad, poniendo de manifiesto el desarrollo y uso de herramientas paralelamente al desarrollo de las civilizaciones, de relaciones culturales y sociales de los grupos humanos (2). en este tipo de investigaciones, se ha llamado la atención sobre la necesidad de que en los estudios históricos se reconozca a los objetos en cuanto tales y como objetos constituidos por significados (3). el mundo material para los cuidados de enfermería es específicamente el conformado por todo objeto utilizado por la enfermera4 para cuidar; una amplia variedad de instrumentos de distintas formas y funciones que dan soporte a los cuidados (4); objetos cuyo valor no deriva exclusivamente de su origen y funciones preestablecidas, sino de sus significados a partir del uso (5). en el mundo material para el cuidado de cualquier época, los objetos tienen en común facilitar la labor de la enfermera (6). la época entre 1855 y 1955, en la que se sitúa el estudio, es un tiempo en el que conviven varias figuras dedicadas a la atención a los enfermos como son los practicantes, las enfermeras y las matronas, con otras que desaparecieron, como los sangradores. aunque todos ellos se dedicaban al cuidado de las personas enfermas, había diferencias (1). los sangradores, oficialmente reconocidos y especialistas en realizar extracciones de sangre, fueron precursores de los practicantes, desapareciendo cuando estos obtienen su titulación (7). los practicantes gozaban 4 en el presente artículo, enfermera es el concepto que se utiliza para nombrar de forma general a los profesionales, hombres y mujeres, dedicados a cuidar a los enfermos. a lo largo del texto, el lector encontrará que había diferentes figuras dedicadas a labores de cuidados en la época en la que se sitúa el estudio; todas ellas fueron, en españa, precursoras del actual profesional enfermería. de una formación y un título profesional desde 1857, mientras que las enfermeras obtuvieron el título más de cincuenta años después, en 1915 (8). ambas figuras desarrollaban su labor en el hospital y en los domicilios.5 sus funciones eran diferenciadas y los practicantes tenían más autonomía que las enfermeras. las matronas, cuya titulación profesional data de la misma fecha que la de los practicantes, también gozaban de autonomía, pero se dedicaban específicamente a la atención del parto normal (8). en el año 1955, practicantes, matronas y enfermeras se unifican bajo la denominación de ayudantes técnicos sanitarios (ats), que posteriormente daría paso al título de diplomado universitario en enfermería, a finales del siglo xx (8). respecto a los instrumentos, se debe señalar que en esa época la medicina estaba experimentando un cambio en la manera de concebir la enfermedad. se transitaba de la teoría de los miasmas como causa de las afecciones, a la teoría de los gérmenes como etiologías causantes de las enfermedades (10). así, a mediados del siglo xix, en españa se crean los primeros laboratorios para el desarrollo de la bacteriología y la bioquímica (11). gracias a ellos, a finales del siglo xix se identificaron una gran cantidad de microorganismos causantes de enfermedades (12) y adquirieron importancia las prácticas de asepsia y antisepsia en el cuidado de las personas enfermas. a esto se le añade la tecnología de los rayos x, introducida en la misma época en las instituciones hospitalarias del país (13). así pues, estamos ante un periodo en transición en el que convive lo viejo con lo nuevo; la teoría de los miasmas con la de los gérmenes y el sangrador con el futuro profesional de enfermería. en esta época, paradójicamente la enfermería era la denominación de un espacio físico y no una profesión, a pesar de estar ya iniciada su reforma por florence ninghtingale. considerando lo anterior, surgió la pregunta de investigación que ha dado lugar al estudio general: ¿cómo era el mundo material para los cuidados en españa entre 1855 y 1955? se ha elegido esta época por motivos ya expuestos en otra publicación (1). así, el hecho de que existieran diferentes figuras para la prestación de los cuidados de enfermería, hace de está época un periodo complejo e interesante de documentar. a esto 5 con frecuencia, se tiende a asociar y restringir la práctica de enfermería en el pasado, con la ejecución de técnicas como aplicar inyecciones, poner sondas y hacer curaciones; estudios sobre la historia de la enfermería incluyen los cuidados para el confort, la alimentación y la seguridad de las personas enfermas (4, 9). 430 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 se suma el cambio en la manera de concebir la enfermedad, que promovió notoriamente el desarrollo de la medicina, además de la publicación de la primera ley sobre sanidad del país en 1855 (8). el propósito general del estudio del que se deriva este trabajo, es conocer y comprender el escenario material para los cuidados en españa entre 1855 y 1955, y el objetivo del estudio que aquí se presenta es describir el mundo material para los cuidados de enfermería en españa en la época de interés. antecedentes es de anotar que la historia de la enfermería española y sus significativos cambios, han sido temáticas atractivas, abordadas por diferentes historiadores y desde distintas y enriquecedoras perspectivas. algunos se han centrado en señalar la transición de los cuidados religiosos a la práctica laica (14), otros trabajos han ilustrado la evolución histórica del cuidado desde sus orígenes como práctica para la supervivencia hasta la profesionalización (8). más esfuerzos se han centrado en posicionar y reconocer diferentes ocupaciones como vertientes de la enfermería actual, como los sangradores (7); mientras que otros han puesto de manifiesto el legado de órdenes religiosas en la enfermería española (15). por otro lado, en norteamérica existe una gran tradición de estudios sobre la historia de la enfermería y los objetos. la tecnología en diferentes épocas y su influencia en la profesión enfermera han motivado trabajos entre los que se pueden destacar el de sandelowsky (4), el de fairman y lynaugh (16) y el de zulumas (17). en el primero, se argumenta la visibilidad del cuidado de enfermería a través de los objetos que usa y la histórica influencia del género como condicionante y limitante de su práctica. en el segundo trabajo, las autoras describen el impacto del uso de tecnología, cada vez más compleja, en la labor de enfermería práctica, en su reconocimiento social y formación académica. por su parte, zulumas (17) recoge, bajo la metodología de historia oral, testimonios de enfermeras de las unidades de cuidado crítico de 1950, que le permiten mostrar el rápido cambio tecnológico que ha tenido lugar en estas unidades y que ha traído aparejada una necesidad constante de ajustes en los roles de las enfermeras, quienes cada vez más están rodeadas de un complejo aparataje, que puede parecer de ciencia ficción y que les demanda nuevas habilidades, competencias y juicios. en brasil también se han realizado estudios sobre el mundo material para los cuidados bajo el concepto de tecnología en enfermería. en estos se muestra el efecto emancipatorio de la tecnología en la práctica profesional (18). también se ha indagado sobre la contribución de las enfermas en el desarrollo de recursos tecnológicos para el cuidado (19) y sobre el impacto de la tecnología en la práctica de la enfermería (20). estos trabajos resaltan que en la tecnología, la enfermera ha encontrado un medio para hacer frente a dificultades del trabajo, como su baja participación en decisiones institucionales, la rutina de los servicios y la práctica meramente técnica (18). asimismo, se ha hallado que en las creaciones tecnológicas de las enfermeras, existe una intencionalidad clara, en cuanto a satisfacer las necesidades de confort y seguridad de los enfermos (19), y que se requiere una postura crítica y reflexiva permanente, respecto al uso de tecnología y la presencia humanizadora de la enfermera al lado de la persona enferma en ambientes tecnológicos (20). metodología se trata de un estudio histórico (21), descrito en otra publicación (1), en el que se utilizan técnicas cualitativas. tiene como objetivo primordial, el contribuir al conocimiento de los instrumentos utilizados para el cuidado en españa entre 1855 y 1955. la búsqueda del conocimiento de esta parte del pasado profesional se cimienta en la tradición hermenéutica weberina, en cuanto al convencimiento de que el pasado no es posible explicarlo, sino comprenderlo, y que para comprenderlo es necesario describirlo (22). las fuentes de información fueron los manuales para la formación de los profesionales dedicados a los cuidados en la época de interés. en los manuales, los objetos eran nombrados, descritos y a menudo ilustrados. los manuales debían cumplir con criterios como: estar escrito en español, ser publicado entre 1855 y 1955 y estar dirigidos a formar enfermeras u otras figuras históricamente reconocidas y dedicadas a labores de cuidado a los enfermos. se excluyeron de la descripción los instrumentos quirúrgicos a excepción de aquellos que los profesionales de la época utilizaban cotidianamente y fuera de las salas de operaciones, como las pinzas de presión o el bisturí. al ser la atención al parto una practica técnica especializada del trabajo de enfermería (9), no se han considerado en este estudio los objetos propios de la atención al parto y al recién nacido (tabla 1). en la recolección de datos se incorporaron procedimientos de muestreo cualitativos, de manera que, entre todos los manuales localizados y disponibles, la selección de las fuentes fue, en pri431 un mundo en transición. los objetos para los cuidados en españa entre 1855 y 1955 l claudia patricia arredondo gonzález y otros tabla 1. fuentes de datos código año autor título del manual información editorial ca1 1856 cisneros, bonifacio manual práctico de fleboarteriotomía y otras operaciones de cirugía menor cáceres, imprenta de don nicolás maría jiménez cm2 1866 calvo y martín, josé manual para el uso del practicante madrid, imprenta nacional gv3 1901 garcía velásquez, jerónimo manual del practicante y del interno de hospital madrid, mariano núñez samper editor cb4 1903 cubells blasco, arturo manual del practicante. obra escrita con arreglo al programa de practicante (t. iii, obstetricia) valencia, bubul y morales editores fc5 1917 fernández corredor y chicote, mariano manual de la enseñanza de enfermeras valladolid, taller cuesta gt6 1937 garcía tornel, lorenzo manual del practicante y de la enfermera, t. ii, 4ª ed. barcelona, bosch lm7 1937? labré, marcel manual de la enfermera hospitalaria, 12 ed. traducción marcel labré bc8 1951 box, maría y cospedal, antonio manual teórico-práctico para practicantes, matronas y enfermeras, t. i y ii, 3 ed. madrid, editorial reus mer lugar, con propósito y de acuerdo con los objetivos del estudio, y, en segundo lugar, una vez iniciado el análisis, el muestreo fue discriminado (23) para obtener información más específica. así, se estudiaron íntegramente ocho manuales con un total de 3043 páginas. de estos ocho documentos, cuatro se localizaron en el museo histórico de enfermería fundación josé llopis en alicante (españa). para acceder a ellos, fue necesario solicitar una autorización en la cual constaban los objetivos del estudio y el compromiso ético para el manejo de los documentos. los otros cuatros manuales se localizaron en formato digital, en la web de la biblioteca del colegio oficial de enfermería de madrid, cuyo acceso es público y abierto. para el análisis de los datos, se siguieron los procedimientos del método histórico, en cuanto a la elaboración de fichas (21). se elaboraron fichas descriptivas de las fuentes y fichas de análisis. además, se escribieron memorandos de tipo metodológico y analítico (23). al ser las ilustraciones representaciones gráficas de las descripciones textuales, también fueron consideradas fuentes de información. los datos se codificaron y en el proceso de análisis los códigos se agruparon siguiendo los procedimientos de la teoría fundamentada, lo que permitió analizar el contexto del mundo material y describir sus objetos en términos de sus propiedades relativas al uso (23). durante este análisis, se lograron conceptualizaciones cada vez más abstractas, al agrupar y reagrupar los códigos y las categorías. el trabajo ha sido dinámico, interactivo y fascinante; un ir y venir entre datos, códigos, categorías y bibliografía para aprender y describir el que fue mundo material para los cuidados de enfermería entre 1855 y 1955. resultados con el objetivo de hacer más comprensibles los resultados al lector, en primer lugar se hará una descripción del contexto saludenfermedad y principales escenarios físicos en los que tenía lugar la práctica de la enfermería entre 1855 y 1955, según las fuentes estudiadas. seguidamente, se presentarán las propiedades de los objetos relativas al uso: reutilizables y polivalentes, sustituibles e importados. estas propiedades permiten reconocer la variedad de objetos que constituían el mundo material para los cuidados. contexto, escenarios y cuidadores en el mundo material el contexto del cuidado en españa entre 1855 y 1955, la salud y enfermedad, las figuras dedicadas a los cuidados y los escenarios 432 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 donde se cuidaba pueden reconocerse a través de los manuales para el adiestramiento y la enseñanza de quienes se dedicaban a cuidar a los enfermos en dicha época. en los manuales revisados, el contexto, los escenarios y las personas dedicados a los cuidados se presentan concurrentemente. así, a mediados del siglo xix, los manuales se centraban en la descripción anatómica del cuerpo humano y en la exposición de intervenciones y acciones de cuidado, indicadas por el médico, según los síntomas que presentara una persona enferma como: vómitos, diarreas, asfixia, estreñimiento, aumento de la temperatura y sangrados. también se describían ampliamente cuidados en los cambios durante el embarazo y la atención al parto sin complicaciones y el parto distócico. hasta el inicio del siglo xx, los cuidados eran generales y la atención estaba limitada a la higiene, la alimentación y a las órdenes que daba el médico durante su visita al enfermo. de forma general, en el siglo xix y principios del siglo xx, ante una persona enferma se debían tener en cuenta la limpieza de la habitación y su ropa, el mantenimiento de la temperatura e iluminación, la alimentación, la comodidad de la cama y la disponibilidad de objetos como orinales y escupideras. todo esto estaba determinado explícitamente por el médico. así, para brindar estos cuidados generales, se formaba a las enfermeras proporcionándoles conocimientos limitados sobre las enfermedades, de tal forma que en los manuales de mediados del siglo xix, algunas enfermedades se nombran, pero no se decribe su patogenia. se cuidaba a los enfermos y a todos prácticamente de la misma manera. las enfermedades infecciosas como el cólera, la rabia, el sarampión, el paludismo, la tuberculosis, la sífilis y el tétanos —muy presentes en el siglo xix junto a enfermedades crónicas como la diabetes, el cáncer y el reumatismo— empiezan a ser más descritas a medida que avanza el siglo xx. padecimientos agudos, que requerían intervenciones inmediatas y continuas, también se describen poco a poco con más detalle, como las fracturas, las heridas y los envenenamientos. a medida que se sabía más de las enfermedades y las afecciones, se conocía más acerca de los cuidados específicos que requerían los enfermos y se incorporaban más recursos materiales para su atención. los cuidados generales, que en el siglo xix dependían de los síntomas y de indicaciones médicas específicas, evolucionan en el siglo xx a prácticas que ayudaban a curar y prevenir enfermedades. estas estaban guiadas por los desarrollos de la asepsia, la antisepsia y la vacunación. así, a medida que la formación de los practicantes y las enfermeras se ampliaba, los cuidados empezaban ser específicos y de acuerdo con la enfermedad que padecía la persona enferma. no obstante, estos cuidados seguían siendo prescritos por el médico, pero ahora los practicantes y las enfermeras sabían más de las enfermedades, su origen, evolución y formas de contagio, conocimiento que les propiciaba un poco de autonomía. en los manuales estudiados están presentes las cuatro figuras dedicadas a la labor de cuidar: sangradores, enfermeras, practicantes y matronas. estas figuras hicieron parte del contexto y compartieron el escenario de los cuidados. así, en la época del estudio, existía entre estos profesionales una división intrínseca de responsabilidades, de funciones y de objetos. sin embargo, al ser vertientes reconocidas y dedicadas a los cuidados de los enfermos, todos los objetos que usaban forman en conjunto el mundo material para los cuidados, hoy reconocible como amplio y heterogéneo. tomando como ejemplo al sangrador, según las fuentes este se dedicaba casi de forma exclusiva a realizar sangrías, curaciones, y, algunas veces, extracciones dentarias. la sangría era practicada con frecuencia en el tratamiento de diversas enfermedades; en el procedimiento bien podía utilizar sanguijuelas o también instrumentos cortantes como las lancetas. a los sangradores de mediados del siglo xix, se les formaba especialmente en anatomía humana y su entrenamiento era dirigido al cumplimiento de ciertos requisitos, no solo en cuanto al saber teórico, sino al hacer práctico, lo que conllevaba cualidades para relacionarse con las personas enfermas y también con los instrumentos que utilizaba: 1º. será amable, y de finos modales, pues con ellos cautivará á las gentes, y con especialidad al enfermo: 2º. será prudente no solo en tolerar los melindres, y hasta impudencias de algunos enfermos, y de los asistentes ó personas allegadas á este, si que también para quedar airoso en ciertos compromisos que sobreviene á veces en el acto de la sangría, ó por la sangría: 3º. será limpio, así para su persona, como para los instrumentos […] 4º. es muy conveniente la reserva al sangrador, no solo para no traslimitar sus funciones, sino es mas que práctico ministrante, introduciéndose en la medicina como por desgracia acostumbra alguna vez, sí que también para guardar un silencio con el que se honra y puede honrar. 5º. debe ser pródigo en el número de 433 un mundo en transición. los objetos para los cuidados en españa entre 1855 y 1955 l claudia patricia arredondo gonzález y otros lancetas teniéndolas siempre limpias y bien vaciadas, pues esto dá facilidad y seguridad en la operación, y mas que todo, que el enfermo siente muy poco la sangría aunque tenga esta mas dimensión que la dada. 6º. debe el sangrador ser listo, estar ágil, y práctico en sangrar, y manejar indistintamente las dos manos para picar […] 7º. últimamente, este no tendrá vicios graves, con especialidad el de la bebida. los sangradores, no la sangría ni sus instrumentos, desaparecieron completamente del panorama de los cuidados a finales del siglo xix. el capítulo dedicado a la descripción de la sangría en todos los manuales revisados demuestra la permanencia del procedimiento y de sus instrumentos, que tras la desaparición de los sangradores, era realizado por practicantes y posteriormente también por enfermeras. por tanto, el mundo material para los cuidados se ha construido y enriquecido por las diferentes figuras dedicadas a cuidar y por sus instrumentos. en cuanto al escenario físico para los cuidados, el mundo material no podía existir en el vacío, existía en la medida en que había un lugar con condiciones físicas y ambientales, en el que a las cosas se les daba un orden práctico dentro de cual adquirían significado. el lugar para los cuidados era plural, es decir, había más de uno posible, pero todos tenían la misma finalidad: ser un espacio para cuidar a la persona enferma. los principales lugares para cuidar eran dos, el hospital y el domicilio de los enfermos. estos dos lugares, aunque diferentes a primera vista, tenían en común el objetivo de alojar al enfermo y todo lo que se necesitara para aliviar su padecimiento. dentro del hospital y del domicilio, como si de un escenario teatral se tratara, era acondicionada la habitación para hospedar a la persona enfermera y todo su contenido era seleccionado y ubicado en el espacio disponible, de manera que lo que no fuera útil y necesario no estaría dentro del escenario. además, como accesorios, estaba el resto del hospital y su contenido —salas de cirugía, cocinas, laboratorio, baños y demás—, así como el resto del domicilio y sus contenidos —cocina, baños, mesas, recipientes y ropas, entre otros—, todo esto disponible para atender al enfermo. según los manuales revisados, la habitación de la persona enferma, en el hospital o en el domicilio, era el escenario principal del mundo material para los cuidados de la época. la habitación era el lugar específico y delimitado donde las personas interactuaban entre sí y actuaban sobre objetos, dándoles uso y significados. los objetos de la habitación de una persona enferma se convertían en objetos materiales para cuidar, con una función terapéutica asignada. aquellos objetos que no representaban un elemento para cuidar —por ejemplo, un cuadro— eran retirados de la habitación. en ambos sitios, como si de un ritual se tratara, la cama adquiría un lugar central. en la habitación y alrededor de la cama se ejecutaban procedimientos propios de los cuidados, la mayoría de las veces, mediados por instrumentos. en el hospital o en los domicilios, la cama debía ser suficientemente confortable, tener una altura adecuada y estar siempre limpia. las condiciones de la habitación y de la cama de los enfermos a mediados del siglo xix se describían así: …estará limpio y desembarazado, renovando el aire con frecuencia y conservándole seco ó húmedo, exento de humo, polvo y malos olores […] el médico indicará la temperatura que debe tener el dormitorio, la intensidad de la luz natural ó artificial […] en las inflamaciones agudas y violentas, en las fiebres con delirio, conviene oscuridad cási completa. en las enfermedades crónicas y diatésicas son útiles buen aire y mejor sol. el ruido es siempre incómodo, y alguna vez es hasta indispensable andar sobre la punta de los pies […] no debe ser demasiado dura [la cama] para evitar daño a la piel en los casos de enfermedades graves y largas, ni tan blanda que favorezca la congestión. no debe estar arrimada a la pared a fin de que los asistentes puedan circular libremente a su alrededor […] en muchos enfermos conviene entre meter sabanas dobladas y en no pocos, colocar un hule grande debajo de última sabana. el escenario es tan importante como los actores que entran en escena. por ello, con el tiempo, la habitación cobró más protagonismo en el cuidado de los enfermos. a medida que se reconocía el efecto beneficioso de la higiene de los lugares y la limpieza de las cosas para eliminar microbios, prevenir contagios y favorecer la recuperación de la salud, la habitación y la cama adquirían una forma cada vez más específica y detallada, que reclamaba condiciones de construcción y acondicionamiento para un ambiente óptimo, duradero y fácilmente conservable. los materiales de construcción, las dimensiones, la orientación de acuerdo con el sol, los ángulos de las paredes y el suelo de la habitación, así como el tamaño y altura de las ventanas y el mobiliario, entre otros, eran factores modernos que se tenían en cuenta en las habitaciones de los hospitales de mediados del siglo xx, además de los acostumbrados de ventilación y temperatura. de forma similar, en los domicilios la elección e improvisación de la habitación 434 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 para cuidar de una persona enferma era también más rigurosa y detallada, como su contenido. con todo esto, las condiciones físicas y ambientales de la habitación, es decir, del escenario para los cuidados, eran tan importantes como lo eran los procedimientos de cuidado que se desarrollaban en él. la habitación era un escenario para cuidar que también debía ser cuidado. por ello, a mediados del siglo xx, las condiciones y especificidades de la habitación para una persona enferma, en el hospital o fuera de él, ya se habían convertido en una parte central de la organización de los cuidados generales, que los auxiliares del médico, es decir, los practicantes y las enfermeras, debían favorecer y preservar con un alto nivel de detalles. la habitación de un enfermo debe contener el menor número de muebles posible, y a poder ser, debería estar situada contiguo a un cuarto de baño con lavabo y retrete. es necesario que tenga bastante capacidad, a fin de que el enfermo disponga de suficiente aire respirable, así como de la mayor cantidad de luz y de sol posibles […]; las paredes, de ángulos redondeados, a fin de evitar rincones, que se llenan de polvo, serán pintadas en forma que puedan lavarse fácilmente […] para la ventilación se procurará disponer de aberturas en las partes superiores de las ventanas, de manera que puedan abrirse y cerrase fácilmente y que el aire no vaya directamente al enfermo […] en el medio rural las cortinas de malla metálica o de flecos de bambú en las puertas, impiden el paso de moscas y mosquitos. para invierno hay que contar con la calefacción necesaria; a ser posible, la mejor es la calefacción central con radiadores, por cuyo interior circula vapor de agua; a falta de esto se recurrirá a las estufas eléctricas y en último caso, se utilizarán estufas o salamandras, con tubo para la salida de gases al exterior; deben ser rigurosamente prohibidas toda clase de estufas, sea cual sea el sistema y el combustible empleado, que nos dispongan de dichas salidas de gases, pues, en mayor o menor proporción, todas vician de un modo pernicioso la atmósfera de la habitación; con mucho mayor motivo serán proscritos, los braseros por la misma causa. la lectura de los manuales permite reconocer que, a lo largo del tiempo, la habitación fue transformada para acoger con cada vez mayor higiene y comodidad a los enfermos y todo cuanto se pudiera necesitar para su cuidado. la habitación, con su mobiliario y condiciones físicas y ambientales, ha sido el escenario principal para los cuidados de una persona enferma. este escenario daba valor y significado a los objetos usados en él. estos instrumentos en las manos de los profesionales de la época eran como actores en los cuidados y representaban un papel terapéutico. de estos instrumentos, sus usos y propiedades, se trata a continuación. propiedades de los objetos del mundo material para los cuidados la sangría fue un procedimiento común a lo largo del periodo estudiado, que permite ilustrar la variedad de objetos identificados, la permeabilidad de la frontera de sus usos y sus propiedades. la tabla 2 reúne los objetos utilizados en las sangrías y señala sus propiedades. reutilizables y polivalentes la principal propiedad, común a los objetos del mundo material para los cuidados, es que eran reutilizables. usar y volver a usar un objeto varias veces era lo habitual; podía hacerse y debía hacerse, como consta en los manuales. en el grupo de objetos que se utilizaron en la sangría no había un número de reutilizaciones que limitara la vida útil de un objeto; además, parecía que entre más veces se reutilizara un objeto, de mejor calidad era este. solo el deterioro tras los sucesivos usos o el arribo de otros objetos mejorados para realizar la misma función de forma más fácil, segura o menos traumática, marcaban el fin de la vida útil del predecesor. los manuales evidencian cómo las enfermeras devolvían los objetos a su estado inicial al lavarlos, desinfectarlos y esterilizarlos. así, por ejemplo, las jeringas de cristal, los escarificadores y las ventosas, los guantes, los irrigadores, las sondas uretrales y las vendas eran reutilizados. el material de un solo uso era mínimo. solo unos cuantos objetos marcaban la excepción, tales como las torundas de algodón, los apósitos, las gasas y compresas, así como los hilos de sutura y corchetes o agrafes que se desechaban tras su uso. estos elementos no reutilizados constituían objetos que, al ser utilizados, eran altamente contaminados por secreciones y fluidos corporales que, aunque se lavaran y desinfectaran, era imposible devolverlos a su estado inicial, o como los agrafes que al ser usados se deformaban definitivamente. de otro lado, reutilizar un objeto y darle nuevos usos, son asuntos diferentes. con frecuencia, y para dar respuesta a las necesidades de cuidado, las enfermeras tomaban objetos y los hacían polivalentes, esto es, les daban nuevos usos. la polivalencia 435 un mundo en transición. los objetos para los cuidados en españa entre 1855 y 1955 l claudia patricia arredondo gonzález y otros tabla 2. objetos para la sangría nº nombre del objeto propiedades reutilizable polivalente sustituible importado 1 agujas de inyección hipodérmica x x 2 algodón hidrofílico x 3 apósito aséptico x 4 bandejas x x 5 bisturí x 6 cama x x x 7 cepillo x x x 8 compresas x 9 compresor x x 10 copa de cristal x x x x 11 copa de laboratorio x x x x 12 escarificador x x 13 jeringuilla de cristal/ luer x x 14 jeringuilla de cristal/ récord x x 15 lámpara de alcohol x x x 16 lanceta x x x 17 lancetero x 18 moneda x x x 19 naipe x x x 20 papel de cigarrillo x x 21 pinza de presión x 22 recipiente graduado x x x 23 recipientes x x x x 24 reloj con segundero x 25 riñonera/cubeta x x x 26 sanguijuelas x x 27 silla x x x 28 sonda acanalada x x x 29 sonda de goma para cateterismo vesical x x 30 termocauterio x 31 tubo de caucho x x x x 436 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 es una propiedad que se atribuía y se lograba en la práctica cotidiana y no en la producción o manufactura del objeto propiamente dicho. tal atribución era común y legítima en la práctica y en la formación de las personas dedicadas a los cuidados, al punto de que en los manuales se aportan claros ejemplos de la manera ingeniosa de satisfacer una necesidad, dándole nuevos y prácticos usos a algunos objetos disponibles cuando se carecía de otros. por ejemplo, la lámpara de alcohol para iluminar una habitación (lm7), podía usarse para desinfectar objetos (cb4, gt6), para enrarecer el aire de las ventosas (ca1, lm7), para calentar un tubo de ensayo con orina en búsqueda de albúmina (fc5) y como fuente de calor para el funcionamiento de un pulverizador de vapor (bc8). en la sangría, una sonda de goma para cateterismo uretral se podía usar como compresor en la extremidad donde se encontrara la vena por puncionar de forma que las hiciera más aparentes (lm7). en el mundo material para los cuidados, los objetos eran susceptibles de ser usados en diversas circunstancias y con distintas finalidades de aquellas para las cuales fueron ideados y diseñados inicialmente. la polivalencia de un objeto permitía responder ante la carencia de instrumentos específicos o ausentes en un procedimiento dado. la capacidad de los profesionales de reconocer las posibilidades de uso de los objetos enriquecía el mundo material y solucionaba problemas en la práctica. un objeto único no tenía una función única; según las necesidades de las personas enfermas se le podían asignar más y nuevas funciones. de ahí la riqueza del mundo material entre 1855 y 1955, un mundo donde reutilizar y usar con diferentes fines un objeto determinado permitía reconocer el papel activo del profesional de los cuidados y su rol de artífice, más que de mero usuario de instrumentos. sustituibles e importados la existencia de objetos determinados para funciones específicas desde su fabricación no eliminaba la posibilidad de usar otros para sustituirlos, cuando no estaban disponibles en el mundo material para los cuidados. estos sustitutos, la mayoría de las veces, provenían de otros contextos diferentes al de los cuidados, de manera que se importaban y se les daba un nuevo uso práctico en el escenario de los cuidados. en la sangría, por ejemplo, la vasija para sangrar podía ser reemplazada por una copa graduada de laboratorio (bc8) o por un recipiente de la cocina (ca1), y las ventosas por un vaso común (lm7). en la sangría de una vena del cuello, la cánula que se requería para conducir la sangre al recipiente, podía ser sustituida por un naipe arrollado en forma de canal (ca1). suplir un instrumento necesario para los cuidados, usando otro que pertenecía a otros contextos, como los juegos de azar y el doméstico, era una situación común en la que se encontraban la enfermera y el practicante de la época y que los manuales han permitido apreciar. otro ejemplo de la sustitución e importación de objetos lo encontramos en los usos de la cuchara. este objeto, fabricado para tomar alimentos, se llevaba al mundo material para los cuidados y podía usarse como espátula para mezclar medicinas (ca1), medio para administrar pociones (cm2), como depresor lingual, como instrumento para instilaciones nasales o para realizar baños de oídos, y, también, para improvisar artesanalmente un aparato con el cual iluminar la garganta de una persona enferma, anteponiendo a la cuchara la luz de una vela (lm7). en efecto, existían espátulas, depresores linguales y objetos específicos para instilar la nariz e iluminar fuente: elaboración propia. nº nombre del objeto propiedades reutilizable polivalente sustituible importado 32 vasija de sangrar x x 33 vaso x x x 34 vela x x x x 35 vendas x x 36 ventosa mecánica x x 37 ventosas x x 437 un mundo en transición. los objetos para los cuidados en españa entre 1855 y 1955 l claudia patricia arredondo gonzález y otros la garganta, pero no siempre estaban a mano, de manera que otros los sustituían. en los manuales estudiados, se sugería que las enfermeras y los practicantes llevaban al escenario clínico objetos de la vida cotidiana y, una vez en este nuevo escenario, su uso variaba y, por tanto, cambiaba su significado. así, un plato para comer se convertía en una bandeja para instrumentos, un cinturón de ropa en un torniquete, un pañuelo se usaba como venda y una camisa como cabestrillo. a pesar de que su identidad intrínseca los situaba en otros escenarios de la vida diferentes al de los cuidados, se trataba de objetos comúnmente utilizados por enfermeras y practicantes de la época para satisfacer una necesidad de cuidado, por tanto, eran parte de su mundo material. de esta manera, los objetos importados al escenario clínico ampliaban y diversificaban el mundo de la práctica de los cuidados en la época. es importante señalar que la polivalencia de los objetos, propiedad de la que ya se ha hablado antes, hace posible la importación y sustitución de instrumentos en el escenario de los cuidados. los objetos que se habían diseñado y manufacturado con una función claramente determinada tenían nuevos usos en las manos de una enfermera o de un practicante. así, se sustituía con lo que se tuviera a mano, aquello que no estaba disponible o que aún estaba por inventarse clínicamente. por ejemplo, en el primer tercio del siglo xx, para alimentar a un niño cuya debilidad no le permitía succionar, se tomaba una sonda urinaria de tipo nelatón número 14 o 16, y un pequeño embudo de cristal, ambos se ajustaban para lograr un aparato que permitía la alimentación del niño, introduciéndole la sonda por la boca y vertiendo el alimento líquido a través del embudo: “ajustad el embudo a la extremidad de la sonda y elevadle por encima de la cabeza hasta que desaparezca todo el líquido” (lm7). en este ejemplo, la sonda de nelatón era un instrumento que en esencia pertenecía al mundo material para los cuidados, que se complementaba con otro objeto importado, y ambos sustituían la carencia de un instrumento específico para la alimentación de un niño enfermo. así, la sustitución no siempre era con objetos importados, sino también con objetos clínicos disponibles, o con una combinación de objetos de diferentes contextos. discusión y conclusiones el estudio de los manuales consultados en esta investigación ha permitido conocer mejor el contexto de los cuidados en españa entre 1855 y 1955, al documentar el mundo de los objetos para los cuidados. la necesidad de estudiar el campo que representa la tecnología utilizada para los cuidados de enfermería fue expuesta por collière (24) en la década de los ochenta del siglo pasado. ella argumentaba que la tecnología siempre ha estado presente en la histórica labor de cuidar (24). en este trabajo se explora y describe el mundo material para los cuidados entre 1855 y 1955 en españa; mundo material reconocible a través de los manuales dirigidos a formar a quienes se ocupaban de cuidar de los enfermos en la época. lejos de ser exhaustivo, este trabajo llama la atención y destaca la amplitud del mundo material para los cuidados, además de presentar algunas posibilidades descriptivas e interpretativas de la práctica de enfermería en la época. los estudios históricos sobre la enfermería en españa y latinoamérica han descubierto las raíces de los cuidados (25). en la mayoría de estos trabajos se ha indagado sobre la labor de cuidar en contexto social, moral, político y religioso, sin profundizar en el mundo material que posibilitaba el cuidado de las personas enfermas. al respecto, este estudio sobre el mundo material para los cuidados, es un acercamiento a otra raíz histórica de la profesión de enfermería. aquí se ha mostrado que el mundo material para los cuidados entre 1855 y 1955, lo constituía el espacio físico y los objetos para cuidar. era un escenario de interacción, cuyo aspecto y ambiente también se velaba. la habitación era el escenario por excelencia para el cuidado de un enfermo. el cuidado de las habitaciones, de las personas enfermas y el ayudar a los médicos, ha sido histórica y socialmente asimilado al trabajo de empleadas domésticas, en parte, por lo sencillo de sus instrumentos y, también, por asuntos de género y de la división sexual del trabajo (4). en efecto, los manuales revisados estaban dirigidos a formar auxiliares del médico que cuidarían del escenario y del enfermo; personas a quienes el conocimiento técnico-científico era restringido y cuyas herramientas de trabajo se describían como comunes, sencillas y vulgares. no obstante, el mundo material de su labor, las acciones e interacciones, la cantidad, variedad y posibilidades de uso de los objetos, pone en relieve una labor más compleja, creativa y entusiasta que ayuda a diferenciarla del trabajo de la empleada doméstica. en los estudios históricos sobre la enfermería española se ha separado con frecuencia entre enfermeras y practicantes. además, se ha sugerido que las enfermas han utilizado menos instrumentos tecnológicos que los practicantes, debido al carácter 438 año 15 vol. 15 nº 3 chía, colombia septiembre 2015 aquichan issn 1657-5997 femenino de su ocupación (8). aquí se ha podido reconocer que tanto enfermeras como practicantes han compartido también el contexto de salud-enfermedad, los escenarios para cuidar y ambos han utilizado gran número de objetos en su labor. tales objetos eran cotidianos y clínicos, sencillos y complejos. constituían sus recursos tecnológicos y tenían valor e importancia tanto para las enfermeras como para los practicantes en el momento de cuidar y satisfacer las necesidades de una persona enferma. la revisión de los manuales permite reconocer que el mundo material para los cuidados entre 1855 y 1955, existía de acuerdo con los requerimientos del cuidado de las personas enfermas y no con los de las ocupaciones dedicadas a cuidar. este estudio sugiere que la división respecto a los objetos que conformaban el mundo material para los cuidados resultaría imprecisa y reproduciría inadvertidamente un sesgo de género. enfermeras y practicantes eran el grupo dedicado a los cuidados y estaban sometidos al control y la supervisión del médico. como cualquier grupo social, tenían sus teorías, recetas y estrategias para cumplir con los requisitos, tácitos y explícitos, que aceptaban y los hacían aceptables socialmente (26). la histórica alianza de practicantes y enfermeras unió también sus instrumentos. por esto, el mundo material para los cuidados de entonces es el legado histórico-material de su labor, que se revela como un mundo amplio, heterogéneo y en transición. en este trabajo se han reconocido propiedades de los objetos relativas al uso en el cuidado de las personas enfermas. el estudio de las cualidades físicas de los objetos puede ser tema para otras investigaciones y desde la perspectiva de la cultura material (27). son los instrumentos aquello en lo que el trabajo encuentra su permanencia y lo que queda de este y lo trabajado (28). los manuales como fuentes de información han permitido reconocer el mundo material de la época y las interacciones y los cuidados de enfermería. los usuarios de los instrumentos están reflejados en ellos, de manera que los objetos con los que históricamente se ha cuidado a los enfermos es lo que nos queda como evidencia de los cuidados y los cuidadores. es necesario y sería revelador realizar nuevos estudios desde la perspectiva de la cultura material en enfermería y del mundo material en los cuidados, caminos hasta ahora poco transitados en la historia de la enfermería española y latinoamericana. referencias 1. arredondo gonzález cp, de la cuesta benjumea c, ávila olivares ja. material world and social recognition: nursing care in spain (1855-1955). invest educ enferm. 2015;33(1):128-137.. 2. mannoni t, giannichedda e. arqueología. marteriales, objetos y producciones. barcelona: ariel; 2006. 3. hodder i. interpretación en arqueología. corrientes actuales. barcelona: crítica; 1994. 4. sandelowski m. devises & desires gender,technology and american nursing. chapel hill and london (united states of america): the university of north carolina press; 2000. 5. dant t. material civilization: things and society. br j sociol. 2006;2(57):289-308. 6. arredondo gonzález cp, de la cuesta benjumea c, ávila olivares ja. el mundo material para los cuidados de enfermería. index enferm (gran). 2013;22(1-2):65-69. 7. ávila olivares ja. ¿existió realmente una titulación oficial con el nombre de ministrante? cultura de los cuidados. 2010;xiv(27):12-29. 8. siles gonzález j. historia de la enfermería en españa. madrid: difusión y avances en enfermería; 2011. 9. dingwall r, rafferty a, webster c. an introduction to the social history of nursing. london: routledge; 1991. 10. escobar gónima ce. de los miasmas al germen. el descubrimiento de la entidad etiológica. génesis y desarrollo en antioquia. iatreia. 1996;9(1):32-36. 11. simon lorda d, rúa dominguez ml. el laboratorio municipal de ourense (1910-1930). antecedentes y breves apuntes históricos. en campos r, montiel l, huertas r, coordinadores. medicina, ideología e historia en españa (siglos xvi-xxi). madrid: consejo superior de investigaciones científicas (csic); 2007. 439 un mundo en transición. los objetos para los cuidados en españa entre 1855 y 1955 l claudia patricia arredondo gonzález y otros 12. de esteban marfil b. la guerra de cuba (1895-1898), como caso paradigmático de las enfermedades infecto-contagiosas. en campos r, montiel l, huertas r, coordinadores. medicina, ideología e historia en españa (siglos xvi-xxi). madrid: consejo superior de investigaciones científicas (csic); 2007. 13. sáez gómez jm, lópez gonzález j, garcía medina v, marset campos p. la introducción de la radiología en la región de murcia. en campos r, montiel l, huertas r, coordinadores. medicina, ideología e historia en españa (siglos xvi-xxi). madrid: consejo superior de investigaciones científicas (csic); 2007. 14. hernández martín f. historia de la enfermería en españa: (desde la antigüedad hasta nuestros días). madrid: síntesis; 1996. 15. garcía martínez mj. el capitulo x d las constituciones manuscritas elaboradas por bernardino de obregón: un nuevo concepto de enfermería a finales del siglo xvi. híades. 2008;1(10):256-269. 16. fairman j, lynaugh j. critical care nursing a history. philadelphia: university of pennsyvania press; 1998. 17. zulumas j. caring in crisis. an oral history of critical care nursing. philadelphia: university of pennsyvania press; 1995. 18. nietszche e, leopardi mt. tecnologia emancipatória: uma perspectiva de transformação da práxis de enfermagem. texto y contexto enferm. 2000;9: 25-41. 19. müller dias lp, montecelli m, reibnitz k, matos lima l. possibilidades de cohecimiento e arte na produçao de inventos de enfermagem. texto y contexto enferm. 1996;5(1):92-110. 20. barra dcc, nascimento erp, martins jj, albuquerque gl, erdmann al. evolução histórica e impacto da tecnologia na área da saúde e da enfermagem. revista eletrônica de enferm [internet]. 2006 [citado 2013 sep 19]; 8(3):422-430. disponible en: http://www.fen.ufg.br/revista/revista8_3/v8n3a13.htm 21. aróstegui j. la investigación histórica: teoría y método. barcelona: crítica; 2001. 22. von wright g. explicación y comprensión. madrid: alianza; 1987. 23. strasuss a, corbin j. bases de la investigación cualitativa. técnicas y procedimientos para desarrollar teoría fundamentada. colombia: universidad de antioquia; 2002. 24. colliére m. promover la vida. de la práctica de las mujeres cuidadoras a los cuidados de enfermería. madrid: mcgrawhill/interamericana; 1993. 25. arratia figueroa a. investigación y documentación histórica en enfermería. texto y contexto enferm. 2005;14(4):567-574. 26. wolf m. sociologías de la vida cotidiana. madrid: cátedra; 1979. 27. sennett r. el artesano. barcelona: anagrama; 2009. 28. habermas j. ciencia y técnica como ideología. madrid: tecnos; 1989. 183 194 bienestar en enfermeria.indd 183 amparo oliver1 noemí sansó2 laura galiana3 josé m. tomás4 enric benito5 evaluación psicométrica en profesionales de enfermería de cuidados paliativos 1 orcid.org/0000-0002-1207-4088. universitat de valència, españa. oliver@uv.es 2 orcid.org/0000-0002-5847-9654. universitat de les illes balears, españa. noemi.sanso@ssib.es 3 orcid.org/0000-0002-5342-5251. universitat de valència, españa. laura.galiana@uv.es 4 orcid.org/0000-0002-3424-1668. universitat de valència, españa. tomasjm@uv.es 5 orcid.org/0000-0002-0489-4668. universitat de les illes balears, españa. recibido: 27 de enero de 2016 enviado a pares: 29 de enero de 2016 aceptado por pares: 3 de agosto de 2016 aprobado: 23 de agosto de 2016 doi: 10.5294/aqui.2017.17.2.7 para citar este artículo / to reference this article / para citar este artigo oliver a, sansó n, galiana l, tomás jm, benito e. evaluación psicométrica en profesionales de enfermería de cuidados paliativos. aquichan. 2017; 17(2): 183-194. doi: 10.5294/aqui.2017.17.2.7 resumen objetivo: validar las escalas de bienestar psicológico de ryff en enfermería y relacionarlas con variables clave en calidad de vida laboral. materiales y métodos: participaron por encuesta electrónica, autoadministrada anónima, 433 profesionales, 33,1% de ellos profesionales de enfermería (n = 123) en quienes se realizó el estudio. además de los datos sociodemográficos, se recogió información sobre bienestar psicológico, atención consciente, afrontamiento de la muerte y calidad de vida. la validez de constructo fue evaluada con análisis factorial confirmatorio. se estimó fiabilidad y se recogieron evidencias de validez externa. resultados: el modelo mostró ajuste adecuado: x2(362) = 438,59 (p = 0,01), cfi = 0,98, rmsea = 0,05 (0,03-0,06) y fiabilidad adecuada para todas las dimensiones, excepto autonomía. las dimensiones de bienestar se relacionaron moderada y positivamente con autoconciencia, afrontamiento ante la muerte y satisfacción por compasión, y negativamente con fatiga por compasión y burnout. se destacan las relaciones entre dominio del entorno y burnout (-0,54) y propósito en la vida con satisfacción (0,54) y con afrontamiento de la muerte (0,50). conclusiones: los resultados apoyan el uso de estas escalas en enfermería, pues muestran adecuada fiabilidad y validez, y varias de ellas explican hasta una cuarta parte de indicadores relevantes en salud laboral como burnout o satisfacción vital. palabras clave reproducibilidad de resultados; condiciones de trabajo; validez de las pruebas; calidad de vida; enfermería (fuente: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 183-194 184 aquichan issn 1657-5997 eissn 2027-5374 año 17 vol. 17 nº 2 chía, colombia junio 2017 l 183-194 psychometric evaluation of nursing professionals involved in palliative care abstract objective: the study was intended to validate ryff’s psychological well-being scales in nursing and to relate them to key variables in the quality of life at work. materials and method: four hundred thirty-three (433) professionals took part through an anonymous, selfadministered electronic survey; 33.1% were nursing professionals (n = 123) and the authors focused on them. in addition to sociodemographic data, information was collected on psychological well-being, mindfulness, coping with death, and quality of life. construct validity was evaluated through confirmatory factor analysis. reliability was estimated and evidence of external validity was collected. results: the model showed adequate adjustment: x2(362) = 438.59 (p = 0.01), cfi = 0.98, rmsea = 0.05 [0.03-0.06] and adequate reliability for all the dimensions except autonomy. the dimensions of well-being were moderately and positively with self-awareness, coping with death, and satisfaction from compassion, and negatively with fatigue from compassion and burnout. the association between dominance of the environment and burnout (-0.54), purpose in life and satisfaction (0.54) and coping with death (0.50) stood out. conclusions: the results support the use of these scales in nursing, since they demonstrate adequate reliability and validity. in fact, several of them explain up to a quarter of the relevant indicators in occupational health, such as burnout or satisfaction with life. keywords reproducibility of results; working conditions; validity of the tests; quality of life; nursing (source: decs, bireme). 185 evaluación psicométrica en profesionales de enfermería de cuidados paliativos l amparo oliver y otros avaliação psicométrica em profissionais de enfermagem de cuidados paliativos resumo objetivos: validar as escalas de bem-estar psicológico de ryff em enfermagem e relacioná-las com variáveis fundamentais em qualidade de vida no trabalho. materiais e método: participaram por enquete eletrônica autoadministrada anônima 433 profissionais — 33,1 % profissionais de enfermagem (n=123), nos quais nos focamos. além de informação sociodemográfica, coletou-se informação sobre bem-estar psicológico, atenção consciente, enfrentamento da morte e qualidade de vida. a validade de constructo foi avaliada com análise fatorial confirmatória. estimou confiabilidade e coletaram-se evidências de validade externa. resultados: o modelo mostrou ajuste adequado: x2(362) = 438,59 (p = 0,01), cfi = 0,98, rmsea = 0,05 [0,03-0,06] e confiabilidade adequada para todas as dimensões, exceto autonomia. as dimensões do bem-estar foram relacionadas moderada e positivamente com autoconsciência, enfretamento da morte e satisfação por compaixão, e negativamente com fatiga por compaixão e burnout. destacam-se as relações entre domínio do ambiente e burnout (-0,54), propósito na vida com satisfação (0,54) e com enfrentamento da morte (0,50). conclusões: os resultados apoiam o uso dessas escalas em enfermagem, pois mostram adequada confiabilidade e validade, e várias delas explicam até um quarto de indicadores relevantes em saúde do trabalho, como burnout ou satisfação vital. palavras-chave condições de trabalho; enfermagem; qualidade de vida; reprodutibilidade de resultados; validade dos testes (fonte: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 183-194 186 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 introducción la atención que la investigación dedica al bienestar y la salud mental ha ido en aumento durante la última década, convirtiéndose en un tema de interés tanto en círculos académicos como políticos (1). aunque la mayor parte de los investigadores están de acuerdo con la definición general del bienestar ofrecida por ryan y deci (2), en la que este se conceptualiza como “el funcionamiento y la experiencia psicológica óptima”, el debate sobre su naturaleza continúa. una de las perspectivas más fundamentadas empíricamente ha sido el enfoque eudaimónico del bienestar, o modelo psicológico del bienestar. según esta perspectiva, se anima a las personas a vivir de acuerdo con su verdadero yo (2). carol ryff, autora de referencia en el estudio del bienestar eudaimónico, define el bienestar como “la búsqueda de la perfección que representa la realización del verdadero potencial de uno mismo” (3). en este contexto, el bienestar se ha asociado a una mejor salud percibida, menor morbilidad, menor dolor y mayor longevidad (4-6). pressman et al. (7), en un estudio de carácter mundial, encontraron que las emociones positivas eran capaces de predecir la salud percibida. así pues, diversos autores han llamado a la inclusión del bienestar como factor protector de la salud, en la implementación de acciones de diversa índole, siendo especialmente importantes para el objetivo de estudio aquellas relacionadas con el contexto laboral (8). el bienestar de los trabajadores resulta especialmente crítico en aquellos que deben lidiar con sucesos estresantes en su día a día, como es el caso de los profesionales de la salud, que presentan altas tasas de enfermedades relacionadas con el estrés, y multitud de quejas mentales y somáticas (9). en concreto, se ha expresado la preocupación por los efectos del estrés sobre la salud y el bienestar de los profesionales enfermeros (10, 11). entre los diversos problemas que caracterizan el entorno laboral de los enfermeros se han destacado factores como el bajo apoyo en las relaciones del trabajo, bajo control, necesidad continua de formación (12) y altas demandas del trabajo (11); ser trasladados a diferentes unidades clínicas de la organización, limitación de recursos, afrontar la muerte y excesiva carga de trabajo (13); rotación de turnos, demanda de tiempo (14); falta de control e implicación emocional (15); relaciones laborales ineficaces con los médicos (16); y pobres relaciones con los supervisores (17). a este panorama tan complejo se añade, además, en el caso de los enfermeros de cuidados paliativos, un reto adicional: trabajar diariamente en contacto con la muerte. recientes estudios apuntan a que los profesionales de cuidados paliativos padecen mayor sufrimiento (18), burnout (19) y fatiga de la compasión (20), de ahí la importancia de estudiar el bienestar de los/as enfermeros/as de cuidados paliativos. para evaluar este constructo complejo se han utilizado diversos instrumentos a lo largo de la literatura. tradicionalmente, el estudio sobre el bienestar subjetivo ha mostrado especial interés en el análisis de los afectos y la satisfacción con la vida, y el bienestar psicológico ha centrado su atención en el desarrollo de las capacidades y el crecimiento personal. sus primeras concepciones se articularon en torno a nociones como la autoactualización, el funcionamiento pleno o la madurez (21). a pesar de su relevancia teórica, ninguna de ellas llegó a tener un impacto significativo en el estudio del bienestar, debido, fundamentalmente, a la ausencia de fiabilidad y validez en los procedimientos de medida. buscando los puntos de convergencia entre todas estas formulaciones, carol ryff (22) desarrolló un modelo que se concreta en una escala de seis dimensiones de la realización humana: autoaceptación (tener una actitud positiva hacia uno mismo), relaciones positivas con los demás (tener relaciones satisfactorias y de calidad), autonomía (independencia y autodeterminación), dominio del entorno (manejo de la propia vida), crecimiento personal (estar abierto a nuevas experiencias) y propósito en la vida (dar sentido a la vida) (21, 22). este modelo es uno de los más utilizados para evaluar el bienestar de las personas (1), de forma que las escalas han sido traducidas y validadas en al menos 18 lenguas (23-25). sin embargo, y a pesar de haberse aplicado recientemente en población de enfermería (26-28), hasta la fecha no se han estudiado sus propiedades psicométricas. derivado de lo anterior, dos propósitos se proponen para esta investigación: el primero, validar las escalas de bienestar psicológico de ryff, en concreto, su versión española de 29 ítems, y conocer sus propiedades psicométricas en una muestra de profesionales de la enfermería de cuidados paliativos; el segundo, ampliar el conocimiento actual de este campo, aportando evidencia sobre algunos de los factores que influyen en dicho bienestar, en concreto, mostrando cuantía y signo de su relación con burnout, fatiga por compasión, satisfacción con la compasión, afrontamiento de la muerte y autoconciencia. 187 evaluación psicométrica en profesionales de enfermería de cuidados paliativos l amparo oliver y otros materiales y métodos diseño, procedimiento y muestra. el diseño fue de corte transversal, con procedimiento por encuesta electrónica anónima realizada en el año 2013 a nivel nacional en españa. de los 1.309 miembros de la sociedad española de cuidados paliativos (secpal) invitados a participar, 433 respondieron y, de estos, 385 cumplieron los criterios de inclusión. el 40,3 % eran médicos, 33,1 % enfermeros, 14,2 % psicólogos, 4,8 % auxiliares de enfermería, 4,0 % trabajadores sociales y el 0,8 % restante tenía más de una de estas profesiones. de esta forma, la muestra objeto de estudio estuvo compuesta por 123 enfermeros. la descripción detallada de la muestra se observa en la tabla 1. tabla 1. características de los participantes en el estudio m dt edad 46,91 8,91 años de experiencia en salud 23,97 9,30 años de experiencia en cuidados paliativos 9,75 6,27 n % sexo hombres 15 12,3 mujeres 107 87,7 perdidos 1 -unidad o servicio unidad de cuidados paliativos 20 25,6 unidad de cuidados paliativos en centro socio-sanitario 10 12,8 hospice 3 3,8 cuidados domiciliarios 26 33,3 unidad de cuidados paliativos pediátricos 2 2,6 equipo de apoyo hospitalario 17 21,8 perdidos 45 -fuente: elaboración propia. instrumentos. además de los datos sociodemográficos, se utilizaron las siguientes escalas: 1. escalas de ryff de bienestar psicológico (21). la versión utilizada en este estudio fue la adaptación española (25), que evalúa 29 ítems que forman parte de 6 dimensiones del bienestar interdependientes (ver apéndice). la medición se realiza mediante una escala de likert de 6 puntos, desde 1 (totalmente en desacuerdo) a 6 (totalmente de acuerdo). esta escala puede consultarse en el apéndice. 2. escala de atención consciente (29). esta escala mide la tendencia general a estar atento y consciente a las propias experiencias de la vida diaria. cuenta con 15 elementos que se miden mediante una escala likert de 6 puntos, desde 1 (casi siempre) a 6 (casi nunca). algunos ejemplos son: “yo podría experimentar una emoción y no ser consciente de ello hasta más tarde” o “me resulta difícil mantener la concentración en lo que está sucediendo en el presente”. la consistencia interna (alfa de cronbach) fue de 0,90. 3. escala de afrontamiento ante la muerte (30). trata de evaluar la competencia de afrontamiento ante la muerte. incluye ítems que examinan la presencia de una serie de destrezas y capacidades para afrontar la muerte, y las creencias y actitudes sobre la existencia de las mismas. cuenta con 30 ítems, que puntúan en escala tipo likert de 7 anclajes, desde 1 (totalmente en desacuerdo) a 7 (totalmente de acuerdo), 3 de los cuales son ítems invertidos. ejemplos de ítems son: “tengo una buena perspectiva de la muerte y del proceso de morir” o “estoy familiarizado con los arreglos previos al funeral”. la puntuación total en afrontamiento ante la muerte se obtiene mediante la suma de las puntuaciones de los 30 ítems. el alfa de cronbach fue de 0,89. 4. escala de calidad de vida profesional (31), formada por tres subescalas (fatiga de compasión, riesgo de síndrome de burnout y satisfacción de compasión). esta escala mide el riesgo de sufrir fatiga de compasión y riesgo de padecer el síndrome de burnout, como consecuencias negativas de las profesiones de ayuda, y el nivel de satisfacción de compasión que experimenta el sujeto evaluado. estas tres dimensiones se evalúan mediante 10 ítems cada una, que puntúan en una escala con anclajes tipo likert de 6 puntos que van desde 0 (nunca) a 5 (siempre). para la subescala de satisfacción de compasión el alfa de cronbach fue de 0,77, para la fatiga de compasión 0,78 y para el riesgo de burnout 0,54. 188 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 análisis de datos. la validez de constructo fue evaluada mediante un análisis factorial confirmatorio (afc) con una estructura a priori de seis factores. el método de estimación fue de máxima verosimilitud, con correcciones robustas para los errores estándar y correlaciones policóricas, el recomendado para datos ordinales y no normales (32). la plausibilidad del modelo se evaluó utilizando diversos índices (33): a) el estadístico chi cuadrado (34); el comparative fit index (cfi) (35); y el root mean squared error of approximation (rmsea) (36). se calcularon estadísticos descriptivos (medias, desviaciones típicas, puntuaciones mínimas y máximas) para las dimensiones del bienestar estudiadas, así como distintas estimaciones de fiabilidad: alfa de cronbach, coeficiente rho y greatest lower bound (glb). alfa es el índice de fiabilidad más comúnmente utilizado, con valores entre 0,70 y 0,79 considerados como moderados, y estimaciones de 0,80 o superiores consideradas indicadores de alta fiabilidad (37). sin embargo, alfa está influido por la longitud de la escala y tan solo es apropiado para ítems tau-equivalentes, siendo un límite inferior de la verdadera fiabilidad (38). de esta forma, los índices rho y glb, calculados en el contexto de los modelos de ecuaciones estructurales, también fueron estimados. finalmente, se calcularon correlaciones entre las dimensiones del bienestar y las variables relacionadas con el trabajo aportando evidencias de su validez. resultados la validez factorial de las escalas de ryff se estableció mediante un modelo de ecuaciones estructurales, en concreto, un análisis factorial confirmatorio. este modelo mostró un ajuste adecuado: x2(362) = 438,59 (p = 0,01), cfi = 0,98, rmsea = 0,05 (0,03-0,06), pues los distintos índices de ajuste tomaron valores comprendidos entre las recomendaciones que ofrece la literatura (33, 35, 36). adicionalmente, el ajuste analítico fue también adecuado, con todas las cargas factoriales elevadas y estadísticamente significativas en las dimensiones correspondientes (figura 1). la saturación factorial más baja fue para el ítem 17 (β = 0,70) y las más altas para los ítems 1 y 24 (β = 0,77) en la dimensión de autoaceptación; en la de relaciones positivas, la más baja para el ítem 2 (β = 0,51) y la más alta para el ítem 25 (β = 0,69); en autonomía, para el ítem 23 (β = 0,30) y 4 (β = 0,53), respectivamente; en dominio del entorno, la saturación más baja fue la del ítem 19 (β = 0,37) y la más alta la del ítem 29 (β = 0,69); en crecimiento personal, la más baja para los ítems 21 y 27 (β = 0,76) y la más alta para el ítem 28 (β = 0,89); y, finalmente, en propósito en la vida la saturación más baja fue para el ítem 11 (β = 0,66) y la más alta para el ítem 16 (β = 0,77). figura 1. saturaciones factoriales estandarizadas del análisis factorial confirmatorio puesto a prueba notas: todas las saturaciones factoriales fueron estadísticamente significativas (p < 0,01). para mayor claridad, no se muestran los errores estándar. las correlaciones entre los factores pueden observarse en la tabla 2. fuente: elaboración propia. 189 evaluación psicométrica en profesionales de enfermería de cuidados paliativos l amparo oliver y otros las correlaciones entre los factores fueron positivas y estadísticamente significativas, tal y como se esperaba. las correlaciones de mayor valor fueron las de la dimensión de dominio del entorno, con valores que oscilaron entre 0,72 y 0,98, y las de menor valor las de autonomía, oscilando entre 0,48 y 0,84 (tabla 2). tabla 2. correlaciones entre los factores del modelo de ecuaciones estructurales, estadísticos descriptivos, estimaciones de fiabilidad y correlaciones con las variables relacionadas notes: aa = autoaceptación; rp = relaciones positivas con los demás; au = autonomía; de =dominio del entorno; cp = crecimiento personal; pv = propósito en la vida; * = p < 0,05; ** = p < 0,01. fuente: elaboración propia. en la tabla 2 se presentan los estadísticos descriptivos de cada una de las dimensiones del bienestar. en cuanto a la fiabilidad, alfa, rho y glb fueron adecuados para todas las dimensiones del bienestar, con valores que oscilaron entre 0,73 (dominio del entorno) y 0,85 para el alfa y el rho (propósito en la vida), y entre 0,76 (dominio del entorno) y 0,88 (propósito en la vida) para el glb. únicamente en el caso de la dimensión de autonomía los valores de fiabilidad no llegaron al punto mínimo recomendado (37) pues se obtuvieron valores de 0,59 (en los casos de alfa y rho) y 0,69 (en el caso de glb). se calcularon correlaciones con el fin de probar la validez externa del instrumento, y estudiar al mismo tiempo la relación entre el bienestar y las variables relacionadas con el trabajo. como se observa en la tabla 2, no se han encontrado relaciones estadísticamente significativas entre las dimensiones del bienestar y la edad (oscilando entre r = -0,05, p > 0,05 y r = 0,16, p > 0,05), años de experiencia en salud (oscilando entre r = -0,03, p > 0,05 y r = 0,15, p > 0,05) y en cuidados paliativos (oscilando entre r = 0,01, p > 0,05 y r = 0,18, p > 0,05), lo que coincide con los resultados obtenidos en el estudio realizado por arrogante et al. (39). por el contrario, sí se encontraron relaciones positivas y estadísticamente significativas entre el bienestar y la autoconciencia, la competencia de afrontamiento ante la muerte y la satisfacción de compasión, excepto para el caso concreto de las relaciones positivas con los demás y la autoconciencia (r = 0,18 > 0,05). por último, todas las relaciones entre el bienestar y las dimensiones negativas de la calidad de vida (fatiga de compasión y riesgo de síndrome de burnout) fueron estadísticamente significativas y negativas, a excepción del crecimiento personal y la fatiga de compasión (r = -0,05, p > 0,05). correlaciones entre los factores del modelo aa rp au de cp pv autoaceptación 1,00 relaciones positivas con los demás 0,74 1,00 autonomía 0,54 0,84 1,00 dominio del entorno 0,96 0,93 0,72 1,00 crecimiento personal 0,70 0,73 0,49 0,79 1,00 propósito en la vida 0,95 0,72 0,48 0,98 0,70 1,00 estadísticos descriptivos m 4,84 4,95 4,31 4,88 5,33 4,90 dt 0,75 0,76 0,74 0,69 0,60 0,77 min 2,00 2,50 2,33 2,60 3,33 2,20 max 6,00 3,00 5,83 6,00 6,00 6,00 estimaciones de fiabilidad α 0,83 0,78 0,59 0,73 0,81 0,85 rho 0,83 0,78 0,59 0,73 0,82 0,85 glb 0,83 0,84 0,69 0,76 0,82 0,88 correlaciones con las variables relacionadas edad 0,096 -0,054 -0,048 0,056 0,132 0,162 años de experiencia en salud 0,066 0,002 -0,032 0,019 0,151 0,110 años de experiencia en cuidados paliativos 0,131 0,073 0,026 0,112 0,013 0,183 autoconciencia 0,266** 0,188 0,256** 0,352** 0,270** 0,319** correlaciones entre los factores del modelo aa rp au de cp pv afrontamiento de la muerte 0,476** 0,304** 0,286** 0,438** 0,349** 0,502** satisfacción con la compasión 0,411** 0,364** 0,148 0,463** 0,261** 0,537** fatiga de la compasión -0,283** -0,405** -0,318** -0,389** -0,053 -0,207* burnout -0,356** -0,399** -0,254* -0,536** -0,247* -0,441** 190 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 discusión el objetivo del estudio fue valorar la validez de la versión española de 29 ítems de la escala de ryff de bienestar psicológico, en una población española de profesionales de enfermería. los resultados señalaron buenas propiedades psicométricas cuando se utiliza en el colectivo de enfermeros, lo que confirma los resultados obtenidos en una muestra de estudiantes de enfermería (39, 40). el análisis factorial confirmatorio ofreció evidencia de la estructura tradicional de seis factores, con un buen ajuste global y analítico. la fiabilidad estimada fue también adecuada, excepto para la dimensión de autonomía, que presentó valores de alfa y rho. sin embargo, cuando fue calculada por otros procedimientos (glb), la fiabilidad fue aceptable. por último, la evidencia externa proporcionada por las correlaciones entre factores del bienestar y otras variables relacionadas también fue adecuada, y las relaciones con constructos psicológicos estaban en la línea de otros trabajos. por ejemplo, se encontró una relación negativa entre el burnout y el bienestar, como se reportó en el trabajo de amutio et al. (41). en cambio, y siguiendo con los hallazgos de este estudio, en el que demostraban una relación negativa entre la edad y el nivel de bienestar psicológico (41), en el presente trabajo no se encontraron relaciones significativas entre el bienestar y los datos sociodemográficos. los resultados remarcan el papel esencial de variables como la autoconciencia, el afrontamiento de la muerte y la calidad de vida de los profesionales de la enfermería en la determinación de su bienestar. estos resultados concuerdan con lo propuesto por sansó et al. (42), quienes señalan la importancia de cultivar la vida interna de los profesionales para prevenir el trauma vicario y, en general, mejorar su bienestar personal y su efectividad terapéutica. pese a que se han encontrado trabajos previos similares (3941), este es el primero que evalúa el bienestar psicológico de los profesionales de enfermería con las escalas de bienestar psicológico de ryff (21, 22) y que ofrece un estudio detallado de las propiedades de este instrumento en una muestra de esta población. tal y como apunta una reciente revisión sobre el tema (43), la literatura en este contexto se ha caracterizado por utilizar un amplio rango de instrumentos en la medida del bienestar psicológico, lo que ha dificultado enormemente la comparación de los resultados encontrados en los distintos estudios, sin poner a prueba sus bondades estadísticas. en cuanto a sus limitaciones, a pesar de encuestar a toda la población de enfermeros de la sociedad española de cuidados paliativos, la tasa de respuesta hizo que la muestra del colectivo de enfermería fuese finalmente limitada. futuras investigaciones deberían contar con muestras de mayor tamaño y ampliarlas a otras áreas de la enfermería. conclusiones esta investigación da respuesta a la necesidad señalada de contar con estudios que evalúen la adecuación de las medidas del bienestar en el colectivo de los profesionales de enfermería (43). los resultados sobre la validez de la escala de bienestar psicológico de ryff dan muestra de su idoneidad para usarla en enfermeros de cuidados paliativos. precisamente, el bienestar de estos profesionales es de particular interés, dada su influencia en los pacientes que atienden, sobre todo teniendo en cuenta el ambiente de alta densidad emocional en el que trabajan, con una presencia muy frecuente de dolor y sufrimiento. en esta investigación se ha podido cuantificar la especial relevancia de las relaciones entre dimensiones de bienestar tales como dominio del ambiente con el burnout, o el propósito en la vida con la satisfacción por compasión. estos son solo algunos de los datos que pueden guiar el diseño de intervenciones para promover la salud laboral en enfermería en situaciones de alta demanda o sobrecarga emocional como son los cuidados paliativos. es posible conseguir un mayor dominio del ambiente dotando al personal de más autonomía y flexibilidad en la organización del trabajo, de los turnos y la asignación de tareas, lo que redundaría en un menor burnout. asimismo, es necesaria una toma de conciencia sobre el propósito en la vida, e incorporar en las sesiones de trabajo y en la formación en enfermería técnicas para mejorar la autoconciencia, como mindfulness que, además, podrían facilitar ese cultivo interior tan propicio para desarrollar una mayor satisfacción por la compasión, que redundaría en un doble beneficio para el profesional y el paciente. 191 evaluación psicométrica en profesionales de enfermería de cuidados paliativos l amparo oliver y otros referencias 1. steptoe a, deaton a, stone aa. subjective wellbeing, health, and ageing. lancet. 2015;385(14):640-8. 2. ryan r, deci el. on happiness and human potentials: a review of research on hedonic and eudaimonic well-being. annu rev psychol. 2001;52:141-66. 3. ryff cd. psychological well-being in adult life. curr dir psychol sci. 1995;4:99-104. 4. stranges s, samaraweera pc, taggart f, kandala n, stewart-brown s. major health-related behaviours and mental wellbeing in the general population: the health survey for england. bmj open. 2014;4(9):e005878. 5. diener e, chan m. happy people live longer: subjective well-being contributes to health and longevity. appl psycholhlth we. 2011;3:1-43. 6. friedman hs, kern ml. personality, well-being, and health. annu rev psychol. 2014;65:719-42. 7. pressman sd, gallagher mw, lopez sj. is the emotion-health connection a “first-world problem”? 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and coping with death. j pain symptom manage. 2015;50(2):200-7. 43. galiana l, oliver a, sansó n. palliative care professionals’ quality of life: an integrative, systematic review on nurses’ well-being. en: silbermann m. palliative care perspective, practices and impact on quality of life global view. nova science publishers, inc.: new york; in press. 193 evaluación psicométrica en profesionales de enfermería de cuidados paliativos l amparo oliver y otros apéndice. escalas de bienestar psicológico de ryff ítem dimensión contenido 1 aa when i look at the story of my life, i am pleased with how things have turned out. cuando repaso la historia de mi vida estoy contento con cómo han resultado las cosas. 2 rp i often feel lonely because i have few close friends with whom to share my concerns. a menudo me siento solo porque tengo pocos amigos íntimos con quienes compartir mis preocupaciones. 3 au i am not afraid to voice my opinions, even when they are in opposition to the opinions of most people. no tengo miedo de expresar mis opiniones, incluso cuando son opuestas a las opiniones de la mayoría de la gente. 4 au i am concerned about how other people evaluate the choices i have made in my life. me preocupa cómo otra gente evalúa las elecciones que he hecho en mi vida. 5 de i have difficulty arranging my life in a way that is satisfying to me. me resulta difícil dirigir mi vida hacia un camino que me satisfaga. 6 pv i enjoy making plans for the future and working to make them a reality. disfruto haciendo planes para el futuro y trabajar para hacerlos realidad. 7 aa in general, i feel confident and positive about myself. en general, me siento seguro y positivo conmigo mismo. 8 rp i don't have many people who want to listen when i need to talk. no tengo muchas personas que quieran escucharme cuando necesito hablar. 9 au i tend to worry about what other people think of me. tiendo a preocuparme sobre lo que otra gente piensa de mí. 10 de i have been able to build a home and a lifestyle for myself that is much to my liking. he sido capaz de construir un hogar y un modo de vida a mi gusto. 11 pv i am an active person in carrying out the plans i set for myself. soy una persona activa al realizar los proyectos que propuse para mí mismo. 12 rp i feel like i get a lot out of my friendships. siento que mis amistades me aportan muchas cosas. 13 au i tend to be influenced by people with strong opinions. tiendo a estar influenciado por la gente con fuertes convicciones. 14 de in general, i feel i am in charge of the situation in which i live. en general, siento que soy responsable de la situación en la que vivo. 15 pv i feel good when i think of what i’ve done in the past and what i hope to do in the future. me siento bien cuando pienso en lo que he hecho en el pasado y lo que espero hacer en el futuro. 16 pv my aims in life have been more a source of satisfaction than frustration to me. mis objetivos en la vida han sido más una fuente de satisfacción que de frustración para mí. 17 aa i like most aspects of my personality. me gusta la mayor parte de los aspectos de mi personalidad. 194 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 ítem dimensión contenido 18 au i have confidence in my opinions, even if they are contrary to the general consensus. tengo confianza en mis opiniones incluso si son contrarias al consenso general. 19 de the demands of everyday life often get me down. las demandas de la vida diaria a menudo me deprimen. 20 pv i have a sense of direction and purpose in life. tengo clara la dirección y el objetivo de mi vida. 21 cp in general, i feel that i continue to learn more about myself as time goes by. en general, con el tiempo siento que sigo aprendiendo más sobre mí mismo. 22 rp i have not experienced many warm and trusting relationships with others. no he experimentado muchas relaciones cercanas y de confianza. 23 au it's difficult for me to voice my own opinions on controversial matters. es difícil para mí expresar mis propias opiniones en asuntos polémicos. 24 aa for the most part, i am proud of who i am and the life i lead. en su mayor parte, me siento orgulloso de quien soy y la vida que llevo. 25 rp i know that i can trust my friends, and they know they can trust me. sé que puedo confiar en mis amigos, y ellos saben que pueden confiar en mí. 26 rp when i think about it, i haven't really improved much as a person over the years. cuando pienso en ello, realmente con los años no he mejorado mucho como persona. 27 cp i have the sense that i have developed a lot as a person over time. tengo la sensación de que con el tiempo me he desarrollado mucho como persona. 28 cp for me, life has been a continuous process of learning, changing, and growth. para mí, la vida ha sido un proceso continuo de estudio, cambio y crecimiento. 29 de if i were unhappy with my living situation, i would take effective steps to change it. si me sintiera infeliz con mi situación de vida daría los pasos más eficaces para cambiarla. notas: aa = autoaceptación; rp = relaciones positivas con los demás; au = autonomía; de = dominio del entorno; cp = crecimiento personal; pv = propósito en la vida. la versión española de las escalas está en cursiva. 140 149 fatores associados ao diagnostico.indd 140 érida maria diniz-leite1 isadora costa-andriola2 maria isabel da conceição dias-fernandes3 juliane rangel-dantas4 jéssica dantas de sá tinôco5 ana luisa brandão de carvalho lira6 fatores associados ao diagnóstico risco de volume de líquidos defi ciente em pacientes em hemodiálise 1 orcid.org/0000-0003-2452-7483. universidade federal do rio grande do norte, brasil. compclp@ufrn.edu.br 2 orcid.org/0000-0003-3446-675x. universidade federal do rio grande do norte, brasil. isacosta@ufrn.edu.br 3 orcid.org/0000-0003-0569-5027. universidade federal do rio grande do norte, brasil. mariaisabel@ufrn.edu.br 4 orcid.org/0000-0002-1542-1559. universidade federal do rio grande do norte, brasil. jessicads@ufrn.edu.br 5 orcid.org/0000-0002-1111-0390. universidade federal do rio grande do norte, brasil. julianerangel@ufrn.edu.br 6 orcid.org/0000-0002-7255-960x. universidade federal do rio grande do norte, brasil. analira@ufrnet.br recibido: 01 de marzo de 2016 enviado a pares: 22 de abril de 2016 aceptado por pares: 22 de agosto de 2016 aprobado: 06 de septiembre de 2016 doi: 10.5294/aqui.2017.17.2.3 para citar este artículo / to reference this article / para citar este artigo diniz-leite em, costa-andriola i, dias-fernandes mic, rangel-dantas j, dantas de sá tinôco j, brandão de carvalho lira al. fatores associados ao diagnóstico risco de volume de líquidos deficiente em pacientes em hemodiálise. aquichan. 2017;17(2):140-149. doi: 10.5294/aqui.2017.17.2.3 resumo objetivo: verificar a associação entre as características socioeconômicas e clínicas e os fatores associados ao diagnóstico risco de volume de líquidos deficiente em pacientes em hemodiálise. materiais e método: estudo transversal, realizado em uma unidade de diálise de um hospital universitário no nordeste do brasil, com 50 pacientes, por meio de entrevista e exame físico. para a análise dos dados, utilizou-se o teste de u mann-whitney. resultados: verificaram-se as seguintes associações significativas: deficiência de conhecimento e tempo de hemodiálise (p=0,037); extremos de peso e renda familiar (p=0,040); extremos de peso e volume de ultrafiltração (p=0,010), e perda de líquidos por vias anormais e volume de ultrafiltração (p=0,000). conclusões: foram identificadas associações entre os fatores associados do diagnóstico de enfermagem risco de volume de líquidos deficiente e as características socioeconômicas e clínicas presentes nos pacientes submetidos ao tratamento hemodialítico. assim, constatou-se que os fatores associados do diagnóstico em questão podem sofrer influências de características socioeconômicas e clínicas. palavras-chave diagnóstico de enfermagem; diálise renal; enfermagem; líquidos corporais; pesquisa em enfermagem clínica (fonte: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 140-149 141 fatores associados ao diagnóstico risco de volume de líquidos deficiente em pacientes em hemodiálise l érida maria diniz-leite e outros año 17 vol. 17 nº 2 chía, colombia junio 2017 l 140-149 factores asociados al diagnóstico riesgo de volumen deficiente de líquidos en pacientes en hemodiálisis resumen objetivo: verificar la asociación entre las características socioeconómicas y clínicas, y los factores asociados al diagnóstico riesgo de volumen deficiente de líquidos en pacientes en hemodiálisis. materiales y método: estudio transversal, realizado en una unidad de diálisis de una clínica universitaria en el noreste de brasil, con 50 pacientes, por medio de entrevistas y examen físico. para análisis de los datos se empleó la prueba u mann-whitney. resultados: se verificaron las siguientes asociaciones significativas: deficiencia de conocimiento y tiempo de hemodiálisis (p=0,037); extremos de peso y renta familiar (p=0,040); extremos de peso y volumen de ultrafiltración (p=0,010), y pérdida de líquidos por vías anormales y volumen de ultrafiltración (p=0,000). conclusiones: se identificaron asociaciones entre los factores asociados del diagnóstico de enfermería riesgo de volumen deficiente de líquidos y las características socioeconómicas y clínicas presentes en los pacientes sometidos al tratamiento hemodialítico. así, se encontró que los factores asociados de tal diagnóstico pueden sufrir influencias de características socioeconómicas y clínicas. palabras clave diagnóstico de enfermería; diálisis renal; enfermería; investigación en enfermería clínica; líquidos corporales (fuente: decs, bireme). 142 aquichan issn 1657-5997 eissn 2027-5374 factors associated with a diagnosis of fluid volume deficit risk in patients on hemodialysis abstract objective: verify the association between socioeconomic and clinical characteristics and the factors associated with a diagnosis of fluid volume deficit risk in patients who are on hemodialysis. materials and methods: this is a cross-sectional study done at the dialysis unit of a university hospital in northeastern brazil. featuring 50 patients, it was conducted through interviews and physical examinations. the mann-whitney u-test was used to analyze the data. results: a number of significant associations were verified; namely, knowledge deficit and hemodialysis time (p = 0.037); weight extremes and family income (p = 0.040); weight extremes and ultrafiltration volume (p = 0.010), and fluid loss through abnormal pathways and ultrafiltration volume (p = 0.000). conclusions: associations were identified between the factors associated with a nursing diagnosis of fluid volume deficit risk and the socioeconomic and clinical characteristics of patients who are undergoing hemodialysis. the factors associated with that diagnosis can be influenced by socioeconomic characteristics and clinical aspects. keywords nursing diagnosis; renal dialysis; nursing; nursing research; body fluids (source: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 140-149 143 fatores associados ao diagnóstico risco de volume de líquidos deficiente em pacientes em hemodiálise l érida maria diniz-leite e outros introdução no âmbito da prática profissional, hodiernamente, sabe-se que a utilização dos diagnósticos de enfermagem (de) é imprescindível à escolha de intervenções capazes de produzir resultados desejados no tratamento de uma clientela, de modo que suas necessidades sejam atendidas. a partir da difusão dessa linguagem padronizada enseja-se o alcance de aspectos relevantes concernentes à segurança do paciente (1). nesse sentido, compreende-se que a utilização de taxonomias de enfermagem, cujo objetivo é categorizar cientificamente a linguagem, a exemplo dos diagnósticos de enfermagem, fundamenta a prática profissional baseada em evidência. o de, no papel de segunda etapa do processo de enfermagem pode ser estabelecido com base no uso da nanda internacional, por se tratar de uma das mais utilizadas taxonomias em âmbito mundial (2). nesse contexto, o de risco de volume de líquidos deficiente (rvld), presente nessa taxonomia, pertencente ao domínio nutrição, classe hidratação, pode ser definido como “risco de diminuição do líquido intravascular, intersticial e/ou intracelular. refere-se à desidratação, com perda de água apenas, sem mudança no sódio” (1). esse diagnóstico revela-se significativo na conjuntura dos pacientes portadores de doença renal crônica (drc) submetidos ao tratamento hemodialítico, provavelmente devido à retirada excessiva de líquido do volume plasmático durante a terapia (3,4). realidade comprovada por estudo que verificou a presença de desidratação em grande parte dos pacientes com drc após o período de hemodiálise (3). corroborando com esses dados, outro estudo realizado com 47 pacientes com doença renal crônica em hemodiálise mostrou a presença da desidratação em 52,2 % dos pacientes no período pós-diálise (4). nesse contexto, a doença renal crônica, afecção na qual se observa uma deterioração lenta e progressiva da função renal, cuja classificação poderá se subdividir em cinco estágios distintos conforme a variação da taxa de filtração glomerular (tfg) verifica-se no quinto e último estágio, uma tfg incompatível com a vida, requerendo uma terapia de substituição renal, com vistas à retirada de excretas nitrogenadas, líquidos e eletrólitos em excesso (5). nessa perspectiva, compreende-se que a presença do risco de volume de líquidos deficiente em pacientes renais submetidos à hemodiálise é consequência de seu tratamento, que por meio de mecanismos de ultrafiltração propicia a perda de líquidos por vias anormais. a retirada do líquido intravascular, quando excessiva, não consegue ser compensada pelo deslocamento do líquido intersticial e intercelular, e consequentemente, desenvolve-se uma anormalidade hídrica. nesse sentido, a ocorrência de desidratação excessiva é preocupante, tendo-se em vista o desencadeamento de um tempo de recuperação mais longo após a sessão de hemodiálise, além de acelerar a perda da função renal residual e aumentar o risco de formação de coágulo na fístula arteriovenosa ou acesso vascular (3,6-8). entretanto, apesar das constatações sobre o risco de desidratação na clientela estudada e das repercussões que esse problema gera à saúde do paciente, o déficit do volume de líquidos nessa clientela ainda é algo pouco estudado na literatura, em detrimento disso, a maioria dos estudos na área aborda a alta prevalência do excesso do volume de líquidos (9-11), problemática também relevante, mas que se apresenta no período interdialítico e que é resolvido nas sessões de hemodiálise. somado a isso, é relevante ressaltar a expressividade em termos quantitativos de pacientes renais crônicos em terapia de substituição renal no brasil, país que em 2014 apresentou um total de 112.004 indivíduos em terapia dialítica, 20 mil pacientes a mais quando comparado ao ano de 2010. desse total, a maioria (91,4 %) realizava a hemodiálise como tratamento. preocupante também é o número de óbitos que atingiu, apenas em 2014, 21.281 indivíduos (12). nesse aspecto, é importante também enfatizar que a doença renal crônica despontava em 1990 como a vigésima sétima causa de morte na população mundial, posicionamento que se modificou para a décima oitava colocação em 2010 (13), taxas que sugerem preocupação sobre essa afecção. destarte, torna-se necessário e relevante o desenvolvimento de estudos que sejam capazes de subsidiar um aprofundamento do conhecimento científico nessa temática. desse modo, questiona-se: existe associação entre as características socioeconômicas e clínicas e os fatores associados ao diagnóstico risco de volume de líquidos deficiente em pacientes em hemodiálise? como objetivo, traçou-se verificar a associação entre as carac144 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 terísticas socioeconômicas e clínicas e os fatores associados ao diagnóstico risco de volume de líquidos deficiente em pacientes em hemodiálise. materiais e métodos trata-se de um estudo transversal, realizado em uma unidade de diálise de um hospital universitário, localizado no nordeste do brasil, com pacientes em tratamento hemodialítico. o referido hospital é uma instituição voltada para o ensino, pesquisa e extensão, o qual oferece leitos hospitalares, salas ambulatoriais, salas cirúrgicas, leitos de unidade de terapia intensiva para adultos, unidade de transplante renal, centro de diagnóstico por imagem, laboratórios de análises clínicas e de patologia e uma unidade de diálise. a unidade de diálise oferece atendimento em terapia renal substitutiva do tipo hemodiálise, assim, os pacientes atendidos por meio dessa unidade são internos do próprio hospital, provenientes das enfermarias, unidade de terapia intensiva e unidade de transplante renal e que por motivos clínicos não podem ser encaminhados para as clínicas de hemodiálise. a população foi composta pelo total de pacientes atendidos nessa unidade, no período de um ano, de janeiro de 2012 a janeiro de 2013, perfazendo um total de 210 pacientes, cujos dados foram extraídos a partir do sistema informatizado de registros de admissão. para o desenvolvimento do estudo, obteve-se uma amostra de 50 pacientes, os quais se encontravam internados no referido hospital e em tratamento hemodialítico durante a pesquisa. esse número foi alcançado a partir da aplicação da fórmula para populações finitas, por meio dos parâmetros: nível de confiança do estudo de 95 % (z ∞ = 1,96), erro amostral de 12 %, população de 210 pacientes e valor conservador de 50 % para a prevalência diagnóstica. o processo de amostragem empregado foi por conveniência do tipo consecutivo. como critérios de inclusão foram estipulados: estar internado e realizando hemodiálise no hospital do estudo; ter idade igual ou superior a 18 anos; estar consciente e orientado. como critérios de exclusão: gestantes e pacientes em tratamento por plasmaférese. a coleta dos dados decorreu da aplicação de um formulário de entrevista e de exame físico, o qual continha dados de identificação, dados relacionados ao tratamento e referentes ao diagnóstico em estudo. o instrumento foi validado em conteúdo e aparência por dois estudiosos reconhecidos na área da sistematização da assistência de enfermagem. as alterações propostas foram acatadas e incorporadas ao formulário. a entrevista e o exame físico foram realizados durante a sessão de diálise, no entanto, informações relevantes, a exemplo de dados de identificação não recordados pelo paciente ou dados atuais do tratamento clínico, foram extraídas também do prontuário durante e após a sessão. a coleta dos dados ocorreu de dezembro de 2013 a maio de 2014. os dados extraídos a partir da aplicação do instrumento supracitado foram organizados da seguinte forma: foram elaboradas 50 planilhas no microsoft office excel 2010, cada uma contendo os dados relacionados a cada paciente, como as variáveis sociodemográficas e clínicas, como também a lista dos fatores associados ao diagnóstico rvld, na qual foi assinalada pela pesquisadora a presença ou ausência de cada um desses fatores para o paciente em questão. essa organização facilitou a compreensão e subsidiou a tomada de decisões de um grupo de especialistas concernente à inferência diagnóstica do risco de volume de líquidos deficiente frente aos dados apresentados. para a etapa da inferência, enfermeiros diagnosticadores foram envolvidos no julgamento da presença do diagnóstico rvld à clientela em questão. para tanto, seis especialistas foram submetidos a treinamento com posterior avaliação de suas capacidades diagnósticas, por meio da aplicação de casos clínicos. desse modo, três especialistas foram selecionados por apresentarem melhores resultados. posteriormente, os diagnosticadores tiveram acesso às 50 planilhas já mencionadas para realizar a inferência diagnóstica do rvld em cada um dos pacientes. para a análise e processamento dos dados, utilizou-se o pacote ibm spss statistic versão 19.0 for windows, a partir do qual se verificou a existência de associação entre as variáveis socioeconômicas e clínicas apresentadas pela clientela portadora da doença renal e dos fatores associados presentes no diagnóstico de enfermagem em questão, por meio do teste de u mannwhitney, com p-valor de 0,05. as variáveis socioeconômicas estudadas foram: idade, anos de estudo e renda familiar, e as variáveis clínicas foram: meses de doença renal, tempo de hemodiálise em meses, duração da hemodiálise em horas e volume de ultrafiltração. os fatores associados analisados foram: falha nos 145 fatores associados ao diagnóstico risco de volume de líquidos deficiente em pacientes em hemodiálise l érida maria diniz-leite e outros mecanismos reguladores, perda de líquidos por vias anormais, deficiência de conhecimento, fatores que influenciam na necessidade de líquidos, extremos de peso, perda ativa de volume de líquidos, perdas excessivas por vias normais, desvios que afetam a absorção de líquidos, desvios que afetam a ingestão de líquidos e extremos de idade (indivíduos com idade superior a 65 anos). o desenvolvimento do estudo atendeu as normas nacionais e internacionais da ética em pesquisa envolvendo seres humanos. assim, recebeu parecer favorável, sob o número 392.535, com certificado de apresentação para apreciação ética (caae) número 18710613.4.00005537. ressalta-se que os pacientes e diagnosticadores receberam e assinaram o termo de consentimento livre e esclarecido autorizando a coleta dos dados. resultados referente à caracterização socioeconômica da clientela, a média de idade foi de 47,23 (±14,61) anos; a média de estudo foi de 6,44 (±4,93) anos; e a renda familiar obteve média de 1,5 salários mínimos. com relação aos dados clínicos, os meses de doença renal e tempo de hemodiálise apresentaram medianas de 64,15 e 40,68 meses, respectivamente; a duração da hemodiálise apresentou mediana de 4 horas; e o volume de ultrafiltração obteve mediana de 1,93 litros, sendo o mínimo de zero litros (sem perdas) e o valor máximo de 4,10 litros. o diagnóstico de enfermagem rvld esteve presente em 38 pacientes. os fatores associados presentes nesses indivíduos diagnosticados com o risco de volume de líquidos deficiente serão demonstrados na tabela 1 abaixo. fatores associados n % falha nos mecanismos reguladores 38 100 perda de líquidos por vias anormais 35 92,1 deficiência de conhecimento 28 73,6 fatores que influenciam na necessidade de líquidos 12 31,5 extremos de peso 10 26,3 perda ativa de volume de líquidos 8 21 perdas excessivas por vias normais 4 10,5 desvios que afetam a absorção de líquidos 1 2,6 desvios que afetam a ingestão de líquidos 1 2,6 extremos de idade 1 2,6 tabela 1. distribuição dos fatores associados entre os indivíduos diagnosticados com risco de volume de líquidos deficiente. natal/rn, 2016 fonte: elaboração própria. tabela 2. associação entre os fatores associados do risco de volume de líquidos deficiente e as variáveis socioeconômicas e clínicas dos pacientes submetidos à hemodiálise. natal/rn, 2016 a partir da tabela 1, visualiza-se como fatores associados mais prevalentes para esse diagnóstico: falha dos mecanismos reguladores (100 %), perda de líquidos por vias anormais (92,1 %) e deficiência de conhecimento (73,6 %). concernente à associação entre os fatores associados e as características socioeconômicas e clínicas dos indivíduos em hemodiálise, explana-se na tabela 2 a seguir. ressalta-se que o fator associado falha nos mecanismos reguladores não permitiu a realização de testes de associação estatística uma vez que não permite a geração de tabelas 2x2 por sua frequência hegemônica nos pacientes deste estudo. fatores associados idade anos de estudo renda familiar meses de doença renal tempo de hemodiálise duração da hemodiálise em horas volume de ultrafiltração deficiência de conhecimento 0,088* 0,833* 0,524* 0,109* 0,037* 0,757* 0,987* desvios que afetam a absorção de líquidos 0,474* 0,526* 0,421* 0,632* 0,842* 0,789* 0,474* desvios que afetam a ingestão de líquidos 0,579* 0,211* 1,000* 0,158* 0,105 0,789* 0,789* extremos de idade 0,053* 0,211* 0,421* 0,158* 0,316* 0,158* 0,579* extremos de peso 0,125* 0,334* 0,040* 0,334* 0,568* 0,683* 0,010* 146 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 verificaram-se, a partir do cruzamento, as seguintes associações significativas: deficiência de conhecimento e tempo de hemodiálise em meses (p=0,037); extremos de peso e renda familiar (p=0,040); extremos de peso e volume de ultrafiltração (p=0,010); e perda de líquidos por vias anormais e volume de ultrafiltração (p=0,000). discussão o diagnóstico risco de volume de líquidos deficiente obteve alta prevalência (78 %) nos pacientes deste estudo. para tanto, a verificação de quais fatores associados, inseridos nessa problemática, possuíam maior relação com os dados socioeconômicos e clínicos foi necessária, tendo-se em vista a necessidade de cuidados focados na prevenção desse diagnóstico, em virtude das complicações ocorridas na presença do volume de líquidos deficiente. dessa forma, o fator deficiência de conhecimento esteve presente em 73,6 % da amostra, além de associar-se estatisticamente com o tempo de hemodiálise em meses. na maioria das vezes, a deficiência de conhecimento pode estar relacionada ao nível de escolaridade, considerada baixa na amostra estudada. tal fato pode repercutir na baixa adesão ao regime terapêutico, visto que a escolaridade deficiente pode dificultar a compreensão acerca do processo de saúde-doença, além do entendimento do tratamento a ser instituído, o qual requer intervenções específicas, complexas, e cuja obediência é fundamental à sua eficácia. outrossim, o cumprimento do regime terapêutico é crucial na determinação da sobrevida desses pacientes, tendo em vista as complicações tanto da sobrecarga hídrica, como as repercussões negativas da retirada excessiva de líquidos (10-11,14). além disso, o tratamento de longa duração, ou ao longo de toda vida, é citado como fator que influencia a adesão ao tratamento, visto que a cronicidade dessa condição gera mudanças impactantes no estilo de vida do indivíduo com drc, além de limitar consideravelmente suas atividades e restringir sua liberdade (15). destarte, a baixa adesão ao regime terapêutico decorrente de deficiência de conhecimento age como facilitador da progressão da insuficiência renal crônica e poderá antecipar a necessidade de instituir-se a terapia dialítica, aumentando, portanto o tempo de hemodiálise em meses. essas variáveis interferem, pois, no risco de alterações do estado hídrico dessa clientela. no tocante à renda familiar, encontrou-se uma mediana de 1,5 salários mínimos, correspondente ao valor de r$ 1.320,00 ao se considerar o salário mínimo brasileiro vigente no ano de 2016 (r$ 880,00), caracterizando uma população com baixo nível socioeconômico. esse resultado corrobora com diversos estudos, os quais fizeram menção à baixa renda familiar nessa clientela (9,10,16). neste estudo, a renda familiar associou-se estatisticamente com extremos de peso. a literatura evidencia a relação existente entre a renda mensal e a desnutrição em pacientes submetidos à hemodiálise em centros de diálise em belo horizonte/brasil. verificou, portanto, que aqueles com renda mensal inferior ou igual a um salário mínimo apresentavam 1,6 a 4,2 mais chances de ser desnutrido. ademais, pacientes com idade superior a 60 anos, com depressão e os aposentados possuem também maiores chances de ser desnutridos, sendo a hipertensão um fator de proteção (17). a obesidade é outro distúrbio nutricional presente em pacientes submetidos à hemodiálise. pesquisa aponta prevalência de 44,77 % nesses pacientes, sendo mais preponderante em indivíduos do sexo feminino. como fatores que aumentam o risco para o desenvolvimento desse problema destaca-se a baixa renda, idade superior aos 40 anos, ingestão de proteínas menor que 1,2 g/kg/ fonte: elaboração própria. *teste u mainn-whitney. fatores associados idade anos de estudo renda familiar meses de doença renal tempo de hemodiálise duração da hemodiálise em horas volume de ultrafiltração fatores que influenciam na necessidade de líquidos 0,792* 0,988* 0,129* 0,525* 0,411* 0,505* 0,699* perda ativa de volume de líquidos 0,562* 0,265* 0,470* 0,958* 0,221* 0,875* 0,765* perda de líquidos por vias anormais 0,346* 0,136* 0,644* 0,607* 0,759* 0,720* 0,000* perdas excessivas por vias normais 0,801* 0,368* 0,276* 0,343* 0,125* 0,909* 0,945* 147 fatores associados ao diagnóstico risco de volume de líquidos deficiente em pacientes em hemodiálise l érida maria diniz-leite e outros dia e um índice de massa corporal (imc) maior que 25 kg/m² (18). diante do exposto, percebe-se que a renda familiar pode influenciar no estado nutricional tanto tendendo à desnutrição quanto ao sobrepeso, conduzindo-os, assim, aos extremos de peso. o fator associado extremo de peso apresentou associação significativa também com o volume de ultrafiltração. nesse tocante, estudiosos demonstram uma associação negativa entre sobrecarga hídrica e o índice de massa corporal (imc). desse modo, em pacientes com maior imc foi detectada a menor ocorrência da sobrecarga de volume de líquidos. em contrapartida, um índice de massa corporal inferior é conhecido por ser fortemente associado com o aumento da mortalidade na população em hemodiálise e particularmente naqueles com sobrecarga do volume de líquidos (11, 14, 19). nesse sentido, o desequilíbrio no estado hídrico desses pacientes, principalmente a sobrecarga de líquidos, demanda um aumento no volume de ultrafiltração do sangue, com vistas à retirada do líquido em excesso do organismo do paciente (14). essa realidade poderá ocasionar o volume de líquidos deficiente nesses indivíduos. no tocante à associação evidenciada no presente estudo entre perda de líquidos por vias anormais e volume de uf, destacase a própria natureza da terapia hemodialítica como produtora de alterações não fisiológicas nos fluídos corporais em decorrência de seus princípios básicos de remoção de fluídos por ultrafiltração intermitente (14). na clientela em estudo, obteve-se uma média de volume de uf de 1,93 litros, sendo que o valor mínimo obtido correspondeu àqueles pacientes cuja hemodiálise não apresentou perdas e o valor máximo encontrado foi de 4,10 litros. desse modo, a literatura mostra que quanto maior o volume de líquidos a ser removido em uma sessão, maior o risco da ocorrência de hipovolemia e hipotensão (14). estudo aponta a hipotensão como complicação mais frequente durante a sessão de hemodiálise, consequente à grande quantidade de líquidos removida do volume plasmático. no momento em que o ritmo da uf ultrapassa a capacidade de reenchimento vascular é gerada a hipovolemia e hipotensão. além disso, a diminuição da osmolaridade do plasma a partir da remoção rápida de solutos também contribui para o problema, resultando em diminuição da pressão osmótica. isso acarreta uma diminuição tanto no reabastecimento de fluídos do espaço extravascular para o intravascular, como provoca um deslocamento de fluídos do meio extracelular para o intracelular (20). diante do exposto, a identificação da associação entre os fatores associados e o diagnóstico risco de volume de líquidos deficiente e as características socioeconômicas e clínicas subsidiará as condutas e tomadas de decisão do enfermeiro nefrologista frente à prevenção do problema de enfermagem volume de líquidos deficiente, o qual possui repercussões graves na saúde física do paciente em hemodiálise. destaca-se, pois, a relevância desse tipo de estudo para o fortalecimento das taxonomias de enfermagem ao se estabelecer relações entre seus elementos constituintes e as características evidenciadas pelo paciente na prática clínica, para o qual deve ser direcionado o cuidado de enfermagem. assim, confere-se maior grau de cientificidade ao uso dos diagnósticos de enfermagem, e consequentemente proporciona um enriquecimento à profissão. como limitações deste estudo, aponta-se o fato de ter sido realizado apenas com a clientela com doença renal crônica em hemodiálise, desse modo, seus resultados não podem ser extrapolados para indivíduos com outras terapêuticas. destarte, estimula-se a realização de novos estudos que ampliem a população estudada, com vistas a contribuir para o uso dos sistemas de classificação da prática profissional. conclusão a partir do presente estudo, conclui-se que há associação entre os fatores associados do diagnóstico de enfermagem risco de volume de líquidos deficiente e determinadas características socioeconômicas e clínicas do paciente com doença renal crônica submetido ao tratamento hemodialítico. os fatores associados mais frequentes nessa clientela, e que apresentaram associação significativa, foram extremos de peso, perda de líquidos por vias anormais e deficiência de conhecimento. constatou-se que os baixos níveis socioeconômicos justificam a deficiência de conhecimento, fato que poderá acarretar dificuldades de adesão à terapêutica conservadora e consequente aumento do período de terapia dialítica, expresso em tempo de hd em meses; a perda de líquidos por vias anormais está relacionada ao volume de ultrafiltração decorrente do próprio mecanismo de perdas concernente à natureza da hemodiálise; os extremos de peso mantém relação com o status hídrico do paciente e assim influenciam o volume de ultrafiltração a ser estimado; e os extremos de peso podem ser relacionados à renda familiar, a exemplo 148 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 referências 1. herdman th. diagnósticos de enfermagem da nanda: definições e classificação – 2012/2014. 2ª ed. porto alegre: artmed; 2013. 2. herdman th, kamitsuru s. diagnósticos de enfermagem da nanda: definições e classificação 2015-2017. 10ª ed. porto alegre: artmed; 2015. 3. lindley e, keane d. are haemodialysis patients at risk of excessive dehydration? renal society of austral asia journal. 2013;9(3):110-1. 4. soares v, avelar srs, vieira mf, silva ms. composição corporal de pacientes renais crônicos em hemodiálise: antropometria e análise vetorial por bioimpedância. revlatino amenferm. 2013;21(6):1240-47. 5. brasil. ministério da saúde. secretaria de atenção à saúde. departamento de atenção especializada e temática. diretrizes clínicas para o cuidado ao paciente com doença renal crônica – drc no sistema único de saúde. secretaria de atenção à saúde. departamento de atenção especializada e temática – brasília: ministério da saúde; 2014. 6. daurgidas jt, blake pg, ing ts. manual de diálise. 4ª ed. rio de janeiro: guanabara koogan; 2008. 7. fermi mrv. diálise para enfermagem: guia prático. 2ª ed. rio de janeiro: guanabara koogan; 2010. 8. riella mc. princípios de nefrologia e distúrbios hidroeletrolíticos. 5ª ed. rio de janeiro: guanabara koogan; 2010. 9. fernandes micd, medeiros aba, macedo bm, vitorino abf, lopes mvo, lira albc. prevalência do diagnóstico de enfermagem volume de líquidos excessivo em pacientes submetidos à hemodiálise. rev esc enferm usp. 2014;48(3):446-53. 10. frazão cmfq, ramos vp, lira albc. qualidade de vida de pacientes submetidos à hemodiálise. rev enferm uerj. 2011; 19(4):577-82. 11. tapolyai m, faludi m, réti v, lengvárszky z, szarvas t, berta k. dyalisis patients fluid overload, antihypertensive medications, and obesity. asaio j. 2011; 57(6):511-5. 12. sesso rc, lopes aa, thomé fs, lugon jr, martins ct. inquérito brasileiro de diálise crônica 2014. j bras nefrol. 2016; 38(1):54-61. 13. lozano r, naghavi m, foreman k, lim s, shibuya k, aboyan v et al. global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease study 2010. lancet. 2012;380:2095-128. 14. atlanger m, hecking m, haidinger m, werzowa j, kovarik jj, paul g et al. fluid overload in hemodialysis patients: crosssectional study determine its association with cardiac biomarkers and nutritional status. bmc nephrol. 2013;14:266. 15. maldaner cr, beuter m, brondani cm, budó mld, pauletto mr. fatores que influenciam a adesão ao tratamento na doença crônica: o doente em terapia hemodialítica. revgaúcenferm. 2008;29(4):647-53. 16. costa ags, santos rmb, vitor af, araujo tl. nursing diagnosis of patients in treatment of hemodialysis in teaching hospital. rev enferm ufpe online. 2010;4(3):1477-83. 17. oliveira gtc, andrade eig, acurcio fa, cherchiglia ml, correia mitd. avaliação nutricional de pacientes submetidos à hemodiálise em centros de belo horizonte. rev assoc med bras. 2012;58(2):240-7. da desnutrição e obesidade, os quais são evidenciados como fatores predisponentes ao desequilíbrio hídrico em pacientes em hd. como limitação ressalta-se a impossibilidade de mensuração do peso seco e do ganho de peso interdialítico em todos os pacientes do estudo, tendo-se em vista que alguns pacientes apresentavam-se impossibilitados de serem pesados na balança, por não deambularem, além disso, no hospital as camas não possuíam sistema de balança, o que inviabilizou a exposição desse dado. 149 fatores associados ao diagnóstico risco de volume de líquidos deficiente em pacientes em hemodiálise l érida maria diniz-leite e outros 18. freitas atvs, vaz imf, ferraz sf, peixoto mrg, campos mivm, fornés ns. prevalência e fatores associados à obesidade abdominal em pacientes em hemodiálise em goiânia – go. j bras nefrol. 2013;35(4):265-72. 19. caravaca f, del viejo mc, villa j, gallardo mr, ferreira f. hydration status assessment by multifrequency bioimpedance in patients with advanced chronic kidney disease. nefrologia. 2011;31(5):537-44. 20. coli l, la manna g, comai g, ursino m, ricci d, piccari m et al. automatic adaptive system dialysis for hemodialysis associated hypotension and intolerance: a non controlled multicenter trial. am j kidney dis. 2011;58(1):93-100. 413 424 dialogo com equipes de saude.indd 413 larissa p. de macedo1 márcia r. cangiani fabbro2 jamile c. de castro bussadori3 graziani izidoro ferreira4 diálogo com equipes de saúde da família sobre parto no pré-natal: uma investigação comunicativa5 1 orcid.org/0000-0002-4981-6989. pontifícia universidade católica de campinas, brasil. 2 orcid.org/0000-0003-2601-8818. universidade federal de são carlos, brasil. cangiani@ufscar.br 3 orcid.org/ 0000-0002-3048-5593. universidade federal de são carlos, brasil. jamile@ufscar.br 4 orcid.org/ 0000-0002-4769-0104. universidade de brasília, brasil. gra.izidoro@aluno.unb.br 5 fonte de financiamento: iniciação científica do conselho nacional de desenvolvimento científico e tecnológico (ic/cnpq). recibido: 15 de agosto de 2016 enviado a pares: 02 de diciembre de 2016 aceptado por pares: 13 de enero de 2017 aprobado: 23 de febrero de 2017 doi: 10.5294/aqui.2017.17.4.5 para citar este artículo / to reference this article / para citar este artigo macedo l.p., fabbro m.r.c., bussadori, j.c.c., ferreira g.i. diálogo com equipes de saúde da família sobre parto no pré-natal: uma investigação comunicativa. aquichan. 2017; 17(4): 413-424. doi: 10.5294/aqui.2017.17.4.5 resumo o diálogo entre gestantes e profissionais de saúde sobre parto pode ser uma importante ferramenta para mudanças na prática de cesáreas no brasil. entretanto, a priorização desse tema no pré-natal e a forma como ele é abordado estão diretamente relacionadas à sua valorização e às dificuldades de abordagem. objetivos: analisar, junto com equipes de saúde da família, os elementos que dificultam a abordagem do parto no pré-natal. materiais e método: pesquisa qualitativa, que utilizou a metodologia comunicativa para identificar elementos facilitadores e dificultadores para o exercício de uma prática ou benefício. foram realizados grupos de discussão comunicativos com as equipes, entre 2013 e 2014. resultados: os elementos dificultadores perpassam a formação profissional, o processo e as condições de trabalho nas unidades, que interferem nas atividades educativas, na falta de articulação entre a atenção básica e a hospitalar, e nas próprias vivências pessoais dos profissionais com o tema, aspectos que influenciam negativamente a abordagem do parto. conclusões: é necessário investimento na qualificação dos profissionais nas questões referentes ao parto, com espaços de diálogo que permitam explorar as possibilidades de superação das dificuldades institucionais e expressar suas próprias vivências, a fim de desfazer mitos e crenças em relação ao parto. palavras-chave cuidado pré-natal; estratégia saúde da família; parto; pessoal de saúde; saúde materna (fonte: decs, bireme). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 413-424 414 aquichan issn 1657-5997 eissn 2027-5374 año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 413-424 diálogo con equipos de salud de la familia acerca del parto prenatal: una investigación comunicativa resumem el diálogo entre gestantes y profesionales de la salud acerca del parto puede ser una importante herramienta para cambios en la práctica de cesarianas en brasil. sin embargo, la priorización del tema en el prenatal y la forma como este es abordado están directamente relacionadas a su valoración y a dificultades de enfoque. objetivos: analizar, junto con equipos de salud de la familia, los elementos que dificultan el abordaje del parto en prenatal. materiales y método: investigación cualitativa, que utilizó la metodología comunicativa para identificar elementos facilitadores y dificultadores para el ejercicio de una práctica o beneficio. se realizaron grupos de discusión comunicativos con los equipos, entre el 2013 y el 2014. resultados: los elementos dificultadores permean la formación profesional, el proceso y las condiciones de trabajo en las unidades, e interfieren en las actividades educacionales, en la falta de articulación entre la atención básica y la hospitalaria, y en las propias vivencias personales de los profesionales con el tema, aspectos que influencian negativamente el abordaje del parto. conclusiones: se necesita inversión en la capacitación de los profesionales en cuestiones referentes al tema, con espacios de diálogo que permitan explorar las posibilidades de superación de dificultades institucionales y expresar sus propias vivencias, con el fin de deshacer mitos y creencias en relación con el parto. palabras clave cuidado prenatal; estrategia salud de la familia; parto; personal de salud; salud materna (fuente: decs, bireme). 415 diálogo com equipes de saúde da família sobre parto no pré-natal: uma investigação comunicativa l larissa p. de macedo malmegrim e outros dialogue on childbirth with family health teams during prenatal care: a communicative study abstract dialogue between pregnant women and health professionals about childbirth can be an important tool for prompting changes in the practice of cesarean deliveries in brazil. however, prioritizing this topic in prenatal care and the way it is addressed are directly related to its assessment and to the difficulties concerning the approach. objectives: analyze, in conjunction with family health teams, the elements that make it difficult to address the issue of childbirth in prenatal care. materials and method: this is a qualitative study in which the communicative methodology was used to identify elements that facilitate and/or hamper the implementation of a particular practice or benefit. communicative discussion groups were held with the teams between 2013 and 2014. results: the elements that pose difficulty permeate professional training, the process and working conditions in the health units, and interfere in educational activities, in the lack of articulation between basic and hospital care, and in the personal experiences of professionals concerning this subject. all of these aspects negatively influence the approach to childbirth. conclusions: investment in professional training on issues related to childbirth is needed, with room for dialogue that makes it possible to explore possibilities for overcoming institutional difficulties and provides professionals with an opportunity to express their own experiences in order to undo myths and beliefs with respect to childbirth. keywords prenatal care; family health strategy; birth; health personnel; maternal health (source: decs, bireme). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 413-424 416 año 17 vol. 17 nº 4 chía, colombia diciembre 2017 aquichan issn 1657-5997 eissn 2027-5374 introdução no mundo, desde a década de 1990, observa-se a crescente preocupação com a forma de nascer. no brasil, o ministério da saúde e a sociedade civil organizada têm proposto mudanças a fim de garantir boas práticas obstétricas e neonatais, bem como nascimentos mais respeitosos às mulheres e aos recém-nascidos (1). embora evidências científicas, diretrizes da organização mundial da saúde (oms) e políticas públicas (programa de humanização do parto e nascimento —phpn— e a rede cegonha) (2) há anos enfatizem a importância da humanização da assistência ao parto, o modelo de assistência obstétrica e neonatal ainda segue um modelo medicalizado e tecnocrático, que valoriza a tecnologia sobre as relações humanas e é centrado no médico. há 40 anos, o índice de cesarianas, no brasil, tem crescido, com índice atual de 52 % no geral e 88 % na rede privada (36). esses índices são considerados um fenômeno multifatorial que, além de ser determinante na morbimortalidade materna e perinatal, exige gastos desnecessários para o sistema de saúde. o avanço científico na área de obstetrícia foi muito importante, contudo o uso de tecnologias inapropriadas na assistência à gestação e ao parto medicalizaram a assistência, proporcionando um desfecho de cesarianas desnecessárias e perpetuando a cultura do medo do parto (7-12). desde o phpn, e atualmente a rede cegonha, tem-se apontado o pré-natal como um espaço de aprendizado e empoderamento da mulher; importante ferramenta para a educação em saúde na busca dessa mudança de paradigma (2, 13). nesse contexto, a assistência pré-natal deve, além de ser um espaço de rastreamento das patologias e das situações de risco gestacional, ser responsável por ações educativas (14-17). também deve promover às gestantes maior apropriação da fisiologia e da importância do parto normal, desconstruindo o senso comum de experiências negativas veiculadas socialmente (1, 17-18). a criação de vínculos e a relação de confiança entre o profissional e a gestante com melhor monitoramento da gestação são evidenciadas quando o mesmo profissional a acompanha (16). através das tecnologias leves, que valorizam o diálogo, o inter-relacionamento e a troca de saberes profissional-gestante, é possível explorar o que a gestante pensa a respeito do parto, crenças que o rodeiam, trazendo à tona o mundo da vida (19) da própria gestante, bem como o do profissional que, ao ouvir e dialogar, expõe seus pontos de vista e reflete sobre eles. para isso, é necessário que as relações entre profissionais de saúde e comunidade baseiem-se no diálogo igualitário, e não em relações de poder (20). na assistência pré-natal, no programa de saúde da família, apesar de a estratégia propor uma relação diferenciada entre usuários e profissionais, especialmente na vigilância em saúde —formas de prevenção e promoção—, pouco se tem feito, pois a percepção biologista e fragmentada do ser humano continua entrelaçada aos profissionais de saúde; no caso das gestantes, eles atuam em consultas e procedimentos mecanizados, o que torna a qualidade do cuidado intermediária (7). no brasil, 66 % das mulheres preferem o parto vaginal no início da gestação à cesariana (26,7 %), o que reflete a dissociação da postura profissional (6, 21). nesse sentido, esta pesquisa teve como objetivo analisar, junto às equipes de saúde da família, os elementos que dificultam a abordagem do tema parto no ambiente do pré-natal. os questionamentos foram: como é a formação dos profissionais? como foram suas vivências em relação ao tema parto? o que conhecem sobre o parto humanizado? materiais e métodos pesquisa qualitativa, que utilizou para o delineamento a metodologia comunicativa (22), na qual a intenção é compreender dialogicamente, pelo compartilhamento de conhecimentos, no diálogo aberto entre investigados e investigador, o objeto de pesquisa e propor recomendações para os profissionais de saúde, de gestão, entre outros. a metodologia comunicativa fundamenta-se nas elaborações da teoria da ação comunicativa de habermas (19) e da teoria da ação dialógica de paulo freire (23-24). a pesquisa foi realizada após a aprovação do comitê de ética (parecer n.˚ 26/2013), com 4 equipes de unidades de saúde da família (usf) de uma cidade do interior de são paulo (brasil), de agosto de 2013 a agosto de 2014. no momento da pesquisa, essa cidade contava com 14 usf e 17 equipes de saúde da família (esf). a princípio, o critério para a escolha da usf foi a existência de 1 grupo de gestantes na unidade, contudo o convite para participar da pesquisa foi estendido a todas as usf. 417 diálogo com equipes de saúde da família sobre parto no pré-natal: uma investigação comunicativa l larissa p. de macedo malmegrim e outros instrumentos de coleta e análise dos dados após a autorização do comitê de ética, os pesquisadores fizeram um primeiro contato com os profissionais das usf para apresentação da pesquisa e convite para a participação da equipe nela. a técnica de coleta de dados foi o grupo de discussão comunicativo (gdc), o qual busca reunir diversas pessoas pertencentes a um grupo “natural” para confrontar a subjetividade individual com a grupal e, com isso, pretende colocar em contato diferentes perspectivas, experiências e pontos de vista (22, 25). foram dois encontros com cada equipe, realizados durante as reuniões de equipe das unidades. no primeiro encontro, foi aplicado um questionário para caracterizar os profissionais que participaram da pesquisa e realizado o gdc. o roteiro do gdc continha quatro temas: o primeiro foi um vídeo disparador, construído pela autora para esse fim (disponível em: https://www. youtube.com/watch?v=iuppdrcfb4o&feature=youtu.be). o segundo tema foi as opiniões de profissionais de saúde sobre o parto; o terceiro foi as vantagens e as desvantagens do parto normal e da cesárea, e o quarto e último tema foi as dificuldades e as facilidades em falar sobre parto. no segundo encontro, foi apresentada a análise parcial dos dados aos participantes para validação. o nível básico para a análise de dados compreendeu a ordenação dos elementos que representaram dificuldades/obstáculos e aqueles que foram identificados como transformadores com relação ao tema parto no pré-natal, dispostos nas duas categorias previamente determinadas pelo método: sistema e mundo da vida, conforme a matriz final (quadro 1). para este artigo, foram selecionados os elementos dificultadores. quadro 1. matriz final resultados participaram do estudo: 2 médicos, 3 enfermeiros, 17 agentes comunitários de saúde, 5 dentistas, 1 auxiliar de enfermagem, 1 auxiliar de dentista, 1 auxiliar de limpeza, 1 educador físico, 1 fonoaudiólogo e 1 nutricionista. destes, 26 eram mulheres e 7 homens, com idades entre 25 e 58 anos, dos quais a maioria trabalha na esf há mais de cinco anos; 22 relataram ter filhos, dos quais 4 foram por parto normal e 6 com presença de acompanhante no parto. as usf foram enumeradas (usf1, usf2...) em ordem de ocorrência do grupo de discussão. a tabela 1 apresenta os elementos dificultadores emergentes da análise final; os autores a elaboraram em conjunto com os dados coletados durante a pesquisa, tendo como base o referencial metodológico. foram identificados dez elementos dificultadores relacionados ao sistema, e dez, ao mundo da vida. os elementos dificultadores relacionados ao sistema —“formação do profissional de saúde”, “modelo de atenção ao parto” e “banalização da violência obstétrica”— estão relacionados ao modelo de formação dos profissionais de saúde e ao modelo de atenção ao parto, aspectos interligados e que se refletem na assistência ao parto e, consequentemente, na maneira como os profissionais da atenção primária o veem. “existem instituições de ensino que o papel é ensinar técnica. a humanização você vai pela sua personalidade, você vai aprender na prática.” (médico 1/usf 1) “eu acho que a falta de informação [dos profissionais] é mais predominante do que a pessoa tem informação... eu acredito que mesmo que tenha acompanhamento pré-natal em consultório particular... tudo, acho que falta muita informação.” (dentista 2/ usf 4) “choca... mas não choca tanto por conta de estar acostumada […]” (enfermeira 1/usf 4, ao se referir à violência obstétrica) os elementos “pouco conhecimento dos profissionais com relação à fisiologia do parto e das leis que envolvem a gestante”, “falta de conhecimento das diferenças e das vantagens dos tipos de parto” estão interligados e apontam para a manutenção de conhecimentos errôneos quanto à definição de parto humanizado e ao direito legal do acompanhante no parto. isso favorece o surgimento do dificultador “falta de segurança e de argumentação dos profissionais ao discutirem questões de parto com a gestante”. sistema mundo da vida elementos dificultadores n1 n2 elementos transformadores n3 n4 fonte: adaptado de gómez (21). 418 año 17 vol. 17 nº 4 chía, colombia diciembre 2017 aquichan issn 1657-5997 eissn 2027-5374 tabela 1. elementos dificultadores identificados pelas equipes usf para a abordagem do tema parto com gestantes sistema mundo da vida elementos dificultadores 1. formação do profissional de saúde. 1. medo da dor do parto. 2. modelo de atenção ao parto. 2. parto normal sofre mais. 3. banalização da violência obstétrica. 3. parto visto como solitário/solidão (tanto na cesárea quanto no normal). 4. pouco conhecimento dos profissionais com relação à fisiologia do parto e das leis que envolvem a gestante. 4. falta de apoio da família no momento do parto. 5. falta de conhecimento das diferenças e das vantagens dos tipos de parto. 5. influência familiar na decisão do parto. 6. falta de conhecimento da definição de parto humanizado. 6. não ter passado pela experiência do parto. 7. falta de segurança e de argumentação dos profissionais ao discutirem questões de parto com a gestante. 7. vergonha de falar em público. 8. parto visto como procedimento muito “intervencionista”. 8. cesárea vista como um ato cirúrgico com recompensa — filho. 9. descontinuidade do trabalho realizado com a gestante na usf. 9. cesárea vista como nascimento sem sofrimento — porém denotando egoísmo da mãe. 10. cesárea como principal escolha dos profissionais de saúde. 10. humanização na dependência exclusiva da postura do profissional. fonte: elaborada a partir de dados empíricos da pesquisa. a conjunção desses fatores culmina com a formação do elemento “parto visto como procedimento muito ‘intervencionista’” e sustenta a ideia de que parto normal é ruim e “coisa” de pobre. “minha dificuldade é não saber argumentar... porque, se a gestante me disser que não quer fazer parto normal, eu não sei argumentar […]” (acs 1/usf 3) “isso é novo, né [lei do acompanhante]?! porque você larga a mulher lá e vai embora... você não pode ficar lá […]” (acs 4/usf 4) o elemento “descontinuidade do trabalho realizado com a gestante na usf” surgiu a partir da fala de alguns profissionais da usf, que, ao ouvirem queixas de puérperas quanto ao atendimento prestado na atenção hospitalar, se ressentiram de que seu trabalho foi perdido pela descontinuidade e pela falta de articulação da atenção primária com a atenção hospitalar. “no grupo de gestante, a gente viu que muitas gestantes não sabiam de muita coisa e, quando souberam, optaram por fazerem parto normal... algumas não conseguiram, né... mas é isso que eu falo, às vezes você empodera aqui e lá não... porque às vezes faz um trabalho aqui, tá muito bonito o trabalho, mas não chegou lá... então é uma barreira muito grande.” (dentista 3 /usf 3) a “cesárea como principal escolha dos profissionais de saúde” revela a influência dos serviços de saúde, em especial das crenças e dos conhecimentos dos profissionais, nas escolhas pelo tipo de parto. “no brasil, a parte cirúrgica obstétrica é a melhor do mundo, ninguém fala isso... ninguém bate nesse ponto. ah, mas o brasil faz muita cesárea! mas nós somos os melhores do mundo nisso.” (médico 1/usf1) 419 diálogo com equipes de saúde da família sobre parto no pré-natal: uma investigação comunicativa l larissa p. de macedo malmegrim e outros os elementos dificultadores do mundo da vida trazem questões subjetivas relacionadas às próprias experiências de vida e às crenças dos participantes. os elementos “medo da dor do parto”, “parto normal sofre mais” e “parto visto como solitário/solidão (tanto na cesárea quanto no normal)” revelam que o medo do parto está fortemente ligado, entre outros fatores, com o medo da dor, que é percebida como insuportável, ligada também à ansiedade que a incrementa e retroalimenta a ideia de morte. o elemento “falta de apoio da família no momento do parto”, somado à sensação de solidão, aponta para a ausência de um acompanhante e a vulnerabilidade da mulher diante do processo do parto e do nascimento, influenciando no significado da dor. “eu acho que, quando você não tem o apoio de ninguém, você se sente sozinha, a dor pode ter aumentado por isso.” (acs 6/usf 1) “[…] a gestante se sente protegida na hora que ela tem um apoio de outra pessoa. e é difícil quando você tá sozinha, porque você precisa ir atrás das coisas e não fica calma. eu acho que isso muda muito a dor.” (enfermeira 2/usf 4) os elementos “não ter passado pela experiência do parto” e “vergonha de falar em público” estão relacionados ao eu pessoal, subjetivo. em decorrência de não ter vivenciado o parto, o profissional relatou sentir-se despreparado para falar do assunto. “e também eu não vivi isso... acho que se eu tivesse passado por um parto normal, eu me sentiria mais segura em falar sobre isso pra elas […]” (acs 7/usf 3) para as profissionais de saúde que haviam realizado cesárea, houve um movimento de buscar justificativas para proteger sua decisão sobre fazer uma cesárea eletiva. os elementos do mundo da vida que se enquadraram nesse sentido foram: “cesárea vista como um ato cirúrgico com recompensa — filho” e “cesárea vista como nascimento sem sofrimento — porém egoísmo da mãe”. “uma cirurgia... alegre... porque vem um fruto daí... é um nascimento sem sofrimento! mas eu fui egoísta... era sem dor pra mim, não pra ele... hoje que eu tenho mais informação, eu faria normal também.” (asc9/usf 4) a “humanização na dependência exclusiva da postura do profissional” apareceu como elemento dificultador independentemente do nível de experiência profissional que este possui. “mas temos médicos aí que são experientes e não são humanizados. vai variar de cada pessoa, o que cada um entende de ser humano... a prática é importante... se você vivenciar mais a prática do parto humanizado, a tendência é você seguir aquela linha... mas, se a pessoa não tem isso dentro dela, como caráter dela, não é aquilo, não adianta, por mais prática que tenha, a experiência com a prática humanizada vai ajudar a fazer o parto humanizado.” (acs 10/usf 1) discussão a formação dos profissionais de saúde que participaram desta pesquisa reflete o modelo biomédico centrado na lógica reducionista e técnica, que desconsidera a perspectiva holística (14, 26). a supervalorização da tecnologia em detrimento da assistência baseada nos direitos e na dignidade dos usuários ressalta o olhar para o processo gravídico-puerperal como fenômeno biotécnico, e não como uma vivência pessoal e sociocultural (27-29). como resultado, vê-se a reprodução de técnicas sem comprovação de benefícios por evidências científicas e equipes cada vez mais despreparadas e desqualificadas (15). “estar acostumado” a situações violentas vividas pelas mulheres no período gravídico puerperal, como evidenciado pela presente pesquisa, reflete a forma como os membros da equipe veem o parto. a violência obstétrica, geralmente, não é percebida pelos profissionais como violenta, mas sim como um exercício de autoridade num contexto considerado “difícil”; no entanto, é a expressão de abuso físico, imposição de intervenções não consentidas, intervenções aceitas com base em informações parciais ou distorcidas, cuidado não confidencial ou privativo, cuidado indigno e abuso verbal, discriminação baseada em certos atributos, abandono, negligência ou recusa de assistência, discriminação social, violência verbal e física, abuso sexual e uso inadequado de tecnologia com intervenções e procedimentos desnecessários com potenciais riscos e sequelas, que, maquiados de boa prática, se tornam invisíveis no cotidiano assistencial (30-31). a insegurança dos profissionais da atenção primária em abordar o tema parto perpetua conceitos errôneos como o de que a cesárea é a forma mais segura de nascimento; além disso, viola a humanização da assistência obstétrica baseada na autonomia e em direitos. desde a assistência pré-natal, as mulheres são vistas como objeto, fora de contexto, a “máquina” é examinada 420 año 17 vol. 17 nº 4 chía, colombia diciembre 2017 aquichan issn 1657-5997 eissn 2027-5374 e não se estabelece vínculo com o profissional (8). grande parte dos médicos e profissionais da enfermagem relacionou o parto humanizado à presença de acompanhante familiar, ao atendimento às necessidades físicas e emocionais da parturiente e ao contato precoce mãe-bebê; no entanto, desconsiderou as boas práticas de assistência no parto como: alimentação durante o trabalho de parto, movimentação durante o primeiro estágio de trabalho de parto, uso de métodos não farmacológicos para o alívio da dor e monitoramento da evolução do trabalho de parto com partograma (5). os profissionais da atenção primária relatam grandes dificuldades no retorno das informações de contrarreferência da atenção hospitalar (8), aspecto semelhante aos resultados da presente pesquisa. normalmente, a informação era proveniente da própria gestante, ferindo um princípio básico do sistema único de saúde (sus): a integralidade. a ausência de informação e a não integração entre hospitais e serviços de assistência pré-natal impediu que o processo reprodutivo fosse visto em sua totalidade e favoreceu a descontinuidade na assistência materno-infantil. outros estudos referendam que os índices de cesárea são influenciados pelo modelo biomédico, a qualidade da orientação recebida pela gestante ou até mesmo a falta de informação a respeito do parto normal (28, 34), aspectos que corroboram a presente pesquisa. as dificuldades relacionadas às atividades educativas no prénatal, identificadas na presente pesquisa, reforçam a necessidade de infraestrutura física e material para o desenvolvimento de ações de educação e promoção da saúde, aspectos considerados importantes para propiciar boas práticas assistenciais (35-36). o papel educativo no pré-natal é uma importante ferramenta de influência na ca deia de crenças e opiniões sobre as vias de parto e, consequentemente, sobre a escolha final, devendo estar à altura das necessidades de informa ção das gestantes (36-37). a associação da dor do parto normal à fantasia de morte faz com que a não escolha por aquele seja uma realidade (34). para as mulheres participantes deste estudo, em especial para aquelas que passaram por experiências traumáticas no parto, a dor é vista de modo negativo, “dor de morte”: “[…] a dor do parto pra mim é uma dor de morte.” (acs 5 /usf 1) “[…] essa questão da dor é uma expectativa já gerada, uma pré dor, que a pessoa já tá lá pensando que se ficar gestante vai sofrer, vai ter dor... e, quando o filho chega, tem dor e sofre mesmo, porque é uma projeção do inconsciente.” (dentista 1/usf 1) o medo da morte pode ser acentuado pela ausência de acompanhante no trabalho de parto e nascimento, o que coloca a mulher em situação de vulnerabilidade de gênero e proporciona situações de abandono, solidão e sentimento de desrespeito (37-40). portanto, a ideia perpetuada de um parto sofrido, as experiências e as vivências anteriores, bem como a compreensão familiar, do parceiro e de outros membros do convívio social da mulher a respeito da gravidez influenciam a sua escolha pelo parto normal ou pela cesárea (28, 37). a cultura medicalizada de atenção ao parto exerce influência sobre as experiências das famílias e pode comprometer o conhecimento da mulher sobre seu próprio corpo, sua fisiologia, capacidade e autonomia, contribuindo para a crença de periculosidade do parto vaginal e potencializando a insegurança da mulher e o seu medo de tomar a decisão em prol desse parto (41). as experiências de cesáreas dos participantes da presente pesquisa oscilam entre aspectos positivos e negativos. o estudo referenciado aponta que, entre os positivos, está a associação com a ausência da dor, a rapidez do procedimento e a possibilidade de marcar uma data ou realizar uma laqueadura. entre os negativos, destacaram-se os riscos da cirurgia, as dores no pósparto, as dificuldades com a recuperação e o retorno das atividades sexuais, além de preocupações e experiências prévias com a anestesia e maiores níveis de medo e descontentamento ao lembrar do nascimento de seus filhos (12). outro elemento destacado foi o entendimento restrito do conceito de humanização da assistência à saúde. para os elementos relacionados à humanização, devem ser consideradas questões de acessibilidade ao serviço nos níveis primário, secundário e terciário de assistência, como provisão de insumos e tecnologias necessárias, formalização de sistemas de referência e contrarreferência, disponibilidade de informações e orientação da clientela e a sua participação na avaliação dos serviços (42). a humanização é muito mais do que tratar bem e com delicadeza. o cuidado humanizado no pré-natal é direcionado em sua integralidade e é importante considerar as gestantes e os familiares no conjunto social, econômico, político e cultural em que atuam e geram mudanças (26, 43, 44). 421 diálogo com equipes de saúde da família sobre parto no pré-natal: uma investigação comunicativa l larissa p. de macedo malmegrim e outros em relação à formação dos profissionais de saúde, vale destacar que, para a construção de um olhar humanístico, o ensino e a aprendizagem devem ser um processo permanente, no qual o estímulo à criatividade e à utilização de tecnologias deve também contribuir para instrumentalizar o profissional a estabelecer relações que sejam satisfatórias, tanto para ele próprio quanto para os por ele assistidos. dessa maneira, a formação profissional deve favorecer o olhar humano no desenvolvimento de competências capazes de oferecer uma assistência humanizada (14). é fundamental avaliar as demandas das mulheres bem como analisar o discurso dos profissionais de saúde, para ver como se coaduna com a proposta de humanização (29). a implementação de todos os aspectos de uma assistência humanizada também inclui uma assistência segura. diminuir as altas taxas de mortalidade materna é um dos objetivos de desenvolvimento sustentável para 2030, acordados pelos países-membro da organização das nações unidas (45). é preciso que os serviços públicos e privados de saúde obstétrica, os profissionais de saúde e a sociedade civil se unam em busca de melhores condições de assistência materno-infantil, para sejam criadas e implementadas políticas públicas de saúde que qualifiquem os serviços e atendam às necessidades das mulheres de modo universal e equânime (inclusive para as mulheres mais vulneráveis), aumentando a força de trabalho, capacitando continuamente o profissional, garantindo recursos financeiros sustentáveis, com o uso das melhores evidências para informar à prática clínica com foco nos direitos da mulher e agindo com responsabilidade ética (46). conclusão a presente pesquisa conclui que os profissionais da atenção primária, em especial da esf nas equipes pesquisadas, apresentam dificuldades para a abordagem do parto no pré-natal, o que consequentemente influenciará a qualidade da assistência prestada. essas dificuldades são de causas multifatoriais: formação da maioria dos profissionais em modelo biomédico, desconhecimento da fisiologia do parto, das boas práticas do parto, até falta de reconhecimento dos direitos das gestantes. ainda é forte a ideia de que o parto normal é ruim, “coisa” de pobre. quanto à educação em saúde e à atenção à saúde em redes, este estudo mostrou que existem fragilidades que perpassam desde a falta de espaço físico e recursos materiais para atividades educativas até a frágil articulação da atenção primária com a maternidade. do ponto de vista das histórias de vida dos profissionais, suas vivências de parto reforçam a percepção distorcida e a opção da cesárea como forma de nascimento de seus filhos. mesmos os não pais demonstram que a falta de experiência pessoal e a vergonha os tornam inseguros em falar sobre parto. a maioria dos profissionais envolvidos na pesquisa percebeu, no decorrer da pesquisa, como o mundo da vida, que compreende os relatos relacionados às vivências cotidianas das pessoas participantes, pode refletir positiva ou negativamente na assistência prestada. o diálogo igualitário, pressuposto da metodologia comunicativa, permitiu repensar as preconcepções decorrentes das experiências pessoais e profissionais, de forma que novas informações pudessem ser construídas no decorrer do próprio processo de investigação, munindo os profissionais de novas ferramentas que possibilitassem a transformação de suas realidades pessoais e profissionais. portanto, há necessidade de se investir em espaços dialógicos para a discussão do tema parto na atenção primária a fim de fazer parte do cotidiano das usf, valorizando, dessa forma, uma importante ferramenta —a educação permanente em saúde— com investimentos na qualificação dos profissionais nas questões referentes ao parto, buscando espaços de diálogo que lhes permitam explorar suas próprias vivências e desmistificar ideias que sustentem a cesárea como a melhor via de nascimento em qualquer situação. 422 año 17 vol. 17 nº 4 chía, colombia diciembre 2017 aquichan issn 1657-5997 eissn 2027-5374 referências bibliográficas 1. gomes mas. compromisso com a mudança. cad. saude publica [internet]. 2014; 30(1): 41-2. 2. brasil. ministério da saúde. portaria gm/ms n.º 1.459, de 2 de junho de 2011. institui, no âmbito do sistema único de saúde —sus—, a rede cegonha. diário oficial da união da república federativa do 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[acesso em: março de 2016]. disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=s0102311x2014001300017&lng=pt 34. weidle wg, medeiros crg, grave mtq & bosco smd. escolha da via de parto pela mulher: autonomia ou indução? cien saude colet. 2014; 22(1):46-53. doi: 10.1590/1414-462x201400010008 35. oliveira dc, mandú emt, corrêa acp, tomiyoshi jt & teixeira rc. estrutura organizacional da atenção pós-parto na estratégia saúde da família. esc. anna nery r. enferm. 2013; 17(3): 446-54. 36. guerreiro em, rodrigues dp, queiroz aba & ferreira ma. educação em saúde no ciclo gravídico-puerperal: sentidos atribuídos por puérperas. rev bras enferm. 2014; 67(1):13-21. doi 10.5935/0034-7167.20140001 37. domingues rmsm, dias mab, pereira mn, torres já, d’orsi e, pereira ape, et al. processo de decisão pelo tipo de parto no brasil: da preferência inicial das mulheres à via de parto final. cad. saude publica. 2014; (30): 101-16. 38. enderle cf, kerber npc, susin lro & gonçalves bg. parto de adolescentes: elementos qualitativos da assistência. rev esc enferm usp. 2012; 46(2): 287-94. 39. jordá dg, díaz-bernal z & álamo ma. el nacimiento en cuba: análisis de la experiencia del parto medicalizado desde una perspectiva antropológica. cien saude colet. 2012; 17(7): 1893-902. 424 año 17 vol. 17 nº 4 chía, colombia diciembre 2017 aquichan issn 1657-5997 eissn 2027-5374 40. dodou hd, rodrigues dp, guerreiro em, guedes mvc, lago pn & mesquita ns. a contribuição do acompanhante para a humanização do parto e nascimento: percepções de puérperas. esc anna nery r. enferm. 2014; 18(2): 262-9. 41. lagomarsino bs, van der sand icp, perlini mnog, linck cl & ressel lb. a cultura mediando preferências pelo tipo de parto: entrelaçamento de fios pessoais, familiares e sociais. reme — rev min enferm. 2013; 17(3): 680-94. 42. giovanella l, escorel s, lobato lvc, noronha jc & carvalho ai. políticas e sistemas de saúde no brasil. rio de janeiro: editora fiocruz; 2012. 43. malheiros pa, alves vh, rangel tsa & vargens oms. parto e nascimento: saberes e práticas humanizadas. texto contexto enferm. 2012; 21(2): 329-37. 44. brasil. ministério da saúde. secretaria de vigilância em saúde. departamento de análise de situação de saúde. saúde brasil 2011: uma análise da situação de saúde e a vigilância da saúde da mulher / ministério da saúde, secretaria de vigilância em saúde, departamento de análise de situação de saúde. brasília: editora do ministério da saúde; 2012. 45. un general assembly, transforming our world: the 2030 agenda for sustainable development. a/res/70/1. 2015. [acesso em: março de 2016]. disponível em: http://www.refworld.org/docid/57b6e3e44.html 46. koblinsky m. quality maternity care for every woman, everywhere: a call to action. lancet. 2016; 388(10057): 2307-20. [acesso em: março de 2016]. disponível em: https://www.ncbi.nlm.nih.gov/pubmed/27642018 340 358 visita restrictiva.indd 340 paulina anativia montenegro1 daniela farias-reyes2 maría alejandra galiano-gálvez3 natalia quiroga-toledo4 visita restrictiva / visita no restrictiva en una unidad de paciente crítico adulto 1 orcid.org/0000-0002-9926-2152. clínica universidad de los andes, chile. panativia@clinicauandes.cl 2 orcid.org/ 0000-0001-6605-2100. clínica las condes, chile. danielafarias.reyes@gmail.com 3 orcid.org/0000-0002-8430-3089. clínica universidad de los andes, chile. magalianog@uandes.cl 4 orcid.org/0000-0002-3853-2008. clínica universidad de los andes, chile. nquiroga@clinicauandes.cl recibido: 17 de diciembre de 2014 enviado a pares: 17 de marzo de 2015 aceptado por pares: 17 de abril de 2016 aprobado: 13 de mayo de 2016 doi: 10.5294/aqui.2016.16.3.6 para citar este artículo / to reference this article / para citar este artigo anativia montenegro p, farias-reyes d, galiano-gálvez ma, quiroga-toledo n. visita restrictiva / visita no restrictiva en una unidad de paciente crítico adulto. aquichan. 2016; 16(3): 340-358. doi: 10.5294/aqui.2016.16.3.6 resumen objetivo: buscar evidencia que responda a la pregunta ¿cuál es el impacto en el paciente, familia y personal de salud de visitas no restrictivas versus restrictivas? método: revisión sistemática. estrategia de búsqueda: 1993-2016 en cochrane library, joanna briggs, ebsco, pubmed, cinhal, trip database, con términos mesh y palabras clave. criterios de selección de artículos: revisiones sistemáticas, ensayos clínicos randomizados, no randomizados, cohortes, casos controles, estudios descriptivos correlacionales, uci adultos, español e inglés. recolección y análisis: selección inicial de 293 artículos, aplicando criterios de selección quedaron 13 artículos para análisis crítico. calidad metodológica analizada con guías caspe. resultados: la visita no restrictiva no incrementa riesgo de infección, la ansiedad del paciente es menor, la satisfacción de enfermeras es mayor, la presencia familiar ayuda a la recuperación del paciente, la familia está más informada, satisfecha y con mejor conocimiento de situación. la frecuencia de complicaciones cardiovasculares es mayor en pacientes con visitas restrictivas. conclusiones: las visitas no restrictivas en uci no generan daño al paciente, por el contrario, contribuyen a la recuperación de su salud física y emocional. palabras clave visitas a pacientes; cuidados críticos; unidades hospitalarias; enfermería de cuidados críticos (fuente: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 340-358 341 visita restrictiva / visita no restrictiva en una unidad de paciente crítico adulto l paulina anativia montenegro y otros año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 340-358 restricted/unrestricted visits to adult patients in the intensive care unit abstract objective: to search for evidence to answer the question: how do unrestricted visits affect patients, their families and healthcare professionals, as opposed to restricted visits? method: systemic review. search strategy: 1993-2016 in cochrane library, joanna briggs, ebsco, pubmed, cinhal, trip database, with mesh terms and key words. criteria for selecting articles: systematic reviews, randomized and nonrandomized clinical trials, cohort studies, control studies, descriptive correlational studies, icu adults, spanish and english. collection and analysis: initial selection of 293 articles and a final selection of 13 articles for critical analysis after applying the selection criteria. the researchers used the caspe guidelines to assess methodological quality. results: unrestricted visits do not increase risk of infection, patient’s anxiety is lower, nurses are more satisfied, family presence helps in patient recovery, families are better informed, more satisfied and have a better understanding of the situation. the frequency of cardiovascular complications is higher in patients with restricted visits. conclusions: unrestricted visits to the icu do not harm the patient but instead contribute to their physical and emotional health. key words visiting patients; critical care; hospital units; critical care nursing (source: decs, bireme). 342 aquichan issn 1657-5997 visita proibida/visita não proibida numa unidade de paciente crítico adulto resumo objetivo: buscar evidência que responda à pergunta: qual é o impacto no paciente, na família e no pessoal de saúde de visitas não proibidas versus proibidas? método: revisão sistemática. estratégia de busca: 1993-2016 em cochrane library, joanna briggs, ebsco, pubmed, cinhal, trip database, com termos mesh e palavras-chave. critérios de seleção de artigos: revisões sistemáticas, ensaios clínicos randomizados, não randomizados, coortes, casos controle, estudos descritivos correlacionais, uti adultos, espanhol e inglês. coleta e análise: seleção inicial de 293 artigos; após seleção, ficaram 13 artigos para análise crítica. qualidade metodológica analisada com guias caspe. resultados: a visita não proibida não aumenta o risco de infeção, a ansiedade do paciente é menor, a satisfação de enfermeiras é maior, a presença familiar ajuda a recuperação do paciente, a família está mais informada, satisfeita e com melhor conhecimento da situação. a frequência de complicações cardiovasculares é maior em pacientes com visitas proibidas. conclusão: as visitas não proibidas em uti não prejudicam o paciente; ao contrário, contribuem para a recuperação de sua saúde física e emocional. palavras-chave visita a pacientes; cuidados críticos; unidades hospitalares; enfermagem de cuidados críticos (fuente: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 340-358 343 visita restrictiva / visita no restrictiva en una unidad de paciente crítico adulto l paulina anativia montenegro y otros introducción el ingreso a una unidad de cuidado intensivo (uci) es un acontecimiento estresante tanto para el paciente como para la familia (1-3). la familia es el elemento esencial dentro del proceso de salud de todo individuo; por ello, cuando una persona ingresa a un hospital, la participación de esta debe ser activa para conseguir un cuidado integral y un entorno terapéutico óptimo (4). las políticas de visitas se originan en el año 1965 cuando se da lugar a la creación de las uci en estados unidos, siendo una característica importante de ellas la limitación de ingreso a los familiares, puesto que se afirmaba que las visitas generaban efectos negativos en la salud del paciente crítico por la complejidad de su condición física, su manejo y tratamiento (5). en 1979, molter realizó un estudio sobre las necesidades de los familiares de los pacientes críticos, identificando, entre otras cosas, el deseo de mantenerse cerca de su ser querido (6) . en la actualidad existe poca conciencia de esta necesidad; las uci, en comparación con otros servicios, suelen ser lugares inhóspitos, ajenos y llenos de incertidumbre para los pacientes y familiares (7); se trata, en general, de espacios cerrados y regulados por los profesionales. los tiempos limitados de visitas fueron introducidos como una medida de control, para beneficio de las instituciones y no de los individuos (8). por muchas décadas se estableció que solo pacientes hospitalizados en salas privadas o semiprivadas tenían derecho a recibir visitas sin restricción de horario (9). en los últimos cuarenta años, las uci han experimentado un gran progreso en relación con el conocimiento de las patologías del paciente crítico y las herramientas de apoyo al diagnóstico y tratamiento; sin embargo, la restricción de visitas es una práctica que se ha mantenido constante en gran parte del mundo a través de los años (8). giannini considera que la lógica detrás de este arraigado comportamiento de aislar al paciente de su familia y amigos radica posiblemente en que el objetivo de preservar la vida del paciente y su salud justifica esta especie de “secuestro” (8). los motivos que manifiesta el equipo de salud, en especial las enfermeras, para restringir las visitas, son el incremento de los riesgos de infección para el paciente (8, 10, 11), la interferencia que la familia podría ocasionar en el tratamiento al aumentar el tiempo de trabajo del equipo de salud, el incremento de los niveles de estrés para el paciente, su familia y las enfermeras, y la violación de la privacidad del paciente (8, 12, 13). hoy en día hay opiniones encontradas entre lo que el personal de salud y los pacientes creen que es la mejor práctica en cuanto a las visitas (2, 14-18). a nivel mundial, los hospitales y las clínicas tienen diferentes protocolos de visitas, los cuales son establecidos por la institución. las diferencias en estos protocolos ocasionan que los pacientes y familiares se encuentren confundidos respecto de las restricciones en los horarios de visitas (19). giannini et al., argumentan a favor de las visitas flexibles abiertas en la unidad de cuidados intensivos (uci). manifiestan que una política abierta fortalecería los lazos entre el paciente, la familia y los amigos, y permitiría que los miembros de la familia participen en el tratamiento (20). otros autores manifiestan que las visitas sin restricciones pueden mejorar la seguridad de la atención y mejorar la satisfacción del paciente y familia, especialmente en las uci (4, 21-23). estudios europeos realizados en francia (24), italia (25) y más recientemente en bélgica (26) y holanda (27), señalan políticas restrictivas de visitas en un 70 a 100 % de las uci estudiadas, en contraste con una investigación realizada en suiza que revela que el 70 % de uci no tienen restricciones respecto a las visitas durante el día o la noche (28). otros autores refieren que la evidencia reciente muestra que los pacientes con demencia y aquellos en riesgo de caídas pueden beneficiarse con el sistema de visitas abiertas (29-31). una revisión realizada en hospitales canadienses mostró que las políticas de visitas abiertas no son comprendidas a cabalidad por el personal o bien son implementadas en forma deficiente (32). a nivel de latinoamérica, específicamente en brasil, se ha estudiado la problemática de las políticas de visitas para los médicos y las enfermeras; estos refieren que el beneficio de las visitas abiertas es principalmente para el paciente en lugar de la familia o el personal de salud (33). sin embargo, otro estudio realizado en el mismo país muestra la relación positiva entre las horas de visita y la satisfacción de los familiares (p < 0,004) (34). en chile, las políticas relacionadas con el régimen de visitas a los pacientes han sido históricamente determinadas por regulaciones particulares de cada institución de salud; sin embargo, en los últimos años, desde el ministerio de salud han surgido lineamientos relacionados con esta problemática. en el 2007 surge el programa “hospital amigo”, dirigido a hospitales del sistema público de salud; su finalidad es incorporar buenas prácticas de atención centradas en el usuario, la familia y la comunidad, orientadas al trato digno, acogedor y amable (35). dentro de las actividades específicas considera la implementación de una visita diaria de familiares de a lo menos seis horas en todos los hospitales públicos del país, sin excepción, en cualquier unidad clínica del establecimiento. el éxito de esta iniciativa es variable ya que, 344 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 en su implementación, el programa ha encontrado dificultades relacionadas con la falta de liderazgo por las direcciones de los distintos hospitales y la resistencia de los funcionarios. en instituciones privadas la determinación de políticas de visitas emana de sus propias políticas internas; no obstante, en el año 2012 entró en vigencia la ley 20.584 (36), la cual establece derechos y deberes de las personas en relación con las acciones vinculadas a la atención de salud, resguardando principios básicos que deberán aplicarse en las instituciones tanto públicas como privadas. esta ley establece que las personas tendrán derecho a “compañía y asistencia espiritual, se le permita ser visitado por familiares o amigos durante su hospitalización o ir acompañado a la consulta médica o recibir orientación religiosa o espiritual si lo desea” (36); no obstante, no se refiere en forma clara a la frecuencia, la duración o los límites de estas visitas. dada la problemática expuesta, surge la necesidad de realizar una revisión sistemática sobre el tema para contribuir en la toma de decisiones al respecto. por tanto, el objetivo de este artículo es evaluar y sintetizar la mejor evidencia disponible que responda la pregunta: ¿cuál es el impacto de las visitas no restrictivas frente a restrictivas en el paciente, la familia y el personal de salud en una uci de adultos? materiales y métodos revisión sistemática de la literatura en bases de datos cochrane library, joanna briggs, ebsco, pubmed, cinhal, trip data base, beic y epistemonikos. estrategia de búsqueda bibliográfica: se realiza una búsqueda detallada entre 1993 y 2016 utilizando términos mesh “visitor to patients”, “intensive care units”, “health personnel”, “family”, “visiting policies”, con las palabras clave: “visintig hours”, “flexible visiting”. se realizan combinaciones de estas palabras clave y términos mesh utilizando el operador boleano “and”. se utilizan filtros de búsqueda según las posibilidades de cada base de datos. la primera selección de artículos se lleva a cabo por análisis del título, encontrándose 293 artículos. el detalle de la búsqueda y sus hallazgos se muestra en la tabla 1. criterios de selección de artículos: revisiones sistemáticas, ensayos clínicos randomizados, no randomizados, cohortes, casos controles, estudios descriptivos correlacionales, en uci adultos, en español, inglés y portugués, con acceso a full text. criterios de exclusión: estudios cualitativos, revisiones de la literatura, estudios realizados en pacientes pediátricos y neonatales o en unidades clínicas no intensivas. el impacto en el paciente se evalúa a través de investigaciones que consideran las preferencias del paciente, variables fisiológicas como el estado de conciencia, complicaciones infecciosas, signos vitales (presión arterial, frecuencia cardiaca, extrasístole, latidos ectópicos), variables emocionales como ansiedad o estrés en el paciente e indicadores como mortalidad, estadía hospitalaria y satisfacción usuaria. el impacto familiar se evalúa a través de investigaciones que consideran el rol de la familia y seres queridos como cuidadores del paciente, variables emocionales como ansiedad y estrés e indicadores como la satisfacción de la familia. el impacto en el personal de enfermería se evalúa a través de investigaciones que consideran las opiniones, actitudes y creencias respecto a las políticas de visitas abiertas y satisfacción del personal. en esta revisión los términos de visita “flexible” y “abierta” son empleados indistintamente. la familia se define como el grupo de individuos ligados por fuertes lazos emocionales y no solo consanguíneos. el listado inicial de artículos fue depurado, eliminándose artículos repetidos y los que no se ajustaban directamente al tema, llegando así a 84 artículos. de ellos, se eliminan 22 por no tener acceso a full text. a cada texto se le aplican los criterios de inclusión y exclusión descritos, eliminándose 49 publicaciones. de estas, 7 se descartan por corresponder a investigaciones cualitativas, 12 por no tener directa relación con el tema, 14 por ser estudios descriptivos no correlacionales, 11 por ser revisiones de la literatura, 3 por corresponder a opinión de experto y 2 por ser artículo de editorial. el proceso de búsqueda y selección inicial de artículos que se someten a análisis crítico se muestra en la figura 1. para el análisis final se seleccionan 13 publicaciones, de las cuales 2 corresponden a revisiones sistemáticas, 2 a ensayos clínicos randomizados, 2 a estudios cuasi experimentales y 7 a estudios descriptivos correlacionales (tabla 2). cuatro investigadores evalúan, en forma independiente, la calidad metodológica de cada publicación seleccionada, con el apoyo de las guías caspe correspondientes a cada diseño. resultados de los 13 artículos analizados (tabla 3) 5 (37-41) estudian con diferentes metodologías los beneficios del sistema de visitas en el paciente. el estudio de schulte (37) plantea que los pacientes con horario no restrictivo tienen, una vez terminada la visita, una frecuencia cardiaca menor. no hay diferencia estadísticamente significativa en la frecuencia de disritmias entre los grupos. el estudio de fumigalli (38) muestra una mayor contaminación por hongos y bacterias en las habitaciones de los pacientes que tie345 visita restrictiva / visita no restrictiva en una unidad de paciente crítico adulto l paulina anativia montenegro y otros nen políticas no restrictivas (p < 0,05); sin embargo, la incidencia de neumonías, infecciones del tracto urinario, sepsis generalizada y otras infecciones es similar en ambos grupos. el grupo de pacientes con visita restrictiva tiene un riesgo de edema pulmonar o shock 6,1 veces más que el grupo con visitas abiertas (or: 6,1; ic 95 %: 1,3-29,8); el riesgo de cualquier tipo de complicación cardiovascular es el doble en el grupo con visitas restrictivas (or: 2,0; ic 95 % 1,1-3,5). así mismo, en este grupo se observa que el grado de falla cardiaca medida a través del killip no varía entre el valor al ingreso a la unidad y el valor al momento del egreso (p > 0,05); sin embargo, el 58,8 % de los pacientes con visitas no restrictivas tiene una mejoría en su falla cardiaca, medida a través del descenso en la puntuación del killip entre el ingreso y el egreso de la unidad (p < 0,05). la mortalidad hospitalaria es menor en el grupo con visitas restrictivas que en el grupo sin restricción (5,2 y 1,8 % respectivamente), esta diferencia no es estadísticamente significativa. la ansiedad es similar en ambos grupos al ingreso del paciente a la unidad, pero posteriormente hay una reducción estadísticamente significativa en el grupo con visitas no restrictivas. en relación con la variable depresión, no se observa diferencia en ninguno de los dos grupos entre el ingreso a la unidad y el egreso. en el estudio de abassi (39) hay diferencia estadísticamente significativa cuando se comparan las frecuencias absolutas y relativas de la puntuación de la escala de glasgow, lo que refieren como un mayor nivel de conciencia al sexto día de realizada la intervención en favor de los pacientes del grupo expuesto al programa de estimulación. además, muestra las diferencias de puntuación media en la escala de glasgow para cada uno de los días de intervención, donde se obtiene una diferencia estadísticamente significativa en los puntajes obtenidos a partir del segundo día hasta el sexto, cuando termina la intervención. eriksson (40) muestra que la variable visita no es explicativa de la sobrevida de los pacientes ni tampoco del tiempo de estadía. no se encuentra relación entre las visitas y la mortalidad al mes, a los 3 y a los 6 meses. rodríguez (41) encuentra que el 58,7 % de los pacientes acepta la permanencia de un acompañante. la probabilidad de desear la presencia de acompañante se asocia al mayor número de veces de internación en una uci (p = 0,03) y al sexo femenino (p = 0,051). se concluye que el régimen de visita debe ser consultado individualmente, explicitando el momento en que los pacientes desean las visitas. en cuanto al efecto que tienen las políticas de visitas abiertas en el equipo de salud y familia, se encuentran 7 publicaciones (4, 42-48). el primer artículo tiene como objetivo analizar la relación entre las creencias de las enfermeras y sus actitudes sobre el efecto que la visita abierta produce en ellas, en los pacientes y la familia. las enfermeras piensan que las visitas abiertas son más beneficiosas para los pacientes (puntuación media de 3,001 [ds 0,23]) para un valor máximo de 4 y mínimo de 1; igualmente, en todas las subescalas de creencias de beneficio de visitas abiertas en el paciente, la familia y la enfermera, se obtienen correlaciones positivas y estadísticamente significativas. la investigación concluye que las enfermeras tienen un criterio unánime con respecto a la creencia de que la familia proporciona apoyo emocional al paciente, incrementa su deseo de vivir y no altera su hemodinamia. en cuanto a la familia, la visita abierta aumenta la satisfacción en esta, disminuye su ansiedad, le proporciona una mayor información y un conocimiento real de la situación del paciente. se concluye, además, que la visita abierta no incrementa el cansancio en la familia y tampoco se sienten obligados a permanecer cerca del paciente. en las enfermeras, las visitas abiertas aumentan la satisfacción profesional ya que, pese a reconocer que es una carga física y psíquica mayor, merece la pena, crea un entorno beneficioso para la recuperación del paciente y proporciona valiosa información sobre hábitos y reacciones del paciente que permiten planificar mejor los cuidados. un hallazgo importante de este estudio es que las creencias de las enfermeras en relación con los efectos positivos de las visitas abiertas se corresponden con las actitudes que ellas adoptan. la política de visitas abiertas es beneficiosa desde el punto de vista de las enfermeras. el segundo artículo, de knutsson (42), es un estudio multicéntrico correlacional que busca conocer las opiniones de las enfermeras con respecto al ingreso de niños como visitantes en las uci; los resultados muestran que el 70 % de las encuestadas afirma tener horas de visita sin restricciones, mientras que el 30 % (17) afirma que limitan las horas de visita en la institución. las principales razones dadas para la restricción de las visitas son: el riesgo de infección para el paciente y el niño (n = 27; 48 %), la condición del paciente (n = 12; 21 %) y el medio ambiente, que podría resultar aterrador para el niño (n = 10; 18 %). giannini et al. (44), en un estudio publicado en el 2013, evalúan cambios en cuanto a ansiedad y burnout en el personal de una uci antes y después de aumentar el horario de visitas, y la opinión de médicos y enfermeras en relación con el cambio de política de visitas. se reclutan 8 uci de italia, que prontamente aumentarían el horario de visitas (hasta 8 horas); el estudio muestra un alto nivel de burnout, presente en el 34,5 % de los participantes al inicio, y en el 42,6 % al año de estudio. todas las fases de la investigación muestran un predominio de burnout en enfermeras en comparación con los médicos (al inicio: 35,7 vs. 32,4 %; al año: 45,7 vs. 37,1 %). antes de la ejecución, el 81,7 % de 346 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 los médicos y el 67,7 % de las enfermeras expresan una opinión positiva (favorable o muy favorable) en relación con el cambio en la política de visitas. después de 1 año, 87 % de los médicos y 62,7 % de las enfermeras expresan una opinión positiva (p = 0,091 y p = 0,001, respectivamente). la diferencia entre médicos y enfermeras para el estado de ansiedad a lo largo del periodo de estudio resultó ser estadísticamente significativa (p = 0,015), y el nivel de burnout aumenta tanto para las enfermeras como para los médicos (p = 0,001). las enfermeras, en promedio, parten con un mayor nivel de agotamiento que los médicos y mantienen esa diferencia durante todo el periodo (p = 0,02). los sujetos con alto nivel de burnout son más propensos a expresar comentarios negativos con el cambio, comparados con los sujetos con bajo nivel (p = 0,011). el estudio de athanasiou (46) muestra que el 95 % de las enfermeras son resistentes al sistema de visitas abierto, principalmente porque les aumenta la carga laboral física y psicológica. el 75 % piensa que les obstaculiza los cuidados. los años de experiencia profesional, la dotación y los turnos nocturnos son predictores de las actitudes y creencias de las enfermeras sobre las visitas. mitchel (47) observa que, en general, la satisfacción de la familia con la atención no cambió posterior al nuevo sistema de visitas; sin embargo, el 85 % refiere estar muy satisfecho con el aumento de la flexibilidad de visitar. el 66 % de las visitas continuó dentro de las horas de visita previo a la flexibilización (11 a.m. 8 p.m.), el 24 % restante acudió en el horario ampliado. las familias reconocen la prioridad de la atención al paciente frente a sus necesidades personales. jacob (48) recoge datos de 41 miembros de la familia antes de la introducción de visita flexible y 140 miembros de la familia después de que fue introducida. en ambos periodos las familias refieren satisfacción en casi la totalidad de los ítemes del instrumento fs-icu. el puntaje más bajo fue en la “toma de decisiones”, con la pregunta: ¿usted tiene control sobre el cuidado de su familiar? los ítemes más altos obtenidos en ambos periodos de tiempo estaban en el “cuidado”. hubo diferencias significativas en las subcalificaciones o puntuaciones totales fs-uci antes y después del cambio. la satisfacción con el ambiente en la sala de espera fue menor en visitas flexibles (p < 0,05) y también en la satisfacción con la cantidad de la atención (p < 0,01). dos de los estudios revisados críticamente corresponden a revisiones sistemáticas, smith (45) y ciufo (19). la primera se centra en publicaciones que tienen relación con creencias y actitudes de los pacientes, familiares y enfermeras respecto a las horas de visita, su percepción acerca del impacto de los actuales modelos de visita de las uci, y explica la congruencia de las políticas de visita con los principios del modelo de atención centrado en el paciente y la familia (pfcc). la revisión incluye 13 artículos: 6 estudios cualitativos y 7 estudios cuantitativos, de los cuales 6 son estudios descriptivos correlacionales y uno de pre y posintervención. el análisis de los artículos cuantitativos muestra que las políticas flexibles de visita en ciertas situaciones son mejores para conocer las necesidades del paciente, de la familia y de la enfermera (fallecimiento del paciente, situaciones en que la familia necesita utilizar otro horario de visita, o casos en que esta puede entregar información relevante para el cuidado a la enfermera). se observa que la falta de cumplimiento de las políticas de visita causa confusión y conflicto entre los familiares y las enfermeras. en 4 estudios las políticas de visitas abiertas permiten la transferencia de importante información entre los pacientes, sus familiares y el equipo de enfermería. finalmente, se señala que un pequeño porcentaje de enfermeras cree que el cuidado de enfermería mejora con la inclusión de la familia. algunas investigaciones informan preferencia de las enfermeras por las visitas restrictivas. la segunda revisión sistemática trata sobre el impacto fisiológico, psicológico o emocional de las políticas de visitas en pacientes pediátricos y adultos, y en sus familiares. analiza 15 estudios de diferentes países y con distintas metodologías, donde la uci fue el escenario en la mayoría de ellos. los estudios son de calidad metodológica variada. plantean finalmente que la evidencia sugiere que las políticas de visitas abiertas pueden ser beneficiosas para los pacientes y sus familias en términos de aumento de satisfacción y de disminución de la ansiedad, sobre todo en las uci. resumen de la calidad de la evidencia la publicación de schulte (37) considera una muestra de 25 pacientes, 13 del grupo sin restricción horaria y 12 con restricción. no se especifica el tamaño muestral necesario como tampoco la población que se va a estudiar. los grupos son similares en relación con edad; sin embargo, al comparar la gravedad de la patología coronaria medida a través de la presencia de infarto agudo al miocardio, se observa una diferencia estadísticamente significativa. para efectos de esta revisión se considera que el tamaño de la muestra, la disparidad en los grupos en relación con la gravedad de la enfermedad coronaria, así como la falta de control de variables intervinientes (como fármacos antiarrítmicos y betabloqueadores), afectan la validez de esta evidencia. el estudio de fumigalli (38) tiene una validez interna sólida debido a la metodología con la cual se llevó a cabo; no obstante, posiblemente el tamaño de la muestra influyó en que los resultados 347 visita restrictiva / visita no restrictiva en una unidad de paciente crítico adulto l paulina anativia montenegro y otros relacionados con la mortalidad no fueran estadísticamente significativos. el estudio de abbasi, mohammadi, sheaykh (39) utiliza una buena metodología, pero estos resultados se invalidan ya que para realizar el análisis de datos se utiliza erróneamente la variable respuesta como variable cuantitativa continua, siendo esta cualitativa ordinal. en el estudio de ericksson (40) , no se realiza una aleatorización para extraer la muestra, lo que posiblemente contribuye a que en los grupos se encuentren diferencias estadísticamente significativas en torno a las variables sexo, edad y nems (escala para valorar la carga de trabajo). el sesgo de selección de la muestra no permite la extrapolación de los resultados. en el estudio de rodríguez y fernández de souza (41), el diseño es acorde a lo que pretenden los investigadores que es relacionar variables. estas se encuentran claramente definidas. la forma de obtención de la muestra no queda clara, como tampoco el tamaño de la población de la cual se obtuvo, lo que dificulta en parte poder evaluar si esta muestra es representativa de la población en estudio. la recolección de datos se realiza a través de una entrevista estructurada a los pacientes para lo cual se creó un instrumento simple y poco elaborado, el cual no tiene prueba piloto. por las características de este diseño los resultados obtenidos no pueden ser extrapolados a otras realidades, y se limitan a una validez local. landa et al. (4) realizan un estudio descriptivo correlacional, en el cual se especifica claramente el objetivo pero no queda clara la definición de las variables actitud y creencias, lo que constituye una falencia teniendo en cuenta la amplitud de definiciones que estos términos pueden llegar a tener. la muestra queda conformada por 46 enfermeras de uci, todas ellas mujeres ya que el personal es solo femenino y corresponde al 100 % de las enfermeras de la unidad; en este caso, la muestra es la población. para la recolección de datos se utiliza un instrumento, con una escala de likert, constituido por 26 ítems divididos en 3 subescalas, la primera de ellas se refiere al efecto que la visita abierta produce en el paciente; la segunda, al efecto que produce en la familia y, por último, al efecto en la enfermera y la unidad, además de 2 preguntas con respuesta dicotómica, una sobre experiencias previas de visitar un familiar cercano en una uci y otra que explora la satisfacción con el actual sistema de visitas, y una pregunta abierta sobre el sistema actual de visitas en la que se solicita añadir otros aspectos positivos o negativos que no hubiesen sido considerados y, finalmente, un ítem de sugerencias. para analizar la actitud de las enfermeras hacia el efecto que la visita abierta tiene en pacientes, familias y enfermeras se utiliza una escala semántica diferencial de 7 grados, a la cual se le calcula la media de toda la escala, así como de las subescalas. una puntuación elevada (máximo de 7) indica una actitud positiva hacia el efecto favorable de la visita abierta. el instrumento de recolección de datos para las creencias se elabora con base en resultados obtenidos en otro estudio y la escala para medir actitudes es la misma que utilizan estos autores, es un instrumento consistente y elaborado que permite de buena manera recolectar la información que se requiere para el análisis posterior. los resultados obtenidos fueron muy bien analizados y no se observa deficiencia en ellos. dada la rigurosidad del estudio y su metodología, los resultados son válidos pero no se puede asegurar que estas conclusiones puedan ser extrapoladas a otras realidades y culturas. el trabajo de knutsson y bergbom (42) invita a participar a todas las uci de la localidad (72 unidades), solo 57 entregan los formularios completos. la elección de los profesionales que debían contestar la encuesta en cada unidad no se realiza en forma aleatoria, sino por designación del jefe de unidad. para la recolección de datos los investigadores construyen un instrumento, el cual validan con una prueba piloto antes de la investigación. si bien este es un estudio multicéntrico, la forma intencional de selección de la muestra, la pérdida de centros que la conforman y la falta de información estadística respecto a la similitud de los grupos estudiados en relación con sus características sociodemográficas u otras variables que pudieran alterar los resultados, afectan su representatividad perdiendo validez interna y externa. en el año 2011 se publica una revisión sistemática (19), cuyo objetivo es analizar los modelos de visita en las unidades de pacientes críticos adultos en el contexto del modelo de atención centrado en el paciente y la familia (pfcc). la revisión incluye mayoritariamente estudios descriptivos correlacionales y cualitativos. la búsqueda realizada para esta revisión sistemática es muy ordenada y exhaustiva, entrega una primera aproximación al tema analizado, al considerar en su mayoría estudios descriptivos y cualitativos; la validez de sus conclusiones es débil de acuerdo con la clasificación de la evidencia de sackett (43). el estudio de giannini (44) explica claramente la selección de la muestra, no aleatoria, pero con un buen porcentaje de respuesta. se utiliza un instrumento probado y validado para medir las variables por estudiar: el maslach burnout inventory-jackson y el inventario de ansiedad estado-rasgo antes de un cambio de política (t0), a 348 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 los 6 meses (t1) y 12 meses (t2), previo consentimiento informado. la medición del burnout se mantuvo ciega. los análisis se ajustan para los principales factores de confusión (edad, sexo, centro, nivel educativo y estado civil, experiencia en la uci, nivel básico de agotamiento o ansiedad, y la tasa de mortalidad). la revisión sistemática de smith et al. (45) comprende 15 estudios con variados diseños de investigación cuantitativos, e incluye 3882 participantes que cumplen con los criterios de inclusión. los estudios son de calidad metodológica variada, un ensayo piloto aleatorio, dos estudios cuasiexperimentales, ocho estudios descriptivos / encuestas transversales y cuatro cuestionarios pre y posintervención. la uci fue el escenario de la mayoría de los estudios y los participantes se conforman por pacientes y enfermeras de uci y maternidad. metodológicamente cumple con los requisitos estipulados para ser una buena revisión sistemática, el mayor problema es el tipo de estudios encontrados y su calidad metodológica. el estudio de athanasiou (46) tiene claramente explícitos el propósito y los objetivos, explora las creencias y actitudes de las enfermeras hacia las visitas y las creencias sobre el efecto en los pacientes, familias y personal de la uci. las variables definidas fueron muestreo por conveniencia de 6 hospitales de atenas (3 públicos y 3 militares), lo que afecta su validez externa. de 226 enfermeras, el 63,3 % responde un cuestionario anónimo y validado previamente. el análisis estadístico es claro y completo. el estudio en general es riguroso en cuanto a su metodología. el trabajo de mitchell (47) está basado en la filosofía de la atención centrada en la familia. como objetivos busca conocer la satisfacción de la familia, el paciente y el personal de salud con una política de visitas abiertas. utiliza metodología mixta antes y después a la implementación de visitas abiertas. solo para evaluar a la familia se utilizó metodología cuantitativa, con versión modificada de encuesta fs-icu. el grupo de familia encuestado posimplementación de visitas abiertas es considerablemente mayor que el de visitas restringidas (140 vs. 41), sin describir los motivos de esa diferencia. se señala que ambos grupos fueron similares en relación con características demográficas, sin ofrecer datos estadísticos. el estudio de jacob (48) tiene objetivos claros, busca conocer las necesidades de los familiares y el grado de satisfacción de estos en una uci neurológica. tiene variables definidas. muestra intencional, relata grupos con características similares, no lo muestra estadísticamente. utilizaron 2 instrumentos validados en otras investigaciones (ccni y fs-icu), este último fue utilizado parcialmente por considerar las preguntas redundantes en comparación con el otro cuestionario y se manipula la escala de los autores para realizar cálculos de medias y sd. se agregaron preguntas desarrolladas por los investigadores. la muestra final (n = 45) se obtuvo de forma no aleatoria y no hay claridad de la representatividad de esta. estas características le restan validez al estudio. conclusiones la política de visitas de las uci es una cuestión controvertida y frecuente objeto de estudios que han suscitado numerosos debates. la diversa procedencia de los estudios refleja que esta problemática es de interés global y que aún no se encuentra resuelta, estando sujeta a políticas locales. a la luz de la evidencia encontrada se puede concluir que las visitas flexibles en las uci no generan daño a los pacientes, por el contrario, contribuyen a la recuperación de su estado de salud físico y emocional. los familiares en general refieren mayor satisfacción con el sistema de visitas abierto. sin embargo, en las enfermeras hay discrepancia en relación con la satisfacción que brindan las visitas abiertas. debido a que la naturaleza de la problemática de las visitas en estas unidades se relaciona, no solo con el estado de salud físico del paciente, sino también con aspectos culturales propios de cada país, y debido a que en latinoamérica existe escasa publicación sobre esta temática, se torna aún más relevante generar investigaciones en nuestro medio. uno de los principales hallazgos de esta revisión es que, aunque existe bibliografía sobre el tema, hay pocos estudios de calidad que determinen el impacto de una política de visitas abiertas en las unidades de cuidados intensivos de pacientes adultos, por lo que sería recomendable la realización de ensayos clínicos aleatorizados o cohorte con un tamaño de muestra adecuado. es necesario generar nuevas investigaciones que nos aporten mayor evidencia respecto al efecto en la satisfacción y el estado emocional de los seres queridos que visitan pacientes adultos en las unidades de cuidados intensivos. 349 visita restrictiva / visita no restrictiva en una unidad de paciente crítico adulto l paulina anativia montenegro y otros referencias 1. errasti-ibarrondo b, tricas s. la visita flexible en las unidades de cuidados intensivos: beneficios para los familiares del paciente crítico. enferm intensiva. 2012;23(4):179-188. 2. gibson v, plowright c, collins t, dawson d, evans s, gibb p, et al. position statement on visiting in adult critical care units in the uk. nursing in critical care. 2012;17(4):213-218. 3. khaleghparast s, joolaee s, ghanbari b, 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1993;2(2):134-6. 38. fumagalli s, boncinelli l, lo nostro a, valoti p, baldereschi g, di bari m, et al. reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit: results from a pilot, randomized trial. circulation. 2006;113(7):946-52. 39. abbasi m, mohammadi e, sheaykh a. effect of a regular family visiting program as an affective, auditory, and tactile stimulation on the consciousness level of comatose patients with a head injuri. jpn j nurs sci. 2009;6(1):21-6. 40. eriksson t, bergbom i. visits to intensive care unit patients frecuency, duration and impact on outcome. nurs crit care. 2007;12(1):20-6. 41. rodrigues m, fernandes de souza m. acompanhante de adulto na unidade de terapia intensiva: uma visao do paciente. acta paul enferm. 2006;19(2):138-43. 42. knutsson s, bergbom i. nurses and physicans viewpoints regarding children visisting/not visiting adult icus. nurs crit care. 2007;12(2):64-73. 351 visita restrictiva / visita no restrictiva en una unidad de paciente crítico adulto l paulina anativia montenegro y otros 43. sackett dl, wennberg je. choosing the best research design for each question. bmj. 1997;315(7123):1636. 44. giannini a, miccinesi g, prandi e, buzzoni c, borreani c. partial liberalization of visiting policies and icu staff: a beforeand-after study. intensive care med. 2013;39(12):2180-7. 45. smith l, medves j, harrison m, tranmer j, waytuck b. the impact of hospital visiting hour policies on pediatric and adult patients and their visitors. jbi library of systematic reviews. 2009 [citado 2012 nov 16];7(2):38-79. disponible en: http://www.joannabriggslibrary.org/index.php. 46. athanasiou a, papathanassoglou e, patiraki e, mccarthy m, giannakopoulou m. family visitation in greek intensive care units: nurses’ perspective. am j crit care. 2014;23(4):326-33. 47. mitchell m l, aitken lm. flexible visiting positively impacted on patients, families and staff in an australian intensive care unit: a before-after mixed method study. aust crit care. 2016 [citado 2016 abril 10]; article in press. disponible en: http://dx.doi.org/10.1016/j.aucc.2016.0. 48. jacob m, horton c, rance ashley s, field t, patterson r, johnson c, et al. needs of patients family members in an intensive care unit with continuos visitation. am j crit care. 2016;25(2):118-25 figura 1 resumen de búsqueda y selección de artículos búsqueda en bases de datos y análisis de títulos eliminación artículos repetidos o sin abstract eliminación publicaciones por criterios de selección o ausencia de full text 1era selección: 293 publicaciones 2da selección: 84 publicaciones selección final: 13 publicaciones fuente: elaboración propia. 352 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 tabla 1. estrategia de búsqueda palabra clave operador boleano palabra clave filtro número de artículos encontrados visintig hours and visiting polices* excluye pacientes pediátricos 138 family* and intensive care units* pacientes adultos 23 family* and flexible visiting* pacientes adultos 17 visitors to patients* and intensive care unit* no 18 visitors to patients* and family* no 14 visitors to patients* and intensive care units* revisiones sistemáticas, ensayos clínicos randomizados, estudios de cohorte y casos control 39 visiting polices* and intensive care unit* no 28 visitors to patients* and visiting hours* no 6 visitors to patients* and health personnel* no 10 total 293 * término mesh fuente: elaboración propia. 353 visita restrictiva / visita no restrictiva en una unidad de paciente crítico adulto l paulina anativia montenegro y otros tabla 2. características de artículos seleccionados para análisis crítico autor / revista título diseño / muestra ciufo d, hader r, holly c. international journal of evidence based healthcare. 2011; (9):362-387. a comprehensive systematic review of visitation models in adult critical care units within the context of patient and family-centred care. revisión sistemática. se analizan críticamente 13 artículos a través de jbi-qari. abbasi m, mohammadi e, rezay a. japan journal of nursing science. 2009; 6:21-26. effect of a regular family visiting as an affective, auditory and tactile stimulation on the consciousness level of comatose patients with a head injury. ensayo clínico aleatorio. grupo control (n = 25), grupo intervención (n = 25). schulte d, burrell l et al. american journal of critical care. 1993;2:134136. pilot study of the relationship between heart rate and ectopy and unrestricted vs restricted visiting hours in the coronary care unit. cuasi experimental. grupo a (n = 13), grupo b (n = 12). fumigalli et al. circulation. 2006;113:946-952. reduced cardiocirculatory complications with unrestrictive visiting policy in an intensive care unit: results from a pilot, randomized trial. ensayo clínico. grupo visitas restringidas (n = 115), grupo visitas no no restringidas (n = 111). knutsson s, otterberg c, bergbom i. intensive and critical care nursing. 2004;20:264-274. visits of children to patients being cared for in adult icus: polices, guidelines and recommendations. estudio multicéntrico descriptivo correlacional (n = 56). rodrigues marcia, fernandes de souza. acta paulista de enfermagem. 2006;19(2):138-143. acompanhante de adulto na unidade de terapia intensiva: uma visao do paciente. estudio correlacional (n = 138). eriksson t, bergbom i. nursing in critical care. 2007;12(1):20-26. visits to intensive care unit patients-frecuency, duration and impact on outcome. estudio correlacional (n = 198). landa m, eguia b, fernandez de pinedo g, adot s, coscojuela m, erro a. enfermería intensiva. 2000;11(3):107-117. creencias y actitudes de las enfermeras de cuidados intensivos sobre el efecto que la visita abierta produce en el paciente, familia y enfermeras. estudio correlacional (n = 46). giannini a, miccinesi g, prandi e, buzzoni c, borreani c. intensive care med. 2013; 39:2180-2187. partial liberalization of visiting policies and icu staff: a before-and-after study. estudio cuasi experimental, antes, después (n = 198). smith l, medves j, harrison m, tranmer j, waytuck b. jbi library of systematic reviews. 2009;7(2):38-79. the impact of hospital visiting hour policies on pediatric and adult patients and their visitors. revisión sistemática. se analizan críticamente 15 artículos a través de jbi-qari. athanasiou a, papathanassoglou e, patiraki e, mccarthy m, giannakopoulou m. am j crit care. 2014; 23(4):326-333 family visitation in greek intensive care units: nurses’ perspective estudio correlacional (n = 143) 354 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 autor / revista título diseño / muestra mitchell m l, aitken lm. aust crit care 2016. flexible visiting positively impacted on patients, families and staff in a australian intensive care unit: a beforeafter mixed method study. estudio observacional de metodología mixta, pre y posintervención (pacientes n = 12, familiares n = 181; personal n = 24) jacob m, horton c, rance ashley s, field t, patterson r, johnson c, et al. american journal of critical care. 2016;25(2):118-125. needs of patients family members in an intensive care unit whith continous visitation estudio observacional, n= 45 familiares de pacientes hospitalizado en una uci neurológica de pacientes adultos. fuente: elaboración propia. 355 visita restrictiva / visita no restrictiva en una unidad de paciente crítico adulto l paulina anativia montenegro y otros tabla 3. resumen de resultados de los artículos y del análisis crítico según guías caspe autor resumen de resultados aspectos relevantes del análisis crítico según diseños ciufo d, hader r, holly c. las visitas flexibles son mejores para conocer las necesidades del paciente, la familia y la enfermera, permiten transferencia de información. un porcentaje de enfermeras cree que el cuidado mejora con la inclusión de la familia. algunos estudios informan preferencia de las enfermeras por visitas restrictivas. estudios principalmente descriptivos. estrategia de búsqueda muy detallada y exhaustiva en importantes bases de datos entre 1988 y 2009. análisis crítico realizado con instrumentos de revisión del jbi. al considerar en su mayoría estudios descriptivos y cualitativos se ve afectada la fuerza de la evidencia. abbasi m, mohammadi e, rezay a. se encuentra diferencia estadísticamente significativa al comparar frecuencias absolutas y relativas de puntuación de escala de glasgow al sexto día de realizada la intervención en favor de los pacientes del grupo expuesto al programa de estimulación. se calcula el promedio del estado de conciencia según la escala de glasgow en ambos grupos durante 6 días de intervención encontrándose diferencia estadísticamente significativa. asignación aleatoria, seguimiento de 6 días, se explica claramente intervención y mediciones con doble ciego. grupos iguales. metodología rigurosa, hay resultados que no son válidos ya que la variable respuesta se trabaja como variable cuantitativa, siendo cualitativa. schulte d, burrell l et al. no hubo diferencias significativas en las tasas de contracciones ventriculares prematuras y contracciones auriculares prematuras entre los dos grupos. los pacientes con visitas sin restricciones tienen una frecuencia cardiaca significativamente menor después de las visitas que los pacientes con visitas restringidas. aleatorización no explícita. muestra escasa. no se explicita seguimiento, pacientes analizados en grupo asignado, no se explicita enmascaramiento. no queda claro si fueron tratados igual en ambos grupos aparte de intervención. grupos no similares. fumigalli et al. no hay diferencia estadísticamente significativa en la incidencia de infecciones entre los grupos. el 58,8 % de los pacientes con visitas no restrictivas presenta una mejoría en su falla cardiaca entre ingreso-egreso y menor ansiedad (p < 0,05). grupo con visitas restrictivas tiene mortalidad hospitalaria menor, diferencia no significativa, frecuencia de edema pulmonar o shock 6,1 veces más que el grupo con visitas abiertas y la presencia de cualquier tipo de complicación cardiovascular es aproximadamente el doble. la hormona tsh, cortisol plasmático y excreción de un metabolito de las cetecolaminas, muestra para ambos grupos un descenso estadísticamente significativo entre los valores al ingreso y egreso. la asignación a los grupos fue aleatoria e impredecible, el seguimiento fue suficiente para el tema estudiado. autores explicitan enmascaramiento y que ambos grupos son iguales salvo en la intervención. todos son analizados en sus grupos iniciales. esta publicación tiene una validez interna sólida, debido a la metodología con la cual se llevó a cabo. 356 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 autor resumen de resultados aspectos relevantes del análisis crítico según diseños knutsson s, otterberg c, bergbom i. 30 % de encuestadas relata visitas de niños restringidas. razones: apariencia del paciente, ambiente atemorizante, riesgo de infección, molestias causadas por niños. diferencia estadísticamente significativa dado que el ruido ocasionado por niños perturba trabajo, siendo mayor en grupo médico. mayor restricción a menores de 3 años. cansancio del paciente y apariencia, son lo que justifica, en opinión de enfermeras, restricción a niños, esta opinión es menor en médicos (p < 0,05). estudio multicéntrico, muestreo no probabilístico intencional, la fuente de información es una enfermera por cada establecimiento estudiado. mayoritariamente hay descripción de resultados lo que contribuye a conocer una realidad específica. rodrigues marcia, fernandes de souza el 58,7 % de pacientes de acuerdo con visitas. la correlación es significativa entre desear la presencia de acompañante y el número de veces de internamiento en la uci (p = 0,03). los datos son significativos entre el querer acompañante y ser del sexo femenino (p = 0,051), las demás variables no son estadísticamente significativas. no hay aleatorización en la selección. la recolección de datos fue a través de una encuesta. no hay mayores explicaciones en cuanto a la metodología. por las características de este diseño, los resultados obtenidos no pueden ser extrapolados a otras realidades y se limitan a una validez débil y local. eriksson t, bergbom i. visitas más frecuentes por parte del cónyuge (23 %); 25 % no tiene visitas durante la estadía. duración promedio de 9 horas. pacientes sometidos a ventilación mecánica por más de 9 días (p = 0,0001) o que han permanecido intubados por más de 5 días (p = 0,0035) reciben visitas más duraderas. cuando paciente permanece en uci por más de 7 días aumenta frecuencia y duración de visitas (p = 0,0001). selección de muestra no aleatoria. grupos no son iguales y resultados no se controlan por esas diferencias. para recolección de algunas variables se utiliza cuestionario elaborado por investigadoras y dos instrumentos validados. recolección de datos se llevó a cabo en 8 meses. no se explicita enmascaramiento. landa m, eguia b, fernandez de pinedo g, adot s, coscojuela m, erro a. correlación positiva entre creencias y actitud (r = 0,523, p < 0,0001), correlaciones significativas y positivas entre cada subescalas (paciente r = 0,427, p = 0,003; familia r = 0,476, p = 0,001; enfermera r = 0,354, p = 0,016). asociación estadísticamente significativa entre actitud y tener hijos (p = 0,03). las visitas abiertas aumentan satisfacción profesional en enfermeras y proporcionan valiosa información sobre hábitos y reacciones del paciente. satisfacción con el sistema actual de visitas, 42 enfermeras (93,3 %) contestaron afirmativamente y tres (6,7 %) negativamente. se describe claramente cómo se medirán las variables e instrumentos. recogida de datos por dos miembros del equipo investigador. para minimizar los sesgos en la recogida de datos, esta se hizo en un periodo de 48 horas y se solicitó a las participantes no hacer ningún comentario al respecto hasta que enfermeras hubiesen contestado el cuestionario. estudio riguroso y con fuerte validez interna. 357 visita restrictiva / visita no restrictiva en una unidad de paciente crítico adulto l paulina anativia montenegro y otros autor resumen de resultados aspectos relevantes del análisis crítico según diseños giannini a, miccinesi g, prandi e, buzzoni c, borreani c. se estudia antes del cambio de política de visita (t0), a los 6 meses (t1) y 12 meses (t2). niveles altos de burnout en 34,5 % de participantes en t0 y 42,6 % en t2 (ajustado p = 0,001). las tres fases muestran alto burnout entre las enfermeras (ajustada p = 0,002). la mayoría considera que el cambio es positivo en t0 (81,7 % médicos; enfermeras 67,7 %) y t2 (médicos 87,0 %; enfermeras 62,7 %). los sujetos con alto burnout son más propensos a comentar negativamente (p = 0,011). nueva política se asocia con nivel de agotamiento de funcionarios. médicos, enfermeras ven política abierta positivamente y mantienen opinión después de 1 año. estudio cuasi experimental donde un 77 % de funcionarios de una uci responde todas las fases del estudio (3). se explicitan claramente las variables por estudiar y la recolección de la información, utilizando instrumentos validados y muy bien detallados. hay enmascaramiento. el seguimiento es suficientemente largo. validez interna aceptable. smith l, medves j, harrison m, tranmer j, waytuck b. resultados inconsistentes entre los estudios. la liberación de horas de visitas no aumenta las complicaciones sépticas. las visitas abiertas otorgan beneficios a los pacientes y familias en términos de aumento de satisfacción y disminución de la ansiedad. concluye realizar estudios metodológicamente mejores. revisión sistemática. estudios con diseños variados, de distintos países. un diseño experimental y dos cuasiexperimentales. estrategia de búsqueda explícita desde 1995 al 2007, en importantes bases de datos. se detallan características de poblaciones y outcomes. metodología para análisis realizado por dos revisores, desacuerdos se consultan. athanasiou a, papathanassoglou e , patiraki e, mccarthy m, giannakopoulou m. las enfermeras estudiadas son resistentes a visitas abiertas (94,4 %). el 87,5 % refiere que las visitas abiertas les aumentarían la carga laboral y el 75,5 % piensa que les obstaculizaría los cuidados. los años de experiencia de trabajo, dotación de personal y el número de turnos nocturnos por 15 días fueron predictores de las actitudes y creencias acerca de las visitas. estudio correlacional. objetivos variables explícitos. muestra por conveniencia de 6 hospitales. recolección de información de forma ciega para investigadores, n = 143 enfermeras, cuestionario anónimo y validado. estudio riguroso. mitchell m l, aitken lm. no se observaron diferencias estadísticamente significativas en la puntuación total del nivel de satisfacción de la familia pre y posintervención (p = 0,3). sin embargo, la satisfacción de los familiares respecto del ambiente en la sala de espera fue peor en el grupo con horario flexible (p = 0,03) y la satisfacción de la familia con la cantidad de tiempo que dedica el personal al cuidado del paciente fue significativamente mayor en este mismo grupo (p < 0,01). estudio observacional mixto. objetivos claros, busca conocer satisfacción en familiares, pacientes y personal de una política abierta. metodología cuantitativa, instrumento validado solo para el análisis en la familia. familiares posintervención mayor que el preintervención (140 vs. 41). señala que grupos fueron similares, sin datos con significancia estadística. 358 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 autor resumen de resultados aspectos relevantes del análisis crítico según diseños jacob m, horton c, rance ashley s, field t, patterson r, johnson c, et col. las necesidades más importantes identificadas fueron las relacionadas con la información del paciente, las visitas, recibir esperanza, hablar con un médico todos los días, y estar seguro de que su paciente recibe la mejor atención. las necesidades menos importantes se relacionan con el confort físico de los familiares. el grado de satisfacción mayor se observó con el cuidado entregado por las enfermeras y los médicos, la cortesía y el respeto entregado al paciente y la familia. estudio observacional, muestra intencional. objetivos claros. busca conocer necesidades de familiares y grado de satisfacción en uci. se utilizaron 2 instrumentos validados (ccni y fs-icu), este último fue utilizado parcialmente y se manipula la escala de los autores para realizar cálculos de medias y sd. se agregaron también preguntas desarrolladas por los investigadores. la muestra final (n = 45) se obtuvo de forma no aleatoria y no hay claridad de la representatividad de esta. fuente: elaboración propia. 257 269 los grupos de sintomas en personas.indd 257 gloria mabel carrillo-gonzález1 los grupos de síntomas en personas con cáncer: una revisión integrativa2 1 orcid.org/0000-0003-4513-104x. universidad nacional de colombia, colombia. gmcarrillog@unal.edu.co 2 trabajo desarrollado en el marco de la tesis de doctorado en enfermería: grupos de síntomas en adultos con cáncer gástrico sometidos a gastrectomía. facultad de enfermería, universidad nacional de colombia, bogotá (colombia). recibido: 09 de abril de 2016 enviado a pares: 10 de junio de 2016 aceptado por pares: 10 de octubre de 2016 aprobado: 02 de noviembre de 2016 doi: 10.5294/aqui.2017.17.3.3 para citar este artículo / to reference this article / para citar este artigo carrillo-gonzález gm. los grupos de síntomas en personas con cáncer: una revisión integrativa. aquichan. 2017; 17(3): 257-269. doi: 10.5294/aqui.2017.17.3.3 resumen objetivo: explorar el estado actual de desarrollo investigativo del área temática de grupos de síntomas en adultos con cáncer. método: revisión integrativa de producción científica generada entre 2001 y 2016. se incluyeron 61 artículos por su aporte en la comprensión del área temática. resultados: el estudio de los grupos de síntomas en personas con cáncer se consolida como un área temática novedosa, pertinente y necesaria para la investigación y práctica de enfermería en oncología, con tendencias y retos que incluyen: (1) el desarrollo de marcos conceptuales que aporten a la fundamentación, atributos y efectos (2) la determinación de métodos y formas de crearlos y clasificarlos (3) la generación de estudios con poblaciones específicas por tipos cáncer y tratamiento y la consolidación de intervenciones de enfermería. conclusiones: los pacientes con cáncer experimentan múltiples síntomas de forma simultánea durante las distintas fases de la enfermedad. es incipiente el estudio de este fenómeno, los retos para la enfermería se centran en la generación de respuestas que alivien la carga de los grupos de síntomas y mejoren la calidad de vida de estos pacientes. es necesario validar escalas de carga del síntoma y explorar los grupos de síntomas incluyendo variables clínicas ligadas a los tratamientos oncológicos. palabras clave enfermería oncológica; jerarquización de los síntomas; evaluación de síntomas; síntomas cancerígenos; análisis por conglomerados (fuente: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 257-269 258 aquichan issn 1657-5997 eissn 2027-5374 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 257-269 symptom clusters in cancer patients: an integrative review abstract objective: the objective of the study was to explore the current state of research developed on symptom clusters in adults with cancer. method: the authors conducted an integrative review of scientific output between 2001 and 2016. sixty-one articles were included, given their contribution towards understanding the subject in question. results: the study of symptom clusters in persons with cancer is emerging as a novel, relevant and necessary area for nursing research and practice in oncology, with trends and challenges that include: (1) developing conceptual frameworks; (2) determining ways and means to create and classify them; and (3) generating studies with specific population groups, according to types of cancer and treatment, and the consolidation of nursing interventions. conclusions: cancer patients experience multiple symptoms simultaneously during the different phases of the disease. research on this phenomenon is incipient and the challenges for nursing are focused on generating responses that relieve the burden of symptom clusters and help to improve the quality of life for these patients. it is necessary to validate symptom load scales and to explore symptom clusters, including clinical variables linked to the different types of oncological treatment. keywords oncological nursing; organizing symptoms into a hierarchy; evaluating symptoms; carcinogenic symptoms; cluster analysis (source: decs, bireme). 259 los grupos de síntomas en personas con cáncer: una revisión integrativa l gloria mabel carrillo-gonzález os grupos de sintomas em pessoas com câncer: uma revisão integrativa resumo objetivo: explorar o estado atual de desenvolvimento da pesquisa da área temática grupos de sintomas em adultos com câncer. método: revisão integrativa de produção científica gerada entre 2001 e 2016. foram incluídos 61 artigos por sua contribuição para a compreensão da área em questão. resultados: o estudo dos grupos de sintomas em pessoas com câncer se consolida como uma área temática nova, pertinente e necessária para a pesquisa e a prática de enfermagem em oncologia, com tendências e desafios que incluem: 1) o desenvolvimento de referenciais conceituais que contribuam para a fundamentação, atributos e efeitos, 2) a determinação de métodos e formas de criá-los e classificá-los, 3) a geração de estudos com populações específicas por tipos de câncer e tratamento, 4) bem como a consolidação de intervenções de enfermagem. conclusões: os pacientes com câncer experimentam vários sintomas de forma simultânea durante as diferentes fases da doença. o estudo desse fenômeno é incipiente, e os desafios para a enfermagem se focam na geração de respostas que aliviem a carga dos grupos de sintomas e melhorem a qualidade de vida desses pacientes. é necessário validar escalas de carga do sintoma e explorar os grupos de sintomas incluindo variáveis clínicas ligadas aos tratamentos oncológicos. palavras-chave análise por conglomerados; avaliação de sintomas; enfermagem oncológica; hierarquização dos sintomas; sintomas cancerígenos (fonte: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 257-269 260 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 introducción el cáncer es una dolencia crónica que se relaciona con sufrimiento, complejos procesos de afrontamiento y adaptación de los pacientes por la multiplicidad de síntomas que se generan como consecuencia de la enfermedad, de los efectos secundarios de los tratamientos oncológicos, y de fases avanzadas en las que se requiere cuidado paliativo. los pacientes con cáncer a menudo experimentan entre 3 y 13 síntomas con un promedio de 6, concurrentes durante la trayectoria de la enfermedad (1-3). en el cáncer avanzado, los enfermos reportan una media de 10 a 11 síntomas (4, 5). los síntomas asociados incluyen fatiga, náuseas, vómito, dolor, depresión y dificultad para dormir, entre otros (6). a pesar de que los individuos sometidos a terapias con cáncer son propensos a experimentar múltiples síntomas de forma simultánea, la investigación que ha predominado sobre estos es la que explora uno en particular, siendo limitada la que aborda los grupos. enfermería asume un papel determinante en el cuidado de los usuarios con cáncer sometidos a diferentes terapéuticas oncológicas, con roles que están orientados en gran medida a la identificación y el manejo de aspectos ligados con los síntomas. por ello, el estudio de estos se constituye como un área de relevancia clínica y específica para guiar la investigación y la práctica de enfermería en oncología. en tal sentido, esta revisión integrativa buscó explorar el estado actual de desarrollo del área temática de grupos de síntomas en adultos con cáncer. materiales y métodos revisión integrativa que consistió en determinar el estado actual de conocimiento sobre los grupos de síntomas en adultos con cáncer; se combinaron datos de literatura teórica y empírica, con varios propósitos: definición de conceptos, revisión de teorías y evidencias, y análisis de metodologías respecto al tópico en particular (7). para la revisión se tuvieron en cuenta los pasos descritos por tavares et al. (7). 1. elaboración de la pregunta orientadora de la revisión: ¿cuáles son las tendencias y los retos que refleja el área temática referente a grupos de síntomas en adultos con cáncer para la investigación y práctica de la enfermería? 2. búsqueda de literatura: se adelantó una búsqueda de artículos, revisiones y editoriales en las bases de datos pubmed, science direct, ovid nursing, cuiden, scielo y cinahl entre los años 2001 y 2016, bajo los descriptores “síntomas”, “grupos de síntomas”, “cáncer” y “enfermería oncológica”, en idioma inglés y español. 3. recolección de información: se identificaron 145 referencias relacionadas con la temática, se excluyeron 84 por no abordar específicamente el fenómeno grupos de síntomas en cáncer, o por estar duplicadas en las bases de datos. fueron seleccionadas 61 piezas que se revisaron utilizando un formato que contenía: objetivos o propósito, definición de sujetos, metodología utilizada, método de análisis, resultados y conclusiones, así como la relevancia del estudio para enfermería, consideradas como la muestra para adelantar el análisis posterior. 4. análisis crítico de estudios incluidos: posteriormente estas piezas fueron analizadas teniendo en cuenta criterios de validez, fiabilidad y aplicabilidad. se identificaron sus aportes más relevantes, siendo el soporte para consolidar las tendencias y los retos para la investigación y práctica de enfermería del fenómeno grupos de síntomas en adultos con cáncer. resultados en la última década, se han generado publicaciones que exploran el área temática de grupos de síntomas en adultos con cáncer en enfermería. de los 61 documentos reportados por la literatura, la mayor parte enfatiza en su importancia como un fenómeno pertinente y necesario para la investigación en enfermería. se identifica que la totalidad de las publicaciones son en inglés, en las que predominan abordajes cuantitativos, diseños descriptivos explicativos, y muy pocos de carácter cuasiexperimental o experimental. se encuentran, además, revisiones, reflexiones, análisis de concepto y teorías de enfermería que incluyen el concepto (figura 1). el análisis de las referencias seleccionadas muestra tendencias y retos para la investigación y práctica de enfermería que incluyen: 1) fundamentación conceptual y atributos de los grupos de síntomas en cáncer; 2) determinación de métodos y formas de crearlos; 3) generación de estudios con poblaciones específicas por tipos de cáncer y tratamiento, así como la consolidación de intervenciones de enfermería con impacto sobre los grupos de síntomas en personas con cáncer. a continuación se describe una panorámica de los hallazgos que reporta la literatura. 261 los grupos de síntomas en personas con cáncer: una revisión integrativa l gloria mabel carrillo-gonzález fundamentación conceptual y atributos de los grupos de síntomas en cáncer la oncology nursing society (ons) llevó a cabo un estudio entre sus miembros en 2008 y determinó cuatro prioridades de investigación en oncología: calidad de vida, efectos tardíos del tratamiento, acceso a la atención y cuidados paliativos. dentro de estas prioridades el abordaje de síntomas se consideró un fenómeno transversal para enfermería (8). dodd et al. (9) plantean la necesidad de considerar los “grupos de síntomas” en la investigación oncológica para capturar la complejidad de su experiencia. sin embargo, afirman que no existe consenso sobre la definición sistemática ni un abordaje metodológico específico al respecto (10). xiao (11) señala que el entendimiento de los grupos de síntomas en pacientes con cáncer ofrece múltiples ventajas, a saber: 1) es una alternativa para considerar el estudio del síntoma de una manera más sistemática y menos compleja; 2) permite una valoración más completa de los síntomas que incluye su interrelación y los efectos sobre otros y sobre los resultados del paciente; 3) ayuda a identificar el origen y la etiología común de un grupo de síntomas; 4) proporciona una vía hacia la evaluación y gestión del síntoma más eficaz, ya que se asegura el manejo de los síntomas clave. no solo los grupos de síntomas tienen resultados clínicos diferentes por individuo, el impacto total de un clúster puede ser mayor que la suma de los efectos de los síntomas individuales (12). este impacto grupal o colectivo se puede describir como la carga del síntoma (13, 14). barsevick (10), dodd et al. (15) y kim et al. (2) coinciden en afirmar que los grupos (clúster) de síntomas son concurrentes, se relacionan y pueden tener o no una etiología común; y el entendimiento de la casuística será clave para guiar las intervenciones (16). ahora bien, aunque un síntoma puede ser compartido por varios y diferentes racimos, existen diferentes posturas respecto al número de síntomas que constituyen un grupo. dodd et al. (9) indican que al menos tres síntomas se deben considerar, y pueden tener un efecto adverso sobre los resultados del paciente y un efecto sinérgico como predictor de morbilidad para el individuo. kim et al. (2) recomiendan como mínimo la presencia de dos síntomas; molassiotis et al. (17) indican, además, que un grupo de síntomas corresponde a dos o más clínicamente significativos, que se relacionan entre sí en un momento dado y comparten una variación importante con su agrupación. aktas et al. (4), chen y lin (18), fox y lyon (19) soportan esta afirmación al referir que dos síntomas agrupados reportan influencias negativas en la calidad de vida o el estado funcional del paciente. xiao (11) reconoce que estas discrepancias conceptuales evidencian diferentes interpretaciones del concepto “grupo de síntomas”, con variaciones directas en el diseño de los estudios, los métodos de identificación y las características de las muestras, entre otros aspectos. el estudio de los síntomas implica el abordaje de las percepciones y las respuestas de los pacientes a la aparición de estos, así como la angustia percibida, por ello es fundamental identificar el significado para evaluar la naturaleza de la experiencia (13). armstrong (20) refiere que el énfasis se debe hacer sobre la experiencia de los síntomas, descrita como la percepción de la frecuencia, intensidad, angustia y el significado de cómo se producen y se expresan. identifica tres categorías de variables que influyen en los síntomas incluyendo factores situacionales, fisiológicos y psicológicos. la capacidad de las personas para percibir el grado de bienestar físico o mental se cree que está influenciada por varios factores tales como la edad, el nivel socioeconómico, la cultura, el papel de la familia, la educación, el conocimiento de la salud y las experiencias pasadas. la percepfigura 1. distribución porcentual hallazgos revisión integrativa grupos de síntomas en cáncer (n = 61) fuente: datos del estudio, 2016. 262 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 ción de los síntomas implica tener la capacidad de reconocer lo que está “oculto”. las características de los pacientes y el impacto que la expresión de los síntomas tiene para ellos pueden modificar esta comprensión. por ello, esta percepción puede ser diferente en cada individuo, y dependerá del tipo y los efectos del tratamiento, y de la edad (21). la expresión o las consecuencias de los síntomas se describen como los cambios en las actividades funcionales y cognitivas, incluyendo el ajuste de la enfermedad, calidad de vida, estado de ánimo, el estado funcional, la progresión de la enfermedad y la supervivencia. las teorías y los estudios de los síntomas que predominan han definido atributos clave de estos como la frecuencia, la intensidad y la angustia que se producen. armstrong (20) enfatiza en que el significado que las personas le asignan a las sensaciones físicas puede tener profundas implicaciones para su salud física y psicológica, y por tanto, para su calidad de vida. cada síntoma individual, así como la interacción de múltiples, tiene la habilidad de afectar el significado situacional o de los pacientes. los síntomas pueden tener un significado positivo, se catalogan como signo de que “el tratamiento debe estar funcionando”, o la experiencia ha acercado a la familia y se dejan ver aspectos positivos con los demás. asimismo, para un individuo el síntoma considerado como el más angustiante puede no ser el más significativo desde el punto de vista clínico. lenz et al. (22) indican que la aparición de estos múltiples síntomas es probable que resulte en una experiencia multiplicativa en lugar de aditiva. los síntomas pueden ocurrir en conglomerados, o actuar como catalizadores de otros o la angustia asociada a ellos. por tanto, para la comprensión de esta experiencia se debe determinar qué síntomas influyen o son influenciados para la aparición de otros. adicionalmente, el equipo de salud debe ser consciente de la coocurrencia de los síntomas, educar e involucrar a los pacientes en la identificación de estos y de los factores agravantes o aliviadores, coordinando las recomendaciones de tratamiento y utilizando estrategias que pueden ser beneficiosas para varios grupos de síntomas (23) . dong et al. (24) describieron las actitudes y estrategias del personal de salud en el manejo de múltiples síntomas en pacientes con cáncer avanzado; identifican que el manejo de los grupos de síntomas es un arte y una ciencia que está llena de incertidumbre en la toma de decisiones. se requiere el fortalecimiento del trabajo interdisciplinario, la continuidad en la atención, planificación más pragmática de los ensayos clínicos para abordar más de un síntoma y el entrenamiento en el manejo de estos (25, 26). en síntesis, en el estudio de los grupos de síntomas se deben reconocer los antecedentes y las consecuencias, añadiendo el valor del significado de la experiencia que los pacientes proporcionan, lo que implica un abordaje individualizado y de mayor complejidad. la determinación de métodos y las formas de crearlos a partir de patrones definidos por los investigadores se identifican dos enfoques metodológicos utilizados para medir y determinar los grupos de síntomas: 1) clínicos: el de selección de síntomas más comunes en la identificación de los grupos; 2) estadísticos: el de selección de todos los síntomas posibles en la identificación de los grupos (11, 12). los clúster clínicos se centran a menudo en pocos síntomas, generalmente dos o tres considerados importantes clínicamente, y determinados de forma empírica. son seleccionados después de la evaluación de todos los síntomas del paciente o se forman de un grupo preseleccionado. se basan en estudios clínicos que sugieren prevalencia o coocurrencia, se relacionan con un mecanismo fisiopatológico común, y con síntomas que influyen de forma adversa en la función o tolerancia a los tratamientos (27). desde este enfoque, los síntomas de fatiga, trastornos del sueño, depresión y dolor han sido estudiados, relacionados especialmente con la funcionalidad y la calidad de vida. kirkova et al. (28) y xiao (11) indican que una limitación importante en el enfoque de los grupos clínicos está en el número de síntomas seleccionados para ser observados, ya que podrían existir correlaciones entre aquellos no incluidos en el grupo predefinido, o quizás las relaciones de los síntomas diferirían en función del que se utilice como variable dependiente. por otro lado, es importante justificar las bases teóricas para la elección de los síntomas analizados. los clúster estadísticos se refieren a la organización de conglomerados y factores de análisis de múltiples síntomas en 263 los grupos de síntomas en personas con cáncer: una revisión integrativa l gloria mabel carrillo-gonzález grupos, sin necesidad de previas suposiciones acerca de las relaciones entre estos. se analizan conjuntos de datos para identificar asociaciones entre los síntomas, de forma que se pueda definir una relación clínicamente importante (11, 28, 29). para conocer y determinar la ocurrencia de síntomas, los pacientes se agrupan en subgrupos basados, en particular, en síntomas comunes. esto es diferente a la agrupación de síntomas en grupos, ya que los individuos pueden experimentar múltiples grupos de estos. para la organización jerárquica de los conglomerados se utilizan coocurrencias entre pares de los síntomas, con el fin de formar agrupaciones que se suelen llevar a cabo a posteriori. el número de síntomas y el contenido de los grupos dependen del tipo de instrumento utilizado y del valor estadístico de corte para determinar el nivel de correlación significativa. dentro de sus principales limitaciones se identifica la necesidad de contrastar y relacionar los grupos de síntomas identificados por estos métodos estadísticos con la clínica del paciente y las interpretaciones que se les pueden atribuir a los hallazgos. de otra parte, barsevick (30) y linder et al. (31) indican que se deben explorar los grupos de síntomas a partir de abordajes cualitativos, y basados en grupos definidos empíricamente. estudios con poblaciones específicas por tipos de cáncer y tratamiento los estudios de grupos de síntomas de pacientes con cáncer identificados se han explorado en mayor proporción en mujeres con cáncer de mama, seguido por cáncer de pulmón, cáncer avanzado y cáncer en general, y en menor proporción se ha determinado el efecto de las intervenciones de enfermería para su manejo. a continuación se describen los principales hallazgos. estudios sobre grupos de síntomas en cáncer en general evidencian, como se señaló, que existe relación directa entre la fatiga y la depresión con el estado funcional y la calidad de vida. el dolor influye en la fatiga y en el patrón de sueño (32-35). el dolor y la fatiga son factores predictores independientes de otros síntomas experimentados (36). son clúster de síntomas en pacientes con cáncer que se encuentran en tratamientos ambulatorios: alta fatiga y bajo dolor, moderada fatiga y alto dolor, todos los síntomas bajos o todos los síntomas altos. los subgrupos de pacientes que reportan altos niveles de fatiga y dolor tienen bajo estado funcional y peor calidad de vida (37). otro grupo de síntomas presente en personas ambulatorias con cáncer son: fatiga, angustia emocional y pobre sensación de bienestar (38). en pacientes con cáncer sometidos a quimioterapia se identifican subgrupos de síntomas de acuerdo con su intensidad (leves, moderados y severos); los más severos reportan la peor calidad de vida. las náuseas son un complejo síntoma afectado por la presencia o severidad de otros concurrentes. un subgrupo de síntomas predictivo de náuseas incluye bajo apetito, sensación de hinchazón, vómitos, cambios en el gusto y falta de energía (17, 39, 40). en general se identifican grupos de síntomas de índole emocional, físicos o malestar general y específicamente de tipo gastrointestinal. la carga de los síntomas emocionales disminuye significativamente el estado de salud y la calidad de vida (41 ,42). en mujeres con cáncer de mama los síntomas cambian durante el tratamiento. los grupos de pacientes con mayores síntomas presentan peor calidad de vida y estado funcional (43). son grupos de síntomas en cáncer de mama: 1) gastrointestinal: náuseas, vómito; 2) dolor, 3) malestar general: cansancio, sensación de debilidad, dolor de cabeza; 4) emocional: sentirse deprimido, sentirse ansioso; 5) nutricional: cambios en el apetito, aumento o disminución de peso; 6) físico general: problemas de boca y garganta, falta de aliento. el malestar general, los factores gastrointestinales y nutricionales son predictores independientes de depresión (44-46, 3). respecto al cáncer de pulmón, la fatiga, el dolor y la ansiedad es un clúster de síntomas prevalente en pacientes sometidos a radioterapia paliativa (47). el grupo dolor, insomnio y fatiga es común durante el tratamiento de quimioterapia; el estado funcional se ve alterado por la presencia de los síntomas (19, 48, 49). los síntomas son predictores independientes de la muerte; asimismo, la etapa del cáncer en el momento del diagnóstico es la mejor fase predictora de síntomas posteriores de la enfermedad (50). en personas con cáncer avanzado se identifican múltiples y severos subgrupos de síntomas que implican menor estado fun264 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 cional físico, emocional, cognitivo, social y calidad de vida en general. son grupos de síntomas de mayor prevalencia: 1) fatiga, somnolencia, náuseas, cambios de apetito, disnea; 2) ansiedad y depresión (51). en personas con cáncer recurrente que inician radiación paliativa por dolor óseo se identifican los síntomas dolor, disminución de peso, fatiga, fiebre, disminución de apetito y sueño (52). en adultos mayores con cáncer en cuidado paliativo se identificaron cinco grupos de síntomas a partir de un análisis de clúster: a) gastrointestinal y urológicos, y sus complicaciones de tratamiento; b) síntomas psicológicos y existenciales; c) dolor, constipación y problemas de respiración, d) problemas en la funcionalidad y e) síntomas relacionados con fatiga (53). en pacientes con cáncer colorrectal se identificaron seis grupos de síntomas prevalentes que se mantenían antes y después de la quimioterapia (54). de la misma forma, en sobrevivientes de este mismo cáncer se evidencia presencia de síntomas moderados, predominando el grupo que incluye problemas para dormir y sensación de cansancio (55). ahora bien, se identificaron estudios que han evaluado la efectividad de intervenciones de enfermería para el manejo de grupos de síntomas: jarden et al. (56), por medio de un ensayo clínico controlado y aleatorizado, exploraron los efectos longitudinales de una intervención educativa sobre los síntomas relacionados con el tratamiento en 42 pacientes con alteraciones hematológicas malignas. se identificaron los grupos: mucositis, función cognitiva, gastrointestinal, y cambios en el afecto. con la intervención hubo una significativa reducción de la intensidad de todos los síntomas excepto el clúster de afecto. kwekkeboom et al. (57), en un ensayo clínico controlado, determinaron la eficacia de una intervención conductiva-conductual para el grupo de síntomas: dolor, fatiga y alteraciones del sueño en 86 pacientes con cáncer avanzado. concluyen que la intervención puede ser apropiada para el tratamiento para este grupo. mustian et al. (58), mediante una revisión sistemática, concluyen que el ejercicio es una opción terapéutica segura, apropiada y efectiva para alivianar la carga de los grupos de síntomas en los pacientes con cáncer. de acuerdo con los hallazgos, se identifica que el tipo de clúster y la composición dependen de las poblaciones, el estadio de la enfermedad, el método de evaluación (por ejemplo, el dominio de los síntomas, la cronología, la redacción de síntomas), los instrumentos y el método estadístico seleccionado (tabla 1). discusión el cáncer es devastador porque se asocia con síntomas o afecta la comodidad que es central en la experiencia de vida. ahora bien, el manejo de síntomas aparece como una tendencia mundial en el desarrollo de la enfermería clínica y es un punto de encuentro entre la teoría y la práctica. a pesar de los avances en el conocimiento de los grupos de síntomas en oncología, se identifican muchos aspectos aún por indagar, y se constituyen en retos para la investigación en enfermería en los próximos años. en primer lugar, se plantea la necesidad de desarrollar marcos teóricos adecuados para la investigación de grupos de síntomas en oncología. los métodos de identificación de clúster necesitan más comparación para ver cuál ofrece la mejor evidencia. se requieren más estudios con poblaciones específicas en el contexto local de corte transversal o longitudinal con el fin de investigar la influencia de los grupos de síntomas en el paciente. los estudios longitudinales que utilizan el enfoque de determinación de patrones de síntomas dentro de un clúster son necesarios para identificar severidad y cambios en los grupos de síntomas con el tiempo (59). por otro lado, se debe establecer un consenso en torno a las metodologías estadísticas empleadas (2, 22, 31, 60). todos los síntomas dentro de un grupo deben ser considerados y ser objetivo clave para la evaluación e intervención; de otro modo, sus importantes beneficios terapéuticos pueden ser pasados por alto. asimismo, es necesario explorar los predictores de la severidad de los síntomas y la angustia que representa para los pacientes (61, 22). los síntomas deben ser evaluados dentro de los resultados del tratamiento sobre la calidad de vida del paciente, el estado funcional, y la reinserción social o laboral. son pocos los estudios que abordan la experiencia de los síntomas en personas adultas con tratamiento quirúrgico, por tanto, es determinante asociar las variables del tratamiento oncológico a mediano y lar265 los grupos de síntomas en personas con cáncer: una revisión integrativa l gloria mabel carrillo-gonzález go plazo (44, 62). por último, las intervenciones necesitan ser desarrolladas y medidas para ayudar efectivamente a los pacientes en el manejo de los múltiples síntomas. en este sentido, la identificación de síntoma centinela se debe considerar como una estrategia clínica que podría mejorar la evaluación de los grupos de síntomas (44). tabla 1. revisión integrativa de grupos de síntomas en personas con cáncer: categorías de análisis, avances y desafíos para enfermería categorías de análisis avances retos para investigación fundamentación conceptual y atributos consenso respecto a que los grupos de síntomas se refieren a dos o más síntomas simultáneos e interrelacionados que ocurren juntos con un alto grado de previsibilidad. no requieren una etiología común, se agrupan en una forma intencional, la composición puede o no ser estable durante todo el curso de la enfermedad. impacto sobre el paciente: multiplicativo no aditivo, mayor que la suma de los efectos de los síntomas individuales. es una forma de determinar carga objetiva del síntoma para el paciente. 1. establecimiento de marcos teóricos específicos. 2. explorar variables: a) número de síntomas que constituyen un grupo; b) estabilidad en el tiempo del grupo; c) significancia clínica. 3. incluir el concepto experiencia: determinar percepción y significados para el paciente. 4. incluir el componente percepción del síntoma para el paciente: los de mayor angustia, estrés y carga. métodos para la construcción clínicos: generalmente dos o tres síntomas de interés clínico y determinados empíricamente. la fatiga, los trastornos del sueño, la depresión y el dolor, han sido estudiados, relacionándolos con la funcionalidad y la calidad de vida. estadísticos: organización de conglomerados y factores de análisis de múltiples síntomas en grupos, sin necesidad de previas suposiciones acerca de las relaciones de los síntomas. 1. consenso respecto a métodos estadísticos de mayor utilidad 2. relacionar los grupos de síntomas identificados frente a la clínica del paciente y las interpretaciones que se le pueden atribuir a los hallazgos. 3. justificar las bases teóricas para la elección de los síntomas predeterminados por el investigador. 4. explorar predictores de la severidad de los síntomas y la angustia que representa para los pacientes. grupos de síntomas en cáncer por tipo de cáncer: mama, pulmón, hemato-oncológicos, neurológicos, hepáticos y otros. por terapéuticas: quimioterapia y radioterapia. por fase de la enfermedad: tratamiento, sobrevivientes y cuidado paliativo. intervenciones de enfermería: educativas en pacientes con alteraciones hemato-oncológicas; conductiva conductual en pacientes con cáncer avanzado. 1. determinar las consecuencias sobre el paciente: calidad de vida, estado funcional, estado emocional, mortalidad y reinserción social y laboral. 2. explorar grupos de síntomas con poblaciones específicas teniendo en cuenta variables ligadas al tipo de tratamiento oncológico o terapias concomitantes. 3. explorar el o los síntomas centinelas. 4. desarrollar estudios longitudinales que reporten cambios en los patrones de los grupos de síntomas, estabilidad en el tiempo y significancia clínica. 5. explorar impacto de variables sociodemográficas y redes de soporte social sobre los grupos de síntomas. 6. consolidar intervenciones de enfermería para el manejo de grupos de síntomas. fuente: elaboración propia, a partir de la revisión integrativa, 2016. 266 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 conclusiones el cuidado de los usuarios con cáncer sometidos a diferentes terapéuticas oncológicas implica el abordaje y manejo de los síntomas. el estudio de estos constituye un área de relevancia clínica que debe guiar la investigación y la práctica de enfermería en oncología. hay un desarrollo importante del tema de grupos de síntomas en personas con cáncer, con interés particular en el reconocimiento de estos a partir de técnicas multivariadas de clúster. los diferentes estudios analizados de manera transversal permiten comprender mejor este fenómeno y dar así un paso esencial para que los enfermeros puedan continuar en su exploración con el fin de orientar la investigación y cualificar la práctica clínica en beneficio de los pacientes. los retos para enfermería se centran en la generación de respuestas que alivien la carga y el sufrimiento de los pacientes a partir de la investigación, la docencia, la disciplina y la asistencia. es necesario validar escalas de la carga del síntoma, explorar los grupos de síntomas incluyendo variables clínicas ligadas a los tratamientos oncológicos; diseñar y evaluar intervenciones de enfermería. por otro lado, se requiere indagar, mediante métodos cualitativos, otros componentes de la experiencia ligados a los procesos y significados que emergen de esta vivencia, brindando una perspectiva que complemente la descripción de la carga de los grupos de síntomas, los factores influyentes y las variables de respuesta referidas por el paciente. finalmente, es preciso fortalecer la enseñanza sobre el cuidado de personas con cáncer en estudiantes de pregrado, posgrado y en personal asistencial, desde la perspectiva de necesidades de cuidado y, en especial, en el diseño de planes de atención de orientados al manejo de la carga de síntomas. agradecimientos la autora expresa sus agradecimientos a las profesoras pilar amaya y maría mercedes durán, docentes del seminario de investigación del doctorado en enfermería. de igual forma, a la profesora beatriz sánchez, directora de tesis, por su acompañamiento y orientación metodológica y temática. referencias 1. dodd mj, miaskowski c, paul sm. symptom clusters and their effect on the functional status of patients with cancer. oncol nurs forum. 2001;28(3):465-70. 2. kim hj, mcguire db, tulman l, barsevick am. symptom clusters: concept analysis and clinical implications for cancer nursing. cancer nurs. 2005;28(4):270-82. 3. kim hj, barsevick am, beck sl, dudley w. clinical subgroups of a psychoneurologic symptom cluster in women receiving treatment for breast cancer: a secondary analysis. oncol nurs forum. 2012;39(1):20-30. 4. aktas a, walsh d, rybicki l. symptom clusters: myth or reality? palliat med. 2010;24(4):373-85. 5. aktas a, walsh d, hu b. cancer symptom clusters: an 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2016;32(4):334-50. 31. linder la, ameringer s, baggott c, erickson j, machperson cf, et al. measures and methods for symptom and symptom cluster assessment in adolescents and young adults with cancer. semin oncol nurs. 2015;31(3):206-15. 32. beck sl, dudley wn, barsevick a. in patients with cancer: using a mediation model to test a symptom cluster. 2005;32(3):48-55. 33. ferreira k, kimura m, teixeira mj, mendoza tr, da nóbrega j, graziani sr, et al. impact of cancer-related symptom synergisms on health-related quality of life and performance status. j pain symptom manage. 2008;35(6),604-16. 268 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 34. fox sw, lyon d, farace e. symptom clusters in patients with high-grade glioma. j nurs scholarsh. 2007;39(1),61-7. 35. fox sw, lyon d. symptom clusters and quality of life in survivors of ovarian cancer. cancer nursing. 2007;30(5):354-61. 36. given b, given c, azzouz f, stommel m. physical functioning of elderly cancer patients prior to diagnosis and following initial treatment. nursing research. 2001;50(4):222-32. 37. pud d, ben s, cooper ba, aouizerat be, cohen d, radiano r, et al. the symptom experience of oncology outpatients has a different impact on quality oflife outcomes. j pain symptom manage. 2008;35(2):162-70. 38. howell d, husain a, seow h, liu y, kustra r, atzema c, et al. symptom clusters in a population-based ambulatory cancer cohort validated using bootstrap methods. eur j cancer. 2012;48(16):3073-81. 39. cherwin c, perkhounkova y. distress-based gastrointestinal symptom clusters and impact on symptom interference and quality of life in patients with a hematologic malignancy receiving chemotherapy. j pain symptom manage. 2016;29. 40. hwang kh, cho oh, yoo ys. symptom cluster of ovarian cancer patients undergoing chemotherapy, and their emotional status and quality of life. eur j oncol nurs. 2016;21:215-22. 41. yamagishi a, morita t, miyashita m, kimura f. symptom prevalence and longitudinal follow-up in cancer outpatients receiving chemotherapy. j pain symptom manage. 2009;37(5):823-30. 42. kenne s, browall m, gaston-johansson f. symptom burden clusters: a challenge for targeted symptom management. a longitudinal study examining symptom burden clusters in breast cancer. j pain symptom manage. 2014;47(4):731-41. 43. dodd mj, cho mh, cooper b, miaskowski c. the effect of symptom clusters on functional status and quality of life in women with breast cancer. eur j oncol nurs. 2010;14(2),101-10. 44. breen sj, baravelli cm, schofield pe, jefford m, yates pm, aranda sk. is symptom burden a predictor of anxiety and depression in patients with cancer about to commence chemotherapy? med j aust. 2009;190(7):99-104. 45. miaskowski c, cooper b, paul sm, dodd m, lee k, aouizerat be, et al. subgroups of patients with cancer with different symptom experiences and quality-of-life outcomes: a cluster analysis. oncol nurs forum. 2006; 33(5):79-89. 46. bender cm, ergÿn fs, rosenzweig mq, cohen sm, sereika sm. symptom clusters in breast cancer across 3 phases of the disease. cancer nursing. 2005;28(3):219-25. 47. han c, richardson a, richardson j. a study to assess the existence of the symptom cluster of breathlessness, fatigue and anxiety in patients with advanced lung cancer. eur j oncol nurs. 2005;9(4):325-33. 48. hoffman aj, given b, von-eye a, gift ag, given cw. relationships among pain, fatigue, insomnia, and gender in persons with lung cancer. oncol nurs forum. 2007;34(4):785-92. 49. franceschini j, jardim jr, luisa a, fernandes g, jamnik s, santoro il. relationship between the magnitude of symptoms and the quality of life: a cluster analysis of lung cancer patients in brazil. j bras pneumol. 2013;39(1):23-31. 50. gift a, stommel m, jablonski a. a cluster of symptoms over time in patients with lung cancer. nursing research. 2003;52(6):393-400. 51. cheung wy, le lw, zimmermann c. symptom clusters in patients with advanced cancers. support care cancer. 2009;17(9):1223-30. 52. francoeur rb. the relationship of cancer symptom clusters to depressive affect in the initial phase of palliative radiation. j pain symptom manage. 2005;29(2):130-55. 53. lancker a, beeckman d, verhaeghe s, noorgate n, hecke a. symptom clustering in hospitalized older palliative cancer patients: a cross-sectional study. int j nurs stud. 2016;61:72-81. 54. rohrl k, gronlie m, miaskowski c, cooper c, my diep l, rustoen t. no differences in symptom burden between colorectal cancer patients receiving curative versus palliative chemotherapy. j pain symptom manage. 2016;52(4):539-47. 269 los grupos de síntomas en personas con cáncer: una revisión integrativa l gloria mabel carrillo-gonzález 55. gosselin t, beck s, abbott d, grambow s, provenzale d, berry p, et al. the symptom experience in rectal cancer survivors. j pain symptom manage. 2016;52(5):709-18. 56. jarden m, nelausen k, hovgaard d, boesen e, adamsen l. the effect of a multimodal intervention on treatment-related symptoms in patients undergoing hematopoietic stem cell transplantation: a randomized controlled trial. j pain symptom manage. 2009;38(2):174-90. 57. kwekkeboom k, abbott-anderson k, cherwin k, roiland r, serlin r. ward s. a pilot randomized controlled trial of a patient-controlled cognitive-behavioral intervention for the pain, fatigue, and sleep disturbance symptom cluster in cancer. j pain symptom manage. 2012;44(6):810-22. 58. mustian k, cole c, asare m, fung c, janelsins c, kamen c, et al. exercise recommendations for the management of symptoms clusters resulting from cancer and cancer treatments. semin oncol nurs. 2016;32(4):383-93. 59. brown jk, cooley me, chernecky c, sarna l. a symptom cluster and sentinel symptom experienced by women with lung cancer. oncol nurs forum. 2011;38(6):425-35. 60. bender cm, engberg sj, donovan hs, cohen sm, houze mp, rosenzweig mq, et al. symptom clusters in adults with chronic. 2008;35(1):1-12. 61. barsevick am. the concept of symptom cluster. semin oncol nurs. 2007;23(2):89-98. 62. kim hj, barsevick am, fang c, miaskowski c. common biological pathways underlying the psychoneurological symptom cluster in cancer patients. cancer nursing. 2012;35(6):1-20. 373 379 primeras paginas.indd 377 editorial hacia una cultura de seguridad del paciente: el futuro de la profesión de enfermería towards a culture of patient safety: the future of the nursing profession rumo a uma cultura de segurança do paciente: o futuro da profissão de enfermagem doi: 10.5294/aqui.2017.17.4.1 del paciente no solo deben estar orientadas a la corrección del error, sino a la prevención del mismo, dadas sus consecuencias para la salud de las personas. curiosamente, si estableciéramos un paralelismo entre ambos conceptos y los paradigmas de atención sanitaria actuales podríamos decir que el clásico paradigma biomédico, centrado en la patología y su curación es directamente proporcional al concepto de “error” y a la acción de “curar”, mientras que los conceptos de “seguridad del paciente” y “prevención de eventos adversos” forman parte de un nuevo paradigma centrado en la salud y no en la enfermedad, más propio de la profesión enfermera. es en dicha transformación del paradigma de atención a las personas en la que la profesión de enfermería emerge como agente de cambio indispensable. por otra parte, el desarrollo de estas iniciativas que sitúan al usuario en el centro de las prioridades de los sistemas sanitarios mundiales, y a la salud como su máximo exponente, paralelamente ha posicionado a la figura de enfermería en un puesto clave para la toma de decisiones dentro del equipo de salud. pero, ¿es consciente realmente el profesional de enfermería de cuál es el paradigma que favorece su propio desarrollo y de las oportunidades que tiene ante sí? prácticamente toda la bibliografía que se ha publicado al respecto procede del mundo anglosajón-estadounidense y aboga por un concepto multidisciplinar, interprofesional y centrado en el paciente. el institute for healthcare improvement (ihi) y la joint commission, en concreto a través de su portal de transiciones en el cuidado (toc portal – transitions of care portal) han sido sus la creación de una cultura centrada en la seguridad del paciente en los diferentes contextos de salud y enfermedad supone un leitmotif para el desarrollo de enfermería como profesión a nivel global en las sociedades actuales. las estrategias sanitarias impulsadas hoy día por entidades como la organización mundial de la salud (oms) o la comisión europea en materia de seguridad del paciente tienen su base en objetivos globales como el empoderamiento del usuario de los sistemas sanitarios para la toma de decisiones sobre su propia salud y enfermedad, el desarrollo de buenas prácticas basadas en evidencias, así como la innovación a través de dispositivos que garanticen la seguridad de unos cuidados centrados en la persona e individualizados. en todos ellos está presente el enfoque de seguridad para el usuario. no hay más que observar las convocatorias de investigación, desarrollo e innovación publicadas por estas organizaciones, también por los gobiernos de las naciones, e incluso por compañías privadas del sector salud para corroborar que el concepto seguridad ha cobrado un matiz transversal a cualquier otro tema, y se ha convertido en un requisito indispensable que debe estar presente, directa o indirectamente, en todas las iniciativas. sin embargo, el concepto “seguridad del paciente” no deja de ser el planteamiento positivo de otra noción que genera desagrado entre los profesionales de la salud, como es el “error”, y cuya connotación es obviamente negativa. las culturas de seguridad manuel lillo-crespo1 1 universidad de alicante, españa. manuel.lillo@ua.es 378 aquichan issn 1657-5997 eissn 2027-5374 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 máximos exponentes, y han lanzado vasta producción documental que ha servido de guía en diferentes contextos a nivel mundial. también se han implementado en la práctica clínica nuevos roles profesionales como el health coach y el patient experience officer, que desde el reino unido y estados unidos, respectivamente, han aunado competencias profesionales relacionadas con la seguridad del paciente y todo lo que ello conlleva en materia de calidad y satisfacción. sin embargo, no son muchos los contextos iberoamericanos donde las culturas de seguridad del paciente se han desarrollado y han sido, en el mejor de los casos, iniciativas con un enfoque marcadamente clínico y relacionadas con especialidades médicas como la medicina preventiva, en un intento por aterrizar el concepto de seguridad del paciente en un paradigma de atención biomédica clásico basado en la patología y alejado de la creación de auténticas culturas transformadoras. no obstante, ¿entiende el mundo iberoamericano el concepto de seguridad del paciente de la misma forma que lo hace el anglosajón? ¿cuál es el papel de enfermería? ¿hasta qué punto son útiles los documentos creados en contextos distintos? posicionamientos específicos de enfermería en esta línea que requieran mención son: las contribuciones de la enfermera doctora linda aiken del centre for health outcomes and policy research, de la escuela de enfermería en la universidad de penn, en filadelfia, quien en su numerosa bibliografía publicada, y de gran calado social, ha aportado claras evidencias científicas que correlacionan índices de mortalidad hospitalaria, datos sobre infecciones nosocomiales, ratios enfermera-paciente, clima o entorno laboral, seguridad del paciente y tasas de satisfacción laboral del personal de enfermería, donde demuestra que todos ellos redundan en la calidad de la institución, y se convierten en aspectos clave de la satisfacción del usuario (1, 2). por no olvidar sus contribuciones sobre los denominados magnet hospitals, centros sanitarios que han demostrado tener mejores ambientes de trabajo y más seguros, personal de enfermería más preparado, con una ratio de enfermera-paciente aceptable de acuerdo con las cargas de trabajo, y mayor colaboración enfermero-médico, por lo que han obtenido mejores resultados en salud (3). por otra parte, la también enfermera doctora afaf meleis, reconocida investigadora y teórica, ha contribuido con el desarrollo de su teoría de las transiciones para dar explicación a través de la investigación a estos temas (4). en los últimos años en europa, y a partir de las recomendaciones de la oms en cuanto a seguridad del paciente y prevención de errores en la práctica profesional, ya se está trabajando en iniciativas como la comenzada en 2014 denominada healthcare improvement science (his), a través del proyecto europeo improvement science training for european healthcare workers (istew) financiado por la comisión europea y en el que participó españa (5, 6). en la actualidad, la inquietud de los países europeos por continuar mejorando la calidad asistencial de sus instituciones —mayoritariamente públicas a diferencia de estados unidos, y sin perder de vista la seguridad del usuario— se ha materializado en esta iniciativa que incluye también una formación específica de los profesionales de la salud y que define a la ciencia de las mejoras en cuidados de salud (healthcare improvement science) como: “la generación de conocimiento para cultivar el cambio y ofrecer una atención centrada en la persona que sea segura, eficaz, eficiente, equitativa y oportuna. implica la mejora en los resultados del paciente, el desempeño de los sistemas sanitarios y la salud de la población” (7). como novedad, esta definición nos hace traspasar las puertas de las instituciones sanitarias y nos conecta con las comunidades y las propias familias, siendo estas uno de los pilares de las sociedades iberoamericanas. en esta línea, la contribución del aprendizaje experiencial y la evidencia procedente de la práctica de los cuidadores, especialmente familiares, tan presentes en las sociedades iberoamericanas, ha dado pie al desarrollo de manuales de buenas prácticas donde la seguridad del paciente va más allá de la omisión de daño, y se articula como una iniciativa que garantice los mejores cuidados posibles y con la mayor calidad para aquellos a quienes van destinados. trabajar en seguridad del paciente supone reconocer aquellas prácticas basadas en la experiencia cuando no existen evidencias científicas. proyectos como palliare, también bajo el paraguas de la comisión europea, ponen de manifiesto la seguridad y las buenas prácticas en el todavía desconocido campo de los cuidados ante la demencia (8, 9). 379 referencias 1. aiken lh, sermeus w, van den heede k, sloane dm, busse r, mckee m. patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in europe and the united states. bmj. 2012;344:e1717. 2. aiken lh, sloane dm, van den heede k, busse r, diomidous m, kinnunen j. nurse staffing and education and hospital mortality in nine european countries: a retrospective observational study. lancet. 2014;383(9931):1824-30. 3. kelly la, mchugh md, aiken lh. nurse outcomes in magnet® and non-magnet hospitals. j nurs adm. 2011;41(10):428-33. 4. meleis ai. transitions theory: middle range and situation specific theories in nursing research and practice. new york: springer publishing company; 2010. 5. macrae r, rooney kd, taylor a, ritters k, sansoni j, lillo m, et al. making it easy to do the right thing in healthcare: advancing improvement science education through accredited pan european higher education modules. nurs educ today. 2016;42:41-6. 6. istew project [sede web]. university of the west of scotland; [visitado 2017 jun 14]. disponible en: http://www.uws. ac.uk/improvementscience/ 7. skela-savič b, macrae r, lillo-crespo m, rooney kd. the development of a consensus definition for healthcare improvement science (his) in seven european countries: a consensus methods approach. sloven j public health. 2016;56(2):82-90. 8. tolson d, holmerova i, macrae r, waugh a, hvalič-touzery s, de abreu w, et al. improving advanced dementia care: an interprofessional palliare learning framework. jamda. 2017;18(7):561-3. 9. palliare project [sede web]. university of the west of scotland; [visitado 2017 jun 14]. disponible en: https://www.uws. ac.uk/palliareproject/ 169 178 cuidado popular de familias.indd 169 lucero lópez-díaz1 fabiola castellanos-soriano2 esperanza muñoz-torres3 cuidado popular de familias con un adulto mayor sobreviviente del primer accidente cerebrovascular 1 doctora en enfermería. universidad nacional de colombia, colombia. helopd@gmail.com 2 doctora en enfermería. pontificia universidad javeriana, colombia. fabiola.castellano@javeriana.edu.co 3 doctora en salud pública. universidad nacional de colombia, colombia. emunozt@unal.edu.co recibido: 14 de septiembre de 2014 enviado a pares: 20 de octubre de 2014 aceptado por pares: 27 de agosto de 2015 aprobado: 07 de septiembre de 2015 doi: 10.5294/aqui.2016.16.2.5 para citar este artículo / to reference this article / para citar este artigo lópez díaz l., castellanos-soriano f, muñoz-torres e. cuidado popular de familias con un adulto mayor sobreviviente del primer accidente cerebrovascular. aquichan. 2015; 16(2):169-178. doi: 10.5294/aqui.2016.16.2.5 resumen introducción: el accidente cerebrovascular afecta a numerosas personas en el mundo y se constituye en la principal causa de muerte. los sobrevivientes pueden padecer discapacidad y sufrir modificaciones en las actividades cotidianas. la familia es el principal apoyo del sobreviviente y al ser parte de una misma cultura, construye acciones de cuidado en búsqueda del bienestar. objetivo: describir las acciones del cuidado popular de las familias con un adulto mayor sobreviviente del primer accidente cerebrovascular. método: estudio etnográfico, con observación participante y entrevistas en profundidad. participaron siete familias bogotanas (siete adultos mayores entre los dos y diez meses posteriores al primer accidente cerebrovascular y los siete cuidadores principales respectivos). resultados: cuidadores y adulto mayor comparten acciones de cuidado para la recuperación, relacionadas con la alimentación, el cuidado personal y la ingesta de medicamentos permeadas por la creencia religiosa, fuente de soporte y vínculo afectivo. conclusión: conocer el cuidado popular de esta población posibilita proponer acciones culturalmente congruentes con sus valores y creencias para potencializar las capacidades familiares e intermediar en los procesos de tratamiento. palabras clave accidente cerebrovascular, adulto mayor, familia, etnografía, cultura (fuente: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 169-178 170 aquichan issn 1657-5997 año 16 vol. 16 nº 2 chía, colombia junio 2016 l 169-178 traditional family care for elderly survivors of a first stroke abstract introduction: many people in the world suffer a stroke and it is the leading cause of death. survivors may encounter disabilities and be subject to changes in their daily activities. the family is the main source of support for a stroke survivor and, because it is part of the same culture, the family constructs actions for care in pursuit of well-being. objective: this research was designed to describe the sort of traditional care families generally provide to elderly survivors of a first stroke. method: it is an ethnographic study featuring participant observation and in-depth interviews. seven families from bogotá took part (seven seniors between two and ten months after their first stroke and their seven respective primary caregivers). results: the caregivers and the elderly adults in question share actions for recovery related to food, personal care and medication intake that are permeated by religious beliefs, a source of support and bonding. conclusion: understanding the type of traditional care provided by this population makes it possible to propose action that is culturally congruent with their values and beliefs, so as to empower the capacity of families and mediate in treatment processes. keywords stroke, elderly person, family, ethnography, culture (source: decs, bireme). 171 cuidado popular de familias con un adulto mayor sobreviviente del primer accidente cerebrovascular l lucero lópez díaz y otros cuidado popular de famílias com idoso sobrevivente do primeiro acidente vascular cerebral resumo introdução: o acidente vascular cerebral afeta numerosas pessoas no mundo e constitui-se na principal causa de morte. os sobreviventes podem padecer deficiência e sofrer alterações de suas atividades cotidianas. a família é o principal apoio do sobrevivente e, ao ser parte de uma mesma cultura, constroem ações de cuidado em busca do bem-estar. objetivo: descrever as ações do cuidado popular das famílias com um idoso sobrevivente do primeiro acidente vascular cerebral. método: estudo etnográfico, com observação participante e entrevistas em profundidade. participaram dele sete famílias bogotanas (sete idosos entre dois e dez meses posteriores ao primeiro acidente vascular cerebral e sete cuidadores principais respectivos). resultados: cuidadores e idosos compartilham ações de cuidado para a recuperação, relacionadas com a alimentação, com o cuidado pessoal e com o consumo de medicamentos, permeadas pela crença religiosa, fonte de suporte e vínculo afetivo. conclusão: conhecer o cuidado popular dessa população possibilita propor ações culturalmente congruentes com seus valores e crenças para potencializar as capacidades familiares e intermediar nos processos de tratamento. palavras-chave acidente vascular cerebral, idoso, família, etnografia, cultura (fonte: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 169-178 172 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 introducción el accidente cerebrovascular (acv) es la segunda causa de muerte en el mundo, con pérdida de años de vida saludable (1, 2). quienes sobreviven al acv pueden padecer discapacidad física o cognitiva, problemas visuales, problemas de comunicación, disminución de la sensibilidad, pérdida de la conciencia de una parte de su cuerpo, limitación en las actividades con secuelas por varios años (3, 4). después de la fase aguda, los sobrevivientes regresan a casa con importantes limitaciones. muchos con dificultades para cuidar de sí mismos por semanas, meses y posiblemente por años. en muchos países, la familia se torna en el principal soporte físico, mental y social. los cuidadores familiares deben enfrentar diversos tipos de problemas y necesidades según la fase del acv (5, 6), y hay correlación directa entre el bienestar físico y mental del cuidador y su calidad de vida cuando provee cuidado a un familiar con escasa discapacidad (7). el número de sobrevivientes de acv y sus cuidadores tienden a crecer con el envejecimiento poblacional y la sobrevida resultante de las intervenciones terapéuticas (8). revisiones cuantitativas y cualitativas han criticado los resultados de los trabajos con sobrevivientes y cuidadores de personas con acv por una tendencia a tratarlos como un grupo homogéneo y el posible desconocimiento del impacto de las diferencias demográficas llamando a poner de una forma interpretativa sus experiencias (8-10). en ese sentido, danzl et al. (9) analizan estudios cualitativos de algunos grupos culturales con acv y muestran la importancia de las diferencias culturales y demográficas pero alertan a considerar las diferencias regionales, sociales y políticas. la enfermería transcultural ha señalado cómo la cultura marca para las personas y las familias trayectorias de cuidado frente a la recuperación y rehabilitación permeada por valores, creencias y prácticas, poco estudiadas en este grupo poblacional (10, 11). comprender el cuidado popular en salud (entendido como valores, creencias y prácticas desarrolladas por el adulto mayor sobreviviente de acv y su cuidador principal en un entorno urbano de nivel socioeconómico medio) permite generar conocimiento para promover un cuidado de enfermería culturalmente congruente o sensible. el estudio presenta las acciones de cuidado popular de las familias con un adulto mayor sobreviviente del primer acv en un contexto urbano con un estatus social medio-bajo. la familia fue considerada como el adulto mayor sobreviviente y el cuidador familiar principal. materiales y métodos el trabajo se realizó desde la etnografía interpretativa, porque permite descubrir los significados de las interacciones sociales observadas y examinar la información en términos de lo que significa para las personas. así, el análisis fue dialógico, donde interactúan las voces de los colaboradores e investigadores para interpretar el fenómeno (12). la observación participante y las entrevistas en profundidad se realizaron con siete familias bogotanas en su respectivo domicilio, para un total de catorce informantes (en adelante se llamarán colaboradores), siete cuidadores familiares principales y siete adultos mayores. los colaboradores claves fueron siete (tres cuidadores familiares principales y cuatro adultos mayores). la captación de los colaboradores partió de 205 registros de personas egresadas por accidente cerebrovascular de un hospital de bogotá. fueron contactadas telefónicamente 63 personas, quienes cumplieron los criterios de inclusión: mayores de 60 años con primer accidente cerebrovascular (entre 1 mes a 11 meses), dependientes de un cuidador familiar mayor de edad, habitantes en bogotá y con posibilidad de hablar de su experiencia. las familias fueron visitadas al azar hasta lograr la saturación de datos. el equipo investigador contó con dos auxiliares de investigación: una enfermera y una psicóloga con entrenamiento en trabajos cualitativos etnográficos en el grupo de investigación de cuidado cultural de la salud de la facultad de enfermería de la universidad nacional de colombia, quienes nutrieron el proceso bajo la supervisión del equipo investigador. todos los datos fueron registrados en diario de campo individual (cada auxiliar) y grupal, las entrevistas fueron grabadas y transcritas (verificadas por las investigadoras). el trabajo de campo se extendió por cinco meses. cada familia fue visitada dos o tres veces, por las dos auxiliares, previa cita telefónica (por solicitud de los participantes). la experiencia en campo llevó a realizar las entrevistas en lugares separados de la casa para la libre expresión tanto del familiar como de la persona anciana y el contraste. la observación participante contó con los registros individuales de las auxiliares en diario de campo, las entrevistas grabadas y transcritas. 173 cuidado popular de familias con un adulto mayor sobreviviente del primer accidente cerebrovascular l lucero lópez díaz y otros la recolección y el análisis de la información se realizaron de forma simultánea, esto permitió el contraste de la información, la formulación de nuevas preguntas y la organización de la información. las nuevas hipótesis, observaciones o ajustes se realizaban en el siguiente encuentro. el equipo construyó una matriz de análisis en word, con subcategorías emergentes y posteriormente se constituyeron las categorías. el contenido, la representación, la agrupación y la nominación se realizaron en grupo (investigadoras y auxiliares) alcanzando un consenso. en el estudio principal emergieron 29 subcategorías y 8 categorías. se presentarán las subcategorías relacionadas directamente con las acciones de cuidado popular de las familias con el adulto mayor sobreviviente del primer acv. el rigor metodológico se obtuvo haciendo uso de un trabajo intenso en campo, contrastando el efecto que la presencia de las auxiliares en el domicilio tenía sobre los datos. al finalizar los encuentros con las familias se hacía un encuentro entre auxiliares/ investigadoras como una forma de contrastar las diferentes fuentes. en los encuentros periódicos hubo lugar para identificarse/ distanciarse con las propias experiencias y las de los participantes para mantener la reflexividad en cuanto a creencias y opiniones. así, las interpretaciones fueron contrastadas en el equipo investigador y discutidas con los colaboradores claves en una nueva entrevista. los criterios anteriores favorecen el criterio de auditabilidad y transferibilidad porque se buscó la representatividad de los datos con la saturación de los mismos. el estudio contó con la aprobación del comité de ética de la facultad de enfermería de la universidad nacional y del hospital que facilitó la información. asimismo, se tuvieron en cuenta todos los cuidados éticos de acuerdo con la resolución 8430 de 1993 del ministerio de salud de colombia, y se contó con la firma del consentimiento informado de los participantes. resultados en la tabla 1 se indican las características de los adultos mayores con acv participantes en el estudio. la edad se encontraba entre los 70 a 81 años, en su mayoría mujeres viudas, con primaria incompleta, que recibían un ingreso mensual proveniente de una pensión, con vivienda propia y el tiempo transcurrido del acv entre 2 a 10 meses. solo un colaborador se definió como de religión protestante, los demás se declararon católicos. la tabla 2 muestra las características de los cuidadores de los adultos mayores con accidente cerebrovascular. la edad se encontraba entre los 46 a 76 años, todas mujeres, la mayoría casadas, con escolaridad de primaria y 2 con estudios superiores de nivel técnico y universitario, quienes desempeñaban el principal rol de ama de casa, casi todas hijas del adulto mayor con acv, con dedicación permanente al cuidado del mismo. tabla 1. características de los adultos mayores posaccidente cerebrovascular características persona anciana (n = 7) edad (años) 70 a 75 3 76 a 81 4 sexo mujeres 4 hombres 3 estado civil viudos 5 casados 2 educación sin educación 1 primaria incompleta 3 primaria completa 1 secundaria incompleta 1 secundaria completa 1 fuente de ingresos pensión 5 ayuda familiar 2 vivienda propia 5 arriendo 2 tiempo transcurrido del ecv (primera visita) 2 a 6 meses 3 7 a 10 meses 4 fuente: elaboración propia. 174 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 tabla 2. características de los cuidadores familiares de un adulto mayor posaccidente cerebrovascular los hallazgos presentados en este artículo se refieren específicamente a las acciones realizadas tanto por el cuidador como por el adulto mayor sobreviviente de acv. aunque se presentan de forma separada, hay congruencia entre el significado de las acciones realizadas y las expectativas frente a las mismas. acciones de cuidado ofrecidas por el cuidador “uno se preocupa por darle comida, bañarlo, vestirlo y darle los medicamentos”. los ancianos y cuidadores refieren el cuidado esencial como la búsqueda de comodidad y el soporte en los medicamentos y asuntos de salud. este consiste en la alimentación, el baño, el vestido, el arreglo de la ropa, la protección del frío, la cama limpia. “llevarla al baño por las noches”; “poner las inyecciones, estar pendiente de la droga, llevarla al médico a sus controles”; “la vestida, que no nos falte nada”; “ella me arropa cuando me acuesto, ella me arropa que no me entre frío, los cuidados de la cama que esté limpia, todo, lavarme la ropa”; “le cuido la sopita a media sal, que no coma con mucha sal porque por eso es que le duele la cabeza”. “hacemos otras cosas que sabemos ayudan”. dentro del cuidado que se brinda en el hogar algunas personas incluyen el uso de plantas aromáticas para ayudar al bienestar del adulto mayor: “agüita de apio para el dolor de estómago, o a veces de yerbabuena… agüita de cidrón, de yerbabuena, de ruda”; “ella mandó comprar valeriana y ahí se la tengo pero quería que se la diera todas las noches… para dormir porque de noche me duelen mucho los huesos”; “…y cidrón… pues para el corazón y los gases porque ella a veces se llena de gases”; “la papayuela las hace dormir, las hace tranquilizar, descansan”. “hacer más fácil la movilidad en casa evitando las caídas”. hay cierta negociación de la familia para adaptar condiciones físicas donde el adulto mayor va a estar la mayor parte del tiempo: “… los primeros días me ayudaban a bañar por lo que no tenía fuerza, ve. ya ahorita yo me baño solita, pero como que me iba de cabeza o me iba pal lado lo que fuera entonces me daba miedo, entonces me sentaban en una silla y ya me traían el agua…”. la sala-comedor fue adaptada como habitación para la adulta mayor, ya que queda en el primer piso de la casa y así ella tiene más fácil acceso para ir al baño y para movilizarse (observación participante, op). características cuidador (n = 7) edad (años) 46 a 55 3 56 a 65 3 66 a 76 1 sexo mujeres 7 hombres 0 estado civil casadas 4 solteras 2 viuda 1 educación sin educación primaria incompleta 2 primaria completa 2 secundaria incompleta 1 universitaria 1 técnico 1 actividad laboral ama de casa 4 pensionada 1 empleada 2 relación con quien recibe el cuidado hijas 4 esposas 2 hermana 1 tiempo dedicado al cuidado permanente 7 fuente: elaboración propia. 175 cuidado popular de familias con un adulto mayor sobreviviente del primer accidente cerebrovascular l lucero lópez díaz y otros “saber sobrellevarlos cuando se les cuida”. el accidente cerebrovascular genera en el adulto mayor y su cuidador incertidumbre, desgaste físico, dependencia, cambios en el estilo de vida y se pueden afectar las relaciones personales. el adulto mayor puede deprimirse con facilidad, o permanentemente estar de mal genio, por eso el cuidador manifiesta que debe tener mayor tolerancia, compasión y aprender a sobrellevarlos. es así como el cuidador principal es quien puede constituirse en la principal fuente de apoyo instrumental, afectivo y emocional para enfrentar la recuperación de la enfermedad: “…llevarle como el mal genio pues nosotros no llevamos una relación buena, esa es la verdad… él es de mal genio… toca tener mucha paciencia… hablar, estar con él, salir…”. “a uno como cuidador le toca responder con las tareas dentro y fuera de la casa". el cuidado al familiar implica trabajo sin remuneración y un aumento en las obligaciones con implicaciones en el bienestar: “…me toca ir a cobrarle la pensión de él, venir y distribuir, pagar los servicios, el mercado”; “yo me levantaba dos veces en la noche, me acostaba a las 11 de la noche me levantaba dos veces a que la llevara a orinar, o ahí en la cama era, luego me acostaba, me levantaba, tenía que llevarle las drogas, que hacer el desayuno”; “ella me baña, hace de todo, ella es la que me baña … y aquí quien arregla la casita?, ella; ¿y pagar servicios? a ella le toca de todo”. acciones de cuidado de la persona mayor “tener voluntad para vivir por la familia y no quedarse quieto”. quien ha sobrevivido el acv asume una actitud de apego a la vida y una gran motivación de superarse por no ver sufrir la familia, esto implica realizar actividades y no quedarse quieto: “…a la voluntad… sí, porque uno debe vivir por la familia, ¿no? seguir por la familia, ¿no? ayudarles, ayudarles en vivir para ellos… en recuperarme, en estar pues con vida para poderles ayudar, ¿no?”; “…a él nunca lo ve acostado, él se muere si se queda quieto… mi hija le trajo una pelota y parecía que no tuviera nada… él, así le duela, él hace sus cosas… dice que el día que se quede quieto se muere ahí sentado”. “tener fe en los tratamientos que nos ordenan”. los sobrevivientes de acv tienen fe no solo en los tratamientos prescritos sino en las personas que los atienden: “tener fe, porque si no se tiene fe de las pastas que le dan allá y sin tener fe, pues no, no le hacen, toca tener fe…”. estos pacientes mantienen la esperanza de ser sanados con los tratamientos ordenados. sin embargo, frente a los medicamentos, tienen la noción de ayuda y no de cura. adaptan su uso de acuerdo a como perciben que “le sientan” los medicamentos, es decir, según la valoración propia de los efectos secundarios percibidos del uso de la medicación: “… los remedios, yo digo que no es tanto recuperación, que lo tienen como estable, que lo tienen como ahí… porque curarlo no lo han curado, que lo tienen como ahí…”. por su parte, las terapias físicas son evaluadas generalmente como algo benéfico para la salud y para recuperar su movilidad e independencia: “…lo ponen a uno con balones… eso da borrachera, luego para acá, luego para este lado… hoy me acostaron… me pusieron a hacer un ejercicio pero estaba que me vomitaba… son ejercicios para la cabeza, entonces lo ponen a uno mareado”; “…tiene avances, entonces hay satisfacción, porque por ejemplo que día empezó a caminar y pues yo pienso que es rápido para ser menos de mes y medio… ya está lúcida, ya habla bien y todo”. la frecuencia de las terapias en casa depende de cómo las evalúa el adulto mayor. al inicio las realizan a pesar de las molestias, pero cuando han recuperado el movimiento bajan la frecuencia o deciden suspenderlas. adaptan elementos para las terapias: pelotas, paredes, máquina de coser, lentejas. “cuidarse con la alimentación". buscan seguir una dieta o limitar los alimentos perjudiciales para la salud. sin embargo, factores de origen económico, preferencias, la cultura, o la información recibida en las instituciones de salud afectan dicha toma de decisiones: “…pues muchas veces no se puede cumplir la dieta porque, por ejemplo, que comer solo verduras. pues es muy difícil y más sin sazón ni nada, un poco de hierbas cocinadas en agua, es difícil, yo creo que con ese sabor se van a sentir más enfermos, que no les alimenta, que no se van a sentir un poco más fuertes”; “…entonces, como dicen, sin sal totalmente tampoco, porque entonces se va a morir de la enfermedad, se va a morir de hambre, hay que echarle un toque, si, no ir a pasarse tampoco, algo que el paciente se pueda comer”. “creer en dios recupera”. las personas reconocen el poder de dios para otorgarles la vida y la salud. le hacen ruegos o piden a otros que oren a dios o a intercesores como la virgen maría, los santos, para que les recupere la salud y les dé fortaleza 176 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 para enfrentar la enfermedad: “yo le pido a mi dios, ahora viene un señor… él hace unas oraciones, con eso cura la gente… con las oraciones”; “…diosito que es el único que le hace a uno los favorcitos… yo le pido mucho a dios… que si me va a dejar pues que me de valentía yo pa´ pararme y ver a mis hijos, ¡te lo pido señor!”. discusión ser mujer es una de las características de los colaboradores del estudio (tanto del adulto mayor como de los cuidadores). el papel de cuidador lo asumieron las hijas y las esposas confirmando hallazgos nacionales e internacionales. la familia es el principal soporte físico, emocional y e informal para los pacientes con acv en muchos países. los pacientes se sienten mejor con su familia para llevar a cabo las actividades de la vida diaria y de autocuidado (4). infortunadamente, los cuidadores pocas veces reciben preparación para esa transición del hospital a la casa y en el proceso de rehabilitación, mostrando la necesidad de ofrecer salidas anticipadas a los conocidos resultados negativos en salud de estos cuidadores (13, 14). las acciones de cuidado popular de las familias con un adulto mayor sobreviviente de primer acv son similares al estudio realizado por braga et al. (15), porque se enfocan en proporcionar una atención en aspectos relacionados con la comodidad, al apoyo en actividades de la vida diaria, el soporte en aspectos de salud y el suministro de medicamentos. además, coincide con el estudio de subgranon y lund (14), porque el cuidado ofrecido por los familiares implica el uso de plantas medicinales junto con los medicamentos alopáticos. el grupo abordado en este estudio permite mostrar un despliegue de responsabilidad y compromiso con el adulto mayor sobreviviente de acv. hay una sincronía en el objetivo del cuidado ofrecido y recibido encaminado a la recuperación de la persona afectada. las acciones del familiar muestran una disponibilidad para el mismo e insinúan una evaluación positiva de su acción. los aspectos religiosos compartidos se convierten en un motor para la acción frente a un escenario de incertidumbre en cuanto a la recuperación o una recaída. la fe se constituye como un eje de resiliencia para enfrentar las demandas de adaptación, y produce acciones de ajuste en la estructura familiar y en la organización del espacio de casa. aunque el familiar no comprende los cambios emocionales del sobreviviente, usa el recurso de la paciencia para mantener una relación armoniosa con su familiar. tanto el sobreviviente del acv como su cuidador súbitamente son forzados a adaptarse a las limitaciones físicas o cognitivas pero esos cambios pueden ser estresantes para los dos y, más aún, si no cuentan con una preparación para enfrentar dicha situación (5, 9, 15). de otro lado, para el trabajo profesional se activan varias alertas; así, debe considerarse cómo esas prácticas y actitudes culturales podría coexistir con gran vulnerabilidad para un determinado grupo (16, 17); el soporte social ha demostrado ser importante para el bienestar tanto del sobreviviente como del cuidador; sin embargo, se deben considerar los ajustes familiares a largo plazo de los cuidadores con los sobrevivientes de acv porque la escasa evidencia muestra alteraciones en la armonía interpersonal y personal de los mismos (5-6). los esfuerzos del cuidado popular reflejan una aproximación intuitiva a las necesidades del sobreviviente y la búsqueda de ajustes acorde con los “énfasis” realizados por el sistema de salud (dieta, ejercicios y medicación). sin embargo, la evidencia cualitativa sobre la experiencia de sobrevivientes de acv señala la necesidad de considerar, para la atención, categorías relacionadas con la interrupción biográfica (cambio, transición, transformación), las pérdidas, el aislamiento social, la adaptación y la reconciliación, más que sobre la enfermedad en sí misma, e invitan a no dejar de lado la discapacidad residual neurológica del sobreviviente de acv y señalan cómo una revisión sistemática con metaanálisis demostró que el 10 % de pacientes pueden desarrollar demencia en el año posterior al primer acv (3, 18, 19). el sobreviviente puede experimentar problemas a largo plazo en su recuperación y afectar su calidad de vida hasta en los cinco años siguientes post-acv. la prevención secundaria de eventos recurrentes es una necesidad, y los cuidadores requieren apoyo a largo plazo y una preparación adecuada (4). por tanto, los profesionales necesitan adaptar los procesos educativos a la experiencia, cultura y fase (aguda, de rehabilitación o crónica) del sobreviviente y la familia; asimismo, cada uno debe considerarse como sujeto de necesidades particulares. especial énfasis debe hacerse a monitorizar los miembros de la familia que asumen el cuidado con el fin de mitigar la susceptibilidad a resultados adversos (7, 9, 20, 21); además, un enfoque multifacético podrá reducir los reingresos después del accidente cerebrovascular (22). 177 cuidado popular de familias con un adulto mayor sobreviviente del primer accidente cerebrovascular l lucero lópez díaz y otros algunas limitaciones deben ser consideradas para futuros estudios. aunque los colaboradores están en diversas fases del proceso de pos-acv, sería ideal incluir las experiencias de las fases crónicas y comprender cómo los cuidados se pueden ir modificando con el tiempo. el estudio se realizó en un área urbana con un grupo de clase social en particular y la mayoría se declaró católico; sin embargo, se requieren estudios con otros grupos poblacionales y étnicos para configurar mayor evidencia sobre el cuidado popular frente a la situación relacionada con acv. conclusión comprender el cuidado popular de las familias con un sobreviviente de acv es un primer paso para el desarrollo de intervenciones y de soporte adaptado y sensible a grupos culturales diversos determinados por etnia, región, clase social, inclinación sexual, etc. si desde los profesionales y junto con las familias se crea conciencia de las etapas del acv, los riesgos y los aportes del cuidado popular, se podrán fortalecer programas de educación, soporte social, acompañamiento y rehabilitación culturalmente sensible a las necesidades, las prácticas y los valores culturales para mitigar la discapacidad y la pérdida de significado vital, tanto de sobrevivientes como cuidadores. las acciones de cuidado popular de la familia con un adulto mayor sobreviviente al primer acv es una tarea, principalmente, femenina de responsabilidad, apoyo, creatividad y de ajuste a la situación. sobreviviente y cuidador son congruentes en la búsqueda de la comodidad, y de forma sincrética adaptan orientaciones de tratamiento alopático con el saber popular en salud. buscan mantener la funcionalidad familiar activando la espiritualidad con la “fe en dios” para mantener el objetivo de recuperar la salud y la estabilidad frente a los cambios. en suma, responden de forma intuitiva mostrando un vacío de las instituciones y los profesionales para ofrecer soporte educativo y social frente a los cambios e incertidumbres creadas por el acv. el trabajo deja implicaciones prácticas como la necesidad de conocer los hábitos y las actitudes culturales con el fin de fortalecer las capacidades de los sobrevivientes y cuidadores; mitigar la vulnerabilidad surgida de esas consideraciones culturales; anticipar y adaptar, acorde con la perspectiva cultural del grupo, las necesidades educativas frente a los procesos de cambio e incertidumbre considerando la fase en la que se encuentren (aguda, rehabilitación o crónica); negociar formas de soporte social para los cambios dejados por el acv; preparar profesionales culturalmente sensibles y con capacidad de dignificar al sobreviviente y sus cuidadores frente al cambio e incertidumbre más que sobre la enfermedad en sí misma. referencias 1. organización mundial de la salud. estrategia paso a paso de la oms para la vigilancia de accidentes cerebrovasculares [internet];2005:1-113. disponible en: http://new.paho.org/hq/dmdocuments/2009/manuales.pdf 2. mathers cd, dejan l. projections of global mortality and burden of disease from 2002 to 2030. plos med [internet]. 2006 [citado 2015 junio 30];3(11):2011-29. disponible en: http://www.plosmedicine.org/article/fetchobject.action?re presentation=pdf&uri=info:doi/10.1371/journal.pmed.0030442 3. mellon l, brewer l, hall p, horgan f, williams d, hickey a. cognitive impairment six months after ischaemic stroke: a profile from the aspire-s study. bmc neurol. 2015;15(31):2-9. 4. nayeri nd, mohammadi s, razi sp, kazemnejad a. investigating the effects of a family-centered care program on stroke patients adherence to their treatment regimen. contemp nurse. 2014;47(1-2):88-96. 5. godwin km, swank pr, vaeth p, ostwald sk. the longitudinal and dyadic effects of mutuality on perceived stress for stroke survivors and their spousal caregivers. aging ment health [internet]. 2013;17(4):423-31. disponible en: http:// dx.doi.org/10.1080/13607863.2012.756457 6. pfeiffer k, beische d, hautzinger m, berry jw, wengert j, hoffrichter r, et al. telephone-based problem-solving intervention for family caregivers of stroke survivors: a randomized controlled trial. j consult clin psychol. 2014;82(4):628-43. 7. clay oj, grant js, wadley vg, perkins mm, haley we, roth dl. correlates of health-related quality of life in african american and caucasian stroke caregivers. rehabil psychol. 2013;58(1):28-35. 178 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 8. greenwood n, mackenzie a. informal caring for stroke survivors : meta-ethnographic review of qualitative literature. maturitas [internet]. elsevier ireland. 2010;66(3):268-76. disponible en: http://dx.doi.org/10.1016/j.maturitas.2010.03.017 9. danzl mm, hunter eg, campbell s, sylvia v, kuperstein j, maddy k, et al. living with a ball and chain: the experience of stroke for individuals and their caregivers in rural appalachian kentucky. j rural heal. 2013;29:368-82. 10. ruiz me, phillips lr, kim h, woods dl. older latinos: applying the ethnocultural gerontological nursing model. j transcult nurs [internet]. 2015; disponible en: http://tcn.sagepub.com/cgi/doi/10.1177/1043659615569539 11. phillips lr, salem be, jeffers ks, kim h, ruiz me, salem n, et al. developing and proposing the ethno-cultural gerontological nursing model. j transcult nurs [internet]. 2014;26(2):118-28. disponible en: http://tcn.sagepub.com/cgi/ doi/10.1177/1043659614563615 12. geertz c. la interpretación de las culturas. barcelona: gedisa; 2009. 13. cameron ji, naglie g, silver fl, gignac mam. stroke family caregivers’ support needs change across the care continuum: a qualitative study using the timing it right framework. disabil rehabil. 2013;35(4):315-24. 14. subgranon r, lund da. maintaining caregiving at home: a culturally sensitive grounded theory of providing care in thailand. j transcult nurs. 2000;11(3):166-73. 15. braga c, cavalcante rn, magalhães e, magalhães tm, sales da silva lm ms. o cuidado domiciliar de idosos acometidos por acidente vascular cerebral: cuidadores familiares. rev enferm uerj. 2009;17(1):41-5. 16. greenwood n, mackenzie a, wilson n, cloud g. managing uncertainty in life after stroke : a qualitative study of the experiences of established and new informal carers in the first 3 months after discharge. int j nurs stud. 2009;46:1122-33. 17. sörensen, s, pinquart m. racial and ethnic differences in the relationship of caregiving stressors, resources, and sociodemographic variables to caregiver depression and perceived physical health. aging ment health. 2005;9(5):482-95. 18. salter k, hellings c, foley n, teasell r. the experience of living with stroke: a qualiative meta-synthesis. j rehabil med. 2008;40:595-602. 19. kitson al, dow c, calabrese jd, locock l. stroke survivors ’ experiences of the fundamentals of care : a qualitative analysis. int j nurs stud. 2013;50:392-403. 20. hafsteinsdóttir t, vergunst t, lindeman e sm. patient education and counseling educational needs of patients with a stroke and their caregivers : a systematic review of the literature. patient educ couns. 2011;85:14-25. 21. pringle j, drummond js, mclafferty e. revisioning, reconnecting and revisiting: the psychosocial transition of returning home from hospital following a stroke. disabil rehabil [internet]. 2013;35(23):1991-9. disponible en: http://informahealthcare.com/dre 22. white cl, brady tl, saucedo ll, motz d, sharp j, birnbaum l a. towards a better understanding of readmissions after stroke: partnering with stroke survivors and caregivers. j clin nurs [internet]. 2015;24(7-8):1091-100. disponible en: http://doi.wiley.com/10.1111/jocn.12739 1-7 iniciales.pdf 4 revista aquichan issn 1657-5997 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 esde sus inicios, en 1991, la facultad de enfermería de la universidad de la sabana asumió el reto de desarrollar un programa curricular novedoso, de excelencia y visionario de acuerdo con las tendencias internacionales que promueven la implementación de modelos y teorías de enfermería. a sus fundadores se les sugirió que, siendo éste un programa cuyo propósito era preparar profesionales para el siglo xxi, y reuniendo la universidad de la sabana las características que se requerían para asumir este reto, debía tener como marco de referencia un modelo conceptual. se seleccionó el modelo de adaptación de roy, por la coherencia de los principios filosóficos que plantea con los propios de la universidad. ambos están fundamentados en el humanismo y en la visión cristiana del hombre. contar con un modelo como el de roy, que ha evidenciado un gran desarrollo, provee un marco de referencia esencial para el análisis y el estudio del cuidado de enfermería en diferentes escenarios de la práctica, evitando que éste se centre únicamente en el hacer, ya que permite analizar la situación particular de cada persona como ser holístico, y estudia las implicaciones de sus intervenciones en el proceso de adaptación de individuos y grupos. la utilización del modelo ha sido, entre otros, el sello que caracteriza el programa de enfermería de la universidad de la sabana, y ha contribuido a su posicionamiento y desarrollo. lo anterior se refleja en publicaciones, resultados de investigación, asesorías a otros programas y en el reconocimiento obtenido, en 2005, por parte de colciencias al grupo de estudio sobre el modelo de adaptación en categoría b. de otro lado, se ha fortalecido el programa de internacionalización de la facultad, a través del contacto con pares internacionales para el desarrollo de proyectos de investigación, el apoyo y la asesoría de enfermeras de gran trayectoria como es el caso de la doctora callista roy, quien participó como invitada central en el seminario internacional, desarrollo del conocimiento en la práctica de enfermería, y permaneció una semana en calidad de profesora visitante en marzo del presente año. quince años después de su apertura, los procesos de consolidación, madurez y desarrollo académico se han hecho una realidad y han demostrado que su fundadora y decana por nueve años, leonor pardo novoa, vislumbró lo que sería este programa en el panorama de la formación universitaria de enfermería. gracias al camino trazado, a su liderazgo, a su capacidad de trabajo, a su ejemplo y a su generosidad, hemos avanzado en este proyecto. 5 la renovación de la acreditación de alta calidad otorgada el pasado 30 de mayo por el ministerio de educación nacional por siete años, y la reciente indexación de aquichan en publindex, en categoría c, ratifican el compromiso con la excelencia y la calidad académica del programa trazado hace quince años. aquichan, vocablo indígena que significa “cuidado”, nace en el 2001, como edición conmemorativa de los diez años del programa. según como se mire, estos cinco años pueden resultar cortos para el desafío que se adquiere al tener una publicación académica de alta calidad y para asegurar su continuidad y reconocimiento. en estos cinco años aquichan ha circulado nacional e internacionalmente, incrementando con cada edición el número de lectores y autores de artículos de investigación, de reflexión, de revisión y ensayos, entre otros. académicos y enfermeras(os) de servicio de países como brasil, colombia, chile, estados unidos, españa y méxico se encuentran entre nuestros autores. de esta manera, aquichan contribuye a difundir la producción de conocimiento de enfermería, tal como lo plantea su misión. el ingreso de aquichan al programa publindex de colciencias es un importante reconocimiento al nivel académico de los autores, al trabajo riguroso de los miembros de los consejos consultivos nacionales e internacionales, quienes tienen la difícil tarea de evaluar los artículos, y a los miembros del consejo editorial, que han logrado los estándares de excelencia y calidad editorial. ¿cómo consolidar y desarrollar entonces un proyecto editorial en la comunidad académica? en primer lugar, gracias al compromiso institucional de apoyar la publicación de revistas científicas, y al trabajo conjunto de la facultad de enfermería con la oficina de publicaciones que posibilitan la realización de este proyecto por parte de la facultad de enfermería. ¿enfermería investiga? con mucha frecuencia oímos esta sencilla pero trascendental pregunta, y en ocasiones hacemos grandes esfuerzos por explicar el alcance de enfermería como disciplina profesional. sólo a través de los resultados de investigación y las publicaciones se logra hacer visible la esencia y razón de ser de la enfermería, y aquello que parece intangible e invisible logra tomar forma. como resultado de la indexación, a partir de 2007 aquichan tendrá una periodicidad semestral con circulación en abril y en octubre. esperamos igualmente que sean los estudiantes de programas de pre y posgrado nuestros permanentes lectores. son ellos quienes hacia el futuro avanzarán en el desarrollo de la enfermería. maría clara quintero laverde retos y logros académicos editorial 448 459 diferencias de sexo en el uso de estrategias.indd 448 manuela torregrosa-ruiz1 josé manuel tomás-miguel2 diferencias de sexo en el uso de estrategias de afrontamiento en personas con lesión medular 1 orcid.org/ 0000-0001-8393-8720. universitat de valencia, españa. matorui2@alumni.uv.es 2 orcid.org/ 0000-0002-3424-1668. universidad de valencia, españa. jose.m.tomas@uv.es recibido: 11 de enero de 2016 enviado a pares: 30 de enero de 2016 aceptado por pares: 18 de octubre de 2016 aprobado: 04 de noviembre de 2016 doi: 10.5294/aqui.2017.17.4.8 para citar este artículo / to reference this article / para citar este artigo torregrosa-ruiz m, tomás-miguel jm. diferencias de sexo en el uso de estrategias de afrontamiento en personas con lesión medular. aquichan. 2017; 17(4): 448-459. doi: 10.5294/aqui.2017.17.4.8 resumen objetivo: profundizar en la experiencia de afrontamiento en personas con lesión medular (lm), teniendo en cuenta tanto el afrontamiento actual como el afrontamiento durante momentos iniciales tras sufrir la lm. materiales y métodos: estudio transversal de encuesta. participaron 127 personas con lm de larga evolución, 95 hombres y 32 mujeres. los datos fueron recogidos por medio de un cuestionario online con información sociodemográfica y el cuestionario de afrontamiento del estrés (cae). se han realizado análisis descriptivos, pruebas t de student y análisis multivariados de la varianza (manovas) resultados: las comparaciones intrasujetos muestran que la estrategia de focalización en solución de problemas se usa más en el afrontamiento actual. la autofocalización negativa es más utilizada en el afrontamiento pasado, en los momentos iniciales tras sufrir la lm. los resultados de los manovas muestran que no existen diferencias en función del sexo en el afrontamiento rememorado ni en el actual. los anova de seguimiento para el afrontamiento actual evidencian que las mujeres utilizan más las estrategias de búsqueda de apoyo social y expresión emocional abierta. conclusiones: no hay diferencias de sexo en el uso de las estrategias de afrontamiento en la lm. se sugiere seguir investigando cómo el género puede actuar en este proceso. palabras clave adulto; lesiones de la médula espinal; adaptación psicológica; género y salud; personas con discapacidad (fuente: decs, bireme). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 448-459 449 diferencias de sexo en el uso de estrategias de afrontamiento en personas con lesión medular l manuela torregrosa-ruiz y otro año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 448-459 gender differences in the use of coping strategies by persons with a spinal cord injury abstract objective: delve into the experience of coping on the part of persons with a spinal cord injury (sci), contemplating both current coping and coping during the initial moments after suffering a sci. materials and methods: this is cross-sectional survey. the participants included 127 persons with long-term sci: 95 men and 32 women. the information was collected through an online questionnaire with sociodemographic information and through the stress coping questionnaire (cae). descriptive analyzes, student t-tests and multivariate analysis of variance (manovas) were conducted. results: intrasubject comparisons show the strategy focused on problem-solving is used more in current coping. negative self-targeting was used more in past coping, during the initial moments after suffering the ml. the results of the manovas show there are no gender differences in remembered coping or in current coping. the follow-up anova for current coping shows women make more use of strategies involving a search for social support and open emotional expression. conclusions: there are no gender differences in the use of coping strategies in the case of ml. it is suggested that further research be done on how gender can act in this process. keywords adult; spinal cord injuries; psychological adaptation; gender and health; people with disabilities (fuente: decs, bireme). 450 aquichan issn 1657-5997 eissn 2027-5374 diferenças de sexo no uso de estratégias de enfrentamento em pessoas com lesão medular resumo objetivo: aprofundar na experiência de enfrentamento em pessoas com lesão medular (lm), contemplando tanto o enfrentamento atual quanto o enfrentamento durante momentos iniciais após sofrer a lm. materiais e métodos: estudo transversal com questionário. participaram 127 pessoas com lm de longa evolução, 95 homens e 32 mulheres. os dados foram coletados por meio de um questionário on-line com informação sociodemográfica e pelo questionário de enfrentamento do estresse. foram realizadas análises descritivas, testes t de student e análises multivariadas da variância (manovas). resultados: as comparações realizadas intrassujeitos mostram que a estratégia de focalização em solução de problemas se usa mais no enfrentamento atual. a autofocalização negativa é mais utilizada no enfrentamento passado, nos momentos iniciais logo após sofrer a lm. os resultados das manovas mostram que não há diferenças em função do sexo no enfrentamento recordado nem no atual. as anova de seguimento para o enfrentamento atual evidenciam que as mulheres utilizam mais as estratégias de busca de apoio social e expressão emocional aberta. conclusões: não se constataram diferenças de sexo no uso das estratégias de enfrentamento na lm. sugere-se continuar pesquisando como o gênero pode agir nesse processo. palavras-chave adaptação psicológica; adulto; gênero e saúde; lesões da medula espinhal; pessoas com deficiência (fonte: decs, bireme). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 448-459 451 diferencias de sexo en el uso de estrategias de afrontamiento en personas con lesión medular l manuela torregrosa-ruiz y otro introducción la aparición de una lesión medular (lm) es una situación que conlleva un alto estrés asociado pues es un suceso vital traumático. su manifestación produce muchos cambios en la vida de la persona y requiere grandes esfuerzos de adaptación y reajuste a la nueva situación (1, 2). la pérdida brusca o paulatina de una capacidad física es siempre una situación traumática y de crisis que, en muchos casos, es vivida como intolerable y puede influir en la autoestima y el bienestar psicológico. supone una amenaza a la integridad física o psicológica de la persona y se asocia con frecuencia con emociones negativas extremas, quiebra las creencias de invulnerabilidad y control sobre la propia vida, la confianza en los otros y los referentes de seguridad del ser humano (3-5). la manera como cada persona afronte esta situación y pueda volver a ser alguien productivo, creativo y feliz dependerá de diversos factores como la personalidad previa, circunstancias externas, apoyo familiar, edad, tipo de discapacidad, creencias, actitudes, etc. (5, 6). en el proceso de adaptación a la lm, las estrategias de afrontamiento son un factor clave para lograr un ajuste psicológico y social exitoso (6-9). la forma en que los individuos evalúan la situación y sus recursos para hacer frente a su lm afectan su respuesta emocional y su posterior ajuste (9). en general, se suelen presentar algunas formas de afrontamiento más eficaces que otras: el afrontamiento centrado en el problema frente a la emoción, el afrontamiento activo frente al pasivo y el afrontamiento de aproximación frente a la evitación. estas, además, se consideran eficaces o adaptativas si contribuyen al bienestar fisiológico, psicológico y social de la persona y sus efectos a largo plazo (10, 11). básicamente, los estudios de afrontamiento de la lm se han centrado en la búsqueda de aquellas estrategias utilizadas por este colectivo, y en el análisis de su eficacia; han predominado los estudios durante la fase aguda de la rehabilitación, y el afrontamiento general a largo plazo ha sido el menos investigado (9, 12-14). a pesar de la falta de consenso existe bastante acuerdo entre los autores en que el afrontamiento activo y centrado en la resolución de problemas está asociado a menores índices de depresión en los primeros momentos en el entorno rehabilitador (3, 15), mientras que el afrontamiento pasivo, que incluye principalmente las estrategias de evitación o centradas en la emoción, suele ir acompañado de un mayor malestar psicológico (7, 13-26). en general, las estrategias de afrontamiento se mantienen más o menos estables a pesar del tiempo que pase desde la lesión (1, 9, 13, 27, 28) y hay evidencia de que el uso de estrategias activas favorece la adaptación y el ajuste social a una lm (17-28). por otra parte, al valorar su eficacia hay que tener en cuenta, además, otros factores (29) que pueden influir y pueden explicar las diferencias individuales en el afrontamiento: como el momento en el tiempo, a corto o a largo plazo; el contexto; variables psicológicas y de personalidad; incluso ciertas variables sociodemográficas como la edad, el género, el nivel socioeconómico, etc. el estudio de las estrategias de afrontamiento desde una perspectiva de género en personas con lm ha sido relativamente poco abordado, aunque en los últimos años han aparecido varias publicaciones que evalúan el afrontamiento en mujeres con lm (5, 15, 30). en general, la literatura señala la no existencia de diferencias significativas de género en las variables psicológicas relacionadas con el ajuste a una lm (31). no obstante, otros sugieren que sí (15, 30, 32-36), dado que ciertos aspectos relacionados con el rol tradicional masculino, como la capacidad de modelar emociones fuertes, puede ser adaptativo en los primeros momentos tras sufrir una lesión medular (15). además, hay evidencias de que las mujeres experimentan cambios en su red social de apoyos, ya que esta disminuye, e incluso desaparece, y tienen que desarrollar de forma gradual diferentes estrategias para adaptarse a la nueva situación (35-36). sin embargo, dada la escasa bibliografía disponible en esta área y el poco apoyo empírico consistente, surge la necesidad de más estudios de investigación que aborden esta temática. el objetivo general de este trabajo es profundizar en el conocimiento de la experiencia de afrontamiento en hombres y mujeres con lm, contemplando tanto el afrontamiento general a largo plazo como el afrontamiento específico durante los primeros momentos tras sufrir la lm. con base en estos supuestos, el presente estudio pondrá a prueba las siguientes hipótesis: h1: aparecerán diferencias significativas en el uso de las estrategias de afrontamiento con el paso del tiempo, es decir, entre el afrontamiento rememorado y el actual, lo cual indicaría que algunas estrategias son más útiles en la fase aguda que en la fase crónica. h2: en el afrontamiento rememorado no aparecerán diferencias significativas en función del sexo; en cambio, aparecerán diferencias significativas en las estrategias de afrontamiento general en 452 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 el presente. se espera que, en promedio, las mujeres utilicen más las estrategias de búsqueda de apoyo social y las centradas en la emoción que los hombres. materiales y métodos participantes la muestra estuvo compuesta por 127 personas con lm, 95 hombres (74,8 %) y 32 mujeres (25,2 %). los participantes eran personas con lesión medular de larga evolución. sus edades oscilaban entre los 20 y los 72 años, con media en 40,5 años (dt = 9,78). el tiempo transcurrido desde la lesión era de un mínimo de 1 año y un máximo de 64 años, con una media de 17,07 años (dt = 11,55). el procedimiento utilizado para seleccionar la muestra siguió los siguientes criterios: i) personas con lm con al menos un año de evolución; ii) con nivel educativo básico, y iii) conocimientos sobre el uso de internet y redes sociales. diseño y procedimiento el diseño de investigación es un estudio cuantitativo, descriptivo y transversal. la captación de individuos con lm se llevó a cabo con el apoyo de organizaciones de personas con discapacidad, quienes colaboraron en la difusión del estudio entre sus asociados. para la realización de la investigación se siguieron los estándares éticos de la american psychological association (apa) (37). de acuerdo con las normas éticas, las características del estudio hacen que este sea de riesgo mínimo, o sin ningún tipo de riesgo. se informó a todos participantes, tal y como recomienda la apa, sobre las características y la naturaleza del estudio, así como las garantías de anonimato y confidencialidad de las respuestas. tras esta información, los participantes, todos ellos voluntarios, dieron el consentimiento informado. en una segunda fase, y con la finalidad de obtener el mayor número posible de participantes, se difundió la información del estudio a través de la red social facebook. para la recogida de datos se empleó un cuestionario online a través de la plataforma limesurvey (2009) que tuvo lugar entre agosto y septiembre de 2012, y fue difundido entre las personas con lm que vivían en españa a través de la asociación de lesionados medulares y grandes discapacitados físicos (aspaym). esta plataforma es una herramienta open access que cumple con todos los estándares éticos del muestreo online, pues permite el diseño de encuestas anónimas, y cumple así la normativa española de confidencialidad de datos para encuestas electrónicas. adicionalmente, ninguno de los investigadores tenía conflicto de interés. instrumentos para medir las variables se construyó un cuestionario online que constaba de distintas escalas que recogían información de diverso tipo. en concreto, las variables de esta encuesta que se analizarán en esta investigación fueron: 1. cuestionario sociodemográfico: recogía información sobre datos personales, los sociodemográficos habituales, además de datos descriptivos de su tipo y grado de discapacidad. • cuestionario de afrontamiento del estrés (cae) (38): es una medida de autoinforme de 42 ítems que en estudios exploratorios presentó una estructura factorial de 7 componentes etiquetados como: 1) focalizado en la solución del problema, 2) autofocalización negativa, 3) reevaluación positiva, 4) expresión emocional abierta, 5) evitación, 6) búsqueda de apoyo social, 7) religión. el formato es de tipo likert, con 5 posibilidades de respuesta (de nunca a casi siempre). el cuestionario está dirigido a evaluar el afrontamiento como rasgo, aunque si se modifican las instrucciones puede emplearse para evaluar el afrontamiento ante situaciones o momentos específicos de estrés (38). para este estudio se administró el cae dos veces, una en pasado, dirigido a evaluar el afrontamiento durante las primeros momentos en que supo que se padecía una lm. los ítems son los mismos del cuestionario original, pero con el verbo redactado en pasado. obviamente, se trata de una reconstrucción de lo que sucedió desde el punto de vista de la persona con lm. para ello se modificaron las instrucciones de cumplimentación para centrarlas en ese momento. para evaluar el afrontamiento ante situaciones de estrés general y estresores del día a día se aplicó de nuevo el cuestionario cae, pero esta vez en su versión original y con el tiempo verbal en presente. los coeficientes de fiabilidad obtenidos en las 7 subescalas para evaluar las estrategias de afrontamiento rememoradas fueron los siguientes: búsqueda de apoyo social (alpha = 0,87), expresión emocional abierta (alpha = 0,72), religión (alpha = 0,89), focalización en solución de problemas (alpha = 0,75), evitación (alpha = 0,67), autofocalización negativa (alpha = 0,58) y reevaluación positiva (alpha = 0,78). por otra parte, el alfa de cronbach para cada uno de los factores del cae en presente fueron: búsqueda de apoyo social (0,94), expresión emocional 453 diferencias de sexo en el uso de estrategias de afrontamiento en personas con lesión medular l manuela torregrosa-ruiz y otro tabla 1 resultados manova en función del sexo en las estrategias de afrontamiento rememoradas (cae pasado) y las estrategias de afrontamiento generales (cae presente). variables lambda de wilks f grados de libertad p η2 parcial hipótesis error cae pasado 0,945 0,984 7 119 0,129 0,082 cae presente 0,880 1,857 7 103 0,084 0,112 fuente: elaboración propia, 2012. f = resultado de la prueba f; p = significación, p < 0,05; η2 parcial = cuadrado eta parcial; cae pasado = búsqueda de apoyo social, expresión emocional abierta; religión, focalización en solución de problemas, evitación, autofocalización negativa, revaluación positiva; cae presente = búsqueda de apoyo social, expresión emocional abierta; religión, focalización en solución de problemas, evitación, autofocalización negativa, revaluación positiva abierta (0,70), religión (0,91), focalización en solución problemas (0,90), evitación (0,77), autofocalización negativa (0,75), reevaluación positiva (0,75). análisis de datos los análisis estadísticos se llevaron a cabo en el programa spss 22. se realizaron análisis multivariados de la varianza (manovas) para determinar los efectos del género en las estrategias de afrontamiento, tanto rememoradas como actuales; se comprobó previamente la normalidad de la distribución mediante la prueba no paramétrica de kolmogorov-smirnov y la prueba de lèvene para comprobar la homocedasticidad de la muestra. el manova se complementó con análisis de varianza de continuación en donde se encontraron diferencias estadísticamente significativas. se realizaron pruebas t para muestras relacionadas a fin de poner a prueba la posible existencia de diferencias significativas entre las estrategias de afrontamiento utilizadas en el pasado y las utilizadas en el presente. el nivel de significación establecido fue 5 % (p < 0,05). resultados los contrastes multivariados realizados para averiguar si el sexo de los participantes tenía relaciones significativas con las estrategias de afrontamiento rememoradas en su conjunto y que aparecen en la tabla 1 señalan la no existencia de efectos principales del sexo en las estrategias de afrontamiento en los momentos iniciales tras sufrir una lm (labmda de wilk’s = 0,945; f (7,119) = 0,984; p = 0,446; η2 = 0,055). en cuanto a las estrategias de afrontamiento rememoradas –durante los momentos iniciales tras sufrir una lm–, el análisis univariado de varianza (anova) no mostró diferencias significativas entre hombres y mujeres. en general, existen diferencias individuales en cada una de las subescalas analizadas, pero dichas diferencias no están influenciadas por el género de las personas. los análisis descriptivos (tabla 2) evidencian que la estrategia más utilizada por los participantes ha sido la revaluación positiva tanto en hombres ( = 14,37) como en mujeres ( = 15,15). en segundo lugar ha sido la estrategia de focalización en solución de problemas, tanto para los hombres ( = 11,35) como para las mujeres ( = 10,90). en cambio, la menos utilizada ha sido la estrategia religión en ambos sexos: hombres ( = 3,03) y mujeres ( = 3,65). por otra parte, en los análisis descriptivos realizados para las estrategias de afrontamiento actual, ante situaciones de estrés general, de nuevo se observa que las medias más utilizadas han sido prácticamente las mismas; la más usada ha sido la revaluación positiva, tanto para hombres ( = 15,51) como para las mujeres ( = 16,82). seguida de la focalización en solución de problemas, donde los hombres obtienen una media de 15,21 y las mujeres de 16,71. nuevamente, la estrategia menos utilizada es la religión tanto para los hombres ( = 2,60) como para las mujeres ( = 2,75). es interesante señalar que aunque haya una tendencia a utilizar las mismas estrategias de afrontamiento en el presente y en el pasado de la lm, hay algunas diferencias sustanciales en el grado en que algunas estrategias se usan en ambas situaciones. 454 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 tabla 2 medias, desviaciones típicas y resultados de los anova para cada estrategia de afrontamiento en el cae pasado fuente: elaboración propia, 2012. sd = desviación típica; gl = grados de libertad; num = grados libertad numerador; den = grados libertad denominador; f = resultado de la prueba f; sig. = significación, p < 0,05; η2 parcial = tamaño o eta cuadrado parcial; bas = búsqueda de apoyo social; eea = expresión emocional abierta; rlg = religión; fsp = focalización en solución de problemas; evt = evitación; afn = autofocalización negativa; rvp = revaluación positiva. todas las comparaciones intrasujetos de los factores en pasado y en presente son significativas (tabla 3), excepto la estrategia evitación (t = 1,48; p ≤ = 0,001; d = 0,132). la mayor diferencia se encuentra en la focalización en solución de problemas (t = -7,55; p ≤ = 0,001; d = -0,756), que se usa mucho más en el afrontamiento actual y en los problemas cotidianos, que en el afrontamiento pasado. y también en la autofocalización negativa (t = 5,78; p ≤ = 0,001; d = 0,466) en la que sucede todo lo contrario. con respecto a los contrastes multivariados realizados con las estrategias de afrontamiento actuales (tabla 1) tampoco se puso de manifiesto la existencia de efectos principales del sexo en el afrontamiento general (lambda de wilk’s = 0,880; f (7,103) = 1,857; p = 0,084; η2 = 0,112). aunque en este caso hay que tener en cuenta el tamaño del efecto pues este es bastante alto, dado que el género explica el 11,2 % de la varianza. debido a que el tamaño género media sd gl num den f sig η2 parcial bas hombre 6,84 5,06 1 125 1,224 0,27 0,010 mujer 8,06 6,30 eea hombre 5,92 4,24 1 125 1,477 0,22 0,012 mujer 6,96 4,05 rlg hombre 3,03 5,00 1 125 0,370 0,54 0,003 mujer 3,65 5,07 fsp hombre 11,35 5,29 1 125 0,171 0,68 0,001 mujer 10,90 5,52 evt hombre 11,29 5,09 1 125 0,192 0,66 0,002 mujer 11,75 5,03 afn hombre 8,65 4,37 1 125 0,095 0,75 0,001 mujer 8,93 4,97 rvp hombre 14,37 5,14 1 125 0,555 0,95 0,009 mujer 15,15 4,97 del efecto es relevante en este caso particular, y que la muestra no es excesivamente elevada, en el caso de las estrategias en el presente sí se pasará a analizar mediante anovas de continuación el detalle de cada una de las estrategias empleadas. en la tabla 4 se presentan los resultados de los anova de seguimiento para el efecto de la variable sexo en el uso de las estrategias de afrontamiento ante situaciones de estrés general (cae presente). los anova de continuación indicaron que existían diferencias significativas en función del sexo en las estrategias: búsqueda de apoyo social: f (1,109) = 5.808; p = 0,018; 2 = 0,051, y en expresión emocional abierta: f (1,109) = 3.996; p = 0,048; η2 = 0,035). en concreto, las mujeres utilizan más estrategias de búsqueda de apoyo social y de expresión emocional para afrontar las situaciones de estrés general y así adaptarse a las situaciones. las mujeres tenían mayores puntuaciones medias que los hombres en ambas estrategias. 455 diferencias de sexo en el uso de estrategias de afrontamiento en personas con lesión medular l manuela torregrosa-ruiz y otro tabla 3 medias, desviaciones típicas y resultados de la prueba t para muestras relacionadas para cada estrategia de afrontamiento en el cae pasado y presente cae media sd gl t sig. d bas pasado 7,19 5,28 113 -3.302 ,001 -,27 presente 8,71 5,80 eea pasado 6,20 4,24 113 3.709 ,000 ,29 presente 5,05 5,28 rlg pasado 3,21 5,03 112 2.360 ,020 ,12 presente 2,61 4,69 fsp pasado 11,55 5,24 112 -7.557 ,000 -,75 presente 15,55 5,32 evt pasado 11,34 4,96 113 1.480 ,142 ,13 presente 10,69 4,85 afn pasados 8,50 4,32 112 5.782 ,000 ,46 presente 6,47 4,14 rvp pasado 14,93 4,84 113 -2.181 ,031 -,17 presente 15,74 4,22 fuente: elaboración propia, 2012. sd = desviación típica; gl = grados de libertad; t = resultado de la prueba t para muestras relacionadas; sig. = significación, p < 0,05; η2 parcial = tamaño o eta cuadrado parcial; cae = cuestionario afrontamiento estrés; bas = búsqueda de apoyo social; eea = expresión emocional abierta; rlg = religión; fsp = focalización en solución de problemas; evt = evitación; afn = autofocalización negativa; rvp = revaluación positiva. tabla 4 medias, desviaciones típicas y resultados de los anova para cada estrategia de afrontamiento en el cae presente género media sd gl num den f sig η2 parcial bas hombre 7,79 5,52 1 109 5,808 0,01 0,051 mujer 10,75 5,84 eea hombre 4,55 3,35 1 109 3,996 0,04 0,035 mujer 6,03 3,44 rlg hombre 2,60 4,95 1 109 0,020 0,88 0,000 mujer 2,75 4,20 fsp hombre 15,21 5,33 1 109 1,659 0,20 0,015 mujer 16,71 5,40 evt hombre 10,73 4,77 1 109 0,013 0,90 0,000 mujer 10,85 5,27 456 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 fuente: elaboración propia, 2012. nota: sd = desviación típica; gl = grados de libertad; num = grados libertad numerador; den = grados libertad denominador; f = resultado de la prueba f; sig. = significación, p < 0,05; η^2 parcial = tamaño o eta cuadrado parcial; bas = búsqueda de apoyo social; eea = expresión emocional abierta; rlg = religión; fsp = focalización en solución de problemas; evt = evitación; afn = autofocalización negativa; rvp = revaluación positiva. discusión en relación con la primera de las hipótesis, nuestros resultados ponen de manifiesto que aunque haya una tendencia a utilizar las mismas estrategias de afrontamiento en el presente y en el pasado en las personas con lm, hay algunas diferencias sustanciales en cuanto al grado en que algunas estrategias se usan en ambas situaciones. principalmente, la mayor diferencia se encuentra en la estrategia de focalización de problemas, donde hay un mayor uso en el afrontamiento actual, es decir, en las situaciones de estrés cotidianas. en cambio, en la estrategia de autofocalización negativa sucede todo lo contrario, es más utilizada en el pasado, en los momentos iniciales tras sufrir una lm. cuando una persona se encuentra ante una situación adversa se pregunta ¿qué puedo hacer?, y las estrategias de afrontamiento que utiliza para enfrentarse a eventos como la discapacidad van a estar influenciadas por la interpretación cognitiva del evento, el significado que le dé la persona a la calidad de vida, el apoyo social percibido y la valoración asignada a las redes sociales como una fuente de apoyo para la adaptación a la discapacidad (39). en nuestro estudio, los resultados apoyan la hipótesis 1 en el sentido de que a pesar de cierta estabilidad en el uso de estrategias (9, 13, 27) hay evidencia de una dinámica de afrontamiento con el paso del tiempo, especialmente en lo referente al grado, uso y variedad de estrategias empleadas que son más significativas en el afrontamiento presente. todo parece apuntar a que las estrategias centradas en la emoción predominan en los momentos iniciales y las estrategias más activas y de resolución de problemas predominan en el afrontamiento presente. y aunque este resultado se contradice con los encontrados por otros autores (3, 7, 9, 20, 21, 25, 28) que señalan que el uso de estrategias activas se relaciona con menores índices de depresión y un mejor ajuste social, está en la línea con otros estudios que informan que el uso de estrategias de corte emotivo, especialmente en las primeras etapas del proceso de adaptación, ayudan a reducir el impacto emocional cuando la situación de salud se percibe incontrolable (19, 23, 26-27, 38). para resumir los resultados anteriores, en los primeros momentos de crisis y aparición de la lm las estrategias centradas en la emoción, aunque asociadas a un mayor malestar psicológico, pueden ser útiles para minimizar los efectos del estrés, pero a largo plazo el uso de estrategias de afrontamiento activas sería un indicativo de ajuste y adaptación a la discapacidad. en lo que respecta a la segunda hipótesis, con base en los análisis realizados podemos decir que se confirma parcialmente, pues los resultados obtenidos no permiten establecer diferencias estadísticamente significativas en función del sexo de los participantes en cuanto al afrontamiento pasado, es decir, en los momentos iniciales tras sufrir una lm. aunque en el afrontamiento en el presente sí se han encontrado diferencias significativas entre sexos, en concreto, en las estrategias de búsqueda de apoyo social y en expresión emocional abierta, que son más utilizadas en mujeres cuando se evalúa el estrés actual. en la revisión de la literatura tampoco se ha podido encontrar bibliografía que justifique estas diferencias entre ambos constructos: afrontamiento en el pasado y en el presente. en general, en la mayoría de los estudios revisados no se encontraron diferencias de afrontamiento en función del sexo (31), aunque en algunos de ellos se ha encontrado que las mujeres usan en mayor medida estrategias positivas y activas (15) y utilizan más la género media sd gl num den f sig η2 parcial afn hombre 6,44 3,49 1 109 0,143 0,70 0,001 mujer 6,10 4,31 rvp hombre 15,51 4,05 1 109 2,046 0,155 0,018 mujer 16,82 4,49 457 diferencias de sexo en el uso de estrategias de afrontamiento en personas con lesión medular l manuela torregrosa-ruiz y otro referencias 1. botero pa, londoño c. factores psicosociales predictores de la calidad de vida en personas en situación de discapacidad física. act colom psicol. 2013;16(2):125-137. doi: 10.41718/acp.2013.16.2.12. 2. díaz cf. intervenciones enfermeras en el proceso de aceptación y compromiso con la vida ante una lesión medular adquirida: revisión de la literatura. rev cient soc esp enferm neurol. 2016;43:8-16. http://dx.doi.org/10.1016/j.sedene.2015.11.002. 3. lindwall jj, russell hf, kelly eh, klaas sj, mulcahey mj, betz rr, vogel lc. coping and participation in youth with spinal cord injury. top spin cord inj rehabil. 2012;18(3):220-31. doi: 10.1310/sci1803-220. búsqueda de apoyo social (35), o que los hombres presentan más ansiedad tras sufrir una lm y menor adaptación (30). en cambio, estudios realizados en población no discapacitada, como el de cabanach et al. (39), señalan que las mujeres recurren al apoyo social como estrategia de afrontamiento más a menudo que los varones. estos autores ofrecen evidencia de las diferencias de afrontamiento entre los participantes en función del sexo: mientras que los hombres tienen actitudes y acciones realistas hacia la enfermedad, centradas en la búsqueda de información, de tratamiento y de apoyo, las mujeres presentan una mayor utilización de estrategias de tipo emocional y de corte social. sin embargo, aún hace falta obtener más datos para llegar a conclusiones definitivas en esta materia, si se considera la influencia de las variables culturales y de personalidad. por tanto, nuestros resultados están en la línea con los encontrados por isaksson y hellman (35) que afirman que las mujeres con lm suelen perder su red social de apoyos y para adaptase a la situación tienen que desarrollar, de forma gradual, diferentes estrategias para participar en la comunidad (31). podemos hipotetizar que esta diferencia significativa entre hombres y mujeres pueda deberse a determinadas variables personales asociadas al afrontamiento del estrés, y a ciertas variables sociodemográficas como el nivel de lesión neurológica (5, 31), la etiología de la lesión (5), la edad y el momento cuando se tuvo la lm (12,19), nivel socioeconómico, la educación (5,12, 26), etc. aunque, en general, son numerosos los estudios que encuentran mayor predisposición de las mujeres con lm a presentar síntomas depresivos y un peor ajuste a la discapacidad (33), pero la falta de consenso teórico y metodológico dificulta llegar a conclusiones firmes. la disparidad de resultados presentes en la literatura plantea la reflexión acerca de las construcciones socioculturales de los roles femeninos y masculinos, y de ciertos estereotipos relacionados con la discapacidad, pues también pueden explicar, en parte, las diferencias en función del sexo observadas, dado que estas generan una imagen social negativa de la mujer con discapacidad. los roles de género se imbrican con otras variables que hacen que la vida cotidiana de las personas con lm (40, 41), especialmente las mujeres, manifiesten tasas más altas de depresión y barreras que sus homólogos masculinos, aspecto este de la experiencia que merece más atención. las limitaciones de este estudio son varias. en primer lugar, los resultados encontrados no son fácilmente generalizables, puesto que se trata de una muestra no representativa, aunque sí heterogénea y variada. sería más conveniente una muestra mayor, en donde haya una representación más elevada de mujeres con lm. por otra parte, el tipo de diseño utilizado, transversal, limita la interpretación de las relaciones encontradas. finalmente, otros factores no evaluados pueden actuar como mediadores, lo que a su vez abre nuevas puertas para futuras investigaciones. conclusiones estos resultados sugieren que aunque se ha encontrado cierta estabilidad en los estilos de afrontamiento con el paso del tiempo, existen diferencias entre el afrontamiento en el pasado y el afrontamiento actual en las mujeres, pero no así en los hombres: estas utilizan más estrategias de afrontamiento de búsqueda de apoyo social y de expresión emocional abierta. esto puede ser indicador de una dinámica personal en la utilización de dichas estrategias y en la influencia de ciertas variables sociodemográficas y socioculturales (nivel, etiología, momento, tiempo transcurrido de la lesión, nivel educativo, nivel económico y laboral, roles de género, etc.) que pueden influir en este proceso de adaptación a una lm. 458 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 4. ordóñez-camblor n, fonseca-pedrero e, paino m, garcía-álvarez l, pizarro-ruiz jp, lemos-giráldez s. evaluación de experiencias traumáticas tempranas en adultos. papeles del psicólogo. 2016;37(1):36-44. [vistado 2015 ago 19]. disponible en: http://www.redalyc.org/html/778/77844204005/. 5. kalpakjian cz, mccullumsmith cb, fann jr, richards js, stoelb bl, heinemann aw, bombardier ch. post-traumatic growth following spinal cord injury. j spin cord med. 2014;37(2):218-25. doi: 10.1179/2045772313y.0000000169. 6. january am, zebracki k, chlan km, vogel lc. understanding post-traumatic growth following pediatric-onset spinal cord injury: the critical role of coping strategies for facilitating positive psychological outcomes. dev med child neurol. 2015;57(12):1143-49. doi: 10.1111/dmcn.12820. 7. livneh h, martz e. coping strategies and resources as predictors of psychosocial adaptation among people with spinal cord injury. rehabil psychol. 2014;59(3):329-39. doi: 10.1037/a0036733. 8. saurí j, umana mc, chamarro a, soler m d, gilabert a, elfström ml. adaptation and validation of the spanish version of the spinal cord lesion-related coping strategies questionnaire (scl csq-s). spinal cord. 2014;52(11):842-49. 9. kennedy p, lude p, elfstrom m, smithson e. appraisals, coping and adjustment pre and post sci rehabilitation: a 2-year follow-up study. spinal cord. 2012;50:112–8. doi: 10.1038/sc.2011.127. 10. lazarus rs, folkman s. estrés y procesos cognitivos. barcelona: martínez roca; 1986. 11. kunz s, joseph s, geyh s, peter c. posttraumatic growth and adjustment to spinal cord injury: moderated by posttraumatic depreciation? 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(2001). the roy adaptation model and content analysis. raa review, 1 (2), 5-6, with permission. 1 college of nursing and health sciences, university of massachusetts, boston. 100 morrissey blvd. boston, ma 02125-3393. usa. jacqueline.fawcett@umb.edu recibido: 8 de junio de 2006 aprobado: 30 de julio de 2006 resumen palabras clave modelo de adaptación roy, preguntas abiertas, análisis de contenido. roy adaptation model, open-ended questions, content analysis. el objetivo del presente estudio consiste en explicar de qué manera se puede utilizar el modelo de adaptación de roy para guiar el análisis de contenido cuantitativo y cualitativo de respuestas a preguntas abiertas en una entrevista. estas respuestas pueden ser catalogadas como adaptativas o inefectivas respecto de los modos de adaptación psicosocial, autoconcepto, función de rol e interdependencia y, entonces, asociadas a un determinado puntaje de adaptación. el modelo de adaptación de roy. análisis de contenido año 6 vol. 6 nº 1 (6) 34-37 chía, colombia octubre 2006 the roy adaptation model and content analysis. el modelo de adaptación de roy. análisis de contenido 35 ontent analysis involves classification of textual material, “reducing it to more relevant, manageable bits of data” (1). the textual material typically is in the form of interview transcripts, essays, journal articles or book chapters, diaries, speeches, and other printed documents. nurse researchers frequently use content analysis to classify responses to openended interview questions. classification of textual material into manageable data is accomplished by carefully reading the document and inducing categories from the words, phases, and sentences in the textual material. for example, the response to an open-ended question may be a word, a phrase or an entire sentence found in the transcript of an interview. the word, phrase, or sentence is examined for similarities and differences with other words, phrases, and sentences in the transcript and eventually placed in an evolving category. another approach is to place the words, phrases, and sentences into preexisting categories. this approach is appropriate if the textual material is the raw data collected from participants in conceptual model-based studies. the concepts of the conceptual model can then serve as the preexisting categories. although many people regard content analysis as an exclusively qualitative methodology, some experts add a quantitative component to the analysis (2, 3). according to weber (3), “the best content-analytic studies use both qualitative and quantitative operations on texts”. the purpose of this paper is to explain how the roy adaptation model can be used to guide a combined qualitative and quantitative content analysis of responses to open-ended interviews. the example is from a series of studies of women’s responses to cesarean birth (4, 5, 6, 7, 8). women who had experienced a cesarean delivery were asked to respond to the cesarean birth experience questionnaire (cbeq). the cbeq is made up of five questions: how did you feel, physically and emotionally, when you found out you were to have your baby by the cesarean method? how did you feel, physically and emotionally, during the actual birth experience? what happened after the baby was born? how did you feel physically and emotionally during that time? what were your greatest needs during the entire experience? what could have been done, and by whom, to make this experience better for you? as can be seen in figure 1, the words, phrases, and/or sentences that represent the women’s responses to the five questions are classified within the four adaptive modes of the roy adaptation model (physiological, self-concept, role function, interdependence). responses that do not reflect any of the adaptive modes are placed in an “other” category. in keeping with the roy model, the responses also are classified as adaptive or ineffective responses. examples of responses are given in table 1. once they are classified, the total number of responses in each cell in figure 1 is entered into a computer database and quantitative analyses are performed. for example, the total revista aquichan issn 1657-5997 36 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 number of responses is computed by adding all cells across all questions. the total number of adaptive responses across all questions is computed by adding the “a” cells (p,a; sc,a; rf,a; i,a; and o,a), and the total number of ineffective responses across all questions is computed by adding the “i” cells (p,i; sc,i; rf,i; i,i; and o,i). the total number of adaptive or ineffective responses for a particular question is computed by adding all “a” or “i” cells for that question. frequency statistics can be used to obtain tallies of the various categories of responses. chi-square statistics can be used to examine differences in responses for such contextual stimuli as cultural groups, regional or general anesthesia, partner presence or absence at delivery, planned or unplanned cesarean birth, and cesarean birth information obtained or not obtained prior to the delivery. in addition, a total adaptation score can be computed by dividing the total number of adaptive responses by the total number of responses (adaptive + ineffective responses) and multiplying by 100. the potential range of adaptation scores is 0 to 100, with higher scores indicating greater adaptation. in the example given for the cbeq (figure 1), an adaptation score can be calculated for each question or each mode of adaptation or for all questions. the total number of adaptive responses and the total number of ineffective responses can be obtained from the “sum” statistic in the spss “descriptives” program. the adaptation score than can be used in correlational and analysis of variance statistical procedures. for example, the correlation between the number of cesarean births a group of women have experienced and their adaptation scores can be calculated. or, the difference in mean adaptation scores for women who had unplanned cesarean births and those who had planned cesarean births can be calculated. readers are encouraged to adapt this content analysis methodology for their studies. questions may be addressed to dr. jacqueline fawcett, po box 1156, waldoboro, me 04572; e-mail: jacqueline. fawcett@umb.edu. mode adaptive responses ineffective responses table 1. classification of cbeq responses: examples for the adaptive modes physiological “physically, i felt fine.” “i felt very tired.” “i did not feel any pain.” “all i wanted to do was sleep.” “after the epidural, i did not feel anything.” “i had a lot of pain.” self-concept “i was so happy.” “i was really scared.” “i was thrilled that my baby was born.” “i was very anxious.” “i was completely out of it” “i cried when i found out about the cesarean.” role function “i am so relieved that my baby is healthy.” “i wasn’t able to have my baby vaginally.” “i really like being a mother.” “i was so disappointed that i could not breastfeed my baby right away.” “i do not know how to hold the baby so that it does not hurt my incision.” interdependence “my partner was so supportive.” “i wish my partner could have been with me.” “the nurses were very helpful.” “the staff were not supportive of my needs.” directions: underline the words, phrases, or sentences that represent a response to the question. assign conse-cutive numbers to each word, phrase, or sentence. place the number of each underlined word, phrase, or sentence in the appropriate cell (p,a; p,i; sc,a; sc,i; etc.) for each question. calculate the sum of the responses in each cell for each question and enter that number in the computer database. (for example, calculate the sum of all responses in cell p,a for question 1) the roy adaptation model and content analysis. el modelo de adaptación de roy. análisis de contenido 37 id p, a p, i sc, a sc, i rf, a rf, i i, a i, i o, a o, i question 1 question 2 question 3 question 4 question 5 1. lewis-beck ms. series editor’s introduction. in r. p. weber, basic content analysis. 2 ed. newbury park, ca: sage; 1990. 2. krippendorff k. content analysis: an introduction to its methodology. newbury park, ca: sage; 1980. 3. weber rp. basic content analysis. 2 ed. newbury park, ca: sage; 1990. 4. fawcett j. needs of cesarean birth parents. journal of obstetric, gynecologic, and neonatal nursing 1981; 10: 372 376. 5. fawcett j, aber c, weiss m, mayers st, king c. [correlates of women’s responses to cesarean birth.] unpublished raw data; 2006. references legend: id = study participant code number p,a = physiological mode, adaptive response p, i = physiological mode, ineffective response sc, a = self-concept mode, adaptive response sc, i = self-concept mode, ineffective response rf, a = role function mode, adaptive response rf, i = role function mode, ineffective response i, a = interdependence mode, adaptive response i, i = interdependence mode, ineffective response o, a = other, adaptive response o, i = other, ineffective response figure 1. cesarean birth experience questionnaire coding sheet. 6. fawcett j, burritt j. an exploratory study of antenatal preparation for cesarean birth. journal of obstetric, gynecologic, and neonatal nursing 1985; 14: 224 230. 7. fawcett j, weiss me. cross-cultural adaptation to cesarean birth. western journal of nursing research 1993; 15: 282-297. 8. reichert ja, baron m, fawcett j. changes in attitudes toward cesarean birth. journal of obstetric, gynecologic, and neonatal nursing 1993; 22: 159167. 9. roy c, andrews ha. the roy adaptation model. 2 ed. stanford, ct: appleton and lange; 1999. << /ascii85encodepages false /allowtransparency false /autopositionepsfiles true /autorotatepages /all /binding /left /calgrayprofile (dot gain 20%) /calrgbprofile (srgb iec61966-2.1) /calcmykprofile (u.s. web coated \050swop\051 v2) /srgbprofile (srgb iec61966-2.1) /cannotembedfontpolicy /warning /compatibilitylevel 1.4 /compressobjects /tags /compresspages true /convertimagestoindexed true /passthroughjpegimages true /createjdffile false /createjobticket false /defaultrenderingintent /default /detectblends true /detectcurves 0.0000 /colorconversionstrategy /leavecolorunchanged /dothumbnails false /embedallfonts true /embedopentype false /parseiccprofilesincomments true /embedjoboptions true /dscreportinglevel 0 /emitdscwarnings false /endpage -1 /imagememory 1048576 /lockdistillerparams false 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/untaggedcmykhandling /leaveuntagged /untaggedrgbhandling /leaveuntagged /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 305 315 encerrado a oscuras.indd 305 daniel ricardo zaraza-morales1 dora maría hernández-holguín2 encerrado a oscuras: signifi cado de vivir con esquizofrenia para diagnosticados y sus cuidadores, medellín-colombia 1 orcid.org/0000-0002-4197-3787. universidad pontificia bolivariana, colombia. daniel.zaraza@upb.edu.co 2 orcid.org/0000-0002-1050-6625. universidad de antioquia, colombia. doram.hernandez@udea.edu.co recibido: 27 de mayo de 2016 enviado a pares: 16 de junio de 2016 aceptado por pares: 29 de septiembre de 2016 aprobado: 26 de octubre de 2016 doi: 10.5294/aqui.2017.17.3.7 para citar este artículo / to reference this article / para citar este artigo zaraza-morales dr, hernández-holguín dm. encerrado a oscuras: significado de vivir con esquizofrenia para diagnosticados y sus cuidadores, medellín, colombia. aquichan. 2017; 17(3): 305-315. doi: 10.5294/aqui.2017.17.3.7 resumen vivir con esquizofrenia representa un enigma para todas aquellas personas que no presentan la enfermedad o conviven con alguien que la padece. objetivo: comprender el significado de vivir con esquizofrenia para personas que presentan la enfermedad y sus familiares, quienes acudieron a una institución estatal para la atención de problemas de salud mental de alta complejidad en colombia durante el 2014 y 2015. materiales y método: se utilizó un enfoque cualitativo y la información fue analizada por medio del método de la teoría fundamentada. las técnicas de recolección de información fueron ocho entrevistas a profundidad y dos grupos focales, con una participación de 21 personas diagnosticadas y sus cuidadores. resultados: por medio de la codificación, el muestreo teórico, la comparación constante y los memos analíticos, se llegó a la categoría “vivir con esquizofrenia es vivir encerrado, a oscuras y con los sueños truncados”. conclusiones: para los pacientes, la familia y para los cuidadores, vivir con esquizofrenia conlleva una sensación de encerramiento que afecta el proyecto de vida de unos y otros. palabras clave esquizofrenia; enfermos mentales; salud mental; enfermería psiquiátrica; teoría fundamentada (fonte: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 305-315 306 aquichan issn 1657-5997 eissn 2027-5374 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 305-315 locked in darkness: what living with schizophrenia means to diagnosed patients and their caregivers. medellín colombia abstract living with schizophrenia is an enigma to all who do not have the disease or live with someone who does. objective: the purpose of the study was to understand what living with schizophrenia means for people with the disease and their relatives, specifically in the case of patients who sought help during 2014 and 2015 at a state institution in colombia that is dedicated to handling highly complex mental health problems. materials and method: a qualitative approach was employed and the grounded theory methodology was used to analyze the information, which was gathered through eight in-depth interviews and two focus groups. twenty-one individuals took part, including xx diagnosed with schizophrenia and their caregivers. results: through coding, theoretical sampling, constant comparison and analytical memos, a category was established; namely, "living with schizophrenia is living locked up and in the dark, with curtailed dreams". conclusions: for patients, their families and caregivers, living with schizophrenia leads to a sense of confinement that affects all their lives. keywords schizophrenia; the mentally ill; mental health; psychiatric nursing; grounded theory (source: decs, bireme). 307 encerrado a oscuras: significado de vivir con esquizofrenia para diagnosticados y sus cuidadores, medellín, colombia l daniel ricardo zaraza-morales y otro envolto na escuridão: significado de viver com esquizofrenia para os diagnosticados e seus cuidadores, medellín, colômbia resumo viver com esquizofrenia representa um enigma para todas aquelas pessoas que não apresentam a doença ou convivem com alguém que a padece. objetivo: compreender o significado de viver com esquizofrenia para pessoas que apresentam a doença e seus familiares, que recorriam a uma instituição estatal para o atendimento de problemas de saúde mental de alta complexidade na colômbia durante 2014 e 2015. métodos: foi utilizada uma abordagem qualitativa, e a informação foi analisada por meio do método da teoria fundamentada. as técnicas de coleta de informação foram oito entrevistas a profundidade e dois grupos focais, com a participação de 21 pessoas diagnosticadas e seus cuidadores. resultados: por meio da codificação, da amostragem teórica, da comparação constante e dos relatórios analíticos, chegou-se à categoria viver com esquizofrenia é viver preso, às escuras, e com os sonhos interrompidos. conclusões: para os pacientes, para a família e para os cuidadores, viver com esquizofrenia implica uma sensação de encerramento que afeta o projeto de vida de todos. palavras-chave doentes mentais; enfermagem psiquiátrica; esquizofrenia; saúde mental; teoria fundamentada (fuente: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 305-315 308 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 el avance en la comprensión de la percepción sobre vivir con esquizofrenia, y lo que esto conlleva, permite humanizar cada intervención por parte del profesional de enfermería (17), ya que puede sensibilizar la práctica y la gestión del cuidado, y es importante para evidenciar la forma en la que se concibe y se lleva a cabo la atención, visualizando con ello mecanismos para innovar las acciones del personal de salud en pro de la mejora de la calidad de vida de las personas diagnosticadas (18). materiales y método esta investigación tuvo un enfoque cualitativo y fue sustentada en el interaccionismo simbólico (19). la teoría fundamentada desde la propuesta de strauss y corbin fue el método que guió el análisis de los datos (20). los participantes en el estudio fueron personas diagnosticadas con esquizofrenia y sus cuidadores, residentes en el departamento de antioquia (colombia), que en el momento recibieran servicios y atención ambulatoria psiquiátrica. se utilizó el muestreo teórico para la selección de los participantes (21). se estableció un contacto directo con cada uno de ellos ya fuera en consulta externa o en los grupos psicoeducativos. se realizaron ocho entrevistas individuales y dos grupos focales, de los cuales un grupo focal se desarrolló con personas que presentaban la enfermedad y otro con familiares cuidadores, para una participación en total de 21 personas. la información fue recolectada en dos tipos de escenarios, el hospitalario y el comunitario en las residencias de las personas entrevistadas. los criterios para participar fueron los siguientes: personas mayores de edad, que hubieran sido diagnosticadas con esquizofrenia según los criterios del dsm o el cie, y que para el momento de la entrevista estuvieran en tratamiento psiquiátrico ambulatorio; familiares de personas que hubieran sido diagnosticadas con esquizofrenia y fueran cuidadores directos de quien presentaba la enfermedad. en la tabla 1 se muestran las características de los participantes del estudio. para asegurar la calidad de las entrevistas las guías propendieron por preguntas abiertas que fueron discutidas, además de la capacitación del investigador responsable de estas y de la revisión y los ajustes a las primeras entrevistas. por medio de la codificación abierta de las primeras entrevistas realizadas a los cuidadores se llegó a categorías descriptivas como autopercepción, ciclo vital, actividades ocupacionales, cuidador, familia, salud-enfermedad. a partir de un segundo grupo de entrevistas y de un análisis centrado en la codificación axial introducción la esquizofrenia es una enfermedad mental que representa un reto para los sistemas de salud en el mundo, no solo por el grado de cronicidad que conlleva, sino también por el temprano inicio de los síntomas, que afectan en su mayoría a adolescentes o adultos jóvenes (1, 2). se estima que la prevalencia de personas con esquizofrenia es del 1 % a nivel mundial (3). dentro de las situaciones que enfrentan quienes son diagnosticados se encuentran el rechazo social, la muerte prematura por enfermedades asociadas, y la falta de tratamiento y atención oportuna, tanto así que muchos no son atendidos sino mucho tiempo después del inicio de los síntomas, y solo cuando se presenta una crisis (4, 5). se ha establecido que existen factores que pueden incrementar el riesgo de adquirirla, como es el caso del consumo de sustancias psicoactivas (6), situaciones de mucho estrés en algún momento de la vida, y la que más ha adquirido relevancia, la herencia familiar y su correspondiente carga genética (7, 8). en la actualidad, se ha adelantado mucho en materia de investigación en personas con enfermedades mentales; sin embargo, la mayoría de estudios se han realizado en ambientes institucionalizados, que si bien son importantes para determinar intervenciones sobre el individuo, no permiten explorar a ciencia cierta la interacción de este con la comunidad, sus familias y lo que conlleva vivir con esquizofrenia fuera de una clínica u hospital (4, 9). además, pocos estudios dan cuenta del significado que tiene la esquizofrenia para quienes la padecen, buscando comprender la subjetividad que viene con la experiencia de vivir y convivir con la enfermedad (10, 11). experiencias investigativas realizadas en europa y asia, desde un enfoque subjetivo, han mostrado la complejidad con relación al cuidado y el estigma que representa para una persona el vivir con una enfermedad como la esquizofrenia (12, 13). en latinoamérica, se ha estudiado la relación entre la carga de enfermedades mentales crónicas y su impacto en la calidad de vida de las familias con las que conviven, no solo por los múltiples factores que intervienen, sino por las implicaciones culturales que permiten relacionarse positiva o negativamente con la persona cuidada (14). elementos como la esperanza, la espiritualidad y la fuerza de voluntad se han convertido en las mejores herramientas para alcanzar la recuperación, donde el cuidado tanto de la familia como del personal de salud es fundamental (15, 16). 309 encerrado a oscuras: significado de vivir con esquizofrenia para diagnosticados y sus cuidadores, medellín, colombia l daniel ricardo zaraza-morales y otro se obtuvieron las categorías: “estar encerrado y a oscuras”, “un sueño no realizado”, “apoyos fragmentados” y “fortaleciendo el interior”, en cada una de ellas fue posible describir a quiénes se referían los participantes, a qué hacían alusión y bajo qué circunstancias, lo que permitió avanzar en la contrastación de las nuevas categorías con las entrevistas finales, y un grupo focal con personas con esquizofrenia, para validar los hallazgos parciales e integrar las categorías en dos, interpretativas mas no saturadas: “vivir con esquizofrenia es vivir encerrado, a oscuras y con los sueños truncados” y “el valor de los apoyos, un punto subjetivo en la experiencia de vivir con esquizofrenia” (16). finalmente, se realizó un grupo focal con cuidadores en el que se validaron ambas categorías y la integración de “estar encerrado y a oscuras” y “un sueño no realizado”, en: “vivir con esquizofrenia es vivir encerrado, a oscuras y con los sueños truncados”, que es presentada en este artículo. durante todo el proceso de recolección y análisis hubo revisión y discusión de los investigadores, con apoyo de memos analíticos, mapas mentales y socialización con profesionales en enfermería y salud mental. los hallazgos finales fueron socializados con personal de salud del hospital y con un grupo de cuidadores de personas diagnosticadas con esquizofrenia de la ciudad de medellín. esta investigación fue formulada bajo las directrices de la declaración de helsinki y la resolución 8430 de 1993 del ministerio de salud de colombia. recibió el aval ético de las instituciones participantes. para garantizar la confidencialidad, los participantes de la investigación fueron identificados a lo largo del texto por la letra “e” (entrevistado) o “gf” (grupo focal), seguida del número correspondiente al orden de la realización de la participación (p1, p2, p3... p21). resultados a continuación se presentan los hallazgos con respecto a la manera como las personas que viven con esquizofrenia y sus familias han experimentado el proceso salud-enfermedad, antes y tabla 1. características de los participantes personas con esquizofrenia técnica participante código rol edad sexo ei ep2 hijo 29 hombre ei ep4 hija 20 mujer ei ep5 hijo 27 hombre ei ep8 madre 63 mujer gf gfp9 hijo 31 hombre gf gfp10 padre 64 hombre gf gfp11 hijo 39 hombre gf gfp12 hijo 59 hombre gf gfp13 hijo 26 hombre gf gfp14 hijo 31 hombre gf gfp15 hijo 30 hombre gf gfp16 hijo 49 hombre gf gfp17 hijo 48 hombre familiares técnica participante código rol edad sexo ei ef1 hermana 49 mujer ei ef3 madre 51 mujer ei ef6 madre 52 mujer ei ef7 madre 47 mujer gf gff18 madre 52 mujer gf gff19 madre 47 mujer gf gff20 madre 56 mujer gf gff21 hermana 49 mujer ei: entrevista individual gf: grupo focal fuente: elaboración propia. 310 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 después de su diagnóstico, cómo se han ido desarrollando, y los sentimientos y las emociones que les ha generado este proceso. en la siguiente categoría interpretativa se enuncia el surgimiento y desarrollo de la enfermedad en los aspectos relevantes para los participantes, y se hace énfasis en la experiencia de las crisis y la forma como aportan al aislamiento, el rechazo social y algunas experiencias de atención en los servicios de salud. vivir con esquizofrenia es vivir encerrado, a oscuras y con los sueños truncados el inicio de los síntomas, aunque varía en su momento y en su forma de aparecer, progresiva o repentina, es expresado como una experiencia dolorosa debido a los cambios que conlleva para la vida de la persona que es diagnosticada y su grupo familiar. el cambio de comportamiento, que se manifiesta con mayor fuerza en el encerramiento, el temor y las reacciones extrañas para quienes los rodean, es la señal de un sufrimiento que recién empieza, no solamente para quien presenta los síntomas sino para su familia. los cuidadores entrevistados tienen muy presentes las manifestaciones que han marcado este inicio, entre ellas, dificultades en la socialización, alucinaciones y miedo, como puede verse a continuación: porque es que los niños, supongamos ella… a la edad que ella tenía, pequeños, póngale usted diez, ocho, once años, les gusta mucho salir a jugar, estar juntos, estar… pues, todos unidos jugando, y ella de un momento a otro, ella no quiso volver a salir, ya se quedó, es que me acuerdo como si fuera hoy, a los once años ella se quedó encerrada y ella no volvió a salir. ef6 era normal, él era normal, pero el año pasado él se puso agresivo y casi mata al hermanito y al papá… para mí él comenzó vomitando y al otro día ya comenzó raro y mire hasta donde llegó, a defecarse en la ropa, a hacer las necesidades en la ropa y todo… ep5 los nuevos comportamientos extraños se relacionan con el aislamiento social, que refieren como una experiencia permanente, y las reacciones ante alucinaciones que generan temor en la persona con esquizofrenia, lo que puede derivar en reacciones agresivas y poner en peligro al grupo familiar. sin embargo, es la primera crisis, precedida o no por los síntomas que ya estaban alterando la tranquilidad personal y familiar, una experiencia que marca de manera más cruda el principio de la enfermedad, que abruptamente interrumpe, señala, fragmenta y divide en un antes y un después la experiencia vital. este primer momento crítico está cargado de sensaciones y emociones como desesperación, temor y frustración, no solo en la persona enferma, sino en su familia y las personas que lo rodean. al fragmentar la relación con el familiar, la crisis deja ver de manera más clara la manifestación de la enfermedad y el profundo sufrimiento del ser querido que la padece. …él empezó como a alucinar, que nos iban a matar, que no podíamos salir a la calle, le cogió miedo a la policía… era agresivo… que ahí fue donde me lo remitieron para acá [institución de salud]. gff20 estaba empelota [desnudo] en la calle, ya cuando llegó le conté a mi esposo y entonces llamamos a la policía, y se lo llevaron para la unidad intermedia [de salud], y de allí lo remitieron al mental [institución de salud]. ef7 estas crisis son situaciones que conllevan afectación emocional, dolor y temor en quienes las presencian, no solo por el riesgo de perder la vida sino por la impotencia de no saber cómo reaccionar ante las complejas manifestaciones de su familiar. las crisis que uno tiene a veces son duras porque uno se desespera, uno pasa al lado de la familia y son… no sé, es muy duro porque uno es temblando… entonces a veces a uno se le va la paloma [pierde el contacto con la realidad] y no sabe tomarse la medicación, entonces eso es muy duro porque a veces uno no consigue pensar bien o piensa solo en violencia, entonces eso es muy duro porque perjudica a la familia, también a uno. ep2 yo, cuando él está en una crisis así, le hablo de muy lejitos porque si estoy muy cerca creo que me va a dar [golpear] con lo que tenga en la mano. ef3 por su parte, el personal de salud, a pesar de ser una ayuda, genera sentimientos de temor y desesperanza, tanto en la persona con esquizofrenia como en sus familiares, no solo por el trauma que produce una mala atención por intervenciones insensibles con la persona que presenta la enfermedad y su familiar, sino también porque al depositar su confianza en los profesionales se espera que sus actuaciones sean en pro del bienestar físico y psicológico, lo que se torna en una contradicción cuando se violenta su integridad. 311 encerrado a oscuras: significado de vivir con esquizofrenia para diagnosticados y sus cuidadores, medellín, colombia l daniel ricardo zaraza-morales y otro [una cuidadora con respecto a su familiar]…ella ya salió, pero salió muy nerviosa, ella salió con mucho trauma, muchísimo. ef6 …yo sí veo mucha frialdad en ellos, o sea, son muy secos, muy secos… yo a veces veo que los doctores son muy fríos, como muy secos, eso duele, eso da tristeza… falta como más entrega a los pacientes, más amor. ef7 a partir del inicio de los síntomas, cuya gravedad es ratificada con la primera crisis, comienzan en la cotidianidad de la familia una serie de explicaciones propias sobre la causa de la enfermedad. estas explicaciones se relacionan con las creencias populares del origen de esta, como efectos de algún tipo de hechizo, posesión de demonios o el resultado entre la interacción del contexto con todos sus factores de riesgo, como el consumo de marihuana y la presión social. …yo decía: ah! eso fue lo que lo puso así, la marihuana, mire ese cerebro es débil, lo puso así tanta marihuana, y de tanto pensar, y los pelaos [muchachos en la calle] en vez de ayudarlo lo desorientaron, molestándolo, tocándolo, ¿sí o no?, cuando uno el cerebro es débil y otra persona encima de uno, uno se descontrola mentalmente ¿o no? ef7 la enfermedad misma, y las experiencias que se derivan de ella, entre las cuales se encuentra la hospitalización, llevan a un aislamiento del resto de la sociedad cada vez más definitivo, y se constituye en una especie de encerramiento. esto es descrito como una situación muy difícil, un contexto que se desconoce, y, sobre todo, un escenario que entra en choque con los ideales de la persona que sufre los síntomas de la enfermedad. …uno estar encerrado un mes aquí no es cualquier cosa [hospital psiquiátrico], eso es algo muy duro… porque usted tiene que empezar con su subconsciente: yo no estoy loco, yo no estoy loco, yo estoy enfermo, tengo una enfermedad pero no estoy loco, pero de todas maneras usted entiende que está en un hospital psiquiátrico, pero es muy duro, pues, para mí ha sido muy duro. gfp12 durante la primera hospitalización se genera soledad, temor e incertidumbre por desconocer lo que sucede. este desconocimiento puede causar además desesperación, desesperanza, ansiedad y, en algunos casos, pérdida del principio de realidad, que se genera por vivir una situación nueva, lejos de la familia y de personas cercanas. “entrevistador [con respecto a una crisis]: ¿en algún momento llegaste a sentir miedo? participante: sí, me sentía muy solo, no sabía cómo era la movida, la salida, las luces, me encandelillaban las luces y no dormía…”. ep5 a partir de las crisis y de la hospitalización surge, entonces, la idea de estar encerrado en un cuarto oscuro, donde se presentan diferentes vivencias en la experiencia de las personas que tienen la enfermedad, caracterizadas por el encerramiento y la oscuridad, en un continuo cuyo caso extremo se nombra como “descender a los infiernos”. …el hecho es que el cuarto oscuro es una forma de saber cuán oscura es la esquizofrenia cada vez que yo me sumo en mi mente… salir de esos momentos de oscuridad, es cómo continuar viviendo y compartiendo. gfp14 …cuando uno está en el cuarto oscuro, uno baja como en un ascensor y baja y baja, y son días bajando, uno no se acuerda de comida, no se acuerda de nada,… así es la esquizofrenia. gfp10 …describir ese momento… como un lugar en el infierno, sumido en las profundidades horribles. gfp17 el diario vivir de una persona que es diagnosticada con esquizofrenia se convierte en un descender continuo emocionalmente y un ascenso de los síntomas, y a medida que lo hacen vienen las dificultades. entre estas se encuentran los problemas para conciliar el sueño, la fluctuación emocional y los cambios nutricionales derivados de la sintomatología. …la enfermedad va… no se queda ahí, en un solo sitio, entonces va subiendo… no dormía, porque lo que más le ha atormentado a ella es el no dormir, más que todo, y de pronto… ella es muy sentimental y de pronto a veces llora por todo. ef6 …ya no me recibía de comer porque lo iba a envenenar, si eran frijoles porque él quería lentejas, siempre era lo contrario… además él ya no estudiaba. ep5 para las familias es complejo saber cómo se vive dentro de ese cuarto oscuro, primero porque no se conocen los pensamientos del familiar enfermo; segundo, por la dificultad que existe para dialogar sobre la enfermedad y sus síntomas. …nadie puede pensar como piensa otro, todos tenemos un pensamiento y es así, o sea, nadie puede meterse en el pensamiento 312 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 del otro, qué tal que así fuera o que bueno para estas personas enfermas, sería maravilloso, por ejemplo que uno pudiera ingresar a la mente de un esquizofrénico a descubrir por qué es así. ef3 como se puede observar, desde los cambios insinuados de comportamiento, pasando por la hospitalización y después de ella, se vive con la sensación, que a la vez se experimenta de manera física, de estar encerrado, lo cual no se relaciona solo con la falta de libertad impuesta por otras personas, sino con las consecuencias que trae el inicio de la enfermedad, con sus síntomas y las respuestas comportamentales que presenta la persona durante su cotidianidad. pero es un cambio muy bravo uno estar como está ahora, uno enfermo ya uno no sale, más bien como encerrado, pues, uno llega por ejemplo de aquí a la casa de uno, a uno no le provoca salir… es muy duro estar usted encerrado, no porque lo quieran mantener encerrado, sino porque a usted le nace estar encerrado, y siente a veces esa necesidad de salir de la casa, y uno sale un momentico y ahí mismo otra vez pa’ dentro. gfp12 en el plano emocional la experiencia es coherente con el alejamiento social, en ella la tristeza hace presencia y de allí que la alegría es concebida como algo momentáneo, algo que se busca pero que es muy difícil que aparezca a pesar de los esfuerzos de los familiares. en contraste, se encuentra que la tristeza puede estar presente a pesar del tratamiento farmacológico prescrito para evitarla. entrevistador: ¿cómo es eso de vivir con esquizofrenia? participante: eso es triste, por ejemplo yo me tomo las pastillas y no me provoca levantarme, o si uno se levanta, se levanta con mucha tristeza... la alegría le dura a uno por ahí tres minutos en el día, de resto es tristeza. gfp10 las expectativas que se tenían sobre el proyecto de vida ahora entran en choque con la realidad dada por la vivencia de la enfermedad. aparece entonces la desesperanza y el deseo de no tener ese diagnóstico, de ser alguien “normal”, sin síntomas que alteren su vida y sus proyectos. …ella misma me dice a mí que ella quisiera no tener nada, que ella quisiera no sentir nada de eso, porque ella tiene muchos proyectos de vida, a ella le encantaría…ella siempre desde pequeñita dice que ella quiere ser una profesional, que ella quiere trabajar, que ella quiere hacer muchas cosas, y de pronto saber que ella tiene eso [la enfermedad] que le da impedimento. ef6 pese a la difícil experiencia ligada a la enfermedad, la recuperación es posible. existe una “salida del cuarto”, a pesar de muchos obstáculos y oscuridad. esta recuperación se da en un marco de incertidumbre, que se mezcla con un sentimiento de desesperanza y resignación en la familia, al pensar que la presencia de la enfermedad es algo que les tocó vivir. entrevistador: ¿qué piensa sobre una posible salida? gff18: pues siempre hay una salida, o de pronto ya es uno acostumbrarse a convivir así, a tratar de mejorar cada día, pero ya uno como que tiene en la cabeza que eso es lo que le tocó ya. gff21: eso fue lo que nos tocó a nosotros. gff18: aceptar la situación y… no tratar de verla ya así, no seguir uno que es un problema, sino aceptarlo, y tratar de mejorar cada día más ese proceso. esta sensación de estar encerrado, de sueños no realizados, lleva a conocer las sombras, esa percepción subjetiva de oscuridad que se mantiene en la persona diagnosticada. discusión los hallazgos de la investigación permiten reconocer aspectos ya documentados con respecto a la esquizofrenia, como el hecho de ser diagnosticado que interfiere enormemente en la tranquilidad de la persona que ha sido etiquetada (22), y trae consigo cambios en todas las esferas de su cotidianidad (23), como en la social, la laboral, familiar y afectiva (24, 25). estos cambios se ven reflejados en la percepción de un antes y un después, caracterizado por la falta y el deterioro en las habilidades y capacidades propias de quien se consideraba, hasta antes del diagnóstico, una persona normal (26). la sensación de encerramiento ha sido documentada desde la psiquiatría tradicional como una manifestación clásica de los síntomas de la enfermedad (27, 28). se ha descrito como un tipo de aislamiento social resultante de la desregularización en las vías serotoninérgicas y el sistema nigroestriado-dopaminérgico, que puede producir abulia y apatía (27). en otras palabras, los cambios en la neurotransmisión y la serotonina, específicamente, incrementan la sensación de estar y permanecer encerrado. desde la neuropsicología también se ha argumentado la deficiencia 313 encerrado a oscuras: significado de vivir con esquizofrenia para diagnosticados y sus cuidadores, medellín, colombia l daniel ricardo zaraza-morales y otro neuronal que imposibilita las relaciones sociales en la persona que tiene esquizofrenia (29). una de las situaciones que genera mayor inquietud y miedo son las crisis generadas durante el proceso salud-enfermedad. estas crisis son las manifestaciones más visibles de la heterogeneidad de los síntomas, y muestran la particularidad que existe en sus posibles etiologías y la forma de tratarlas (30). se ha documentado que las intervenciones no adecuadas por parte del personal de salud durante un momento de crisis ponen en riesgo la vida y la recuperación de quien vive con la enfermedad o convive con alguien que la presenta (31). esto se debe al manejo brusco y agresivo resultante de la contención física y, en otros casos, al manejo farmacológico y sus efectos adversos (26). a su vez, estas crisis incrementan la carga de cuidados que deben sobrellevar los familiares, ya que tienen que estar más pendientes de riesgos como las autolesiones o la agresión hacia otros (32). diferentes estudios han mostrado cómo el hecho de ser diagnosticado con una enfermedad mental acarrea una serie de consecuencias desfavorables, no solo para la persona que tiene la enfermedad y su familia (8, 33), sino a su vez para la comunidad, dados los altos recursos que deben destinarse para tratar la enfermedad, con el agravante de la pérdida social que se genera, pues en un gran porcentaje los síntomas inician en jóvenes en etapa productiva (34). la sensación de descenso a los infiernos también ha sido descrita por personas que han sido diagnosticadas con esquizofrenia, como un aspecto que muestra lo oscuro y aterrador que puede llegar a ser la vivencia de la enfermedad (26). el proceso de hospitalización influye en la percepción negativa de la experiencia vivida (9). este impacto, como lo vemos en los resultados, se asocia con el hecho de estar lejos de la familia y, por tanto, enfrentarse a un contexto que le es ajeno, lo que incrementa esa sensación de encerramiento (35). sin embargo, como es explicado por los participantes, la recuperación es posible y esta recuperación está ligada a la percepción de esperanza y mejoramiento que tienen durante su tratamiento, que es apoyado por diferentes elementos que permiten acrecentar esa sensación (31, 36). la utilización de teorías de mediano rango, como el modelo de recuperación de la salud mental, propuesto por phil barker, permite conceptualizar de forma amplia la importancia de introyectar aspectos del ser humano como alguien espiritual, que a través de la esperanza en su proceso de recuperación, puede trascender y ayudar a otros en su camino hacia el bienestar (37). conclusiones las ideas de desesperanza surgidas luego de no realizar ese sueño que se tenía visualizado influyen tanto en la persona que vive con la enfermedad como en su familia, y es la frustración de los sueños una experiencia dolorosa y triste. creemos es necesario seguir realizando investigaciones que aborden la experiencia de vivir con una enfermedad mental como la esquizofrenia, desde la subjetividad de quienes son diagnosticados y sus cuidadores. más allá de las causas etiológicas de orden fisiológico que influyan en esa sensación de encerramiento, es preciso abordar el sufrimiento, el desconocimiento y la intranquilidad que pueden gestarse también en sus familiares, quienes corren generalmente con la responsabilidad de cuidarlos. esto, sin lugar a dudas, enriquece la forma en que se concibe la salud mental y se dan nuevos lineamientos para la formación de los profesionales de enfermería con criterios éticos y humanizados. conflicto de intereses: ninguno declarado. referencias 1. pagsberg ak. schizophrenia spectrum and other psychotic disorders. eur child adolesc psychiatry. 2013;22(1):s3-9. 2. tandon r. schizophrenia and other psychotic disorders in dsm-5 : clinical implications of revisions from dsm-iv. schizophr relat psychoses. 2013;16-20. 3. organización mundial de la salud (oms). the global burden of disease 2004. geneva: oms; 2004. 4. millier a, schmidt u, angermeyer mc, chauhan d, murthy v, toumi m, et al. humanistic burden in schizophrenia: a literature review. j psychiatr res. 2014;54:85-93. 314 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan 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2010;31(3):171-80. 205 218 vivencias de familiares.indd 205 dora isabel giraldo-montoya1 hsirley calderón-bejarano2 cristian felipe rivera-cardona3 sandra milena velásquez-vergara4 heidy mesa-ballesteros5 vivencias de familiares en sala de espera de trabajo de parto 1 universidad pontificia bolivariana. medellín. dora.giraldo@upb.edu.co 2 universidad pontificia bolivariana. colombia. hsirley.calderon@upb.edu.co 3 universidad pontificia bolivariana. colombia. cristian.rivera@upb.edu.co 4 universidad pontificia bolivariana. colombia. samivelasquez@hotmail.es 5 universidad pontificia bolivariana. colombia. hei.mesa@hotmail.com recibido: 02 de febrero de 2015 enviado a pares: 14 de marzo de 2015 aceptado por pares: 11 de diciembre de 2015 aprobado: 16 de diciembre de 2015 doi: 10.5294/aqui.2016.16.2.8 para citar este artículo / to reference this article / para citar este artigo giraldo-montoya di, calderón-bejarano h, rivera-cardona cf, velásquez-vergara sm, mesa-ballesteros h. vivencias de familiares en sala de espera de trabajo de parto. aquichan. 2016; 16(2): 205-218. doi: 10.5294/aqui.2016.16.2.8 resumen objetivo: describir las vivencias de los familiares en sala de espera de trabajo de parto. materiales y métodos: estudio cualitativo etnográfico. se entrevistaron diez participantes y cuatro grupos focales; la saturación se logró cuando los investigadores no encontraron más explicación, interpretación o descripción de la experiencia. para el análisis, se usó el método de spradley, se construyeron categorías y dominios, y se realizó análisis taxonómico. se desarrollaron notas de campo y observación participante. se utilizó el software atlas ti. resultados: los familiares experimentan necesidades de información oportuna y eficiente. el lenguaje verbal y no verbal y el contenido de la información les produjo ansiedad e incertidumbre. los familiares sienten la necesidad de acompañar a la gestante durante el trabajo de parto para brindarle apoyo. el ambiente en la sala de espera depende de los factores internos del familiar y los factores externos de la sala. la educación en la sala de espera representó una excelente oportunidad para aprovechar el tiempo. emergieron los dominios: comunicación terapéutica, acompañamiento, ambiente y educación. conclusión: el significado cultural de esperar es un acontecimiento de la vida altamente significativo, atravesado por cuatro circunstancias: la comunicación, el acompañamiento, el ambiente de la sala y la educación, situaciones que cambiaron la experiencia del nacimiento. palabras clave trabajo de parto, relaciones profesional-familia, investigación cualitativa, información, educación en salud (fuente: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 205-218 206 aquichan issn 1657-5997 año 16 vol. 16 nº 2 chía, colombia junio 2016 l 205-218 experiences of family members in the labor room abstract objective: describe the experiences of family members in the labor room. materials and methods: this is a qualitative ethnographic study in which ten participants and four focus groups were interviewed; saturation was achieved when the researchers found no further explanation, interpretation or description of the experience. spradley’s method was used for the analysis. categories and domains were constructed and a taxonomic analysis was done. field notes and participant observation were developed. atlas ti software was used. results: family members want and feel they need timely and efficient information. verbal and non-verbal language and the content of the information provided can cause them anxiety and uncertainty. family members want to accompany and support the expectant mother during labor prior to childbirth. the atmosphere in the labor room depends on the internal factors of the family member and the external factors of the room. education in the waiting room proved to be an excellent opportunity to take advantage of the time. several domains emerged; namely, therapeutic communication, accompaniment, environment and education. conclusion: the cultural significance of waiting for birth to occur is a highly meaningful event in life and is marked by four factors: communication, accompaniment, the environment in the room and education. these are situations that changed the birth experience. keywords birth labor, nurse -family relations, qualitative research, information, health education (source: decs, bireme) 207 vivencias de familiares en sala de espera de trabajo de parto l dora isabel giraldo-montoya y otros vivências de familiares na sala do parto resumo objetivo: descrever as vivências dos familiares na sala de espera de trabalho de parto. materiais e métodos: estudo qualitativo etnográfico. foram entrevistados dez participantes e quatro grupos focais. a saturação foi atingida quando os pesquisadores não encontraram mais explicação, interpretação ou descrição da experiência. para a análise, usou-se o método de spradley e foram construídos categorias e domínios, além de realizada análise taxonômica. desenvolveram-se anotações de campo e observação participante. utilizouse o software atlas ti. resultados: os familiares experimentaram necessidades de informação oportuna e eficiente. a linguagem verbal e não verbal, e o conteúdo da informação lhes produziram ansiedade e incerteza. os familiares sentem a necessidade de acompanhar a gestante durante o trabalho de parto para oferecer-lhe apoio. o ambiente na sala de espera depende dos fatores internos do familiar e dos fatores externos da sala. a educação na sala de espera representou uma excelente oportunidade para aproveitar o tempo. emergiram os domínios: comunicação terapêutica, acompanhamento, ambiente e educação. conclusão: o significado cultural de esperar é um acontecimento da vida altamente significativo, permeado por quatro circunstâncias: a comunicação, o acompanhamento, o ambiente da sala e a educação, situações que mudaram a experiência do nascimento. palavras-chave trabalho de parto, relação profissional-família, pesquisa qualitativa, informação, educação em saúde (fonte: decs, bireme). año 16 vol. 16 nº 2 chía, colombia junio 2016 l 205-218 208 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 introducción durante la espera, los familiares perciben condiciones concretas de atención, influidas por un conjunto de mediaciones culturales y sociales. es más evidente en situaciones que tienen que ver con intervenciones de salud relacionadas con problemas que comprometen la vida o acciones médicas de alta valoración, como la atención del nacimiento (1). los familiares de gestantes en trabajo de parto perciben los procesos con otros ojos, especialmente cuando tienen que esperar para recibir información sobre el estado de salud de su familiar y del hijo por nacer (1). durante su estancia en la sala, expresan ansiedad y temores, que van a depender del estado de salud de la gestante. el estudio de semczuk et al. (2) mostró que durante la espera de un parto de madres de alto riesgo, los niveles de ansiedad de las parejas son altos y el mayor nivel de estrés se produce en aquellas parejas en las que las gestantes sufren de una enfermedad crónica como la hipertensión arterial y la diabetes. dichas situaciones generan tensión e incertidumbre frente a una condición clínica que puede ser grave para la madre y el feto. la literatura tiene poca evidencia sobre las vivencias de los familiares en salas de trabajo de parto, sin embargo, hay estudios realizados en los servicios de urgencias y de cuidado intensivo que reportan las experiencias de los acompañantes. el estudio de lopera, garcía, madrigal y forero (3) sobre la espera de acompañantes en el servicio de urgencias refiere que los familiares expresan que deben pasar por varias situaciones tensionantes, entre ellas, la espera larga en el servicio de admisiones, la pérdida de tiempo, la falta de información, el miedo, estar cautivos y los obstáculos para lograr compañía y ayuda. el estudio de frizon, nascimento, bertoncello y martins (4) refiere que los familiares que esperan a sus pacientes en la uci de adultos revelan sentimientos como dolor, angustia, tristeza, impotencia, miedo, desesperación, ansiedad y expectativa infinita. la investigación de colenci, abdala y braga (5) reporta que los acompañantes expresan ansiedad, incertidumbre, confianza en dios y en el equipo médico, y preocupación por el paciente cuando se somete a procedimientos anestésicos o quirúrgicos. en cuanto a la satisfacción de los familiares en la sala de espera, el estudio de vicuña (1) encontró que la insatisfacción más frecuente fue la demora en la atención, el maltrato, la falta de información, deficiencias en el confort, la falta de privacidad y la falta de confianza que inspira el personal de salud. de la misma manera, los familiares o acompañantes expresan que existen obstáculos relacionados con la obtención de información oportuna y eficiente sobre el estado de salud del familiar. dicha situación la relacionan con las actitudes del personal de salud en cuanto al lenguaje verbal y no verbal, y el contenido de la información (3). el estudio de vicuña (1) identificó que los familiares tienen necesidades de información sobre los procedimientos que se van a realizar: de qué manera, por qué y para qué. así, ellos comprenderán las medidas terapéuticas y no asistirán como simples espectadores a las decisiones tomadas por el personal de salud. otro aspecto que se manifiesta en los familiares es la necesidad de acompañamiento, tanto para ellos como para la gestante. cantero muestra que la gran mayoría de las mujeres en trabajo de parto deseaban estar acompañadas por su marido, pareja, madre o algún familiar que le otorgara la posibilidad de no sentirse sola y poder tener a un referente de su entorno para apoyarla emocional y psicológicamente (6). desde la interacción social, el estudio de gómez (7) concluye que la sala de espera fue reconocida por los acompañantes como un espacio de intercambio de conversación y para compartir con otras personas. para enriquecer el cuidado de enfermería desde la experiencia del familiar, surge la necesidad de conocer las vivencias de los familiares en las salas de espera de trabajo de parto; en este sentido, los profesionales de la salud que laboran en trabajo de parto y parto, en una institución de salud de la ciudad de medellín (colombia), se motivaron a indagar más al respecto. la institución en mención (8) tiene un flujo mensual aproximado de 400 pacientes obstétricas. por cada materna hay un acompañante autorizado para entrar a la institución, lo que representa aproximadamente 400 acompañantes mensuales, sin contar aquellos que ingresan sin permiso. el espacio es pequeño, no tiene aire acondicionado, cuenta con 36 sillas que permanecen ocupadas y, por ello, algunos se sientan en las escaleras. cuenta con dispensadores de comestibles, dos televisores y una zona administrativa para la recepción de documentos. las encuestas de satisfacción de estas 209 vivencias de familiares en sala de espera de trabajo de parto l dora isabel giraldo-montoya y otros salas muestran que la principal necesidad de los acompañantes es recibir información oportuna y clara de sus familiares y del hijo por nacer. por lo anterior, el presente estudio tuvo por objetivo describir las vivencias de los familiares de gestantes en trabajo de parto en las sala de espera, en una institución de salud de la ciudad de medellín (colombia) durante al año 2014. materiales y métodos estudio cualitativo de tipo etnográfico, que buscó identificar desde la metodología de james spradley, las vivencias de los familiares en la sala de espera. el estudio se desarrolló desde la etnografía focalizada (9, 10), ya que se concentró en una población muy definida, en este caso, familiares en sala de espera de trabajo de parto. su orientación fue particularista o focalizada, consistió en aplicar el método etnográfico a cualquier unidad social o grupo humano aislable y permitió saber que los datos obtenidos representaron la realidad vivida en la sala de espera de trabajo de parto. la población estuvo conformada por los acompañantes (esposo, compañero u otro familiar), en sala de espera de las mujeres en trabajo de parto. el total de los participantes fue de diez, con entrevista individual, y cuatro grupos focales con cuatro y cinco participantes en cada uno; la selección no se hizo en cantidad, sino en la calidad de la información que los participantes suministraron, y se tuvieron en cuenta los siguientes criterios: a. criterios de inclusión: procedentes de zona urbana, mayores de 18 años de edad y familiares con madres en trabajo de parto normal, de 37 y más semanas de gestación. b. criterios de exclusión: familiares de madres con trastornos hipertensivos, ruptura prematura de membranas, diabetes gestacional, síndrome de parto pretérmino, fetos con malformaciones o anormalidades, abortos previos, mortinatos o feto valioso. el término etnografía focalizada se aplicó a un grupo localizado de personas que compartieron características sociales y culturales en sala de espera (9), con una habitualidad cultural propia. la estancia en sala de espera osciló entre 10 a 12 horas, tiempo en el cual un familiar asume los comportamientos comunes de esperar y convive de forma habitual en este espacio. los miembros de este grupo se caracterizaron porque tuvieron un gran sentido de solidaridad mutua, basada en factores comunes de lenguaje, residencia, económicos, relaciones sociales, creencias y prácticas sobre el parto y la expectativa del nacimiento (9). el trabajo de campo, por lo regular, implica estar con la gente por largos periodos de tiempo en su ambiente natural, y la observación participante es central para un trabajo de campo efectivo; sin embargo, en algunos ambientes particulares, la técnica de observación participante suele no ser continua y consiste en cortos periodos de observación intensa, repartidos durante un periodo de tiempo largo (9). en este sentido, para obtener una mayor comprensión de la experiencia, desde la perspectiva del participante, el trabajo de campo se desarrolló durante once meses y la observación participante fue de seis horas diarias, donde se advirtió de manera consciente lo que estaba pasando y se plasmó en las notas de campo, con el fin de identificar los diferentes componentes culturales de las personas en su medio: las relaciones con el grupo, sus creencias, sus símbolos y rituales, los objetos que utilizaron, sus costumbres y sus valores, los cuales fueron revisados durante el análisis para identificar significados y confrontar los hallazgos del estudio. se utilizó la entrevista etnográfica de spradley (11), la cual partió de una sola pregunta: ¿cuál es su experiencia en esta sala de espera?, que permitió posteriormente desarrollar otra serie de cuestiones de tipo descriptivo, estructural o de contraste. las entrevistas permitieron distinguir lo normal de lo insólito, la norma de la excepción y describirlo. el análisis renglón por renglón de la transcripción de una entrevista, fue uno de los mecanismos por el cual se logró hallar significados implícitos, valores culturales y vínculos con otros conceptos o contextos. la saturación se logró cuando se conoció de manera amplia, y lo más profundamente posible, la experiencia de los familiares, es decir, cuando los investigadores no encontraron de parte de los familiares más explicación, interpretación o descripción de la experiencia (9). para poder entrar en el campo y evitar el choque que se produce entre la cultura de los otros (emic) y la cultura de los investigadores (etic), estos últimos utilizaron ropa informal y se dispusieron sentados en la sala, así como permanecían los acompañantes en la sala de espera. al reconocer la sala desde su dinámica (movimiento de las personas, congestión de la sala, estados de ánimo, temperatura y lo que se hace en la sala), el investigador comenzó a participar, integrándose como uno más, para pensar, 210 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 hablar y sentir como ellos. esto se logró en la medida que los investigadores visitaban con más frecuencia la sala y permanecían más tiempo allí. al principio, cada vez que se llamaba a los acompañantes seleccionados de acuerdo con los criterios de inclusión, se presentaron momentos de máxima reactividad (12), por lo que se consideró, antes de las entrevistas, realizar una actividad introductoria relacionada con la educación sobre los cuidados del recién nacido y el posparto. dicha actividad anticipatoria a la entrevista tuvo como propósito: “romper el hielo”, generar confianza, establecer empatía, brindar seguridad al informante y aclarar dudas. los investigadores se presentaron y se dieron las explicaciones oportunas respondiendo a la curiosidad de la gente, se presentó el objetivo de la investigación, pero sin llegar a profundizar demasiado. fue muy importante mantener un clima de buenas relaciones y empatía con los familiares. después de la entrevista, los informantes recibieron educación sobre: las actividades que desarrolla el personal de salud que de modo directo o indirecto atendían a las gestantes, los procedimientos, los equipos utilizados y su propósito. además, para ubicar al familiar sobre los lugares por donde pasa la gestante, se les mostraron fotografías del interior de la sala de trabajo de parto y parto; esto con el fin de aclarar las dudas que con frecuencia surgían cuando se realizaban las preguntas. se hizo la prueba piloto, aplicando la entrevista etnográfica de sprapley (11) a dos familiares, lo que permitió que el investigador incrementara la habilidad en formular preguntas descriptivas, estructurales y de contraste, para garantizar la validez y confiabilidad en el análisis de la información. para el análisis de la información, se utilizó el concepto etnográfico de spradley (11); desde este punto, se identificaron y analizaron los patrones más característicos que existían en los datos y surgió un primer elemento que fue el dominio o los nombres para un conocimiento cultural; esta fase exploratoria surgió en el primer contacto con los datos recolectados, posteriormente aparecieron los términos incluidos que son aquellos que pertenecen al conocimiento cultural o el dominio. dicho procedimiento se logró a través de la elaboración de una “matriz por atributos”, así: se definieron tantas filas con situaciones culturales y tantas columnas con atributos de esas situaciones; al inspeccionar las columnas, se pudo hallar cuáles atributos fueron críticos en diferentes situaciones. posteriormente, se construyeron las relaciones semánticas que enlazaban los términos incluidos, de acuerdo con la guía de relaciones semánticas de spradley (11). la relación semántica opera sobre el principio general de la inclusión y su función fue definir los términos incluidos para colocarlos dentro del dominio cultural. este proceso se llevó a cabo a través de las fichas de análisis de dominios sistematizadas en el programa word. en la medida que se avanzaba en el proceso de recolección de la información y en el propio proceso de análisis, surgió la conceptualización de los datos y, progresivamente, se fue desarrollando una depuración empírica y conceptual. se presentó a cada informante el análisis de las entrevistas a través de cuatro grupos focales. los dominios fueron confrontados con los informantes, por medio de preguntas descriptivas, estructurales y de contraste. esta técnica permitió garantizar la validez de los datos recolectados, en la medida que estos fueron reconocidos como ciertos por los informantes. durante las entrevistas hubo un informante que no respondió algunas preguntas porque presentaba dudas o expresó significados extraños; por tanto, se entrevistó a un informante general, quien se encontraba en la sala y aclaró los significados extraños expresados por el informante clave. para dar validez y confiabilidad a la información recolectada se realizaron cuatro fases simultáneas que incluyeron: a) verificación de los datos obtenidos con los informantes (feedback); b) análisis de las notas de campo; c) triangulación: entrevista a profundidad, grupos focales y observación participante; d) análisis de los dominios de manera permanente por los investigadores. todo lo anterior estuvo sujeto a verificaciones con los informantes. el almacenamiento y la organización de los datos se elaboró en el software atlas ti, y todas las entrevistas fueron transcritas en el programa word por los investigadores. el estudio contó con el consentimiento informado y por escrito del familiar, y se llevó a cabo cuando se obtuvo la autorización de los estamentos respectivos. se protegió la privacidad del familiar y la entrevista no tuvo su identificación. según la resolución 008430 de 1993, fue una investigación de riesgo mínimo, teniendo en cuenta que se movilizaron respuestas emotivas. 211 vivencias de familiares en sala de espera de trabajo de parto l dora isabel giraldo-montoya y otros resultados la edad promedio de los informantes fue de 34,4 años. la mayoría fueron los esposos, seguidos de la madre de la gestante. surgió un tema central que identificó la esencia de las vivencias en la sala de espera de trabajo de parto y parto: “la sala de espera de trabajo de parto y parto: un espacio para vivirlo con satisfacción”. los siguientes fueron los dominios analíticos obtenidos durante el análisis: 1. comunicación terapéutica. 2. acompañamiento. 3. el ambiente en la sala de espera. 4. educación. para cada dominio analítico se buscaron los términos incluidos que fueron considerados como los nombres para todas las categorías más pequeñas dentro del dominio (11). dominio 1. comunicación terapéutica 1. relacional: buen trato a través de las relaciones semánticas “es una forma de”, se develan los significados sobre la relación entre enfermera-familiar en la sala de espera. el respeto, el ser prudente, el ser formal, es una forma o modo de experimentar relaciones de buen trato, el cual se caracterizó por ser respetuoso, prudente y formal de parte de las personas involucradas en los procesos de comunicación terapéutica en la sala de espera. de mucho respeto, creo que de mi parte siempre trato de ser lo más respetuoso posible, igual el trato del personal, muy atentos, muy serviciales y muy respetuosos. inf. 7 ….hay muchos que son muy mala clase y no lo saben atender a uno como se debe, pero él súper formalito. inf. 5 2. relacional: mal trato desde las relaciones semánticas “es una manera de”, se halló el mal trato en la relación terapéutica. los informantes manifiestan que la manera como se dicen las cosas (despectivo, poco claro, muy preciso, poco personalizado o no responder al llamado), es una forma o modo de experimentar relaciones de mal trato. manifestaron que en algunas ocasiones encontraron un trato despectivo, poco claro, con uso de lenguaje técnico que coloca barreras en la comunicación, dificultando la comprensión del mensaje por parte de los acompañantes. también expresan que la información que les brindan es muy concisa y limitada, obstaculizando así la posibilidad de interactuar con el personal de salud y expresar los posibles interrogantes que surgen: “un poco tortuosa en sí, porque la desinformación le causa a uno mucho agobio y uno preguntaba y no me daban mucha información”. inf. 8 3. oportunidad en la información la oportunidad en la información está relacionada con el tiempo y la frecuencia, develados a través de las relaciones semánticas “es la razón para”. los participantes refieren que el personal de salud acumula información para todos e informan cuando están desocupados, razón por la cual no ofrecen información oportuna. esta situación limita el tiempo de interacción entre el personal de salud y la familia, se disminuye la frecuencia de los reportes de avances de sus familiares, y hay mayor espera para obtener información: “… pues yo me siento inconforme con eso, porque averigüé en varias ocasiones y siempre me dice “es que la enfermera salió a dar reporte a tales horas y ya no sale, por decir, hasta dentro de cuatro horas”. inf. 1 dominio 2. acompañamiento 1. acompañarla adentro la relación semántica “es una razón para” describe que vivir el nacimiento, alentar a la mujer durante las contracciones y el parto, y vivenciar su valiente esfuerzo son razones para acompañar a la gestante durante el trabajo de parto. para el compañero significa conectarse con la pareja para compartir el dolor y el agotamiento, respirar con ella y darle la bienvenida a su hijo. me imagino estar ahí al lado, darle la mano a mi esposa, estar ahí con ella, hablándole; yo sé que igual el personal estaba ahí con ella, dándole ánimo, pero si hubiera podido estar ahí, hubiera sido también bonito, por la conexión que uno tiene con la pareja, el compartir ese espacio, como tratar de compartir ese dolor y ese agotamiento, estar con ella, servirle de apoyo, cogerle la 212 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 mano, hablarle, respirar con ella, dejar que me apretara y ya finalmente ver a la bebé y si era posible, cortar el cordón umbilical y darle la bienvenida. inf. 6 2. no acompañarla la relación semántica que sobresale en este apartado “es una razón para”. los obstáculos que se presentan desde la entrada de la institución, y aquellos que se encuentran en la misma sala de trabajo de parto, son las razones para no poder acompañarla. los obstáculos más relevantes son la congestión en el número de maternas, las normas antisépticas y las normas institucionales. allá adentro están muy ocupados, yo sé que están para acá y para allá; me gustaría que fuera distinto, pero por normas de salud, no se puede y por seguridad sé que no se puede… porque allá tiene que entrar uno con pijamas y muy organizado, porque allá cualquier cosita que se entre puede infectar, entonces no se puede, desde ahí es entendible. inf. 5 3. acompañar al que espera afuera el acompañamiento no solo debe pensarse para la gestante, también debe contemplarse para el familiar. la necesidad de ser acompañados en la sala significa un apoyo fundamental para cumplir con las labores que acarrea la espera. en este sentido, la relación semántica que se destaca es: “acompañar al que espera”, es una forma de apoyarlo. cuando son dos los que esperan, la experiencia cambia. es importantísimo tener una compañía en un lugar donde estás prácticamente con una mente inquieta todo el tiempo, tener a alguien con quién compartir lo que estás sintiendo, a quién dejar en el momento en que tenés que bajar o hacer una llamada, que esté pendiente de esa persona que tienes ahí, ¡claro, es fundamental! inf. 4 dominio 3. el ambiente en sala de espera 1. externo: lo propio de la sala a. lo que se hace en la sala de espera: las relaciones semánticas para el término, incluido lo externo o lo propio de la sala, muestran que se hacen actividades variadas, propias o características de una sala de espera. ver televisión, hablar, caminar, comer o dormir, son actividades propias de este entorno que ayudan a pasar el tiempo. uno trata de hacer lo que pueda, pues ver televisión, hablar con mi suegro, hablar con la gente, porque le ayudan a uno a liberar tensión; de pronto cuando uno no se hallaba de estar sentado, se paraba y estaba de aquí para allá y de allá para acá, el famoso caminar, el run run de aquí para allá para liberar tensiones, pero bien, uno se distrae con cualquier cosita. inf. 6 b. las comodidades de la sala de espera: hay otros factores que componen la escena cultural de la sala y son las incomodidades. la relación semántica identificada es: “las incomodidades son las causas para la insatisfacción de los acompañantes”. en este sentido, el espacio locativo, las sillas, la temperatura de la sala, los dispensadores de alimentos y hasta los precios ofrecidos en la cafetería, son aspectos que influyen en la satisfacción de los familiares. sin embargo, es tan fuerte el deseo y la expectativa del nacimiento, que algunas incomodidades pasan a un segundo plano y son aceptadas con resignación por los participantes. desde las adecuaciones de los espacios como tal que presta la institución para uno esperar… no es mucho… pues se llena mucho, no hay sillas totalmente cómodas y después de un tiempo uno se cansa y para pasar la noche, ahí como a uno le dé, se trata de acostarse en las sillas, porque realmente el agotamiento es alto, pero el espacio se puede decir que es aceptable para lo que uno requiere, y uno no se fija tanto en eso. inf. 6 c. la imagen de la institución: otro aspecto relacionado con lo propio de la sala, es la buena imagen de la institución de salud en la ciudad, como una razón para consultar o ir a tener el parto. sin embargo, al momento de conocer y vivenciar las vicisitudes del espacio, los familiares opinaron de manera contraria, especialmente en el aspecto de la información. este factor fue muy importante para evaluar como bueno o malo el servicio. igualmente, los informantes ofrecieron sugerencias para mejorar el ambiente en la sala y poder afirmar en el futuro que el servicio sí es tan bueno como se dice. pero yo nunca me imaginé que me tuviera que tocar aquí solo y que no la pudiera ni ver, porque desde que entró no la he visto, ni he tenido ningún contacto con ella, no puedo hablar con ella ni nada, lógicamente influye el hecho de que tenga fama, de que es muy buena clínica y que atienden muy bien a la paciente, pero los que vinimos con la paciente no. inf. 3 213 vivencias de familiares en sala de espera de trabajo de parto l dora isabel giraldo-montoya y otros d. sugerencias para la sala de espera: los participantes expresan la necesidad de cambiar la manera como se da la información y a través de sus propias experiencias, sugieren acciones para mejorar la sala. la relación semántica que se destaca son las “sugerencias de los acompañantes como una forma de mejorar el ambiente en la sala”. como ejemplo sugieren: una sola persona que preste información permanente, monitores de pantalla visibles para describir cómo van y por dónde van las gestantes, y ofrecer charlas educativas durante la espera. que tengan una persona para dar la información, que lo orienten a uno o charlas que lo distraigan y uno no esté como enfocado en lo que hay allá adentro, cierto, como esa charla que dieron las alumnas ahora; eso es bueno porque hay muchos primíparos que no saben ni cómo bañar a un bebé. inf. 3 2. interno: lo propio del familiar a. las expectativas de ver al hijo: las expectativas de ver al hijo son parte de las sensaciones relacionadas con la espera. se crean imaginarios relacionados con el futuro cercano y lejano. estas expectativas son características propias que identifican al futuro padre o abuela. experimentan alegría, pero también ansiedad sobre el futuro próximo. la sensación a veces de ansiedad, nerviosismo al no saber cómo nos va a cambiar la vida, o de saber qué le depara el futuro a uno y para el niño todo eso, es como lo más notorio, porque aunque uno mucha veces diga yo ya estoy listo, pienso que nadie está preparado para ser padre, eso es una experiencia nueva que nos va a cambiar y hay que saberla afrontar. inf. 7 b. la invocación divina o búsqueda de protección: es de especial interés en los informantes la invocación de un ser supremo como una forma de obtener protección en situaciones de grandes expectativas o en experiencias negativas como en el caso de una complicación. la invocación divina a través de rezos u oraciones son formas de obtener protección para la gestante y el bebé. cada persona o cada familia tiene sus creencias, en mi caso, nosotros creemos en dios, nos gusta también orar para que las cosas salgan bien; yo no he preguntado, la verdad, no sé si hay un espacio para orar, si hay una capillita o una salita pequeña, no sé la verdad, no he preguntado, pero sí me siento a rezar, a hablar con dios, que todas las cosas salgan bien y que la bebita salga bien de salud y que salga bien fuerte. inf. 10 c. experiencias ajenas que afectan: el ambiente de la sala está permeado por las experiencias ajenas, las cuales son las causas de emociones fuertes. la sala de espera se convierte en un espacio para conocer y compartir con otros, con los mismos objetivos y expectativas. aquí he conocido personas, he compartido con ellas sus experiencias y uno comparte las experiencias de uno con esas personas, entonces es algo positivo, siempre que uno no se aísle en un rincón, sino que uno, uno aprende a compartir y escucha a las otras personas, eso hace que también la espera sea menos difícil. inf. 1 d. manifestaciones psíquicas de la espera: el cuerpo expresa, a través de manifestaciones psíquicas o físicas, todas las emociones y expectativas. las altas cargas de sensaciones vividas en la sala de espera producen síntomas psíquicos y físicos. los informantes manifiestan ansiedad, estrés, angustia e incertidumbre, otros presentan taquicardia, sudoración y cefalea. bueno, la espera es, digámoslo así, como algo de ansiedad e intranquilidad, porque como igual a ellas las entran y uno no puede estar al lado ni nada, entonces uno se angustia un poquito, pero en general, la experiencia es de incertidumbre. inf. 7 dominio 4. educación 1. educación para la salud: aprender mientras se espera el desconocimiento sobre lo que sucede alrededor del trabajo de parto y el parto les produjo intranquilidad. se generó la relación semántica: “explicar qué pasa adentro y resolver dudas, son formas de tranquilizar al acompañante”. preguntan sobre la dilatación, sin saber exactamente lo que significa, sobre los dolores, el monitoreo electrónico y para qué sirve, sobre las funciones de los estudiantes en formación que entran en contacto con la gestante, sobre las complicaciones tanto de la madre como del bebé y sobre los posibles errores médicos. entonces queda uno como ¿qué estará pasando adentro, en qué dilatación estará?, pues son muchas cositas que uno quisiera saber un poquito más, para uno estar mucho más tranquilo, porque detrás del compañero hay muchas personas que quieren saber cómo está ella… eso es entonces un poquito preocupante, 214 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 porque dirán que pasan muchas cosas, si va a ser cesárea, si va a ser un parto normal, como ese tipo de cositas que le preocupan a uno. inf. 10 2. información: saber qué pasa adentro los acompañantes se imaginan lo que “pasa allá adentro” y requieren que la información que se les proporcione tenga unas características especiales, entre ellas: cómo está la gestante desde lo físico y lo emocional, cómo va evolucionando y en cuál espacio físico de la sala se encuentra. “me gustaría saber cómo es el procedimiento que ellas siguen cuando llegan, como desde que llegó ella; me imagino que tienen un protocolo con ella, que primero le hacen un monitoreo, qué reporte tiene el monitoreo”. inf. 8 discusión 1. dominio: comunicación terapéutica la comunicación terapéutica tiene que ver con la relación enfermera-persona, situación que es ampliamente abordada por la teoría enfermera y que forma parte de los conceptos fundamentales de las definiciones de enfermería encontradas en la literatura como una “relación de ayuda, que acompaña a la persona” (13). en el presente estudio, esta relación debe ser practicada no solo con la mujer en trabajo de parto, sino también con su familia, entendiendo por familia a aquellos seres que tienen un vínculo afectivo cercano a la gestante y que están actuando como acompañantes en la sala de espera; los planes de cuidado de enfermería deben estar enfocados, de acuerdo con la teoría enfermera, al paciente y a la familia. los profesionales de enfermería deben evitar al máximo encuentros que se perciban como mal trato; es indispensable tener en cuenta todas las características propias de la comunicación verbal y no verbal, considerar como un determinante en esta interacción las condiciones ambientales externas e internas, no solo de los acompañantes, sino también del profesional de enfermería responsable de direccionar el espacio de comunicación. así lo expresa el estudio de vicuña sobre la satisfacción de los familiares en un servicio de obstetricia (1). por tal razón, los escenarios de comunicación terapéutica en una sala de espera deben estar dotados no solo de elementos tangibles (espacio físico adecuado, con pocos contaminantes auditivos, confortable, iluminado, agradable, etc.); sino también, de elementos intangibles (buen tono de voz, interés por comunicar, respeto, comprensión, etc.) que favorezcan una percepción positiva por parte de los familiares. los profesionales de enfermería tienen el reto de asumir el cuidado de la familia que se encuentra en sala de espera de trabajo de parto, como parte de los planes y protocolos de la institución. en relación con las habilidades de retroalimentación, se debe hacer que el familiar entienda que los enfermeros quieren ayudar y no mostrarse superiores; describir la situación de manera clara, sin juicio de valores; estar preparados para recibir las respuestas, y pensar con el acompañante sobre lo que se dijo, para que ambos tengan el mismo entendimiento sobre lo que fue comunicado (14). otro aspecto que llama la atención frente a la comunicación es la información que esta contiene, y la frecuencia con que se da. en el presente estudio, los acompañantes perciben la comunicación con falencias, y también señalan que la frecuencia con que se comunican e informan no cumple con la necesidad que tienen de saber de su ser querido. al respecto, la investigación de rondeau (15) concluye que la comunicación amplia, frecuente y multicanal es esencial para el mantenimiento de buenas relaciones. los acompañantes que están esperando necesitan tener la seguridad de que no han sido olvidados y deben ser constantemente actualizados sobre los progresos de la mujer mientras esperan. cuando la información no se mueve rápidamente, los familiares necesitan saber con seguridad cuándo pueden esperar el servicio. la investigación sugiere que con el fin de mantener a los acompañantes satisfechos, deben ser informados cada 15 minutos, y que la mejor política es la comunicación en todo momento de una manera honesta y directa. 2. dominio: acompañamiento acompañar, según la real academia española (16), es “estar o ir en compañía de otra u otras personas”; el presente estudio trasciende esta mirada y se enmarca en un concepto más integral de “vivir la experiencia con el otro”. los familiares no quieren ser simplemente espectadores, sino protagonistas de un proceso del que, consideran, también forman parte. 215 vivencias de familiares en sala de espera de trabajo de parto l dora isabel giraldo-montoya y otros los estudios muestran que el acompañamiento es de gran beneficio y no tiene ningún riesgo asociado con el apoyo en el trabajo de parto y el parto. de la misma manera lo manifiestan silva et al. (17), quienes refieren que son claros los beneficios y se debe hacer todo tipo de esfuerzo para asegurarse de que todas las mujeres reciban apoyo, no solo de las personas allegadas, sino también de acompañantes profesionales, especialmente formados para ello. este apoyo debe incluir la presencia constante, que se otorguen medidas de alivio y confort, y que se brinde aliento continuo. el estudio de ariza y herrera (18) demostró que los padres que participan en el nacimiento de su hijo manifiestan reacciones como “mayor protección de la esposa, mayor orgullo en relación con su matrimonio y con su propia virilidad, y el disfrute previo de su paternidad”. así es como la familia expresa que la importancia de acompañar radica no solo en estar ahí presente, sino también en participar y compartir las vivencias buenas o malas de la gestante, apoyar en el sufrimiento o la alegría y experimentar la llegada del nuevo ser. el estudio de katri vehviläinen-julkunen y anja liukkonen (19), refiere que la presencia de los padres en el parto ha demostrado ser un punto culminante en la vida de ellos. los hombres no solo están para apoyar a su pareja, sino que para ellos también es una experiencia extraordinaria: es cuando, en realidad, se convierten en padres. expresan que la presencia del padre en el parto se considera importante para la aceptación de la paternidad (20-23). el personal de enfermería tiene una tarea importante en la prestación de apoyo y orientación para los padres en su nueva situación de vida o en alentarlos a interactuar con su nuevo bebé (24, 25). deben hacer frente y abogar por las gestantes en situaciones donde hay que estar presentes para acompañar o buscar la mejor compañía para la madre. también es necesario explicar a la familia las razones por las cuales no se permite la entrada a la sala de partos. aunque los familiares suponen que existe una justificación científica para no poder acceder, es importante que comprendan y se sientan satisfechos con las explicaciones. dejar a la imaginación los motivos para no entrar con la gestante afecta la imagen de la institución y crea insatisfacciones. 3. dominio: el ambiente en la sala de espera se hizo visible que el contexto tanto interno (lo propio del familiar) como externo (lo propio de la sala), son factores que influyen en la estadía grata o no del acompañante. en el presente estudio, entre los factores internos se analizó la motivación como elemento esencial en la experiencia de esperar. los acompañantes, especialmente los padres y las abuelas, revelan que la espera es tolerable porque están motivados por ver al nuevo hijo y por las expectativas creadas para el futuro. la espiritualidad fue considerada como otro factor interno necesario cuando se vive un momento de gran tensión, como el nacimiento; así surge la esperanza de contar con un ser superior, que ayuda, protege y evita complicaciones para la madre y el hijo por nacer. rezar en la sala de espera se convierte en una actividad cotidiana, especialmente en un contexto cultural con alto contenido de creencias y tradiciones, alrededor de los mitos y rituales religiosos. la espiritualidad es una fuerza que le da sentido a la vida y, en un determinado momento y circunstancia, adquiere un mayor valor o significado, como en situaciones de enfermedad, sufrimiento o muerte (26, 27). de igual manera, las experiencias ajenas que viven los familiares durante la espera fueron un factor interno que afectó su nivel de tolerancia a la misma. dichas experiencias fueron expresadas a otros para conversar y establecer relaciones sociales; en este sentido, todos participaron y compartieron situaciones similares y con un mismo objetivo. esa interacción social que se desarrolló en la sala de espera despertó el sentido de solidaridad. como lo refiere rondeau (15), las personas en una sala de espera experimentan una interacción grupal típica y desarrollan dinámicas de grupo, a pesar de que la composición del grupo esté en constante cambio. el presente estudio muestra que los familiares tienen altas cargas de estrés y fuertes choques emocionales que van desde el miedo, la angustia y la ansiedad, hasta la felicidad. estos sentimientos se reflejan en el estado de salud física del familiar, manifestado por fatiga, sudoración, taquicardia, dolor muscular y cefalea. dichas sensaciones cambian con respecto a los que esperan en otras salas de atención en salud. los estudios muestran que los compañeros o esposos experimentaron sentimientos fuertes de placer y de orgullo, como también de miedo, ansiedad e impotencia (15, 19). enfermería debe intentar asumir encuentros interpersonales con los usuarios. es decir, desde la perspectiva de la teoría de enfermería como cuidado, el profesional está preparado para 216 año 16 vol. 16 nº 2 chía, colombia junio 2016 aquichan issn 1657-5997 trascender los contextos sociales y situacionales, y tiene los conocimientos para generar respuestas de cuidado que alienten a la persona y le den esperanza y consuelo. los profesionales de enfermería que intervienen en estas situaciones pueden ayudarlos, permitiéndoles expresar sus sentimientos. de otro lado, la imagen de la institución es una razón que tuvieron los informantes para consultar el servicio de obstetricia. la imagen positiva y la reputación que se tiene en la comunidad, es un factor relevante para la gran afluencia de maternas. sin embargo, cuando viven la experiencia de esperar, la percepción cambia y surgen comentarios que indican no querer volver por los servicios. el estudio de rondeau (15) encontró que un cliente insatisfecho, que ha tenido un problema, dirá a nueve o diez personas lo sucedido, generando un impacto negativo en el futuro para la institución. la experiencia negativa más relevante fue la frecuencia y la calidad de la información. en este sentido, enfermería tiene una labor transcendental, a través del establecimiento de planes de cuidado para la familia, que incluyan como actividad diaria y permanente el ofrecimiento de información clara, precisa, oportuna, frecuente y cálida. 4. dominio: educación en la sala de espera las salas de espera en las instituciones de salud son espacios que se deben aprovechar para hacer el tiempo más eficiente y más productivo. en este sentido, el presente estudio determinó que la educación es fundamental en este espacio, y que hay características que deben tenerse en cuenta para hacer más ameno y productivo este tiempo considerado como perdido o muerto. en el campo de la salud, la educación adquiere una importancia relevante, especialmente para el personal de enfermería. así como lo expresan durán et al. (28), es en este contexto que la educación para la salud adquiere una gran importancia, ya que es un proceso que promueve cambios de conceptos, comportamientos y actitudes frente a la salud, la enfermedad y al uso de servicios, reforzando conductas positivas. igualmente, para los usuarios, la educación es percibida como relevante para su aprendizaje; esto se evidencia en un estudio de peñaranda y blandón, donde refieren que los usuarios consideraban necesaria y valiosa la orientación impartida por los profesionales de la salud, puesto que “encuentran que no son suficientes sus experiencias, ni los conocimientos de las personas de su ambiente próximo” (29). los profesionales de enfermería deben educar e informar y proporcionar una espera más amena y productiva. en este sentido, y de acuerdo con las vivencias de los informantes, la educación para la salud y la información en sala de espera de trabajo de parto se debe basar en: 1. educación para la salud: el proceso de la dilatación, el manejo del dolor en trabajo de parto, el monitoreo electrónico fetal, actividades de docencia en la institución, complicaciones para la madre y el bebé y medidas de seguridad para evitar errores médicos. 2. información: las actividades que se desarrollan al interior de las salas de obstetricia. aquí se debe tener en cuenta no solamente cómo se encuentra la madre desde lo físico, sino también desde lo emocional, la evolución de su trabajo de parto e informar en cuál espacio físico va. el estudio de pérez (30) identificó que a los familiares que esperan en la sala de trabajo de parto y parto se les debe ofrecer información sobre cómo se encuentra la parturienta y cómo evoluciona el parto, con el objetivo de calmar la ansiedad que surge durante esta espera. el acercamiento a los familiares en la sala de espera mediante la educación, crea espacios para que estos, y especialmente los esposos, tengan la oportunidad de compartir experiencias y despejar dudas, además de conocer sobre los temas de la maternidad, como se evidenció en el estudio de magnoni y komura (31), quienes señalan que la información recibida por los padres les permitía profundizar más en las relaciones con sus parejas y fortalecer el papel paternal que iniciaban. el establecimiento de un protocolo educativo e informativo debe garantizar que los familiares se sientan participantes activos en la espera de su ser querido, de la misma manera se les debe mostrar que el equipo de salud se interesa por ellos a través de la educación e información clara y permanente. conclusión la presente investigación se consideró como un primer referente institucional para abordar de manera apropiada a los fami217 vivencias de familiares en sala de espera de trabajo de parto l dora isabel giraldo-montoya y otros liares en salas de espera. se logró identificar, desde la etnografía focalizada, un soporte teórico para la construcción de políticas institucionales y planes de cuidado encaminados a tener en cuenta servicios más humanos, caracterizados por una adecuada comunicación con el familiar, que contenga educación continua e información permanente, un ambiente propicio que garantice un estado de confort y tranquilidad, y la posibilidad de acompañamiento en las salas de trabajo de parto. referencias 1. vicuña m. nivel de satisfacción y las disfunciones percibidas sobre la calidad de la atención de los servicios obstétricos. an fac med [internet]. 2002 [citado 2014 ago 26]; 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16(1):105-114. disponible en: http://www.scielo.cl/scielo.php?script=sci_ arttext&pid=s0717-95532010000100012&lng=pt. 328 352 terapias de sustitucion de la funcion renal.indd 328 lorena mesa-melgarejo1 ana julia carrillo-algarra2 ruth alexandra castiblanco3 liliana marcela reina4 tania marcela ávila5 terapias de sustitución de la función renal: metaestudio y síntesis de evidencias cualitativas 1 orcid.org/0000-0002-2781-080x. fundación universitaria de ciencias de la salud, colombia. lpmesa1@fucsalud.edu.co 2 orcid.org/0000-0002-3765-7474. fundación universitaria de ciencias de la salud, colombia. ajcarrillo@fucsalud.edu.co 3 orcid.org/0000-0001-8328-9601. fundación universitaria de ciencias de la salud, colombia. racastiblanco@fucsalud.edu.co 4 orcid.org/0000-0003-4982-939x. fundación universitaria de ciencias de la salud, colombia. lmreina1@fucsalud.edu.co 5 orcid.org/0000-0003-2861-8120. fundación universitaria de ciencias de la salud, colombia. tmavila@fucsalud.edu.co recibido: 26 de noviembre de 2015 enviado a pares: 16 de diciembre de 2015 aceptado por pares: 01 de noviembre de 2016 aprobado: 03 de noviembre de 2016 doi: 10.5294/aqui.2017.17.3.9 para citar este artículo / to reference this article / para citar este artigo mesa-melgarejo l, carrillo-algarra aj, castiblanco ra, reina lm, ávila tm. terapias de sustitución de la función renal: metaestudio y síntesis de evidencias cualitativas. aquichan. 2017; 17(3): 328-352. doi: 10.5294/aqui.2017.17.3.9 resumen el objetivo del presente estudio fue sintetizar en términos de evidencias cualitativas o evidencias q hallazgos derivados de estudios cualitativos frente al tema de las terapias de sustitución de la función renal (tsfr). método: metaestudio cualitativo desarrollado en cuatro momentos. resultados: se integraron 75 estudios. de los cuales, 52 exploraban experiencias relacionadas con hemodiálisis (hd), 10 de diálisis peritoneal (dp), 6 trasplante, 6 dp y hd al mismo tiempo y 1 estudio exploró las 3 tsfr. los estudios incluidos describen y representan el fenómeno de vivir en una condición de cronicidad y estar sometido a una tsfr de manera muy semejante, que se agruparon en patrones comunes del fenómeno, estos son descritos en tres grandes temáticas: la metamorfosis de la vida; dolores diversos y la terapia invade la vida. conclusión: los resultados dan cuenta de la estrecha interrelación de las dimensiones humanas, por esto el fenómeno de vivir en una tsfr genera una transfiguración el “ser”, como totalidad, pues no es posible desligar una dimensión de otra, de allí la importancia de pensar la atención de las necesidades en perspectiva relacional y no jerarquizada. palabras clave investigación cualitativa; diálisis renal; prestación de atención de salud; atención al paciente; servicios de salud (fuente: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 328-352 329 terapias de sustitución de la función renal: metaestudio y síntesis de evidencias cualitativas l lorena mesa-melgarejo y otros año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 328-352 renal replacement therapy: a meta-study and synthesis of qualitative evidence abstract the objective of this study was to synthesize, in terms of qualitative or q evidence, the findings derived from qualitative studies on the subject of renal function substitution therapies (rfst). method: a qualitative meta-study was carried out in four instances. results: seventy-five (75) studies were included. of these, 52 explored experiences related to hemodialysis (hd), 10 concerned peritoneal dialysis (pd), six were on transplants, six concerned pd and hd at the same time, and one looked at the three rfsts. the studies that were included describe and represent the phenomenon of living with a chronic condition and being subjected to a rfst in a very similar way. the common patterns of the phenomenon were grouped and described in three main subject areas: metamorphosis of life; various aches and pains; and therapy invades life. conclusion: the results show the human dimensions are closely interrelated. accordingly, the phenomenon of living with a rfst generates a change in one’s “being" as a whole, since it is not possible to separate one dimension from another. this underscores the importance of thinking about attending to needs from a relational and non-hierarchical perspective. keywords qualitative research; renal dialysis; health care delivery; patient care; health services (source: decs, bireme). 330 aquichan issn 1657-5997 eissn 2027-5374 terapias de substituição da função renal: metaestudo e síntese de evidência qualitativa resumo objetivo: sintetizar em termos de evidências qualitativas ou evidências q achados derivados de estudos qualitativos sobre o tema das terapias de substituição da função renal (tsfr). método: metaestudo qualitativo desenvolvido em quatro momentos. resultados: foram integrados 75 estudos, dos quais 52 exploraram experiências relacionadas com hemodiálise (hd), 10 com diálise peritoneal (dp), 6 com transplante, 6 com dp e hd ao mesmo tempo e 1 estudo explorou as três tsfr. os estudos incluídos descrevem e representam o fenômeno de viver numa condição de cronicidade e estar submetido a uma tsfr de maneira muito semelhante, que foram agrupados em padrões comuns do fenômeno, estes são descritos em três grandes temáticas: a metamorfose da vida, dores diversas e a terapia invade a vida. conclusões: os resultados evidenciam a estreita inter-relação das dimensões humanas, por isso o fenômeno de viver numa tsfr gera uma transfiguração do ser, como totalidade, pois não é possível desligar uma dimensão da outra; em consequência, destaca-se a importância de pensar o atendimento das necessidades em perspectiva relacional, e não hierarquizada. palavras-chave atendimento ao paciente; diálise renal; pesquisa qualitativa; prestação de atenção de saúde; serviços de saúde (fonte: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 328-352 331 terapias de sustitución de la función renal: metaestudio y síntesis de evidencias cualitativas l lorena mesa-melgarejo y otros introducción la insuficiencia renal terminal (irt) es una situación clínica no transmisible, progresiva, de incidencia, prevalencia y mortalidad elevadas, que obliga al paciente a depender de una terapia o tratamiento sustitutivo de la función renal (tsfr) de manera permanente (1) (hemodiálisis, diálisis peritoneal y trasplante renal), indispensable para la supervivencia, que modifica el modo de vida de las personas y requiere atención permanente y especializada del sistema de salud y alta capacidad de autocuidado. durante el 2015, países como taiwán, méxico y estados unidos presentaron la mayor incidencia de irt y de personas con alguna tsfr (458, 421 y 363 por millón de población, respectivamente), mientras para colombia esta cifra fue de 123. diversas investigaciones (2, 3) demuestran que lo experiencial es fundamental en la dolencia crónica, incluida la irt, por tanto, el número de estudios cualitativos que exploran el fenómeno creció en las últimas décadas a nivel global; sin embargo, “dichas dimensiones no suelen incluirse en planes de cuidado, estrategias institucionales o como parte del tratamiento” (4), afirmación que llama la atención, si se tiene en cuenta la disponibilidad de resultados de investigación, y el aporte que hace al cuidado de las personas en tsfr; además, permite retomar la discusión sobre la implementación de evidencias científicas en el cuidado directo. según galindo, la dificultad para implementar evidencias en las relaciones intersubjetivas propias de los actos de cuidado se produce porque estas “siguen moviéndose en la lógica de la ciencia moderna” (5), y responden a necesidades del profesional o la institución —y no del sujeto—, que son impuestas por el sistema gubernamental en el que se circunscribe el cuidado de la salud; la autora señala un asunto fundamental, muchas veces olvidado, en las premisas de la metodología de la práctica basada en la evidencia: la perspectiva de los pacientes; por tanto, quien desarrolla investigación cualitativa tiene una responsabilidad inherente al paradigma y es que los resultados impacten y transformen la realidad, lo que implica utilizar mecanismos y formas de divulgación para que profesionales de enfermería logren implementarlos de modo consciente y explícito. como investigadores nos cuestionamos sobre esas rutas y opciones que hacen posible la implementación de evidencias derivadas de investigaciones cualitativas; nos preguntamos cómo hacer fácil, concreta y útil la aplicación de sus resultados por parte de los equipos de salud en la práctica de cuidado diario. una de las rutas que ha tomado fuerza recientemente es la “síntesis de evidencias cualitativas”, propuesta emergente desde finales de los años noventa, que está ganando reconocimiento (6); por ejemplo, en 2013, la organización mundial de la salud (oms) incorporó los resultados de una revisión sistemática de estudios cualitativos publicada por la colaboración cochrane (7), como fuente de recomendaciones para los programas de cuidado materno-infantil en el primer nivel de atención (8, 9). según gálvez (10), cuando se trata de problemas de la práctica asistencial relacionados con dimensiones socioculturales, o que dan cuenta de la heterogeneidad de las respuestas humanas en los procesos salud-enfermedad, como es el caso de la irc y los tsfr, se dispone de abundantes estudios cualitativos, recuperables y posibles de sintetizar para obtener respuestas aplicadas que ayuden a la toma de decisiones; afirma, además, que las metasíntesis son el camino hacia el cual debe dirigirse la búsqueda de evidencias. al compartir esta premisa, se propuso sintetizar en términos de evidencias-q, hallazgos derivados de estudios cualitativos frente al tema de los tsfr. materiales y métodos metaestudio cualitativo desarrollado en cuatro momentos: 1) búsqueda sistemática de literatura relevante y pertinente; 2) evaluación de la calidad metodológica, relevancia, coherencia y suficiencia de datos (cerqual); 3) integración de los estudios; 4) síntesis de evidencias-q o cualitativas. búsqueda sistemática de la literatura para identificar y recuperar los estudios se construyó una estrategia de búsqueda electrónica basada en descriptores mesh y decs relacionados con tsfr e investigación cualitativa, que fueron organizados en diversas ecuaciones incluyendo operadores boléanos and y or, las ecuaciones se adecuaron al lenguaje documental de cada base seleccionada con el ánimo de identificar la mayor cantidad de estudios. las búsquedas se realizaron desde el servidor de la fundación universitaria de ciencias de la salud de bogotá. las bases de datos incluidas fueron: medline-ovid, embaseelsevier, cochrane library, cinahl, dialnet, lilacs, web of science, psyiarticles, cuiden y scopus (tabla 1). no se usaron filtros por año, ni se hizo búsqueda de documentos no publicados. 332 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 selección de estudios. se seleccionaron estudios originales publicados en inglés, español o portugués, con metodologías cualitativas (descriptivas o interpretativas), declaradas explícitamente por los autores, que incluyeran participantes adultos en cualquiera de los tsfr y exploraran vivencias o experiencias relacionadas con tsfr desde la perspectiva del paciente. se hizo preselección por título y luego por resumen; de esta última se recuperaron los textos completos, se verificó que abordaran el tema de interés y correspondieran a estudios originales de investigación cualitativa. evaluación cerqual la evaluación de los estudios siguió la propuesta cerqual elaborada por el cochrane collaboration qualitative & implementation methods group (11), que proporciona a los investigadores pautas para saber si confiar en los resultados encontrados a la hora de hacer metasíntesis, y la describen como un análogo de grade (12, 13). cerqual evalúa cuatro dimensiones: • calidad metodológica: se hizo revisión por pares para evaluar la calidad metodológica; para esto se contactaron expertos en metodología cualitativa de españa y colombia, a quienes se invitó a participar voluntariamente; se asignó un número de 6 artículos a cada uno y se aseguró que cada artículo contara con dos revisores. se utilizó la herramienta caspe (critical appraisal skills programme español), para estudios cualitativos (14). la evaluación de pares se recolectó a través de un formulario electrónico diseñado desde la herramienta específica de google. se incluyeron artículos con un puntaje promedio de las dos evaluaciones igual o superior a 17 puntos, de 20 posibles. para cuantificar las puntuaciones se siguió la escala: 2 (sí), 1 (no sé), 0 (no) (15). no se encontraron reportes de índices de validez y fiabilidad para caspe; sin embargo, es una herramienta de amplio uso en las ciencias de la salud (16). • coherencia: valora las posibles diferencias sustanciales entre los estudios frente al mismo fenómeno estudiado, es decir, la posibilidad de identificar un patrón común entre los estudios y que las variaciones o diferencias sean explicadas por aspectos relacionados con el contexto. • relevancia: implica la valoración por parte de los investigadores de la contribución del estudio al tema de interés, si aporta o no a su comprensión. • suficiencia de datos: juicio de valor frente al número de estudios que se incluyen en la metasíntesis, es decir, si aportan la suficiente información sobre el fenómeno de interés. las dimensiones de coherencia, relevancia y suficiencia de datos fueron evaluadas por consenso por el equipo investigador. la confidence (8), descrita por cerqual, es el resultado de integrar las cuatro dimensiones anteriores y se determina como alta, moderada, baja o muy baja, de acuerdo con los resultados de la evaluación de las diferentes dimensiones; se integraron al análisis aquellos estudios valorados con confidence alta y moderada. integración de los estudios para integrar los estudios se siguió la propuesta metodológica denominada metaestudio, definida por zhao como: “el análisis de resultados de previos análisis” (17), en ella se integran resultados de investigación sobre una misma temática, explorada desde la perspectiva cualitativa, reconociendo aspectos comunes y distintos, significativos para comprender integralmente el fenómeno (18). se hizo lectura y relectura de los artículos hasta familiarizarse con las descripciones e interpretaciones allí plasmadas, de modo que posibilitó crear un esquema del fenómeno en conjunto a partir de las relaciones entre los hallazgos de los diferentes estudios, que permitió identificar patrones comunes a modo de temas sobre las experiencias de vida y sintetizarlos en una nueva temática de mayor abstracción. tabla 1.bases de datos y resultados de búsqueda base de datos fecha de búsqueda resultados scopus julio de 2014 583 embase-elsevier mayo de 2014 422 cuiden junio de 2014 307 lilacs mayo de 2014 194 medline ovid1946 to pressent mayo de 2014 176 cochrane library mayo de 2014 111 dialnet mayo de 2014 65 psyiarticles mayo de 2014 55 web of science mayo de 2014 52 cinahl mayo de 2014 34 total 1999 fuente: elaboración propia, 2015. 333 terapias de sustitución de la función renal: metaestudio y síntesis de evidencias cualitativas l lorena mesa-melgarejo y otros síntesis de evidencias q una vez realizado el metaestudio, se extrajeron los resultados en términos de evidencias y recomendaciones para su implementación en la práctica clínica. resultados caracterización de los estudios las búsquedas iniciales arrojaron 1.999 documentos, después de remover los artículos duplicados se obtuvieron 1.197; se seleccionaron por título y resumen 252, cuyos textos completos fueron recuperados para lectura detallada y exhaustiva. de esta selección, 103 artículos fueron evaluados siguiendo la propuesta cerqualy; según la evaluación por pares, 78 cumplían con la calidad metodológica, de ellos 3 no cumplían los criterios de coherencia, relevancia y suficiencia de datos. finalmente, se integraron 75 estudios (anexo); de estos, 52 exploraban experiencias relacionadas con hemodiálisis (hd), 10 con diálisis peritoneal (dp), 6 con trasplante, 6 con dp y hd conjuntamente, y uno exploró los 3 tsfr. el rango de fechas de publicación estuvo entre los años 2003 y 2017. se identificaron 14 metodologías diferentes (tabla 2), dentro de estas, la fenomenología fue descrita desde 9 perspectivas distintas (tabla 3). todos los estudios (exceptuando las 2 metasíntesis) usaron la entrevista semiestructurada y en profundidad como técnica de recolección de datos; un estudio reportó entrevistas y grupos de discusión y otro, además de las dos anteriores, realizó observaciones. en suma, incluidas las metasíntesis, los estudios incluyeron 1.353 participantes, con edades entre 18 y 90 años, la mayoría mujeres. se reportaron 21 nacionalidades distribuidas en cinco continentes, las de mayor frecuencia fueron brasil (28 %), estados unidos (9 %) y canadá (6 %). respecto a la formación académica del primer autor, el 76,27 % de los artículos fueron desarrollados por enfermeras(os). temáticas sintetizadas los estudios describen y representan el fenómeno de vivir en condición de cronicidad y estar en tsfr de manera semejante y no diferenciada por el tipo de tratamiento, aun con la diversidad de nacionalidades y metodologías reportadas. tales semejanzas se agruparon en patrones comunes del fenómeno, que se integran en tres grandes temáticas: la metamorfosis de la vida; dolores diversos y la terapia invade cada rincón de la vida, cuyas propiedades específicas se describen como subtemas. la metamorfosis de la vida. la mayoría de los artículos refieren procesos de cambio (change) como principal aspecto relacionado con la irt y las tsfr, la lectura del conjunto de estudios y los códigos que los representan da cuenta de una profunda transformación en la cotidianidad de las personas y en sus dimensiones físicas, emocionales y afectivas, que surgen desde el momento en que son diagnosticados con irt (19-36). a partir de la metáfora de la metamorfosis se busca dar cuenta del profundo cambio y de la imposibilidad de retornar a un “antes”; incluso en pacientes trasplantados no hay retorno a la vida anterior. uno de los asuntos recurrentes es la transformación a nivel corporal. los cambios físicos y el autoconcepto son manifestaciones comunes en las personas por tsfr (31, 37); la presencia de la fístula o de la incisión abdominal, y los cambios de textura y color de la piel, impactan mucho en las personas, sin embargo, la fatiga es el cambio físico que tiene mayor peso en la transformación de la cotidianidad (27, 30, 32, 33, 38), pues aunque tengan motivaciones para realizar actividades normales, la sensación de cansancio imposibilita y frustra a las personas (26, 35). adicionalmente, reportan modificaciones en los patrones de sueño, que no se experimenta como restaurador (32, 35). dos estudios mencionan cambios negativos en la vida sexual de las personas (28, 39). en estrecha relación con las transformaciones físicas, las emociones, los sentimientos y las expectativas de las personas en tsfr (35), algunos estudios reportan depresión (2), ansiedad (28), incertidumbre (40) e incluso dolor emocional (41); simultáneamente emergen el optimismo y las ganas de luchar, que representan las contradicciones propias de la existencia humana ante un fenómeno complejo (42). algunos estudios refieren que hombres y mujeres en tsfr experimentan cambios de rol, pues las características de la enfermedad y de la terapia dificultan o imposibilitan su desempeño en empleos formales, informales o trabajo doméstico (20, 23, 39, 43). esto obliga al abandono laboral a pesar de las implicaciones financieras y de identidad (36). ningún estudio usó enfoque de género para el análisis, pero es posible abstraer que el rol de las mujeres madres se ve profundamente impactado, llegando a considerar que descuidan a sus hijos (39). para los hombres la pérdida del trabajo y dejar de ser proveedores para sus familias 334 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 tabla 2. metodologías reportadas en los estudios metodología no. de estudios que la reportan descriptivo exploratorio 19 fenomenología 16 no explicito (solo mencionan investigación cualitativa) 9 teoría fundamentada 9 descriptivo 6 estudio de caso 4 clínico – cualitativo 2 metasíntesis 2 narrativo 2 relato biográfico 2 descriptivo exploratorio y narrativo 1 etnografía clásica o tradicional 1 fenomenografía 1 investigación basada en la comunidad 1 fuente: elaboración propia, 2015. tabla 3. variantes de la fenomenología especificación de la perspectiva no. fenomenología (ricoeur) 4 fenomenología (sin otra especificidad) 2 fenomenología (husserl) 2 fenomenología hermenéutica (heidegger) 2 fenomenología (hycner. actualizada con kvale) 1 fenomenología (giorgi) 1 fenomenología (husserl y giorgi) 1 fenomenología (spiegelberg) 1 fenomenología existencial (merleau ponty) 1 fenomenología exploratoria (field y morse) 1 fuente: elaboración propia, 2015. es lo que más impacta su identidad de género (44); esto genera reacomodaciones al interior de la familia o reasignación de roles (21, 43). la dimensión espiritual se desconfigura, las personas sienten una pérdida del desempeño de sus prácticas espirituales, porque no es fácil movilizarse a los lugares sagrados o de culto, ni seguir desempeñando labores religiosas (21). la metamorfosis también se presenta en las relaciones con amigos y colegas llevando al aislamiento (19, 45), descrito e interpretado en los estudios como una forma de mantener la enfermedad en la esfera más privada, por temor (46) al rechazo social por los cambios físicos y emocionales descritos previamente (19, 37, 44, 46-51). un aspecto que marca la experiencia vivida en el tsfr es la dependencia, referida por familiares y pacientes (52-54). en todos los tratamientos, la sensación de “depender de…” limita y genera sentimientos negativos. esta dependencia se da hacia la familia, el cuidador principal, el equipo de salud, la medicación y el sistema de salud; este último puede representar una barrera de atención (40, 45, 55-58). para las personas en postrasplante, se suma el miedo a perder el órgano (59). dolores diversos. el tema “dolor” es recurrente y requiere una reflexión individualizada, por la diversidad y los matices que se describen en los estudios (20, 41, 50, 60); además, los profesionales refieren muchas dudas sobre el manejo farmacológico, pues la alteración renal dificulta las decisiones sobre la analgesia (41). el dolor tiene que ver con lo físico, lo emocional y lo social (45), en términos generales, dolor y sufrimiento son conceptos que se usan indistintamente y son transversales a la experiencia (20, 41); como síntoma es en sí mismo complejo de dimensionar y debido a su carácter subjetivo el abordaje es más difícil, asunto que impacta la calidad de vida de las personas (50), incluso la experiencia se define como dolencia (60). los pacientes soportan el dolor por temor a que los analgésicos lesionen el riñón y por considerar que no amerita atención del equipo de salud (61). el manejo no farmacológico fue explorado por un estudio que menciona técnicas de meditación como estrategia y reporta déficit de herramientas en los profesionales de las unidades renales para reconocerlo, dimensionarlo y abordarlo (41). la terapia invade la vida. esta temática integra contenidos y categorías que diversos estudios describen como dinámicas alrededor de los tsfr que permean las dimensiones humanas, los espacios físicos y esferas concretas (2, 24, 25, 46, 62), y generan una profunda contradicción en las personas, pues hay concien335 terapias de sustitución de la función renal: metaestudio y síntesis de evidencias cualitativas l lorena mesa-melgarejo y otros cia de la necesidad del tratamiento para sobrevivir y, a la vez, es un “mal necesario”, un aspecto inevitable al cual se deben someter, por esta razón, el fenómeno se convierte en una “adherencia obligada” (63, 64). el tratamiento ocupa un espacio central por los tiempos dedicados, la enorme atención que el proceso requiere, los insumos/equipos que empiezan a ser parte del mobiliario de la casa y las restricciones que de este se derivan (65). es un aliado y un enemigo, sin él no es posible sobrevivir, pero es complejo e impactante lidiar con sus implicaciones (66); además, algunos estudios hacen evidente que la máquina de hd o la cicladora se “personifican” y simbolizan la dependencia, aquello que los ata y los limita (63). las restricciones más descritas por los estudios se relacionan con alimentos, líquidos, actividad física y ocio (58, 67), ellas generan malestar emocional (distress), y son poco comprendidas por los pacientes, porque las explicaciones que brinda el equipo de salud permanecen en el plano biomédico (35, 43, 68). la búsqueda del porqué es común entre las experiencias, por ello la información juega un rol fundamental (38, 59, 64, 69). tanto pacientes como familiares dedican bastante tiempo a buscar información que les ayude a hacer llevadero el proceso; describen como fuentes: el equipo de salud (34, 70-72), internet, amigos cercanos, otros pacientes (73, 74) y, quizás la más relevante, el aprendizaje a partir de la propia experiencia (70, 75). la comprensión de la enfermedad y el tratamiento emerge del tejido de discursos y concepciones (76, 77), por un lado, la incorporación de lo biomédico al lenguaje propio y por otro, las explicaciones relacionadas con el contexto y la cultura (63, 64, 78). con este tejido discursivo las personas fabrican autointerpretaciones y explicaciones sobre la enfermedad y el cuidado, facilitando el afrontamiento (27) y la adherencia (44, 79). los artículos describen que las personas acuden a recursos como: lazos afectivos y relaciones de cercanía con el equipo de salud, temor a la muerte, fe y esperanza para afrontar su enfermedad y adherirse al tratamiento (35, 56, 74, 80-86). el acompañamiento de la familia se convierte en un pilar para hacer frente a las transformaciones y dolencias; estos lazos afectivos se reconocen como la red principal (84). en un segundo plano están los lazos afectivos y las relaciones que establecen con el personal de salud, especialmente con las enfermeras (82, 83, 85). la percepción de las relaciones es contradictoria, se reconocen como cercanas, afectuosas, importantes para el afrontamiento, pero a veces poco asertivas (81). algunos estudios reportan reproducción de relaciones de poder entre el equipo y el paciente, lo cual restringe la toma de decisiones y el empoderamiento (54, 58, 87-89). síntesis de evidencias-q la síntesis de la literatura indica que los pacientes en tsfr reconocen que pierden autonomía por la dependencia al tratamiento como única forma de supervivencia (30, 35, 53, 54), por tanto, el equipo de salud debe desarrollar intervenciones que favorezcan la recuperación de esta; una alternativa es educar a los cuidadores no formales y a los pacientes para que realicen las actividades de la vida cotidiana que les sean posibles (30), y promover aficiones que no representen actividad física intensa, como pintar o hacer manualidades (49, 58, 90). otra intervención es establecer contacto con los servicios sociales para buscar la integración a la vida social y laboral (23, 39, 43). adaptarse a una terapia requiere modificar los estilos de vida, horarios, alimentación, ingesta de líquidos (56, 74, 84, 86, 90, 91) y tipo de ejercicio, aspectos que deben incluirse en la educación inicial del paciente, la familia o los cuidadores no formales, de manera que el cambio se convierta en una estrategia de equipo (35, 69). asimismo, el cansancio se debe manejar con siestas y descansos breves durante el día (26, 27, 32, 33, 38). la intervención más reconocida por pacientes en dp fue la visita domiciliaria, porque entienden más fácilmente los procedimientos cuando se encuentran en un ambiente conocido, y los profesionales de la salud pueden incluir en las estrategias educativas elementos reales del entorno del paciente (30, 31). en el caso del trasplante, los donantes expresan sensación de abandono, por tanto, es necesario fortalecer programas de seguimiento para ellos (89). los programas educativos deben adaptar su lenguaje a palabras comprensibles en el marco sociocultural de los pacientes, pues los términos biomédicos (30, 70, 78, 91) dificultan la apropiación de cambios recomendados (2, 19-32, 37, 53). la estrategia “aprender de la experiencia de otros” con quienes comparten el lenguaje y la situación de vida (33-35) resulta efectiva para los procesos educativos; asimismo, la experiencia de los pacientes describe que la comunicación que genera lazos afectivos favorece la incorporación de las recomendaciones (74, 80-82, 84), por ello lo indicado es que los programas educativos, las consultas y las visitas 336 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 domiciliarias sean desarrollados por el mismo equipo de salud, pues cambiar el personal impacta en los procesos de adaptación; además, se reconoce al enfermero(a) como el profesional que logra mayor interacción con los usuarios (31, 75, 87). por último, se evidencia que con la población joven es importante incluir intervenciones que mejoren el autoconcepto (30-32, 91). discusión los resultados del presente metaestudio dan cuenta de la estrecha interrelación de las dimensiones humanas, por esto el fenómeno de vivir con tsfr genera una transfiguración del “ser” como totalidad, que constituye un fenómeno complejo, pues no es posible desligar una dimensión de otra, de allí la importancia de pensar la atención de las necesidades en perspectiva relacional y no necesariamente jerarquizada, pues, como se deduce del metaestudio, lo que para el personal de salud es importante para el paciente puede no estar en su marco de referencia (92, 93). la síntesis de evidencias a partir de estudios cualitativos permite pensar una atención más allá de la patología y repensar el marco médico-clínico en el quehacer del cuidado; aspecto identificado en síntesis cualitativas de otras temáticas del área de la salud (94). un cuidado de enfermería de calidad implica rescatar la narrativa del paciente de modo que se interprete su experiencia y le permita participar de su situación y recuperación; integrar su voz dentro del tratamiento le ayuda a resignificar de manera positiva su vida con la enfermedad, los cambios físicos, emocionales, espirituales y su rol dentro de la sociedad, de manera que se adapte y recupere su estado de salud de manera más efectiva (95-96). los relatos de quienes transitan por un tsfr se consideran evidencias válidas sintetizadas a partir de hallazgos de estudios cualitativos, y representan facilidad para su implementación en la práctica cotidiana de cuidado; sería importante desarrollar estudios que evalúen su implementación e impacto, como momentos integrales de las prácticas basadas en evidencias, y fortalecer los programas de seguimiento que aumenten la interacción del paciente con el equipo de salud. conclusión los resultados de investigación cualitativa como fuente de evidencias fortalecen las relaciones intersubjetivas como fundamento ontológico del cuidado de la persona en tsfr, ya que hacen explícitas las interacciones entre las diferentes dimensiones de lo humano. las evidencias q obtenidas aportan elementos para la reflexión frente a la praxis de enfermería que son transversales a los diferentes ámbitos del cuidado, pensándolo como la resolución de las necesidades en perspectiva relacional y no jerarquizada, lo que supone un cambio paradigmático hacia una atención centrada en la integración de las relaciones del ser humano y no solo desde una visión biologisista. esto representa un gran desafío para los profesionales que deberán actuar como guías, basados en las evidencias, en este caso cualitativas, y en su experiencia para lograr que el sujeto sea capaz de ejercer su autocuidado desde lo que significa el tsfr para su desarrollo como persona, y las relaciones que pueden aportar al mantenimiento de su calidad de vida. limitaciones del estudio. una de las limitaciones es la herramienta de evaluación de la calidad metodológica de los estudios porque no se identificaron las propiedades psicométricas en la literatura publicada. en términos epistemológicos y metodológicos quedan interrogantes frente al abordaje de los fenómenos relacionados con la enfermedad desde la perspectiva cualitativa, pues a pesar de la diversidad de métodos, la descripción e interpretación de las experiencias fue homogénea y, en ocasiones, no fue posible identificar las particularidades metodológicas en los resultados; 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17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 66. branco jma, lisboa mtl. adesão de clientes renais crônicos ao tratamento hemodialítico: estratégias de enfermagem. rev enferm uerj. 2010;18(4):578-83. 67. silveira m. as atividades lúdicas em unidade de hemodiálise. acta sci. health sci. 2005;27(2):103-12. 68. yumang mj, hammond l, filteau n, purden m. perceptions of risk for foot problems and foot care practices of patients on hemodialysis. nephrol nurs j. 2009;36(5):509-16. 69. santos fk, valadares gv. conhecendo o mundo do ser que enfrenta a diálise peitoneal: nexos simbólicos presentes no cotidiano. rev enferm uerj. 2011;19(3):473-78. 70. prieto ma, escudero mj, suess a, march jc, ruiz a, danet a. análisis de calidad percibida y expectativas de pacientes en el proceso asistencial de diálisis. anales sis san navarra. 2011;34(1):21-31. 71. heiwe s, tollin h. patients’ perspectives on the implementation of intra-dialytic cycling-a 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78. paterson bl, sock la, leblanc d, brewer j. ripples in the water: a toolkit for aboriginal people on hemodialysis. cannt j. 2010;20(1):20-8. 79. araujo es, pereira ll, anjos mf. autonomia do paciente com doença renal crônica em tratamento hemodialítico: a aceitação como fator decisório. acta paul enferm. 2009;22(1):509-4. 80. elliott ba, gessert ce, larson p, russ te. religious beliefs and practices in end-stage renal disease: implications for clinicians. j pain symptom manage. 2012;44(3):400-9. 81. campos cj, turato er. a equipe de saúde, a pessoa com doença renal em hemodiálise e suas relações interpessoais. rev bras enferm. 2003;56(5):502-6. http://dx.doi.org/10.1590/s0034-71672003000500008. 82. pacheco im. sobrevivir con enfermedad renal crónica. el padecimiento de una mujer dependiente de la hemodiálisis. arch memoria. 2010;7(5). 83. pereira lp, cavalcante mv. hemodiálise: a percepção do portador renal crônico. cogitare enferm. 2009;14(4):689-95. 84. mitchell a, farrand p, 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hernández-zambrano s, hueso-montoro c, montoya-juárez r, gómez-urquiza j, bonill-de-las-nieves c. metaestudio cualitativo sobre vivencias y gestión del cotidiano en adultos mayores que padecen enfermedades crónicas. cultura de los cuidados. 2016;20(44):75-90. doi:10.14198/cuid.2016.44.07 96. mariano l, rodríguez m, conde d. cuidados basados en narrativas: redefiniendo la jerarquía de la evidencia. index enferm. 2013;22(1-2):55-9. 97. capilla-díaz c, et al. the patient experience of having a stoma and its relation to nursing practice: implementation of qualitative evidence through clinical pathways. gastrointestinal nursing; 2016;14(3):39-46. 98. mesa-melgarejo l. reflexiones epistemológicas y metodológicas sobre la investigación cualitativa en terapias de sustitución de la función renal. investig enferm imagen desarr 2017;19 (2): 97-112. 342 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 anexo 1 medline –ovid 1 kidney diseases/ (70546) 2 exp 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(nursing process) or tema: (nursing diagnosis) or tema: (nursing, team) or tema: (nurse patient relations) # 2 tema: (renal dyalisis) or tema: (dialysis) or tema: (peritoneal dialysis) or tema: (peritoneal dialysis, continuous ambulatory) or tema: (dialysis solutions) or tema: (hemodialysis) para eliminar este conjunto # 1 tema: (kidney diseas*) or tema: (kidney failure) or tema: (chronic kidney failure) or tema: (kidney) or tema: (renal impairement) or tema: (renal disease) and tema: (kidney damage) 346 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 psyarticles s7 (((qualitative or qualitative analysis or qualitative nursing research or qualitative reading inventory or qualitative reasoning or qualitative research) and (s1 and s2 and s3 and s4 and s5 and s6)) and (s1 and s2 and s3)) and (s1 and s2 and s3 and s4 and s5 and s6) 34 s6 qualitative or qualitative analysis or qualitative nursing research or qualitative reading inventory or qualitative reasoning or qualitative research 22,862 s5 view* or experiences or experien* or opinion or opinion* or attitude or attitud* or attitudes towards death or knowledge or know* or understand* 161,228 s4 questionnaire or questions or interviews or intervie* or focus group or focus group* or phenomenology or ethnography or participant observation 85,306 s3 nurse or ( nurse and patient ) or nurse patient relationship or nurse practitioners or nurse-patient ratio or nursing assessment or nursing diagnosis or nursing care facilities or nursing care plans or nursing services or nurs* or nursing team 191,707 s2 dialysis or renal dialysis or peritoneal dialysis or hemodialysis or hemodialysis patients or hemodialysis facility or hemodialysis equipment 4,265 s1 kidney disease or kidney failure or kidney damage or chronic kidney failure or renal disease or renal impairement 347 terapias de sustitución de la función renal: metaestudio y síntesis de evidencias cualitativas l lorena mesa-melgarejo y otros anexo 2 id base de datos autor título revista año 1 lilacs hilário, edson andré pereira; reinaldo, amanda márcia dos santos a apropriação e a reprodução do discurso médico por paciente com insuficiência renal crônica rev. enferm. uerj 2007 4 embase campos. claudinei josé gomes; turato, egberto ribeiro a equipe de saúde, a pessoa com doença renal em hemodiálise e suas relações interpessoais revista brasileira de enfermagem 2003 5 lilacs mattos, magda de; maruyama, sônia ayako tao a experiência de uma pessoa com doença renal crônica em hemodiálise rev gaucha enferm 2010 6 cuiden/ lilacs mattos, magda de; maruyama, sônia ayako tao a experiência em família de uma pessoa com diabetes mellitus e em tratamento por hemodiálise ree -bra2009 7 embase/ lilacs sadala ml, bruzos ga, pereira er, bucuvic em a experiência vivida pelos pacientes em diálise peritoneal domiciliar: uma abordagem fenomenológica revista latino-americana de enfermagem 2012 14 lilacs branco, joyce martins arimatea; lisboa, marcia tereza luz adesão de clientes renais crônicos ao tratamento hemodialítico: estratégias de enfermagem rev. enferm. uerj 2010 19 embase wiederhold d, langer g, landenberger m ambivalent lived experiences and instruction need of patients in the early period after kidney transplantation: a phenomenological study nephrology nursing journal : journal of the american nephrology nurses' association 2011 26 dialnet maría angeles prieto rodríguez, maría josé escudero carretero, astrid suess, joan carles march cerdá, ainhoa ruiz azarola, alina danet danet análisis de calidad percibida y expectativas de pacientes en el proceso asistencial de diálisis anales del sistema sanitario de navarra 2011 28 lilacs brasil, maria de lourdes silveira; schwartz, eda as atividades lúdicas em unidade de hemodiálise acta sci., health sci 2005 32 cuiden autonomia do paciente com doença renal crônica em tratamento hemodialítico: a aceitação como fator decisório acta paul enferm -bra2009 34 embase martin-mcdonald k being dialysis-dependent: a qualitative perspective collegian 2003 36 lilacs beanlands, h.; horsburgh, m.e.; fox, s.; howe, a.; lockingcusolito, h.; pare, k.; thrasher, c. caregiving by family and friends of adults receiving dialysis nephrol nurs j 2005 348 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 id base de datos autor título revista año 43 embase/ lilacs/ medline yngman-uhlin, p.; friedrichsen, m.; gustavsson, m.; fernström, a.; edéll-gustafsson, u. circling around in tiredness: perspectives of patients on peritoneal dialysis nephrol nurs j 2010 49 embase/ lilacs mccarthy, a.; shaban, r.; boys, j.; winch, s. compliance, normality, and the patient on peritoneal dialysis nephrol nurs j 2010 50 cuiden dos santos, fk conhecendo as estratégias de ação e interação utilizadas pelos clientes para o enfrentamento da diálise peritoneal esc. anna nery r. enferm. -bra2013 51 cuiden dos santos, fk conhecendo o mundo do ser que enfrenta a diálise peitoneal: nexos simbólicos presentes no cotidiano r enferm uerj 2011 57 lilacs fujii, cinthia dalasta caetano desafios da integralidade no cuidado em hemodiálise: a ótica da equipe de saúde e dos usuários repositorio universidad federal rio grande del sur 2009 74 cuiden pacheco lopéz, im sobrevivir con una enfermedad renal crónica. el padecimiento de una mujer dependiente de la hemodiálisis arch memoria 2010 77 lilacs/ scopus de carvalho, m. f.; moreira, m. r. c.; nunes, c. m. estágios do pesar nos discursos de joven sem tratamento renal substitutivo revista enfermagem 2012 79 lilacs/ medline leung, s.s.; shiu, a.t. experience of hong kong patients awaiting kidney transplantation in mainland china j clin nurs 2007 80 embase/ lilacs/ medline kazemi, m.; nasrabadi, a.n.; hasanpour, m.; hassankhani, h.; mills, j. experience of iranian persons receiving hemodialysis: a descriptive, exploratory study nurs health sci 2011 89 embase lawrence c, sharma s, 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nursing 2011 204 216 formacao em enfermagem e o mundo.indd 204 norma valéria dantas de oliveira souza1 ariane da silva pires2 francisco gleidson de azevedo gonçalves3 kelly fernanda assis tavares4 ana terra porciúncula baptista5 thamiris marinho gollo bastos6 formação em enfermagem e mundo do trabalho: percepções de egressos de enfermagem 1 orcid.org/0000-0002-2936-3468. universidade do estado do rio de janeiro, brasil. 2 orcid.org/0000-0003-1123-493x. universidade do estado do rio de janeiro, brasil. arianepires@oi.com.br 3 orcid.org/0000-0002-6468-8137. universidade do estado do rio de janeiro, brasil. 4 orcid.org/0000-0003-2445-6208. universidade do estado do rio de janeiro, brasil. 5 orcid.org/0000-0002-4670-2070. universidade do estado do rio de janeiro, brasil. 6 orcid.org/0000-0001-7092-3247. universidade do estado do rio de janeiro, brasil. recibido: 20 de octubre de 2015 enviado a pares: 6 de abril de 2016 aceptado por pares: 29 de junio de 2016 aprobado: 21 de julio de 2016 doi: 10.5294/aqui.2017.17.2.9 para citar este artículo / to reference this article / para citar este artigo souza nvdo, pires as, gonçalves fga, tavares kfa, baptista atp, bastos tmg. formação em enfermagem e o mundo do trabalho: percepções de egressos de enfermagem. aquichan. 2017;17(2):204-216. doi: 10.5294/aqui.2017.17.2.9 resumo objetivos: descrever e analisar a percepção de egressos do curso de graduação em enfermagem sobre o processo de formação e o mundo do trabalho em saúde e enfermagem. materiais e método: pesquisa qualitativa, descritiva e exploratória, desenvolvida na faculdade de enfermagem da universidade do estado do rio de janeiro (brasil). trinta egressos participaram da pesquisa. a coleta de dados foi realizada por meio de entrevista semiestruturada. os dados foram tratados com fundamento na análise temática de conteúdo. resultados: a partir da análise, emergiu a seguinte categoria empírica: dinamicidade e complexidade do mundo do trabalho e formação: a ótica do egresso de enfermagem. tal categoria reuniu duas subcategorias denominadas: características do mundo do trabalho contemporâneo e fatores relacionados à profissão de enfermagem que interferem no trabalho do enfermeiro. conclusões: os participantes apresentam um ponto de vista crítico e uma visão macroestrutural sobre o mundo do trabalho contemporâneo aproximada da discussão de sociólogos e estudioso do trabalho. no que tange à profissão, os participantes ressaltam o pouco reconhecimento profissional e a desvalorização social da enfermagem, e entendem que essa situação está atrelada a questões histórica, cultural, religiosa, econômica e política. palavras-chave bacharelado em enfermagem; currículo; educação; enfermagem; saúde do trabalhador (fonte: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 204-216 205 formação em enfermagem e o mundo do trabalho: percepções de egressos de enfermagem l norma valéria dantas de oliveira souza e outros año 17 vol. 17 nº 2 chía, colombia junio 2017 l 204-216 formación en enfermería y mundo laboral: percepciones de egresados de enfermería resumen objetivos: describir y analizar la percepción de egresados de pregrado en enfermería acerca del proceso de formación y el mundo laboral en salud y enfermería. materiales y método: investigación cualitativa, descriptiva y exploratoria, desarrollada en la facultad de enfermería de la universidade do estado do rio de janeiro (brasil). treinta egresados participaron en la investigación. la recolección de datos se realizó por medio de entrevista semiestructurada. los datos se estudiaron con base en el análisis temático de contenido. resultados: a partir del análisis surgió la siguiente categoría empírica: dinamicidad y complejidad del mundo laboral y formación: la óptica del egresado de enfermería. tal categoría arrojó dos subcategorías denominadas: características del mundo laboral contemporáneo y factores relacionados con la profesión de enfermería que interfieren en el trabajo del enfermero. conclusiones: los participantes presentan un punto de vista crítico y una visión macroestructural acerca del mundo laboral contemporáneo aproximada a la discusión de sociólogos y estudiosos del trabajo. en cuanto a la profesión, los participantes resaltan el poco reconocimiento profesional y el desprestigio social de la enfermería; asimismo, entienden que esta situación está asociada con cuestiones históricas, culturales, religiosas, económicas y políticas. palabras clave currículo; educación; enfermería; pregrado en enfermería; salud del trabajador (fuente: decs, bireme). 206 aquichan issn 1657-5997 eissn 2027-5374 nursing education and the workplace: perceptions of nursing graduates abstract objectives: describe and analyze how graduate students in nursing perceive the training process and the work world in health and nursing. materials and methods: this is a qualitative, descriptive study of an exploratory nature developed at universidade do estado do rio de janeiro school of nursing in brazil. thirty graduate students took part. the data were collected through semi-structured interviews and examined via thematic content analysis. results: the following empirical category emerged from the analysis: dynamicity and complexity of the work world and training: the nursing graduate’s perception. this category yielded two subcategories: characteristics of the contemporary work world and factors associated with the nursing profession that can interfere with the nurse’s work. conclusions: those who took part in the study offered a critical point of view and a macrostructural vision of the contemporary work world, one that is similar to the discussion of work among sociologists and scholars on the subject. as for the profession, the participants emphasized the lack of professional recognition and the social stigma that surrounds nursing. they also understand this situation is associated with historical, cultural, religious, economic and political issues. keywords curriculum; education; nursing; undergraduate nursing; worker health (source: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 204-216 207 formação em enfermagem e o mundo do trabalho: percepções de egressos de enfermagem l norma valéria dantas de oliveira souza e outros introdução em 1994, o ministério da educação, por meio da portaria nº 1.721/1994, propôs um novo currículo para o curso de enfermagem, privilegiando o perfil do enfermeiro generalista, com uma visão não fragmentada de sistemas e especialidades, isto é, com um olhar holístico e capacitado para desempenhar quatro áreas fundamentais: assistência, gerência, ensino e pesquisa (1). a lei de diretrizes e bases (ldb) nº 9.394/1996, também gerou mudanças inovadoras na educação brasileira, além de ter possibilitado a reorganização dos cursos de graduação e a adoção de diretrizes curriculares específicas para cada curso. por outro lado, favoreceu a extinção dos currículos mínimos. a nova ldb assegura às instituições de ensino superior autonomia didático-científica, bem como autonomia em fixar os currículos dos seus cursos e programas (2). para atender as exigências da nova ldb, surgiram as diretrizes curriculares dos cursos de graduação em saúde, que objetiva: “levar os alunos dos cursos de graduação em saúde a aprender a aprender, que engloba aprender a ser, aprender a fazer, aprender a viver juntos e aprender a conhecer, garantindo a capacitação de profissionais com autonomia e discernimento para assegurar a integralidade da atenção e a qualidade e humanização do atendimento prestado aos indivíduos, família e comunidade” (3: 37). a partir de todos esses eventos, a faculdade de enfermagem da universidade do estado do rio de janeiro (enf/uerj) foi influenciada e motivada a criar coletivamente um projeto político pedagógico (ppp) que estivesse em consonância com os princípios do sistema único de saúde (sus), com a lei do exercício profissional e com a ldb. em 1996, a enf/uerj elaborou e efetivou um ppp inovador, com o objetivo de romper com a prática pedagógica tradicional embasada no paradigma newtoniano-cartesiano, no qual o estudante é considerado um mero reprodutor de costumes, acrítico e com poucas possibilidades de promover mudanças significativas em seu contexto. assim, a enf, por meio de uma construção coletiva, adotou outro paradigma para nortear o processo ensino-aprendizagem, a teoria crítica da educação, fundamentada na pedagogia problematizadora (4). dessa forma, o atual currículo do curso de graduação em enfermagem da uerj (implantado em 1996) tem uma estrutura integrada que desenvolve a perspectiva da totalidade e da interdisciplinaridade, favorecendo a superação da visão fragmentada do homem e da saúde. além disto, ele busca a formação de enfermeiros críticos, reflexivos, com sólida visão histórico-social, o que possibilita melhores respostas aos desafios impostos pela prática em saúde. com as diretrizes curriculares nacionais (dcn) de 2001, ficou estabelecido que os cursos de graduação em enfermagem incluíssem nos seus currículos o estágio curricular supervisionado, que aconteceria em hospitais, em ambulatórios, na rede básica de serviço de saúde e junto à comunidade. ainda fundamentadas nessas diretrizes, o enfermeiro deveria atuar com fundamentos técnico-científicos e compreender a natureza humana em suas dimensões, em suas expressões e nas fases evolutivas (3). “as diretrizes curriculares definem ainda, que a formação do enfermeiro tem por objetivo dotar o profissional dos conhecimentos requeridos para o exercício das seguintes competências e habilidades gerais: atenção à saúde, tomada de decisões, comunicação, liderança, administração e gerenciamento e educação permanente” (2: 572). no âmbito do ministério da educação (mec), em 1993, a portaria nº 130, da secretaria de educação superior (sesu), criou a comissão nacional de avaliação das universidades brasileiras, com o intuito de “estabelecer diretrizes e viabilizar a implementação do processo de avaliação institucional nas universidades brasileiras” (5). a criação dessa comissão ocorreu a partir da avaliação do panorama de ensino superior no cenário brasileiro, que apresentava um quadro crítico e incompatível com as demandas de mercado exigidas pelo modelo de produção vigente, que carecia de profissionais com maior capacitação. nesse contexto, destaca-se a portaria nº 646/1997 do mec, a qual determina que os mecanismos permanentes de avaliação devem incluir tanto o sistema de acompanhamento de egressos no mundo do trabalho quanto estudos de demanda profissionais (6). além disto, a resolução nº 03/2001, na qual o conselho nacional de educação (cne) institui as diretrizes curriculares nacionais (dcn) do curso de graduação em enfermagem, também propõe acompanhamento desses egressos a fim de permitir os ajustes necessários no processo de ensino/aprendizagem, para atingir níveis cada vez mais elevados de ensino (3). 208 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 diante do contexto político, econômico e educacional da enfermagem brasileira supracitado, torna-se de suma importância a realização de pesquisas acerca dos egressos das faculdades de enfermagem, pois dessa forma, são produzidos conhecimentos que irão favorecer uma melhora na qualificação do processo ensino-aprendizagem e, ao mesmo tempo, permite o atendimento as diretrizes do mec e do cne. este estudo ancora-se na crença de que é pela formação profissional que se pode transformar a realidade do trabalho em saúde, a qual se encontra precarizada em muitos sentidos. observa-se precarização dos recursos humanos, das relações no trabalho e das condições laborais. no que diz respeito especificamente às condições de trabalho, elas vêm se reconfigurando a partir do advento do neoliberalismo e da globalização, instituídos no brasil desde os anos 1990, tornando os ambientes laborais cada vez mais hostis (7). considerando esta contextualização, a presente pesquisa apresenta a seguinte questão norteadora: qual a percepção dos egressos do curso de graduação em enfermagem sobre o mundo do trabalho em saúde e enfermagem, considerando o processo de formação? como vistas a responder a questão norteadora de pesquisa traçaram-se como objetivos: descrever e analisar a percepção de egressos do curso de graduação em enfermagem sobre o processo de formação e o mundo do trabalho em saúde e enfermagem. materiais e métodos pesquisa descritiva, exploratória e de natureza qualitativa. o cenário desta pesquisa foi enf/uerj, especificamente, utilizou-se a coordenação de ensino de graduação, o centro de memória nalva pereira caldas e as coordenações de ensino lato e stricto sensu para levantar os números de telefones, endereços e e-mails dos egressos do curso de graduação, por meio dos quais foram feitos contatos para participarem da pesquisa. a coleta de dados aconteceu nas dependências da enf/uerj, ou no impedimento do deslocamento dos egressos à faculdade de enfermagem, as entrevistas foram realizadas nos locais de trabalho dos participantes, tendo-se o cuidado de efetuá-las em ambiente reservado, no qual não ocorressem interrupções das entrevistas, conforme rigor ético das pesquisas qualitativas. coletaram-se os dados com 30 egressos, dos quais 12 entrevistas foram realizadas em cenários diferentes da enf/uerj, como: hospitais públicos e faculdades privadas no munícipio e no estado do rio de janeiro. o encerramento da coleta de dados ocorreu pelo critério de saturação de informações, operacionalmente definido como suspensão de inclusão de novos participantes, pois os dados obtidos passam a apresentar, na avaliação do pesquisador, certa redundância ou repetição (8). utilizou-se o seguinte critério de inclusão no estudo: egressos do curso de graduação em enfermagem, da enf/uerj, oriundos do currículo implantado em 1996, no qual, formou a primeira turma no primeiro semestre de 2000 (2000-1). incluiu-se na pesquisa egressos graduados até o segundo semestre de 2010 (2010-2). como critério de exclusão, foi vetada a participação do recém-egresso, uma vez que o mesmo é definido como aquele que está formado há menos de três anos e que ainda está se consolidando no mundo do trabalho, procurando uma colocação adequada às suas aspirações; ademais, o recém-egresso leva em torno de dez meses para se inserir no mundo do trabalho (9). logo, fundamentando-se nessa perspectiva, desejou-se coletar os dados com egressos que já conhecessem com certa profundidade o mundo do trabalho em saúde, sua organização e processo laboral, para discorrerem com consistência sobre ele. sendo assim, foram excluídos do estudo os egressos graduados a partir de 2011, visto que a coleta de dados iniciou-se no mês de dezembro de 2013, prazo em que se completavam três anos de formação com a turma de egressos do segundo semestre de 2010. outro critério para exclusão refere-se ao fato de o egresso nunca ter trabalhado na profissão, não construindo, assim, opiniões ou desenvolvido percepções sobre o mundo laboral em saúde e enfermagem. por fim, estabeleceu-se como critério somente coletar dados com egressos que trabalhassem na profissão há pelo menos um ano, tempo suficiente para ter uma visão aproximada da realidade laboral. obedecendo aos preceitos éticos, esta pesquisa foi cadastrada na plataforma brasil do ministério da saúde, conforme preconiza a resolução nº 466/2012, do conselho nacional de saúde, que regulamenta o desenvolvimento de pesquisas envolvendo seres humanos (10), sendo aprovada sob o número 360.021. utilizaram-se duas técnicas de captação de participantes em pesquisa qualitativa: i) seleção por conveniência, quando se inicia 209 formação em enfermagem e o mundo do trabalho: percepções de egressos de enfermagem l norma valéria dantas de oliveira souza e outros com uma amostra de conveniência (também denominada amostra voluntária); técnica que foi utilizada para a seleção dos cinco primeiros participantes deste estudo (ocorreu por meio da captação de egressos que se encontravam cursando a pós-graduação lato sensu ou stricto sensu na faculdade de enfermagem); e ii) bola de neve, que permite que os primeiros participantes do estudo indiquem outros participantes para a pesquisa (11). implementou-se essa técnica apresentando-se uma listagem nominal aos participantes, constando o nome completo de todos os egressos das turmas de 2000-1 até 2010-2 e, ao final de cada entrevista, o participante indicava três nomes de outros egressos de quaisquer turmas que compunham a referida listagem. preservou-se a identidade dos participantes utilizando-se um código iniciado pela letra e, de entrevista, acompanhado por um número cardinal (1, 2, 3...), que seguia a ordem cronológica das entrevistas; em complementação, foi acrescido o ano de colação de grau do egresso. o instrumento de coleta de dados foi a entrevista individual semiestruturada. o roteiro de entrevista foi composto por questões fechadas e mistas contendo dados como: idade, sexo, tempo de formado, tempo de atuação profissional, cargo ocupado, grau de instrução (especialização/residência, mestrado, doutorado). além dessas questões, o roteiro compunha-se de quatro perguntas abertas sobre questões referentes ao objeto de estudo. tais perguntas encontram-se descritas a seguir: 1. considerando sua formação na faculdade de enfermagem, comente sobre sua percepção acerca do mundo do trabalho em saúde e enfermagem; 2. discorra sobre se você se considera agente de transformação da realidade laboral em que se insere, destacando as situações que fundamentam sua opinião; 3. fale sobre sua formação na faculdade de enfermagem e se você considera que ela lhe possibilitou uma visão aproximada e/ou distanciada da realidade do mundo do trabalho em saúde e enfermagem; 4. comente sobre as facilidades e as dificuldades que você encontra para atuar com qualidade no mundo do trabalho em saúde e enfermagem, explanando seu ponto de vista sobre as repercussões dessas facilidades e dificuldades em sua vida. a análise dos dados foi realizada e fundamentada na técnica de análise temática de conteúdo, sendo ainda sistematizados de acordo com a análise temático-categorial, processo pelo qual o material empírico é cuidadosamente transformado e codificado em unidades, temas e categorias empíricas que expressam as características pertinentes ao conteúdo dos depoimentos analisados (8). resultados e discussão antes de desenvolver a análise e discussão referente às questões abertas do estudo, é apropriado apresentar uma breve caracterização dos participantes, estes dados foram obtidos por meio das questões fechadas ou mistas. verificou-se que, dos trinta egressos entrevistados, 43,4 % têm entre 26 a 30 anos e 40,0 % têm de 31 a 35 anos. uma pessoa não declarou sua idade. constatou-se também o predomínio feminino na profissão: 80 % dos participantes são desse sexo, e apenas 20 % eram do sexo masculino. ao serem questionados sobre local de atuação profissional, muitos dos participantes possuíam mais de um vínculo empregatício e, por isso, obtiveram-se 41 locais de atividade laboral. prevaleceu a atuação hospitalar, pois 51,3 % dos participantes desta pesquisa trabalham em hospitais públicos municipais, estaduais e federais. outros 31,8 % atuavam como docentes em faculdades, escolas de nível técnico e cursos preparatórios para concurso. quanto ao cargo que ocupavam nos seus locais de trabalho, 31,3 % responderam que atuavam como docentes; 29,2 % como enfermeiros assistenciais e 20,8 % ocupavam cargo de chefia. quanto à capacitação profissional, um considerável número dos egressos investigados (96,7 %) já havia realizado algum tipo de especialização. parte do grupo (66,7 %) havia finalizado especialização lato sensu, incluindo a modalidade de residência; 25,0 % possuem o título de mestre e apenas 8,3 % haviam efetuado o doutorado. os que finalizaram a especialização lato sensu revelaram ser especialistas numa variedade de áreas, dentre as quais se destacam: enfermagem do trabalho, saúde pública, estomaterapia, terapia intensiva, enfermagem obstétrica, centro cirúrgico e central de material e esterelização e livre docência para o ensino superior. o último aspecto a ser abordado refere-se à caracterização dos participantes, aos quais se indagou sobre o tempo decorrido para inserção no mercado de trabalho, ou seja, para o egresso conseguir o primeiro emprego. dos entrevistados, 63,3 % declararam 210 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 que transcorreu até um mês para conseguirem o primeiro emprego; 16,6 % informaram que se inseriram no mundo do trabalho imediatamente após a formatura; 13,2 % revelaram que, antes mesmo de se formarem (no final do último período da graduação), já tinham um emprego. por meio da análise de dados emergiram quatro categorias empíricas, denominadas: a dinamicidade e a complexidade do mundo do trabalho contemporâneo e a formação: a ótica do egresso de enfermagem; a dialética do mundo do trabalho: facilidades e adversidades enfrentadas no cotidiano laboral e sua influência no processo saúde-doença; a formação em enfermagem e a interface com o mundo do trabalho: dilemas e desafios a superar; e significados, habilidades e competências construídas ao longo da formação e suas repercussões na prática laboral. no presente estudo será apresentada e discutida a seguinte categoria: dinamicidade e complexidade do mundo do trabalho e a formação: a ótica do egresso de enfermagem a presente categoria obteve como base para discussão o ponto de vista dos egressos sobre o mundo do trabalho, evidenciando as características da organização e do processo laboral em saúde e enfermagem, confrontados com o processo de formação no curso de graduação da enf/uerj. essa categoria constituiu-se de duas subcategorias: i) características do mundo do trabalho contemporâneo; ii) fatores relacionados à profissão de enfermagem que interferem no trabalho do enfermeiro. características do mundo do trabalho contemporâneo com relação a essa subcategoria, destacou-se nos depoimentos dos participantes o fato de que há um distanciamento entre, de um lado, a configuração do mundo do trabalho em saúde e em enfermagem e, de outro, o processo de formação na academia, pois, frequentemente, o que está prescrito sobre a organização e processo de trabalho pouco se aproxima do real. os participantes discorreram sobre o distanciamento entre o que é ensinado sobre divisão de tarefas, normas, protocolos, ritmos laborais, controles e comandos e, o que verificam na organização real do trabalho, revelando, desse modo, as contradições presentes no mundo do trabalho contemporâneo e no ensino. atrelado a essa questão, encontra-se o ato das adaptações e improvisações de materiais e de recursos humanos por parte dos egressos, que, diante da escassez, utilizam dessa prática com intuito de garantir a assistência e de suprir as demandas dos usuários dos serviços de saúde, mesmo que de maneira equivocada e, portanto, distante do que é prescrito e do que foi ensinado na enf/uerj. em alguns momentos, a gente precisa tomar soluções que não são as ideais e sim as possíveis dentro da realidade em que se trabalha. neste momento, você terá que usar os conhecimentos técnico-científicos aprendidos na faculdade e propor soluções possíveis que não causem danos ao cliente atendido. ou seja, usar o famoso “jeitinho”, as adaptações e improvisações para dar conta das demandas, mas que ficam um pouco contrário ao que foi aprendido na faculdade (e16 — egresso/2004-2). as adaptações e as improvisações de materiais e equipamentos realizadas no contexto assistencial, as quais visam assegurar o cuidado ao paciente, são primordialmente resultados da precarização das condições de trabalho, que impõe uma escassez qualitativa e quantitativa de materiais para a prestação do cuidado. o qual corrobora um estudo realizado em hospital público do rio de janeiro que verificou uma articulação entre a precarização, a prática de improvisações de materiais e as características das organizações laborais fundamentadas no preceito neoliberal, que têm como objetivos o enxugamento da máquina pública e o aumento da produtividade, sem considerar a subjetividade do trabalhador e a especificidade do trabalho em saúde (12). a realidade do mundo do trabalho é complexa, de tal forma que nenhuma regra ou manual pode dar conta de todas as situações inerentes à vivência laboral (13). ressalta-se que, devido a tal complexidade, haverá sempre um distanciamento entre a organização prescrita do trabalho e a organização do trabalho real, uma vez que, nesse contexto, estão sempre presentes as variabilidades e os imprevistos do processo de trabalho (14). e é nesse distanciamento que trabalhadores podem criar e adquirir certa autonomia, desde que a organização laboral dê margem para isso. outro aspecto ressaltado pelos participantes diz respeito à precarização das condições laborais em saúde e enfermagem, muito enfatizada pelos egressos nas questões referentes ao vínculo empregatício, à competitividade de mercado e à alta exigência por produtividade, concomitante à redução da qualidade da assistência em saúde. 211 formação em enfermagem e o mundo do trabalho: percepções de egressos de enfermagem l norma valéria dantas de oliveira souza e outros você não é mais estatutário, na maioria das vezes, mesmo em instituição pública. normalmente, você assina um contrato sem nenhum benefício extra, a não ser de trabalhar e receber. sem décimo terceiro, sem auxílio, sem férias, sem fgts [fundo de garantia do tempo de serviço] ou quando não, na melhor das hipóteses, você tem um contrato de trabalho por clt consolidação das leis do trabalho]. além de tudo trabalha muito e sob condições muito difíceis (e06 — egresso/2009-2). o neoliberalismo teve sua origem no pensamento liberal, definindo-o como uma política econômica de abertura indiscriminada do mercado nacional ao internacional (15). porém, o neoliberalismo não é só uma filosofia econômica; é também um modo de viver social, que influencia valores culturais e psicoemocionais, que vem transformado a vida na sociedade e as relações de trabalho. a partir do advento do modelo neoliberal constata-se o surgimento de diversas formas de contratação de trabalhadores, além do aumento do desemprego estrutural. verificam-se trabalhadores cooperativados, terceirizados, temporários, entre outras formas de contratação que retiraram dos trabalhadores direitos antes concedidos —como, por exemplo, as férias remuneradas, o auxílio doença, o 13º salário—, deixando o trabalhador abandonado à própria sorte em termos de amparo social (16). em contrapartida, verifica-se uma elevada cobrança ao trabalhador para produzir mais e melhor; assim, ele precisa se capacitar, ser polivalente e multifuncional, mostrar-se resiliente no enfrentamento das dificuldades do mundo do trabalho (16). essas questões são perversas para os egressos, e as academias quase nunca ensinam as formas de enfrentamento, nem tão pouco discutem sobre elas. no mundo da enfermagem, é o seguinte: pouco emprego para muitas pessoas, e isso se deve ao grande aumento das universidades privadas que tem aflorado em cada esquina. então, ou você é bom naquilo que você faz, tem condições de entrar pela sua própria capacidade, um concurso que você seja aprovado, ou a questão do qi quem indica, que é a situação das o.s [organizações sociais] (e12 — egresso/2006-2). o que eu vejo é que as enfermeiras precisam ser muito polivalentes, então a gente pode tanto atuar em um nível terciário e se especializar nessa área, quanto trabalhar em atenção básica e se especializar nessa área também para tentar dar conta de tudo, e é muita coisa! (e22 — egresso/2010-1). conforme explicitado nos depoimentos, podem-se analisar os efeitos macro e micro do contexto de precarização das condições de trabalho e de vida da sociedade contemporânea, sob o jugo de um capitalismo voraz. em termos de contexto macro, os empregos formais diminuem, os concursos públicos reduzem drasticamente e a quantidade dos trabalhadores informais aumenta. consequentemente há o medo do desemprego e mesmo de adoecer, porque os trabalhadores informais não possuem direitos trabalhistas e, por sua vez, há um quantitativo imenso de pessoas que estão à margem de qualquer tipo de trabalho (16,17). mesmo entre os mais instruídos, cresceu o desemprego; concomitantemente, apesar da elevação da escolaridade da população e da expansão de postos de trabalho, houve diminuição da remuneração. tais repercussões são corroboradas por meio de pesquisas, as quais verificaram que a classe trabalhadora, em sua maioria, vive exercendo trabalhos precários, parciais, temporários, terceirizados, instáveis, vivenciando em seu cotidiano o desemprego estrutural. cada vez mais os homens e as mulheres em fase produtiva encontram menos trabalho; assim, aceitam trabalhar sob condições precárias e em escala global (16,18). em nível microeconômico, verifica-se uma enfermagem subjugada às formas de contratação por cooperativas, sem direito trabalhista, sendo necessário trabalhar de forma multifuncional e polivalente, em praticamente todas as áreas do conhecimento de enfermagem, em um mesmo local de trabalho. o enfermeiro gerencia, treina equipe, realiza consulta de obstetrícia e de pediatria, faz visita domiciliar na busca e orientação dos hipertensos e diabéticos; enfim, executa de tudo num mesmo vínculo empregatício. para atender a toda essa complexidade, ele precisa se capacitar por conta própria, subsidiando economicamente essa capacitação, trabalhando sob ritmo elevado e sob o medo de ficar desempregado, caso não agrade a tal organização laboral (19). tal situação aponta uma contradição entre o processo de formação e o mundo do trabalho, uma vez que a dcn estabelecem a formação com perfil generalista e o mundo do trabalho exige do profissional um perfil especializado e polivalente. ademais, a organização laboral fundamentada em preceitos neoliberais exige um novo perfil de trabalhador, capaz de acompanhar as mutações da lógica produtiva e as novas formas de produção. para tanto, os trabalhadores devem desenvolver características como criatividade, iniciativa, sensibilidade, liderança, maturidade pessoal e capacidade de interação interpessoal. 212 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 tais habilidades são necessárias para se obter vantagens competitivas e agregar valores à produção, levando, consequentemente, ao acúmulo de capital. assim sendo, a lógica neoliberal deseja um trabalhador qualificado, polivalente/multifuncional, condizente com um repertório de habilidades e comportamentos de alto padrão, difícil de encontrar na realidade nacional (20). nesse sentido, constata-se que o aparelho formador precisa estar atento a essa nova forma de produção, de contexto de trabalho e de cenário macroeconômico, a fim de instrumentalizar e capacitar os estudantes para o enfrentamento dessa realidade laboral. nessa perspectiva, as universidades devem refletir e analisar essa situação, buscando traçar estratégias para contribuir na mudança dessa realidade, bem como capacitar os docentes para desenvolver um processo ensino-aprendizagem mais próximo do cenário real do trabalho em saúde. desse modo, a qualidade do ensino elevaria, a qualidade do profissional formado seria ainda melhor e se minimizaria o sofrimento do egresso decorrente do distanciamento significativo entre a formação e o mundo trabalho. e, principalmente, pode-se desenvolver um ensino que possibilita formar enfermeiros reflexivos, críticos e com maiores potenciais para transformar essa realidade, que se apresenta, muitas vezes, perversa para o trabalhador (21). associado à precarização dos vínculos trabalhistas encontra-se o fato de as organizações laborais, assentadas no modelo neoliberal, alterarem os modos de produzir do trabalhador, a partir da intensificação no trabalho. com a intensificação obtém-se uma maior quantidade e/ou uma melhor qualidade dos resultados do trabalho, com maior dispêndio de energia do trabalhador no mesmo tempo (22). outra coisa é você atuar exclusivamente em cima de uma determinada produtividade, claro que tem que ter uma produtividade. mas, como você avalia essa produtividade? por exemplo, uma visita domiciliar que demore três horas; e quantas vezes eu ouvi gente falando que não podia ficar, tinha que ser uma “visitinha rápida” porque tem que dar conta de fazer tantas visitas, tem que dar conta de fazer tantas consultas, atendimentos e outras coisas. só que não é assim, como é que você vai de fato conhecer a vida daquela família, como é que você vai entender aquele contexto, se você sempre tem que estar rapidinho, porque você tem uma tonelada e meia de outras coisas (e28 — egresso/2003-1). o modelo neoliberal utiliza artifícios que se concretizam nas formas de subordinação do trabalhador às necessidades da organização, muitas vezes impondo a flexibilização da vida em nome do cumprimento das exigências oriundas do processo laboral. assim, as novas formas de gestão têm por objetivo regular as subjetividades, utilizando a estratégia de incorporar as metas e objetivos da empresa, buscando dessa maneira nublar a exploração da força de trabalho (23). fatores relacionados à profissão de enfermagem que interferem no trabalho do enfermeiro nesta subcategoria, analisam-se questões relacionadas ao reconhecimento e valorização da profissão de enfermagem, emergindo dos depoimentos um forte aspecto sobre a desvalorização profissional no sentido não só da representação social dessa profissão ao longo do tempo, mas também de uma perspectiva política e econômica. desse modo, os egressos identificam a pouca valorização cultural e socioeconômica da enfermagem, percebendo ainda a falta de reconhecimento da categoria por parte dos clientes, de outros profissionais e até mesmo das instituições de saúde. além disto, apontam a subserviência como uma problemática para o alcance da autonomia profissional. existe uma desvalorização muito grande do enfermeiro, em relação ao paciente e à própria chefia. porque a maioria dos lugares é tudo a mesma coisa, você trabalha, trabalha, e nunca tem valor. historicamente, a enfermagem é uma profissão mal vista pelas pessoas, a mídia dificilmente elogia, mostra o que realmente é a enfermagem, geralmente é contra a enfermagem, aponta o erro, coloca a culpa. eu acho que essas questões precisavam ser melhores abordadas dentro da faculdade de enfermagem para nos empoderarmos a mudar esta situação (e12 — egresso/2006-2). o que tem acontecido hoje é a desqualificação da categoria, aliado ao fato que o campo dos enfermeiros está tomado pelos técnicos, que estão se graduando, mas que não incorporam o espírito de ser enfermeiros, são enfermeiros no dia a dia, mas que se comportam como técnicos. isso faz com que a gente tenha uma relação de subserviência muito grande em relação às outras categorias (e26 — egresso/2004-2). a problemática da divisão social e técnica do trabalho de enfermagem tem raízes históricas, pois florence nightgale, ao lançar as bases da enfermagem moderna, instituiu que o trabalho de 213 formação em enfermagem e o mundo do trabalho: percepções de egressos de enfermagem l norma valéria dantas de oliveira souza e outros enfermagem seria desenvolvido por nurses— que fariam o trabalho manual de higienização e desenvolvimentos de outras técnicas menos complexas —e ladies nurses— que fariam a tarefa intelectual de supervisão, planejamento, avaliação. as ladies nurses eram de camadas sociais mais abastadas e tinham refinada educação; em contrapartida, as nurses advinham de estratos sociais bem menos privilegiados, com pouca educação e trato social (24). essa questão da divisão social e técnica do trabalho gerou uma forte hierarquia, que, por sua vez, originou relações de poder e tensionamentos ora velados, ora extremamente acirrados. além disto, tal divisão acabou por nublar a visão do público em geral e da mídia sobre quem é quem dentro da profissão de enfermagem, bem como não deixou claras as atribuições e responsabilidades de cada componente da enfermagem. e, nesse sentido, há um forte desconforto por parte dos enfermeiros quando são confundidos pela mídia ou pelos usuários, principalmente, com relação a algum fato que desprivilegie ou que macule a imagem do enfermeiro (25). ao aprofundar-se nesse contexto da valorização e reconhecimento profissional, alguns componentes do trabalho do enfermeiro são conhecidos como enfraquecedores da valorização profissional: o fato de a profissão ser essencialmente feminina e sofrer preconceitos decorrentes de uma sociedade androcêntrica; o número reduzido de profissionais de enfermagem no atendimento em saúde, o que prejudica a qualidade do serviço prestado pelo enfermeiro, em algumas situações; a dificuldade em delimitar os diferentes papéis entre enfermeiros, técnicos e auxiliares de enfermagem, e a falta de reconhecimento nítido entre o público em geral de quem é o enfermeiro; e o caráter caritativo que envolve a profissão (26). a enfermagem é exercida por sujeitos: auxiliares, técnicos e enfermeiros com diferentes formações que se dão em diferentes tempos de qualificação e graus de complexidade (os auxiliares são profissionais que possuem escolaridade em nível fundamental, os técnicos em nível médio e os enfermeiros em nível superior). assim, o processo de trabalho na enfermagem caracteriza-se, predominantemente, por apresentar-se de modo que sua execução encontra-se distribuída entre os seus vários agentes, teoricamente determinadas, de acordo com a qualificação exigida pelo grau de complexidade que as tarefas compõem (26). na dimensão socioeconômica, pode-se citar a desvalorização salarial da categoria, que, na maioria das vezes, leva à multiplicidade de vínculos. o trabalhador de enfermagem se submete a múltiplos empregos para tentar manter o padrão de vida e também para se sentir mais seguro diante da necessidade de garantir sua subsistência (22). consequentemente submete-se a cargas horárias de trabalho elevadíssimas, a ritmos laborais intensos e a redução das horas de lazer, descanso e convívio com a família. eu percebo que hoje a gente vive no mundo do trabalho multifacetado, com uma influência fortíssima do modelo neoliberal, de um capitalismo perverso que escraviza o profissional de saúde como um todo, de modo que o profissional de enfermagem encontra-se com vínculos bastante precários de trabalho, sendo praticamente escravizado. então, hoje o trabalho em saúde é um trabalho extremamente defasado por baixos salários que levam os profissionais a acumularem vínculos e condições de trabalho ruins (e05 — egresso/2009-1). essa multiplicidade de vínculos empregatícios, muitas vezes precários, pode gerar o sentimento de desvalorização profissional, a partir da falta de reconhecimento e incentivo salarial da profissão. o reconhecimento é o processo de valorização do esforço e do sofrimento investido para a realização do trabalho, que possibilita ao sujeito a construção de sua identidade, ou seja, a vivência do prazer e da realização de si mesmo (26). na perspectiva da psicodinâmica do trabalho, a construção da identidade mobiliza o processo de retribuição simbólica, de reconhecimento do trabalhador em sua singularidade pelo outro. essa retribuição é obtida a partir tanto das suas contribuições à organização do trabalho, quanto do espaço para construir um coletivo de trabalho no qual estão presentes as margens de liberdade para ajustar as suas necessidades à tarefa (26). transpor as barreiras da organização do trabalho e as suas rígidas prescrições abre espaço para a autonomia de ação dos trabalhadores, permitindo a vivência de liberdade, autorrealização, reconhecimento e valorização de suas ações. porém, a falta desse reconhecimento espolia o trabalhador e compromete sua motivação, principalmente quando essa liberdade que lhe é oferecida torna-se, na verdade, uma imposição frente às constantes adversidades do meio (27). enfatiza-se que as rápidas transformações socioeconômicas e políticas que ocorrem na sociedade contemporânea impõem desafios tanto para os profissionais quanto para as instituições formadoras. considerando que, para se atingirem as exigências 214 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 impostas pelo mundo do trabalho, os profissionais de enfermagem necessitam de uma refinada qualificação, que está embutida a polivalência, a multifuncionalidade, a capacidade de julgamento e tomada de decisão, a empatia e o enfretamento de tensões e conflitos, entre outras habilidades, atitudes e competências. nesse sentido, faz-se mister a necessidade de superação, por parte das instituições formadoras, da dicotomia existente entre teoria e prática, e entre dinamismo do mundo do trabalho e certo engessamento dos currículos e de docentes. conclusão com relação à percepção dos egressos sobre a dinamicidade e complexidade do mundo do trabalho em saúde e enfermagem, destaca-se que oriundos de uma formação problematizadora, os egressos da enf/uerj conseguem perceber o mundo do trabalho de forma reflexiva e crítica, identificando os distanciamentos existentes entre o trabalho prescrito e o trabalho real, no cenário atual dos serviços de saúde. nesta perspectiva, também referem à multiplicidade de elementos que permeiam o cenário laboral, tornando o trabalho complexo e dinâmico. ademais, os egressos citam outros aspectos negativos do mundo do trabalho os quais não foram suficientemente refletidos e discutidos durante a graduação: a elevada e contínua inserção da tecnologia no trabalho em saúde, a precarização dos recursos humanos em termos qualitativo e quantitativo, o ritmo de trabalho elevado, a escassez de materiais, as relações de poder e de hierarquias extremamente marcadas. nesse sentido, pode-se concluir que, quanto maior é o distanciamento entre o trabalho prescrito e o trabalho real, entre a formação e a atuação como enfermeiros, maior é a dificuldade de adaptação e de atuação em tais cenários laborais e, por sua vez, maior é o sofrimento psíquico dos egressos. para os egressos, as precárias condições de trabalho, as formas de contratação temporária (cooperativas e terceirizadas) e a baixa qualidade dos recursos humanos vinculam-se a um modelo produtivo perverso para o trabalhador —o neoliberalismo—, o qual interfere na sua condição de agente transformador da realidade laboral. os egressos ainda apontam a intensificação do ritmo de trabalho, a remuneração insuficiente e a escassez de concursos públicos como consequência desse modelo produtivo, o que muitas vezes aliena e engessa o trabalhador para mudar a realidade. desse modo, na perspectiva do objetivo deste estudo, conclui-se que os participantes apresentam um ponto de vista crítico e uma visão macroestrutural sobre o mundo do trabalho contemporâneo aproximada da discussão de sociólogos e estudioso do trabalho. por conseguinte, considera-se que a formação na enf/uerj contribuiu para a construção dessa visão crítica, reflexiva e politizada sobre a realidade do trabalho que os egressos vivenciam. no que se refere à profissão de enfermagem, os participantes ressaltam o pouco reconhecimento profissional e a desvalorização social da enfermagem, e entendem que essa situação está atrelada a questões histórica, cultural, religiosa, econômica e política. além disto, para os egressos, tais questões precisam ser mais bem discutidas durante a graduação, a fim de formar enfermeiros para o enfrentamento dessa situação, considerada por eles outro aspecto da formação que precisa ser aproximado do mundo real do trabalho. uma das limitações do presente estudo refere-se à natureza da pesquisa qualitativa, realizado em um único cenário, portanto não se pretende generalizar seus achados. assim, consideram-se que foram alcançados os objetivos inicialmente traçados para este trabalho e que a questão norteadora foi respondida; por outro lado, ainda há muito que se pesquisar sobre a temática do processo de formação em enfermagem e sobre sua influência na prática profissional em saúde. e, com base nos resultados apreendidos, recomenda-se que outras pesquisas sejam desenvolvidas, como o estudo da satisfação de graduados referente ao processo de formação. sugerem-se também estudos em que as instituições formadoras investiguem se o processo de formação encontra-se coerente como o perfil profissional almejado nas dcn e com as demandas da sociedade brasileira. 215 formação em enfermagem e o mundo do trabalho: percepções de egressos de enfermagem l norma valéria dantas de oliveira souza e outros referências 1. brasil. ministério da educação e do desporto. portaria n° 1.721, de 15 dezembro de 1994. fixa os mínimos de conteúdo e duração do curso de graduação em enfermagem. diário oficial [da] república federativa do brasil, brasília, df, 16 de dez 1994. seção i, p.19.801. 2. brasil. lei n° 9.394, de 20 de dezembro de 1996. estabelece as diretrizes e bases da educação nacional. diário oficial [da] república federativa do brasil, brasília, df, 23 de dez 1996. 3. brasil. conselho nacional de educação. resolução cne/ces nº 3, de novembro de 2001. institui diretrizes curriculares nacionais do curso de graduação em enfermagem. diário oficial [da] república federativa do brasil, brasília, df, 9 de nov 2001. seção i, p. 37. 4. correia lm, henriques rlm, nogueira mfh, pacheco as, romano rt. construção do projeto político pedagógico: experiência da faculdade de enfermagem da uerj. rev bras enferm. 2004;57(6):649-53. 5. ministério da educação e do esporte. secretaria do ensino superior. programa de avaliação institucional das universidades brasileiras paiub. brasília, df; 1993. 6. brasil. ministério da educação e cultura. portaria nº 646, de 14 de maio de 1997. regulamenta a implantação do disposto nos artigos 39 a 42 da lei federal nº 9.394 e no decreto federal nº 2.208/97 e dá providências. diário oficial da república federativa do brasil, brasília, df: 26 de maio 1997. 7. antunes r. adeus ao trabalho? ensaios sobre as metamorfoses e a centralidade do mundo do trabalho. são paulo: cortez; 2011. 8. bardin l. análise de conteúdo. 70ª ed. lisboa; 2011. 9. d’ávila tb. satisfação no trabalho de enfermeiros recém-egressos [dissertação]. rio de janeiro (rj): universidade federal do estado do rio de janeiro; 2012. 10. conselho nacional de saúde. resolução 466 de 12 de dezembro de 2012. diretrizes e normas regulamentadoras de pesquisas envolvendo seres humanos. brasília, df, 2012. disponível em: <http://bvsms.saude.gov.br/bvs/saudelegis/ cns/2013/res0466_12_12_2012.html>. (acesso em: 20 maio 2014). 11. polit df, beck ct, hungler bp. fundamentos de pesquisa em enfermagem: métodos, avaliação e utilização. 7ª ed. porto alegre: artmed; 2011. 12. hanzelmann rs, passos jp. imagens e representações da enfermagem acerca do stress e sua influência na atividade laboral. rev esc enferm usp. 2010;44(3):694-701. 13. anjos fb, mendes am, santos av, facas ep. trabalho prescrito, real e estratégias de mediação do sofrimento de jornalistas de um órgão público. revista eletrônica sistemas & gestão. 2011;6:562-82. 14. dejours c, gustavo a. ramos mn. psicodinâmica do trabalho e teoria da sedução. psicol estud. 2012;17(3):363-71. 15. abadia-barrero c, pinilla-alfonso my, ariza kr, hector crs. neoliberalismo en salud: la tortura de trabajadoras y trabajadores del instituto materno infantil de bogotá. rev salud pública. 2012;14 supl 1:18-31. 16. antunes r, druck mg. a terceirização como regra? rev tst. 2013;79(3):214-31. 17. antunes r. o caracol e sua concha: ensaios sobre a nova morfologia do trabalho. 5ª ed. são paulo: boitempo; 2011. 18. pires dep. transformações necessárias para o avanço da enfermagem como ciência do cuidar. rev bras enferm. 2013;66(esp):39-44. 19. gois ps, medeiros sm, guimarães j. neoliberalismo e programa saúde da família: a propósito do trabalho precarizado. rev enferm ufpe. 2010; 4 (esp):1204-10. 20. dal rosso s. jornadas excessivas de trabalho. revista paranaense de desenvolvimento. 2013;34(124):73-91. 21. silva kl, sena rr, silveira mr, tavares ts, silva pm. desafios da formação do enfermeiro no contexto da expansão do ensino superior. esc anna nery. 2012;16(2):380-7. 216 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 22. mauro myc, paz af, mauro ccc, pinheiro mas; silva vg. condições de trabalho da enfermagem nas enfermarias de um hospital universitário. esc anna nery. 2010;14(2):244-52. 23. pereira ib. conhecimento social, educacional e escolar: a busca da totalidade social na formação dos trabalhadores da saúde. interface (botucatu). 2014;3:132. 24. carvalho ls. uma antiga profissão do futuro: percepções de enfermeiros sobre sua formação e inserção profissional. [dissertação]. rio de janeiro (rj): fundação oswaldo cruz; 2011. 25. oro j, matos e. organização do trabalho da enfermagem e assistência integral em saúde. enfermagem em foco. 2011; 2(2):137-40. 26. sprandel lis, vaghetti hh. valorização e motivação de enfermeiros na perspectiva da humanização do trabalho nos hospitais. rev. eletr. enf. [internet]. 2012 oct/dec; [acesso em: 08 set 2014]; 14(4):794-802. disponível em: http://www. fen.ufg.br/revista/v14/n4/v14n4a07.htm. 27. martins jt, robazzi mlcc, bobroff mcc. prazer e sofrimento no trabalho da equipe de enfermagem: reflexão à luz da psicodinâmica dejouriana. rev esc enferm usp. 2010;44(4):1107-11. 170-186 finales.pdf 173 la investigación y el cuidado en américa latina la investigación es una de las tareas fundamentales que debe desarrollar el profesional de enfermería con el fin de dar a conocer en primer lugar lo que hace en pro de sus pacientes y en segundo lugar mejorar los cuidados que brinda, bien sea al paciente, familia o comunidad. por otro lado, el libro hace relación al cuidado de enfermería el cual implica una verdadera relación interpersonal, llena de confianza, respeto y afecto entre el cuidador y el ser cuidado. es importante considerar que cuidar es una ciencia humana, y un arte que exige conocimientos, actitudes, aptitudes, intereses y motivaciones, partiendo del principio de que el cuidado es único e irrepetible. el libro está dividido en dos partes: la conceptualización y práctica del cuidado en américa latina, en donde se exponen temas como la gerencia como cuidado de enfermería y la investigación en esta área; cuidado al anciano y a su cuidador; la enfermería como disciplina, como ciencia y como arte, a través de varios artículos que muestran la enfermería desde su historia, impacto social de la disciplina en el contexto político, formación del recurso humano como compromiso de la profesión, cómo hacer visible el cuidado de enfermería en diferentes contextos y cómo cuidar en la adversidad, y prácticas de cuidado durante la gestación. y una segunda parte donde se presentan resultados de investigación sobre caracterización de la familia como base para el desarrollo de la salud familiar; modificación de estilos de vida para disminuir problemas cardiovasculares; cómo cuidar en situación de enfermedad crónica; cuidado a los cuidadores de salas de cirugía y recuperación quirúrgica; aplicación de temas administrativos a los servicios hospitalarios, y validez de contextos del instrumento “protocolo de integración del rol de la mujer modificado”. grupo de cuidado facultad de enfermería universidad nacional de colombia primera edición, 2005 reseñas revista aquichan issn 1657-5997 174 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 john r. cutcliff hugo p. mckenna editorial elsvier, 2005 the essential concepts of nursing (conceptos esenciales de enfermería) en su prólogo las doctoras peggy chinn y afaf meleis comentan respectivamente: “este libro y su colección de conceptos significativos, ilustra la asombrosa complejidad y diversidad del dominio de enfermería y la riqueza de sus recursos metodológicos. no se limita con exclusividad a desarrollar una serie de conceptos bajo una misma visión paradigmática, los autores asumen la posición de mostrar el conocimiento de enfermería a partir de la definición de enfermería como la ciencia y el arte de sanar y cuidar. la forma de presentación de los conceptos permite una interpretación a partir de imágenes mentales que apuntan a la cuestión del dominio, construyendo un dibujo muy claro de la profundidad y amplitud de lo que es enfermería. desde el punto de vista metodológico se permite una apreciación valorativa sucinta, crítica y bien equilibrada del manejo de los conceptos en la literatura”. “este libro nos recuerda todo el progreso que ha logrado enfermería, al trabajar los conceptos a partir de la práctica basada en la evidencia científica. tres características ameritan señalarse en su contenido: 1) refleja un desarrollo colaborativo internacional y comparte perspectivas y diversidades para el desarrollo de conceptos; 2) es una piedra angular del desarrollo del conocimiento, dado el abordaje académico que utilizan los autores al combinar sustancia y estructura para presentar sus hallazgos, y 3) representa un quiebre en el desarrollo del conocimiento porque brinda ejemplos efectivos de la síntesis y la interpretación del conocimiento relacionado con conceptos clave de enfermería que promoverán a partir del pensamiento crítico, un mayor desarrollo del conocimiento”. el libro presenta 19 conceptos de utilización común tanto en la práctica como en la investigación de enfermería, algunos de ellos son: abuso, cuidado, comodidad, afrontamiento, empoderamiento, fatiga, esperanza, soledad, apoyo de enfermería, confianza…, cada uno de ellos analizado bien con un enfoque cualitativo o cuantitativo, de acuerdo con su origen paradigmático, pero ceñido éste al rigor del análisis de conceptos. un valor agregado de cada capítulo es la excelente y actualizada revisión bibliográfica que los autores refieren. aunque no está traducido al español, es texto de referencia obligado para estudiantes de maestrías y doctorado disciplinar, al igual que para docentes de enfermería. maría mercedes durán de villalobos asesora facultad de enfermería, universidad de la sabana finalmente, es importante resaltar el trabajo que ha venido desarrollando el grupo de cuidado de la universidad nacional de colombia, el cual ha permitido que la enfermería en el país se desarrolle como profesión y como disciplina. el libro es uno de los resultados que muestran el cuidado como parte fundamental de nuestra profesión. beatriz pérez giraldo directora de posgrados, facultad de enfermería, universidad de la sabana. 123 127 primeras paginas.indd 127 editorial ejes fundamentales del conocimiento enfermero the crux of nursing know-how eixos fundamentais do conhecimento em enfermagem doi: 10.5294/aqui.2017.17.2.1 en consecuencia, hago la invitación a los investigadores y potenciales autores para que nos acompañen con sus aportes en estas áreas de interés, que estoy segura contribuirán de manera significativa al desarrollo del conocimiento de enfermería. agradezco especialmente al comité editorial, revisores, autores y lectores, quienes han hecho de aquichan una de las mejores revistas de enfermería en colombia y en latinoamérica. así como mis antecesoras, maría clara quintero laverde y maría elisa moreno fergusson, con el actual equipo que apoya mi labor como editora, continuaremos trabajando y asegurando la edición de artículos de calidad que ratifiquen el compromiso ético y científico de nuestra revista con la comunidad académica internacional. referencias 1. fawcett j, garity j. evaluating research for evidence based nursing research. philadelphia: f. a. davis; 2009. 2. grove sk, burns n, gray jr. the practice of nursing research: appraisal, synthesis, and generation of evidence. 7th ed. st. louis: elsevier/saunders; 2013. la revista aquichan tiene un carácter consultivo internacional, respaldado por reconocidos académicos de todo el mundo, autores y árbitros, quienes a través de sus trabajos contribuyen a su posicionamiento en latinoamérica. su publicación continua, con aportes al desarrollo del conocimiento en enfermería, marca una diferencia y crea cambios constantes en el entorno de la disciplina. como nueva editora de aquichan, quiero compartir una mirada sobre cuatro ejes fundamentales de conocimiento disciplinar, considerados de interés actual en el desarrollo de las nuevas tendencias de investigación para teóricos, investigadores y profesionales de enfermería: el cuidado desde el punto de vista epistemológico, la práctica basada en la evidencia, el cuidado crónico y la promoción y prevención. en adelante, la producción de aquichan se concentrará en estas temáticas. de igual manera, y para fortalecer el conocimiento enfermero, se hará énfasis en la inclusión de modelos conceptuales y teorías de enfermería, siempre que los mismos estén explícitos en los reportes de investigación para su aprobación (1). desde esta perspectiva, la revista asume el avance y la visibilidad de la disciplina, y el fomento de teorías empíricamente adecuadas, que sirvan de evidencia para respaldar la práctica (2). alejandra maría alvarado-garcía1 1 universidad de la sabana, colombia. alejandra.alvarado@unisabana.edu.co 1-7 iniciales.pdf 6 revista aquichan issn 1657-5997 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 programa cuidadores he leído el artículo escrito por las profesoras natividad pinto a., lucy barrera ortiz y beatriz sánchez herrera, titulado “reflexiones sobre el cuidado a partir del programa cuidando a los cuidadores”, y encuentro que se han descrito y representado de una forma clara los conceptos y elementos que deben ser tenidos en cuenta cuando se “cuida” a un binomio de seres humanos que se encuentran vivenciando una enfermedad crónica. se aprecia una amplia recopilación de investigaciones sobre la temática, lo que muestra que existe ya una información confiable y de utilidad para desarrollar una propuesta definida y que realmente permita que los cuidadores sean tenidos en cuenta, tanto por los servicios de salud como por los profesionales del área. es importante resaltar que las sugerencias que se hacen al final de este artículo cubren tanto los ámbitos ambulatorios como hospitalarios, pero queda la inquietud de saber si la percepción y las implicaciones a las que se hace referencia son aplicables al cuidador que se encuentra en un servicio de hospitalización, por lo que debería considerarse la posibilidad de corroborar a través de nuevas investigaciones en este escenario los hallazgos presentados en el artículo. luz patricia díaz heredia profesora asociada, universidad nacional de colombia la temática abordada por maría elisa moreno en su artículo “importancia de los modelos conceptuales y teorías de enfermería” es pertinente desde la perspectiva de liderazgo y autonomía en la práctica de enfermería, como también en los procesos de acreditación de los programas de enfermería. me parece esencial del artículo ratificar que los modelos conceptuales y teorías de enfermería, que definen la disciplina y explican su razón de ser, sean aplicados en los escenarios de práctica; pero además, sirven de fundamento al plan de cuidados del paciente de acuerdo con sus necesidades, situación que hace de la enfermería una disciplina con liderazgo y autonomía. es pertinente que un programa de enfermería tenga un modelo específico que lo haga distinguirse entre otros programas de formación, sin que esto excluya el conocimiento de otros enfoques de modelos y teorías de enfermería. modelos conceptuales 6 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 7 encuentro especialmente interesante la contribución de la doctora jacqueline fawcett con el artículo “middle-range nursing theories are necessary for the advancement of the discipline” (“las teorías de mediano rango de enfermería son necesarias para el progreso de la disciplina”), artículo que debería ser publicado en español, para poner al alcance de la mayoría de los profesionales de enfermería la explicación tan completa y comprensible que hace la doctora fawcett sobre la estructura jerárquica del conocimiento de enfermería, que la autora denomina holarchy. ella explica esta estructura jerárquica desde el nivel más abstracto de los paradigmas y filosofía, hasta arribar a través de la construcción de los modelos conceptuales y teorías de enfermería al nivel más concreto del conocimiento de enfermería que formula o construye indicadores empíricos, que se pueden aplicar para influir en la calidad y condiciones de la práctica de enfermería. explica la autora cómo se construyen las teorías de mediano rango y cómo los indicadores empíricos son esenciales para generar y validar las teorías de mediano rango. me parece que es interesante y útil para los profesionales la explicación que hace de la forma como se conectan y se derivan las teorías del mediano rango de los modelos conceptuales. ilustra este proceso con ejemplos de investigaciones de enfermería que han llevado a construir teorías de mediano rango derivadas del modelo de adaptación de roy, y además ilustra cómo se conecta el modelo de roy con teorías de mediano rango derivadas de otros modelos teóricos de enfermería y de otras disciplinas. es además enriquecedor este artículo para los profesionales que aún mantienen actitudes pesimistas frente a la utilidad de los modelos teóricos de enfermería, por la creencia de la poca o ausente aplicabilidad de los modelos teóricos y teorías de enfermería para mejorar la práctica y para producir nuevo conocimiento científico disciplinar. la autora explica la “forma como se conectan los modelos conceptuales y las teorías de mediano rango para asegurar la lógica congruencia entre el modelo conceptual y la teoría”. la congruencia lógica surge de los términos utilizados en el modelo conceptual, el significado de cada concepto que se construye es una forma distintiva del lenguaje, factor importante para crear y enriquecer el lenguaje científico propio de la disciplina de enfermería. este aspecto, más los tres métodos que explica la autora para conectar un modelo conceptual con las teorías de mediano rango ayudan a las investigadoras en este campo a enriquecer el conocimiento y la práctica de enfermería: 1) la derivación directa de una teoría de mediano rango de un modelo conceptual de enfermería; 2) relacionar una teoría de mediano rango ya existente con un modelo conceptual y 3) relacionar una teoría de mediano rango de otra disciplina con un modelo conceptual de enfermería. para finalizar mi comentario quisiera proponer a la directora y al consejo editorial de la revista aquichan, solicitar a la doctora fawcett continuar en otro artículo sus valiosas orientaciones para las investigadoras de enfermería que posiblemente estarán motivadas en construir teorías de mediano rango derivadas de los modelos conceptuales y teorías de enfermería que ya han venido estudiando y utilizando para enriquecer el conocimiento de enfermería y su práctica. nelly garzón alarcón presidenta tribunal nacional ético de enfermería colombia teorías de mediano rango de enfermería es positivo cómo la autora aborda el desarrollo del modelo de adaptación de callista roy, a mi parecer desde dos puntos de vista: el hecho de aplicar y desarrollar el modelo en la práctica real, como fundamento de la misma, y la implementación del modelo por etapas, de forma clara y organizada, teniendo en cuenta el proyecto educativo institucional. zaider g. triviño v. enfermera, magíster en salud pública doctoranda en enfermería universidad de concepción, chile correo del lector 455 460 primeras paginas.indd 459 editorial el escenario deseado para la enfermería latinoamericana the desired scenario for latin american nursing o cenário desejado para a enfermagem latino-americana doi: 10.5294/aqui.2015.15.4.1 beatriz sánchez h.1 que sucede de manera heterogénea y en muchos casos apoyado en la transferencia de procesos desarrollados para otros contextos e incluso por ensayo y error. a pesar de ello, a nivel regional se ha afianzado la regulación profesional (4), han aumentado las instituciones formadoras de enfermeros(as) y el nivel de formación, se ha logrado un avance en la consolidación y aceptación del objeto de estudio, se ha incrementado el trabajo en red y se han ampliado los roles tradicionales de asistencia, administración, docencia e investigación, para incorporar otros elementos y nuevos roles con mayor impronta de liderazgo, innovación e incursión en la política púbica (5, 6). sin embargo, y a pesar de la magnitud de su fuerza constructora y comprometida, no puede afirmarse lo mismo sobre la visibilidad de la enfermería latinoamericana, ni sobre su aporte a la transformación de la realidad social regional en medio de sistemas de salud que no responden a las necesidades de la población. será preciso iniciar en cada país un ejercicio que aporte a su propio desarrollo y que, a su vez, contribuya como insumo para generar una mirada transversal en la región. valdría la pena reunir a nivel nacional fuerzas representativas de diversos sectores como las asociaciones nacionales de enfermería y las de escuelas o facultades, los tribunales éticos, la representación del nivel decisorio del estado, las representaciones locales de instancias internacionales de enfermería y algunos líderes de grupos reconocidos en la construcción del desarrollo profesional a nivel teórico-conceptual, académico, asistencial o investigativo, para que de manera conjunta desarrollen este tipo de planeación sumada varios interrogantes con respecto al escenario deseado para la enfermería latinoamericana están por resolverse y, quizás, al hacerlo de manera adecuada, se logre un mayor impacto. ¿en dónde y cómo se proyecta a veinte años la enfermería en la región? ¿qué estamos haciendo para ello? ¿cuáles son las características y cuál el desempeño que debe tener la enfermería latinoamericana para cuidar mejor la experiencia de la salud en cada integrante de la población? ¿cuáles son sus retos y sus fortalezas comunes? para responder estas y otras preguntas similares, se han realizado algunos ejercicios de prospectiva y planeación regional de un valor incalculable (1, 2). no se registran, empero, propuestas que cuenten con un enfoque integrado de prospectiva y estrategia. la planeación prospectiva es un proceso que permite concentrar la atención sobre el futuro deseado para orientar la trayectoria de los eventos con miradas integrales y creativas a partir de acuerdos convergentes (3). cuando a este proceso se le suma una estrategia para asegurar la toma de decisiones óptimas en cada momento, se logra consolidar una herramienta poderosa de liderazgo aplicable en múltiples ámbitos, que incluyen el desarrollo de la enfermería en américa latina. al mirar la historia de la enfermería en la región, es indiscutible su paso de la profesionalización al profesionalismo, hecho 1 enfermera mscnsg. profesora catedrática universidad de la sabana. profesora especial universidad nacional de colombia. 460 aquichan issn 1657-5997 año 15 vol. 15 nº 4 chía, colombia diciembre 2015 a la estrategia. pueden ser aportes significativos para el análisis los planteamientos estructurados de los usuarios y los de otros integrantes del equipo de salud. una vez se logre determinar el futuro deseado y proponer la estrategia que lo garantice, esos aportes podrán ser insumo importante para proyectar el desarrollo requerido por la enfermería en américa latina. en ejercicio de la autonomía de enfermería a nivel regional, es preciso definir el escenario deseado y establecer la estrategia para llegar a él. el empleo de estas herramientas metodológicas permite facilitar y sistematizar la reflexión colectiva pero, ante todo, respalda el desarrollo de una enfermería que se reconozca y se haga visible, en especial por su aporte a la salud. referencias 1. manfredi m. el desarrollo de enfermería en américa latina: una mirada estratégica. rev latino-am enfermagem [internet]. enero 1993 [visitado 2015 septiembre 25]; 1(1):23-35. disponible en: http://www.scielo.br/scielo.php?script=sci_ arttext&pid=s0104-11691993000100004&lng=en. http://dx.doi.org/10.1590/s0104-11691993000100004. 2. nájera rm, castrillón mc. la enfermería en américa latina. situación actual, áreas críticas y lineamientos para un plan de desarrollo [internet]. [visitado 2015 septiembre 25]. disponible en: http://www.aladefe.org/articulos/la_enfermeria_en_america_latina.pdf 3. godet m, coates jf, radford k. creating futures: scenario planning as a strategic management tool. washington, d.c: economica brookings diffusion; año. p. 280. 4. regulación de la enfermería en américa latina [internet]. 2011 [visitado 2015 septiembre 25]. disponible en: http://www.paho.org/hq/index.php?option=com_content&view=article&id=6405%3a2012-regulacion-enfermeriaamerica-latina&catid=526%3ahuman-resources-health&itemid=2054&lang=es 5. malvárez sm, castrillón mc. panorama de la fuerza de trabajo en enfermería en américa latina. washington, d.c.: organización panamericana de la salud [internet]. 2005 [visitado 2015 septiembre 25]. disponible en: http://www.ops. org.bo/textocompleto/ift26346.pdf 6. organización mundial de la salud, organización panamericana de la salud. acerca de enfermería [internet]. [visitado 2015 septiembre 25]. disponible en: http://www.paho.org/hq/index.php?option=com_content&view=article&id=1117 0&itemid=41547&lang=en 1 editorial.p65 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 20054 año 5 vol. 5 nº 1 (5) 4-5 chía, colombia octubre 2005 os profundos y rápidos cambios del contexto mundial y nacional, las políticas de salud derivadas de la implementación de la ley 100 de 1992, nuevas tendencias y paradigmas en la formación del recurso humano en salud, al igual que los cambios sociales, avances en ciencia y tecnología y el impacto en las condiciones y los estilos de vida de personas y comunidades, hacen necesario que enfermería, como disciplina profesional, enfrente nuevos retos ante los desafíos que debe asumir en el presente siglo. procesos como la apertura, la globalización, el libre comercio, la bioingeniería y los grandes avances científicos están a la orden del día. cabe resaltar la importancia que la producción y generación del conocimiento tienen para la disciplina de enfermería y para la salud de las poblaciones, en especial si se tienen en cuenta los actuales cambios que enfrenta la sociedad. el conocimiento científico promueve el desarrollo de las disciplinas y da un soporte teórico al ejercicio profesional; enfermería no es ajena a estos procesos. el fomento de la utilización y socialización de resultados de investigación es un imperativo ético que retroalimenta la práctica y, por ende, las acciones de cuidado. la facultad de enfermería de la universidad de la sabana promueve en cada una de las actividades académicas esta retroalimentación. la demanda cada vez mayor de resultados de investigación y de avances en el desarrollo de nuevas tecnologías y sistemas de información hacen parte, entre otros, de los nuevos desafíos del siglo xxi. se hace necesario que desde la academia se promueva la publicación de resultados de trabajos de investigación que permitan fortalecer los logros y avances de nuestra disciplina y den nuevas luces a las demandas del mundo contemporáneo. aquichan, publicación anual de la facultad de enfermería, tiene establecida en su misión que esta revista sea un órgano orientado a la promoción y el estímulo del desarrollo teórico de la disciplina de enfermería y a la divulgación de avances y resultados de investigación. en ese sentido, la revista ha promovido desde su inicio la publicación de trabajos y resultados de investigación, ensayos, artículos de reflexión y revisión, entre otros, que contribuyen al desarrollo de la práctica y de la disciplina de enfermería, de enfermeras(os) de servicio, de profesores e investigadores, tanto nacionales como internacionales. igualmente, en los números anteriores se han venido reseñando los avances logrados por el grupo de investigación sobre el modelo de adaptación de callista roy reconocido por colciencias en septiembre de 2003 y recientemente clasificado en categoría b. editorial 5 lo anterior es el resultado de un serio proceso de trabajo y consolidación académica del grupo y un importante logro para la facultad de enfermería. en la actualidad, los programas de posgrado que se ofrecen desde 2002 �especialización en cuidado crítico pediátrico, en convenio con la fundación cardio infantil, especialización en gestión en rehabilitación, en convenio con la clínica universitaria teletón y el nuevo programa de especialización en salud escolar�, evidencian igualmente el avance y desarrollo logrados en los procesos académicos e investigativos. en esta nueva edición, aquichan ofrece diferentes temáticas de interés para enfermería, como resultados de investigación clínica sobre cáncer, estrés en las unidades de cuidado intensivo, ética, modelos y teorías de enfermería, cuidadores y discapacidad, entre otros. igualmente, hemos incorporado una nueva sección, �correo del lector�, con el propósito de abrir espacios para la retroalimentación que recibimos de los lectores acerca de los trabajos publicados. con ello queremos destacar la importancia del trabajo conjunto con pares académicos, lectores y colaboradores, en los ámbitos nacional e internacional. en este quinto número resaltamos la publicación del trabajo �middle-range nursing theories are necessary for the advancement of the discipline�, de la doctora jacqueline fawcett, importante teórica e investigadora de la universidad de massachusetts, en boston, reconocida en el mundo académico de enfermería. la doctora fawcett es autora de numerosas obras y artículos científicos. la facultad de enfermería se siente muy honrada de contar con la publicación del trabajo presentado por videoconferencia por la doctora fawcett durante el ii seminario internacional �avances en la aplicación de teorías de enfermería en la práctica y la investigación en latinoamérica y el caribe�, el cual se realizó en el auditorio david mejía velilla del campus universitario, en octubre de 2004. gracias a la aceptación y al reconocimiento logrados en estos primeros años de circulación, aquichan continuará trabajando en la consolidación y el fortalecimiento del desarrollo disciplinar de enfermería. maría clara quintero laverde realidad y retos para enfermería nota de la dirección: en este número la revista aquichan, de acuerdo con las normas de indexación, asume el concepto de volumen y número que, para tal fin, tienen las publicaciones seriadas. 1 8 primeras paginas.indd 5 editorial una mirada hacia afuera: proyección de enfermería para el 20501 looking ahead: the forecast for nursing in 2050 um olhar para a frente: projeções de enfermagem para 2050 doi: 10.5294/aqui.2018.18.1.1 ¿qué somos y cómo manejamos el conocimiento? enfermería es una entidad profesional de la salud reconocible y socialmente aceptada e imprescindible (1). pero este reconocimiento no asegura que la profesión mantenga un estatus de independencia y estabilidad laboral adecuado. esta situación tiene raíces antiguas, difíciles, mas no imposibles de transformar, como se ha demostrado con el tiempo cuando se rompen tradiciones y esquemas predefinidos y se confirma la viabilidad de formas de ejercicio profesional diferentes. en colombia, tales tradiciones y esquemas han mostrado ser fuertes y casi permanentes en el tiempo. las razones de esta permanencia se deben, entre otros, a dos hechos. el primero es el contexto del sistema de salud que, a pesar de llevar una reforma de 24 años, no ha modificado de manera sustancial su enfoque de atención médica-enfermedad; el segundo, derivado de esta, es la modalidad de prestación de servicios que enfatiza la atención institucional (última reforma) frente a la promoción y prevención extrainstitucionales (2). enfermería se reconoce por ser una disciplina profesional. existe consenso (3-8) en que la esencia de enfermería es la práctica sustentada en el conocimiento científico. este conocimiento científico se fundamenta en el conocimiento propio de enfermería derivado de los resultados de su investigación, y del conocimiento cuando se desea pensar en el futuro es necesario mirar el presente. es impensable tratar de dar forma al futuro sin tener identificados los pros y contras del estado actual de enfermería y, asimismo, ser capaces de identificar las mejoras requeridas para fortalecer los pros y crear las condiciones necesarias para modificar los contras. pero también se debe tener presente que los momentos coyunturales por los cuales atraviesa una profesión deben servir como resortes para construir un ideal futuro. sin desconocer la problemática actual de enfermería, sus múltiples logros y sus grandes aportes en favor de la salud de la gente, no es inapropiado tratar de modelar el futuro de forma tal que, en un tiempo prudente de treinta años, se logre fortalecer aún más la profesión y aportar a la sociedad enfermeras con mayor proactividad y autonomía. para lograr esta utopía —y se plantea como utopía porque la naturaleza misma de la enfermería impide que la profesión se sustraiga totalmente de ciertos aspectos dependientes de su quehacer rutinario— debemos reflexionar sobre los puntos que se mencionan, con la certeza de que existen otros muy importantes pero que, dada la situación, no se tocarán en este escrito. estos puntos son: qué somos y cómo manejamos el conocimiento, qué deseamos para el futuro, y examinar lo que realmente podemos ser, dadas las condiciones contextuales del sistema de salud en colombia. maría mercedes durán de villalobos2 1 estos pensamientos fueron planteados en el consejo de directoras de la asociación colombiana de facultades y escuelas de enfermería (acofaen), del 31 de marzo de 2017. 2 universidad nacional de colombia, universidad de la sabana, colombia. mariadurvi@unisabana.edu.co 6 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 1 chía, colombia marzo 2018 teórico propio y de otras disciplinas aplicado y adaptado a la práctica, que conforman la esencia disciplinar. pero como estamos en el ¿qué somos?, vale la pena preguntar: nuestra práctica, que es profesional, ¿responde a las exigencias de una práctica disciplinar? la repuesta es dudosa porque, en nuestro contexto, enfermería es una disciplina profesional que mira hacia adentro. es decir, la investigación que genera, tanto en ámbitos académicos como en ámbitos de prestación de servicios tiene características tradicionales y poco incursiona en aspectos interprofesionales o en temas innovadores que hagan dinámico el crecimiento del conocimiento. como enfermería mira hacia adentro es lógico que tenga poca visibilidad en el ámbito de las disciplinas de la salud y, como sugiere reed (6), en muchas oportunidades el conocimiento disciplinar de enfermería es adoptado y utilizado por otras disciplinas como si fuera propio, y son tales estas las que lo hacen visible. en otros términos, enfermería no reconoce el conocimiento derivado de su práctica porque la rutina y la tradición no le permiten “mirar hacia afuera”. el conocimiento disciplinar debe respaldar la práctica y debe partir de esta con unos requisitos de innovación y creatividad. sin estas características, que son la puerta de entrada para la visibilidad, llegará el 2050 con la misma práctica rutinaria y poco renovadora. se puede concluir, entonces, que la práctica o el ejercicio clínico basado en conocimiento científico es lo que hará visible a enfermería. pero actualmente, ¿cómo es esa práctica? ¿es autónoma o está determinada por otros? ¿es una práctica disciplinar de cuidado? ¿está basada en evidencia científica (resultados de investigación y teoría de enfermería, mayormente)? ¿manejamos un ejercicio disociado? las respuestas a estas cuestiones tienen que ver con la forma como manejamos el conocimiento, y es difícil responder porque cada quien tiene su propia imagen sobre el tema. la práctica de enfermería es parcialmente autónoma por dos razones: mucho de su quehacer no es disciplinar. son actividades ajenas al cuidado propiamente dicho, que se han adjudicado a enfermería por las administraciones institucionales de forma un tanto irrazonable, y porque los estándares, las guías de práctica y otras modalidades de atención utilizadas en las instituciones, con su obligatoriedad, alejan a enfermería de cuidar con relativa autonomía. lo que conduce a pensar que la práctica de enfermería difícilmente se puede clasificar como un quehacer disciplinar de cuidado. el otro tema fundamental es el de la evidencia, ¿qué tipo de evidencia se maneja para la práctica? evidencia médica en su mayoría porque, como se mencionó, enfermería tiene baja jurisdicción sobre su conocimiento. la baja jurisdicción se relaciona con el manejo de la ciencia de enfermería y por las formas de abstracción teóricas utilizadas para tomar las decisiones en la práctica. como consecuencia, se presenta una práctica disociada, uno es el discurso disciplinar, y otra cosa un tanto diferente son las exigencias de la práctica profesional. si se mantiene la problemática será difícil lograr que el desarrollo del conocimiento (la ciencia de enfermería y la investigación) y la práctica sean los elementos fundamentales de la evolución de la disciplina profesional; y solamente con la eliminación de la disociación enfermería podrá ser más efectiva y reconocida en el trabajo con los grupos asistenciales de salud, es decir será una disciplina que mirará hacia afuera. ¿qué deseamos para el futuro? es natural que se pretendan corregir los aspectos que presentan dificultades en la actualidad y, para tal efecto, se requeriría visualizar una disciplina profesional articulada, científica y gremialmente dinámica, sin brechas entre el conocimiento disciplinar y la práctica, que valore el conocimiento nacido de la experiencia (6), con jurisdicción sobre el mismo y con una investigación que aclare y verifique lo que se requiere para un desarrollo autónomo. la articulación docencia-servicio se torna, entonces, en el eje central del trabajo mencionado, porque tanto los servicios de enfermería como las instituciones docentes deben aclarar el significado del “servicio de la práctica de enfermería”, mejor dicho, cuál es la meta en los servicios. así, la práctica clínica de enfermería institucional y docente podrá mantener un diálogo constante con el conocimiento disciplinar y la indagación científica. para esto se requieren facultades y escuelas de enfermería para el 2050. sin descuidar aspectos indispensables para la formación de profesionales idóneos, el énfasis en el conocimiento disciplinar es una necesidad. no se puede esperar jurisdicción sobre el conocimiento, si el énfasis curricular reposa en saberes de otras disciplinas afines. tampoco se puede esperar autonomía de la práctica si el conocimiento que la sustenta es ajeno a enfermería, y no se puede esperar interacción de enfermería con 7 otros profesionales, si no se garantiza el rol de los profesionales, si estos no son conscientes de la riqueza de tener un quehacer sustentado por una disciplina de cuidado. la perspectiva del futuro de enfermería se aclara cuando se reconocen las oportunidades que deparan las propuestas de salud y educación. el futuro lo modela la disciplina, no es posible que otros lo modelen para ella. se requiere el compromiso personal y grupal, con empeño profesional y social (patrón de conocimiento emancipatorio) (9), porque es necesario romper con las tradiciones y las imposiciones indiscriminadas, lo cual exige profesionales autónomos pero que interactúen con otros profesionales de la salud. ¿qué podrá ser enfermería? enfermería podrá ser lo que desee llegar a ser. es difícil señalar, de manera homogénea e inalterable, vías de acción para “mirar hacia afuera” y generar proyecciones para el 2050. no todos tenemos que ser iguales y es oportuno buscar estrategias individuales, de acuerdo con las idiosincrasias particulares, siempre con metas comunes. el pensamiento creativo hace la diferencia, y por rutas diversas se puede lograr un mismo objetivo. en enfermería, mirar hacia afuera es crucial. el pensamiento para crear el 2050 nos debe llevar a una enfermería diferente de la del 2020. para alcanzar los deseos de transformación se requieren estrategias que permitan la diversidad y búsqueda de nuevas oportunidades. en esta empresa la educación de profesionales juega un papel fundamental. la idea de formar profesionales con títulos universitarios, en mayor número, es importante, pero la calidad es tan esencial como el número. la formación de posgrado es vital porque, por un lado, genera en las enfermeras capacidades creativas para enfrentar los problemas del cuidado y poder modificar la práctica y, por otro, aumenta las posibilidades de contactos de “afuera”, sin perder la visión disciplinar y nuclear de la razón de ser de enfermería. la labor educativa no es exclusivamente de las instituciones universitarias. las instituciones prestadoras de servicios juegan un papel fundamental y son la condición sin la cual no se puede garantizar una educación de calidad. por ello, la articulación docente-asistencial amerita revisión y entendimiento en su cabal intensión, ya que es a través de la investigación de los fenómenos de la práctica clínica que se sucede en los servicios, en donde se concreta y clarifica la utilidad del conocimiento disciplinar. si bien las facultades y escuelas son indispensables, las agremiaciones científicas y profesionales no se pueden perder de vista. ellas son las que nos deben proponer “mirar hacia afuera” porque son las rectoras de enfermería. son las generadoras de ideas y políticas novedosas, y deben proponer estrategias para el cambio que respondan a las problemáticas contextuales y sociales. estamos en la cancha de juego y la pelota es nuestra. referencias 1. chan m. alocución de la directora general de la organización mundial de la salud (oms) ante la conferencia del consejo internacional de enfermeras: enfermeros y ciudadanos del mundo: conformar la enfermería para las futuras necesidades de los ciudadanos. seúl, república de corea. 2015 [visitado 2017 nov 17]. disponible en: http://www.who.inf/dg/ speeaches/2015/international.conference/nurses/es 2. política de atención integral en salud. ministerio de salud y protección social. 2016 [visitado 2017 nov 17]. disponible en: http://www.minsalud.gov.co. 3. fawcett, j, desanto-madeya s. contemporary nursing knowledge: analysis and evaluation of bussing models and theories. 3 edition. philadelphia: f.a. davis company; 2013. 4. meleis ai. theoretical nursing: development and progress. 5 edition. philadelphia: lippincott williams & wilkins; 2014. 5. newman m, smith m, dexheimer m. the focus of the discipline revisited. adv nurs sc. 2008;31(1):e16-e27. 8 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 1 chía, colombia marzo 2018 6. reed, p, crawford s. editors. nursing knowledge and theory innovation: advancing the science of practice. new york: springer publishing company; 2011. 7. rogers m. nursing science: a science of unitary man. conferencia presentada en la segunda conferencia de docentes de enfermería, 1978. 8. rodgers b. developing nursing knowledge: philosophical traditions and influences. philadelphia: lippincott williams & wilkins; 2005. 9. chinn pl, kramer mk. integrated theory and knowledge development in nursing. 8 ed. st. louis: mosby; 2011. ��������� ���� ������ ���������� ���� �� �� ����� �� �� �� •� ������ ��������� �� ������ ����� ���� �� �� ����� �� �� �� •� ������ ��������� �� ������ ����� ��������� � �� � ������ � �� � �� ��������� �� ��������������� � � ��������� �������������� �� ��� �� � ��������������� ������������������������� ������������� ������������������������������ �� ����������������������� �� ��� ��� �������� �� ���� ������������ � ����� �� �!�� ����� ����� ���������� �������������������� �����������!������ ��������� ���������������� ���� ����!��������� ���������� ���������� � ��������� �� ���� ��� � � � ����������������� ��� ������������"��� ������� �����# 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���������� 4�02</<����2��/9./,� 4� �� ����� ������ 1��)�����������/ ����������/���� 411 417 primeras paginas.indd 415 editorial la práctica de enfermería como foco de reflexión nursing practice as a focus for reflection a prática de enfermagem como foco de reflexão doi: 10.5294/aqui.2016.16.4.1 nes y a trabajar con indagaciones, lo que provee el desarrollo de habilidades y actitudes que conducen a la adquisición de un “poder técnico” y también “político”, a fin de actuar en beneficio de la sociedad. componente importante en este proceso, en la práctica, es la enfermera clínica, que durante el desarrollo de su labor diaria y con objetivos dirigidos hacia la gestión del cuidado de la persona que demanda su atención, debe al mismo tiempo cosupervisar y apoyar la formación de los estudiantes, futuros profesionales de enfermería (3). conocer y comprender a la enfermera clínica como una persona con responsabilidades propias y copartícipe del proceso de formación de los estudiantes de enfermería, también permite a quienes forman, los docentes, desarrollar nuevas miradas acerca de la experiencia clínica y su contexto, para fortalecer este espacio (4). la integración docencia-servicio se constituye, entonces, en un reto que debe ser enfrentado para construir conocimiento práctico y también teórico a través de proyectos de gestión e investigación, que surgen de las necesidades identificadas en los diferentes ámbitos de la práctica y logran materializarse a través de proyectos conjuntos, permitiendo mejorar el quehacer, generar una mayor autonomía, empoderamiento y visibilidad a enfermería. estudiosos del tema definen estos espacios de experiencia clínica como una estructura organizativa, producto de la alianza entre una institución formadora y una institución de servicios, con el objetivo específico de llevar a cabo procesos educativos, mediante la integración de la docencia y el servicio, para el desarrollo la práctica es una palabra que se utiliza mucho en enfermería; deriva del latín “activo” o “que actúa” (1). es descrita, asimismo, como el ejercicio de cualquier arte o facultad conforme a sus reglas; aquello que se organiza bajo la dirección de un maestro y que, por cierto tiempo, tienen que realizar algunas profesiones para habilitarse y poder ejercer públicamente su profesión (1). pensar en la práctica de enfermería significa, entonces, responder o situarse en dos contextos: el espacio académico y el clínico o asistencial. el académico permite analizar la práctica de enfermería a través del ejercicio que realiza el estudiante, con el apoyo de un maestro, que centra su quehacer en la enseñanza del cuidado humano y en los procesos de análisis y práctica reflexiva. es, en este espacio, donde se articulan e integran la teoría y la práctica de enfermería. la formación de los profesionales de enfermería se considera un factor clave. su inclusión y permanencia en los servicios de salud, así como la participación en la mayoría de los procesos de atención y conexión con todo el equipo de salud, demanda que su preparación garantice competencias para desarrollar un rol activo a favor de la calidad y la seguridad de la atención (2). en esta formación se destaca la práctica clínica donde el docente no solamente instruye, sino también estimula al estudiante a la toma de decisiones, a hacer observaciones, a percibir relaciosandra valenzuela-suazo1 1 profesor titular, universidad de concepción, chile. svalenzu@udec.cl 416 aquichan issn 1657-5997 eissn 2027-5374 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 de competencias teórico-prácticas en salud. la organización panamericana de la salud (ops) la visualiza como la ...unión de esfuerzos, en un proceso de creciente articulación, entre instituciones de servicios de salud y de educación para contribuir a mejorar las condiciones de vida de la colectividad, mediante la prestación de servicios adecuados a las necesidades reales de la población, la producción de conocimientos y la formación de recursos humanos necesarios en un determinado contexto de la práctica de servicios de salud y de enseñanza (5). es necesario reforzar que la práctica requiere que los profesionales de enfermería se posicionen con actitud de pregunta y reflexión frente a las realidades que la circundan, en una búsqueda de respuestas que permitirá construir y transformar la realidad (6). se reconocen sus competencias a través de la vivencia cotidiana que sostiene su experiencia, por lo que su visión es extremadamente pertinente y debe ser incorporada en todos aquellos procesos dirigidos a mejorar la docencia como son rediseños, innovación o revisiones curriculares; la acreditación o el establecimiento de nuevos perfiles profesionales. por otra parte, un elemento central en esta reflexión es incorporar el contexto, el mundo del trabajo asistencial, en los diversos lugares donde le corresponde actuar a los profesionales de enfermería, reconociendo su labor como “el ejercicio de la gestión del cuidado humano”, considerado un círculo fundamentalmente particular y complejo que busca generar, mantener o restituir la salud de las personas. estos espacios donde enfermería desarrolla su quehacer son muy variados y, en numerosas ocasiones, con muchas limitaciones que hacen difícil la tarea. para el consejo internacional de enfermeras (cie), estas profesionales, a través de su práctica, están en la búsqueda de justicia social, son una fuerza para el cambio, trabajan para reducir las diferencias y promover el acceso igualitario a la salud. las profesionales de enfermería ven día a día ejemplos de inequidad, por esto tienen un papel significativo que desempeñar para contribuir a la consecución de sistemas de salud fuertes y equitativos en su práctica cotidiana y favorecer el acceso universal. sin embargo, el cie, igualmente, reconoce que existe necesidad de adaptarse y cambiar más rápidamente, y que los retos establecidos para los próximos años requerirán una nueva generación con desafíos asociados a un quehacer vinculado a la innovación y el liderazgo (7). estos retos en la formación deben ser incorporados por la academia. en materia de gestión y liderazgo, las enfermeras tienen gran participación en el logro de los objetivos, asumiendo un rol de líder, no siempre reconocido por el equipo de salud. representan un desafío para la profesión y la disciplina, ya que el liderazgo contribuye al desarrollo de los servicios de salud en forma integral, eficiente, equitativa y de calidad para lograr salud para todos (8). asimismo, la innovación en enfermería es vista como significativa para la entrega de cuidados, como un esfuerzo colectivo en la promoción y prevención, para el crecimiento profesional, a fin de transformar y avanzar en las formas de intervención y en las tecnologías que utiliza la práctica del cuidado de enfermería. finalmente, se enfatiza en este documento la importancia del ambiente y el contexto donde se desarrolla esta práctica clínica de los estudiantes de enfermería: un ambiente motivador y potenciador del aprendizaje si la reflexión se sitúa en la docencia práctica, o un ambiente laboral para los profesionales de enfermería, con buena comunicación y clima organizacional, favorecedor de satisfacción de este trabajador y de los usuarios, que permite mejorar los procesos de trabajo, fomentar el trabajo en equipo, y aumentar la calidad y humanidad en el cuidado de enfermería. todos estos se constituyen en factores determinantes de los procesos organizativos de gestión, liderazgo e innovación, puntos clave que se subrayan en esta reflexión. 417 referencias 1. real academia española. diccionario de la lengua española. disponible en: http://dle.rae.es/?id=ttemsxj 2. moreno monsiváis mg. calidad y seguridad de la atención. cienc enferm. 2013 [citado 2016 oct 10]; 19(1):7-9. 3. bettancourt l, muñoz la, merighi m, barbosa a, fernandes dos santos m. el docente de enfermería en los campos de práctica clínica: un enfoque fenomenológico. rev latino-am enfermería. 2011 [citado 2016 oct 10]; 19(5):1197-204. 4. marcia fernandes dos santos m, merighi m, barbosa a, muñoz la. a experiência de enfermeiras assistenciais com estudantes de enfermagem: uma análise fenomenológica. rev esc enferm usp. 2009 [citado 2016 oct 10]; 43(3):528-34. 5. soto p, garcía a. impacto de un modelo de integración docente asistencial en la formación profesional y el campo clínico. cienc enferm. 2011 [citado 2016 oct 19]; 17(3):51-68. 6. ospina rave be, toro ocampo já, aristizábal botero ca. rol del profesor en el proceso de enseñanza-aprendizaje de la investigación en estudiantes de enfermería de la universidad de antioquia, colombia. invest educ enferm. 2008;26(1):106-14. 7. consejo internacional de enfermeras. las enfermeras: una fuerza para el cambio – mejorando la capacidad de recuperación de los sistemas de salud. 2016. disponible en: http://www.icn.ch/images/stories/documents/publications/ind/ ind_kit_2016_es.pdf 8. quezada torres c, illesca pretty m, cabezas gonzález m. percepción del liderazgo en las(os) enfermeras(os) de un hospital del sur de chile. cienc enferm. 2014 [citado 2016 oct 10]; 20(2):41-51. 1 6 primeras paginas.indd 5 editorial sucessos, lições e prioridades emergentes no sistema de editoração científica na enfermagem da américa latina éxitos, lecciones y prioridades emergentes en el sistema de edición científica en enfermería en latinoamérica successes, lessons and emerging priorities in the scientific publishing system in nursing in latin america doi: 10.5294/aqui.2016.16.1.1 nando revisores especialistas voluntários, capazes de detectar a credibilidade científica e consistência do manuscrito, sua originalidade, rigor, estilo, adequação teórico-metodológica, dentre outras competências. aos revisores, deve-se creditar o valor da cooperação, de grande utilidade para o trabalho do editor, a quem cabe, de fato, a decisão de publicar ou não os manuscritos. embora o processo de revisão por pares seja adotado amplamente e seja revestido de reconhecidos méritos, apresenta limitações que precisam ser constantemente avaliadas pelo editor. dentre as lições de sucesso dos mencionados empreendedores, podemos elencar a capacidade de estabelecer e cumprir metas de normalização, periodicidade, pontualidade, indexação gradativa e crescente em termos de quantidade e qualidade das bases de dados, o que repercute positivamente na valorização científica da profissão, de seus autores e das instituições a que estão ligados em cada país. nesse contexto, é de se ressaltar os ganhos obtidos por toda a comunidade em decorrência da introdução gradativa de títulos de enfermagem em bases que disponibilizam todos os artigos em acesso aberto. ao mérito de ser admitido em uma base de elevado conceito e utilidade, deve ser somado o mérito da permanência nessas bases, o que só ocorre se indicadores de produtividade na última década, os periódicos de enfermagem tiveram uma evolução digna de nota na qualidade do sistema de editoração científica, sob os esforços de enfermeiros-líderes que tomaram para si, em nome de suas instituições, a responsabilidade e o desafio de assumir essa missão. diferentemente do sistema padrão de editoração científica utilizado em países de outras regiões e continentes, em que o editor científico relaciona-se com uma empresa comercial especializada e a ela transfere toda a interface complementar e operacional para a edição do periódico, a área de enfermagem na américa latina assume todas as funções vinculadas ao papel do editor. essa prática se dá por questões culturais, econômicas e sociais, que são os determinantes da assunção de papéis para os quais os envolvidos não foram profissionalmente preparados: aprendem com a prática, esforçam-se por adquirir expertise, muitas vezes, acumulando essa árdua responsabilidade a tantas outras de natureza acadêmica das quais suas instituições de vínculo não podem liberá-los para o exercício do papel de editor. esses enfermeiros empreendedores aprenderam a lidar e aplicar políticas e estratégias de editoração selecionando e acio1 universidade de são paulo, brasil. iamendes@eerp.usp.br isabel amélia costa mendes1 6 aquichan issn 1657-5997 año 16 vol. 16 nº 1 chía, colombia marzo 2016 qualificada e de impacto forem alcançados com a frequência esperada. assim, aos editores recaem cada vez mais responsabilidades e desafios. movimentos solidários e estratégias de compartilhamento têm surgido ao longo do caminho, como a organização de fóruns de discussão em cada país da região, o que resulta em ganhos para os editores, para os autores e para a enfermagem. há vários exemplos dessas conquistas e de iniciativas bem-sucedidas. dentre elas, cabe aqui ressaltar o trabalho em rede, por meio de iniciativas nacionais e a rededit, criada em 2006. essa rede tem como metas o alcance de padrões homogêneos de qualidade e estratégias comuns para indexação, além de amplitude à visibilidade do conhecimento gerado pela enfermagem ibero-americana. entre suas funções mais promissoras estão as de estimular e manter o interesse e o vínculo entre os membros da rede, coordenar atividades regionais de disseminação e capacitação de técnicos e editores, promover encontros bianuais presenciais para discussão de temas no fórum latino-americano de editoração científica em enfermagem. além do seu evento próprio, a rededit reúne suas lideranças anualmente, seja nos colóquios pan-americanos de investigação em enfermagem, organizados por centros colaboradores da ops/oms da região das américas, com o apoio da ops/oms, seja nos eventos organizados pela associação latino -americana de escolas e faculdades de enfermagem (aladefe). são membros dessa rede 43 periódicos oriundos de 11 países (1), representados nas reuniões por seus editores e colaboradores, que estão abertas aos interessados no tema. também é aberta à inclusão de outros periódicos. os êxitos obtidos nessa trajetória pelas revistas apresentamse acompanhados por desafios que vão surgindo na medida em que se galgam novos patamares, como o aumento da produtividade e consequente demanda de manuscritos. esse desafio aponta para uma prioridade a ser enfrentada pelos editores, em articulação com as instituições formadoras de pesquisadores: o sistema precisa contar com um quantitativo maior de revisores qualificados. uma segunda prioridade que emerge também na medida do volume e da complexidade do sistema de editoração é sua profissionalização. temos defendido que a enfermagem precisa encarar a editoração científica como um negócio e destiná-la a empresas do setor, as quais possuem profissionais com as competências necessárias para oferecer o apoio e prestar os serviços especializados que os editores científicos precisam. poderão estes, assim, manter seu foco na definição da política editorial e na gestão do conhecimento a ser disseminado pela revista e na gestão dos talentos que contribuem com a faceta científica da editoração. portanto, são prioridades emergentes: investir na formação e no desenvolvimento de revisores e associar-se a editores profissionais. temos defendido essa visão em reuniões regulares sobre editoração e acreditamos que é chegada a hora de ações correspondentes. valoriza-se, assim, os enfermeiros-editores, empreendedores que têm trazido inquestionável contribuição para a enfermagem! referências 1. escola de enfermagem de ribeirão preto, universidade de são paulo. centro colaborador da opas/oms para o desenvolvimento da pesquisa em enfermagem. rededit. 2015 [acesso em 10 dez. 2015]. disponível em: http://www.eerp.usp.br/whocc/ 418 429 the health promotion model.indd 418 aquichan issn 1657-5997 eissn 2027-5374 yeow chye ng1 angela caires2 the health promotion model in hiv care 1 orcid.org/0000-0003-3955-0440. college of nursing, university of alabama in huntsville. united states. yeowchye.ng@uah.edu 2 orcid.org/0000-0001-7030-0680. college of nursing, university of alabama in huntsville. united states. angela.caires@uah.edu recibido: 11 de septiembre de 2016 enviado a pares: 18 de septiembre de 2016 aceptado por pares: 18 de octubre de 2016 aprobado: 26 de octubre de 2016 doi: 10.5294/aqui.2016.16.4.2 para citar este artículo / to reference this article / para citar este artigo ng yc, caires a. the health promotion model in hiv care. aquichan. 2016; 16 (4): 418-429. doi: 10.5294/aqui.2016.16.4.2 abstract effective medical treatment with uninterrupted engagement in care is critical to improving the survival and the quality of life of patients infected with the human immunodeficiency virus (hiv). objectives: multiple behavioral interventions have been conducted to promote adherence behaviors. however, adherence to hiv medications and medical appointments is still an issue of global concern. method: the health promotion model (hpm) is a nursing adaption of the health belief model. the hpm focuses on individual characteristics and experiences, as well as behavior specific cognitions and outcomes. integrating the hpm in addressing adherence behaviors could be one of the building blocks of success in changing health behavior. results: a search of the literature turned up no studies that applied the hpm in adherence behavior studies conducted among hiv-infected populations. conclusion: this paper presents the reader with the availability of current adherence-behavior interventions and strategies that align with the hpm model components. it further proposes the need for medical treatment team members to adopt the hpm in current clinical practice settings so as to effectively address adherence behavior issues. keywords hiv medication adherence; adherence theory; health promotion model; linkage to hiv care; nursing promotion model (source: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 418-429 419 the health promotion model in hiv care l yeow chye ng and other año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 418-429 el modelo de promoción de la salud en el cuidado del vih resumen un tratamiento médico eficaz con un compromiso ininterrumpido en el cuidado es crítico para mejorar la supervivencia y la calidad de vida de los pacientes infectados con el virus de la inmunodeficiencia humana (vih). objetivos: se han llevado a cabo múltiples intervenciones conductuales para promover comportamientos de adherencia. sin embargo, la adhesión a los medicamentos contra el vih y las citas médicas siguen siendo un tema de preocupación mundial. método: el modelo de promoción de la salud (hpm) es una adaptación de enfermería del modelo de creencias de salud. el hpm se centra en características y experiencias individuales, así como cogniciones y resultados específicos del comportamiento. la integración del hpm en el abordaje de los comportamientos de adherencia podría ser uno de los pilares del éxito en el cambio del comportamiento de la salud. resultados: una búsqueda en la literatura no mostró ningún estudio que aplicó el hpm en los estudios de comportamiento de adherencia realizados entre las poblaciones infectadas por el vih. conclusión: este artículo presenta al lector la disponibilidad de las actuales intervenciones de adherencia-comportamiento y estrategias que se alinean con los componentes del modelo hpm. además, propone la necesidad de que los miembros del equipo de tratamiento médico adopten el hpm en la práctica clínica actual con el fin de abordar eficazmente los problemas de comportamiento de adherencia. palabras clave adhesión a los medicamentos para el vih; teoría de la adherencia; modelo de promoción de la salud; vinculación a la atención del vih; modelo de promoción de la enfermería (fuente: decs, bireme). 420 aquichan issn 1657-5997 eissn 2027-5374 o modelo de promoção da saúde no cuidado do hiv resumo um tratamento médico eficaz com um compromisso ininterrupto no cuidado é fundamental para melhorar a sobrevivência e a qualidade de vida dos pacientes infectados com o vírus da imunodeficiência humana (hiv). objetivos: realizaram-se múltiplas intervenções comportamentais para promover condutas de adesão. no entanto, a adesão aos medicamentos contra o hiv e às consultas médicas continua sendo um tema de preocupação mundial. método: o modelo de promoção da saúde (hpm, por sua sigla em inglês) é uma adaptação de enfermagem do modelo de crenças em saúde. o hpm centra-se em características e experiências individuais, bem como cognições e resultados específicos do comportamento. a integração do hpm na abordagem dos comportamentos de adesão poderia ser um dos pilares do sucesso na mudança do comportamento da saúde. resultados: uma busca na literatura não mostrou nenhum estudo que aplicou o hpm nos estudos de comportamento de adesão realizados entre as populações infectadas pelo hiv. conclusão: este artigo apresenta ao leitor a disponibilidade das atuais intervenções de adesão-comportamento e estratégias que se alinham com os componentes do modelo hpm. além disso, propõe a necessidade de que os membros da equipe de tratamento médico adotem o hpm na prática clínica atual ao fim fim de abordar eficazmente os problemas de comportamento de adesão. palavras-chave adesão aos medicamentos para o hiv; modelo de promoção da enfermagem; modelo de promoção da saúde; teoria da adesão; vinculação ao atendimento do hiv (fonte: decs, bireme). año 16 vol. 16 nº 4 chía, colombia diciembre 2016 l 418-429 421 the health promotion model in hiv care l yeow chye ng and other introduction the advancement of antiretroviral therapy (art) has provided multiple positive health benefits to the hiv-infected population. the life expectancy of hiv-infected patients who choose to follow art treatment has been dramatically prolonged. hiv is no longer considered a terminal illness by many medical professionals, but rather a chronic disease. however, many infected persons do not fully benefit from the best-managed treatment plans, because they do not consistently adhere to routine clinical care. ensuring treatment adherence has proven to be a significant challenge in health care globally and in the united states. adherence is defined as the extent to which a patient follows instructions for prescribed treatment(s) (1). individuals who do not fully adhere to prescribed treatment regimens may face higher mortality and morbidity rates due to the untreated advancement of their disease (2). research has shown that effective medical treatment and correct diagnosis have proven to be critical to improving the quality of life of hiv patients and assuring their long-term survival (3). failure to follow the precise recommendations and instructions of health care providers is a barrier to effective medical treatment. in addition, non-compliance or non-adherence to hiv care and treatment poses a significant economic burden to society (4). globally, non-adherence to antiretroviral therapy in the adult hiv-infected population ranges from 33% to 88 % (5). in the united states alone, non-adherence has led to tremendous yearly medical expenditures (6). in 2015, the global health observatory data repository indicated that approximately 1.1 million people died of hiv-related illnesses (7). the economic burden and death rate among hiv patients can be addressed and improved only through effective communication and commitment to the development and implementation of effective, evidence-based treatment regimens and adherence to them. effective hiv treatment often requires a multidisciplinary team approach, and the coordination of care is critical to achieving success with respect to improving rates of adherence. researchers have been struggling with the issue of adherence behavior for more than 50 years (8), and the problem of non-adherence is still listed as a priority research topic by the world health organization (9). an extensive review of the literature uncovered no studies that developed and implemented the hpm as a methodology to address non-adherence behaviors. this paper discusses the clinical adherence intervention strategies currently available and explores other theoretical models that could successfully align with the hpm. in most clinical settings, nurses are the healthcare professionals who spend the most time with patients (10). therefore, this is an opportunity for nurses to embrace the health promotion model (hpm) to further encourage adherence behavior strategies among their patients. the health promotion model the health promotion model (hpm) was designed as a health protection model that defined health as a state of positive metabolic and functional efficiency of the body and not merely the absence of disease (11). the hpm is a nursing adaption of the health belief model, which is directed toward increasing a patient’s level of well-being and self-efficacy as the patient interacts with the surrounding environment. thus, the hpm is described as the art and science of assisting patients as they adapt to changes and improve their life style, while progressing toward a state of optimum health. figure 1 provides an overview of the hpm, which focuses on three major components: 1) individual characteristics and experiences, 2) behavior-specific cognitions and affect, and 3) behavioral outcomes. the model maintains that each individual has personal experiences and characteristics that are unique to that person and can affect subsequent actions and outcomes (11). the behavior-specific knowledge variables have motivation characteristics that are helpful to improving individual engagement in health. these behavior variables can be applied in nursing. thus, health promotion behaviors shape the desired behavioral outcome. behavior should positively enhance a better quality of life, as well as improve functional abilities and health across all development stages. the hpm embodies the following assumptions (11). 1. patients must actively regulate their behavior. 2. patients, in their biopsychosocial complexity, transform the environment as they interact progressively and transform behavior over time. 3. physicians and nurses play an integral role in development of the interpersonal environment that exerts influence on the lives of patients. 4. personal-environmental interactive patterns alter a patient’s behavior. 422 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 figure 1. health promotion model (adapted from 11) table 1. the relationship of other theories and models with the three components of the hpm 1. individual characteristics and experiences 2. behavior-specific cognitions and affect 3. behavioral outcomes educational adherence strategy self-motivation adherence strategy communication theory cognitive theory self-regulation model behavioral perspective theory to explain adherence the biomedical theory to explain adherence 423 the health promotion model in hiv care l yeow chye ng and other improving hiv patient adherence using the hpm hiv treatment effectiveness is based on the level of patient adherence to the therapeutic regimen. health care systems, hivtreatment team members, and patients all have a responsibility in improving adherence to medication. a single technique is not able to improve the adherence of hiv patients to a therapeutic regimen. instead, the development and implementation of diverse methods focused on improving adherence is needed. table 1 presents the different theories and models that have been applied to explore adherence behaviors. these theories and models are grouped under the three major components of the hpm: individual characteristics and experiences, behavior-specific cognitions and affect, and behavioral outcomes. these models could be implemented within the hpm framework by team members, with the overarching goal of improving adherence to scheduled medical appointments and daily medications. 1. individual characteristics and experiences individual characteristics and experiences involve personal biological factors, psychological factors, and socio-cultural factors (12). the factors are shaped by the nature of the behavior in question and are considered to be predictive of a particular behavior (12). the following strategies could be implemented by treatment team members utilizing the hpm model: the educational adherence strategy most research supports the effectiveness of patient education in the areas of adherence, knowledge, and patient outcomes (6, 13, 14). education positively impacts adherence among hiv patients, especially with regard to daily medication routines. this may be due to the many educational programs that are available to assist with improving adherence to treatment regimens. one example involves providing precise instructions and recommendations on self-care activities during scheduled medical appointments. through collaborative care, adherence interventions can be implemented by utilizing the expertise of other treatment team members (physicians, nurses, dietitians, and social workers) (15). nurses play a major role, not only in utilizing this strategy in daily practice, but also as team leaders who are pivotal in promoting collaborative care. the self-motivation adherence strategy koenig, bernard (16) reported that adherence to a treatment plan improves as physicians use the patient’s current laboratory results as a launching point in talking with the patient during clinical visits. as patients are made aware of their current viral load, this information may motivate them to take control of managing their health (16). other interventions such as providing groceries, meal tickets, and other tangible bonuses as part of attendance rewards have been shown to improve adherence in routine hiv medical care (17, 18). directly observed therapy (dot) is another strategy that also could improve medication adherence. berg and colleagues conducted a randomized trial using dot to explore adherence behavior. the study indicated dot enabled patients to maintain low viral loads and found they were more accepting of future medical evaluations and more likely to maintain art adherence (17). theoretical models to explain educational and self-motivation adherence educational and self-motivation adherence strategies are referred to as responses that are intended to improve an individual’s ability to manage his/her disease (19). behavioral principles such as feedback and reinforcement are often integrated into these strategies (19). the effectiveness of educational and self-motivational interventions should be tailored to address specific patient needs. another important component that requires exploration is the quality of the relationship between the patient and the healthcare provider (20). the concept of educating patients and addressing their needs appears to be daunting and complex, and does not refer to didactic or cognitive theoretical models. multiple theories (self-regulation perspectives, cognitive perspectives, and communication perspectives) can be applied to the sociocultural and psychological factors in educating patients as they apply this knowledge and become self-motivated and more likely to adhere to their scheduled medical appointments and daily medication routines. the communication theory communication models are essential to applying the educational and self-motivation strategies. these models focus on the transfer of knowledge and information related to a disease and its effective management (21). communication models incorporate 424 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 patient-specific information that can have a positive impact on motivation, as well as attitudes toward adherence. based on recent studies, it was found that information presented to patients should be tailored to a sixth grade reading level if it is to be effective and understood (22). limiting prescribed messages to no more than three specific points, with supporting statements for each topic, was found to be most useful (23). other factors that can contribute to message acceptance are a physician’s concern, interest, friendliness or empathy toward the patient and the alliance that may form once trust is established (24). thus, through the use of communication theory, a provider can influence and create positive behavioral change that might significantly improve patient adherence to daily medications and medical appointments (25). before initiating art, providers should take the time to discuss with the patient the advantages and disadvantages, risks and benefits of each medication protocol (26). an example would be when a patient might express concern about the possible side effects of a medication or treatment regimen. by presenting reliable treatment options and individualized treatment plans to patients and discussing options with them, they can be involved in the decision-making process. this is key and a cornerstone to the collaborative development of a successful treatment strategy. the cognitive theory the cognitive model emphasizes the beliefs and perceptions of patients as motivating behavioral factors. it also assumes health-related behavior is determined by an understanding of health benefits and the threats perceived in health behavior choices made by the patient (19). the primary model dimension is the perceived severity and probability of the threat and the perceived benefits and barriers of such behavior. actions are based on the individual’s subjective perception of the advantages and disadvantages, and are not necessarily based on rational objective computations (19). there are different cognitive concepts applied in adherence behavior studies. however, applying single cognition concepts in adherence behavior studies might not provide sufficient data, wihout considering other preexisting behavioral factors such as alcohol use disorders (27). the self-regulation model the self-regulation theory is directed toward patient selfmanagement, using educational interventions. it is determined by perceived social norms and/or group or social consequences (28). the theory maintains patients engage strategies that allow them to assume the role of active problem solvers. thus, patient behavior is influenced by subjective emotions and experiences. these are based on perceptions of the goal and current status, the patient’s plans to change his/her present state in order to achieve a goal, and the patient’s appraisal to reach the target. when goals are altered or not achieved, a patient can change his/her perception and coping strategies (28). coping among patients is based on cognitive considerations. the emotional and cognitive signals to cope are triggered by either external or internal stimuli (29). media messages and symptoms are examples of external and internal stimuli. 2. behavior-specific cognitions and affect this concept involves patient perception about the anticipated personal benefits of pursuing positive health outcomes that might result from a given health behavior (11). thus, it entails situational influences, interpersonal influences, activity-related affect, perceived self-efficacy, perceived barriers to action, and perceived benefits of action. historically, most medication adherence studies describe patient forgetfulness as the greatest barrier to non-adherence (30-33). this is considered a non-intentional factor. forgetfulness can be challenged and even improved as providers implement various reminder strategies such as cellular phone messages, alarms, emails, telephone reminders, and direct mail letters (17). engaging the assistance of hiv patient caregivers establishes another route to removing non-adherence as a barrier to a medical regimen (34). family-based or couples’ interventions provide motivation and support for patients to adhere to their medication (35). soliciting help from the hiv patient’s family members and establishing trust via communication between the patient and the provider are vital components in assisting a patient toward selfefficacy and treatment adherence (36). providers monitor and evaluate patient adherence by using support, rewards, calendars, and diaries, as well as by providing concise and consistent feedback (37). financial incentives were reported to improve adherence behavior to hiv management in the short-term and while the incentives were in place (38, 39). however, only a few limited controlled studies have been reported to date (38). 425 the health promotion model in hiv care l yeow chye ng and other most research confirms that telephone prompts and mail reminders are beneficial in reducing patient non-adherence to scheduled medical appointments (40-42). one of the suggested intervention models that can be implemented easily by healthcare providers is a personal telephone call or a short reminder message sent a few days before a scheduled medical appointment. this kind of direct, personal communication reminds the patient of the importance of the pending medical appointment (17). computerized reminders also are highly cost-effective and can motivate higher levels of adherence among hiv patients. as noted, adherence behavioral interventions are essential to improving adherence to scheduled medical appointments and daily medication, as medical providers seek to improve the health status of this highly vulnerable population. the behavioral perspective theory to explain adherence interventions based on incentives are essential to improving the hiv patient’s adherence levels. behavioral-adherent interventions are explained by using the behavioral theory. the model states the behavior of humans is largely based on cues or stimuli; these prompt specific responses that are essential in reinforcing behavior (19). incentives can act as cues, reminders, and rewards for adherent behavior. the major principle of the behavior model is that behavior is learned by forming and/or gradually shaping behavior patterns. for a desired behavior to remain consistent, it must be reinforced through automation and frequent repetition. reminders are, therefore, essential in improving adherence to scheduled medical appointments and daily medication. due to advances in technology, reminders are the most inexpensive and direct intervention option available to hiv patients. by using electronic technology, these messages may be sent frequently by the provider, at little or no cost (43). 3. behavioral outcomes the third hpm concept involves identification and intention of a planned strategy to implement a health behavior. it also can involve alternative behaviors that patients are not able to control because of environmental contingencies (12). behavioral outcome interventions can be implemented by providers using technical strategies such as unit-dose and/or blister-packaging for medication, as compared to bottles and envelopes (13). with this model, the adherence strategies are aimed at reducing the number of drug types in the regimen or doses per day through the use of fixed-dose combination pills or extended release formulations. fixed dose combination pills involve the formulation of two or more drugs in proportions that are set and/or blister packaged medicinal products in fixed dosage combinations. additional adherence improvement aids include printed medication schedules and calendars that specify the time of day for daily medications and specific packaging such as pill boxes that indicate dosage frequencies (44). the average rate of adherence is higher for a single daily dose compared to patients taking multiple daily doses (14). therefore, treatment team members should consider dosing frequency when developing medication regimens and attempt to limit the number of daily doses required. another strategy is the use of electronic medication container caps for elderly hiv patients who may have difficulty opening regular bottles (44). these electronic vial caps serve as a reminder system by beeping whenever a dose should be administered. the patient is rewarded with an accurate record of when medication(s) was (were) last dispensed. therefore, the development and implementation of reliable medication-product modifications should be a priority in improving patient adherence. another important component of adherence involves followup appointments with the provider and the healthcare team. wait times are an important factor and influence patient adherence to medical appointments. the longer a patient has to wait to schedule a visit to be seen by the provider, the lower the rate of adherence among the hiv-patient population (45). there is robust and consistent evidence that indicates simplifying scheduled medical appointments and dosage regimens improves adherence by reducing the frequency of daily dosages (44). this can result in decreased health care costs and better health outcomes for hiv patients. as stated previously, a strong level of respect and professionalism must be developed between the healthcare provider and the patient in order to create this environment. different therapeutic options and the manner in which they can be adhered to must be considered and implemented jointly by patients and providers. acknowledgement of the crucial role each plays in the plan is critical to the development of trusting and respectful relationships between healthcare providers and patients. 426 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 the biomedical theory to explain adherence the biomedical perspective theory assumes patients to be passive recipients of instructions and recommendations provided by treatment team members. it also discusses alternative behaviors patients are not able to control, based on environmental and technical contingencies. thus, it envisions the identification of a planned best-managed strategy to implement health behavior(s). a disease such as hiv involves biomedical causes, and the predominant focus of treatment is restoration of health. adopting the current advancement of a newer drug regimen is preferred (19). technical adherence strategies simplify the regimen by simplifing packaging and improving dosage adherence among hiv patients. such interventions are part of a biomedical model in which providers seek solutions for hiv patients. the biomedical model, therefore, assists in motivating the development of technological advances in enhancing scheduled medical appointments and daily medication routines (19, 20). in summation, simplification of treatment options is interpreted as a logical and practical solution. summary in summary, no single adherence approach can resolve the status of commitment to patient adherence levels. factors impacting adherence levels, such as the therapeutic relationship between treatment team members and the patient, should be addressed in an ongoing and/or proactive way (13). adherence success is based on tailoring interventions to a patient’s unique characteristics, readiness to engage in care, and the outcome expected from the treatment. collaboration between treatment team members and patients is still the foundational core of success in improving adherence behaviors. negotiation, collaboration, engagement, and participation all enhance opportunities for an ideal therapeutic approach that will assist hiv patients as they develop the skills needed to maintain their adherence equation. such partnerships influence patient adherence at all levels, foster patient satisfaction, and create positive healthcare outcomes. thus, all of these critical adherence elements can be linked to retention and improved health outcomes in the care of hiv-infected patients. conventional interventions used to schedule medical appointments and reminders of daily medications, based on technical solutions, do not adequately explain the human situational thought processes. there is a need to present and utilize the components provided by the hpm before implementing such intervention(s). adherence interventions such as reminders and incentives that stem from behavioral models are essential for non-adherent hiv patients who do not abide by their scheduled medical appointments and daily medications on a routine basis. it is unclear if educational, behavioral, biomedical and self-regulation models are more or less reliable in improving the level of adherence among hiv patients. concentrated efforts to improve adherence can lead to a win-win solution in which healthcare providers, patients, and the community at large can all benefit. in order to effectively contribute to and validate the hpm, there is a need to promote and pursue further multidisciplinary, collaborative research that delves into the underlying issues of adherence as a cohesive team effort focused on improving healthcare for all hiv patients. conclusion the paper contributes to advancement in the field by introducing the health promotion model and describing its applicability to patient adherence behavior. the issue of adherence behavior in the hiv-infected population not only aligns with current research trends in united states (46), it also is the main research priority listed by the world health organization (9). regardless of the types of hiv behavioral-related research topics, the hpm could still be appropriate as a foundation framework for interventions to address adherence. the challenge facing hiv patients has no simple solution in the area of behavioral change or adherence. the hpm can shed light on the processes underlying behavioral change. the theoretical model is essential for developing and implementing successful adherence interventions. more analysis is required to explore theory-based interventions in healthcare practices that are operative and developed based on a clear and relevant theoretical foundation. finally, documentation shows that cohesive and dedicated teams of nurses spend the greatest amount of time with patients (10). to overcome adherence barriers and issues facing hiv patients with respect to daily medications and medical appointments , medical healthcare providers should be poised to assume a proactive role in promoting positive health habits over the long term through the health promotion model. 427 the health promotion model in hiv care l yeow chye ng and other references 1. centers for disease control and prevention. primary care and public health initiative: medication adherence. centers for disease control and prevention; 2013. 2. altice fl, kamarulzaman a, soriano vv, schechter m, friedland gh. treatment of medical, psychiatric, and substanceuse comorbidities in people infected with hiv who use drugs. lancet (london, england). 2010;376(9738):367-87. 3. mugavero mj, norton we, saag ms. health care system and policy factors influencing engagement in hiv medical care: piecing together the fragments of a fractured health care delivery system. clinical infectious diseases. 2011;52(suppl 2):s238-s46. 4. cohen ms, chen yq, mccauley m, gamble t, hosseinipour mc, kumarasamy n, et al. prevention of hiv-1 infection with early antiretroviral therapy. the new england journal of medicine. 2011;365(6):493-505. 5. mills ej, nachega jb, bangsberg dr, singh s, rachlis b, wu p, et al. adherence to haart: a systematic review of developed and developing nation patient-reported barriers and facilitators. plos medicine. 2006;3(11):e438. 6. barnighausen t, tanser f, dabis f, newell ml. interventions to improve the performance of hiv health systems for treatment-as-prevention in sub-saharan africa: the experimental evidence. current opinion in hiv and aids. 2012;7(2):140-50. 7. global health observatory (gho) data [internet]. 2015 [cited september 11, 2016]. available from: http://www.who. int/gho/hiv/epidemic_status/deaths/en/. 8. martin lr, williams sl, haskard kb, dimatteo mr. the challenge of patient adherence. therapeutics and clinical risk management. 2005;1(3):189-99. 9. world health organization. priority interventions : hiv/aids prevention, treatment and care in the health sector: world health organization, hiv/aids department; 2010. report no.: 9789241596961 9241596961. 10. delucia pr, ott te, palmieri pa. performance in nursing. reviews of human factors and ergonomics. 2009;5(1):1-40. 11. pender nj, pender ar. health promotion in nursing practice. stamford, conn.: appleton & lange; 1996. 12. mcewen m, wills em. theoretical basis for nursing. philadelphia: wolters kluwer/lippincott williams & wilkins; 2011. 13. thompson ma, mugavero mj, amico kr, cargill va, chang lw, gross r, et al. guidelines for improving entry into and retention in care and antiretroviral adherence for persons with hiv: evidence-based recommendations from an international association of physicians in aids care panel. ann intern med. 2012;156(11):817-33. 14. ryscavage p, anderson ej, sutton sh, reddy s, taiwo b. clinical outcomes of adolescents and young adults in adult hiv care. journal of acquired immune deficiency syndromes (1999). 2011;58(2):193-7. 15. parry mf, stewart j, wright p, mcleod gx. collaborative management of hiv infection in the community: an effort to improve the quality of hiv care. aids care. 2004;16(6):690-9. 16. koenig sp, bernard d, dévieux jg, atwood s, mcnairy ml, severe p, et al. trends in cd4 count testing, retention in pre-art care, and art initiation rates over the first decade of expansion of hiv services in haiti. plos one. 2016;11(2):e0146903. 17. berg km, litwin a, li x, heo m, arnsten jh. directly observed antiretroviral therapy improves adherence and viral load in drug users attending methadone maintenance clinics: a randomized controlled trial. drug and alcohol dependence. 2011;113(2-3):192-9. 18. haukoos js, witt md, coil cj, lewis rj. the effect of financial incentives on adherence with outpatient human immunodeficiency virus testing referrals from the emergency department. academic emergency medicine. 2005;12(7):617-21. 19. munro s, lewin s, swart t, volmink j. a review of health behaviour theories: how useful are these for developing interventions to promote long-term medication adherence for tb and hiv/aids? bmc public health. 2007;7:104. 428 año 16 vol. 16 nº 4 chía, colombia diciembre 2016 aquichan issn 1657-5997 eissn 2027-5374 20. armitage cj, conner m. social cognition models and health behaviour: a structured review. psychology & health. 2000;15(2):173-89. 21. osterberg l, blaschke t. adherence to medication. the new england journal of medicine. 2005;353(5):487-97. 22. paasche-orlow mk, cheng dm, palepu a, meli s, faber v, samet jh. health literacy, antiretroviral adherence, and hivrna suppression: a longitudinal perspective. journal of general internal medicine. 2006;21(8):835-40. 23. merrill j, kukafka r, bakken s, ferat r, agopian e, messeri p. tailored health communication: crafting the patient message for hiv tips. amia annual symposium proceedings. 2003;2003:932-. 24. sluijs em, knibbe jj. patient compliance with exercise: different theoretical approaches to short-term and long-term compliance. patient education and counseling. 1991;17(3):191-204. 25. loeliger kb, niccolai lm, mtungwa ln, moll a, shenoi sv. “i have to push him with a wheelbarrow to the clinic.”: community health workers’ roles, needs, and strategies to improve hiv care in rural south africa. aids patient care stds. 2016;30(8):385-94. 26. world health organization. consolidated guidelines on the use of antiretroviral drugs for treating and preventing hiv infection: recommendations for a public health approach. world health organization; 2013. report no.: 9789241505727 9241505729. 27. parsons jt, rosof e, mustanski b. medication adherence mediates the relationship between adherence self-efficacy and biological assessments of hiv health among those with alcohol use disorders. aids and behavior. 2008;12(1):95-103. 28. leventhal h, lambert jf, diefenbach m, leventhal ea. from compliance to social-self-regulation: models of the compliance process. treatment compliance and the therapeutic alliance. 1997:17-33. 29. delmas p, delpierre c, cote j, lauwers-cances v, delon s. study of the promosud cohort. predictors of adherence to treatment plans by french patients living with hiv. perspective infirmiere : revue officielle de l’ordre des infirmieres et infirmiers du quebec. 2008;5(7):28-35. 30. hansana v, sanchaisuriya p, durham j, sychareun v, chaleunvong k, boonyaleepun s, et al. adherence to antiretroviral therapy (art) among people living with hiv (plhiv): a cross-sectional survey to measure in lao pdr. bmc public health. 2013;13:617. 31. polis s, zang l, mainali b, pons r, pavendranathan g, zekry a, et al. factors associated with medication adherence in patients living with cirrhosis. journal of clinical nursing. 2016;25(1-2):204-12. 32. roberts kj. barriers to and facilitators of hiv-positive patients’ adherence to antiretroviral treatment regimens. aids patient care stds. 2000;14(3):155-68. 33. kagee a, nel a, saal w. factor structure of the beck depression inventory-ii among south africans receiving antiretroviral therapy. aids care. 2014;26(2):257-62. 34. lyon me, trexler c, akpan-townsend c, pao m, selden k, fletcher j, et al. a family group approach to increasing adherence to therapy in hiv-infected youths: results of a pilot project. aids patient care stds. 2003;17(6):299-308. 35. robbins rn, spector ay, mellins ca, remien rh. optimizing art adherence: update for hiv treatment and prevention. current hiv/aids reports. 2014;11(4):423-33. 36. rachlis b, naanyu v, wachira j, genberg b, koech b, kamene r, et al. identifying common barriers and facilitators to linkage and retention in chronic disease care in western kenya. bmc public health. 2016;16:741. 37. smith v, devane d, begley cm, clarke m. methodology in conducting a systematic review of systematic reviews of healthcare interventions. bmc medical research methodology. 2011;11(1):1-6. 38. defulio a, silverman k. the use of incentives to reinforce medication adherence. preventive medicine. 2012;55(suppl): s86-s94. 39. petry nm, rash cj, byrne s, ashraf s, white wb. financial reinforcers for improving medication adherence: findings from a meta-analysis. the american journal of medicine. 2012;125(9):888-96. 429 the health promotion model in hiv care l yeow chye ng and other 40. mayer je, fontelo p. meta-analysis on the effect of text message reminders for hiv-related compliance. aids care. 2016:1-9. 41. van andel e, been sk, rokx c, van der ende me. risk factors in an hiv-infected population for refraining from specialist care. aids care. 2016;28(10):1255-60. 42. madhvani n, longinetti e, santacatterina m, forsberg bc, el-khatib z. correlates of mobile phone use in hiv care: results from a cross-sectional study in south africa. preventive medicine reports. 2015;2:512-6. 43. leventhal h, cameron l. behavioral theories and the problem of compliance. patient education and counseling. 1987;10(2):117-38. 44. raboud j, li m, walmsley s, cooper c, blitz s, bayoumi am, et al. once daily dosing improves adherence to antiretroviral therapy. aids behav. 2011;15(7):1397-409. 45. nachega jb, parienti jj, uthman oa, gross r, dowdy dw, sax pe, et al. lower pill burden and once-daily antiretroviral treatment regimens for hiv infection: a meta-analysis of randomized controlled trials. clinical infectious diseases : an official publication of the infectious diseases society of america. 2014;58(9):1297-307. 46. the henry j. kaiser family foundation. u.s federal funding for hiv/aids: trends over time. the henry j. kaiser family foundation; 2016. 395 rocío lópez rangel1 olga janneth gómez ramírez2 experiencia del cuidador familiar de quien fallece por cáncer: un dolor del cual hay que aprender a sobreponerse 1 orcid.org/0000-0002-1283-7647. universidad nacional de colombia, instituto nacional de cancerología, colombia. rlopezr@cancer.gov.co 2 orcid.org/0000-0002-9160-4170. universidad nacional de colombia, instituto nacional de cancerología, colombia. ojgomezr@unal.edu.co recibido: 31/07/2018 enviado a pares: 06/08/2018 aceptado por pares: 06/09/2018 aprobado: 22/10/2018 doi: 10.5294/aqui.2018.18.4.2 para citar este artigo / para citar este artículo / to reference this article lópez-rangel r, gómez-ramírez oj. experiencia del cuidador familiar de quien fallece por cáncer durante el momento de la muerte. aquichan; 18(4): 395-406. doi: 10.5294/ aqui.2018.18.4.2 resumen objetivo: describir la experiencia que tiene durante el momento de la muerte el cuidador de un familiar que falleció por cáncer. metodología: estudio descriptivo, fundamentado en el enfoque fenomenológico de husserl con el método de colaizzi. los participantes del estudio fueron dieciséis adultos que desempeñaron el rol de cuidador familiar principal por más de seis meses, dentro de un periodo de 8 a 18 meses, antes de realizarse la entrevista a profundidad. los códigos descriptores y nominales se identificaron y transcribieron entre enero y marzo de 2018. se realizó una revisión cruzada. resultados: la experiencia que tuvo durante el momento de la muerte el cuidador de un familiar que falleció por cáncer se construyó a partir de siete temas: el final de una gran batalla; el cuerpo presente y el alma ausente; sentirse incompleto; preguntarse por qué; establecer lo urgente; despedirse, y buscar motivos para seguir viviendo. conclusiones: para el cuidador de un familiar que ha fallecido por cáncer, afrontar el momento de la muerte genera un dolor indescriptible. en esta experiencia convergen factores sociales, económicos, psicológicos y espirituales, por lo que es necesario superar obstáculos y situaciones inesperadas que, a pesar de su dificultad, obligan a aprender de ellas y a hallar un significado. palabras clave (fuente: decs) cuidador; muerte; luto; neoplasia; enfermería; cáncer. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 395-406 temática: cuidado crónico. aporte a la disciplina: el momento de morir es un periodo en el que intervienen varias disciplinas, pero la enfermería, que se interesa por el cuidado de la experiencia de la salud humana, debe liderar este avance para dar al cuidador familiar el apoyo y el protagonismo requeridos. la comprensión de esta vivencia, en el límite entre la vida y la muerte, el dolor y la búsqueda de significado, exige a la enfermería una mirada nueva y trascendente. https://orcid.org/0000-0002-1283-7647 https://orcid.org/0000-0002-9160-4170 mailto:ojgomezr@unal.edu.co http://dx.doi.org/10.5294/aqui.2018.18.4.2 http://dx.doi.org/10.5294/aqui.2018.18.4.2 http://dx.doi.org/10.5294/aqui.2018.18.4.2 396 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 395-406 experience of caregivers of relatives who died of cancer: pain they must learn to overcome abstract objective: to describe the experience that caregivers of relatives who died of cancer went through at the time of death. materials and methods: descriptive study, based on husserl’s phenomenological approach and colaizzi’s method. the study participants were 16 adults who performed the role of primary family caregiver for more than six months, within an 8-18-month period, before the in-depth interview. descriptive and nominal codes were identified and transcribed between january and march 2018. a cross-review was performed. results: the experience that the caregiver of a relative who died of cancer underwent at the time of death was built from seven themes: the end of a great battle; the present body and the absent soul; feeling incomplete; wondering why; establishing the urgent; saying goodbye; and looking for reasons to continue living. conclusions: for the caregiver of a relative who dies of cancer, facing the time of death causes indescribable pain. social, economic, psychological and spiritual factors converge in this experience; therefore, it is necessary to overcome obstacles and unexpected situations that, despite their difficulty, force us to learn from them and find meaning. keywords (source: decs). caregivers; death; bereavement; neoplasms; nursing; cancer. 397 experiencia del cuidador familiar de quien fallece por cáncer: un dolor del cual hay que aprender a sobreponerse l rocío lópez rangel y otro experiência do cuidador de um familiar que morre de câncer: uma dor que você tem que aprender a superar resumo objetivo: descrever a experiência que tem, na hora da morte, o cuidador de um familiar que morre de câncer. metodologia: tratase de um estudo descritivo fenomenológico, fundamentado na husserl metodologia de colaizzi. dezesseis adultos que desempenharam o papel de cuidador familiar principal por mais de seis meses, no período de 8-18 meses prévios à realização das entrevistas, participaram do estudo. transcreveu-se e identificou-se códigos descritivos e nominais, de janeiro a março de 2018. realizou-se uma revisão cruzada. resultados: construiu-se a experiência que o cuidador teve na hora da morte de um familiar com câncer a partir destes sete temas: o fim da uma grande batalha; o corpo presente e a alma ausente; sentir-se incompleto; indagar-se por quê; determinar o que é urgente; despedir-se; e procurar razões para continuar a viver. conclusões: para o cuidador de um familiar que faleceu de câncer, enfrentar a hora da morte provoca uma dor indescritível. nessa difícil prova convergem fatores sociais, econômicos, psicológicos e espirituais, de forma que é necessário superar os obstáculos e situações inesperadas que fazem com que aprendamos delas e descubramos um significado. palavras-chave (fonte: decs). cuidadores; morte; luto; neoplasia; enfermagem; câncer. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 395-406 398 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 introducción el cáncer es la segunda causa de muerte en el mundo, pues representa alrededor del 70 % de los fallecimientos (1). en colombia, la enfermedad es un problema de salud pública creciente, con grandes repercusiones sociales, económicas y emocionales (2). la carga del cáncer en el perfil de salud de los colombianos requiere intervenciones oportunas, certeras y coordinadas. el propósito de este estudio es lograr el impacto esperado a escalas individual y poblacional sobre la incidencia, discapacidad, calidad de vida y mortalidad (2). por otro lado, se sabe que los pacientes que padecen de cáncer habitualmente son atendidos por sus propios familiares, quienes suelen tener un bajo nivel educativo. estos cuidadores presentan el 1,8 % de analfabetismo en la región andina, que, paradójicamente, es la más desarrollada del país. este hecho implica un factor de riesgo considerable en el cuidado especializado que las personas con cáncer requieren (3). el rol del cuidador familiar en colombia, dadas las condiciones sociopolíticas que el país atraviesa, confronta barreras sociales, administrativas, educativas y económicas que se suman a la experiencia compleja de tener que cuidar a un familiar enfermo (4). entre las familias de personas que viven con cáncer, el cuidador familiar es quien asume la responsabilidad de cuidar al enfermo y a quien la muerte de ese ser querido afecta de manera personal (5). en este sentido, cuando se enfrenta a la pérdida, aquel, aunque esté rodeado de otros familiares o de amigos, suele vivir un dolor profundo en soledad. este estudio es útil para los cuidadores formales, que intervienen en el cuidado del cuidador familiar desde el momento de enterarse del fallecimiento (periodo considerado en la investigación) hasta la despedida del cuerpo sin vida del ser querido en el cementerio. según estudios cualitativos, las instituciones de salud consideran al cuidador informal como alguien que necesita atención y cuidado durante la muerte de su familiar. esta investigación es importante por cuanto redimensiona el cuidado de la enfermería en el acto de morir y permite comprender el significado de la pérdida de un ser querido y su cuerpo sin vida. aunque estos conceptos requieren un manejo técnico científico, para el cuidador tienen un valor incalculable en su propio proceso de vida. no se conocen estudios que hayan considerado la experiencia que tiene el cuidador de un familiar que falleció por cáncer durante el momento de su muerte, vista esta como un momento de trascendencia y oportunidad. así, el presente estudio se llevó a cabo con el propósito de describir la experiencia del cuidador familiar durante el momento de la muerte de una persona que falleció por cáncer. materiales y métodos el presente estudio utilizó un enfoque descriptivo-fenomenológico, basado en husserl y en la metodología de colaizzi, el cual permite describir un fenómeno subjetivo, suponiendo que las verdades esenciales acerca de la realidad están arraigadas en las experiencias de las personas (6). así, al aplicar en nuestro estudio el análisis cualitativo, se describió un retrato de quien experimentó una situación determinada, en este caso, del cuidador familiar durante el momento del fallecimiento de su ser querido a causa del cáncer. en cuanto al vínculo de parentesco con el familiar que cuidaban, ocho de los cuidadores familiares participantes en nuestra investigación eran hijos; una era la cuñada; una era la abuela; cuatro eran esposos; una era la sobrina, y dos, las madres. doce cuidadores practicaban la religión católica y cuatro eran cristianos evangélicos. en cuanto a los pacientes que fallecieron por cáncer, la edad osciló entre los 3 y los 97 años. los diagnósticos oncológicos presentaron tumor cerebral, cáncer gástrico, melanoma, leucemia mieloide, tumor maligno de tiroides, sarcoma de ewing, tumor retroperitoneal, tumor tercio medio del esófago y osteosarcoma. doce personas fallecieron en el hospital, y cuatro, en su domicilio. para cumplir con los propósitos de nuestra investigación cualitativa, se llevaron a cabo las entrevistas a profundidad de forma personal, en un tiempo y en un espacio dispuestos previamente. el enfoque del fenómeno se ejecutó de forma inductiva, sin vincular experiencias anteriores que pudieran alterar la fidelidad de los datos captados. asimismo, se realizó una constante revisión cruzada para contrastar la descripción de la experiencia de los participantes del estudio y el debido proceso de validación de los datos con el acompañamiento de un asesor experto en investigación fenomenológica. si bien es cierto que la descripción que se presenta retrata cómo el cuidador familiar experimentó la pérdida del ser querido 399 experiencia del cuidador familiar de quien fallece por cáncer: un dolor del cual hay que aprender a sobreponerse l rocío lópez rangel y otro a quien le brindaba cuidado, no se realizó ningún juicio sobre lo que la persona es ni sobre lo que expresó. en este sentido, siempre se respetó la originalidad de la persona objeto de análisis, tanto en el contexto metodológico, como en el ético. para construir la descripción exhaustiva de la experiencia, se transcribieron las entrevistas de manera textual y línea por línea; se identificaron en ellas códigos descriptores o vivos codificados (e: 11,18:19), tal como los mencionaron los cuidadores familiares, y se establecieron códigos nominales a partir de enunciados significativos. los códigos nominales se agruparon en sentidos comunes, lo cual permitió establecer temas que, en conjunto, permitieron describir la experiencia de forma exhaustiva (tabla 1). tabla 1. ejemplo de codificación del estudio: experiencia del cuidador familiar de quien fallece por cáncer en el estudio participaron dieciséis cuidadores familiares, residentes en la ciudad de bogotá, y con edades entre los 29 y los 70 años. todos los participantes cuidaron, por un periodo mínimo de seis meses, a la persona que falleció por cáncer, la cual pudo haber sido un niño o un adulto. con una muestra teórica, se consideró la saturación de los datos tan pronto las experiencias de los participantes ya no aportaran nuevos códigos ni categorías diferentes. la investigación se realizó de enero a marzo de 2018 y consideró los criterios de rigor pertinentes para realizar una investigación cualitativa: credibilidad de los resultados y de las conclusiones; transferibilidad para que los resultados sean aplicables a otras personas o contextos; dependencia; velar porque los resultados de la investigación sean estables y confirmados (6). por último, se adoptó lo descrito en la ley 911 de 2004, por la cual se dictan disposiciones en materia de responsabilidad deontológica para el ejercicio de la profesión de enfermería en colombia, se establece el régimen disciplinario correspondiente y se dictan otras disposiciones (7), y la resolución 8430 de 1993, por la cual se establecen las normas científicas, técnicas y administrativas para la investigación en salud (8). del mismo modo, se contó con los avales, tanto del comité de ética de la facultad de enfermería de la universidad nacional de colombia, como de la institución participante. los resultados se dieron a conocer a los participantes al finalizar el estudio. resultados a partir de la codificación y categorización de las entrevistas, surgió una descripción exhaustiva de la experiencia, durante el momento de la muerte, del cuidador familiar de quien fallece por cáncer. el proceso incluyó siete categorías conformadas por sus respectivos códigos: 1) el final de una gran batalla: el cuidador familiar se rinde frente a la certeza de la muerte, de la evidencia del cuerpo sin vida del ser querido, y siente un dolor indescriptible, acompañado de escepticismo y miedo. 2) el cuerpo presente y el alma ausente: se percibe un cuerpo extraño, se somatizan las emociones y se presentan alteraciones del sueño e inapetencia. 3) sentirse incompleto: se experimenta incertidumbre, desolación y un vacío insondable. 4) preguntarse por qué: hay una duda ante los designios de dios, una lucha interior y un estado de enajenación. 5) establecer lo urgente: hace referencia a esas tareas que no se pueden postergar: realizar los trámites para el alta hospitalaria, comunicar la noticia, organizar el funeral, escoger la ropa para su familiar fallecido y ser el anfitrión del evento, entre código descriptor código nominal categoría “en ese momento, la fuerza de mis piernas se fue, me tuvieron que entrar casi que alzado a ver el cuerpo sin vida de mi esposa”. dolor indescriptible el final de una gran batalla. “arranco para el hospital, para la clínica de cancerología, llego y ya, pues, se vive la realidad de la vida: la muerte no es nada más allá, sino esa”. rendirse “sabe, yo que pensaba que ella se había ido para el tolima, que ella de pronto se había ido, y que más tarde, de pronto, yo la iba a ver”. escepticismo “pues con el dolor del alma, la vergüenza, bueno… en ese momento no me dio nada; yo lo cogí de los hombros… no escucha que mi mamá se murió. lo empuje y salí corriendo”. sentir miedo “para uno de familiar, el cuerpo es algo especial, y uno pretende que ese cuerpo se trate con delicadeza, a sabiendas de que no siente, de que ya está muerto”. el cuerpo sin vida fuente: elaboración propia. 400 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 otras actividades que implican, a su vez, contar con un presupuesto para gastos. 6) despedirse: incluye la esperanza de que el ser que se va obtendrá un lugar en el cielo, a la vez que el enfrentamiento de una pérdida desgarradora, del ataúd y la tierra como barrera física. 7) buscar motivos para seguir viviendo: estado en el que se pretende enfrentar nuevas batallas (tabla 2). tabla 2. descripción de la experiencia del cuidador familiar durante el momento de la muerte de quien fallece por cáncer a continuación se describe la experiencia del cuidador familiar durante el momento de la muerte de quien fallece por cáncer. el final de una gran batalla le puedo contar que él falleció en mis brazos. (e: 2, 8:8) para los cuidadores de familiares que fallecen por cáncer, el momento de la muerte del enfermo es el principio del final de varias batallas: es detenerse y observar lo que dejó la guerra; es llorar, gritar, estar horrorizado y descompuesto: “cuando llegué al hospital, lo vi en la camilla y me pregunté: ‘por qué no se para, por qué no me abraza, por qué no me dice que me quiere”, (e: 5,165:169). para comprender la realidad de la muerte del ser querido, es necesario tocar el cuerpo sin vida, saber si esta frío o caliente, mirar el pecho para corroborar si respira o no, moverlo para que responda. el cuidador confirma la realidad de la muerte por medio del cuerpo sin vida, pero el cuerpo funciona como una terapia al estilo de un “bálsamo”: suaviza el dolor incomparable y mitiga el miedo. esta situación ayuda a experimentar en el presente lo que dejó el pasado, para así poder distinguir las consecuencias que el evento trae para el futuro. mientras el cuidador familiar cuida del cuerpo sin vida, encuentra una nueva conexión con la persona que murió: “se viene cualquier cantidad de recuerdos, fotos de cuando yo era un bebé y me tenía alzado; ella me contaba que hacía quince días que yo llegaba aquí a la tierra, y la felicidad de ella, y de ahí todo hasta el momento” (e: 13 ,67:68). durante el momento, interioriza lo está viendo y se da cuenta de lo que él hace en el cuerpo exánime; el cuidador puede ver que el enfermo dejó de sufrir, y ahora se observa rejuvenecido, como si se le hubiera quitado un peso de encima: “verla a ella fue como ver ese cuerpo ya descansado, como que si se hubiera quitado un peso de encima, paradójicamente rejuvenecido. descanso fue lo que vi” (e: 11,63:64). el momento de la muerte provoca miedo: miedo de enterarse del fallecimiento del ser querido que se ha estado cuidando; miedo de dejar el cuerpo en manos ajenas, del escalofrío por ver el cuerpo del familiar en un lugar como la morgue de un hospital o en su propia cama: “le dan a uno unas ganas inmensas de volver a consentirla, de volverla a tocar, y no te lo permiten… es lo pritema unidad de significado el final de una gran batalla rendirse dolor indescriptible escepticismo sentir miedo el cuerpo sin vida el cuerpo presente y el alma ausente en un cuerpo extraño somatización alteraciones del sueño inapetencia sentirse incompleto incertidumbre desolación un vacío insondable preguntarse por qué lo incomprensible de dios lucha interior enajenación establecer lo urgente improvisando tareas un buen anfitrión el retrato final dinero inmediato despedirse un sitio en el cielo una pérdida desgarradora barrera física motivos para vivir nuevas batallas fuente: elaboración propia. 401 experiencia del cuidador familiar de quien fallece por cáncer: un dolor del cual hay que aprender a sobreponerse l rocío lópez rangel y otro mero que te dicen: “no la puede tocar”, “el cuerpo no se puede tocar”. con esa cosa en el corazón, yo me amarraba las manos duro para no volvérmele a tirar encima, porque esa era la segunda vez que la veía después de la muerte” (e: 7, 138:140). el dolor ante la pérdida del ser querido es indescriptible, intenso; llega a hacer que las piernas se doblen por la disminución de la fuerza física, la cual también se agota, tanto en el corazón, como en alma del que lo experimenta. no existe en la industria farmacéutica algo que lo mitigue: “en ese momento, la fuerza de mis piernas se fueron… me tuvieron que entrar casi que alzado a ver el cuerpo sin vida de mi esposa” (e: 11,18:19). el cuerpo presente y el alma ausente luego de enterarse y rendirse, el cuidador familiar sale de la habitación, pero antes se pregunta: “¿a dónde van a llevar a mi familiar?”. “¿qué le van a hacer?”. siente habitar un cuerpo extraño; se siente lleno por el hálito gélido de la muerte, cree pertenecer a otro, se siente poseído por el espíritu de la racionalidad. el cuidador siente que no puede moverse; somatiza las emociones, siente inapetencia y le resulta difícil conciliar el tan apreciado sueño: “entonces ahí yo siento como que uno sigue, aunque no lo creo… en qué pasó, pero como que no sé, algo extraño, un cuerpo extraño… no sé, yo digo que a uno lo posee alguien, el espíritu de la razonabilidad” (e: 7,117:118). con frecuencia, el acto de olvidar el contexto es habitual para el cuidador familiar durante el momento de la muerte, pues solo puede pensar en lo que ocurrió. se siente confundido y extraño, como un laberinto sin luz; no puede siquiera hablar; desea aislarse y se mueve como si no tuviera voluntad propia, siguiendo las instrucciones de los trámites para el alta hospitalaria, cuando en realidad no sabe cómo enfrentar lo indispensable, lo urgente: “yo ahí me pasmé y no volví a llorar, parecía un ente: no lloraba, no comía, hablaba lo necesario” (e: 7,164:164). sentirse incompleto el cuidador se siente desolado, con un vacío insondable que no puede ocupar nada ni nadie; se parece al silencio que ahora inunda su hogar, en el cual ha aprendido a llorar con el alma y a solas; no es fácil hacerse a la idea de que esa persona se fue y que ha perdido parte de su ser: “mi espíritu, mi alma quedo allá con ella [yo le digo a mi hijo todas esa películas de fantasmas y de zombis que a él gustan]. así soy yo, ando para que tú termines de ser el hombre que tu mamá quería, pero yo ya no tengo vida, mi vida está allá” (e: 9, 112:113). preguntarse por qué “¿por qué?” no se puede comprender a dios ni sus decisiones; por eso, en medio de su alegato, el cuidador expone sus luchas, piensa si valió o no la pena adoptar los tratamientos: “¿por qué el cáncer?”. “¿por qué?” “¿siento culpa por la muerte de mi ser querido?”. “es algo injusto, ¿por qué?”. “¿tal vez la muerte pudo ser lo mejor?” todas estas preguntas van de la mano de la incertidumbre por no conocer el futuro: “en ese momento no sirve nada, no sirven ni las palabras, ni el dinero, ni la ciencia; no sirve nada, ni siquiera tus creencias” (e: 9, 132:133). establecer lo urgente la ahora evidente incapacidad del cuidador para encontrar soluciones inmediatas lo lleva a hacer uso del cuerpo extraño, lo cual es útil para enfrentar lo urgente: “¿y ahora qué hay que hacer, qué tengo que hacer?” (e: 7, 119:119). no olvida comportarse como un buen anfitrión, ese que tras bambalinas logra que todo salga bien, con el fin de hacer el mejor homenaje: “en el velorio yo conducía; en ese mismo día llevaba y traía a mis familiares; estaba tan atenta, que la gente me decía: ‘qué buena anfitriona en este tipo de eventos tan dolorosos’” (e: 2, 30:30). el retrato final es la imagen de cómo el cuidador quiere que sea recordado su ser querido, un rostro bello como el que tenía cuando vivía: la idea era que se llevaran la imagen de cómo era mi papá, y no de cómo había quedado. el de la funeraria nos dijo que lo iba arreglar muy bien. yo fui por la ropa y le compré un suéter cuello tortuga y un gorro para que le tapara la masa. quedó bonito. (e: 4, 31:32) no hay tiempo para sentir dolor. el cuidador se apresura en busca de ayuda, improvisa tareas y consigue dinero de forma rápida para costear las necesidades imprevistas: “cobraron cinco millones de pesos para enterrarlo ahí; mi suegra le había prestado al sobrino… nos enteramos de eso después de que el niño había sido enterrado” (e: 9, 132:133). 402 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 despedirse durante el momento de la muerte, el cuidador experimenta la despedida del ser querido de forma paulatina, sea en el momento de presenciar o de enterarse de la muerte, sea al identificar al familiar fallecido en la morgue. en el funeral, el cuidador atrapa un recuerdo del rostro del ser querido, en seguida de los actos religiosos. el destino final, con una barrera física, tiene lugar en el cementerio, y es un momento doloroso. para algunos, es preciso permanecer unos segundos más al lado del cuerpo sin vida, para ser capaz de decir “adiós”. “empieza a descender ese cajón, y yo cojo una rosa y la lanzo, solo una, y la lanzo con un beso” (e: 9, 100:100). una vez roto el vínculo físico, el cuidador toma la decisión de continuar. este tiempo es diferente en cada persona, pues se logra paulatinamente, al interiorizar el pacto hecho con el ser querido antes de morir. motivos para vivir la muerte es el final y el comienzo de una nueva etapa. el cuidador familiar es un guerrero invisible, y ahora siente satisfacción por el deber cumplido; ha podido comprender que hay eventos de los que no se obtiene respuesta. por su parte, tiene una nueva batalla: un compromiso con él mismo, hallar el sentido para seguir viviendo: él es responsable de lo que suceda con su vida de ahora en adelante: “la amo con ese amor de hermana, no de sangre, sino del que se construyó a lo largo de lo que vivimos las dos. yo sé que no me escucha, pero sé y siento que está aquí conmigo y que me está diciendo: ‘para adelante’” (e: 5; 235:235). discusión desde los inicios de la humanidad, la muerte y lo que sucede alrededor de esta ha sido un tema de interés, como lo demuestra el presente estudio. desde múltiples enfoques, tanto teóricos como filosóficos, se considera un bien; es un suceso tan real como la propia vida, un imperante de responsabilidad, algo propio o ajeno, aunque también es visto como un asunto vergonzante (9-13). el cáncer como diagnóstico de enfermedad terminal, tal como lo refleja el contexto del presente estudio, es una cuestión cotidiana (14). a pesar de esto, la enfermería, y en el campo de la oncología en especial, cuenta con un escaso registro documental sobre el cuidado que se debe brindar a los cuidadores de pacientes con cáncer (15). en este sentido, nuestra investigación es un aporte a la comunidad académica que indaga por la comprensión de la experiencia que tiene el cuidador familiar de quien fallece por cáncer durante el momento de la muerte. con respecto al perfil sociodemográfico de los participantes del estudio en desarrollo, este coincide con el descrito para américa latina. según los datos consultados, ocho de cada diez cuidadores son de género femenino, y este hecho se suma a la escasa capacidad del sistema de salud para cubrir la demanda y brindar apoyo en la experiencia de cuidado (3, 16, 17, 18,19). uno de los principales problemas con respecto a la experiencia de duelo que vive el familiar de un paciente con cáncer es el temor a la inminente pérdida del ser querido, circunstancia también evidente en nuestro estudio (20). esta pérdida, como ha sido descrita por los cuidadores entrevistados, genera un duelo intenso, pues aquellos perciben que su mundo interior se derrumba. es un proceso complejo que se va presentando en el cuidador familiar que pierde a un ser querido, por etapas secuenciales hasta llegar a la aceptación; un proceso en el que se viven la desesperanza y el desapego, y para el cual el profesional de la salud debe estar preparado (10, 21, 22, 23, 24). esta experiencia se caracteriza por revelar una insensibilidad emocional, pues es frecuente negar la difícil realidad (25). por lo anterior, este proceso se ha considerado un espacio de evasión y conmoción, de embotamiento de la sensibilidad, al cual debe seguir la reconstrucción de significados, hasta llegar a un estado mayor de desarrollo personal (23, 25, 26). los resultados de esta investigación invitan a consolidar las acciones de cuidado que antes se concentraban en la persona moribunda, pues ahora deberán dirigirse, con la misma intensidad, hacia el cuidador familiar. el propósito es comprender ese dolor ajeno para poderlo consolar, y esto se revela como un aporte al nuevo conocimiento disciplinar (27). sin embargo, en la actualidad, el escenario en el que el cuidador familiar pierde a su ser querido le ofrece poco apoyo: la carga laboral de los profesionales de enfermería no les permite considerar los casos específicos ni aportar con su experiencia estrategias de afrontamiento inmediato a la muerte (20). esta carga se asocia con una falta de atención centrada en las personas y en los procesos de humanización institucionales, que deberían otorgar un tiempo y un espacio reales para el cuidado de enfermería, 403 experiencia del cuidador familiar de quien fallece por cáncer: un dolor del cual hay que aprender a sobreponerse l rocío lópez rangel y otro y que esta tarea no se convierta en una que se asuma al proceso de atención (27). a pesar de reconocer las dificultades, la complejidad de la experiencia y el impacto de la aparición del cáncer en el seno de la familia, la literatura consultada no refleja mayor conocimiento sobre la reacción del cuidador familiar durante el momento de la muerte y se desconocen las acciones de cuidado específicas para estas circunstancias (28, 29). estudios que abordan el duelo de los cuidadores en la fase final de vida señalan que la última semana representa un momento importante para las personas que mueren de cáncer y sus familias, lo cual influye de forma directa en la dificultad de los procesos de duelo anticipatorio (30). si bien se espera apoyar una muerte digna con una atención integral que fortalezca la autonomía, esta experiencia implica la ruptura de un vínculo; exige encontrarle un sentido al suceso y trascender para que, en medio de su situación, el cuidador familiar pueda revelar dignidad y autonomía (2, 31). atender estos problemas bajo un paradigma más integral, que busque apoyar a los cuidadores y aliviar su elevada carga en los procesos, es indispensable y urgente (31). los cuidadores de personas que fallecen por cáncer están en riesgo de desarrollar complicaciones de salud, de manejo del duelo y de reestructuración familiar luego de la pérdida del ser querido. por esta razón, la investigación sobre las experiencias de cuidado y duelo como un proceso continuo deben complementarse, de manera que sea posible respaldar el cuidado de estas personas (32, 33). los profesionales de la salud pueden llevar a cabo intervenciones antes y durante el proceso de la muerte. cuando el paciente está vivo, el profesional puede influir en la experiencia de morir, facilitar la preparación para el momento y, en consecuencia, mejorar la percepción del cuidador familiar posterior a la pérdida (34). las intervenciones preventivas, como la conformación de grupos de preparación o de apoyo frente al duelo, podrían ser beneficiosos para reducir el riesgo de dolor emocional posterior a la muerte del ser querido (35, 36). sin embargo, como se ha mostrado en este estudio, el momento de la muerte requiere un cuidado específico, y esto hace que sea preciso conocer la experiencia del cuidador familiar, pues tiene un valor incalculable para poder generar alivio en medio de esta carga tan complicada. conclusiones la experiencia del cuidador familiar de quien fallece por cáncer durante el momento de la muerte genera un dolor indescriptible. en esta situación convergen factores sociales, económicos, psicológicos y espirituales, por lo que es necesario superar obstáculos y situaciones inesperadas. a pesar de ser un momento de la vida muy difícil, surge la oportunidad de aprender cómo y por qué sobreponerse, modo en que es posible hallar un significado de todo el proceso. conocer la experiencia del cuidador permite sustentar mejor la práctica de enfermería con una mirada nueva y trascendente de la labor asistencial, docente y de gestión. con respecto a la política en salud, el país ha avanzado con la creación de leyes frente al cuidado paliativo, pero el camino por recorrer es aún largo. sería deseable el desarrollo de políticas que establezcan mecanismos concretos de apoyo al cuidador familiar. el momento de morir es un periodo en el que intervienen varias disciplinas; sin embargo, la enfermería, que se interesa por el cuidado de la experiencia de la salud humana, debe liderar este avance para dar al cuidador familiar el apoyo y protagonismo requeridos para enfrentar el final de la gran batalla, vivir con el cuerpo presente y el alma ausente, protegerlo mientras se siente incompleto, acompañarlo cuando se pregunta por qué, ayudarle a establecer lo urgente, permitirle despedirse y, en especial, ayudarlo a que busque motivos para seguir viviendo. por último, se recomienda continuar la línea de investigación en el cuidado del cuidador familiar. es primordial realizar otras investigaciones que midan el impacto en la reorganización social, laboral, económica y familiar del cuidador, así como investigar a fondo el significado que para el cuidador tienen el cuerpo sin vida y las repercusiones en la experiencia. conflicto de intereses: ninguno declarado. 404 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 referencias 1. plummer m, de martel c, vignat j, ferlay j, bray f, franceschi s. global burden of cancers attributable to infections in 2012: a synthetic analysis. lancet glob health [internet]. 2016 [citado 2018 jul. 24];4(9):e609-e616. doi: 10.1016/ s2214-109x(16)30143-7 2. cuenta de alto costo. fondo colombiano de enfermedades de alto costo. situación del cáncer en la población adulta atendida en el sgsss de colombia 2016 [internet]. bogotá: cuenta de alto costo, fondo colombiano de enfermedades de alto costo; 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[citado 2018 jul. 24];3(2):1-32. disponible en: http://revistas.um.es/eglobal/article/view/546/566 25. guic e, salas a. el trabajo de duelo. ars médica [internet]. 2005 [citado 2018 jul. 24];34(2):1-9 disponible en: http:// www.arsmedica.cl/index.php/med/article/view/215/148 26. astudillo w, mendinueta c, casado a. cómo afrontar mejor las pérdidas en cuidados paliativos. rev soc esp dolor [internet]. 2007 [citado 2018 jul. 24];14(7):511-526. disponible en: http://scielo.isciii.es/pdf/dolor/v14n7/revision2.pdf 27. ministerio de salud y protección social [internet]. bogotá: ministerio de salud y protección social; 2017 [actualizada: 13 oct 2018; acceso: 24 jul 2018]. presentaciones modelo integral de atención en salud (mias) [aprox. 1 pantalla]. disponible en: https://www.minsalud.gov.co/paginas/presentaciones-modelo-integral-atencion-salud-mias.aspx 28. pérez c, rodríguez f. repercusión familiar de un diagnóstico oncológico. psicol am lat [internet]. 2005 [citado 2018 jul. 24];(3):1 29. rocha rs, pinheiro lp, oriá mo, ximenes lb, pinheiro ak, aquino ps. social determinants of health and quality of life of caregivers of children with cancer. rev gaúcha enferm [internet]. 2016 [citado 2018 jul. 24];37(3):e57954. doi: 10.1590/1983-1447.2016.03.57954 30. dobrina r, vianello c, tenze m, palese a. mutual needs and wishes of cancer patients and their family caregivers during the last week of life: a descriptive phenomenological study. j holist nurs [internet]. 2016 [citado 2018 jul. 24];34(1):2434. doi: 10.1177/0898010115581936 31. ibáñez-masero o, ortega-galán ám, carmona-rega mi, ruiz-fernández md, cabrera-troya j, garcía-cisneros r et al. el significado de morir dignamente desde la perspectiva de las personas cuidadoras: estudio fenomenológico. enferm clín [internet]. 2016 [citado 2018 jul. 24];26(6):358-366. doi: 10.1016/j.enfcli.2016.07.003 32. dumont i, dumont s, mongeau s. end-of-life care and the grieving process: family caregivers who have experienced the loss of a 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t. limonero g. el fenómeno de la muerte en la investigación de las emociones. rev psicol gen y apl rev la fed española asoc psicol [internet]. 1996 [citado 2018 jul. 24];49(2):249-265. disponible en: https://dialnet.unirioja. es/servlet/articulocodigo=2358236 https://dx.doi.org/10.1177/0269216315603261 http://dx.doi.org/10.1186/s12904-016-0129-0 http://dx.doi.org/10.1186/s12904-016-0129-0 https://dialnet.unirioja.es/servlet/articulocodigo=2358236 https://dialnet.unirioja.es/servlet/articulocodigo=2358236 263 rita fernandes1 beatriz araújo2 fátima pereira3 dinâmicas, transições identitárias e desenvolvimento profissional de enfermeiros na mercantilização da saúde 1 orcid.org/0000-0002-9870-2128. universidade católica portuguesa, centro de investigação interdisciplinar em saúde e centro hospitalar são joão, portugal. 393209008@ucpcrp.pt 2 orcid.org/0000-0003-0266-2449. universidade católica portuguesa, centro de investigação interdisciplinar em saúde, portugal. baraujo@porto.ucp.pt 3 orcid.org/0000-0003-1107-7583. universidade do porto, faculdade de psicologia e ciências da educação, portugal. fpereira@fpce.up.pt recebido: 26/02/2018 submetido: 22/05/2018 aceito por pares: 12/06/2018 aceito: 14/06/2018 doi: 10.5294/aqui.2018.18.3.2 para citar este artículo / to reference this article / para citar este artigo fernandez r, araújo b, pereira f. dinâmicas, transições identitárias e desenvolvimento profissional de enfermeiros na mercantilização da saúde. aquichan. 2018; 18(3): 263-274. doi: 10.5294/aqui.2018.18.3.2 resumo objetivo: conhecer as identidades profissionais de enfermeiros portugueses e os sentidos das transições em curso, para fornecer os suportes necessários aos desafios identitários profissionais. materiais e método: investigação de abordagem mista realizada entre 2016 e 2017. utilizou-se como instrumento de recolha de dados um inventário de identidade psicossocial de zavalloni e louis-guérin, junto duma amostra de 102 enfermeiros, dos quais 19 foram posteriormente entrevistados. resultados: analisaram-se alguns dados que correspondiam aos possíveis selves e à identificação do núcleo central e dos elementos periféricos da identidade profissional, tais como as condicionantes profissionais. verificou-se a existência de um grupo dominante de enfermeiros numa dualidade identitária entre o enfoque nos cuidados e na autonomia profissional e o enfoque nas exigências institucionais, com o receio de despersonalização dos cuidados. também se identificou um outro grupo profissional, mais relacionado com o cuidar, que não apresenta año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 263-274 temática: epistemologia contribuições para a disciplina: o artigo permite entender as condicionantes e os problemas que a mercantilização na saúde impõe aos profissionais enfermeiros. esta pesquisa poderá ter implicações para a gestão, para a docência, para a prática, para o movimento sindical e regulamentar da profissão. urge repensar as medidas que possam conduzir às transições identitárias em prol da profissão, dos cuidados e do desenvolvimento profissional, correspondendo ao cuidar e não ao conceito de mercado. http://orcid.org/0000-0002-9870-2128. http://orcid.org/0000-0003-0266-2449. http://orcid.org/0000-0003-1107-7583. 264 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 263-274 marcas dessa institucionalização, mas que deseja um maior desenvolvimento das relações humanas e do conhecimento científico. conclusões: as possíveis transições identitárias identificadas podem ocorrer conforme os reforços e os reconhecimentos oferecidos, ora com correspondência a fatores de mercado e consequente despersonalização do cuidar, ora com a conquista da autonomia e resgate do cuidar, assentem na cientificidade profissional. palavras-chave identidade; identificação social; mercantilização; enfermagem; relações enfermeiro-paciente (fonte: decs). dinámicas, transiciones de identidad y desarrollo profesional de enfermeras en la mercantilización de la salud resumen objetivo: conocer las identidades profesionales de enfermeros portugueses y los sentidos de las transiciones en curso, para proporcionar el apoyo necesario a los desafíos de identidad profesional. materiales y método: investigación de enfoque mixto realizada entre 2016 y 2017. se utilizó el inventario de identidad psicosocial de zavalloni y louis-guérin como herramienta de recolección de datos, junto a una muestra de 102 enfermeros, de los cuales 19 fueron entrevistados posteriormente. se analizaron datos que correspondían a los posibles selves, a la identificación del núcleo central, a los elementos periféricos de identidad profesional y las condiciones profesionales. resultados: se verificó la existencia de un grupo dominante de enfermeros en una dualidad de identidad entre el enfoque en los cuidados y la autonomía profesional y el enfoque en las exigencias institucionales, con temor a la externalización del cuidado. se identificó otro grupo profesional, más relacionado con el cuidado, que no presenta evidencias de institucionalización, sino que persigue un mayor desarrollo de las relaciones humanas y del conocimiento científico. conclusiones: las posibles transiciones de identidad reconocidas pueden ocurrir según refuerzos y reconocimientos ofrecidos, que correspondan a factores de mercado y consecuente despersonalización del cuidado, o con la conquista de la autonomía y el rescate del cuidado, basado en la cientificidad profesional. palabras clave identidad; identificación social; mercantilización; enfermería; relaciones enfermero-paciente (fuente: decs). 265 dinâmicas, transições identitárias e desenvolvimento profissional de enfermeiros na mercantilização da saúde l rita fernandes e outros nurses’ dynamics, identity transitions and professional development in the commodification of health abstract objective: to know the professional identities of registered nurses in portugal and the meaning of ongoing transitions in order to provide the necessary support for professional identity challenges. materials and method: mixed approach research conducted between 2016 and 2017. a psychosocial identity inventory was utilized as an instrument of data collection, along with a sample of 102 nurses, 19 of which were subsequently interviewed. we analyzed some data that corresponded to the possible selves and the identification on the core and peripheral elements of the professional identity, and also of the professional factors. results: a dominant group of nurses was discovered divided between the focus on care with professional autonomy, and the focus on institutional needs, fearing the depersonalization in care. we also identified another professional group, more related to caring, which shows no signs of this institutionalization, but wishes to achieve a greater development regarding human relations and scientific knowledge. conclusions: the possible identity transitions identified, can occur according to the acknowledgment of their work and reinforcements offered, sometimes corresponding with business model of healthcare management and subsequent depersonalization of care, or with a sense of autonomy achievement and the rescue of care, based on scientific profession. keywords identity; social identification; nursing; commodification; nurse-patient relations (source: decs). año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 263-274 266 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 introdução as evoluções complexas e constantes no sector da saúde e na abordagem à pessoa exigem dos enfermeiros novas formas identitárias profissionais, em busca da inovação e da criatividade, tal como o desejo de desenvolvimento, que se encontram em estreita relação com a implicação, a pertença à profissão e o sentido dos cuidados. a mercantilização na saúde impõe desafios identitários profissionais que podem colocar em causa a pertença e o envolvimento profissional. em face deste momento conturbado da enfermagem, pretende-se conhecer as identidades profissionais de enfermeiros e os sentidos das transições em curso. referenciais histórico-sociais e conceptuais na identidade dos enfermeiros portugueses o conhecimento histórico da profissão permite desenvolver o pensamento crítico sobre o passado; em consequência, permite reforçar a identidade profissional dos enfermeiros e contribuir para dar resposta aos desafios atuais e futuros na complexidade de cuidados (1). neste sentido, abordam-se nos parágrafos seguintes as principais influências históricas e sociais passadas e presentes para os enfermeiros portugueses. na época que decorre desde a idade média até ao século xx, não existia o reconhecimento da necessidade de outros conhecimentos para além dos considerados práticos e morais, veiculandose valores como submissão e obediência quer à instituição, quer ao médico (2), com consequências identitárias naqueles profissionais, nos seus contextos de trabalho e que, por estas caraterísticas, se pode denominar por era vocacional dos enfermeiros. o período designado de era profissional dos enfermeiros tem início no século xx. o ensino de enfermagem passava a ser ministrado nas escolas de enfermagem, mas com predomínio do ensino biomédico ou tecnicista (3). todavia, com sinais subtis na tentativa de autonomização dos enfermeiros, com algumas atividades profissionais autónomas nos contextos de ensino e de trabalho ligadas à revalorização da relação e com evoluções na formação ao nível das especialidades, que ainda se mantêm atualmente. na era da autonomização dos enfermeiros, estes desencadearam um reconhecimento da autonomização profissional com a entrada do ensino de enfermagem para o ensino superior, ao nível do ensino superior politécnico, em 1988. a esta autonomização, seguiu-se a publicação do regulamento do exercício profissional dos enfermeiros em 1996, com a regulamentação de cuidados autónomos e interdependentes, e a identificação da profissão de enfermagem com um campo disciplinar próprio e distinto, através do desenvolvimento da investigação no âmbito dos mestrados em enfermagem, em 1991, e do doutoramento em enfermagem, em 2002; e ainda, através da conquista de espaços de intervenção autónomos. apesar de constarem, também, os cuidados interdependentes na execução de atos prescritos por outros profissionais, as ações interdependentes exigem uma atitude crítica e ativa por parte dos enfermeiros. de facto, esta seria a época “dourada” para a enfermagem, dando-se o reconhecimento social da disciplina, crucial para a população. no entanto, se, a nível profissional, a evolução da profissão ocorreu de forma favorável, as condições económicas e políticas foram desfavoráveis a esse reconhecimento profissional. se, inicialmente, as transformações sociais decorrentes da entrada de portugal na união europeia originam reformas no ensino com o processo de bolonha, nas organizações e instituições de saúde, em 2008, em face da crise económica e financeira, os países e, mais especificamente portugal, entram num período de austeridade, cujo declínio económico se reflete nas condições de trabalho dos enfermeiros. segundo a comissão europeia (4), o número de enfermeiros em portugal, no ano de 2017, é inferior à média da união europeia, com 6,3/1000 habitantes, comparativamente com 8,4/1000, sendo também este um dos possíveis fatores responsáveis pela sobrecarga laboral e descontentamento profissional. apesar do reconhecimento da cientificidade dos saberes em enfermagem a nível académico, a nível político-económico-social, com as medidas de contenção, verificou-se o congelamento das progressões a partir de 2005; além disso, as estruturas sindicais desencadearam uma reformulação da carreira em 2009, que não foi devidamente concretizada, originando a estagnação da carreira profissional existente e, deste modo, não se reconhecendo os investimentos na formação e a experiência clínica destes profissionais. por conseguinte, os enfermeiros encontram-se em crise identitária profissional, crise decorrente dos constrangimentos económicos e sociopolíticos do país que se estendem por vários anos. no entanto, portugal e os enfermeiros portugueses não são os únicos afetados pelo designado neoliberalismo (5); a nível 267 dinâmicas, transições identitárias e desenvolvimento profissional de enfermeiros na mercantilização da saúde l rita fernandes e outros internacional, verifica-se que os fatores sociais, culturais e organizacionais interferem com os valores e comportamentos dos profissionais de saúde, com a saúde e os cuidados. a identidade de enfermagem carateriza-se pela articulação entre as competências técnico-científicas e os atributos do cuidar; uma sociedade com ideais de mercado reforça as primeiras competências, mas fragiliza os valores inerentes ao cuidar, na respetiva competitividade económica (5). a identidade profissional dos enfermeiros constrói-se na formação académica, mas não termina neste contexto; ela transforma-se no tempo noutro espaço — no contexto de trabalho e nas interações profissionais intra e intergrupais (6, 7). são estes os espaços e os momentos essenciais para clarificar e fortalecer os valores concernentes à atividade de enfermagem e consequentemente o reforço da identidade profissional dos enfermeiros (5). as alterações que a sociedade e a profissão de enfermagem sofreram desencadearam perfis identitários que necessitam de ser explorados, para reconhecer quais os sentidos que os enfermeiros desejam seguir nas suas transições identitárias, num tempo e espaços conturbados para a enfermagem. assim, serão explicitadas as concetualizações teóricas do estudo das identidades utilizadas para sua análise e transições identitárias. referenciais teóricos no estudo das identidades os referenciais teóricos do estudo das identidades desta pesquisa basearam-se na teoria das representações sociais de moscovici, na teoria da dinâmica da identidade de dubar, na teoria do núcleo central e elementos periféricos de abric e na teoria dos selves possíveis de markus e nurius. a identidade assume caráter dinâmico e múltiplo, reconhecendo não uma única identidade profissional, mas uma pluralidade de identidades profissionais, pois os sujeitos suscitam crises identitárias ante mutações sociais e relacionais (8). a teoria das representações sociais possibilita aceder à identidade do sujeito e esta aos seus pensamentos, ideologias e comportamentos. o estudo das representações sociais permite conhecer não o comportamento ou o processamento de informações, mas o pensamento do sujeito, isto é, quando ele se questiona e procura respostas (9). através da linguagem, ou seja, da relação, referenciação e significação dos signos/palavras, consegue-se aceder ao agir, aos comportamentos desse sujeito (10). o indivíduo não é um ser passivo, mas sim ativo e criativo, que, apesar de estar ligado a uma história social, também apresenta uma história individual, estando estas histórias e representações intrinsecamente relacionadas, permitindo as representações sociais entender comportamentos e interações sociais (11). os selves podem ser explorados através de representações sociais, reconhecendo uma elaboração individual e simultaneamente coletiva (social), com influências do contexto sociocultural e histórico, abrangendo uma forma construtiva e inovadora da pessoa, mas também a forma como o self é delimitado socialmente (12). os selves incluem o self real, o self ideal e o self rejeitado; o self real refere-se a como a pessoa reconhece o seu potencial (o que sou); o self ideal demonstra o que a pessoa deseja, as suas aspirações (aquilo que posso ser ou gostaria de ser) e o self rejeitado exprime o que se rejeita para si (o que tenho medo de ser). os autores explicitam que a dinâmica entre estes possíveis selves permite entender as ligações entre o potencial, as motivações e o desenvolvimento possível. o self desejado relembra ao indivíduo os seus desejos ou objetivos, com vista ao seu alcance, sendo conotado como o desenvolvimento possível porque é reconhecido e desejado, numa mudança temporária ou duradoura (12). o conhecimento dos possíveis selves é importante para entender os incentivos aos possíveis comportamentos, isto é, o que eu quero aproximar e o que quero afastar de mim, reconhecendo o sentido do passado e as referências para atitudes atuais e futuras. os desenvolvimentos ou mudanças futuras não são pensadas isoladamente, mas reelaboradas, em função dos contextos que nos rodeiam (12). a dinâmica da identidade profissional pode ser estudada através dos possíveis selves profissionais. a identidade é formada por um núcleo central, com maior dificuldade na mudança, ligado à história coletiva e a contextos organizacionais, e núcleos periféricos, que são mais maleáveis e situacionais, mas são estes últimos, os núcleos periféricos, que permitem as transições identitárias se inseridas num contexto transformador (12). 268 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 a pesquisa, sendo baseada nestes pressupostos teóricos, utilizou uma metodologia que incluísse estas teorias no estudo do seu objeto de estudo. considerando que, no núcleo central das identidades, se encontram as orientações dos comportamentos e, nos elementos periféricos, as possíveis transformações que podem ocorrer (13). assim, realiza-se a assimilação das dinâmicas identitárias, explorando as ligações entre o self reivindicado do indivíduo (self real), o que aspira ou deseja atingir (self ideal) e o que rejeita ou se opõe (self rejeitado), isto a nível identitário profissional (12). as identidades estruturam-se entre o meio interior — indivíduo — e o meio exterior — sociedade — que se processam na memória social e onde se consegue aceder através da palavra (14). com base nessas premissas, zavalloni e louis-guérin construíram o inventário da identidade psicossocial, que se utilizou nesta pesquisa, visto que, através do discurso dos entrevistados, se consegue aceder ao coletivo através do individual, à conceção de self e de mundo. materiais e método estudo descritivo transversal de abordagem mista, com recolha de dados efetuada em duas fases, entre 2016 e 2017. na primeira fase, recorreu-se a uma amostra não probabilística por redes ou snowballing, por se utilizar um inventário que exigia abstração e reflexividade acerca do objeto na colocação de palavras (significado) que definissem o seu pensamento. estabeleceu-se como critério de inclusão: enfermeiros com 10 ou mais anos de exercício de enfermagem em portugal. nesta fase, os dados foram recolhidos, junto duma amostra constituída por 102 enfermeiros, através do inventário da identidade psicossocial de zavalloni e louis-guérin, adaptado (15) na sua parte inicial, tendo sido utilizadas as primeiras impressões ou as evocações dos indivíduos e assumiu-se a ordem de aparição de palavras. assim, foram colocadas das primeiras para seguintes evocações de palavras (como um processo de evocação de palavras). solicitou-se aos participantes que referissem três ou mais vocábulos que completassem as seguintes frases: “nós enfermeiros somos….”; “o enfermeiro ideal é….” e “o enfermeiro péssimo é….”; também se considerou a ordem pela qual os sujeitos escreviam nos inventários. após o preenchimento do inventário, os participantes foram questionados acerca da sua disponibilidade para a continuação do estudo com entrevista caso se justificasse, solicitando-se que se identificassem, se assim o desejassem. posteriormente, na segunda fase, realizaram-se entrevistas semidiretivas até ocorrer a saturação de dados conseguida com a participação de 19 dos 102 enfermeiros que participaram na primeira fase deste estudo, na procura da resposta à seguinte questão: “quais as condicionantes que não permitem atingir o enfermeiro ideal?”. a estratégia quantitativa permitiu aceder rapidamente aos elementos centrais e periféricos das identidades, assim como encontrar identidades marginais. a opção por complementar com a qualitativa deveu-se à necessidade de continuar o método de zavalloni para compreender as condicionantes que os sujeitos referenciam para a dificuldade de atingir o enfermeiro ideal, que veio fornecer contributos para reforçar os dados obtidos na primeira fase — a de mercantilização da saúde. assim, para o tratamento de dados, foram utilizados dois softwares; na primeira fase, recorreu-se ao openevoc 0,83, desenvolvido por hugo cristo, e, na segunda fase, ao nvivo 10. com o software openevoc, trataram-se os primeiros dados do inventário, com a identificação dos elementos centrais e periféricos mais evocados no self real ou reivindicado, no self ideal e no self rejeitado para identificar as diversas dinâmicas identitárias presentes, utilizando-se medidas de estatística descritiva. posteriormente, procedemos à análise de conteúdo como técnica de tratamento de dados e análise de informação. com recurso ao software nvivo, criaram-se categorias (16) que permitiram entender algumas das interligações efetuadas na primeira fase. este estudo seguiu as considerações éticas e legais da declaração de helsínquia, revista em 2013, e foi aprovado favoravelmente pela comissão de ética do instituto de ciências da saúde da universidade católica portuguesa. na recolha de dados pelo inventário, os sujeitos foram devidamente informados do objetivo deste estudo, dos objetivos do instrumento de recolha de dados, bem como do caráter anónimo e da confidencialidade das informações obtidas. para a realização das entrevistas, foram pedidas, aos participantes, a autorização de gravação, bem como a assinatura do consentimento informado. após a transcrição das entrevistas, foi devolvido o discurso em suporte escrito aos sujeitos, sendo-lhes dada a liberdade de modificá-lo. foi, ainda, explicada a possibilidade de recusa da participação em qualquer momento da pesquisa. 269 dinâmicas, transições identitárias e desenvolvimento profissional de enfermeiros na mercantilização da saúde l rita fernandes e outros resultados dos 102 enfermeiros que participaram no estudo, 80 são do sexo feminino e 22 do sexo masculino, apresentando uma média de idades de 39,63 anos, um desvio-padrão de 5,98, com idade mínima de 31 anos e idade máxima de 60. os participantes exercem funções como enfermeiros no norte, centro e sul de portugal continental, têm uma média de 17,42 anos de serviço, um desvio-padrão de 5,46. a maioria dos enfermeiros possui o grau de licenciatura, havendo ainda quem possua o de bacharel (três), o de mestrado (dezasseis) e um enfermeiro, o doutoramento. destes enfermeiros, 40 referem apresentar desde pós-graduações (dezasseis) a pós-licenciaturas de especialização em enfermagem (vinte e quatro). no programa openevoc 0,83, introduziram-se todas as palavras registadas pelos participantes, respeitando a ordem colocada, e solicitou-se ao software para gerar as tabelas de frequências e ordem, também denominada de rangmot, com indicação de frequência de 1,4, ordem 2,1 e com palavras com frequência mínima de 0,84, para os três selves em estudo. no núcleo central, encontram-se as palavras mais citadas e mais importantes; nos elementos de primeira periferia, estão as palavras mais citadas de menor importância; e os elementos de segunda periferia foram os pouco citados, mas foi-lhes atribuída muita importância, isto é, um pequeno número de pessoas referiu o que julga ser importante; nos elementos de terceira periferia, situam-se os considerados menos frequentes e com menor grau de importância (17). como podemos observar pela tabela 1, em relação ao “self do enfermeiro real ou reivindicado”, foram evocadas 360 palavras; no quadrante respeitante ao núcleo central, destacam-se os vocábulos: competentes, responsáveis, polivalentes; nos elementos de primeira periferia, salientam-se: profissionais, humanos, trabalhadores e cuidadores. verifica-se a existência de um subgrupo de enfermeiros que se carateriza pelos vocábulos compreensivos e amigos. o facto de se considerarem mal remunerados é uma caraterização, mas, apesar de ser referida, é relegada para segundo plano. tabela 1. frequência e ordem de evocação das palavras reproduzidas pelo enfermeiro real ou reivindicado fonte: elaboração própria. frequência ≥1,4 ordem de evocação <2,1 ordem de evocação ≥2,1 palavras frequência oe palavras frequência oe núcleo central primeira periferia competentes 7,22 % 1,88 profissionais 4,17 % 2,33 responsáveis 6,11 % 2 humanos 3,33 % 2,17 polivalentes 3,06 % 2,09 trabalhadores 2,78 % 2,5 importantes 2,22 % 1,38 cuidadores 2,5 % 2,11 qualificados 1,94 % 1,57 disponíveis 1,94 % 2,43 organizados 1,94 % 1,71 empáticos 1,94 % 2,57 dedicados 1,67 % 2,67 frequência <1,4 segunda periferia terceira periferia compreensivos 1,11 % 1,75 mal remunerados 1,39 % 3,4 amigos 1,11 % 2 presentes 1,11 % 2,25 atentos 1,11 % 2,5 imprescindíveis 1,11 % 2,75 interessados 1,11 % 3 pacientes 1,11 % 3,75 270 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 na tabela 2, apresentam-se as evocações registadas para a caracterização do “self do enfermeiro ideal”, com o total de 358 palavras. no núcleo central, o enfermeiro ideal possui, como destaque, as caraterísticas de humano, amigo e simpático; nos elementos de primeira periferia, destacam-se o competente, empático, responsável e disponível. o subgrupo de enfermeiros destaca o atencioso, o cuidador e os conhecimentos científicos. na tabela 3, foram evidenciadas as 339 evocações do “self do enfermeiro rejeitado”; no núcleo central, salienta-se a distanciação ao desumano e arrogante; nos elementos de primeira periferia, a oposição a incompetente, irresponsável, conflituoso e desinteressado. o subgrupo de enfermeiros rejeita para si, como profissional enfermeiro, o ser mal-humorado e despreocupado. posteriormente, foram questionados 19 dos 102 enfermeiros acerca das condicionantes que não permitiam atingir o enfermeiro ideal e emergiram como categorias os défices de recursos, quer humanos, quer materiais e condições físicas dos espaços de trabalho; em segundo plano, a falta de motivação (gráfico 1). frequência ≥1,4 ordem de evocação <2,1 ordem de evocação ≥2,1 palavras frequência oe palavras frequência oe núcleo central primeira periferia humano 5,59 % 1,6 competente 9,5 % 2,15 amigo 1,68 % 1,67 empático 6,15 % 2,32 simpático 1,68 % 2 responsável 5,59 % 2,25 organizado 1,4 % 1,6 profissional 2,51 % 2,11 disponível 5,51 % 2,56 atualizado 1,96 % 2,43 ético 1,96 % 2,43 bom ouvinte 1,96 % 2,57 dinâmico 1,68 % 2,67 trabalha em equipa 1,68 % 3,17 interessado 1,4 % 2,2 paciente 1,4 % 2,4 frequência <1,4 segunda periferia terceira periferia atencioso 1,12 % 1,5 qualificado 0,84 % 2,67 conhecimentos científicos 1,12 % 1,75 dedicado 0,84 % 3 cuidador 1,12 % 1,75 presente 0,84 % 3 assertivo 0,84 % 1,33 bom relacionamento 0,84 % 3,33 capacidade técnica 0,84 % 1,67 tolerante 0,84 % 3,33 atento 0,84 % 1,67 inovador 0,84 % 3,33 comunicador 0,84 % 3,67 tabela 2. frequência e ordem de evocação das palavras e reproduzidas em enfermeiro ideal fonte: elaboração própria. 271 dinâmicas, transições identitárias e desenvolvimento profissional de enfermeiros na mercantilização da saúde l rita fernandes e outros gráfico 1. condicionantes que não permitem atingir o enfermeiro ideal tempo para fazer as coisas com mais fluidez, com mais rigor, se calhar demorar mais tempo com as pessoas, dar-lhes mais tempo, tem a ver com isso!” (participante n.º 12). no défice de recursos materiais e condições do espaço físico, a resposta que caracteriza esta categoria é: “[...] os espaços físicos, falta de espaços ideais para trabalhar” (participante n.º 30). a desmotivação é referida, tendo em conta “[...] o retorno económico que poderia ser uma motivação adicional — se bem que ache que isso não é o mais importante! o reconhecimento social da nossa importância e autonomia, era essencial” (participante n.º 21). frequência ≥1,4 ordem de evocação <2,1 ordem de evocação ≥2,1 palavras frequência oe palavras frequência oe núcleo central primeira periferia desumano 4,13 % 2,07 incompetente 8,26 % 2,11 arrogante 3,83 % 1,85 irresponsável 5,6 % 2,42 desorganizado 2,36 % 1,75 conflituoso 4,13 % 2,21 preguiçoso 2,06 % 1,71 desinteressado 4,13 % 2,29 ausência de conhecimentos técnicos 1,77 % 1,67 sem conhecimentos baseados na evidência científica 2,65 % 2,11 desatualizado 2,65 % 2,67 sem brio profissional 2,36 % 2,63 sem competências comunicacionais 2,06 % 2,14 antipático 2,06 % 2,57 individualista 1,77 % 3,67 distante 1,47 % 2,2 frequência <1,4 segunda periferia terceira periferia mal-humorado 0,88 % 1,33 insensível 1,18 % 2,25 despreocupado 0,88 % 1,67 sem empatia 1,18 % 2,75 intolerante 0,88 % 2 mau colega 1,18 % 3 mentiroso 0,88 % 2 desmotivado 0,88 % 2,33 desonesto 0,88 % 2 apenas técnico 0,88 % 3 tabela 3. frequência e ordem de evocação das palavras reproduzidas em enfermeiro rejeitado fonte: elaboração própria. fonte: elaboração própria. a resposta que carateriza melhor o défice de recursos humanos é “[...] a dotação do serviço, ter mais profissionais para dar 272 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 discussão na análise dos dados apresentados, pode-se identificar um grupo dominante de enfermeiros que se define profissionalmente com o núcleo central relacionado com as competências, a responsabilidade e a polivalência; esta última centrada na lógica de mercado na saúde. porém, os enfermeiros reconhecem no núcleo central o desejo de desenvolver a humanização, a amizade e a simpatia, sendo características da área das relações humanas que não só desejam desenvolver como também têm receio que, ao invés disso, se possam distanciar, com a oposição à desumanização e à arrogância. reconhece-se que estes enfermeiros se encontram numa dualidade identitária nos elementos mais situacionais e em mudança, seja na tentativa de corresponder ao exigido pelas organizações institucionais na profissionalização e como trabalhadores, seja na tentativa de corresponder à sua profissão como cuidadores e humanos. encontra-se, também, apesar de em menor destaque, a sua caraterização como profissionais mal remunerados. num estudo realizado em portugal, a profissão de enfermagem depara-se com a diminuição do reconhecimento social, da remuneração e o aumento da burocratização, consequências da empresarialização na saúde e da instabilidade profissional (18). apesar de os enfermeiros se verem confrontados com o enquadramento da lógica de mercado e de eficiência nos cuidados, eles desejam resgatar o cuidado (19) com a manutenção e o desenvolvimento nas relações humanas, que sentem em risco para corresponder ao solicitado pela instituição e conquistar a autonomia profissional, através da reivindicação das suas competências e responsabilidades profissionais. com efeito, a enfermagem encontra-se numa tensão constante ao nível identitário, entre a orientação para a instituição e a orientação para o cuidar (20) e na conquista da autonomia. numa pesquisa realizada na colômbia (21), as enfermeiras, perante as exigências burocráticas, administrativas e as pressões economicistas nas instituições de saúde, apesar de centrarem a sua motivação no cuidado de forma holística, enfrentam as exigências de cuidar num ambiente com sobrecarga de trabalho e desempenhando tarefas que não reconhecem como funções de enfermagem, suscitando sentimentos de culpa, esgotamento, stress e limitação de autonomia. identifica-se um subgrupo de enfermeiros que reclama para si vocábulos como compreensivo e amigo, que deseja desenvolver o ser atencioso, cuidador e os seus conhecimentos científicos; da mesma maneira, rejeita para si o mau humor e a despreocupação. este subgrupo de enfermeiros enquadra-se numa identidade muito próxima das relações interpessoais, com as possíveis transições no seu aperfeiçoamento na área relacional e no desenvolvimento dos conhecimentos científicos, distanciando-se, quer do modelo biomédico, quer do modelo vocacional submisso, de épocas anteriores (22, 23). num outro estudo realizado no peru (24), as enfermeiras confrontando-se com limitações de recursos materiais e humanos, jornadas de trabalho prolongadas, poucas horas de descanso, trabalho por turnos e rotatividade frequente entre especialidades, dispersaram-se em funções que as distanciaram do cuidar, podendo refletir-se num trabalho pouco humanizado. no entanto, as enfermeiras que participaram nesse estudo, apesar de sentirem estas pressões sociais e económicas, projetaram a valorização do cuidar na interação enfermeira-doente que se baseia no conhecimento científico em todas as áreas da disciplina, com enfoque nos aspetos psicossociais-culturais e humanísticos, contemplando também os processos biológicos. no reino unido (25), em face das medidas de austeridade na saúde, o paradigma de mercado impregnou instituições e organizações, incorporando os valores de mercado na prática de enfermagem, não integrando o conhecimento mais humanizado e interpessoal do cuidado e despersonalizando o cuidar, numa envolvência da competitividade emergente na mercantilização da saúde. nessa pesquisa acerca da evidência produzida na inglaterra, confirmou-se que as culturas sociais, políticas e organizacionais influenciam os valores profissionais dos enfermeiros, mas que estes profissionais não são os potenciadores desta transformação, mas sim as alterações decorrentes da mercantilização da saúde. esta situação impõe desafios aos quais os profissionais e especificamente os enfermeiros deverão responder com a denúncia dessas manifestações negativas no seu trabalho e na sua identidade profissional, expondo a sua indignação perante a consequente despersonalização do cuidar que se destaca na introdução de conceitos de mercado na saúde. os enfermeiros em portugal, mas também a nível internacional, diante das recentes transformações na sociedade, na saúde e na profissão, procuram o incremento de pertença e de reconheci273 dinâmicas, transições identitárias e desenvolvimento profissional de enfermeiros na mercantilização da saúde l rita fernandes e outros mento social, já não em ideologias identitárias passadas, mas em dinâmicas identitárias criativas, que se retroalimentam através do reconhecimento entre pares, que podem ser alteradas ou estagnadas com a empresarialização da saúde e dos cuidados, onde a “mercantilização da saúde, na qual o cuidado com o outro e a cura passam a ser objetos de lucro” (26). conclusões estão em curso transições identitárias que podem ocorrer de diversas formas, conforme as condições e transformações decorrentes dos contextos profissionais, quer em termos da correção dos défices de recursos humanos, materiais e o melhoramento de espaços físicos, quer da aposta no aumento da motivação que passa por um aumento de remuneração, mas, principalmente, pelo reconhecimento social, apoio e suporte entre pares e superiores hierárquicos. as dinâmicas identitárias observadas nestes selves vêm reconhecer as possíveis transições identitárias, assentes na afirmação da profissionalização baseada na conquista da autonomia profissional e no desenvolvimento do cuidar e que contracenam com as exigências de mercado, as quais transtornam essas transições, transparecendo a dificuldade na afirmação de uma identidade do cuidar. contudo, existem uma procura e um desejo da necessidade de resgatar o cuidar para a identidade profissional restrita às exigências do mercado na saúde, o que se reflete no receio da despersonalização dos profissionais enfermeiros do cuidar. limitações e implicações este estudo, apesar de tentar aliar a metodologia qualitativa e quantitativa no tratamento dos dados, é predominantemente de natureza interpretativa e, por isso, não pode ser generalizado. contudo, permite entender as condicionantes e os problemas que a mercantilização na saúde impõe a estes profissionais enfermeiros. esta pesquisa poderá ter implicações para a gestão, para a docência, para a prática, para o movimento sindical e regulamentar da profissão. urge repensar as medidas que possam conduzir às transições identitárias em prol da profissão, dos cuidados e do desenvolvimento profissional, correspondendo seja à evolução nos cuidados, seja ao envolvimento no cuidar, e não ao conceito de mercado. conflito de interesses: nenhum declarado. referências 1. holme a. why history matters to nursing. nurse educ today. 2015; 35(5):635-7. 2. santos lfcl. uma história da enfermagem em portugal (1143-1973). a constância do essencial num mundo em evolução permanente [tese de doutoramento em enfermagem, na especialidade de história e filosofia de enfermagem]. porto: universidade católica portuguesa, instituto de ciências da saúde; 2012. 3. pires amb. ser enfermeira em portugal da i república à 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revenfermeria.sld.cu/index.php/enf/article/view/1529/295 3 visibilidad.p65 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 20058 año 5 vol. 5 nº 1 (5) 8-19 chía, colombia octubre 2005 luz eugenia ibáñez alfonso1 inés cecilia amaya de gamarra2 viviana marycel céspedes cuevas3 recibido: 10 de agosto de 2005 aprobado: 29 de agosto de 2005 resumen la información real de los diagnósticos y las intervenciones que realizan los estudiantes y docentes durante la práctica permite conocer la correspondencia entre la academia y la asistencia, retroalimentar el proceso de reforma curricular, definir los diagnósticos y las intervenciones de enfermería en los contextos reales, y hacer visible el papel de la escuela de enfermería en los campos de práctica. se realizó un estudio descriptivo, diseñado e implementado mediante el seguimiento de prácticas y el sistema de registro de las mismas, diligenciado por estudiantes que cursaron asignaturas teórico-prácticas desde el 2001 hasta el 2004. el formato fue elaborado, y cuenta con la validez de contenido, por parte de los docentes de la escuela. se elaboró el software sipce (sistema de información de prácticas clínico-comunitarias de enfermería) que permite sistematizar los datos. se presentan los diagnósticos de enfermería más frecuentes por género, edad y situación de salud. también se presentan las intervenciones de enfermería realizadas por estudiantes y docentes durante la práctica. palabras clave proceso de enfermería, diagnósticos de enfermería, north american nursing diagnostics association (nanda), intervenciones de enfermería, nursing intervention classification (nic), resultados de enfermería, nursing outcomes classification (noc), registros de enfermería. abstract the real information of diagnosis and interventions done by students and teachers during practice, allows knowing the correlation between academy and assistance, giving feedback to the process of curricular reform, defining diagnostics and nursing interventions in real context, and making visible the role of nursing schools in the practice fields. a descriptive study took place, designed and implemented following up the practice and its system of registry, carried out by students who attend theory practice subjects, from 2001 to 2004. the format was elaborated, and has validated its contents by teachers of the school. the software sipce was developed (system of information of nursing community-clinic practices) allowing the systematization of data. most frequent nursing diagnostics are presented by gender, age and health situation. it also presents nursing interventions done by students and teachers during practice. key words nursing process, nursing diagnostics, north american nursing diagnostics association (nanda), nursing interventions, nursing interventions classification (nic), nursing outcomes classification (noc), nursing records. 1 enfermera especialista en docencia universitaria, msc. en pedagogía; profesora asociada, uis, colombia. l i b a n e s @ u i s . e d u c o . c o 2 enfermera especialista en educación sexual y procesos afectivos; profesora titular, uis, colombia. i n a m a y a @ u i s . e d u c o . c o 3 enfermera especialista en cuidado crítico, uis, colombia. vivian44@latinmail.com universidad industrial de santander visibilidad de la escuela de enfermería en los campos de práctica. universidad industrial de santander 9 objetivo escribir los diagnósticos y las intervenciones de enfermería realizadas por estudiantes y docentes de prácticas clínicas entre los años 2001 y 2004. justificación el presente trabajo de investigación busca suplir la carencia de registros propios de enfermería que permitan hacer visible el desempeño de la enfermera en el campo académico y profesional. enfermería tiene un mínimo de procedimientos registrados en comparación con las intervenciones que realiza durante el desempeño del cuidado, lo cual requiere fortalecer la cultura del registro propio de la profesión para hacerla visible, reconociendo la importancia que tiene el proceso de enfermería en sus diferentes etapas y su aplicación en el contexto real de desempeño. el trabajo permite, además, establecer un sistema de información y documentación sistematizada que facilite la gestión del cuidado de enfermería en los diferentes sitios de práctica, a la luz de los requerimientos de los convenios docente-asistenciales, y retroalimentar el proceso de reforma curricular mediante información que facilite el análisis de los diagnósticos y las intervenciones de enfermería al individuo, la familia y la comunidad. marco teórico evolución histórica de los sistemas de registro a partir del siglo xx el ejercicio de la enfermería se ha visto acompañado de un desarrollo científico y un componente visible de la práctica que han repercutido en la educación. de hecho, �durante la guerra de crimea, florence nightingale, mediante el diagnóstico y tratamiento de los problemas de salud logró disminuir la mortalidad del 42 al 2,2%� (1). en 1923, los aspectos físicos y el carácter médico de los cuidados dados a los enfermos hospitalizados empiezan a tomar gran relevancia y sirven de base a los cuidados de enfermería. el interés se centra en el estudio de los procesos fisiológicos y aparecen las publicaciones de cuidados clínicos de enfermería (1), que se enriquecerán gracias al aporte de las ciencias sociales. a comienzos de los años sesenta se empieza a usar el concepto de bases científicas para los cuidados de enfermería y la utilización del método de resolución de problemas. faye abdellah y virginia henderson (2) proponen organizar el cuidado de enfermería a partir de problemas propios de la disciplina y no de diagnósticos médicos, y organizar los programas académicos de enfermería de acuerdo con este enfoque, con base en los 21 problemas de enfermería de abdellah y las 14 necesidades básicas de virginia henderson. este hecho condujo a la idea de un proceso de enfermería que en sus comienzos estaba conformado únicamente por dos etapas: la identificación de problemas de la disciplina y el establecimiento de un plan de acción para resolverlos. con la participación de más de 40 escuelas de enfermería, y bajo la coordinación de la enfermera faye abdellah, se realizó el trabajo de clasificación y se logró una primera lista de 21 problemas, que fueron considerados objetivos terapéuticos de enfermería; era el momento histórico en el cual se hacía indispensable trabajar sobre las necesidades y los problemas del paciente (3). en 1966, virginia henderson identificó 14 necesidades humanas básicas que según ella involucraban las funciones fundamentales de enfermería. tanto la lista de abdellah como la revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200510 de henderson han sido ampliamente utilizadas en la educación y en la práctica como instrumentos de valoración. el surgimiento del proceso de enfermería y su aporte a la visibilidad de la profesión una situación que presionó la definición del quehacer de enfermería fueron los cambios generados en el sistema de salud de los estados unidos; enfermería era un servicio que ni siquiera aparecía en la factura, pues estaba incluido en los costos de alojamiento y alimentación. las enfermeras, enfrentadas a todas estas restricciones y regulaciones, debían mantener la calidad del cuidado al mismo tiempo que ofrecer una serie de servicios de enfermería cuyo costo pudiera ser calculado y facturado por separado (4). preocupadas por esta situación, dos enfermeras docentes de la escuela de enfermería de la universidad de san luis, kristine gebbie y mary ann lavin, empezaron a plantearse la necesidad de definir en forma concreta los �problemas de enfermería�, expresión que había evolucionado hacia �diagnósticos de enfermería� (1). se hacía necesario definir los enunciados para esos diagnósticos que se encontraban en el dominio de la práctica de la profesión, y para ello organizaron la primera conferencia para la definición y clasificación de los diagnósticos de enfermería (5). como resultado de la conferencia se conformó el grupo nacional para la clasificación de los diagnósticos de enfermería, que debería reunirse cada dos años a fin de presentar a la comunidad de enfermería los progresos en la definición de los diagnósticos, y al mismo tiempo encargarse de la divulgación de los mismos. en la undécima conferencia celebrada en 1994 se analizó la dificultad relacionada con una gran cantidad de diagnósticos admitidos que presentaban problemas para clasificarlos dentro de las categorías presentes en la taxonomía i; por tal razón, se propuso estudiar diferentes posibilidades de clasificación de diagnósticos y, finalmente, se acordó adoptar un tipo de marco basado en los patrones funcionales de marjory gordon. con permiso de la autora se hicieron algunas modificaciones a la estructura, convirtiendo los patrones en dominios, de donde surgió la taxonomía ii, aprobada en la decimotercera conferencia celebrada en 1998. hoy día hay consenso en que el empleo de un sistema de clasificación proporciona a las enfermeras un marco común de referencia y facilita la comunicación oral y escrita, haciéndola más eficaz; para que enfermería pueda ser considerada como una profesión completa, necesita contar con un sistema de clasificación (taxonomía) para aquellas funciones y responsabilidades que son exclusivas de la enfermera y que por lo tanto, le dan autonomía en su quehacer (4). en la escuela de enfermería de la universidad industrial de santander (uis) se ha venido realizando un seguimiento al proceso evolutivo de los diagnósticos de la north american nursing diagnostics association (nanda) y, de hecho, ello se ha reflejado en los procesos educativos, investigativos y docente-asistenciales apoyados en los anteriores lineamientos históricos y conceptuales. la escuela sustenta tanto el proceso de formación como el de registro del desempeño de profesores y estudiantes en sus diferentes sitios de práctica, para lo cual utiliza una nomenclatura reconocida en el mundo y con la que se pueden mostrar resultados del desempeño profesional en el abordaje de las respuestas humanas a los problemas de salud. para este fin, desde el primer semestre de 2001 se diseñó e implementó un formato en el cual se describen los diagnósticos y las intervenciones de enfermería que los estudiantes realizan en las prácticas desde el enfoque clínico, familiar y comunitario. el registro de este formato se ha sistematizado mediante el software sipce (sistema de información de prácticas clínico-comunitarias de enfermería), facilitando su análisis. clasificación de las intervenciones de enfermería y su importancia en los sistemas de registro la selección y formulación de las intervenciones de enfermería constituyen parte importante del planeamiento del cuidado, pues son las indicaciones o prescripciones que la enfermera(o) considera necesarias para obtener los resultados esperados, en términos de corrección, disminución o mantenimiento de las condiciones de salud deseables en el individuo. los planes de intervención deben estar estrechamente relacionados con diagnósticos de enfermería identificados; con base en ellos se establecen las metas o los resulla selección y formulación de las intervenciones de enfermería constituyen parte importante del planeamiento del cuidado, pues son las indicaciones o prescripciones que la enfermera(o) considera necesarias para obtener los resultados esperados, en términos de corrección, disminución o mantenimiento de las condiciones de salud deseables en el individuo. visibilidad de la escuela de enfermería en los campos de práctica. universidad industrial de santander 11 tados que se espera lograr a través de la realización de dichas intervenciones de enfermería. por lo anterior, los objetivos de la selección de intervenciones serán: controlar el estado de salud, resolver o controlar un problema, ayudar con las actividades de la vida diaria, promover un óptimo estado de salud e independencia y minimizar los riesgos. es importante recalcar que gran parte del cuidado de la salud compete a enfermería, y es un hecho que éste es indispensable para asegurar el bienestar de las personas; sin embargo, el impacto del cuidado de enfermería es casi invisible y son numerosos los cuestionamientos al respecto: ¿qué hace exactamente un profesional de enfermería? ¿suponen sus acciones alguna diferencia en la calidad de los cuidados sanitarios que se ofrecen? ¿la práctica de los cuidados de enfermería influye en la prevención de condiciones patológicas, reduce complicaciones o asegura el mejoramiento de la salud y el bienestar de las personas? éstas y otras preguntas obligan al profesional de enfermería a cuestionar su labor en un mundo de grandes avances tecnológicos, donde los profesionales que no pueden mostrar su efectividad pierden vigencia en el medio; las profesiones existen como respuesta a una necesidad social y si no la cubren en forma efectiva tienden a desaparecer. es preciso entonces que la disciplina pueda explicar en forma concreta y clara cuál es su función y de qué manera ayuda a las personas a lograr los resultados esperados planteados para solucionar los diagnósticos de enfermería; la herramienta que le permite mostrar su quehacer es el proceso de enfermería. en respuesta a esta situación, desde 1987 un grupo de enfermeras de la universidad de iowa, liderado por joanne mccoskey y gloria bulecheck (6), se dedicó a trabajar en la elaboración de una taxonomía de intervenciones de enfermería, y en 1992 publicaron su primer trabajo: nursing intervention classification (nic), en el cual se incluían 336 intervenciones de enfermería, cada una de ellas con una denominación, una definición y un grupo de actividades relacionadas que describían las acciones del profesional de enfermería requeridas para implementar la intervención. en 1996 se presentó la segunda edición del nic con un total de 433 intervenciones distribuidas por niveles para su organización. el nivel 1 corresponde a los campos, que son 7; el nivel 2, a las clases para un total de 29, y el nivel 3 corresponde a las 433 intervenciones. en la actualidad se cuenta ya con la tercera edición, la cual presenta un total de 486 intervenciones, organizadas en 7 campos y 30 clases (6). entre las múltiples razones que sustentan la necesidad de utilizar la clasificación de intervenciones se encuentran las siguientes: estandarización de la nomenclatura de las intervenciones de enfermería, ampliación del conocimiento de enfermería con respecto a la relación entre diagnósticos, intervenciones y resultados, y desarrollo de un sistema de información del cuidado de enfermería. la historia clínica como sistema de registro y su influencia en la enfermería como profesión según carpenito (2), las enfermeras dedican entre el 8 y el 30% de su tiempo a la manipulación de datos y, sin embargo, la información sobre las actividades de enfermería registrada en la documentación clínica y administrativa es bastante deficiente en lo que se refiere a su calidad e, incluso, a su cantidad. aunque la obtención de datos sea eficaz, éstos pocas veces son transformados en información significativa (7). la estructura actual de la documentación de enfermería, los vocabularios y la calidad de los datos registrados son un problema agravado por la demanda. hay factores que complican aún más estos temas, entre ellos cabe mencionar los siguientes: � la gran demanda de atención en enfermería. � la escasez de enfermeras matriculadas. � la gran disparidad con respecto a los medios, los niveles y la calidad de la educación profesional y el desempeño. � la mayor parte de la asistencia de enfermería está a cargo de auxiliares, los requisitos específicos para documentar la atención varían según el organismo, la institución, el nivel de educación profesional, la tradición, las rutinas y el entorno jurídico, lo que impide emplear documentación normalizada. � el que no se reconozca que la documentación de enfermería es un aspecto importante para explicar y caracterizar la contribución de la enfermería a la atención de salud. los planes de intervención deben estar estrechamente relacionados con diagnósticos de enfermería identificados; con base en ellos se establecen las metas o los resultados que se espera lograr a través de la realización de dichas intervenciones de enfermería. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200512 � la carencia de documentación con un formato normalizado, que impide extraer información para su análisis. � el uso de distintos sistemas de clasificación provenientes de otros países, que a menudo no son adecuados para los usuarios locales y el modelo de atención. � la falta de validación y evaluación de los sistemas de clasificación. � la carencia de datos y conjuntos normalizados de términos o terminologías de atención de enfermería para sustentar la ejecución del proceso. � la carencia de métodos de comparación de prácticas y de herramientas para asegurar la calidad y la eficacia en función de los costos de la atención de enfermería. � la falta de experiencia en el manejo de organizaciones complejas, entornos cambiantes y equipos multiprofesionales. � la falta de conocimientos y aptitudes en materia de tecnologías de la información y de motivación para aprender sobre ellas, agravada por el hecho de no reconocerlas como un recurso personal esencial para la evaluación del desempeño profesional (7). en la actualidad existen diferentes formas de registro; entre ellas se mencionan las que se han utilizado en las prácticas de las estudiantes en las diferentes instituciones de salud, que no corresponden al sistema de registro de éstas sino que se convierten en una exigencia académica por cuanto en la mayoría de las instituciones no se establecen parámetros claros de registro de las intervenciones de enfermería. el método dar, que ha sido adoptado por la escuela de enfermería de la universidad industrial de santander, se aplica de la siguiente forma: d: se refiere al registro de cada uno de los diagnósticos de enfermería aceptados por la nanda (5), identificados a través de la valoración; cada diagnóstico debe ir acompañado de los datos objetivos y subjetivos que permiten su validación. a: se registran las acciones de enfermería realizadas para el diagnóstico, teniendo cuidado especial de consignar la hora precisa en la cual fueron realizadas y las respuestas humanas generadas por la actividad. es importante aclarar que el enfoque conceptual retoma la estructura de la clasificación de intervenciones de enfermería del grupo iowa. r: hace referencia a los resultados obtenidos con la ejecución de las actividades realizadas, por tanto, antes de registrarlos es preciso realizar la evaluación. de igual manera, el enfoque conceptual retoma la estructura de la clasificación de resultados de enfermería (8). cualquiera que sea el sistema de registro utilizado se requiere conocer los criterios establecidos para que éstos sean efectivos: estar adaptado a los tipos de problemas que presenta con mayor frecuencia la población de personas de la institución, reflejar el uso del proceso de enfermería, detectar la inconveniencia de la doble documentación, aumentar la calidad de los registros enfermeros, y ser legalmente adecuados (9). los sistemas de acreditación han dirigido su atención hacia la eficacia de los cuidados y requieren datos acerca de los pacientes y la correlación de los problemas de salud, intervenciones y resultados, de modo que se puedan analizar datos en conjunto y se generen nuevos conocimientos acerca de la calidad y utilidad de los cuidados que se brindan. materiales y métodos estudio descriptivo realizado mediante el seguimiento de las prácticas clínicas desde agosto de 2001 hasta la fecha, período en el cual se diseñó e implementó el sistema de registro de las prácticas clínicas, diligenciado por todos los estudiantes inscritos en el programa de formación y cursando las asignaturas de práctica clínica, desde el tercer semestre de la carrera. el formato cuenta con el aval del docente supervisor de cada sitio de práctica. variables nominales: género, problemas de salud, diagnóstico de enfermería prioritario, diagnóstico de enfermería secundario según etiquetas de la nanda, intervención de enfermería según clasificación de las intervenciones de enfermería (nic), institución de salud y servicios donde se realizan las prácticas. variable continua: edad de pacientes intervenidos. la mayor parte de la asistencia de enfermería está a cargo de auxiliares; los requisitos específicos para documentar la atención varían según el organismo, la institución, el nivel de educación profesional, la tradición, las rutinas y el entorno jurídico, lo que impide emplear documentación normalizada. visibilidad de la escuela de enfermería en los campos de práctica. universidad industrial de santander 13 aspectos metodológicos de la propuesta primera etapa: � prueba piloto en el primer semestre de 2001 con 750 registros de personas hospitalizadas en el hospital universitario gonzález valencia (hurgv). � base de datos en epi info. 6.04. segunda etapa: � diseño de un segundo formato. � inclusión de nuevas intervenciones y variables como edad, género, diagnóstico de enfermería, diagnóstico médico, institución y rotación, lo cual hace extensiva la aplicación del formato a todos los campos de práctica con quienes se mantiene el convenio docente-asistencial. � construcción de un instructivo individual. tercera etapa: � directrices de la escuela frente a la operacionalización de los indicadores. � implementación de la clasificación de los resultados de enfermería (noc) incluyendo las escalas de medición. resultados se analizaron 2.351 registros provenientes de 11 instituciones donde se llevó a cabo la práctica clínica durante el período de estudio. el diseño y diligenciamiento del sistema de registros de enfermería ha permitido conocer comportamientos importantes de las prácticas clínicas relacionadas con las personas intervenidas según género, edad, situación de salud, diagnóstico de enfermería prioritario y secundario, e intervenciones de enfermería, rotación e institución. de igual manera ha sido posible conocer, dentro de la población intervenida, la relación entre edad y situación de salud, edad e intervenciones de enfermería, edad y diagnósticos de enfermería, rotación y diagnósticos de enfermería, rotación e intervenciones de enfermería y su análisis en las respectivas instituciones. a través de estos años de registro de prácticas clínicas se han podido encontrar tendencias interesantes relacionadas con la prevalencia de diagnósticos de enfermería como son: riesgo de infección, dolor agudo, conocimientos deficientes, deterioro de la movilidad física, riesgo de lesión, riesgo de deterioro de integridad cutánea, deterioro de integridad tisular y desequilibrio nutricional por defecto. las intervenciones de enfermería más frecuentes han sido: enseñanza individual, monitoreo de signos vitales, recibo y entrega de turnos, arreglo de unidad, cuidados de medicamentos parenterales, monitoreo de líquidos, mantenimiento de acceso venoso, manejo del dolor, control de la infección y manejo de heridas. a continuación se presentan algunos datos relacionados con la experiencia académico-asistencial de la escuela de enfermería durante el primer semestre de 2004, con el objetivo de ilustrar los aspectos metodológicos que permiten registrar las prácticas de formación de estudiantes y docentes. en la tabla 1 se presenta la prevalencia diagnóstica prioritaria; en la tabla 2 se presenta la prevalencia diagnóstica secundaria; la tabla 3 muestra la prevalencia diagnóstica según edad; en la tabla 4 se observa la prevalencia diagnóstica según servicio de rotación, y en la tabla 5 la prevalencia de intervenciones de enfermería según nic. conocer la prevalencia diagnóstica de enfermería permite a los profesionales profundizar sobre los problemas que con mayor frecuencia se enfrentan en la práctica diaria, reconociéndolos con un lenguaje y una estructura conceptual estandarizada. es importante resaltar en la tabla 1 la prevalencia de diagnósticos reales como: dolor agudo, conocimientos deficientes, deterioro de la movilidad física, de la integridad cutánea y tisular, los cuales se convierten en campos específicos del desempeño de enfermería. de igual manera, se resalta la prevalencia de diagnósticos de riesgo como: infección, lesión y deterioro de la integridad cutánea, los cuales se convierten en hallazgos que permiten evidenciar el papel activo que asume el profesional de enfermería en el diseño y diligenciamiento del sistema de registros de enfermería ha permitido conocer comportamientos importantes de las prácticas clínicas relacionadas con las personas intervenidas según género, edad, situación de salud, diagnóstico de enfermería prioritario y secundario, e intervenciones de enfermería, rotación e institución. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200514 tabla 1. prevalencia diagnóstica prioritaria. primer semestre, 2004 riesgo de infección 59 18,07 dolor agudo 44 14,14 conocimientos deficientes 41 13,18 deterioro de la movilidad física 37 11,89 riesgo de lesión 34 10,93 riesgo de deterioro de la integridad cutánea 24 7,71 deterioro de la integridad cutánea 24 7,71 ansiedad 20 6,43 deterioro de la integridad tisular 17 5,46 desequilibrio nutricional por defecto 11 3,53 total 311 100 diagnóstico n % la prevención de los diagnósticos reales, y el impacto positivo para las personas intervenidas y para las instituciones prestadoras de servicios de salud. encontrar dentro de la prevalencia diagnóstica los casos de ansiedad, refleja la ruptura que desde hace algunos años los profesionales han logrado al pasar de un enfoque biologista a un enfoque integral que involucra diagnósticos de enfermería psicosociales permitiendo además adelantar proyectos curriculares dentro de un contexto más humanizante. tabla 2. prevalencia diagnóstica secundaria. primer semestre, 2004 riesgo de infección 87 20,76 dolor agudo 70 16,70 deterioro de la movilidad física 53 12,64 conocimientos deficientes 52 12,41 perfusión tisular inefectiva 45 10,73 deterioro de la integridad tisular 37 8,83 desequilibrio nutricional por defecto 25 5,96 patrón respiratorio ineficaz 25 5,96 riesgo de déficit de volumen de líquidos 25 5,96 total 419 100 diagnóstico n % visibilidad de la escuela de enfermería en los campos de práctica. universidad industrial de santander 15 tabla 3. prevalencia diagnóstica según edad. primer semestre, 2004 comparando la prevalencia diagnóstica secundaria con la tabla 1 sobre prevalencia diagnóstica primaria, existe la correspondencia en cuanto a diagnósticos que con mucha frecuencia se encuentran en diferentes campos de desempeño y que se convierten en prioridades del rol profesional, facilitando elementos cognoscitivos que permiten realizar intervenciones de calidad en las personas afectadas. de un mes a 5 años 1. dolor agudo 5 25 2. riesgo de infección 4 20 3. hipertermia 4 20 4. riesgo de deterioro de la integridad cutánea 4 20 5. limpieza ineficaz de vías aéreas 3 15 total 20 100 de 5 años a 10 años 1. deterioro de la movilidad física 4 31 2. riesgo de disfunción neurovascular periférica 3 23 3. riesgo de lesión 2 15 4. baja autoestima situacional 2 15 5. deterioro de la dentición 2 15 total 13 100 de 10 años a 29 años 1. riesgo de infección 68 31 2. dolor agudo 51 23 3. conocimientos deficientes 39 18 4. riesgo de lesión 36 16 5. deterioro de la movilidad física 25 11 total 219 100 de 29 años a 45 años 1. riesgo de infección 34 31 2. dolor agudo 26 24 3. conocimientos deficientes 21 19 4. deterioro de la integridad tisular 15 14 5. deterioro de la movilidad física 14 13 total 110 100 mayores de 45 años 1. deterioro de la movilidad física 44 24 2. perfusión tisular inefectiva 37 21 3. riesgo de infección 36 20 4. riesgo de lesión 33 18 5. conocimientos deficientes 30 17 total 180 100 rango de edad diagnóstico n % revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200516 conocer la prevalencia diagnóstica ha permitido, dentro de la escuela de enfermería, identificar los diagnósticos de enfermería más frecuentes, según rango de edad, al igual que el comportamiento de los mismos en las diferentes rotaciones y semestres. se destaca cómo durante el primer semestre de 2004 la población más intervenida fue la de 10 a 29 años, con diagnósticos de enfermería muy específicos para algunos rangos de edad como dolor agudo, riesgo de infección e hipertermia, en menores de 5 años y la baja autoestima situacional y el deterioro de la dentición entre 5 y 10 años. se destaca el diagnóstico de conocimientos deficientes presente en la población mayor de 10 años. los datos anteriores han permitido reconocer la correspondencia académico-asistencial, la integración teórico-práctica y el proceso de retroalimentación necesario en el actual cambio de currículo, el cual está unido a procesos externos como las nuevas políticas de salud, problemas de salud específicos de la región y procesos internos dados por las nuevas tendencias en cuanto a tecnología y educación. tabla 4. prevalencia diagnóstica según servicio de rotación. primer semestre, 2004 medicina interna 1. riesgo de lesión 21 21 2. riesgo de infección 15 15 3. deterioro de la movilidad física 10 10 4. desequilibrio nutricional por defecto 10 10 5. patrón respiratorio ineficaz 9 9 6. conocimientos deficientes 8 8 7. intolerancia a la actividad 7 7 8. protección inefectiva 7 7 9. perfusión tisular inefectiva 6 6 10. limpieza ineficaz de vías aéreas 6 6 total 99 100 quirúrgicas 1. desequilibrio nutricional por defecto 18 17 2. deterioro de la integridad tisular 18 17 3. dolor agudo 17 16 4. riesgo de infección 14 14 5. volumen deficiente de líquidos 9 9 6. deterioro de la integridad cutánea 9 9 7. conocimientos deficientes 6 6 8. patrón respiratorio ineficaz 5 5 9. riesgo de déficit de volumen de líquidos 4 4 10. retención urinaria 3 3 total 103 100 servicio diagnóstico n % visibilidad de la escuela de enfermería en los campos de práctica. universidad industrial de santander 17 el conocimiento detallado de los diagnósticos de enfermería por rotación permite identificar los problemas más frecuentes en los que ésta interviene, según servicios de atención; lo anterior ha permitido construir protocolos de manejo y estándares de atención, al igual que orientar la integración y pertinencia de nuestro programa de formación. utilizar las bases conceptuales y clasificatorias para registrar las intervenciones de enfermería constituye un aporte significativo a la visibilidad del desempeño profesional, en cuanto permite cuantificar con un lenguaje estandarizado las acciones de enfermería, facilitando la relación de diagnósticos y sus intervenciones para solucionar los más relevantes, como los siguientes: trabajo de parto y 1. riesgo de infección 30 24 parto de alto riesgo 2. riesgo de lesión 28 22 3. ansiedad 16 13 4. conocimientos deficientes 16 13 5. dolor agudo 10 8 6. perfusión tisular inefectiva 10 8 7. riesgo de déficit de volumen de líquidos 8 6 8. riesgo de desequilibrio de volumen de líquidos 4 3 9. lactancia materna efectiva 2 2 10. manejo efectivo del régimen terapéutico 2 2 total 126 100 comunidad 1. conocimientos deficientes 34 31 2. riesgo de lesión 13 12 3. riesgo de infección 10 9 4. patrón respiratorio ineficaz 9 8 5. dolor agudo 9 8 6. conductas generadoras de salud 9 8 7. temor 8 7 8. hipertermia 7 6 9. limpieza ineficaz de vías aéreas 6 5 10. desequilibrio nutricional por defecto 6 5 total 111 100 servicio diagnóstico n % revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200518 � conocimientos deficientes con enseñanza individual. � riesgo de infección con control de infección y monitoreo de signos vitales. � dolor agudo con manejo de dolor. � riesgo de deterioro de la integridad cutánea con prevención de úlceras por presión y cambios posturales. � ansiedad con apoyo emocional. de igual manera, se puede resaltar la importancia del registro de intervenciones básicas que brindan bienestar a las personas intervenidas, tales como: arreglo de unidad, cuidado en cama, baño con ayuda parcial, promoción de reposo y sueño, y apoyo emocional, intervenciones que no se registran y mucho menos se reconoce su importancia en la atención de los pacientes. otras intervenciones como recibo y entrega de turno, y documentación o interpretación de datos de laboratorio, deben ser registradas e interpretadas como indicadores de calidad del cuidaenseñanza individual 476 9,4 monitoreo de tensión arterial 435 8,6 monitoreo de pulso 432 8,5 recibo y entrega de turno 404 8,0 monitoreo de temperatura 389 7,7 arreglo de la unidad 298 5,9 cuidados de medicamentos parenterales 277 5,4 monitoreo de líquidos 248 4,9 mantenimiento de acceso venoso 233 4,6 manejo del dolor 209 4,1 control de infección 221 4,3 cuidado en cama 218 4,3 cambios posturales 217 4,3 documentación 206 4,0 interpretación de datos de laboratorio 201 3,9 cuidados de medicamentos orales 184 3,6 baño con ayuda parcial 180 3,5 promoción de reposo-sueño 166 3,2 apoyo emocional 166 3,2 prevención de úlcera por presión 152 3,0 monitoreo respiratorio 128 2,5 total 5.040 100 intervenciones n % tabla 5. prevalencia de intervenciones de enfermería según nic. primer semestre, 2004 visibilidad de la escuela de enfermería en los campos de práctica. universidad industrial de santander 19 do de enfermería por cuanto reflejan continuidad y monitoreo permanente de la evolución de las personas intervenidas. desde el punto de vista del papel de la enfermera en el apoyo farmacológico se encuentran intervenciones prevalentes como: cuidados de medicamentos parenterales, monitoreo de líquidos, mantenimiento de acceso venoso, cuidado de medicamentos orales, las cuales resaltan la importancia del papel de enfermería en este campo. conclusiones el análisis de la información anterior ha permitido redefinir el enfoque curricular y el diseño de los núcleos temáticos, fundamentados en diagnósticos e intervenciones de enfermería más frecuentes. de igual manera, ha permitido presentar informes institucionales rescatando un lenguaje unificado y sistematizado que visibiliza la profesión y retroalimenta permanentemente el desarrollo de las prácticas clínicas de nuestro programa. la escuela de enfermería de la uis ha venido utilizando como herramienta metodológica el proceso de enfermería tanto en el desarrollo teórico como en las experiencias prácticas en diferentes instituciones. con el diseño de la experiencia se pretende rescatar en las prácticas clínicas el proceso de enfermería en su conjunto, haciendo énfasis en: diagnósticos, intervenciones y resultados de enfermería, considerados como fuentes importantes de datos para analizar la eficacia de los tratamientos, beneficios y contribución del cuidado de enfermería en la salud de la población. actualmente la escuela de enfermería asume un papel protagónico a nivel nacional al dirigir la subgerencia de los servicios de enfermería del nuevo hospital universitario de santander. el plan conjunto de trabajo que se desarrolla entre el hospital y la universidad permite la integración de los avances tecnológicos y científicos con la asistencia. la utilización de los registros clínicos sistematizados ha posibilitado que la escuela haga visible la labor que desempeña en la nueva institución, y ha generado proyectos de costos que alimentan la unidad de negocios de la subgerencia de enfermería. por tal razón, los beneficios están relacionados con: � desarrollo académico fundamentado en el contexto real. � información sistematizada que refleja el rol de la profesión, logrando mayor posicionamiento dentro del equipo de salud. � información cuantitativa que fundamenta el valor generado por enfermería en las instituciones donde se realizan las prácticas, permitiendo avanzar en el desarrollo de planes de negocio de enfermería. referencias bibliográficas 1. gordon m. diagnóstico enfermero. proceso y aplicación. 3° ed. españa: mosby doyma; 1998. 2. carpenito lj. diagnóstico de enfermería. 9° ed. españa: editorial interamericana; 2000. 3. abdellah f. improving the teaching of nursing through research in patient care. heiderken le, editor. washington: catholic university of america; 1959. 4. ibáñez le, sarmiento lv. el proceso de enfermería. 1ª ed. bucaramanga: ediciones uis; 2003. 5. nanda internacional, diagnósticos enfermeros: definición y clasificación. madrid: elservier imprint 6. bulechek g, mccloskey j. nursing intervention classification. 4 ed. madrid: mosby. 7. ops-oms, desarrollo de sistemas normalizados de información en enfermería. washington: ops; 2001. 8. johnson m, maas meridean m, nursing outcomes classification (noc). 3 ed. madrid: mosby; 2000. 9. alfaro r. aplicación del proceso enfermero. barcelona: editorial springer-verlag ibérica; 1999. 1 gloria mabel carrillo1 narda patricia santamaria2 ricardo oliveros wilches3 follow-up of gastrectomized patients due to gastric cancer in a cancer center of bogota, colombia 1 orcid.org/0000-0003-4513-104x. universidad nacional de colombia, colombia. gmcarrillog@unal.edu.co 2 orcid.org/0000-0002-4617-4116. instituto nacional de cancerología, colombia. nsantamaria@cancer.gov.co 3 orcid.org/0000-0002-4189-8844. instituto nacional de cancerología, colombia. received: 18/08/2018 sent to peer reviewers: 05/09/2018 accepted by peers: 14/02/2019 approved submission: 02/20/2019 doi: 10.5294/aqui.2019.19.2.8 to reference this article / para citar este artículo / para citar este artigo carrillo gm, santamaría np, oliveros r. follow-up of gastrectomized patients due to gastric cancer in a cancer center of bogota, colombia. aquichan 2019; 19(2): e1928. doi: 10.5294/aqui.2019.19.2.8 abstract objective: to determine the perceived burden and functional status of gastric cancer patients with gastrectomy in a center of cancer in bogota (colombia) between 2013 and 2016. materials and methods: retrospective description of patients intervened by gastrectomy distributed in three groups: patients with gastrectomy from 1 to 12 months of surgical intervention, 13 to 14 months and 25 to 36 months. for this, it was used the disease burden perception instrument and the karnofsky scale. results: 127 patients were included. 63 from 1 to 12 months, 43 from 13 to 24 months, and 21 from 25 to 36 months of intervention. gastric adenocarcinoma of intestinal pattern stage iii and ii predominate. more than 50 % of the patients required total gastrectomy and received adjuvant chemotherapy. the majority of participants performed regular activities with mild signs and symptoms, presented low overall perceived burden and functional performance without statistically significant differences between groups. patients from 1 to 12 months of intervention reported greater levels of physical discomfort. conclusions: in patients with gastrectomy for gastric cancer, physical symptoms persist such as emotional disturbances, economic difficulties and limitations in the work role, findings to be included in follow-up programs. keywords (source: decs) stomach neoplasms; stomach cancer; gastrectomy; cost of illness, follow-up studies; nursing oncology. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1928 theme: chronic care contribution to the discipline: description of perceived burden and state of performance in patients with cancer who have gone through oncology therapy constitute a fundamental element to generate evidence-based indicators that guide follow-up plans from the experience reported by the participants once they leave the hospital institutions. http://orcid.org/0000-0003-4513-104x file:///d:/temporales/ http://orcid.org/0000-0002-4617-4116 file:///d:/temporales/ http://orcid.org/0000-0002-4189-8844 http://dx.doi.org/10.5294/aqui.2019.19.2.8 http://orcid.org/0000-0003-4513-104x http://orcid.org/0000-0002-4617-4116 http://orcid.org/0000-0002-4189-8844 http://dx.doi.org/10.5294/aqui.2019.19.2.8 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1928 seguimiento de pacientes gastrectomizados por cáncer gástrico en un centro oncológico de bogotá, colombia resumen objetivo: evaluar el seguimiento de pacientes gastrectomizados por cáncer gástrico en un centro de oncología en bogotá, entre 2013 y 2016, y determinar el estado funcional y la percepción de la carga de enfermedad. material y métodos: descripción retrospectiva de pacientes intervenidos por gastrectomía, distribuidos en tres grupos: de 1 a 12 meses de seguimiento luego de la intervención, de 13 a 14 meses, y de 25 a 36 meses. se utilizó un instrumento de percepción de carga de enfermedad crónica validado y la escala de karnofsky. resultados: se incluyeron 127 pacientes: 63 a un año, 43 a 2 años y 21 a 3 años. predomina el adenocarcinoma gástrico de patrón intestinal. más del 50 % requirió gastrectomía total, más quimioterapia adyuvante, y estaba en estadios ii y iii. la mayoría realiza actividad normal con signos y síntomas leves, con una carga de enfermedad percibida global baja y un estado funcional sin diferencias significativas entre los grupos. los pacientes con seguimiento de 1 a 12 meses reportaron un mayor malestar físico. conclusiones: en pacientes gastrectomizados por cáncer gástrico, persisten síntomas físicos, alteraciones emocionales, dificultades económicas y limitación en el rol laboral, hallazgos por ser incluidos en los programas de seguimiento. palabras clave (fuente: decs) neoplasias gástricas; cáncer de estómago; gastrectomía; costo de enfermedad; estudios de seguimiento; enfermería oncológica. 3 follow-up of gastrectomized patients due to gastric cancer in a cancer center of bogota, colombia l gloria mabel carrillo y otros seguimento de pacientes gastrectomizados por câncer gástrico em um centro de oncológico em bogotá, colômbia resumo objetivo: avaliar o seguimento de pacientes gastrectomizados emum centro de referêncianacidade de bogotá entre 2013 e 2016, determinando o status funcional e a percepção da carga da doença. material e métodos: descriçãoretrospropectiva dos pacientes intervencionados por gastrectomiadistribuídosemtrês grupos, que têm entre 1 a 12 meses de intervençãocirúrgica, 13 a 14 meses e 25 a 36 meses. utilizamos o instrumento de percepção da carga de doençascrônicas, desenhado, avaliado e a escala de karnofsky. resultados: 127 pacientes foramacompanhados por gastrectomia por câncer gástrico; 63 emum ano, 43 em 2 anos e 21em 36 meses. do ponto de vista histopatológico, predomina o adenocarcinoma gástrico intestinal. mais de 50 % necessitaram de gastrectomia total, além de quimioterapia adjuvante e corresponderamaosestágios ii e iii. a maioria dos pacientes commonitorizaçãoactividade normal realizada sinais e sintomas leves comumabaixa carga global percebida e um estado funcional, semdiferenças significativas entre os grupos namonitorização de doentesacompanhados durante 1 a 12 meses relatados maisdesconforto físico. conclusões: nos pacientes gastrectomizados por câncer gástrico, a percepção de sobrecarga da doença é baixa. alguns sintomas físicos persistem, disturbios emocionais e dificuldades econômicas, bem como limitação no papel do trabalho, achados a serem considerados no desenvolvimento de programas de acompanhamento. palavras-chave (fonte: decs) neoplasias gástricas; cancro do estômago; gastrectomia; efeitos psicosociais da doença; seguimentos; enfermagem oncológica. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1928 4 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1928 aquichan issn 1657-5997 eissn 2027-5374 introduction every year, globally, over one million de new cases of gastric cancer occur, and close to 850 000 people die. estimates predict a two-fold increase of cases and deaths in men and women (1). in colombia, according to globocan 2018, there were 7419 new cases of gastric cancer, figures ranking this disease as third in frequency and as the first cause of mortality (1). surgical techniques and perioperative management have improved in recent decades. survival five years after the curative resection for patients with locally advanced disease is from 20 % to 30 % (2). gastrectomy — a highly complex surgery, with important consequences for the patient from the nutritional, functional, and emotional points of view — is the principal effective curative option in treating gastric cancer. there are body changes that imply adaptation and preparation to return to daily activities, a situation that reflects the impact and burden for patients during follow-up (2, 3). within the 10-year plan for cancer control in colombia 20122020, improving the quality of life with implementation of social support service and follow-up to patients and caregivers are strategic action lines (4). studies have explored mortality, quality of life, survival rates, and postsurgical complications in patients with gastric cancer (5-11). often, health problems are evaluated in terms of mortality, but this indicator fails by not considering the time lost due to disability and other non-fatal health results. the distribution of health resources is made based on the indicator of mortality, but leaves out the weight generated by morbidity (12). this last aspect of perceived burden of the disease has not been evaluated in the follow-up of patients gastrectomized due to gastric cancer. perceived burden refers to the additional effort that implies satisfying the needs of the person with a chronic condition. it includes three dimensions: psychological and spiritual suffering, general and physical discomfort, and sociocultural and family alteration (judgment a person makes upon the impact and burden represented by the health condition on family and social roles). each situation associated with the additional effort is measured in terms of frequency (13). the description of this burden contributes important knowledge on the patient’s performance after surgery, bearing in mind psychological and spiritual aspects, general discomfort, and physical discomfort, as well as the sociocultural and family alteration (13). in literature, few approaches describe perceived burden due to disease and the state of performance in those who have undergone gastrectomy. it should be highlighted that this situation has not been explored as research by nursing, thus, the lack of evidence-based indicators that guide follow-up planes from experiences reported by patients, once they are discharged from hospital institutions. the aim of this study was to determine the perceived burden and functional state of patients with gastric cancer after undergoing gastrectomy in a reference cancer center. after the surgical intervention, three groups were monitored: 1) from 1 to 12 months, 2) from 13 to 24 months, and 3) from 25 to 36 months by applying a functional scale (karnofsky) and an instrument for perception of disease burden. materials and methods cross-sectional, descriptive retrospective study, which included 127 adults (>18 years) with diagnosis of gastric adenocarcinoma, subjected to gastrectomy between 2013 and 2016. the follow-up was organized in three groups: 1) from 1 to 12 months after the surgical intervention; 2) from 13 to 24 months after the intervention; and 3) from 25 to 36 months after intervention. the study included participants with or without adjuvant treatment, and with capacity to communicate verbally. after reviewing the clinical histories, 175 subjects possibly eligible were identified; excluding 16 due to death, 9 for not having gastric adenocarcinoma, 18 due to wrong phone number, and 5 who wished not to participate in the study. a final intentional sample of 127 patients was acquired, distributed thus: 63 to group 1, 43 to group 2, and 21 to group 3. participants were reached via telephone and through consultation at the gastroenterology service, where informed consent was obtained and questionnaires were distributed to be filled out. application of the scales was carried out in person in the external gastroenterology consultation service. the average time to apply the scales was 20 min, with a minimum of 18 and a maximum of 45 min. a file was filled out for sociodemographic characterization, and the instrument of perception of chronic disease burden was developed and validated within the colombian context (13), from 5 follow-up of gastrectomized patients due to gastric cancer in a cancer center of bogota, colombia l gloria mabel carrillo y otros the theory of symptom management (14). this instrument has 48 items that explore three dimensions of burden: psychological and spiritual; discomfort and physical discomfort; and sociocultural and family alteration. participants indicated the frequency of the discomfort from a likert-type scale, from 1 (absence of the problem) to 4 (maximum problem). scale reliability was at 0.89 (cronbach’s alpha). additionally, karnofsky’s scale was applied, which consists in a self-report report of the physical capabilities of the patient. in oncology, it is used to evaluate the performance level: a score of 100 % indicates the individual can perform normal activities and that there is decrease in the state of performance (15). the analysis was conducted by using the statistical package for social sciences (spss). measures of central tendency and dispersion were calculated to determine the perceived burden, distribution of frequencies, percentages, sociodemographic profile and state of performance. comparison of the groups in perceived burden and in each of the dimensions was carried out through nonparametric tests, like the kruskal-wallis test. institutional research and ethics committees endorsed this work. results characteristics of the participants intestinal pattern gastric adenocarcinoma and stages ii and iii prevailed within the three groups. over 50 % of the patients required total gastrectomy and received adjuvant chemotherapy. regarding age, a mean from 60 to 62.5 years was identified. in patients with follow-up from 1 to 12 months after surgical intervention, and in those from 13 to 24 months, the highest occurrence of disease was in males. low schooling, the household as principal occupation, married, socioeconomic level 2 (stratum) prevailed in the three groups (table 1). table 1. profile of patients gastrectomized due to gastric cancer variables gastrectomized gastric cancer intervention groups 1 to 12 months 13 to 24 months 25 to 36 months n = 63 (%) n = 43 (%) n = 21 (%) type of gastrectomy subtotal gastrectomy 34.9 44.2 42.9 total gastrectomy 65.1 55.8 57.1 variables gastrectomized gastric cancer intervention groups 1 to 12 months 13 to 24 months 25 to 36 months n = 63 (%) n = 43 (%) n = 21 (%) adenocarcinoma type intestinal 55.6 74.4 71.4 diffuse 25.4 16.3 23.8 mix 19.0 9.3 4.8 stage in situ cancer (0) 14.3 9.3 4.8 ia-ib 17.5 9.3 14.3 ii (iia-iib) 28.6 34.9 42.9 iii (iiia-iiib) 34.9 41.9 33.3 iv 4.8 4.7 4.8 adjuvant treatments received chemotherapy 54.0 69.8 76.2 received radiotherapy 23.8 48.8 52.4 current chemotherapy treatment 41.3 16.3 9.5 current radiotherapy treatment 12.7 0.0 0.0 age group 18 to 35 years 3.2 4.7 0.0 36 to 59 years 39.7 41.9 42.9 60 to 75 years 39.7 46.5 38.1 76 and over 17.5 9.3 14.3 sex female 41.3 39.5 47.6 male 58.7 60.5 52.4 schooling illiterate 7.9 9.3 0.0 high school 22.2 30.2 33.3 graduate 0.0 2.3 0.0 primary 55.6 46.5 42.9 technical 6.3 2.3 9.5 complete university 7.9 9.3 14.3 marital status married 46.0 48.8 42.9 separated 9.5 9.3 4.8 single 14.3 16.3 19.0 common-law 25.4 16.3 23.8 widow (er) 4.8 9.3 9.5 occupation employed 11.1 7.0 0.0 home 41.3 44.2 47.6 none 34.9 34.9 33.3 independent work 12.7 14.0 19.0 socioeconomic level 1 11.1 11.6 9.5 2 68.3 55.8 38.1 3 20.6 32.6 57.1 age mean (sd) 62.5 (11.1) 61.8 (11.9) 60.04 (12.4) source: own elaboration. 6 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1928 aquichan issn 1657-5997 eissn 2027-5374 a. functional state (karnofsky scale) in relation with to the functional state in the three groups, most scored > 90, that is, perform normal activities, with slight signs and symptoms of disease. in the group from 1 to 12 months, 36 patients of 63 scored > 90. in the group from 25 to 36 months after surgical intervention, 31 patients of 43 had scores > 90, while in the group with greater follow-up 14 of 21 scored > 90 (figure 1). figure 1. functional state (karnofsky) of patients gastrectomized and on follow-up by months from intervention source: own elaboration. bapplication of the instrument: perception of chronic disease burden: three dimensions of burden: psychological and spiritual discomfort and physical discomfort and sociocultural and family alteration. the dimension of spiritual and emotional burden (possible scores: 15 60) tends to be low in the three groups and has no statistically significant differences among the groups (figure 2a). the dimensions of general discomfort and physical discomfort (possible scores: 19 76) and sociocultural and family alteration (possible scores: 14 56) tend to be low, and no statistically significant differences were found among the groups (table 2, figures 2b and 2c). the global disease burden perceived (possible scores: 48 192) tends to be low in the three groups, and statistically significant differences were not found either (figure 2d). table 2. dimensions of disease burden in the follow-up of patients gastrectomized due to gastric cancer group statistic spiritual and social burden physical discomfort sociocultural and family alteration global burden perceived 1-12 months of intervention median 23.4 36 20.74 80.23 sd 6.21 8.4 5.69 17.29 13-24 months of intervention median 23.5 33.9 19.83 77.3 sd 5.9 8.7 5.03 16.22 25-36 months of intervention median 22.33 34.05 19.04 75.42 sd 6.1 7.89 5.4 17.18 statistical significance (p value) 0.64 0.23 0.17 0.42 sd: standard deviation of statistical significance p < 0.005. source: own elaboration. figure 2. burden in patients with gastric cancer gastrectomized 2a. emotional suffering by intervention groups 2b. physical discomfort by intervention groups 7 follow-up of gastrectomized patients due to gastric cancer in a cancer center of bogota, colombia l gloria mabel carrillo y otros 2c. sociocultural and family alteration by intervention groups 2d. total burden perceived by intervention groups source: own elaboration. in terms of spiritual and emotional burden, the most-frequent symptoms in the three groups were sadness, anguish, uncertainty, fear, and melancholy. with respect to physical discomfort, the most-frequent discomfort in the three groups were weakness, distress, diarrhea, changes in appetite, pain, fatigue, cramps, sleep alterations, and weight loss. the group from 1 to 12 months of follow-up reports a greater frequency of these annoyances compared to the others. regarding the burden of sociocultural and family alteration, the three groups highlight economic difficulty and alterations in work role. upon analyzing the items individually, statistically significant changes are only identified for anxiety, anguish, weight loss, and alteration of the work role. values reported in the group from 1 to 12 months are the highest (table 3). table 3. perceived burden in the follow-up of patients gastrectomized due to gastric cancer perceived burden group 01 group 02 group 03 p value sp ir itu al a nd e m ot io na l b ur de n neglect 1.270 1.233 1.333 0.74 anxiety 1.698 1.605 1.286 0.03 anguish 1.968 1.628 1.571 0.01 low self-esteem 1.492 1.442 1.333 0.67 distrust 1.238 1.163 1.048 0.17 despair 1.571 1.581 1.667 0.98 guilt 1.254 1.302 1.048 0.13 uncertainty 1.905 1.884 1.905 0.98 lability 1.762 1.791 1.762 0.99 melancholy 1.921 2.209 2.000 0.31 sadness 2.079 2.302 2.333 0.35 loss of identity 1.032 1.163 1.095 0.38 fear 1.762 1.767 1.667 0.74 shame 1.190 1.163 1.095 0.6 deficit of cognitive capacity 1.349 1.326 1.190 0.59 ph ys ic al d is co m fo rt distress 2.413 2.070 2.143 0.15 cutaneous alterations 1.778 1.884 1.667 0.49 alteration in daily life activities 2.111 1.791 1.857 0.24 alteration of motor functionality 1.730 1.860 1.667 0.6 alteration of sensitivity 1.254 1.256 1.190 0.87 weakness 2.413 2.233 2.286 0.43 disfigurement 1.683 1.581 1.333 0.38 deterioration of verbal communication 1.159 1.070 1.000 0.22 sexual dysfunction 1.349 1.628 1.286 0.29 pain 2.286 2.186 2.238 0.6 fatigue 2.206 2.023 2.190 0.32 alterations in balance 1.778 1.767 2.000 0.4 sleep alterations 2.159 2.070 2.095 0.83 changes in appetite 2.413 2.070 2.000 0.55 diarrhea 2.317 2.209 2.000 0.44 urinary discomfort 1.254 1.302 1.571 0.36 respiratory discomfort 1.270 1.302 1.333 0.97 cramps 2.016 1.860 2.238 0.2 weight loss 2.413 1.791 1.952 0.008 8 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1928 aquichan issn 1657-5997 eissn 2027-5374 perceived burden group 01 group 02 group 03 p value so ci oc ul tu ra l a nd fa m ily a lte ra tio n social isolation 1.365 1.256 1.381 0.73 alteration of family dynamics 1.333 1.326 1.333 0.72 alteration of the family role 1.238 1.209 1.190 0.95 alteration of the work role 1.952 1.651 1.286 0.03 affectation of a caregiver 1.317 1.233 1.143 0.76 economic dependence 1.619 1.488 1.190 0.12 economic difficulty 2.175 2.372 2.190 0.48 deterioration of social interaction 1.540 1.419 1.429 0.6 discrimination 1.095 1.093 1.143 0.87 cultural confrontation 1.159 1.023 1.048 0.42 stigmatization 1.159 1.140 1.095 0.98 architectural exclusion 1.032 1.047 1.000 0.43 loss of social status 1.143 1.209 1.095 0.58 subjection 1.175 1.047 1.095 0.26 statistical significance: p<0.005 source: own elaboration. discussion the study reflects the gastric cancer profile in colombia: most patients are older adults (in the sixth decade of life), with advanced stages and intestinal adenocarcinomas (16-18). the disease occurs more in men than in women. the majority of patients can perform normal activities, data agreeing with findings in literature (19-21). however, the group with follow-up from 1 to 12 months, after gastrectomy, has a higher affectation of the state of performance against the other two, probably because they are in the initial phase of surgery adaptation (post-gastrectomy) and receive adjuvant treatments, like chemotherapy and radiotherapy. patients from the three groups have low perceived disease burden, an observation that differs from other studies in which it tends to be high with alterations in quality of life (6-9). it is possible that those surviving cancer, usually report positive aspects in their quality of life and a lower burden of symptoms because they experience change with respect to their wellbeing, given a positive oncological evolution of their disease, as reported by other authors (22, 23). in spiritual and emotional burden, the findings for the three groups tend to be low; however, sadness, anguish, uncertainty, fear, and melancholy persist. information available is limited on alterations of this type in outpatients who remain disease-free during some time after diagnosis or treatment. han et al. (23) found that the prevalence of mood alterations in patients with stomach cancer, who were disease-free during at least one year was 43.9 %, a high rate with respect to other cancer survivors. several factors are associated with these alterations, confirming their multidimensional nature; it is possible that these patients in follow-up, after surgery, have greater difficulty to perform their habitual work and, consequently, less income and high economic burden (24). furthermore, they reflect the impact of their diagnosis with cancer, the presence of post-operative discomfort, and changes in body image after treatments (8). in physical discomfort, patients from 1 to 12 months of surgical intervention have a greater burden, that is, a greater number of symptoms, a finding that coincides with that described in the literature (6, 25). after total or subtotal gastrectomy, there is initial worsening of physical symptoms (loss of appetite and weight [which are not easily recovered], diarrhea and distress [6-9]), but tend to recover slowly between 3 and 6 months. said symptoms, which are new, are associated with symptoms derived from complementary treatments and are aggravated. bearing in mind that patients in follow-up after cancer surgery experience different symptoms according to the type of neoplasia and treatment, intervention strategies must adapt to specific management approaches. education on the risk of developing late symptoms must start prior to treatment because it can help patients to predict and control their symptoms (21). likewise, it is necessary to classify side effects or complications expected to provide information during the follow-up, which permits patients to treat symptoms with greater efficacy and, thus, improve their quality of life (26). in a long-term follow-up study, after total gastrectomy due to carcinoma (9), alteration of sleep pattern was identified, linked to multiple factors, like physical discomfort, uncertainty regarding the future, and anguish, findings that coincide with our study. weakness, distress, and fatigue are reported as a group of symptoms that must be cared for in follow-up programs. fatigue is a common discomfort and of high prevalence, with great impact 9 follow-up of gastrectomized patients due to gastric cancer in a cancer center of bogota, colombia l gloria mabel carrillo y otros on the quality of life of people that endure it and on their social functioning (27). junn et al. (28) state that fatigue may be related with anemia, due to lack of iron. lim et al. (29), in an observational study of patients gastrectomized due to early gastric cancer, reported that the risk of anemia increased over time and affected 37.1 % of patients 48 months after surgery. in the sociocultural and family component, economic problems and difficulty to return to the work role prevail in the three groups of patients, findings that coincide with han et al. (30). cancer survivors experience difficulties due to the economic impact they face because of the reduction of their socioeconomic activity or because of problems returning to work, besides the burden of health costs during treatment. multidisciplinary rehabilitation during follow-up of gastrectomized patients is an intervention that can have a positive impact on the capacity of patients to return to work and, hence, reduce the economic burden on their families and society in general (31). nursing plays an active role in caring for patients with cancer, who have complex care needs at home (32). due to this, nursing must consider the physical symptoms, emotional alterations, and limitation of the functional state in survivors with cancer. thus, it is essential to strengthen the education of these patients in aspects concerning eating habits, report of discomfort symptoms during monitoring and follow-up of outpatient programs. in addition, it is decisive to involve other health professionals to obtain articulated care, based on management consensus, with active participation by patients with gastric cancer. this type of study has several limitations, which is why the findings must be carefully interpreted. disease burden perceived by patients with gastric cancer was addressed in only one cancer institution in the city of bogota; this, although a referent, is not the only institution managing these types of users. additionally, access to patients turned out wasteful and affected involving a higher number of participants. bearing in mind the aforementioned, future research must include a higher number of patients and be of longitudinal nature in gastrectomized survivors to determine the contribution by clinical, social, and cultural factors in perceived burden. however, this is a first referent that approached patients as source of direct information. it compared three groups with the variable time of surgical intervention to provide information related to morbidity expressed in the symptoms to define the disease burden. all this will permit proposing strategies aimed at improving the quality of life of survivors with cancer. conclusions most patients gastrectomized due to gastric cancer in the group of up to 36 months of follow-up have a low global disease burden in the dimensions of symptoms of emotional and spiritual distress, physical discomfort and sociocultural and family alteration. however, in the follow-up group from 1 to 12 months, physical discomfort is higher. in relation with the functional scale, most patients are above 90 in their score. conflict of interests: none declared. acknowledgments: national cancer institute (instituto nacional de cancerología), bogota (colombia) for its support in the development of the research within the framework of the phd thesis groups of symptoms in adults with gastric cancer subjected to gastrectomy. faculty of nursing, universidad nacional de colombia. 10 año 19 vol. 19 nº 2 chía, 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junio de 2017 aprobado: 5 de diciembre de 2017 doi: 10.5294/aqui.2018.18.1.6 para citar este artículo / to reference this article / para citar este artigo moreno-gonzález mm, salazar-maya am, tejada-tayabas lm. experiencia de cuidadores familiares de mujeres con cáncer de mama: una revisión integradora. 2018; 18(1): 56-68. doi: 10.5294/aqui.2018.18.1.6 resumen objetivo: identificar la evidencia científica de enfermería relacionada con la experiencia de los cuidadores familiares de mujeres con cáncer de mama. método: revisión integradora siguiendo los lineamientos de ganong; búsqueda en bases de datos: embase, ovid, pubmed, sage journals, scielo, google academic, isi web of science e scopus, artículos publicados entre los años 2000 y 2016. resultados: se incluyeron 18 artículos producto de investigaciones primarias de tipo cualitativo, cuyos referentes teórico-metodológicos fueron fenomenología y teoría fundamentada; las técnicas de recolección de datos fueron la entrevista semiestructurada y en profundidad. se presentan y discuten como hallazgos las siguientes categorías: impacto del diagnóstico; lo que implica ser cuidador; efectos en el cuidador; estrategias de afrontamiento; cambios en los roles y las relaciones; apoyo social. conclusiones: las características de los cuidadores son variables, es necesario conocer sobre la cultura y recursos propios de cada contexto. los cuidadores requieren información clara y oportuna en relación su función y las habilidades a desarrollar, especialmente para otorgar apoyo emocional. es necesaria la indagación de dichas experiencias en el contexto mexicano. las relaciones padres e hijos en las familias de mujeres con cáncer de mama es un asunto poco estudiado, se requieren futuros estudios en este tema. palabras clave neoplasias de la mama; cuidadores; enfermería; literatura de revisión como asunto (fuente: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 56-68 57 experiencia de cuidadores familiares de mujeres con cáncer de mama: una revisión integradora l maría mercedes moreno-gonzález y otros año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 56-68 experience of family caregivers of women with breast cancer: an integrative review abstract objective: identify scientific nursing evidence related to the experience of family caregivers of women who have breast cancer. method: an integrative review was conducted following ganong’s guidelines. it included a database search of embase, ovid, pubmed, sage journals, scielo, google academic, isi web of science e scopus. the focus was on articles published between 2000 and 2016. results: the review included 18 articles that are the result of qualitative primary studies; their theoretical-methodological references were phenomenology and the grounded theory. semi-structured and in-depth interview were the data collection techniques used. the following categories are presented and discussed as findings: impact of the diagnosis; what it means to be a caregiver; effects on the caregiver; coping strategies; changes in roles and relationships; and social support. conclusions: the characteristics of the caregivers vary and it is necessary to know about the culture and resources in each context. caregivers require clear and timely information about their role and the skills they must develop, especially if they are to provide emotional support. it is necessary to research these experiences in the mexican context. the relationship between parents and children in the families of women with breast cancer is a topic that has received little study, and future research on this subject is required. keywords breast neoplasms; caregivers; nursing; literature review as a subject (source: decs). 58 aquichan issn 1657-5997 eissn 2027-5374 experiência de cuidadores familiares de mulheres com câncer de mama: uma revisão integradora resumo objetivo: identificar a evidência científica de enfermagem relacionada com a experiência dos cuidadores familiares de mulheres com câncer de mama. método: revisão integradora que segue os lineamentos de ganong; busca em bases de dados: embase, ovid, pubmed, sage journals, scielo, google academic, isi web of science e scopus, artigos publicados entre 2000 e 2016. resultados: foram incluídos 18 artigos produto de pesquisas primárias de tipo qualitativo, cujos referenciais teórico-metodológicos foram fenomenologia e teoria fundamentada, técnicas de coleta de dados foram a entrevista semiestruturada e em profundidade. são apresentados e discutidos como achados as seguintes categorias: impacto do diagnóstico; o que implica ser cuidador; efeitos no cuidador; estratégias de enfretamento; mudanças nos papéis e nas relações; apoio social. conclusões: as características dos cuidadores são variáveis; é necessário conhecer sobre a cultura e recursos próprios de cada contexto. os cuidadores requerem informação clara e oportuna sobre sua função e habilidades a desenvolver, em especial para oferecer apoio emocional. requer-se o questionamento dessas experiências no contexto mexicano. as relações pais-filhos nas famílias de mulheres com câncer de mama é assunto pouco estudado e, portanto, exige estudos. palavras-chave cuidadores; enfermagem; literatura de revisão como assunto; neoplasias da mama (fonte: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 56-68 59 experiencia de cuidadores familiares de mujeres con cáncer de mama: una revisión integradora l maría mercedes moreno-gonzález y otros introducción la agencia internacional para la investigación sobre el cáncer (globocan) reporta que el cáncer de mama (cama) representa el 25 % de todos los cánceres, es la primera causa de muerte en mujeres de las regiones menos desarrolladas, y la segunda causa en las de mayor desarrollo después del cáncer de pulmón (1). la organización mundial de la salud (oms) promueve su control mediante la prevención y detección oportuna. a pesar de ello, su incidencia continúa al alza (2). a nivel mundial, diversos grupos de investigación de enfermería trabajan en la búsqueda de métodos de detección oportuna más efectivos y accesibles, en la identificación de riesgos y en la mejora en los tratamientos, en donde figuran principalmente países como españa, estados unidos e irlanda (3-5). en países de américa latina, como méxico, se observa el mismo patrón internacional: los casos nuevos se presentan primordialmente en mujeres mayores de 40 años (6), es la segunda causa de mortalidad en las mujeres de 20 años y más (14,8 %), y ocupa la cuarta causa por tumores malignos en general (7,7 %) (6). el cama es una enfermedad que produce sufrimiento en quien la padece debido a la incertidumbre de su pronóstico; al tratamiento, que incrementa los trastornos físicos, y a su relación con la muerte, lo que produce gran impacto en la dinámica familiar ya que comúnmente la mujer realiza roles de esposa, madre y cuidadora por excelencia en las diferentes etapas de desarrollo de quienes le rodean (7). la mujer diagnosticada con cama tiene diversas necesidades de cuidado que se modifican de acuerdo con el tratamiento y la trayectoria de la enfermedad; a lo largo de este proceso presenta sentimientos de ansiedad y temor, además de manifestar múltiples signos y síntomas como náuseas, fatiga y dolor que deterioran su calidad de vida (8, 9). el cuidado es una actividad compleja que se transforma con el paso del tiempo, y es fundamental para la subsistencia y el desarrollo del ser humano (10); en el cuidado prevalece una relación de interés y atiende a las necesidades de quien es cuidado (11). la familia es la fuente primordial de cuidados cuando alguno de sus integrantes se ve afectado por la enfermedad, especialmente en el caso de las afecciones crónicas, las cuales son permanentes y con tendencia al deterioro de la persona afectada (12, 13). el cuidador familiar brinda soporte en la toma de decisiones, acompaña durante la hospitalización y el tratamiento, apoya en las actividades de higiene personal; es representante, comunicador, proveedor económico; brinda apoyo emocional y compensa los roles antes desempeñados por la mujer al mismo tiempo que los suyos propios, lo que resulta en un proceso desgastante que puede generar sentimientos de impotencia al no contar con una capacitación y no tener una idea clara del proceso de la enfermedad y de lo que tiene que hacer. la experiencia de ser cuidador modifica de manera trascendental su vida, transforma las relaciones con la persona cuidada, consigo mismo y con sus semejantes (14), y es un factor determinante para el éxito del tratamiento y la mejora del pronóstico de salud de la mujer (8). por lo anterior surge la necesidad de realizar una revisión integrativa como método de investigación, que permite el proceso de creación y organización de un cuerpo de literatura, así como la incorporación de las evidencias en la práctica clínica. este método de indagación está sujeto a los mismos estándares de rigor, claridad y réplica de una investigación primaria (15). pregunta de investigación: ¿cuál es la evidencia científica de enfermería relacionada con la experiencia de los cuidadores familiares de las mujeres con cama? el objetivo del presente estudio es identificar la evidencia científica de enfermería relacionada con la experiencia de los cuidadores familiares de mujeres con cama. como principal aporte al conocimiento disciplinar se destaca que al reunir y sintetizar los resultados encontrados se profundizará en la experiencia de los cuidadores de mujeres con cama, ello favorece la apreciación del estado del arte en un contexto general, que guía a los profesionales de la salud para identificar las áreas de oportunidad de futuras investigaciones, además de favorecer la aplicación del conocimiento existente. método se realizó una revisión integrativa de la evidencia científica bajo la metodología propuesta por ganong (16), quien plantea cinco pasos para su desarrollo: selección de pregunta para la revisión, búsqueda y selección de estudios de acuerdo con criterios establecidos, representación de las características de los estudios, información relevante y valoración de los hallazgos, interpretación y síntesis de la información. 60 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 durante el periodo agosto-octubre de 2016 se realizó una búsqueda en las bases de datos: ebscohost, embase, ovid, pubmed, sage journals, scielo, google académico, isi web of science y scopus, como se observa en la figura 1. las palabras clave utilizadas fueron: breast cancer, experience, caregivers, family care, informal care, nursing, las cuales se combinaron mediante los operadores boleanos “and” y “or”. los criterios de inclusión fueron: investigaciones primarias realizadas por personal de enfermería, con texto completo disponible en línea, en los idiomas inglés, español y portugués, publicados en el periodo 2000 al 2016. se excluyeron: tesis, capítulo de libro y editoriales. los artículos que se encontraron repetidos en diferentes bases de datos se consideraron solo una vez. figura 1. diagrama de flujo de identificación, selección e inclusión de los estudios resultados caracterización de los artículos se identificaron 493 artículos, de los cuales 18 cumplieron los criterios de inclusión para conformar la muestra de esta revisión integradora. se caracterizó cada uno de los artículos seleccionados y se realizó un análisis exhaustivo de los contenidos; se elaboró una matriz de análisis con los siguientes datos: título, año, país de origen, objetivo, métodos, categorías identificadas, características de los cuidadores, discusión, conclusiones y referente teórico, como se observa en la tabla 1. los artículos fueron publicados en las revistas científicas: psycho oncology [3], cancer nursing tm [3], support care cancer [2], western journal of nursing research [1], international journal of nursing practice [1], quality life research [1], european journal of oncology nursing [1], esc anna nery [1], revista brasileira enfermagem [1], leisure sciences [1], canadian oncology nursing journal [1], oncology nursing society [1] y malaysian journal of public health medicine [1]. los países de origen fueron: canadá [5], brasil [3], irán [2], australia [2], estados unidos [2], finlandia [1], inglaterra [1], corea [1] y malasia [1]. en relación con el año de publicación, durante el periodo del 2000 al 2005 se identificaron dos artículos, del 2006 al 2010 se identificaron cuatro artículos y en los años del 2011 al 2016 se identificaron 12 artículos. el total de los estudios son de tipo cualitativo, tres de ellos se realizaron con un enfoque fenomenológico, uno hermenéutico y uno con la teoría fundamentada; el resto de estudios [13] no especifica el referente teóricometodológico empleado. las técnicas reportadas para la colecta de la información fueron: entrevistas semiestructuradas cara a cara [7], entrevistas vía electrónica [2], entrevista en profundidad [4], entrevista no estructurada [1], cuestionarios autoaplicados [3], grupos focales [1]; las preguntas fueron dirigidas a cuestionar la experiencia de ser cuidador de una mujer con cáncer. para el análisis de los datos los artículos reportan el uso de análisis de contenido [4], temático [4], fenomenológico [2], análisis desde la teoría fundamentada [1], técnico [1], análisis de narrativa [2] y de interpretación básica [1]; los demás artículos [3] no definen el tipo de análisis de datos utilizado. el número de participantes de cada estudio osciló entre 6 y 91, con una media de 23; un estudio estuvo dirigido a cuidadoras mujeres, ocho incluyeron a hombres fuente: moher d, liberati a, tetzlaff j, altman dg, the prisma group. preferred reporting items for systematic reviews and meta-analyses: the prisma statement. 2009; plos med 6(7): e1000097. doi:10.1371/journal.pmed.1000097 61 experiencia de cuidadores familiares de mujeres con cáncer de mama: una revisión integradora l maría mercedes moreno-gonzález y otros título base de datos revista y año de publicación idioma país 1. viviendo bajo una nube de amenaza: la experiencia de las mujeres cuidadoras iraníes con un pariente de primer grado con cáncer de mama (24) ebsco psycho oncology 2016 inglés irán 2. perspectivas de los hombres en el afrontamiento individual y familiar del cáncer de mama y quimioterapia de sus esposas (26) ebsco western journal of nursing research. 2000 inglés canadá 3. el papel de otras personas importantes en el cuidado de las mujeres con cáncer de mama (23) ebsco international journal of nursing practice. 2007 inglés finlandia 4. transición al nuevo rol de cuidador para familias de pacientes con cáncer de mama: un estudio descriptivo exploratorio cualitativo (18) ebsco support care cancer 2015 inglés irán 5. "los dos simplemente confiamos y nos apoyamos en el señor": un estudio cualitativo de la religiosidad y la espiritualidad entre las sobrevivientes de cáncer de mama afroamericanas y sus cuidadores (33) ebsco qual life reseach 2014 inglés usa 6. apoyo de los cuidadores primarios para los miembros femeninos de la familia con cáncer de mama o ginecológico (27) embase cancer nursingtm 2016 inglés corea 7. exploración del papel y las fortalezas de la familia después de que una mujer joven es diagnosticada con cáncer de mama: puntos de vista de las mujeres y sus familias (29) ovid european journal of oncology nursing. 2012 inglés australia 8. cuidadores masculinos de pacientes con cáncer de mama y ginecológico. experiencias de cuidado de sus cónyuges y compañeros (21) pubmed cancer nursingtm 2012 inglés australia 9. llegando al apuro con el cáncer de mama: experiencias de los cónyuges con sus esposas en los primeros seis meses (20) google académico journal psychosoc oncology. 2010 inglés estados unidos 10. significado del cuidado familiar a las mujeres mastectomizadas (34) scielo esc anna nery 2012 portugués brasil 11. un estudio cualitativo explorador de la experiencia de los parientes de sobrevivientes de cáncer y sus puntos de vista sobre el papel de la atención primaria (31) scielo support care cancer 2012 inglés inglaterra 12. nuestra vida después del cáncer de mama: percepciones e implicaciones desde la perspectiva de la pareja (22) scielo revista brasileira enfermagem 2011 portugués brasil 13. “estaba atrapado en casa”: experiencias de los hombres con el ocio y el significado de esas experiencias durante y después del diagnóstico de cáncer de mama de su pareja (32) pubmed leisure sciences 2015 inglés canadá 14. “todo lo que puedo hacer es ayudar”: experiencias de transición de cónyuges masculinos cuidadores de las mujeres con cáncer de mama (25) pubmed canadian oncology nursing journal 2016 inglés canadá 15. cuidado para mujeres con cáncer de mama avanzado (28) pubmed psycho oncology 2003 inglés canadá 16. perspectivas psicosociales de las parejas de pacientes con cáncer de mama tratadas con mastectomía (9) ovid cancer nursingtm 2008 inglés brasil 17. participación de la esperanza: las experiencias de los cónyuges masculinos de mujeres con cáncer de mama (19) ovid oncology nursing society. 2012 inglés canadá 18. experiencia de los maridos con el cáncer de mama de sus esposas: un estudio cualitativo (30) scopus malaysian journal of public health medicine 2012 inglés malasia tabla 1. artículos incluidos en la síntesis fuente: elaboración propia. 62 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 cuidadores cónyuges, dos investigaciones consideraron a la diada paciente-cuidador y los restantes [7] tuvieron como población de estudio a los cuidadores familiares en general. en todos los casos, los participantes fueron elegidos por conveniencia de acuerdo con los criterios de inclusión. no se identificaron modelos o teorías de enfermería en el marco de referencia de los artículos. síntesis de los resultados se realizó el análisis de contenido de los resultados de cada artículo (17); se identificaron las categorías descritas por los investigadores, coincidencias y variaciones; emergieron 7 categorías y 15 subcategorías, como se muestra en la figura 2. figura 2. experiencia de los cuidadores familiares de mujeres con cama intención, sin preparación y sin conocimiento (18); esto los lleva a desarrollar sentimientos de desesperación, enojo, depresión y tristeza (9). dichos sentimientos pueden influir en gran medida en la experiencia de cada cuidador. los cuidadores refieren la necesidad de atender la ansiedad que presentan constantemente, ellos se sienten más tranquilos al observar que sus familiares son atendidos, además de recibir información veraz y oportuna que les permita colaborar en cada etapa del tratamiento (18, 23). amenaza y riesgo. los cuidadores manifiestan sentirse vulnerables ante la posibilidad de tener cáncer (24), ya sea por la presencia real de la enfermedad en su familiar, o al sentirse con mayor probabilidad de padecerlo (24). se identifica como amenaza el hecho de que el cuidador se percibe como ineficiente para afrontar el cuidado (18), además de sentirse incapaz de modificar la realidad del diagnóstico de su pareja (25). existe miedo constante e incertidumbre respecto al proceso de la enfermedad (21), preocupación por las finanzas (21) y la pérdida de la estabilidad laboral (25). lo que implica ser cuidador familiar. el cuidado familiar requiere una participación sincera y cariñosa; no es solo la realización de procedimientos técnicos. al respecto se identifican las siguientes subcategorías: 1. conocimiento de la enfermedad. tras el diagnóstico, una de las primeras reacciones del cuidador es buscar información (25) acerca de la enfermedad y su pronóstico (23), y el cuidado físico y emocional (26) después de la cirugía y la quimioterapia (27). para los cuidadores es importante que la información recibida sea honesta y sencilla (23). 2. cuidado técnico. consiste en la realización de cuidados específicos, algunos tan cotidianos como ayudar a la mujer a tomar un baño, hasta aquellos que implican un grado de preparación como el cuidado de una herida y el registro de los fluidos drenados (25). los cuidadores se preocupan por realizar las técnicas de manera apropiada para proteger y evitar cualquier daño (21). mencionan sentir ansiedad y, en algunos casos, satisfacción al demostrar su ingenio y capacidad (21). a medida que las pacientes se volvieron más débiles, el cuidado requerido fue mayor y uno de los retos más importante fue otorgar cuidado ante una fase terminal (28). 3. apoyo emocional. se manifiesta a través de la presencia y cercanía con las mujeres afectadas, es un “estar ahí” (25, 27, 29). fuente: elaboración propia. impacto del diagnóstico. para los cuidadores, el conocer el diagnóstico de cama en la mujer se expresó como la aparición inesperada de una enfermedad catastrófica (18) relacionada con una amenaza de muerte inminente (9, 18, 19). algunos refieren tener la sensación de “estar clavados” por el cama (20) al identificarlo como un proceso doloroso para el cual no se encuentran preparados (9, 18, 21, 22), desconocen lo que significa ser cuidador de una persona con cáncer y se convierten súbitamente en uno sin 63 experiencia de cuidadores familiares de mujeres con cáncer de mama: una revisión integradora l maría mercedes moreno-gonzález y otros este tipo de cuidado generó mayor preocupación, pues se encontró más estresante y difícil de manejar (25), ya que como cuidadores juegan un papel importante para sobrellevar los cambios emocionales de sus esposas (30). los participantes dedicaron parte de sus vidas solo a mantenerse al lado de la mujer con cama, por medio de actividades placenteras antes del tratamiento y acompañándolas durante los trayectos hacia y desde el hospital (29, 31). el cama afecta el autoconcepto y la autoestima de la mujer que lo padece (22, 24, 27) debido al valor que se otorga a la mama respecto a su feminidad, lo que ocasiona inseguridad y vulnerabilidad (22, 24). ejercer la sexualidad plenamente y sentirse atractiva requiere de la intimidad, el respeto y la comunicación con su pareja (9, 22). el cuidador familiar contribuye a reafirmar el autoconcepto y autoestima de la mujer (22, 30). las mujeres que no tienen compañero pueden presentar mayor dificultad en relación con los cambios en la vida diaria, especialmente respecto a la sexualidad (22). efectos en el cuidador 1. reconocimiento de su función. el esposo de la mujer con cama que asume el papel de cuidador lo hace como parte de su alianza matrimonial (28); otros cuidadores asumen este papel como la extensión de una función como hija, hermana, o bien como amigos, principalmente cuando la paciente no tiene una pareja sentimental o dicha pareja no asume el papel de cuidador (28). algunos participantes experimentaron un cambio en la identidad asociado a una pérdida, en donde la tarea de cuidar a la mujer los llevó a descuidar las cuestiones relacionadas con ellos mismos, y a dejar de lado compromisos, actividades y proyectos de su vida propia (18, 21, 28, 31). los cuidadores se prepararon con el deseo de ser capaces de participar activamente en el cuidado de las mujeres; algunos manifiestan haber estado presentes y activos en cada momento del tratamiento, otros refieren haber estado presentes en calidad de observadores, en contraste con aquellos que se sintieron ignorados y excluidos (23, 18, 21). 2. cambios en el autocuidado. se observó que ser cuidador de una mujer con cama genera implicaciones directas en el autocuidado; en un primer momento se presenta un abandono total de su persona debido a los cambios en los roles y las necesidades de la mujer (18, 21, 28, 31). con el paso del tiempo se identifica un aumento en las actividades de autocuidado, las cuidadoras mujeres refieren la importancia de la autoexploración mamaria debido a que perciben mayor riesgo de padecer cama (21, 24, 31). otras de las actividades de autocuidado son dirigidas a mantener el equilibrio entre el compromiso de cuidar, el ocio y el descanso (29, 32), o bien para acompañar a la mujer en el cuidado de su salud (26, 27, 29). 3. sentimientos. los cuidadores refieren sentimientos de tristeza, incertidumbre, preocupación y miedo (25). algunos de ellos sintieron culpa por la sensación de haber contribuido a que el cáncer apareciera (27); por sentirse incapaces para atender las necesidades de cuidado (32), o por creer que hubiesen podido hacer mejor las cosas (21). refieren haberse sentido “atrapados en casa” (32), sentimiento que no siempre externalizaban al tener dificultad para expresar sus emociones, o bien, preferían callarlo para no ocasionar mayor conflicto (21). estrategias de afrontamiento 1. hacer lo que funciona. esto significa buscar la manera de saber qué es lo que funciona y cómo ponerlo en práctica (19, 20). los cuidadores necesitaron ser sensibles a lo que ocurría en torno al estado de salud de la mujer (20, 25) identificando sus necesidades físicas y emocionales (20), algunos le llamaron “hacer lo que se tiene que hacer” (20, 33), o bien, “tomar la carga” (20); asimismo, coincidieron en la necesidad de orientar los esfuerzos para facilitar la recuperación de su ser querido (28, 33, 34). 2. espiritualidad y religiosidad. existe una tendencia a buscar respuestas en algo divino, se hace referencia a un ser supremo, en quien los cuidadores y sus familias confían y tienen fe. buscan un significado de la enfermedad y la fortaleza para enfrentarla (22, 23, 25, 33), además de identificarlo como un medio de defensa psicológica (30). 3. tener esperanza y ser positivo. en relación con la espiritualidad y religiosidad se identificó que la esperanza (22, 23, 25, 33) y la decisión de ser positivo (19, 20) fueron estrategias que contribuyeron para afrontar el proceso de la enfermedad (27, 33), en un intento por regresar y permanecer en la normalidad el mayor tiempo posible (19, 33); manifestaron no detenerse ante el cáncer y esperar siempre lo mejor (19, 20, 25). cambios en los roles y las relaciones 1. relación de pareja. se identifican cambios en la vida de pareja en relación con la convivencia diaria; se encuentran dos efectos: uno de ellos es que la pareja se une más, al querer 64 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 pasar más tiempo juntos (9, 19, 32), ya sea por el temor a la pérdida, por el cambio de rutina o por un nuevo sentido de la convivencia (28). por el contrario, otros manifiestan una relación más difícil de sobrellevar que provoca la separación; en algunos casos, el compromiso de proporcionar cuidado a las mujeres los llevó a descuidar las cuestiones relacionadas con ellos mismos y con sus parejas. otro factor presente es el cambio en la relación íntima derivado del proceso del cáncer y los efectos del tratamiento, principalmente los cambios en la imagen de la mujer (20, 21, 30). 2. roles en la familia. se identifica la presencia de cambios en los roles realizados por los integrantes de la familia (27), y las relaciones entre ellos (25), con un ajuste de sus prácticas y estilos de vida de acuerdo con el estadio de la enfermedad y las necesidades de las mujeres (24, 27). para este proceso, la comunicación fue un factor de vital importancia (29, 25). previo al diagnóstico, las mujeres desarrollaban roles de esposa, madre, ama de casa y trabajadora; sin embargo, en cierto momento, especialmente después de la cirugía o durante la quimioterapia, las mujeres se ven imposibilitadas y en algunos casos los cuidadores desempeñan también dichos roles (22). 3. relación padre-hijos. algunos de los cuidadores refirieron que su rol como padre se había deteriorado y la comunicación con sus hijos había disminuido debido a la carga de cuidado y el sentirse siempre abrumados (20). los hombres señalaron que realizar de manera simultánea las actividades de cuidado de la mujer, y las actividades domésticas y laborales les dificultó la realización de sus roles anteriores, principalmente el rol de padres y la comunicación con sus hijos; emplearon diversas estrategias de afrontamiento como la reorganización y distribución de las tareas del hogar y el apoyo de personas ajenas a su familia; no obstante, en repetidas ocasiones refirieron la sensación de pérdida de la libertad asociada a su rol de cuidador (26, 32). apoyo social 1. familia. es la red de apoyo más sobresaliente, con diversas funciones y situaciones según el contexto (9, 20, 22, 26, 27, 34). ya sea desde el momento del diagnóstico, después de la cirugía (34), o en los momentos de tensión (26), la familia interviene en la experiencia de los cuidadores; existe una relación de apoyo mutuo (20, 22). se identifica una relación de apoyo bidireccional, en donde la mujer en su condición de enfermedad mantiene una participación activa para lograr el afrontamiento familiar (20, 29). 2. amigos y sociedad. algunos cuidadores mencionan la importancia del apoyo de los amigos al ser considerados como de la familia (23, 25, 30). por el contrario, para otros, la ayuda ofrecida no era la más oportuna, a lo que llamaron la “paradoja de la ayuda” (29); ante esta situación la familia actuaba como un “tapón de la sociedad” ya que las mujeres con cáncer no deseaban ser vistas por nadie y se sentían mejor en casa y solo con su familia (29). 3. los sistemas de salud. como apoyo social son poco mencionados (9), los cuidadores se enfocan más en la observación de las barreras para recibir atención (31) y en el deseo de contar con mayor información en torno al tratamiento y pronóstico de sus familiares (23). discusión ninguno de los artículos incluidos en la presente revisión fue publicado en idioma español; brasil es el único país de américa latina en donde se identificó producción científica. al igual que lo reportado por swore et al. (35) prevalece la presencia de estudios de canadá, estados unidos, irán, australia y corea. aunque la producción de evidencia científica resultado de investigaciones cualitativas sobre el tema es incipiente, se aprecia un incremento de publicaciones en los últimos cinco años (35), lo que denota el interés y la necesidad de abordar el tema específico de la experiencia de los cuidadores de mujeres con cama. la ausencia de la aplicación de modelos o teorías de enfermería como marco de referencia no es exclusiva de las investigaciones relacionadas con la experiencia de los cuidadores de mujeres con cama, blum y sherman (36) refieren que las enfermeras rara vez utilizan de manera consciente modelos o teorías en su práctica cotidiana, y el uso de estos marcos para el cuidado de pacientes con cáncer y sus familias es una necesidad. los estudios dirigidos por martín, struthers, jung hee y sus respectivos colaboradores coinciden en que el cáncer produce un impacto intenso en la familia y desencadena sentimientos como ansiedad, depresión, tristeza y culpabilidad (25, 27, 37). el impacto del diagnóstico se debe a los cambios que inician de manera súbita, como las nuevas responsabilidades y la variación de hábitos en la alimentación, entre otros (37). las hijas de mujeres con cama tienen mayor conciencia de la detección precoz de la enfermedad, al sentirse vulnerables y con mayor riesgo de padecerlo (24). 65 experiencia de cuidadores familiares de mujeres con cáncer de mama: una revisión integradora l maría mercedes moreno-gonzález y otros por otro lado, diversos estudios reportan que el cáncer representa una carga económica considerable debido a las pérdidas de productividad por bajas laborales y el costo de los servicios (21, 25, 38). los cuidadores ayudan en tareas particulares como la alimentación, el aseo, el apoyo en la ejecución de tratamientos o medicinas (21, 25, 39). y quienes proveen de cuidados a pacientes en estadios de disfuncionalidad más avanzados por la enfermedad oncológica presentan sobrecarga en las áreas física, social, psíquica y económica de su vida (28, 40). el apoyo emocional sirve como un amortiguador para afrontar los eventos estresantes que implica padecer el cama; el paciente se siente más vulnerable y requiere de los cuidados que le puede otorgar su cuidador (25, 30, 41-43). por su parte, el cuidador familiar puede sentirse agobiado (44, 45); cuidar familiares con enfermedad crónica genera un impacto sobre la libertad personal y la salud del propio cuidador (32, 46, 47). el estudio de krikorian et al. relata que los cuidadores aplazan sus actividades cotidianas como los encuentros sociales y las actividades de ocio (46). el impacto emocional del rol de cuidador fue destacado por garcía et al. (48) como estrés ante la incertidumbre que desencadena el no saber el rumbo de la enfermedad; en contraste, este mismo autor refiere como emociones positivas: alegría, felicidad, optimismo que son debidas a la mejora y esperanza del cuidador ante la posibilidad de recuperación (19, 20, 48). la espiritualidad puede convertirse en una poderosa fuente de fortaleza como estrategia de afrontamiento (22, 23, 25, 30, 33), es un proceso de recuperar la fuerza interior para dar sentido a su situación, y se identifica como un factor que puede ser alimentado (49, 50); de la misma manera, tener esperanza juega un papel preponderante en mantener una actitud positiva (22, 23, 25, 33). krikorian et al. (46) identificaron dificultades del cuidador en la relación con la paciente; por el contrario, qiuping li y yuen loke (50) concluyeron que hay una sensación de cercanía. en la presente revisión, al igual que lo enunciado por sánchez (47), se identificó una dualidad entre los cambios de la relación de la pareja, con situaciones de mayor cercanía, así como de distanciamiento. martín et al. refieren que la incertidumbre debe manejarse de manera efectiva para lograr la adaptación y el afrontamiento (37); ante esta situación, el cuidador presenta un cambio de papel, abandona súbitamente el rol primario en su hogar, e incluso el laboral (18, 21, 28, 31). cortés et al. concluyen que las familias funcionales presentan una mayor adaptación psicológica ante la presencia del cáncer (51). la familia juega un papel primordial como red de apoyo de la mujer, al igual que en niños y adolescentes en tratamiento oncológico (52-54). carrillo et al. reiteran que el cuidado es asumido principalmente por cónyuges, familiares del paciente y allegados, quienes no poseen formación relacionada con el cuidado y no reciben remuneración económica (55). krikorian et al. (46), así como ambrosio (43), se suman a lo encontrado en esta revisión en lo referente a la necesidad expresada de los cuidadores sobre la falta de orientación y aceptación por parte de los profesionales de la salud (18, 21, 23). conclusiones en la integración de la evidencia encontrada hay una gran diversidad en las características de los cuidadores, por lo que los profesionales deben conocer sobre la cultura, las creencias y los recursos propios de cada contexto para dirigir las intervenciones. el cama en méxico es un problema de salud de gran importancia, con alto impacto en la calidad de vida de la mujer y su familia, al igual que en otros países como canadá, estados unidos y brasil; sin embargo, la evidencia científica para el cuidado de los pacientes no es identificable en el contexto mexicano, por tanto, es necesaria la indagación y difusión de dichas experiencias. los cuidadores familiares requieren ser escuchados y acompañados en la realización de sus funciones de cuidado, y tienen derecho a recibir información clara y oportuna sobre lo que significa ser un cuidador familiar, los conocimientos y las habilidades que deben desarrollar. las intervenciones deben considerar a la familia como una unidad, y deben estar dirigidas a fortalecer las habilidades para proporcionar apoyo emocional, basadas en las principales estrategias de afrontamiento como la espiritualidad y la esperanza. las relaciones entre padres e hijos de las familias de mujeres con cama son un asunto poco estudiado, por lo que se requieren futuras investigaciones en este tema. si bien la presencia y cercanía, el “estar ahí”, constituyen un soporte importante para las mujeres, el proceso de comunicación no queda del todo claro a través de los hallazgos de los estudios revisados; la comunicación verbal como estrategia de soporte, tanto para la mujer como para el cuidador, es un aspecto importante por indagar. conflicto de interés: ninguno declarado. 66 año 18 vol. 18 nº 1 chía, colombia marzo 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adolescentes com câncer: experiências com a quimioterapia. rev lat am enfermagem. 2010;18(5):864-72. disponible en: http://www.scielo.br/scielo.php?script=sci_arttext&pid=s010411692010000500005&lng=en&nrm=iso&tlng=eshttp://jpepsy.oxfordjournals.org/content/36/4/375.full 53. lombardo ms, popim rc, suman al. da onipotência ao desgaste : as perspectivas do adolescente. rev latino-am enferm. 2011;19(3). 54. dos santos d, brito guirardello e, yamaguchi kurashima a. estrés relacionado al cuidado: el impacto del cáncer infantil en la vida de los padres. rev lat enferm. 2013;21(1):1-7. disponible en: http://www.scielo.br/pdf/rlae/v21n1/ es_v21n1a10.pdf 55. carrillo g. g, sánchez-herrera b, barrera-ortiz l. habilidad de cuidado de cuidadores familiares de niños con cáncer. rev salud pública. 2015;17(3):394-403. disponible en: http://10.0.60.86/rsap.v17n3.32408%5cnhttps://search.ebscohost.com/login.aspx?direct=true&db=lth&an=111060770&lang=es&site=ehost-live 07. valores humanos año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 18 resumen el presente artículo analiza algunos aspectos relacionados con los valores y actitudes como elementos básicos en la formación del profesional de enfermería, puesto que gran parte de la práctica de enfermería se relaciona con la fundamentación teórica y los conocimientos técnicos y científicos; se dejan un poco de lado la formación humanística y la ética, que constituyen aspectos esenciales para el desempeño de una profesión que se desarrolla a través de las relaciones humanas. por lo tanto, el conocimiento y la formación ética del profesional de enfermería deben fortalecerse durante sus etapas de formación, tanto en el pregrado como en el postgrado, ya que el enfermero trabaja bajo la influencia de una escala de valores profesional y personal cuando entra en relación con los pacientes, y en algunos momentos los valores del profesional de enfermería pueden entrar en conflicto con los del paciente. de acuerdo con la american association of colleges of nursing, que planteó algunos valores como esenciales en la práctica de la enfermería profesional, se debería tener en cuenta que las actitudes y los valores en cuanto contenidos educativos no comparten la misma estructura formal y material que los conceptos o principios identificados comúnmente como contenidos instructivos o conocimientos, ya que son las convicciones básicas las que sirven de criterio para orientar la propia vida y las disposiciones personales para hacer o dejar de hacer algo, preferir un curso u otro de acción, o estar dispuesto a comportarse de una manera determinada. por ello, es importante utilizar estrategias particulares para la enseñanza y la evaluación, fundamentadas en métodos cualitativos. palabras clave valores humanos, conocimientos moral, técnico y científico. abstract this article analyzes some aspects related with values and attitudes as basic elements in the formation of nursing professionals, because much of nursing practice is related with theoretic founding and technical and scientific knowledge; humanistic and ethical formation, important aspects for the performance of the profession, developed through human relations, are set aside. as a matter of fact, knowledge and ethical formation of nursing professionals must be strengthen during undergraduate and postgraduate formation, due to the nurse patient relation influenced by a scale of professional and personal values, and sometimes the professional values may be in conflict with the patient values. according to the american association of colleges of nursing that states some values as essential for professional nursing practice, it must be considered that the attitudes and values as educative contents does not share the same formal and material structure as the concepts or principles commonly identified as instructive contents or knowledge, because the basic convictions are the ones which serves as criteria to guide ones life and personal dispositions to do something or to prefer one way to act. it is important to use particular strategies for teaching and evaluation, based on qualitative methods. key words human values, moral, technical and scientific knowledges. ángela susana hernández posada algunas consideraciones acerca de los valores humanos y el profesional de enfermería 19 s importante que un profesional de enfermería aprenda, por ejemplo, la teoría y las técnicas apropiadas de reanimación cardiopulmonar (rcp), pero de igual importancia para este caso son los conocimientos éticos que tenga, ya que estos le ayudarán a saber cuándo y por qué debe realizarse la reanimación. también puede encontrarse con que algunos casos de reanimación entran en conflicto con su escala personal de valores. por lo tanto, el conocimiento y desarrollo ético del profesional de enfermería debe fortalecerse durante sus etapas de formación, tanto en el pregrado como en el postgrado, ya que el enfermero trabaja bajo la influencia de una escala de valores tanto profesional como personal cuando entra en relación con los pacientes y, a su vez, estos también tienen su propia escala de valores. en algunos momentos, los valores del profesional de enfermería pueden entrar en conflicto con los del paciente. en estos casos el primero deberá diseñar un plan de atención en el cual se brinde cuidado al paciente sin lesionar sus valores. una parte fundamental en la formación del profesional de enfermería debe orientarse hacia el conocimiento de sí mismo, con el objeto de comprender mejor sus actitudes, sentimientos y comportamientos y cómo inciden estos en las relaciones profesionales. una vez que haya identificado los valores que motivan su comportamiento personal y profesional, le será más fácil ayudar a los pacientes a determinar los valores personales que influyen en sus actitudes y comportamiento. la comprensión de los valores personales y profesionales de uno mismo y los fundamentos éticos sobre los que se construye la profesión de enfermería ayudan a la enfermera a enfrentarse a la angustia e incertidumbre morales, a los desafíos y a los dilemas éticos que con frecuencia creciente influyen en la práctica de enfermería. la american association of colleges of nursing1 planteó en 1986 los siguientes valores como esenciales en la práctica de la enfermería profesional: • la estética: la expresión personal armónica, el interés por las cosas amables, la habilidad e iniciativa creadoras. • el altruismo: el interés por el bien ajeno, aun a costa del propio. • la igualdad: la capacidad para identificarse con los demás, considerándolos semejantes con los mismos derechos. • la libertad: la libre determinación de la capacidad de elección y selección que tiene un individuo y la cual, a su vez, presupone un compromiso con sí mismo y con los demás. • el respeto a la dignidad humana: consideración, deferencia y atención en el trato hacia el otro, quien merece ser reconocido y estimado. • la justicia: actitud moral o voluntad decidida a dar a cada uno lo que es suyo. es la virtud de la equidad, medida, igualdad y orden. • la verdad: conjunto de principios en los que se supone ha de basarse no solo el comportamiento del ser humano sino su comprensión del universo. nitidez y claridad en juicios y razonamientos. • la prudencia: saber actuar con tacto, cautela, prevención y moderación. discreción, guardar lo que pueda hacer daño a otro. • la tolerancia: consideración hacia la manera de ser, obrar y pensar de los demás, aunque sea contraria a la propia. • la responsabilidad personal y profesional: capacidad de sentirse obligado a dar una respuesta o cumplir un trabajo sin presión externa alguna. responder por los actos propios y de otros. • el cuidado y la salud: esmero y atención para fomentar, prevenir, evitar el deterioro y recuperar el estado óptimo que le permita al individuo ejercer todas sus funciones. 1 american college of nursing. essentials of college and university education for professional nursing, washington, d.c., 1986. “bueno”, “malo”, “valores”, “significado”, el “debería ser...” son palabras que se utilizan para describir el conocimiento moral de la enfermería. gran parte de la práctica de enfermería se relaciona con los conocimientos técnicos, es decir, con el aprendizaje de los motivos y los métodos para realizar las técnicas necesarias. sin embargo, los conocimientos científicos, la fundamentación teórica y especialmente la formación humanística y ética son aspectos esenciales para el desempeño de una profesión que se desarrolla a través de las relaciones humanas. año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 20 está bastante difundida la idea de que los valores y las actitudes son contenidos de enseñanza-aprendizaje que no son competencia exclusiva de los docentes. hay quienes piensan, con bastante sentido común, que el medio sociofamiliar en el que se desenvuelven niños y adolescentes y los medios de comunicación audiovisual con los que ellos se relacionan constituyen las principales y más poderosas fuentes de aprendizaje efectivo. algunos autores consideran que es poco importante evaluar los valores y actitudes y pretender su enseñanza, dado que, por lo general, lo que de ellos se enseña en las instituciones educativas está en clara oposición con aquellos otros que están presentes en la sociedad: ¿cómo educar en la solidaridad, la tolerancia y el diálogo cuando en nuestra vida cotidiana se dan continuas muestras de comportamientos insolidarios, injustos o dogmáticos? por esta vía de argumentación, tan real como desalentadora, fácilmente se llegaría a convenir en la imposibilidad de enseñar y, por tanto, evaluar valores y actitudes en el marco educativo. sin negar que los valores y las actitudes se aprenden en distintos contextos sociales, familiares y escolares, constituye un reduccionismo eludir la función educadora y también evaluadora de estos contenidos irremediablemente educativos dentro de la institución escolar. además, rechazar esta función es contribuir a que los alumnos se abandonen a toda suerte de valores y contravalores, actitudes positivas y negativas. sin la necesaria formación sistemática en unos valores y actitudes determinados, estaría constantemente hipotecada su educación y, por tanto, el futuro de la sociedad. con bastante frecuencia se aplica la misma lógica de enseñanza de los conocimientos a los valores. muchos profesionales de la educación creen que estos son unos contenidos que se añaden a los ya tradicionales y que, por ello, deben continuar con la misma forma de enseñarlos. sin embargo, las actitudes y los valores en cuanto contenidos educativos no comparten la misma estructura formal y material que los conceptos o principios identificados comúnmente como contenidos instructivos o conocimientos. por ello, deben utilizarse estrategias particulares para enseñarlos y evaluarlos, fundamentadas en métodos cualitativos. cuando se enseñan conocimientos de historia o de ciencias, fácilmente se percibe que el profesor expone ante sus alumnos un conjunto de hechos, ideas o explicaciones para demostrar, con suficiente rigor, la verdad de lo expuesto. además, aumentará su validez si con ello cada alumno aprende del modo más correcto posible. son, a fin de cuentas, conocimientos, bien de hechos o de ideas, que se rigen por ciertas reglas lógicas y que, por lo común, discurren entrelazados. en los ámbitos del saber, especialmente los relacionados con la ciencia, se comparte la convicción de que todo conocimiento humano es discursivo, es decir, solo puede ser racional, y cuando este carece de razones, aquel otro no puede ser conocido y, por lo tanto, enseñadoaprendido y evaluado. si los conocimientos son un conjunto de saberes que están basados en razones de diversa índole, ordenados de forma sistemática y pretenden alcanzar la verdad de los hechos, las actitudes y los valores se basan no en razones de orden intelectual, sino en el orden del corazón, y justamente se exhiben en el sentimiento y la voluntad del hombre. a través de estas fuentes de conocimiento no racional se puede conocer un ámbito peculiar de la realidad humana: las formas de interpretar, de estar y actuar en el mundo en que se vive. y estas formas son la manifestación más evidente de los valores y las actitudes de cada individuo. son las convicciones básicas, que sirven de criterio para orientar la propia vida, y las disposiciones personales para hacer o dejar de hacer algo, preferir un curso u otro de acción, o estar dispuesto a comportarse de una manera determinada. pero, como ya se analizó, es necesario atender las vigencias sociales para establecer cuál es el contenido de los valores y las actitudes. lo que entendamos por valor determinará, en gran medida, cómo se enseña y se evalúa. por esta razón, considero necesario, antes de explicitar los modos de evaluación, aclarar brevemente cuál es el concepto de valor y delimitar, en sus rasgos más generales, cómo se enseña. el valor es, a la vez, una realidad objetiva y subjetiva. por eso, los valores comparten una dualidad no separable: poseen una realidad en sí valiosa (objetiva) y, simultáneamente, admiten interpretaciones variadas. de ahí que se pueda decir que la vida humana, espacio donde se realizan los valores, exige la participación de todas las personas implicadas como elementos imprescindibles para aceptar que el valor es algo real y también para crear nuevas perspectivas del mismo. en educación debemos acentuar el carácter real de los valores. estos no son objetos de la imaginación, ni ficciones que pertenecen al mundo de lo ideal. son realidades enraizadas en nuestra cultura, desde las que pensamos y actuamos. solo puede ser tomado como real un valor cuando, en educación, descubrimos que merece la pena esforzarse por ello en nuestra vida. y con tal fin, el profesor debe presentarlo como algo valioso, alejado de la vaguedad y de la fantasía. junto con el carácter real del valor debe resaltarse su doble faceta de acerca de la enseñanza y evaluación de los valores algunas consideraciones acerca de los valores humanos y el profesional de enfermería 21 inevitable y cotidiano. no hay persona sin valores. por eso, no se puede prescindir de ellos en tanto que constituyen claves de interpretación del hombre y de sus realizaciones concretas. por otra parte, con bastante frecuencia se los ha presentado ligados a grandes personajes o a proyectos de gran envergadura. de ahí que haya sido normal otorgarles cierto carácter mítico, al relacionarlos con personas extraordinarias, excepcionales. vista así, la enseñanza de los valores ha carecido de la fuerza suficiente para que los individuos se apropien de ellos, por considerarlos propios de personalidades con características poco comunes. por eso, es preciso “desmitificar” el valor. sin negar la importancia que tiene el uso de modelos para su enseñanza, sería conveniente rescatar su carácter cercano, próximo o cotidiano. los valores percibidos en la realidad más cercana a uno mismo se vuelven más atractivos a nuestra sensibilidad estimativa. asimismo, la perspectiva teórica de la actitud en la que nos situemos determinará cómo entendemos su enseñanza y evaluación. las actitudes son disposiciones, relativamente estables, para comportarse de una determinada manera y en determinadas situaciones, referentes a personas, objetos o acontecimientos. pueden predecir la conducta y expresan, además, los distintos modos de situarse el individuo ante los valores. es decir, las actitudes se derivan de estos y dinamizan la conducta dándole fuerza y tensión, más que dirección y sentido, que serían más propios del valor. constituyen, por así decirlo, la vía operativa de plasmación de los valores en una determinada conducta. en cuanto disposiciones relativamente estables al realizar determinadas conductas, las actitudes nos permiten actuar frente a personas, objetos o situaciones concretas de un modo más fácil, oportuno, coherente y constante. la educación en actitudes es una tarea no solo posible, deseable, sino también exigible, si se quiere educar realmente en una dimensión tan importante del educando. ante los rápidos y profundos cambios que continuamente se producen en nuestra sociedad, así como ante la velocidad creciente con que los conocimientos se suceden unos a otros, el continuo avance científico y técnico, el sentido cada vez más provisional de los saberes y la pluralidad de valoraciones que los seres humanos manifiestan en los asuntos sociales justifican de algún modo el esfuerzo por una educación cuyo objetivo sea el facilitar a los alumnos disposiciones estables en su conducta, que les permitan aprender a pensar, investigar, tomar decisiones, participar en asuntos públicos, etc. si, en definitiva, educamos personas para que sean capaces de ser protagonistas de su propio proceso de aprendizaje, el desafío de cada individuo es lograr, mantener y asumir plenamente sus responsabilidades y compromisos, acrecentar su propia cultura y ejercer sus derechos, todo ello ayudado por una educación permanente o recurrente a lo largo de toda la vida. cabe ahora preguntarse: ¿cuáles son los criterios y los modos de evaluar los contenidos actitudinales? si la evaluación implica definir aquello que se pretende evaluar y la definición de valor y actitud ya ha sido abordada en el apartado anterior, ahora corresponde centrarse en los criterios y metodologías que son apropiados para su adecuada evaluación. resulta aparentemente paradójico que en los currículos actuales se destaque como novedad importante la incorporación de los contenidos actitudinales a la práctica educativa del aula, mientras que casi no se aportan criterios de evaluación a este respecto. por el contrario, hay abundancia de ellos para los contenidos conceptuales y algo menos para los procedimentales. ¿por qué se ha producido esta situación? félix ortega, en su libro la profesión del maestro, explica que esto puede deberse a las siguientes razones: 1. los valores y las actitudes, al no enseñarse como conocimientos, exigen ser reinterpretados a la luz de las normas, reglas y hábitos que regulan la convivencia en el contexto en que se desenvuelven los alumnos. 2. un mismo valor puede ser interpretado y manifestado de diversos modos, por lo que el profesorado deberá establecer una prioridad estimativa que le permita determinar qué conductas o expresiones de valor se corresponden con las interpretaciones que son más comúnmente aceptadas en la sociedad. 3. existen multitud de actitudes hacia personas, objetos o situaciones. los profesores, padres y otros agentes educadores, directamente implicados en el proceso formativo del alumno, deberán establecer qué actitudes son objeto de enseñanza-aprendizaje para las distintas etapas y ciclos educativos. 4. deben seleccionarse aquellos valores y actitudes que estén orientados prioritariamente al desarrollo personal y humanizador de los alumnos. 5. deben atenderse las actitudes y los valores que gozan de mayor demanda y relevancia social. 6. es preferible elegir aquellos valores y actitudes que constituyen el mínimo común denominador de todas las áreas curriculares ampliamente compartido. por ello, no tienen por qué ser abordados todos y cada uno de los valores y actitudes posibles en el currículo escolar: se aconseja concentrar los esfuerzos en torno a un valor y a las actitudes necesarias para su consecución. año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 22 alzate piedrahíta, maría victoria. “la educación moral y los valores son también un ambiente de desarrollo cognitivo y evolutivo”, revista ciencias humanas, vol. 4, n° 12, junio, 1997. arango puerta, gerardo. “los valores en la educación superior en américa latina”, revista orientaciones universitarias. arizmendi p., octavio. universidad y valores, santafé de bogotá, 1992. arroyo, m. p. ética y legislación en enfermería, mcgraw-hill interamericana, madrid, 1992. camargo, rafael a. ética y educación: aportes a la polémica sobre los valores, magisterio, 1994. camps cervera, victoria. los valores de la educación, 1994. carreras, llorenc, y otros. cómo educar en valores, narcea, 1997. elliot. el cambio educativo desde la investigación, acción moral, 1993. farrel, marlene. memorias. ponencia: tendencia y proyección del ejercicio profesional de enfermería. primer simposio nacional de enfermería “impacto de la política social en la educación y la práctica de enfermería”, universidad de la sabana, 1996. garavito rodríguez, alberto. el lenguaje de los valores, impresión urbana ltda., 1997. garcía hoz, víctor, y otros. perfiles de la educación personal, aspaen. hernández, ángela. percepción y vivencia de los valores institucionales en docentes y estudiantes de la facultad de enfermería de la universidad de la sabana, universidad santo tomás, 1998. kolvenbanch, peter-hans. “educación y valores”, universidad iberoamericana, revista orientaciones universitarias, septiembre, 1991. lópez rivera y colaboradores. valores humanos con base en la convivencia social, universidad de san buenaventura, facultad de educación, santafé de bogotá, d.c., 1996. mesa, josé alberto. “crisis de valores en la educación. hacia una nueva visión de la educación moral”, revista ciencias humanas, vol. 2, n° 35, enero-junio de 1992. mora, guillermo e. valores humanos y actitudes positivas, voluntad, 1995. niño d., jaime. educación ética y valores humanos. lineamientos curriculares, ministerio de educación nacional, magisterio, 1998. orestano, francesco. los valores humanos. ortega, félix; velazco, agustín. la profesión de maestro, cide, 1991. prieto castillo, adriana. educación y valores, universidad de san buenaventura, bogotá, 1990. reich, ben. valores, actitudes y cambios de conducta, 1980. revista unión javeriana, “educación en valores”, vol. 6, n° 1, abril, 1997. rodríguez estrada, mauro. los valores clave de la excelencia, 1993. salas, begoña. desarrollo de capacidades y valores de la persona, magisterio, 1995. suárez higuera, mariela. familia y valores, magisterio, 1998. zubiría samper, miguel. tratado de pedagogía conceptual. formación de valores, 1996. bibliografía 7. existe cierta resistencia del profesorado a la adquisición de actitudes y valores como objetivos educativos, al considerar que ello podría ser una injerencia indebida en la conciencia de los alumnos. en cuanto a las metodologías para evaluar valores y actitudes, aún no contamos con los suficientes conocimientos pedagógicos para poder hacerlo en la práctica escolar. en general, existen métodos, técnicas e instrumentos que proceden de otras áreas de investigación (psicología social, antropología cultural, sociología, etc.), que si bien pueden ser aplicados en el aula, no son totalmente transferibles al ámbito educativo, ni es dable considerarlos válidos en cualquier proceso de enseñanza-aprendizaje. son muy escasos aún los esfuerzos por desarrollar una evaluación netamente pedagógica de actitudes y valores para que esta sea más adecuada a la realidad escolar. algunos métodos y técnicas de evaluación proceden de la investigación cualitativa. la observación sistemática, el análisis de las producciones de los alumnos, los diarios de clase, los debates, entrevistas y asambleas son algunos de los instrumentos propuestos para la evaluación de los contenidos actitudinales. estos instrumentos requieren una preparación específica para su correcto uso e interpretación, se necesita cierto tiempo adicional para la obtención de los datos objetivos y, en algunas técnicas, se emplean métodos de análisis de cierta complejidad. sin negar su validez para la evaluación de actitudes y valores, creo que se debe tratar de llegar, de modo realista, a que puedan ser utilizados en las condiciones normales de enseñanza de los centros, sin sobrecargar un trabajo que lo convertiría en irrealizable y sin la exigencia de conocimientos y técnicas muy especializados. la información que proporcionan las técnicas de evaluación cualitativa es de gran importancia para encauzar de modo más sistemático las intuiciones, evidencias y matices que el profesor va recogiendo de su trabajo diario como docente. sin embargo, el empleo de otras técnicas o instrumentos de evaluación que posibiliten la objetivación de la evaluación proporciona información más contrastada, sistematizada y, por lo tanto, más objetiva que la sola información facilitada por las evidencias subjetivas del profesor. no obstante, el uso de metodologías combinadas cualitativas y cuantitativas (observación del participante, experimentos de laboratorio, experimentos de campo, encuestas, etc.) aporta información parcial para poder juzgar, de modo más completo y real, las actitudes y los valores de los alumnos en el aula. 1 carla chacón valera1 maria bartolomé regué2 sergi font ritort3 esther cabrera torres4 how to undertake aging in a healthy way: changes and opportunities 1 orcid.org/0000-0001-8524-6189. escuela superior de ciencias de la salud, universidad pompeu fabra, spain. cchacon@escs.tecnocampus.cat 2 orcid.org/0000-0002-9802-3811. consorci sanitari del maresme, spain. mbartolome@csdm.cat 3 orcid.org/0000-0003-0056-0457. consorci sanitari del maresme, spain. sfont@csdm.cat 4 orcid.org/0000-0002-7353-0542. escuela superior de ciencias de la salud, universidad pompeu fabra, spain. ecabrera@tecnocampus.cat received: 23/10/2018 sent to peers: 05/11/2018 approved: 06/12/2018 accepted: 10/01/2019 doi: 10.5294/aqui.2019.19.1.5 to reference this article / para citar este artículo / para citar este artigo chacón c, bartolomé m, font s, cabrera e. cómo afrontar el envejecimiento de forma saludable: cambios y oportunidades. aquichan; 19(1): e1915. doi: 10.5294/aqui.2019.19.1.5 abstract objective: to know the socio-demographic characteristics of the elderly adults (60-70 years), of the population of mataró (barcelona), and their relationship with the knowledge degree and training needs perceived to face a healthy aging. materials and methods: descriptive observational cross-sectional study in which a sample of 306 people was analysed. socio-demographic data and variables related to leisure activities, health status, training, formative needs and predisposition to take a course on aging were evaluated. results: about a 60 % of the respondents showed interest in receiving training about; healthy habits (59,1 %), proper diet (62,0 %), work out (59,6 %), future limitations (62,6 %), why we grow old (61,0 %), frequent illnesses in the elderly (62,5 %), use of medication (66,1 %), use of the health system (61,9 %), social resources (70,0 %), new technologies (64,0 %), care of sick people (60,5 %), and security aspects (61,6 %). conclusions: there is a need to receive training among the elderly adult population in order to cope with aging in a healthier way. the main needs perceived by the elderly are: healthy habits, possible future limitations due to the aging process, use of medication, functioning of the health system and access to social resources, new technologies and, finally, caring for sick relatives. key words (source: decs) aging; retirement; health; habits; healthy lifestyle; training; knowledge. año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1915 the topic: promotion and prevention. contribution to the discipline: the increasing population aging brings up to health professionals, especially to community nursing, the need to know and develop the factors that have an impact on the positive development and well-being of elderly people. the present study provides a faithful picture of the training needs and interests perceived by the elderly adults in mataró. from these results, nursing can plan interventions which can be implemented from primary care centers, based on the interests of the target population, with a greater guarantee that they will improve the follow-up of health and quality of life guidelines to cope with aging in a healthier way. http://orcid.org/0000-0001-8524-6189 http://orcid.org/0000-0002-9802-3811 http://orcid.org/0000-0003-0056-0457 http://orcid.org/0000-0002-7353-0542 http://dx.doi.org/10.5294/aqui.2019.19.1.5 http://orcid.org/0000-0001-8524-6189 https://orcid.org/0000-0002-9802-3811 http://orcid.org/0000-0003-0056-0457 http://orcid.org/0000-0002-7353-0542 http://dx.doi.org/10.5294/aqui.2019.19.1.5 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1915 cómo afrontar el envejecimiento de forma saludable: cambios y oportunidades resumen objetivo: conocer las características sociodemográficas de las personas adultas mayores (60-70 años) de la población de mataró (barcelona) y su relación con el grado de conocimientos y las necesidades formativas percibidas para afrontar un envejecimiento saludable. materiales y método: estudio observacional descriptivo transversal en una muestra de 306 personas. se valoraron datos sociodemográficos y variables relacionadas con el tiempo libre, el estado de salud, la formación, los intereses formativos y la predisposición a realizar un curso sobre envejecimiento. resultados: el 60 % de los encuestados mostró interés en recibir formación sobre hábitos saludables (59,1 %), dieta adecuada (62,0 %), ejercicio físico (59,6 %), limitaciones futuras (62,6 %), por qué envejecemos (61,0 %), enfermedades frecuentes en la tercera edad (62,5 %), uso de medicamentos (66,1 %), uso del sistema sanitario (61,9 %), recursos sociales (70,0 %), nuevas tecnologías (64,0 %), cuidado de las personas enfermas (60,5 %) y aspectos de seguridad (61,6 %). conclusiones: existe la necesidad de recibir formación, entre la población adulta mayor, para afrontar el envejecimiento saludablemente. así, es preciso tener un conocimiento amplio sobre las posibles limitaciones causadas por el envejecimiento, el uso de medicamentos, el funcionamiento del sistema sanitario, el acceso a los recursos sociales, las nuevas tecnologías, el cuidado de los familiares enfermos y hábitos de vida saludables. palabras clave (fuente: decs) envejecimiento; jubilación; salud; hábitos; estilo de vida saludable; capacitación; conocimiento. 3 how to undertake aging in a healthy way: changes and opportunities l carla chacón valera and others como encarar o envelhecimento de forma saudável: mudanças e oportunidades resumo objetivo: conhecer as características sociodemográficas das pessoas idosas (60-70 anos) da população de mataró (barcelona) e sua relação com o grau de conhecimentos e com as necessidades formativas percebidas para encarar um envelhecimento saudável. materiais e método: estudo observacional descritivo transversal com uma amostra de 306 pessoas. dados sociodemográficos e variáveis relacionadas com o tempo livre, o estado de saúde, a formação, os interesses formativos e a predisposição a fazer um curso sobre envelhecimento foram avaliados. resultados: 60 % dos entrevistados demostrou interesse em receber formação sobre hábitos saudáveis (59,1 %), dieta adequada (62 %), exercício físico (59,6 %), limitações futuras (62,6 %), motivos do envelhecimento (61 %), doenças frequentes na terceira idade (62,5 %), uso de medicamentos (66,1 %), uso do sistema sanitário (61,9 %), recursos sociais (70 %), novas tecnologias (64 %), cuidado de pessoas doentes (60,5 %) e aspectos de segurança (61,6 %). conclusões: entre a população idosa, existe a necessidade de receber formação para encarar o envelhecimento saudável. assim, é preciso ter um conhecimento amplo sobre as possíveis limitações causadas pelo envelhecimento, pelo uso de medicamentos, pelo funcionamento do sistema sanitário, pelo acesso aos recursos sociais, pelas novas tecnologias, pelo cuidado dos familiares doentes e pelos hábitos de vida saudáve. palavras-chave (fonte: decs) envelhecimento; aposentadoria; saúde; hábitos; estilo de vida saudável; capacitaçao; conhecimento. año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1915 4 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 introduction aging is a physiological transformation process which is inherent to the human being and it evolves differently on each person. it is considered an important change in people’s lives because it changes their daily routines and affects their own perception and their health-related behaviours (1, 2). the world is undergoing a demographic transformation: the life expectancy increase and the fertility rate decrease are causing an inversion of the population pyramid (2, 3). currently, the spanish society reveals one of the highest life expectancies in the world: 82.87 years (4). during aging, dependency rates, disability and chronic diseases increase which causes a greater expenditure of social and health resources (5). in addition to the physical consequences, there are changes that can significantly influence the quality of life of elderly people, such as the retirement. retirement marks a turning point in people’s lives since it constitutes a transition that impels them to assume a new role in life. despite this, many people find themselves immersed in this stage without having considered its meaning or the best way to cope with it (6, 7). retirement challenges people to learn how to spend, satisfactorily, meaningfully and healthily, the time they have (8). therefore, this moment is an ideal space to provide elderly adults (9) with intervention tools that allow them a good aging process (10). healthy aging is based on promoting and maintaining functional capacity that allows well-being during old age (2). however, a high percentage of people start this stage assuming excessive burdens that can harm their health and life quality (11, 12, 13): on one hand, the parents and grandchildren’s care and, increasingly, the partner’s care (9, 10); on the other, the growing number of elderly people living on their own and taking care of themselves (11, 12). facing this scenario, there is a need to make changes in our healthcare system, coordinating health services and social services to achieve a healthy aging in a comprehensive, effective and sustainable way. health professionals have the opportunity and responsibility to respond to this new situation by enhancing preventive work, especially, the primary care nursing professionals, who have the community health work assigned. assisting the elderly to plan their old age stage, taking into account tertiary prevention, functional loss situations, and autonomy that are generated by having a chronic disease, can help to promote a healthy aging (14, 15). there are many documented interventions generated from the nursing experience to promote healthy aging (16, 17), but, in our environment, there are no studies in which the description of the subjects that concern elderly people, or what they think it would be useful to know have been identified. this is what in our study we have defined as “training needs”. the increasing on population’s aging that we are currently facing is exerting a great pressure on social and health system (18, 19). therefore, it is necessary to know the needs of the elderly adults and find answers that allow them to maintain their autonomy, functional independence and quality of life as long as possible (20). the principal aim of this study was to know the elderly sociodemographic characteristics (60-70 years), of the population of mataró (barcelona), and their relationship with the knowledge degree and training needs perceived to face a healthy aging. materials and methods study design descriptive cross-sectional observational study carried out in the primary care centers (cap), cirera-molinos, gatassa, matarócentro, riera, ronda cerdaña and ronda prim, from the city of mataró (barcelona), which covers a population of 124,280 inhabitants (19), of which 12,309 are between 60 and 70 years old (47 % men and 53 % women) (20). the study started in may 2016 and concluded in may 2017. population and sample the study population was the elderly people from the city of mataró. the inclusion criteria were: being between 60 and 70 years old, being registered in the city of mataró and being able to answer the survey autonomously. the exclusion criteria were: being included in the home care program (atdom), being admitted to a social or residential centre or not understanding catalan or spanish. the sample was selected by a randomized sampling from the population census assigned to each health centre, estimating to obtain a sample size of 300 people. for the sample size, a 5 how to undertake aging in a healthy way: changes and opportunities l carla chacón valera and others confidence level of 95 % was established, a matrix whose x-axis presented the power 80 to 95 was presented, and expected correlations between 0,1 and 0,5. a sample size of at least 244 subjects was calculated, with a power of 95 and an expected correlation of 0,1. the final number of subjects surveyed was 306. the research team was responsible for contacting the selected people; each subject was asked to participate by a telephone call. in the case that the selected patient did not meet the inclusion criteria or did not want to participate in the study, the next one was chosen from the list, and so on. study variables the main variables analysed were self-perceived knowledge degree and the training needs or interests, as well as the occupation of free time, the health status, the dose regular medication and the pathological background. the socio-demographic variables that were taken into account were age, sex, country of birth, marital status, residence neighbourhood, health reference centre, the maximum level of education accomplished, employment situation, occupation, family situation and approximate amount of monthly household income. measurement instruments the questionnaire on healthy ageing (qha) was used for data collection, developed ad hoc by a team of experts in the field of geriatrics and primary health care. the qha is aimed at the young elder population (60-70 years) and consisted of 139 items. the questionnaire evaluated demographics (including age, sex, country of origin, level of education, employment status, marital status, family situation and income level), how they spend their leisure time (activities carried out on a regular basis, including taking care of the grandchildren, time dedicated to them and caring of an ill relative), health status (this included two items which make reference to general health status: one of them has five options likert-type response option, the second item was a vertical visual analogue scale (vas) of 20 centimetres, measured in millimetres, ranging from 0, which would be the worst imaginable health state, to 100, referring to the best imaginable health state). in it, the individual had to mark the point on the vertical line that best reflected the assessment of his/her global health in that moment. it also included four more items on chronic diseases, common medicines, degree of autonomy and perception of ageing, management of new technologies (section which consists of four items with option of a dichotomous response) and, finally, the training and training needs (included 112 items with likert-type answer with four options each). the qha measures six dimensions of knowledge and training needs: health, social, spiritual, legal and economic, and leisure traits. in order to calculate the results by size, the items were codified from 0 to 3, where 0 meant “nothing”, 1 “a little”, 2 “quite a lot”, and 3 “a lot”. the total of the items belonging to the same dimension were added up together, and then, divided by the maximum possible score within in it, and the total was multiplied by 10, so each dimension was scored from 0 to 10 to ease the measurements’ comprehension. the first version of the qha was monitored by a group of 14 persons who matched with the study inclusion criteria. all of them contributed with their comments about the questionnaire through a form. taking this into account, as well as for its extension, it was determined that the questionnaire could not be done on the telephone, and this could be auto-administrated. the final version was validated by health professionals from the social ambit, as well as with the investigating team. data collect the subjects went to different health centres of the city, arrenged by telephone from their health centre. the questionnaire was completed in a self-administered way and under the supervision of two members of the research team. the questionnaire was completed in groups of between 5 and 10 people. it lasted approximately 20 minutes. data analysis a descriptive analysis of the data with central tendency and dispersion measures for the quantitative variables, and with frequency distribution for the qualitative ones was realized. the level of statistical significance was established at a p-value <0,05. the comparisons between categorical variables were realized by means of the chi-square test, and the continuous ones, with t-student or their nonparametric equivalents. the data was analysed through the statistical program spss statistics version 14.0. 6 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 ethical considerations the study was fulfilled in accordance with the articles pertaining to the helsinki declaration on ethical principles for medical research in humans, approved by the 64th world medical assembly in 2013. the permission to carry out this study (version 6 of 03/16/2016) was obtained from the ethics committee of clinical research of the maresme health consortium and the university institute for research in primary care (idiap jordi gol). all the individuals participated voluntarily, and they informed about their consent for the study: they received an informative document explaining the objectives of the study and in what it consisted of. results the data from a total of 306 subjects was obtained: the 52.1 % of them were men, and the 47,9 % women, with an average age of 64,4 years old (ds ± 3,19). the 77,6 % were married or maintained a relationship, the 12,5 % lived on their own, and the 28 % was taking care of an ill person, generally their parents. the 21 % didn’t have studies, and on the other hand, the 78 % had studies (primary studies [52 %]) or secondary studies/high school [26 %]). the digital alphabetization resulted to be majority on the positive side, as a 62,8 % of the participants affirmed to have skills on internet. as far as their labour situation, the 81,10 % were retired; the 65,60 % spend their time on, for example, sports or dancing (48,8 %), volunteering (20,8 %), arts or music (8,9 %), and more. despite that, the 19,0 % was taking care of their grandchildren as the only activity. the 56,5 % of the participants was in good health and reflected an average of 71,3 (ds ± 18,8) out of the 100 possible points. although this, mostly all the participants suffered from a chronic disease (83,6 %) and was taking an average of 2,94 pills per day (per person). regarding their aging, the 73,1 % declared their acceptation on the aging issue, while the 26.9 % felt fear, laziness or concern towards this process. table 1 shows the percentage of high self-perceived knowledge and of formative interest of the participants with respect to the different issues raised before, understanding as a high degree of knowledge or of formative interest when the subject answered “a lot” or “quite a lot” in the different items. mainly all the participants affirmed that they had a high degree of knowledge regarding aspects related to life habits (70.6 %), an adequate diet (64.2 %), work out (70.2 %), possible future limitations (67.3 %), architectural barriers (64.5 %) and the living will (68.2 %). however, around a 60 % of the respondents showed interest in receiving training about different aspects related to a healthy lifestyle (59,3 %), an appropriate diet (62,2 %), work out (59,7 %), possible future limitations (62,7 %), issues related to aging (61,1 %), frequent diseases in the elderly (62,6 %), taking medications (66,2 %) %), the use of the health system (61,9 %), social resources (70,1 %), new technologies (64,2 %), care of sick people (60,5 %) and security aspects (61,7 %). moreover, while only a 28.5 % of the subjects surveyed had completed a training course in the last five years, the 50.7 % of them said that they would take a training course on some of the previous mentioned aspects. it should be noted that the spiritual, legal, economic and leisure aspects are the least interesting among the population studied. the table 2 shows the results corresponding to the relationship between the degree of self-perceived knowledge and sociodemographic aspects. it was found that a low level of education (up to primary school) is related to a lower degree of knowledge, this relationship is statistically significant (p = 0.001) in all aspects, except in leisure, where the trend is maintained in a non-significant way (p = 0,059). likewise, in most of the aspects, men showed discreetly more knowledge, this tendency is statistically significant only in the case of the economic-legal aspects (p = 0,005). we also found an association between lower income and less knowledge, this relationship being significant in aspects of health (p = 0,003) and in economic aspects (p = 0,013). no association was found between the degree of knowledge and the employment situation, the marital status and the family situation. finally, the table number 3 shows the relationship between training interests and socio-demographic aspects. there was a clear tendency to the greater formative interest from the women over the men in all the studied aspects, being this significant in aspects of health (p = 0,014), spiritual aspects (p = 0,021) and aspects of leisure (p = 0.038). although in all aspects the highest level of studies was related to a greater educational interest, only statistical significance was found in the spiritual aspects (p = 0,040). 7 how to undertake aging in a healthy way: changes and opportunities l carla chacón valera and others table 1. percentage of high degree of auto-perceived knowledge and educational interests of participants (n = 306) in mataró (barcelona) spain source: own elaboration. percentage that manifests having a lot or quite a lot self-perceived knowledge percentage that has a lot or quite a lot interest in receiving training on this subject health do you know healthy lifestyle habits for an elder person? 70,6 59,3 do you know what is the right diet for an elder person? 64,2 62,2 do you know what kind of work out is recommended at your age? 70,2 59,7 do you know what are the possible future limitations that you may have as a result of aging? 67,3 62,7 do you know why we age and what factors intercede in it? 52,6 61,1 do you think you have information about sexuality in elder people? 34,5 46,2 do you know what are the most frequent diseases when you get elder and how do they behave? 52,3 62,6 do you know what changes in relation to medicines in the elderly? 22,0 66,2 what knowledge do you have of how to use the health system? 59,4 61,9 social traits how well do you think you know the resources and the existing social help for the elderly people? 26,7 70,1 what knowledge do you have about architectural barriers? 64,5 53,8 do you know how new technologies can help? 32,1 64,2 do you think you are ready for the role change in the family that old age supposes? 55,3 56,1 do you know how to take care of an ill person? 46,7 60,5 do you know security aspects in elderly people? do you know how to avoid risks? 53,3 61,7 do you know ways to meet people of your age? 48,3 41,4 spiritual traits are you interested in reflecting on the transcendental or spiritual dimension of life? 31,2 28,5 in the third age, a revision of one's life project is often made. how do you think you are prepared to do it? 49,5 45,5 do you feel ready to face death? 47,5 41,1 legal and economic aspects how do you assess your knowledge of making a will and inheritance issues? 68,2 45,3 do you know the document of anticipated wills? 48,3 53,0 when you retire, family income is often diminished. do you think you will be able to adapt to living with less money? 84,0 43,8 if that were the case, would you know how to invest your money? 55,7 37,5 do you have knowledge about guarantees, mortgages and other banking matters? 52,9 33,3 leisure aspects what degree of knowledge do you have about volunteering activities that the elderly people can do? 35,7 46,9 what information do you have about studies aimed at older people? 20,3 46,1 do you know where to find leisure offers and promotions for seniors? 37,2 51,2 do you know about traveling in the elderly? 40,9 56,8 8 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 table 2. relationship between the degree of auto-perceived knowledge and socio-demographic aspects (n = 306) in mataró (barcelona) spain source: own elaboration. self-perceived knowledge health traits social traits spiritual traits legal and economic traits leisure traits x (±ds) p-value x (±ds) p-value x (±ds) p-value x (±ds) p-value x (±ds) p-value sex man 5,09 (1,68) 0,956 4,74 (1.64) 0,951 4,24 (1,89) 0,663 5,83 (2,04) 0,005 3,94 (1,90) 0,277 woman 4,99 (1,81) 4,73 (1.72) 4,41 (2,19) 5,12 (2,21) 3,67 (2,24) education none 4,24 (1,90) 0,000 4,19 (1,81) 0,001 3.67 (2,16) 0,001 4,57 (2,07) 0,000 3,39 (1,91) 0,059 any education level 5,32 (1,60) 4,92 (1,57) 4,52 (1,94) 5,81 (2,07) 3,96 (2,11) employment situation active 5,09 (1,56) 0,620 4,65 (1,64) 0,803 4,57 (1,80) 0,744 5,91 (1,90) 0,101 3,29 (1,69) 0,052 unemployment 4,84 (1,68) 5,01 (1,54) 4,41 (2,21) 4,94 (2,06) 3,40 (2,44) retired 5,09 (1,77) 4,70 (1,70) 4,27 (2,05) 5,59 (2,17) 4,01 (2,06) never worked 4,95 (2,11) 4,76 (1,90) 4,11 (2,28) 4,93 (2,25) 4,25 (2,29) civil status in a relationship or married 5,10 (1,69) 0,248 4,71 (1,65) 0,651 4,23 (1,93) 0,268 5,50 (2,10) 0,626 3,84 (2,01) 0,670 single, widowed, separated or divorced 4,86 (1,90) 4,81 (1,77) 4,71 (2,31) 5,60 (2,22) 3,72 (2,31) family situation not living alone 5,05 (1,70) 0,985 4,74 (1,66) 0,638 4,22 (1,97) 0,133 5,49 (2,13) 0,488 3,90 (2,04) 0,090 live alone 5,05 (2,00) 4,70 (1,80) 5,11 (2,32) 5,70 (2,14) 3,26 (2,28) monthly income ≤1000 4,42 (1,87) 0,003 4,28 (1,73) 0,168 3,96 (2,02) 0,638 4,70 (2,19) 0,013 3,36 (2,23) 0,3341001-2500 4,93 (1,74) 4,60 (1,76) 3,97 (2,10) 5,49 (2,05) 3,59 (1,96) ≥2500 5,83 (1,45) 4,76 (1,49) 4,20 (1,89) 6,11 (1,97) 4,17 (2,04) regarding the marital status and the family situation, it was found that people who did not have a partner or who lived alone showed a greater formative interest, being significant in leisure aspects (p = 0,02 and p = 0,018). in addition, there was a trend towards greater training interest on the part of retired compared to the rest of work situations options, and on the part of those who receive an average income (1,000-2,500) compared to those who have lower and higher incomes, but we do not find statistically significant the differences in these cases. discussion the purpose of this study was to know the sociodemographic characteristics of the “young” elderly (60-70 years) of the population of mataró (barcelona), as well as the relationship with their knowledge and training needs perceived on aspects related to the coping of a healthy aging. the results obtained show that there is a need for training population sector. this study has allowed to know that as peo9 how to undertake aging in a healthy way: changes and opportunities l carla chacón valera and others table 3. relationship between socio-demographic aspects and educational interests (n = 306) in mataró (barcelona) spain source: own elaboration. training interests health traits social traits spiritual traits legal and economic traits leisure traits x (±ds) p-valor x (±ds) p-valor x (±ds) p-valor x (±ds) p-valor x (±ds) p-valor sex man 5,14 (2,52) 0,014 5,16 (2,39) 0,095 3,49 (2,62) 0,021 5,41 (3,57) 0,137 4,58 (2,50) 0,038 woman 5,89 (2,70) 5,56 (2,82) 4,32 (3,04) 6,07 (3,88) 5,17 (2,84) education none 4,85 (3,07) 0,067 4,80 (2,95) 0,183 3,35 (3,01) 0,040 5,14 (3,91) 0,135 4,33 (2,73) 0,097 any education level 5,72 (2,46) 5,53 (2,45) 4,08 (2,79) 5,92 (3,66) 5,00 (2,63) employment situation active 5,35 (2,57) 0,071 5,26 (2,78) 0,113 3,63 (2,59) 0,256 5,76 (3,48) 0,241 4,80 (2,46) 0,276 unemployment 5,46 (2,76) 5,08 (2,89) 3,83 (2,94) 6,16 (4,34) 4,90 (2,78) retired 5,73 (2,59) 5,59 (2,50) 4,12 (2,90) 5,86 (3,69) 5,00 (2,74) never worked 4,26 (2,48) 4,26 (2,02) 2,83 (2,76) 4,16 (3,04) 3,92 (2,36) civil status in a relationship or married 5,41 (2,70) 0,284 5,25 (2,61) 0,172 3,81 (2,86) 0,336 5,57 (3,74) 0,135 4,60 (2,65) 0,002 single, widowed, separated or divorced 5,88 (2,27) 5,71 (2,56) 4,19 (2,82) 6,36 (3,58) 5,77 (2,63) family situation not living alone 5,53 (2,63) 0,900 5,36 (2,60) 0,845 3,86 (2,85) 0,374 5,67 (3,77) 0,348 4,73 (2,69) 0,018 live alone 5,53 (2,47) 5,47 (2,50) 4,26 (2,78) 6,31 (3,27) 5,91 (2,25) monthly income ≤1000 5,09 (2,87) 0,811 5,13 (2,72) 0,553 3,64 (2,76) 0,305 5,52 (3,78) 0,372 4,68 (2,75) 0,2531001-2500 5,34 (2,78) 5,24 (2,79) 3,70 (2,86) 6,63 (3,87) 4,59 (2,63) ≥2500 5,05 (2,76) 4,65 (1,98) 2,59 (2,02) 4,29 (2,97) 3,61 (2,37) ple get older, they perceive that they need to know more about healthy lifestyle habits and possible future limitations in the aging process, especially on how to deal with the care of a member of the family. yet, they would like to know and have more social and technological resources. a report from the spanish ministry of health (imserso, 2002) and the health survey of catalonia (esca, 2017) already showed that, for the elder, the aspects of greatest satisfaction in their lives are their health, their fitness, their free time and their lifestyle (21,22). the characteristics of the sample are similar to other studies which have been already carried out in the catalan population (23). it is significant that more than half of the participants reported being in good health and that the average of those scored their self-perceived health status with 71.3 points. this shows that people perceive their state of health as good as long as it allows them to continue carrying out their daily activities autonomously (22,24). likewise, the results are alike to the data obtained in 2017 in the catalonia’s population (21). it is also interesting to observe the digital literacy of the participants, who the majority of them, confirm they manage well on the internet. regarding self-perceived knowledge, men claimed to have more knowledge on legal and economic aspects than women. in a study that analysed the differences between cognitive aspects and quality of life on elderly men and women, it was observed that there were differences between both genders since men had a better subjective health than women (25). however, in our study, 10 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 we obtained similar results between both sexes in the rest of the scale dimensions. from another point of view, the educational level was found to be significant in all aspects of the survey: a higher level of education implies a greater degree of self-perceived knowledge. in this respect, the study by navarro et al. (25), who found that the educational level was the major variability determinant regarding the quality of life in the elderly, beyond all the differences explained by the age or sex of the participants (25). otherwise, it was observed that the level of monthly income was related to the health and economic-legal knowledge perceived, thus having a higher knowledge people with higher incomes. aguilar-palacio et al. (26) presented similar results, in which it concluded that there were differences in terms of health and the use of the health services in the elderly according to their social class. therefore, it is necessary to ensure the accessibility and equity of health services (26). regarding the educational interest, women showed greater interest in all the survey aspects, a fact that can be explained by the progressive increase in the number of women living alone (27, 28). as other studies show, women have a greater need for social integration, which indicates that their interest in receiving training could be related, especially, with variables linked to the other’s support (25,28). besides, people who were not in a relationship, or married, or who lived alone showed more interest in leisure issues. these results agree with the solger study (24), which shows that people who live alone are more interested in doing social and leisure activities (24). literature defines in an extensive way the negative effects that can cause the role of the caregiver (29, 30, 31), although it also describes positive traits of the act of caring when the caregiver lives his task as a privilege (30). even so, the exclusive dedication to this task makes it impossible to develop other activities that could be related to a healthy aging (32). in our population, the 28 % of them took care of a relative, and the 19 % took care of their grandchildren as their only activity. although it is not the objective of our study, the role of the caregiver is considered relevant in relation to the possible affectation of the quality of life and predisposition to be formed of these people. planning aging means considering everything that can keep us active and healthy, live to the fullest and be able to meet the basic needs. in many cases, the lack of information and training can trigger situations of isolation or loss of life quality. in general, the results that emerge from this study show that older adults are interested in receiving training on different aspects of their lives to acquire knowledge that helps them maintain a good state of health during their aging. these results can help to design intervention strategies aimed at older adults to help them anticipate their needs and plan an active and healthy aging. at the same time, there is a raising in the need to have social and health resources that help older adults to occupy their free time in a satisfactory manner and without negative consequences for their own health, emphasizing facilitating the role of caregiver. different psychoeducational interventions directed to the caregiver have demonstrated their effectiveness in the past (30,16,17). an experimental study, developed by zabalegui et al., concluded that the intervention information, training and social support (infosa) reduced the overload and emotional stress and improved the perceived social support of the participants (31). similarly, other studies carried out psychoeducational interventions that showed positive effects on overload, anxiety and depression (30,16). these studies indicate that the application of psychoeducational interventions entails significant improvements in terms of people’s health and that, in addition, the application of these interventions over prolonged periods could maintain their long-term positive effects (30,16,17). given the cross-sectional nature of the study, causal relationships between the factors studied cannot be identified. however, the results obtained allow us to better understand the degree of knowledge and the training needs perceived by the elderly in relation to how they want to face their retirement and their aging. even so, it would be interesting to replicate the study in populations with different social classes, as well as to split the sample between retired and non-retired people in order to compare possible differences. the nursing professional, from primary care consultations, identifies elderly people who are in a new stage of the life cycle, in which, due to ignorance or poor planning, they find themselves in situations of isolation and loneliness, which in many cases sometimes it causes a progressive loss of health. this study will allow nursing professionals to design psychoeducational interventions adapted to the real needs of this population, which help improve their knowledge, attitudes, habits and, consequently, the health outcomes of this sector of the population. 11 how to undertake aging in a healthy way: changes and opportunities l carla chacón valera and others conclusions the findings of this study cosign that training needs perceived by older people are fundamentally, the healthy life habits, i.e. work out and diet, the possible future limitations related to aging, the use of medicine, how the health system runs, the acces to social resources, the new technologies and, finally, their ill relatives’ care. on the other side, it also validates that elements 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16(3): 370-381. doi: 10.5294/aqui.2016.16.3.8 resumen objetivo: explorar las emociones que emergen en la mujer durante el embarazo, parto y el puerperio a lo largo del itinerario asistencial de atención primaria y hospitalaria. método: estudio cualitativo basado en la teoría fundamentada. se realizaron dos grupos de discusión a profesionales: obstetras, matronas y enfermeras. igualmente, se desarrollaron entrevistas en profundidad a mujeres en el puerperio. resultados: las emociones de la mujer en la atención perinatal aparece como categoría central. a partir de ésta, las emociones negativas emergen por la interacción de cinco metacategorías: a) miedo: dolor al parto y desajuste de expectativas, b) ansiedad e incertidumbre: enfrentándose a la amenaza del riesgo y la desinformación, c) vergüenza: comprometiendo la privacidad, d) ira y desamparo: asimetría en la estructura relacional, e) soledad: discontinuidad en la atención asistencial. las emociones positivas surge de la metacategoría: f) tranquilidad y confianza: construyendo una interacción clínica simétrica y humanizada. conclusiones: se constata una variabilidad emocional debido a la coexistencia de los modelos tecnocrático y biopsicosocial. este proyecta humanidad en los cuidados perinatales, frente a un modelo biomédico marcado por una estructura relacional paternalista y asistencia fragmentada; ambos serán determinantes en la emergencia de emociones en la atención perinatal. palabras clave emociones; atención perinatal; satisfacción del paciente; prestación de atención de salud; enfermería; enfermería obstétrica; enfermería maternoinfantil (fuente: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 370-381 371 explorando las emociones de la mujer en la atención perinatal. un estudio cualitativo l josé arnau sánchez y otros año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 370-381 exploring women’s emotions in perinatal care: a qualitative study abstract objective: to explore women’s emotions during pregnancy, childbirth and the postpartum period throughout the primary and hospital care itinerary. method: qualitative study based on grounded theory. two discussion groups were held with obstetricians, midwives and nurses. in-depth interviews were conducted with women in the postpartum period. results: women’s emotions in perinatal care are a central category. based on this category, negative emotions emerge from the interaction between five meta-categories: a) fear: childbirth pain and mismatched expectations, b) anxiety and uncertainty: facing the threat of risk and misinformation, c) shame: compromising privacy, d) anger and helplessness: asymmetry in the relational structure, e) loneliness: discontinued care. positive emotions emerge from meta-category: f) calm and confidence: building a symmetrical and humanized clinical interaction. conclusions: the researchers found an emotional variability due to the coexistence of the technocratic and bio-psycho-social models. these models cast a sense of humanism on perinatal care, compared to a biomedical model marked by a paternalistic, relational structure and a fragmented care; both are decisive in the emergence of emotions in perinatal care. keywords emotions; perinatal care; patient satisfaction; health care services; nursing; obstetrical nursing; maternal-child nursing (source: decs, bireme). 372 aquichan issn 1657-5997 explorando as emoções da mulher no atendimento perinatal. um estudo qualitativo resumo objetivo: explorar as emoções que emergem na mulher durante a gestação, parto e pós-parto ao longo do itinerário assistencial de atenção primária e hospitalar. método: estudo qualitativo baseado na teoria fundamentada. realizaram-se dois grupos de discussão com obstetras, parteiras e enfermeiras. além disso, desenvolveram-se entrevistas em profundidade a mulheres no puerpério. resultados: as emoções da mulher no atendimento perinatal aparece como categoria central. a partir desta, as emoções negativas emergem pela interação de cinco metacategorias: 1) medo — dor ao parto e desajuste de expectativas; 2) ansiedade e incerteza — enfrentamento da ameaça do risco e da desinformação; 3) vergonha — comprometimento da privacidade; 4) ira e desamparo — assimetria na estrutura relacional; 5) solidão — descontinuidade no atendimento assistencial. as emoções positivas surgem da metacategoria: 6) tranquilidade e confiança — construção de uma interação clínica simétrica e humanizada. conclusão: constata-se uma variabilidade emocional devido à coexistência dos modelos tecnocrático e biopsicossocial. este projeta humanidade nos cuidados perinatais, diante de um modelo biomédico marcado por uma estrutura relacional paternalista e uma assistência fragmentada; ambos serão determinantes na eclosão das emoções no atendimento perinatal. palavras-chave emoções; atendimento perinatal; satisfação do paciente; prestação de atenção de saúde; enfermagem; enfermagem obstétrica; enfermagem materno-infantil (fonte: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 370-381 373 explorando las emociones de la mujer en la atención perinatal. un estudio cualitativo l josé arnau sánchez y otros introducción el embarazo, parto y puerperio, etapas del proceso perinatal, constituyen una poderosa experiencia para las mujeres caracterizada por un particular sentido de fragilidad, vulnerabilidad, estrés psíquico y cambios emocionales que marcan la vivencia de la mujer (1). el deseo de que el proceso reproductivo culmine con el nacimiento de una criatura sana, sin menoscabo de la salud materna, ha propiciado no solo la institucionalización médica de la atención perinatal, sino también una atención asistencial bajo la égida del modelo médico hegemónico (2, 3). este paradigma presenta rasgos basados en el biologicismo, estructura asimétrica y pasiva en la relación sanitario-paciente, privando a la mujer de la atención a la que tiene derecho. esta despersonalización encuentra en las instituciones sanitarias una atmósfera muy favorable, excluyendo la actuación autónoma de los agentes de salud e instaurándose la secuencialización y el control del proceso productivo. esta forma de trabajo fragmentada impacta en la vivencia de la mujer a lo largo del proceso reproductivo (4). en el ámbito hospitalario se establece una asimetría de poder entre la mujer y los agentes de salud basada en una relación de dominio-adaptación en la que el paciente debe adaptarse a lo instituido, proyectando una visión empobrecida del enfermo, al que frecuentemente se le priva del respeto y la atención a que tiene derecho como persona. esta despersonalización encuentra en el hospital moderno una atmósfera muy favorable dado que las prácticas sanitarias se llevan cabo en busca de la máxima racionalidad y productividad, excluyendo la actuación autónoma de los trabajadores e instaurándose la secuencialización y el control del proceso productivo. esta forma de trabajo fragmentada y discontinua impacta en la vivencia de la mujer a lo largo del proceso reproductivo (4). con base en esa estructura asimétrica que caracteriza al modelo médico hegemónico, la relación sanitariopaciente cobra importancia al considerarse uno de los principales indicadores de la calidad de la atención sanitaria prestada (5, 6). conforme nos acercamos a un modelo intervencionista característico del pensamiento médico hegemónico, emerge un tipo de relación más paternalista donde el equipo obstétrico expresa sus objetivos técnicos y profesionales, desconociendo y excluyendo los saberes y afectos del paciente, expresándose a través de la negación, el desinterés o la carencia de importancia dada a la palabra del paciente. los distintos tipos de interacción clínica que conforman la estructura relacional y se presentan en el contexto asistencial son el paternalista, consumista, informativo, deliberativo y sistémico.. en este sentido, la estructura relacional va a estar en conexión con los valores institucionales y profesionales, generando unas prácticas asistenciales que son responsables de las situaciones emocionales que experimentan los usuarios cuando interactúan con la cultura de las instituciones sanitarias, determinando la percepción, la satisfacción y los sentimientos generados a partir de la experiencia vivida (5). encuestas corporativas de satisfacción de usuarios en atención especializada correspondientes a los barómetros sanitarios del año 2009 en la región de murcia concluyeron que las infraestructuras del área de partos, la información ofrecida al usuario y el trato recibido por el personal sanitario necesitan ser mejoradas (7). relacionado con la interacción clínica, el estudio cuantitativo desarrollado por takács et al. (8) ponía de manifiesto que la comunicación escasa y el deficiente apoyo emocional del personal durante el parto y puerperio generaban una importante insatisfacción en la parturienta así como sentimientos de preocupación y angustia. otra investigación, llevada a cabo a 1400 mujeres embarazadas en reino unido, puso de manifiesto que el nivel de satisfacción de las mujeres en la experiencia del parto era deficiente cuando no recibían ayuda de los agentes de salud y estos entraban y salían continuamente de la sala de partos (9). un reciente estudio realizado en suecia y australia mostró que los sentimientos de la mujer en el periodo perinatal se circunscribían al miedo originado por la incertidumbre durante embarazo y por la pérdida de autocontrol y deficiente apoyo del equipo de salud en el momento del parto (10). en esta línea, roosevelt y low (11), mediante el uso de grupos de discusión, identificaron que los sentimientos de miedo y ansiedad que la mujer podría experimentar en el parto estaban relacionados no solo con el dolor del parto, sino también con la dominante jerarquía médica y aspectos estructurales del modelo de cuidado de las maternidades. con la finalidad de mejorar la satisfacción de la mujer en el proceso reproductivo, el ministerio de sanidad, política social e igualdad español, publica en 2010 la guía de práctica clínica sobre la atención al parto normal. esta contempla que los profesionales, por un lado, tienen dificultades para prestar excesiva atención al bienestar emocional de la mujer y adaptación a la maternidad y, por otro, deben comprender las necesidades básicas de la mujer 374 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 en la atención perinatal para asegurar una experiencia satisfactoria (2). desde la psicología experimental se han clasificado las emociones como positivas y negativas para dar explicación a las reacciones de los individuos en su interacción y adaptación al entorno (12). en el contexto sanitario aparecen como resultado de las acomodaciones vitales que experimenta el paciente no solo en su interacción con el medio y el equipo asistencial, sino también en la concordancia o disonancia de sus expectativas con la atención recibida (13). así pues, el objetivo principal de este estudio fue identificar las emociones que se generan en la mujer durante el embarazo, parto y puerperio en relación con el itinerario asistencial de atención primaria y hospitalaria. materiales y métodos se trata de una investigación cualitativa, enmarcada en la teoría fundamentada (14) que forma parte de un proyecto más amplio cuyo objetivo general es estudiar el fenómeno de la humanización del parto y puerperio en los hospitales del servicio murciano de salud. nos apoyamos en el desarrollo de grupos de discusión como técnica necesaria para captar con riqueza descriptiva las representaciones ideológicas que los profesionales poseen sobre las unidades de análisis por explorar (15). se desarrollaron dos: uno perteneciente a personal de enfermería y matronas, y otro a personal médico. el primero estuvo constituido por tres enfermeras pertenecientes a la unidad de hospitalización de puerperio, tres matronas que ofrecen asistencia en unidad de paritorio y tres matronas que ejercen su actividad en atención primaria. el grupo focal relativo al equipo médico fue conformado por siete obstetras de las unidades de paritorio y hospitalización de puerperio. se recurrió a la entrevista en profundidad (16) por ser una herramienta de gran utilidad para el estudio de las emociones que permite a los sujetos de estudio analizar los detalles de su entorno así como recuperar el pasado de aquellas situaciones no observadas directamente. esta técnica constituye un instrumento valioso para adentrarnos en las emociones que la mujer ha experimentado en el itinerario asistencial. dado que se trataba de una investigación at home (15) y los investigadores eran conocidos en el campo laboral donde se llevó a cabo el estudio, se decidió que la moderación de los grupos de discusión y las entrevistas fuesen realizadas por pedagogos ajenos al ámbito sanitario y expertos en el manejo de herramientas cualitativas, con el fin de evitar interferencias en el discurso de los participantes. durante el desarrollo de las técnicas, las funciones del equipo investigador se circunscribieron a la supervisión del desarrollo de las sesiones y realización de anotaciones en el diario de campo de aquellos aspectos más relevantes para el análisis. una vez elaborado el guion del grupo de discusión y la entrevista fue validado mediante pruebas de pilotaje para comprobar la fiabilidad, estabilidad, consistencia, sensibilidad y especificidad del instrumento de recogida de datos (17). para ello se realizaron dos grupos de discusión exploratorios a profesionales sanitarios en la universidad de murcia. con esto se pretendía comprobar la fiabilidad y validez de las preguntas, adaptando o modificando aquellas confusas para el informante. respecto a la entrevista, se hicieron tres pruebas piloto en tres centros de salud del área de estudio, seleccionando a puérperas que cumplían los requisitos de inclusión en el estudio. sobre esta herramienta se exploraron las siguientes dimensiones: a) inteligibilidad de las preguntas en cuanto a contenido y significado, b) coherencia entre la información que se pretende extraer con los objetivos del estudio, c) idoneidad del contexto y valoración del espacio, hora del día y duración de la entrevista, y por último, d) se prestaría atención a los procedimientos de inicio-desarrollo y final de la entrevista como proceso comunicativo. con el propósito de mejorar los resultados, se decide triangular los datos confrontando la información extraída a través de la observación a profesionales que forman parte del equipo obstétrico (matronas, obstetras y enfermeras), y cuyos datos fueron recogidos en el diario de campo. dado que los investigadores eran conocidos en el ámbito hospitalario, se optó por una observación externa o no participante en la que los investigadores no se implican directamente con los informantes, manteniendo una posición neutra, sin alterar el escenario donde se desarrollan los acontecimientos (18). la distribución temporal fue de cuatro meses en centros de salud y seguidamente cuatro meses en hospital. los centros de salud de atención primaria y el hospital del área de salud i murcia oeste fueron seleccionados como unidades de estudio. las unidades de observación relativas al centro de salud fueron las consultas de las matronas. a estas llegan las gestantes derivadas por su médico de familia para la captación y el seguimiento del embarazo de bajo riesgo. se seleccionaron aquellos 375 explorando las emociones de la mujer en la atención perinatal. un estudio cualitativo l josé arnau sánchez y otros centros de salud cuyas matronas actuaron como informantes clave para la selección de las puérperas y según variables del estudio relativas a: área de salud de pertenencia y existencia de unidades ginecológicas de apoyo (uga). en aquellos centros de salud que poseen uga, unidades donde se realiza control ecográfico a la embarazada, se permitiría no solo hacer una observación más exhaustiva de la atención integral a la gestante en atención primaria, sino también explorar la naturaleza de la relación clínica establecida entre la mujer, el obstetra y la matrona. respecto al hospital fueron: unidad de paritorio (salas de dilatación y partos) y unidad de hospitalización de puerperio. es en estos espacios donde no solo va recibir la atención al parto y puerperio, sino también donde la interacción con el equipo obstétrico va a ser mayor. en ambos niveles asistenciales la observación se centró en la actitud de los profesionales, la interacción con los agentes de salud, el proceso de comunicación en la interacción clínica, los sentimientos de la mujer que emergen de dicha relación y la información recibida por el equipo asistencial. el diario de campo constituyó un recurso fundamental para el registro de memos analíticos y descriptivos. en él se recogieron anotaciones sobre el contexto donde tiene lugar la aplicación de las herramientas, las características medio-ambientales y de los informantes, sus reacciones, la colocación de los objetos, las emociones y los sentimientos de las participantes. los sujetos de estudio relativos a los profesionales se definieron atendiendo a variables específicas de selección. los perfiles básicos de las mujeres que iban a formar parte del estudio siguieron los siguientes criterios: nivel asistencial de procedencia (atención primaria y hospital del área i salud), tipo de parto (eutócico, fórceps, vacuum, cesárea no electiva), acompañamiento (continuo o permanente de la pareja), origen (españolas e inmigrantes con dominio del español), edad (20-40 años), antecedentes obstétricos (primíparas y multíparas). en relación con los profesionales, estos fueron seleccionados atendiendo: a) al nivel asistencial de procedencia, b) perfil profesional y c) funciones que desarrolla. la muestra total fue conformada por 18 mujeres y 16 profesionales. el muestreo finalizó cuando no se encontraron aportaciones relevantes para el estudio y se alcanzó la saturación de los datos (17). el trabajo de campo se realizó entre enero y diciembre 2010. los encuentros tuvieron lugar en seis centros de salud, excepto una entrevista que se desarrolló en el domicilio por expreso deseo de la mujer. los testimonios fueron grabados en formato mp3. las entrevistas duraron entre 60 y 90 minutos. el proceso de análisis de los datos fue desarrollado siguiendo los principios de la teoría fundamentada (14) y realizando una codificación abierta, axial y selectiva. en la codificación abierta, los datos fueron fragmentados en unidades más simples y manejables denominados códigos. posteriormente, seguimos el método de la comparación constante para encontrar similitudes y diferencias entre ellos. durante este proceso se obtuvieron categorías y metacategorías. se codificaron 71 códigos, los cuales fueron categorizados en 16 metacategorías. posteriormente, en la codificación axial se analizaron, compararon y discutieron estas categorías individuales emergentes para la elección de las categorías predominantes. se continuó con el muestreo teórico a la búsqueda de nuevos casos que aportaran más información y ayudaran a definir la teoría. con el proceso de codificación selectiva, y siguiendo el método de la comparación constante, se reorganizaron las categorías preliminares en categorías mayores. en total se hallaron seis categorías que dieron consistencia a los hallazgos. estas constituyeron las áreas de conocimiento a partir de la cuales, y por saturación teórica, emergió la categoría central: emociones de la mujer en la atención perinatal. esta aportó sentido a los datos y sus interrelaciones. este estudio fue aprobado por el comité ético institucional del área de salud. posteriormente, se enviaron cartas a la gerencia de dicha área detallando el propósito de la investigación. los sujetos de estudio accedieron a participar libremente, previa entrega de información verbal y escrita antes de obtener su consentimiento informado por escrito. asimismo, se les pidió el consentimiento verbal y escrito para realizar las grabaciones y se garantizó la confidencialidad de los datos. los participantes fueron informados de sus derechos y que ellos podrían abandonar el estudio en cualquier momento si lo deseaban (19). con la finalidad de preservar el anonimato, se utilizaron pseudónimos. resultados identificadas las categorías y sus relaciones teóricas, se estableció el proceso analítico de acción e interacción de las mismas que dio explicación a las emociones que expresa la mujer en la atención perinatal. este proceso representa el significado simbólico que emana de la interacción clínica. las categorías constituidas fueron miedo: dolor al parto y desajuste de expectativas; ansiedad 376 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 e incertidumbre: enfrentándose al halo del riesgo y la desinformación; vergüenza: comprometiendo la privacidad; ira y desamparo: asimetría en la estructura relacional; soledad: discontinuidad en la asistencia; tranquilidad y confianza: construyendo una interacción clínica simétrica y humanizada. miedo: dolor al parto y desajuste de expectativas el miedo tiene un origen multifactorial, con la relación clínica de los profesionales y el impacto de la cultura institucional en la atención del proceso como ejes principales. los factores que van a dar lugar a esta emoción están estrechamente vinculados a la falta de cumplimiento de expectativas de la mujer y al desajuste en las transacciones entre la mujer y los agentes de salud. otro factor vinculado al miedo, que adquiere relevancia en los testimonios, es el dolor de las contracciones. estas provocan que la experiencia sea vivida de manera traumática ante el miedo a que sean muy dolorosas. … teníamos planificado que mi marido iba a estar conmigo durante toda la dilatación y el parto, sin embargo me tocó vivirlo sin compañía porque los profesionales no le dejaron pasar y eso me asustó mucho porque era algo en lo que habías pensado durante todo el embarazo y finalmente no se pudo dar” (p 10). … me daban contracciones ya dolorosas, no dilataba nada, y era muy doloroso. finalmente me pusieron la epidural, y ya maravilloso porque yo ahí me relajé […]. yo creo que no lo hubiera disfrutado si no hubiera tenido la epidural, hubiera sido algo horroroso (p 13). las mujeres se ponen muy nerviosas y están atemorizadas cuando ven que tienen contracciones y el anestesista tarda en ponerle la epidural, y ya no te digo nada cuando ha pasado el tiempo y no se la pueden poner (m/área de paritorio diario de campo). ansiedad e incertidumbre: enfrentándose al halo del riesgo y la desinformación esta categoría se conforma cuando existe un desconocimiento real de lo que puede ocurrir a lo largo de la atención perinatal, siendo el riesgo que entraña el proceso la principal preocupación. este es representado como una amenaza constante, que no solo podría afectar la evolución de la gestación y el parto, sino también al estado de bienestar fetal. estas emociones se presentan en los dos niveles asistenciales. mientras que en atención primaria obedece a factores relacionados con las experiencias previas y la amenaza del riesgo, en la atención hospitalaria emerge como resultado de un importante déficit de información por parte de los profesionales. aunque este sentimiento aparece en la sala de dilatación, se hace más evidente en la unidad de hospitalización de puerperio debido a la escasa educación sanitaria relacionada con el asesoramiento de la lactancia y los cuidados del recién nacido. …estuve bastante preocupada con este embarazo porque hace tres años me quedé embarazada y tuve un problema en la placenta que finalmente me tuvieron que ingresar (p/atención primaria diario de campo). cuando subes a puérperas, estás muy desorientada y lo pasas fatal porque no sabes cómo manejar a tu niño […]. eché de menos unas nociones básicas, por ejemplo, ¿qué haces cuando tiene gases?; ¿lo pongo de una postura u otra?, ¿le puedo dar manzanilla o no le doy? […], en ese sentido. ahí, la atención sí que fue muy deficiente (p 4). ...lo cierto es que aunque las enfermeras en planta damos información sobre lactancia, en ocasiones es insuficiente para la señora. yo creo que si estuviéramos más implicadas, la lactancia sería más exitosa (e 1). vergüenza: comprometiendo la privacidad la vergüenza se presenta en el área de paritorio y unidad de puérperas ante la pérdida de intimidad causada tanto por factores estructurales como por la actitud de los profesionales. la observación constató que las dilataciones son compartidas y el acceso a estos espacios permanece constantemente abierto. lo mismo ocurre en el piso de puérperas donde en cada habitación hay dos camas separadas por una cortina, circunstancia que impide preservar la intimidad de la mujer en ambos espacios. ...las habitaciones [las de dilatación] se comunican unas con otras. en la otra habitación había una chica con su familiar y estaban mirándome, sentí un poco de vergüenza estar tan expuesta (p 1). ...las salas de paritorio son como un mercado, mucha gente entrando y saliendo, ¿ves? no hay privacidad para la mujer (m/ unidad de paritorio diario de campo). 377 explorando las emociones de la mujer en la atención perinatal. un estudio cualitativo l josé arnau sánchez y otros ...hay mucha gente alrededor de la mujer en el momento del parto, probablemente sea muy incómodo para la mujer que está pariendo (o 4). cuando estuve en la planta fue bastante incómodo porque no había intimidad […]. era muy difícil porque la otra señora estaba al lado con sus acompañantes (p 7). ira y desamparo: asimetría en la estructura relacional estas emociones aparecen de manera clara en la unidad de hospitalización de puerperio debido a una marcada estructura relacional paternalista entre el obstetra y la mujer, dando lugar a un déficit de apoyo informativo y tangible por parte del equipo asistencial. en este espacio se pone de manifiesto una jerarquía estructurada que coloca al personal médico en la escala superior de la estructura y al resto de profesionales en posiciones subordinadas. este espacio jerarquizado y de sumisión al colectivo médico ejerce una influencia en las actitudes del personal de enfermería, las cuales van a estar orientadas hacia una relación clínica fría y distante que conlleva despersonalización de la asistencia a la mujer. …ese trato de “venga, si te quieres ir de alta ya puedes ir estirando las piernas”, lo recuerdo fatal […]. me hizo sentir fatal, no sé qué adjetivo ponerle a esa situación. me dio mucha rabia que me tratara así (p 3). nosotras pasamos la consulta con los médicos a las 9 de la mañana, vamos con las historias clínicas de cada señora y preparándoles todo lo que necesitan para la exploración, como toda la vida se ha hecho, en esto no se ha cambiado nada (e 1). estás bien en el hospital por lo que te puedan ayudar los familiares, pero ahí las enfermeras no están contigo. las enfermeras no te ayudan a levantarte, y el primer día no te puedes ni levantar, te sientes muy débil (p 7). soledad: discontinuidad en la atención asistencial relacionado con lo anterior, emerge la soledad por la falta de atención del equipo debido a la propia organización asistencial basada en los principios del modelo médico hegemónico. en el hospital de estudio existe una organización de trabajo taylorizada en la medida que las matronas realizan sus actividades por tareas y no por procesos, hecho que dificulta la atención personalizada y el continuum asistencial a la mujer. tanto los profesionales como las mujeres lo perciben como una atención despersonalizada ...lo que es la dilatación, como un poco de abandono, pero… porque ves tantas señoras, y solo una matrona por ahí mirando, y dices: “se le habrá olvidado que estoy yo” (p 1). …no es lo mismo la relación que tú estableces con un profesional con el que te tiras 12 o 14 horas atendiéndote, asistiéndote, recuperándote; a un profesional que te coge una vía, otro te pone la epidural, otro te hace el expulsivo y otro te hace el puerperio; al final no te quedas con la cara de nadie (o 5). el problema es que hay momentos puntuales que se sienten un poco solas […].. aunque soy consciente de que están solas, es muy difícil ofrecerles una asistencia continua porque tengo que atender a más mujeres (m 6). tranquilidad y confianza: construyendo una interacción clínica simétrica y humanizada esta categoría emerge como resultado de la percepción de una atención personalizada basada en el diálogo, aportada tanto por las matronas de atención primaria como por aquellas que desarrollan su actividad en las salas de paritorio. la percepción de tranquilidad y confianza surge de la ayuda facilitada a la mujer por el equipo obstétrico para cubrir sus necesidades relacionadas con las dudas que se le pueden plantear a lo largo del proceso reproductivo, así como las actitudes de los mismos profesionales relacionadas con la empatía, sensibilidad, cortesía y amabilidad. …con la matrona de atención primaria me comunicaba muy bien, si no hubiera sido como es ella, no me habría resultado fácil el contarle cualquier problema, y eso me dio tranquilidad y confianza (p 4). …la matrona que me atendió en el parto fue muy simpática, recuerdo que me decía: “sí, ya sé que esto es muy doloroso, más sin epidural”, dice, “pero bueno, te ha venido así, tú confía en mí, dame la mano, apriétame a mí…” estuvo ahí conmigo todo el tiempo hablándome (p 15). …para mí el parto fue una experiencia muy grata y satisfactoria. recuerdo que los médicos y las matronas estaban conmigo 378 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 constantemente, me preguntaban cómo me encontraba, qué necesitaba. fueron todos muy amables, sabían en todo momento lo que podía necesitar (p 17). categoría central: emociones de la mujer en la atención perinatal una vez analizado el itinerario asistencial de atención primaria y hospitalaria que la mujer debe recorrer en todo el proceso perinatal, se llegó a comprender que aunque aparecen emociones positivas relativas a la tranquilidad y confianza, y negativas basadas en el miedo, la incertidumbre, la vergüenza, la soledad, la ira y el desamparo, son estas últimas las que adquieren mayor relevancia en la atención hospitalaria. los datos arrojaron que la mujer tiene que realizar múltiples procesos de adaptación y acomodación en su interacción con el entorno donde tendrá lugar la atención obstétrica. un medio que se rige por una organización sanitaria propia del pensamiento tecnocrático y un modo de entender la atención obstétrica compatible con los principios del modelo biomédico. esta relación repercute negativamente en las expectativas creadas por la mujer y, por consiguiente, en la satisfacción de la experiencia vivida en el medio hospitalario. sin embargo, en momentos puntuales, el equipo de salud trata de satisfacer y humanizar la experiencia de la mujer conectándose con sus valores, deseos, preocupaciones y expectativas, garantizando una experiencia rica en emociones positivas. discusión el estudio pone de manifiesto que el dolor a las contracciones y el desajuste entre la información adquirida en atención primaria y lo que sucede en la institución hospitalaria es la principal causa del miedo experimentado en la mujer en atención hospitalaria. investigaciones internacionales relacionan el miedo con las creencias, experiencias negativas en el parto anterior, deficiencias en la información aportada y la falta de empoderamiento de la mujer en las decisiones sobre el proceso reproductivo (20, 21); sin embargo, en nuestro estudio adquiere mayor relevancia la incapacidad de la mujer ante el abordaje del dolor, la idea de un dolor inaguantable y el desajuste de expectativas derivado de la escasa adecuación de información desde la atención primaria. resultados que coinciden con estudios de corte cuantitativo y cualitativo cuyos hallazgos revelan, por un lado, que la mayor preocupación de las mujeres es el grado de dolor y su duración en el parto así como la inseguridad que tienen para enfrentarse a esta emoción, y, por otro, la necesidad del equipo de salud en explorar las expectativas de la mujer sobre su parto y ajustar la información obtenida en atención primaria para reducir tanto el dolor como el miedo en el parto (10, 22-24). relacionado con lo anterior aparecen la incertidumbre y ansiedad, emociones que surgen del halo del riesgo amenazante durante la gestación, el déficit en la información aportada a la mujer, la actitud de los profesionales en la atención obstétrica y las experiencias previas en gestaciones anteriores (21, 25). respecto a ello, nuestro estudio difiere de otras investigaciones que afirman que la incertidumbre se circunscribe al momento del parto, evidenciando no existir una clara relación entre la ansiedad y las experiencias previas (26, 27). no obstante, recientes investigaciones concluyen que existen altos niveles de incertidumbre y ansiedad en nulíparas más que en multíparas debido a la excesiva preocupación por el estado de bienestar del feto (28, 29). esta circunstancia no se presentó en el ámbito de estudio. respecto a las emociones que surgen derivadas de la estructura relacional entre el equipo asistencial y la mujer, los hallazgos se alinean con otros estudios que concluyen que la falta de información del equipo de salud sobre la evolución del proceso reproductivo dificulta un adecuado manejo de los sentimientos de la mujer durante el proceso perinatal (21-23, 10). esta situación de estrés interfiere en los procesos de acomodación, adaptación y evolución de los acontecimientos que se desarrollan a lo largo del itinerario asistencial, hecho que explica que las mujeres manifiesten la necesidad de tener una interacción clínica simétrica con la finalidad de establecer una comunicación empática que les permita sentir el apoyo emocional y espiritual de los agentes de salud; aspectos estos importantes para la percepción satisfactoria de la vivencia del proceso perinatal (10, 30). relacionado con ello, la matrona de atención primaria emerge como la profesional que fácilmente se alinea con los valores y las necesidades de la mujer. sus actitudes, basadas en la confianza y el diálogo, constituirán los principales ejes de la interacción clínica, contribuyendo a cumplir las expectativas y necesidades de la mujer en el control prenatal (24, 31). en relación con la interacción clínica, en la unidad de hospitalización de puérperas existe unidireccionalidad de la comunicación y ausencia de feedback con la mujer, lo que genera sentimientos de ira y desamparo. esto pone de relieve la presencia de un modelo médico hegemónico fuertemente instaurado en el ámbito hospi379 explorando las emociones de la mujer en la atención perinatal. un estudio cualitativo l josé arnau sánchez y otros talario que fomenta un tipo de interacción clínica paternalista, que interfiere en la visión holística de la mujer. los hallazgos coinciden con estudios que revelan que este pensamiento tecnocrático es incompatible con la función cuidadora del equipo asistencial, el cual está centrado en el empleo de prácticas científico técnicas con escasa competencia relacional (3, 32). aunque los participantes del estudio ponen de manifiesto que el factor generacional influye en este tipo de estructura relacional, la investigación no ofrece datos para hacer tal aseveración dado que no se contempló dicho criterio en el estudio. asimismo, los resultados revelan una importante jerarquización en las relaciones entre profesionales, fruto de la cultura de las organizaciones sanitarias, las cuales siguen los principios del modelo médico hegemónico. pese a que actualmente se están abriendo a otros modelos, a día de hoy se sigue trabajando de una manera jerarquizada y centrada en el modelo tecnocrático (3, 33). los hallazgos ponen de manifiesto que las matronas pertenecientes a la unidad de paritorio tienen dificultad para el desarrollo de un abordaje de cuidados holísticos debido a la organización asistencial regida por los principios del modelo biomédico, lo que genera sentimientos de soledad y desconfianza en la mujer. esta afirmación está en concordancia con investigaciones que señalan que el hospital supone un ambiente despersonalizado en el cual no es posible mantener una relación individualizada basada en la confianza, y como tal satisfactoria, debido a la falta de continuidad de los cuidados (24, 34). sin embargo, revisiones recientes realizadas por la cochrane acerca de los diferentes modelos de cuidados ofrecidos por la matrona en el parto, concluyen que pese a la existencia de estudios que vinculan la atención continuada con la satisfacción de la mujer, aún no se puede aseverar tal relación (35). a tenor de los resultados se comienza a vislumbrar un modelo de atención biopsicosocial que proporciona un mayor humanismo a la atención asistencial. este aspecto se da tanto en atención primaria como en la unidad de paritorio. en estos espacios tiene lugar un tipo de estructura relacional sistémica basada en la mutua confianza y el diálogo. aunque este tipo de interacción lo ofrecen tanto obstetras como matronas, son estas las que más lo dispensan, convirtiéndose en un profesional que no solo proporciona autonomía y seguridad a la mujer, sino que es capaz de adentrarse en sus valores y detectar sus necesidades (23, 24, 35). en relación con las infraestructuras, el estudio muestra que estas son inadecuadas en las salas de parto y unidad de puérperas, comprometiendo no solo la calidad de los cuidados sino también la privacidad de la mujer, provocándole vergüenza. respecto a ello, la investigación se alinea con los resultados de otros estudios que relacionan los elementos arquitectónicos de los espacios donde se lleva a cabo la atención perinatal con la calidad asistencial y las emociones que experimenta la mujer, argumentando que intimidad, seguridad y privacidad solo se consiguen cuando la mujer da a luz en entornos arquitectónicamente adaptados para ello (35, 36). entre las limitaciones de la investigación, aparte de las anteriormente mencionadas relativas al factor generacional y su impacto en la estructura relacional, se deberían contemplar los valores adquiridos por los profesionales en el proceso de socialización laboral. este aspecto ayudaría a entender hacia qué modelo de atención se orienta la práctica profesional. asimismo, se deben destacar las limitaciones asociadas al desarrollo de una investigación at home, dado que los investigadores están directamente involucrados en el escenario laboral. por otra parte, ante la dificultad en desplazar a las mujeres a un lugar neutro, se optó por desarrollar las entrevistas en las instituciones. teniendo en cuenta el sesgo que podría causar en los discursos de las participantes, esta circunstancia fue contemplada por los investigadores. conclusiones la atención perinatal en el área i de salud de la región de murcia está regida bajo la égida de un modelo médico hegemónico fuertemente instaurado. este va a ser determinante en las emociones negativas que emergen en la atención perinatal, en la medida que la atención asistencial va a estar basada en una estructura asimétrica, reduccionismo de la mujer, homogeneización de las necesidades en la asistencia perinatal y segmentación de los cuidados perinatales ofrecidos por el equipo asistencial. estos aspectos contribuyen a proveer una interacción clínica paternalista que dificultará seriamente el acomodamiento y afrontamiento de situaciones de estrés de la mujer en el ámbito hospitalario, repercutiendo negativamente en su experiencia vivida. sin embargo, desde el ámbito de la atención primaria y salas de partos emerge una estructura relacional deliberativa compatible con un modelo humanista que contribuye a un aumento del empoderamiento de la mujer, y proporciona una vivencia más satisfactoria y rica en emociones positivas. consideramos que este estudio puede aportar un conocimiento exhaustivo acerca de la satisfacción de la mujer en la atención 380 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 perinatal en un momento de confrontación de paradigmas biomédicos y humanistas. el conocimiento de las emociones de la mujer en la atención perinatal puede ayudar a los profesionales relacionados con la atención obstétrica a hacer una reflexión crítica de sus prácticas orientándolas a un modelo de asistencia cuyo eje sea la mujer, contemplando sus valores, necesidades y expectativas. asimismo, los resultados del estudio podrían contribuir a que las administraciones sanitarias reflexionen y elaboren estrategias eficaces para impulsar un modelo de atención compatible con la humanización del proceso reproductivo. referencias 1. awhonn. association of women´s health, obstetric and neonatal nurses. mood and anxiety disorders in pregnant and pospartum women. journal of obstetric, gynecologic & neonatal nursing. 2015;44(5):687-89. 2. ministerio sanidad y política social. guía de práctica clínica sobre la atención al parto normal. plan de calidad sistema nacional de salud 2010 [citado 2013 dic 15]. disponible en: http://www.msssi.gob.es/organizacion/sns/plancalidadsns/pdf/equidad/guiapracclinpartocompleta.pdf 3. hunter b, segrott j. renegotiating inter-professional boundaries in maternity care: implementing a clinical pathway for normal labour. sociology of health & illness. 2014;36(5):719-37. 4. menéndez el. intencionalidad, experiencia y función: la articulación de los saberes médicos. revista de antropología social. 2005. [citado 2014 jul 11]. disponible en: http://revistas.ucm.es/index.php/raso/article/view/raso0505110033a 5. kelley jm, kraft-todd g, schapira l, kossowsky j, riess h. the influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. plosone. 2014;9(4): e94207. 6. boissy a, windover ak, bokar d, karafa m, neuendorf k, frankel rm, et al. comunication skills training for physicians improves patient satisfaction. journal of general internal medecine. 2016 feb 26 [citado 2016 mar 24]. disponible en: http://link.springer.com/article/10.1007%2fs11606-016-3597-2 7. barómetro sanitario 2009. tabulación por comunidades. [internet]. madrid: ministerio sanidad, política social e igualdad [citado 2014 abril 17]. disponible en: http://www.msssi.gob.es/estadestudios/estadisticas/docs/bs_2009_total_ por_ccaa.pdf 8. takács l, seidlerová jm, smolík f, hoskovcová s, antonín p, vařáková j, et al. satisfaction with perinatal care in vysočina region in the period between october 2013 and september 2014. ceska gynekol. 2016; 80(6):426-35. 9. redshaw m, heikkila k. delivered with care: a national survey of women’s experience of maternity care 2010 [internet]. university of oxford. the national perinatal epidemiology unit; 2010 [citado 2014 abril 11]. disponible en: https:// www.npeu.ox.ac.uk/downloads/files/reports/maternity-survey-report-2010.pdf 10. haines hm, rubertsson c, pallant jf, hildingsson i. the influence of women´s fear, attitude and biliefs of childbirth on mode and experience of birth. bmc pregnancy childbirth. 2012 [citado 2016 mar 30]; 12: 55. disponible en: http:// www.ncbi.nlm.nih.gov/pmc/articles/pmc3449179/ 11. roosevelt l, low lk. exploring fear of childbirth in the united states through a qualitative assessment of the wijma delivery expectancy questionnaire. jognn. 2016;45(1):28-38. 12. piqueras j, ramos v, martínez ae, oblitas la. emociones negativas y su impacto en la salud mental y física. suma psicológica. 2009;16(2):85-112. 13. rodríguez j, zurriaga r. estrés, enfermedad y hospitalización. revista psicothema. 1999;11(1):237-38. 14. bowen ga. grounded theory and sensiting concepts. international journal of qualitative methods. 2006;5(3):13-23. 15. téllez a. la investigación antropológica. alicante: editorial club universitario; 2007. 16. vargas jiménez, ll. the interview in the qualitative research: trends and challengers. revista calidad en la educación superior. 2012;3(1):119-39. 381 explorando las emociones de la mujer en la atención perinatal. un estudio cualitativo l josé arnau sánchez y otros 17. anderson c. presenting and evaluating qualitative research. american journal of pharmaceutical education. 2010 [citado 2016 mar 24]; 74(8). disponible en: http://www.ajpe.org/doi/pdf/10.5688/aj7408141 18. anguera mt. metodología cualitativa. en: anguera mt, arnau j, ato m, martínez mr, pascual j, vallejo g, editors. métodos de investigación en psicología. madrid: síntesis; 1995. p. 513-76. 19. wma declaration of helsinkiethical principles for medical research involving human subjects [internet]. helsinki: wma general assembly. jun 1964. [citado 2015 feb 12]. disponible en: http://www.wma.net/en/30publications/10policies/b3/ 20. fenwick j, toohill j, creedy dk, smith j, gamble j. sources, responses and moderators of childbirth fear in australian women: a qualitative investigation. midwifery. 2015;31(1):239-46. 21. stoll k, edmonds jk, hall wa. fear of childbirth and preference for cesarean delivery among young american women before childbirth: a survey study. birth. 2015;42(3):270-6. 22. klomp t, mannniën j, de jonge a, hutton ek, lagro-janssen al. what do midwives need to know about approaches of women towards labour pain management? a qualitative interview study into expectations of management of labour pain for pregnant women receiving midwife-led care in the netherlands. midwifery. 2014;30(4):432-38. 23. haines hm, holdingsson i, pallant jf, rubertson c. the role of women’s attitudinal profiles in satisfaction with the quality of their antenatal and intrapartum care. jognn. 2013;42(4):428-41. 24. anwar s, jan r, qureshi rn, rattani s. perinatal women’s perceptions about midwifery led model of care in secondary care hospitals in karachi, pakistan. midwifery. 2014;30(3):e79-e80. 25. shorten a, shorten b, kennedy hp. complexities of choice after prior cesarean: a narrative analysis. birth. 2014;41(2):178-84. 26. storksen ht, eberhard-gran m, garthus-niegel s, eskild a. fear of childbirth; the relation to anxiety and depression. acta obstetricia gynecologica scandinavica. 2012;91(2):237-42. 27. storksen ht, garthus-niegel s, vangen s, gran me. the impact of previous birth experiences on maternal fear of childbirth. acta obstetricia gynecologica scandinavica. 2013;92(3):318-24. 28. rouhe h, salmela k, toivanen r, halmesmäki e, saisto t. obstetric outcome after intervention for severe fear of childbirth in nulliparous women – randomised trial. bjog 2013;120(1):75-84. 29. fenwick j, gamble j, nathan e, baya s, hauck y. preand postpartum levels of childbirth fear and the relationship to birth outcomes in a cohort of australian women. journal of clinical nursing. 2009;18(5):667-77. 30. rubarth lb, schoening am, cosimano a, sandhurst h. women’s experience of hospitalized bed rest during high-risk pregnancy. jognn. 2012;41(3);398-407. 31. butler mm, sheehy l, kington m, walsh mc, brosnan mc, murphy m, et al. evaluating midwife-led antenatal care: choice, experience, effectiveness, and preparation for pregnancy. midwifery. 2015;31(4):418-25. 32. schwennesen n, koch l. representing and intervening: ‘doing’ good care in first trimester prenatal knowledge production and decision-making. sociology of health & illness. 2012;34(2):283-98. 33. copeland f, hannah g. dahlen, homer se. conflicting contexts: midwives’ interpretation of childbirth through photo elicitacion. women and birth. 2014;27(2):126-31. 34. sandall j, soltani h, gates s, shennan a, devane d. midwife-led continuity models versus other models of care for childbearing women. cochrane database of systematic reviews 2013; 8. disponible en: http://dx.doi.org/10.1002/14651858. cd004667.pub3 35. stark ma, remynse m, zwelling e. importance of the birth environment to support physiologic birth. jognn. 2016;45(2):285-94. 36. martin d, nettleton s, buse c, prior l, twigg j. architecture and health care: a place for sociology. sociology of health & illness. 2015;37(7):1007-22. 292 304 validacion de la version española de escala.indd 292 sara cano-plans1 laia lacueva-pérez2 esther cabrera-torres3 adelaida zabalegui4 validación de la versión española: expectativas y conocimiento recibido del paciente hospitalizado 1 orcid.org/0000-0002-1317-0565. jaume i university, españa. al282316@uji.es 2 orcid.org/0000-0003-3817-1676. hospital del mar, parc de salut mar, españa. llacueva@parcdesalutmar.cat 3 orcid.org/0000-0002-7353-0542. tecno campus, university pompeu fabra, españa. ecabrera@tecnocampus.cat 4 orcid.org/0000-0003-1205-399. hospital clínic of barcelona, españa. azabaleg@clinic.ub.es recibido: 12 de agosto de 2015 enviado a pares: 23 de septiembre de 2015 aceptado por pares: 9 de noviembre de 2016 aprobado: 23 de noviembre de 2016 doi: 10.5294/aqui.2017.17.3.6 para citar este artículo / to reference this article / para citar este artigo cano-plans s, lacueva-pérez l, cabrera-torres e, zabalegui a. validación de la versión española de la escala: expectativas y conocimiento recibido del paciente hospitalizado. 2017; 17(3): 292-304. doi: 10.5294/aqui.2017.17.3.6 resumen objetivo: evaluar la validez y la fiabilidad de la versión española del instrumento expectativas y conocimiento recibido del paciente hospitalizado (ecph/crph) en pacientes con osteoartritis intervenidos de artroplastia total de rodilla. material y métodos: el proceso de validación siguió las recomendaciones internacionales: validez de contenido, validez de constructo, validez de criterio y fiabilidad. un total de 248 pacientes que debían intervenirse de artroplastia total de rodilla en 5 hospitales públicos españoles contestaron la ecph antes de ser hospitalizados y 220 pacientes contestaron el crph al darles el alta hospitalaria. resultados: el análisis factorial confirmó las dimensiones de la escala original para el conocimiento recibido, pero no en la escala para las expectativas. la correlación de las dimensiones de la ecph con la escala de opinión de la salud de krantz (khos) y la correlación de las dimensiones de la crph con la escala de acceso a la información (aks) indicaron la validez de criterio mostrando unas relaciones positivas. los resultados señalaron buena fiabilidad con valores de alfa cronbach elevados. conclusión: el proceso de validación indica que la versión española del ecph/crph es un instrumento válido y fiable para medir las expectativas y el conocimiento recibido en pacientes quirúrgicos en el contexto español. palabras clave educación en salud; conocimiento; estudios de validación; osteoartritis; enfermería ortopédica (fuente: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 292-304 293 validación de la versión española de la escala: expectativas y conocimiento recibido del paciente hospitalizado l sara cano-plans y otros año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 292-304 validation of the spanish version: expectations and knowledge received in the hospitalized patient abstract objective: the objective of the study was to assess the validity and reliability of the spanish version of expectations and received knowledge in the hospitalized patient (ecph / crph), specifically among patients with osteoarthritis who are undergoing total knee arthroplasty. material and methods: the validation process followed international recommendations in terms of content validity, construct validity, criterion validity and reliability. a total of 248 patients who were about to undergo total knee arthroplasty at five (5) spanish public hospitals answered the ecph before being hospitalized and 220 patients answered the crph when they were discharged. results: factor analysis confirmed the dimensions of the original scale for the knowledge received, but not with respect to the scale for expectations. the correlation of the ecph dimensions with the krantz health opinion scale (khos) and the correlation of the crph dimensions with the information access scale (aks) indicated criterion validity, showing positive relationships. the results suggested good reliability with high cronbach alpha values. conclusion: the validation process showed the spanish version of ecph / crph is a valid and reliable instrument to measure the expectations and knowledge received in surgical patients in the spanish context. keywords health education; knowledge; validation studies; osteoarthritis; orthopedic nursing (source: decs, bireme). 294 aquichan issn 1657-5997 eissn 2027-5374 validação da versão espanhola do instrumento expectativa e conhecimento recebido do paciente hospitalizado resumo objetivo: avaliar a validade e a confiabilidade da versão espanhola do instrumento expectativa e conhecimento recebido do paciente hospitalizado (ecph/crph) em pacientes com osteoartrite submetidos à artroplastia total de joelho. métodos: o processo de validação seguiu as recomendações internacionais: validade de conteúdo, validade de construto, validade de critério e confiabilidade. 248 pacientes que devem ser submetidos à artroplastia total de joelho em cinco hospitais públicos espanhóis responderam ao ecph antes de serem hospitalizados, e 220 pacientes responderam ao crph ao ganharem alta. resultados: a análise fatorial confirmou as dimensões da escala original para o conhecimento recebido, mas não na escala para as expectativas. a correlação das dimensões do ecph com a escala de opinião da saúde de krantz (khos) e a correlação das dimensões do crph com a escala de acesso à informação (aks) indicaram a validade de critério e mostraram umas relações positivas. os resultados indicam boa confiabilidade com valores de alfa cronbach elevados. conclusões: o processo de validação indica que a versão espanhola do ecph/crph é um instrumento válido e confiável para medir as expectativas e o conhecimento recebido em pacientes em regime de internamento no contexto espanhol. palavras-chave conhecimento; educação em saúde; enfermagem ortopédica; estudos de validação; osteoartrite (fonte: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 292-304 295 validación de la versión española de la escala: expectativas y conocimiento recibido del paciente hospitalizado l sara cano-plans y otros introducción el aumento de la esperanza de vida ha conllevado una gran prevalencia de enfermedades crónicas, entre ellas la osteoartritis (oa). esta enfermedad se caracteriza por la pérdida del cartílago de las articulaciones; causa dolor y pérdida funcional, sobre todo en rodillas y caderas, y afecta al 9,6 % de los hombres y al 18 % de las mujeres mayores de 60 años a nivel mundial. la prevalencia de osteoartritis se incrementa con la edad, y es mayor en mujeres que en hombres; aunados a la edad y sexo femenino otros factores de riesgo incluyen obesidad, traumatismo, factores genéticos, mecánicos y relacionados con la ocupación, así como cirugías previas (1, 2). se calcula que 242 millones de personas en el mundo padecen artrosis, y que esta enfermedad genera un importante impacto en la salud y en la capacidad funcional de la persona que la padece. según la organización mundial de la salud (oms), es una de las diez enfermedades que más discapacidades causan en el mundo. con el aumento de la esperanza de vida y el envejecimiento de la población, la oa se ha convertido en la cuarta causa de morbilidad en el mundo (3). dentro de estas, las enfermedades reumatológicas se encuentran entre las causas más frecuentes de morbilidad, incapacidad y utilización de servicios de salud (4). en este contexto, la artrosis se transforma en una preocupación especial sobre todo en países de latinoamérica (5), que la señala como la segunda patología más diagnosticada (6), además de producir molestia y limitación funcional en adultos (7). en españa, la esperanza de vida ha aumentado más rápido que en muchos otros países de la unión europea (83,2 años) (8), y la prevalencia de oa es de 16,59 % para la población general (9, 10). según la organización para la cooperación y el desarrollo económico en europa (oecd), el reemplazo de la articulación se considera la mejor opción para los pacientes que sufren de oa severa y sintomática (9), se consigue una mejora funcional casi completa, con el aumento de la calidad de vida y la satisfacción de los pacientes (10, 11). en los últimos años ha habido un gran incremento de cirugías ortopédicas y, a la vez, una disminución de las estancias hospitalarias, lo que ha provocado una reducción del tiempo para la educación sanitaria durante el ingreso de los pacientes (12, 13). el postoperatorio de cirugías ortopédicas conlleva limitaciones tanto físicas como funcionales que provocan un cambio en la vida diaria de los pacientes y esto les genera grandes necesidades de información y educación que esperan recibir para poder afrontar la nueva situación y conseguir así la máxima recuperación posible (14, 15). esto nos obliga a plantear nuevos enfoques en la educación al paciente y en su participación en la toma de decisiones de su proceso de salud (15). la educación al paciente se considera una de las bases de la atención. la educación impartida por enfermería durante la hospitalización se describe como un conjunto de actividades planificadas para conseguir un cambio en el conocimiento, los comportamientos y las actitudes del paciente relacionadas con la nueva situación de salud (16, 17). el objetivo final de esta educación debería ser ayudar al paciente en su empoderamiento (17). el empoderamiento, como un proceso en el que los individuos ganan maestría y control sobre sus vidas, fue definido por primera vez en el año 1973 por el educador brasileño paulo freire (18). esta definición continúa vigente y se ha ido adaptando en las diferentes áreas y aspectos de la persona. en el ámbito de la salud se habla de empowering patient education, para referirse a la educación encaminada a incentivar que los pacientes tomen el control de su propio proceso de salud (19). el proceso de empoderamiento varía según la persona, el contexto y el tiempo, por tanto, antes de planificar cualquier estrategia educativa sanitaria necesitamos conocer a nuestros pacientes y su situación (20). no es posible proporcionar una educación que ayude al enfermo a capacitarse solo con programas estándares ya que, algunas veces, el punto de vista de los profesionales sanitarios no corresponde con las necesidades de conocimiento del paciente. se asume que cuando se cumplen las expectativas de conocimiento con la información proporcionada se genera conocimiento nuevo el cual posibilita el proceso de toma de decisiones del paciente (21, 22). según la revisión de la literatura, existen distintos instrumentos que miden el empoderamiento en salud (23), pero solo la doble escala expectations and received knowledge hospital patient (24, 25), llamada en español expectativas y conocimiento recibido del paciente hospitalizado (ecph/crph), permite evaluar si se han alcanzado las expectativas de conocimiento del paciente durante su hospitalización según el marco conceptual de la educación empoderadora (26). este doble instrumento surge de las teorías sociales-psicológicas y constructivas aplicadas al empoderamiento de los pacientes a través de la educación (27). la ecph/crph fue creada originalmente en finlandia, para pacientes con esclerosis múltiple (25), y más tarde fue utilizada para pacientes quirúrgicos (28-30). la validez y la fiabilidad han sido demostradas en los diversos estudios previos. 296 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 la ecph/crph se considera una doble escala porque con los mismos contenido y preguntas, en un primer tiempo permite evaluar las expectativas de conocimiento que tienen los pacientes antes de ingresar en el hospital (ecph) y, en un segundo tiempo, es decir, en el momento del alta hospitalaria, con la misma escala se puede evaluar el conocimiento recibido durante la hospitalización (crph). por ello, tanto las expectativas como los conocimientos se evalúan con los mismos 40 ítems (preguntas) divididos en 6 dimensiones o categorías: biofisiológica (preguntas 1 a 8, sobre enfermedad, síntomas, pruebas, tratamientos y complicaciones), funcional (preguntas 9 a 16, sobre movilidad, reposo, nutrición e higiene corporal), de experiencia (preguntas 17 a 19, sobre sentimientos y experiencias), ética (preguntas 20 a 28 sobre derechos, deberes, participación en la toma de decisiones y confidencialidad), social (preguntas 29 a 34, sobre cuidadores, personas de soporte y organizaciones de pacientes) y económica (preguntas 35 a 40 sobre los costes). las preguntas se puntuaban según una escala de likert de cuatro puntos (1 = completamente en desacuerdo, 4 = completamente de acuerdo, 0 = no aplicable en mi caso). a mayor puntuación, mayor conocimiento recibido por parte de los pacientes. este estudio forma parte de un proyecto europeo sobre educación empoderadora en pacientes con osteoartritis en un contexto quirúrgico (31). el objetivo del actual estudio fue evaluar la validez y la fiabilidad de la versión española de la doble escala ecph/crph en pacientes con oa operados de artroplastia total de rodilla (atr). materiales y métodos diseño del estudio y recolección de datos estudio multicéntrico, longitudinal y descriptivo para validar la versión española de la doble escala expectations and received knowledge hospital patient (ecph/crph). se utilizó un muestreo no probabilístico consecutivo, reclutando todos los pacientes que ingresaban programados para una intervención quirúrgica de atr en cinco hospitales públicos españoles. antes del ingreso en el hospital para ser intervenidos, los participantes cumplimentaron un cuestionario con datos sociodemográficos, la versión española de la escala de expectativas de conocimiento (ecph) y la escala de opinión de salud de krantz (khos). y en el momento del alta hospitalaria, el cuestionario constaba de datos sociodemográficos, la versión española de conocimiento recibido (crph) y la escala de acceso al conocimiento (aks). la inclusión de los participantes y la recolección de datos fue llevada a cabo según el criterio de los profesionales de enfermería responsables de los pacientes en cada centro y que previamente habían recibido formación e información sobre el proyecto. el periodo de recolección fue entre junio de 2011 y diciembre de 2012. participantes según las recomendaciones (32) de incluir cinco participantes por ítem de la escala, el tamaño muestral necesario para este estudio fue de 200 participantes. teniendo en cuenta la posible pérdida de la muestra, se decidió incluir 250 pacientes. los criterios de inclusión fueron: ser mayor de 18 años, comprensión del español, no presentar problemas cognitivos, ser capaz de cumplimentar el cuestionario con o sin ayuda, e indicación de la cirugía primaria por oa. el criterio de exclusión fueron las cirugías no programadas. los pacientes incluidos en el estudio siguieron los protocolos de admisión y educación propios de cada hospital. traducción y retrotraducción del instrumento original el proceso de traducción y retrotraducción siguió las directrices utilizadas para este tipo de estudios (32, 33). dos traductores bilingües y biculturales, con amplia experiencia en el campo sanitario, y cuya lengua materna era el inglés, fueron seleccionados para traducir de forma separada e independiente el instrumento del inglés al español. las dos versiones traducidas se compararon con el original por los miembros del equipo de investigación para resolver las ambigüedades y discrepancias con los traductores y obtener una versión española preliminar. seguidamente, esta versión preliminar fue retrotraducida al idioma original (inglés) por otros dos traductores independientes. una vez más, los miembros del equipo de investigación compararon las dos versiones por si había incoherencias y, al no encontrarse, se aprobó la versión española final de la ecph/crph. después de un consenso de la gramática y la adaptación cultural, tan solo dos ítems necesitaron ser modificados. la versión final del cuestionario se pilotó con 10 participantes (muestra de expertos y pacientes) para confirmar la claridad de las instrucciones y los elementos, y a su vez, justificar la validez 297 validación de la versión española de la escala: expectativas y conocimiento recibido del paciente hospitalizado l sara cano-plans y otros de contenido. este cuestionario mostró una buena adaptación y comprensión sin necesidad de realizar más cambios. análisis estadístico y propiedades psicométricas para la adaptación al español de la ecph/crph se estudió la validez de constructo, la validez de criterio y la fiabilidad. la validez de constructo es el grado en que un instrumento mide lo que se pretende medir. se realizaron los test de bartlett y de kaiser-meyer-olkin (kmo) para demostrar la idoneidad de la muestra y justificar la exploración del análisis factorial exploratorio. el análisis factorial utilizando la rotación varimax se realizó para confirmar las 6 dimensiones que definen los 40 ítems del instrumento original. el criterio utilizado para determinar las dimensiones fue de un mínimo de 1,00. para la validez de criterio se exploró, por un lado, la correlación de las dimensiones de la ecph con una subescala de la krantz health opinion survey (khos) (34) y, por el otro, la correlación de las dimensiones de la crph con la acces knowledge scale (aks) (35). la khos es un instrumento ampliamente utilizado (36-40) que consta de dos subescalas: preferencias de información (7 ítems) y conducta participativa (9 ítems). la subescala de preferencias de la información (khos_1) hace referencia a la tendencia de los pacientes a buscar de manera activa información relacionada con la salud y la participación en las decisiones relacionadas con el tratamiento. esta subescala utiliza una puntuación binaria de sí/ no. la puntuación máxima total es de 16:7 en la khos_1. a mayor puntuación mayor interés en buscar información. la aks está formada por 8 ítems de la good nursing care scale, la cual evalúa la calidad de los cuidados y ha sido utilizada y validada en diferentes contextos y culturas (41, 42). los 8 ítems de la aks evalúan la manera como las enfermeras y los médicos responden a las preguntas de los pacientes y justifican sus acciones. cada ítem se puntúa con una escala likert 4, desde 1 = totalmente en desacuerdo hasta 4 = totalmente de acuerdo; el 4 indica la mejor calidad posible. la puntuación total es el resultado de los 8 ítems, los cuales fueron tratados como una escala. para analizar la fiabilidad se midió su consistencia interna para toda la escala y para cada una de las dimensiones de la versión española ecph/crph. para ello de utilizó el rango de correlación de spearman y se consideró aceptable un coeficiente alfa de cronbach de al menos 0,80. para este estudio se incluyeron solo los cuestionarios que fueron contestados como mínimo en el 50 % de los ítems. los datos fueron analizados mediante el paquete estadístico spss 20.0 (ibm corp., armonk, ny, u/sa). consideraciones éticas el estudio fue aprobado por el comité de ética e investigación del hospital clínic de barcelona (expediente # 2010/5955 *2010/5915) y el resto de los hospitales españoles participantes en el estudio (hospital universitario mútua de terrassa, hospital universitario germans trias i pujol, hospital universitario de bellvitge y hospital de l’esperança). durante todo el estudio se aplicaron los principios éticos para la investigación en seres humanos de la declaración de helsinki (2008). los pacientes fueron informados sobre el propósito y los procedimientos del estudio y los principios de voluntariedad y confidencialidad. se obtuvo el consentimiento informado por escrito de todos los pacientes antes de cumplimentar el cuestionario. resultados características de los participantes de los 250 participantes incluidos inicialmente, 2 fueron excluidos en la primera recolección del estudio por haber respondido menos del 50 % de los ítems del cuestionario, y en la segunda recolección hubo una pérdida del 12 %. finalmente, la muestra compuesta por pacientes quirúrgicos de 5 hospitales públicos españoles fue de 248 para la primera recolección y de 220 para la segunda. la mediana de edad fue de 70,2 años (de 8,6) y la mayoría eran mujeres, jubiladas, con un bajo nivel educativo y con patologías crónicas asociadas. los pacientes estuvieron 7,6 días de media en el hospital. un 80 % de los participantes habían estado ingresados previamente en el mismo hospital, y solo el 7 % eran o habían sido trabajadores en el ámbito sanitario o social. la mayoría fueron a sus domicilios tras el alta hospitalaria y el 4,8 % fueron trasladados a otro centro sociosanitario para su rehabilitación. solo el 7,9 % de los participantes tuvieron una experiencia hospitalaria diferente de la que esperaban antes del ingreso. todas las variables sociodemográficas se presentan en la tabla 1. validez de constructo el test de bartlett, que valora la homogeneidad de las variancias de la muestra, fue estadísticamente significativo para las dos 298 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 escalas (p < 0,001), y el test de kmo (0,920 para ecph y 0,942 para crph) indicó que el tamaño de la muestra era más que suficiente para el estudio; estas dos pruebas justificaron la realización del análisis factorial en las dos escalas. el análisis factorial con rotación varimax reveló 7 factores con valor > 1, que explican el 73,7 % de la varianza para la ecph, y 6 factores con valor > 1 que explican el 73,4 % de la varianza para la crph (tabla 2). la interrelación entre las dimensiones fue de moderada a alta, tanto para la ecph (r = 0,47-0,82) como para la crph (r = 0,560,84). como muestra la tabla 3, las correlaciones entre los ítems indican que la escala mide conceptos muy similares, a excepción de la dimensión económica, que tiene una relación significativa pero moderada tanto en la ecph (r = 0,48-0,68) como en la crph (r = 0,56-0,76). validez de criterio la escala ecph y la subescala khos_i tienen una relación positiva en todos sus componentes, con una significación en la mitad de las dimensiones y en el total de la escala. en el caso de la escala de conocimiento recibido, la variable externa aks resultó estar relacionada de manera significativa y positiva en todas las dimensiones y en el total de la escala crph (tabla 4). fiabilidad los valores del alfa de cronbach fueron altos tanto para los totales de las escalas (0,961 en la ecph y 0,973 en la crph), como para cada dimensión del conocimiento, estos oscilaron (entre 0,764 y 0,953 en la ecph y entre 0,811 y 0,959 en la crph). estos resultados indican una buena fiabilidad de la versión española de la doble escala ecph/crph (tabla 5). discusión los resultados del estudio sugieren que la versión española de la doble escala ecph/crph es un instrumento con buenas propiedades psicométricas, válido y fiable para medir tanto las expectativas de conocimiento como el conocimiento que han recibido los pacientes operados de artroplastia de rodilla durante su ingreso hospitalario. mediante el método de traducción y retrotraducción se consiguió una versión española del instrumento que resultó conceptualmente equivalente al original, y cuya utilización para estudios en el contexto español es factible y comprensible para los pacientes. las 6 dimensiones de la escala original fueron confirmadas para la crph y en el caso de la ecph resultaron 7 dimensiones con el estudio del análisis factorial, una dimensión más de la esperada y la cual no se tuvo en cuenta para el resto de análisis. las diferentes dimensiones tuvieron una relación demasiado estrecha en ambos casos para poder confirmar que medían distintos constructos exceptuando la dimensión económica. aun así, el interés del estudio por evaluar las expectativas y el conocimiento general recibido del paciente hospitalizado se da por válido, ya que el constructo general es la información, independientemente de cómo se estructure. la dimensión económica, tanto para la ecph como para la crph, sí obtuvo unos valores de correlación que justificaban una subescala diferenciada del resto, este hecho se podría explicar ya que el contexto del estudio fue en un sistema sanitario público donde no existe coste directo para el paciente, y, por tanto, los pacientes no tienen por qué esperar para recibir información sobre temas económicos. de igual forma, en la validez de criterio de la escala, que fue satisfactoria en su totalidad, se obtuvo una relación positiva entre las expectativas de conocimiento y las preferencias de información, pero en menor puntuación en la dimensión económica. sí lo hizo en las dimensiones biofisiológica, de experiencia y ética. con los resultados se confirma que a mayor expectativas de conocimiento por parte de los pacientes, mayor interés de estos en buscar información sobre su estado de salud, tratamientos, posibles complicaciones, sintomatología y participación en la toma de decisiones. en cuanto al conocimiento recibido se observó una significativa y positiva relación con el nivel de acceso a la información, lo cual demuestra que los pacientes que tienen la percepción de un mayor acceso a esta por parte de los profesionales sanitarios durante la hospitalización generan un mayor conocimiento. información no es sinónimo de conocimiento. el paciente ha de recibir la información adecuada en el momento y contexto adecuados para que se genere nuevo conocimiento (19, 21). este hecho es el que confirma que una educación sanitaria encaminada a dar apoyo al proceso de empoderamiento del paciente no puede darse de manera estandarizada, sino que debe personalizarse. la consistencia interna fue alta en ambas escalas, tanto para la escala en general como para las diferentes dimensiones que las conforman. los valores del alfa de cronbach son comparables con los referidos por otros autores que utilizaron este doble instrumento. 299 validación de la versión española de la escala: expectativas y conocimiento recibido del paciente hospitalizado l sara cano-plans y otros n % promedio (de) sexo mujer hombre 176 66 72,7 27,3 edad 70,3 (8,6) educación básica o inferior primaria secundaria 144 50 39 61,8 21,5 16,7 educación superior ninguna ciclo formativo diplomatura universitaria licenciatura universitaria máster o doctorado universitario 162 22 8 8 1 80,6 10,9 4 4 0,5 estado laboral empleado jubilado ama/o de casa desempleado otros 29 118 62 3 2 13,6 55,1 29 1,4 0,9 profesional sanitario o de servicios sociales sí no 17 227 7 93 otras enfermedades crónicas sí no 134 106 55,8 44,2 ingresos anteriores en el mismo hospital sí no 199 49 80,2 19,8 días en el hospital 7,6 (1,48) < 5 de 5 a 10 >11 1 196 5 0,5 97 2,5 destino al alta casa centro sanitario 198 10 95,2 4,8 experiencia hospitalaria esperada sí no 197 17 92,1 7,9 tabla 1. datos sociodemográficos de la muestra fuente: elaboración propia, 2013. 300 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 escala ecph escala crph factores total % de la varianza % acumulado factores total % de la varianza % acumulado 1 16,71 41,82 41,82 1 20,2 50,51 50,51 2 4,81 12,03 53,85 2 3,57 8,93 59,44 3 2,35 5,87 59,72 3 1,66 4,16 63,6 4 1,77 4,41 64,13 4 1,56 3,9 67,5 5 1,49 3,73 67,86 5 1,28 3,2 70,7 6 1,15 2,9 70,75 6 1,08 2,7 73,4 7 1,02 2,55 73,3 tabla 2. análisis factorial: varianza total explicada fuente: elaboración propia, 2013. método de extracción: máxima verosimilitud. dimensiones de la ecph económica biofisiológica funcional de experiencia ética biofisiológica 0,477** funcional 0,507** 0,818** de experiencia 0,554** 0,723** 0,820** ética 0,677** 0,656** 0,713** 0,731** social 0,592** 0,571** 0,716** 0,725** 0,743** dimensiones de la crph biofisiológica 0,585** funcional 0,563** 0,836** de experiencia 0,604** 0,754** 0,766** ética 0,763** 0,781** 0,771** 0,834** social 0,720** 0,734** 0,710** 0,746** 0,842** tabla 3. intercorrelación de las 6 dimensiones de las escalas ecph y crph fuente: elaboración propia, 2013. correlación de spearman. ** p < 0,01 301 validación de la versión española de la escala: expectativas y conocimiento recibido del paciente hospitalizado l sara cano-plans y otros dimensiones del conocimiento ecph crph promedio (de) alfa de cronbach promedio (de) alfa de cronbach biofisiológica 3,53 (0,88) 0,886 3,14 (1,11) 0,922 funcional 3,34 (1,05) 0,932 3,20 (1,11) 0.902 de experiencia 3,13 (1,22) 0,815 2,83 (1,28) 0,914 ética 3,19 (1,17) 0,892 2,78 (1,31) 0,933 social 3,35 (1,08) 0,764 3,10 (1,28) 0,811 económica 3,29 (1,33) 0,953 2,89 (1,54) 0,959 total escala 3,35 (1,09) 0,961 2,99 (1,26) 0,973 ecph crph dimensiones del conocimiento khos_1 aks biofisiológica 0,182** 0,623** funcional 0,087 0,683** de experiencia 0,183** 0,503** ética 0,152* 0,535** social 0,098 0,581** económica 0,082 0,319** total escala 0,143* 0,628** fuente: elaboración propia, 2013. * p < 0,05 ** p < 0,01 tabla 4. correlación de las dimensiones y total escala con variables externas tabla 5. fiabilidad de las dimensiones de las escalas ecph y crph fuente: elaboración propia, 2013. en el estudio publicado más reciente, con una muestra de pacientes intervenidos de artroplastia, el alfa de cronbach fue de 0,87 a 0,94 (ecph) y de 0,89 a 0,91 (crph). para completar el análisis de fiabilidad serían necesarios nuevos estudios que valoraran la reproducibilidad intrasujeto en nuestro contexto para evaluar la estabilidad temporal de la escala. este estudio tiene algunas limitaciones que merecen ser consideradas. por un lado, la elección de los centros hospitalarios donde se recolectó la muestra no fue aleatoria, sino por conveniencia. por otro lado, cabe mencionar que el estudio no tuvo en cuenta los diferentes protocolos de educación a los pacientes establecidos en cada hospital. conclusión las organizaciones sanitarias han pasado de estar centradas en los profesionales a poner el centro de su atención en los pacientes y sus expectativas. las instituciones quieren conocer la percepción de los pacientes sobre la calidad de atención que reciben, en particular sobre la información recibida. para ello, es importante disponer de un instrumento de medida válido y fiable, 302 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 con buenas propiedades psicométricas, que explore los distintos componentes del proceso de información y toma de decisiones, y que mida las expectativas y el conocimiento que han recibido los pacientes durante la hospitalización. a mayores expectativas de conocimiento, mayor interés de los pacientes en buscar información sobre su salud y su tratamiento. a partir de los resultados obtenidos en el estudio pueden surgir futuras investigaciones para profesionales de enfermería –que serían de gran interés en el ámbito de la salud– sobre los diferentes sistemas de evaluación de la información-educación de los pacientes quirúrgicos que refuerzan la autogestión en todo su proceso, y la estandarización de los cuidados de pacientes con osteoartritis con programas que faciliten su empoderamiento. agradecimientos el estudio ha sido posible gracias a la contribución de varias personas a quienes queremos agradecer su dedicación en el proyecto. nuestra más sincera gratitud a cristina moreno, teresa faura, núria sapena, agnès nicolau, olga monistrol, teresa camps y joan manuel verge. fuentes de financiación: este estudio recibió financiación del colegio 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european joint arthroplasty patients. orthop nurs. 2016;35(3):174-82. 39. le t, chaudhuri s, white c, thompson h, demiris g. trust in health information sources differs between young/middle and oldest old. am j heal promot. 2017;28(4):239-41. 40. nilsson ug, ivarsson b, alm-roijer c, svedberg p. behavioral involvement and preference for information among male and females with cardiac disease. open j nurs. 2012;2(2):138-42. 41. zhao sh, akkadechanunt t, xue xl. quality nursing care as perceived by nurses and patients in a chinese hospital. j clin nurs. 2009;18(12):1722-8. 42. donmez yc, ozbayır t. validity and reliability of the “good perioperative nursing care scale” for turkish patients and nurses. j clin nurs. 2011;20(1-2):166-74. 243 256 intervencoes de enfermagem para pacientes.indd 243 maria cristina freitas de castro1 willian alves dos santos2 patricia dos santos claro fuly3 mauro leonardo salvador caldeira dos santos4 telma ribeiro garcia5 intervenções de enfermagem para pacientes oncológicos com odor fétido em ferida tumoral 1 orcid.org/0000-0001-5229-7756. universidade federal fluminense, brasil. mcfcastro@id.uff.br 2 orcid.org/0000-0003-0190-2199. universidade federal fluminense, brasil. willian_alves@id.uff.br 3 orcid.org/0000-0002-0644-6447. universidade federal fluminense, brasil. patriciafuly@enf.uff.br 4 orcid.org/0000-0002-3713-7700. universidade federal fluminense, brasil. mcaleo@id.uff.br 5 orcid.org/0000-0003-3086-0565. universidade federal da paraíba, brasil. tegarcia@ccs.ufpb.br recibido: 19 de marzo de 2015 enviado a pares: 04 de mayo de 2015 aceptado por pares: 03 de noviembre de 2016 aprobado: 21 de noviembre de 2016 doi: 10.5294/aqui.2017.17.3.2 para citar este artículo / to reference this article / para citar este artigo freitas de castro mc, santos wa, fuly psc, santos mlsc & ribeiro-garcia t. intervenções de enfermagem para pacientes oncológicos com odor fétido em ferida tumoral. aquichan. 2017; 17(3): 243-256. doi: 10.5294/aqui.2017.17.3.2 resumo objetivo: identificar intervenções de enfermagem para o diagnóstico de odor fétido em ferida tumoral. métodos: revisão integrativa da literatura realizada por meio das bases de dados medline, cinahl, lilacs e cochrane, que culminou com a seleção de 48 artigos científicos sobre a temática pesquisada. resultados: com base nas evidências empíricas identificadas nos artigos incluídos no estudo, foram elaboradas 24 intervenções de enfermagem para o controle e a redução do odor fétido em feridas tumorais. conclusão: as intervenções de enfermagem apresentadas neste estudo possibilitam a promoção da qualidade de vida ao paciente com ferida tumoral em cuidado paliativo. como sugestão posterior ao conselho internacional de enfermeiros, devem ser validadas clinicamente para que sua inserção seja feita no subconjunto terminológico cuidados paliativos para uma morte digna, da classificação internacional para a prática de enfermagem (cipe®). palavras-chave ferimentos e lesões; cuidados paliativos; enfermagem oncológica; cuidados de enfermagem; pacotes de assistência ao paciente (fonte: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 243-256 244 aquichan issn 1657-5997 eissn 2027-5374 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 243-256 intervenciones de enfermería para pacientes oncológicos con olor fétido en herida tumoral resumen objetivo: identificar intervenciones de enfermería para el diagnóstico de olor fétido en herida tumoral. métodos: revisión integradora de la literatura a partir de las bases de datos medline, cinahl, lilacs e cochrane, que resultó en la selección de 48 artículos científicos acerca de la temática investigada. resultados: con base en las evidencias empíricas identificadas en los artículos incluidos en el estudio, se elaboraron 24 intervenciones de enfermería para el control y la reducción del olor fétido en heridas tumorales. conclusiones: las intervenciones de enfermería presentadas en el estudio posibilitan la promoción de la calidad de vida al paciente con herida tumoral en cuidado paliativo. como sugerencia posterior al consejo internacional de enfermeros, se deben validar clínicamente para que su inserción se realice en el subconjunto terminológico cuidados paliativos para una muerte digna, de la clasificación internacional para la práctica de enfermería (cipe®). palabras clave cuidados de enfermería; cuidados paliativos; enfermería oncológica; heridas y lesiones; paquetes de asistencia al paciente (fuente: decs, bireme). 245 intervenções de enfermagem para pacientes oncológicos com odor fétido em ferida tumoral l maria cristina freitas de castro e outros nursing intervention for cancer patients experiencing foul odor from malignant wounds abstract objective: the objective of the study was to identify nursing interventions to diagnose foul odor from malignant wounds. methods: an integrative review of the literature in the medline, cinahl, lilacs and cochrane databases resulted in the selection of 48 scientific articles on the subject. results: based on the empirical evidence found in the articles included in the study, 24 nursing interventions were developed to control and reduce foul odor from malignant wounds. conclusions: the nursing interventions outlined in the study make it possible to improve the quality of life for patients in palliative care who have malignant wounds. a subsequent suggestion to the international council of nurses is that these interventions be clinically validated so they can be inserted into the subset of the international classification of nursing practice (icnp) concerning palliative care for a dignified death. keywords nursing care; palliative care; oncological nursing; wounds and injuries; patient care packages (source: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 243-256 246 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 introdução o câncer, nome dado ao conjunto de mais de uma centena de doenças, é caracterizado pelo crescimento desordenado de células malignas que invadem tecidos e órgãos, o que leva à perda funcional destes. no brasil, sua incidência é alarmante e é nomeado como segunda causa de morte, o que o mantém como importante problema de saúde pública (1, 2). observa-se que o aumento da incidência do câncer tem sido acompanhado pela mortalidade, o que evidencia a importância do diagnóstico precoce e do tratamento adequado e oportuno. entretanto, nos dias atuais, ainda é evidente o retardamento no diagnóstico e no acesso à rede de serviço terapêutica adequada, o que repercute negativamente no prognóstico da doença (3). para aqueles com câncer em estágio avançado, ou seja, cuja doença não responde ao tratamento curativo, o foco da atenção multiprofissional é voltado para o controle de sinais e sintomas. nessa etapa, o cuidado paliativo é de grande importância, caracterizando-se por um conjunto de ações multiprofissionais que buscam a promoção da qualidade de vida do paciente e de seus familiares por meio da prevenção e do alívio do sofrimento, atingindo aspectos de natureza física, psicossocial e espiritual (4, 5). diversas práticas assistenciais são executadas junto aos pacientes com câncer avançado no âmbito dos cuidados paliativos, dentre as quais se destaca o atendimento àqueles com feridas tumorais (6, 7). historicamente, a incidência dessa condição não é bem documentada, o que dificulta a obtenção de dados estatísticos oficiais, embora estudos apontem que entre 5% e 10% dos pacientes oncológicos são acometidos por essas afecções em decorrência de tumor primário ou de tumores metastáticos, as quais determinam grande impacto na vida do paciente (6, 8-11). do ponto de vista fisiopatológico, as feridas tumorais são lesões crônicas formadas pela infiltração de células malignas nas estruturas que compõem a pele, o que causa a quebra do tegumento mediante o processo de oncogênese. caso as células malignas não sejam controladas por meio de quimioterapia, radioterapia ou hormônios, elas podem se espalhar e, como consequência, ocasionar danos no local da ferida, com uma combinação de perda de vascularização, crescimento proliferativo e ulceração (6, 12). essas feridas acometem de forma progressiva a pele e desfiguram o corpo; assim, elas se tornam friáveis, dolorosas, secretivas e fétidas, e estão presentes, na maioria dos casos, nos últimos seis meses de vida (6, 13). ressalta-se que o cuidado dessas lesões possui como finalidade o tratamento e o controle de sinais clínicos e sintomas, já que são os principais fatores que influenciam no declínio da qualidade de vida dos pacientes oncológicos com feridas tumorais (14). o cuidado aos pacientes com feridas tumorais é complexo e envolve um olhar multidisciplinar. além disso, pode acarretar em aumento das despesas para a saúde pública, caso não haja um controle efetivo dos sinais e dos sintomas, já que pode resultar em internações e tratamentos que poderiam ser evitados. a enfermagem deve implementar intervenções no âmbito dos cuidados paliativos e promover, por meio de curativos estéticos e efetivos, um atendimento individualizado ao paciente que resulte em controle da dor, do odor e da quantidade de exsudato e sangramento (15). o odor é um sinal clínico de presença constante e que implica grande impacto no cotidiano dos pacientes com ferida maligna. estima-se que 10,4% dos pacientes com feridas tumorais o apresentam. o problema é oriundo do crescimento desordenado e anormal das células neoplásicas, que ocasiona a formação de agregados de massa tumoral necrótica no leito da ferida, na qual comumente ocorre a contaminação por micro-organismos aeróbicos (pseudômonas aeruginosa e staphylococcus aureus) e anaeróbicos (bacteroides). o produto final do metabolismo desses micro-organismos são os ácidos graxos voláteis (ácido acético, caproico), bem como gases putrescina e cadaverina, que conferem odor fétido às feridas tumorais (6, 14, 16). com o avanço da doença e da lesão, o odor desagradável pode gerar constrangimento, angústia, isolamento social e familiar e, consequentemente, exigir um maior cuidado, que abranja as necessidades físicas, psicossociais e espirituais do paciente e seus familiares. o declínio do estado nutricional deficitário também é notado, decorrente do odor exalado pela ferida, que pode ser tão impactante a ponto de ocasionar náuseas e vômitos no paciente (14, 17-19). assim, o acesso a cuidado especializado, com profissionais capacitados, e a curativos modernos, com vistas ao controle efetivo dos sinais e dos sintomas, permite mais conforto ao paciente, menos angústia e redução do estigma e do isolamento social (20). a práxis profissional de enfermagem dispõe de vários instrumentos que subsidiam o atendimento em saúde em várias áreas 247 intervenções de enfermagem para pacientes oncológicos com odor fétido em ferida tumoral l maria cristina freitas de castro e outros de atuação, no âmbito do cuidado paliativo. o subconjunto terminológico cuidados paliativos para uma morte digna da classificação internacional para a prática de enfermagem (cipe®) sustenta o raciocínio clínico e a padronização da documentação da prática profissional no momento da prestação de cuidados. munido de diagnósticos, resultados e intervenções para os cuidados paliativos de enfermagem, proporciona uma assistência individualizada em vários domínios (21). apesar dos vários domínios que são contemplados nesse subconjunto terminológico da cipe®, observa-se que não há descrição de diagnóstico e intervenções específicas para o controle do odor em feridas tumorais. isso aponta para a demanda de mais investimento científico para aperfeiçoamento de tal subconjunto, já que, para os pacientes com feridas tumorais, o odor fétido caracteriza-se como um fator determinante na deterioração da sua qualidade de vida. assim, o objetivo deste estudo foi o de identificar, na literatura, intervenções de enfermagem para o diagnóstico de odor fétido em ferida tumoral. metodologia trata-se de uma revisão integrativa da literatura realizada a partir de levantamento bibliográfico digital nas seguintes bases de dados: medical literature analysis and retrieval sistem online (medline) via pubmed e biblioteca virtual de saúde (bvs), cumulative index to nursing & allied health literature (cinahl), literatura latino-americana e do caribe em ciências da saúde (lilacs) e cochrane database of systematic reviews (cochrane). a pesquisa foi orientada pela seguinte questão: que intervenções são descritas na literatura para o controle de odor em pacientes com feridas tumorais? para elaboração da questão norteadora, utilizou-se a estratégia pico: p — pacientes com feridas tumorais, i — intervenções e co — controle de odor. a estratégia de busca foi efetuada por meio do cruzamento dos descritores em ciências da saúde (decs) ferimentos e lesões e cuidados paliativos pelo medical subject headings (mesh), com os termos: wounds and injuries, palliative care; bem como com as palavras-chave: feridas neoplásicas, feridas tumorais, malignant wound (ferida maligna); fungating wound (ferida fungosa); malignant fungating wound (ferida maligna fungosa). a não existência de descritores nacionais e internacionais específicos para feridas tumorais culminou na necessidade do cruzamento entre descritores e palavras-chave, conectados com os operadores booleanos and e or. a seleção de artigos científicos realizou-se a partir da adoção dos seguintes critérios de inclusão: aderência ao eixo temático; texto na íntegra disponível on-line; horizonte temporal de janeiro de 2002 a dezembro de 2015; idiomas português, inglês ou espanhol. foram excluídos artigos cujo conteúdo envolvesse crianças e adolescentes. a pesquisa nas bases de dados foi realizada entre setembro e outubro de 2013, e em julho de 2017 para atualização. foram identificados 1067 artigos científicos nas bases de dados, dentre os quais, ao final da estratégia metodológica, selecionaram-se 48, o que viabilizou a execução deste estudo (figura 1). figura 1. fluxograma esquemático da estratégia utilizada para seleção de artigos fonte: fluxograma elaborado com base nos artigos encontrados em base de dados. após a seleção e a leitura analítica dos 48 artigos, organizouse um quadro com as intervenções recomendadas pelos autores para o controle do odor em feridas tumorais, com discriminação dessas intervenções e indicação dos artigos que as recomendaram (quadro 1). 248 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 quadro 1. intervenções recomendadas para o controle do odor em feridas tumorais intervenções recomendadas para o controle do odor na ferida tumoral discriminação/referências debridamento • debridamento autolítico: manter ambiente úmido/hidrogel/esferas ou pastas de polissacarídeos/coberturas de espuma ou alginato (9, 15, 22, 23, 24-27); • debridamento enzimático (23, 28); • métodos mecânicos suaves (esfregaço suave com gaze saturada com solução salina ou solução de limpeza) (9, 26); • irrigação com baixa pressão (uso de solução salina em seringa agulhada) (9); • debridamento cirúrgico (9). limpeza da ferida/manejo da colonização bacteriana local • banho de chuveiro (9, 27, 29-30); • irrigação com solução salina ou limpeza com sabão neutro com ingredientes antibacterianos (9, 17, 25-27, 29); • limpeza da ferida (13, 22, 23, 26, 29); • uso de soluções antissépticas (clorexidina 0,05% ou ácido acético 0,25%) (22, 25-26). manejo da sobrecarga bacteriana com uso tópico de agentes antimicrobianos • uso tópico de metronidazol gel 0,75%-0,8% (6, 7, 9, 11, 13, 15, 17, 2225, 28-39); • uso tópico de metronidazol creme 1% (7, 25, 32); • uso tópico de comprimidos de metronidazol macerados (6, 7, 9, 13, 23, 29, 32, 40); • uso de metronidazol spray (36); • uso tópico de metronidazol (18, 26, 27, 4042); • uso tópico de metronidazol pomada vaginal (6); • compressa de gaze embebida com solução venosa (6, 7, 13); • uso tópico de flagyl em pó (41, 43); • sulfadiazina de prata (6, 13, 22, 25); • iodosorb (gel de cadexômero com liberação lenta de iodo) (9, 23, 27); • peróxido de hidrogênio (6, 9); • solução de dakin (hipoclorito de sódio) (9, 27, 41); • povidine iodado-pvp-i (6, 9, 25, 40). curativos • curativos oclusivos de prata (22, 24, 26-27, 32, 33-36, 40, 44-46); • curativos de carvão (4, 67, 9, 11, 13, 15,17, 22-27, 29, 32-36, 37, 39-42, 44, 47-48); • curativos antimicrobianos (20, 23, 41, 48); • curativos de espuma (15, 20, 32, 35); • curativos de alginato de cálcio (15, 23, 27, 32); • curativos de hidrofibras (32); • carvão ativado (coberturas ou tabletes macerados envoltos em gaze estéril e aplicados na camada superior do curativo) (26-27, 40, 46); • uso de curativos de carvão ativado impregnados de prata (43); • curativo à base de solução salina (28); • curativos hidropolímeros (28); • curativos absorventes de hidrocoloide (36); • uso de gaze impregnada de sódio (23); • gazes embebidas com hidróxido de alumínio-odor i (6); • curativos bem ajustados à ferida para não escapar agentes odoríferos/hermeticamente fechados (24, 32, 34, 42, 44). 249 intervenções de enfermagem para pacientes oncológicos com odor fétido em ferida tumoral l maria cristina freitas de castro e outros fonte: intervenções de enfermagem encontradas nos artigos selecionados a partir das bases de dados pesquisadas. resultados todos os 48 artigos selecionados nas bases de dados eletrônicas citaram o odor como evidência empírica que confere grande impacto no cotidiano dos pacientes com feridas tumorais e interfere, assim, em sua qualidade de vida. ressalta-se também que, ainda que esse sinal clínico apresente grande relevância no cenário referido, ele não é incluído no modelo de cuidados paliativos para uma morte digna. outras substâncias • uso de sachês de chá verde como curativo secundário (43); • uso tópico de extrato de chá verde (26, 28); • uso tópico de iogurte (11, 22, 29, 35, 42); • uso de iogurte + metronidazol (11); • pasta de açúcar (15, 22); • uso tópico de buttermilk (resíduo ácido resultante da produção da manteiga) (29, 35); • uso tópico ou oral de clorofila (46); • uso tópico de óleos essenciais (20, 26, 28, 30, 33, 35). regime de troca de curativos (22, 23, 29, 32-34, 36, 42) • observar regime de troca diária do curativo; • trocar curativos quando estiverem molhados/trocas frequentes; • manter curativos secos. medidas para controle do odor ambiental • uso de desodorizantes de ambientes (26-29, 32, 35); • uso de bandeja com areia para gatos no ambiente (7, 9, 13, 25, 27-28, 32); • almofadas de ervas (46); • óleo essencial (46); • neutralizadores ambientais de odor (38, 46); • colocação de tigela com pó de café no quarto (13, 27, 46); • aromaterapia (hortelã pimenta) (9, 27, 34, 42); • bicarbonato de sódio embaixo da cama (7, 25, 27); • uso de difusores aromáticos (28); • carvão estrategicamente espalhado pelo quarto (9, 13, 30, 36); • uso de perfumes ou fragrâncias para mascarar o odor (36); • ventilação do ambiente na troca dos curativos/ abrir janelas (26, 34-36, 44); • uso de odores fortes: vinagre, baunilha (13). • disposição apropriada dos curativos sujos (13, 35). outras medidas • uso de bolsas ou coletores na ferida (42); • higiene pessoal constante (34, 44, 48). com base nos achados da revisão integrativa da literatura, foram elaboradas 24 intervenções de enfermagem para o controle do odor em pacientes com feridas tumorais (quadro 2). são inúmeras as intervenções que o profissional de enfermagem pode aplicar aos pacientes com o diagnóstico de odor fétido em ferida tumoral. a escolha depende da análise clínica e do saber crítico-reflexivo, a fim de atender melhor às necessidades desses indivíduos e buscar, assim, promover sua qualidade 250 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 quadro 2. intervenções de enfermagem para o diagnóstico odor fétido em ferida tumoral fonte: intervenções de enfermagem elaboradas a partir de mapeamento cruzado com o cipe®. nota: isugestão de termos para inclusão no eixo meios da cipe®; iisugestão de termos para inclusão no eixo ação da cipe®. intervenções de enfermagem fazer debridamentoi. avaliar necessidade de debridamentoi por cirurgia. esfregar suavementeii a ferida com curativo de gaze com solução salinai. esfregar suavementeii a ferida com curativo de gaze com solução para limpar. irrigar a ferida com solução salinai em seringa com agulha. autorizar banhar a ferida no chuveiro. limpar a ferida com solução apropriada. aplicar terapia tópica com antibiótico. aplicar terapia com solução apropriada. aplicar curativo de ferida. aplicar curativo oclusivoi de ferida. aplicar bolsas de drenagem de ferida. orientar trocar curativo de ferida a cada dia. instruir sobre cuidados com a ferida. gerenciar controle do odor fétido no local da ferida. implementar aromaterapia no local da ferida. estimular habilidade para fazer higiene. orientar paciente e família sobre como descartar curativos após trocar. instruir sobre controle do odor no edifício residencial. ventilar edifício residencial ao trocar o curativo. coletar amostra de secreção na ferida. avaliar necessidade de administrar antibiótico. evitar demonstrar desconforto ao odor fétido. fornecer material instrucional sobre controle do odor fétido no local da ferida. de vida. dessa forma, o enfermeiro possui autonomia profissional para planejar e executar as intervenções de acordo com as necessidades individuais de cada paciente, não se limitando às intervenções sugeridas neste trabalho. discussão para a equipe de enfermagem de cuidados paliativos, é um grande desafio o manejo dos sinais e dos sintomas relacionados à ferida tumoral, com destaque para o odor, responsável por situações de isolamento social e declínio da qualidade de vida do paciente (41). nesse contexto, o odor é caracterizado como um sinal clínico que implica grande impacto na vida do paciente, pois a constante lembrança do avanço da doença causa angústia, isolamento social e consequente perda em qualidade de vida, o que torna imprescindível a implementação da sistematização da assistência de enfermagem. mesmo sendo uma grande problemática para os pacientes com feridas tumorais, o odor e as intervenções para o seu manejo não estão presentes no subconjunto terminológico cipe® —cuidados paliativos para uma morte digna—, bem como um domínio específico direcionado para ferida tumoral. portanto, as evidências empíricas presentes na amostra coletada por meio da trajetória metodológica e do mapeamento cruzado com a cipe® versão 2013 (50) possibilitaram a construção do diagnóstico odor fétido e intervenções para o seu manejo. o odor em feridas tumorais tem sido historicamente atribuído ao tecido desvitalizado e à mistura de gases voláteis (putrescina e cadaverina) produzidos por bactérias anaeróbicas e aeróbicas presentes no leito da lesão (23). a técnica de debridamento é frequentemente citada na literatura atual para a diminuição do tecido desvitalizado por meio do uso de procedimentos mecânicos e/ou químicos (51). a escolha do método a ser utilizado deve ser feita pelo enfermeiro de acordo com a indicação e as características da lesão. no contexto do cuidado às feridas tumorais, são indicados os debridamentos autolítico, enzimático, mecânico e cirúrgico (9, 22, 24). o debridamento autolítico é a quebra natural do tecido necrosado pelas enzimas e pelos leucócitos presentes no fluido da ferida que pode ser alcançado com o uso de coberturas que mantenham o leito da ferida úmido e liquefaçam as crostas e escaras 251 intervenções de enfermagem para pacientes oncológicos com odor fétido em ferida tumoral l maria cristina freitas de castro e outros com consequente redução de odor (24, 51). esse procedimento é importante no tratamento de feridas tumorais, pois a retirada de tecidos mortos, que contêm as bactérias, podem melhorar significativamente o desempenho de agentes antibacterianos ou até mesmo torná-los desnecessários (9, 15, 20, 22-24, 32, 35). o debridamento enzimático é um procedimento recomendado nesses casos pela utilização de agentes químicos específicos, ou seja, substâncias enzimáticas (23, 28), usadas para suavizar e remover o tecido necrosado (28). em pacientes com feridas tumorais, avaliar o acometimento de sangramento em menos de sete dias é uma conduta que deve ser realizada antes da escolha desse método (51). já o debridamento mecânico pode ser realizado com esfregaço suave de gaze embebida em soluções de limpeza, irrigação com solução salina através de seringa com agulha calibre 19 ou jatos de solução salina (9, 52). a irrigação da ferida com solução salina, à temperatura ambiente, sob baixa pressão e utilizando seringa de 20 ml com agulha de calibre 19, pode proporcionar a retirada de tecido desvitalizado solto no leito da ferida e a remoção superficial da carga bacteriana (6, 9). esse procedimento é útil para remoção de tecido necrótico que não estiver firmemente aderido. vale mencionar também que o debridamento cirúrgico é uma técnica que consiste na retirada do tecido necrosado com uso de material cortante (tesoura ou bisturi) (9, 51). o enfermeiro tem competência para realização de debridamento instrumental conservador (usando pinça, tesoura ou bisturi), desde que possua conhecimentos e habilidades para isso (53, 54). de acordo com as metas do cuidado paliativo, esse tipo de debridamento pode ser indicado, a fim de permitir a prevenção de infecção, controle de odor e administração da quantidade de exsudato (9, 22), porém a sua indicação deve ser feita com precaução e de maneira criteriosa, avaliando o risco de sangramento e dor (6, 46, 51). no caso de pequena expectativa de vida, opta-se por deixar o ambiente seco e por manter o tecido necrosado (46). em alguns estudos, a utilização de curativos à base de solução salina para controle do mau odor e auxílio do debridamento é destacada, e a retirada de tecido necrótico local e esfacelo não firmemente aderido pode ser realizada por meio de lavagem suave com gaze saturada com solução salina aquecida à temperatura ambiente (9, 28-29). a limpeza da ferida tem como intuito a remoção de bactérias e restos necróticos, o que previne a infecção sistêmica e a sepse. o uso da solução deve ser realizada com suave esfregaço, suficiente para a retirada do tecido desvitalizado sem causar traumas. a lavagem com o uso de sabonetes suaves utilizados no banho e ingredientes antimicrobianos (6, 9, 23, 42) são eficazes no controle e na redução da colonização bacteriana e do odor local. no entanto, o uso de determinados produtos deve ser ponderado e avaliado pelo profissional de acordo com a necessidade clínica, já que sua utilização pode causar irritação local, dessecação da ferida, com dor e sangramento após a retirada do curativo, o que gera incômodo nos pacientes (9, 22, 29, 41). vale mencionar que evidências empíricas apontam que a lavagem da ferida durante o banho de aspersão é um método que auxilia no controle e na redução do odor. nos casos em que a lesão não for friável e o paciente estiver em boas condições físicas, pode-se orientar a limpeza da ferida no chuveiro, de modo a permitir que a água, em temperatura ambiente, escorra na pele acima da ferida em direção à lesão. isso não só fornece a limpeza local, mas também promove o benefício psicológico adicional de ajudar o paciente a se sentir limpo (9, 29, 34). a utilização tópica de antibióticos é tema controverso no tratamento de feridas. no entanto, no caso de feridas tumorais, a diminuição da perfusão e a disseminação da droga devido ao tecido necrosado e à vascularização débil no leito da ferida, torna o uso tópico uma indicação (7, 32, 42). a terapia com antibiótico na ferida possui como finalidade promover o controle da colonização bacteriana e do odor, cujos benefícios justificam seu uso em cuidados paliativos (6). mesmo que o uso de soluções antissépticas seja questionado devido aos efeitos tóxicos ao tecido saudável para cicatrização, a utilização desses produtos em feridas tumorais pode ser indicada, já que a cicatrização da lesão não é a meta (6). o acesso a curativos especializados tem sido um determinante na melhoria da qualidade de vida e da autoestima do paciente com feridas tumorais (20). conhecer os diferentes tipos de curativos, sua indicação, custo e benefício é importante para que sejam selecionados criteriosamente. o uso de coberturas com ação antimicrobiana (20, 23, 41, 48) é importante ferramenta para o manejo do odor nas feridas tumorais, assim como curativos oclusivos, hermeticamente fechados e bem ajustados à ferida, a fim 252 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 de evitar o vazamento de agentes odoríferos voláteis, para que o controle do odor possa ser alcançado (14, 24, 34, 42, 44). ressalta-se também que o uso de bolsas coletoras na ferida tumoral pode promover a função de contenção da quantidade de exsudato e odor, alternativa eficiente quando estes são incontroláveis. porém, sua finalidade torna-se difícil de ser alcançada em afecções em áreas da face, pescoço e mama (35, 42-43, 55). evidências empíricas apontam o sucesso do uso desse método em conjunto com a troca adequada de curativos em quantidade de duas a três vezes por dia. o exsudato estagnado nos curativos pode contribuir para a presença e/ou exacerbação do odor (35). estudos indicam que curativos saturados com exsudato necessitam de troca frequente, o que, além de mantê-los secos, contribui significativamente para o manejo do mau cheiro. um regime de troca diária ajuda a prevenir maus odores resultantes de um acúmulo de exsudato (33). o curativo ideal não deve ser volumoso e deve ocupar apenas o tamanho da ferida, oferecer conforto, aderência suave, relação custo-benefício, ambiente úmido, minimização de cisalhamento, atrito e pressão, impermeabilidade de bactérias, absorção de exsudado e facilidade de seu uso pelo paciente ou cuidador. ressalta-se que a presença de exsudato pode desativar a ação de agentes antimicrobianos e dificultar, assim, o controle do odor (22, 32, 36). as trocas sucessivas de curativos devem ser avaliadas criticamente pelo enfermeiro, já que esse fator pode promover, além de dor e incômodo ao paciente, a diminuição do orçamento econômico familiar devido ao aumento do gasto com produtos e recursos humanos. estudos indicam que cuidadores estão despreparados para a tarefa de cuidar deste tipo de ferida, muitas vezes em pessoas queridas ou membros da família (56-58). o baixo nível de informação e a ausência de ajuda profissional podem levar alguns pacientes a usarem estratégias que podem exacerbar os sinais e os sintomas (20, 41). assim, é imprescindível que o enfermeiro os mantenha informados sobre os procedimentos, promova o desenvolvimento de habilidades necessárias para o cuidado e envolva-os nesse processo, já que são essenciais para o adequado tratamento dos pacientes (35). dentre as várias medidas que visam ao gerenciamento do controle de odor nas feridas tumorais, pode-se destacar o uso tópico de desodorantes comerciais (23, 33) e óleos essenciais (11, 20, 28, 33, 35), que podem ser aplicados acima do curativo ou até mesmo entre as camadas deste. outra medida é o uso de aromaterapia; embora disponíveis e menos onerosos, esses óleos apenas mascaram o odor e não substituem a necessidade da troca de curativos (23). devido à lacuna existente com relação a protocolos padronizados, baseados em pesquisas e evidências, o tratamento dessas lesões ainda é baseado em estudo de casos ou opinião de peritos (9, 32). cabe, então, ao enfermeiro avaliar a situação e definir qual a melhor conduta a ser adotada, com critérios científicos, para o controle do odor. o extravasamento de exsudato com consequente sujidade das roupas pessoais e de cama é fator de exacerbação do odor. o enfermeiro deve orientar o paciente e familiar e estimular a troca tão logo sujem de secreção, a fim de auxiliar no controle. em alguns casos, pode ser difícil para o paciente manter a sua própria higiene, de forma independente, portanto o familiar deve ser orientado sobre a importância de que a higiene seja executada apropriadamente (34, 44, 48). a orientação deve se estender também à estratégia para o controle ambiental do odor, principalmente quanto ao descarte adequado de curativos sujos, pois a manutenção dessa bandagem em ambiente fechado favorece a estagnação do odor no ambiente depositado. por isso, é aconselhável, após a retirada do curativo usado, o descarte fora do ambiente caseiro do paciente (13, 35). orientações sobre medidas para controle do odor ambiental incluem o uso de desodorantes ambientais (28, 29, 32, 35) bem como a ventilação do ambiente, com as janelas abertas inclusive durante as trocas dos curativos (34-36, 44). o odor desagradável é associado com o aumento da carga bacteriana que acontece devido à formação de verdadeiras massas necróticas no leito da ferida, infectadas por flora bacteriana mista (6). para isso, é relevante a identificação do caráter etiológico do agente causador da contaminação, de forma a auxiliar na escolha do tratamento ideal e consequente controle da infecção e redução de odor. porém, esse método deve ser executado com cuidado, pois pode causar traumas e dor ao paciente. estudos evidenciam que a coleta de swab do local da lesão possibilita a identificação de vários agentes, o que viabiliza a gestão da contaminação com antibiótico apropriado e pode, assim, reduzir o odor (34, 44). é relevante mencionar que, caso o odor seja refratário, vale considerar o uso de antibioticoterapia sistêmica junto à equipe médica (6, 9, 11, 22, 29, 30, 36, 44, 46, 48). 253 intervenções de enfermagem para pacientes oncológicos com odor fétido em ferida tumoral l maria cristina freitas de castro e outros o constrangimento experimentado pelo paciente devido ao odor fétido muitas vezes resulta da reação de profissionais ou familiares (34). o desenvolvimento de habilidades da comunicação é fundamental para que se possa responder de forma efetiva às necessidades do paciente. uma abordagem calma e sensível é de extrema relevância, já que a expressão facial pode transmitir a verdadeira extensão dos sentimentos (34). logo, é imperativo que expressões de repugnância que podem advir dos profissionais sejam evitadas para não aumentar o sofrimento do paciente em situações de constrangimento (34). a educação em saúde é uma faceta de grande importância na práxis profissional de enfermagem. como as informações fornecidas em momentos de ansiedade e estresse podem ser de difícil compreensão para os familiares e pacientes, o apoio do material impresso com orientações sobre o manejo do odor pode facilitar o entendimento das informações inerentes ao cuidado do paciente. a pequena expectativa de vida do paciente portador de uma ferida tumoral associada à complexidade inerente ao seu quadro clínico, a carência de pesquisas relacionadas à efetividade no controle dos sinais e dos sintomas dessas feridas nos últimos anos, e a falta de instrumentos e protocolos que subsidiem as ações de enfermagem nos cuidados a esses pacientes foram fatores determinantes nas limitações apresentadas durante o estudo. conclusão os estudos analisados identificaram inúmeras intervenções empíricas que, ao serem cruzadas com a cipe® versão 2013, tornaram possível a construção de fundamentais intervenções de enfermagem no âmbito dos cuidados paliativos para o controle de odor em feridas tumorais. isso evidencia as enormes contribuições que o enfermeiro pode trazer à vida do paciente, que podem levar à melhora da qualidade de vida deste. nessa etapa de tratamento, o foco da atenção multiprofissional não é a cura do paciente, mas sim o controle de sinais e sintomas, a fim de promover melhor qualidade vida. o enfermeiro, membro ativo da equipe multidisciplinar, desempenha inúmeras atribuições nesse contexto. diversas práticas assistenciais são executadas junto aos pacientes com câncer avançado no âmbito dos cuidados paliativos. dentre elas, destaca-se o atendimento aos pacientes com feridas tumorais, que são responsáveis por acometer a pele e desfigurar o corpo, tornando-se friáveis, dolorosas, com sinais clínicos e sintomas limitantes, presentes, na maioria dos casos, nos últimos seis meses de vida. com essa demanda, torna-se evidente a importância da elaboração desse subconjunto terminológico para intervenção de enfermagem como o controle de odor em feridas tumorais, com o intuito de corroborar para uma prática de enfermagem que busca a manutenção de dignidade do paciente ao fim da vida. a partir deste estudo e da elaboração do subconjunto terminológico, ressaltamos a importância do posicionamento do enfermeiro diante de um cuidado baseado em evidências científicas, que reverte em segurança para o paciente ao fornecer subsídios para uma ação de enfermagem segura no manejo dos sinais e dos sintomas das feridas tumorais. pode também resultar em dados para o ensino e para a pesquisa, o que leva a novos conhecimentos, e pode facilitar o processo gerencial da prática diária, com suas tomadas de decisão, além de fornecer uma base consistente para a documentação da prática da enfermagem. assim, é indispensável a continuidade de pesquisas na área para proporcionar a criação de um domínio para feridas tumorais no subconjunto terminológico cuidados paliativos para uma morte digna (cipe®), bem como a construção de outras intervenções de enfermagem que atinjam o controle de outros sinais e sintomas, que são grandes responsáveis pelo declínio do bem-estar do paciente com ferida tumoral. 254 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 referências 1. instituto nacional de câncer. diretrizes para a vigilância do câncer relacionado ao trabalho. rio de janeiro: instituto 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[acesso 2013 jul. 12]. disponível em: http://portal.coren-sp.gov.br/sites/default/ files/parecer_coren_sp_2009_13.pdf 55. recka k, montagnini m & vitale ca. management of bleeding associated with malignant wounds. j palliat med. 2012;15(8):952-4. 56. probst s, arber a, trojan a & faithfull s. caring for a loved one with a malignant fungating wound. support care cancer. 2012;20(12):3065-70. 57. gibson s, green j. review of patients’ experiences with fungating wounds and associated quality of life. j wound care. 2013;22(5):265-75. 58. probst s, arber a & faithfull s. coping with an exulcerated breast carcinoma: an interpretative phenomenological study. j wound care. 2013;22(7):252-60. 311 carlos yecid bernal-cárdenas1 viviana marycel céspedes-cuevas2 olivia inés sanhueza-alvarado3 modelo conceptual del manejo del síntoma: evaluación y crítica 1 orcid.org/0000-0001-7953-2314. universidad nacional de colombia, colombia. cybernalc@unal.edu.co 2 orcid.org/0000-0001-9728-0704. universidad nacional de colombia, colombia. vmcespedesc@unal.edu.co 3 orcid.org/0000-0002-0184-8957. universidad de concepción de chile, chile. osanhue@udec.cl recibido: 14/12/2017 enviado a pares: 06/03/2018 aceptado por pares: 13/06/2018 aprobado: 15/06/2018 doi: 10.5294/aqui.2018.18.3.6 para citar este artículo / to reference this article / para citar este artigo bernal-cárdenas cy, céspedes-cuevas vm, sanhueza-alvarado oi. modelo conceptual del manejo del síntoma: evaluación y crítica. aquichan. 2018; 18(3): 311-326. doi: 10.5294/aqui.2018.18.3.6 resumen objetivos: evaluar, analizar y criticar el modelo conceptual del manejo del síntoma a partir de los pasos planteados por fawcett en 2013, y mostrar la relevancia que tiene este ejercicio académico en el área investigativa, tanto a nivel académico como asistencial en enfermería. materiales y métodos: se realizó una búsqueda sistemática de piezas de investigación, las cuales fueron sometidas a un proceso de lectura crítica por medio de la aplicación de las siguientes herramientas: critical appraisal skills programme (caps) para las piezas de investigación cualitativas, macmaster university para la piezas de investigación de tipo cuantitativo, el rigor metodológico y la estructura conceptual teórico-empírica planteada por fawcett en 2013, con lo cual se garantizó la calidad de las piezas de investigación seleccionadas. resultados: se logró identificar los planteamientos del modelo conceptual del manejo del síntoma y de investigaciones donde se utilizó este modelo como marco teórico para realizar una evaluación y crítica de este, en la que se tuvieron en cuenta: sus orígenes, el enfoque único del modelo, su congruencia lógica, la generación de teoría, su credibilidad y las contribuciones para la disciplina de enfermería, que corresponden a los pasos recomendados por fawcett para la evaluación crítica de modelos conceptuales. conclusión: a año 18 vol. 18 nº 3 chía, colombia -septiembre 2018 l 311-326 temática: epistemología. aporte a la disciplina: el modelo conceptual del manejo del síntoma (mcms) ha sido utilizado ampliamente, y ha obtenido resultados muy importantes en la generación de conocimientos nuevos, relevantes para la investigación y la práctica, ya que ha logrado abordar varios síntomas en diferentes etiologías, ha demostrado su utilidad y relevancia en la producción de conocimientos, y ha brindado herramientas que le permiten al enfermero identificar, prevenir e intervenir los síntomas. el mcms cuenta con características dentro su estructura conceptual, teórica y empírica que le permiten ser aplicado en el área clínica e investigativa de una forma sencilla; asimismo, se puede seleccionar una parte de él, según la necesidad o fenómeno, lo que demuestra el aporte novedoso a la ejecución de un cuidado respaldado por un modelo conceptual de enfermería o el desarrollo de una investigación con un sustento teórico novedoso y sólido, totalmente pertinente para cualquier fenómeno. http://orcid.org/0000-0001-7953-2314 mailto:cybernalc@unal.edu.co http://orcid.org/0000-0001-9728-0704 mailto:vmcespedesc@unal.edu.co http://orcid.org/0000-0002-0184-8957 mailto:osanhue@udec.cl 312 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 311-326 pesar de ser un modelo conceptual nuevo cuenta con fuertes bases teóricas y filosóficas que permiten su aplicación a cualquier fenómeno referente a la experiencia de los síntomas; sin embargo, se debe realizar más investigación donde se haga uso de las dimensiones de “los componentes de estrategias de manejo de los síntomas” y “resultados”, ya que un amplio volumen de investigación realizada hasta el momento ha hecho uso de la dimensión “la experiencia de los síntomas”. palabras clave investigación en enfermería; educación en enfermería; modelos de enfermería; evaluación de síntomas; investigación en evaluación de enfermería (fuente: decs). 313 modelo conceptual del manejo del síntoma: evaluación y crítica l carlos yecid bernal-cárdenas y otros conceptual model symptom management: critical evaluation abstract objectives: the purpose of this study was to evaluate, analyze and critique the conceptual model for symptom management based on the steps outlined by fawcett in 2013, and to show the relevance of this academic exercise in the field of research, both at the academic level and in terms of nursing care. materials and methods: a systematic search of pieces of research was conducted and they were subject to a critical reading process through the application of a series of tools; namely, the critical appraisal skills program (caps) for qualitative pieces of research, the macmaster university critical review for quantitative studies, and the methodological rigor and theoretical-empirical conceptual structure proposed by fawcett in 2013. this guaranteed the quality of the selected pieces of research. results: it was possible to identify the approaches featured in the conceptual model for symptom management and the studies in which it has been used. this process provided a kind of theoretical framework for evaluating and commenting on the model. it took into account the origins of the model, its unique approach, and logical congruence, generation of theory, its credibility and its contributions to the discipline of nursing, all of which pertain to the steps recommended by fawcett for a critical evaluation of conceptual models. conclusion: despite being a new conceptual model, it has a strong theoretical and philosophical footing that enables it to be applied to any phenomenon related to symptoms experience. however, more research should be done using the aspects focused on "components of symptom management strategies" and "results," since a large volume of the research done so far has made use of the "systems experience" dimension. keywords nursing research; education, nursing; models, nursing; symptom assessment; nursing evaluation research (source: decs). año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 311-326 314 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 modelo conceitual de gestão de sintoma: avaliação e crítica resumo objetivos: avaliar, analisar e criticar o modelo conceitual do manejo do sintoma a partir dos passos propostos por fawcett em 2013, e mostrar a relevância que esse exercício acadêmico tem para a área de pesquisa, tanto no âmbito acadêmico quanto no assistencial em enfermagem. materiais e métodos: realizou-se uma busca sistemática de peças de pesquisa, as quais foram submetidas a um processo de leitura crítica por meio da aplicação das ferramentas: critical appraisal skills programme (caps) para as peças de pesquisa qualitativa, macmaster university, para as peças de pesquisa quantitativa, o rigor metodológico e a estrutura conceitual teórico-empírica proposta por fawcett em 2013, com o que se garantiu a qualidade das peças de pesquisa selecionadas. resultados: pôde-se identificar as propostas do modelo conceitual do manejo do sintoma e de pesquisas em que esse modelo foi utilizado como referencial teórico para realizar uma avaliação e crítica dele, em que se consideraram: suas origens, a abordagem única do modelo, sua congruência lógica, a geração de teoria, sua credibilidade e as contribuições para a disciplina de enfermagem, que correspondem aos passos recomendados por fawcett para a avaliação crítica de modelos conceituais. conclusão: embora seja um modelo conceitual novo, conta com fortes bases teóricas e filosóficas que permitem sua aplicação a qualquer fenômeno referente à experiência dos sintomas; contudo, deve-se realizar mais pesquisas em que se utilizem as dimensões dos “componentes de estratégias de manejo dos sintomas” e “resultados”, já que um amplo volume de pesquisa realizada até o momento tem utilizado somente a dimensão “a experiência dos sintomas”. palavras-chave pesquisa em enfermagem; educação em enfermagem; modelos de enfermagem; avaliação de sintomas; pesquisa em avaliação de enfermagem (fonte: decs). 315 modelo conceptual del manejo del síntoma: evaluación y crítica l carlos yecid bernal-cárdenas y otros introducción la necesidad de contar con elementos y conceptos propios de la disciplina hace evidente la noción de cuidado como distintivo en la atención del ser humano en una situación de salud y enfermedad. al respecto, enfermería comenzó a hacer planteamientos conceptuales que pudieran respaldar cada una de sus actividades, lo que permitió poco a poco conformar marcos de conocimiento explícitos y muy bien sustentados, que más adelante se convirtieron en un modelo conceptual (mc), y se ubicaron dentro de una jerarquía de abstracción, luego de los metaparadigmas y las filosofías, como la más amplia y fuerte base para el desarrollo disciplinar y científico de la disciplina. como lo plantea popper (1), los mc son “un horizonte de expectativas” que proporciona un marco de referencia distintivo, el cual le brinda al investigador una forma de observar e interpretar a profundidad una realidad, y ofrecen elementos para observar e interpretar los fenómenos de interés para enfermería; los mc están conformados por un conjunto de conceptos relativamente abstractos y generales que se dirigen a los fenómenos de interés dentro de la disciplina (2), lo que es interpretado erróneamente como conceptos de difícil entendimiento y compleja aplicación en la vida real del quehacer diario del profesional de enfermería (2). la importancia de los mc radica en ofrecer una manera sistemática de entender los fenómenos, guiar las acciones y proporcionar un marco para la aplicación de los conceptos (2) a fenómenos específicos por medio del planteamiento de teorías de rango medio (trm), con el uso de investigación respaldada en un modelo conceptual o una parte de este, lo que demuestra su valor en el desarrollo científico de enfermería (1). es de resaltar cómo los mc evolucionaron de las observaciones empíricas y las concepciones intuitivas de enfermeras(os) en el área clínica o de deducciones que forman ideas creativas a partir de diferentes campos de indagación, como es el caso del modelo conceptual del manejo del síntoma (mcms) desarrollado por dodd, et al. (3), que a pesar de ser relativamente nuevo ha sido ampliamente utilizado en diferentes fenómenos abordados por medio de investigaciones que han reportado su utilidad, como se mostrará a continuación, por lo cual se realizó una crítica teórica que permitió identificar sus fortalezas y debilidades. materiales y métodos para la realización de la crítica teórica del mcms se llevó a cabo una búsqueda de las piezas de investigación en las bases de datos: pubmed vía medline, bvs, ebsco, scopus, asc, dynamed, ovid journals, ovid nursing e isi web of science; la búsqueda se realizó durante un periodo de 6 meses, desde abril hasta septiembre del año 2017, y reportó un total 126 artículos, los cuales fueron filtrados por medio de la lectura del título y el resumen, con lo cual se logró seleccionar 52 artículos que fueron sometidos a una lectura crítica por medio de la aplicación de las siguientes herramientas: caps para las piezas de investigación de tipo cualitativo, macmaster university para la piezas de investigación de tipo cuantitativo, el rigor metodológico y la estructura conceptual teórico-empírica planteada por fawcett (1), lo cual garantizó la calidad de las piezas de investigación seleccionadas, que correspondió a 36 artículos de investigación publicados en el periodo comprendido entre los años 2004 y 2017, donde se hacía evidente la utilización del mcms. adicional a este proceso se consultaron y se utilizaron las recomendaciones dadas por fawcett (4), referentes a la crítica de mc, siguiendo cada uno de los pasos que recomienda, lo que garantizó la realización de un ejercicio que refleja un proceso descriptivo, de razonamiento analítico y de crítica del mcms; los pasos que se desarrollaron fueron los siguientes: paso 1: orígenes el primer paso en el análisis de un mc de enfermería es el examen de cuatro aspectos de sus orígenes. en primer lugar, la descripción de la evolución histórica del mc de enfermería, y la descripción de la motivación del autor para su desarrollo. en segundo lugar, la descripción de los reclamos filosóficos del autor sobre las estrategias de enfermería, y el desarrollo de conocimientos que se utilizan para formular el mc de la disciplina. en tercer lugar, las influencias en el pensamiento del autor de académicos de enfermería y de los estudiosos de disciplinas complementarias. finalmente, en cuarto lugar se especifica la identificación de la visión del mundo en el mc de enfermería (4). paso 2: enfoque único del modelo en este segundo paso se hace un examen de su enfoque único, que se deriva de la identificación y comprensión del objetivo general de enfermería dentro del mc, el cual corresponde a la 316 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 impronta con la que cuentan cada uno de los modelos, ya que estos abordan diferentes fenómenos o situaciones de enfermería, lo que determina su enfoque único (4). paso 3: congruencia lógica este paso se lleva a cabo inicialmente a fin de categorizar el contenido del mc en los conceptos: seres humanos, medio ambiente, salud y enfermería, luego se identifican las proposiciones no relacionales que definen y describen los conceptos, y, finalmente, las proposiciones que relacionan los conceptos son extraídas y clasificadas de acuerdo con los vínculos entre los cuatro conceptos metaparadigmáticos planteados dentro del mc de enfermería (4). paso 4: generación de teoría en este paso se evalúa y juzga el grado en que el mc conduce a la generación de teoría, donde lo que se espera es que los conceptos abstractos y las proposiciones del mc sean suficientemente claras para que aquellos de las grandes teorías y de las teorías de rango medio permitan deducir hipótesis comprobables y posteriormente formularlas (4). paso 5: credibilidad del modelo el objetivo final de la evaluación de la credibilidad es determinar cómo los mc de enfermería son apropiados para su uso en ciertas situaciones de la práctica y en poblaciones específicas. en particular, la credibilidad es examinada por medio de la definición de los criterios de utilidad, congruencia y significado sociales dentro del mc (4). paso 6: contribuciones para la disciplina de enfermería la sexta y última etapa de la evaluación corresponde a la identificación de las contribuciones del mc a la disciplina de enfermería por medio de su aplicación en diferentes investigaciones y distintos fenómenos, aspecto que puede ser descrito de una forma tan general por los autores, como el mismo mc. para desarrollar este paso se requiere un juicio de valor con respecto a las contribuciones del modelo a la disciplina de enfermería. las afirmaciones no deben hacerse sobre la base de la comparación de un modelo con otro, al contrario, cada modelo de enfermería debe ser juzgado por sus propios méritos y en concordancia con sus propias afirmaciones filosóficas (2). la crítica teórica en investigación como herramienta fundamental para la comprensión del conocimiento disciplinar en el momento que un investigador en el área de enfermería se enfrenta a la definición de un marco teórico que le permita respaldar el planteamiento de su investigación y el fenómeno por abordar debe garantizar que tanto las piezas de investigación como el mc o teoría correspondan a conocimiento y planteamientos relevantes frente a dicho fenómeno, donde se cuente con varias estrategias para garantizar este aspecto, una de ellas corresponde al proceso de crítica teórica que permita hacer una evaluación y crítica con la cual pueda justificar su selección. por lo anterior, desde hace muchos años los profesionales de enfermería se han comenzado a preocupar por ser consumidores de la mejor evidencia científica y teórica; al respecto, burns y groves (1) indicaron que en las décadas de los cuarenta y cincuenta la investigación de enfermería generó críticas que no eran agradables; en consecuencia, se llevó a cabo poca investigación en enfermería hasta los años ochenta y noventa. lo interesante es que hasta el momento todos los estudios tienen algunas imperfecciones, pero ese argumento no corresponde a una razón válida para no realizar investigaciones, al contrario, esto ha permitido diseñar los análisis centrados en las limitaciones y fortalezas de los estudios (4). es esencial que los enfermeros(as) hagan un uso más consciente y constante de la crítica teórica en la literatura y de las teorías que utilizan en sus planteamientos e investigaciones, ya que de esta forma pueden hacer un aporte importante a los conocimientos propios de la disciplina y a la expansión de la teoría o mc. análisis y evaluación del modelo conceptual del manejo del síntoma el análisis y la evaluación del mcms se realizó a partir de los pasos planteados por fawcett (4), teniendo en cuenta cada uno de los parámetros, los planteamientos reportados por los autores principales de este modelo, así como de la literatura adicional 317 modelo conceptual del manejo del síntoma: evaluación y crítica l carlos yecid bernal-cárdenas y otros consultada con base en las necesidades que se generan en el transcurso del presente estudio. orígenes el modelo se desarrolla desde el interés que surge en la facultad de enfermería de la universidad de san francisco, california (usfc), por un grupo de académicos y estudiantes que veían cómo los síntomas les generaban angustia y alteración en el funcionamiento social a los pacientes con cáncer, y cómo el manejo de estos síntomas y los resultados se convertían en una responsabilidad del paciente y de los miembros de su familia; además, identificaron que la investigación existente hasta ese momento solo se dirigía a un síntoma, que podía ser el dolor o la fatiga, o a la evaluación de los síntomas asociados con la depresión y los trastornos del sueño. sin embargo, la práctica clínica y el desarrollo de la investigación mostró la necesidad de un planteamiento teórico que permitiera abordar varios síntomas al tiempo y de diferentes etiologías, por lo cual consultaron literatura relevante en enfermería como lo reportado por larson (5), orem, citado por céspedes (6), sorofman, et al. y lenz, citados por humphreys et al. (7), y planteamientos desarrollados por otras disciplinas como los realizados por bandura (8), cameron y leventhal (9), cioffi (10), teel (11), y suchman, harvey y mahler, y leventhal, citados por humphreys et al. (7), cioffi (10), lo que les permitió conformar unas fuertes bases teóricas para el posterior planteamiento de un mc por medio del cual se brindaran estrategias de manejo de síntomas para ser aplicadas en entornos agudos, ya que pocos modelos habían sido probados empíricamente (3, 12). a continuación se ampliará y analizará cada uno de los planteamientos realizados por los autores mencionados. el desarrollo de este modelo partió del modelo de gestión del síntoma de larson (5), que plantea un enfoque integrado sobre el tratamiento de los síntomas referente al efecto de la gestión de estos en la consecución de los resultados deseados, y cómo este corresponde a un proceso de una evaluación continua; define el síntoma como una experiencia subjetiva que refleja cambios tanto en el componente biopsicosocial como en la cognición de un individuo. la conceptualización se basó inicialmente en modelos que habían sido desarrollados desde enfermería: el modelo de autocuidado de orem, citada por larson (5), que describe cómo las enfermeras ayudan a los pacientes a satisfacer sus requisitos de autocuidado; el modelo de autocuidado de los síntomas de sorofman et al., citada por larson (5), que describe la respuesta de una persona a los síntomas, o el reconocimiento de estos y su evaluación, la consulta, la consideración e implementación del tratamiento, y el resultado de los síntomas; finalmente, dentro de sus bases teóricas se evidencia una teoría de mediano rango que plantea la sincronía en la ocurrencia de más de un síntoma, como señala lenz (7). posteriormente, se identificaron otros modelos dentro de sus bases teóricas que corresponden a planteamientos realizados desde otras disciplinas, como la antropología, la sociología y la psicología, dentro de los cuales se encuentran: bandura (8), que diserta sobre los comportamientos sociales; cameron y leventhal (9) hacen planteamientos sobre la autorregulación del síntoma; cioffi (10) y teel (11) muestran los procesos cognitivos para el manejo de los síntomas; suchman, citada por humphreys et al. (7) plantea que el síntoma es una señal que representa una anomalía causada por una enfermedad identificada del individuo; harvey y mahler, citados por humphreys et al. (7) identifican los factores que afectan el proceso de toma de decisión, como los cognitivos y emocionales, y leventhal (9) y cioffi (10), quienes plantean el razonamiento bayesiano que implica la toma de decisiones basadas en la lógica y la probabilidad frente a una experiencia del síntoma. dentro de estas posturas se pueden identificar puntos en común, como los componentes cognitivos, que corresponden a un elemento fundamental para tener en cuenta cuando se aborda la experiencia de los síntomas, como en cada uno de los planteamientos se tienen en cuenta diferentes momentos dentro de dicha experiencia, lo que finalmente influirá en la respuesta o las conductas de los individuos frente a esta, y, adicionalmente, esta experiencia está influenciada por unas variables contextuales. el mcms es amplio y abarca una extensa variedad de condiciones contextuales de cualquier síntoma, en las que se consideran las correlaciones de las dimensiones del modelo (3), dentro de este se considera que la experiencia del síntoma no ocurre en el vacío, sino que interactúa con una serie de factores que incluyen las características personales, ambientales y el estado de salud de la persona (13); gracias a esto el mc es altamente generalizable, como se pudo comprobar en el trabajo realizado en el centro para el manejo del síntoma de la facultad de enfermería de la universidad de san francisco, donde trabajan aproximadamente 318 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 170 profesionales de distintas disciplinas, y en donde cada uno de ellos desarrolla investigaciones sobre diversos fenómenos, en las que se comprueban partes del mc en diferentes asuntos por medio de varios métodos investigativos (7). el modelo de gestión de síntomas de la ucsf fue revisado en 2001 (3), se utilizaron algunos estudios de investigación publicados para construir una estructura basada en evidencia que permitiera comparar y contrastar los conceptos; posteriormente, en la revisión de 2008, se modificaron ligeramente los conceptos y la naturaleza de las relaciones entre los conceptos, y se hizo explícita la influencia de los dominios persona, medio ambiente y salud/enfermedad; el modelo se situó en estas esferas (3). el modelo tiene múltiples partes interrelacionadas dentro de un contexto específico (figura 1) donde se desarrollan los fenómenos; el contexto y la experiencia de los síntomas son aspectos importantes dentro del modelo, lo que legitima la acción; las relaciones dentro de la experiencia de los síntomas son recíprocas por medio del modelo; la realidad es relativa, multidimensional y depende del contexto, y el ser humano es una entidad integrada, no reducible a partes discretas, que tienen significado dentro del entorno del individuo que cursa por la experiencia del síntoma, e interactúa con otros seres humanos y su contexto, por lo cual el modelo se ubica dentro de una visión del mundo de interacción recíproca. es muy importante analizar cómo desde la experiencia clínica en el cuidado brindado a pacientes con cáncer las enfermeras(os) identifican la necesidad o el vacío en el conocimiento propio de un marco conceptual que les permita abordar los síntomas de estos pacientes y logran, con un arduo trabajo científico, obtener el figura 1. representación algorítmica del modelo conceptual de manejo del síntoma fuente: desarrollado por los autores a partir de los planteamientos de dodd et al. (3). 319 modelo conceptual del manejo del síntoma: evaluación y crítica l carlos yecid bernal-cárdenas y otros planteamiento de un mc, a tal punto de crear un centro de atención de este fenómeno, que continúa con la generación de investigación en torno a este, proceso que siempre ha estado liderado por enfermería; esta experiencia debe ser replicada, ya que en el área clínica siempre surgen necesidades prioritarias por intervenir, que pueden ser comunes y para las cuales no exista un respaldo teórico y conceptual, lo que puede despertar el interés de un grupo de enfermeras(os) que, por medio de la investigación, den respuesta a estas necesidades, competencias que deben ser estimuladas desde el área clínica, con lo cual se permitiría reducir la brecha entre la academia y la práctica asistencial. enfoque único del modelo el mcms asegura un enfoque integral de la gestión de los síntomas que abarque la experiencia, las estrategias integradas de manejo y los resultados, a fin de permitir una sistematización de la gestión de los síntomas, proporcionar la dirección para el desarrollo de investigaciones y las estrategias para el cuidado, en busca de una mitigación de los efectos adversos de estos en la vida de los individuos, lo cual requiere de mayor investigación en los diferentes niveles de evidencia que permitan la comprobación y expansión del modelo, investigación que se desarrolla en diferentes grupos de pacientes y en distintas etiologías; de la misma forma, se demuestra su utilidad en la formación profesional, en la atención primaria, en la identificación de necesidades prioritarias por intervenir, y en las acciones de cuidado por desarrollar en el área clínica (14). inicialmente, el modelo planteó como foco principal los síntomas, ya que estas experiencias subjetivas por lo general causan la mayor angustia, pero posteriormente, gracias al trabajo científico realizado en la facultad de enfermería de la usfc, en el centro de investigación de la gestión del síntoma, se replanteó el foco principal hacia el individuo con uno o varios síntomas de cualquier etiología, lo que permitió garantizar aún más un enfoque integral del modelo. este tipo de enfoque permite a las enfermeras(os) contar con elementos conceptuales para abordar integralmente y de una forma oportuna las necesidades de cuidado de sus pacientes, lo que justifica cada vez más llevar a la práctica asistencial los mc y las teorías, que erróneamente se considera un proceso complejo para llevar a cabo. congruencia lógica y generación de teoría el mc plantea la definición de metaparadigmas, los cuales son planteados por los autores como los dominios de la ciencia de enfermería (persona, salud/enfermedad y medio ambiente), pero esta no se define explícitamente dentro del modelo; el metaparadigma planteado influye en las tres dimensiones: experiencia del síntoma, estrategias y resultados de gestión, y se define de la siguiente forma: persona: corresponde a las variables demográficas, psicológicas, sociológicas y filosóficas; son intrínsecas a la forma de un punto de vista individual correspondiente a la experiencia de los síntomas, incluye el nivel de desarrollo o la maduración de un individuo (3). salud y enfermedad: se compone de variables únicas para el estado de salud o enfermedad de un individuo, e incluye factores de riesgo, lesiones o discapacidades; asimismo, contiene efectos directos e indirectos sobre la experiencia del síntoma, la gestión y los resultados (3). medio ambiente: se refiere a la suma de condiciones o el contexto en que se produce un síntoma, es decir, incluye variables físicas, sociales y culturales. el entorno físico puede abarcar el hogar, el trabajo y el hospital. los aspectos sociales incluyen la propia red de apoyo social y las relaciones interpersonales. los aspectos culturales del medio ambiente son aquellas creencias, valores y prácticas exclusivos de un grupo étnico, racial o religioso determinado (3). enfermería: no se encuentra definida de manera explícita, pero implícitamente se puede identificar cómo el modelo determina que la enfermera debe brindar un cuidado holístico, que requiere un conocimiento previo para el abordaje de la experiencia del síntoma y sus factores asociados, con lo cual sea capaz de generar confianza y apoyo (3). como se evidencia, los conceptos metaparadigmáticos se encuentran claramente definidos y considerados dentro del mc, con el respaldo de investigaciones referentes a la experiencia del síntoma con diferentes etiologías e individuos; además se presenta una clara definición de los conceptos y subconceptos propios del modelo. 320 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 las proposiciones no relacionales se identifican dentro de las definiciones conceptuales de cada metaparadigma, y las proposiciones relacionales se evidencian dentro de la estructura de los conceptos y subconceptos del modelo, a fin de establecer una relación entre ellos de forma bidireccional. para tener más claridad, a continuación se definirán cada uno de ellos. experiencia de los síntomas: incluye la percepción de un síntoma en un individuo, la evaluación de su significado y la respuesta a este (3). percepción de los síntomas: se refiere a si una persona nota un cambio en la forma en que generalmente se siente o se comporta (3). evaluación del síntoma: las personas evalúan sus síntomas emitiendo juicios sobre la gravedad, la causa, la capacidad de tratamiento y el efecto de estos en sus vidas (3). respuesta a los síntomas: las respuestas a los síntomas incluyen componentes fisiológicos, psicológicos, socioculturales y conductuales (3). estrategias de manejo de síntomas: corresponden al objetivo del tratamiento de los síntomas, evitan o retrasan un resultado negativo por medio de estrategias biomédicas, profesionales y de autocuidado (3). resultados: surgen de las estrategias de manejo y de la experiencia de los síntomas. en el modelo revisado, la dimensión de resultados se centra en ocho factores: quién, qué, cuándo, dónde, por qué, cuánto cuesta, a quién y cómo (3). dentro del modelo se plantea la necesidad de investigar acerca de la correlación de estos conceptos para identificar la fuerza entre ellos y la expansión de las dimensiones, así como estrategias ante el síntoma y la respuesta, ya que la dimensión más utilizada en diversas investigaciones corresponde a la experiencia de los síntomas. los supuestos del modelo de gestión de los síntomas son seis: • el estándar de oro para el estudio de los síntomas se basa en la percepción del individuo que experimenta el síntoma y su autoinforme (3). • el síntoma no tiene que ser experimentado por un individuo para aplicarle este modelo de manejo. el individuo puede estar en riesgo para el desarrollo del síntoma debido a la influencia (impacto) de una variable del contexto, como un peligro en el trabajo. las estrategias de intervención podrían iniciarse antes de que un individuo experimente los síntomas (3). • los pacientes no verbales (bebés, posictus, afásicos) pueden experimentar síntomas, la interpretación de estos la pueden hacer los padres o cuidadores, esta interpretación se supone que es exacta a los efectos de la intervención (3). • todos los síntomas molestos deben ser gestionados (3). • la estrategia de gestión puede estar dirigida a una persona, un grupo, una familia o el entorno del trabajo (3). • la gestión de los síntomas es un proceso dinámico, es decir, que es modificado por los resultados individuales y las influencias de los dominios de enfermería de persona, salud, enfermedad o medio ambiente (3). en la actualidad, la complejidad en el alto volumen de actividades que desarrollan las enfermeras(os) en el área clínica, que en la mayoría de los casos corresponden a actividades administrativas, ha generado que se olviden las definiciones metaparadigmáticas que respaldan el quehacer de enfermería, que ubican al individuo dentro de un contexto propio e individual, lo que determinará el cuidado que se debe brindar; sin embargo, al no tener presentes estos elementos, el cuidado se convierte en una actividad meramente mecanicista e instrumental. generación de teoría el mc ha sido ampliamente utilizado en diferentes investigaciones, con diversos métodos y en distintos grupos poblacionales con diferentes etiologías, lo que ha permitido su expansión y comprobación en algunos componentes, con resultados muy interesantes y conocimientos muy útiles para la disciplina. este modelo nació a partir de la experiencia que habían tenido las autoras en el cuidado brindado a pacientes con cáncer y de diversas investigaciones realizadas por ellas mismas en el área de oncología, por lo cual el mc tiene un importante volumen de investigación realizado que se ha aplicado a diferentes fenómenos dentro del área de oncología, que se ha mantenido hasta la 321 modelo conceptual del manejo del síntoma: evaluación y crítica l carlos yecid bernal-cárdenas y otros actualidad, tal es el caso de una investigación que abordó diferentes síntomas de pacientes con cáncer de útero, donde se utilizó el mcms para describir la experiencia de la fatiga, la angustia psicológica, los recursos para la respuesta y la calidad de vida; este estudio logró identificar una correlación significativa entre la fatiga y la ansiedad, y entre la fatiga general y la depresión (15). los primeros trabajos donde se comenzaron a utilizar los planteamientos del mc fueron los desarrollados en la ucsf, como los de kohlman et al., citados por larson (5), quienes en su investigación inicial exploraron la experiencia de los síntomas del paciente y las respuestas a la disnea; su estudio descubrió la diversa experiencia de los síntomas de los individuos y la variedad de términos que los pacientes usaron para describirla. ellos produjeron algunas de las evidencias más tempranas para la dimensión de la disnea, y han seguido con la exploración de la angustia relacionada con la disnea en el contexto clínico (5). el mayor volumen inicial de investigación basado en el mc corresponde al realizado en áreas de pacientes con cáncer, disnea y diabetes mellitus, que ha progresado hasta el punto en que los investigadores han descrito experiencias de síntomas de los pacientes, han desarrollado estrategias de manejo y realizado pruebas de su eficacia (5). el significativo volumen de investigación donde se comenzó a utilizar el mcms desde un abordaje descriptivo permitió generar en otros investigadores el interés por desarrollar estudios cuantitativos a partir del mcms, como se podrá identificar a continuación. el mc ha brindado herramientas adecuadas para la creación de modelos de atención en pacientes y etiologías específicas, como es el caso de un modelo de atención para mujeres afroamericanas con diabetes, que demostró la facilidad de la adaptación del mc para este fenómeno, y logró comprobar su efectividad (6, 15); de la misma forma, en asia utilizaron el mc en el planteamiento de un modelo de intervención para personas de la tercera edad con artritis, que facilitó tanto la investigación de este fenómeno como la práctica clínica que les permitió comprender las experiencias de los síntomas incapacitantes en las personas con artritis, sus estrategias de manejo y los resultados (16). el mc ha permitido abordar fenómenos de forma novedosa, como es el caso del área del cuidado paliativo, donde el mc se utilizó para la identificación de la barreras que bloquean los esfuerzos para aliviar la carga de los síntomas al final de la vida brindados por enfermería, con el uso de dos componentes del modelo: las estrategias de gestión de los síntomas y las barreras relacionadas con el dominio del medio ambiente (los contextos físico, social y cultural en los que se producen los síntomas), para determinar su impacto en el alivio de los síntomas; allí se promueve el uso del mcms a fin de identificar y corregir los impedimentos para el manejo eficaz de los síntomas y reducir el sufrimiento del paciente al final de la vida (17). en el área cardiovascular el mc ha demostrado ser de muy alta utilidad en el abordaje de diferentes fenómenos, como en la generación de instrumentos; tal es el caso de una investigación donde por medio de la identificación de subgrupos de mujeres con síndrome coronario agudo (sca) según la experiencia del síntoma: percepción, evaluación y respuesta, se desarrolló un instrumento para la medición de los tres componentes que permitió hacer una comprobación teórica por medio de la verificación de los planteamientos del mcms, específicamente en la primera dimensión (experiencia del síntoma), lo que generó un aporte a la teoría (6, 18). igualmente, dentro de la dimensión de “la experiencia del síntoma” se han realizado investigaciones donde se ha comprobado la correlación que existe entre sus componentes, específicamente entre la evaluación y la respuesta, lo que permitió comprobar los planteamientos realizados por el mcms (19). en la actualidad está en curso una investigación donde se pretende identificar los factores psicosociales que influyen en la toma de decisiones de las mujeres con síntomas coronarios (20). a nivel internacional, el mc ha permitido identificar cómo el género afecta los resultados cardiovasculares; así, las mujeres tienen mayor morbilidad y mortalidad después de una cirugía de bypass coronario y después del infarto del miocardio (21). el modelo ha sido muy útil en la descripción de la experiencia de los síntomas, como es el caso de una investigación que describió las acciones de respuesta de la mujer y el tiempo de demora para solicitar ayuda ante los síntomas que sugieren un síndrome coronario agudo, donde se utilizó el instrumento diseñado por céspedes (22); esta investigación permitió comprender el fenómeno de respuesta de las mujeres ante los síntomas de sca, expandió el mc y demostró la utilidad del instrumento diseñado (23). el instrumento de céspedes (18) ha demostrado tener cualidades psicométricas para su uso por otros investigadores, por 322 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 medio de publicaciones de la fase investigativa psicométrica para demostrar su validez; como se señaló, fue diseñado para medir la experiencia de mujeres con sca según la percepción, evaluación y respuesta a los síntomas a partir del mcms (7). además de estos reportes de investigación se han documentado aportes importantes para el diseño de instrumentos y para la medición de los datos obtenidos por esta herramienta, específicamente lo que tiene que ver con la direccionalidad de los ítems y cómo esto incide en la validez, la objetividad y la confiabilidad de los instrumentos de medición (23). desde un nivel de comprobación, se realizó una investigación donde se desarrolló una estrategia de manejo cognitivo de los síntomas de enfermedad coronaria en la mujer, elaborada a partir del mcms, y comprobó la importancia de incluir elementos cognitivos y enfoque de género dentro de los programas de rehabilitación cardíaca (24). credibilidad del modelo utilidad social el centro de investigación para la gestión de los síntomas de la usfc realiza una formación especial en varios aspectos centrales del fenómeno de la experiencia de los síntomas y el mc para estudiantes de doctorado y posdoctorado por medio de unas becas. en cuanto a la posibilidad de la aplicación de este mc a la práctica por medio de protocolos se han desarrollado varias exploraciones, como por ejemplo, en el área del cuidado paliativo, donde aplicaron el mc para expandir la comprensión de las necesidades de los pacientes moribundos y las barreras ambientales que les impiden recibir los cuidados necesarios (17); asimismo, utilizaron el modelo como marco conceptual para un programa de educación que busca formar líderes en enfermería clínica que permita evaluar eficazmente los síntomas del paciente y desarrollar estrategias de manejo efectivas con resultados óptimos (25). por lo anterior, se ha hecho evidente cómo el mc ha sido útil para hacer investigación en la práctica con individuos de todas las edades y diferentes condiciones de salud. además, han derivado protocolos para la práctica y herramientas de valoración del estado de la salud en pacientes oncológicos y cardiovasculares (7). el modelo ha sido fuertemente utilizado en investigación referente a síntomas causados por diferentes tipos de cáncer, también se ha utilizado en el desarrollo de instrumentos para medir la experiencia del síntoma en pacientes con alteraciones cardiovasculares, y es eje fundamental en el desarrollo de investigación y de atención dentro de la práctica de enfermería en el centro del manejo del síntoma de la usfc, donde trabaja un amplio grupo multidisciplinario liderado por enfermería que genera un alto volumen de investigación en diferentes líneas, ha sido fuertemente investigado en la primera dimensión del modelo (7). congruencia social es relevante mencionar los instrumentos generados por el mc, ya que ha brindado herramientas para que el profesional de enfermería evalúe la experiencia de los síntomas de los pacientes que a diario cuidan (19). la investigación existente referente a la aplicación del modelo en la práctica no es suficiente, se hace necesario hacer más investigación que demuestre la utilidad de este modelo en diferentes patologías y diversos grupos, ya que existe un amplio volumen de investigaciones realizadas en oncología y el área cardiovascular; de la misma forma, es necesario aportar investigación en las otras dos dimensiones del modelo (estrategias de manejo de los síntomas y resultados), ya que lo abordado a nivel investigativo corresponde a la dimensión de la experiencia del síntoma. significancia social por medio de investigaciones el mc ha producido conocimiento relevante para dar solución a diferentes fenómenos relacionados con la gestión de los síntomas, principalmente en el área de oncología, donde se han desarrollado clúster de síntomas en personas con cáncer gástrico sometidas a gastrectomía (26), e intervenciones en unidades oncológicas para su manejo (27), con lo cual se ha logrado unificar conocimientos que le permitan en un futuro al profesional de enfermería intervenir oportunamente un grupo de síntomas específico según las prioridades que identifique en sus pacientes previamente valorados. contribuciones para la disciplina de enfermería a pesar de que el modelo es relativamente nuevo ha demostrado su utilidad y relevancia en área clínica e investigativa, con 323 modelo conceptual del manejo del síntoma: evaluación y crítica l carlos yecid bernal-cárdenas y otros elementos capaces de abordar cualquier fenómeno y su correspondiente experiencia de los síntomas; el mc requiere de mayor difusión en la academia para su uso en los diferentes niveles de formación de enfermería, a fin de brindar herramientas novedosas para el desarrollo de nuevas investigaciones en cualquier nivel de evidencia científica y su utilidad en las experiencias de cuidado a las que se enfrenta el profesional de enfermería día a día. el mcms cuenta con características dentro su estructura conceptual, teórica y empírica que le permiten ser aplicado en el área clínica e investigativa de una forma sencilla, a partir del seguimiento de un proceso metódico y sistemático; no necesariamente tiene que ser utilizado todo el modelo, se puede seleccionar una parte de él, según la necesidad o fenómeno, lo que demuestra el aporte novedoso a la ejecución de un cuidado respaldado por un mc de enfermería o el desarrollo de una investigación con un sustento teórico novedoso y sólido, totalmente pertinente en cualquier evento. discusión la contribución realizada por fawcett (1, 2) referente a los elementos que se deben evaluar en el momento de la selección de un mc para su uso dentro de una investigación permitió identificar, por medio de un proceso de análisis crítico, los atributos más relevantes del mcms. a pesar de ser un mc relativamente nuevo ha sido utilizado ampliamente por diferentes investigadores, en distintos fenómenos, y ha demostrado su utilidad para dar un respaldo teórico y garantía en la idoneidad de sus planteamientos, ya que hasta el momento se ha comprobado lo planteado por medio de diferentes metodologías investigativas, con diversos niveles de evidencia, y en todos ha sido importante su participación y respaldo a los resultados obtenidos en estas investigaciones. a pesar de que el mcms ha sido utilizado ampliamente en el cuidado de enfermería, en las áreas de oncología y cardiovascular, con resultados muy importantes en la generación de conocimientos nuevos, investigadores de otras áreas y fenómenos de interés han aportado conocimientos relevantes para la investigación acerca de su utilidad, ya que han logrado abordar varios síntomas en diferentes momentos dentro de la experiencia en distintas etiologías. a pesar de su nivel de abstracción, el mcms es fácil de comprender y de aplicar en diferentes fenómenos; en el área de enfermería cardiovascular se ha comenzado a utilizar y se han obtenido resultados interesantes y relevantes para diversas problemáticas, donde a partir de estos resultados se realizan investigaciones de tipo cuasiexperimental; adicionalmente, este mc brinda elementos para ser aplicados en diversos escenarios en los cuales interviene enfermería, como la atención primaria, la identificación de prioridades y su aplicación en intervenciones y cuidados, aspecto que lo hace más relevante frente a otros mc o trm que solo son aplicables luego de la presentación del síntoma (6, 25). hasta el momento se ha comprobado ampliamente la dimensión de la experiencia de los síntomas, a diferencia de las otras dos dimensiones (estrategias de manejo de los síntomas y resultados), que no han sido significativamente utilizadas en investigación, lo que ha dificultado generar aportes para su comprobación y expansión, por lo cual se recomienda generar investigación en estas áreas. este proceso de evaluación y crítica no corresponde a un ejercicio académico fácil de realizar, al contrario, corresponde a un proceso sistemático de suma importancia que respalda la decisión del investigador para la selección y el uso del mc; todo este proceso debe ser plasmado dentro de la investigación, con lo cual se demuestra la fuerza y la relevancia de un mc seleccionado para el abordaje del fenómeno de interés. es de resaltar cómo estos procesos de evaluación y de crítica no se evidencian en los reportes de investigación, no queda claro si no se reportan por su no realización, lo que muestra una aceptación y adherencia a los planteamiento del mc sin argumentos, o quizá porque no se considera como un proceso académico relevante por lo cual no es tenido en cuenta en las publicaciones científicas. así el mc haya sido sometido a un proceso de evaluación y de crítica previa por otros autores, en nuevos usos de este por otros investigadores se debe realizar todo el proceso, ya que estos pudieron refutar planteamientos o expandirlos por medio de sus investigaciones, o generar teorías de mediano rango a partir de los mc, y estos elementos deben ser tenidos en cuenta en el caso de ser utilizados en nuevas investigaciones. en el caso del uso de teorías de rango medio (trm), la realidad no es diferente cuando se usan mc, ya que tampoco se logra identificar bajo qué criterios los investigadores seleccionaron su teoría para abordar determinados fenómenos. fawcett (2, 4) también plantea al respecto una serie de pasos para realizar evaluación, 324 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 análisis y crítica para trm, con el mismo rigor que plantea para los mc, por lo cual vale la pena hacer uso de estas recomendaciones cuando se utilice una trm, proceso que debe quedar plasmado en el documento final de la investigación, así como en publicaciones científicas donde se haga evidente el proceso, y de esta forma se pueda aportar y expandir dicha teoría por medio de su uso como marco teórico en las diferentes investigaciones, teniendo siempre presente como respaldo de su elección un proceso de crítica teórica, lo que determina y demuestra claridad conceptual como garante preliminar para la investigación científica. con lo anterior se enfatiza la necesidad de llevar a la práctica los resultados de investigaciones realizadas en enfermería y comprobar lo propuesto en ellas, y de hacer uso de manera continua de los mc, en este caso el mcms, en diferentes escenarios clínicos, comunitarios y académicos, lo que le brida rigor científico a cada una de las intervenciones de enfermería planteadas. conclusión se logró evidenciar cómo los pasos recomendados por fawcett (4) corresponden a una herramienta muy importante para hacer una evaluación y crítica de los mc, previo a su selección como referente dentro de una investigación, proceso que debe ser documentado y publicado dentro de los desarrollos investigativos, ya que corresponde a un ejercicio crítico y analítico relevante, que concierne a un proceso que demanda tiempo y dedicación, donde se debe estar ampliamente capacitados en el uso de estos pasos, a fin de comprender el mc que se critica y evalúa. así como es prioritario en el planteamiento de un proyecto de investigación el consultar la mejor literatura científica por medio de la crítica investigativa, con el uso de herramientas como el caps, prisma, consort, strobe, coreq, entre otras, lo que garantiza unas bases teóricas sólidas que respalden el fenómeno, es igualmente importante que se realice un proceso de análisis, evaluación y crítica de los mc o trm que delimitan el marco teórico y guían en el desarrollo de la investigación, este proceso debe ser ampliamente documentado por su relevancia metódica y aporte a los mc y trm. por medio de la crítica teórica utilizada se logró determinar que el mcms, a pesar de ser un mc nuevo, posee unos fuertes orígenes tanto teóricos como filosóficos, por lo cual ha sido ampliamente utilizado en diferentes fenómenos, con distintos diseños de investigación, y ha demostrado congruencia en sus planteamientos, comprobados por medio de diversas investigaciones, lo que ha permitido expandir el mc, a demás de ser ampliamente generalizable en personas con fenómenos de diferente origen etiológico. cabe resaltar la necesidad de desarrollar más investigación en las dimensiones de componentes de estrategias de manejo y en la de resultados, ya que la mayoría de estudios producidos hasta el momento han sido en la dimensión de la experiencia del síntoma. este ejercicio académico de evaluación crítica es esencial dentro de un proceso de investigación o cuando un grupo de enfermeras en las áreas clínica o comunitaria decidan hacer uso de un mc o trm para intervenir un fenómeno de su interés, lo que respaldaría con contundencia su decisión; tal es el caso del uso del mcms que brinda elementos conceptuales, teóricos y empíricos aplicables, lo que daría solución a fenómenos y problemáticas a los cuales se encuentran enfrentados día a día. de la misma forma existen instrumentos de mc que pueden ser utilizados en pacientes con experiencias de síntomas de diferente origen etiológico, con lo cual podrían contar con elementos que respalden las propuestas de cuidado e intervención de sus pacientes. conflicto de intereses: ninguno declarado. 325 modelo conceptual del manejo del síntoma: evaluación y crítica l carlos yecid bernal-cárdenas y otros referencias 1. fawcett j. applying conceptual models of nursing: quality improvement, research, and practice. new york: springer publishing company; 2017. 2. fawcett j, hall c. a proposed conceptual model of nursing and population health. nursing outlook. 2015; 63(3): 288-98. 3. dodd m, janson s, facione n, faucett j, froelicher e, humphreys j, et al. advancing the science of symptom management. j adv nurs. 2001;33(5):668-76. 4. fawcett j. analysis and evaluation of contemporary nursing knowledge, nursing models and theories. 3 ed. philadelphia: fa davis company; 2013. 5. larson pj. amodel for symptom management. image j nurs sch. 1994;26:272-6. 6. céspedes vm. modelo conceptual del manejo del síntoma: clasificación por percepción, evaluación y respuesta de mujeres con síndrome coronario agudo; originada por la construcción de un instrumento validado en bogotá, colombia. universidad nacional de colombia. tesis doctoral, doctora en enfermería, 2009. 7. humphreys j, janson s, donesky d, dracup k, lee k, puntillo k, et al. a middle range theory of symtom management. 3 ed. smith mj, liehr pr, editors. new york: springer publishing co; 2014. 8. bandura a. on the functional properties of perceived self-efficacy revisited. j manag. 2012 38(1):9-44. 9. cameron l, leventhal ea, leventhal h. symptom representations and affect as determinants of care seeking in a community-dwelling, adult sample population. health psychol. 1993;12(3):171-9. 10. cioffi d. beyond attentional strategies: a cognitive-perceptual model of somatic interpretation. phychol bull. 1991;109(1):25-41. 11. teel cs. perspectives unifying. symptom interpretation. j nurs scholar. 1997;29(2):175-81. 12. boswell c, cannon s. introduction to nursing research, incorporating evidence based practice. 2 ed. boston: jones and bartlett publishers; 2011. 13. beebe k, gay c, richoux s, lee k. symptom experience in late pregnancy. j obstet ginecol neon nurs. 2017. 14. ahlberg k, ekman t, wallgren a, gaston-johansson f. fatigue, psychological distress, coping and quality of life in patients with uterine cancer. j advan nurs. 2004;45(2):205-13. 15. skelly ah, leeman j, carlson j, soward a, burns d. conceptual model of symptom-focused diabetes care for african americans. j nurs scholar. 2008;40(3):261-7. 16. shin sy. disability intervention model for older adults with arthritis: an integration of theory of symptom management and disablement process model. asian nurs res. 2014;8:241-6. 17. jablonski a, wyatt g. a model for identifying barries to effective symptom management at the end of life. j hosp pall nurs. 2005;7(1):23-36. 18. céspedes-cuevas vm. atipicidad en la mujer con enfermedad coronaria: propuesta de medición y clasificación. av enferm. 2015;33(1):10-8. 19. bernal-cárdenas cy. relación entre la evaluación y respuesta de los síntomas en mujeres con síndrome coronario agudo. tesis de maestría. bogotá: universidad nacional de colombia, facultad de enfermería; 2014. 20. castañeda-valencia cr. factores psicosociales que influyen en la toma de decisiones de las mujeres con síntomas coronarios. tesis doctoral. bogotá: universidad nacional de colombia, facultad de enfermería; 2017. 21. rankin s. differences in recovery from cardiac surgery: a profile of male and female patients. heart and lung. 1990;19:481-6. 326 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 22. padilla-garcía ci, sáenz-montoya x. respuestas de la mujer frente a los síntomas de síndrome coronario agudo basados en el modelo conceptual del manejo de los síntomas. av enferm. 2014;32(1):102-13. 23. céspedes-cuevas vm, tristán lópez a. influencia de la direccionalidad de los ítems en los resultados de instrumentos de medición. revista diversitas perspectivas en psicologia. 2014;10(1):29-43. 24. motta-leon cp. eficacia de una estrategia de manejo cognitivo de los síntomas de enfermedad coronaria en la mujer. tesis de maestría. bogotá: universidad nacional de colombia, facultad de enfermería; 2017. 25. maag mm, buccheri r, capella e, jennings dl. a conceptual framework for a clinical nurse leader program. j prof nurs. 2006;22(6):367-72. 26. carrillo-gonzález m. grupo de síntomas en adultos con cáncer gástrico sometidos a gastrectomía. tesis doctoral. bogotá: universidad nacional de colombia, facultad de enfermería; 2016. 27. dodd m, miaskowski c, paul s. clusters and their effect on the functional status of patients with cancer. oncol nurs forum. 2001;20(3): 465-9. el subsistema cognitivo.pmd revista aquichan issn 1657-5997 68 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 resumen el presente artículo es producto de una amplia revisión teórica acerca del crecimiento y desarrollo del niño en su etapa preescolar realizada durante la investigación para diseñar y validar un instrumento que permita la valoración de la adaptación del niño entre los 25 y 72 meses tomando como base el modelo de adaptación de la doctora callista roy, investigación que se está llevando a cabo en la facultad de enfermería de la universidad de la sabana. en el desarrollo del artículo se presentarán los conceptos generales sobre adaptación y mecanismos de afrontamiento, y se analizará con mayor detenimiento el mecanismo cognitivo y su desarrollo en la etapa preescolar, caracterizada por procesos preoperacionales, preconvencionales y premorales, la autonomía, la iniciativa y el inicio de la socialización. palabras clave ángela hernández posada1 1 facultad enfermería universidad de la sabana. campus universitario del puente del común, km. 21, autopista norte de bogotá d.c., chía, cundinamarca, colombia. angela.hernandez@unisabana.edu.co recibido: 28 de junio de 2006 aprobado: 17 de agosto de 2006 abstract key words adaptation, confrontation mechanism, cognitive subsystem, autonomy, initiative. adaptación, mecanismo de afrontamiento, subsistema cognitivo, autonomía, iniciativa. cognitive subsystem in pre-school stages this article is the result of a broad theoretical review about children’s growing and development in pre-school stages; this review was done while researching to design and validate an instrument for assessing child’s adaptation between 25 and 72 months based on the roy adaptation model. the investigation is being conducted at the nursing faculty of la sabana university. while developing the article, some general concepts about adaptation and confrontation mechanisms will be presented. the cognitive mechanism and its development in pre-school stages will be thoroughly analyzed; this stage is featured by pre-operational, pre-conventional and pre-moral processes, autonomy, initiative and socialization’s beginning. año 6 vol. 6 nº 1 (6) 68-77 chía, colombia octubre 2006 el subsistema cognitivo en la etapa preescolar. cognitive subsystem in pre-school stages 69 el proceso de adaptación según la doctora callista roy ara que un preescolar logre la adaptación es necesario un proceso dinámico que permita ajustar el organismo a su medio (regular los comportamientos en función del entorno), a través de mecanismos de asimilación (personalización de las influencias externas) y acomodación (reorganización de las propias estructuras internas con base en la asimilación), con el objetivo de conseguir la homeostasis (armonía, equilibrio, sintonía) en su crecimiento y desarrollo; para ello son necesarios los mecanismos de afrontamiento o procesos de control, definidos en el modelo de roy (1) como las formas de interactuar innatas y adquiridas que responden e influyen en un ambiente que está en continuo cambio. los procesos innatos de afrontamiento están genéticamente determinados, son comunes a todas las especies y actúan automáticamente, es decir, la persona no tiene que pensar en ellos el subsistema regulador hace parte de estos procesos. se basa en las “respuestas del sistema neuroquímico ante un estímulo y su acción sobre los órganos efectores”. los procesos adquiridos se desarrollan a través de estrategias como el aprendizaje, ya que las experiencias en cada etapa de la vida contribuyen a dar respuestas definidas y esperadas ante un estímulo particular; el subsistema cognitivo forma parte de estos procesos y su desarrollo en la etapa preescolar será el objeto de este ensayo. con respecto a los mecanismos de afrontamiento en niños debe tenerse en cuenta que su capacidad de adaptación depende de las características naturales, del apoyo social y del afrontamiento familiar. a medida que el niño madura, va adquiriendo y ampliando sus técnicas o procesos adquiridos de afrontamiento (2, 3). generalidades del desarrollo en la etapa preescolar entre los 3 y 5 años, los pequeños hacen la transición de la edad de los primeros pasos a la niñez temprana, la etapa del preescolar o edad del juego, clasificaciones dadas por algunos autores como papalia (4) y shaffer (5). a partir de los tres años ya no es un bebé sino un gran aventurero, siente que su casa es el mundo y está ansioso por explorar todas sus capacidades en desarrollo de su cuerpo y su mente. ha superado los riesgos de los primeros años para ingresar a la etapa preescolar en una forma más saludable pero con nuevas amenazas. el crecimiento y el cambio en esta etapa son menos rápidos pero continúan entrelazándose el desarrollo físico, cognoscitivo, emocional y social. sus cuerpos se tornan más delgados, sus habilidades motoras y mentales se agudizan, y su personalidad y relaciones interpersonales se vuelven más complejas (6, 7, 8, 9, 10, 11). las destrezas que el niño ha adquirido le permiten desempeñar un papel mucho más activo en su relación con el ambiente: se desplaza libremente, siente gran curiosidad por el mundo que lo rodea y lo explora con entusiasmo, es autosuficiente y busca ser independiente. entre los 3 y 5 años, los pequeños hacen la transición de la edad de los primeros pasos a la niñez temprana, la etapa del preescolar o edad del juego. revista aquichan issn 1657-5997 70 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 las tareas principales en esta etapa se caracterizan por: dominio de habilidades neuromusculares, inicio de la socialización, logro de la autonomía temprana, desarrollo del sentimiento de iniciativa e inicio de la tipificación sexual. la creciente facilidad con que el preescolar va manejando el lenguaje (básicamente individualista: mío, dame, yo solo) y las ideas, le permiten formar su propia visión del mundo, a menudo sorprendiendo a los que lo rodean. va desarrollando su capacidad para utilizar símbolos en pensamientos y acciones, y comienza a manejar conceptos como: tiempo, espacio, relación y clasificación, aspectos que van demostrando su desarrollo cognitivo (12, 13, 14, 15, 16). el desarrollo del subsistema cognitivo en el preescolar el subsistema cognitivo mediado por la capacidad del sistema nervioso para percibir, asociar, interpretar y responder a la información que recibe constantemente del ambiente, a través de los sentidos, da significado a las experiencias humanas (17, 18). la cognición según roy (2) es la “capacidad de pensar, sentir y actuar”, expresada a través de funciones motoras como el lenguaje, la expresión corporal y los movimientos en general; en este proceso se involucran también la conciencia y los estímulos, la emoción, la percepción, el juicio y el aprendizaje (19). los aspectos enumerados anteriormente (cognitivo y conciencia) son difíciles de valorar en un niño, especialmente en lactantes y preescolares, debido a su nivel de desarrollo cognitivo, el cual se manifiesta en la creciente facilidad que el preescolar adquiere para manejar el lenguaje y las ideas, permitiéndole formar su propia visión del mundo, a menudo sorprendiendo a los que le rodean. aún no logra separar completamente lo real de lo irreal, y su lenguaje es básicamente egocéntrico, y todavía le cuesta aceptar el punto de vista de otra persona. las principales características del desarrollo cognitivo en esta etapa pueden resumirse en: desarrollo de la función simbólica, es decir, de la capacidad para representarse mentalmente imágenes visuales, auditivas o cinestésicas que tienen alguna semejanza con el objeto representativo. la función simbólica se manifiesta a través del lenguaje, la imitación diferida y el juego simbólico. comprensión de identidades: comprensión de que ciertas cosas siguen siendo iguales aunque cambien de forma, tamaño o apariencia. el desarrollo y convencimiento de esto no es definitivo pero es progresivo. comprensión de funciones. el niño comienza a establecer relaciones básicas entre dos hechos de manera igual y vaga, no con absoluta precisión. su mundo ya es más predecible y ordenado, pero aún existen características que hacen que el pensamiento preoperacional esté desprovisto de lógica. es la etapa en la cual se empiezan a utilizar los símbolos y el pensamiento se hace más flexible (20, 21, 22). el niño demuestra que puede percibir características específicas como olor, forma los aspectos enumerados anteriormente (cognitivo y conciencia) son difíciles de valorar en un niño, especialmente en lactantes y preescolares, debido a su nivel de desarrollo cognitivo, el cual se manifiesta en la creciente facilidad que el preescolar adquiere para manejar el lenguaje y las ideas, permitiéndole formar su propia visión del mundo, a menudo sorprendiendo a los que le rodean. el subsistema cognitivo en la etapa preescolar. cognitive subsystem in pre-school stages 71 y tamaño. la capacidad verbal juega aquí un papel muy importante para que pueda calificar lo que percibe. como el preescolar desarrolla sus habilidades de lenguaje con mucha rapidez, es importante que los padres lean cuentos al niño con regularidad y hablen con él muchas veces durante el día; un retraso del discurso o problemas de la articulación pueden indicar un déficit de oído, una falta de estímulo medioambiental, un ambiente bilingüe, o un retraso de desarrollo generalizado (9, 10, 15). el lenguaje va perfeccionándose, sobre todo a nivel de construcción: así mismo utilizará artículos, preposiciones, conjunciones, acercándose al lenguaje de los adultos. así mismo, la memoria se desarrolla en esta edad, retiene con más facilidad aquello que sea de su interés y ahora lo hará claramente. los preescolares recuerdan y procesan información. en general se dice que su capacidad de reconocimiento es buena y su recuerdo es pobre pero ambos mejoran entre los 2 y los 5 años. es importante que los padres tengan presente que en esta etapa los periodos de atención no son mayores de 15 a 20 minutos (22, 23, 24, 25, 26). esta etapa es un momento crucial para el niño: se produce la toma de “conciencia de sí mismo”; esto puede reconocerse en el uso de los pronombres personales (yo). su personalidad actúa en función de dos mecanismos: uno subjetivo, basado en el conocimiento y la valoración de sí mismo (expectativas propias, autoconcepto) y otro objetivo, basado en el conocimiento y la valoración que los demás hacen de él (expectativas ajenas), su rol e interdependencia (20, 21, 22). al final del tercer año hay una reestructuración global de todas las funciones psíquicas. normalmente suele haber terminado la etapa del “no” o del negativismo. ello hará que esta etapa sea más fácil de tratar. el niño ahora es capaz de representar en su pensamiento la acción que va a realizar (antes de realizarla), así como expresar mediante el lenguaje hechos pasados. se inicia la escolaridad. la actitud que adopten los padres ante esta nueva situación marcará la actitud del niño. hay que intentar no sobreprotegerlo, pues con ello no se favorece su autonomía. en 1980, erickson (20) planteó que en esta edad comienza la etapa de iniciativa frente a la culpa, que consiste esencialmente en el desenvolvimiento del niño, donde su energía le permite olvidar rápidamente los fracasos y afrontar lo que le parece deseable, aún cuando sea incierto y peligroso; ha superado ya la crisis de los tanteos y temores, y está ahora siempre activo y en movimiento. el niño goza en el ataque y la conquista, en rivalizar con los hermanos y amigos, en “ser el mejor”. deja atrás su apego exclusivo a los padres e inicia su crecimiento independiente. puede aparecer ahora un sentimiento de culpa en el niño cuando las aspiraciones y metas que desea están fuera de su alcance. es aquí donde los padres deben ayudarle porque la iniciativa trae la rivalidad y los celos que se dan frecuentemente entre hermanos y amigos. cuando el niño no logra destacarse, sobre todo ante la mamá, aparecen la resignación, la culpa, la ansiedad, que dificultarán su desarrollo psicosocial adecuado (27, 28). como su lenguaje es más claro ellos creen en el poder de la palabra y aceptan su significado literalmente; por ello cuando puede aparecer un sentimiento de culpa en el niño cuando las aspiraciones y metas que desea están fuera de su alcance. revista aquichan issn 1657-5997 72 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 se les dice que son malos porque hicieron algo equivocado lo asimilan y se consideran malas personas. por tal razón, no es conveniente decirles que son malos sino que fue una cosa mal hecha. también tienden a sentirse culpables cuando ocurre un suceso inesperado que no pueden explicarse (la muerte de un ser querido), debido a su inhabilidad para buscar una explicación razonable acerca de la causa y el efecto de una enfermedad, herida o accidente (29, 30). el niño tiene la necesidad de afirmarse como persona: es capaz de imitar a los adultos en muchas cosas. alrededor de los cuatro años descubrirá de forma natural la diferencia anatómica entre los sexos. intentará verificar cada vez que le sean posibles esas diferencias, tanto con otros niños como con sus padres. será algo natural el hacerlo. a través del dibujo de la figura humana va siendo capaz de representar aquellas partes del cuerpo que conoce bien; a medida que vaya conociendo más, irá completando su dibujo (9, 13, 29). su capacidad de integración cerebral se esboza en la acomodación que hace de diversos objetos, aún cuando no los sepa clasificar adecuadamente; por último, en esta etapa culmina el proceso de individualización emocional en relación con la figura materna (17, 18). erickson (20) sugiere a los padres ayudar a los niños a que encuentren un balance sano: dejarlos hacer cosas por sí mismos pero guiarlos y establecer límites firmes. es importante en esta etapa observar la relación que el padre tiene con el niño. un padre que sostiene una interacción visual con el niño de manera lejana, evita el contacto de los ojos con el infante, o es incapaz de leer las señales, indica ausencia de lazos afectivos. la intervención temprana es indispensable. piaget (21, 23) en su teoría cognitiva no considera separadamente al niño entre los 3 y 5 años, lo incluye en la etapa preoperacional (2 a 7 años). la cual divide en dos: fase uno: preconceptual entre los 2 a 4 años, y fase dos: pensamiento intuitivo entre los 4 a 7 años. en la primera fase (preconceptual) el niño es capaz de pensar y expresar lo que piensa sin tener en cuenta lo que puedan estar pensando o sintiendo los demás (pensamiento egocéntrico). y en la segunda fase (pensamiento intuitivo) puede expresar solo una idea a la vez y no es capaz de considerar todas las partes que componen un todo. los preescolares asumen que las demás personas piensan como ellos y que una breve explicación de sus pensamientos hace que todos lo entiendan. el preescolar aprende a relacionarse socialmente observando e imitando a los demás. también identifica qué tipo de conducta es o no es aceptable, siendo el ejemplo de las personas adultas y de otros niños de más edad las influencias más poderosas en la formación del comportamiento y la personalidad del niño. los niños aprenden copiando lo que los demás hacen, y no lo que los demás les dicen que deben hacer. si los adultos se comportan con gritos y violencia, los niños aprenderán que ésta es la conducta adecuada. si los adultos tratan a los niños y a las demás personas con amabilidad, consideración y paciencia, los pequeños también seguirán su ejemplo. de esta manera aprende las habilidades sociales necesarias para jugar y trabajar con otros niños (31, 44, 45). las medidas de disciplina del niño en esta etapa dan la oportunidad para hacer los niños aprenden copiando lo que los demás hacen, y no lo que los demás les dicen que deben hacer. si los adultos se comportan con gritos y violencia, los niños aprenderán que ésta es la conducta adecuada. el subsistema cognitivo en la etapa preescolar. cognitive subsystem in pre-school stages 73 elecciones y enfrentar nuevos retos, manteniendo siempre límites claros. para un niño de esta edad, es importante tener una estructura y una rutina diaria que incluya tareas acordes con su edad, que el niño pueda realizar y sentirse parte importante de la unidad familiar, mejorando la autoestima. es posible que recordarles dichas tareas y supervisarlos sea necesario para el logro de estas rutinas. el reconocimiento y recompensa por un buen comportamiento o un deber realizado correctamente o sin recordatorios adicionales es extremadamente importante, por lo que los padres deben tomarse el tiempo para reconocer y recompensar los “buenos” comportamientos (31, 32). la mejor forma para entender su nivel de desarrollo cognitivo y psicosocial es a través del juego ya que parte de su lenguaje es no verbal y se les facilita comunicarse con otros niños de esta forma, evidenciándose a través de estas actividades también su forma de pensar (pensamiento mágico), y su desarrollo moral y espiritual (27, 33). el preescolar tiene un pensamiento mágico, su imaginación es ilimitada y la habilidad para inventar e imitar están en su apogeo; a causa de su egocentrismo y de su forma de razonar creen que todos sus pensamientos son poderosos; la imaginación es un motor importante en su desarrollo y se manifiesta en casi todas sus actividades cotidianas, especialmente a través del juego (34, 35, 36). según bouldin y pratt (36), les encanta fingir que son otra persona. es importante fomentar esta conducta ya que permite al niño desarrollar su imaginación. también les ayuda a comprender y aceptar las formas en que otras personas se comportan, lo cual contribuye a su desarrollo cognitivo. su capacidad de cooperar con más compañeros se incrementa. aunque pueden participar en juegos que tienen reglas, éstas pueden cambiar con la frecuencia que imponga el niño más dominante. es común, en grupo de niños preescolares pequeños, ver surgir a un niño dominante que tiende a “mandar” a los demás sin mucha resistencia por parte de los otros niños (37, 38, 39). es normal que en esta edad los niños pongan a prueba sus limitaciones en términos de proezas físicas, comportamientos y expresiones de emoción y habilidades de pensamiento. es importante que exista un ambiente seguro y estructurado, que incluya límites bien definidos, dentro de los cuales el niño pueda explorar y enfrentar nuevos retos. los niños juegan para divertirse, pero el juego también es un aspecto importante de su aprendizaje y su desarrollo. el juego ayuda al niño a ampliar sus conocimientos y experiencias, y a desarrollar su curiosidad y su confianza (39, 40, 41). los niños aprenden intentando hacer cosas, comparando los resultados, haciendo preguntas, fijándose nuevas metas y buscando la manera de alcanzarlas. la estimulación y el juego son especialmente importantes si el niño padece una discapacidad. el juego también favorece el desarrollo del dominio del lenguaje y de la capacidad de razonamiento, planificación, organización y toma de decisiones, por tanto, es un elemento importante en la estructuración del subsistema cognitivo, y el desarrollo moral y espiritual, esenciales para la estructuración de la conciencia (superego) en los niños (41, 42, 43, 44, 45). según kolhberg (30), los preescolares van adquiriendo el juicio moral en su nivel es normal que en esta edad los niños pongan a prueba sus limitaciones en términos de proezas físicas, comportamientos y expresiones de emoción y habilidades de pensamiento. revista aquichan issn 1657-5997 74 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 más básico preconvencional o premoral, para ellos las normas y expectativas sociales son algo externo a sí mismos. aprenden a comportarse según la libertad o restricción para realizar actividades y acciones impuestas por sus padres o cuidadores. van entendiendo que una acción puede ser buena o mala según obtenga un premio o un castigo; entre los 2 y 4 años evitan romper las normas solo para escapar de un castigo, obedecen por obedecer y así evitar causar daño físico a otros, pero primero piensan en si mismos. posteriormente, entre los 4 y los 7 años son individualistas, su finalidad es instrumental y de intercambio, siguen las normas para conseguir sus propios intereses y satisfacer sus necesidades. aceptan intercambios, acuerdos o tratos, reconociendo que otras personas también pueden tener sus propios intereses y que éstos son diferentes a los suyos (29, 30, 46, 47). el conocimiento que van adquiriendo los niños en esta etapa también se relaciona con la fe y la religión, y es tomado de sus padres, cuidadores u otras personas que sean significativas para ellos. sin embargo, la espiritualidad en los preescolares está influenciada por su nivel de desarrollo cognitivo. tienen una concepción concreta acerca de dios, con las características físicas de un amigo imaginario. ellos entienden historias simples, aprenden oraciones cortas, pero su capacidad para entender el significado real de los ritos religiosos es limitada: los libros con dibujos y las pequeñas estatuas o imágenes son útiles para explicar a los niños el significado religioso (9, 16, 32). es importante que los niños vean a dios como un ser superior capaz de brindarles un amor incondicional, más que como un juez que juzga lo bueno y lo malo, ya que en esta etapa se introyectan estos conceptos. rezar las oraciones y participar en los ritos religiosos puede ayudar al niño a afrontar periodos estresantes como un procedimiento o una separación temporal (16, 32). otro aspecto que cabe destacar en esta etapa es el desarrollo de la conciencia, entendida ésta como la facultad o estancia psíquica gracias a la cual se adquiere el conocimiento del mundo externo y de sí mismo, e implica el aprendizaje sociocultural y la herencia familiar. dependiendo de la convergencia de diferentes tipos de actitudes el niño aprenderá no solo comportamientos apropiados, sino también a ser tolerante, o a tener prejuicios étnicos, sociales, religiosos. gran parte de esta herencia puede permanecer latente hasta que entra en contacto con niños o adultos de otros grupos, culturas y etnias, demostrando su aceptación o rechazo con sus propias actitudes (18). para vigotsky (17), en su teoría sociocultural hace hincapié en las influencias sociales y culturales sobre el desarrollo intelectual. cada cultura transmite creencias, valores y métodos referidos de pensamiento o de solución de problemas, es decir, herramientas de adaptación intelectual a cada generación; por tanto la cultura enseña a los niños qué pensar y cómo hacerlo. ese pensamiento egocéntrico (según piaget) o privado (como lo denomina vigotsky) es un sistema de autodirección cognoscitiva que regula las actividades de solución de problemas que el niño internaliza con el tiempo, para transformarlo en un pensamiento verbal abstracto en etapas del desarrollo posteriores. el lenguaje según este autor desempeña una función muy importante en el desarrollo intelectual del preescolar (21, 22, 48, 49, 50, 51). otro aspecto que cabe destacar en esta etapa es el desarrollo de la conciencia, entendida ésta como la facultad o estancia psíquica gracias a la cual se adquiere el conocimiento del mundo externo y de sí mismo, e implica el aprendizaje sociocultural y la herencia familiar. el subsistema cognitivo en la etapa preescolar. cognitive subsystem in pre-school stages 75 explica además que las grandes funciones de planeación y organización en el desarrollo cognoscitivo del niño aparecen dos veces: la primera como resultado de la interacción con otras personas (adultos), y la segunda una vez el niño ha interiorizado las enseñanzas de los adultos. sus teorías se basan en el planteamiento de una zona proximal del desarrollo (zpd), en la cual primero los adultos dirigen y organizan el aprendizaje del niño, retirándose poco a poco a medida que éste es capaz de realizar la acción por sí mismo sin ayuda (17). finalmente, puede concluirse que al llevarse a cabo los procesos descritos en las etapas: preoperacional, preconvencional o premoral, va quedando estructurada la personalidad del preescolar, de tal manera que todos los fenómenos van siendo percibidos, comprendidos por el niño y expresados a través del lenguaje, su comportamiento y su relación con los demás, a medida que adquiere el conocimiento del mundo externo y de sí mismo, a través del juego y del aprendizaje sociocultural, y condicionado por la herencia familiar y cultural. referencias 1. roy c, andrews ha. the roy adaptation model. the definitive statement. norwalk conneticut: appleton & lange; 1991. 2. roy c, andrews ha. the roy adaptation model. norwalk conneticut. appleton & lange. second edition; 2002. 3. díaz et al. aplicación del modelo de adaptación en el ciclo vital humano. chía: facultad enfermería. universidad de la sabana; 2003. 4. papalia d. psicología del desarrollo. de la infancia a la adolescencia. bogotá mcgraw-hill. quinta edición; 1992. 5. shaffer d. psicología del desarrollo. infancia y adolescencia. méxico: thomson. quinta edición; 2000. 6. papalia d, wendkos s. desarrollo humano. bogotá: mcgraw-hill. novena edición; 2004. 7. maier h. tres teorías sobre el desarrollo del niño: erickson, piaget, sears. buenos aires: amorrortu; 1980. 8. thomas rm. comparing theories of child development. belmont, california: brookscole; 1999. 9. wong dl, hockenberry mj. nursing care for infants and children. mosby: 7th edition; 2003. 10. aguilar mj. tratado de enfermeria infantil. cuidados pediátricos. madrid: elsevier; 2003. 11. carpenito l, juall. diagnósticos de enfermería. aplicaciones a la práctica clínica. madrid: mcgraw-hill; 2002. 12. gómez ci, et al. enfermería de la infancia y la adolescencia. barcelona: mcgraw-hill; 2001. 13. gómez ci. enfermería del niño y del adolescente. interamericana; 2001. 14. university of south florida. division of child development and neurology. developmental delay. 2004 may [cited dec 13, 2004]; 1(1). available from: url: http://www.dbpeds.org/articles/detail.cfm? textid=60 [consultado enero 2006] 15. ruiz md et al. enfermería del niño y adolescente. difusión y avances de enfermería; 2000. 16. whaley & wong. enfermería pediátrica. mosby; 2000. 17. vygotsky ls. mind in society. the development of higher mental processes. cambridge. harvard university press1978; (2): 251-256. 1998. 18. johnson mh, gilmore ro. developmental cognitive neuroscience: a biological perspective on cognitive change. perceptual and cognitive development. academic press: san diego ca; 1996. 19. izard ce. four systems for emotion activation: cognitive and no cognitive processes. psychological review, 1993; 100, 68-90. revista aquichan issn 1657-5997 76 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 20. erickson e. infancia y sociedad. buenos aires: hormé; 1980. 21. piaget j. the role of action in the development of thinking. knowledge and development. new york: vol. 1; 1977. 22. huttenlocher j: language input and language growth, prevention medicine 2000: 27 (7): 240-242. 23. piaget j. seis estudios de psicología. barcelona: barral editores; 1977. 24. nelson we. tratado de pediatría. mcgraw-hill. interamericana. 16 edición vols. i ii; 2000. 25. illingworth rs. el niño normal. méxico: manual moderno; 2000. 26. posada á, gómez jf, ramírez h. el niño sano. medellín. universidad de antioquia. 2da edición; 1998. 27. mcdevit s, carey. the measurement of temperament in 37 year old children, j child psychopsychiatry 1978; 19(3):245-253. 28. murris p, merckelbach h. prins e: how serious are common childhood fears? ii the parent´s point of view, beba res ther 2000; 38 (3):813-818. 29. lissauer tc. gran texto ilustrado de pediatría. hartcourt / mosby; 2003. 30. kolhberg lawrence. psicología del desarrollo moral. biblioteca de psicología. bilbao: desclee de brouwer, s.a.. 1.992 31. castro, caballero, cipriano, maldonado, olga. benguigui, yehuda. la niñez, la familia y la comunidad. aiepi, washington: ops/paltex; 2004. 32. brenner v, fox ra. parental discipline and behavior problems in young children. j genetic psychology 159. 33. american academy of pediatrics committee on psychosocial aspects of child and family health: guidance for effective discipline. pediatrics 1998b; 101 (4): 723-728. 34. jaffe ac. the gifted child. pediatric rev 2000; 21(7): 240-242. 35. kenny g. assessing children’s spirituality: what is the way forward? br nurs 1999; 8 (1): 28, 30-32. 36. bouldin p, pratt c: characteristics of preschool and school age children with imaginary companions. j genet psychol 1999; 160 (4): 397410. 37. kramer l. what´s real in children´s fantasy play? fantasy play across the transition to becoming a sibiling. j psychol psychiatry 1996; 37 (3): 329-337. 38. gottesman, mm: playing to learn: the work of children and their parents. j pediatric health care 1999; 13(5): 259-262. 39. atkin l et al. paso a paso. cómo evaluar el crecimiento y desarrollo en niños. méxico: pax; 1987. 40. betancourt c. armando vida: cartilla de crecimiento y desarrollo. bogotá: colsubsidio; 1996. 41. brazelton t. momentos claves en su desarrollo desde el periodo prenatal hasta los seis años. bogotá: norma, 1994. 42. catalán s et al. la supervisión de la salud del niño y del adolescente. chile: unicef. mediterráneo; 2000. 43. cusminsky m, moreno e, suárez e. crecimiento y desarrollo. hechos y tendencias. washington dc: publicación científica n 510.ops/oms; 1988. 44. cusminsky m, moreno e, suárez e. crecimiento y desarrollo del niño. washington dc. ops/oms; 1990. 45. fondo de la naciones unidas para la infancia. supervivir. ministerio de salud. escala abreviada de desarrollo. bogotá: unicef; 1991. 46. ministerio de trabajo y seguridad social. normas técnicas y guías de atención. documentos técnicos gobierno de colombia. bogotá; 2000. 47. servicio de salud de caldas. universidad de caldas. bases teóricas y pautas para estimulación para el niño desde la gestación hasta los seis años. manizales. universidad de caldas; 1985. el subsistema cognitivo en la etapa preescolar. cognitive subsystem in pre-school stages 77 48. organización panamericana de la salud. promoción del crecimiento y desarrollo integral de niños y adolescente. módulos de aprendizaje. washington: ops; 1995. 49. organización panamericana de la salud. manual de atención integrada a las enfermedades prevalentes de la infancia. aiepi: washington: paltex; 2004. 50. velásquez oj. pediadatos. medellín: todográficas limitada; 2004. 51. robert v kail. cognitive development in preschool children. study guide. 1995-2004 pearson education inc. publishing a pearson prentice halle. website. available from: http://wps.prenhall.com/hss_kail_ children_1/0,5756,371676-,00.html [consultado febrero 2006] << /ascii85encodepages false 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5.0 and later.) >> /namespace [ (adobe) (common) (1.0) ] /othernamespaces [ << /asreaderspreads false /cropimagestoframes true /errorcontrol /warnandcontinue /flattenerignorespreadoverrides false /includeguidesgrids false /includenonprinting false /includeslug false /namespace [ (adobe) (indesign) (4.0) ] /omitplacedbitmaps false /omitplacedeps false /omitplacedpdf false /simulateoverprint /legacy >> << /addbleedmarks false /addcolorbars false /addcropmarks false /addpageinfo false /addregmarks false /convertcolors /noconversion /destinationprofilename () /destinationprofileselector /na /downsample16bitimages true /flattenerpreset << /presetselector /mediumresolution >> /formelements false /generatestructure true /includebookmarks false /includehyperlinks false /includeinteractive false /includelayers false /includeprofiles true /multimediahandling /useobjectsettings /namespace [ (adobe) (creativesuite) (2.0) ] /pdfxoutputintentprofileselector /na /preserveediting true /untaggedcmykhandling /leaveuntagged /untaggedrgbhandling /leaveuntagged /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 296 312 evaluacion de una estrategia.indd 296 alina danet1 maría ángeles prieto-rodríguez2 maría carmen valcárcel-cabrera3 joan carles march-cerdà4 evaluación de una estrategia formativa entre iguales en fi bromialgia. un análisis de género5 1 orcid.org/0000-0002-9025-982x. ciber de epidemiología y salud pública (ciberesp). escuela andaluza de salud pública. instituto de investigación biosanitaria de granada, españa. alina.danet.easp@juntadeandalucia.es 2 orcid.org/0000-0003-3367-9956. escuela andaluza de salud pública. instituto de investigación biosanitaria de granada. ciber de epidemiología y salud pública (ciberesp), españa. mariaangeles.prieto.easp@juntadeandalucia.es 3 orcid.org/0000-0002-6644-0012. escuela andaluza de salud pública. instituto de investigación biosanitaria de granada, españa. mariac.valcarcel.easp@juntadeandalucia.es 4 orcid.org/0000-0003-2372-3781. escuela andaluza de salud pública. instituto de investigación biosanitaria de granada. ciber de epidemiología y salud pública (ciberesp), españa. joancarles.march.easp@juntadeandalucia.es 5 un agradecimiento especial al equipo escuela de pacientes por su colaboración en el desarrollo de la investigación. recibido: 26 de enero de 2015 enviado a pares: 27 de abril de 2015 aceptado por pares: 16 de marzo de 2016 aprobado: 16 de marzo de 2016 doi: 10.5294/aqui.2016.16.3.3 para citar este artículo / to reference this article / para citar este artigo danet a, prieto-rodríguez ma, valcárcel-cabrera mc, march-cerdà jc. evaluación de una estrategia formativa entre iguales en fibromialgia. un análisis de género. aquichan. 2016; 16(3): 296-312. doi: 10.5294/aqui.2016.16.3.3 resumen la fibromialgia es una enfermedad crónica altamente feminizada que requiere mayor autonomía y autoeficiencia en el manejo de los cuidados. objetivo: evaluar, desde una perspectiva de género, la estrategia formativa de pacientes con fibromialgia de la escuela de pacientes, basada en la formación “entre iguales”. método: estudio cuantitativo, con diseño cuasiexperimental pretestpostest, con 600 participantes con fibromialgia. se utilizó un cuestionario adaptado del programa de paciente experto de la universidad de stanford que recoge las variables: salud autopercibida, estrés emocional, calidad y hábitos de vida, limitaciones, relación con el personal sanitario y autoeficiencia. se empleó el análisis bivariado y multivariado y análisis del cambio entre pretest/postest. resultados: los participantes en la formación (98 % mujeres) describieron un mal estado de salud, con altos niveles de cansancio, dolor y limitaciones, con diferencias significativas en función del perfil sociodemográfico. tras la formación, mejoró el estrés emocional y los hábitos de vida, se redujeron las visitas médicas y aumentó el automanejo de la enfermedad. conclusión: la formación entre iguales representó una estrategia educativa eficiente y un espacio óptimo para reforzar el compromiso y apoyo social, con resultados positivos para la salud emocional y autoconfianza de las mujeres con fibromialgia. palabras clave formación entre iguales, fibromialgia, impacto en salud, investigación cuantitativa (fuente: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 296-312 297 evaluación de una estrategia formativa entre iguales en fibromialgia. un análisis de género l alina danet y otros año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 296-312 evaluation of a training strategy between peers in the field of fibromyalgia: a gender analysis abstract fibromyalgia is a chronic disease found more commonly in women that requires a greater autonomy and self-sufficiency in care management. objective: to evaluate, from a gender perspective, the strategy for training fibromyalgia patients from the school of patients, based on training “between peers”. method: quantitative study before and after testing, with 600 participants with fibromyalgia. a questionnaire adapted from the expert patients programme at standford university that includes the following variables: self-perceived health, emotional stress, quality and lifestyle, limitations, relationship with the health care personnel and self-efficacy. the bivariate and multivariate analysis was used, as well as the analysis of change between pre-test/post-test. results: participants in the training (98% women) described a poor health, with high levels of fatigue, pain and limitations, with significant differences according to the sociodemographic profile. after the training, emotional stress and lifestyle improved, the number of visits to the doctor dropped and disease self-management increased. conclusion: training between peers represented an effective education strategy and an optimal opportunity to reinforce social commitment and support, with positive results for the emotional health and self-confidence of women with fibromyalgia. keywords peer training, fibromyalgia, impact on health, quantitative research (source: decs, bireme). 298 aquichan issn 1657-5997 avaliação de uma estratégia formadora entre pessoas com fibromialgia. uma análise de gênero resumo a fibromialgia é uma doença crônica altamente feminizada que requer maior autonomia e autoeficiência na gestão dos cuidados. objetivo: avaliar, sob uma perspectiva de gênero, a estratégia formadora de pacientes com fibromialgia da escola de pacientes, baseada na formação “entre iguais”. método: estudo quantitativo pré-teste e pós-teste, realizado com 600 participantes na formação sobre fibromialgia. utilizou-se um questionário adaptado do programa de paciente especializado da stanford university, que coleta as variáveis: saúde autopercebida, estresse emocional, qualidade e hábitos de vida, limitações, relação com o pessoal sanitário e autoeficiência. empregou-se a análise bivariada e multivariada, e a análise da mudança entre pré-teste e pós-teste. resultados: os participantes na formação (98% mulheres) descreveram um mau estado de saúde, com altos níveis de cansaço, dor e limitações, com diferenças significativas em função do perfil sociodemográfico. após a formação, melhorou-se o estresse emocional e os hábitos de vida, reduzem-se as visitas médicas e aumentou-se a autogestão da doença. conclusão: a formação entre iguais representou uma estratégia educativa eficiente e um espaço adequado para reforçar o compromisso e o apoio social, com resultados positivos para a saúde emocional e a autoconfiança das mulheres com fibromialgia. palavras-chave formação entre iguais, fibromialgia, impacto em saúde, pesquisa quantitativa (fonte: decs, bireme). año 16 vol. 16 nº 3 chía, colombia septiembre 2016 l 296-312 299 evaluación de una estrategia formativa entre iguales en fibromialgia. un análisis de género l alina danet y otros introducción la fibromialgia, tipificada como enfermedad por la organización mundial de la salud (oms) en los años noventa (1), afecta a un porcentaje variable de 1 al 4 % de la población en los países desarrollados y el 90 % de los casos se registran entre mujeres, especialmente entre aquellas con recursos económicos y educacionales reducidos, divorciadas y de mediana edad (2). en españa se estima que un 4,2 % de las mujeres y el 0,2 % de los hombres padecen fibromialgia (3), y el perfil sociodemográfico mayoritario describe la mujer con edades comprendidas entre 40 y 50 años, ama de casa, con estudios básicos y casada (4, 5). la distribución desigual de la enfermedad entre los dos sexos no ha sido objeto de estudio prioritario en las ciencias médicas y sociales (6), aunque se han elaborado diversas hipótesis explicativas de orden biológico y psicológico (1). dentro de estas posturas, algunos autores critican los objetivos mercantilistas en el proceso de medicalización de los dolores reumáticos (7), mientras que otros consideran la fibromialgia como una enfermedad fingida (8, 9) o incluso la interpretan como una nueva dimensión de la histeria del siglo xxi (10). desde la perspectiva de género, los debates han puesto de manifiesto el reconocimiento tardío de la enfermedad al ser experimentada mayoritariamente por mujeres (3), la elección sesgada de los criterios de diagnóstico y la mayor susceptibilidad de las mujeres con base en su rol social (6), la vivencia y expresión diferencial de los síntomas por parte de hombres y mujeres (11), el deterioro del autoconcepto y satisfacción personal de las mujeres con fibromialgia (12), o las dificultades de acceso y credibilidad de las mujeres en las consultas médicas (13). pese a la polémica en torno a las causas y consecuencias que impone la feminización de la fibromialgia, en la bibliografía disponible encontramos un consenso generalizado con respecto a las importantes limitaciones funcionales, psicológicas y sociales que merman la calidad de vida de las mujeres enfermas (14, 15). aunque el dolor y el cansancio suelen ser las dificultades fundamentales, las personas con fibromialgia demandan también mayor comprensión, empatía y reconocimiento a nivel social (16), a la vez que manifiestan la necesidad de mayor información sobre cómo vivir con la enfermedad (17), para mantener el control y el equilibrio en su vida cotidiana (18). desde esta perspectiva, la fibromialgia no representa solo una suma de signos biológicos y psicológicos (enfermedad o patología), sino que adquiere, a través de su vivencia a nivel individual y colectivo, una dimensión sociocultural y significada (padecimiento o dolencia), enmarcada en un proceso de socialización complejo que opera a partir de las fuerzas económico-políticas e institucionales específicas (vivencia total de la enfermedad) (1). en este marco teórico, las necesidades experimentadas por las personas enfermas adquieren la misma hegemonía y legitimidad o más, que las necesidades observadas desde fuera, por parte de profesionales y autoridades sanitarias o población general), por lo que se considera importante reforzar también los saberes, las prácticas y las estrategias de autogestión que las propias personas enfermas desarrollan en el manejo de su enfermedad (1), lo que menéndez (19) denomina modelo de autoatención (cuando se desarrolla a nivel familiar o comunitario) o autocuidados (cuando se realiza a nivel individual). estudios recientes han reiterado el impacto positivo de los autocuidados y la autoeficiencia en el manejo de la fibromialgia, destacando la reducción de los niveles de dolor y ansiedad (20), la mayor motivación y éxito en el desarrollo de estrategias de afrontamiento y toma de decisiones, los mejores resultados clínicos y la reducción de costes sanitarios (21). aunque la educación para la salud se ha realizado tradicionalmente desde el ámbito sanitario, en los últimos años han surgido programas de formación entre iguales, cuyos resultados apoyan no solo una destacada mejora de la autoconfianza y de las habilidades y herramientas de autogestión (22), sino también muestran la importancia de las estructuras de apoyo y de ayuda igualitaria —lo que sontag denomina “reciprocidad horizontal” (23) , como fuentes de motivación y bienestar para las personas enfermas implicadas (1). las mujeres con fibromialgia representan un colectivo con altas expectativas en este sentido, ya que existe evidencia con respecto a su búsqueda de apoyo en asociaciones y grupos de ayuda mutua, mientras que los hombres tienden a buscar sustento en el ámbito familiar (12). para dar respuesta a las necesidades de formación en autocuidado con base en redes de apoyo y solidaridad, en la universidad de stanford se creó un programa pionero, patient education research center, hoy con réplicas en diferentes países occidentales6, que mostró los beneficios de la formación de pacientes a 6 entre los programas existentes cabe destacar a nivel nacional: programa de pacientes expertos de país vasco, universidad de pacientes, programa paciente experto del institut catala de la salut, forum clinic, escuela de salud y cuidados de castilla la mancha, escuela 300 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 través de iguales-tutores con la misma enfermedad, entrenados en técnicas didácticas y con especial sensibilidad y conocimiento de la misma (22). con el mismo objetivo, en andalucía, la consejería de salud puso en marcha en el año 2008 un programa de formación entre iguales denominado escuela de pacientes, que reúne pacientes, personas cuidadoras, familiares, asociaciones y profesionales de la salud en torno a la necesidad de aprender y enseñar las mejores formas de cuidar y de cuidarse. dentro de este programa, la estrategia formativa en fibromialgia comenzó como línea prioritaria en 2012, con los primeros cursos realizados con pacientes y formadores. los contenidos de los talleres: identificación de necesidades y existencia de recursos disponibles, hábitos de vida saludable —actividad física, dieta saludable, técnicas de relajación—, diseño de un plan de acción, resolución de problemas, comunicación con el entorno social y gestión emocional de la enfermedad—, prestaron atención a las diferencias y desigualdades en salud existentes entre hombres y mujeres, y persiguieron adaptar la estrategia formativa a las necesidades específicas de las enfermas crónicas, aunque sin excluir, visibilizando y atendiendo, las expectativas de la población masculina minoritaria. objetivos el objetivo general de este trabajo es evaluar, desde una perspectiva de género, la estrategia formativa de pacientes con fibromialgia de la escuela de pacientes, basada en la formación “entre iguales”. los objetivos específicos son: 1) definir los perfiles sociodemográficos de las personas participantes en las actividades formativas de la escuela de pacientes; 2) conocer y comparar la autopercepción sobre salud, calidad y hábitos de vida, limitaciones para la vida cotidiana, atención sanitaria y autogestión de la enfermedad entre la población participante al iniciar la formación (estudio pretest); 3) valorar el grado de satisfacción con la formación, su utilidad e impacto; 4) evaluar el impacto de la actividad formativa a los seis meses de su finalización (estudio postest), midiendo las ganancias netas en mujeres y hombres participantes, con respecto a las variables medidas en el objetivo 2. materiales y métodos estudio cuantitativo, con diseño cuasi experimental pretestpostest, realizado entre 2012 y 2013, con 600 pacientes con fibrode salud de castilla y león, programa paciente experto de murcia, escola galega de pacientes o la red ciudadana de formación en seguridad del ministerio de sanidad. mialgia, participantes en un programa de formación entre iguales de la escuela de pacientes de la escuela andaluza de salud pública. la actividad formativa incluyó 30 cursos para pacientes (6 horas lectivas cada uno) y 4 cursos de formador de formadores (20 horas), llevados a cabo entre 2012 y 2013. participantes. 1) pacientes formadores/as del aula de fibromialgia de la escuela de pacientes: personas que realizaron el curso de formación de formadores/as de la escuela de pacientes y superaron la evaluación del mismo; 2) pacientes con fibromialgia que recibieron formación por parte de pacientes formadores en el aula de fibromialgia de la escuela de pacientes. los criterios de inclusión fueron: 1) ser paciente con fibromialgia, con edades comprendidas entre 18 y 80 años; 2) realizar al menos un curso completo de la escuela de pacientes y superar la evaluación final; 3) para pacientes formadores, cumplir las características del perfil de formador/a de la escuela de pacientes: disponibilidad, compromiso e interés, habilidades de comunicación y habilidades técnicas. la captación de las personas participantes en los cursos de formación se realizó a través de informantes clave (asociaciones de pacientes con enfermedades crónicas y profesionales sanitarios de centros de salud del servicio andaluz de salud), así como a través de técnicas de difusión (carteles en centros sanitarios, web de la escuela de pacientes) y bola de nieve. todas las personas participantes firmaron un consentimiento informado y el protocolo del estudio fue aprobado por la comisión de investigación y el comité de ética de la escuela andaluza de salud pública. el número previsto de participantes fue inicialmente de 16 formadores (2 por cada provincia andaluza) y 45 pacientes (3 cursos con 15 personas) cada año. sin embargo, durante los años 2012 y 2013 se amplió la oferta formativa a 4 cursos para formadores y 30 cursos para pacientes, lo que generó una población total de 41 formadores y 559 pacientes. la técnica de recogida de datos fue un cuestionario adaptado del programa de paciente experto de la universidad de stanford, validado previamente, que se pasó telefónicamente a las personas participantes antes de la actividad formativa (pretest) y transcurridos 6 meses de la misma (postest). el instrumento está formado por bloques de preguntas dicotómicas, en escala likert o de cumplimiento libre (tabla 1). 301 evaluación de una estrategia formativa entre iguales en fibromialgia. un análisis de género l alina danet y otros los objetivos 2 y 3 se aplicaron al perfil mayoritario definido, realizando análisis bivariado (comparación de medias, estudio de correlación) y multivariado (modelo de regresión lineal) de los datos pretest, tomando como variables dependientes las propuestas por la universidad de stanford: 1) salud autopercibida; 2) estrés emocional (índice calculado como media de las 4 preguntas del bloque); 3) calidad de vida (cansancio y dolor); 4) incorporación o mejora de hábitos saludables (horas / semana de actividad física y valoración de la dieta); 5) limitaciones para la vida diaria (índice calculado como media de las 4 preguntas del bloque); 6) uso y satisfacción con los servicios sanitarios (relación y confianza con el personal sanitario, número de visitas a atención primaria, número de bajas laborales); 7) autoeficacia para el manejo de la enfermedad crónica (índice calculado como media de las 8 preguntas del bloque). las variables independientes utilizadas fueron: sexo, edad, años de enfermedad, nivel de estudios (sin estudios, primarios, medios y superiores), estado civil (casado o en pareja, otras situaciones), situación laboral (trabaja o desempleo, jubilado/a, ama de casa). para el objetivo 4 se seleccionaron solo los casos que disponían tanto de pretest como de postest y se calcularon las ganancias netas en las variables dependientes referidas, a través de la prueba t para muestras relacionadas (para datos paramétricos) o el test de wilcoxon (para datos no paramétricos). a fin de comprobar los supuestos que permiten utilizar las pruebas paramétricas se aplicó la prueba de shapiro-wilk (distribución normal de las puntuaciones) y la prueba de levene (de homogeneidad de las varianzas). resultados la tabla 2 describe los perfiles establecidos en función de los datos sociodemográficos. la media total de edad fue de 54 años (mínimo 25 años; máximo 78 años; dt 9,63) y la duración media de la enfermedad 14 años (mínimo 0,5 años; máximo 40 años; dt 9,47). por área geográfica, las provincias más representadas en el estudio son huelva con el 55 % de la población, jaén (17 %) y córdoba (18 %). se observa una distribución equilibrada de los y las pacientes, con respecto a la pertenencia a una asociación (un 40 % pertenece a una asociación, frente al 60 % que no). el perfil mayoritario identificado es el de las mujeres con fibromialgia, que se caracterizan por: edad media 54 años (dt 9,73), duración de la enfermedad 14 años (dt 9,45), casadas o en pareja el 83 %, estudios básicos el 56 %. la situación laboral se distribuye homogéneamente, con un tercio en cada una de las situaciones: población activa (trabajando o buscando empleo), jubiladas o amas de casa. el 6 % del total de mujeres participantes son formadoras, aunque de las personas que siguieron el curso para pacientes, el 30 % muestran disponibilidad para ser formadoras. un segundo perfil identificado, el de los hombres con fibromialgia, representa menos del 2 % del total y está formado por varones con una media de edad de 50 años (dt 4,12) y 13 años de enfermedad (dt 10,7), mayoritariamente casados (70 %), con una distribución homogénea del nivel de estudios (el 50 % tiene como máximo estudios primarios y la otra mitad suma estudios medios y superiores) y en mayor medida jubilados (80 %). en la tabla 3 se presentan los resultados del pretest en función del perfil por sexo. todas las personas participantes indican una salud autopercibida como “mala”, escasa calidad de vida, con altos niveles de cansancio y dolor e importantes niveles de estrés emocional y limitaciones para la vida diaria. los hombres describen peor el estado general de su salud, así como su estrés y limitaciones y, aunque realizan más actividad física y valoran mejor su dieta y relación con el personal sanitario, refieren mayor dificultad que las mujeres para controlar su cansancio, tristeza y dolor, con diferencias estadísticamente significativas en estas variables. en la tabla 4 se recogen los resultados del análisis bivariado para el perfil mayoritario de mujeres. de las diferencias estadísticamente significativas, destaca el mejor estado de salud general autopercibida por las mujeres que viven sin pareja (solteras, separadas o viudas). el modelo de regresión lineal calculado para la variable “salud autopercibida” (r = 0,23) no confirma la significación estadística de esta diferencia por estado civil, sin embargo, refleja que el perfil que mejor percibe su salud (media de 3,7 puntos) es el de las mujeres que tienen < 3 años con fibromialgia y que trabajan o buscan empleo (las amas de casa suman 0,5 puntos, las jubiladas 0,2 y las con > 10 años de enfermedad 0,2 puntos; p < 0,05). el estado de mayor estrés emocional (índice que oscila de 0 a 5, siendo 5 el máximo nivel de estrés) es referido por las mujeres con menos años de enfermedad, aquellas que trabajan o buscan empleo y que no forman parte de ninguna asociación, tal y como se puede observar en la tabla 4. el estudio de regresión lineal ajustado para la variable dependiente “estrés” (r2 = 0,45) confirma 302 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 estos datos, con una media de 2,9 en el nivel de estrés para este perfil de paciente. a partir de este valor de referencia, las amas de casa reducen su estrés una media de 0,4 puntos (p < 0,05), las que tienen > 20 años de enfermedad en 0,7 puntos (p < 0,05) y las que forman parte de una asociación mejoran en 0,2 puntos. en la medición del cansancio y del dolor se observa una altísima incidencia, sobre todo entre las mujeres < 45 años, que viven en pareja y tienen un nivel de estudios bajo. si completamos la comparación de medias con un análisis de contingencia, observamos que de las mujeres que viven en pareja, el 67 % puntúa el cansancio ≥ 8 (frente al 58 % en el caso de las mujeres que viven sin pareja) y el 75 % consideran que su dolor es ≥ 8 (frente al 62 % de las que viven sin pareja). las diferencias son estadísticamente significativas si comparamos el dolor en función del nivel de estudios: de las participantes que tienen estudios primarios completos o incompletos, el 56 % refiere dolor ≥ 9, frente al 38 % de las mujeres con estudios medios o superiores. por edad, las mujeres < 45 años describen un cansancio más intenso: el 46 % puntúa esta variable ≥ 9, frente al 30 % del resto de edades, aunque no se observan diferencias con respecto a la escala del dolor. con respecto a los hábitos de vida no se observan diferencias notables en función de las variables sociodemográficas: en general, las mujeres realizan una media de 3 horas de ejercicio físico a la semana (las que pertenecen a una asociación acercan su media a 4 horas / semana, p < 0,05) y puntúan su dieta alrededor del valor 7 (las mujeres con estudios superiores evalúan con un 6,5, frente a las que tienen estudios primarios, con un 7,2; p < 0,05). las limitaciones para la realización de la vida cotidiana se consideran más frecuentes entre las mujeres con una duración de la enfermedad de 3-10 años y entre aquellas que están jubiladas. el modelo de regresión (r2 = 0,37) sitúa la media del perfil de referencia (mujer que trabaja o busca empleo, < 3 años de enfermedad y no perteneciente a una asociación) en 2,2 puntos. este valor empeora en la mujer jubilada en 0,3 puntos, pero mejora en el ama de casa en 0,2 puntos (p < 0,05). así mismo, aumentan las limitaciones entre las mujeres con más años de enfermedad (0,5 puntos para 3-10 años y 0,4 puntos para 10-20 años de enfermedad; p < 0,05) y se reducen las limitaciones entre las pacientes que están en una asociación (0,2 puntos; p < 0,05). la comunicación con el personal sanitario es, en general, escasa en la población participante: las mujeres con estudios medios y que están jubiladas son las que mejor puntúan en su comunicación con el personal sanitario, aunque se registran menos visitas tanto a atención primaria como a urgencias, entre las amas de casa, las pacientes con > 20 años de enfermedad y las que pertenecen a una asociación. en el automanejo de la enfermedad crónica no se observan diferencias estadísticamente significativas en el análisis bivariado, salvo en cuanto a la mejor autogestión de las mujeres que pertencen a una asociación. en el modelo de regresión para el perfil de referencia mujer < 45 años, con pareja, < 3 años de enfermedad, que no pertenece a una asociación (r2 = 0,32), la media es de 6,4 puntos. las mujeres jubiladas y amas de casa mejoran este valor en 0,4 y 0,6 puntos respectivamente, las que pertenecen a una asociación en 0,6 puntos (p < 0,05) y las que tienen > 20 años de enfermedad en 1,2 puntos. sin embargo, refieren peor automanejo las pacientes con una duración de la enfermedad de 3 a 10 años (0,5 puntos menos) y de 11 a 20 años (0,3 puntos menos). a continuación presentamos los resultados del análisis comparativo pretest / postest. del total de 41 formadores (39 mujeres) y 559 pacientes (550 mujeres) que realizaron el pretest y la actividad formativa, cumplimentaron el postest de los 6 meses, 1 hombre y 29 mujeres formadores (73 % de las personas formadoras que realizaron el pretest), y 349 mujeres y 5 hombres pacientes (63 % del total de pacientes participantes en el estudio). la evaluación de la formación a través de las dos preguntas específicas incluidas en el cuestionario se resume en la tabla 5. las participantes puntuaron la contribución de la actividad formativa sobre su estado de salud y sobre el control de la enfermedad con una media de 7,17 (dt 2,15) y de 7,29 (dt 1,94), respectivamente. se observa una valoración más alta por parte de las mujeres con < 3 años de enfermedad, las que viven casadas o en pareja y las que forman parte de una asociación. los cursos de formador de formadores se evaluron de forma superior al curso para pacientes. los resultados comparativos pretest/postest se presentan en la tabla 6, incluyendo solo la población de mujeres. la actividad formativa no tiene impacto en la autopercepción de la salud, salvo en el caso de las formadoras que refieren un 0,3 puntos de empeoramiento. el estrés emocional mejora con más intensidad entre las formadoras (0,53). el cansancio y el dolor crecen entre 303 evaluación de una estrategia formativa entre iguales en fibromialgia. un análisis de género l alina danet y otros las pacientes, pero mejora entre las formadoras, que además incrementan su actividad física en 0,2 horas semanales. los cambios alimentarios (hacia una dieta equilibrada, variada y adaptada a la edad de las mujeres) mejoran la calidad de la dieta en toda la población y las limitaciones para la vida cotidiana se reducen en 0,33 puntos entre las pacientes, cuya autogestión de cuidados mejora en 0,8 puntos. la formadoras reducen su número de vistas a atención primaria y a urgencias. entre los hombres (n = 6), la estrategia formativa tiene impacto positivo en las siguientes variables: la salud general mejora en 0,17 puntos (prestest 4,33 ± 0,81, frente a 4,16 ± 0,40) y el estrés emocional en 0,03 puntos (prestest 3,21 ± 1,4). aumenta en 0,3 horas el tiempo semanal de ejercicio físico, se reduce el número de visitas a atención primaria (de 10 a 8,5 consultas en los últimos 6 meses) y aumenta la autoeficiencia en los cuidados (prestest 5,23 ± 1,96; postest 6,33 ± 2,81). sin embargo, el cansancio y el dolor aumentan 0,3 puntos (pretest 8,33 ± 0,76 y 9,33 ± 0,51 respectivamente), la calidad de la dieta se reduce en 0,5 puntos (prestest 7,33 ± 0,76) y empeoran en 0,3 puntos las limitaciones para la vida cotidiana (pretest 2,94 ± 1,34). discusión el perfil mayoritario de las personas con fibromialgia participantes en la formación está representado por mujeres de edad media, con una duración de la enfermedad de casi 15 años, con estudios básicos y en su mayoría casadas o conviviendo en pareja. su salud autopercibida es mala, con altos niveles de cansancio y dolor, sus hábitos de vida son en general saludables, pero se perciben limitaciones en el desempeño de las actividades cotidianas y una capacidad media-baja en el automanejo de la enfermedad. el peor estado de salud lo perciben las personas con < 3 años de enfermedad y las que trabajan o buscan empleo, con un peor nivel de estrés emocional, y mayor dolor y cansancio, especialmente entre las más jóvenes, casadas y con menor nivel de estudios. la pertenencia a una asociación y no realizar una actividad laboral remunerada (ser ama de casa) son factores protectores que reducen las visitas médicas, así como las limitaciones para las actividades diarias, a la vez que mejoran la autoeficiencia de los autocuidados. tras 6 meses de la actividad formativa (evaluada positivamente por las participantes), se observan mínimos cambios negativos en la autopercepción de la salud, niveles de dolor y cansancio. sin embargo, mejoran el estrés emocional y los hábitos de vida, se reducen las visitas a los centros sanitarios y las limitaciones para la vida cotidiana (especialmente entre formadoras) y aumenta la capacidad de automanejo de la enfermedad (entre las pacientes). la principal limitación de este estudio se asocia a la selección de pacientes con fibromialgia, ya que es posible que su participación voluntaria se relacione con altos niveles de motivación previos a la formación. pese a este sesgo, estudios similares realizados en el ámbito internacional usan el mismo sistema de selección, por lo que nuestros resultados pueden ser contrastados con otros de diferentes contextos. así mismo, en la evaluación del impacto formativo, las diferencias pre / post podrían atribuirse no solo a la eficacia del programa, sino también al efecto de mayor concienciación de la población participante. por último, la escasa participación de varones no ofrece resultados estadísticamente significativos en la comparación por sexo. pese a estas limitaciones, creemos que la metodología empleada permitió la consecución de los objetivos propuestos y, para próximos estudios, valoramos aplicar un diseño de tipo experimental, con grupo control, así como un abordaje cualitativo que recoja las experiencias y vivencias de las personas participantes, expresadas en primera persona. los resultados de este estudio confirman la altísima feminización de la población con fibromialgia, así como la escasa calidad de vida de este colectivo (14), cuyas principales dificultades y limitaciones de tipo funcional y emocional, son causadas por el dolor y el cansancio (5). sin embargo, la participación en la formación no es contradictoria con el alto nivel de dolor y fatiga expresado por las personas participantes, ya que la bibliografía disponible demuestra que, entre las mujeres con fibromialgia, la intensidad del dolor genera más estrategias de búsqueda de información y formación en autocuidados (15). aunque no se observa la reducción del dolor tras la actividad formativa, la educación entre iguales tiene un efecto reductor del estrés, mejora la autovaloración personal y los hábitos de vida, lo que es coherente con los resultados de otros programas formativos similares (24). el hecho de que el impacto positivo sea más evidente entre las formadoras nos indica la relevancia del compromiso y apoyo social, tanto para la salud individual como en términos de capital social para la salud comunitaria. estudios recientes refuerzan estos resultados, mostrando que la implicación en redes de ayuda mutua confiere bienestar a las pacientes crónicas, llegando incluso a fomentar su adaptación al dolor crónico (25). 304 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 la participación social y colaboración de las enfermas crónicas en los procesos de autoatención y educación sanitaria, sector fundamentalmente femenino (20), ha sido objeto de críticas especialmente desde la psicología social, interpretándose a veces como un mecanismo de reforzamiento de las conductas de dependencia, el catastrofismo y la necesidad de visibilización social en roles de enfermas (26). sin embargo, nuestros resultados, coherentes con estudios anteriores, muestran que la estrategia de formación entre iguales favorece la independencia y autoatención de las pacientes (8), en una enfermedad donde el tratamiento farmacológico no consigue los resultados esperados y requiere un enfoque multidisciplinar que dé respuesta a las necesidades de las pacientes (27). por tanto, sería recomendable fortalecer las relaciones de formación y apoyo entre iguales, potenciando así la capacidad de acción y creatividad de las mujeres con fibromialgia, a la vez que validando sus saberes. el ámbito asociativo se revela como el espacio óptimo para el desarrollo de las estructuras y redes de apoyo en enfermedades crónicas —de hecho, los resultados del estudio muestran que las mujeres que pertenecen a asociaciones refieren menos limitaciones y mejor autoeficiencia en los cuidados—. en primer lugar, porque la formación en salud parece más eficiente cuando se realiza fuera del espacio sanitario y, en segundo lugar, porque al operar entre la autoatención doméstica y la atención médica institucionalizada, los grupos de iguales (asociaciones, clubes sociales) se configuran a la vez como espacios de autonomía, donde las mujeres perciben reconocimiento y visibilización social, lo que menéndez denomina estructura de afianzamiento de micropoderes (20). otro aspecto que cabe comentar son las diferencias sociodemográficas que se observan en la autopercepión sobre la salud y calidad de vida, entre los diferentes perfiles de mujeres participantes en nuestro estudio. la interseccionalidad de las variables (desempeño de actividad laboral, edad, duración de la enfermedad, nivel de estudios y estado civil) se evidencia como un factor explicativo de las peores condiciones y hábitos de vida de las mujeres trabajadoras menores de 45 años, con menos de 3 años con fibromialgia, con menor nivel educativo y casadas, lo que es coherente con otros estudios disponibles (4, 5). la actividad laboral se podría interpretar como un factor agravante del deterioro en la salud y calidad de vida: en nuestros resultados, las mujeres que trabajan están más cansadas, sufren más dolor, tienen menos tiempo para realizar una actividad física adecuada —siendo conocida la importancia del ejercicio físico para el control del dolor y la rigidez (28)— o cuidar su dieta (29). sin embargo, en la bibliografía disponible encontramos estudios que contemplan la actividad laboral como un factor protector para la salud de la mujer con fibromialgia: el compromiso profesional refuerza la autoconfianza e independencia, mejorando la autovaloración y autoestima de las mujeres. posiblemente este aspecto se podría verificar en el caso de las personas con una carrera profesional consolidada y con estudios superiores, que disponen de más recursos y herramientas para combatir las limitaciones impuestas por la enfermedad y que, además, conciben la actividad laboral como una vía para disfrutar la vida, cuidarse y buscar soluciones creativas para el dolor (30). por último, cabe destacar que, aunque los hombres representan solo el 2 % de la población, su autopercepción con respecto al estado de salud, estrés, limitaciones y automanejo es peor que la de las mujeres, lo que muestra la necesidad de mayor formación de este colectivo, especialmente en habilidades de gestión emocional. aunque desde la perspectiva de género se ha resaltado la preocupación por la vida laboral como tema prioritario para los hombres con enfermedades crónicas (31), en nuestro estudio, la presencia mayoritaria de jubilados permite evidenciar la relevancia de sus dificultades psicológicas y afectivas. por otra parte, resulta llamativo que, contrario a las evidencias sobre comportamientos sanitarios, los hombres realizan más visitas a atención primaria que las mujeres. en nuestro estudio, son también los hombres los que mejor evalúan la comunicación con su personal sanitario, lo que podría representar un indicio sobre la mayor adecuación, calidad y eficiencia de los encuentros sanitarios de los hombres con fibromialgia, en comparación con los beneficios percibidos por las mujeres (11). conclusiones el perfil mayoritario de la población con fibromialgia participante en la formación entre iguales es: mujer de mediana edad, casada, con estudios básicos y una duración prolongada de la enfermedad, que autopercibe su salud como mala y tiene importantes limitaciones funcionales, emocionales y sociales, altos niveles de dolor y cansancio, y autoeficiencia media-baja en el manejo de su enfermedad. la población femenina con fibromialgia no es homogénea, observándose la existencia de subperfiles con diferencias estadísticamente significativas en función de: realización de actividad laboral, edad, duración de la enfermedad, nivel de estudios y 305 evaluación de una estrategia formativa entre iguales en fibromialgia. un análisis de género l alina danet y otros estado civil. el peor estado de salud física y emocional lo describen las mujeres trabajadoras, menores de 45 años, con menos de 3 años con fibromialgia, con menor nivel educativo y casadas. el perfil minoritario de los hombres describe un estado de salud aún más deficiente que el de las mujeres, con mayor estrés emocional, más visitas al personal sanitario de atención primaria y peor autogestión para los cuidados, lo que indica las necesidades específicas de formación y apoyo para este colectivo. la estrategia formativa entre iguales es evaluada positivamente por las personas participantes en el estudio y genera mejoras en el estrés emocional y los hábitos de vida, reducción del número de consultas médicas y aumento de la autoeficiencia en el manejo de la enfermedad. la formación entre iguales representa, por tanto, una estrategia eficiente de educación para la salud y un espacio óptimo para reforzar el compromiso y el apoyo social, con resultados positivos para la salud emocional y autoconfianza de las mujeres con fibromialgia. sin embargo, los programas de educación sanitaria deberían adaptarse a las necesidades y demandas específicas de las personas con fibromialgia, poniendo especial atención a la vulnerabilidad de ciertos perfiles sociodemográficos, sobre todo de las mujeres con menos recursos educativos y económicos. referencias 1. carrasco acosta mc. fibromialgia: la enfermedad silenciada. percepciones, significaciones y estrategias de autoatención. tesis doctoral. universidad de huelva; 2012. 2. ministerio de sanidad, política social e igualdad. fibromialgia. arganda del rey, madrid: din impresores; 2011. 3. lousada arochena jf. el tratamiento jurídico de la fibromialgia en perspectiva de 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cdphp. 2013;5(2). 22. lorig k, holman h, sobel d, laurent d, gonzález v, minor m. living a healthy life with chronic conditions. self-management of heart disease, arthritis, diabetes, depression, asthma, bronchitis, emphysema and other physical and mental health conditions. boulder: bull publishing company; 2013. 23. sontang s. la enfermedad y sus metáforas. buenos aires: taurus; 1978. 24. yukawa k, yamazaki y, yonekura y. effectiveness of chronic disease self-management program in japan: preliminary report of a longitudinal study. nursing and health sciences. 2010;(12):456-463. 25. son j, yarnal c, kerstetter d. engendering social capital through a leisure club for middle-aged and older women: implications for individual and community health and well-being. leisure studies. 2010;29(1):67-83. 26. sullivan mjl, tripp da, santor d. gender differences in pain and pain behaviour: role of catastrophizing. cogn ther res. 2000;24:121-34. 27. fernández rodríguez s, argüelles otero l. abordaje del paciente con fibromialgia en atención primaria. rqr enfermeria comunitaria. 2015;3(1):25-42. 28. sañudo b, galiano d, carrasco l, blagojevic m, de hoyo m, saxton j. aerobic exercise versus combined exercise therapy in women with fibromyalgia syndrome: a randomized controlled trial. archives of physical medicine and rehabilitation. 2010;91:1838-43. 29. briones-vozmediano e, ronda-pérez e, vives-cases c. percepciones de pacientes con fibromyalgia sobre el impacto de la enfermedad en el ámbito laboral. aten primaria. 2015;47(4):205-212. 30. löfgren m, ekholm j, ohman a. “a constamt struggle”: successful strategies of women in work despite fibromialgia. disabil rehabil. 2006;28(5):447-55. 31. matute bravo s, gil lacruz m, garcia lanzuela y. la influencia del género en el acceso y valoración de los servicios sanitarios. acciones e investigaciones sociales 2005;20:75-90. 307 evaluación de una estrategia formativa entre iguales en fibromialgia. un análisis de género l alina danet y otros bloque preguntas escala de medición salud general en general, diría que su salud es… 1 (excelente) – 5 (muy mala) estrés emocional estuvo desanimado/a por sus problemas de salud. 0 (nunca) – 5 (siempre) sintió miedo por el futuro de su salud. 0 (nunca) fue la salud una preocupación en su vida. 0 (nunca) se sintió incapaz para afrontar sus problemas de salud. 0 (nunca) calidad de vida en las últimas dos semanas ha sentido cansancio o fatiga. 0 (nada) – 10 (muchísimo) en las últimas dos semanas ha tenido dolor. 0 (nada) – 10 (muchísimo) hábitos de vida durante la última semana, ¿realizó alguna actividad física? sí / no ¿qué actividad realizó? horas / semana ¿cómo calificaría su dieta actual? 1 (nada saludable) – 10 (muy saludable) limitaciones para las actividades cotidianas en las últimas dos semanas su estado de salud le ha dificultado sus relaciones sociales. 0 (nunca) – 4 (siempre) en las últimas dos semanas su estado de salud le ha dificultado sus actividades de ocio. 0 (nunca) – 4 (siempre) en las últimas dos semanas su estado de salud le ha dificultado sus actividades diarias. 0 (nunca) – 4 (siempre) en las últimas dos semanas su estado de salud le ha dificultado el desempeño de su trabajo. 0 (nunca) – 4 (siempre) comunicación y confianza con el personal sanitario antes de ir a la consulta, ¿prepara una lista de preguntas? 0 (nunca) – 5 (siempre) en la consulta, ¿pregunta dudas y cuestiones que no comprende? 0 (nunca) – 5 (siempre) en la consulta, ¿plantea cuestiones personales que pueden estar relacionadas con la enfermedad? 0 (nunca) – 5 (siempre) uso de servicios sanitarios en los últimos 6 meses, ¿cuántas visitas a atención primaria realizó? sí / no en los últimos 6 meses, ¿cuántas veces fue a urgencias? en los últimos 6 meses, ¿cuántas veces fue hospitalizado durante una noche o más? en los últimos 6 meses, ¿estuvo de baja laboral? autoeficiencia (capacidad de automanejo) se siente capaz de tomar correctamente la medicación. 1 (capacidad nula) – 10 (capacidad total) se siente capaz de dormir y descansar adecuadamente. 1 (capacidad nula) – 10 (capacidad total) se siente capaz de realizar la actividad física que le han recomendado. 1 (capacidad nula) – 10 (capacidad total) se siente capaz de llevar una dieta saludable y apropiada para su enfermedad. 1 (capacidad nula) – 10 (capacidad total) se siente capaz de reconocer signos de alerta en la evolución de su enfermedad. 1 (capacidad nula) – 10 (capacidad total) se siente capaz de controlar su fatiga y cansancio para que no interfieran en su vida cotidiana. 1 (capacidad nula) – 10 (capacidad total) se siente capaz de hacer sus actividades diarias pese al dolor y las molestias físicas. 1 (capacidad nula) – 10 (capacidad total) se siente capaz de hacer sus actividades diarias pese a la tristeza o el estado anímico bajo. 1 (capacidad nula) – 10 (capacidad total) evaluación de la actividad formativa (solo postest) ¿en qué medida considera que la formación recibida en la escuela de pacientes ha contribuido a mejorar su estado de salud? 1 (nada) – 10 (muchísimo) ¿en qué medida considera que le ha ayudado a mejorar el control que usted tiene sobre su enfermedad y su tratamiento? 1 (nada) – 10 (muchísimo) tabla 1. bloques de preguntas del cuestionario fuente: adaptado del cuestionario del programa de pacientes expertos de la universidad de stanford para pacientes con fibromialgia. 308 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 tabla 2. descripción sociodemográfica de la muestra, según el sexo variables sociodemográficas sexo total hombre n (%) mujer n (%) n (%) estado civil casado/a o en pareja 7 (70) 423 (83,1) 430 (82,9) separado/a 2 (20) 29 (5,6) 31 (5,9) soltero/a 1 (10) 30 (5,8) 31 (5,9) viudo/a 0 27 (5,3) 27 (5,3) nivel de estudios sin estudios 1 (10) 118 (23,5) 119 (23,2) primarios 4 (40) 228 (45,4) 232 (45,3) medios 3 (30) 109 (21,7) 112 (21,9) superiores 2 (20) 47 (9,4) 49 (9,6) situación laboral trabaja o desempleo 2 (20) 187 (37,6) 189 (37,2) jubilado/a pensionista 8 (80) 140 (28,1) 148 (29,1) ama de casa 0 171 (34,3) 171 (33,7) relación con la enfermedad paciente 9 (81,8) 549 (97,3) 558 (97) cuidador/a 2 (18,2) 15 (2,7) 17 (3,0) tipo de formación formador/a 2 (18,2) 39 (6,6) 41 (6,8) paciente 9 (81,8) 550 (93,4) 560 (92,2) disponibilidad para ser formador no 5 (71,4) 178 (70,6) 183 (70,7) sí 2 (28,6) 74 (29,4) 76 (29,3) provincia almería 0 12 (2,0) 12 (2,0) cádiz 1 (9,1) 71 (12,1) 72 (12,0) córdoba 1 (9,1) 17 (2,9) 18 (3,0) granada 1 (9,1) 30 (5,1) 31 (5,2) huelva 5 (45,5) 324 (55,0) 329 (54,8) jaén 3 (27,3) 98 (16,6) 101 (16,8) málaga 0 23 (3,9) 23 (3,8) sevilla 0 14 (2,4) 14 (2,3) pertenencia a asociación sí 6 (54,5) 230 (39,0) 236 (39,3) no 5 (45,5) 359 (61) 364 (60,7) uso de redes sociales sí 2 (20) 131 (22,2) 133 (22,1) no 8 (80) 457 (77,8) 467 (77,9) fuente: elaboración propia. 309 evaluación de una estrategia formativa entre iguales en fibromialgia. un análisis de género l alina danet y otros tabla 3. resultados pretest por sexo * mayor valor, indica peor autopercepción. ** diferencias estadísticamente significativas (test de chi cuadrado). fuente: elaboración propia. resultados pretest sexo total hombre n = 11 media (dt) mujer n = 589 media (dt) n = 600 media (dt) salud autopercibida (escala 1-5)* 4,18 (0,75) 3,95 (0,57) 3,96 (0,57) estrés emocional* (escala 0-5) 2,90 (1,20) 2,44 (1,16) 2,46 (1,16) calidad de vida cansancio o fatiga (escala 1-10)* dolor (escala 1-10)* 7,36 (2,73) 7,81 (2,78) 7,75 (1,88) 8,26 (1,72) 7,74 (1,90) 8,25 (1,74) actividad física (horas / semana) 3,8 (2,65) 3,5 (2,95) 3,57 (2,94) alimentación saludable (escala 1-10) 7,27 (1,42) 6,89 (2,13) 6,91 (2,12) limitaciones para la vida cotidiana (escala 0-4)* 2,52 (1,26) 2,22 (1,11) 2,22 (1,12) comunicación con el personal sanitario (0-5) 2,24 (1,22) 1,74 (1,26) 1,75 (1,25) nº visitas a atención primaria en los últimos 6 meses 6,5 (2,11) 4,5 (2,05) 4,6 (2,05) nº visitas a urgencias en los últimos 6 meses 0,1 (0,30) 0,8 (1,29) 0,7 (1,28) autoeficiencia (capacidad de automanejo) (escala 1-10) 5,42 (2,27) 6,18 (1,71) 6,18 (1,73) tomar correctamente la medicación 8,80 (2,25) 8,23 (2,40) 8,25 (2,40) dormir y descansar 5,20 (3,55) 5,61 (2,73) 5,60 (2,75) mantener dieta saludable 6,70 (3,09) 7,07 (2,33) 7,07 (2,35) controlar fatiga y cansancio** 3,80 (2,69) 5,41 (2,49) 5,38 (2,50) controlar su dolor 4,10 (3,10) 5,36 (2,55) 5,33 (2,57) controlar su tristeza** 3,90 (2,96) 5,47 (2,59) 5,44 (2,60) 310 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 tabla 4. resultados pretest por variables sociodemográficas. población de mujeres * mayor valor, indica peor autopercepción. ** diferencias estadísticamente significativas (test anova para la comparación de medias, p < 0,05) fuente: elaboración propia. variables sociodemográficas salud calidad de vida hábitos de vida actividades cotidianas uso servicios sanitarios autoeficacia salud general* (1-5) estrés emocional* (0-5) cansancio* (1-10) dolor* (1-10) actividad física (horas/ semana) dieta saludable (1-10) limitaciones para actividades comunic. personal sanitario (0-4)* visitas a ap últimos 6 meses (0-5) visitas a ae últimos 6 meses capacidad de automanejo (1-10) ed ad < 45 años 4,07 ± 0,5 2,74 ± 1,0 8,25 ± 1,4** 8,27 ± 1,4 2,85 ± 2,3 7,00 ± 2,4 2,40 ± 1,0 1,78 ± 1,2 4,4 ± 2,2 1,2 ± 2,0 6,26 ± 1,7 45-55 años 3,92 ± 0,5 2,44 ± 1,1 7,81 ± 1,4** 8,28 ± 1,4 3,61 ± 3,1 6,57 ± 2,4 2,43 ± 1,0 1,61 ± 1,2 4,2 ± 1,3 1,0 ± 1,7 6,26 ± 1,6 > 55 años 3,97 ± 0,5 2,44 ± 1,0 7,52 ± 1,6** 8,11 ± 1,6 3,34 ± 2,8 6,98 ± 1,8 2,32 ± 1,1 1,86 ± 1,1 4,2 ± 1,3 0,9 ± 1,6 6,36 ± 1,7 añ os c on la en fe rm ed ad < 3 años 3,86 ± 0,5 2,54 ± 1,2** 7,59 ± 1,8 8,27 ± 1,5 2,96 ± 2,6 7,01 ± 1,8 2,13 ± 1,0** 1,53 ± 1,0 4,8 ± 2,2** 0,6 ± 1,3** 6,68 ± 1,6 3-10 años 3,95 ± 0,5 2,31 ± 1,0** 7,94 ± 1,1 8,11 ± 1,5 3,81 ± 3,2 6,75 ± 2,4 2,49 ± 1,0** 1,60 ± 1,1 4,9 ± 2,2** 1,0 ± 1,3** 6,10 ± 1,6 11-20 años 4,05 ± 0,5 2,42 ± 1,1** 7,88 ± 1,8 8,55 ± 1,3 3,64 ± 2,8 6,92 ± 2,1 2,41 ± 1,0** 1,86 ± 1,2 4,8 ± 2,1** 0,9 ± 1,3** 6,04 ± 1,8 > 20 años 3,97 ± 0,5 1,90 ± 1,0** 7,82 ± 1,9 8,17 ± 1,0 3,96 ± 3,6 6,76 ± 2,1 2,02 ± 1,1** 1,65 ± 1,3 2,8 ± 1,5** 0,4 ± 1,3** 6,12 ± 1,6 es ta do c iv il casada / en pareja 3,96 ± 0,5** 2,39 ± 1,1 7,77 ± 1,7 8,31 ± 1,5** 3,37 ± 2,9 6,89 ± 2,1 2,22 ± 1,1 1,74 ± 1,2 4,5 ± 2,0 0,7 ± 1,3 6,21 ± 1,7 separada / soltera / viuda 3,82 ± 0,5** 2,42 ± 0,9 7,58 ± 2,0 7,69 ± 2,1** 3,80 ± 3,0 6,87 ± 2,1 2,24 ± 1,2 1,71 ± 1,1 5,0 ± 2,2 0,8 ± 2,2 6,15 ± 1,5 n iv el d e es tu di os sin estudios 4,00 ± 0,6 2,45 ± 1,1 7,82 ± 1,8 8,37 ± 1,7** 3,35 ± 2,9 6,69 ± 2,3** 2,09 ± 1,2 1,84 ± 1,2** 4,1 ± 2,1** 0,9 ± 1,3 6,10 ± 1,7 primarios 3,98 ± 0,5 2,38 ± 1,1 7,87 ± 1,8 8,44 ± 1,5** 3,61 ± 2,9 7,13 ± 1,9** 2,19 ± 1,0 1,50 ± 1,0** 3,5 ± 2,0** 0,7 ± 1,3 6,37 ± 1,6 medios 3,84 ± 0,5 2,34 ± 1,2 7,79 ± 1,6 7,71 ± 1,7** 3,26 ± 2,5 6,68 ± 2,3** 2,42 ± 1,1 2,04 ± 1,3** 4,2 ± 2,2** 0,7 ± 1,3 5,97 ± 1,9 superiores 3,91 ± 0,6 2,33 ± 1,1 7,44 ± 2,0 7,71 ± 1,7** 3,58 ± 4,3 6,51 ± 1,6** 2,24 ± 1,2 1,68 ± 1,4** 4,0 ± 2,2** 0,7 ± 1,3 6,20 ± 1,3 si tu ac ió n la bo ra l trabaja / desempleada 3,87 ± 0,5 2,62 ± 1,0** 7,82 ± 1,8 8,27 ± 1,6 3,38 ± 3,1 6,89 ± 2,1 2,26 ± 1,1** 1,70 ± 1,3** 4,5 ± 2,1 1,2 ± 1,4** 6,14 ± 1,6 jubilada 3,99 ± 0,6 2,33 ± 1,2** 7,84 ± 1,8 8,29 ± 1,5 3,46 ± 2,9 7,03 ± 2,1 2,42 ± 1,1** 1,97 ± 1,2** 4,5 ± 2,1 1,2 ± 2,2** 6,32 ± 1,8 ama de casa 3,98 ± 0,6 2,22 ± 1,0** 7,60 ± 1,7 8,18 ± 1,7 3,51 ± 2,8 6,74 ± 2,1 2,01 ± 1,1** 1,54 ± 1,1** 4,0 ± 2,1 0,5 ± 0,8** 6,21 ± 1,7 pe rt en en ci a a as oc ia ci ón sí 3,94 ± 0,5 2,30 ± 1,1** 7,77 ± 1,9 8,28 ± 1,7 3,83 ± 3,2** 7,02 ± 2,0 2,18 ± 1,1 1,64 ± 1,3 4,5 ± 2,2 0,9 ± 1,5** 6,38 ± 1,5** no 3,97 ± 0,5 2,55 ± 1,1** 7,74 ± 1,8 8,25 ± 1,7 3,36 ± 2,6** 6,80 ± 2,2 2,24 ± 1,1 1,82 ± 1,1 4,3 ± 1,9 0,6 ± 1,1** 6,08 ± 1,8** 311 evaluación de una estrategia formativa entre iguales en fibromialgia. un análisis de género l alina danet y otros tabla 5. contribución de la actividad formativa para la mejora de la salud y el control de la enfermedad ** diferencias estadísticamente significativas (test anova para la comparación de medias, p < 0,05). fuente: elaboración propia. variables sociodemográficas media (dt) contribuye a mejorar la salud (1-10) contribuye a mejorar el control (1-10) sexo hombre (n = 0) mujer (n = 337) 7,17 (2,15) 7,29 (1,94) años de enfermedad < 3 años (n = 8) 8,12 (1,80) 8,12 (1,45) 3-10 años (n = 0) 11-20 años (n = 49) 7,22 (1,99) 7,04 (1,98) > 20 años (n = 69) 7,05 (2,29) 7,27 (2,07) estado civil casada / en pareja (n = 138) 7,27 (2,06) 7,39 (1,89)** separada / soltera / viuda (n = 22) 6,54 (2,70) 6,63 (2,32)** nivel de estudios sin estudios (n = 40) 7,17 (1,96) 7,12 (2,10) primarios (n = 82) 7,15 (2,19) 7,37 (1,87) medios (n = 26) 7,30 (2,61) 7,30 (2,25) superiores (n = 11) 7,00 (1,57) 7,40 (1,57) situación laboral trabaja o desempleo (n = 59) 7,22 (2,23) 7,37 (2,10) jubilado/a pensionista (n = 39) 7,28 (2,18) 7,64 (1,93) ama de casa (n = 56) 7,03 (2,15) 6,87 (1,89) tipo de formación formador/a (n = 3) 7,33 (0,57) 8,33 (1,52) paciente (n = 161) 7,17 (2,17) 7,27 (1,95) pertenencia a asociación sí (n = 64) 7,35 (1,93) 7,15 (1,82) no (n = 100) 7,06 (2,28) 7,38 (2,02) uso de redes sociales sí (n = 44) 7,43 (1,83) 7,63 (1,43) no (n = 120) 7,08 (2,25) 7,16 (2,10) 312 año 16 vol. 16 nº 3 chía, colombia septiembre 2016 aquichan issn 1657-5997 tabla 6. resultados comparativos pretest y postest (a los 6 meses de la formación) * mayor valor indica peor autopercepción. todos los resultados son estadísticamente significativos. fuente: elaboración propia. variables tipo de formación media ± dt diferencia (pretest-postest) ± dt prestest postest salud autopercibida (escala 1-5)* n = 347 3,96 ± 0,57 -0,05 ± 0,52 formadoras (n = 17) 3,64 ± 0,49 +0,30 ± 0,42 pacientes (n = 330) 3,98 ± 0,57 -0,07 ± 0,53 estrés emocional* (escala 0-5) n = 191 2,53 ± 1,09 -0,42 ± 1,12 formadoras (n = 15) 2,23 ± 1,09 -0,53 ± 1,00 pacientes (n = 176) 2,58 ± 1,10 -0,41 ± 1,14 cansancio o fatiga (escala 1-10)* n = 361 7,80 ± 1,66 +0,36 ± 1,81 formadoras (n = 18) 7,94 ± 1,10 -0,28 ± 1,41 pacientes (n = 343) 7,81 ± 1,68 +0,38 ± 1,82 dolor (escala 1-10)* n = 367 8,31 ± 1,56 +0,19 ± 1,74 formadoras (n = 19) 8,15 ± 1,16 -0,10 ± 1,68 pacientes (n = 348) 8,33 ± 1,57 +0,22 ± 1,73 actividad física (horas / semana) n = 289 3,52 ± 2,78 -0,14 ± 2,78 formadoras (n = 18) 3,47 ± 2,96 +0,20 ± 3,66 pacientes (n = 271) 3,53 ± 2,77 -0,15 ± 2,42 alimentación saludable (escala 1-10) n = 352 6,85 ± 2,24 + 0,76 ± 1,61 formadoras (n = 19) 7,05 ± 1,95 +0,42 ±1,54 pacientes (n = 333) 6,85 ± 2,21 +0,79 ± 1,62 limitaciones para la vida cotidiana (escala 0-4)* n = 353 2,33 ± 1,07 -0,34 ± 1,20 formadoras (n = 17) 2,47 ± 0,95 -0,22 ± 1,38 pacientes (n = 336) 2,33 ± 1,08 -0,35 ± 1,22 nº visitas a atención primaria (6 meses) n = 338 5,0 ± 2,19 -0,20 ± 1,94 formadoras (n = 18) 7,3 ± 2,13 -1,80 ± 2,04 pacientes (n = 320) 5,2 ± 2,19 -0,5 ± 1,94 nº visitas a urgencias (6 meses) n = 330 0,8 ± 1,36 -0,09 ± 1,30 formadoras (n = 18) 0,9 ± 1,56 -0,5 ± 0,46 pacientes (n = 312) 0,8 ± 1,34 -0,1 ± 1,32 autoeficiencia (escala 1-10) n = 293 6,13 ± 1,78 + 0,76 ± 1,47 formadoras (n = 17) 6,85 ± 1,57 0 ± 1,54 pacientes (n = 276) 6,07 ± 1,78 +0,81 ± 1,51 (17 rese\321as.pdf) revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005150 cómo cuidar un enfermo en casa para introducir esta presentación es necesario señalar que la realidad de quienes viven la experiencia de cuidar a una persona en casa puede ser a la vez sencilla y cotidiana o extremadamente compleja, en especial cuando no se tiene la orientación adecuada. la situación de la sociedad colombiana, en donde día a día se incrementan las situaciones de discapacidad y de enfermedad crónica, es preocupante. el consumo del presupuesto nacional dedicado a la atención de estas personas es elevado, y sin embargo, la respuesta a sus necesidades está lejos de lo que se requiere, quizá porque los modelos de prestación de servicios de salud están centrados en el individuo y no en el grupo familiar y, además, no prevén situaciones de cuidado a largo plazo. las instituciones no han dado a los cuidadores la mirada que ellos requieren como una parte fundamental del sistema de salud y, en muchos casos, estas personas deben asumir roles para los cuales no se encuentran preparadas. ser cuidador familiar de una persona con discapacidad o enfermedad crónica implica ver la vida de una manera diferente, modificar las funciones a las que se está acostumbrado, tomar decisiones en medio de alternativas complicadas, asumir responsabilidades o realizar tareas y acciones de cuidado físico, social, psicológico y religioso para atender las necesidades cambiantes de la persona cuidada. el libro cómo cuidar un enfermo en casa, que presentan la universidad de la sabana y la clínica universitaria teletón, refleja una mirada institucional que trasciende lo individual para mirar lo colectivo, y comprende la necesidad sentida y vivida por las familias en su cotidianidad en donde son muchas las personas valientes que aportan parte de su propia vida para apoyar a un ser querido. las instrucciones básicas para el cuidado de la salud de la persona discapacitada o enferma y del cuidador son producto de la experiencia interdisciplinaria de trabajo de los profesionales con estas personas, editadas de manera sencilla y pertinente como lo que es fundamental en la vida. con base en la investigación de muchos años con este grupo poblacional, este libro responde de la mejor forma a un llamado urgente para cualificar el cuidado de quienes tienen estas situaciones en su núcleo familiar. los contenidos, separados en dos grandes capítulos que incluyen la salud del cuidador y el cuidado del enfermo, dejan ver la forma como se aborda y se comprende este tema ya que ninguna experiencia de cronicidad afecta a un individuo de manera aislada. año 5 vol. 5 nº 1 (5) 150-155 chía, colombia octubre 2005150 reseñas 151 maría elisa moreno y colaboradores editorial el manual moderno, universidad de la sabana, 2005, 162 págs. en la primera sesión, �la salud del cuidador� se parte de comprender el significado de ser cuidador, para pasar a analizar sus aspectos psicológicos, las implicaciones que este rol conlleva desde la mirada ética y llegar a incluir ayudas para mejorar el estilo de vida, como el ejercicio, la postura y la información, en especial la relacionada con el sistema de salud. la segunda sesión, dedicada al cuidado de la persona enferma, incluye la asistencia básica en los trastornos cognitivos, la comunicación, la alimentación y nutrición, la eliminación, la disreflexia, las actividades básicas cotidianas, la comodidad, los cuidados de la piel, y llega hasta la previsión de las situaciones de emergencia. vale la pena señalar la escasez de estas referencias para el contexto latinoamericano, lo que da particular valor a esta obra que apoyará la formación de los profesionales de la salud y el desempeño de las personas que cuidan de un familiar en situación de enfermedad crónica o discapacitante en el hogar. la vivencia de los cuidadores es por lo general difícil y, aunque algunos logran redimensionarla y darle un sentido más profundo a sus vidas, la gran mayoría pasan a un segundo plano durante la misma. cómo cuidar a un enfermo en casa deja ver a esos pacientes ocultos, les da una herramienta de respaldo y hace un llamado a la sociedad, cuya dinámica cambiante la lleva a enfrentarse cada día con más casos de esta naturaleza. el libro es muy útil e importante porque responde a las inquietudes esenciales que vive el cuidador de una persona con limitaciones en la vida diaria, y le indica de manera práctica y actualizada la forma en que debe actuar para dar un cuidado adecuado, estimular la autonomía y preservar la dignidad de la persona a su cargo. por último, es de resaltar el valioso aporte de la facultad de enfermería de la universidad de la sabana y de la clínica universitaria teletón con su ejemplo de integración docente-asistencial y de trabajo interdisciplinario efectivo evidenciado en este avance académico. este producto da como valor agregado una gran lección a la comunidad académica e incrementa el reconocido prestigio de estas dos instituciones con una muestra más del desarrollo del conocimiento que han venido generando en sus 25 años de existencia y dentro del marco filosófico del compromiso social. beatriz sánchez herrera profesora asociada, facultad de enfermería, universidad nacional de colombia. 162 170 qualidade da assistencia de enfermagem.indd 162 ana claudia alcântara-garzin1 marta maria melleiro2 qualidade da assistência de enfermagem em medicina diagnóstica: construção e validação de um instrumento 1 0000-0002-5090-5508. universidade de são paulo, brasil. anagarzin@usp.br 2 0000-0002-8835-406x. universidade de são paulo, brasil. melleiro@usp.br recibido: 22 de febrero de 2016 enviado a pares: 18 de abril de 2016 aceptado por pares: 21 de abril de 2016 aprobado: 31 de octubre de 2016 doi: 10.5294/aqui.2017.17.2.5 para citar este artículo / to reference this article / para citar este artigo alcantara-garzin, ac, melleiro mm. qualidade da assistência de enfermagem em medicina diagnóstica: construção e validação de um instrumento. aquichan. 2017;17(2): 162-170. doi: 10.5294/aqui.2017.17.2.5 resumo objetivos: construir e validar um instrumento de coleta de dados sobre qualidade da assistência de enfermagem em serviços de medicina diagnóstica. materiais e método: a construção do instrumento baseou-se nas etapas teóricas descritas por pasquali, e o processo de validação ocorreu em dois momentos: análise de conteúdo, realizada por nove juízes, e análise de consistência interna, que utilizou o alpha de cronbach nos dados obtidos após aplicação do instrumento a 203 profissionais da equipe de enfermagem de uma instituição privada de medicina diagnóstica. resultados: as 45 proposições avaliadas pelos juízes alcançaram níveis satisfatórios relacionados a relevância, pertinência, clareza e sensibilidade, o que demonstra conteúdo adequado ao objeto do estudo. o alpha de cronbach obteve escore de 0,90, o que caracteriza um bom nível de consistência interna. conclusões: o instrumento validado fornecerá subsídios para intervenção e reorganização dos processos de trabalho assistenciais e gerenciais nesse segmento de atuação da enfermagem. palavras-chave avaliação em saúde; enfermagem; qualidade da assistência à saúde; segurança do paciente; serviços de diagnóstico (fonte: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 162-170 163 qualidade da assistência de enfermagem em medicina diagnóstica: construção e validação de um instrumento l ana claudia alcântara-garzin e outro año 17 vol. 17 nº 2 chía, colombia junio 2017 l 162-170 calidad de la asistencia de enfermería en medicina diagnóstica: construcción y validación de un instrumento resumen objetivos: construir y validar un instrumento de recolección de datos acerca de la calidad de la asistencia de enfermería en servicios de medicina diagnóstica. materiales y método: la construcción del instrumento se basó en las etapas teóricas descritas por pasquali, y el proceso de validación ocurrió en dos momentos: análisis de contenido, realizado por nueve jueces, y análisis de consistencia interna, que utilizó el alpha de cronbach en los datos obtenidos tras la aplicación del instrumento a 203 profesionales del personal de enfermería de una institución privada de medicina diagnóstica. resultados: las 45 proposiciones evaluadas por los jueces alcanzaron niveles satisfactorios relacionados con relevancia, pertinencia, claridad y sensibilidad, lo que demuestra contenido adecuado al objeto del estudio. el alpha de cronbach obtuvo puntaje de 0,90, lo que caracteriza un buen nivel de consistencia interna. conclusiones: el instrumento validado brindará herramientas para intervención y organización de los procesos de trabajo asistenciales y gerenciales en este campo de actuación de la enfermería. palabras clave calidad de la asistencia a salud; enfermería; evaluación en salud; seguridad del paciente; servicios de diagnóstico (fuente: decs, bireme). 164 aquichan issn 1657-5997 eissn 2027-5374 the quality of nursing care in diagnostic medicine: construction and validation of an instrument abstract objectives: construct and validate an instrument for collecting data on the quality of nursing care in medical diagnostic services. materials and method: the instrument was constructed pursuant to the theoretical stages described by pasquali [rd1] and was validated in two ways: through content analysis by nine judges and via an analysis of internal consistency using cronbach’s alpha on the data obtained by applying the instrument to 203 professional members of the nursing staff at a private medical diagnostic center. results: the 45 proposals evaluated by the judges were satisfactory in terms of relevance, pertinence, clarity and sensitivity. this demonstrates adequate content with respect to the object of the study. cronbach’s alpha scored 0.90, which shows a good level of internal consistency. conclusions: the validated instrument can be used to support intervention and the organization of care and management in this particular field of nursing. keywords quality of health care; nursing; health evaluation; patient safety; diagnostic services (source: decs, bireme). año 17 vol. 17 nº 2 chía, colombia junio 2017 l 162-170 165 qualidade da assistência de enfermagem em medicina diagnóstica: construção e validação de um instrumento l ana claudia alcântara-garzin e outro introdução o avanço tecnológico no setor saúde tornou imperativo que a ciência buscasse métodos diagnósticos cada vez mais sensíveis e precisos. assim, surgiu a especialidade denominada medicina diagnóstica (md), a qual é considerada como um conglomerado de especialidades direcionadas à realização de exames complementares, que contribuem em toda a cadeia de saúde: prevenção, diagnóstico, prognóstico e acompanhamento terapêutico (1, 2). a atuação da enfermagem em md ocorre na fase que compreende, principalmente, a assistência e o preparo do usuário para a realização de exames específicos de imagem e métodos gráficos e a coleta de amostras biológicas, objetivando a qualidade do exame, da assistência prestada e a segurança do paciente. a qualidade no setor saúde pode ser considerada como a razão entre o nível de eficácia do serviço e a expectativa do usuário, que vem sendo almejada pelas instituições que se preocupam em garantir um ambiente seguro para o exercício profissional e, consequentemente, com o mínimo risco aos usuários (3, 4). nessa direção, cabe aos gestores a avaliação contínua da qualidade, por meio de instrumentos que a propiciem. no entanto, dadas a escassez de estudos que enfoquem a avaliação da qualidade e a segurança da assistência de enfermagem em md, bem como a inexistência de escalas ou instrumentos disponíveis e validados para esse fim, constatou-se a necessidade de elaborar um instrumento que permita essa avaliação, sob a perspectiva da equipe de enfermagem e que, consequentemente, contribua na gestão dos serviços de md. considera-se relevante obter dados referentes à percepção da equipe de enfermagem a respeito da qualidade da assistência prestada, uma vez que os resultados, em grande parte, dependem do compromisso e do comprometimento desses profissionais, o que justifica este estudo. para a elaboração de um instrumento de avaliação, deve ser considerado o preceito do rigor metodológico por meio de etapas e procedimentos precisos e bem definidos (5, 6). outrossim, o pesquisador deve estar ciente de que os fenômenos nos quais está interessado em estudar devem ser traduzidos em conceitos que possam ser medidos, observados ou registrados (7, 8). o processo de validação de um instrumento pode ser entendido como um procedimento metodológico de avaliação da capacidade desse instrumento em medir, com precisão, um dado fenômeno (7, 8). por conseguinte, este estudo objetivou descrever as etapas e os critérios empregados na construção e na validação de um instrumento para a avaliação da qualidade e da segurança da assistência de enfermagem em md, por meio da análise de conteúdo e da análise de consistência interna. materiais e método pesquisa metodológica com foco na elaboração e na validação de um instrumento de avaliação, cujo projeto foi submetido e aprovado pelo comitê de ética em pesquisa da própria instituição onde o estudo foi realizado, mediante o parecer 006/2010. trata-se de instituição privada de md, na qual trabalhavam 38 enfermeiros e 372 auxiliares e técnicos de enfermagem em 21 unidades de atendimento, sendo 19 no estado de são paulo (brasil). o referencial metodológico utilizado foi baseado em pasquali, que descreveu as etapas necessárias para elaboração e validação de um instrumento de medida escalar, divididos em três grandes polos: teórico, empírico e analítico (9). o polo teórico enfoca a teoria que deve fundamentar o construto para o qual se quer desenvolver um instrumento e a operacionalização do construto em itens; o polo empírico é composto pelas etapas e as técnicas de aplicação do instrumento, bem como pela coleta de informações para proceder à avaliação psicométrica do instrumento; no polo analítico, destacam-se as análises estatísticas dos dados coletados para a validação do instrumento (5, 9). polo teórico esta etapa objetiva a construção e a validação do conteúdo do instrumento. nesse sentido, a construção teórica foi pautada na revisão da literatura nacional e internacional sobre os temas: qualidade assistencial e md; na experiência profissional da pesquisadora em md e no referencial teórico de donabedian, que amplia a abrangência do conceito de qualidade para além do plano individual, e propicia a avaliação da interação entre o comportamento individual e os componentes de estrutura, processo e resultado (10, 11). 166 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 assim, foram elaboradas 45 proposições com atributos positivos e negativos, distribuídas equitativamente nas dimensões de estrutura, processo e resultado, sob a forma de um instrumento de medida escalar tipo likert, com cinco graus de escolha: discordo totalmente, discordo parcialmente, nem concordo, nem discordo, concordo parcialmente e concordo totalmente. tomouse o cuidado de adequar a linguagem com os termos específicos utilizados na instituição na qual o instrumento seria aplicado após o processo de validação. a escala de likert é concebida para permitir que os sujeitos respondam com graus variados de satisfação a cada item, estabelecendo respostas graduadas para cada afirmação, com vistas a medir percepções e atitudes (8, 12). as proposições relacionadas à dimensão de estrutura abordaram os recursos físicos, materiais, quadro de pessoal de enfermagem e infraestrutura; as proposições vinculadas à dimensão de processo diziam respeito ao conjunto de atividades desenvolvidas pela equipe de enfermagem, o que inclui relacionamento interpessoal e capacitação profissional; as proposições a que se referiam à dimensão de resultado trataram das características desejáveis do serviço, o resultado da assistência, a satisfação do profissional e do usuário. após a construção, o instrumento foi analisado para validação de conteúdo por meio do julgamento de nove juízes, dentre eles três professores doutores, dois mestres e quatro especialistas em enfermagem com reconhecida experiência nos assuntos relacionados à avaliação da qualidade nos serviços de saúde, à metodologia empregada ou à temática de md. essa etapa ocorreu nos meses de março e abril de 2010. cada proposição foi avaliada pelos juízes considerando como parâmetros a relevância, a pertinência, a clareza e a sensibilidade, tendo como opção sim e não para cada um dos parâmetros e um espaço destinado para sugestão e adequação. a escala empregada também foi avaliada quanto a ser efetiva, exequível e suficiente. polo empírico o objetivo desta etapa é possibilitar a análise estatística de consistência interna ou homogeneidade e, assim, proporcionar confiabilidade ao instrumento de medida após a validação de conteúdo realizada. nesse sentido, o instrumento foi aplicado durante os meses de maio e junho de 2010; os participantes foram esclarecidos acerca dos objetivos desta pesquisa e sobre o sigilo das informações. aos que aceitaram participar, foi entregue o termo de consentimento livre e esclarecido. para a coleta de dados, a população foi constituída por enfermeiros, técnicos e auxiliares de enfermagem atuantes nas unidades de atendimento do estado de são paulo, e excluídos aqueles com cargos gerenciais e de consultoria, em gozo de férias e licenças e, ainda, aqueles contratados há menos de seis meses. assim, o questionário foi respondido por 203 participantes, dentre os 217 elegíveis. com a finalidade de assegurar a compreensão, identificar possíveis falhas e, caso necessário, proceder às adequações, foi realizado um pré-teste do instrumento piloto com um grupo de onze participantes, escolhidos aleatoriamente, composto por enfermeiros, técnicos e auxiliares de enfermagem. esses participantes foram excluídos da população do estudo. polo analítico com vistas à análise e à validação estatística da consistência interna do instrumento, foco desta etapa metodológica, as respostas dos 203 participantes foram inseridas e armazenadas em planilha eletrônica excel®. posteriormente, por meio do software stata 10.0, esses dados foram analisados e correlacionados para a determinação do coeficiente do teste de alpha de cronbach, o qual tem por finalidade estimar a confiabilidade do instrumento, a partir da correlação entre respostas do questionário por meio da análise do perfil das respostas obtidas (13). quanto mais elevadas forem as covariâncias ou correlações entre os itens, ou seja, quanto mais próximo a um, maior a homogeneidade dos itens e a consistência com que medem a mesma dimensão ou construto teórico (13, 14). resultados na validação de conteúdo, os nove juízes analisaram as 45 proposições distribuídas equitativamente nas dimensões de estrutura, processo e resultado descritas no modelo donabediano de avaliação da qualidade em serviços de saúde, considerando individualmente para cada proposição os quesitos de relevância, pertinência, clareza e sensibilidade. 167 qualidade da assistência de enfermagem em medicina diagnóstica: construção e validação de um instrumento l ana claudia alcântara-garzin e outro após o retorno de todos os instrumentos de validação pelos juízes, procedeu-se à análise dos pareceres, para a qual foi definido o critério de 80% de concordância para cada quesito, em cada uma das proposições, conforme referencial metodológico utilizado (5, 6). a tabela 1 apresenta a análise resultante dos pareceres dos juízes em cada uma das dimensões avaliativas, totalizando 135 análises para cada uma das dimensões. as sugestões propostas pelos juízes no quesito clareza foram analisadas e acatadas. dessa forma, em virtude das pequenas alterações sugeridas e realizadas, não foi necessário o retorno do instrumento aos juízes. assim, o instrumento foi constituído de duas partes, sendo a primeira designada para os dados sociodemográficos e a segunda composta pelas proposições validadas pelos juízes, descritas no quadro 1. todos os questionários do pré-teste foram devolvidos e não houve necessidade de realizar alterações devido à compreensão dos participantes. na etapa de validação estatística do instrumento, foi realizada a análise da consistência interna por meio do teste de alpha de cronbach, cujo resultado individual das proposições variou entre 0,890 e 0,902, obtendo-se o valor total do instrumento de 0,90. discussão para garantir que esse instrumento estivesse adequado ao objeto de estudo, foi necessário assegurar o rigor metodológico nas etapas de construção e validação, por meio de ações bem definidas, descritas por pasquali (5, 9). a validação de um instrumento medida demonstra qualidade e confiabilidade para a sua utilização. na etapa de validação do conteúdo, a escolha dos juízes deve ocorrer de modo criterioso, pois cabe a eles analisar e julgar cada um dos itens quanto à adequação e à representação do construto (5). a validação pelos juízes é fundamental, na medida em que busca um consenso e considera que o instrumento possui validade de conteúdo quando os itens que o constituem são representativos do universo teórico que ele pretende representar (5, 6). considera-se adequado um número mínimo de seis juízes para essa tarefa e a concordância de pelo menos 80% desses juízes pode servir como critério de decisão sobre a adequação do item a que teoricamente se refere (5, 6). nesse sentido, as 45 proposições distribuídas nas dimensões de estrutura, processo e resultado avaliadas pelos nove juízes alcançaram níveis satisfatórios relacionados a relevância, pertinência, clareza e sensibilidade, o que demonstrou conteúdo adequado ao objeto do estudo. tabela 1. análise dos pareceres dos juízes quanto a relevância, pertinência, clareza e sensibilidade das proposições das dimensões de estrutura, processo e resultado (são paulo, 2010) relevância pertinência clareza sensibilidade sim (%) não (%) sim (%) não (%) sim (%) não (%) sim (%) não (%) proposições da dimensão de estrutura 135 (100%) 135 (100%) 121 (90%) 14 (10%) 135 (100%) proposições da dimensão de processo 135 (100%) 135 (100%) 117 (87%) 18 (13%) 135 (100%) proposições da dimensão de resultado 135 (100%) 135 (100%) 121 (90%) 14 (10%) 135 (100%) total 405 (100%) 405 (100%) 359 (89%) 46 (11%) 405 (100%) fonte: elaboração própria. 168 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 quadro 1. proposições validadas para coleta de dados (são paulo, 2010) avaliação da qualidade da assistência em medicina diagnóstica 1. a área física em que atuo não propicia o bom andamento do processo de trabalho da equipe de enfermagem. 2. a equipe de enfermagem manuseia com facilidade os equipamentos, mesmo quando suas instruções estão em outro idioma. 3. as monitorias dos procedimentos de enfermagem contribuem para a diminuição de não conformidades. 4. os indicadores de qualidade do atendimento de enfermagem demonstram satisfação dos clientes em relação aos procedimentos realizados pela equipe de enfermagem. 5. o sigilo das informações obtidas durante o atendimento aos clientes é mantido pela equipe de enfermagem. 6. os fluxos propostos para o atendimento na instituição visam ao acolhimento dos clientes. 7. as salas de exames não propiciam privacidade ao cliente. 8. a realização dos procedimentos padronizados é dificultada pela qualidade dos materiais disponibilizados. 9. a equipe de enfermagem deixa de cometer falhas nos procedimentos ao consultar as instruções gerais (igs). 10. a equipe de enfermagem tem liberdade para fazer sugestões que possam contribuir para a melhoria da assistência prestada. 11. a instituição disponibiliza equipamentos de proteção individual (epi) aos seus trabalhadores. 12. ocorre desperdício de tempo no atendimento devido às distâncias percorridas entre o início e a finalização do procedimento. 13. há relatos de insatisfação, por parte dos clientes, com os materiais utilizados durantes os procedimentos. 14. a instituição é reconhecida pela atitude ética de seus trabalhadores. 15. não há discussões entre a coordenação e a equipe de enfermagem a respeito dos indicadores da área. 16. a equipe enfermagem está capacitada para atuar nos procedimentos. 17. as instruções gerais (igs) não possuem informações atualizadas. 18. os atendimentos são realizados apressadamente em razão do número de trabalhadores existentes. 19. ocorre manipulação de equipamentos de forma equivocada, pois as instruções não estão em português. 20. há relatos de queixas, por parte dos clientes, referentes à sua segurança. 21. ao atender os clientes, a equipe de enfermagem demonstra interesse por suas expectativas. 22. a instituição disponibiliza um canal de comunicação entre os trabalhadores e a diretoria. 23. os equipamentos que utilizo durante minhas atividades são de difícil manuseio. 24. a equipe de enfermagem utiliza as instruções de trabalho (itrs) para assegurar-se dos procedimentos padronizados. 25. os treinamentos realizados para a equipe de enfermagem propiciam atualização profissional. 26. a equipe de enfermagem nem sempre utiliza os equipamentos de proteção individual (epi) preconizados para as atividades. 27. no meu local de trabalho, há um espaço para divulgação de informações de interesse da equipe de enfermagem. 28. as instruções de trabalho (itrs) são suficientemente detalhadas. 29. a equipe de enfermagem explica os procedimentos aos clientes de forma individualizada. 30. a eficácia das atividades desenvolvidas pela equipe de enfermagem fica comprometida em virtude da área física. 31. a equipe de enfermagem sente-se insegura no exercício de suas atividades devido às condições oferecidas pela instituição. 169 qualidade da assistência de enfermagem em medicina diagnóstica: construção e validação de um instrumento l ana claudia alcântara-garzin e outro apenas no item clareza foi apontado necessidade de alterações semânticas, cujas propostas sugeridas pelos juízes foram analisadas e acatadas. a etapa de validação de conteúdo pelos juízes finaliza o polo teórico da construção de um instrumento de medida, o que permite realizar o polo empírico que consiste em coletar informação válida e submetê-la às análises estatísticas no polo analítico (5, 9). assim, após a aplicação do instrumento na população do estudo, os dados foram analisados estatisticamente e submetidos à análise de consistência interna com o alpha de cronbach, cujo resultado pode variar de 0 a 1, e quanto mais próximo de 1 melhor é a confiabilidade do instrumento. de modo geral, são adotados como valores de confiabilidade escores acima de 0,70 (14, 15). neste estudo, o alpha de cronbach total encontrado foi de 0,90, o que confere ao instrumento bom nível de consistência interna e permite que as proposições avaliem de forma homogênea a percepção da qualidade da assistência de enfermagem em md. conclusão o presente artigo descreveu os procedimentos referentes à construção e à validação do instrumento de coleta de dados acerca da qualidade e da segurança da assistência de enfermagem em serviços de md, baseado no modelo avaliativo donabediano, que contempla as dimensões de estrutura, processo e resultado. a validação do instrumento pode ser considerada adequada, tendo em vista o processo de seleção dos seus itens, a criteriosa análise e as sugestões dos juízes que compuseram a validação de conteúdo, tal como a avaliação de consistência interna. assegura-se, assim, que o instrumento esteja situado dentro da abordagem teórica referente à qualidade do cuidado de enfermagem em md, e a sua utilização contribuirá com o diagnóstico situacional e com a identificação dos fatores que interferem nessa assistência, mediante as dimensões avaliativas de estrutura, processo e resultado, além de fornecer subsídios para a intervenção e a reorganização dos processos de trabalho assistenciais e gerenciais da enfermagem nessa área específica de atuação da equipe de enfermagem. 32. os treinamentos desenvolvidos pelo setor de educação não atendem às necessidades da equipe de enfermagem. 33. o sistema de informação da instituição permite acesso dos trabalhadores aos dados sigilosos do cliente. 34. o mobiliário da unidade não é adequado para atender, com segurança, às necessidades dos clientes. 35. a equipe de enfermagem tem dificuldade em encontrar as informações necessárias nas instruções gerais (igs) quando em dúvida sobre algum exame. 36. as insatisfações manifestadas pelos clientes referentes à demora no atendimento de enfermagem não se devem ao número reduzido de trabalhadores. 37. as instruções de trabalho (itrs) propiciam a qualidade assistencial devido à sua clareza. 38. os resultados dos indicadores não são divulgados, periodicamente, para a equipe de enfermagem. 39. a equipe de enfermagem segue as orientações preconizadas pela instituição, visando minimizar riscos ao cliente. 40. o número de trabalhadores na equipe de enfermagem é suficiente para o número de atendimentos prestados. 41. os materiais disponibilizados para a realização de exames são adequados aos procedimentos realizados. 42. os indicadores de satisfação dos clientes demonstram que estes se sentem acolhidos durante a sua permanência na instituição. 43. a equipe de enfermagem demonstra satisfação com a qualidade do atendimento que presta ao cliente. 44. na ocorrência de não conformidade relativa à assistência de enfermagem, são implementadas ações para que isso não se repita. 45. na instituição em que atuo, não existem protocolos referentes à segurança do cliente. fonte: elaboração própria. 170 año 17 vol. 17 nº 2 chía, colombia junio 2017 aquichan issn 1657-5997 eissn 2027-5374 referências 1. campana ga, oplustil cp, faro lb. tendências em medicina laboratorial. j bras patol med lab [on-line]. 2011 ago. [citado 29 ago. 2016]; 47(4):399-408. disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=s1676-24442011000400003 2. auriemo cc, rosenfeld lgm. a medicina diagnóstica no brasil. em: amorin mcs, perillo ebf. organizadores. para entender a saúde no brasil. são paulo (sp): lcte; 2006. p. 159-67. 3. pena mm, silva ems, tronchin dmr, melleiro mm. o emprego do modelo de qualidade de parasuraman, zeithaml e berry em serviços de saúde. rev esc enferm usp [on-line]. 2013 ago. [citado 29 ago. 2016]; 47(5):1235-40. disponível em: http://www.revistas.usp.br/reeusp/article/view/78084/82145 4. tronchin dmr, freitas gf, melleiro mm. avaliação de serviços, qualidade e segurança do paciente no setor de saúde. em: kurcgant p. organizadora. gerenciamento em enfermagem. rio de janeiro: guanabara koogan; 2016. p. 59-73. 5. pasquali l. instrumentação psicológica: fundamentos e práticas. porto alegre: artmed; 2010. 6. balan maj, meschial wc, santana rg, suzuki sml, oliveira mlf. validação de um instrumento de investigação de conhecimento sobre o atendimento inicial ao queimado. texto contexto-enferm. [on-line]. 2014 jun. [citado 12 jun. 2015]; 23(2):373-81. disponível em: http://www.scielo.br/pdf/tce/v23n2/pt_0104-0707-tce-23-02-00373.pdf 7. lima tc, gallani mcbj, freitas mip. validação do conteúdo de instrumento para caracterizar pessoas maiores de 50 anos portadoras do vírus da imunodeficiência humana/síndrome da imunodeficiência adquirida. acta paul enferm [on-line]. 2012 [citado 12 jun. 2015]; 25(1):4-10. disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=s010321002012000100002&lng=en.%20http://dx.doi.org/10.1590/s0103-21002012000100002 8. polit df, beck ct. fundamentos de pesquisa em enfermagem: avaliação de evidências para a prática da enfermagem. 7ª ed. porto alegre: artmed; 2011. 9. pasquali l. psicometria: teoria dos testes na psicologia e na educação. 5ª ed. petrópolis: vozes; 2013. 10. donabedian a. the quality of care. how can it be assessed? jama. 1988;260(12):1743-8. 11. donabedian a. the role of outcomes in quality assesment and assurance. qual rev bull. 1992;20(6):975-92. 12. sullivan gm, artino jr ar. analyzing and interpreting data from likert-type scales. j grad med educ. [on-line]. 2013 [citado 27 ago. 2016]; 5(4):541-2. disponível em: http://www.ncbi.nlm.nih.gov/pmc/articles/pmc3886444/pdf/i19498357-5-4-541.pdf 13. figueiredo db. uso da análise fatorial exploratória em psicologia. aval psicol [on-line]. 2012 [citado 27 ago. 2016]; 11(2):213-28. disponível em: http://pepsic.bvsalud.org/pdf/avp/v11n2/v11n2a07.pdf 14. tavakol m, dennick r. making sense of cronbach’s alpha. int j med educ [on-line]. 2011 [citado 27 ago. 2016]; (2): 53-5. disponível em: https://www.ijme.net/archive/2/cronbachs-alpha.pdf 15. bellucci júnior ja, matsuda lm. construção e validação de instrumento para avaliação do acolhimento com classificação de risco. rev. bras. enferm. [on-line]. 2012 out. [citado 12 jun. 2015]; 65(5):751-7. disponível em: http://www. scielo.br/scielo.php?script=sci_arttext&pid=s0034-71672012000500006 5 middle-range.p65 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200532 año 5 vol. 5 nº 1 (5) 32-43 chía, colombia octubre 2005 jacqueline fawcett1 recibido: 24 de octubre de 2004 aprobado: 21 de abril de 2005 resumen este artículo trata de discutir aspectos generales sobre los patrones de conocimiento de enfermería, y los elementos de fundamentación para el desarrollo del conocimiento y la práctica. en primera instancia muestra la importancia del desarrollo del conocimiento que sustenta la práctica, y cómo éste se expresa en cuatro patrones: empírico o ciencia de enfermería, ético, estético o arte de enfermería y el conocimiento personal. se hace asi mismo una descripción de cada patrón de conocimiento, comenzando por el personal. el significado de este patrón, el menos desarrollado de los cuatro, se muestra como algo básico para el desarrollo de los patrones ético y estético, ya que es casi condición sin la cual los mencionados patrones no pueden desarrollarse a plenitud ni ser expresados en la práctica de manera satisfactoria. se plantea la discusión de la evolución de las preguntas epistemológicas de los patrones hacia lo filosófico y ontológico. es decir, se pretende progresar del conocer hacia el ser o esencia de lo conocido para terminar resumiendo las repercusiones que tiene la inclusión de los patrones del conocimiento en la sintaxis de la disciplina de enfermería. palabras clave práctica de enfermería, patrón de conocimiento, patrón de conocimiento personal, patrón empírico o ciencia de enfermería, patrón ético y moral de enfermería, patrón estético o arte de enfermería. abstract this article tries to discuss general aspects on models of nursing knowledge, basic elements for its development and practice. first, it shows the importance of the development of knowledge sustained by the practice and the expression of it by means of four knowledge models: empirical or nursing science, ethical, esthetical or nursing art, and personal. a description of each model of knowledge takes place, beginning with the personal one. its meaning is showed as something basic for the development of ethical and aesthetical models, as it is a condition sine qua non such models are not totally developed or expressed satisfactorily in practice. it presents the discussion on evolution of epistemological questions toward philosophy and ontology. it tries to progress in the knowledge of the self or essence of what is known, to end with a summary on repercussions of knowledge models inclusion in syntax of nursing discipline. key words nursing practice, knowledge model, personal knowledge model, empirical model or nursing science, ethical model and nursing moral, aesthetic model or nursing art. * paper presented at a conference sponsored by universidad de la sabana. facultad de enfermería, chía, cundinamarca, colombia, october 26, 2004. 1 phd, rn, faan. professor college of nursing and health sciences university of massachusetts boston, usa. j a c q u e l i n e . f a w c e t t @ u m b . e d u middle-range nursing theories are necessary for the advancement of the discipline 33 am honored by the invitation to speak with you today. i bring you greetings from your nursing colleagues throughout the united states of america and especially, from the nursing faculty and students at the university of massachusetts boston. this morning, i will discuss my ideas about the role middle-range nursing theories play in the advancement of the discipline of nursing. i will start by identifying the place of middle-range theories within the larger body of nursing knowledge, which i call a structural holarchy. i will then define each component of the structural holarchy and explain its function. next, i will identify three types of middlerange theories and associated types of research. then, i will discuss the derivation of middle-range theories from conceptual models and identify three approaches to connecting conceptual models with middle-range theories. i will continue by identifying middle-range nursing theories that have been derived from roy�s adaptation model. finally, i will discuss the importance of continued development and testing of middle-range theories to the advancement of the discipline of nursing. the structural holarchy of nursing knowledge i have identified a structural holarchy of nursing knowledge that differentiates five components of nursing knowledge according to their level of abstraction (1). a holarchy is made up of components that are whole within themselves but also part of a larger whole. in this case, the larger whole is nursing knowledge. thus, each component of nursing knowledge is a complete whole but also is a part of a larger whole. as can be seen in figure 1, the most abstract component is the metaparadigm and the most concrete component is the empirical indicator. figure 1. the structural holarchy of nursing knowledge: components and levels of abstraction 1234567890123456789012345678901212345678901234567890123456789012123456 1234567890123456789012345678901212345678901234567890123456789012123456 1234567890123456789012345678901212345678901234567890123456789012123456 1234567890123456789012345678901212345678901234567890123456789012123456 1234567890123456789012345678901212345678901234567890123456789012123456 1234567890123456789012345678901212345678901234567890123456789012123456 1234567890123456789012345678901212345678901234567890123456789012123456 1234567890123456789012345678901212345678901234567890123456789012123456 1234567890123456789012345678901212345678901234567890123456789012123456 1234567890123456789012345678901212345678901234567890123456789012123456 1234567890123456789012345678901212345678901234567890123456789012123456 1234567890123456789012345678901212345678901234567890123456789012123456 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1234567890123456789012345678901212345678901234567890123456789012123456 metaparadigm most abstract philosophy conceptual model theory empirical indicator most concrete revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200534 components of nursing knowledge: metaparadigm a metaparadigm is defined as the global concepts that identify the phenomena of central interest to a discipline, the global propositions that describe the concepts, and the global propositions that state the relations between the concepts (1). the concepts and propositions of a metaparadigm are admittedly extremely abstract and provide no definitive direction for such activities as research and practice. rather, the function of a metaparadigm is to identify the basic subject matter of the discipline. the subject matter of nursing encompasses human beings, environment, health, and nursing (1). components of nursing knowledge: philosophy a philosophy may be defined as a statement encompassing ontological claims about the phenomena of central interest to a discipline, epistemic claims about how those phenomena come to be known and ethical claims about what the members of a discipline value (1). the function of a philosophy is to communicate what the members of a discipline believe to be true in relation to the phenomena of interest to that discipline, what they believe about how the knowledge about those phenomena should be developed, and what they value with regard to their actions and practices. those functions of a philosophy sometimes are presented in the form of world views. three major world views evident in the works of nurse scholars are the reaction world view, the reciprocal interaction world view, and the simultaneous action world view (1). the major features of each world view are presented in table 1. components of nursing knowledge: conceptual model a conceptual model is defined as a set of relatively abstract and general concepts that address the phenomena of central interest to a discipline, the propositions that broadly describe those concepts, and the propositions that state relatively abstract and general relations between two or more of the concepts (1). the function of each conceptual model is to provide a distinctive frame of reference that tells members of a discipline how to observe and interpret the phenomena of interest to the discipline. although conceptual models address all of the concepts representing the subject matter of the discipline, as identified in the metaparadigm, each metaparadigm concept is defined and described in a different way in different conceptual models. the most widely recognized and utilized conceptual models of nursing in the united states of america, and perhaps in other countries, are johnson�s behavioral system model, king�s conceptual system, levine�s conservation model, neuman�s systems model, orem�s self-care framework, rogers� science of unitary human beings, and roy�s adaptation model (2-16). components of nursing knowledge: theory a theory is defined as one or more relatively concrete and specific concepts that are derived from a conceptual model, the propositions that narrowly describe those concepts, and the propositions that state relatively concrete and specific relations between two or more of the concepts (1). the functions of a theory are to narrow and more fully specify the phenomena contained in a conceptual model and to provide a relatively concrete and specific structure for the interpretation of initially puzzling behaviors, situations, and events. theories vary in their level of abstraction and scope. grand theories are relatively abstract and broad, though less abstract than conceptual models. widely used nursing grand theories include leininger�s (17) theory of culture care diversity and universality, newman�s (18, 19) theory of health as expanding consciousness, and parse�s (20, 21) theory of human becoming. frederick suppe, a philosopher of science from the united states of america, has pointed out that �as science matures, the development of knowledge moves from the [conceptual models and] grand theories to the development of middle-range theories that are less abstract and more empirical or practice based� (suppe, as cited in schmidt, p. 9) (22). given our interest in the advancement of the discipline of nursing, this presentation focuses on middlerange theories. middle-range nursing theories are necessary for the advancement of the discipline 35 middle-range theories are more concrete and narrower than grand theories; they are made up of a limited number of concepts and propositions that are written at a relatively concrete and specific level. widely used middle-range nursing theories include orlando�s (23) theory of the deliberative nursing process, peplau�s (24, 25) theory of interpersonal relations, and watson�s (26, 27) theory of human caring. many other middle-range nursing theories exist. indeed, one can argue that the product of every nursing study represents a middle-range theory (28). several explicit middle-range theories have been presented in two recently published books. one book includes chapters addressing a theory of pain, the theory of unpleasant symptoms, the theory of self-efficacy, the theories of reasoned action and planned behavior, a theory of empathy, the theory of chronic sorrow, a theory of social support, the theory of interpersonal relations, the theory of modeling and role-modeling, the theory of comfort, a theory of health-related quality of life, the theory of health promotion, the theory of the deliberative nursing process, a theory of self-efficacy, a theory of planned change, and a theory of resilience (29). the other book includes chapters addressing the theories of uncertainly in illness, a theory of selfefficacy, the theory of unpleasant symptoms, a theory of family stress and adaptation, a theory of community empowerment, a theory of meaning, the theory of self-transcendence, and a theory of attentively embracing story (30). although all of the theories included in the two books have been tested in studies conducted by nurses, i am not convinced that all of them are middle-range nursing theories. for example, the theories of social support, self-efficacy, reasoned action, and planned behavior were initially developed table 1. major features of the reaction, reciprocal interaction, and simultaneous action world views 12345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678901234567890123456789012123456789012 12345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678901234567890123456789012123456789012 12345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678901234567890123456789012123456789012 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only in the context of the whole. � human beings are active, and interactions between human beings and their environments are reciprocal. � change is a function of multiple antecedent factors, is probabilistic, and may be continuous or may be only for survival. � reality is multidimensional, context-dependent, and relative. simultaneous action world view � unitary human beings are identified by pattern. � human beings are in mutual rhythmical interchange with their environments. � human beings change continuously, unpredictably, and in the direction of more complex self-organization. � the phenomena of interest are personal knowledge and pattern recognition. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200536 within the discipline of social psychology. one could, however, argue that as the result of their testing in nursing situations, those theories may be regarded as shared theories (31, 32). but do shared theories advance our discipline? perhaps they do but not, i think, as much as nursing discipline-specific theories. components of nursing knowledge: empirical indicator an empirical indicator is defined as a very concrete and specific real world proxy or substitute for a middle-range theory concept; an actual instrument, experimental condition, or procedure that is used to observe or measure a middle-range theory concept (1). the information obtained from empirical indicators typically is called data. the function of empirical indicators is to provide the means by which middle-range theories are generated or tested. empirical indicators that are instruments yield data that can be sorted into qualitative categories or calculated as quantitative scores. for example, responses to an interview schedule made up of open-ended questions can be analyzed to yield categories or themes, and responses to questionnaires made up of fixed-choice items can be subjected to mathematical calculations that yield a number or score. empirical indicators that are experimental conditions or procedures tell the researcher or practitioner exactly what to do. they are protocols or scripts that direct actions in a precise manner. empirical indicators, then, are needed to generate and test middle-range theories. types of middle-range theories there are three types of middle-range theories. middle-range descriptive theories are the most basic type of middle-range theory. each descriptive theory describes or classifies a phenomenon and, therefore, may encompass just one concept. when a middle-range descriptive theory describes a phenomenon, it simply names the commonalities found in discrete observations of individuals, groups, situations, or events. when a middle-range descriptive theory classifies a phenomenon, it categorizes the described commonalities into mutually exclusive, overlapping, hierarchical, or sequential dimensions. a middle-range classification theory may be referred to as a typology or a taxonomy. middle-range descriptive theories are generated and tested by means of descriptive research, which may be qualitative or quantitative in design. peplau�s theory of interpersonal relations is an example of a middle-range descriptive classification theory. middle-range explanatory theories specify relations between two or more concepts. each explanatory theory explains why and the extent to which one concept is related to another concept. middle-range explanatory theories are generated and tested by means of correlational research, which typically is quantitative in design. watson�s theory of human caring is an example of a middle-range explanatory theory. middle-range predictive theories move beyond explanation to the prediction of precise relations between concepts or the effects of one or more concepts on one or more other concepts. this type of middle-range theory addresses how changes in a phenomenon occur. middle-range predictive theories are generated and tested by means of experimental research, which typically is quantitative in design. orlando�s theory of the deliberative nursing process is an example of a middle-range predictive theory. middle-range theories and conceptual models the definition of a theory given earlier indicates that a conceptual model always is the precursor to a theory. indeed, the british physicist and philosopher of science sir karl popper (33) maintained that inasmuch as �we approach everything in the light of a preconceived theory (33), the belief held by some that theory development proceeds outside the context of a conceptual frame of reference is �absurd� (34). indeed, �all theories � stem from cultural and historic contexts that lend them meaning and influence how they are understood and implemented� (35). the particular cultural and historical context from which a theory stems is evident in the conceptual models from which the theory was derived. many middle-range theories are needed to deal with all of the phenomena encompassed by any one conceptual model because each theory deals with only a limited aspect of the total reality encompassed by a conceptual model. each conceptual model, then, is more fully specified by several middle-range theories (figure 2). middle-range nursing theories are necessary for the advancement of the discipline 37 approaches to connecting conceptual models and middle-range theories three approaches to connecting conceptual models and middlerange theories have been identified. one approach is the direct derivation of a middle-range theory from a conceptual model. for example, two theories of family health have been directly derived from king�s conceptual system (36-39). this approach assures a logical linkage between the conceptual model and the middle-range theory. the logic is assured because the world view (reaction, reciprocal interaction, simultaneous action) undergirding the conceptual model and the world view undergirding the theory are the same. the second approach is to link an existing middle-range nursing theory with a conceptual model of nursing. for example, a researcher might want to link the nursing theory of uncertainty in illness with johnson�s behavioral system model. this approach is problematic in that the world view undergirding johnson�s conceptual model and the world view undergirding the conceptual model from which the theory was derived may not be logically congruent. logical congruence would be evident only if the world view undergirding johnson�s conceptual model and the world view undergirding the conceptual model from which the theory was derived are the same. the third approach is to link an existing middle-range theory borrowed from another discipline with a conceptual model of nursing. for example, the theory of planned behavior, from the discipline of social psychology, has been linked with neuman�s systems model and with orem�s self-care framework (32). as with the second approach, this approach is problematic in that the world view undergirding the orem�s conceptual model and the world view undergirding the conceptual model from which the theory was derived may not be logically congruent. logical congruence would be evident only if the world view undergirding orem�s conceptual model and the world view undergirding the conceptual model from which the theory was derived are the same. 12345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678901234567890123456789012123456789012345678 12345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678901234567890123456789012123456789012345678 12345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678901234567890123456789012123456789012345678 12345678901234567890123456789012123456789012345678901234567890121234567890123456789012345678901212345678901234567890123456789012123456789012345678 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disciplines. (40). roy�s adaptation model and middle-range theories early in te 21st century, watson (41) declared, �it seems that nursing�s very survival is at stake at this moment in history� (41). she went on to issue a �call for nursing to reconsider the very source and core of its existence and whether it is grounded enough to survive� in the reality of modern healthcare (41). i believe that roy�s adaptation model provides the necessary grounding for the survival of the discipline of nursing. this conceptual model of nursing, which was first presented almost 35 years ago (42), continues to be widely used by nurses in many countries as a guide for nursing research, nursing practice, nursing education, and administration of nursing services. when used as a guide for all those nursing activities, roy�s adaptation model must be connected with one or more middlerange theories. the first approach to connecting conceptual models and middle-range theories has been used for more than 20 years by nurses who have adopted roy�s model. roy and roberts (43) developed a general theory of the person as an adaptive system, which may be considered a grand theory (44) and separate middle-range theories of the four modes of adaptation the theory of the physiological mode, the theory of the self-concept mode, the theory of the role function mode, and the theory of the interdependence mode. the theory of the person as an adaptive system considers the person holistically. the theory of the physiological mode encompasses regulator subsystem responses related to exercise and rest, nutrition, elimination, fluid and electrolytes, oxygen and circulation, temperature, the senses, and the endocrine system. the theory of the self-concept mode, the theory of the role function mode, and the theory of the interdependence mode consider those modes as systems �through which the regulator and cognator subsystems act to promote adaptation� (43). each theory describes the relevant system in terms of its wholeness, subsystems, relation of parts, inputs, outputs, and self-regulation and control. the hypotheses derived from the propositions of each theory still have not been tested empirically. however, roy and roberts recognized the need for a systematic program of research to test the hypotheses they formulated, as well as other hypotheses that could be derived from the theories. they also recognized the need to further develop and test the theory of the person as an adaptive system. they commented, �we must look at the theory of the adaptive person to further explain the interrelatedness of the adaptive modes. in this process we must also search for multivariable and nonlinear relationships. cognator and regulator processes must be studied to discover the proposed hierarchy of processes� (43). roy and roberts� (43) pioneering work paved the way for derivation of many other middle-range nursing theories. the nursing model of cognitive processing (45,46), which actually is a rudimentary middle-range theory of information processing, focuses attention on the basic cognitive processes of arousal and attention, sensation and perception, coding, concept formation, memory, language, planning, and motor responses. the model proposes that the basic cognitive processes, which occur within the field of consciousness, are dependent on neurological and neurochemical functions. the model further proposes that cognitive processes are directed toward dealing with the focal stimulus of the immediate sensory experience, taking the contextual and residual stimuli of the person�s education and experience into account. roy (47) has extended the theory of the self-concept mode, the theory of the role function mode, and the theory of the interdependence mode by introducing middle-range theories of processes. she proposed that within the self-concept mode of adaptation, theories about the physical self and personal self address processes of developing self; theories about self consistency address processes of focusing self, theories about self ideal address processes of choosing self, and theories about the moral-ethicalspiritual self address processes of valuing self. within the role function mode, theories about primary, secondary, and tertiary roles address processes of developing roles; theories about role transition address processes of role taking; and theories about role set address processes of integrating roles. within the middle-range nursing theories are necessary for the advancement of the discipline 39 interdependence mode, theories about significant others address processes of giving and receiving, as well as processes of learning and maturing in relationships, and theories about support systems address processes of securing resources. other few explicit middle-range theories that have been derived from the roy adaptation model are: � theory of caregiver stress (48, 49). � theory of adapting to diabetes (50). � theory of psychosocial adaptation to termination of pregnancy for fetal anomaly (51). � theory of adaptation during childbearing (52). additional theory development work stemming from the roy adaptation model includes the construction of explicit conceptual-theoretical-empirical structures for several studies, including: � preparation for cesarean childbirth (53). � correlates of functional status in normal life situations and serious illness (54-56). � adaptation to chronic illness (57). � cross-cultural responses to pain (58). � stress experiences of spouses of coronary artery bypass graft patients (59, 60). � correlates of physiological and psychosocial adaptation in spinal cord-injured persons (61). � correlates of psychological distress and life satisfaction in diverse caregiver populations (62, 63). � effects of walking exercise for women with breast cancer (64, 65). the theoretical component of each of those conceptualtheoretical-empirical structures now needs to be formalized as an explicit middle-range theory. the second and third approaches to connecting conceptual models and middle-range theories also can be used to link roy�s adaptation model with existing middle-range theories. the second approach is evident in the linkage of orlando�s (23) theory of the deliberative nursing process with roy�s model. that linkage gives nurses a theoretical basis for validating their perceptions, thoughts, and feelings about relevant stimuli with patients (66). inasmuch as the reciprocal interaction world view undergirds both roy�s adaptation model and the conceptual model from which orlando�s theory was derived (1), the linkage of the conceptual model and the theory is logically congruent. other existing middle-range nursing theories that are logically congruent with roy�s adaptation model are uncertainty in illness, unpleasant symptoms, and community empowerment. smith and liehr (30) indicated that those theories were developed within the philosophic context of the interactive-integrative paradigm, which is similar to the reciprocal interaction world view. logical congruence in the use of the third approach would be evident if a theory borrowed from another discipline but derived from a conceptual model undergirded by the reciprocal interaction world view were to be linked with roy�s adaptation model. two such theories are self-efficacy and family stress and adaptation. those theories, according to smith and liehr (30), were developed within the philosophic context of the interactive-integrative paradigm. advancing the discipline of nursing given latham�s (40) objection to creating linkages between conceptual models of nursing and middle-range theories by using theories borrowed from other disciplines, and the extensive work required to identify the world view undergirding existing middlerange nursing theories and theories from other disciplines, we may want to focus our future efforts on deriving middle-range theories directly from a conceptual model of nursing. that first approach to connecting conceptual models and middle-range theories virtually assures logical congruence between the conceptual model and the theory. furthermore, the language of the theory, that is, the terms used for the theory concepts and the meaning of each concept, will be in keeping with the distinctive language of the conceptual model. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 200540 the importance of and need for a distinctive nursing language is mandatory if nursing is to advance as a discipline. more specifically, the vocabulary of each conceptual model and each theory should not be considered unnecessary jargon. rather, the terminology used by the author of each conceptual model and each theory is the result of considerable thought about how to precisely convey the meaning of that particular perspective to others (67). nurses have long understood the need for a distinctive vocabulary that differentiates nursing from other sciences and especially from medicine (27). �language�, batey and eyres (68) explained, �is fundamental to the evolution of all disciplines and within any discipline, selected terminology evolves to become the concepts that denote the specific knowledge domains and methodologies of that discipline� (68). akinsanya (69) added, �every science has its own peculiar terms, concepts and principles which are essential for the development of its knowledge base. in nursing, as in other sciences, an understanding of these is a prerequisite to a critical examination of their contribution to the development of knowledge and its application to practice� (69). and, barrett (70) commented, �how would one understand anatomy and physiology, microbiology, pharmacology, � without the precise use of language reflecting those domains of knowledge? � yet various professional groups and consumers may be able to grasp the meaning precisely due to the specificity of description. how else is substantive knowledge to be communicated without saying � what it is �!� (70). finally, watson (71) declared, �the attention to language is especially critical to an evolving discipline in that during this postmodern era, one�s survival depends upon having language; writers in this area remind us �if you do not have your own language you don�t exist�� (71). in conclusion, i urge you to select a conceptual model of nursing that interests you and derive middle-range theories from that conceptual model, so that you, too, will contribute most directly to the survival and advancement of our discipline. the widespread use of roy�s adaptation model, as well as other conceptual models of nursing, indicates that they are appropriate guides for nursing activities in diverse cultures. thus, you may select from among several conceptual models as you begin your journey toward middlerange theory development. taylor�s (72) comments about orem�s self-care framework are equally applicable to many other conceptual models of nursing, including roy�s adaptation model. she noted, �for years there have been references to a cultural bias in orem�s work. yet at our conferences and in visits to countries other than the united states of america, there is evidence that orem�s selfcare framework has an appeal and universality that extends to all cultures. the requirement, in using [the model], that the unique aspects of various cultures and practices be considered is a part of what makes this so� (73). each of you has a great deal to contribute to the advancement of our discipline. indeed, although many nursing conceptual models and theories were initially developed by nurse scholars in the united states of america, the recognition of the value of distinctive nursing knowledge and its use and further development now is greater in many other countries (72). much work already has been accomplished but much remains to be done. for example, as roy and roberts (43) pointed out, nursing practice theories, or what roy (73) later called clinical nursing science, must be developed. that is, theories must be derived from conceptual models of nursing to predict the effects of specific nursing interventions on the responses of individuals and groups. furthermore, programs of research must be designed to systematically generate and test middle-range descriptive, explanatory, and predictive theories derived from many different conceptual models of nursing. i am confident that each of you can contribute to that work. thank you very much for this opportunity to share my ideas about nursing knowledge with you. it is an honor to be part of this wonderful and important nursing conference. middle-range nursing theories are necessary for the advancement of the discipline 41 references 1. fawcett j. contemporary nursing knowledge: analysis and evaluation of nursing models and theories. 2nd ed. philadelphia: f. a. davis; 2005. 2. johnson de. the behavioral system model for nursing. in: j.p. riehl & c. roy (eds.), 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[guest editorial.] icus and nursing web journal 2002; 9: 1-7. www.nursing.gr/. 42. roy c. adaptation: a conceptual framework for nursing. nursing outlook 1970; 18 (3): 42-5. 43. roy c, roberts sl. theory construction in nursing. an adaptation model. englewood cliffs, nj: prentice-hall; 1981. 44. alligood mr. philosophies, models, and theories: critical thinking structures. in: m. r. alligood & a. marriner tomey (eds.), nursing theory: utilization and application st. 2nd ed., louis: mosby 2001; 41-61. 45. roy c. altered cognition: an information processing approach. in: p. h. mitchell, l. c. hodges, m. muwaswes, & c. a. walleck (eds.), aann�s neuroscience nursing: phenomenon and practice: human responses to neurological health problems. norwalk, ct: appleton and lange; 1988a; 185-211. 46. roy c. alterations in cognitive processing. in: c. stewartamidei & j.a. kunkel (eds.), aann�s neuroscience nursing: human responses to neurologic dysfunction. 2nd ed. philadelphia: saunders; 2001; 275-323. 47. roy c. implications of the 21st century developments of the roy adaptation model. paper presented at the 4th annual conference of the roy adaptation association. kennebunkport, me; 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1984. 67. biley f. wordly wise. nursing (london) 1990; 4 (24): 37. 68. batey mv, eyres sj. interdisciplinary semantics: implications for research. western journal of nursing research 1979; 1: 139-41. 69. akinsanya ja. introduction. recent advances in nursing 1989; 24, i-ii. 70. barrett eam. response to letter to the editor. nursing science quarterly 2003; 16: 27-280. 71. watson j. the theory of human caring: retrospective and prospective. nursing science quarterly 1997; 10: 49-52. 72. taylor sg. from the president. self-care, dependent-care, and nursing 2004; 12 (2): 11. 73. roy c. an explication of the philosophical assumptions of the roy adaptation model. nursing science quarterly, 1988b; 1: 26-34. 343 alma de coral elías-viramontes1 liliana gonzález-juárez2 intervención educativa de enfermería para el autocuidado de los pies en personas que viven con diabetes tipo 2 1 orcid.org/0000-0001-8356-2153. universidad nacional autónoma de méxico (méxico). coralev@comunidad.unam.mx 2 orcid.org/0000-0001-9364-550x. universidad nacional autónoma de méxico (méxico). glezjuarez@comunidad.unam.mx recibido: 19/04/2018 enviado a pares: 10/05/2018 aceptado por pares: 15/08/2018 aprobado: 29/08/2018 doi: 10.5294/aqui.2018.18.3.8 para citar este artículo / to reference this article / para citar este artigo elías-viramontes ac, gonzález-juárez l. intervención educativa de enfermería para el autocuidado de los pies en personas que viven con diabetes tipo 2. aquichan. 2018; 18(3): 343-354. doi: 10.5294/aqui.2018.18.3.8 resumen objetivo: probar una intervención educativa con fundamento en la teoría de autocuidado, con aplicación pedagógica de la educación dialógica para el autocuidado de los pies. materiales y métodos: estudio cuantitativo de diseño cuasiexperimental de preprueba y posprueba. el grupo experimental estuvo conformado por 40 personas y el grupo de comparación por 32. la variable de autocuidado de los pies se midió a través de dos instrumentos, “autocuidados para prevenir el pie diabético” y “autocuidados del pie diabético”, este último elaborado por investigadores de la universidad de málaga. resultados: en la preprueba, el 35 % de las personas del grupo experimental presentó un nivel bajo de autocuidado, el 28 % medio y el 37 % alto. después de la intervención se observó un incremento estadísticamente significativo (p = 0,000) en el autocuidado; en cambio, el grupo de comparación mantuvo casi los mismos porcentajes, sin encontrarse diferencias significativas. conclusiones: los resultados sugieren que una intervención educativa con fundamento teórico influye en la mejora del autocuidado de los pies de las personas que viven con diabetes, donde la enfermería cumple un papel fundamental para su desarrollo. palabras clave pie diabético; investigaciones educativas de enfermería; enfermería; autocuidado; complicaciones de la diabetes (fuente: decs). año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 343-354 temática: promoción y prevención. aporte a la disciplina: al realizar la búsqueda en la literatura internacional y nacional, se encuentran pocos estudios que evalúen el efecto de una intervención educativa de enfermería en el autocuidado de los pies de personas con diabetes, basada en la educación dialógica; además, dichas investigaciones presentan limitaciones relacionadas con el tipo de estudio, el sustento teórico y la fundamentación bibliográfica científica en las sesiones educativas. http://orcid.org/0000-0001-8356-2153 http://orcid.org/0000-0001-9364-550x 344 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 343-354 nursing educational intervention for foot self-care in persons living with type 2 diabetes abstract objective: the main objective of this study was to test an educational intervention that is founded on the theory of self-care and can be applied for teaching purposes in dialogic learning on foot self-care. materials and methods: this is a quantitative study with a quasiexperimental design featuring a pre-test and post-test. there were 40 people in the experimental group and 32 in the comparison group. the “foot self-care” variable was measured through two instruments: "self-care to prevent a diabetic foot" and "self-care of the diabetic foot". the latter was developed by researchers from the university of málaga. results: in the pretest, 35% of those in the experimental group had a low level of self-care; 28%, a medium level; and 37%, a high level. a statistically significant increase (p = 0.000) in self-care was observed after the intervention. on the other hand, the comparison group maintained almost the same percentages, with no significant differences being found. conclusions: the results suggest an educational intervention with a theoretical basis helps to improve foot self-care among people living with diabetes, and nursing plays a fundamental role in its development. keywords diabetic foot; educational nursing research; nursing; self care; diabetes complications (source: decs). 345 intervención educativa de enfermería para el autocuidado de los pies a personas que viven con diabetes tipo 2 l alma de coral elías-viramontes y otro intervenção educativa de enfermagem para o autocuidado dos pés em pessoas que vivem com diabetes tipo 2 resumo objetivo: testar uma intervenção educativa com fundamentos na teoria de autocuidado, com aplicação pedagógica da educação dialógica para o autocuidado dos pés. materiais e métodos: estudo quantitativo de desenho quase-experimental de pré-teste e pós-teste. o grupo experimental esteve conformado por 40 pessoas e o grupo de comparação por 32. a variável de autocuidado dos pés foi medida por meio de dois instrumentos, “autocuidados para prevenir o pé diabético” e “autocuidados do pé diabético”; este último elaborado por pesquisadores da universidad de málaga. resultados: no pré-teste, 35 % das pessoas do grupo experimental apresentou um nível baixo de autocuidado; 28 %, médio e 37 %, alto. após a intervenção, observou-se um aumento estatisticamente significativo (p = 0,000) no autocuidado; em contrapartida, o grupo de comparação manteve quase as mesmas porcentagens, sem diferenças significativas. conclusões: os resultados sugerem que uma intervenção educativa com fundamento teórico, na qual a enfermagem cumpre um papel fundamental para seu desenvolvimento, influencia na melhora do autocuidado dos pés das pessoas que vivem com diabetes. palavras-chave pé diabético; enfermagem; autocuidado; complicações do diabetes (fonte: decs). año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 343-354 346 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 introducción la prevalencia de diabetes tipo 2 (dt2) ha alcanzado proporciones epidémicas en todo el mundo; de acuerdo con la federación internacional de diabetes (fid), hasta el 2017 existían 425 millones de personas con esta enfermedad, de los cuales el 79 % vivía en países de ingresos bajos y medios (1). se estima que cada 30 segundos alguien pierde en el mundo una extremidad inferior por amputación total o parcial, como consecuencia de la diabetes dt2 (2). a nivel mundial, en promedio el pie diabético se presenta en un 6,4 %, siendo más frecuente en personas con dt2 (2, 3). en méxico, de acuerdo con la encuesta nacional de salud y nutrición de medio camino del 2016, el 9,4 % de los adultos entrevistados mencionaron haber recibido el diagnóstico de diabetes. y dentro de las complicaciones de las diabetes relacionadas con el pie diabético, el 9,1 % reportó presencia de úlceras y el 5,5 % de amputaciones. asimismo, el 41,2 % reportó ardor, dolor o pérdida de la sensibilidad en la planta de los pies (4). además, otro estudio describe que el mayor riesgo de complicaciones vasculares y neuropáticas se presentó en los hombres (p = 0,04), y hubo una mayor presencia de deformidades en las mujeres (p < 0,01). también se observó déficit de conocimientos en más de la mitad de los pacientes, relacionado con la hidratación diaria de los pies (p < 0,01) y el uso de calzado adecuado (p < 0,01) (5). méxico presenta un índice de amputaciones en diabetes muy elevado comparado con países como estados unidos, españa, dinamarca, suecia, entre otros, y para el año 2013, en reportes emitidos por servicios de salud de primer nivel, se menciona un índice mucho mayor que el reportado por la organización para la cooperación y el desarrollo económicos (ocde) en 2009 (6). lo anterior es consistente con los resultados de un estudio realizado en una provincia de méxico donde se detectó neuropatía diabética en 81,1 %, asociada a género masculino, 59,4 %; edad de 51 a 60 años, 39,6 %; nivel de escolaridad bajo, 35,8 %; de 5 a 10 años de evolución de la diabetes, 52,7 %; sobrepeso, 52,8 %; descontrol glucémico, 69,8 %; anormalidad en el aspecto de los pies, 82,1 %, y disminución de sensibilidad, 76,4 % (7). se ha detectado que dichos problemas se incrementan cuando se posterga su detección y diagnóstico, con reportes de amputación de 4,54 % en las personas que tienen más de 12 años de evolución con dt2 (8), por lo que se considera que un mayor número de años de diagnóstico expone a las personas a un mayor riesgo de padecer pie diabético. existen condiciones que aumentan la posibilidad de padecer pie diabético, estas se clasifican como factores de riesgo no modificables y modificables. dentro de los no modificables se encuentran la edad avanzada, la raza o etnia, antecedentes de dt2 en un familiar en primer grado, antecedentes de dm gestacional y el síndrome del ovario poliquístico (9); otros autores incluyen el número de años de diagnóstico (10, 11, 12), ser de género masculino (1, 11, 13), problemas en la visión, y úlceras o heridas previas. los modificables corresponden a obesidad, sobrepeso y obesidad abdominal, sedentarismo, patrones dietéticos, trastornos de regulación de la glucosa, tener poco contacto con pláticas educativas sobre la enfermedad, vivir solo, consumo de alcohol o tabaco, usar calzado inapropiado (1, 9, 10, 14), alteraciones ortopédicas y deformidades (15). las personas que sufren lesiones en los pies o una amputación ven afectada su calidad de vida en diferentes esferas tales como la social, la emocional, la psicológica, entre otras (16). la fid estima que el 85 % de todas las amputaciones podrían ser prevenidas si las personas realizaran evaluaciones completas del riesgo del pie diabético y tuvieran un cuidado de los pies basado en la prevención, la educación y un enfoque que incluya a un equipo multidisciplinar (2, 1), donde se reconozca que la modificación de hábitos y comportamientos tiene una carga cultural que lo hace complejo y requiere de la participación de profesionales de la salud (17), por lo que consideramos que es aquí donde la enfermera cumple una función importante para promover el autocuidado. en la disciplina de enfermería se ha indagado por la noción de autocuidado a partir de la concepción de dorothea e. orem en su teoría de enfermería del déficit de autocuidado y, particularmente, en la teoría de sistemas de enfermería, desde el sistema de apoyo-educación, donde el agente es capaz de realizar y debería aprender a realizar las medidas requeridas de autocuidado terapéutico interna o externamente orientado, (18) a fin de desarrollar su “capacidad de agencia de autocuidado” que le permitirá regular su propio funcionamiento y desarrollo; sin embargo, para hacerlo requiere de ayuda. en este sentido, se considera que para fomentar el autocuidado de los pies como una práctica cotidiana de vida y salud en las personas con dt2, la educación dialógica puede arrojar re347 intervención educativa de enfermería para el autocuidado de los pies a personas que viven con diabetes tipo 2 l alma de coral elías-viramontes y otro sultados positivos ya que este enfoque permite, a través de una representación comunicativa basada en la conjetura, la crítica y la reconstrucción de ideas, donde el promotor de autocuidado funge como facilitador, socio en la investigación, y aprendiz junto al sujeto de cuidado –ya que ambos exploran en conjunto los problemas a través de preguntas y respuestas recíprocas (19)–, contribuir a un mejor entendimiento sobre las limitaciones a fin de desarrollar habilidades para el autocuidado de los pies. es importante señalar que en una revisión integrativa sobre intervenciones de enfermería y autocuidado refieren que en más de la mitad de los estudios no fue considerado el uso de las estrategias cognitivo-comportamentales, así como el uso de una fundamentación teórica para orientar la intervención (20); por tanto, el objetivo central de este estudio fue desarrollar una intervención educativa con fundamento en la teoría de autocuidado y con aplicación pedagógica de la educación dialógica para el autocuidado de los pies. asimismo, esta investigación incluyó como objetivos específicos la identificación de factores de riesgo, signos y síntomas de alarma presentes en la muestra, los cuales fueron determinantes para dirigir el contenido de las sesiones educativas. materiales y métodos estudio de tipo cuantitativo, de diseño cuasiexperimental; para lograr su control y validez interna la investigación se realizó en dos grupos –experimental y de comparación– con características semejantes determinadas a través de los criterios de inclusión, exclusión y eliminación, y sin diferencias estadísticamente significativas. el muestreo fue no probabilístico por conveniencia, ya que se trabajó con grupos intactos, su asignación para grupo experimental o de comparación fue aleatoria simple. esta investigación se realizó de enero del 2015 a diciembre del 2016. los agentes de cuidado que participaron en este estudio reunieron los siguientes criterios de inclusión: personas con dt2 diagnosticada, mayores de 18 años, sin diagnóstico actual de pie diabético, consentimiento informado autorizado y que habían asistido previamente a siete sesiones educativas del programa oficial de diabetimss de una unidad médica familiar de una institución gubernamental, en la ciudad de méxico. lo anterior llevó a un total de 88 personas; sin embargo, solo 72 completaron las etapas del estudio, con 40 personas para el grupo experimental (ge) y 32 para el grupo de comparación (gc) (figura 1). las variables sociodemográficas contempladas fueron: edad, género, estado civil, ocupación y escolaridad; la variable de estudio del autocuidado de los pies se midió a partir de dos escalas: autocuidado de pie diabético, elaborada por la universidad de málaga (apd-uma) (21), y autocuidado para prevenir el pie diabético, las cuales incluyen datos sobre el tiempo de diagnóstico con dt2 e hipertensión, índice de masa corporal (imc), presión arterial, glucemia capilar, hemoglobina glucosilada, triglicéridos, colesterol, medidas de autoexploración y autocuidado, uso de calzado y calcetines, signos y síntomas de alarma, factores de riesgo y nivel de conocimientos. para el análisis inferencial de los datos se tomó como referencia un intervalo de confianza del 95 % y un margen de error de 5 %. instrumentos para la recolección de los datos fue utilizado el instrumento autocuidado de pie diabético elaborado por la universidad de málaga (apd-uma), el cual consta de tres dimensiones: autocuidado personal (5 ítems), autoexploración (5 ítems) y calzado y calcetines (6 ítems); con respuestas de escala de frecuencias de cinco puntos, que van de comportamiento muy deficiente de autocuidado (1 punto) a comportamiento muy adecuado de autocuidado (5 puntos) (21). además, para la recolección de otras variables importantes para el estudio se utilizó el instrumento autocuidado para prevenir el pie diabético de autoría propia –ante la ausencia de instrumentos que incluyeran las variables de interés–, que fue sometido a la opinión de expertos para la validez de contenido y se aplicó en una prueba piloto a 22 sujetos con características semejantes a la muestra. finalmente, quedaron cuatro dimensiones: conocimientos (10 ítems), signos y síntomas de alarma (8 ítems), factores de riesgo (6 ítems) y autocuidado (15 ítems); 22 preguntas con opción de respuesta tipo dicotómica, con una puntuación figura 1. diagrama de flujo de la intervención o: aplicación de instrumento; x: intervención educativa. fuente: elaboración propia. 348 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 de 0 y 1, y 17 preguntas con opción de respuesta de tipo escala de frecuencia que van de nunca, casi nunca, algunas veces, casi siempre y siempre, con una puntación de 1 a 5; el alfa de cronbach fue débil (0,562), por lo que se considera en un futuro profundizar en su estructura para obtener una mejor confiabilidad y validez del mismo. la evaluación del autocuidado fue realizada a través del número de aciertos obtenidos en cada instrumento, los resultados se ponderaron a través de puntos de corte con los percentiles 25, 50 y 75 en niveles bajo, medio y alto de autocuidado, para ambos instrumentos. procedimiento se solicitó la aprobación del comité de ética del programa de maestría en enfermería para llevar a cabo el estudio (oficio: eneo/ci/147/2017). para la realización de la intervención educativa de enfermería se consideraron los factores condicionantes básicos de la muestra para comprender el contexto social de los participantes, a quienes se les dio a conocer el estudio y se les solicitó la firma del consentimiento informado, en atención a lo establecido en los capítulos 13 y 14 acerca de los aspectos éticos de la investigación en seres humanos del reglamento de la ley general de salud en materia de investigación para la salud de méxico (22). posteriormente, se aplicó el pretest en un ambiente privado, respetando la integridad de la persona. los parámetros de hemoglobina glucosilada, triglicéridos y colesterol fueron tomados de los valores más recientes reportados en la historia clínica. para la toma de glucemia capilar pospandrial se consideró la norma oficial mexicana nom-015-ssa2-1994 para la prevención, el tratamiento y el control de la diabetes a través de un glucómetro marca accu-chek; la medición de la presión arterial con base en la norma oficial mexicana nom-030-ssa2-2009, para la prevención, la detección, el diagnóstico, el tratamiento y el control de la hipertensión arterial sistémica con baumanómetro de la marca welch allyn; y se midió el peso y la talla con base en la norma oficial mexicana nom-174-ssa1-1998, para el manejo integral de la obesidad a través de una báscula con estadiómetro. estos instrumentos se utilizaron tanto en el pretest como en el postest. las sesiones educativas se enfocaron principalmente en acciones de autocuidado para prevenir el pie diabético (2, 15, 2325); dicha planeación fue sometida a evaluación de expertos. el tiempo de entrega de la intervención educativa de enfermería fue de seis meses, lo que incluyó pretest, tres sesiones educativas (de dos horas y media cada una) y postest, adicionales a las sesiones oficiales del programa diabetimss. en la estructuración del contenido de dichas sesiones se consideraron los datos obtenidos en el pretest. las temáticas abordadas fueron: ¿qué es el pie diabético?, ¿qué lo causa?, signos y síntomas de alarma y factores de riesgo, y, finalmente, autocuidados para prevenir el pie diabético, este último fue el tema central de la intervención. en el desarrollo de la intervención educativa se utilizó material didáctico (maniquís de pies, lima de uñas, toalla, espejo, calcetines para personas que viven con diabetes) como método de enseñanza. además, se recurrió a una presentación en powerpoint, carteles, folletos y un video que presentaba un lavado quirúrgico del pie diabético, a partir de los cuales se llevó a un diálogo reflexivo profundo y constante. se utilizaron preguntas exploratorias, diálogo de experiencias, discusión de grupo, y se expuso a una situación problema donde participaron todos los miembros del grupo experimental (ge). la información recolectada se procesó con el programa statistical package for the social sciences (spss) versión 21, donde se realizó el análisis descriptivo de los datos a través de porcentajes y frecuencias, mediante su presentación en tablas y gráficas; posteriormente se procedió al análisis inferencial. con apoyo de la prueba de normalidad shapiro-wilk se verificó la distribución de las variables escalares, con lo cual se decidió utilizar la prueba t de student para muestras relacionadas e independientes, u de mann-whitney, kruskal-wallis y chi cuadrado. para la asociación de variables se utilizó la correlación de pearson. consideraciones éticas la investigación fue realizada bajo los preceptos éticos del código de núremberg, principalmente lo relacionado a la importancia del consentimiento voluntario del sujeto (26), así como en atención al título quinto sobre investigación para la salud, capítulo único, artículos 98 y 100 de la ley general de salud en méxico; al capítulo segundo de los aspectos éticos de la investigación en seres humanos; capítulo i, de las disposiciones comunes; artículos 13 y 14 del reglamento de la ley general de salud en méxico, respecto a la clasificación de esta investigación como de riesgo mínimo (22, 27). 349 intervención educativa de enfermería para el autocuidado de los pies a personas que viven con diabetes tipo 2 l alma de coral elías-viramontes y otro resultados caracterización de la muestra el ge estuvo integrado por 40 personas y el gc por 32, que representan el 55 % de un universo de 130 personas del servicio de diabetimss. la tabla 1 muestra los datos sociodemográficos, denominados por orem como factores condicionantes básicos. la edad media del ge fue de 61 ± 11,39 años, con un mínimo de 37 y un máximo de 85 años; en el gc, la media fue de 62 ± 11,09 con un mínimo de 31 y un máximo de 86 años. tabla 1. caracterización de las muestras evaluación del autocuidado de los pies en personas con dm2 cuestionario autocuidados para prevenir el pie diabético. respecto a los años de diagnóstico con dm2 la media del ge fue de 8 ± 8,00 años, con un mínimo de tres meses y un máximo de 40 años; en cambio, en el gc la media fue de 11 ± 8,47 años, con un mínimo de 4 meses y un máximo de 32 años. el 58 % del ge y el 56 % del gc padecen hipertensión arterial. en la tabla 2 se presentan los resultados de la dimensión factores de riesgo para padecer pie diabético, la mayor incidencia se encuentra en los factores modificables; la dimensión signos y síntomas de alarma se presenta en la tabla 3. de acuerdo con los parámetros del estado nutricional propuestos por la organización mundial de la salud (oms), la mayoría de las personas en ambos grupos presentan sobrepeso y obesidad; el porcentaje del estado nutricional normal del ge tuvo un incremento del 6 % después de la ie; sin embargo, no existen diferencias significativas. no se encontraron cambios significativos en los parámetros clínicos. tabla 2. factores de riesgo modificables y no modificables que predisponen al pie diabético variable experimental (40) comparación (32) n % n % género femenino 22 55 19 59 masculino 18 45 13 41 estado civil soltero 19 47 8 25 casado 19 48 19 59 viudo 2 5 5 16 escolaridad no estudió, pero sabe leer y escribir 3 7 2 6 básica 17 43 15 47 media superior 9 22 6 19 licenciatura 10 25 7 22 posgrado 1 3 2 6 ocupación hogar 13 33 11 35 empleado 18 45 13 41 comercio 2 5 2 6 jubilado 5 13 3 9 pensionado 2 5 3 9 fuente: elaboración propia. datos recolectados de la presente investigación. factores de riesgo experimental (40) comparación (32) valor de p* n % n % no modificables problemas en la visión 12 30 9 28 0,862 úlceras o heridas previas 6 15 3 9 0,473 más de 10 años con dm 13 33 16 50 0,132 vejez (> 60 años) 25 63 17 53 0,423 género masculino 18 45 13 41 0,709 modificables callos o durezas 24 60 20 63 0,829 piel reseca o agrietada 21 53 17 53 0,958 consumo de bebidas alcohólicas 18 45 14 43 0,916 consumo de cigarro 7 18 4 13 0,558 control glucémico inadecuado 7 18 6 19 0,891 * prueba chi cuadrado fuente: elaboración propia. datos recolectados de la presente investigación. 350 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 tabla 3. signos y síntomas que predisponen al pie diabético por otro lado, el gc se mantuvo con una media de 62,91 ± 5,76 en la preprueba y 62,34 ± 5,93 en la posprueba, sin diferencias significativas (t = 1.006, gl = 31, p = 0,322). en el ge se encontraron diferencias significativas en la dimensión autocuidado del cuestionario apd-uma, según el grupo de edad (x2 = 3.857, gl = 1, p = 0,049). se observaron mayores prácticas de autocuidado en el adulto maduro a diferencia del adulto mayor. por otro lado, en los resultados de la posprueba del ge en el cuestionario autocuidados para prevenir el pie diabético, el autocuidado difiere respecto al género (t = 2.083, gl = 38, p = 0,044), con una media mayor en el género femenino (68,27) que en el masculino (63,78). además, se presentó una asociación lineal estadísticamente significativa, moderada y directamente proporcional en los resultados de la posprueba entre los instrumentos (r p = 0,589, p = 0,000). signos y síntomas experimental (40) comparación (32) valor de p* n % n % hinchazón en los pies 17 43 12 38 0,667 pies enrojecidos 7 18 6 19 0,891 dolor 20 50 15 47 0,792 pies fríos 17 43 10 31 0,327 adormecimiento, hormigueo o calambres 27 68 21 66 0,867 pérdida de sensibilidad 5 13 5 16 0,703 deformidad en el pie 9 23 5 16 0,464 amputación previa 1 3 0,368 * prueba chi cuadrado fuente: elaboración propia. datos recolectados de la presente investigación. respecto a la dimensión conocimientos necesarios para poder prevenir el pie diabético, el ge presentó una mejora en la media de 3,88 ± 1,11 a 4,23 ± 0,891; sin embargo, solo se encontraron diferencias significativas en el último corte de uñas (p = 0,039). en el gc ningún dato fue significativo. en la dimensión autocuidados para prevenir el pie diabético, el ge presentó un incremento del 30 % en el nivel alto (figura 2), con diferencias significativas específicamente en los ítems: comer cinco veces al día (z = -2.519, p = 0,012), realiza ejercicio físico (z = -2.646, p= 0,008), utiliza un espejo para revisar sus pies (z = -4.284, p = 0,000) y revisa su zapato antes de calzarlo (z = -3.217, p = 0,001). cuestionario “apd-uma”. se presentó un incremento del 50 % en el nivel alto de autocuidado después de la ie, en la puntuación global de este cuestionario, con diferencias estadísticamente significativas (t = 7.243, gl = 39, p = 0,000); es decir, el autocuidado de los pies del grupo que recibió la intervención educativa es mayor al grupo sin intervención. en la dimensión 1, el nivel alto presentó un decremento del 4 % y el nivel medio un incremento del 7 % (t = 2.075, gl = 39, p = 0,045). en cambio, el nivel alto de autocuidado aumentó un 48 % en la dimensión 2 (t = 8.020, gl = 39, p = 0,000), y un 50 % en la dimensión 3 (t = 5.951, gl = 39, p = 0,000). figura 2. puntuación de la dimensión autocuidado* para prevenir el pie diabético de ambos grupos, antes y después de la intervención educativa fuente: elaboración propia. datos recolectados de la presente investigación. 351 intervención educativa de enfermería para el autocuidado de los pies a personas que viven con diabetes tipo 2 l alma de coral elías-viramontes y otro discusión los agentes de autocuidado incluidos en el estudio corresponden, en su mayoría, al género femenino, lo cual concuerda con otros estudios (14, 28-30); este resultado podría estar asociado a que las mujeres acuden con mayor frecuencia a los servicios de salud (31). en particular, en el postest del cuestionario autocuidado para prevenir el pie diabético las mujeres presentaron un mayor autocuidado que los hombres (31, 32). por otro lado, la media de edad de las muestras corresponde a adultos mayores (28, 29) que presentaron más de diez años de evolución con la dt2 (30), estos dos factores de riesgo son no modificables y predisponen al pie diabético; además, los adultos maduros presentaron mejores prácticas de autocuidado que los adultos mayores, lo anterior coincide con lo propuesto por orem, quien menciona que la edad es un factor condicionante básico que influye en las capacidades de autocuidado (18). en los resultados del pretest los participantes presentaron conocimientos sobre el tema, pero sus medidas de autocuidado en la práctica no eran aplicadas, ya que más de una tercera parte calificó con un nivel bajo; lo anterior concuerda con sánchez (33) y muestra la importancia de incidir en el desarrollo de habilidades para el autocuidado. al igual, estos resultados concuerdan con los obtenidos por pérez (34) y por pereira, este último señala que el conocimiento acerca de la enfermedad es la base para el desarrollo de acciones para el autocuidado de la diabetes, aunque no es el elemento único en la modificación del comportamiento (35). al evaluar el postest, se presentó un ligero incremento en la dimensión conocimientos, y un cambio notable y estadísticamente significativo en la dimensión de autocuidado; con lo cual suponemos que contar con los elementos cognitivos no es suficiente para lograr un cambio de conducta, ya que este último involucra otros elementos tales como creencias, motivación y habilidades; tal y como lo señala orem en el apartado demandas comportamentales y de recursos del autocuidado “el autocuidado requiere un conocimiento general […] además de una interiorización de las reflexiones, sensaciones y motivación […] comprendiendo los requerimientos de autocuidado presentes, así como el déficit de autocuidado” (18). en el cuestionario apd-uma se presentó un incremento de la mitad en el nivel alto de autocuidado después de la intervención en la puntuación global de este cuestionario, con diferencias estadísticamente significativas, es decir, el autocuidado de los pies del grupo que recibió la intervención educativa es mayor que el presentado por el gc; asimismo, se encontraron diferencias significativas en la dimensión de autocuidado según el grupo de edad, con mayores prácticas de autocuidado en el adulto maduro a diferencia del adulto mayor. de acuerdo con orem, el autocuidado comprende fases de acción intencionadas y se moldea por ellas, consideramos que el hecho de acudir al servicio de salud, al grupo de apoyo y la intervención misma formaron parte de estas acciones, lo que sumado a la reflexión dialógica facilitó la toma de decisiones para ejercer el autocuidado de los pies; sin embargo, observamos que es necesario reforzar la adquisición de la habilidad. lo anterior resalta la importancia de implementar intervenciones educativas de manera permanente y continua hacia la atención de personas con dt2 que consideren el sistema de apoyo-educación como una herramienta de soporte permanente en el desarrollo de las capacidades de autocuidado, donde se tengan en cuenta elementos cognitivos, motivacionales y de desarrollo de habilidades. además, considerar una determinada estrategia educativa grupal con base en las necesidades de los participantes, que posibilite atender el problema o desarrollar una habilidad, estimula la participación del individuo en el control de su enfermedad y en la prevención de sus complicaciones (36). es importante señalar que los resultados obtenidos en el presente estudio indican que la educación grupal –centrada en la educación dialógica– fue de gran impacto para la mejora de la práctica de autocuidado de los pies (36, 37); en particular, imazu supone que este hecho se debe a la posibilidad del diálogo, la reflexión, el intercambio de conocimientos y experiencias, que favorecen la adhesión a las prácticas de autocuidado (37). conclusiones los resultados sugieren que una intervención educativa con fundamento teórico y estrategias dinámicas, participativas e interactivas del agente es determinante para comprender la importancia de las prácticas de autocuidado e influye significativamente en la mejora del autocuidado de los pies en personas con dt2, donde la participación del profesional de enfermería en actividades de prevención secundaria juega un papel central. 352 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 los participantes de este estudio presentaron dolor y adormecimiento, hormigueo o calambres en ambos grupos. comúnmente, se cree que las personas con mayor nivel académico deben presentar un mayor nivel de aprendizaje en intervenciones de salud como esta; sin embargo, en este estudio el nivel educativo de las personas no influyó en las prácticas de autocuidado, se encontró solo una ligera mejora en la media general, y diferencias significativas en el ítem corte de uñas. tanto en el ge como en el gc se destacó una mayor incidencia de los factores modificables que representan una mayor oportunidad de prevención del pie diabético, principalmente se destacan la presencia de callos y durezas, piel seca o agrietada y, en menor proporción, el consumo de bebidas alcohólicas en ambos grupos, situación de oportunidad para que el personal de enfermería refuerce el autocuidado de estas personas a través de acciones educativas, motivacionales y de desarrollo de habilidades. un elemento importante de destacar fue que el ge mostró un incremento en el nivel de estado nutricional normal después de la intervención; no obstante, no se presentaron diferencias significativas, por lo cual consideramos que el estado nutricional está relacionado estrechamente con la cultura y las dinámicas situacionales de la vida diaria, donde la educación dialógica no fue suficiente para lograr un cambio. finalmente, la dimensión de autocuidado presentó un incremento en el nivel alto, con diferencias significativas para los ítems de comer cinco veces al día, realiza ejercicio físico, utiliza un espejo para revisar sus pies y revisa su zapato antes de calzarlo. asimismo, es importante observar que la dimensión de autocuidado difiere respecto al sexo, con una media mayor en las mujeres que en los hombres. la educación dialógica desarrollada en la educación grupal de la intervención mejoró la práctica de autocuidado de los pies, ya que facilitó el intercambio de ideas, la expresión de dudas y el compartir las dificultades y los beneficios del autocuidado para la prevención del pie diabético; sin embargo, para futuras intervenciones sugerimos incluir sesiones individuales. consideramos que para futuras investigaciones es importante continuar aplicando los modelos teóricos y, en el caso particular de la entrega de la intervención, ampliar el número de sesiones educativas y el seguimiento del agente a mediano y largo plazo para promover las prácticas de autocuidado en el diario vivir, y fomentar el empoderamiento en el paciente. otra recomendación es continuar ajustando el cuestionario apd-uma. conflicto de intereses: ninguno declarado. referencias 1. hernández am, pablo gj, reynoso nn. diabetes mellitus en méxico. el estado de la epidemia. salud pública. 2013 [visitado 2015 abr];55(2). disponible en: http://www.scielo.org.mx/scielo.php?script=sci_arttext&pid =s0036-36342013000800009 2. international diabetes federation. idf diabetes atlas. 8 ed. 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malaga, spain (dfsq-uma). j tissue viability. 2015;24:24-34. doi: 10.1016/j.jtv.2014.11.001 22. secretaría de salud méxico. reglamento de la ley general de salud en materia de investigación para la salud [monografía en internet]. secretaría de salud. 2017 [visitado 2018 ago]:768-76. http://www.salud.gob.mx/unidades/cdi/nom/ compi/rlgsmis.html 23. instituto carlos slim de la salud. manual para profesionales de la salud. diabetes mellitus tipo 2 [monografía en internet]. 2011 [visitado 2015 oct]:185-92. disponible en: http://www.salud.carlosslim.org/manuales_cliki/profesionales/ cliki_prof_diabetesmellitus.pdf http://www.medigraphic.com/pdfs/atefam/af-2018/af181c.pdf http://www.alad-americalatina.org/wp-content/uploads/2016/11/consenso-pie-diabetico-alad-2010.pdf http://www.alad-americalatina.org/wp-content/uploads/2016/11/consenso-pie-diabetico-alad-2010.pdf http://www.msal.gob.ar/images/stories/bes/graficos/0000001037cnt-prevencion-cuidados-pie-diabetes.pdf http://www.msal.gob.ar/images/stories/bes/graficos/0000001037cnt-prevencion-cuidados-pie-diabetes.pdf 354 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 24. rodríguez rp, estany ga, moreno pm, blázquez dm, rodríguez mf. autocuidados diarios en la prevención del pie diabético. póster. gerokomos. 2014 [visitado 2016 ene];25:1. http://scielo.isciii.es/pdf/geroko/v25n1/helcos5.pdf 25. world health organization-region office for europe. therapeutic patient programmers for healthcare providers in the field of prevention of chronic diseases. report of a who working group [monografía en internet]. 1998 [visitado 2016 jun]:5. disponible en: http://apps.who.int/iris/bitstream/10665/108151/1/e63674.pdf 26. código de núremberg. tribunal internacional de núremberg. experimentos médicos permitidos. de mainetti ja (trad.). ética médica. la plata; 1989. 27. secretaría de salud méxico. ley general de salud [monografía en internet]. secretaría de salud. 1984 [visitado 2018 ago]:1-135 disponible en: http://www.salud.gob.mx/cnts/pdfs/ley_general_de_salud.pdf 28. bustos-saldaña r, pérez-macedo i, pérez-quispe p, alfaro-ramírez j, garcía-villalobos e. autocuidados de los pies de diabéticos tipo 2 con régimen de seguridad social de méxico y bolivia. mpa e-j med fam at prim int. 2008 [visitado 2016 nov];2(2):77-84. disponible en: http://www.idefiperu.org/mpanro2/2_p77-84%20orig1bustos.pdf 29. trilla sm, espluga ca, mengual mn, bundó vm, juanola cj, aubá lj, et al. autocuidados y factores de riesgo de pie diabético en pacientes con dm2. atención primaria. 1997 [visitado 2016 nov];20:186-90. disponible en: http://www. elsevier.es/es-revista-atencion-primaria-27-articulo-autocuidado-factores-riesgo-pie-diabetico-14614 30. rodrígues hf, dias fa, zuffi fb, borges mf, lara bh, ferreira la. cuidado de los pies: conocimiento de los individuos con diabetes mellitus. enferm glob. 2014 [visitado 2016 nov];35:41-51. disponible en: http://scielo.isciii.es/pdf/eg/ v13n35/clinica3.pdf 31. rossaneis ma, haddad mcfl, mathias taf, marcon ss. differences in foot self-care and lifestyle between men and women with diabetes mellitus. rev latino-am enfermagem. 2016 [visitado 2017 sep];24:e2761. doi: 10.1590/15188345.1203.2761. 32. laclé a, valero-juan lf. diabetes-related lower-extremity amputation incidence and risk factors: a prospective seven-year study in costa rica. rev panam salud pública. 2012;32:192-8. disponible en: https://www.scielosp.org/pdf/ rpsp/2012.v32n3/192-198 33. sánchez uj. nivel de conocimientos sobre autocuidado de los pies y aplicación de medidas de autocuidado en pacientes adultos con diabetes. hospital albrecht, trujillo. cientifi-k. 2014 [visitado 2016 nov];2:36-43. disponible en: http://revistas.ucv.edu.pe/index.php/cientifi-k/article/view/287 34. pérez-rodríguez mc, cruz-ortíz m, reyes-laris p, mendoza-zapata jg, hernández-ibarra le. conocimientos y hábitos de cuidado: efecto de una intervención educativa para disminuir el riesgo de pie diabético. ciencia y enfermería. 2015;21(3):23-36. doi: 10.4067/s0717-95532015000300003. 35. pereira da, costa nmsc, sousa all, jardim pcbv, zanini cro. efecto de intervención educativa sobre el conocimiento de la enfermedad en pacientes con diabetes mellitus. rev latino-am enfermagem. 2012;20(3). disponible en: http:// www.scielo.br/pdf/rlae/v20n3/es_a08v20n3.pdf 36. ramón-cabot j, fernández-trujillo m, forcada-vega c, pera-blanco g. efectividad a medio plazo de una intervención educativa grupal dirigida al cuidado de los pies en pacientes con diabetes tipo 2. enferm clin. 2008 [visitado 2015 sep];18(6): 302-8. doi: 10.1016/s1130-8621(08)75852-2 37. imazu mfm, faria bn, arruda go, sales ca, marcon ss. efectividad de las intervenciones individuales y en grupo en personas con diabetes tipo 2. rev latino-am enfermagem. 2015;23(2):200-7. doi: 10.1590/0104-1169.0247.2543 437 447 percepcion de la autoridad parental.indd 437 emilce salamanca-ramos1 patricia chávez-ávila2 jaime alberto carmona-parra3 percepción de la autoridad parental en adolescentes escolarizados víctimas de desplazamiento 1 orcid.org/0000-0002-3549-7067. universidad de los llanos, colombia. esalamanca@unillanos.edu.co 2 orcid.org/0000-0003-0393-8849. universidad de los llanos, colombia. pchavez@unillanos.edu.co 3 orcid.org/0000-0001-5263-2374. universidad de manizales, colombia. jcarmona@umanizales.edu.co recibido: 15 de julio de 2016 enviado a pares: 23 de agosto 2016 aceptado por pares: 29 de enero de 2017 aprobado: 01 de marzo de 2017 doi: 10.5294/aqui.2017.17.4.7 para citar este artículo / to reference this article / para citar este artigo salamanca-ramos e, chávez-ávila p, carmona-parra ja. percepción de la autoridad parental en adolescentes escolarizados víctimas de desplazamiento. aquichan. 2017; 17(4): 437-447. doi: 10.5294/aqui.2017.17.4.7 resumen objetivo: identificar los estilos de socialización parental percibidos por adolescentes escolarizados en un sector vulnerable de población, de villavicencio, colombia, víctima de desplazamiento por conflicto armado. materiales y métodos: estudio cuantitativo descriptivo. se tomó como muestra el total de la población de adolescentes escolarizados del sector (n = 184) entre los 12 y 19 años de edad. se aplicó la escala de socialización parental en la adolescencia (espa 29) en el año 2015, donde el adolescente valora la reacción de cada progenitor frente a 29 situaciones cotidianas. resultados: se clasificó a cada padre de familia en un estilo de socialización o crianza entre cuatro posibles opciones: los adolescentes de sexo masculino en general percibieron estilos más indulgentes en sus padres y más autoritativos en sus madres; las adolescentes percibieron estilos más autoritativos en sus madres y menos autoritarios o negligentes en sus padres. la población en general percibe a sus progenitores más asociados al diálogo y al afecto, con un patrón de socialización más cercano a la aceptación-implicación. conclusiones: los adolescentes de ambos sexos perciben en sus padres un estilo de crianza más autoritativo e indulgente que autoritario o negligente. distinguen una socialización familiar más basada en el diálogo y el afecto que en la displicencia y la indiferencia, lo que constituye un factor protector para esta población. palabras clave familia; relaciones familiares; socialización; responsabilidad parental; adolescencia (fuente: decs, bireme). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 437-447 438 aquichan issn 1657-5997 eissn 2027-5374 año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 437-447 perception of parental authority among adolescent school children who are victims of displacement abstract objective: identify the styles of parental socialization perceived by adolescent school children in a vulnerable sector of the population in villavicencio (colombia) that is a victim of displacement due to armed conflict. materials and methods: this is a descriptive quantitative study. the total population of adolescents between 12 and 19 years of age who were enrolled in the sector (n = 184) was taken as a sample. the parental socialization scale in adolescence (espa 29) was applied during 2015. in this case, the adolescent values the reaction of each parent in response to 29 everyday situations. results: each parent was classified according to a particular socialization or parenting style. there were four possible options: male adolescents in general perceived more lenient styles in their parents and more authoritative styles in their mothers; adolescents perceived more authoritative styles in their mothers and more authoritarian or negligent styles in their parents. the population, in general, perceives parents as being associated more with dialogue and affection, with a socialization pattern closer to acceptance-involvement. conclusions: adolescents of both sexes perceive a parenting style that is more authoritative and indulgent than authoritative or negligent. they perceive family socialization based more on dialogue and affection than on lack of concern and indifference, which is a protective factor for this population. key words family; family relationships; socialization; parental responsibility; adolescence (fuente: decs, bireme). 439 percepción de la autoridad parental en adolescentes escolarizados víctimas de desplazamiento l emilce salamanca-ramos y otros percepção da autoridade parental em adolescentes escolarizados vítimas de deslocamento resumo objetivo: identificar os estilos de socialização parental percebidos por adolescentes escolarizados num setor vulnerável de população de villavicencio (colômbia), vítima de deslocamento por conflito armado. materiais e métodos: estudo quantitativo descritivo. tomou-se como amostra o total da população de adolescentes escolarizados do setor (n = 184) entre 12 e 19 anos de idade. aplicou-se a escala de socialização parental na adolescência (espa 29) no ano 2015, pela qual o adolescente avalia a relação de cada progenitor diante de 29 situações cotidianas. resultados: classificou-se a cada pai de família num estilo de socialização ou criação entre quatro possíveis opções: os adolescentes de sexo masculino em geral perceberam estilos mais indulgentes em seus pais e mais autoritários em suas mães; as adolescentes perceberam estilos mais autoritários em suas mães e menos autoritários ou negligentes em seus pais. a população em geral percebe seus progenitores mais associados ao diálogo e ao afeto, com um padrão de socialização próximo à aceitação-implicação. conclusões: os adolescentes de ambos os sexos percebem em seus pais um estilo de criação mais autoritário e indulgente que autoritário ou negligente. diferenciam uma socialização familiar mais baseada no diálogo e no afeto do que na displicência e na indiferença, o que constitui um fator protetor para essa população. palavras-chave adolescência; família; relações familiares; responsabilidade parental; socialização (fonte: decs, bireme). año 17 vol. 17 nº 4 chía, colombia diciembre 2017 l 437-447 440 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 introducción la socialización es el proceso mediante el cual se transmite la cultura de una generación a la siguiente, es un proceso de aprendizaje no formalizado, y en gran parte no consciente, a través de un entramado complejo de transformaciones e interacciones (1). para berguer y luckman, la socialización se basa en la interiorización de la realidad externa como propia y significativa, y en el reconocimiento de los otros y de uno mismo (2); para durkheim, como la adaptación social (3); por su parte, mead la concibe como un sujeto activo inmerso en interacciones sociales (4). en este sentido, la socialización da cuenta de la identidad social y se adquiere a través de la interiorización de interrelaciones que se dan dentro y fuera de la familia, como son los escenarios escolares, entre otros, donde los sujetos están en permanente adaptación. para musitu y garcía la socialización es el proceso mediante el cual las personas interiorizan los valores, las creencias, normas y formas de conducta apropiadas en la sociedad a la que pertenecen (5), además consideran los periodos de la infancia, la niñez y la adolescencia fundamentales en este proceso y, en consecuencia, la familia se ha considerado un lugar especialmente privilegiado para la transmisión de valores en sus integrantes. la socialización familiar se considera un importante correlato del bienestar psicosocial de los hijos e hijas (5), y la dinámica intrafamiliar ofrece un abanico de experiencias vitales al adolescente que siguen participando activamente en la construcción de su identidad individual y social (6); sin embargo, muchos adolescentes y sus familias se ven aquejados por las problemáticas sociales y condiciones de riesgo que afectan su entorno y su sano desarrollo. colombia tiene más de 47 millones de habitantes, 32 % de ellos son niños, niñas y adolescentes (7); según unicef, este es uno de los grupos en situación de riesgo; a pesar de los esfuerzos significativos realizados, colombia sigue siendo un país desigual y la movilidad social se ve afectada por el género, la ubicación geográfica, la etnia, la edad y los factores relacionados con el conflicto armado; todo ello repercute en la socialización del adolescente. la comunidad del barrio trece de mayo, sector donde se realizó el estudio, hace parte de la comuna 4 de la ciudad de villavicencio y se originó en el año 2008 cuando aproximadamente un grupo de 900 familias desplazadas de diferentes zonas del departamento del meta y de otras partes del país decidieron invadir este sector, propiedad de la alcaldía municipal. la habitan aproximadamente 3.352 personas, de las cuales 1.630 (48,6 %) son menores de edad y el 52 % se identifican como víctimas del desplazamiento forzado. es una población que no cuenta con los servicios básicos necesarios, y las condiciones de vivienda reflejan el grado de pobreza y desigualdad que se vive en este sector. sus condiciones sociales están caracterizadas por factores de riesgo asociados a la baja escolaridad, riesgo de reclutamiento forzado, además de altos índices de criminalidad, microtráfico, drogadicción (8) y embarazos a temprana edad (9), comparados con otros estudios de orden nacional donde se reportan factores similares (10-13). otro estudio de caracterización sociodemográfica en el sector reporta que el 15 % de la población entre 14 y 26 años se identifica como jefes cabeza de hogar, a cargo de la toma de decisiones en su grupo familiar. en el aspecto educativo, a partir del año 2010 cuenta con una institución educativa con capacidad aproximada para 1.500 alumnos, que ofrece a niños, niñas, adolescentes y jóvenes servicios en los niveles de preescolar, básica y media (14). esta población es víctima del desplazamiento forzado por el conflicto armado de la región, con necesidades básicas insatisfechas y otros factores de riesgo, que hacen necesaria una aproximación teórica y práctica a la realidad de los adolescentes en su entorno familiar para entender y favorecer unas relaciones familiares que contribuyan con el bienestar de todos sus miembros. el interés de la investigación fue identificar los estilos de socialización parental a partir de las percepciones de los adolescentes escolarizados del sector, con el fin de acercarse al contexto familiar para generar propuestas de intervención interdisciplinarias e intersectoriales desde la familia para contrarrestar los riesgos y problemas expuestos. materiales y métodos diseño de tipo descriptivo, de corte transversal y de abordaje cuantitativo. la muestra comprendió 184 estudiantes, por medio de un muestreo no probabilístico de sujetos voluntarios. criterios de inclusión: consentimiento informado expresado mediante la firma tanto del joven como de su tutor legal (padre, madre o cuidador), en cumplimiento de los parámetros éticos que rigen a las profesiones involucradas en el trabajo con personas (15); estar entre los 12 a 19 años, y ser estudiantes de los grados noveno, décimo y once de un colegio de la comunidad seleccionada. se utilizó como instrumento la escala de socialización parental en la adolescencia (espa29) (1), en la que el adolescente debe valorar la actuación de cada progenitor en 29 situaciones de la vida diaria en distintos escenarios representativos de la cultura occidental. estas valoraciones permiten obtener medidas globales 441 percepción de la autoridad parental en adolescentes escolarizados víctimas de desplazamiento l emilce salamanca-ramos y otros para cada padre en las dimensiones de aceptación/implicación y coerción/imposición y, a partir de las dos dimensiones, se tipifica el estilo de socialización de cada padre como autorizativo, indulgente, autoritario o negligente. las dos dimensiones globales contienen subescalas más específicas encargadas de detallar los estilos de socialización de cada padre, como el afecto, la indiferencia, el diálogo, la displicencia, la privación, la coerción verbal y la coerción física. para la identificación de los estilos de socialización se parte de los baremos disponibles en el manual del espa29 y el análisis descriptivo con los estilos consolidados de socialización (autoritario, autorizativo, negligente e indulgente), los cuales se definen por la posición relativa de las puntuaciones en las dos grandes dimensiones —coerción–imposición y aceptación–implicación—. de esta forma, la combinación particular de los niveles en estas dos grandes dimensiones se asocia a uno de los cuatro grandes estilos de socialización. por ejemplo, altos niveles de coerciónimposición y bajos niveles de aceptación-implicación se asocian a un estilo más autoritario. el procedimiento se realizó mediante el diligenciamiento del protocolo de la escala, en la cual cada adolescente valoró las actuaciones de sus padres. de las 29 situaciones planteadas, 16 son positivas y 13 son negativas. en las positivas el adolescente evalúa 32 posibles respuestas de cada padre y en las negativas 80, en una escala de 4 puntos (1, nunca; 2, algunas veces; 3, muchas veces; 4, siempre) que estima la frecuencia en términos cualitativos de cada actuación parental. el procesamiento y análisis de datos se apoyó en la estadística descriptiva con el análisis de frecuencias, medidas de tendencia central e indicadores de dispersión; y para el análisis de las dimensiones evaluadas, en algunos casos se tuvieron en cuenta las puntuaciones directas, en escala de 1 a 4, y en otros casos las puntuaciones percentilares en un rango de 1 a 99. la estructura factorial del espa29 se ha confirmado en varios estudios en diferentes muestras de españa y brasil (1, 16, 17); en argentina, perú (18, 19) y colombia (20). la consistencia interna del conjunto global de la escala es de 0,968 según alfa de cronbach; la consistencia interna de aceptación/implicación para la madre fue de 0,951 y para el padre de 0,945; mientras que en coerción/imposición en la madre fue de 0,929 y en el padre de 0,927 (21). para cada dimensión global: la aceptación/implicación, α = 0,97 y el coerción/imposición, α = 0,96; y para cada subescala: afecto, α = 0,96; indiferencia, α = 0,95; el diálogo, α = 0,95; desprendimiento, α = 0,90; reprimenda verbal, α = 0,94; castigo físico, α = 0,93; revocar privilegios, α = 0,96 (22). en las siete subescalas: afecto, 0,950; indiferencia, 0,936; diálogo, 0,950; displicencia, 0,900; coerción verbal, 0,937; coerción física, 0,927; privación, 0,941 (23). para las prácticas individuales de las madres y padres se reporta: afecto, 0,943 y 0,940; indiferencia, 0,918 y 0,922; diálogo, 0,930 y 0,931; displicencia, 0,840 y 0,820; coerción verbal, 0,897 y 0,901; coerción física, 0,901 y 0,907; privación, 0,913 y 0,916, respectivamente (24). para conocer alguna variables sociodemográficas se utilizó un cuestionario realizado por las autoras del proyecto. el instrumento presentado contó con los permisos respectivos. la investigación cumplió con los parámetros éticos estipulados en la resolución 008430 de 1993 del ministerio de salud de colombia, la ley 1090 de 2006 y el código de ética de enfermería, ley 911 de 2004, y aplicó los principios de confidencialidad, veracidad, beneficencia y no maleficencia; además, contó con la aprobación y autorización del instituto de investigaciones de la orinoquia – universidad de los llanos. resultados dentro de las características sociodemográficas, de los 197 estudiantes que conformaron el universo de investigación se evaluó una muestra de 184 estudiantes (93,4 % de la población), 89 del género femenino (48,4 %) y 95 del género masculino (51,6 %), con edades comprendidas entre los 13 y los 19 años (x = 15,5; de = 1,2). en cuanto a su distribución por grado y sexo, se encontró que al aumentar de grado escolar el número total de adolescentes disminuyó, así: del grado 9° hubo un total de 80 estudiantes (43,5 %) entre 13 y 17 años (x = 14,88; de = 1,05), 41 de género masculino (51,25 %) y 39 de género femenino (48,75 %); del grado 10° se sumó un total de 63 estudiantes (34,2 %) entre 14 y 18 años (x = 14,44; de = 0,88), 22 de género masculino (34,92 %) y 41 de género femenino (65,08 %); finalmente del grado 11° un total de 41 estudiantes (22,3 %) entre 14 y 19 años (x = 16,59; de = 0,92), 26 de género masculino (63,41 %) y 15 de género femenino (36,59 %). respecto de la clasificación socioeconómica de los participantes, y según la agrupación por estratos que establece el departamento administrativo nacional de estadística (dane) (25), se encontró predominancia del estrato uno (80,98 %) y el 59,2 % pertenecen al régimen subsidiado en salud. 442 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 estilos identificados de socialización parental. en las figuras 1 y 2 se presentan los estilos de socialización identificados en diagramas de dispersión, uno para cada género (masculino y femenino); en cada diagrama, el eje vertical corresponde a la dimensión de coerción-imposición, y el eje horizontal a la dimensión de aceptación-implicación, en una escala de 1 a 99 puntos percentiles. de esta forma, en el diagrama se ubica la posición de los puntajes baremados para cada género, de acuerdo con los distintos rangos de edad, por convenciones, en donde los círculos representan la percepción de los adolescentes con respecto a sus padres y los cuadrados la percepción de los adolescentes con respecto a sus madres; estas convenciones están, además, diferenciadas según el rango de edad establecido. así, por ejemplo, en la figura 1 los jóvenes del sexo masculino en general perciben estilos más indulgentes en sus padres y más autorizativos en sus madres (excepto en los niños de 12-13 años cuyas madres son percibidas como más indulgentes). figura 1. estilos de socialización identificados por adolescentes de sexo masculino según rango de edad fuente: elaboración propia a partir de bases de datos de la investigación. adicionalmente, en la figura 3 se representó gráficamente la identificación detallada de las dimensiones específicas que caracterizan los estilos de socialización de cada padre: diálogo, afecto, indiferencia y displicencia, correspondientes a la dimensión global aceptación/implicación; y las dimensiones específicas: privación, coerción verbal y coerción física de la dimensión global coerción/ imposición, a partir de los promedios de puntuación obtenidos y discriminados según el progenitor (padre/madre), sin discriminar por rangos de edad ni por género de los adolescentes. la interpretación de estos datos se basó en la escala de calificaciones de cada una de las dimensiones específicas que se encuentra en figura 2. estilos de socialización identificados por adolescentes de sexo femenino según rango de edad fuente: elaboración propia a partir de bases de datos de la investigación. figura 3. dimensiones específicas de estilos de socialización por adolescentes de ambos sexos (n = 184) fuente: elaboración propia a partir de bases de datos de la investigación. el rango de 1 a 4 puntos, por lo cual entre más se acerque a cuatro puntos el promedio indica una mayor predominancia de la percepción de un estilo de socialización determinado. de esta manera, en la figura 3 se puede observar que los adolescentes (género masculino y femenino) perciben estilos más asociados al diálogo y al afecto (un patrón de socialización más cercano a la aceptación-implicación), tanto en sus padres como en sus madres que obtienen valoraciones muy similares. 443 percepción de la autoridad parental en adolescentes escolarizados víctimas de desplazamiento l emilce salamanca-ramos y otros discusión en relación con algunas características sociales y demográficas, dentro del estudio la x = 15,5 años; esta etapa de la vida del ser humano conlleva grandes y profundos cambios biológicos, psicosociales que son fundamentales y pueden trascender en la vida adulta. para la organización mundial de la salud (oms), la etapa de adolescencia es considerada como el periodo en el que el individuo adquiere la capacidad de reproducirse, transita desde los patrones psicológicos de la niñez a los de la vida adulta y consolida su independencia económica. lo define como el periodo que transcurre entre los 10 y 19 años, que comprende la adolescencia inicial o preadolescencia, entre los 10 y 14 años, y la adolescencia final o adolescentes jóvenes entre los 15 y 19 años (26). se observa que en cada grado la concentración de los estudiantes es muy similar por género, sin embargo, en cuanto a su distribución por grado y sexo se reporta un significativo descenso de adolescentes a medida que se incrementa el grado de escolaridad, lo que indica un nivel alto de deserción escolar según informe de la misma institución. la tasa nacional actual de deserción escolar está en 3,1 %, según datos del ministerio de educación nacional de colombia, 2015; está asociada a las condiciones socioeconómicas, a la movilidad social y la desigualdad de capacidades y, por tanto, afecta la socialización de los niño, las niñas y los adolescentes. el 80,98 % de la población corresponde al estrato socioeconómico de nivel uno y el 59,2 % pertenecen al régimen subsidiado en salud, que identifica las condiciones de la población más pobre, es decir, aquella que se considera débil en su capacidad para dotarse de las condiciones de atender sus necesidades básicas. en colombia, en 2011, uno de cada tres niños vivía en la pobreza (27), dato que se refleja en la población estudiada e indica un factor de riesgo donde las necesidades básicas insatisfechas exponen a los adolescentes a situaciones de abandono escolar, o condiciones de vulnerabilidad que entorpecen el buen desarrollo de esta población. por otro lado, las condiciones de vulnerabilidad de muchas familias expuestas a fenómenos de desplazamiento en la región afecta de manera importante las condiciones ideales en las que se debieran desarrollar sus miembros, muchos de ellos adolescentes. estas condiciones se confirman en la población de adolescentes participantes quienes pertenecen a las familias del sector reconocidas como víctimas del desplazamiento forzado, y familias de reinsertados con nivel socioeconómico uno, pertenecientes al régimen subsidiado, cuyos padres no cuentan con una fuente de trabajo estable. en relación con los estilos de socialización parental, el primer hallazgo señala que los adolescentes de género masculino, independiente del rango de edad, por un lado, percibieron a sus padres como más indulgentes, donde se caracterizan por un alto uso de prácticas de responsabilidad y bajo uso de prácticas de exigencia, es decir que consideran que sus padres buscan una comunicación adecuada con ellos, prefieren actuar de manera afectiva y tienden a tolerar sus impulsos, deseos y acciones. según musitu y garcía, el estilo de socialización indulgente demuestra que la norma no se identifica como un tema esencial, sino que se hace prevalecer sobre cualquier método la comunicación horizontal y directa con los hijos, y se utiliza la coerción a través del razonamiento y la reflexión (1). con respecto a las madres, los adolescentes las identificaron como más autorizativas, en tanto perciben que se esfuerzan por dirigir sus actividades pero de una forma racional, orientada al proceso formativo; asimismo, estimulan el diálogo verbal y comparten con ellos el razonamiento que sustenta sus principios. si bien tanto el estilo indulgente del padre como el estilo autorizativo de la madre se centran en buscar una buena comunicación con sus hijos, en usar la razón más que otros medios para disciplinar y en fomentar la búsqueda de acuerdos, presentan una valoración diferente en cuanto a las medidas globales de la socialización en tanto que, en el estilo indulgente del padre se presenta una alta aceptación/implicación con baja coerción/imposición, y en el estilo autorizativo de la madre ocurre una alta aceptación/implicación, pero, esta vez con más alta coerción/ imposición (1), es decir que, cuando el hijo se comporta de manera incorrecta, junto con el diálogo también se utilizan la coerción física, verbal y las privaciones. estudios demuestran que los estilos de socialización indulgente y autorizativo son factores protectores para evitar el consumo de sustancias psicoactivas (spa) (20, 28) y el alcoholismo (20), y fomentan el desarrollo sano y adecuado en medio de situaciones y sectores de riesgo psicosocial, que los lleva a presentar menores problemas de conducta de riesgo (20, 23, 29); asimismo, son facilitadores para la adherencia de los adolescentes a programas artísticos, culturales y familiares que la institución educativa desarrolla como parte de su proyecto pedagógico (28). 444 año 17 vol. 17 nº 1 chía, colombia marzo 2017 aquichan issn 1657-5997 eissn 2027-5374 en cuanto a la percepción de las adolescentes de sexo femenino, se encontró que tienden a ver a las madres como autorizativas, al igual que en el caso de los jóvenes; pero a diferencia de ellos, las jóvenes adolescentes ven a sus padres como autoritarios o negligentes. bajo el estilo autoritario, la hija percibe al padre como altamente demandante pero a la vez, poco atento y sensible a sus necesidades y deseos, el cual ejerce un mensaje verbal unilateral y más de carácter reprobatorio, que tiende a no ofrecer razones cuando emite órdenes, y estimula poco la respuesta verbal y el diálogo ante las transgresiones. a este se suma el estilo negligente que es bajo en afecto, en coerción y, en consecuencia, en límites, es decir que se añaden la indiferencia, falta de supervisión, control y cuidado. los estilos autoritario y negligente aparecen como factores de riesgo para el consumo de spa (20, 21), el riesgo de generar mayor resentimiento hacia el padre, el no adquirir la internalización de las normas familiares y los comportamientos sociales, puesto que la obediencia se basa en la inseguridad y el miedo (30), y al menor autoconcepto familiar; a estas adolescentes también se les puede dificultar adquirir la suficiente responsabilidad, lo que repercute en su rendimiento académico y las expone a factores de riesgo (31, 32). finalmente, es importante señalar que de la forma como los adolescentes (hombres y mujeres) calificaron los estilos de socialización de la familia, en especial sus figuras paterna y materna, al hacer el análisis detallado de las subcategorías o las dimensiones específicas de socialización (figura 3) se encontró que los adolescentes en general conceden una valoración más alta al diálogo y al afecto, así como una valoración más baja a la displicencia e indiferencia; esta tendencia resume que los adolescentes perciben tanto de su padre como de su madre “relaciones filiales basadas en una mayor aceptación-implicación y una menor coerción-imposición” (1). lo anterior significa que las relaciones parentales se expresan por medio de la aprobación y el afecto cuando los/las adolescentes se comportan de acuerdo con las normas familiares, cuando el desarrollo de su autonomía se incluye en el proceso de socialización en la medida en que participa y se involucra, y genera bienestar, reconocimiento, afecto y satisfacción para los miembros que participan de los procesos (1, 33-35), lo que permite una mayor cohesión en el funcionamiento familiar, una responsabilidad familiar y escolar, y una mayor capacidad de adaptación social en el adolescente (20, 30, 36). la familia se convierte en un espacio de socialización en los adolescentes, en sí misma es la principal proveedora de cuidado para sus miembros, por lo cual adquiere un papel fundamental en la promoción de la salud, el autocuidado (37, 38) y la prevención de enfermedades (39-41) o riesgos que pueden afectar la integridad de los adolescentes y demás integrantes del núcleo familiar. conclusión se resaltan aspectos sociales y demográficos de la población adolescente escolarizadas: el promedio de edad está en 15,5 años, 85,9 % viven con sus padres, lo que constituye un factor protector para el desarrollo de esta población. el 80,98 % pertenece al nivel socioeconómico uno, coherente con las condiciones de hábitat que indican la fragilidad para atender sus necesidades básicas, y lleva muchas veces a generar niveles altos de deserción escolar. los estilos de socialización de los padres y las madres se identificaron a partir de las percepciones de sus hijos e hijas adolescentes en diferentes situaciones de la vida diaria, en un contexto familiar y social vulnerable que se acentúa en una comunidad como la trece de mayo. de esta manera, los resultados obtenidos permiten señalar que los estilos de socialización parental indulgente y autorizativo, identificados por los adolescentes participantes, se constituyen en factores protectores en la vida de los jóvenes, y se traducen en relaciones familiares que previenen más los problemas de conducta de los hijos e hijas, aún en situaciones difíciles de tipo social, cultural y económico. las familias del grupo de adolescentes escolarizados desarrollan una alta aceptación/implicación durante los procesos de socialización familiar con sus hijos e hijas, y una baja coerción/ imposición. estos hallazgos pueden estar relacionados con la condición de ser adolescentes escolarizados, sumado a los proyectos de formación integral y extracurricular que la institución educativa desarrolla por medio del arte y el trabajo con las familias o los cuidadores. sin embargo, se observó en el estudio, en algún grado, la percepción de estilos autoritario y negligente por parte de las jóvenes adolescentes en relación con los padres, y autorizativas respecto a las madres. lo anterior plantea la necesidad imperiosa de generar estrategias que permitan vincular y orientar a los padres para afrontar de manera adecuada los procesos de socialización dentro de entorno familiar. una de las maneras de proteger a los/las adolescentes escolarizadas con los factores de riesgo encontrados es fortalecer las 445 percepción de la autoridad parental en adolescentes escolarizados víctimas de desplazamiento l emilce salamanca-ramos y otros relaciones familiares en la fase inicial de la adolescencia, donde se fomente el desarrollo del joven como persona y como integrante de una sociedad, a fin de consolidar patrones de comportamiento que pueden afectar el resto de sus vidas. el apoyo a las familias es importante, no solo a través de recursos y ayudas sociales, sino a partir de una intervención en la que se aborden aspectos relacionados con las dinámicas familiares, responsabilidades en el hogar, revisión de normas, organización familiar, relaciones entre los integrantes de la familia, autocontrol, autocuidado, entre otros, con un enfoque interdisciplinario e interinstitucional. para la enfermería familiar es importante conocer los problemas al igual que sus fortalezas en torno a la familia, así como las interacciones que se producen entre sus miembros, con el fin de planear una atención integral, si se tiene en cuenta que las características de la familia están relacionadas con las prácticas de salud. agradecimientos. a los adolescentes escolarizados, sus cuidadores y las directivas de la institución educativa donde se desarrolló el proyecto. a la universidad de los llanos por el aval y el apoyo económico. a los estudiantes principiantes de investigación, del programa de enfermería, facultad de ciencias de la salud. a los grupos de investigación gesi y gdhin por su continuo apoyo. financiación: universidad de los llanos. conflictos de intereses: ninguno declarado. referencias 1. musito g, garcía f. escala de estilos de socialización parental en la adolescencia espa 29. madrid: tea. ediciones s.a.; 2004. 2. berger pl, luckmann th. la construcción social de la realidad. buenos aires: amorrortu editores; 1995. 3. 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http://www.psicothema.com/pdf/1196.pdf 36. granada echeverri p, domínguez de la ossa e. las competencias parentales en contextos de desplazamiento forzado. psicología desde el caribe. 2014 [visitado 2016 may 23];29(2):456-82. disponible en: http://www.redalyc.org/articulo. oa?id=21324851009. 37. de la villa moral jiménez m, ovejero bernal a, rodríguez díaz f j, bringas molleda c. afrontamiento de conflictos en la socialización adolescente. propuesta de un modelo. psicología desde el caribe. 2016 [visitado 2016 may 23];33(1):1-13. disponible en: http://www.redalyc.org/articulo.oa?id=21345152001. 38. garcía pc, díaz er, velasco rdcg. salud familiar y enfermería. méxico: el manual moderno; 2016. 39. jiménez-picón n, lima-rodríguez j, lima-serrano m. relación entre variables familiares y el ajuste conyugal. aten prim. 2017 [visitado 2017 ago 2]; 1448:1-8. issn 0212-6567. doi: http://dx.doi.org/10.1016/j.aprim.2017.02.012 40. moreno f, carmona j, tobón j. why do girls join guerrilla and paramilitary groups in colombia? rev latin psicol. 2010;42(3):453-67. 41. prieto-montoya ja, cardona-castañeda lm, vélez-álvarez c. estilos parentales y consumo de sustancias psicoactivas en estudiantes de 8º a 10º. rev latinoam cienc soc niñez juv. 2016 [visitado 2017 feb 22];14(2):1345-56. disponible en http://www.scielo.org.co/scielo.php?script=sci_arttext&pid=s1692-715x2016000200032&lng=en http://dx.doi.org /10.11600/1692715x.14231161015. 32 42 puerperas usuarias de crack.indd 32 juliane portella ribeiro1 daiani modernel xavier2 giovana calcagno gomes3 marina soares mota4 simone quadros alvarez5 mara regina santos da silva6 puérperas usuárias de crack: difi culdades e facilidades enfrentadas no cuidado ao recém-nascido 1 orcid.org/0000-0002-1882-6762. universidade federal do rio grande (furg), brasil. juliane.ribeiro@ufpel.edu.br 2 orcid.org/0000-0003-3832-2120. universidade federal do rio grande (furg), brasil. daiamoder@furg.br 3 orcid.org/ 0000-0002-2464-1537. universidade federal do rio grande (furg), brasil. giovanacalcagno@furg.br 4 orcid.org/0000-0002-5717-9406. universidade federal do rio grande-furg. brasil. marinamota@furg.br 5 orcid.org/0000-0002-0501-7202. universidade federal do rio grande (furg), brasil. simone.alvarez@aedu.com 6 orcid.org/0000-0002-7385-7609. universidade federal do rio grande (furg), brasil. marare@brturbo.com.br recibido: 08 de septiembre de 2016 enviado a pares: 6 de octubre de 2016 aceptado por pares: 4 de abril de 2017 aprobado: 25 de abril de 2017 doi: 10.5294/aqui.2018.18.1.4 para citar este artículo / to reference this article / para citar este artigo xavier dm, gomes gc, ribeiro jp, mota ms, alvarez sq, da silva mrs. puérperas usuárias de crack: dificuldades e facilidades enfrentadas no cuidado ao recém-nascido. aquichan. 2018; 18(1): 32-42. doi: 10.5294/aqui.2018.18.1.4 resumo introdução: os recém-nascidos de usuárias de crack sofrem os efeitos da dependência já nas primeiras horas de vida e podem apresentar quadro de irritabilidade, sudorese, hipertonia e dificuldade nos ciclos de sono e vigília. essa realidade torna necessário o auxílio profissional à puérpera usuária de crack para sua instrumentalização ao cuidado do recém-nascido. objetivo: conhecer dificuldades e facilidades de puérperas usuárias de crack no cuidado ao recém-nascido. método: realizou-se pesquisa com abordagem qualitativa em uma maternidade do sul do brasil, mediante entrevistas semiestruturadas com 18 puérperas. resultados: a partir da análise de conteúdo, identificaram-se como dificuldades: abstinência da droga, não amamentação, falta de apoio familiar, vigilância dos profissionais do conselho tutelar, falta de habilidade para a realização de cuidados diretos ao recém-nascido, medo de machucá-lo e falta de condições financeiras. como facilidades, revelaram o fato de o recém-nascido chorar pouco, ser tranquilo e quieto; apoio da família, vizinhos e amigos, e auxílio financeiro do companheiro e familiares. conclusão: puérperas usuárias de crack necessitam de auxílio para desempenharem seu papel de cuidadoras do recém-nascido. devem ser captadas durante a gestação e acompanhadas de forma a realizarem o pré-natal, orientadas acerca dos cuidados com a criança e acolhidas em serviços de apoio. palavras-chave cocaína; crack; enfermagem; período pós-parto; recém-nascido; transtornos relacionados ao uso de substâncias (fonte: decs). año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 32-42 33 puérperas usuárias de crack: dificuldades e facilidades enfrentadas no cuidado ao recém-nascido l juliane portella ribeiro e outros año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 32-42 puérperas dependientes de crack: dificultades y facilidades afrontadas en el cuidado al recién nacido resumen introducción: los recién nacidos de dependientes de crack sufren los efectos de la dependencia ya en las primeras horas de vida y pueden presentar cuadro de irritabilidad, sudoración, hipertonía y dificultad en los ciclos de sueño y vigilia. esta realidad requiere el auxilio profesional a la puérpera usuaria de crack para su instrumentalización al cuidado del recién nacido. objetivo: conocer dificultades y facilidades de puérperas dependientes de crack en el cuidado al recién nacido. método: se realizó investigación con enfoque cualitativo en una maternidad del sur de brasil, por medio de entrevistas semiestructuradas con 18 puérperas. resultados: desde el análisis de contenido, se identificaron como dificultades: abstinencia de la droga, no lactancia, falta de respaldo familiar, vigilancia de los profesionales del consejo tutelar (similar al bienestar familiar en colombia), falta de habilidad para la realización de cuidados directos al recién nacido, miedo a lastimarlo y falta de condiciones financieras. como facilidades, se encontró que el recién nacido llore poco, sea tranquilo y quieto; respaldo de la familia, vecinos y amigos, y auxilio financiero del compañero y familiares. conclusión: puérperas dependientes de crack necesitan de auxilio para que cumplan su rol de cuidadoras del recién nacido. deben ser identificadas durante el embarazo y acompañadas de forma a que realicen el prenatal, orientadas acerca de los cuidados con el niño y recibidas en servicios de apoyo. palabras clave cocaína; crack; enfermería; periodo postparto; recién nacido; trastornos relacionados con el uso de narcóticos (fuente: decs). 34 aquichan issn 1657-5997 eissn 2027-5374 crack-dependent postpartum women: newborn care difficulties and facilities abstract introduction: newborns of crack-dependent mothers suffer the effects of drug dependence in the first hours of life and can exhibit irritability, sweating, hypertonia and difficulty in their sleep and wake cycles. this reality means the crack-dependent mother requires professional help to be able to care for her newborn child. objective: the purpose of the study is to identify the newborn care difficulties and facilities facing postpartum women who are dependent on crack. method: a qualitative study was conducted at a maternity hospital in southern brazil, through semi-structured interviews with 18 postpartum women. results: the content analysis made it possible to identify a number of difficulties; namely, abstinence from crack cocaine, no breastfeeding, lack of family support, surveillance by professionals from the guardianship council, lack of ability to care for the newborn, fear of hurting the newborn and financial problems. as for facilities, it was found the newborns of crack-dependent mothers cry little and are quiet and tranquil. support from family members, neighbors and friends and financial help from the partner and the family are possible resources as well. conclusion: crack-dependent postpartum women need help to fulfill their role as newborn caregivers. they should be identified during pregnancy so as to receive guidance during the prenatal period and orientation on newborn care and the support services to which they are entitled. keywords postpartum period; disorders related to substance abuse; crack cocaine; newborn, nursing (source: decs) año 18 vol. 18 nº 1 chía, colombia marzo 2018 l 32-42 35 puérperas usuárias de crack: dificuldades e facilidades enfrentadas no cuidado ao recém-nascido l juliane portella ribeiro e outros introdução crack é uma substância ilícita que surgiu na década de 1980, em bairros pobres e marginalizados de los angeles, nova york e miami. resulta da dissolução de cloridrato de cocaína em água e adição de uma base que, aquecida, forma pedaços de cristais e pó (1). seu uso pode causar dependência psicológica e resultar em sentimentos de vazio, solidão, angústia e depressão (2). o uso de drogas ilícitas durante a gravidez tornou-se um problema de saúde pública mundial. nos estados unidos da américa, a prevalência do uso de drogas ilícitas durante a gravidez em mulheres entre 15 e 44 anos que relataram o uso dessas substâncias nos últimos 30 dias atingiu 4,4 %. na europa, estudo que analisou substâncias ilícitas indicou que 7,9 % das gestantes foram expostas a substâncias psicoativas. em 4,4 %, o uso foi exclusivamente de cocaína (3). estudo em que se analisaram pacientes de 25 unidades básicas de saúde do município de maringá, no estado do paraná, e concluiu-se que a prevalência de uso de drogas ilícitas foi de 1,5 % em mulheres grávidas (4). o world drug report (5), publicado em 2016 pelo united nations office on drugs and crime, apontou que há uma tendência em nível global em relação ao aumento no consumo de cocaína, seja na forma intranasal (pó), seja na fumada (crack, merla ou oxi), principalmente na américa do sul. no brasil, especificamente, o índice cada vez mais elevado de consumo de crack, nas diferentes regiões do país, tem sido objeto de publicações específicas por parte dos órgãos especializados e tem se constituído uma preocupação crescente das autoridades de saúde. considerando que há um grande número de mulheres usuárias, sendo muitas gestantes, essa situação se torna ainda mais grave. isso porque o uso de crack está associado à relação sexual desprotegida e à não realização do pré-natal, o que leva à negligência da própria saúde e a do bebê (6). pesquisa que buscou verificar a heterogeneidade dos dependentes de substâncias psicoativas constatou que, embora a prevalência do consumo de crack masculino seja maior, as mulheres têm um risco mais significativo de contrair infecções sexualmente transmissíveis, pois a prostituição como atividade informal é mais prevalente entre o grupo de mulheres (7). estudo mostrou que essas mulheres são resistentes em aderir ao tratamento e aos programas de auxílio psicossocial direcionados a gestantes em situações de vulnerabilidades. constatou-se que a maioria das mulheres grávidas eram solteiras, ficaram grávidas três ou mais vezes e relataram ter trocado sexo por dinheiro ou por substâncias psicoativas (8). o uso de crack ou de outras formas de administração da cocaína está relacionado a graves efeitos adversos maternos, como risco aumentado de descolamento prematuro de placenta, líquido amniótico meconial, ruptura prematura de membranas ovulares, anomalias de trato geniturinário, prematuridade e baixo peso ao nascimento. pacientes dependentes que desenvolvem hipertensão durante a gestação devem ser investigadas para pré-eclâmpsia e intoxicação aguda (9-10). os recém-nascidos sofrem os efeitos da dependência já nas primeiras horas de vida e podem apresentar quadro de irritabilidade, sudorese, hipertonia e dificuldade nos ciclos de sono e vigília. todos esses sinais requerem ser averiguados para constatar se o recém-nascido precisa de medicação (8). dentre as limitações infantis mais frequentes, estão alterações no padrão de sucção, comprometimento cognitivo, menor propensão a interagir socialmente e maior propensão a morrer de síndrome da morte súbita (10). essa realidade torna necessário o auxílio profissional à puérpera usuária de crack para sua instrumentalização ao cuidado do recém-nascido. cabe, então, aos profissionais da saúde, o delineamento de ações voltadas a essas crianças e puérperas, assim como a prevenção, a detecção precoce e o tratamento adequado, com vistas à reabilitação da díade mãe e bebê. no intuito de facilitar o cuidado à criança exposta ao crack, destaca-se a intervenção baseada na orientação da puérpera para a prestação dos cuidados à criança e para a promoção da saúde desta. o consumo de crack é um grave problema de abrangência mundial, que atinge não apenas o usuário, mas também as pessoas que com ele convivem, o que inclui sua família. atender adequadamente a esse público requer dos enfermeiros sensibilidade e conhecimento científico para embasar as práticas profissionais desenvolvidas com essas pessoas nos diferentes cenários onde buscam assistência em saúde (4). o uso de crack no período gestacional é tema de difícil abordagem na prática assistencial. devido à necessidade do cuidado ao recém-nascido exposto ao crack e à usuária, o objetivo do presen36 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 te estudo foi conhecer as dificuldades e as facilidades de puérperas usuárias de crack no cuidado ao recém-nascido. considera-se que o conhecimento produzido poderá auxiliar os profissionais da saúde/enfermagem na instrumentalização para atuar ante o binômio puérpera usuária e recém-nascido. método trata-se de uma pesquisa do tipo exploratória e descritiva, com abordagem qualitativa. a pesquisa exploratória e descritiva aborda a descrição do fenômeno investigado e possibilita conhecer os problemas vivenciados, além de aprofundar seu estudo nos limites de uma realidade específica (11). a abordagem qualitativa considera, como fonte de estudo, a ótica dos indivíduos que vivenciam determinado fenômeno e seus significados (11). foi realizada em uma maternidade de um hospital universitário do sul do brasil (hu), referência em gravidez de alto risco e no atendimento a usuários de drogas. participaram 18 puérperas usuárias de crack. os critérios de inclusão foram: ser usuária de crack, ter tido o filho no hu, estarem lúcidas e orientadas, e terem 18 anos ou mais. o número de participantes foi definido pela saturação dos dados definida quando, na avaliação do pesquisador, ocorre uma certa redundância ou repetição, não sendo considerado relevante persistir na coleta de dados (12). todas foram orientadas acerca dos objetivos e da metodologia do estudo; em seguida, assinaram o termo de consentimento livre e esclarecido em duas vias. os dados foram coletados por meio de entrevistas semiestruturadas únicas com cada participante, nas quais se questionaram sobre suas percepções acerca da influência do uso de crack no cuidado ao recém-nascido. as entrevistas objetivaram inferir algo a respeito de uma realidade representativa de uma população que também apresenta unidades individuais (13). foram realizadas no pós-parto em sala da unidade que garantiu o conforto e a privacidade da participante. foram gravadas e transcritas para análise. as falas das participantes foram identificadas pela letra m, seguida do número da entrevista. os depoimentos foram submetidos à análise de conteúdo de bardin (13), compreendida como um conjunto de instrumentos metodológicos que se aplicam a discursos, o que proporciona, ao investigador, a busca pelo latente, não aparente e escondido. esse método foi operacionalizado manualmente por meio de três fases: pré-análise, exploração do material e, por último, tratamento dos resultados, inferência e interpretação. a pré-análise foi a fase de organização do material transcrito com o objetivo de tornar operacional e sistematizar as ideias iniciais a partir da leitura flutuante, o que permitiu constituir um corpus. na fase de exploração e análise do material, o texto foi recortado em unidades de registro para posterior codificação e categorização. após, foi realizada a leitura dos resultados obtidos para mais cinco puérperas usuárias de crack, com a finalidade de confirmar os dados encontrados da análise, complementá-los e validá-los (13). foram respeitados os princípios éticos, conforme a resolução 466/2012 da pesquisa que envolve seres humanos (14). o projeto de pesquisa foi submetido ao comitê de ética da universidade federal do rio grande (furg) e aprovado mediante parecer 135/2013. resultados a seguir, apresentam-se as participantes do estudo e as categorias geradas a partir da análise dos dados. caracterização das participantes do estudo participaram do estudo 18 puérperas usuárias de crack que tiveram seus filhos na maternidade do hu, no período de realização do estudo. suas idades variaram entre 24 e 36 anos. todas residentes na periferia da cidade do rio grande (estado do rio grande do sul, brasil). residem em casas de duas a cinco peças; quatro das entrevistadas moram em casas de alvenaria; oito, de madeira, e seis, mista (alvenaria e madeira), com água e luz, sendo que cinco casas não possuem saneamento básico. quanto à escolaridade, todas possuíam o ensino fundamental incompleto. quanto ao estado civil, 11 referiram ser solteiras; três casadas e quatro em união estável. quanto à profissão, sete se autointitularam do lar; oito, desempregadas, e três, profissionais do sexo. quanto ao número de filhos, cinco referiram possuir dois filhos; seis, três; cinco, quatro; uma, cinco, e uma, oito filhos. apenas duas utilizavam exclusivamente o crack. as outras, além do crack, utilizam, também, cocaína, maconha, álcool, merla e tabaco. iniciaram a utilizar substâncias psicoativas entre 14 e 32 anos. apenas duas tiveram o crack como primeira droga de consumo. 37 puérperas usuárias de crack: dificuldades e facilidades enfrentadas no cuidado ao recém-nascido l juliane portella ribeiro e outros dificuldades de puérperas usuárias de crack no cuidado ao recém-nascido como dificuldades para o cuidado ao recém-nascido, verificou-se que, na tentativa de não usar o crack, as puérperas apresentam abstinência da droga e, com isso, manifestam sintomas como, fraqueza, cansaço e depressão, além de desejo de conversar com a criança ou de se apegar a ela. preciso de repouso. ganhei um bebê e estou com crises depressivas de abstinência do crack. me sinto fraca e cansada. estou em acompanhamento psicológico aqui no hospital. fiquei depressiva. não consigo ter vontade de dar carinho e de cuidar minha filha. sinto falta da droga que parei de usar há dois meses. (m1) estou depressiva, agitada e sem carinho para dar à criança. (m5) só vou me apegar a ela quando eu perceber que vai sobreviver. vou dar para ela os cuidados que precisar. está difícil, pois estou sem a droga. (m6) além disso, algumas puérperas relatam a recomendação recebida para a não amamentação da criança, tendo em vista que os resíduos do crack podem ser transmitidos ao leite para o bebê e podem afetá-lo. não posso amamentar o meu bebê. sou usuária de crack. (m12) não estão querendo deixar eu amamentar meu bebê. disseram que estou com o efeito do crack e que vou passar para ele a droga. fiquei preocupada! (m13) o uso do crack impede que eu amamente em função da droga passar pelo leite. ela já nasceu com crise de abstinência e muito parada. foi direto para a uti infantil, com dificuldades respiratórias. (m8) não vou poder amamentar. vai passar a droga pelo leite para minha filha. a neném é viciada porque eu usei crack toda a gestação. no dia que vim para o hospital ganhar minha filha, eu fumei crack, mas não muito. (m6) a dependência química do crack, associada à falta de apoio familiar para o cuidado ao recém-nascido fazem com que a puérpera fique sob a vigilância do conselho tutelar. por isso algumas puérperas referem medo pela sua falta de condições em assumir a criação da criança sozinha. como sou dependente de crack, o conselho tutelar não quer deixar a criança morar comigo. o pai dela está preso e não tenho condições de criar sozinha. (m11) não quero que o conselho tutelar tire ele de mim, por causa do uso do crack. embora pretenda parar de usar. acho que eles não vão acreditar em mim. (m13) constata-se que, devido aos episódios de tremores, advindos da abstinência do crack, referiram dificuldades de prestar cuidados diretos à criança, como dar banho e realizar curativos do coto umbilical, portanto necessitam da ajuda de familiares para isso. quando estou tremendo, minha dificuldade passa a ser o dar o banho. quem dá banho é o pai dele. ele sabe que tremo da abstinência e, por isso, ele me ajuda. tenho medo do umbigo aparecendo. (m3) tenho medo do umbigo. parece que vou machucar meu filho. minha mãe é quem faz os cuidados. ela aproveita e já dá o banho. (m7) algumas puérperas também expressam dificuldades para cuidar o recém-nascido prematuro, com problemas respiratórios e malformação congênita, temendo machucá-lo. para tanto, passam a conviver com o apoio dos serviços de saúde e a enfrentar a necessidade de cuidados diferenciados da criança. a dificuldade para cuidar da minha filha é o medo que tenho de quebrar ela. é pequena e delicada. pesou 910 gramas. nasceu de seis meses de gravidez. (m11) ela nasceu com problema respiratório. teve uma parada cardíaca, mas se recuperou bem. ela é muito parada, não se mexe e nem chora muito. a fonoaudióloga disse que terei que levar minha filha ao centro de referência para correção de fenda palatina e lábio leporino para tentarem corrigir a boca e o lábio dela que estão abertos e exigem cuidados. (m15) minha filha nasceu com malformações. ela não tem uma orelhinha e não tem a mandíbula. não sei nem por onde começar a cuidar. (m16) revelam sua dificuldade de aprender a lidar com as tecnologias que a criança necessita para sobreviver. meu cuidado tem sido em virar ele de lado. tenho medo que ele fique machucado ou se engasgue com a sondinha que vai até o estômago. (m9) 38 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 aqui no hospital é feita nebulização para que não dê falta de ar. também, é dada a medicação receitada pelo médico do plantão. me sinto insegura e peço informações. (m14) em relação ao sustento e ao cuidado da criança, algumas puérperas revelaram dificuldades financeiras, referindo medo de recorrer novamente à prostituição, como forma de atividade econômica. não tenho condições para comprar o leite. quando eu sair do hospital, vou pedir ajuda no posto de saúde. aqui no hospital o leite é dado de graça. (m12) vou ter dificuldades em cuidar da minha filha. não poderei amamentar e comprar os mantimentos dela. estou sem dinheiro. vou pedir ajuda para o pai dela e para minha mãe. se a situação financeira não melhorar, terei que voltar para a prostituição. tenho medo dessa situação, pois me levará a ficar mais perto das drogas. (m18) facilidades de puérperas usuárias de crack no cuidado ao recém-nascido quanto às facilidades para o cuidado direto ao recém-nascido, puérperas usuárias de crack referiram que o fato de a criança chorar pouco, ser tranquila e quieta facilita seu cuidado. meu filho é um bebê que não dá trabalho. é tranquilo e pouco chora. (m7) cuido direitinho do meu bebê. não me incomoda em nada. dou leite, troco as fraldas e coloco para dormir. gosto dele porque está sempre quieto. não é um chorão. (m3) ela é boazinha e quase não chora. quero sair da maternidade e amamentar minha filha para não precisar fazer maisena grossa e nem dar leite de saquinho na mamadeira. não terei dificuldade de cuidar minha filha. (m16) outra facilidade elencada foi o apoio da família para a prestação do cuidado direto à criança. os dados do estudo mostram que mães, sogras, companheiros, irmãos e filhos mais velhos se organizam para auxiliar a puérpera no cuidado direto ao recém-nascido. confio minha filha aos cuidados da minha mãe, por ser a única pessoa em quem confio. minha filha só poderá sair daqui do hospital com a assinatura da minha mãe se responsabilizando pelos cuidados dela. meu irmão, também, me disse que vai auxiliar minha mãe nos cuidados da minha filha. (m17) tenho a ajuda do meu marido, aqui no hospital. ele reveza os cuidados comigo. enquanto ele trabalha, sou eu quem cuida e, quando ele chega para cuidar, sou eu quem vai para casa descansar. (m4) a única ajuda que tenho é dada pela minha sogra. ela ajuda a cuidar do bebê para mim. foi ela quem me ajudou a fazer o enxoval do meu filho. sempre me deu todo apoio. (m10) o meu marido será meu apoio. ele gosta de alimentar, dar banho e trocar as fraldas. disse que me ajudará a levar ao médico quando necessário. tenho dificuldades de ser carinhosa com minha filha. (m15) além dos familiares, constatou-se que vizinhos e amigos também se aproximam da puérpera usuária de crack a fim de compor uma rede de apoio social para seu auxílio, oferecendo roupas, fraldas e leite para o bebê, além do apoio emocional e do incentivo à puérpera. minha comadre juntou as roupinhas que não servem no bebê dela para mim. todas as conhecidas dela estão ajudando também. (m18) tenho uma vizinha e duas amigas que me ajudaram na aquisição das fraldas e do leite. isso me incentiva a cuidar do meu bebê. (m2) outra forma de facilitar o cuidado ao recém-nascido pela puérpera é o fornecimento de auxílio financeiro pelo companheiro e pela sogra para que a criança tenha suas necessidades atendidas. meu atual companheiro vai me ajudar no cuidado e nas despesas com ela. disse que na pobreza e na tristeza vai sempre me ajudar. ele não usa droga. ganha bem com o salário da aposentadoria e do emprego de moto-táxi. (m2) quando sair da maternidade, será meu marido e minha sogra quem me sustentarão. vamos ficar morando com a minha sogra. (m1) discussão a partir da análise, constatou-se que a puérpera usuária de crack pode apresentar abstinência do crack logo após o parto, quando procura diminuir seu consumo devido à gestação (15). a 39 puérperas usuárias de crack: dificuldades e facilidades enfrentadas no cuidado ao recém-nascido l juliane portella ribeiro e outros abstinência faz com que as puérperas se sintam cansadas, enfraquecidas e deprimidas, portanto não têm vontade de conversar e isso pode influenciar na diminuição do seu apego à criança. devido à dependência do crack, podem tornar-se insensíveis e deixar de se preocupar com atividades básicas da vida diária, as quais consideravam importantes, como lazer em família, sono e repouso, estudo, trabalho, leis, regras e higiene corporal, podendo sequer lembrar-se da sua gravidez ou do bebê (16). em geral, as pessoas que usam crack tendem a ser irritadas e deprimidas, o que impede um ambiente afetivo sadio de cuidado para que a criança se desenvolva adequadamente (17). o uso prolongado dessa substância pela mulher pode prejudicar suas habilidades cognitivas e emocionais, a função executiva e a atenção, importantes habilidades necessárias ao cuidado da criança (18). outra dificuldade referida pelas puérperas usuárias de crack é a não indicação da amamentação (19). evidências clínicas demonstram efeitos adversos do aleitamento materno para os recém-nascidos e desaconselham seu uso. comportamento agressivo e conflitivo dessas pacientes, associado à diminuição de senso de julgamento, pode levá-las a não aderirem adequadamente às orientações médicas e de enfermagem. por tais motivos, é recomendado que dependentes ativas de cocaína ou crack e pacientes sem histórico confiável de suspensão do uso da droga sejam consideradas contraindicadas ao aleitamento materno (9, 18). a utilização de crack durante a gravidez e a amamentação pode trazer consequências graves para o bebê devido a suas propriedades farmacocinéticas. ele pode ficar excessivamente irritável e taquicárdico (20). a falta de apoio familiar para o cuidado ao recém-nascido assim como o temor da vigilância do conselho tutelar e da perda da guarda da criança foram referidas. geralmente, são mulheres usuárias de crack que se encontram em situação de vulnerabilidade social, com rompimento dos vínculos familiares, percebidas como falha de caráter (21). a perda do vínculo familiar pode fazer com que vivam em situação de moradia de rua. em são paulo (brasil), no ano de 2007, houve apenas um caso de dependente de crack que perdeu a guarda de seu filho recém-nascido, mas esse número está aumentando a cada ano. em 2008, foram 15; em 2009, o número cresceu para 26 e, em 2010, o número de casos em que os hospitais encaminharam os recém-nascidos para o conselho tutelar ou para a vara da infância e da juventude foi de 43, crescimento de 65 % apenas de 2009 a 2010 (22). estudo acerca da influência do ambiente familiar no consumo de crack apontou a deficiência de suporte parental dos usuários (23). outro estudo realizado com o objetivo de conhecer o vínculo familiar de usuários atendidos em um serviço de emergência psiquiátrica identificou graves perdas nos vínculos relacionais com a família e o meio social. os autores referiram que a falta de vínculos familiares pode estimular a continuidade do uso de drogas. entre os usuários participantes do estudo, poucos mantinham contato com as famílias, e a maioria dos vínculos familiares encontrava-se fragilizada ou totalmente rompida (24). puérperas usuárias de crack podem apresentar dificuldade em prestar cuidados diretos ao recém-nascido quando retornam a casa (25) e necessitar do auxílio de familiares —rotineiramente, da mãe ou da avó— para se adaptarem ao puerpério no domicílio. o agravante passa a ser o estresse sofrido pela retomada dos cuidados com o lar e com o recém-nascido, como o banho e o curativo do coto, visto que ainda se encontram em uma fase de recuperação pós-parto e podem apresentar abstinência do crack (26). essas usuárias podem apresentar medo de machucar o bebê devido à sua prematuridade, malformações congênitas, problemas respiratórios e uso de tecnologias mais complexas de cuidado. apresentam necessidades específicas e fragilidade, em termos de condições clínicas pós-natais, quando comparados a recémnascidos a termo de mães não usuárias da droga. muitas vezes, puérperas usuárias de crack justificam sua falta de vínculos com a criança devido ao medo que o bebê morra. demonstram, geralmente, indiferença em relação a outras pessoas, tendo uma tendência para distúrbios de humor. podem apresentar, também, uma má reação ao estresse, alienação e estados agressivos relacionados a distúrbios orgânicos causados pelo uso do crack (10, 27). a falta de recursos financeiros dificulta o cuidado à criança, o que deixa a puérpera usuária de crack em situação de maior fragilidade (28). além disso, essas crianças podem nascer com alteração no tempo de emissão e no timbre do choro devido à ação do crack no sistema nervoso central (26). o apoio da família, vizinhos e amigos para o cuidado ao recém-nascido corrobora para o cuidado da mãe com o bebê. diante da necessidade de se adaptar à maternidade, a puérpera recorre à sua rede de apoio social, que age como mediadora na reestruturação de suas relações afetivas. 40 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 o contexto que envolve essas puérperas usuárias de crack implica a necessidade de apoio social com olhar compreensivo, especialmente para o enfrentamento de sentimentos como medo e incompetência materna, e deve promover suporte favorável à saúde mental da puérpera e do recém-nascido (29). sabe-se que a maternidade é mobilizadora de recursos pessoais e financeiros para o enfrentamento das demandas acrescidas pela gravidez, e que promove suporte favorável à saúde mental da puérpera e do recém-nascido (30). conclusão o estudo possibilitou conhecer dificuldades e facilidades de puérperas usuárias de crack no cuidado ao recém-nascido. constatou-se como dificuldades para o cuidado a abstinência da droga, o que dificultou seu apego à criança; a recomendação da não amamentação; a falta de apoio familiar; a vigilância dos profissionais do conselho tutelar; a falta de habilidade para a realização de cuidados diretos à criança; o medo de machucar a criança com malformações e problemas respiratórios, além da falta de condições financeiras para prover as necessidades da criança. como facilidades, revelaram o fato de a criança chorar pouco, ser tranquila e quieta assim como o apoio da família, de vizinhos e amigos, além do auxílio financeiro do companheiro e familiares. os dados indicam que as puérperas usuárias de crack necessitam de auxílio para desempenharem adequadamente seu papel de cuidadoras do recém-nascido, tendo em vista as dificuldades que enfrentam. assim, precisam ser precocemente captadas e acolhidas pelos profissionais da saúde/enfermagem durante a gestação e acompanhadas de forma a realizarem o pré-natal. embora não haja dados concretos no brasil acerca do número de gestantes usuárias de crack, os profissionais da saúde/enfermeiros que atuam nas maternidades e centros obstétricos precisam estar preparados para conduzir o parto dessas mulheres, acompanhando-as no seu puerpério imediato. é preciso saber orientar a mulher acerca dos cuidados com o recém-nascido e verificar aqueles em risco social para fazer os devidos encaminhamentos, o que garantirá sua segurança e cuidado. do mesmo modo, as puérperas necessitam ser acolhidas em serviços de apoio que lhes deem sustentação para que possam superar suas dificuldades de forma mais amena, desenvolvendo habilidades e competências para o cuidado ao recém-nascido. recém-nascidos de puérperas usuárias de crack, a partir da alta hospitalar, devem ter garantido o acompanhamento periódico por profissionais da saúde e do conselho tutelar para que possam ser identificadas, precocemente, situações de abandono e maltrato, garantindo sua segurança. para tanto, os profissionais de saúde/enfermagem devem refletir acerca de sua atuação ante a puérpera usuária de crack e o recém-nascido, além de identificar e aplicar intervenções terapêuticas eficazes e eficientes em prol da sua saúde. aponta-se como estratégia no novo cenário da saúde mental que os serviços de saúde mental atuem e pautem suas ações de forma a contemplar a gestante e a puérpera usuárias de crack e o recém-nascido. como limitação do estudo, destaca-se ter sido realizado com participantes vinculadas a um único hospital, o que levou a achados de uma realidade específica à compreensão do fenômeno sob um dado ponto de vista. futuros estudos que considerarem outras realidades poderão contribuir com novos achados sobre o fenômeno em questão. conflito de interesse: nenhum declarado. 41 puérperas usuárias de crack: dificuldades e facilidades enfrentadas no cuidado ao recém-nascido l juliane portella ribeiro e outros 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breastfeeding mother. pract midwife. 2015; 18(1):19-22. 21. benoit c, magnus s, phillips r, marcellus l, charbonneau s. complicating the dominant morality discourse: mothers and fathers’ constructions of substance use during pregnancy and early parenthood. int j equity health. 2015; 14(72):1-11. 22. secretaria do estado de saúde de são paulo. vício em crack e cocaína separa mães de seus bebês em sp. são paulo: secretaria da saúde; 2011. 42 año 18 vol. 18 nº 1 chía, colombia marzo 2018 aquichan issn 1657-5997 eissn 2027-5374 23. seleghim mr, oliveira mlf. influência do ambiente familiar no consumo de crack em usuários. acta paul enferm. 2013; 26(3):263-8. 24. seleghim mr, marangoni sr, marcon ss, oliveira ml. vínculo familiar de usuários de crack atendidos em uma unidade de emergência psiquiátrica. rev latino-am enfermagem. 2011; 19(5):1-8. 25. mattoo sk, nebhinani n, kumar bn, basu d, kulhara p. family burden with substance dependence: a study from india. indian j med res. 2013; 137(4):704-11. 26. chiriboga ca, kuhn l, wasserman ga. neurobehavioral and developmental traiectories associated with level of prenatal cocaine exposure. j neurol psychol. 2014; 2(3):1-24. 27. perez jmr, golombek sg, fajardo c, sola a. a laminar flow unit for the care of critically ill newborn infants. med devices. 2013; 6(1):163-7. 28. brakenhoff b, slesnick n. “the whole family suffered, so the whole family needs to recover”: thematic analysis of substance-abusing mothers’ family therapy sessions. j soc serv res. 2015; 41(2):216-32. 29. diehl a, cordeiro dc, laranjeira r. dependência química: prevenção, tratamento e políticas públicas. in: duncan bb, schmidt mi, giugliani erj. organizadores. medicina ambulatorial. porto alegre: artmed; 2011. p. 169-78. 30. shan q, li x, stanton b. social support and hiv-related risk behaviors: a systematic review of the global literature. behav aids. 2014; 18(2):419-41. 11 psychometric.p65 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 20059 6 año 5 vol. 5 nº 1 (5) 96-107 chía, colombia octubre 2005 stephanie e. burgess* abbas tavakoli** recibido: 8 de agosto de 2005 aprobado: 31 de agosto de 2005 abstract purpose. the purpose of this study was to assess the psychometric properties of the burgess-partner abuse scale for teens (b-past) by examining internal consistency and construct validity. methods. a convenience sample of 239 teen girls ages 13 to 19 years old that were seen in three private primary health care practices agreed to participate. subjects were administered two measures of interpersonal violence, two measures of psychosocial well-being, and a demographic questionnaire. construct validity was assessed by 1) conducting exploratory factor analysis with a priori decision to retain two factors, and 2) measuring differential correlates of interpersonal violence and psychosocial well-being using pearson correlation. in order to determine the instrument�s ability to discriminate between teen girls who reported partner abuse and those who did not report partner abuse, differences in contrasted group means (abused vs. non-abused) were examined. one-way anova was used to determine differences in interpersonal violence and psychosocial wellbeing. the internal consistency of the b-past was examined by setting a criterion for the alpha coefficient above .70. results. the results showed that 70.9% of the variance was explained by the b-past. factor analysis demonstrated a 22-item scale with two distinct subscales. the b-past correlated with one measure of interpersonal peer violence (r = .39) and two measures of poor psychosocial well-being, low level of hope and increased depression (r = -.42, r = .46). differences in contrasted means showed that teen girls who were abused by a partner reported higher scores for interpersonal violence. one-way anova showed that abused teen girls scored higher for interpersonal violence and depression but lower in hope. the internal consistency for the final total scale was .97 and .95 for physical/sexual abuse and .91 for the social/emotional abuse subscales. conclusions. results provide support for reliability and validity for the bpast as a measure of partner abuse in teen girls ages 13 to 19. key words: partner abuse, teenagers, psychometric assessment. * phd, aprn-bc. clinical professor, college of nursing , university of south carolina, columbia. scburgess@aol.com * * dr.ph. director of statistics laboratory, college of nursing, university of south carolina, columbia, sc 29208. abbas.tavakoli@sc.edu resumen propósito. evaluar las propiedades psicométricas de la escala para adolescentes �burgués-partner abuse scale� (b-past), examinando la consistencia interna y validándola. métodos. a una muestra de 239 niñas adolescentes, entre 13 y 19 años, que formaron parte de la práctica privada y que aceptaron participar, se le aplicó dos medidas de violencia interpersonal, dos de bienestar psicológico y un cuestionario demográfico. la validez fue valorada por 1) un factor de análisis de conducta exploratoria con una decisión a priori para retener dos factores, y 2) medición de la correlación diferencial de la violencia interpersonal y el bienestar psicosocial usando la correlación de pearson. con el fin de determinar la habilidad del instrumento para discriminar entre niñas que informaron abuso de sus compañeros y aquéllas que no lo informaron, se examinaron las diferencias de la media de los grupos (abusadas vs. no abusadas). un anova de una vía se utilizó para determinar las diferencias de la violencia interpersonal y el bienestar psicosocial. se examinó la consistencia interna del b-past, estableciendo un criterio para el coeficiente alfa sobre .70. resultados. el 70.9 % de la variable se explicó por medio del b-past. el factor de análisis demostró una escala de 22 ítemes con dos subescalas diferentes. el b-past correlacionado con una medida de violencia interpersonal de los compañeros (r=.39) y dos medidas de bienestar psicosocial pobre, bajo nivel de esperanza y aumento de la depresión (r=-.42, r=.46). las diferencias en los contrastes de la media mostraron que las niñas adolescentes que habían sido abusadas por un compañero reportaron cifras más altas de violencia interpersonal. el anova de una vía mostró que las niñas tenían cifras más altas para violencia interpersonal y depresión y bajas para esperanza. la consistencia interna para la escala total final fue de .97 y .95 para abuso físico/sexual y .91 para las subescalas de abuso social/emocional. conclusión. los resultados respaldan la confiabilidad y validez del b-past como una medida para el abuso entre compañeros en niñas adolescentes entre los 13 y 19 años. palabras claves abuso de compañeros, adolescentes, evaluación psicométrica psychometric assessment of the burgess-partner abuse scale for teens (b-past) 9 7 artner abuse of teen girls is recognized as an emerging health problem in the united states (1). studies suggest an incidence rate of 21% to 60% in teen girls (2-13) and 10% to 22% in pregnant teen girls (14-21). likewise, other studies report that annually 6% of teen girls are murdered by partners and 8% are sexually assaulted by partners (22-28). problems reported with teen partner abuse include depression (13, 29-30), less hope (31-34), peer violence/ harassment (15, 28, 35-36) and substance abuse (8, 12-13, 16, 37-39). despite these findings, preventing teen partner abuse remains difficult for a myriad of reasons including the lack of age appropriate screening measurement scales (40-43). this gap is heightened by the u.s preventive services task force (uspstf) 2004 findings that suggested a void in scales designed to measure partner abuse in different populations and age groups (42). according to the task force, current partner abuse scales (44-48), although widely used with extensive reliability and validity reports, are not linked with outcomes, define partner abuse differently, were developed and tested on adult women living in shelters or with a male partner, and depending on the scale, are limited in their measurement of social or sexual partner abuse except for forced sex or rape (42). literature review it has been suggested that teen partner relationships differ from adult partner relationships (3-25, 49-52), especially in social and sexual aspects, therefore rendering adult partner abuse instruments possibly invalid or unreliable for use in teen girls. in order to determine if current instruments are appropriate for measuring partner abuse in teen girls, a critique of each was conducted. the index of spouse abuse (isa) is a 30-item 5-point likert type scale designed to measure the magnitude or severity of both physical and nonphysical partner abuse of adult women in heterosexual relationships (46). the isa was initially evaluated in samples of women living in protective shelters and college aged or adult married women living with a male partner. the initial internal consistency ranged from .90 to .94 for the physical subscale and .91 to .97 for the non-physical subscale (46). the isa was shown to discriminate between women who were abused vs. those who were not abused in that abused women scored higher for partner abuse and personal and social problems (e.g., depression, low selfesteem, sexual dissatisfaction, and family discord) (46). the original isa has been revised resulting in two separate scales: partner abuse scale-physical (pas-p) and the partner abuse scale-non-physical (pas-np) (45). the two scales reflect partner abuse in nontraditional couples containing three items relating to sexual and four items relating to social partner abuse (45). tested among 90 adult women living in shelters or with partners, the pasp and the pas-np produced internal consistency reliability coefficients of .90 to .95, respectively (45). the severity of violence against women scale (svaws) is a 4point likert type scale consisting of 46 items that were constructed to measure the magnitude (severity) of perceived threats, attempts, or completed physical violence acts on adult women by male partners in an intimate relationship (48). tested in adult women, the initial internal consistency was .93 (48). based on orem�s theory of self-care (53), the danger assessment instrument was conceptualized by campbell to help battered women enhance their personal awareness of danger for homicide from a partner (44). tested among 79 adult battered women who were recruited from shelters, the cronbach alpha was .84 (44). support for construct validity was provided with a moderate to strong correlation (r = .43) with the conflict tactics scale (44, 47). conceptualized as a one-dimensional instrument, the danger assessment consists of 15 dichotomous items (yes/no). fourteen items relate to physical danger, including forced sex, and one item relates to a partner�s attempt to control household money and the car (44). the conflicts tactics scale (cts) was developed to assess a married couple�s conflict in three domains: reasoning, verbal aggression, and physical aggression (47). the scale originated from the literature in the 1970s on victimization, wife beating, marital violence, and wife abuse (47). the cts consists of physical abuse items (e.g., �does he hit, push, kick, bite, or shove you?�), emotional items (e.g., �does he threaten, insult, or swear at you?�), and reasoning (�does he make you cry?�) (47). the initial internal consistency reliability was .79 among married women with followup studies producing internal consistencies of .80 to .83 among married and non-married heterosexual couples(47). in contrast to items measured by adult partner abuse scales, the substantive literature review showed that teen partners typically used more sexual and social control of teen girls (13-25, 51). tactics included intimidation, verbal harassment, humiliation, and using revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 20059 8 drugs/alcohol to diminish the teen girl�s awareness to protect herself in sexual activity (13-25, 51). partners also dictated what clothes to wear or what social activities the teen girls could participate in. partners controlled whom the teen girls could associate with, talk to, or hang around with, especially at school or at social events (4-12). additionally abusive partners demanded that teen girls account for their whereabouts, time and activities by reporting in by cell phone or pager, so that the partners could find them at a moment�s notice (52). in summary, important methodological issues emerge when adult scales are used to measure teen partner abuse. first, adult partner abuse instruments were developed and tested for use among adult women, rendering validity and reliability concerns for their use in teen girls. second, adult partner abuse instruments are limited, if of any use, in their measurement of social or sexual partner abuse. third, none measure social or sexual aspects specific to teen relationships. the burgess-partner abuse scale (b-past) is intended to measure partner abuse in teen girls, paying particular attention to aspects of social and sexual teen partner abuse (52). according to experts, an instrument that can measure teen partner abuse will enhance the opportunity to identify correlates, confirm risk factors, develop interventions, and validate outcomes that indicate that assessing teen girls for partner abuse prevents or reduces disability (42). the major purpose of this study was to assess the psychometric properties of the b-past. it was hypothesized that the b-past 1) would be composed of two separate but related teen partner abuse dimensions, 2) would positively correlate with peer violence and depression but negatively with hope, and 3) would report higher scores for interpersonal violence and depression but less hope in abused teen girls. conceptual framework scholarly attention to partner abuse has increased in the past 30 years in order to offer explanations about factors that create and perpetuate partner abuse (54-55). for this study, an ecological framework was used, which explains that partner abuse is in part the result of interplay between situational and personal factors (56-59). situational factors are defined as perceived or actual interpersonal interactions between individuals. interactions can encompass interpersonal violence with a partner or peers. personal factors are defined as demographic characteristics and psychosocial well-being. psychosocial well-being is often influenced by interactions with individuals and with the larger community. for this study, the b-past was assessed by measuring correlations between the interpersonal interactions of the teen girl, her partner, and peers. other differential correlates were assessed between the teen girl�s level of hope and depression, and partner abuse. in order to determine the instrument�s ability to discriminate between teen girls who reported partner abuse and those who did not report partner abuse, differences in contrasted group means (abused vs. non-abused) were examined for abuse. one-way anova was used to determine differences in interpersonal violence, hope, and depression. methods subjects a convenience sample composed of 257 teen girls ages 13 to 19 agreed to participate. criteria for inclusion for this study were teen girls: 1) ages 13 to 19, 2) currently enrolled in school either part time or full time, 3) reporting a current partner (past 12 months), and 4) able to read and write english. after 18 surveys were removed for failing to meet study criteria, the final sample (n = 239) was composed of 62.76% (n = 150) caucasian and 35.98% (n = 86) african-american. the mean age of the teen girl was 16.50 years with a mean education of 11.27 years. the mean age of the partner was 19.03 years with a mean education of 9.9 years (table 1). forty-three percent (n = 103) reported partner abuse based on a b-past score of 9/88. no subjects reported a same-sex partner. the mean age for teen girls initiating sexual activity was 14.26 years, and 44% (n = 105) reported 3 to 6 lifetime sexual partners. sixteen percent (n = 38) reported a current pregnancy. twelve percent (n = 27) reported they had witnessed their parents hitting each other. twenty-three percent (n = 55) reported they used drugs (marijuana, ecstasy, or cocaine) and 26.1% (n = 63) reported their partners used drugs (marijuana, ecstasy, or cocaine). forty-two percent (n = 101) were covered by the state�s government health insurance plan (medicaid) issued to low-income individuals and 57.4% (n = 137) were covered by private health insurance plans. procedure data collection occurred over an eight-month period following institutional review board approval. prior to data collection, the investigator received in-depth training to ensure uniformity to a written data collection procedure, protecting human subjects, maintaining confidentiality, avoiding study coercion, and solving ethical situations for teens seeking help from abusive partner relationships. three private health care sites agreed to provide access to potential participants for data collection. subjects were recruited and invited to participate in the study after they had completed their health care visit. informed consents were obtained from participants and legal guardians/parents if the participant was under the age of 18. in privacy, subjects completed and sealed the questionnaire packet, and deposited it in a locked box at the health care office labeled �q.� the investigator retrieved the questionnaire packets at the end of the day. the investigator�s psychometric assessment of the burgess-partner abuse scale for teens (b-past) 9 9 contact information and a list of counseling and partner abuse services were attached to all questionnaire packets. two individuals refused to participate in the study. measures decisions to select instruments for construct validity hypothesis testing were guided by scales measuring problems in interpersonal relationships and psychosocial well-being of abuse victims. instruments selected were the index of peer relations (ipr) (6061), the miller hope scale (mhs) (62), and the center of epidemiologic studies-depression scale (ces-d scale) (63). burgess-partner abuse scale for teens (b-past). the 22-item scale is a self-report norm-referenced index, designed to measure the frequency of partner abuse in two dimensions: physical/ sexual (12 items) and social/emotional (10 items). the physical/ sexual partner abuse subscale is defined as a partner imposing a physical threat or actual bodily harm, with or without the use of a weapon, or a verbal or actual sexual behavior that threatens the teen girl�s reproductive or sexual integrity. the social/emotional partner abuse subscale is defined as a partner statement or gesture that puts down, shames, humiliates, dictates, or demands what the teen girl can and cannot do regarding social activities. each item is preceded by the stem �my partner� followed by responses such as �forces me to use drugs�, �follows me when i do things with my family�, or �won�t let me go out my friends.� item response options are scored on a 5-point likert type scale (range 0 to 4) and no items require a reversal in scoring. interpretations of response options are left to the respondent. because the domains are considered to be different yet related dimensions, item scores within each domain are summed to create subscales. computed scores range from 0 to 88 for the total scale, 0 to 48 for the physical/ sexual partner abuse subscale, and 0 to 40 for the social/emotional abuse subscale. higher scores reflect greater frequency of partner abuse. severity of abuse has not been established. flesch-kincaid reading level is indicated at grade 2.3 (52). the index of peer relations (ipr). the ipr is a well validated self-report measure of the degree or magnitude of problems, dysfunction, or violence a teen has with his/her friends (60-61). the likert questionnaire�s 25 items ask adolescents (over age 12) to rate the frequency with which they experienced rejection, poor treatment by peers, or not getting along with peers. on a total score of 130, with item ranges from 0 to 6, higher scores indicate interpersonal violence and peer harassment. flesch-kincaid reading level is estimated at grade 3 (60-61, 64). the miller hope scale (mhs). the mhs is a widely used, reliable, and extensively validated self-report measure of the degree of hope and is defined by the anticipation for a future that is good and incorporates positive interpersonal relationships with others (62). the mhs consists of 40 items on a six-point likert type scale (range 0 to 6) yielding a total score of 240. higher scores indicate higher hope levels. however, no set score has been established to determine where hope is present or absent. flesch-kincaid reading level is estimated at grade 3 (62). the center of epidemiologic depression scale (cesd). the ces-d scale is a reliable and valid unidimensional selfreport measure consisting of 20 items designed to measure current (past 7 days) mood. a sad mood is described as the blues, loneliness, crying, sadness, or feelings of not being close or liked by others (63). the likert type scale was developed out of a pool of several depression scales and interviews in the normal healthy population above age 12. item responses range from 0 to 3 with higher scores indicating greater feelings of depression in the individual. no set score is established, though, for clinical depression. flesch-kincaid reading level is estimated at grade 2.1 (63). data analysis plan because the b-past (52) is a relatively new instrument, the internal consistency was examined by setting a criterion for the alpha coefficient above .70 (65-66). poorly defined items were classified as those items that, when deleted, increased the alpha by more than .10. items with correlations of less than .30 with the total scale score or items that negatively correlated with other items in the total scale or subscale were examined for their untoward effect on internal consistency (65-66). construct validity was examined by identifying and summarizing the major underlying dimensions of the b-past using exploratory factor analysis and standard procedures for identifying the factor structure (communality estimates, factor extraction, and promax rotation for the standard regression coefficients) (67). the factorloading cut off criterion was established at .40 and complex situations were defined when items loaded onto two factors showed differences in loadings of .2 or less (67). promax rotation was selected in order to maximize the variability of items. the determination of meaningful factors was based on four criteria: (1) eigenvalues greater than one, (2) notable breaks in the scree test, (3) proportion of explained variance above 25% for each factor, and (4) conceptual interpretability (67). further b-past construct validity was evaluated using the following criteria for correlations: p values less than .05 and pearson correlations (68) of .30 or greater with the ipr scale (60-61) and the ces-d scale, (63) and less than -.30 with the mhs (62). one way anova and differences in contrasted group means (abused vs. non-abused) were used to determine statistical differences (p values were less than .05) for interpersonal violence, depression, and hope (62). in order to satisfy assumptions for factor analysis, contrasting group means, one-way anova testing and pearson correlations, revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005100 the data were assessed using the following criteria: (1) likert instruments were considered interval measurements; (2) participants were conveniently sampled but were obtained crossing ethnic, income, and geographical boundaries to achieve randomness and each score represented one observed variable; (3) the normal distribution was reviewed using frequency distributions. data outliers were removed leaving a range of scores and standard deviations as low to moderate in size on the total instruments and their subscales; and (4) analyses remained robust because of the sample size of 239 (67-68). results validity responses from the teen sample were subjected to exploratory factor analysis using squared multiple correlations as prior communality estimates (67). in interpreting the rotated factor pattern, two factors emerged into the physical/sexual and the social/emotional dimensions (table 2). furthermore, dimensions were related yet distinct from the each other. approximately 70.9% of the variance was explained by these two factors. beyond factor two, the variance explained was insignificant. factor one, physical/sexual abuse, incorporates items related to actual or threats of physical and sexual partner abuse (i.e. �my partner kicks me, my partner says he will hurt me using a weapon, my partner gives me sex infections�). this factor explained the 37.5% of the variance and had the highest factor loadings. its dominance is consistent with the literature and interactions involving a partner�s threats or actual physical/sexual abuse. factor two, social/emotional abuse, explained 33.4% of the variance, and items within this scale reflect behaviors consistent with a partner�s tactics to humiliate, put down, demand, or dictate what another person can do (i.e. � my partner calls me bad names like bitch, my partner doesn�t let me go out with my friends, my partner tells me what to wear�). as expected, findings demonstrated that the b-past had a negative correlation with the mhs (r = -.42, p < .001) and a positive correlation with the ipr (r = .39, p < .001) and the cesd (r = .46, p < .001). statistical differences in contrasted group means (abused vs. non-abused) demonstrated that teen girls who were abused by a partner reported higher scores for abuse overall and for each subscale (n = 239, p < .0001). one-way anova demonstrated that abused teens scored higher for violence in interpersonal peer relationships (n = 239, t = -2.50, p < .01) and more depression (n = 239, t = -4.09, p < .0001) but less hope (n = 239, t = 4.04, p < .0001). internal consistency the internal consistency coefficients for the 22-item b-past were .97, .95, and .91 for the total scale, physical/sexual abuse subscale, and the social/emotional abuse subscale, respectively. item-to-total correlations for the 22-item scale ranged from .38 to .88. no items were found to increase the alpha by more than .10 if deleted. additionally, no items were found to negatively correlate with items in the total scale or within its own subscale. the interfactor (physical/sexual subscale with the social/emotional subscale) correlation analysis revealed a moderate to strong correlation (r = .64), which suggested that each factor represented a related but distinct dimension of partner abuse. table 4 outlines the reliability analyses. discussion compatible with the literature, the study confirmed that teen girls experience partner abuse (1-30, 34-39). the results also showed that the b-past extends the number of social and sexual acts perpetrated reported in the literature, which gives a more complete picture of teen partner abuse (1-26, 30, 35, 37). empirical support for hypothesis testing was provided by factor analysis, pearson correlation, and one-way anova or contrasted means to determine the instrument�s ability to discriminate between teen girls who reported partner abuse and those who did not. a two-factor solution accounted for a high proportion of explained variance (70.9%) for the 22-item b-past. other partner abuse scales have produced adequate explained variance but are limited to development and psychometric testing among adults (44-48). pearson correlation showed a relationship between abused teen girls and depression, less hope, and peer interpersonal violence. these findings are consistent with the literature (2-26, 29-32, 3436, 49, 52). one-way anova and differences between contrasted groups (abused vs. non-abused) were also consistent with the literature that showed teen girls abused by partners report higher scores for partner abuse, problems in other relationships (2-26, 29, 36, 49, 52), depression (30, 32), and less hope (31, 34). additionally, the findings lend support to the notion that social/emotional abuse is an aspect of partner abuse that may be especially relevant to teens. in teen girls, social/emotional partner abuse is important to address since partners often do not live together, and therefore, physical abuse is more difficult to impose or keep hidden from the teen girl�s family. the literature suggests that teen girls are more apt to comply with social control in an effort to please the partner (51-52). finally, the findings indicated that the b-past is well suited to measure partner abuse in teen girls. the cronbach alpha coefficient psychometric assessment of the burgess-partner abuse scale for teens (b-past) 101 was high suggesting a strong internal consistency. based on a reading level of 2.3, the instrument was easy to read and complete, usually taking about five minutes. efforts were made to reduce the effect of non-probability sampling by obtaining adequate numbers of subjects across three settings to ensure representation of ethnic, income, and geographical groups. none-the-less, the subject to item ratio was well above the recommended number to conduct factor analysis. in summary, the major contribution of this study was the psychometric assessment of a scale that can measure teen partner abuse, paying particular attention to social and sexual teen partner abuse. because the b-past is designed to detect partner abuse in teen girls, it is anticipated that the recognition of partner abuse could aid clinicians to intervene or provide assistance to teen girls in dealing with this problem. given that the results are limited to the scope of this study, further investigation is planned with similar and diverse samples of teens to assess replicability of these findings. a hispanic translation as well as a back-translation of the b-past is in development to extend cultural relevance. upon completion of these endeavors, the information gathered through the b-past can be used to identify risk factors and develop interventions. age 13 15 6.27 14 22 9.21 15 21 8.78 16 58 24.26 17 30 12.55 18 75 31.33 19 17 7.11 missing data 1 0.40 race white 150 62.76 black 86 35.98 hispanic 2 0.83 asian 1 0.40 missing data 0 0.00 grade 6 3 1.25 7 6 2.51 8 15 6.27 9 18 7.53 10 60 25.10 11 24 10.04 12 46 19.24 post high school 66 27.61 missing data 1 0.40 partner�s age 13 1 0.40 14 5 2.09 15 11 4.60 16 9 3.76 17 18 7.53 18 32 13.38 19 42 17.57 20 24 10.04 21 12 5.02 over 21 64 26.77 missing data 21 8.78 table 1. demographic data for study participants (n = 239) demographic category total frequency % revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005102 table 2. factor structure of the 22-item b-past, two-factor solution (n = 239) 15 forces me to use drugs .95 14 hurt me using a weapon .91 13 gives me sex infections .85 20 chokes me .83 17 will hurt my family .82 16 beats me up .79 7 forces me to have sex .78 6 will hurt me using a weapon .73 12 can have sex with others .69 11 kicks me .66 4 says he will hurt me .50 9 follows me .47 1 won�t let me go out .88 19 tells me what friends to hang out with .87 21 yells at me .84 8 calls me stupid .81 18 tells me what school activities i can and cannot do .76 5 calls me names .75 22 says we can�t break up .71 10 hits something when mad .67 2 tells me what to wear .65 3 no sex, no love .52 item description factor 1 factor 2 physical/sexual social/emotional partner�s race white 133 54.64 black 81 32.89 hispanic 3 1.25 asian 1 0.41 missing data 21 11.38 partner�s highest grade level 6 2 0.83 7 12 5.02 8 28 11.71 9 46 19.24 10 46 19.24 11 33 13.80 12 24 10.04 post high school 15 6.27 missing data 33 13.80 demographic category total frequency % psychometric assessment of the burgess-partner abuse scale for teens (b-past) 103 table 3. pearson correlation matrix (n = 239) b-past 1.00 .39 -.42 .46 ipr 1.00 -.43 .45 mhs 1.00 -.51 cesd 1.00 b-past ipr mhs cesd burgess-partner abuse scale for teens directions: during the past 12 months, you and one of your partners may have had a fight. below is a list of things one of your partners may have done to you. please circle the number of how often this partner did these things to you. this is not a test and there are no right or wrong answers. remember, having a partner (s) does not mean you are having sex with the partner (s). if you have not had a partner in the past 12 months, do not fill this form out. total 22 1.49 .54 0-4 .97 1-22 physical/sexual 12 1.12 .49 0-4 .95 4, 6, 7, 9, 11, 12, 13, 14, 15, 16, 17, 20 social/emotional 10 2.4 .65 0-4 .91 1, 2, 3, 5, 8, 10, 18, 19, 21, 22 note. sd = standard deviation scale number of items mean sd range alpha items table 4. reliability analyses: two-factor 22-item scale (n = 239) 1. my partner doesn�t let me go out with my friends 0 1 2 3 4 2. my partner tells me what to wear 0 1 2 3 4 3. my partner says if i don�t have sex with him/her 0 1 2 3 4 then i don�t love him/her 4. my partner says he/she will hurt me if i talk to 0 1 2 3 4 another guy/girl 5. my partner calls me bad names like bitch 0 1 2 3 4 6. my partner says he/she will hurt me with a weapon 0 1 2 3 4 a few more than routinely never once times a few times or a lot revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005104 a few more than routinely never once times a few times or a lot 7. my partner forces me to have sex 0 1 2 3 4 8. my partner tells me i am stupid or dumb 0 1 2 3 4 9. my partner follows me when i do things with my 0 1 2 3 4 friends or family 10. my partner hits or kicks something when 0 1 2 3 4 he/she gets mad at me 11. my partner kicks me 0 1 2 3 4 12. my partner says he/she can have sex with other 0 1 2 3 4 even though he/she said i can�t 13. my partner gives me sex infections 0 1 2 3 4 14. my partner hurts me using a weapon 0 1 2 3 4 15. my partner forces me to use drugs even though 0 1 2 3 4 i don�t want to 16. my partner beats me up so bad 0 1 2 3 4 17. my partner says he/she will hurt my family if i 0 1 2 3 4 don�t do what he/she says 18. my partner tells me what school activities 0 1 2 3 4 i can and can�t do 19. my partner tells me what friends 0 1 2 3 4 i can hang out with 20. my partner chokes me if he/she gets mad at me 0 1 2 3 4 21. my partner yells at me if he/she doesn�t know 0 1 2 3 4 where i am 22. my partner says we can�t break up even though 0 1 2 3 4 i want to how many partners have you had in the past 12 months?__________ copyright, 2002 & 2003 stephanie e. burgess permission is granted for use in 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guedes6 instrumento tarjetas de cualidad del dolor: adaptación cultural y evidencias de validez en niños 1 orcid.org/0000-0001-7977-6431. universidade de são paulo, brasil. milyconstanza@usp.br 2 orcid.org/0000-0003-3375-8101. universidade de são paulo, brasil. rossato@usp.br 3 orcid.org/0000-0002-3139-2540. the hospital for sick children (sickkids), canada. mariana.bueno@sickkids.ca 4 orcid.org/0000-0002-1715-006x. universidade federal do recôncavo da bahia, brasil. emeireles@ufrb.edu.br 5 orcid.org/0000-0002-0893-0478. universidad nacional de colombia, colombia. nsguerrerog@unal.edu.co 6 orcid.org/0000-0001-7962-2483. universidade de são paulo, brasil. danilaguedes@usp.br recibido: 06/06/2017 enviado a pares: 10/07/2017 aceptado por pares: 04/12/2017 aprobado: 08/03/2018 doi: 10.5294/aqui.2018.18.2.7 para citar este artículo / to reference this article / para citar este artigo moreno-ramos mc, mariano-rossato l, bueno m, meireles e, guerrero ns, guedes dm. instrumento tarjetas de cualidad del dolor: adaptación cultural y evidencias de validez en niños. aquichan 2018; 18(2): 198-209. doi: 10.5294/aqui.2018.18.2.7 año 18 vol. 18 nº 2 chía, colombia abril 2018 l 198-209 temática: práctica basada en la evidencia. aporte a la disciplina: adaptar culturalmente y validar un instrumento multidimensional para la evaluación del dolor permite al profesional de enfermería tener acceso a una herramienta adecuada para el contexto colombiano que viabilice en su práctica clínica e investigativa la evaluación del dolor en población pediátrica con heridas. el instrumento también contribuye a la elaboración del proceso de enfermería durante el cuidado a esta población, puesto que facilita la primera fase del proceso que corresponde a la valoración del paciente para, posteriormente, establecer los diagnósticos y las intervenciones de enfermería de manera objetiva y asertiva, así como la evaluación posterior de las intervenciones aplicadas. además de esto, el instrumento facilita la expresión dolorosa por parte del niño y fortalece los procesos comunicativos entre el enfermero, el niño y su familia. resumen objetivo: evaluar la adaptación cultural y encontrar evidencias de validez del instrumento tarjetas de cualidad del dolor (itcd). materiales y método: estudio metodológico y de validación de pruebas, que para la adaptación y validación de contenido realizó la traducción, retrotraducción, panel de expertos, revisión por niños en edad escolar y prueba piloto del itcd. además, se evaluó la validez de criterio externo con 90 niños en edad escolar hospitalizados y con heridas. la investigación fue realizada entre enero y febrero de 2015. resultados: el instrumento fue traducido y retrotraducido a español y a portugués, respectivamente. en la evaluación del panel de expertos fue establecido un índice de validez de contenido de 0,92. en la revisión realizada por los niños se efectuaron cambios a los descriptores de siete tarjetas según sus sugerencias. el estudio piloto, mostró que 17 tarjetas presentaron claridad semántica para más del 90% de los niños. en cuanto a las evidencias basadas en el criterio externo, las variables diagnóstico médico, tipo de herida, infección de la herida e intensidad del dolor mostraron resultados significativos (p<0,05). conclusiones: el instrumento tarjetas de cualidad del dolor fue adaptado culturalmente y mostró evidencias de validez basadas en el contenido y en el criterio externo. palabras clave niño; dimensión del dolor; estudios de validación; enfermería pediátrica; heridas y lesiones (fuente: decs). 199 instrumento tarjetas de cualidad del dolor: adaptación cultural y evidencias de validez en niños l mily constanza moreno-ramos y otros año 18 vol. 18 nº 2 chía, colombia abril 2018 l 198-209 pain quality cards: cultural adaptation and evidence of validity in children abstract objective: evaluate cultural adaptation and find evidence of the validity of pain quality cards as a tool. materials and method: this is a methodological study with test validation. translation, retranslation, a panel of experts, a review by school-age children, and a pilot test of pain quality cards were used to adapt and validate the content. moreover, the validity of the external criterion was evaluated with ninety school-aged children who were hospitalized and had wounds or injuries. this research was conducted between january and february 2015. results: the tool was translated into spanish then retranslated into portuguese. the evaluation by the panel of experts established a content validity index of 0.92. in response to the review carried out by the children, changes were made to the descriptors of seven cards, according to their suggestions. the pilot study showed seventeen cards had semantic clarity for more than 90% of children. regarding the evidence based on the external criterion, the variables of medical diagnosis, wound type, wound infection and pain intensity showed significant results (p <0.05). conclusions: the pain quality cards were culturally adapted and showed evidence of validity based on content and the external criterion. keywords child; dimension of pain; validation studies; pediatric nursing; wounds and injuries (source: decs). 200 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 2 chía, colombia abril 2018 l 198-209 instrumento cartões de qualidade da dor: adaptação cultural e evidências de validade em crianças resumo objetivo: avaliar a adaptação cultural e encontrar evidências de validade do instrumento cartões de qualidade da dor (icqd). materiais e método: estudo metodológico e de validação de testes que, para a adaptação e validação de conteúdo, realizou tradução, retrotradução, painel de especialistas, revisão por crianças em idade escolar e teste-piloto do icqd. além disso, analisou-se a validade de critério externo com 90 crianças em idade escolar hospitalizadas e com feridas. a pesquisa foi realizada entre janeiro e fevereiro de 2015. resultados: o instrumento foi traduzido e retrotraduzido a espanhol e a português, respectivamente. na avaliação do painel de especialistas, foi estabelecido um índice de validade de conteúdo 0,92. na revisão realizada pelas crianças, efetuaram-se mudanças nos descritores de sete cartões segundo suas sugestões. o estudo-piloto mostrou que 17 cartões apresentaram clareza semântica para mais de 90 % das crianças. quanto às evidências baseadas no critério externo, as variáveis diagnóstico médico, tipo de ferida, infecção da ferida e intensidade da dor mostraram resultados significativos (p < 0,05). conclusão: o icqd foi adaptado culturalmente e mostrou evidências de validade baseadas no conteúdo e no critério externo. palavras-chave criança; dimensão da dor; estudos de validação; enfermagem pediátrica; ferida e lesões (fonte: decs). 201 instrumento tarjetas de cualidad del dolor: adaptación cultural y evidencias de validez en niños l mily constanza moreno-ramos y otros introducción la prevalencia del dolor en la población pediátrica varía entre el 27 y el 87 %, donde los niños con diagnósticos quirúrgicos experimentan mayores niveles de dolor agudo en comparación con niños con diagnósticos médicos (1, 2). los niños hospitalizados con diagnósticos quirúrgicos generalmente poseen heridas derivadas de estos procedimientos, que generan dolor en respuesta a los daños tisulares ocasionados por fuerzas mecánicas, irritación química, daño vascular, inflamación o infección, además del propio tratamiento y de procedimientos relacionados con la herida (3, 4). por estas razones, la evaluación del dolor en niños constituye una actividad fundamental de los profesionales de la salud con miras a la elección del tratamiento más adecuado (5). de acuerdo con la organización mundial de la salud (oms) (5), la evaluación del dolor debe realizarse con regularidad y por profesionales debidamente entrenados, con instrumentos válidos y confiables que midan con precisión su multidimensionalidad y ayuden en la evaluación de la eficiencia del tratamiento. la evaluación del dolor en niños con heridas ha sido una situación de salud poco estudiada en el mundo, particularmente en américa latina. la literatura internacional reporta algunos estudios que evaluaron el dolor en niños víctimas de quemaduras a través de instrumentos unidimensionales, que generalmente evaluaban solo la intensidad. un estudio realizado en un hospital de estocolmo (suecia), con 98 niños víctimas de quemaduras, encontró una intensidad de dolor en promedio de 2,7 y mostró que las niñas sienten más dolor que los niños, con mayor intensidad en la primera semana de tratamiento (6). un estudio brasileño (7) que evaluó 100 niños con quemaduras mostró que las quemaduras de segundo grado producían una intensidad de dolor mayor que las quemaduras de tercer grado en los niños. por otro lado, una revisión sistemática (8) que analizó los instrumentos disponibles que evalúan el dolor en niños y adolescentes con dolor agudo posquirúrgico, derivado de procedimientos y hospitalizaciones, encontró cerca de 34 instrumentos, de los cuales apenas seis eran válidos y confiables en cuanto a su contenido, constructo, interpretabilidad, viabilidad y capacidad para medir los cambios. de esa manera, se identificó la necesidad de adaptar y validar al idioma español un instrumento que permitiera evaluar el dolor de manera multidimensional en niños con heridas. entre los instrumentos que evalúan el dolor de una manera multidimensional se destaca el instrumento tarjetas de cualidad del dolor (itcd) (9), construido en brasil en 1996 a partir del mcgill pain questionnaire. el instrumento contiene dieciocho descriptores de cualidad del dolor, acompañados por una representación gráfica con el personaje cebollita (diseños elaborados por maurício de souza produções s.a), que facilita la calificación por la población infantil. los descriptores, a su vez, están distribuidos en cuatro componentes de acuerdo con la teoría multidimensional del dolor (10): el componente sensorial (tarjetas 1-8), que representa las propiedades temporales, espaciales, de presión y térmicas; el componente afectivo (tarjetas 9-13), que alude a la tensión, al miedo y a las propiedades autonómicas; el componente evaluativo (tarjeta 14), que representa la intensidad global y subjetiva de la experiencia dolorosa, y el componente miscelánea (tarjetas 15-18), que engloba descriptores que no se encuentran ligados a los otros componentes. el instrumento cuenta con diferentes estudios de validación y aplicación en niños y adolescentes brasileños, en los que se ha identificado su utilidad. un estudio (9) cuyo objetivo fue verificar la representatividad del itcd aplicó el instrumento en 50 niños en edad preescolar, escolar y adolescente en el hospital y mostró que, para el grupo escolar, 14 (77,8 %) de las tarjetas fueron reconocidas correctamente y 4 (22 %) no fueron reconocidas. la utilización del ictd mostró ser factible y capaz de evaluar y discriminar las diferentes dimensiones del fenómeno doloroso en población pediátrica. otro estudio (11) realizado en niños y adolescentes hospitalizados en una unidad de onco-hematologia pediátrica de un hospital público tuvo como objetivo realizar la evaluación del dolor con el uso del itcd; dicho estudio mostró que fueron identificadas 13 tarjetas por 8 niños y adolescentes. las tarjetas más identificadas fueron queimação, dolorida, atormenta, forte, aperto, además que los niños eligieron más de una tarjeta. un estudio transversal (12) que tuvo por objetivo evaluar el dolor de 48 niños hospitalizados en edad escolar y verificar la asociación entre género, franja etaria y diagnóstico médico de estos, y la elección de las tarjetas del itcd, encontró que niños con menos edad eligieron más la tarjeta forte, y niños con mayor edad eligieron más las tarjetas cansativa y aborrecida. con relación al género no se encontraron diferencias en la elección de las 202 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 tarjetas realizada por los niños y las niñas; y, por último, niños con diagnósticos neurológicos eligieron más las tarjetas fisgada y apavorante, y niños con infecciones bacterianas o virales eligieron más la tarjeta repuxa. el itcd tiene por objetivo cualificar el dolor de acuerdo con el relato y la elección del niño de manera fácil, rápida, práctica y lúdica (13). permite también comprender el dolor como fenómeno multidimensional y fortalecer la comunicación entre el paciente, la familia y los profesionales de la salud, orientando la elección y evaluación del tratamiento del dolor. sin embargo, por encontrarse en idioma portugués, fue necesario realizar su adaptación cultural y validación, para posibilitar su uso en el contexto colombiano. según lo expuesto, el objetivo de la investigación fue evaluar la adaptación cultural del itcd y encontrar evidencias de validez de contenido y criterio externo en niños colombianos con heridas. materiales y métodos estudio de tipo metodológico y de validación de pruebas, que siguió las directrices internacionales recomendadas para la adaptación y validación de instrumentos (14-16). para la adaptación del itcd se obtuvo la autorización de la autora del instrumento en su versión original, así como la aprobación del comité de ética de la escola de enfermagem da universidad de são paulo (brasil) (no. 884.464), y del comité de ética del hospital pediátrico fundación hospital de la misericordia (no. cei-55-14) localizado en la ciudad de bogotá (colombia). la investigación fue realizada durante los meses de enero y febrero del 2015. adaptación cultural y validación de contenido 1. traducción: fueron realizadas dos traducciones a la lengua española de la versión en portugués del itcd (t1 y t2) por profesionales bilingües nativos de colombia, de los cuales uno era profesional del área de la salud, con conocimientos de dolor pediátrico y del objetivo del estudio, y el segundo tenía formación académica en el área de lingüística, sin conocimiento del estudio. 2. síntesis de las traducciones: se elaboró una versión síntesis (v1) en donde se unificaron las dos traducciones del instrumento. dicho procedimiento fue realizado por los profesionales responsables de la traducción y la investigadora principal. 3. retrotraducción: fueron realizadas dos traducciones al idioma portugués (rt1 y rt2) de las dos traducciones (t1 y t2) del itcd en idioma español por dos lingüistas bilingües nativos de brasil que no tenían conocimiento de los objetivos del estudio. además, la investigadora principal y la autora del instrumento compararon la versión original del itcd con rt1 y rt2, para garantizar que la síntesis de las traducciones (v1) mantuviera el contenido de la versión original del instrumento. 4. validación de expertos: se conformó un comité con siete especialistas cuyo idioma materno era el español, con experiencia en, por lo menos, uno de los siguientes temas: adaptación/validación de instrumentos, abordaje asistencial del dolor, enfermería pediátrica o prevención y tratamiento de heridas, aprendizaje o enseñanza a niños. la investigadora principal contactó a los profesionales a través de mensajes electrónicos a donde fue enviada la versión síntesis del instrumento (v1) y un instrumento para evaluar cuantitativa y cualitativamente su equivalencia semántica, idiomática, cultural y conceptual, además de su contenido con relación a la representatividad, claridad semántica y dimensión teórica. las discrepancias fueron resueltas vía electrónica, en donde la investigadora principal consultaba a los especialistas para realizar los ajustes propuestos en el instrumento de evaluación. dichas alteraciones se realizaban si 5 de los 7 especialistas estaban de acuerdo. una vez resueltas las discrepancias entre los especialistas, se obtuvo la versión en español (v2) del itcd. 5. revisión por la población objeto: esta revisión tuvo por objetivo examinar el contenido del instrumento en relación con la claridad, adecuación y comprensión de los ítems (15). la revisión fue realizada por sesenta niños entre 6 y 12 años que fueron abordados en un colegio privado (n = 30) y en un hospital pediátrico (n = 30). la muestra fue estimada con el objetivo de garantizar su homogeneidad, puesto que en cada grupo fueron entrevistados 15 niños y 15 niñas de cada franja etaria. los criterios de inclusión contemplados fueron haber nacido en colombia –hispanohablantes– y tener capacidad preservada de comunicación, es decir, poder verbalizar e indicar sus necesidades. los niños que aceptaron participar en la investigación firmaron el asentimiento informado (ai), y se obtuvo autorización de los 203 instrumento tarjetas de cualidad del dolor: adaptación cultural y evidencias de validez en niños l mily constanza moreno-ramos y otros responsables por medio de la firma del consentimiento informado (ci). en relación con los niños abordados en el hospital, se aplicó el mismo procedimiento descrito, se adicionó como criterio de inclusión niños que tuvieran una herida y como criterios de exclusión posoperatorio inmediato, bajo ventilación mecánica y en uso de sedantes continuos. para la recolección de los datos la investigadora les mostró a los niños el itcd (v2) y les realizó individualmente la siguiente pregunta: “cebollita está con dolor. ¿cuénteme cómo es el dolor de él?” de acuerdo con la descripción de los niños, se evaluó la representatividad de cada tarjeta, es decir, si había o no correspondencia entre la descripción y el descriptor. además, se preguntó si la palabra era clara; si no era clara, ellos daban sugerencias. se mantuvieron los descriptores representativos y claros para más del 60 % de cada muestra, en caso contrario, las palabras sugeridas por los niños fueron analizadas e incluidas en la versión en español (v3) del itcd. 6. prueba piloto: se realizó con treinta niños hospitalizados con heridas diferentes a las de los niños entrevistados en la etapa anterior, de acuerdo con las directrices internacionales para estudios de adaptación y validación de contenido (14, 16), y se utilizaron los mismos criterios de elegibilidad y aspectos éticos. luego se recolectaron los datos sociodemográficos y clínicos de las historias clínicas; se mostró el itcd (v3) y se les preguntó “estas tarjetas muestran que cebollita está con dolor. ¿cuál o cuáles tarjetas representan su dolor?” también se les preguntó si los descriptores eran claros. con base en la respuesta, se realizaron los ajustes necesarios para obtener la versión final del itcd (v4). evidencias de validez de criterio externo las evidencias de validez basadas en las relaciones con las variables externas (diagnóstico médico, tipo de herida, infección en la herida e intensidad del dolor) representan las principales fuentes que permiten verificar la aplicabilidad de un instrumento de medida para fines de diagnóstico o predictivos (17, 18). para evaluar esta propiedad, se construyó una muestra de conveniencia de noventa niños hospitalizados con heridas. no fue posible aleatorizar la muestra debido al bajo número de niños disponibles en los servicios de hospitalización que cumplían con los criterios de inclusión. según hair et al. (19), en los procesos de validación es necesario incluir un mínimo de cinco personas por cada ítem del instrumento, en este caso el número de ítems fue 17, lo equivalente a un mínimo de 85 individuos. teniendo en cuenta que la etapa escolar envuelve diferentes franjas etarias y género, se decidió seleccionar una cantidad equitativa de niños de ambos sexos y de cada edad (6, 7, 8, 9, 10, 11 y 12 años), con los mismos criterios de elegibilidad y aspectos éticos de los grupos de niños anteriores (pasos 5 y 6). además, se compararon los valores de elección de cada componente del itcd (sensorial, afectivo, evaluativo y misceláneo) por parte de los niños en relación con las variables externas (diagnóstico médico, tipo de herida, infección en la herida e intensidad del dolor). se recolectaron los datos sociodemográficos y clínicos de la historia clínica, y, en seguida, se presentó el itcd versión final (v4) y la siguiente pregunta: “estas tarjetas muestran que cebollita está con dolor. ¿cuál o cuáles tarjetas representan su dolor?”. enseguida se le presentó la escala numérica del dolor al niño, y se le solicitó la elección del número que mejor representara su dolor, donde 0 era sin dolor y 10 era el máximo dolor imaginable. se eligió esta escala por evaluar la intensidad del dolor, que fue considerada una variable externa para obtener evidencias en la validez de criterio externo. la intensidad del dolor fue presentada en tres categorías: dolor leve de 1 a 3, dolor moderado de 4 a 6 y dolor fuerte de 7 a 10. análisis de los datos los datos fueron procesados a través del programa statistical package for the social sciences-ibm® versión 19. el análisis descriptivo de los datos se realizó presentando valores de frecuencias absoluta y relativa para variables categóricas; para variables numéricas, media y desviación estándar. la muestra presentó distribución anormal, por tanto, los análisis comparativos se realizaron por medio de estadísticas no paramétricas. para las comparaciones entre dos grupos se utilizó el test mann-whitney, y para tres o más grupos el test kruskal wallis. se asumió un nivel de significancia p < 0,05. 204 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 resultados adaptación cultural y validación de contenido 1. traducción: se reportaron algunas dificultades en los descriptores 2 fisgada, 6 repuxa y 18 espalha, pues no existe traducción exacta del descriptor para el español, pero se optó por elegir la palabra que más se aproximara a la palabra original del instrumento; el resultado fue: 2 tirón, 6 sacudida y 18 se extiende. 2. retrotraducción: hubo una adecuada equivalencia de las palabras respecto a la versión original, por lo que no fue necesario realizar ajustes en la síntesis de las traducciones (v1). 3. comité de especialistas: se sugirió modificar la palabra de la tarjeta 10, atormenta, por la palabra desespero, para que fuera más comprensible. el 70 % de los especialistas sugirió la eliminación de la tarjeta 6, sacudida, ya que indicó que la imagen representaba el mismo contenido que la tarjeta 2, tirón. sin embargo, no se eliminó con miras a obtener mayores evidencias en fases posteriores. se obtuvo un índice de validez de contenido (ivc) total de 0,92, lo que mostró la validez de contenido del itcd (valor adecuado mayor a 0,78) (20). el prevalence adjusted and bias adjusted kappa (pabak) (21) mostró un valor de 0,79 para representatividad; de 0,74 para dimensión teórica, y de 0,69 para claridad semántica; son aceptables valores mayores a 0,21. 4. revisión por la población objeto: doce tarjetas fueron representativas y quince fueron consideradas claras para más del 60 % de la muestra. los descriptores de las tarjetas que presentaron dificultad para ser representativos y claros fueron: 1 quemazón, 5 hormigueo, 7 punzante, 10 atormenta, 12 marea, 13 enloquecedor y 18 se extiende. por tanto, se realizaron ajustes en dichos descriptores de acuerdo con las sugerencias de los niños, lo que generó las siguientes modificaciones: 1 ardor, 5 cosquilleo, 7 chuzón, 10 tormentoso, 12 mareo, 13 desesperante, 18 en todo el cuerpo. 5. prueba piloto: se observó que ninguno de los niños escogió la tarjeta 6 sacudida; además, que el 33,3 % expresó semejanza entre las tarjetas 2 tirón y 6 sacudida, por lo que se decidió eliminar esta última. los restantes diecisiete ítems del instrumento fueron claros y representativos para más del 90 % de los niños, con excepción del ítem 10 tormentoso, que mostró ser claro para más del 70 %. la figura 1 presenta la versión adaptada (v4) del itcd para la lengua española, con un total de diecisiete tarjetas acompañadas de número y leyenda. para su aplicación, el profesional debe ofrecer el instrumento al niño y realizar la siguiente pregunta: “estas tarjetas muestran que cebollita está con dolor. ¿cuál o cuáles tarjetas representan su dolor?”, en seguida debe pedir al niño que realice su elección y anotar el respectivo registro. evidencias de validez de criterio externo la mayoría de los niños que participaron de esta etapa eran de sexo femenino (53,3 %), con una edad promedio de 9 (± 2) años, procedentes de bogotá (78,9 %), y con su madre como cuidadora principal (63,3 %). en relación con las características clínicas, el diagnóstico médico predominante fue de cirugía abdominal (57,8 %), con un promedio de 5,1 (± 4,6) días de hospitalización. los niños tenían heridas quirúrgicas (60 %) y agudas (96,7 %), localizadas en el abdomen y el área pélvica (60 %), con una duración de 5,2 (± 7,5) días, sin signos de infección local (87,8 %). en relación con la evaluación del dolor, los niños presentaron dolor de tipo agudo (98,9 %), con una intensidad en promedio de 5 (± 3,2) según la escala numérica del dolor, y tenían prescritos medicamentos para el dolor (96,7 %). a continuación se presentan los resultados estadísticamente significantes (p < 0,05) de las comparaciones entre la puntuación de elección de las tarjetas y las variables externas, es decir, los niños con diagnóstico médico, tipo de herida, infección e intensidad del dolor. diagnóstico médico: según la tabla 1, los componentes sensorial y misceláneo diferenciaron el grupo de niños con trauma general u ortopédico del grupo de niños con cirugías abdominales. también diferenciaron a los niños con cirugías abdominales de aquellos con quemaduras, y a niños con trauma general u ortopédico de los niños con quemaduras. tipo de herida: según la tabla 2, las comparaciones muestran que los componentes sensorial, evaluativo y misceláneo diferenciaron el grupo de niños con heridas quirúrgicas del grupo de niños con quemaduras. además, diferenciaron a los niños con heridas traumáticas u ortopédicas de aquellos víctimas de quemaduras. por último, el componente sensorial también diferenció a los niños con heridas quirúrgicas del grupo de niños con heridas traumáticas y ortopédicas. 205 instrumento tarjetas de cualidad del dolor: adaptación cultural y evidencias de validez en niños l mily constanza moreno-ramos y otros tabla 1. comparaciones entre diagnóstico médico y componente. test mann whitney u. bogotá (colombia), 2015 figura 1. instrumento tarjetas de cualidad del dolor (itcd) versión adaptada (v4). bogotá colombia, 2015 componente diagnóstico médico n mann-whitneyu valor p sensorial cirugías abdominales 52 361,500 0,009 trauma general ortopédico 22 misceláneo cirugías abdominales 52 416,500 0,047 trauma general u ortopédico 22 sensorial cirugías abdominales 52 51,000 0,000 quemaduras 10 misceláneo cirugías abdominales 51 144,000 0,029 quemaduras 10 sensorial trauma general u ortopédico 22 49,500 0,023 quemaduras 10 misceláneo trauma general u ortopédico 22 40,500 0,004 quemaduras 10 fuente: elaboración propia. fuente: elaborado por rossato-mariano l (2006) y maurício de souza produções s.a. 206 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 intensidad del dolor: se constató correlación estadísticamente significativa entre la intensidad del dolor del niño y la elección de las tarjetas, la cual fue estadísticamente significante en los componentes sensorial (r = 0,254; p = 0,015), afectivo (r = 0,232; r = 0,028) y evaluativo (r = 0,227; p = 0,031). también se compararon las categorías de intensidad del dolor (1 a 3 = leve; 4 a 6 = moderado; 7 a 10 = fuerte) con la elección de tarjetas. según la tabla 3, los componentes sensorial, afectivo y evaluativo diferenciaron significativamente el grupo de niños con dolor fuerte del grupo de niños con dolor leve. tabla 3. comparaciones entre intensidad de dolor y componente. test mann whitney u. bogotá (colombia), 2015. infección de la herida: el componente sensorial diferenció el grupo de niños sin infección del grupo de niños con infección (mann whitney u = 189.500; p = 0,001). discusión para la adaptación cultural de este instrumento fue adoptado como referencial metodológico la propuesta desarrollada por beaton et al. (14, 16), por ser ampliamente utilizada en diversas investigaciones de adaptación cultural a nivel mundial, lo que demanda una menor inversión de tiempo y de recursos financieros y humanos en comparación con otras metodologías de adaptación más contemporáneas (22, 23). en la validación realizada por los expertos con relación al contenido del instrumento se obtuvo un ivc total de 0,92. sin embargo, hubo ítems que presentaron valores aceptables de 0,78, como 1 ardor y 15 aburridor para representatividad, claridad semántica y dimensión teórica. otros ítems, como 4 adolorido y 15 aburridor también presentaron índices aceptables con relación a la representatividad. en general, la concordancia (pabak) entre los expertos fue sustancial, es decir, con valores mayores a 0,69, lo que resultó en la validación en contenido del itcd. tabla 2. comparaciones entre tipo de herida y componente. test mann whitney u, bogotá (colombia), 2015 fuente: elaboración propia. componente tipo de herida n mann whitneyu valor p sensorial quirúrgica 54 491,000 0,050 traumáticas u ortopédicas 24 sensorial quirúrgica 54 74,000 0,000 quemaduras 10 evaluativo quirúrgica 54 173,000 0,023 quemaduras 10 misceláneo quirúrgica 54 160,000 0,014 quemaduras 10 sensorial traumáticas u ortopédicas 24 58,000 0,013 quemaduras 10 evaluativo traumáticas u ortopédicas 24 73,000 0,028 quemaduras 10 misceláneo traumáticas u ortopédicas 24 55,000 0,004 quemaduras 10 componentes intensidad del dolor n mann-whitney u valor p sensorial leve 33 366,500 0,020 fuerte 32 afectivo leve 33 394,500 0,043 fuerte 32 afectivo moderado 23 247,000 0,017 fuerte 32 evaluativo leve 33 361,000 0,005 fuerte 32 fuente: elaboración propia. 207 instrumento tarjetas de cualidad del dolor: adaptación cultural y evidencias de validez en niños l mily constanza moreno-ramos y otros en la evaluación cualitativa realizada por los especialistas, algunos de ellos sugirieron incluir nuevos ítems, modificar las imágenes, eliminar el componente misceláneo o construir definiciones operacionales para garantizar una mejor comprensión de las tarjetas; dichos ajustes no se realizaron porque no hubo consenso entre los especialistas para la ejecución de estos cambios. asimismo, diferentes autores (14, 24) refieren que estudios de adaptación cultural de instrumentos deben producir una equivalencia entre el instrumento original y el adaptado con base en el contenido, a fin de garantizar la retención de las propiedades psicométricas. además, modificar sustancialmente el instrumento implicaría ejecutar procedimientos relacionados con la construcción de uno nuevo y no de adaptación. en la revisión realizada por la población objeto se observaron dificultades en la claridad y compresión de los descriptores: 1 quemazón, 5 hormigueo, 7 punzante, 10 atormenta, 12 marea, 13 enloquecedor y 18 se extiende, principalmente en niños de menor edad (6 y 7 años). esto pudo deberse a la complejidad gramatical de los descriptores puesto que algunos de estos se encuentran relacionados con contenidos abstractos, y los procesos cognitivos ligados a lo abstracto están en desarrollo en niños en edad escolar (25, 26). a pesar de las dificultades en la claridad de las palabras, los niños propusieron nuevas palabras que para ellos representaban la imagen. estas fueron analizadas por la investigadora del estudio y se modificaron aquellas que se mostraron adecuadas, como se decribió anteriormente en los resultados. aunque el descriptor 12 marea presentó una claridad semántica superior al 60 %, se decidió cambiar el sentido femenino del descriptor por el masculino (12 mareo), porque los niños refirieron que era confuso ya que tenía dos significados, el primero relacionado con la corriente del mar, y el segundo relacionado con la sensación de mareo. por tanto, al ajustar el término se eliminó la posibilidad de confusión puesto que la palabra mareo cuenta con un único significado. en las evidencias basadas en el criterio externo se observó que los niños eligieron predominantemente tarjetas del componente sensorial y misceláneo, lo cual muestra la ausencia de niños con dolor neuropático o crónico en la muestra de este estudio. además, de acuerdo con la teoría del desarrollo cognitivo, los niños se encontraban en la etapa de operaciones concretas, caracterizada por el pensamiento lógico y limitado a la realidad física, por lo que eran capaces de clasificar y especificar hechos sobre el mundo (25, 26). esto puede explicar la predominante elección de tarjetas del componente sensorial, ya que el pensamiento de los niños en edad escolar está más orientado a las sensaciones físicas. por último, en la prueba piloto se observó que la versión final del itcd (v4), compuesto por diecisiete ítems, fue clara para más del 70 % de la muestra, sin requerir modificaciones adicionales. por tanto, se consideró la adaptación del instrumento para el idioma español en colombia. por otro lado, en relación con las comparaciones en el diagnóstico médico, se encontraron diferencias significativas entre la elección de las tarjetas de los componentes sensorial y misceláneo, y los diferentes diagnósticos, y de la misma manera para el tipo de herida. esto puede explicarse por la naturaleza nocioceptiva del dolor agudo (27), relacionado con las heridas agudas, ya que dentro del proceso de cicatrización ocurre una liberación intensa de sustancias algogénicas que activan los receptores cutáneos y los neurotransmisores, lo que lleva a que el niño manifieste cualidades sensoriales derivadas de la herida (27). en este estudio se identificaron correlaciones bajas y estadísticamente significativas entre la intensidad del dolor y la elección de las tarjetas de todos los componentes del itcd en general. los resultados de un estudio (28) realizado en cinco niños y adolescentes entre 8 y 17 años, en california, con el instrumento adolescent pediatric pain tool, solo reportaron correlación entre la intensidad del dolor y la elección de descriptores sensoriales. finalmente, el componente sensorial diferenció el grupo de niños sin infección del grupo de niños con infección. algunos autores afirman que la infección prolonga la fase inflamatoria de la cicatrización, hecho que perpetuaría el dolor nocioceptivo asociado a esta fase y, por tanto, la evaluación de las cualidades del dolor permitiría identificar niños con infección en la herida y así elegir el tratamiento más adecuado para resolver la infección y, por consiguinte, aliviar el dolor (3, 4). conclusión el itcd se adaptó culturalmente para el contexto colombiano en niños escolares con heridas, y presentó una adecuada validez basada en el contenido y en el criterio externo, lo que contribuye a fortalecer el cuidado de enfermería dirigido hacia los niños 208 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 portadores de heridas que enfrentan situaciones de dolor, con instrumentos confiables y válidos, para establecer intervenciones que lo traten. además de esto, ofrecer un instrumento de evaluación del dolor para la práctica clínica de los profesionales de la salud facilita la expresión dolorosa por parte del niño y fortalece la comunicación entre el enfermero, el niño y su familia. se recomienda la realización de estudios posteriores en muestras mayores de niños con diferentes franjas etarias, enfermedades y heridas, para determinar otras propiedades psicométricas del instrumento como la validez de constructo y la confiabilidad. así como la realización de otros estudios en diferentes países de américa latina para generar versiones del instrumento adecuadas a cada población. limitaciones el ictd cuenta con pocos estudios de adaptación y validación de algunas propiedades psicométricas, lo que limitó las comparaciones y las discusiones con relación a las propiedades analizadas. conflictos de interés: ninguno declarado. referencias 1. groenewald cb, rabbitts ja, schroeder dr, harrison te. prevalence 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2006;8(20):1-12. 18. pasquali l. validade dos testes psicológicos: será possível reencontrar o caminho? psicol teor e pesqui. 2007;23(especial):99-107. 19. hair jf, black wc, babin bj, anderson re, tatham rl. análise multivariada dos dados. 6a. ed. pearson; 2009. 20. alexandre nmc, coluci mzo. validade de conteúdo nos processos de construção e adaptação de instrumentos de medidas. cien saude colet. 2011;16(7):3061-8. 21. sim j, wright cc. the kappa statistic in reliability studies: use, interpretation, and sample size requirements. phys ther. 2005;85(3):257-68. 22. gjersing l, caplehorn jrm, clausen t. cross-cultural adaptation of research instruments: language, setting, time and statistical considerations. bmc med res methodol. 2010;10:13. 23. ohrbach r, bjorner j, metric q, jezewski m, john mt, lobbezoo f. guidelines for establishing cultural equivalency of instruments. new york: university of bufalo; 2013. 24. pasquali l. instrumentação psicológica: fundamentos e práticas. porto alegre: artmed; 2010. 25. siegler rs. continuity and change in the field of cognitive development and in the perspectives of one cognitive developmentalist. child dev perspect. 2016;10(2):128-33. 26. barrouillet p. theories of cognitive development: from piaget to today. dev rev. 2015;38:1-12. 27. baliki mn, apkarian av. nociception, pain, negative moods, and behavior selection. neuron. 2015;87(3):474-91. 28. jacob e, mack ak, savedra m, cleve l van, wilkie dj. adolescent pediatric pain tool for multidimensional measurement of pain in children and adolescents. pain manag nurs. 2014;15(3):694-706. 270 283 disturbio na imagem corporal.indd 270 isabelle katherinne fernandes costa1 samilly márjore dantas liberato2 luana souza freitas3 marjorie dantas medeiros melo4 julliana fernandes de sena5 lays pinheiro de medeiros6 distúrbio na imagem corporal: diagnóstico de enfermagem e características defi nidoras em pessoas ostomizadas 1. orcid.org/0000-0002-1476-8702. universidade federal do rio grande do norte, brasil. isabellekfc@ufrn.edu.br 2. orcid.org/0000-0003-1611-286x. universidade federal do rio grande do norte, brasil. samillyliberato@ufrn.edu.br 3. orcid.org/0000-0001-9733-8734. universidade federal do rio grande do norte, brasil. luna_souza@ufrn.edu.br 4. orcid.org/0000-0002-0873-4629. universidade federal do rio grande do norte, brasil. mahmelo@ufrn.edu.br 5. orcid.org/0000-0002-8968-1521. universidade federal do rio grande do norte, brasil. jullianasena@ufrn.edu.br 6. orcid.org/0000-0002-1753-5330. universidade federal do rio grande do norte, brasil. laysenfermagen@ufrn.edu.br recibido: 02 de marzo de 2016 enviado a pares: 06 de abril de 2016 aceptado por pares: 31 de octubre de 2016 aprobado: 16 de noviembre de 2016 doi: 10.5294/aqui.2017.17.3.4 para citar este artículo / to reference this article / para citar este artigo fernandes costas ik, márjore dantas liberato s, souza freites l, dantas medeiros melo m, fernandes de sena j, medeiros lp. distú rbio na imagem corporal: diagnó stico de enfermagem e caracterí sticas de nidoras em pessoas ostomizadas. aquichan. 2017; 17(3): 270-283. doi: 10.5294/aqui.2017.17.3.4 resumo objetivo: identificar na literatura as características definidoras (cd) do diagnóstico de enfermagem distúrbio na imagem corporal em estudos desenvolvidos com pessoas ostomizadas. materiais e métodos: trata-se de uma revisão integrativa realizada no mês de novembro de 2015, nas bases de dados literatura latino-americana e do caribe em ciências da saúde (lilacs), medical literature analysis and retrieval system online (medline), índice bibliográfico espanhol de ciências da saúde (ibecs), pubmed central, cumulative index to nursing and allied health literature (cinahl), web of science e sciverse scopus (scopus). a análise foi realizada mediante consulta à taxonomia nanda-i, com a qual se buscou identificar as características definidoras do diagnóstico em questão. resultados: a amostra foi de 43 publicações, nas quais foram identificadas 14 das 37 cd que compõem o diagnóstico estudado. conclusões: os estudos apontaram relações entre o distúrbio na imagem corporal e alterações na sexualidade, restrições sociais, mudanças no estilo de vida e qualidade de vida. palavras-chave estomia; imagem corporal; diagnóstico de enfermagem; processos de enfermagem; enfermagem (fonte: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 270-283 271 distúrbio na imagem corporal: diagnóstico de enfermagem e características definidoras em pessoas ostomizadas l isabelle katherinne fernandes costa e outros año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 270-283 disturbio en la imagen corporal: diagnóstico de enfermería y características definidoras en pacientes ostomizados resumen objetivo: identificar en la literatura las características definidoras del diagnóstico de enfermería disturbio en la imagen corporal en estudios desarrollados con personas ostomizadas. métodos: se trata de una investigación bibliográfica, en la modalidad revisión integradora de la literatura, descriptiva y con enfoque cualitativo, realizada en noviembre del 2015, en las bases de datos literatura latinoamericana y del caribe en ciencias de la salud, medical literature analysis and retrieval system online, índice bibliográfico español de ciencias de la salud, pubmed central, cumulative index to nursing and allied health literature, web of science y sciverse scopus. el análisis se llevó a cabo por medio de consulta a la taxonomía nanda-i, con la que se buscó identificar las características definidoras del diagnóstico en cuestión. resultados: la muestra fue de 43 publicaciones, en las que se identificaron 14 de las 37 características definidoras que componen el diagnóstico estudiado. conclusiones: los estudios señalan relaciones entre el disturbio en la imagen corporal y alteraciones en la sexualidad, restricciones sociales, cambios en el estilo de vida y calidad de vida. palabras clave diagnóstico de enfermería; estomia; imagen corporal; ostomia; procesos de enfermería (fuente: decs, bireme). 272 aquichan issn 1657-5997 eissn 2027-5374 body image distortion: nursing diagnosis and defining characteristics in ostomized patients abstract objective: the objective was to identify, in the literature, the defining characteristics of a nursing diagnosis of body image distortion in studies developed with ostomized patients. methods: this is a bibliographical study based on an integrative review of the literature in several databases; namely, latin american and caribbean health sciences literature (lilacs), the medical literature analysis and retrieval system online (medline), the spanish bibliographical index of health sciences (ibecs), pubmed central, the cumulative index to nursing and allied health literature (cinahl), web of science and sciverse scopus (scopus). it was conducted in november 2015, using a descriptive and a qualitative approach. the analysis was done by consulting the nanda-i taxonomy and sought to identify the defining characteristics of the diagnosis in question. results: the sample consisted of 43 publications, in which 14 of the 37 defining characteristics that made up the diagnosis were identified. conclusions: studies point to a relationship between body image distortion and alterations in sexuality, social restrictions, changes in lifestyle and quality of life. keywords ostomy; body image; nursing diagnosis; nursing processes; nursing (source: decs, bireme). año 17 vol. 17 nº 3 chía, colombia septiembre 2017 l 270-283 273 distúrbio na imagem corporal: diagnóstico de enfermagem e características definidoras em pessoas ostomizadas l isabelle katherinne fernandes costa e outros introdução estomia é uma abertura criada artificialmente no intuito de desviar o trajeto habitual de eliminação ou alimentação. as estomias de eliminação a partir do trato gastrointestinal são nomeadas a partir do segmento intestinal afetado: denominam-se ileostomias, quando o estoma é realizado na altura do intestino delgado, e colostomias, quando são confeccionadas no intestino grosso. no trato urinário, o desvio do fluxo de urina é intitulado urostomia. o procedimento pode ser classificado como temporário ou definitivo de acordo com a possibilidade de reestabelecimento do trajeto habitual das eliminações (1). para fins de padronização, neste estudo, será adotado o termo estomia por ser utilizado pela sociedade brasileira de estomaterapia (sobest) e por ser o mais apropriado à língua portuguesa, conforme recomendação da academia brasileira de letras. segundo a united ostomy associations of america (uoaa), estima-se que, em 2013, existam aproximadamente 700 mil estomizados nos estados unidos da américa. no brasil, conforme a associação brasileira de ostomizado (abraso), há 33.864 pessoas estomizadas; destas, 4.176 se encontram no nordeste, e 450, no rio grande do norte (2, 3). a realização da cirurgia de derivação acontece pelos mais diversos fatores, tais como: traumas, anomalias congênitas, neoplasias e doenças inflamatórias. ressalta-se a ocorrência de câncer de cólon e reto como uma das principais indicações de realização da estomia (4). considerando essa neoplasia como importante causa de estabelecimento de estomias, estimam-se 17.620 novos casos da neoplasia de cólon e reto em mulheres e 16.660 casos em homens para 2016. avalia-se, segundo estimativas mundiais do ano de 2012, que a neoplasia é a terceira mais comum em pessoas do sexo masculino, incidindo em 746 mil homens; no sexo feminino, por sua vez, é a segunda, determinando 614 mil novos casos (5). a construção da estomia acarreta diversas consequências, tanto físicas quanto psicológicas, para o indivíduo; dentre elas, destacam-se fadiga, náuseas e vômitos, dor, constipação, diarreia, impacto financeiro, alterações na imagem corporal, função sexual, entre outras (6). a imagem corporal pode ser entendida como uma imagem tridimensional, que envolve aspectos psicológicos, sociológicos e fisiológicos que cada indivíduo forma de si mesmo. corroborando com isso, a north american nursing diagnosis association (nanda) define o diagnóstico de enfermagem (de) como “distúrbio na imagem corporal”, uma “confusão na imagem mental do eu físico de uma pessoa”. para determinar um de, é imprescindível o reconhecimento dos dados objetivos e subjetivos, adquiridos durante a coleta de dados do processo de enfermagem, os quais compõem as características definidoras do diagnóstico em questão (7-9). as características definidoras são elementos essenciais para a inferência diagnóstica; trata-se de um conjunto de sinais e sintomas inerentes ao indivíduo que permite observar a presença ou a ausência de um de (10). nesse sentido, as alterações na imagem corporal causadas pela estomia, como o desconforto com a aparência física, a falta de controle sobre o barulho ocasionado pelos movimentos intestinais e a eliminação dos gases, os vazamentos de conteúdo fecal, a rejeição e a vergonha da nova imagem culminam em isolamento social, alterações na sexualidade e mudanças no estilo de vida (11). a variável “imagem corporal” é abordada em diversos estudos que tratam da qualidade de vida das pessoas estomizadas, a fim de avaliar o impacto desse aspecto na adaptação a essa nova conformação física e fisiológica (11, 12). isso posto, objetivou-se, neste estudo, identificar, na literatura científica, as características definidoras do diagnóstico de enfermagem “distúrbio na imagem corporal” em estudos desenvolvidos com pessoas estomizadas. metodologia trata-se de uma pesquisa bibliográfica, na modalidade revisão integrativa da literatura, descritiva e com abordagem qualitativa. esse tipo de revisão sintetiza os estudos disponíveis sobre determinado tema e conduz a prática baseando-se em conhecimento científico (13). para a construção deste estudo, utilizou-se as seguintes etapas: identificação do tema e elaboração da questão de pesquisa, estabelecimento de critérios para inclusão e exclusão de estudos, definição dos dados a serem obtidos a partir dos estudos selecionados, categorização dos estudos, avaliação dos estudos escolhidos, interpretação dos resultados e exibição da síntese das informações (14). 274 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 para o desenvolvimento desta revisão, formulou-se a seguinte questão norteadora: quais as características definidoras relacionadas ao diagnóstico de enfermagem “distúrbio na imagem corporal” em pessoas com estomias? iniciou-se a etapa de estratégia de busca no mês de novembro de 2015, nas bases de dados literatura latino-americana e do caribe em ciências da saúde (lilacs), medical literature analysis and retrieval system online (medline), índice bibliográfico espanhol de ciências da saúde (ibecs), pubmed central, cumulative index to nursing and allied health literature (cinahl), web of science e sciverse scopus (scopus ). durante o levantamento das publicações, foram utilizados descritores não controlados do vocabulário medical subject headings (mesh), na língua inglesa: “ostomy” e “body image”. a opção por descritores não controlados ocorreu em virtude da quantidade limitada de publicações referentes ao objetivo deste estudo. o cruzamento desses descritores ocorreu por meio do operador booleano and, sendo esta uma combinação restritiva. não houve delimitação temporal, de ano ou de idioma, uma vez que se buscou encontrar o maior número de evidências que pudessem expressar a presença das características definidoras nesse público. foram incluídos na pesquisa os estudos que obedeceram aos seguintes critérios: artigos disponíveis na íntegra e gratuitamente nas bases de dados supracitadas e os que apresentassem nos seus resultados pelo menos uma característica definidora do de estudado. foram excluídos os gêneros textuais editorial, carta ao editor e revisão de literatura, além de estudos de natureza acadêmica, como monografias, dissertações e teses. por fim, após a leitura na íntegra dos artigos selecionados na etapa anterior, foram definidos os artigos que conformaram a amostra final desta revisão integrativa da literatura. a análise dos estudos ocorreu a partir da taxonomia nanda-i e buscou-se identificar as características definidoras do diagnóstico em questão. para análise do nível de evidência, utilizou-se como parâmetro o instituto joanna briggs, que classifica os estudos em quatro níveis de evidência científica: “nível i ─ evidência obtida a partir de revisão sistemática que continha apenas ensaios clínicos controlados randomizados; nível ii ─ evidência obtida a partir de, pelo menos, um ensaio clínico controlado randomizado; nível iii.1 ─ evidência obtida a partir de ensaios clínicos controlados bem delineados, sem randomização; nível iii.2 ─ evidência obtida a partir de estudos de coorte bem delineados ou caso-controle, estudos analíticos, preferencialmente de mais de um centro ou grupo de pesquisa; nível iii.3 ─ evidência obtida a partir de séries temporais múltiplas, com ou sem intervenção e resultados dramáticos em experimentos não controlados; nível iv ─ parecer de autoridades respeitadas, baseadas em critérios clínicos e experiências, estudos descritivos ou relatórios de comitês de especialistas (15). a figura 1 descreve quantitativamente os passos realizados nas bases de dados para obtenção dos 43 estudos que compõem a amostra final desta revisão. figura 1. descrição das etapas realizadas durante a revisão da literatura fonte: dados da pesquisa. resultados a caracterização da amostra evidencia que a maioria dos estudos possuía abordagem qualitativa (58,1 %), realizados em território internacional (74,4 %), publicados há mais de cinco anos (44,1 %) e com nível de evidência iv (76,7 %). sobre as características definidoras (cd), 14 do total de 37 foram identificadas nos estudos. mudança real na estrutura (100 %), relatos de percepções que refletem uma visão alterada na aparência do próprio corpo (88,4 %) e sentimentos negativos em relação ao corpo (79,1 %) foram as mais reconhecidas na literatura. a tabela 1 descreve a distribuição dos estudos conforme identificação das cd. 275 distúrbio na imagem corporal: diagnóstico de enfermagem e características definidoras em pessoas ostomizadas l isabelle katherinne fernandes costa e outros tabela 1. identificação das cd do de “distúrbio na imagem corporal” características definidoras estudos total n (%) cd objetivas mudança real na estrutura 04,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35, 36,37,38,39,40,41,42,43,44,45,46, 47,48,49,50,51,52,53,54,55 43 (100) mudança no envolvimento social 04,15,16,17,18,19,21,22,24,25,26,27,28,29,30,31,36,37,39,40,41,42,43, 47,49,50,51,53 28 (65,1) comportamentos de monitorar o próprio corpo 15,16,17,18,19,21,24,25,26,27,28,29,30,35,37,38,39,51,52,53 20 (46,5) esconder intencionalmente parte do corpo 14,16,17,18,19,21,24,25,26,28,30,35,38,39,47,50,52 17 (39,5) cd subjetivas relato de percepções que refletem uma visão alterada na aparência do próprio corpo 04,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35, 36,37,38,39,40,41,42,43,44,45, 47, 49,51,52,53 38 (88,4) sentimentos negativos em relação ao corpo 04,14,15,16,17,18,19,20,21,23,24,25,26,27,28,29,30,34,35,36,37,38,39, 40,42,43,45,46,47,48,50,51,52,53 34 (79,1) relato de mudança no estilo de vida 04,15,16,17,18,19,21,22,23,24,25,26,27,28,29,30,35,36,37,38,39,40,41, 42,44,46,47,48,51,52,53 31 (72,1) medo da reação dos outros 15,16,17,18,19,21,23,26,27,28,29,30,37,38,39,47,52,53 18 (41,9) preocupação com a mudança 17,18,19,21,22,25,26,28,37,38,39,48,50,52 14 (32,5) não olhar para uma parte do corpo 16,18,21,24,25,30,35,37,46 9 (20,9) ênfase nos pontos positivos que permaneceram 18,19,21,23,24,25,27,37 8 (18,6) foco na aparência do passado 17,21,26,27,28,52 6 (13,9) não tocar em partes do corpo 18,30,37,46 4 (9,3) personalização de uma parte do corpo por meio de um nome 15,28,52 3 (6,9) fonte: dados da pesquisa. discussão verificou-se, nesta pesquisa, a predominância dos estudos descritivos, que têm como propósito observar, descrever e documentar determinada situação. sobre o nível de evidência, o iv, caracterizado por pareceres de autoridades respeitadas, baseados em critérios clínicos e experiências, estudos descritivos ou relatórios de comitês de especialistas, mostrou-se maioria e evidencia a necessidade de estudos que possam basear a prática clínica, em especial relacionada a pessoas com estomias, visto que há perspectiva de aumento da incidência desse procedimento associado ao crescimento da incidência de câncer (14, 57-58). quanto ao local de realização do estudo, a maior parte dos estudos que abordam a temática em questão é internacional, com destaque para os estados unidos da américa. apenas um estudo nacional compôs a amostra final deste estudo; notoriamente, esse fato deve-se tanto à quantidade superior de bases internacionais em comparação às nacionais quanto à utilização de descritores em inglês para realização deste estudo. 276 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 no que se refere ao de “distúrbio na imagem corporal”, sabese que este é dividido em cd objetivas e subjetivas, como exposto na tabela 1. a objetividade refere-se às condições de vida da pessoa; em contrapartida, a subjetividade está relacionada às avaliações que a pessoa faz da sua vida (59). mudança real na estrutura essa característica definidora reporta-se ao procedimento cirúrgico para realização da estomia e, por esse motivo, foi identificada em todos os estudos. refere-se à alteração física e fisiológica do trajeto percorrido pelo conteúdo urinário e/ou intestinal. resulta em um orifício abdominal que substitui as vias de eliminação de excretas, o que modifica interna e externamente a estrutura corporal (1). comportamentos de monitorar o próprio corpo o distúrbio na imagem corporal não é uma alteração somente física, pois se caracteriza como o indivíduo se enxerga, se sente e se comporta após a mudança. essa alteração interfere diretamente em um aspecto psicológico de suma importância: a autoestima, que se apresenta como uma avaliação global do indivíduo e evidencia-se como uma expressão de aprovação ou desaprovação de si mesmo (42). nesse sentido, a monitoração constante do corpo constitui uma ação nítida nas falas das pessoas com estomias e é motivada pela preocupação com a possibilidade de vazamentos do conteúdo intestinal, alteração na imagem corporal e outras preocupações associadas a esse procedimento, como as alterações nos padrões de atividade sexual, a qual demanda cuidados especiais com a bolsa coletora para mantê-la limpa e segura (15, 60-62). soma-se a isso a forte influência da mídia na idealização do corpo “perfeito”. monitorar, cuidar, modificar e adequar o formato corporal ao preconizado como modelo são atitudes frequentes na população contemporânea. caso contrário, o distúrbio na imagem corporal torna-se evidente, a autoestima diminui, a marginalização e o preconceito, por parte dos que se consideram dentro dos “padrões”, afastam e constrangem os que estão fora deles (62-64). assim, com os estomizados, não poderia ser diferente, visto que a mudança real na estrutura ganha destaque na nova conformação corporal, a qual está longe de ser o que a mídia propaga como belo, levando a pessoa com estomia ao comportamento de monitoramento constante da sua condição física distinta (62, 65). sentimentos negativos com relação ao corpo sobre as principais questões que traspassam essa característica, destacam-se as dificuldades de ajustamento físico, psicológico e social encarados por algumas pessoas com estomias. a literatura demonstra uma forte relação do distúrbio na imagem corporal com o tempo de estomia, de modo que essa perturbação é mais acentuada nos pacientes que realizaram a estomia imediatamente após a cirurgia de ressecção do câncer colorretal, em comparação com os que a fizeram mais tardiamente. além disso, há poucas evidências de ajustamento do distúrbio na imagem corporal, visto que a insatisfação aumentou ao longo do tempo (66). por conseguinte, observou-se, nos resultados deste estudo, uma presença significativa do distúrbio na imagem corporal em pessoas com estomia, especialmente no sexo feminino. um estudo sobre estresse psicológico e enfrentamento em mulheres com câncer demonstra influência das maneiras pessoais das mulheres de avaliar, enfrentar e superar situações de estresse e adoecimento, de modo que percepções mais positivas, otimistas, flexíveis e diretas de lidar com os momentos estressantes favoreceram adaptações mais saudáveis e a minimização do impacto do estresse durante o processo de adequação. ademais, para as mulheres com estomia, o apoio do companheiro é fundamental para um processo adaptativo eficaz, o que demonstra a necessidade de aceitação do outro para melhoria do bem-estar físico e psicológico (67). esconder intencionalmente parte do corpo as alterações no estilo de vestir-se constituem uma etapa fundamental para o processo adaptativo e são necessárias para manter a bolsa coletora da ostomia segura, firme e escondida. para isso, independentemente do padrão corporal, a maioria dos estomizados opta por roupas largas e folgadas (60, 62). o estilo de roupas, principalmente as femininas, possui forte relação com o momento histórico vivido pelas diferentes culturas e sociedades. o século xx caracteriza-se pela “reabilitação 277 distúrbio na imagem corporal: diagnóstico de enfermagem e características definidoras em pessoas ostomizadas l isabelle katherinne fernandes costa e outros do corpo”, que se torna pilar da identidade social, transformando o autoconceito da sociedade em geral (68). a valorização social do corpo e os novos padrões de estética corporal influenciam a vestimenta e estabelecem uma nova relação com o corpo. o que antes escondia e apertava, agora realça e dá mais visibilidade. nesse sentido, as mulheres estomizadas vão de encontro a esse movimento ao retrocederem à época da repressão do corpo, escondendo-o e ofuscando sua própria feminilidade (69). preocupação com a mudança inúmeras são as razões que preocupam o estomizados. destacam-se: a necessidade de manter a bolsa sempre limpa, protegida e escondida; o odor e os ruídos desagradáveis que provêm dos vazamentos, da incontinência, principalmente de flatos e alteração do fluxo das excretas; as modificações na dieta, no estilo de vestirse e a busca incessante por alternativas que auxiliem o processo adaptativo a essa nova condição física e psicológica (12). essa cd possui forte relação sobre todas as outras, de modo que, como dito anteriormente, o controle e a atenção permanente com as alterações no corpo são motivados pelas inquietações que a ostomia proporciona. além desta, outras cd que recebem essa influência são a “mudança no envolvimento social” e “relatos de mudança no estilo de vida” em virtude da alteração na função social e as restrições de lazer motivadas pela vergonha, a insegurança na aderência da bolsa de estomia e as dificuldades para realizar a irrigação e a higiene do dispositivo (60, 70). a realização da irrigação tem a finalidade de esvaziar o colón de gases, muco e fezes, o que permite ao estomizado a regularidade do trânsito intestinal e possibilita o manejo do estoma sem a necessidade do uso do dispositivo coletor por um período de tempo (59, 60). a técnica é feita introduzindo o cateter no estoma, o que leva à fluidez de 500 a 1.500 ml de água tépida por um período de 5 a 10 minutos; grande parte dos efluentes será expelida em 10 a 15 minutos (59). considerado um procedimento seguro e eficaz, ressalta-se sua importância como técnica de alívio e conforto que facilita o convívio da pessoa estomizada em sociedade e que contribui para melhoria do bem-estar e da qualidade de vida dos estomizados (61). as possibilidades de viagens também estão limitadas em decorrência da necessidade de cuidados específicos com a bolsa, os quais exigem tempo e espaço adequados para esse fim. soma-se a isso o fato de muitos dos ostomizados se sentirem marginalizados e estigmatizados pela família, o que os leva ainda mais para o isolamento social e físico (60, 70). o “medo da reação dos outros”, cd subjetiva, também se correlaciona com a “preocupação com a mudança”, principalmente no quesito sexual. diversos estudos revelam a aflição que muitos ostomizados enfrentam no âmbito da sexualidade. o receio de não ser aceito pelo companheiro após as mudanças físicas, a vergonha de se expor e a insatisfação pessoal com a nova conformação corporal permeiam a adaptação sexual da pessoa com ostomia (12, 16, 60, 61). vale ressaltar que a sexualidade é um dos múltiplos componentes da qualidade de vida de um indivíduo, em especial do ostomizado, já que, durante o tratamento para o câncer, ele é submetido a várias técnicas cirúrgicas e antineoplásicas (quimioterapia e/ou radioterapia) que alteram a função sexual fisiológica e psicologicamente (61). ênfase nos pontos positivos que permaneceram a aceitação da ostomia constitui-se um produto final de estratégias eficazes de enfrentamento. vários fatores contribuem e dificultam o processo adaptativo do ostomizado, como a presença de comorbidades associadas, relacionamentos instáveis, sentimentos positivistas e esperançosos, facilidades e entraves no acesso ao serviço de saúde e de apoio especializado, apoio familiar, entre outros. isso posto, é pertinente ressaltar que escores maiores de qualidade de vida são observados em ostomizados que aceitaram a ostomia e enfrentaram de maneira positiva e ativa essa nova condição (60, 71-73). por fim, o entendimento da qualidade de vida de um indivíduo envolve a conciliação de fatores subjetivos e objetivos que refletem a satisfação, a aceitação e a adaptação a essa novidade que afeta o ostomizado em diversas vertentes físicas e psicológicas (71-72). conclusões com base na análise desenvolvida, os estudos demonstraram que o diagnóstico de enfermagem “distúrbio na imagem corporal” pode estar relacionado com pessoas ostomizadas, visto que se identificou na literatura 14 das 37 características definidoras desse diagnóstico. 278 año 17 vol. 17 nº 3 chía, colombia septiembre 2017 aquichan issn 1657-5997 eissn 2027-5374 dentre essas características, as mais frequentes foram: mudança real na estrutura, comportamentos de monitorar o próprio corpo, mudanças no estilo de vida, relato de percepções que refletem uma visão alterada na aparência do próprio corpo, sentimentos negativos com relação ao corpo, esconder intencionalmente parte do corpo e preocupação com a mudança. este estudo evidencia a necessidade de uma percepção mais ampliada desse diagnóstico, que não se restrinja apenas à imagem corporal física, mas também que o considere como um distúrbio que recebe influências, que incluem o gênero, a capacidade de resiliência, coping e a adaptação do ostomizado, e que causa impacto significativo na qualidade de vida, na sexualidade, no estilo de vida e no envolvimento social. baseado nisso, o de, componente fundamental do processo de enfermagem e da sistematização da assistência de enfermagem, poderá contribuir para o planejamento e a execução do cuidado integral para essa população, compreendendo a ostomia além do procedimento cirúrgico e técnico, a fim de proporcionar um apoio holístico à pessoa com ostomia. finalmente, as limitações do estudo incluem a dificuldade em obter na íntegra todos os artigos potencialmente relevantes ao objeto de estudo e a necessidade de síntese dos resultados do grande quantitativo de estudos obtidos. referências 1. bartle c, darbyshire m, gaynor p, hassan c, whitfield j & gardiner a. addressing common stoma complications. nursing & residential care [internet] 2013. 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[acesso 29 nov. 2015]; 15(1):108-15. disponível em: http://www.revistarene.ufc.br/revista/index.php/revista/article/view/1483/pdf 14 reflexiones.p65 revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005128 año 5 vol. 5 nº 1 (5) 128-137 chía, colombia octubre 2005 natividad pinto afanador1 lucy barrera ortiz2 beatriz sánchez herrera3 recibido: 11 de julio de 2005 aprobado: 26 de agosto de 2005 resumen los cuidadores familiares experimentan situaciones ignoradas tanto por el actual sistema de seguridad social como por la familia, ya que no cuentan con un servicio oportuno y eficiente para el fortalecimiento de la habilidad de cuidado en casa y el reconocimiento de la labor. estos aspectos permitieron para enfermería la indagación de algunos aspectos básicos como la caracterización, la importancia de su labor, las necesidades, la calidad de vida y la forma de vivir esa experiencia. el programa �cuidando a los cuidadores® � aborda estos aspectos y ha permitido formular algunas sugerencias para las enfermeras que cuidan personas con enfermedad crónica en el ambiente hospitalario y comunitario. las reflexiones principales apuntan a la identificación de un cuidador hábil que puede desempeñarse tanto en situaciones de enfermedad como de no enfermedad, aplicando así medidas de prevención e intervención. palabras clave cuidador familiar, cuidado, programa para cuidadores. abstract family caregivers experience ignored situations by the current social security system and the family, as they don�t have an opportune and efficient service to enhance the ability of home care and the recognition of their work. these aspects allowed nurses to inquire some basic aspects such as the characterization, the importance of their work, necessities, life quality and the way to live this experience. the program �caring the caregivers ® � approaches these aspects and allows the statement of some suggestions for nurses who care patients with chronic disease in hospitals of communities. the main reflections, are directed toward the identification of an expert caregiver which can be approached even in situations o f illness or health, applying measures of prevention and intervention. key words family caregiver, care, program for caregivers. nota: cuidando a los cuidadores® es un programa que adelanta el grupo de cuidado al paciente crónico de la facultad de enfermería de la universidad nacional de colombia, con el objetivo de fortalecer la habilidad de cuidado del cuidador familiar de una persona con enfermedad crónica. 1 profesora asociada, facultad de enfermería, universidad nacional de colombia. rnpintoa@unal.edu.co 2 profesora asociada, facultad de enfermería, universidad nacional de colombia. barrerao@unal.edu.co 3 profesora asociada, facultad de enfermería, universidad nacional de colombia. cbsanchezh@unal.edu.co reflexiones sobre el cuidado a partir del programa �cuidando a los cuidadores�® 129 través de varios años de trabajo con cuidadores familiares, y con base en la experiencia del programa cuidando a los cuidadores® , el grupo de cuidado al paciente crónico ha ido sacando algunas conclusiones que considera importante socializar con los profesionales de la salud para continuar en la construcción colectiva de este tema. a continuación se responden las preguntas fundamentales del trabajo con cuidadores, contrastando la mencionada experiencia con la revisión de la literatura internacional. ¿quién es el cuidador familiar? se denomina cuidador familiar la persona que tiene un vínculo de parentesco o cercanía y asume la responsabilidad del cuidado de un ser querido que vive con enfermedad crónica. este cuidador participa en la toma de decisiones, supervisa y apoya la realización de las actividades de la vida diaria para compensar la disfunción existente en la persona con la enfermedad (1). los cuidadores familiares son en su mayoría mujeres de edad intermedia, menores que el receptor del cuidado, con estados civiles variados, algunas empleadas y otras amas de casa, con niveles de educación y socioeconómicos heterogéneos, quienes por lo general cuidan al ser querido desde el momento de su diagnóstico y llevan cuidándolo más de seis meses. estas personas sienten que la actividad ocupa la mayor parte del día y, por lo general, desconocen el rol que asumen (2). ¿por qué es importante el cuidador familiar? el estado actual de conocimiento muestra con claridad la importancia de los cuidadores en la atención de las personas con enfermedad crónica, la mayor parte de las cuales son cuidadas por un familiar. se ha señalado de manera reiterada que para los receptores del cuidado la presencia, la actitud y los conocimientos de los cuidadores son definitivos como parte de su entorno y bienestar (3-8). los cuidadores familiares son en su mayoría mujeres, y conforman la parte más importante de las redes de apoyo y soporte social de quienes están enfermos o incapacitados, y desarrollan su potencial de cuidado de múltiples formas (9). se puede afirmar que la situación de los cuidadores atañe a la salud en nuestro medio y que debe abordarse de manera prioritaria, tanto por ellos como por las personas que se benefician de su cuidado (10). es esencial dar al cuidador herramientas para mejorar su habilidad en términos de incrementar la capacidad de afrontamiento de manera tal que satisfaga las necesidades de la persona enferma, responda a la problemática familiar, mantenga su propia salud y fomente la buena relación cuidador-persona cuidada, reconociendo y estableciendo apoyos formales e informales, manejando sentimientos de inadecuación o culpa, y planeando su propio futuro y el de su grupo familiar (11). puesto que los patrones de comportamiento familiar en salud dependen, en gran medida, de aspectos culturales modificados por las influencias del entorno en donde cada día se presentan más amenazas frente a un estilo de vida saludable, y dado que estas amenazas terminarán aumentando la incidencia de enfermedad crónica (12), se debe tener en cuenta una herramienta adicional para fortalecer el cuidado preventivo del cual a la fecha poco nos hemos ocupado. puede, entonces, afirmarse que fortalecer las habilidades de cuidado de los cuidadores familiares es necesario tanto en las revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005130 situaciones de enfermedad como de no enfermedad. se hace indispensable hacer propuestas que contemplen la interrelación con el medio ambiente con el fin de favorecer conductas que minimicen factores de riesgo reconocidos en la aparición y las complicaciones de la enfermedad crónica. ¿qué necesita el cuidador familiar? en el cuidado a largo término la oferta de servicios sociales y de salud no responde a las necesidades de los usuarios quienes, en muchos casos, se encuentran vulnerables y con sentimientos de frustración a pesar de lo cual deben asumir tareas para las que no tienen preparación adecuada (9). con frecuencia los cuidadores hablan de dificultades con la soledad, la falta de servicios accesibles de salud y los costos de los tratamientos ordenados (13). en américa latina se ha observado que las personas que tienen un familiar con enfermedad crónica tienen la obligación de desempeñarse como cuidadores, pero no cuentan con la orientación requerida. se ha documentado de manera importante una deficiente habilidad de cuidado entre estos cuidadores familiares (14-17), pero también se han identificado en ellos fortalezas diferentes a las de otras latitudes, que pueden apoyar el servicio requerido como la disponibilidad de soporte social para los cuidadores (18-20). en nuestros sistemas de salud el cuidador es desconocido, no se le tiene en cuenta o se considera que no sabe, y no se han generado mecanismos sólidos y colectivos para apoyarlo en su responsabilidad. de forma paradójica, cada día con mayor frecuencia el cuidador recibe nuevas delegaciones para las cuales no está capacitado. le entregamos a un familiar enfermo o limitado porque el costo institucional de hospitalización es muy alto para las empresas prestadoras de los servicios de salud o porque no existen servicios adecuados y suficientes de cuidado a largo plazo, y el cuidador debe llevar a esta persona al hogar sin saber qué sucederá. aunque en los últimos tiempos se menciona el fortalecimiento del cuidado en el hogar falta un gran camino por recorrer (21). en los países bajos se ha estudiado un cuidado orientado a la demanda que pudiera ser una alternativa interesante para satisfacer la necesidad de los usuarios. este cuidado parte del reconocimiento de los valores del receptor como algo que subyace en la solicitud. la unicidad, la comprensión, el continuar viviendo, la justicia y la autonomía, así como la relación cuidadorcuidado con equidad, acompañamiento e interdependencia surgen como elementos centrales en la propuesta de interacción. los sentimientos de reconocer a los beneficiarios a partir de un diálogo como fundamento del servicio parecen reforzar la autonomía, la autoestima y la participación (22). estas iniciativas que corresponden a paradigmas propios del cuidado deben ser estudiadas en nuestro contexto, en especial si se considera que el desarrollo de habilidades de cuidado exige el reconocimiento de quienes están inmersos en la experiencia (9). la experiencia de ser cuidador la experiencia de ser cuidador(a) modifica la vida de las personas de manera importante. la experiencia va más allá de tener una tarea o responsabilidad por otra persona para generar una forma de vida y relación diferente consigo misma, con la persona cuidada y con el mundo (23). el cuidador se ve sometido a un estrés permanente por la limitación física, psicológica o cognitiva para realizar su labor, la alteración de la ejecución habitual del rol, la de las interacciones sociales, la percepción de la falta de soporte social y de apoyo de los sistemas de cuidado de la salud, la falta de actividad, de dispersión, la alteración de la ejecución del trabajo habitual, la severidad de la enfermedad del receptor del cuidado, la cantidad de cuidado o supervisión requerida y la alteración de la relación cuidador-cuidado (24). en sus reportes los cuidadores señalan que no saber la evolución de la enfermedad de su ser querido, sentirse solos, la fatiga física de responder por muchos roles y el cansancio emocional son malos compañeros en estas experiencias. las sien nuestros sistemas de salud el cuidador es desconocido, no se le tiene en cuenta o se considera que no sabe, y no se han generado mecanismos sólidos y colectivos para apoyarlo en su responsabilidad. reflexiones sobre el cuidado a partir del programa �cuidando a los cuidadores�® 131 en un estudio sobre enfermedad crónica y cuidado se expone el impacto que en la familia tiene la vivencia de estas situaciones. la autora resalta dentro de la expresión de la habilidad de cuidado los aspectos de cambio de rol y las finanzas. señala que el gasto de la cronicidad es grande, no únicamente en forma personal y emocional sino también financiera; hay usualmente necesidad de múltiples medicamentos, equipos, suministros y, con frecuencia, existe la necesidad de atención médica y de ayuda de otros profesionales (30). estar listo para ser cuidador familiar significa estar disponible para los momentos de verdad en la labor, es saber escuchar y tener el valor, el conocimiento y la paciencia para cuidar. para ello requiere de una capacitación mínima, debe reconocer al ser cuidado en todos los aspectos de la vida y, además, aceptar ser cuidador. sin embargo, es preciso recordar que la expresión de la habilidad no depende en todos los casos de capacidades sino de factores de motivación internos o externos para el desarrollo de la misma (31). el cuidador que es hábil tendrá la posibilidad de encontrar significado en los hallazgos, de mantener un vínculo significativo, de hacer actividades de una forma armónica, de tomar las decisiones pertinentes para determinar el curso de la acción y poder conducir de manera honrosa su actividad. el cuidador hábil es capaz de comprender que él y la persona a su cargo son en todo momento seres trascendentes y totales que pertenecen a un contexto con el cual interactúan, que tienen una historia individual y una historia compartida y que tienen capacidad de desarrollarse en la acción de cuidar. muchos de ellos, a través de esta experiencia, dan sentido a su vida y, a pesar de la limitación, se reconocen como una extensión mutua, admitiendo en cada uno una identidad propia y aceptando con humildad la condición humana. esta habilidad se refleja mediante el compromiso, la presencia auténtica, la responsabilidad, el crecimiento mutuo y la motivación hacia el cuidado (32). la experiencia de cuidado varía con el género; la mujer, por su naturaleza, comprende y entiende el cuidado como una situación del diario vivir. ella cuida de sus hijos, de sus padres, de quienes le rodean. tiende a ser detallista y observadora, y de manera casi instintiva busca, en la mayor parte de los casos, preservar la vida. la mujer entiende con familiaridad aspectos de las situaciones de enfermedad, de los problemas diarios y de la conservación del tuaciones familiares, la intolerancia de quienes no comprenden la experiencia y las exigencias explícitas o implícitas de su ser querido los hacen sentirse en algunos momentos sometidos. los riesgos para la salud son evidentes, aunque en algunas condiciones son más dramáticos que en otras, por el estigma social y la perspectiva de la pérdida. de manera paradójica, en un estudio que comparó a los cuidadores de personas con vih con los cuidadores de personas con cáncer se encontró que quienes viven mayor dificultad y tienen menos apoyo familiar han reportado mayor satisfacción con el mismo (25). la necesidad y el beneficio del descanso y el apoyo han sido bien documentados (26, 27), lo mismo que la importancia de conocer los servicios que el contexto ofrece para el cuidador y la persona cuidada. en forma lamentable se sabe que ese conocimiento es muy deficiente en otros países y ese reporte puede ser similar en este medio. en ese sentido, se tiene el reto interno y externo de dar a conocer a los cuidadores familiares de personas con enfermedad crónica los recursos disponibles más allá de los que las personas buscan con sus amigos o conocidos (28). son muchos los momentos críticos que debe afrontar el cuidador de un familiar, cuando el estrés y el agotamiento lo embargan, cuando la enfermedad del ser querido se complica, cuando no encuentra apoyo en los otros miembros de la familia y cuando se debe responder ante otros familiares que algunas veces toman roles de jueces o veedores. esta angustia de la familia se ha categorizado en cuatro grandes aspectos que incluyen: la condición del ser querido, la atención que recibe por parte del equipo de salud, el cuidado futuro que dará el cuidador familiar y los aspectos financieros (29). son muchos los momentos críticos que debe afrontar el cuidador de un familiar, cuando el estrés y el agotamiento lo embargan, cuando la enfermedad del ser querido se complica, cuando no encuentra apoyo en los otros miembros de la familia y cuando se debe responder ante otros familiares que algunas veces toman roles de jueces o veedores. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005132 entorno. el hombre, por el contrario, busca ser planificador, organizado y responsable, es más práctico y, en ese sentido, participa y colabora en el cuidado mirando otros aspectos que las mujeres en algunos momentos no valoran. estos aspectos han sido documentados en nuestro contexto en cuidadores de niños con fibrosis quística (33) y en otros contextos con poblaciones de diferentes edades (34). la experiencia de cuidado compromete, de manera sustancial, la calidad de vida de todos los cuidadores �hombres, mujeres, mayores o menores� de la persona con enfermedad (35-41). aunque algunos autores señalan patrones culturales que intervienen en el cuidado (42), en casi todas las culturas se refleja que la familia ha evolucionado. al cuidar de personas de generaciones diferentes y por largo tiempo, esta evolución genera problemas. las personas se sienten más seguras con costumbres o imaginarios anteriores, que en algunos casos alteran de manera importante la adaptación. no es parte habitual de nuestro aprendizaje comprender que los roles son finitos, vemos entonces situaciones en que la madre se está muriendo y quiere desempeñar aún las funciones del hogar, y el padre no acepta ser sustituido en sus labores, ni acepta, en muchos casos, el proceso de envejecimiento o la dependencia de sus hijos. para los hijos tampoco es fácil cambiar de ser controlados a ejercer el control. la generación intermedia que vive la experiencia de ser cuidadora se ve también abocada a modificar sus costumbres y expectativas, a acercarse a los cambios de la ciencia y la tecnología, y a responder a los nuevos retos de la sociedad sin tener el tiempo y la disposición para hacerlo. el cuidador de la generación intermedia vive, además de los mencionados, otra serie de conflictos: aceptar roles que no ha buscado; pérdida de los que ha logrado o de la disponibilidad de tiempo y energía para ser competitivo dentro de los mismos; en algunos momentos pierde control sobre su propia vida y su entorno socio familiar, puesto que tiene que mantener y cuidar la vida de otros y, en muchos casos, no tiene tiempo suficiente para sí mismo ni para las personas menores que dependen de su sostén (43, 44). no es infrecuente que el cuidador se vea sometido a dejar su trabajo porque el cuidado de su ser querido se lo exige, o que se generen relaciones deficientes con la persona cuidada que la hacen más dependiente (45). al parecer son las mujeres más que los hombres, y en especial aquellas que se encuentran en esta generación intermedia, las más propensas a sufrir de estrés en estas situaciones, lo cual hace pensar en estas personas de manera particular (46, 47). como está descrito en la literatura, existe en las familias el denominado cuidador pretencioso que sin tomar parte en las actividades de cuidado siempre tiene una opinión de cómo se pueden hacer mejor las cosas. éste resulta devastador para el cuidador principal por la falta de reconocimiento que su actitud genera (9). s e ha documentado también que los cuidadores afrontan inmensas dificultades de soledad, incertidumbre y temor por tener que tomar decisiones sin comprender las implicaciones de éstas, y que estos cuidadores no perciben el apoyo por parte de las instituciones o profesionales de salud (48). la capacidad de resolver problemas parece ser esencial en estos casos, tal como se ilustra de manera detallada con la experiencia de cuidadores de personas que se recuperan de una insuficiencia cardiaca congestiva (49). por fortuna, varias propuestas novedosas para la formación profesional han comenzado a escucharse frente a estas situaciones (50), lo mismo que llamados para no ignorar aquellas condiciones del servicio que hacen particularmente difíciles las tareas de los cuidadores frente a algunos trastornos como los de bipolaridad (51) y deterioro de la esfera cognitiva (52). de igual forma, resulta muy alentador contar con guías contextualizadas para el manejo del enfermo crónico en casa que tengan en cuenta tanto a los enfermos como a sus cuidadores (53). pero no todo es dificultad en el cuidado, aunque en el ámbito profesional se han establecido como parámetros de adaptación y aceptación del rol la satisfacción con la salud física, con la salud emocional, con el estilo de vida, con la ejecución del rol habitual, con el soporte social, con el apoyo instrumental, con el soporte profesional y con las relaciones sociales (54), no es infrecuente que el cuidador se vea sometido a dejar su trabajo porque el cuidado de su ser querido se lo exige, o que se generen relaciones deficientes con la persona cuidada que la hacen más dependiente. reflexiones sobre el cuidado a partir del programa �cuidando a los cuidadores�® 133 sugerencias para las enfermeras que trabajan con personas en situación de enfermedad crónica por fortuna, algunos avances recientes en enfermería confirman que trabajando de una forma sistemática y organizada es posible incrementar las habilidades de los cuidadores familiares de personas con enfermedad crónica. a partir de las vivencias de los cuidadores se han extractado algunas sugerencias para las enfermeras que trabajan con personas en situación de enfermedad crónica para que tengan en cuenta en el cuidado de las familias: � escuche a los otros, no sólo al paciente sino también al cuidador, él la necesita. � reconozca siempre el esfuerzo que el cuidador hace aunque sólo sea con su presencia, algunas veces se necesita mucho valor para estar allí, al lado de ese ser querido, en medio de una infinita angustia y desconcierto. � organice dentro de las actividades de cuidado un espacio para formar a quien la remplazará una vez salga del contacto con la institución. su tiempo al lado del cuidador es valioso porque de la capacitación que él tenga dependerán, en gran medida, los efectos terapéuticos y la disposición que ese cuidador tenga frente al cuidado. � busque fortalecer al cuidador en sus aspectos físico, social, psicológico y espiritual. � sea honesta en el cuidado, busque dar lo mejor de usted con amor a las cosas, las personas y la vida. el cuidador familiar, además de los inmensos retos que vive y quizás a consecuencia de ellos, ve afectada con frecuencia su salud física en el patrón de sueño, la tensión arterial, el nivel de energía, el bienestar físico, el nivel de movimiento, la resistencia a la infección, la funcionalidad física, los cambios en el peso y el funcionamiento gastrointestinal. ellos tienen, además, la necesidad de tomar algunos medicamentos. es preciso, por tanto, considerar como un indicador la percepción de la salud general del cuidador y el uso de proveedores de salud (56). además, tener en cuenta aspectos culturales y motivacionales para promover estilos de vida más saludables como aquellos en los que se fomenta la actividad física de los cuidadores (57). escuchando a los cuidadores se puede señalar que es satisfactorio saber que el ser querido está entre nosotros, saber que evoluciona positivamente y que en ello se ha puesto un granito de arena, o que no sufre tanto como pudiera y se le ha podido aliviar con el cuidado; es satisfactorio percibir el cariño y afecto de ese ser querido que depende de nuestro cuidado. en la experiencia positiva del cuidador es fundamental la confianza en la resolución de problemas, el reconocimiento de cambios en el estatus de salud del receptor de cuidado, y en su comportamiento, la habilidad para anticipar las necesidades de dicho receptor, la capacidad de obtener y supervisar los servicios necesarios para éste, al reconocimiento de las necesidades de cuidado de la persona con enfermedad, la habilidad para solucionar problemas de cuidado con los cuidadores directos, y la confianza en la realización de las tareas necesarias (55). al cuidador, en su desempeño, lo apoya el compromiso de otros miembros de la familia, los profesionales involucrados de la institución de salud a la cual está afiliado que orienta el cuidado, el tener comodidad y espacio para cuidar. en esta experiencia es preciso anotar como un apoyo fundamental la espiritualidad, el vínculo con un ser superior, con los demás, con uno mismo y con el universo; ésta es una vivencia que acompaña y fortalece al cuidador. ser cuidador permite crecer en el campo espiritual y emocional. permite entender muchos aspectos de la vida con mayor facilidad, comprender el valor de la familia, de la solidaridad como la más fuerte de todas las virtudes para el cuidado. la comunicación es fundamental: escuchar y ponerse en el lugar del otro permite comprender y aceptar. ser cuidador permite crecer en el campo espiritual y emocional. permite entender muchos aspectos de la vida con mayor facilidad, comprender el valor de la familia, de la solidaridad como la más fuerte de todas las virtudes para el cuidado. revista aquichan issn 1657-5997 año 5 vol. 5 nº 1 (5) • chía, colombia octubre 2005134 en los casos de los cuidadores con personas hospitalizadas la adaptación de éstos a la hospitalización del ser querido se evidencia en la confianza que tiene en los demás cuidadores, el mantenimiento del control deseado sobre el cuidado, la participación en el cuidado como lo desea, el mantenimiento de la relación cuidadorcuidado, la comunicación con las agencias de los cuidadores, la expresión de su experiencia sobre el cambio, la resolución de sus sentimientos de culpa y de rabia, el empleo de métodos de resolución de conflictos, el sentimiento de comodidad con la transición del rol, la habilidad para consentir el tratamiento, el suministro de los ítems que dan comodidad al paciente y la comunicación de las necesidades de cuidado que el receptor no verbaliza (58). la experiencia del trabajo en el programa cuidando a los cuidadores® refleja que es necesario hacer esfuerzos para tener en cuenta al binomio cuidador-cuidado, y que estos esfuerzos son valiosos porque modifican de manera muy importante la condición de quienes viven con enfermedad crónica y la de sus cuidadores. en ese sentido, la invitación queda abierta para demostrar que la enfermería no tiene fronteras, que está dispuesta a ser grande y a continuar en una construcción colectiva que en lugar de competir sume a favor de quienes en verdad lo necesitan. referencias bibliográficas 1. barrera l et al. cuidando a los cuidadores. bogotá: universidad nacional de colombia y colciencias; 2005 (en prensa). 2. barrera l et al. evaluación de un programa de fortalecimiento de habilidades de cuidado dirigido a cuidadores familiares de personas con enfermedad crónica. universidad nacional de colombia y colciencias; 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medicine 2005;80(4):352-355. 51. alan o. the burden on informal caregivers of people with bipolar disorder. bipolar disorders supplement 2005;7(suppl 1):25-32. 52. habermann b et al. caring for family with alzheimer�s disease and parkinson�s disease: needs, challenges, and satisfactions. journal of gerontological nursing 2005;31(6):49-54. 53. moreno me et al. cómo cuidar un enfermo en casa. bogotá: el manual moderno; 2005. 54. johnson m et al. nursing outcomes classification (noc): bienestar del cuidador. eeuu: mosby year book inc; 1999. 55. johnson, m et al. nursing outcomes classification (noc): desempeño del cuidador: cuidado indirecto. eeuu: mosby year book inc; 1999. 56. johnson m et al. nursing outcomes classification (noc): salud física del cuidador. eeuu: mosby year book inc; 1999. 57. wei-chen t. stages of change for physical activity among family caregivers. journal of advanced nursing 2005;49(5):513-521. 58. johnson, marion y cols. nursing outcomes classification (noc): adaptación del cuidador a la institucionalización del paciente. eeuu: mosby year book inc; 1999. páginas web sugeridas 1. http://www.enfermeria.unal.edu.co/revista/2004_1.htm 2. www.enfermeria.unal.edu.co 3. http://tone.udea.edu.co/revista/sep99/experiencia.htm 4. http://www.index-f.com/cuidadores.php 5. http://www.um.es/eglobal/6/06e04.html 1 jamille pinheiro cunha1 gilmara holanda da cunha2 andrea bezerra rodrigues3 fabiane do amaral gubert4 maria célia de freitas5 neiva francenely cunha vieira6 nursing diagnoses in institutionalized elderly individuals according to betty neuman 1 orcid.org/0000-0002-9480-192x. universidade federal do ceará, brasil. jamillepcunha@alu.ufc.br 2 orcid.org/0000-0002-5425-1599. universidade federal do ceará, brasil. gilmaraholanda@ufc.br 3 orcid.org/0000-0002-2137-0663. universidade federal do ceará, brasil. andreabr@ufc.br 4 orcid.org/0000-0003-3016-9619. universidade federal do ceará, brasil. fabianegubert@ufc.br 5 orcid.org/0000-0003-4487-1193. universidade federal do ceará, brasil. celia.freitas@uece.br 6 orcid.org/0000-0002-9622-2462. universidade federal do ceará, brasil. nvieira@ufc.br received: 17/05/2018 sent to peer reviewers: 25/06/2018 accepted by peers: 29/08/2018 approved submission: 24/09/2018 doi: 10.5294/aqui.2019.19.1.6 to reference this article / para citar este artículo / para citar este artigo cunha jp, cuhna gh, rodrigues ab, gubert fda, de freitas mc, vieira nfc. nursing diagnoses in institutionalized elderly individuals according to betty neuman. aquichan 2019; 19(1): e1916. doi: 10.5294/aqui.2019.19.1.6 abstract objective: to identify nursing diagnoses in caregivers of institutionalized elderly and to associate them with stressors, according to the betty neuman model. materials and methods: a cross-sectional, descriptive and quantitative study with 41 formal caregivers of institutionalized elderly. the data were collected using a structured form according to the betty neuman systems model. subsequently, the diagnoses were formulated based on the nanda-i taxonomy and these were associated with the stressors perceived by the caregiver. results: there was a prevalence of women with eight to 12 years of schooling who did not attend a caregiver course for the elderly. the stressors perceived by caregivers were family, financial, work and health. fifteen nursing diagnoses were identified, highlighting: sedentary lifestyle, anxiety, stress overload and impaired comfort. conclusions: the use of the neuman model facilitated the identification of nursing diagnoses. the family stressor was the most prevalent in the caregivers’ report. the main diagnoses identified show the need to meet the health demands of caregivers, since they can impact on the quality of care provided to the elderly. keywords (source: decs) nursing diagnosis; caregivers; old man; institution of long stay for the elderly; professional exhaustion; institutionalized elderly. año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1916 theme: promotion and prevention. contribution to the discipline: of the works already published about the theme of the present study, there is no association of the use of the betty neuman model with formal elderly caregivers. thus, the relevance and contribution of this article is evidenced so that the academic community know about the needs of this type of caregiver, in order to promote formative and care actions that have repercussions in the quality of life of the institutionalized elderly. special attention is given to interventions aimed at reducing stress and stimulating caregiver self-care. http://orcid.org/0000-0002-9480-192x http://orcid.org/0000-0002-5425-1599 http://orcid.org/0000-0002-2137-0663 http://orcid.org/0000-0003-3016-9619 http://orcid.org/0000-0003-4487-1193 http://orcid.org/0000-0002-9622-2462 https://dx.doi.org/10.5294/aqui.2019.19.1.6 http://orcid.org/0000-0002-9480-192x http://orcid.org/0000-0002-5425-1599 http://orcid.org/0000-0002-2137-0663 http://orcid.org/0000-0003-3016-9619 http://orcid.org/0000-0003-4487-1193 http:// orcid.org/0000-0002-9622-2462 https://dx.doi.org/10.5294/aqui.2019.19.1.6 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1916 diagnósticos de enfermería en cuidadores de ancianos institucionalizados según betty neuman resumen objetivo: identificar diagnósticos de enfermería en cuidadores de ancianos institucionalizados y asociarlos a los estresores, según el modelo de betty neuman. materiales y método: estudio transversal, descriptivo y cuantitativo, desarrollado con 41 cuidadores formales de ancianos institucionalizados. los datos fueron recolectados mediante un formulario estructurado de acuerdo con el modelo de sistemas de betty neuman. posteriormente, se formularon los diagnósticos basados en la taxonomía nanda-i y estos se asociaron a los estresores percibidos por el cuidador. resultados: hubo prevalencia de mujeres que tenían de 8 a 12 años de estudio y que no hicieron curso de cuidador de ancianos. los estresores percibidos por los cuidadores fueron del ámbito familiar, financiero, trabajo y salud. se identificaron 15 diagnósticos de enfermería, de los que se destacan: estilo de vida sedentario, ansiedad, sobrecarga de estrés y comodidad perjudicada. conclusiones: la utilización del modelo de neuman facilitó la identificación de los diagnósticos de enfermería. el estresante familiar fue el más prevalente en el relato de los cuidadores. los principales diagnósticos identificados muestran la necesidad de atender las demandas de salud de los cuidadores, ya que pueden impactar en la calidad del cuidado prestado a los ancianos. palabras clave (fuente: decs) diagnóstico de enfermería; cuidadores; adulto mayor; institución de larga permanencia para ancianos; agotamiento profesional; ancianos institucionalizados. 3 nursing diagnoses in institutionalized elderly individuals according to betty neuman l jamille pinheiro cunha and other diagnósticos de enfermagem em cuidadores de idosos institucionalizados segundo betty neuman resumo objetivo: identificar diagnósticos de enfermagem em cuidadores de idosos institucionalizados e associá-los aos estressores, segundo o modelo de betty neuman. materiais e método: estudo transversal, descritivo e quantitativo, desenvolvido com 41 cuidadores formais de idosos institucionalizados. os dados foram coletados mediante formulário estruturado de acordo com o modelo de sistemas de betty neuman. posteriormente, foram formulados os diagnósticos baseados na taxonomia nanda-i e estes foram associados aos estressores percebidos pelo cuidador. resultados: houve prevalência de mulheres, de 8 a 12 anos de estudo e que não fizeram curso de cuidador de idosos. os estressores percebidos pelos cuidadores foram familiar, financeiro, trabalho e saúde. foram identificados 15 diagnósticos de enfermagem, dos quais se destacam: estilo de vida sedentário, ansiedade, sobrecarga de estresse e conforto prejudicado. conclusões: a utilização do modelo de neuman facilitou a identificação dos diagnósticos de enfermagem. o estressor familiar foi o mais prevalente no relato dos cuidadores. os principais diagnósticos identificados mostram a necessidade de atender às demandas de saúde dos cuidadores, visto que eles podem impactar na qualidade do cuidado prestado aos idosos. palavras-chave (fonte: decs) diagnóstico de enfermagem; cuidadores; idoso; instituição de longa permanência para idosos; esgotamento profissional; idosos institucionalizados. año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1916 4 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 introduction the global population is aging, because the number of elderly grows more than the number of people born (1). in brazil, this fact led to changes in the demographic and epidemiological profile (2), which increased the demand for long-term stay institutions for the elderly (ltsie). these are facilities that provide care for people 60 years of age or older and who are functionally dependent or independent (3). in the ltsie, the caregiver is supervised by the nurse, whose responsibility, among others, is to identify physical and psychological changes in these individuals. that daily care of the elderly is exhausting and requires physical and psychological conditions from the caregivers. therefore, caregivers of the elderly in the ltsie are susceptible to stress, which can cause disastrous consequences for their physical and mental health, and compromise the quality of care (4). in order to promote individualized care and adequate to the needs, there is the nursing process (5). the nursing diagnosis is one of the steps in said process and represents a clinical judgment on the human response to health conditions and life processes, as well as representing vulnerability to such a response. nurses diagnose health problems, states of risk, and provision for health promotion (6), using theories to promote holistic patient care. this study used the neuman systems model, which assesses caregiver stress and their reaction to such. environmental influences are classified as intra (stressors within the limits of the client’s system), inter (stressors outside the limits of the client’s system), and extra-personal (stressors beyond the limits of the client’s system and which are at a greater distance than the interpersonal). the individual relates to internal and external stressors towards a state of equilibrium (7-8). using this model in the study is justified by identifying the principal stressors of the individual (9). furthermore, it is deemed that the combined use of the neuman model and the nursing diagnoses can identify the stressors in the caregiver-care relationship, to guide the nurse’s decision-making in the health promotion of the caregiver. formal caregivers of elderly have high stress that can interfere in the care (4). thereby, this study will help nurses and multidisciplinary staff to promote training and care actions that affect the quality of life of the elderly in ltsie. in this regard, this research sought to identify nursing diagnoses in caregivers of institutionalized elderly and associate them to the stressors, according to betty neuman’s model. materials and method cross-sectional, descriptive, and quantitative study developed in two ltsie in fortaleza, ceará, brazil, a governmental institution and a philanthropic institution, from april to june 2016. these institutions have specialized care, high complexity attention, and treatment of the elderly in partial, total, and terminal-phase dependence. the philanthropic ltsie serves 220 elderly and the governmental serves 88. these entities assist in the areas of social action, health, nutrition and management, comprised by multi-professional staff. in addition, they are references in the care of the elderly in fortaleza, which justifies their selection as research locations. the study population was comprised by 60 formal caregivers. the sample included 41 participants, selected by the nonprobabilistic sampling technique and by convenience, including those who were on duty during the data collection period and who had time available to respond to the instrument. caregivers from both genders participated, who had worked at least for one year. nineteen professionals were excluded because they were on vacation or on leave. the questionnaire was elaborated according to the aforementioned model and involved three stages: a) input summary (name, age, gender, schooling, marital status, number of children, former occupation); b) stressors perceived by the caregiver (principal area of stress, changes in standard of living, prior experiences, ways of coping, consequence of the current situation, self-help, help from third parties); c) summary of feelings: c1) interpersonal-physical factors (pathologies, medications, musculoskeletal problems, cigarette and alcohol consumption, periodic health assessment, nightly rest, anthropometric measurements, eating habits), psycho-sociocultural (physical activity, recreation, support social network), system of spiritual beliefs (religion, hope, help during moments of sadness); c2) interpersonal factors (family relationship, with elderly and caregivers), and c3) extra-personal factors (locomotion and job satisfaction, financial provider of the home, family monthly income) (7-8). data was collected through interview conducted by one of the nurse authors of the study, in a private environment, lasting 30 5 nursing diagnoses in institutionalized elderly individuals according to betty neuman l jamille pinheiro cunha and other minutes, using an instrument constructed by the authors, structured according to betty neuman’s model (7-8). prior to starting the interview, each caregiver was explained the objective of the research and asked to sign the free and informed consent form (ficf), which was shared with the participant. participants were protected as provided by resolution 466/2012 by the national health council. from the ficf, caregiver anonymity was guaranteed, and the information collected was used for educational purposes. some questions were a cause for participant embarrassment. this showed, measures were taken to minimize it: give participants the freedom to not respond and respect their time, waiting for when they wished to resume speaking. the project was submitted to the research ethics committee at universade estadual do ceará and approved on 13 april 2016, under protocol # 1,489,910 and certificate of presentation for ethical appraisal (cpea) # 26897314.1.0000.5534. the data obtained were analyzed and used for the sociodemographic characterization of the caregivers, the description of the stressors perceived by them, identification of the nursing diagnoses, and the relationship of such stressors with the diagnoses identified. identification of the nursing diagnoses was conducted according to the nanda-i taxonomy (6). the diagnoses were determined by two researchers, who collected the data and a second specialist in nursing diagnosis, who carried out the process of diagnostic reasoning based on the assessments of the instruments. in cases in which there was no consensus of the diagnoses, a third specialist was consulted. said researchers were selected by consulting the lattes curriculum, which identified those with experience in nursing diagnosis. the data were tabulated in microsoft excel. the statistical package for the social sciences software, version 18.0 was used for analysis. pearson’s chi-square test was applied to verify the association among the variables of age, gender, schooling, marital status, number of children, family monthly income, and stressors (family, financial, health, and work) with the nursing diagnoses, considering a value of p < 0.05 as statistically significant. results of the 41 interviewees, 31 were female (75.6 %). the age group with the highest prevalence between men and women was from 50 to 59 years (36.6 %). regarding marital status, 23 caregivers were married/stable union (56.1 %); 22 had between one and two children (53.7 %), and 24 lived with four or more people in the home (58.5 %). in terms of schooling, 28 reported 8 to 12 years of studies (68.3 %). more than half had not taken a course on caregiver for the elderly (65.8 %) and had no prior experience in the area (90.3 %). a principal prior occupation was doctor’s office attendant (26.8 %), see table 1. table 1. sociodemographic characterization of formal caregivers of institutionalized elderly. fortaleza, ceará, brazil, 2016 (n = 41) variables n % gender female 31 75.6 male 10 24.4 age* 30-39 9 22.0 40-49 13 31.7 50-59 15 36.6 > 60 4 9.7 marital status married/stable union 23 56.1 single 13 31.7 separated/divorced 3 7.3 widow(er) 2 4.9 children do not have 3 7.3 1-2 22 53.7 > 3 16 39.0 number of residents in the household 1-3 17 41.5 ≥ 4 24 58.5 6 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 a table 2 shows the relationship between the stressors of betty neuman’s model and the nursing diagnoses of formal caregivers of institutionalized elderly. the family stressor prevailed (51.2 %), while health itself was the least reported complaint (14.6 %). family stressors involved problems with the spouse, children and parents. in the financial aspect, debt was the main complaint. in relation to work, they reported work overburden. as for health, complaints were cited, like being overweight, as well as osteoarticular and gynecological problems. it is highlighted that each caregiver can have more than one nursing diagnosis, with caregivers who identified the family as the principal area of stress obtaining more diagnoses. fifteen nursing diagnoses were identified; among them, it is worth noting the diagnosis of dysfunctional family processes, which were present in 83.3 % of caregivers with health problems, 61.9 % with family stressor, and 42.8 % with complaints at work (p = 0.042) (table 2). variables n % schooling < 8 5 12.2 8-12 28 68.3 > 12 8 19.5 elderly caregiver course took a course 14 34.2 did not take the course 27 65.8 prior occupation caregiver 4 9.7 other 37 90.3 *age (years): mean: 47.9; minimum: 30; maximum: 65. source: own elaboration. table 2. relationship between the stressors identified according to betty neuman’s model and the nursing diagnoses of formal caregivers of institutionalized elderly. fortaleza, ceará, brazil, 2016 stressors of betty neuman’s model family n (%) financial n (%) health n (%) work n (%) number of caregivers nursing diagnoses 21 (51.2) 7 (17.1) 6 (14.6) 7 (17.1) p value* deficient recreational activity 15 (71.4) 3 (42.8) 4 (66.7) 5 (71.4) 0.981 sedentary lifestyle 17 (81.0) 4 (57.1) 4 (66.7) 6 (85.7) 0.865 ineffective health maintenance 12 (57.1) 4 (57.1) 4 (66.7) 4 (57.1) 0.682 overweight 13 (61.9) 4 (57.1) 3 (50.0) 7 (100.0) 0.131 obesity 3 (14.2) 1 (14.3) 1 (16.7) 0.709 impaired sleep pattern 15 (71.4) 5 (71.4) 6 (100.0) 5 (71.4) 0.949 fatigue 7 (33.3) 3 (42.8) 2 (33.3) 4 (57.1) 0.443 impaired home maintenance 15 (71.4) 4 (57.1) 5 (83.3) 0.072 willingness for improved hope 21 (100.0) 5 (71.4) 6 (100.0) 6 (85.7) 0.592 dysfunctional family processes 13 (61.9) 5 (83.3) 3 (42.8) 0.042 willingness for improved relationship 20 (95.2) 7 (17.1) 6 (100.0) 7 (100.0) 0.545 tension in the caregiver role 4 (19.0) 2 (28.6) 3 (50.0) 4 (57.1) 0.148 anxiety 20 (95.2) 5 (71.4) 5 (83.3) 5 (71.4) 0.570 stress overload 21 (100.0) 5 (71.4) 6 (100.0) 3 (42.8) 0.112 discomfort 16 (76.1) 4 (57.1) 6 (100.0) 5 (71.4) 0.780 * pearson’s chi-square test. source: own elaboration. 7 nursing diagnoses in institutionalized elderly individuals according to betty neuman l jamille pinheiro cunha and other twenty seven (65.8 %) caregivers state not engaging in leisure activities due to not having the financial conditions and time. from that, deficient recreational activity was a diagnosis characterized by boredom, related to insufficient recreational activities. said diagnosis was present in 74.2 % of the women and in only 40 % of the men (p = 0.047). it was verified that 31 individuals (75.6 %) did not practice physical exercise, configuring the sedentary lifestyle diagnosis characterized by daily physical activity below that recommended for gender and age, related to the lack of motivation and to insufficient resources to perform it. among the participants, 24 did not perform periodic health assessments (58.5 %). thereby, the diagnosis of ineffective health maintenance was observed, characterized by the absence of health-seeking behaviors, related to ineffective coping strategies, insufficient financial resources and time. anthropometric measurements (weight and height) of the workers were verified, and 27 of them (65.8 %) had a body mass index (bmi) ≥ 25 kg/m², which classifies as diagnosis of overweight. five caregivers (12.2 %) had bmi > 30 kg/m², attributed to the diagnosis of obesity. said diagnoses are related to inadequate eating behaviors and to a sedentary lifestyle. the caregivers reported only three large meals a day because they were hungrier. due to the lack of time to prepare meals, they also ate high-calorie foods of low nutritional content because of their ease of preparation. tiredness after nocturnal sleep was reported by 22 individuals (53.7 %), and 17 (41.5 %) had insomnia or difficulty sleeping because they were alert during the night shift, or were anxious at home. they reported that, even during breaks, they had difficulty sleeping because they were accustomed to night work, waking up feeling tired. alterations in the sleep pattern were reported by employees who worked during the day. thus, the diagnosis of impaired sleep pattern was identified, characterized by altered sleep pattern, dissatisfaction with sleep and not feeling rested, having as factors related to environmental barrier and non-restorative sleep. said diagnosis had a relationship of dependence with the number of children, given that only 66.7 % of the people who did not have children had altered sleep, while 95.5 % of those with one or two children and all the caregivers with more than three children had that diagnosis (p = 0.048). sixteen participants (39 %) reported physical symptoms (headache, tiredness, lack of energy, and bodily pain, mainly of the back), due to the routine of work and home. the nursing diagnosis of fatigue was emphasized, given the existence of a non-restorative sleep pattern, consequential of increased physical effort, stress, and of the job requirements. twenty four (58.5 %) caregivers mentioned insufficient income for monthly expenses, needing support for household expenses. the diagnosis of impaired home maintenance was verified, characterized by debt and insufficient financial resources, overwhelming family responsibilities, and request for help to maintain the house, having as related factor insufficient family planning. people with income above four minimum wages did not have said diagnosis (p = 0.001). thirty eight caregivers (92.7 %) considered themselves optimistic about their problems and stated that they expected improvement in the situation they were experiencing, indicating the diagnosis of disposition for improved hope. not having good relationships with some relatives was verbalized by 21 caregivers (51.2 %), who reported misunderstandings, disrespect from the children, betrayal, and not being valued by the spouse. these facts are present in the defining characteristics of the diagnosis of dysfunctional family processes, related to ineffective coping strategies and insufficient problem-solving skills. said diagnosis was more present in women (61.3 %) than in men (20.0 %) (p = 0.023). among the caregivers, 90.3 % reported good relationship with other caregivers and elderly (97.5 %). the diagnosis of disposition for improved relationship was evidenced, characterized by the expression of desire to improve collaboration, communication, and mutual respect between partners. meanwhile, 13 individuals (31.7 %) were not satisfied with their work, complaining of delays in wages, lack of professional recognition by the institution, injustice, and humiliation. the diagnosis of stress of the caregiver role, characterized by fatigue, frustration, anger, and nervousness, related to insufficient care and to excessive care activities, was identified among the caregivers. fear, anguish, tension, anxiety and apprehension about the problems were observed in 35 participants (85.4 %). these elements define the anxiety diagnosis and are related to stressors and important change (economic and health condition), besides situational crisis. symptoms of stress were observed in 35 workers (85.4 %), with 82.9 % women and 17.1 % men (p = 0.009). thereafter, 8 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 the diagnosis of stress overload was defined by increased impatience, excessive stress, tension and its negative impact (physical symptoms and psychological suffering), related to repeated stressors and to insufficient financial resources. the association with income was statistically significant, given that caregivers with incomes above four minimum wages present lower frequency of said diagnosis (11.4 %) (p = 0.006). the anxiety diagnosis was not present in individuals without children (p = 0.000) and these represented only 2.9 % of the participants with stress overload (p = 0.029). however, those with anxiety (95.5 %) and stress overload (90.9 %) were caregivers with one to two children. many caregivers (75.6 %) felt pain, especially in the back and joints. the diagnosis of discomfort was present by being unable to relax and by the sense of discomfort, related to insufficient situational control and symptoms related to the disease. discussion there was greater prevalence of individuals of female gender, from 8 to 12 years of studies and without a course for providing care to the elderly, which revealed the precariousness of the profession due to training and qualification difficulties in the area (10-11) and, consequently, to the lack of professional preparation (4). another study with caregivers identified that 48 % of them had no adequate preparation, and 67 % considered it necessary to seek more in-depth training (12). it should be emphasized that the regulation for caregivers as professionals is underway for approval, under senate bill # 284 (13). the qualified professional directly influences the care provided. thereby, it is important to provide knowledge to employees to ensure quality of care. the diagnoses of deficient recreation activity and sedentary lifestyle were the most present among caregivers, prevailing among women. the influence of gender was verified in the determination of the diagnoses, consequential of the overload of daily tasks, like work, household chores, and caring for relatives. this last task was the factor that interfered most in the lack of time for themselves and for moments of leisure. caring for another restricts the caregiver’s capacity to carry out personal activities (14). this finding points to the need for educational strategies that aim at changes in life habits, given that a sedentary lifestyle is a risk factor for health problems. physical exercise is an effective, low-cost measure to promote health. adoption of a healthy lifestyle is related to improved quality of life and favors controlling overweight and obesity identified in this research (15-16). more than half of the caregivers had a diagnosis of inefficient health management, that is, they did not conduct periodic consultations and exams. prevalence was noted on the emphasis to care for another and forget oneself. caring for an elderly individual for a long period is a risk factor for caregiver sickness. therefore, as important as the well-being of the elderly is that of the caregivers (17), given that they need to healthy to promote the wellbeing of others. regarding nutritional status, many participants had overweight or obesity nursing diagnoses. excess weight can be associated to the work environment in shifts, mainly the night shift, besides the service overload and the psychosocial stress at work (18-19). the interaction of said factors affects the physiological and psychological condition, which can affect weight gain (20). these findings, together with physical inactivity and no periodic medical evaluation can aggravate cardiovascular risks, especially considering the age range of caregivers. studies show that weight gain and increased abdominal circumference are prognostic indicators for cardiovascular diseases (21-22). with respect to the diagnosis of impaired sleep pattern, it was observed that the participants did not have restful sleep, especially those working the night shift. in this regard, another study revealed that 72.5 % of the caregivers of elderly had difficulty falling asleep and 100 % had sleep disorders, with the low quality of such being associated to psychological symptoms and to lower quality of life (23). the diagnosis of fatigue results from excess of activities with physical effort and double work shift, like at work and home. tiredness was also cited by caregivers of elderly in a mexican study (24). this physical and mental wear compromises the quality of care to the elderly and limits the disposition and concentration of the caregiver. the complexity of caring for the elderly and the work overload harm professionals and patients, given that caregivers perform functions beyond their capacity, which can result in providing care in imbalanced manner and unsatisfactory results (14). the need is highlighted for more support by adopting prevention measures and a support social network to the caregivers (24). 9 nursing diagnoses in institutionalized elderly individuals according to betty neuman l jamille pinheiro cunha and other the diagnosis of impaired maintenance of the home referred to difficulties in the family budget and in meeting their needs. in another study, caregivers of elderly had low income and unfavorable economic conditions (25). it has been shown that the levels of stress in caregivers of elderly individuals are due to the job demands and activities at home (16). although the economic conditions of the caregivers do not seem favorable to them, they showed disposition for improved hope. hope is a factor that contributes to well-being, satisfaction, and adaptation to stress caused by daily adversities (26). said feeling impacts upon the perception of the subjects about the quality of life, social relationships, physical and psychological health, and can modify positively their views during difficulties (27). family problems arising from affective relationships with their partner can affect the caregivers’ emotional conditions during their service. such conditions interfere negatively at work, generating fatigue and exhaustion (28). said data agrees with this study, in which many caregivers with diagnosis of dysfunctional family processes report having their health as principal area of concern, followed by family stressor. it is worth noting that caregivers manifested symptoms of anxiety, insomnia, and other psychological manifestations. caregivers had good relationships with one another and, especially, with the elderly. continuous contact with elderly individuals cooperates in the construction of affective relationships, leading caregivers to consider the elderly as their relatives (4). it is highlighted that the elderly desire social interaction; thus, daily contact and good relationships are relevant for their quality of life (29). it is perceived that the process of caring for the elderly requires skills and essential virtues, such as dedication, love, patience and fulfillment. such attitudes were revealed in most of the accounts by the participants who reported feeling pleasure in working with the elderly. stress in the caregiver role was associated to work overload and to the lack of recognition of the caregivers in detriment of other professional categories. the caregiver function has poor visibility, and the occupation is, often, underestimated (14). a study conducted in colombia identified that 22.2 % of the caregivers of elderly individuals report intense overload, which reinforces the need for an instrumental, informative, and emotional support network for the caregiver (30). the discomfort diagnosis was related to the type of care provided to the elderly, notably regarding the hourly workload and the limited time for leisure and rest. such conditions are essential for any type of health worker, especially, those in the nursing area, whose activities require physical effort and constant attention to the person cared for. other studies also referred to work overload and discomfort (31), besides the physical problems that affected the capacity of caregivers at work (16). conclusion application of the questionnaire according to betty neuman’s model was efficient for data collection and contributed with the clinical reasoning, facilitating the identification of the nursing diagnoses, given that it guided the data collection according to the caregiver’s context, above all in aspects related to stress. it was noted that interpersonal stressors were the variables that led most to nursing diagnoses. it was verified that caregivers did not have the training required to perform the function; also, problems were observed in relation to their quality of life and to physical and mental health, which resulted in 15 nursing diagnoses, highlighting sedentary lifestyle, anxiety, stress overload, and discomfort. the research results were presented to the nurses responsible for the institutions and proposals were suggested for changes at work, seeking to improve the quality of life of the caregivers and the care to the elderly, given that the worker’s health and the working conditions impact upon the quality of the care provided. the study recommends reformulating the working conditions of the caregivers, independent of not having regulated labor legislation. this is necessary due to the importance of the work of the caregivers with the elderly population. the precariousness of the caregivers’ work can be prevented and reduced with institutional support, psychological support, and recognition. although the caregiver is not legally a part of the nursing staff, in practice, said caregiver is supervised by the nurse in the ltsie. hence, it is important for nurses to supervise and guide the care provided to the elderly by caregivers. the institution needs to be aware of the working conditions of its employees to try to reduce the stress overload of the caregivers and improve the work environment. it is worth highlighting the need to create 10 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 mechanisms to prevent injuries and promote the health of the institution’s workers. during the data collection, some employees felt somewhat uncomfortable reporting family and work problems, needing more time to ensure closeness with the researcher. in addition, one of the ltsie was philanthropic and the other governmental; hence representing different operational dynamics, which may have hindered obtaining research findings, in terms of the working conditions of the caregivers. this study contributes to the work of nurses with the elderly and caregivers, and showed the principal aspects in which to intervene. research is suggested that implements and evaluates interventions with positive impact on the quality of life and work, considering the reduction of stress. such activities may include improvement courses, continuing education on service, individual or group activities, 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[internet]. 2013 [cited 08 june 2016]; 16(4):769-79. available in: http://www.scielo.br/pdf/rbgg/v16n4/1809-9823-rbgg-16-04-00769.pdf 22. barazzetti r, siviero j, bonatto s. estado nutricional, consumo de calorias e macronutrientes de mulheres participantes de uma universidade da terceira idade no sul do país. estud. interdiscip. envelhec., [internet]. 2013 [cited 09 june 2016]; 18(2):331-47. available in: http://seer.ufrgs.br/index.php/revenvelhecer/article/view/30483/27661 23. cupidi c, realmuto s, lo coco g, cinturino a, talamanca s, arnao v et al. sleep quality in caregivers of patients with alzheimer’s disease and parkinson’s disease and its relationship to quality of life. int psychogeriatr. 2012 [cited 20 aug. 2017]; 24(11):1827-35. doi: 10.1017/s1041610212001032 24. valle-alonso mj, hernández-lópez ie, zúñiga-vargas ml. martínez-aguilera p. sobrecarga y burnout en cuidadores informales del adulto mayor. enferm. univ. [internet]. 2015 [cited 06 sept. 2018]; 12(1):19-27. available in: http://www. scielo.org.mx/pdf/eu/v12n1/v12n1a4.pdf 25. anjos kf, boery rnso, pereira r, santos vc, boery en, casotti ca. profile of family caregivers of elderly at home. rev. pesqui. cuid. fundam. (online) [internet]. 2014 [cited 09 june 2016]; 6(2):450-61. available in: http://www.seer.unirio. br/index.php/cuidadofundamental/article/view/3083/pdf_1224 26. jafari n, farajzadegan z, zamani a, bahrami f, emami h, loghmani a. spiritual well-being and quality of life in iranian women with breast cancer undergoing radiation therapy. support. care cancer. 2013 [cited 20 aug. 2017]; 21(5):1219-25. doi: 10.1007/s00520-012-1650-1 27. daneault s, lussier v, mongeau s, yelle l, côté a, sicotte c et al. ultimate journey of the terminally ill: ways and pathways of hope. can. fam. physician. [internet]. 2016 [cited 20 aug. 2017]; 62(8):648-56. available in: https://www. ncbi.nlm.nih.gov/pmc/articles/pmc4982727/pdf/0620648.pdf 28. leineweber c, baltzer m, hanson llm, westerlund h. work-family conflict and health in swedish working women and men: a 2-year prospective analysis (the slosh study). eur. j. public health. 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[internet]. 2014 [cited 10 june 2016]; 14(112):1-13. available in: http://www.ncbi.nlm.nih.gov/pmc/articles/ pmc4210571/pdf/12877_2014_article_1047.pdf 30. barrera-ortiz l, campos ms, gallardo-solarte k, coral-ibarra rc, hernández-bustos a. soporte social percibido por las personas con enfermedad crónica y sus cuidadores familiares en cinco macro regiones geográficas de colombia. univ. salud. [internet]. 2016 [cited 06 sept. 2018]; 18(1):102-12. available in: http://www.scielo.org.co/pdf/reus/v18n1/ v18n1a11.pdf 31. gratao acm, vendrúscolo trp, talmelli lfs, figueiredo lc, santos jlf, rodrigues rap. burden and the emotional distress in caregivers of elderly individuals. texto & contexto enferm. [internet]. 2012 [cited 20 aug. 2017]; 21(2):304-12. available in: http://www.scielo.br/pdf/tce/v21n2/en_a07v21n2.pdf http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4210571/pdf/12877_2014_article_1047.pdf http://www.ncbi.nlm.nih.gov/pmc/articles/pmc4210571/pdf/12877_2014_article_1047.pdf http://www.scielo.org.co/pdf/reus/v18n1/v18n1a11.pdf http://www.scielo.org.co/pdf/reus/v18n1/v18n1a11.pdf http://www.scielo.br/pdf/tce/v21n2/en_a07v21n2.pdf a la hora del.pmd a la hora del medicamento. taking medicines time 125 resumen a partir de una situación de enfermería con el paciente quemado en el área asistencial hospitalaria, desarrollar un análisis teóricoconceptual, donde se hace visible el valor del cuidado respaldado en principios filosóficos, éticos, epistemológicos y teóricos, como contribución al desarrollo científico de la profesión de enfermería. este trabajo fue realizado en el hospital simón bolívar, unidad de quemados, bogotá, colombia, agosto 5 de 2005. palabras clave situación de enfermería, cuidado de enfermería cotidiano. bertha stella villalobos vásquez1 1 unidad de quemados hospital simón bolívar, carrera 7 nº 165-00 bogotá, colombia. berthasvillalobos@yahoo.es recibido: 8 de febrero de 2006 aprobado: 6 de marzo de 2006 abstract from a nursing situation with burnt patients in the assistance hospital area, a theoretic-conceptual analysis is developed, where it is evident the care value supported by principles from philosophy, ethics, epistemology and theory as a contribution for scientific development of nursing profession. the work was pursued in the burns unit of simón bolívar hospital, city of bogotá (colombia) on august 5 2005. key words nursing situation, nursing plus care, daily. taking medicines time año 6 vol. 6 nº 1 (6) 125-136 chía, colombia octubre 2006 revista aquichan issn 1657-5997 126 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 introducción a actividad que tiene lugar al administrar medicamentos conforma una de las intervenciones de cuidado en la práctica de enfermería en el área hospitalaria. el momento de administrar medicamentos constituye para el paciente un instante de reconocimiento de su persona por parte de otro (la enfermera); en forma simultánea, el medicamento mismo conforma un factor de esperanza para calmar su dolor y sanar su enfermedad, una esperanza de alivio a su cuerpo y a su alma. se trata de escoger “el momento de administrar el medicamento” para mostrar cómo en este acto puntual, elemental, básico y absolutamente cotidiano de una enfermera(o), en cualquiera de las áreas clínicas, puede ser visualizado lo fundamental de la enfermería, tanto como profesión como disciplina científica. se ha dicho con propiedad que “el cuidado es el eje central o núcleo de la disciplina y por lo tanto requiere ser investigado para generar una práctica del cuidado basado en teorías que lo sustenten, práctica que ha de ser autónoma y de calidad…”. según durán de villalobos (1), un tipo tal de práctica “puede llegar a influir en la política pública” con miras a una óptima prestación de los servicios de salud. el análisis puntual de lo que ocurre en “el momento de administrar el medicamento”, ha de permitir explorar la principios filosóficos y éticos que estructuran la práctica del cuidado, como también confrontar las teorías que se han dado al respecto, todo en orden a un desempeño más profesional en la interacción enfermera(o)-paciente. de esta manera se estaría contribuyendo a dar cumplimiento a lo propuesto por durán. un punto especial que ofrece el momento de administrar el medicamento es hacer tangible el aspecto de la “ganancia mutua” que ha de tener tal práctica. es ahí donde el enfermo puede recibir el “don” del otro y, a su vez, la enfermera(o) el “don” del paciente (2, 3).2 el don, en este caso, es un darse –un darse del sí mismo en que consiste cada persona– que abre la oportunidad al otro para darse a su vez. aprovechar esas oportunidades es lo que hace crecer como persona. la persona no solamente se define como un sí mismo consciente, sino como un ser en permanente apertura de crecimiento, es decir, en lograr un plus –un algo más– permanente, dinámico (4).3 la relación con un profesional de la salud (en el sentido integral) le ha de permitir al paciente utilizar la misma enfermedad para realizarse como persona. no se trata sólo de curarse. se trata de potenciarse más como ser humano. de hecho este potenciarse incidirá positivamente en su recuperación. 2 en la teoría antropológica, uno de los pensadores que más contribuyó a resaltar la importancia del don fue el francés marcel mauss. el don puede llegar a constituir uno de los hechos sociales fundamentales en la estructuración de la cultura humana. por tanto; de la humanización del hombre. cf. 2: pp. 471 ss. el desarrollo del darse puede verse en la obra de ignace lepp, la comunicación de las existencias (3). el espectro que cubre el don de sí es muy amplio. va desde el abrirse al otro simplemente para oírlo, hasta todas las acciones más complejas a que dé lugar una relación interpersonal y transpersonal. 3 plus es una expresión latina que quiere decir más. se dice, basándose en la doctrina que aristóteles formula en relación con el hombre, que el ser humano tiene un algo más (plus) en relación con el animal. ese algo más es la razón (la capacidad racional). el ser humano se ha caracterizado a través de toda su historia en ir más allá de la satisfacción de lo puramente instintivo. esto equivale a dar un plus, un algo más, un paso más. tal parece pues que en eso consistiría lo esencial del hombre: su capacidad de poder dar siempre un algo más, un rebasar su propio límite. el momento de administrar medicamentos constituye para el paciente un instante de reconocimiento de su persona por parte de otro (la enfermera). a la hora del medicamento. taking medicines time 127 en todo esto hay algo de suma importancia. la situación traumática del paciente –tanto más si es de cierta gravedad– generalmente le ofrece a éste la oportunidad de revisar a fondo su mundo interno. de todo el equipo de salud es la enfermera la que mayor tiempo y más cercanía tiene con el paciente, llegando a establecer relaciones de confianza e intimidad. esta situación privilegiada le permite a la enfermera captar otro tipo de necesidades, simultáneas a aquellas que lo han llevado a la hospitalización, y que requieren la intervención de otros miembros del equipo de salud. la enfermera será tanto más profesional en cuanto tenga mayor formación complementaria.4 ha sido establecido que “todo conocimiento de enfermería, reside dentro de la situación de enfermería. (…) la situación de enfermería es a la vez el depósito del conocimiento de enfermería y el contexto del conocimiento de enfermería. esta situación es conocida como una experiencia vivida y compartida en donde el cuidado entre la enfermera y su paciente las fortalecen como personas” (5). descripción del servicio donde se vivencia esta experiencia de cuidado esta experiencia ocurre con el paciente quemado durante el turno nocturno de enfermería en el hospital simón bolívar, empresa social del estado, que cuenta con una de las unidades de quemados más grandes del país. garantiza atención a toda la población de bogotá, y a personas remitidas desde diferentes departamentos de colombia. por estratificación la población atendida corresponde en un 70% a los estratos 1, 2 y 3, es decir, población de escasos recursos. el servicio cuenta con 30 camas repartidas en tres áreas: para agudos, 7 cunas para niños y 6 camas para adultos, 3 camas para cuidados intensivos y 15 camas para quirúrgicos (5 cunas y 10 camas). para el año 2004 se atendieron en total 439 pacientes de diferentes etiologías. en el primer semestre de 2005 brindó atención a 245 personas, las cuales requieren del cuidado directo de enfermería las 24 horas del día. algunas características del paciente quemado la persona que sufre quemaduras y es hospitalizada vive de manera súbita un cambio especialmente complejo en sus patrones de vida, pasando a un estado de angustia, pérdida de autonomía, dependencia, enajenación, dolor, expectativa ante la desfiguración, aislamiento, soledad, mal olor… en su mundo emocional puede vivir sentimientos de rabia, temor, ansiedad, frustración, tristeza, abandono, resentimiento, culpa, colocándolo en una posición de mayor vulnerabilidad física y emocional con respecto a otro tipo de pacientes. el aspecto sociocultural es determinante. según ravanal, “las condiciones de pobreza externa, establecen una estructuración-síquica como reflejo. este reflejo al interiorizarse y tornarse actitud 4 uno de los aportes que se puede dar desde el análisis de ese “momento privilegiado” es propender por una formación más integral del profesional de enfermería, especialmente en áreas de las ciencias humanas. la situación traumática del paciente –tanto más si es de cierta gravedad– generalmente le ofrece a éste la oportunidad de revisar a fondo su mundo interno. revista aquichan issn 1657-5997 128 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 permanente forja personalidades con estructuras yoicas débiles” (6), coloca a este tipo de pacientes en una posición, entre otras, de autocompasión y autoabandono. situación de enfermería en la cotidianidad de mi desempeño profesional de enfermería, tal como suelo actuar con cada uno de los pacientes, a la hora de ofrecer los medicamentos me acerqué a la cama de rosa*, una mujer de 51 años que había sufrido quemaduras con gasolina en un 23% de superficie corporal; tenía comprometidos sus dos brazos, el abdomen y su pierna derecha. era nuestro primer encuentro, así que la saludé y me presenté como la enfermera que estaría en ese turno para cuidarla. su respuesta verbal fue mínima pero amable. el timbre de su voz me sugirió que era paisa. el contacto visual fue escaso. le expliqué que le iba a ofrecer sus medicamentos, dos tabletas para evitar el dolor, una para dormir y unas vitaminas para ayudar al restablecimiento de su piel. luego le pregunté con qué deseaba tomarlas, si con agua o con fresco. me respondió que con lo que yo quisiera. le insistí: ¿qué le gusta más?, o ¿con qué los prefiere? hubo un silencio … al cabo dijo: me gusta más con agua, lo otro es muy dulce. le pregunté si los quería tomar al tiempo o una por una, y ella respondió que de dos en dos. levantó un poco su cabeza, apoyé su nuca en mi mano y procedí a ofrecer las tabletas y a dar el agua. mientras observaba su rostro, ella no me miraba, parecía ausente. le pregunté si deseaba más agua y ella manifestó sentirse bien así y me lo agradeció; yo continué explicándole la administración de otro medicamento, el anticoagulante: doña rosa, por la misma quemadura y por lo que no se va a mover mucho, se pueden formar coágulos en su sangre; para evitarlos debo administrarle una inyección; se la puedo aplicar en uno de sus brazos o en su pierna izquierda; es un poco molesto, pero yo lo voy hacer con mucho cuidado. ¿dónde quiere que se la aplique? me miró lentamente. sus ojos azules y todo su rostro tenían expresión de tristeza. nuevamente respondió que donde bien quisiera. yo le puse entusiasmo a mi voz: a veces uno tiene un lado que le duele más que el otro, o de pronto ya le han colocado varias y qué tal que yo se la ponga justo en el mismo lado. intentó esbozar una sonrisa; movió un hombro, luego el otro con una expresión de recuerdo; algo pasó por su mente y, con una señal de la mirada y la cabeza, se decidió por el brazo izquierdo. tras una ligera fricción con las yemas de mis dedos y la limpieza con alcohol, se la apliqué. dio las gracias. le pregunté qué tanto dolor sentía. contestó que no mucho. le hice saber que si llegara a tener dolor o necesitara algo de mí, estaría dispuesta a regresar para atenderla. me despedí con cariño. el siguiente turno se dio una situación similar. como ya la había observado desde el recibo del turno, me acerqué a ella con más cuidado en mi voz y en mi mirada; mientras la saludaba le coloqué mi mano sobre su cabeza. la invité a elegir y a reconocer su dolor físico en la escala 4 a 10; lo clasificó en 4. su expresión seguía siendo de tristeza, pero entre las dos ya se había establecido cierta empatía. observé su mesa auxiliar donde había yogures y frutas; eran las huellas de la visita. aproveché la presencia de esas cosas para contactarla con esos otros. le pregunté quién la había visitado. comentó que su * el nombre es ficticio con el fin de proteger la identidad de la paciente y su familia, y dar aplicabilidad a los principios éticos. la persona que sufre quemaduras y es hospitalizada vive de manera súbita un cambio especialmente complejo en sus patrones de vida, pasando a un estado de angustia, pérdida de autonomía, dependencia, enajenación, dolor, expectativa ante la desfiguración, aislamiento, soledad, mal olor… a la hora del medicamento. taking medicines time 129 esposo y una hija, y habló un poco de cada uno, del valor de su mamá y otros parientes; me dejó conocer algunas cosas de ellos, pero sobre todo de la unión, el afecto familiar y su fe en dios. al verla tan triste le pregunté qué le pasaba. como si le pusieran el dedo en una llaga, después de algunos deslizamientos de su mirada, me dijo que se quería morir. aguardé unos instantes por si continuaba. quedó en silencio. le pregunté que cómo era eso de muchas veces. ella se tornó más tranquila y empezó a narrarme cómo dos años atrás ella, toda su familia, y como 20 más, fueron obligados a abandonar sus tierras, ubicadas en el campo antioqueño, donde tenían su casa, dos criaderos de trucha, algunos cultivos y ganado. me contó que tuvieron que dejarlo todo, llevando sólo lo que cupo en sus manos y el cuerpo resistió. escuchaba e imaginaba no sólo la marcha de aquella y otras familias; pensaba en los niños, los ancianos; imaginaba lo que podría ser esa nostalgia de dejarlo todo, salir sin nada, donde quizá no hubo ni un espacio para una mirada de despedida a todo eso que había sido su vida, y luego continuar un largo viaje hasta llegar a esta ciudad tan ajena a sus cotidianidades, a empezar de la nada, sostenidos por la unidad familiar en una lucha por continuar adelante, con el empuje de cada uno, ya que ellos nunca habían acudido a ninguna red de apoyo para desplazados pues lo consideraban peor, …“y ahora me quemo”. su narración era lenta, remembraba los lugares, ¿cómo no conmoverse, cómo no compartir su tristeza y comprender su deseo de morir? ante tanto dolor pensé que no es para menos. como este caso en colombia ¿cuántos a diario? entonces, qué queda… ¿morirnos? con el mayor respeto le expresé lo comprensible de su tristeza y el derecho que tenía de vivirla. me pregunté si habría algo más. me atreví a preguntar si habían podido salir todos. dio gracias a dios porque así fue. por encima de todo estábamos frente a la vida; entonces de allí me agarré para que mirara lo valioso de poder estar todos vivos, así fuera con dificultades y en esta nueva situación; además, la lucha que habían dado con su unidad familiar, el soporte moral de su madre, una mujer de 70 años. ella lo reconoció pero su tristeza era profunda. le hablé de lo útil que le podía resultar ser vista por siquiatría, en razón a ese deseo de morir. le expliqué el valor científico de esa disciplina, tan lejano de la creencia popular. rosa recibió de buena manera la sugerencia. su accidente seguramente tenía estrecha relación con lo narrado; quizá su hospitalización obedecía, de modo inconsciente, a su necesidad de un reposo forzado. rememorando a margaret newman, esta alteración de salud, como expresión, podría ser saludable, pero por ahora era sufi-ciente. nuestra conversación terminó en un tono de mayor tranquilidad, habiéndose creado un ambiente de solidaridad, una sonrisa, una expresión de dulzura en su rostro y un agradecimiento por parte de ella: “gracias por escucharme”. y yo di las gracias por haberme confiado su vida. hablé con el médico sobre la necesidad de un apoyo para rosa por parte de siquiatría. fue así como pasó a ser valorada por esta especialidad. al siguiente turno, a la hora de los medicamentos, le incluí una lectura; hice resaltar lo bello del contenido, pues aunque es una historia al borde de la muerte, mantiene un hilo de amor por la vida (7). anteponiendo su voluntad e interés para recibirlo o no, concertamos algunas cosas, entre otras, ella eligió que yo se lo leyera. nos dimos una cita para su lectura una vez terminara de ofrecer los medicamentos al resto de pacientes. cuando regresé junto a su lecho, ella apagó su celular –para mí buena señal–; estaba dispuesta, se acomodó en su cama para escuchar, y yo dejé abierto el espacio por si en algún momento no le interesaba, se cansaba, quería un alto en la lectura o pidiera algunas aclaraciones. una vez terminada la lectura creció el silencio entre las dos. no cabían palabras, sólo una sencilla de gracias por parte de ella, y la misma de mi parte por escucharme. nos despedimos. al siguiente turno ¡oh sorpresa! escuché en la sala de t.v. una voz garbosa y fuerte, la de rosa. la expresión de tristeza no estaba presente en ese momento. me saludó efusivamente por mi nombre en diminutivo, me sentí muy contenta de verla sentada y animada fuera de la habitación, y se lo manifesté; sin preámbulos me dijo: necesito pedirle un favor, y es que me venda una copia de esa lectura que me hizo, es que me llegó al alma, ¡ah¡ y me la firma me hace el favor, la quiero guardar de recuerdo. se me confundió la felicidad entre verla allí en la sala, con las expresiones de “me llegó al alma” “la quiero de recuerdo”, y la petición de la firma. en ese instante tuve la certeza de haber ofrecido el mejor medicamento. visión de enfermería la narración cumple con las características de la visión “unitaria transformativa” o de “acción simultánea” (8), dentro de una corriente filosófica que tiene que ver con la fenomenología y la hermenéutica. las razones son las siguientes: revista aquichan issn 1657-5997 130 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 rosa tiene una respuesta de cambio se dan los encuentros, en la relación enfermera-paciente, específica mente en el momento de ofrecer los medicamentos. la enfermera escucha dando un valor central a la narración, a las experiencias anteriores frente a las actuales circunstancias. “dos años atrás fueron obligados a dejar sus tierras y todo”. a toda su vivencia como desplazada se suma el haberse quemado, activando en su mundo interno “el deseo de morir”, al cual llega la enfermera tras identificar la “tristeza”. paralelamente con el ofrecimiento de otros medicamentos, la enfermera orienta el cuidado en el reconocimiento de su yo: a través de sus gustos o deseos del momento, “¿con qué los desea, agua o fresco?” al recibir la respuesta de rosa: “con lo que usted quiera”, la enfermera agrega elementos que la orientan sobre ella misma: “¿con qué le gusta más?, ¿con qué los prefiere?” la invita y da el espacio para reconocer su cuerpo con la valoración del dolor y el sitio para la aplicación del anticoagulante. al establecer una relación de empatía, la enfermera centra su compromiso moral en un cuidado del yo y la dignidad por la vida, pues rosa ha ido construyendo su deseo de morir. busca y encuentra para la intervención de cuidado un recurso: “una lectura, con un hilo de amor”. la percepción que tiene la enfermera de la personalidad de rosa la adquiere a través de la interacción, la interpretación, la observación, actitudes, respuestas, la narración y reconocimiento de las características idiosincrásicas regionales (cultura). la enfermera hace una valoración general cuidadosa de las condiciones y características de rosa para ofrecerle el cuidado más apropiado y personalizado. una teoría y sus conceptos la teórica que respalda la situación de enfermería “a la hora del medicamento” es jean watson (9, 10) en cuanto: la persona la ve integrada por mente, cuerpo y alma, incluye a la enfermera, al paciente y la familia. la ve como un ser humano, de manera individual, única y singularizada. reconoce la realidad espiritual de la experiencia humana. enfatiza que los seres humanos no se pueden tratar como objetos y no se pueden separar: ni de sí mismos, ni de otros, ni de la naturaleza, ni del universo. cree que la dimensión de lo humano le da a cada uno una conexión con lo universal (es una energía universal que eleva nuestro potencial mayor, donde todo lo que yo haga lo hago para toda la humanidad). el alma humana es la energía interna y es única para cada uno. al establecer una relación de empatía, la enfermera centra su compromiso moral en un cuidado del yo y la dignidad por la vida. a la hora del medicamento. taking medicines time 131 el ambiente el entorno es un espacio que se puede crear facilitando el desarrollo de un potencial humano que permita a la persona elegir la acción óptima en cada caso y momento. reconoce que el mundo interno y externo influyen en el proceso de salud y enfermedad. la salud la define como la armonía entre mente, cuerpo, alma y espíritu que engendra un proceso de autoconocimiento, autorrespeto, autocuración y autocuidado. al hacer una ampliación del yo mismo incluye un concepto de salud mental. la define como sanar. cuando la totalidad física no es alcanzable totalmente (de manera natural o por otro accidente), otras energías de la existencia crecen a menudo para compensar y lograr armonía. la enfermería en cuanto al cuidado: el cuidado y el amor componen la energía psíquica primordial y universal. más que una conducta orientada al trabajo, es una actividad moral. está orientado a preservar la dignidad humana trascendiendo el marco espacial y temporal para adquirir dimensiones espirituales. genera más salud que la curación. se orienta a la satisfacción de necesidades humanas, biofísicas (orden inferior), psicofísicas (orden superior) y psicosociales (orden superior). orientado a intervenciones que incluyen la salud, la enfermedad o la muerte. a través de la enseñanza-aprendizaje interpersonal, permite mantener informado al paciente haciéndolo responsable de su bienestar y de su salud, fomentando el desarrollo personal. las intervenciones se llevan a cabo a través de una relación interpersonal y transpersonal. su práctica es el elemento central de la enfermería. exige unos requerimientos de conocimiento, compromiso, valores humanos, morales, sociales y personales por parte de la enfermera. formula un sistema de valores humanos altruistas, definido como la satisfacción que se recibe al prestar ayuda o como la ampliación del sentido de uno mismo. hace un reconocimiento y reverencia por la persona y la vida humana con valores no paternalistas que se relaciona con la autonomía humana y libertad de escogencia. en cuanto a la enfermera: exige un compromiso moral intencional, y la “conciencia caritativa” de protección para engrandecer, promoel entorno es un espacio que se puede crear facilitando el desarrollo de un potencial humano que permita a la persona elegir la acción óptima en cada caso y momento. revista aquichan issn 1657-5997 132 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 ver y potenciar la dignidad humana, en su totalidad y su sanidad donde quiera que una persona crea o co-crea su propio significado de existencia, su sanidad –su totalidad–, su vivir y su morir. el reconocimiento de los sentimientos conduce a una autorrealización de uno mismo y esto opera tanto para la enfermera como para el paciente. la enfermera, al reconocer sus sentimientos, se hace más sincera, auténtica y sensible ante los demás. el cuidado humano de enfermería está en función de aspectos humanitarios de la vida, define a enfermaría como una disciplina interrelacionada con la calidad de vida incluida la muerte, y con la prolongación de la existencia. aplicación de los conceptos principales en la narración persona la enfermera hace un acercamiento holístico y humanístico. reconoce en rosa sus características regionales, su historia anterior frente a la actual, los valores de la unidad y la dignidad en la forma como cada uno de los miembros de su familia han asumido la condición de desplazados, los valores religiosos, su tristeza, su estado de postración y su vulnerabilidad. el ambiente el hospitalario para recibir cuidado y tratamiento de sus quemaduras como expresión de otros móviles. de cómo la enfermera observa en repetidos encuentros a rosa en la cama. los objetos de la mesa auxiliar como un ambiente que conecta con la familia. el espacio que se construye tanto por la enfermera como rosa para la lectura de un texto. cómo en ese espacio para el medicamento, el texto se convierte en otro medicamento. rosa sentada en la sala de t.v. enfermería cada vez que va ofrecer el medicamento la enfermera está plenamente consciente de su acto. hace del momento del medicamento la parte central del cuidado, buscando el fortalecimiento del yo en ese estado de vulnerabilidad del paciente quemado. para cuidar del paciente construye preguntas donde invita a reconocer sus gustos o deseos, a reconocer su cuerpo. propone y administra un medicamento no convencional que abre un espacio de reflexión en el mundo interno de la paciente. para ofrecer el cuidado, los diferentes recursos están apoyados en una continúa creación. salud la recuperación emocional para ese momento como respuesta a los diferentes recursos dispuestos por la el reconocimiento de los sentimientos conduce a una autorrealización de uno mismo y esto opera tanto para la enfermera como para el paciente. a la hora del medicamento. taking medicines time 133 enfermera en el estado en que se encuentra rosa. la utilización de la palabra para orientar a la paciente hacia un autorreconocimiento como persona (dimensión corporal y espiritual). las palabras explicativas relacionadas con las bondades de los medicamentos utilizados para la recuperación de su piel y posibles complicaciones. la orientación en la autovaloración del dolor como consecuencia de las quemaduras. la sugerencia al médico sobre la necesidad de una intervención por parte de otro miembro del equipo de salud. el ofrecimiento a rosa, y posterior aceptación, de un apoyo por otra área del equipo de salud. proposiciones relacionales de la narración las expresiones no verbales de la paciente hablan de “un algo más”. la enfermera crea ambientes en búsqueda de un autorreconocimiento por parte de la paciente. la presencia oportuna y cuidadosa de la enfermera permite establecer una relación de confianza y de empatía bidireccional. la enfermera encuentra y administra un medicamento no convencional. las observaciones de enfermería son puestas al servicio de otra disciplina de salud el cambio de actitud de la paciente evidencia un resultado de calidad del cuidado de enfermería. las expresiones de gratitud por parte de la paciente miden la calidad del cuidado de enfermería. la enfermería ejercida con compromiso dignifica a la persona, tanto a la paciente como a la enfermera. la enfermería ejercida con compromiso dignifica la profesión. intervenciones de enfermería con valores éticos protegen la integridad del paciente y la enfermera. intervenciones de enfermería con valores morales protegen la integridad del paciente y la enfermera. patrones de conocimiento conocimiento personal las cualidades humanas de la enfermera le permiten identificar las características emocionales de rosa, para interactuar con ella. la calidez por parte de la enfermera está presente en todo momento del cuidado centrado en el acto de ofrecer los medicamentos. la calidez por parte de la enfermera está presente en todo momento del cuidado centrado en el acto de ofrecer los medicamentos. revista aquichan issn 1657-5997 134 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 la utilización de diferentes recursos por parte de la enfermera, en busca del fortalecimiento del yo. la recursividad en el uso de la palabra para lograr dinamizar el mundo interno de rosa. la enfermera establece verdaderas relaciones inter y transpersonales de confianza y comprensión, donde acepta y promueve el fortalecimiento del yo para proteger la dignidad. se hace evidente su competitividad científica y teórica en su desempeño. la creatividad lleva a encontrar y ofrecer un medicamento no convencional. el compromiso de la enfermera la lleva a hacer un seguimiento de la situación del paciente. conocimiento empírico a través de una amplia base de conocimientos teóricos, interpreta las respuestas fisiológicas y psicológicas en los diferentes estadios del manejo y tratamiento de las quemaduras. la observación, la experiencia, el desarrollo como persona y como profesional de la enfermería, le permiten una intervención de cuidado en forma individualizada a la hora del medicamento, con una creación continua llena de recursos para orientar a rosa en su autorreconocimiento como persona, brindando un apoyo a través de una relación de confianza y respeto. la intervención de enfermería a través de la actividad de ofrecer el medicamento como acto humano, cuando da a conocer sus beneficios, genera una confianza y seguridad en el paciente quemado para su recuperación. el diagnóstico por parte de la enfermera de la tristeza permite llegar al punto de mayor vulnerabilidad no visible de rosa (a su quemadura interna). conocimiento ético indicación para qué lo hace y cómo lo hace. proporciona los parámetros que comprenden el significado y las obligaciones que conllevan el cuidar del paciente quemado. la forma como se acerca: de manera cuidadosa con su voz, un gesto, un contacto físico. dar a conocer a la paciente la razón y las bondades de cada medicamento. el respeto por la persona permitiéndole elegir: “agua o fresco”, “todas o una por una”, “qué parte de su cuerpo”. el respeto con que escucha su historia para comprender su deseo de morir. lo necesario de otra especialidad para apoyarla en su área mental. el compromiso que la lleva a encontrar otro recurso. el respeto con que ofrece una opción no convencional. el respeto por el silencio. el autorreconocimiento por parte de la enfermera al fundir sus sentimientos de alegría, por verla afuera en la sala la intervención de enfermería a través de la actividad de ofrecer el medicamento como acto humano, cuando da a conocer sus beneficios, genera una confianza y seguridad en el paciente quemado para su recuperación. a la hora del medicamento. taking medicines time 135 de t.v., con las expresiones halagadoras por parte de la paciente relacionadas con el texto de la lectura. los medicamentos ofrecidos dentro de un acto humano, contribuyen en el paciente quemado a tomar acciones de independencia y autocuidado. conocimiento estético cómo la enfermera comprende el poco deseo de hablar de la paciente, apoyada en la observación y las respuestas verbales y no verbales de la paciente. las palabras para invitar a la paciente a decidir sobre su gusto o deseo. la forma como aprovecha la técnica para administrar un medicamento subcutáneo, haciendo del contacto físico una caricia. la calidez con que se despide y deja abierto un espacio. la forma como simbólicamente las huellas de la visita representan a la familia allí con ella. cómo la enfermera escucha la narración del desplazamiento y trasciende para imaginar los espacios y los sentimientos de estos nómadas por la fuerza. cómo rescata la vida en medio de la tristeza por las pérdidas y la actual situación al apoyarse en la persona más fuerte y ejemplar, su madre, una mujer de 70 años. el recurso del texto lo vuelve un medicamento, el más efectivo para ese momento de gran vulnerabilidad. conclusiones la enfermera logra orientar el cuidado en el fortalecimiento del yo, utilizando un lenguaje sencillo y de manera personalizada. el silencio cobra un valor de vital importancia para mantener una relación de respeto. el compromiso como actividad moral por parte de la enfermera mantiene una continuidad para el seguimiento. la relación enfermera-paciente se mantiene mediada por el respeto. la actividad de enfermería, “ofrecer el medicamento”, se convierte en una verdadera interacción de cuidado cuando se ejerce con la aplicabilidad del conocimiento. la vulnerabilidad física y emocional del paciente quemado, por ser un tanto mayor, exige de una calidad de atención muy cuidadosa en el uso de la palabra y en las demás actitudes y comportamientos del profesional de enfermería. la hora del medicamento es una oportunidad para abordar al paciente quemado y abrir otros espacios para su cuidado y recuperación. un paciente fortalecido en su yo facilitará y participará más comprometidamente con las diferentes intervenciones de cuidado y tratamientos. la satisfacción del paciente como respuesta a las intervenciones de enun paciente fortalecido en su yo facilitará y participará más comprometidamente con las diferentes intervenciones de cuidado y tratamientos. revista aquichan issn 1657-5997 136 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 fermería, permiten medir la calidad de la atención. el ejercicio ejercido con profesionalismo abre espacios a intervenciones de cuidado no convencionales. conclusión para recuperar o mantener el estatus científico de la profesión de enfermería en nuestro país, es necesario poner en la prácreferencias 1. durán m m. enfermería. desarrollo teórico e investigativo. bogotá: facultad de enfermería, universidad nacional de colombia; 2001. 2. bonte p, izard, m. diccionario de etnología y antropología. madrid: ediciones akal; 1996. 3. lepp i. la comunicación de las existencias. buenos aires: ediciones carlos lohlé; 1962. 4. ferrater j. diccionario de filosofía. barcelona: editorial ariel; 1994. 5. boykin, schoenhofer. enfermería como cuidado: un modelo para transformar la práctica. nueva york: aln; 1993. tica todo el desarrollo teórico y científico generado hasta ahora por teóricos de otros países; conocimiento que está a la espera de los aportes nuestros, producto de la investigación. en el presente trabajo se ha podido mostrar que en el campo de la clínica, en un acto puntual, elemental, básico y cotidiano propio de la práctica del cuidado de enfermería (como es el caso de dar el medicamento), es posible visualizar lo fundamental como profesión y disciplina de la enfermería. tener en cuenta los diferentes aspectos implicados en la práctica puntual, retroalimenta, a su vez, la reflexión sobre los fundamentos epistemológicos y éticos de la disciplina, en orden a experimentarlos, confrontarlos y enriquecerlos. estas consideraciones podrían ser aplicadas, posiblemente, en otras prácticas de enfermería. 6. rabanal c. cicatrices de la pobreza. caracas: editorial nueva sociedad; 1989. 7. sagan c. miles de millones. barcelona: sine qua non; 1997. 8. fawcett j. analysis and evaluation of contemporary nursing knowledge. nursing models and theories. philadelphia: f. a. davis company; 2000. (cap. 1, traducción edilma de reales). 9. watson j. naturaleza del cuidado humano y valores de cuidado en enfermería. nacional league for nursing; 1988. (adaptación y traducción de beatriz sánchez). 10. watson j. cuidado humano en enfermería. national league for nursing; 1988. 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/untaggedcmykhandling /leaveuntagged /untaggedrgbhandling /leaveuntagged /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 210 221 factores asociados a la vulnerabilidad.indd 210 alejandra segura-cardona1 doris cardona-arango2 ángela segura-cardona3 diana i. muñoz-rodríguez4 daniel jaramillo-arroyave5 douglas lizcano-cardona6 maite catalina agudelo-cifuentes7 santiago a. morales-mesa8 factores asociados a la vulnerabilidad cognitiva de los adultos mayores en tres ciudades de colombia 1 orcid.org/0000-0002-1624-0952. universidad ces, colombia. dsegura@ces.edu.co 2 orcid.org/0000-0003-4338-588x. universidad ces, colombia. dcardona@ces.edu.co 3 orcid.org/0000-0002-0010-1413. universidad ces, colombia. asegura@ces.edu.co 4 orcid.org/0000-0003-4255-4813. universidad ces, colombia. dmunoz@ces.edu.co 5 orcid.org/0000-0001-8735-7050. universidad ces, colombia. dajaramillo@ces.edu.co 6 orcid.org/0000-0002-1652-3231. universidad ces, colombia. d.lizcano@uces.edu.co 7 orcid.org/0000-0003-1501-9452. universidad ces, colombia. agudelo.maite@uces.edu.co 8 orcid.org/0000-0002-8987-7399. universidad ces, colombia. samorales@ces.edu.co recibido: 03/05/2017 enviado a pares: 22/06/2017 aceptado por pares: 23/10/2017 aprobado: 21/02/2018 doi: 10.5294/aqui.2018.18.2.8 para citar este artículo / to reference this article / para citar este artigo segura-cardona a, cardona-arango d, segura-cardona a, muñoz-rodríguez di, jaramillo-arroyave d, lizcano-cardona d, et al. factores asociados a la vulnerabilidad cognitiva de los adultos mayores en tres ciudades de colombia. aquichan 2018; 18(2): 210-221. doi: 10.5294/aqui.2018.18.2.8 año 18 vol. 18 nº 2 chía, colombia abril 2018 l 210-221 temática: promoción y prevención aporte a la disciplina: la población mayor va en aumento, con una mayor esperanza de vida que obliga a pensar en la promoción de un envejecimiento saludable, donde se prevengan las enfermedades mentales y se reduzca el deterioro cognitivo a fin de procurar que más personas lleguen a esta etapa del ciclo vital con buena función cognitiva que reduzca la dependencia y disminuya el cuidado que prodigan su familias, cuidadores y profesionales de la salud, como la enfermería. resumen objetivo: identificar los factores asociados a la vulnerabilidad cognitiva de los adultos mayores en tres ciudades de colombia en el año 2016. materiales y método: se condujo un estudio cuantitativo, transversal analítico, con fuente de información primaria, encuestando a 1514 adultos mayores residentes en la zona urbana de barranquilla, medellín y pasto, empleando muestreo probabilístico bietápico. la condición cognitiva se evaluó con el mini examen cognoscitivo modificado. se realizaron análisis univariados, bivariados y multivariados, cálculos estadísticos y epidemiológicos, intervalos de confianza y pruebas estadísticas menores del 5%. resultados: el riesgo de deterioro cognitivo se presentó en un 5,1% en medellín, un 2,7% en pasto y un 1,7% en barranquilla, predominantemente en hombres, con edades entre los 75 y 89 años, sin pareja y con bajos niveles de escolaridad. el 100% de quienes tenían deterioro cognitivo refieren no realizar actividad física, el 13% reportaron depresión y el 7,7% soporte social escaso. conclusiones: los factores asociados a la vulnerabilidad cognitiva de los adultos mayores incluyen características demográficas, sociales y de estilos de vida. es importante considerar estos resultados en las políticas de salud para la población de adultos mayores con el fin de reorientar la atención en la prevención de la vulnerabilidad cognitiva. palabras clave anciano; cognición; envejecimiento; vulnerabilidad; apoyo social (fuente: decs). 211 factores asociados a la vulnerabilidad cognitiva de los adultos mayores en tres ciudades de colombia l alejandra segura-cardona y otros año 18 vol. 18 nº 2 chía, colombia abril 2018 l 210-221 factors associated with the cognitive vulnerability of older adults in three colombian cities abstract objective: identify the factors associated with the cognitive vulnerability of older adults in three colombian cities during 2016. materials and methods: a quantitative, cross-sectional, analytical study was conducted with a primary source of information by surveying 1514 older adults living in the urban areas of barranquilla, medellín and pasto. two-stage probabilistic sampling was used. the cognitive condition of the adults in the sample was evaluated with the modified mini cognitive exam. univariate, bivariate and multivariate analyzes, statistical and epidemiological calculations, confidence intervals and statistical tests of less than 5% were performed. results: the risk of cognitive deterioration was found in 5.1% of the sample in medellín, 2.7% in pasto and 1.7% in barranquilla, predominantly among men between 75 and 89 years of age who are without a partner and have low levels of schooling. one hundred percent (100%) of those with cognitive impairment reported having no physical activity, 13% reported depression, and 7.7% indicated social support was scarce. conclusions: the factors associated with cognitive vulnerability among older adults include demographic, social and lifestyle characteristics. it is important to consider these results when drafting health policies for the elderly population to redirect attention to the prevention of cognitive vulnerability. keywords elder persons; cognition; aging; vulnerability; social support (source: decs). 212 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 2 chía, colombia abril 2018 l 210-221 fatores associados à vulnerabilidade cognitiva dos idosos em três cidades da colômbia resumo objetivo: identificar os fatores associados à vulnerabilidade cognitiva dos idosos em três cidades da colômbia em 2016. materiais e método: estudo quantitativo, transversal analítico, com fonte de informação primária, que entrevistou 1514 idosos residentes na zona urbana de barranquilla, medellín e pasto, empregando amostra probabilística bietápica. a condição cognitiva foi avaliada com o miniexame cognoscitivo modificado. foram realizadas análises univariadas, bivariadas e multivariadas, cálculos estatísticos e epidemiológicos, intervalos de confiabilidade e testes estatísticos menores de 5 %. resultados: o risco de deterioração cognitiva foi apresentado em 5,1 % em medellín; 2,7 % em pasto e 1,7 % em barranquilla, predominantemente em homens, com faixa etária entre 75 e 89 anos, sem companheiro(a) e com baixo nível de escolaridade. 100 % dos que apresentaram deterioração cognitiva referem não realizar atividade física; 13 % relataram depressão e 7,7 %, apoio social escasso. conclusão: os fatores associados à vulnerabilidade cognitiva dos idosos incluem características demográficas, sociais e de estilos de vida. é importante considerar os resultados nas políticas de saúde para a população de idosos a fim de reorientar a atenção na prevenção da vulnerabilidade cognitiva. palavras-chave ancião; cognição; envelhecimento; vulnerabilidade; apoio social (fonte: decs). 213 factores asociados a la vulnerabilidad cognitiva de los adultos mayores en tres ciudades de colombia l alejandra segura-cardona y otros introducción para la organización mundial de la salud (oms), el envejecimiento es la confluencia de una acumulación de daños moleculares y celulares, que lleva a la pérdida de capacidades físicas y mentales, con aumento de enfermedades y muerte; proceso no uniforme en las personas (1). el informe mundial sobre envejecimiento y salud (2) considera que la pérdida de funciones cognitivas tales como la pérdida de memoria, la capacidad para desarrollar tareas complejas y para aprender se encuentra relacionada con la edad. sin embargo, no todas funciones se deterioran ya que el lenguaje, la comprensión, la capacidad de leer y el vocabulario se mantienen estables durante toda la vida. la vulnerabilidad se identifica como la disposición interna a ser afectado por una amenaza, bien sea endógena o exógena, y dependiendo de su exposición puede haber incapacidad inherente a la respuesta; es una característica más evidenciable en la vejez. entre los factores relacionados con la vulnerabilidad se encuentran los sociales (menor poder adquisitivo, soledad, aislamiento, falta de integración y problemas familiares), los psicológicos (depresión, deterioro cognitivo, muerte de seres queridos y viudez), los físicos (pérdida de la independencia, dificultad para la realización de las actividades diarias), y factores económicos en donde los estratos sociales forman parte importante para la discriminación del déficit en algunos aspectos del desarrollo (3). en este estudio se abordó la vulnerabilidad cognitiva como la percepción que tiene la persona de no poseer control interno o externo sobre los peligros, lo cual afecta el sistema cognitivo y la forma de percibir el mundo (4). entre los factores de riesgo asociados a la vulnerabilidad se encuentra el deterioro cognitivo; las funciones que más se afectan con el declive de la edad son las relacionadas con la velocidad y precisión del procesamiento de la información (5). el sistema cognitivo es el conjunto de operaciones mentales que se realizan mediante la interpretación perceptual de estímulos para transferirla a una respuesta o conducta de desempeño. en estas operaciones se encuentran involucrados los procesos cognitivos simples y complejos: sensación, percepción, atención, concentración, memoria, pensamiento, lenguaje e inteligencia (6). para evaluar la capacidad cognitiva de los adultos existen instrumentos de medición rápidos, confiables y validados en el medio, como el mini mental state examination (mmse) (7), el cual ha mostrado ser un instrumento con buen rendimiento (8, 9). el mmse es una herramienta que puede ser utilizada para evaluar el estado cognitivo en forma sistemática y exhaustiva; consta de 11 preguntas que analizan algunas áreas de funcionamiento cognitivo como: orientación, registro, atención, cálculo, memoria y lenguaje. ha sido validado y utilizado extensamente, tanto en la práctica como en la investigación clínica, desde su creación en 1975 (10). existe una versión modificada, que cuenta con 6 ítems con una puntuación máxima de 19; a partir de 13 puntos o menos se sugiere déficit cognitivo (11). en colombia son pocas las mediciones que se han realizado en personas mayores. en investigaciones encontradas en el ámbito nacional se destaca la llevada a cabo en bucaramanga, en la cual se obtuvo una prevalencia de 2,6 % entre deterioro cognitivo leve y moderado que, según los autores, podía estar relacionada con el hecho de que la muestra evaluada aún contaba con la mayoría de sus facultades físicas y mentales, además estaban en actividad continua e independiente para realizar sus tareas diarias (12). la encuesta sabe colombia, realizada en el 2015 –la cual tenía como objetivo conocer la situación de las personas adultas mayores por medio de una exploración interdisciplinaria de la vejez y envejecimiento en el marco de los determinantes del envejecimiento activo y desde el modelo de los determinantes sociales de la salud–, reportó una prevalencia de 17,5 % en los adultos mayores del país (13). a nivel departamental, el estudio de la situación de salud del adulto mayor de antioquia encontró que el 83,1 % de los adultos mayores presentaba riesgo de deterioro cognitivo, con mayor riesgo para las personas de edad más avanzada (14). por lo anterior, el presente estudio tiene como objetivo identificar los factores asociados a la vulnerabilidad cognitiva de los adultos mayores en tres ciudades de colombia: medellín, barranquilla y pasto, en el año 2016. materiales y métodos estudio observacional analítico de corte transversal, enmarcado dentro del enfoque cuantitativo, con fuente de información primaria, realizado en tres ciudades de colombia, las cuales fueron seleccionadas según número de personas mayores, clasificadas como grande (medellín), mediana (barranquilla) y pequeña (pasto). se tomó como población de referencia las 593.409 personas de 60 años y más de edad que vivían en la zona urbana de 214 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 medellín (391.429), barranquilla (146.445) y pasto (42.271) en el año 2016, según las proyecciones poblacionales del departamento administrativo nacional de estadística (dane). para el cálculo del tamaño muestral se utilizó la fórmula de fleiss para poblaciones finitas, con un nivel de confianza del 95 %, un error de muestreo del 5 %, con una proporción de mayores con buen estado de salud del 50 % y un efecto de diseño (deff) del 1,0. la muestra quedó conformada por 1.514 adultos de 60 años y más de edad: medellín (495), barranquilla (513) y pasto (506). la muestra fue seleccionada mediante muestreo probabilístico, por conglomerado bietápico, según la distribución geográfica y administrativa de cada ciudad, que permitió la aplicación de factores de expansión para lograr la representatividad en los indicadores proyectados por el dane para cada una de las ciudades incluidas en el estudio. fue probabilístico porque todos los adultos mayores de las tres ciudades tuvieron probabilidad de selección conocida mayor que cero. los conglomerados estuvieron conformados por las comunas (medellín y pasto), y localidades en el caso de barranquilla; bietápico porque la selección se realizó en dos etapas: la primera consistió en la selección de los barrios al interior de cada comuna a través de muestreo sistemático aleatorio (msa), como unidad secundaria de muestreo (usm); y la segunda y última etapa consistió en la selección de manzanas al interior de cada barrio como unidades primarias de muestreo (upm) con muestreo aleatorio simple. la unidad final de análisis (ufa) fueron todas las personas mayores residentes en las viviendas que conformaron la manzana; por tanto, se hizo censo en cada manzana seleccionada que cumpliera con los criterios de elegibilidad. para la medición de los factores de interés, se aplicó una encuesta diseñada con escalas para cada una de las variables de análisis ya validadas en el medio a fin de detectar: capacidad funcional, depresión y apoyo social. las variables independientes fueron sexo, edad, estado civil y nivel de escolaridad. la función cognitiva fue medida a partir de la escala mini examen cognoscitivo (mmse) modificado, instrumento práctico, válido y confiable; es una escala neuropsicológica ampliamente utilizada por su ra pidez y facilidad en la puntuación. valora seis aspectos del área cognoscitiva: orientación en tiempo, lugar y espacio; repetición de palabras y memorización; concentración; memoria a corto plazo; lenguaje, y función ejecutiva. este instrumento presenta coeficientes de sensibilidad, especificidad y valor predictivo, que lo convierten en una prueba fiable para su utilización en los pacientes ancianos que residen en su domicilio (15). en colombia, su validación se realizó en un estudio poblacional de una muestra aleatoria estratificada de residentes urbanos y rurales de cinco regiones, con una sensibilidad de 92,3 y especificidad de 53,7 % (16). todos los participantes firmaron un consentimiento informado donde aceptaron voluntariamente hacer parte del estudio. el análisis de los datos se hizo con el paquete estadístico spss versión 21 (spss inc; chicago, illinois, usa) licencia de la universidad ces. se realizó un análisis univariado, donde se calcularon medidas de frecuencia absolutas y relativas a las variables cualitativas, y medidas de resumen para las variables cuantitativas previa prueba de normalidad (kolmogorov-smirnov). se calcularon razones de prevalencias (rp) crudas y la prueba estadística chi-cuadrado para determinar las variables que se encontraban asociadas, con su intervalo de confianza del 95 % (ic 95 %), y se consideró asociación estadística con valores p menores del 5 %. igualmente, se realizó un análisis multivariado estratificado y regresión logística con fines explicativos para el cálculo del rp ajustado; con este análisis se controló la confusión e interacción de variables con cada una de las variables independientes. este proyecto fue considerado de riesgo mínimo y aprobado por el comité institucional de ética de la universidad ces en la sesión número 81 del 9 de junio de 2015; se contó con financiación de colciencias. resultados la prevalencia de riesgo de deterioro cognitivo fue de 4,0 % (mmse < 13). el puntaje promedio de los adultos mayores en la escala fue de 16,2 (de 2,3 puntos); el 50 % obtuvo puntuaciones de 16,0 o menos (ri 3 puntos). los hombres presentaron como puntaje mínimo 4 puntos, con unas puntuaciones promedio de 16,2 (de 2,1 puntos) y las mujeres presentaron valores mínimos de 0 puntos, con un promedio de 16,3 (de 2,5 puntos). al comparar por sexo se observó mayor predominio de deterioro cognitivo en los hombres, con un 4,1 %, comparado con las mujeres, con un 3,9 %; sin embargo, no se encontró asociación estadísticamente significativa entre el sexo y el riesgo de deterioro cognitivo (x2 = 0,54; p = 0,46). por ciudad, la mayor prevalencia de riesgo se registró en la ciudad de medellín con un 6,7 % al compararse con las otras ciudades; se evidenciaron diferencias significativas (x2 = 24,57; 215 factores asociados a la vulnerabilidad cognitiva de los adultos mayores en tres ciudades de colombia l alejandra segura-cardona y otros p = 0,000). en la ciudad de medellín el puntaje promedio obtenido por los adultos mayores en la escala fue de 15,9 puntos (de 2,3 puntos); los hombres presentaron unas puntuaciones promedio de 15,8 (de 2,2 puntos); las mujeres presentaron un promedio de 16,0 puntos (de 2,4 puntos). en barranquilla el puntaje promedio obtenido en la escala fue de 16,9 (de 2,3 puntos); los hombres presentaron puntuaciones promedio de 17,0 (de 1,7 puntos); las mujeres presentaron un promedio de 16,7 puntos (de 2,6 puntos). en la ciudad de pasto el puntaje promedio obtenido por los adultos mayores fue de 16,3 (de 1,9 puntos); los hombres presentaron puntuaciones promedio de 16,3 (de 1,8 puntos); las mujeres presentaron promedios de 16,3 puntos (de 1,9 puntos). lo anterior indica que los mayores residentes en medellín presentan menores valores en la medición lo cual muestra mayor riesgo de presentar deterioro cognitivo, especialmente en las mujeres; por otro lado, la ciudad de pasto muestra mayores puntajes en la medición de la función cognitiva tanto en hombres como en mujeres (tabla 1). al analizarlo por edad se observó mayor predominio de deterioro cognitivo en los adultos mayores con edades entre los 75 y 89 años, con un 60,8 %; este grupo de edad fue el de mayores prevalencias en las tres ciudades (medellín, 54,5 %; barranquilla, 55,6 %; pasto, 88,9 %). la edad tiene relación estadísticamente significativa con el riesgo de deterioro cognitivo (x2 = 53,52; p = 0,000). de los adultos mayores con riesgo de deterioro cognitivo, más del 65 % se encuentra sin pareja (viudo, separado/divorciado o soltero), y el porcentaje restante tiene pareja (casado o vive en unión libre); en medellín y pasto el mayor porcentaje de deterioro se encuentra en los viudos (42,4 % y 77,8 %, respectivamente), y en barranquilla en los viudos y los casados (44,4 % para ambos). el estado civil también muestra una relación estadísticamente significativa con la variable de interés (x2 = 16,03; p = 0,003). el 52,9 % de los mayores con riesgo tenían como máxima escolaridad la primaria, seguidos de aquellos que no tenían ningún nivel de escolaridad (41,2 %); aquellos con más escolaridad presentaron menores puntuaciones de deterioro cognitivo, siendo inferiores al 10 %, lo que evidencia una relación significativa entre la escolaridad y dicho riesgo (x2 = 59,89; p = 0,000). en cuanto a la capacidad funcional, el 11,6 % de los adultos mayores presentaba alguna condición de dependencia (leve, moderada o severa); de aquellos con deterioro cognitivo, el 100 % refiere no realizar actividad física; sin embargo, no se encontró asociación significativa entre el deterioro cognitivo y la realización de actividad física (x2 = 2,94; p = 0,086). las personas mayores con escaso o nulo soporte social son el 7,7 %, y el riesgo de depresión en la muestra se ubica en un 13 %; sin embargo, ninguno reportó deterioro cognitivo. con respecto a la orientación temporo-espacial, un alto porcentaje demostró adecuada orientación; se presentaron mayores dificultades en la evocación del día con un 5,9 % (34.294), seguido del año con un 5,6 % (32.294); y las menores dificultades se presentaron en la identificación del mes 2,1 % (12.418) y el día de la semana 2,3 % (13.081). al comparar por ciudad, medellín presentó mayor dificultad para la identificación del año con un 5,6 % (21.993); en barranquilla y pasto se presentó mayor dificultad en la evocación del día con un 6,0 % (8.827) y un 9,7 % (4.025), respectivamente (tabla 2). deterioro cognitivo medellín barranquilla pasto total n % n % n % n % con deterioro hombre 9.268 5,7 169 0,3 570 3,2 10.007 4,1 mujer 10.783 4,7 1.816 2,1 533 2,3 13.131 3,9 sin deterioro hombre 152.714 94,3 62.817 99,7 17.310 96,8 232.841 95,9 mujer 217.915 95,3 83.464 97,9 23.065 97,7 324.444 96,1 total 390.680 100,0 148.265 100,0 41.478 100,0 580.423 100,0 tabla 1. medellín, barranquilla, pasto: distribución absoluta y porcentual de los adultos mayores según deterioro cognitivo por sexo, 2016 fuente: cardona, segura, segura, muñoz, jaramillo, lizcano et al. (17). 216 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 tabla 2. medellín, barranquilla, pasto: distribución absoluta y porcentual de los adultos mayores según funciones mentales superiores, 2016 fuente: cardona, segura, segura, muñoz, jaramillo, lizcano et al. (17). ítems medellín barranquilla pasto total n % n % n % n % orientación mes 381.115 97,6 146.453 98,8 40.437 97,5 568.005 97,9 día 369.238 94,5 139.438 94,0 37.453 90,3 546.129 94,1 año 368.687 94,4 140.185 94,6 39.205 94,5 548.078 94,4 día de la semana 382.806 98,0 145.315 98,0 39.221 94,6 567.342 97,7 memoria de fijación árbol 389.880 99,8 146.640 98,9 41.404 99,8 577.924 99,6 mesa 389.017 99,6 139.362 94,0 40.644 98,0 569.023 98,0 avión 388.060 99,3 142.572 96,2 40.752 98,2 571.384 98,4 atención y concentración dígito 1 307.367 78,7 133.285 89,9 31.554 76,1 472.206 81,4 dígito 2 290.957 74,5 115.652 78,0 32.258 77,8 438.867 75,6 dígito 3 297.186 76,1 104.818 70,7 33.514 80,8 435.518 75,0 dígito 4 288.866 73,9 101.639 68,6 34.120 82,3 424.624 73,2 dígito 5 327.009 83,7 107.199 72,3 37.808 91,2 472.017 81,3 memoria de evocación árbol 234.245 60,0 131.531 88,7 29.431 71,0 395.208 68,1 mesa 160.890 41,2 110.505 74,5 22.583 54,4 293.978 50,6 avión 127.709 32,7 111.732 75,4 14.508 35,0 253.949 43,8 función ejecutiva y lenguaje comprensivo tomarlo 381.267 97,6 146.883 99,1 41.478 100,0 569.628 98,1 doblarlo 381.164 97,6 146.883 99,1 41.478 100,0 569.525 98,1 colocarlo 381.402 97,6 146.779 99,0 41.102 99,1 569.283 98,1 praxias sí 383.833 98,2 146.960 99,1 40.999 98,8 571.792 98,5 no 6.847 1,8 1.305 0,9 479 1,2 8.631 1,5 total 390.680 100,0 148.265 100,0 41.478 100,0 580.423 100,0 217 factores asociados a la vulnerabilidad cognitiva de los adultos mayores en tres ciudades de colombia l alejandra segura-cardona y otros en relación con la memoria de fijación (capacidad de nombrar tres palabras con intervalos de tiempo determinados), los adultos mayores tuvieron altos porcentajes; en la primera palabra 99,6 %, en la segunda 98,0 % y en la tercera 98,4 %. esta tendencia en la capacidad de evocación inmediata se mantuvo de manera uniforme en las tres ciudades. en la memoria de evocación disminuyó la capacidad de los adultos mayores, una tercera parte de ellos (68,1 %) logró recordar solo la primera palabra, y las demás fueron disminuyendo en porcentaje gradualmente. se identifica que en la ciudad de barranquilla fue donde más se logró mantener la memoria de evocación con valores superiores en los tres estímulos con respecto a las demás ciudades (tabla 2). al comparar por ciudad la atención y la concentración, los residentes en pasto presentan más dificultad para iniciar la prueba en el primer dígito; en barranquilla se percibe mayor irregularidad en el desarrollo de la prueba con fluctuaciones entre cada uno de los dígitos, indicativo de mayores dificultades para identificar el patrón de la tarea. en la ciudad de medellín se identifica un patrón estable en la medición (tabla 2). en la función ejecutiva y la capacidad lingüística se identificó un alto porcentaje, tanto a nivel general como por ciudad. en consecuencia, con el puntaje obtenido en la capacidad ejecutiva, igualmente la capacidad práxica obtuvo altas puntuaciones en la medición, y se ubicó como la capacidad cognitiva más conservada en los adultos mayores junto con la función ejecutiva (tabla 2). al analizar las razones de prevalencia (rp) crudas, en la ciudad de medellín se encontró la probabilidad más alta de presentar riesgo de deterioro cognitivo (rp = 3,94; ic95 %: 1,86-8,33). ser mujer y estar sin pareja aumenta dicha probabilidad, pero la condición que más contribuye a la vulnerabilidad cognitiva es la edad, lo que indica que a mayor edad mayor riesgo. una vez se ajusta la relación con las variables de ciudad, sexo y estado civil, se observa que vivir en la ciudad de medellín y una mayor edad conservan asociación estadística; las demás variables no ingresan en el modelo estadístico final, pero sí se conserva el aumento de la probabilidad en las mujeres y en las personas mayores sin pareja (tabla 3). tabla 3. medellín, barranquilla, pasto: razón de prevalencia de la vulnerabilidad en el adulto mayor, según factores asociados, 2016 variable rpc ic 95 % rpa ic 95 % x2 p li ls li ls ciudad medellín 3,944 1,867 8,332 3,997 1,776 7,968 19,347 0,000* barranquilla 0,986 0,388 2,505 1,056 0,397 2,568 pasto 1,000 1,000 sexo hombre 1,000 1,000 . 0,001 0,976 mujer 1,257 0,682 2,319 1,084 0,532 1,915 estado civil sin pareja 2,030 1,124 3,667 1,769 0,953 3,286 3,263 0,071 con pareja 1,000 1,000 grupo de edad de 60 a 74 1,000 1,000 37,137 0.000* de 75 a 89 5,609 3,032 10,371 5,571 2,986 10,395 de 90 a 99 8,010 2,193 29,254 8,024 2,091 30,784 de 100 + 66,750 3,997 1114,7 27,707 1,626 472,08 *rpc: razón de prevalencia cruda; rpa: razón de prevalencia ajustada; ic: intervalo de confianza; *p: valor de p estadísticamente significativo. fuente: cardona, segura, segura, muñoz, jaramillo, lizcano et al. (17). 218 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 discusión se evidencia que tener una edad por encima de los 75 años, vivir solo debido a viudez, separación o soltería, y tener bajo nivel de escolaridad podría aumentar la probabilidad de padecer deterioro cognitivo en la vejez. estos datos son congruentes a lo encontrado por cárdenas, villareal y salinas en méxico (18), escobar et al. en perú (19), cerquera en colombia (20) y por samuel et al. en india (21), en los que se destaca que el declive cognitivo se manifestó de manera especial en los individuos de mayor edad y con bajos niveles educativos. en españa, un estudio sobre prevalencia de deterioro cognitivo encontró que este evento se presenta principalmente en mujeres y que aumenta de manera exponencial con la edad (22). la prevalencia de deterioro cognitivo hallada en este estudio se debe clasificar como de severidad leve, debido a que dentro de los criterios de selección debieron excluirse los adultos mayores con capacidad cognitiva severamente deteriorada que les impedía responder a los instrumentos empleados en la investigación; por tanto, la prevalencia de este deterioro de ubicó en el 4 %, similar a la reportada por mejía et al. en méxico (23), pero menor a la reportada por el estudio nacional de salud, bienestar y envejecimiento (sabe) (13) realizado en colombia en el año 2015, donde se reportó una presencia de deterioro cognoscitivo leve de 17 %, así como en un estudio reciente con población de adultos mayores que viven en comunidad en brasil, donde la prevalencia fue de 13,64 % (ic 95 %: 10,33-16,64) (24). en esta investigación se observó una frecuencia más alta del sexo masculino relacionado con el deterioro cognitivo, esta asociación no fue significativa, al igual que en el estudio de escobar et al. en perú (19). el predominio de deterioro cognitivo en hombres está ampliamente documentado en la mayor parte de los antecedentes, nacionales e internacionales (1820, 25); sin embargo, algunas de las diferencias reportadas en las investigaciones con relación al sexo podrían deberse a las distribuciones socioculturales de las poblaciones, pero se destaca que una vez se ajusta la asociación con otras variables demográficas, el ser mujer aumenta la probabilidad de tener vulnerabilidad cognitiva. se encontró una clara asociación entre el deterioro cognitivo y la edad, pues se observó mayor predominio en los adultos mayores con edades entre los 75 y 89 años, con un 60,8 %; este grupo de edad fue el de mayores prevalencias en las tres ciudades, lo que indica que a mayor edad menor puntuación en la prueba aplicada, igual a lo encontrado en perú (19), méxico (18), cuba (26) y chile (27). la mayoría de las investigaciones señala una relación entre la edad y el funcionamiento cognitivo debido a que a medida que avanza la edad el metabolismo cambia, lo que se traduce en una disminución de entrada de glucosa y recaptación de glutamato extracelular, lo que ocasiona muerte de neuronas en el hipocampo; y si a esto se le agregan los componentes del estilo de vida, las posibilidades de que a mayor edad mayor probabilidad de deterioro cognitivo son más altas (28). es importante mencionar que los adultos mayores que viven acompañados obtienen mejores resultados que los que viven solos, debido a la posibilidad de estimulación e interacción constante; asimismo, se ha reportado que el contexto de vida familiar puede actuar como catalizador de condiciones que pongan en riesgo al adulto mayor, en la medida en que los miembros de la familia conocen y atienden las necesidades de estas personas y, por tanto, contribuyen a mantener el bienestar y la calidad de vida (29). en la presente investigación se encontró que seis de cada diez adultos mayores con deterioro cognitivo eran viudos, separado/divorciados o solteros. el 52,9 % de los adultos mayores que presentaron deterioro cognitivo se encontraban con máxima escolaridad de primaria, seguidos de aquellos que no presentaba ningún nivel de escolaridad; esta relación fue significativa. lo anterior se reporta ampliamente en la literatura debido a que las personas que tienen niveles altos de instrucción tienen mayor preferencia por las actividades cognitivamente estimulantes, como la lectura, la escritura, los juegos, etc. en colombia, un estudio poblacional en cinco regiones encontró que 16 de las 19 preguntas de la escala minimental mostraron diferencias significativas (p < 0,001) según el nivel educativo; las puntuaciones del mmse se correlacionaron estrechamente con esta variable (16). de otro lado, diversos estudios mencionan que la actividad mental ayuda a la adquisición de las reservas neural y cognitiva, lo que previene los estragos de la muerte neuronal ya sea por envejecimiento normal o por deterioro cognitivo leve (30). en un estudio realizado en méxico en el 2006 (18) se encontró que un bajo puntaje de la escala de depresión geriátrica indicativo 219 factores asociados a la vulnerabilidad cognitiva de los adultos mayores en tres ciudades de colombia l alejandra segura-cardona y otros de depresión moderada se relacionó con el trastorno cognitivo y, recientemente, se sigue documentando sobre el riesgo que corren las personas mayores con depresión para tener un riesgo elevado de deterioro cognitivo (31). en la actual investigación, aunque se encontró una prevalencia moderada de depresión, esta no se asoció con el declive cognitivo presentado por los adultos mayores. en la adultez mayor, ciertas funciones cognitivas se encuentran preservadas o escasamente afectadas, y no se altera la autonomía funcional en las actividades de la vida diaria (32); sin embargo, la evidencia clínica ha demostrado que existen alteraciones en otras funciones cognitivas como la atención, la función ejecutiva y la memoria, lo cual se ha denominado como deterioro cognitivo leve (33). dado que el razonamiento es un determinante del funcionamiento diario de los adultos mayores, el desempeño exitoso en las tareas diarias puede verse influenciado por la función cognitiva ejecutiva (34). en la investigación se evidencia que las funciones cognitivas más preservadas en los adultos mayores son las praxias y la función ejecutiva; las más alteradas son la atención y la memoria de evocación. en la vejez puede presentarse pérdida progresiva de la memoria, lo que genera angustia por considerarla un preludio de la demencia (35). como limitaciones del estudio se resalta que el mmse es un instrumento de detección, no de diagnóstico. conclusiones desde los modelos teóricos se ha propuesto que una adecuada función cognitiva hace parte esencial del desempeño en otras esferas del individuo tales como su funcionalidad y su desempeño familiar, social y laboral, lo que se constituye en una buena calidad de vida. por tanto, este estudio aporta al conocimiento de los factores asociados a la vulnerabilidad cognitiva de los adultos mayores, los que incluyen características demográficas, sociales y de estilos de vida, a partir de las cuales se provee información para el ajuste de las intervenciones, incluso desde edades más tempranas, para prevenir el deterioro cognitivo. además, pueden fortalecerse los servicios de salud mental que se ofrezcan a las personas mayores, donde se les eduque con estrategias de autocuidado, para evitar las enfermedades mentales y funcionales. agradecimientos: los investigadores agradecen a las instituciones financiadoras que hicieron posible la realización de este proyecto, y a las personas mayores de las tres ciudades. conflicto de interés: ninguno declarado. financiación: este proyecto de investigación fue financiado por el departamento administrativo de ciencia, tecnología e innovación (colciencias) de colombia (contrato: 122871149710), con el apoyo de la universidad ces de medellín, colombia (código universitario: inv.082016.001). referencias 1. organización mundial de la salud. envejecimiento y salud. nota descriptiva 404. 2015 [visitado 2017 may 28]. disponible en: http://www.who.int/mediacentre/factsheets/fs404/es/. 2. organización mundial de la salud. informe mundial sobre el envejecimiento y la salud. ginebra: oms; 2015. 3. miu j, negin j, salinas-rodriguez a, manrique-espinoza b, sosa-ortiz al, cumming r, et al. factors associated with cognitive function in older adults in mexico. glob health action. 2016;9:30747. 4. jauregui j, rubin r. fragilidad en el adulto mayor. rev hosp ital baires. 2012;32(3):110-5. 5. albinet ct, boucard g, bouquet ca, audiffren m. processing speed and executive functions in cognitive aging: how to disentangle their mutual relationship? brain cogn. 2012;79(1):1-11. 6. otero mr. psicología cognitiva, representaciones mentales e investigación en enseñanza de las ciencias. investig em ensino ciênc. 2016;4(2):93-119. 7. trivedi d. cochrane review summary: mini-mental state examination (mmse) for the detection of dementia in clinically unevaluated people aged 65 and over in community and primary care populations. prim health care res dev. 2017;1-2. 220 año 18 vol. 18 nº 2 chía, colombia abril 2018 aquichan issn 1657-5997 eissn 2027-5374 8. costa d, severo m, fraga s, barros h. mini-cog and mini-mental state examination: agreement in a cross-sectional study with an elderly sample. dement geriatr cogn disord. 2012;33(2-3):118-24. 9. razali r, jean-li l, jaffar a, ahmad m, shah sa, ibrahim n, et al. is the bahasa malaysia version of the montreal cognitive assessment (moca-bm) a better instrument than the malay version of the mini mental state examination (m-mmse) in screening for mild cognitive impairment (mci) in the elderly? compr psychiatry. 2014;55(suppl 1):s70-75. 10. organización panamericana de la salud. oficina regional de la organización mundial de la salud. evaluación del estado mental y emocional del adulto mayor. módulo 4. parte i: módulos de valoración clínica. oms. 2011;10. 11. organizacion panamericana de la salud. módulos de valoración clínica. evaluación del estado mental y emocional del adulto mayor. consultado: [visitado 2016 may 01]. disponible en: http://www.minsa.gob.pe/portal/servicios/susaludesprimero/adultomayor/documentos/02modulos/modulo4.pdf.). 12. uribe af, molina jm, barco m, gonzález l. relación entre deterioro cognitivo y sintomatologia depresiva en mujeres mayores colombianas. rev esp geriatr gerontol. 2008;43(2):85-9. 13. ministerio de salud. república de colombia. sabe colombia 2015: estudio nacional de salud, bienestar y envejecimiento. 2015 resumen ejecutivo. disponible en: https://www.minsalud.gov.co/sites/rid/lists/bibliotecadigital/ride/ vs/ed/gcfi/resumen-ejecutivo-encuesta-sabe.pdf. 14. cardona d, segura a, garzón m, segura a, cano sm. health status of elderly persons of antioquia, colombia. rev bras geriatr gerontol. 2016;19(1):71-86. 15. lobo a, marcos g, día j, de la cámara c, ventura t, morales f. validación y estandarización del mini-examen cognoscitivo (primera edición española del mini-mental status examination) en la población geriátrica general. med clin (barc). 1999;112:767-74. 16. rosselli d, ardila a, pradilla g, morillo l, bautista l, rey o, et al. the mini-mental state examination as a selected diagnostic test for dementia: a colombian population study. geneco. rev neurol. 2000;30(5):428-32. 17. cardona d, segura a, segura a, muñoz d, jaramillo d, lizcano, d, et al. índice de vulnerabilidad de los adultos mayores, en tres ciudades de colombia, 2016. medellín: universidad ces/colciencias; 2016. 18. cardenas l, villarreal j, salinas r. capacidad cognitiva de los pacientes de un servicio geriátrico ambulatorio en monterrey, méxico. medicina universitaria. 2006;8(31):84-7. 19. escobar g, ramos l, rodriguez c, montero a, peñalva j, valencia k. deterioro cognitivo leve en adultos mayores pertenecientes a clubes y albergues de la tercera edad de la ciudad de tacna. rev psicol arequipa. 2013;3(1):27-38. 20. cerquera am. relación entre los procesos cognitivos y el nivel de depresión en las adultas mayores institucionalizadas en el asilo san antonio de bucaramanga. univ psychol. 2008;7(1):271-81. 21. samuel r, mclachlan cs, mahadevan u, isaac v. cognitive impairment and reduced quality of life among old-age groups in southern urban india: home-based community residents, free and paid old-age home residents. qjm mon j assoc physicians. 2016;109(10):653-9. 22. vega t, miralles m, mangas jm, castrillejo d, rivas ai, gil m, et al. prevalencia de deterioro cognitivo en españa. estudio gómez de caso en redes centinelas sanitarias. neurología 2016 [citado 2017 sept 21]. disponible en: http://linkinghub. elsevier.com/retrieve/pii/s0213485316302171 23. mejía-arango s, miguel-jaimes a, villa a, ruiz-arregui l, gutiérrez-robledo l. deterioro cognoscitivo y factores asociados en adultos mayores en méxico. salud publica mex. 2007;49(supl 4):475-81. 24. gondim as, coelho jm, cavalcanti a de a, roriz j de s, nogueira cb, peixoto junior aa, et al. prevalence of functional cognitive impairment and associated factors in brazilian community-dwelling older adults. dement neuropsychol. 2017;11(1):32-9. 25. moquillaza-risco m, león e, dongo m, munayco c. caracteristicas sociodemográficas y de salud de los adultos mayores en situación de calle en lima, perú. rev peru med exp salud publica. 2015;32(4):693-9. 26. rodríguez jr, tabares vz, jiménez es, lópez rs, cervantes m del c. el manejo del adulto mayor. panor cuba salud. 2014;9(1):35-41. 221 factores asociados a la vulnerabilidad cognitiva de los adultos mayores en tres ciudades de colombia l alejandra segura-cardona y otros 27. poblete f, matus c, díaz e, vidal p, ayala m. depresión, cognición y calidad de vida en adultos mayores activos. revista ciencias de la actividad física ucm. 2015;16(2):71-7. 28. carlson n. fisiología de la conducta. madrid: pearson; 2009. 29. durán-badillo t, aguilar rm, martínez ml, rodríguez t, gutiérrez g, vázquez l. depresión y función cognitiva de adultos mayores de una comunidad urbano marginal. enferm univ. 2013;10(2):36-42. 30. meléndez j, mayordomo t, sales a. comparación entre ancianos sanos con alta y baja reserva cognitiva y ancianos con deterioro cognitivo. universitas psychologica. 2013;12(1):73-80. 31. valkanova v, ebmeier kp, allan cl. depression is linked to dementia in older adults. the practitioner. 2017;261(1800):11-5. 32. reyes-figueroa j, rosich-estrago m, bordas-buera e, gaviria-gomez a, vilella e, labad-alquezar a. síntomas psicológicos y conductuales como factores de progresión a demencia tipo alzheimer en el deterioro cognitivo leve. rev neurol. 2010;50:653-60. 33. laso fj. diagnóstico diferencial en medicina interna. 2013 [visitado 2017 oct 31]. disponible en: http://public.eblib. com/choice/publicfullrecord.aspx?p = 1746514 34. gross al, rebok gw, unverzagt fw, willis sl, brandt j. cognitive predictors of everyday functioning in older adults: results from the active cognitive intervention trial. j gerontol b psychol sci soc sci. 2011;66(5):557-66. 35. gomez jf, curcio cl. salud del anciano: valoración. manizales: blanecolor; 2014. que significa discapacidad.pmd revista aquichan issn 1657-5997 78 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 resumen este estudio constituye la primera fase de un proyecto intersectorial e interdisciplinario de investigación-acción participativa denominado “participación comunitaria para la inclusión social de las personas con discapacidad y sus familias”, dirigido a las personas en situación de discapacidad y sus familias residentes en la vereda la balsa del municipio de chía, cundinamarca, colombia. el propósito de este proyecto fue analizar y relacionar los significados que alrededor de la discapacidad han construido las personas con discapacidad, los cuidadores y las redes de apoyo comunitario, y describir alternativas de solución para la inclusión social de dichas personas a partir de las propuestas de los participantes. palabras clave discapacidad, cuidadores, inclusión social. maría elisa moreno fergusson1 maría clara rodríguez2 marybell gutiérrez duque3 luz yorladi ramírez4 olga barrera pardo5 recibido: 3 de julio de 2006 aprobado: 14 de agosto de 2006 1 facultad de enfermería, universidad de la sabana. campus universitario del puente del común, km. 21, autopista norte de bogotá d.c., chía, cundinamarca, colombia. mariae.moreno@unisabana.edu.co 2 facultad de psicología, universidad de la sabana. maria.rodriguez1@unisabana.edu.co 3 facultad de educación, universidad de la sabana. marguty@cable.net.co 4 facultad de enfermería de la sabana. olga.barrera@unisabana.edu.co 5 estudiante de pedagogía infantil, facultad de educación, universidad de la sabana. olga.barrera@unisabana.edu.co abstract the present study is the first stage of an inter-sectoral and multidisciplinary participative action research project known as “community participation for social inclusion of disabled people and their families,” addressed towards people in disabled situation and their families living at la balsa, municipality of chia (colombia). the aim of this project is to analyze and to correlate the meanings surrounding disability that have been built up by the people who go through it, their carers and the supporting community networks, as well as to describe solving alternatives for the social inclusion of disabled people from participants’ proposals. key words disability, carers, social inclusion. what does disability mean? año 6 vol. 6 nº 1 (6) 78-91 chía, colombia octubre 2006 ¿qué significa la discapacidad? what does disability mean? 79 introducción n los últimos años se ha visto con preocupación cómo la incidencia de las enfermedades crónicas y discapacitantes ha venido aumentando en forma progresiva. la tasa de discapacidad en colombia es de 18 por 1000 habitantes, distribuidos así: del cuidado personal (2,3%), de la conducta (2,7%), de la locomoción (36,6%), de la comunicación (61,8%) (1). la discapacidad ha sido considerada como una problemática que tiene consecuencias personales, familiares y sociales que llevan a la exclusión social. en un estudio realizado por la presidencia de la república (2) en nueve ciudades del país, se encontró que el 9,6% de las personas con discapacidad se encuentran con necesidades básicas insatisfechas (nbi), el 55% de los hogares viven con 1 a 3 salarios mínimos, y el 57,6% no tienen acceso a servicios de salud. la condición de discapacidad causa múltiples cambios en la vida de una persona y de sus familiares, los cuales se relacionan con la condición de dependencia asociada a una limitación física o mental, la alteración del estado de salud, y la modificación en el rol y en las actividades sociales. las personas se describen a sí mismas en términos más negativos, tienen menos aspiraciones y expectativas sobre el futuro, lo cual ocasiona ansiedad y depresión. los estudiantes con dificultades de aprendizaje o con necesidades educativas especiales también presentan aislamiento, alineación y rechazo por parte de sus compañeros (3, 4, 5, 6, 7, 8.). por su parte, los familiares más cercanos, también deben afrontar cambios importantes en su estilo de vida. en la forma como se adaptan a estos cambios influyen factores específicos como son sus características personales, la severidad de la enfermedad del paciente, y los ajustes que deben hacer en su estilo de vida y en el rol familiar para satisfacer las demandas de cuidado (9). un estudio realizado por moreno y cols. (10) mostró que un número significativo de los cuidadores perciben un compromiso ligero en su estado de salud física y emocional. esta situación ha sido estudiada ampliamente en el ámbito mundial y por el estado colombiano, y su preocupación se refleja en el marco legal que protege a esta población: la ley 100 de 1993 (sistema de seguridad social); la ley 115 de 1994 (general de educación); la ley 361 de 1997 (integración social para limitados); la ley 762 del 2002, desaprobando la “discriminación contra las personas con discapacidad”; la ley 582 del 2000 (recreación y deporte), y los decretos reglamentarios de cada una de ellas. a pesar de las leyes mencionadas y las políticas expresadas en el plan nacional de atención a las personas con discapacidad y en el plan nacional de desarrollo 2002-2006 (11), el estudio de necesidades, oferta y demanda de servicios de rehabilitación realizado por la fundación saldarriaga concha, con el respaldo del ministerio de protección social y la vicepresidencia de la república, en el 2003, muestran que a pesar de que existe oferta de servicios de rehabilitación, el acceso de las personas con discapacidad a éstos es muy limitado debido a barreras físicas y económicas (12). la discapacidad ha sido considerada como una problemática que tiene consecuencias personales, familiares y sociales que llevan a la exclusión social. revista aquichan issn 1657-5997 80 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 los programas que existen actualmente se enmarcan en modelos de rehabilitación apoyados en diferentes perspectivas teóricas: los modelos tradicionales de rehabilitación, centrados en los síntomas, que se desarrollan en centros hospitalarios y de educación especial; el de rehabilitación basada en la comunidad, centrado en el modelo médico de promoción, prevención, tratamiento y rehabilitación, con participación comunitaria (13). en el ámbito local el municipio de chía, atendiendo a las políticas expresadas por la ordenanza 021 de 2001 (14), del departamento de cundinamarca, en la cual se establecen los lineamientos para la atención integral de las personas con discapacidad, inició en el año 2003 el programa de rehabilitación “manos a la obra”, que cuenta con un centro día con una granja integral, un centro de vida sensorial, un programa de atención domiciliaria, y el trabajo en red con los entes municipales para atender las necesidades de las 479 personas que se han identificado en esta condición, cuyas limitaciones más frecuentes son: las deficiencias sensoriales, las mentales, osteoarticulares, del sistema nervioso y cardiorrespiratorias. si bien este programa ha mostrado resultados importantes con las personas que tienen la posibilidad de desplazarse y acceder a estos servicios, hay un grupo de población que por sus condiciones actuales no puede participar activamente de los mismos. de allí la necesidad de que sea la comunidad quien asegure la inclusión social de estas personas. este estudio constituye la primera fase de un proyecto intersectorial e interdisciplinario de investigación-acción participativa denominado “participación comunitaria para la inclusión social de las personas con discapacidad y sus familias”, cuyo propósito es elaborar y evaluar con la comunidad un programa de inclusión social dirigido a las personas en situación de discapacidad y sus familias residentes en la vereda la balsa del municipio de chía, cundinamarca. se ha seleccionado esta vereda porque en ella viven un 10% de las personas con discapacidad del municipio. el propósito de la primera etapa del proyecto fue analizar y relacionar los significados que alrededor de la discapacidad han construido las personas con discapacidad, los cuidadores y las redes de apoyo comunitario, y describir alternativas de solución para la inclusión social de dichas personas a partir de las propuestas de los participantes, residentes en la vereda la balsa del municipio de chía en cundinamarca. en su desarrollo se plantearon las siguientes preguntas: ¿qué significado le dan las personas en condición de discapacidad, a la discapacidad?, ¿qué significado le dan los cuidadores principales de estas personas, y las redes de apoyo comunitarias a la discapacidad?, ¿qué alternativas de solución proponen para promover la inclusión social de las personas con discapacidad? con base en estos significados, y en los datos objetivos recolectados por el programa de discapacidad de la secretaría de salud de chía, se iniciará la segunda etapa, en la cual se propondrá, junto con la comunidad, un programa piloto de inclusión social fundamentado en un modelo socioecológico que, de acuerdo con los resultados obtenidos, pueda replicarse más adelante en todo el municipio. este estudio constituye la primera fase de un proyecto intersectorial e interdisciplinario de investigación-acción participativa denominado “participación comunitaria para la inclusión social de las personas con discapacidad y sus familias”. ¿qué significa la discapacidad? what does disability mean? 81 diseño metodológico para el desarrollo del proyecto de investigación se partió de las premisas postuladas por el enfoque cualitativo del interaccionismo simbólico (15), que afirma que las personas actúan frente a una situación o fenómeno de acuerdo con el significado que le atribuyen a ellas, y ese significado se deriva de la interacción social que establece con los otros. los significados son los insumos para la interpretación que el sujeto hace de su realidad, lo que obliga al investigador a ver el mundo desde la perspectiva de los sujetos que investiga. el proyecto se desarrolla en dos fases: una fase exploratoria que tiene por objeto obtener una comprensión profunda de la problemática abordada, es decir, comprender cómo las personas en situación de discapacidad y la comunidad experimentan sus vidas, y cuáles son los significados que le atribuyen; y una fase práctica colaborativa, que busca la valoración de las alternativas de solución y la toma de decisiones concertadas con la comunidad sobre las forma en que se procurará la inclusión social de la persona con discapacidad, rescatando así su papel protagónico y transformador de la realidad que se quiere intervenir. en la primera fase se utilizaron diversas estrategias, tales como: 1) recoger los datos de las personas que han experimentado la situación de discapacidad; 2) analizarlos mediante la identificación de categorías para luego transformarlas en conceptos más amplios de significados, y 3) encontrar los significados compartidos que permitan elaborar un texto en donde se describa la experiencia y cómo fue leída por el implicado en ella. en esta fase se utilizaron técnicas cualitativas para acceder a la información, tales como entrevistas en profundidad y de grupos focales. las entrevistas en profundidad constituyen una herramienta fundamental para el desarrollo de estudios cualitativos. consisten en una conversación a través de la cual el investigador busca obtener información sobre las experiencias, los sentimientos y pensamientos del entrevistado con relación a un tema específico. en su desarrollo es fundamental dar a conocer los objetivos de la entrevista, asegurando el valor que tienen las opiniones del entrevistado y la confidencialidad con que se hará el análisis de la información. es indispensable generar un ambiente de confianza que permita a la persona entrevistada expresarse libremente (16). la técnica de grupos focales consiste en organizar un grupo semiestructurado de personas que se reúnen con el propósito de recolectar información sobre un tema específico. esta metodología es muy útil cuando se trata de abordar temas sensibles y por esta razón se seleccionó como estrategia para indagar el significado de la discapacidad en las redes de apoyo comunitarias (17). la interpretación de los datos se basó en la estrategia de codificación abierta desarrollada por böhms y cols. citado por flick (15). el primer paso consistió en la categorización de los datos, para lo cual se seleccionaron los códigos sustantivos o etiquetas que son secuencias breves de textos originales o manifestaciones literales expresadas por los entrevistados. a partir de esto se definió la categoría correspondiente, dentro de la cual se incluyen todos los códigos sustantivos que tuvieron el mismo significado, con sus colos significados son los insumos para la interpretación que el sujeto hace de su realidad, lo que obliga al investigador a ver el mundo desde la perspectiva de los sujetos que investiga. revista aquichan issn 1657-5997 82 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 rrespondientes memos derivados de las observaciones de campo. posteriormente, los códigos resultantes se reagruparon en categorías amplias, que representaban los fenómenos descubiertos en los datos, y se le dio un significado a cada una de ellas, con el ánimo de explicar por qué cada categoría recibía la denominación correspondiente. a partir del listado de categorías obtenidas se identificaron aquellas que fueron comunes y las que fueron específicas para cada participante. el siguiente paso fue establecer relaciones entre las categorías y subcategorías que respondían a la pregunta de investigación, para comprender los significados que las personas, familias y grupos otorgan a la situación de discapacidad. participantes en esta primera fase participaron 6 personas (5 hombres y una mujer) en situación de discapacidad, que no presentaban déficit cognitivo, cuyas edades oscilaron entre los 18 y los 70 años. cinco cuidadoras informales cuyas edades oscilaban entre 45 y 70 años, 3 de ellas esposas y dos madres de las personas en situación de discapacidad. dos grupos comunitarios: la junta de acción comunal del sector la balsa centro (6 principales y 6 suplentes), y un grupo conformado por 6 personas integrantes de las redes de apoyo comunitario. en estos grupos participan profesionales, empleados del municipio, trabajadores independientes que tienen su negocio en la vereda y amas de casa. la muestra del estudio la constituye la información recopilada a través de las entrevistas en profundidad y de los grupos focales. el criterio de saturación de la muestra se logró en el momento en que al realizar el análisis de la información no se encontró información nueva que ampliara las categorías que habían sido determinadas, motivo por el cual el número de informantes quedó definido como se explicó anteriormente. procedimiento de recolección de la información en la fase de preparación, y con el propósito de afinar las competencias para recopilar la información por parte de los investigadores y auxiliares de investigación, se llevó a cabo un entrenamiento en entrevistas en profundidad para todos los miembros del grupo. posteriormente se definieron las preguntas que se harían a los entrevistados, y se realizó una prueba piloto en cámara de gessell, con una persona en situación de discapacidad, que no participaría en esta primera fase. con base en los resultados de esta actividad se consolidaron las preguntas que se utilizarían en la entrevista. una vez concluida esta fase de preparación, se contactaron los participantes y se conformaron tres unidades de informantes diferentes: las personas con discapacidad, sus cuidadores principales y dos grupos comunitarios. se acordaron citas con cada uno de ellos para explicarles el propósito y la importancia del proyecto e indagar si querían participar en el. en cada una de las entrevistas participaron dos investigadores, uno dirigió la entrevista y el otro registró los memos relacionados con su desarrollo. las entrevistas se llevaron a cabo en la residencia de las personas, previo consentimiento informado. en cada una de las entrevistas participaron dos investigadores, uno dirigió la entrevista y el otro registró los memos relacionados con su desarrollo. las entrevistas se llevaron a cabo en la residencia de las personas, previo consentimiento informado. ¿qué significa la discapacidad? what does disability mean? 83 al realizar la entrevista se solicitó a las personas con discapacidad y a los cuidadores que describieran ampliamente cómo era su vida en ese momento. se les solicitó igualmente la descripción de las relaciones que habían establecido con la familia, con la comunidad y con otras instituciones y, por último, algunas sugerencias o recomendaciones que harían si tuvieran la oportunidad de desarrollar un programa para ellos en la comunidad. la duración aproximada de las entrevistas fue de hora y media. para su recolección total se condujeron de una a tres entrevistas, con cada una de las personas según la necesidad. los datos fueron grabados y transcritos textualmente. en la transcripción se incluyeron las observaciones y los registros de las expresiones no verbales. la información de las redes de apoyo comunitario se recolectó utilizando la técnica de grupos focales. en una cita previa se presentó a los miembros de la junta y a la comunidad la propuesta del proyecto. los miembros de la junta y de la comunidad discutieron esta propuesta en ausencia de los investigadores, y decidieron que en la siguiente reunión se podría realizar el grupo focal. en este grupo participaron diez personas integrantes de la junta de acción comunal del sector de la balsa centro, y el rector del instituto educativo departamental la balsa. la reunión se llevó a cabo en el aula múltiple de este plantel. previo a su iniciación se solicitó el consentimiento informado a cada uno de los participantes, la autorización para iniciar la sesión y para la grabación de la misma, garantizando su confidencialidad. la información fue recolectada por tres investigadores, uno de los cuales dirigió el grupo y los otros dos registraron los memos relacionados con el desarrollo de la sesión. el otro grupo focal se realizó con seis personas residentes en la comunidad e integrantes de las redes de apoyo, quienes fueron contactadas por la promotora de salud de la vereda y manifestaron estar interesadas en el tema de la discapacidad. la reunión se realizó en el salón comunal del sector sabaneta de la misma vereda, y contó con la participación de dos investigadores, uno de los cuales dirigió la sesión y el otro registró los memos relacionados con su desarrollo. las preguntas que se hicieron estuvieron enfocadas a conocer el significado de la discapacidad para los integrantes, el tipo de apoyo que reciben por parte de la comunidad las personas con discapacidad en la vereda la balsa, y cómo se vinculan estas personas a las actividades comunitarias. aspectos éticos las consideraciones éticas del proyecto se basan en las disposiciones legales establecidas en la resolución 008430 de 1993 del ministerio de salud, en la cual se establecen las normas científicas, técnicas y administrativas para la investigación en salud. por otro lado, la propuesta fue presentada a las personas con discapacidad y sus familias, así como a los representantes de las juntas de acción comunal y líderes comunitarios involucrados en el proyecto. las personas en situación de discapacidad y sus familias firmaron un consentimiento informado autorizando la entrevista en profundidad y la grabación de la misma para la recolección de la inel otro grupo focal se realizó con seis personas residentes en la comunidad e integrantes de las redes de apoyo, quienes fueron contactadas por la promotora de salud de la vereda y manifestaron estar interesadas en el tema de la discapacidad. revista aquichan issn 1657-5997 84 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 formación y su participación en el estudio. así mismo, se les dio a conocer que tenían la libertad de retirarse en el momento en que así lo desearan. este consentimiento fue leído con el participante y solo se procedió a firmarlo cuando manifestaron haberlo comprendido y aceptado. análisis de los datos el análisis de los datos se inició desde el momento en que se realizaron las entrevistas, si se tiene en cuenta que los investigadores revisaban constantemente los registros para verificar si debían formular nuevas preguntas o ampliar las descripciones. la información recopilada en las entrevistas fue transcrita textualmente para facilitar su lectura y análisis. los investigadores leyeron cada una de las frases y subrayaron aquellas que reflejaban las vivencias relacionadas con su situación, la relación con redes de apoyo, las necesidades sentidas y sus propuestas para un programa comunitario. esta estrategia facilitó la codificación y la organización en categorías, en las cuales se evidenciaron las percepciones, las creencias, los sentimientos y el comportamiento de la persona en situación de discapacidad, de los cuidadores y de los líderes de la comunidad, frente a su interacción con los contextos inmediatos y cotidianos y con los diferentes sistemas sociales y culturales. al analizar los textos de las entrevistas y los grupos focales se identificaron en total 65 códigos sustantivos, que representan las expresiones utilizadas por las personas entrevistadas. algunos de estos códigos se encontraron únicamente en las personas con discapacidad, otros sólo en las familias y otros se identificaron en la comunidad. algunos de los códigos son comunes a todos y otros solamente a algunos de ellos. identificación de los códigos sustantivos el primer paso fue la categorización de los datos, para lo cual se seleccionaron los códigos sustantivos de las expresiones de cada uno de los entrevistados: personas con discapacidad, cuidadores y redes de apoyo. el proceso realizado con cada uno de los códigos se ilustra a continuación con el siguiente ejemplo: algunas de las expresiones de las personas con discapacidad, codificadas fueron: “me gustaría ayudar a las personas con alguna discapacidad de pronto auditiva, de pronto a ellos aunque a todas las personas que entiendan la pintura (lo expresa con seguridad)”: apoyo a los demás. “si claro, si sumercé, yo ayudo… yo pues como pongamos que el día de… lunes, cogemos las aromáticas y me voy el martes para bogotá, el día diez y el jueves hacemos lo mismo, cogemos eso y el día de hoy madrugo (si) madrugo, madrugo y ahí traigo lo que mi dios socorre lo del mercadito digámoslo para… para eso, entonces ahí la pasamos… ahí, ahí vamos”: resiliencia. “pues un poco me ha cambiado el mal genio… [afirmando con un movimiento de la cabeza] he estado mejor en el genio, porque estamos también como le cuento a su persona yendo a una oración de saneamiento, entonces me he sentido un poco mejor”: apoyo en las creencias. al analizar los textos de las entrevistas y los grupos focales se identificaron en total 65 códigos sustantivos, que representan las expresiones utilizadas por las personas entrevistadas. ¿qué significa la discapacidad? what does disability mean? 85 de las expresiones codificadas de los cuidadores se seleccionaron estos ejemplos: “un día normal mío es bien hacer mis oficios, bregar con todos estos chinitos. por la tarde llega mi hija, ella estudia entonces le tengo el almuercito, almuerza y como tiene servicio social se va y hasta la tarde vuelve por ahí a las seis o seis y media. de resto yo me la paso con ellos, hay veces sale por ahí a la tienda y se demora por ahí, mientras tanto yo me estoy con los niños”: sobrecarga en las funciones. “hay… pues a veces me siento como que estoy tan enferma (suspira), la verdad le digo… a veces me siento tan cansada” (énfasis en la expresión): fatiga. “al principio recién que quedó en esa silla pues lógico que aquí había que ayudarle por lo que queda como en subidita ¿no? había que ayudarlo para que, para entrarlo, pero se podía bañar solito. inclusive se vestía solito pero ahora no, ahora me toca desde bañarlo en adelante, vestirlo todo, hacerle todo” (énfasis en la expresión): capacidad de cuidar a otro. algunas de las expresiones de los grupos comunitarios que fueron codificadas son: “uno tiene que tener mucha paciencia, tiene que tener con esas personas minusválidas… que uno no debe mirar a las personas con rencor ni con lástima sino aprender uno como a ser que, es decir uno mismo, que es un pedacito de uno mismo”: sentimientos de empatía “cuando empezamos a hablar de la discapacidad el término en sí es discriminatorio, es mejor hablar de personas con dificultades en… porque todos tenemos dificultades en algo”: necesidad de inclusión social. “yo he trabajado a partir de la docencia, yo he trabajado en musicoterapia aplicada, es mucho lo que podemos hacer. hay que clasificar cuando hay personas con dificultades, se puede utilizar este tipo de terapia y generalmente es exitosa”: capacidad de apoyar a otros. definición y descripción de las categorías posteriormente se procedió a analizar los códigos identificados y a agruparlos por temas según su significado, lo cual dio origen a las categorías que fueron referidas a las descripciones originales para validarlas. siguiendo el mismo proceso que se ilustra en el siguiente ejemplo, con la categoría de resiliencia en las personas con discapacidad, se identificaron las demás categorías en estas personas, en los cuidadores y en las redes de apoyo social. 1. resiliencia esfuerzo: “ya trabajé así en una finca yo toda la vida trabajé en ganadería. de allá saqué para comprar la casa en la finca de los montoyas se llama carimagua, de allá sacamos, saqué pa’ comprar acá porque ya era muy pobre, en la calle casi, mi madre murió y dormíamos en la calle, ellos no nos dejaron nada, y con el sudor de mi frente compre acá, yo tengo acá y eso le cuento”. persistencia: “después de ensayar muchas veces solo y con mi mamá, de contarle a las niñas de la universidad y de ir varias veces a la alcaldía, logré que me escucharan y así me hicieron una audición y conseguí el trabajo en la emisora”. “me gustaría ayudar a las personas con alguna discapacidad de pronto auditiva, de pronto a ellos aunque a todas las personas que entiendan la pintura (lo expresa con seguridad)”. revista aquichan issn 1657-5997 86 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 proyección: “la idea mía es seguir pintando…y proyectarme, yo tengo una meta muy grande respecto a la pintura. muchas personas han logrado muchas metas aunque estén físicamente discapacitadas, han logrado conseguir muchas metas”. autovalía: “por eso digo que la discapacidad de persona es la misma persona que se siente con discapacidad, terrible porque nunca de pronto va a salir adelante, nunca va a poder demostrar lo que puede aprender o lo que sabe hacer”. descripción de la categoría estos códigos se agruparon en la categoría de resiliencia, la cual es entendida como la capacidad que tienen las personas en situación de discapacidad para proyectarse hacia el futuro a pesar de las dificultades que supone su condición. se evidencia en las acciones que realizan las personas con discapacidad a lo largo del tiempo con un sentido propositivo, en respuesta a una necesidad de superación. éstas incluyen el trabajo (ocupación que ejerce o ejercía la persona con discapacidad para conseguir su sustento y el de su familia), la autodeterminación y autovalía (reconocimiento de su propio valor como persona con posibilidades independientemente de su condición para salir adelante y ayudar a otros), la persistencia (búsqueda insistente de posibilidades y recursos para lograr un propósito), y la claridad frente a lo que quieren conseguir y la satisfacción por haberlo logrado. otras de las categorías identificadas en las personas con discapacidad son: 2. respaldo es el apoyo familiar, comunitario e institucional que necesitan y reciben las personas en situación de discapacidad para satisfacer sus necesidades y lograr sus propósitos. este respaldo les permite realizar actividades de la vida diaria, y recibir apoyo económico e institucional a través del cual tienen acceso a servicios fundamentales como los de salud, educación, y servicios religiosos cuando se requieren. 3. apoyo en las creencias soporte en lo espiritual e intangible de la vida y de los seres humanos que ayuda a las personas, en virtud de su convicción, a afrontar la experiencia de la discapacidad. este apoyo se relaciona con la fe, la espiritualidad y la religiosidad. tiene que ver con el propósito de su existencia y desencadena sentimientos de gratitud por lo que tienen. 4. sentimientos respuestas emocionales y afectivas relacionadas con su situación de limitación actual y frente a su futuro. en el análisis se identifican sentimientos de autovalía, tales como autonomía, seguridad en sí mismo, aceptación y gratitud que contribuyen a mantener la integridad y el bienestar de las personas. esta categoría incluye también sentimientos negativos como minusvalía, exclusión y rechazo, impotencia, resignación, desesperanza e insatisfacción, que se relacionan con las dificultades para lograr sus metas y temor a sufrir una lesión o a una complicación de su estado actual. la resiliencia es entendida como la capacidad que tienen las personas en situación de discapacidad para proyectarse hacia el futuro. ¿qué significa la discapacidad? what does disability mean? 87 5. modificación de la rutina diaria son los cambios en las actividades que acostumbraban realizar las personas con discapacidad como consecuencia de su estado de salud actual. ésta se relaciona con un cambio en el desempeño de rol, aislamiento social, falta de actividades recreativas. categorías encontradas en las entrevistas con los cuidadores 1. sobrecarga en las funciones se relaciona con todas las responsabilidades a las que tiene que responder el cuidador en un día normal, adicionales a las relacionadas con el cuidado de la persona con discapacidad. esta sobrecarga está asociada con la modificación de la rutina diaria y el aislamiento social, y se expresa en la sensación de cansancio, fatiga, alteración del estado de salud, demanda de necesidad de atención y de actividades recreativas. 2. creatividad en el cuidado esta categoría tiene relación con todas las actividades que realizan los cuidadores con compromiso y responsabilidad, encaminadas a proteger a las personas con discapacidad y atender las demandas de cuidado que por su condición no pueden atender por sí mismas. los cuidadores demuestran ser hábiles, creativos, recursivos para la consecución y disposición de las condiciones que faciliten el cuidado del otro. 3. respaldo familiar, comunitario e institucional al igual que en las personas en situación de discapacidad, esta categoría se relaciona con el apoyo que necesitan y reciben los cuidadores para satisfacer sus necesidades y lograr sus propósitos y los de la persona a su cuidado. este respaldo está dado por la familia y personas de la comunidad, de quienes reciben ayuda para realizar actividades de la vida diaria, compañía, cercanía, apoyo económico y apoyo institucional a través del cual tienen acceso a servicios fundamentales como los de salud, educación y servicios religiosos cuando se requieren. es importante anotar que algunos cuidadores reconocen las posibilidades de las personas con discapacidad y destacan el apoyo que reciben de ellas. 4. apoyo en las creencias soporte en lo espiritual e intangible de la vida y de los seres humanos que ayuda a las personas, en virtud de su convicción, a afrontar el rol de cuidador. este apoyo se relaciona con la fe, la espiritualidad y la religiosidad, así como con el propósito de su existencia, y da sentido a las dificultades que se presentan en la vida cotidiana y al esfuerzo que conlleva cuidar de otros. 5. sentimientos respuestas emocionales y afectivas relacionadas con su experiencia actual como cuidadores y frente a su futuro. en el en el análisis se identifican sentimientos de autonomía, seguridad en sí mismo, respeto por el tiempo y el espacio de los otros, gratitud y responsabilidad que contribuyen a mantener su integridad y el bienestar. revista aquichan issn 1657-5997 88 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 análisis se identifican sentimientos de autonomía, seguridad en sí mismo, respeto por el tiempo y el espacio de los otros, gratitud y responsabilidad que contribuyen a mantener su integridad y el bienestar. también se identifican sentimientos de dolor frente a la discapacidad del ser querido, depresión, vergüenza, culpa, resignación, incertidumbre, desesperanza e insatisfacción que se relacionan con las dificultades para lograr sus metas, temor a la evaluación o juicio social, y temor al daño o a la lesión de la persona con discapacidad. categorías en las redes de apoyo comunitarias 1. reconocimiento del vínculo conciencia de la presencia del otro en las redes de apoyo comunitarias, que propicia sentimientos de afecto, compasión, empatía y cercanía. se relaciona con la necesidad sentida de dar protección y de promover la inclusión o la aceptación social de las personas con discapacidad, para de esta manera contribuir con el bienestar de la comunidad y el logro de sus propósitos. 2. respaldo familiar, comunitario e institucional esta categoría se relaciona con las posibilidades que tienen las redes de apoyo familiar, comunitario e institucional de dar soporte a las personas con discapacidad, y la necesidad de obtener ayuda institucional para promover la inclusión social de estas personas en la vereda la balsa de chía. está determinado fundamentalmente por el aprovechamiento de los recursos humanos y locativos disponibles en la comunidad, y la necesidad de apoyo por parte de las instituciones como el gobierno municipal, las entidades educativas, la empresa privada y la iglesia. 3. sentimientos respuestas emocionales y afectivas hacia las personas con discapacidad, en las cuales se evidencian sentimientos de temor y rechazo, especialmente hacia aquellas que tienen trastornos mentales y emocionales. discusión el análisis de las categorías encontradas muestra que hay algunas que se encuentran únicamente o son específicas para las personas en situación de discapacidad tales como la resiliencia y la modificación de la rutina diaria. en los cuidadores la sobrecarga por sus múltiples funciones y labores de cuidado, y en las redes de apoyo el reconocimiento del vínculo. se encontraron otras que son comunes o que son compartidas como es el caso de la categoría de respaldo identificada en las tres unidades de informantes, los sentimientos de auto y minusvalía, y el apoyo en las creencias que se hallaron tanto en los cuidadores como en las personas con discapacidad. las categorías descritas reflejan el significado de la discapacidad para cada uno de los grupos entrevistados. las personas con discapacidad identifican factores como su estado de salud, en el cual la presencia de dolor ocasionado por trastornos articulares severos, parálisis y déficit sensoriales y cognitivos ha resel análisis de las categorías encontradas muestra que hay algunas que se encuentran únicamente o son específicas para las personas en situación de discapacidad tales como la resiliencia y la modificación de la rutina diaria. ¿qué significa la discapacidad? what does disability mean? 89 tringido su capacidad para realizar algunas de las actividades de su vida diaria. esta condición, especialmente en los mayores, desencadena temor e inseguridad para realizar actividades con autonomía. ellos expresan que su estado de salud, unido a la falta de recursos económicos, ha motivado su exclusión de algunas actividades educativas, laborales, recreativas y religiosas modificando su estilo de vida y limitando a su vez sus posibilidades de desarrollo personal y de participación en la comunidad. esta situación despierta en las personas mayores sentimientos de minusvalía, resignación, desesperanza, impotencia e insatisfacción que contrastan significativamente con la apreciación de los más jóvenes quienes con su autodeterminación y sentimientos de autovalía consideran que la discapacidad está en la conciencia de las personas o es construida por ellos, quienes sienten que no tienen habilidades para conseguir las metas que se proponen. un aspecto fundamental para todos es el apoyo en las creencias, las cuales les han ayudado a afrontar las situaciones más difíciles y les han dado un propósito a su existencia. ellos identifican que han recibido apoyo por parte de sus familias y tienen sentimientos de gratitud hacia ellos. este aspecto lo consideran esencial, y les reconocen sus cualidades y la seguridad y ayuda en las actividades que no pueden realizar por sí mismos. algunos expresan preocupación por el estado de salud de sus cuidadores, en quienes observan cansancio y cambios en el estado de ánimo. los que tienen mayor dificultad para movilizarse sostienen que necesitan apoyo de instituciones como la iglesia para recibir los sacramentos; todos manifiestan que requieren soporte de las instituciones educativas y del gobierno municipal para prepararse y participar en actividades productivas y de integración social. se observa también en estas personas el deseo de superación, expresan su interés por aprender nuevos oficios acordes con sus capacidades para ser más productivas, aspecto que ha marcado en algunas de ellas un cambio importante en los roles familiares: pasar de ser el proveedor del sustento familiar a ser el receptor de dicho sustento, asumido en muchos casos por el cuidador. se observa entonces una inversión de roles que puede tener un efecto importante en la autoestima del discapacitado y una sobrecarga de funciones en el cuidador. son propositivos en cuanto a sus posibilidades de enseñar lo que saben a los niños y a otras personas de la comunidad con algún tipo de discapacidad. ellos se proyectan hacia el futuro como participantes activos en los procesos comunitarios. para los cuidadores, haber asumido este rol cambió su vida en una forma radical. expresan que fue doloroso aceptar la condición de sus familiares. para ellos, cuidar a una persona con discapacidad representa una tarea adicional a las que tienen cotidianamente. ellos sienten la necesidad de cuidarlos, para lo cual han venido desarrollando habilidades que reflejan una gran creatividad e imaginación, a fin de aprovechar al máximo los recursos disponibles. para los cuidadores, haber asumido este rol cambió su vida en una forma radical. expresan que fue doloroso aceptar la condición de sus familiares. para ellos, cuidar a una persona con discapacidad representa una tarea adicional a las que tienen cotidianamente. revista aquichan issn 1657-5997 90 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 uno de los componentes del cuidado se refleja en la necesidad de amparo, hasta llegar a sentir temor de morir antes que ellos. pueden llegar a sentirse culpables por haberlos sobreprotegido, pero manifiestan temor de que puedan sufrir un accidente o ser agredidos por otras personas que se aprovechen de su condición. los cuidadores, al igual que las personas en situación de discapacidad, necesitan el respaldo de sus familiares, de los amigos, los vecinos y las instituciones. así mismo, les brindan soporte emocional y espiritual en momentos de crisis. el respaldo social satisface las necesidades de apego, alivia el estrés, y les refuerza el valor de sí mismos. igualmente, reconocen en ellos las potencialidades y los valores, condición que permite privilegiar su aceptación, así como la disposición de ciertas condiciones para garantizar las mismas oportunidades en relación con el trabajo, el estudio y la vinculación a las actividades de la comunidad, para lo cual requieren del apoyo de las redes sociales, las instituciones de salud, las entidades educativas, la iglesia y el gobierno municipal. este rol implica un compromiso que ellos asumen con responsabilidad. en general, anteponen las necesidades del otro a las propias, es así como han desatendido el cuidado de su salud y en algunas ocasiones la consecución de los recursos para su atención los ha llevado a afrontar situaciones que despiertan sentimientos de vergüenza y temor al juicio social (ejemplo, pedir limosna). los cuidadores manifiestan que tienen pocas oportunidades para recrearse, se sienten cansados y dicen tener problemas de salud como consecuencia de las múltiples tareas que deben realizar. en las creencias religiosas encuentran el propósito de su existencia, alrededor de ellas justifican y dan sentido a las dificultades que supone el rol de cuidador. los integrantes de las redes comunitarias ven en la discapacidad un problema para la persona y para las familias. esta situación despierta en ellos sentimientos de afecto, compasión y solidaridad hacia los cuidadores, así como intolerancia, rechazo y temor a ser agredidos por las personas que tienen trastornos cognitivos y psicológicos. son conscientes de que en ocasiones las ignoran o le dan más importancia a las limitaciones que a las posibilidades de salir adelante que tienen estas personas. expresan que deben ser conscientes de que ellas existen y forman parte de la comunidad. sienten la necesidad de prepararse, de conocer más sobre este tema para ayudar a los demás y evitar su exclusión social. identifican la discapacidad como un problema social, más que una limitación personal; expresan que la sociedad ignora esta problemática. reconocen en ellos valores y un sentido de pertenencia que pueden contribuir con el desarrollo de programas de inclusión. conclusiones conocer el significado que tiene la discapacidad para las personas, los cuidadores y las redes de apoyo es un aspecto esencial a fin de entender cómo afecta esta situación a cada uno de los actores del programa e identificar los elementos que serían indispensables para la construcción conjunta del modelo de inclusión social que se espera desarrollar. la complejidad de esta problemática justifica plenamente el abordaje interdisciplinario e intersectorial con el que se ha venido trabajando. como resultado de estos encuentros se evidencian aspectos que son centrales en la forma como estas personas asumen y afrontan los eventos de la vida cotidiana. se observa que las emociones no sólo presentan componentes positivos sino también negativos. en este sentido se explicitan bifurcaciones en la forma en que se valora y da significado a la discapacidad. es probable encontrar personas que le asignan a esta condición un valor relacionado con expectativas positivas como oportunidades de logro o, por el contrario, la restricción de posibilidades. es claro entonces encontrar momentos en los cuales las percepciones y los comportamientos se desorganizan, pero que en el flujo de la cotidianidad pueden tomar otras rutas diferentes que facilitan la restauración o reconstrucción de los estados emocionales, lo cual impacta directamente al significado que estas personas le atribuyen. al hablar de sentimientos de autovalía y a la vez de minusvalía, dan cuenta de esta conceptualización. otro aspecto de gran interés, que surge de las entrevistas realizadas, se relaciona con el deseo de las personas de recibir la capacitación necesaria para vincularse a actividades productivas y de apoyo a la comunidad. en este sentido identifican que el desarrollo de estrategias puede ser una alternativa que los puede ayudar a controlar la situación, como son tener “una guardería donde los cuidaran un rato y les hicieran recreación, les hicieran talleres, ejercicios y que los enseñaran algo, no sé si de pronto algo que ellos pudieran crear con sus manos, el que tiene sus manos buenas o en fin o por lo menos a ser más tolerantes”, lo cual está acorde con las cate¿qué significa la discapacidad? what does disability mean? 91 gorías que evidencian la capacidad de respaldo, la resiliencia y la proyección que tienen hacia el futuro. en el desarrollo del grupo focal, en s u s intervenciones los participantes 1. departamento administrativo nacional de estadística (dane). información estadística de la discapacidad, julio de 2004. htpp//: www.discapacidadcolombia. com/informacion_discapacidappdf. [consulta, 2 de agosto de 2005]. 2. presidencia de la república, red de solidaridad social. revisión de estudios sobre la situación de discapacidad en colombia, 1994-2001. bogotá; 2002. 3. whitlatch c, feinberg lf. depression and health in family caregivers. journal of aging and health 1997; 9: 222-244. 4. chang a, et al. the psicosocial impact of stroke. journal of clinical nursing 1999; (8): 477-81. 5. chambers m. exploring the emotional support needs and coping strategies of family carers. journal of psychiatric and mental health nursing 2001; (8): 99-106. 6. howes h, edwards s, benton d. male body image following acquired brain injury. brain injury 2005; 19 (2): 35-148. 7. mailhan l, azouvi, p, dazord a. life satisfaction and disability after severe traumatic brain injury. brain injury 2005; 19(4): 227-239. 8. donoghue a, renee. academic self-concept formation in students with learning disabilities. widener university, institute for graduate clinical psychology; 2005. 9. pinto n, sánchez b. el reto de los cuidadores: familiares de personas en situación crónica de enfermedad. en cuidado y práctica de enfermería, grupo de cuidado, facultad de enfermería universidad nacional de colombia; 2000, p. 173. 10. moreno me, nader, a, lópez de mesa c. relación entre las características de los cuidadores familiares de pacientes con discapacidad y la percepción de su estado de salud. avances en enfermería 2004; xxii(1): p. 27-38. 11. república de colombia, ministerio de protección social. plan nacional de discapacidad, 2002-2006. w w w . d i s c a p a c i d a d . g o v . c o / p _ p u b l i c a / informeactualizado.doc [consulta junio de 2006]. 12. fundación saldarriaga concha. estudio nacional de necesidades, oferta y demanda de servicios de rehabilitación. http://www.discapacidad.gov.co/ d_interes/mps.doc [consulta marzo de 2005]. 13. cuervo c, escobar m, trujillo a. más allá de una visión clínica de la discapacidad. revista ocupación humana 2000; 8(4). 14. asamblea de cundinamarca. ordenanza 021 de julio de 2001. 15. flik u. introducción a la investigación cualitativa. madrid: morata; 2004. 16. rubin h, rubin i. qualitative interviewing. the art of hearing data. sage publications; 1995, pp. 17-41. 17. streubert h, carpenter d. qualitative research in nursing. advancing the humanistic imperative. philadelphia: lippincott; 1999, pp. 24-25. develan algunas estrategias que pueden contribuir a promover la inclusión social de las personas con discapacidad en la vereda la balsa, como son la sensibilización frente al tema de la discapacidad, y el compromiso y la educación de las personas frente a esta realidad; programar una jornada de actividades con personas con discapacidad que involucren a todos; vinculando al colegio y a la asociación de padres de familia y visitando los hogares. referencias << /ascii85encodepages false /allowtransparency false /autopositionepsfiles true /autorotatepages /all /binding /left /calgrayprofile (dot gain 20%) /calrgbprofile 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/untaggedcmykhandling /leaveuntagged /untaggedrgbhandling /leaveuntagged /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 170-186 finales.pdf 173 la investigación y el cuidado en américa latina la investigación es una de las tareas fundamentales que debe desarrollar el profesional de enfermería con el fin de dar a conocer en primer lugar lo que hace en pro de sus pacientes y en segundo lugar mejorar los cuidados que brinda, bien sea al paciente, familia o comunidad. por otro lado, el libro hace relación al cuidado de enfermería el cual implica una verdadera relación interpersonal, llena de confianza, respeto y afecto entre el cuidador y el ser cuidado. es importante considerar que cuidar es una ciencia humana, y un arte que exige conocimientos, actitudes, aptitudes, intereses y motivaciones, partiendo del principio de que el cuidado es único e irrepetible. el libro está dividido en dos partes: la conceptualización y práctica del cuidado en américa latina, en donde se exponen temas como la gerencia como cuidado de enfermería y la investigación en esta área; cuidado al anciano y a su cuidador; la enfermería como disciplina, como ciencia y como arte, a través de varios artículos que muestran la enfermería desde su historia, impacto social de la disciplina en el contexto político, formación del recurso humano como compromiso de la profesión, cómo hacer visible el cuidado de enfermería en diferentes contextos y cómo cuidar en la adversidad, y prácticas de cuidado durante la gestación. y una segunda parte donde se presentan resultados de investigación sobre caracterización de la familia como base para el desarrollo de la salud familiar; modificación de estilos de vida para disminuir problemas cardiovasculares; cómo cuidar en situación de enfermedad crónica; cuidado a los cuidadores de salas de cirugía y recuperación quirúrgica; aplicación de temas administrativos a los servicios hospitalarios, y validez de contextos del instrumento “protocolo de integración del rol de la mujer modificado”. grupo de cuidado facultad de enfermería universidad nacional de colombia primera edición, 2005 reseñas revista aquichan issn 1657-5997 174 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 john r. cutcliff hugo p. mckenna editorial elsvier, 2005 the essential concepts of nursing (conceptos esenciales de enfermería) en su prólogo las doctoras peggy chinn y afaf meleis comentan respectivamente: “este libro y su colección de conceptos significativos, ilustra la asombrosa complejidad y diversidad del dominio de enfermería y la riqueza de sus recursos metodológicos. no se limita con exclusividad a desarrollar una serie de conceptos bajo una misma visión paradigmática, los autores asumen la posición de mostrar el conocimiento de enfermería a partir de la definición de enfermería como la ciencia y el arte de sanar y cuidar. la forma de presentación de los conceptos permite una interpretación a partir de imágenes mentales que apuntan a la cuestión del dominio, construyendo un dibujo muy claro de la profundidad y amplitud de lo que es enfermería. desde el punto de vista metodológico se permite una apreciación valorativa sucinta, crítica y bien equilibrada del manejo de los conceptos en la literatura”. “este libro nos recuerda todo el progreso que ha logrado enfermería, al trabajar los conceptos a partir de la práctica basada en la evidencia científica. tres características ameritan señalarse en su contenido: 1) refleja un desarrollo colaborativo internacional y comparte perspectivas y diversidades para el desarrollo de conceptos; 2) es una piedra angular del desarrollo del conocimiento, dado el abordaje académico que utilizan los autores al combinar sustancia y estructura para presentar sus hallazgos, y 3) representa un quiebre en el desarrollo del conocimiento porque brinda ejemplos efectivos de la síntesis y la interpretación del conocimiento relacionado con conceptos clave de enfermería que promoverán a partir del pensamiento crítico, un mayor desarrollo del conocimiento”. el libro presenta 19 conceptos de utilización común tanto en la práctica como en la investigación de enfermería, algunos de ellos son: abuso, cuidado, comodidad, afrontamiento, empoderamiento, fatiga, esperanza, soledad, apoyo de enfermería, confianza…, cada uno de ellos analizado bien con un enfoque cualitativo o cuantitativo, de acuerdo con su origen paradigmático, pero ceñido éste al rigor del análisis de conceptos. un valor agregado de cada capítulo es la excelente y actualizada revisión bibliográfica que los autores refieren. aunque no está traducido al español, es texto de referencia obligado para estudiantes de maestrías y doctorado disciplinar, al igual que para docentes de enfermería. maría mercedes durán de villalobos asesora facultad de enfermería, universidad de la sabana finalmente, es importante resaltar el trabajo que ha venido desarrollando el grupo de cuidado de la universidad nacional de colombia, el cual ha permitido que la enfermería en el país se desarrolle como profesión y como disciplina. el libro es uno de los resultados que muestran el cuidado como parte fundamental de nuestra profesión. beatriz pérez giraldo directora de posgrados, facultad de enfermería, universidad de la sabana. bienestar espiritual.pmd revista aquichan issn 1657-5997 8 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 abstract the present study investigated the correlation between the levels of spiritual well-being and the levels of anxiety-been, in a sample of 190 patients obtained by means of nonprobabilístic sampling, the inclusion criteria were: adults of 35 to 85 years of age, diagnosed with diabetes mellitus type 2, excluded the patients with dementia. the theoretical frame that guided the study is the model of adaptation of roy. the design was descriptive, cross-sectional, correlational. the population sample was distributed normally with a power of the 80. it was used the questionnaire of espirituality of reed and the scale of anxiety-been of spielberger; the instruments displayed a favorable internal consistency with a alpha de cronbach of 894 and 877 respectively. the information was successfully obtained of four institutions of health, one of first level and three of the second level of attention. the analysis of the data was carried out through statistical package spss version 13th. the average age of the participants was of 57,36 years with a standard deviation of 11,4; 55% were female gender, the 83,2% professes the catholic religion, the 51,5% presents some type of complication associated to diabetes. the coefficient of correlation between the spiritual well-being and anxiety-been was significant. these results support the hypothesis of the study that refers to greater spirituality smaller level of anxiety-been; situation that it invites to deepen as much in the study of these phenomena in the educative area as welfare in the nursing discipline. key words ma. del refugio zavala1 olga vázquez martínez2 martha v. whetsell3 recibido: 20 de junio de 2006 aprobado: 8 de agosto de 2006 resumen palabras clave bienestar espiritual, ansiedad-estado, diabetes mellitus tipo 2. spiritual well-being, anxiety-been, diabetes mellitus type 2. el presente estudio investigó la correlación entre los niveles de bienestar espiritual y los niveles de ansiedad-estado, en una muestra de 190 pacientes obtenida por medio de muestreo no probabilístico; los criterios de inclusión fueron: adultos de 35 a 85 años de edad, diagnosticados con diabetes mellitus tipo 2, se excluyeron los pacientes con demencia. el marco teórico que guió el estudio es el modelo de adaptación de callista roy. el diseño fue descriptivo, transversal, correlacional. la muestra poblacional se distribuyó normalmente con una potencia de 80. se utilizó el cuestionario de espiritualidad de reed y la escala de ansiedad-estado de spielberger; los instrumentos presentaron una consistencia interna favorable con un alpha de cronbach de .894 y .847 respectivamente. la información se recabó de cuatro instituciones de salud, una del primer nivel y tres del segundo nivel de atención. el análisis de los datos se llevó a cabo a través del paquete estadístico spss versión 13. la edad media de los participantes fue de 57,36 años, con una desviación estándar de 11,4; el 55% fueron del sexo femenino, el 83,2% profesa la religión católica, el 51,5% presenta algún tipo de complicación asociada a la diabetes. el coeficiente de correlación entre el bienestar espiritual y la ansiedad-estado fue significativo. estos resultados apoyan la hipótesis del estudio que refiere a mayor espiritualidad menor nivel de ansiedad-estado, situación que invita a profundizar en el estudio de estos fenómenos tanto en el área educativa como asistencial en la disciplina de enfermería. spiritual well-being and anxiety in diabetic patients 1 facultad de enfermería, campus tampico, universidad autónoma de tamaulipas, méxico. matamoros 8 y 9 zona centro cp. 87100 cd. victoria, tamaulipas, méxico. mzavala@uat.edu.mx 2 facultad de enfermería, campus tampico. universidad autónoma de tamaulipas, méxico. matamoros 8 y 9 zona centro cp. 87100 cd. victoria, tamaulipas, méxico. ovazquez@uat.edu.mx 3 lehman college of nursing, bronx, n.y. shuster hall room 158, bedford park blvd. west. bronx, ny 10468-1589 u.s.a. facultad de enfermería, campus tampico. universidad autónoma de tamaulipas, méxico. matamoros 8 y 9 zona centro cp. 87100 cd. victoria, tamaulipas, méxico. marwhet@hotmail.com año 6 vol. 6 nº 1 (6) 8-21 chía, colombia octubre 2006 bienestar espiritual y ansiedad en pacientes diabéticos. spiritual well-being and anxiety in diabetic patients 9 introducción a diabetes mellitus tipo 2 es una enfermedad crónica y degenerativa susceptible de presentarse en todos los grupos socioeconómicos, étnicos y culturales; sus manifestaciones clínicas son progresivas dando lugar a una posible discapacidad parcial, completa o a la muerte. en 1993, la encuesta nacional de enfermedades crónicas de la secretaría de salud reportó que en méxico la diabetes mellitus afectó entre 8 y 10% de la población mexicana mayor de 20 años, pero esta prevalencia aumenta sensiblemente en personas entre los 40 a 50 años de edad (1), situación que la pone de manifiesto como uno de los principales problemas de salud pública; en 1998, la diabetes fue la séptima causa de morbilidad, con 336.967 casos diagnosticados (98% con diabetes tipo 2), para 1999 se notificaron cerca de 239.000 casos en control y alrededor de 3.500 casos acumulados únicamente en la secretaría de salud. se estima que para el 2025, a nivel mundial, nuestro país ocupará el séptimo lugar, con 12 millones de enfermos (2). en el 2002 la diabetes mellitus tipo 2 se ubicó a escala nacional como la primera de las principales causas de mortalidad en mujeres con un 14,6%, y la segunda causa en hombres con un 9,9% (3). en este mismo año, en el estado de tamaulipas, esa enfermedad crónica alcanzó una tasa de mortalidad, estandarizada por edad de 88,1 por 100.000 habitantes en mujeres, y en hombres la tasa fue de 90,9 (3), y fue la tercera de las principales causas de mortalidad general en esta misma entidad federativa con un 14,9% (4). en el año 2003 se reportó que en méxico la diabetes mellitus alcanzó un porcentaje de defunciones generales del 15,5 en el grupo de edad de 30 a 64 años; en cuanto al sexo, en los hombres representó el 12,5% y en las mujeres el 20,4% (5). diversos estudios reportan que los pacientes con diabetes mellitus tipo 2 no sólo son afectados físicamente sino que también desarrollan problemas emocionales a medida que la enfermedad progresa a un estado de cronicidad, lo cual conlleva un deterioro del bienestar y de la calidad de vida de quienes la padecen. una de esas alteraciones emocionales son los cuadros de ansiedad o angustia que se manifiestan mediante miedo, incertidumbre, inseguridad, nerviosismo, entre otras conductas reactivas. entre las diversas definiciones del concepto de ansiedad se encuentra la de lazarus (citado por lewis y cols.) (6), quien la describe como una relación particular entre el individuo y el entorno, que es evaluada por éste como amenazante o superior a sus recursos, y que pone en riesgo su bienestar. por su parte, spielberger (7) señala el estado de ansiedad como sensaciones subjetivas, conscientemente percibidas de manera transitoria, es decir, la aprehensión, tensión y preocupación varían en intensidad y fluctúan en un cierto plazo de tiempo. gordon (8) establece varios niveles de ansiedad, el nivel leve lo define como el aumento del estado de alerta asociado con la expectativa de una amenaza (no definida) para el yo o relaciones significativas. la capacidad de resistencia ante la ansiedad varía entre las personas, dependiendo del funcionamiento físico, de las capacidades de afrontamiento y de la duración e intensidad de los periodos de ansiedad experimentados. para efectos del presente estudio se utilizó únicamente la escala de ansiedad-estado que mide el estado de ánimo situacional de las personas; las características esenciales que evalúa involucran sentimientos de tensión, nerviosismo, preocupación y aprensión. revista aquichan issn 1657-5997 10 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 uno de los factores que contribuye a afrontar los estados de ansiedad que vive el individuo es el referente a sus creencias espirituales. meravigilia (9) señala que la espiritualidad se relaciona con las experiencias individuales que son únicas a cada persona, en este sentido el bienestar espiritual se relaciona con las creencias o los sistema de valores que constituyen en el individuo su fuente de fuerza, esperanza y trascendencia para la vida. reed (citado por whetsell) (10) llevó a cabo varios estudios sobre el bienestar espiritual, en ellos describe la espiritualidad como la inclinación para encontrar significado en la vida por medio de un sentido de interrelación con algo mayor, que trasciende el yo y lo fortalece, por tanto, existen diferencias en las respuestas adaptativas tanto conductuales como fisiológicas en los momentos de ansiedad que vive el individuo. el presente estudio fue guiado por el modelo de adaptación de callista roy, en donde la ansiedad fue considerada como el estímulo focal que genera estímulos contextuales que alteran los modos adaptativos: el fisiológico, el del rol, el de autoconcepto y el de interdependencia, desencadenando alteraciones en los mecanismos regulador y cognitivo, lo cual incide en que las personas sean menos independientes y se deterioren tanto en lo físico como en lo psicológico. con base en estas consideraciones se planteó la siguiente pregunta de investigación: ¿existe relación entre el nivel de bienestar espiritual y el nivel de ansiedad que manifiestan los adultos con diabetes mellitus tipo 2 en el rango de edad de 35 a 85 años? la hipótesis fue: a mayor bienestar espiritual menor nivel de ansiedad en los adultos con diabetes mellitus tipo 2. los objetivos del estudio fueron: 1. determinar el perfil sociodemográfico de los pacientes con diabetes mellitus tipo 2 hospitalizados y de consulta externa en cuatro instituciones de salud de tampicocd. madero tamaulipas, méxico, por medio de una cédula demográfica. 2. identificar los niveles de ansiedadestado que presentan los pacientes participantes con diabetes mellitus tipo 2 mediante una escala de autoevaluación. 3. identificar los niveles de bienestar espiritual que manifiestan los pacientes con diabetes mellitus tipo 2 por medio de un cuestionario con preguntas cerradas. 4. detectar estadísticamente si existe correlación entre los niveles de ansiedad y los niveles de bienestar espiritual en los pacientes con diabetes mellitus tipo 2, participantes en el estudio. marco teórico esta investigación se guió por el modelo de adaptación de callista roy (ram) en enfermería (11), el cual permite estudiar todo problema que produce desadaptación en la persona, como es el caso de las enfermedades crónicas, entre ellas la diabetes mellitus tipo 2. el ram provee las bases para conceptualizar relaciones mediante la identificación de conceptos cognitivos y emocionales positivos que puedan ayudar al proceso de enfrentamiento a los cambios que producen los problemas de salud crónicos. desde la perspectiva de roy, los aspectos que afectan a la persona se llaman estímulos uno de los factores que contribuye a afrontar los estados de ansiedad que vive el individuo es el referente a sus creencias espirituales. bienestar espiritual y ansiedad en pacientes diabéticos. spiritual well-being and anxiety in diabetic patients 11 y provocan una respuesta adaptativa o inefectiva, además representan el punto de interacción del sistema adaptativo humano con el ambiente. la ansiedad producida por la diabetes mellitus actúa como estímulo focal o como factor amenazante que confronta al enfermo en sus cuatro modos adaptativos: los cambios físicos como la pérdida de peso, alteración en los niveles de glicemia, disminución de la sensibilidad y del riego sanguíneo en miembros inferiores con mayor susceptibilidad a infecciones y disfunción en el metabolismo de los nutrientes que afecta el modo fisiológico. al mismo tiempo, estos cambios traen con ellos sentimientos de desesperanza, dependencia e inseguridad, lo cual incide en el autoconcepto. la función de rol se ve alterada en cuestiones laborales, familiares y sociales. debido a todos estos cambios, el modo de interdependencia cambia a una función de dependencia. los estímulos contextuales, como los factores demográficos de edad, género, religión, escolaridad y ocupación, tienen una influencia en el efecto del estímulo focal. el mecanismo cognitivo, siendo el procesador que el individuo usa para pensar y desarrollar habilidades a fin de enfrentar los efectos del cambio, es usado para confrontar los efectos causados por el estímulo focal y para crear nuevas estrategias que ayuden a un cambio positivo. específicamente en el ram, el cognitivo es postulado como un subsistema para desarrollar estrategias cognitivas y emocionales para enfrentar los cambios del medio ambiente. a continuación se esquematizan estos conceptos del marco teórico. revista aquichan issn 1657-5997 12 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 estudios relacionados por lo general todas las personas, en el transcurso de la vida, presentan periodos de temor y ansiedad generados por diversos factores, estas respuestas son reacciones defensivas ante un peligro, pueden evolucionar desde una respuesta adaptativa a un trastorno incapacitante, con repercusiones en el desarrollo psicológico y social de las personas, manifestándose mediante un conjunto de respuestas fisiológicas, cognitivas y conductuales (12). en 1973, basado en el trabajo de hildegard peplau (citado por young) (14), la ansiedad fue identificada como diagnóstico en el oficio de la enfermera; en 1980, fue suprimida de la lista de la north american nursing diagnosis association (nanda) como diagnóstico de enfermería y se convirtió en una característica que dependía del diagnóstico, miedo. en 1982, la ansiedad fue restablecida como diagnóstico y definida, con 17 indicadores subjetivos y 12 objetivos. metzer e hiltunen (citados por young) (14) identificaron seis respuestas como señales críticas de la ansiedad: ansioso, aprehensión, tensión creciente, preocupación, miedo de consecuencias específicas y apenado. esto refleja la importancia de la incidencia de este problema de salud y el de poder detectarlo y atenderlo de forma adecuada por el personal del área. gordon (8) define la ansiedad como un vago sentimiento de incomodidad cuyo origen es frecuentemente inespecífico o desconocido para el individuo; la clasifica en ansiedad leve, moderada y severa, diferenciándose por el aumento del nivel de alerta asociado con la expectativa de una amenaza que puede ser hacia el autoconcepto, el estado de salud, la posición socioeconómica, el desempeño del rol, los patrones de interacción o el entorno. gordon dice también que la ansiedad puede estar asociada a un conflicto inconsciente (valores esenciales o metas vitales). otra de las definiciones de ansiedad y semejante a la anterior es la de mccloskey y bulechek (13), quienes la definen como un sentimiento de aprehensión causado por la anticipación de un peligro, como una señal de alerta que advierte de un peligro inminente y permite al individuo tomar medidas para afrontarlo; para la resolución de este problema, las autoras proponen, entre otras intervenciones, aumentar el afrontamiento, ayuda en la exploración, técnicas de relajación, distracción, enseñanza individual, facilitar las visitas y grupos de apoyo. entre los estudios que se han realizado sobre la variable de ansiedad, se encontró el de young y cols. (14); ellas realizaron un estudio descriptivo, longitudinal, uno de sus propósitos fue explorar la ansiedad en pacientes adultos que experimentaban el transplante de médula, los datos fueron recogidos en tres momentos, en el primer día del condicionamiento, 25 días más adelante, y 100 días de postransplante. de los 32 pacientes que iniciaron el estudio solamente 10 estaban vivos y disponibles en el tercer momento de recolección de datos. utilizaron el inventario de ansiedad de state/trait (stai) y la escala gráfica de la ansiedad (gas). se encontró una correlación positiva significativa entre el stai y las cuentas del gas. la cuenta de la ansiedad-estado fue moderada en los momentos 1 y 3, y de ansiedad baja en la etapa 2. lawrence y cols. (15), efectuaron un estudio transversal de observación en un centro de medicina familiar con el propósito de analizar las relaciones entre síntomas, diagnósticos y la severidad de la enfermedad como indicadores de ansiedad y de la depresión. en los pacientes con niveles más altos de síntomas, era más probable que presentaran los diagnósticos tales como dolor de cabeza, osteoartritis, dolor abdominal y de diabetes mellitus. en todas las regresiones logísticas, el sexo femenino, la percepción de la salud más baja, más dolor y la mayor inhabilidad (días en cama), persistieron como estadísticos predictores positivos y significativos de síntomas más altos de ansiedad y depresión. en cuanto a la asociación entre la diabetes mellitus y la ansiedad, de los ríos, sánchez, barrios y guerrero (16) llevaron a cabo un estudio ex post facto, transversal, con 100 pacientes con diabetes mellitus tipo 2, con edades entre 26 y 78 años. utilizaron la escala de calidad de vida relacionada con la salud (escaviris). los resultados revelaron que el 43% de la muestra cursó con algún grado de deterioro en su calidad de vida; una de las áreas que sobresalió fue la psicosocial, en donde se evaluaron aspectos emocionales como la ansiedad, depresión, temores, preocupaciones, autoconcepto y algunos elementos de interacción social; el 60% de los pacientes no mostró deterioro y en un 15% fue severo (p<0,003). los resultados revelan la importancia de tomar en cuenta los factores psicosociales del paciente en el manejo y control de su enfermedad. en el 2004, de los ríos, barrios y ávila (17) efectuaron otro estudio ex post facto con el propósito de examinar la frecuencia de alteración emocional en una muestra de 100 de pacientes con insuficiencia renal crónica por neufropatía diabética. utilizaron el instrumento ghk-28 (general health questionnaire) de goldberg. los bienestar espiritual y ansiedad en pacientes diabéticos. spiritual well-being and anxiety in diabetic patients 13 resultados indicaron que el 86% de los pacientes cursaban con algún grado de alteración emocional; tuvieron más riesgo de padecerla aquéllos con más de diez años de evolución de su enfermedad. se concluyó que la alteración emocional en este tipo de pacientes es alta y está asociada a la evolución degenerativa del padecimiento. murphy y cols. (18) realizaron un estudio en donde examinaron las tendencias históricas con respecto a la ansiedad en términos de su predominio, de su distribución por edad y género, y de su correspondencia con la depresión. las muestras de adultos fueron seleccionadas y entrevistadas en 1952, 1970 y 1992. encontraron que la ansiedad es dos veces más común que la depresión; el predominio de la ansiedad era igualmente estable. una redistribución de edades en 1992, indicó que la depresión –pero no así la ansiedad– había aumentado perceptiblemente entre mujeres más jóvenes (¼ 0,03 de p). en el transcurso del estudio, aproximadamente la mitad de los casos con ansiedad también presentó depresión, concluyendo que las relaciones entre la ansiedad y la depresión seguían siendo en un cierto grado similares, con la excepción del hecho de que la depresión vino asemejarse a la ansiedad como desorden, a la cual las mujeres estaban considerablemente más vulnerables que los hombres. respecto al concepto de espiritualidad existen diversas concepciones pero a la vez complementarias; cawley (citado por mcsherry) (22) propone que se pueden clasificar en dos amplias escuelas, los que creen en un dios y los que no lo hacen. en contraste, burnard (citado por mcsherry) (22) señala que el concepto de espiritualidad se aplica a toda la gente, incluso a las personas que no crean en un dios o ser supremo. por su parte, stoll (citado por meraviglia) (9) describe dos dimensiones de la espiritualidad: la dimensión vertical en su conexión con dios o un ser supremo, y la dimensión horizontal en su relación con uno mismo o la naturaleza. él señala que esta dimensión refleja los valores y las creencias supremos de los sujetos. labun (citado por meraviglia) (9) considera que cada una de estas dimensiones está correlacionada, influyendo en los aspectos restantes de la persona. en consonancia con el concepto de bienestar espiritual, ellison (citado por cooper) (20) lo describió como un estado doble, con un componente religioso y un componente espiritual o existencial; este aspecto otorga un sentido de propósito y satisfacción con la vida personal. de ahí que la religión se defina como un sistema organizado de creencias y de prácticas compartidas por una determinada colectividad (19). frankl (citado por garcía y cols.) (19) afirma que la tarea del espíritu no es observarse así mismo, lo esencial y específico del hombre es estar ordenado y orientado a algo o a alguien, y sólo en esa medida de espiritualidad el hombre está en sí mismo. se dice que el espíritu va más allá de lo sensible, es un impulso capaz de crear realidades particulares ya que se manifiesta en cada uno de los comportamientos de los individuos. con relación a la asociación de este concepto y la salud, reed y peri (citados por whetsell) (10) coincidían en señalar en que existe una conexión entre una espiritualidad fuerte y una mejoría en la salud mental, con la habilidad para afrontar el estrés de una enfermedad y el duelo; reed describe la espiritualidad como la inclinación por encontrar significado en la vida por medio de un sentido de interrelación con algo mayor, que trasciende el yo y lo fortalece. él indica que la se dice que el espíritu va más allá de lo sensible, es un impulso capaz de crear realidades particulares ya que se manifiesta en cada uno de los comportamientos de los individuos. revista aquichan issn 1657-5997 14 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 interrelación puede ser experimentada en forma intrapersonal, interpersonal o transpersonal. respecto al estudio de la espiritualidad, piles (citado por tongprateep, 2000) (21) opinó que no puede ser definida o aprobada por métodos científicos, ya que es una capacidad interna, propia de cada persona, por lo que muchos profesionales de la salud no consideran la espiritualidad como un aspecto importante en el cuidado del paciente. emblen (citado por whetsell) (10) analizó las definiciones de bienestar espiritual en la literatura de enfermería, coincidiendo en que la falta de una definición unificada sobre espiritualidad para la disciplina entorpece la investigación y el desarrollo de intervenciones espirituales. burkhardt (citado por whetsell) (10) definió la espiritualidad como “el misterio revelado por medio de una interconexión armoniosa que nace de la fortaleza íntima”, utilizó la palabra “espiritualidad” como un concepto que connota un proceso y como tal se considera más útil para enfermería. goddard (citado por whetsell) (10), mediante un análisis filosófico del concepto, propone una definición de espiritualidad como una energía integradora que es capaz de producir armonía interna y holística, que combina cuerpo, mente y espíritu. algunos atributos de la espiritualidad que goddard identifica son la corporeidad, la vitalidad y fortaleza. los hallazgos de algunas investigaciones sobre la espiritualidad reportan sus beneficios en la vida de las personas; en este sentido, cooper-effa y cols. (20) llevaron a cabo un estudio descriptivo, transversal para examinar el efecto del bienestar espiritual en los pacientes que presentaban dolor por enfermedad de la célula de la hoz. utilizaron la escala de bienestar espiritual de ellison, compuesta por 20 reactivos, 10 reactivos se centran en la satisfacción y dirección de la vida (bienestar existencial), el resto de reactivos se centran en la creencia en dios (bienestar religioso). la capacidad de hacer frente al dolor fue determinada con el inventario multidimensional del dolor west havenyale, constituido por 52 reactivos distribuidos en tres apartados: severidad del dolor, control de la vida e interferencia en la vida. el bienestar espiritual no se correlacionó con el nivel de interferencia con las actividades diarias y tampoco con la valoración del dolor de los pacientes, sin embargo, sí se correlacionó con la opinión de los pacientes del efecto de la enfermedad sobre sus vidas. por tanto, el componente existencial del bienestar espiritual parece desempeñar un mayor papel, ya que puede predecir el control de la vida. tongprateep (21) realizó un estudio cualitativo con el propósito de describir los elementos esenciales de la espiritualidad entre 12 ancianos tailandeses rurales. el análisis de los datos arrojó tres categorías: la creencia espiritual con base en dos temas: la ley del karma (ley de la causa y el efecto) y de la vida después de la muerte; la práctica religiosa consistió en cuatro temas: actos meritorios, la observación de preceptos morales, la gratitud y cuidado de la familia y la meditación. la tercera categoría se refirió a las consecuencias de la espiritualidad, contemplando los aspectos siguientes: afrontamiento de las vicisitudes de la vida, esperanza y una mente pacífica. en este estudio, la espiritualidad sirvió como la fuerza impulsora para los pensamientos, sensaciones, opiniones y las expresiones de los participantes con su creencia religiosa budista. el componente existencial del bienestar espiritual parece desempeñar un mayor papel, ya que puede predecir el control de la vida. bienestar espiritual y ansiedad en pacientes diabéticos. spiritual well-being and anxiety in diabetic patients 15 la autora propone que la investigación adicional se debe conducir a través del proceso continuo de la salud y de la enfermedad con todos los grupos de edad y con individuos de diversas culturas y sistemas de creencias; además, consideró que los resultados del estudio proporcionan una base de conocimientos para explorar la espiritualidad y promover el cuidado holístico. hungelman (citado por whetsell) (10) desarrolló un estudio cualitativo para determinar los componentes del bienestar espiritual; 31 participantes con edades entre 65 y 85 años fueron entrevistados, y se observaron durante 150 horas. se identificaron tres categorías relativas al vínculo: a otro último, a otros y la naturaleza, a sí mismo y en relación con el tiempo, la percepción y aceptación del pasado, presente y futuro de cada uno. la teoría que unificó todo lo anterior fue la interconexión armónica. otro estudio en esta misma línea fue el de trice (citado por whetsell) (10), quien realizó una investigación cualitativa para entender qué experiencias vitales tenían significado para las personas ancianas; participaron nueve mujeres y dos hombres, con edades entre 65 y 87 años. a cada participante se le pidió que describiera las experiencias y los sentimientos que daban significado a su vida. los temas que resultaron estaban conectados con las experiencias relacionadas con la preocupación por otros. esto se vincula con un sentido de bienestar espiritual, y el significado y la habilidad para relacionarse con otros de forma trascendente. reed (citado por whetsell) (10) estudió la autotrascendencia y la salud mental; en un estudio participaron 55 personas ancianas con edades entre 80 y 97 años. se utilizó la escala de autotrascendencia (sts), integrada por 15 ítems para medir una visión más amplia de sí mismo en experiencias interpersonales, intrapersonales y temporales. se usó una entrevista semiestructurada que permitió a los participantes describir su enfoque en cosas diferentes a ellos mismos, las perspectivas sobre sus cambios físicos, de su pasado, presente y futuro. la salud mental se midió con la escala de depresión del centro de estudios epidemiológicos y la escala de sintomatología de salud mental. el análisis matriz de la entrevista cualitativa obtuvo cuatro categorías: 1. generalidad: ayuda a otros y participación de la familia; 2. introyección: aprendizaje a través de los años y pasatiempos, viajes y trabajo en el hogar; 3. integración temporal: sentimientos sobre el pasado, presente y futuro; 4. trascendencia del cuerpo. las correlaciones entre el sts y las dos medidas de salud mental fueron significativas, lo cual fue respaldado en el análisis de la matriz. en otro estudio se aplicó la escala de perspectiva espiritual (sps) de reed y el índice de experiencias espirituales en la versión del autotest y el inspirit-r. en este trabajo se desarrolló la intervención de enfermería para el inventario de cuidado espiritual (nisci) con la finalidad de medir la importancia de las intervenciones de enfermería. el estudio arrojó una correlación positiva entre el sts, el sps y el inspirit: los ítems preferidos en el nisci fueron los que estaban dirigidos hacia una actitud de cuidado, respeto por las creencias religiosas, ayuda a sentirse esperanzado, escucha y dar privacidad a la actividad espiritual. los ítems menos preferidos fueron las intervenciones que incluyeron rezar con la persona y discutir ideas sobre dios. este resultado, de acuerdo con bauer y barrón, podría estar relacionado con la percepción de que el papel de la enfermera no es participar con el individuo en aspectos privados de su vida. mcsherry y cols. (22) realizaron una investigación de corte cualitativo con el propósito de conocer cómo los pacientes, las enfermeras y la gente de las principales religiones del mundo entienden el concepto de la espiritualidad. los resultados demostraron que mientras las enfermeras expresaron definiciones claras de la espiritualidad en línea de murray y zentner (1989), para los pacientes era confuso su significado y además lo consideraban como sinónimo de religión. las expresiones registradas en el estudio sugirieron que el concepto de la espiritualidad no puede ser reconocido de manera universal, ya que tiene diversos significados e interpretaciones, por lo que se necesita tener precaución al intentar aplicar el concepto a los diversos grupos religiosos. los resultados también implican la necesidad de considerar las diferencias interculturales, ya que la espiritualidad se puede percibir en forma diferente por las enfermeras y los pacientes; además, puede haber diferencia cultural en y entre profesionales del cuidado médico. metodología se utilizó un diseño descriptivo, transversal y correlacional; la muestra se determinó mediante la técnica de muestreo no probabilístico; por disponibilidad, se integró con 190 pacientes con base en los siguientes criterios de inclusión: pacientes adultos de 35 años en adelante, ambos géneros, con diagnóstico médico de diabetes mellitus tipo 2 con y sin complicaciones; la muestra poblacional fue seleccionada de los servicios de hospitalización y consulta externa de cuatro instituciones de salud revista aquichan issn 1657-5997 16 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 (una del primer nivel de atención y tres del segundo nivel) ubicadas en tampico y ciudad madero tamaulipas. el criterio de exclusión fue que no tuvieran demencia. para la recolección de los datos se utilizó una cédula sociodemográfica con la que se capturó la edad, el género, la escolaridad, el estado civil, el tipo de trabajo, el salario, la religión, el número de integrantes por familia de los usuarios y la procedencia; también se consideró el diagnóstico médico y los años de evolución de la enfermedad. para la medición de la espiritualidad se utilizó el formulario estandarizado de reed estructurado con 10 reactivos, los cuatro primeros se relacionan con cuestiones de bienestar espiritual y se califican con una escala de seis puntos: 1 = nunca, 2 = menos de una vez al año, 3 = más o menos una vez al año, 4 = más o menos una vez al mes, 5 = más o menos una vez a la semana, 6 = más o menos una vez al día. el resto de reactivos se refieren a aspectos de religión y se califican con la siguiente escala: 1 = extremadamente en desacuerdo, 2 = desacuerdo, 3 = en desacuerdo más que en acuerdo, 4 = de acuerdo más que en desacuerdo, 5 = de acuerdo, 6= extremadamente de acuerdo. por encontrar resultados similares en los dos componentes del cuestionario, se reportaron en forma global. en cuanto a la medición de la variable ansiedad, se aplicó el inventario de ansiedad: rasgo-estado (idare), de spielberger y díaz-guerrero (1975), en su versión al español, denominado formulario de autoevaluación. para efectos del presente estudio se utilizó únicamente la escala de ansiedad-estado que mide el estado de ánimo situacional de las personas; las características esenciales que evalúa involucran sentimientos de tensión, nerviosismo, preocupación y aprensión. la cédula contempla 20 reactivos con una escala de respuestas de cuatro puntos: 1= no en lo absoluto, 2= un poco, 3= bastante y 4= mucho; su puntuación mínima es de 20 y la máxima de 80. la escala ansiedad-estado del idare está balanceada para evitar la respuesta indiscriminada mediante 10 reactivos con calificación directa y 10 reactivos con calificación invertida (1, 2, 5, 8, 10, 11, 15, 16, 19 y 20), es decir, en el caso de estos reactivos la calificación para las respuestas marcadas 1, 2, 3 ó 4, viene a ser de 4, 3, 2 y 1 respectivamente. se abordó a cada uno de los pacientes de manera individual, se les explicó la finalidad del estudio y se les preguntó si estaban de acuerdo en participar, en caso afirmativo, se les solicitó que firmaran el formato de consentimiento informado y se les informó que tenían la libertad de retirarse del estudio cuando quisieran; además, se les invitó a que respondieran las peguntas según se sintieran en ese momento de la entrevista. si bien se efectuó un estudio sin riesgo, dado que no se realizó ninguna intervención, siempre se respetó el anonimato de la información al no identificar los cuestionarios con el nombre de los participantes. la información se recabó en un periodo de tiempo de dos meses, y se procesó mediante el paquete estadístico spss versión 13; se analizó mediante estadística descriptiva a través de medidas de tendencia central, frecuencias y proporciones, además se determinó la correlación entre las variables en estudio. también se determinó, mediante el coeficiente alpha de cronbach, la consistencia interna de los instrumentos de medición. la espiritualidad no puede ser reconocida de manera universal, ya que tiene diversos significados e interpretaciones, por lo que se necesita tener precaución al intentar aplicar el concepto a los diversos grupos religiosos. bienestar espiritual y ansiedad en pacientes diabéticos. spiritual well-being and anxiety in diabetic patients 17 resultados con relación a los datos sociodemográficos de la muestra constituida por 190 pacientes con diabetes mellitus tipo 2, en la tabla 1 se detecta que predominó el género femenino; en cuanto a la edad, el mayor porcentaje de la población en estudio, de ambos géneros, se concentró en el rango de 50 a 64 años. el promedio de edad de los participantes fue de 57,36 con una desviación estándar (de) de 11,40; mediana de 58,00 y moda de 60. grupo de masculino femenino total edad tabla 1. distribución de pacientes por grupos de edad y género f % f % f % 35 49 17 9,0 29 15,2 46 24,2 50 64 45 23,7 49 25,8 94 49,5 65 85* 24 12,6 26 13,7 50 26,3 total 86 45,3 104 54,7 190 100,0 *rango no homogéneo por encontrar un solo sujeto en el rango de 80-85 años. la mayoría de los participantes saben leer y escribir (85,3%); en la tabla 2, predominaron los estudios de enseñanza básica, cerca del 20% sin ningún tipo de estudios. respecto al estado civil, aproximadamente el 50% de los pacientes son casados; un alto porcentaje profesan la religión católica. tabla 2. características sociodemográficas de pacientes participantes fuente: cédula sociodemográfica. n=190. variable f % escolaridad ninguno 33 17,4 primaria 77 40,5 secundaria 40 21,0 otros 40 21,0 estado civil viudo 39 20,5 casado 87 45,8 otro 64 33,7 religión católica 158 83,1 otro 24 12,6 revista aquichan issn 1657-5997 18 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 en relación con el número de integrantes por familia, la mayor proporción estaba conformada por tres a cuatro miembros (40,5%). en cuanto a la percepción económica de los 67 pacientes que manifestaron que trabajan de manera eventual, la mayoría percibe un salario semanal que oscila de 400 a 900 pesos. los participantes procedían de los estados de veracruz, tamaulipas y san luis potosí. la tabla 3 indica que los pacientes tenían de uno a treinta años de padecer la diabetes mellitus tipo 2, más del 50% ya presentaban algún tipo de complicación, en su mayoría, con un rango de uno a diez años de evolución. respecto a los instrumentos de medición, obtuvieron una consistencia interna aceptable, el cuestionario de espiritualidad obtuvo un alpha de cronbach de 0,89 y la escala de ansiedad-estado alcanzó un alpha de 0,84 con base en el bienestar espiritual de la población en estudio, los resultados se categorizaron por niveles en función de la puntuación total de la escala (60), la tabla 4 muestra que en ambos géneros osciló de moderado a alto, con predominio de este último nivel en la mujer. en la tabla 5 se indica el nivel de ansiedad en función de la puntuación máxima en la escala (80), también se categorizaron los datos, se encontró moderado nivel de ansiedad en más del 50% en ambos sexos. con los puntajes de cada instrumento de medición se obtuvieron índices, tanto para la escala de espiritualidad como de ansiedad, lo que se retomó para un análisis de correlación de spearman, por la naturaleza ordinal de las variables originales, la relación lineal entre las variables del objeto de estudio resultó estadísticamente significativa (-.276, valor p= .000) con relación a un nivel de significancia de .01 previamente establecido. años de diabetes mellitus nefropatía diabética pie diabético evolución f % f % f % 1 5 31 16,3 18 9,5 15 7,9 6 10 34 17,9 20 10,5 11 5,8 11 15 11 5,8 8 4,2 9 4,7 16 20 8 4,2 7 3,7 4 2,1 21 25 4 2,1 1 0,5 3 1,6 26 30 4 2,1 1 0,5 1 0,5 total 92 48,4 55 28,9 43 22,6 tabla 3. años de evolución de la diabetes mellitus tipo 2 con y sin complicaciones en pacientes encuestados fuente: cédula sociodemográfica. n=190. tabla 4. bienestar espiritual en pacientes participantes * leve: 10-30; moderado: 31-45; alto: 46-60. n= 190. escala original con puntaje máximo de 60* nivel hombres mujeres f % f % leve 16 18,6 18 17,3 moderado 35 40,7 37 35,6 alto 35 40,7 49 47,1 total 86 100,0 104 100,0 bienestar espiritual y ansiedad en pacientes diabéticos. spiritual well-being and anxiety in diabetic patients 19 discusión no obstante que algunas investigaciones (15, 18) reportan mayor vulnerabilidad en las mujeres en presentar estados de ansiedad, esto no coincide con los resultados de este estudio, pues incluso se encontró mayor porcentaje de hombres (10,5%) en el nivel de ansiedad severo en comparación con las mujeres (2%). sin embargo, lo más pertinente es detectar cuáles son las diferentes formas de afrontamiento de la ansiedad más que las diferencias de género, de manera que se puedan establecer las intervenciones de salud en función de las respuestas individuales de los pacientes. en la muestra en estudio se destacó el porcentaje de mujeres con diabetes mellitus, así como también el rango de edad de 50 a 64 años en ambos sexos, lo cual coincide con datos estadísticos a nivel estatal y nacional en méxico (1, 2, 3, 4, 5). otro dato demográfico pertinente en resaltar es el porcentaje de pacientes que ya presentan algún tipo de complicación (51%), situación que refuerza la necesidad de educarlos en su autocuidado con un enfoque integral. estadísticamente se encontró una asociación significativa (rho de spearman -.276, p=.000) entre los niveles de las variables centrales en la muestra poblacional participante, pues los datos muestran evidencia de que a mayor nivel de espiritualidad menor nivel de ansiedad, resultado que apoya la hipótesis del estudio y coincide con trabajos realizados en donde se reporta el efecto positivo de la espiritualidad en el estilo de vida de los individuos (10, 20, 21). sin embargo, es pertinente señalar que a través de la interacción con los pacientes, ellos dimensionaron con mayor predominio esa característica de su personalidad en la línea de lo religioso, pues expresaban que su fe les daba la fuerza para sobrellevar su estado de salud hasta que dios se los permita (10, 20, 21). tabla 5. nivel de ansiedad de pacientes participantes * leve: 20-40; moderado: 41-60; severo: 61-80. n=190. el presente trabajo constituye una aproximación al estudio de las variables de ansiedad y bienestar espiritual, ya que en méxico son escasas las investigaciones con este enfoque en el ámbito de enfermería, por lo que es recomendable realizar otros estudios en muestras con características similares y distintas con el fin de identificar los factores implicados para que las personas encuentren sentido de su existencia en función de sus valores, creencias y experiencias personales. implicaciones teóricas los resultados de este estudio confirman que el bienestar espiritual se puede clasificar como estímulo contextual positivo que contribuye de manera significativa a que las personas con diabetes mellitus tipo 2 tengan la capacidad para afrontar las reacciones emocionales consecuentes con la evolución crónica e incapacidad física y social derivadas de la enfermedad y logren, en la medida de lo posible, adaptarse a las condiciones de salud en las que se encuentran actualmente a consecuencia de este padecimiento. los niveles altos de bienestar espiritual, para la población participante, significan que la fe les ayuda a apreciar el sentido de la vida y a encauzar el camino para tratar de lograr la adaptación a estilos de vida favorables. implicaciones para enfermería en la práctica de enfermería clínica, promover el bienestar espiritual relacionado con la salud puede ayudar al paciente a afrontar el cambio físico y psicosocial que se produce por el avance progresivo de la cronicidad de las patologías degenerativas. en este sentido, el papel de enfermería implica entender y reflexionar escala original con puntaje máximo de 80* nivel hombres mujeres f % f % leve 26 30,2 25 24,0 moderado 51 59,3 77 74,0 severo 9 10,5 2 2,0 total 86 100,0 104 100,0 revista aquichan issn 1657-5997 20 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 referencias la importancia de la espiritualidad, lo que puede fortalecer de modo eficaz y adecuado el cuidado holístico de los pacientes y de esta manera hacer visible la ayuda profesional en esta dimensión humana. los resultados de este estudio también tienen implicaciones en la educación de usuarios y profesionales de la salud. la función educativa de enfermería debe enfatizar en el desarrollo de estrategias para que los individuos con diabetes mellitus tipo 2 participen en forma activa y asuman la responsabilidad en su autocuidado para mejora en su calidad de vida. por tanto, a fin de que la educación de los usuarios de los servicios de salud sea efectiva se necesita una serie de condiciones, tales como capacidad de comunicación efectiva, actitud de empatía, comprensión de patrones culturales y valores de los pacientes. aunado a lo anterior, se debe considerar a la familia como una red de apoyo. en lo que respecta a la formación educativa de los alumnos de enfermería se requiere que los profesores mediten con más profundidad en su currículo oculto, lo cual contribuye al fortalecimiento de habilidades del saber ser en connotación con el saber y el saber hacer en su práctica diaria, a fin de que puedan contribuir de forma más significativa en la preparación de nuevas generaciones que respondan a las necesidades de salud de nuestro tiempo. 1. secretaría de salud. encuesta nacional de enfermedades crónicas. méxico; 2001. 2. kuri m., vargas z., zárate h. y juárez v. secretaría de salud. dirección general de epidemiología. la diabetes en méxico [en línea]. [con acceso en 02/03/ 2006]. disponible en: http://www.invdes.com.mx/ anteriores/junio2001/index2.html 3. estadísticas de mortalidad. revista de salud pública de méxico 2004; 46(2): 169, 175-176, 178, 181. 4. secretaría de salud. principales causas de mortalidad general, tamaulipas, méxico; 2002. 5. instituto nacional de estadística, geografía e informática (inegi). estadísticas de mortalidad. méxico [en línea]. [con acceso en 05/10/2005]. disponible en: http://www.inegi.gob.mx/est/contenidos/ español/rutinas/ept.asp?t 6. lewis, heitkemper, dirksen, o’brien, giddens, bucher. enfermería medicoquirúrgica. valoración y cuidados de problemas clínicos. 6a ed. madrid: mosby; 2004. respecto al área de investigación, en el campo de enfermería en américa latina son escasos los estudios sobre espiritualidad y sus implicaciones en la salud, por lo que es un campo rico en oportunidades para planificar e implementar proyectos de investigación en los servicios de salud que incrementen el conocimiento propio de enfermería, y generen elementos teórico-prácticos que aumenten la calidad del cuidado acordes con las demandas de necesidades de la población. agradecimientos este trabajo de investigación fue financiado con presupuesto federal a través de pifi-2. 7. spielberger, díaz-guerrero. inventario de ansiedad: rasgo-estado (idare). méxico d.f.: el manual moderno; 1975. 8. gordon m. manual de diagnósticos enfermeros. 10a ed. españa: mosby; 2003. 9. meraviglia m. critical análisis of spirituality and its empirical indicators. revista de enfermería holística 1999; 17(1):18-33 [en línea]. [con acceso en 14/08/ 2005]. disponible en: http://www.blackwellsinergy.com 10. whetsell, frederickson, aguilera, maya. niveles de bienestar espiritual y de fortaleza relacionados con la salud en adultos mayores. revista aquichan 2005; 4(1): 73-85. 11. roy c, andrews h. the roy adaptation model. stanford: connectitud: appleton y lange; 1999. 12. becerra v. gabinete de psicología. trastornos por ansiedad. cádiz 2005 [en línea]. [con acceso en 14/ 08/2005]. disponible en: http://www.cop.es/ colegiados/s-02633/ansiedad.html bienestar espiritual y ansiedad en pacientes diabéticos. spiritual well-being and anxiety in diabetic patients 21 13. mccloskey j, bulechek g. clasificación de intervenciones de enfermería (nic). 4ª ed. madrid: mosby; 2005. 14. young todd, sandy, simuncak. validation of the diagnosis of anxiety in adults wtih marrow grafo [en línea]. [con acceso en 10 /10/2005]. disponible en: http://www.findarticles.com/p/articles/mi_qa4065/ is_200207/ai_n9110748 15. lawrence, parkerson, doraiswamy. opinion, pain and incapacity of health as correlations of anxiety symptoms and the depression in patients of the primary care [en línea]. [con acceso en 10/09/2005]. disponible en: http://www..medscape.com/ viewartticle/434349_2 16. de los ríos, sánchez, barrios, guerrero. calidad de vida en pacientes con diabetes mellitus tipo 2. revista médica, imss, 2003; 42(2): 109-116 [en línea]. [con acceso en 14/10/2005]. disponible en: http:// buscador.imss.gob.mx:8080/search engine/jsp/ search advsearch.jsp?querytext=espiritualidad &resultstart=1&resultcount=20&serverspec= 11.254.14.41%3a9920&lastquery=%28ansiedad %29&sortspec= score+desc&x=40&y=4 17. de los ríos, barrios, ávila. alteraciones emocionales en pacientes diabéticos con nefropatía. revista médica imss, 2004; 42(5): 379-385 [en línea]. [con acceso en 14/10/2005]. disponible en: http://www.imss.gob.mx /nr/rdonlyres/5185e4ab-507a-4159-8dba-c2df5a 576dfb/0/2004rm4205alt_emocionales.pdf 18. murphy, horton, laird, monson, sobol, leighton. anxiety and depressión: a 40 year perspective on relationships regarding, prevalence, distribution and comorbidity. acta psychiatr scand 2004; 109:355-375 [en línea]. [con acceso en 17/08/2005]. disponible en: http://www.blackwell-synergy.com 19. garcía, passaro, sarmiento, goetz, cúneo, díez, et al., claves para la vida. 1º ed. estados unidos de américa: barsa planeta; 2001. 20. cooper-effa, blount, kaslow, rothenberg, eckman. role of spirituality in patients whit cell disease. journal american board of family practice, 2001; 14(2): 116-122 [en línea]. [con acceso en10/09/2005]. disponible en: http://www..medscape.com/vie wartticle/434349_2 21. tongprateep t. the essential elements of spirituality among rural thai elders. journal of advenced nursing 2000; 32(1): 197-203 [en línea]. [con acceso en 14/ 08/2005]. disponible en: http://www.blackwellsinergy.com 22. mcsherry, cash, ross. meaning of spirituality: implications for nursing practice. journal of clinical nursing 2004; 13: 934-941 [en línea]. 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+,� 6� �$����-���������$����� ��������� ����&��$���$� �@��� � ��& �$����� ��� �� ����� � �������� ��������� . ����� � ����� � ������ �� � �<-���� ����;��5�>�?��,� 5� ��$����-�������������� ��� �����$����� ������-�� � ��& �$���$� ����� � ��&��$����� ��� �� ����� � �������� � �������<���� ��������!�8 �� ���/���� ���!�:�� -������$��� �&�3-�� �������*�*;),�!���� �������+�6� )� 3�����2!�<�� ��� �.������$����� ���$������*�� ��3�" a��1��%��:��"+# �����)) � ��� ��� ���!�#�����<��. ���� ��� b �� � �c& ���� �� � � ��� ���� �����%�d ����%�:��"+# ���. ������� �� �������� �������� � �� ������������������������������������������������������� ����������� ����������� �������� ������������ ������� ������������������ � ��� �e �$�0��!���$����� �2��@�� �� b � ���������� ���� � b �� �������� ���������f4� ������ ��,�>*?��*��+*�5� ��� #����������3�������4����� ������c���<����e��9 ���� � 3�� � ��� �������4 ����))�!����c�-����*��� � �*� �<��" �/���� � � ��� ������� � b �� ��� �����c����� -��+ � b ��%gd ����%� -���%� �� �������� � � �&� &&��� ��� � �� �� ���� %������� � %�!� %�� �� ���� �� :��� ����� ����3-�� ����� ������� ������ �����$ �� ���$ �� 8<���������))5� 477 maristela lopes gonçalves nunes1 vera lucia conceição de gouveia santos2 instrumentos de avaliação das complicações na pele periestoma: revisão integrativa 1 orcid.org/0000-0002-1450-9487. escola de enfermagem da universidade de são paulo (eeusp), brasil. marisgoncalves@usp.br 2 orcid.org/0000-0002-1288-5761. escola de enfermagem da universidade de são paulo (eeusp), brasil. veras@usp.br recebido: 03/07/2018 submetido: 16/07/2018 aceito por pares: 21/09/2018 aceito: 10/10/2018 doi: 10.5294/aqui.2018.18.4.9 para citar este artigo / para citar este artículo / to reference this article nunes mlg, santos vlcg. instrumentos de avaliação das complicações da pele periestoma: revisão integrativa. aquichan 2018; 18(2): 477-491. doi: 10.5294/aqui.2018.18.4.9 resumo objetivo: identificar e analisar os instrumentos utilizados para a avaliação das complicações da pele periestoma por meio de revisão integrativa. materiais e métodos: realizou-se revisão nas bases e portais de dados: biblioteca virtual da saúde (bvs), pubmed/ medline, cinahl, scopus e web of science, de janeiro a fevereiro de 2018. durante a busca nas bases de dados, foram utilizados os descritores: estomia, colostomia, dermatite; e as palavras-chave: instrumentos, complicação da pele periestoma e avaliação da pele periestoma. foram incluídos estudos que atenderam aos seguintes critérios: estar disponível na íntegra, estar publicado em espanhol, inglês e português, sem limite temporal e versar sobre os instrumentos de avaliação das condições da pele periestoma. resultados: a análise identificou a existência de nove instrumentos, com diferentes parâmetros para descrever a pele periestoma. de maneira geral, estes descrevem as alterações com base na classificação da complicação, na causa dos danos na pele ou nas características clínicas presentes. os estudos mostraram, ainda, que a maioria dos instrumentos não possui propriedades de medida testadas. conclusão: dos nove instrumentos de avaliação identificados, apenas quatro possuem propriedades de medidas testadas. o enfermeiro deve conhecer os instrumentos confiáveis e válidos disponíveis para descrever e classificar a gravidade dos problemas da pele periestoma, o que contribui para a sistematização de um diagnóstico mais acurado e melhora, portanto, a qualidade do cuidado. palavras-chave (fonte: decs) estomia; colostomia; dermatite; instrumentos; complicação da pele periestoma; avaliação da pele periestoma. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 477-491 temática: prática baseada em evidência. contribuição para a disciplina: o enfermeiro tem um papel crucial na avaliação e gestão das complicações do estoma e da pele periestoma. a avaliação precisa da gravidade das complicações na pele periestoma é parte integrante de qualquer decisão diagnóstica e terapêutica. por isso, o uso de um instrumento que possibilite avaliar, diagnosticar e classificar as condições da pele periestoma de forma padronizada torna-se essencial para a prática clínica. http://orcid.org/0000-0002-1450-9487 mailto:marisgoncalves@usp.br http://orcid.org/0000-0002-1288-5761 mailto:veras@usp.br http://dx.doi.org/10.5294/aqui.2018.18.4.9 http://dx.doi.org/10.5294/aqui.2018.18.4.9 478 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 477-491 instrumentos de evaluación de complicaciones de la piel periestoma: revisión integradora resumen objetivo: identificar y analizar las herramientas utilizadas para evaluar las complicaciones de la piel periestoma a través de revisión integradora de la literatura. materiales y método: la búsqueda se dio en estas bases y portales de datos: biblioteca virtual de la salud (bvs), pubmed/medline, cinahl, scopus y web of science, de enero a febrero de 2018. durante la búsqueda en las bases de datos, se utilizaron los descriptores: ostomía, colostomía, dermatitis y las palabras clave: instrumentos, complicaciones de la piel periestoma y evaluación de la piel periestoma. se incluyeron estudios que cumplieron los siguientes criterios: que estén disponibles en su totalidad, que estén publicados en español, inglés y portugués, no se tuvo en cuenta el rango de tiempo y tenía que ser acerca de las herramientas de evaluación de las condiciones de la piel periestoma. resultados: el análisis identificó la existencia de nueve instrumentos con diferentes parámetros para describir la piel periestoma. en general, los instrumentos describen los cambios basados en la clasificación de la complicación, en la causa del daño a la piel o en las características clínicas presentes. los estudios evidenciaron, además, que la mayoría de los instrumentos no poseen propiedades de medida probadas. conclusión: de los nueve instrumentos de evaluación identificados, solo cuatro tienen propiedades de medidas probadas. el enfermero debe conocer los instrumentos existentes confiables y válidos para describir y clasificar la gravedad de los problemas de la piel periestoma, lo que aporta a la sistematización de un diagnóstico más preciso y mejora, por lo tanto, la calidad del cuidado. palabras clave (fuente: decs) estoma; colostomía; dermatitis; instrumentos; complicaciones de la piel periestoma; evaluación de la piel periestoma. 479 instrumentos de avaliação das complicações na pele periestoma: revisão integrativa l maristela lopes gonçalves nunes e outro tools for peristomal skin complications assessment: integrative review abstract objective: the aim of this study was to identify and analyze the tools used to evaluate the peristomal skin complications by an integrative review. materials and methods: a literature review was performed through the following databases: virtual health library (bvs), pubmed/medline, cinahl, scopus and web of science, from january to february 2018. during the search in the databases, the following descriptors were used: stoma, colostomy, and dermatitis. the keywords were: tools, peristomal skin complication and peristomal skin assessment. studies were added to the following inclusion criteria: articles published in portuguese, english or spanish, full paper access, no time limit and they had to be about tools for peristomal skin complications assessment. results: the analysis identified the existence of nine tools with different parameters to describe peristomal skin complications. in general, they describe the peristomal skin changes based on classification, the peristomal skin complications or in the present clinical characteristics. the majority of the tools have not tested psychometric measures. conclusion: four out of the nine instruments identified have psychometric measures tested. the nurse should be aware and must know the existing valid and reliable tools to describe and classify how grave is the skin issue. this in order to give an accurate diagnosis and to improve the care quality. keywords (source: decs) ostomy; colostomy; dermatitis; tools; peristomal skin complication; peristomal skin assessment. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 477-491 480 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 introdução a construção de um estoma intestinal ou urinário continua a ter um papel fundamental no tratamento de doenças como o câncer colorretal e de bexiga, na incontinência anal, trauma, doença inflamatória intestinal, retocolite ulcerativa e nos casos de fistula retovaginal (1-3). as colostomias e as ileostomias são definidas como estomas intestinais de eliminação em que o segmento cólico e ileal são exteriorizados, respectivamente. já nos estomas urinários, há a exteriorização do conduto urinário, que se justifica para a manutenção da função renal (3, 4). em todas as situações, sem a presença do esfíncter uretral ou anal, o uso de um equipamento coletor faz-se necessário para a coleta do efluente e para a proteção da pele. o desenvolvimento de complicações no estoma e na pele periestoma é bastante frequente, e atinge índices acima de 70 % (5). estima-se que uma pessoa estomizada experimentará algum tipo de complicação na pele periestoma dentro de dois anos após a cirurgia, apesar dos avanços cirúrgicos e dos cuidados prestados no pós-operatório (6-8). as complicações podem estar associadas a diferentes fatores. genericamente, tais complicações podem ser minimizadas com o planejamento do local de implantação do estoma, com a técnica cirúrgica correta e adequada, e com a orientação do paciente e da família/cuidadores quanto ao (auto)cuidado (9). manter a saúde da pele ao redor do estoma é imprescindível e permanece sendo um desafio para pacientes, cuidadores e equipes de saúde (10, 11). a sua importância se dá pelo fato de a pele ser a superfície na qual o equipamento coletor permanecerá aderido (12). a perda da sua integridade reduz a capacidade de aderência da base adesiva, permitindo que o recorrente vazamento do efluente aumente os danos na epiderme e cause desconforto e dor na área afetada, além de aumentar os custos com os cuidados de saúde (12-15). portanto, a adaptação à nova condição de vida depende substancialmente da preservação da integridade da pele periestoma. problemas na pele periestoma são as complicações mais frequentes de quem convive com um estoma (15). apesar dos avanços em técnicas e produtos para o cuidado, sua incidência e prevalência afetam significativamente a qualidade de vida do estomizado (16-20). o tipo mais comum de complicação na pele é a dermatite periestoma associada à umidade, também conhecida como dermatite periestoma, frequentemente resultante da exposição da pele ao efluente do intestinal ou urinário (19-21). os estomas mais propensos e com maiores coeficientes de danos na pele são as ileostomias, devido principalmente à composição do efluente altamente corrosivo, quando comparadas às colostomias (21). as causas dos danos na pele periestoma são complexas e multifatoriais, porém uma característica comum é o vazamento do efluente entre a barreira protetora do equipamento coletor e a pele. por sua vez, um conjunto de fatores pode resultar em vazamento do efluente, como o tipo e localização do estoma, o nível de protrusão, o trauma mecânico e a infecção que dificultam o bom ajuste do equipamento coletor, o que leva à fuga do efluente e à irritação da pele (22-24). os altos índices de danos causados na pele periestoma ressaltam a importância da avaliação precoce que busca identificar os primeiros sinais de lesão, estabelecer o diagnóstico e programar o tratamento adequado (25). ações que são prioritárias para o cuidado do estomizado e que resultam na manutenção de uma pele periestoma saudável (20, 22, 24, 26). a avaliação da gravidade das condições da pele periestoma é parte integrante de qualquer decisão diagnóstica e apropriada intervenção (27-29). a avaliação clínica e as descrições da etiologia e danos causados na pele periestoma diferem entre os profissionais de saúde, o que dificulta a interpretação e a comunicação entre a equipe. é importante que enfermeiros utilizem uma linguagem comum para descrever as condições da pele periestoma, contribuindo para a sistematização da assistência e para a construção de evidências que fundamentem a prática de cuidados com estomas. assim, o uso de instrumentos validados para a avaliação da pele periestoma ajudam a padronizar a descrição e a comunicação sobre as suas condições (30-32). alguns instrumentos de avaliação das condições da pele periestoma já foram desenvolvidos, mas não há consenso internacional sobre o mais adequado. diferentemente das ferramentas de avaliação de feridas, aquelas utilizadas para a avaliação da pele periestoma, na grande maioria, não possuem análises de suas propriedades de medida bem como terminologia padronizada, o que torna mais difícil o seu uso e aceitação (33-35). tendo em vista que os instrumentos existentes apenas começam a ser adaptados e validados em nosso meio, o objetivo deste estudo foi identificar e analisar os instrumentos utilizados para a avaliação das complicações da pele periestoma, por meio de revisão da literatura. 481 instrumentos de avaliação das complicações na pele periestoma: revisão integrativa l maristela lopes gonçalves nunes e outro materiais e métodos para a elaboração deste estudo, optou-se pelo método de revisão integrativa (ri), que compreende uma ampla abordagem do tema, pois possibilita incluir estudos com diferentes metodologias, como estudos experimentais e não experimentais, estudos empíricos e teóricos (36). esse método tem um vasto leque de propósitos que se referem a reunir e sintetizar os estudos realizados sobre um determinado tema, a partir dos resultados evidenciados, o que permite gerar uma fonte de conhecimento atual e determina se o conhecimento é válido para dar suporte à tomada de decisão e à melhoria da prática clínica (37, 38). para ser considerada uma pesquisa com rigor metodológico, a ri deve seguir o um processo de elaboração de pesquisa, descrito sucintamente em seis fases (37, 39): • 1ª fase: elaboração da pergunta norteadora para a elaboração da revisão integrativa; • 2ª fase: estabelecimento de critérios para a inclusão e exclusão de estudos/busca de literatura; • 3ª fase: definição das informações a serem extraídas dos estudos selecionados; • 4ª fase: análise crítica dos estudos incluídos; • 5ª fase: interpretação dos resultados; • 6ª fase: apresentação da revisão/síntese do conhecimento. a definição da pergunta norteadora é a fase mais importante da revisão, pois determina quais serão os estudos incluídos. nesse sentido, este estudo buscou responder ao seguinte questionamento: quais são os instrumentos para a avaliação das complicações da pele periestoma descritos na literatura? a busca foi realizada nos meses de janeiro e fevereiro de 2018 nas seguintes bases de dados: medical literature analysis and retrievel system online (medline/pubmed), cumulative index to nursing and allied health literature (cinahl), scopus e web of science, e nos portais da biblioteca virtual da saúde (bvs). durante a busca nas bases de dados, os seguintes descritores foram utilizados: “estomia”, “colostomia”, “dermatite”, além das seguintes palavras-chave/mesh: “complicação da pele periestoma”, “instrumentos” e “avaliação da pele periestoma”. os descritores foram combinados com operadores boleanos “and” e “or” a fim de refinar a busca. não foi estabelecido limite de tempo cronológico para a busca. foram incluídos estudos que atenderam aos seguintes critérios: estar disponível na íntegra, estar publicado nos idiomas espanhol, inglês e português, sem limite temporal e versar sobre os instrumentos de avaliação das condições da pele periestoma. após as exclusões, nove estudos fizeram parte da amostra final. para a coleta de dados, as autoras elaboraram um instrumento desenvolvido no programa microsoft word. nele, incluíram-se as seguintes variáveis: autor(es), ano e local de publicação, tipo de estudo e nível de evidência, resumo dos métodos, resumo dos resultados e conclusões. com o propósito de avaliar a qualidade metodológica dos estudos incluídos nesta revisão, estes foram submetidos à ferramenta denominada strengthening the reporting of observational studies in epidemiology (strobe), que oferece recomendações sobre como relatar estudos observacionais de forma mais precisa e completa (40, 41). a lista de verificação contém 22 itens assim subdivididos: título e resumo, introdução, métodos, resultados, discussão e outras informações. cada um dos 22 critérios recebe uma pontuação de zero (não atende) a 1 (atende). após a avaliação dos critérios, cada artigo recebe uma nota de 0 a 22, resultado da somatória dos critérios atendidos (42). o instrumento de coleta de dados também continha espaço para a pontuação strobe. quanto às evidências dos estudos selecionados, elas foram classificadas em cinco níveis de hierarquia (43): • nível 1 — 1a: revisão sistemática de ensaios clínicos controlados; 1b: ensaio clínico controlado randomizado com intervalo de confiança estreito; 1c: resultados terapêuticos do tipo “tudo ou nada”; • nível 2 — 2a: revisão sistemática de estudos de coorte; 2b: estudo de coorte (que inclui ensaio clínico randomizado de menor qualidade); 2c: observação de resultados terapêuticos (outcomes research); • nível 3 — 3a: revisão sistemática de estudos caso-controle; 3b: estudo caso-controle; • nível 4 — relato de casos (que incluiu coorte ou caso-controle de menor qualidade); • nível 5 — opinião de especialistas desprovida de avaliação crítica ou baseada em matérias básicas (estudo fisiológico ou estudo com animais). 482 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 após a fase de busca nas bases e portais de dados selecionados, os títulos e os resumos foram analisados quanto à concordância com a questão norteadora utilizando os critérios de elegibilidade predefinidos. definidos os estudos, estes foram acessados na íntegra, e seus dados foram extraídos e analisados por meio de instrumentos de coleta de dados, de avaliação crítica e de nível de evidências, quando pertinente. resultados preliminarmente, identificaram-se 267 publicações por meio da busca nas bases de dados e no portal de periódicos selecionados. após a leitura inicial do título e do resumo, 214 artigos foram eliminados, porque não se encontravam disponíveis na íntegra, foram publicados em duplicidade (em mais de uma base de dados), abordavam outros aspectos da pele periestoma, como definição e descrição das complicações, tratavam de epidemiologia, etiologia, prevenção e tratamento ou não empregavam instrumentos de avaliação ou qualquer forma sistematizada de avaliação das condições da pele periestoma. quando houve dúvidas quanto à inclusão ou não do artigo, este era lido na íntegra. ao final do processo de seleção, nove artigos compuseram a revisão, conforme demonstrado na figura 1. a análise dos nove artigos da amostra revelou que as publicações se concentraram no período de 1987 a 2014, sendo a pubmed a base com maior número de publicações (oito artigos). a maioria dos artigos é proveniente da europa (dinamarca, inglaterra, itália, rússia e suécia), havendo também representantes da índia e do japão. a maior pontuação strobe foi alcançada pelo estudo prospectivo acerca das propriedades de medida de indicadores de cor, utilizando o domínio discolouration do instrumento det®score para a validação relacionada ao critério, realizado pela doutora hiromi sanada (44) da universidade de tóquio. esse estudo preencheu 17 dos 22 itens do instrumento; trata-se de um estudo prospectivo — nível 2. embora três artigos não tenham obtido a pontuação strobe, por serem estudos metodológicos, eles foram mantidos como parte da amostra. figura 1. processo de seleção dos artigos incluídos na revisão integrativa fonte: elaborado pelas autoras. artigos identificados inicialmente nas bases de dados (n=267) bvs (n=49) pubmed (n=38) cinahl (n=101) scopus (n=54) web of science (n=25) artigos selecionados após a primeira análise (n=53) 53 artigos lidos na íntegra pubmed (n=8) cinahl (n=1) artigos selecionados após a leitura completa (n=09) 44 artigos excluídos após a leitura completa artigos com outras temáticas artigos fora do idioma especificado 214 artigos excluídos após a leitura do título e do resumo artigos duplicados artigos com aspectos não abordados nesta revisão indisponíveis na íntegra 483 instrumentos de avaliação das complicações na pele periestoma: revisão integrativa l maristela lopes gonçalves nunes e outro nos artigos que compuseram a amostra, identificaram-se nove instrumentos desenvolvidos com o propósito de avaliar as complicações da pele periestoma, sendo eles: classification of peristomal skin, classification of peristomal skin (cps) changes in patients with urostomy, canadian ostomy assessment guide (caog), study on peristomal skin lesions (sacstm instrument), ostomy skin tool, peristomal skin assessment tool (psat), stoma care ostomy research (scor) index, color indicators using digital image analysis of peristomal skin photographs e o peristomal skin assessment tool for patients with colostomy. esses instrumentos descrevem as alterações da pele periestoma com base na classificação da complicação (como dermatite por trauma, dermatite por infecção, dermatite alérgica), na causa dos danos na pele (como exposição ao efluente) ou quanto às características clínicas presentes (como coloração vermelha da pele, erosão e ulceração). as características dos nove artigos são apresentadas na tabela 1. tabela 1. caracterização da produção científica sobre os instrumentos de avaliação na pele periestoma (são paulo, brasil, 2018) autor(es), local e ano de publicação objetivo tipo de estudo/ nível de evidência métodos resultados/conclusões pontuação strobe herlufsen p et al. (2006) (10) dinamarca avaliar a frequência, a diversidade e a gravidade das condições da pele periestoma em estomizados e investigar como a saúde da pele era percebida pelos pacientes. estudo transversal/ nível de evidência — 2 as condições da pele periestoma de 202 estomizados foram avaliadas por enfermeiros e dermatologistas simultaneamente. as alterações da integridade da pele periestoma foram categorizadas em: leve (discreta mudança na pele, envolvendo de 0,1-0,5cm ao redor do estoma); moderada (mudanças na pele, como ulcerações, em uma área >2,0cm2) e grave (comprometimento considerável da pele, o que exige mudanças do equipamento coletor e cuidado tópico, tais como uso de medicamentos). um total de 45 % dos participantes apresentou complicações na pele periestoma, diagnosticadas por enfermeiros e dermatologista (57 % foram categorizadas como leves; 33 %, moderadas, e 10 %, graves). predominaram complicações moderadas e graves entre urostomizados (44 % e 22 %, respectivamente). dos diagnósticos, 77 % estavam relacionados ao contato com o efluente do estoma. apenas 38 % dos participantes concordaram que tinham danos na pele e mais de 80 % não procuraram profissionais de saúde. 14 borglund e, nordström g, nyman cr (1988) (45) suécia avaliar, descrever e classificar sistematicamente as alterações na pele periestoma em urostomizados. estudo observacional/nível de evidência — 2 cinquenta e sete pacientes com conduto ileal foram avaliados por um estomaterapeuta e um dermatologista quanto às características das alterações macroscópicas da pele periestoma. a documentação fotográfica das condições da pele compôs a base para uma classificação sistematizada em três grupos de alterações: sem sinais de lesões irritativas, lesões eritematosas-erosivas e lesões pseudoverrucosas. posteriormente, as lesões foram classificadas quanto à gravidade em: ausência de lesão, lesão moderada e lesão grave. o instrumento não gera uma pontuação geral. quanto aos pacientes examinados de acordo com o instrumento classification of peristomal skin (cps), um terço não apresentou sinais de eritema, erosão ou lesões pseudoverrucosas, apesar dos achados comuns como descoloração da pele. dez dos 13 pacientes com lesões pseudoverrucosas também exibiram lesões eritematosas-erosivas; lesões eritematoso-erosivas graves foram reconhecidas em 7 % dos pacientes. o cps usa definições e termos de acordo com a terminologia dermatológica, e os autores esperam que possa ser usado para facilitar a avaliação e documentação das alterações na pele periestoma. 08 diane st-cyr (2002) (46) canadá avaliar as condições da pele periestoma e a utilidade de um instrumento de avaliação clínica entre enfermeiros não especialistas. estudo coorte prospectivo/nível de evidência — 2 durante um período de seis meses, 18 enfermeiras avaliaram a utilidade do canadian ostomy assessment guide (coag) como ferramenta clínica para enfermeiros não especialistas. cinquenta pacientes foram avaliados três vezes e, em cada visita, o enfermeiro avaliava o estoma e a pele periestoma. em seguida, eram aplicados produtos indicados pelo instrumento. cada enfermeiro completou uma avaliação final sobre a utilidade do coag usando uma escala tipo likert de 5 pontos. o coag possui três algoritmos: colostomias e ileostomias, urostomias e problemas comuns da pele periestoma. os problemas de pele periestoma foram observados em 42 % da população no início do estudo (t0), em 48 % na visita de acompanhamento e em 44 % na avaliação final. entre os enfermeiros participantes, 78 % acreditaram que o instrumento coag foi útil para a sua prática clínica. 10 484 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 autor(es), local e ano de publicação objetivo tipo de estudo/ nível de evidência métodos resultados/conclusões pontuação strobe bosio g, pisani f, lucibello l et al. (2007) (33) itália desenvolver um instrumento para classificar as complicações da pele periestoma com base na apresentação clínica e na localização. estudo prospectivo, observacional/ nível de evidência — 2 desenvolvido em oito centros especializados na itália, composto por 339 estomizados com complicações na pele periestoma, avaliados por estomaterapeutas e cirurgiões entre 2003 e 2006. as lesões foram examinadas em intervalos definidos por um período de dois anos por observações clínicas. cinco categorias de lesões (l) foram definidas: l1 — lesão com hiperemia; l2 — lesão erosiva; l3 — lesão ulcerativa; l4 — lesão fibrinosa/necrótica ulcerativa e lx — lesões proliferativas (granulomas, depósitos de oxalato, neoplasia). os quadrantes ao redor do estoma foram identificados para facilitar topografia das lesões. a concordância interobservadores quanto à classificação dos diagnósticos foi considerada “excelente” (k = 0,91). 14 jemec gb, martins l, ayello ea, claessens i, hansen as, poulsen lh, sibbald rg (2011) (30) canadá avaliar a confiabilidade inter e intraobservadores e o ost — det®score em comparação com um grupo “padrão ouro”, definido por um painel de especialistas. estudo metodológico/não se aplica para estudos de análise psicométrica trinta fotografias de complicações da pele periestoma foram avaliadas por um grupo de vinte enfermeiros especialistas em dois momentos. em ambas as sessões, os enfermeiros atribuíram uma pontuação utilizando o instrumento det®score. um painel de especialistas composto por cinco membros avaliou as mesmas 30 fotografias duas vezes usando um instrumento de gravidade de 0 a 10. as avaliações foram comparadas para validar as pontuações. o det®score pontua clinicamente as condições da pele com base em três parâmetros: descoloração (d), erosão/ulceração (e) e tecido com crescimento excessivo (t). a pontuação det® varia de 0 a 15 pontos de acordo com a soma das pontuações para cada domínio. observou-se uma alta concordância de avaliação intraobservadores (k = 0,84) e de moderada a boa na avaliação interobservadores (k= 0,54), sem diferença entre os dos grupos. no grupo de “experts”, houve uma alta concordância (k = 0,70). em conclusão, o instrumento det®score mostra-se ser confiável e preciso; fornece uma linguagem comum para descrever a extensão da gravidade e distúrbios da pele periestoma. não se aplica em estudo de análise psicométrica sodhi jk, aharma p (2012) (50) índia construir um instrumento padronizado de avaliação e prevenção de complicações da pele periestoma em colostomizados. estudo metodológico/não se aplica para estudos análise psicométrica esse estudo foi desenvolvido conforme as seguintes fases: fase i — preparação preliminar (revisão de literatura, seleção de itens que representassem os parâmetros para a avaliação da pele periestoma); fase ii — validação do primeiro draft pela técnica delphi modificada e alterações de acordo com a opinião do especialista, e fase iii — validação de conteúdo. fotos foram adicionadas no instrumento de acordo com os critérios de classificação. o resultado final foi a formulação do peristomal skin assessment tool (psat). composto por seis parâmetros de avaliação: cor, tipo de tecido e tipo de exsudato, sangramento, margens da ferida e hidratação. o índice de validade de conteúdo (ivc) do instrumento psat foi de 0,80. não se aplica em estudo de análise psicométrica williams j et al. (2010) (24) inglaterra identificar os problemas da pele periestoma em relação ao uso de diferentes tipos de equipamentos coletores e adjuvantes e comparar as percepções dos estomizados e enfermeiros especialistas quanto às condições de pele. estudo descritivo/ multicêntrico/nível de evidência — 4 usando questionários estruturados, 80 estomizados foram entrevistados, e uma fotografia da pele periestoma foi tirada; suas respostas foram comparadas com a avaliação do enfermeiro utilizando o stoma care ostomy research (scor) index. observou-se que 68 % dos pacientes apresentavam problemas na pele, dos quais 44 % eram irritação, 12 % ulceração, 9 % alergia e 3 % maceração/erosão. os resultados demonstraram diferenças significativas entre a percepção de problemas da pele entre os estomizados e a observação por enfermeiros especialistas. educação do paciente e acompanhamento regular do enfermeiro especialista são imperativos. não se aplica em estudo descritivo kalashnikova i, achkasov s, fadeeva s, vorobiev g (2011) (51) rússia desenvolver um algoritmo para padronizar e facilitar a avaliação e opções de tratamento de complicações do estoma e da pele periestoma. estudo prospectivo/nível de evidência — 2 o algoritmo foi desenvolvido baseado na literatura existente, opiniões de profissionais e de uma análise retrospectiva dos registros de pacientes de um centro de coloproctologia da russia. o algoritmo definiu como causas dos danos na pele periestoma: extravasamento do efluente, infecção da pele, alergia e doenças preexistentes. a dermatite periestoma foi avaliada de acordo com as mudanças da coloração e a gravidade da pele em três grupos: 1) eritema e maceração; 2) vesículas e erosão; 3) úlceras. para testar o seu uso na prática clínica, o algoritmo foi utilizado por enfermeiras não especialistas para orientar a avaliação e cuidado em 1.427 pacientes ambulatoriais. dos 1.427 pacientes atendidos, 553 (38,8 %) apresentaram 742 complicações. destas, 355 (47,8 %) foram classificadas como problemas na pele periestoma e 387 (52,2 %) como complicações do estoma. dos 553 pacientes com complicações, a mais frequente observada foi a dermatite periestoma associada à umidade (184 pacientes, 33,3 %). os resultados desse estudo concluem que os usos dos algoritmos facilitam a categorização rápida das complicações e a seleção do tratamento, embora os autores mencionem que as avaliações continuam sujeitas a interpretações e subjetividades. 14 485 instrumentos de avaliação das complicações na pele periestoma: revisão integrativa l maristela lopes gonçalves nunes e outro fonte: elaborado pelas autoras. autor(es), local e ano de publicação objetivo tipo de estudo/ nível de evidência métodos resultados/conclusões pontuação strobe iizaka s, asada m, koyanagi h, sasaki s, naito a, konya c, sanada h (2014) (44) japão avaliar a confiabilidade e validade dos indicadores de cor utilizando a análise de imagens digitais para a avaliação da pele periestoma. estudo prospectivo/nível de evidência — 2 realizado com 21 pacientes (14 colostomizados, 6 ileostomizados e 1 urostomizado) em quatro ambulatórios especializados do japão. as fotografias foram processadas utilizando a análise de imagem digital, que envolveu calibração de cores, processamento de imagens e cálculo de indicadores. índice de eritema (ei), índice de melanina (mi) e índice de hipopigmentação foram criados para representar graus elevados de coloração vermelha, preta e branca, respectivamente, e seus valores médios foram comparados com o domínio descoloração do instrumento det®score. o ei e im da pele periestoma foram significativamente maiores que os da pele intacta (n = 42/ p < 0,001). todos os indicadores de cor em regiões adjacentes e áreas onde a base foi aplicada foram associados com o escore de gravidade de descoloração e escore de intensidade de dor (p < 0,05). a correlação significativa entre a pontuação da gravidade da descoloração e os indicadores de cor nesse estudo indicou que a análise de imagem tinha validade relacionada ao critério para classificação de cores. segundo os autores, os indicadores de cor permitem que os profissionais executem de forma precisa e sofisticada a avaliação das condições da cor da pele periestoma. 17 discussão nove artigos compuseram a amostra desta revisão de literatura, a qual se propôs a identificar os instrumentos de avaliação da pele periestoma. o conteúdo dos artigos selecionados refere-se à descrição geral do instrumento utilizado e ao resultado da análise psicométrica testada. deve-se destacar que alguns instrumentos foram desenvolvidos como primeiras tentativas de sistematizar a avaliação e classificação dos problemas na pele periestoma, e, embora não tenham sido submetidos a testes de validade e confiabilidade, são discutidos neste estudo. em 2006, herlufsen et al. (10) avaliaram a pele periestoma de 202 estomizados com estomas definitivos, na dinamarca, com o objetivo de analisar a frequência, a gravidade e a diversidade de complicações nela presentes. adicionalmente, os autores pesquisaram como os pacientes percebiam as condições da sua pele comparativamente à avaliação realizada pelos investigadores. antes de iniciar o estudo, os pesquisadores definiram pela periestoma saudável como a completa ausência de qualquer alteração visível da pele na área periestoma. quanto à categorização de qualquer alteração de sua integridade, foi realizada de acordo com as características clínicas presentes, em: leve, moderada e grave. alterações leves eram classificadas como discreta mudança na pele, que envolvia de 0,5 a 1,0 cm ao redor do estoma, sem necessidade de alterações quanto ao uso do equipamento coletor utilizado; alterações moderadas eram definidas como mudanças na pele, como ulcerações periestoma em uma área superior a 2,0 cm2, necessitando da mudança do equipamento coletor e/ ou indicação de terapia tópica; alterações graves eram aquelas com importante comprometimento da pele, exigindo mudanças do equipamento coletor e cuidado tópico, tais como uso de medicamentos. essa categorização não gera uma pontuação total, apenas quantifica a frequência média de pacientes com complicações na pele periestoma, segundo a categoria encontrada. testes de confiabilidade e validade não foram publicados. para descrever, definir e classificar os tipos de lesões e sua gravidade, borglund et al. (45) desenvolveram um sistema de classificação para as complicações da pele periestoma em pacientes com urostomias. a avaliação proposta também foi baseada nas alterações clínicas da pele, distribuídas nos seguintes grupos: sem sinais de lesões irritativas na pele, lesões eritematosas-erosivas e lesões pseudoverrucosas. a proposta incluiu ainda classificação quanto à gravidade: ausência de lesão, lesão moderada e lesão grave, sendo definidas conforme a área: eritematosas menores e maiores que 1x2 cm, respectivamente para moderadas e graves. um quadro com imagens das diferentes alterações clínicas compõe o instrumento. embora tenham sido desenvolvidos há 30 anos, testes de confiabilidade e validade também não foram encontrados. o estudo (46) que originou o desenvolvimento do canadian ostomy assessment guide (coag) teve como principais objetivos: avaliar as mudanças no estado da pele peristoma, o impacto financeiro no custo total dos produtos para cuidados com estomas, a percepção geral do paciente quanto ao bem-estar e à aceitação em relação ao equipamento coletor selecionado e a utilidade do 486 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 coag como ferramenta clínica para o enfermeiro não especializado. desenvolvido no canadá por um grupo de estomaterapeutas, em 1999, o coag possui três algoritmos de acordo com o tipo de estoma: 1) colostomias e ileostomias, 2) urostomias e 3) problemas comuns da pele periestoma. o algoritmo da pele periestoma inclui as seguintes categorias para as complicações: candidíase cutânea, dermatite de contato alérgica, masd (descrito como dermatite de contato irritativa), maceração, foliculite, psoríase, úlceras por pressão, pioderma gangrenoso, sangramento excessivo e separação mucocutânea. cada algoritmo contém uma lista de critérios de avaliação com perguntas para confirmar os achados clínicos. até o ano de 2001, 4.500 enfermeiros em todo o canadá foram capacitados para usar o coag em sua prática clínica. porém, tanto os resultados de sua utilização como os de avaliação psicométrica não foram testados. desenvolvido por bosio et al. (33), o instrumento sacstm (studio alterazioni cutanee stomali ou study on peristomal skin disorders) foi elaborado na itália, a partir de um estudo prospectivo observacional em oito centros de cuidados com estomas nesse país, desenvolvido entre 2003 e 2006. os pacientes foram divididos em dois grupos de acordo com o tempo de cirurgia (grupo 1: < 1 ano; grupo 2: > 1 ano), para diferenciar complicações precoces e tardias. um total de 656 pacientes estomizados compôs a amostra final, e as lesões na pele periestoma foram examinadas por observações clínicas e imagens digitais em intervalos definidos, ao longo de 24 semanas. após o período de observação, os membros do grupo de estudo, dos oito centros participantes, validaram a classificação das complicações de pele, durante três conferências de consenso. as classificações foram baseadas em observações e conhecimento sobre o mecanismo das lesões da pele periestoma. como anteriormente apresentado, o sacstm descreve as alterações na pele periestoma de acordo com sua apresentação clínica e localização topográfica em quatro quadrantes ao redor do estoma. as cinco lesões mais comuns observadas no estudo e incluídas no instrumento são: l1 — hiperemia (vermelhidão da pele periestoma sem perda de substância); l2 — lesão erosiva (com perda de substância que não ultrapassa a derme); l3 — lesão ulcerativa que se estende além da derme; l4 — lesão ulcerativa fibrinosa/lesão necrótica e l5 — lesões proliferativas (granulomas, depósitos de oxalato, neoplasia). posteriormente à classificação dos diagnósticos do instrumento sacstm, foi atestada por um grupo de quatro profissionais que não participaram da construção do instrumento, e a concordância interobservadores foi considerada como quase perfeita ou excelente (k = 0,91). adaptado e validado em 2015, na turquia (47), a confiabilidade interobservadores foi considerada muito boa (k = 0,90; ic 95 % 0,80-0,99). recentemente, o instrumento sacstm foi revisto com o objetivo de classificar lesões que não eram categorizadas pelo instrumento. uma nova categoria foi incluída: lesão ulcerativa que envolve planos além da fáscia muscular (com ou sem fibrina, necrose, pus ou fístula). a nova versão é denominada sacs 2.0 (48). o estudo de adaptação cultural e análise das propriedades psicométricas do sacstm se encontra em fase de finalização no brasil. outro esforço para fornecer aos profissionais de saúde um instrumento de classificação das condições da pele periestoma, o ostomy skin tool (ost) (30) foi desenvolvido por um grupo internacional de 12 enfermeiros especialistas em cuidados com estomas, em 2008. a primeira seção do ost pontua clinicamente as condições da pele com base em três parâmetros clínicos: descoloração (d), erosão/ulceração (e) e tecido com crescimento excessivo (t). esses parâmetros foram identificados como os domínios que descrevem a mais ampla gama de problemas da pele periestoma e são utilizados para calcular a pontuação det® (resultante da soma das pontuações para cada domínio). dentro de cada um dos parâmetros, considera-se a extensão da área afetada sob a barreira adesiva, baseada em uma pontuação de 0-3. quanto à gravidade, cada um dos três domínios é pontuado em uma escala de 1 a 2. a pontuação total do det® varia de 0 a 15 pontos. a segunda parte do ost inclui um guia que fornece o diagnóstico da pele periestoma de acordo com a avaliação clínica e as descrições padronizadas. em 2010, as propriedades de medida do ost foram testadas por jemec et al. (30). a concordância interobservadores foi considerada moderada (k = 0,54) e excelente para concordância intraobservadores (k = 0,84). recentemente, na turquia, o ost foi adaptado e validado (49), e foi obtida concordância interobservadores moderada (k = 0,51-0,77) excelente para a confiabilidade intraobservadores (k = 0,83-1) na avaliação individual dos domínios (área e gravidade). o estudo de adaptação cultural e análise das propriedades psicométricas do ost se encontra em fase de finalização no brasil. o estudo de adaptação cultural para a língua portuguesa e a análise das propriedades psicométricas do ost se encontram em fase de finalização no brasil. em 2012, sodhi e sharma (50) desenvolveram um estudo metodológico para criar o peristomal skin assessment tool (psat), para a avaliação dos problemas da pele periestoma de colostomizados. a técnica delphi modificada foi utilizada para analisar o primeiro draft do instrumento. após essa fase, um painel de especialistas concebeu a versão final, que consiste em uma lista 487 instrumentos de avaliação das complicações na pele periestoma: revisão integrativa l maristela lopes gonçalves nunes e outro de seis parâmetros baseados, como anteriormente, na avaliação clínica da pele: coloração, sangramento, margens da lesão, tipo de tecido e tipo de exsudato e hidratação, com critérios de pontuação máxima até 18. fotos foram adicionadas ao instrumento de acordo com os critérios de classificação. o índice de validade de conteúdo (ivc) do psat foi de 0,8. demais testes de confiabilidade e validade não foram realizados. em um estudo descritivo e multicêntrico, conduzido por william et al. (24) com o objetivo de identificar e classificar as complicações da pele periestoma relacionadas ao uso de equipamentos coletores e adjuvantes, 80 estomizados foram avaliados por meio do stoma care ostomy research (scor) index. esse instrumento combina dois parâmetros: a avaliação da aparência clínica da pele e o diagnóstico da complicação. os autores definiram pele periestoma saudável como a completa ausência de qualquer diferença visível entre a pele periestoma e a pele abdominal oposta. os problemas da pele periestoma foram classificados e codificados quanto à gravidade, de leve a grave. quanto às complicações, estas foram categorizadas como alergia, ulceração, eritema, maceração/erosão e irritação. o instrumento scor não apresenta sistema de pontuação. análises psicométricas do instrumento ainda não foram publicadas. a fim de desenvolver uma abordagem uniforme para o diagnóstico e tratamento de complicações do estoma e da pele, e que fosse de fácil uso por enfermeiros não especialistas, kalashnikova et al. (51) desenvolveram um algoritmo para diagnóstico e escolha do tratamento em complicações em estomas, em 2004. os distúrbios na pele periestoma foram diagnosticados com base em observações clínicas que utilizam dois parâmetros: mudanças na cor da pele periestoma e gravidade do dano causado na pele. os autores consideraram ainda como essas condições afetam a seleção do tratamento. de acordo com a gravidade das lesões, a dermatite periestoma foi dividida em três grupos: 1) eritema, maceração, 2) vesículas, erosão e 3) úlceras. estudos de análises psicométricas do algoritmo precisam ser conduzidos. a cor é considerada um indicador importante na avaliação de danos da pele periestoma e sua gravidade, bem como na sua restauração. diante disso, sanada et al. (44) desenvolveram um estudo prospectivo para avaliar a confiabilidade e validade dos indicadores de cores que usam fotografias digitais da pele periestoma. conforme as observações clínicas da pele, índice de eritema (ei), índice de melanina (mi) e índice de hipopigmentação foram criados para representar graus aumentados de colorações vermelha, preta e branca, respectivamente, e seus valores médios foram calculados em relação aos valores da pele intacta. os índices de eritema e de melanina da pele periestoma foram significativamente maiores que os da pele intacta (p < 0,001). esse método objetivo e simples teve reprodutibilidade adequada e validade relacionada ao critério, e pode ser útil para a avaliação da pele periestoma. todos os indicadores de cor na região da base adesiva foram associados à gravidade do escore do domínio descoloração do instrumento det®score. os autores acreditam que esse método de avaliação ajudará na tomada de decisões clínica, no monitoramento e na melhoria do efeito do cuidado prestado, bem como na habilidade de avaliação de enfermeiros especializados na prática diária. comparando os instrumentos apresentados nesta revisão integrativa, podemos verificar que os autores utilizaram diferentes parâmetros de avaliação e uma variedade de nomenclaturas para classificar as complicações da pele periestoma, o que pode dificultar a escolha, pelo enfermeiro, de qual instrumento é o mais apropriado para usar na prática clínica. adicionalmente, há falta de estudos de análises psicométricas ou poucas propriedades de medida testadas nos instrumentos de avaliação aqui apresentados, o que pode justificar que, embora eles tenham sido desenvolvidos e introduzidos ao longo dos anos, nenhum deles obteve uso clínico difundido ou foi considerado universalmente aceito (33-35). como limitação deste estudo, pode-se mencionar a não obtenção de uma amostra de estudos com alto rigor metodológico e baixo nível de evidência; portanto, faz-se necessário o desenvolvimento de estudos mais robustos sobre a temática. conclusão em suma, este estudo possibilitou identificar nove instrumentos internacionais, que foram desenvolvidos com a proposta de classificar as complicações da pele periestoma. destes, apenas quatro instrumentos possuem propriedades de medidas testadas, sendo que o ost e o sacstm possuem mais estudos de adaptação cultural e validação para uso em outras línguas. é essencial que os profissionais de saúde avaliem sistematicamente, registrem e comuniquem as condições da pele periestoma, de forma consistente e padronizada. vários instrumentos de avaliação já foram desenvolvidos, mas não há consenso internacional sobre o mais adequado. os instrumentos descritos neste estu488 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 do utilizam diferentes maneiras para descrever a gravidade das complicações da pele periestoma, o que dificulta a padronização de terminologia e a comparação de resultados. a utilização de um instrumento validado para monitorar os danos na pele periestoma contribui para a sistematização da assistência ao possibilitar uma linguagem padronizada entre os profissionais. sua utilização consiste em uma poderosa ferramenta de comunicação, clara e consistente, e viabiliza a continuidade do cuidado e a melhor monitorização dos resultados alcançados. conflito de interesse: nenhum declarado. referências 1. habr-gama a, neto as, araújo sea. estomas intestinais: aspectos conceituais e técnicos. em: santos vlcg, cesaretti iur, organizadoras. assistência em estomaterapia: cuidando de pessoas com estomias. 2ª ed. são paulo: editora atheneu; 2015. p. 41-46. 2. paula pr, speranzini mb. colostomias e ileostomias. em: paula mab, paula pr, cesaretti iur, organizadoras. estomaterapia em foco e o cuidado especializado. são caetano do sul. sp: yendis editora; 2014. p. 15-32. 3. rodrigues p. estomas urinários: aspectos conceituais e técnicos. em: santos vlcg, cesaretti iur, organizadoras. 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instrumentos de avaliação das complicações na pele periestoma: revisão integrativa l maristela lopes gonçalves nunes e outro 49. harputlu d, özsoy as. turkish reliability and validity of the ostomy skin tool. j nur healthcare. 2017 [citado em 13 jun. 2018].;2(4):1-5. disponível em: https://www.opastonline.com/wp-content/uploads/2017/10/turkish-reliabilityand-validity-of-the-ostomy-skin-tool-jnh-17.pdf 50. sodhi jk, sharma p. a methodological study to develop a peristomal skin assessment tool for patients with colostomy in selected hospital, ludhiana, punjab. int j nurs educ. 2012 [citado em 20 jun. 2018];4(2):209-12. disponível em: http://web.b.ebscohost.com/ehost/detail/detail?vid=17&sid=67415270-f952-4263-bbe4-c4fdc9e17013%40pdc-v-sess mgr03&bdata=jnnpdgu9zwhvc3qtbgl2zszzy29wzt1zaxrl#db=ccm&an=104394696 51. kalashnikova i, achkasov s, fadeeva s, vorobiev g. the development and use of algorithms for diagnosing and choosing treatment of ostomy complications: results of a prospective evaluation. ostomy wound manage. 2011 [citado em 20 jun. 2018];57(1):20-7. disponível em: https://www.o-wm.com/content/development-and-use-algorithms-diagnosing-and-choosing-treatment-ostomy-complications-result https://www.opastonline.com/wp-content/uploads/2017/10/turkish-reliability-and-validity-of-the-ostomy-skin-tool-jnh-17.pdf https://www.opastonline.com/wp-content/uploads/2017/10/turkish-reliability-and-validity-of-the-ostomy-skin-tool-jnh-17.pdf http://web.b.ebscohost.com/ehost/detail/detail?vid=17&sid=67415270-f952-4263-bbe4-c4fdc9e17013%40pdc-v-sessmgr03&bdata=jnnpdgu9zwhvc3qtbgl2zszzy29wzt1zaxrl#db=ccm&an=104394696 http://web.b.ebscohost.com/ehost/detail/detail?vid=17&sid=67415270-f952-4263-bbe4-c4fdc9e17013%40pdc-v-sessmgr03&bdata=jnnpdgu9zwhvc3qtbgl2zszzy29wzt1zaxrl#db=ccm&an=104394696 https://www.o-wm.com/content/development-and-use-algorithms-diagnosing-and-choosing-treatment-ostomy-complications-result https://www.o-wm.com/content/development-and-use-algorithms-diagnosing-and-choosing-treatment-ostomy-complications-result el modelo se salud.pmd revista aquichan issn 1657-5997 148 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 abstract enduring morals through adversity and conflict use to be a challenge. notwithstanding, our compromise as integral human beings is to overcome milieu obstacles and daily ethical dilemmas. as health staff, it is our duty to take possession of the individual and social responsibility of rendering a quality nursing care. these duties are not easy to cope with, even more if we are aware of the economical, political and social elements of the health model that are definitively influencing the nursing practice. undoubtedly, enquiring about nursing duty and its consequences is a constant for ethical pondering. therefore, as moral subjects we must give raise and take advantage of debating spaces in order to assume real changing compromises, moral awareness and strengthening of the profession. as a result and as life quality guards, the general proposal and argument of the present document is to conduct actions and make decisions that, even in difficult times, safeguard the inner good of our profession: humane beings health care. key words maría eugenia molina restrepo1 * ponencia presentada en el panel el impacto del modelo de salud en la calidad del cuidado de enfermería, xvi congreso nacional de enfermería, anec, medellín, colombia. 2005. 1 facultad de enfermería, universidad de antioquia. calle 67 nº 53 -108 apartado aéreo 1226, medellín, colombia. mariaetica@hotmail.com recibido: 13 de febrero de 2006 aprobado: 11 de abril de 2006 resumen palabras clave sistema general de seguridad social en salud, cuidado de enfermería, responsabilidad individual, dignidad humana. health social security general system, nursing care, individual responsibility, human dignity. mantener los principios morales, en medio de la adversidad y el conflicto, suele ser todo un desafío. sin embargo, nuestro compromiso como seres humanos íntegros es superar las contrariedades del medio y los dilemas éticos que plantea el día a día. también nos corresponde, como personal de salud, apropiarnos de la responsabilidad individual y social de brindar cuidados de calidad en enfermería. estos deberes no son fáciles de cumplir, más cuando somos conscientes de que el modelo de salud tiene unos condicionantes económicos, políticos y sociales que influyen categóricamente en el ejercicio de la profesión. indudablemente, el cuestionamiento sobre el quehacer de enfermería y sus repercusiones es una constante para la reflexión ética. por ello, como sujetos morales, debemos generar y aprovechar espacios de deliberación con el propósito de asumir verdaderos compromisos para el cambio, la toma de conciencia moral y el fortalecimiento de la profesión. en ese orden de ideas, la propuesta y argumentación general del texto consiste en que, como benefactores de la calidad de vida, llevemos a cabo acciones y decisiones que, en medio de la dificultad, salvaguarden el bien interno de nuestra profesión: el cuidado de la salud de los seres humanos. colombian health model and nursing care quality año 6 vol. 6 nº 1 (6) 148-155 chía, colombia octubre 2006 el modelo de salud colombiano y la calidad del cuidado de enfermería. colombian health model and nursing care quality 149 introducción ara iniciar los planteamientos de este artículo se tomará, del libro la dimensión ética de la empresa de fernando savater, un fragmento titulado “ética, aún en medio del holocausto”, el cual se recomienda para la reflexión sobre el trabajo de enfermería en el actual sistema de salud y con las políticas de flexibilización laboral que equivalen a trabajar en la adversidad (1). el psicoanalista infantil bruno bettelheim cuenta en un libro muy interesante, sobrevivir, su experiencia como prisionero de un campo de concentración nazi. para la charla que nos ocupa, me gustaría referirme a esa aguda observación de bettelheim sobre los prisioneros que apenas llegaban al campo perdían o renunciaban a todos sus controles morales, pensando –como lo podía hacer cualquiera de nosotros– que la ética es un lujo para tiempos mejores, para periodos más civilizados, y que en una situación tan infernal como un campo de concentración no se podía menos que renunciar a todo uso moral y buscar exclusivamente el provecho propio como fuera posible. contrario a esa lógica, bettelheim anota que fueron precisamente todos los que así pensaron los que primero perecieron, mientras que aquellas personas que por convicciones morales o por la simple rutina de toda la vida de comportarse de una cierta manera moral, que admitían los aplazamientos y las restricciones de su propio deseo y reconocían la realidad del otro, eran los que tenían mayor posibilidad de sobrevivir. la historia narrada por bettelheim no sólo nos muestra los usos de la moral, sino la orientación práctica que ésta tiene, la experiencia vital de la cual proviene y por qué podemos recomendarla para otras actividades, incluida la empresarial (2). lo que se quiere representar con un hecho tan lamentable como el holocausto, y con los dilemas que surgieron en torno a los campos de concentración es que, pese a las difíciles circunstancias que se imponen en el contexto en el que nos concierne vivir, la moral puede y debe subsistir ante las adversidades y contradicciones del medio. nótese que cuando el panorama ha sido verdaderamente desolador, las prácticas humanas no logran, a veces, insertarse dentro de un sentido ético, y los principios morales quedan entre paréntesis; se propicia el desarrollo de prácticas para alcanzar lo que comúnmente se entiende por vida, es decir, así como en el holocausto, las personas buscan defenderse para sobrevivir, sin considerar los sentimientos ajenos o sin detenerse a pensar en los demás. nada niega la posibilidad de un compromiso moral, aunque superar las dificultades sea todo un desafío. por ejemplo, en lo que corresponde al modelo de salud, se observa como éste se centra en una economía de mercado donde se privilegian las ganancias y la rentabilidad y, en consecuencia, la salud resulta siendo un servicio que se vende y se compra, es decir, una mercancía. en colombia la salud es un bien regulado por el mercado, que excluye a sectores de la población que carecen de recursos económicos o de empleo. bajo esta perspectiva, se genera una determinada cultura corporativa u organizacional y una ética empresarial que, sin duda alguna, influye en la calidad del cuidado de enfermería, en una ética del cuidado y, por ende, en la ética del profesional. en colombia la salud es un bien regulado por el mercado, que excluye a sectores de la población que carecen de recursos económicos o de empleo. revista aquichan issn 1657-5997 150 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 la dificultad no exime de responsabilidad en ese orden de ideas, podemos deducir que un modelo de salud con una ética empresarial que no se plantea la pregunta por el ser humano y su condición, sino que simplemente concibe a las personas bajo la categoría de recurso humano o de cliente, que maximiza los recursos para generar ganancias, y cuyo discurso en salud tiene un fuerte acento economicista, amerita una profunda reflexión ética de cada persona en su condición de ser humano, de ciudadano y de profesional. “el trabajo en el mundo de la salud pone al profesional frente a muchas situaciones en las que necesita reflexionar desde la ética para discernir y aquilatar la responsabilidad moral de sus decisiones” (3). teniendo en cuenta, entonces, que el profesional de enfermería debe estar en una constante interiorización y valoración de su condición y la del medio, el modelo de salud debe suscitarle innumerables reflexiones en torno a la responsabilidad y sus variables. en este caso, cabe preguntar: ¿cómo hablar de cuidado de enfermería y de responsabilidad en el contexto que ofrece el actual modelo de salud?, ¿frente a qué y ante quiénes se establecen responsabilidades? es claro que la responsabilidad puede ser considerada bajo una dualidad de perspectivas. por una parte, está la responsabilidad individual correspondiente a la del profesional y, por otro lado, hay una responsabilidad social, colectiva o grupal que se relaciona con las entidades del sistema general de seguridad social en salud, las entidades promotoras de salud (eps), las instituciones prestadoras de servicios de salud (ips), el gremio, los trabajadores de salud, el estado y la sociedad. al respecto, victoria camps apunta que “las acciones y decisiones moralmente relevantes, raramente son atribuidas a un solo individuo” (4). en esa medida, y de acuerdo con estas palabras, se puede afirmar que la acción individual cuenta con una cadena de insospechados precedentes, repercusiones e interrelaciones sociales que nos conducen a pensar que la responsabilidad del sujeto moral se articula, también, a la perspectiva colectiva. a propósito de esta visión de las interconexiones, la autora se pregunta: “¿cómo responder de algo que siempre está conectado con otras muchas cosas y cuyo sentido global inevitablemente se nos escapa?” (4). para el propósito de este artículo, me permito retomar el anterior interrogante para ajustarlo a la reflexión sobre el modelo de salud: ¿cómo responder por el cuidado de enfermería que siempre está conectado con otras muchas cosas y cuyo sentido global inevitablemente se nos escapa? de acuerdo con estos cuestionamientos, es necesario pensar no sólo en la responsabilidad del profesional de enfermería como individuo en el cuidado de los seres humanos, sino también en la vinculación o compromiso de otros aspectos que intervienen en el contexto de la salud, la cual no debe ser reducida a simples relaciones clínicas o de dedicación profesional. con esto se ratifica la idea de que ahora hay que hablar de enlaces y proximidades, en tanto la oposición del mundo al individualismo nos exige concebir la responsabilidad más allá de la simple censura o el señalamiento por culpabilidad a un individuo. si nos referimos de forma más específica a lo que atañe al modelo de salud, decimos que “además del médico y el paciente, están las enfermeras, la administración hospitalaria, los proveedores farmacéuticos, los familiares del paciente y una constitución política que obliga a hacernos responsables de unos derechos fundamentales entre los cuales está la protección de la salud” (4). la responsabilidad en el cuidado de enfermería no puede atribuirse sólo al cuidador, también es pertinente examinarla en el marco institucional y en el sistema de salud. generalmente, la responsabilidad institucional y del sistema suele diluirse y, en este caso, no se trata sólo los problemas clínicos como tales, sino de la responsabilidad moral que entra en juego y que rara vez se concatena. como el desarrollo del texto lo sugiere se trata, entonces, de propiciar un espacio para la reflexión sobre la responsabilidad individual y colectiva en la prestación del cuidado de enfermería. es comprensible que existan disensiones sobre el tema y es, precisamente por ello, que se plantean nuevos cuestionamientos que alimenten el debate y abran nuevas perspectivas, discursos y enfoques. una vez el lector se identifique con la posición de relacionar el individuo con la colectividad o, por el contrario, tenga puntos de desacuerdo con el tema, aspiro a dejar varios interrogantes con la firme convicción de que sólo mediante la pregunta se generan nuevas vías de discernimiento. de manera concreta, y aludiendo reiteradamente al tema que nos une, cabe responder a la pregunta: ¿cuál es la responsabilidad del profesional de enfermería en el sistema general de seguridad social en salud? el modelo de salud colombiano y la calidad del cuidado de enfermería. colombian health model and nursing care quality 151 la inquietud sobre el papel del profesional surge teniendo en cuenta las experiencias de cuidado que relatan colegas, personal de salud o pacientes sobre la situación que se vive en las instituciones, más cuando el marco legislativo, específicamente la ley 100 de 1993, impone limitaciones que, si se piensan en forma simplista, se podrían atribuir a las carencias del sistema general de seguridad social en salud. pero si consideramos cuál es el fin o bien interno de la profesión de enfermería,2 que le da pertinencia y legitimidad social, se deduce que pese a las dificultades materiales y morales o los dilemas éticos, “aún en medio del holocausto”, es responsabilidad del profesional de enfermería brindar un cuidado de calidad a los seres humanos sanos y enfermos, individuos, familias y colectivos. la idea de ser humano en el cuidador hablar de cuidado implica algo más que brindar asistencia clínica, se trata también de relacionarse con la persona necesitada de cuidados desde otras perspectivas, pues “el cuidado de enfermería no es un acto sencillo y habitual, característico del cuidado como actividad humana, la forma organizada de cuidar constituye una disciplina humanística y sanitaria que utiliza conocimientos científicos naturales, sociales y de conducta” (5). las consideraciones anteriores ponen de manifiesto que para brindar un cuidado de calidad humana y técnica, es preciso tener claridad y criterios para respondernos de manera integral qué idea de ser humano tenemos. en lo que concierne a la concepción de humanidad, josé luis aranguren, filósofo español, destaca que los comportamientos que se lleven a cabo con los seres humanos derivan de la idea de ser humano que se tiene (6). según esta afirmación, debemos clarificar y precisar cuál es la idea de ser humano que tenemos en nuestra condición de ciudadanos, de cuidadores, de profesionales en asistencia, docencia e investigación. para ello, partimos de la idea de ser humano digno, en términos de inmanuel kant, con una dignidad ontológica o inherente a todos los seres humanos por su condición de humanidad y, por ello, todos los seres humanos deben ser considerados fines en sí mismos y no sólo medios (7). este asunto es explicado, por este último filósofo mencionado, cuando asevera que “el ser humano no tiene precio porque no puede ser sustituido por algo equivalente. el hombre es persona y, en cuanto tal, tiene dignidad porque tiene un valor intrínseco” (7). el concepto de dignidad humana se refleja en el respeto a la autonomía o a la libertad de autodeterminación de los seres humanos, según su proyecto de vida, considerados fines en sí mismos. así, hay respeto a la dignidad humana al evitar los riesgos y maximizar los beneficios en la interacción con los sujetos de cuidado. es tan importante este concepto que se constituye en la base, en la piedra angular, de muchas propuestas éticas posteriores, y fundamenta los derechos humanos, entre ellos, el derecho a la salud. por esto, si al sujeto de cuidado lo consideramos como un ser humano digno por su condición de humanidad y, por tanto, sujeto de derechos, la salud se considera como un derecho humano para todas las personas sin distingo la responsabilidad en el cuidado de enfermería no puede atribuirse sólo al cuidador, también es pertinente examinarla en el marco institucional y en el sistema de salud. 2 según la naturaleza filosófica de la profesión de enfermería, y los modelos conceptuales que proporcionan su fundamentación, la definición de la enfermería es asistir al individuo en actividades tendientes a su salud; en esa medida, el bien interno de la profesión es el cuidado, aspecto que se ratifica con la práctica. para ampliar estos conceptos es necesario revisar algunos autores que han aportado valiosas teorías en la construcción filosófica de la profesión. revista aquichan issn 1657-5997 152 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 de raza, sexo, nacionalidad, credo, condición social, económica y de prestación de servicios de salud. de esta manera, me apropio de las palabras de aranguren para que reflexionemos sobre la idea de ser humano que se desarrolla en el contexto del sistema general de seguridad social en salud, ley 100 de 1993. cuando se acude a las instituciones del sistema de salud, la primera pregunta de rigor para el paciente es: ¿cuál es su eps? a continuación, se le solicita el carné y, acto seguido, se le verifican sus datos en el sistema para, finalmente, confirmarle o no su estado de afiliación o de registro; de esto depende que quien amerite el servicio sea o no atendido. esta situación, típica de nuestro sistema, hace pensar que la salud se compra y se vende según la capacidad adquisitiva o de pago, por eso la calidad en la prestación de la misma obedece a una categorización de la persona frente al tipo de servicio. por ejemplo, las condiciones varían si es un paciente que sufraga todos los gastos –como ocurre con la medicina privada y prepagada– o que tiene un plan obligatorio de salud (pos), contributivo o subsidiado o si, por el contrario, no está afiliado al sistema. ¿qué idea de ser humano tiene el sistema general de seguridad social en salud, cuando la prestación de servicios depende del tipo de afiliación de las personas? ¿será que para el sistema, el ser humano equivale a un carné de afiliación, a una cotización, a una factura por los servicios prestados para que luego se pueda cobrar a la entidad correspondiente? si en este sistema la salud fuera un derecho humano tendría el carácter de universalidad, “es decir, para todas las personas sin ningún tipo de distinción. ello implica que todos los componentes que permiten la preservación de la salud y la curación de la enfermedad deben ser accesibles a todos”, en condiciones de igualdad, gratuidad y equidad, eliminando las barreras económicas, sociales, culturales y de otro orden que permitan el acceso universal a la salud como derecho (8). somos conscientes de las condiciones y limitaciones del sistema, y no por eso se plantea la propuesta de adaptarnos con simpleza a las circunstancias; en tanto, el deseo es seguir otorgando prioridad a la calidad y ética en el servicio. la invitación es para que cada uno se visualice en una institución de salud recibiendo un servicio y piense que, independientemente de las condiciones del sistema, espera que, con agrado, sus situaciones de salud o de enfermedad impliquen para el personal de salud un verdadero compromiso en la calidez y el respeto; generalmente, eso es lo que espera cualquier paciente y su familia. no olvidemos que la esencia de la práctica de enfermería, o el bien interno de la profesión, “consiste ante todo en cuidar con calidad, desarrollando al máximo los hábitos, las actitudes y las virtudes que resulten necesarias” (9) para proporcionar cuidados por un ser humano a otros seres humanos, con conocimiento, sensibilidad y compasión. el sufrimiento, una visión desde el cuidado los diversos entornos laborales y campos de acción, y la coyuntura social, política y económica que constantemente varía son, sin duda alguna, factores que inciden sustancialmente en la convicción del cuidador para brindar cuidados de calidad. algunos de los aspectos que más influyen en el cuidador son: las condiciones salariales o el tipo de contratación, la complejidad creciente de los pacientes, la disminución cuantitativa y cualitativa del personal, la disponibilidad de equipos y materiales, la autonomía en el ejercicio profesional, la oportunidad, continuidad y el grado de satisfacción que tengan los pacientes, las familias y los allegados con la prestación de los servicios de salud. como puede notarse, actualmente hay un predomino de la perspectiva económica en la prestación de servicios de salud, ello representa mayores exigencias y nuevos desafíos. en las actuales condiciones de vida y el difícil contexto que caracteriza nuestro país, de alguna manera sufrimos como cuidadores, como personal de salud. lo que hay que tener en cuenta es que “sufrir no da razón”, así también lo argumenta un filósofo español, javier marías, cuando menciona que “hay una idea muy extendida y perjudicial según la cual el sufrimiento posee un efecto “limpiador”, ennoblece y hasta dispensa una garantía de inocencia al sufridor” (10). en nuestro caso, como cuidadores, no debe ocurrir igual, pues aunque las condiciones nos apesadumbren o representen algún sufrimiento, y las circunstancias nos sean desfavorables, ello no nos exime de responsabilidad, pues no por ser víctimas tenemos siempre la razón, ni la tenemos en todo, ni tan siquiera serlo nos convierte en buenas personas. para nadie es un secreto que sufrir es una condición inmanente a la naturaleza humana, aún así nuestro reto es asumir, a pesar de todo lo adverso, una posición valiente3 para no hacer sufrir al sujeto de cuidado, para no dar un cuidado de mala calidad o para no privar del cuidado de enfermería. 3 en términos de pellegrino, citado por torralba, equivale a la virtud del coraje necesario para poder desarrollar la actividad de un modo óptimo. el modelo de salud colombiano y la calidad del cuidado de enfermería. colombian health model and nursing care quality 153 así como en el ejercicio de la enfermería ocurren situaciones que nos remiten a pensar que el sufrimiento y los variados inconvenientes del cuidador pueden terminar por afectar al paciente, voluntaria o involuntariamente, así mismo ocurre en otras realidades y en otros escenarios donde el sufrimiento pasa inadvertido sin despertar mayor conmoción; tal y como lo observamos en la cotidianidad de las calles, los hospitales, las comunidades menos favorecidas o, en general, con las problemáticas sociales que exponen los medios de comunicación. al respecto puede mencionarse el caso de un fotógrafo sudafricano llamado kevin carter, quien en 1993 fue a fotografiar la hambruna en sudán. en el poblado de ayod tomó la foto de una bebé moribunda que se arrastraba al único sitio donde había comida, mientras en un cercano segundo plano la espera un buitre tres veces más grande que ella. pese a que el periodista ganó el pullitzer, su vida terminó a los 33 años en el suicidio debido a la angustia que le generaron las críticas por limitarse a hacer su trabajo de expectante sin hacer algo por la pequeña. entre las críticas que recibió se decía que carter hubiese podido ayudar a la niña antes de hacer clic (11).4 así como el fotógrafo pasó indiferente ante una situación de sufrimiento, de igual manera nos puede suceder como cuidadores reducidos al quehacer sin ponernos, aunque sea momentáneamente, en el lugar del otro, sin hacer conciencia del dolor y del sufrimiento para contrarrestarlos, y sin comprometernos, desde la solidaridad y la compasión, en la ayuda. si la solidaridad es una tarea de compartir y de ayuda, y la compasión consiste en asumir como propio el sufrimiento ajeno, para los y las cuidadoras es preciso dar un paso más allá. en otras palabras, nos corresponde hacer algo para evitar el “suicidio” como profesionales y como gremio, para superar el “muro de las lamentaciones” y las quejas de la cafetería y el pasillo, para pasar de la preocupación a la ocupación, a la denuncia y a la acción. a fin de ejercer estas actividades es necesario el desarrollo de actitudes para el trabajo en grupo y el fortalecimiento del gremio en torno al fin de la profesión de enfermería. el cambio: ¿qué hacer para dar un paso más allá? sara fry habla de la cooperación como …una actitud que incluye la participación activa con otras, a fin de obtener una atención de calidad para los pacientes, la colaboración en la planificación de enfoques hacia los cuidados de enfermería y la reciprocidad con aquellos con los que se identifican profesionalmente los enfermeros. la cooperación promueve redes de apoyo muto y estrechas relaciones de trabajo. el concepto de cooperación preconiza actividades de enfermería tales como la colaboración con los demás para alcanzar objetivos comunes, el cumplimiento de promesas, la prioridad de los intereses mutuos y el sacrificio de los intereses personales al mantenimiento de la relación profesional a largo término (12). también se propone que ante la visión sombría que se tenga de las situaciones, se pueda ver la realidad bajo otras miradas, adoptando una actitud de compromiso para hacer cambios, por pequeños que parezcan, que si se van sumando llegarán a ser significativos. bien sabemos que lo que pasa siempre no es lo que únicamente puede si la solidaridad es una tarea de compartir y de ayuda, y la compasión consiste en asumir como propio el sufrimiento ajeno, para los y las cuidadoras es preciso dar un paso más allá. 4 resumen de una descripción a la que hace referencia una página de la internet, especializada en reportajes gráficos. revista aquichan issn 1657-5997 154 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 pasar, y cuando contemplamos el mundo y lo describimos, hay que ir más allá hasta transformarlo. dicha transformación comienza con asuntos que sí tenemos al alcance, pues desde nuestra posición podemos mover así sea un poco a la opinión pública y llamar la atención sobre el problema. complementariamente, es necesario escribir: describir los hechos y dejar constancia de ello en los medios de comunicación, en publicaciones especializadas y en los organismos de dirección del sistema, de las eps, ips y de los gremios. lo que se pretende es que el adquirir conciencia de una determinada situación implique, además, ponerse el reto de plantear soluciones para mejorar; por ello también es oportuno propiciar espacios para la reflexión como los foros y conversatorios intraprofesionales e interprofesionales con personas de las áreas de docencia, investigación y asistencia, con el propósito de lograr un mayor acercamiento de la teoría y la práctica, hacer visible el cuidado de enfermería y la necesidad de un cuidado de enfermería de calidad, tener profesionales excelentes en el cuidado y el trabajo en grupo, como equipo de salud y como gremio de enfermería. nos quedan otras alternativas como fortalecer a los individuos y a los colectivos en los aspectos físicos, sociales y psicológicos para ayudar a afianzar en ellos la autonomía y el autocuidado, el conocimiento de sus derechos en salud y de los medios para reclamarlos y hacer uso de ellos. además, repetir y hacer realidad, en cada uno y una, las palabras de virginia henderson, “si hoy escribiera sobre enfermería, pondría más énfasis en la necesidad de asistencia universal y en la preparación de los ciudadanos para valorar sus necesidades y poder ayudarse a sí mismos de forma eficaz. insisto en que la atención sanitaria es un asunto político” (13). tenemos que empoderarnos de nuestra profesión, de nuestros derechos y deberes, con el fin de poder llegar a hacer realidad la salud como un derecho humano. volvernos solidarios y cómplices con las personas a quienes atendemos en sus experiencias de salud y enfermedad, en vez de seguir viéndolas y tratándolas como extrañas, como la otra cara de la moneda. así, desde la solidaridad, buscar espacios para la palabra, para romper el silencio, para escuchar, para reconocer la dignidad humana, la autonomía y el saber del otro. se trata de llevar a cabo una práctica que preserve, por encima de todo, los derechos de las personas, que promueva el reconocimiento de la salud como un derecho humano, y que abogue para que las personas reciban los servicios del sistema de salud. las apreciaciones anteriores de propender por una actitud comprometida en el cuidador se resumen así: asumir el reto no sólo de ser un buen enfermero o enfermera, sino además un enfermero o enfermera buena. la historia de la humanidad ha mostrado que siempre hay una opción para la dignidad cuando un pueblo o un grupo se unen, para ello necesitamos identidad profesional, voluntad de hacerse cargo y vocación que, en términos de arroyo, “es la sensibilidad suficiente como para dejarse impactar por el bien interno de la profesión, el cuidado de los seres humanos vulnerables que tienen necesidades, dolor y sufrimiento” (14), y actuar en consecuencia. conclusiones las particularidades del modelo de salud colombiano suscitan varios cuestionamientos en la construcción reflexiva de un discurso ético sobre el cuidado de enfermería. es innegable que la mirada economicista del mundo recae sobre la calidad de vida de las personas e incluso tiene incidencia en los aspectos más íntimos de nuestras vidas. el entorno de la salud no es la excepción o no se libra de esta visión, por el contrario, las instituciones del sistema general de seguridad social en salud adoptan políticas restrictivas acordes con el modelo de prestación de servicios, cuestión que es de conocimiento común no sólo por lo que nos pueda corresponder como cuidadores, sino que nuestra condición de seres humanos nos exige tener constantemente la experiencia como sujetos de cuidado. en las condiciones propias del modelo de salud es perentorio que los profesionales del área reflexionen en torno a su grado de responsabilidad frente a las prácticas de cuidado, pues aunque la prestación de servicios de salud cuenta con un marco legal que especifica sus requerimientos, ello no exime al personal de salud de brindar un cuidado de calidad y de preservar su compromiso ético de cuidar a los seres humanos con conocimiento, sensibilidad y compasión. el panorama actual representa, entonces, mayores exigencias y nuevos desafíos, y es innegable que frente a las situaciones que vivencia la sociedad, el cuidador como ser humano también sufre. sin embargo, la diferencia radica en que las circunstancias desfavorables no pueden ser una justificación para menoscabar los principios éticos del el modelo de salud colombiano y la calidad del cuidado de enfermería. colombian health model and nursing care quality 155 1. romero mn. resistencia en la adversidad: cuatro compromisos desde la docencia. en: memorias xvi congreso nacional de enfermería; 2005. julio 27-30; medellín: asociación nacional de enfermeras de colombia. cd-room. 2. savater f. la dimensión ética de la empresa. santafé de bogotá: siglo del hombre; 1998, pp. 25 y 26. 3. asociación peruana facultades y escuelas de enfermería. enfermería formación ética para la vida. lima: imprenta propaceb; 1999. 4. camps v. una vida de calidad: reflexiones sobre bioética. barcelona: ares y mares; 2001, p. 194. 5. aponte a, molina me. del significado del cuidado en la práctica de enfermería [tesis de grado maestría en filosofía con énfasis en ética.] medellín: universidad pontificia bolivariana. facultad de ciencias eclesiásticas; 2004, p. 21. 6. aranguren jl. ética. barcelona: altaya; 1994, p. 54. 7. kant i. fundamentación de la metafísica de las costumbres. méxico: porrúa; 1996, p. 47. ejercicio de enfermería. para sobrepasar los límites de la conformidad o los estados de lamentación con las situaciones adversas que se viven en el ámbito de la salud, es referencias necesario proponer alternativas enfocadas a despertar un mayor grado de conciencia para hacer realidad, o al menos posibilitar, la asistencia universal con el reconocimiento de la dignidad y el saber, en nosotros y en los demás, pues siempre existen otras opciones, tal y como ocurrió en medio del holocausto. 8. paredes n. derecho a la salud: su situación en colombia. bogotá: cinep; 2003, pp. 50-71. 9. arroyo mp, cortina a, torralba mj y zugasti j. ética y legislación en enfermería. madrid: mcgraw-hill; 1998, p. 64. 10. marías j. sufrir no da razón. diario el país, sl. en: el colombiano 2005, 3 de julio; sección g “generación”, p. 3. 11. fernández h. everything must go [sitio en internet] cinemanía musicalia. disponible en: http:// www.lahiguera.net/musicalia/artistas/manic_street_ preachers/discoh/61/. [acceso el 29 de agosto de 2005]. 12. fry s. conceptos éticos en la práctica de enfermería. en: la ética en la práctica de enfermería: guía para la toma de decisiones éticas. ginebra: consejo internacional de enfermería; 1994, pp. 53 y 54. 13. henderson v. la naturaleza de la enfermería: reflexiones 25 años después. barcelona: mcgraw-hill; 1994, p. 33. << /ascii85encodepages false /allowtransparency false /autopositionepsfiles true /autorotatepages /all /binding /left /calgrayprofile (dot gain 20%) /calrgbprofile (srgb iec61966-2.1) /calcmykprofile (u.s. web coated \050swop\051 v2) /srgbprofile (srgb iec61966-2.1) /cannotembedfontpolicy /warning /compatibilitylevel 1.4 /compressobjects /tags /compresspages true /convertimagestoindexed true /passthroughjpegimages true /createjdffile false /createjobticket false /defaultrenderingintent /default /detectblends true /detectcurves 0.0000 /colorconversionstrategy /leavecolorunchanged /dothumbnails false /embedallfonts true /embedopentype 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/untaggedcmykhandling /leaveuntagged /untaggedrgbhandling /leaveuntagged /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 415 mónica muñoz-serrano1 claudia uribe-torres2 luiza hoga3 padre preparado y comprometido en su rol de acompañante durante el proceso de parto 1 orcid.org/0000-0001-9104-3687. escuela de enfermería, pontificia universidad católica de chile, chile. mmunozse@uc.cl 2 orcid.org/0000-0002-0699-7695. escuela de enfermería, pontificia universidad católica de chile, chile. curibet@uc.cl 3 orcid.org/0000-0002-6433-5307. escola de enfermagem, universidade de são paulo, brasil. kikatuca@usp.br recibido: 24/08/2018 enviado a pares: 07/09/2018 aprobado por pares: 23/10/2018 aprobado: 09/11/2018 doi: 10.5294/aqui.2018.18.4.4 para citar este artículo / to reference this article / para citar este artigo muñoz-serrano m, uribe-torres c, hoga l. padre preparado y comprometido en su rol de acompañante durante el proceso de parto. aquichan. 2018; 18(4): 415-425. doi: 10.5294/aqui.2018.18.4.4 resumen objetivo: identificar las necesidades de preparación del padre acompañante para brindar apoyo a su pareja durante el proceso de parto. método: metodología cualitativa: investigación-acción con la participación de doce padres y sus parejas, con quienes se exploraron las necesidades educativas por medio de grupos focales y entrevistas estructuradas. se desarrolló, implementó y evaluó la preparación antenatal del padre en su rol de acompañante durante los años 2015 y 2016. resultados: una expectativa que se constituyó en un gran tema emergente fue “conocer más acerca del proceso de parto” y “estar ahí con ella y para ella”, como beneficio para su rol de acompañante preparado y sensible a las necesidades de la mujer. conclusión: es indispensable considerar estrategias que fortalezcan el rol del padre y aumenten sus competencias para la integración, empoderamiento y acompañamiento durante el proceso de parto. palabras clave (fuente: decs) educación prenatal; nacimiento; parto; padre; apoyo social; investigación-acción; investigación en servicios de salud. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 415-425 temática: promoción y prevención. aporte a la disciplina: al conocer los esfuerzos por mejorar la calidad asistencial en el proceso de parto, cuando se trata de implementar acciones de promoción de la salud que se perpetúen en el tiempo, ocurre que un proceso relativamente simple y fisiológico muchas veces se transforma en algo complejo en su abordaje. el estudio a través de la investigación-acción permite desarrollar un trabajo de sistema, ya que mediante intervenciones complejas e integradoras, se promueve la comprensión del beneficio de la participación, la motivación y el compromiso para llevarla a cabo. desde la mirada sistémica, es imprescindible la participación comprometida de los distintos actores (el padre, la madre y el equipo de salud) porque permite la promoción de acciones con miras al desarrollo de una paternidad saludable y, en consecuencia, de familias comprometidas con sus hijos y con su crianza. algunas iniciativas actuales de preparación de los padres para el parto y para el nacimiento se han focalizado en las necesidades de la madre y de su hijo para tener una maternidad segura y con bienestar. para esta última década, el desafío es involucrar al padre en el nacimiento de manera efectiva. http://orcid.org/0000-0001-9104-3687 http://orcid.org/0000-0002-0699-7695 http://orcid.org/0000-0002-6433-5307 http://dx.doi.org/10.5294/aqui.2018.18.4.4 http://dx.doi.org/10.5294/aqui.2018.18.4.4 416 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 415-425 fathers prepared for and committed to their role as companions during the birth process abstract objective: to identify fathers’ needs in their preparation as a companion to provide emotional support to mothers during childbirth. materials and methods: an action research project was carried out involving twelve men and their wives. their educational needs were explored using focus groups and structured interviews during 2015 and 2016. results: the main emerging themes were “knowing more about the birth process” and “being there with her and for her” as benefits that contribute to the role of a sensitive companion prepared to understand the woman’s needs. considering one of the major emerging themes, antenatal training for fathers as companions and support during childbirth was developed, implemented and evaluated. conclusion: it is essential to consider different strategies to strengthen the father’s role by increasing their skills for integration, empowerment and support during birth, and to enhance their satisfaction in meeting the needs felt in a family birth scenario. keywords (source: decs) prenatal education; childbirth; parturition; fathers; social support; action research; health services research. 417 padre preparado y comprometido en su rol de acompañante durante el proceso de parto l mónica muñoz-serrano y otros pai preparado e comprometido em seu papel como acompanhante durante o processo de nascimento resumo objetivo: identificar as necessidades de preparação do pai acompanhante para oferecer suporte e continência para a sua parceira durante o processo de parto. método: trata-se de uma metodologia qualitativa de pesquisa, que contou com a participação de 12 pais e suas parceiras, com os quais foram exploradas as necessidades educativas, por meio da utilização de técnicas de grupo focal e entrevistas estruturadas. foi desenvolvida, implementada e avaliada a preparação pré-natal para o desempenho de seus papéis de acompanhante durante 2015 e 2016. resultados: expectativas que se constituíram como grandes temas emergentes foram “conhecer mais sobre o processo de parto” e “’estar aí’ com ela e para ela” como benefícios para seus papéis de acompanhantes preparados e sensíveis às necessidades da mulher. conclusão: é indispensável considerar estratégias que permitam relevar o papel do pai, aumentando suas competências para a integração, empoderamento e acompanhamento durante o processo de parto, para promover a satisfação da necessidade sentida de um genuíno nascimento em família. palavras-chave (fonte: decs) educação pré-natal; nascimento; parto; pai; apoio social; pesquisa ação; pesquisa sobre serviços de saúde. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 415-425 418 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 introducción con el objetivo de alcanzar el cuidado integral del nacimiento, el desafío hoy, en el mundo, es considerar e involucrar al padre en el nacimiento de su hijo, para que este se constituya en un participante activo, tanto en el apoyo a la mujer y contención materna durante el nacimiento (1), como en acciones de promoción de vinculación con su hijo recién nacido (2). el modelo actual de atención, principalmente en latinoamérica, considera las prácticas de participación paterna de una manera hegemónica y directiva, con escasa o nula preparación previa, lo que puede generar situaciones de estrés y ambivalencia emocional en los varones (3). la preparación requerida para promover los cambios en la actitud de los padres está distante de lo que puede aportar la intervención de la salud tradicional, en la que la educación se transfiere de forma vertical y los participantes asumen un rol pasivo (4). asimismo, algunos autores han hecho explícita la recomendación de desarrollar propuestas de intervenciones especiales para los padres (5-7). esta preparación dirigida al acompañamiento y soporte de la mujer para el parto aparece en los estudios reportados como una necesidad de preparación elemental y prioritaria (5, 8-10). no obstante, el padre continua siendo visibilizado en un lugar secundario y pasivo, como espectador del parto de la mujer (10), y, por ende, cuando este manifiesta sus demandas, las plantea para cumplir ese rol a partir de las necesidades maternas (6, 10, 11). un verdadero rol de acompañante, para “ayudar a parir” o “parir junto a su mujer” (7, 12), debe enmarcarse desde la satisfacción que se genera en el padre acompañante cuando siente que ha sido útil al brindar apoyo físico para el alivio del dolor, así como fuerzas a la mujer, todo desde una experiencia particular e individual como padre-acompañante y con roles bien definidos (2). la realidad chilena aún muestra un escenario precario respecto a la inclusión paterna efectiva en el proceso de nacimiento (13). aunque las políticas de protección a la primera infancia han promovido la participación paterna desde la gestación, los padres no han mostrado la adherencia esperada durante el periodo de gestación y nacimiento (14); aquellos más jóvenes y con mayor nivel de educación son los más involucrados en el proceso reproductivo y de paternidad (13). podría pensarse que los procesos educativos de preparación para el parto dirigidos a las madres no son los indicados para mantener motivados a los padres (9), o que las metodologías utilizadas no son las adecuadas para las necesidades de aquellos. en virtud de lo señalado, el objetivo de este estudio es explorar las necesidades educativas de los padres para implementar una preparación prenatal acorde a sus expectativas de participación en el parto y el nacimiento. este artículo considera todo el proceso de investigación-acción (ia) que emerge de una de las categorías relacionadas con la participación de los padres en su rol de acompañante. material y método durante el periodo 2015-2016, se condujo un estudio de naturaleza cualitativa, a través del proceso de ia, vinculado a una tesis de grado del programa de doctorado inter-unidades entre dos prestigiosas universidades de la región. el propósito de utilizar la ia, sustentada en el paradigma crítico (15), fue explorar las necesidades de preparación antenatal y modificar la realidad de los participantes varones. de este modo, se desarrolló un proceso de ia en sus tres fases: exploratoria, de intervención y de evaluación, por medio de grupos focales (dos para la fase exploratoria, uno para la intervención y uno para la evaluación, cada uno de aproximadamente setenta minutos de duración). las tres fases de la ia conducidas por las investigadoras cumplieron con los tres objetivos de esta metodología: conocer la realidad de los participantes y levantar los temas generativos (fase exploratoria); implementar la preparación con sesiones educativas (detalladas conforme al rigor científico de la ia en la sección de resultados) (fase de intervención), y validar la intervención en conjunto investigador-participante (fase de evaluación). todo el proceso de investigación fue continuo, durante un año aproximadamente, y se llevó a cabo en una red de salud de la ciudad de santiago de chile (zona metropolitana). esta red abarca un sistema mixto de salud, dispuesto en dos ubicaciones geográficas de la ciudad, para atender a dos segmentos de la población de distinto nivel socioeconómico. uno de ellos corresponde al sistema público (institucionalizado); el otro, al sistema privado de atención. la captación de los participantes correspondió a la atención prenatal en ambos centros ambulatorios de esa red de atención, sin que existiera un vínculo previo entre los investigadores y los participantes. estos accedieron a información previa del estudio por medio de afiches donde se describían el propósito y más detalles de la investigación. los interesados se contactaron por medio de correo electrónico y teléfono con las investigadoras. 419 padre preparado y comprometido en su rol de acompañante durante el proceso de parto l mónica muñoz-serrano y otros participantes el grupo estuvo constituido por doce varones acompañantes de mujeres embarazadas: cinco provenientes del sistema privado, y siete provenientes del sistema público institucionalizado de atención, según un criterio de selección muestral por propósito (16). los criterios de inclusión fueron: ser adulto; tener una pareja mayor de edad que esté cursando un embarazo fisiológico de tercer trimestre al ingreso del estudio; tener acceso a los servicios de la red de salud. el total de participantes se distribuyó en cuatro subgrupos de preparación de 2-3 varones, conforme a su incorporación según la edad gestacional. del primer subgrupo, surgió la necesidad de incluir en el estudio a sus parejas embarazadas como acompañantes, lo que obligó, en consonancia con el paradigma crítico y participativo, a enmendar el estudio e incluir opcionalmente la participación de aquellas. esta alternativa se replicó de manera voluntaria en los subgrupos siguientes. finalmente, se conformó un grupo total de doce participantes varones y once embarazadas, quienes accedieron a participar luego del proceso y firma del consentimiento informado. protección de la identidad y confidencialidad de la información todo encuentro, desde la fase exploratoria hasta las de evaluación y cierre, fue grabado en modalidad de audio mp3 y transcrito textualmente. a esto se agregaron las notas de campo y los contenidos de los cuestionarios semiestructurados. se utilizaron nombres de fantasía para proteger la identidad de los participantes: de jugadores de futbol para los varones participantes del sistema privado, y de colores para el grupo del sistema público institucionalizado. todos los procedimientos de investigación fueron desarrollados conforme a la resolución 466 de 2012 do conselho nacional de saúde do brasil y de la ley 20.120 de regulación de la investigación biomédica en chile. se contó, por lo tanto, con la aprobación de los comités éticos científicos universitarios de brasil y de chile. resultados los resultados detallados a continuación responden a la exploración de la realidad de los participantes y al análisis sistemático de la información de todas las fases de la ia. la figura 1 muestra la fuente de los resultados obtenidos del proceso, particularmente de la identificación del tema-generativo referido en este artículo (rol de acompañante), el cual, al cumplir con el criterio de rigor de confirmabilidad, fue enviado y validado por cada participante. las características sociodemográficas de los padres varones que participaron del proceso de ia se detallan en la tabla 1. respecto a la edad de los varones, el promedio del total de los participantes fue de 32 años. al observarlos por grupo, el promedio de edad en el sistema privado fue de 32 años, mientras que en el grupo del sistema institucionalizado fue de 36 años, al considerar las edades extremas de 23 y 54 años, respectivamente. sobre el nivel de escolaridad, se observa una clara diferencia: el nivel de formación de los participantes del sistema privado de la red de salud es mayor. otro aspecto por destacar es la poca frecuencia de padres con experiencia previa de ser padres: solo tres participantes del total del grupo habían tenido hijos y presencia en el nacimiento. fase exploratoria de la investigaciónacción: comprensión de la realidad los resultados de esta fase surgieron en torno a la reflexión y a las dinámicas desarrolladas en los grupos focales. de este modo, a partir de una dinámica, se generó el concepto de participación, al responder a la pregunta: “para mí participar del nacimiento de mi hijo significa/ha significado…”, mientras que desde la reflexión de los participantes varones, se levantaron las expectativas de participación en su rol de acompañante: “me gustaría”, “yo espero”, “yo quiero”. el significado de la participación se relacionó con la oportunidad de estar presentes para acompañar y dar soporte efectivo al bienestar de su pareja, especialmente durante el trabajo de parto: “participar es estar ahí en el acontecimiento, por ella y para ella”. los participantes expresaron el deseo de estar presentes y de no quedarse fuera del “acontecimiento”, de ese momento maravilloso, en el que podrían acompañar a su pareja y ayudar en lo que se pueda: “estar presente de todas maneras. quiero estar acompañando a mi señora. creo que es importante estar en ese momento y no estar aislado del acontecimiento porque en verdad es un acontecimiento” (pinilla). “estar ahí también acompañando a mi esposa porque es un momento, al fin y al cabo, maravilloso y de los dos. quiero estar ahí y ayudarla en lo que pueda” (messi). 420 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 figura 1. fuentes de resultados del proceso investigación –acción tabla 1. participantes por grupos y características sociodemográficas participante edad nacionalidad escolaridad previsión situación de pareja sistema privado *vidal 34 chileno educación superior isapre casado *medel 35 chileno educación superior isapre casado *sánchez 29 chileno posgrado isapre casado *pinilla 32 chileno educación superior isapre casado *messi 30 argentino educación superior isapre casado sistema público institucionalizado *rojo 23 chileno educación media isapre soltero *marrón 39 chileno técnico profesional isapre casado *calipso 27 chileno educación media fonasa soltero *jade 45 chileno técnico profesional fonasa soltero *gris 54 chileno educación media fonasa casado *sepia 35 chileno técnico profesional fonasa soltero *dorado 31 chileno técnico profesional fonasa soltero fuente: elaboración propia. fuente: elaboración propia. comprensión de la realidad. rol de acompañante significado de la participación expectativas de participación fase exploratoria tema generativo "un mundo desconocido": necesidad de los padres de conocer más acerca del proceso de parto fase intervención competencias para el saber competencias actitudinales "ser" competencias para el hacer fase de evaluación conocimiento sobre el proceso sensación de seguridad herramientas de apoyo y contención 421 padre preparado y comprometido en su rol de acompañante durante el proceso de parto l mónica muñoz-serrano y otros participar es estar ahí, por ella y para ella, de distintas formas en sus narrativas, los padres atribuyeron a la participación un sentido de acompañamiento y la manifestación de apoyo físico y emocional: “dando apoyo emocional, con ciertas palabras que se pueden ocupar, masajes, hacerle cariño, cosas así. siempre dijeron que era muy bueno para que la mujer también se relajara” (rojo). “estar cuando tiene las contracciones, tomarle la mano para que se sienta más acompañada, apoyándola” (calipso). “¿cómo puedo ayudar? no sé… con contención, palabras lindas, haciéndole masajes si lo necesita, sosteniéndole la mano o quedándome a un costado callado, lo que ella vaya a querer” (messi). las expectativas de participación se generaron en torno a la reflexión grupal, correspondiendo principalmente a los significados atribuidos a aspectos actitudinales del “ser” de los varones como acompañantes y como soporte de su pareja. expectativa de estar involucrado siendo útil el deseo de involucrarse pareciera corresponder a la apertura, motivación y sensibilidad para dar respuesta a las necesidades de la mujer y del proceso en sí mismo: “ser un papá motivado y metido en el cuento del parto, y no solo estar ahí con cara de “qué hago”, sino saber realmente qué hacer en cada momento” (medel). “quiero ser útil, no quiero estar ahí como una maceta. quiero estar ahí y ayudar en algo” (messi). “yo espero, en la parte previa [al parto], más que nada, ser ‘el apoyo’ en los momentos que haya cierta agonía o cierto agobio. más que nada, ser apoyo para petunia” (gris). expectativa de mantener el control de la situación en alguno de los padres se manifestó la necesidad de mantener el control para ser apoyo y aporte en situaciones límite del proceso, en las que podrían verse amenazados y superados. esto se relaciona con uno de los aspectos más influyentes en la orientación del tema generativo: en la etapa previa con ella, no desesperarme yo, tratar de darle calma y que la situación no me supere. mi pareja está súper nerviosa y, como es nuestro primer hijo, ella todo lo busca. de repente se le pasa la mano y busca cosas malas en internet. entonces siento que ella se me escapa un poco de las manos, eso no quiero, que se me escape de las manos. (dorado) expectativa de ser reconocido como parte del proceso los padres manifestaron la necesidad de ser valorados y reconocidos en sus necesidades durante el proceso, así como de conocer los detalles prácticos que involucra su participación: “a mí que me informen cuándo puedo ir a comer. el trabajo de parto es largo, y, si uno sale, qué desubicado de mi parte estar comiendo” (vidal) “que no solo sea el bolsito del niño o el de la mamá, sino que también haya un bolso del papá, especial” (medel). tema generativo relacionado con el rol de acompañante a partir de la fase exploratoria, los participantes y los investigadores determinaron, en conjunto, los temas generativos. aquel relacionado con la problemática del acompañante correspondió a “un mundo desconocido”: la necesidad de los padres de conocer más acerca del proceso del parto. los participantes expresaron las demandas educativas con relación al desarrollo de competencias en los ámbitos del saber, del saber hacer y del ser sobre el soporte y contención en el proceso de parto. las expresiones “cómo saber,” “cómo poder” y “cómo ser” reflejaron la necesidad genuina de los padres de prepararse para acompañar integralmente a sus parejas. competencias del saber estas se relacionaron con conocer más el proceso de parto, su inicio, duración y etapas. el saber responder frente al estrés o ansiedad que se generan enfrente a situaciones complicadas del proceso, o simplemente saber a lo que se pueden enfrentar en una situación normal de parto: “no sé cuánto se pueda demorar un parto, pero lo que sí sé es que la dilatación de la mujer puede durar horas, puede durar mucho tiempo, entonces en realidad no todos los tiempos son iguales. yo creo que eso sería, para empezar, saber más sobre todo eso” (rojo). “hay personas que quedan en shock, no saben qué hacer, no entienden nada, entonces es muy diferente decirlo. creer cómo va a ser a vivirlo es muy diferente. yo creo que lo que hay que desarrollar primero es a lo que uno se va a enfrentar (en el parto)” (vidal). 422 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 competencia del saber hacer se enfocaron en la necesidad de adquirir herramientas para acompañar de forma efectiva a su pareja, física y emocionalmente, para hacer esta experiencia más sostenible para la mujer: “cómo saber, cómo poder ayudarla para que sea más fácil vivirlo, que no sea tan pesado para ella […] por ejemplo ciertos masajes o palabras para ayudarla” (calipso). competencia del ser en los relatos de los padres, las expresiones que revelan el sentimiento de ser padre y acompañante parecieran ser inseparables, por tratarse de una experiencia plena: “participar activamente del nacimiento de su hijo, participar activamente en el momento del apego, pero también ser compañero de su esposa, ser apoyo para lo que ella necesite… pero también ser papá” (sánchez). fase de planificación e intervención de la investigación-acción: desarrollo de las sesiones educativas esta fase se desarrolló con base en un trabajo colaborativo entre participantes e investigadores, según los temas generativos y sus demandas educativas. se programaron alrededor de tres a cuatro sesiones educativas con cada subgrupo, de las cuales una estaba orientada al conocimiento sobre el proceso de parto y la presencia activa del padre. cada sesión permitió modificar o levantar nuevas demandas, además de las establecidas en la primera fase, dado que el proceso de ia es flexible y dinámico en su totalidad (17). la sesión educativa que correspondió a la preparación del padre en su rol de acompañante en el proceso de parto incluyó: conocer las etapas del proceso de parto; identificar las señales del inicio del trabajo de parto; comprender las diferencias entre proceso de parto y nacimiento; conocer los roles y la participación paterna en el proceso de parto y en el nacimiento; identificar y analizar las necesidades, tanto de la madre durante el proceso de parto, como del padre acompañante. la sesión inició con un video, que cada participante presenció en silencio; esto permitió sorprender y emocionar a la audiencia: “cuando uno lo mira, el proceso de parto tiene sus tiempos, tiene sus etapas, pero cuando uno lo mira sin estos ojos de la biología, que son muy parciales, el momento es súper mágico” (vidal). la segunda parte de la sesión correspondió a la dinámica de ronda de preguntas, que exploraba las percepciones de los conocimientos o las experiencias previas relacionadas al proceso de parto y a la participación del padre. esta actividad en grupo se focalizó en cómo vivir dicha participación en beneficio del proceso de parto. en la reflexión por parte de los padres se habló sobre la empatía y la distancia respetuosa. uno de los padres explicó este concepto y lo abordó desde el respeto al espacio del otro: no estaríamos juntos si no llegáramos al punto de... por algo nos conocemos y tenemos nuestra propia dinámica, y yo respeto mucho el espacio de ella. eso no significa que yo no esté atento a todo. también sé cuándo estar. pese a que estoy siempre, sé cuando actuar y cuando no actuar. (sepia) la última parte de la sesión correspondió al aspecto práctico de la simulación del mecanismo del parto. durante esta, los participantes tuvieron contacto con modelos fetales y pelvis maternas; tocaron al feto e intentaron movilizarlo en la pelvis hasta que saliera, simulando el mecanismo del parto. fase de evaluación de la investigación-acción la fase de evaluación se consolidó en la sesión final de la intervención. los resultados se generaron desde la reflexión grupal y desde la aplicación de un instrumento de evaluación. los padres refirieron haber alcanzado una mayor comprensión de lo que viven la mujer y su hijo en el útero. sin embargo, el beneficio principal fue el conocimiento que los padres y las madres adquirieron como pareja sobre las necesidades de la mujer en el parto, y sobre cómo el padre puede contribuir a su bienestar. un aspecto que apareció con frecuencia se relacionó con el lugar que se asignó a los padres durante todo el proceso de preparación. los participantes sintieron que la presencia de aquel tenía un valor real para el momento del parto y del nacimiento: “[hay que] animar al padre a tener un rol activo y a la par, tanto en el embarazo, como en el parto” (margarita). ellos percibían que al término del taller, habían adquirido habilidades y potenciado actitudes para enfrentar el proceso: “de una forma activa, participando en todas las etapas del parto y del nacimiento, acompañando a 423 padre preparado y comprometido en su rol de acompañante durante el proceso de parto l mónica muñoz-serrano y otros la madre, apoyándole en el parto y, posteriormente, ayudando en el cuidado del bebé” (pinilla). otro aspecto relevante, y frecuente, fue el aprendizaje compartido: los participantes le asignaron un valor especial al poder compartir y aprender de las experiencias de sus pares. el hecho de no sentirse solos en situaciones o vivencias particulares les proporcionaba un aprendizaje con confianza y convicción. algunos de los participantes manifestaron estas ideas como un evidente beneficio: “la experiencia de los demás participantes es un complemento de la experiencia personal” (magnolia); “el aporte al conocimiento desde lo personal y desde las experiencias de las otras parejas” (marrón). finalmente, el beneficio percibido por los padres respecto a la preparación antenatal señala un antes y un después. aquellos manifestaron sentirse más seguros y con más herramientas para enfrentar el parto y el nacimiento: “uno aprende eso, y debo decir que lo que hicimos en los talleres a mí me sirvió mucho […] ni siquiera la parte conceptual, sino la parte empírica pura” (sepia). “uno se siente más seguro, como que me entregaron las herramientas para estar ahí, y después para poder desarrollarme más, o sea, yo le agradezco que me entregaron esta seguridad” (pinilla). “con seguridad y conocimiento, gracias a lo aprendido en el taller y a la reflexión que realizamos en el grupo”(pinilla). discusión todo el proceso vivido desde la gestación hasta el nacimiento del hijo marca un hito en la vida de las madres y de los padres (1, 5, 18). con certeza, el acompañamiento profesional para los padres durante el periodo antenatal resulta beneficioso para el proceso, pero compartir y reflexionar en torno a sus necesidades bajo un modelo de preparación maternal puede no resultar efectivo para ellos. así, algunos autores recomiendan desarrollar intervenciones especiales para los padres (2, 5-7). el proceso de ia permitió desarrollar esta preparación especial para varones con un enfoque participativo (1, 19), lo que requiere que los padres estén involucrados en el embarazo y que deseen hacer parte del momento del nacimiento, situación poco frecuente en la actualidad, tanto en chile, como en el resto del mundo (20). la captación y preparación de los padres varones que se distancian del proceso desde el embarazo (14), y que no toman parte en el nacimiento de su hijo (13), puede requerir intervenciones motivacionales más complejas. los estudios recientes demuestran que factores como el estrés, la falta de apoyo y la violación de las expectativas del padre podrían relacionarse con sentimientos negativos hacia la participación en el embarazo y el nacimiento (21), así como la sensación de ser ignorados por parte del equipo de profesionales durante todo el proceso previo al parto. esto demuestra la necesidad de incluir preparaciones de tipo participativas y de naturaleza crítico-reflexiva (22) para usuarios y profesionales. bajo el perfil de motivación descrito, los varones de este estudio fueron activos participantes de las intervenciones educativas, por lo cual los resultados representan a este grupo de padres acompañantes. en el transcurso de la preparación, se demostró que los padres poseen necesidades especiales y particulares para vivir una experiencia compartida con su pareja mujer, lo que concuerda con lo reportado en otro estudio (20). contrario a los resultados de las encuestas nacionales y regionales, no se identificaron diferencias entre los subgrupos provenientes del sistema privado y del público respecto al conocimiento sobre el proceso de parto ni sobre las necesidades educativas que emanaron de este. para aguayo, sí existen diferencias respecto a la actitud de participación y de involucramiento en padres de distinto nivel de escolaridad y edad (13). desde la perspectiva de los contenidos de la preparación, muchos de los estudios que reportan contenidos educativos para el acompañamiento del varón se basan en actividades prácticas, como técnicas de acompañamiento para la relajación y respiración de la mujer en proceso de parto (9), pero muy poco respecto a la dimensión actitudinal. si bien es cierto que el ser un buen acompañante para la mujer representa una necesidad relevante de preparación práctica para poder otorgar soporte físico (8, 9, 23), este hecho de acompañar se ha generado de manera retrospectiva, con estudios cualitativos que recogen la experiencia. este estudio, en cambio, recoge información sobre las necesidades y las expectativas de manera anticipada, lo cual podría explicar la aparición de la actitud del “ser un buen acompañante”, en términos del respeto de los tiempos del proceso de parto, de la lectura que se da a las necesidades de la mujer y de la seguridad que adquieren para poder otorgar contención en momentos difíciles (24). esto permite comprender que si las demandas educativas se exploran y se trabajan en un momento previo al nacimiento, y en 424 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 un contexto de preparación participativa, el padre podrá manifestar sus necesidades y expectativas sobre lo que desea vivir como acompañante, más que sobre lo que le correspondió vivir, si estas se recogen una vez ocurrido el evento. conclusión este estudio permitió relevar el rol del padre y empoderarlo en su rol paterno y de acompañamiento durante el proceso de parto, pues este es un aspecto fundamental por considerar para fomentar el proceso del nacimiento en familia. comprender la experiencia paterna en este evento ha fortalecido, desde la mirada disciplinar, la implementación de un modelo de cuidado integral, desarrollado en chile desde hace una década, con resultados positivos en bienestar materno (25), pero con una comprensión limitada de la inclusión paterna. un nacimiento que se vive en familia, y con la participación activa del padre, puede tener un impacto futuro en la salud mental y en los procesos de vinculación familiar saludable, focos relevantes del accionar de la enfermería y de su responsabilidad social. conflicto de interés: ninguno declarado. referencias 1. manganiello a, hoga l. orgulho de pai : cartilha educativa para promocão do envolvimento paterno na gravidez. usp são paulo; 2012. 2. uribe c, contreras a, hoga l. presencia activa del padre en el nacimiento integral: significados atribuidos por padres y madres a los roles paternos. rev chil 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2007;41(4):559-66. doi: 10.1590/s0080-62342007000400004 20. guadagno m, mackert m, rochlen a. improving prenatal health: setting the agenda for increased male involvement. am j mens heal. 2013;7(6):523-6. doi: 10.1177/1557988313490785 21. saxbe d, horton kt, tsai ab. the birth experiences questionnaire: a brief measure assessing psychosocial dimensions of childbirth. j fam psychol. 2018;32(2):262-8. doi: 10.1037/fam0000365 22. franco mas. pedagogía da pesquisa ação. educ e pesqui. 2005;31(3):483-502. doi: 10.1590/s1517-97022005000300011 23. abushaikha l, massah r. the roles of the father during childbirth: the lived experiences of arab syrian parents. health care women int [internet]. 2011;33(2):168–81. doi: 10.1080/07399332.2011.610534 24. li h, lin-koh s, seow l, he h-g. first-time fathers’ experiences and needs during pregnancy and childbirth: a descriptive qualitative study. midwifery [internet]. 2014;30(6):779–87. doi: 10.1016/j.midw.2013.10.002 25. uribe c, contreras a, bravo p, villarroel l, abarzúa f. modelo de asistencia integral del parto: concepto de integralidad basado en la calidad y seguridad. rev chil obs ginecol. 2018;83(3):266-76. doi: 10.4067/s0717-75262018000300266 http://hdl.handle.net/11441/12861 http://hdl.handle.net/11441/12861 http://dx.doi.org/10.1016/j.srhc.2011.11.001 http://dx.doi.org/10.1590/s0080-62342007000400004 http://dx.doi.org/10.1177/1557988313490785 http://dx.doi.org/10.1037/fam0000365 http://dx.doi.org/10.1590/s1517-97022005000300011 http://dx.doi.org/10.1080/07399332.2011.610534 http://dx.doi.org/10.1016/j.midw.2013.10.002 http://dx.doi.org/10.4067/s0717-75262018000300266 1 ellen thallita hill araújo1 camila aparecida pinheiro landim almeida2 jaiana rocha vaz3 edilane jales leite magalhães4 carlos henrique lima alcantara5 eliana campêlo lago6 use of social networks for data collection in scientific productions in the health area: integrative literature review 1 orcid.org/0000-0001-5303-5571. centro universitário uninovafapi, brasil. 2 orcid.org/0000-0003-4843-4572. centro universitário uninovafapi, brasil. camila@uninovafapi.edu.br 3 orcid.org/0000-0003-3112-5343. centro universitário uninovafapi, brasil. 4 orcid.org/0000-0003-1163-8803. centro universitário uninovafapi, brasil. 5 orcid.org/0000-0003-2132-1180. centro universitário cesmac, brasil. 6 orcid.org/0000-0001-6766-8492. universidade estadual do maranhão (uema) y centro universitário uninovafapi, brasil. received: 06/10/2018 sent to peers: 21/11/2019 approved: 12/02/2019 accepted: 01/03/2019 doi: 10.5294/aqui.2019.19.2.4 to cite this article / para citar este artículo / para citar este artigo araujo eth, almeida capl, vaz jr, magalhães ejl, alcantara chl, lago ec. use of social networks for data collection in scientific productions in the health area: integrative literature review. aquichan 2019; 19(2): e1924. doi: 10.5294/aqui.2019.19.2.4 abstract objective: to investigate evidence on the use of social networks to collect data in scientific productions in the health area. material and method: an integrative literature review from primary studies indexed in the scielo, pubmed, lilacs, scopus, and web of science platforms. results: 16 scientific articles were selected, of which nine focused on the use of whatsapp; five, on the use of facebook; and two, on employing twitter to collect data in scientific productions. growth was noted on the number of investigations associated to the use of social networks, although an important paradigm still exists related to the use to generate scientific evidence, resulting in a still low number of investigations on this theme. conclusions: the health area needs to approach evermore the development of research associated to social networks, given that this would enable a viable and rapid intervention in obtaining responses, besides being a low cost and very promising tool for data collection. keywords (source: decs) social networking; data collection; statistics and numerical data; nursing; health; article; scielo; pubmed; lilacs; scopus; web of science; whatsapp; facebook; twitter. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1924 theme: evidence-based practice. contribution to the discipline: this review seeks to promote a broader understanding of the use of social networks in the collection of data in scientific productions in the health area. data collection in social networks may be challenging due to lack of trust by researchers regarding the credibility of the methodology. it was evidenced that the use of information technologies enables obtaining reliable and rapid data at low cost and with demystifying potential of information for a large number of connected users. however, a great paradigm of use still exists to generate scientific evidence, which results in research still being scarce in this area. http://orcid.org/0000-0001-5303-5571 http://orcid.org/0000-0003-4843-4572 http://orcid.org/0000-0003-3112-5343 http://orcid.org/0000-0003-1163-8803 http://orcid.org/0000-0003-2132-1180 http://orcid.org/0000-0001-6766-8492 http://dx.doi.org/10.5294/aqui.2019.19.2.4 http://orcid.org/0000-0001-5303-5571 http://orcid.org/0000-0003-4843-4572 http://orcid.org/0000-0003-3112-5343 http://orcid.org/0000-0003-1163-8803 http://orcid.org/0000-0003-2132-1180 http://orcid.org/0000-0001-6766-8492 http://dx.doi.org/10.5294/aqui.2019.19.2.4 http://www.isko.org/ko.html 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1924 uso de redes sociales para recolección de datos en producciones científicas en el área de la salud: revisión integrativa de la literatura resumen objetivo: investigar las evidencias del uso de redes sociales para recolectar datos en producciones científicas en el área de salud. material y método: una revisión integrativa de la literatura a partir de estudios primarios indexados en las plataformas scielo, pubmed, lilacs, scopus y web of science. resultados: se seleccionaron 16 artículos científicos, de los cuales nueve se centraron en el uso de whatsapp; cinco, en el uso de facebook; y dos, en empleo de twitter para recolectar datos en producciones científicas. hubo crecimiento en el número de investigaciones asociadas al uso de redes sociales, aunque aún existe un gran paradigma relacionado a su uso para generar evidencia científica, lo que resulta en un número aún reducido de investigaciones en esta temática. conclusiones: el área de la salud necesita acercarse cada vez más al desarrollo de investigaciones asociadas a las redes sociales, pues esto posibilitaría una intervención viable y rápida en la obtención de respuestas, además de ser una herramienta de bajo costo y bastante promisoria para la recolección de datos. palabras clave (fuente: decs) red social; recolección de datos; estadística & datos numéricos; enfermería; salud; artículo; scielo; pubmed; lilacs; scopus; web of science; whatsapp; facebook; twitter. http://www.isko.org/ko.html 3 use of social networks for data collection in scientific productions in the health area: integrative literature review l ellen thallita hill araújo and others utilização de redes sociais para coleta de dados em produções científicas na área da saúde: revisão integrativa da literatura resumo objetivo: investigar as evidências da utilização de redes sociais para coleta de dados em produções científicas na área da saúde. material e método: uma revisão integrativa da literatura a partir de estudos primários indexados nas plataformas scielo, pubmed, lilacs, scopus e web of science. resultados: foram selecionados 16 artigos científicos, dos quais nove apresentaram foco na utilização do whatsapp; cinco, no uso do facebook; e dois, no emprego do twitter para coleta de dados em produções científicas. houve um crescimento no número de pesquisas associadas à utilização de redes sociais, embora ainda exista um grande paradigma relacionado ao uso para a geração de evidências científicas, o que resulta em um número ainda reduzido de pesquisas nessa temática. conclusões: a área da saúde precisa aproximar-se cada vez mais do desenvolvimento de pesquisas associadas às redes sociais, pois isso possibilitaria uma intervenção viável e rápida na obtenção de respostas, além de ser uma ferramenta de baixo custo e bastante promissora para a coleta de dados. palavras-chave (fonte: decs) rede social; coleta de dados; estatística & dados numéricos; enfermagem; saúde; artigo; scielo; pubmed; lilacs; scopus; web of science; whatsapp; facebook; twitter. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1924 http://www.isko.org/ko.html 4 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1924 aquichan issn 1657-5997 eissn 2027-5374 introduction the internet is considered the most-used communication means in the daily life of the global population. it has become commonplace for people to declare that they cannot live without it, whether for the use of social networks, leisure, or work (1-3). brazil, in 2015, reached the mark of 94.2 million internet users, making it the fifth country with the largest number of connections to the global computer network and the one with the highest use of social media in latin america (4-6). within the context of the digital culture (or cyber culture), which has been developing since the expanded access to personal computers, online social networks are defined as a social structure integrated by people, organizations, or entities connected to each other through one or several types of relationships (7-9). this technology is indicated in the scientific literature as a facilitator in teaching. additionally, processes mediated by digital technologies increasingly articulate labor markets and social relations (10-12). the use of social networks is a relatively recent phenomenon and is being used for studies in several areas of knowledge (1314). in this perspective, its use in scientific research is increasing on a large scale, especially in the health area. specific platforms have been developed for interaction, data collection, and information sharing among researchers (15-19). in spite of the growing interest from the academic community in social networks as a scientific communication tool, research is still lacking on the profile of this use, and on how this data can be published in journals with scientific impact (20-21). given this, it should be noted that social media has been presented as a useful platform for informal discussions on health care, with great potential for research due to its ability to connect users and real-time feedback (22-25). increased use of the internet in all age groups has instigated researchers to use social networks as an alternative to obtain innovative answers and results in scientific work (26-29). thus, the aim of this study was to investigate the evidence of social network use for data collection in scientific productions in the health area, to synthesize content on the theme and define the literature gap associated with this type of approach. data collection in social networks can be challenging due to the distrust from researchers regarding the reliability of the methodology. in this sense, this study is relevant insofar as it makes it possible to highlight innovation in scientific production through tools characteristic of a new digital era, which can contribute to make this process more secure, attractive, flexible, and with greater ease and agility of access to population responses and samples. material and method to achieve the proposed objective, an integrative literature review was necessary. in the operation of the development of this review, six well-defined stages were covered: 1) elaboration of the research question; 2) sampling or search for primary studies in the literature; 3) data extraction; 4) evaluation of the primary studies included; 5) analysis and synthesis of the results; 6) review submission (21). in order to guide this integrative review, the following research question was formulated: “what is the evidence on the use of social networks for data collection in scientific productions?” the search for primary studies was performed according to the criteria and manuals of each database. the following descriptors were used: (medical subject headings) — social networking; data collection; article; nursing and health and the uncontrolled descriptors (keywords) — facebook, whatsapp and twitter, combined with boolean operators (and and or). the descriptors were researched during the period comprised between january and february 2018, in the following virtual libraries and databases: scielo, pubmed, lilacs, scopus, and web of science. the descriptors were combined in different manners to guarantee a broad search, whose combinations are described in table 1. inclusion criteria of the primary studies defined were scientific articles portraying the use of social networks for data collection in scientific productions in the health area, published from january 2013 to july 2018. these had the following classifications: individual study with experimental design, study with nonexperimental design, as correlational and qualitative descriptive research or http://www.isko.org/ko.html 5 use of social networks for data collection in scientific productions in the health area: integrative literature review l ellen thallita hill araújo and others case studies, case reports or data obtained systematically, of verifiable quality, or evaluation data of programs published in portuguese, english, and spanish. therefore, levels of evidence 2, 3, 4, and 5 were considered (30-31). the exclusion criteria established included informal case reports, book chapters, dissertations, theses, reports, news items, editorials, nonscientific texts. from the results obtained after complying strictly with the inclusion and exclusion criteria, the title and summary of each scientific article were read to verify their suitability to the guiding question. the flow diagram, according to the main items for reporting systematic reviews and meta-analysis (prisma) model, is shown in figure 1 (32). databases cross references nº scielo social networking and data collect and article 2 pubmed nursing and whatsapp and health 5 lilacs social networking and data collect or health 92 scopus social networking and data collect 1 web of science social networking and data collect or nursing 81 scielo social networking and article and facebook 8 pubmed social networking and nursing and article and twitter 20 lilacs social networking and nursing and article 1 scopus social networking and data collect and nursing 318 web of science social networking and health 23 scielo data collect and article and social networking or whatsapp or facebook or twitter 41 pubmed data collect and health and nursing and social networking 4 lilacs social networking and nursing and article or social networking and article 32 scopus social networking and whatsapp and facebook 1 web of science social networking and article and health 11 table 1. cross references among descriptors used in the databases scielo, pubmed, lilacs, scopus, web of science, 2013-2018 source: own elaboration. figure 1. flow diagram of the article search, exclusion, and exclusion process source: own elaboration. two independent reviewers selected the studies according to the eligibility and inclusion criteria and developed the study concordance method and selection process. the 16 articles were analyzed in descriptive manner, which allowed evaluating the level and quality of the available evidence on the use of social networks for data collection in scientific productions in the health area, besides identifying knowledge gaps for future research. 6 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1924 aquichan issn 1657-5997 eissn 2027-5374 to classify the level of evidence of the works, the study used the categorization of the agency for healthcare research and quality (ahrq). the quality of evidence is classified in six levels, namely: level 1, meta-analysis of multiple controlled studies; level 2, individual study with experimental design; level 3, study with a quasi-experimental design as study, without randomization with single preand post-test group, time series or case-control; level 4, study with nonexperimental design, such as correlational and qualitative descriptive research or studies; level 5, case report or data obtained systematically, of verifiable quality or program evaluation data; level 6, opinion by reputable authorities based on clinical competence or opinion by expert committees, including interpretation of non-research based information (31). the study adhered to national and international ethical precepts governing research, with absence of conflicts of interest. results of the 16 articles selected in the thematic area of this study, five (31.2 %) were published in 2018; four (25 %) in 2016; three (18.7 %) in 2014; two (12.5 %) in 2017; and one (6.2 %) in 2015 and 2013. regarding the study site, three (18.7 %) were carried out in brazil, followed by two (16.6 %) in the united states of america and italy. in relation to the databases, pubmed stood out with 56.2 % of the publications. regarding the design of the studies selected, non-experimental studies were highlighted with 11 (68.7 %) publications. therefore, considered as scientific evidence level 4 (31). from the 16 studies selected and included in this integrative review, a summary of primary studies is presented in table 2, according to title, year of publication, place of study, design and level of scientific evidence. to better identify each study selected, articles were organized in alphanumeric sequence starting from a1 to a16. furthermore, to analyze and discuss the use of social networks for data collection in scientific productions, the studies selected were organized into categories by thematic adhesion of each research, namely: “use of whatsapp for data collection in scientific productions”; “use of facebook for data collection in scientific productions”; and “use of twitter for data collection in scientific productions” (table 3). use of whatsapp for data collection in scientific productions in relation to the category “use of whatsapp for data collection in scientific productions”, five scientific articles were selected. each study was related to a differentiated area of instruction, but all used the whatsapp social network to aid in the data collection of the articles. among the publications, one of the studies analyzed the testimonies of people with human immunodeficiency virus (hiv) during health follow-up through the whatsapp application, which promoted the patient’s accessibility to health professionals and provided an open and immediate communication channel (33). other studies analyzed the whatsapp groups to analyze the experiences of nurses and health professionals to improve education in primary care. the experiences of the discussion groups by using the social media application favor teaching and learning (34-35). another research presented experiences and results of a plastic surgery team at chu amiens picardie who used instant messaging as part of medical transmissions for almost three years. this research showed improvement in the fluidity and lucidity of communications and transparency in patient management during hospitalization (36). different studies have proposed evaluating progress in telemedicine with the possibility of sending case images to professionals for assessment via whatsapp. the use of this mobile technology supported communication about health conditions between physicians and patients (37-39). the latest research analyzed experiences of whatsapp as a communication tool among team members as a positive effect through the application on the quality of the work of nurses (40-41). use of facebook for data collection in scientific productions in the category “use of facebook for data collection in scientific productions”, five studies were selected that contemplated the use of said social media in the collection of information and dissemination of evidence. this social network was used to disseminate three pain management interventions during painful 7 use of social networks for data collection in scientific productions in the health area: integrative literature review l ellen thallita hill araújo and others table 2. characterization of the articles selected according to title, author, year of publication, place of study, database, and level of scientific evidence, 2013-2018 source: own elaboration. nº title author year place database level of evidence a1 use of the facebook social network in data collection and dissemination of evidence vieira ac, harrison dm, bueno m, guimaraes n 2018 pelotas, brazil scielo 4 a2 use of the whatsapp application in health follow-up of people with hiv: a thematic analysis lima icv, galvão mtg, pedrosa sc, cunha gh, costa akb. 2018 fortaleza, brazil scielo 4 a3 mobile instant messaging for rural community health workers: a case from malawi pimmer c, mhango s, mzumara a, mbyundula f. 2017 malawi, east africa scopus 4 a4 undergraduate nurses reflections on whatsapp use in improving primary health care education willemse jj 2015 western cape, south africa pubmed 4 a5 whatsapp: improvement tool for surgical team communication sidhoum n, dast s, abdulshakoor a, assaf n, herlin c, sinna r. 2016 amiens, france pubmed 3 a6 mobile phone use among medical residents: a crosssectional multicenter survey in saudi arabia jamal a, temsah mh, khan sa, al-eyadhy a, koppel c, chiang mf. 2016 riyadh, saudi arabia pubmed 4 a7 whatsapp use in the evaluation of hematuria sener te, butticè s, sahin b, netsch c, dragos l, pappalardo r6 magno c. 2018 messina, italy pubmed 2 a8 effectiveness of positive thinking training program on nurses’ quality of work life through smartphone applications jahromi mm, fereidouni z, dehghan z. 2018 fasa, iran scopus 3 a9 experiences of indian health workers using whatsapp for improving aseptic practices with newborns: exploratory qualitative study pahwa p, lunsford s, livesley n. 2018 delhi, india web of science 4 a10 whatsapp: a telemedicine platform for facilitating remote oral medicine consultation and improving clinical examinations petruzzi m, de benedittis m 2016 bari, italy pubmed 3 a11 using information technology and social networking for recruitment of research participants: experience from an exploratory study of pediatric klinefelter syndrome close s, smaldone a, fennoy i, reame n, grey m. 2013 new haven, the united states of america pubmed 4 a12 facebook use and adolescents emotional states of depression, anxiety, and stress labrague lj 2014 the philippines, asia lilacs 4 a13 social networking as a learning tool: nursing students' perception of efficacy tower m, latimer s, hewitt j 2014 nathan, australia pubmed 4 a14 twitter as a tool to enhance student engagement during an inter-professional patient safety course mckay m, sanko js, shekhter i, birnbach dj. 2014 gables, the united states pubmed 4 a15 introducing twitter as an assessed component of the undergraduate nursing curriculum: case study jones r, kelsey j, nelmes p, chinn n3, chinn t, proctorchilds t. 2016 bristol, england pubmed 5 a16 prep forum: an on-line debate on the use of preexposure prophylaxis in brazil queiroz aafn, sousa afl 2017 ribeirão preto, brazil scielo 4 8 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1924 aquichan issn 1657-5997 eissn 2027-5374 procedures and evaluate prior knowledge, scope, dissemination, and intention to use strategies in the future (42). social media platforms, among them facebook, have the potential to increase students’ self-efficacy in learning and conduct learning at a deeper level (43). another paper described the strategy of using information technology through social networks to improve access to difficult pediatric research participants. other research demonstrated the effects of using facebook on emotional states of depression, anxiety, and stress in adolescents (44-45). in the same thematic category, the last scientific article found identified health promoters focused on hiv/aids prevention in posts linked to a facebook group for discussions on the use of pre-exposure prophylaxis (prep), which exposed a situation of vulnerability and alerted to a potential public health problem (46). use of twitter for data collection in scientific productions lastly, two scientific articles were selected according to their main emphasis in the category “use of twitter for data collection in scientific productions”. this category found a publication exploring the social network as a method to promote student involvement during an inter-professional patient safety course (47). in the research, this form of social media has successfully captured behind-the-scenes conversations and students’ experiences that otherwise would not be achieved. in addition, students gain broader perspectives and better comprehension of social media as a whole (48). discussion the data analyzed demonstrated, through the scientific articles published, that the use of social networks for data collection in scientific productions in the health area is a new field and with a perspective of increasing magnification. studies conducted between 2013 and 2018 have greater concentrations in 2018, with five publications. timid expansion is noted of publications on this theme over the years and it is felt that this number may increase due to the popularization of using information technologies. one survey observed rapid and growing reach of the interest group during a short period, reaching several municipalities in different states of brazil, at a relatively low cost, when compared to other studies involving the application of questionnaires in person, and showed the geographical coverage potential of social networks (33-34, 38). the ease of the data collection method in the digital age can be attributed or probably related to the attractive and flexible mode and ease of access and response through smartphones, compared to computers and laptops, which permits rapid dissemination among the virtual network of contacts (38). thus, social networks can be quite useful as research tool due to the great popularity of use in brazil and the world, with possibility of broad reach because of the number of connections established among the people who use it. in addition, it is an easy-to-use, low-cost, and rapid-dissemination method (33, 38). studies with this approach in the methodology may offer aids to identify information needs, from the perspective of those involved, and favor expansion of health communication and research tools (35-36). research analyzing the testimonies of people living with hiv during a health follow-up showed that the use of whatsapp is favorable as a care tool for virus carriers and has been shown to be a potential pathway to clear doubts and promote adherence to treatment (33). it is worth highlighting that the global use of mobile devices with their connectivity capacity, integrated with the possibilities of social media networks, also provides a platform rich in resources for innovative scientific experiences in student-led learning (34). table 3. classification of the studies into thematic accession categories, 2013-2018 categories articles selected use of whatsapp to collect data in scientific productions a2, a3, a4, a5, a6, a13, a14, a15, and a16 use of facebook to collect data in scientific productions a1, a7, a8, a9, and a12 use of twitter to collect data in scientific productions a10 and a11 source: own elaboration. 9 use of social networks for data collection in scientific productions in the health area: integrative literature review l ellen thallita hill araújo and others a research in italy described the use of a whatsapp based smartphone to share clinical information about oral medicine. thus, it has been shown that telemedicine applications can support communication between physicians and patients. consultation through social networks reduced geographic barriers and significantly encouraged patients to undergo specialized clinical examinations (37). another study in the united states of america has revealed that registering pediatric samples for research is challenging due to parental mistrust, privacy concerns, and family time constraints. from this perspective, information technology strategies with social networks were used to improve access to pediatric research participants, obtaining simpler engagement through facebook (40). an additional scientific study explored the use of twitter as a mean to promote involvement of university students during an inter-professional course on patient safety. the tool increased participant engagement, attention, and interaction, as well as helped guide future inter-professional educational programming in medical and nursing schools (43). despite the promising benefits these unique technological advances offer, such as social capital and articulation of friendship, growing concerns have emerged about their negative impacts on people’s well-being. still from this perspective, research using social networks would identify users who at risk of developing negative emotional states and would increase awareness about the issue (41). according to a research in malawi, despite some challenges and constraints, implementation of whatsapp was received positively by professionals in the basic health care network and was considered a useful tool to support the work of these professionals in the rural community (35). according to a study on experimental design, it is possible to evaluate hematuria and the unnecessary costs of light clinical services by using tele-medicine. whatsapp provides valuable help to tertiary hospitals where a urologist is not always present (39). in this sense, it can be said that social networks are configured as an important interaction setting that offers a convenient platform to share information, circulate speeches, and transmit information. in the health field, it is felt that said potential should be explored further (46-50). however, despite growth in research associated with the use of social networks and popularization of communication technologies, a great paradigm prevails of their use to generate scientific evidence, and the amount of research focusing on this subject is still minimal. conclusion analysis of the scientific articles selected in this integrative review permitted highlighting a methodological innovation by using social networks in data collection in scientific research, which made it possible to demonstrate a new contribution to multidisciplinary knowledge. for the most part, studies involving the use of whatsapp relied on mobile technology as support in team communication, which contributed to improved health education. likewise, twitter served as a tool to promote student involvement and knowledge. the use of information technologies permitted obtaining reliable, rapid, and low-cost data with potential to demystify information to a large number of connected users. as a limitation, we highlight the lack of studies with data collection using elderly populations because this is a type of user with less frequency of use of social networks. furthermore, the need to train health professionals and researchers is emphasized, so that they feel comfortable and secure in the process of using information technologies to conduct scientific research. it is expected of this paper to become a basis for future studies related to using social media platforms as research tools or methodological strategies. conflict of interests: none declared. 10 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1924 aquichan issn 1657-5997 eissn 2027-5374 references 1. pereira ccm, botti ncl. o suicídio na comunicação das redes sociais virtuais: 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http://dx.doi.org/10.1590/s1980-220x2016021603219 https://www.ncbi.nlm.nih.gov/pubmed/?term=teo ar%5bauthor%5d&cauthor=true&cauthor_uid=30266029 https://www.ncbi.nlm.nih.gov/pubmed/?term=chan bk%5bauthor%5d&cauthor=true&cauthor_uid=30266029 https://www.ncbi.nlm.nih.gov/pubmed/?term=saha s%5bauthor%5d&cauthor=true&cauthor_uid=30266029 https://www.ncbi.nlm.nih.gov/pubmed/?term=nicolaidis c%5bauthor%5d&cauthor=true&cauthor_uid=30266029 http://dx.doi.org/10.1016/j.jad.2018.09.043 http://dx.doi.org/10.1016/j.jad.2018.09.043 327 camila da silva lemos1 ana gabriela lacerda rodrigues2 ana carolina de castro mendonça queiroz3 hélio galdino júnior4 suelen gomes malaquias5 práticas integrativas e complementares em saúde no tratamento de feridas crônicas: revisão integrativa da literatura 1 orcid.org/0000-0001-5535-6600. universidade federal de goiás (fen-ufg), brasil. camila@enf.grad.ufg.br 2 orcid.org/0000-0001-5535-6600. universidade federal de goiás (fen-ufg), brasil. enfermagem.cientifico@accg.org.br 3 orcid.org/0000-0001-7302-3682. universidade federal de goiás (fen-ufg), brasil. ana_gabi@enf.grad.ufg.br 4 orcid.org/0000-0002-5570-818. universidade federal de goiás (fen-ufg), brasil. helio_junior@ufg.br 5 orcid.org/0000-0001-8530-9100. universidade federal de goiás (fen-ufg), brasil. suelen.g.malaquias@ufg.br recebido: 22/12/2017 submetido: 15/02/2018 aceito por pares: 16/04/2018 aceito: 14/06/2018 doi: 10.5294/aqui.2018.18.3.7 para citar este artículo / to reference this article / para citar este artigo lemos cs, rodrigues agl, queiroz accm, galdino júnior h, malaquias sg. práticas integrativas e complementares em saúde no tratamento de feridas crônicas: revisão integrativa da literatura. aquichan. 2018; 18(3): 327-342. doi: 10.5294/aqui.2018.18.3.7 resumo objetivo: identificar na literatura práticas relacionadas à medicina tradicional e complementar em saúde utilizadas no tratamento de pessoas com feridas crônicas. materiais e método: estudo de revisão integrativa da literatura, cuja busca realizou-se nas bases: national library of medicine (medicine–pubmed), web of science, eletronic library online (scielo), cumulative index of nursing and allied health literature (cinahl), science direct (elsevier), science direct (scopus), e biblioteca virtual da saúde e bvs em medicinas tradicionais, complementares e integrativas (bvs-mtci). resultados: foram analisados 18 artigos que envolvem úlceras de perna (94,4 %) e año 18 vol. 18 nº 3 chía, colombia -septiembre 2018 l 327-342 temática: práctica basada en la evidencia. contribuição à disciplina: essa revisão pretende promover a compreensão mais ampliada sobre a utilização das práticas integrativas e complementares em saúde no tratamento de pessoas com feridas crônicas. na assistência de enfermagem, sob o referencial teórico de wanda de aguiar horta, pela teoria das necessidades humanas básicas, possibilita refletir sobre a indissociabilidade das necessidades psicobiológicas, psicossociais e psicoespirituais do ser humano. identificam-se lacunas quanto à evidência de intervenções que abranjam dimensões além das biofisiológicas, limitando a assistência a essa clientela ao manejo tópico das lesões. as práticas mais utilizadas na assistência a pacientes com feridas foram a fitoterapia, a apiterapia e a ozioterapia. estes achados revelam um vasto campo a ser explorado no tratamento de pessoas com feridas crônicas, e suscita-se a necessidade de estudos bem-delineados com outras modalidades de prática; uma vez confirmada sua eficácia, abrem possibilidades terapêuticas que a enfermagem pode se apropriar para ampliar o repertório de intervenções. http://orcid.org/0000-0001-5535-6600. http://orcid.org/0000-0001-5535-6600. http://orcid.org/0000-0001-7302-3682. http://orcid.org/0000-0002-5570-818. http://orcid.org/0000-0001-8530-9100. 328 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 327-342 lesões por pressão (5,6 %). identificaram-se fitoterapia (66,7 %), apiterapia (22,2 %) e ozonioterapia (11,1 %) como todos desfechos que se relacionavam com cicatrização de feridas. conclusão: considerando as três modalidades de práticas identificadas e seus desfechos clínicos, evidenciam-se lacunas na literatura. não há evidências que sustentem indicação de alguma prática no atendimento a essa população, o que reforça o campo promissor de atuação do enfermeiro. palavras-chave pé diabético; úlcera por pressão; úlcera venosa; úlcera da perna; terapias complementares (fonte: decs). prácticas integrativas y complementarias en salud para el tratamiento de las heridas crónicas: revisión integrativa de la literatura resumen objetivo: identificar en la literatura prácticas relacionadas a la medicina tradicional y complementaria en salud utilizadas en el tratamiento de personas con heridas crónicas. materiales y método: estudio de revisión integradora de la literatura, cuya búsqueda se realizó en las bases: national library of medicine (medicine-pubmed), web of science, eletronic library online (scielo), cumulative index of nursing and allied health literature (cinahl), science direct (elsevier), science direct (scopus), y biblioteca virtual de la salud y bvs en medicinas tradicionales, complementarias e integrativas (bvs-mtci). resultados: se analizaron 18 artículos que trataban de úlceras de la pierna (94,4 %) y lesiones por presión (5,6 %). se identificaron fitoterapia (66,7 %), apiterapia (22,2 %) y ozonioterapia (11,1 %) como todos los resultados que se relacionaban con cicatrización de heridas. conclusión: teniendo en cuenta las tres modalidades de prácticas identificadas y sus resultados clínicos, se evidenciaron vacíos en la literatura. no hay pruebas que sostengan indicación de alguna práctica en la atención a esta población, lo que refuerza el campo prometedor de actuación del enfermero. palabras clave pie diabético; úlsera por presión; úlsera varicosa; úlcera de la pierna; terapias complementarias (fuente: decs). 329 práticas integrativas e complementares em saúde no tratamento de feridas crônicas: revisão integrativa da literatura l camila da silva lemos e outros complementary and integrative practices in health for the treatment of chronic wounds: an integrative review of the literature abstract objective: the objective of this study is to identify in literature the practices related to traditional and complementary medicine in health that are being used to treat people with chronic wounds. materials and methods: this is an integrative literature review conducted through a search of the following databases: national library of medicine (medicine-pubmed), web of science, eletronic library online (scielo), cumulative index of nursing and allied health literature ( cinahl), science direct (elsevier), science direct (scopus), and virtual health library and vhl in traditional, complementary and integrative medicine (vhl-mtci). results: eighteen (18) articles dealing with leg ulcers (94.4%) and pressure injuries (5.6%) were analyzed. phytotherapy (66.7%), apitherapy (22.2%) and ozone therapy (11.1%) were identified as all the results that were related to wound healing. conclusion: taking into account the three types of practices that were identified and their clinical results, it was evident that there are gaps in the literature. there is no evidence to support an indication of any practice in the care of this population, which reinforces the promising field for action on the part of nurses. keywords diabetic foot; pressure ulcer; varicose ulcer; leg ulcer; complementary therapies (source: decs). año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 327-342 330 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 introdução a assistência à saúde ainda é predominantemente fundamentada no modelo biomédico, que enfoca a abordagem na doença e que entende que a cura ocorre a partir de parâmetros biológicos, cujos determinantes psicossociais e culturais são pouco relevantes para o diagnóstico e a terapêutica (1). contudo, observam-se tendências de mudanças nas concepções e práticas de saúde voltadas ao cuidado integral, as quais não comportam mais um olhar fragmentado e direcionado à doença. nesse sentido, a organização mundial da saúde (oms) se posicionou valorizando a denominada medicina tradicional e complementar (mtc), por ser esta a responsável pelo atendimento de expressiva parcela da população mundial, desde lugares longínquos a grandes centros urbanos. esse posicionamento tem como pressuposto a política de integração das racionalidades em saúde como complementares, mediante o desenvolvimento de programas nacionais de saúde representativos desse movimento, assim como a tríade “segurança, eficácia e qualidade”, o acesso dos usuários à mtc e seu uso racional (2). no brasil, práticas integrativas e complementares em saúde (pics), expressão que será utilizada neste estudo, corresponde à expressão “medicina tradicional e complementar” da oms (2013), em que “medicina tradicional” se refere à somatória de conhecimento, habilidade e práticas baseados em teorias, crenças e experiências culturais, utilizados na manutenção da saúde, bem como na prevenção, diagnóstico e tratamento de doenças físicas e mentais. enquanto “medicina complementar” é definida como o conjunto amplo de práticas de cuidados de saúde diferentes das convencionais e que não estão totalmente integradas no sistema de saúde dominante (2). baseado na iniciativa da oms de incentivar seus estadosmembros a elaborarem e implementarem políticas públicas para o uso racional e integrado de medicina tradicional (mt) e medicina complementar-alternativa (mca), publica-se no brasil, em 2006, a política nacional de práticas integrativas e complementares (pnpic), no sistema único de saúde (sus). inicialmente, compunham as práticas na pnpic: acupuntura, homeopatia, medicina antroposófica, medicina tradicional chinesa, fitoterapia e crenoterapia (3). em 2017, ampliaram-se as práticas e incluíramse: arteterapia, ayurveda, biodança, dança circular, meditação, musicoterapia, naturopatia, osteopatia, quiropraxia, reflexoterapia, reiki, shantala, terapia comunitária integrativa e yoga (4). logo, em 2018, houve outra ampliação nas modalidades de pics e foram acrescentadas: aromaterapia, apiterapia, bioenergética, constelação familiar, cromoterapia, geoterapia, hipnoterapia, imposição de mãos, medicina antroposófica/antroposofia aplicada à saúde, ozonioterapia, terapia de florais e termalismo social/ crenoterapia (5). entre os objetivos da pnpic, destacam-se a contribuição para a resolubilidade do sus e a promoção da racionalização das ações em saúde, os quais devem ser embasados pela promoção do cuidado humanizado e integral à saúde dos indivíduos. buscase, assim, uma prática assistencial de acolhimento do indivíduo, a qual respeite sua singularidade a partir da indissociação das dimensões biopsicossociais e espirituais, ao considerar processos de adoecimento e saúde (2). dessa forma, as pics são aplicadas a diferentes modalidades de assistência à saúde, como, por exemplo, para o alívio da dor na oncologia (6) e entre parturientes (7), para a redução da ansiedade, para a melhora no humor e para o estímulo em atividades laborais de pessoas em tratamento de dependência de álcool e drogas ilícitas (8). no entanto, entre pessoas com feridas crônicas, mediante essa perspectiva, observam-se iniciativas isoladas, mas pouca evidência há da implementação das pics nos atendimentos e, consequentemente, de suas implicações e efetividade. sabe-se que feridas crônicas impactam na vida do indivíduo nas dimensões biológicas, psíquicas e sociais (8, 9), o que reforça a necessidade de abordar de forma holística esses pacientes. nesse sentido, elaborou-se a seguinte questão de pesquisa: as práticas integrativas e complementares são utilizadas no atendimento a pacientes com feridas crônicas? assim, o objetivo deste estudo foi identificar na literatura as pics utilizadas no tratamento de pessoas com feridas crônicas. metodologia trata-se de uma revisão integrativa da literatura, realizada de agosto de 2016 a maio de 2018, a partir da questão norteadora “quais práticas integrativas e complementares utilizadas no tratamento às pessoas com feridas crônicas estão descritas na literatura?” 331 práticas integrativas e complementares em saúde no tratamento de feridas crônicas: revisão integrativa da literatura l camila da silva lemos e outros realizou-se a busca nas seguintes bases de dados: national library of medicine (medicine-pubmed), web of science, eletronic library online (scielo), cumulative index of nursing and allied health literature (cinahl), science direct (elsevier), science direct (scopus) e biblioteca virtual da saúde (bvs). foi incluída também a biblioteca virtual em saúde em medicinas tradicionais, complementares e integrativas (bvs-mtci), lançada em março de 2018, na qual foi realizada busca em período posterior às demais citadas (maio de 2018). utilizaram-se descritores controlados e não controlados (figura 1) conforme a base de dados, a fim de obter maior abrangência de busca. os critérios de inclusão foram artigos na língua portuguesa, espanhola e inglesa, publicados a partir de 2006, que apresentassem o uso de alguma prática diferente do tratamento convencional em pessoas com feridas crônicas (úlceras de perna e lesão por pressão). de forma independente, dois pesquisadores aplicaram testes de relevância, elaborados conforme os critérios de inclusão, aos títulos e, em seguida, aos resumos; também foram discutidas e resolvidas divergências com um terceiro pesquisador. excluíram-se revisões da literatura, estudos de caso, editoriais ou opiniões de especialistas, assim como estudos in vivo em modelos animais não humanos ou que envolvessem populações que não apresentassem feridas crônicas. da mesma forma, exestratégia de busca: "diabetic foot" or "pressure ulcer" or "venose ulcer" or "varicose ulcer" or "leg ulcer" and "complementary therapies" or "alternative medicine" and "wounds and injuries" or "wound healting" n.º artigos 28691 pub med scopus: scielo: web of science bvs: cinahl: bvs mtci: 1252 434 733 science: 838 direct: 1085 7975 14543 1831 após teste relevância 1 (titulos)*: artigos que não estavam em inglês, português e espanhol: 19035 artigos que não estavam entre os anos de 2006 e 2016: 15441 artigos que não abordavam mtc no tratamento de pessoas com up ou lpp: 27123 após teste relevância 2 (resumos e textos na integran): 344 artigos que não eram estudo coorte, caso-controle, experimentais ou quase experimentais: 60 artigos que não abordavam mtc no tratamento de pessoas com up/lpp: 207 artigos que não abordavam população com feridas: 10 artigos que não abordavam humanos: 8 duplicados: 41 artigos selecionados: 18 in cl uí do s el eg ib ili da de tr ia ge m id en tif ic aç ão figura 1. fluxograma do processo de inclusão dos estudos *consideraram-se exclusões por mais de um motivo dos estabelecidos; mtc — medicina tradicional e complementar. fonte: elaboração própria. 332 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 cluíram-se estudos que não abordassem alguma modalidade de mtc no tratamento de pessoas com feridas, seja isolada, seja associada à terapia convencional. os artigos identificados mais de uma vez na base ou entre as bases foram excluídos. as informações extraídas dos estudos selecionados foram organizadas por meio de um formulário previamente elaborado, conforme o objetivo do estudo. assim, realizou-se a avaliação crítica dos estudos incluídos a partir das informações coletadas. compararam-se os achados com pics descritas no documento da oms (2) e na pnpic brasileira (2, 3). após a leitura dos artigos selecionados, agruparam-se as modalidades de pics, a fim de facilitar o entendimento. os estudos selecionados foram classificados por níveis de evidência (10). por fim, elaborou-se este relatório da revisão a partir das recomendações do prisma statment (11). resultados foram encontradas 28691 referências das bases de dados. a seleção por título resultou em 344 artigos, dos quais 18 artigos foram incluídos, após a aplicação do teste de relevância 2 aos resumos e aos textos na íntegra. o fluxograma contido na figura 1 apresenta os descritores utilizados na estratégia de busca bem como o processo de seleção dos artigos. dos 18 artigos selecionados, 14 (77,8 %) estavam disponíveis na língua inglesa, 14 (77,8 %) foram publicados entre 2010 e 2016, 5 (27,8 %) foram identificados na bvs-mtci, base específica da bvs de estudos relacionados à mtc, 6 (33,3 %) estudos, todos com fitoterápicos, foram realizados no brasil, 2 (11,1 %) no méxico e os demais, cada um, em países europeus (22,2 %), asiáticos (11,1 %), da oceania (11,1 %) e da américa do sul (5,6 %). predominaram autores médicos (66,6 %) entre os listados, mas também houve autores enfermeiros (16,7 %), biólogos (11,1 %) e engenheiros eletricistas (5,6 %). em relação às modalidades de pics, 12 (66,7 %) artigos tratavam de fitoterápicos (12-23), 4 (22,2 %) de apiterapia (24-27) e 2 (11,1 %) de ozonioterapia (28-29). entre os fitoterápicos, calendula officinalis foi identificada em mais de um estudo (22,2 %), isoladamente (11,1 %) ou em associação a outros fitoterápicos (5,6 %) e terapia a laser de baixa intensidade (5,6 %). nos estudos que envolvem apiterapia, destaca-se o mel manuka (mm) (5,6 %), que, em um estudo (24), apresentou desfecho positivo e, em outro (27) (5,6 %), com amostra de 368 participantes, houve pior desempenho em relação ao grupo controle (gc) e foi, inclusive, mais oneroso. em ambas as intervenções, em úlceras venosas, utilizaram-se o mm impregnado à cobertura primária que no estudo com melhores resultados não é descrita e, no segundo, alginato de cálcio. em ambos, o tempo de seguimento e periodicidade de avaliação foram os mesmos, no entanto não está clara a periodicidade de troca no estudo com impregnação do mm ao alginato de cálcio. quanto à descrição da população estudada, predominaram pessoas com 60 anos ou mais (77,8 %); idade não informada em 1 (5,6 %) estudo e, faixa etária de 50 a 78 anos, em 1 (5,6 %) estudo. quanto ao sexo, identificaram-se 8 (44, %) estudos com predomínio de participantes do sexo feminino e 6 (33,3 %) em que esse dado não foi apresentado. em 17 (94,4 %) estudos, realizaram-se intervenções a pessoas com úlceras de perna e apenas 1 (5,6 %) estudo envolveu pessoas com lesões por pressão. dos estudos de úlceras de perna, 12 (66,7 %) abordavam úlceras venosas e 5 (27,8 %) úlceras por complicação isquêmica/ neuroisquêmica decorrentes de diabetes mellitus. o número total de participantes variou de 5 a 368, predominando amostras maiores que 20 a 50 indivíduos (61,1 %) (quadro 1). como desfechos, os estudos investigaram predominantemente a análise da eficácia e segurança das intervenções propostas (55,6 %). em 4 (22,2 %), mencionam-se especificamente a cicatrização das lesões; os efeitos no controle microbiológico em dois (11,1 %); os efeitos histológicos em 1 (5,6 %); a descrição clínica das lesões associadas à intervenção conjuntamente à cicatrização em um mesmo estudo em 1 (5,6 %) e o teste de sistema indutor de cicatrização em 1 (5,6 %). em relação aos resultados dos estudos, considerando as intervenções propostas, predominaram efeitos positivos aos grupos experimentais identificados por epitelização completa apresentada em 7 (38,9 %) estudos, redução da área das lesões em 9 (50,0 %), tempo menor de cicatrização em 3 (16,6 %), diminuição de necrose em 2 (11,1 %), redução de carga microbiana ou sinais flogísticos em 2 (11,1 %) e melhora da dor em 1 (5,5 %). três (16,6 %) estudos apontaram ausência de melhora mediante diferença estatisticamente significativa. houve, ainda, 1 (5,5 %) estudo em que o tempo de cicatrização e os custos do 333 práticas integrativas e complementares em saúde no tratamento de feridas crônicas: revisão integrativa da literatura l camila da silva lemos e outros tratamento foram maiores entre os participantes do grupo experimental (ge) que entre os do grupo de controle (gc). em 1 estudo (5,5 %), foi descrito arquétipo de menor complexidade entre participantes em uso de fitoterápico. o tempo de seguimento dos estudos variou de 2 a 30 semanas; em 11 (61,1 %) estudos, entre 5 e 24 semanas. quanto ao nível de evidência dos estudos, predominaram estudos experimentais (77,8 %) como esperado pelos critérios de inclusão estabelecidos nesta revisão. ressaltam-se, porém, fragilidades na descrição metodológica de vários dos estudos. discussão a proporção discrepante entre artigos identificados e incluídos demonstra a dificuldade de realizar estudos de revisão integrativa da literatura que respondam a questões incomuns. bases de dados temáticas como a bvs-mtci podem otimizar o levantamento de estudos e evitar o baixo aproveitamento final a partir do volumoso número de artigos encontrados na busca, como observado na presente revisão. considerando o maior número de estudos por país, o brasil se destacou entre todos e especialmente entre os relacionados aos fitoterápicos para o tratamento de feridas. esse fato pode ser explicado pela biodiversidade e pelos aspectos culturais desse país que favorecem a franca disponibilidade desses recursos aos pesquisadores (2), mesmo mediante as fragilidades legais dos sistemas de saúde para o aproveitamento dessa tecnologia (13). outros estudos também apresentaram modalidades de pics correspondentes às regiões onde foram desenvolvidos os estudos. nesse sentido, como pressuposto das racionalidades em saúde, as pics devem representar também o fortalecimento de saberes e ações populares regionais, que necessitam ser permanentemente investigadas para subsidiar intervenções baseadas em evidência científica (2). da diversidade de pics elencadas pela oms, três modalidades foram identificadas nesta revisão para o atendimento de pessoas com feridas crônicas. encontraram-se vários estudos com outras modalidades no processo de inclusão, mas com desenho metodológico inadequado para as análises requeridas neste estudo, o que sugere algumas suposições. primeiramente, há de se ressaltar o possível privilégio para a inclusão de determinadas abordagens metodológicas dos estudos para indicar evidências científicas, sendo que, para algumas modalidades de pics, a análise quantitativa é dificultada. portanto, é preciso considerar a reflexão sobre as conduções metodológicas mais adequadas para estudos que envolvam pics para uma apresentação mais assertiva destas, no tocante à análise de evidências. por outro lado, há realmente fragilidades metodológicas em alguns estudos que dificultam as análises mais profundas e implementação das técnicas em outros contextos. mas é possível, ainda, cogitar que a compreensão da assistência a pessoas com feridas seja direcionada a intervenções tópicas. a totalidade dos desfechos dos estudos incluídos nesta revisão, os quais estão relacionados à cicatrização ou aos resultados clínicos que envolvem as condições das úlceras, evidencia essa compreensão. assim, não foram encontradas pesquisas com pics que abordassem o indivíduo com ferida crônica de forma mais holística. mesmo as modalidades de pics identificadas nos estudos foram apresentadas dissociadas de uma abordagem mais ampla que envolvesse intervenções de dimensões para além da biofisiológica, como recomendado em documentos de consenso (30-32). a fitoterapia, predominante entre as pics dos estudos, assim como o uso de plantas medicinais, é utilizada na abordagem antroposófica e na medicina tradicional chinesa, esta última originou outras modalidades de pics. dessa forma, distancia-se a compreensão dos modelos conceituais que rompem com a racionalidade biomédica vigente, a qual tende a desconsiderar a unicidade do ser humano e a necessidade de uma abordagem integral (2). esse achado indica a necessidade crescente de ampliar a avaliação e intervenções dessa clientela para além do tratamento tópico. a inclusão de pics pode promover essa abordagem mais ampliada a partir da multidisciplinaridade, da interdisciplinaridade, bem como do empoderamento da própria população com feridas crônicas (33-34). para tanto, é imprescindível que a equipe multiprofissional se motive e se instrumentalize para essa modalidade de atenção. quanto à fitoterapia, observa-se maior avanço organizacional para esse atendimento em vários cenários mundiais. no brasil, há dois grandes marcos: a pnpic no sus e o programa nacional de plantas medicinais e fitoterápicos (33, 35). esses marcos foram 334 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 decorrentes de movimentos internacionais anteriores, a declaração de alma-ata na conferência internacional sobre atenção primária em saúde, que recomendou aos estados-membros o desenvolvimento de políticas e regulamentações nacionais para o uso de produtos tradicionais com comprovação de eficácia e para o treinamento sobre o uso na atenção primária à saúde (37-39). posteriormente, a oms criou o programa de medicina tradicional com o objetivo de facilitar a integração da mtc (37-40). assim, no brasil, em 2006, é publicada a pnpic e lançado o programa nacional de plantas medicinais e fitoterápicos a fim de garantir o acesso seguro e o uso racional desses recursos. nessa mesma direção, foram elaboradas políticas nacionais relacionadas ao uso de plantas medicinais e fitoterápicos nos países onde se identificaram estudos nesta revisão (37-39). no méxico, iniciou-se o programa nacional de plantas medicinales (pronaplamed) em 1999, realizado por membros da red mexicana de plantas medicinales y aromáticas scl (redmexplam), da qual participam camponeses, profissionais da área da saúde, pesquisadores que desenvolvem atividades de formação e articulação política local nessa temática (40). devido às características climáticas e do solo, a sérvia apresenta ampla diversidade de espécies de plantas medicinais por área, comparada aos outros países europeus, como observado no estudo identificado desse país (17). a regulação quanto ao uso clínico seguro, em pesquisas e no comércio de plantas medicinais, de produtos homeopáticos, assim como a outras modalidades de pics é realizada pela cambrella, uma agência de regulação de países europeus e da união europeia, gerenciada pela norway’s national research center in complementary and alternative medicine (nafkam) (41). marcos normativos que regulamentam o uso de plantas medicinais/fitoterapia e a prática das demais modalidades de pics têm sido revisados na austrália. para a china, a dinâmica da rede de assistência à saúde inclui a medicina tradicional conjuntamente à convencional, em todos os níveis de atenção (2). em termos conceituais, a planta medicinal representa uma espécie vegetal, cultivada ou não, utilizada com propósitos terapêuticos. a planta fresca é aquela coletada no momento de uso, e a planta seca a que foi precedida de secagem e equivale à droga vegetal (33). a fitoterapia, por sua vez, é definida como “terapia com plantas medicinais de diferentes formas farmacêuticas, sem utilização de substâncias ativas isoladas, ainda que de origem vegetal” (38). a utilização de plantas como terapia e cura é uma prática antiga. as sociedades acumulavam informações e experiências acerca do ambiente no qual viviam, e, através disso, interagiam com este, como forma de atender às suas necessidades e como forma de sobrevivência (33-34). as plantas medicinais são aquelas que produzem princípio ativo capaz de alterar o funcionamento de órgãos e sistemas (33-34,37-38). dessa forma, o valor terapêutico e utilização das plantas medicinais recomendada pelos profissionais de saúde vêm se estabelecendo progressivamente de forma sistematizada. porém, o papel do enfermeiro ante a questão ainda é deficiente pela falta de conhecimento científico e apropriação desse saber. assim, figuras populares assumem essa função, como o raizeiro, que manipula e comercializa plantas medicinais e, consequentemente, populariza essa terapia (33-34). isso reforça a necessidade de pesquisas clínicas para a utilização de forma segura, pois o uso inadequado, mesmo que de baixa toxicidade, pode induzir distúrbios graves desde que preexistam outros fatores de risco (33-35). vários fitoterápicos já são comercializados por indústrias farmacêuticas para o tratamento de feridas, como a biomembrana vegetal, desenvolvida a partir do látex da seringueira (hevea brasiliensis), árvore comum da região norte do brasil. há descrito efeito de indução do processo cicatricial, principalmente no estágio inflamatório, que são confirmados resultados das lesões nos estudos incluídos que usaram esse fitoterápico (14, 16). os extratos de calendula officinalis e mimosa tenuiflora demonstraram efeitos positivos para a cicatrização das lesões e foram os fitoterápicos identificados em mais de um estudo. o extrato etanólico da casca da mimosa tenuiflora é rico em polifenóis, principalmente taninos, que possuem um poder adstringente e hemostático, ou seja, favorece que as proteínas da região lesada se precipitem, ao formar um revestimento protetor contra o crescimento de micro-organismos e promover uma ação antisséptica (42). o extrato de flores de calendula officinalis contém como principais componentes bioativos os flavonoides, que possuem ação antioxidante e anti-inflamatória, que favorecem o processo de cicatrização (43). 335 práticas integrativas e complementares em saúde no tratamento de feridas crônicas: revisão integrativa da literatura l camila da silva lemos e outros além dos fitoterápicos, destacaram-se os seguimentos da apiterapia, prática que utiliza derivados de abelhas para fins terapêuticos (2). entre esses derivados, estão o próprio mel e o própolis, os quais foram identificados em estudos desta revisão. o uso do mel é eficaz tanto na forma in natura quanto na processada e esterilizada como anti-inflamatório, na redução de edema, na quimiotaxia de macrófagos, na proliferação de angioblastos e fibroblastos e na atividade antimicrobiana; ainda, pode ser uma alternativa de baixo custo (24-27). além da osmolaridade e da acidez, a ação antimicrobiana do mel e do própolis é decorrente de fitoquímicos que estão em sua composição, entre os quais flavonoides, também presentes nos fitoterápicos. mediante os resultados de apiterapia, há de se considerar a necessidade de descrição nos estudos da análise melissopalinológica, em que é analisada a pureza do mel, sendo descrita em apenas um desses. a cobertura primária a que o mel foi impregnado também configura possibilidade de interferência nos resultados dos estudos com o mm. ainda, a própria proveniência do mel — manuka, polifloral — e o de ulmo — unifloral — pode contribuir para o desempenho superior deste último entre os estudos apresentados (24-25, 27). pondera-se, por outro lado, que, apesar de as condições clínicas das lesões serem mais complexas, no estudo com o mel de ulmo, a amostra foi expressivamente menor (4,9 % e 16,7 % da população dos estudos com o mm). mas há de se considerar a sugestão dos autores de que o uso oral da vitamina c pode potencializar a ação anti-inflamatória do mel (25). a variabilidade dos parâmetros utilizados nos estudos para avaliar as condições de cicatrização das lesões impossibilita análises mais aprofundadas para a avaliação conjunta das tecnologias investigadas. variações de descrição entre os próprios grupos (ge-gc), além de um estudo para outro, prejudicaram comparações. observou-se descrição da área total da úlcera e da área média, do índice de contração da úlcera e, ainda, da média desse índice. além disso, a não descrição dos tecidos inviabiliza avaliar o desempenho mais amplo da intervenção. os dados sociodemográficos e clínicos também são desigualmente apresentados nos estudos, o que impossibilita analisar alguma interveniência desses aspectos sobre as pics. de qualquer forma, aponta-se a necessidade de mais estudos comprobatórios da eficácia dessas tecnologias para a cicatrização de feridas crônicas, com base em parâmetros clínicos, uma vez que menor complexidade das lesões, como pequenas áreas, indicam maior probabilidade de epitelização completa. a partir disso, infere-se que os estudos ainda apresentam baixo nível de evidência científica e impossibilitam a indicação das tecnologias, assim como o estabelecimento de critérios clínicos para a respectiva indicação. faz-se imprescindível a reflexão de que a cronicidade das feridas estudadas representa resultado de complexidade clínica importante, a qual prejudica a própria evolução positiva dos casos. dessa forma, por diversas vezes, a cicatrização pode não ser o desfecho possível, mas outros não devem ser desconsiderados na perspectiva da abordagem holística ou integral do indivíduo. compreende-se, assim, a necessidade de investigações dos desfechos relacionados às dimensões para além das biofisiológicas, no que diz respeito à tecnologia utilizada bem como às evidências identificadas. importante ressaltar que em todos os estudos, além das pics, foram consideradas intervenções direcionadas à situação clínica etiológica das úlceras, como terapia compressiva, para as úlceras de perna de origem venosa e para o gerenciamento da mudança de decúbito nas úlceras por pressão. isso deve ser compreendido como integralidade da assistência tanto quanto as intervenções mais abrangentes de dimensões sociopsicoemocionais. conclusão as pics identificadas na literatura para o tratamento de pessoas com feridas crônicas foram fitoterapia, apiterapia e ozonioterapia. os desfechos clínicos envolviam a cicatrização das lesões, sem implicar dimensões humanas mais amplas dessas populações. da mesma forma, os estudos não descreveram o uso dessas modalidades de pics em um contexto de abordagem holística, dissociando-as dos pressupostos da mtc. de qualquer forma, aponta-se a necessidade de mais estudos comprobatórios da eficácia dessas tecnologias para a cicatrização de feridas crônicas, a partir de parâmetros clínicos, uma vez que a menor complexidade das lesões, como pequenas áreas, indicam, isoladamente, maior probabilidade de epitelização completa. novos estudos, mesmo com pics já consagradas pela literatura científica, como acupuntura, necessitam ser desenvolvidos 336 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 para sustentar a indicação e respectivo estabelecimento de critérios clínicos dessas tecnologias ou, ao menos, sua descrição, direcionados à população com feridas crônicas. as diversas modalidades de pics identificadas nos estudos, mesmo as de tratamento tópico de feridas, reforçam o campo promissor de atuação do enfermeiro que precisa ser explorado e avançar no protagonismo. no entanto, ainda são necessárias mais pesquisas clínicas que abordem lesões mais complexas, a fim de sustentar maiores níveis de evidência. conflito de interesse: nenhum declarado. quadro 1. caracterização dos estudos com fitoterápicos quanto a apresentação farmacêutica, características da população estudada, tempo de segmento, objetivos, resultados, conclusão, tipo de estudo e nível de evidência es tu do fitoterápico características da população tempo de segmento objetivos principais resultados conclusões n ív el d e ev id ên ci a e1 (1 2) b ra si l plenusdermax® — calendula officinalis, extrato hidroglicólico. apresentação líquida, com aplicação tópica por spray. aplicação em leito e bordas, aguardando secagem por 5 minutos. tipo de ferida • lesão por pressão (lpp). características sociodemográficas • 41 participantes em atendimento ambulatorial. • sexo masculino: 27 (66 %). • idade: 52 ± 19,2 anos. características clínicas (baseline) • lpp estágio 3 (70,3 %), região glútea (42,8 %), 3,74 cm2 área; 41,4 semanas. • escore total push: 9,63±2,4. • microbiologia: s. aureus, e. coli (14,8 %, ambas). 30 semanas — tempo total de seguimento. avaliação quinzenal. avaliar os benefícios terapêuticos do extrato de bioativos de c. officinalis no controle da colonização microbiológica, evolução tecidual das lesões. • cicatrização completa das lesões por pressão em 88 % dos pacientes em 30 semanas. • média de tempo de cicatrização: 12,5 (±7,8) semanas. • área final das lesões (cm²): 0,55 ± 1,66 (p≤ 0,001). • diminuição da colonização das lesões (p=0,011). • índice de contração da lesão (semana): 36,1 ± 32,6 (p=0,465). o uso do spray plenusdermax® resultou em cicatrização completa, auxiliou no desbridamento das lesões e promoveu a redução significativa de colonização bacteriana. 3 c e2 (1 3) c hi na pomada da fórmula/ preparação chinesa patenteada “tangzu yuyang” (tyo), à base de óleo de gergelim e cera de abelha, e composição predominante de extratos de raízes com ações antioxidante, anti-inflamatória, analgésica, antimicrobiana, inibidora de agregação plaquetária, entre outras. tipo de ferida • úlcera por complicação neuroisquêmica de diabetes mellitus (dm). características sociodemográficas • sexo masculino predominante (75 %, ge; 54,2 %, gc). • idade média: 60 anos, ambos os grupos. grupos (n=48, 24/24) • úlceras predominantemente neuropática (75 %, ge; 66,7 %, gc). • gc: desbridamento e solução salina (tratamento-padrão). • ge: tratamento-padrão e tyo. 24 semanas — tempo total de seguimento. avaliação dias 0, 4, 12, 24. avaliar a eficácia e segurança do composto tópico de ervas chinesas (tyo). houve maior melhora das úlceras no grupo tyo (p=0,017). o número de úlceras completamente cicatrizadas foi semelhante em ambos os grupos, assim como o número de eventos adversos. o tempo de cicatrização foi de 96 ± 56 dias (n=19) no grupo tyo e 75 ± 53 dias (n=14) no grupo swt (p=0,271). tyo associado ao tratamento-padrão é mais efetivo que o tratamento-padrão isoladamente no manejo de úlceras por complicação de dm, além de poucos efeitos colaterais. 1 c e3 (1 4) b ra si l biomembrana vegetal de hevea brasiliensis. aplicação no leito da úlcera, sem ultrapassar as bordas, oclusão com gaze e ataduras. tipo de ferida • úlcera venosa. características sociodemográficas • sexo feminino: 100 % (gc), 64,3 % (gc). • idade: 61,6 anos gc; 64,1 anos ge. grupos (21 participantes) • gc: n=7, 116 meses de duração da úlcera, colagenase com clorafenicol, curativos diários. • ge: n=14, 102,4 meses de duração da úlcera, biomembrana, troca 2/2 dias. contexto • ambulatório de hospital universitário. 120 dias — tempo total de seguimento. avaliações dias 1, 30, 60 e 90. avaliar as alterações clínicas e histológicas da reparação tecidual das úlceras venosas com a biomembrana vegetal da seringueira hevea brasiliensis (vbm), em comparação com o tratamento convencional com colagenase. a redução da área ocorreu similarmente em ambos os grupos (p=0,043). a taxa de cicatrização das úlceras não apresentou diferença estatisticamente significativa entre os grupos (p=0,39) em 30 dias. mas houve aumento progressivo dessa taxa no seguimento (60º, 90º, 120º dia) para o ge. a biomembrana vegetal favoreceu a cicatrização, especialmente na fase inflamatória, o que pode estar relacionado à intensa angiogênese seguida de reepitelização. 1 c 337 práticas integrativas e complementares em saúde no tratamento de feridas crônicas: revisão integrativa da literatura l camila da silva lemos e outros es tu do fitoterápico características da população tempo de segmento objetivos principais resultados conclusões n ív el d e ev id ên ci a e4 (1 5) m éx ic o extrato da casca de mimosa tenuiflora. associação com polietileno-glicol (peg200) e carbopol®. tipo de ferida • úlcera venosa. características • 40 participantes; 61 anos (média); contexto ambulatorial. • média de tempo da úlcera: 8,5 anos. demais características não mencionadas (referência de homogeneidade). grupos • gc: n=20. • ge (n=20): tratamento com hidrogel associado ao peg-200 e ao carbopol®. 13 semanas. avaliação semanal. avaliar a eficácia terapêutica de fármaco a partir do extrato da casca de mimosa tenuiflora no tratamento com úlceras venosas. todas as úlceras tratadas com mimosa tenuiflora foram cicatrizadas ao final das 13 semanas. houve redução de 92 % (média) da área das úlceras na 8ª semana de tratamento, enquanto um do gc apresentou esse efeito terapêutico (p=0,0001). não se observaram efeitos colaterais entre os grupos. efeitos terapêuticos do fármaco foram identificados. necessitam-se estudos para identificar precisamente as propriedades do grupo tanino presente nesse fármaco. 1 b e5 (1 6) b ra si l látex natural (60 %) em folha — palmilha (cobertura primária). sistema composto da associação da palmilha a um dispositivo com liberação de diodo emissor de luz (led). tipo de ferida • úlcera em pé por complicação de dm. características • 5 participantes/10 úlceras; 61 anos (média); contexto ambulatorial. • média de tempo da úlcera: 8,5 anos. demais características não mencionadas (referência de homogeneidade). 4 semanas. avaliação semanal. desenvolver e testar o sistema indutor de cicatrização de úlceras de pé por complicação de dm. houve aumento significativo (p<0,001) no índice de contração da úlcera do ge em relação ao gc. o método proposto parece promissor para esse tratamento. 3d e6 (1 7) s ér vi a plantoderm® (leito da úlcera): pomada de extratos alcoólicos de calendulae off., symphytum off., achilea millefolium, salvia off. fitoven® (pele perilesão e membro inferior): gel de extrato alcoólico de aesculus hipp., melilotus off., rosmarini e lavandulae *tratamento: aplicação 2x/dia, ambos os grupos. tipo de ferida • úlceras venosas. grupos • 32 participantes (ge: 17; gc: 15); atendimento ambulatorial. • gc: antibióticos tópicos conforme antibiograma. • área das lesões (baseline): ge: 7,04 cm2 (±1,4); gc: 6,7 cm2 (±1,1). • bactéria isolada predominante (baseline): s. aureus (ge: 76,5 %; gc: 60 %). características sociodemográficas • ge: sexo feminino (58,8 %); idade média 68,8 anos. • gc: feminino (53,3 %); idade média 68,1 anos. 7 semanas. seguimento semanal. avaliar a cicatrização e efeito antimicrobiológico da terapia de ervas. houve maior redução da área das úlceras do ge (p<0,05) na 7ª semana. houve maior diminuição do número de bactérias isoladas distintas nas úlceras do ge (p<0,05). observaram-se efeitos de cicatrização e anti-microbiológicos da terapia com ervas. 1c e7 (1 8) b ra si l plenusdermax® — calendula officinalis, extrato hidroglicólico. apresentação líquida, com aplicação tópica por spray. aplicação em leito e bordas, aguardando secagem por 5 minutos. tipo de ferida • úlcera venosa. características sociodemográficas (n=57; gc=19; ge=38) • sexo feminino: (58 %, gc; 71 %, ge). • idade: 68 ± 9,8 anos (gc); 63± 10,8 anos. • atendimento ambulatorial. características clínicas (baseline) • duração (semanas): 295 (gc); 269 (ge). • área: 15cm2 (gc); 14,8 cm2 (ge). • predominante tecido de granulação (52,6 % gc e ge), exsudato moderado (47,4 %, gc; 52,6 %, ge), s. aureus (42,1 %, gc; 36,8 %, ge). 30 semanas. 2 avaliações por semana. avaliar a eficácia clínica da calendula off. no tratamento de úlceras venosas. a média de contração da úlcera foi maior entre ge (42,7 mm2/semana) em relação gc (12,3 mm2/semana) (p<0,001). houve aumento 4 vezes maior da velocidade de cicatrização semanal entre ge (7,4 %) em relação ao gc (1,7 %). não se observaram eventos adversos quanto ao uso da calendula off. extrato de calendula officinalis representou tratamento efetivo para úlceras venosas. 1c 338 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 es tu do fitoterápico características da população tempo de segmento objetivos principais resultados conclusões n ív el d e ev id ên ci a e8 (1 9) b ra si l carboximetilcelulose (cmc) 20 % em pasta. aplicação no leito da lesão. umectação de pele perilesão com petrolato. curativos diários (1 vez/dia): 1 vez/ semana no ambulatório (pesquisadores), demais vezes no domicílio (participante/ familiar). tipo de ferida • úlceras venosas. características sociodemográficas • 30 participantes; atendimento ambulatorial. • sexo feminino (53,3 %), 59,9±8,7 anos. características clínicas • área das lesões (baseline): 19,7 cm2. • tempo de duração: > 10 anos (53,3 %). 20 semanas. avaliação semanal. avaliar a eficácia da cmc 20 % na cicatrização de úlceras venosas refratárias ao tratamento convencional. houve redução média da área das úlceras 9,6 cm, o que corresponde a 44,7 % (p=0,0001). autores inferem que cmc 20 % é uma possibilidade terapêutica de baixo custo para o tratamento de úlceras venosas refratárias. 1c e9 (2 0) t ai w an creme tópico de p. amboinicus e c. asiática (wh-1). aplicação 2 vezes ao dia, apenas em leito; camada fina (2mm) e uniforme. tipo de ferida • úlceras por complicação de dm. características sociodemográficas • 24 participantes (12/12). • sexo feminino (66,7 %, wh-1; 58,3 %, aquacel®). • 75,5 anos — wh-1; 69,5 anos — aquacel®. características clínicas • área das lesões (baseline): 3,9 cm2 (wh-1); 4,5 cm2 (aquacel®). 2 semanas. avaliação dias 7 e 14. avaliar o efeito do creme tópico wh-1 comparado ao efeito de hidrocoloide em fibra (aquacel®) em úlceras por complicação de dm. não houve diferença estatisticamente significativa entre os grupos quanto a mudanças na área das lesões (p=0,673). houve leve aumento no grau da classificação wagner entre grupo wh-1 (90,9 %) em comparação com o grupo aquacel (70 %), sem diferença estatisticamente significante. autores afirmam que o creme wh-1 é segura alternativa ao aquacel, mas sem diferença estatística quanto à efetividade. 1c e1 0 (2 1) a us tr ál ia extrato da semente de castanha-da-índia (aesculus hippocastanum). administração oral, 2x/dia. tipo de ferida • úlcera venosa. características sociodemográficas (n=27, gc=12, gnc=15) • sexo masculino: 66,7 %, gc; 73,3 %, gnc; atendimento ambulatorial. • idade: 76 anos (gc); 79 anos (gnc). sem outras descrições para a caracterização da população estudada. 12 semanas. avaliação de 4/4 semanas. identificar características clínicas e padrões de resposta ao tratamento com castanha-da-índia, entre grupo com úlcera cicatrizada (gc) e grupo com úlcera não cicatrizada (gnc). entre o gc, identificaram-se arquétipo de úlceras menores (p=0,12), de menor duração (p=0,09), não histórico de enxerto cutâneo (p=0,08) e uso de psicotrópico (p=0,03). apesar da não evidência estatística, condições clínicas menos complexas são indicadas para o uso de castanha-da-índia, por sugerirem maior efetividade desse fitoterápico. 3e e1 1 (2 2) b ra si l calendula officinalis associada à terapia a laser de baixa intensidade (tlbi), led (diodo emissor de luz). aplicação no leito 5ml de óleo de calêndula (embrafarma®), 1x/ dia, após limpeza com solução salina. tipo de ferida • úlceras por complicação de dm. características • 32 participantes; ambos os gêneros; 40 a 70 anos; dm tipo ii descompensados; sem outras descrições clínicas. grupos c: controle; l: tlbi; age: óleo de calêndula; lage: tlbi com age. 30 dias. avaliação nos dias 0 e 30. avaliar os efeitos da tlbi isolada e associada ao óleo de calendulla off. no reparo de úlceras por complicação de dm. observou-se redução da dor estatisticamente significante para os grupos l (p<0,001) e lage (p<0,001). houve redução da área para os grupos de intervenção, sendo para age, 4,9 para 3,3cm2 (p=0,4658) e lage 9,3 para 2,6 cm2 (p<0,0032). a tlbi isolada ou associada com calendula off. é eficaz no alívio da dor e na redução da área total das úlceras. 2d e1 2 (2 3) m éx ic o extrato de mimosa tenuiflora em gel (mtc-2g). aplicação diária após limpeza com solução salina e desbridamento, quando necessário. oclusão com gaze não aderente, sendo trocado curativo secundário 2x/dia, em caso de maior drenagem de exsudato. tipo de ferida • úlceras venosas. características • 41 participantes (gc: 19; ge: 22) em atendimento ambulatorial; sexo feminino (gc: 68,4 %; ge: 59,1 %); 62 anos (gc), 58 anos (ge). • tempo de duração médio: 38 meses. grupos ge: mtc-2g; gc: mesma fórmula do ge, com exceção do fitoterápico. 8 semanas, com avaliação semanal. avaliar a efetividade e segurança do mtc2g no tratamento de úlceras venosas de pacientes de um centro de referência. houve 9 perdas de seguimento (gc: 5, ge: 4) com motivos clínicos predominantemente relacionados aos protocolos de intervenção. houve redução da área média das úlceras nos dois grupos, sendo superior no ge (6,3cm2/5,8 cm2, p=0,0001, ambos), sem diferença estatística ao se compararem os grupos (p=0,815). os autores referem efeito superior do hidrogel com mtc-2g ao do hidrogel isoladamente, no tratamento de úlceras venosas. 1c fonte: elaboração própria. 339 práticas integrativas e complementares em saúde no tratamento de feridas crônicas: revisão integrativa da literatura l camila da silva lemos e outros quadro 2. caracterização dos estudos quanto a prática integrativa complementar em saúde, características da população estudada, tempo de segmento, objetivos, resultados, conclusão, tipo de estudo e nível de evidência es tu do s descrição da pics características da população tempo de segmento objetivos principais resultados conclusões n ív el d e ev id ên ci a ev id ên ci a e1 3 (2 4) i rl an da curativo à base de mel manuka (mm) (woundcare 18+®), dose de 5g/20cm2, aplicação tópica semanal. tipo de ferida • úlceras venosas. características (gc: hidrogel; ge: mm) • 108 participantes; atendimento ambulatorial ou hospitalar (54/54). • 68 anos (ge-gc). • tempo de duração: 39 (ge); 29 (gc) semanas. • área: 10 cm2 (ge); 9,9 cm2 (gc). • % esfacelo: 85 (ge); 78 (gc), 12 semanas. avaliação semanal. comparar a eficácia e a cicatrização após 12 semanas de mm e terapia-padrão (hidrogel) no tratamento de úlceras venosas. houve maior redução de esfacelo no ge (67 %) que no gc (52,9 %), após a 4ª semana (p=0,054). a redução média da área foi 33 % (ge) e 13 % (gc). após 12 semanas, houve cicatrização de 44 % (ge) e 33 % (gc) (p=0,037). o mm favoreceu incidência de cicatrização e de controle de infecção. 1c e1 4 (2 5) c hi le extrato do mel de ulmo (eucryphia cordifolia), 91 % de pureza, aplicação tópica diária. administração concomitante de ácido ascórbico 500mg, diariamente. tipo de ferida • úlceras venosas. características • 18 participantes, hospitalizados para a intervenção (estudo). • idade média: 64 anos. • tempo de duração médio: 13 meses. • condições clínicas sugestivas de maior complexidade (68,4 %), conforme a categorização usada no estudo; 61 % com infecção local. 60 dias. avaliação a cada 3 semanas. avaliar o efeito clínico de tratamento tópico com o mel de ulmo associado à administração oral de ácido ascórbico em pessoas com úlceras venosas. houve 100 % de cicatrização das úlceras dos participantes, sem sinais de complicação ou reações adversas. a média de tempo de cicatrização foi de 37 dias. o tratamento atendeu à finalidade clínica esperada. autores referem evidência de excelentes resultados e sugerem estudos histológicos. 2c e1 5 (2 6) p ol ôn ia própolis 7 %, aplicação tópica diária, após limpeza com solução salina. tipo de ferida • úlceras venosas. características (ge: própolis 7 %); gc: bota de unna) • 56 participantes; atendimento ambulatorial (28/28). • ge: 50-78 anos; gc: 52-70. • sexo feminino (ge: 61 %; gc: 64 %). • tempo de duração: 15-36 (ge); 13-38 (gc) meses. • área: 7-10 cm2 (ge); 7-9 cm2 (gc). 16 semanas; avaliação semanal. avaliar a efetividade do tratamento tópico de própolis na cicatrização de úlceras venosas. houve cicatrização de 100 % do ge na 6ª semana, 21 % do gc na 16ª semana. tempo médio de cicatrização foi menor no ge (24 dias) que no gc (76 dias) (p<0,005). o uso do própolis aumenta a eficácia do tratamento com bandagem compressiva de curto estiramento, sendo mais efetivo que tratamento com bota de unna isoladamente. 1c e1 6 (2 7) n ov a ze lâ nd ia curativo a base de alginato de cálcio impregnado com mel manuka (mm) (apinatetm umf® 18+), aplicação a cada troca das bandagens compressivas, conforme necessidade clínica. tipo de ferida • úlceras venosas. características • 368 participantes; atendimento ambulatorial (ge: 187; gc: 181). • ge: 66,9 anos; gc: 68 anos • sexo feminino (ge: 51,3 %; gc: 50,8 %). • tempo médio de duração: 20 (ge), 16 (gc) semanas. • área média: 2,7cm2 (ge), 2,6cm2 (gc). 12 semanas, avaliação semanal. avaliar a efetividade do curativo impregnado com mm no tratamento de úlceras venosas. houve aumento de 5,9 % na cicatrização do ge (55,6 %) em relação ao gc (49,7 %) (p=0,258). a diferença média do tempo de cicatrização foi 1,8 dia, superior no gc (65,3 dias) em relação ao ge (63,5 dias) (p=1,553). o tratamento com mm foi mais oneroso e associado a eventos adversos (p=0,013). o estudo não demonstrou melhora estatisticamente significativa, para a cicatrização em 12 semanas de úlceras venosas, mediante o uso de curativo impregnado com mm, em relação ao tratamento usual. 1c 340 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 fonte: elaboração própria. es tu do s descrição da pics características da população tempo de segmento objetivos principais resultados conclusões n ív el d e ev id ên ci a ev id ên ci a e1 7 (2 8) i sr ae l ozonioterapia associada ao tratamento convencional. tipo de ferida • úlceras por complicação de dm. características • 61 participantes; atendimento ambulatorial (ge: 32; gc: 29). • ge: 62,6 (±9,8) anos. • sexo masculino: 62 %. • classificação de wagner: estágios 2, 3 e 4 após o desbridamento. • úlceras de ≥ 8 semanas de duração. 12 semanas. avaliação semanal. examinar a eficácia da ozonioterapia não invasiva no tratamento de úlceras por complicação de dm. não houve diferença estatisticamente significativa quanto à cicatrização completa entre os grupos (ge: 41 %; gc: 33 %, p=0,34). entre os 34 participantes que completaram o protocolo do estudo (ge: 16; gc: 18), houve maior taxa de cicatrização completa para o ge (81 %) que para o gc (44 %) (p=0,03). em relação à completa cicatrização de úlceras por complicação de dm, o tratamento com ozonioterapia complementar ao tratamento convencional foi superior a este isoladamente. 1c e1 8 (2 9) r om ân ia óleo ozonizado associado ao α-bisabolol, aplicação diária. tipo de ferida • úlceras venosas. características • 29 participantes; atendimento ambulatorial (ge: 15; gc: 14). gc: creme que contém vitaminas a e e, talco e óxido de zinco. 30 dias. avaliação nos dias 0, 7, 14 e 30. avaliar a eficácia da fórmula de óleo ozonizado e α-bisabolol comparado a tratamento-padrão com creme de epitelização. a proporção de cicatrização completa foi maior no ge (25 %) que no gc (0 %), ao final do tratamento. mudanças na área da lesão foram maiores no ge que no gc (p<0,05), com progressiva diminuição. a fórmula de óleo 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2013(254017):1-5. 27. jull a, walker n, parag v, molan p et al. randomized clinical trial of honey-impregnated dressings for venous leg ulcers br j surg. 2008;95:175-82. https://www.ncbi.nlm.nih.gov/pubmed/?term=rivera-arce e%5bauthor%5d&cauthor=true&cauthor_uid=17088036 https://www.ncbi.nlm.nih.gov/pubmed/?term=chávez-soto ma%5bauthor%5d&cauthor=true&cauthor_uid=17088036 https://www.ncbi.nlm.nih.gov/pubmed/?term=herrera-arellano a%5bauthor%5d&cauthor=true&cauthor_uid=17088036 https://www.ncbi.nlm.nih.gov/pubmed/?term=arzate s%5bauthor%5d&cauthor=true&cauthor_uid=17088036 https://www.ncbi.nlm.nih.gov/pubmed/?term=agüero j%5bauthor%5d&cauthor=true&cauthor_uid=17088036 https://www.ncbi.nlm.nih.gov/pubmed/?term=feria-romero ia%5bauthor%5d&cauthor=true&cauthor_uid=17088036 http://dx.doi.org/10.1155/2012/418679 342 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 28. wainstein j, feldbrin z, boaz m, harman-boehm i. efficacy of ozone-oxygen therapy for the treatment of diabetic foot ulcers. diabetes technol ther. 2011;13(12):1255-60. 29. solovăstru lg, stîncanu a, de ascentii a, capparé g, et al. randomized, controlled study of innovative spray formulation containing ozonated oil and α-bisabolol in the topical treatment of chronic venous leg ulcers. adv skin wound care. 2015;28(9): 406-9. 30. frykberg rg, banks j. challenges in the treatment of chronic wounds. advances in wound care. 2015;4(9): 560-82. 31. wounds uk. best practice statement: holistic management of venous leg ulceration. londres: wounds uk; 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[acesso 20 jun. 2018]. disponível em: https://uit.no/content/336413/deliverable%209%20-%20report%20no.2%20cam%20medicinal%20products-webb.pdf 42. simões cmo, schenkel ep, mello jcp, mentz la, petrovick pr. farmacognosia: do produto natural ao medicamento. porto alegre: artmed; 2017. 43. olennikov dn, kashchenko ni. componential profile and amylase inhibiting activity of phenolic compounds from calendula officinalis l. leaves. the scientific world j. 2014(654193): 1-9. https://www.ncbi.nlm.nih.gov/pubmed/?term=solov%c4%83stru lg%5bauthor%5d&cauthor=true&cauthor_uid=26280699 https://www.ncbi.nlm.nih.gov/pubmed/?term=st%c3%aencanu a%5bauthor%5d&cauthor=true&cauthor_uid=26280699 https://www.ncbi.nlm.nih.gov/pubmed/?term=de ascentii a%5bauthor%5d&cauthor=true&cauthor_uid=26280699 https://www.ncbi.nlm.nih.gov/pubmed/?term=cappar%c3%a9 g%5bauthor%5d&cauthor=true&cauthor_uid=26280699 https://www.ncbi.nlm.nih.gov/pubmed/26280699 https://www.ncbi.nlm.nih.gov/pubmed/26280699 261 editorial building the science of nursing interventions in latin america construyendo la ciencia de las intervenciones de enfermería en latinoamérica construindo a ciência das intervenções de enfermagem na américa latina doi: 10.5294/aqui.2018.18.3.1 once the protocol has been developed, feasibility and pilot studies are necessary to determine recruitment, participation, implementation, as well as to explore the potential effect on outcomes of interest. upon successful completion of pilot studies, intervention protocols are finalized and efficacy trials are conducted to determine the effect of the nursing intervention on mediating and proximal outcomes. while this process can take considerable time and effort, much can be learned to enhance intervention implementation, outcomes, and scalability. adapting evidence-based interventions from one global context to another is another important priority for nursing science and practice. over the past 20 years, considerable evidence on the efficacy of many nursing interventions has been established. thus, there is a need for systematic reviews of nursing interventions to be conducted to inform global health initiatives. for nurses in latin america countries, evidence from the united states or other countries will often need to be adapted to the culture, context, and health care system. cultural adaptation has been defined as “the systematic modification of an evidence-based treatment (ebt) or intervention protocol to consider language, culture, and context in such a way that it is compatible with the client’s cultural patterns, meanings, and values” (4). several models have been proposed to guide the cultural adaptation and evaluation of interventions that are relevant to nursing (5). steps to this process include information gathering, preliminary adaptation design of intervention, preliminary adaptation test of interglobally, there has been a shift in health care from a focus on communicable diseases to address increased longevity of life and non-communicable diseases. many countries worldwide not only need to prevent and control infectious diseases, but must also address the morbidity and mortality associated with chronic disease, such as diabetes and cardiovascular disease (1). nurses play an important role in global health, both in the prevention and management of communicable and non-communicable disease. recent initiatives in the united states advocate for nurses to practice to the full extent of their education and training within collaborative models of health care (2). this applies to nurses globally. building the evidence-base of nursing interventions will improve nursing autonomy in practice and health outcomes. thus, nurses need to be developing evidence to improve global health outcomes, adapting evidence-based interventions to the local context, as well as evaluating the implementation process and outcomes of evidence-based interventions. the development and evaluation of nursing interventions requires a systematic and scientific process as many nursing interventions are complex, with multiple components, requiring specification of the content, dose, timing, and outcomes (3). formative work is often required to better understand the needs of stakeholders (providers and patients) to optimize the protocol and ensure the feasibility and acceptability of novel interventions. robin whittemore1 1 orcid.org/0000-0001-9434-0230. yale school of nursing, united states of america. robin.whittemore@yale.edu http://orcid.org/0000-0001-9434-0230 262 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 vention (for feasibility and acceptability), adaptation refinement, and lastly implementation and evaluation. latin american nursing research has grown significantly in the past several decades (6). strategies to continue to enhance the development and implementation of culturallyrelevant evidence-based nursing interventions include: building the research infrastructure of nursing research through participation in conferences and workshops such as the pan american nursing research colloquium2 and/or international research meetings (nursing and interdisciplinary); building collaborations across universities and between universities and clinical settings; and disseminating research results through conference presentations and publications. there is much to be gained by the development and evaluation of nursing interventions world-wide. 2 more information in: https://www.caipe.org/news/xvi pan american nursing research colloquium referencias 1. world health organization. chronic diseases and health promotion: integrated chronic disease prevention and control. 2018. available from: http://www.who.int/chp/about/integrated_cd/en/ 2. institute of medicine. assessing progress in the institute of medicine report: the future of nursing. washington d.c.: national academy of sciences; 2015. 3. whittemore r, grey m. the systematic development of nursing interventions. journal of nursing scholarship. 2002; 34: 115-120. 4. bernal g, jimenez-chafey mi, domenech-rodríguez mm. cultural adaptation of treatments: a resource for considering culture in evidence-based practice. professional psychology: research and practice. 2009; 40: 361–368. 5. barrera m, castro fg, strycker la, toobert d. cultural adaptations of behavioral health interventions: a progress report. journal of consulting and clinical psychology. 2013; 81: 196-205. 6. mendoza‐parra s, paravic‐klijn t, muñoz‐muñoz am, barriga oa, jiménez‐contreras e. visibility of latin american nursing research (1959-2005). journal of nursing scholarship. 2009; 41: 54-63. https://www.caipe.org/news/xvi http://www.who.int/chp/about/integrated_cd/en/ 393 editorial spiritualty based on the roy adaptation model for use in practice, teaching and research espiritualidad basada en el modelo de adaptación de roy para uso en la práctica, la enseñanza y la investigación espiritualidade baseada no modelo de adaptação de roy para uso na prática, ensino e pesquisa doi: 10.5294/aqui.2018.18.4.1 this aspect of self embraces a belief system and an evaluation of who one is in relation to the universe. the person asks the question: “why am i here?” or, based on a particular belief system, “why did god make me?” the characteristics of this part of the personal self include how the self is viewed in relation to one’s sacred, ethical beliefs and value system. the processes of selfconcept add to the consistency, unity and organization of self over time. the process of focusing self is particularly relevant to spiritualty. it involves being in touch with self in a way that surfaces hope, energy, continuity, meaning, purpose and pride. through this process, there is an awareness of who one is and one’s place as an individual among other people in society. it moves the self beyond individualism to perceiving self as part of the common patterns and integral relations of persons and earth, and includes an identity of self within groups. with the ram view of spiritualty based on veritivity and the moral-ethical-spiritual self, we can derive approaches for nursing practice. a nurse will always convey deep respect for the other’s common humanity; demonstrate empathy; show one’s own dependence on god and commitment to faith; believe in another spiritual self; be nonjudgmental about how that self is expressed; and create a trusting relationship. some specific strategies for individuals and families will include active listening; helping to find ways to connect with god, if desired; facilitating religious practices; reading scripture, as relevant; facilitating spiritual thoughts and feelings; praying with and for the other person; in today’s fast-paced and complex world, the need for spiritualty is greater than ever. the roy adaptation model (ram) (1) provides a strong basis for spiritualty. spirituality allows us to look beyond the material world to have a central experience of seeking a higher power. this seeking is related to the essence of the person and their relationships with others. through spirituality, we search for fulfillment, meaning and purpose in life. the ram (1) reflects spiritualty as rooted in the philosophical assumption of veritivity that sees truth in a creator with principles of unity, diversity and self-expression reflected in all of creation, the earth and in people. people have a basic need for spiritualty. according to the model, spirituality is an influencing factor or stimulus for all adaptive behavior. spirituality is also a strategy for coping and adapting. common human spiritual experiences are wonder, awe and gratitude for life, along with acknowledgement of human dependence, finitude and interdependence. strategies for spiritualty, in practice, include understanding and valuing unity, diversity and self-expression. based on understanding earth spiritualty, nurses use knowledge, values and commitment to create just structures; to strive for equitable distribution of the earth’s resources; and to promote the integration of people with their environment. in the self-concept adaptive mode, the personal self includes the moral-ethical-spiritual self. callista roy1 1 william f. connell school of nursing boston college, united states of america. royca@bc.edu http://dx.doi.org/10.5294/aqui.2018.18.4.1 394 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 protecting the patient’s religious articles; and referring to spiritual care experts, as desired. some years ago, stoll (2) provided several guidelines for spiritual assessment that give four major categories and examples of questions. these can be useful today, if adjusted according to the particular nurse-patient situation. first, the nurse finds out about the concept of god or a deity by asking questions such as: “is religion or god significant to you?” “do you find prayer helpful?” secondly, there are questions about sources of hope and strength, particularly people and relationships, for example: “who is the most important person to you?” or “to whom do you turn when you need help?” the third category is religious practices and the nurse can ask questions such as “do you feel your faith is helpful to you?” “has your illness interfered with any religious practices that are important to you?” lastly, the nurse can assess the relationship between spiritual belief and health, including existential concerns or visions for the future by asking questions like “what has bothered you most about being sick (or what is happening to you)?” “what do you think is going to happen to you?” based on these insights into what spiritualty is and how the ram provides a basis for including spirituality in practice, the nurse can take the further important step of teaching others about the use of spirituality. finally, we need to learn more about spiritualty in nursing and to further research in this regard. the view of spirituality provided herein offers many possibilities for designing both qualitative and quantitative research to develop knowledge about spirituality in nursing. references 1. roy c. the roy adaptation model. 3rd ed. upper saddle river, nj: prentice hall health; 2009. 2. stoll r. guidelines for spiritual assessment. am j nurs. 1979; 79(9): 1574-7. available from: https://journals.lww.com/ ajnonline/citation/1979/09000/guidelines_for_spiritual_assessment.41.aspx https://journals.lww.com/ajnonline/citation/1979/09000/guidelines_for_spiritual_assessment.41.aspx https://journals.lww.com/ajnonline/citation/1979/09000/guidelines_for_spiritual_assessment.41.aspx 407 jacqueline fawcett1 lorraine tulman2 adaptation to high-risk childbearing: a preliminary situation-specific theory* 1 orchid.org/0000-0002-1091-8873. department of nursing, university of massachusetts, united states of america. jacqueline.fawcett@umb.edu 2 orcid.org/0000-0002-1579-0602. school of nursing, university of pennsylvania, united states of america. tulman@nursing.upenn.edu * this paper is adapted from fawcett j, tulman l, lowry l. correlates of maternal and paternal functional status during high risk pregnancy and the postpartum: a pilot study. roy adaptation association review 2012, spring; 15(2): 4-6. with permission of c. roy. we are grateful to dr. lois lowry (deceased) for her substantial contributions to the study that is the source of data for this paper. recibiddo: 16/08/2018 enviado a pares: 14/09/2018 aceptado por pares: 10/10/2018 aprobado: 26/10/2018 doi: 10.5295/aqui.2018.18.4.3 to reference this article / para citar este artículo / para citar este artigo fawcett j, tulman l. adaptation to high-risk childbearing: a preliminary situation-specific theory. aquichan 2018; 18(4): 407-414. doi: 10.5295/aqui.2018.18.4.3 abstract the purpose of this paper is to present a discussion of a preliminary situation-specific theory of adaptation to high-risk childbearing for expectant and new mothers and fathers. roy’s adaptation model guided the design and conduct of the pilot study of correlates of maternal and paternal functional status from which the theory was derived. the conceptual-theoretical-empirical structure for the study is displayed in a diagram. the concepts of the theory—functional status, physical symptoms, physical energy, psychological symptoms, and relationship quality--are identified and defined, and their linkages are identified. implications for testing and potential use of the theory in nursing practice are discussed. keywords (source: decs) functional status; mothers; fathers; childbearing; reproductive behavior; roy adaptation model; situation-specific theory. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 407-414 the topic: epistemology contribution to the discipline: development of the theory that we present in this paper was guided by the roy adaptation model of nursing, which is one of the most widely used nursing conceptual models for research, education, and practice. the theory is based on data from a pilot study of mothers’ and fathers’ adaptation to high-risk childbearing, a population whose experiences have not yet been studied extensively. we regard the theory as preliminary, due to the small number of study participants, a number that is acceptable for a pilot study. we also regard the theory as situation-specific due to its focus on a specific population (expectant and new parents) and a specific health condition (childbearing). the theory adds to the continuing growing amount of theoretical literature associated with the roy adaptation model and to the growing number of situation-specific theories. future research with larger numbers of participants may provide data that will support or call for revisions of this preliminary theory and suggest ways in which the theory could be used to guide nursing practice with mothers and fathers who are experiencing high risk childbearing. reflection paper http://dx.doi.org/10.5294/aqui.2018.18.4.3 http://dx.doi.org/10.5294/aqui.2018.18.4.3 408 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 407-414 adaptación a la maternidad de alto riesgo: una teoría preliminar específica de la situación resumen el propósito de este artículo es presentar una discusión sobre una teoría preliminar específica, de la situación de la adaptación a la maternidad de alto riesgo, para las futuras madres y los nuevos padres. el modelo de adaptación de roy sirvió de guía para el diseño y la realización del estudio piloto de correlatos del estado funcional materno y paterno del cual se derivó la teoría. la estructura conceptualteórico-empírica para el estudio se muestra en un diagrama. se identifican y definen los conceptos de la teoría: estado funcional, síntomas físicos, energía física, síntomas psicológicos y calidad de la relación, y se identifican sus vínculos. se discuten las implicaciones para las pruebas y el uso potencial de la teoría en la práctica de enfermería. palabras clave (fuente: decs) estado funcional; madres; padres; parto; conducta reproductiva; modelo de adaptación de calista roy; teoría específica de la situación. 409 adaptation to high-risk childbearing: a preliminary situation-specific theory l jacqueline fawcett and other adaptação à maternidade de alto risco: uma teoria preliminar específica da situação resumo o objetivo deste artigo é apresentar uma discussão de uma teoria preliminar específica da situação de adaptação à maternidade de alto risco para as futuras mães e os novos pais. o modelo de adaptação de roy serviu como um guia para desenho e implementação do estudo piloto de correlatos do estado funcional materno e paterno do qual a teoria foi derivada. a estrutura conceitual-teórico-empírica para o estudo é mostrada em um diagrama. os conceitos da teoria são identificados e definidos: estado funcional, sintomas físicos, energia física, sintomas psicológicos e qualidade da relação, e seus elos são identificados. as implicações para o teste e o uso potencial da teoria na prática de enfermagem são discutidas. palavras-chave (fonte: decs) estado funcional; mães; pai; parto; comportamento reprodutivo; modelo de adaptação de roy; teoria em situação-específica. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 407-414 410 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 the purpose of this paper is to present a preliminary situation-specific theory that is based on the findings of a pilot study of correlates of maternal and paternal functional status during high-risk pregnancy and the postpartum (1), and to discuss how the theory could be tested and used in nursing practice. the pilot study and derivation of the theory were guided by roy’s adaptation model (ram) (2). a pilot study typically includes a relatively small number of participants and is conducted to determine whether a study with a larger number of participants would be feasible. determination of feasibility includes the appropriateness of the research design, the adequacy of the procedures used to recruit and retain participants and to collect and analyze the data, the appropriateness of the empirical indicators (research instruments), and effect sizes (3, 4). effect size refers to the magnitude of the association between empirical indicators for concepts, rather than statistical significance (5). a situation-specific theory is defined as a set of concepts and statements about the concepts that address a specific population and a specific health condition (6). the statements about the concepts include their theoretical and operational definitions, and the links between the concepts. definitions are the non-relational propositions of a theory, whereas statements of linkages are the relational propositions (3). our preliminary situation-specific theory focuses on a population of expectant and new mothers and fathers experiencing high-risk childbearing. the pilot study was the next step in a program of research addressing functional status during low-risk childbearing, which began 30 years ago with women from mid-atlantic states (7-9) the pilot study was approved by university and hospital institutional review boards and all participants gave written or oral informed consent. each study participant was compensated $10 for time spent on data collection. the participants, who resided in either a new england or a southern state of the united states of america, were recruited from hospital clinics and a private physician’s office. the typical study participant was 31 years of age; white, non-hispanic; had at least a high school education; and was employed outside the home or was on maternity or paternity leave. data were collected in person or by telephone. descriptive statistics (means, standard deviations, ranges) indicated that maternal functional status was relatively high during pregnancy, whereas paternal functional status was moderate at that time. both maternal and paternal functional status was moderate during the postpartum. the preliminary situation-specific theory: adaptation to high-risk childbearing the conceptual-theoretical-empirical structure for the pilot study is depicted in the figure. as can be seen in the figure, the ram adaptive system was represented by expectant and new mothers and fathers; the samples from the pilot study were the empirical indicators. the focal stimulus was represented by high-risk pregnancy, as documented by a healthcare provider. contextual stimuli were represented by demographic variables, recorded on the background data sheet; these data were used to describe the characteristics of the samples. the five concepts of the situation-specific theory of adaptation to high-risk childbearing were linked to the ram adaptive modes. functional status, measured by inventories of functional status (10-12), represented the ram role function mode. physical symptoms, measured by the symptoms checklist (13), and physical energy, measured by the physical energy scale (8), represented the ram physiological mode. psychological symptoms, measured by the symptoms checklist (13), represented the ram self-concept; relationship quality, measured by the relationship change scale (14), represented the ram interdependence mode. (see the figure). the theoretical definition for each concept and the way in which each concept was measured are given in table 1. the relational propositions for the situation-specific theory are based on the ram proposition that responses in one adaptive mode are associated with responses in other adaptive modes (2). for the purposes of development of the situation-specific theory of adaptation to high-risk childbearing, the relations of the physiological, self-concept, and interdependence modes to the role function mode are relevant. the relational propositions of the theory, which are listed below, were determined by an examination of the magnitude of the correlations of the empirical indicators for the theory concepts representing the modes of adaptation. the correlations seen in table 2 are interpreted as effect sizes; statistical significance was not relevant due to the small sample sizes (5). correlations below 0.10 are too small to be considered as meaningful relations and, therefore, are not included as relational propositions for the theory. 411 adaptation to high-risk childbearing: a preliminary situation-specific theory l jacqueline fawcett and other figure 1. conceptual-theoretical-empirical structure for a pilot study of correlates of maternal and paternal functional status during high-risk pregnancy and the post-partum. source: own elaboration. table 1. definitions of the concepts of the theory of adaptation to high-risk pregnancy concept theoretical definitions empirical indicators functional status continued performance of an individual’s usual household, social and community, family, personal care, occupational, and educational activities during pregnancy and the postpartum, and assumption of infant care responsibilities during the postpartum inventory of functional status-antepartum period (tulman et al., 1991) inventory of functional status after childbirth (fawcett, tulman, & myers, 1988) inventory of functional status-fathers (tulman, fawcett, & weiss, 1993) physical symptoms twenty common physical complaints and/or discomforts experienced during pregnancy or the postpartum ( indigestion, nausea and/or vomiting, increase or decrease in appetite, food cravings, constipation, diarrhea, increased urination, hemorrhoids, backache, toothache, difficult breathing, sensitivity to odors, skin irritations, feel warmer than usual, feel bloated, more or less active than usual, feel clumsy or awkward, feel tired or sleep often) symptoms checklist (fawcett & york, 1986) physical energy level of energy felt during pregnancy or the postpartum compared to pre-pregnancy level of energy physical energy scale (tulman & fawcett, 2003) psychological symptoms three common emotional feelings during pregnancy or the postpartum (anxiety, depression, feel better than usual) symptoms checklist (fawcett & york, 1986) relationship quality the individual's perception of changes in the relationship with his or her partner with regard to satisfaction, communication, trust, intimacy, sensitivity, openness, and understanding, compared to prior to the current pregnancy relationship change scale (guerney, 1977). source: own elaboration. roy adaptation model adaptive system focal stimulus contextual stimuli physiological mode self-concept mode interdependence mode role function mode expectant and new mothers and fathers high-risk pregnancy demographic variables physical symptoms physical energy psychological symptoms relationship quality maternal and paternal functional status 48 high-risk pregnant women and 34 of their male partners 11 women who had had high-risk pregnancies and 10 of their male partners healthcare provider documentation background data sheet symptoms checklist physical energy scale symptoms checklist relationship change scale inventory of functional status-antepartum period inventory of functional status after childbirth inventory of functional status-fathers cross-sectional research design descriptive statistics spearman’s rho correlation coefficients 412 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 table 2. effect sizes (spearman’s rho correlation coefficients) for correlates of maternal and paternal functional status during pregnancy and the postpartum inventories of maternal and paternal functional status symptoms checklist-physical symptoms physical energy scale symptoms checklist psychological symptoms relationship change scale maternal functional status: inventory of functional status-antepartum period -0.39** 0.39** 0.04 -0.02 paternal functional status: inventory of functional status—fathers (pregnancy) 0.08 -0.03 0.01 -0.20* maternal functional status: inventory of functional status after childbirth -0.22* 0.23* -0.37** -0.43** paternal functional status: inventory of functional status-fathers (postpartum) 0.14* -.29** 0.05 -0.57*** *small effect sizes (rho = .10) are considered relations of low magnitude; **medium effect sizes (rho = .30) are considered relations of moderate magnitude; ***large effect sizes (rho = .50) are considered relations of large magnitude. source: own elaboration during pregnancy, for expectant mothers: • there is a negative relation of moderate magnitude between physical symptoms and maternal functional status; so, the greater the number of physical symptoms, the lower the maternal functional status. • there is a positive relation of moderate magnitude between physical energy and maternal functional status; so, the greater the level of physical energy, the higher the maternal functional status during pregnancy, for expectant fathers: • there is a negative relation of low magnitude between relationship quality and paternal functional status; so, the less the change in relationship quality, the greater the paternal functional status during the postpartum, for new mothers: • there is a negative relation of low magnitude between physical symptoms and maternal functional status; so, the greater the number of physical symptoms, the lower the maternal functional status. • there is a positive relation of low magnitude between physical energy and maternal functional status; so, the greater the level of physical energy, the higher the maternal functional status • there is a negative relation between psychological symptoms and maternal functional status; so, the greater the number of psychological symptoms, the lower the maternal functional status. • there is a negative relation of moderate magnitude between relationship quality and maternal functional status; so, the less the change in relationship quality, the greater the maternal functional status. during the postpartum, for new fathers: • there is a positive relation of low magnitude between physical symptoms and paternal functional status; so, the greater the number of physical symptoms, the higher the paternal functional status • there is a negative relation approaching moderate magnitude between physical energy and paternal functional status; so, the greater the physical energy, the lower the paternal functional status 413 adaptation to high-risk childbearing: a preliminary situation-specific theory l jacqueline fawcett and other • there is a negative relation of large magnitude between relationship quality and paternal functional status; so, the less the change in relationship quality, the greater the paternal functional status. discussion as can be seen in table 2, the correlations on which the relational propositions are based revealed that correlates of maternal functional status differ from correlates of paternal function status, these correlations also revealed that physical symptoms and physical energy during pregnancy have relations with maternal functional status of stronger magnitude than did these concepts during the postpartum; that is, effect sizes were larger during pregnancy than during the postpartum. in addition, the correlations revealed that relationship quality had the greatest influence on both maternal and paternal functional status postpartum than any other concept; that is, the largest effect sizes were for relationship quality for both parents during the postpartum. implications for nursing research and nursing practice the situation-specific theory of adaptation to high-risk pregnancy is at a preliminary stage of development. future research should focus on determining the empirical adequacy of the theory by testing each of the relational propositions to determine whether the effect sizes are stable with larger samples. ideally, a longitudinal study should be conducted to follow expectant parents from early in pregnancy through at least six months postpartum. although it is tempting to recommend how the theory could be used in practice at this time, it is important to wait until research findings indicate whether the theory is empirically adequate. however, a test of the theory could be conducted in the “real world” of clinical nursing practice, rather than in a “formal” research project. the benefit of this approach would be that a nurse researcher from a university could form a partnership with one or more nurses who are in the “real world” of practice to test the theory propositions, as well as to determine the feasibility of implementing the theory in practice. references 1. fawcett j, tulman l, lowry l. correlates of maternal and paternal functional status during high risk pregnancy and the postpartum: a pilot study. raa rev. 2012; 15(2): 4-6. 2. roy c. the roy adaptation model. 3rd ed., upper saddle river (nj): pearson, 2009 3. fawcett j, garity j. evaluating research for evidence-based nursing practice. philadelphia (pa): fa davis company, publishers, 2009. 4. prescott pa, soeken k. the potential uses of pilot work. nurs res. 1989; 38:60-62. 5. cohen j. a power primer. psych bull. 1992; 112:155-9. 6. meleis ai. theoretical nursing: development and progress. 5th ed., philadelphia (pa): wolters kluwer health/lippincott williams & wilkins. 2012. 7. tulman l, fawcett j. return of functional ability after childbirth. nurs res, 1988: 37: 77-81. 8. tulman l, fawcett j. women’s health during and after pregnancy: a theory-guided study of adaptation to change. new york (ny): springer publishing company, 2003. 9. tulman l, fawcett j, groblewski l, silverman l. (1990). changes in functional status after childbirth. nurs resl 1990; 39:70-5. 10. tulman l, higgins k, fawcett j, nunno c, vansickel c, haas mb, et al. the inventory of functional status-antepartum period: development and testing. j nurs midwif. 1991; 36:117-23. 414 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 11. tulman l. fawcett j. weiss m. the inventory of functional status-fathers: development and psychometric testing. j nurs midwif. 1993; 38:276-82. 12. fawcett j. tulman l, myers st. (1988). development of the inventory of functional status after childbirth. j nurs midwif.1988; 33:252-60. 13. fawcett j, york r. spouses’ physical and psychological symptoms during pregnancy and the postpartum. nurs res.1986; 35:144-8. 14. guerney bg. relationship enhancement. san francisco (ca): jossey-bass, 1977. ��������� ���� ������ ���������� ���� �� �� ����� �� �� �� •� ������ ��������� �� ������ ����� ���� �� �� ����� �� �� �� •� ������ ��������� �� ������ ���� ���������� ��� � � � ����� � ���� �������� ������ � ����������� �������� ��� ��������� ����� � ������ �� ������ ��������� � �������� ���������� ���� ���������� �� ��� � ������� � ���� �� ���������� ���� � � ����� ��� ������������ �������� �� �� ����� � �� � ������ ���� ���������� ��������������� �� � ������ � � ����� ��������� ��� ���������� ������������� � ������� ��! �� ��������� ��� ���� �� ������� ���� �� � � �������� ��� �� ���� � � � ������ �� �������������� �� ��������"��������� � ��������� � ���� �� ������� � 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���� ������������� ������� ��� ������ ������ ���� ���� � �������� ���� ����������� ���� � � �����4� �� ��� ����� � ��� � �� �� ��� �# ��� ���� ��� ���������� ����������������������������� ��� ����� ����� ��������� � � ������� ���� �� ���� ����� ���������� ����������� ������ ��� ��� �� � ����� �0���� � ��������� ������ � � ������ ������ �� � �� ������� ��� �� ���� ����� ��'���� � �'� ������ ����4�����=� ������ ��>�� =���� ������ ��� ���� ��5��� ���: �������'��� ����������� �7���� �����" ����� �� �������� ������� � �� ��� ���# ������� �� ����� ����������������" ������ ����������'� �� ��� ��������$� ����� � �� ����������� 9�����'�����?�� � ��� � 5�� ����� ��������� � ��@� ����� �� ����� 275 chanita tantacharoenrat1 tassanee prasopkittikun2 somsiri rungamornrat3 kawewan limprayoon4 use of a user-friendly tablet application to communicate with pediatric patients on mechanical ventilators 1 orcid.org/0000-0003-1037-5175. mahidol university, thailand. chanita.tan@mahidol.ac.th 2 orcid.org/0000-0001-6168-6622. mahidol university, thailand. tassanee.pra@mahidol.ac.th 3 orcid.org/0000-0002-8162-4899. mahidol university, thailand. somsiri.run@mahidol.ac.th 4 orcid.org/0000-0002-3856-9812. mahidol university, thailand. kaweewan.lip@mahidol.ac.th received: 03/05/2018 sent to peer reviewers: 08/05/2018 accepted by peers: 25/07/2018 approved submission: 15/08/2018 doi: 10.5294/aqui.2018.18.3.3 to reference this article / para citar este artículo / para citar este artigo tantacharoenrat c, prasopkittikun t, rungamornrat s, limprayoon k. use of a user-friendly tablet application to communicate with pediatric patients on mechanical ventilators. aquichan. 2018; 18(3): 275-286. doi: 10.5294/aqui.2018.18.3.3 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 275-286 the topic: evidence-based practice. contribution to the discipline: the contribution of this study to the nursing discipline is twofold. first, use of a user-friendly tablet application to communicate with voiceless pediatric patients on a mechanical ventilator demonstrates how to incorporate information technology into nursing practice. second, the study findings encourage pediatric nurses to bring a technology-based assistive communication device to enhance two-way communication for supporting nurse/caregiver-patient interaction and providing responsive care. abstract objectives: to examine the effect of using a tablet application as a communication aid with mechanically ventilated pediatric patients on communication satisfaction of nursing staff and caregiver-patient dyads. materials and method: the one-group pretest-posttest design was used to examine communication satisfaction for the nursing staff, and a nonequivalent pretest-posttest control group design was used for caregivers. the sample comprised 44 nursing staff and 18 dyads of caregivers and the ventilated pediatric patients from two hospitals in thailand. a paired t-test was used for comparison of nursing staff, the mann-whitney u test for comparison of caregivers, and descriptive statistics to describe the children’s satisfaction. results: the nursing staff was more satisfied with communication using the tablet application than regular communication methods (t = -9.13, df = 43, p < .001). caregivers who used the tablet application also reported more communication satisfaction, compared to those who used regular communication methods (u = -3.41, p < .001). nearly 90% of the pediatric patients reported being completely satisfied with the use of the application. conclusions: the tablet application designed for facilitating communication with mechanically ventilated pediatric patients improved communication satisfaction. it should be encouraged as one of the assistive communication devices for wide use. keywords communication; pediatric nursing, personal satisfaction; tablet applications; mobile applications; ventilators (source: mesh). http://orcid.org/0000-0003-1037-5175. http://orcid.org/0000-0001-6168-6622. http://orcid.org/0000-0002-8162-4899. http://orcid.org/0000-0002-3856-9812. 276 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 275-286 uso de una aplicación user-friendly para tableta en la comunicación con pacientes pediátricos sometidos a respirador artificial resumen objetivos: examinar cómo el uso de una aplicación para tableta como ayuda en la comunicación con pacientes pediátricos con respirador artificial afecta el nivel de satisfacción con la comunicación por parte del personal de enfermería y en las díadas cuidador–paciente. materiales y método: se utilizó el diseño pretest-postest de un solo grupo para analizar el nivel de satisfacción del personal de enfermería con la comunicación y se utilizó un diseño de grupo de control pretest-postest no equivalente para los cuidadores. la muestra estaba conformada por 44 miembros del personal de enfermería y 18 díadas de cuidadores y pacientes pediátricos con ventilación de dos hospitales en tailandia. se utilizó una prueba de t pareada para comparar al personal de enfermería, la prueba u de mann-whitney para comparar los cuidadores y una estadística descriptiva para describir la satisfacción de los niños. resultados: el personal de enfermería se sintió más satisfecho con la comunicación al usar la aplicación de la tableta que los métodos de comunicación regulares (t = -9,13, df = 43, p < ,001). los cuidadores que usaron la aplicación para tableta también reportaron una mayor satisfacción con la comunicación respecto a aquellos que usaron los métodos de comunicación regulares (u = -3,41, p < ,001). casi el 90 % de los pacientes pediátricos reportaron sentirse completamente satisfechos con el uso de la aplicación. conclusiones: la aplicación para tableta diseñada para facilitar la comunicación con pacientes pediátricos con respirador artificial mejoró los niveles de satisfacción con la comunicación y debe promoverse como uno de los dispositivos de comunicación de asistencia para uso amplio. palabras clave comunicación; enfermería pediátrica; satisfacción personal; aplicaciones para tableta; respiradores (fuente: mesh). 277 use of a user-friendly tablet application to communicate with pediatric patients on mechanical ventilators l chanita tantacharoenrat y otro uso de um aplicativo para tablet fácil de usar para comunicação com pacientes pediátricos em ventilação mecânica resumo objetivos: examinar como o uso de um aplicativo auxiliar na comunicação com pacientes pediátricos em ventilação mecânica afeta o nível de satisfação com a comunicação da equipe de enfermagem e das díades cuidador-paciente. materiais e método: usou-se o pré-teste pós-teste de um único grupo para analisar o nível de satisfação da equipe de enfermagem com a comunicação e um desenho de grupo de controle pré-teste pós-teste não equivalente para os cuidadores. a amostra estava composta por 44 membros da equipe de enfermagem e 18 díades de cuidadores e pacientes pediátricos em ventilação mecânica de dos hospitais na tailândia. usou-se um teste t pareado para comparar a equipe de enfermagem, o teste u de mann-whitney para comparar os cuidadores e uma estatística descritiva para descrever a satisfação das crianças. resultados: a equipe de enfermagem sentiu-se mais satisfeita com a comunicação usando o aplicativo para tablet do que os métodos de comunicação comuns (t = -9,13, df = 43, p < ,001). os cuidadores que usaram o aplicativo para tablet também relataram maior satisfação com a comunicação em comparação com os que usaram métodos de comunicação comuns (u = -3,41, p < ,001). quase 90% dos pacientes pediátricos relataram sentir-se completamente satisfeitos com o uso do aplicativo. conclusões: o aplicativo para tablet desenhado para facilitar a comunicação com pacientes pediátricos em ventilação mecânica melhorou os níveis de satisfação com a comunicação e deve ser promovida como um dos dispositivos de comunicação de assistência para ampla utilização. palavras-chave comunicação; enfermagem pediátrica; satisfação pessoal; aplicativos para tablet; ventilação mecânica (fonte: decs). año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 275-286 278 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 introduction critically ill pediatric patients whose spontaneous ventilations are inadequate to maintain life will be put on mechanical ventilators. while a mechanical ventilator assists children’s respiratory efforts, it renders them unable to express their needs and feelings verbally (1). patients’ difficulty in verbal communication causes the nursing staff and the caregivers, as well as the patients themselves, to become exhausted and discouraged (2); finally, the patients are left without communication, leading to stress. in general, mechanically ventilated patients require augmentative and alternative communication (aac) tools and strategies to facilitate communication (3). aac includes all forms of communication, except oral speech, that are used to express message; its types included unaided systems (e.g., gestures, facial expressions, and sign language) and aided systems (e.g., pen and paper, letter/ picture boards) (4) are usually used as the regular communication methods with children on mechanical ventilators. even though these methods aid the communication between the patients and their communication partners, the limitations from being under mechanical ventilators, together with the illness severity, often decrease the efficiency of the communication. the loss of two-way communication can affect the patients’ mental health greatly. previous studies revealed that severe emotional reactions among mechanically ventilated patients — such as frustration, disconnection, helpless, stress, anxiety, and fear — could arise (5–7). these adverse emotional reactions also happened with caregivers and nursing staff due to their inability to comprehend the patient’s needs and feelings, and a limited competence to find strategies to facilitate communication (7–9). the communication difficulties with mechanically ventilated patients have been improved by the use of assistive communication devices that are available for both adult and pediatric patients. these devices include communication cards (10), a textillustrated communication board (11), a communication board (12–13), an electronic communication device (14), an electronic voice-output communication aids (15), and a handheld computer device (16), for example. however, these devices still carry some limitations, including insufficient information about needs and requirements of the patient, poor device positioning, discomfort during the use of device, for example (17). in the current digital age, communication technology is much more advanced. tablets are one of the most popular and friendlyuse communication devices with users across all age groups, even among nurses and other health professionals (18). there are many tablet applications, either paid or free, available to aid communication among pediatric patients, nursing staff, and caregivers (19); however, the free communication applications available have a limitation for use with thai population because most of the applications were developed in english. in thailand, the assistive communication devices are for outdated operation technology, and there is no current tablet application for use to communicate with pediatric patients on mechanical ventilators. thus, the researchers became interested in developing “my voice board,” a tablet application running on the android operating system, with the purpose of enhancing effective communication between pediatric patients on mechanical ventilators and nursing staff, as well as caregivers. this study was conducted with the purpose of examining the effect of using the “my voice board” tablet application on communication satisfaction of nursing staff and caregivers, as well as the satisfaction of pediatric patients with the use of the application. the hypotheses of this study were: 1) nursing staff had greater communication satisfaction when using my voice board to communicate with pediatric patients, compared to the use of regular communication methods; 2) caregivers who used my voice board to communicate with pediatric patients had greater communication satisfaction than those who used regular communication methods. conceptual framework the osgood and schramm circular model of communication (20) was used as a conceptual framework of the study. according to the model, communication is viewed as a circular, rather than linear, process that takes place between a sender (encoder) and a receiver (decoder). when the message is transmitted and reaches the receiver, his responsibility is to understand or decode what the sender wants to convey and provide feedback to the (previous) sender. this model was selected because communicating effectively with mechanically ventilated patients is essential for their care. communication between nursing staff/caregivers and patients must be a two-way process, so the needs and feelings of both parties are not only conveyed, but also understood, and responded to. effective communication is particularly challenging with pediatric patients. therefore, in this study, the model was adapted by integrating a user-friendly tablet application (my voice board) to facilitate communication. 279 use of a user-friendly tablet application to communicate with pediatric patients on mechanical ventilators l chanita tantacharoenrat y otro methods design the study was a quasi-experimental research. in this study, the one-group pretest-posttest design was implemented with nursing staff, and nonequivalent pretest-posttest control group design was used with caregiver-patient dyads. participants convenience sampling was used to recruit nursing staff and caregiver-pediatric patient dyads from two intensive care units (icus) of a hospital located in bangkok, thailand. due to a limited number of eligible pediatric patients, caregiver-pediatric patient dyads from an icu of a second hospital located in vicinity were also recruited. these pediatric icus encouraged caregivers to visit, but they could only visit four hours each day. during visit, simple assistive communication tools (such as paper and pencil) may be provided if requested. eligible nursing staff in the study included professional nurses and practical nurses (assistant nurses with one year of training) who were able to use a smartphone/tablet. eligible caregivers had to take care of their children retaining ventilators for at least two days, be literate, and be able to use a smartphone/tablet. among the inclusion criteria for the pediatric patients were those who were literate and receiving either continuous noninvasive or invasive ventilators with glasgow coma scores of 10t. in this study, all of the nursing staff in the icus (n=51) were invited to participate in the study, and 44 (86%) agreed. for the sample size of caregivers, a power analysis via g*power program using the large effect size from a previous study (16) with alpha set at .05 and power of .80 was performed to determine the number of caregiver-pediatric patient dyads. finally, 18 dyads of caregivers and pediatric patients were included in the study; that is, 9 pairs in the control group and the other 9 pairs in the intervention group. instruments the my voice board tablet application was developed by the researchers on asus zenpad c7.0 tablet operating on android system version 5.0 (lollipop). the tablet came with a 7.00-inch display, a dimension of 189.00 x 109.00 x 8.40 (height x width x thickness in millimeters) and the weight of 265.00 grams. it was powered by a 3450 mah battery. its rom and ram were 16 gb and 1 gb, respectively. based on the literature reviews and associated documents, 53 messages were developed by the researchers to indicate the problems and needs of critically ill pediatric patients. the messages were classified into four main menus of needs, feelings, questions, and emergency requests, all of which were also composed of submenus as follows. • needs, including six submenus: food and water, excretion, changing position, breathing, hygiene, and relaxation; • feelings, including two submenus: physical and psychological; • questions, including three submenus: questions about parents, physical well-being or symptoms, and time; • emergency, consisting of three messages: severe pain, dyspnea, and nausea/vomiting. the messages for the my voice board application were validated for appropriateness and congruency among pictures, sounds and words used by three content experts in the field of media and communication and nursing profession, plus six children (8–14 years of age), and their caregivers. this process was repeated until 100% consensus was obtained. to use the my voice board application for communication, a user can use his/her fingers to control the touch screen. first, the user should select the patient’s sex by tapping the gender button so that the pictures and voice will correspond to the child’ gender. next, the user taps on a selected menu, from which he/ she can access the submenus. the user can slide a finger up and down the screen to go through the list of submenus. tapping a selected submenu, the user will see different images accompanied with text messages showcasing the application. when a picture with text message that the patient wants to convey is tapped, the selected message will be transformed into voice to indicate the patient’s needs. the user can press the home button at any time to go back to the primary home screen. the users could be nurses, caregivers, and even the pediatric patients. figure 1 displays the my voice board tablet application. figure 1 showed a main menu of the my feelings menu with, for example, four windows of pictures saying, “i feel thirsty,” “i feel hungry,” “i didn’t sleep well,” and “it’s noisy” (from left to right and down). the bottom shows the other three main menus (i.e., my needs, my questions, emergency), and a home menu symbol. 280 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 the data collecting instruments included: 1. the personal information form, which consisted of 8 items asking nursing staff and caregivers about their gender, age, position, education, years of experience in the care of children with ventilators, regular communication methods, problems faced when communicating with the children, and experience in use of applications on a tablet. 2. the communication satisfaction scale consisted of 10 items asking nursing staff and caregivers how satisfied they felt with the communication in terms of, for example, understanding the patients’ problems, feelings, and needs; response to patients’ needs; explicitness of message sent/received; and increase of participation in care for patients. the response scale ranged from 1 (least satisfied) to 5 (extremely satisfied) and yielded the total scores ranging from 10–50; the higher the total scores, the more satisfaction in the communication. validated by the three content experts, the content validity index (cvi) of this questionnaire in the current study was .91, and cronbach’s alpha coefficients were .88 and .91 when tested with nursing staff and caregivers, respectively. 3. the suitability for use scale consisted of 18 items asking nursing staff’s and caregivers’ opinions about the suitability of the my voice board application for use as a communication aid. the suitability was measured in terms of content (including categories of needs, clear statement and picture, sufficient number of statements representing basic needs and feelings, synchronization of statements, pictures, and voice), design (including simplicity for use, appropriateness of font, pictures, and voice in terms of size, color, and clarity), and device (including weight, size, and mobility). the response scale ranged from 1 (strongly disagree) to 5 (strongly agree) and yielded total scores ranging from 18 to 90. to ease the interpretation, the total scores divided by the number of items gave the average scores ranging from 1 to 5; the higher average scores, the more suitability for use of the application. validated by the three content experts, the cvi of this questionnaire in the current study was 1.00. 4. the pediatric patient’s satisfaction questionnaire was a single item measure asking if the child was satisfied with the use of the my voice board application for aiding their communication during mechanical ventilation. the answer was a rating scale ranging from 1 (least satisfactory) to 5 (extremely satisfactory); the higher scores, the more satisfied the child was. intervention and data collection intervention and data collection were performed between october 2016 and august 2017 with the following groups of participants. nursing staff prior to the implementation of the intervention among nursing staff, they were required to answer: 1) the personal information form, and 2) the communication satisfaction scale (pretest); in this step, the respondents’ satisfaction was based on the regular methods they used to communicate with ventilated patients. then, the researcher (ct) demonstrated how to use my voice board for communicating with the patients. all the nursing staff demonstrated the use of all messaging functions in the application under the researcher’s supervision to ensure that they were able to use it correctly. they were allowed to use the application with patients for seven consecutive days because this timeframe would allow all nurses in the study units to be able to use the tablet with patients. afterward, the nursing staff completed the communication satisfaction scale again (post-test); in this step, their responses were based on their satisfaction after using the application. in addition, their opinions regarding the suitability of my voice board for use as a communication aid were also collected via the suitability for use scale. figure 1. my voice board tablet application source: own picture. 281 use of a user-friendly tablet application to communicate with pediatric patients on mechanical ventilators l chanita tantacharoenrat y otro caregivers the implementation of the experiment among caregivers and their children started with the control group, specifically those who used regular communication with the patients. upon their consent to be the study participants, the caregivers were required to answer 1) the personal information form, and 2) the communication satisfaction scale (pretest). then, they were allowed to take care of and communicate with their children as usual for two consecutive days. afterward, the caregivers completed the communication satisfaction scale again (post-test). upon completing the data collection in the control group, caregivers in the experimental group were required to complete the personal information form and the communication satisfaction scale. then, the researcher demonstrated how to use the my voice board application for communicating with their children. all caregivers demonstrated the use of all messaging functions in the application under the researcher’s supervision to ensure that they were able to use it correctly. mostly, patients were weaned by 3–5 days; thus, the caregivers in this study were allowed to use the application with the patients for two consecutive days. during this period, the nursing staff could be of further assistance, if needed, to the caregivers regarding the use of application. afterwards, they were asked to complete the communication satisfaction scale again. their opinions regarding the suitability of the application for use as a communication aid were also collected via the suitability for use scale. pediatric patients personal information of the pediatric patients about age, sex, education, medical diagnosis, type of ventilator used, duration on ventilator, and intravenous sedation was collected from medical records. this study did not investigate the difference of communication satisfaction between ventilated pediatric patients who used the application and those who used the conventional methods of communication. basically, patients in icus are critically ill and sedated, and therefore it might not be appropriate to ask them a set of questions during such time. thus, after weaning from ventilators, only the patients in the experimental group were asked to rate their satisfaction towards the use of my voice board. statistical analysis the comparison of communication satisfaction scores in the nursing staff group between prior to and after the use of tablet intervention was assessed using paired t-test. due to the small sample size of caregivers in both control and experimental groups, the mann-whitney u test was used to analyze and compare the communication satisfaction scores between before and after the intervention in both groups. ethics the ethical consideration of this study was approved by the institutional review boards of the study hospitals (coa-si 559/2016 and coa-rbhec 009/2017). results nursing staff the sample group of this study consisted of 44 nursing staff. table 1 contained their demographic data. the top three regular communication methods used were lip reading (91%), asking yes-no questions (75%), and gesturing (73%). the top three communication problems with pediatric patients being on mechanical ventilators were: being unable to understand the message through lip reading (93%), being unable to comprehend patient’s gestures (86%), and time-consuming of communication (75%). about half of them (52%) never used tablets before. as shown in table 2, the nursing staff reported more communication satisfaction with the use of the my voice board application, compared to the use of regular communication methods (p < .001). the results shown in table 4 revealed that mean scores of their agreement on the suitability of the tablet application was 4.12 and varied between 4.01 and 4.24 for its content, design, and device. according to the findings, nursing staff mostly agreed that my voice board was suitable as a communication aid for use with pediatric patients on mechanical ventilators. caregivers there were 18 caregivers in this study. table 1 contained their demographic data. the caregivers in both control and intervention groups did not have a significant difference in these personal characteristics. the main regular methods used to communicate with their sick children being on ventilators were: talking directly to the child (89%), using yes-no questions (50%), observing the child’s 282 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 demographics n % nursing staff (n = 44) age: m = 32.98, sd = 8.77, min-max = 23–57 sex: female 40 91 position: registered nurses 35 80 education: bachelor degree 33 75 experience with mechanical ventilator: over 10 years 21 48 caregivers (n = 18) age: m = 39.28, sd = 9.19, min-max = 19–62 sex: female (mothers) 12 67 education: high school 10 56 experience with mechanical ventilator: no experience 14 78 pediatric patients (n = 18) age: m = 12.06; sd = 2.1, min-max = 8–15 sex: female 13 72 education: primary school 10 56 table 1. participant demographics table 2. comparison of communication satisfaction scores between the uses of regular communication methods and tablet application among the nursing staff source: own elaboration. communication satisfaction (n = 44) possible range use of regular methods use of tablet application t (df) p m (sd) m (sd) total scores 10–50 29.61 (6.50) 41.20 (4.59) -9.13 (43) < .001 average scores 1–5 2.96 (.65) 4.12 (.46) source: own elaboration. facial expressions (72%), and lip reading (67%). the top three communication problems when these methods were used to communicate with their child were: being unable to understand what the child tried to convey (78%), being unable to understand the child through lip reading (67%) and time-consuming communication (61%). every caregiver knew how to use the applications on the tablets. as shown in table 3, caregivers in the intervention group who used my voice board to communicate with their children exhibited significantly higher communication satisfaction than those in the control group who used the regular communication methods (t = -9.13, df = 43, p < .001) (table 3). whereas, prior to the study, both groups had shown the same level of satisfaction from regular methods used for communication (p > 0.05). 283 use of a user-friendly tablet application to communicate with pediatric patients on mechanical ventilators l chanita tantacharoenrat y otro as shown in table 4, caregivers also evaluated the suitability of the tablet application. the mean scores of their agreement on the suitability of the tablet application was 4.29 and varied between 4.15 and 4.38 for its content, design, and device. the findings indicated that the my voice board application was suitable as a communication aid for use with pediatric patients on mechanical ventilators. pediatric patients there were 18 pediatric patients in this study. table 1 contained their demographic data. in addition, nearly 30% of them were diagnosed with autoimmune diseases, followed by 17% with respiratory diseases, and 17% with urological diseases. seventytwo percent of them were ventilated with endotracheal tube and 28% with bipap; 78% of the pediatric patients were on first-time ventilators. the duration of mechanical ventilators used among the study patients ranged from 4 to 9 days (m = 5, sd = 1.37), and 61% of them received intravenous sedation while they were on the ventilators. the pediatric patients in both the control and intervention groups did not significantly differ in the aforementioned characteristics (p > .05). eight out of nine pediatric patients using the my voice board application rated the highest scores, or 5, for their satisfaction with the use of the application, resulting in average satisfaction scores of 4.89 (sd = .33). discussion the study results supported the first hypothesis—that is, nursing staff had greater communication satisfaction with the use of the my voice board application, compared to the use of regular methods of communication. the reason why the my voice board application obtained more satisfaction may be due to its userfriendly design as well as the sufficient coverage of needs and feelings illustrated for communication with this group of patients; the application was evidently supportive, as shown by the nurtable 3. comparison of communication satisfaction scores between the control and intervention groups table 4. nursing staff’s and caregivers’ agreement on the suitability of the tablet application as a communication aid communication satisfaction possible range control group (n=9) intervention group (n=9) u p m (sd) m (sd) total scores 10-50 29.00 (6.40) 44.67 (5.45) -3.41 < .001 average scores 1-5 2.90 (.64) 4.47 (.555) source: own elaboration. suitability nursing staff (n = 44) caregivers (n = 9) m (sd)a m (sd) a content 4.01 (.39) 4.38 (.63) design 4.10 (.50) 4.33 (.66) device 4.24 (.48) 4.15 (.73) average scores 4.12 (.41) 4.29 (.66) a possible range was between 1–5 source: own elaboration. 284 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 sing staff’s agreement of its suitability for use. based on previous findings (12, 13, 16, 21) when patients’ needs were quicker and more explicitly expressed via an effective communication device, there was no doubt that their needs and feelings would be responded to, leading to compliance and participation towards the treatment and care received. according to the findings from a previous systematic review (17), the regular communication methods (i.e., lip reading, asking yes-no questions, and gesturing) mostly used by nursing staff were not only inadequate to understand the pediatric patients’ needs but they were also time consuming and frustrating for both patients and nursing staff. thus, it was not surprising why communication satisfaction of the nursing staff increased when they had a more effective and modern communication method. similar to a previous study that emphasized the essential role of nurses to develop effective communication strategy used with pediatric patients to promote patient/parent engagement and satisfaction (22–23). the findings of this study were significant in demonstrating how nurse communication can be improved though a modern and simple device. the results of the study also supported the second hypothesis that caregivers who used the my voice board application to communicate with their mechanically ventilated children had greater communication satisfaction than those who used regular methods of communication. the possible reason could be explained by the same logic as why the nursing staff was more satisfied—namely, that the application on a tablet, an effective communication aid, made it easier for them to communicate with their mechanically ventilated patients through its user-friendly design, as well as the sufficient coverage of needs and feelings shown in the statements and pictures. based on these findings, the my voice board application could be one solution to many of the existing issues with conventional methods of communication. the application might help bringing the caregivers and the patients to a common understanding with ease because it facilitates two-way communication. even though the study results support the implementation of the my voice board application, as one aac method, in communicating with this group of patients, the wise use of conventional methods is also important. it is noteworthy that talking directly to the patients was mostly used by the caregivers as a regular communication method, while a better method, yes-no questions, was used by only half of them. talking to the patients directly was a form of one-way communication conveying only the caregivers’ needs rather than receiving and perceiving the patients’ needs and feelings. this finding from the current study did confirm that the caregivers were unprepared for the communication difficulties with their critically ill. previous studies revealed that the presence of family members could lighten the patients’ adverse experiences of being on mechanical ventilators (24) and communication of the patients with their family members influenced their psychological well-being (25) that would help to improve quality of care. the caregivers in the current study should be advised on how to communicate with their ventilated children. the comparison of the pediatric patients’ communication satisfaction between the usages of regular methods and the my voice board application was not analyzed because most critically ill patients were sedated and required rest, and thus it might not be appropriate to interview them during that time. after weaning, most patients might have little memory of their experience during mechanical ventilation (26), and therefore the communication satisfaction assessed from the pediatric patients’ recall may not be reliable. in the current study, satisfaction with the use of my voice board rated on one single item was assessed among the pediatric patients in the intervention group only. all of them, except one patient, gave the highest score, 5, about their level of satisfaction with the use of the application. findings did confirm the effectiveness of the application on tablet for improving the communication during mechanical ventilation, but it is not known what the children in the control group thought. this was a preliminary study aimed to develop a tablet application, my voice board, and to examine the nursing staff’s and caregivers’ communication satisfaction with pediatric patients on ventilators when using the application. the interpretation of the study findings should be cautious due to its certain limitations. first, the study did not use random samples, and thus, the study sample was not a good representative of the population. second, selection bias could arise because the subjects were not randomized to the study groups, this means, the caregiver subjects were divided into two groups: application user vs. application non-user. the researchers did not randomly assign them to the groups. they completed the first group and then started with the second. conclusions and recommendations an innovative my voice board application was developed and used in a clinical nursing context to facilitate communication between nursing staff/caregivers and pediatric patients on mechanical ventilators who could not verbally and explicitly communicate to 285 use of a user-friendly tablet application to communicate with pediatric patients on mechanical ventilators l chanita tantacharoenrat y otro others as usual. the study findings indicated that my voice board worked effectively, resulting in greater communication satisfaction among the users. due to its user-friendly design on a modern device with a comprehensive message representing the needs of the patients, the nursing staff and caregivers strongly agreed that my voice board was suitable for use as a communication aid. thus, the my voice board application should be encouraged as one of the assistive communication devices for use with pediatric patients who have speaking difficulties due to their need for mechanical ventilation. this application could be used in icus and with home care of mechanically ventilated pediatric patients. however, pediatric nurses should firstly assess the patient and the caregiver communication potentials and, then, select an alternative communication method that fits their potential and conditions. a combination of various communication methods and useful assistive tools like my voice board is also advised due to the strengths of each method. in addition, the my voice board application is a preliminary innovative communication device, and its functions need further development. for example, users should be able to add up new vocabulary and message statements representing the patients’ specific needs to the message inventory of the application. further and continuing development of this tablet application is essential so that its function will be up-to-date with the modern technology. acknowledgement the authors are grateful to the department of pediatrics, faculty of medicine of siriraj hospital, mahidol university for partly funding this study under the funding for pediatric critical care development, siriraj foundation, thailand. conflict of interest: none was declared. references 1. costello jm, patak l, pritchard j. communication vulnerable 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[epub ahead of print]. 23. aldekhyyel rn, melton gb, hultman g, pitt mb. using a bedside interactive technology to solicit and record pediatric pain reassessments: parent and nursing perspectives on a novel workflow. amia jt summits transl sci proc. 2018;may18:300-309. 24. baumgarten m, poulsen i. patients’ experiences of being mechanically ventilated in an icu: a qualitative metasynthesis. scand j caring sci. 2015 jun;29(2):205-14. doi: 10.1111/scs.12177. 25. saeed am, galal ih, shata ak. evaluation of the psychological status of patients during and after weaning from mechanical ventilation. egypt j bronchol. 2014;8:160-6. doi: 10.4103/1687-8426.145718. 26. engstrom a, nystrom n, sundelin g, rattray j. people’s experiences of being mechnically ventilated in an icu: a qualitative study. intensive crit care nurs. 2013;29(2):88-95. doi: 10.1016/j.iccn.2012.07.003. https://doi.org/10.1016/j.hrtlng.2003.12.005 https://doi.org/10.1186/s13054-016-1483-2 file:///f:/temporal/ 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���������'�����(��� ����������������g���� ����� �'�����(�� h����������� =�������� ��� �����"���� ,��� �! h��"�"���)�+***!��c3��@�� 1 dóris helena ribeiro farias1 giovana calcagno gomes2 mauro francisco ferreira de almeida3 valéria lerchlunardi4 daiani modernel xavier5 maria veraci de oliveira queiroz6 barriers present in the process of construction of the cultural family care to the child in the hospital: transcultural approach* 1 orcid.org/0000-0003-3864-0145. school of nursing, universidade federal do rio grande, brazil. dorisenf@furg.br 2 orcid.org/0000-0002-2464-1537. school of nursing, universidade federal do rio grande, brazil. giovanacalcagnog@furg.br 3 orcid.org/0000-0001-7268-8471. faculty of medicine, universidade federal do rio grande, brazil. mauroalmeida@furg.br 4 orcid.org/0000-0002-0380-1829. school of nursing, universidade federal do rio grande, brazil. valeria.lunardi@pesquisador.cnpq.br 5 orcid.org/0000-0003-3832-2120. school of nursing, universidade federal do rio grande, brazil. daiamoder@furg.br 6 orcid.org/0000-0002-7757-119x. universidade estadual do ceará, brazil. maria.queiroz@uece.br * extracted from the thesis “a cultura como referencial de cuidado familiar à criança no hospital: subsídios para o cuidado na enfermagem”. postgraduate from the program in nursing, federal university of rio grande, brasil, 2017. received: 07/02/2018 sent to peers: 03/04/2018 approved: 11/05/2018 accepted: 10/07/2018 doi: 10.5294/aqui.2019.19.1.2 to reference this article / para citar este artigo / para citar este artículo farias dhr, gomes gc, almeida mff, lunardi vl, xavier dm, queiroz mvo. barriers present in the process of construction of the cultural family care to the child in the hospital: transcultural approach. aquichan 2019; 19(1): e1912. doi: 10.5294/aqui.2019.19.1.2 abstract objective: to know the barriers in the process of building family cultural care for the child in the hospital. methodology: this is a qualitative study with a cross-cultural theoretical reference of madeleine leininger, called theory of diversity and cultural universality of care, and with a methodological reference of the ethno-inference. it was developed in 2017 at the pediatric unit of a university hospital in the south of brazil, through non-participant observation, participant observation and interview with 15 family caregivers of hospitalized children. the data were coded, classified and scrutinized to identify the saturation of ideas and similar or different patterns; also, it were re-coded and the theoretical formulations and recommendations were performed. ethical aspects were followed, according to the resoaño 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1912 the topic: chronic care. contribution to the subject: the results of this study point out that the cultural care is a process to add knowledge. also, it can be considered a new paradigm for nursing care to provide mutual growth and the construction of new knowledge, an affective, reflexive, human and empathic relationship between nurse-child-family. http://orcid.org/0000-0003-3864-0145 http://orcid.org/0000-0002-2464-1537. http://orcid.org/0000-0001-7268-8471. http://orcid.org/0000-0002-0380-1829. http://orcid.org/0000-0003-3832-2120. http://orcid.org/0000-0002-7757-119x. http://dx.doi.org/10.5294/aqui.2019.19.1.2 http://dx.doi.org/10.5294/aqui.2019.19.1.2 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1912 lution of the national research ethics council 466/2012. results: the data showed as a barrier the need for hospitalization as a factor of family vulnerability, control of the unit’s health team members, hospital norms and routines, and the need to transgress as a manifestation of family care. conclusion: cultural care is a process that aggregates knowledge and can be considered a new paradigm for the accomplishment of nursing care by providing the mutual growth and construction of new knowledge, an affective, reflexive, human and empathic relationship between the nurse, the child and the family. keywords (source: decs) child care; hospitalized child; family; culture; cultural anthropology; cross-cultural nursing. 3 barriers present in the process of construction of the cultural family care to the child in the hospital: transcultural approach l dóris helena ribeiro farias and others barreras presentes en el proceso de construcción del cuidado familiar cultural al niño en el hospital: enfoque transcultural* resumen objetivo: conocer las barreras presentes en el proceso de construcción del cuidado familiar cultural al niño en el hospital. metodología: estudio cualitativo que tuvo como referencial teórico transcultural de madeleine leininger, denominado teoría de la diversidad y la universalidad de los cuidados culturales, y como referencial metodológico la etnoenfermería. se desarrolló en 2017 en la unidad de pediatría de un hospital universitario del sur de brasil, mediante observación no participante, observación participante y entrevista con 15 familiares cuidadores de niños hospitalizados. los datos han sido codificados, clasificados y analizados para identificar la saturación de ideas y los patrones similares o diferentes; además, han sido recodificados y se realizaron las formulaciones teóricas y las recomendaciones. los aspectos éticos fueron cumplidos, de acuerdo a la resolución de la comisión nacional de ética en investigaciones 466/2012. resultados: los datos de la investigación han mostrado barreras como la necesidad de hospitalización del niño como factor de vulnerabilidad familiar, el control de los miembros del equipo de salud de la unidad, las normativas y rutinas del hospital y la necesidad de transgredir como manifestación del cuidado familiar. conclusión: el cuidado cultural es un proceso que aporta saberes y puede ser considerado un nuevo paradigma para la realización del cuidado de enfermería al proporcionar el crecimiento mutuo y la construcción de nuevos saberes, de una relación afectiva, reflexiva, humana y empática entre enfermero-niño-familia. palabras clave (fuente: decs) cuidado del niño; niño hospitalizado; familia; cultura; antropología cultural; enfermería transcultural. año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1912 * extraído de la tesis “a cultura como referencial de cuidado familiar à criança no hospital: subsídios para o cuidado na enfermagem”. posgrado en enfermería, universidad federal de río grande, brasil, 2017. 4 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 barreiras presentes no processo de construção do cuidado familiar cultural à criança no hospital: abordagem transcultural* resumo objetivo: conhecer as barreiras presentes no processo de construção do cuidado familiar cultural à criança no hospital. metodologia: estudo qualitativo, que teve como referencial teórico transcultural de madeleine leininger, denominado teoria da diversidade e universalidade cultural do cuidado, e como referencial metodológico a etnoenfermagem. foi desenvolvido em 2017 na unidade de pediatria de um hospital universitário do sul do brasil, mediante observação não participante, observação participante e entrevista com 15 familiares cuidadores de crianças internadas. os dados foram codificados, classificados e escrutinados para identificar a saturação de ideias e os padrões semelhantes ou diferentes; além disso, foram recodificados e as formulações teóricas e as recomendações realizadas. os aspectos éticos foram seguidos, conforme a resolução do conselho nacional de ética em pesquisa 466/2012. resultados: os dados do estudo mostraram como barreiras a necessidade da internação da criança como fator de vulnerabilidade familiar, o controle dos membros da equipe de saúde da unidade, as normas e rotinas do hospital, e a necessidade de transgredir como manifestação de cuidado familiar. conclusão: o cuidado cultural é um processo que agrega saberes e pode ser considerado um novo paradigma para a realização do cuidado de enfermagem ao proporcionar o crescimento mútuo e a construção de novos saberes, de uma relação afetiva, reflexiva, humana e empática entre enfermeiro-criança-família. palavras-chave (fonte: decs) cuidado da criança; criança hospitalizada; família; cultura; antropologia cultural; enfermagem transcultural. * extraído da tese “a cultura como referencial de cuidado familiar à criança no hospital: subsídios para o cuidado na enfermagem”, programa de pós-graduação em enfermagem, universidade federal do rio grande, 2017. 5 barriers present in the process of construction of the cultural family care to the child in the hospital: transcultural approach l dóris helena ribeiro farias and others introduction children hospitalization is a critical time for both the child and the family. it is a period that brings countless repercussions, such as the absence of the home, distance from family and friends, and the exposure to painful procedures (1). the experience of hospitalization for the child is generally related to the patient’s age, hospitalization time, type of condition, guidelines for hospitalization, and therapeutic contacts before, during and after the hospitalization (2). in the hospital, the family tends to be depersonalized as it needs to adapt to the norms and routines imposed by the hospital institution (3). it is up to the nursing professional to organize and develop caregiving actions with each family according to their needs, and participation in child care in this context (4). the stress suffered by the conflicts generated by the imposition of hospital norms and routines can compromise the care of the hospitalized children. faced with norms and routines, the family member may feel their life invaded by different institutional duties to their beliefs, values, and habits of life (5). the coexistence in the family and the nursing team has shown that even if the family understands norms and routines as necessary, it is not always subject to compliance, which can generate conflicts that compromise this relationship (6). given the complexity of the child´s experience in the hospital, this environment should have a relationship of affection and cooperation between the family, the child and the nursing team (5, 7). when feeling with less autonomy during hospitalization, the family may present anguish and suffering for conflicting interpersonal relationships with the health team (8). in addition to this, the family tries to take care of the child in the hospital based on their care practices. these are based on their beliefs, customs, resources, and visions of the world, not always compatible with the care culture of the multi-professional team. in this sense, the nursing professional who works in the hospital needs to consider the patient’s culture in the planning of care (9). from a cultural perspective, the family is a health care unit with its own views on health and illness, its own attitudes and ways of caring (10). in this manner, the ethno-inference is appropriate to the theme of the study by highlighting the cultural aspect of family care as an indivisible dimension of the human being. thus, the diversity and cultural universality of care also permeate child care in the pediatric unit. such understanding enables the professional to take care of the patients´ culture (9). the ability of the family to stay healthy is based on their care practices, based on their resources as a unit with beliefs, values, knowledge, and ways of caring (11). professional and popular health care practices come from culture and influence nursing practices and systems. these two care systems have their own values and practices and may lead to disagreements among them in some societies (9). the possible cause of conflicts that hinder the development of the nursing work process in the hospital environment can be due to the cultural shock, because of the presence of the family and professionals in the same environment, having to divide the space and be adjusted, leading different behaviors, beliefs and worldviews. culturally congruent care can be understood as an intentional action built by the interaction between scientific knowledge and the appreciation of the cultural knowledge of children and their families, by the health professionals who provide it (12, 13). thus, one of the strategies for caring is to seek to understand the everyday reality of being cared, that is, an understanding of the human being in its various dimensions, including the cultural dimension (2). when sharing the child´s care with the family, nursing needs to know their cultural references of care to help them experience the hospitalization of the child in the best possible way. nursing attributes the quality of working with multiculturality, drawing attention to the cultural diversity of care (9). thus, it needs to deepen not only the clinical aspects of this relationship but also to get closer to the culture of those families that interacts professionally. in this context, this study has as guiding question: which are the barriers present in the construction of family cultural care to the child in the hospital? the barriers are understood as the aspects that hinder the expression of cultural care by the families. from this, it was aimed to know the barriers present in the process of construction of the cultural family care to the child in the hospital. methodology the methodological reference used in this study was the ethnographic survey, used to obtain facts, feelings, worldviews and 6 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 other types of data that reveal the reality, truths and ways of life of people, which allows understandingthe beliefs and values. the context is the unit of pediatrics of a university hospital (hu) of the south of brazil. this hospital is a reference in maternal and child care. the pediatric unit has 18 beds for children aged from 0 to incomplete 12 years old, who are hospitalized by the unified health system (uhs). the key informants were 15 family caregivers who met the inclusion criteria: being a family member of the child and providing direct care in the hospital setting, and being over 18 years old. family members who only visited the children in the hospital were excluded. the key informants signed the informed consent term. the insertion of the researcher in the field was in august 2016, through the different work shifts in which it was possible to approach the team of the unit and the family caregivers. the data collection was developed during the period from december 2016 to may 2017 with four phases of observation and an interview. the observation script was based on the beliefs, values,and ways of caring for these families. this methodology seeks to show how they express their cultural values in the hospital environment and the barriers present in the process of building family cultural care for children in the hospital. each family member was observed during three shifts of the morning, three shifts of the afternoon and three shifts of the night (from 19:00 to 00:00), so they identified their manifestations of care to the child in the different periods of the day. there was a total of 765 hours of observation. observations during the investigation were recorded in the field diary. during the non-participant observation, that is, without establishing any kind of interrelationship with the family, it was sought to enter into the world of informants and have a broad view of the cultural context of the place of study (11). in the second phase, the observation occurred with some participation, at which time informal conversations and interaction with the key informants occurred, observing and perceiving their actions and answers. the researcher was able to spend more time with each participant and to follow up on his activities, which allowed him a closer approximation and a more detailed observation (9, 11). in the third phase of observation, after the establishment of an interaction, the participation became more active and sought to seize the informants’ worldviews, feelings, and experiences (9, 11). after these three phases of observation, an interview script was elaborated with questions about the identification data and other questions that contemplated specific situations of each key informant. family caregivers were questioned about their care, respecting their culture, that is, their beliefs and values in the process of caring for the child in the hospital environment, and the barriers present in the process of building family cultural care for children in the hospital. the interviews were conducted in the same ward where the child was, and then recorded and transcribed for analysis. in the fourth phase of the observation, reflexive observations were performed, aiming at rethinking observed phenomena and evaluating the information recorded in the field diaries (9,11). it was a period in which the informants could be searched again to discuss the results, offering greater trustworthiness to them. this phase was characterized by the field exit and the reflection on the experiences with the informants. data analysis was performed in four stages. in the first stage, the collection and documentation of the raw data were performed. in the second stage, the data were coded and classified according to the domain of the inquiry and the guiding question of the study. in the third stage, the data were scrutinized to discover the saturation of ideas and recurrent patterns of similar or different meanings by performing a re-coding. in the fourth stage, the themes and the relevant findings of the research were identified, and the theoretical formulations and recommendations were performed. the consideration was given to resolution 466/2012 of the national health council, which deals with the ethical aspects of the research. the project was approved by the ethics committee with opinion number 16/2017. participants were identified by the letter f, followed by the interview number. the excerpts from the observations were identified by the letters obs. results fifteen family members participated in the study: 12 mothers and three grandparents. they were aged between 18 and 58 years old, with incomplete elementary school predominance (8 key informants). the study data showed the barriers of the need to admit the child as a factor of family vulnerability, control of the unit’s health team members, hospital norms and routines, and the need to transgress as a manifestation of family care. 7 barriers present in the process of construction of the cultural family care to the child in the hospital: transcultural approach l dóris helena ribeiro farias and others the need for child hospitalization as a factor of family vulnerability the hospitalization is perceived as a disturbing situation, which raises family crisis and disruption situation, being a barrier to care. hospitalization of the child can make the family caregiver vulnerable emotionally and cause distress and suffering. in this sense, each culture has its way of perceiving, reacting and communicating the disease, as can be evidenced in the statements below. i was terrified, in shock. i never imagined my daughter being hospitalized [...] (f5) the hospitalization of the child for the family is a source of suffering, some of them presented anxious and tearful, emotionally unstructured. (obs) imagine my grandchild being hospitalized again for this disease! i was shocked, i cried a lot. everyone was sad, worried. (f7) i was scared because we went to the doctor’s office and the doctor sent me to the hospital. [...] my son had a high fever a few days ago. (f9) the control of unit health team members when the child is hospitalized, the family member appropriates the hospital culture and acquires knowledge about the child’s conditions, the institution’s functioning standards, the identification and hierarchy of the health team members, in an attempt to provide the best for the child and to organize the care environment. the institutional norms are reproduced in the behavior of the health team influenced by the customs, roles, and behaviors that are established in the interactions that occur in this scenario. the family reacts to the control exercised by the health team in their actions in the unit. they are dissatisfied when asked about their care. (obs) i think they control us here. another mother told me that they look inside the bags to see if she brought food from home. they always say how to take care and repeat: “do you think that i do not know how to take care of my son?” (f8) the norms and routines of the hospital and the need to transgress as a manifestation of family cultural care in the hospital, families live with the norms and routines of the place and need to adapt to them. the establishment of schedules by professionals of the nursing team aims to organize the work process and discipline the behavior of children and family caregivers in the pediatric unit. faced with the incorporation of hospital culture, the family caregiver becomes more demanding and questioning. the schedules are very different here, the food comes very early and sometimes he is not hungry. even because he is taking too much medicine and he gets nauseous, he vomits sometimes. he even lost weight here in the hospital. it seems like everything in the hospital is like that, but it’s hard to adapt. (f6) families have difficulty adjusting to the times established in the hospital. this fact is revealed as a reason for daily questioning and confrontation. (obs) facing with the imposition of norms and routines, some families are resistant and opt to transgress them. they recognize that they are vulnerable due to the child’s illness, requiring understanding and support, which would justify their resistance movements to instituted norms. one of the forms of transgression is to bring food from home to please the child and encourage him to eat. family practices and knowledge are understood as manifestations of their cultural identities. if they see us with food, they will not let us enter the hospital. we bring it hidden. the visit has to be quick. it’s a lot of bureaucracy. it had to be different. (f9) the transgression of norms and routines is perceived as common,as a form of coping with the things imposed by them. (obs) i even have freedom, because he is my son, but there are also the rules to be fulfilled. everything here is different. it’s complicated, he is missing things and sometimes he cries. (f7) when they enter the world of the hospital, families begin to take their actions, including those of child care, governed by norms and routines, but do not always acceptable to submit to 8 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 them. they mentioned that the norms and routines are emptied of the affective component of care, which makes relationships between the health team and the families more impersonal and bureaucratized, besides relativizing the autonomy of the family as caregiver of their child. the instituted institutional culture may not provide space for flexibility, dialogue or negotiations. when this occurs, the family can often feel helpless, which hinders them to adapt and develop skills and competencies for child care. we have hard time here [cry]. no one is coming. then i washed her clothes and hung them at the window. there’s a guild here saying it’s forbidden. in fact, i understand that i’m not at home, but they do not understand our side of being in a hospital, without having anyone to bring clothes to us. (f15) the lack of flexible rules and routines in the hospital weakens the families and hinders their adaptation, favoring their transgression as a form of resistance. (obs) i bring hidden food because i refuse to starve. we have to spend the night awake taking care and we need to have a cup of coffee to be strong. (f7) norms and routines can be perceived by families as mechanisms of surveillance and control used, apparently, as a form of institutional domain. it is believed that the surveillance performed by the health team for compliance is a mechanism of power used for people and submitted by the institution. these norms and routines of the hospital are for them to give us orders. they want to make us do things we do not agree with. i want him to take a bottle of milk. (f7) the institutional culture is based on the imposition of norms and routines, being understood by the families as an attempt of control. (obs) you cannot eat anything because it has to be everything from here. they live watching over us. if you are going to eat something, you have to eat it hidden, as if we had stolen it. (f3) discussion the ways of relating to one another based on the culture and care needs of each person should be respected so the care performed is meaningful (9). the process of building family cultural care for the child in the hospital is permeated by several barriers. in this study, the barriers were: family vulnerability to child hospitalization, control, norms and routines imposed on families by members of the health team unit, and the need for transgression of norms and routines as a manifestation of family cultural care. the need for the child’s hospitalization makes the family vulnerable and often triggers a crisis with several feelings such as fear, anguish, and guilt. in this sense, during hospitalization, it is often the child-family-health professionals relationship is permeated by a situation of family vulnerability, caused by the distancing between the team and the family, by the perception of team hostility, by the feeling of exclusion and disregard by the team (3). the family has values, beliefs, and attitudes that are acquired in the environment where they live, which can lead to the existence of a clash between family and hospital culture (14). thus, it is necessary to negotiate with the family members at each hospitalization for the commitment to care for the child, as each family and each situation are unique. cultural knowledge means understanding and appreciating culturally specific beliefs and their practices of health care, as well as factors that contribute to building cultural values (15). the act of caring involves respect for the way each individual lives, according to their beliefs, values, customs,and culture (9). the study found that the hospitalization of a child is a situation that significantly increases the anxiety of family members, who consider nurses and doctors as sources of support (16). due to the need for hospitalization, the family caregiver may have a sense of incapacity, dependence, insecurity, and lack of control due to the condition of the child’s illness (3). another barrier of the families in the hospital is the control by the unit health team members over them. organizations tend to develop a dominant culture (17). in the practice, it is observed that there is a tenuous limit on what the family member can or cannot do when taking care of inside the hospital space. generally, there is no regulation in the organizations about the family’s participation in the care, although the family performs activities with the child during hospitalization. this fact makes the family and professionals of the health team live a silent and implicit relationship of power, in which the care and even responsibility is assumed by the nursing team. 9 barriers present in the process of construction of the cultural family care to the child in the hospital: transcultural approach l dóris helena ribeiro farias and others man needs control mechanisms to order his behavior and this is dependent on the control mechanisms acquired by cultural programs (18). the actions developed by the nurses are based on knowledge that converges to the personal and institutional culture. for this, people able to perform such care actions are needed, with respect to the individuality of each person, patient or professional (9). when this care involves the participation of the family in the care of hospitalized children, there is a need to have a better balance between the power of the professional sector and the valorization of family autonomy to share knowledge and experiences in the groups (19). the balance between culture and science enables to construct effective care practices by positively associating the knowledge of families and nursing professionals (20). many professionals adapt to the institutional perspective and use exacerbated control over the families, forgetting their essential role as caregivers. when communicating, the nurse should try to understand the worldview of families of hospitalized children, reflect on their culture, values, beliefs, experiences,and meanings about the moments they lived during the hospitalization of the child (9). in this sense, the family should be recognized as responsible for the health of its members, hearing their doubts, considering their opinion and encouraging their participation (14). the hospitalization process is accompanied by the imposition of institutional norms and routines with strict hours for bathing, meals, and visits, imposing the loss of the family privacy, affective, social and leisure losses, removing them from their habits and undervaluing their personal characteristics. also, in many hospitals, there is not suitable family accommodation. visiting, food and others are suitable for the convenience of the services. although families in many situations are submitted to the regulations imposed by the hospital and the team, they create mechanisms of resistance as a way of coping during their coexistence in the hospital. they interpret their ways of acting before the norms and routines of the hospital as forms to be inserted in this environment and, equally, of the team inserting it in the institutional scene, considering that both perspectives are adopted according to the culture of families and hospital institutions (18). it is important to consider the characteristics and needs of each family through a sensitive listening, respecting their life history and their worldview in the concrete reality of family and child as a way to assist them in this confrontation (9). the use of norms and routines are administrative tools that help the team maintain some distance so they can carry out their care without greater emotional involvement. they seem to be able to frame the families and keep them under control. similarities and differences are observed in the way that families coexist and deal with institutional rules and team professionals, as well as in the way the team interprets the movements of the families, getting involved and living with them in the medium of prescriptions and rules during the period of hospitalization. it is evidenced that the institutional norms are an instrument of control and, as the family needs to adapt to the norms and routines imposed by the hospital institution, tending to deny them, which affects their condition of subject and their autonomy (3). the longer the mothers stay with the child, the more they appropriate the hospital culture. in this context, despite being instruments of control, the compliance of the norms and routines influence the customs, roles, and behaviors that are established in the interactions that occur in this scenario (14). the relevance of the use of norms and routines in the organization and operation of the pediatrics unit is emphasized, but not as an instrument of subjection and obedience seeking of the familiar caregiver. the work process needs to meet the needs of the child and his/her family caregiver and will allow family practices and spaces of freedom, autonomy, and resistance (5). the effort to humanize care in pediatrics makes the team need to establish culturally adapted norms and routines that cover the specificities and individualities of each family-child needs. the organization of the work process, elaborated with the intention of caring for the child cannot be an additional source of family suffering and family structure, but a qualification of care (22). caring for a hospitalized child should strengthen the link between health professionals and the family, requiring intersubjectivity, and it will be the essential dialogue to maintain care (23). nurses must negotiate with the family members at each hospitalization of the child, because by respecting the care of the child, the family is directly committed to their basic needs (24). 10 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 the organization of the team focused on the care of the child and his/her family contributes to the proposal of norms and hospital routines directed to a participatory management (25), which allows the construction of a work that privileges the health team actions of an ethical and democratic form. conclusion hospitalization is perceived as a disruptive situation in the life of any person and has special contours when it happens to the child. it is emphasized that each culture has its way of perceiving, of reacting and communicating the disease, constituting a phenomenon rarely anticipated in the scope of care. the barriers imposed in the cultural family care process to the child in the hospital, there is the need for hospitalization of the child as a factor of family vulnerability, control of the unit’s health team members, hospital norms and routines, and the need for transgress as a manifestation of family care. it was concluded that there is a need for greater interaction with families, to accept the challenge of let them participate and to create reception spaces to facilitate the expression of their difficulties and possibilities of assistance, which would minimize barriers that hinder expression of the cultural care to the child. it is important to understand culture as a therapeutic instrument to be apprehended in hospital care. the limitation of the study was to be carried out in a single context. future research should be carried out in other contexts about cultural family care and how nursing has been contemplating transculturality in its professional work, which may contribute with new findings on this theme. conflict of interest: none declared. references 1. santos dr, bonfim cs, mazza va, wall ml, alves m.processo de brincar da criança hospitalizada guia do pelo modelo lúdico. cogitare enferm. 2014;14(3):617-20. doi: 10.5380/ce.v19i3.36669 2. nascimento wg, silva g, oliveira jms,moura mgm, santos rvo.humanização da equipe de enfermagem no contato com a criança e a família através do lúdico: um relato de experiência. revista da 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http://dx.doi.org/10.5935/1414-8145.20170019 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4869776/ http://dx.doi.org/10.5935/1414-8145.20150037 https://www.ncbi.nlm.nih.gov/pubmed/25200238 http://dx.doi.org/10.1590/s1414-32832011005000008 298 alejandro morales-jinez1 esther c. gallegos cabriales2 karen t. d’alonzo3 alicia ugarte-esquivel4 francisco j. lópez-rincón5 bertha cecilia salazar-gonzález6 social factors contributing to the development of allostatic load in older adults: a correlationalpredictive study 1 orcid.org/0000-0002-2463-7482. universidad autónoma de coahuila, mexico. alejandro_morales@uadec.edu.mx 2 orcid.org/0000-0003-3619-2596.universidad autónoma de nuevo león, mexico. esther.gallegoscb@uanl.edu.mx 3 orcid.org/0000-0002-3912-7442. rutgers, the state university of new jersey, united states of america. kdalonzo@rutgers.edu 4 orcid.org/0000-0002-4218-5889. universidad autónoma de coahuila, mexico. alicia.ugarte@uadec.edu.mx 5 orcid.org/0000-0003-0837-9396. universidad autónoma de coahuila, mexico. franciscolopezrinco@uadec.edu.mx 6 orcid.org//0000-0002-6610-8052. universidad autónoma de nuevo león, mexico. bertha.salazargn@uanl.edu.mx received: 16/04/2018 sent to peer reviewers: 02/05/2018 accepted by peers: 25/07/2018 aproved submission: 21/08/2018 doi: 10.5294/aqui.2018.18.3.5 to cite this article / para citar este artículo / para citar este artigo morales-jinez a, gallegos-cabriales ec, d’alonzo kt, ugarte-equivel a, lópez-rincón fj, salazar-gonzález bc. social factors contributing to the development of allostatic load in older adults: a correlational-predictive study. aquichan. 2018; 18(3): 298-310. doi: 10.5294/aqui.2018.18.3.5 año 18 vol. 18 nº 3 chía, colombia -septiembre 2018 l 298-310 topic: promotion and prevention. contribution to discipline: this study is based on betty neuman’s systems model and presents evidence on how social factors directly affect the health of older people. abstract objective: to determine if social factors, such as housing conditions, satisfaction with one’s house, neighborhood characteristics, social support, family relations and church attendance affect allostatic load in older adults. materials and method: a correlationalpredictive, cross-sectional study was conducted. the instruments used were sociodemographic data, the perceived family relationships instrument, the medical outcomes study-social support survey and the abbreviated version of the neighborhood environment walkability scale. the allostatic load biomarkers used were: systolic and diastolic blood pressure, body mass index, waist circumference, waist-hip ratio, total cholesterol, high density lipoprotein, glycated hemoglobin, fibrinogen, and c-reactive protein. sample size was estimated to contrast the no relation (r2 = 0) hypotheis in a multiple lineal regression model with 11 covariables, with a significance level of .05, power of 90% (.90), when coefficient of determination (r2) is .15, resulting in a sample of 131 older adults. the statistical analysis included descriptive measures and generalized linear models. results: the participants had either mediumor high-risk allostatic load. multivariate http://orcid.org/0000-0002-2463-7482 http://orcid.org/0000-0003-3619-2596 http://orcid.org/0000-0002-3912-7442 http://orcid.org/0000-0002-4218-5889 http://orcid.org/0000-0003-0837-9396 http://orcid.org//0000-0002-6610-8052 299 social factors contributing to the development of allostatic load in older adults: a correlational-predictive study l alejandro morales-jinez and others año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 298-310 linear regression model analysis showed that better housing conditions, satisfaction with own house, presence of dead-end streets, and church attendance reduce allostatic load, while dangerous traffic increases allostatic load. conclusions: there are several social factors contributing to the development of allostatic load in older adults. it is necessary to create nursing care strategies toward the social environment to decrease allostatic load in older adults. keywords allostasis; aging; family relations; residence characteristics; social support (source: decs). factores sociales que contribuyen al desarrollo de la carga alostática en adultos mayores: un estudio correlacional-predictivo resumen objetivo: determinar si factores sociales como las condiciones de vivienda, la satisfacción con la casa, las características del vecindario, el apoyo social, las relaciones familiares y la asistencia a la iglesia contribuyen al desarrollo de la carga alostática en los adultos mayores. materiales y método: se realizó un estudio correlacional y predictivo de corte transversal. los instrumentos utilizados fueron una hoja de datos sociodemográficos, el instrumento de relaciones familiares percibidas, el cuestionario de apoyo social y la escala de movilidad activa en el entorno comunitario, versión corta. los biomarcadores de carga alostática utilizados fueron: presión arterial sistólica y diastólica, índice de masa corporal, circunferencia de la cintura, relación cintura-cadera, colesterol total, lipoproteína de alta densidad, hemoglobina glicosilada, fibrinógeno y proteína c-reactiva. la muestra se calculó para para el contraste de la hipótesis de no relación (r2 = 0), en un modelo de regresión lineal múltiple con 11 covariables, con un nivel de significancia del .05 y una potencia del 90 % (.90), cuando el coeficinete de determinación poblacional (r2) es .15, tamaño de muestra que resultó en 131 adultos mayores. el análisis estadístico incluyó medidas descriptivas y modelos lineales generalizados. resultados: los participantes tenían un riesgo medio o alto de carga alostática. el análisis del modelo de regresión lineal multivariante mostró que las mejores condiciones de vivienda, la satisfacción con la propia casa, la presencia de calles sin salida y la asistencia a la iglesia reducen la carga alostática y que el tráfico peligroso aumenta la carga alostática. conclusiones: existen varios factores sociales que contribuyen al desarrollo de la carga alostática en adultos mayores. es necesario crear estrategias de cuidado de enfermería hacia el entorno social para disminuir la carga alostática en el adulto mayor. palabras clave allostasis; envejecimiento; relaciones familiares; características de la residencia; apoyo social (fuente: decs). 300 aquichan issn 1657-5997 eissn 2027-5374 fatores sociais que contribuem para o desenvolvimento da carga alostática em idosos: um estudo preditivo correlacional resumo objetivo: determinar se fatores sociais, como as condições de moradia, a satisfação com a casa, as características do bairro, o apoio social, as relações familiares e a freqüência à igreja afetam a carga alostática em idosos. materiais e método: um estudo de correlação transversal e preditivo foi realizado. os instrumentos utilizados foram dados sociodemográficos, o instrumento de relações familiares percebido, o medical outcomes study-social support survey e a abbreviated neighborhood environment walkability scale. os biomarcadores de carga alostática utilizados foram: pressão arterial sistólica e diastólica, índice de massa corporal, circunferência da cintura, relação cintura-quadril, colesterol total, lipoproteína de alta densidade, hemoglobina glicada, fibrinogênio e proteína c-reativa. a amostra foi calculada para o contraste do hipóseo de nenhuma relação (r2 = 0), em um modelo de regresión múltiple linear con 11 covariáveis, com um nível de significância de 0.05 e uma potencia de 90% (0.90), quando o coeficiente de determinação populacional (r2) es .15, o tamanho da amostra resultou em 131 idosos. a análise estatística incluiu medidas descritivas e modelos lineares generalizados. resultados: os participantes tinham risco médio ou alto de carga alostática. a análise multivariada do modelo de regressão linear mostrou que melhores condições de moradia, satisfação com a casa própria, presença de ruas sem saída e freqüência à igreja reduzem a carga alostática e o tráfego perigoso aumenta a carga alostática. conclusões: existem vários fatores sociais que contribuem para o desenvolvimento da carga alostática em idosos. é necessário criar estratégias de cuidados de enfermagem em direção ao ambiente social para diminuir a carga alostática no idoso. palavras-chave alostase; envelhecimento; relações familiares; características da residência; apoio social (fonte: decs). año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 298-310 301 social factors contributing to the development of allostatic load in older adults: a correlational-predictive study l alejandro morales-jinez and others introduction the world is undergoing an accelerated aging process. in 2015, 12.3% of the world’s total population were older adults; this figure will increase to 21.5% by the year 2050 (1). latin america expects a higher percentage of growth in the older adult population, from 11% in the 2017 to an estimated 25% in a span of 35 years (2). these demographic and epidemiological changes are influenced by the social environment, birth reduction and the technological advances in health care. the world health organization acknowledged the existence of social determinants that may either favor or negatively affect an individual’s health. the social determinants of health are defined as the conditions in which people are born, grow, live, work, and age. if the conditions are not favorable for an individual, they can become a cause of stress, which can have an impact on health (3, 4). stressful situations of daily life, as well as the environment, may trigger a series of biochemical reactions aimed at maintaining body stability, known as allostasis. the body reacts by changing internal parameters in an attempt to adapt to the demand (5, 6). once the older person consciously detects a situation as stressful, a biochemical reaction is generated to achieve allostasis or adaptation to the perceived threat. however, if the adaptation process does not occur, the allostatic load arises. allostatic load is defined as the accumulated physiological wear and tear that results from poor adaptation to environmental stressors. elevated allostatic load involves the abnormal functioning of primary mediators such as cortisol and secondary mediators such as c-reactive protein (crp), fibrinogen, blood pressure, total cholesterol, high-density lipoproteins (hdl), glycosylated hemoglobin, among others (4, 7, 8). chronic diseases such as obesity, diabetes, cancer, cognitive decline and heart disease have been associated with social determinants of health, specifically the social environment, an aspect that is relevant in the case of older adults due to their vulnerability (3, 9, 10). the evidence generated in european countries and north america shows that social factors such as socioeconomic status, educational level (4, 7, 11, 12, 13), gender, ethnicity, occupational hierarchy (11, 14, 15), church attendance (16, 17), and neighborhood’s socioeconomic status (18, 19, 20, 21) have being studied in relation to allostatic load. low neighborhood socioeconomic level was associated with higher allostatic load (18, 19, 20, 21), the participant’s poorer self rated health, more difficulty doing daily activities, and less physical activity in taiwanese women (22), while religiosity was associated to lower allostatic load (16, 17). studies in latin america have addressed the association between cortisol, a primary mediator of allostatic load, and its relation with social factors such as education, income, and wealth. the research results indicate no significant association with these social factors and cortisol level in a sample of latin american older adults (23). another study in puerto rico indicates that low neighborhood socioeconomic status is related to higher allostatic load (24). no research was found on social factors and allostatic load in mexico. this study is based on the neuman systems model (nsm), which visualizes the person as a holistic system composed of five variables: physiological, psychological, sociocultural, developmental, and spiritual. these variables interact with each other and are in constant relation with the environmental stressors. stressors have the ability to produce tension in the client and cause a negative, positive, or neutral effect, which is manifested by reactions in any of the five variables of the basic system; in this case, the physiological variable was taken into account (25). the degree of reaction to a stressor depends on the resources available to the client to deal with the situation, the type of stressor or the amount of stressors that try to enter the system. this research focused on two types of stressors: interpersonal and extrapersonal. the interpersonal stressors are forces of the external environment occuring outside the boundaries of the client systema at proximal range (family and social support, among others), and the extrapersonal ones are external environmental interaction forces occuring outside the boundaries of the client system at distal range (characteristics of the neighborhood and of the dwelling). when the older adult does not have the ability to cope with stressors (flexible line and normal line of defense), stability is lost and defense mechanisms are activated (line of resistance). if there are insufficient resources to address the threat, signs and symptoms occur that reflect that reflect the alternation in the well-being of the client (25). to summarize, there is still controversy between the association of social factors and allostatic load. many studies do not consider social factors as having important direct effects on health; rather, social factors are seen as secondary influences (22, 23, 302 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 26). more specifically, the characteristics of the neighborhood acting as a source of stressors for allostatic load in older adults have not been studied and, in latin america, there are a few studies of allostatic load and social factors in older adults. detecting early risks of health due to social factors in older adults is important for nursing, to reduce or prevent further complications and diseases and to contribute to the overall quality of life and well-being (27). the aim of this research was to determine if social factors — particularly neighborhood characteristics, church attendance, and perception of family relationships — contribute to the development of allostatic load in a sample of community dwelling elders. materials and method a quantitiave, correlational-predictive (28), prospective and cross-sectional design was used. the sample consisted of older adults (60 years old and older) living in the monterrey (mexico) metropolitan area. a non-probabilistic convenience sampling was used. participants were recruited from a public senior club and a church. participants were excluded if they had suffered an acute myocardial infarction during the 6 months prior to the study or if they had had liver problems, as there are consecuences of allostatic load being present in the older adults and liver problems modify the results of the fibrinogen. sample size was estimated using the nquery advisor version 4 software (29). for a significance level of .05 and 90% power, with a multiple regression model and r2 = .15, the resulting sample size of 131 subjects was calculated. study variables a sociodemographic data sheet was used to register age, sex, marital status, number of years of education, occupation, current diseases, place of residence, housing satisfaction, religion, number of religious services attended weekly, and monthly income, systolic and diastolic blood pressure, height, weight, bmi, waist and hip circumference, and waist-hip ratio were also assessed. social factors considered as stressors in this study were: perception of housing conditions, satisfaction with one’s house, neighborhood characteristics, social support, church attendance, and family relations, because the allostatic load is the result of multiple stressors of the physical, psychosocial and environmental type. the aging itself involves several psychosocial changes, and the selected stressors are those that older adults face frequently, according to the literature (7, 26). the perception of family relations test in elders (30) evaluates the following dimensions of family relationships: boundaries, communication, role development, support system, hierarchy, and tolerance. the instrument has 30 items with a five-point likertscale; scores range from 30 to 150 points. authors report a cronbach’s alpha coefficient of 0.90; in this study, a coefficient of 0.89 was obtained. higher scores represent better family relationships. the instrument is categorized as follows: 146 to 150 points = very harmonious family relationships; 140 to 145 points = harmonious family relationships; 129 to 139 points = little harmonious family relationships; and 30 to 128 points = disharmonious family relationships. scores were transformed into an index of 0–100 points to compare among other instruments. the medical outcomes study-social support survey (mossss) is a tool that measures the structural and functional dimensions of social support. the spanish-language tool reports a cronbach’s alpha coefficient of 0.94 (31), similar to the value obtained in this study of alpha = 0.95. the instrument consists of 19 items on a five-point likert-scale, ranging from “never” to “always,” plus one question about social network size. scores range from 19 to 95 points. the higher the score, the higher the perceived social support. an index of 0–100 points was obtained. the abbreviated neighborhood environment walkability scale (news-a) measures the perceived characteristics of the neighborhood. cerin and colleagues validated the new-a in 16 neighborhoods of county king, washington, and reported a cronbach’s alpha of 0.80 (32), and the alpha was 0.62 in our study. fifty-four items were used corresponding to the following dimensions: (a) type of housing in the neighborhood, (b) distance to relevant sites, (c) service accessibility, and (d) neighborhood security. these four dimensions break into 12 sub dimensions. the news-a uses a fiveand four-point likert-type response patterns. the five-point response pattern assesses types of houses in the neighborhood, and these response options range from: none = 1, to all of them = 5. the four-point response pattern is used with the dimensions of service accessibility, streets conditions, and neighborhood security, and the response options are: strongly disagree = 1, to strongly agree = 4 points. the measurement of distance to relevant sites is based on the approximate time in minutes an older adult estimates it takes him or her to get from their house to nearby places. the responses are: 1–5, 6–10, 11– 20, 20–30 minutes, and more than 30 minutes. in cases where the respondent could not provide an estimation, the response was 303 social factors contributing to the development of allostatic load in older adults: a correlational-predictive study l alejandro morales-jinez and others considered to be more than 30 minutes. index points of 0–100 were obtained for the whole instrument applied, and for each of the 12 sub-dimensions separately. the selection of specific biomarkers and the method for calculation of a specific score differ widely in the literature. thus, following the methods of seeman et al. (33), a measure of allostatic load (al) was designed to summarize levels of physiological activity across a range of regulatory systems, including: systolic blood pressure, diastolic blood pressure, body mass index, waist circunference, waist-hip ratio, total cholesterol, high-density lipoprotein (hdl), glycated hemoglobin, fibrinogen, and c-reactive protein. to construct an allostatic load index, each biomarker was given a value of zero (low risk) if it was found within normal levels and a value of one (high risk) if the biomarker was above reference values. in the case of hdl, a zero (low risk) was assigned when this biomarker was high, and a value of one (high risk) when concentration levels were low. finally, all biomarkers and anthropometric measurements were summed up. the possible range was 0 to 10. participants were categorized as follows: the “low risk” category included subjects whose biomarkers and anthropometric measures were unaltered, “medium risk” when two or three biomarkers were altered, and “high risk” when four or more biomarkers and anthropometric measures were altered (34). biomarkers measurements were performed as follows: blood pressure. blood pressure measurement was carried out using a mercury sphygmomanometer and a stethoscope. blood pressure was taken twice on the participants’ left arm after 10 minutes of rest in the sitting position; values were registered in the data sheet. measurements were averaged to obtain an overall systolic and diastolic blood pressure. body mass index. we use the quetelet formula, wherein the participants’ weight in kilograms was divided by their height in square meters (kg/m2). to calculate weight and height, an electronic scale with infrared stadiometer was used, which was calibrated and data was transcribed on the data sheet. waist-hip ratio (whr). whr was the result of the waist circumference divided by hip circumference. to calculate waist and hip, a fiberglass tape measure was used, and we followed the protocol described by the world health organization (35). cholesterol, hdl, glycated hemoglobin, fibrinogen, and creactive protein. one of three blood samples per participant was analyzed for c-reactive protein, total cholesterol, hdl, glycated hemoglobin, and fibrinogen levels; these blood samples were collected in tubes by qualified personnel, stored on a cooler and transported to the laboratory for immediate glycated hemoglobin analysis; the other two samples were centrifuged, and serum was frozen for hdl, c-reactive protein, fibrinogen, and total cholesterol testing the following week. the following procedures were used for each biomarker measurement: turbidimetry for glycated hemoglobin, coagulometric method for fibrinogen, colorimetry and turbidimetry for c-reactive protein. total cholesterol and hdl were measured using the enzymatic, coagulometric, and selective ion methods. the biomarkers cut-off points proposed (36) are shown in table 1. table 1. allostatic load biomarker cut-off points biomarker cut-off point total cholesterol (mg/dl) > 240 high density lipoprotein (mg/dl) < 36 glycated hemoglobin (%) > 7.1 fibrinogen (mg/dl) > 336 c-reactive protein (mg/dl) > 0.3 systolic blood pressure (mmhg) > 148 diastolic blood pressure (mmhg) > 83.3 waist-hip ratio (whr): > 0.94 body mass index (bmi) > 25 waist (cm) female > 85 male > 95 source: adapted from gruenewald, seeman, karlamangla, and sarkisian (36). this study was approved by the ethics committee of the autonomous university of nuevo león school of nursing (faen-d-1007 record; irb 00002060 record). once the project was approved, agreements were made with corresponding authorities to gather data at the selected sites. the principal investigator explained the study and invited potential participants. participants who agreed and met the selection criteria signed an informed consent. participants were informed in writing and verbally about the requisites for laboratory sample drawing (12-hour fasting) and the date of the appointment. after the blood sample was drawn, sociodemographic data and anthropometric measures were collected. each 304 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 participant was given another appointment to receive his or her laboratory results and to complete the instruments. statistical analysis the spss software version 22 for mac was used for data analysis. descriptive analysis was calculated for the characteristics of participants and study variables. alpha cronbach’s coefficients were reported in the measure section. generalized linear models were used to determine the contribution of social factors on allostatic load. a p value of .05 was used to determine significance. results of the 131 older adults in the final sample, 92.4% [121] were female. the mean age was 73.5 years old (sd=6.75, range 60 – 89 years), and of years of school was 3.68 years (sd=3.09, range 0–15 years). fifty-six percent of participants (n = 74) said they were widowed, 31.3% [41] were married, and the rest were either divorced, or single. the majority of participants (85.5%, n =112) were homemakers, 11.5% [15] described themselves as retired, and 3% [4] had their own business or volunteered for a non-governmental organization. the mean church attendance was 1.63 times per week (median = 1, sd=1.72). anthropometric measures for weight, height, body mass index, waist, hip, waist-hip ratio, systolic and diastolic blood pressure are presented in table 2. average bmi and waist circumference, both in men and in women, were found to be high; however, average waist-hip ratio, systolic and diastolic blood pressure were normal. only 30 (24.8%) women, and 4 out of 10 men (40%) had waist circumferences within the acceptable range. fibrinogen (n=102, 78%), and c-reactive protein (n=139, 99%), total cholesterol (n=19, 14.5%, glycated hemoglobin (n=22, 17%) were elevated, and high-density lipoprotein levels (n=37, 29%) were low, indicating high-risk parameters for allostatic load. mean 95% confidence interval median sd minimum maximum biomarker lcl ucl weight (kg) 66.87 64.60 69.14 65.60 13.13 41.10 111.30 height (cm) 149.00 147.00 150.03 148.00 9.00 129.00 183.00 body mass index 30.14 29.29 31.00 29.66 4.96 19.50 49.50 waist (cm) female 96.63 94.52 98.74 96.00 11.73 72.00 133.00 male 98.40 86.96 109.84 104.00 15.99 70.00 125.00 hip (cm) 108.07 105.64 110.50 106.00 14.04 85.00 197.00 waist hip ratio 0.90 0.88 0.91 0.89 0.09 0.44 1.19 systolic blood pressure (mmhg) 132.35 129.73 134.98 130.00 15.17 105.00 180.00 diastolic blood pressure (mmhg) 84.23 82.56 85.91 85.00 9.69 65.00 125.00 total cholesterol (mg/dl) 200.07 192.82 207.32 202.00 41.94 103.00 320.00 high density lipoprotein (mg/dl) 48.21 45.71 50.71 44.00 14.46 28.00 95.00 c-reactive protein (mg/dl) 1.22 1.10 1.35 1.10 0.72 0.20 5.00 fibrinogen (mg/dl) 428.27 410.84 445.70 425.00 100.84 238.00 753.00 glycated hemoglobin (%) 6.16 5.97 6.35 5.90 1.11 4.00 11.60 table 2. anthropometric, clinical and biochemical descriptive data source: own elaboration. 305 social factors contributing to the development of allostatic load in older adults: a correlational-predictive study l alejandro morales-jinez and others twenty-one (16%) subjects were classified as having medium allostatic load risk (two or three biomarkers above the cut-off point) and 84% [110] as having high risk (four or more altered biomarkers). there were no cases of low allostatic load risk. a generalized linear model was used to determine the contribution of potential stressors. a total of 15 independent variables were entered into the equation and allostatic load as dependent variable, including perception of family relations, social support, and number of times per week attending church, and 12 subdimensions of the news instrument accessibility of services, satisfaction with their house, distance to relevant sites, street aesthetics, general neighborhood characteristics, dangerous traffic, housing conditions, sloped streets, street connectivity, pedestrian infrastructure, dead-end streets, neighborhood security. the general model was significant: f (15, 115) = 2.645 p < .05, r 2=16% (table 3). when the backward elimination method was used, the explained variances improved f (5, 125) = 7.466, p < .001, r2= 19.9%. table 4 also shows that better housing conditions, satisfaction with own house, presence of dead-end streets, and church attendance reduce allostatic load, and that increase in dangerous traffic increases allostatic load. discussion for neuman (25), the person is an open system that is in constant interaction with the environment. in the environment, there are forces that can alter the basic structure or client’s system. according to neuman, a physiological variable can cause a serious imbalance to the client when he or she has insufficient resources to cope with stressors. in this study, the physiological variable was allostatic load, and a high proportion of participants fell under a high risk pf allostatic load (four or more altered biomarkers) table 3. generalized linear model for social factors contributing to allostatic load in older adults independent variable b ee β p housing conditions -.011 .005 -.226 .014 sloped streets .002 .003 .518 .605 street aesthetics -.004 .004 -.086 .393 dead-end streets -.008 .003 -.244 .003 pedestrian infrastructure .000 .007 .002 .987 street connectivity -.003 .005 -.068 .528 satisfaction with one’s house -.015 .006 -.218 .023 distance to relevant sites -.171 .207 -.078 .411 family relationships .000 .012 .004 .977 dangerous traffic .012 .004 .271 .007 neighborhood security -.003 .005 -.064 .514 accessibility to services .005 .006 .097 .357 social support -.005 .008 -.081 .524 neighborhood characteristics .004 .018 .041 .822 church attendance -.156 .066 -.195 .019 source: own elaboration. 306 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 and less participants under a medium risk for allostatic load (two or three altered biomarkers), suggesting that the elder’s physiological system was not able to overcome the imbalance. fibrinogen and c-reactive protein were elevated in a high proportion of participants. fibrinogen and c-reactive protein are produced in the liver, and life-styles, such as lack of exercise or physical activity and alcohol and tabacco consumption may affect the liver, and the rise of fibrinogen and c-reactive protein in conjunction with elevated bmi increase the risk for clots development and myocardial infarction. c-reactive protein is closely related to bmi due to inflammation processes. most of the participants showed mean abdominal circumference and bmi above the established acceptable standards. according to the neuman system, the model results of participants suggest they were not able to maintain the normal line of defense through healthy eating and exercise. moreover, these results confirm those of the national health survey that revealed a higher prevalence of obesity among older adult populations in northern mexican states (37, 25). the environmental stressors to which the elderly person is subjected can be very diverse. from a physiological point of view, the body may reach a point where it cannot sustain regulation of basic processes to maintain an allostasis. this lack of regulation may then trigger illness, with the end result being a decreased quality of life for the elder. in this research, the interpersonal and extrapersonal stressors included neighborhood characteristics, housing conditions, satisfaction with one’s house, presence of dead-end streets, and weekly attendance to church (26). the statistical analysis confirmed that interpersonal and extrapersonal stressors positively affected the explained variance of allostatic load, while dangerous traffic negatively affected the explained variance of the allostatic load. the positive effects of housing conditions and satisfaction with own house are supported by some authors, who found an association between satisfaction and better housing conditions, and well-being, and low pathology incidence among older adults (38, 39, 40). results also showed that dangerous traffic increases allostatic load. participants frequently reported feeling stressed by vehicles running at high speeds, because they feared accidents. in this regard, the literature review indicates that noise produced by heavy traffic has negative effects on the cardiovascular system, which also impacts allostatic load risk (41, 42, 43, 44). this study did not specifically inquire about vehicle noise, but it is assumed that noise comes with heavy traffic. the presence of dead-end streets contributed as a protective variable; in this sense, participants pointed out that there was less traffic in these streets, and therefore less stress. also, it was inferred that dead-end streets encouraged them to walk and get from one place to another in the neighborhood. the neuman system model assumes that spiritual variable empowers the client toward well-being by positively directing spiritual energy for use first by the mind and then by the body, and the religion is an important component of spirituality (25). attending religious services contributed to explain lower allostatic load. religiousness, or the number of times per week that a person goes to church, has been reported as a protective agent against allostatic load, which plays a protective role among women, given that they tend to be more committed to religion (12), and in this research most of the participants in the present study were women. another explanation might be the social networks developed while an elder attends church services, and that religiousness could enable them to cope better with health and social problems (44, 45, 46). table 4. final generalized linear model for social factors contributing to allostatic load in older adults independent variable b ee β p housing conditions -.014 .006 -.197 .025 satisfaction with one’s house -.012 .004 -.233 .007 dangerous traffic .011 .003 .257 .002 dead-end streets -.008 .003 -.244 .003 church attendance -.156 .066 -.195 .019 source: own elaboration. 307 social factors contributing to the development of allostatic load in older adults: a correlational-predictive study l alejandro morales-jinez and others limitations results cannot be generalized due to selection method (convenience sampling) and lack of enough men in the study. all the older adults lived in neighborhoods with similar characteristics, which could have affected variability and the ability to obtain more significant results. a neighborhood-based sampling strategy and the analysis of other variables such as vehicle noise and, particularly, family relations and social support, need to be approached from a qualitative perspective or other instruments. as a final note, the ten biomarkers used in the present study are classified as secondary biomarkers (47). the incorporation of primary biomarkers such as cortisol, epinephrine, and norepinephrine could help to better understand whether such primary biomarkers are better explained by social factors. conclusion the main concern of nursing is to maintain the elderly within a maximum level of well-being through actions aimed at reducing threats or stressors in the environment. this study contributes to the discovery of social factors that are stressful for the elderly and that have sometimes been minimized within the preventive practice of health. according to the results of the study, the characteristics of the neighborhood and the housing conditions affect the physiological variable of the elderly. on the contrary, the number of times per week that the elder attends religious events, the good conditions of the home in which he lives, and being satisfied with his home were negatively associated with an elevated allostatic load. the application of scientific evidence should be in primary and secondary prevention in order to strengthen the flexible line of defense and reduce the possibility that an interpersonal or extrapersonal stressor affects the elder adult. the results of scientific research need to generate more evidence to develop new assessments in the social aspect of elder adults. likewise, these results can contribute to modify or generate political proposals to improve the health of our population older than 60. acknowledgments we would like to thank the national system for integral family development (dif) of monterrey (mexico) facilitating the collection of data and providing the use of their facilities during the investigation. conflict of interest: none was declared. references 1. global agewatch. índice global de envejecimiento, agewatch 2015: resumen ejecutivo. 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aneshensel cs, phelan jc, bierman a. editors. handbooks of sociology and social research. dordrecht: springer; 2013. p. 457–478. 310 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 45. aldwin cm, park cl, jeong yj, nath r. differing pathways between religiousness, spirituality, and health: a self-regulation perspective. psychology of religion and spirituality 2014; 6 (1): 9–21. doi: 10.1037/a0034416. 46. rocha acal, ciosak ai. chronic desease in the elderly: spirituality and coping. rev esc enferm usp 2014; 48 (esp2): 87–93. doi: 10.1590/s0080-623420140000800014. 47. bizik g, picard m, nijjar r, tourjman v, mcewen bs, lupien sj, juster rp. allostatic load as a tool for monitoring physiological dysregulations and comorbidities in patients with severe mental illnesses. harv rev psychiatry 2013; 21 (6): 296–313. doi: 10.1097/hrp.0000000000000012. autonomy a realistic.pmd revista aquichan issn 1657-5997 92 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 abstract autonomy can be defined as independence or freedom. when it is used to describe individual work, it refers to the ability to make decisions without undue influence from others. the purpose of this paper is to critique two models of autonomy, one developed from the discipline of occupational health, and one developed from the discipline of nursing. these models potentially provide insight to the work of nurses in hospitals. additionally, this paper will explore the possibility of applying these traditional western models to cultures and countries other than the us, europe, and australia. the question of whether a hospital nurse can be autonomous is complicated by the structure of the society in which the work of the nurse exists and the barriers produced by those structures. in order for nurses and women to exercise more autonomy in work settings, powerful members of the society must acknowledge the reality of the under valued status of women and women’s work and allow for a greater exercise of discretion by women. key words nurse, women, autonomy, hospital, work. jean ann seago1 recibido: 10 de noviembre de 2005 aprobado: 27 de marzo de 2006 1 university of california, san francisco. ca 94143, 415/476-9000. usa. jean.ann.seago@nursing.ucsf.edu resumen la autonomía puede ser sinónimo de independencia o libertad. cuando se utiliza para referirse al trabajo individual, se entiende como la habilidad para tomar decisiones sin injerencia de terceros. el propósito del presente artículo consiste en realizar una crítica a dos modelos de autonomía, uno desarrollado desde la disciplina de la salud ocupacional y el otro desde la disciplina de la enfermería. estos modelos potencialmente suscitan una reflexión sobre el trabajo de la enfermería hospitalaria. adicionalmente, en este documento se explorará la posibilidad de aplicar estos modelos tradicionales occidentales en culturas distintas a las de estados unidos, europa y australia. la pregunta acerca de si una enfermera hospitalaria puede ser autónoma es compleja debido a la estructura social en la que se desarrolla su trabajo y a las barreras que esas estructuras le imponen. para que las enfermeras, y las mujeres, puedan ejercer su autonomía en los ambientes de trabajo, los miembros más poderosos de la sociedad deben reconocer la realidad del subvalorado estatus de la mujer y de su trabajo, y así considerar un mayor ejercicio de su discrecionalidad. palabras clave enfermera, mujeres, autonomía, hospital, trabajo. autonomía: ¿una meta realista para la práctica hospitalaria de enfermería? año 6 vol. 6 nº 1 (6) 92-103 chía, colombia octubre 2006 autonomy: a realistic goal for the practice of hospital nursing?. autonomía: ¿una meta realista para la práctica hospitalaria de enfermería? 93 utonomy can be simply defined as independence or freedom (1, 2). when it is used to describe individual work, it refers to the ability to make decisions without undue influence from others (3). decisions are made independently and are based on education and experience of the individual worker. the decisions are generally considered immune from the arbitrary exercise of authority (4, 5). the concepts of autonomy and work have been discussed for several decades by scientists and theorists, particularly in relationship to the work of women and the professions and occupations that have traditionally been associated with women (2, 49). nurse scientists and leaders have been among the people interested in the notion of autonomy for nurses. that interest now extends beyond the boundaries of traditional western cultures, and includes cultures and countries in asia and south america. but how much autonomy do nurses actually have and how does the concept of autonomy, especially for women, fit into different cultures? there are a number of scientists in occupational health, women and work, nursing organizations, and nursing work environment (10-15), who have studied autonomy, work, and nurses. the purpose of this paper is to critique two models of autonomy, one developed by karasek (16-19), from the discipline of occupational health, and one developed by kramer (20-24) with additions by aiken (25, 26), from the discipline of nursing. these models potentially can provide insight to the work of nurses in hospitals. additionally, this paper will explore the possibility of applying these traditional western models to cultures and countries other than the us, europe, and australia. interest in nurses and the work of nurses waxes and wanes depending on the various cycles of nurse shortage and surplus. today, there is a nurse shortage that extends worldwide (27-29), so interest is intense. in order to help alleviate the shortage, wealthy countries, such as the us, uk, uae, and saudi arabia, have had some success in recruiting nurses from poorer or less developed countries. these countries typically have fewer financial resources, lower nurse wages, and a more difficult nurse work environment (29-32). however, even with more resources committed to nurse immigration, nurse education, and nurse work environment, the us has a severe and, likely, sustained nurse shortage that has been predicted to extend well into the 21st century (33-37). critical nurse shortage areas in the us include hospital bedside nurses and nursing faculty. strategies that have been suggested to help alleviate the shortage include providing a more favorable work environment for nurses and increasing wages in the acute shortage areas. nursing faculty shortages have occurred and are occurring for reasons different from bedside nurses and will not be discussed in this paper. rather, this paper will focus on the shortage of hospital bedside nurses. there is evidence that simply increasing wages will not resolve the nursing shortage. rather, it will be necessary to create and sustain a more favorable work environment that may encourage nurses to remain at work at the hospital bedside (25, 38-40). evidence suggest (41-43) that some nurses at the hospital bedside would be more satisfied with the work environment if they had increased workplace autonomy. scientists have found that the ability to make decisions about patient care, about the organization of one’s work, and about one’s work schedule are associated with increased job satisfaction (44-46). this autonomy includes the freedom to work or not to work, the freedom to decide when and how to do the work, and, in the professional opinion of the nurse, the ability and revista aquichan issn 1657-5997 94 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 freedom to plan the work to provide the best outcome for the patient. this need for freedom seems obvious for any professional group, but has proven illusive for all nurses, especially hospital nurses. nurses have sought freedom or autonomy in numerous ways but with minimal success. these strategies, such as by becoming advanced practice nurses, by moving to technologically advanced practiced areas, by moving away from practice areas dominated by physicians, by moving into management, or by achieving advanced credentials and educational degrees, have frequently taken them away from the hospital and bedside nursing (3, 15, 45, 47-49). but the autonomy sought by nurses has not been forthcoming, particularly work in hospitals and specifically at the direct care level. the question of why autonomy for nurses has been so illusive has not been answered. critique of the following models related to autonomy may provide some clues to this contentious issue. in the 1970s and 1980s, karasek (1618) developed a model to describe the work of various occupational groups and professionals, specifically to explain the interaction between the psychological demands of work and the decision latitude that exists in work. the model has been tested for several decades in various countries and in numerous occupational groups (8, 9, 16, 18, 19). karask has hypothesized that occupational groups that experience high psychological demand and low decision latitude experience significant “job strain”, which is defined as inability to work effectively and which produces discomfort for people in the work environment that is similar to job stress. karasek and others (8, 18, 50, 51) have consistently found that professional nurses as an occupational group, when given the karasek job content questionnaire (18, 19), perceive they have a high level of decision latitude and a high level of psychological demand related to their work. in contrast, there is evidence that nurse assistants express a high level of psychological demand but a low level of decision latitude in their work. so, registered nurses, compared to nurse assistants and other select occupational groups, experience a more positive or “active” work environment, according to the karasek model, as indicated by their expression of control over decisions related to their work. this decision latitude helps moderate the high psychological demand associated with the work. this finding seems to contradict the extensive literature (48, 52-57) that describes job dissatisfaction among professional nurses. there is a literature of several decades describing job dissatisfaction and “burn out” particularly among hospital bedside nurses (25, 58-62). several studies have evaluated the relationship between the karasek model and job satisfaction, but those studies with nurse participants typically investigate the relationships between the job strain and physiological symptoms or diseases (9, 50, 51, 63-65). one explanation for the contradictions found in the karasek model testing literature and the nurse burnout and job dissatisfaction literature may be that the karasek model is relational and the values are not absolute. so, professional nurses may appear to be in the active work or nonjob strain quadrant of the model compared to other occupational groups, but still express dissatisfaction with aspects of the work over which they have little control and want more control. another explanation might be that the respondents to the karasak questionnaire may hold jobs in ... occupational groups that experience high psychological demand and low decision latitude experience significant “job strain”, which is defined as inability to work effectively and which produces discomfort for people in the work environment that is similar to job stress. autonomy: a realistic goal for the practice of hospital nursing?. autonomía: ¿una meta realista para la práctica hospitalaria de enfermería? 95 nursing where there is more decision control about the work. the psychological demand responses have tended to remain high but the decision latitude responses vary. since the original karasek model was developed, the author has added additional scales measuring additional aspects of work. some of these additional measures might be useful in providing more context about the various types of nursing work and the responses to that work. the model might prove useful in guiding the study of autonomy in nurse work; but it requires more clarification of the potential mediating effects of the various scales, more specifics about the different types of autonomy, and more study of the relationship between job strain, nurse job dissatisfaction, and burnout. kramer (20, 21, 23, 66) developed a model of autonomy in the work of nurses as it related to the “magnet” hospital program. during1980s there was another nursing shortage and the magnet hospital program (21-23) was created to identify hospitals that were designated as good places for nurses to work. the hospitals were selected by nurse leaders but the selection criteria were vague and based primarily on opinion. more recently, kramer and others have begun to empirically test the notion of autonomy in magnet hospitals (3, 44, 67-69). in the more recent magnet model, kramer defines autonomy as “the person “who own(s)ed the problem, issue, and solution” and the “degree of effectiveness of control” as reflected in visibility, viability, and recognition of a formal structure allowing and encouraging nurses’ control over practice” (3, 44). kramer (70) developed a questionnaire to measure autonomy and has found that magnet hospital nurses do not always perceive they have autonomy in their clinical practice (3). aiken (26) and others (25, 67, 71, 72) have used a version of the kramer model and modified karmer’s question-naire. it is called the nurse work index-revised (nwir) and the scientists have found relationships between aspects of autonomy and positive patient outcomes. the specific areas of autonomy in the model that seem to be important are collaboration with physicians, control over practice, and decision-making. scientists have also found relationships between increased collaboration with physicians, control over practice, and decision making to be related to improved job satisfaction (12, 25, 52, 73-76). this is consistent with work done in the 1990s by shortell and others (77, 78) related to nurse work environment in the intensive care units. aiken’s early work tended to use nurse respondents from pennsylvania, so selection bias may have been a problem in some of these studies. however, later work has included nurse respondents from other countries, primarily canada and the uk, and the studies have produced similar results (79-82). in summary, the body of literature testing the karasek model indicates that nurses have more decision latitude about their work than other health workers, such as nurse assistants. but the model is not specific to health care environments and tends to find that all the professional workers fit into the non-job strain or active work quadrants of the model. additionally, the model is designed to measure job strain, which is defined as an interaction between psychological demand and decision latitude, so the measures may not be sensitive enough to detect the specific issues of hospital nurses, particularly those nurses who provide direct bedside care. the studies in the body of literature testing the kramer/aiken model provide scientists have also found relationships between increased collaboration with physicians, control over practice, and decision making to be related to improved job satisfaction. revista aquichan issn 1657-5997 96 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 substantial evidence that nurse-physician collaboration, decision making ability, and control of practice in hospital bedside nurses is related to nurse job satisfaction and select positive patient outcomes (15, 83-85). if we accept the evidence in this literature; that is that nurse autonomy is related to nurse job satisfaction, that nurse job satisfaction is important to reduce nurse turnover (86-88); and that nurse autonomy is related to positive patient outcomes; why does the hospital work environment for bedside nurses continue to reflect a lack of autonomy related to the work of nurses? to answer this question, some health care leaders would respond that the issue is cost (67, 88-92). in order to improve the work environment for bedside nurses, hospital organizations and the broader society must provide more nurses in the environment. undoubtedly, increasing the number of nurses in the work environment allows for a more reasonable distribution of work and a higher level of job satisfaction for nurses (93-96). it also allows more time for nurses to perform activities for which they have been specifically trained; surveillance of the patient and vigilance in observation of the instability/stability of the patients’ condition, interception of errors or disease complications and prevention of harm related to those errors or complications, management and/or maintenance of the patients’ current health status, and the ability to provide comfort to the patient and family and improvement in the patients’ health status; versus simply “following doctors’ orders and doing as they are told”. because there is the economic assumption that resources are finite in any society, increasing the resources provided for one section of the society will, by definition, necessitate decreasing the resources in another section. therefore, the cost of adding (recruiting, training, educating, providing salaries and benefits) additional professional nurses must be not be discounted and must be considered in light of the competing demands for health resources and other resources in a community, society, or country. another argument for maintaining the current hospital working conditions, and therefore lack of autonomy for nurses is that nurses do not have sufficient training or education to exercise the autonomy they desire (6, 15, 49, 97-99). this is the argument that only “doctors know best” about patient care. this argument perpetuates the notion that hospital bedside nurses are simply an extension of the physician and that their role is only that of conduit of information between the patient and physician, with no thinking or independent action needed or taken. but, all health care professionals, whether they acknowledge it or not, know that this limited role of the nurse is complete fantasy. this is the fantasy role of the nurse that is often displayed in the media and in literature. this is the fantasy role of the nurse that many hospital administrators, physicians, and other high-ranking officials want to believe is reality. but all these officials know that without the critically thinking, technologically skilled, and competent professional nurse, modern day hospitals would cease to exist. nurses, like all other health professionals, vary in their talents and skills but, overall, hospital bedside nurses are completely capable, by virtue of education, training, and experience, of exercising autonomy in their work, specifically collaboration with physicians, control of practice, and decision making about patient care. therefore, i would argue that high cost and lack of education are not the only or even the most significant barriers in preventing hospital bedside nurses from another argument for maintaining the current hospital working conditions, and therefore lack of autonomy for nurses is that nurses do not have sufficient training or education to exercise the autonomy they desire. autonomy: a realistic goal for the practice of hospital nursing?. autonomía: ¿una meta realista para la práctica hospitalaria de enfermería? 97 exercising autonomy in the form of a more lateral collaboration with physicians, control of nursing practice, and decision making about patient care. to understand the resistance that exists toward nurses having autonomy, i would suggest the consideration of the theory of oppressed group behavior (100-103). there is a small feminist literature relating oppressed group behavior theory and the work of nurses. roberts and others have argued for this concept for several decades (100-107). however, nurses and feminists have long had a contentious relationship and often discount the work and thoughts of each other (11, 108-110). feminists have frequently characterized nurses as existing in the past in a profession that is virtually exclusively female and therefore less desirable than other professions or occupations. feminist activism has tended to focus on forcing the inclusion of females in occupations and professions that have been more exclusively male-dominated. nurses, on the other hand, have viewed feminist activism as extreme and have generally denied the oppression that exists for the nursing profession as a whole. it is very difficult for educated, capable, and proud women to acknowledge that they exist in a profession that is oppressed by men, organizations, and societies. individual nurses who think about their status and the status of the nursing profession often feel disempowered and helpless if they acknowledge the oppression. so, they deny the oppression and attribute any weakness or perceived lack of knowledge or skill to the individual nurse. this, of course, is one of the hallmarks of oppressed group behavior. this rationalization can lead to “horizontal violence” or “blaming the victim” within the group, which is blaming any weaknesses on individual members of the group or on sub-groups other than those in which you are a member (111-115). for example, in a hospital intensive care or operating room nurses often view themselves as more independent, autonomous, and therefore, “betterthan” medical-surgical nurses. they can align themselves with powerful (male) physicians and then distance themselves from those “others” (weaker female)medical-surgical nurses who just cannot seem to do their jobs”. this same rationalization can force nurse administrators and managers to take sides against bedside nurses. the nurse administrators or mangers align themselves with the hospital executives, another powerful male group, and can then distance themselves from those “emotional (weaker female) nurses at the bedside who just cannot seem to or refuse to understand money matters”. applying the concepts of oppressed group behavior to the nursing profession requires a suspension of the denial that most nurses express about nurses as victims. it requires that nurses accept that all nurses are members of an oppressed group (116, 117). accepting this notion does not mean that individual nurses are weak or bad or helpless. it does mean that persons other than nurses make many of the decisions that are critical to the work of nurses and that nurses often have little or no voice when those decisions are made. it means that many of the decisions associated with the ability of many nurses to perform their jobs adequately are out of the control of those nurses. it means that blaming groups of nurses for a perceived inadequacy or injustice or incompetence, is often unrealistic and damaging. the “blame” and responsibility for many of the organizational or societal conditions lie with the powerful (male) groups in the hospital or in feminists have frequently characterized nurses as existing in the past in a profession that is virtually exclusively female and therefore less desirable than other professions or occupations. revista aquichan issn 1657-5997 98 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 the society, the physicians and the hospital executives. these powerful groups are dominated by men or by male-oriented reasoning and thinking. nurses, that is females, are often discounted for using reasoning or thinking that is different from this “male standard”. even nurse executives, frequently have very limited control over allocation of resources for nurses and have limited autonomy in decision making about support services and other resources that are necessary for nurses to do work adequately. this oppression of traditionally female occupations and professions has not changed significantly in most societies. some of these occupations and professions have benefited in status and wages by the addition of males to their ranks but this is not universally the case. many societies still place little value, as demonstrated by relative status and wages, on elementary or secondary school teachers, childcare or elder care workers, secretaries, flight attendants, or dental assistants, all traditionally female professions. in the us, female professors continue to be under represented in the higher paid and higher status professorial and tenured ranks in universities (118). the women tend to be relegated to the lower paid and lower status ranks of instructor, lecturer, or non-tenured faculty ranks (119-121). in the us, females are consistently penalized for taking time away from work in business or industry for childbearing, child rearing, or providing elder care (121, 122). so, is it is possible for hospital bedside nurses, or any nurses, to achieve autonomy in the workplace? the question is complicated by the structure of the society in which the work of the nurse exists. the ability of the nurse to attain a measure of autonomy in work will depend on the ability of the society to re-evaluate and re-value the traditional work of women. the societal structures that produce barriers to this autonomy run very deep and are very strong. in order for nurses to exercise more autonomy in hospitals, powerful people in the hospital and members of the society at large must acknowledge the reality of the under valued status of women and women’s work in that society. only then would it be possible to orchestrate a societal and/or organizational change in the value placed on the traditional work of women and permit women to exercise autonomy in work. people who become nurses are raised and nurtured in the same societal structure in which all people in the society are raised. people who become nurses have been taught the same biases and prejudices as those people in the general society about the lack of worth of the traditional work of women, work such as caring for the sick, the weak, the young, and elderly. so, people who become nurses may, and often do, bring with them the societal notion of devaluing the work of nurses. just because you are a nurses does not mean that you do not have biases and prejudices toward nurses. nurses and others, often characterize these feelings in the individual nurse as poor self-worth, poor self-esteem, poor self-image, and even self-loathing. this is also characterized as the poor public “image of the nurse” and the nursing profession has sought to change this image by expending much effort and expense toward advertising and marketing. but attempting to change the image is treating the symptom, not affecting a cure. in order for a “cure” to be achieved, the people in the society must value the work of the nurse and demonstrate this perception of value by awarding higher status and higher wages to nurses. in the us, females 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/untaggedcmykhandling /leaveuntagged /untaggedrgbhandling /leaveuntagged /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice curriculo por competencias.pmd currículo por competencias en la universidad de la sabana. competence curriculum at la sabana university 117 resumen la presente investigación tiene como objetivo analizar si el desarrollo de la práctica educativa de los profesores de las asignaturas de cuidado de enfermería corresponde a la formación por competencias, con relación a la planeación, ejecución y evaluación de los procesos de enseñanza y aprendizaje. el estudio, de tipo descriptivo cualitativo, se llevó a cabo durante el primer semestre de 2006 en la facultad de enfermería de la universidad de la sabana. sus principales hallazgos son: con relación a la programación de las asignaturas se encontró que éstas tienen los elementos básicos de la educación por competencias, contemplando el saber ser, el conocer y el hacer propios de cada asignatura. sin embargo, dentro de esta programación no se encuentra la metodología que se empleará en las clases. tampoco hay una relación clara entre las estrategias didácticas, el proceso evaluativo y el logro de las competencias. en el desarrollo de las clases se encontró que los profesores manejan los temas en forma clara y concisa, pero hay diferencias entre el profesor novato, que se centra más en los contenidos, y el experto, que se ocupa de forma más natural por los procesos y por promover el análisis. la metodología más utilizada por los profesores durante las clases consiste en realizar y responder preguntas mientras se expone o se discute determinado tema. con relación al proceso evaluativo, éste se centra principalmente en los contenidos, excepto en las prácticas donde se valora el saber, el hacer y el ser en forma integral. falta evidenciar la autoevaluación y la coevaluación en todas las asignaturas, aspectos necesarios dentro de la formación por competencias. la recuperación es una herramienta valiosa que apunta a la educación por competencias, es aplicada en todas las asignaturas y permite valorar en forma individual los logros del alumno al establecer un plan de mejoramiento orientado por el profesor. palabras clave currículo, competencias, práctica educativa, programación, desarrollo de la asignatura, proceso evaluativo. angélica maría ospina romero1 recibido: 17 de julio de 2006 aprobado: 28 de agosto de 2006 1 facultad de enfermería. universidad de la sabana. campus universitario del puente del común, km. 21, autopista norte de bogotá d.c., chía, cundinamarca, colombia. angelica.ospina@unisabana.edu.co abstract this paper’s objective is to analyze if teachers performing development in nursing care subjects corresponds to competence education, according to planning, implementing and assessing teaching and learning processes. it is based on a qualitative and descriptive study, implemented during the first term of 2005 at la sabana university. one of the main findings associated with subjects programming is that subjects have the basic elements of competence education regarding to know, know how and know how to be. however this programming does not express the methodology to be implemented in the classroom, nor is present a particular relationship among didactic strategies, assessment process and competences achievement. class developing evidenced that teachers clearly and concisely handle the topics; in spite of that, there are differences between an amateur teacher, who is focused on content, and an expert, who is able to naturally cope with processes and analysis fostering. the most common methodology used by teachers in the classroom is asking and answering inquires, while presenting or debating any particular topic. regarding the assessment process, it is mainly focused on content, except for practical subjects where know, know how and know how to be are assessed as a whole. self-evaluation and co-evaluation are still pending of implementation in order to complete the picture of competency education. recovery, a valuable tool for competence education, is applied to all the subjects; it allows to individual assessing of students achievements, setting up an improvement plan leaded by teachers. key words curricula, competence, teachers performance, programming, subject development, assessment process. competence curriculum at la sabana university año 6 vol. 6 nº 1 (6) 117-124 chía, colombia octubre 2006 revista aquichan issn 1657-5997 118 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 introducción n la actualidad, a nivel mundial se están viviendo fenómenos que marcan el comportamiento de las sociedades, y modifican la cultura y las exigencias del mercado laboral y educativo. aspectos como la globalización, el marcado uso de nuevas tecnologías, la sociedad del conocimiento, obligan a que las instituciones educativas modifiquen la forma de enseñar, se flexibilicen y formen individuos en competencias que abarquen los conocimientos, las habilidades, las actitudes y los valores que respondan a las necesidades del medio (1). desde hace algunos años, en la educación primaria y secundaria en colombia se ha venido trabajando en la formación por competencias, como se referencia en el documento sobre revolución educativa y el plan de desarrollo del ministerio de educación (2002) (2). esta transformación también responde a un proceso de flexibilización que debe ser asumido por la educación superior en colombia; en él se deben gestar modificaciones en los procesos académicos entre ellos la formación basada en destrezas, habilidades y desempeños frente a una formación centrada en competencias (1). como consecuencia de esto, la facultad de enfermería de la universidad de la sabana ha formulado el programa educativo basado en competencias. después de cuatro años de haber implementado este modelo de educación es importante analizarlo y revisar en especial la práctica educativa, con el fin de plantear estrategias de mejoramiento que refuercen el proceso. además, cuando se inicia un nuevo proceso es aconsejable revisarlo para verificar si los individuos y los grupos están respondiendo adecuadamente (3). esta valoración facilita el análisis y la toma de decisiones, y permite fortalecer las áreas en que se esté fallando. en el modelo de educación por competencias el profesor se convierte en facilitador del aprendizaje y el alumno en constructor de su propio conocimiento a partir de su propia voluntad, buscando que el estudiante tenga como base aprender a aprender siendo autónomo, constructor de conocimiento y aprendizaje (4, 5). para enfermería, la educación por competencias facilita la promoción de diversos contextos de aprendizaje, teniendo en cuenta que el hacer debe fundamentarse en el conocimiento y en el actuar coherente. huerta y cols. reconocen la práctica como recurso para consolidar lo que se sabe, para poner en acción lo que se sabe y para aprender más (6). metodología la metodología del estudio fue de tipo descriptivo con abordaje cualitativo. descriptivo porque se pretendió tener mayor conocimiento de la práctica educativa a través de la identificación, caracterización y el análisis de los elementos utilizados por los profesores en la programación, ejecución de la asignatura y evaluación de los alumnos y su correspondencia con la formación por competencias. además, el análisis de los datos subjetivos brindó la oportunidad de construir conocimiento, asignando significado a la experiencia de los profesores frente a la programación, desarrollo de la clase y evaluación de los alumnos en en el modelo de educación por competencias el profesor se convierte en facilitador del aprendizaje y el alumno en constructor de su propio conocimiento a partir de su propia voluntad, buscando que el estudiante tenga como base aprender a aprender siendo autónomo, constructor de conocimiento y aprendizaje. currículo por competencias en la universidad de la sabana. competence curriculum at la sabana university 119 figura 1. la educación basada en competencias fuente: el autor. las diferentes asignaturas. la investigación cualitativa permitió que el conocimiento del tema fuera visto como un todo y no como una serie de fenómenos aislados, dándole una visión holística al estudio (13). para el análisis de la información se realizó la categorización y triangulación. la recolección de la muestra se hizo a través de informantes clave seleccionados en forma intencional dadas las características del estudio. éstos fueron: profesores de las asignaturas de cuidado de primero a octavo semestre, estudiantes de los diferentes semestres y los programas de estas asignaturas. la información se recolectó hasta saturarse. para la recolección de datos se utilizaron los siguientes instrumentos: lista de chequeo, cuestionario para alumnos, entrevista a profesores y guía de observación. cada uno de los instrumentos tuvo como fin recolectar la siguiente información: lista de chequeo: de acuerdo con polit y hungler, este formato comprende una serie de aspectos que se deben responder en el mismo formato y deben ser diligenciados por el investigador (14). este instrumento permitió recopilar información para el análisis de las asignaturas. se revisó el planteamiento de las competencias, la aplicación de los tres elementos de competencia (saber, ser y hacer), las unidades de competencia y el manejo de los contenidos, las estrategias metodológicas y didácticas, el planteamiento del trabajo independiente y presencial y, finalmente, el proceso evaluativo, para luego analizar la coherencia entre las partes. cuestionario para alumnos: el cuestionario es la transcripción de los objetivos de la investigación en preguntas específicas (14). en este caso se buscó recopilar información para el análisis de la metodología empleada por los profesores en el desarrollo de la asignatura y las estrategias de evaluación implementadas. se contemplaron los siguientes aspectos: el concepto de los alumnos sobre competencia, su aplicación y el conocimiento sobre las competencias que van a desarrollar en el semestre que cursan, las actitudes, los revista aquichan issn 1657-5997 120 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 valores y las habilidades promovidas en la asignatura, la metodología empleada para el trabajo independiente y presencial, la aplicación de problemas reales para su estudio, las estrategias evaluativas y la retroalimentación. entrevista a profesores: se aplicó una entrevista semiestructurada en donde el entrevistador utilizó una serie de preguntas específicas pero dio libertad al entrevistado para profundizar en las respuestas (14). a través de la interacción con el profesor se buscó investigar, desde la perspectiva del docente, su participación en la programación de la asignatura, la metodología que emplea y las estrategias evaluativas que aplica. se indagó sobre cómo participan los profesores en la estructuración del contenido de los programas, su conocimiento sobre la formación basada en competencias y la forma en que lo aplica, las dificultades que ha tenido en su aplicación, la respuesta de los alumnos, la capacitación recibida sobre el tema, el modelo pedagógico que refiere utilizar, la forma en que involucra problemas reales a la asignatura, cómo promueve el trabajo independiente y, finalmente, cómo aplica el proceso evaluativo, qué estrategias emplea, cómo hace la retroalimentación y la recuperación. guía de observación: de acuerdo con hernández sampieri y otros, citado por fernández, esta técnica de observación ejerce un mínimo de interferencia sobre el comportamiento de las personas con las cuales se recopila la información, con ella se registra la conducta que surge de las personas de una manera espontánea (15). se utilizó básicamente para obtener información sobre la metodología empleada por los profesores en el desarrollo de la asignatura y las estrategias evaluativas aplicadas. se tuvieron en cuenta los siguientes parámetros de observación: desarrollo de la clase, exploración de experiencias previas, correspondencia con algún modelo pedagógico, revisión del trabajo independiente, competencias básicas fomentadas, rol del docente, rol del alumno, trabajo individual o grupal, actitud de las personas en clase, evaluaciones aplicadas, retroalimentación. procedimiento. antes de iniciar la recolección de la información, y de acuerdo con los lineamientos éticos, se informó y pidió autorización a la unidad académica para la aplicación de los instrumentos, al igual que el consentimiento informado a los participantes del estudio. la investigación se realizó en las siguientes etapas: revisión de los instrumentos: una vez elaborados los instrumentos se solicitó la revisión de dos expertos (profesores con maestría en educación de la facultad de enfermería), se realizó la prueba piloto con profesores y alumnos de diferentes asignaturas a las contempladas para el estudio, y se realizaron los correctivos para su posterior aplicación. recolección de la información: la información se recolectó en las asignaturas de cuidado. el primer paso fue revisar el contenido de los programas, luego se realizó la observación en el aula y se aplicaron los cuestionarios para alumnos; finalmente se realizaron las entrevistas a los profesores. análisis de la información organización de la información: una vez recolectados los datos se procedió a transcribirlos y organizarlos para poder proceder a la categorización. como refieren polit y hungler, el primer paso en el análisis de datos cualitativos es organizarlos. la principal tarea de esta organización es desarrollar un método para clasificar la información (14). en la presente investigación se utilizó la categorización, dado que en los estudios descriptivos se tiende a utilizar categorías concretas. para realizar la categorización de la información se realizó un primer nivel de interpretación que consistió en el análisis del contenido, en donde se interpretaron los datos de las diferentes fuentes. el paso a seguir fue subrayar para identificar las frases con sentido y significado que apuntaran a resolver la pregunta de investigación, y de acuerdo con lo anterior se enunciaron las categorías, teniendo en cuenta su pertinencia con el tema de investigación. el resultado fue el siguiente: categoría 1. programación de la asignatura; formalidad o realidad. categoría 2. desarrollo de la clase; apropiación del conocimiento o repetición de errores. categoría 3. proceso evaluativo; conclusión o continuidad. de cada una de estas categorías se desprenden las siguientes subcategorías: currículo por competencias en la universidad de la sabana. competence curriculum at la sabana university 121 categoría 1. programación de la asignatura; formalidad o realidad subcategoría 1. estructuración del programa; una mirada holística. subcategoría 2. estrategias de enseñanza aprendizaje planteadas; cuál es la intención. categoría 2. desarrollo de la clase; apropiación del conocimiento o repetición de errores subcategoría 1. rol del profesor; compromiso e interés. subcategoría 2. rol del alumno; actividad o pasividad. subcategoría 3. trabajo en el aula; tradición o innovación. categoría 3. proceso evaluativo; conclusión o continuidad figura 2. enlace entre las categorías fuente: el autor. subcategoría 1. estrategias evaluativas planteadas en el programa; ¿evaluación integral? subcategoría 2. estrategias evaluativas ejecutadas; la conclusión del profesor. subcategoría 3. estrategias de retroalimentación y recuperación; un esfuerzo adicional. después de categorizar se realizó la triangulación. con relación a este término polit y hungler refieren que esta técnica incrementa la probabilidad de que los resultados de estudios cualitativos sean creíbles, entendiendo triangulación como el uso de referentes múltiples para llegar a conclusiones acerca de lo que constituye la verdad (14). en el caso de la presente investigación se realizó una triangulación de métodos debido al uso de diversas fuentes. con la triangulación se pretendió contrastar los resultados obtenidos en la aplicación de los diferentes instrumentos con el fin de revista aquichan issn 1657-5997 122 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 encontrar relaciones y divergencias entre la programación, la metodología de clase y el proceso evaluativo frente a la formación por competencias. la triangulación de datos supone el empleo de distintas estrategias de recogida de datos. su objetivo es verificar las tendencias detectadas en un determinado grupo de observaciones (16). resultados y conclusiones uno de los aspectos esenciales de la educación por competencias es que el microcurrículo esté acorde con el proyecto educativo institucional. en el caso de la facultad de enfermería, se encontró que las asignaturas de cuidado son coherentes con el proyecto educativo institucional de la universidad de la sabana, porque se promueve en el alumno el conocimiento disciplinar, pero también la habilidad, junto con las actitudes y los valores necesarios para una formación integral. la educación por competencias exige que el alumno se apropie del conocimiento, se haga responsable de su formación; para ello se hace necesario que el alumno conozca adecuadamente cuál es el fin, qué competencias están propuestas para cada asignatura. a pesar de que los alumnos manifiestan conocer las competencias que se deben desarrollar en cada asignatura, no tienen claro cuáles han desarrollado hasta el momento. la falta de apropiación de las mismas puede hacer que el estudiante no sepa a dónde debe llegar o simplemente se caiga en el conductismo, en donde sólo se dan conocimientos a los alumnos sin importar la reflexión que este haga sobre los mismos. la estructura de los programas corresponde, en términos generales, a la formación basada en competencias, falta aclarar y unificar conceptos sobre las unidades de competencia, las estrategias didácticas y las estrategias metodológicas. estas últimas no se encuentran en los programas, ni son contempladas por los profesores. aunque existen variadas estrategias didácticas planteadas por los profesores para el trabajo independiente y presencial, se encuentran dos dificultades, la primera es que no existe una relación clara entre la estrategia didáctica y el cumplimiento de logros, la clase se estructura pensando en qué estrategia es más conveniente para que adquieran determinado conocimiento y no la competencia correspondiente. segundo, aunque la estrategia esté bien elaborada metodológicamente, no todos los alumnos responden de la misma manera, algunos se encuentran más motivados que otros o tienen un ritmo diferente de aprendizaje, esto sucede en especial en los grupos numerosos. la práctica es el escenario ideal para trabajar en forma individual con los alumnos, porque por cada profesor hay entre 6 y 8 estudiantes, pero son muy pocos los catedráticos2 comprometidos realmente, como lo refieren los comisionados de grupo entrevistados, corriéndose el riesgo de perder la secuencia entre la teoría y la práctica. en la evaluación se utilizan algunas estrategias, pero la mayoría de las clases se desarrollan con la exposición del profesor, quien formula preguntas y resuelve dudas. el alumno aún espera la organización establecida por el profesor para participar. en la mayoría de los cursos el estudiante se muestra muy pasivo frente a su formación, estudia lo que le corresponde, participa cuando se le prela educación por competencias exige que el alumno se apropie del conocimiento, se haga responsable de su formación; para ello se hace necesario que el alumno conozca adecuadamente cuál es el fin, qué competencias están propuestas para cada asignatura. 2 profesores contratados para orientar la práctica. currículo por competencias en la universidad de la sabana. competence curriculum at la sabana university 123 gunta, pero rara vez va más allá de lo que el profesor propone. el modelo por competencias requiere que el profesor motive al alumno, que organice ambientes y experiencias de aprendizaje que lo lleven a la construcción de su propio conocimiento. durante la recolección de la información se observó una actitud de interés y compromiso de los profesores frente a la educación por competencias, con dominio de los temas y creatividad para desarrollar la clase, preocupándose auténticamente porque los alumnos aprendan. los profesores de planta3 reconocen que en estos aspectos ha influido la capacitación recibida con relación a la formación por competencias, aspecto que difiere en los de cátedra por el cambio constante de este personal. sin embargo, los profesores novatos durante las clases tienden a concentrarse en los contenidos, y los profesores expertos se ocupan de una forma más natural por los procesos y por promover el análisis. esto puede ser el resultado de la apropiación del proceso de formación por competencias en los profesores expertos, pero también puede ser la consecuencia lógica de la experiencia pedagógica. de acuerdo con lo observado, no existe un modelo pedagógico por el cual se rijan los profesores, pero de acuerdo con el análisis, se pueden agrupar por tendencias, entre ellas la conductista, que es más usada a la hora de enseñar procedimientos, como el lavado de manos y el paso de una sonda, pero también en clase, donde se encontraron clases magistrales, con preguntas orientadas a reforzar el conocimiento organizado por el profesor. otra tendencia encontrada fue la constructivista, en la que con situaciones reales se lleva al alumno a deducir, a analizar y a conceptuar a partir de sus propias experiencias, con la orientación del profesor. en el proceso evaluativo existe la heteroevaluación, que se hace profesoralumno, y en séptimo y octavo semestre se involucra a los empresarios, pero no hay evidencias sobre la autoevaluación y la coevaluación, aunque se ha realizado en forma aislada en segundo, quinto y octavo semestre. estas dos formas de evaluar son esenciales dentro de la formación por competencias, porque promueven la autorreflexión, la autonomía, el respeto, la tolerancia, entre otros. la evaluación todavía se queda en la exploración de conocimientos, como se observa en el análisis de datos, excepto el profesionograma que contempla la valoración de los tres saberes: conocer, ser y hacer. el profesor debe propender porque las evaluaciones sean válidas, confiables, flexibles e imparciales (17). ¿se podrá lograr esto en un ambiente en donde el alumno debe llevar el mismo ritmo de aprendizaje de sus compañeros, y presentar las mismas evaluaciones aunque no haya tenido las mismas experiencias de aprendizaje, en especial en la práctica? la recuperación y la retroalimentación son estrategias que van acordes a la formación por competencias, porque permiten al alumno reflexionar y mejorar, y tienen en cuenta la individualidad de la persona y sus capacidades para aprender. para concluir, la facultad de enfermería ha implementado aspectos de la formación por competencias que se ven reflejados en programas que contemplan3 profesores contratados en forma permanente. el modelo por competencias requiere que el profesor motive al alumno, que organice ambientes y experiencias de aprendizaje que lo lleven a la construcción de su propio conocimiento. revista aquichan issn 1657-5997 124 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 los elementos de competencia, el conocer, el ser y el hacer. falta evidenciar la relación entre la formulación de las competencias, la metodología de clase y el proceso evaluativo. un proceso continuo los resultados de este estudio son un aporte al deseo constante de profesores y directivos por mejorar. por ello se recomienda involucrar más a los profesores de cátedra en la planeación de las asignaturas, diseñar las estrategias metodológicas para las clases, capacitar continuamente a los profesores de cátedra nuevos en el proceso de educación por competencias, con un acompañamiento que garantice la aplicación de este modelo de formación. también se deben diseñar estrategias que permitan al alumno entender cuál es su rol frente a la formación por competencias, el del profesor y el de la institución educativa. hacer evidentes las estrategias de coevaluación y autoevaluación. revisar el propósito de las evaluaciones, porque todas pueden estar acordes con la formación por competencias, pero la intención puede quedarse en la continuación de la evaluación por objetivos. es necesario establecer una línea de investigación en educación que fortalezca y oriente las acciones propuestas en la subcomisión de currículo para el trabajo pedagógico en la facultad. se puede analizar desde esta línea de investigación cómo contribuyen las estrategias didácticas empleadas por los profesores a la formación por competencias, y qué impacto tiene la semana de recuperación en el fortalecimiento académico, entre otros. 1. díaz v. flexibilidad y educación superior en colombia. bogotá: instituto colombiano para el fomento de la educación superior; 2002. 2. ministerio de educación nacional de colombia. revolución educativa (plan sectorial 2002-2006). [recuperado 15 de septiembre de 2005]. disponible en: http://www.mineducacion.gov.co/documentos/ 3. huber d. liderazgo y administración en enfermería. méxico: mcgraw hill interamericana; 1999. 4. gómez i. competencias profesionales: una propuesta de evaluación para las facultades de ciencias administrativas. revista educación y educadores; 2005. 5. cejas m. la educación basada en competencias: una metodología que se impone en la educación superior y que busca estrechar la brecha existente entre el sector educativo y el productivo. [recuperado en 2005]. disponible en: http://www.upf.edu/bolonya/ butlletins/2005/febrer1/brecha.pdf 6. huerta j, pérez i, castellanos a. desarrollo curricular por competencias profesionales integrales. revista educar; 2000. [recuperado el día 29 de octubre de 2005]. disponible en: http:/ educacion.jalisco. gob.mx/consulta/educar/13/13huerta.html 7. mcdonald r, boud d, francis j, gonczi a. nuevas perspectivas sobre la evaluación. unesco; 1995. 8. tobón s. formación basada en competencias. bogotá: ecoe ediciones; 2004. 9. becerril s. comprender la práctica docente. méxico: instituto tecnológico de querétaro; 1999. 10. garcía b, secundino n, navarro l, rueda y díaz barriga f (comps.). el análisis de la práctica educativa: consideraciones metodológicas. paidós educador; 2002. 11. argudín y. educación basada en competencias. méxico: trillas; 2000. 12. esteve j. la aventura de ser maestro. cuaderno de pedagogía 266; 1998. 13 ruiz j. metodología de la investigación cualitativa. españa: universidad deusto; 1999. 14. polit d, hungler b. investigación científica en ciencias de la salud. méxico: mcgraw-hill interamericana; 2000. 15. fernández i. diccionario de investigación holística. bogotá: editorial magisterio; 2002. 16. rodríguez o. la triangulación como estrategia de investigación en las ciencias sociales. tribuna de debate; 2005. [recuperado el día 14 de noviembre de 2005]. disponible en: http://www.madrimasd.org/ revista/revista31/tribuna/tribuna2.asp 17. bogoya d. la evaluación: ¿instrumento de educación o de segregación? revista escuela de administración de negocios 2003; 48: 8-17. referencias << /ascii85encodepages false /allowtransparency false /autopositionepsfiles true /autorotatepages /all /binding /left /calgrayprofile (dot gain 20%) /calrgbprofile (srgb iec61966-2.1) /calcmykprofile (u.s. web coated \050swop\051 v2) /srgbprofile (srgb iec61966-2.1) /cannotembedfontpolicy /warning /compatibilitylevel 1.4 /compressobjects /tags /compresspages true /convertimagestoindexed true /passthroughjpegimages true /createjdffile false /createjobticket false /defaultrenderingintent /default /detectblends true /detectcurves 0.0000 /colorconversionstrategy /leavecolorunchanged /dothumbnails false /embedallfonts true /embedopentype false /parseiccprofilesincomments true /embedjoboptions true /dscreportinglevel 0 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/untaggedcmykhandling /leaveuntagged /untaggedrgbhandling /leaveuntagged /usedocumentbleed false >> ] >> setdistillerparams << /hwresolution [2400 2400] /pagesize [612.000 792.000] >> setpagedevice 355 aline marcelino ramos1 edison luiz devos barlem2 jamila geri tomaschewski barlem3 laurelize pereira rocha4 cristiane lopes amarijo5 larissa merino de mattos6 preditores da advocacia em saúde identificados por enfermeiros no contexto hospitalar 1 orcid.org/0000-0003-3672-1689. universidade federal do rio grande, brasil. eenf@furg.br 2 orcid.org/0000-0001-6239-8657. universidade federal do rio grande, brasil. ebarlem@furg.br 3 orcid.org/0000-0001-9125-9103. universidade federal do rio grande, brasil. jbarlem@furg.br 4 orcid.org/0000-0001-9334-6550. universidade federal do rio grande, brasil. laurelizerocha@furg.br 5 orcid.org/0000-0002-4441-9466. universidade federal do rio grande, brasil. eenf@furg.br 6 orcid.org/0000-0003-2139-5278. universidade federal do rio grande, brasil. eenf@furg.br recebido: 07/03/2018 submetido: 10/04/2018 aceito por pares: 20/05/2018 aceito: 14/06/2018 doi: 10.5294/aqui.2018.18.3.9 para citar este artículo / to reference this article / para citar este artigo ramos am, devos el, tomaschewski jg, pereira l, lopes c, merino de mattos l. preditores da advocacia em saúde identificados por enfermeiros no contexto hospitalar. aquichan. 2018; 18(3): 355-365. doi: 10.5294/aqui.2018.18.3.9 resumo objetivos: identificar os preditores do exercício da advocacia em saúde por enfermeiros no contexto hospitalar. materiais e método: estudo quantitativo, transversal analítico, realizado com 157 enfermeiros de duas instituições hospitalares do sul do brasil, uma pública e uma filantrópica. a coleta de dados foi realizada entre os meses de setembro e outubro de 2015. foi utilizado o instrumento protective nursing advocacy scale — versão brasileira, constituído por 20 itens, dispostos em cinco constructos. para a análise dos dados, utilizou-se de elementos da estatística descritiva, da correlação de pearson e da análise de regressão linear. resultados: os resultados evidenciaram moderada associação entre facilitadores ao exercício da advocacia e percepções que favorecem seu exercício. a dimensão “facilitadores ao exercício da advocacia” obteve a maior média do instrumento e foi o principal preditor da advocacia em saúde no contexto hospitalar, capaz de deflagrar nos enfermeiros a sensibilidade e o desejo em advogar. conclusões: o sentimento de responsabilidade por parte dos enfermeiros em manter o bom funcionamento da equipe e gerir questões conflitantes eleva a necessidade em oferecer segurança aos pacientes, mesmo que diante de resistências oriundas do local de trabalho. palavras-chave: advocacia em saúde; enfermagem; ética em enfermagem; defesa do paciente; hospitais (fonte: decs). año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 355-365 temática: promoção e prevenção. contribuição à disciplina: o artigo contribui para o fortalecimento das atribuições de enfermagem relacionadas ao cuidado e advocacia em saúde, que, quando efetivadas, proporcionam a oportunidade de transformação pessoal e o crescimento dos profissionais envolvidos; além disso, as ações de advocacia em saúde oferecem informações importantes aos pacientes e aos familiares que visam à capacitação e ao empoderamento destes. http://orcid.org/0000-0003-3672-1689. http://orcid.org/0000-0001-6239-8657 http://orcid.org/0000-0001-9125-9103 http://orcid.org/0000-0001-9334-6550. http://orcid.org/0000-0002-4441-9466. http://orcid.org/0000-0003-2139-5278. 356 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 355-365 predictores de abogacía en salud identificados por enfermeros en el contexto hospitalario resumen objetivos: identificar los predictores del ejercicio de la abogacía en salud por enfermeros en el contexto hospitalario. materiales y método: estudio cuantitativo, transversal analítico, realizado con 157 enfermeros de dos instituciones hospitalarias del sur de brasil, una pública y una filantrópica. se realizó la recolección de datos entre los meses de septiembre y octubre del 2015. se utilizó el instrumento protective nursing advocacy scale — versión brasileña, constituido por 20 ítems, dispuestos en cinco constructos. para el análisis de los datos, se utilizaron elementos de la estadística descriptiva, la correlación de pearson y el análisis de regresión lineal. resultados: los resultados evidenciaron moderada asociación entre facilitadores al ejercicio de la abogacía y percepciones que favorecen su ejercicio. la dimensión “facilitadores al ejercicio de la abogacía” obtuvo el mayor promedio del instrumento y fue el principal predictor jurídico en salud en el contexto hospitalario, capaz de provocar en los enfermeros la sensibilidad y el deseo en abogar. conclusiones: el sentimiento de responsabilidad por parte de los enfermeros en mantener el buen funcionamiento del equipo y manejar cuestiones conflictivas en ofrecer seguridad a los pacientes, aun ante resistencias oriundas del local de trabajo. palabras clave defensa de la salud; enfermería; ética en enfermería; defensa del paciente; hospitales (fuente: decs). 357 preditores da advocacia em saúde identificados por enfermeiros no contexto hospitalar l aline marcelino ramos e outros legal predictors in health identified by nurses in the hospital environment abstract objectives: the purpose of this study was to identify the predictors of the practice of health advocacy by nurses in the hospital environment. materials and methods: this is a quantitative, cross-sectional analytical study carried out with 157 nurses from two hospitals in southern brazil, one public and one philanthropic. data collection was done between september and october 2015. the brazilian version of the protective nursing advocacy scale, consisting of 20 items, arranged in five constructs, was the instrument was used. elements of descriptive statistics, the pearson correlation and linear regression analysis were used to examine the data. results: the study showed a moderate association between facilitators of the practice of advocacy and perceptions that favor its exercise. the dimension "facilitators of the practice of advocacy" obtained the highest average with the instrument and was the main legal predictor in health in the hospital context, capable of inspiring in nurses the sensitivity and desire to advocate. conclusions: the nurse has a feeling of responsibility to make sure equipment continues to function properly and to handle conflicting questions when offering security to patients, even in the face of resistance originating in the workplace. keywords health advocacy; nursing; ethics, nursing; patient advocacy; hospitals (source: decs). año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 355-365 358 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 introdução o papel político desenvolvido pelos enfermeiros junto aos usuários passou a ser reconhecido como advocacia em saúde, de forma a representar um dos conceitos-chave da ética em enfermagem, discutido na literatura desde 1973, quando o conselho internacional de enfermeiros (cie) o introduziu no código de ética da profissão (1, 2). originou-se a partir do termo em latim advocatus, diretamente relacionado ao termo advogado, aquele que intercede, defende ou julga a outra pessoa (3). dessa forma, de acordo com o cie, o enfermeiro possui o papel inerente à profissão de respeito aos direitos humanos, incluindo o direito à vida, à dignidade e ao de ser tratado com respeito (2). a advocacia em saúde passou a ser problematizada na prática de enfermagem com maior ênfase na década de 1980, nos estados unidos da américa, sendo considerada, ainda hoje, um papel relativamente novo para a profissão, com interpretações conceituais bastante variáveis (2, 3). a atribuição de defesa do paciente também é desenvolvida por outros profissionais de saúde; contudo, verifica-se que a enfermagem possui um papel de destaque no exercício da advocacia; devido à relação de proximidade enfermeiro-paciente e ao maior tempo de permanência nas unidades de saúde, o enfermeiro encontra-se em uma posição única para o desenvolvimento desse papel, por possuir maior inteiração na relação terapêutica e maior envolvimento no quadro de saúde dos pacientes, o que facilita o esclarecimento dos objetivos do tratamento e a defesa de suas necessidades e desejos (3). a importância da defesa em saúde é citada não só na literatura filosófica, mas também introduzida nas competências educacionais e nos códigos de ética, tais como o código de ética para enfermagem da american nurses association (4), em que a advocacia é considerada como um componente importante na garantia dos direitos e da segurança do paciente, tanto para alcançar os resultados esperados pelos profissionais como para agir em prol daqueles que não são capazes de se defender (5). na enfermagem brasileira, o código de ética dos profissionais leva em consideração a necessidade e o direito de assistência em enfermagem da população, o interesse do profissional e de sua organização, além de destacar a premente necessidade de aprimoramento técnico, científico e cultural do profissional no desenvolvimento de suas ações (6). a defesa do paciente é um elemento inerente da ética profissional. assim, o enfermeiro necessita agir como advogado em prol dos pacientes que se encontram sob seus cuidados, direcionando esforços para a prática de apoio e para o respeito da autonomia e privacidade deles, a fim de subsidiar e respeitar seus direitos em saúde, uma vez que os enfermeiros se encontram munidos de condições para identificar e compreender situações em que precisam interceder (7). no tocante à prática de advocacia, os enfermeiros podem enfrentar repercussões pessoais negativas, ao se depararem com certos obstáculos e consequências, relacionados a conflitos de interesse da organização e às relações próprias do ambiente de trabalho, o que pode tornar-se um desafio no exercício da advocacia e afetar a capacidade do enfermeiro em atuar como um defensor, bem como originar a relutância em assumir esse papel (7, 8). desse modo, alguns fatores podem contribuir para que os enfermeiros não exerçam a função de advogados, como insegurança no emprego, opressões, indisposição com membros da equipe, mudança de status no trabalho, falta de apoio, conflitos e temor de represálias que constituem desafios na capacidade de acesso aos cuidados de saúde dos pacientes (2, 9). diante do estágio atual da produção científica da enfermagem, observam-se diversas lacunas ainda existentes no que concerne a essa temática (10). dessa forma, a necessidade de identificação dos preditores da advocacia em saúde vivenciadas no cotidiano profissional de enfermeiros, no contexto hospitalar, justificou a realização deste estudo, uma vez que o não exercício da advocacia pode resultar em dificuldades no desenvolvimento das potencialidades desses profissionais e queda na qualidade do cuidado, havendo necessidade de uma compreensão mais abrangente acerca da temática. assim, a necessidade de conhecimentos acerca dos fatores advindos do exercício da advocacia em saúde, na enfermagem, ressalta a relevância deste estudo, principalmente por meio das elucidações das principais contribuições e limitações imbricadas nessas ações, de modo a gerar maior qualidade e autonomia no processo de trabalho. foi objetivo deste estudo identificar os principais fatores emergentes do exercício da advocacia em saúde por enfermeiros no contexto hospitalar. 359 preditores da advocacia em saúde identificados por enfermeiros no contexto hospitalar l aline marcelino ramos e outros materiais e métodos estudo quantitativo, transversal analítico, realizado com 157 enfermeiros de duas instituições hospitalares do sul do brasil, uma pública e uma filantrópica. a coleta de dados foi realizada entre os meses de setembro e outubro de 2015. foram realizadas visitas às unidades dos dois hospitais selecionados; os instrumentos foram entregues diretamente aos informantes em um envelope de papel pardo, sem identificação, juntamente com o termo de consentimento livre e esclarecido (tcle). foi utilizada a modalidade de amostragem não probabilística por conveniência (11), de modo que todos os participantes da pesquisa fossem selecionados de acordo com sua presença e disponibilidade no local e no momento em que ocorreu a coleta de dados, desde que atendessem aos critérios de inclusão e exclusão (12). foram critérios de inclusão: ser enfermeiro, atuar profissionalmente nos hospitais selecionados e atuar a mais de seis meses na instituição, por acreditar ser este um tempo necessário para a adaptação às rotinas e à organização. foram critérios de exclusão para a participação na pesquisa: estar ausente do local de trabalho (unidade hospitalar) no momento da coleta de dados devido a férias, paralisação, afastamento ou licença e ser profissional de contrato temporário. para a seleção do tamanho amostral, adotou-se uma fórmula específica, que objetivou estimar o mínimo tamanho amostral, com vistas a garantir um nível de confiança mínimo de 95 %. conhecendo previamente a população das duas instituições, composta por 235 enfermeiros, e após a realização do cálculo amostral, chegou-se ao número mínimo de 145 informantes (12). contudo, na tentativa de selecionar o maior número de participantes possíveis para a obtenção de uma margem de segurança, obteve-se uma amostra de 157 enfermeiros, de modo a ultrapassar o valor estimado pela fórmula. para a coleta de dados, o instrumento escolhido para investigar os aspectos atrelados à advocacia em saúde foi uma adaptação da protective nursing advocacy scale (pnas), desenvolvida originalmente nos estados unidos e aplicada em enfermeiros da especialidade médico-cirúrgica no ano de 2010 (2); essa escala foi adaptada culturalmente e validada para o contexto brasileiro em 2015 (13). a pnas original é composta por 43 questões, sendo respondida por meio de uma escala de frequência do tipo likert de cinco pontos, utilizando-se 1 para discordo totalmente, 2 para discordo parcialmente, 3 para não concordo nem discordo, 4 para concordo parcialmente e 5 para concordo totalmente. a pnas em sua versão inicial apresenta 37 questões validadas em quatro constructos: 1) atuação como advogado, que reflete ações tomadas pelos enfermeiros quando advogam para os pacientes; 2) situações de trabalho e ações de advocacia, que reflete as possíveis consequências da advocacia de pacientes no ambiente de trabalho; 3) ambiente e influências educacionais, que engloba a influência do conhecimento e ambiente interno dos enfermeiros, como valores pessoais, confiança e crenças para atuarem como advogados; 4) suporte e barreiras para a advocacia, que consiste de itens que indicam os facilitadores e as barreiras para a advocacia do paciente na enfermagem, o que inclui o ambiente de trabalho como um todo (2). em sua versão brasileira (13), o instrumento é constituído por 20 itens, sendo operacionalizado por meio de uma escala de frequência do tipo likert de cinco pontos, utilizando-se 1 para discordo totalmente, 2 para discordo parcialmente, 3 para não concordo nem discordo, 4 para concordo parcialmente e 5 para concordo totalmente. apresenta cinco constructos: 1) implicações negativas do exercício da advocacia, que ilustra possíveis consequências do exercício da advocacia no ambiente de trabalho; 2) ações de advocacia, que envolve questões atreladas ao exercício profissional que representem advogar, agir pelo paciente; 3) facilitadores ao exercício da advocacia, que inclui questões pessoais e profissionais que possam contribuir para o exercício da advocacia; 4) percepções que favorecem o exercício da advocacia, que aborda o entendimento de situações em que o exercício da advocacia se faz importante; 5) barreiras ao exercício da advocacia, que engloba aspectos pessoais que inviabilizam ou prejudicam as ações de advocacia (13). o instrumento brasileiro apresenta, ainda, uma parte inicial de caracterização dos participantes que contém características sociodemográficas, que possam ser significativas para a correlação com a advocacia do paciente, tais como: idade, sexo, tempo de formação, instituição de trabalho, carga horária de trabalho, tempo de atuação profissional, outros cursos concluídos (especialização, mestrado, doutorado), modalidade de atendimento e realização de reuniões na unidade de trabalho. neste estudo, o instrumento pnas — versão brasileira manteve-se com os cinco 360 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 constructos já existentes; o alfa de cronbach do instrumento apresentou valor 0,78, enquanto os coeficientes dos cinco constructos se situaram entre 0,70 e 0,87. para a aplicação do instrumento de coleta de dados, foi realizada visitas às unidades hospitalares, de forma que os enfermeiros fossem convidados a participar do estudo no próprio local e turno de trabalho. após os procedimentos relacionados aos aspectos éticos, o instrumento foi entregue diretamente aos participantes em um envelope de papel pardo, sem identificação, e recolhido logo após seu preenchimento, conforme agendamento. para a análise dos dados, utilizou-se o software estatístico statistical package for social sciences, versão 23.0. foram realizados dois testes estatísticos para garantir a validade dos instrumentos, a análise fatorial para a sumarização dos dados através da identificação de fatores comuns entre as questões, agrupandoos em constructos através da média das respostas, e o alfa de cronbach, que buscou avaliar o nível de confiabilidade do instrumento através da verificação de características contidas em cada grupo de questões, verificando se as questões incluídas no questionário conseguiram medir de maneira consistente os fenômenos em questão. a normalidade dos dados foi atestada através do teste de kolmogorov-smirnov. para analisar a correlação existente entre as variáveis quantitativas, de advocacia em saúde, recorreu-se ao coeficiente de correlação linear de pearson. trata-se de um método de análise bivariada que analisa simultaneamente duas varáveis dependentes, medindo a intensidade da relação existente entre elas (11). o segundo tipo de análise estatística realizada foi a multivariada através da regressão linear, que busca estabelecer a relação entre os fatores de intensidade e frequência de sofrimento moral com a advocacia do paciente, através da análise de uma variável dependente com outras independentes. os aspectos éticos foram respeitados, conforme as recomendações da resolução 466/2012 do conselho nacional de saúde, de forma que o estudo foi aprovado pelo comitê de ética em pesquisa local (parecer 97/2013 do comitê de ética local). resultados os resultados evidenciaram moderada associação entre facilitadores ao exercício da advocacia e percepções que favorecem seu exercício. a dimensão “facilitadores ao exercício da advocacia” foi o principal preditor da advocacia em saúde no contexto hospitalar, capaz de deflagrar nos enfermeiros a sensibilidade e o desejo em advogar. o instrumento pnas — versão brasileira foi utilizado na avaliação das crenças e ações da advocacia do paciente de enfermeiros. mediante a análise de componentes principais, a questão 10 do instrumento original foi excluída por apresentar baixa carga fatorial, com autovalor menor que 0,500. o alfa de cronbach do instrumento apresentou valor 0,78, enquanto os coeficientes dos cinco constructos se situaram entre 0,70 e 0,87, ilustrados na tabela 1. tabela 1. análise fatorial dos fatores de advocacia do paciente (rio grande, rs, brasil, 2015) constructos questões alfa (ά) média facilitadores ao exercício da advocacia 11, 12, 13, 14, 15 0, 817 3,06 implicações negativas do exercício da advocacia 1, 2, 3, 4, 5 0, 832 1,78 ações de advocacia 6, 7, 8, 9 0, 833 2,69 barreiras ao exercício da advocacia 18, 19, 20 0, 708 1,40 percepções que favorecem o exercício da advocacia 16, 17 0, 701 2,94 fonte: elaboração própria. a análise descritiva permitiu identificar que o constructo “facilitadores ao exercício da advocacia” apresentou a maior média do instrumento (3,06), o que evidenciou que características e competências dos enfermeiros favorecem o exercício da advocacia, bem como o comprometimento e maior dedicação à enfermagem. o constructo “percepções que favorecem o exercício da advocacia” apresentou a segunda maior média do instrumento (2,94); relaciona-se às percepções dos enfermeiros quanto à advocacia e aos cuidados prestados aos pacientes, que podem favorecer suas ações como advogado, principalmente no que tange à percepção de vulnerabilidade. em seguida, tem-se a dimensão “ações de advocacia” (2,69), que indica ações multidimensionais de advocacia dos enfermeiros, como agir e falar em nome do paciente, variando de acordo com o contexto clínico. 361 preditores da advocacia em saúde identificados por enfermeiros no contexto hospitalar l aline marcelino ramos e outros o constructo “implicações negativas do exercício da advocacia” obteve média de 1,78; constatou-se que consequências do exercício da advocacia são relevantes para os enfermeiros e podem culminar em perda do emprego e até mesmo rotulações negativas formuladas por colegas de trabalho. já o constructo “barreiras ao exercício da advocacia” obteve a menor média (1,40) e demonstrou que barreiras que dificultam ou impedem que os enfermeiros realizem seu fazer como advogado podem não ser percebidas pelos enfermeiros. preditores da advocacia em saúde identificados por enfermeiros por meio da análise de correlação de pearson, foi possível identificar que os constructos “facilitadores ao exercício da advocacia” e “percepções que favorecem o exercício da advocacia” se relacionam com uma moderada força de associação (0,455), com significância ao nível de 5 %, ao passo que covariam de maneira previsível. as correlações entre os demais constructos de advocacia em saúde apresentaram força de associação do tipo leve, quase imperceptível. a figura 1 representa a correlação existente entre os constructos “facilitadores ao exercício da advocacia” e “percepções que favorecem o exercício da advocacia” de forma a evidenciar as questões de maior média contidas nesses constructos. figura 1. correlação existente entre os constructos de advocacia em saúde e questões de maiores médias (rio grande, rs, brasil, 2015) advocacia; barreiras ao exercício da advocacia e percepções que favorecem o exercício da advocacia. foi possível perceber como fator significativo estatisticamente que as ações de advocacia causam maior efeito sobre as implicações negativas do exercício da advocacia, ou seja, o exercício de advogar pelo paciente pode resultar em implicações negativas, especialmente relacionadas a conflitos e retaliações. assim, conforme evidenciado, houve relação moderada entre as dimensões de advocacia em saúde intituladas como “facilitadores ao exercício da advocacia” e “percepções que favorecem o exercício da advocacia”. discussão facilitadores ao exercício da advocacia concernente à dimensão “facilitadores ao exercício da advocacia”, estão relacionadas, principalmente, as competências e habilidades dos enfermeiros. o enfermeiro com conhecimento e domínio da área em que atua é um profissional capaz de influenciar a equipe de saúde com habilidades naturalmente adquiridas e argumentos que efetivam a advocacia do paciente, uma vez que, ao lidar com a vida, alguns conhecimentos específicos precisam ser reforçados, bem como o conhecimento legal, social e político, para obtenção de cuidados e direitos, bem como educação continuada como ferramenta para atualização em saúde (14). a atuação de acordo com a obrigação ética e moral da profissão de enfermagem e o respeito aos direitos dos pacientes também podem constituir elementos facilitadores da prática da advocacia. destacando que uma boa interação entre a equipe de enfermagem e a equipe médica também podem auxiliar para que o exercício da advocacia ocorra de forma mais eficaz e menos conflituosa por meio não governamental ou governamental (15). além disso, a relação estabelecida entre enfermeiro e paciente configura-se como um fator relevante, pois o estabelecimento de uma interação positiva pode estabelecer uma atmosfera de confiança, equivalente à do vínculo familiar, o que culmina em outro fator facilitador da advocacia: o estabelecimento do diálogo (16). a identificação de recursos oriundos das instituições de saúde e comunidade também recebe ênfase. ao ser considerado que a fonte: elaboração própria. foi realizada, ainda, a análise de regressão para a identificação dos efeitos causados pelo exercício da advocacia em saúde no contexto hospitalar dos enfermeiros. foram consideradas a soma total das questões do instrumento como variável dependente e as dimensões em saúde: facilitadores ao exercício da advocacia; implicações negativas do exercício da advocacia; ações de 362 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 atitude de defesa engloba múltiplos fatores, a atuação isolada do profissional ou de uma determinada unidade de saúde pode se tornar incapaz de alcançar a resolutividade almejada, o que torna imperativo para o profissional de saúde, além dos conhecimentos e habilidades essenciais para o exercício da advocacia, o desenvolvimento de um processo de comunicação para o estabelecimento de parcerias, redes com outros setores e serviços em saúde (6). por meio do diálogo, o enfermeiro também é capaz de realizar uma avaliação eficaz das necessidades dos pacientes/clientes, pois o estabelecimento de uma comunicação efetiva garante que o profissional adquira maior habilidade para reconhecer e identificar as possíveis carências individuais, o que pode lhe fornecer subsídios suficientes para agir em sua defesa (16). percepções que favorecem o exercício da advocacia percepções dos enfermeiros em relação à advocacia e aos cuidados que prestam aos pacientes podem favorecer seu exercício nos ambientes de trabalho. assim, destaca-se que situações de vulnerabilidade e risco à saúde dos pacientes impulsionam os enfermeiros a agirem como advogados, principalmente quando as necessidades daqueles não parecem satisfeitas ou, ainda, quando a qualidade dos serviços diminui e os pacientes não recebem cuidados adequados (13). é relevante destacar que, embora nem todos os pacientes sejam considerados vulneráveis, a combinação de doença, hospitalização e prognóstico negativo pode dificultar o ato de expressão plena de suas opiniões e escolhas, havendo a necessidade de um intermediador; diante do quadro, o enfermeiro percebe-se como o profissional capaz de defendê-los, tendo por base suas crenças e valores (6, 8). desse modo, os achados deste estudo vão ao encontro de outras pesquisas que identificaram que os enfermeiros parecem advogar pelos pacientes em seus ambientes de trabalho, especialmente quando identificam que estes se encontram desprovidos de informações que garantam sua autonomia e esclarecimentos acerca do quadro clínico e medidas futuras a serem tomadas (17, 18). a compreensão acerca das percepções que favorecem o exercício da advocacia se estendem também àqueles que se encontram em fim de vida, já que o enfermeiro percebe a necessidade do seu envolvimento como mediador e facilitador, em busca da manutenção na qualidade do atendimento, uma vez que nessa fase os pacientes precisam ser tratados com solidariedade e compaixão, fato este que comove e instiga o enfermeiro a advogar, principalmente diante da evidência de descaso na qualidade da assistência (14). ainda, ao relacionar a advocacia com as situações de vulnerabilidade, cumpre destacar o grupo etário infantil, que necessita de maior atenção dos profissionais na identificação de suas fragilidades. em um estudo que discorreu sobre a atuação profissional em saúde na unidade de pediatria, pode-se identificar que a equipe de saúde percebe a criança e a família vulneráveis e que precisam de profissionais que atuem como um elo entre o paciente e os serviços de saúde; além disso, ressalta-se o papel do enfermeiro como conselheiro e advogado, numa perspectiva de “advogar pela causa” como uma arte e uma ciência (6). para a avaliação do efeito do exercício de advocacia em saúde no trabalho dos enfermeiros atuantes em instituições hospitalares, foi possível identificar que as ações de advocacia possuem efeito sobre as implicações negativas do seu exercício. nesse caso, a atuação em saúde em prol dos direitos dos pacientes e da garantia de informações fidedignas pode repercutir de forma negativa no trabalho do enfermeiro, na forma de punições e taxações pejorativas. as ações de advocacia exercidas pelos enfermeiros podem variar de acordo com diferentes situações clínicas, ambientes e relações (13). no contexto brasileiro, de acordo com a constituição federal de 1988, a saúde é um direito de todos e um dever do estado, norteada por formas de defesa, elencadas em artigos, das quais a população pode lançar mão, especialmente nos casos em que seus direitos são violados. todavia, tais direitos são pouco conhecidos entre pacientes/usuários e profissionais de saúde; assim, mesmo diante da existência de legislações adequadas, sua aplicabilidade pode não ser efetiva (15). nessa perspectiva, as ações de advocacia podem ser definidas como um processo que visa promover direitos não respeitados seja por falta de regulamentação, seja por falta de execução, por 363 preditores da advocacia em saúde identificados por enfermeiros no contexto hospitalar l aline marcelino ramos e outros meios legais e éticos, a favor de grupos sociais, desfavorecidos ou oprimidos em seus cuidados em saúde (14, 15). um exemplo de ação em advocacia inclui o ato de informar e educar os pacientes, com vistas à sua capacitação e empoderamento, de modo a agir em defesa de um direito ainda não reconhecido ou não materialmente garantido. é importante destacar que, por trás das escolhas dos pacientes, existe a responsabilidade do profissional (8, 16). a cultura, política da instituição de saúde, pode minar as ações dos enfermeiros, de forma a aliená-los, uma vez que podem levar em conta unicamente a garantia dos interesses políticos e econômicos da instituição, através da contenção de custos e de limitações na autonomia dos pacientes e profissionais. além disso, os enfermeiros vivenciam situações conflituosas entre advogar ou manter-se no emprego (14, 17). no tocante às ações de advocacia em saúde, algumas consequências podem levar os enfermeiros a serem acusados de insubordinação e sofrerem perda da reputação profissional, podendo, até mesmo, receberem rotulações como péssimos colegas de trabalho e serem perturbados em suas vidas pessoais (18). sob esse prisma, alguns estudos convergentes a este achado destacam que as ações de advocacia, muitas vezes, deixam de ocorrer por estarem associadas com suas consequências negativas, como a possibilidade de recusa dos demais profissionais em atuarem coletivamente com o profissional defensor, a conferência de uma reputação negativa, situações de constrangimento moral, a falta de apoio da instituição, retaliações advindas dos empregadores e até mesmo a perda do emprego (14-19). mesmo diante de tais dificuldades, foi identificado que os enfermeiros que mantinham sua responsabilidade ética e moral afirmavam advogar, ainda ante limitações advindas da instituição em saúde, principalmente através da denúncia, o que demonstra coragem na tentativa de romper com situações cotidianas que, por vezes, não são modificadas ou questionadas em seus contextos de trabalho (13, 20). apesar dos conflitos, e aparente desgaste provocado, os enfermeiros expressaram sensação de alívio e dever cumprido ao exercer suas atribuições no que concerne à advocacia. na tentativa de reverter essa situação, destaca-se a necessidade dos enfermeiros em desenvolverem a coragem moral para superar o medo de possíveis riscos punitivos relacionados às adversidades dos sistemas em saúde, de modo a influenciar os demais enfermeiros a exercerem autonomia em seus espaços de saúde (19-22). espera-se, com este estudo, instigar a reflexão sobre a importância imbricada no exercício da advocacia em saúde e a necessidade constante do reconhecimento das instituições de saúde acerca dessa atribuição, de modo a buscar subsídios que possam contribuir com a qualidade do atendimento prestado pelos enfermeiros, através do fortalecimento de sua identidade profissional e do desenvolvimento de ações autônomas e éticas. conclusão os resultados deste estudo se constituem em importante avanço para a enfermagem, especialmente ao indicarem a necessidade de reflexão constante das atividades da profissão, com efeito nas atribuições e manejos do exercício da advocacia em saúde. isso porque as situações abordadas elucidam as principais dimensões que envolvem esse processo, que, por vezes, podem desencadear desfechos negativos que impossibilitem a atuação do enfermeiro como advogado em saúde. nesse sentido, os profissionais reconhecem a necessidade em advogar e, ao mesmo tempo, podem vivenciar limitações em decorrência de suas ações. assim, é preciso investir em estratégias de reduções dos possíveis efeitos negativos, oriundos das práticas de advocacia em saúde, de forma a propiciar práticas profissionais mais qualificadas e dinâmicas, que beneficiem o binômio enfermeiro-paciente. foi possível identificar que a dimensão “facilitadores ao exercício da advocacia” é o principal preditor capaz de incitar os enfermeiros a advogarem em seus diferentes contextos de saúde. portanto, o sentimento de responsabilidade por parte dos enfermeiros em manter o bom funcionamento da equipe e gerir questões conflitantes eleva a necessidade em oferecer segurança aos pacientes, já que, quando o enfermeiro se encontra comprometido com seu exercício profissional, pode se sentir mais seguro para desenvolver suas ações com autonomia e confiança, a fim de conservar e defender suas crenças, mesmo diante de represálias. como limitação do estudo, destaca-se que ele foi conduzido em uma pequena amostra de enfermeiros atuantes em dois hos364 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 pitais de uma cidade do extremo sul do brasil; portanto, não é possível a generalização dos resultados. destaca-se a necessidade em realizar outros estudos de relação entre a advocacia do paciente e as possíveis implicações negativas de seu exercício para os enfermeiros, de modo a contribuir para transformar a realidade e aprimorar o comportamento ético desses profissionais, mediante um enfrentamento adequado de situações específicas do ambiente de trabalho. conflito de interesse: nenhum declarado. referências 1. hamric ab, borchers ct, epstein eg. development and testing of an instrument to measuremoral distressin healthcare professionals. am. j. bioeth. 2012; 3(2):1-9. 2. hanks rg. the medical-surgical nurse perspective of advocate role. nurs. forum. 2010; 45(2):97-107. 107. doi: 10.1111/j.1744-6198.2010.00170.x 3. vaartio h, leino-kilpi h, suominen t, puukka p. nursing advocacy in procedural pain care. nurs. ethics. 2009; 16(3):340-62. 4. annas gj. the patient rights advocate: can nurses effectively fill the role? superv. nurse. 1974; 5(7):20-5. 5. selanders l, crane p. the voice of florence nightingale on advocacy.online j. issues nurs. 2012; 17(1). doi: 10.3912/ ojin.vol17no01man01 6. andrade rd, mello df. organizações sociais e instituições governamentais: perspectivas de parceria na atenção à saúde da criança através dos voluntários e da pastoral da criança. rev esc enferm. usp. 2006; 40(1):93-7. 7. barlem eld, lunardi vl, lunardi gl, tomaschewski-barlem jg, silveira rs. moral distress in everyday nursing: hidden traces of power and resistance. rev latinoam. enferm. 2013; 21(1):293-9. 8. hanks rg. development and testing of an instrument to measure protective nursing advocacy. nurs. ethics. 2010; 17(2):255-67. 9. arries ej. patient safety and quality in healthcare: nursing ethics for ethics quality. nurs. ethics. 2014; 21(1):3-5. 10. vaartio h, leino-kilpi h, suominen t, puukka p. nursing advocacy in procedural pain care. nurs. ethics. 2009; 16(3):340-62. 11. gaya a. (col). ciências do movimento humano: introdução à metodologia da pesquisa. porto alegre: artmed; 2008. 12. hill mm, hill a. investigação por questionário. lisboa: editora sílabo; 2012. 13. tomaschewski-barlem jg, lunardi vl, barlem eld, silveira rs, dalmolin gl, ramos am. rev. adaptação transcultural e validação do instrumento protective nursing advocacy scale para enfermeiros brasileiros. rev latinoam. enferm. 2015; 23(4):669-76. 14. betancur mal. cuidados al final de la vida: una oportunidad para fortalecer el patrón emancipatorio de enfermería. av. enferm. 2015; 33(1):124-32. 15. rocha ds, zíoni f, caetano aca. advocacia sanitária, cidadania e participação social: análise, histórico e conquistas da associação dos portadores de hepatite do acre. rev. direito sanit. 2015; 15(3):122-41. 16. josse-eklund a, jossebo m, sandin-bojo ak, wildelarsson b, petzall k. swedish nurses’ perceptions of influencers on patient advocacy. nurs. ethics. 2014; 21(6):673-83. 17. mahlin m. individual patient advocacy, collective responsibility and activism within professional nursing associations. nurs. ethics. 2010; 17(2):247-54. 365 preditores da advocacia em saúde identificados por enfermeiros no contexto hospitalar l aline marcelino ramos e outros 18. tomaschewski-barlem jg, lunardi vl, barlem eld, ramos am, silveira rs, vargas mao. como enfermeiros vêm exercendo a advocacia do paciente no contexto hospitalar? — uma perspectiva foucaultiana. texto & contexto enferm. 2016; 25(1):1-8. 19. harrowing jn, judy mb. moral distress among ugandan nurses providing hiv care: a critical ethnography. int. j. nurs. stud. 2010; 47:723-31. 20. barlem eld, lunardi vl, tomaschewisk jg, lunardi gl, lunardi filho wd, schwonke crgb. moral distress: challenges for an autonomous nursing professional practice. rev. esc. enferm. usp. 2013; 47(2):506-10. 21. neutzling brs, barlem jgt, barlem eld, hirsch cd, pereira la, schallenberguer cd. em defesa dos direitos da criança no ambiente hospitalar: o exercício da advocacia em saúde pelos enfermeiros. esc. anna nery rev. enferm. 2017; 21(1):e20170025. 22. nogario acd, barlem eld, tomaschewski-barlem jg, lunardi vl, ramos am, oliveira acc. nursing actions in practicing inpatient advocacy in a burn unit. rev. esc. enferm. usp. 2015; 49(5):811-8. calidad de vida de los.pmd revista aquichan issn 1657-5997 38 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 abstract the aim of this research is to describe, from an ethnographical view, the way life quality of family carers of elderly population functionally dependent could be affected, as consequence of performing as such, as well as their own point of view. this is an ethnographical study, supported by focused ethnography, among 14 family carers of 65 years people, who had been caring for more than six months. it was done in the municipality of envigado (colombia), in the year 2002. the sampling was made of fifteen in depth interviews. the interview analysis evidenced seven major topics or categories about carers own perception on their role as such and its effects on their life quality: meaning of life quality; carers perception about their own role; physical and mental health consequences of the role; carer-caree relations; knowledge and learning about care people; carers support for developing as such; and invisibility of carers’ job. the resulting categories coincide with the ones of some other studies. the category “invisibility of family carers’ job” is noticeable but it is the least documented in literature and in the importance on value and group traditions approach for analyzing their responses to social life. key words clara inés giraldo molina1 gloria maría franco agudelo2 recibido: 19 de mayo de 2006 aprobado: 4 de julio de 2006 resumen palabras clave cuidadora familiar, dependencia funcional, calidad de vida, invisibilidad del cuidado. family carer, functional dependency, life quality, invisibility of care job. el objetivo de esta investigación es describir, desde la perspectiva etnográfica, cómo podría estar afectada la calidad de vida de los cuidadores familiares de adultos mayores con dependencia funcional, como consecuencia del desempeño del rol de cuidador, y según su percepción. se trata de un estudio cualitativo etnográfico, con apoyo en la etnografía enfocada, en 14 cuidadoras familiares de adultos mayores de 65 años, con más de seis meses a su cuidado, en el municipio de envigado, colombia, en 2002, y una muestra de quince entrevistas en profundidad. el análisis de las entrevistas identificó siete grandes temas o categorías con las percepciones de las cuidadoras sobre su rol y los efectos de éste en su calidad de vida: significado de calidad de vida, percepción de la cuidadora sobre el rol de cuidadora, consecuencias del rol sobre su salud física y mental, relaciones cuidadora y persona cuidada, conocimientos y aprendizajes sobre el cuidado de las personas, apoyos que recibe la cuidadora para el cuidado, y la invisibilidad del trabajo de las cuidadoras. las categorías que emergieron coinciden con las de otros estudios; se hace énfasis en la categoría “la invisibilidad del trabajo de la cuidadora familiar”, en tanto es la menos documentada en la literatura, y en la importancia del acercamiento a los valores y las tradiciones de grupos para la interpretación de las respuestas de su vida social. life quality among family carers * investigación financiada por el centro para el desarrollo de la investigación (codi), universidad de antioquia, y por el municipio de envigado, antioquia, colombia. 1 facultad de enfermería, universidad de antioquia. calle 67 nº 53 -108 apartado aéreo 1226, medellín, colombia. cigiraldo@catios.udea.edu.co 2 facultad de enfermería, universidad de antioquia. calle 67 nº 53 -108 apartado aéreo 1226, medellín, colombia. gmfranco@tone.udea.edu.co año 6 vol. 6 nº 1 (6) 38-53 chía, colombia octubre 2006 calidad de vida de los cuidadores familiares. life quality among family carers 39 introducción as situaciones de enfermedad crónica, los procesos de enfermedades terminales, el envejecimiento de la población y los cambios en las formas de los servicios de salud han abierto la puerta al cuidado familiar y, desde luego, a las personas que proveen este cuidado, los cuidadores familiares; lo anterior en tanto no todos los periodos de la situación de salud de una persona aquejada por una enfermedad crónica o por una enfermedad terminal, así como las fases con dificultad de la última etapa del ciclo de vida de los seres humanos, requieren atención de salud institucionalizada. por ello, no es de extrañar que al comienzo del siglo xxi se recurra con insistencia a la atención en el hogar bien sea mediante el cuidado familiar o bien mediante la hospitalización domiciliaria. como se hace referencia al envejecimiento de la población, conviene entonces ver las razones de su surgimiento, entre ellas se identifican las transformaciones en la estructura demográfica nacional e internacional con un incremento notorio de la población adulta mayor (de 60 y más años), en tanto según proyecciones del fondo poblacional de las naciones unidas, para mediados del siglo xxi la esperanza promedio de vida en el mundo será de 76 años, y la población mundial llegará a los 9 mil millones, de los cuales el 21% será mayor de 60 años; en este mismo orden de ideas, para colombia el crecimiento poblacional estará cerca de los 71 millones, donde también un 21% será mayor de 60 años (1). como las consecuencias de la transición se hacen evidentes en este comienzo del siglo xxi, paralelamente en colombia surgen los cuidadores familiares de adultos mayores, lo que se ha descrito en varios estudios realizados en el país (2, 3). ¿quiénes son los cuidadores familiares? de acuerdo con los estudios revisados sobre el cuidado familiar, se puede afirmar que éste se caracteriza por ser provisto por los familiares o los vecinos muy allegados a la persona que lo requiere, el cual no está regulado, ni sometido a horarios, ni a remuneración económica, y generalmente quienes lo proveen no han tenido educación formal al respecto, al menos cuando comienzan a desempeñar este rol. como lo expresan soldo y cols. “... se trata de una fuente de cuidados... para que las personas mayores en situación de fragilidad o dependencia, las personas discapacitadas u otros grupos, puedan seguir viviendo en su hogar, o en la comunidad y no ser institucionalizadas” (4). este cuidado también se caracteriza por ser realizado en su mayoría por mujeres de edad media, hijas o esposas de la persona que recibe el cuidado, que generalmente conviven con ella, y con un nivel de escolaridad diverso. de otra parte, la literatura científica también da cuenta de cómo ser cuidador familiar trae consecuencias sociales, emocionales, físicas y de salud para las personas que proveen este cuidado; en este sentido, hace referencia a la sobrecarga, carga emocional, estrés y depresión, fatiga, pérdida del apetito, insomnio, trastornos del ciclo circadiano y aislamiento social, entre otros (3, 5, 6). igualmente, se han encontrado como factores causantes del deterioro psicosocial del cuidador familiar de adultos mayores la enfermedad, la discapacidad, el deterioro funcional y cognitivo o los problemas de conducta de los mayores a quienes de acuerdo con los estudios revisados sobre el cuidado familiar, se puede afirmar que éste se caracteriza por ser provisto por los familiares o los vecinos muy allegados a la persona que lo requiere, el cual no está regulado, ni sometido a horarios, ni a remuneración económica, y generalmente quienes lo proveen no han tenido educación formal al respecto, al menos cuando comienzan a desempeñar este rol. revista aquichan issn 1657-5997 40 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 cuidan, que constituyen posibles antecedentes de estrés del cuidador. justamente, los problemas de salud son percibidos como la principal amenaza, tanto por el cuidador como por el anciano, y esto es más delicado cuando ambos son de edad avanzada (5). considerando la magnitud de la situación detallada, el presente estudio se orientó a describir cómo podía estar afectada la calidad de vida de los cuidadores familiares de adultos mayores con dependencia funcional, como consecuencia del desempeño del rol de cuidador, y según su percepción. los hallazgos permitirían identificar la relación del cuidado profesional y del familiar, y de qué manera los profesionales de enfermería podrían acompañar, orientar y apoyar a los cuidadores familiares en esta labor, para mejorar su calidad de vida y las acciones de cuidado. para lograr el objetivo planteado, en envigado, colombia, se adelantó un estudio cualitativo con respaldo en la perspectiva etnográfica, específicamente “la etnografía enfocada” (7) –concepto que se desarrolla en el apartado de materiales y métodos–, en un grupo de 14 cuidadoras familiares de adultos mayores de 65 años, que llevaban más de seis meses al frente de su cuidado; la muestra la constituyeron quince entrevistas en profundidad a las cuidadoras, adelantadas después de la fase exploratoria. el análisis de las entrevistas permitió agrupar en siete grandes temas las percepciones de las cuidadoras sobre su rol, y los efectos de éste en su calidad de vida, así: 1) significado de calidad de vida; 2) percepción de la cuidadora sobre el rol de cuidadora; 3) consecuencias del rol sobre su salud física y mental; 4) relaciones cuidadora y persona cuidada; 5) conocimientos y aprendizajes sobre el cuidado de las personas; 6) apoyos para el cuidado que recibe la cuidadora; 9) invisibilidad del trabajo de las cuidadoras familiares. entre las principales conclusiones se menciona cómo las categorías descritas coinciden con las de otros estudios, se profundiza en la categoría “la invisibilidad del trabajo de la cuidadora familiar” en tanto es lo más novedoso del estudio. de otra parte, la soledad de la cuidadora, su aislamiento social, la sobrecarga de este trabajo cotidiano, el deterioro de su salud física y mental, y el olvido de sí son, entre otras, algunas de las consecuencias desafortunadas en su calidad de vida; sin embargo, la satisfacción con este trabajo, sentirse útiles, poder retribuirle a quien en otro momento le aportó a su vida, y el saber que adquieren, son consecuencias muy venturosas que parecen compensarles los momentos adversos del cuidado familiar. materiales y métodos teniendo presente que según morse (8) “...la etnografía es un método que permite describir un grupo cultural o un fenómeno asociado con un grupo cultural”, y según nigenda y langer (9) “...la etnografía busca descubrir los símbolos y categorías que una cultura dada usa para interpretar el mundo...”, es decir, intenta comprender la realidad elaborada a partir de la concepción del mundo, los valores y las normas de un grupo particular, se realizó una investigación cualitativa en la perspectiva etnográfica. específicamente, el estudio se adelantó con respaldo en una “etnografía enfocada”, como la denomina muecke (7), en tanto se orientó a describir e interpretar en el grupo de cuidadores el significado de ser cuidador, y cómo su calidad de vida podía estar la soledad de la cuidadora, su aislamiento social, la sobrecarga de este trabajo cotidiano, el deterioro de su salud física y mental, y el olvido de sí son, entre otras, algunas de las consecuencias desafortunadas en su calidad de vida. calidad de vida de los cuidadores familiares. life quality among family carers 41 afectada por ese rol. las etnografías enfocadas son estudios en un grupo o institución realizados en un tiempo limitado, se centran en aspectos particulares o específicos, el número de participantes también es limitado y se puede apoyar de entrevistas en profundidad, acompañadas o no de observación participante (7). como puede verse, no se asumió una macroetnografía por que ésta se refiere a la observación participante de un grupo por un periodo extenso y el asunto de interés de estudio es más amplio. la muestra se fue configurando a medida que el estudio progresó, tal como se determina en los estudios cualitativos; en este sentido, mediante quince entrevistas en profundidad realizadas a las 14 cuidadoras, se completó la muestra por cuanto con ellas se logró saturar la información requerida (10). la selección de los participantes se realizó con base en criterios como la complejidad del cuidado de la persona a su cargo determinada según el estado de la capacidad funcional y la condición de salud, el tiempo de dedicación al cuidado no inferior a seis meses, ser el cuidador principal, la convivencia con la persona cuidada y la aceptación de participar en el estudio. es de anotar que el género, la escolaridad, la edad y el nivel socioeconómico no se consideraron como criterios de inclusión. para obtener la información se recurrió a la estrategia de entrevistas en profundidad, de tal manera que a través de ellas se lograra comprender el significado cultural del cuidado familiar en la percepción de los mismos cuidadores familiares, y los efectos de él en su calidad de vida. antes de las entrevistas se adelantó una fase exploratoria con tres cuidadoras, lo que permitió ajustar la guía de las entrevistas y familiarizar a las investigadoras con esta estrategia metodológica. con la intención de facilitar la continuidad del cuidado y de lograr la observación del ambiente y las relaciones del cuidado, así como los recursos disponibles para el mismo, las entrevistas se realizaron en la vivienda de la cuidadora, y, con la debida autorización de las participantes, fueron grabadas. una vez concluidas las entrevistas, las entrevistadoras, por fuera de la vivienda, realizaban las anotaciones en el diario de campo para enriquecer el análisis. ahora bien, como fruto del examen de las primeras cuatro entrevistas se mejoró la guía a la luz de los objetivos del estudio. una vez transcritas las entrevistas por las mismas entrevistadoras, se procedió a la identificación de códigos empíricos, que fueron la base para la determinación de las categorías analíticas que en últimas constituyen los siete grandes temas en los que se agrupa lo encontrado. para el análisis se partió de la perspectiva emic, es decir, de la realidad según la visión del participante o informante, esa visión del interior del participante que es considerada como fundamental para interpretar el comportamiento, en este caso del cuidador; y la perspectiva etic que constituyó el referente teórico o las abstracciones conceptuales que orientaron, en este caso, a las investigadoras para tener una explicación de la realidad (11). como era interés de las investigadoras describir la situación desde los cuidadores, en los resultados se retoman las apreciaciones de las cuidadoras en relación con los conceptos propuestos en los objetivos. aspectos éticos del estudio según la resolución 008430 de 1993 del ministerio de salud de colombia, el estudio no ofrecía riesgo para los participantes, en tanto no tenía procedimientos o técnicas que pudieran afectar a los individuos en sus aspectos orgánicos o psicológicos, la incorporación a él se hizo de manera voluntaria, y después de una explicación precisa sobre los alcances y objetivos de la investigación las cuidadores familiares dieron su autorización por escrito mediante el consentimiento informado exigido por la resolución. se dio trato confidencial a la información para preservar la identidad de las personas e instituciones participantes. también se dio la posibilidad del retiro voluntario cuando cada participante lo quisiera hacer. del mismo modo en los resultados, cuando se describen testimonios de los participantes, se recurre a nombres ficticios para preservar su identidad. resultados como resultado de la codificación empírica y analítica de las entrevistas se identificaron varias categorías analíticas, y con base en el análisis de éstas se agruparon en áreas temáticas como se describe a continuación. la determinación del área temática corresponde al análisis conceptual del significado de las subcategorías. áreas temáticas: significado de calidad de vida, percepción de la cuidadora sobre su rol, consecuencias del rol sobre su salud física y mental, relaciones cuidadora y persona cuidada, conocimientos y aprendizajes sobre el cuidado, apoyos para el cuidado que recibe, y la invisibilidad del trabajo de las cuidadoras familiares. cada área temática incorpora unos subtemas que corresponden a lo que en otros estudios denominan subcategorías. como algunas de las áreas temáticas han sido ampliamente documentadas en otras investigaciones, en la presente se trabajó en los temas relacionados más direvista aquichan issn 1657-5997 42 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 rectamente con los objetivos propuestos y en especial el tema de la invisibilidad del trabajo de las cuidadoras, por cuanto al momento del estudio es uno de los menos documentados en el país. la descripción de los temas y subtemas se ilustra con testimonios de las cuidadoras familiares identificados en las entrevistas en profundidad. tema 1: significado de calidad de vida mucho se ha investigado y escrito sobre calidad de vida; así, para coelho y amante, “...la calidad de vida es la condición de la existencia del ser humano referida a los modos de vivir en sociedad, esto es, dentro de los límites establecidos en cada momento histórico para vivir la cotidianidad”, “...esta existencia también debe satisfacer las exigencias o demandas que la cotidianidad genera para las personas que integran la sociedad. la insatisfacción de las exigencias y demandas de su modo de andar la vida cotidianamente constituirá el sufrimiento que se quiere evitar o revertir por medio de las acciones de salud” (12). por su parte, las corrientes de pensamiento sobre cuidado holístico ecológico citadas por patricio (13) se refieren al concepto “vida” como toda forma de energía expresa en los procesos de producción humana, lo que conlleva una diversidad de procesos y productos de interacción biológica socio-espiritual en constante transformación; ésta es construida en todo el proceso de vivir. la calidad es entendida como los atributos, las características o propiedades de determinado fenómeno, en este caso de la vida. es decir, el concepto calidad califica al elemento que lo precede. son numerosas las definiciones sobre calidad de vida y la mayoría de ellas incorporan la posibilidad de que la persona sea gestora de la satisfacción de sus necesidades básicas. marín sevilla (14) considera que la calidad de vida depende de la situación funcional, del grado de comodidad y del nivel de autoestima de la persona. por su parte, canam c. y acorn s. (15) se refieren a la calidad de vida como el bienestar psicológico entendido como la satisfacción con la vida, metas alcanzadas y felicidad; bienestar físico que incluye la realización de las actividades de la vida diaria, el apetito y el sueño, el bienestar social e interpersonal, el bienestar financiero y material. de acuerdo con las distintas definiciones sobre calidad de vida, se aprecia cómo este concepto no es único y mucho menos universal. cada persona lo va construyendo a medida que camina por los senderos de su vida, es un concepto que está influenciado por las distintas circunstancias que acompañan a la persona en cada momento, es decir, está determinado por diferentes factores de la persona y de su entorno; tiene que ver las posibilidades educativas, los aspectos biológicos y psicológicos, y demás aspectos culturales y sociales relacionados con ella. en consecuencia, es un concepto individual, y es dinámico, es decir, cambia en el tiempo, una misma persona tiene diferentes conceptos de calidad de vida en momentos distintos. ahora bien, esta área temática fue de gran dificultad para el estudio, en tanto formular la pregunta apropiada para provocar respuestas acertadas exigió a las investigadoras indagar de diversas formas hasta lograr ser comprensible para las cuidadoras y así obtener la respuesta pertinente, así como ocurre en las situaciones en las que se intenta encontrar definiciones de algún concepto. no obstante las dificultades señaladas, el tema “significado de calidad de vida” está representado por los siguientes subtemas que emergieron de las diferentes entrevistas: vida buena o normal; el bienestar proporcionado por sus allegados; la satisfacción de las necesidades de sus hijos o parientes más cercanos; tener salud; conquistar metas en estudio, en trabajo o en roles sociales; disponer de recursos económicos para satisfacer necesidades; ser autónoma, independiente o libre para tomar decisiones; y cumplir satisfactoriamente con las obligaciones o responsabilidades adquiridas. testimonios como los siguientes dan cuenta del tema y los subtemas encontrados cuando a las cuidadoras se les indagó sobre el significado de calidad de vida: fátima de 22 años, que cuidaba desde hacía dos años de magdalena, su suegra de 87 años, quien padecía diabetes mellitus con compromiso en el sistema endocrino, con independencia funcional en las actividades básicas de la vida diaria y dependiente en las actividades instrumentales, se expresó así sobre calidad de vida: “... mucha cosa, vida muy buena, salud, educación, recreación, sentirse satisfecho...”. por su parte, lucía de 65 años, cuidadora de su hermana natividad de 72 años, con compromiso en el sistema neurológico, con máxima dependencia en ambas actividades básicas e instrumentales de la vida diaria, se refirió: vivir bien, y yo, yo vivo muy bien, tengo hijos muy buenos y el esposo también, y uno no vive amargado ... ellos [esposo e hijos] han sido muy comprensivos conmigo, ellos me apoyan, me colaboran ...mi vida es normal, pues hasta el mocalidad de vida de los cuidadores familiares. life quality among family carers 43 mento yo no me he aburrido, o sea, me siento bien, ... no hago las cosas porque las tenga que hacer, o sea, me nace hacer las cosas. juana, de 57 años, que cuidaba desde hacía cuatro años a josé, su padre, de 90 años, quien tenía afectado su sistema neurológico, con máxima dependencia en ambas actividades, básicas e instrumentales, de la vida diaria, expresó lo siguiente sobre lo que significa para ella calidad de vida: ... yo hice primaria, en ese entonces era más difícil para uno estudiar ...a mí me provocó mucho casarme, pero mi dios no me tuvo para esa dicha ...yo nunca pensé en nada, lo que la vida me trajera, al fin y al cabo uno bien pobre para qué me iba a poner a anhelar que iba a tener algo... de otro lado maría, de 43 años, cuidadora de su madre auxilio, de 76 años, con compromiso en los sistemas respiratorio y circulatorio, con dependencia moderada tanto en las actividades básicas como en las instrumentales de la vida diaria, manifestó sobre calidad de vida: ...que lleva una vida muy bien, muy bonita la vida que lleva. yo nunca pensaba tener la vida que llevo ahora de bregar un enfermo [cuidar a su madre] sino vivir mi vida bien, estudiar, me fascinó estudiar, no tuve la meta ...yo quería ser doctora, una enfermera, pero realicé lo otro que yo quería ...hubiera querido seguir trabajando como vendedora; ...yo quería independizarme y conseguir empleo. las dificultades o limitaciones en la conceptualización y el significado sobre calidad de vida, así como la naturaleza de los subtemas que emergieron en esta área, parecen guardar relación con la situación de salud de la persona que estuviesen cuidando y con el nivel socioeconómico y cultural del grupo de cuidadoras, así: el 89,7% disponía de un ingreso familiar promedio igual o menor a dos salarios mínimos mensuales legales vigentes3; el 92,2% de sus viviendas se clasificaron en los estratos tres o dos; el 56,2% de ellas con niveles educativos correspondientes a secundaria incompleta o primaria incompleta; el 17,6% con secundaria completa y ninguna con estudios de educación superior; datos identificados en el componente cuantitativo del estudio (16). tema 2: percepción o sentimientos de la cuidadora sobre su rol de acuerdo con la revisión de literatura, la percepción es definida como el “reconocimiento y comprensión de una impresión que se ha presentado a los sentidos. proceso mental mediante el cual percibimos la realidad” (17); como uno de los sinónimos es el concepto “sentimiento”, éste es definido como: “...acción y efecto de sentir. impresión que causan en el alma las cosas espirituales. parte del ser humano opuesta a la inteligencia o razón. estado del ánimo afligido” (18). según kant, sentimiento es “una impresión consciente y subjetiva que no implica conocimiento o representación de un objeto. los sentimientos son de dos clases, de placer o de dolor. no representan nada real en los objetos, sino que revelan un estado o condición del sujeto. kant vio en el placer y el dolor, respectivamente, fuerzas promotoras o destructoras de la vida. el placer resulta de la armonía de un objeto con las condiciones subjetivas de vida y conciencia, mientras que el dolor es darse cuenta de la desarmonía” (19). es decir, son los sentimientos o las emociones que cada quien experimenta frente a determinadas situaciones de la vida, lo cual está influenciado por las experiencias previas, motivaciones, estímulos, la cultura, el grado de inteligencia y los intereses personales. en este sentido, las percepciones son individuales, cambian en el tiempo regidas por las diferentes vivencias, se enriquecen a medida que cada individuo crece como persona. así, en el estudio se develó cómo las cuidadoras manifestaron sentimientos variados frente a su rol, y se pudieron identificar en una misma entrevista sentimientos afines y contrarios, sentimientos de aceptación y de satisfacción con el rol, o bien sentimientos adversos y de insatisfacción. estas expresiones, a medida que se presentaban, estaban relacionadas con el momento del relato en el cual se apoyaba la cuidadora, de un lado con el inicio como cuidadora o de otro, con momentos más avanzados de su experiencia. en este tema o categoría se inscribieron aquellos sentimientos o emociones identificados en las cuidadoras familiares relacionados con el rol de cuidadora, entre los cuales están los siguientes que constituyen subtemas o subcategorías: aceptación, ambivalencia, sacrificio, satisfacción, compasión y tristeza. respecto al subtema “aceptación”, que significa “...recibir voluntariamente algo, aprobar también. acción y efecto de aceptar. aprobación y aplauso” (20), la aceptación implicó que el cuidado fue asumido 3 el valor del salario mínimo legal mensual (smlm), de colombia a julio de 2006 corresponde a $408.000.00 pesos, moneda corriente; valor equivalente a ciento sesenta dólares (us$160). revista aquichan issn 1657-5997 44 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 por las cuidadoras, bien como un deber moral, o por resignación, por retribución, u obligación; lo cual pudo estar afectado por los contextos social, cultural y económico, la evolución del proceso, los apoyos y el tiempo como cuidadora. mariela, una cuidadora de 66 años, llevaba 17 años al cuidado de su madre sofía, de 97 años, con parkinson y consecuencias de una fractura de fémur, situación que contribuyó a que en los últimos 14 años se incrementara el grado de dependencia cuando llegó al máximo grado tanto en las actividades básicas e instrumentales de la vida diaria, –determinadas por el índice de katz y la escala de lawton y brody–, en este sentido, requería asistencia permanente en las actividades cotidianas, y al averiguarle sobre sus sentimientos frente al rol, respondió: “....yo nunca reniego ni me ofusco para arreglarla a ella...”. de otra parte, cuando a bernarda, cuidadora de 45 años, soltera, quien desde hacía cinco años cuidaba también a su madre rosa, con una dedicación de 18 horas por día, en tanto su mamá con 78 años mostraba compromiso de los sistemas cardiovascular y neurológico, con dependencia funcional severa para las actividades básicas, y moderada en las actividades instrumentales de la vida diaria, se le inquirió el significado de su experiencia de cuidar a su madre, manifestó diversos sentimientos: ...pa (sic) mi sí significa mucho. vea, por una parte uno se siente muy triste, cierto. eso sí lo afecta mucho a uno de verla así [por su enfermedad] … pero, por otro lado yo me alegro mucho porque yo veo que ella es muy apegadita a mí ... yo me siento muy bien porque ya que ella todo nos lo dio a nosotros [hermanos], ahora uno tiene una manera de cosecharle o devolverle todo lo que ella hizo por mí,... pero que eso ¡ave maría! afecta horrible, ¡que cambio!, a mí sí me cambió mucho la vida. renata, quien tenía 72 años y desde hacía seis años cuidaba de su hermana camila, de 76, que presentaba epoc, hipertensión y fractura de fémur, con dependencia funcional severa en las actividades básicas, y moderada en las actividades instrumentales, lo que le exigió una dedicación al cuidado cercana a 16 horas al día, respondió lo siguiente cuando se le preguntó qué ha significado cuidar de su hermana: ...en cuanto a los cuidados... ¡bendito sea mi dios que me ayuda mucho! como yo ya tenía alguna práctica en cuestiones de salud, yo sentía que me hacía falta pues, eh... como una entrega más grandecita que la normal en una casa, ¿cierto? entonces el cuidado, así sea de día, y pues de noche, y toda esa cosa, a mí no me afecta. yo me siento con mucha capacidad y naturalmente uno de pronto sí siente como que ¡dios mío! que yo no vaya a faltar. aunque se siente uno tan útil... otros subtemas: ambivalencia. en la literatura revisada se encuentran varias definiciones sobre este concepto: “ambivalencia es la condición de lo que se presta a dos interpretaciones opuestas” (18); también es definida como la “existencia de sentimientos emocionales contradictorios hacia un objeto, comúnmente de amor y odio por otra persona. si estos sentimientos se producen hasta un grado marcado, conducen a trastornos psicológicos” (21). de otra parte, la ambivalencia es circunstancial, hay momentos de aceptación la ambivalencia es circunstancial, hay momentos de aceptación y otros de rechazo, es decir, cada sentimiento está influenciado por el contexto, en este caso de la situación de salud del paciente, de la disponibilidad de apoyos o recursos con los que contaba frente al cuidado, entre otros. calidad de vida de los cuidadores familiares. life quality among family carers 45 y otros de rechazo, es decir, cada sentimiento está influenciado por el contexto, en este caso de la situación de salud del paciente, de la disponibilidad de apoyos o recursos con los que contaba frente al cuidado, entre otros. satisfacción. “razón, acción o modo con que se prepara una injuria o daño. presunción vanagloria. confianza, seguridad del ánimo. cumplimiento del deseo o del gusto” (18). sentimiento. “emoción dirigida hacia algún objeto o persona. los sentimientos son adquiridos e influyen profundamente en las acciones de una persona” (21). tema 3: consecuencias del rol sobre su calidad de vida el concepto consecuencia, también reconocido como resultado, efecto o impacto, tiene su significado en la literatura, como el “hecho o acontecimiento que se sigue o resulta de otro. ... por efecto, como resultado de...” (18). numerosos estudios han reportado en los escritos científicos los efectos que puede tener el cuidado en la vida del cuidador, tanto consecuencias que benefician a la persona como resultados adversos que pueden afectar su calidad de vida, ya en su salud física, como en aspectos psicológicos, y en su vida social (22). los resultados adversos están relacionados con el cambio que se genera en la vida del cuidador, como consecuencia de las jornadas extensas e intensas de cuidado, las situaciones de estrés, los altos grados de dependencia funcional y el deterioro progresivo de la salud de la persona a quien se cuida, las faltas de apoyo familiar o formal y de recursos para el cuidado, la pérdida de roles sociales y familiares, y la carencia de conocimientos y de experiencia para afrontar situaciones de cuidado, para mencionar algunas causas (5, 2, 23, 24). por su parte, los beneficios que reportan las cuidadoras tienen que ver con encontrarle sentido a su vida, sentirse útiles a la sociedad, el saber que adquieren sobre la salud y el cuidado, la oportunidad de retribuirle a un ser querido que mucho les ha dado en momentos anteriores, y la creatividad para el cuidado, entre otros, asuntos que están mediados y relacionados con los valores y las creencias de la población envigadeña, grupo cultural al que pertenecen las cuidadoras. en el componente cuantitativo de este estudio se indagó sobre el tiempo que llevaban al cuidado de su familiar y la dedicación en horas al día por parte de las treinta y nueve cuidadoras familiares4 a las actividades de cuidado, donde se encontró que el 30,8% de ellas llevaba entre 3 y 6 años, el 12,9% más de 12 años; y de otro lado, el 76,9% dedicaba más de ocho horas al día a actividades de cuidado. al desagregar esta información se encontró que el 48,7% de ellas invertían más de 16 horas y el 28,2% entre 8 y 16 horas por día (16). en el presente estudio se identificaron los siguientes subtemas o subcategorías inherentes a esta área temática: cambio en la vida de la cuidadora, deterioro de la salud física y mental, el olvido de sí, el aislamiento y la invisibilidad del trabajo de la cuidadora; este último se trata como un tema especial. los beneficios que reportan las cuidadoras tienen que ver con encontrarle sentido a su vida, sentirse útiles a la sociedad, el saber que adquieren sobre la salud y el cuidado, la oportunidad de retribuirle a un ser querido que mucho les ha dado en momentos anteriores, y la creatividad para el cuidado. 4 el componente cuantitativo del estudio describe el perfil sociodemográfico y las características del cuidado que prodigan 39 cuidadoras familiares de ancianos dependientes. de este grupo se tomaron las cuidadoras familiares para el componente cualitativo, del que hace referencia el presente artículo. revista aquichan issn 1657-5997 46 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 cambio en la vida de la cuidadora este concepto tiene varias acepciones, se retoman las siguientes: “cambio es la acción y efecto de cambiar. ... cambiar: dar o recibir una cosa por otra que la sustituya. convertir en otra cosa. intercambiar. mudar o alterar una persona o cosa su condición o apariencia física o moral.” también, cambio se ha definido como, “... el devenir otro, el paso de un modo de ser a otro... en sentido propio se denomina cambio únicamente el cambio interno en el cual un determinante existente en la cosa o propio de la cosa misma se convierte en otro distinto... el cambio es una realidad incompleta, en la medida en que supone una transición de la posibilidad (potencia) a la realidad de una cosa o de un estado” (25). en la revisión de artículos científicos sobre cuidado y cuidadores familiares es frecuente encontrar el cambio que ocurre en la vida de los cuidadores como consecuencia de haber asumido el cuidado de algún familiar en su casa; ellos refieren cómo el cumplimiento de este nuevo rol significa dedicar largas jornadas a ello, realizar tareas a veces delicadas, y otras consecuencias señaladas anteriormente. es de anotar cómo las catorce cuidadoras en las quince entrevistas que se efectuaron en el estudio manifestaron que la actividad de cuidar les cambió su vida, asunto que es consistente con diferentes estudios realizados con cuidadores familiares tanto en el país como en otros contextos (26, 27). al asumir el cuidado de su familiar o allegado las cuidadoras transformaron su rutina diaria, su cotidianidad fue modificada sustancialmente, incluso algunas dejaron de trabajar, muchas se alejaron de toda actividad social, disminuyeron o suprimieron el esparcimiento, multiplicaron los roles, y en algunas ocasiones las relaciones de pareja se vieron afectadas. cuando se invitó a mariela a compartir con las investigadoras un poco de su vida como cuidadora, en su testimonio ella presenta varios sentimientos frente al cuidado, y entre ellos menciona el cambio: ...entonces, pues, la vida a mí me ha cambiado horrible, el cambio de vida ha sido horrible, pero a pesar del cambio tan brusco que hubo, pues yo le pido mucho a mi dios paciencia y me someto a estar encerrada, a estar aquí pendiente de ella únicamente visitaba la familia, o pues, antes de empezar los enfermos a enfermarse íbamos mucho a cine, teníamos una hija y salíamos con ella, o íbamos a fútbol, hacíamos muchas actividades, yo iba a gimnasia, bueno pero todo eso se echó a tierra... de manera similar, la vida le cambió a bernarda, cuando manifestó: ... a mí me cambió mucho la vida. ... por todo; vea empezando por la acostada, eso, yo dormía parejo toda la noche, ... en cambio ahora a mí me ha dado muy duro porque como yo soy la que duermo al ladito de ella [la mamá], hace cinco años, solamente yo soy al lado de ella, porque lo que hace que ella se enfermó, ella no duerme sino al lado mío y entonces ella siempre molesta, ella siempre es muy desveladita, y entonces a mí sí me ha dado muy duro eso porque uno con harto sueño y uno bien cansado y ella, que me levante, que me siente, que voy a orinar y no orina nada, y vuelvo y la acuesto y no que pa’ un ladito y no que para el otro. es de anotar cómo las catorce cuidadoras en las quince entrevistas que se efectuaron en el estudio manifestaron que la actividad de cuidar les cambió su vida, asunto que es consistente con diferentes estudios realizados con cuidadores familiares tanto en el país como en otros contextos. calidad de vida de los cuidadores familiares. life quality among family carers 47 deterioro de la salud física y mental teniendo presente que la actividad del cuidado familiar significa entonces largos periodos de tiempo, desde meses hasta años, con extensas jornadas diurnas y aún nocturnas al cuidado, también conlleva la realización de múltiples tareas y actividades de cuidado y de acompañamiento a la persona enferma o que requiere su asistencia, y ha originado que los cuidadores dispongan de escaso tiempo para las actividades sociales y de descanso, lo que constituye poco cuidado de sí; igualmente, las situaciones de estrés a que se ven sometidos con mucha frecuencia, entre otros, son factores que evidentemente pueden contribuir con el deterioro de su salud física y mental. ahora bien, en las entrevistas algunas de las cuidadoras mencionaron problemas y síntomas como gastritis, anemia, fatiga, insomnio, cefalea, dolores de espalda, desnutrición, depresión, ansiedad, angustia y estrés. dificultades que emergen en sus testimonios: bernarda en su testimonio muestra que se siente enferma: ... quiera o no quiera, ya uno tiene que sacar fuerzas y así uno se sienta mal o así enfermo uno, hacerse el bobito o aguantarse los dolores uno, porque ella se pone triste, como llorando, y dice que vea que ella es una carga, que ya no sirve pa’ nada, entonces eso a uno le duele mucho. el olvido de sí. en este aspecto se encontró cómo en la mayoría de las cuidadoras sus intereses, motivaciones y expectativas en su proyecto de vida pasaban a un segundo plano, todo el tiempo lo dedicaban al cuidado del otro; de esta manera presentaban pérdida de la autoestima. el olvido se define como: “cesación de la memoria que se tenía. cesación del afecto que se tenía. descuido de una cosa que se debía tener presente” (18). al preguntar a mariela qué cosas realizaba para ella misma, respondió: ... nada, no hago nada, por mí no hago nada, ni salgo; eso es rara la vez que me voy para donde una cuñada o alguien que esté enfermo; pero eso es a la carrerita que vine pero ya me voy. yo no dispongo de tiempo para mí, para nada, yo no salgo sino a mercar, eso es la vida mía... en la respuesta de renata sobre el tiempo le dedicaba a sus cosas, a hacer el mercado, las vueltas de la casa y de los servicios, se percibió cómo ella pasaba a un segundo plano en la cotidianidad: ...el mercao (sic) y los servicios, yo tengo quién me haga el favor; eh, para las vueltas de pensión de ella [su hermana camila], mías y de mi cuñado que vive en estados unidos, tengo que ser yo; eso sí lo sigo haciendo. ...a veces es como difícil, ¡uh! no me alcanza el tiempo... y muchas cosas mías ya se me están olvidando. ...por ejemplo [suelta en llanto], llevo dos meses sin el control de la presión arterial, a mí se me ha olvidado; y no es por eso, pues porque yo me siento bien y compro la droga ... [continúa sollozando]. se me seguía olvidando, y con el papelito ahí ya el viernes, y sí, ya pasó la cita que era a las 9 y me acordé a las 10. ... el desconsuelo mío, es que se me olviden las cosas. aislamiento. este subtema o subcategoría está representado en la pérdida del rol social, también en las manifestaciones de abandono, de soledad y de encerramiento que reiteradamente emergieron en el análisis de las entrevistas. así, al escuchar repetidamente las entrevistas con las cuidadoras familiares se encuentra que casi todas ellas manifiestan cambios en su vida desde que comenzaron a cuidar a su familiar; estos cambios se daban en dos direcciones, algunas hacían alusión al aislamiento, y otras a lo que significa ser cuidadora. en la casi totalidad de las entrevistas hay expresiones referidas al aislamiento. así, en la entrevista con renata respondió lo siguiente al preguntársele sobre lo que hacía antes de dedicarse a cuidar a su hermana: bueno, tenía mis saliditas con mis compañeras de grupo (asociación de seglares misioneras) ...teníamos reunioncitas cada mes; también teníamos un grupo de voluntarias acá, hacíamos reuniones mensuales en donde recogíamos fondos y nos entreteníamos mucho, jugábamos bingo,... pasábamos muy sabroso; de eso hace más de año y medio que no... de otro lado, bernarda relató así lo que hacía antes de cuidar de su madre: ... no, ¿ahora adónde va a salir uno?, yo salgo pero solamente a hacer vueltas no más, mandados; es que las amistades mías ya todas se acabaron porque ya nadie me tiene en cuenta pa´salir o un programa, porque ellos ya saben que siempre digo no, no, que porque no puedo, no, y yo no salgo ya a ninguna parte... los beneficios que reporta el cuidado familiar muchos momentos de la vida de las cuidadoras estaban impregnados de sarevista aquichan issn 1657-5997 48 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 tisfacciones y logros por la labor que realizaban, lo cual se percibió en las entrevistas; renata se expresaba así sobre su experiencia de ser cuidadora de camila, su hermana: “....pues me ha enseñado que si uno no está siendo útil, ¿para qué la vida?, para ser útil. no la quiero ver sufriendo...”. tema 4: relaciones cuidadora y persona cuidada este tema agrupa aquellos subtemas que se identificaron en las entrevistas y que prácticamente daban cuenta del tipo de relaciones entre las cuidadoras y los ancianos a quienes cuidaban. toda acción de cuidar conlleva una interacción entre dos personas, quien cuida y quien recibe el cuidado, y la interacción significa un intercambio de mensajes entre ellas (28). así como en los cuidados de enfermería, en el cuidado familiar se “...expresa una relación de interdependencia que solo tiene sentido y solo puede ser eficaz dentro de un circuito de intercambios, donde cada cual toma y recibe, se desarrolla y se forma a través de todo aquello que hace difícil la vida y, al mismo tiempo, despierta la vida de las personas cuidadas y de los cuidadores, la estimula, la hace más creadora”(29). de acuerdo con los relatos, el tipo de relación que se establecía tenía que ver con la situación de salud, también con las relaciones de ambas personas previas a la situación de cuidado, con el contexto familiar, con las situaciones de estrés, con la disponibilidad o no de apoyo, entre otros. en este sentido, en el análisis emergieron los siguientes subtemas o subcategorías: relaciones demandantes, agresivas, afectuosas, respetuosas, despectivas, dependencia, codependencia y cíclicas. así se expresó socorro, de 89 años, con compromisos en el sistema cardiovascular, con dependencia en las actividades instrumentales, al referirse a su nieta trinidad, de 34 años, quien la cuidaba: “...no me gusta salir con nadie sino con ella ... no mija a mí me gusta con usted, ... no uno con otro puede ser de la misma casa pero no me gusta sino con ella”. en cuanto a las relaciones que habían establecido concepción y joaquín, esposos, ella de 71 años, su cuidadora desde hacía doce años, y él, quien tenía compromiso osteomuscular con dependencia máxima y severa en las actividades instrumentales y básicas respectivamente, se identificó una relación respetuosa en su respuesta sobre este asunto: a mí me parece que es buena; que es muy paciente. ...yo creo que él vive agradecido conmigo pues porque uno esclava de él, y, que no he fallado, que soy capaz de bregarlo con mucho fundamento,... yo soy capaz de bregarlo hasta que mi dios me lo quite. el afecto entre cuidadora y persona cuidada emergió frecuentemente en las distintas entrevistas; a modo de ilustración, en un momento de la entrevista, cuando a bernarda se le preguntó cómo se relacionaba con su madre, respondió: ah sí oiga, ave maría, sí que pecao (sic), pues fuera de la enfermedad que sí me ha dado tan duro, pero yo como en los cuidados ya pal (sic) tratamiento así con ella yo me siento muy bien, feliz y dichosa, porque yo veo que le he servido de mucho a ella, ... por esa enfermedad uno le ha demostrado más cariño, más apegamiento, yo sé, ella se debe de sentir bien nosotras, con todas. tema 5: la invisibilidad del trabajo de la cuidadora del análisis de las distintas entrevistas y de las áreas temáticas anteriores, las investigadoras identificaron una categoría que subyace y que consideraron importante resaltar, en tanto era la menos documentada en los estudios revisados; ésta tenía que ver con el desconocimiento del rol de cuidadora familiar como un trabajo, como una actividad que requería conocimientos, salario, horario, remuneración, apoyo, descanso, en fin, como cualquier otro trabajo humano. en este sentido, durante la experiencia de las entrevistas con el grupo de cuidadoras familiares se encontró que las categorías cuidado familiar y cuidadora familiar eran absolutamente extrañas para ellas, quienes no se identificaron como tales, sino como la persona que en la casa se responsabilizaba de atender a ese familiar enfermo. no percibían que iban asumiendo un trabajo cotidiano, complejo, que ameritaría asistencia de otros sectores sociales para su realización a fin de tener mínimas consecuencias infortunadas en su calidad de vida. simplemente lo asumían como una tarea más del hogar, como un deber moral, que en la cultura antioqueña, –región donde se ubica el municipio de envigado donde viven las cuidadoras–, es propia de quienes permanecen más tiempo en el hogar, y especialmente de las mujeres. el deber moral es un valor que se ha arraigado por influencia religiosa, un elemento que contribuye a sobrellevar la obligación que les implica cuidar a su familiar enfermo. calidad de vida de los cuidadores familiares. life quality among family carers 49 la categoría de cuidadora la fueron reconociendo en la medida que participaban en las entrevistas, cuando comenzaron a ser conscientes de que su trabajo tenía algún significado para otras personas. es decir, el cuidado familiar y ser cuidador o cuidadora, prácticamente pasó inadvertido, fue invisible, no solo para las personas que no tenían relación directa o indirecta con ello, sino aún para las mismas cuidadoras. según james v. (30), la “...invisibilidad se puede atribuir al carácter femenino y doméstico del cuidado: un trabajo de mujeres, natural y socialmente esperado”. y como, según se ha documentado ampliamente en la literatura, la mayoría de las cuidadoras son mujeres, esto contribuye a que ellas hayan “asumido el rol tradicional de cuidar como algo propio de su sexo [...]”(31), característica que contribuye a la invisibilidad del rol de cuidadora. ahora bien, esta invisibilidad de su rol puede ser una razón importante de las consecuencias que trae esta actividad en la persona que asume el cuidado familiar. la falta de reconocerse como un trabajo, que significa una carga para quien lo asume, lleva a no asignársele las garantías sociales, laborales y legales de un trabajo. discusión varios asuntos encontrados en los resultados del estudio llevan a la reflexión teórica y práctica de conceptos como calidad de vida, deber moral y cuidado familiar, y ¿qué hacer, entonces, desde el punto de vista de enfermería como disciplina y profesión para trasformar los infortunios que viven las cuidadoras familiares en su diario cuidar, en momentos de satisfacción y crecimiento personal? calidad de vida, como se mencionó, es un concepto individual, dinámico, que cambia a través de los distintos momentos que experimenta la persona, y por ende está afectado por el contexto cultural, social, económico y político, en este sentido, según shin y johnson, calidad de vida se refiere a “la posesión de los recursos necesarios para la satisfacción de las necesidades individuales y de los deseos, la participación en actividades que permitan el desarrollo personal y la autorrealización y la comparación satisfactoria entre uno mismo y los demás” (32), todo lo cual está directamente relacionado con el pasado histórico de la persona en todos sus ámbitos y, por ende, del conocimiento que ha ido construyendo en su devenir social. así, en las entrevistas con las cuidadoras se fue percibiendo su sentido de calidad de vida relacionado éste con su pasado y trayectoria personal, familiar y social. ahora bien, como muchas cuidadoras asumieron este papel como un deber moral, y por deber se entiende: “lo que es necesario o preciso; o lo que uno está moralmente obligado a hacer en oposición a lo que a uno le gustaría o estaría inclinado a hacer. también, puede designar la obligación moral en sí misma o la ley o principio en que se expresa. en ética el deber es comúnmente asociado con consecuencia, razón, rectitud, ley moral y virtud” (33). y, según adolfo sánchez vásquez “la moral es un conjunto de normas aceptadas libre y conscientemente que regulan la conducta individual y social de las personas” (34). igualmente, el término “moral se emplea a veces como sinónimo de ‘ética’, pero más frecuentemente se usa para designar los códigos, conductas y costumbres de individuos, o grupos, como por ejemplo, cuando se habla de moral de una persona o pueblo” (33). desde el punto de vista culdurante la experiencia de las entrevistas con el grupo de cuidadoras familiares se encontró que las categorías cuidado familiar y cuidadora familiar eran absolutamente extrañas para ellas, quienes no se identificaron como tales, sino como la persona que en la casa se responsabilizaba de atender a ese familiar enfermo. revista aquichan issn 1657-5997 50 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 tural, las cuidadoras se apropiaron de su trabajo, cumpliendo así con un deber moral que el grupo cultural al cual pertenecían había incorporado en su sistema de valores y tradiciones, y quizás por ello no vieron la posibilidad de recurrir a otros sectores sociales en búsqueda de soluciones colectivas. por su parte, morse expresa: “el cuidado que da el cuidador familiar puede ser visto como una obligación o mandato moral, que generalmente recae en las mujeres de la familia” (35). en este sentido, al considerar el cuidado como un deber moral, deber que hacía parte de sus valores culturales, lo aceptaban, algunas con más agrado que otras, pero se puede afirmar que todas manifestaron momentos de satisfacción con la labor cumplida. lo anterior guarda correspondencia con lo que expresa thomas barfield: “en la tradición cristiana es corriente hablar de sacrificio en el sentido de dedicación personal o altruismo” (36). en consecuencia, el análisis de las entrevistas en articulación con la revisión teórica permitió comprender el concepto, “deber” en el cuidado familiar como sinónimo de obligación de hacer, o de actuar, ante diferentes circunstancias inesperadas que se presentaban en la cotidianidad de las personas, obligación que iba ligada a la moral o al sistema de creencias individual, familiar y social. por tanto, el cuidado al anciano enfermo era una actividad que no se podía evitar, y correspondía entonces al familiar más cercano que tuviese labores en el hogar, que en la totalidad de los casos del estudio fue una mujer quien asumió el rol. esto da cuenta de cómo la categoría de cuidadora solo la fueron reconociendo en la medida en que participaban en las entrevistas, cuando comenzaron a ser conscientes del significado social de su trabajo. es decir, el cuidado familiar y ser cuidador o cuidadora, prácticamente pasó inadvertido, fue invisible, no solo para las personas que no tenían relación directa o indirecta con ello, sino aún para las mismas cuidadoras. con respecto a los apoyos para el cuidado, resultó muy sintomático el hecho de que para llegar al grupo de cuidadoras familiares se tuvo que acudir a la pastoral de salud de envigado, después de ser infructuosas las gestiones de las investigadoras ante el sector salud y otros sectores formales del municipio, entidades que carecían de información sobre cuidadores familiares, o sobre personas ancianas que requirieran cuidado en el hogar. muy sintomático, por cuanto ello dice de la inexistencia o desconocimiento de alguna forma de apoyo formal establecido para acompañar y orientar esta forma de cuidado que ya se ha institucionalizado en otros países, y que en colombia apenas comienza a ser reconocida, de una parte por el grupo de neurociencias de la universidad de antioquia con acciones propias de apoyo a los cuidadores familiares de pacientes con alzheimer, y de otra, en los estudios realizados por el grupo de investigación “la práctica de enfermería en el contexto social” (37) de la universidad de antioquia, por el grupo de cuidado de la universidad nacional, y por estudios de profesoras de la universidad del valle, para mencionar algo de lo encontrado. de los resultados del estudio se pudo concluir que las cuidadoras familiares hacen un valioso aporte a la sociedad, asudesde el punto de vista cultural, las cuidadoras se apropiaron de su trabajo, cumpliendo así con un deber moral que el grupo cultural al cual pertenecían había incorporado en su sistema de valores y tradiciones, y quizás por ello no vieron la posibilidad de recurrir a otros sectores sociales en búsqueda de soluciones colectivas. calidad de vida de los cuidadores familiares. life quality among family carers 51 miendo el cuidado de los adultos mayores en situación de dependencia o limitación física o psicológica, tarea que el estado no ha reconocido como parte de los deberes del sector salud. se observó que la mayoría de las cuidadoras, después de un tiempo de estar al cuidado de un anciano enfermo, y luego de hacer los ajustes necesarios en el estilo de vida, asumen el rol de cuidado con satisfacción y humildad; algunas abrigan la esperanza de un reconocimiento futuro cuando serán premiadas por la dedicación a esa persona, a quien le han dado sus mejores cuidados. también se concluyó que es importante considerar cómo el cuidado formal y el familiar tienen en común el objetivo de contribuir con soluciones oportunas y efectivas a un problema de salud existente, aportando cada uno desde sus posibilidades y recursos, por ello es imperativo que, como lo expresan francisco del rey y mazarrasa “el sistema formal debe reorientar su oferta de servicios y contemplar en todas sus acciones a los cuidadores familiares como agentes de salud”; en este sentido, los profesionales de los sistemas formales de educación y servicio deben acercarse a quienes proveen el cuidado familiar de tal manera que puedan conocer sus ejecutorias y también sus necesidades para, con base en ellas, desarrollar planes de acción tendientes a su cualificación y apoyo asistencial. lo anterior guarda correspondencia con lo sugerido por escudero rodríguez y cols., “las cuidadoras informales merecen y reclaman que desde el sistema de salud empecemos a tenerlas en cuenta”. en este sentido, por todo lo expuesto, el sistema formal y como parte de él, los profesionales de la enfermería, deben considerar y dar repuestas efectivas a estos problemas. ahora bien, las consecuencias del rol de cuidadora en la calidad de su vida, como la soledad, el aislamiento social, la sobrecarga del trabajo habitual, el deterioro de su salud física y mental, y el olvido de sí, entre otras, no obstante ser desafortunadas por lo que representaron para su diario vivir, fueron superadas con apoyo en las tradiciones y los valores de su cultura, en tanto les significó también satisfacción con el deber cumplido, sentirse útiles, poder retribuirle a quien en otro momento le aportó a su vida, y los aprendizajes que adquirieron sobre el mundo del cuidado. pero, ¿será posible, en el marco del sistema general de seguridad social en salud de colombia, que el cuidado familiar, las cuidadoras familiares y los ancianos que requieren cuidado en el hogar, sean considerados como un fin y una meta de las acciones de salud? interrogante que más que respuestas teóricas espera en un futuro muy próximo acciones como la institucionalización de redes de apoyo al cuidado familiar, a las cuidadoras y a los adultos mayores. agradecimientos al comite para el desarrollo de la investigación universidad de antioquia (codi) y al municipio de envigado por el apoyo financiero a este proyecto. a las cuidadoras familiares por su inmensa sencillez y franqueza al compartir su experiencia de vida al cuidado de un adulto mayor, cuyas descripciones permitieron correr otro poco el velo que cubre el mundo del cuidado familiar. a la profesora gloria alcaraz, por sus generosas y oportunas enseñanzas en esta difícil pero fascinante aventura de la investigación cualitativa. 1. dulcey-ruiz e, mantilla g, carvajal lm, camacho g. envejecimiento comunicación y política. bogotá: ministerio de comunicaciones y centro de psicología gerontológica (cepsiger); 2004, p. 33. 2. cuesta c. cuidado artesanal: la invención ante la adversidad. medellín: editorial universidad de antioquia; 2004, p. 2. 3. sánchez b. la experiencia de ser cuidadora de una persona en situación de enfermedad crónica. invest. educ. enferm. 2001; 19(2): 36-49. referencias 4. soldo bj, agree em y wolf da. the balance between formal and informal care. in: ory mg, bond k. aging and health care londres: rouledge, p. 193-216. citado por domínguez c. familia, cuidados informales y políticas de vejez. en: staab as, hodges lc. enfermería gerontológica. méxico: mcgraw hillinteramericana; 1998, pp. 464-475. 5. montoro j. las consecuencias psicosociales del cuidado informal a personas mayores. revista internacional de sociología 1999; (23): 22. revista aquichan issn 1657-5997 52 año 6 vol. 6 nº 1 (6) chía, colombia octubre 2006 6. artaso b, goñi a, huici y, gómez ar. sobrecarga del ciudador informal del paciente con demencia institucionalizado. geriatrica 2002; 18 (6): 35-39. 7. muecke m a. sobre la evaluación de las etnografías. en: morse j. (ed.). asuntos críticos en los métodos de investigación cualitativa. medellín: editorial universidad de antioquia; 2003, pp. 233-238. 8. morse jm (ed.). qualitative health research. sage publications inc.; 1992. 9. nigenda g, langer a. (eds.). métodos cualitativos para la investigación en salud pública. perspectivas en salud pública. méxico; 1995. 10. taylor sj, bogdan r. introducción a los métodos cualitativos de investigación. la búsqueda de significados. barcelona: ediciones paidos; 1992, p. 34. 11. boyle j. estilos de etnografía. en: asuntos críticos en los métodos de investigación cualitativa. medellín: editorial universidad de antioquia; 2003, p. 193. 12. coelho mi y amante ln. quaalidade de vida: reflexao de enfermeiras. texto & contexto enfermagem 1999; (3): 11. 13. patricio z. métodos qualitativos de pesquisa e de educação participante como mediadores na construção da qualidade da vida: novos paradigmas, outros desafios e compromisos sociais. texto & contexto 1999; 8(3): 56. 14. marín j, adsuara mj, bernat a, avariento b, montes p, et al. pacientes y calidad de vida. evolución tras el alta de uci. rol de enfermería 1995; 18(202): 24. 15. canam c, acorn s. quality of life for family caregivers of peopel with chronic health problems. rehabilitation nursing 1999; 24(5): 194. 16. giraldo c, franco g, corre ls, salazar mo y tamayo a. cuidadores familiares de ancianos: quiénes son y cómo asumen este rol. artículo en proceso de publicación por parte de la revista de la facultad de salud pública, universidad de antioquia, medellín, colombia; 2005. 17. weller b, wells r. diccionario de enfermería. 21 ed. madrid: interamericana mcgraw-hill; 1995, p. 365. 18. diccionario nuevo espasa ilustrado. espasa calpe s.a.; 2005, p. 1207. 19. runes d (ed.). diccionario de filosofía. 3 ed. grijalbo; 1969, p. 338. 20. diccionario nuevo espasa ilustrado. espasa calpe s.a. 2005; p. 11. 21. weller b, wells r. diccionario de enfermería. 21 ed. madrid: interamericana mcgraw-hill; 1995, p. 23. 22. biurrun a. intervención grupal con familiares cuidadores de enfermos de alzheimer. geriátrika 2003; 19(2): 35-39. 23. heierle c. cuidando entre cuidadores. intercambio de apoyo en la familia. granada: fundación index; 2004, pp. 30-40. 24. barrera l, pinto an, sánchez hb (eds.). el arte y la ciencia del cuidado. bogotá: unibiblos universidad nacional de colombia; 2002, pp. 247-252. 25. brugger w. diccionario de filosofía. 11 ed. barcelona: editorial herder; 1988, p. 88. 26. cuesta d. cuidado familiar en condiciones crónicas: una aproximación a la literatura. texto & contexto enfermagem (brasil) 2004; 13(1): 137-46. 27. flórez ja. el síndrome del cuidador. geriátrika 2002; 18(7): 22-26. 28. cibanal l, arce m. relación enfermera/paciente. alicante: publicaciones universidad de alicante; 1991, p. 24. 29. collière mf. promover la vida. madrid: mcgraw-hillinteramericana; 1997, p. 339. 30. james v. unwaged carers and the provision of health care. en: field d, taylor s (eds.). sociological perspectives on health: illness and health care. londres: blackwell science; 1998, p. 211-229, citado por cuesta c. cuidado artesanal: la invención ante la adversidad; 2004, p. 7. 31. panisello m, lasaga a, mateu ml. cuidadores principales de ancianos con demencia que viven en el hogar. gerokomos 2000; 11(4): 167-173. 32. shin dc, johnson dm. a vowel happiness as an overal assessment of the quality of life. in: social indicators research 1978; 5: 475-492. citado por bowling a. la medida de la salud. revisión de las escalas de calidad de vida de los cuidadores familiares. life quality among family carers 53 medida de la calidad de vida. barcelona: masson; 1994, p. 10. 33. runes d. diccionario de filosofía. caracas: grijalbo; 1994, p. 273. 34 sánchez a. ética: tratados y manuales. méxico: grijalbo; 1969, p. 57. 34. sánchez a. ética: tratados y manuales. méxico: grijalbo; 1969, p. 57. 35. morse et al. comportamiento contemporáneo del liderazgo. iv. philadelphia: lippincott; 1994, pp. 2541, citado por sánchez hb. habilidades de cuidado de los cuidadores de personas en situación de enfermedad crónica. en: barrera l, pinto n, sánchez b (eds.). el arte y la ciencia del cuidado. bogotá: unibiblos; 2002, p. 374. 36. 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"!�a, #2� � � b����� &4� ������ 7� ����������+� � ��� �=����� �������" ����� �� �����������+�� ���������, %�����$ �>>;� � �� 1 ana lucia lira pessoa de souza1 thalyta cássia de freitas martins2 thais martins pedrosa3 daniela guimarães ferreira da silva4 marianne regina silva potengy de mello5 camila drumond muzi6 raphael mendonça guimarães7 global and multidimensional symptom assessments in patients presenting abdominal neoplasms 1 orcid.org/0000-0002-8810-9937. instituto nacional de câncer josé alencar gomes da silva, brasil. ana.pessoa@inca.gov.br 2 orcid.org/0000-0002-6225-7245. instituto nacional de câncer josé alencar gomes da silva, brasil. thalyta.martins@inca.gov.br 3 orcid.org/0000-0001-7199-6157. instituto nacional de câncer josé alencar gomes da silva, brasil. thais.pedrosa@inca.gov.br 4 orcid.org/0000-0001-9296-7486. instituto nacional de câncer josé alencar gomes da silva, brasil. daniela.silva@inca.gov.br 5 orcid.org/0000-0001-9364-1656. universidade federal do estado do rio de janeiro. brasil, marianne.potengy@fiocruz.br 6 orcid.org/0000-0002-5567-0437. instituto nacional de câncer josé alencar gomes da silva, brasil. camila.muzi@inca.gov.br 7 orcid.org/0000-0003-1225-6719. fundação oswaldo cruz, brasil. raphael.guimaraes@fiocruz.br received: 15/07/2018 sent to peer reviewers: 11/09/2018 accepted by peers: 14/01/2018 approved submission: 15/01/2019 doi: 10.5294/aqui.2019.19.1.4 to reference this article / para citar este artículo / para citar este artigo lira al, de freitas tc, martins t, guimarães d, silva mr, drumond c, guimarães rm. global and multidimensional symptom assessments in patients presenting abdominal neoplasms. aquichan 2019; 19(1): e1914. doi: 10.5294/aqui.2019.19.1.4 abstract objective: to evaluate symptoms among patients with abdominal cancer and associated factors. materials and methods: a cross-sectional study with 100 patients. the prevalence of symptoms was evaluated through the memorial symptom assessment scale (msas) and its association with demographic and clinical variables using chi-square and anova tests. results: the most prevalent symptoms were weight loss (64.0 %), pain (56.0 %), dry mouth (50.0 %), “i do not look more myself” (48.0 %) and lack of energy (45.0 %). there was a significant difference between sex and high-frequency (phys-h) (p = 0.001) and low-frequency (phys-l) physical symptoms (p = 0.004), and for general scale (tmsas) (p = 0.002); (p = 0.001), general range (p = 0.027) and borderline significance for the año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1914 theme: chronic care. contribution to the area: the care prescribed to the patient with abdominal cancer should be based on evidence. the occurrence of these symptoms should consider certain dimensions, rather than observed in isolation. thus, it is important to identify instruments that can aggregate these symptoms in these dimensions, and, from the diagnosis, the plan of care can be prescribed more effectively and efficiently. for this reason, it is believed that the present study brings a new way of approaching the symptoms of patients with this disease. from the methodological point of view, this is an innovative proposal. in the theoretical scope, scientific evidence of what characteristics are most common to these patients is presented, which helps the nursing professional to perform more accurate clinical evaluations. http://orcid.org/0000-0002-8810-9937 mailto:ana.pessoa@inca.gov.br http://orcid.org/0000-0002-6225-7245 mailto:thalyta.martins@inca.gov.br http://orcid.org/0000-0001-7199-6157 mailto:thais.pedrosa@inca.gov.br http://orcid.org/0000-0001-9296-7486 http://orcid.org/0000-0001-9364-1656 mailto:marianne.potengy@fiocruz.br http://orcid.org/0000-0002-5567-0437 mailto:camila.muzi@inca.gov.br http://orcid.org/0000-0003-1225-6719 mailto:raphael.guimaraes@fiocruz.br http://dx.doi.org/10.5294/aqui.2019.19.1.4 http://orcid.org/0000-0002-8810-9937 http://orcid.org/0000-0002-6225-7245 http://orcid.org/0000-0001-7199-6157 http://orcid.org/0000-0001-9296-7486 http://orcid.org/0000-0001-9364-1656 http://orcid.org/0000-0002-5567-0437 http://orcid.org/0000-0003-1225-6719 http://dx.doi.org/10.5294/aqui.2019.19.1.4 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1914 global scale (gdi) (p = 0.051); high-frequency physical symptoms (p = 0.022), low-frequency physical symptoms (p = 0.034) and the overall scale (p = 0.034). there was one major complaint regarding the severity of high-frequency physical symptoms in patients with liver cancer (p = 0.018). conclusion: symptoms of physical and psychological aspects in cancer patients were associated with gender, race, marital status and tumor location. there is a need for tools to assess symptoms and enable health professionals to intervene more effectively. keywords (source: decs) symptom assessment; medical oncology; abdominal neoplasms; surveys and questionnaires; signs and symptoms. evaluación global y multidimensional de síntomas en pacientes con neoplasias abdominales resumen objetivo: evaluar los síntomas entre los pacientes con cáncer abdominal y factores asociados. materiales y método: estudio transversal realizado con 100 pacientes. se evaluó la prevalencia de los síntomas, a través de la memorial symptom assessment scale (msas), y su asociación con variables demográficas y clínicas, por medio de pruebas de chi cuadrado y anova. resultados: los síntomas más prevalentes fueron pérdida de peso (64,0 %), dolor (56,0 %), boca seca (50,0 %), “no me siento yo mismo” (48,0 %) y falta de energía (45,0 %). hay una diferencia significativa entre el sexo y los síntomas físicos de alta frecuencia (phys-h) (p = 0,001) y de baja frecuencia (phys-l) (p = 0,004), y para escala general (tmsas) (p = 0,002); entre la raza y los síntomas físicos de alta frecuencia (p = 0,008), la escala general (p = 0,027) y la significancia limítrofe para la escala global (gdi) (p = 0,051); el estado civil y los síntomas físicos de alta frecuencia (p = 0,022), los síntomas físicos de baja frecuencia (p = 0,034) y la escala general (p = 0,034). hubo una queja mayor en relación a la gravedad de los síntomas físicos de alta frecuencia en pacientes con cáncer de hígado (p = 0,018). conclusión: síntomas de aspectos físicos y psicológicos en pacientes oncológicos se han asociado al sexo, la raza, el estado civil y la localización del tumor. existe la necesidad de instrumentos para que los síntomas sean evaluados y permitan que los profesionales de la salud puedan intervenir de manera más eficaz. palabras clave (fuente: decs) evaluación de síntomas; oncología médica; neoplasias abdominales; encuestas y cuestionarios; signos y síntomas. 3 global and multidimensional symptom assessments in patients presenting abdominal neoplasms l ana lucia lira pessoa de souza and others avaliação global e miltidimensional de sintomas em pacientes com neoplasias abdominais resumo objetivo: avaliar sintomas entre pacientes com câncer abdominal e fatores associados. materiais e método: estudo transversal realizado com 100 pacientes. foi avaliada a prevalência dos sintomas, através do memorial symptom assessment scale (msas), e sua associação com variáveis demográficas e clínicas, por meio de testes de qui quadrado e anova. resultados: os sintomas mais prevalentes foram perda de peso (64,0 %), dor (56,0 %), boca seca (50,0 %), “eu não pareço mais eu mesmo” (48,0 %) e falta de energia (45,0 %). há diferença significativa entre sexo e sintomas físicos de alta frequência (phys-h) (p = 0,001) e de baixa frequência (phys-l) (p = 0,004), e para escala geral (tmsas) (p = 0,002); entre raça e sintomas físicos de alta frequência (p = 0,008), escala geral (p = 0,027) e significância limítrofe para a escala global (gdi) (p = 0,051); estado civil e sintomas físicos de alta frequência (p = 0,022), sintomas físicos de baixa frequência (p = 0,034) e a escala geral (p = 0,034). houve uma queixa maior em relação à gravidade de sintomas físicos de alta frequência em pacientes com câncer de fígado (p = 0,018). conclusão: sintomas de aspectos físico e psicológico em pacientes oncológicos foram associados a sexo, raça, estado civil e localização do tumor. há necessidade de instrumentos para que os sintomas sejam avaliados e permitam que profissionais de saúde possam intervir de maneira mais eficaz. palavras-chave (fonte: decs) avaliação de sintomas; oncologia; neoplasias abdominais; inquéritos e questionários; sinais e sintomas. año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1914 4 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 introduction cancer, a collection of over 100 diseases that have in common disordered cell growth and the ability to invade tissues and organs, is a chronic-degenerative disease, is currently considered a public health problem in both developed and undeveloped countries that affects several dimensions of human life (1). in fact, chronic non-communicable diseases are responsible for most of the world’s deaths, and cancer is believed to be the major cause, becoming the main barrier to life expectancy evolution worldwide in the 21st century. currently, the burden of diseases associated with cancer indicates that it is the first or second cause of premature deaths (before the age of 70) in 52.9 % of the world’s countries, and 58.1 % in latin america (2). in brazil, cancer represents the second leading cause of death, and an estimated 600,000 new cases are expected for the 2018-2019 biennium. some of the most prominent cancer types are located in the abdominal area, such as the colon and rectum, stomach, liver and biliary tract (3). cancer is a stigmatized disease, presenting repercussions in society in general, and since it is a complex disease, from diagnosis to treatment, the patient suffering from this ailment presents symptoms that permeate the physical, material and even the emotional spheres (4). thus, symptoms presented by oncological patients comprise multiple dimensions, such as physical and psychological, and require a careful evaluation that comprises these various aspects (5). it should be noted that one symptom can influence the occurrence and the meaning of others. patients with uncontrolled symptoms present significant losses in quality of life. symptoms that are identified late and left untreated are directly related to changes in patient functional capacity, worsening of quality of life and repercussions in the reduction of the overall survival of these subjects. one of the clinical, diagnostic and social approaches in this context is the use of adapted scales and questionnaires. adapted scales are an effective way of measuring certain phenomena (6). the memorial symptom assessment scale (msas) was developed in 1994 with the aim of providing multidimensional information on a diverse group of physical and psychological symptoms common to oncology patients. it allows the evaluation of 32 physical and psychological symptoms and their frequency, severity and distress, through a scale of likert-type points. in addition, this instrument provides a more comprehensive method of symptom assessment and may be useful when information on symptoms is desirable, such as clinical trials or epidemiological studies (7). recently, it has been adapted for brazil (8, 9). in particular, abdominal cancer encompasses a diverse group of tumors that are classified according to location, with higher colon and stomach incidences (3). due to the diversity of affected organs and their specificities, patients with abdominal cancer may present multiple symptoms, which are likely to cause changes in physical and psychosocial structures. it is important to emphasize that patient symptoms vary according to the severity, frequency and duration of the disease (4). in this context, the aim of the study was to evaluate the symptoms presented by patients with abdominal cancer and their associated factors. methodology study design this is a cross-sectional study that used a set of data on symptom prevalence and treatment in patients presenting abdominal tumors treated at the national cancer institute (inca, for its initials in portuguese), located in southeastern brazil. it welcomes patients from all over the country. sample the convenience sample of this study included 100 adult subjects hospitalized between march and december 2016, equivalent to 82 % of the total patients in that period. inclusion criteria comprised patients aged 18 years or older with abdominal neoplasias admitted to the inca’s cancer hospital i (or inca/ hci). data collection was performed through the application of the msas-br scale in the form of individual interviews, after the patients were given previous information concerning the objectives of the research, agreed to participate in the study and signed of the informed consent form. due to the educational deficit of most of the participants, the chosen instrument consisted in an interview, replacing the self-applied questionnaire, as recommended in a previous study during the first stage of instrument validation (9). inclusion criteria favored the participation of patients over 18 years old, presenting cancers whose primary origin was the abdomen-pelvic region, including liver, stomach, colon, rectum and pancreas, regardless of staging. the exclusion criteria comprised patients with cognitive disorders previously evaluated through the mini-mental exam, those in a position to compromise 5 global and multidimensional symptom assessments in patients presenting abdominal neoplasms l ana lucia lira pessoa de souza and others the veracity of the answers and individuals presenting neoplasia or metastasis to the central nervous system (cns) whose information was obtained through medical records. for the collection of additional data, a form prepared by the authors was used, including sociodemographic and clinical information, such as age, sex, marital status, educational level, race, primary diagnosis, the presence of metastasis, device use and location (outpatient or inpatient). this information was obtained through patient interviews. another questionnaire included the memorial symptom assessment scale (msas). the msas is a 32-item evaluation tool developed to measure the prevalence of symptoms and three associated characteristics (frequency, severity and distress) concerning the physical and psychological aspects experienced by cancer patients in the week prior to the interview. symptom scores represent the means of three dimensions, where the highest symptom scores represent higher frequency, greater severity, and greater distress. the mean frequency and standard deviation distribution for each msas item was obtained. the msas symptom scale is further divided into subscales that assess psychological symptoms: (psych), comprising six items, (phys h), which evaluates physical high frequency symptoms, consisting of 12 items and (phys l), which evaluates physical symptoms presenting relatively low frequency, comprising 14 items. a fourth subscale containing four psychological symptoms and six physical symptoms is also present, which assesses the global distress index (gdi), which may present significant variations when applied, for example, to outand inpatients, and is considered the most useful subscale, in clinical terms. finally, an index that consists of the means between the three domains and all items (tmsas) was also applied. the subscales and their respective items are described in table 1. it is important to indicate that the subscale scores represent the means of their comprising items. the msas reveals good results regarding reliability and validity in the cancer population, as described in previous studies. the scale reliability was satisfactory in the retest tests. the kappa weighted index values obtained for each item of the scale ranged between 0.69 and 0.96. regarding the subscales, the index value was of 0.84 for high-frequency physical symptoms, 0.81 for lowfrequency physical symptoms, 0.81 for psychological symptoms, and 0.78 for the gdi (8. 9). it is important to highlight that the scale, because it comprises an inventory, does not present a cutoff point for patient classification. thus, its main objective is to describe symptom frequency and, when necessary, patient classification in studies are established, usually through the median presented in the surveys (9). table 1. description of the msas subscales subscales domain nº of items msas items phys h physical (high frequency) 12 2, 3, 6, 7, 8, 11, 13, 21, 22, 26, 27, 29 phys l physical (low frequency) 14 4, 9, 12, 14, 15, 17, 19, 20, 23, 25, 28, 30, 31, 32 psych psychic 6 1, 5, 10, 16, 18, 24 gdi global distress index 10 2, 3, 5, 6, 8, 16, 18, 21, 24, 29 tmsas total 32 1 to 32 source: rocha et al. (8) when a symptom is experienced, its score is determined by the mean intensity, frequency, and distress scores, or, when applicable, only by intensity and distress scores. thus, the scores for each subscale were calculated and the association between subscales, demographic variables (sex, age, education, race, marital status) and clinical status (tumor location, the presence of metastasis, type of care and presence of any device) were evaluated. an analysis of variance (anova) test was applied to the categorical variables and a statistical significance level of 95 % was accepted. the data analyses were performed using the spss statistical package, version 22. patients were approached in the abdomino-pelvic surgery ward, at a time when they were not vulnerable or in a situation that would compromise the decision to participate in the study. regarding ethical aspects, the study complied with the ethical and legal specifications of resolution 466/12, of the national health council/ministry of health, which regulates research involving human beings. the study was authorized by the inca ethics and research committee (cep), through a substantiated opinion number 863.339, on november 8, 2014, and does not involve any conflicts of interest. 6 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 results the study population presented a discrete male predominance (52.0 %), with little over half of the patients categorized in an age group of 60 years old or more (52.0 %). the majority (60.0 %) declared themselves white. a predominance of a high school level of education (49.0 %) was observed, with only 16.0 % of the interviewees at the university level. regarding marital status, a higher prevalence of married individuals was noted, representing 61.0 % of the population. considering tumor location, a higher frequency of colon tumors was observed, at 42.0 %, followed by stomach and rectum, both at 22.0 %. a total of 60.0 % of the patients did not present metastases (table 2). in general, concerning symptom frequency, the category representing low/medium severity was the most recurrent response of patients to most of the symptoms, when present. the most frequent symptoms were “shortness of breath” (66.7 %), “sadness” (65.8 %), “problems with sexual desire or activity” (65.0 %), “difficulty swallowing” (62.5 %) and “nervousness” (62.1 %). the less cited category was that representing low severity for most variables. regarding intensity, the category referring to “moderate” severity was the most frequent response. the highest percentages for this category were “diarrhea” (64.7 %), “problems with sexual desire or activity” (63.2 %), “lack of energy” (58 %), “concerns” (57.3 %) and “pain” (55.9 %). finally, with regard to distress, the prevalent category referred to average severity symptoms, with the highest percentage in this category comprising “difficulty in concentrating” (100 %), “sadness” (60.0 %), “mouth sores” (50.0 %), “itching” (50.0 %) and “dizziness” (47.4 %). the less cited category was that referring to the absence of distress (table 3). the most prevalent symptoms were “weight loss” (64.0 %), “pain” (56.0 %), “dry mouth” (50.0 %), “concerns” (49.0 %), “i do not seem like myself” (48.0 %) and “lack of energy” (45.0 %). the least prevalent symptoms were “itching” (12.0 %), “sweating” (11.0 %), “coughing” (11.0 %), “difficulty swallowing” (9.0 %), “difficulty concentrating” (6.0 %) and “mouth sores” (2 %). many patients reported not having symptoms. however, among those who did severity was high, since the means of the items, whether for intensity, frequency or distress, increased considerably when analyzing the group presenting symptoms separately (table 4). when assessing the differences in the score of total symptoms and subscales by variable category, no difference in symptom severity (totals and subscales) for age, schooling and the presence of metastasis was observed. regarding sex, a statistically significant difference was identified for high-frequency physical symptoms (phys-h) (p = 0.001), low-frequency physical symptoms (physl) (p = 0.004) and for the general scale (tmsas) (p = 0.002), with higher severity complaints among women. concerning race, significance was observed for high-frequency physical symptoms (p = 0.008) and the general scale (p = 0.027), and borderline significance was noted for the gdi (p = 0.051), with complaints of greater severity among blacks and mulattos. concerning marital status, statistically significant differences were found for high frequency physical symptoms (p = 0.022), low frequency physical symptoms (p = 0.034), and for the general scale (p = 0.034), with a higher complaint of severity among unmarried patients (single and widowed/separated). finally, more frequent complaints of the severity of high-frequency physical symptoms were observed for patients with liver cancer (p = 0.018) (table 5). table 2. clinical and demographic characteristics (n = 100) characteristic n (%) characteristic n (%) sex marital status male 52 (52.0) single 28 (28.0) female 48 (48.0) married 61 (61.0) age widow 11 (11.0) 20 39 years 4 (4.0) metastasis 40 59 years 44 (44.0) yes 40 (40.0) 60 years and more 52 (52.0) no 60 (60.0) race topograph white 61 (61.0) colon 42 (42.0) black 39 (39.0) stomach 22 (22.0) literacy liver 5 (5.0) fundamental 35 (35.0) pancreas 7 (7.0) high school 49 (49.0) peritoneum 2 (2.0) graduate 16 (16.0) rectum 22 (22.0) source: own elaboration. 7 global and multidimensional symptom assessments in patients presenting abdominal neoplasms l ana lucia lira pessoa de souza and others table 3. frequency of the msas symptoms concerning frequency, intensity and distress (n = 100) item p re va le nc e (% ) frequency (%) intensity (%) distress (%) 1 2 3 4 1 2 3 4 0 1 2 3 4 1. difficulty concentrating 6.0 14.4 57.1 0.0 28.6 57.1 42.9 0.0 0.0 0.0 0.0 100.0 0.0 0.0 2. pain 56.0 6.9 60.3 20.7 12.1 8.5 55.9 30.5 5.1 0.0 26.8 32.1 23.2 17.9 3. lack of energy 45.0 2.0 58.0 20.0 20.0 15.7 58.8 23.5 2.0 0.0 17.8 28.9 22.2 31.1 4. cough 11.0 26.7 53.3 13.3 6.7 68.8 18.8 12.5 0.0 18.2 63.6 9.1 0.0 9.1 5. feeling nervous 29.0 6.9 62.1 13.8 13.8 18.5 51.9 22.2 7.4 3.4 24.1 31.0 10.3 31.0 6. dry mouth 50.0 10.3 58.6 17.2 13.2 19.6 50.0 19.6 10.7 2.0 28.0 30.0 18.0 22.0 7. nausea 42.0 10.9 58.7 21.7 8.7 15.6 53.3 17.8 13.3 0.0 28.6 26.2 11.9 33.3 8. feeling drowsy 35.0 15.4 43.6 35.9 5.1 18.9 48.6 24.3 8.1 11.4 17.1 34.3 17.3 22.9 9. numbness/tingling in hands/ feet 20.0 15.0 50.0 15.0 20.0 31.8 45.5 18.2 4.5 5.0 40.0 25.0 15.0 15.0 10. difficulty sleeping 39.0 9.1 52.3 20.5 18.1 20.0 52.5 27.5 0.0 0.0 17.9 38.5 20.5 23.1 11. feeling bloated 44.0 4.0 60.0 15.0 30.0 14.3 51.0 26.2 8.2 0.0 11.4 38.6 27.3 22.7 12. problems with urination 10.0 11.1 55.6 33.3 0.0 55.6 33.3 11.1 0.0 0.0 0.0 40.0 30.0 30.0 13. vomiting 22.0 10.3 55.2 34.5 0.0 17.9 46.4 32.1 3.6 0.0 9.1 36.4 27.3 27.3 14. shortness of breath 13.0 6.6 66.7 26.7 0.0 42.9 42.9 14.3 0.0 0.0 7.7 46.2 23.1 23.1 15. diarrhea 12.0 17.6 35.3 41.2 5.9 23.5 64.7 11.8 0.0 0.0 25.0 33.3 33.3 8.3 16. feeling sad 40.0 7.9 65.8 23.7 2.6 18.4 42.1 34.2 5.3 0.0 5.0 60.0 15.0 20.0 17. sweats 11.0 16.7 50.0 25.0 8.3 33.3 38.4 27.8 0.0 9.1 27.3 27.3 9.1 27.3 18. worrying 49.0 7.5 52.8 26.5 13.3 8.7 57.3 32.6 4.3 2.0 8.2 42.9 16.3 30.6 19. problems with sexual interest or activity 20.0 10.0 65.0 20.0 5.0 15.8 63.2 21.1 0.0 0.0 10.0 30.0 10.0 50.0 20. itching 12.0 25.0 50.0 25.0 0.0 40.0 46.7 13.3 0.0 0.0 8.3 50.0 0.0 41.7 21. lack of appetite 40.0 4.5 56.8 25.1 13.6 11.6 44.2 39.5 4.7 2.2 15.0 27.5 27.5 27.5 22. dizziness 19.0 21.7 60.9 13.1 4.3 28.6 52.4 19.0 0.0 0.0 5.3 47.4 10.5 36.8 23. difficulty swallowing 9.0 0.0 62.5 0.0 37.5 10.0 50.0 40.0 0.0 0.0 0.0 33.3 22.2 44.4 24. feeling irritable 26.0 11.1 70.4 7.4 0.0 15.4 53.8 30.8 0.0 0.0 11.5 38.5 23.1 26.9 25. mouth sores 2.0 33.3 66.7 0.0 0.0 0.0 0.0 50.0 50.0 0.0 26. change in the way food tastes 21.0 12.0 68.0 12.0 8.0 4.8 4.8 33.8 23.8 33.3 27. weight loss 64.0 6.9 61.1 29.2 2.8 10.9 20.3 18.8 23.4 26.6 28. hair loss 16.0 16.7 75.0 8.3 0.0 6.3 31.3 25.0 12.5 25.0 29. constipation 27.0 3.1 59.4 34.4 3.1 0.0 7.4 22.2 37.0 33.3 30. swelling of arms or legs 24.0 22.2 51.9 25.9 0.0 0.0 16.7 45.8 25.0 12.5 31. "i don't look like myself" 48.0 12.0 48.0 38.0 2.0 0.0 4.2 12.5 31.3 52.1 32. changes in skin 30.0 6.9 69.0 24.1 0.0 0.0 10.0 23.3 10.0 56.7 source: own elaboration. 8 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 table 4. summary of the msas test items statistics (n = 100) item frequency intensity distress with symptoms total with symptoms total with symptoms total mean sd mean sd mean sd mean sd mean sd mean sd 1. difficulty concentrating 2.43 1.13 0.17 0.68 1.43 0.53 0.10 0.38 2.00 0.00 0.12 0.47 2. pain 2.38 0.79 1.38 1.32 2.32 0.70 1.37 1.26 3.32 1.06 1.86 1.83 3. lack of energy 2.58 0.83 1.29 1.42 2.12 0.68 1.08 1.16 3.67 1.10 1.65 1.97 4. cough 2.00 0.84 0.30 0.78 1.44 0.72 0.23 0.60 2.18 1.07 0.24 0.76 5. feeling nervous 2.45 0.94 0.71 1.22 2.19 0.83 0.59 1.06 3.41 1.26 0.99 1.69 6. dry mouth 2.34 0.84 1.36 1.33 2.21 0.88 1.24 1.28 3.30 1.16 1.65 1.85 7. nausea 2.28 0.77 1.05 1.25 2.29 0.89 1.03 1.29 4.67 7.89 1.96 5.58 8. feeling drowsy 2.31 0.80 0.90 1.23 2.22 0.85 0.82 1.19 3.20 1.30 1.12 1.71 9. numbness/tingling in hands/feet 2.40 0.99 0.48 1.05 1.95 0.84 0.43 0.90 2.95 1.19 0.59 1.29 10. difficulty sleeping 2.48 0.90 1.09 1.37 2.08 0.69 0.83 1.11 3.49 1.04 1.36 1.82 11. feeling bloated 2.38 0.66 1.19 1.28 2.29 0.81 1.12 1.28 3.61 0.97 1.59 1.91 12. problems with urination 2.22 0.66 0.20 0.66 2.56 0.72 0.23 0.76 3.90 0.87 0.39 1.20 13. vomiting 2.24 0.63 0.65 1.07 2.21 0.78 0.62 1.08 3.73 0.98 0.82 1.61 14. shortness of breath 2.20 0.56 0.33 0.81 1.71 0.72 0.24 0.65 3.62 0.96 0.47 1.26 15. diarrhea 2.35 0.86 0.40 0.95 1.88 0.60 0.32 0.75 3.25 0.96 0.39 1.10 16. feeling sad 2.21 0.62 0.84 1.14 2.26 0.82 0.86 1.21 3.50 0.87 1.40 1.80 17. sweats 2.25 0.86 0.27 0.79 1.94 0.80 0.35 0.82 3.18 1.40 0.35 1.09 18. worrying 2.45 0.82 1.30 1.36 2.33 0.70 1.07 1.25 3.65 1.07 1.79 1.98 19. problems with sexual interest or activity 2.20 0.69 0.44 0.93 2.05 0.62 0.39 0.85 4.00 1.12 0.80 1.68 20. itching 2.00 0.73 0.24 0.69 1.73 0.70 0.26 0.67 3.75 1.13 0.45 1.28 21. lack of appetite 2.48 0.79 1.09 1.34 2.37 0.75 1.02 1.27 3.63 1.12 1.45 1.91 22. dizziness 2.00 0.73 0.46 0.91 1.90 0.70 0.40 0.84 3.79 1.03 0.72 1.55 23. difficulty swallowing 2.75 1.03 0.22 0.79 2.30 0.67 0.23 0.72 4.11 0.92 0.37 1.21 24. feeling irritable 2.15 0.71 0.58 1.02 2.15 0.67 0.56 1.00 3.65 1.01 0.95 1.69 25. mouth sores 1.67 0.57 0.05 0.29 3.50 0.70 0.07 0.49 26. change in the way food tastes 2.16 0.74 0.54 1.00 3.76 1.13 0.79 1.62 27. weight loss 2.28 0.63 1.64 1.15 3.34 1.35 2.14 1.94 28. hair loss 1.92 0.51 0.23 0.64 3.19 1.32 0.51 1.28 29. constipation 2.38 0.60 0.76 1.16 3.96 0.94 1.07 1.83 30. swelling of arms or legs 2.04 0.70 0.55 0.97 3.33 0.91 0.80 1.49 31. "i don't look like myself" 2.30 0.70 1.15 1.25 4.31 0.85 2.07 2.24 32. changes in skin 2.17 0.53 0.63 1.03 4.13 1.10 1.24 1.99 note: sd stands for standard deviation. source: own elaboration. 9 global and multidimensional symptom assessments in patients presenting abdominal neoplasms l ana lucia lira pessoa de souza and others table 5. statistics for the symptom inventory subscales (msas) note: sd stands for standard deviation. source: own elaboration. characteristic phys-h phys-l psych gdi tmsas score sd p value score sd p value score sd p value score sd p value score sd p value sex male 23.5 13.97 0.001 9.49 4.67 0.004 18.93 16.70 0.318 25.02 17.10 0.061 16.85 9.13 0.002 female 34.2 17.11 15.21 6.21 22.30 16.89 31.33 16.18 23.60 11.73 age 20 39 years 24.22 16.58 0.720 9.40 12.67 0.607 11.80 14.05 0.300 18.64 16.89 0.464 15.30 13.11 0.644 40 59 years 27.77 17.77 13.29 11.45 23.04 16.65 27.49 15.32 20.67 12.19 60 years and more 29.79 15.30 11.56 8.75 19.12 16.99 29.25 18.16 19.97 9.67 race white 25.25 13.81 0.008 11.53 10.01 0.387 18.78 15.15 0.189 25.43 14.72 0.051 18.16 9.67 0.027 black 34.04 18.67 13.54 10.30 23.32 18.95 32.15 19.28 23.11 12.21 literacy fundamental 28.43 15.99 0.861 10.17 7.86 0.062 20.11 18.13 0.808 28.91 18.96 0.828 19.21 10.44 0.401 high school 29.44 17.63 11.25 21.54 17.04 28.18 16.89 21.52 11.93 graduate 26.88 13.74 9.37 18.48 13.35 25.78 12.09 17.66 8.52 marital status single 34.78 20.29 0.022 16.43 12.59 0.034 24.45 19.64 0.293 31.51 19.76 0.407 24.52 19.93 0.034married 25.12 13.96 10.58 8.83 19.55 15.76 26.34 16.09 18.07 9.63 widow 32.86 13.10 10.75 6.98 16.16 13.76 28.71 12.72 20.02 4.96 metastasis yes 30.54 18.43 0.355 11.91 6.58 0.794 23.05 17.23 0.226 29.05 16.34 0.632 20.88 12.54 0.559 no 27.43 14.87 12.45 7.41 18.80 16.43 27.38 17.34 19.57 9.81 topograph colon 25.99 5.48 0.018 11.29 10.33 0.471 20.99 18.71 0.549 27.25 18.55 0.205 18.77 11.12 0.051 stomach 33.33 16.58 12.10 11.59 20.95 16.71 29.83 18.79 21.99 12.58 liver 49.02 26.54 21.19 10.24 28.60 17.63 42.83 18.01 33.54 11.64 pancreas 31.44 15.32 11.22 7.56 26.58 14.53 24.34 11.91 20.90 8.52 peritoneum 31.25 34.37 15.92 6.10 20.83 29.46 43.12 2.05 23.89 2.89 rectum 23.42 9.77 12.12 8.88 15.53 12.31 24.26 10.87 17.05 7.48 10 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 discussion cancer patients consistently experience physical and psychological symptoms regarding both illness and treatment. when the symptoms are not identified (especially psychological ones, which will, consequently, not be treated) the illness will deteriorate the quality of life of cancer patients (10). studies by other authors corroborate the results obtained herein. regarding symptom frequency, for example, tranmer et al. (11) analyzed physical and psychological symptoms in cancer patients, and observed that the three most prevalent psychological symptoms were “concerns” (61 %), “difficulty sleeping” (55 %) and “sadness” (55 %), whereas physical symptoms consisted in “lack of energy” (83 %), “dry mouth” (82 %) and “pain” (78 %). similarly, kolankiewicz (12), when assessing the profile of 268 patients undergoing oncologic treatment for the validation of the md anderson symptom inventory (mdasi), with mean participant age of over 60, described that the frequent symptoms were “fatigue” (63.1 %), “difficulty remembering things” (56.2 %), “dry mouth” (54.9 %) and “concerns” (54.7 %). thus, even in the case of distinct populations, symptom similarities are observed. it should be noted that women have a subtler self-perception of health than men, and therefore, present more complaints concerning symptom severity. in this regard, dun et al. (13) state that women report higher levels of depression and anxiety compared to men, which is corroborated by miakowski et al. (14), who reported that higher rates of depression in females are due to the fact that women report their anxieties more easily than men. it is important to note that this perception can be divergent according to marital status, since married patients count on greater social support from their families. in fact, dun et al. (13) consider that social support directly affects patient quality of life. with regard to topography, liver cancer has been highlighted as the type of cancer whose symptoms are described as being of greater severity. in fact, this is a highly lethal topography. it is mainly related to the high incidence of unresectable metastatic disease in this group, which leads to poor prognoses. in addition, an aggressive management of disease symptoms and treatmentrelated symptoms is particularly critical in preserving patient functional status and quality of life (14). the main symptoms in this type of cancer, according to that study, are pain, fatigue and weight loss. regarding colon and rectum cancer, the different forms of therapeutic intervention may lead to a deconstruction of the patient’s self-image, as a result of colostomy, which alters patient quality of life, in addition to the most common symptoms, also observed herein, including fatigue and physical distress (15). it is important to note that the msas is restricted to describing the severity of 32 symptoms. a strong point of this study is the possibility of the analysis of a large scope of symptoms. however, several instruments are currently available for the evaluation of multiple symptoms, but differing in the number of assessed symptoms, level of measurement (ordinal, nominal, continuous, etc.) and the evaluation period to which they refer to (i.e. the last 24 hours, the last week, the last month, etc.). the most frequently applied are the symptom distress scale (sds), memorial symptom assessment scale (msas), rotterdam symptom checklist (rsc), edmonton symptom assessment (esas) and, more recently, the md anderson symptom inventory (mdasi) (16, 17). in addition, symptoms are usually manifested in combination with each other and should be investigated through multiple symptom assessment tools. studies demonstrate that combinations or groupings of symptoms are more important than individual symptoms, and that simultaneous symptoms are likely to be multiplicative in nature and have catalytic effect on one another (18). regarding this proposed analysis, the cluster concept has been proposed as a new direction to better understand the complexity of the multiple symptoms experienced by cancer patients. symptom clusters are defined as groups of at least two or three simultaneous symptoms related to each other (17, 18). in this sense, boeira et al. (18) carried out a systematized research and pointed out that symptom clusters comprise “neuropsychological” and “gastrointestinal” symptoms. the authors also emphasize that the symptoms have an effect on each other, and, when observed alone, are not specific and sensitive. thus, the evaluation of these combinations or clusters will present a direct impact on the quality of care provided to cancer patients (19, 20). therefore, cancer patients are prone to numerous symptoms due to the complexity of the disease and their own way of dealing with changes in their health status. transformations arising from the disease lead to both psychological and physical symptoms. therefore, it is extremely important for health professionals to identify these multiple symptoms, from the time of admission to discharge, in order to be able to provide direct care, and for patients who will benefit from the intervention, as symptom summaries allow for this care coverage. in order to do so, clinical protocols should be reviewed, so that this action may be incorporated into patient service routines. 11 global and multidimensional symptom assessments in patients presenting abdominal neoplasms l ana lucia lira pessoa de souza and others conclusions the present study aimed to evaluate the most frequent symptoms presented by patients diagnosed with abdominal cancer by applying the msas-br scale. symptoms were identified and their relationship with characteristics (such as tumor location, gender, age and marital status) were evaluated. the described symptoms, especially when applying the msas subscales, indicate the need for a view that goes beyond physical aspects, and that the psychological and behavioral repercussions that these symptoms generate should be exploited, which may present a significant impact on the quality of life of cancer patients. it is important to emphasize that cancer patients present symptoms that surpass the physical and material sence: it also affects the emotions of the patient. such symptoms are multifactorial and can be influenced from diagnosis to treatment. these patients require a holistic view from their health profes-sionals, as several of the symptoms may be related to each other. this indicates the importance of support instruments, so that symptoms may be evaluated in a contextualized manner, allowing health professionals to intervene more effectively and adequately, through a multidisciplinary team. conflict of interest: none was declared. references 1. bray f, colombet m, mery l, piсeros m, znaor a, zanetti r, et al., editors. cancer incidence in five continents. vol. xi (electronic version). lyon: international agency for research on cancer; 2017. available from: http://ci5.iarc.fr 2. bray f, ferlay j, soerjomataram i, siegel, torre la, jemal a. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca cancer j clin. 2018; 68: 394-424. doi: 10.3322/ 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10.1016/s0885-3924(03)00074-5 http://ci5.iarc.fr, acesso em dezembro 2018 http://dx.doi.org/10.3322/caac.21492 http://dx.doi.org/10.3322/caac.21492 http://dx.doi.org/10.1016/j.homp.2016.11.001 http://dx.doi.org/10.22034/apjcp.2018.19.4.1047 http://dx.doi.org/10.1093/jncimonographs/lgh008 http://dx.doi.org/10.1016/0959-8049(94)90182-1 http://periodicos.ufes.br/rbps/article/view/20584 http://dx.doi.org/10.1590/s1679-45082017ao3645 https://doi.org/10.1016/j.apnr.2016.10.002 http://dx.doi.org/10.1016/s0885-3924(03)00074-5 12 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 12. kolankiewicz a, domenico e, lopes lf, magnago t. validaзгo do inventбrio de sintomas do md anderson cancer center para a lнngua portuguesa. rev esc enferm usp . 2014; 48(6): 999-1005. doi: 10.1590/s0080-623420140000700006 13. dunn j, ng sk, holland j, aitken j, youl p, baade pd, et al.. trajectories of psychological distress after colorectal cancer. psychooncology. 2013; 22(8): 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from: http://www1.inca.gov.br/rbc/n_60/v04/pdf/10revisao-de-literatura-cluster-de-sintomas-e-cancer-na-pesquisa-em-enfermagem-revisao-sistematica.pdf 19. cooley me, siefert ml. assessment of multiple co-occurring cancer symptoms in the clinical setting. semin oncol nurs. 2016; 32(4): 361-72. doi: 10.1016/j.soncn.2016.08.003 20. kenzik km. health care use during cancer survivorship: review of 5 years of evidence. cancer. 2018; (epub ahead of print). doi: 10.1002/cncr.31852 http://pesquisa.bvsalud.org/enfermagem/?lang=pt&q=au:%22magnago, t%c3%a2nia solange bosi de souza%22 http://dx.doi.org/10.1590/s0080-623420140000700006 https://www.ncbi.nlm.nih.gov/pubmed/?term=dunn j%5bauthor%5d&cauthor=true&cauthor_uid=23125004 https://www.ncbi.nlm.nih.gov/pubmed/?term=ng sk%5bauthor%5d&cauthor=true&cauthor_uid=23125004 https://www.ncbi.nlm.nih.gov/pubmed/?term=holland j%5bauthor%5d&cauthor=true&cauthor_uid=23125004 https://www.ncbi.nlm.nih.gov/pubmed/?term=aitken j%5bauthor%5d&cauthor=true&cauthor_uid=23125004 https://www.ncbi.nlm.nih.gov/pubmed/?term=youl p%5bauthor%5d&cauthor=true&cauthor_uid=23125004 https://doi.org/10.1002/pon.3210 https://www.ncbi.nlm.nih.gov/pubmed/?term=sun vc%5bauthor%5d&cauthor=true&cauthor_uid=18842532 http://dx.doi.org/10.1188/08.cjon.759-766 https://dx.doi.org/10.1016%2fj.jgo.2015.04.001 https://dx.doi.org/10.1016%2fj.jgo.2015.04.001 http://dx.doi.org/10.1590/s0080-623420140000700006 http://dx.doi.org/10.1016/j.soncn.2016.08.004 http://dx.doi.org/10.1016/j.soncn.2016.08.004 http://www1.inca.gov.br/rbc/n_60/v04/pdf/10-revisao-de-literatura-cluster-de-sintomas-e-cancer-na-pesquisa-em-enfermagem-revisao-sistematica.pdf http://www1.inca.gov.br/rbc/n_60/v04/pdf/10-revisao-de-literatura-cluster-de-sintomas-e-cancer-na-pesquisa-em-enfermagem-revisao-sistematica.pdf http://dx.doi.org/10.1016/j.soncn.2016.08.003 http://dx.doi.org/10.1002/cncr.31852 08. la educacišn como proceso la educación como proceso holístico, la comunicación participativa y la motivación, principales elementos del cambio 23 leonor pardo novoa resumen para que colombia avance en su desarrollo social, político y cultural, se requiere un cambio radical en los procesos educativos actuales. hay que pensar no solo en una educación intelectual, sino en un proceso educativo holístico, que abarque todos los aspectos del ser humano: lo cognitivo, lo afectivo y lo social. para que ese proceso pueda producirse se requieren tres elementos fundamentales: 1. unidad en la concepción de lo que es educar. 2. una comunicación efectiva. 3. una motivación para el cambio. con estos tres elementos, los educadores, sea cual fuere el nivel en el que eduquen, podrán fijarse metas comunes, en lugar de trabajar de manera independiente; deberán trabajar con sus alumnos niveles de comprensión, análisis, síntesis y evaluación, necesarios para el avance científico, y lograrán en sus estudiantes el verdadero compromiso y la energía necesaria para vencer las dificultades que todo cambio genera. palabras clave educación holística, comunicación efectiva, motivación, integridad, superioridad del hombre. abstract for cultural, political and social advance in colombia, a radical change in a holistic educative process, is needed, containing all aspects of human being: knowledge, affection and social areas. to obtain this process three fundamental elements are needed: 1. unity in the conception of education. 2. effective communication. 3. motivation for change. with these three elements, the educators, of any level of education, may establish common rules, instead of working independently; level of comprehension, analysis, synthesis and evaluation will be worked with the students, necessary for the scientific advance, obtaining from their students truly compromise and energy to overcome the difficulties generated from change. key words holistic education, effective communication, motivation, integrity, men’s superiority. año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 24 uando hace algún tiempo tuve que leer, como ejercicio de análisis de un seminario, el resumen del documento titulado cartas desde la misión misión de ciencia, educación y desarrollo, me surgió la inquietud de aprovechar las ideas allí plasmadas, para analizar y sustentar, desde mi punto de vista, aquellos planteamientos que desde la educación se hallan consignados en la misión de la universidad, y que el programa de enfermería ha colocado en su proyecto educativo como elementos de gran importancia. con el ánimo de involucrar al lector en el tema del documento mencionado, me propongo hacer, en primera instancia, una corta descripción de su contenido, para luego plantear lo que considero pueden ser tres pilares fundamentales para el cambio educativo, que sin duda repercutirá positivamente en el tan ansiado cambio de las estructuras colombianas. ellos son: la educación como proceso holístico, la comunicación participativa y la motivación. el documento titulado cartas desde la misión nº 1, elaborado a solicitud del gobierno nacional, en 1994, por los diez denominados sabios1, describe en forma narrativa y poética los hechos y fenómenos de un proceso histórico-político vivenciado de manera general por el mundo, pero de manera particular por el pueblo colombiano, el cual, expresado grosso modo, se relaciona con la evolución que, a partir de la educación, deben lograr los países para afrontar acertadamente los retos del futuro. en sus cuatro primeros capítulos, el libro se dedica a presentar abiertamente el panorama de la situación que en materia de educación, ciencia y tecnología tiene colombia, y a plantear inquietudes sobre los puntos en los cuales esta problemática radica, sin olvidar el planteamiento de propuestas encaminadas, en primer término, a educar a los colombianos, entendiéndose este proceso como la formación de mentes cuestionadoras, analíticas, productoras de avance tecnológico, proceso que elevará la calidad de vida y permitirá el desarrollo integral y equitativo de una colombia, en la cual, la potencialidad de sus mentes se confunde con la riqueza de su ecología, para hacer posible cualquier utopía que se proponga. muy difícil resulta delimitar un texto único que describa la tesis central del documento. de una parte, desde el discurso de instalación, el ex presidente césar gaviria plantea la necesidad de establecer unas verdaderas y claras relaciones entre la educación, la ciencia y la tecnología, y esta idea es plasmada por el doctor llinás, cuando en el texto introductorio de su artículo habla sobre el desarrollo como avance económico, político y cultural; y cuando se refiere a la educación, puntualiza cómo, en los países desarrollados, la inversión a largo plazo y el mejoramiento de los sistemas formales de educación han sido los factores que han demostrado ser clave en el mejoramiento de la capacidad competitiva, del crecimiento económico y del desarrollo social en general. la alta calidad de la educación, afirma el doctor llinás, es determinante en la preparación de ciudadanos responsables y en la formación académica e integral. estos postulados, unidos a los planteamientos que en el capítulo 1 expresa gabriel garcía márquez, y a las recomendaciones de los capítulos finales del libro, muestran una relación relevante entre el cambio social requerido y la educación como órgano esencial en ese proceso, hecho a través del cual el lector puede percibir una unidad en torno a los planteamientos de la misión. es así como, a través del documento, se afirma de una u otra manera que la educación es el punto esencial y previo para lograr la producción de ciencia y tecnología, procesos sin los cuales colombia no podría entrar a competir honrosamente en el mundo futuro. sin embargo, desde mi punto de vista, el planteamiento que recoge todas las reflexiones de los autores y que se convierte en el eje central para el desarrollo del documento, está descrito por el doctor llinás en muy cortos espacios de su conferencia: “sin un sistema educativo que promueva la autoestima, la 1 eduardo aldana valdés, luis fernando chaparro, rodrigo gutiérrez duque, rodolfo llinás, marco palacios rozo, manuel elkin patarroyo, eduardo posada flórez, ángela restrepo moreno, carlos eduardo vasco y gabriel garcía márquez. la educación es el punto esencial y previo para lograr la producción de ciencia y tecnología, procesos sin los cuales colombia no podría entrar a competir honrosamente en el mundo futuro. la educación como proceso holístico, la comunicación participativa y la motivación, principales elementos del cambio 25 dignidad humana, el respeto a la vida y el acceso equitativo a ella, la creatividad y el reconocimiento científico, y que abra la posibilidad de incorporar nuevas conceptualizaciones, colombia sacrificará el potencial mental, físico, cultural y científico, así como las riquezas que posee. el patrimonio más importante de los colombianos son sus vidas y sus mentes, y la posibilidad de crear su historia y su memoria; este patrimonio actualmente se desaprovecha; es necesario encontrar mecanismos que permitan canalizarlo hacia el mejoramiento cuantitativo y cualitativo de la vida en colombia”2. pasando al plano del análisis estructural del texto, esta clara posición de los diez sabios, expresada en el libro cartas desde la misión misión de ciencia, educación y desarrollo, es sustentada por diferentes tipos de argumentos, en su mayoría basados en hechos y fenómenos del vivir político y social de la nación, los cuales en determinados momentos llevan al lector a reconocer la importancia y eficacia de los planes propuestos por el gobierno, pero que al ser contrastados con la realidad social crean grandes expectativas sobre la viabilidad de esta transformación, la cual debe ir dirigida más hacia la mente de cada colombiano y hacia el sentir de los grupos y conjuntos de la sociedad, que hacia el desarrollo per se de la tecnología. en este momento del texto es donde, sin apartarnos de la motivación y el optimismo que comunican los autores, pero conscientes a la vez de nuestras deficiencias en el área del saber, debemos iniciar un proceso de análisis aún más profundo, de causas y efectos a nivel educativo, para encontrar el punto clave de partida que nos permita involucrarnos comprometidamente en la transformación del país, sin llevar por delante el lastre de una frustración. con este ánimo, y con la finalidad de propiciar un proceso de comunicación multidireccional, me propongo exponer a continuación algunos planteamientos, que podrían denominarse elementos fundamentales para el cambio educativo en colombia. al retomar en esta parte la problemática general planteada en el documento cartas desde la misión, y concentrando la atención más en el análisis de las causas que en los hechos que permanentemente observamos, es importante mencionar, en primera instancia y como primer elemento de cambio, la necesidad de unificar el concepto sobre lo que es educar, definición que por demás podría considerarse fundamental, pues de ella se derivan una serie de implicaciones, no solo para quienes educan sino para los educandos y para las instituciones educativas, que como entes académicos organizan los procesos y se comprometen con la sociedad a egresar, de tanto en tanto, grupos de profesionales, quienes supuestamente deben estar capacitados para continuar y mejorar el desarrollo del mundo en el cual viven. en el más amplio sentido de la palabra, educar es un proceso dirigido al hombre por el hombre; con esto estoy afirmando, primero, que se produce entre los seres superiores de la naturaleza, y que no es un hecho aislado o circunstancial, sino un conjunto de sucesos interrelacionados, y, segundo, que dentro de ese proceso hay que considerar como variables ineludibles todos aquellos componentes de que está hecho el hombre: mente, espíritu, corporeidad, afectos, emociones y sociabilidad, elementos que intervienen para determinar la ocurrencia o no de los sucesos, su grado de intensidad y la orientación hacia donde ellos se dirigen. es decir, hay que educar al hombre en su totalidad, o sea, holísticamente. “el hombre es un animal racional y comparte con los demás animales irracionales la facultad de la sensación y el apetito sensitivo, mientras que tiene de común con los ángeles el intelecto y la voluntad, que son facultades superiores. por el entendimiento el hombre conoce la verdad y por la voluntad desea o ama aquellos objetos que el entendimiento declara buenos. la voluntad es una facultad libre, cuya acción depende de nosotros mismos, de tal manera que ningún objeto creado puede obligarla a actuar”3. es por eso que educar, desde la óptica mencionada, en donde se totaliza la integridad y la superioridad del hombre, implica la ocurrencia libre y consciente de innumerables y permanentes fenómenos prácticamente imposibles de manejar y analizar separadamente, y que es el hombre mismo quien tiene la potencialidad de hacerlo, permitiéndose para sí, y para los demás de su especie, la realización de un proceso comunicativo activo, en donde hay un intercambio de ideas, argumentos, posturas, y en el cual, mediante un dar y recibir, el hombre pone a prueba sus conocimientos, los afianza o modifica, y de esta manera desarrolla su propia identidad, conformada esta por una sutil combinación de las influencias que él ejerce y las que recibe4. 2 llinás, r. cartas desde la misión, pág. 18, párrafo nº 2. 3 bonylan, eugene. en dificultades en la oración mental, pág. 29. 4 miller. en el prólogo del libro la persuasión en la comunicación, pág. 15, párrafo nº 2. la educación es un proceso del hombre para el hombre. año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 26 si aceptamos lo anterior, educar resulta ser un proceso difícil; sin embargo, por más complejo que resulte el asunto de educar, es necesario abordarlo por cualquiera de sus partes, y para este caso particular me anima la inquietud de iniciar el análisis por aquel aspecto que no solo se vivencia a través de nuestra historia, sino que se ha convertido en la inquietud permanente de quienes con conciencia del papel de educadores nos cuestionamos la falta de mentes críticas e inquietas, que generen posicionamientos de fondo y compromiso para llevar a cabo el cambio personal, y permitir a los demás la realización de un verdadero proceso educativo, tema central del documento producido por la misión y punto de partida del presente escrito. en esta línea de ideas y a partir del concepto de educar ya expuesto, creo pertinente citar el que considero es el segundo elemento fundamental para el cambio educativo en colombia, el cual a su vez explicaría, en parte, por qué los esfuerzos por mejorar la calidad de la educación en nuestro país han resultado, en términos generales, fallidos, y solo podemos contar en la actualidad con brotes aislados de cambio, muchos de los cuales aún están en la etapa de experimentación, y sus posibles buenos resultados solo nos enriquecerán en un mediano plazo. el punto en mención se denomina la comunicación efectiva. tradicionalmente, la comunicación se ha concebido como un proceso lineal: un emisor que genera un mensaje, el medio o medios que lo conducen y un receptor que percibe, decodifica e interpreta a su manera el contenido del insumo y, en consecuencia, lo toma o lo deja, según lo considere compatible o incompatible, factible o irrealizable, motivante o carente de interés. esta comunicación lineal difícilmente afecta todos los elementos constitutivos del hombre: mente, espíritu y cuerpo, y, por consiguiente, las reacciones que se producen en quien recibe el mensaje provienen, a su vez, solamente del elemento afectado, y cuando logra afectar más de uno, no permite el fluir de la comunicación en un sentido bi o multidireccional. una persona inmersa en las circunstancias particulares del medio ambiente que en ese momento la rodea, y afectada generalmente en uno solo de los aspectos que la conforman, genera reacciones y resultados parcializados, y a consecuencia de ellos actúa. vista de esta manera, la comunicación, que denomino lineal, sirve para transmitir noticias, exponer teorías, contar experiencias y muchas otras cosas más, pero siempre en forma unidireccional, sin promover la acción de respuesta de uno o varios interlocutores; por consiguiente, está lejos de ser el proceso interactuante en el cual el hombre establece un circuito de dar y recibir, en el que los mensajes del uno estimulan las respuestas del otro, y se genera un permanente fluir de ideas, posiciones y argumentos, que, como ya lo decía, son los elementos que van a permitir que los interlocutores enriquezcan sus conocimientos, fortalezcan y afiancen sus ideas, y se vayan formando sus propios criterios de acción y compromiso, sin que esto implique, en un momento dado, la aceptación o el rechazo total de las posiciones de su interlocutor. sin este círculo, sin esta reciprocidad, sin permitirnos compartir las ideas y posiciones de manera abierta y desprevenida, la comunicación continuará siendo el mecanismo por el cual los seres humanos emitimos mensajes que solo pretenden influir en los demás para obtener de ellos una respuesta generalmente primaria, manejable a su vez con otras influencias o mensajes, que posiblemente pasen de largo, sin hacer el más mínimo aporte al enriquecimiento del hombre. en efecto, si la comunicación continúa siendo lineal y si no cambiamos los mensajes persuasivos unidireccionales por otras formas de comunicación interactuante, es posible que el hombre pensante del cual hablamos, el hombre que posee mente cuestionadora y voluntad libre, no solo permanezca desmotivado ante el deseo de cambio que a diario se predica, sino que, al contrario de lo que se espera, genere un rechazo a los mensajes especulativos o a las disposiciones de mando, y cree para sí y para los demás, argumentaciones defensivas, hecho que está muy lejos de ser el método adecuado para lograr que se produzca un proceso educativo en la forma como se describió al inicio de este escrito, cuando se exponían los conceptos y recomendaciones de los diez actores de cartas desde la misión. la educación tradicional colombiana, en la cual se utilizan con frecuencia razones o argumentos retomados de personajes de la historia a quienes se les atribuye la cientificidad, la razón de una argumentación y el reconocimiento de poseer la verdad inmodificable de una ciencia determinada, está muy ligada a la comunicación lineal, en la cual el receptor recibe los mensajes, pero carece de las oportunidades para poner en común con su emisor sus propias interpretaciones. este es posiblemente el mensaje que entre líneas percibo, al leer las frases ...el patrimonio más importante de los colombianos son sus vidas y sus mentes, y la posibilidad de crear su historia y su memoria... la educación como proceso holístico, la comunicación participativa y la motivación, principales elementos del cambio 27 enfatizadas de garcía márquez, al referirse al tipo de educación que poseemos: “una educación conformista y represiva, que parece concebida para que los niños se adapten por la fuerza”5, y también lo que, a su vez, genera mi propuesta de iniciar el cambio que el país necesita para su progreso, por la modificación radical de los sistemas utilizados para educar, y adoptar en su lugar un método que permita a los hombres avanzar en los procesos cognitivos, mediante una comunicación abierta que les genere ciencia y tecnología, que a su vez se traduzca en un cambio sociopolítico y económico. nuestra cultura educativa colombiana no ha avanzado como lo ha hecho en otros países. ya en las antiguas grecia y roma se enseñaba a comprender los argumentos persuasivos y a formarse los propios; y en la universidad de harvard del siglo xvii, los estudiantes tenían la oportunidad de estudiar argumentación y se les pedía que demostraran lo aprendido, adoptando una posición, defendiéndola o criticando las opiniones de los demás. “la confrontación de contrarios es un proceso fundamental de razonamiento”6. dicho lo anterior en otras palabras, parte del proceso de cambio educativo que se requiere en colombia debe centrarse en la modificación del mecanismo tradicional utilizado para educar, basado en la comunicación unidireccional, hacia la utilización de un método que promueva y facilite la puesta en común de ideas y planteamientos, para que todos aquellos interesados, o doctos en la materia, opinen y contrapongan sus propios planteamientos con los de los demás. de esta manera se ejercitan el análisis, la argumentación y el respeto por las nuevas ideas, así como la capacidad de cambiar de posiciones cuando la ciencia así nos lo demuestre. este proceso, aunque parezca solo mental, realmente llega a los demás elementos del ser humano, y de manera muy sutil el hombre va ejercitando y aprendiendo el control emocional, el respeto, la prudencia, entre otros tantos comportamientos, y va logrando un crecimiento integral, tanto personal como profesional. si este proceso no se da, continuaremos aceptando, promoviendo y asistiendo pasivamente al mismo espectáculo que por años hemos presenciado, de una educación impuesta, que solo genera la continuidad de la mediocridad intelectual y el retraso científico, social, político y moral de nuestro pueblo colombiano. para educar, a todo nivel, no bastan las normas administrativas y curriculares, ni las disposiciones legales que con tan buena voluntad genera el gobierno; es necesario permitirle al hombre convencerse de la importancia de su cambio, de la necesidad de ser el coautor de su aprendizaje y del requerimiento que el mundo le hace para que se comprometa con el bienestar del futuro, y esto solo podrá lograrse en la medida en que el hombre ponga al servicio de los demás su integridad de ser superior, y se creen espacios para conocer lo que pensamos acerca de algo, las motivaciones que nos mueven o las limitaciones que las experiencias negativas nos han dejado. el tercer elemento que propongo para el cambio educativo, que bien podría haber sido el primero, dada su importancia, tiene íntima relación con los dos anteriores, pero se deriva del aspecto psicológico, que como parte constitutiva del hombre le permite comprometerse emocionalmente en el desarrollo de empresas y cometidos de gran envergadura, aunque también se origina en aquella cualidad superior de su voluntad que lo lleva a actuar basándose en los hechos que su entendimiento declara como buenos. me estoy refiriendo ahora a la motivación, como punto de partida para lograr un cambio en el método educativo. para el desarrollo de este aspecto, conviene iniciar por la presentación de lo que para los estudiosos del tema significa la motivación, y hacer una breve relación de esta con el éxito que las personas y las instituciones alcanzan cuando del logro de metas se trata. motivación es una palabra derivada del vocablo latino movere, que significa mover. la motivación es la fuerza interna que permite iniciar, guiar y mantener un determinado comportamiento, hasta que se alcance la meta deseada. frederick herzberg dice: “la motivación me indica hacer algo, porque resulta importante para mí hacerlo”. por su parte, kelly afirma que la motivación “tiene algo que ver con las fuerzas que mantienen y alteran la dirección, la calidad y la intensidad de la conducta”. sin motivación inicial es muy difícil obtener una satisfacción al finalizar las acciones. las motivaciones difieren de un individuo a otro, evolucionan y pueden cambiar con el transcurso de los años, en la medida en que se alcancen las metas propuestas o estas se replanteen. 5 garcía márquez, gabriel. cartas desde la misión. 6 patkanis, a., y aronson, e. en la era de la propaganda, 1994. año 1 nº 1 • bogota, colombia octubre 2001 revista aquichan issn 1657-5997 28 en el ámbito académico, son factores de motivación, entre muchos otros, los retos, las innovaciones, la experimentación, el conocimiento que se obtiene, los beneficios de su aplicabilidad, los estímulos que se reciben, el trato del profesor y el reconocimiento grupal y familiar. las necesidades también motivan nuestras conductas; en cada etapa de la vida y a medida que se evoluciona, las necesidades cambian, y las que se van generando producirán el deseo y el impulso de producir nuevos comportamientos y de esforzarnos para satisfacerlas. a finales de los años sesenta, edwin locke presentó su teoría del establecimiento de metas, y afirmó que la intención de alcanzarlas es una fuente básica de motivación. las metas son importantes en cualquier actividad humana, ya que motivan, guían nuestros actos y nos impulsan a dar un mejor rendimiento. de esta forma, las personas se comprometen al máximo sin tener en cuenta el esfuerzo que ello les implique. las metas específicas motivan más que las de índole general; asimismo, las de naturaleza más difícil motivan más que las que se logran fácilmente. sin embargo, las metas deben plantearse como algo alcanzable, pues aquellas para cuyo logro se requieren esfuerzos sobrehumanos pueden disminuir la motivación, y si no se alcanzan, llevarán a una frustración. las necesidades de crecimiento propio se centran en el yo, e incluyen el deseo y la oportunidad de desarrollo y progreso personal. a esta categoría corresponden la autoestima y la autorrealización, mencionadas por maslow. estas necesidades se satisfacen solo cuando el individuo logra aprovechar al máximo sus potencialidades y se siente satisfecho con sus logros. aunque varias acepciones del vocablo motivación se han venido utilizando en la labor académica, y los docentes nos hemos esforzado permanentemente por motivar a los estudiantes para que aprendan, quiero, en un intento de cambiar de paradigma, hacer notar una diferencia, que aunque parece pequeña es de gran magnitud e importancia, por cuanto de ella pueden derivarse profundas modificaciones, que el proceso educativo colombiano necesita para lograr el verdadero cambio al que he venido refiriéndome desde el comienzo de este artículo. la diferencia radica en el uso que el verbo motivar debiera tener en el contexto educativo, y más específicamente cuando se hace referencia a los papeles que desempeñan el docente y el estudiante en el proceso, tan conocido en la academia, como enseñanza-aprendizaje. motivar, desde mi punto de vista y dentro del marco del aprendizaje, a cualquier nivel que este se lleve a cabo, debería conjugarse más como un verbo reflexivo, que como una decisión ejecutada desde afuera por alguien denominado maestro, quien en un empeño sobrehumano, se propone hacer algo para que los estudiantes desarrollen un sentimiento de entusiasmo, de gusto, de ilusión, que los conduzca a hacer o desarrollar acciones para el logro de sus objetivos de aprendizaje, o lo que en el lenguaje común manejamos como lograr que aprendan. si nos detenemos en las implicaciones que tiene el utilizar uno u otro vocablo, motivar a versus motivarse, podremos observar que: 1. motivar al estudiante implica, académicamente hablando, que el profesor, quien sabe algo sobre algo, haga esfuerzos a veces no muy específicos sino más bien generalizados, para que en todos sus alumnos nazca, se desarrolle o se reavive un interés por conocer o profundizar sobre un tema, que él como docente se ha comprometido a que manejen teórica o prácticamente. 2. si es el docente quien se propone “motivar”, es él quien debe hacer las acciones para que los discentes logren aprender, en contraposición a si se concibe este ejercicio como la acción que recae sobre el estudiante. a este, motivarse le implica hacer por sí mismo el esfuerzo de buscar, en los entornos en donde se mueve, los elementos que llenen sus expectativas y que le van a ayudar a iniciar y mantener el impulso, el gusto y el reto de aprender, para lograr sus metas personales y profesionales. 3. nadie motiva a nadie. la motivación es algo personal, que depende de un número de variables; por eso, en el intento de motivar, el docente se enfrenta a la necesidad de llegar a la individualidad de cada uno de sus estudiantes, para tocar sus fibras personales y lograr que cada uno, con las particularidades de su personalidad, con el bagaje de sus experiencias y sus intereses personales y profesionales, presentes y futuros, reaccione positivamente y aprenda sobre el tema en cuestión. por el entendimiento el hombre conoce la verdad y por la voluntad desea o ama aquellos objetos que en el entendimiento declara buenos. la educación como proceso holístico, la comunicación participativa y la motivación, principales elementos del cambio 29 bonylan, eugene. dificultades en la oración mental, 1989. miller, f. la persuasión en la comunicación, bogotá. pardo novoa, leonor. apuntes del seminario alemán dictado por el doctor carlos eduardo maldonado, universidad de la sabana, chía, 1996-1998. patkanis, a., y aronso, e. la era de la propaganda, bogotá, 1994. presidencia de la república de colombia, consejería para la modernización del estado colombiano. vasco, carlos eduardo, y otros. cartas desde la misión misión de ciencia, educación y desarrollo, zeta periodismo, bogotá, 1994. bibliografía lograr esto en grupos que sobrepasan los 40 ó 50 alumnos resulta casi una utopía, y por esta razón el profesor opta, en el mejor de los casos, por realizar procesos de motivación grupal, en los que posiblemente algunos estudiantes encuentren elementos de interés, pero que para otros solo son ejercicios de integración o de descanso, que caen bien dentro de la monotonía de una clase, pero que no son determinantes para un cambio de actitud ante la responsabilidad de su aprendizaje. 4. al contrario, motivarse implica, por una parte, que cada alumno, utilizando su propio conocimiento en cuanto a sus cualidades, debilidades, intereses y metas, asuma la responsabilidad de encontrar, en todo cuanto le brindan la institución y el profesor, los elementos significativos para su aprendizaje, en términos de beneficios presentes y futuros, de logro de metas, de satisfacciones personales, familiares, sociales, de elevación de su autoestima, y, por otra parte, que el profesor centre sus esfuerzos ya no en procesos para lograr que cada estudiante se motive, sino en la creación de ambientes adecuados y posibilidades y opciones de elección, en la presentación de posibles caminos que hay que seguir y en el señalamiento de diversidad de recursos que se han de utilizar, para que cada estudiante pueda elegir aquello que lo impulse a aprender no solo lo previsto en los cursos, sino todo lo que que le sirva de complemento, de respuesta a sus inquietudes y de oportunidades de incursionar en nuevos terrenos, que posiblemente no tenía previstos al inicio de su proceso de aprendizaje. cuando el profesor logra proveer entornos enriquecidos, los estudiantes no miden ni tasan los esfuerzos que deben realizar, y dedican a su aprendizaje todo el tiempo que este les exija. en este proceso de motivarse, el estudiante por lo general va más allá de las cortas metas impuestas en un curso determinado; logra ejercitar simultáneamente sus potencialidades cognitivas, físicas y sociales, de modo que alcanza su desarrollo integral, aspecto importante que se mencionó al inicio de este escrito. visto desde este ángulo, el acto de motivarse le corresponde ejecutarlo al estudiante, y le implica que, al igual que en el proceso de aprendizaje, sea él quien busque, dentro del contexto académico, las vías y mecanismos que le sean significativos, de manera que pueda, apoyado en ellos, mantener activa la fuerza íntima que se requiere en todo el tiempo que dure su proceso de aprendizaje. motivarse para aprender es un proceso endógeno, de desarrollo propio, que se apoya en los recursos del medio académico, incluida dentro de ellos la labor del profesor; en la medida en que el docente programa una estructura de clase y tareas o actividades en las cuales el estudiante pueda participar, tanto en el diseño como en su desarrollo y valoración, nacerá en él el deseo de experimentar y demostrar lo que aprendió. pero si no es así, sino que todo se le entrega hecho, ¿cómo logra el estudiante motivarse? de ahí que la responsabilidad del docente en el proceso de motivación y aprendizaje, por parte del estudiante, vaya más allá del papel tradicional y por demás monótono de repetidor y expositor, y se centra muy específicamente en el de ser proveedor de espacios, experiencias y recursos; en el de ser orientador de procesos, asesor, comunicador y generador de vivencias, que en un momento dado sirvan de patrón de análisis y experimentación y apoyen la toma de decisiones por parte de los estudiantes. cumplir con esta misión no le resultará fácil al docente, porque para poder realizarla a cabalidad deberá responderse qué es lo que debe proponer para que el estudiante encuentre motivos, y además, una vez iniciado el proceso, manejar una comunicación efectiva, necesaria para la orientación, el desarrollo de un pensamiento analítico, para la formación de criterios y la toma de posiciones argumentadas por parte del estudiante. de esta manera, él podrá irse formando como agente de cambio, desde el sector de su profesión y en los contextos sociales y políticos en donde se encuentre. retomando las ideas expuestas a lo largo de este artículo, vuelvo a insistir en la necesidad de un cambio radical en los procesos educativos expuestos por los autores del documento cartas desde la misión, para recalcar la importancia que tiene la unificación del concepto sobre educar, la comunicación efectiva y la automotivación en el logro de la meta que todas las grandes instituciones educativas se plantean: apoyar la formación de ciudadanos profesionales, que contribuyan al tan deseado cambio que colombia necesita para alcanzar el desarrollo científico, tecnológico y político. 438 martha dalila mendez-ruiz1 gerardo abdiel ortiz-moreno2 ivett adriana eligio-tejada3 brenda guadalupe yáñez-castillo4 miguel ángel villegas-pantoja5 percepción del riesgo y consumo de alcohol en adolescentes de preparatoria 1 orcid.org/0000-0002-4527-0296. facultad de enfermería, universidad autónoma de tamaulipas, méxico. mdmendez@docentes.uat.edu.mx 2 orcid.org/0000-0002-0167-9209. facultad de enfermería, universidad autónoma de tamaulipas, méxico. 3 orcid.org/0000-0001-7078-7564. facultad de enfermería, universidad autónoma de tamaulipas, méxico. 4 orcid.org/0000-0002-3203-8156. facultad de enfermería, universidad autónoma de tamaulipas, méxico. bgyanez@docentes.uat.edu.mx 5 http://orcid.org/0000-0001-9917-8439. universidad autónoma de tamaulipas, méxico. mapantoja@uat.edu.mx recibiddo: 22/07/2018 enviado a pares: 17/08/2018 aceptado por pares: 09/09/2018 aprobado: 26/09/2018 doi: 10.5294/aqui.2018.18.4.6 para citar este artigo / para citar este artículo / to reference this article méndez-ruíz md, ortiz-moreno ga, eligio-tejada ia, yáñez-castillo bg, villegas-pantoja ma. percepción de riesgo y consumo de alcohol en adolescentes mexicanos de preparatoria. aquichan 2018; 18(4): 438-448. doi: 10.5294/aqui.2018.18.4.6 resumen objetivos: determinar la relación entre la percepción del riesgo frente a las bebidas alcohólicas y el consumo de alcohol en adolescentes mexicanos e identificar la prevalencia de consumo de alcohol, el nivel de percepción de riesgo y los patrones de consumo de alcohol según el sexo. materiales y métodos: estudio cuantitativo de corte transversal y diseño correlacional, con una muestra probabilística de 251 adolescentes de nuevo laredo, méxico, en 2017. se utilizó una cédula de datos personales, el cuestionario de percepción de riesgo hacia el consumo de alcohol y el alcohol use disorders identification test (audit) o prueba de identificación de trastornos relacionados con el consumo de alcohol. resultados: un mayor nivel de percepción del riesgo frente al alcohol se relacionó con un menor consumo de dicha sustancia (rs = –.235, p <.001). la mayoría de los adolescentes consumieron alcohol alguna vez en la vida (59,0 %) y en el último año (51,8 %). la percepción del riesgo y los patrones de consumo de alcohol no fueron significativamente diferentes según el sexo. conclusiones: los hallazgos indican vulnerabilidad frente a la adicción al alcohol en la población de estudio. se invita a profundizar, mediante redes de trabajo multidisciplinario, en los niveles de percepción sobre los riesgos del uso de drogas, con miras a contribuir a la producción de conocimientos que guíen acciones preventivas dirigidas a hombres y mujeres adolescentes. palabras clave (fuente: decs) percepción; riesgo; consumo de bebidas alcohólicas; adolescente; prevención primaria. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 438-448 temática: promoción y prevención. aporte a la disciplina: el complejo fenómeno del consumo de drogas ha sido estudiado por disciplinas como la psicología, la sociología, la antropología y, en las últimas décadas, la enfermería, la cual lo aborda desde una perspectiva holística. este estudio provee información estadística actualizada sobre la percepción del riesgo que tienen los consumidores —actuales y potenciales— de alcohol, en especial los adolescentes. dicha información tiene un precedente en la frontera norte de méxico, zona históricamente afectada por el consumo de sustancias. así, los hallazgos pueden servir de apoyo en la toma de decisiones respecto al enfoque de los programas preventivos de enfermería, en particular de aquellos desarrollados en áreas geográficas con elevado consumo de sustancias, por lo cual se enfatiza en el establecimiento de redes de trabajo y desarrollo de estrategias para profundizar en la comprensión de las percepciones sobre los riesgos del uso de drogas. http://orcid.org/0000-0002-4527-0296 http://orcid.org/0000-0002-0167-9209 http://orcid.org/0000-0001-7078-7564 http://orcid.org/0000-0002-3203-8156 http://orcid.org/0000-0001-9917-8439 mailto:mapantoja@uat.edu.mx http://dx.doi.org/10.5294/aqui.2018.18.4.6 http://dx.doi.org/10.5294/aqui.2018.18.4.6 439 percepción del riesgo y consumo de alcohol en adolescentes de preparatoria l martha dalila mendez-ruiz y otros año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 438-448 risk perception and alcohol consumption in high school adolescents abstract objectives: to determine the relationship between alcohol-related risk perception and alcohol use in mexican adolescents and to identify alcohol use prevalence, risk perception level and alcohol use patterns by sex. materials and methods: cross-sectional quantitative study with correlational design using a probabilistic sample of 251 teenagers from nuevo laredo, mexico, in 2017. a personal data card, the alcohol use risk perception questionnaire and the alcohol use disorders identification test (audit) were employed. results: a higher alcohol-related risk perception level was associated with lower use of this substance (rs = –.235, p <.001). the majority of adolescents used alcohol sometime in their lives (59.0 %) and in the last year (51.8 %). risk perception and alcohol use patterns were not significantly different by sex. conclusions: findings suggest vulnerability to alcohol addiction in the study population. it is advisable to delve, through multidisciplinary research networks, into levels of perception of the risks of drug use to contribute to the production of knowledge that guides preventive actions for teenage men and women. keywords (source: decs) perception; risk; alcohol drinking; adolescent; primary prevention. 440 aquichan issn 1657-5997 eissn 2027-5374 percepção do risco e uso de álcool em adolescentes do ensino médio resumo objetivos: determinar a relação entre a percepção de risco para bebidas alcoólicas e o consumo de álcool em adolescentes mexicanos. também foi proposto identificar a prevalência do uso de álcool, determinar o risco percebido em relação ao álcool e os padrões de uso de álcool de acordo com o sexo. materiais e método: uma amostra probabilística de 251 adolescentes de nuevo laredo, méxico, foi selecionada em 2017. utilizou-se um registro de dados sociodemográficos, o questionário de percepção de risco de álcool e o audit. resultados: maiores níveis de percepção de risco sobre o uso de álcool foram relacionados ao menor consumo dessa substância (rs = –.235, p <.001). a maioria dos participantes ingeriu álcool pelo menos uma vez na vida (59%) e no último ano (51,8%). não houve diferenças significativas entre a pontuação de percepção de risco e padrões de uso de álcool de acordo com sexo. conclusões: os resultados indicam vulnerabilidade à dependência de álcool na população estudada. é feito um convite à colaboração em redes de trabalho multidisciplinares, para aprofundar o estudo do risco percebido em relação ao uso de drogas, a fim de contribuir para a produção de conhecimentos que orientem ações preventivas direcionadas a adolescentes. palavras-chave (fonte: decs) percepção; risco; consumo de bebidas alcoólicas; adolescente; prevenção primária. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 438-448 441 percepción del riesgo y consumo de alcohol en adolescentes de preparatoria l martha dalila mendez-ruiz y otros introducción los efectos psicoactivos producidos por el consumo de bebidas alcohólicas se deben a la presencia de etanol, sustancia que modifica las funciones cognitivas, perceptivas y motoras del ser humano, y a la cual se atribuye el potencial adictivo de dichas bebidas. por esta propiedad, el consumo de alcohol se ha convertido en un problema de salud pública, ubicado dentro de los cinco principales factores de riesgo para contraer una enfermedad, discapacidad o muerte (1). si bien el problema puede afectar a cualquier persona, existen algunos segmentos de la población que resultan de especial interés por parte de los profesionales de la salud; uno de estos es el de los adolescentes. el consumo de alcohol en etapas tempranas de la vida conlleva riesgos para la salud, tanto a corto como a largo plazo, en los ámbitos físico, psicológico y social (1). a pesar de esto, en la adolescencia es un problema en constante incremento (2). en 2014, la organización mundial de la salud (oms) calculó que el 24,8 % de los adolescentes en el mundo consumía alcohol, principalmente por ser una sustancia de fácil acceso en casa, a tal grado de que el 16,0 % llegó a tener un problema de adicción antes de llegar a la adultez. esta problemática es más notoria en europa y en américa, donde se presentan los mayores porcentajes de adolescentes consumidores de alcohol (1,3 %). al respecto, se estima que el 36,4 % de los adolescentes del continente americano (entre 15 y 19 años de edad) presentan episodios de consumo excesivo de alcohol, después de los europeos. en el caso de méxico, en 2017 se estimó que el 39,8 % de los adolescentes entre 12 y 17 años consumió alcohol alguna vez en la vida, y, de estos, el 8,3 % presentó un consumo excesivo en el último mes. desafortunadamente, más de la mitad (61,5 %) empezó a consumir alcohol antes de los 17 años (4). esta tendencia hacia el incremento ha motivado el desarrollo de diversos estudios e iniciativas gubernamentales para combatir el problema. sin embargo, una razón que podría estar detrás de la escalada en las prevalencias del consumo de alcohol es la percepción que los adolescentes tienen sobre los riesgos que dicha acción conlleva. la percepción del riesgo se define como aquellos juicios o intuiciones que se tienen sobre la peligrosidad de una situación. desde la sociología y la antropología, la percepción del riesgo tiene sus orígenes en factores sociales y culturales (como el círculo social y las tradiciones), mientras que desde el punto de vista de la psicología, se trata de estrategias mentales que las personas emplean para dar sentido a situaciones inciertas (5). respecto a las drogas, la percepción del riesgo es un factor importante para prevenir las adicciones: las hipótesis apuntan a que cuando la población tiene una mayor percepción de resultar dañada, es más probable que no consuma (6). un estudio realizado en los estados unidos demostró que una percepción del riesgo mayor por parte de los adolescentes sobre distintas drogas generaba un consumo menor de aquellas (7). en españa y en méxico se encontró que los adolescentes perciben el consumo de alcohol como poco perjudicial y, en ocasiones, como una forma de socialización con sus pares. esto podría motivar su consumo, a pesar de las advertencias (8-10). este panorama denota una falta de comprensión del problema y, por consiguiente, una inasistencia por parte de los profesionales sanitarios, pues a pesar de las restricciones de acceso, consumo y venta de alcohol (11), el uso de bebidas alcohólicas continúa aumentando. en la región, los datos recientes sobre los niveles de percepción del riesgo frente al alcohol son escasos, especialmente en adolescentes de ciertas áreas geográficas. por ejemplo, no hay antecedentes sobre la población de nuevo laredo, una zona ubicada en el noreste de méxico, conocida por el elevado consumo y comercio de sustancias ilícitas. esto supone un área de interés para el desarrollo de estrategias contra las adicciones, ya que el alcohol es una droga de inicio que facilita el posterior consumo de sustancias ilegales. además, la percepción del riesgo puede cambiar según los factores sociales y contextuales, lo cual amerita una constante evaluación de esta variable (5). se espera que el estudio de este fenómeno permita orientar las estrategias preventivas de la enfermería para aumentar el nivel de percepción del riesgo y, con ello, prevenir o reducir el consumo de alcohol en los adolescentes. con base en la información expuesta, se formuló la siguiente pregunta de investigación: ¿cuál es la relación entre la percepción del riesgo y el consumo de alcohol en adolescentes de nuevo laredo, méxico? además, se consideró pertinente formular los siguientes objetivos específicos: 1) identificar el nivel de percepción del riesgo frente al consumo de alcohol según el sexo; 2) identificar la prevalencia global, lápsica, actual e instantánea del consumo de alcohol; 3) identificar los patrones de consumo de alcohol según el sexo. 442 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 metodología diseño del estudio, muestra y muestreo se desarrolló un estudio cuantitativo, de corte transversal y diseño correlacional (12), que se realizó durante el año 2017. la población estuvo conformada por 500 alumnos de segundo semestre de una preparatoria pública de nuevo laredo, tamaulipas, méxico. se utilizó un muestreo probabilístico donde se seleccionaron al azar cinco conglomerados de 50 alumnos aproximadamente. de esta manera, la muestra final estuvo conformada por n = 251. el tamaño muestral se calculó a través de g*power versión 3.1, y fue suficiente para ejecutar pruebas de correlación bivariada, considerando una probabilidad de error α del 5 %, potencia (1 – β) del 89 % y detección de un tamaño de efecto mediano (ρ = .02). instrumentos se empleó una cédula de datos personales y de prevalencia del consumo de alcohol y dos instrumentos de autoinforme. el primero fue el cuestionario de percepción de riesgo hacia el consumo de alcohol, adaptado del cuestionario de uribe, verdugo y zacarías para la población mexicana (13). dentro de la adaptación solo se utilizaron los reactivos del primer apartado del cuestionario original, que corresponde a la percepción de riesgo del consumo de alcohol, con previa autorización del autor. el instrumento adaptado constó de 22 ítems con opción de respuesta tipo likert de cinco anclas (1 = totalmente en desacuerdo, 2 = en desacuerdo, 3 = nada de acuerdo, 4 = de acuerdo, 5 = totalmente de acuerdo). cada pregunta aporta a un puntaje global que oscila entre 22 y 110 puntos. dado que no se cuenta con puntos de corte para clasificar la percepción del riesgo, se realizó el siguiente procedimiento: las puntuaciones ubicadas a más de una desviación estándar por encima de la media se consideraron percepción de riesgo alta; aquellas ubicadas a más de una desviación estándar por debajo del promedio se les denominó percepción de riesgo baja. los casos que se encontraron dentro de una desviación estándar alrededor de la media se clasificaron como percepción de riesgo moderado. el instrumento registró un coeficiente alfa de cronbach aceptable (0,82). el segundo instrumento utilizado fue la prueba de identificación de desórdenes por uso de alcohol (audit, en inglés), diseñado para detectar los patrones de uso de alcohol (14). este cuestionario se compone por 10 ítems de opción múltiple que examinan el consumo excesivo de alcohol. el audit tiene 3 dominios: los reactivos 1 a 3 (dominio de consumo riesgoso) determinan la cantidad y la frecuencia de consumo de alcohol; los reactivos 4 a 6 (dominio de síntomas de dependencia) determinan situaciones de pérdida de control sobre el consumo, aumento de la relevancia del consumo y uso matutino de alcohol, y los reactivos 7 a 10 (dominio de consumo perjudicial) permiten determinar posibles daños relacionados con el consumo de alcohol. la escala total oscila entre 0 y 40 puntos, donde una mayor puntuación sugiere un mayor nivel de riesgo por el consumo de alcohol. la oms establece que las personas con puntuaciones menores a 8 se consideran casos con riesgo de problemas relacionados con el alcohol (es decir, existe un consumo riesgoso de esta sustancia), mientras que puntuaciones mayores o iguales a 8 constituyen casos de consumo perjudicial de dicha sustancia. las puntuaciones iguales o mayores a 20 sugieren un consumo perjudicial, pero también demandan una evaluación diagnóstica ante una posible dependencia. el instrumento registró una confiabilidad aceptable (α = 0,84). procedimientos para iniciar la recolección de datos, se solicitaron las listas de los grupos por semestre para realizar la selección aleatoria, con previa autorización de la institución educativa. posteriormente se visitó a los grupos seleccionados para invitarlos a participar en el estudio y explicarles los objetivos, los instrumentos y el tiempo requerido para contestarlos, así como el lugar y la fecha de su aplicación. consideraciones éticas se contó con la autorización de las comisiones de ética e investigación de la facultad de enfermería de la universidad autónoma de tamaulipas, y en todo momento el estudio se apegó al reglamento de la ley general de salud en materia de investigación para la salud (15), para asegurar la protección de los derechos de los participantes, así como su confidencialidad y libertad de participación. por ser aquellos menores de edad, se redactó un consentimiento informado para los padres de familia o tutores y un asentimiento informado para los alumnos. al finalizar el estudio, se les agradeció a los adolescentes por su participación y se les brindó una breve charla sobre las consecuencias del consumo de alcohol. 443 percepción del riesgo y consumo de alcohol en adolescentes de preparatoria l martha dalila mendez-ruiz y otros plan de análisis de datos los análisis se efectuaron mediante el paquete estadístico spss versión 22.0 para mac osx. para responder a los objetivos del estudio, se utilizó una estadística descriptiva (frecuencias, proporciones, medidas de tendencia central y de dispersión) y una estadística inferencial no paramétrica, debido a que las variables no reportaron normalidad en la distribución de los datos (coeficiente de correlación de spearman y prueba chi cuadrado). para identificar la distribución de los datos, se empleó la prueba kolmogórov-smirnov con corrección de lilliefors. resultados con respecto a las características sociodemográficas de la muestra, predominó el sexo masculino (57,4 %), y la media de edad fue de 15,34 años (mdn = 15, de = 0,5). por otra parte, el 88,0 % de los adolescentes se dedicaba únicamente a estudiar al momento de contestar los instrumentos. sobre el consumo de alcohol, el promedio de edad de inicio en las mujeres fue de 13,73 años (mdn = 14,0, de = 1,85), y en los hombres fue de 13,31 años (mdn = 14,0, de = 2,29). por otra parte, las mujeres consumieron en promedio 2,16 bebidas estándar (mdn = 1,0, de = 1,78), mientras que los hombres consumieron 2,94 bebidas estándar (mdn = 2,0, de = 2,75) en un día típico. respecto al primer objetivo específico, el cual señala identificar el nivel de percepción del riesgo hacia el consumo de alcohol según el sexo, la mayoría de los participantes contaban con una percepción del riesgo moderada hacia el consumo de alcohol, como se muestra en la tabla 1. aunque se registró una tendencia en las mujeres a percibir un mayor riesgo, la prueba chi cuadrado no mostró diferencias estadísticamente significativas entre tales porcentajes (χ2 = 1,660, p = .234). tabla 1. nivel de percepción del riesgo hacia el consumo de alcohol en adolescentes respecto al segundo objetivo específico (identificar la prevalencia global, lápsica, actual e instantánea del consumo de alcohol), se identificó que más de la mitad de los adolescentes ha consumido alcohol alguna vez en la vida (59,0 %), seguida de quienes han consumido en el último año (51,8 %, tabla 2). tabla 2. prevalencia global, lápsica, actual e instantánea del consumo de alcohol en adolescentes variables total hombres mujeres f % f % f % percepción del riesgo baja 34 13,5 21 14,6 13 12,1 percepción del riesgo moderada 174 69,3 102 70,8 72 67,3 percepción del riesgo alta 43 17,1 21 14,6 22 20,6 nota: ƒ = frecuencias, % = porcentajes, n = 251. fuente: elaboración propia. variables sí no ic 95 % f % f % li ls alguna vez en la vida (prevalencia global) 148 59,0 103 41,0 52,8 65,0 en el último año (prevalencia lápsica) 130 51,8 121 48,2 45,5 58,0 en el último mes (prevalencia actual) 61 24,3 190 75,7 18,9 29,6 en la última semana (prevalencia instantánea) 25 10,4 226 89,6 6,5 14,1 nota: ƒ = frecuencias, % = porcentajes, ic 95 % = intervalo de confianza al 95 %, li = límite inferior, lc = límite superior, n = 251. fuente: elaboración propia. el tercer objetivo específico fue identificar los patrones de consumo de alcohol según el sexo. la mayor parte de los participantes tuvo un mismo patrón de consumo riesgoso de alcohol (es decir, puntuaciones menores a ocho), seguida por los participantes abstemios y quienes tuvieron un consumo perjudicial. en ningún patrón de consumo se registraron diferencias significativas según el sexo (p > .05). tabla 3. patrones de consumo de alcohol en adolescentes de preparatoria variable total hombres mujeres f % f % f % abstemios 103 41,0 66 45,8 37 34,6 consumo riesgoso de alcohol 132 52,6 67 46,5 65 60,7 consumo perjudicial 15 6,0 11 7,6 4 3,7 consumo perjudicial y probable dependencia 1 0,4 0 0,0 1 0,9 nota: ƒ = frecuencias, % = porcentajes, n = 251. fuente: elaboración propia. 444 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 respecto al objetivo general del presente estudio, al calcular el coeficiente de correlación de spearman, se encontró una relación significativa y negativa, de intensidad moderada, entre la puntuación de la percepción del riesgo y el puntaje total del audit (rs = –.235, p = .001). esto indica que a mayor percepción del riesgo hacia el consumo de alcohol, menor es la implicación con dicha sustancia en los adolescentes. de forma similar, se detectó otra correlación significativa entre el puntaje de la percepción del riesgo hacia el alcohol y la puntuación del dominio del consumo del riesgo del audit (rs = –.241, p = .003). discusión en este estudio se observó que los hombres iniciaron el consumo de alcohol a los 13,31 años de edad, y las mujeres, a los 13,73. los resultados sugieren un inicio más temprano que el reportado en la literatura (4), donde se menciona que el promedio nacional de edad de inicio en el consumo de alcohol en los hombres es de 16,7 años, y de 19,2 en las mujeres. la edad de inicio también fue ligeramente inferior a la que se presenta en otros países, como colombia (14,1 años) (16) y ecuador (13,83 años) (7). esto significa que la población estudiada presenta un riesgo mayor de consumir alcohol. respecto a la cantidad consumida, los resultados difieren de los detectados en una investigación realizada en el norte de méxico (18). en la citada publicación, los varones consumían 4,33 bebidas alcohólicas estándar por ocasión, mientras que las mujeres reportaron 2,24 bebidas. al respecto, las diferencias que se muestran en este estudio son menos acusadas (2,94 versus 2,16, respectivamente); las mujeres tienen un nivel de consumo cercano al de los hombres de su misma edad, por lo que se encuentran en las mismas condiciones de vulnerabilidad para desarrollar patologías y adquirir hábitos de vida no saludables (19). en cuanto al primer objetivo específico, prevaleció la percepción del riesgo moderada hacia el consumo de alcohol (69,3 % de la muestra). aunque el ideal del profesional sanitario es que la población tenga una elevada percepción del riesgo, se puede decir que los hallazgos son superiores a lo encontrado en otras investigaciones. por ejemplo, en un estudio realizado en estados unidos (20), los adolescentes tenían una percepción más baja de las consecuencias negativas producidas por el consumo de bebidas alcohólicas (mdn = 31,49, de = 31,70, mínimo = 0 y máximo = 100). en el caso de méxico, algunos análisis han documentado (4, 21) que los adolescentes que no han consumido alcohol reportan una mayor percepción del riesgo en comparación de sus pares que sí lo consumen. sin embargo, en tales casos no se calcularon niveles de percepción del riesgo. las puntuaciones encontradas pueden responder a diferentes aspectos, como la tolerancia social y la violencia experimentada en la región. algunos datos (4) indican que los adolescentes que consumen alcohol tienen más familiares que se muestran tolerantes hacia el consumo frecuente de alcohol (7,2 % de los hombres y 7,6 % de las mujeres) frente aquellos que no consumen (3,1 % de los hombres y 1,8 % de las mujeres). también se ha determinado que hay una elevada tolerancia por parte de los amigos, pues los adolescentes que consumen alcohol tienen altas proporciones de pares tolerantes al consumo (41,9 % de los hombres y 40,8 % de las mujeres). por otra parte, la violencia en relación con el narcotráfico podría tener efectos sobre la percepción del riesgo. un estudio desarrollado en tamaulipas, méxico (22) puntualizó que los jóvenes tienen presente que quienes compran o consumen sustancias se arriesgan a presenciar eventos peligrosos. de este modo, su percepción del riesgo les prevendría ante posibles consecuencias. sin embargo, no se puede negar que la percepción del riesgo sobre el alcohol dista de ser elevada. esto también puede explicarse por la naturaleza de la adolescencia, pues en esta etapa persisten creencias de invulnerabilidad, ya que la mayoría considera que las consecuencias de las conductas no saludables solo ocurren a terceros (23). en relación con el segundo objetivo, prevaleció el consumo de alcohol alguna vez en la vida (59,0 %). esta cifra supera la media nacional (4) y podría deberse a la influencia y presión por parte de los pares para encajar en un determinado círculo social, así como por el deseo de tener experiencias nuevas a su corta edad (18). por su parte, las desigualdades y la falta de oportunidades también pueden provocar reacciones negativas, porque las conductas de riesgo se muestran como una forma de escapar de sus problemas (23). respecto al tercer objetivo específico, no se encontraron diferencias significativas entre los patrones de consumo de alcohol según el sexo. esto podría tener una explicación en lo señalado por fernández, dema y fontanil (24), quienes en su estudio cualitativo en adolescentes españoles documentaron que los cambios 445 percepción del riesgo y consumo de alcohol en adolescentes de preparatoria l martha dalila mendez-ruiz y otros en las pautas de consumo entre ambos sexos podrían responder a una ruptura con el sistema tradicional de género, en el cual las mujeres pasan de un sistema con dominancia masculina hacia una participación en prácticas tradicionalmente reservadas para los varones. asimismo, el uso de alcohol podría constituir un medio de empoderamiento femenino utilizado para contribuir a la construcción de su identidad. además, como en este estudio los adolescentes provienen de una región limítrofe con los estados unidos, es posible que los estereotipos de la sociedad mexicana que limitaban el acceso de las mujeres a las bebidas alcohólicas —como el marianismo y el familismo (25)— estén perdiendo fuerza. fernández et al. puntualizaron que la implicación con el alcohol se asocia a ciertos periodos de desarrollo (24). así, la generalización del consumo riesgoso en las mujeres se presenta en la adolescencia tardía (entre los 16 y los 18 años), es decir, en un periodo donde se normaliza el consumo de alcohol asociado con una actitud transgresora. de forma diferente, en la juventud (entre los 19 y los 24 años) desaparece ese deseo de transgresión a través del consumo excesivo y comienza una transición de vuelta a los roles de género tradicionales. esto también podría explicar los resultados, ya que la mayor parte de la muestra se encontraba próxima a iniciar la adolescencia tardía (promedio de edad: 15,34 años). dichos resultados obligan al personal de enfermería a dedicar atención a la población femenina, pues es más vulnerable a los efectos tóxicos orgánicos inducidos por el alcohol. la razón de esto es que la mujer posee una mayor proporción de tejido adiposo que de agua (el alcohol es hidrosoluble), por lo cual existe una menor actividad gástrica de χ-alcohol-deshidrogenasa, mayor oxidación hepática y menor vaciado gástrico de alcohol (26-27). finalmente, en respuesta al objetivo general, se observó que ante una mayor percepción del riesgo hacia el consumo de alcohol, menor es el consumo de dicha sustancia (rs = –.235, p < .001). los resultados coinciden con una investigación (21) llevada a cabo en adolescentes de monterrey, méxico, donde se reportó una correlación negativa y significativa entre dichas variables, aunque de casi el doble de intensidad (rs = –.418, p < .001). esto indica que es más probable que los adolescentes que consumen alcohol en bajas cantidades presenten una alta percepción del riesgo, y viceversa. la diferencia de intensidad entre los estudios resulta llamativa, pues ambas investigaciones se realizaron en el norte de méxico, con el mismo segmento de edades e instrumento de medición. una explicación de esta condición puede surgir desde la literatura clásica. aunque la percepción del riesgo se modifica mediante la reflexión de nuestras conductas (5), también está mediada por factores externos sociales y culturales. en este sentido, las mediciones demuestran la asociación entre la percepción del riesgo y una conducta (uso de alcohol), pero ciertos aspectos sociales externos (como proceder de un estado con elevadas prevalencias de uso de sustancias, con mayor oportunidad de experimentar violencia y consecuencias sociales asociadas a las drogas) (22) podrían modificar las variables medidas. por otro lado, las correlaciones significativas y la percepción del riesgo moderada hacia el consumo de alcohol conllevan a desarrollar investigaciones sobre las razones que promueven el uso de sustancias, teniendo en cuenta las características de las áreas geográficas. es importante diseñar estrategias preventivas que puedan ser utilizadas por la enfermería para orientar a la comunidad, especialmente a los adolescentes durante la educación secundaria, dado que es la edad de inicio de consumo de alcohol. el modelo de creencias de salud de rosenstock podría ser de utilidad (28), debido a que se fundamenta en la explicación de conductas saludables (como mantenerse alejado del uso de sustancias) en función de las creencias de las personas sobre acontecimientos relacionados a su salud. para modificar la percepción del riesgo, interactúan la vulnerabilidad percibida por el sujeto (entre mayor es el riesgo que percibe de enfermar, mayor es la conducta saludable que adopta), la gravedad de las consecuencias de la conducta (ante repercusiones más serias, más sencillo resultará adoptar una conducta saludable), así como los beneficios y los costos de adoptar conductas saludables (ante menos barreras y más beneficios, la persona se motivará a mantenerse sana). seguir estos lineamientos con recursos disponibles en internet (como ilustraciones gráficas, videos o testimonios) permite desarrollar estrategias costo-efectivas para aumentar la percepción del riesgo de los adolescentes y, así, reducir su involucramiento con sustancias adictivas. una ventaja de que el personal de enfermería se comprometa con la administración y el desarrollo de estrategias preventivas es su amplia presencia en el primer nivel de atención (29), que es precisamente donde se pueden llevar a cabo intervenciones preventivas. no obstante, hay que considerar el trabajo conjunto con otras disciplinas, con el objetivo de lograr el bienestar del individuo me446 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 diante un enfoque integral. asimismo, la difusión de los hallazgos de investigación en ámbitos locales y regionales, para que puedan ser replicados y utilizados en otras latitudes. en este sentido, la formación y la participación en redes de trabajo e investigación pueden ser herramientas útiles para la reducción del consumo de drogas. limitaciones dada la naturaleza transversal del estudio, los resultados deben interpretarse con cautela, sin realizar inferencias de causalidad; toda hipótesis generada ha de confirmarse mediante estudios experimentales. asimismo, el defecto inherente a los instrumentos de autoinforme radica en que los participantes podrían no ser del todo sinceros al responder. una opción para mejorar la comprensión del fenómeno podría ser recurrir a abordajes cualitativos mediante entrevistas, para obtener información adicional. por otra parte, las diferencias culturales pueden limitar la generalización de los hallazgos. por ejemplo, los motivos que propician la percepción del riesgo y el consumo de alcohol en los individuos del estudio podrían no ser del todo comparables con los de otras poblaciones, como en la citada investigación desarrollada en monterrey (21), pues entre las dos poblaciones hay algunas diferencias culturales y geográficas que suscitan una reflexión: nuevo laredo es una zona fronteriza, con un tamaño poblacional casi diez veces menor que el de monterrey, ubicada dentro de una entidad federativa con menores índices de salud y educación (30), y con serios problemas de narcotráfico y violencia (22). conclusión según la muestra, un mayor nivel de percepción del riesgo hacia el consumo de alcohol se relaciona con un menor uso de dicha sustancia. la mayoría de los adolescentes ha consumido alcohol alguna vez en la vida, refirió tener una percepción del riesgo moderada y presenta un consumo riesgoso de alcohol, sin diferencias estadísticamente significativas según el sexo. los hallazgos invitan a colaborar en redes de trabajo para investigar con mayor profundidad las percepciones sobre los riesgos del uso de drogas, de modo que se produzcan conocimientos que permitan orientar futuras intervenciones multidisciplinares para aumentar la percepción del riesgo sobre las sustancias adictivas, en especial entre los adolescentes de educación secundaria, donde se ubicó el promedio de edad de inicio del consumo de alcohol. por otra parte, dado que las prevalencias del consumo de alcohol no tuvieron diferencias significativas entre ambos sexos, es preciso dirigirse a hombres y a mujeres por igual, en lugar de 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27. instituto nacional de abuso de alcohol y alcoholismo. alcohol. an important women’s health issue. rockville (md):niaaa [internet]; 2005. disponible en: https://pubs.niaaa.nih.gov/publications/aa62/aa62.htm 28. garcía ja. concepto de percepción de riesgo y su repercusión en las adicciones. salud drogas [internet]. 2012 dic. 12(2):133-51. doi: 10.21134/haaj.v12i2 29. secretaría de salud. sistema de información administrativa de recursos humanos de enfermería [internet]. ciudad de méxico: secretaría de salud; 2018. disponible en: http://www.salud.gob.mx/unidades/cie/siarhe/?id_url=antecedentes 30. programa de las naciones unidas para el desarrollo. índice de desarrollo humano para las entidades federativas [internet], méxico. d.f., méxico: programa de las naciones unidas para el desarrollo; 2015. disponible en: http://www. mx.undp.org/content/dam/mexico/docs/publicaciones/publicacionesreduccionpobreza/informesdesarrollohumano/pnud_boletinidh.pdf https://doi.org/10.3109/14659891.2010.518199 http://dx.doi.org/10.21134/haaj.v12i2 http://www.mx.undp.org/content/dam/mexico/docs/publicaciones/publicacionesreduccionpobreza/informesdesarrollohumano/pnud_boletinidh.pdf http://www.mx.undp.org/content/dam/mexico/docs/publicaciones/publicacionesreduccionpobreza/informesdesarrollohumano/pnud_boletinidh.pdf http://www.mx.undp.org/content/dam/mexico/docs/publicaciones/publicacionesreduccionpobreza/informesdesarrollohumano/pnud_boletinidh.pdf 287 michelle araújo-moreira1 mirian santos-paiva2 maria natália pereira-ramos3 polliana santos-ribeiro4 jéssica suellen barbosa mendes-ramos5 experiências migratórias e intergeracionais sobre a amamentação no espaço familiar: um estudo de representações sociais6 1 orcid.org/0000-0002-6998-8665. universidade estadual de santa cruz, brasil. mamoreira@uesc.br 2 orcid.org/0000-0003-4399-321x. universidade federal da bahia, brasil. mirian@ufba.br 3 orcid.org/0000-0002-8448-1846. universidade aberta de lisboa, portugal. natalia@uab.pt 4 orcid.org/0000-0002-8041-0231. universidade estadual de santa cruz, brasil. polli.enfa@icloud.com 5 orcid.org/0000-0003-0081-5325. universidade estadual de santa cruz, brasil. jsuellen7@gmail.com 6 projeto de pesquisa intitulado “experiências trigeracionais sobre a amamentação em famílias de migrantes: um estudo de representações sociais”, financiado pela coordenação de aperfeiçoamento de pessoal de nível superior (capes). recebido: 04/05/2018 submetido: 15/06/2018 aceito por pares: 04/08/2018 aceito: 28/08/2018 doi: 10.5294/aqui.2018.18.3.4 para citar este artigo / para citar este artículo / to reference this article moreira ma, paiva ms, ramos mnp, ribeiro ps, ramos jsbm. experiências migratórias e intergeracionais sobre a amamentação no espaço familiar: um estudo de representações sociais. aquichan. 2018; 18(3): 287-297. doi: 10.5294/aqui.2018.18.3.4 resumo objetivos: analisar as experiências intergeracionais de mulheres migrantes da mesma família sobre a amamentação; apreender as representações sociais dessa população ao longo das gerações sobre a experiência de amamentar. material e métodos: trata-se de uma pesquisa qualitativa, fundamentada na teoria das representações sociais, e realizada com 63 mulheres da mesma família e de diferentes gerações, 21 tríades no total. utilizou-se, para a coleta dos dados, o teste de associação livre de palavras e, para a análise año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 287-297 temática: promoção e prevenção. contribuição para a disciplina: este estudo contribui para a ciência da enfermagem e saúde das mulheres migrantes no contexto nacional e internacional, no que tange à amamentação de seus filhos, por possibilitar que possamos, enquanto profissionais da área da saúde, compreender as migrantes em suas experiências, narrativas, projetos, sonhos e cultura; além disso, possamos atuar sobre crenças, valores, mitos e tabus que atravessam gerações dentro do ambiente familiar e impedem ou dificultam a amamentação plena. ademais, as representações sociais sobre a amamentação nas distintas gerações podem sofrer modificações, especialmente quando as mulheres vivenciaram o processo de migração geográfica e/ou afetiva, o que resulta em novos constructos ao longo do tempo. nesse sentido, a equipe de saúde e os profissionais de áreas afins podem oportunizar que novas redes de apoio à amamentação sejam formadas para permitir que as mulheres migrantes e de diferentes gerações desenvolvam essa prática com êxito e satisfação, ultrapassando as dimensões do biológico em direção à importância da cultura, da parentalidade e da família. http://orcid.org/0000-0002-6998-8665 http://orcid.org/0000-0003-4399-321x. http://orcid.org/0000-0002-8448-1846. http://orcid.org/0000-0002-8041-0231. http://orcid.org/0000-0003-0081-5325. 288 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 287-297 destes, o software tri-deux-mots. resultados: para as mulheres migrantes, a prática de amamentar permanece atrelada a benefícios fisiológicos e emocionais para o filho, exigindo abnegação e satisfação. no período de amamentação, as mulheres que se deslocam para novos territórios são mais vulneráveis em decorrência da adaptação geográfica, sociocultural e afetiva a que serão submetidas. ressaltase que o processo migratório pode influenciar na amamentação e estar na origem de conflitos de maternagem, especialmente entre gerações mais jovens, pois estas necessitam de referências familiares que, muitas vezes, permanecem distantes ou ausentes. conclusões: constata-se que a diversidade sociocultural e o território influenciam grande parte das mulheres migrantes que amamentam, tornando-se necessário compreender os determinantes regionais e culturais, e as influências familiares e geracionais que permeiam esse processo. palavras-chave aleitamento materno; relação entre gerações; migração humana; saúde da mulher; enfermagem (fonte: decs). experiencias migratorias e intergeneracionales con respecto a la lactancia materna en el entorno familiar: un estudio de las representaciones sociales resumen objetivos: analizar las experiencias intergeneracionales de mujeres migrantes de la misma familia sobre la lactancia; se aprehende las representaciones sociales de esa población a lo largo de las generaciones sobre la experiencia de amamantar. material y métodos: investigación cualitativa, fundamentada en la teoría de las representaciones sociales y realizada con 63 mujeres de la misma familia y de diferentes generaciones, 21 tríadas en total. se utilizó, para la recolección de los datos, la prueba de asociación libre de palabras y, para el análisis de estos, el software tri-deux-mots. resultados: para las mujeres migrantes, la práctica de amamantar permanece ligada a beneficios fisiológicos y emocionales para el hijo, exigiendo abnegación y satisfacción. en la lactancia, las mujeres que se desplazan a nuevos territorios son más vulnerables como consecuencia de la adaptación geográfica, sociocultural y afectiva a la que serán sometidas. el proceso migratorio puede influir en la lactancia y estar en el origen de conflictos de maternidad, especialmente entre generaciones más jóvenes, pues estas necesitan referencias familiares que, muchas veces, permanecen distantes o ausentes. conclusiones: la diversidad sociocultural y el territorio influencian gran parte de las mujeres migrantes que amamantan, y es necesario comprender los determinantes regionales y culturales, y las influencias familiares y generacionales que permean ese proceso. palabras-clave lactancia materna; relaciones intergeneracionales; migración humana; salud de la mujer; enfermería (fuente: decs). 289 experiências migratórias e intergeracionais sobre a amamentação no espaço familiar: um estudo de representações sociais l michelle araújo moreira e outros migratory and intergenerational experiences on breastfeeding in the family space: a study of social representations abstract objectives: to analyze the intergenerational experiences of female migrants from the same family on breastfeeding; to grasp the social representations of this population over the generations about the experience of breastfeeding. material and methods: this is a qualitative research based on social representations theory and carried out with 63 women from the same family and from different generations, 21 triads in total. for the data collection, the free word association test was used and, for the analysis of these, the trideux-mots software. results: for migrant women, the practice of breastfeeding remains tied to physiological and emotional benefits for the child, requiring self-denial and satisfaction. in the breastfeeding period, women who move to new territories are more vulnerable due to the geographical, sociocultural and affective adaptation to which they will be subjected. it should be emphasized that the migratory process can influence breastfeeding and be the cause of maternal conflicts, especially among younger generations, since they require family references that often remain distant or absent. conclusions: socio-cultural diversity and territory influence the majority of breastfeeding migrant women, making it necessary to understand the regional, cultural, family, and generational influences that permeate this process. keywords breastfeeding; intergenerational relations; human migration; women’s health; nursing (source: decs). año 18 vol. 18 nº 3 chía, colombia septiembre 2018 l 287-297 290 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 introdução a amamentação, processo complexo que envolve aspectos biológicos, psicológicos, sociais, culturais, econômicos e políticos, quando vivenciada pelas mulheres, requer modelos que sirvam de base teórica e prática, na maioria das vezes, calcados na cultura e na relação familiar e na linearidade geracional (1). assim, determinadas práticas de cuidado aprendidas em suas culturas juntamente com o fenômeno migratório podem influenciar os modos de significar, de atuar e nutrir das novas gerações, proporcionando novas simbologias no seio familiar. percebe-se, no cenário internacional, que o processo de migração advém do contexto da globalização, momento em que os contatos interculturais entre as sociedades de origem e de acolhimento ocorrem, com especial destaque para a prática da amamentação. nota-se uma vulnerabilidade ampliada nas mulheres migrantes que amamentam, pois estas terão que se adaptar a uma nova cultura e a um novo constructo sobre a amamentação, o que evidencia a relevância social e científica da temática. para tanto, torna-se necessário compreender a dialética de ensino, aprendizagem e transmissão entre as gerações, e atentar para as relações coletivas e individuais das mulheres durante a amamentação, seja no contexto internacional, seja no nacional (2-3). entender o fenômeno da amamentação no contexto migratório, intergeracional e familiar em um país multicultural como o brasil é de fundamental importância, especialmente em regiões mais carentes como o nordeste, berço de processos de aculturação, no que tange ao constructo sobre a amamentação, bem como local de migração interna e externa como mecanismo de melhoria da qualidade de vida. além disso, a coexistência e a coabitação, cada vez mais frequente, entre diferentes gerações de mulheres que migraram na modalidade intermunicipal e interestadual, e amamentaram independentemente do tempo e da quantidade de filhos, oportunizam que existam influências familiares diferentes sobre a prática do amamentar. sabe-se que o envelhecimento da população brasileira amplia a proximidade entre as gerações e que o deslocamento geográfico e afetivo do local de origem para o local de acolhimento em busca de novas oportunidades permite que as mulheres migrantes e de gerações distintas possam se ajudar mutuamente na experiência da amamentação. nessa perspectiva, pesquisar questões geracionais e migratórias associadas à amamentação oportuniza analisar as experiências e trocas intergeracionais ancoradas nos aspectos sociais, culturais, geográficos e históricos, valorizando a subjetividade de cada mulher (4). dessa maneira, reafirma-se como objeto de estudo: as experiências intergeracionais sobre a amamentação entre mulheres migrantes da mesma família. a partir disso, questionam-se: como mulheres migrantes da mesma família e de gerações distintas representam a amamentação? quais os mecanismos culturais e de solidariedade intergeracional existem na amamentação por mulheres migrantes da mesma família? como as relações de afeto, separação e conflito contribuem para a manutenção ou suspensão da amamentação entre mulheres migrantes da mesma família? diante disso, definiram-se como objetivos deste estudo: analisar as experiências intergeracionais de mulheres migrantes da mesma família sobre a amamentação e apreender as representações sociais de mulheres migrantes da mesma família ao longo das gerações sobre a experiência de amamentar. material e métodos trata-se de um estudo qualitativo, fundamentado na teoria das representações sociais, por valorizar as simbologias, os significados e o padrão de herança familiar dessa prática, na perspectiva intergeracional. o estudo contou com a participação de 63 mulheres, ou seja, 21 tríades no total. a seleção das depoentes foi realizada na modalidade snowball (bola de neve), através de critérios de inclusão: ter filha e neta (1ª geração), mãe e filha (2ª geração), mãe e avó materna ou paterna (3ª geração) que amamentaram ou amamentam, independentemente do tempo de amamentação e da quantidade de filhas(os); residir no município de ilhéus (estado da bahia) ou em cidades do entorno; ter migrado internamente no país ou ter migrado na modalidade internacional na condição voluntária; possuir laço de consanguinidade e/ou afetividade com as mulheres da mesma família e de gerações diferentes, a exemplo de mãe adotiva, avó adotiva ou sogra; ter convivência com as mulheres da mesma família e de diferentes gerações; ter situação de migração em pelo menos uma geração de mulheres da mesma família. em consequência, os critérios de exclusão foram: ser uma refugiada; não ter capacidade civil plena; não ter 291 experiências migratórias e intergeracionais sobre a amamentação no espaço familiar: um estudo de representações sociais l michelle araújo moreira e outros amamentado; ter migrado na modalidade de domicílio; ter uma convivência esporádica entre as mulheres da mesma família. destaca-se que, na modalidade snowball, as participantes iniciais do estudo eram escolhidas com base nos critérios de inclusão e estas indicavam novas participantes que se enquadrassem nos mesmos critérios definidos anteriormente, até que fosse alcançado o ponto de saturação dos conteúdos teóricos. o estudo foi realizado no município de ilhéus (estado da bahia, brasil). a escolha por essa cidade caracterizou-se por ser local de constante migração para mulheres de outros países, regiões, estados e municípios juntamente com seus familiares, que passaram ou passam pela experiência da amamentação. a coleta dos dados foi realizada no domicílio entre março e maio de 2016, em dia, horário e local determinados pelas depoentes, e após a assinatura do termo de consentimento livre e esclarecido. utilizou-se a técnica de associação livre de palavras (talp) com todas as tríades em ambiente privativo, livre de ruídos externos, e entregou-se uma folha de resposta específica, que foi preenchida individualmente por cada participante e, na impossibilidade de esta efetuar o registro, este foi realizado pelas pesquisadoras, por se tratar de um grupo com vulnerabilidades, a exemplo da baixa escolaridade. sabe-se que o talp é uma técnica projetiva que torna a estrutura psicológica dos sujeitos palpável, através das reações, das evocações e das criações (5). para a aplicação do talp, a folha de resposta específica continha os seguintes estímulos indutores, através da expressão “diga-me cinco palavras que vêm imediatamente à sua mente quando eu falo: ‘amamentação’, ‘com quem aprendeu sobre a amamentação’, ‘influência da cultura da sua cidade sobre a amamentação’, ‘apoio da família na amamentação’, ‘troca de experiências sobre a amamentação com sua filha e neta’, ‘troca de experiências sobre a amamentação com sua mãe e filha’, ‘troca de experiências sobre a amamentação com sua mãe e avó’, referente à primeira, segunda e terceira geração”. a codificação das palavras ditas ou registradas pelas depoentes na folha do talp foi organizada em um dicionário correspondente para cada estímulo por similaridade semântica e depois processada pelo software tri-deux-mots. os dados foram validados a partir da frequência máxima de evocações para cada estímulo e comparados com outras pesquisas nacionais e internacionais sobre a amamentação; os resultados do estudo foram devolvidos às participantes, através da divulgação em eventos locais. convém destacar que o projeto se encontra pautado nos princípios éticos da pesquisa que envolve seres humanos, definidos e regulamentados na resolução n.º 466/2012, do conselho nacional de saúde, sendo aprovado sob o parecer n.º 1.459.882, validado através do cruzamento entre as variáveis fixas (escolaridade, geração, cor/etnia e religião) e as variáveis de opinião que consistem na resposta dos sujeitos aos cinco estímulos indutores. isso permitiu maior aproximação ou distanciamento do campo representacional de um determinado objeto. tal proximidade ou distância permanece representada nos eixos fatoriais (f1 e f2), momento em que as palavras aparecem acompanhadas de um número do estímulo que foi aplicado às depoentes. por tratar-se de um estudo qualitativo, a validade se deu por meio da triangulação dos dados, embora, neste estudo, se apresentem o talp e a utilização do software tri-deux-mots no processamento da informação dada pelas depoentes de maneira interpretativa. resultados e discussão as 63 participantes do estudo caracterizam-se por serem mulheres migrantes de três gerações diferentes. a grande maioria tinha ensino médio completo, era solteira, autodeclarava-se pela cor não negra e era adepta do catolicismo. de posse do perfil, os dados provenientes do talp foram processados pelo software tri-deux-mots, a partir da análise fatorial por correspondência (afc), o que possibilitou o registro de 315 evocações. dessas palavras, 66 foram diferentes para o estímulo 1, 58 para o estímulo 2, 102 para o estímulo 3 e 4, e 127 para o estímulo 5, reduzidas de acordo com a junção dos termos com similaridade semântica, conforme a figura 1. dessa maneira, percebe-se que as mulheres migrantes na modalidade interestadual e negras, correspondentes ao eixo f1(+), demonstram que a prática da amamentação permanece atrelada ao campo do cuidado ao filho em decorrência dos inúmeros benefícios fisiológicos, motores, sensoriais e cognitivos (6). além disso, proporciona maior vínculo entre mãe e filho com significativa melhoria na qualidade de vida (7). sabe-se ainda que, durante décadas, as mulheres negras amamentavam os filhos das mulheres brancas no intuito de que estas últimas mantivessem um padrão de beleza próprio da época. naquele período, os senhores quase sempre preferiam que seus filhos fossem amamentados por suas escravas. acreditava-se que 292 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 elas eram mais saudáveis e remetiam força, além de produzirem leite mais forte, portanto mais saúde para seus filhos. para tanto, tinham que ser dedicadas, o que se reflete nas representações das mulheres migrantes e negras nos dias atuais (8). por outro lado, visualiza-se que as mulheres migrantes não negras situadas no eixo f1(-) mantêm suas representações sobre a amamentação como uma prática de alimentação da criança centrada no prazer, mas também permeada por algumas dificuldades, o que revela a necessidade de doação e abnegação. ao mesmo tempo, a amamentação é permeada por ambiguidades na própria experiência das mulheres migrantes, ou seja, felicidade por conseguir aleitar versus o surgimento de intercorrências mamárias. a ausência de conhecimento sobre a amamentação, a disseminação dos mitos ao longo das gerações, a própria mudança espacial e o fator sociocultural podem influenciar nas simbologias maternas a cada tempo social (9). assim, destaca-se que o exercício de amamentar durante o processo de migração pode trazer alterações no âmbito do pertencimento sociocultural, especialmente em cenários com crenças e valores distintos (10). portanto, a amamentação se constitui em uma prática social e cultural, transmitida entre diferentes gerações como fruto de vivências individuais e coletivas (11). no que se refere ao estímulo 2, as mulheres migrantes na modalidade interestadual e negras objetivaram que o aprendizado sobre a amamentação se desenvolveu no seio familiar, local predominantemente feminino, bem como nos hospitais com apoio das enfermeiras, através da influência midiática e da observação de outras mulheres que amamentavam. ademais, as mulheres migrantes sustentam o processo de aprendizado sobre a amamentação nas experiências e vivências de sua rede familiar, que fortalecem a prática de aleitar como ato cultural que se impregna de processos de deslocamento e saberes de modo intergeracional (12). portanto, esse processo de deslocamento territorial, a necessidade de adaptação geográfica e afetiva, o reconhecimento dos novos grupos sociais e a interação cultural podem influenciar na representação que essas mulheres possuem sobre a amamentação (13). embora as mulheres migrantes recebam orientações sobre o aleitamento materno durante todo o período gravídico-puerperal, fonte: dados da pesquisa, 2016. figura 1. plano fatorial de correspondência das representações sociais elaboradas por mulheres migrantes da mesma familia e de diferentes gerações sobre a amamentação 293 experiências migratórias e intergeracionais sobre a amamentação no espaço familiar: um estudo de representações sociais l michelle araújo moreira e outros muitas preferem não seguir as recomendações em virtude da importância atribuída às crenças familiares e à influência geracional nesse processo (14). por outro lado, as mulheres migrantes da 1ª geração referiram que seu processo de aprendizado sobre a amamentação deuse a partir da observação e de leituras. portanto, compreende-se que a aquisição do conhecimento adveio da vivência com suas mães, avós, vizinhas ou amigas que amamentaram. entende-se que a experiência sobre a amamentação se desenvolve na rede familiar e social a partir da reprodução de saberes entre mulheres de diferentes gerações (10, 15). ademais, as leituras serviram como aprendizado para a amamentação, momento em que as mulheres migrantes utilizaram materiais instrucionais como livros e revistas para a ampliação do conhecimento (16). com relação ao estímulo 3, no fator f1(+) e f1(-), evidenciase que a migração interestadual influenciou positivamente na prática da amamentação de mulheres negras, pois reafirmou um modelo de aleitar como nutrição e, para tanto, utilizou-se do apoio familiar para fomentar tal simbologia. contudo, as mulheres da 1ª geração não negras revelaram pouca influência do processo de migração em virtude do contexto histórico e social do aleitar em suas épocas, centrado na figura do médico como fonte de poder e de conhecimento, denotando que essas mulheres não possuíam preparo suficiente para tal prática. dessa maneira, percebe-se que as migrações concatenam significações de ambientes diferentes, servindo como um mecanismo de proteção ou estresse (17-18). essas mudanças e/ou rupturas espaciais propiciam a necessidade de incorporação de novas regras culturais, sociais, comunicacionais e de cuidados nas experiências da amamentação (10, 17). no que tange ao estímulo 4, o apoio na amamentação se sustenta pelo afeto, pelo respeito e pelos ensinamentos, mas também pelas formas de reverter o despreparo das nutrizes com o auxílio e apoio de suas mães. verifica-se ainda que algumas mulheres migrantes percebem certo despreparo por parte de seus familiares quanto ao apoio recebido na fase da amamentação, o que contribui para a perpetuação de crenças, tabus e mitos que interferem na duração e permanência do aleitamento materno (19). por sua vez, nas evocações f1(-) das mulheres migrantes da 1ª geração e não negras, a mãe é a principal figura de apoio dentro da família, o que pode ser justificado pela maior proximidade afetiva entre ambas. essa relação afetiva contribui para o sentimento de confiança que a nutriz direciona à sua mãe, avó, sogra ou demais membros de sua conformação familiar. o apoio ou ajuda é tido como mecanismo de proteção para essas mulheres, que se apresentam vulneráveis e despreparadas quanto aos manejos que envolvem a amamentação, principalmente as mais jovens. contudo, existem casos em que a interferência familiar pode ser desfavorável à continuidade do aleitamento materno, sobretudo se pressionarem as novas mães (20). para o estímulo 5, percebe-se que a troca entre as gerações se ancora na observação, no apoio, na troca de informações, no cuidado e no entendimento sobre a amamentação como alimentação. além disso, há uma valorização das experiências e da sabedoria das antigas gerações no intuito de compreender essa prática como algo prazeroso. entretanto, a relação entre as gerações pode ocasionar conflitos, pois algumas mulheres podem apresentar uma aquisição de conhecimento “diferente” quando comparado aos saberes de suas mães e/ou avós. além disso, a observação coloca-se como elemento importante para a transmissão de conhecimento entre gerações, especialmente diante da coexistência ou coabitação entre a 2ª e 3ª gerações. o sucesso do aleitamento depende da criação de vínculo das mulheres migrantes com a equipe multidisciplinar bem como da observação das formas de amamentar durante as consultas de pré-natal e/ou nas atividades educativas com materiais instrucionais e vídeos (21). em relação ao fator 2, apreende-se que as representações de mulheres migrantes da 1ª geração e alfabetizadas para o estímulo 1, e mulheres migrantes da 3ª geração, verificou-se que a amamentação se ancora na vinculação afetiva e de amor entre o binômio e de dedicação entre as mulheres das diferentes gerações. cabe entender que o processo geracional envolve fenômenos que vão desde a posição familiar, partilhas sociais e históricas, até o mecanismo de agrupamento social e cultural. assim, a prática de amamentação para as mulheres migrantes da 1ª geração e alfabetizadas aponta para a necessidade de se sentirem acolhidas e doar-se com vistas a proteger o desenvolvimento do filho, representação que perpassa o tempo e apa294 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 rece na simbologia de mulheres migrantes da 3ª geração quando estas afirmam que necessitam de doação e amor para que o processo aconteça com felicidade e vinculação. entende-se ainda que a amamentação traz inúmeras vantagens cientificamente comprovadas, dentre estas, o contato pele a pele e a criação do vínculo afetivo entre mãe e filha(o). além disso, o aleitamento materno exclusivo até os seis meses é fonte de alimentação completa para a criança, levando a benefícios como o crescimento e desenvolvimento adequados, à prevenção de morbidade como a anemia ferropriva, além da proteção contra doenças crônicas e infecciosas (22). portanto, a amamentação possui uma dimensão biológica, mas também emocional, econômica, sexual, psíquica e relacional. algumas mulheres podem experienciá-la de forma positiva, através de sentimentos como alegria e prazer. por outro lado, há outras mulheres que vivenciam a amamentação como um processo de proteção e doação nutricional para a(o) filha(o), esquecendose dos benefícios para si mesmas (23). quanto ao estímulo 2, verificou-se que o aprendizado sofre influência das condições socioeconômicas, culturais, das experiências pregressas individuais, do seu grupo de pertencimento familiar e da mídia (24). nesse contexto, mulheres migrantes da 1ª geração e alfabetizadas representam a amamentação como uma prática instintiva, embora se saiba que esta se constitui em uma ação fundamentada na subjetividade e no contexto geográfico e social da nutriz. em contrapartida, as mulheres migrantes da 3ª geração representam o aprendizado da amamentação a partir de um componente social, cultural e midiático, momento em que atribuem a familiares e à mídia o seu processo de empoderamento, de autonomia, de autodeterminação, assumindo um maior controle sobre seu corpo e as formas que reproduzem suas relações (25). outro fator marcante para as mulheres migrantes da 3ª geração refere-se à universalidade ao acesso midiático e às facilidades tecnológicas, tornando a amamentação uma prática influenciada por fatores como a televisão e a internet. esses veículos de comunicação são mais acessíveis à população brasileira e, dessa forma, influenciam significativamente às mulheres de diferentes gerações (26). com relação ao estímulo 3, evidencia-se que a diversidade sociocultural e o território influenciam grande parte das mulheres que amamentam, por isso torna-se importante o conhecimento dos determinantes locais acerca do aleitamento materno, o que permitiria explicar e avaliar as mudanças nas simbologias (18). para as depoentes da 1ª geração e alfabetizadas, a migração insere a família em determinados nichos ecológicos, que influenciam direta ou indiretamente seus membros, seja no desenvolvimento, seja, até mesmo, na saúde de modo a trazer benefícios ou dificuldades (27). por outro lado, as depoentes da 3ª geração revelam que o processo migratório interfere pouco nas suas representações sobre a amamentação. para essas mulheres, mesmo com a mudança de local, há uma preservação do constructo sobre o aleitamento materno em virtude do modelo cultural centrado no amor, na dedicação, na proteção e no prazer que foi disseminado pelas antigas gerações dentro do espaço familiar (17, 28). outro fator existente relaciona-se às mulheres que imputam à figura médica a responsabilização pelo aprendizado sobre a amamentação. contudo, verifica-se que isso reflete o paradigma biomédico e dificulta que as migrantes percebam o aleitamento dentro do modelo assistencial do sistema único de saúde (sus), que se pauta na integralidade (29). ressalta-se que, no estímulo 4, para as mulheres migrantes, a família constitui o primeiro referencial no processo da amamentação, razão pela qual há um reconhecimento positivo nas relações de afeto, cuidado e práticas transmitidas. no núcleo familiar, verifica-se um apoio para que o aprendizado entre as gerações aconteça a contento durante a amamentação (30). ademais, para as mulheres migrantes da 3ª geração, a avó simboliza o apoio presencial, emocional e informativo durante a amamentação (11). as avós atuam como cuidadoras da família, dando maior atenção e carinho, dedicando seu tempo às filhas e às noras no período puerperal e passando informações adquiridas no seu convívio sociocultural (31). esse conhecimento transmitido pelas avós pode ser contraditório quando comparado às informações dadas pelos profissionais de saúde, mas tem valor pela relação hierárquica e de afeto entre as mulheres da mesma família. por sua vez, a figura paterna começa a ser representada como fonte de ajuda no incentivo à amamentação. a participação do pai 295 experiências migratórias e intergeracionais sobre a amamentação no espaço familiar: um estudo de representações sociais l michelle araújo moreira e outros é considerada um dos motivos para a manutenção do aleitamento materno pelo apoio, pela divisão de tarefas ou pelo sustentáculo emocional, especialmente quando dividem a preocupação com a saúde dos filhos (32-33). portanto, a inclusão do pai é importante para a ampliação de vínculos e aprendizado familiar sobre a amamentação (34). verifica-se que os pais demonstram satisfação em cuidar dos filhos e apoiar a companheira na amamentação, especialmente quando os profissionais de saúde reconhecem suas ações e acertos (35). em seguida, no estímulo 5, as mulheres denotam grande importância ao apoio da família e principalmente as trocas que acontecem entre as gerações. entende-se que as formas de comunicação entre as gerações influenciam a qualidade da relação familiar, as quais permitem que o indivíduo se realize como ser social. por meio desses relacionamentos, os vínculos familiares se estabelecem, e os diferentes papéis geracionais são construídos com influências de gênero, socioeconômicas, culturais, de proximidade geográfica, de frequência de contato, dentre outras (36). percebe-se, então, que os familiares representam uma rede de apoio social, principalmente as gerações mais antigas por estarem balizadas por conhecimento pregresso, sabedoria e tradição (37). no convívio geracional, as mulheres migrantes da 1ª geração e alfabetizadas demonstram que as relações familiares estão ancoradas nas trocas afetivas, no apoio ao aleitamento materno, mas também nas experiências com as gerações predecessoras. conclusões as evidências demonstraram que, para as mulheres migrantes da mesma família e de diferentes gerações, a amamentação constitui-se como uma prática social, cultural e intergeracional construída a partir dos afetos, dos conflitos, das histórias e vivências compartilhadas e do conhecimento local. nota-se que as condições socioeconômicas das mulheres migrantes associadas à vulnerabilidade do processo migratório permitem que a amamentação seja permeada por mecanismos de estresse e ansiedade decorrentes das mudanças geográficas, sociais e culturais. ressalta-se que, para as mulheres migrantes das gerações mais velhas, o processo migratório influenciou afetivamente menos em relação às gerações mais novas, devido ao contexto histórico e social de naturalizar a obrigatoriedade da amamentação e ao acompanhamento dos seus cônjuges em outros locais para a própria sobrevivência. evidencia-se ainda que as mulheres migrantes apoiam-se na figura da mãe, do médico e do hospital como elementos de suporte na amamentação, especialmente quando está em processo de adaptação cultural e espacial. por fim, constata-se que a diversidade sociocultural e o território influenciam parte das mulheres que amamentam ou amamentaram mesmo que em épocas distintas. portanto, torna-se necessário compreender a influência da migração na prática da amamentação e atentar para os determinantes locais de cada região e para as representações históricas e culturais que são elaboradas cotidianamente. nesse sentido, os profissionais de saúde, especialmente as(os) enfermeiras(os) como cuidadoras(es) diretas(os) desse processo, devem reconhecer a individualidade e subjetividade de cada mulher migrante, valorizando a sua cultura de origem e a de acolhimento, de modo que possam incentivar a amamentação na perspectiva da multi/ interculturalidade e da intergeracionalidade. evidencia-se que a(o) enfermeira(o) pode atuar na rede de incentivo à amamentação da mulher migrante, principalmente na orientação sobre os cuidados com a mama e o desenvolvimento do bebê, ultrapassando a dimensão puramente biológica que permeia esse processo. ressalta-se que as limitações da pesquisa se centraram na escassez de estudos nacionais e internacionais sobre o tema com enfoque na intergeracionalidade e migração. contudo, a representatividade teórica elaborada pelas pesquisadoras superou tais limitações em virtude do elevado referencial teórico levantado em bases nacionais e internacionais sobre amamentação, migração e geração. ademais, o levantamento bibliográfico realizado para esta pesquisa abarca estudos publicados em revistas indexadas de alta qualificação no brasil e no exterior, trazendo aspectos na área da saúde e afins com destaque para a multi e/ou transculturalidade na amamentação. destaca-se ainda que as pesquisadoras envolvidas nesta pesquisa possuem ampla experiência em produções científicas no âmbito nacional e internacional sobre a temática, especialmente em países como o brasil e portugal, o que pode ser validado no acervo bibliográfico utilizado para este estudo. conflito de interesse: nenhum declarado. 296 año 18 vol. 18 nº 3 chía, colombia septiembre 2018 aquichan issn 1657-5997 eissn 2027-5374 referências 1. moreira ma. continuidades e descontinuidades intergeracionais sobre a experiência de amamentar: um estudo de representações sociais [tese]. salvador: universidade federal da bahia; 2011. 2. rabelo df, neri al. a complexidade emocional das relações intergeracionais e a saúde mental dos idosos. pensando fam. 2014;18(1):138-53. 3. camargo bv, contarello a, wachelke jfr, morais dx, picolo c. representações sociais do envelhecimento entre diferentes 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10.4025/actascihealthsci.v38i2.28165. 35. rêgo rmv, alves e souza am, rocha tna, alves mds. paternity and breastfeeding: mediation of nurses. acta paul enferm. 2016;29(4):374-80. doi: 10.1590/1982-0194201600052. 36. yamashiro já, matsukura ts. apoio intergeracional em famílias com crianças com deficiência. psicol estud. 2012;19(4):705-15. doi: 10.1590/1413-73722419312. 37. prates la, schmalfuss jm, lipinski jm. social support network of post-partum mothers in the practice of breastfeeding. esc anna nery. 2015;19(2):310-5. doi: 10.5935/1414-8145.20150042. 1 ivonne vargas celis1 camila concha méndez2 moral distress, sign of ethical issues in the practice of oncology nursing: literature review 1 orcid.org/0000-0003-2756-7640. escuela de enfermería, pontificia universidad católica de chile, chile. ivargase@uc.cl 2 orcid.org/0000-0001-5141-0091. unidad de oncología, hospital calvo mackenna, chile. caconcha2@uc.cl received: 17/09/2018 sent to peer reviewers: 10/10/2018 accepted by peers: 06/12/2018 approved submission: 12/12/2018 doi: 10.5294/aqui.2019.19.1.3 to reference this article / para citar este artículo / para citar este artigo vargas i, concha ca. moral distress, sign of ethical issues in the practice of oncology nursing: literature review. aquichan 2019; 19(1): e1913. doi: 10.5294/aqui.2019.19.1.3 abstract objective: to describe the factors that influence the emergence of moral distress in oncology nurses. methodology: integrative review of the literature whose search will be performed in web of science databases, cinahl (ebsco), scielo, proquest, pubmed and psycinfo using the keywords moral distress and oncology nursing and their similes in spanish, without restriction for years of publication until 2017. results: the results of this review were grouped into three groups of factors each with subgroups: 1) organizational factors: ethical climate, evasive culture and resources for ethics delivered by the organization. 2) particular clinical situations: pain management, information delivery, futile treatment, and assistance to the patient and their family in the process of death, 3) interpersonal relationships: poor communication, power relations, trust in the team’s competence. conclusion: the three factors described are triggers of moral distress in oncology nurses. when there are ethical problems and the nurses do not participate in the deliberation process, these problems can be hidden and be normalized, which can diminish the moral sensitivity of the professionals, as well as the possibility of acting as moral agents. keywords (source: decs) moral distress; oncology nursing; ethics; ethical climate; ethical issues; interprofessional relations. año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1913 thematic area: chronic care. contribution to the discipline: the synthesis of the evidence that exists around the triggering factors of moral distress in oncology nurses, permits understanding how this phenomenon develops in the teams working with people with cancer and, thus, guide clinical nursing professionals and the nursing organizational leaders in investigating this problem, and in the development of interventions that protect the ethical exercise of the care practice. https://orcid.org/0000-0003-2756-7640 mailto:ivargase@uc.cl http://orcid.org/0000-0001-5141-0091 mailto:caconcha2@uc.cl http://dx.doi.org/10.5294/aqui.2019.19.1.3 http://orcid.org/0000-0003-2756-7640 http://orcid.org/0000-0001-5141-0091 http://dx.doi.org/10.5294/aqui.2019.19.1.3 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1913 angustia moral, señal de problemas éticos en la práctica de enfermería oncológica: revisión de literatura resumen objetivo: describir los factores que influyen en el surgimiento de la angustia moral en enfermeras oncológicas. metodología: revisión integradora de la literatura cuya búsqueda se realizó en las bases de datos web of science, cinahl (ebsco), scielo, proquest, pubmed y psycinfo, a partir del uso de las palabras clave moral distress y oncology nursing y sus símiles en español, sin restricción por años de publicación hasta 2017. resultados: se clasificaron en tres grupos de factores, cada uno con subgrupos: 1) factores organizacionales: clima ético, cultura evasiva y los recursos para la ética que entrega la organización; 2) situaciones clínicas complejas: el manejo del dolor, la entrega de información, el tratamiento fútil, y la asistencia al paciente y su familia durante el proceso de muerte; 3) relaciones interpersonales: una comunicación deficiente, las relaciones de poder, la confianza en la competencia del equipo. conclusión: los tres factores son desencadenantes de angustia moral en las enfermeras oncológicas. cuando existen problemas éticos, y las enfermeras no participan del proceso de deliberación, estos pueden quedar ocultos y, así, disminuir la sensibilidad moral de los profesionales, así como la posibilidad de actuar como agentes morales. es necesario explorar la relación entre la angustia moral y las implicancias en el cuidado del paciente. palabras clave (fuente: decs) angustia moral; enfermería oncológica; clima ético; problemas éticos; relaciones interprofesionales. 3 moral distress, sign of ethical issues in the practice of oncology nursing: literature review l ivonne vargas celis y otro angústia moral, sinal de problemas éticos na prática de enfermagem oncológica: revisão de literatura resumo objetivo: descrever os fatores que influenciam no surgimento da angústia moral em enfermeiras oncológicas. metodologia: revisão integradora da literatura cuja pesquisa foi realizada nas bases de dados web of science, cinahl (ebsco), scielo, proquest, pubmed e psycinfo, a partir do uso das palavras-chave moral, distress e oncology nursing e seus pares em espanhol, sem restrição por ano de publicação até 2017. resultados: criou-se três grupos de fatores, cada um deles com subgrupos: 1) fatores organizacionais – clima ético, cultura evasiva e recursos para a ética que a organização entrega; 2) situações clínicas complexas – o tratamento da dor, a entrega de informação, o tratamento fútil e a assistência ao paciente e à sua família durante o processo de morte; 3) relações interpessoais – uma comunicação deficiente, as relações de poder, a confiança na competência da equipe. conclusão: os três fatores são desencadeantes de angústia moral nas enfermeiras oncológicas. quando existem problemas éticos e as enfermeiras não participam do processo de deliberação, estes podem ficam ocultos e, assim, diminuir a sensibilidade moral dos profissionais, bem como a possibilidade de atuar como agentes morais. é necessário explorar a relação entre a angústia moral e suas implicações no cuidado do paciente. palavras-chave (fonte: decs) angústia moral; enfermagem; oncología; clima ético; problemas éticos; sensibilidade moral. año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1913 4 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 figure 1. conceptual model of moral distress by barlem and ramos source: barlem eld, ramos frs (3). introduction clinical situations exist in which nursing professionals have a clear opinion of what is the morally correct course of an action, but the institutional or hierarchical structure often keeps them from deciding what should be their own moral actions; this experience is what jameton denominates moral distress (1). distress is something different from fear or uncertainty, given that it is related with the experience of freedom as possibility, that is, the faculty an individual has to act freely (2). nursing professionals, as moral agents, have the possibility of choosing to do what is correct, but their election can be restricted by something external or internal, which generates in them a sense of powerlessness when not being able to act correctly (3). hence, moral distress appears. literature describes moral distress as a current and important problem that affects patients in different health systems (47). this phenomenon has been explored in the area of critical care (8-10) and has been described as a threat to the integrity of the nurses, as well as to the quality of patient care (11). studying it is an opportunity to transform moral distress into moral resilience and to help nurses, and other health providers, to mitigate its effects, improve the ethical environment of the practice and quality in care (12). the concept of moral distress has been discussed by different authors (3, 11, 13, 14), who are critical of the way this problem has been researched, given that errors have been detected in the objectives of the studies, as well as in the operationalization of the concept itself (14). some suggest that research should focus on improving the quality of the moral decision, moral conduct, among others (11). however, recent studies propose rethinking the way it is being investigated and suggest that it is an opportunity to address its causes, its development, and its moral foundations (15). within the literature, the work by barlem and ramos (3) stands out, proposing a conceptual model (figure 1) that explains the emergence and manifestations of moral distress. this model has as central point the moral deliberation process, which is an ethical approach where dialogue seeks to discuss rationally and reflect critically to reach an agreement (3). the deliberation process and the moral sensitivity permit seeing moral problems that could remain hidden and, therein, discuss the possible solutions or ways of coping with them within the health staff. in addition, the authors establish that multiple micro-spaces of power exist in which health professionals perform and develop their relational dynamics (3). in the oncology area, this is a growing phenomenon with health staff caring for cancer patients (16-21). among the motives 5 moral distress, sign of ethical issues in the practice of oncology nursing: literature review l ivonne vargas celis y otro how is moral distress measured? what factors contribute to the development of moral distress in oncology nurses? what factors slow down the development of moral distress in oncology nurses? for the emergence of moral distress in this area, ethical conflicts are highlighted associated with the use of advanced technology, both in relation with caring for patients, as with the treatments, entailing ethical challenges for nurses (18, 22, 23), which are derived from the complex clinical situations they experience next to their patients. due to the aforementioned, this literature review describes the factors that influence upon the emergence of moral distress in oncology nurses. methodology the review was developed from the six stages proposed by ganong (24): 1. guiding question: what are the factors that influence upon the emergence of moral distress in oncology nurses? the search used key words in english: moral distress, oncology nursing and their similes in spanish. 2. inclusion criteria: articles, editorials and reflections related with moral distress in the area of oncology nursing. no restriction was applied for years of publication, given that it is a new theme of which no literature review was found encompassing the objective of this work. the study included articles in spanish, english, and portuguese and excluded those that do not address the phenomenon of moral distress explicitly or which were not related with oncology nursing. 3. the data were obtained from the databases web of science, ebsco (cinahl), proquest central, pubmed, and psycinfo, between august and december 2017. from the key words established in the different databases, 177 registries were found; both researchers selected the articles according to the title and abstract, and discriminated them from the objective of the document, and in contrast with the initial question of the review. those not related with moral distress in oncology were excluded, as well as those from the area of palliative care and whose theme was clinical research, for a total of 38 registries (139 eliminated); and the duplicated registries (20 eliminated), for a total of 18 selected (figure 2). 4. each of the 18 articles selected was subjected to a critical reading using a process of abstraction, synthesis, and data analysis from the guide questions (chart 1) to synthesize the information collected on moral distress in the area of nursing oncology. figure 2. search strategy source: moher d, liberati a, tetzlaff j, altman dg (25). chart 1: guide questions to analyze the articles source: own elaboration. in this process, the reviewers agreed on eliminating an article that did not deal specifically with moral distress; thus, leaving a total of 17 registries for this review. both reviewers extracted from each of the articles the information corresponding to the factors that influence upon the emergence of 6 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 moral distress and gathered this information into themes or subcategories that group the factors that influence —both favorably and unfavorably— the emergence of moral distress; in turn, this information was classified into three large categories (figure 3). 5. to introduce the results, each of the categories was described according to the findings in the articles, and to discuss the results, the results obtained were contrasted and integrated with the model by barlem and ramos (3), when comparing the elements present in said model with the findings from this review, creating a new matrix to understand the phenomenon of moral distress in the area of oncology nursing (figure 4). results of the 17 articles selected for this review, seven corresponded to qualitative studies (22, 23, 26-30); six to quantitative studies (16, 31-35); two were reflections (36, 37); and two were editorials (17, 18) (figure 3). eighteen percent of the articles were published between 2006 and 2011, and 82% between 2012 and 2016 (figure 4). the studies were conducted in different countries: most of them from the united states and the rest from europe, south america, and asia (figure 5). figure 3. distribution according to the type of article source: own elaboration. figure 4. distribution by years of publication source: own elaboration. figure 5. distribution of articles according to country quantitative studies used the instrument moral distress scale (mds) (34) or the version moral distress scale revised (mds-r) (31, 35) to measure moral distress in nurses from the oncology area. another study used the pediatric version of the mds (mdspv): the items in this scale differ from the mds only in reference to pediatric subjects instead of adults (33). source: own elaboration. editorial o re�exión; 4; 24 % cuantitativo; 6; 35 % cualitativo; 7; 41 % brasil: 1; 6 % bélgica: 1; 6 % suecia: 1; 6 %inglaterra: 1; 6 % india: 1; 6 % italia: 1; 6 % irán: 1; 6 % usa; 10; 58 % 7 moral distress, sign of ethical issues in the practice of oncology nursing: literature review l ivonne vargas celis y otro table 1. articles found in the literature on moral distress in oncology nursing authors research focus study design sample summary of results ameri, safavibayatneed and kavousi (31) assess the intensity and frequency of moral distress and determine the clinical situations that lead to moral distress in oncology units. quantitative descriptive 148 nurses most of the nurses had high to moderate scores of moral distress. the nurses had experienced higher moral distress in relation with the informed consent of the patients regarding unnecessary tests during the last stages of life of these patients. bartholdson et al. (16) describe the perceptions of the hospital pediatric ethical climate among health professionals caring for children with cancer. quantitative descriptive physicians (n = 15), nurses (n = 36), and nursing aides (n = 38). a good ethical climate is a factor that could diminish moral distress. bohnenkamp et al. (32) describe how a hospital nursing staff addressed the ethical concerns and the problems occurring in the surgical oncology unit. quantitative descriptive two surveys are applied one year apart in the same place: n = 19 and n = 22 nurses. the clinical situations identified as morally distressing and the most relevant were working with inadequate or incompetent personnel (nursing or medical) and providing (by the physician) inappropriate or inefficient care to the patient. sirilla (35) explore the existence of moral distress in oncology nurses. quantitative correlational 73 oncology nurses. the type of unit and level of moral suffering were correlated, finding an inverse relationship between the level of education and moral distress. lazzarin et al. (33) translate from english into italian the pediatric version of the mds and mds-pv. quantitative correlational 156 oncology and hematology nurses. the results confirm the validity of the mds-pv to use this scale on pediatric oncology nurses and describe the results of the application of the scale. maningo-salinas et al. (34) examine the relation between the levels of moral distress experienced by oncology nurses and the probability of their rotation intention. quantitative correlational thesis 180 oncology nurses. a higher level of moral distress was weakly correlated with greater anticipated rotation. a higher level of perceived organizational support was strongly correlated with lower anticipated rotation. lievrouw et al. (27) explore variations to confront moral distress between physicians and nurses in the oncology setting of a university hospital. qualitative 18 oncology nurses with different levels of experience. moral distress was prolonged when it was accompanied by emotional distress. the four dominant forms of coping suggested the existence of a tendency to internalize or externalize moral distress and a tendency to focus on rational or experiential elements. luz et al. (22) know the ethical issues lived by oncology nurses. qualitative 18 nurses. two categories related with the experience of ethical issues: when reporting or not becomes a dilemma; investing or not dilemma related to death, compromising patient care. pavlish et al. (29) examine the challenges and postures surrounding ethically difficult situations in oncology practice. qualitative, ethnographic 30 oncology nurses. many health professionals remain silent regarding ethical concerns until a precipitating crisis occurs and the ethical issues can no longer be avoided. pavlish et al. (23) explore ethical conflicts in oncology practice and the nature of the contexts of medical care in which ethical conflicts can be avoided or mitigated. qualitative, ethnographic 30 oncology nurses. the majority of ethical conflicts refer to end-of-life complex situations. three factors were associated with ethical conflicts: delaying or avoiding difficult conversations, feeling divided between obligations in competence and silencing of different moral perspectives. 8 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 source: authors’ elaboration. authors research focus study design sample summary of results lebaron, beck, black and palat (26) explore the experience of moral distress in oncology nurses and other providers. qualitative, ethnographic 37 oncology nurses. the participants described significant problems related with the work, but the moral dimension of this distress was less clear, given that some key aspects of moral distress have limited applicability in settings where alternative courses of action are unknown, or not feasible, and where different social and cultural norms influence moral sensitivity. pye (30) explore the perceptions of physicians and nurses who work in a pediatric oncology unit, their experiences and feelings with respect to moral distress. qualitative, phenomenological 4 nurses. three themes were identified that expressed the morally distressing experiences for the participants: the importance of decision making processes, conflict on the right to treatment and retention of treatment, and communication within the staff. pavlish et al. (28). explore the experiences of oncology nurses and other key players in ethically difficult clinical situations. qualitative, ethnographic 30 nurses. nurses experienced six principal challenges to comply their objectives: being the eyes and arms of the patient’s suffering; experiencing the precariousness of conflicting obligations; navigating through the complexities of hope and honesty; managing the urgency caused by waiting, making efforts to find time and weigh the risks of speaking in hierarchical structures. shepard (18) propose that the complexity of oncological care may require interventions at various levels to address moral distress. editorial does not apply. oncology nurses are impacted by the burden of moral distress and this can affect significantly the care they offer to patients. given their pursuit of ethical discussions, they need professional and administrative support, as well as guidelines on advanced care to safeguard patient autonomy. cohen and erickson (17) present ethical agreements in nursing, as well as the situations in which oncology nurses confront ethical dilemmas. editorial does not apply. although the oncology area has unidentified ethical dilemma, scarcity of physical resources and staff, nurses can improve their practice environment, becoming examples to other nurses, as well as communication with the rest of the work staff. jodoin et al. (36) reflect on the impact of moral distress in caring for patients. reflection does not apply reflection is important along with the safe space to discuss thoughts and feelings of nurses to mitigate moral distress and, thus, be able to provide quality care to the following patients and their families. pelton et al. (37) describe the approaches used to alleviate moral distress of nurses in a surgical oncology unit and the challenges faced when addressing the complex factors contributing to that moral distress. reflection 34 oncology nurses. three areas were identified as necessary to improve: communication, education, and self-care in healthcare. 9 moral distress, sign of ethical issues in the practice of oncology nursing: literature review l ivonne vargas celis y otro from the critical analysis of the articles selected, it was possible to establish the factors that, according to the literature, favor the emergence of moral distress in oncology nurses (table 2). table 2. factors influencing upon the emergence of moral distress in oncology nurses found in the integrative review source: own elaboration. organizational factors ethical climate ethical climate refers to those factors in an organization that contribute to the skills of health professionals to identify and deal with ethical issues to provide adequate ethical care (16). a poor ethical climate is described as a trigger of moral distress in physicians and nurses in oncology units and affects inter-professional interaction (16). likewise, pavlish et al., point to the need to develop health systems in moral communities where all the members are urged to clear their ethical concerns and to deal with them in a way that promotes trust, shared understanding, and mutual respect (23). the study by bartholdson et al., on ethical climate shows that a lower percentage of the participants reported having the necessary tools to solve ethical issues, as well as time for reflection and discussion when there were ethical conflicts related with the treatment and care. according to maningo-salinas et al., health staff leaders could influence positively on the inquest of the phenomenon of moral distress in nursing professionals, upon recognizing the situations that produce moral distress (34) and when becoming aware of the impact this phenomenon can have on the team (27). organizational factors most-frequent clinical situations in oncology inter-professional relations in the oncology staff ethical climate pain management poor communication evasive culture information delivery power relations resources for ethics futile treatment little trust on the skills of other professionals assistance to the family and patient in their process of death similarly, jodoin et al., highlight the importance of creating an ethical climate; one of the useful strategies in their unit is the creation of ethical rounds (36). evasive culture to deal with difficult ethical issues according to pavlish et al., ethical conflicts in oncology are caused by delaying or avoiding difficult conversations about the poor prognosis of the patient or about the end-of-life care. in another study by the same author (29), nurses and other health providers state that ethical questions can damage relations with patients, relatives, and colleagues, which is why they avoid talking about such. the authors found that many health professionals remain silent about ethical concerns until a precipitating crisis occurs, where these matters can no longer be avoided (29). resources for ethics lack of resources for ethics, like participation in specialized programs, funding for follow-up, and time for discussion also influence on the emergence of moral distress (17, 27, 37). cohen and erickson propose that the lack of recognition of the ethical dilemma and their appropriate discussion in the team lead to having moral distress; upon this, sirilla adds that it is necessary to analyze the ethical problem through theoretical approaches that guide nurses (35). in the study by pelton et al., nurses and physicians established key words that allowed them to communicate when they disagreed, for example, with respect to a physician’s care plan. when these words were mentioned, a discussion was begun in that respect; thus, the physician reported how decisions were made in light of different processes of the disease, and this permitted the nurses to understand the steps of the treatment to facilitate their care role. additionally, in this study, the participants worked in inter-professional groups, developing solutions for stressing factors in the unit, and this allowed them an emotional bond to open communication opportunities (37). training in ethics and in coping with death can benefit nurses by increasing their self-trust in their knowledge about the end of life and on their awareness with respect to moral distress (35). sirilla recommends starting education during the initial orientation of the practice to ensure that all nurses are aware of the signs and consequences of moral distress (35). 10 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 lack of time is another resource revealed as a general concern in nurses when dealing with ethical issues. not addressing the ethical issues related with the treatment and care can trigger moral distress (16). communication, reflection, and discussion of ethical issues in specific clinical situations allow the opinions to be heard of all the members involved, and this could contribute to better ethical climate in oncology (16, 27). furthermore, the existence of support groups for the nursing professionals, comprised by other colleagues, can facilitate discussion of difficult cases, provide support and, thus, reduce moral distress (18). the same study suggests that rotation of complex patients may be useful to diminish the individual burden of moral distress (18). complex clinical situations in the area of oncology, complex clinical situations exist in which ethical aspects arise that have been widely discussed in the literature and which are a common place of current bioethics. pain management it is a complex situation that causes ethical conflicts among health professionals (34). in diverse studies, participants report that, on occasion, discrepancies exist among the team members with respect to the doses of analgesics that should be administered to a patient (29, 33, 34). they also indicate that they must follow medical indications that are not aimed at controlling the patient’s pain; thereby, this need is postponed (32). inadequate management of pain is consequential of patient suffering, which can be a source of moral distress for nurses (26), given that providing inadequate care to patients interferes with the good development of their role, which is related with a high intensity of moral distress in these professionals (31). pain management is also influenced by cultural aspects: the study conducted by lebaron et al., in india shows that nurses endure moral distress because they cannot manage their patients’ pain due to scarce resources and administrative barriers, which keeps them from acting as they believe is best for patients. information delivery oncology patients are subjected to multiple diagnostic and therapeutic procedures for which it is necessary to obtain informed consent from the patients or their families. on some occasions, nursing professionals feel they must ignore situations in which patients have no adequate information that ensures a correct process of informed consent (22, 33, 38). the study by luz et al., shows that several of the ethical issues are related with the transmission of information and orientation to patients in relation to their disease (22). reporting or not to patients and to their relatives is one of the principal ethical dilemmas experienced by nurses, and this can be potentiated by the family’s difficulty in perceiving the information (22, 23). oncology patients have doubts about the diagnosis and medical prognosis of the cancer, and that makes nurses act as links between them and other members of the health staff to make sure patients are informed and have clarity about their care (22). futile treatments at the end of life shepard and pavlish et al., demonstrate that, for the majority of nurses, administering an aggressive treatment to oncology patients during the end of their lives is an ethically difficult situation (18, 23). similarly, witnessing the adverse effects of the treatment causes them moral distress, especially when the objective of care is focused on palliative care and not on curative care (28). the study by lazzarin et al., shows that the situations in which the family wishes to continue with the treatment, although this is not the best for the child, is a circumstance that causes moral distress to the nurses caring for pediatric patients with cancer (33). the study by pye mentions that for nurses moral conflicts emerge when limits do not exist with respect to the reanimation of patients at the end of their lives (30). shepard, in turn, indicates that ethical conflicts appear when physicians and the families make decisions that harm the quality of life of the patients (18). assistance to patients and their families during the process of death a qualitative study found that some of the important ethical conflicts in oncology refer to confronting situations appertaining to end of life, like administering aggressive treatments during this stage (29), responding to the request of suicide assistance by the patient when a bad prognosis is received (34), and delivering inadequate palliative care (30). this prolongs the process of death with unnecessary aggressive care and offers false hope (32). 11 moral distress, sign of ethical issues in the practice of oncology nursing: literature review l ivonne vargas celis y otro along with these situations, it has been added that many times health providers delay conversations about precarious prognoses or about the treatment at the end of life (29). remaining silent upon these situations can act as a trigger of moral distress in nurses (23, 29, 33). interpersonal relations in the oncology staff poor communication the health staff in oncology is comprised of members from various disciplines, and lack of communication among them lead to important problems being misinterpreted or misunderstood, which could provoke moral distress in its members (37). the qualitative research conducted by pye indicates that poor communication and scarce dynamics within the team and within the decision-making process can influence the appearance of moral distress in nurses (30). in this regard, jodoin et al., indicates that respect is fundamental for the opinions of the rest when the different professions do not coincide on what is best for the patient (36). inclusion of nurses as equal partners and informed in formal communication and in the deliberation processes is key to prevent moral distress (23, 28, 29, 32). staff meetings permit clarifying the procedure to follow in relation to the treatment and care plan (35). discussing ideas, concerns, and feelings that emerge from the complex clinical situation permit diminishing moral distress (23, 32) and having better management to provide quality care to other patients (36). power relations differences in professional roles involve distinct power relations, and this can be reflected in the perception of a more or less positive ethical climate among the team members (16). lack of participation in decision making leads to feelings of powerlessness and devaluation in nurses (30); these can believe that they are incapable of solving ethical conflicts, as well as fearing failure when solving them, or not having enough experience, and this will keep them from formulating ethical questions in the interaction with other professionals (17). in the study by pavlish et al., nurses report that working in ethically difficult situations requires time and space; however, the care system in oncology, often, sacrifices comprehensive care for care focused on efficiency due to the high demands of care (28). additionally, some nurses expressed fear of speaking when their own professional or personal perspectives differed from the predominant voices of the medical care team (28). trust in the team’s competence the study carried out by ameri et al., in iran (31) shows that working with colleagues or other health care providers who are quite competent to care for oncology patients propitiates the emergence of moral distress. recognition of inadequate situations related with negligence, lack of preparation, and professional incompetence can lead these professionals to suffer this phenomenon (22, 32, 39). added to this are prejudices among the different disciplines: for example, nurses indicate that physicians do not experience moral distress, given that they do not spend sufficient time with patients to have ethical conflicts (27). discussion figure 6 links the results from this review in light of the central concepts of the conceptual model of distress proposed by barlem and ramos. said figure demonstrates that the scenario in which the emergence of moral distress is described in nursing professionals is the health institution, particularly the oncology unit, a micro-space of power that frames the health staff caring for cancer patients, as well as the relations developed among its members. this health staff is made up by different professionals, among which there are the nursing professionals. nursing professionals who work with people with cancer are exposed constantly to complex clinical situations with associated ethical aspects. besides, in this model, a key aspect is moral sensitivity, which implies having self-critical view to perceive the moral content of the actions, facts and thoughts related with their clinical practice (3) to, thus, become moral agents (40). figure 6 lists the triggering factors of moral distress in oncology nurses. first, there are the organizational factors that correspond to the ethical climate, evasive culture, and resources for ethics; these generate the organizational context in which the health staff performs. the institution plays a fundamental role in delivering the resources to develop ethical competences, and these permit nurses to negotiate and confront administrative and relational obstacles. the findings in this review agree with other authors (41, 42) who indicate that it is necessary to provide a support environment in the hospitals and to consider strategies to diminish 12 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 moral distress. in the oncology area, nurses report that the principal barriers for an ethical practice to take place are lack of time, absence of physical spaces for debate and support by the institutional leaders and policies that permit the development of an ethical climate, which coincides with the results found in nurses who work in the area of critical care (8, 43). the second factor in figure 6 is the health staff confronting complex clinical situations, like pain management, information delivery, consideration of a treatment as futile, and assistance to patients and their families during the process of death. these situations can be favorable scenarios for the appearance of moral distress in oncology nurses (44), when these professionals do not participate in decision making in relation to therapeutic actions or when a clash of values occurs between the nurse’s perspective and that of other professionals in decision making. this finding is similar to that found in investigations in critical care (45, 46), neonatal and pediatric areas (10, 47), and is different from that found in emergency units, where other factors exist, like acute technical environment and high demand with insufficient resources (48). the third factor that triggers moral distress (figure 6) is inter-professional relations in the oncology staff. in oncology, poor communication, differences in power relations, and poor trust in the competence of other professionals are described in this setting. power relations, according to barlem and ramos, are not merely structures or prohibitions, but also consequences of constant and sustained confrontations over time that define the micro-spaces of power. in the case of oncology, the results show that a scarce dynamic exists within the teams, which marks these spaces with diminished participation by the nurses in decision making. likewise, the relationship of power is manifested in the fear of nurses in dealing with difficult themes because they are afraid of damaging current or future work relations, which agrees with other studies (49). in this review, power relations defined the space in which the moral deliberation process took place in oncology. in this key stage of the model, the professionals can discuss their own perspective, bearing in mind the visions of the rest of the team members, and this coincides with other authors who have highlighted the importance of the organization of the teams in the development of moral distress (50). when this process is obstructed, moral perspectives are silenced and the consequence is a feeling of powerlessness in the nurses that keeps them from undertaking the actions they perceive as correct. the obstruction triggers a chain of moral distress that includes the sense of impotence, mortification of their own interests and reduction of resistance to the phenomenon of moral distress. this triggers a process of normalization of the situation and of indifference toward the moral problems of the daily practice of oncology nursing. conclusions the model of moral distress by barlem and ramos (3) permits giving flow to the elements presents in the emergence of moral distress and shows how the obstruction of the moral deliberation process and power relations are central elements in the chain of moral distress, by making it possible to link, coherently, the results of this review. furthermore, it permitted arranging the results of the review in a cohesive diagram that exposes the dynamics of the teams shown by oncology nurses in the distinct articles reviewed. when ethical issues exist in the clinical situations experienced by oncology nurses, and they do not participate in the deliberation process, these can remain hidden and be presented as normal, which diminishes the moral sensitivity of the professionals and the possibility of acting as moral agents. in all, the three factors described are triggers of moral distress in oncology nurses. the concept of moral distress applied in oncology involves problems related with the growing demand for care by patients and their families, scarcity of human and material resources, scarce organizational support, training in ethics, correct management of the information provided to the family on the patient’s treatments, times of reflection and dialogue regarding death, among others, which makes the study of this phenomenon in oncology even more complex. finally, in terms of the professional role, it is worth noting that studies are needed to explore physical, psychological, and behavioral manifestations in oncology nurses. likewise, it would be important to investigate the implications of moral distress in caring for cancer patients. it is fitting to ask why some nursing professionals normalize the contexts in which moral problems develop and give up on moral resilience (51). the answer could be related with factors, like lack of personal skills, the wear caused by negotiating with other professionals, and clinical demands in oncology that take up an important part of the nurses’ time. conflict of interest: none declared. acknowledgments: the authors thank the school of nursing at pontificia universidad católica of chile for providing space to the elaboration of this work. 13 moral distress, sign of ethical issues in the practice of oncology nursing: literature review l ivonne vargas celis y otro figure 6. approximation of the review results of the factors that influence upon the emergence of moral distress in oncology nurses to the model 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http://dx.doi.org/10.1177/0969733017712082 http://dx.doi.org/10.1177/0969733012462049 http://onf.ons.org/onf/33/5/understanding-moral-distress-nurses-witnessing-medically-futile-care http://onf.ons.org/onf/33/5/understanding-moral-distress-nurses-witnessing-medically-futile-care http://dx.doi.org/10.1016/j.aucc.2017.01.007 http://dx.doi.org/10.4037/ajcc2018968 http://dx.doi.org/10.1177/0969733017708330 http://dx.doi.org/10.1016/j.jen.2015.08.008 http://dx.doi.org/10.1097/ans.0000000000000004 http://dx.doi.org/10.1177/0969733014534879 https://www.ncbi.nlm.nih.gov/pubmed/27323473 https://www.ncbi.nlm.nih.gov/pubmed/27323473 1 josé augusto gomes1 maria manuela martins2 daisy maria rizatto trochin3 carla sílvia fernandes4 validation of a scale on structure indicators in the operating room: contributions to nursing 1 orcid.org/0000-0002-7486-1378. instituto de ciências biomédicas abel salazar, portugal. joseaugusto.gomes@limacorporate.com 2 orcid.org/0000-0001-5530-3891. escola de enfermagem do porto, portugal. mmartins@esep.pt 3 orcid.org/0000-0003-3192-1956. nursing school, universidade de são paulo, brasil. daisyrt@usp.br 4 orcid.org/0000-0001-7251-5829. universidade fernando pessoa, portugal. csfernandes@ufp.edu.pt received: 16/08/2018 sent to peer reviewers: 04/09/2018 accepted by peers: 14/11/2018 approved submission: 10/12/2018 doi: 10.5294/aqui.2019.19.1.7 to reference this article / para citar este artículo / para citar este artigo gomes ja, martins mm, trochin d, fernandes cs . validation of a scale on structure indicators in the operating room: contributions to nursing. aquichan 2019; 19(1): e1917. doi: 10.5294/aqui.2019.19.1.7 abstract objective: measuring instruments play, namely, an important role in the safety and quality of care. the aim of this study consists in validating a scale conceived to evaluate the structure of the operating room (or). materials and methods: validation and psychometric evaluation were carried out of the instrument. the sample was comprised of 1019 professionals working in the or for at least two years in 71 portuguese hospitals; the research was conducted in 2017. results: the results obtained in the reliability and validity tests reveal good internal consistency. the 28 items of the scale, and after the principal components analysis, were grouped into seven dimensions: “environment and equipment”, “resources for quality and safety”, “circuits in the operating room”, “facilities and operating requirements”, “training and praxis in the operating room”, “continuity in nursing care”, and “specificities of professional groups”. conclusion: the psychometric study allows us to state that the scale of structure indicators in the operating room (sior) is a reliable and valid instrument. its use will permit evaluating and monitoring the structural conditions of the ors. keywords (source: decs) health evaluation; operating rooms; quality of health care; validation studies. año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1917 theme: promotion and prevention contribution to the discipline: monitoring the quality of care provided in the operating room is of particular importance for the continuous improvement and safety of care, for which valid instruments must be used. this study presents the validation of a scale with indicators on the structure in the operating room, with particular importance for nursing, due, principally, to the different roles nurses perform in the intraoperative (instrumentalist nurse, circulating nurse e anesthesia nurse), but also to the decisive role as managers in the operating rooms. http://orcid.org/0000-0002-7486-1378 mailto:joseaugusto.gomes@limacorporate.com http://orcid.org/0000-0001-5530-3891 mailto:mmartins@esep.pt http://orcid.org/0000-0003-3192-1956 mailto:daisyrt@usp.br http://orcid.org/0000-0001-7251-5829 http://dx.doi.org/10.5294/aqui.2019.19.1.7 http://orcid.org/0000-0002-7486-1378 http://orcid.org/0000-0001-5530-3891 http://orcid.org/0000-0003-3192-1956 http://orcid.org/0000-0001-7251-5829 http://dx.doi.org/10.5294/aqui.2019.19.1.7 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1917 validación de una escala sobre indicadores de estructura en el bloque operatorio: contribución para la enfermería resumen objetivo: los instrumentos de medida desempeñan, particularmente, un importante papel en la seguridad y la calidad de los cuidados. el objetivo de este estudio consiste en validar una escala concebida para evaluar la estructura del bloque operatorio (bo). materiales y método: se realizó la validación y la evaluación psicométrica del instrumento. la muestra fue de 1019 profesionales con actividad en el bo durante al menos dos años en 71 hospitales portugueses; la investigación se realizó en 2017. resultados: los resultados obtenidos en las pruebas de confiabilidad y validez revelan una buena consistencia interna. los 28 ítems de la escala, y después del recurso al análisis de componentes principales, quedaron agrupados en 7 dimensiones: "ambiente y equipamientos", "recursos para la calidad y seguridad", "circuitos en el bloque operatorio", "instalaciones y requisitos de funcionamiento "," formación y praxis en el bloque operatorio "," continuidad en la asistencia de enfermería ", y" especificidades de los grupos profesionales ". conclusión: el estudio psicométrico permite afirmar que la escala de indicadores de estructura en el bloque operativo (iebo) es un instrumento fidedigno y válido. su utilización permitirá evaluar y monitorear las condiciones estructurales de los bo. palabras clave (fuente: decs) evaluación en salud; quirófanos; sala de cirugía; calidad de la atención de salud; estudios de validación. 3 validation of a scale on structure indicators in the operating room: contributions to nursing l josé augusto gomes and others validação de uma escala sobre indicadores de estrutura no bloco operatório: contributos para a enfermagem resumo objetivo: os instrumentos de medida desempenham, nomeadamente, um importante papel na segurança e qualidade dos cuidados. o objetivo deste estudo consiste em validar uma escala concebida para avaliar a estrutura do bloco operatório (bo). material e método: foram realizadas a validação e a avaliação psicométrica do instrumento. a amostra foi constituída por 1019 profissionais com atividade no bo há pelo menos dois anos em 71 hospitais portugueses; a pesquisa foi realizada em 2017. resultados: os resultados obtidos nos testes de confiabilidade e validade revelam uma boa consistência interna. os 28 itens da escala, e após o recurso à análise de componentes principais, ficaram agrupados em sete dimensões: “ambiente e equipamentos”, “recursos para a qualidade e segurança”, “circuitos no bloco operatório”, “instalações e requisitos de funcionamento”, “formação e práxis no bloco operatório”, “continuidade na assistência de enfermagem”, e “especificidades dos grupos profissionais”. conclusão: o estudo psicométrico permite-nos afirmar que a escala de indicadores de estrutura no bloco operatório (iebo) é um instrumento fidedigno e válido. a sua utilização permitirá avaliar e monitorizar as condições estruturais dos bos. palavras-chave (fonte: decs) avaliação em saúde; salas cirúrgicas; qualidade da assistência à saúde; estudos de validação. año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1917 4 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 introduction the operating room (or) is a complex work structure in the health area and, with the quality and safety of the work processes, it must be continually monitored (1-3). the health sector, notably competitive and dynamic, promoted hospitals to offer higher quality of services through efficient evaluation systems to control, monitor, and improve the efficiency of the service provided by health organizations in the or (4). the ors are hospital units with large and costly resources (5, 6) that often respond for the financial success of a hospital (6). the quality of care provided in the or is, thereby, a high priority for hospitals, especially during an era in which the provision of health care is increasingly challenging (3), which makes it essential to use efficient and accurate measuring systems as a useful tool, and allows managers to control and monitor health services (5). numerous factors restrict the productivity and efficiency of the or, including its structure, problems in managing human, financial, and material resources, among others (6). in a review study of evaluation instruments in the or, the authors highlight that the instruments are more frequent within the scope of the process, in addition to being essentially associated with the safety and risk culture proposed by the world health organization (who) (1). the measurement should be multidimensional and involve several components; however, what we frequently observe in health are indicators very focused on financial aspects, that is, on operational results, ignoring other indicators (4). that aspect highlights the need for further development of valid and more comprehensive instruments, integrating the different components of quality evaluation (1), among them, the structure indicators. the structure deals with the relatively stable and necessary characteristics to provide care and integrates the resources and the organizational structure (7). proper functioning of the or also depends on the physical structure, new technologies, adequate materials and equipment, among others (8). while there is little doubt that technological advances have contributed to patient safety, the growing disparity between surgical innovations and the physical environment may contribute to an unacceptable number of adverse events that can be avoided (9). in a literature review study on the environmental conditions of the or, the authors, in 182 empirical cases, focus on some aspects related to the structure of the or, like size, temperature, humidity and air quality, noise, and ergonomic design (10). in addition, another review study seeking to identify instruments to assess the culture of safety in ors; of the 47 studies included, the authors state that although the culture of patient safety is considered important in healthcare, the number of studies using valid instruments is still quite small (11). in health services, care is no longer centered on individual professions or specialties and converges on the organization as a whole, in which the principles and strategies of total quality management include the rupture of professional barriers and better management of resources, with nursing playing a predominant role. everyone should commit to improving the quality of the health services offered to patients and their families, especially in variables that may affect the quality and safety of the care provided. thus, the need and relevance of this study is reiterated, inserted in the nursing field, considering, on the one hand, the different roles nurses play in the intraoperative (instrumentalist nurse, circulating nurse, and anesthesia nurse), as well as the decisive role they hold as managers in the ors. however, the management systems used by nursing in the or are highly subjective and do not integrate all the work components associated with the safety and quality of care (12), which justified the need for this research. from this problematic, it is emphasized that, despite the increasing use of health measurement instruments in health, it was not possible to find in the literature adequate instruments to evaluate the structure of the or. thus, this study sought to validate a scale designed to evaluate the structure in question (scale of structure indicators in the or — sior scale). we believe that the research could become an important contribution to analyze, monitor, and improve the quality of service provided in the or. materials and method this was a methodological study comprising the construction and validation of the sior scale, following the steps recommended in the literature (9). in a review of the literature, we verified that emphasis has been placed on the importance of adequate psychometric evaluation of the measuring instruments, especially with regard to the evidence of its validity and reliability (13-17). 5 validation of a scale on structure indicators in the operating room: contributions to nursing l josé augusto gomes and others the construction of said scale, as well as the items included in it, results from prior studies. initially, there was a first field study, of qualitative nature, when interviews were conducted with physicians, nurses, service directors, and members of the administration of hospital units to identify what dimensions would be necessary to include to evaluate quality in the or. to the set of indicators resulting from the analysis of the previous data other indicators were added resulting from a systematic revision on instruments to evaluate quality in the or (1). to gauge the new proposal of instrument, it was reviewed by a panel of experts through a focal group, from which resulted the 28-item scale within the structure used in the course (2). the items of the scale are expressed in affirmative phrases, which must be answered through a likert scale with five response options: “totally disagree”, “partially disagree”, “indifferent”, “partially agree”, and “totally agree”. thereafter, a pre-test was conducted of the scale with 30 nurses who did not participate in the study. after applying the pre-test, it was possible to make some modifications in certain questions to avoid incongruities in the answers. thus, the sior scale was made up of 28 items. the data were collected through a questionnaire with characterization of the participants and through the sior scale. in relation to the sociodemographic characterization, the variables were gender, age, profession, professional category, type of block, years of professional experience, and years working in the or. the questions in the sior scale encompass variables associated with the facilities, environments, equipment, along with human, financial, and organizational resources. the questionnaire was applied through an electronic form to 1019 professionals working in the or and who met the following inclusion criterion: being a nurse or physician with direct action in or for more than two years in portugal. data collection took place from january to may 2018. data treatment used the statistical package for the social sciences (spss), version 24. for the psychometric study, recommendations from the literature on the theme were followed (15). namely, through the kaiser-meyer-olkinque measure to compare simple correlations, and the principal components analysis with orthogonal varimax rotation, the factorial analysis was performed based on the kaiser rule, excluding factor loads <0.30, in case of existing (13). in addition, a total explained variance greater than 40 was used, as well as the internal consistency evaluation through cronbach’s alpha. regarding ethical considerations, the study was carried out after authorization from an ethics commission (nº ces246-16) and then forwarded to the other institutions. respondents were informed of the study and its objectives and of the voluntary nature of their participation, through informed consent. in addition, anonymity and confidentiality were guaranteed in all responses and the research participants’ right to privacy was ensured. results the validation of the sior scale, composed of 28 items, included 1019 professionals working in the or, namely nurses (73.4 %) and physicians (26.6 %) from 71 portuguese hospitals. of these, 69.2 % were females, with a mean age of 43 years (± 9.7) and an average time of professional exercise of 19.5 (± 9.6) years. throughout the text, assessments regarding the psychometric characteristics of the scale are presented, especially with regard to their reliability and validity. table 1 presents data regarding the characterization of the minimum (min), maximum (max), median (med), mode and variation coefficient (var coeff). the categories of the likert scale were designated by the respective orders, where it is observed that the participants’ answers cover the whole range of the scale, that is, from 1 to 5. psychometric characteristics of the sior scale after the individual study of the evaluation items of the sior scale referring to the or structure, we proceeded to an analysis of the conceptual structure of this scale through an exploratory analysis factor, keeping in mind the identification of the underlying factors of said assessment. such factors allowed understanding the motivations behind the pattern found in the responses, as well as measuring the validity of said instrument for the objective sought. at first, correlations were noted between the degrees of agreement of the various items, as well as the existence of many moderate correlations and a considerable number of high correlations. in addition, the inter-item medium correlation is 0.267, which is due to the existence of low correlations between some items (usual situation in any questionnaire, given that this value is acceptable). in turn, the corrected item-total correlations are all 6 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 table 1. descriptive statistical analysis of the sior scale source: own elaboration. min max med mode var coeff 1the or has the necessary dimensions for adequate functioning. 1 5 4 4 40.7 2the ors have the required dimensions (useful area > 36 m2 and length > 5.5 m). 1 5 4 5 37.3 3the recovery unit has the necessary dimensions for the activity of this or. 1 5 4 4 51.5 4the safety of the professionals is ensured in the or. 1 5 4 4 34.8 5the patient’s safety is guaranteed in the or. 1 5 4 4 25.6 6the or has the necessary infrastructure for adequate functioning. 1 5 4 4 34.7 7the or has an anesthetic induction room to increase its efficiency. 1 5 2 1 61.7 8the or has a waiting room for patients, before they enter the or. 1 5 2 1 58.3 9the clean and dirty circuit is clearly separated. 1 5 4 5 48.4 10the circuit of professionals, patients, and materials is duly separated. 1 5 4 4 50,1 11the physical work environment (temperature, humidity, noise, and lighting) is appropriate for the practice of surgical care. 1 5 4 4 41.8 12the technology of the equipment is suitable for the types of procedures performed in the or. 1 5 4 4 28.3 13the equipment is that necessary for the procedures carried out. 1 5 4 4 27.8 14preventive maintenance actions are carried out on existing equipment. 1 5 4 4 34.3 15corrective maintenance actions are performed in timely manner. 1 5 4 4 36.2 16waste is minimized in the or activity. 1 5 4 4 33.5 17the professionals have the necessary skills to perform functions in the or. 1 5 4 4 24.1 18the ratios in their professional area are adequate for the or activity. 1 5 4 4 42.1 19the specific characteristics (schedule, functions, etc.,) of some professional groups interfere with the functioning of the or. 1 5 4 4 28.6 20the pre-operative activities to provide quality health care are adequate. 1 5 4 4 37.6 21the post-operative activities to provide quality health care are adequate. 1 5 4 4 33.1 22the or nurse makes a pre-operative visit. 1 5 1 1 71.3 23the or nurse makes a post-operative visit. 1 5 1 1 72.9 24patients have anesthesia consultations prior to hospitalization. 1 5 4 4 30.9 25the anesthesiologist makes a preoperative visit. 1 5 4 4 44.1 26top management is involved in the definition and implementation of management policies in the or. 1 5 4 4 37.6 27teaching activities are carried out in the or. 1 5 4 4 32.8 28continuous training activities are conducted in the or. 1 5 4 4 32.9 7 validation of a scale on structure indicators in the operating room: contributions to nursing l josé augusto gomes and others moderate or somewhat elevated, with the sole exception of item 19. thereafter, we proceeded to calculate the adequacy measure of the kaiser-meyer olkin sampling, presented in table 2 for each item and for the whole scale (global value). obtaining a value of 0.9 in the kaiser-meyer olkin coefficient allowed gauging the adequacy of the analysis factor. the data revealed that the factorability of the correlation matrix is appropriate to perform a factor analysis from them. table 2. structure dimension subscale ― adequacy measurement of the kmo sampling items kmo items kmo items kmo items kmo 1 0.916 8 0.911 15 0.894 22 0.686 2 0.921 9 0.850 16 0.955 23 0.678 3 0.909 10 0.873 17 0.947 24 0.925 4 0.936 11 0.966 18 0.957 25 0.895 5 0.930 12 0.881 19 0.427 26 0.972 6 0.958 13 0.877 20 0.902 27 0.848 7 0.915 14 0.899 21 0.907 28 0.839 global 0.900 source: own elaboration. the factor analysis was performed with extraction of factors through the principal components method, in which a solution was obtained of seven factors that included the 28 items of the scale and explained 62.1 % of the total variance. the results of the factor analysis forced to seven factors followed by varimax rotation and kaiser normalization are presented in the following table, with reference to communalities. that is, the percentage of variance of each item was explained together with the seven factors extracted. in the factor analysis, no item was excluded and all presented a correlation value ≥ 0.4. with regard to the factorial structure obtained, it should be highlighted that factor 1 explained 31.30 % of the variance and is composed of five items, namely, 11, 12, 13, 14, and 15. once the items are associated with the presence of equipment, technology, maintenance, and environmental characteristics, principally temperature, humidity, among others, the designation of “environment and equipment” was attributed. factor 2 explained 8.16 % of the variance and it includes items 5, 16, 17, 18, 20, 21, and 26; because these items relate to human, table 3. factor analysis items fact.1 fact.2 fact.3 fact.4 fact.5 fact.6 fact.7 com. 11 0.495 0.537 12 0.742 0.716 13 0.768 0.727 14 0.767 0.694 15 0.770 0.712 5 0.422 0.574 16 0.554 0.583 17 0.562 0.458 18 0.575 0.408 20 0.643 0.609 21 0.706 0.630 26 0.397 0.437 7 0.701 0.517 8 0.578 0.419 9 0.745 0.667 10 0.720 0.655 1 0.647 0.683 2 0.634 0.646 3 0.598 0.548 4 0.479 0.601 6 0.618 0.658 25 0.464 0.400 24 0.413 0.428 27 0.819 0.774 28 0.838 0.802 22 0.873 0.794 23 0.868 0.803 19 0.943 0.905 source: own elaboration. organizational, and financial resources to provide quality care, as well as variables associated to safety, the factor was designated “resources for quality and safety”. factor 3 already explained 6.33 % of the variance and saturate items 7, 8, 9, and 10. the items are related to the circuits inside the or referring to the patient, professionals and clean and dirty circuits, which is why the factor was called “circuits in the operating room”. 8 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 factor 4, in turn, was composed of six items (1, 2, 3, 4, 6, and 25) and explained 4.58 % of the variance. the items relate to variables associated with the dimensions of the different or structures and the necessary conditions for its functioning. thus, we attribute to this factor the designation of “facilities and operating requirements”. with regards to factor 5, it explained 4.43 % of the variance and is composed of items 24, 27, and 28. the items relate to issues associated with education and training and to the set of activities aimed at promoting quality and way of performing in the practice. the factor was titled “training and praxis in the operating room”. with relation to factor 6, it was composed by items 22 and 23 and explained 3.69 % of the variance because it is associated with pre-and postoperative nursing visits. it was designated as “continuity in nursing care”. lastly, factor 7 is composed of only one item (19) and explained 3.58 % of the variance. the item was not associated to any other, that is, it was isolated in a factor, meaning that the response pattern is different from all the other items. in fact, this item focuses on a very particular and diverse aspect of all the others, given that it refers to the specific characteristics of the professional groups, especially schedules, functions, etc., and how these interfere in the or functioning. the factor was designated as “specificities of professional groups”. although factor 7 only has one item, it was maintained by the relevance of its evaluation, highlighted by the review on the theme (1) and by the group of experts (2), especially regarding, for example, the schedule gap of the different professionals who integrate the surgical team. spearman’s matrix of correlations between the factors is found in table 4. the factor “environment and equipment” (factor 1) had significant correlations with all the others, except with the “specificities of professional groups” (factor 7). these correlations are all positive, although moderate with factors 2 to 5 and weak with factor 6. the factor “resources for quality and safety” (factor 2) had relevant correlations with the following factors, except with the “specificities of professional groups” (factor 7). the correlations were also all positive, likewise moderate with factors 3 to 5 and weak with factor 6. the factor “circuits in the operating room” (factor 3) had significant correlations with the following factors, except with the “specificities of professional groups” (factor 7). the correlations were all positive, although moderate with factors 4 and 5 and weak with factor 6. the factor “facilities and operating requirements” (factor 4) presented significant correlations with the following, except with the “specificities of professional groups” (factor 7). the correlations were both positive, but moderate with factor 5 and weak with factor 6. the factor “training and praxis in the operating room” (factor 5) had significant, positive and weak correlation with factor 6 and a non-significant correlation with factor 7. already the factor “continuity in nursing care” (factor 6) presented a non-significant correlation with the factor “specificities of professional groups” (factor 7). it should be noted, therefore, that this last factor was not correlated with any of the others, being the only one in this situation. in fact, the factorial weight of the item in factor 7 is very high (0.913), as well as the respective communality (0.905), which leads to admitting the utility of keeping this item in the scale, that is, the relevance of its validity. it was concluded, in fact, that it is a different aspect from all the others contemplated in the instrument, but it remains important, that is, it was considered that it is relevant to evaluate the functioning of the or in the part given by this item and, therefore, opting to consider it valid and to keep it in the instrument. for the quality evaluation of the factorial model obtained, it was possible to observe the matrix of the residuals, that is, the matrix of the differences between the existing correlations between the items and those estimated by the factorial model with the seven factors retained. herein, 113 residuals were identified (that is 2 %) with an absolute value > 0.05, which indicates a good quality of fit, that is, when the waste percentage is < 50 %. in addition, the quality index of fit or goodness of fit index (gfi) was 0.839, indicating good quality. in turn, the root mean square residual (rmsr) was 0.05, which also means that the fit has a good quality. in synthesis, the coefficients show overall that the fit has good quality. 9 validation of a scale on structure indicators in the operating room: contributions to nursing l josé augusto gomes and others factors alpha fc 1 environment and equipment 0,848 0,856 2 resources for quality and safety 0,805 0,811 3 circuits in the or 0,751 0,768 4 facilities and operating requirements 0,806 0,821 5 training and praxis in the or 0,715 0,765 6 continuity in nursing care 0,819 0,819 table 4. matrix of correlations among the factors of the sior scale fa ct or s factors factor 1 factor 2 factor 3 factor 4 factor 5 factor 6 factor 7 factor 1 coeff. 1.000 0.636 0.390 0.568 0.430 0.171 -0.032 p val <0.001 <0.001 <0.001 <0.001 <0.001 0.307 factor 2 coeff. 1.000 0.424 0.591 0.523 0.280 -0.060 p val <0.001 <0.001 <0.001 <0.001 0.054 factor 3 coeff. 1.000 0.572 0.325 0.147 0.032 p val <0.001 <0.001 <0.001 0.315 factor 4 coeff. 1.000 0.381 0.118 -0.002 p val <0.001 0.0002 0.944 factor 5 coeff. 1.000 0.294 -0.003 p val <0.001 0.913 factor 6 coeff. 1.000 -0.040 p val 0.206 factor 7 coeff. 1.000 p val source: own elaboration. finally, the reliability and the validity of the scale were evaluated. the values of cronbach’s alpha coefficient and of reliability are found in table 5. the last factor was not included because it had only one item and it was not possible to calculate. the alpha value for the whole scale was 0.907, which is very high and shows a very strong internal consistency. referring to the composite reliability of all the factors, these showed high reliability. for their future application and according to the dimensions obtained to be applied as evaluation instrument of the structure in the or, standardization criteria are proposed of the scale presented in table 6. table 5. coefficients of internal consistency table 6. standardization criteria of the scale source: own elaboration. factors min-max level of quality values environment and equipment 5-25 low 5 to 14 medium 15 to 19 high 20 to 25 resources for quality and safety 7-35 low 7 to 20 medium 21 to 27 high 28 to 35 circuits in the or 4-20 low 4 to 11 medium 12 to 15 high 16 to 20 facilities and operating requirements 6-30 low 6 to 17 medium 18 to 23 high 24 to 30 training and praxis in the or 3-15 low 3 to 8 medium 9 to 11 high 12 to 15 continuity in nursing care and specificities of professional groups 2-10 low 2 to 5 medium 6 to 7 high 8 to 10 specificities of professional groups 1-5 low 1 to 2 medium 2 to 3 high 4 to 5 source: own elaboration. discussion this study sought to validate a scale to evaluate the structure in the or (sior scale). measurement in health is essential in scientific research and in clinical practice. through the application of scales in health, decisions can be made, which is why the instruments must be reliable and valid. on the contrary, serious risk exists of obtaining inaccurate or biased results that may lead to erroneous conclusions (13). the sior scale presents good validity and reliability indicators. it was possible to observe that the data obtained were subject to factor analysis. the kmo value obtained was 0.900 and permitted stating that the correlation matrix factor is good (14). the factor analysis, with extraction of factors using the principal components method, by means of the kaiser rule, permitted 10 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 explaining 62.1 % of the total variance. said analysis involved an acceptable number of factors and was considered the best solution in terms of interpretation and meaning of the dimensions. all the items collected, in the different factors, weights above or equal to 0.4. according to the authors, the parameters of the coefficient of reliability vary, but, in general, values below 0.40 are considered low reliability; between 0.40 and 0.69, moderate reliability; and above 0.70, high reliability (15). in the instrument presented, the majority of the items revealed high reliability. the correlational analysis among the items of the scale and the global scale also supports the suitability of the instrument. the internal consistency of the scale established by cronbach’s alpha showed adequate reliability indices for its global version (0.9) and for each of its factors, in which none of the results was below 0.7. most researchers evaluate internal consistency through cronbach’s alpha coefficient (16), but there is no consensus as to which cronbach’s alpha coefficient values are ideal, but, in general, it is recommended to adopt coefficients > 0.70 (13, 14, 16). from the exploratory factor analysis with varimax rotation, the 28 items were grouped into seven dimensions, namely: “environment and equipment”, “resources for quality and safety”, “circuits in the operating room”, “facilities and operating requirements”, “training and praxis in the operating room”, “continuity in nursing care”, and “specificities of professional groups”. referring to questions of “environment and equipment”, the hospitals face increasing pressure to meet the demands, often contradictory, of providing a safe environment and, at the same time, control operational costs. data based on scientific evidence is necessary to provide adequate information to manage the or facilities and respond to said demands. given this framework, the use of measurable environmental quality indicators can contribute to optimizing the cost and quality of an or (18). furthermore, the or equipment plays a crucial role in caring for patients in a health environment. with the development of innovative and advanced equipment, surgeons are able to perform surgeries efficiently as it becomes easier to manage increasingly complex procedures; however, they represent high costs for the hospitals (19). the factor “resources for quality and safety” incorporated items referring to human, financial, and organizational resources promotors of a culture of safety in the or. the safety issues associated with the checklist concept have been widely disseminated by the who as central guideline for care practice in the or (1). the factor “facilities and operating requirements” evidenced some architectural aspects of these units. according to the authors, many ors were built more than 30 years ago, and a common solution has been to increase the size of the surgical center to try to accommodate more equipment and larger teams. nevertheless, most are inadequately designed to handle equipment, processes, technology, and people that a well-functioning contemporary or needs (10). the ideal project of an or must incorporate the best practices to reduce environmental contamination, but should also consider the optimal placement of equipment and recognize that circuits are critical to patient safety. the regulation of clean and dirty circuits is important to reduce the risk of infection (20). this aspect is visible in factor 3 referring to the “clean and dirty circuit” in the operating room. in addition, advances in surgery support the need for a greater focus on training and the surgical practice, by means of simulators and serious games in the training programs of the most diverse levels (21) and replicate them so there is better “training and praxis in the operating room”, visible in factor 5. factor 6, titled “continuity in nursing care”, reinforces the importance of the preand post-operative visits made by the or nurse. in a study on the pre-operative visit made by nurses, the authors emphasize that preoperative teaching increases self-care skills, of patient compliance, and helps to reduce anxiety. the preoperative visit made by the nurses also contributed to establishing a relationship based on trust between the staff and the patient, in addition to providing them with diverse information (22). related to the high costs of the ors, in addition to the aforementioned materials, are the personnel costs (surgeons, anesthetists, nurses). management of resources requires adequate coordination and permits better planning and efficiency of the ors; however, synchronizing all these resources is no easy task (23), an aspect visible in the factor referring to the “specificities of professional groups”. the validated scale contemplates the essential indicators and dimensions to guarantee adequate evaluation of the or structure. as a limitation of this instrument, it was considered that it was restricted to questions of structure, other instruments related to 11 validation of a scale on structure indicators in the operating room: contributions to nursing l josé augusto gomes and others the process and the result are being developed and validated to ensure evaluation and monitoring of quality in the or as a whole. conclusion this study permitted evidencing the quality of the sior scale, through evidences of how the measurement properties were evaluated to justify the selection of this instrument to measure the or structure. the psychometric study of the scale, composed by 28 items, permitted stating that it is a reliable and valid instrument. the factor analysis also permitted identifying seven dimensions, namely “environment and equipment”, “resources for quality and safety”, “circuits in the operating room”, “facilities and operating requirements”, “training and praxis in the operating room”, “continuity in nursing care”, and “specificities of professional groups”. said factors prove to be important aspects for a correct assessment of the ors structure and integrate the amplitude of their indicators. the measuring instruments play an important role in research, in the clinical practice, and in health evaluation. the definition of valuable, reliable, and useful quality indicators for applicability in the or is a first step in the improvement process, but it is necessary to consider how these metrics can be used and how changes can be implemented. the items integrated in the scale permitted nurses to measure, evaluate, and monitor the structures of the or and potentiate corrective measures to guarantee the quality and safety of care. conflict of interests: none declared. references 1. gomes ja, martins mm, fernandes cs. 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1318-23. doi: 10.1016/j. ajic.2017.07.024 19. pr newswire. operating room (or) equipment market 2016 to 2020. new research report. available at wiseguyreports.com. pr newswire us [internet]. 2016 apr 7 [cited 2019 jan 15]. available from: http://search.ebscohost.com/ login.aspx?direct=true&db=bwh&an=201604071652pr.news.uspr.mn65878&lang=pt-br&site=ehost-live 20. wahr j, abernathy j. environmental hygiene in the operating room: cleanliness, godliness, and reality. international anesthesiology clinics. 2013; 51(1): 93-104. doi: 10.1097/aia.0b013e31827da44b 21. graafland m, schraagen j, boermeester m, bemelman w, schijven m. training situational awareness to reduce surgical errors in the operating room. the british journal of surgery. 2015; 102(1): 16-23. doi: 10.1002/bjs.9643 22. gürsoy a, candaş b, güner s, yılmaz s. preoperative stress: an operating room nurse intervention assessment. journal of perianesthesia nursing. 2016; 31(6): 495-503. doi: 10.1016/j.jopan.2015.08.011 23. di martinelly c, baptiste p, maknoon m. an assessment of the integration of nurse timetable changes with operating room planning and scheduling. international journal of production research. 2014; 52(24): 7239-50. doi: 10.1080/00207543.2014.916827 https://doi.org/10.1111/jebm.12255 https://doi.org/10.1016/j.aucc.2016.04.003 https://doi.org/10.1016/j.aucc.2016.04.003 https://doi.org/10.1007/s11136-010-9606-8 https://doi.org/10.1371/journal.pone.0191747 http://dx.doi.org/10.13037/ras.vol14n49.3671 http://dx.doi.org/10.1590/0104-07072017001600017 http://dx.doi.org/10.1590/0104-07072017001600017 http://dx.doi.org/10.5123/s1679-49742017000300022 http://dx.doi.org/10.1016/j.ajic.2017.07.024 http://dx.doi.org/10.1016/j.ajic.2017.07.024 http://search.ebscohost.com/login.aspx?direct=true&db=bwh&an=201604071652pr.news.uspr.mn65878&lang=pt-br&site=ehost-live http://search.ebscohost.com/login.aspx?direct=true&db=bwh&an=201604071652pr.news.uspr.mn65878&lang=pt-br&site=ehost-live http://dx.doi.org/10.1097/aia.0b013e31827da44b https://doi.org/10.1002/bjs.9643 http://dx.doi.org/10.1016/j.jopan.2015.08.011 http://dx.doi.org/10.1080/00207543.2014.916827 461 glenda agra1 nilton soares formiga2 simone helena dos santos oliveira3 alana tamar oliveira de sousa4 maria júlia guimarães oliveira soares5 marta miriam lopes costa6 indicadores psicométricos do saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral 1 orcid.org/0000-0002-7628-9029. unidade acadêmica de enfermagem, universidade federal de campina grande, brasil. glendaagra@outlook.com 2 orcid.org/0000-0003-4907-9736. universidade potiguar, brasil. 3 orcid.org/0000-0002-9556-1403. universidade federal da paraíba, brasil. 4 orcid.org/0000-0002-1683-2851. universidade federal de campina grande, brasil. 5 orcid.org/0000-0001-8025-9802. universidade federal da paraíba, brasil. 6 orcid.org/0000-0002-2119-3935. universidade federal da paraíba, brasil. recebido: 01/06/2018 submetido: 25/06/2018 aceito por pares: 30/07/2018 aceito: 24/08/2018 doi: 10.5294/aqui.2018.18.4.8 para citar este artigo / para citar este artículo / to reference this article agra g, soares n, dos santos sh, oliveira de sousa at, guimarães mj, lopes mm. indicadores psicométricos do saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral. aquichan 2018; 18(4): 461-476. doi: 10.5294/aqui.2018.18.4.8 resumo objetivo: verificar a discriminação de itens, a representatividade do conteúdo e a fidedignidade da medida acerca do saber e do fazer de enfermeiros nos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea. material e método: trata-se de estudo metodológico, descritivo e correlacional, realizado com 51 enfermeiros de um hospital filantrópico da paraíba, brasil, durante os meses de junho e julho de 2017. esses profissionais responderam a um instrumento validado com 84 itens referentes ao saber e ao fazer nos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea. na análise dos dados, foi utilizado o programa spss for windows, versão 22.0, com análises descritivas e psicométricas. resultados: ao se verificarem as propriedades psicométricas, a fidedignidade dos itens apresentou alfa de cronbach superior a 0,70 em todos os domínios. assim, foi possível elaborar um pressuposto teórico sobre o fenômeno, no qual quanto maior for o saber relacionado aos cuidados paliativos destinados à pessoa com ferida tumoral año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 461-476 temática: cuidado crônico. contribuição científica para a disciplina: espera-se que o instrumento possa contribuir para o ensino e para a pesquisa, o que leva a novos conhecimentos, bem como possa facilitar o processo de trabalho da prática diária e fornecer uma direção mais consistente para os registros de enfermagem. outrossim, é indispensável a continuidade de pesquisas nessa área, a fim de identificar as especificidades do saber e do fazer na enfermagem, e, desse modo, diminuir as lacunas na área de educação em enfermagem, sobretudo na área de cuidados paliativos. http://orcid.org/0000-0002-7628-9029. http://orcid.org/0000-0003-4907-9736. http://orcid.org/0000-0002-9556-1403. http://orcid.org/0000-0002-1683-2851. http://orcid.org/0000-0001-8025-9802. http://orcid.org/0000-0002-2119-3935 http://dx.doi.org/10.5294/aqui.2018.18.4.8 http://dx.doi.org/10.5294/aqui.2018.18.4.8 462 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 461-476 maligna cutânea, maior será o fazer desses cuidados. conclusões: esse instrumento possibilita que outros profissionais possam adequar a mesma metodologia para outras temáticas e identificar as especificidades do saber e do fazer, o que preencheria as lacunas na área de educação em enfermagem, sobretudo na temática de cuidados paliativos. palavras-chave (fonte: decs) enfermagem; úlcera cutânea; neoplasias; educação; conhecimento. indicadores psicométricos del saber y el quehacer de enfermeros en los cuidados paliativos a la persona con herida tumoral resumen objetivo: verificar la discriminación de ítems, la relevancia del contenido y la fidelidad de la medida, acerca del saber y del hacer de enfermeros, en los cuidados paliativos a las personas con herida tumoral maligna cutánea. material y método: estudio metodológico, descriptivo y correlacional, realizado con 51 enfermeros de un hospital filantrópico de paraíba, brasil, durante junio y julio de 2017, quienes contestaron a un instrumento con 84 ítems referentes al saber y el hacer en los cuidados paliativos, destinados a la persona con herida tumoral maligna cutánea. en el análisis de los datos se utilizó el programa spss para windows, versión 22.0, con análisis descriptivos y psicométricos. resultados: al verificar las propiedades psicométricas, la autenticidad de los ítems presentó alfa de cronbach superior a 0,70 en todos los dominios. por lo tanto, fue posible elaborar un presupuesto teórico sobre el fenómeno, en lo que, cuanto mayor sea el saber relacionado a los cuidados paliativos a la persona con herida tumoral maligna cutánea, mayor será la acción de estos cuidados. conclusiones: este instrumento posibilita que otros profesionales puedan adecuar la misma metodología a otras temáticas e identificar las especificidades del saber y del hacer, lo que podría llenar los vacíos en el área de educación en enfermería, sobre todo en la temática de cuidados paliativos. palabras clave (fuente: decs) enfermería; úlcera cutánea; neoplasias; educación; conocimiento. 463 indicadores psicométricos do saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral l glenda agra e outros psychometric indicators of nurses’ knowledge and work in the palliative care of individuals with a malignant wound abstract objective: to verify item discrimination, content relevance and measurement reliability of nurses’ knowledge and work in the palliative care of individuals with a cutaneous malignant wound. materials and methods: methodological, descriptive, correlational study carried out with 51 nurses from a philanthropic hospital in paraiba, brazil, during june and july of 2017, who answered an instrument with 84 items referring to knowledge and work in the palliative care of individuals with a cutaneous malignant wound. for data analysis, spss for windows, version 22.0, was used with descriptive and psychometric statistics. results: in verifying psychometric properties, item authenticity had a cronbach’s alpha higher than 0.70 in all domains; therefore, we could make a theoretical assumption on the phenomenon, in which the more the knowledge of the palliative care of a person with a cutaneous malignant wound, the more the action of this care. conclusions: this instrument enables other professionals to adapt the same methodology to other themes and to identify the specificities of knowledge and work, which could bridge the gaps in nursing education, especially palliative care. keywords (source: decs) nursing; cutaneous ulcer; neoplasm; education; knowledge. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 461-476 464 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 introdução as feridas tumorais malignas são infiltrações cutâneas de células cancerígenas que se desenvolvem em decorrência do crescimento de um tumor primário de pele ou por metástases de qualquer tumor maligno (1). a prevalência dessas lesões não é bem documentada, mas se estima, a partir de estudos internacionais, que de 5 a 10 % das pessoas com câncer desenvolvem feridas malignas (2-4); já estudos nacionais estimaram o valor de aproximadamente 10 % (5-6). as feridas tumorais malignas cutâneas constituem um agravo na vida da pessoa com câncer, porquanto, progressivamente, desfiguram o corpo, tornando-se friáveis, dolorosas, exsudativas e com odor fétido. essas feridas apresentam efeitos psicológicos e sociais que podem interferir nas relações interpessoais, uma vez que o paciente apresenta sentimentos de rejeição, isolamento social, ansiedade, tristeza e solidão (1-2). além disso, essas feridas remetem à pessoa uma constante lembrança visível da sua enfermidade incurável, do mau prognóstico e, na maioria das vezes, a pessoa traz no seu discurso, no âmbito relacional do tratamento, a condição imperativa da morte que se aproxima. diante de tal situação, a pessoa doente necessita de cuidados paliativos para o controle dos sinais e sintomas dessas lesões. os cuidados paliativos destinados às pessoas com feridas tumorais malignas cutâneas são complexos, pois exigem avaliação de etiologia oncológica, da lesão e da pessoa nas suas dimensões biopsicossocial e espiritual, condição econômica e familiar, controle dos sinais e sintomas, bem como planejamento e orientações dos cuidados a serem executados pela própria pessoa e pela família em seu domicílio, uma vez que a cura da doença e a cicatrização da ferida já não são mais possíveis (3, 7). para isso, os cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea requer do enfermeiro conhecimento específico. nessa perspectiva, um dos caminhos metodológicos para a implementação dos cuidados paliativos pode ter como base os padrões de conhecimento propostos por carper, a saber: o empírico, o estético, o ético e o pessoal, que estão inseridos em teorias que guiam o cuidado de enfermagem (8). devido à complexidade e abrangência de componentes que fundamentam a enfermagem e ao aprofundamento requerido para analisá-los, optou-se pelo padrão de conhecimento empírico ou ciência da enfermagem, pois é fatual, descritivo e fundamentalmente voltado para o desenvolvimento de explicações teóricas e abstratas, além de ser replicável, formulado e verificável (8). a partir dessa concepção, foram selecionadas habilidades para um domínio de conhecimento teórico — o saber — e um de conhecimento prático — o fazer —, com que foi possível elaborar uma escala, cujo objetivo é de verificar, na concepção de enfermeiros responsáveis pelos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea, a correlação entre a dimensão teórica e a prática. na enfermagem, o domínio pode ser compreendido como o âmbito de sua área, ou seja, a abrangência de seu conhecimento, que é um domínio pessoal, uma apropriação e compreensão do saber por uma pessoa. nesse caso, o enfermeiro, durante a sua formação, desenvolve o saber que (um conhecimento explícito — saber teórico) e, em sua prática diária, o saber como (um conhecimento prático — habilidade). hipoteticamente, ambos são interdependentes e fazem parte de um conjunto mais amplo da enfermagem, que inclui componentes éticos e pessoais percebidos durante a implementação do cuidado (9). diante disso, é necessário que, por meio de instrumentos de medição válidos, seja possível avaliar a qualidade da assistência de enfermagem (10), ao passo que o reconhecimento da qualidade dos instrumentos torna-se aspecto fundamental para a legitimidade e credibilidade dos resultados de uma pesquisa, o que reforça a importância do processo de validação (11). o uso de medidas válidas e fidedignas propicia monitorar a qualidade do cuidado dispensado aos pacientes, identificar situações de riscos evitáveis, bem como subsidiar o planejamento de ações corretivas, além de direcionar estratégias e reajuste de metas. ressalta-se que o uso de instrumentos válidos e fidedignos pode contribuir para o avanço do conhecimento da profissão e para o desenvolvimento da teoria que a sustenta (12). fidedignidade implica confiabilidade e concordância, que são aspectos importantes no desenvolvimento de instrumentos de medida. seus resultados fornecem informações sobre a quantidade de erros inerente a essa medida, o que reflete a qualidade da medição (13). diante desse cenário, tem-se como questão de pesquisa: a medida constituída pelo saber e pelo fazer de enfermeiros relativos aos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea atende aos requisitos de discriminação 465 indicadores psicométricos do saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral l glenda agra e outros de itens, representatividade do conteúdo e fidedignidade do instrumento em tela? nesse sentido, a presente pesquisa tem como objetivo verificar a discriminação de itens, a representatividade do conteúdo e a fidedignidade da medida acerca do saber e do fazer de enfermeiros nos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea. materiais e método trata-se de um estudo metodológico do tipo descritivo e correlacional, que apresenta a discriminação dos itens, a representatividade do conteúdo e a fidedignidade do instrumento da pesquisa relacionado ao saber e ao fazer de enfermeiros nos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea, realizado em um hospital filantrópico de referência na paraíba (nordeste do brasil) para o tratamento do câncer (centro de alta complexidade em oncologia — cacon), durante os meses de junho e julho de 2017, após a aprovação do comitê de ética em pesquisa da universidade federal da paraíba, protocolo n.º 031/17 e certificado de apresentação para apreciação ética n.º 64122116.1.0000.5188. a população do estudo foi composta por 57 enfermeiros que exerciam atividades laborais nos diversos setores do referido hospital. para isso, foram adotados os seguintes critérios de inclusão: enfermeiros que exercessem atividades assistenciais diretamente com pacientes e contassem com disponibilidade de horário para responder ao instrumento. desse modo, participaram do estudo 51 enfermeiros assistenciais. a amostra foi do tipo não probabilística, pois se buscou aleatória e intencionalmente enfermeiros que se dispusessem a participar da pesquisa ao responderem ao instrumento “cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea”. em relação ao cálculo da amostra, utilizou-se o pacote estatístico g power 3.1, que se trata de um software destinado a calcular o poder estatístico, tendo como base não apenas o “n” necessário para a pesquisa, mas também o tipo de cálculo a ser realizado (14). para a coleta de dados deste estudo, considerouse uma probabilidade de 95 % (p < 0,05), magnitude do efeito amostral (r ≥ 0,30) e um padrão de poder hipotético (π ≥ 0,80); a partir desses critérios, a amostra de 51 sujeitos revelou-se suficiente (com indicadores: r ≥ 1,98; π ≥ 0,95; p < 0,05). validação de conteúdo e confiabilidade para a coleta de dados, foi elaborado um questionário estruturado, dividido em duas seções: a primeira destinou-se aos aspectos sociodemográficos e profissionais dos enfermeiros, cujo objetivo foi realizar uma breve caracterização dos participantes deste estudo. ele continha informações sobre sexo, idade, tempo de formação acadêmica e tempo de experiência na área de oncologia, cursos de aperfeiçoamento e pós-graduação. a segunda parte é um instrumento validado quanto à concordância e ao conteúdo, composto por cinco categorias: 1) avaliação da lesão e necessidades da pessoa com ferida tumoral maligna cutânea; 2) cuidados básicos realizados com a ferida tumoral maligna cutânea; 3) cuidados específicos realizados com a ferida tumoral maligna cutânea (esta categoria subdivide-se em oito subcategorias, que estão relacionadas ao controle dos sinais e sintomas, a saber: a) o controle da dor; b) do exsudato; c) do prurido; d) da necrose; e) da fístula; f) do sangramento; g) do odor e h) da infestação por miíases); 4) registros das ações de enfermagem e 5) orientações para a alta hospitalar, que abrangem 84 itens a respeito do saber e do fazer dos enfermeiros ante os cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea. tais categorias, subcategorias e itens foram construídos com base numa revisão integrativa da literatura e do manual do instituto nacional do câncer, e submetidos à validação de concordância e conteúdo por meio da técnica delphi (15) em duas avaliações: a primeira com 30 especialistas na área de dermatologia e a segunda com 17. as respostas tanto do saber como do fazer seguiram uma escala do tipo likert de cinco pontos, que variou de 0 — nenhum, 1 — pouco, 2 — moderado, 3 — bom, 4 — excelente. realizou-se o convite pessoal aos enfermeiros que exerciam atividades assistenciais nos três turnos de trabalho, bem como buscou-se a participação voluntária deles. após a apresentação da pesquisa, de seus objetivos, etapas e instruções para o entendimento das questões, solicitou-se que os participantes lessem e assinassem o termo de consentimento livre e esclarecido em duas vias (ficando uma com o participante), e, por fim, que respondessem ao instrumento. vale ressaltar que foram obedecidos a todos os aspectos éticos contidos na resolução n.º 466/2012 do conselho nacional de saúde do ministério da saúde para pesquisas que envolvem seres humanos. o tempo de resposta ao instrumento foi, em média, 30 minutos. 466 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 os dados foram processados por meio do programa excel for windows. as análises estatísticas foram realizadas utilizando-se o statistical package for social sciences (spss) versão 22.0. quanto à análise dos dados, foram realizadas estatísticas descritivas (média e desvio-padrão), teste t de student para avaliar a discriminação de itens; correlação de pearson para verificar a representatividade do conteúdo e, por fim, o cálculo de alfa de cronbach e o coeficiente de correlação intraclasse (cci) para avaliar a fidedignidade e consistência interna da medida proposta. o nível de significância adotado foi de p < 0,001 (16). validação convergente para verificar a proposta do cálculo, realizou-se uma correlação de pearson entre as variáveis-categorias-subcategorias do saber com o fazer. validação lógica e de hipótese foram selecionados dois peritos com especialização na área de psicometria para verificarem a validade lógica e de hipótese do referido estudo e instrumento, com base nos indicadores psicométricos apresentados. resultados dentre os participantes, predominou o sexo feminino (88 %), com variação etária de 26 a 60 anos (média = 40,73, dp = 11,40) e média de 9,61 anos de atuação profissional no hospital onde se realizou a pesquisa, e 57 % deles apresentam pós-graduação lato sensu em enfermagem oncológica. a amostra, em geral, apresentou uma distribuição normal (a assimetria variou de – 1,45 a 1,30 e curtose de – 0,85 a 2,53), dado que os valores de assimetria e curtose se encontram entre – 1 e 3 (16). a seguir, está a tabela 1, em que são apresentados os resultados com indicadores psicométricos dos itens do instrumento relacionado ao saber e ao fazer de enfermeiros nos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea. de acordo com os resultados da tabela 1, foi possível observar que o teste t comprovou que todos os itens que compõem as categorias/subcategorias da medida tanto do saber quando do fazer apresentaram valores discriminativos e estatisticamente significativos. além disso, o cálculo de correlação de pearson realizado constatou que os 84 itens tanto do saber quanto do fazer apresentaram correlações fortes, positivas, significativas e não excluíram nenhum item da medida pretendida. também se constatou que os alfas de cronbach e os intervalos de confiança no cci tanto no saber quanto no fazer foram significativos e maiores que 0,70 e 0,80, respectivamente. a seguir, está a tabela 2, em que são apresentados os resultados da análise convergente das categorias e subcategorias do saber e do fazer de enfermeiros nos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea. na tabela 2, os resultados revelaram que houve uma correlação positiva e significativa acima de 0,40 entre as categorias e subcategorias do saber e do fazer. discussão validação de conteúdo e confiabilidade tendo finalizada a coleta e organizado o banco de dados, procurou-se avaliar, a partir dos pressupostos da teoria clássica dos testes (tct), a diferença do grupo de indivíduos que tiveram alta pontuação total dos que tiveram baixa pontuação total no constructo medido, bem como a interpretação da resposta final, ou seja, o que a soma diz sobre o sujeito (17-18). com a finalidade de discriminar os itens da medida, foi calculada uma pontuação total da escala e, em seguida, sua mediana; os participantes com pontuação abaixo da mediana foram classificados como sendo do grupo inferior, enquanto aqueles com pontuações acima da mediana foram definidos como do grupo superior de respostas. considerando-se cada um dos itens dessa medida, efetuou-se um teste t de student para amostras independentes e compararam-se ambos os grupos, observando quais dos itens da escala discriminam as pessoas com magnitudes próximas, estatisticamente significativas (tabela 1). como pode ser observado, todos os itens foram significativos, o que justifica a sua inserção no instrumento pretendido, pois se aponta em direção à proposta teórica, previamente defendida, de que a dimensão teórica acerca dos cuidados paliativos destinados às pessoas com feridas tumorais malignas cutâneas se associe à dimensão prática dos cuidados paliativos com essas feridas, a qual estabelece relação do conteúdo das cinco categorias do saber e do fazer e seus 84 itens, que fazem parte do constructo “cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea”. 467 indicadores psicométricos do saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral l glenda agra e outros tabela 1. indicadores psicométricos da medida do saber e do fazer de enfermeiros nos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea na cidade de joão pessoa, estado da paraíba, brasil categorias / subcategorias indicadores psicométricos saber fazer t r α cci t r α cci categoria 1 — avaliação da lesão e das necessidades da pessoa com ferida tumoral maligna cutânea 1. localização anatômica da lesão. -4,76 0,59* 0,94* 0,95* (0,92-0,96) -7,88* 0,87* 0,98* 0,97* (0,96-0,98) 2. tamanho — mensuração da lesão (altura, largura, profundidade ou abaulamento). -4,55 0,65* -5,31 0,73* 3. estadiamento (1, 1n, 2, 3, 4). -5,39 0,66* -4,49 0,70* 4. intensidade do odor (grau i, ii, iii). -3,88 0,57* -5,69 0,69* 5. exsudato (tipo e quantidade). -4,72 0,51* -5,50 0,73* 6. intensidade do sangramento (leve, moderado e intenso). -5,02 0,70* -5,93 0,82* 7. intensidade da dor na ferida (leve, moderada, intensa e excruciante), usando a escala visual analógica ou a escala visual numérica. -3,75 0,55* -3,47 0,51* 8. prurido. -5,35 0,60* -7,16 0,80* 9. borda e pele perilesional. -4,96 0,73* -6,80 0,79* 10. sinais de infecção locais (calor, rubor, edema, dor). -5,06 0,72* -6,73 0,82* 11. tipo de tecido (necrose de coagulação, necrose de liquefação, granulação, epitelização). -5,45 0,66* -6,00 0,79* 12. presença de miíases. -5,17 0,58* -548 0,74* 13. fístulas e quantidade drenada. -3,00 0,67 -5,95 0,81* 14. sinus (túneis). -5,54 0,57* -5,32 0,72* 15. classificação morfológica da lesão (nodular, cavitária, vegetante). -5,33 0,58* -4,94 0,68* 16. acometimento ou invasão de órgãos-alvo. -3,57 0,77* -4,85 0,75* 17. avaliação dos aspectos social, psíquico, espiritual e econômico. -6,14 0,56* -4,05 0,77* 18. progressão ou mudança da forma da ferida. -4,23 0,68* -5,94 0,81* 19. identificação das necessidades educacionais da pessoa ou cuidador quanto aos cuidados com a ferida após a alta. -4,92 0,71* -5,87 0,82* 468 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 categorias / subcategorias indicadores psicométricos saber fazer t r α cci t r α cci categoria 2 — cuidados básicos realizados na ferida tumoral maligna cutânea 20. retirar os adesivos cuidadosamente usando solução removedora (solução salina, vaselina ou óleo mineral). -4,11 0,69* 0,94* 0,93* (0,91-0,96) -4,41 0,84* 0,95* 0,95* (0,92-0,97) 21. retirar gazes aderidas ao leito da lesão com irrigação abundante utilizando solução salina. -4,43 0,67* -5,52 0,84* 22. irrigar o leito da ferida com solução salina. -4,48 0,60* -4,30 0,75* 23. lavar a ferida com antisséptico (clorohexidine degermante ou phmb sabonete), para a remoção superficial de bactérias e debris. -4,18 0,57* -4,85 0,87* 24. empregar técnica asséptica. -2,63 0,57* -5,36 0,83* 25. manter úmido o leito da ferida a fim de evitar aderência de gazes. -3,08 0,67* -6,58 0,81* 26. eliminar espaço morto (preenchê-lo com curativo) antes da cobertura selecionada. -3,16 0,67* -5,72 0,85* 27. utilizar coberturas absorventes. -3,47 0,81* -6,34 0,87* 28. considerar o uso de coberturas antiaderentes. -4,49 0,77* -5,38 0,87* 29. considerar a redução das trocas frequentes de curativos utilizando compressas cirúrgicas como coberturas primárias e absorventes íntimos geriátricos descartáveis ou fraldas infantis descartáveis como coberturas secundárias. -5,66 0,69* -4,44 0,87* 30. promover as coberturas em conformidade com os contornos da área para oferecer conforto à pessoa. -6,23 0,59* -5,42 0,74* 31. proteger o curativo com saco plástico ou filme transparente durante o banho de aspersão e abri-lo para a troca somente no leito (o que evita a dispersão de exsudato e micro-organismos no ambiente). -4,18 0,70* -7,49 0,88* categoria 3 — cuidados específicos realizados na ferida tumoral maligna cutânea subcategoria 1 — cuidados específicos realizados na ferida tumoral maligna cutânea para o controle da dor 32. monitorar o nível de intensidade da dor pela escala visual analógica ou pela escala visual numérica. -3,39 0,59* 0,90* 0,89* (0,85-0,93) -4,91 0,89* 0,96* 0,96* (0,95-0,98) 33. iniciar o curativo após 30 minutos para a analgesia oral; 5 minutos para a analgesia subcutânea ou endovenosa e início imediato para a via tópica, conforme prescrição médica. -4,70 0,54* -5,60 0,74* 34. adequar o horário da troca de curativos após a pessoa já estar medicada, respeitando o intervalo de acordo com o tipo de analgesia. -2,92 0,60* -5,96 0,84* 35. avaliar a necessidade de analgesia tópica com lidocaína gel a 2 % conforme prescrição médica. -3,36 0,52* -4,57 0,83* 36. não friccionar com força o leito da ferida. -3,49 0,68* -4,21 0,83* 37. reavaliar a necessidade de alteração do esquema analgésico prescrito. -3,35 0,56* -3,99 0,72* 38. considerar, junto à equipe médica, a necessidade de anti-inflamatórios, radioterapia antiálgica ou cirurgia. -5,17 0,53* -5,61 0,76* 39. registrar a avaliação da dor pela escala visual analógica ou pela escala visual numérica e a analgesia antes e após o curativo. -3,30 0,55* -3,18 0,86* 40. comunicar à equipe médica os casos de sofrimento álgico que fujam ao controle da conduta preconizada. -2,57 0,58* -4,80 0,71* 469 indicadores psicométricos do saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral l glenda agra e outros categorias / subcategorias indicadores psicométricos saber fazer t r α cci t r α cci subcategoria 2 — cuidados específicos realizados na ferida tumoral maligna cutânea para o controle do exsudato 41. coletar material para cultura (aspirado/swab pela técnica de levine) com limpeza prévia da lesão. -2,93 0,55* 0,78* 0,78* (0,70-0,87) -5,17 0,76* 0,88* 0,88* (0,78-0,93)42. empregar carvão ativado/alginato de cálcio/copolímero de amido/espumas com ou sem prata/hidrofibra como cobertura primária e compressas/gazes como cobertura secundária. -2,45 0,72* -3,89 0,86* subcategoria 3 — cuidados específicos realizados na ferida tumoral maligna cutânea para o controle do prurido 43. investigar a causa do prurido. -4,33 0,58* 0,91* 0,91* (0,87-0,94) -6,24 0,71* 0,95* 0,95* (0,93-0,97) 44. utilizar adesivos hipoalergênicos. -4,82 0,67* -5,53 0,76* 45. utilizar dexametasona creme 0,1 % nas áreas do prurido conforme prescrição médica. -2,02 0,74* -5,13 0,86* 46. investigar presença de infecções fúngicas. -4,85 0,72* -5,30 0,74* 47. utilizar nistatina ou sulfadiazina de prata 1 % com ou sem nitrato de cério para a candidíase cutânea nas áreas de hiperemia ao redor da ferida associada a manchas esbranquiçadas conforme prescrição médica. -5,25 0,63* -7,49 0,84* 48. considerar a redução do intervalo dos curativos para evitar esse sintoma e investigar a reação alérgica à cobertura utilizada. -4,65 0,78* -4,98 0,80* 49. caso o prurido persista, considerar, junto à equipe médica, a introdução de terapia sistêmica. -4,14 0,70* -6,26 0,80* 50. utilizar cremes à base de desonida para os casos de alergia conforme prescrição médica. -5,75 0,65* -9,20 0,88* subcategoria 4 — cuidados específicos realizados na ferida tumoral maligna cutânea para o controle da necrose 51. avaliar as necessidades de debridamento, de acordo com a condição clínica da pessoa e as características da lesão (por exemplo, friáveis). -3,93 0,84* 0,93* 0,93* (0,89-0,96) -6,76 0,75* 0,96* 0,96* (0,94-0,98) 52. eleger a forma de debridamento (autolítico, químico, mecânico e instrumental conservador). -3,00 0,73* -6,90 0,81* 53. considerar, prioritariamente, o debridamento autolítico. -5,50 0,75* -6,41 0,90* subcategoria 5 — cuidados específicos realizados na ferida tumoral maligna cutânea para o controle da fístula 54. aplicar óxido de zinco/hidrocoloide/creme barreira/solução polimérica na pele ao redor da fístula. -5,53 0,77* 0,84* 0,83* (0,72-0,91) -7,16 0,79* 0,92* 0,91* (0,85-0,95) 55. adaptar, quando possível, bolsas coletoras nas fístulas de alta drenagem e proteger a área perifistular. -5,21 0,77* -6,01 0,89* 470 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 categorias / subcategorias indicadores psicométricos saber fazer t r α cci t r α cci subcategoria 6 — cuidados específicos realizados na ferida tumoral maligna cutânea para o controle do sangramento 56. aplicar pressão diretamente sobre os vasos sangrantes com emprego de gazes por 10 a 15 minutos. -5,91 0,75* 0,90* 0,89* (0,85-0,93) -6,52 0,85* 0,95* 0,95* (0,93-0,97) 57. considerar a aplicação de solução salina gelada com emprego de gazes e/ou compressas. -6,24 0,70* -7,47 0,86* 58. considerar o uso de curativo hemostático à base de gelatina suína (gelfoam). -5,25 0,69* -7,13 0,83* 59. aplicar alginato de cálcio. -4,37 0,60* -6,39 0,87* 60. considerar o uso de adrenalina (solução injetável) topicamente sobre os pontos sangrantes 1:1000 conforme prescrição médica. -5,68 0,60* -5,86 0,88* 61. verificar, junto à equipe médica, a possibilidade de tratamento com coagulante sistêmico como ácido aminocaproico (comprimidos ou em solução injetável) ou ácido tranexâmico (comprimidos ou em solução injetável). -3,35 0,70* -6,82 0,88* 62. verificar, junto à equipe médica, a possibilidade de tratamento com intervenção cirúrgica nos sangramentos persistentes ou resistentes às terapias convencionais. -3,18 0,59* -6,76 0,84* 63. verificar, junto à equipe médica, a possibilidade de tratamento com radioterapia anti-hemorrágica. -7,20 0,56* -5,14 0,61* 64. verificar, junto à equipe médica, a possibilidade de tratamento com sedação paliativa para os casos de sangramento intenso acompanhado de agitação, desespero e angústia do paciente. -4,77 0,61* -7,63 0,81* 65. em casos de agitação e angústia da pessoa por causa do sangramento intenso, considerar o uso de toalhas de cores escuras para conter a hemorragia. -3,76 0,64* -5,70 0,82* subcategoria 7 — cuidados específicos realizados na ferida tumoral maligna cutânea para o controle do odor 66. considerar a aplicação de solução de phmb. -4,13 0,71* 0,90* 0,90* (0,84-0,94) -6,51 0,83* 0,93* 0,93* (0,89-0,96) 67. considerar o uso de gazes embebidas em hidróxido de alumínio no leito da ferida para odor grau i. -4,85 0,62* -5,58 0,88* 68. considerar o uso de carvão ativado. -5,37 0,67* -8,11 0,65* 69. aplicar gel ou solução de metronidazol 0,8 % para odor grau ii conforme prescrição médica. -3,80 0,61* -6,27 0,84* 70. considerar, junto à equipe médica, a possibilidade de associação de metronidazol sistêmico (endovenoso ou oral) ao uso tópico para odor grau iii. -3,76 0,57* -5,38 0,70* subcategoria 8 — cuidados específicos realizados na ferida tumoral maligna cutânea para o controle da infestação de miíases 71. considerar a aplicação de lidocaína tópica a fim de reduzir a dor durante a retirada manual das larvas conforme prescrição médica. -4,13 0,66* 0,80* 0,80* (0,70-0,88) -5,44 0,77* 0,89* 0,89* (0,83-0,93) 72. aplicar vaselina líquida a fim de impedir que as larvas respirem e facilitar a remoção. -4,85 0,54* -6,78 0,68* 73. realizar a retirada manual (com pinças) das larvas. -5,37 0,55* -6,46 0,85* 74. administrar ivermectina sistêmico conforme prescrição médica. -3,80 0,57* -7,80 0,72* 471 indicadores psicométricos do saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral l glenda agra e outros notas: t — teste t de student (discriminação dos itens); r — correlação de pearson (representatividade de conteúdo); † — σ todos os itens do instrumento; α — alfa de cronbach e icc — coeficiente de correlação intraclasse (fidedignidade e consistência interna); *p < 0,001. fonte: elaboração própria. categorias / subcategorias indicadores psicométricos saber fazer t r α cci t r α cci categoria 4 — registro das ações de enfermagem 75. documentar a avaliação das características da ferida e as necessidades da pessoa. -3,76 0,53* 0,92* 0,92* (0,89-0,95) -7,34 0,74* 0,94* 0,94* (0,91-0,96) 76. documentar todas as intervenções realizadas com a ferida e com a pessoa. -3,63 0,60* -5,70 0,68* 77. documentar a educação realizada com a pessoa e/ou família sinalizando os pontos de dificuldades de entendimento e habilidade. -3,45 0,60* -6,75 0,70* 78. documentar os resultados obtidos. -4,56 0,63* -6,67 0,77* 79. considerar o registro fotográfico das feridas após a autorização da pessoa. -4,27 0,59* -4,95 0,79* categoria 5 — orientações para a alta hospitalar 80. identificar e contatar o cuidador principal para a capacitação na realização dos curativos no domicílio. -4,61 0,53* 0,92* 0,92* (0,88-0,95) -7,00 0,84* 0,95* 0,94* (0,92-0,97) 81. identificar e contatar com a família e a rede de atendimento público que poderá ser acessada para a parceria nos cuidados com relação à ferida e capacitar esse profissional, se necessário. -3,10 0,60* -4,88 0,82* 82. realizar relatório de enfermagem sumarizado com relação à alta hospitalar, aos cuidados com a ferida, aos produtos utilizados, aos resultados obtidos e esperados e ao processo de educação da família. -3,41 0,55* -5,40 0,85* 83. orientar vestuário: roupas mais confortáveis e adaptadas ao melhor acesso à ferida para a troca de curativos. -4,22 0,59* -5,76 0,80* 84. orientar melhores condições para dormir, considerando uso de coxins e outros artefatos para melhorar o posicionamento. -4,41 0,54* -5,55 0,73* 472 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 tabela 2. análise convergente das categorias e subcategorias do saber e do fazer de enfermeiros nos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea, na cidade de joão pessoa, estado da paraíba, brasil c at eg or ia s e su bc at eg or ia s do sa be r categorias e subcategorias do fazer cf 1 cf 2 cf 3 sc f1 sc f2 sc f3 sc f4 sc f5 sc f6 sc f7 sc f8 cf 4 cf 5 cs1 0,77 0,58 0,52 0,52 0,56 0,57 0,75 0,54 0,57 0,53 0,69 0,89 0,78 cs2 0,54 0,59 0,49 0,58 0,55 0,56 0,53 0,57 0,49 0,44 0,52 0,45 0,54 cs3 0,57 0,52 0,66 0,50 0,53 0,52 0,48 0,55 0,49 0,44 0,58 0,46 0,57 scs 1 0,43 0,48 0,45 0,65 0,47 0,40 0,48 0,47 0,42 0,41 0,44 0,44 0,53 scs2 0,69 0,70 0,65 0,70 0,78 0,72 0,68 0,72 0,60 0,56 0,75 0,65 0,61 scs3 0,52 0,53 0,46 0,50 0,57 0,69 0,55 0,51 0,47 0,49 0,52 0,40 0,57 scs 4 0,73 0,59 0,51 0,62 0,62 0,62 0,76 0,57 0,47 0,42 0,57 0,47 0,63 scs5 0,62 0,62 0,56 0,58 0,61 0,60 0,52 0,76 0,67 0,59 0,71 0,54 0,62 scs6 0,66 0,59 0,54 0,54 0,64 0,63 0,64 0,67 0,88 0,74 0,61 0,74 0,71 scs7 0,64 0,42 0,48 0,47 0,46 0,45 0,49 0,51 0,61 0,71 0,47 0,43 0,58 scs8 0,50 0,79 0,77 0,69 0,84 0,77 0,68 0,63 0,73 0,61 0,91 0,86 0,74 c4 0,83 0,45 0,49 0,48 0,50 0,42 0,72 0,58 0,56 0,52 0,57 0,68 0,65 c5 0,51 0,82 0,79 0,70 0,76 0,74 0,75 0,67 0,72 0,68 0,62 0,59 0,68 *notas: cs — categoria saber; scs — subcategoria do saber; cf — categoria fazer; scf — subcategoria do fazer. todas as correlações foram significativas a um p < 0,001. fonte: elaboração própria. ainda na mesma tabela e continuando com base nas concepções da tct, avaliou-se a relação do conteúdo dos itens, tendo por objetivo verificar a representatividade comportamento-domínio expressa nos itens. tal condição tem como objetivo, sistematicamente, avaliar a relação teórica apresentada no instrumento validado com as situações especificadas nos itens e o quanto o instrumento representa os aspectos esperados para a referida medida (19-20). a partir dessa perspectiva, efetuou-se o cálculo de correlação de pearson (r), que mede o grau da correlação (e a direção dessa correlação — se positiva ou negativa) entre duas variáveis de uma escala e assume valores entre – 1 e 1, em que 1 significa uma correlação perfeita positiva entre duas variáveis; – 1 significa uma correlação negativa perfeita entre duas variáveis, isto é, se uma aumenta, a outra diminui, e 0 significa que as duas variáveis não dependem linearmente uma da outra. o cálculo da correlação de pearson foi realizado para verificar a medida dos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea tanto para o contexto do saber quanto do fazer destinados à avaliação dos itens referentes ao desenvolvimento da mesma escala quando observados na validade de conteúdo. com isso, destaca-se que todos os 84 itens, além de apresentarem correlações fortes e positivas, relativas ao constructo em questão (pontuação total da escala; especificamente, para o saber e o fazer), foram significativos e não excluíram nenhum item da medida pretendida. orientado pelos resultados expostos acima, decidiu-se verificar a fidedignidade da escala. o objetivo dessa etapa é apresentar indicadores estatísticos que corroborem a capacidade de mensu473 indicadores psicométricos do saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral l glenda agra e outros ração da escala neste estudo (sobre o saber e o fazer) buscando tornar uma medida acurada. a fidedignidade de um teste se refere à característica que deve possuir ao se mensurar o fenômeno estudado com os mesmos participantes ou outros em ocasiões diferentes e que possa garantir a precisão instrumental com um coeficiente matemático próximo a 1. nessa condição, utilizou-se alfa de cronbach como critério de consistência psicométrica. trata-se de um dos indicadores psicométricos mais utilizados para verificar a fidedignidade ou validade interna do instrumento, que varia de 0,70 a 1; contudo, quanto mais próximo de 1, melhor será sua precisão, o que significa que os itens são homogêneos em sua mensuração e produzem a mesma variância, caracterizando uma segurança para a medida do fenômeno que se quer avaliar (21-25). dessa forma, ao observar a tabela 1, relativa ao saber e ao fazer de enfermeiros nos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea, constata-se que os alfas para a referida medida foram melhores e significativos. chama-se a atenção para o resultado do intervalo de confiança no cci, que permaneceu em intervalos próximos aos observados no alfa de cronbach, o que garante a confiabilidade da medida na amostra estudada. nos resultados apresentados da tabela 1, foi possível destacar que as categorias referidas no instrumento em questão são confiáveis; isto é, foi possível discriminar as respostas dos participantes que pontuaram para mais ou para menos na escala apresentada a eles em relação a cada situação especificada no instrumento, o que revela que os participantes foram capazes de reconhecer as questões relacionadas ao objetivo de estudo, permitindo a estes indicar, em frequência de respostas, o quanto sabem sobre os cuidados paliativos e o quanto o fazem. é também destaque, com base nos resultados, que é possível afirmar que o conteúdo e categoria focados na dimensão da perspectiva teórica abordada e no desenvolvimento empírico do estudo assumiram uma representatividade de conteúdo muito clara, a qual foi observada nas correlações de pearson, com todas apresentando escores correlacionais acima de 0,50, o que demonstra que os itens explicam, aproximadamente, mais de 25 % do item para a especificidade do domínio (22). salienta-se, também, a qualidade consistente da medida, reforçada pelo alfa de cronbach, com todas as categorias do saber e do fazer que apresentam um alfa acima de 0,70, e que os alfas se mantiveram acima do limite aceito na literatura estatística. destaca-se que os resultados dos alfas foram garantidos quando se observou a cci, que, além de ter sido significativa, revelou escores que estiveram muito próximos aos observados nos alfas, o que reforça a consistência da medida em questão (23-27). validação convergente ao garantir a medida de cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea para o saber e o fazer de enfermeiros, resolveu-se verificar a validade convergente dessa medida associando o constructo do saber com o do fazer. a validade convergente é definida como a relação significativa entre duas ou mais medidas de um mesmo constructo ou de constructos teoricamente relacionados, utilizando-se diferentes métodos ou instrumentos de avaliação (17, 20, 26). a escolha de realizar essa etapa psicométrica se deve à condição conceitual e pragmática da abordagem dos padrões de conhecimento e à educação em saúde, na qual, por consequência, é aguardado que esses dois testes apresentem alta correlação entre si. para a verificação dessa proposta do cálculo (validade convergente), realizou-se uma correlação de pearson entre as variáveiscategorias-subcategorias do saber com o fazer. os resultados observados na tabela 2 revelaram que não somente houve uma correlação positiva e significativa acima de 0,40 entre as categorias e subcategorias do saber e do fazer, destacada na diagonal em negrito da tabela em questão, mas também a existência de uma intracorrelação entre as categorias. esses resultados sugerem que uma qualidade no processo do saber referente aos cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea influenciará positivamente no processo do fazer referente ao mesmo fenômeno. assim, é possível elaborar um pressuposto teórico sobre esse fenômeno, no qual quanto maior for o saber nas categorias relacionadas aos cuidados paliativos direcionados à pessoa com ferida tumoral maligna cutânea, maior será o fazer desse “cuidado”. validação lógica e de hipótese com vistas a uma maior garantia desses resultados, realizaram-se mais dois tipos de validade: a da lógica e a de hipótese: a primeira, de acordo com pasquali (17), refere-se à capacidade de peritos (no caso deste estudo, dois peritos com especialização na área da psicometria) avaliarem o instrumento como sendo válido, com base nos indicadores estatísticos apresentados, e a segunda 474 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 tem por base a hipótese levantada no estudo, tendo por orientação a análise de conteúdo do instrumento validado. portanto, dois peritos com experiência na psicometria admitiram que, com base nos critérios psicométricos, a referida medida (do saber e do fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral maligna cutânea) é válida, em consequência, confiável. considerações finais o presente estudo pretendeu verificar, através de cálculos relativos aos indicadores psicométricos (por exemplo, a discriminação dos itens, a representatividade do conteúdo e a fidedignidade) da medida acerca do saber e do fazer de enfermeiros nos cuidados paliativos destinados à pessoa com ferida tumoral. considerando os resultados observados, pode-se destacar que tanto o instrumento proposto quanto a perspectiva teórica abordada em relação ao constructo apresentado foram confirmados, isto é, analisar o quanto o participante é capaz de avaliar a um instrumento de pesquisa e responder a ele, com o objetivo de verificar seus comportamentos ou atitudes (17). nos referidos resultados, o instrumento apresentado contempla uma amplitude avaliativa dos itens quando se pretende observar o saber e o fazer dos enfermeiros no contexto dos cuidados paliativos, além de oferecer uma base mais distribuída sobre as categorias e subcategorias na avaliação profissional e de educação em saúde para os cuidados paliativos; principalmente, quando comparado a outros instrumentos que propõem medidas semelhantes (28, 29). com isso, os achados deste estudo oferecem dois caminhos de reflexão e aplicabilidade na abordagem do fenômeno para a área do saber e o fazer exposto neste artigo. 1. a capacidade empírica de uma medida teoricamente confiável para mensurar tais fenômenos, principalmente, relacionada à garantia psicométrica das respostas dos participantes, de tal forma que demostre a compreensão do saber e do fazer sobre a qualidade do conceito-conteúdo dos itens. este, por sua vez (como foi observado na tabela 1), teve resultado positivo (o participante que indicou sua resposta concordante a um dos domínios avaliados, provavelmente, pontuará também alto nos demais domínios) e foi corroborado de forma consistente, uma vez que os escores dos alfas estiveram acima do estatisticamente exigido. com isso, a partir dessas condições estatísticas, pode-se afirmar que aquilo que se pretende mensurar teoricamente, de fato, foi medido. 2. a comprovação do elemento teórico-empírico. etapa que pretende mensurar axiomas, uma vez que, geralmente, ao se elaborar e/ou adaptar um instrumento, busca-se verificar a associação entre teoria e prática em termos de convergência, haja vista que não se pode conceber uma medida de avaliação que venha do vazio teórico, e sim de uma base numa perspectiva conceitual e aplicada. dessa forma, os resultados apresentados na tabela 2 reforçam que saber e fazer são teoricamente correlacionados. nesse sentido, em termos de axioma da medida de identidade e de aditividade (17), existe legitimidade científica no uso do número na descrição do fenômeno avaliado, salvaguardado o procedimento empírico e sua representação teórica. assim, ao se considerarem tais resultados, existe uma espécie de isomorfismo, na qual propriedades do número na escala de resposta e aspectos dos atributos pontuados à realidade empírica do respondente foram corroborados. de forma geral, a medida das categorias-subcategorias-itens (o constructo sobre os cuidados paliativos destinados à pessoa com ferida tumoral maligna cutânea) do instrumento apresentado sobre o saber e o fazer contribuiu não somente para uma compreensão a respeito da condução e aplicação de conhecimentos teóricos e práticos nos cuidados paliativos voltados às pessoas com feridas tumorais por parte dos enfermeiros, mas também para propor um novo instrumento, já que estudos sobre esse fenômeno são escassos. essa medida poderia também ser utilizada para uma diagnose em termos de estrutura e funcionalidade do conhecimento e ajustamento desses saberes na área da saúde, sobretudo, nos cuidados paliativos e no acolhimento de pessoas com feridas tumorais malignas cutâneas. limitações do estudo apesar de os resultados serem significativos, algumas limitações no estudo podem ser pontuadas: inicialmente, mesmo que o presente instrumento contemple as categorias apresentadas pelo protocolo original (29) sobre o fenômeno abordado nesta pesquisa (cuidados paliativos direcionados às pessoas com feridas tumorais), bem como outros mais, propostos pelos autores deste estudo, a extensão do instrumento é uma condição que merece maior atenção. além disso, sugere-se rever itens e categorias, principalmente, quanto à sua tautologia, que seria de grande utilidade em futuros estudos. outra sugestão para novas pesquisas seria quanto ao tamanho amostral, pois existe um número pequeno de profissionais responsáveis nessa área, condição que promove a 475 indicadores psicométricos do saber e o fazer de enfermeiros nos cuidados paliativos à pessoa com ferida tumoral l glenda agra e outros realização de um estudo multicêntrico ou até transcultural (que contemple centros de saúde que abordem protocolos com os conteúdos na mesma direção); também seria importante conhecer a estabilidade temporal (teste-reteste) ao comparar com os resultados que podem ser indicados por outros autores e a replicabilidade deles, considerando amostras maiores e mais diversificadas no que tange às características dos participantes, que incluiriam também questões da cultura profissional, acadêmico-curriculares e econômicas dos respondentes, do hospital e da condição econômica do estado. para isso, faz-se necessário considerar, na nova avaliação do instrumento, ter em conta os aspectos mais específicos ou universais de cada cultura na avaliação desse instrumento quando se pretender adaptá-lo para outros contextos profissionais, sociais e acadêmicos. por um lado, é importante considerar as dimensões locais, específicas ou exclusivas (emics) da orientação de cada contexto e, por outro, e não menos importante, avaliar as dimensões universais (etics) do mesmo contexto, com o objetivo de comparar o constructo avaliado neste estudo com outro espaço geopolítico e social (24). agradecimentos os autores expressam os seus agradecimentos aos enfermeiros participantes da pesquisa e à instituição que facilitou a sua realização. conflitos de interesse: nenhum declarado. referências 1. tilley c, lipson j, ramos m. palliative wound care for malignant fungating 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de câncer (brasil). coordenação geral de gestão assistencial. hospital do câncer iv. tratamento e controle de feridas tumorais e úlceras por pressão no câncer avançado. instituto nacional do câncer. coordenação geral de gestão assistencial. hospital do câncer iv. rio de janeiro: inca; 2011. disponível em: http://bvsms.saude.gov. br/bvs/publicacoes/inca/feridas_tumorais.pdf http://www.scielo.br/pdf/reeusp/v43n2/a24v43n2.pdf http://www.scielo.br/pdf/reeusp/v43n2/a24v43n2.pdf http://dx.doi.org/10.1016/j.ijnurstu.2011.08.001 http://dx.doi.org/10.1016/j.jclinepi.2010.03.002 http://dx.doi.org/10.17696/2318-3691.22.2.2015.136 http://dx.doi.org/10.5123/s1679-49742017000300022 http://dx.doi.org/10.5123/s1679-49742017000300022 http://dx.doi.org/10.1590/s0102-79722013000200004 http://dx.doi.org/10.1590/0102-311x00131116 http://bvsms.saude.gov.br/bvs/publicacoes/inca/feridas_tumorais.pdf http://bvsms.saude.gov.br/bvs/publicacoes/inca/feridas_tumorais.pdf 449 gabriela cruz noronha silva1 vanessa lourenço almeida2 tábatta renata pereira de brito3 mônica la-salette da costa godinho4 denismar alves nogueira5 lucélia terra chini6 violência contra idosos: uma análise documental 1 orcid .org/0000-0002-4052-981x. escola de enfermagem, universidade federal de alfenas, brasil. 2 orcid.org/0000-0003-0087-5782. escola de enfermagem, universidade federal do alfenas, brasil. 3 orcid.org/0000-0001-9466-2993. faculdade de nutrição, universidade federal do alfenas, brasil. tabatta.brito@unifal-mg.edu.br 4 orcid.org/0000-0003-0826-402x. escola de enfermagem, universidade federal do alfenas, brasil. monica.godinho@unifal-mg.edu.br 5 orcid.org/0000-0003-2285-8764. departamento de estatística, universidade federal de alfenas, brasil. denismar.nogueira@unifal-mg.edu.br 6 orcid.org/0000-0003-0266-5295. escola de enfermagem da universidade federal do alfenas, brasil. lucelia.jonas@unifal-mg.edu.br recebido: 27/07/2018 submetido: 22/08/2018 aceito por pares: 19/09/2018 aceito: 10/10/2018 doi: 10.5294/aqui.2018.18.4.7 para citar este artigo / para citar este artículo / to reference this article silva gcn, almeida vl, brito trp, godinho mlc, nogueira da, chini lt. violência contra idosos: uma análise documental. aquichan 2018; 18(4): 449-460. doi: 10.5294/ aqui.2018.18.4.7 resumo objetivo: analisar os casos de violência contra idosos em um município do sul de minas gerais (brasil) num período de 13 anos. materiais e método: trata-se de um estudo quantitativo, retrospectivo, documental e analítico, que utilizou dados do conselho municipal do idoso. a coleta de dados referentes ao período de 2004 a 2016 ocorreu no primeiro semestre de 2017. para a análise de tendência dos casos de violência, utilizou-se regressão linear simples. resultados: foram registradas 389 denúncias, entretanto apenas 273 caracterizavam denúncias de violência contra a pessoa idosa. quanto ao agressor, 39,56 % eram do sexo masculino e 43,59 % eram filhos das vítimas. com relação ao tipo de violência, destacou-se a negligência (34,80 %), seguida da violência psicológica (16,12 %) e financeira (8,79 %). evidenciaram-se relação estatisticamente significativa entre sexo da vítima (p = 0,017), relação entre vítima e denunciante (p < 0,001), e relação entre vítima e agressor (p < 0,001) com o tipo de violência. conclusão: a violência contra o idoso nesse município envolve, principalmente, os familiares desses indivíduos; ainda, conclui-se que há necessidade de capacitação dos profissionais e elaboração de uma ferramenta completa e padronizada para o registro de ocorrências e ampliação de investigações na área a fim de se implentarem ações de combate à violência contra o idoso. palavras-chave (fonte: decs) idoso; pessoas de idade; violência; maus-tratos ao idoso; direitos dos idosos; defesa dos idosos; enfermagem. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 449-460 temática: promoção e prevenção. contribuição para a disciplina: este estudo é de grande relevância na construção da ciência de enfermagem e no âmbito da saúde coletiva, uma vez que contribui para a literatura referente à temática da violência contra o idoso. os dados encontrados fomentam a reflexão sobre possíveis influências das relações familiares, questões de gênero, determinantes sociais e de saúde nas diversas expressões da violência. dessa forma, o conhecimento dos diferentes aspectos que permeiam a violência contra idosos fornece aos profissionais que atuam nos serviços de saúde subsídio para agirem de modo efetivo na prevenção, identificação, enfrentamento e acompanhamento dessas situações. ademais, esta contribuição facilitará, em longo prazo, a estruturação e aprimoramento de políticas públicas comprometidas com a proteção dos direitos dos idosos. https://orcid.org/0000-0002-4052-981x https://orcid.org/0000-0003-0087-5782 https://orcid.org/0000-0001-9466-2993 http://orcid.org/0000-0003-0826-402x http://orcid.org/0000-0003-2285-8764 http://orcid.org/0000-0003-0266-5295 http://dx.doi.org/10.5294/aqui.2018.18.4.7 450 aquichan issn 1657-5997 eissn 2027-5374 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 449-460 violencia contra los ancianos: un análisis documental resumen objetivo: analizar los casos de violencia contra ancianos en un municipio del sur de minas gerais (brasil), en un periodo de 13 años. materiales y método: estudio cuantitativo, retrospectivo, documental y analítico, que utilizó datos del consejo municipal del anciano. la recolección de los datos referentes al periodo de 2004 a 2016 se dio en el primer semestre de 2017. para el análisis de tendencia de los casos de violencia, se empleó la regresión lineal simple. resultados: se registraron 389 denuncios; sin embargo, solo 273 caracterizaban denuncios de violencia contra el adulto mayor. en cuanto al agresor, el 39,56 % era de sexo masculino y el 43,59 % eran hijos de las víctimas. en relación con el tipo de violencia, se destacó la negligencia (34,80 %), seguida de la violencia psicológica (16,12 %) y financiera (8,79 %). se evidenció una relación estadísticamente significativa entre el sexo de la víctima (p = 0,017), la relación entre víctima y denunciante (p < 0,001) y la relación entre víctima y agresor (p < 0,001), con el tipo de violencia. conclusión: la violencia contra el adulto mayor en tal municipio implica, sobre todo, a los familiares de los individuos. hay necesidad de capacitar a los profesionales que atienden estos casos y hay que elaborar una herramienta completa y estandarizada para el registro de incidencias y ampliación de investigaciones en el área, con el fin de que se implanten acciones que combatan la violencia contra el anciano. palabras clave (fuente: decs) anciano; adulto mayor; violencia; maltrato al anciano; derechos de los ancianos; derechos del adulto mayor; enfermería. 451 violência contra idosos: uma análise documental l gabriela cruz noronha silva e outros violence against elderly people: a documentary analysis abstract objective: to analyze the cases of elder abuse in a municipality in the south of minas gerais (brazil) over a 13-year period. materials and methods: quantitative, retrospective, documentary, analytical study using data from the municipal council of the elderly. the collection of data for the period between 2004 and 2016 took place in the first half of 2017. for the trend analysis of cases of violence, simple linear regression was used. results: 389 reports were received, but only 273 described elder abuse. as for the aggressor, 39.56 % were male and 43.59 % were children of the victims. in relation to the type of violence, negligence stood out (34.80 %), followed by psychological (16.12 %) and financial violence (8.79 %). there was a statistically significant relationship between the sex of the victim (p = 0.017), victim-complainant relationship (p <0.001), victim-aggressor relationship (p <0.001) and the type of violence. conclusion: elder abuse in such municipality generally involves relatives of the individuals. it is concluded that there is a need to train professionals and prepare a complete, standardized tool for recording incidents and expanding research in the area in order to take action to fight elder abuse. keywords (source: decs) aged; elderly; violence; elder abuse; aged rights; aged advocacy; nursing. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 449-460 452 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 introdução no contexto do processo de envelhecimento humano, há uma série de alterações físicas, cognitivas, funcionais e sociais que podem levar ao surgimento de morbidades e, por conseguinte, à maior vulnerabilidade a desfechos adversos. esses fatores somados ao preconceito, ao desrespeito e à desigualdade social podem favorecer a ocorrência de violência contra idosos (1). de acordo com a organização mundial de saúde (2), a violência contra idosos é “qualquer ação ou omissão (negligência), intencional ou não intencional, que cause dano ou sofrimento às pessoas com mais de 60 anos de idade”. esses abusos podem ser físicos, sexuais, psicológicos ou financeiros. a violência contra o idoso tem sérias consequências, que incluem sofrimento desnecessário, lesões, dor, medo e podem ocasionar incapacidade, dependência, comprometimento da qualidade de vida do idoso e até mesmo morte (3, 4). conforme o plano de ação para o enfrentamento da violência contra a pessoa idosa (5), a violência pode ser definida com base na seguinte tipologia: física — refere-se ao uso da força física para obrigar os idosos a fazerem o que não querem, para feri-los, causar-lhes dor, incapacidade ou morte; psicológica — equivale a agressões verbais ou gestuais com o intuito de amedrontar, humilhar, restringir a liberdade ou isolar a pessoa idosa do contato social; sexual — diz respeito ao ato ou jogos sexuais de natureza homo ou heterorrelacional, que envolvem pessoas idosas no sentido de obter excitação, relação sexual ou práticas eróticas por meio de aliciamento, violência física ou até mesmo ameaças; abandono — trata-se de uma forma de violência que se traduz pela ausência ou abandono dos responsáveis governamentais, institucionais ou familiares, os quais não oferecem socorro à pessoa idosa que necessita de proteção; negligência — consiste na recusa ou omissão de cuidados básicos e essenciais aos idosos, por parte dos responsáveis familiares ou institucionais; financeira — refere-se à exploração indevida/ilegal dos idosos ou ao uso não consentido por eles de seus recursos financeiros e patrimoniais; autonegligência — corresponde à conduta do idoso que ameaça sua própria saúde ou segurança, pela recusa de prover cuidados necessários a si mesmo. embora seja um problema de importância social e de saúde pública, trata-se de um tema de difícil investigação, tendo em vista a dificuldade da pessoa idosa em denunciar a própria família, considerada a principal agressora (1). dados evidenciam que apenas um em cada quatro idosos que sofreram violência registra o caso (6). cabe ressaltar que estudos que envolvem a temática violência contra o idoso ainda são incipientes, sobretudo em relação à população brasileira, ainda que o entendimento da questão seja fundamental para promover a saúde, o diagnóstico precoce e o acompanhamento das vítimas e familiares. diante dessa perspectiva, o objetivo deste artigo foi de analisar os requerimentos de denúncia de violência contra idosos registrados no conselho municipal do idoso, em um município do sul de minas gerais, brasil. materiais e método estudo quantitativo, retrospectivo, documental e analítico, realizado em um município do sul de minas gerais, brasil, com dados obtidos a partir das denúncias de violência recebidas pelo conselho municipal do idoso. os dados foram coletados no primeiro semestre de 2017 por alunos de graduação previamente treinados pela coordenadora do estudo. consultaram-se os requerimentos de denúncia de violência contra o idoso registrados entre os anos de 2004 e 2016. nesse período, foram registradas 389 denúncias. para selecionar os requerimentos, adotaram-se os seguintes critérios de inclusão: requerimentos de denúncia que envolvessem como vítimas pessoas com idade igual ou superior a 60 anos, de ambos os sexos. para a coleta dos dados, foi elaborado um roteiro fundamentado nas informações contidas nos requerimentos de denúncia e nas variáveis de interesse dos pesquisadores. o roteiro contempla informações referentes à vítima (idade, sexo, estado civil e escolaridade), ao denunciante (idade, sexo e relação com a vítima), ao agressor (idade, sexo e relação com a vítima), ao tipo de violência (física, psicológica, sexual, por tráfico, financeira, por negligência/abandono, por autonegligência, tortura, institucional e outras) e ao desfecho do caso. os dados foram codificados no programa microsoft excel® e posteriormente exportados para o software stata, versão 13.0. o estudo evidenciou um gap de informações sociodemográficas, ou seja, registro incompleto nos requerimentos de denúncia sobre os idosos, denunciantes e agressores. as informações não disponíveis nos requerimentos de denúncia foram, dessa forma, consideradas ausentes (não informadas). 453 violência contra idosos: uma análise documental l gabriela cruz noronha silva e outros na análise descritiva dos dados, foram estimadas as proporções. as diferenças entre os grupos foram estimadas por meio do teste exato de fisher. para a análise de tendência, utilizou-se regressão linear simples. o número de casos de violência foi a variável dependente (y), e os anos de estudo, variável independente (x). inicialmente, foi construído um diagrama de dispersão entre o número de casos de violência e os anos de estudo, por meio do qual se identificou que a função de primeiro grau seria capaz de expressar a relação de tendência. foi utilizada a variável x centralizada (ano menos o ponto médio da série histórica). utilizou-se como medida de precisão o coeficiente de determinação (r²). no modelo, β0 representa a média de casos de violência do período analisado e o β1 a velocidade da tendência. em todas as análises, foi utilizado nível de significância de 5 %. este estudo obteve a aprovação do comitê de ética em pesquisa da universidade federal de alfenas (cep/unifal-mg), sob o parecer de número 1.940.378. resultados referente aos dados sociodemográficos (tabela 1), constatou-se que 37,73 % dos idosos vítimas de violência tinham de 70 a 79 anos, e a maioria era do sexo feminino (58,24 %). com relação à situação conjugal e escolaridade das vítimas, a maioria dos requerimentos não apresentava dados sobre essas variáveis. dentre os denunciantes, observou-se que 18,7 % tinham mais de 60 anos de idade. destaca-se, entretanto, que 78,02 % dos requerimentos não possuíam essa informação. os denunciantes foram predominantemente do sexo feminino (57,51 %); além disso, evidenciou-se que os filhos (25,65 %) e os próprios idosos (21,62 %) denunciavam a maioria dos casos de violência, embora, em 36,26 % das denúncias, não tenha sido possível constatar essa informação. concernentemente às informações do agressor, nos requerimentos dos quais foi possível extrair tais dados, notou-se distribuição semelhante entre adolescentes (3,67 %), adultos entre 20 e 39 anos (5,49 %), adultos entre 40 e 59 anos (5,49 %) e idosos (5,49 %). ainda, 39,56 % dos agressores eram do sexo masculino, e 43,59 % eram filhos das vítimas. tabela 1. caracterização das informações do idoso vítima de violência, do denunciante e do agressor no município de alfenas-mg de acordo com o conselho municipal do idoso, no período de 2004 a 2016 (alfenas, 2016) variáveis n (%) variáveis do idoso vítima de violência faixa etária 60-69 54 (19,78) 70-79 103 (37,73) 80-89 75 (27,47) mais de 90 15 (5,49) não informada 26 (9,53) sexo feminino 159 (58,24) masculino 114 (41,76) estado civil solteiro 1 (0,36) casado 54 (19,78) divorciado 1 (0,36) viúvo 4 (1,46) não informado 213 (78,2) escolaridade ensino superior 1 (0,36) não informada 272 (99,64) variáveis do denunciante faixa etária 10-19 1 (0,36) 20-39 4 (1,46) 40-59 4 (1,46) mais de 60 anos 51 (18,7) não informada 213 (78,02) sexo feminino 157 (57,51) masculino 69 (25,27) não informado 47 (17,22) 454 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 fonte: elaboração própria. dentre os anos de 2004 a 2016, foram registradas 389 denúncias de violência contra a pessoa idosa no conselho municipal do idoso. dessas notificações, 116 (29,8 %) não eram caracterizadas como denúncia de violência contra a pessoa idosa, mas sim se referiam à solicitação de consultas médicas e cirurgias, medicamentos, fraldas, cestas básicas. o maior registro de denúncia ocorreu no ano de 2016 (21,6 %). cabe destacar que alguns requerimentos de denúncia do ano de 2014 não foram localizados no conselho municipal do idoso (tabela 2). observou-se que, dentre os idosos que sofreram somente um tipo de violência, destacou-se a negligência (34,80 %), seguida da violência psicológica (16,12 %) e financeira (8,79 %). não foram registradas denúncias de violência sexual, tortura ou tráfico. quanto ao encaminhamento das vítimas, 41,39 % dos casos de violência eram direcionados ao centro de referência especializado de assistência social (creas), entretanto, em 53,48 % dos requerimentos avaliados, não havia tal informação (tabela 2). tabela 2. distribuição dos casos de violência segundo ano, categoria de violência e encaminhamento da denúncia de acordo com o conselho municipal do idoso de alfenas-mg, no período de 2004 a 2016 (alfenas, 2016) relação do denunciante com a vítima própria vítima 59 (21,62) filhos 70 (25,65) netos 5 (1,83) irmãos 3 (1,09) vizinhos 4 (1,46) outros familiares/outros 33 (12,09) não informada 99 (36,26) variáveis do agressor faixa etária 10-19 10 (3,67) 20-39 15 (5,49) 40-59 15 (5,49) mais de 60 anos 15 (5,49) não informada 218 (79,86) sexo feminino 77 (28,20) masculino 108 (39,56) não informado 88 (32,24) relação do agressor com a vítima filhos 119 (43,59) cônjuge 7 (2,56) outros familiares/outros 77 (28,2) própria vítima 15 (5,49) não informada 55 (20,16) variáveis n (%) ano 2004 2 (0,73) 2007 1 (0,36) 2008 20 (7,33) 2010 24 (8,80) 2011 42 (15,38) 2012 40 (14,65) 2013 40 (14,65) 2014 1 (0,36) 2015 44 (16,12) 2016 59 (21,62) tipo de violência físico 14 (5,12) psicológico 44 (16,12) financeiro 24 (8,79) abandono/negligência 95 (34,80) autoabandono/autonegligência 21 (7,69) institucional 5 (1,83) mais de um tipo de violência 70 (25,64) encaminhamentos/desfecho dos casos creas/centro de referência de assistência social (cras) 113 (41,39) promotoria 2 (0,73) polícia 1 (0,36) mais de um encaminhamento 11 (4,03) não informado 146 (53,48) fonte: elaboração própria. 455 violência contra idosos: uma análise documental l gabriela cruz noronha silva e outros conforme a tabela 3, evidenciou-se maior proporção de vítimas do sexo feminino nos casos de violência física, psicológica, financeira e abandono/negligência, e maior proporção de vítimas do sexo masculino nos casos de autoabandono e violência institucional (p = 0,017). quanto à relação da vítima com o denunciante, observou-se maior proporção de denúncias de violência física, psicológica, financeira, por abandono/ negligência e institucional realizadas pelo próprio idoso, cônjuge ou filho, enquanto os casos de autoabandono foram denunciados, na maioria da vezes, por não familiares da vítima (p < 0,001). no que diz respeito à relação da vítima com o agressor, evidenciou-se que a maior proporção de casos de violência psicológica, financeira e por abandono/negligência foi cometida por cônjuges ou filhos, enquanto a maior proporção de casos de violência física e institucional foi cometida por não familiares (p < 0,001). a análise de tendência por regressão linear simples foi significativa, o que evidenciou uma tendência ascendente de casos de violência contra idosos. o modelo de regressão estimado foi y = 21,4 + 3,7x (r² = 76 %), o que significa que há um acréscimo médio de 3,7 denúncias ao ano, e a média do período foi de 21,4 casos. o gráfico 1 mostra que houve uma tendência crescente de denúncias de violência entre os anos de 2004 e 2016. tabela 3. distribuição de idosos segundo categoria de violência e características da vítima, do denunciante e do agressor (alfenas, 2016) variáveis* n(%) física n(%) psicológica n(%) financeira n(%) abandono/ negligência n(%) autoabandono n(%) institucional n(%) outras n(%) p** sexo da vítima feminino 9(64,3) 31(70,4) 14(58,3) 56(58,9) 5(23,8) 1(25,0) 43(62,3) 0,016 masculino 5(35,7) 13(29,6) 10(41,7) 39(41,1) 16(76,2) 3(75,0) 26(37,7) sexo do denunciante feminino 7(63,6) 26(61,9) 11(73,3) 60(75,0) 11(64,7) 2(50,0) 41(71,9) 0,676 masculino 4(36,4) 16(38,1) 4(26,7) 20(25,0) 6(35,3) 2(50,0) 16(28,1) relação da vítima com o denunciante próprio idoso 4(36,4) 18(47,4) 4(33,3) 9(15,8) 1(7,1) 3(52,6) 20(33,9) <0,001 cônjuge/filho 4(36,4) 16(42,1) 5(41,7) 29(50,9) 5(35,7) 0(28,9) 11(40,2) outros 3(27,3) 4(10,5) 3(25,0) 19(33,3) 8(57,2) 1(18,4) 7(25,9) sexo do agressor feminino 7(53,8) 17(41,5) 7(38,9) 19(46,3) 2(16,7) 0(0,0) 25(42,4) 0,551 masculino 6(46,2) 24(58,5) 11(61,1) 22(53,7) 10(83,3) 1(100,0) 34(57,6) relação da vítima com o agressor cônjuge/filho 6(46,2) 20(51,3) 9(56,2) 53(77,9) 2(12,5) 1(33,3) 35(55,6) <0,001 outros 7(53,8) 19(48,7) 7(43,8) 15(22,1) 14(87,5) 2(66,7) 28(44,4) *categoria “não informado” omitida. a diferença nos totais se deve à ausência de informação. **valor de p obtido por meio do teste exato de fisher. fonte: elaboração própria. 456 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 gráfico 1. tendência ajustada de casos de violência (alfenas-mg, 2004-2016) fonte: elaboração própria. discussão o presente estudo analisou a violência praticada con tra a pessoa idosa, segundo dados do conselho municipal do idoso de um município do sul de minas gerais, brasil. quanto à caracterização da vítima, verificou-se que as mulheres foram víti mas de violência com maior frequência. esse dife rencial segundo o sexo, também observado por outros autores (7-9), mostra a relação de gênero, marcada pela assimetria e pela hierarquia nas relações, e revela uma sociedade machista, bem como uma cultura de discriminação contra a mulher (1, 10, 11). este estudo apontou que idosos na segunda e terceira décadas do envelhecimento foram mais envolvi dos em situação de violência, o que está em consonância com o estudo documental realizado em itajaí, santa catarina, brasil, o qual avaliou 72 denúncias do ano de 2012 no creas (12). outro estudo evidenciou que as maiores vítimas são os idosos mais velhos com limitações funcionais e cognitivas devido ao aumento do grau de dependência (11). com relação à situação conjugal das vítimas, houve predominância de idosos casados vítimas de violência, corroborando estudo realizado no distrito federal (13), brasil, no qual idosos casados eram maioria — 43,04 % das ocorrências; deve-se associar a isso as especificidades do companheiro e os achados que o apontam como segundo maior agressor (14). entretanto, outras pesquisas evidenciaram maior prevalência de violência em idosos sem companhia marital, ou seja, viúvo, solteiro ou separado (15). esse achado pode relacionar-se ao fato de a ausência de um companheiro também ser apontada como fator potencialmente associado a situações de negligência em idosos (16). no que diz respeito ao denunciante, percebeu-se que o sexo feminino permaneceu com o maior percentual, o que também foi encontrado em estudo realizado em porto alegre, brasil (8). ainda, os mesmos autores destacam que há poucos estudos que descrevem informações sobre os denunciantes. quanto à faixa etária, mais uma vez o item não informado apresenta alto percentual, o que demonstra falhas no registro da denúncia. admite-se que a incidência de denunciantes acima de 60 anos relaciona-se com os casos em que a própria vítima é a delatora, disponibilizando assim a informação sobre a idade. além disso, tal situação está em consonância com a noção de envelhecimento ativo que está associado com a participação e com a autonomia (17). a noção de envelhecimento ativo considera que essa fase deve ser concebida como etapa da vida potencializadora de novas oportunidades, independentemente se existem situações de dependência ou fragilidade social (17), o que permite o reconhecimento da aptidão para alcançar a qualidade de vida satisfatória. os familiares foram os maiores responsáveis pelas denúncias dos casos de violência, indicando o papel familiar no amparo do idoso e na defesa de sua dignidade. a família e o estado têm como atribuição o dever de cuidar do idoso e assegurar sua integridade física, moral e psicológica, segundo o artigo 230 da constituição federal (18). embora a família seja a principal rede de apoio, são seus próprios integrantes que, comumente, praticam a violência (19). quanto ao grau de parentesco, observou-se, assim como em outros estudos (7, 13, 14), que os filhos são os principais agressores. um estudo que investigou a motivação da violência sob a perspectiva do agressor constatou que tal fato pode associar-se a esses indivíduos serem procedentes de lares violentos; assim, os filhos têm atos violentos contra os pais idosos porque foram criados à base de violência (20). além disso, a dificuldade de um agressor em suprir suas próprias necessidades de vida pode fazer com que ele direcione ao idoso sua insatisfação em forma de violência (21). observou-se, neste estudo, que os homens demostra457 violência contra idosos: uma análise documental l gabriela cruz noronha silva e outros ram ser mais violentos; esse achado é compatível com o notado por outros pesquisadores (8, 14, 20). esse comportamento pode ser explicado pelo modelo social dominador e de supremacia masculina existente (22). no presente estudo, analisaram-se os requerimentos de denúncia recebidos no conselho municipal do idoso. este tem como uma de suas atribuições receber e direcionar aos órgãos competentes as petições, as denúncias e as queixas sobre ameaças e descumprimento dos direitos da pessoa idosa, além de exigir das instâncias competentes as medidas cabíveis (23). entretanto, uma porção significativa dos requerimentos identificados como denúncia de violência contra a pessoa idosa não se adequava à respectiva categoria. tal situação pode ser um indicativo de que os profissionais que realizam os registros não estão qualificados para o reconhecimento da violência e para o direcionamento adequado em resposta às diversas demandas expostas pelos cidadãos que procuram o conselho municipal do idoso. o elevado percentual de itens não informados na presente pesquisa, principalmente na categoria escolaridade, não permitiu a análise adequada de algumas variáveis. assim como ocorre em outros estudos sobre violência, há carência de dados nos requerimentos de denúncia. isso pode ser explicado por vários aspectos, a saber: ausência de instrumentos de registro padronizados, preenchimento incompleto das informações, dificuldade do idoso em relatar a ocorrência ou até mesmo de se deslocar até o local de denúncia, medo de ser repreendido pelo agressor (1) e falta de treinamento e capacitação do profissional que acolhe a denúncia. estudo documental realizado em aracaju, brasil (24), destacou a dificuldade de realizar pesquisas que desenvolvessem essa temática devido às fontes de dados se mostrarem escassas. compatível com tal afirmação, foi observada, neste estudo, ausência de registros nos anos de 2005 e 2006. nesse sentido, o uso da tecnologia e de sistemas de informação de apoio à gestão sobressaem como uma estratégia para as organizações no sentido de auxiliá-las no cumprimento de seus objetivos, garantindo agilidade, confiabilidade e qualidade de informações (25). neste estudo, verificou-se um aumento gradativo de denúncias de violências. concomitantemente, no cenário nacional, notam-se as transformações na política de assistência ao idoso, que certamente podem influenciar no padrão de violência registrado. dentre os dispositivos legais de amparo à pessoa idosa, destaca-se a implementação do estatuto do idoso, que é um instrumento de proteção ao direito dos idosos com previsão de pena pelo seu descumprimento (13). com relação ao desfecho das denúncias por parte do conselho municipal do idoso, a maioria dos casos de violência foi encaminhada ao cras e ao creas. tais unidades compõem a rede de proteção social e visam, respectivamente, à prevenção da ocorrência de situações de vulnerabilidade social e ao fortalecimento de vínculo familiar e comunitário, bem como ao trabalho social com as famílias e indivíduos em situação de risco pessoal e social por violação de direitos (26). uma metanálise (27) sobre a prevalência de violência em idosos encontrou inicialmente 38.444 estudos sobre a temática e identificou a negligência, violência psicológica e financeira como as principais cometidas contra essa população, o que é compatível com os achados deste estudo e de outros na literatura nacional (12, 28) e internacional (29). a negligência é presente tanto em nível doméstico quanto em institucional no brasil; dela sobrevêm, recorrentemente, lesões e traumas físicos, emocionais e sociais para a pessoa (30). a violência psicológica pode ter como consequências uma baixa autoestima, decréscimo da confiança e maior debilidade da vítima; pode gerar medo e dificuldades em tomar decisões e diminuir a dignidade individual. como forma de violência financeira, pode-se encontrar a imposição de barreiras ao idoso de usar seus recursos em benefício próprio e a apropriação indevida dos bens do idoso, como, por exemplo, o uso do seu cartão de aposentadoria (7). ao evidenciar que mulheres idosas foram mais frequentemente vítimas de violência física, psicológica, financeira e abandono/ negligência, denota-se um fenômeno persistente e de variadas conformações que expressam a associação do feminino com a fragilidade e a passividade (31). ainda, no que se refere à questão de gênero, uma das atribuições historicamente conferidas ao homem é a de papel de chefe de família, provedor e detentor do poder (31). essa construção da masculinidade e da associação da figura feminina aos cuidados de saúde pode culminar comportamentos que ameaçam a saúde do homem (32). esse fato pode explicar a maior proporção de vítimas do sexo masculino nos casos de autoabandono evidenciada no presente estudo. 458 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 nesta pesquisa, observou-se que pessoas não familiares das vítimas denunciaram na maioria das vezes casos de autoabandono, diminuindo a frequência de denúncias em outros tipos de violência que, consequentemente, envolviam outros agressores que não a própria vítima. assim, observa-se a necessidade de suscitar um processo consistente de informações sobre os direitos dos idosos e estimular a sociedade a comprometer-se efetivamente em prevenir, denunciar e enfrentar a violência contra o idoso (5). no âmbito da saúde coletiva, os profissionais, em especial os enfermeiros, em virtude de sua proximidade com a população em questão, possuem um papel relevante na divulgação e discussão da violência na comunidade. cabe destacar que toda visita da pessoa idosa à unidade de saúde deve ser entendida como uma oportunidade de investigar situações de violência. assim, enfermeiros devem utilizar de estratégias de reconhecimento e enfrentamento do problema empregando instrumentos validados, dinâmicas em grupo e uma escuta atenta e qualificada durante a consulta de enfermagem (33). embora se configure como um grave problema de saúde pública, a violência contra a pessoa idosa ainda constitui uma questão velada na sociedade. diante dessa realidade, é premente a implementação de uma rede articulada e contínua de ações, com definições claras do papel de cada membro, instituição, órgão governamental, setores da sociedade civil e profissionais no atendimento e prevenção da violência. ademais, ressalta-se a necessidade de capacitação de profissionais que atuam nos serviços de saúde para agirem com competência na prevenção, identificação, enfrentamento e acompanhamento de situações de violência contra o idoso (34, 35). a violência está estreitamente relacionada com o processo de envelhecimento-adoecimento. assim, é necessário criar uma cultura que compreenda o processo de envelhecimento como uma etapa normal e irreversível da existência humana, na qual os idosos tenham a liberdade de viver com dignidade, respeito e com oportunidades de participação plena da vida social e sem violência (34, 35). cabe destacar que este estudo apresenta como limitação o registro incompleto dos requerimentos de denúncias. ademais, o formulário de preenchimento das denúncias utilizado no conselho municipal de saúde em questão não permite a inserção de informações sobre as condições de saúde do idoso e de sua funcionalidade, bem como de outros elementos relevantes sobre o agressor, as quais são fundamentais para a compreensão dos principais aspectos que envolvem a violência contra a pessoa idosa. esse fato, aliado à falta de capacitação do profissional que registra a denúncia, dificulta a análise mais detalhada desse problema de saúde pública. conclusões a violência constitui um fator de risco para problemas sociais e de saúde, entretanto é evitável e de responsabilidade da esfera social e da justiça. de acordo com o presente estudo, a violência contra o idoso mais prevalente foi a negligência, sobretudo contra as mulheres com idade entre 70 e 79 anos, cometida por agressor do sexo masculino e membro da própria família. os resultados encontrados neste estudo evidenciam a importância da capacitação dos profissionais que recolhem as denúncias bem como sobre a elaboração de uma ferramenta completa e padronizada para os registros de ocorrências. considerando que as várias expressões de violência podem ser prevenidas e reduzidas a partir do conhecimento dos diferentes aspectos que permeiam a violência contra idosos, sugere-se a ampliação de investigações na área, não somente documentais, mas também de pesquisas de campo, junto aos idosos da comunidade, a fim de preencher as lacunas no conhecimento sobre a extensão do problema, a eficácia dos programas de prevenção e o acesso aos serviços de apoio para o atendimento às vítimas de violência. conflito de interesse: nenhum declarado. 459 violência contra idosos: uma análise documental l gabriela cruz noronha silva e outros referências 1. rodrigues rap, monteiro ea, santos amr, ponte mlf, fhon jrs, bolina af et al. older adults abuse in three brazilian cities. rev bras enferm. 2017;70(4): 783-91. doi: 10.1590/0034-7167-2017-0114 2. world health organization (who). global status report on violence prevention. geneva: who [citado em 20 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colombia. maria.rubio@correounivalle.edu.co 2 orcid.org/0000-0003-0247-9687. escuela de rehabilitación humana, universidad del valle, colombia. nilia.perdomo@correounivalle.edu.co 3 orcid.org/0000-0002-1503-9712. escuela de rehabilitación humana, universidad del valle, colombia. diana.zamudio@correounivalle.edu.co recibiddo: 16/08/2018 enviado a pares: 14/09/2018 aceptado por pares: 10/10/2018 aprobado: 26/10/2018 doi: 10.5294/aqui.2018.18.4.5 para citar este artigo / para citar este artículo / to reference this article rubio-grillo mh, perdomo-oliver nm, zamudio-espinosa dc. estimulación prenatal en gestantes de alto riesgo obstetrico, una mirada desde la ocupación. aquichan 2018; 18(4): 426-437. doi: 10.5294/aqui.2018.18.4.5 resumen objetivo: reeducar gestantes de alto riesgo obstétrico en prácticas de estimulación prenatal y ocuparlas en actividades que mejoren su calidad de vida mientras están hospitalizadas. materiales y métodos: estudio cualitativo de investigación acción participativa durante el segundo semestre de 2015 y el primer semestre de 2016, mediante caracterización sociodemográfica, grupos focales de conocimiento de experiencias y prácticas de las madres, negociación de talleres educativos de estimulación prenatal, ejecución de actividades ocupacionales y evaluación de cambios. resultados: participaron 35 gestantes entre 18 y 41 años, de las cuales el 80 % fueron diagnosticadas con preeclampsia, y el 50 % tenían menos de 33 semanas gestacionales. se encontraron diferencias y similitudes en los conocimientos y las prácticas sobre estimulación prenatal, así como la necesidad de mejorarlos. la negociación de los talleres educativos propició la realización e incorporación de prácticas como actividad ocupacional con significado; la elaboración de un juguete para año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 426-437 temática: práctica basada en la evidencia, promoción y prevención. aporte a la disciplina: la terapia ocupacional es una alternativa de apoyo especializado a las mujeres embarazadas de alto riesgo. reconoce al feto como un ser capaz de actuar y reaccionar en el vientre materno frente a estímulos intrauterinos de tipo visual, táctil, motor y auditivo, y motiva la sensibilidad e interacción de la madre frente a su hijo por nacer. el trabajo de los terapeutas ocupacionales se dirige al modelado de las características de las gestantes, al rendimiento ocupacional y a la creación de adaptaciones y modificaciones en las actividades y ambientes ocupacionales. utilizan estrategias de enseñanza-aprendizaje que fomentan nuevos modos de conocer, formas expresivas y creativas que pueden trasformar las prácticas de estimulación prenatal; facilitan la realización de actividades que permitan a las gestantes incorporar la capacidad, eficacia y goce en los procesos adquiridos y realizados en las ocupaciones productivas y significativas y en la participación en ocupaciones con significado y propósito. https://orcid.org/0000-0002-3612-7885 mailto:maria.rubio@correounivalle.edu.co https://orcid.org/0000-0003-0247-9687 https://orcid.org/0000-0002-1503-9712 http://dx.doi.org/10.5294/aqui.2018.18.4.5 http://dx.doi.org/10.5294/aqui.2018.18.4.5 427 estimulación prenatal en gestantes de alto riesgo obstétrico: una mirada desde la ocupación l maría helena rubio-grillo y otros año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 426-437 el bebé generó curiosidad, exploración, habilidades o formas ocupacionales y desempeño consistente en respuesta a demandas del ambiente. conclusiones: al realizar actividades con sentido y propósito, las gestantes incorporaron la capacidad, eficacia y goce en los procesos adquiridos y realizados. estar ocupadas les permitió implementar nuevas formas de saber y hacer, así como motivarse por encontrar actividades significativas en el reaprendizaje de la estimulación prenatal. palabras clave (fuente: decs) mujeres embarazadas; relaciones materno-fetales; educación prenatal; terapia ocupacional; terapia con arte. prenatal stimulation in pregnant women with high obstetric risk: a perspective from activity abstract objectives: to reeducate pregnant women with high obstetric risk in prenatal stimulation practices and to involve them in activities that improve their quality of life while hospitalized. materials and methods: qualitative study with a participatory action research approach conducted during the second half of 2015 and the first half of 2016, through sociodemographic characterization, focus groups of knowledge of mothers’ experiences and practices, negotiation of educational prenatal stimulation workshops, performance of occupational activities, and evaluation of changes. results: thirty-five pregnant women between 18 and 41 years old participated. 80 % were diagnosed with preeclampsia and 50 % were less than 33 weeks pregnant. differences and similarities were found in prenatal stimulation knowledge and practices, as well as the need to improve them. negotiating educational workshops promoted the use and incorporation of practices as meaningful occupational activities; making a toy for the baby caused curiosity, exploration, occupational skills and consistent performance in response to environmental demands. conclusions: in carrying out activities with sense and purpose, pregnant women incorporated ability, effectiveness and enjoyment in the processes conducted. being busy allowed them to implement new ways of knowing and doing and motivated them to find meaningful activities in relearning prenatal stimulation. keywords (source: decs) pregnant women; maternal-fetal relations; prenatal education; occupational therapy; art therapy. 428 aquichan issn 1657-5997 eissn 2027-5374 estimulação pré-natal em manipuladores obstétricos de alto risco: um olhar da ocupação resumo objetivo: reeducar gestantes de alto risco obstétrico nas práticas de estimulação pré-natal e realizar atividades que melhorem a qualidade de vida durante a internação. materiais e métodos: estudo qualitativo da pesquisa ação participativa, durante o segundo semestre de 2015 e o primeiro semestre de 2016. por meio de caracterização sóciodemográfica, grupos focais de conhecimento de experiências e práticas de mães, negociação de oficinas educativas de estimulação pré-natal, execução de atividades ocupacionais e avaliação de mudanças. resultados: participaram 35 gestantes, entre 18 e 41 anos, das quais 80% foram diagnosticadas com pré-eclâmpsia e 50% tinham menos de 33 semanas de gestação. além disso, diferenças e semelhanças foram encontradas no conhecimento e nas práticas de estimulação pré-natal, bem como na necessidade de aprimorá-las. a negociação de oficinas educativas levou à realização e incorporação de práticas como: atividade ocupacional com significado; a elaboração de um brinquedo para o bebê; exploração, habilidades e/ou formas ocupacionais e desempenho consistente em resposta às demandas ambientais. discussão e conclusão: ao realizar atividades com significado e propósito, as gestantes incorporaram a capacidade, a eficácia e o prazer nos processos adquiridos e realizados. o fato de estarem ocupadas permitiu que elas implementassem novas formas de conhecer e fazer, bem como que estivessem motivadas para encontrar atividades significativas na reaprendizagem da estimulação pré-natal. palavras-chave (fonte: decs) mulheres grávidas; relações materno-fetais; educação pré-natal; terapia ocupacional; terapia com arte. año 18 vol. 18 nº 4 chía, colombia diciembre 2018 l 426-437 429 estimulación prenatal en gestantes de alto riesgo obstétrico: una mirada desde la ocupación l maría helena rubio-grillo y otros introducción el embarazo de alto riesgo incrementa la probabilidad de enfermar o morir antes, durante o después del parto (1) y constituye un problema de salud pública mundial, con amplias brechas entre países según su desarrollo económico. en el mundo mueren 800 mujeres por causas relacionadas con el embarazo y el parto, de las cuales el 99 % vive en países en desarrollo (2). en latinoamérica, la cifra es de 80 por cada 100.000 nacidos vivos, y se observan diferencias entre los países norteamericanos y los latinoamericanos: mientras canadá presenta 12 casos, colombia, 71,64, y haití, 325 por cada 100.000 nacidos vivos (3). en el valle del cauca (4), la tasa de mortalidad neonatal es de 7,24 casos por 1000 habitantes, es decir, más baja que la nacional. la organización mundial de la salud recomienda mejorar la calidad de la atención prenatal, reducir el riesgo de muertes prenatales y complicaciones del embarazo y brindar una experiencia positiva durante la gestación (5). es necesario desarrollar un programa educativo, tanto para la madre, como para la familia, así como favorecer los factores personales y ambientales que la protegen, ampliar su seguridad, mejorar su nivel de satisfacción frente a los servicios prestados, ejercerles un mejor control de bienestar físico, mental y social, y contar con un apoyo especializado para las madres gestantes en alto riesgo (6, 7). la estimulación prenatal durante la gestación motiva y promueve el vínculo afectivo madre-hijo. es parte de la preparación psicoafectiva de la psicoprofilaxis obstétrica (8), implica estímulos intrauterinos visuales, táctiles, motores y auditivos (9), y es una estrategia de promoción de la salud materna y neonatal, dependiente de la interacción entre factores biológicos y psicosociales (8, 10). una oportuna y acertada estimulación enriquece y optimiza el desarrollo físico y mental del ser intrauterino, porque permite establecer la mayor cantidad de sinapsis neuronales y capacidad de comunicaciones en la masa cerebral (11, 12). la estimulación prenatal la ejecuta un amplio grupo de profesionales de la salud especializados, como auxiliares de enfermería, fisioterapeutas, terapeutas ocupacionales, enfermeros, matronas y médicos (12, 13), todos pensando y actuando desde donde cada uno puede aportar. en el contexto hospitalario (14), las madres pueden educarse en el manejo prenatal para prevenir factores de riesgo en el desarrollo del bebé (15), así como participar en intervenciones de terapia ocupacional que complementen la estimulación prenatal (16). en latinoamérica, se destacan por sus programas de estimulación prenatal cuba (17) y perú (9), y en el país, sincelejo (18) y tunja (19). su abordaje de la estimulación prenatal no aplica un proceso de aprendizaje-acción enfocado en la ocupación con significado, sino es limitado; por lo tanto, es relevante analizar y concertar, a partir de los conocimientos, percepciones y prácticas, alternativas sobre la estimulación prenatal. así, el propósito de esta investigación fue analizar los conocimientos, experiencias y percepciones sobre la estimulación prenatal de las gestantes hospitalizadas en una unidad de alto riesgo obstétrico (aro) en un hospital de tercer nivel de la ciudad de cali, concertar actividades creativas con sentido y propósito y reeducarlas en la aplicación de la estimulación prenatal. materiales y métodos se realizó una investigación acción participativa (iap) (20), correspondiente al paradigma crítico dialéctico con enfoque cualitativo. el diseño seleccionado concibe a las gestantes hospitalizadas como un grupo de personas en alto riesgo, que durante el tiempo libre de su hospitalización no se ocupan de alguna actividad y necesitan reaprender técnicas de estimulación prenatal. mediante este método, es posible lograr modificaciones en el ámbito hospitalario en cuanto a la participación de gestantes y profesionales de la salud orientados a validar y refinar la estimulación prenatal. asimismo, es importante la contribución en el proceso de la investigación y la solución del problema, independientemente de los factores personales, sociales y culturales (20, 21). la población estuvo constituida por gestantes hospitalizadas de la unidad de alto riesgo obstétrico (aro), en una institución de salud nivel iii de cali, entre el segundo semestre de 2015 y el primero de 2016. no se realizó muestreo; se desarrolló con todas las gestantes que cumplieron con los criterios de inclusión: 1) estancia en la sala de hospitalización durante los periodos de recolección de información; 2) encontrarse entre las 28 y las 40 semanas de gestación; 3) firmar el consentimiento informado manifestando la aceptación para participar en el estudio. por criterios de exclusión, se descartaron dos madres con contraindicación médica y una menor de 18 años. según la resolución 8430 de 1993 (22), el estudio tuvo una clasificación de “riesgo mínimo” para las gestantes. contó con el aval del comité institucional de revisión de ética humana (cireh) de las instituciones participantes, con acta de aprobación 430 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 número 010-012 y con el financiamiento por convocatoria interna de la universidad del valle, con código interno 1781. de manera previa al inicio del estudio, se determinaron las necesidades de dimensionar la importancia de la estimulación prenatal en el ámbito hospitalario y se socializaron los objetivos y las razones para ejecutar el proyecto con los directivos, el personal de salud de la sala y las gestantes. la investigación fue llevada a cabo en tres fases: diagnóstico participativo, implementación de estrategias y reflexión; en todas las fases se tuvo un acercamiento cara a cara con las participantes y se efectuó en la sala de hospitalización de la aro. en la primera fase se realizó la caracterización sociodemográfica de la población, a partir de la revisión de las historias clínicas. se llevaron a cabo observaciones no participantes, para obtener una aproximación inicial de las prácticas sobre estimulación prenatal de las madres; se utilizó una matriz de observación de la comunicación entre los padres y el bebé, estimulación táctil, visual, auditiva y motora, orientada por los objetivos del estudio. la captura de datos la realizaron dos monitores seleccionados por el comité de investigación de la universidad, y entrenados por el equipo de investigadores, a partir de un pilotaje con ajuste de los instrumentos, y supervisión de campo por parte de la investigadora principal. se consignó la información en un archivo de excel®, y el análisis de la información cuantitativa, en el software statav11®, con la obtención de frecuencias absolutas y relativas para variables cualitativas. posteriormente, en un salón que contenía equipos de sonido, grabadora y video, dos de las autoras desarrollaron seis grupos focales. el proceso de cada uno incluyó apertura, preguntas sobre el objeto de estudio y cierre (23). el investigador, como moderador, dirigió la sesión a partir de una guía de indagación sobre los conocimientos, las experiencias y las percepciones de las gestantes sobre la estimulación prenatal; dos estudiantes tomaron nota, realizaron un registro de audio de la sesión, y finalmente se llegó a un consenso colectivo sobre las conclusiones; se agradeció la participación de las madres y se explicó que los datos serían utilizados en la preparación de los talleres. la duración promedio fue de 27 minutos, y se identificó el desconocimiento, prácticas tradicionales, mitos y prejuicios sobre el tema. participaron las gestantes, los investigadores y una auxiliar de enfermería, para atender cualquier complicación que se presentara. el análisis de la información de los grupos lo realizaron dos investigadoras y una magíster en salud pública, en el software ethnographv6®, mediante la codificación axial, con asignación de identificaciones alfanuméricas para cada grupo focal. durante el análisis surgieron dos categorías emergentes relacionadas con conocimientos generales de estimulación prenatal y coherencia del estado emocional entre la madre y el bebé. las categorías se organizaron en un árbol de códigos (figura 1). figura 1. árbol de códigos final de la investigación fuente: elaboración propia. 431 estimulación prenatal en gestantes de alto riesgo obstétrico: una mirada desde la ocupación l maría helena rubio-grillo y otros la información obtenida se analizó desde un enfoque descriptivo. se finalizó con la devolución de los resultados parciales a las gestantes, bajo los criterios de rigor de las investigaciones cualitativas: dependencia, credibilidad, transferencia y confirmación (24), con lo cual se dio paso a la siguiente fase. en la segunda fase se dio a conocer la información obtenida y, de forma participativa, se diseñaron e implementaron estrategias, a partir de talleres sobre la estimulación prenatal y actividades terapéuticas con las madres para aminorar el riesgo prenatal y, así, resolver el problema identificado de desconocimiento sobre la estimulación en esta etapa. dichos talleres se planificaron bajo la orientación de profesionales de terapia ocupacional, y según las necesidades definidas por las gestantes, el equipo de investigadores los efectuó con la participación permanente de las madres. las estrategias de estimulación se planearon y ejecutaron según las propuestas de ludington (25), quien coincide con los roles dominantes que ocupan las madres. las actividades relacionadas con la estimulación sensorial estuvieron acordes al planteamiento de ludington (25) y de verny (26, 27), y a la condición de la madre: la estimulación visual consistió en la sensibilización de la diferencia entre el día y la noche; la estimulación táctil se direccionó hacia la aplicación de texturas (de suaves a burdas), con presión de (suave a mediana) de afuera hacia adentro, en movimientos circulares; en cuanto a la estimulación propioceptivo-vestibular, se utilizó el movimiento anteroposterior en posición sedente, de pie, con y sin desplazamiento. las estrategias aplicadas para la estimulación prenatal están descritas en la (tabla 1). según los planteamientos de aguilar (17), prieto (19), bello (28), lobato (29), federico (30) y begoña (31), y la asesoría del ingeniero mecánico-músico, se seleccionó la música de acuerdo con las características de tonalidad, ritmo e instrumentos que cumplieran con los estándares de la estimulación: para el primero, música suave y relajante, que inspirara sentimientos de amor; para el segundo y tercer trimestre, música que facilitara las acciones ocupacionales. los coordinadores del servicio donde se aplicó la intervención y el coordinador de derechos digitales de sayco avalaron la utilización de la música en este tipo de intervención. la tercera fase incluyó la finalización de los talleres de enseñanza de la estimulación prenatal y la elaboración de un juguete con material desechable, para estimular al bebé una vez naciera. por medio de una encuesta de satisfacción, se evaluaron las estrategias utilizadas con el fin de indagar sobre la transformación en la implementación de la estimulación prenatal. estímulo estrategia de estimulación pistas de audio táctil esponja húmeda con agua meditación (thaïs), de jules massenet [violín y orquesta] canción de la luna (rusalka), de a. dvorak [violín y orquesta] propioceptivo vestibular vaivén air on g string, de j. s. bach [marimba y flauta] canción de la luna (rusalka), de a. dvorak [violín y orquesta] canon in d, de j. pachelbel [cuerdas y órgano] visual simulación día-noche concierto para piano n.º 17, 3.er movimiento, de w. a. mozart [piano y orquesta] procesión de los nobles, de n. rimsky-korsakov [orquesta] tabla 1. estímulos, estrategias de estimulación y pistas de audio empleadas en los talleres de estimulación prenatal a madres gestantes hospitalizadas en la unidad de alto riesgo obstétrico de un hospital nivel iii en cali, 2016 fuente: elaboración propia a partir de los referentes teóricos expuestos. 432 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 resultados primera fase: diagnóstico participativo en la primera fase (caracterización sociodemográfica de las madres y sus condiciones obstétricas) participaron 35 madres gestantes con edades entre 18 y 41 años. la mitad de ellas tenía menos de 33 semanas gestacionales, y el diagnóstico más prevalente fue la preeclampsia no severa (50 %), seguido por la preeclampsia severa (30 %) (tabla 2). tabla 2. datos sociodemográficos de las madres gestantes participantes hospitalizadas en una unidad de alto riesgo obstétrico de un hospital nivel iii (cali, 2015) tabla 3. principales hallazgos de observaciones no participantes realizadas a madres gestantes hospitalizadas en la unidad de alto riesgo obstétrico aro de un hospital nivel iii (cali, 2015) variable frecuencia absoluta (n=35) frecuencia relativa (%) edad gestante en años cumplidos (me, ric) (25, 22-36) estrato socioeconómico 1 9 25,71 2 26 74,29 escolaridad (n=11) técnico 4 36,36 bachillerato completo 2 18,18 bachillerato incompleto 5 45,45 semanas de gestación (me, ric) (33, 24-36) días de hospitalización (me, ric) (9,5, 4-14) fuente: elaboración propia. las observaciones no participantes realizadas al inicio mostraron que los padres se comunicaron con los profesionales de la salud, y entre ellos en una menor cantidad de ocasiones; la mayoría de las interacciones se realizaron mediante caricias y conversaciones con el bebé en gestación. por otro lado, la estimulación más practicada fue la visual, con iluminación natural, auditiva mediante el habla, y táctil con aplicación a través del vientre materno. no se apreció la aplicación de técnicas como el ejercicio, la respiración, el equilibrio u otras que permitieran la estimulación motora del feto (tabla 3). categoría variable observada sí algunas veces no comunicación entre los padres entre los padres: constante y afectuosa 1 4 3 entre los padres y el bebé: caricias y conversación 0 6 2 con el personal de salud 2 2 4 estimulación táctil uso de instrumentos 0 1 7 aplicación a través del vientre materno 0 4 4 estimulación visual luz natural (n=7) 4 1 2 luz artificial 1 1 6 estimulación auditiva sonido 0 3 5 habla 0 4 4 música 1 0 7 estimulación motora ejercicios físicos 0 0 8 respiración 0 0 8 equilibrio 0 0 8 fuente: elaboración propia. la información sobre los conocimientos, las experiencias y las prácticas de las madres obtenida en los grupos focales se relacionó con conocimientos generales. aquellas manifestaron que la estimulación prenatal: “ayuda a que sean más seguros de sí mismos, más amorosos e independientes […] a desarrollar partes del cerebro, conexiones —se hacen más conexiones—, lo que permite que su cerebrito crezca mejor y sea más inteligente cuando nazca” (mgf1). reconocen que hay actividades que facilitan la estimulación, y refieren su experiencia: “este tipo de estímulos se ha dado principalmente en actividades como bailar, hacer ejercicio y los desplazamientos horizontales y verticales (por ejemplo en un ascensor)” (mgf6). con el movimiento, la mayoría reportó dos sensaciones: una de fatiga y otra de relajación, y las relacionaron con la de bienestar: 433 estimulación prenatal en gestantes de alto riesgo obstétrico: una mirada desde la ocupación l maría helena rubio-grillo y otros “relajado, los músculos no están tensionados; el baile realmente es un ejercicio, entonces ayuda a relajar y a ejercitar no solo la mente, sino también el cuerpo, aunque se termina cansado” (mgf6). a la pregunta sobre si los estímulos sensoriales, como las caricias, benefician al feto, las madres respondieron que los relacionaban con el afecto y la comunicación, además de verlos como un medio para detectar un mayor o un menor nivel de actividad de su bebé: “es una manifestación de afecto, de ternura, de amor: cuando uno se identifica con otra persona y recibe de aquella esos sentimientos, uno se da cuenta de que la persona lo quiere. también es una forma de estimular el cariño, la parte sexual…” (mgf1). “todo el día, eso es como un instintito, ¿no?, es como un instinto de uno estarse tocando el estómago” (mgf3). en los grupos focales surgió el estímulo de temperatura. las madres reportaron que los bebés “se esconden” cuando algún estimulo no es de su agrado. por ejemplo, cuando realizaron las ecografías, todas refirieron que se volteaban y “pareciera que esquivaran” el transductor; algunas relacionaron este comportamiento con la temperatura del gel; otras relataron que sus bebés se “incomodan” si les cae agua fría en el vientre durante el baño: “ya ellos saben quién es su mamá, su papá, cuando los está uno estimulando, tocándolos para alguna cosa. cuando le ponen ese doppler, a él no le gusta, entonces muchas veces le tiene uno que hablar para que se deje, porque él se esconde” (mgf3). la estimulación visual la relacionaron con las respuestas ante la luz natural y artificial (con el celular): depende… por ejemplo, para dormir, oscuro, y en la mañana no me gusta que esté con luz, que yo esté durmiendo no, no me gusta. cuando estoy deprimida, no me gusta el sol, pero tampoco quedarme en la oscuridad. por ejemplo, aquí que no bajan las persianas, no me gusta. y para dormir, ojalá lo más oscuro que yo pueda estar… yo le he puesto que lamparita, esa linternita, que el celular, y ellos reaccionan a esa luz… cuando les dan esos destellos así (la luz natural), por eso es que está en ese movimiento. (mgf5) [sic] las madres consideran transversal a todos los estímulos la estimulación auditiva: “hablarle mucho, comentarle lo que uno haga, del papá, en compañía de música suave, de manera que el sonido no altere los nervios” (mgf2). asimismo, hay que tener en cuenta la clase de música, porque puede afectar la personalidad del bebé: “digamos que si uno le coloca reguetón o música así, fuerte, el bebé va a ser más extrovertido. también es importante el tipo de música que le gusta a la mamá, para que aquel sienta esa conexión (mgf2). una categoría emergente corresponde a la coherencia entre el estado emocional de la madre y el feto. en múltiples ocasiones, las madres relatan la relación entre los diferentes tipos de estímulos y cierta sensación que conduce a un estado emocional, y que, a su vez, guarda coherencia con el estado emocional de su bebé en formación, el cual logran identificar a partir de su actividad en el vientre: “todo lo que siente uno es lo que él siente: cuando uno está contento, él está contento; cuando uno está triste, él también está triste. todo eso sale así, así como uno lleve el embarazo, así mismito sale, ni más ni menos” (mgf4). segunda fase: implementación de estrategias al finalizar la primera fase, se identificaron vacíos en la información y necesidades educativas respecto a: 1) cómo se estimula al feto; 2) a partir de qué semana es viable el nacimiento del bebé; 3) cómo manejar al bebé una vez que nace y al estar en su hogar; 4) cuáles son las consecuencias de las enfermedades que padece la madre y cómo estas afectan la salud del bebé, y 5) cuántas son las semanas mínimas de estancia del bebé para que nazca sin complicaciones. lo anterior facilitó la planeación, concertación, diseño y ejecución de talleres educativos, así como la adecuación y orientación de las acciones terapéuticas en la atención prenatal. se realizaron las actividades de intervención en coherencia con los resultados descritos, las necesidades de conocimiento y las prácticas identificadas. en aquellas se enseñó la estimulación prenatal, que reflejó cómo hacer la estimulación visual, táctil, vestibular y de movimiento. de fondo, se utilizó la música, como está descrito en la tabla 1. el 40 % de las madres participó en todos los talleres de estimulación prenatal y actividades terapéuticas; el 26 % se vinculó a los talleres y a una de las actividades terapéuticas, y el 34 % restante solo estuvo presente en los talleres de estimulación prenatal. las participantes del estudio colaboraron y realizaron las actividades propuestas, incluyendo la elaboración del juguete con material desechable, según su gusto. en el transcurso de la actividad se consideró la condición de salud y la motivación de las madres. 434 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 tercera fase: reflexión al finalizar los talleres, las madres reconocieron los beneficios de la estimulación prenatal en el desarrollo del feto antes y después del parto. comentaron acerca de las experiencias y de las sensaciones percibidas durante la aplicación de los estímulos, y ninguna manifestó aversión ni se presentó situación de emergencia alguna. como datos relevantes de las actividades de estimulación, no se observaron limitaciones en el desplazamiento de un sitio a otro ni durante la ejecución de las actividades manipulativas. las coincidencias entre las respuestas de las madres ante las actividades permitió establecer que la comunicación abierta, interactiva, fluida con sus pares, los terapeutas y el personal de salud que las asistió en la sala fue inconforme. al inicio, algunas madres, con lenguaje no verbal, se mostraron apáticas y poco expresivas durante la estimulación, pero al final se observó un cambio de actitud: una mayor empatía e interacción con objetos y estímulos. las madres construyeron elementos para estimular al bebé durante las actividades terapéuticas, y en medio de estas se observaron actitudes de apoyo entre las participantes e intercambios sobre sus emociones. el disfrute fue visible: la comunicación fue asertiva, fluida y coherente, así como la proactividad de las madres, que preguntaban y proponían alternativas frente a los aspectos de procedimiento; estuvieron atentas y concentradas, realizaron un trabajo colaborativo, los implementos los colocaban en su lugar, iniciaban y terminaban la actividad y tenían ritmo y secuenciación en su progreso. para medir el grado de satisfacción de las madres e indagar sobre las experiencias y percepciones de sus vivencias, se utilizaron las encuestas institucionales, y en particular los ítems que les concernían. allí se identificó que todas las madres percibieron un trato adecuado, calificado con 5/5, así como la información que recibieron, también calificada con 5/5 en once ocasiones, excepto por dos de las gestantes, que puntuaron esta categoría con 4/5. solo una de las madres calificó el ambiente físico, con un puntaje de 4/5. por otro lado, la pertinencia fue calificada con 5/5 por trece madres, y respecto a la continuidad de la atención, cinco madres consideraron una puntuación de 5/5, y dos gestantes la calificaron con 4/5. discusión los hallazgos del estudio pueden relacionarse con otras investigaciones desde tres aspectos fundamentales: 1) las características sociodemográficas y clínicas de las gestantes de alto riesgo; 2) la implementación de la estimulación prenatal y sus efectos en la ocupación de las madres, su sentido de autoeficacia y el desarrollo sensorial de los bebés, y 3) la relevancia del abordaje interdisciplinar en los procesos de estimulación prenatal. se identificó una relación entre la distribución de la población de las madres gestantes participantes y los hallazgos en la literatura. mediante el 80 % de los diagnósticos médicos de hospitalización se identificó preeclampsia, de forma coherente con la alta prevalencia de este trastorno en las gestantes (3, 7); de igual forma, la mitad de las madres presentaron una edad gestacional de 33 semanas, lo cual sugiere un alto riesgo obstétrico por debajo de las 37 semanas, y dicha morbilidad materna produce riesgo de prematurez y morbimortalidad neonatal (8, 10). las gestantes que participaron fueron expuestas a un aprendizaje o reaprendizaje de la estimulación prenatal. compartieron conocimientos, experiencias, percepciones, prácticas y ocupaciones, lo cual permitió a los profesionales tener una visión general del proceso, así como comprender las subyacentes influencias articuladas en el compromiso ocupacional. esto favoreció la creación de un espacio que les permitió establecer conexiones, tanto neurales, como afectivas, y en el cual primó la responsabilidad para entender la importancia de estimular al bebé que va a nacer (32-35). además, los ambientes hospitalarios afectan el acceso de una madre a las ocupaciones de la vida diaria, pues influyen en su eficacia y en la calidad del resultado, así como en la satisfacción de aquella respecto a su rendimiento. cuando se adapta el ambiente, pueden lograrse cambios y transformaciones exitosas que favorecen el desempeño de las madres durante la hospitalización (33, 34). las gestantes de este estudio participaron en la ejecución de las estrategias y fueron productivas en la construcción de un material para estimular a su bebé; se ocuparon en actividades con significado, por lo cual alcanzaron un estilo de vida equilibrado y funcional, y apreciaron cambios emocionales, facilitados por la creación de grupos de apoyo (35, 36). las ocupaciones compartidas facilitaron la ejecución, la comunicación fluida y el aprovechamiento del tiempo libre. las 435 estimulación prenatal en gestantes de alto riesgo obstétrico: una mirada desde la ocupación l maría helena rubio-grillo y otros actividades de estimulación prenatal y la preparación para la maternidad, con programas de abordaje colectivo, promueven la salud física y mental de la gestante, previenen complicaciones y, de esta forma, permiten centrarse en lo que les convoca la actividad; esto fue mencionado en los planteamientos de verny (26), aguilar (17), prieto (19), bello (28), lobato (29), federico (30) y begoña (31). además, se afirma que las ocupaciones se convierten en rutinas socialmente interactivas, y esta interacción social es recíproca y se arraiga en los compañeros de ocupaciones (36). por otro lado, la estimulación prenatal se ha estudiado principalmente desde el enfoque cuantitativo (9, 17-19), con aproximaciones teóricas que permiten observar la relevancia de esta práctica en la promoción de la salud (16). esto contrasta con la metodología usada para este estudio, en el cual el enfoque cualitativo permitió comprender el fenómeno desde la perspectiva de las madres, y en consideración del significado otorgado a la ocupación y el desarrollo de autoeficacia y satisfacción personal, aspecto que releva la participación interdisciplinar con inclusión de los terapeutas ocupacionales en dichos procesos. en consecuencia, los profesionales de la salud deben atender de forma interdisciplinar no solo las ocupaciones, sino también la variedad de factores que potencian y hacen que el compromiso y la participación de las madres promuevan aspectos positivos para su salud, desde donde pueden aportar (35, 37). por esto, el apoyo terapéutico fue una guía para la estimulación, la interacción, el manejo de la experiencia del bebé y, como valor agregado, la concientización sobre la humanización de los profesionales en la prestación del servicio para las madres, quienes promovieron la integración permanente de actividades para esta población (37). conclusiones al participar en ocupaciones en el contexto hospitalario, las gestantes implementan nuevas formas de saber y hacer que les motiva a encontrar actividades significativas y de reaprendizaje de estimulación prenatal. los terapeutas ocupacionales reconocen que para lograr una plena participación en la ocupación con significado y propósito, las gestantes deben realizar actividades que les permitan incorporar la capacidad, eficacia y goce en los procesos adquiridos y realizados. las herramientas conceptuales y de praxis del terapeuta ocupacional ofrecen calidad de vida a los seres ocupacionales. a las madres gestantes las apoyan para que ocupen el tiempo libre con actividades creativas, vean la vida de una forma diferente, aprendan otros modos de adquirir conocimiento y desarrollen su sensibilidad frente a los seres con los que interactúan. además, los abordajes grupales con implementación de estrategias de estimulación prenatal propician espacios que favorecen la creatividad, la regeneración de las fuerzas intelectuales, la construcción de identidad, la búsqueda de la felicidad y el sentido de pertenencia, lo cual permite que las gestantes, a partir de los conocimientos adquiridos, identifiquen sus capacidades de creación en la relación entre el campo del saber y su función social; se enseñen a relativizar su aplicación y a tender “puentes” entre el saber cultural y el saber cotidiano, entre la vida y el arte. finalmente, se observa que las ocupaciones promueven la salud física y mental de la gestante, con abordajes integrales e interdisciplinares, porque se centran en aprovechar el tiempo libre, al ejecutar actividades con propósito y modelar la estimulación prenatal. conflicto de intereses: ninguno declarado. 436 año 18 vol. 18 nº 4 chía, colombia diciembre 2018 aquichan issn 1657-5997 eissn 2027-5374 referencias 1. royert j, peñate m. caracterización de las gestantes de alto riesgo obstétrico en el departamento de sucre (colombia), 2015. salud uninorte. 2016 sep.-dic.;32(3):452-60. disponible en: http://rcientificas.uninorte.edu.co/index.php/salud/article/view/9137 2. organización mundial de la salud. mortalidad materna 2018 [internet]. 2018 feb. 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19(2): e1929. doi: 10.5294/aqui.2019.19.2.9 abstract objective: to investigate the concordance between the modified framingham score using the ankle-brachial index and the high-sensitivity c-reactive protein with the other scores. materials and method: cross-sectional study nested with a cohort, with elderly population, from january to march, 2018. the population characterization was presented as mean, median, absolute and relative frequencies according to degree of normality. the kappa concordance of the modified framingham score was calculated with the framingham score itself, with the systematic coronary risk evaluation (score) and with the prospective cardiovascular munster (procam). results: the modified framingham score shows moderate kappa concordance with the framingham score and the score (p < 0.001), but weak with procam. the ultra-sensitive c-reactive protein presented more reclassification of individuals among risk strata than the ankle-brachial index. conclusions: the framingham score modified with the framingham score itself, and then with the score obtained a higher proportion of concordant cases in the high-risk stratum. high-sensitivity c-reactive protein and the ankle-brachial index modify cardiovascular risk as emerging factors to provide an accurate risk stratification and to infer better management of the therapy. thus, the framingham score with its reclassification is the best screening tool for cardiovascular risk. keywords (source: decs): cardiovascular diseases; epidemiological studies; mortality; morbidity; epidemiology. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1929 theme: chronic care. contribution to the subject: the agreement analysis between the risk classification scores set forth in this article strengthens the predictive value of new markers associated with cardiovascular risk scores in the literature. in this study, the framingham score was the best contributor to risk stratification, since there is no definitive evidence of how aggravating factors in cardiovascular risk reclassification occur in practice. the scores alone can not measure with a great magnitude the synergism of the multimorbities that are present: therefore, other indicators are necessary, in addition to the stratifications. thus, by incorporating new risk markers that may be associated with future cardiovascular events, clinical practice is structured with greater safety. https://orcid.org/0000-0002-6346-6110 https://orcid.org/0000-0001-6636-8009 mailto:cacasotti@uesb.edu.br http://dx.doi.org/10.5294/aqui.2019.19.2.9 https://orcid.org/0000-0002-6346-6110 https://orcid.org/0000-0001-6636-8009 http://dx.doi.org/10.5294/aqui.2019.19.2.9 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1929 reclasificación del score de riesgo de framingham y su concordancia con otros tres cálculos resumen objetivo: investigar la concordancia entre el score de framingham modificado por medio del índice tobillo-brazo y la proteína c reactiva ultrasensible con los demás scores. materiales y método: estudio transversal anidado a una cohorte, con adultos mayores, de enero a marzo del 2018. la caracterización de la población se presentó por promedio, mediana, frecuencias absolutas y relativas conforme el grado de normalidad. se calculó la concordancia kappa del score de framingham modificado con el score de framingham mismo, el systematic coronary risk evaluation (score) y el prospective cardiovascular munster (procam). resultados: el score de framingham modificado presenta concordancia kappa moderada con el score de framingham y el score (p < 0,001), pero débil con el procam. la proteína c reactiva ultrasensible presentó más carga de reclasificación de individuos entre los estratos de riesgo que el índice tobillo-brazo. conclusiones: el score de framingham modificado con el score de framingham mismo y, en seguida, con el score obtuvieron mayor proporción de casos concordantes en el estrato de alto riesgo. la proteína c reactiva ultrasensible y el índice tobillo-brazo modifican el riesgo cardiovascular como factores emergentes para conferir precisión a la estratificación del riesgo e inferir en mejor manejo de la terapéutica. así, el score de framingham con su reclasificación es la mejor herramienta de seguimiento para el riesgo cardiovascular. palabras clave (fuente: decs) enfermedades cardiovasculares; estudios epidemiológicos; mortalidade; morbilidad; epidemiologia. 3 reclassification of the framingham risk score and its agreement with other three calculations l alessandra santos sales e outro reclassificação do escore de risco de framingham e sua concordância com outros três cálculos resumo objetivo: investigar a concordância entre o escore de framingham modificado por meio do índice tornozelo-braço e da proteína c reativa ultrassensível com os demais escores. materiais e método: estudo transversal aninhado a uma coorte, com população idosa, de janeiro a março de 2018. a caracterização da população foi apresentada por média, mediana, frequências absolutas e relativas conforme grau de normalidade. foi calculada a concordância kappa do escore de framingham modificado com o próprio escore de framingham, com o systematic coronary risk evaluation (score) e com o prospective cardiovascular munster (procam). resultados: o escore de framingham modificado apresenta concordância kappa moderada com o escore de framingham e o score (p < 0,001), mas fraca com o procam. a proteína c reativa ultrassensível apresentou mais carga de reclassificação de indivíduos entre os estratos de risco do que o índice tornozelo-braço. conclusões: o escore de framingham modificado com o próprio escore de framingham e, em seguida, com o score obtiveram maior proporção de casos concordantes no estrato de alto risco. a proteína c reativa ultrassensível e o índice tornozelo-braço modificam o risco cardiovascular como fatores emergentes para conferir acurácia à estratificação de risco e inferir em melhor condução da terapêutica. assim, o escore de framingham com sua reclassificação é a melhor ferramenta de rastreio para o risco cardiovascular. palavras-chave (fonte: decs) doenças cardiovasculares; estudos epidemiológicos; mortalidade; morbidade; epidemiologia. año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1929 4 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1929 aquichan issn 1657-5997 eissn 2027-5374 introduction the most commonly used cardiovascular risk stratifications are the framingham risk score (frs), the systematic coronary risk evaluation (score) and the prospective cardiovascular munster (procam). however, few studies have measured them in comparison. in addition, it should be noted that the choice of method may involve different interventions according to guidelines established for each classification result. (1) score, as well as other cardiovascular risk prediction scores, is used in specific groups such as patients with rheumatoid arthritis, recommended by organizations such as the european league against rheumatism (eular). this score, by means of age, gender, total cholesterol levels, systolic blood pressure (sbp) and tobacco use (2), estimates mortality from cardiovascular disease (cvd) and atherosclerotic events. procam, like the others, estimates the risk of developing cardiovascular disease in ten years and has the variables ldlcholesterol, triglycerides, diabetes and a family history of cvd. some authors suggest that procam, framingham and other scores do not represent, in their entirety, cardiovascular risk by not including biomarkers of inflammatory activity, for example, in their calculation. (3) in brazil, there are studies performed with score, procam and framingham even though it is known that the current recommendation by the brazilian society of cardiology (sbc) is the framingham score, in order to work on the study of limitations in the real identification of patients of high cardiovascular risk. (4) the 7th brazilian guideline of hypertension, in its chapter 4, which deals with the stratification of cardiovascular risk, stresses that, in a more accurate evaluation in the brazilian population, with a high prevalence of hypertension, the use of a single risk score should be avoided to base the therapeutic decisions. therefore, it recommends multifactorial models in order to obtain a more precise individual risk classification (5). the study of endothelial function by noninvasive techniques is of good predictive value to estimate cardiovascular events and be used as a tool to determine cardiovascular risk in asymptomatic patients. however, more studies need to be developed to strengthen the subject in order to create protocols to establish, in a consensual way, which screening parameters in a given population at risk are needed (6). therefore, the objective of this study was to investigate the agreement between modified frs through the ankle-brachial index (abi) and the high-sensitivity c-reactive protein (rscrp) with the other scores. materials and method cross-sectional, population, observational, descriptive and analytical study, nested to a cohort, conducted from january 2018 to march 2018. elderly access was achieved thanks to a facilitated access by a primary cohort study and by the support of the municipal health secretariat of aiquara, bahia (brazil). it was included in the study people aged 60 years or older, living in the urban area of the municipality of aiquara, bahia, who slept more than three nights at the house where they were located, and that there was in the database information that would allow stratification by the three risk scores simultaneously. the individuals who presented incapacitating cognitive and physical conditions to respond to the form and to measure cardiovascular markers and risk factors and/or blood collection were not included in the study. the data were obtained in three stages, performed by trained researchers and equipped with material needed for each data collection. in the first one, the research form was applied through home visits. in the second, the arterial pressures of the arm and the ankle were measured. in the last one, blood was collected in the morning with the elderly, after nocturnal fasting of 8 to 12 hours. the blood samples were collected, adapted and processed by the central laboratory of vitória da conquista (lacem). in the laboratory, serum levels of total cholesterol, hdl cholesterol, ldl cholesterol, triglycerides and glucose were processed by colorimetric enzymatic reactions and dosed on the beckman coulter au 680 automated analyzer by the spectrophotometry method. for those individuals with triglyceride values > 400 mg/dl, ldl cholesterol was calculated by the friedwald equation. the rscrp dosage was done in the same analyzer by the immunoturbidimetry method. the conformation of the instruments of data collection was composed of modules arranged on the basis of groups of variables: 5 reclassification of the framingham risk score and its agreement with other three calculations l alessandra santos sales e outro 1) sociodemographic characteristics, family history of cardiovascular disease and referred morbidity; 2) clinical and biochemical variables (abi, systemic blood pressure, glucose, hdl cholesterol, ldl cholesterol, total cholesterol, triglycerides and rscrp). systolic blood pressure (sbp) was measured in triplicate by automatic digital blood pressure omron, hem-7320 model, in the same upper limb, and was considered elevated when ≥ 140mmhg and/or diastolic blood pressure (dbp) ≥ 90mmhg according to the 7th brazilian arterial hypertension guideline (7). high fasting glycemia was given as values > 100 mg/dl according to the brazilian society of diabetes guideline parameter (8). total cholesterol was determined as altered with values ≥ 200 mg/dl; the hdl-c fraction < 40 mg/dl in men and < 50 mg/dl in women; the high ldl-c will be ≥ 160 mg/dl and triglycerides (tg) ≥ 150 mg/dl, according to the 5th brazilian directive on dyslipidemias (9). the reclassification of the frs score was performed based on the abi and rscrp. the abi was determined by the automatic oscillometric method, and adjusted the cutoff point from 0.9 to 1.0 second according to the meta-analysis. (10) the rscrp was dichotomized from the cutoff point of > 2mg/l, indicative of cardiovascular risk and individuals with more than 10mg/l were excluded because they corresponded to a high inflammatory state (9). the fmr considered classification at high risk, without stratifying, individuals with presence of dm and episode of acute myocardial infarction (11). the procam and frs score (11) had its rcv in 10 years < 10 % classified as low risk, between 10 and 20 % intermediate risk and ≥ 20 % as high risk. the score was classified as low risk (< 1 %), intermediate (1-4 %) and high risk (≥ 5 %) (2). the degree of normality was verified for all variables using the kolmogorov-smirnov test. the qualitative variables were presented by means of absolute and relative frequencies and the continuous variables by mean and standard deviation or median and minimum and maximum values, according to normality. for the analysis of the concordance of the modified frs stratification with the other scores, the kappa statistic was used with the categorization of very good (0.81 to 1.00), good (0.61 to 0.80), moderate (0.41 to 0.60), weak (0.21 to 0.40) and poor (< 0.20) (12). when the value of p was < 0.05, statistical significance was considered. double data entry was performed to minimize possible typing errors and correction through a spreadsheet built in excel. the analysis of the data was performed in the software ibm spss® (statistical package for the social sciences), 21.0 version. the research was approved by the committee of ethics in research in human beings, from the universidade estadual do sudoeste da bahia, under project number 1,575,825. all individuals were informed about the purpose and risks of the research and signed a free and informed consent form as recommended. results individuals who met all the eligibility criteria to participate in the study totaled 158. there were 17 denials and 23 losses for cognition, 100 losses for not having enough data for the three stratifications simultaneously, and 16 were not found. the characteristics of the population with data for the three risk scores are presented according to their sociodemographic and biochemical variables of cardiovascular risk in table 1. of the elderly evaluated, 59.5 % were female, 67.7 % were hypertensive, 47.6 % had altered rscrp levels and 18.6 % were abi. the high-risk stratifications for reclassified frs, the frs, procam and score were respectively 52.5 %, 39.9 %, 12 % and 43 %. the kappa statistic showed a weak agreement between the modified frs and procam, and a moderate agreement with the reclassified frs and the frs, as well as the score. significant differences (p < 0.001) were identified between the reclassified frs and the frs, as well as between the reclassified frs and the score (table 2). the reclassification with the rscrp had a larger quantity than the abi. it was found that 8 people were reclassified from low to high risk and 6 from moderate to high risk in relation to abi. it was also identified that 25 elderly people were reclassified from low to high risk and 11 from moderate to high risk compared to rscrp (table 3). 6 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1929 aquichan issn 1657-5997 eissn 2027-5374 table 1. characteristics of the study population. aiquara, bahia, brazil (2018) values are presented as absolute number and frequency, mean ± standard deviation or median (minimum-maximum). source: own elaboration. table 2. kappa concordance analysis between reclassified frs with other cardiovascular risk scores. aiquara, bahia, brazil (2018) table 3. reclassification of the modified frs with the frs itself from the addition of abi and rscrp. aiquara, bahia, brazil (2018) frs score procam cardiovascular risk h ig h a ve ra ge lo w h ig h a ve ra ge lo w h ig h a ve ra ge lo w re cl as si fie d fr s high n 63 17 3 58 25 0 15 37 31 % 39,9 10,8 1,9 36,7 15,8 0 9,5 23,4 19,6 average n 0 25 27 6 46 0 4 11 37 % 0 15,8 17,1 3,8 29,1 0 2,5 7,0 23,4 low n 0 0 23 4 19 0 0 3 20 % 0 0 14,6 2,5 12,0 0 0 1,9 12,7 kappa 0,545 moderate 0,417 moderate 0,054 poor p < 0,001 < 0,001 0,181 n concordant cases (%) 70,3 65,8 29,1 source: own elaboration. low moderate high erf 53 42 63 modified frs 23 52 83 source: own elaboration. discussion among the elderly in aiquara, self-reported arterial hypertension was the most prevalent risk factor, affecting 67.7 % of them. the mean systolic pressure was 144.44 mmhg, thus above the value recommended by the 7th brazilian hypertension guideline (8). among the study population, 53.2 % had the frequency of systolic blood pressure levels changed. the national survey on access, use and promotion of the rational use of medications (pnaum), a population-based study conducted in municipalities of brazil between september 2013 and february 2014 identified a lower prevalence of self-reported hypertension in the 60-year-old population (59 %). (13) another brazilian national survey, for individuals older than 75 years, the prevalence was 55.1 %; (14) in campina grande, paraíba (brazil), was higher (75.6 %) (15) and in a survey of the surveillance system for risk factors and protection for chronic diseases by telephone inquiry (vigitel), the prevalence in age group of 55-64 was 50.3 % and, at 65 years or more, was 60.4 % (16). when comparing the self-reported prevalence of hypertension in the elderly of aiquara (67.7 %) with those of the pnaum (59 %), it was identified that the values obtained in aiquara, a small municipality, although superior, are close. it is worth mentioning that the pnaum evaluated the resident population in municipalities of different population sizes. faced with the increasing tendency of hypertension (13), the differences related only to the population size no longer sustain. the prevalence of hypertension in the study is probably due to the presence of many risk factors, easy access to the diagnosis provided by the family health strategy, greater recognition of the elderly patient’s hypertensive condition or a synergism of all these factors. characteristics general (n = 158) age (years) 70.50 (60-92) female sex [n(%)] 94 (59.5) diabetes [n(%)] 43 (27.2) hypertension [n(%)] 107 (67.7) sbp (mmhg) 144.44 ± 20.01 dbp (mmhg) 85.35 ± 11.33 fasting glycemia (mg/dl) 81.50 (54-410) total cholesterol (mg/dl) 186.93 ± 43.05 hdl cholesterol (mg/dl) 47 (28-107) ldl cholesterol (mg/dl) 112.18 ± 38.26 triglycerides (mg/dl) 110 (42-522) abi changed [n(%)] 29 (18.6) crp changed [n(%)] 61 (33.9) bmi 26.61 (18.01-69.62) 7 reclassification of the framingham risk score and its agreement with other three calculations l alessandra santos sales e outro another important cardiovascular risk factor in all stratification is the presence of diabetes, whose self-reported prevalence in aiquara was 27.2 %; this value is greater than that reported in elderly brazilians in the national sample survey (pnad) (16.1 %) (17) and also in population of four communities in the united states of america (10 %) (18). it is important to mention that the isolated presence of diabetes classifies the individual in the category of high cardiovascular risk without having to make stratification to the frs and score since 2007. it is considered, however, that the stratification given by procam considers the diagnosis of diabetes or the high glycemic value in its calculation, while others do not consider it, considering that the presence of this complaint already classifies the individual in the category of high risk. the prevalence of the high-risk category scores of the reclassified framingham, framingham, procam and score were respectively 52.5 %, 39.9 %, 12 % and 43 %. the value obtained by procam distances more from the two frs when compared to the score that presented better agreement by kappa analysis. thus, there was a moderate agreement between reclassified frs and procam, as well as between reclassified frs and frs with statistical significance (p <0.001), but weak agreement between reclassified frs and procam. probably because there is inclusion of the variables ldl, triglycerides and glycemic value in procam that is absent in the others. in addition, the score did not present the category of low risk, since in it the age of 60 marks the elderly in the highest stratum. considering that the results obtained by the different methods used to estimate cardiovascular risk employ variables that are not always equivalent, and that there are also differences between geographic regions, time of patient follow-up, quality of data filling, it is presented justifications for differences of agreement in the classification of cardiovascular risk (19) demonstrated in the present study. however, there is no consensus that the available scores can predict the risk of cardiovascular disease in lowand middle-income countries. it is necessary, however, to have these cardiovascular risk assessment tools to support daily clinical practice (20), with the objective of directing resolutive health practices. in brazil, frs is the most commonly used cardiovascular risk screening method and recommended by sbc. it also presents the possibility of reclassifying risk through so-called “emerging factors” such as abi and rscrp. (9) the reclassification of frs significantly improves the validity of cardiovascular risk, (5) since no score used in the risk assessment accommodates all known factors, and it would not be possible at all places to continuously produce updated risk functions based on prospective cohort studies (21). therefore, reclassification is considered the best viable alternative (21). thus, in this research, abi and rscrp were used as additional investigation to improve cardiovascular risk assessment. the reclassification of the frs from the abi caused 14 elderly people to change their classification, and 36 elderly people reclassified by rscrp. based on these results, rscrp, due to its higher prevalence of altered values (47.6 %) compared to abi, contributed to a greater magnitude with the reclassification of cardiovascular risk. it is important to add that rscrp, considered an inflammatory marker, is also useful in improving cardiovascular risk assessment in individuals with atherosclerosis, even if they present only one or none of the traditional risk factors (22). the rscrp, for being part of the general inflammatory state, can detect chronic infections of low grade in several places and, therefore, contribute to the reclassification of risk. reclassification is especially important in prevention, since high-risk individuals have a concrete indication of pharmacological treatment, while the same measure has an uncertain efficacy in the category of intermediate risk (22). however, it is worth mentioning that, even though it is recommended by sbc, there is still no consensus on the use of rscrp in routine primary prevention, although it presents clinically higher predictive capacity. despite these findings, there is an indication of the need for validation of rscrp in large-scale studies in order to clarify whether it contributes to reduce cardiovascular morbidity and mortality, but there is no doubt about its value as a marker of risk (22). in this sense, more studies are needed for an evaluation of the benefits and damages of adding these indices to the traditional risk assessment for cvd in asymptomatic adults to prevent cvd events (23). like rscrp, abi also has the ability to improve classification, discrimination (ability to distinguish between people who will or will not experience an event) and reclassification (transfer risk 8 año 19 vol. 19 nº 2 chía, colombia mayo 2019 l e1929 aquichan issn 1657-5997 eissn 2027-5374 strata) (24). a meta-analysis, performed in the japanese population using the oscillometric method, concluded that the lower the abi values, the greater the risk of cvd and all-cause mortality (24). studies suggest the use of abi in the reclassification of cardiovascular risk. results of the artper cohort, conducted in spain, with people over 49 years (the artper), support the addition of abi to the reclassification of cardiovascular risk (25). another study (longitudinal study of adult health — elsa/brazil), in which three different abi methods were calculated, was associated with a high load of cardiovascular risk factors and, therefore, the authors recommend its application in primary care (26). thus, based on the results found, it is possible to infer that the reclassification of risk in the modified erf generated large changes of classification and, consequently, may have more strongly influenced the level of agreement weak kappa between the modified frs and procam. the modified frs and the frs as well as the modified erf with the score, presenting a moderate agreement, bear similarities mainly in the high-risk category. even so, the frs presents greater prediction of cardiovascular risk in aiquara. conclusion from the kappa concordance analysis, it was concluded that the reclassified frs presented statistical significance with the frs and the score, with the highest number of cases consistent with the frs. the rscrp and the abi modify the cardiovascular risk of individuals between the strata and allow a more reliable and therefore more effective targeting of the therapy. since stratification is part of the standardized clinical management for those with systemic arterial hypertension, a highly prevalent and basic disease for numerous cardiovascular conditions, it is necessary to handle them appropriately considering the addition of emerging variables to give robustness to the results. the frs better predicts risk, however, coupled with aggravating factors, adds even more accuracy to more specific individual clinical guidance. this study demonstrates that the information on rscrp and abi obtained mainly in individuals at intermediate risk by frs, which resulted in their change of category, brings an incremental value analysis to the stratification of cardiovascular events. new markers, then, can improve stratification in groups at risk of multimorbidity, such as the elderly. therefore, it is necessary a clinical practice with the greatest possible contribution of measures to 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cardiovascular primary prevention. european heart journal. 2010; 31(7):777-83. doi: 10.1093/eurheartj/ehq022 23. us preventive services task force. risk assessment for cardiovascular disease with nontraditional risk factors us preventive services task force recommendation statement. jama. 2018; 320(3):272-80. doi: 10.1001/jama.2018.8359 24. ohkuma t, ninomiya t, tomiyama h, kario k, hoshide s, kita y et al. ankle-brachial index measured by oscillometryis predictive for cardiovascular disease and premature death in the japanese population: an individual participant data meta-analysis. atherosclerosis. 2018; 275:141-8. doi: 10.1016/j.atherosclerosis.2018.05.048 25. forés r, alzamora mt, pera g, baena-díez jm, mundet-tuduri x, torán p. contribution of the ankle-brachial index to improve the prediction of coronary risk: the artper cohort. 2018; 13(1):e0191283. doi: 10.1371/journal.pone.0191283 26. miname m, bensenor im, lotufo pa. different methods of calculatin gankle-brachial index in mid-elderly men and women: the brazilian longitudinal study of adult health (elsa-brasil). braz j med biol res. 2016; 49(12):e5734. doi: 10.1590/1414-431x20165734 https://doi.org/10.1097/hpc.0000000000000045 https://doi.org/10.1016/j.jacc.2009.07.020 https://doi.org/10.1093/eurheartj/ehq022 https://doi.org/10.1001/jama.2018.8359 https://doi.org/10.1016/j.atherosclerosis.2018.05.048 https://doi.org/10.1371/journal.pone.0191283 https://doi.org/10.1590/1414-431x20165734 1 joyce souza lemes1 kelle vanessa álvares amaral2 cynthia de assis barros nunes3 ana clara alves campo4 alexia nunes batista5 suelen gomes malaquias6 instruments to assess the subjective repercussions of people with chronic wounds: integrative review 1 orcid.org/0000-0002-7401-2608. faculdade de enfermagem, universidade federal de goiás, brazil. joyce@enf.grad.ufg.br 2 orcid.org/0000-0002-9758-4270. faculdade de enfermagem, universidade federal de goiás, brazil. kelle.amaral@ebserh.gov.br 3 orcid.org/0000-0001-8322-8737. faculdade de enfermagem, universidade federal de goiás, brazil. chyntia@posgrad.ufg.br 4 orcid.org/0000-0002-1683-7249. faculdade de enfermagem, universidade federal de goiás, brazil. anaclara@enf.grad.ufg.br 5 orcid.org/0000-0002-0031-4400. faculdade de enfermagem, universidade federal de goiás, brazil. alexianb@enf.grad.ufg.br 6 orcid.org/0000-0001-8530-9100. faculdade de enfermagem, universidade federal de goiás, brazil. suelen.g.malaquias@ufg.br received: 28/07/2018 sent to peer reviewers: 22/08/2018 accepted by peers: 28/10/2018 approved submission: 29/11/2018 doi: 10.5294/aqui.2019.19.1.8 to reference this article / para citar este artículo / para citar este artigo lemes js, amaral kva, nunes cab, campos aca, batista an, malaquias sg. instruments to assess the subjective repercussions of people with chronic wounds: integrative review. aquichan 2019; 19(1): e1918. doi: 10.5294/aqui.2019.19.1.8 abstract objective: to analyze the instruments described in the literature for extended assessment in people with chronic wound. materials and methods: study of integrative review of the literature. the search was conducted on databases including pubmed, web of science, scielo, cinahl, science direct (elsevier), scopus, and biblioteca virtual da saúde (bvs). results: the search found 19 060 articles; after relevance tests, 41 were left. the instrument most used in the studies of this review was the short form 36 health survery (sf-36), which is a tool to assess quality of life (qol). conclusion: a diversity of instruments was identified for extended assessment of people with wounds, with those investigating qol being the most frequent. the repercussions are, mostly, contained in the qol assessment instruaño 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1918 theme: evidence-based practice. contribution to the discipline: this review sought to contribute to better understanding of the instruments of subjective or holistic assessment of individuals with chronic wounds. it is necessary for nursing care to consider the individual as a whole, which can be facilitated from the theoretical reference by wanda de aguiar horta through the theory of basic human needs. hence, the selection of instruments capable of assessing the broader needs of a population, enables the systematization of nursing care and the orientation towards more assertive interventions. instruments that evaluate quality of life are capable of evaluating people with wounds, suggesting that other repercussions are identified through said evaluation. it is highlighted that evidence-based practice (ebp) emerges from the clinical observations and from the essential demands, which provides health professionals knowledge, in systematic and consistent manner, to support their decision-making on health care to individuals. thus, within the context of this study, evidence-based actions minimize intuitive behaviors and aid in the systematization of nursing care. http://orcid.org/0000-0002-7401-2608 http://orcid.org/0000-0002-9758-4270 http://orcid.org/0000-0001-8322-8737 http://orcid.org/0000-0002-1683-7249 http://orcid.org/0000-0002-0031-4400 http://orcid.org/0000-0001-8530-9100 http://dx.doi.org/10.5294/aqui.2019.19.1.8 http://orcid.org/0000-0002-8810-9937 http://orcid.org/0000-0002-9758-4270 http://orcid.org/0000-0001-8322-8737 https://orcid.org/0000-0002-1683-7249 https://orcid.org/0000-0002-0031-4400 https://orcid.org/0000-0002-0031-4400 http://dx.doi.org/10.5294/aqui.2019.19.1.8 2 aquichan issn 1657-5997 eissn 2027-5374 año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1918 ments, but superficially and/or not explicitly, as in the sf-36, the means most-frequently identified in the studies of this review. these findings suggest the likelihood of differentiated implications of these instruments according to the etiology of the lesions, psychosocial and psychospiritual needs of the individual, as well as the context to which they are destined, like teaching, clinical practice, or research. keywords (source: decs) quality of life; wounds and injuries; leg ulcer; evaluation; evaluation of research programs and tools. instrumentos para evaluar las repercusiones subjetivas de personas con heridas crónicas: revisión integrativa resumen objetivo: analizar los instrumentos descritos en la literatura para evaluación ampliada en personas con herida crónica. material y métodos: estudio de revisión integrativa de la literatura. la investigación se realizó en las bases de datos pubmed, web of science, scielo, cinahl, science direct (elsevier), scopus y biblioteca virtual de la salud (bvs). resultados: se encontraron 19 060 artículos; después de las pruebas de relevancia, quedaron 41. el instrumento más utilizado en los estudios de esta revisión fue el short form 36 health survery (sf-36), que es una herramienta de evaluación de la calidad de vida (cv). conclusión: se identificaronó diversidad de instrumentos para evaluación ampliada de personas con heridas, siendo los de investigación de la cv los más frecuentes. las repercusiones están, en su mayoría, contenidas en los instrumentos de evaluación de la cv, pero de forma superficial y/o poco explícita, como en el sf-36, medio más frecuentemente identificado en los estudios de esta revisión. estos hallazgos sugieren la posibilidad de implicaciones diferenciadas de esos instrumentos según la etiología de las lesiones, necesidades psicosociales y psicoespirituales del individuo, así como el contexto a que se destinan, tales quales enseñanza, práctica clínica o investigación. palabras clave (fuente: decs) calidad de vida; heridas y lesiones; úlcera de la pierna; evaluación; evaluación de programas e instrumentos de investigación. 3 instruments to assess the subjective repercussions of people with chronic wounds: integrative review l joyce souza lemes e outros instrumentos para avaliação das repercussões subjetivas de pessoas com feridas crônicas: revisão integrativa resumo objetivo: analisar os instrumentos descritos na literatura para avaliação ampliada em pessoas com ferida crônica. material e métodos: estudo de revisão integrativa da literatura. a busca foi feita nas bases de dados pubmed, web of science, scielo, cinahl, science direct (elsevier), scopus, e biblioteca virtual da saúde (bvs). resultados: foram encontrados 19060 artigos; após os testes de relevância, restaram quatro. o instrumento mais utilizado nos estudos dessa revisão foi o sf-36, que é uma ferramenta de avaliação da qualidade de vida (qv). conclusão: identificou-se diversidade de instrumentos para avaliação ampliada de pessoas com feridas, sendo os de investigação da qv os mais frequentes. as repercussões estão, em sua maioria, contidas nos instrumentos de avalição de qv, porém de forma superficial e/ou pouco explícita, como no short form 36 health survery (sf-36), meio mais frequentemente identificado nos estudos dessa revisão. esses achados sugerem a possibilidade de implicações diferenciadas desses instrumentos conforme a etiologia das lesões, necessidades psicossociais e psicoespirituais do indivíduo, bem como o contexto a que se destinam, tais como ensino, prática clínica ou pesquisa. palavras-chave (fonte: decs) qualidade de vida; ferimentos e lesões; úlcera da perna; avaliação; avaliação de programas e instrumentos de pesquisa. año 19 vol. 19 nº 1 chía, colombia febrero 2019 l e1918 4 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 introduction the occurrence of chronic wound, to the demands and limitations caused by the ulcer, triggers several representations to individuals. in this sense, it is possible that the following situations are observed: chronic pain syndrome, change in body image, reduced work capacity, and altered family and social dynamics. they can lead individuals to a condition of social isolation, which impacts upon their quality of life (qol) (1, 2). to adequately care for these individuals, technical-scientific knowledge is necessary that considers aspects that go beyond the topical care of lesions. it is necessary to address the impacts of wounds on the daily lives of individuals, respecting the feelings, sensations, and biopsychosocial needs that must be addressed (3). to be resolute in the context of clinical practice, interventions in the aforementioned situations must be systematized and based on scientific evidence, so that cases are duly followed up. in this sense, strategies exist to aid professionals to minimize the bias of subjectivity associated with this type of evaluation. it is known that to make a holistic approach in people with chronic comorbidities, it is necessary to consider the aspects mentioned. nevertheless, identifying those conditions may not be a simple task, given that these are aspects involving personal interpretations or impressions. this makes the evaluations made by the professionals superficial, detailed, or very subjective. an important tool to guide said assessment is the use of patient report outcome measures (prom), which are instruments that permit knowing and measuring patients’ opinions about their health and which, when applied during different moments of treatment, enable monitoring possible changes. these instruments serve as an aid because they estimate the evaluation in measurable manner and favor follow-up without the evaluator’s personal impressions (4). currently, several instruments are available for said purpose in diverse populations, even in people with wounds. however, it is observed that each study chooses a method, based on its priorities, and indicates somewhat inconclusive results regarding the use of the method chosen. knowing the instruments that evaluate beyond the conditions of healing can contribute to the integral care of the individual, as well as influence upon decisions of care, treatment and/or interventions, along with the formulation of health programs and institutional policies (5). thus, this research is justified by the need to identify which of these instruments are or are not validated and to evidence their particularities. the initiative can favor the actions of professionals caring for people with those characteristics, with the purpose of optimizing the evaluation of psychophysiological repercussions. by identifying the most effective instruments, it is possible to plan more assertive interventions in clinical practice and conduct experimental research, as well as aid in the professional formation of nurses and other professionals caring for said patients. objective to analyze instruments of subjective evaluation of people with chronic wound described in the literature. materials and methods this was a study of integrative review of the literature, conducted from august 2016 to july 2017. for the purpose of reporting this study, the work followed the recommendations of the preferred reporting items for systematic reviews and metaanalyses (prisma). this is a checklist with 27 items, seeking to help authors to direct, more consistently and objectively, the presentation of systematic reviews and meta-analyses (6). to elaborate the research question, the pvo strategy was used, where (p) is the person with chronic wound, (v) are the evaluation instruments, and (o) the outcomes the individual presents (6). the guiding question of this study was: what instruments are used for a subjective evaluation in people with chronic wounds? the research included articles written between february 2006 and february 2017; in portuguese, english, and spanish; articles dealing with extended evaluation in people with chronic wounds (pressure lesions and/or leg ulcer, patients with complications in the feet due to diabetes mellitus, psoriasis), and also articles that use instruments for this evaluation. dissertations, theses, book chapters, editorials, reviews, comments, abstracts, systematic and integrative review articles, and duplicate articles were excluded. 5 instruments to assess the subjective repercussions of people with chronic wounds: integrative review l joyce souza lemes e outros on 16 february 2017, a search was conducted in the following databases: national library of medicine (medicine ― pubmed), web of science, electronic library online (scielo), cumulative index of nursing and allied health literature (cinahl), science direct (elsevier), science direct (scopus), and biblioteca virtual em saúde (bvs). the following search strategy was used: “quality of life” or “fatigue” or “pain” or “anxiety” or “depression” and “wounds and injures” or “leg ulcer” or “varicose ulcer” or “pressure ulcer” or “diabetic foot” and “evaluation” or “evaluation of research programs and tools”. the 19 060 articles identified in the search were saved, on the same day via e-mail, to control and apply relevance tests (rt) elaborated according to the inclusion criteria, which were established from the research question (7). the study considered articles in english, portuguese, and spanish, published between 2006 and 2017, and which addressed leg ulcer or holistic subjective assessment of the individual. first, the rt was applied to the titles of the articles identified, configuring rt 1, and, thereafter, the abstracts, representing the rt 2. thus, duplicates, theses, dissertations, monographs, book chapters, editorials, opinion articles, and literature reviews were also excluded. a form was drawn up to extract data from each article. thus, extraction, organization, and summarization of information continued through the analysis of authenticity, methodological quality, importance of information, and representativeness, as well as the judgment of the study with regard to the degree of evidence (7, 8). to verify the degree of evidence of each article selected, the study used the joanna briggs reviewer’s manual, elaborated as a comprehensive guide to conduct systematic reviews, by categorizing the studies from their methodological designs (8). results from the search in all the databases, 19 060 articles were obtained; by applying the relevance test 1, 18 726 were excluded because of language, temporal cut prior to 2006, and not addressing repercussions among people with chronic wounds. thereafter the relevance test 2 was applied, which excluded 293 articles because they did not contain instruments of extended assessment, and being duplicates and literature review articles, theses, dissertations, opinion articles, course completion works, and editorials. thus, 41 articles were included to read in full and extract data (figure 1). table 1 evidences the characterization of the 41 studies selected, according to methodological design, population, objective, conclusion, and level of evidence, according to recommendations by the joanna briggs institute (8). a higher number of publications was identified after 2014, indicating a growing demand for greater understanding on aspects concerning the extended assessment of people with chronic wounds. with regards to types of studies, 26 (63.4 %) were cross-sectional, 10 (24.4 %) validation, translation, and adaptation of instruments, two (4.9 %) were pilot studies, two (4.9 %) control cases, and one (2.4 %) cohort study. there was prevalence of research conducted in american countries (51.2 %), of which 76.2 % were brazilian, followed by european studies (43.9 %). with respect to the authors’ formation area, 20 (48.8 %) were from medicine, 11 (26.8 %) from nursing, 6 (14.6 %) from physiotherapy, and 4 (9.8 %) from nutrition. in relation to the characteristics of the populations studied, 31 studies (75.6 %) had prevalence of female gender; in 63.4 % of the studies, age ranged between 60 and 70 years. the comorbidities found were diabetes (39 %), vascular disease (26.8 %), diabetes and figure 1. flowchart of the study inclusion process source: own elaboration. 6 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 table 1. characterization of the studies according to type, population, objective, conclusion, and level of evidence. goiania, 2017. nº type of study location of study population objective of the study principal findings level of evidenceage sex e1 (9) exploratory, descriptive, crosssectional brazil < 60 41 % 60-70 58 % > 70 1 % more than 50 % f observe and compare feelings of powerlessness in people with venous ulcer and in people with foot ulcer due to complications of diabetes mellitus (dm) using the powerlessness assessment tool (pat) scale. the results indicated that patients with venous disease e foot ulcer due to complications of dm had very strong feelings of powerlessness for living with this. said feelings are significantly stronger in patients with foot ulcer due to complications of dm (p: 0.002). 4b e2 (10) crosssectional, descriptive and analytic study the united kingdom mean of 65 years 54 % f test the pressure ulcer qol (pu-qol) among people with pressure lesion (pl). the pu-qol instrument provides a standardized method to assess qol (qol) specific of the pressure ulcer. 4b e3 (11) crosssectional, descriptive and analytic study germany mean of 67.8 years 55 % f assess the level of pain of patients related to leg ulcer and determine the impact of said pain on the qol of said patients, using the eq 5d instrument. in 46 % of the participants with pain, it was identified that high levels of pain correlated with worse health status. greater reduction of qol was noted related to pain for women (r20.56, men; r20.08, women). 4b e4 (12) crosssectional comparative study greece mean 48.2 years 50 % f compare qol, anxiety and depression, self-esteem and feeling of loneliness in patients with psoriasis and leg ulcer (lu). both groups present worse conditions of the items evaluated. people with psoriasis present greater loneliness, social isolation, and anxiety (p < 0.001) than people with lu. self-esteem had no significant difference between the groups. 4b e5 (13) observational, crosssectional, analytic, multicenter study spain mean of 72.06 years 55 % m determine qol in patients with venous ulcer and the relation severity of the ulcer loss of qol, as well as identify the aspects of qol most negatively affected by the venous ulcer. relationship exists between severity of the ulcer and lower qol (r: 0.546; p ≤ 0.001). presence of non-viable tissue, exudate and infection determine worse qol. new studies are necessary to confirm said findings. 4b e6 (14) crosssectional, random multicenter study canada mean of 65 years 55 % f observe the association between sociodemographic and clinical factors and qol in patients with chronic leg ulcer. higher levels of pain (p < 0.01; ci = 1.3-4.7), lower age (p < 0.01; ci = 1.1-1.5), higher time of ulcer duration (p < 0.01; ci = 1.7-5.0), limitation in mobility (p = 0.02; ci = 1.2-3.2) were associated to worse qol. 1c e7 (15) prospective non-randomized cohort study the united kingdom mean of 69.7 years 76 % m evaluate factors associated to the healing process and impact of the limb loss on the qol of patients with foot ulcer due to complications of dm. in all the domains of the diabetic foot scale (dfs), qol was improved over the cohort of our patients (p ˂ 0.0001), independent of their outcome (healing or amputation). significant improvement was also observed in self-care after follow up. 3c e8 (16) crosssectional, descriptive, analytic study brazil 31.7 % < 60 65 % 61-70 33 % > 70 73 % f identify feelings of powerlessness among people with venous ulcer, from the (pat) scale. high pat scores were identified, revealing strong (32 %) or very strong (52 %) feelings of powerlessness, which can provoke negative effects on qol. 4b e9 (17) comparative, crosssectional study brazil mean of 65 years 80 % f evaluate qol and self-esteem in patients with foot ulcer due to complications of dm. patients with ulcer on diabetic foot present lower qol regarding physical aspects (p = 0.043), functional capacity (p = 0.003), social aspects (p = 0.022), emotional aspects (p = 001). there was no statistical difference of self-esteem among groups of diabetic patients without ulcer. 4b 7 instruments to assess the subjective repercussions of people with chronic wounds: integrative review l joyce souza lemes e outros nº type of study location of study population objective of the study principal findings level of evidenceage sex e10 (18) crosssectional study india mean of 62 years 58.5 % f evaluate the impact of foot ulcer on qol of diabetic patients, using the rand 36 scale and the dfs scale. diabetic patients with and without foot ulcer had impaired qol (score ˂ 50 points). the group of patients with foot ulcer due to complication of dm presented compromised qol in all six domains of dsf ― short form. patients with foot ulcer due to complication of dm had worse qol when compared to diabetic patients without ulcer. 4b e11 (19) quantitative, descriptive and crosssectional research brazil 38 to 59 years 63.3 % f analyze the impact of venous ulcers on the qol of people attended in primary health care. compromise of qol was identified, the most affected dimensions were emotional state and aesthetics, especially in individuals with lesion for more than a year. association was observed between current time of lesion and emotional state (p: 0.008), in which individuals with lesion for more than one year had higher measurements (64.5). 4b e12 (20) observational crosssectional study portugal mean 71.9 years 63.3 % f evaluate the impact of chronic leg ulcers on qol of patients in portugal using the nottingham health profile (nhp) scale, and verify changes after 12 weeks of treatment. patients had high scores in all nph domains. after 12 weeks, an increase was noted in all the dimensions of nph and a statistically significant improvement, in pain (p: 0.003) and in the euroqol score (p: 0.027). 4b e13 (21) control case the united states mean of 57 years 80 % f compare the qol of patients with chronic neuropathy (charcot) with and without ulcerations on the feet due to complications of dm. the study did not evidence significant difference in qol among patients with chronic neuropathy with and without foot ulcer, due to complications of dm, except for the subscale bodily pain, which had lower scores in patients who did not have ulcer (p: 0.04). 3d e14 (22) crosssectional study czech republic mean of 64 years 72 % m evaluate the influence of pain on qol of patients with foot ulcer due to complication of dm. the ulcer affects significantly the qol of the patient. patients who had pain with greater frequency evidence lower qol. a statistically negative correlation was found among the intensity of pain and qol in the following domains: physical health (r = 0.592; p < 0.001), daily activities (r = 0.456; p < 0.001), emotions (r = 0.503; p < 0.001), and treatment (r = 0.434, p < 0.001). 4b e15 (23) instrument validation study colombia mean of 78.6 years 63 % f validate the spanish version of the charing cross venous ulcer questionnaire (ccvuq-e). the ccvuq-e has good internal consistency (cronbach’s alpha ≥ 0.80). the correlation between the ccvuq-e and the push-e, at the beginning of the search, was r: 0.49 (p: ≤ 0.001), and, after six weeks it was r: 0.64 (p: 0.006). the instruments demonstrated adequate sensitivity to change (p: ≤ 0.001). hence, the preliminary results show that the ccvuq-e has satisfactory psychometric properties. 4b e16 (24) crosssectional study brazil mean of 60 years 74.5 % f compare the qol of patients with chronic venous disease with and without ulcer and identify the most affected aspects. the qol of patients with and without venous ulcer was different in the eight domains and in both dimensions of sf-36 (p < 0.05). the most affected aspects were: physical aspect (p < 0.001), functional capacity (p < 0.001), social aspects (p < 0.001), and physical health (p < 0.001). people with venous ulcer had worse qol when compared to people without that lesion. 4b e17 (25) a crosssectional probabilistic study brazil mean of 52.8 years 62 % f evaluate qol and analyze the association between personal characteristics and health in qol of patients with chronic leg ulcers. the sampling had better qol (median = 21.6; sd = 3.4). the domain of health and functioning had the lowest scores (median = 19.7; sd = 3.7). age (p = 0.0165), number of children (p = 0.0083), and religious practice (p = 0.0394) had significant positive effect on qol. 4b 8 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 nº type of study location of study population objective of the study principal findings level of evidenceage sex e18 (26) control case greece mean of 62.29 years 51 % m evaluate qol, anxiety, and depression, self-esteem and loneliness in patients with leg ulcer. patients of female gender had a higher score of anxiety (p = 0.027) and social isolation (p = 0.048) and worse qol (p = 0.018) than patients of male gender. a serious compromise of qol was observed, and reflected significant psychosocial impact in patients with leg ulcers (p < 0.05). 3d e19 (27) descriptive crosssectional study the united states mean of 56.9 years 80 % m compare qol in patients with foot ulcer due to complications of dm with and without infection. scores of the physical aspects (p < 0.001) and mental (p = 0.025) of sf-36 were significantly reduced in patients with infection indicated a negative effect on general health, besides a reduction in the function of the lower extremities (p < 0.001). 4b e20 (28) validation longitudinal study germany mean of 65.3 years 54,5 % m develop a questionnaire to evaluate qol in people with chronic leg ulcers. the wound-qol has good internal consistency (cronbach’s alpha 0.71 to 0.91), convergent validity (r = 0.48 to 0.69) and responsiveness (r = 0.18 to 0.52). the wound-qol has satisfactory psychometric properties to assess qol in people with leg ulcer in germany. 4b e21 (29) multicenter, prospective, descriptive, analytic study. brazil between 60 and 70 years majority f evaluate self-esteem and bodily image of patients with venous ulcer (vu). low scores for bodily image (7.43), bodily care (5.71) and body touch (12.3) in patients with vu indicate negative feelings regarding the body (p < 0.05). in addition, the low score (22.66) for the rosenberg selfesteem (rse) scale also indicates low self-esteem in these patients (p < 0.05). e22 (30) crosssectional, translation and cultural adaptation study brazil mean of 56.2 years 100 % f translate and adapt the charing cross venous ulcer questionnaire for a brazilian population. in the process of translation and adaptation, some terms needed to be changed to facilitate their comprehension. the charing cross venous ulcer questionnaire was translated and adapted for use in a brazilian population. 4b e23 (31) crosssectional, translation and cultural adaptation study brazil mean of 67.3 years 68 % f translate the venous leg ulcer qol questionnaire (vlu-qol) into brazilian portuguese, culturally adapt, and validate the vlu-qol-br questionnaire for the brazilian population. the instrument has high internal consistency (cronbach’s alpha: 0.94), good reproducibility (interclass correlation coefficient: 0.78; p ˂ 0.01), the confirmatory analysis maintained the same domains of the original version of the instrument. the instrument has satisfactory psychometric properties, which permits its use in brazil. it is recommended to evaluate its performance in other regions and in different samples of individuals. 4b e24 (32) crosssectional instrument validation brazil mean of 63.2 years 80 % f validate the charing cross venous ulcer questionnaire for the brazilian population. the instrument has good internal consistency (cronbach’s alpha: 0.92), high correlation in the evaluation of inter-observer reproducibility and its stability, presents inter-class correlation coefficients above 0.80 for all domains. furthermore, the instrument presented reasonable correlations with the sf-36 domains. the ccvuq-brazil is validated in portuguese. 4b e25 (33) multicenter, randomized instrument validation study the united kingdom mean of 68.6 years 50.07 m validate the veines-qol to evaluate qol in people with venous ulcer. the instrument has good internal consistency (cronbach’s alpha: 0.88), reproducibility (interclass correlation coefficient: 0.80), adequate correlation with the components of the sf-12, and moderate responsiveness. 1c e26 (34) crosssectional study brazil mean of 60 years 53.6 % f evaluate a qol in people with foot ulcer due to complications of dm and its association with age and gender. participants presented domains of qol that tend to have a worse health status, however, there was no significant difference in the results between groups regarding age and gender. 4b 9 instruments to assess the subjective repercussions of people with chronic wounds: integrative review l joyce souza lemes e outros nº type of study location of study population objective of the study principal findings level of evidenceage sex e27 (35) translation and cultural adaptation study uruguay mean of 63.4 years 52 % f translate and adapt the charing cross venous ulcer questionnaire (ccvuq) for uruguay. the translation and adaptation of the version of ccvuq was easy to understand and apply, showing adequate psychometric properties. 4b e28 (36) observational longitudinal study germany mean of 62 years 60 % f validate the freiburg life quality assessment instrument to evaluate qol in people with venous ulcer. the instrument presented good internal consistency (cronbach’s alpha: ≥ 0.85), reliability, convergent validity with the euroqol questionnaire of qol (eq-5d) and sensitivity to change (r: 0.59-0.61). e29 (37) crosssectional analytic study brazil mean of 55 years 60 % f evaluate qol and depression in elderly patients with pl. patients with lu had significantly low qol scores, when compared to the control group, in all domains of the short form-36 (sf-36), with lower scores in the domains physical function and emotional function (p < 0.0001). seventy (80.9 %) patients had depression (p = 0.002). 4b e30 (38) crosssectional pilot study the united kingdom mean of 70 years 58 % f determine the impact of pl in (qol) in people with pl. pl impacts qol negatively, independent of concomitant comorbidities (diabetes, arthritis, cva, cancer, orthopedic, respiratory, neurological. in spite of borderline significance (p = 0.06), the pain perceived is higher among people with lp. 4b e31 (39) crosssectional multicenter study italy mean of 60 years 61 % f access pain and qol in patients with chronic leg ulcer. leg ulcers are painful and result in low qol that is directly related to the time of duration of the lesion and its area. 4b e32 (40) crosssectional analytic turkey between 30 and 51 years 65 % m determine the correlation between depression and level of social support perceived of people with foot ulcers due to complications of dm. depression and social support perceived correlate with foot ulcers due to complications of dm (p < 0.01). 4b e33 (41) translation and adaptation of the instrument poland mean of 62.5 years 70 % f translate into polish the diabetic foot ulcer scale (dfs). the translated instrument can be used in polish patients. 4b e34 (42) crosssectional pilot study poland mean of 56 years 75 % f compare qol of people with vascular ulcers and those with chronic venous insufficiency (cvi), without ulcer. significant differences were observed (p < 0.05) on the qol of people with vascular ulcers and people with cvi without chronic ulcer. 4b e35 (43) methodological study to adapt and validate the instrument brazil mean of 55.7 years 54 % f adapt into brazilian portuguese and test reliability and validity of the brazilian version of the neuropathy ― and foot ulcer ― specific qol instrument ― (neuroqol) to people with diabetic neuropathy with foot ulcers. the findings evidence psychometric properties that confirm validity and reliability to neuroqol, with cultural adaptation being necessary in other regions of brazil. statistically significant correlations (p < 0.01) were verified in domains of pain and mental component, loss of sensitivity and physical component, anguish and physical component, activities of daily life and physical component. 4b e36 (44) analytic, cross-sectional, controlled, and comparative study brazil mean of 55 years 62 % f evaluate the qol of people with dm with foot ulcer in relation to people with dm without ulcer. in patients from the control group, the mean score of the sf-36 was 69.38 ± 21.90 and from the study group, 30.34 ± 14.45 (p < 0.001). the mean scores in all sf36 domains of the study group were lower in relation to the control group (p < 0.001); thus, demonstrating that diabetic patients with foot ulcer present changes in qol, which impacts multi-dimensionally. 4b e37 (45) crosssectional study the united kingdom mean of 62 years 60 % m evaluate anxiety and depression of people with charcot foot due to complication of dm, compared with diabetic individuals without foot complications. patients with charcot foot had high levels of mental problems when compared to patients without ulcer. anxiety and depression had high scores, 6.4 ± 4 and 6.3 ± 3.6, respectively. the risk of anxiety was not significant, but the risk of depression was significant (p < 0.05). 4b 10 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 source: own elaboration. nº type of study location of study population objective of the study principal findings level of evidenceage sex e38 (46) crosssectional study brazil mean of 61 years 59 % f evaluate level and intensity of depression of patients with chronic wounds (venous ulcer, pressure lesion, foot ulcer due to dm) from the beck inventory. among patients with venous ulcer, 7 (28 %) had slight to moderate depression and 3 (12 %) had moderate to serious depression. sixteen (53.3 %) patients with pressure ulcers manifested slight to moderate depression, and 5 (16.7 %), moderate to serious depression; 10 (55.6 %) diabetic patients with foot ulcer had slight to moderate depression, and 4 (22.20 %) without depression or minimum depression. 4b e39 (47) exploratory, descriptive, and crosssectional study brazil between 60 and 69 years 60 % f evaluate the intensity of depression and depressive symptoms in diabetic patients with foot ulcers. diabetic patients with foot ulcers had varying degrees of depressive symptoms, with prevalence of “moderate” level (64 %) and symptoms: self-depreciation, sadness, and distortion of the bodily image. the statistical difference between the levels “minimum or none” and “moderate”, with relation to number of depressive symptoms, was significant (p < 0.001). 4b e40 (48) crosssectional prospective study the united states mean of 64.1 years 52 % m it is determined that depression is associated to increased incidence of foot ulcers of patients with type 2 diabetes. compared to patients without depression, patients with higher depression have greater risk of having foot ulcer due to complications of dm (ci = 1.24 – 3.25). there was no statistically significant association within minor depression. 4b e41(49) crosssectional study norway 20 years or more 60 % f compare levels of anxiety and depression, psychological wellbeing and health perception among people with diabetes, with or without history of foot ulcer, and people from the community without diabetes. anxiety, depression, and perceived health had interaction with age and presence of dm (p = 0.002). 4b hypertension (19.7 %), heart disease (7.3 %), orthopedic trauma (4.8 %), neurological disorders (2.4 %), and cancer (2.4 %). the 11 studies that evaluated schooling of the participants identified complete primary education in seven (63.6 %), and four (36.4 %) with more than half the population being illiterate. in terms of the etiology of the lesion, there was significant relevance of the studies of people with leg ulcers (lu) (92.7 %), followed by pressure lesion (7.3 %). studies with lu identified those that evaluated different populations, of which 16 (42.2 %) addressed people with foot ulcers due to complications of diabetes mellitus (dm), 16 (42. %) venous ulcer, two (5.2 %) arterial ulcer, one (2.6 %) neuropathic ulcer, one (2.6 %) compared populations with venous ulcer and ulcer due to complication of dm, one (2.6 %) compared people with ulcers due to psoriasis and leg ulcer, and one (2.6 %) compared populations with and without foot ulcers due to complications of dm. table 2 describes the assessment instruments used in the investigations. of these, 15 (36.5 %) studies opted for using more than one instrument to evaluate the human repercussions investigated, or even evaluated more than one repercussion in the same study. the most notable repercussion in the studies was qol, identified in each in 35 (85.3 %) studies, followed by “pain” in five (12.2 %), self-esteem in five (12.2 %), depression in five (12.2 %), anxiety and depression, together, in four (9.7 %), feeling of powerlessness in two (4.8 %), loneliness in two (4.8 %), perceived social support in one (2.4 %), and general health in one (2.4 %) study. considering the studies (n = 35, 85.3 %) that evaluated qol, concomitantly, three studies (8.5 %) evaluated bio-physiological dimensions, sought correlations with qol. of these, one (33.3 %) evaluated the healing conditions through the pressure ulcer scale healing (push); one (33.3 %), mental state through the mental state mini exam; and one (33.3 %), the functional capacity of the ankle through the foot ankle ability measurement. in turn, 11 (31.4 %) studies evaluated qol simultaneously with another psycho-physiological or psychosocial repercussion, with emphasis for “pain” (45.4 %) as repercussion most associated in the studies. the studies of said 11 instruments to assess the subjective repercussions of people with chronic wounds: integrative review l joyce souza lemes e outros table 2. human impacts and respective instruments of extended assessment applied among people with chronic wounds. goiania, 2017 impact assessed name of the instrument frequency (n, %) / studies population for which the instrument was elaborated description of the instrument qol 36-item short-form health survey* (sf-36) 8 19.5 % e9, e13, e16, e19, e26, e30. e35, e36 adults in diverse clinical situations sf-36 is comprised of 36 items encompassed in eight components: functional capacity (10 items), physical aspects (four items), pain (two items), general state of health (five items), vitality (four items), social aspects (two items), emotional aspects (three items), mental health (five items), and one comparative question on the current perception of health and one year ago. the charing cross venous ulcer questionnaire (ccvuq) 6 14.6 % e5, e11, e15, e22, e24, e27 people with venous ulcer ccvuq is composed of 21 items that identify four important domains of health: social interaction, domestic activities, aesthetics, and emotional state, yielding scores of 0 100 in which a higher score indicates worse qol. diabetic foot ulcer scale-short form (dfs-sf)* 4 9.7 % e7, e10. e14, e33 patients with foot ulcer due to complications of dm dfs-sf consists in 58 items (each in a 5-point likert-type scale) grouped into 11 domains: leisure, physical health, daily activities, emotions, noncompliance, family, friends, treatment, satisfaction, positive attitudes, financial. 12-item shortform health survey (sf-12) 3 7.3 % e6, e25, e31 adults in diverse clinical situations sf-12 is a reduced version of the sf-36, composed of 12 items that evaluate two big components: the physical component or physical component score (pcs) and the mental component or mental component score (mcs). the scores vary from 0 to 100 in which 0 represents worse qol and 100 better qol. dermatology life quality index (dlqi)* 2 4.8 % e4, e18 patients with dermatological problems dlqi has 10 items divided into four domains: personal relationships, daily activities, leisure, and treatment. the maximum score is 30, with 0 indicating the lower damage and 30 the greater commitment in the patient’s qol. review (11, 14, 20, 21, 22, 38, 39) evidenced that greater pain meant lower qol of patients with leg ulcers and pressure lesion. thirty-three instruments were identified in the studies of this review, with 18 (54.5 %) being referents to assess qol. among them, we highlight the short form 36 health survey (sf-36), identified in eight (44.4 %) studies, and the charing cross venous ulcer questionnaire (ccvuqe), used in six (33.3 %). it should be emphasized that of the studies evaluating qol, five (14.2 %) use more than one instrument to evaluate that same repercussion. of these, one (20.0 %) study used four different instruments, and, in the rest (80.0 %) investigated, two instruments were identified. regarding the dimensions evaluated in the qol instruments (n = 18), higher occurrence was observed of the referents to activities of daily life, identified in 13 (72.2 %) instruments. questions corresponding to the evaluation of the dimension of “pain and discomfort” were found in nine (50 %) instruments, as well as “social aspects” in eight (44.4 %) and “emotional aspects” in six (33.3 %). it should also be noted that the same instrument contains an evaluation of more than one of the dimensions mentioned. some instruments, like the venous leg ulcer qol (vlu-qol) guide the research considering the clinical characteristics according to the etiology of the ulcers, through most commonly observed symptoms. in relation to the other repercussions, four instruments identified were used, each, in four (12.1 %) studies: diabetic foot ulcer scale (dfs), visual analog scale (vas), rosenberg selfesteem scale, and hospital anxiety and depression scale (hads). the instruments health survey (sf-12) and beck’s depression and anxiety inventory were identified in three (9.1 %) studies each. lastly, the dermatology quality index (dlqi), eq-5d powerlessness assessment tool (pat) questionnaire, and loneliness scale (ucla) were each used in two (6.1 %) studies. 12 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 impact assessed name of the instrument frequency (n, %) / studies population for which the instrument was elaborated description of the instrument qol eq-5d questionnaire* 2 4.8 % e3, e30 people with chronic ulcer it includes a scale from 0 to 100 points, and is divided into eight domains: mobility, personal care, activities of daily life, pain and discomfort, anxiety and depression. the answers register three levels of severity (without any problems or moderate problems, external problems). freiburg life quality assessment (flqa-w)* 2 4.8 % e20. e28 patients with chronic wounds flqa-w consists of 6 domains: physical symptoms, daily life, social life, psychological wellbeing, treatment, and satisfaction. the calculation of the domains is carried out by the arithmetic mean of each response, after recoding the satisfaction domain. the total score is through the mean values of the domains. qol index by ferrans and powers ― version wounds 1 2.4 % e17 people with acute and chronic wounds this instrument has 35 items distributed into four domains: health and functioning, socioeconomic, psychological/spiritual and family. the total score and for each domain varies from 0 (worse qol) to 30 (better qol). the rand 36-item health survey (rand-36) 1 2.4 % e10 people with chronic wounds it has 36 items divided into eight domains: physical functioning, bodily pain, function limitations due to problems of physical health, function limitations due to personal or emotional problems, emotional wellbeing, social functioning, energy/fatigue and general perceptions of health. venous leg ulcer qol questionnaire (vlu-qol) 1 2.4 % e23 people with venous ulcers these are 34 questions divided into three dimensions: activities, psychological, and symptoms of the ulcer. the score is made by the likert scale, varying from 0 (never) to 100 (always). venous insufficiency epidemiological and economic study ― qol/symptom (veines-qol) 1 2.4 % e25 people with venous insufficiency consists of 26 items: 10 related to symptoms, nine to performance of activities of daily life, one to the time of day that the symptoms are more intense, one to changes occurring in relation to the disease in the last year, and five to the psychological impact. the time considered for questions related to symptoms, limitations in daily life, and psychological impact comprises the last four weeks. pressure ulcer ― qol instrument (pu-qol instrument) 1 2.4 % e2 patients with pressure lesion pu-qol contains 10 domains: pain, exudate, smell, sleep, mobility, activity, vitality, emotional, wellbeing, and self-concept. patients assess "nuisance" level assigned over the past week on a 3-point response scale. the scores of the scale are generated by the sum of items, with lower scores indicating better result. the skindex-29 questionnaire 1 2.4 % e34 patients with dermatological conditions skindex-29 includes 29 statements on the potential effects of the dermatological condition, divided into eight domains: cognitive effects, social effects, effects of the depression, fear, shame, anger, discomfort, and limitations. the score varies between 29, corresponding to the highest qol or lack of negative effects of the condition, and 145, corresponding to lower qol or maximum negative influence of the condition. neuropathy ― and foot ulcer ― specific qol ― neuroqol 1 2.4 % e35 people with diabetic neuropathy and foot ulcer composed by 35 items distributed into six domains: pain, reduction of sensitivity, diffuse sensory-motor symptoms, limitations of activities in daily life, disorder in social relationships, and emotional anguish. there are also two final items on the scale that assess, respectively, the impact of foot changes on qol and on its overall classification. the scores are calculated by the average of the weighted items of domains. the score varies between 1 and 15 in which higher values indicate worse qol. 13 instruments to assess the subjective repercussions of people with chronic wounds: integrative review l joyce souza lemes e outros impact assessed name of the instrument frequency (n, %) / studies population for which the instrument was elaborated description of the instrument qol nottingham health profile (nhp)* 1 2.4 % e12 adults in diverse clinical situations divided into six domains: level of energy, pain, emotional, sleep, social and physical abilities. the score varies between 0 and 100, higher values represent more negative interference qol. wound qol* 1 2.4 % e20 people with chronic wounds composed of 17 items, with three domains: daily life, bodily, and psychological. patients are asked how many times they felt any of the 17 items and they respond (not even a little, a little, moderately, very much, extremely). the cardiff wound impact schedule (cwis)* 1 2.4 % e20 people with chronic wounds cwis consists of three domains: wellbeing, physical symptoms, social life, and daily life. scores vary from 0 to 100, in which higher values indicate better qol. würzburg wound score (wws)* 1 2.4 % e20 people with chronic wounds wws is composed of 17 items related to pain, sleep, happiness, frustration, worry, smell, discomfort, fear, activities of daily life, mobility, limitation, dependence, and financial. pain visual analog scale (vas)* 4 9.7 % e12, e14, e30. e33 adults in diverse clinical situations vas provides a one-dimensional measurement of pain intensity. it has anchors of 0 (without pain) to 10 (worse pain possible). mcgill pain questionnaire (mpq) 1 2.4 % e6 adults in diverse clinical situations seeks to provide qualitative measurements of pain that can be analyzed statistically. evaluates the sensory, affective, temporal and miscellaneous qualities of pain. in addition, it presents an evaluation of the spatial distribution and intensity of pain (“without pain” to “excruciating”). self-esteem rosenberg selfesteem scale (rses) 4 9.7 % e4, e9, e18, e21 adult patients rses is a 10-item questionnaire answered in a 4-point scale. scores vary from 0 to 30; scores from 15 to 25 are considered within the normal interval, while scores below 15 suggest feelings of low self-esteem. the body investment scale* 1 2.4 % e21 adult patients includes 20 items grouped into four domains: bodily feelings, body touch, bodily care, and bodily protection. the items are scored in a 5-point likert scale, varying from totally disagree (1) to totally agree (5). anxiety and depression hospital anxiety and depression scale (hads)* 4 9.7 % e4, e18, e37, e41 adults in diverse clinical situations hads has 14 items, projected to measure anxiety and depression, most likely to cause psychological suffering in patients (seven items for each subscale). answers to the items are indicated in a 4-point likert scale from 0 to 3, with a high score indicating more symptoms. depression beck’s depression assessment inventory* 3 7.3 % e32, e38, e39 destined for patients over 13 years of age consists of 21 categories and each category has 4 points. the highest score is 63; the higher the score, higher degree of intensity of depression. 0 to 10 indicates no symptom of depression, 11 to 17 indicates few symptoms, 18 to 29, moderate, and 30 to 63 indicates high level of depressive symptoms. 15-item geriatric depression scale 1 2.4 % e 29 destined for elderly patients consists of 15 questions made in interview form with ‘yes or no’ answers, which evaluate if the elderly patient has or does not have depressive symptoms. patient health questionnaire-9 (phq-9) 1 2.4 % e40 adults in diverse clinical situations composed of nine questions that evaluate the presence of nine symptoms of depression: depressed mood, anhedonia, problems sleeping, tiredness, change in appetite or weight, feeling of guilt or uselessness, lack of concentration, feeling slow or restless, and suicidal thoughts. and presents a tenth question that evaluates the impact of these symptoms in activities of daily life. each item is considered positive if it remains for more than half the days in the last two weeks. 14 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 source: own elaboration. impact assessed name of the instrument frequency (n, %) / studies population for which the instrument was elaborated description of the instrument feeling of powerlessness powerlessness assessment tool (pat) 2 4.8 % e1, e8. adults in postoperatory the instrument consists of a measure of 12 items distributed into three domains: capacity to perform behavior, perception of the capacity to make decisions, and emotional response to the control of situations. the pat evaluates the feeling of powerlessness in a 5-point likert-type scale, varying from "never" (1) to "always" (5). the total pat varies between 12 and 60, with higher scores corresponding to strong feeling of powerlessness. loneliness ucla loneliness scale (version 3)* 2 4.8 % e4, e18 not shown by study ucla (version 3) is a questionnaire with 20 items that measures the personal perception of loneliness and of social isolation. the stronger these feelings were, the higher the ucla score. perceived social support multidimensional scale of perceived social support* 1 2.4 % e32 adults in diverse clinical situations consists of 12 items, evaluates the perception of adequate support perceived by 3 domains: family, friends, and significant others. likert-type scale in which the lowest score is 12 and the highest is 28, with the higher scores indicating higher level of social support. healing pressure ulcer scale of healing (push) 1 2.4 % e15 people with pressure lesion evaluates three aspects of healing: size of the ulcer, amount of exudate and type of tissue. each has a sub-score that will be added and will form the total score. the lower the score, the better the prognosis. functionality foot and ankle ability measurement (faam) 1 2.4 % e19 adults in diverse clinical situations developed as a specific measure to verify the functionality of people with muscular-skeletal disorders of the ankle-foot complex. it evaluates two aspects: activity of daily life (adl) and sports appraisals. the adl subscale includes 21 activities, and the sports subscale includes eight activities. patients are asked to register the difficulty the face with various activities. there are three scores, one for each subscale and a total score. the maximum score in the adl and sports subscale is 84 and 32, respectively. general health the short form global health of promis 1 2.4 % e27 patients with chronic disease composed of 10 items that evaluate aspects of physical, mental, and social health, plus an item to classify general health. this instrument is composed of two specific scales, global physical health and global mental health, each composed of four items. the global physical health scale includes items of physical health (03), physical function (06), intensity of pain (07), and fatigue (08). and the scale of global mental health is constituted by items of qol (02), mental health (04), satisfaction with social activities and relationships (05), and emotional problems (global 10). the answer categories are likert-type scales of 5 points, except for the global 07 item, which evaluated by a scale from 0 to 10 in which 0 means lack of pain and 10 presence of worse pain imaginable. cognition mini mental – mental exam 1 2,4 % e29 adults in diverse clinical situations mini-mental state consists of a test to examine the mental state that assesses orientation, memory, attention, and language. higher scores indicate better cognitive performance. the maximum score is 30 points. due to the influence of schooling on the total scores of the mini-mental state, the evaluation of the result occurs according to the schooling of the individuals. *instruments used concomitantly for at least one more instrument, and not in isolated manner, in the studies. 15 instruments to assess the subjective repercussions of people with chronic wounds: integrative review l joyce souza lemes e outros discussion regarding the design diversity of the studies included, it is associated with the research question of this review that sought to know the instruments introduced in the literature for extended assessment of people with wounds. as expected, studies related to psychometrics were identified, however, it is possible to observe the scarcity of clinical research in this assessment context, making it difficult to judge the applicability of the instruments. the greater occurrence of research carried out in american countries, especially brazil, reinforces the potential to conduct investigations on this theme. nursing still needs further investment to carry out studies like these, given that it is one of the professional areas with greatest contact with the studied population, and which, sometimes, identifies nuances of the multidimensional repercussions among these individuals in the daily care. in addition, research is a recommended assessment demand in specific guidelines to approach this population (2). in relation to the characteristics of the population found in the articles in this review, the results reinforce the findings from the literature for the etiologies identified (50). this fact points to the presence of specific profiles that may help in directing actions in the context studied. it is possible to identify association between sociodemographic data and psychosocial repercussions, like the highest occurrence of low self-esteem, anxiety, and depression in women, which can be related to a higher number of stressful factors, such as pregnancy, menopause, and social oppression (51, 52). another example is the occurrence of depression associated to age, demonstrated by changing roles and, consequently, by alterations resulting from interaction and social function, in addition to continuous use of many medications (53, 54). the prevalence of studies that address people with leg ulcers can be associated to the profile of the individuals in what refers to socioeconomic aspects. because of their lower morbidity in relation to individuals with pressure lesion, leg ulcer patients still perform functions in the groups and social institutions to which they belong; people with pressure lesion, due to the most frequent comorbidities, like cancer and neurological disorders (45, 46), are unable to perform these roles. in this sense, it may be inferred that instruments specific to the etiology of the lesions can guide the approach and identify more precisely the broader repercussions, without ignoring the need to validate this affirmation in different clinical and cultural contexts. the diversity of instruments existing in the literature to assess the human repercussions mentioned points to understanding the complexity of the investigation, as well as for the possibility of these instruments meeting different objectives, considering variables, like clinical practice, teaching, and research, which needs validation by other studies. evaluation of qol, as the most frequent outcome investigated in the instruments found, draws attention to the scope of the theme and points to the possibility of exhausting the subjective assessment (holistic) of these individuals. however, it should be emphasized that the approach, in some instruments of qol, is superficial or even inconsiderate in relation to certain repercussions, such as “feeling of powerlessness”, “anxiety”, “depression”, and “social aspects” (22, 41, 47). said finding indicates that qol instruments can be tracers and not determinants in judging the presence or absence of these repercussions in this population. pain was also investigated frequently in the instruments, being an important aspect in the multidimensional evaluation of professionals in this type of care, despite being detailed or inadequately addressed. assessment of pain, if carried out regularly, allows nurses to become aware of the level of pain manifested by patients not only when conducting certain procedures. additionally, the frequency of evaluation will enable obtaining information related to the intensity of pain that people with venous ulcers must endure or experience in their daily lives. thus, it may be stated that the evaluation and registry of intensity of pain permit patients greater possibility of control over their condition, with positive effect on their capacity to develop strategies to cope with the problem. assessment of pain is also a means of measuring the efficacy and response to treatment, and influences the prognosis (19, 22, 28, 29, 30, 46, 47). pain represents an infectious process, neuropathy (22), or even psycho-emotional aspects involved (22, 28, 29). through several instruments validated to evaluate the intensity and characteristic of pain, it is recommended to use the same instrument to facilitate comparison of results and evolution of cases. such instruments can be determinant in the selection or adjustments in doses of analgesics, as well as in prescribing the most adequate coverage for healing (55). 16 año 19 vol. 19 nº 1 chía, colombia febrero 2019 aquichan issn 1657-5997 eissn 2027-5374 this study highlights the visual analogue scale of pain and the questionnaire on pain by de mcgill as instruments to evaluate and measure pain in patients with wounds. although specific instruments exist to aid in this evaluation, they are still poorly used in clinical practice. in a study conducted in brazil, in four hospitals that had the so-called “curative commissions”, merely 5 % of the nurses used some specific instrument to assess pain (56). this fact points to the need for a review of managerial aspects and to greater understanding by professionals regarding the importance of this evaluation. the greater occurrence of the use of the sf-36 can be justified because it is an instrument that addresses a greater diversity of the dimensions identified as human repercussions, besides comparing the current perception of health in different temporal cut-offs (57), or in clinical situations and different care scenarios (58). while promoting a wide-ranging assessment of various dimensions, this type of instrument does not address major repercussions that affect the chronic wound, such as self-esteem, anxiety, depression, feelings of powerlessness, and loneliness. a search made with people with chronic wounds identified that the perception of those with chronic lesion is marked by pain, preconception, dependence for daily activities, and consequential emotional alterations. patients face the adversities resulting from the lesion in different ways, and health professionals, especially nurses, must respect the individuality and understand how those repercussions affect patients (1). in nursing, theoretical references can help direct the holistic approach to this population, besides supporting the systematization of actions. the theory by wanda de aguiar horta, “theory of basic human needs”, represents simple possibilities applicable in various contexts of clinical practice (59), and which can be jointly implemented in the evaluation of subjective repercussions of this population. thus, the importance is evident of directed evaluation by the nurse to implement and use certain instruments, considering the social and clinical context of the population with wounds to be cared for. conclusion diverse instruments were identified for extended assessment of people with wounds, with those investigating qol being the most frequent. the other subjective repercussions found in the instruments analyzed were: anxiety, depression, loneliness, self-esteem, feelings of powerlessness, and perceived social support, in addition to specific instruments to evaluate mental state and healing. the repercussions are, mostly, contained in instruments to evaluate qol, but superficially and/or not very explicit, like in the sf-36, an instrument identified most frequently in the studies of this review. hence, it is therein inferred that qol instruments can be considered trackers of alterations of the aforementioned repercussions, but they hinder more directed judgment. the findings in this research reinforce the contributions of using instruments for extended assessment of people with chronic wounds, and suggest the possibility of differentiated implications, according to the etiology of the lesions, psychosocial and psychospiritual needs of the individual, as well as the context to which they are destined, that is, teaching, clinical practice, or research. it is also worth highlighting the importance of 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